2020 Complete Drug List (Formulary)

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

Toll-free 1-800-950-9355, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.myAARPMedicare.com

Formulary ID Number 00020047, Version 9 Y0066_190628_124536_C v15.01 Last updated October 1, 2019 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...... 29 Covered drugs with a quantity limit (QL)...... 108

Questions?

If you have questions, we’re here to help. Call UnitedHealthcare Customer Service at: Toll-free 1-800-950-9355, 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, 2019. For an up-to-date list of covered drugs or if you have questions, please call UnitedHealthcare Customer Service. Our contact information is on the cover. This drug list has changed since last year. Please review this document to make sure your prescription drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan,” “our plan,” or “your plan,” it means AARP Medicare Advantage Plans. 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 12–28 to see the ...... list of drug names in alphabetical order. Find the name of your drug. The page number where ...... you can find the drug will be next to it. 2. By medical condition. Turn to section “Covered drugs by medical condition” on pages ...... 29–107 to look for drugs based on your medical conditions. For example, if you have a heart ...... condition, you should look in the category Cardiovascular Agents. This is where you will find ...... drugs that treat heart conditions.

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

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

What is a compounded drug? A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription medication customized to the needs of an individual patient. Generally compounded drugs are non-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage determination from us to have your compounded drug covered. Compounded drugs may be Part D eligible. For more information about compounded drugs, please review your Evidence of Coverage. 4 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 29. The codes and what they mean are shown below and on the next page. You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call UnitedHealthcare Customer Service. Our contact information is on the cover. Coverage Rules and Limits

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

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

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

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

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

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

After we get the statement from your doctor supporting your request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting 72 hours. If your request for an expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s supporting statement. 8 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 were a member last year and it’s the in a nursing home or long- at least a 31-day first 90 days of your plan year term care facility temporary supply 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, any time during the year in a nursing home or long- at least a 31-day term care facility temporary supply

The prescription must be filled at a network pharmacy. If your prescription is written for fewer days, we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) We will not pay for more of your drug after you get this temporary or emergency supply unless you receive authorization from the plan. 10 9 Can the drug list change? Most changes in drug coverage happen on January 1. We may need to make changes during the plan year for safety or other reasons that can affect you. We must follow Medicare rules in making these changes. The drug list may change during the year if your plan: · Adds new drugs, including generic drugs, as they become available. · Removes a drug that has been found to be ineffective or unsafe. · Changes the coverage rules or limits for a drug. · Moves a drug into a different cost-sharing tier. If we add new generic drugs We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section “How can I get an exception?” on page 8. If we remove a drug from the list

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

We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You can find out if your drug has any rules or limits by looking in the chart on pages 108-134. We’ll tell you about other changes

If a drug you are taking is removed from the drug list during the plan year, we’ll include an update in your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about other changes to our drug list at least 30 days before they go into effect or when you request a refill of the drug. If you find out when requesting a refill, you will receive at least a 30-day supply of the drug so you have time to talk with your doctor. To get updated information about the drugs covered by your plan, please call UnitedHealthcare Customer Service. Our contact information is on the cover. 10 11 Drugs with dosages other than a 1-month supply Drugs packaged in an extended day supply Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription. For more information, please call Customer Service. Our contact information is on the cover. Daily cost-sharing for oral medications filled for less than a 1-month supply A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Daily cost-sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than 1 month under applicable law. The daily cost-sharing requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.

For more information For more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan’s prescription drug coverage, please call UnitedHealthcare Customer Service. Our contact information, along with the date we last updated the drug list, is on the cover. If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week. 12 12Tracked 12 Covered drugs by name (Drug index) track

A Albendazole...... 52 Amlodipine Besylate...... 68 Abacavir Sulfate...... 58 Albuterol Sulfate...... 104 Amlodipine-Atorvastatin...... 69 Abacavir Sulfate-Lamivudine Alclometasone Dipropionate Amlodipine-Benazepril...... 69 ...... 59 ...... 84 Amlodipine-Olmesartan...... 70 Abacavir-Lamivudine- Alcohol Prep Pads...... 100 Amlodipine-Valsartan...... 70 Zidovudine...... 59 Alecensa...... 50 Amlodipine-Valsartan-HCTZ Abelcet...... 45 Alendronate Sodium...... 99 ...... 70 Abilify Maintena...... 54 Alfuzosin HCl ER...... 83 Ammonium Lactate...... 75 Abiraterone Acetate...... 48 Alinia...... 52 Amoxapine...... 44 Acamprosate Calcium...... 32 Aliskiren Fumarate...... 69 Amoxicillin...... 36 Acarbose...... 61 Allopurinol...... 46 Amoxicillin-Potassium Acebutolol HCl...... 68 Alocril...... 101 Clavulanate...... 37 Acetaminophen-Codeine...... 31 Alomide...... 101 Amoxicillin-Potassium Clavulanate ER...... 37 Acetazolamide...... 71 Alosetron HCl...... 81 Amphetamine- Acetazolamide ER...... 71 Alphagan P...... 101 Dextroamphetamine...... 73 Acetic Acid...... 103 Alprazolam...... 60 Amphetamine- Acetylcysteine...... 105 Altavera...... 87 Dextroamphetamine ER...... 73 Acitretin...... 75 Alunbrig...... 50 Amphotericin B...... 45 Actemra...... 96 Alyacen 1/35...... 88 Ampicillin...... 37 Actemra ACTPen...... 96 Alyq...... 105 Ampicillin Sodium...... 37 ActHIB...... 96 Amantadine HCl...... 53 Ampicillin-Sulbactam Sodium Actimmune...... 96 AmBisome...... 45 ...... 37 Acyclovir...... 57 Ambrisentan...... 105 Ampyra...... 74 Acyclovir Sodium...... 57 Amethia...... 88 Anadrol-50...... 87 Adacel...... 96 Amethia Lo...... 88 Anagrelide HCl...... 65 Adapalene...... 75 Amikacin Sulfate...... 33 Anastrozole...... 50 Adefovir Dipivoxil...... 57 Amiloride HCl...... 71 Androderm...... 87 Adempas...... 105 Amiloride-Hydrochlorothiazide Anoro Ellipta...... 106 Advair Diskus...... 105 ...... 69 Apokyn...... 53 Advair HFA...... 105 Aminosyn II...... 77 Apraclonidine HCl...... 101 Afinitor...... 50 Aminosyn-PF...... 77 Aprepitant...... 45 Afinitor Disperz...... 50 Amiodarone HCl...... 67 Apri...... 88 Aimovig...... 47 Amitiza...... 81 Apriso...... 98 Ala-Cort...... 84 Amitriptyline HCl...... 44 Aptiom...... 41 13Tracked 13 13 Aptivus...... 59 Azopt...... 101 Betimol...... 101 Aralast NP...... 82 Aztreonam...... 36 Bevespi Aerosphere...... 106 Aranelle...... 88 B Bexarotene...... 52 Aranesp...... 65 Bacitracin...... 33 Bexsero...... 96 Arcalyst...... 96 Bacitracin-Polymyxin B...... 100 Bicalutamide...... 48 Aripiprazole...... 54 Baclofen...... 106 Bicillin C-R...... 37 Aripiprazole ODT...... 54 Bactocill in Dextrose...... 37 Bicillin C-R 900/300...... 37 Aristada...... 54 Bactroban...... 34 Bicillin L-A...... 37 Aristada Initio...... 54 Balsalazide Disodium...... 98 BiDil...... 70 Arnuity Ellipta...... 103 Balversa...... 50 Biktarvy...... 59 Ashlyna...... 88 Balziva...... 88 Binosto...... 99 Aspirin-Dipyridamole ER...... 66 Banzel...... 41 Bisoprolol Fumarate...... 68 Atazanavir Sulfate...... 59 Baraclude...... 57 Bisoprolol-Hydrochlorothiazide Atenolol...... 68 BCG Vaccine...... 96 ...... 70 Atenolol-Chlorthalidone...... 70 Belsomra...... 107 Blephamide...... 100 Atomoxetine HCl...... 74 Benazepril HCl...... 67 Blephamide S.O.P...... 100 Atorvastatin Calcium...... 72 Benazepril-Hydrochlorothiazide Blisovi 24 Fe...... 88 Atovaquone...... 52 ...... 70 Blisovi Fe 1.5/30...... 88 Atovaquone-Proguanil HCl.... 52 Benlysta...... 96 Boostrix...... 97 Atripla...... 58 Benznidazole...... 52 Bosentan...... 105 Atropine Sulfate...... 100 Benzoyl Peroxide-Erythromycin Bosulif...... 50 ...... 76 Atrovent HFA...... 104 Braftovi...... 50 Benztropine Mesylate...... 53 Aubagio...... 74 Breo Ellipta...... 106 Bepreve...... 101 Aubra...... 88 Briellyn...... 88 Berinert...... 93 Auryxia...... 80 Brilinta...... 66 Besivance...... 38 Austedo...... 74 Brimonidine Tartrate...... 101 Betamethasone Dipropionate Aviane...... 88 BRIVIACT...... 40 ...... 84 Avonex Pen...... 75 Bromocriptine Mesylate...... 53 Betamethasone Dipropionate Budesonide...... 99, 103 Avonex Prefilled...... 75 Aug...... 84 Budesonide ER...... 99 Azasite...... 38 Betamethasone Valerate...... 84 Bumetanide...... 71 Azathioprine...... 94 Betaseron...... 75 Buprenorphine...... 30 Azelaic Acid...... 75 Betaxolol HCl...... 68, 101 Buprenorphine HCl...... 32 Azelastine HCl...... 101, 103 Bethanechol Chloride...... 84 Buprenorphine HCl-Naloxone Azithromycin...... 38 Bethkis...... 104 HCl...... 32 14 14Tracked 14 Bupropion HCl...... 43 Carbamazepine...... 41, 42 Chantix Starting Month Pak...33 Bupropion HCl SR...... 33, 42 Carbamazepine ER...... 41 Chemet...... 80 Bupropion HCl XL...... 43 Carbidopa...... 53 Chenodal...... 81 Buspirone HCl...... 60 Carbidopa-Levodopa...... 53 Chlordiazepoxide HCl...... 60 Butalbital-Acetaminophen- Carbidopa-Levodopa ER...... 53 Chlorhexidine Gluconate...... 75 Caffeine...... 29 Carbidopa-Levodopa ODT.....53 Chloroquine Phosphate...... 52 Butalbital-Aspirin-Caffeine..... 29 Carbidopa-Levodopa- Chlorothiazide...... 71 Butorphanol Tartrate...... 31 Entacapone...... 53 Chlorpromazine HCl...... 53 Bydureon...... 61 Carteolol HCl...... 101 Chlorthalidone...... 71 Bydureon BCise...... 61 Cartia XT...... 68 Chlorzoxazone...... 106 Byetta 10MCG Pen...... 61 Carvedilol...... 68 Cholbam...... 82 Byetta 5MCG Pen...... 61 Cayston...... 104 Cholestyramine...... 72 Bystolic...... 68 Caziant...... 88 Cholestyramine Light...... 72 C Cefaclor...... 35 Ciclopirox...... 45 Cabergoline...... 92 Cefadroxil...... 35 Ciclopirox Olamine...... 45 Cablivi...... 66 Cefazolin Sodium...... 35 Cilostazol...... 66 Cabometyx...... 50 Cefdinir...... 35 Ciloxan...... 38 Calcipotriene...... 76 Cefepime HCl...... 35 Cimduo...... 59 Calcitonin Salmon...... 99 Cefixime...... 35 Cimetidine...... 81 Calcitriol...... 76, 99 Cefotetan Disodium...... 35 Cimetidine HCl...... 81 Calcium Acetate...... 80 Cefoxitin Sodium...... 35 Cimzia...... 94 Calquence...... 50 Cefpodoxime Proxetil...... 35, 36 Cimzia Prefilled...... 94 Camila...... 91 Cefprozil...... 36 Cinacalcet HCl...... 99 Camrese Lo...... 88 Ceftazidime...... 36 Cinryze...... 93 Canasa...... 98 Ceftriaxone Sodium...... 36 Cipro HC...... 103 Candesartan Cilexetil...... 67 Cefuroxime Axetil...... 36 Ciprodex...... 103 Candesartan Cilexetil-HCTZ Cefuroxime Sodium...... 36 Ciprofloxacin...... 39 ...... 70 Celecoxib...... 29 Ciprofloxacin HCl...... 38 Caprelsa...... 50 Celontin...... 40 Ciprofloxacin in D5W...... 39 Captopril...... 67 Cephalexin...... 36 Citalopram Hydrobromide..... 43 Captopril-Hydrochlorothiazide Cesamet...... 45 Claravis...... 76 ...... 70 Cetirizine HCl...... 103 Clarithromycin...... 38 Carac...... 76 Chantix...... 33 Clarithromycin ER...... 38 Carafate...... 82 Chantix Continuing Month Pak Clenpiq...... 81 Carbaglu...... 77 ...... 33 15Tracked 15 15 Climara Pro...... 88 Cometriq...... 50 D Clindamycin HCl...... 34 Complera...... 58 Dalfampridine ER...... 75 Clindamycin Palmitate HCl.... 34 Compro...... 44 Daliresp...... 105 Clindamycin Phosphate...34, 76 Constulose...... 81 Dalvance...... 34 Clindamycin Phosphate in D5W Copiktra...... 49 Danazol...... 87 ...... 34 Cordran...... 85 Dantrolene Sodium...... 106 Clindamycin Phosphate- Corlanor...... 70 Dapsone...... 48 Benzoyl Peroxide...... 76 Cortisone Acetate...... 85 Daptacel...... 97 Clobazam...... 40 Cortisporin...... 76 Daptomycin...... 34 Clobetasol Propionate..... 84, 85 Cosentyx...... 76 DARAPRIM...... 52 Clobetasol Propionate Cosentyx Sensoready...... 76 Emollient Base...... 84 Daurismo...... 50 Cosopt PF...... 101 Deblitane...... 91 Clomipramine HCl...... 44 Cotellic...... 50 Deferasirox...... 80 Clonazepam...... 60 Coumadin...... 64 Delstrigo...... 58 Clonazepam ODT...... 60 Creon...... 83 Delyla...... 88 Clonidine...... 67 Crinone...... 91 Clonidine HCl...... 67 Demeclocycline HCl...... 39 Crixivan...... 59 Demser...... 70 Clonidine HCl ER...... 74 Cromolyn Sodium...... 81, 101, Denavir...... 58 Clopidogrel Bisulfate...... 66 105 Depen Titratabs...... 84 Clorazepate Dipotassium...... 61 Cryselle-28...... 88 Depo-Estradiol...... 88 Clotrimazole...... 45 Cuvposa...... 80 Clotrimazole-Betamethasone Depo-Provera...... 91 Cyclafem 1/35...... 88 ...... 76 Descovy...... 59 Cyclafem 7/7/7...... 88 Clozapine...... 56 Desipramine HCl...... 44 Cyclobenzaprine HCl...... 106 Clozapine ODT...... 57 Desmopressin Acetate...... 86 Cyclophosphamide...... 48 Coartem...... 52 Desmopressin Acetate Spray Cycloset...... 61 Codeine Sulfate...... 31 ...... 86 Cyclosporine...... 94 Desogestrel-Ethinyl Estradiol Colchicine...... 47 Cyclosporine Modified...... 94 ...... 88 Colcrys...... 47 Cyproheptadine HCl...... 103 Desonide...... 85 Colesevelam HCl...... 72 Cyred...... 88 Desoximetasone...... 85 Colestipol HCl...... 72 Cystadane...... 83 Desvenlafaxine Succinate ER Colistimethate Sodium...... 34 ...... 43 Cystagon...... 83 Colocort...... 99 Dexamethasone...... 85 Cystaran...... 100 Combigan...... 101 Dexamethasone Intensol...... 85 Combivent Respimat...... 106 16 16Tracked 16 Dexamethasone Sodium Diltiazem HCl ER Beads...... 68 Durezol...... 102 Phosphate...... 102 Diltiazem HCl ER Coated Dutasteride...... 83 Dexilant...... 82 Beads...... 68 Dymista...... 106 Dexmethylphenidate HCl...... 74 Dipentum...... 98 E Dexmethylphenidate HCl ER Diphenoxylate-Atropine...... 81 E.E.S. Granules...... 38 ...... 74 Diphtheria-Tetanus Toxoids DT Econazole Nitrate...... 45 Dextroamphetamine Sulfate ...... 97 Edarbi...... 67 ...... 73 Disulfiram...... 32 Edarbyclor...... 70 Dextroamphetamine Sulfate ER Diuril...... 71 ...... 73 Edurant...... 58 Divalproex Sodium...... 61 Dextrose...... 77 Efavirenz...... 58 Divalproex Sodium ER...... 61 Dextrose-NaCl...... 78 Egrifta...... 92 Dofetilide...... 67 Diastat AcuDial...... 40 Elestrin...... 88 Donepezil HCl...... 42 Diastat Pediatric...... 40 Eliquis...... 64 Donepezil HCl ODT...... 42 Diazepam...... 61 Eliquis Starter Pack...... 64 Dorzolamide HCl...... 101 Diazepam Intensol...... 61 Elmiron...... 84 Dorzolamide HCl-Timolol Diclofenac Epolamine...... 29 Maleate...... 101 Embeda...... 30 Emcyt...... 49 Diclofenac Potassium...... 29 Dorzolamide HCl-Timolol Diclofenac Sodium...... 29, 76, Maleate Preservative Free Emoquette...... 88 102 ...... 101 Emsam...... 43 Diclofenac Sodium ER...... 29 Dovato...... 58 Emtriva...... 59 Dicloxacillin Sodium...... 37 Doxazosin Mesylate...... 67 Enalapril Maleate...... 67 Dicyclomine HCl...... 80, 81 Doxepin HCl...... 44, 76 Enalapril-Hydrochlorothiazide Didanosine...... 59 Doxercalciferol...... 99 ...... 70 Dificid...... 38 Doxy 100...... 39 Enbrel...... 94 Diflunisal...... 29 Doxycycline Hyclate...... 39 Enbrel Mini...... 94 Digitek...... 70 Doxycycline Monohydrate.... 39, Enbrel SureClick...... 94 Digox...... 70 40 Endocet...... 31 Digoxin...... 70 Dronabinol...... 45 Engerix-B...... 97 Dihydroergotamine Mesylate Drospirenone-Ethinyl Estradiol Enoxaparin Sodium...... 64 ...... 88 ...... 47 Enpresse-28...... 88 Droxia...... 49 Dilantin...... 42 Enskyce...... 88 Duavee...... 88 Dilantin INFATABS...... 42 Entacapone...... 53 Dulera...... 106 Dilt-XR...... 69 Entecavir...... 57 Duloxetine HCl...... 74 Diltiazem HCl...... 69 Entresto...... 70 Diltiazem HCl ER...... 69 Duramorph...... 31 17Tracked 17 17 Enulose...... 81 Ethosuximide...... 40 Firazyr...... 93 Envarsus XR...... 94 Ethynodiol Diacetate-Ethinyl Firmagon...... 92 Epclusa...... 57 Estradiol...... 88 Flac...... 103 Epidiolex...... 40 Etodolac...... 29 Flarex...... 102 Epinastine HCl...... 101 Etodolac ER...... 29 Flebogamma DIF...... 95 Epinephrine...... 104 Eurax...... 52 Flecainide Acetate...... 67 EpiPen 2-Pak...... 104 Evotaz...... 59 Flector...... 29 EpiPen Jr 2-Pak...... 104 Exelderm...... 45 Flovent Diskus...... 103 Epitol...... 42 Exemestane...... 50 Flovent HFA...... 103 Epivir HBV...... 57 Ezetimibe...... 72 Fluconazole...... 45, 46 Eplerenone...... 71 Ezetimibe-Simvastatin...... 72 Fluconazole in Sodium Eprosartan Mesylate...... 67 F Chloride...... 45 Eraxis...... 45 Falmina...... 88 Flucytosine...... 46 Ergotamine-Caffeine...... 47 Famciclovir...... 58 Fludrocortisone Acetate...... 85 Erivedge...... 50 Famotidine...... 81 Flunisolide...... 103 Erleada...... 48 Fanapt...... 55 Fluocinolone Acetonide...... 85, 103 Erlotinib HCl...... 50 Fanapt Titration Pack...... 55 Fluocinolone Acetonide Scalp Errin...... 91 Farydak...... 50 ...... 85 Ertapenem Sodium...... 36 Fayosim...... 88 Fluocinonide...... 85 Ery...... 76 Febuxostat...... 47 Fluocinonide Emulsified Base Erythrocin Lactobionate...... 38 Felbamate...... 41 ...... 85 Felodipine ER...... 69 Erythromycin...... 38, 76 Fluorometholone...... 102 Femring...... 88 Erythromycin Base...... 38 Fluorouracil...... 76 Femynor...... 88 Erythromycin Ethylsuccinate Fluoxetine HCl...... 43 ...... 38 Fenofibrate...... 72 Fluphenazine Decanoate...... 54 Esbriet...... 105 Fenofibrate Micronized...... 72 Fluphenazine HCl...... 54 Escitalopram Oxalate...... 43 Fenofibric Acid...... 72 Flurbiprofen...... 29 Esomeprazole Magnesium.... 82 Fentanyl...... 30 Flurbiprofen Sodium...... 102 Estarylla...... 88 Fentanyl Citrate...... 31 Flutamide...... 48 Estradiol...... 88 Ferriprox...... 80 Fluticasone Propionate...... 85, Estradiol Valerate...... 88 Fetzima...... 43 103 Estring...... 88 Fetzima Titration...... 43 Fluticasone-Salmeterol...... 106 Ethacrynic Acid...... 71 Finacea...... 76 Fluvastatin Sodium...... 72 Ethambutol HCl...... 48 Finasteride...... 83 Fluvoxamine Maleate...... 43 18 18Tracked 18 FML...... 102 Genotropin MiniQuick...... 86 Havrix...... 97 FML Forte...... 102 Gentak...... 33 Heparin Sodium...... 64 Fondaparinux Sodium...... 64 Gentamicin Sulfate...... 33 HepatAmine...... 78 Forteo...... 99 Gentamicin Sulfate-0.9% Hetlioz...... 107 Fosamprenavir Calcium...... 60 Sodium Chloride...... 33 Hiberix...... 97 Fosinopril Sodium...... 67 Genvoya...... 58 Humalog...... 63 Fosinopril Sodium-HCTZ...... 70 Geodon...... 55 Humalog Junior KwikPen...... 63 FreAmine HBC...... 78 Gianvi...... 88 Humalog KwikPen...... 63 Furosemide...... 71 Gilenya...... 75 Humalog Mix 50/50...... 63 Fuzeon...... 59 Gilotrif...... 50 Humalog Mix 50/50 KwikPen Fyavolv...... 88 Glassia...... 83 ...... 63 Fycompa...... 41 Glatiramer Acetate...... 75 Humalog Mix 75/25...... 63 G Glatopa...... 75 Humalog Mix 75/25 KwikPen ...... 63 Gabapentin...... 40 Gleostine...... 48 Humatrope...... 87 Galantamine Hydrobromide Glimepiride...... 61 ...... 42 Glipizide...... 61 Humira...... 94 Galantamine Hydrobromide ER Glipizide ER...... 61 Humira Pediatric Crohns Start ...... 94 ...... 42 Glipizide-Metformin HCl...... 61 Humira Pen...... 94 Gammagard...... 95 GlucaGen HypoKit...... 63 Humira Pen Crohns Disease Gammagard S/D Less IgA.....95 Glucagon Emergency...... 63 Starter...... 94 Gammaked...... 95 Glyxambi...... 61 Humira Pen Psoriasis Starter Gammaplex...... 95 Granisetron HCl...... 45 ...... 94 Gamunex-C...... 96 Granix...... 65, 66 Humulin 70/30...... 63 Gardasil 9...... 97 Griseofulvin Microsize...... 46 Humulin 70/30 KwikPen...... 63 Gatifloxacin...... 39 Griseofulvin Ultramicrosize....46 Humulin N...... 63 Gattex...... 81 Guanfacine HCl ER...... 74 Humulin N KwikPen...... 63 Gauze...... 100 Guanidine HCl...... 48 Humulin R...... 63 GaviLyte-C...... 82 H Humulin R U-500...... 64 GaviLyte-G...... 82 Haegarda...... 93 Humulin R U-500 KwikPen.....64 GaviLyte-N with Flavor Pack Hailey 24 Fe...... 88 Hydralazine HCl...... 73 ...... 82 Halobetasol Propionate...... 85 Hydrochlorothiazide...... 71 Gemfibrozil...... 72 Haloperidol...... 54 Hydrocodone-Acetaminophen Generlac...... 82 Haloperidol Decanoate...... 54 ...... 31 Gengraf...... 94 Haloperidol Lactate...... 54 Hydrocodone-Ibuprofen...... 31 Genotropin...... 86 Hydrocortisone...... 85, 99 19Tracked 19 19 Hydrocortisone Butyrate...... 85 Incruse Ellipta...... 104 Isosorbide Dinitrate ER...... 73 Hydrocortisone Valerate...... 85 Indapamide...... 71 Isosorbide Mononitrate...... 73 Hydrocortisone-Acetic Acid Indomethacin...... 29 Isosorbide Mononitrate ER.... 73 ...... 103 Infanrix...... 97 Isotretinoin...... 77 Hydromorphone HCl...... 31 Ingrezza...... 74 Itraconazole...... 46 Hydromorphone HCl ER...... 30 Inlyta...... 51 Ivermectin...... 52 Hydromorphone HCl Inrebic...... 49 Ixiaro...... 97 Preservative Free...... 31 Insulin Lispro...... 64 J Hydroxychloroquine Sulfate Insulin Syringes, Needles.... 100 Jadenu...... 80 ...... 52 Intelence...... 58 Jadenu Sprinkle...... 80 Hydroxyurea...... 49 Intralipid...... 78 Hydroxyzine HCl...... 60 Jakafi...... 51 Intron A...... 57 Jantoven...... 64 Hydroxyzine Pamoate...... 44 Introvale...... 89 Janumet...... 62 Hysingla ER...... 30 I Invega Sustenna...... 55 Janumet XR...... 62 Invega Trinza...... 55 Januvia...... 62 Ibandronate Sodium...... 99 Invirase...... 60 Jardiance...... 62 Ibrance...... 50 Invokamet...... 62 Jasmiel...... 89 Ibu...... 29 Invokamet XR...... 62 Jentadueto...... 62 Ibuprofen...... 29 Invokana...... 62 Jentadueto XR...... 62 Icatibant Acetate...... 93 Ionosol-MB in D5W...... 78 Jinteli...... 89 Iclusig...... 50 IPOL...... 97 Jublia...... 46 IDHIFA...... 50 Ipratropium Bromide...... 104 Juleber...... 89 Ilevro...... 102 Ipratropium-Albuterol...... 106 Juluca...... 58 Imatinib Mesylate...... 50 Irbesartan...... 67 Junel 1.5/30...... 89 Imbruvica...... 51 Irbesartan-Hydrochlorothiazide Junel 1/20...... 89 Imipenem-Cilastatin...... 36 ...... 70 Junel Fe 1.5/30...... 89 Imipramine HCl...... 44 Iressa...... 51 Junel Fe 1/20...... 89 Imipramine Pamoate...... 44 Isentress...... 58 Junel Fe 24...... 89 Imiquimod...... 76 Isentress HD...... 58 Juxtapid...... 72 Imiquimod Pump...... 77 Isibloom...... 89 K Imovax Rabies...... 97 Isolyte-P in D5W...... 78 Kaitlib Fe...... 89 Imvexxy Maintenance Pack... 89 Isolyte-S...... 78 Imvexxy Starter Pack...... 89 Kaletra...... 60 Isoniazid...... 48 Kalydeco...... 106 Incassia...... 91 Isosorbide Dinitrate...... 73 Kariva...... 89 Increlex...... 87 20 20Tracked 20 KCl in Dextrose-NaCl...... 78 LARIN 1.5/30...... 89 Levocetirizine Dihydrochloride KCl-Lactated Ringers-D5W.... 78 LARIN 1/20...... 89 ...... 103 Kelnor 1/35...... 89 LARIN Fe 1.5/30...... 89 Levofloxacin...... 39 Kelnor 1/50...... 89 LARIN Fe 1/20...... 89 Levofloxacin in D5W...... 39 Ketoconazole...... 46 Larissia...... 89 Levonest...... 89 Ketoprofen...... 30 Lastacaft...... 100 Levonorgestrel-Ethinyl Estradiol ...... 89 Ketorolac Tromethamine..... 102 Latanoprost...... 102 Levonorgestrel-Ethinyl Estradiol Kineret...... 94 Latuda...... 55 & Ethinyl Estradiol...... 89 Kinrix...... 97 Layolis Fe...... 89 Levonorgestrel-Ethinyl Estradiol Kionex...... 80 Leena...... 89 91-Day...... 89 Kisqali...... 49 Leflunomide...... 96 Levora 0.15/30...... 89 Kisqali Femara...... 49 Lenvima 10MG Daily Dose.... 51 Levorphanol Tartrate...... 30 Klor-Con...... 78 Lenvima 12MG Daily Dose.... 51 Levothyroxine Sodium...... 92 Klor-Con 10...... 78 Lenvima 14MG Daily Dose.... 51 Levoxyl...... 92 Klor-Con 8...... 78 Lenvima 18MG Daily Dose.... 51 Lexiva...... 60 Klor-Con M10...... 78 Lenvima 20MG Daily Dose.... 51 Lidocaine...... 32 Klor-Con M15...... 78 Lenvima 24MG Daily Dose.... 51 Lidocaine HCl...... 32 Klor-Con M20...... 78 Lenvima 4MG Daily Dose...... 51 Lidocaine Viscous...... 32 Klor-Con Sprinkle...... 78 Lenvima 8MG Daily Dose...... 51 Lidocaine-Prilocaine...... 32 Korlym...... 87 Lessina...... 89 Lindane...... 52 Kurvelo...... 89 Letrozole...... 50 Linezolid...... 34 Kuvan...... 83 Leucovorin Calcium...... 49 Linzess...... 81 L Leukeran...... 48 Liothyronine Sodium...... 92 Labetalol HCl...... 68 Leukine...... 66 Lisinopril...... 67 Lacrisert...... 100 Leuprolide Acetate...... 92 Lisinopril-Hydrochlorothiazide Lactulose...... 82 Levalbuterol HCl...... 104 ...... 70 Lamivudine...... 57, 59 Levemir...... 64 Lithium...... 61 Lamivudine-Zidovudine...... 59 Levemir FlexTouch...... 64 Lithium Carbonate...... 61 Lamotrigine...... 41 Levetiracetam...... 40 Lithium Carbonate ER...... 61 Lanoxin...... 70 Levetiracetam ER...... 40 Lithostat...... 84 Lansoprazole...... 82 Levo-T...... 92 Livalo...... 72 Lanthanum Carbonate...... 80 Levobunolol HCl...... 101 Lokelma...... 80 Lantus...... 64 Levocarnitine...... 78 Lonhala Magnair Refill Kit....104 Lantus SoloStar...... 64 Lonsurf...... 49 21Tracked 21 21 Loperamide HCl...... 81 Meclizine HCl...... 44 Methyldopa- Lopinavir-Ritonavir...... 60 Medroxyprogesterone Acetate Hydrochlorothiazide...... 70 Lorazepam...... 61 ...... 91 Methylphenidate HCl...... 74 Lorbrena...... 49 Mefloquine HCl...... 52 Methylphenidate HCl ER...... 74 Lorcet...... 31 Megestrol Acetate...... 91 Methylprednisolone...... 85, 86 Lorcet HD...... 31 Mekinist...... 51 Metoclopramide HCl...... 44 Lorcet Plus...... 31 Mektovi...... 51 Metolazone...... 72 Loryna...... 89 Melodetta 24 Fe...... 89 Metoprolol Succinate ER...... 68 Losartan Potassium...... 67 Meloxicam...... 30 Metoprolol Tartrate...... 68 Losartan Potassium-HCTZ.....70 Memantine HCl...... 42 Metoprolol-Hydrochlorothiazide ...... 70 Lotemax...... 102 Memantine HCl ER...... 42 Metronidazole...... 34 Lotemax SM...... 102 Memantine HCl Titration Pak ...... 42 Metronidazole in NaCl 0.79% Loteprednol Etabonate...... 102 Menactra...... 97 ...... 34 Lovastatin...... 72 Menest...... 89 Mexiletine HCl...... 67 Low-Ogestrel...... 89 Mentax...... 46 Mibelas 24 Fe...... 89 Loxapine Succinate...... 54 Menveo...... 97 Miconazole 3...... 46 Lumigan...... 102 Mercaptopurine...... 49 Microgestin 1.5/30...... 89 Lupaneta Pack...... 93 Meropenem...... 36 Microgestin 1/20...... 89 Lupron Depot...... 93 Mesalamine...... 98 Microgestin Fe 1.5/30...... 89 Lutera...... 89 Mesnex...... 52 Microgestin Fe 1/20...... 90 Lynparza...... 51 Metadate ER...... 74 Midodrine HCl...... 67 Lysodren...... 92 Metaproterenol Sulfate...... 104 Migergot...... 47 Lyza...... 91 Metformin HCl...... 62 Miglitol...... 62 M Metformin HCl ER...... 62 Miglustat...... 83 M-M-R II...... 97 Methadone HCl...... 30 Mili...... 90 Magnesium Sulfate...... 78 Methazolamide...... 71 Minitran...... 73 Malathion...... 52 Methenamine Hippurate...... 34 Minocycline HCl...... 40 Maprotiline HCl...... 43 Methimazole...... 93 Minoxidil...... 73 Marlissa...... 89 Methotrexate...... 94 Mirtazapine...... 43 Marplan...... 43 Methotrexate Sodium...... 94 Mirtazapine ODT...... 43 Matulane...... 48 Methoxsalen Rapid...... 77 Mirvaso...... 77 Matzim LA...... 69 Methscopolamine Bromide... 81 Misoprostol...... 82 Mavyret...... 57 Methyclothiazide...... 72 Modafinil...... 107 Mayzent...... 75 Methyldopa...... 67 Moexipril HCl...... 67 22 22Tracked 22 Molindone HCl...... 54 Necon 0.5/35...... 90 Nitrofurantoin Macrocrystal... 34 Mometasone Furoate.....86, 103 Nefazodone HCl...... 43 Nitrofurantoin Monohydrate Montelukast Sodium...... 103 Neomycin Sulfate...... 33 ...... 34 Morphine Sulfate...... 31, 32 Neomycin-Bacitracin-Polymyxin Nitroglycerin...... 73 Morphine Sulfate ER...... 30 ...... 100 Nitrostat...... 73 Moxifloxacin HCl...... 39 Neomycin-Polymyxin- Nora-BE...... 91 Bacitracin-Hydrocortisone Moxifloxacin HCl in NaCl...... 39 Norditropin FlexPro...... 87 ...... 100 Multaq...... 67 Norethindrone...... 92 Neomycin-Polymyxin- Norethindrone Acetate...... 91 Mupirocin...... 34 Dexamethasone...... 100 Norethindrone Acetate-Ethinyl Mupirocin Calcium...... 34 Neomycin-Polymyxin- Estradiol...... 90 Myalept...... 81 Gramicidin...... 100 Norethindrone Acetate-Ethinyl Mycamine...... 46 Neomycin-Polymyxin-HC.... 100, Estradiol-Fe...... 90 103 Mycophenolate Mofetil.... 94, 95 Norgestimate-Ethinyl Estradiol NephrAmine...... 78 Mycophenolate Sodium...... 95 ...... 90 Nerlynx...... 51 Myrbetriq...... 83 Norgestimate-Ethinyl Estradiol N Neulasta...... 66 Triphasic...... 90 Neupogen...... 66 Nabumetone...... 30 Norlyroc...... 92 Neupro...... 53 Nadolol...... 68 Normosol-M in D5W...... 78 Nevirapine...... 58 Nadolol-Bendroflumethiazide Normosol-R in D5W...... 78 ...... 70 Nevirapine ER...... 58 Normosol-R pH 7.4...... 79 Nafcillin Sodium...... 37 Nexavar...... 51 Northera...... 67 Naftifine HCl...... 46 Niacin ER...... 72 Nortrel 0.5/35...... 90 Naftin...... 46 Niacor...... 72 Nortrel 1/35...... 90 Naloxone HCl...... 33 Nicardipine HCl...... 69 Nortrel 7/7/7...... 90 Naltrexone HCl...... 32 Nicotrol...... 33 Nortriptyline HCl...... 44 Namzaric...... 74 Nicotrol NS...... 33 Norvir...... 60 Naproxen...... 30 Nifedipine ER...... 69 Noxafil...... 46 Naproxen DR...... 30 Nifedipine ER Osmotic Release Nubeqa...... 48 ...... 69 Naratriptan HCl...... 47 Nucala...... 106 Nikki...... 90 Narcan...... 33 Nucynta ER...... 30 Nilutamide...... 48 Natacyn...... 46 Nuedexta...... 74 Nimodipine...... 69 Nateglinide...... 62 Nuplazid...... 55 Ninlaro...... 49 Natpara...... 99 Nutrilipid...... 79 Nitro-Bid...... 73 Nebupent...... 52 Nutropin AQ NuSpin 10...... 87 Nitrofurantoin...... 34 23Tracked 23 23 Nutropin AQ NuSpin 20...... 87 Oseltamivir Phosphate...... 60 Penicillamine...... 84 Nutropin AQ NuSpin 5...... 87 Osphena...... 92 Penicillin G Potassium...... 37 Nyamyc...... 46 Otezla...... 96 Penicillin G Procaine...... 37 Nymalize...... 69 Oxacillin Sodium...... 37 Penicillin G Sodium...... 37 Nystatin...... 46 Oxandrolone...... 87 Penicillin V Potassium...... 37 Nystop...... 46 Oxcarbazepine...... 42 PENTAM 300...... 52 O Oxsoralen Ultra...... 77 Pentasa...... 98 Ocaliva...... 83 Oxybutynin Chloride...... 83 Pentoxifylline ER...... 70 Ocella...... 90 Oxybutynin Chloride ER...... 83 Perforomist...... 104 Octagam...... 96 Oxycodone HCl...... 32 Perindopril Erbumine...... 67 Octreotide Acetate...... 93 Oxycodone-Acetaminophen Permethrin...... 52 Odefsey...... 58 ...... 32 Perphenazine...... 44 Odomzo...... 51 Oxycodone-Aspirin...... 32 Perseris...... 55 Ofev...... 105 Oxycodone-Ibuprofen...... 32 Phenadoz...... 103 Ofloxacin...... 39 Ozempic...... 62 Phenelzine Sulfate...... 43 Ogestrel...... 90 P Phenobarbital...... 41 Olanzapine...... 55 Pacerone...... 67 Phenoxybenzamine HCl...... 67 Olanzapine ODT...... 55 Paliperidone ER...... 55 Phenytek...... 42 Olmesartan Medoxomil...... 67 Panretin...... 52 Phenytoin...... 42 Olmesartan Medoxomil-HCTZ Pantoprazole Sodium...... 82 Phenytoin Sodium Extended ...... 70 Panzyga...... 96 ...... 42 Olmesartan-Amlodipine-HCTZ Paricalcitol...... 99 Phoslyra...... 80 ...... 70 Paromomycin Sulfate...... 33 Phospholine Iodide...... 101 Olopatadine HCl...... 101 Paroxetine HCl...... 43 Picato...... 77 Omega-3-Acid Ethyl Esters.... 72 Paser...... 48 Pifeltro...... 58 Omeprazole...... 82 Paxil...... 43 Pilocarpine HCl...... 75, 101 Ondansetron HCl...... 45 Pazeo...... 101 Pimecrolimus...... 77 Ondansetron ODT...... 45 Pediarix...... 97 Pimozide...... 54 Opsumit...... 105 Pedvax HIB...... 97 Pimtrea...... 90 Orencia...... 95 PEG-3350-Electrolytes...... 82 Pindolol...... 68 Orencia ClickJect...... 95 PEG-3350-NaCl-Na Pioglitazone HCl...... 62 Orenitram...... 105 Bicarbonate-KCl...... 82 Pioglitazone HCl-Glimepiride Orfadin...... 83 Peganone...... 42 ...... 62 Orkambi...... 105 Pegasys...... 57 Pioglitazone HCl-Metformin HCl Orsythia...... 90 Pegasys ProClick...... 57 ...... 62 24 24Tracked 24 Piperacillin-Tazobactam...... 38 Prednisone...... 86 Promacta...... 66 Piqray...... 49, 50 Prednisone Intensol...... 86 Promethazine HCl...... 103 Pirmella 1/35...... 90 Pregabalin...... 74 Promethegan...... 103 Piroxicam...... 30 Premarin...... 90 Propafenone HCl...... 68 Plasma-Lyte 148...... 79 Premasol...... 79 Propafenone HCl ER...... 68 Plasma-Lyte A...... 79 Premphase...... 90 Proparacaine HCl...... 100 Plenamine...... 79 Prempro...... 90 Propranolol HCl...... 68 Podofilox...... 77 Prevalite...... 72 Propranolol HCl ER...... 68 Polymyxin B Sulfate...... 35 Previfem...... 90 Propranolol-HCTZ...... 70 Polymyxin B-Trimethoprim Prezcobix...... 60 Propylthiouracil...... 93 ...... 100 Prezista...... 60 ProQuad...... 97 Pomalyst...... 48 Priftin...... 48 Prosol...... 79 Portia-28...... 90 Prilosec...... 82 Protriptyline HCl...... 44 Potassium Chloride...... 79 Primaquine Phosphate...... 52 Pulmozyme...... 106 Potassium Chloride CR...... 79 Primidone...... 41 Purixan...... 49 Potassium Chloride ER...... 79 Privigen...... 96 Pyrazinamide...... 48 Potassium Chloride in Dextrose ProAir HFA...... 104 Pyridostigmine Bromide...... 48 ...... 79 ProAir RespiClick...... 104 Pyridostigmine Bromide ER Potassium Chloride in NaCl...79 Probenecid...... 47 ...... 48 Potassium Citrate ER...... 79 Probenecid-Colchicine...... 47 Q Praluent...... 72 Procalamine...... 79 Quadracel...... 97 Pramipexole Dihydrochloride Prochlorperazine...... 44 Quetiapine Fumarate...... 56 ...... 53 Prochlorperazine Maleate...... 44 Quetiapine Fumarate ER...... 55 Prasugrel HCl...... 66 Procrit...... 66 Quinapril HCl...... 67 Pravastatin Sodium...... 72 Procto-Med HC...... 99 Quinapril-Hydrochlorothiazide Praziquantel...... 52 ...... 71 Procto-Pak...... 99 Prazosin HCl...... 67 Quinidine Gluconate ER...... 68 Proctosol HC...... 99 Pred Mild...... 102 Quinidine Sulfate...... 68 Proctozone-HC...... 99 Pred-G...... 100 Quinine Sulfate...... 52 Progesterone Micronized...... 92 Pred-G S.O.P...... 100 R Proglycem...... 63 Prednicarbate...... 86 RabAvert...... 97 Prograf...... 95 Prednisolone...... 86 Rabeprazole Sodium...... 82 Prolastin-C...... 83 Prednisolone Acetate...... 102 Raloxifene HCl...... 92 Prolensa...... 102 Prednisolone Sodium Ramelteon...... 107 Phosphate...... 86, 102 Prolia...... 99 Ramipril...... 67 25Tracked 25 25 Ranitidine HCl...... 81 Rifater...... 48 Scopolamine...... 44 Ranolazine ER...... 71 Riluzole...... 74 Selegiline HCl...... 53 Rasagiline Mesylate...... 53 Rimantadine HCl...... 60 Selenium Sulfide...... 77 Rasuvo...... 95 Riomet...... 62 Selzentry...... 59 RAVICTI...... 83 Risedronate Sodium...... 99 Serevent Diskus...... 104 Rayaldee...... 99 Risperdal Consta...... 56 Serostim...... 81 Rebif...... 75 Risperidone...... 56 Sertraline HCl...... 43, 44 Rebif Rebidose...... 75 Risperidone ODT...... 56 Setlakin...... 90 Rebif Rebidose Titration Pack Ritonavir...... 60 Sevelamer Carbonate...... 80 ...... 75 Rivastigmine...... 42 Sharobel...... 92 Rebif Titration Pack...... 75 Rivastigmine Tartrate...... 42 Shingrix...... 98 Reclipsen...... 90 Rivelsa...... 90 Signifor...... 93 Recombivax HB...... 98 Rizatriptan Benzoate...... 47 Sildenafil Citrate...... 105 Rectiv...... 73 Rizatriptan Benzoate ODT..... 47 Silodosin...... 84 Regranex...... 77 Rocklatan...... 101 Silver Sulfadiazine...... 39 Relenza Diskhaler...... 60 Ropinirole HCl...... 53 Simbrinza...... 101 Relistor...... 81 Rosuvastatin Calcium...... 72 Simponi...... 95 Repaglinide...... 62 Rotarix...... 98 Simvastatin...... 72 Repaglinide-Metformin HCl... 62 RotaTeq...... 98 Sirolimus...... 95 Repatha...... 73 Roweepra...... 40 Sirturo...... 48 Repatha Pushtronex System Roweepra XR...... 40 Sodium Chloride...... 79, 80 ...... 73 Rubraca...... 50 Sodium Fluoride...... 80 Repatha SureClick...... 73 Ruconest...... 93 Sodium Lactate...... 80 Rescriptor...... 58 Rydapt...... 51 Sodium Phenylbutyrate...... 83 Restasis...... 100 Rytary...... 53 Sodium Polystyrene Sulfonate Retacrit...... 66 S ...... 80 Revlimid...... 49 Saizen...... 87 Sofosbuvir-Velpatasvir...... 57 Rexulti...... 56 Saizenprep...... 87 Solifenacin Succinate...... 83 Reyataz...... 60 Sancuso...... 45 Soliqua...... 62 Rhopressa...... 100 Sandimmune...... 95 Soltamox...... 49 Ribasphere...... 57 Santyl...... 77 Somatuline Depot...... 93 Ribavirin...... 57 Saphris...... 56 Somavert...... 93 Ridaura...... 96 Savella...... 74 Sotalol HCl...... 68 Rifabutin...... 48 Savella Titration Pack...... 74 Sovaldi...... 57 Rifampin...... 48 26 26Tracked 26 Spiriva HandiHaler...... 104 Syeda...... 90 Tegsedi...... 83 Spiriva Respimat...... 104 Sylatron...... 57 Telmisartan...... 67 Spironolactone...... 71 Symbicort...... 106 Telmisartan-Amlodipine...... 71 Spironolactone-HCTZ...... 71 Symfi...... 58 Telmisartan-HCTZ...... 71 Sprintec 28...... 90 Symfi Lo...... 58 Temazepam...... 107 Spritam...... 40 SymlinPen 120...... 62 Tenivac...... 98 Sprycel...... 51 SymlinPen 60...... 62 Tenofovir Disoproxil Fumarate SPS...... 80 Sympazan...... 41 ...... 59 Sronyx...... 90 Symtuza...... 60 Terazosin HCl...... 84 SSD...... 39 Synarel...... 93 Terbinafine HCl...... 46 Stavudine...... 59 Synjardy...... 62 Terconazole...... 46 Stelara...... 77 Synjardy XR...... 63 Testosterone...... 87 Stiolto Respimat...... 106 Synribo...... 50 Testosterone Cypionate...... 87 Stivarga...... 51 Synthroid...... 92 Testosterone Enanthate...... 87 Streptomycin Sulfate...... 33 T Tetrabenazine...... 74 Stribild...... 58 Tabloid...... 49 Tetracycline HCl...... 40 Suboxone...... 33 Tacrolimus...... 77, 95 Thalomid...... 49 Sucraid...... 83 Tadalafil...... 105 Theophylline...... 105 Sucralfate...... 82 Tafinlar...... 51 Theophylline ER...... 105 Sulfacetamide Sodium...... 39 Tagrisso...... 51 Thioridazine HCl...... 54 Sulfacetamide-Prednisolone Talzenna...... 50 Thiothixene...... 54 ...... 100 Tamoxifen Citrate...... 49 Tiagabine HCl...... 41 Sulfadiazine...... 39 Tamsulosin HCl...... 84 Tibsovo...... 51 Sulfamethoxazole- Targretin...... 52 Tigecycline...... 35 Trimethoprim...... 39 Tarina 24 Fe...... 90 Timolol Maleate...... 47, 102 Sulfamylon...... 35 Tarina Fe 1/20...... 90 Timolol Maleate Ophthalmic Sulfasalazine...... 99 Gel Forming...... 102 Tasigna...... 51 Sulindac...... 30 Tinidazole...... 35 Tazarotene...... 77 Sumatriptan...... 47 Tivicay...... 58 Tazicef...... 36 Sumatriptan Succinate...... 47 Tizanidine HCl...... 106 Tazorac...... 77 Sumatriptan Succinate Refill TOBI Podhaler...... 105 Taztia XT...... 69 ...... 47 TobraDex...... 100 TDVAX...... 98 Suprax...... 36 TobraDex ST...... 100 Tecfidera...... 75 Suprep Bowel Prep Kit...... 82 Tobramycin...... 33, 105 Tecfidera Starter Pack...... 75 Sutent...... 51 Tobramycin Sulfate...... 33 27Tracked 27 27 Tobramycin-Dexamethasone Tri-Lo-Sprintec...... 91 Ursodiol...... 81 ...... 101 Tri-Mili...... 91 V Tobrex...... 33 Tri-Previfem...... 91 Valacyclovir HCl...... 58 Tolak...... 77 Tri-Sprintec...... 91 Valchlor...... 48 Tolcapone...... 53 Tri-VyLibra...... 91 Valganciclovir HCl...... 57 Topiramate...... 41 Tri-VyLibra Lo...... 91 Valproic Acid...... 41 Toremifene Citrate...... 49 Triamcinolone Acetonide...... 75, Valsartan...... 67 Torsemide...... 71 86 Valsartan-Hydrochlorothiazide Toujeo Max SoloStar...... 64 Triamterene...... 71 ...... 71 Toujeo SoloStar...... 64 Triamterene-HCTZ...... 71 Vancomycin HCl...... 35 TPN Electrolytes...... 80 Triderm...... 86 Vandazole...... 35 Tracleer...... 105 Trientine HCl...... 80 VAQTA...... 98 Tradjenta...... 63 Trifluoperazine HCl...... 54 Varivax...... 98 Tramadol HCl...... 32 Trifluridine...... 58 Varizig...... 96 Tramadol HCl ER...... 30 Trihexyphenidyl HCl...... 53 Vascepa...... 73 Tramadol-Acetaminophen..... 32 TriLyte...... 82 Velivet...... 91 Trandolapril...... 67 Trimethoprim...... 35 Velphoro...... 80 Tranexamic Acid...... 66 Trimipramine Maleate...... 44 Veltassa...... 80 Transderm-Scop...... 45 Trintellix...... 44 Vemlidy...... 57 Tranylcypromine Sulfate...... 43 Triumeq...... 58 Venclexta...... 51 Travasol...... 80 Trivora...... 91 Venclexta Starting Pack...... 51 Trazodone HCl...... 44 TrophAmine...... 80 Venlafaxine HCl...... 44 Trecator...... 48 Trulicity...... 63 Venlafaxine HCl ER...... 44 Trelegy Ellipta...... 106 Trumenba...... 98 Ventavis...... 105 Trelstar Mixject...... 93 Truvada...... 59 Verapamil HCl...... 69 Tresiba...... 64 Turalio...... 51 Verapamil HCl ER...... 69 Tresiba FlexTouch...... 64 Twinrix...... 98 Versacloz...... 57 Tretinoin...... 52, 77 Tybost...... 58 Verzenio...... 50 Tretinoin Microsphere...... 77 Tykerb...... 51 Vibramycin...... 40 Trexall...... 95 Tymlos...... 99 Victoza...... 63 Trezix...... 32 Typhim Vi...... 98 Videx...... 59 Tri-Estarylla...... 91 U Videx EC...... 59 Tri-Legest Fe...... 91 Udenyca...... 66 Vienva...... 91 Tri-Lo-Estarylla...... 91 Unithroid...... 92 Vigabatrin...... 41 28 28Tracked 28 Vigadrone...... 41 Xarelto...... 65 Zelapar...... 53 Viibryd...... 44 Xarelto Starter Pack...... 65 Zelboraf...... 52 Viibryd Starter Pack...... 44 Xatmep...... 95 Zemaira...... 83 Vimpat...... 42 Xeljanz...... 95 Zenpep...... 83 Viracept...... 60 Xeljanz XR...... 95 Zerbaxa...... 36 Viread...... 59 Xgeva...... 99 Zidovudine...... 59 Vitrakvi...... 51 Xifaxan...... 81 Zileuton ER...... 104 Vivitrol...... 32 Xiidra...... 101 Zioptan...... 102 Vizimpro...... 51 Xofluza...... 60 Ziprasidone HCl...... 56 Voriconazole...... 46 Xolair...... 96 Zirgan...... 57 Vosevi...... 57 Xospata...... 51 Zolinza...... 50 Votrient...... 51 Xpovio...... 49 Zolpidem Tartrate...... 107 VP-PNV-DHA...... 80 Xtampza ER...... 31 Zonisamide...... 40 Vraylar...... 56 Xtandi...... 48 Zorbtive...... 81 Vyfemla...... 91 Xulane...... 91 Zortress...... 95 VyLibra...... 91 Xyrem...... 107 Zostavax...... 98 Vyndaqel...... 71 Y Zovia 1/35E...... 91 Vyvanse...... 73 YF-Vax...... 98 Zyclara Pump...... 77 Vyzulta...... 102 Yuvafem...... 91 Zydelig...... 52 W Z Zyflo...... 104 Warfarin Sodium...... 65 Zafirlukast...... 103 Zykadia...... 52 Wixela Inhub...... 106 Zaleplon...... 107 Zyprexa Relprevv...... 56 WYMZYA Fe...... 91 Zarah...... 91 X Zarxio...... 66 Xalkori...... 51 Zejula...... 50 tRACK 29 29 Covered drugs by medical condition 128 The list below has information about the drugs covered by this plan. Find your medical condition to see what drugs are covered. If you have trouble finding your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-28. The first column lists the drug name, which may include the dosage form and strength. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column lists the drug tier or coverage level. The third column lists any rules or limits for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 108-134. tRACK

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

C1 Eto dola A1 c ER Analgesics Etodolac ER (Oral B1 Analgesics Tablet Extended 4

C1 Buta lbital - Acet ami Release 24 Hour) nop hen- Caff C1 eine Eto Butalbital- dola c Etodolac (Oral Acetaminophen- 3 QL 3 Capsule)

Caffeine (Oral Tablet) C1 Eto C1 dola c Buta lbital - Aspi rin- Caff eine Etodolac (Oral Tablet Butalbital-Aspirin- 3 Immediate Release)

Caffeine (Oral 3 QL C1 Flec Capsule) tor Flector (Transdermal

B1 4 PA; QL Nonsteroidal Anti-inflammatory Drugs Patch) C1 C1 Flur bipr Cele ofen coxi b Celecoxib (Oral Flurbiprofen (Oral 3 QL 2 Capsule) Tablet) C1 C1 Ibu Dicl ofen ac Epol ami ne Diclofenac Epolamine Ibu (600MG Oral 4 PA; QL (Transdermal Patch) Tablet, 800MG Oral 2

Dicl ofen ac Pota ssiu m Tablet)

C1 Diclofenac Potassium Ibup rofe 2 n (Oral Tablet) Ibuprofen (Oral C1 2 Dicl ofen ac Sodi um ER Suspension)

C1 Diclofenac Sodium ER Ibup rofe n (Oral Tablet Extended 2 Ibuprofen (400MG Release 24 Hour) Oral Tablet, 600MG

C1 Dicl 2 ofen ac Sodi um Diclofenac Sodium Oral Tablet, 800MG Oral Tablet)

(Oral Tablet Delayed 2 Indo met haci Release) n Indomethacin (Oral

C1 Dicl ofen ac Sodi um Diclofenac Sodium Capsule Immediate 2 3 (1% Transdermal Gel) Release)

C1 Diflu nisal Diflunisal (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 30 tRACK 30 Last updated October 1, 2019 229 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Ket Hyd opr rom ofen orph one HCl ER Ketoprofen (Oral Hydromorphone HCl 7D; MME; Capsule Immediate 3 ER (Oral Tablet ER 24 4 Release) Hour Abuse-Deterrent) DL; QL

C1 C1 Mel Hysi oxic ngla am Meloxicam (Oral ER Hysingla ER (Oral 1 7D; MME; Tablet) Tablet ER 24 Hour 3 C1 Nab ume tone DL; QL Nabumetone (Oral Abuse-Deterrent)

C1 Lev orph 2 anol

Tartr Tablet) ate 7D; MME; C1 Levorphanol Tartrate Nap roxe n DR 5 Naproxen DR (Oral (Oral Tablet) DL; QL

C1 Met had one Tablet Delayed HCl Methadone HCl (Oral 7D; MME; 2 3 Release) (Generic EC- Solution) DL; QL

Met had one Naprosyn) HCl

Nap roxe n Methadone HCl (Oral 7D; MME; Naproxen (Oral 3 4 Tablet) DL; QL

Mor phin Suspension) e Sulf ate C1 ER Nap roxe n Morphine Sulfate ER Naproxen (Oral Tablet 2 (100MG Oral Tablet Immediate Release)

C1 Piro xica Extended Release, m Piroxicam (Oral 3 15MG Oral Tablet Capsule) 7D; MME; C1 Extended Release, Suli nda c 3 Sulindac (Oral Tablet) 2 30MG Oral Tablet DL; QL B1 Opioid Analgesics, Long-acting Extended Release,

Bup reno rphi ne 60MG Oral Tablet Buprenorphine Extended Release) (Transdermal Patch 4 7D; DL; QL (Generic MS Contin)

C1 Mor Weekly) phin e Sulf C1 ate ER Emb eda Morphine Sulfate ER Embeda (Oral 7D; MME; (200MG Oral Tablet 7D; MME; Capsule Extended 3 4 DL; QL Extended Release) DL; QL Release) C1 (Generic MS Contin) Fent anyl C1 Nuc ynta Fentanyl (100MCG/HR ER Nucynta ER (Oral 7D; MME; Transdermal Patch 72 Tablet Extended 3 Hour, 12MCG/HR DL; QL Release 12 Hour)

C1 Tra Transdermal Patch 72 mad ol HCl Hour, 25MCG/HR ER Tramadol HCl ER 7D; MME; (Biphasic) (Oral Tablet 7D; MME; Transdermal Patch 72 4 3 Hour, 50MCG/HR DL; QL Extended Release 24 DL; QL Hour)

Transdermal Patch 72 C1 Tra mad ol HCl ER Hour, 75MCG/HR Tramadol HCl ER (Oral 7D; MME; Transdermal Patch 72 Tablet Extended 3 Hour) Release 24 Hour) DL; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 31 31 330 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Xta Hyd mpz roco a don ER e- Ibup rofe Xtampza ER (Oral n Hydrocodone- 7D; MME; 7D; MME; Capsule ER 12 Hour 3 Ibuprofen (7.5-200MG 3 DL; QL DL; QL Abuse-Deterrent) Oral Tablet) C1 Hyd rom orph one B1 Opioid Analgesics, Short-acting HCl Hydromorphone HCl

C1 Acet ami nop hen- Cod eine Acetaminophen- (2MG/ML Injection 4 DL 7D; MME; Solution)

C1 Codeine (120-12MG/ 2 Hyd rom orph one 5ML Oral Solution) DL; QL HCl Hydromorphone HCl 7D; MME;

C1 Acet 4 ami nop hen- Cod eine (1MG/ML Oral Liquid) DL; QL Acetaminophen- C1 Hyd rom orph one HCl Hydromorphone HCl Codeine (300-15MG 7D; MME; Oral Tablet, 300-30MG 2 (2MG Oral Tablet DL; QL Oral Tablet, 300-60MG Immediate Release, 7D; MME; Oral Tablet) 4MG Oral Tablet 2

But orph DL; QL anol

Tartr ate Butorphanol Tartrate 7D; MME; Immediate Release, 3 (Nasal Solution) DL; QL 8MG Oral Tablet

Cod eine Immediate Release) Sulf ate C1

Hyd rom orph 7D; MME; one Codeine Sulfate (Oral HCl Pres erva tive 3 Free Hydromorphone HCl Tablet) DL; QL

C1 Dur amo Preservative Free rph Duramorph (Injection 4 DL (10MG/ML Injection 4 DL Solution) Solution, 50MG/5ML C1 End ocet Endocet (10-325MG Injection Solution) C1

Lorc et Oral Tablet, 5-325MG HD Lorcet HD (Oral 7D; MME; 7D; MME; 3 Oral Tablet, 3 Tablet) DL; QL DL; QL C1 Lorc 7.5-325MG Oral et 7D; MME; Tablet) Lorcet (Oral Tablet) 3

C1 Fent anyl Citra DL; QL te

C1 Lorc et Fentanyl Citrate Plus Lorcet Plus (Oral 7D; MME; (Buccal Lozenge On A 5 PA; DL; QL 3 Tablet) DL; QL Handle) C1 Mor phin C1 e Sulf Hyd ate roco don e- Acet ami nop 7D; MME; hen Morphine Sulfate (Oral Hydrocodone- 3 7D; MME; Solution) DL; QL Acetaminophen C1 Mor phin e Sulf 3 ate (7.5-325MG/15ML DL; QL Morphine Sulfate Oral Solution) (8MG/ML Intravenous

C1 Hyd roco 4 DL don e- Acet ami nop hen Hydrocodone- Solution Prefilled Syringe)

Acetaminophen C1 Mor phin e Sulf (10-325MG Oral 7D; MME; ate Morphine Sulfate 3 Tablet, 5-325MG Oral DL; QL (10MG/ML Injection 4 DL Tablet, 7.5-325MG Solution) Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 32 tRACK 32 Last updated October 1, 2019 431 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Mor Lido phin cain e e Sulf ate Morphine Sulfate Lidocaine (5% External 7D; MME; 4 QL (Oral Tablet 3 Ointment) C1 Lido cain DL; QL e Immediate Release) Lidocaine (5% External

C1 Oxy cod one 4 PA; QL HCl Oxycodone HCl Patch) C1 Lido cain e 7D; MME; HCl (100MG/5ML Oral 4 Lidocaine HCl (4% DL; QL 2 Concentrate) External Solution)

C1 C1 Oxy cod Lido one cain HCl e Oxycodone HCl (5MG/ 7D; MME; HCl Lidocaine HCl 3 2 5ML Oral Solution) DL; QL (External Gel)

C1 C1 Lido Oxy cain cod one e Visc HCl ous Oxycodone HCl Lidocaine Viscous (2% (10MG Oral Tablet Mouth/Throat 2 Immediate Release, Solution)

Lido cain e- Prilo cain 15MG Oral Tablet e Lidocaine-Prilocaine 3 Immediate Release, 7D; MME; (External Cream) 20MG Oral Tablet 2 A1 Anti-Addiction/Substance Abuse Treatment Immediate Release, DL; QL Agents 30MG Oral Tablet B1 Alcohol Deterrents/Anti-craving

Immediate Release, C1 Aca mpr osat e Calc 5MG Oral Tablet ium Acamprosate Calcium Immediate Release) (Oral Tablet Delayed 4

Oxy cod one- Acet ami nop hen Release) Oxycodone- C1 Disu lfira 7D; MME; m Acetaminophen (Oral 3 Disulfiram (Oral Tablet) 3

C1 Nalt rexo DL; QL ne Tablet) HCl C1 Naltrexone HCl (Oral

Oxy cod one- Aspi rin 3 Oxycodone-Aspirin 7D; MME; Tablet) C1 Vivit 3 rol (Oral Tablet) DL; QL Vivitrol C1 Oxy cod one- Ibup rofe n Oxycodone-Ibuprofen 7D; MME; (Intramuscular 3 5 (Oral Tablet) DL; QL Suspension

C1 Tra mad ol HCl Tramadol HCl (Oral Reconstituted)

7D; MME; B1 Tablet Immediate 2 Opioid Dependence Treatments

Bup DL; QL reno rphi ne Release) HCl C1 Buprenorphine HCl Tra mad ol- Acet ami nop 2 QL hen Tramadol- (Tablet Sublingual)

C1 7D; MME; Bup reno rphi ne HCl- Nalo Acetaminophen (Oral 2 xon e HCl Buprenorphine HCl- Tablet) DL; QL C1 Naloxone HCl 4 QL Trez ix 7D; MME; (Sublingual Film)

C1 Bup Trezix (Oral Capsule) 4 reno rphi ne HCl- Nalo xon e DL; QL HCl Buprenorphine HCl- A1 Anesthetics Naloxone HCl (Tablet 2 QL B1 Local Anesthetics Sublingual)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 33 33 532 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Sub Gen oxo tak ne Suboxone (Sublingual Gentak (Ophthalmic 4 QL 2 Film) Ointment) C1 Gen tami cin B1 Sulf ate- 0.9 % Sodi um Chlo Opioid Reversal Agents ride Gentamicin

C1 Nalo xon e HCl Naloxone HCl (0.4MG/ Sulfate-0.9% Sodium 2 4 ML Injection Solution) Chloride (Intravenous

C1 Nalo xon e HCl Solution)

C1 Gen tami Naloxone HCl cin Sulf ate Gentamicin Sulfate (Injection Solution 2 2 (External Cream) Cartridge) C1 Gen tami C1 cin Sulf Nalo ate xon e HCl Gentamicin Sulfate Naloxone HCl 2 (External Ointment) (Injection Solution 2 C1 Gen tami cin Sulf Prefilled Syringe) ate Gentamicin Sulfate C1 Nar can Narcan (Nasal Liquid) 3 (40MG/ML Injection 4

B1 Solution)

Gen tami Smoking Cessation Agents cin Sulf ate C1 Bup ropi on HCl SR Gentamicin Sulfate 2 Bupropion HCl SR (Ophthalmic Solution)

C1 Neo myci (150MG Oral Tablet n Sulf ate Neomycin Sulfate (Oral Extended Release 12 2 2 Tablet) Hour Smoking- C1 Paro mo myci n Sulf Deterrent) ate Paromomycin Sulfate

C1 Cha 4 ntix Con tinui ng Mon th (Oral Capsule) Pak Chantix Continuing C1 Stre pto myci n Sulf ate Month Pak (Oral 3 Streptomycin Sulfate Tablet) (Intramuscular

C1 5 Cha ntix Solution Chantix (Oral Tablet) 3

C1 Cha ntix Reconstituted) Start ing Mon C1 th Pak Tob ram Chantix Starting ycin Tobramycin 2 Month Pak (Oral 3 (Ophthalmic Solution)

C1 Tob ram ycin Tablet) Sulf ate

C1 Nico trol Tobramycin Sulfate Nicotrol (Inhalation 4 (10MG/ML Injection Inhaler) 4

C1 Solution, 80MG/2ML Nico trol NS Nicotrol NS (Nasal Injection Solution)

C1 Tob 4 rex Solution) Tobrex (Ophthalmic

A1 4 Antibacterials Ointment) B1 Aminoglycosides B1 Antibacterials, Other

C1 C1 Ami Baci kaci traci n n Sulf ate Amikacin Sulfate Bacitracin (Ophthalmic 2 (500MG/2ML Injection 4 Ointment) Solution)

Bold type = Brand name drug Plain type = Generic drug 34 tRACK 34 Last updated October 1, 2019 633 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Bact Line roba zoli n Bactroban (2% Nasal d Linezolid (Oral 4 PA Ointment) Suspension 5

C1 Clin dam ycin HCl Reconstituted) Clindamycin HCl (Oral C1 Line zoli 2 d Capsule) Linezolid (Oral Tablet) 4 QL C1 C1 Met Clin hen dam ami ycin ne Pal Hip mita pura te te HCl Methenamine Clindamycin Palmitate 4 HCl (Oral Solution 2 Hippurate (Oral Tablet) C1 Metr onid azol Reconstituted) e Metronidazole (0.75% C1 Clin dam ycin Pho 4 sph ate in D5 W Clindamycin External Cream) C1

Metr onid azol Phosphate in D5W 4 e Metronidazole (0.75% (Intravenous Solution) External Gel, 1% 4 C1

Clin dam ycin Pho sph ate Clindamycin External Gel) C1

Metr onid azol Phosphate (300MG/ e Metronidazole (0.75% 4 2ML Injection Solution, External Lotion)

C1 4 Metr onid azol e in NaC l 600MG/4ML Injection 0.79 % Metronidazole in NaCl Solution, 900MG/6ML 0.79% (Intravenous 4 Injection Solution)

Clin Solution) dam ycin Pho C1 sph ate Metr onid azol Clindamycin e Metronidazole (250MG Phosphate (Vaginal 3 Oral Tablet, 500MG 2 Cream)

C1 Coli Oral Tablet) stim etha te C1 Sodi Metr um onid azol Colistimethate Sodium e Metronidazole (0.75% (CBA) (Injection 3 5 Vaginal Gel) C1

Mup iroci n Solution Calc ium Mupirocin Calcium Reconstituted) 4 C1 Dalv anc e (External Cream)

C1 Mup iroci Dalvance n Mupirocin (External (Intravenous Solution 5 PA 2 Ointment)

C1 Nitr ofur Reconstituted) anto in Mac C1 rocr ystal Dap tom ycin Nitrofurantoin Daptomycin (350MG Macrocrystal (100MG Intravenous Solution 5 Oral Capsule, 50MG 3 Reconstituted)

C1 Oral Capsule) (Generic Dap tom ycin Daptomycin (500MG Macrodantin)

C1 Nitr ofur anto in Mon ohy drat Intravenous Solution 5 e Nitrofurantoin Reconstituted)

C1 Monohydrate (Generic 3 Line zoli d Linezolid (Intravenous Macrobid)

Nitr 4 ofur anto Solution) in Nitrofurantoin (Oral 4 Suspension)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 35 35 734 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Poly Cefa myxi drox n B il Sulf ate Polymyxin B Sulfate Cefadroxil (Oral (Injection Solution 4 Suspension 2 Reconstituted) Reconstituted)

C1 C1 Sulf Cefa amyl zolin on Sodi Sulfamylon (External um Cefazolin Sodium 4 Cream) (10GM Injection

C1 Tige cycli ne Tigecycline Solution Reconstituted, 1GM (Intravenous Solution 5 4 Reconstituted) Injection Solution

C1 Tini daz ole Reconstituted, 500MG Tinidazole (Oral 4 Injection Solution Tablet)

Trim etho Reconstituted) prim C1 Cef Trimethoprim (Oral dinir 2 Cefdinir (Oral Capsule) 3

C1 Cef Tablet) dinir

Van com ycin HCl Cefdinir (Oral Vancomycin HCl Suspension 3 (10GM Intravenous Reconstituted)

Cef epi Solution me HCl Reconstituted, 1GM Cefepime HCl Intravenous Solution (Injection Solution 4 4 Reconstituted) Reconstituted, 500MG C1 Cefi xim e Cefixime (Oral Intravenous Solution 3 Reconstituted, 750MG Capsule) C1 Cefi xim Intravenous Solution e Cefixime (Oral Reconstituted) Suspension 4 C1 Van com ycin HCl Vancomycin HCl Reconstituted) C1 Cef otet an Diso diu (250MG Intravenous m Cefotetan Disodium 4 Solution (Injection Solution 4 Reconstituted) Reconstituted) C1 C1 Cef oxiti Van n com Sodi ycin um HCl Vancomycin HCl (Oral Cefoxitin Sodium 4 QL Capsule) (Injection Solution 4

C1 Van daz ole Reconstituted) Vandazole (Vaginal C1 Cef oxiti n Sodi 3 um Gel) Cefoxitin Sodium B1 Beta-lactam, Cephalosporins (Intravenous Solution 4

C1 Cefa clor Reconstituted)

C1 Cef pod oxi Cefaclor (Oral me Prox 2 etil Capsule) Cefpodoxime Proxetil

C1 Cefa drox il (Oral Suspension 4 Cefadroxil (Oral 2 Reconstituted) Capsule)

Bold type = Brand name drug Plain type = Generic drug 36 tRACK 36 Last updated October 1, 2019 835 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Cef Sup pod rax oxi me Prox etil Cefpodoxime Proxetil Suprax (Oral Capsule) 3

C1 Sup 4 rax (Oral Tablet)

C1 Suprax (500MG/5ML Cef proz il Cefprozil (Oral Oral Suspension 3 Suspension 3 Reconstituted)

C1 Sup Reconstituted) rax C1 Cef Suprax (Oral Tablet proz il 3 Cefprozil (Oral Tablet) 3 Chewable) C1

Ceft C1 azidi me Tazi Ceftazidime (Injection cef Tazicef (Injection Solution 4 Solution 4 Reconstituted) Reconstituted) C1

Ceft C1 riax one Zer Sodi bax um Ceftriaxone Sodium a Zerbaxa (Intravenous (1GM Injection Solution 5 PA Solution Reconstituted)

Reconstituted, 250MG B1 Beta-lactam, Other C1 Injection Solution Aztr eon 4 am Reconstituted, 2GM Aztreonam (1GM Injection Solution Injection Solution 4 Reconstituted, 500MG Reconstituted) C1 Erta pen em Sodi um Injection Solution Ertapenem Sodium Reconstituted) (Injection Solution 4 C1

Ceft riax one Sodi um Ceftriaxone Sodium Reconstituted) C1 Imip ene m- Cila stati (10GM Intravenous n 4 Imipenem-Cilastatin Solution (Intravenous Solution 4 Reconstituted) Reconstituted) C1 C1 Cef urox Mer ime ope Axet nem il Cefuroxime Axetil (Oral 2 Meropenem Tablet) (Intravenous Solution 4 C1 Cef urox ime Sodi um Cefuroxime Sodium Reconstituted)

B1 (Injection Solution 4 Beta-lactam, Penicillins

C1 Am oxici Reconstituted) llin C1 Amoxicillin (Oral Cef urox ime Sodi um 1 Cefuroxime Sodium Capsule) C1 Am oxici (Intravenous Solution 4 llin Amoxicillin (Oral Reconstituted) C1 Suspension 1 Cep hale xin Cephalexin (Oral Reconstituted)

Am 2 oxici Capsule) llin C1 Amoxicillin (Oral Cep hale xin 1 Cephalexin (Oral Tablet) C1 Am oxici Suspension 2 llin Amoxicillin (Oral 1 Reconstituted) Tablet Chewable)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 37 37 936 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Am Bicill oxici in C- llin- R Pota ssiu m Clav ulan ate ER Amoxicillin-Potassium Bicillin C-R

Clavulanate ER (Oral 4 (Intramuscular 4 Tablet Extended Suspension)

C1 Bicill in L- Release 12 Hour) A

C1 Am Bicillin L-A oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium (Intramuscular 4 Clavulanate (Oral 2 Suspension) C1 Dicl oxa cillin Suspension Sodi um Dicloxacillin Sodium Reconstituted) 2 C1 Am oxici llin- (Oral Capsule) Pota ssiu m C1 Clav ulan Nafc ate illin Sodi Amoxicillin-Potassium um Clavulanate (Oral Nafcillin Sodium (1GM 2 Tablet Immediate Injection Solution Release) Reconstituted, 2GM 4

C1 Am oxici llin- Injection Solution Pota ssiu m Clav ulan ate Amoxicillin-Potassium Reconstituted)

Nafc illin Sodi Clavulanate (Oral 2 um Tablet Chewable) Nafcillin Sodium

Am picill in (10GM Intravenous Ampicillin (Oral 4 2 Solution Capsule)

Am Reconstituted) picill in Sodi C1 um Oxa cillin

Sodi Ampicillin Sodium um Oxacillin Sodium (125MG Injection (Injection Solution 4 Solution 4 Reconstituted) C1 Peni cillin G Reconstituted, 1GM Pota ssiu m Injection Solution Penicillin G Potassium (20000000UNIT Reconstituted) 4 C1 Am picill in Injection Solution Sodi um Ampicillin Sodium Reconstituted)

C1 Peni cillin G (10GM Intravenous Proc 4 aine Solution Penicillin G Procaine Reconstituted) (Intramuscular 4

C1 Am picill in- Suspension) Sulb acta m C1 Sodi um Peni cillin G Ampicillin-Sulbactam Sodi um Sodium (Injection Penicillin G Sodium 4 Solution (Injection Solution 5 Reconstituted)

C1 Reconstituted) Peni cillin V C1 Pota ssiu Bact m ocill in Dext rose Bactocill in Dextrose Penicillin V Potassium 4 (Oral Solution 2 (Intravenous Solution)

Bicill in C- Reconstituted) R 900/ 300 C1 Peni cillin V Pota Bicillin C-R 900/300 ssiu m Penicillin V Potassium 2 (Intramuscular 4 (Oral Tablet) Suspension)

Bold type = Brand name drug Plain type = Generic drug 38 tRACK 38 Last updated October 1, 2019 1037 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Pipe Eryt racill hro in- myci Taz n oba Bas cta e m Piperacillin- Erythromycin Base Tazobactam (Oral Tablet Immediate 4 4 (Intravenous Solution Release)

C1 Eryt hro myci n Bas Reconstituted) e Erythromycin Base

B1 Macrolides (Oral Tablet Delayed 4

C1 Aza site Release) Azasite (Ophthalmic C1 Eryt hro myci n Ethy 4 lsuc cina Solution) te Erythromycin

C1 Azit hro myci n Ethylsuccinate Azithromycin (Intravenous Solution 4 (200MG/5ML Oral 4 Reconstituted) Suspension

Azit hro myci n Reconstituted)

C1 Eryt hro Azithromycin (Oral myci n Ethy lsuc cina te Suspension 1 Erythromycin Reconstituted) Ethylsuccinate (Oral 4

Azit hro myci n Tablet)

Eryt hro Azithromycin (Oral myci 1 n Erythromycin Tablet) 2 C1 Clari thro myci n (Ophthalmic Ointment) ER

Clarithromycin ER B1 Quinolones (Oral Tablet Extended 3 C1 Besi vanc Release 24 Hour) e Besivance

C1 Clari thro myci n (Ophthalmic 4 Clarithromycin (Oral Suspension 4 Suspension) C1 Cilo Reconstituted) xan Ciloxan (Ophthalmic C1 Clari thro myci n 4 Clarithromycin (Oral Ointment)

C1 Cipr oflo xaci n Tablet Immediate 3 HCl Ciprofloxacin HCl 2 Release) (Ophthalmic Solution) C1

Dific C1 id Cipr oflo xaci n Dificid (Oral Tablet) 5 HCl Ciprofloxacin HCl C1 E.E. S. Gra nule s E.E.S. Granules (Oral (100MG Oral Tablet 3

Suspension 4 Immediate Release) C1 Cipr oflo xaci n Reconstituted) HCl Ciprofloxacin HCl

C1 Eryt hroc in Lact obio nate Erythrocin (250MG Oral Tablet Lactobionate Immediate Release, 4 (Intravenous Solution 500MG Oral Tablet 2 Reconstituted) Immediate Release,

C1 Eryt hro myci n Bas 750MG Oral Tablet e Erythromycin Base Immediate Release) (Oral Capsule Delayed 4 Release Particles)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 39 39 1138 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Cipr oflo xaci B1 n in D5 W Ciprofloxacin in D5W Sulfonamides

C1 Silv er Sulf adia (200MG/100ML 4 zine Silver Sulfadiazine Intravenous Solution) 3

C1 (External Cream) Cipr oflo C1 xaci n SSD Ciprofloxacin (Oral SSD (External Cream) 3 C1 Sulf acet ami de Suspension 4 Sodi um Sulfacetamide Sodium Reconstituted) 2

C1 Gatif loxa (Ophthalmic Ointment) cin C1

Sulf acet ami de Gatifloxacin Sodi 3 um Sulfacetamide Sodium (Ophthalmic Solution) 2

C1 Lev oflo (Ophthalmic Solution) xaci n in D5 C1 W Sulf adia Levofloxacin in D5W zine Sulfadiazine (Oral (500MG/100ML 4 Tablet)

C1 Sulf ame Intravenous Solution, 4 thox azol e- Trim etho 750MG/150ML prim Sulfamethoxazole- Intravenous Solution) Trimethoprim (Oral 2

Lev oflo xaci n Suspension)

C1 Sulf ame Levofloxacin (25MG/ thox azol e- Trim etho ML Intravenous 4 prim Sulfamethoxazole- Solution) Trimethoprim (Oral 2

Lev oflo xaci n Tablet) Levofloxacin (0.5% B1 3 Tetracyclines Ophthalmic Solution) C1 De mec C1 locy cline Lev HCl oflo xaci n Demeclocycline HCl Levofloxacin (25MG/ 4 4 (Oral Tablet) ML Oral Solution) C1 Dox y C1 100 Lev oflo xaci n Levofloxacin (250MG Doxy 100 (Intravenous Oral Tablet, 500MG Solution 4 1 Reconstituted) Oral Tablet, 750MG C1 Dox ycyc line Hycl Oral Tablet) ate Doxycycline Hyclate

C1 Mox iflox 3 acin HCl in NaC l (Oral Capsule) Moxifloxacin HCl in C1 Dox ycyc line Hycl ate NaCl (Intravenous 4 Doxycycline Hyclate Solution) (100MG Oral Tablet C1 Mox iflox acin HCl Moxifloxacin HCl Immediate Release, 3 4 (Ophthalmic Solution) 20MG Oral Tablet

C1 Mox iflox acin HCl Immediate Release)

C1 Dox ycyc Moxifloxacin HCl (Oral line Mon ohy drat 3 e Tablet) Doxycycline

C1 Oflo xaci n Monohydrate (100MG Ofloxacin (Ophthalmic 3 2 Oral Capsule, 50MG Solution)

C1 Oflo xaci Oral Capsule) n Ofloxacin (Oral Tablet) 3

Oflo xaci n Ofloxacin (Otic 3 Solution)

Bold type = Brand name drug Plain type = Generic drug 40 tRACK 40 Last updated October 1, 2019 1239 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Dox Row ycyc eepr line a Mon ohy drat e Doxycycline Roweepra (Oral Tablet 2 Monohydrate (Oral Immediate Release)

C1 Row 4 eepr Suspension a XR Roweepra XR (Oral Reconstituted)

C1 Tablet Extended 3 Dox ycyc line Mon ohy drat e Doxycycline Release 24 Hour)

C1 Sprit Monohydrate (100MG am Spritam (Oral Tablet

Oral Tablet, 50MG Oral 3 Disintegrating 4 Tablet, 75MG Oral Soluble)

Tablet) B1

C1 Min ocy cline HCl Calcium Channel Modifying Agents

Celo Minocycline HCl (Oral ntin 2 Celontin (Oral Capsule) 4 C1 Min ocy cline HCl Capsule)

Etho Minocycline HCl (Oral suxi mid e Ethosuximide (Oral Tablet Immediate 4 3 Capsule) Release) C1 Etho C1 suxi mid Tetr e acyc line HCl Ethosuximide (Oral Tetracycline HCl (Oral 3 4 Solution)

Capsule) C1 Zoni C1 sami de Vibr amy cin Vibramycin (50MG/ Zonisamide (Oral 4 2 5ML Oral Syrup) Capsule)

B1 A1 Anticonvulsants Gamma-aminobutyric Acid (GABA)

B1 Augmenting Agents

Clo Anticonvulsants, Other baz am

C1 BRI VIA CT Clobazam (2.5MG/ML BRIVIACT (Oral 5 PA; QL 5 PA; QL Oral Suspension)

C1 Clo baz Solution) am

BRI VIA CT Clobazam (10MG Oral BRIVIACT (Oral 4 PA; QL 5 PA; QL Tablet) C1 Clo baz Tablet) am

C1 Epid iolex Clobazam (20MG Oral 5 PA; QL Epidiolex (Oral Tablet)

5 PA C1 Dias tat Acu Solution) Dial

C1 Lev etira Diastat AcuDial ceta m ER 4 Levetiracetam ER (Oral (Rectal Gel) C1

Dias tat Pedi Tablet Extended 3 atric Diastat Pediatric Release 24 Hour) 4 C1 Lev etira ceta m (Rectal Gel)

Gab ape Levetiracetam (Oral ntin 2 Gabapentin (Oral Solution) 2 C1

Lev etira ceta m Capsule)

C1 Gab ape Levetiracetam (Oral ntin Gabapentin (250MG/ Tablet Immediate 2 3 5ML Oral Solution)

C1 Release) Gab ape ntin Gabapentin (Oral 2 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 41 41 1340 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Phe Lam nob otrig arbit ine al Phenobarbital (Oral Lamotrigine (100MG 2 Elixir) Oral Tablet Immediate

C1 Phe nob arbit al Phenobarbital (Oral Release, 150MG Oral 2 Tablet) Tablet Immediate C1 Prim idon e Primidone (Oral Release, 200MG Oral 2 2 Tablet) Tablet Immediate

C1 Sym paz an Release, 25MG Oral Sympazan (Oral Film) 5 PA; QL C1 Tablet Immediate Tiag abin e HCl Tiagabine HCl (Oral Release)

C1 4 Lam otrig Tablet) ine C1 Lamotrigine (25MG Valp roic Acid Valproic Acid (Oral Oral Tablet Chewable, 2 3 Capsule) 5MG Oral Tablet C1 Valp roic Acid Valproic Acid (Oral Chewable) C1 Topi ram 2 ate Solution) Topiramate (Oral C1 Viga batri n Vigabatrin (Oral Capsule Sprinkle 2 5 PA; LA; QL Packet) Immediate Release) C1

C1 Topi ram Viga ate batri n Vigabatrin (Oral Topiramate (Oral 5 PA; LA; QL 2 Tablet) Tablet)

Viga B1 dron e Vigadrone (Oral Sodium Channel Agents C1

Apti 5 PA; LA; QL om Packet) Aptiom (Oral Tablet) 5 QL

C1 Ban B1 Glutamate Reducing Agents zel Banzel (Oral

C1 Felb ama te 5 Felbamate (Oral Suspension) C1 Ban 5 zel Suspension) Banzel (Oral Tablet) 5 C1

Felb C1 ama te Car bam aze pine Felbamate (Oral ER 4 Carbamazepine ER Tablet) (Oral Capsule C1

Fyc omp a 3 Fycompa (Oral Extended Release 12 5 Suspension) Hour) C1

C1 Car bam Fyc aze omp pine a Fycompa (Oral ER Carbamazepine ER 5 Tablet) (Oral Tablet Extended 3 Release 12 Hour)

C1 Car bam aze pine Carbamazepine (Oral 3 Suspension)

C1 Car bam aze pine Carbamazepine (Oral Tablet Immediate 3 Release)

Bold type = Brand name drug Plain type = Generic drug 42 tRACK 42 Last updated October 1, 2019 1441 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Car Gala bam nta aze min pine e Hyd robr omi de Carbamazepine (Oral ER Galantamine 3 Tablet Chewable) Hydrobromide ER

C1 Dila ntin INF ATA BS Dilantin INFATABS (Oral Capsule 4 QL 3 (Oral Tablet Chewable) Extended Release 24

C1 Dila ntin Hour)

C1 Gala Dilantin (Oral Capsule) 3 nta min e C1 Hyd robr Epit omi ol de Galantamine Epitol (Oral Tablet) 3

Oxc arba zepi Hydrobromide (Oral 4 QL ne Oxcarbazepine Solution) C1 Gala nta min e (300MG/5ML Oral 4 Hyd robr omi de Galantamine Suspension)

Oxc arba zepi Hydrobromide (Oral 4 QL ne Oxcarbazepine Tablet)

C1 Riva stig min e (150MG Oral Tablet, Tartr 3 ate Rivastigmine Tartrate 300MG Oral Tablet, 3 QL (Oral Capsule)

Riva 600MG Oral Tablet) stig min e C1 Peg ano ne Peganone (Oral Rivastigmine 4 (Transdermal Patch 24 4 ST; QL Tablet)

C1 Phe nyte Hour) k

Phenytek (Oral B1 2 N-methyl-D-aspartate (NMDA) Receptor Capsule)

C1 Phe nyto in Antagonist

C1 Me man tine HCl Phenytoin (Oral ER 2 Memantine HCl ER Suspension)

Phe nyto in (Oral Capsule Phenytoin (Oral Tablet 3 PA; QL 2 Extended Release 24 Chewable) C1 Hour) Phe nyto in C1 Sodi um Me Exte man nde tine d Phenytoin Sodium HCl Memantine HCl (2MG/ 4 PA; QL Extended (Oral 2 ML Oral Solution)

C1 Me man tine Capsule) HCl

C1 Vim pat Memantine HCl (10MG Vimpat (Oral Solution) 4 QL C1 Oral Tablet, 5MG Oral 2 PA; QL Vim pat Vimpat (Oral Tablet) 4 QL Tablet)

Me A1 man tine HCl Titra tion Antidementia Agents Pak Memantine HCl B1 Cholinesterase Inhibitors Titration Pak (Oral 3 PA

C1 Don epe zil HCl Donepezil HCl (Oral Tablet) 1 QL A1 Tablet) Antidepressants

C1 Don epe zil B1 HCl ODT Donepezil HCl ODT Antidepressants, Other

C1 Bup ropi on HCl (Oral Tablet 2 QL SR Bupropion HCl SR Dispersible) (Oral Tablet Extended 2 Release 12 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 43 43 1542 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Bup Esci ropi talo on pra HCl m XL Oxal Bupropion HCl XL ate Escitalopram Oxalate 2 (150MG Oral Tablet (Oral Solution)

C1 Esci talo pra m Oxal Extended Release 24 ate Escitalopram Oxalate 2 1 Hour, 300MG Oral (Oral Tablet)

C1 Fetz Tablet Extended ima Fetzima (Oral Release 24 Hour)

C1 Bup ropi on Capsule Extended 4 ST; QL HCl Bupropion HCl (Oral Release 24 Hour)

C1 Fetz ima Tablet Immediate 2 Titra tion Release) Fetzima Titration

C1 Mirt aza pine (Oral Capsule ER 24 4 ST Mirtazapine (Oral 2 Hour Therapy Pack)

C1 Tablet) Fluo xeti ne C1 HCl Mirt aza pine

ODT Mirtazapine ODT (Oral Fluoxetine HCl (10MG 2 Tablet Dispersible) Oral Capsule

B1 Immediate Release, Monoamine Oxidase Inhibitors

Ems 20MG Oral Capsule 2 am Emsam (Transdermal 5 QL Immediate Release, Patch 24 Hour) 40MG Oral Capsule

C1 Mar plan Marplan (Oral Tablet) 4 Immediate Release) C1

Fluo C1 xeti Phe ne nelzi HCl ne Sulf ate Phenelzine Sulfate Fluoxetine HCl (90MG 3 (Oral Tablet) Oral Capsule Delayed 4

C1 Tran ylcy pro min e Sulf Release) ate C1 Tranylcypromine Fluo xeti ne 4 HCl Fluoxetine HCl (20MG/ Sulfate (Oral Tablet) 2 B1 5ML Oral Solution)

C1 SSRI/SNRI (Selective Serotonin Reuptake Fluv oxa min e Mal eate Fluvoxamine Maleate Inhibitors/Serotonin and Norepinephrine 3 (Oral Tablet)

C1 Reuptake Inhibitors) Map rotili ne C1 HCl Cital opra m Hyd robr omi de Maprotiline HCl (Oral Citalopram 4 Tablet)

Hydrobromide (Oral 3 Nef azo don e Solution) HCl Nefazodone HCl (Oral

C1 Cital 4 opra m Hyd robr omi de Tablet)

C1 Citalopram Paro xeti ne HCl Hydrobromide (Oral 1 Paroxetine HCl (Oral Tablet) Tablet Immediate 2

C1 Des venl afaxi ne Suc cina te Release) ER C1 Desvenlafaxine Paxil Paxil (Oral Succinate ER (Oral 4 Tablet Extended 3 QL Suspension)

C1 Sert ralin e Release 24 Hour) HCl Sertraline HCl (Oral 4 (Generic Pristiq) Concentrate)

Bold type = Brand name drug Plain type = Generic drug 44 tRACK 44 Last updated October 1, 2019 1643 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Sert Imip ralin rami e ne HCl Pam Sertraline HCl (Oral oate Imipramine Pamoate 1 4 Tablet) (Oral Capsule)

C1 C1 Traz Nort odo ripty ne line HCl Trazodone HCl HCl Nortriptyline HCl (Oral 2 (100MG Oral Tablet, Capsule)

C1 Nort 1 ripty line 150MG Oral Tablet, HCl Nortriptyline HCl (Oral 50MG Oral Tablet) 2

C1 Solution) Traz odo C1 ne HCl Prot ripty line Trazodone HCl HCl 2 Protriptyline HCl (Oral (300MG Oral Tablet) 4

C1 Tablet) Trint ellix C1 Trim ipra min e Mal Trintellix (Oral Tablet) 4 QL eate C1 Trimipramine Maleate Venl afaxi ne HCl ER 4 Venlafaxine HCl ER (Oral Capsule) (Oral Capsule A1 2 Antiemetics Extended Release 24 B1 Antiemetics, Other

C1 Co mpr Hour) o

Venl afaxi ne HCl Compro (Rectal 4 Venlafaxine HCl (Oral Suppository)

C1 Hyd roxy Tablet Immediate 3 zine Pam oate Hydroxyzine Pamoate Release) 3 C1 Viibr yd (Oral Capsule)

Mec Viibryd (Oral Tablet) lizin 4 QL e HCl C1 Viibr yd Start er Pac Meclizine HCl (Oral k Viibryd Starter Pack 2 4 QL Tablet) C1 Met oclo pra (Oral Kit) mid e HCl

B1 Metoclopramide HCl Tricyclics

Amit (5MG/5ML Oral 2 ripty line HCl Amitriptyline HCl (Oral Solution)

C1 4 Met oclo pra mid e Tablet) HCl C1 Am Metoclopramide HCl oxa pine 1 Amoxapine (Oral (Oral Tablet)

C1 3 Per phe nazi Tablet) ne

C1 Clo Perphenazine (Oral mipr ami ne HCl 4 Clomipramine HCl Tablet)

4 Proc hlor pera zine Mal (Oral Capsule) eate

C1 Desi Prochlorperazine pra min e HCl 2 Desipramine HCl (Oral Maleate (Oral Tablet) 3 C1 Proc hlor pera Tablet) zine C1 Dox Prochlorperazine epin HCl 4 Doxepin HCl (Oral (Rectal Suppository)

C1 3 Sco pola min Capsule) e

Dox Scopolamine epin HCl Doxepin HCl (Oral 3 (Transdermal Patch 72 4 Concentrate) Hour) C1 Imip rami ne HCl Imipramine HCl (Oral 4 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 45 45 1744 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Tran Cicl sder opir m- ox Sco p Transderm-Scop Ciclopirox (External 3 (1.5MG) Gel) C1 Cicl opir 4 ox (Transdermal Patch Ciclopirox (External 3 72 Hour) Shampoo)

C1 Cicl opir B1 Emetogenic Therapy Adjuncts ox Ciclopirox (External

C1 Apr epit 3 ant Solution)

Aprepitant (Oral C1 Cicl opir ox Ola min e Ciclopirox Olamine Therapy Pack, Oral 4 PA 3 Capsule) (External Cream)

C1 C1 Cicl Ces opir ame t ox Ola min Cesamet (1MG Oral e Ciclopirox Olamine 5 PA 3 Capsule) (External Suspension) C1

C1 Clot rima Dro nabi zole nol Dronabinol (Oral Clotrimazole (External 4 PA 2 Capsule) Cream) C1 C1 Clot rima Gra nise zole tron HCl Granisetron HCl (Oral Clotrimazole (External 4 B/D, PA; QL 2 Tablet) Solution) C1 C1 Clot rima Ond zole ans etro n HCl Ondansetron HCl (Oral Clotrimazole (Mouth/ 4 B/D, PA 2 Solution) Throat Lozenge) C1 C1 Eco naz Ond ole ans Nitr etro ate n HCl Ondansetron HCl (Oral Econazole Nitrate 2 B/D, PA 4 QL Tablet) (External Cream) C1

C1 Erax is Ond ans etro n ODT Eraxis (100MG Ondansetron ODT (Oral Tablet 2 B/D, PA Intravenous Solution 5 Dispersible) Reconstituted)

C1 C1 San cus Erax o Sancuso is Eraxis (50MG 5 (Transdermal Patch) Intravenous Solution 4 A1 Antifungals Reconstituted) C1 Exel der m B1 Antifungals Exelderm (External

C1 Abel cet 4 Cream)

Abelcet (Intravenous C1 Exel der 4 B/D, PA m Suspension) Exelderm (External

Am Biso 4 me Solution)

AmBisome C1 Fluc ona zole in Sodi um Chlo (Intravenous ride Fluconazole in Sodium 5 B/D, PA Suspension Chloride (Intravenous 4 Solution) Reconstituted) C1 Fluc C1 ona zole Am phot erici n B Amphotericin B Fluconazole (Oral (Intravenous Solution 4 B/D, PA Suspension 2 Reconstituted) Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 46 tRACK 46 Last updated October 1, 2019 1845 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Fluc Nox ona afil zole Fluconazole (Oral Noxafil (Oral 2 5 QL Tablet) Suspension) C1 C1 Fluc ytosi Nox ne Flucytosine (Oral afil Noxafil (Oral Tablet 5 5 PA; QL Capsule) Delayed Release) C1

Gris C1 eofu lvin Nya Micr myc osiz e Griseofulvin Microsize Nyamyc (External 4 2 (Oral Suspension) Powder) C1

Gris C1 eofu lvin Nyst Micr atin osiz e Griseofulvin Microsize Nystatin (External 4 2 (Oral Tablet) Cream) C1

Gris C1 eofu lvin Nyst Ultra atin micr osiz e Griseofulvin Nystatin (External 2 Ultramicrosize (Oral 4 Ointment)

Nyst Tablet) atin C1 Itrac Nystatin (External ona zole 2 Itraconazole (Oral Powder) 4 PA; QL C1 Nyst Capsule) atin C1 Itrac Nystatin (Mouth/ ona zole 2 Itraconazole (Oral Throat Suspension) 5 PA C1 Nyst Solution) atin

C1 Jubli Nystatin (Oral Tablet) 2 a

C1 Nyst Jublia (External op 4 Nystop (External Solution) 2 C1 Powder) Ket oco naz C1 ole Terb inafi ne Ketoconazole (External HCl 2 QL Terbinafine HCl (Oral Cream) 2 C1 Tablet) Ket oco naz C1 ole Terc ona Ketoconazole (External zole 2 Terconazole (Vaginal Shampoo) 3 C1 Cream) Ket oco naz C1 ole Terc ona Ketoconazole (Oral zole 2 Terconazole (Vaginal Tablet) 3 C1 Suppository) Men tax C1 Vori con azol Mentax (External e 4 Voriconazole Cream)

C1 (Intravenous Solution 5 Mic ona zole 3 Miconazole 3 (Vaginal Reconstituted)

Vori 3 con azol Suppository) e

C1 Voriconazole (Oral Myc ami ne Mycamine Suspension 5

(Intravenous Solution 5 Reconstituted) C1

Vori con azol Reconstituted) e Voriconazole (Oral

Nafti fine HCl 4 Naftifine HCl (External Tablet)

4 A1 Cream) Antigout Agents

C1 Nafti n B1 Naftin (External Gel) 4 Antigout Agents

C1 C1 Nata Allo cyn puri Natacyn (Ophthalmic nol Allopurinol (Oral 4 1 Suspension) Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 47 47 1946 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Colc Riza hicin tript e an Ben zoat e Colchicine (0.6MG ODT Rizatriptan Benzoate Oral Capsule) (Brand 3 QL ODT (Oral Tablet 3 QL Equivalent Mitigare) Dispersible) C1

C1 Sum atrip Colc tan hicin e Sumatriptan (Nasal Colchicine (0.6MG 4 QL Oral Tablet) (Brand 3 QL Solution) C1 Sum atrip tan Suc cina Equivalent Colcrys) te Sumatriptan Succinate

C1 Colc rys Colcrys (Oral Tablet) 3 QL (100MG Oral Tablet, C1 2 QL Feb uxo stat Febuxostat (Oral 25MG Oral Tablet, 3 ST 50MG Oral Tablet)

C1 Tablet) Sum atrip tan C1 Suc cina Pro te ben Refil ecid Probenecid (Oral l Sumatriptan 2 Tablet) Succinate Refill

C1 4 QL Pro ben ecid - Colc (Subcutaneous hicin e Probenecid-Colchicine 2 Solution Cartridge)

C1 (Oral Tablet) Sum atrip tan Suc cina te A1 Antimigraine Agents Sumatriptan Succinate

B1 (6MG/0.5ML Ergot Alkaloids 4 QL

C1 Dihy Subcutaneous droe rgot ami ne Mes ylate Dihydroergotamine Solution)

C1 Sum atrip tan Suc cina Mesylate (Nasal 5 te Sumatriptan Succinate Solution)

C1 Erg (4MG/0.5ML ota min e- Caff eine Ergotamine-Caffeine 3 Subcutaneous (Oral Tablet) Solution Auto-Injector, 4 QL C1 Mig ergo t Migergot (Rectal 6MG/0.5ML 5 Suppository) Subcutaneous B1 Solution Auto-Injector) Prophylactic C1 Sum atrip C1 tan Suc Aim cina ovig Aimovig te Sumatriptan (Subcutaneous Succinate (6MG/ 4 PA; QL 0.5ML Subcutaneous Solution Auto- 4 QL Injector) Solution Auto-

Tim olol Mal eate Injector) (Generic Timolol Maleate (Oral 3 Imitrex STATdose)

C1 Tablet) Sum atrip tan Suc cina te B1 Serotonin (5-HT) 1b/1d Receptor Agonists Sumatriptan Succinate

C1 Nar atrip tan HCl (6MG/0.5ML Naratriptan HCl (Oral 3 QL Subcutaneous 4 QL Tablet)

C1 Riza Solution Prefilled tript an Ben zoat e Rizatriptan Benzoate 3 QL Syringe) (Oral Tablet) A1 Antimyasthenic Agents

Bold type = Brand name drug Plain type = Generic drug 48 tRACK 48 Last updated October 1, 2019 2047 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Sirtu ro B1 Parasympathomimetics Sirturo (Oral Tablet) 5 PA; LA

C1 C1 Gua Trec nidi ator ne HCl Guanidine HCl (Oral Trecator (Oral Tablet) 4

3 A1 Tablet) Antineoplastics C1 Pyri dost igmi ne B1 Bro mid e ER Pyridostigmine Alkylating Agents

Cycl oph osp ham ide Bromide ER (Oral Cyclophosphamide 4 4 B/D, PA Tablet Extended (Oral Capsule)

Gle osti Release) ne

C1 Pyri dost igmi Gleostine (100MG ne Bro mid e Pyridostigmine 5 Oral Capsule)

C1 Gle osti Bromide (Oral 5 ne Gleostine (10MG Oral Solution) C1

Pyri dost igmi ne Bro Capsule, 40MG Oral mid 3 e Pyridostigmine Capsule)

C1 Bromide (60MG Oral Leu kera 3 n Leukeran (Oral Tablet Immediate 5 Release) Tablet)

C1 Mat ulan A1 Antimycobacterials e Matulane (Oral

B1 5 LA Antimycobacterials, Other Capsule) C1

C1 Valc hlor Dap son e Dapsone (Oral Tablet) 3 Valchlor (External

C1 Rifa 5 PA; LA buti n Rifabutin (Oral Gel) 4 B1 Capsule) Antiandrogens C1 Abir ater one B1 Acet Antituberculars ate Abiraterone Acetate

C1 Etha 5 PA; QL mbu tol HCl (Oral Tablet) Ethambutol HCl (Oral C1 Bica luta mid 3 e Tablet) Bicalutamide (Oral

C1 Ison 2 iazid Tablet) Isoniazid (Oral Syrup) 4 C1 Erle ada C1 Ison iazid Erleada (Oral Tablet) 5 PA; QL Isoniazid (Oral Tablet) 2 C1 Flut ami C1 de Pas er Flutamide (Oral Paser (Oral Packet) 4 3 C1

Prifti n Capsule)

C1 Nilut ami Priftin (Oral Tablet) 4 de

C1 Pyra zina mid e Nilutamide (Oral Pyrazinamide (Oral 5 4 Tablet)

C1 Nub Tablet) eqa

C1 Rifa mpi n Nubeqa (Oral Tablet) 5 PA; QL

C1 Xtan Rifampin (Intravenous di Solution 4 Xtandi (Oral Capsule) 5 PA; LA; QL Reconstituted) B1 Antiangiogenic Agents C1 C1 Pom Rifa alyst mpi n Rifampin (Oral Pomalyst (Oral 3 5 PA; QL Capsule) Capsule)

Rifat er Rifater (Oral Tablet) 5

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 49 49 2148 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Revl imid Revlimid (Oral B1 Antineoplastics, Other

C1 Cop 5 PA; LA; QL iktra Capsule) Copiktra (Oral C1 Thal omi d 5 PA; QL Thalomid (Oral Capsule)

C1 Inre 5 PA; QL bic Capsule) Inrebic (Oral Capsule) 5 PA; QL

B1 Kisq Antiestrogens/Modifiers ali Kisqali (200MG Dose) C1 Emc yt 5 PA; QL Emcyt (Oral Capsule) 5 (Oral Tablet)

C1 C1

Solt Kisq amo ali x Soltamox (Oral Kisqali (400MG Dose) 5 5 PA; QL Solution) (Oral Tablet)

C1 C1

Tam Kisq oxif ali en Citra te Tamoxifen Citrate Kisqali (600MG Dose) 2 5 PA; QL (Oral Tablet) (Oral Tablet) C1 C1 Tore mife Kisq ne ali Citra Fem te Toremifene Citrate ara 5 Kisqali Femara (Oral Tablet) (400MG Dose) (Oral 5 PA; QL B1 Antimetabolites Tablet Therapy Pack)

C1 C1 Dro xia Kisq ali Fem Droxia (Oral Capsule) 4 ara Kisqali Femara

Hyd roxy urea Hydroxyurea (Oral (600MG Dose) (Oral 5 PA; QL 2 Capsule) Tablet Therapy Pack)

C1 C1 Mer Kisq capt ali opur Fem ine Mercaptopurine (Oral ara Kisqali Femara 3 Tablet) (200MG Dose) (Oral 5 PA; QL C1 Puri xan Purixan (Oral Tablet Therapy Pack)

Leu cov orin 5 PA Calc Suspension) ium Leucovorin Calcium C1 Tabl oid (10MG Oral Tablet, Tabloid (Oral Tablet) 4 PA 3 B1 Antineoplastics 15MG Oral Tablet,

Xpo vio 5MG Oral Tablet)

C1 Leu cov Xpovio (100MG Once orin Calc ium Leucovorin Calcium Weekly) (Oral Tablet 5 PA; QL 4 (25MG Oral Tablet)

C1 Lon Therapy Pack) surf

C1 Xpo vio Lonsurf (Oral Tablet) 5 PA; LA; QL

C1 Lorb Xpovio (60MG Once rena Lorbrena (Oral Weekly) (Oral Tablet 5 PA; QL 5 PA; QL Tablet)

C1 Therapy Pack) Ninl aro

C1 Xpo vio Ninlaro (Oral Xpovio (80MG Once 5 PA; QL Capsule)

C1 Weekly) (Oral Tablet 5 PA; QL Piqr ay Therapy Pack) Piqray (200 MG Daily

C1 Xpo vio Xpovio (80MG Twice Dose) (Oral Tablet 5 PA; QL Weekly) (Oral Tablet 5 PA; QL Therapy Pack) Therapy Pack)

Bold type = Brand name drug Plain type = Generic drug 50 tRACK 50 Last updated October 1, 2019 2249 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Piqr Alun ay Piqray (250 MG Daily brig Alunbrig (Oral Tablet 5 PA; LA; QL Dose) (Oral Tablet 5 PA; QL Therapy Pack)

C1 Bos Therapy Pack) ulif Bosulif (Oral Tablet) 5 PA; QL C1 Piqr C1 ay Braf Piqray (300 MG Daily tovi Braftovi (Oral 5 PA Dose) (Oral Tablet 5 PA; QL Capsule)

C1 Cab ome Therapy Pack) tyx

C1 Cabometyx (Oral Synr ibo 5 PA; LA; QL Synribo Tablet)

Calq uen (Subcutaneous ce Calquence (Oral 5 PA 5 PA; QL Solution Capsule)

Cap rels Reconstituted) a

C1 Verz Caprelsa (Oral Tablet) 5 PA; LA enio

C1 Co metr Verzenio (Oral Tablet) 5 PA; LA; QL iq

C1 Zoli Cometriq (100MG nza 5 PA; LA Zolinza (Oral Daily Dose) (Oral Kit)

5 PA C1 Co metr Capsule) iq Cometriq (140MG B1 Aromatase Inhibitors, 3rd Generation 5 PA; LA C1 Daily Dose) (Oral Kit) Ana stro zole C1 Co metr Anastrozole (Oral iq 1 Cometriq (60MG Tablet) 5 PA; LA

C1 Exe Daily Dose) (Oral Kit) mes tane C1

Cot Exemestane (Oral ellic 4 Cotellic (Oral Tablet) 5 PA; LA; QL C1 Dau rism Tablet) o

C1 Letr ozol e Daurismo (Oral 5 PA; LA; QL Letrozole (Oral Tablet) 2 Tablet) B1

C1 Eriv edg Enzyme Inhibitors e

C1 Balv ersa Erivedge (Oral Balversa (Oral Tablet) 5 PA; QL 5 PA; LA; QL C1 Capsule) Rub raca C1 Erlot inib Rubraca (Oral Tablet) 5 PA; LA; QL HCl C1 Erlotinib HCl (Oral Talz enn a 5 PA; QL Talzenna (Oral Tablet)

Fary 5 PA; LA; QL dak Capsule)

C1 Farydak (Oral Zeju la 5 PA Zejula (Oral Capsule) 5 PA; LA; QL Capsule)

Gilot B1 Molecular Target Inhibitors rif Gilotrif (Oral Tablet) 5 PA; LA C1 C1 Afini tor Ibra Disp nce erz Afinitor Disperz (Oral Ibrance (Oral 5 PA 5 PA; LA; QL Tablet Soluble) Capsule) C1 C1 Afini tor Iclus Afinitor (Oral Tablet) 5 PA ig Iclusig (Oral Tablet) 5 PA; LA; QL C1 C1 Alec ens IDHI a Alecensa (Oral FA IDHIFA (Oral Tablet) 5 PA; LA; QL

Imat 5 PA; LA; QL inib Mes Capsule) ylate

C1 Imatinib Mesylate (Oral Alun brig 5 PA; QL Alunbrig (Oral Tablet) 5 PA; LA; QL Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 51 51 2350 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Imbr Mek uvic tovi a Imbruvica (Oral Mektovi (Oral Tablet) 5 PA

C1 Nerl 5 PA; LA; QL ynx Capsule) Nerlynx (Oral Tablet) 5 PA; LA; QL C1 Imbr C1 uvic a Nex Imbruvica (Oral avar Nexavar (Oral Tablet) 5 PA; LA

C1 5 PA; QL Odo Tablet) mzo

C1 Odomzo (Oral Inlyt a 5 PA; LA; QL Inlyta (Oral Tablet) 5 PA; LA; QL Capsule) C1 Ires C1 sa Ryd Iressa (Oral Tablet) 5 PA; LA; QL apt Rydapt (Oral Capsule) 5 PA; QL C1

Jaka C1 fi Spry Jakafi (Oral Tablet) 5 PA; LA; QL cel Sprycel (Oral Tablet) 5 PA; QL C1

Len C1 vima Stiv 10M arga G Dail y Dos e Lenvima 10MG Daily Stivarga (Oral Tablet) 5 PA; LA; QL

C1 Sute Dose (Oral Capsule 5 PA; LA nt Sutent (Oral Capsule) 5 PA; QL

C1 Tafi Therapy Pack) nlar

C1 Len Tafinlar (Oral vima

12M G Dail y Dos 5 PA; LA e Lenvima 12MG Daily Capsule)

Tagr Dose (Oral Capsule 5 PA; LA isso Tagrisso (Oral Tablet) 5 PA; LA; QL

C1 Tasi Therapy Pack) gna

C1 Len vima Tasigna (Oral 14M G Dail y Dos e 5 PA; QL Lenvima 14MG Daily Capsule)

C1 Tibs Dose (Oral Capsule 5 PA; LA ovo Tibsovo (Oral Tablet) 5 PA; QL

C1 Tura Therapy Pack) lio

C1 Len vima

18M G Turalio (Oral Capsule) 5 PA; LA; QL Dail y Dos C1 e Tyk Lenvima 18MG Daily erb Tykerb (Oral Tablet) 5 PA; LA

C1 Dose (Oral Capsule 5 PA; LA Ven clext a Therapy Pack) Venclexta (100MG

Len vima

20M G Dail Oral Tablet, 50MG 5 PA; LA; QL y Dos e Lenvima 20MG Daily Oral Tablet)

C1 Dose (Oral Capsule 5 PA; LA Ven clext a Therapy Pack) Venclexta (10MG Oral C1 3 PA; LA; QL Len vima

24M G Dail Tablet) y Dos e C1 Lenvima 24MG Daily Ven clext a Start ing Pac Dose (Oral Capsule 5 PA; LA k Venclexta Starting Therapy Pack) Pack (Oral Tablet 5 PA; LA

C1 Len vima

4M G Dail Therapy Pack) y Dos e C1 Lenvima 4MG Daily Vitra kvi Vitrakvi (Oral Dose (Oral Capsule 5 PA; LA 5 PA; LA; QL Capsule)

Therapy Pack) C1 Vitra C1 kvi Len vima

8M G Dail y Dos Vitrakvi (Oral e Lenvima 8MG Daily 5 PA; LA; QL Solution)

Dose (Oral Capsule 5 PA; LA C1 Vizi mpr Therapy Pack) o Vizimpro (Oral Tablet) 5 PA; LA; QL C1 C1 Votri Lyn ent parz a Lynparza (Oral Votrient (Oral Tablet) 5 PA; LA; QL C1 Xalk 5 PA; LA; QL ori Tablet) Xalkori (Oral Capsule) 5 PA; LA

C1 C1

Mek Xos inist Mekinist (Oral Tablet) 5 PA; LA pata Xospata (Oral Tablet) 5 PA; QL

Bold type = Brand name drug Plain type = Generic drug 52 tRACK 52 Last updated October 1, 2019 2451 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Zelb Ben oraf znid azol Zelboraf (Oral Tablet) 5 PA; LA; QL e Benznidazole (Oral

C1 Zyd elig 4 Zydelig (Oral Tablet) 5 PA; LA; QL Tablet) C1 C1 Chlo roqu Zyk ine adia Pho sph Zykadia (Oral ate Chloroquine 5 PA; QL Capsule) Phosphate (Oral 2

C1 Zyk adia Tablet)

C1 Coa Zykadia (Oral Tablet) 5 PA; QL rtem B1 Coartem (Oral Tablet) 4

C1 DAR Retinoids APR IM C1

Bex arot ene DARAPRIM (Oral Bexarotene (Oral 5 5 PA Tablet)

C1 Capsule) Hyd roxy chlo C1 roqu Panr ine Sulf etin ate Hydroxychloroquine Panretin (External 2 5 Sulfate (Oral Tablet)

Mefl Gel) oqui ne HCl C1 Targ retin Mefloquine HCl (Oral Targretin (External 2 5 PA Tablet)

C1 Neb upe Gel) nt

C1 Treti noin Nebupent (Inhalation Tretinoin (Oral 5 Solution 4 B/D, PA; QL Capsule)

B1 Reconstituted)

C1 PEN TA M Treatment Adjuncts 300

C1 Mes nex PENTAM 300 Mesnex (Oral Tablet) 5 (Injection Solution 4 A1 Antiparasitics Reconstituted)

B1 C1 Prim aqui ne Pho sph Anthelmintics ate C1 Primaquine Phosphate Albe nda zole 4 Albendazole (Oral (Oral Tablet)

C1 5 QL Quin ine Sulf Tablet) ate C1 Quinine Sulfate (Oral Iver mec tin Ivermectin (Oral 4 PA 3 Capsule) Tablet) B1 C1 Pediculicides/Scabicides Praz iqua ntel C1 Eura Praziquantel (Oral x Eurax (External 4 4 Tablet) Cream) B1 C1 Eura Antiprotozoals x

C1 Alini Eurax (External a Alinia (Oral 4 Lotion) C1

Lind Suspension 5 ane Lindane (External Reconstituted) 4 C1 Shampoo) Alini a C1 Mal athi Alinia (Oral Tablet) 5 on C1 Malathion (External Atov aqu one 4 Atovaquone (Oral Lotion)

C1 5 Per met Suspension) hrin C1 Permethrin (External Atov aqu one- Pro gua nil 3 HCl Atovaquone-Proguanil 3 Cream) HCl (Oral Tablet) A1 Antiparkinson Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 53 53 2552 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Rop iniro B1 le Anticholinergics HCl Ropinirole HCl (Oral

C1 Ben ztro pine

Mes ylate Benztropine Mesylate Tablet Immediate 2 2 (Oral Tablet) Release)

C1 B1 Trih exy phe nidyl HCl Trihexyphenidyl HCl Dopamine Precursors/L-Amino Acid 2 (Oral Elixir) Decarboxylase Inhibitors C1 C1 Car bido Trih pa exy phe nidyl HCl Trihexyphenidyl HCl Carbidopa (Oral 2 4 (Oral Tablet) Tablet) C1 Car bido pa- Lev B1 odo pa Antiparkinson Agents, Other ER Carbidopa-Levodopa C1 Ama ntad ine HCl Amantadine HCl (Oral ER (Oral Tablet 1 3 Extended Release)

C1 Capsule) Car bido pa- C1 Lev Ama odo ntad pa ine HCl Amantadine HCl (Oral Carbidopa-Levodopa 2 Syrup) (Oral Tablet Immediate 1

C1 Ama ntad ine HCl Release)

Car bido pa- Amantadine HCl (Oral Lev odo pa 3 ODT Tablet) Carbidopa-Levodopa

C1 Enta cap one ODT (Oral Tablet 2 Entacapone (Oral 4 Dispersible) C1 Car bido pa- Tablet) Lev odo C1 pa- Enta Tolc cap apo one ne Carbidopa-Levodopa- Tolcapone (Oral 5 QL Entacapone (Oral 4 Tablet) Tablet) B1 C1 Ryta Dopamine Agonists ry

C1 Apo Rytary (Oral Capsule kyn 4 ST Apokyn Extended Release) (Subcutaneous 5 PA; LA; QL B1 Monoamine Oxidase B (MAO-B) Inhibitors

Ras agili ne Solution Cartridge) Mes ylate

C1 Bro moc ripti Rasagiline Mesylate ne Mes ylate 4 Bromocriptine (Oral Tablet) C1 Sele gilin e Mesylate (Oral 3 HCl Selegiline HCl (Oral Capsule) 3

Bro moc ripti Capsule) ne Mes ylate C1 Sele gilin e Bromocriptine HCl 3 Selegiline HCl (Oral Mesylate (Oral Tablet) 3

Neu pro Tablet)

C1 Zela Neupro (Transdermal par 4 Zelapar (Oral Tablet Patch 24 Hour) 5

C1 Pra mip exol Dispersible) e Dihy droc hlori de Pramipexole A1 Dihydrochloride (Oral Antipsychotics 2 B1 1st Generation/Typical

Tablet Immediate C1 Chlo rpro mazi ne Release) HCl Chlorpromazine HCl 4 (Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 54 tRACK 54 Last updated October 1, 2019 2653 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Flup Trifl hen uop azin eraz e ine Dec HCl ano ate Fluphenazine Trifluoperazine HCl 3 Decanoate (Injection 4 (Oral Tablet) Solution) B1

C1 2nd Generation/Atypical Flup hen C1 azin e Abili HCl fy Mai nten Fluphenazine HCl a Abilify Maintena

(2.5MG/ML Injection 4 (Intramuscular 5 Solution)

C1 Flup Prefilled Syringe) hen azin e C1 HCl Abili fy Mai nten Fluphenazine HCl a Abilify Maintena (5MG/ML Oral 3 (Intramuscular Concentrate) 5

C1 Flup hen azin Suspension e HCl Fluphenazine HCl Reconstituted ER)

Aripi praz (2.5MG/5ML Oral 4 ole Aripiprazole (1MG/ML Elixir) 4 QL C1

Flup hen azin e HCl Oral Solution)

Aripi praz Fluphenazine HCl ole Aripiprazole (10MG (10MG Oral Tablet, 1MG Oral Tablet, 2 Oral Tablet, 15MG Oral 2.5MG Oral Tablet, Tablet, 20MG Oral 5MG Oral Tablet) Tablet, 2MG Oral 3 QL

Halo peri dol Dec ano Tablet, 30MG Oral ate Haloperidol Decanoate Tablet, 5MG Oral (Intramuscular 4 Tablet)

C1 Aripi praz Solution) ole ODT C1 Halo peri dol Lact Aripiprazole ODT ate Haloperidol Lactate 4 (10MG Oral Tablet (Injection Solution)

C1 Halo peri Dispersible, 15MG 5 QL dol Lact ate Haloperidol Lactate 2 Oral Tablet (Oral Concentrate)

C1 Dispersible) Halo peri C1 dol Arist ada Initi Haloperidol (Oral o 2 Aristada Initio Tablet) C1 (Intramuscular 5 Lox apin e Suc cina te Loxapine Succinate Prefilled Syringe) 2 C1 Arist (Oral Capsule) ada

C1 Moli Aristada ndo ne HCl Molindone HCl (Oral 4 (Intramuscular 5 Tablet) C1 Prefilled Syringe) Pim ozid e Pimozide (Oral Tablet) 4

C1 Thio rida zine HCl Thioridazine HCl (Oral 3 Tablet)

Thio thix ene Thiothixene (Oral 3 Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 55 55 2754 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Fan Inve apt ga Trin Fanapt (10MG Oral za Invega Trinza Tablet, 12MG Oral (Intramuscular 5 Tablet, 4MG Oral Suspension Prefilled 5 ST; QL Tablet, 6MG Oral Syringe)

C1 Latu Tablet, 8MG Oral da Latuda (Oral Tablet) 5 QL

C1 Nup Tablet) lazid

C1 Nuplazid (Oral Fan apt 5 PA; QL Fanapt (1MG Oral Capsule)

C1 Nup Tablet, 2MG Oral 4 ST; QL lazid Nuplazid (Oral Tablet) 5 PA; QL

Olan zapi Tablet) ne

C1 Fan Olanzapine (10MG apt Titra tion Pac k Fanapt Titration Pack 4 ST Intramuscular Solution 4 (Oral Tablet) Reconstituted) C1 C1 Geo don Olan zapi Geodon ne Olanzapine (10MG (Intramuscular Oral Tablet, 15MG Oral 4 Solution Tablet, 2.5MG Oral Reconstituted) Tablet, 20MG Oral 2 QL

Inve ga Sust enn a Invega Sustenna Tablet, 5MG Oral Tablet, 7.5MG Oral (117MG/0.75ML Tablet)

C1 Olan zapi Intramuscular ne ODT Suspension Prefilled Olanzapine ODT (10MG Oral Tablet Syringe, 156MG/ML Dispersible, 15MG Intramuscular Oral Tablet Suspension Prefilled 4 QL 5 Dispersible, 20MG Syringe, 234MG/ Oral Tablet 1.5ML Intramuscular Dispersible, 5MG Oral Suspension Prefilled Tablet Dispersible)

C1 Pali peri don e Syringe, 78MG/ ER Paliperidone ER (Oral 0.5ML Intramuscular Tablet Extended 4 QL Suspension Prefilled Release 24 Hour)

C1 Pers Syringe) eris Perseris C1

Inve ga Sust enn a Invega Sustenna (Subcutaneous 5 (39MG/0.25ML Prefilled Syringe)

Que tiapi ne Fum arat e Intramuscular 4 ER Quetiapine Fumarate Suspension Prefilled ER (Oral Tablet 3 QL Syringe) Extended Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 56 tRACK 56 Last updated October 1, 2019 2855 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Que Risp tiapi erid ne one Fum ODT arat e Quetiapine Fumarate Risperidone ODT (Oral Tablet Immediate 2 QL (0.25MG Oral Tablet Release) Dispersible, 0.5MG

C1 Rex ulti Rexulti (Oral Tablet) 5 QL Oral Tablet

C1 Risp erda l Con sta Risperdal Consta Dispersible, 1MG Oral Tablet Dispersible, 4 (12.5MG 2MG Oral Tablet Intramuscular Dispersible, 3MG Oral Suspension 4 Tablet Dispersible, Reconstituted, 25MG 4MG Oral Tablet Intramuscular Dispersible)

C1 Sap Suspension hris Saphris (Tablet 5 QL Reconstituted) Sublingual) C1 Risp erda C1 l Con Vray sta Risperdal Consta lar Vraylar (1.5MG Oral (37.5MG Capsule, 3MG Oral Intramuscular Capsule, 4.5MG Oral 5 ST; QL Suspension 5 Capsule, 6MG Oral Reconstituted, 50MG Capsule)

C1 Vray Intramuscular lar Vraylar (Oral Capsule 4 ST Suspension Therapy Pack)

Zipr asid one Reconstituted) HCl

Risp erid Ziprasidone HCl (Oral one 3 QL Risperidone (1MG/ML Capsule)

4 C1 Zypr exa Relp Oral Solution) revv

Risp erid Zyprexa Relprevv one Risperidone (0.25MG (210MG

Oral Tablet, 0.5MG Intramuscular 4 Oral Tablet, 1MG Oral Suspension Tablet, 2MG Oral 2 Tablet, 3MG Oral Reconstituted) Tablet, 4MG Oral B1 Treatment-Resistant C1 Cloz apin Tablet) e Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral 3 Tablet, 50MG Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 57 57 2956 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Cloz Intro apin n A e ODT Clozapine ODT Intron A (Injection 5 PA; LA (100MG Oral Tablet Solution)

C1 Intro Dispersible, 12.5MG n A Intron A (Injection Oral Tablet Solution 5 PA; LA Dispersible, 150MG Reconstituted)

C1 Peg Oral Tablet 4 QL asys

Pro Clic Dispersible, 200MG k Pegasys ProClick Oral Tablet (Subcutaneous 5 PA Dispersible, 25MG Solution) C1 Peg Oral Tablet asys Pegasys Dispersible)

C1 (Subcutaneous 5 PA Vers aclo z Versacloz (Oral Solution)

Riba 5 sph Suspension) ere Ribasphere (600MG A1 3 Antivirals Oral Tablet)

Riba virin B1 Anti-cytomegalovirus (CMV) Agents Ribavirin (Oral Tablet) 3

C1 C1 Valg Syla anci tron clovi r HCl Valganciclovir HCl Sylatron 5 PA (Oral Solution 5 QL (Subcutaneous Kit) Reconstituted) B1 C1 Anti-hepatitis C (HCV) Direct Acting Agents Valg anci clovi C1 r HCl Epcl Valganciclovir HCl usa 5 QL Epclusa (Oral Tablet) 5 PA; QL C1

Mav (Oral Tablet) yret

C1 Zirg an Mavyret (Oral Tablet) 5 PA; QL

C1 Sof osb uvir- Zirgan (Ophthalmic Velp atas 4 vir Sofosbuvir-Velpatasvir Gel) 5 PA; QL (Oral Tablet) B1

C1 Sov Anti-hepatitis B (HBV) Agents aldi

C1 Ade fovir Sovaldi (Oral Tablet) 5 PA; QL

Dipi voxil C1 Vos Adefovir Dipivoxil (Oral evi 5 Vosevi (Oral Tablet) 5 PA; QL

Tablet) B1

Bara clud e Antiherpetic Agents

Acy Baraclude (Oral clovi 4 r Acyclovir (External Solution) 4 QL C1 Ente cavir Ointment)

C1 Acy clovi Entecavir (Oral Tablet) 4 r

C1 Epiv ir HBV Acyclovir (Oral Epivir HBV (Oral 2 4 Capsule) C1 Acy clovi Solution) r

C1 Lam ivudi ne Acyclovir (Oral Lamivudine (100MG 3 3 Suspension) C1 Acy clovi Oral Tablet) r

Vem lidy Acyclovir (Oral Tablet) 1

Acy clovi r Sodi Vemlidy (Oral Tablet) 5 QL um

B1 Acyclovir Sodium 4 B/D, PA Anti-hepatitis C (HCV) Agents, Other (Intravenous Solution)

Bold type = Brand name drug Plain type = Generic drug 58 tRACK 58 Last updated October 1, 2019 3057 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Den Co avir mpl Denavir (External era Complera (Oral 5 QL 5 QL Cream) Tablet)

C1 C1 Fam Dels ciclo trigo vir Famciclovir (Oral Delstrigo (Oral 3 QL 5 QL Tablet) Tablet) C1 C1 Trifl uridi Edu ne Trifluridine rant Edurant (Oral Tablet) 5 QL

C1 3 Efav iren (Ophthalmic Solution) z C1 Efavirenz (Oral Vala cycl ovir HCl 4 QL Valacyclovir HCl (Oral Capsule)

C1 3 QL Efav iren Tablet) z Efavirenz (Oral Tablet) 5 QL

B1 C1

Intel enc Anti-HIV Agents, Integrase Inhibitors (INSTI) e C1 Intelence (100MG Dov ato Dovato (Oral Tablet) 5 QL Oral Tablet, 200MG 5 QL C1 Gen voya Genvoya (Oral Tablet) 5 QL Oral Tablet)

C1 C1 Isen Intel tres s enc HD Isentress HD (Oral e Intelence (25MG Oral 5 QL 4 QL Tablet) Tablet)

C1 C1 Isen tres Julu s Isentress (Oral ca Juluca (Oral Tablet) 5 QL

C1 Nevi 4 QL rapi ne Packet) ER Nevirapine ER (Oral C1

Isen tres s Isentress (Oral Tablet Extended 4 QL 5 QL Tablet) Release 24 Hour) C1

C1 Nevi rapi Isen ne tres s Nevirapine (Oral Isentress (100MG 4 QL Suspension)

Oral Tablet 5 QL C1 Nevi rapi Chewable) ne Nevirapine (Oral Tablet

C1 Isen 3 QL tres s Immediate Release) Isentress (25MG Oral C1 Ode 3 QL fsey Tablet Chewable) Odefsey (Oral Tablet) 5 QL C1

C1 Pifel tro Strib ild Stribild (Oral Tablet) 5 QL Pifeltro (Oral Tablet) 5 QL C1

C1 Res cript Tivic or ay Tivicay (10MG Oral Rescriptor (Oral 4 QL 4 QL Tablet) Tablet) C1

C1 Sym fi Lo Tivic ay Tivicay (25MG Oral Symfi Lo (Oral Tablet) 5 QL C1 Sym Tablet, 50MG Oral 5 QL fi Symfi (Oral Tablet) 5 QL Tablet) B1 Anti-HIV Agents, Nucleoside and Nucleotide C1 Triu meq Triumeq (Oral Tablet) 5 QL Reverse Transcriptase Inhibitors (NRTI)

C1 C1 Aba Tyb cavir ost Sulf Tybost (Oral Tablet) ate Abacavir Sulfate (Oral 4 QL 4 QL B1 Solution) Anti-HIV Agents, Non-nucleoside Reverse C1 Aba cavir

Sulf Transcriptase Inhibitors (NNRTI) ate Abacavir Sulfate (Oral

Atri 4 QL pla Atripla (Oral Tablet) 5 QL Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 59 59 3158 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Aba Vire cavir ad

Sulf ate- Lam ivudi ne Abacavir Sulfate- Viread (150MG Oral Lamivudine (Oral 4 QL Tablet, 200MG Oral 5 QL Tablet) Tablet, 250MG Oral C1 Aba cavir - Lam ivudi ne- Zido vudi ne Abacavir-Lamivudine- Tablet)

C1 Zido vudi Zidovudine (Oral 5 QL ne Zidovudine (Oral Tablet) 3 QL

C1 Capsule) Bikt arvy C1 Zido vudi Biktarvy (Oral Tablet) 5 QL ne

C1 Zidovudine (Oral Cim duo 3 QL Cimduo (Oral Tablet) 5 QL Syrup)

C1 C1 Des covy Zido vudi Descovy (Oral Tablet) 5 QL ne Zidovudine (Oral

Dida nosi ne 3 QL Didanosine (Oral Tablet) Capsule Delayed 3 QL B1 Anti-HIV Agents, Other

Fuz Release) eon C1 Fuzeon Emt riva Emtriva (Oral (Subcutaneous 4 QL 5 QL Capsule) Solution C1 Emt riva Emtriva (Oral Reconstituted)

C1 Selz entr 4 QL y Solution) Selzentry (Oral C1 Lam ivudi ne 5 QL Lamivudine (10MG/ML Solution)

C1 Selz 3 QL entr Oral Solution) y

C1 Selzentry (150MG

Lam ivudi ne Lamivudine (150MG Oral Tablet, 300MG 5 QL Oral Tablet, 300MG 3 QL Oral Tablet, 75MG Oral Tablet)

C1 Oral Tablet) Lam ivudi C1 ne- Zido Selz vudi entr ne Lamivudine- y Selzentry (25MG Oral 3 QL Zidovudine (Oral 4 QL Tablet)

Tablet) B1

C1 Stav udin e Anti-HIV Agents, Protease Inhibitors

C1 Apti Stavudine (Oral vus 3 QL Aptivus (Oral Capsule) 5 QL C1 Ten ofov ir Diso Capsule) prox il Fum C1 arat e Apti Tenofovir Disoproxil vus 4 QL Fumarate (Oral Tablet) Aptivus (Oral

C1 5 QL Truv ada Solution)

C1 Ataz Truvada (Oral Tablet) 5 QL anav ir Sulf C1 ate Vide x EC Atazanavir Sulfate Videx EC (125MG 5 QL (Oral Capsule)

Crixi Oral Capsule Delayed 4 QL van Crixivan (Oral Release) 3 QL C1 Vide x Capsule)

Evot Videx (Oral Solution az 4 QL Reconstituted) Evotaz (Oral Tablet) 5 QL

C1 Vire ad Viread (Oral Powder) 5 QL

Bold type = Brand name drug Plain type = Generic drug 60 tRACK 60 Last updated October 1, 2019 3259 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Fos Rele amp nza rena Disk vir hale Calc r ium Fosamprenavir Relenza Diskhaler 5 QL Calcium (Oral Tablet) (Inhalation Aerosol C1 Invir ase 3 QL Invirase (Oral Tablet) 5 QL Powder Breath

C1 Kale tra Kaletra (100-25MG Activated) C1 Rim anta dine 4 QL HCl Oral Tablet) Rimantadine HCl (Oral

C1 Kale tra 4 Tablet)

Kaletra (200-50MG C1 Xofl 5 QL uza Oral Tablet) Xofluza (Oral Tablet

C1 Lexi 3 QL va Lexiva (Oral Therapy Pack) 4 QL A1 Suspension) Anxiolytics

Lopi B1 navi r- Rito navi r Lopinavir-Ritonavir Anxiolytics, Other C1

Bus piro ne 4 QL HCl (Oral Solution) Buspirone HCl (Oral C1 Nor vir 2 Norvir (Oral Packet) 4 QL Tablet) C1 C1 Hyd roxy Nor zine vir Norvir (Oral Solution) 4 QL HCl Hydroxyzine HCl (Oral

C1 Prez 3 cobi x Syrup)

C1 Prezcobix (Oral Hyd roxy zine 5 QL HCl Tablet) Hydroxyzine HCl (Oral C1 3 Prez ista Tablet) Prezista (Oral 5 QL B1 Benzodiazepines Suspension) C1 Alpr azol C1 am Prez ista Prezista (150MG Oral Alprazolam (Oral Tablet, 75MG Oral 4 QL Tablet Immediate 1 QL Release)

C1 Chlo Tablet) rdia zep oxid C1 e HCl Prez ista Chlordiazepoxide HCl Prezista (600MG Oral 2 (Oral Capsule)

C1 Clon aze Tablet, 800MG Oral 5 QL pam Tablet) Clonazepam (0.5MG

C1 Rey ataz Oral Tablet, 1MG Oral Reyataz (Oral Packet) 5 QL 2 QL C1 Tablet, 2MG Oral Rito navi r Ritonavir (Oral Tablet) 3 QL Tablet) C1 C1 Sym tuza Clon aze pam

Symtuza (Oral Tablet) 5 QL ODT Clonazepam ODT C1 Vira cept Viracept (Oral Tablet) 5 QL (0.125MG Oral Tablet B1 Anti-influenza Agents Dispersible, 0.25MG

C1 Osel tami vir Pho Oral Tablet sph ate Oseltamivir Phosphate 3 QL Dispersible, 0.5MG (Oral Capsule) 4 QL

C1 Osel Oral Tablet tami vir Pho sph ate Oseltamivir Phosphate Dispersible, 1MG Oral (Oral Suspension 3 QL Tablet Dispersible, Reconstituted) 2MG Oral Tablet Dispersible)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 61 61 3360 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Clor Lithi aze um pate Car bon Dip ate otas siu m Clorazepate Lithium Carbonate Dipotassium (Oral 3 QL (Oral Tablet Immediate 2 Tablet) Release)

C1 C1 Diaz Lithi epa um m Inte nsol Diazepam Intensol Lithium (Oral 3 (5MG/ML Oral 2 QL Solution)

Concentrate) A1 C1 Blood Glucose Regulators Diaz epa m Diazepam (5MG/5ML B1 2 Antidiabetic Agents C1

Acar bos Oral Solution) e

C1 Diaz epa m Acarbose (Oral Tablet) 1 QL

Byd ureo n Diazepam (10MG Oral BCis e Tablet, 2MG Oral Bydureon BCise 2 QL Tablet, 5MG Oral (Subcutaneous Auto- 3 QL Injector)

Tablet) C1 Byd C1 ureo n Lora zep am Lorazepam (2MG/ML Bydureon 2 QL Oral Concentrate) (Subcutaneous Pen- 3 QL

Lora zep am Injector) Lorazepam (0.5MG C1 Byet ta 10M CG Oral Tablet, 1MG Oral Pen Byetta 10MCG Pen 1 QL Tablet, 2MG Oral (Subcutaneous 4 QL Tablet) Solution Pen-Injector)

C1 Byet A1 ta 5M CG Bipolar Agents Pen Byetta 5MCG Pen B1 Mood Stabilizers (Subcutaneous 4 QL

C1 Diva lpro ex Sodi um ER Divalproex Sodium ER Solution Pen-Injector) C1

Cycl oset (Oral Tablet Extended 2 Cycloset (Oral Tablet) 4 PA; QL

C1 Glim epiri Release 24 Hour) de C1 Glimepiride (Oral Diva lpro ex Sodi um 1 QL Divalproex Sodium Tablet) C1 Glipi zide (Oral Capsule Delayed 2 ER Glipizide ER (Oral Release Sprinkle) C1 Tablet Extended 1 QL Diva lpro ex Sodi um Divalproex Sodium Release 24 Hour) C1 Glipi (Oral Tablet Delayed 2 zide Glipizide (Oral Tablet Release) 1 QL C1 Immediate Release) Lithi um Car C1 bon Glipi ate zide- ER Metf ormi n Lithium Carbonate ER HCl Glipizide-Metformin 1 QL (Oral Tablet Extended 2 HCl (Oral Tablet)

Glyx amb Release) i

C1 Lithi um Glyxambi (Oral Car bon ate Lithium Carbonate 3 QL 2 Tablet) (Oral Capsule)

Bold type = Brand name drug Plain type = Generic drug 62 tRACK 62 Last updated October 1, 2019 3461 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Invo Oze kam mpi et Invokamet (Oral c Ozempic (0.25 or 0.5 Tablet Immediate 3 QL MG/DOSE) 3 QL Release) (Subcutaneous

C1 Invo kam et XR Invokamet XR (Oral Solution Pen-Injector) C1 Oze mpi Tablet Extended 3 QL c Ozempic (1 MG/ Release 24 Hour) DOSE)

C1 Invo kan a 3 QL Invokana (Oral Tablet) 3 QL (Subcutaneous

C1 Jan ume t Solution Pen-Injector)

Janumet (Oral Tablet C1 Piog litaz one 3 QL HCl Immediate Release) Pioglitazone HCl (Oral

Jan 1 QL ume t XR Tablet)

C1 Janumet XR (Oral Piog litaz one HCl- Glim epiri Tablet Extended 3 QL de Pioglitazone HCl- Release 24 Hour) Glimepiride (Oral 1 QL

Jan uvia Tablet)

Piog litaz Januvia (Oral Tablet) 3 QL one HCl- Metf C1 ormi n Jard HCl ianc e Pioglitazone HCl- Jardiance (Oral 3 QL Metformin HCl (Oral 1 QL Tablet)

C1 Jent Tablet) adu eto C1

Rep agli Jentadueto (Oral nide Repaglinide (Oral 1 QL Tablet Immediate 3 QL Tablet)

C1 Rep agli nide - Metf Release) ormi n HCl C1 Jent Repaglinide-Metformin adu eto XR 4 QL Jentadueto XR (Oral HCl (Oral Tablet)

C1 Rio Tablet Extended 3 QL met Riomet (Oral Release 24 Hour) 4 QL C1 Solution) Metf ormi n C1 HCl ER Soli Metformin HCl ER qua Soliqua (Oral Tablet Extended (Subcutaneous 3 QL Release 24 Hour) 1 QL Solution Pen-Injector)

Sym (Generic Glucophage linP en 120 XR) SymlinPen 120

C1 Metf ormi n HCl Metformin HCl (Oral (Subcutaneous 5 PA Solution Pen-Injector) Tablet Immediate 1 QL C1 Sym linP en Release) 60 SymlinPen 60

C1 Migl itol Miglitol (Oral Tablet) 4 QL (Subcutaneous 5 PA

C1 Nat egli nide Solution Pen-Injector)

C1 Nateglinide (Oral Synj 1 QL ardy Synjardy (Oral Tablet Tablet) 3 QL Immediate Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 63 63 3562 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Synj Hu ardy mal XR og Mix 50/5 Synjardy XR (Oral 0 Humalog Mix 50/50

Tablet Extended 3 QL (Subcutaneous 3 Release 24 Hour) Suspension)

C1 C1 Trad Hu jent mal a og Mix 75/2 5 Kwi kPe Tradjenta (Oral n Humalog Mix 75/25 3 QL Tablet) KwikPen

C1 Truli city Trulicity (Subcutaneous 3 (Subcutaneous 3 QL Suspension Pen- Solution Pen-Injector) Injector) C1 C1 Hu mal Vict og oza Mix 75/2 5 Humalog Mix 75/25 Victoza (Subcutaneous 3 QL (Subcutaneous 3 Solution Pen-Injector) Suspension) C1 Hu mal og B1 Glycemic Agents Humalog C1 Gluc aGe n Hyp oKit GlucaGen HypoKit (Subcutaneous 3 Solution) (Injection Solution 4 C1 Hu mal Reconstituted) og Humalog C1 Gluc ago n Eme rgen cy Glucagon Emergency (Subcutaneous 3 3 Solution Cartridge)

(Injection Kit) C1 Hu muli C1 n Pro 70/3 glyc 0 em Kwi kPe Proglycem (Oral n Humulin 70/30 5 KwikPen Suspension) B1 Insulins (Subcutaneous 3

Hu mal og Juni Suspension Pen- or Kwi kPe n Humalog Junior Injector)

C1 Hu muli KwikPen n 70/3 3 0 Humulin 70/30 (Subcutaneous Solution Pen-Injector) (Subcutaneous 3

C1 Hu mal og Kwi Suspension) kPe n C1 Hu muli Humalog KwikPen n N Kwi kPe n (Subcutaneous 3 Humulin N KwikPen (Subcutaneous Solution Pen-Injector) 3 C1 Hu mal og Mix Suspension Pen- 50/5 0 Kwi kPe n Humalog Mix 50/50 Injector)

C1 Hu muli KwikPen n N Humulin N (Subcutaneous 3 Suspension Pen- (Subcutaneous 3 Suspension)

C1 Injector) Hu muli n R Humulin R (Injection 3 Solution)

Bold type = Brand name drug Plain type = Generic drug 64 tRACK 64 Last updated October 1, 2019 3663 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Hu Tres muli iba n R U-50 0 Humulin R U-500 Tresiba

(Concentrated) (Subcutaneous 3 3 (Subcutaneous Solution) Solution) A1 Blood Products/Modifiers/Volume Expanders C1 Hu muli n R U-50 0 B1 Kwi kPe n Humulin R U-500 Anticoagulants

C1 Cou mad KwikPen in Coumadin (Oral 3 4 (Subcutaneous Tablet)

Eliq Solution Pen-Injector) uis

C1 Insul Eliquis (Oral Tablet) 3 QL in Lisp ro C1

Eliq uis Start er Pac Insulin Lispro k Eliquis Starter Pack (Subcutaneous 3 3 QL (Oral Tablet)

C1 Eno Solution) xap arin Sodi C1 um Insul in Lisp ro Enoxaparin Sodium Insulin Lispro (Subcutaneous 4 QL (Subcutaneous 3 Solution)

C1 Fon Solution Pen-Injector) dap arin ux C1 Sodi um Lant us Solo Star Fondaparinux Sodium Lantus SoloStar (10MG/0.8ML (Subcutaneous 3 Subcutaneous Solution Pen-Injector) C1 Solution, 5MG/0.4ML Lant us Lantus 5 Subcutaneous (Subcutaneous 3 Solution, 7.5MG/ Solution) 0.6ML Subcutaneous

C1 Lev emir

Flex Tou ch Solution) Levemir FlexTouch C1 Fon dap arin ux Sodi um (Subcutaneous 3 Fondaparinux Sodium Solution Pen-Injector) (2.5MG/0.5ML

C1 4 Lev emir Subcutaneous Levemir Solution)

Hep arin (Subcutaneous 3 Sodi um Solution) Heparin Sodium

C1 Touj eo Max (10000UNIT/ML Solo Star Toujeo Max SoloStar Injection Solution, (Subcutaneous 3 20000UNIT/ML 3 Solution Pen-Injector) Injection Solution, C1

Touj eo Solo Star Toujeo SoloStar 5000UNIT/ML

(Subcutaneous 3 Injection Solution) C1 Hep arin Sodi Solution Pen-Injector) um Heparin Sodium

C1 Tres iba Flex Tou ch Tresiba FlexTouch (1000UNIT/ML 3 B/D, PA Injection Solution) (Subcutaneous C1 3 Jant ove n Solution Pen-Injector) Jantoven (Oral Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 65 65 3764 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Warf Aran arin esp Sodi um Warfarin Sodium (Oral Aranesp (Albumin 1 Tablet) Free) (100MCG/ C1 Xare lto Xarelto (Oral Tablet) 3 QL 0.5ML Injection

C1 Xare lto Start er Pac k Xarelto Starter Pack Solution Prefilled (Oral Tablet Therapy 3 QL Syringe, 150MCG/ Pack) 0.3ML Injection B1 Blood Formation Modifiers Solution Prefilled

Ana greli de HCl Syringe, 200MCG/ Anagrelide HCl (Oral 3 Capsule) 0.4ML Injection

Aran esp Solution Prefilled 5 PA Aranesp (Albumin Syringe, 300MCG/ Free) (100MCG/ML 0.6ML Injection Injection Solution, Solution Prefilled 200MCG/ML Syringe, 500MCG/ML Injection Solution, 5 PA Injection Solution 300MCG/ML Prefilled Syringe, Injection Solution, 60MCG/0.3ML 60MCG/ML Injection Injection Solution Solution)

C1 Aran esp Prefilled Syringe)

C1 Aran Aranesp (Albumin esp Aranesp (Albumin Free) (25MCG/ML Free) (10MCG/0.4ML Injection Solution, 4 PA Injection Solution 40MCG/ML Injection Prefilled Syringe, Solution) 25MCG/0.42ML 4 PA Injection Solution Prefilled Syringe, 40MCG/0.4ML Injection Solution Prefilled Syringe)

C1 Gra nix Granix (Subcutaneous 5 ST Solution)

Bold type = Brand name drug Plain type = Generic drug 66 tRACK 66 Last updated October 1, 2019 3865 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Gra Reta nix Granix crit Retacrit (10000UNIT/ (Subcutaneous ML Injection Solution, 5 ST Solution Prefilled 2000UNIT/ML Syringe) Injection Solution,

C1 Leu kine 4 PA Leukine (Injection 3000UNIT/ML Solution 5 PA Injection Solution, Reconstituted) 4000UNIT/ML

C1 Neul asta Injection Solution)

Neulasta C1 Reta crit (Subcutaneous Retacrit (40000UNIT/ 5 PA 5 PA Solution Prefilled ML Injection Solution) C1 Ude Syringe) nyca Udenyca

C1 Neu pog en Neupogen (Injection (Subcutaneous 5 ST 5 PA Solution) Solution Prefilled

Neu pog en Syringe)

Neupogen (Injection C1 Zarx io Zarxio (Injection Solution Prefilled 5 ST Syringe) Solution Prefilled 5

Proc rit Procrit (10000UNIT/ Syringe) ML Injection Solution, B1 Hemostasis Agents C1

Tran exa mic 2000UNIT/ML Acid Tranexamic Acid (Oral 3 Injection Solution, Tablet)

4 PA B1 3000UNIT/ML Platelet Modifying Agents

C1 Aspi rin- Dipy rida mol e Injection Solution, ER Aspirin-Dipyridamole 4000UNIT/ML ER (Oral Capsule 3 QL Injection Solution) Extended Release 12

C1 Proc rit Procrit (20000UNIT/ Hour) C1 Brili ML Injection Solution, nta Brilinta (Oral Tablet) 3 QL C1

Cabl 5 PA ivi 40000UNIT/ML Cablivi (Injection Kit) 5 PA; QL

C1 Cilo staz ol Injection Solution) Cilostazol (Oral Tablet) 2 C1 Pro mac C1 ta Clo pido grel Bisu Promacta (Oral lfate Clopidogrel Bisulfate 5 PA; LA; QL 2 QL Packet) (75MG Oral Tablet) C1 Pro C1 mac Pras ta ugre l Promacta (Oral HCl Prasugrel HCl (Oral 5 PA; LA; QL 3 QL Tablet) Tablet) A1 Cardiovascular Agents B1 Alpha-adrenergic Agonists

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 67 67 3966 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Clon idin e B1 HCl Clonidine HCl (Oral Angiotensin-converting Enzyme (ACE) Tablet Immediate 1 Inhibitors

C1 Ben aze pril Release) HCl C1 Benazepril HCl (Oral Clon idin e 1 QL Clonidine Tablet) C1 Cap topri (Transdermal Patch 4 l Captopril (Oral Tablet) 1 QL

C1 Enal april

Weekly) Mal eate

C1 Met hyld opa Enalapril Maleate (Oral Methyldopa (Oral 1 QL 3 Tablet) C1

Fosi nopr il Tablet) Sodi um

C1 Mid odri ne Fosinopril Sodium HCl Midodrine HCl (Oral 1 QL 3 (Oral Tablet) C1

Lisin Tablet) opril

Nort hera Lisinopril (Oral Tablet) 1 QL

C1 Moe xipril Northera (Oral HCl 5 PA; LA; QL Moexipril HCl (Oral Capsule) 1 QL Tablet) B1

C1 Peri ndo pril Erb umi Alpha-adrenergic Blocking Agents ne

C1 Dox azos Perindopril Erbumine in Mes ylate 1 QL Doxazosin Mesylate (Oral Tablet)

2 C1 Quin april (Oral Tablet) HCl

C1 Phe nox Quinapril HCl (Oral ybe nza min e HCl 1 QL Phenoxybenzamine Tablet) 5 C1 Ram HCl (Oral Capsule) ipril

C1 Praz osin Ramipril (Oral HCl 1 QL Prazosin HCl (Oral Capsule) 2 C1 Tran dola Capsule) pril Trandolapril (Oral B1 Angiotensin II Receptor Antagonists 1 QL

C1 Tablet) Can des arta n Cile xetil Candesartan Cilexetil B1 Antiarrhythmics

1 QL C1 Ami odar one (Oral Tablet) HCl

C1 Edar bi Amiodarone HCl Edarbi (Oral Tablet) 4 QL 1

C1 (200MG Oral Tablet) Epr osar C1 tan Mes Dof ylate etili Eprosartan Mesylate de 1 QL Dofetilide (Oral (Oral Tablet) 4

C1 Capsule) Irbe sart C1 an Flec aini de Acet Irbesartan (Oral Tablet) 1 QL ate C1 Flecainide Acetate Los arta n Pota ssiu 2 m Losartan Potassium (Oral Tablet)

C1 Mex 1 QL iletin e (Oral Tablet) HCl C1 Mexiletine HCl (Oral Olm esar tan Med oxo 3 mil Olmesartan Capsule)

C1 Mult Medoxomil (Oral 1 QL aq Multaq (Oral Tablet) 3 QL

C1 Pac eron Tablet) e

C1 Tel misa Pacerone (200MG Oral rtan Telmisartan (Oral 1 1 QL Tablet) Tablet)

C1 Vals arta n Valsartan (Oral Tablet) 1 QL

Bold type = Brand name drug Plain type = Generic drug 68 tRACK 68 Last updated October 1, 2019 4067 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Pro Nad pafe olol non e HCl ER Propafenone HCl ER Nadolol (Oral Tablet) 4

C1 Pind olol (Oral Capsule Pindolol (Oral Tablet) 3

4 C1 Pro pran olol HCl Extended Release 12 ER Propranolol HCl ER Hour)

C1 Pro pafe (Oral Capsule non e HCl Propafenone HCl (Oral 2 2 Extended Release 24 Tablet)

C1 Hour) Quin idin C1 e Gluc Pro onat pran e olol ER Quinidine Gluconate HCl Propranolol HCl (Oral 2 ER (Oral Tablet 4 Solution)

Pro pran olol Extended Release) HCl

C1 Quin idin Propranolol HCl (Oral e Sulf ate Quinidine Sulfate (Oral 2 2 Tablet) Tablet) B1

Sota lol Calcium Channel Blocking Agents HCl C1 Aml odip ine Bes Sotalol HCl (AF) ylate 2 Amlodipine Besylate (120MG Oral Tablet) 1

Sota lol (Oral Tablet) HCl C1 Carti Sotalol HCl (Oral a XT 2 Cartia XT (Oral Tablet) Capsule Extended 2 B1 Beta-adrenergic Blocking Agents

C1 Release 24 Hour) Ace buto C1 lol HCl Dilti aze m HCl ER Bea Acebutolol HCl (Oral ds 2 Diltiazem HCl ER Capsule)

C1 Beads (360MG Oral Aten olol Atenolol (Oral Tablet) 1 Capsule Extended

C1 Beta xolo l HCl Betaxolol HCl (Oral Release 24 Hour, 2 3 Tablet) 420MG Oral Capsule

C1 Biso prol ol Fum arat e Bisoprolol Fumarate Extended Release 24 2 Hour)

Dilti (Oral Tablet) aze m HCl C1 ER Coa Byst ted olic Bea Bystolic (Oral Tablet) 3 QL ds Diltiazem HCl ER

C1 Carv edil ol Coated Beads (120MG Carvedilol (Oral Tablet) 1 C1 Oral Capsule Extended Lab etal ol HCl Labetalol HCl (Oral 2 Release 24 Hour, Tablet) 180MG Oral Capsule C1

Met opr olol Suc cina te ER Extended Release 24 Metoprolol Succinate 2 ER (Oral Tablet Hour, 240MG Oral 1 Extended Release 24 Capsule Extended Hour) Release 24 Hour,

C1 Met opr olol Tartr ate Metoprolol Tartrate 300MG Oral Capsule (100MG Oral Tablet, Extended Release 24 1 25MG Oral Tablet, Hour) 50MG Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 69 69 4168 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Dilti Vera aze pam m il HCl HCl ER ER Diltiazem HCl ER (Oral Verapamil HCl ER Capsule Extended 2 (100MG Oral Capsule Release 12 Hour) Extended Release 24

C1 Dilti aze m HCl Hour, 120MG Oral Diltiazem HCl (Oral Tablet Immediate 2 Capsule Extended Release) Release 24 Hour,

C1 Dilt- XR Dilt-XR (Oral Capsule 180MG Oral Capsule Extended Release 24 Extended Release 24 2 3 Hour) Hour, 200MG Oral

C1 Felo dipi ne Capsule Extended ER Felodipine ER (Oral Release 24 Hour, Tablet Extended 2 240MG Oral Capsule Release 24 Hour) C1 Extended Release 24 Mat zim LA Matzim LA (Oral Tablet Hour, 300MG Oral Extended Release 24 2 Capsule Extended Hour) Release 24 Hour) C1 C1 Nica rdipi Vera ne pam HCl il HCl Nicardipine HCl (Oral ER 3 Verapamil HCl ER Capsule) (360MG Oral Capsule C1 Nife dipi ne ER 3 Nifedipine ER (Oral Extended Release 24 Tablet Extended 2 QL Hour)

C1 Vera pam il HCl Release 24 Hour) ER C1 Verapamil HCl ER Nife dipi ne ER Os moti c Rele ase Nifedipine ER Osmotic (Oral Tablet Extended 2 Release (Oral Tablet Release)

C1 2 QL Vera pam il Extended Release 24 HCl Verapamil HCl (Oral Hour) C1 Tablet Immediate 2 Nim odip ine Nimodipine (Oral 4 Release) Capsule) B1 C1 Cardiovascular Agents, Other Nym alize C1

Alis kire n Fum arat Nymalize (60MG/ e 5 Aliskiren Fumarate 20ML Oral Solution) 4 QL

C1 (Oral Tablet) Tazt ia C1 XT Amil orid e- Hyd roch lorot hiazi Taztia XT (Oral de Amiloride- Capsule Extended 2 Hydrochlorothiazide 2 Release 24 Hour) (Oral Tablet)

C1 Aml odip ine- Ator vast atin Amlodipine- Atorvastatin (Oral 2 QL Tablet)

C1 Aml odip ine- Ben aze pril Amlodipine-Benazepril 1 QL (Oral Capsule)

Bold type = Brand name drug Plain type = Generic drug 70 tRACK 70 Last updated October 1, 2019 4269 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Aml Enal odip april ine- - Olm Hyd esar roch tan lorot hiazi Amlodipine- de Enalapril- Olmesartan (Oral 2 QL Hydrochlorothiazide 1 QL Tablet) (Oral Tablet)

C1 C1 Aml Entr odip esto ine- Vals arta n Amlodipine-Valsartan Entresto (Oral Tablet) 3 QL

C1 Fosi 2 QL nopr il Sodi um- HCT (Oral Tablet) Z

C1 Fosinopril Sodium- Aml odip ine- Vals arta 1 QL n- HCT Z Amlodipine-Valsartan- HCTZ (Oral Tablet)

C1 Irbe 2 QL sart an- Hyd roch lorot hiazi HCTZ (Oral Tablet) de

C1 Irbesartan- Aten olol- Chlo rthal idon e Atenolol- Hydrochlorothiazide 1 QL Chlorthalidone (Oral 1 (Oral Tablet)

Lan Tablet) oxin

C1 Lanoxin (Oral Tablet) 4 Ben aze C1 pril- Hyd Lisin roch opril lorot - hiazi Hyd de roch lorot hiazi Benazepril- de Lisinopril- Hydrochlorothiazide 1 QL Hydrochlorothiazide 1 QL (Oral Tablet)

C1 (Oral Tablet) BiDil C1 Los arta n Pota ssiu m- HCT BiDil (Oral Tablet) 3 QL Z

C1 Losartan Potassium- Biso prol ol- Hyd roch 1 QL lorot hiazi de Bisoprolol- HCTZ (Oral Tablet)

C1 Met hyld opa- Hyd roch lorot hiazi Hydrochlorothiazide 2 QL de Methyldopa- (Oral Tablet)

C1 Hydrochlorothiazide 3 Can des arta n Cile xetil- HCT Z Candesartan Cilexetil- (Oral Tablet)

C1 Met 1 QL opr olol- Hyd roch lorot hiazi HCTZ (Oral Tablet) de

C1 Metoprolol- Cap topri l- Hyd roch lorot hiazi de Captopril- Hydrochlorothiazide 2 Hydrochlorothiazide 1 QL (Oral Tablet)

Nad olol- Ben drofl ume thiaz (Oral Tablet) ide

C1 Nadolol- Corl anor Corlanor (Oral Bendroflumethiazide 3 4 PA; QL Solution) (40-5MG Oral Tablet) C1 C1 Olm Corl esar anor tan Med oxo mil- HCT Corlanor (Oral Tablet) 4 PA; QL Z Olmesartan

C1 De mse r Demser (Oral Medoxomil-HCTZ (Oral 1 QL 5 Tablet)

C1 Capsule) Olm esar tan- C1 Aml odip Digit ine- ek HCT Z Digitek (Oral Tablet) 2 Olmesartan-

Dig ox Amlodipine-HCTZ 2 QL Digox (Oral Tablet) 2 C1 (Oral Tablet) Dig oxin C1 Pent oxify lline Digoxin (Oral ER 3 Pentoxifylline ER (Oral Solution)

C1 Tablet Extended 2 Dig oxin Digoxin (Oral Tablet) 2 Release)

C1 C1

Edar Pro bycl pran or olol- HCT Edarbyclor (Oral Z Propranolol-HCTZ 4 QL 2 Tablet) (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 71 71 4370 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Quin Bum april etan - ide Hyd roch lorot hiazi de Quinapril- Bumetanide (Oral 1 Hydrochlorothiazide 1 QL Tablet)

C1 Etha cryn ic (Oral Tablet) Acid C1 Ethacrynic Acid (Oral Ran olazi ne ER 4 Ranolazine ER (Oral Tablet)

C1 Furo sem Tablet Extended 3 QL ide Furosemide (Injection Release 12 Hour) 4 B/D, PA

C1 Solution) Spir onol C1 acto ne- Furo HCT sem Z Spironolactone-HCTZ ide 2 Furosemide (Oral (Oral Tablet) 2

C1 Solution) Tel misa C1 rtan- Aml Furo odip sem ine Telmisartan- ide Furosemide (Oral 1 Amlodipine (Oral 1 QL Tablet)

Tors emi Tablet) de

Tel misa Torsemide (Oral rtan- HCT Z Telmisartan-HCTZ 2 1 QL Tablet) (Oral Tablet) B1

Tria mter Diuretics, Potassium-sparing ene- HCT Z C1 Amil orid e Triamterene-HCTZ HCl 2 Amiloride HCl (Oral (Oral Capsule) 2

C1 Tria mter Tablet) ene- HCT Z C1 Eple reno Triamterene-HCTZ ne 2 Eplerenone (Oral (Oral Tablet) 3

C1 Vals arta Tablet) n- Hyd roch C1 lorot hiazi Spir de onol acto Valsartan- ne Spironolactone (Oral Hydrochlorothiazide 1 QL 2 Tablet)

C1 Tria mter (Oral Tablet) ene

C1 Vyn daq el Triamterene (Oral Vyndaqel (Oral 4 5 PA; QL Capsule)

Capsule) B1

B1 Diuretics, Thiazide

C1 Chlo rothi azid Diuretics, Carbonic Anhydrase Inhibitors e

C1 Acet azol ami de Chlorothiazide (Oral ER 2 Acetazolamide ER Tablet)

Chlo rthal idon (Oral Capsule e 4 Chlorthalidone (Oral Extended Release 12 2 Tablet)

C1 Hour) Diuri l

C1 Acet azol ami de Diuril (Oral Acetazolamide (Oral 4 3 Suspension) Tablet) C1 Hyd roch C1 lorot hiazi Met de haz ola mid e Hydrochlorothiazide Methazolamide (Oral 1 4 (Oral Capsule) Tablet) C1 Hyd roch lorot hiazi de B1 Diuretics, Loop Hydrochlorothiazide

C1 1

Bum etan ide (Oral Tablet)

C1 Inda pam Bumetanide (Injection ide 4 Indapamide (Oral Solution) 2 Tablet)

Bold type = Brand name drug Plain type = Generic drug 72 tRACK 72 Last updated October 1, 2019 4471 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Met Ros hycl uvas othi tatin azid e Calc Methyclothiazide (5MG ium Rosuvastatin Calcium 3 1 QL Oral Tablet) (Oral Tablet)

C1 C1 Met Sim olaz vast one Metolazone (Oral atin Simvastatin (Oral 3 1 QL Tablet) Tablet) B1 Dyslipidemics, Fibric Acid Derivatives B1 Dyslipidemics, Other

C1 C1 Fen Chol ofibr esty ate rami Micr ne oniz Ligh ed Fenofibrate Micronized t Cholestyramine Light 4 (134MG Oral Capsule, (Oral Powder)

Chol 2 esty rami 200MG Oral Capsule, ne Cholestyramine (Oral 67MG Oral Capsule) 4

C1 Packet) Fen ofibr C1 ate Cole seve lam Fenofibrate (145MG HCl Colesevelam HCl (Oral 3 Oral Tablet, 48MG Oral 2 Packet)

C1 Cole seve lam Tablet) HCl C1 Fen ofibr Colesevelam HCl (Oral ate 3 Fenofibrate (160MG Tablet) C1 Cole stip ol Oral Tablet, 54MG Oral 1 HCl Colestipol HCl (Oral Tablet) 4

C1 Fen ofibr Packet) ic Acid C1 Cole stip ol Fenofibric Acid (Oral HCl Colestipol HCl (Oral Capsule Delayed 3 3 Tablet)

Ezet imib Release) e

C1 Fen ofibr ic Acid Ezetimibe (Oral Tablet) 2 QL

C1 Ezet Fenofibric Acid imib e- Sim vast 3 atin Ezetimibe-Simvastatin (105MG Oral Tablet) 3 QL C1 Fen ofibr ic (Oral Tablet) Acid

C1 Juxt Fenofibric Acid (35MG apid 3 Juxtapid (Oral Oral Tablet) 5 PA; LA C1

Ge mfib rozil Capsule)

C1 Niac in Gemfibrozil (Oral ER 2 Tablet) Niacin ER

B1 (Antihyperlipidemic) Dyslipidemics, HMG CoA Reductase 4 (Oral Tablet Extended Inhibitors

C1 Ator Release) vast atin Calc C1 ium Niac Atorvastatin Calcium or 1 QL Niacor (Oral Tablet) 2 C1

Om ega- 3- (Oral Tablet) Acid Ethy l C1 Este Fluv rs asta tin Omega-3-Acid Ethyl Sodi um Fluvastatin Sodium 2 QL Esters (Oral Capsule) 4 QL (Oral Capsule)

Lival (Generic Lovaza) o C1 Pral Livalo (Oral Tablet) 3 QL uent C1 Praluent Lov asta tin Lovastatin (Oral 1 QL (Subcutaneous 4 PA; LA; QL Tablet) C1 Solution Pen-Injector) Prav asta tin C1 Sodi um Prev Pravastatin Sodium alite 1 QL Prevalite (Oral Packet) 4 (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 73 73 4572 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Rep Nitr atha o- Bid Pus htro nex Syst em Repatha Pushtronex Nitro-Bid (Transdermal 4 System Ointment) C1 Nitr ogly ceri 4 PA; QL n (Subcutaneous Nitroglycerin (Tablet 2 Solution Cartridge) Sublingual)

C1 C1 Rep Nitr ogly atha ceri n Repatha Nitroglycerin (Subcutaneous (Transdermal Patch 24 2 4 PA; QL Solution Prefilled Hour) C1 Nitr ogly ceri Syringe) n Nitroglycerin

C1 Rep 3 atha

Sure Clic k (Translingual Solution) Repatha SureClick C1 Nitr osta (Subcutaneous t Nitrostat (Tablet 4 PA; QL 3 Solution Auto- Sublingual) C1

Rect Injector) iv Rectiv (Rectal

C1 Vas cep a 4 Vascepa (Oral Ointment)

4 A1 Capsule) Central Nervous System Agents B1 Vasodilators, Direct-acting Arterial B1 Attention Deficit Hyperactivity Disorder

Hyd ralaz ine HCl Hydralazine HCl (Oral Agents, Amphetamines C1 Am phet ami 2 ne- Dext roa mph eta min Tablet) e ER Amphetamine- C1 Min oxid il Minoxidil (Oral Tablet) 2 Dextroamphetamine B1 Vasodilators, Direct-acting Arterial/Venous ER (Oral Capsule 4 QL

C1 Isos orbi de Extended Release 24 Dinit rate ER Isosorbide Dinitrate ER Hour)

Am phet ami (Oral Tablet Extended 2 ne- Dext roa mph eta min Release) e Amphetamine-

Isos orbi de Dinit Dextroamphetamine 3 QL rate Isosorbide Dinitrate (Oral Tablet)

C1 Dext roa mph (Oral Tablet Immediate 2 eta min e Sulf ate Release) ER Dextroamphetamine

C1 Isos orbi de Sulfate ER (Oral Mon onitr ate ER 4 QL Isosorbide Capsule Extended Mononitrate ER (Oral 2 Release 24 Hour) C1 Dext roa mph Tablet Extended eta min e Sulf ate Dextroamphetamine Release 24 Hour) 4 QL C1 Isos orbi de Sulfate (Oral Tablet) Mon onitr ate C1 Vyv ans Isosorbide e Vyvanse (Oral Mononitrate (Oral 4 2 Capsule) Tablet Immediate C1 Vyv ans Release) e Vyvanse (Oral Tablet

C1 Mini tran 4 Minitran (Transdermal Chewable) 2 Patch 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 74 tRACK 74 Last updated October 1, 2019 4673 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Ingr ezza B1 Attention Deficit Hyperactivity Disorder Ingrezza (Oral Agents, Non-amphetamines Capsule Therapy 5 PA; QL

C1 Ato mox etin e HCl Atomoxetine HCl (Oral Pack) C1 Na mza 4 QL ric Capsule) Namzaric (Oral C1 Clon idin e HCl ER Clonidine HCl ER (Oral Capsule ER 24 Hour 3 PA; QL Tablet Extended 4 PA Therapy Pack)

C1 Na mza Release 12 Hour) ric

C1 Namzaric (Oral Dex met hylp heni date HCl ER Dexmethylphenidate Capsule Extended 3 PA; QL HCl ER (Oral Capsule Release 24 Hour)

4 C1 Nue dext Extended Release 24 a Nuedexta (Oral Hour) 4 PA

Dex met hylp Capsule) heni date HCl C1 Rilu Dexmethylphenidate zole 3 QL Riluzole (Oral Tablet) 3

Tetr HCl (Oral Tablet) abe nazi ne C1

Gua nfac ine HCl ER Tetrabenazine (Oral Guanfacine HCl ER 5 PA; LA; QL (Oral Tablet Extended 4 Tablet) B1 Fibromyalgia Agents

Release 24 Hour) C1 Dulo C1 xeti ne Met HCl adat e ER Metadate ER (Oral Duloxetine HCl (20MG Tablet Extended 4 QL Oral Capsule Delayed Release) Release Particles,

C1 Met hylp heni date HCl ER 30MG Oral Capsule Methylphenidate HCl 2 QL ER (10MG Oral Tablet Delayed Release Extended Release, 4 QL Particles, 60MG Oral 20MG Oral Tablet Capsule Delayed Release Particles)

C1 Pre Extended Release) gab alin C1 Met hylp heni date HCl Pregabalin (Oral Methylphenidate HCl 3 QL 4 QL Capsule)

Pre (Oral Solution) gab alin C1

Met hylp heni date HCl Pregabalin (Oral Methylphenidate HCl 3 QL Solution)

C1 Sav (Oral Tablet Immediate ella 3 QL Savella (Oral Tablet) 3

Release) (Generic C1 Sav ella Titra tion Pac Ritalin) k Savella Titration Pack

B1 3 Central Nervous System, Other (Oral Tablet)

Aust B1 edo Austedo (Oral Tablet) 5 PA; LA; QL Multiple Sclerosis Agents C1

C1 Am pyra Ingr ezza Ingrezza (Oral Ampyra (Oral Tablet 5 PA; QL Capsule) Extended Release 12 5 QL Hour)

Aub agio Aubagio (Oral Tablet) 5 LA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 75 75 4774 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Avo Rebi nex f Pen Titra tion Pac Avonex Pen k Rebif Titration Pack (Intramuscular Auto- 5 QL (Subcutaneous 5 QL Injector Kit) Solution Prefilled

C1 Avo nex Prefi lled Avonex Prefilled Syringe) C1 Tecf ider a Start er Pac (Intramuscular 5 QL k Tecfidera Starter 5 LA Prefilled Syringe Kit) Pack (Oral)

C1 C1 Beta Tecf sero ider n Betaseron a Tecfidera (Oral 5 QL (Subcutaneous Kit) Capsule Delayed 5 LA; QL

C1 Dalf amp ridin e ER Dalfampridine ER (Oral Release) Tablet Extended 5 QL A1 Dental and Oral Agents Release 12 Hour) B1 C1 Dental and Oral Agents Gile nya C1

Chlo rhex idin e Gluc onat Gilenya (0.5MG Oral e 5 QL Chlorhexidine Capsule)

C1 Gluconate (Mouth 2 Glati ram er Acet ate Glatiramer Acetate Solution)

C1 Pilo carp ine (Subcutaneous HCl Pilocarpine HCl (Oral 5 QL 4 Solution Prefilled Tablet)

C1 Tria mci nolo ne Acet Syringe) onid e C1 Glat opa Triamcinolone Glatopa Acetonide (Dental 3 (Subcutaneous 5 QL Paste) Solution Prefilled A1 Dermatological Agents

Syringe) B1

C1 May zent Dermatological Agents

C1 Acitr Mayzent (Oral Tablet) 5 QL etin

C1 Rebi f Rebi dos e Acitretin (Oral Rebif Rebidose 4 Capsule)

C1 Ada pale (Subcutaneous ne 5 QL Adapalene (External Solution Auto- 4 Cream)

C1 Ada pale Injector) ne

Rebi f Rebi dos Adapalene (0.1% e Titra tion Pac k 3 Rebif Rebidose External Gel)

Am mon ium Titration Pack Lact ate Ammonium Lactate (Subcutaneous 5 QL 3 (External Cream)

Am mon ium Solution Auto- Lact ate Ammonium Lactate Injector) 3

C1 Rebi f (External Lotion)

C1 Azel aic Rebif (Subcutaneous Acid Azelaic Acid (External 4 Solution Prefilled 5 QL Gel) Syringe)

Bold type = Brand name drug Plain type = Generic drug 76 tRACK 76 Last updated October 1, 2019 4875 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Ben Clot zoyl rima Per zole- oxid Beta e- met Eryt has hro one myci n Benzoyl Peroxide- Clotrimazole- Erythromycin (External 4 Betamethasone 4 Gel) (External Lotion)

C1 C1 Calc Cort ipotr ispo iene Calcipotriene (External rin Cortisporin (External 4 4 Cream) Cream) C1 C1 Calc ipotr Cort iene ispo Calcipotriene (External rin Cortisporin (External 4 4 Ointment) Ointment) C1

Calc C1 ipotr iene Cos enty Calcipotriene (External x 3 Cosentyx (300 MG Solution) C1 Dose) (Subcutaneous Calc itriol Calcitriol (External 5 PA; LA 4 Solution Prefilled Ointment) Syringe) C1

Cara C1 c Cos enty x Sen sore Carac (External ady 5 PA Cosentyx Sensoready Cream) (300 MG) C1 Clar avis Claravis (10MG Oral (Subcutaneous 5 PA; LA Capsule, 20MG Oral 4 PA Solution Auto- Capsule, 40MG Oral Injector)

Dicl ofen ac Sodi Capsule) um

C1 Clin Diclofenac Sodium dam ycin Pho sph ate 4 PA Clindamycin (3% Transdermal Gel)

C1 Dox epin Phosphate (External 3 HCl Doxepin HCl (External Gel) 5 PA; QL

C1 Clin Cream) dam ycin Pho C1 sph ate Ery Clindamycin Ery (External Pad) 3

C1 Eryt hro Phosphate (External 3 myci n Erythromycin (External Lotion) 4 C1

Clin dam ycin Pho Gel) sph ate C1

Eryt hro myci Clindamycin n Erythromycin (External Phosphate (External 3 2 Solution)

C1 Solution) Fina cea C1 Clin dam ycin Pho sph ate Finacea (External Clindamycin 4 Foam)

Phosphate (External 3 C1 Fluo rour Swab) acil Fluorouracil (0.5%

C1 Clin dam 5 ycin Pho sph ate- Ben zoyl External Cream) Per oxid e Clindamycin C1 Fluo rour Phosphate-Benzoyl acil Fluorouracil (5% 4 4 Peroxide (1-5% External Cream)

Fluo rour External Gel) acil Fluorouracil (External C1 Clot rima zole- Beta met 3 has one Clotrimazole- Solution)

Imiq uim Betamethasone 3 od Imiquimod (5% 4 (External Cream) External Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 77 77 4976 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Imiq Taz uim orac od Pum p Imiquimod Pump Tazorac (0.05% 5 PA (3.75% External 5 PA External Gel)

C1 Taz Cream) orac C1 Tazorac (0.1% Isotr etin oin 4 PA Isotretinoin (Oral External Gel) 4 PA C1 Tola Capsule) k

C1 Met Tolak (External hox sale n Rapi d 4 Methoxsalen Rapid Cream)

5 C1 Treti (Oral Capsule) noin

C1 Mirv aso Tretinoin (External Mirvaso (External Gel) 4 4 PA C1 Cream) Oxs oral C1 en Ultra Treti Oxsoralen Ultra (Oral noin 5 Tretinoin (0.01% Capsule) External Gel, 0.025% 4 PA C1

Pica to Picato (External Gel) 3 External Gel) C1 C1 Treti Pim noin ecro limu Micr s osp Pimecrolimus (External here Tretinoin Microsphere 4 ST 4 PA Cream) (External Gel)

C1 C1 Zycl Pod ara ofilo Pum x Podofilox (External p Zyclara Pump 3 5 PA Solution) (External Cream)

C1 Reg rane x Regranex (External A1 Electrolytes/Minerals/Metals/Vitamins

5 PA B1 Gel) Electrolyte/Mineral Replacement C1

Sant C1 yl Ami nos Santyl (External yn II Aminosyn II 4 4 B/D, PA Ointment) (Intravenous Solution) C1

Sele C1 niu m Ami Sulfi nos de yn- Selenium Sulfide PF 2 Aminosyn-PF (External Lotion) 4 B/D, PA

C1 (Intravenous Solution) Stel ara C1 Car bagl Stelara u Carbaglu (Oral 5 LA (Subcutaneous 5 PA Tablet)

C1 Dext Solution) rose

C1 Stel Dextrose (10% ara 4 Stelara Intravenous Solution)

Dext (Subcutaneous rose Dextrose (5% 5 PA 4 B/D, PA Solution Prefilled Intravenous Solution) Syringe)

Tacr olim us Tacrolimus (External 4 ST Ointment)

Taz arot ene Tazarotene (External 4 PA Cream)

C1 Taz orac Tazorac (0.05% 4 PA External Cream)

Bold type = Brand name drug Plain type = Generic drug 78 tRACK 78 Last updated October 1, 2019 5077 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Dext Klor- rose Con - 10 NaC l Dextrose-NaCl Klor-Con 10 (Oral

(10-0.2% Intravenous Tablet Extended 3 Solution, 10-0.45% Release)

C1 Klor- Con Intravenous Solution, M10 Klor-Con M10 (Oral 2.5-0.45% Tablet Extended 2 Intravenous Solution, Release)

C1 Klor- Con 4 M15 5-0.2% Intravenous Klor-Con M15 (Oral Solution, 5-0.225% Tablet Extended 2 Intravenous Solution, Release) C1 Klor- Con 5-0.33% Intravenous M20 Klor-Con M20 (Oral Solution, 5-0.45% Tablet Extended 2 Intravenous Solution) Release) C1

C1 Klor- Dext Con rose - NaC l Dextrose-NaCl Klor-Con (Oral Packet) 3 C1

Klor- Con (5-0.9% Intravenous 4 B/D, PA 8 Klor-Con 8 (Oral

Solution) Tablet Extended 3

C1 Fre Ami ne HBC FreAmine HBC Release) C1 Klor- Con Spri 4 B/D, PA nkle (Intravenous Solution) Klor-Con Sprinkle

C1 Hep atA min e HepatAmine (8MEQ Oral Capsule 3 4 B/D, PA Extended Release) (Intravenous Solution) C1 Lev ocar C1 nitin e Intra lipid Levocarnitine (1GM/ Intralipid (Intravenous 3 4 B/D, PA 10ML Oral Solution)

C1 Emulsion) Lev ocar nitin C1 e Iono sol- MB in D5 W Levocarnitine Ionosol-MB in D5W 3 4 (330MG Oral Tablet)

C1 (Intravenous Solution) Mag nesi um C1 Sulf ate Isoly te-P in D5 W Isolyte-P in D5W Magnesium Sulfate 4 (Intravenous Solution) (50% Injection 4

C1 Isoly te-S Solution)

C1 Mag Isolyte-S (Intravenous nesi um Sulf 4 ate Solution) Magnesium Sulfate

C1 KCl in Dext (50% (10ML Syringe) 4 rose - NaC l KCl in Dextrose-NaCl 4 Injection Solution) C1 Nep hrA min (Injection) e

KCl- Lact NephrAmine ated

Ring ers- D5 W KCl-Lactated Ringers- 4 B/D, PA (Intravenous Solution) C1 Nor mos ol-M in D5W (Intravenous 4 D5 W Normosol-M in D5W Solution) 4 (Intravenous Solution)

Nor mos ol-R in D5 W Normosol-R in D5W 4 (Intravenous Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 79 79 5178 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Nor Pota mos ssiu ol-R m pH Chlo 7.4 Normosol-R pH 7.4 ride Potassium Chloride 4 (Intravenous Solution) (10MEQ/100ML

C1 Nutr ilipid Nutrilipid Intravenous Solution, (Intravenous 4 B/D, PA 20MEQ/100ML 4 B/D, PA Emulsion) Intravenous Solution,

C1 Plas ma- Lyte 148 Plasma-Lyte 148 40MEQ/100ML 4 Intravenous Solution)

(Intravenous Solution) C1 Pota ssiu C1 m Plas Chlo ma- ride Lyte A Plasma-Lyte A Potassium Chloride 4 (Intravenous Solution) (2MEQ/ML

Plen ami ne Intravenous Solution, 4 B/D, PA Plenamine 4 B/D, PA 2MEQ/ML (20ML) (Intravenous Solution)

C1 Pota Intravenous Solution) ssiu m Chlo C1 ride CR Pota ssiu m Chlo Potassium Chloride ride Potassium Chloride 3 CR (Oral Tablet 2 (Oral Packet)

C1 Pota ssiu m Extended Release) Chlo ride C1 Pota ssiu m Chlo Potassium Chloride ride ER 3 Potassium Chloride ER (Oral Solution)

Pota ssiu (Oral Capsule 2 m Citra te Extended Release) ER Potassium Citrate ER

C1 Pota ssiu m Chlo (Oral Tablet Extended 3 ride in Dext rose Potassium Chloride in Release)

Pre mas Dextrose (Intravenous 4 B/D, PA ol Premasol (Intravenous Solution) 4 B/D, PA

C1 Pota ssiu Solution) m Chlo ride C1 in Proc NaC ala l min Potassium Chloride in e Procalamine NaCl (20-0.45MEQ/L- 4 B/D, PA 4 B/D, PA (Intravenous Solution)

C1 Pros % Intravenous ol Solution) Prosol (Intravenous C1 4 B/D, PA Pota ssiu m Chlo ride in Solution) NaC l C1 Potassium Chloride in Sodi um Chlo ride Sodium Chloride NaCl (20-0.9MEQ/L-% Intravenous Solution, 4 B/D, PA (0.45% Intravenous 4 Solution)

40-0.9MEQ/L-% C1 Sodi um Chlo ride Sodium Chloride (0.9% Intravenous Solution) 4 B/D, PA Intravenous Solution)

C1 Sodi um Chlo ride Sodium Chloride (3% Intravenous Solution, 4 B/D, PA 5% Intravenous Solution)

Bold type = Brand name drug Plain type = Generic drug 80 tRACK 80 Last updated October 1, 2019 5279 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Sodi SPS um Chlo ride Sodium Chloride SPS (Oral Suspension) 3

C1 Trie ntin 3 e (Irrigation Solution) HCl Trientine HCl (Oral C1 Sodi um Fluo ride 5 PA; QL Sodium Fluoride (Oral Capsule) C1 Velt 2 assa Tablet) Veltassa (Oral Packet) 5 QL C1 Sodi um Lact ate Sodium Lactate B1 Phosphate Binders

C1 4 Aury (Intravenous Solution) xia

C1 Auryxia (Oral Tablet) 5 PA TPN Elec troly C1 tes Calc ium Acet TPN Electrolytes ate 4 Calcium Acetate (Intravenous Solution)

C1 (Phosphate Binder) 3

Trav asol Travasol (Intravenous (Oral Capsule)

C1 Calc ium 4 B/D, PA Acet Solution) ate Calcium Acetate C1

Tro phA min e TrophAmine (10% (Phosphate Binder) 3 4 B/D, PA (Oral Tablet)

Intravenous Solution) C1 Lant han um Car bon B1 Electrolyte/Mineral/Metal Modifiers ate Lanthanum Carbonate C1 5 Che met (Oral Tablet Chewable)

C1 Pho Chemet (Oral slyra 5 Capsule) Phoslyra (Oral

C1 3 Def eras irox Solution)

Sev Deferasirox (Oral ela mer Car bon 5 PA ate Tablet Soluble) Sevelamer Carbonate C1 5 Ferri prox (Oral Packet)

C1 Sev Ferriprox (Oral ela mer Car bon 5 PA ate Solution) Sevelamer Carbonate C1 Ferri prox (Oral Tablet) (Generic 4 Ferriprox (Oral 5 PA Renvela) C1 Velp Tablet) horo

C1 Jad enu Velphoro (Oral Tablet Jadenu (Oral Tablet) 5 PA 5

C1 Jad Chewable) enu Spri nkle Jadenu Sprinkle (Oral B1 5 PA Vitamins C1

VP- PNV - Packet) DHA

Kion ex VP-PNV-DHA (Oral Kionex (Oral 2 3 Capsule)

Suspension) A1

Lok elm a Gastrointestinal Agents

Lokelma (Oral B1 4 QL Antispasmodics, Gastrointestinal

C1 Cuv Packet) pos a

C1 Sodi um Poly styr ene Cuvposa (Oral Sulf onat e Sodium Polystyrene 4 PA Solution)

C1 Sulfonate (Oral 3 Dicy clo min e Powder) HCl Dicyclomine HCl (Oral C1 2 Sodi um Poly styr ene Sulf Capsule) onat e C1 Sodium Polystyrene Dicy clo min e HCl Dicyclomine HCl (Oral Sulfonate (Oral 3 2 Suspension) Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 81 81 5380 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Dicy Zor clo btiv min e e HCl Dicyclomine HCl (Oral Zorbtive 2 Tablet) (Subcutaneous C1 Met hsc opol ami 5 PA; LA ne Bro mid e Methscopolamine Solution 4 Bromide (Oral Tablet) Reconstituted) B1 Gastrointestinal Agents, Other B1 Histamine2 (H2) Receptor Antagonists

C1 C1 Che Cim nod etidi al ne Chenodal (Oral Tablet) 5 HCl Cimetidine HCl (Oral

Cro mol yn 2 Sodi um Cromolyn Sodium Solution) C1 Cim etidi 3 ne (Oral Concentrate) Cimetidine (Oral

Diph eno xylat 2 e- Atro pine Tablet) Diphenoxylate- C1

Fam otidi 4 ne Atropine (Oral Liquid) Famotidine (Oral

C1 Diph eno xylat e- Atro pine Diphenoxylate- Suspension 4 4 Atropine (Oral Tablet) Reconstituted) C1

Fam C1 otidi Gatt ne ex Gattex Famotidine (20MG 5 PA; LA (Subcutaneous Kit) Oral Tablet, 40MG Oral 2

C1 Lop era mid e HCl Tablet)

C1 Rani Loperamide HCl (Oral tidin e 2 HCl Capsule) Ranitidine HCl (75MG/

C1 2 Myal ept 5ML Oral Syrup)

C1 Rani Myalept tidin e HCl (Subcutaneous Ranitidine HCl (150MG 5 PA; LA Oral Tablet, 300MG 2 Solution Oral Tablet)

Reconstituted) B1

C1 Reli stor Irritable Bowel Syndrome Agents

Alos etro Relistor (Oral Tablet) 5 PA; QL n HCl

C1 Reli stor Alosetron HCl (Oral Relistor 5 PA Tablet)

C1 Amit (Subcutaneous 5 PA iza Amitiza (Oral Solution) 3 QL

C1 Ser osti m Capsule)

C1 Linz Serostim ess Linzess (Oral (Subcutaneous 3 QL 5 PA; LA Capsule)

C1 Xifa Solution xan Reconstituted) Xifaxan (Oral Tablet) 5 PA

B1 C1

Urs odio l Laxatives C1 Ursodiol (Oral Clen 3 piq Capsule) Clenpiq (Oral

C1 Urs 3 odio l Solution)

Ursodiol (Oral Tablet) 4 C1 Con stul ose Constulose (Oral 2 Solution)

C1 Enul ose Enulose (Oral Solution) 2

Bold type = Brand name drug Plain type = Generic drug 82 tRACK 82 Last updated October 1, 2019 5481 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Gavi Dexi Lyte lant -C GaviLyte-C (Oral Dexilant (Oral Solution 2 Capsule Delayed 4 QL Reconstituted) Release) C1

Gavi C1 Lyte -G Eso mep razo le Mag nesi GaviLyte-G (Oral um Esomeprazole Solution 2 Magnesium (Oral Reconstituted) Capsule Delayed 3 QL C1 Gavi Lyte -N with Flav or Pac k GaviLyte-N with Flavor Release) (Generic Pack (Oral Solution 2 Nexium)

C1 Lan sopr azol Reconstituted) e Lansoprazole (Oral C1 Gen erla c Generlac (Oral Capsule Delayed 2 QL 2 Solution) Release)

C1 C1 Om Lact epra ulos zole e Lactulose (10GM/ Omeprazole (10MG 2 15ML Oral Solution) Oral Capsule Delayed 2 QL

PEG -335 0- Elec troly tes Release) PEG-3350-Electrolytes C1 Om epra (Oral Solution zole Omeprazole (20MG 2 Reconstituted) Oral Capsule Delayed (Generic Colyte) Release, 40MG Oral 2

C1 PEG -335 0- NaC l-Na Bica rbon ate- Capsule Delayed KCl PEG-3350-NaCl-Na Release) Bicarbonate-KCl (Oral C1 Pant opra zole

Sodi 2 um Solution) (Generic Pantoprazole Sodium NuLYTELY) (Oral Tablet Delayed 1 QL

C1 PEG -335 0- Elec troly tes Release) PEG-3350-Electrolytes C1 Prilo sec (Oral Solution) 2 Prilosec (Oral Packet) 4 PA

C1 Rab epra zole

Sodi (Generic GoLYTELY) um Rabeprazole Sodium C1 Sup rep Bow el Pre p Kit Suprep Bowel Prep (Oral Tablet Delayed 3 3 Kit (Oral Solution) Release)

TriL A1 yte TriLyte (Oral Solution Genetic or Enzyme Disorder: Replacement, 2 Reconstituted) Modifiers, Treatment

B1 B1 Protectants Genetic or Enzyme Disorder: Replacement,

C1 Cara fate Carafate (Oral Modifiers, Treatment C1 Aral ast 4 NP Suspension) Aralast NP (1000MG

C1 Mis opr osto l Misoprostol (Oral Intravenous Solution 5 PA; LA 3 Tablet) Reconstituted) C1 C1 Chol Sucr bam alfat e Cholbam (Oral Sucralfate (Oral Tablet) 2 5 PA B1 Proton Pump Inhibitors Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 83 83 5582 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Cre Teg on Creon (Oral Capsule sedi Tegsedi

Delayed Release 3 (Subcutaneous 5 PA; LA Particles) Solution Prefilled

C1 Cyst ada ne Cystadane (Oral Syringe) C1 Zem 5 aira Powder) Zemaira (Intravenous

C1 Cyst ago n Cystagon (Oral Solution 5 PA; LA 4 LA Capsule) Reconstituted) C1 C1 Zen pep Glas sia Glassia (Intravenous Zenpep (Oral Capsule 5 PA; LA Solution) Delayed Release 3

Kuv an Kuvan (Oral Packet) 5 LA Particles)

C1 A1 Kuv an Kuvan (Oral Tablet Genitourinary Agents 5 LA B1 Soluble) Antispasmodics, Urinary C1

C1 Myr betri Migl q usta t Miglustat (Oral Myrbetriq (Oral 5 PA; LA Capsule) Tablet Extended 3

C1 Ocal iva Ocaliva (Oral Tablet) 5 PA; QL Release 24 Hour) C1 Oxy C1 buty Orfa nin din Chlo ride Orfadin (Oral ER Oxybutynin Chloride 5 LA Capsule) ER (Oral Tablet

C1 2 QL Orfa din Extended Release 24 Orfadin (Oral 5 LA Hour) C1 Oxy buty Suspension) nin Chlo ride C1 Prol astin -C Oxybutynin Chloride 2 Prolastin-C (Oral Syrup)

C1 Oxy buty nin (Intravenous Solution Chlo 5 PA; LA ride Oxybutynin Chloride Reconstituted)

C1 RAV ICTI (Oral Tablet Immediate 2 RAVICTI (Oral Liquid) 5 LA; QL

C1 Release) Sodi um C1 Phe nylb Solif utyr ena cin ate Suc cina Sodium te Solifenacin Succinate 3 QL Phenylbutyrate (Oral 5 (Oral Tablet)

Powder) B1

Sodi um Benign Prostatic Hypertrophy Agents Phe nylb utyr C1 ate Alfu zosi n HCl Sodium ER Alfuzosin HCl ER (Oral Phenylbutyrate (Oral 5 Tablet Extended 2 Tablet)

Sucr aid Release 24 Hour)

C1 Duta steri Sucraid (Oral de Dutasteride (Oral 5 LA 3 QL Solution) Capsule)

Fina steri de Finasteride (5MG Oral Tablet) (Generic 1 Proscar)

Bold type = Brand name drug Plain type = Generic drug 84 tRACK 84 Last updated October 1, 2019 5683 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Silo Beta dosi met n has one Dipr opio nate Silodosin (Oral Aug Betamethasone 3 QL Capsule) Dipropionate Aug 3

C1 Tam sulo sin HCl (External Lotion) Tamsulosin HCl (Oral C1 Beta met has one 1 Dipr opio nate Capsule) Aug Betamethasone

C1 Tera zosi n HCl Terazosin HCl (Oral Dipropionate Aug 3 2 (External Ointment)

Capsule) C1 Beta met has one Dipr B1 opio Genitourinary Agents, Other nate Betamethasone C1

Beth ane chol

Chlo Dipropionate (External 3 ride Bethanechol Chloride 2 Cream)

C1 Beta (Oral Tablet) met has one C1 Dipr opio Dep en nate Titra tabs Betamethasone Depen Titratabs (Oral 5 Dipropionate (External 3 Tablet)

C1 Elmi ron Lotion)

Beta met has one Elmiron (Oral Dipr opio 5 nate Betamethasone Capsule)

C1 Lith Dipropionate (External 3 osta t Lithostat (Oral Tablet) 5 Ointment) C1 Peni C1 cilla Beta min met e has one Vale Penicillamine (Oral rate 5 PA Betamethasone Capsule) Valerate (External 3 A1 Hormonal Agents, Stimulant/Replacement/ Cream) C1 Beta met has one Vale Modifying (Adrenal) rate Betamethasone B1 Hormonal Agents, Stimulant/Replacement/ Valerate (External 3 Lotion) Modifying (Adrenal) C1 Beta met C1 has one Ala- Vale Cort Ala-Cort (External rate Betamethasone 2 Cream) Valerate (External 3

C1 Alcl ome taso ne Dipr Ointment) opio nate C1 Clo beta Alclometasone sol Pro pion ate Emo llient

Bas Dipropionate (External 3 e Clobetasol Propionate Cream) Emollient Base 4

Alcl ome taso ne Dipr (External Cream) opio nate C1

Clo beta Alclometasone sol Pro pion ate Clobetasol Propionate Dipropionate (External 3 4 (External Cream) Ointment) C1 Clo beta C1 sol Pro Beta pion met ate has one Dipr opio nate Clobetasol Propionate Aug Betamethasone 4 (External Gel) Dipropionate Aug 3 C1 Clo beta sol Pro pion (External Cream) ate Clobetasol Propionate

C1 Beta met 4 has one Dipr opio nate Aug (External Ointment) Betamethasone C1 Clo beta sol Pro pion ate Clobetasol Propionate Dipropionate Aug 3 4 (External Gel) (External Shampoo)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 85 85 5784 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Clo Fluo beta cino sol nide Pro pion ate Clobetasol Propionate Fluocinonide (External 3 3 (External Solution) Ointment)

C1 C1 Cor Fluo dran cino Cordran (External nide Fluocinonide (External 4 3 Tape) Solution) C1 C1 Fluti Cort cas ison one e Pro Acet pion ate Cortisone Acetate ate Fluticasone Propionate 4 3 (Oral Tablet) (External Cream) C1 C1 Fluti Des cas onid one e Pro pion Desonide (External ate Fluticasone Propionate 4 3 Ointment) (External Ointment) C1 C1 Halo Des beta oxi sol met Pro aso pion ne Desoximetasone ate Halobetasol 4 (External Cream) Propionate (External 4

Dex ame thas one Inte nsol Cream) Dexamethasone C1 Halo beta sol Pro pion Intensol (Oral 2 ate Halobetasol Concentrate) Propionate (External 4

C1 Dex ame thas one Ointment) Dexamethasone (Oral C1 Hyd roco rtiso ne Buty 2 rate Elixir) Hydrocortisone C1 Dex ame thas one Dexamethasone (Oral Butyrate (External 3 2 Ointment) Tablet) C1 Hyd roco C1 rtiso ne Flud roco rtiso ne Acet ate Fludrocortisone Hydrocortisone (1% 2 Acetate (Oral Tablet) External Cream, 2.5% 2

Fluo cino lone External Cream) Acet onid e C1 Hyd roco Fluocinolone rtiso ne Hydrocortisone (2.5% Acetonide (External 3 3 External Lotion) Cream) C1 Hyd roco C1 rtiso ne Fluo cino lone

Acet onid e Fluocinolone Hydrocortisone (1% External Ointment, Acetonide (External 3 2 Ointment) 2.5% External

C1 Fluo cino lone Ointment) Acet onid e C1 Hyd roco Fluocinolone rtiso ne Hydrocortisone (Oral Acetonide (External 3 3 Tablet) Solution) C1 Hyd roco C1 rtiso ne Fluo Vale cino rate lone

Acet onid e Hydrocortisone Scal p Fluocinolone Acetonide Scalp 4 Valerate (External 4 Cream) (External Oil) C1 Hyd roco C1 rtiso ne Fluo Vale cino rate nide

Emu lsifie d Hydrocortisone Bas e Fluocinonide Emulsified Base 3 Valerate (External 4 Ointment) (External Cream) C1 Met hylp C1 redn isol Fluo one cino nide Fluocinonide (External Methylprednisolone 3 2 Gel) (Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 86 tRACK 86 Last updated October 1, 2019 5885 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Met Pre hylp dnis redn one isol one Methylprednisolone Prednisone (10MG (Oral Tablet Therapy 2 (21) Oral Tablet Pack) Therapy Pack, 10MG

C1 Mo met aso ne Furo ate Mometasone Furoate (48) Oral Tablet 2 (External Cream) Therapy Pack, 5MG 1

C1 Mo met aso ne Furo ate Mometasone Furoate (21) Oral Tablet 2 (External Ointment) Therapy Pack, 5MG

C1 Mo met aso (48) Oral Tablet ne Furo ate Mometasone Furoate 2 Therapy Pack) C1 Tria mci nolo ne (External Solution) Acet onid C1 e

Pre dnic arba Triamcinolone te Prednicarbate 4 Acetonide (External 2 (External Cream) C1 Cream) Pre dnic arba C1 te Tria mci nolo ne Acet onid Prednicarbate e 4 Triamcinolone (External Ointment) C1 Acetonide (External 2 Pre dnis olon e Prednisolone (Oral Lotion)

C1 2 Tria mci nolo ne Acet onid Solution) e C1 Triamcinolone Pre dnis olon e Sodi um Pho sph ate Prednisolone Sodium Acetonide (External 2 Phosphate (25MG/ Ointment) C1 Trid 5ML Oral Solution, 2 erm Triderm (0.1% External 2 6.7MG/5ML Oral Cream)

Solution) A1

C1 Pre dnis one Hormonal Agents, Stimulant/Replacement/ Inte nsol Prednisone Intensol 2 Modifying (Pituitary)

(Oral Concentrate) B1

Pre dnis one Hormonal Agents, Stimulant/Replacement/ Prednisone (5MG/5ML 2 Modifying (Pituitary)

C1 Des mop Oral Solution) ressi n C1 Acet ate Pre dnis one Desmopressin Acetate Prednisone (10MG 3 (Oral Tablet)

C1 Des Oral Tablet, 1MG Oral mop ressi n Acet ate Spra y Desmopressin Acetate Tablet, 2.5MG Oral 4 Spray (Nasal Solution) Tablet, 20MG Oral 1 C1 Gen otro pin Mini Quic Tablet, 50MG Oral k Genotropin MiniQuick Tablet, 5MG Oral (Subcutaneous 5 PA Tablet) Solution Reconstituted)

C1 Gen otro pin Genotropin (Subcutaneous 5 PA Solution Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 87 87 5986 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Hu Ana matr drol- ope Humatrope (Injection 50 Anadrol-50 (Oral 5 PA Solution Tablet)

C1 And rode Renconstituted), 5 PA rm Androderm Humatrope Combo (Transdermal Patch 3 QL Pack (Injection) 24 Hour) C1 Incr C1 elex Dan azol Increlex Danazol (Oral Capsule) 4

C1 Oxa ndro (Subcutaneous 5 PA; LA lone Oxandrolone (10MG 4 PA; QL Solution) Oral Tablet) C1

Nor C1 ditro pin Oxa Flex ndro Pro Norditropin FlexPro lone Oxandrolone (2.5MG 3 PA; QL (Subcutaneous 5 PA Oral Tablet)

Test oste rone

Cypi onat Solution) e

C1 Testosterone Nutr opin AQ NuS pin 10 Nutropin AQ NuSpin Cypionate 2 10 (Subcutaneous 5 PA (Intramuscular Solution) Solution) C1

C1 Test oste Nutr rone opin AQ Ena NuS ntha pin te 20 Nutropin AQ NuSpin Testosterone Enanthate 20 (Subcutaneous 5 PA 3 Solution) (Intramuscular

Nutr opin AQ NuS Solution) pin 5 C1 Test oste Nutropin AQ NuSpin rone 5 (Subcutaneous 5 PA Testosterone (25MG/ 2.5GM 1% Solution)

C1 Saiz en Transdermal Gel, Saizen (Injection 50MG/5GM 1% 3 Solution 5 PA; LA Transdermal Gel), Reconstituted) Testosterone Pump

C1 Saiz enpr ep Saizenprep (Injection (1% Transdermal Gel) C1 Test oste Solution 5 PA; LA rone Testosterone Reconstituted) (20.25MG/1.25GM A1 Hormonal Agents, Stimulant/Replacement/ 1.62% Transdermal Gel, 40.5MG/2.5GM Modifying (Prostaglandins) 4

B1 1.62% Transdermal Hormonal Agents, Stimulant/Replacement/ Gel), Testosterone Modifying (Prostaglandins)

C1 Pump (1.62% Korl ym Korlym (Oral Tablet) 5 PA; LA; QL Transdermal Gel) A1 Hormonal Agents, Stimulant/Replacement/ B1 Estrogens

C1 Alta vera Modifying (Sex Hormones/Modifiers) Altavera (Oral Tablet) 4 B1 Androgens

Bold type = Brand name drug Plain type = Generic drug 88 tRACK 88 Last updated October 1, 2019 6087 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Alya Dro cen spir 1/35 eno ne- Ethi nyl Estr adio Alyacen 1/35 (Oral l Drospirenone-Ethinyl 4 4 Tablet) Estradiol (Oral Tablet)

C1 C1 Ame Dua thia vee Lo Amethia Lo (Oral Duavee (Oral Tablet) 4

C1 Eles 4 trin Tablet) C1 Elestrin (Transdermal Ame thia 4 Amethia (Oral Tablet) 4 Gel) C1 C1 Apri Emo quet te Apri (Oral Tablet) 4 Emoquette (Oral C1

Aran elle 4 Aranelle (Oral Tablet) 4 Tablet) C1

C1 Enp ress Ashl e-28 yna Ashlyna (Oral Tablet) 4 Enpresse-28 (Oral

C1 Aub 4 ra Tablet)

Aubra (Oral Tablet) 4 Ens kyce C1 Avia ne Enskyce (Oral Tablet) 4

C1 Aviane (Oral Tablet) 4 Esta rylla C1 Balz iva Estarylla (Oral Tablet) 4

C1 Balziva (Oral Tablet) 4 Estr adio l C1 Blis ovi 24 Fe Estradiol (Oral Tablet) 3

C1 Blisovi 24 Fe (Oral Estr adio 4 l Tablet) Estradiol (Transdermal

C1 Blis 3 QL ovi Fe 1.5/ 30 Patch Weekly) C1 Blisovi Fe 1.5/30 (Oral Estr adio 4 l Tablet) Estradiol (Vaginal

C1 Briel 4 lyn Cream)

C1 Briellyn (Oral Tablet) 4 Estr adio l C1 Cam rese Lo Estradiol (Vaginal Camrese Lo (Oral 4 QL 4 Tablet)

C1 Tablet) Estr adio l C1 Vale Cazi rate ant Estradiol Valerate Caziant (Oral Tablet) 4 4 C1

Clim ara Pro (Intramuscular Oil)

C1 Estri Climara Pro ng Estring (Vaginal Ring) 4

Ethy (Transdermal Patch 4 nodi ol Diac etat e- Ethi nyl Estr adio Weekly) l Ethynodiol Diacetate- C1 Crys elle- 28 Ethinyl Estradiol (Oral 4 Cryselle-28 (Oral 4 Tablet) C1

Fal min Tablet) a C1 Cycl afe m 1/35 Falmina (Oral Tablet) 4

C1 Fay osi Cyclafem 1/35 (Oral m 4 Fayosim (Oral Tablet) 4 Tablet) C1 Fem ring C1 Cycl afe m 7/7/ 7 Femring (Vaginal Cyclafem 7/7/7 (Oral 4 4 Ring)

Tablet) C1 Fem C1 ynor Cyre d Femynor (Oral Tablet) 4

Cyred (Oral Tablet) 4 C1 Fyav C1 olv Dely la Fyavolv (Oral Tablet) 4

Delyla (Oral Tablet) 4 C1 Gian C1 vi Dep o- Estr adio l Gianvi (Oral Tablet) 4 Depo-Estradiol C1 Hail ey 24 4 Fe (Intramuscular Oil) Hailey 24 Fe (Oral

C1 Des oge 4 strel - Ethi nyl Estr adio Tablet) l Desogestrel-Ethinyl 4 Estradiol (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 89 89 6188 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Imv LAR exxy IN Fe Mai 1/20 nten anc e Pac k Imvexxy Maintenance LARIN Fe 1/20 (Oral 3 PA; QL 4 Pack (Vaginal Insert) Tablet) C1 C1 Lari Imv ssia exxy

Start er Pac k Imvexxy Starter Pack Larissia (Oral Tablet) 4 C1 Lay olis 3 PA; QL Fe (Vaginal Insert) Layolis Fe (Oral

C1 Intro vale 4 Introvale (Oral Tablet) 4 Tablet Chewable) C1 C1 Lee Isibl na oom Isibloom (Oral Tablet) 4 Leena (Oral Tablet) 4 C1 C1 Less Jas ina miel Jasmiel (Oral Tablet) 4 Lessina (Oral Tablet) 4 C1 C1 Lev Jint one eli st Jinteli (Oral Tablet) 4 Levonest (Oral Tablet) 4 C1 C1 Lev Jule onor ber gest rel- Ethi nyl Estr adio l & Ethi nyl Levonorgestrel-Ethinyl Juleber (Oral Tablet) 4 Estr adio l C1 Jun el 1.5/ 30 Junel 1.5/30 (Oral Estradiol & Ethinyl 4 4 Estradiol (Oral Tablet) Tablet) C1 Lev onor C1 gest rel- Jun Ethi el nyl 1/20 Estr adio l 91- Junel 1/20 (Oral Day Levonorgestrel-Ethinyl 4 Tablet) Estradiol 91-Day (Oral 4

Jun el Fe 1.5/ Tablet) 30

C1 Lev onor Junel Fe 1.5/30 (Oral gest rel- Ethi nyl Estr adio 4 l Levonorgestrel-Ethinyl Tablet) 4 C1 Jun el Fe 1/20 Estradiol (Oral Tablet)

Lev ora Junel Fe 1/20 (Oral 0.15 4 /30 Levora 0.15/30 (28) Tablet) 4 C1 Jun el Fe 24 (Oral Tablet)

C1 Lory Junel Fe 24 (Oral na 4 Loryna (Oral Tablet) 4 Tablet) C1 Low - C1 Oge strel Kaitl ib Fe Low-Ogestrel (Oral Kaitlib Fe (Oral Tablet 4 4 Tablet) Chewable) C1 Lute ra C1 Kari va Lutera (Oral Tablet) 4 Kariva (Oral Tablet) 4 C1 Marl issa C1 Keln or 1/35 Marlissa (Oral Tablet) 4 Kelnor 1/35 (Oral C1 Mel odet ta 24 4 Fe Tablet) Melodetta 24 Fe (Oral

C1 Keln 4 or 1/50 Tablet Chewable) Kelnor 1/50 (Oral C1 Men 4 est Tablet) Menest (Oral Tablet) 3 C1 C1 Mib Kurv elas elo 24 Fe Kurvelo (Oral Tablet) 4 Mibelas 24 Fe (Oral

C1 LAR 4 IN 1.5/ 30 Tablet Chewable) LARIN 1.5/30 (Oral C1 Micr oge stin 1.5/ 4 30 Tablet) Microgestin 1.5/30

C1 LAR 4 IN 1/20 (Oral Tablet) LARIN 1/20 (Oral C1 Micr oge stin 4 1/20 Tablet) Microgestin 1/20 (Oral

C1 LAR 4 IN Fe 1.5/ 30 Tablet) LARIN Fe 1.5/30 (Oral C1 Micr oge stin Fe 1.5/ 4 30 Microgestin Fe 1.5/30 Tablet) 4 (Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 90 tRACK 90 Last updated October 1, 2019 6289 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Micr Nort oge rel stin 1/35 Fe 1/20 Microgestin Fe 1/20 Nortrel 1/35 (21) (Oral 4 4 (Oral Tablet) Tablet)

C1 C1 Mili Nort rel 1/35 Mili (Oral Tablet) 4 Nortrel 1/35 (28) (Oral

C1 Nec on 4 0.5/ 35 Tablet) Necon 0.5/35 (28) C1 Nort rel 7/7/ 4 7 (Oral Tablet) Nortrel 7/7/7 (Oral

C1 Nikk i 4 Tablet)

Nikki (Oral Tablet) 4 C1 Ocel C1 la Nor ethi ndro ne Acet ate- Ethi nyl Ocella (Oral Tablet) 4 Estr adio l Norethindrone C1 Oge strel Acetate-Ethinyl Ogestrel (Oral Tablet) 4

Orsy thia Estradiol (0.5-2.5MG- Orsythia (Oral Tablet) 4 4 C1 Pimt rea MCG Oral Tablet, Pimtrea (Oral Tablet) 4

C1 Pirm ella 1-5MG-MCG Oral 1/35 Tablet) Pirmella 1/35 (Oral

C1 4

Nor ethi ndro ne Acet Tablet) ate- Ethi nyl C1 Estr Porti adio a-28 l Norethindrone Portia-28 (Oral Tablet) 4 Acetate-Ethinyl C1 Pre mari 4 n Estradiol (1-20MG- Premarin (Oral 4 QL MCG Oral Tablet) Tablet)

C1 C1 Nor Pre ethi mari ndro n ne Acet ate- Ethi nyl Estr adio l-Fe Norethindrone Premarin (Vaginal 3 Acetate-Ethinyl Cream)

C1 4 Pre mph Estradiol-Fe (1-20MG- ase Premphase (Oral MCG(24) Oral Tablet) 4 QL

C1 Nor Tablet) ethi ndro ne Acet C1 ate- Pre Ethi mpr nyl o Estr adio l-Fe Norethindrone Prempro (Oral Tablet) 4 QL

Prev Acetate-Ethinyl ifem Previfem (Oral Tablet) 4 Estradiol-Fe C1 Recl ipse n (0.4-35MG-MCG Oral Reclipsen (Oral Tablet) 4 C1 Rive lsa Tablet Chewable, 4 Rivelsa (Oral Tablet) 4

C1 Setl akin 0.8-25MG-MCG Oral Setlakin (Oral Tablet) 4

C1 Spri ntec Tablet Chewable, 28 Sprintec 28 (Oral 1-20MG-MCG(24) Oral 4 Tablet)

C1 Tablet Chewable) Sro nyx

C1 Nor gest imat e- Ethi nyl Sronyx (Oral Tablet) 4 Estr adio l C1 Norgestimate-Ethinyl Sye 4 da Estradiol (Oral Tablet) Syeda (Oral Tablet) 4 C1

C1 Tari na Nor 24 gest Fe imat e- Ethi nyl Estr adio l Tarina 24 Fe (Oral Trip hasi Norgestimate-Ethinyl c 4 Estradiol Triphasic 4 Tablet) C1 Tari na Fe (Oral Tablet) 1/20 Tarina Fe 1/20 (Oral C1 Nort rel 0.5/ 4 35 Nortrel 0.5/35 (28) Tablet) 4 (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 91 91 6390 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Tri- Crin Esta one rylla Tri-Estarylla (Oral Crinone (Vaginal Gel) 4 PA

C1 Debl 4 itan Tablet) e

C1 Deblitane (Oral Tablet) 3 Tri- Leg C1 est Fe Dep o- Prov Tri-Legest Fe (Oral era 4 Depo-Provera Tablet) C1 (400MG/ML Tri- Lo- Esta rylla Tri-Lo-Estarylla (Oral 4 4 Intramuscular Tablet)

C1 Suspension) Tri- Lo- Spri C1 ntec Errin Tri-Lo-Sprintec (Oral Errin (Oral Tablet) 3

4 C1 Inca Tablet) ssia

Tri- Mili Incassia (Oral Tablet) 3 C1 Tri-Mili (Oral Tablet) 4 Lyza

Tri- Prev Lyza (Oral Tablet) 3 ifem

C1 Med roxy pro gest Tri-Previfem (Oral eron e Acet 4 ate Medroxyprogesterone Tablet)

C1 Tri- Spri Acetate (150MG/ML ntec Tri-Sprintec (Oral 4 4 Intramuscular Tablet)

C1 Suspension) Triv ora C1 Med roxy pro gest eron e Acet Trivora (28) (Oral ate 4 Medroxyprogesterone Tablet)

C1 Acetate (150MG/ML Tri- VyLi bra Lo Tri-VyLibra Lo (Oral 4 Intramuscular 4 Tablet) Suspension Prefilled

Tri- VyLi bra Tri-VyLibra (Oral Syringe) C1 Med roxy pro gest 4 eron e Acet Tablet) ate Medroxyprogesterone

C1 Veli vet Velivet (Oral Tablet) 4 Acetate (10MG Oral C1 Vien va Vienva (Oral Tablet) 4 Tablet, 2.5MG Oral 2

C1 Vyfe mla Tablet, 5MG Oral Vyfemla (Oral Tablet) 4 C1 Tablet) VyLi bra C1 Meg estr ol Acet VyLibra (Oral Tablet) 4 ate C1 Megestrol Acetate WY MZ YA Fe WYMZYA Fe (Oral 4 (40MG/ML Oral 3 Tablet Chewable) Suspension) C1 Xula C1 ne Meg estr ol Acet Xulane (Transdermal ate 4 Megestrol Acetate Patch Weekly) (625MG/5ML Oral 4 C1 Yuv afe m Yuvafem (Vaginal Suspension) C1 Meg estr ol 4 QL Acet Tablet) ate Megestrol Acetate C1 Zara h 3 Zarah (Oral Tablet) 4 (Oral Tablet) C1 C1 Nor Zovi a-BE a 1/35 E Zovia 1/35E (28) (Oral Nora-BE (Oral Tablet) 3 C1

Nor ethi ndro 4 ne Acet Tablet) ate Norethindrone Acetate

B1 2 Progestins (5MG Oral Tablet)

C1 Cam ila Camila (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 92 tRACK 92 Last updated October 1, 2019 6491 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Nor Unit ethi hroi ndro d ne Norethindrone Unithroid (100MCG 3 (0.35MG Oral Tablet) Oral Tablet, 112MCG C1 Norl yroc Norlyroc (Oral Tablet) 3 Oral Tablet, 125MCG

C1 Pro gest eron e Micr oniz ed Oral Tablet, 150MCG Progesterone Micronized (Oral 2 Oral Tablet, 175MCG Capsule) Oral Tablet, 200MCG

C1 Shar obel 3 Sharobel (Oral Tablet) 3 Oral Tablet, 25MCG B1 Selective Estrogen Receptor Modifying Oral Tablet, 300MCG Agents Oral Tablet, 50MCG

Osp hen a Osphena (Oral Tablet) 3 PA; QL Oral Tablet, 75MCG

C1 Ralo xife ne HCl Oral Tablet, 88MCG Raloxifene HCl (Oral 3 QL Oral Tablet) Tablet) A1

A1 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Stimulant/Replacement/ B1 Hormonal Agents, Suppressant (Adrenal) Modifying (Thyroid) C1 Lys odre n B1 Lysodren (Oral Hormonal Agents, Stimulant/Replacement/ 5 Modifying (Thyroid) Tablet)

C1 A1

Lev o-T Levo-T (Oral Tablet) 3 Hormonal Agents, Suppressant (Pituitary)

C1 B1 Lev othy roxi ne Sodi um Hormonal Agents, Suppressant (Pituitary) Levothyroxine Sodium C1 Cab ergo 1 line (Oral Tablet) Cabergoline (Oral

C1 Lev 3 oxyl Tablet) Levoxyl (Oral Tablet) 3 C1 Egrif ta C1 Liot hyro nine

Sodi um Liothyronine Sodium Egrifta (1MG 2 (Oral Tablet) Subcutaneous C1 5 PA; LA Synt hroi d Synthroid (Oral Solution 3 Reconstituted)

C1 Tablet) Firm ago n Firmagon (120MG Subcutaneous 5 PA Solution Reconstituted)

Firm ago n Firmagon (80MG Subcutaneous 4 PA Solution Reconstituted)

C1 Leu proli de Acet ate Leuprolide Acetate 4 PA (Injection Kit)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 93 93 6592 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Lup Syn anet arel a Pac k Lupaneta Pack Synarel (Nasal 5 PA 5 (Combination Kit) Solution)

C1 C1 Lupr Trel on star Dep Mixj ot Lupron Depot (1- ect Trelstar Mixject Month) 5 PA (Intramuscular 5 PA (Intramuscular Kit) Suspension

C1 Lupr on Dep ot Lupron Depot (3- Reconstituted) Month) 5 PA A1 Hormonal Agents, Suppressant (Thyroid) (Intramuscular Kit) B1 Antithyroid Agents C1 Lupr C1 on Dep Met ot him azol Lupron Depot (4- e Methimazole (Oral 2 Month) 5 PA Tablet)

Pro pylt hiou (Intramuscular Kit) racil C1 Propylthiouracil (Oral

Lupr on Dep ot 2 Lupron Depot (6- Tablet) Month) 5 PA A1 Immunological Agents (Intramuscular Kit) B1

C1 Angioedema Agents Octr eoti C1 de Acet Beri ate Octreotide Acetate nert Berinert (Intravenous 5 PA; LA (1000MCG/ML Kit)

Cinr Injection Solution, 5 PA yze 500MCG/ML Injection Cinryze (Intravenous Solution) Solution 5 PA; LA

C1 Octr eoti de Acet ate Reconstituted)

C1 Fira Octreotide Acetate zyr (100MCG/ML Injection Firazyr Solution, 200MCG/ML (Subcutaneous 5 PA; QL 4 PA Injection Solution, Solution) C1 Hae gard 50MCG/ML Injection a Haegarda Solution)

C1 (Subcutaneous Sign ifor 5 PA; LA Signifor Solution (Subcutaneous 5 PA; LA Reconstituted)

C1 Icati bant

Acet Solution) ate

C1 Icatibant Acetate Som atuli ne Dep ot Somatuline Depot (Subcutaneous 5 PA; QL (Subcutaneous 5 Solution) C1

Ruc one Solution) st Ruconest C1

Som aver t Somavert (Intravenous Solution 5 PA; LA (Subcutaneous Reconstituted)

5 PA; LA; QL B1 Solution Immune Suppressants Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 94 tRACK 94 Last updated October 1, 2019 6693 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Azat Hu hiop mira rine Pedi atric

Cro hns Azathioprine (Oral Start Humira Pediatric 2 B/D, PA Tablet) Crohns Start C1 Cim zia Prefi lled 5 PA Cimzia Prefilled (Subcutaneous 5 PA (Subcutaneous Kit) Prefilled Syringe Kit)

C1 C1 Hu Cim mira zia Cimzia Pen Humira Pen 5 PA (Subcutaneous Kit) (Subcutaneous Pen- 5 PA

C1 Cycl osp orin e Mod ified Cyclosporine Modified Injector Kit) C1 Hu mira Pen 3 B/D, PA Cro hns Dise ase Start (Oral Capsule) er Humira Pen Crohns

Cycl osp orin e Mod ified Cyclosporine Modified Disease Starter 3 B/D, PA 5 PA (Oral Solution) (Subcutaneous Pen-

Cycl osp orin e Cyclosporine (Oral Injector Kit) C1 Hu mira Pen 3 B/D, PA Psor iasis

Start Capsule) er Humira Pen Psoriasis C1 Enb rel Mini Enbrel Mini Starter 5 PA (Subcutaneous 5 PA (Subcutaneous Pen- Solution Cartridge) Injector Kit)

C1 C1 Hu Enb mira rel Enbrel Humira (Subcutaneous (Subcutaneous 5 PA 5 PA Solution Prefilled Prefilled Syringe Kit)

Kine Syringe) ret Kineret C1 Enb rel Enbrel (Subcutaneous 5 PA (Subcutaneous Solution Prefilled 5 PA Solution Syringe)

C1 Met hotr exat Reconstituted) e Methotrexate (Oral C1

Enb rel Sure 2 Clic k Enbrel SureClick Tablet) C1 Met hotr exat e Sodi (Subcutaneous um Methotrexate Sodium 5 PA (50MG/2ML Injection Solution Auto- 2 Injector) Solution Prefilled

C1 Env arsu s XR Syringe)

C1 Envarsus XR (Oral Met hotr exat e Sodi Tablet Extended 4 B/D, PA um Methotrexate Sodium Release 24 Hour) (50MG/2ML Injection 2

C1 Gen graf Solution)

Myc oph enol Gengraf (Oral Capsule) 3 B/D, PA ate Mof C1 etil Gen graf Mycophenolate Mofetil 3 B/D, PA Gengraf (Oral Solution) 3 B/D, PA (Oral Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 95 95 6794 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Myc Tacr oph olim enol us ate Mof etil Mycophenolate Mofetil Tacrolimus (Oral 3 B/D, PA (Oral Suspension 5 B/D, PA Capsule)

C1 Trex Reconstituted) all

C1 Trexall (Oral Tablet) 4 Myc oph C1 enol ate Xat Mof mep etil Mycophenolate Mofetil 3 B/D, PA Xatmep (Oral (Oral Tablet) 4 PA C1 Solution) Myc oph enol C1 ate Sodi Xelj um Mycophenolate anz Xeljanz (Oral Tablet 5 PA; QL Sodium (Oral Tablet 4 B/D, PA Immediate Release)

Xelj anz Delayed Release) XR

C1 Ore ncia Clic kJec Xeljanz XR (Oral t Orencia ClickJect Tablet Extended 5 PA; QL (Subcutaneous 5 PA Release 24 Hour)

Zort Solution Auto- ress Injector) Zortress (Oral Tablet) 5 B/D, PA B1 C1

Ore ncia Immunizing Agents, Passive

C1 Orencia Fleb oga mm a (Subcutaneous DIF Flebogamma DIF 5 PA Solution Prefilled (5GM/50ML 5 PA Intravenous Solution)

Syringe) C1 Ga mm C1 agar d Pro graf Prograf (Oral Packet) 5 B/D, PA Gammagard (2.5GM/

C1 Ras uvo Rasuvo 25ML Injection 5 PA Solution)

C1 (Subcutaneous Ga mm agar d S/ D Less 4 PA IgA Solution Auto- Gammagard S/D Injector) Less IgA (Intravenous

C1 5 PA San dim mun e Sandimmune (Oral Solution 4 B/D, PA Reconstituted)

C1 Solution) Ga mm ake d C1 Sim poni Simponi Gammaked (1GM/ (Subcutaneous 10ML Injection 5 PA 5 PA Solution)

C1 Solution Auto- Ga mm aple x Injector) Gammaplex (10GM/

Sim poni Simponi 100ML Intravenous (Subcutaneous Solution, 10GM/ 5 PA 200ML Intravenous Solution Prefilled 5 PA Syringe) Solution, 20GM/

C1 Sirol imu s 200ML Intravenous Sirolimus (Oral 5 B/D, PA Solution, 5GM/50ML Solution)

C1 Sirol imu s Intravenous Solution) Sirolimus (Oral Tablet) 4 B/D, PA

Bold type = Brand name drug Plain type = Generic drug 96 tRACK 96 Last updated October 1, 2019 6895 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Ga Benl mun ysta ex-C Gamunex-C (1GM/ Benlysta 10ML Injection 5 PA (Subcutaneous 5 PA Solution) Solution Prefilled

C1 Oct aga m Octagam (1GM/20ML Syringe) C1 Lefl uno mid Intravenous Solution, e Leflunomide (Oral 5 PA 2 2GM/20ML Tablet) C1 Ote Intravenous Solution) zla Otezla (Oral Tablet) 5 PA; LA

C1 C1 Pan zyga Ote Panzyga (Intravenous zla Otezla (Oral Tablet 5 PA 5 PA; LA Solution) Therapy Pack)

C1 C1 Privi Rida gen Privigen (20GM/ ura Ridaura (Oral 5 200ML Intravenous 5 PA Capsule)

Xola Solution) ir Xolair (Subcutaneous C1

Vari zig Varizig (Intramuscular Solution Prefilled 5 PA; LA 5 Solution) Syringe)

C1 Xola B1 Immunomodulators ir Xolair (Subcutaneous

C1 Acte mra ACT Pen Actemra ACTPen Solution 5 PA; LA (Subcutaneous Reconstituted)

5 PA B1 Solution Auto- Vaccines

C1 Act Injector) HIB ActHIB C1 Acte mra Actemra (Intramuscular 3 (Subcutaneous Solution 5 PA Solution Prefilled Reconstituted)

Ada Syringe) cel Adacel C1 Acti mm une Actimmune (Intramuscular 3 (Subcutaneous 5 LA Suspension)

C1 BC G Vac Solution) cine BCG Vaccine C1

Arca lyst 3 Arcalyst (Injection)

C1 Bex (Subcutaneous sero 5 PA; LA Bexsero Solution (Intramuscular 3 Reconstituted) Suspension Prefilled C1 Benl ysta Benlysta Syringe) (Subcutaneous 5 PA Solution Auto- Injector)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 97 97 6996 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Boo IPO strix L Boostrix (5-2.5-18.5 IPOL (Injection) 3

C1 Ixiar Intramuscular o Ixiaro (Intramuscular 3 Suspension, Suspension) C1 Kinri 5-2.5-18.5 (0.5ML 3 x Kinrix (Intramuscular 3 Syringe) Suspension)

C1 Men actr Intramuscular a Menactra Suspension)

C1 Dap (Intramuscular 3 tace l Daptacel Injectable)

Men (Intramuscular 3 veo Menveo Suspension)

C1 Diph (Intramuscular theri a- Teta nus Tox oids DT 3 Diphtheria-Tetanus Solution Toxoids DT Reconstituted)

3 C1 M- M-R (Intramuscular II M-M-R II Suspension)

C1 Eng (Subcutaneous 3 erix- B Engerix-B (Injection Injectable)

3 B/D, PA C1 Pedi Suspension) arix

C1 Gar Pediarix dasil 9 Gardasil 9 (Intramuscular 3 (Intramuscular 3 Suspension)

C1 Ped vax Suspension) HIB

C1 Gar Pedvax HIB dasil 9 Gardasil 9 (Intramuscular 3 (Intramuscular Suspension)

3 C1 Pro Qua Suspension Prefilled d ProQuad Syringe)

C1 Havr (Subcutaneous ix Havrix (Intramuscular 3 3 PA Suspension Suspension)

C1 Reconstituted) Hibe rix C1

Qua drac Hiberix (Injection el Quadracel

Solution 3 (Intramuscular 3 Reconstituted)

C1 Suspension) Imo vax Rabi C1 es Rab Aver Imovax Rabies t RabAvert (Intramuscular 3 B/D, PA (Intramuscular Injectable) 3 B/D, PA

C1 Suspension Infa nrix Infanrix Reconstituted) (Intramuscular 3 Suspension)

Bold type = Brand name drug Plain type = Generic drug 98 tRACK 98 Last updated October 1, 2019 7097 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Rec Vari omb vax ivax HB Recombivax HB Varivax

(Injection 3 B/D, PA (Subcutaneous 3 Suspension) Injectable)

C1 C1 Rot YF- arix Rotarix (Oral Vax YF-Vax

Suspension 3 (Subcutaneous 3 Reconstituted) Injectable)

C1 C1 Rot Zost aTe avax q RotaTeq (Oral Zostavax 3 Solution) (Subcutaneous

C1 Shin grix 4 PA Shingrix Suspension (Intramuscular Reconstituted)

3 PA A1 Suspension Inflammatory Bowel Disease Agents Reconstituted) B1 Aminosalicylates C1

TDV C1 AX Apri TDVAX so Apriso (Oral Capsule (Intramuscular 3 Extended Release 24 3 QL Suspension) Hour) C1

Teni C1 vac Bals alazi de Diso diu Tenivac m Balsalazide Disodium 4 (Intramuscular 3 (Oral Capsule)

C1 Can Injectable) asa Canasa (Rectal C1 Tru men ba 5 Trumenba Suppository)

C1 Dipe ntu (Intramuscular m Dipentum (Oral 3 5 Suspension Prefilled Capsule)

Mes ala min Syringe) e C1 Mesalamine (1.2GM Twi nrix Twinrix Oral Tablet Delayed 3 QL (Intramuscular Release) (Generic 3 Suspension Prefilled Lialda) C1 Mes ala min Syringe) e Mesalamine (Rectal

C1 Typ him Vi 4 QL Typhim Vi Enema) C1 Mes ala min e (Intramuscular 3 Mesalamine (Rectal 5 Solution) Suppository) C1 C1 Pent VAQ asa TA VAQTA Pentasa (Oral (Intramuscular 3 PA Capsule Extended 4 QL Suspension) Release) B1 Glucocorticoids

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 99 99 7198 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Bud Calc eso itriol nide ER Budesonide ER (Oral Calcitriol (Oral 2 B/D, PA Tablet Extended 5 ST Capsule)

C1 Calc Release 24 Hour) itriol

C1 Calcitriol (Oral Bud eso nide 2 B/D, PA Budesonide (Oral Solution)

C1 Cina calc et Capsule Delayed 4 HCl Cinacalcet HCl (30MG Release Particles) 4 B/D, PA; QL

C1 Oral Tablet) Col ocor C1 t Cina calc et Colocort (Rectal HCl 4 Cinacalcet HCl (60MG Enema)

C1 Oral Tablet, 90MG Oral 5 B/D, PA; QL Hyd roco rtiso ne Hydrocortisone (Rectal Tablet)

Dox 4 erca lcife Enema) rol

C1 Doxercalciferol (Oral Proc to- Med HC 4 B/D, PA; QL Procto-Med HC (Rectal Capsule)

Fort 2 eo Cream)

C1 Forteo Proc to- Pak Procto-Pak (Rectal 2 (Subcutaneous 5 PA; QL Cream) Solution) C1

Proc C1 toso l HC Iban dron ate Sodi Proctosol HC (Rectal um Ibandronate Sodium 2 2 QL Cream) (Oral Tablet) C1

Proc C1 tozo ne- Nat HC Proctozone-HC (Rectal para 2 Natpara Cream) (Subcutaneous 5 PA; LA B1 Sulfonamides Cartridge) C1

Sulf C1 asal azin Pari e calci Sulfasalazine (Oral tol Paricalcitol (Oral 4 B/D, PA Tablet Immediate 2 Capsule)

Proli Release) a

C1 Sulf Prolia (Subcutaneous asal azin e Sulfasalazine (Oral Solution Prefilled 4 QL Tablet Delayed 2 Syringe)

C1 Ray alde Release) e

A1 Rayaldee (Oral Metabolic Bone Disease Agents Capsule Extended 5 QL B1 Metabolic Bone Disease Agents

C1 Release) Alen dron C1 ate Sodi Rise um dron ate Sodi Alendronate Sodium um 4 Risedronate Sodium (Oral Solution) C1 (Oral Tablet Immediate 3 QL Alen dron ate Sodi um Alendronate Sodium Release)

C1 Tym 1 QL los (Oral Tablet)

C1 Tymlos Bino sto Binosto (Oral Tablet 4 QL (Subcutaneous 5 PA; QL Effervescent) Solution Pen-Injector) C1 Calc C1 itoni Xge n va Sal mon Calcitonin Salmon Xgeva (Subcutaneous 3 QL 5 PA (Nasal Solution) Solution)

Bold type = Brand name drug Plain type = Generic drug 100 tRACK 100 Last updated October 1, 2019 7299 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Neo myci A1 n- Poly myxi n- Dex ame thas Miscellaneous Therapeutic Agents one Neomycin-Polymyxin-

B1 Miscellaneous Therapeutic Agents Dexamethasone C1 Alco hol Pre p Pad s Alcohol Prep Pads 3 (3.5-10000-0.1 2

C1 Gau ze Ophthalmic Gauze (Non-medicated 3 Suspension) C1 Neo myci n- Poly 2X2 Pad) myxi n- C1 Gra mici Insul din in Syri Neomycin-Polymyxin- nge s, Nee dles Insulin Syringes, 3 Gramicidin 3 Needles (Ophthalmic Solution)

A1 C1 Neo myci n- Poly myxi n- Ophthalmic Agents HC Neomycin-Polymyxin- B1 Ophthalmic Agents, Other HC (Ophthalmic 4 C1 Atro pine

Sulf ate Atropine Sulfate Suspension) C1 Poly myxi n B- Trim 3 etho (Ophthalmic Solution) prim Polymyxin B-

C1 Baci traci n- Poly myxi n B Bacitracin-Polymyxin B Trimethoprim 2 2 (Ophthalmic Solution) (Ophthalmic Ointment) C1 Pre C1 d-G

Neo myci n- Poly myxi n- Baci traci Pred-G (Ophthalmic n- Hyd roco Neomycin-Polymyxin- rtiso ne 4 Bacitracin- Suspension) C1

Pre d-G S.O. 3 P. Hydrocortisone Pred-G S.O.P.

(Ophthalmic Ointment) (Ophthalmic 4 C1 Blep ham ide Blephamide Ointment)

C1 Pro para cain e (Ophthalmic 4 HCl Proparacaine HCl 2 Suspension) (Ophthalmic Solution) C1 C1 Blep ham Rest ide asis S.O. P. Blephamide S.O.P. Restasis (Ophthalmic 4 3 QL (Ophthalmic Ointment) Emulsion) C1

Cyst C1 aran Rho pres Cystaran (Ophthalmic sa Rhopressa 5 LA 3 ST Solution) (Ophthalmic Solution) C1

Lacr C1 isert Sulf acet ami de- Pre dnis olon Lacrisert (Ophthalmic e 4 Sulfacetamide- Insert) Prednisolone 2 C1

Last acaf t Lastacaft (Ophthalmic Solution) C1 Tob raD 3 ex (Ophthalmic Solution) TobraDex

C1 Neo myci n- Baci traci n- Poly myxi n Neomycin-Bacitracin- (Ophthalmic 3 Polymyxin Ointment) C1 Tob raD 3 ex (5-400-10000 ST TobraDex ST Ophthalmic Ointment)

C1 (Ophthalmic 4 Neo myci n- Poly myxi n- Dex ame thas one Neomycin-Polymyxin- Suspension) Dexamethasone 2 (Ophthalmic Ointment)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 101 101 73100 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Tob Brim ram onid ycin- ine Dex Tartr ame ate thas one Tobramycin- Brimonidine Tartrate

Dexamethasone 3 (0.15% Ophthalmic 4 (Ophthalmic Solution)

C1 Brim onid ine Tartr Suspension) ate

C1 Xiidr Brimonidine Tartrate a Xiidra (Ophthalmic 4 QL (0.2% Ophthalmic 2 Solution) Solution)

C1 Cart B1 eolo l Ophthalmic Anti-allergy Agents HCl Carteolol HCl C1 Aloc ril 2 Alocril (Ophthalmic (Ophthalmic Solution) C1 Co mbi 4 gan Solution) Combigan

Alo mid e 3 Alomide (Ophthalmic (Ophthalmic Solution) C1

Cos opt 4 PF Solution) Cosopt PF

Azel astin e 4 HCl Azelastine HCl (Ophthalmic Solution) C1

Dor zola mid 3 e (Ophthalmic Solution) HCl Dorzolamide HCl C1 Bep reve 2 Bepreve (Ophthalmic (Ophthalmic Solution) C1 Dor zola mid 4 e HCl- Tim olol Mal Solution) eate Dorzolamide HCl-

C1 Cro mol yn Sodi um Cromolyn Sodium Timolol Maleate 2 2 (Ophthalmic Solution)

(Ophthalmic Solution) C1 Dor C1 zola mid Epin e astin HCl- e Tim HCl olol Mal eate

Pres Dorzolamide HCl- erva tive Epinastine HCl Free 3 (Ophthalmic Solution) Timolol Maleate C1 4 Olo pata dine HCl Preservative Free Olopatadine HCl 3 (Ophthalmic Solution)

C1 Lev (Ophthalmic Solution) obu nolo l C1 HCl Paz eo Levobunolol HCl Pazeo (Ophthalmic 2 3 (Ophthalmic Solution)

Pho sph Solution) olin e Iodi de B1 Phospholine Iodide Ophthalmic Antiglaucoma Agents

C1 Alph aga n P (Ophthalmic Solution 4 Alphagan P (0.1% 3 Reconstituted) C1 Pilo carp ine Ophthalmic Solution) HCl

C1 Apr aclo nidi Pilocarpine HCl ne HCl Apraclonidine HCl 3 3 (Ophthalmic Solution) C1 Roc klata (Ophthalmic Solution) n

Azo pt Rocklatan Azopt (Ophthalmic 3 ST 3 (Ophthalmic Solution) C1 Sim brin Suspension) za

C1 Beta xolo l Simbrinza HCl Betaxolol HCl 3 (Ophthalmic 3 (Ophthalmic Solution)

C1 Beti mol Suspension) Betimol (Ophthalmic 4 Solution)

Bold type = Brand name drug Plain type = Generic drug 102 tRACK 102 Last updated October 1, 2019 74101 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Tim Lote olol max Mal eate

Oph thal mic Gel For min Timolol Maleate Lotemax (Ophthalmic g 4 Ophthalmic Gel Gel) C1 Lote Forming (Ophthalmic 3 max Lotemax (Ophthalmic 4 Solution) (Generic Ointment)

C1 Lote Timoptic-XE) max

C1 Tim olol Mal eate Lotemax (Ophthalmic Timolol Maleate 4 Suspension)

C1 Lote (0.25% Ophthalmic max SM Lotemax SM Solution, 0.5% 2 4 Ophthalmic Solution) (Ophthalmic Gel) C1

Lote pred nol Etab onat (Generic Timoptic) e Loteprednol Etabonate B1 Ophthalmic Anti-inflammatories (Ophthalmic 4

C1 Dex ame thas one Sodi um Suspension) Pho sph ate C1 Dexamethasone Pre d Mild Pred Mild Sodium Phosphate 2 (Ophthalmic Solution) (Ophthalmic 4

Dicl ofen ac Sodi um Suspension) Diclofenac Sodium C1 Pre dnis olon e 2 Acet (Ophthalmic Solution) ate Prednisolone Acetate

C1 Dur ezol Durezol (Ophthalmic (Ophthalmic 3 3 Suspension) Emulsion) C1 Pre dnis C1 olon e Flar Sodi ex um Pho sph Flarex (Ophthalmic ate Prednisolone Sodium 4 Suspension) Phosphate (1% 2

C1 Fluo rom etho Ophthalmic Solution) lone

C1 Prol ens Fluorometholone a Prolensa (Ophthalmic (Ophthalmic 3 4 Suspension) Solution)

C1 B1 Flur bipr ofen

Sodi um Flurbiprofen Sodium Ophthalmic Prostaglandin and Prostamide 2 Analogs

(Ophthalmic Solution) C1 Lata C1 nopr ost FML Fort e Latanoprost FML Forte 1 (Ophthalmic Solution) (Ophthalmic 4 C1 Lum igan Suspension) Lumigan (Ophthalmic

C1 FML 3 Solution)

FML (Ophthalmic C1 Vyz 4 ulta Ointment) Vyzulta (Ophthalmic

C1 Ilevr 4 o Solution) Ilevro (Ophthalmic C1 Ziop 3 tan Suspension) Zioptan (Ophthalmic

C1 Ket 4 orol ac Tro met ham ine Ketorolac Solution) A1 Tromethamine 3 Otic Agents (Ophthalmic Solution) B1 Otic Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 103 103 75102 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Acet Pro ic met Acid hazi ne Acetic Acid (Otic HCl Promethazine HCl 2 Solution) (12.5MG Rectal

C1 Cipr o 4 HC Cipro HC (Otic Suppository, 25MG 4 Rectal Suppository) Suspension) C1 Pro met C1 heg an Cipr ode x Ciprodex (Otic Promethegan (25MG 3 4 Suspension) Rectal Suppository) B1 C1 Flac Anti-inflammatories, Inhaled Corticosteroids

C1 Flac (Otic Oil) 4 Arn uity Ellip C1 ta

Fluo cino lone

Acet onid Arnuity Ellipta e Fluocinolone 4 Acetonide (Otic Oil) (Inhalation Aerosol

C1 3 QL Hyd roco rtiso ne- Acet Powder Breath ic Acid Hydrocortisone-Acetic 3 Activated)

C1 Acid (Otic Solution) Bud eso nide C1 Neo myci n- Poly myxi n- HC Budesonide (Inhalation Neomycin-Polymyxin- 4 B/D, PA 3 Suspension)

HC (1% Otic Solution) Flov ent Disk C1 us Neo myci n- Poly myxi n- Flovent Diskus HC Neomycin-Polymyxin- 3 (Inhalation Aerosol HC (Otic Suspension) 3 QL A1 Respiratory Tract/Pulmonary Agents Powder Breath

B1 Activated)

C1 Flov ent Antihistamines HFA

C1 Azel astin e HCl Flovent HFA Azelastine HCl (0.1% 3 QL (Inhalation Aerosol)

C1 Flun Nasal Solution, 0.15% 3 isoli de Nasal Solution) Flunisolide (Nasal

C1 1 Ceti rizin e HCl Solution)

C1 Fluti Cetirizine HCl (1MG/ cas one Pro pion 2 ate ML Oral Solution) Fluticasone Propionate

C1 2 Cyp rohe ptad ine HCl (Nasal Suspension)

Mo Cyproheptadine HCl met aso ne Furo 4 ate (Oral Syrup) Mometasone Furoate C1 4 Cyp rohe ptad ine HCl (Nasal Suspension) Cyproheptadine HCl 4 B1 Antileukotrienes

(Oral Tablet) C1 Mon C1 telu kast Lev Sodi ocet um irizin e Dihy droc hlori de Montelukast Sodium Levocetirizine 2 QL (Oral Packet)

Dihydrochloride (Oral 1 QL C1 Mon telu kast Sodi Tablet) um Montelukast Sodium

C1 Phe nad 1 QL oz (Oral Tablet) Phenadoz (12.5MG C1 Mon telu kast Sodi 4 um Rectal Suppository) Montelukast Sodium

C1 Pro met 2 QL hazi ne HCl (Oral Tablet Chewable) Promethazine HCl C1 Zafir luka 3 st (Oral Syrup) Zafirlukast (Oral

C1 Pro met 3 QL hazi ne HCl Promethazine HCl Tablet) 3 (Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 104 tRACK 104 Last updated October 1, 2019 76103 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Zile Epin uton ephr ER Zileuton ER (Oral ine Epinephrine (Injection 3 QL Tablet Extended 5 ST Solution Auto-Injector)

C1 EpiP en 2- Release 12 Hour) Pak

C1 EpiPen 2-Pak Zyfl o Zyflo (Oral Tablet (Injection Solution 5 ST 3 QL Immediate Release) Auto-Injector)

C1 EpiP B1 en Jr 2- Bronchodilators, Anticholinergic Pak EpiPen Jr 2-Pak C1 Atro vent

HFA Atrovent HFA (Injection Solution 3 QL

(Inhalation Aerosol 4 Auto-Injector)

C1 Lev albu terol Solution) HCl Levalbuterol HCl C1

Incr use Ellip ta Incruse Ellipta (Inhalation 4 B/D, PA Nebulization Solution)

(Inhalation Aerosol C1 Met apro tere nol Sulf 3 QL ate Metaproterenol Sulfate Powder Breath 4 Activated) (Oral Syrup) C1

C1 Perf oro Iprat mist ropi um Bro mid e Ipratropium Bromide Perforomist 2 B/D, PA (Inhalation Solution) (Inhalation

C1 Iprat ropi 4 B/D, PA; QL um Bro mid e Ipratropium Bromide Nebulization 2 (Nasal Solution) Solution) C1 C1 Pro Air Lon HFA hala Mag nair Refil l Kit ProAir HFA Lonhala Magnair Refill Kit (Inhalation 5 QL (Inhalation Aerosol 3 Solution) Solution) C1 C1 Pro Air Spiri Res va piCli Han ck diHa ler Spiriva HandiHaler ProAir RespiClick 3 QL (Inhalation Capsule) (Inhalation Aerosol

C1 Spiri 3 va Res pim at Spiriva Respimat Powder Breath Activated)

(Inhalation Aerosol 3 QL C1 Sere vent

Disk Solution) us Serevent Diskus B1 Bronchodilators, Sympathomimetic (Inhalation Aerosol

C1 3 QL Albu terol

Sulf ate Albuterol Sulfate Powder Breath (Inhalation 2 B/D, PA Activated) Nebulization Solution) B1 Cystic Fibrosis Agents C1 C1 Beth Albu kis terol

Sulf ate Albuterol Sulfate (Oral Bethkis (Inhalation 4 Syrup) Nebulization 5 B/D, PA; QL

Albu terol

Sulf ate Albuterol Sulfate (Oral Solution) C1 Cay ston Tablet Immediate 4 Cayston (Inhalation Release) Solution 5 PA; LA Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 105 105 77104 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Ork Ore amb nitra i Orkambi (Oral m Orenitram (0.25MG 5 PA; LA; QL Packet) Oral Tablet Extended

C1 Ork amb i Orkambi (Oral Tablet) 5 PA; LA; QL Release, 1MG Oral

C1 TOB I Pod hale r TOBI Podhaler Tablet Extended 5 PA; QL (Inhalation Capsule) Release, 2.5MG Oral 5 PA; LA

C1 Tob ram ycin Tobramycin (Inhalation Tablet Extended 5 B/D, PA; QL Nebulization Solution) Release, 5MG Oral

B1 Tablet Extended Mast Cell Stabilizers

Cro mol yn Sodi Release) um C1 Sild enaf il Cromolyn Sodium Citra te (Inhalation 3 B/D, PA Sildenafil Citrate Nebulization Solution) (20MG Oral Tablet) 3 PA; QL

B1 (Generic Revatio)

C1 Tad Phosphodiesterase Inhibitors, Airways alafil Tadalafil (PAH) (20MG Disease 5 PA; QL

C1 Dalir esp Oral Tablet)

C1 Trac Daliresp (Oral Tablet) 4 PA; QL leer

C1 The oph Tracleer (Oral Tablet yllin e ER 5 PA; LA; QL Theophylline ER Soluble)

Vent (300MG Oral Tablet avis 2 Ventavis (Inhalation Extended Release 12 5 PA; LA; QL Hour) Solution)

C1 B1 The oph yllin e ER Pulmonary Fibrosis Agents Theophylline ER (Oral C1 Esbr iet Tablet Extended 2 Esbriet (Oral Capsule) 5 PA; LA; QL C1 Esbr Release 24 Hour) iet Esbriet (Oral Tablet) 5 PA; LA; QL C1

The C1 oph yllin Ofe e Theophylline (Oral v 2 Ofev (Oral Capsule) 5 PA; LA; QL Solution) B1 Respiratory Tract Agents, Other B1 C1 Acet ylcy stei Pulmonary Antihypertensives ne

C1 Ade Acetylcysteine mpa s 2 B/D, PA Adempas (Oral (Inhalation Solution)

C1 5 PA; LA Adv air Disk Tablet) us C1 Advair Diskus Alyq Alyq (Oral Tablet) 5 PA; QL (Inhalation Aerosol C1

Am bris enta n 3 QL Ambrisentan (Oral Powder Breath 5 PA; LA; QL Tablet) Activated) C1 Bos C1 enta n Adv air Bosentan (Oral Tablet) 5 PA; LA; QL HFA Advair HFA C1 Ops umit 3 QL Opsumit (Oral Tablet) 5 PA; LA (Inhalation Aerosol)

C1 Ore nitra m Orenitram (0.125MG Oral Tablet Extended 4 PA; LA Release)

Bold type = Brand name drug Plain type = Generic drug 106 tRACK 106 Last updated October 1, 2019 78105 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1

Ano Nuc ro ala Ellip ta Anoro Ellipta Nucala (Inhalation Aerosol (Subcutaneous 3 QL 5 PA; LA; QL Powder Breath Solution Activated) Reconstituted)

C1 C1 Bev Pul espi moz yme Aer osp here Bevespi Aerosphere Pulmozyme 3 QL 5 B/D, PA; QL (Inhalation Aerosol) (Inhalation Solution)

C1 C1 Bre Stiol o to Ellip Res ta pim Breo Ellipta at Stiolto Respimat (Inhalation Aerosol (Inhalation Aerosol 3 QL 3 QL Powder Breath Solution)

C1 Sym bico Activated) rt Symbicort (Inhalation C1 Co mbi vent

Res 3 QL pim at Combivent Respimat Aerosol)

Trel egy Ellip (Inhalation Aerosol 3 QL ta Trelegy Ellipta Solution) (Inhalation Aerosol C1

Dule ra 3 QL Dulera (Inhalation Powder Breath 4 QL Aerosol) Activated)

C1 C1

Dym Wix ista ela Inhu Dymista (Nasal b Wixela Inhub 4 Suspension) (Inhalation Aerosol

C1 Fluti cas one- Sal met erol Fluticasone-Salmeterol Powder Breath 3 QL (Inhalation Aerosol Activated) (Generic 3 QL Powder Breath Advair) Activated) A1 Skeletal Muscle Relaxants

C1 Iprat ropi B1 um- Albu terol Ipratropium-Albuterol Skeletal Muscle Relaxants C1 Bacl 1 B/D, PA ofen (Inhalation Solution) Baclofen (Oral Tablet) 2 C1 Kaly C1 dec o Chlo rzox azo Kalydeco (Oral ne Chlorzoxazone 5 PA; LA; QL 3 Packet) (500MG Oral Tablet) C1 C1 Kaly dec Cycl o obe nza prin e Kalydeco (Oral HCl Cyclobenzaprine HCl 5 PA; LA; QL Tablet) (10MG Oral Tablet, 2

C1 Nuc ala 5MG Oral Tablet)

Nucala C1 Cycl obe nza prin e (Subcutaneous HCl Cyclobenzaprine HCl 5 PA; LA; QL 4 Solution Auto- (7.5MG Oral Tablet) C1 Dant role ne Sodi Injector) um Dantrolene Sodium

C1 Nuc 4 ala (Oral Capsule) Nucala C1 Tiza nidi ne (Subcutaneous HCl Tizanidine HCl (Oral 5 PA; LA; QL 2 Solution Prefilled Tablet) Syringe) A1 Sleep Disorder Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2019 107 107 79106 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 GABA Receptor Modulators B1 Sleep Disorders, Other

C1 C1 Tem Bels aze omr pam Temazepam (15MG a Belsomra (Oral 3 QL Oral Capsule, 30MG 2 QL Tablet)

C1 Hetli Oral Capsule) oz C1 Hetlioz (Oral Capsule) 5 PA; LA; QL Zale plon C1 Mod Zaleplon (Oral afinil 3 QL Modafinil (Oral Tablet) 4 PA; QL C1

Ram elte Capsule) on

C1 Zolp ide m Ramelteon (Oral Tartr ate 4 QL Zolpidem Tartrate Tablet)

Xyre (Oral Tablet Immediate 2 QL m Release) Xyrem (Oral Solution) 5 PA; LA; QL

Bold type = Brand name drug Plain type = Generic drug 108108 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 Sulfate (Oral Solution) Maximum of 32 ml per day Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day Acarbose (25MG Oral Tablet) Maximum of 12 tablets per day Acarbose (50MG Oral Tablet) Maximum of 6 tablets per day Acetaminophen-Codeine (120-12MG/5ML Oral Maximum of 150 ml per day Solution) Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Maximum of 13 tablets per day Tablet) Acyclovir (External Ointment) Maximum of 1 tube (30 grams) per 30 days Advair Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Aimovig (140MG/ML Subcutaneous Solution Maximum of 1 ml (1 pen) per 30 days Auto-Injector) Aimovig (70MG/ML Subcutaneous Solution Maximum of 2 ml per 30 days Auto-Injector) Albendazole (Oral Tablet) Maximum of 16 tablets per day Alecensa (Oral Capsule) Maximum of 8 capsules per day Alendronate Sodium (10MG Oral Tablet, 40MG Maximum of 1 tablet per day Oral Tablet, 5MG Oral Tablet) Alendronate Sodium (35MG Oral Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70MG Oral Tablet) Maximum of 4 tablets per 28 days Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last109 updated October 1, 2019 2 2 109 Drug Name Quantity Limit Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, Maximum of 4 tablets per day 1MG Oral Tablet Immediate Release) Alprazolam (2MG Oral Tablet Immediate Maximum of 5 tablets per day Release) Alunbrig (180MG Oral Tablet, 90MG Oral Maximum of 1 tablet per day Tablet) Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days Alyq (Oral Tablet) Maximum of 2 tablets per day Ambrisentan (Oral Tablet) Maximum of 1 tablet per day Amitiza (Oral Capsule) Maximum of 2 capsules per day Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day Amphetamine-Dextroamphetamine ER (Oral Maximum of 2 capsules per day Capsule Extended Release 24 Hour) Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, Maximum of 2 tablets per day 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet) Amphetamine-Dextroamphetamine (20MG Oral Maximum of 3 tablets per day Tablet) Ampyra (Oral Tablet Extended Release 12 Maximum of 2 tablets per day Hour) Androderm (Transdermal Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day Apriso (Oral Capsule Extended Release 24 Maximum of 4 capsules per day Hour) Aptiom (200MG Oral Tablet, 400MG Oral Maximum of 1 tablet per day Tablet) Aptiom (600MG Oral Tablet, 800MG Oral Maximum of 2 tablets per day Tablet) Aptivus (Oral Capsule) Maximum of 4 capsules per day Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days

Bold type = Brand name drug Plain type = Generic drug 110110 3 3 Last updated October 1, 2019 Drug Name Quantity Limit Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, Maximum of 1 tablet per day 30MG Oral Tablet, 5MG Oral Tablet) Aripiprazole ODT (10MG Oral Tablet Maximum of 3 tablets per day Dispersible) Aripiprazole ODT (15MG Oral Tablet Maximum of 2 tablets per day Dispersible) Arnuity Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per 30 days Breath Activated) Aspirin-Dipyridamole ER (Oral Capsule Maximum of 2 capsules per day Extended Release 12 Hour) Atazanavir Sulfate (150MG Oral Capsule, Maximum of 1 capsule per day 300MG Oral Capsule) Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day Atomoxetine HCl (100MG Oral Capsule, 60MG Maximum of 1 capsule per day Oral Capsule, 80MG Oral Capsule) Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Maximum of 2 capsules per day Capsule) Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day Atripla (Oral Tablet) Maximum of 1 tablet per day Aubagio (Oral Tablet) Maximum of 1 tablet per day Austedo (Oral Tablet) Maximum of 4 tablets per day Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days Avonex Prefilled (Intramuscular Prefilled Maximum of 1 kit per 28 days Syringe Kit) Balversa (3MG Oral Tablet) Maximum of 3 tablets per day Balversa (4MG Oral Tablet) Maximum of 2 tablets per day Balversa (5MG Oral Tablet) Maximum of 1 tablet per day Belsomra (Oral Tablet) Maximum of 1 tablet per day Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days Bethkis (Inhalation Nebulization Solution) Maximum of 8 ml (2 ampules) per day Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days BiDil (Oral Tablet) Maximum of 6 tablets per day Biktarvy (Oral Tablet) Maximum of 1 tablet per day Binosto (Oral Tablet Effervescent) Maximum of 4 tablets per 28 days

Bold type = Brand name drug Plain type = Generic drug Last111 updated October 1, 2019 4 4 111 Drug Name Quantity Limit Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day Bosentan (Oral Tablet) Maximum of 2 tablets per day Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day Bosulif (400MG Oral Tablet, 500MG Oral Maximum of 1 tablet per day Tablet) Breo Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Brilinta (Oral Tablet) Maximum of 2 tablets per day BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day BRIVIACT (100MG Oral Tablet, 10MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet, Maximum of 2 tablets per day 75MG Oral Tablet) Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day Buprenorphine HCl-Naloxone HCl (12-3MG Maximum of 2 films per day Sublingual Film, 4-1MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (2-0.5MG Maximum of 3 films per day Sublingual Film, 8-2MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days Butalbital-Acetaminophen-Caffeine (Oral Tablet) Maximum of 6 tablets per day Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Bydureon BCise (Subcutaneous Auto- Maximum of 4 pens (3.4 ml) per 28 days Injector) Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days Byetta 10MCG Pen (Subcutaneous Solution Maximum of 1 pen (2.4 ml) per 30 days Pen-Injector) Byetta 5MCG Pen (Subcutaneous Solution Maximum of 1 pen (1.2 ml) per 30 days Pen-Injector) Bystolic (10MG Oral Tablet, 2.5MG Oral Maximum of 1 tablet per day Tablet, 5MG Oral Tablet) Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day Cablivi (Injection Kit) Maximum of 1 kit per day Cabometyx (20MG Oral Tablet, 60MG Oral Maximum of 1 tablet per day Tablet) Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days Calquence (Oral Capsule) Maximum of 2 capsules per day

Bold type = Brand name drug Plain type = Generic drug 112112 5 5 Last updated October 1, 2019 Drug Name Quantity Limit Candesartan Cilexetil (16MG Oral Tablet, 32MG Maximum of 1 tablet per day Oral Tablet, 4MG Oral Tablet) Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day Captopril (100MG Oral Tablet) Maximum of 4 tablets per day Captopril (12.5MG Oral Tablet, 25MG Oral Maximum of 3 tablets per day Tablet) Captopril (50MG Oral Tablet) Maximum of 9 tablets per day Captopril-Hydrochlorothiazide (25-15MG Oral Maximum of 3 tablets per day Tablet, 50-15MG Oral Tablet) Captopril-Hydrochlorothiazide (25-25MG Oral Maximum of 2 tablets per day Tablet, 50-25MG Oral Tablet) Celecoxib (Oral Capsule) Maximum of 2 capsules per day Cimduo (Oral Tablet) Maximum of 1 tablet per day Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Maximum of 2 tablets per day Tablet) Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day Clobazam (10MG Oral Tablet, 20MG Oral Maximum of 2 tablets per day Tablet) Clonazepam (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, Maximum of 4 tablets per day 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible) Clonazepam ODT (2MG Oral Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day Clozapine ODT (100MG Oral Tablet Dispersible) Maximum of 9 tablets per day Clozapine ODT (12.5MG Oral Tablet Maximum of 2 tablets per day Dispersible) Clozapine ODT (150MG Oral Tablet Dispersible) Maximum of 6 tablets per day Clozapine ODT (200MG Oral Tablet Dispersible) Maximum of 4 tablets per day Clozapine ODT (25MG Oral Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (Oral Tablet) Maximum of 6 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last113 updated October 1, 2019 6 6 113 Drug Name Quantity Limit Colchicine (0.6MG Oral Capsule) (Brand Maximum of 4 capsules per day Equivalent Mitigare) Colchicine (0.6MG Oral Tablet) (Brand Maximum of 4 tablets per day Equivalent Colcrys) Colcrys (Oral Tablet) Maximum of 4 tablets per day Combivent Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 20 days Solution) Complera (Oral Tablet) Maximum of 1 tablet per day Copiktra (Oral Capsule) Maximum of 2 capsules per day Corlanor (Oral Solution) Maximum of 15 ml per day Corlanor (Oral Tablet) Maximum of 2 tablets per day Cotellic (Oral Tablet) Maximum of 3 tablets per day Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day Cycloset (Oral Tablet) Maximum of 6 tablets per day Dalfampridine ER (Oral Tablet Extended Maximum of 2 tablets per day Release 12 Hour) Daliresp (Oral Tablet) Maximum of 1 tablet per day Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day Delstrigo (Oral Tablet) Maximum of 1 tablet per day Denavir (External Cream) Maximum of 1 tube (5 grams) per 30 days Descovy (Oral Tablet) Maximum of 1 tablet per day Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 4 tablets per day Pristiq) Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Maximum of 1 tablet per day Tablet Extended Release 24 Hour) (Generic Pristiq) Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day Dextroamphetamine Sulfate ER (10MG Oral Maximum of 6 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (15MG Oral Maximum of 4 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (5MG Oral Maximum of 3 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day

Bold type = Brand name drug Plain type = Generic drug 114114 7 7 Last updated October 1, 2019 Drug Name Quantity Limit Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day Diazepam (10MG Oral Tablet, 2MG Oral Tablet, Maximum of 4 tablets per day 5MG Oral Tablet) Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day Didanosine (200MG Oral Capsule Delayed Maximum of 2 capsules per day Release) Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Maximum of 1 capsule per day Release) Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day Donepezil HCl (23MG Oral Tablet, 5MG Oral Maximum of 1 tablet per day Tablet) Donepezil HCl ODT (10MG Oral Tablet Maximum of 2 tablets per day Dispersible) Donepezil HCl ODT (5MG Oral Tablet Maximum of 1 tablet per day Dispersible) Dovato (Oral Tablet) Maximum of 1 tablet per day Doxepin HCl (External Cream) Maximum of 90 grams per 30 days Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day Doxercalciferol (1MCG Oral Capsule, 2.5MCG Maximum of 4 capsules per day Oral Capsule) Dulera (Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Maximum of 2 capsules per day Release Particles, 60MG Oral Capsule Delayed Release Particles) Dutasteride (Oral Capsule) Maximum of 1 capsule per day Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days Edarbi (Oral Tablet) Maximum of 1 tablet per day Edarbyclor (Oral Tablet) Maximum of 1 tablet per day Edurant (Oral Tablet) Maximum of 1 tablet per day Efavirenz (Oral Capsule) Maximum of 3 capsules per day Efavirenz (Oral Tablet) Maximum of 1 tablet per day Eliquis (Oral Tablet) Maximum of 2 tablets per day Eliquis Starter Pack (Oral Tablet) Maximum of 1 pack (74 tablets) per 30 days Embeda (100-4MG Oral Capsule Extended Maximum of 3 capsules per day Release)

Bold type = Brand name drug Plain type = Generic drug Last115 updated October 1, 2019 8 8 115 Drug Name Quantity Limit Embeda (20-0.8MG Oral Capsule Extended Release, 80-3.2MG Oral Capsule Extended Maximum of 4 capsules per day Release) Embeda (30-1.2MG Oral Capsule Extended Release, 50-2MG Oral Capsule Extended Maximum of 2 capsules per day Release) Embeda (60-2.4MG Oral Capsule Extended Maximum of 6 capsules per day Release) Emsam (Transdermal Patch 24 Hour) Maximum of 1 patch per day Emtriva (Oral Capsule) Maximum of 1 capsule per day Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day Enalapril-Hydrochlorothiazide (10-25MG Oral Maximum of 2 tablets per day Tablet) Enalapril-Hydrochlorothiazide (5-12.5MG Oral Maximum of 1 tablet per day Tablet) Endocet (10-325MG Oral Tablet, 5-325MG Oral Maximum of 12 tablets per day Tablet, 7.5-325MG Oral Tablet) Enoxaparin Sodium (100MG/ML Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150MG/ML Subcutaneous Solution) Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (30MG/0.3ML Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (40MG/0.4ML Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60MG/0.6ML Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution) Entresto (Oral Tablet) Maximum of 2 tablets per day Epclusa (Oral Tablet) Maximum of 1 tablet per day Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days EpiPen 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 days Injector) EpiPen Jr 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 days Injector) Eprosartan Mesylate (Oral Tablet) Maximum of 1 tablet per day Erivedge (Oral Capsule) Maximum of 1 capsule per day Erleada (Oral Tablet) Maximum of 4 tablets per day

Bold type = Brand name drug Plain type = Generic drug 116116 9 9 Last updated October 1, 2019 Drug Name Quantity Limit Erlotinib HCl (100MG Oral Tablet, 150MG Oral Maximum of 1 tablet per day Tablet) Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day Esbriet (Oral Capsule) Maximum of 9 capsules per day Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day Esomeprazole Magnesium (20MG Oral Capsule Maximum of 3 capsules per day Delayed Release) (Generic Nexium) Esomeprazole Magnesium (40MG Oral Capsule Maximum of 2 capsules per day Delayed Release) (Generic Nexium) Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days Estradiol (Vaginal Tablet) Maximum of 1 tablet per day Evotaz (Oral Tablet) Maximum of 1 tablet per day Ezetimibe (Oral Tablet) Maximum of 1 tablet per day Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day Famciclovir (125MG Oral Tablet, 250MG Oral Maximum of 2 tablets per day Tablet) Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 4MG Oral Maximum of 2 tablets per day Tablet, 6MG Oral Tablet, 8MG Oral Tablet) Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, Maximum of 15 patches per 30 days 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour) Fetzima (Oral Capsule Extended Release 24 Maximum of 1 capsule per day Hour) Firazyr (Subcutaneous Solution) Maximum of 9 ml per day Flector (Transdermal Patch) Maximum of 2 patches per day Flovent Diskus (Inhalation Aerosol Powder Maximum of 2 inhalers (120 blisters) per 30 Breath Activated) days Flovent HFA (110MCG/ACT Inhalation Maximum of 1 inhaler (12 grams) per 30 days Aerosol) Flovent HFA (220MCG/ACT Inhalation Maximum of 2 inhalers (24 grams) per 30 days Aerosol) Flovent HFA (44MCG/ACT Inhalation Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days

Bold type = Brand name drug Plain type = Generic drug Last117 updated October 1, 2019 10 10 117 Drug Name Quantity Limit Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair) Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Maximum of 1 inhaler per 30 days Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo) Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day Forteo (Subcutaneous Solution) Maximum of 1 pen (2.4 ml) per 28 days Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day Fuzeon (Subcutaneous Solution Maximum of 2 vials per day Reconstituted) Galantamine Hydrobromide ER (Oral Capsule Maximum of 1 capsule per day Extended Release 24 Hour) Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day Genvoya (Oral Tablet) Maximum of 1 tablet per day Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days Glatiramer Acetate (20MG/ML Subcutaneous Maximum of 1 syringe (1 ml) per day Solution Prefilled Syringe) Glatiramer Acetate (40MG/ML Subcutaneous Maximum of 12 syringes (12 ml) per 28 days Solution Prefilled Syringe) Glatopa (20MG/ML Subcutaneous Solution Maximum of 1 syringe (1 ml) per day Prefilled Syringe) Glatopa (40MG/ML Subcutaneous Solution Maximum of 12 syringes (12 ml) per 28 days Prefilled Syringe) Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day Glimepiride (2MG Oral Tablet) Maximum of 4 tablets per day Glimepiride (4MG Oral Tablet) Maximum of 2 tablets per day Glipizide ER (10MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 118118 11 11 Last updated October 1, 2019 Drug Name Quantity Limit Glipizide ER (2.5MG Oral Tablet Extended Maximum of 8 tablets per day Release 24 Hour) Glipizide ER (5MG Oral Tablet Extended Maximum of 4 tablets per day Release 24 Hour) Glipizide (10MG Oral Tablet Immediate Maximum of 4 tablets per day Release) Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day Glipizide-Metformin HCl (2.5-250MG Oral Maximum of 8 tablets per day Tablet) Glipizide-Metformin HCl (2.5-500MG Oral Maximum of 4 tablets per day Tablet, 5-500MG Oral Tablet) Glyxambi (Oral Tablet) Maximum of 1 tablet per day Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day Hetlioz (Oral Capsule) Maximum of 1 capsule per day Hydrocodone-Acetaminophen (7.5-325MG/ Maximum of 180 ml per day 15ML Oral Solution) Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Maximum of 12 tablets per day Tablet) Hydrocodone-Ibuprofen (7.5-200MG Oral Maximum of 5 tablets per day Tablet) Hydromorphone HCl ER (Oral Tablet ER 24 Maximum of 2 tablets per day Hour Abuse-Deterrent) Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Maximum of 8 tablets per day Release) Hydromorphone HCl (8MG Oral Tablet Maximum of 6 tablets per day Immediate Release) Hysingla ER (Oral Tablet ER 24 Hour Abuse- Maximum of 1 tablet per day Deterrent) Ibandronate Sodium (Oral Tablet) Maximum of 1 tablet per 28 days Ibrance (Oral Capsule) Maximum of 1 capsule per day Icatibant Acetate (Subcutaneous Solution) Maximum of 9 ml per day Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day IDHIFA (Oral Tablet) Maximum of 1 tablet per day Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day

Bold type = Brand name drug Plain type = Generic drug Last119 updated October 1, 2019 12 12 119 Drug Name Quantity Limit Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day Imbruvica (Oral Tablet) Maximum of 1 tablet per day Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day Incruse Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per 30 days Breath Activated) Ingrezza (Oral Capsule) Maximum of 1 capsule per day Ingrezza (Oral Capsule Therapy Pack) Maximum of 28 capsules (1 pack) per 28 days Inlyta (Oral Tablet) Maximum of 4 tablets per day Inrebic (Oral Capsule) Maximum of 4 capsules per day Intelence (100MG Oral Tablet, 200MG Oral Maximum of 2 tablets per day Tablet) Intelence (25MG Oral Tablet) Maximum of 4 tablets per day Invirase (Oral Tablet) Maximum of 4 tablets per day Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day Invokamet XR (Oral Tablet Extended Release Maximum of 2 tablets per day 24 Hour) Invokana (Oral Tablet) Maximum of 1 tablet per day Irbesartan (150MG Oral Tablet, 300MG Oral Maximum of 1 tablet per day Tablet) Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Iressa (Oral Tablet) Maximum of 2 tablets per day Isentress HD (Oral Tablet) Maximum of 2 tablets per day Isentress (Oral Packet) Maximum of 2 packets per day Isentress (Oral Tablet) Maximum of 2 tablets per day Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day Itraconazole (Oral Capsule) Maximum of 4 capsules per day Jakafi (Oral Tablet) Maximum of 2 tablets per day Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day Janumet XR (100-1000MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Janumet XR (50-1000MG Oral Tablet Extended Release 24 Hour, 50-500MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Januvia (Oral Tablet) Maximum of 1 tablet per day Jardiance (Oral Tablet) Maximum of 1 tablet per day Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 120120 13 13 Last updated October 1, 2019 Drug Name Quantity Limit Jentadueto XR (2.5-1000MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Jentadueto XR (5-1000MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Juluca (Oral Tablet) Maximum of 1 tablet per day Kaletra (100-25MG Oral Tablet) Maximum of 2 tablets per day Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day Kalydeco (Oral Packet) Maximum of 2 packets per day Kalydeco (Oral Tablet) Maximum of 2 tablets per day Ketoconazole (External Cream) Maximum of 90 grams per 30 days Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day Kisqali (400MG Dose) (Oral Tablet) Maximum of 3 tablets per day Kisqali (600MG Dose) (Oral Tablet) Maximum of 3 tablets per day Kisqali Femara (400MG Dose) (Oral Tablet Maximum of 1 pack (91 tablets) per 28 days Therapy Pack) Kisqali Femara (600MG Dose) (Oral Tablet Maximum of 1 pack (91 tablets) per 28 days Therapy Pack) Kisqali Femara (200MG Dose) (Oral Tablet Maximum of 1 pack (91 tablets) per 28 days Therapy Pack) Korlym (Oral Tablet) Maximum of 4 tablets per day Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day Latuda (120MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet, 40MG Oral Tablet, 60MG Oral Tablet) Latuda (80MG Oral Tablet) Maximum of 2 tablets per day Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day Lexiva (Oral Suspension) Maximum of 60 ml per day Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days Lidocaine (5% External Patch) Maximum of 3 patches per day Linezolid (Oral Tablet) Maximum of 2 tablets per day Linzess (Oral Capsule) Maximum of 1 capsule per day Lisinopril (Oral Tablet) Maximum of 2 tablets per day Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Maximum of 1 tablet per day Tablet)

Bold type = Brand name drug Plain type = Generic drug Last121 updated October 1, 2019 14 14 121 Drug Name Quantity Limit Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Maximum of 4 tablets per day Tablet) Lisinopril-Hydrochlorothiazide (20-25MG Oral Maximum of 2 tablets per day Tablet) Livalo (Oral Tablet) Maximum of 1 tablet per day Lokelma (Oral Packet) Maximum of 90 packets per 30 days Lonhala Magnair Refill Kit (Inhalation Maximum of 2 vials (2 ml) per day Solution) Lonsurf (15-6.14MG Oral Tablet) Maximum of 10 tablets per day Lonsurf (20-8.19MG Oral Tablet) Maximum of 8 tablets per day Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day Lorazepam (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day Lorcet HD (Oral Tablet) Maximum of 12 tablets per day Lorcet (Oral Tablet) Maximum of 12 tablets per day Lorcet Plus (Oral Tablet) Maximum of 12 tablets per day Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day Losartan Potassium (25MG Oral Tablet, 50MG Maximum of 2 tablets per day Oral Tablet) Losartan Potassium-HCTZ (100-12.5MG Oral Maximum of 1 tablet per day Tablet, 100-25MG Oral Tablet) Losartan Potassium-HCTZ (50-12.5MG Oral Maximum of 2 tablets per day Tablet) Lovastatin (10MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet) Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day Lynparza (Oral Tablet) Maximum of 4 tablets per day Mavyret (Oral Tablet) Maximum of 3 tablets per day Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day Memantine HCl ER (Oral Capsule Extended Maximum of 1 capsule per day Release 24 Hour) Memantine HCl (2MG/ML Oral Solution) Maximum of 10 ml per day Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 122122 15 15 Last updated October 1, 2019 Drug Name Quantity Limit Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day Mesalamine (1.2GM Oral Tablet Delayed Maximum of 4 tablets per day Release) (Generic Lialda) Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day Metadate ER (Oral Tablet Extended Release) Maximum of 3 tablets per day Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 4 tablets per day Glucophage XR) Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 2 tablets per day Glucophage XR) Metformin HCl (1000MG Oral Tablet Immediate Maximum of 2.5 tablets per day Release) Metformin HCl (500MG Oral Tablet Immediate Maximum of 5 tablets per day Release) Metformin HCl (850MG Oral Tablet Immediate Maximum of 3 tablets per day Release) Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day Methylphenidate HCl ER (10MG Oral Tablet Maximum of 4 tablets per day Extended Release) Methylphenidate HCl ER (20MG Oral Tablet Maximum of 3 tablets per day Extended Release) Methylphenidate HCl (10MG/5ML Oral Maximum of 30 ml per day Solution) Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day Methylphenidate HCl (Oral Tablet Immediate Maximum of 3 tablets per day Release) (Generic Ritalin) Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day Miglitol (25MG Oral Tablet) Maximum of 12 tablets per day Miglitol (50MG Oral Tablet) Maximum of 6 tablets per day Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day Montelukast Sodium (Oral Packet) Maximum of 1 packet per day Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last123 updated October 1, 2019 16 16 123 Drug Name Quantity Limit Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Maximum of 3 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (200MG Oral Tablet Maximum of 2 tablets per day Extended Release) (Generic MS Contin) Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Maximum of 4 tablets per day Release) (Generic MS Contin) Morphine Sulfate (10MG/5ML Oral Solution) Maximum of 100 ml per day Morphine Sulfate (20MG/5ML Oral Solution) Maximum of 50 ml per day Morphine Sulfate (15MG Oral Tablet Maximum of 8 tablets per day Immediate Release) Morphine Sulfate (30MG Oral Tablet Maximum of 6 tablets per day Immediate Release) Multaq (Oral Tablet) Maximum of 2 tablets per day Namzaric (Oral Capsule ER 24 Hour Therapy Maximum of 1 capsule per day Pack) Namzaric (Oral Capsule Extended Release 24 Maximum of 1 capsule per day Hour) Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution Reconstituted) Maximum of 300 mg (1 vial) per 28 days Nerlynx (Oral Tablet) Maximum of 6 tablets per day Nevirapine ER (100MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Nevirapine ER (400MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Nevirapine (Oral Suspension) Maximum of 40 ml per day Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day Nifedipine ER (Oral Tablet Extended Release 24 Maximum of 2 tablets per day Hour) Nifedipine ER Osmotic Release (Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days Northera (100MG Oral Capsule) Maximum of 3 capsules per day Northera (200MG Oral Capsule, 300MG Oral Maximum of 6 capsules per day Capsule)

Bold type = Brand name drug Plain type = Generic drug 124124 17 17 Last updated October 1, 2019 Drug Name Quantity Limit Norvir (Oral Packet) Maximum of 12 packets per day Norvir (Oral Solution) Maximum of 16 ml per day Noxafil (Oral Suspension) Maximum of 20 ml per day Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day Nubeqa (Oral Tablet) Maximum of 4 tablets per day Nucala (Subcutaneous Solution Auto-Injector) Maximum of 3 ml per 28 days Nucala (Subcutaneous Solution Prefilled Maximum of 3 ml per 28 days Syringe) Nucala (Subcutaneous Solution Maximum of 3 vials per 28 days Reconstituted) Nucynta ER (Oral Tablet Extended Release Maximum of 2 tablets per day 12 Hour) Nuplazid (Oral Capsule) Maximum of 1 capsule per day Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day Ocaliva (Oral Tablet) Maximum of 1 tablet per day Odefsey (Oral Tablet) Maximum of 1 tablet per day Odomzo (Oral Capsule) Maximum of 1 capsule per day Ofev (Oral Capsule) Maximum of 2 capsules per day Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, Maximum of 1 tablet per day 5MG Oral Tablet, 7.5MG Oral Tablet) Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Maximum of 1 tablet per day Tablet Dispersible, 5MG Oral Tablet Dispersible) Olmesartan Medoxomil (20MG Oral Tablet, Maximum of 1 tablet per day 40MG Oral Tablet) Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day Omega-3-Acid Ethyl Esters (Oral Capsule) Maximum of 4 capsules per day (Generic Lovaza) Omeprazole (10MG Oral Capsule Delayed Maximum of 3 capsules per day Release) Orkambi (Oral Packet) Maximum of 56 packets per 28 days Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day Oseltamivir Phosphate (Oral Suspension Maximum of 26 ml per day Reconstituted)

Bold type = Brand name drug Plain type = Generic drug Last125 updated October 1, 2019 18 18 125 Drug Name Quantity Limit Osphena (Oral Tablet) Maximum of 1 tablet per day Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10MG Oral Tablet Maximum of 3 tablets per day Extended Release 24 Hour) Oxybutynin Chloride ER (15MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Oxybutynin Chloride ER (5MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Oxycodone HCl (100MG/5ML Oral Maximum of 6 ml per day Concentrate) Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day Oxycodone HCl (10MG Oral Tablet Immediate Maximum of 12 tablets per day Release, 5MG Oral Tablet Immediate Release) Oxycodone HCl (15MG Oral Tablet Immediate Maximum of 8 tablets per day Release) Oxycodone HCl (20MG Oral Tablet Immediate Maximum of 6 tablets per day Release, 30MG Oral Tablet Immediate Release) Oxycodone-Acetaminophen (Oral Tablet) Maximum of 12 tablets per day Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day Oxycodone-Ibuprofen (Oral Tablet) Maximum of 4 tablets per day Ozempic (0.25 or 0.5 MG/DOSE) Maximum of 1 pen (1.5 ml) per 28 days (Subcutaneous Solution Pen-Injector) Ozempic (1 MG/DOSE) (Subcutaneous Maximum of 2 pens (3 ml) per 28 days Solution Pen-Injector) Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour) Paliperidone ER (6MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Pantoprazole Sodium (20MG Oral Tablet Maximum of 3 tablets per day Delayed Release) Pantoprazole Sodium (40MG Oral Tablet Maximum of 2 tablets per day Delayed Release) Pentasa (250MG Oral Capsule Extended Maximum of 12 capsules per day Release) Pentasa (500MG Oral Capsule Extended Maximum of 8 capsules per day Release) Perforomist (Inhalation Nebulization Solution) Maximum of 2 vials (4 ml) per day

Bold type = Brand name drug Plain type = Generic drug 126126 19 19 Last updated October 1, 2019 Drug Name Quantity Limit Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day Pifeltro (Oral Tablet) Maximum of 1 tablet per day Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Maximum of 1 tablet per day Tablet) Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day Piqray (200 MG Daily Dose) (Oral Tablet Maximum of 1 tablet per day Therapy Pack) Piqray (250 MG Daily Dose) (Oral Tablet Maximum of 2 tablets per day Therapy Pack) Piqray (300 MG Daily Dose) (Oral Tablet Maximum of 2 tablets per day Therapy Pack) Pomalyst (Oral Capsule) Maximum of 1 capsule per day Praluent (Subcutaneous Solution Pen- Maximum of 2 pens (2 ml) per 28 days Injector) Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Maximum of 3 capsules per day Capsule, 50MG Oral Capsule, 75MG Oral Capsule) Pregabalin (225MG Oral Capsule, 300MG Oral Maximum of 2 capsules per day Capsule) Pregabalin (Oral Solution) Maximum of 30 ml per day Premarin (Oral Tablet) Maximum of 1 tablet per day Premphase (Oral Tablet) Maximum of 1 tablet per day Prempro (Oral Tablet) Maximum of 1 tablet per day Prezcobix (Oral Tablet) Maximum of 1 tablet per day Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days Prezista (150MG Oral Tablet) Maximum of 6 tablets per day Prezista (600MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Prezista (800MG Oral Tablet) Maximum of 1 tablet per day Prolia (Subcutaneous Solution Prefilled Maximum of 1 syringe per 180 days Syringe) Promacta (Oral Packet) Maximum of 6 packets per day Promacta (12.5MG Oral Tablet, 25MG Oral Maximum of 1 tablet per day Tablet)

Bold type = Brand name drug Plain type = Generic drug Last127 updated October 1, 2019 20 20 127 Drug Name Quantity Limit Promacta (50MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Maximum of 3 tablets per day Immediate Release, 50MG Oral Tablet Immediate Release) Quetiapine Fumarate (25MG Oral Tablet Maximum of 4 tablets per day Immediate Release) Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Maximum of 2 tablets per day Immediate Release) Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day Quinapril-Hydrochlorothiazide (10-12.5MG Oral Maximum of 1 tablet per day Tablet) Quinapril-Hydrochlorothiazide (20-12.5MG Oral Maximum of 2 tablets per day Tablet, 20-25MG Oral Tablet) Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day Ramelteon (Oral Tablet) Maximum of 1 tablet per day Ramipril (Oral Capsule) Maximum of 2 capsules per day Ranolazine ER (Oral Tablet Extended Release Maximum of 2 tablets per day 12 Hour) RAVICTI (Oral Liquid) Maximum of 17.5 ml per day Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day Rebif Rebidose (Subcutaneous Solution Auto- Maximum of 12 pens (6 ml) per 28 days Injector) Rebif Rebidose Titration Pack (Subcutaneous Maximum of 1 pack (4.2 ml) per 28 days Solution Auto-Injector) Rebif (Subcutaneous Solution Prefilled Maximum of 12 syringes (6 ml) per 28 days Syringe) Rebif Titration Pack (Subcutaneous Solution Maximum of 1 pack (4.2 ml) per 28 days Prefilled Syringe)

Bold type = Brand name drug Plain type = Generic drug 128128 21 21 Last updated October 1, 2019 Drug Name Quantity Limit Relenza Diskhaler (Inhalation Aerosol Powder Maximum of 3 inhalers (60 blisters) per 30 days Breath Activated) Relistor (Oral Tablet) Maximum of 3 tablets per day Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day Repaglinide-Metformin HCl (Oral Tablet) Maximum of 5 tablets per day Repatha Pushtronex System (Subcutaneous Maximum of 1 cartridge (3.5 ml) per 28 days Solution Cartridge) Repatha (Subcutaneous Solution Prefilled Maximum of 3 syringes (3 ml) per 28 days Syringe) Repatha SureClick (Subcutaneous Solution Maximum of 3 pens (3 ml) per 28 days Auto-Injector) Rescriptor (Oral Tablet) Maximum of 6 tablets per day Restasis (Ophthalmic Emulsion) Maximum of 2 vials per day Revlimid (Oral Capsule) Maximum of 1 capsule per day Rexulti (Oral Tablet) Maximum of 1 tablet per day Reyataz (Oral Packet) Maximum of 6 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Risedronate Sodium (150MG Oral Tablet Maximum of 1 tablet per 30 days Immediate Release) Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Maximum of 1 tablet per day Release) Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Maximum of 4 tablets per 28 days Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release) Ritonavir (Oral Tablet) Maximum of 12 tablets per day Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days Rizatriptan Benzoate ODT (Oral Tablet Maximum of 12 tablets per 30 days Dispersible) Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day Rubraca (Oral Tablet) Maximum of 4 tablets per day Rydapt (Oral Capsule) Maximum of 8 capsules per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days

Bold type = Brand name drug Plain type = Generic drug Last129 updated October 1, 2019 22 22 129 Drug Name Quantity Limit Selzentry (150MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Selzentry (25MG Oral Tablet, 300MG Oral Maximum of 4 tablets per day Tablet) Serevent Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 inhalations) per 30 Breath Activated) days Sildenafil Citrate (20MG Oral Tablet) (Generic Maximum of 3 tablets per day Revatio) Silodosin (Oral Capsule) Maximum of 1 capsule per day Simvastatin (Oral Tablet) Maximum of 1 tablet per day Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day Soliqua (Subcutaneous Solution Pen-Injector) Maximum of 18 ml (6 pens) per 30 days Somavert (Subcutaneous Solution Maximum of 1 vial per day Reconstituted) Sovaldi (Oral Tablet) Maximum of 1 tablet per day Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day Spiriva Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 30 days Solution) Sprycel (100MG Oral Tablet, 140MG Oral Maximum of 1 tablet per day Tablet, 70MG Oral Tablet) Sprycel (20MG Oral Tablet, 50MG Oral Maximum of 3 tablets per day Tablet) Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day Stavudine (Oral Capsule) Maximum of 2 capsules per day Stiolto Respimat (Inhalation Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Stivarga (Oral Tablet) Maximum of 4 tablets per day Stribild (Oral Tablet) Maximum of 1 tablet per day Suboxone (12-3MG Sublingual Film, 4-1MG Maximum of 2 films per day Sublingual Film) Suboxone (2-0.5MG Sublingual Film, 8-2MG Maximum of 3 films per day Sublingual Film) Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100MG Oral Tablet, Maximum of 12 tablets per 30 days 25MG Oral Tablet, 50MG Oral Tablet) Sumatriptan Succinate Refill (Subcutaneous Maximum of 12 injections (6 ml) per 30 days Solution Cartridge) Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution)

Bold type = Brand name drug Plain type = Generic drug 130130 23 23 Last updated October 1, 2019 Drug Name Quantity Limit Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/ Maximum of 12 injections (6 ml) per 30 days 0.5ML Subcutaneous Solution Auto-Injector) Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Auto-Injector) Maximum of 12 injections (6 ml) per 30 days (Generic Imitrex STATdose) Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution Prefilled Syringe) Sutent (12.5MG Oral Capsule, 25MG Oral Maximum of 1 capsule per day Capsule, 50MG Oral Capsule) Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day Symbicort (Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Symfi Lo (Oral Tablet) Maximum of 1 tablet per day Symfi (Oral Tablet) Maximum of 1 tablet per day Sympazan (Oral Film) Maximum of 2 films per day Symtuza (Oral Tablet) Maximum of 1 tablet per day Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day Synjardy XR (10-1000MG Oral Tablet Extended Release 24 Hour, 25-1000MG Oral Maximum of 1 tablet per day Tablet Extended Release 24 Hour) Synjardy XR (12.5-1000MG Oral Tablet Extended Release 24 Hour, 5-1000MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day Tagrisso (Oral Tablet) Maximum of 1 tablet per day Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day Tasigna (200MG Oral Capsule) Maximum of 4 capsules per day Tasigna (50MG Oral Capsule) Maximum of 14 capsules per day Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day Telmisartan (Oral Tablet) Maximum of 1 tablet per day Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day Telmisartan-HCTZ (40-12.5MG Oral Tablet, Maximum of 1 tablet per day 80-25MG Oral Tablet) Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day Temazepam (15MG Oral Capsule, 30MG Oral Maximum of 1 capsule per day Capsule) Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last131 updated October 1, 2019 24 24 131 Drug Name Quantity Limit Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day Thalomid (100MG Oral Capsule, 50MG Oral Maximum of 1 capsule per day Capsule) Thalomid (150MG Oral Capsule, 200MG Oral Maximum of 2 capsules per day Capsule) Tibsovo (Oral Tablet) Maximum of 2 tablets per day Tivicay (10MG Oral Tablet, 25MG Oral Tablet) Maximum of 1 tablet per day Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day Tobramycin (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day Tolcapone (Oral Tablet) Maximum of 6 tablets per day Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day Tradjenta (Oral Tablet) Maximum of 1 tablet per day Tramadol HCl ER (Biphasic) (Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Tramadol HCl ER (Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Tramadol HCl (Oral Tablet Immediate Release) Maximum of 8 tablets per day Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day Trandolapril (1MG Oral Tablet, 2MG Oral Maximum of 1 tablet per day Tablet) Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day Trelegy Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Trezix (Oral Capsule) Maximum of 10 capsules per day Trientine HCl (Oral Capsule) Maximum of 8 capsules per day Trintellix (Oral Tablet) Maximum of 1 tablet per day Triumeq (Oral Tablet) Maximum of 1 tablet per day Trulicity (Subcutaneous Solution Pen- Maximum of 4 pens (2 ml) per 28 days Injector) Truvada (Oral Tablet) Maximum of 1 tablet per day Turalio (Oral Capsule) Maximum of 4 capsules per day Tybost (Oral Tablet) Maximum of 1 tablet per day Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 132132 25 25 Last updated October 1, 2019 Drug Name Quantity Limit Valganciclovir HCl (50MG/ML Oral Solution Maximum of 36 ml per day Reconstituted) Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day Valsartan (160MG Oral Tablet, 40MG Oral Maximum of 2 tablets per day Tablet, 80MG Oral Tablet) Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day Veltassa (Oral Packet) Maximum of 1 packet per day Vemlidy (Oral Tablet) Maximum of 1 tablet per day Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day Verzenio (Oral Tablet) Maximum of 2 tablets per day Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days Videx EC (125MG Oral Capsule Delayed Maximum of 4 capsules per day Release) Videx (Oral Solution Reconstituted) Maximum of 40 ml per day Vigabatrin (Oral Packet) Maximum of 6 packets per day Vigabatrin (Oral Tablet) Maximum of 6 tablets per day Vigadrone (Oral Packet) Maximum of 6 packets per day Viibryd (Oral Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days Vimpat (Oral Solution) Maximum of 40 ml per day Vimpat (Oral Tablet) Maximum of 2 tablets per day Viracept (250MG Oral Tablet) Maximum of 10 tablets per day Viracept (625MG Oral Tablet) Maximum of 4 tablets per day Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days Viread (150MG Oral Tablet, 200MG Oral Maximum of 1 tablet per day Tablet, 250MG Oral Tablet) Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day Vitrakvi (Oral Solution) Maximum of 20 ml per day Vizimpro (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last133 updated October 1, 2019 26 26 133 Drug Name Quantity Limit Vosevi (Oral Tablet) Maximum of 1 tablet per day Votrient (Oral Tablet) Maximum of 4 tablets per day Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule, 4.5MG Oral Capsule, 6MG Oral Maximum of 1 capsule per day Capsule) Vyndaqel (Oral Capsule) Maximum of 4 capsules per day Wixela Inhub (Inhalation Aerosol Powder Breath Maximum of 1 inhaler (60 blisters) per 30 days Activated) (Generic Advair) Xarelto (10MG Oral Tablet, 20MG Oral Tablet) Maximum of 1 tablet per day Xarelto (15MG Oral Tablet, 2.5MG Oral Maximum of 2 tablets per day Tablet) Xarelto Starter Pack (Oral Tablet Therapy Maximum of 1 pack (51 tablets) per 30 days Pack) Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day Xeljanz XR (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Xiidra (Ophthalmic Solution) Maximum of 2 vials per day Xofluza (Oral Tablet Therapy Pack) Maximum of 2 tablets per 30 days Xospata (Oral Tablet) Maximum of 3 tablets per day Xpovio (100MG Once Weekly) (Oral Tablet Maximum of 20 tablets per 28 days Therapy Pack) Xpovio (60MG Once Weekly) (Oral Tablet Maximum of 12 tablets per 28 days Therapy Pack) Xpovio (80MG Once Weekly) (Oral Tablet Maximum of 16 tablets per 28 days Therapy Pack) Xpovio (80MG Twice Weekly) (Oral Tablet Maximum of 32 tablets per 28 days Therapy Pack) Xtampza ER (13.5MG Oral Capsule ER 12 Hour Abuse-Deterrent, 18MG Oral Capsule Maximum of 3 capsules per day ER 12 Hour Abuse-Deterrent, 9MG Oral Capsule ER 12 Hour Abuse-Deterrent) Xtampza ER (27MG Oral Capsule ER 12 Hour Abuse-Deterrent, 36MG Oral Capsule ER 12 Maximum of 6 capsules per day Hour Abuse-Deterrent) Xtandi (Oral Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day Zafirlukast (Oral Tablet) Maximum of 2 tablets per day Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day

Bold type = Brand name drug Plain type = Generic drug 134134 27 27 Last updated October 1, 2019 Drug Name Quantity Limit Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day Zejula (Oral Capsule) Maximum of 3 capsules per day Zelboraf (Oral Tablet) Maximum of 8 tablets per day Zidovudine (Oral Capsule) Maximum of 6 capsules per day Zidovudine (Oral Syrup) Maximum of 64 ml per day Zidovudine (Oral Tablet) Maximum of 2 tablets per day Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day Zolpidem Tartrate (Oral Tablet Immediate Maximum of 1 tablet per day Release) Zydelig (Oral Tablet) Maximum of 2 tablets per day Zykadia (Oral Capsule) Maximum of 3 capsules per day Zykadia (Oral Tablet) Maximum of 3 tablets per day track

Bold type = Brand name drug Plain type = Generic drug 135 0 135 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 Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. The AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. For more up-to-date information or if you have other questions, please call UnitedHealthcare Customer Service at:

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AAEX20HM4540544_001 Last updated October 1, 2019