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2017 Comprehensive FORMULARY (Complete list of covered drugs)
UnitedHealthcare® Group Medicare Advantage
Please read: This document contains information about the drugs we cover in this plan. For more recent information or if you have other questions, please call UnitedHealthcare Group Medicare Advantage Customer Service at:
Toll-Free 1-800-457-8506, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday www.UHCRetiree.com
Formulary ID Number 00017015, Version 12 Y0066_160722_193913 Last updated August 1, 2016 2
2 This Comprehensive Formulary is a complete list of the drugs covered by our plan. It is current as of August 1, 2016. For a complete up-to-date formulary (drug list), please call us. Our contact information, along with the date we last updated the formulary, is on the cover. When this formulary (drug list) refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan” or “our plan,” it means UnitedHealthcare Group Medicare Advantage. This list of covered drugs is called a Formulary. We call it a “drug list” for short. Note to existing members: This complete drug list has changed since last year. Please review this document to make sure your drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. 3
3 The UnitedHealthcare Group Medicare Advantage COMPREHENSIVE FORMULARY (drug list)
A formulary (drug list) is a list of covered drugs selected by your plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in our drug list as long as the drug is: · Medically necessary · The prescription is filled at a plan network pharmacy · Other plan rules are followed For more information on how to fill your prescriptions, please review your Evidence of Coverage.
This document is a complete drug list of the drugs covered by your plan. For your drug to be covered by your plan, it must be included in the complete drug list. To find out if your drug is covered: 1. See if your drug is included in this complete drug list. 2. Visit your plan website. Use the online tools to look up your drugs. The information is updated on a regular basis. The web address is on the cover. 3. Or call Customer Service. Our contact information is on the cover. In most cases, your prescription must also be filled at one of our network pharmacies. 4 The drug list may change We try to make as few changes to the drug list as possible during the plan year. · If there are changes to the drug list, such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements. · If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The drug list may change during the year if your plan: · Adds new drugs, including generic drugs, as they become available. · Removes a drug that has been found to be ineffective or unsafe. · Changes the requirements or limits for a drug. · Moves a drug into a different tier.
Generally, if you are taking a drug on the 2017 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 plan year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from the list, will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the plan year. We feel it is important for you to have access for the entire plan year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, during the plan year we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) declares a drug on our drug list to be unsafe, or if the drug’s manufacturer removes the drug from the market, your plan will immediately remove the drug from the drug list and notify members who take the drug. The enclosed drug list is current as of the date printed on the cover. To get updated information about the drugs covered by your plan, please call Customer Service or visit our website using the information provided on the cover of this drug list.
4 5 Drug payment stages and drug tiers The amount you pay for a covered drug will depend on: · Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in. · The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier has a co- pay and/or co-insurance amount. The chart below shows the differences between the tiers. For more information about drug coverage and co-pay or co-insurance amounts for each tier, please review your Evidence of Coverage.
Drug Tier Includes
Tier 1: All covered generic drugs. Preferred generic
Tier 2: Many common brand name drugs, called preferred Preferred brand brands.
Tier 3: Non-preferred brand name drugs. In addition, Part D Non-preferred drug eligible compound medications are covered in Tier 3.
Tier 4: Unique and/or very high-cost brand drugs. Specialty tier
If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call Customer Service. Our contact information is on the cover.
5 6 How to use the drug list There are two ways to find your prescription drugs in this complete drug list: 1. Medical condition: Turn to the “Covered drugs by medical condition” section, which begins on page 12, to look for drugs based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Agents” category and look under “Dyslipidemics, HMG CoA Reductase Inhibitors.”
2. Alphabetical list (index): If you are not sure what category to look under, turn to the “Index of covered drugs” section, which begins on page 156. Find the name of your drug. The page number where you can find the drug will be next to it.
Generic drugs Your plan covers both brand name drugs and generic drugs. Generic drugs: · Are approved by the Food and Drug Administration (FDA) as having the same active ingredients as brand name drugs. · Usually cost less than brand name drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. 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).
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Dummy 7 Required actions, restrictions or limits Some covered drugs may have additional requirements or limits on coverage. If your drug has any requirements or limits, there will be a code(s) in the “Required actions, restrictions or limits” column of the drug list. The codes and what they mean are shown below.
Utilization Management Restrictions PA - Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug for one co-pay/co-insurance or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. LA - Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy. MED - Morphine Equivalent Dose Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is calculated based on the number of opioid drugs prescribed for you over a period of time. This cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for those individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 7 2
8 You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the “Covered drugs by medical condition” section that begins on page 12. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, is on the cover. You and your doctor may ask the plan for an exception to these requirements, restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the, “How to request an exception to the UnitedHealthcare Group Medicare Advantage drug list” section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug. If your drug is not on the drug list If your drug is not included in this complete formulary (list of covered drugs), you should call Customer Service and ask if your drug is covered. Our contact information, along with the date we last updated the drug list, is on the cover. If you learn that your plan does not cover your drug, you have two options: 1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the appropriate drugs from the list. 2. Ask your plan to make an exception and cover your drug. See next page for information about how to request an exception.
8 9 How to request an exception to the UnitedHealthcare Group Medicare Advantage drug list At times you may need to ask for drug coverage that’s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination). You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask us to make.
· Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. · Tiering exception: You can ask your plan to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. · Utilization exception: You can ask your plan to waive coverage restrictions or limits on your drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a quantity limit, you can ask your plan to waive the limit and cover more. Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects. Who can ask for a coverage decision You, your authorized representative or your doctor can ask for an initial coverage decision for a formulary exception, tiering exception or utilization restriction exception. When you are requesting a formulary exception, tiering exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. Receiving a coverage decision Generally, your plan will make a coverage decision within 72 hours after receiving your prescribing physician’s statement. You can request an expedited, or fast, decision if you or your doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a decision within 24 hours after your plan receives your doctor’s or prescribing physician’s supporting statement.
9 10 What to do while you talk to your doctor about changing your drugs or requesting an exception New or continuing members As a new or continuing member in your plan, you may be taking drugs that are not on the drug list. Or you may be taking a drug that is on the drug list but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that your plan covers, or request a formulary exception so your plan will cover the drug you are currently taking. While you talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days you are a member of your plan. For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited, your plan may cover at least a temporary 30-day supply (unless you have a prescription written for fewer days) from a network pharmacy. After you receive at least a 30-day supply, your plan will not pay for these drugs, even if you have been a member of your plan less than 90 days. Long-term care facility residents If you’re a resident of a long-term care facility, your plan may allow you to refill your prescription until you have been provided with at least a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is written for fewer days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a member of your plan. If you need a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of membership in the plan, your plan will cover at least a 31-day emergency supply of the drug (unless your prescription is written for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care. If this happens and your doctor prescribes a drug that is not on the drug list, or a drug that is on the drug list but your ability to get it is limited, your plan may cover a one-time supply of at least 30- days. You may ask for a one-time emergency supply of at least 30-days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception.
10 11 Drugs with dosages other than a one-month supply Drugs packaged in an extended day supply Some drugs are packaged from the manufacturer to provide more than a one-month supply. When you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single prescription. For more information, please call Customer Service using the information on the cover. Daily cost share for oral medications filled for less than a one-month supply Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than one month under applicable law. The daily cost share requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.
For more information For more information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please call us toll-free at 1-800-457-8506, TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday. Or visit us online at www.UHCRetiree.com. If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.
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12 Covered drugs by medical condition The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered drugs,” which begins on page 156. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column of the chart lists which coverage level (Tier) your drug is in. The “Required Actions, Restrictions or Limits” column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 120-155. tRACK Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Analgesics Diclofenac Sodium ER Sodium ER
Nonsteroidal Anti-inflammatory Drugs (Tablet Extended- 1
Anaprox DS Anaprox DS (Tablet) 3 Release 24 Hour)
Diclofenac Sodium/Misoprostol Arthrotec 50 Diclofenac Sodium/ Arthrotec 50 (Tablet 3 Delayed-Release) Misoprostol (Tablet 1
Arthrotec 75 Delayed-Release) Arthrotec 75 (Tablet 3 Diflunisal Delayed-Release) Diflunisal (Tablet) 1
Duexis
Cambia Cambia (Packet) 3 Duexis (Tablet) 4 ST
EC-Naprosyn Celebrex EC-Naprosyn (Tablet Celebrex (Capsule) 3 QL 3
Celecoxib Delayed-Release)
Celecoxib (Capsule) 1 QL Etodolac Etodolac (200mg Daypro Daypro (Tablet) 3 Capsule, 300mg Diclofenac Potassium Potassium Capsule, 400mg Tablet 1 (Tablet Immediate- 1 Immediate-Release, Release) 500mg Tablet Diclofenac Sodium Sodium Immediate-Release) (1% Gel, 1.5% 1 PA Etodolac ER ER (Tablet
Transdermal Solution) Extended-Release 24 1 Diclofenac Sodium DR Sodium DR Hour)
Feldene (Tablet Delayed- 1 Feldene (Capsule) 3 Release)
Bold type = Brand name drug Plain type = Generic drug 12 2tRACK 2
Last updated August 1, 2016 13 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Fenoprofen Calcium Calcium Naprelan (375mg 1 (400mg Capsule) Tablet Extended- Fenoprofen Calcium Calcium Release 24 Hour, 1 4 (600mg Tablet) 500mg Tablet Flector (Patch) 3 PA, QL Extended-Release 24
Flurbiprofen Hour)
Flurbiprofen (Tablet) 1 Naprelan Naprelan (750mg Ibuprofen Ibuprofen (100mg/5ml Tablet Extended- 3 Suspension, 400mg 1 Release 24 Hour)
Tablet, 600mg Tablet, Naprosyn Naprosyn (Tablet) 3 800mg Tablet) Naproxen Ketoprofen (Capsule Naproxen (125mg/5ml 1 Immediate-Release) Suspension, 250mg
Ketoprofen ER Tablet Immediate- Ketoprofen ER Release, 375mg Tablet 1 (Capsule Extended- 1 Immediate-Release, Release 24 Hour) 500mg Tablet Ketorolac Tromethamine Ketorolac Immediate-Release)
Tromethamine (15mg/ Naproxen DR Naproxen DR (Tablet ml Injection, 30mg/ml 1 PA, HRM Delayed-Release) 1 Injection, 60mg/2ml (Generic EC-Naprosyn)
Injection) Naproxen Sodium
Meclofenamate Sodium Naproxen Sodium Meclofenamate 1 (Tablet Immediate- Sodium (Capsule) 1 Release) (Generic Mefenamic Acid Acid 1 Anaprox DS) (Capsule) Naproxen Sodium CR Naproxen Sodium CR Meloxicam Meloxicam (15mg (Tablet Extended- 1 1 Tablet, 7.5mg Tablet) Release 24 Hour) Meloxicam (7.5mg/ 1 (Generic Naprelan) 5ml Suspension) Naproxen Sodium ER Sodium ER
Mobic Mobic (15mg Tablet, (Tablet Extended- 1 7.5mg Tablet, 7.5mg/ 3 Release 24 Hour) 5ml Suspension) (Generic Naprelan)
Nabumetone Oxaprozin Nabumetone (Tablet) 1 Oxaprozin (Tablet) 1
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 13 3tRACK 3
14 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Pennsaid Exalgo (12mg Tablet (Transdermal 4 PA Extended-Release 24 Solution) Hour Abuse-
Piroxicam Piroxicam (Capsule) 1 Deterrent, 8mg Tablet 3 QL, MED
Sulindac Extended-Release 24 Sulindac (Tablet) 1 Hour Abuse- Tolmetin Sodium Sodium Deterrent)
(400mg Capsule, 1 Exalgo Exalgo (16mg Tablet 600mg Tablet) Extended-Release 24 Vimovo (Tablet 4 ST Hour Abuse- Delayed-Release) Deterrent, 32mg 4 QL, MED
Vivlodex Vivlodex (Capsule) 3 QL Tablet Extended- Voltaren (Gel) 3 PA Release 24 Hour Zipsor (Capsule) 3 ST Abuse-Deterrent)
Fentanyl
Zorvolex Fentanyl (Patch 72 Zorvolex (Capsule) 3 ST 1 QL, MED Hour)
Opioid Analgesics, Long-acting Hydromorphone HCl ER
Conzip Hydromorphone HCl Conzip (Capsule ER (12mg Tablet Extended-Release 24 3 QL, MED Extended-Release 24 Hour) Hour Abuse-Deterrent,
Dolophine Dolophine (Tablet) 3 QL, MED 16mg Tablet Extended-
Duragesic 1 QL, MED Duragesic (100mcg/ Release 24 Hour hr Patch 72 Hour, Abuse-Deterrent, 8mg 4 QL, MED 75mcg/hr Patch 72 Tablet Extended- Hour) Release 24 Hour Duragesic (12mcg/hr Abuse-Deterrent) Patch 72 Hour, Hydromorphone HCl ER HCl 25mcg/hr Patch 72 3 QL, MED ER (32mg Tablet Hour, 50mcg/hr Extended-Release 24 1 QL, MED Patch 72 Hour) Hour Abuse- Embeda (Capsule Deterrent) 2 QL, MED Extended-Release)
Bold type = Brand name drug Plain type = Generic drug 14 4tRACK 4
Last updated August 1, 2016 15 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Hysingla ER ER (Tablet Methadone HCl HCl 1 Extended-Release 24 (10mg/ml Injection) 2 QL, MED Hour Abuse- Deterrent) Kadian (100mg Capsule Extended- Release 24 Hour, 200mg Capsule Extended-Release 24 Hour, 40mg Capsule Extended-Release 24 4 QL, MED Hour, 50mg Capsule Extended-Release 24 Hour, 60mg Capsule Extended-Release 24 Hour, 80mg Capsule Extended-Release 24 Hour) Kadian (10mg Capsule Extended- Release 24 Hour, 20mg Capsule 3 QL, MED Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour) Levorphanol Tartrate Tartrate 1 QL, MED (Tablet) Methadone HCl HCl (10mg Tablet, 5mg Tablet, 10mg/5ml Oral 1 QL, MED Solution, 5mg/5ml Oral Solution)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 15 5tRACK 5
16 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Morphine Sulfate ER Sulfate ER Extended-Release 24 (100mg Capsule Hour, 90mg Capsule Extended-Release 24 Extended-Release 24 Hour, 10mg Capsule Hour) (Generic Avinza) Extended-Release 24 MS Contin Contin (100mg Hour, 20mg Capsule Tablet Extended- Extended-Release 24 Release, 200mg 4 QL, MED Hour, 30mg Capsule Tablet Extended- Extended-Release 24 Release, 60mg Tablet Hour, 50mg Capsule Extended-Release) Extended-Release 24 MS Contin Contin (15mg Hour, 60mg Capsule Tablet Extended- 3 QL, MED Extended-Release 24 Release, 30mg Tablet Hour, 80mg Capsule Extended-Release)
Extended-Release 24 Nucynta ER Nucynta ER (Tablet Hour) (Generic Extended-Release 12 2 QL, MED Kadian), (100mg Hour)
Tablet Extended- 1 QL, MED Opana ER Opana ER (Tablet Release, 15mg Tablet Extended-Release 12 Extended-Release, 2 QL, MED Hour Abuse- 200mg Tablet Deterrent) Extended-Release, OxyContin 30mg Tablet Extended- OxyContin (Tablet Extended-Release 12 Release, 60mg Tablet 2 QL, MED Extended-Release) Hour Abuse- (Generic MS Contin), Deterrent) (120mg Capsule Oxymorphone HCl ER HCl ER Extended-Release 24 (Tablet Extended- 1 QL, MED Hour, 30mg Capsule Release 12 Hour) Extended-Release 24 Hour, 45mg Capsule Extended-Release 24 Hour, 60mg Capsule Extended-Release 24 Hour, 75mg Capsule
Bold type = Brand name drug Plain type = Generic drug 16 6tRACK 6
Last updated August 1, 2016 17 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Tramadol HCl ER HCl ER Acetaminophen/Acetaminophen/Codeine (100mg Capsule Codeine Extended-Release 24 (120mg-12mg/5ml Hour, 200mg Capsule Oral Solution, 1 QL, MED 3 QL, MED Extended-Release 24 300mg-15mg Tablet, Hour, 300mg Capsule 300mg-30mg Tablet, Extended-Release 24 300mg-60mg Tablet) Hour) Actiq (Lollipop) 4 PA, QL
Tramadol HCl ER Tramadol HCl ER Butorphanol Tartrate Tartrate (100mg Tablet (10mg/ml Nasal 1 QL, MED Extended-Release 24 Solution) Hour, 200mg Tablet Butorphanol Tartrate Tartrate
Extended-Release 24 1 QL, MED (1mg/ml Injection, 1 Hour) (Generic Ultram 2mg/ml Injection)
ER), (300mg Tablet Capital/Codeine Capital/Codeine Extended-Release 24 3 QL, MED (Suspension) Hour) (Generic Ryzolt) Codeine Sulfate
Ultram ER Codeine Sulfate Ultram ER (Tablet 1 QL, MED (Tablet) Extended-Release 24 3 QL, MED Dilaudid Hour) Dilaudid (1mg/ml
Xartemis XR Liquid, 2mg Tablet, Xartemis XR (Tablet 3 QL, MED 3 QL, MED 4mg Tablet, 8mg Extended-Release)
Xtampza ER Tablet)
Xtampza ER (Capsule Duramorph Extended-Release 12 Duramorph (Injection) 1 3 QL, ST, MED Endocet Hour Abuse- Endocet (Tablet) 1 QL, MED Deterrent) Fentanyl Citrate Oral Transmucosal Citrate Oral Zohydro ER ER (Capsule Transmucosal 1 PA, QL Extended-Release 12 PA, QL, (Lollipop)
3 Fentora Hour Abuse- MED Fentora (Tablet) 4 PA, QL Deterrent) Hycet (Oral Solution) 3 QL, MED Opioid Analgesics, Short-acting Abstral (Tablet 4 PA, QL Sublingual)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 17 7tRACK 7
18 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Hydrocodone Bitartrate/Acetaminophen Hydrocodone Lortab (Tablet) 1 QL, MED Bitartrate/ Morphine Sulfate Sulfate Acetaminophen (100mg/5ml Oral (10mg-300mg Tablet, 1 QL, MED Solution, 10mg/5ml 1 QL, MED 5mg-300mg Tablet, Oral Solution, 20mg/ 7.5mg-300mg Tablet, 5ml Oral Solution) 7.5mg-325mg/15ml Morphine Sulfate Sulfate Oral Solution) (10mg/ml Injection, Hydrocodone/Acetaminophen 1 Hydrocodone/ 4mg/ml Injection, Acetaminophen 8mg/ml Injection)
(10mg-325mg Tablet, Morphine Sulfate 1 QL, MED Morphine Sulfate 2.5mg-325mg Tablet, (15mg Tablet 5mg-325mg Tablet, Immediate-Release, 1 QL, MED 7.5mg-325mg Tablet) 30mg Tablet Hydrocodone/Hydrocodone/Ibuprofen 1 QL, MED Immediate-Release) Ibuprofen (Tablet) Morphine Sulfate Sulfate Hydromorphone HCl HCl 1 (2mg/ml Injection) (10mg/ml Injection, 1 Nalbuphine HCl HCl 1 50mg/5ml Injection) (Injection) Hydromorphone HCl
Hydromorphone HCl Norco Norco (Tablet) 3 QL, MED (1mg/ml Liquid, 2mg Nucynta (100mg Tablet Immediate- 4 QL, MED Release, 4mg Tablet 1 QL, MED Tablet) Nucynta (50mg Immediate-Release, 3 QL, MED 8mg Tablet Immediate- Tablet, 75mg Tablet) Release) Opana (10mg Tablet 4 QL, MED Hydromorphone HCl HCl Immediate-Release) 1 Opana (2mg/ml Injection) Opana (5mg Tablet 3 QL, MED Ibudone (Tablet) 1 QL, MED Immediate-Release) Lazanda (Nasal 4 PA, QL Solution) Lorcet (Tablet) 1 QL, MED Lorcet Plus Plus (Tablet) 1 QL, MED
Bold type = Brand name drug Plain type = Generic drug 18 8tRACK 8
Last updated August 1, 2016 19 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Oxycodone HCl HCl Percocet 3 QL, MED (100mg/5ml (2.5mg-325mg Tablet) Concentrate, 10mg Primlev (10mg-300mg Tablet Immediate- Tablet, 7.5mg-300mg 4 QL, MED Release, 15mg Tablet Tablet) Immediate-Release, Primlev (5mg-300mg 3 QL, MED 20mg Tablet Tablet)
Immediate-Release, 1 QL, MED Reprexain Reprexain (Tablet) 1 QL, MED 30mg Tablet Roxicodone (15mg Immediate-Release, 3 QL, MED 5mg Tablet Immediate- Tablet, 5mg Tablet) Roxicodone (30mg Release, 5mg Capsule 4 QL, MED Immediate-Release, Tablet) 5mg/5ml Oral Subsys (Liquid) 4 PA, QL Solution) Synalgos-DC Oxycodone/Acetaminophen 3 QL, MED Oxycodone/ (Capsule) Acetaminophen Tramadol HCl HCl (Tablet 1 QL, MED (10mg-325mg Tablet, Immediate-Release)
2.5mg-325mg Tablet, Tramadol HCl/Acetaminophen 1 QL, MED Tramadol HCl/ 5mg-325mg Tablet, Acetaminophen 1 QL, MED 7.5mg-325mg Tablet, (Tablet)
325mg/5ml-5mg/5ml Trezix Trezix (Capsule) 1 QL, MED Oral Solution) Tylenol/Codeine #3 Oxycodone/Aspirin Tylenol/Codeine #3 1 QL, MED 3 QL, MED (Tablet) (Tablet) Tylenol/Codeine #4 Oxycodone/Ibuprofen Tylenol/Codeine #4 1 QL, MED 3 QL, MED (Tablet) (Tablet)
Ultracet Oxymorphone HCl HCl Ultracet (Tablet) 3 QL, MED (Tablet Immediate- 1 QL, MED Ultram (Tablet) 3 QL, MED Release) Vicodin (Tablet) 1 QL, MED
Percocet Percocet Vicodin ES ES (Tablet) 1 QL, MED
(10mg-325mg Tablet, Vicodin HP 4 QL, MED Vicodin HP (Tablet) 1 QL, MED 5mg-325mg Tablet, 7.5mg-325mg Tablet)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 19 9tRACK 9
20 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Xodol Xodol (10mg-300mg Vivitrol (Injection) 4 PA Tablet, 7.5mg-300mg 4 QL, MED Opioid Dependence Treatments Tablet) Belbuca PA, QL, Xodol (5mg-300mg Belbuca (Film) 3 3 QL, MED MED Tablet) Bunavail Bunavail (Film) 3 PA, QL Zamicet
Zamicet (Oral Solution) 1 QL, MED Buprenex Buprenex (Injection) 4
Anesthetics Buprenorphine HCl Buprenorphine HCl Local Anesthetics 1 (0.3mg/ml Injection) Lidocaine
Lidocaine (5% Buprenorphine HCl 1 Buprenorphine HCl Ointment) (2mg Tablet Lidocaine 1 PA, QL Lidocaine (5% Patch) 1 PA, QL Sublingual, 8mg Tablet Lidocaine HCl HCl (0.5% Sublingual)
1 B/D, PA Buprenorphine HCl/Naloxone HCl Injection, 2% Injection) Buprenorphine HCl/ Lidocaine HCl HCl (4% Naloxone HCl (Tablet 1 PA, QL 1 External Solution) Sublingual)
Butrans Lidocaine HCl Lidocaine HCl (Gel) 1 Butrans (Patch 2 QL, MED Lidocaine Viscous Viscous Weekly) 1 Evzio (Solution) Evzio (Injection) 4 ST Lidocaine/Prilocaine Naloxone HCl HCl 1 1 (Cream) (Injection)
Lidoderm Narcan Lidoderm (Patch) 3 PA, QL Narcan (Liquid) 2 Xylocaine (Injection) 3 B/D, PA Suboxone (Film) 3 PA, QL Anti-Addiction/Substance Abuse Treatment Zubsolv (Tablet 3 PA, QL Agents Sublingual) Alcohol Deterrents/Anti-craving Smoking Cessation Agents
Acamprosate Calcium DR Acamprosate Calcium Buproban (Tablet
DR (Tablet Delayed- 1 Extended-Release 12 1 Release) Hour)
Antabuse Chantix Antabuse (Tablet) 3 Chantix (Tablet) 2
Disulfiram Chantix Continuing Month Pak Disulfiram (Tablet) 1 Chantix Continuing 2 Naltrexone HCl HCl Month Pak (Tablet) 1 (Tablet)
Bold type = Brand name drug Plain type = Generic drug 20 10tRACK 10
Last updated August 1, 2016 21 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Chantix Starting Month Pak Starting Streptomycin Sulfate Sulfate 2 3 Month Pak (Tablet) (Injection)
TOBI Nicotrol Inhaler Nicotrol Inhaler 3 TOBI (Nebulized 4 B/D, PA, QL Nicotrol NS NS (Nasal Solution) 3 TOBI Podhaler Podhaler Solution) 4 PA, QL Zyban (Tablet (Capsule) Tobradex Tobradex (0.3%-0.1% Extended-Release 12 3 2 Hour) Ophthalmic Ointment) Tobramycin (Nebulized Antibacterials 1 B/D, PA, QL Aminoglycosides Solution)
Tobramycin Sulfate Amikacin Sulfate Sulfate Tobramycin Sulfate 1 (0.3% Ophthalmic (Injection) Bethkis (Nebulized Solution, 10mg/ml 1 4 B/D, PA, QL Solution) Injection, 80mg/2ml
Gentak Injection)
Gentak (Ophthalmic Tobrex 1 Tobrex (0.3% Ointment) 2
Gentamicin Sulfate Ophthalmic Ointment)
Gentamicin Sulfate Tobrex Tobrex (0.3% (0.1% Cream, 0.1% 3 Ointment, 0.3% Ophthalmic Solution) Ophthalmic Ointment, Antibacterials, Other
1 Altabax 0.3% Ophthalmic Altabax (Ointment) 3
BACiiM Solution, 10mg/ml BACiiM (Injection) 1
Injection, 40mg/ml Bacitracin Bacitracin (50000unit Injection) Injection, 500unit/gm 1 Gentamicin Sulfate/0.9% Sodium Chloride Sulfate/ Ophthalmic Ointment)
0.9% Sodium Chloride 1 Bactroban Bactroban (Cream) 3 (Injection) Bactroban Nasal
Isotonic Gentamicin Bactroban Nasal Isotonic Gentamicin 3 PA 1 (Ointment) (Injection) Chloramphenicol Sodium Succinate
Neomycin Sulfate Chloramphenicol Neomycin Sulfate 1 Sodium Succinate 1 (Tablet)
Paromomycin Sulfate (Injection) Paromomycin Sulfate 1 (Capsule)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 21 11tRACK 11
22 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Cleocin (100mg Furadantin 4 Suppository, 150mg (Suspension)
Hiprex Capsule, 300mg 3 Hiprex (Tablet) 3
Capsule, 75mg Lincocin Lincocin (Injection) 3 Capsule, 2% Cream) Lincomycin HCl
Cleocin in D5W Lincomycin HCl Cleocin in D5W 1 3 (Injection) (Injection) Linezolid
Cleocin Pediatric Granules Linezolid (100mg/5ml Cleocin Pediatric Suspension, 600mg/ 1 PA Granules (Oral 3 300ml Injection)
Solution) Linezolid
Cleocin Phosphate Linezolid (600mg Cleocin Phosphate 1 PA, QL 3 Tablet) (Injection) Macrobid
Clindamycin HCl Macrobid (Capsule) 3 QL, HRM Clindamycin HCl Macrodantin (100mg (Capsule Immediate- 1 3 QL, HRM Release) Capsule)
Macrodantin Clindamycin Palmitate HCl Palmitate Macrodantin (25mg 1 HCl (Oral Solution) Capsule, 50mg 3 Clindamycin Phosphate Capsule) Methenamine Hippurate Phosphate (2% Cream, Methenamine 1 300mg/2ml Solution, 1 Hippurate (Tablet)
MetroCream 900mg/6ml Solution, MetroCream (Cream) 3
MetroGel 600mg/4ml Injection) MetroGel (Gel) 3
Clindamycin Phosphate in D5W Clindamycin MetroGel-Vaginal 3 Phosphate in D5W 1 (Gel)
(Injection) MetroLotion MetroLotion (Lotion) 3 Clindesse Clindesse (Cream) 3 Colistimethate Sodium Sodium 1 (Injection)
Cubicin Cubicin (Injection) 4 Dalvance (Injection) 4 PA Flagyl (250mg Tablet,
500mg Tablet, 375mg 3 Capsule)
Bold type = Brand name drug Plain type = Generic drug 22 12tRACK 12
Last updated August 1, 2016 23 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Metronidazole Noritate Metronidazole (0.75% Noritate (Cream) 4
Nuvessa Cream, 0.75% Gel, 1% Nuvessa (Gel) 3
Gel, 0.75% Lotion, Orbactiv Orbactiv (Injection) 4 250mg Tablet Polymyxin B Sulfate B Sulfate Immediate-Release, 1 1 500mg Tablet (Injection) Immediate-Release, Sivextro (200mg 375mg Capsule Injection, 200mg 4 PA Immediate-Release) Tablet)
Sulfamylon Metronidazole in NaCl 0.79% in NaCl Sulfamylon (5% 1 4 0.79% (Injection) Packet)
Sulfamylon Metronidazole Vaginal Vaginal Sulfamylon (85mg/ 1 3 (Gel) gm Cream)
Synercid Monurol Monurol (Packet) 3 Synercid (Injection) 4
Mupirocin Tindamax Mupirocin (2% Cream, Tindamax (Tablet) 3 1 Tinidazole 2% Ointment) Tinidazole (Tablet) 1
Neomycin/Polymyxin B Sulfates Neomycin/Polymyxin B Trimethoprim Trimethoprim (Tablet) 1
Sulfates (Irrigation 1 Tygacil Tygacil (Injection) 4 Solution) Vancocin HCl Nitrofurantoin Vancocin HCl 1 4 PA (Suspension) (Capsule) Vancomycin HCl Nitrofurantoin Macrocrystals Vancomycin HCl
Macrocrystals (100mg (1000mg Injection, 1 QL, HRM 1 Capsule) (Generic 10gm Injection, 500mg Macrodantin) Injection) Vancomycin HCl Nitrofurantoin Macrocrystals Vancomycin HCl Macrocrystals (25mg (125mg Capsule, 1 PA
Capsule, 50mg 1 250mg Capsule) Vandazole Capsule) (Generic Vandazole (Gel) 1 Macrodantin) Xifaxan (Tablet) 4 PA
Nitrofurantoin Monohydrate Nitrofurantoin Zyvox (100mg/5ml Monohydrate (100mg 1 QL, HRM Suspension, 600mg/ 4 PA Capsule) (Generic 300ml Injection) Macrobid)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 23 13tRACK 13
24 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Zyvox Cefotetan Zyvox (600mg Tablet) 4 PA, QL Cefotetan (Injection) 1 Beta-lactam, Cephalosporins Cefoxitin Sodium Sodium Avycaz (10gm Injection, 1gm Avycaz (Injection) 4 PA 1 Cedax (180mg/5ml Injection, 2gm
Suspension, 400mg 3 Injection) Cefpodoxime Proxetil Capsule) Cefpodoxime Proxetil Cefaclor (125mg/5ml (100mg Tablet, 200mg
Suspension, 375mg/ 3 Tablet, 100mg/5ml 1 5ml Suspension) Suspension, 50mg/5ml
Cefaclor Suspension)
Cefaclor (250mg Cefprozil Capsule Immediate- Cefprozil (125mg/5ml Suspension, 250mg/ Release, 500mg 1 Capsule Immediate- 5ml Suspension, 1 Release, 250mg/5ml 250mg Tablet, 500mg Suspension) Tablet) Ceftazidime Cefaclor ER ER (Tablet Ceftazidime (Injection) 1 Ceftin (125mg/5ml Extended-Release 12 1 Hour) Suspension, 250mg/ 3 Cefadroxil (1gm 5ml Suspension)
Ceftin Tablet, 250mg/5ml Ceftin (500mg Tablet) 4
Ceftriaxone Sodium Suspension, 500mg/ 1 Ceftriaxone Sodium 5ml Suspension, (10gm Injection, 1gm 500mg Capsule) Injection, 2gm
Cefazolin Sodium 1 Cefazolin Sodium Injection, 250mg 1 (Injection) Injection, 500mg Cefdinir (125mg/5ml Injection) Suspension, 250mg/ Cefuroxime Axetil Axetil 1 1 5ml Suspension, (Tablet) 300mg Capsule) Cefuroxime Sodium Sodium
Cefepime 1 Cefepime (Injection) 1 (Injection)
Cefixime Cefixime (Suspension) 1 Cefotaxime Sodium Sodium 1 (Injection)
Bold type = Brand name drug Plain type = Generic drug 24 14tRACK 14
Last updated August 1, 2016 25 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Cephalexin (125mg/ Azactam in Iso-Osmotic Dextrose in Iso-
5ml Suspension, Osmotic Dextrose 3 250mg/5ml (Injection) Suspension, 250mg Aztreonam 1 Aztreonam (Injection) 1 Capsule, 500mg Doribax Doribax (Injection) 2
Capsule, 750mg Imipenem/Cilastatin Imipenem/Cilastatin Capsule, 250mg 1 Tablet, 500mg Tablet) (Injection) Invanz Claforan (10gm Invanz (Injection) 3
Meropenem Injection, 500mg 3 Meropenem (Injection) 1
Merrem Injection) Merrem (Injection) 3
Claforan Claforan (1gm Primaxin IV Primaxin IV (Injection) 3 Injection, 2gm 3 Beta-lactam, Penicillins
Injection) Amoxicillin
Fortaz Amoxicillin (125mg Fortaz (1gm Injection, Tablet Chewable, 2gm Injection, 6gm 3 250mg Tablet Injection) Chewable, 125mg/5ml Maxipime Maxipime (Injection) 3 Suspension, 200mg/ Suprax (100mg Tablet 5ml Suspension,
Chewable, 200mg 2 250mg/5ml 1 Tablet Chewable) Suspension, 400mg/ Suprax (100mg/5ml 5ml Suspension, 3 Suspension) 250mg Capsule, Suprax (200mg/5ml 500mg Capsule, 4 Suspension) 500mg Tablet, 875mg Suprax (400mg Tablet)
Capsule, 500mg/5ml 2 Suspension)
Tazicef Tazicef (Injection) 1
Teflaro Teflaro (Injection) 4 Zerbaxa (Injection) 4 PA
Zinacef Zinacef (Injection) 3 Beta-lactam, Other
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 25 15tRACK 15
26 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Amoxicillin/Amoxicillin/Clavulanate Potassium Ampicillin-Sulbactam Clavulanate Potassium (10gm-5gm Injection, 1 (200mg-28.5mg Tablet 1gm-0.5gm Injection, Chewable, 2gm-1gm Injection) 400mg-57mg Tablet Augmentin 4 Chewable, 200mg/ (Suspension) 5ml-28.5mg/5ml Bactocill in Dextrose in Dextrose 3 Suspension, 250mg/ (Injection)
5ml-62.5mg/5ml Bicillin C-R Bicillin C-R (Injection) 3 Suspension, 400mg/ Bicillin L-A 5ml-57mg/5ml 1 Bicillin L-A (Injection) 3 Suspension, 600mg/ Dicloxacillin Sodium Sodium 1 5ml-42.9mg/5ml (Capsule) Suspension, Nafcillin Sodium Sodium 1 250mg-125mg Tablet (Injection) Immediate-Release, Oxacillin Sodium Sodium 1 500mg-125mg Tablet (Injection) Immediate-Release, Penicillin G Potassium G Potassium 1 875mg-125mg Tablet (Injection)
Immediate-Release) Penicillin G Potassium in Iso-Osmotic Dextrose Penicillin G (Generic Augmentin)
Amoxicillin/Clavulanate Potassium ER Potassium in Iso- 2 Amoxicillin/ Osmotic Dextrose Clavulanate Potassium 1 (Injection)
ER (Tablet Extended- Penicillin G Procaine Penicillin G Procaine Release 12 Hour) 1
Ampicillin (Injection)
Ampicillin (125mg/5ml Penicillin G Sodium Penicillin G Sodium Suspension, 250mg/ 1 (Injection) 5ml Suspension, 1 Penicillin V Potassium 250mg Capsule, Penicillin V Potassium (125mg/5ml Oral 500mg Capsule)
Ampicillin Sodium Solution, 250mg/5ml 1 Ampicillin Sodium Oral Solution, 250mg (10gm Injection, 1 Tablet, 500mg Tablet) 125mg Injection, 1gm Piperacillin/Piperacillin/Tazobactam Injection) 1 Tazobactam (Injection)
Bold type = Brand name drug Plain type = Generic drug 26 16tRACK 16
Last updated August 1, 2016 27 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
EryPed 200 Unasyn Unasyn (Injection) 3 EryPed 200 3 Unasyn Bulk Pack Bulk Pack (Suspension) 3 EryPed 400 400 (Injection) 4 Zosyn Zosyn (Injection) 3 (Suspension) Ery-Tab (Tablet Macrolides 3
Azasite Delayed-Release)
Azasite (Ophthalmic Erythrocin Lactobionate 3 Erythrocin Solution)
Azithromycin Lactobionate 3 Azithromycin (100mg/ (Injection)
5ml Suspension, Erythrocin Stearate
200mg/5ml Erythrocin Stearate 3 Suspension, 250mg 1 (Tablet) Erythromycin Tablet, 500mg Tablet, Erythromycin (250mg Capsule Delayed- 600mg Tablet, 500mg 1 Injection) Release, 5mg/gm Azithromycin (1gm Ophthalmic Ointment) 1 Erythromycin Base Base Packet) 1 Biaxin (250mg Tablet, (Tablet) Erythromycin Ethylsuccinate 500mg Tablet, Erythromycin 3 1 250mg/5ml Ethylsuccinate (Tablet) Suspension) Ilotycin (Ophthalmic 1 Clarithromycin Ointment) (125mg/5ml Ketek (Tablet) 3 PA Suspension, 250mg/ PCE (Tablet Delayed- 1 3 5ml Suspension, Release) 250mg Tablet, 500mg Zithromax (100mg/ Tablet) 5ml Suspension, Clarithromycin ER ER 200mg/5ml (Tablet Extended- 1 Suspension, 1gm 3 Release 24 Hour) Packet, 250mg Dificid (Tablet) 4 PA Tablet, 500mg Tablet,
E.E.S. 400 E.E.S. 400 (Tablet) 3 600mg Tablet, 500mg
E.E.S. Granules Injection) E.E.S. Granules 3 (Suspension)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 27 17tRACK 17
28 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Zithromax Tri-Pak Tri-Pak Ciprofloxacin HCl HCl 3 (Tablet) (0.3% Ophthalmic Zithromax Z-Pak Z-Pak Solution, 100mg Tablet 3 (Tablet) Immediate-Release,
Zmax 250mg Tablet Zmax (Suspension) 3 1 Immediate-Release, Quinolones 500mg Tablet Avelox (400mg Immediate-Release, Tablet, 400mg/ 3 750mg Tablet 250ml-0.8% Injection) Immediate-Release)
Avelox ABC Pack Avelox ABC Pack Ciprofloxacin I.V. in D5W I.V. in 3 1 (Tablet) D5W (Injection)
Besivance Besivance Gatifloxacin 3 1 (Suspension) (Ophthalmic Solution)
Ciloxan Ciloxan (0.3% Levaquin Levaquin (Tablet) 3
Ointment, 0.3% 3 Levofloxacin Levofloxacin (0.5% Ophthalmic Solution)
Cipro Ophthalmic Solution, Cipro (250mg Tablet, 250mg Tablet, 500mg 500mg Tablet, Tablet, 750mg Tablet, 1 500mg/5ml 3 25mg/ml Injection, Suspension, 5gm/ 25mg/ml Oral 100ml Suspension) Solution) Cipro I.V. in D5W
Cipro I.V. in D5W Levofloxacin in D5W 3 Levofloxacin in D5W (Injection) 1 (Injection) Ciprofloxacin Ciprofloxacin (250mg/ Moxeza (Ophthalmic 5ml Suspension, 3 Solution)
500mg/5ml 1 Moxifloxacin HCl Moxifloxacin HCl Suspension, 400mg/ 1 (400mg Tablet) 40ml Injection) Moxifloxacin HCl
Ciprofloxacin ER Moxifloxacin HCl Ciprofloxacin ER (400mg/250ml 3 (Tablet Extended- 1 Injection) Release 24 Hour) Ocuflox (Ophthalmic 3 Solution)
Bold type = Brand name drug Plain type = Generic drug 28 18tRACK 18
Last updated August 1, 2016 29 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Ofloxacin (0.3% Tetracyclines Ophthalmic Solution, Adoxa 1 Adoxa (Capsule) 4 0.3% Otic Solution, Demeclocycline HCl HCl 1 400mg Tablet) (Tablet) Vigamox
Vigamox (Ophthalmic Doxy 100 3 Doxy 100 (Injection) 1 Solution) Doxycycline
Zymaxid Doxycycline (150mg Zymaxid (Ophthalmic 3 Capsule, 75mg Solution) 1 Capsule, 25mg/5ml Sulfonamides Suspension) Bactrim Bactrim (Tablet) 3 Doxycycline Hyclate Hyclate
Bactrim DS Bactrim DS (Tablet) 3 (100mg Capsule Bleph-10 (Ophthalmic Immediate-Release, 3 Solution) 50mg Capsule
Silvadene Immediate-Release, Silvadene (Cream) 3 1
Silver Sulfadiazine 100mg Injection, Silver Sulfadiazine 1 100mg Tablet (Cream) Immediate-Release, Sodium Sulfacetamide Sulfacetamide 1 20mg Tablet (Ophthalmic Solution) Immediate-Release) SSD SSD (Cream) 1 Doxycycline Hyclate DR Hyclate Sulfacetamide Sodium Sulfacetamide Sodium DR (Tablet Delayed- 1 (10% Ophthalmic 1 Release) Ointment) Doxycycline Monohydrate
Sulfadiazine Sulfadiazine (Tablet) 1 Monohydrate (100mg Sulfamethoxazole/Trimethoprim Capsule, 50mg Sulfamethoxazole/ Trimethoprim Capsule, 100mg 1 (200mg-40mg/5ml Tablet, 150mg Tablet,
Suspension, 1 50mg Tablet, 75mg 400mg-80mg Tablet, Tablet)
Minocin 400mg-80mg/5ml Minocin (Capsule) 4 Injection) Sulfamethoxazole/Sulfamethoxazole/Trimethoprim DS
Trimethoprim DS 1 (Tablet)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 29 19tRACK 19
30 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Minocycline HCl HCl BRIVIACT (100mg (100mg Capsule Tablet, 10mg Tablet, Immediate-Release, 25mg Tablet, 50mg 4 QL 50mg Capsule Tablet, 75mg Tablet, Immediate-Release, 10mg/ml Oral 75mg Capsule Solution)
Immediate-Release, 1 BRIVIACT (50mg/5ml 3 QL 100mg Tablet Injection) Immediate-Release, Fycompa (0.5mg/ml 50mg Tablet Suspension, 10mg Immediate-Release, Tablet, 12mg Tablet, 3 75mg Tablet 2mg Tablet, 4mg Immediate-Release) Tablet, 6mg Tablet, Minocycline HCl ER HCl ER 8mg Tablet) (Tablet Extended- 1 Keppra (1000mg Release 24 Hour) Tablet, 500mg Tablet, Oracea (Capsule 3 750mg Tablet, 4 Delayed-Release) 100mg/ml Oral Solodyn (Tablet Solution)
Extended-Release 24 4 Keppra (250mg 3 Hour) Tablet)
Tetracycline HCl Tetracycline HCl Keppra XR XR (Tablet 1 (Capsule) Extended-Release 24 4 Vibramycin (100mg Hour) Capsule, 25mg/5ml 3 Suspension, 50mg/ 5ml Syrup) Anticonvulsants Anticonvulsants, Other
Bold type = Brand name drug Plain type = Generic drug 30 20tRACK 20
Last updated August 1, 2016 31 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Levetiracetam Zarontin (250mg/5ml 3 (1000mg Tablet Oral Solution)
Zonegran Immediate-Release, Zonegran (Capsule) 4
250mg Tablet Zonisamide Zonisamide (Capsule) 1 Immediate-Release, 500mg Tablet Gamma-aminobutyric Acid (GABA) 1 Immediate-Release, Augmenting Agents Depacon 750mg Tablet Depacon (Injection) 3 Immediate-Release, Depakene (250mg 3 100mg/ml Oral Capsule) Solution, 500mg/5ml Depakene (250mg/ 4 Injection) 5ml Syrup)
Levetiracetam Diastat AcuDial Levetiracetam Diastat AcuDial (Gel) 3
(1000mg/100ml Diastat Pediatric Diastat Pediatric (Gel) 3 Injection, 1500mg/ 1 Diazepam (10mg Gel, 100ml Injection, 1 500mg/100ml 2.5mg Gel, 20mg Gel)
Gabapentin Injection) Gabapentin (100mg Levetiracetam ER ER Capsule, 300mg Capsule, 400mg (Tablet Extended- 1 1 Release 24 Hour) Capsule, 250mg/5ml
Potiga Oral Solution, 600mg Potiga (Tablet) 4 QL Tablet, 800mg Tablet) Roweepra Roweepra (Tablet) 1 Gabitril (12mg Tablet, Spritam (Tablet 3 QL 16mg Tablet) Disintegrating 3 Gabitril (2mg Tablet, 3 Soluble) 4mg Tablet)
Mysoline Calcium Channel Modifying Agents Mysoline (Tablet) 4 Celontin Celontin (Capsule) 3 Neurontin (100mg
Ethosuximide Ethosuximide (250mg Capsule, 300mg
Capsule, 250mg/5ml 1 Capsule, 400mg 3 Oral Solution) Capsule, 250mg/5ml Zarontin (250mg Oral Solution) 3 Capsule)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 31 21tRACK 21
32 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Neurontin (600mg Lamictal Chewable Dispersible Chewable 4 Tablet, 800mg Tablet) Dispersible (25mg 4 Onfi (10mg Tablet, Tablet Chewable)
4 QL Lamictal Chewable Dispersible 20mg Tablet) Lamictal Chewable
Onfi (2.5mg/ml Dispersible (5mg 3 4 Suspension) Tablet Chewable)
Lamictal ODT Phenobarbital Lamictal ODT (Tablet Phenobarbital (100mg 3 Tablet, 15mg Tablet, Dispersible) 16.2mg Tablet, 30mg Lamictal Starter Starter (Blue 3 Tablet, 32.4mg Tablet, 1 PA, HRM Kit) 60mg Tablet, 64.8mg Lamictal Starter Starter 4 Tablet, 97.2mg Tablet, (Green Kit) 20mg/5ml Elixir) Lamictal Starter Starter Primidone 3 Primidone (Tablet) 1 (Orange Kit)
Sabril Sabril (500mg Packet, Lamictal XR XR (100mg 4 PA, QL, LA 500mg Tablet) Tablet Extended-
Tiagabine HCl Tiagabine HCl (Tablet) 1 Release 24 Hour, Valproate Sodium Sodium 200mg Tablet 1 (100mg/ml Injection) Extended-Release 24
Valproic Acid Hour, 250mg Tablet Valproic Acid (250mg Extended-Release 24 Capsule, 250mg/5ml 1 4 Hour, 25mg Tablet Syrup) Extended-Release 24 Glutamate Reducing Agents Hour, 300mg Tablet
Felbamate Felbamate (400mg Extended-Release 24 Tablet, 600mg Tablet, 1 Hour, 50mg Tablet 600mg/5ml Extended-Release 24 Suspension) Hour)
Felbatol
Lamictal XR Felbatol (400mg Lamictal XR (Kit) 3 Tablet, 600mg Tablet, 4 600mg/5ml Suspension)
Lamictal Lamictal (Tablet) 4
Bold type = Brand name drug Plain type = Generic drug 32 22tRACK 22
Last updated August 1, 2016 33 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Lamotrigine (100mg Topamax (100mg 4 Tablet Immediate- Tablet, 200mg Tablet) Release, 150mg Tablet Topamax (25mg 3 Immediate-Release, Tablet, 50mg Tablet) 200mg Tablet Topamax Sprinkle Sprinkle
Immediate-Release, 1 (15mg Capsule 3 25mg Tablet Sprinkle)
Immediate-Release, Topamax Sprinkle Topamax Sprinkle 25mg Tablet (25mg Capsule 4 Chewable, 5mg Tablet Sprinkle)
Chewable) Topiramate
Lamotrigine ER Topiramate (100mg Lamotrigine ER (Tablet Tablet Immediate- Extended-Release 24 1 Release, 200mg Tablet Hour) Immediate-Release, Lamotrigine ODT ODT 1 25mg Tablet (Tablet Dispersible) Immediate-Release, Qudexy XR Qudexy XR (100mg 50mg Tablet 1 Capsule Extended- Immediate-Release, Release 24 Hour 15mg Capsule Sprinkle, 25mg Sprinkle Immediate- Capsule Extended- 3 PA Release, 25mg Release 24 Hour Capsule Sprinkle Sprinkle, 50mg Immediate-Release) Capsule Extended- Topiramate ER ER Release 24 Hour (Capsule Extended- 1 PA Sprinkle) Release 24 Hour Qudexy XR XR (150mg Sprinkle) Capsule Extended- Release 24 Hour Sprinkle, 200mg 4 PA Capsule Extended- Release 24 Hour Sprinkle)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 33 23tRACK 23
34 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Trokendi XR XR (100mg Carbamazepine ER ER Capsule Extended- (100mg Capsule Release 24 Hour, Extended-Release 12 25mg Capsule Hour, 200mg Capsule 3 PA, QL Extended-Release 24 Extended-Release 12 Hour, 50mg Capsule Hour, 300mg Capsule Extended-Release 24 Extended-Release 12 1 Hour) Hour, 100mg Tablet Trokendi XR XR (200mg Extended-Release 12 Capsule Extended- 4 PA, QL Hour, 200mg Tablet Release 24 Hour) Extended-Release 12 Sodium Channel Agents Hour, 400mg Tablet
Aptiom Extended-Release 12 Aptiom (200mg 3 QL Hour) Tablet) Carbatrol
Aptiom Carbatrol (Capsule Aptiom (400mg Extended-Release 12 3 Tablet, 600mg Tablet, 4 QL Hour) 800mg Tablet) Cerebyx Banzel (200mg Cerebyx (Injection) 4 Dilantin Tablet, 400mg Tablet, 4 Dilantin (Capsule) 2 40mg/ml Suspension) Dilantin INFATABS INFATABS
Carbamazepine 2 Carbamazepine (Tablet Chewable) (100mg Tablet Dilantin-125 3 Chewable, 100mg/5ml (Suspension) 1 Epitol Suspension, 200mg Epitol (Tablet) 1
Tablet Immediate- Fosphenytoin Sodium Fosphenytoin Sodium Release) 1 (Injection) Oxcarbazepine (150mg Tablet, 300mg
Tablet, 600mg Tablet, 1 300mg/5ml Suspension) Oxtellar XR XR (Tablet Extended-Release 24 3 PA Hour)
Bold type = Brand name drug Plain type = Generic drug 34 24tRACK 24
Last updated August 1, 2016 35 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Donepezil HCl ODT Peganone Peganone (Tablet) 3 Donepezil HCl ODT 1 QL Phenytek Phenytek (Capsule) 1 (Tablet Dispersible)
Exelon Phenytoin (125mg/5ml Exelon (1.5mg
Suspension, 50mg 1 Capsule, 3mg Tablet Chewable) Capsule, 4.5mg
Phenytoin Sodium Capsule, 6mg Phenytoin Sodium 1 Capsule, 13.3mg/ 3 QL (Injection) 24hr Patch 24 Hour, Phenytoin Sodium Extended Sodium 1 4.6mg/24hr Patch 24 Extended (Capsule) Hour, 9.5mg/24hr Tegretol (100mg/5ml Patch 24 Hour) Suspension, 200mg 3 Galantamine HBr HBr Tablet) (12mg Tablet, 4mg Tegretol-XR (Tablet Tablet, 8mg Tablet, Extended-Release 12 3 16mg Capsule Hour) Extended-Release 24 Trileptal (150mg Hour, 24mg Capsule 1 QL 3 Tablet, 300mg Tablet) Extended-Release 24 Trileptal (300mg/5ml Hour, 8mg Capsule
Suspension, 600mg 4 Extended-Release 24 Tablet) Hour, 4mg/ml Oral Vimpat (100mg Solution) Tablet, 150mg Tablet, Razadyne (Tablet) 3 QL 200mg Tablet, 50mg 3 QL Razadyne ER ER Tablet, 10mg/ml Oral (Capsule Extended- 3 QL Solution) Release 24 Hour)
Vimpat Vimpat (200mg/20ml Rivastigmine Tartrate 3 PA Rivastigmine Tartrate Injection) (Capsule Immediate- 1 QL Antidementia Agents Release) Cholinesterase Inhibitors Rivastigmine Transdermal System Aricept (Tablet) 3 QL Transdermal System 1 QL Donepezil HCl HCl (Tablet (Patch 24 Hour) 1 QL Immediate-Release) N-methyl-D-aspartate (NMDA) Receptor Antagonist
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 35 25tRACK 25
36 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Memantine HCl HCl (10mg Forfivo XL XL (Tablet
Tablet, 5mg Tablet, 1 PA, QL Extended-Release 24 3 2mg/ml Oral Solution) Hour) Memantine HCl Titration Pak HCl Mirtazapine (Tablet 1 PA 1 Titration Pak (Tablet) Immediate-Release) Namenda (10mg Mirtazapine ODT ODT 1 Tablet Immediate- (Tablet Dispersible) Release, 5mg Tablet Olanzapine/Fluoxetine 3 PA, QL 1 Immediate-Release, (Capsule)
Remeron 10mg/5ml Oral Remeron (Tablet) 3
Solution) Remeron Soltab
Namenda Titration Pak Remeron Soltab Namenda Titration 3 3 PA (Tablet Dispersible)
Pak (Tablet) Symbyax
Namenda XR Symbyax (Capsule) 3 Namenda XR Wellbutrin SR SR (Tablet (Capsule Extended- 2 PA, QL Release 24 Hour) Extended-Release 12 3
Namenda XR Titration Pack Hour) Namenda XR Titration Wellbutrin XL Pack (Capsule Wellbutrin XL (Tablet 2 PA, QL Extended-Release 24 Extended-Release 24 4 Hour) Hour) Antidepressants Monoamine Oxidase Inhibitors Emsam (Patch 24 Antidepressants, Other 4 QL Aplenzin Hour) Aplenzin (Tablet Marplan Extended-Release 24 4 Marplan (Tablet) 3
Nardil Hour) Nardil (Tablet) 3
Bupropion HCl Parnate Bupropion HCl (Tablet Parnate (Tablet) 1 4 Immediate-Release) Phenelzine Sulfate Sulfate Bupropion HCl SR HCl SR 1 (Tablet) (Tablet Extended- 1 Tranylcypromine Sulfate 1 Release 12 Hour) Sulfate (Tablet) Bupropion HCl XL HCl XL SSRI/SNRI (Selective Serotonin Reuptake (Tablet Extended- 1 Inhibitors/Serotonin and Norepinephrine Release 24 Hour) Reuptake Inhibitors)
Bold type = Brand name drug Plain type = Generic drug 36 26tRACK 26
Last updated August 1, 2016 37 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Fluoxetine HCl Brisdelle Brisdelle (Capsule) 3 Fluoxetine HCl (10mg
Celexa Celexa (Tablet) 3 Capsule Immediate-
Citalopram HBr Release, 20mg Citalopram HBr (10mg Capsule Immediate- Tablet, 20mg Tablet, 1 Release, 40mg 1 40mg Tablet, 10mg/ Capsule Immediate- 5ml Oral Solution) Release, 10mg Tablet, Desvenlafaxine ER Desvenlafaxine ER 20mg Tablet, 20mg/ (Tablet Extended- 3 QL, ST 5ml Oral Solution)
Release 24 Hour) Fluoxetine HCl Fluoxetine HCl (60mg Effexor XR XR (Capsule 1 Tablet)
Extended-Release 24 3 Fluvoxamine Maleate Fluvoxamine Maleate Hour) 1 (Tablet) Escitalopram Oxalate
Escitalopram Oxalate Fluvoxamine Maleate ER Fluvoxamine Maleate (10mg Tablet, 20mg ER (Capsule Extended- 1 Tablet, 5mg Tablet, 1 Release 24 Hour)
5mg/5ml Oral Khedezla Solution) Khedezla (Tablet
Fetzima Extended-Release 24 3 QL, ST Fetzima (Capsule Hour)
Extended-Release 24 3 QL, ST Lexapro Hour) Lexapro (10mg
Fetzima Titration Pack Tablet, 20mg Tablet, Fetzima Titration 3 5mg Tablet, 5mg/5ml Pack (Capsule 3 ST Oral Solution)
Extended-Release 24 Maprotiline HCl Maprotiline HCl Hour Therapy Pack) 1
Fluoxetine DR (Tablet)
Fluoxetine DR Nefazodone HCl Nefazodone HCl (Capsule Delayed- 1 1 Release) (Tablet) Paroxetine HCl HCl (Tablet 1 PA, HRM Immediate-Release) Paxil (10mg Tablet, 20mg Tablet, 30mg Tablet, 40mg Tablet, 3 PA, HRM 10mg/5ml Suspension)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 37 27tRACK 27
38 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Pristiq (Tablet Venlafaxine HCl ER HCl ER Extended-Release 24 3 QL (150mg Capsule Hour) Extended-Release 24 Prozac (10mg Hour, 37.5mg Capsule
Capsule, 20mg 3 Extended-Release 24 Capsule) Hour, 75mg Capsule Prozac (40mg Extended-Release 24 4 1 Capsule) Hour, 150mg Tablet
Prozac Weekly Extended-Release 24 Prozac Weekly Hour, 37.5mg Tablet (Capsule Delayed- 3 Extended-Release 24 Release)
Sarafem Hour, 75mg Tablet Sarafem (Tablet) 3 Extended-Release 24
Sertraline HCl Sertraline HCl (100mg Hour) Tablet, 25mg Tablet, Venlafaxine HCl ER 1 Venlafaxine HCl ER 50mg Tablet, 20mg/ml (225mg Tablet 1 Concentrate) Extended-Release 24 Trazodone HCl Trazodone HCl (Tablet) 1 Hour)
Trintellix Trintellix (Tablet) 3 QL Viibryd (Tablet) 3 QL
Venlafaxine HCl Venlafaxine HCl Viibryd Starter Pack Starter Pack 3 QL (Tablet Immediate- 1 (Kit) Release) Zoloft (100mg Tablet, 25mg Tablet, 50mg 3 Tablet, 20mg/ml Concentrate) Tricyclics Amitriptyline HCl HCl 1 PA, HRM (Tablet) Amoxapine (Tablet) 1 PA, HRM Anafranil (Capsule) 4 PA, HRM Clomipramine HCl HCl 1 PA, HRM (Capsule)
Bold type = Brand name drug Plain type = Generic drug 38 28tRACK 28
Last updated August 1, 2016 39 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Desipramine HCl Compro Desipramine HCl Compro (Suppository) 1 1 PA, HRM (Tablet) Hydroxyzine Pamoate Pamoate Doxepin HCl 1 PA, HRM Doxepin HCl (100mg (Capsule) Capsule, 10mg Meclizine HCl HCl (12.5mg 1 PA, HRM Capsule, 150mg Tablet)
Capsule, 25mg Metoclopramide HCl 1 PA, HRM Metoclopramide HCl Capsule, 50mg (10mg Tablet, 5mg
Capsule, 75mg Tablet, 5mg/5ml Oral 1 Capsule, 10mg/ml Solution, 5mg/ml Concentrate) Injection) Elavil Elavil (Tablet) 4 PA, HRM Metoclopramide ODT ODT Imipramine HCl HCl 1 1 PA, HRM (Tablet Dispersible) (Tablet) Metozolv ODT ODT (Tablet Imipramine Pamoate Pamoate 4 1 PA, HRM Dispersible) Perphenazine (Capsule) Perphenazine (Tablet) 1
Norpramin Norpramin (Tablet) 3 PA, HRM Prochlorperazine Nortriptyline HCl 1 Nortriptyline HCl (Suppository) (10mg Capsule, 25mg Prochlorperazine Edisylate Capsule, 50mg 1 1 PA, HRM Edisylate (Injection) Capsule, 75mg Prochlorperazine Maleate Prochlorperazine Capsule, 10mg/5ml 1 Maleate (Tablet)
Oral Solution) Reglan
Pamelor Reglan (Tablet) 3 Pamelor (Capsule) 4 PA, HRM Transderm-Scop
Protriptyline HCl Transderm-Scop Protriptyline HCl 3 1 PA, HRM (Patch 72 Hour)
(Tablet) Vistaril
Surmontil Vistaril (Capsule) 3 PA, HRM Surmontil (Capsule) 3 PA, HRM
Tofranil Emetogenic Therapy Adjuncts
Tofranil (Tablet) 4 PA, HRM Aloxi
Trimipramine Maleate Aloxi (Injection) 4
Trimipramine Maleate Anzemet 1 PA, HRM Anzemet (100mg (Capsule) 4 B/D, PA Tablet, 50mg Tablet)
Antiemetics Anzemet Anzemet (20mg/ml Antiemetics, Other 3 Injection) Akynzeo
Akynzeo (Capsule) 3 PA Cesamet Cesamet (Capsule) 4 PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 39 29tRACK 29
40 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Zofran Dronabinol (Capsule) 1 PA, QL Zofran (4mg Tablet, Emend (Pack, 125mg 8mg Tablet, 4mg/5ml 4 B/D, PA Capsule, 40mg Oral Solution) 3 PA Zofran ODT ODT (Tablet Capsule, 80mg 4 B/D, PA Capsule) Dispersible)
Zuplenz Emend (150mg Zuplenz (4mg Film) 3 B/D, PA 3 Injection) Zuplenz (8mg Film) 4 B/D, PA
Granisetron HCl Granisetron HCl Antifungals (0.1mg/ml Injection, 1 Antifungals
1mg/ml Injection, Abelcet Abelcet (Injection) 4 B/D, PA 4mg/4ml Injection) AmBisome Granisetron HCl HCl (1mg AmBisome (Injection) 4 B/D, PA 1 B/D, PA, QL Amphotericin B B Tablet) 1 B/D, PA Marinol (10mg (Injection)
Ancobon Capsule, 5mg 4 PA, QL Ancobon (Capsule) 4
AVC Capsule) AVC (Cream) 3
Marinol Marinol (2.5mg Cancidas 3 PA, QL Cancidas (Injection) 4 Capsule) Ciclopirox Ciclopirox (0.77% Gel, Ondansetron HCl Ondansetron HCl 0.77% Suspension, 1% 1 (24mg Tablet, 4mg Shampoo)
Tablet, 8mg Tablet, 1 B/D, PA Ciclopirox Nail Lacquer Ciclopirox Nail 4mg/5ml Oral Lacquer (External 1 Solution) Solution) Ondansetron HCl
Ondansetron HCl Ciclopirox Olamine 1 Ciclopirox Olamine (4mg/2ml Injection) 1 (Cream) Ondansetron ODT
Ondansetron ODT Clotrimazole 1 B/D, PA Clotrimazole (1% (Tablet Dispersible) Cream, 1% External Sancuso 1 Sancuso (Patch) 4 Solution, 10mg Varubi (Tablet) 3 B/D, PA Troche)
Cresemba Zofran (40mg/20ml Cresemba (186mg 3 Injection) Capsule, 372mg 4 PA Injection)
Bold type = Brand name drug Plain type = Generic drug 40 30tRACK 30
Last updated August 1, 2016 41 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Diflucan (100mg Jublia (External 3 Tablet, 150mg Tablet, Solution)
50mg Tablet, 10mg/ 3 Kerydin (External 4 ST ml Suspension, Solution) 40mg/ml Suspension) Ketoconazole (2%
Diflucan Diflucan (200mg Cream, 2% Foam, 2% 4 1 Tablet) Shampoo, 200mg Econazole Nitrate Nitrate Tablet)
1 Lamisil (Cream) Lamisil (125mg
Eraxis Eraxis (Injection) 4 Packet, 187.5mg 3
Ertaczo Ertaczo (Cream) 4 Packet)
Lamisil Exelderm (1% Cream, Lamisil (250mg 3 4 1% External Solution) Tablet) Loprox
Extina Extina (Foam) 4 Loprox (Cream) 3 Loprox Shampoo Fluconazole (100mg Loprox Shampoo 4
Luzu Tablet, 150mg Tablet, Luzu (Cream) 3 200mg Tablet, 50mg Mentax 1 Mentax (Cream) 3 Tablet, 10mg/ml Miconazole 3 3 1 Suspension, 40mg/ml (Suppository)
Suspension) Mycamine
Fluconazole in NaCl Mycamine (100mg Fluconazole in NaCl 4 1 Injection)
(Injection) Mycamine Mycamine (50mg Flucytosine 3 Flucytosine (Capsule) 1 Injection)
Griseofulvin Microsize Griseofulvin Microsize Naftifine HCl HCl (1% (125mg/5ml 1 1 Cream) Suspension, 500mg Naftifine HCl Naftifine HCl (2% Tablet) 1 Cream) Griseofulvin Ultramicrosize
Griseofulvin Naftin 1 Naftin (1% Gel, 2% Ultramicrosize (Tablet) 3 Gel, 2% Cream) GRIS-PEG GRIS-PEG (Tablet) 3 Natacyn Natacyn (Suspension) 2 Gynazole-1 Gynazole-1 (Cream) 3 Nizoral Nizoral (Shampoo) 3 Itraconazole (Capsule) 1 PA, QL
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 41 31tRACK 31
42 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Noxafil Vfend IV Noxafil (100mg Tablet Vfend IV (Injection) 4 4 PA, QL Delayed-Release) Voriconazole (200mg Noxafil (40mg/ml Injection, 200mg 4 QL 1 Suspension) Tablet, 50mg Tablet,
Nyamyc Nyamyc (Powder) 1 40mg/ml Suspension)
Zazole Nystatin Nystatin (Cream, Zazole (Cream) 1
Ointment, Powder, 1 Antigout Agents Suspension, Tablet) Antigout Agents
Nystatin/Triamcinolone Nystatin/ Allopurinol Allopurinol (Tablet) 1
Triamcinolone (0.1% 1 Aloprim Aloprim (Injection) 3 Cream, 0.1% Ointment) Colchicine
Nystop Colchicine (0.6mg Nystop (Powder) 1 Capsule) (Generic 3 QL ONMEL ONMEL (Tablet) 4 PA Mitigare)
Oravig Oravig (Tablet) 4 Colchicine (0.6mg Oxiconazole Nitrate Nitrate Tablet) (Generic 2 QL 1 (Cream) Colcrys) Oxistat (1% Cream, Colcrys (Tablet) 3 PA, QL 3 1% Lotion) Mitigare (Capsule) 3 QL
Sporanox Sporanox (100mg Probenecid 4 PA, QL Probenecid (Tablet) 1
Capsule) Probenecid/Colchicine
Sporanox Probenecid/Colchicine Sporanox (10mg/ml 1 4 PA (Tablet)
Oral Solution) Uloric
Terazol 3 Uloric (Tablet) 2 ST Terazol 3 (Cream) 3 Zyloprim
Terazol 7 Zyloprim (Tablet) 3 Terazol 7 (Cream) 3
Terbinafine HCl Antimigraine Agents Terbinafine HCl 1 Ergot Alkaloids (Tablet) Cafergot Terconazole (0.4% Cafergot (Tablet) 2 Dihydroergotamine Mesylate Cream, 0.8% Cream, 1 80mg Suppository) Mesylate (1mg/ml 1 Vfend (200mg Tablet, Injection)
50mg Tablet, 40mg/ 4 ml Suspension)
Bold type = Brand name drug Plain type = Generic drug 42 32tRACK 32
Last updated August 1, 2016 43 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Dihydroergotamine Mesylate Onzetra Xsail Xsail (Exhaler 3 QL Mesylate (4mg/ml 1 Powder) Nasal Solution) Relpax (Tablet) 3 QL, ST
Ergomar Ergomar (Tablet Rizatriptan Benzoate 3 Rizatriptan Benzoate Sublingual) (Tablet Immediate- 1 QL
Migergot Migergot (Suppository) 4 Release) Migranal (Nasal Rizatriptan Benzoate ODT Benzoate 4 Solution) ODT (Tablet 1 QL Serotonin (5-HT) 1b/1d Receptor Agonists Dispersible)
Sumatriptan Almotriptan Malate Malate Sumatriptan (Nasal 1 QL 1 QL (Tablet) Solution)
Sumatriptan Succinate Amerge (Tablet) 3 QL Sumatriptan Succinate
Axert (100mg Tablet, 25mg Axert (12.5mg Tablet) 3 QL 1 QL Tablet, 50mg Tablet, Axert Axert (6.25mg Tablet) 4 QL 6mg/0.5ml Injection)
Frova Frova (Tablet) 3 QL Sumatriptan Succinate Refill Frovatriptan Succinate Succinate Succinate Refill 1 QL 1 QL (Tablet) (Injection) Imitrex (100mg Sumavel DosePro DosePro 4 QL Tablet, 25mg Tablet, (Injection) 50mg Tablet, 20mg/ Treximet 3 QL Treximet (Tablet) 4 QL, ST act Nasal Solution, Zembrace Symtouch Symtouch 4 QL 5mg/act Nasal (Injection)
Solution) Zolmitriptan
Imitrex Zolmitriptan (Tablet) 1 QL Imitrex (6mg/0.5ml 4 QL Zolmitriptan ODT ODT Injection) 1 QL
Imitrex Statdose Refill (Tablet Dispersible) Imitrex Statdose Refill 4 QL Zomig (2.5mg Tablet, (Injection) 4 QL
Maxalt 5mg Tablet)
Maxalt (Tablet) 3 QL Zomig Nasal Spray
Maxalt-MLT Zomig Nasal Spray Maxalt-MLT (Tablet 3 QL (2.5mg Solution, 5mg 3 QL Dispersible) Solution) Naratriptan HCl Naratriptan HCl Zomig ZMT ZMT (Tablet 1 QL 4 QL (Tablet) Dispersible)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 43 33tRACK 33
44 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Antimyasthenic Agents Rifadin (150mg 3 Parasympathomimetics Capsule)
Rifadin Guanidine HCl HCl Rifadin (300mg 2 3 (Tablet) Capsule)
Rifadin Mestinon (60mg Rifadin (600mg 4 Tablet, 60mg/5ml 4 Injection)
Rifamate Syrup) Rifamate (Capsule) 3
Mestinon Timespan Mestinon Timespan Rifampin Rifampin (150mg (Tablet Extended- 4 Capsule, 300mg 1 Release) Capsule, 600mg Pyridostigmine Bromide Injection) Bromide (180mg Rifater 1 Rifater (Tablet) 3 Tablet Extended- Sirturo Sirturo (Tablet) 4 PA Release, 60mg Tablet) Trecator Trecator (Tablet) 3 Antimycobacterials Antimycobacterials, Other Antineoplastics
Dapsone Alkylating Agents Dapsone (Tablet) 1 Alkeran
Mycobutin Alkeran (Injection) 3 Mycobutin (Capsule) 3 BiCNU
Rifabutin BiCNU (Injection) 4 Rifabutin (Capsule) 1 Busulfex Busulfex (Injection) 4 Antituberculars Cyclophosphamide Capastat Sulfate Sulfate Cyclophosphamide 3 3 B/D, PA (Injection) (Capsule) Dacarbazine Ethambutol HCl HCl Dacarbazine (Injection) 1 1 Gleostine (Tablet) Gleostine (Capsule) 3 Isoniazid (100mg Hexalen (Capsule) 4 PA
Tablet, 300mg Tablet, Ifex 1 Ifex (Injection) 3
100mg/ml Injection, Ifosfamide Ifosfamide (Injection) 1 50mg/5ml Syrup) Leukeran Myambutol Leukeran (Tablet) 2 Myambutol (Tablet) 3
Matulane
Paser Matulane (Capsule) 4 LA Paser (Packet) 3 Melphalan HCl
Priftin Melphalan HCl Priftin (Tablet) 3 1 (Injection) Pyrazinamide Pyrazinamide (Tablet) 1
Bold type = Brand name drug Plain type = Generic drug 44 34tRACK 34
Last updated August 1, 2016 45 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Cytarabine Aqueous Mustargen Mustargen (Injection) 4 Cytarabine Aqueous 1 B/D, PA Treanda (Injection) 4 PA (Injection) Droxia Valchlor (Gel) 4 PA, LA Droxia (Capsule) 3 Elitek
Zanosar Zanosar (Injection) 3 Elitek (Injection) 4 Fluorouracil (2.5gm/ Antiandrogens 1 B/D, PA
Bicalutamide 50ml Injection)
Bicalutamide (Tablet) 1 Folotyn
Casodex Folotyn (Injection) 4
Casodex (Tablet) 3 Gemcitabine HCl Gemcitabine HCl Flutamide 1 Flutamide (Capsule) 1 (Injection)
Nilandron Gemzar Nilandron (Tablet) 4 Gemzar (Injection) 4
Xtandi
Hydrea Xtandi (Capsule) 4 PA, QL Hydrea (Capsule) 3
Zytiga
Hydroxyurea Zytiga (Tablet) 4 PA, QL Hydroxyurea (Capsule) 1 Antiangiogenic Agents Lonsurf (Tablet) 4 PA, QL
Pomalyst Pomalyst (Capsule) 4 PA, QL Mercaptopurine Revlimid 1 Revlimid (Capsule) 4 PA, QL, LA (Tablet)
Thalomid Nipent Thalomid (Capsule) 4 PA, QL Nipent (Injection) 4 Antiestrogens/Modifiers Purixan (Suspension) 4 PA
Emcyt Emcyt (Capsule) 4 Tabloid (Tablet) 4 PA
Fareston Fareston (Tablet) 4 Antineoplastics, Other
Faslodex Abraxane Faslodex (Injection) 4 Abraxane (Injection) 4 PA
Soltamox Soltamox (Oral Alecensa (Capsule) 4 PA, QL 3 Amifostine Solution) Amifostine (Injection) 1
Tamoxifen Citrate
Tamoxifen Citrate Arranon 1 Arranon (Injection) 4 (Tablet) Azacitidine (Injection) 1 PA Antimetabolites Beleodaq
Adrucil Beleodaq (Injection) Adrucil (Injection) 1 B/D, PA 4 PA Bleomycin Sulfate
Alimta Bleomycin Sulfate Alimta (Injection) 4 PA 1 B/D, PA (Injection) Cladribine
Cladribine (Injection) 1 B/D, PA Camptosar Camptosar (Injection) 3 Clolar
Clolar (Injection) 4 Carboplatin Carboplatin (Injection) 1
Cisplatin Cisplatin (Injection) 1
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 45 35tRACK 35
46 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Cosmegen Jevtana Cosmegen (Injection) 4 Jevtana (Injection) 4 PA
Leucovorin Calcium Dacogen Dacogen (Injection) 4 Leucovorin Calcium Daunorubicin HCl HCl (100mg Injection, 1 350mg Injection, 10mg (Injection) 1 Decitabine Tablet, 15mg Tablet, Decitabine (Injection) 1
Dexrazoxane 25mg Tablet, 5mg Dexrazoxane 1 PA Tablet)
(Injection) Levoleucovorin Calcium Levoleucovorin Docefrez 1 Docefrez (Injection) 4 Calcium (Injection)
Docetaxel Docetaxel (80mg/4ml Lynparza 1 Lynparza (Capsule) 4 PA, QL
Injection) Mesna
Docetaxel Mesna (Injection) 1
Docetaxel (80mg/8ml Mesnex 1 Mesnex (100mg/ml Injection) 3
Doxil Injection)
Doxil (Injection) 4 Mesnex Mesnex (400mg Doxorubicin HCl HCl 4 1 B/D, PA Tablet)
(Injection) Mitomycin
Doxorubicin HCl Liposome Mitomycin (Injection) 1
Doxorubicin HCl Mitoxantrone HCl 1 Mitoxantrone HCl Liposome (Injection) 1
Ellence (Injection)
Ellence (Injection) 4 Ninlaro Ninlaro (Capsule) Erwinaze 4 PA, QL
Erwinaze (Injection) 4 Oxaliplatin
Farydak Oxaliplatin (Injection) 1
Farydak (Capsule) 4 PA Paclitaxel
Fludarabine Phosphate Paclitaxel (Injection) 1
Fludarabine Phosphate Proleukin 1 (Injection) Proleukin (Injection) 4 PA
Synribo
Fusilev Fusilev (Injection) 4 Synribo (Injection) 4 PA
Taxotere Halaven (Injection) 4 PA Taxotere (Injection) 4
Thiotepa Ibrance (Capsule) 4 PA, QL Thiotepa (Injection) 1
Trisenox Idamycin PFS PFS Trisenox (Injection) 3
4 Velcade (Injection) Velcade (Injection) 4 PA
Idarubicin HCl Idarubicin HCl Venclexta (100mg 1 4 PA, QL (Injection) Tablet)
Irinotecan Venclexta Irinotecan (Injection) 1 Venclexta (10mg 3 PA, QL Istodax (Injection) 4 PA Tablet, 50mg Tablet)
Bold type = Brand name drug Plain type = Generic drug 46 36tRACK 36
Last updated August 1, 2016 47 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Venclexta Starting Pack Starting Topotecan HCl HCl 1 Pack (Tablet Therapy 4 PA (Injection) Pack) Molecular Target Inhibitors
Vidaza Vidaza (Injection) 4 PA Afinitor (Tablet) 4 PA
Vinblastine Sulfate Vinblastine Sulfate Afinitor Disperz Disperz 1 B/D, PA 4 PA (Injection) (Tablet Soluble)
Vincasar PFS Vincasar PFS Bosulif 1 B/D, PA Bosulif (Tablet) 4 PA, QL (Injection) Cabometyx Cabometyx (Tablet) 4 PA, QL Vincristine Sulfate
Vincristine Sulfate Caprelsa 1 B/D, PA Caprelsa (Tablet) 4 PA, LA (Injection)
Cometriq Vinorelbine Tartrate Tartrate Cometriq (Kit) 4 PA 1 Cotellic (Injection) Cotellic (Tablet) 4 PA, QL, LA
Erivedge Zaltrap (Injection) 4 PA Erivedge (Capsule) 4 PA, QL
Gilotrif Zinecard (Injection) 4 PA Gilotrif (Tablet) 4 PA
Gleevec Zolinza (Capsule) 4 PA Gleevec (Tablet) 4 PA, QL
Iclusig Zydelig (Tablet) 4 PA, QL Iclusig (15mg Tablet) 4 PA, QL, LA
Iclusig Zykadia (Capsule) 4 PA, QL Iclusig (45mg Tablet) 4 PA, QL Aromatase Inhibitors, 3rd Generation Imatinib Mesylate Mesylate 1 PA, QL Anastrozole Anastrozole (Tablet) 1 (Tablet)
Imbruvica
Arimidex Arimidex (Tablet) 3 Imbruvica (Capsule) 4 PA, QL
Inlyta
Aromasin Aromasin (Tablet) 4 Inlyta (Tablet) 4 PA, QL
Iressa
Exemestane Exemestane (Tablet) 1 Iressa (Tablet) 4 PA, QL
Jakafi
Femara Femara (Tablet) 4 Jakafi (Tablet) 4 PA, QL, LA
Lenvima Letrozole Lenvima (Capsule Letrozole (Tablet) 1 4 PA Therapy Pack) Enzyme Inhibitors Mekinist
Etopophos Mekinist (Tablet) 4 PA Etopophos (Injection) 4 Nexavar
Etoposide Nexavar (Tablet) 4 PA Etoposide (Injection) 1 Odomzo
Hycamtin Odomzo (Capsule) 4 PA, QL, LA Hycamtin (Injection) 4 Sprycel
Toposar Sprycel (Tablet) 4 PA, QL Toposar (Injection) 1 Stivarga (Tablet) 4 PA, QL
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 47 37tRACK 37
48 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Targretin Sutent (Capsule) 4 PA, QL Targretin (1% Gel, 4 PA Tafinlar (Capsule) 4 PA 75mg Capsule)
Tretinoin
Tarceva Tretinoin (10mg Tarceva (Tablet) 4 PA, QL 1 Capsule) Tasigna (Capsule) 4 PA, QL Antiparasitics Tykerb Tykerb (Tablet) 4 PA Anthelmintics
Votrient Votrient (Tablet) 4 PA, QL Albenza (Tablet) 4 QL
Xalkori
Biltricide Xalkori (Capsule) 4 PA, LA Biltricide (Tablet) 3
Zelboraf Zelboraf (Tablet) 4 PA, QL Emverm (Tablet 4 Monoclonal Antibodies Chewable)
Avastin Ivermectin Avastin (Injection) 4 PA Ivermectin (Tablet) 1
Cyramza Sklice Cyramza (Injection) 4 PA Sklice (Lotion) 3
Darzalex Stromectol Darzalex (Injection) 4 PA, LA Stromectol (Tablet) 3 Empliciti (Injection) 4 PA Antiprotozoals
Alinia Erbitux Alinia (100mg/5ml Erbitux (Injection) 4 PA 3 Herceptin (Injection) 4 PA Suspension) Alinia Kadcyla Alinia (500mg Tablet) 4 Kadcyla (Injection) 4 PA Atovaquone
Keytruda Atovaquone Keytruda (Injection) 4 PA 1 (Suspension) Opdivo
Opdivo (Injection) 4 PA Atovaquone/Proguanil HCl Atovaquone/Proguanil Perjeta Perjeta (Injection) 4 PA HCl (Tablet) (Generic 1 Rituxan (Injection) 4 PA Malarone)
Chloroquine Phosphate Sylvant Chloroquine Sylvant (Injection) 4 PA 1 Tagrisso Phosphate (Tablet) Tagrisso (Tablet) 4 PA, QL, LA Coartem
Tecentriq Coartem (Tablet) 3 Tecentriq (Injection) 4 PA DARAPRIM
Vectibix DARAPRIM (Tablet) 4 Vectibix (Injection) 4 PA Hydroxychloroquine Sulfate
Yervoy Hydroxychloroquine Yervoy (Injection) 4 PA 1 Sulfate (Tablet)
Retinoids Malarone Malarone (Tablet) 3 Bexarotene
Bexarotene (Capsule) 1 PA Mefloquine HCl Mefloquine HCl Panretin 1 Panretin (Gel) 4 PA (Tablet)
Bold type = Brand name drug Plain type = Generic drug 48 38tRACK 38
Last updated August 1, 2016 49 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Amantadine HCl Mepron Mepron (Suspension) 4 Amantadine HCl Nebupent (Inhalation (100mg Capsule, 3 B/D, PA, QL 1 Solution) 100mg Tablet, 50mg/ Pentam 300 300 5ml Syrup) 3 Comtan (Injection) Comtan (Tablet) 3
Entacapone Plaquenil Plaquenil (Tablet) 3 Entacapone (Tablet) 1
Tasmar Primaquine Phosphate Phosphate Tasmar (Tablet) 4 QL
1 Tolcapone (Tablet) Tolcapone (Tablet) 1 QL Qualaquin (Capsule) 3 PA Dopamine Agonists
Quinine Sulfate Quinine Sulfate Apokyn 1 PA Apokyn (Injection) 4 PA, QL (Capsule) Bromocriptine Mesylate
Pediculicides/Scabicides Mesylate (2.5mg 1
Elimite Elimite (Cream) 3 Tablet, 5mg Capsule)
Eurax Mirapex Eurax (10% Cream, Mirapex (Tablet) 3 3 10% Lotion) Mirapex ER ER (Tablet
Lindane Lindane (Shampoo) 1 Extended-Release 24 3
Malathion Malathion (Lotion) 1 Hour)
Neupro Ovide Neupro (Patch 24 Ovide (Lotion) 3 3
Permethrin Hour)
Permethrin (Cream) 1 Pramipexole Dihydrochloride Pramipexole Antiparkinson Agents Dihydrochloride 1 Anticholinergics (Tablet Immediate- Benztropine Mesylate Mesylate Release) (0.5mg Tablet, 1mg 1 PA, HRM Pramipexole Dihydrochloride ER Tablet, 2mg Tablet) Dihydrochloride ER Benztropine Mesylate 1 Benztropine Mesylate (Tablet Extended- 1 (1mg/ml Injection) Release 24 Hour)
Cogentin Requip Cogentin (Injection) 3 Requip (Tablet) 3
Trihexyphenidyl HCl Trihexyphenidyl HCl Requip XL XL (Tablet
(0.4mg/ml Elixir, 2mg 1 PA, HRM Extended-Release 24 3 Tablet, 5mg Tablet) Hour) Antiparkinson Agents, Other
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 49 39tRACK 39
50 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Ropinirole ER Ropinirole ER (Tablet Stalevo 75 Stalevo 75 (Tablet) 3 PA Extended-Release 24 1 Monoamine Oxidase B (MAO-B) Inhibitors
Hour) Azilect Azilect (Tablet) 2 Ropinirole HCl
Ropinirole HCl (Tablet Eldepryl 1 Eldepryl (Capsule) 3 Immediate-Release) Selegiline HCl HCl (5mg Dopamine Precursors/L-Amino Acid 1 Decarboxylase Inhibitors Capsule, 5mg Tablet) Zelapar
Carbidopa Zelapar (Tablet Carbidopa (Tablet) 1 4
Carbidopa/Levodopa Dispersible) Carbidopa/Levodopa Antipsychotics (Tablet Immediate- 1 Release) 1st Generation/Typical Chlorpromazine HCl Carbidopa/Levodopa ER Chlorpromazine HCl
ER (Tablet Extended- 1 (100mg Tablet, 10mg Tablet, 200mg Tablet, Release) 1
Carbidopa/Levodopa ODT 25mg Tablet, 50mg Carbidopa/Levodopa Tablet, 50mg/2ml ODT (Tablet 1 Injection)
Dispersible) Fluphenazine Decanoate
Carbidopa/Levodopa/Entacapone Fluphenazine Carbidopa/Levodopa/ 1 1 Decanoate (Injection)
Entacapone (Tablet) Fluphenazine HCl
Duopa Fluphenazine HCl Duopa (Suspension) 4 PA (10mg Tablet, 1mg Lodosyn Lodosyn (Tablet) 4 Tablet, 2.5mg Tablet,
Rytary Rytary (Capsule 5mg Tablet, 2.5mg/ 1 3 Extended-Release) 5ml Elixir, 2.5mg/ml
Sinemet Sinemet (Tablet) 3 Injection, 5mg/ml Sinemet CR CR (Tablet Concentrate) 3 Haldol Extended-Release) Haldol (Injection) 3
Haldol Decanoate 100 Stalevo 100 Haldol Decanoate 100 Stalevo 100 (Tablet) 4 PA 3 Stalevo 125 (Injection) Stalevo 125 (Tablet) 3 PA Haldol Decanoate 50
Stalevo 150 Haldol Decanoate 50 Stalevo 150 (Tablet) 4 PA 3 (Injection) Stalevo 200 200 (Tablet) 4 PA Stalevo 50 50 (Tablet) 3 PA
Bold type = Brand name drug Plain type = Generic drug 50 40tRACK 40
Last updated August 1, 2016 51 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Haloperidol (0.5mg Fanapt (10mg Tablet, Tablet, 10mg Tablet, 12mg Tablet, 6mg 4 QL, ST 1mg Tablet, 20mg Tablet, 8mg Tablet)
1 Fanapt Tablet, 2mg Tablet, Fanapt (1mg Tablet, 5mg Tablet, 2mg/ml 2mg Tablet, 4mg 3 QL, ST Concentrate) Tablet)
Haloperidol Decanoate Haloperidol Decanoate Fanapt Titration Pack Titration Pack 1 3 ST (Injection) (Tablet)
Haloperidol Lactate Haloperidol Lactate Geodon 1 Geodon (20mg (Injection) Capsule, 40mg Loxapine Succinate Succinate Capsule, 60mg 4 QL (10mg Capsule, 5mg 1 QL Capsule, 80mg Capsule) Capsule) Loxapine Succinate Succinate Geodon (20mg 3 (25mg Capsule, 50mg 1 Injection) Capsule) Invega (Tablet
Molindone HCl Molindone HCl (Tablet) 1 Extended-Release 24 4 PA, QL
Orap Orap (Tablet) 3 Hour)
Invega Sustenna
Pimozide Invega Sustenna Pimozide (Tablet) 1
Thioridazine HCl (117mg/0.75ml Thioridazine HCl Injection, 156mg/ml 1 PA, HRM (Tablet) Injection, 234mg/ 4 Thiothixene Thiothixene (Capsule) 1 1.5ml Injection, Trifluoperazine HCl HCl 78mg/0.5ml 1 (Tablet) Injection) 2nd Generation/Atypical Invega Sustenna Sustenna
Abilify (Tablet) 4 QL (39mg/0.25ml 3 Abilify Maintena Maintena Injection) 4 Invega Trinza Trinza (Injection) 4 PA Aripiprazole (Injection) Aripiprazole (Tablet) 1 QL Latuda
Aripiprazole ODT Latuda (Tablet) 4 QL Aripiprazole ODT 1 QL Nuplazid (Tablet Dispersible) Nuplazid (Tablet) 4 PA, QL
Aristada Aristada (Injection) 4
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 51 41tRACK 41
52 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Olanzapine (10mg Risperdal Consta Consta 1 Injection) (37.5mg Injection, 4 Olanzapine (10mg 50mg Injection) Tablet Immediate- Risperdal M-Tab M-Tab Release, 15mg Tablet (0.5mg Tablet 3 Immediate-Release, Dispersible, 1mg 2.5mg Tablet Tablet Dispersible) Immediate-Release, 1 QL Risperdal M-Tab M-Tab (2mg 20mg Tablet Tablet Dispersible,
Immediate-Release, 3mg Tablet 4 5mg Tablet Immediate- Dispersible, 4mg Release, 7.5mg Tablet Tablet Dispersible) Immediate-Release) Risperidone (0.25mg Olanzapine ODT ODT 1 QL Tablet Immediate- (Tablet Dispersible) Release, 0.5mg Tablet Paliperidone ER ER Immediate-Release, (Tablet Extended- 1 QL 1mg Tablet Immediate-
Release 24 Hour) Release, 2mg Tablet 1 Quetiapine Fumarate Fumarate Immediate-Release, (Tablet Immediate- 1 QL 3mg Tablet Immediate- Release) Release, 4mg Tablet Rexulti (Tablet) 4 QL Immediate-Release,
Risperdal 1mg/ml Oral Solution)
Risperdal (0.25mg Risperidone ODT
Tablet, 0.5mg Tablet, Risperidone ODT 3 1 1mg Tablet, 1mg/ml (Tablet Dispersible) Saphris (Tablet Oral Solution) 3 QL Risperdal (2mg Sublingual) Seroquel Tablet, 3mg Tablet, 4 Seroquel (100mg Tablet, 200mg Tablet, 4mg Tablet) 3 QL Risperdal Consta Consta 25mg Tablet, 50mg
(12.5mg Injection, 3 Tablet) Seroquel (300mg 25mg Injection) 4 QL Tablet, 400mg Tablet)
Bold type = Brand name drug Plain type = Generic drug 52 42tRACK 42
Last updated August 1, 2016 53 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Seroquel XR XR (Tablet Clozapine ODT ODT Extended-Release 24 2 QL (100mg Tablet 1 QL Hour) Dispersible, 25mg Vraylar (1.5mg Tablet Dispersible) Capsule, 3mg Clozapine ODT ODT Capsule, 4.5mg 4 QL, ST (12.5mg Tablet Capsule, 6mg Dispersible, 150mg 1 QL Capsule) Tablet Dispersible, Vraylar (Capsule 200mg Tablet 3 ST Therapy Pack) Dispersible)
Clozaril Ziprasidone HCl HCl Clozaril (100mg 1 QL 4 (Capsule) Tablet)
Clozaril Zyprexa Zyprexa (10mg Clozaril (25mg Tablet) 3
3 Fazaclo Injection) Fazaclo (100mg Zyprexa (10mg Tablet Dispersible, Tablet, 2.5mg Tablet, 150mg Tablet 4 QL 3 QL 5mg Tablet, 7.5mg Dispersible, 200mg Tablet) Tablet Dispersible)
Fazaclo Zyprexa (15mg Fazaclo (12.5mg 4 QL Tablet, 20mg Tablet) Tablet Dispersible, 3 QL Zyprexa Relprevv Relprevv 25mg Tablet 4 (Injection) Dispersible)
Versacloz Zyprexa Zydis Versacloz Zyprexa Zydis (10mg 4 Tablet Dispersible, (Suspension) 3 QL 5mg Tablet Antivirals Dispersible) Anti-cytomegalovirus (CMV) Agents
Zyprexa Zydis Cidofovir Zyprexa Zydis (15mg Cidofovir (Injection) 1
Tablet Dispersible, Cytovene 4 QL Cytovene (Injection) 3 B/D, PA
20mg Tablet Ganciclovir Dispersible) Ganciclovir (Injection) 1 B/D, PA Valcyte (450mg Treatment-Resistant 4 QL
Clozapine Tablet) Clozapine (Tablet 1 Valcyte (50mg/ml Immediate-Release) 4 Oral Solution)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 53 43tRACK 43
54 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Valganciclovir Pegasys Valganciclovir (Tablet) 1 Pegasys (Injection) 4 PA
Pegasys ProClick Zirgan Zirgan (Gel) 3 Pegasys ProClick 4 PA Anti-hepatitis B (HBV) Agents (Injection)
PegIntron Adefovir Dipivoxil Dipivoxil PegIntron (Injection) 4 PA
1 PegIntron REDIPEN (Tablet) PegIntron REDIPEN
Baraclude 4 PA Baraclude (0.05mg/ (Injection) ml Oral Solution, Rebetol (Oral 4 3 0.5mg Tablet, 1mg Solution) Tablet) Ribasphere (200mg
Entecavir Entecavir (Tablet) 1 Capsule, 200mg 1 Epivir HBV HBV (100mg Tablet, 400mg Tablet, 3 Tablet) 600mg Tablet)
Ribasphere Ribapak Epivir HBV HBV (5mg/ml Ribasphere Ribapak 2 1 Oral Solution) (Tablet)
Ribavirin Hepsera Ribavirin (200mg Hepsera (Tablet) 4
Lamivudine Capsule, 200mg 1 Lamivudine (100mg 1 Tablet) Tablet) Sovaldi
Tyzeka Sovaldi (Tablet) 4 PA, QL Tyzeka (Tablet) 4 Sylatron (Injection) 4 PA Anti-hepatitis C (HCV) Agents
Technivie
Copegus Copegus (Tablet) 4 Technivie (Tablet) 4 PA, QL
Viekira Pak
Daklinza Viekira Pak (Tablet Daklinza (Tablet) 4 PA, QL 4 PA, QL Therapy Pack) Harvoni
Harvoni (Tablet) 4 PA, QL Zepatier Zepatier (Tablet) 4 PA, QL Intron A A (Injection) 4 PA Antiherpetic Agents Intron A w/Diluent
Intron A w/Diluent Acyclovir 4 PA Acyclovir (200mg (Injection) Capsule, 200mg/5ml Moderiba (200mg 1 1 Suspension, 400mg Tablet) Tablet, 800mg Tablet)
Moderiba 1200 Dose Pack Moderiba 1200 Dose Acyclovir (5% 1 1 QL Pack (Tablet) Ointment)
Moderiba 800 Dose Pack Moderiba 800 Dose Acyclovir Sodium Sodium 1 1 B/D, PA Pack (Tablet) (Injection)
Bold type = Brand name drug Plain type = Generic drug 54 44tRACK 44
Last updated August 1, 2016 55 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Tivicay Denavir (Cream) 4 QL Tivicay (25mg Tablet, 4 QL Famciclovir (Tablet) 1 QL 50mg Tablet)
Triumeq Famvir (125mg Triumeq (Tablet) 4 QL 3 QL Tybost Tablet, 250mg Tablet) Tybost (Tablet) 3 QL Famvir (500mg Vitekta (Tablet) 4 QL 4 QL Tablet) Anti-HIV Agents, Non-nucleoside Reverse Trifluridine Transcriptase Inhibitors (NNRTI) 1 (Ophthalmic Solution) Atripla (Tablet) 4 QL
Valacyclovir HCl Valacyclovir HCl Complera 1 QL Complera (Tablet) 4 QL
(Tablet) Edurant
Valtrex Edurant (Tablet) 4 QL Valtrex (Tablet) 3 QL Intelence
Viroptic Intelence (Tablet) 4 QL Viroptic (Ophthalmic 3 Nevirapine Solution) Nevirapine (200mg
Xerese Tablet Immediate- 1 QL Xerese (Cream) 4 PA, QL Release) Zovirax
Zovirax (200mg Nevirapine Nevirapine (50mg/ Capsule, 200mg/5ml 3 1 QL 5ml Suspension)
Suspension) Nevirapine ER
Zovirax Nevirapine ER (Tablet Zovirax (5% Cream, 4 QL Extended-Release 24 1 QL 5% Ointment) Hour)
Anti-HIV Agents, Integrase Inhibitors Odefsey Odefsey (Tablet) 4 QL (INSTI) Rescriptor
Evotaz Rescriptor (Tablet) 3 QL Evotaz (Tablet) 4 QL Sustiva
Genvoya Sustiva (200mg Genvoya (Tablet) 4 QL Capsule, 600mg 4 QL Isentress Isentress (100mg Tablet)
Packet, 100mg Tablet Sustiva 4 QL Sustiva (50mg Chewable, 400mg 3 QL Capsule)
Tablet) Viramune
Isentress Viramune (200mg Isentress (25mg 4 QL 2 QL Tablet)
Tablet Chewable) Viramune
Prezcobix Viramune (50mg/5ml 3 QL Prezcobix (Tablet) 4 QL Suspension) Stribild (Tablet) 4 QL Tivicay (10mg Tablet) 3 QL
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 55 45tRACK 45
56 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Viramune XR XR (100mg Retrovir IV Infusion IV Infusion 3 Tablet Extended- 3 QL (Injection) Release 24 Hour) Stavudine (15mg Viramune XR XR (400mg Capsule, 20mg Tablet Extended- 4 QL Capsule, 30mg 1 QL Release 24 Hour) Capsule, 40mg Anti-HIV Agents, Nucleoside and Capsule, 1mg/ml Oral Nucleotide Reverse Transcriptase Solution) Inhibitors (NRTI) Trizivir (Tablet) 4 QL
Abacavir Abacavir (Tablet) 1 QL Truvada (Tablet) 4 QL
Abacavir Sulfate/Lamivudine/Zidovudine Abacavir Sulfate/ Videx EC EC (Capsule 3 QL Lamivudine/ 1 QL Delayed-Release) Zidovudine (Tablet) Videx Pediatric Pediatric (Oral Combivir 3 QL Combivir (Tablet) 4 QL Solution)
Viread Descovy (Tablet) 4 QL Viread (150mg Tablet, Didanosine (Capsule 200mg Tablet, 250mg 1 QL 4 QL Delayed-Release) Tablet, 300mg Tablet, Emtriva (10mg/ml 40mg/gm Powder) Zerit Oral Solution, 200mg 3 QL Zerit (15mg Capsule, Capsule) 20mg Capsule, 30mg Epivir (10mg/ml Oral Capsule, 40mg 3 QL Solution, 150mg 3 QL Capsule, 1mg/ml Oral Tablet, 300mg Tablet) Solution) Ziagen
Epzicom Ziagen (20mg/ml Oral Epzicom (Tablet) 4 QL Solution, 300mg Lamivudine 3 QL Lamivudine (10mg/ml Tablet)
Oral Solution, 150mg 1 QL Zidovudine Zidovudine (100mg Tablet, 300mg Tablet)
Lamivudine/Zidovudine Capsule, 300mg Lamivudine/ 1 QL 1 QL Tablet, 50mg/5ml Zidovudine (Tablet) Syrup) Retrovir Retrovir (100mg Anti-HIV Agents, Other
Capsule, 50mg/5ml 3 QL Fuzeon Fuzeon (Injection) 4 QL Syrup) Selzentry (Tablet) 4 QL
Bold type = Brand name drug Plain type = Generic drug 56 46tRACK 46
Last updated August 1, 2016 57 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits Anti-HIV Agents, Protease Inhibitors Anti-influenza Agents
Aptivus Flumadine Aptivus (100mg/ml Flumadine (Tablet) 3 Oral Solution, 250mg 4 QL Relenza Diskhaler Diskhaler 2 QL Capsule) (Aerosol Powder)
Crixivan Crixivan (Capsule) 2 QL Rimantadine HCl HCl
Invirase 1 Invirase (200mg (Tablet) Capsule, 500mg 4 QL Tamiflu (30mg Tablet) Capsule, 45mg Kaletra (100mg-25mg Capsule, 75mg 3 QL Tablet, Capsule, 6mg/ml 3 QL 400mg-100mg/5ml Suspension) Oral Solution) Antivirals
Kaletra Kaletra (200mg-50mg Virazole (Inhalation 4 QL 4 Tablet) Solution) Lexiva (50mg/ml 3 QL Anxiolytics Suspension) Anxiolytics, Other
Lexiva
Buspirone HCl Lexiva (700mg Tablet) 4 QL Buspirone HCl (Tablet) 1
Norvir Norvir (100mg Hydroxyzine HCl HCl Capsule, 100mg (10mg/5ml Syrup, 3 QL 1 PA, HRM Tablet, 80mg/ml Oral 25mg/ml Injection, Solution) 50mg/ml Injection)
Prezista Prezista (100mg/ml Benzodiazepines
Suspension, 150mg Alprazolam 4 QL Alprazolam (Tablet Tablet, 600mg Tablet, 1 QL Immediate-Release)
800mg Tablet) Alprazolam ER
Prezista Alprazolam ER (Tablet Prezista (75mg 3 QL Extended-Release 24 1 PA, QL Tablet) Hour) Reyataz
Reyataz (150mg Alprazolam Intensol Alprazolam Intensol Capsule, 200mg 1 QL (1mg/ml Concentrate)
Capsule, 300mg 4 QL Alprazolam ODT Alprazolam ODT Capsule, 50mg 1 QL (Tablet Dispersible) Packet) Viracept (Tablet) 4 QL
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 57 47tRACK 47
58 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Alprazolam XR XR (0.5mg Xanax XR XR (0.5mg Tablet Extended- 1 PA, QL Tablet Extended- Release 24 Hour) Release 24 Hour, Ativan (Tablet) 4 QL 1mg Tablet Extended- 3 PA, QL Chlordiazepoxide HCl HCl Release 24 Hour, 1 (Capsule) 3mg Tablet Extended-
Clonazepam Release 24 Hour)
Clonazepam (Tablet Xanax XR 1 QL Immediate-Release) Xanax XR (2mg Tablet
Clonazepam ODT Extended-Release 24 4 PA, QL Clonazepam ODT 1 QL Hour) (Tablet Dispersible)
Clorazepate Dipotassium Bipolar Agents Clorazepate 1 QL Mood Stabilizers Dipotassium (Tablet) Depakote
Diazepam Depakote (Tablet Diazepam (10mg 3 Delayed-Release) Tablet, 2mg Tablet, 1 QL Depakote ER ER (Tablet 5mg Tablet) Diazepam Extended-Release 24 3 Diazepam (1mg/ml 1 Hour) Oral Solution) Depakote Sprinkles
Diazepam Intensol Depakote Sprinkles Diazepam Intensol 1 QL (Capsule Sprinkle 3 (5mg/ml Concentrate)
Klonopin Delayed-Release)
Klonopin (Tablet) 3 QL Divalproex Sodium Divalproex Sodium Lorazepam Lorazepam (Tablet) 1 QL (Capsule Sprinkle 1 Lorazepam Intensol Intensol Delayed-Release) 1 QL (2mg/ml Concentrate) Divalproex Sodium DR Sodium DR
Oxazepam Oxazepam (Capsule) 1 (Tablet Delayed- 1 Tranxene T T (Tablet) 3 QL Release)
Divalproex Sodium ER Valium Divalproex Sodium ER Valium (Tablet) 3 QL
Xanax (Tablet Extended- 1 Xanax (Tablet) 3 QL Release 24 Hour) Equetro (Capsule
Extended-Release 12 3 Hour) Lithium (Oral 1 Solution)
Bold type = Brand name drug Plain type = Generic drug 58 48tRACK 48
Last updated August 1, 2016 59 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Lithium Carbonate Lithium Carbonate Duetact (Tablet) 3 QL (150mg Capsule Farxiga (Tablet) 3 QL, ST
Immediate-Release, Fortamet Fortamet (Tablet 300mg Capsule Extended-Release 24 4 PA, QL Immediate-Release, 1 Hour) 600mg Capsule Glimepiride Immediate-Release, Glimepiride (Tablet) 1 QL Glipizide (Tablet 300mg Tablet 1 QL Immediate-Release) Immediate-Release)
Glipizide ER Lithium Carbonate ER Carbonate ER Glipizide ER (Tablet
(Tablet Extended- 1 Extended-Release 24 1 QL Release) Hour)
Glipizide/Metformin HCl Lithobid (Tablet Glipizide/Metformin 3 1 QL Extended-Release) HCl (Tablet) Blood Glucose Regulators Glucophage (Tablet) 3 QL Antidiabetic Agents Glucophage XR XR Acarbose (Tablet) 1 QL (Tablet Extended- 3 QL Actoplus Met Met (Tablet) 3 QL Release 24 Hour)
Glucotrol Actoplus Met XR Met XR Glucotrol (Tablet) 3 QL
Glucotrol XL (Tablet Extended- 3 QL Glucotrol XL (Tablet Release 24 Hour) Extended-Release 24 3 QL Actos (Tablet) 3 QL Hour) Glumetza
Alogliptin Glumetza (Tablet Alogliptin (Tablet) 3 QL, ST Extended-Release 24 4 PA, QL Alogliptin/Metformin HCl 3 QL, ST Hour)
HCl (Tablet) Glyset
Alogliptin/Pioglitazone Glyset (Tablet) 3 QL
Alogliptin/ Glyxambi 3 QL, ST Pioglitazone (Tablet) Glyxambi (Tablet) 3 QL, ST
Invokamet Amaryl (Tablet) 3 QL Invokamet (Tablet) 2 QL
Invokana Avandia (Tablet) 3 PA, QL Invokana (Tablet) 2 QL
Janumet
Bydureon Janumet (Tablet Bydureon (Injection) 2 QL 2 QL
Byetta Immediate-Release) Byetta (Injection) 3 QL Cycloset (Tablet) 3 PA, QL
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 59 49tRACK 49
60 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Janumet XR XR (Tablet Pioglitazone HCl HCl 1 QL Extended-Release 24 2 QL (Tablet) Hour) Pioglitazone HCl/Glimepiride HCl/
Januvia 1 QL Januvia (Tablet) 2 QL Glimepiride (Tablet)
Pioglitazone HCl/Metformin HCl Jardiance Pioglitazone HCl/ Jardiance (Tablet) 2 QL 1 QL Jentadueto (Tablet) 3 QL Metformin HCl (Tablet) Prandin
Jentadueto XR Prandin (0.5mg Jentadueto XR 3 QL Tablet, 1mg Tablet) (Tablet Extended- 3 QL Prandin Release 24 Hour) Prandin (2mg Tablet) 4 QL
Precose Kazano (Tablet) 3 QL, ST Precose (Tablet) 3 QL
Repaglinide Kombiglyze XR XR Repaglinide (Tablet) 1 QL (Tablet Extended- 2 QL Repaglinide/Metformin HCl 1 QL Release 24 Hour) HCl (Tablet)
Metformin HCl Metformin HCl (Tablet Riomet (Oral Solution) 1 QL 3 QL Immediate-Release) Starlix (Tablet) 3 QL
Metformin HCl ER Metformin HCl ER SymlinPen 120 120 4 PA (1000mg Tablet (Injection)
Extended-Release 24 1 PA, QL SymlinPen 60 SymlinPen 60 Hour) (Generic 4 PA (Injection) Fortamet) Synjardy
Metformin HCl ER Synjardy (Tablet) Metformin HCl ER 2 QL
Tanzeum (500mg Tablet Tanzeum (Injection) 3 QL, ST Extended-Release 24 Tolazamide (Tablet) 1 QL Hour, 750mg Tablet 1 QL Tolbutamide (Tablet) 1 QL
Extended-Release 24 Tradjenta Tradjenta (Tablet) Hour) (Generic 3 QL
Trulicity Glucophage XR) Trulicity (Injection) 2 QL
Victoza Miglitol (Tablet) 1 QL Victoza (Injection) 2 QL
Xigduo XR Nateglinide (Tablet) 1 QL Xigduo XR (Tablet
Nesina Extended-Release 24 Nesina (Tablet) 3 QL, ST 3 QL, ST Hour) Onglyza (Tablet) 2 QL Glycemic Agents Oseni (Tablet) 3 QL, ST
Bold type = Brand name drug Plain type = Generic drug 60 50tRACK 50
Last updated August 1, 2016 61 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
GlucaGen HypoKit HypoKit Humulin N Vial N Vial 3 2 (Injection) (Injection) Glucagon Emergency Kit Emergency Humulin R U-500 KwikPen R U-500 2 2 Kit (Injection) KwikPen (Injection) Proglycem Humulin R U-500 Vial R U-500 Vial 4 (Suspension) (Concentrated) 2 Insulins (Injection)
Humulin R Vial Afrezza Humulin R Vial Afrezza (Powder) 3 PA 2 Apidra SoloStar SoloStar (Injection) 3 PA Lantus SoloStar SoloStar (Injection) 2 Apidra Vial (Injection) Apidra Vial (Injection) 3 PA Lantus Vial Humalog Cartridge Lantus Vial (Injection) 2 Humalog Cartridge 2 Levemir FlexTouch FlexTouch (Injection) 2 Humalog KwikPen KwikPen (Injection) 2 Levemir Vial Vial (Injection) 2 Humalog Mix 50/50 KwikPen Mix 50/50 (Injection) 2 Novolin 70/30 Vial 70/30 Vial KwikPen (Injection) 3 PA Humalog Mix 50/50 Vial Mix 50/50 (Injection) 2 Novolin N Vial N Vial Vial (Injection) 3 PA Humalog Mix 75/25 KwikPen Mix 75/25 (Injection) 2 Novolin R Vial R Vial KwikPen (Injection) 3 PA Humalog Mix 75/25 Vial Mix 75/25 (Injection) 2 NovoLog FlexPen FlexPen Vial (Injection) 3 PA Humalog Vial Vial (Injection) 2 NovoLog Mix 70/30 Prefilled FlexPen (Injection) NovoLog Mix 70/30 Humulin 70/30 KwikPen 70/30 Prefilled FlexPen 3 PA 2 KwikPen (Injection) (Injection) NovoLog Mix 70/30 Vial Humulin 70/30 Vial 70/30 Vial NovoLog Mix 70/30 2 3 PA (Injection) Vial (Injection) NovoLog PenFill Humulin N KwikPen N KwikPen NovoLog PenFill 2 3 PA (Injection) (Injection) NovoLog Vial Vial 3 PA (Injection)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 61 51tRACK 51
62 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Toujeo SoloStar SoloStar Heparin Sodium Sodium 2 1 B/D, PA (Injection) (Injection) Tresiba FlexTouch FlexTouch Heparin Sodium/D5W Sodium/D5W 3 ST 1 B/D, PA (Injection) (Injection)
Jantoven Blood Products/Modifiers/Volume Expanders Jantoven (Tablet) 1 Anticoagulants Lovenox (100mg/ml
Arixtra Arixtra (Injection) 4 Injection, 120mg/
Coumadin Coumadin (Tablet) 2 0.8ml Injection,
Eliquis 150mg/ml Injection, Eliquis (Tablet) 2 PA, QL 4 QL 60mg/0.6ml Enoxaparin Sodium Enoxaparin Sodium Injection, 80mg/ (100mg/ml Injection, 0.8ml Injection, 120mg/0.8ml Injection, 300mg/3ml Injection) 150mg/ml Injection, Lovenox (30mg/0.3ml 30mg/0.3ml Injection, 1 QL Injection, 40mg/ 3 QL 40mg/0.4ml Injection, 0.4ml Injection)
60mg/0.6ml Injection, Pradaxa Pradaxa (Capsule) 80mg/0.8ml Injection, 3 PA, QL
Savaysa 300mg/3ml Injection) Savaysa (Tablet) 3 PA, QL
Warfarin Sodium Fondaparinux Sodium Sodium Warfarin Sodium 1 1 (Injection) (Tablet)
Xarelto Fragmin (10000unit/ Xarelto (Tablet) 2 PA, QL ml Injection, Xarelto Starter Pack Starter Pack 2 PA, QL 12500unit/0.5ml (Tablet Therapy Pack) Injection, 15000unit/ Blood Formation Modifiers
0.6ml Injection, Agrylin Agrylin (Capsule) 3 18000unit/0.72ml 4 Anagrelide HCl HCl Injection, 5000unit/ 1 0.2ml Injection, (Capsule) 7500unit/0.3ml Injection, 95000unit/ 3.8ml Injection) Fragmin (2500unit/ 3 0.2ml Injection)
Bold type = Brand name drug Plain type = Generic drug 62 52tRACK 52
Last updated August 1, 2016 63 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Aranesp Albumin Free Aranesp Albumin Mozobil (Injection) 4 PA Free (100mcg/0.5ml Neulasta (Injection) 4 PA
Injection, 100mcg/ml Neupogen Neupogen (Injection) 4 PA Injection, 150mcg/ Procrit 0.3ml Injection, Procrit (10000unit/ml 200mcg/0.4ml Injection, 2000unit/ Injection, 200mcg/ml ml Injection, 4 PA 3 PA Injection, 300mcg/ 3000unit/ml 0.6ml Injection, Injection, 4000unit/ 300mcg/ml Injection, ml Injection) 500mcg/ml Injection, Procrit (20000unit/ml 60mcg/0.3ml Injection, 40000unit/ 4 PA Injection, 60mcg/ml ml Injection) Injection) Promacta (Tablet) 4 PA, QL
Aranesp Albumin Free Zarxio Aranesp Albumin Zarxio (Injection) 4 Free (10mcg/0.4ml Blood Products/Modifiers/Volume Injection, 25mcg/ Expanders
0.42ml Injection, Argatroban 3 PA Argatroban (125mg/ 25mcg/ml Injection, 1 B/D, PA 125ml-0.9% Injection) 40mcg/0.4ml Argatroban (250mg/ Injection, 40mcg/ml 1 B/D, PA Injection) 2.5ml Injection) Epogen (10000unit/ Coagulants Cyklokapron ml Injection, 3 2000unit/ml (Injection)
Lysteda Injection, 3000unit/ 3 PA Lysteda (Tablet) 4 ml Injection, Tranexamic Acid Acid 4000unit/ml (1000mg/10ml 1 Injection) Injection, 650mg Epogen (20000unit/ 4 PA Tablet) ml Injection) Platelet Modifying Agents
Granix Granix (Injection) 4 PA Aggrenox (Capsule Leukine (Injection) 4 PA Extended-Release 12 3 PA, QL Mircera (Injection) 3 PA Hour)
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64 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Aspirin/Dipyridamole Methyldopate HCl HCl 1 (Capsule Extended- 3 QL (Injection)
Midodrine HCl Release 12 Hour) Midodrine HCl (Tablet) 1
Brilinta Brilinta (Tablet) 2 QL Alpha-adrenergic Blocking Agents
Cilostazol Cardura Cilostazol (Tablet) 1 Cardura (Tablet) 3
Clopidogrel Dibenzyline Clopidogrel (Tablet) 1 QL Dibenzyline (Capsule) 4
Durlaza Durlaza (Capsule Doxazosin Mesylate Mesylate 1 Extended-Release 24 3 (Tablet)
Minipress Hour) Minipress (Capsule) 3
Effient Effient (Tablet) 2 QL Phenoxybenzamine HCl Plavix 1 Plavix (Tablet) 3 QL HCl (Capsule)
Zontivity Prazosin HCl Zontivity (Tablet) 3 PA, QL Prazosin HCl (Capsule) 1 Cardiovascular Agents Angiotensin II Receptor Antagonists Alpha-adrenergic Agonists Atacand (Tablet) 3 QL
Catapres Catapres (Tablet) 3 Avapro (Tablet) 3 QL
Catapres-TTS-1 Catapres-TTS-1 Benicar 3 Benicar (Tablet) 2 QL (Patch Weekly) Candesartan Cilexetil Candesartan Cilexetil Catapres-TTS-2 1 QL 3 (Tablet)
(Patch Weekly) Cozaar Cozaar (Tablet) 3 QL Catapres-TTS-3
Catapres-TTS-3 Diovan 3 (Patch Weekly) Diovan (Tablet) 3 QL
Edarbi Clonidine HCl HCl (0.1mg Edarbi (Tablet) 3 QL Eprosartan Mesylate Mesylate Tablet Immediate- 1 QL Release, 0.2mg Tablet (Tablet) Immediate-Release, Irbesartan (Tablet) 1 QL 0.3mg Tablet Losartan Potassium Potassium 1 1 QL Immediate-Release, (Tablet)
0.1mg/24hr Patch Micardis Micardis (Tablet) 3 QL Weekly, 0.2mg/24hr Telmisartan Patch Weekly, 0.3mg/ Telmisartan (Tablet) 1 QL 24hr Patch Weekly) Valsartan (Tablet) 1 QL Methyldopa (Tablet) 1 PA, HRM
Bold type = Brand name drug Plain type = Generic drug 64 54tRACK 54
Last updated August 1, 2016 65 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Angiotensin-converting Enzyme (ACE) Vasotec (20mg 4 Inhibitors Tablet) Accupril (Tablet) 3 QL Zestril (Tablet) 3 QL Altace (Capsule) 3 QL Antiarrhythmics
Amiodarone HCl Benazepril HCl HCl (Tablet) 1 QL Amiodarone HCl
Captopril (200mg Tablet, 400mg Captopril (Tablet) 1 QL 1
Enalapril Maleate Tablet, 50mg/ml Enalapril Maleate 1 QL Injection)
(Tablet) Betapace
Epaned Betapace (120mg Epaned (Oral 4 3 Tablet, 160mg Tablet)
Solution) Betapace
Fosinopril Sodium Betapace (80mg Fosinopril Sodium 3 1 QL Tablet)
(Tablet) Dofetilide
Lisinopril Dofetilide (Capsule) 1
Lisinopril (Tablet) 1 QL Flecainide Acetate
Lotensin Flecainide Acetate 1 Lotensin (Tablet) 3 QL (Tablet)
Mavik Mavik (1mg Tablet, Mexiletine HCl HCl 3 QL 1 2mg Tablet) (Capsule)
Moexipril HCl Moexipril HCl (15mg Multaq 1 Multaq (Tablet) 2 QL
Tablet) Nexterone
Moexipril HCl Nexterone (Injection) 3
Moexipril HCl (7.5mg Pacerone 1 QL Pacerone (100mg Tablet) 3
Perindopril Erbumine Tablet, 400mg Tablet)
Perindopril Erbumine Pacerone 1 QL Pacerone (200mg (Tablet) 1
Prinivil Tablet)
Prinivil (Tablet) 3 QL Procainamide HCl
Quinapril HCl Procainamide HCl 1 Quinapril HCl (Tablet) 1 QL (Injection)
Ramipril Ramipril (Capsule) 1 QL Propafenone HCl HCl
Trandolapril 1 Trandolapril (Tablet) 1 QL (Tablet)
Propafenone HCl ER Vasotec (10mg Propafenone HCl ER 4 QL Tablet) (Capsule Extended- 1 Vasotec (2.5mg Release 12 Hour) 3 QL Quinidine Gluconate Tablet, 5mg Tablet) Quinidine Gluconate 3 (Injection)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 65 55tRACK 55
66 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Quinidine Gluconate CR Gluconate Carvedilol (Tablet 1 CR (Tablet Extended- 1 Immediate-Release)
Coreg Release) Coreg (Tablet) 3
Quinidine Sulfate Quinidine Sulfate Coreg CR CR (Capsule 1 (Tablet) Extended-Release 24 3
Rythmol Rythmol (Tablet) 3 Hour)
Rythmol SR Corgard Rythmol SR (225mg Corgard (Tablet) 3 Capsule Extended- 3 Inderal LA LA (120mg Release 12 Hour) Capsule Extended- Rythmol SR SR (325mg Release 24 Hour, 4 Capsule Extended- 160mg Capsule Release 12 Hour, 4 Extended-Release 24 425mg Capsule Hour) Extended-Release 12 Inderal LA LA (60mg Hour) Capsule Extended-
Sorine Sorine (Tablet) 1 Release 24 Hour,
Sotalol HCl 3 Sotalol HCl (AF) 80mg Capsule 1 (Tablet) Extended-Release 24
Sotalol HCl Sotalol HCl (Tablet) 1 Hour)
Innopran XL
Sotylize Innopran XL (Capsule Sotylize (Oral 3 PA Solution) Extended-Release 24 3
Tikosyn Hour)
Tikosyn (Capsule) 3 Labetalol HCl Labetalol HCl (100mg Beta-adrenergic Blocking Agents Tablet, 200mg Tablet, Acebutolol HCl HCl 1 1 300mg Tablet, 5mg/ml (Capsule) Injection)
Atenolol Lopressor Atenolol (Tablet) 1 Lopressor (Tablet) 3
Betaxolol HCl Betaxolol HCl (10mg Metoprolol Succinate ER Succinate 1 Tablet, 20mg Tablet) ER (Tablet Extended- 1 Bisoprolol Fumarate Fumarate Release 24 Hour) 1 (Tablet) Bystolic (Tablet) 2 QL
Bold type = Brand name drug Plain type = Generic drug 66 56tRACK 56
Last updated August 1, 2016 67 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Metoprolol Tartrate Tartrate Toprol XL XL (Tablet
(100mg Tablet Extended-Release 24 3 Immediate-Release, Hour) 25mg Tablet Zebeta 1 Zebeta (Tablet) 3 Immediate-Release, Calcium Channel Blocking Agents
50mg Tablet Adalat CC Adalat CC (Tablet Immediate-Release, Extended-Release 24 3 QL 1mg/ml Injection) Hour) Nadolol
Nadolol (Tablet) 1 Afeditab CR Afeditab CR (Tablet Pindolol Pindolol (Tablet) 1 Extended-Release 24 1 QL Propranolol HCl HCl (10mg Hour) Tablet Immediate- Amlodipine Besylate Besylate 1 Release, 20mg Tablet (Tablet)
Calan Immediate-Release, Calan (Tablet) 3
40mg Tablet Calan SR Calan SR (Tablet Immediate-Release, 3 Extended-Release) 60mg Tablet 1 Cardene IV Immediate-Release, Cardene IV (Injection) 3
Cardizem 80mg Tablet Cardizem (Tablet) 4 Immediate-Release, Cardizem CD CD
1mg/ml Injection, (Capsule Extended- 4 20mg/5ml Oral Release 24 Hour) Solution, 40mg/5ml Cardizem LA LA (120mg Oral Solution) Tablet Extended- Propranolol HCl ER HCl ER Release 24 Hour, (Capsule Extended- 1 180mg Tablet Release 24 Hour) Extended-Release 24 Sectral 3 Sectral (Capsule) 3 Hour, 240mg Tablet
Tenormin Tenormin (Tablet) 3 Extended-Release 24
Timolol Maleate Hour, 300mg Tablet Timolol Maleate (10mg Extended-Release 24 Tablet, 20mg Tablet, 1 Hour) 5mg Tablet)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 67 57tRACK 57
68 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Cardizem LA LA (360mg Diltiazem HCl ER HCl ER Tablet Extended- (120mg Capsule Release 24 Hour, Extended-Release 12 3 QL 420mg Tablet Hour, 60mg Capsule Extended-Release 24 Extended-Release 12 Hour) Hour, 90mg Capsule Cartia XT XT (Capsule Extended-Release 12
Extended-Release 24 1 Hour, 120mg Capsule Extended-Release 24 Hour) 1 Diltiazem CD CD (Capsule Hour, 300mg Capsule
Extended-Release 24 1 Extended-Release 24 Hour) Hour, 180mg Capsule
Diltiazem HCl Extended-Release 24 Diltiazem HCl (100mg Hour, 360mg Capsule Injection, 50mg/10ml Extended-Release 24 Injection, 120mg Hour, 420mg Capsule Tablet Immediate- Extended-Release 24 Release, 30mg Tablet 1 Hour) Immediate-Release, Dilt-XR (Capsule 60mg Tablet Immediate-Release, Extended-Release 24 1 90mg Tablet Hour) Felodipine ER ER (Tablet Immediate-Release) Extended-Release 24 1 Hour)
Isradipine Isradipine (Capsule) 1 Matzim LA LA (180mg Tablet Extended- Release 24 Hour, 240mg Tablet 1 Extended-Release 24 Hour, 300mg Tablet Extended-Release 24 Hour)
Bold type = Brand name drug Plain type = Generic drug 68 58tRACK 58
Last updated August 1, 2016 69 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Matzim LA LA (360mg Tiazac (Capsule
Tablet Extended- Extended-Release 24 3 Release 24 Hour, Hour)
1 QL Verapamil HCl 420mg Tablet Verapamil HCl (120mg Extended-Release 24 Tablet Immediate- Hour) Release, 40mg Tablet
Nicardipine HCl Nicardipine HCl Immediate-Release, 1 (2.5mg/ml Injection, 80mg Tablet 1 20mg Capsule, 30mg Immediate-Release, Capsule) 2.5mg/ml Injection) Nifedical XL XL (Tablet Verapamil HCl ER HCl ER Extended-Release 24 1 QL (100mg Capsule Hour) Extended-Release 24 Nifedipine ER ER (Tablet Hour, 120mg Capsule Extended-Release 24 1 QL Extended-Release 24 Hour) Hour, 180mg Capsule
Nimodipine Nimodipine (Capsule) 1 Extended-Release 24
Nisoldipine Hour, 200mg Capsule Nisoldipine (Tablet Extended-Release 24 Extended-Release 24 1 Hour, 240mg Capsule 1 Hour) Extended-Release 24 Nisoldipine ER ER (Tablet Hour, 300mg Capsule Extended-Release 24 1 Extended-Release 24 Hour) Hour, 120mg Tablet Norvasc Norvasc (Tablet) 3 Extended-Release, Procardia XL XL (Tablet 180mg Tablet Extended-Release 24 3 QL Extended-Release, Hour) 240mg Tablet Sular (Tablet Extended-Release) Verapamil HCl SR Verapamil HCl SR Extended-Release 24 3 Hour) (Capsule Extended- 1 Taztia XT XT (Capsule Release 24 Hour) Verelan Verelan (Capsule Extended-Release 24 1 Hour) Extended-Release 24 3 Hour)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 69 59tRACK 59
70 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Verelan PM PM (Capsule Bisoprolol Fumarate/Hydrochlorothiazide Fumarate/
Extended-Release 24 3 Hydrochlorothiazide 1 Hour) (10mg-6.25mg Tablet) Cardiovascular Agents, Other Bisoprolol Fumarate/Hydrochlorothiazide Fumarate/ Accuretic Hydrochlorothiazide Accuretic (Tablet) 3 QL 1 QL Aldactazide (2.5mg-6.25mg Tablet, Aldactazide (Tablet) 3
Amiloride/Hydrochlorothiazide 5mg-6.25mg Tablet)
Amiloride/ Caduet Caduet (Tablet) 3 QL Hydrochlorothiazide 1 Candesartan Cilexetil/Hydrochlorothiazide (Tablet) Candesartan Cilexetil/ Amlodipine Besylate/Atorvastatin Calcium Besylate/ Hydrochlorothiazide 1 QL Atorvastatin Calcium 1 QL (Tablet) Captopril/Hydrochlorothiazide (Tablet) Captopril/ Amlodipine Besylate/Benazepril HCl Besylate/ Hydrochlorothiazide 1 QL Benazepril HCl 1 QL (Tablet) Clorpres (Capsule) Clorpres (Tablet) 3
Corlanor Amlodipine Besylate/Valsartan Besylate/ Corlanor (Tablet) 3 PA, QL
1 QL Corzide Valsartan (Tablet) Corzide (40mg-5mg
Amlodipine/Valsartan/Hydrochlorothiazide 3 QL Amlodipine/Valsartan/ Tablet) Hydrochlorothiazide 1 QL Corzide (80mg-5mg 3 (Tablet) Tablet)
Atacand HCT Demser Atacand HCT (Tablet) 3 QL Demser (Capsule) 4
Atenolol/Chlorthalidone Atenolol/ Digitek (0.125mg 1 1 QL, HRM Chlorthalidone (Tablet) Tablet)
Avalide Avalide (Tablet) 3 QL Digitek (0.25mg 1 PA, HRM Azor (Tablet) 2 QL Tablet)
Digoxin Benazepril HCl/Hydrochlorothiazide Digoxin (0.05mg/ml PA, QL, Benazepril HCl/ 1 Hydrochlorothiazide 1 QL Oral Solution) HRM Digoxin (0.25mg/ml (Tablet) 1 Benicar HCT HCT (Tablet) 2 QL Injection)
Digoxin
BiDil Digoxin (125mcg BiDil (Tablet) 2 QL 1 QL, HRM Tablet) Digoxin (250mcg 1 PA, HRM Tablet)
Bold type = Brand name drug Plain type = Generic drug 70 60tRACK 60
Last updated August 1, 2016 71 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Losartan Potassium/Hydrochlorothiazide Diovan HCT HCT (Tablet) 3 QL Losartan Potassium/ DUTOPROL (Tablet Hydrochlorothiazide 1 QL
Extended-Release 24 3 (Tablet) Hour) Lotrel (Capsule) 3 QL
Dyazide Maxzide Dyazide (Capsule) 3 Maxzide (Tablet) 3
Metoprolol/Hydrochlorothiazide Edarbyclor Metoprolol/ Edarbyclor (Tablet) 3 QL Enalapril Maleate/Hydrochlorothiazide Maleate/ Hydrochlorothiazide 1 Hydrochlorothiazide 1 QL (Tablet) (Tablet) Micardis HCT HCT (Tablet) 3 QL
Moexipril/Hydrochlorothiazide Entresto (Tablet) 2 PA, QL Moexipril/ Exforge (Tablet) 3 QL Hydrochlorothiazide 1 QL
Exforge HCT (Tablet)
Exforge HCT (Tablet) 3 QL Nadolol/Bendroflumethiazide
Fosinopril Sodium/Hydrochlorothiazide Nadolol/ Fosinopril Sodium/ Bendroflumethiazide 1 QL Hydrochlorothiazide 1 QL (40mg-5mg Tablet)
(Tablet) Nadolol/Bendroflumethiazide Nadolol/ Hyzaar Hyzaar (Tablet) 3 QL Bendroflumethiazide 1 Irbesartan/Irbesartan/Hydrochlorothiazide (80mg-5mg Tablet) Hydrochlorothiazide 1 QL Northera (Capsule) 4 PA, QL
(Tablet) Pentoxifylline ER
Lanoxin Pentoxifylline ER Lanoxin (0.25mg/ml 3 (Tablet Extended- 1 Injection) Release) Lanoxin Lanoxin (125mcg Propranolol/Propranolol/Hydrochlorothiazide
Tablet, 62.5mcg 3 QL, HRM Hydrochlorothiazide 1 Tablet) (Tablet) Lanoxin Lanoxin (187.5mcg Quinapril/Quinapril/Hydrochlorothiazide Tablet, 250mcg 3 PA, HRM Hydrochlorothiazide 1 QL Tablet) (Tablet) Lisinopril/Hydrochlorothiazide Lisinopril/ Ranexa (Tablet Hydrochlorothiazide 1 QL Extended-Release 12 2 QL (Tablet) Hour) Lopressor HCT HCT 3 (Tablet)
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72 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Spironolactone/Spironolactone/Hydrochlorothiazide Zestoretic
Hydrochlorothiazide 1 (10mg-12.5mg Tablet, 3 QL (Tablet) 20mg-12.5mg Tablet) Tarka (Tablet Zestoretic 3 QL 3 Extended-Release) (20mg-25mg Tablet) Tekturna (Tablet) 3 QL Ziac (Tablet) 3 QL Tekturna HCT HCT (Tablet) 3 QL Diuretics, Carbonic Anhydrase Inhibitors
Acetazolamide Telmisartan/Telmisartan/Amlodipine Acetazolamide (Tablet 1 QL 1 Amlodipine (Tablet) Immediate-Release)
Acetazolamide ER Telmisartan/Hydrochlorothiazide Acetazolamide ER Telmisartan/ Hydrochlorothiazide 1 QL (Capsule Extended- 1 (Tablet) Release 12 Hour)
Acetazolamide Sodium Tenoretic 100 Acetazolamide Sodium Tenoretic 100 (Tablet) 3 1
Tenoretic 50 Tenoretic 50 (Tablet) 3 (Injection) Diamox
Trandolapril/Verapamil HCl Diamox (Capsule Trandolapril/Verapamil Extended-Release 12 3 HCl (Tablet Extended- 1 QL Hour) Release) Keveyis
Triamterene/Hydrochlorothiazide Keveyis (Tablet) Triamterene/ 4 PA, QL Methazolamide Hydrochlorothiazide 1 (37.5mg-25mg (Tablet)
Capsule, 50mg-25mg 1 Diuretics, Loop Capsule, 37.5mg-25mg Bumetanide (0.25mg/ Tablet, 75mg-50mg ml Injection, 0.5mg 1 Tablet) Tablet, 1mg Tablet, Tribenzor (Tablet) 2 QL 2mg Tablet)
Demadex Twynsta (Tablet) 3 QL Demadex (Tablet) 3
Edecrin Valsartan/Valsartan/Hydrochlorothiazide Edecrin (Tablet) 4 Hydrochlorothiazide 1 QL Ethacrynate Sodium Sodium 1 (Tablet) (Injection)
Vaseretic Furosemide Vaseretic (Tablet) 3 Furosemide (10mg/ml 1 B/D, PA Vecamyl (Tablet) 4 PA Injection)
Bold type = Brand name drug Plain type = Generic drug 72 62tRACK 62
Last updated August 1, 2016 73 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Furosemide (10mg/ml Sodium Diuril Diuril 3 B/D, PA Oral Solution, 8mg/ml (Injection)
Oral Solution, 20mg 1 Dyslipidemics, Fibric Acid Derivatives
Antara Tablet, 40mg Tablet, Antara (Capsule) 2
80mg Tablet) Fenofibrate Fenofibrate (120mg Lasix 4 Lasix (Tablet) 3 Tablet)
Torsemide Torsemide (Tablet) 1 Fenofibrate (130mg Diuretics, Potassium-sparing Capsule, 43mg Aldactone Capsule, 145mg Aldactone (Tablet) 3 1
Amiloride HCl Amiloride HCl (Tablet) 1 Tablet, 160mg Tablet,
Dyrenium 48mg Tablet, 54mg Dyrenium (Capsule) 3 Tablet)
Eplerenone Eplerenone (Tablet) 1 Fenofibrate (150mg
Inspra Inspra (Tablet) 3 Capsule, 50mg 1 Spironolactone Capsule) 1 Fenofibrate (Tablet) Fenofibrate (40mg 3 Diuretics, Thiazide Tablet)
Fenofibrate Micronized
Chlorothiazide Chlorothiazide (Tablet) 1 Fenofibrate Micronized
Chlorothiazide Sodium (134mg Capsule, Chlorothiazide Sodium 1 1 B/D, PA 200mg Capsule, 67mg (Injection)
Chlorthalidone Capsule)
Chlorthalidone (Tablet) 1 Fenofibric Acid Fenofibric Acid Diuril 1 Diuril (Suspension) 3 (Tablet)
Hydrochlorothiazide Hydrochlorothiazide Fenofibric Acid DR Acid DR (12.5mg Capsule, 1 (Capsule Delayed- 1 12.5mg Tablet, 25mg Release) Tablet, 50mg Tablet) Fenoglide (120mg Indapamide 4 Indapamide (Tablet) 1 Tablet)
Methyclothiazide Methyclothiazide Fenoglide (40mg 1 3 (Tablet) Tablet)
Metolazone Fibricor Metolazone (Tablet) 1 Fibricor (Tablet) 3
Microzide Gemfibrozil Microzide (Capsule) 3 Gemfibrozil (Tablet) 1
Lipofen Lipofen (Capsule) 3
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 73 63tRACK 63
74 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Lofibra (134mg Pravastatin Sodium Sodium 1 QL Capsule, 200mg (Tablet)
Capsule, 67mg 3 Rosuvastatin Calcium Calcium 1 QL Capsule, 160mg (Tablet) Tablet, 54mg Tablet) Simvastatin (Tablet) 1 QL Lopid Lopid (Tablet) 3 Zocor (Tablet) 3 QL Tricor Tricor (Tablet) 3 Dyslipidemics, Other
Triglide Triglide (Tablet) 3 Cholestyramine Light Light Trilipix 1 Trilipix (Capsule (Packet) 3 Delayed-Release) Colestid (1gm Tablet, 3 Dyslipidemics, HMG CoA Reductase 5gm Granules) Inhibitors Colestipol HCl HCl (1gm Altoprev 1 Altoprev (Tablet Tablet, 5gm Granules) Extended-Release 24 3 QL, ST Juxtapid (Capsule) 4 PA
Hour) Kynamro Kynamro (Injection) Atorvastatin Calcium 4 PA
Atorvastatin Calcium Lovaza 1 QL Lovaza (Capsule) (Tablet) 3 QL Niacin ER
Crestor Niacin ER (Tablet Crestor (Tablet) 2 QL 1
Fluvastatin Extended-Release)
Fluvastatin (Capsule Niacor 1 QL Immediate-Release) Niacor (Tablet) 1 Niaspan Fluvastatin Sodium ER Niaspan (Tablet Fluvastatin Sodium ER 3 (Tablet Extended- 1 QL Extended-Release) Omega-3-Acid Ethyl Esters Release 24 Hour) Omega-3-Acid Ethyl Lescol XL XL (Tablet Esters (Capsule) 1 QL Extended-Release 24 3 QL (Generic Lovaza)
Praluent Hour) Praluent (Injection) 4 PA, QL, LA
Prevalite Lipitor Lipitor (Tablet) 3 QL Prevalite (Powder) 1
Questran Livalo Livalo (Tablet) 3 QL Questran (Packet) 3
Repatha Lovastatin (Tablet Repatha (Injection) 4 PA, QL
1 QL Repatha SureClick Immediate-Release) Repatha SureClick
Pravachol 4 PA, QL Pravachol (Tablet) 3 QL (Injection)
Vascepa Vascepa (Capsule) 3
Bold type = Brand name drug Plain type = Generic drug 74 64tRACK 64
Last updated August 1, 2016 75 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Vytorin Nitroglycerin Vytorin (Tablet) 3 QL Nitroglycerin (Injection) 1 Welchol (3.75gm Nitroglycerin Lingual Lingual 1 Packet, 625mg 2 (Translingual Solution) Tablet) Nitroglycerin Transdermal
Zetia Zetia (Tablet) 2 QL Transdermal (Patch 24 1 Vasodilators, Direct-acting Arterial Hour)
Nitrolingual Pumpspray Hydralazine HCl HCl Nitrolingual (100mg Tablet, 10mg Pumpspray 3 Tablet, 25mg Tablet, 1 (Translingual 50mg Tablet, 20mg/ml Solution) NitroMist (Aerosol Injection) 3 Minoxidil Minoxidil (Tablet) 1 Solution) Nitrostat (Tablet Vasodilators, Direct-acting Arterial/Venous 2
Isordil Titradose Sublingual) Isordil Titradose 4 Rectiv (Tablet) Rectiv (Ointment) 3 Isosorbide Dinitrate Dinitrate Central Nervous System Agents
(Tablet Immediate- 1 Attention Deficit Hyperactivity Disorder Release) Agents, Amphetamines
Adderall Isosorbide Dinitrate ER Dinitrate ER Adderall (Tablet) 3 QL
(Tablet Extended- 1 Adderall XR XR (Capsule Release) Extended-Release 24 3 QL Isosorbide Mononitrate Mononitrate Hour)
(Tablet Immediate- 1 Adzenys XR-ODT XR-ODT Release) (Tablet Extended- 3 QL Isosorbide Mononitrate ER Mononitrate Release Dispersible)
ER (Tablet Extended- 1 Release 24 Hour) Minitran (Patch 24 1 Hour)
Nitro-Bid Nitro-Bid (Ointment) 3 Nitro-Dur (Patch 24 3 Hour)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 75 65tRACK 65
76 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Amphetamine/Amphetamine/Dextroamphetamine Dexedrine (10mg 1 QL Dextroamphetamine Tablet, 5mg Tablet) (10mg Capsule Dexedrine (5mg Extended-Release 24 Capsule Extended- 3 QL Hour, 15mg Capsule Release 24 Hour) Extended-Release 24 Dextroamphetamine Sulfate Hour, 20mg Capsule Sulfate (Tablet 1 QL Extended-Release 24 Immediate-Release)
Hour, 25mg Capsule Dextroamphetamine Sulfate ER Dextroamphetamine Extended-Release 24 Sulfate ER (Capsule Hour, 30mg Capsule 1 QL Extended-Release 24 Extended-Release 24 Hour)
Hour, 5mg Capsule Methamphetamine HCl Methamphetamine HCl Extended-Release 24 1 QL 1 PA Hour, 10mg Tablet (Tablet) ProCentra (Oral Immediate-Release, 3 12.5mg Tablet Solution)
Vyvanse Immediate-Release, Vyvanse (Capsule) 3 15mg Tablet Zenzedi (10mg Tablet, Immediate-Release, 15mg Tablet, 2.5mg 20mg Tablet Tablet, 20mg Tablet, 3 QL Immediate-Release, 30mg Tablet, 5mg 30mg Tablet Tablet) Immediate-Release, Zenzedi (7.5mg Tablet) 4 QL 5mg Tablet Immediate- Attention Deficit Hyperactivity Disorder Release, 7.5mg Tablet Agents, Non-amphetamines Immediate-Release) Aptensio XR
Desoxyn Aptensio XR (Capsule Desoxyn (Tablet) 4 PA Extended-Release 24 3 QL Dexedrine Dexedrine (10mg Hour)
Capsule Extended- Clonidine HCl ER Clonidine HCl ER Release 24 Hour, 4 QL (Tablet Extended- 1 PA 15mg Capsule Release 12 Hour)
Extended-Release 24 Concerta Concerta (Tablet Hour) 3 QL Extended-Release)
Bold type = Brand name drug Plain type = Generic drug 76 66tRACK 66
Last updated August 1, 2016 77 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Methylphenidate HCl Daytrana (Patch) 3 QL Methylphenidate HCl Dexmethylphenidate HCl (10mg Tablet HCl (Tablet Immediate- 1 QL Chewable, 2.5mg Release) Tablet Chewable, 5mg Dexmethylphenidate HCl ER Tablet Chewable), HCl ER (Capsule (10mg Tablet 1 Immediate-Release, Extended-Release 24 1 QL Hour) 20mg Tablet
Focalin Immediate-Release, Focalin (Tablet) 3 QL 5mg Tablet Immediate- Focalin XR XR (Capsule Release) (Generic Extended-Release 24 3 Ritalin), (10mg/5ml Hour) Oral Solution, 5mg/5ml Kapvay (Tablet Oral Solution) Extended-Release 12 3 PA Methylphenidate HCl CD HCl
Hour) CD (Capsule Extended- 1 Metadate CD CD Release) (Capsule Extended- 3 Methylphenidate HCl ER HCl Release) ER (10mg Tablet Metadate ER ER (Tablet Extended-Release, 1 QL Extended-Release) 20mg Tablet Extended- Methylin (Oral Release, 18mg Tablet 3 QL Solution) Extended-Release 24 Hour, 27mg Tablet 1 QL Extended-Release 24 Hour, 36mg Tablet Extended-Release 24 Hour, 54mg Tablet Extended-Release 24 Hour)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 77 67tRACK 67
78 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Methylphenidate HCl ER HCl Duloxetine HCl HCl (20mg ER (20mg Capsule Capsule Delayed- Extended-Release 24 Release, 30mg 1 Hour, 40mg Capsule Capsule Delayed- 1 QL Extended-Release 24 Release, 60mg Hour) Capsule Delayed- QuilliChew ER ER (Tablet Release) Chewable Extended- 3 QL Duloxetine HCl HCl (40mg Release) Capsule Delayed- 3 QL Quillivant XR XR Release)
3 Irenka (Suspension) Irenka (Capsule 3 QL Ritalin (Tablet) 3 QL Delayed-Release)
Lyrica Ritalin LA LA (Capsule Lyrica (100mg
Extended-Release 24 3 Capsule, 150mg Hour) Capsule, 200mg
Strattera Capsule, 225mg Strattera (Capsule) 3 QL, ST Capsule, 25mg 2 QL Central Nervous System, Other Capsule, 300mg
Gralise Gralise (Tablet) 3 PA Capsule, 50mg Gralise Starter Pack Starter Pack 3 PA Capsule, 75mg Horizant (Tablet Capsule, 20mg/ml 3 PA Extended-Release) Oral Solution)
Savella Namzaric (Capsule Savella (Tablet) 2
Savella Titration Pack Extended-Release 24 2 PA, QL Savella Titration Pack 2 Hour) Multiple Sclerosis Agents
Nuedexta Nuedexta (Capsule) 3 PA Ampyra (Tablet
Rilutek Rilutek (Tablet) 4 Extended-Release 12 4 PA, QL
Riluzole Riluzole (Tablet) 1 Hour)
Aubagio Tetrabenazine (Tablet) 1 PA, QL Aubagio (Tablet) 4 PA, QL
Avonex Xenazine (Tablet) 4 PA, QL, LA Avonex (Injection) 4 PA Avonex Pen Pen Fibromyalgia Agents 4 PA
Cymbalta (Injection) Cymbalta (Capsule 3 QL Betaseron Delayed-Release) Betaseron (Injection) 4 PA
Bold type = Brand name drug Plain type = Generic drug 78 68tRACK 68
Last updated August 1, 2016 79 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Pilocarpine HCl Copaxone (Injection) 4 PA Pilocarpine HCl (5mg 1 Extavia (Injection) 4 PA Tablet, 7.5mg Tablet) Salagen Gilenya (Capsule) 4 PA, QL Salagen (Tablet) 3
Triamcinolone in Orabase
Glatopa Triamcinolone in Glatopa (Injection) 1 PA 1 Orabase (Paste) Plegridy (Injection) 4 PA Dermatological Agents Plegridy Starter Pack Starter Pack 4 PA Dermatological Agents
(Injection) 8-MOP
Rebif 8-MOP (Capsule) 3
Rebif (Injection) 4 PA Absorica
Rebif Rebidose Absorica (Capsule) 4 PA Rebif Rebidose 4 PA Acanya (Injection) Acanya (Gel) 3 ST
Acitretin Rebif Rebidose Titration Pack Rebidose Acitretin (Capsule) 1
Aczone Titration Pack 4 PA Aczone (Gel) 3 (Injection) Adapalene (0.1% Rebif Titration Pack Rebif Titration Pack 4 PA Cream, 0.1% Gel, 0.3% 1 (Injection) Gel)
Tecfidera Tecfidera (Capsule Aldara 4 PA, QL Aldara (Cream) 4 Delayed-Release) Ammonium Lactate Lactate Tecfidera Starter Pack Starter 4 PA (12% Cream, 12% 1 Pack Lotion)
Tysabri Tysabri (Injection) 4 PA Atralin (Gel) 3 PA Dental and Oral Agents Avita (0.025% Cream, 1 PA Dental and Oral Agents 0.025% Gel)
Cevimeline HCl Azelex Cevimeline HCl 1 ST Azelex (Cream) 3 BenzaClin (Capsule) BenzaClin (Gel) 3 Chlorhexidine Gluconate Oral Rinse
Chlorhexidine Benzamycin Benzamycin (Gel) 3 Gluconate Oral Rinse 1 Calcipotriene (Solution) Calcipotriene (0.005%
Evoxac Cream, 0.005% Evoxac (Capsule) 3 ST 1 External Solution, Kepivance Kepivance (Injection) 4 0.005% Ointment)
Periogard Periogard (Solution) 1
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 79 69tRACK 69
80 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Calcipotriene/Calcipotriene/Betamethasone Dipropionate Diclofenac Sodium Sodium 1 PA Betamethasone (3% Gel)
1 Differin Dipropionate Differin (0.1% Cream,
(Ointment) 0.1% Gel, 0.3% Gel, 3 Calcitriol (3mcg/gm 0.1% Lotion) 1 Dovonex Ointment) Dovonex (Cream) 4
Carac
Doxepin HCl Carac (Cream) 4 PA Doxepin HCl (Cream) 1
Claravis
Duac Claravis (Capsule) 1 PA Duac (Gel) 3
Cleocin-T
Efudex Cleocin-T (1% Efudex (Cream) 3
External Solution, 1% Elidel 3 Elidel (Cream) 3 ST Gel, 1% Lotion, 1%
Enstilar Swab) Enstilar (Foam) 4 PA
Epiduo Clindacin PAC Clindacin PAC (Kit) 1 Epiduo (Gel) 3 ST
Epiduo Forte Clindagel Clindagel (Gel) 4 Epiduo Forte (Gel) 3 ST
Ery Clindamax Clindamax (Gel) 3 Ery (2% Pad) 1
Erygel Clindamycin Phosphate Clindamycin Erygel (Gel) 3 Phosphate (1% Erythromycin (2%
External Solution, 1% 1 External Solution, 2% 1 Foam, 1% Gel, 1% Gel) Lotion, 1% Swab) Erythromycin/Benzoyl Peroxide Clindamycin/Benzoyl Peroxide 1 Peroxide (Gel) Evoclin Peroxide (Gel) 1 Evoclin (Foam) 4
(Generic BenzaClin) Fabior
Clotrimazole/Betamethasone Dipropionate Fabior (Foam) 3 PA
Clotrimazole/ Finacea
Betamethasone Finacea (15% Foam, 3 Dipropionate 1 15% Gel) Fluorouracil (0.5% (1%-0.05% Cream, 4 1%-0.05% Lotion) Cream)
Fluorouracil
Condylox Condylox (Gel) 3 Fluorouracil (2%
Cortisporin External Solution, 5% Cortisporin 1 External Solution, 5% (0.5%-0.5% Cream, 3 Cream) 1%-0.5% Ointment) Imiquimod Imiquimod (Cream) 1
Bold type = Brand name drug Plain type = Generic drug 80 70tRACK 70
Last updated August 1, 2016 81 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Sulfacetamide Sodium Klaron (Lotion) 3 PA Sulfacetamide Sodium 1 PA Lotrisone Lotrisone (Cream) 3 (10% Suspension)
Taclonex
Methoxsalen Taclonex Methoxsalen (Capsule) 1 (0.064%-0.005% Mirvaso Mirvaso (Gel) 3 PA Ointment, 4 Myorisan (Capsule) 1 PA 0.064%-0.005%
Neo-Synalar Neo-Synalar (Cream) 3 Suspension)
Tacrolimus Neuac Tacrolimus (0.03% Neuac (Gel) 1
Onexton Ointment, 0.1% 1 Onexton (Gel) 3 Ointment) Oxsoralen Ultra
Oxsoralen Ultra Tazorac 4 Tazorac (0.05% (Capsule) Cream, 0.1% Cream, 3 PA Picato Picato (Gel) 2 0.05% Gel, 0.1% Gel)
Podofilox Podofilox (External Tolak 1 Tolak (Cream) 3 Solution) Tretinoin Tretinoin (0.01% Gel, Protopic Protopic (Ointment) 3 0.025% Gel, 0.05%
PRUDOXIN PRUDOXIN (Cream) 1 Gel, 0.025% Cream, 1 PA Regranex (Gel) 4 PA 0.05% Cream, 0.1%
Retin-A Cream) Retin-A (0.01% Gel, Tretinoin Microsphere 0.025% Gel, 0.025% Tretinoin Microsphere 3 PA 1 PA Cream, 0.05% Cream, (Gel) 0.1% Cream) Tretin-X (Cream) 3 PA
Uvadex Retin-A Micro Retin-A Micro (Gel) 4 PA Uvadex (Injection) 3
Retin-A Micro Pump Vectical Retin-A Micro Pump Vectical (Ointment) 4 4 PA (Gel) Veltin (Gel) 3 PA
Santyl Veregen Santyl (Ointment) 3 Veregen (Ointment) 4
Selenium Sulfide Selenium Sulfide Zenatane 1 Zenatane (Capsule) 1 PA
(Lotion) Ziana
Solaraze Ziana (Gel) 4 PA
Solaraze (Gel) 4 PA Zonalon
Soolantra Zonalon (Cream) 3
Soolantra (Cream) 3 Zyclara
Soriatane Zyclara (Cream) 4 PA
Soriatane (Capsule) 4 Zyclara Pump Zyclara Pump Sorilux 4 PA Sorilux (Foam) 4 (Cream)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 81 71tRACK 71
82 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Enzyme Replacement/Modifiers Pancreaze Enzyme Replacement/Modifiers (17500unit-4200unit- Adagen (Injection) 4 LA 10000unit Capsule
Aldurazyme Delayed-Release, Aldurazyme 4 43750unit-10500unit- (Injection) 3 ST 25000unit Capsule Buphenyl (3gm/tsp Delayed-Release, Powder, 500mg 4 70000unit-16800unit- Tablet) 40000unit Capsule Cerdelga (Capsule) 4 PA, QL Delayed-Release)
Cerezyme Cerezyme (Injection) 4 PA Pancreaze Creon (Capsule (61000unit-21000unit 2 4 ST Delayed-Release) -37000unit Capsule
Cystadane Cystadane (Powder) 4 Delayed-Release) Pertzye
Cystagon Pertzye Cystagon (Capsule) 3 LA (30250unit-8000unit- Elaprase 3 ST Elaprase (Injection) 4 28750unit Capsule Elelyso (Injection) 4 PA, LA Delayed-Release)
Pertzye Fabrazyme Fabrazyme (Injection) 4 Pertzye
Kuvan (60500unit-16000unit Kuvan (100mg 4 ST Packet, 500mg -57500unit Capsule 4 Packet, 100mg Tablet Delayed-Release) Procysbi (Capsule Soluble) 4 Lumizyme Lumizyme (Injection) 4 Delayed-Release)
RAVICTI
Naglazyme Naglazyme (Injection) 4 RAVICTI (Liquid) 4 QL
Sodium Phenylbutyrate Orfadin Sodium Phenylbutyrate Orfadin (10mg 1 Capsule, 2mg (Powder)
Strensiq Capsule, 5mg 4 LA Strensiq (Injection) 4 PA, LA Capsule, 4mg/ml Sucraid (Oral 4 LA Suspension) Solution) Viokace (39150unit-10440unit 3 ST -39150unit Tablet)
Bold type = Brand name drug Plain type = Generic drug 82 72tRACK 72
Last updated August 1, 2016 83 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Viokace Viokace Robinul (1mg Tablet) 3 PA (78300unit-20880unit 4 ST Robinul Forte Forte (Tablet) 3 PA -78300unit Tablet) Gastrointestinal Agents, Other VPRIV
VPRIV (Injection) 4 PA Actigall Actigall (Capsule) 4 Zavesca
Zavesca (Capsule) 4 PA, LA Chenodal Chenodal (Tablet) 4 Zenpep
Zenpep (Capsule Cholbam 2 Cholbam (Capsule) 4 PA Delayed-Release) Cromolyn Sodium Sodium Gastrointestinal Agents (100mg/5ml 1 Antispasmodics, Gastrointestinal
Atropine Sulfate Concentrate)
Atropine Sulfate Diphenoxylate/Atropine Diphenoxylate/ (0.05mg/ml Injection, 1 Atropine 0.1mg/ml Injection)
Bentyl (2.5mg-0.025mg 1 Bentyl (10mg Tablet, Capsule, 10mg/ml 3 2.5mg-0.025mg/5ml Injection, 20mg Liquid)
Tablet) Gastrocrom
Cuvposa Gastrocrom Cuvposa (Oral 4 3 (Concentrate)
Solution) Gattex
Dicyclomine HCl Gattex (Injection) 4 PA
Dicyclomine HCl Lansoprazole/Amoxicillin/Clarithromycin (10mg Capsule, 10mg/ Lansoprazole/ Amoxicillin/ 5ml Oral Solution, 1 1 10mg/ml Injection, Clarithromycin 20mg Tablet) (Therapy Pack) Lomotil Glycopyrrolate (1mg Lomotil (Tablet) 3 1 PA Loperamide HCl HCl Tablet, 2mg Tablet) 1 Glycopyrrolate (4mg/ (Capsule) 1 Movantik 20ml Injection) Movantik (Tablet) 3 PA, QL
Omeclamox-Pak Methscopolamine Bromide Omeclamox-Pak 1 3 Bromide (Tablet) (Therapy Pack)
Prevpac Propantheline Bromide Bromide Prevpac (Therapy 1 PA 4 (Tablet) Pack)
Robinul Pylera Robinul (0.4mg/2ml Pylera (Capsule) 4 3 Injection) Relistor (Injection) 4 PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 83 73tRACK 73
84 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Serostim (Injection) 4 PA Alosetron HCl HCl (Tablet) 1 PA
Urso Amitiza Urso (Tablet) 3 Amitiza (Capsule) 2 QL
Ursodiol Ursodiol (250mg Linzess Linzess (Capsule) 2 QL Tablet, 500mg Tablet, 1 Lotronex (Tablet) 4 PA
300mg Capsule) Viberzi Viberzi (Tablet) Zorbtive 4 PA, QL Zorbtive (Injection) 4 PA Laxatives
Histamine2 (H2) Receptor Antagonists CoLyte-Flavor Packs CoLyte-Flavor Packs Cimetidine 3 Cimetidine (Tablet) 1 (Oral Solution)
Cimetidine HCl Cimetidine HCl (Oral Constulose (Oral 1 1 Solution) Solution)
Famotidine
Enulose Famotidine (20mg Enulose (Oral Solution) 1
Tablet, 40mg Tablet, GaviLyte-C GaviLyte-C (Oral 20mg/2ml Injection, 1 1 Solution)
40mg/5ml GaviLyte-G GaviLyte-G (Oral Suspension) 1
Famotidine Premixed Solution) Famotidine Premixed 1 GaviLyte-H (Injection) GaviLyte-H (Kit) 1
GaviLyte-N/Flavor Pack Nizatidine GaviLyte-N/Flavor Nizatidine (150mg 1 Capsule, 300mg Pack (Oral Solution) 1 Generlac (Oral Capsule, 15mg/ml Oral 1 Solution) Solution)
GoLYTELY Pepcid GoLYTELY (Oral Pepcid (Suspension) 3 3 Ranitidine HCl HCl (150mg Solution) Kristalose Capsule, 300mg Kristalose (Packet) 3 Capsule, 150mg Lactulose (Oral 1 1 Tablet, 300mg Tablet, Solution) 150mg/6ml Injection, MoviPrep (Oral 3 15mg/ml Syrup) Solution)
Zantac Zantac (150mg NuLYTELY/Flavor Packs 3 Tablet, 300mg Tablet, 3 Packs (Oral Solution)
OsmoPrep 25mg/ml Injection) OsmoPrep (Tablet) 3 Irritable Bowel Syndrome Agents
Bold type = Brand name drug Plain type = Generic drug 84 74tRACK 74
Last updated August 1, 2016 85 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
PEG-3350/PEG-3350/Electrolytes Esomeprazole Magnesium Electrolytes (Oral Magnesium (Capsule 1 1 QL Solution) (Generic Delayed-Release) GoLYTELY) (Generic Nexium) PEG-3350/NaCl/Na Bicarbonate/KCl Esomeprazole Sodium Sodium 1 Bicarbonate/KCl (Oral (Injection)
1 Lansoprazole Solution) (Generic Lansoprazole (Capsule 1 QL NuLYTELY) Delayed-Release)
Polyethylene Glycol 3350 Powder Polyethylene Glycol Nexium Nexium (10mg 3350 Powder (Generic 1 Packet, 2.5mg
MiraLAX) Packet, 20mg Packet, 2
Prepopik Prepopik (Packet) 3 40mg Packet, 5mg Suprep Bowel Prep Bowel Prep Packet) 2 Nexium (Oral Solution) Nexium (20mg
TriLyte TriLyte (Oral Solution) 1 Capsule Delayed- Release, 40mg 2 QL Protectants Capsule Delayed- Carafate (1gm Tablet, Release)
1gm/10ml 3 Nexium I.V. Nexium I.V. (Injection) 3 Suspension) Omeprazole
Cytotec Omeprazole (10mg Cytotec (Tablet) 3 Capsule Delayed- Misoprostol Misoprostol (Tablet) 1 Release, 40mg 1 QL
Sucralfate Sucralfate (Tablet) 1 Capsule Delayed- Proton Pump Inhibitors Release)
Omeprazole Aciphex (Tablet Omeprazole (20mg 3 Delayed-Release) Capsule Delayed- 1 Aciphex Sprinkle Sprinkle Release) 3 ST Omeprazole/Sodium Bicarbonate (Capsule Sprinkle) Dexilant (Capsule Bicarbonate 1 3 QL Delayed-Release) (Capsule) Pantoprazole Sodium Sodium (20mg Tablet Delayed- 1 QL Release, 40mg Tablet Delayed-Release)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 85 75tRACK 75
86 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Pantoprazole Sodium Detrol Pantoprazole Sodium Detrol (Tablet) 3 1 (40mg Injection) Detrol LA LA (Capsule Prevacid Prevacid (Capsule 3 QL Extended-Release 24 3 Delayed-Release) Hour)
Prevacid SoluTab Prevacid SoluTab Ditropan XL 3 ST Ditropan XL (Tablet (Tablet Dispersible) Extended-Release 24 3 QL Prilosec (Packet) 3 PA Hour)
Enablex Protonix (20mg Enablex (Tablet Tablet Delayed- Extended-Release 24 3 QL 3 QL Release, 40mg Tablet Hour)
Flavoxate HCl Delayed-Release) Flavoxate HCl (Tablet) 1
Protonix Protonix (40mg Gelnique 3 Gelnique (10% Gel) 3 QL Injection) Myrbetriq (Tablet Protonix (40mg 3 ST Extended-Release 24 2 Packet) Hour)
Rabeprazole Sodium Rabeprazole Sodium Oxybutynin Chloride Oxybutynin Chloride (Tablet Delayed- 1 (5mg Tablet 1 Release) Immediate-Release, Zegerid 5mg/5ml Syrup) (20mg-1100mg Oxybutynin Chloride ER Oxybutynin Chloride Capsule, 4 ER (Tablet Extended- 1 QL 40mg-1100mg Release 24 Hour) Capsule) Oxytrol (Patch Twice Zegerid 3 Zegerid Weekly) (20mg-1680mg Tolterodine Tartrate Tartrate 1 Packet, 4 ST (Tablet)
40mg-1680mg Tolterodine Tartrate ER Tolterodine Tartrate Packet) ER (Capsule Extended- 1 Genitourinary Agents Release 24 Hour) Antispasmodics, Urinary Toviaz (Tablet Darifenacin HBr ER Darifenacin HBr ER Extended-Release 24 3 QL, ST (Tablet Extended- 1 QL Hour) Release 24 Hour)
Bold type = Brand name drug Plain type = Generic drug 86 76tRACK 76
Last updated August 1, 2016 87 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Trospium Chloride Chloride Uroxatral (Tablet 1 (Tablet) Extended-Release 24 3 Trospium Chloride ER Chloride ER Hour)
(Capsule Extended- 1 Genitourinary Agents, Other Release 24 Hour) Bethanechol Chloride Chloride
Vesicare 1 Vesicare (Tablet) 2 QL (Tablet) Benign Prostatic Hypertrophy Agents Cuprimine (Capsule) 4 PA Alfuzosin HCl ER HCl ER Depen Titratabs Titratabs 4 (Tablet Extended- 1 (Tablet)
Elmiron Release 24 Hour) Elmiron (Capsule) 3
Avodart Lithostat Avodart (Capsule) 3 Lithostat (Tablet) 4
Cardura XL
Thiola Cardura XL (Tablet Thiola (Tablet) 4
Extended-Release 24 3 QL Urecholine Urecholine (Tablet) 3 Hour) Cialis (2.5mg Tablet, Phosphate Binders 3 PA, QL Auryxia 5mg Tablet) Auryxia (Tablet) 4 ST
Calcium Acetate Dutasteride Calcium Acetate Dutasteride (Capsule) 1 1 Dutasteride/Dutasteride/Tamsulosin HCl (Capsule) Eliphos Tamsulosin HCl 1 Eliphos (Tablet) 1 (Capsule) Fosrenol (1000mg Finasteride (5mg Packet, 750mg Packet, 1000mg Tablet) (Generic 1 Proscar) Tablet Chewable, 4
Flomax Flomax (Capsule) 3 500mg Tablet
Jalyn Chewable, 750mg Jalyn (Capsule) 3 Tablet Chewable) Proscar
PhosLo Proscar (Tablet) 3 PhosLo (Capsule) 2
Rapaflo Rapaflo (Capsule) 2 QL Phoslyra (Oral Tamsulosin HCl HCl 2 1 Solution) (Capsule) Renagel (Tablet) 2 ST Terazosin HCl HCl 1 (Capsule)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 87 77tRACK 77
88 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Renvela (0.8gm Betamethasone Valerate Packet, 2.4gm Valerate (0.1% Cream, 2 Packet, 800mg 0.1% Lotion, 0.1% 1 Tablet) Ointment, 0.12% Velphoro (Tablet Foam)
4 Capex Chewable) Capex (Shampoo) 3 Hormonal Agents, Stimulant/Replacement/ Clobetasol Propionate Propionate Modifying (Adrenal) (0.05% External Hormonal Agents, Stimulant/Replacement/ Solution, 0.05% Foam,
Modifying (Adrenal) 0.05% Gel, 0.05% 1
A-Hydrocort A-Hydrocort (Injection) 1 Liquid, 0.05% Lotion,
Ala Cort 0.05% Ointment, Ala Cort (Cream) 1 0.05% Shampoo) Ala Scalp Ala Scalp (Lotion) 3 Clobetasol Propionate E Clobetasol Propionate Alclometasone Dipropionate 1 Alclometasone E (Cream)
Clobex Dipropionate (0.05% Clobex (0.05% Liquid, 1 Cream, 0.05% 0.05% Lotion, 0.05% 4 Ointment) Shampoo) Amcinonide
Amcinonide (0.1% Clodan Clodan (Shampoo) 1
Cream, 0.1% Lotion, 1 Cloderm Pump Cloderm Pump 0.1% Ointment) 3
ApexiCon E (Cream)
ApexiCon E (Cream) 4 Cordran Tape
Augmented Betamethasone Dipropionate Cordran Tape (Tape) 3
Augmented Cormax Scalp Application Cormax Scalp Betamethasone Dipropionate (0.05% Application (External 1 1 Cream, 0.05% Gel, Solution) Cortef 0.05% Lotion, 0.05% Cortef (Tablet) 3 Ointment) Cortisone Acetate Acetate
Betamethasone Dipropionate 1 Betamethasone (Tablet)
Cutivate Dipropionate (0.05% Cutivate (Lotion) 1 4 Cream, 0.05% Lotion, Depo-Medrol 3 0.05% Ointment) (Injection)
Dermatop Dermatop (Cream) 3
Bold type = Brand name drug Plain type = Generic drug 88 78tRACK 78
Last updated August 1, 2016 89 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Diprolene Desonate Diprolene (0.05% Desonate (Gel) 3 Desonide (0.05% Lotion, 0.05% 3
Cream, 0.05% Lotion, 1 Ointment)
Diprolene AF 0.05% Ointment) Diprolene AF (Cream) 3 DesOwen (0.05% Elocon (0.1% Cream, 3 Cream) 0.1% Lotion, 0.1% 3 DesOwen (0.05% Ointment)
3 Fludrocortisone Acetate Lotion) Fludrocortisone 1 Desoximetasone Acetate (Tablet) (0.05% Cream, 0.25% Fluocinolone Acetonide 1 Cream, 0.05% Gel, Acetonide (0.01% 0.25% Ointment) Cream, 0.025% Cream, 1 Desoximetasone 0.01% External 1 (0.05% Ointment) Solution, 0.025% Dexamethasone Ointment) Fluocinolone Acetonide Body (0.5mg Tablet, 0.75mg 1 Tablet, 1.5mg Tablet, Acetonide Body (Oil)
Fluocinonide 1mg Tablet, 2mg 1 Fluocinonide (0.05% Tablet, 4mg Tablet, External Solution, 1 6mg Tablet, 0.5mg/ 0.05% Gel, 0.05% 5ml Elixir) Ointment, 0.1% Cream) Dexamethasone Intensol Fluocinonide-E 1 Intensol (1mg/ml 1 (Cream) Concentrate) Flurandrenolide
Dexamethasone Sodium Phosphate 1 Dexamethasone (Cream) Sodium Phosphate Fluticasone Propionate 1 Fluticasone Propionate (10mg/ml Injection, (0.005% Ointment, 1 120mg/30ml Injection) 0.05% Cream, 0.05% DexPak 13 Day 13 Day (Tablet Lotion) 3 Therapy Pack) H.P. Acthar Acthar (Injection) 4 PA Diflorasone Diacetate Diacetate
(0.05% Cream, 0.05% 1 Ointment)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 89 79tRACK 79
90 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Halobetasol Propionate Medrol Dosepak Dosepak 3 Propionate (0.05% (Tablet Therapy Pack)
1 Methylprednisolone Cream, 0.05% Methylprednisolone 1 Ointment) (Tablet)
Halog Halog (0.1% Cream, Methylprednisolone Acetate 4 1 0.1% Ointment) Acetate (Injection)
Hydrocortisone Hydrocortisone (1% Methylprednisolone Dose Pack
Cream, 2.5% Cream, Dose Pack (Tablet 1 1% Ointment, 2.5% Therapy Pack) Ointment, 10mg 1 Methylprednisolone Sodium Succinate
Tablet, 20mg Tablet, Sodium Succinate 1 5mg Tablet, 2.5% (Injection)
Lotion) Millipred Millipred (10mg/5ml Hydrocortisone Butyrate Hydrocortisone Oral Solution, 5mg 3 Butyrate (0.1% External 1 Tablet) Solution, 0.1% Mometasone Furoate Mometasone Furoate Ointment) (0.1% Cream, 0.1% Hydrocortisone Butyrate 1 External Solution, 0.1% Butyrate (Lipophilic) 1 Ointment)
(Cream) Olux Olux (Foam) Hydrocortisone Valerate 4
Hydrocortisone Orapred ODT Orapred ODT (Tablet Valerate (0.2% Cream, 1 3 Dispersible) 0.2% Ointment) Pandel Kenalog (Aerosol Pandel (Cream) 3 3 Prednicarbate (0.1% Solution) 1 Kenalog-10 Cream) Kenalog-10 (Injection) 3 Prednicarbate
Kenalog-40 Prednicarbate (0.1% Kenalog-40 (Injection) 3 1 Ointment) Locoid Locoid (0.1% Cream) 4 Prednisolone Sodium Phosphate Sodium Locoid (0.1% External Phosphate (15mg/5ml Solution, 0.1% Lotion, 3 Oral Solution, 25mg/ 1 0.1% Ointment) 5ml Oral Solution,
LoKara LoKara (Lotion) 1 5mg/5ml Oral
Medrol Medrol (Tablet) 3 Solution)
Bold type = Brand name drug Plain type = Generic drug 90 80tRACK 80
Last updated August 1, 2016 91 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Prednisolone Sodium Phosphate ODT Sodium Triamcinolone Acetonide
Phosphate ODT 1 Acetonide (0.025% (Tablet Dispersible) Cream, 0.1% Cream, Prednisone (10mg 0.5% Cream, 0.025% Lotion, 0.1% Lotion, Tablet, 1mg Tablet, 2.5mg Tablet, 20mg 0.025% Ointment, 1 1 Tablet, 50mg Tablet, 0.1% Ointment, 0.5% 5mg Tablet, 5mg/5ml Ointment, 0.147mg/ Oral Solution) gm Aerosol Solution Prednisone Intensol Intensol Generic Kenalog 1 (5mg/ml Concentrate) Spray)
Trianex Psorcon Psorcon (Cream) 1 Trianex (Ointment) 4
Triderm Rayos (Tablet Triderm (Cream) 1 4 PA Ultravate Ultravate (0.05% Delayed-Release) Solu-Cortef Solu-Cortef (Injection) 3 Cream, 0.05% 3
Solu-Medrol Ointment) Solu-Medrol 3 Ultravate (0.05% (Injection) 4 Synalar Cream Kit Lotion) Synalar Cream Kit 3 Vanos (Kit) Vanos (Cream) 4
Veripred 20 Temovate Veripred 20 (Oral Temovate (Ointment) 3 3 Topicort Solution) Topicort (0.05% Cream, 0.25% Cream, Hormonal Agents, Stimulant/Replacement/ 3 0.05% Gel, 0.25% Modifying (Pituitary) Ointment) Hormonal Agents, Stimulant/Replacement/ Topicort (0.05% Modifying (Pituitary) Chorionic Gonadotropin Ointment, 0.25% 3 Chorionic Liquid) Gonadotropin 1 PA (Injection) DDAVP (0.01% Nasal
Rhinal Tube Solution, 3 0.1mg Tablet)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 91 81tRACK 81
92 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
DDAVP DDAVP (0.01% Nasal Novarel (Injection) 1 PA Spray Solution, 0.2mg Nutropin AQ AQ 4 4 PA Tablet, 4mcg/ml (Injection)
Injection) Omnitrope Omnitrope (Injection) 4 PA Desmopressin Acetate
Desmopressin Pregnyl w/Diluent Benzyl Alcohol/NaCl Pregnyl w/Diluent Acetate (0.01% Nasal 1 Benzyl Alcohol/NaCl 1 PA Rhinal Tube Solution)
Desmopressin Acetate (Injection)
Desmopressin Acetate Saizen Saizen (Injection) 4 PA (0.01% Nasal Spray Stimate (Nasal Solution, 0.1mg Tablet, 1 4 0.2mg Tablet, 4mcg/ Solution) Zomacton (10mg ml Injection) 4 PA Genotropin (12mg Injection) Injection, 5mg Zomacton (5mg 4 PA 3 PA Injection) Injection) Genotropin Miniquick Miniquick Hormonal Agents, Stimulant/Replacement/ 3 PA (0.2mg Injection) Modifying (Prostaglandins) Genotropin Miniquick Miniquick Hormonal Agents, Stimulant/Replacement/ (0.4mg Injection, Modifying (Prostaglandins) 0.6mg Injection, Korlym (Tablet) 4 PA, QL 0.8mg Injection, Hormonal Agents, Stimulant/Replacement/ 1.2mg Injection, 4 PA Modifying (Sex Hormones/Modifiers) 1.4mg Injection, Androgens
1.6mg Injection, Anadrol-50 1.8mg Injection, 1mg Anadrol-50 (Tablet) 4 PA Androderm (Patch 24 Injection, 2mg 2 PA, QL Injection) Hour)
AndroGel Humatrope AndroGel (1% Packet Humatrope (Injection) 4 PA 3 PA Humatrope Combo Pack Gel) Humatrope Combo 4 PA AndroGel (1.62% Pack (Injection) 2 PA
Increlex Packet Gel)
Increlex (Injection) 4 PA AndroGel Pump
Norditropin FlexPro AndroGel Pump Norditropin FlexPro 2 PA 4 PA (1.62% Gel)
(Injection) Aveed Aveed (Injection) 3
Bold type = Brand name drug Plain type = Generic drug 92 82tRACK 82
Last updated August 1, 2016 93 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Axiron Apri Axiron (Transdermal Apri (Tablet) 1 3 PA, QL Aranelle Solution) Aranelle (Tablet) 1 Danazol
Ashlyna Danazol (Capsule) 1 Ashlyna (Tablet) 1
Depo-Testosterone
Depo-Testosterone Aubra 3 Aubra (Tablet) 1 (Injection) Aviane
Fortesta Aviane (Tablet) 1 Fortesta (Gel) 3 PA Balziva
Methitest Balziva (Tablet) 1 Methitest (Tablet) 3 PA Bekyree
Methyltestosterone Bekyree (Tablet) 1 Methyltestosterone 1 PA Beyaz (Capsule) Beyaz (Tablet) 3
Blisovi 24 Fe Natesto (Gel) 3 PA Blisovi 24 Fe (Tablet) 1
Blisovi Fe 1.5/30 Oxandrolone Blisovi Fe 1.5/30 Oxandrolone (Tablet) 1 PA, QL 1 Striant (Tablet) Striant 3 PA Blisovi Fe 1/20
Testim Blisovi Fe 1/20 (Tablet) 1 Testim (Gel) 3 PA Brevicon-28
Testosterone Brevicon-28 (Tablet) 3 Testosterone (25mg/ Briellyn 2.5gm Gel, 50mg/5gm 1 PA Briellyn (Tablet) 1 Gel) Climara Pro Pro (Patch 3 PA, HRM Testosterone (10mg/ Weekly)
3 PA Cryselle-28 act Gel) Cryselle-28 (Tablet) 1
Testosterone Cypionate Cyclafem Testosterone 1 Cyclafem (Tablet) 1 Cyclessa Cypionate (Injection) Cyclessa (Tablet) 3 Testosterone Enanthate
Testosterone Delestrogen 1 Delestrogen 3 Enanthate (Injection) (Injection) Testosterone Pump
Testosterone Pump Delyla 1 PA Delyla (Tablet) 1 (Gel) Depo-Estradiol
Vogelxo Depo-Estradiol Vogelxo (Gel) 3 PA 3 (Injection) Vogelxo Pump
Vogelxo Pump (Gel) 3 PA Desogen Desogen (Tablet) 3
Estrogens Desogestrel/Ethinyl Estradiol Desogestrel/Ethinyl Alora (Patch Twice PA, QL, 1 3 Estradiol (Tablet) Weekly) HRM Drospirenone/Ethinyl Estradiol Drospirenone/Ethinyl Amethia 1 Amethia (Tablet) 1 Estradiol (Tablet)
Amethyst Amethyst (Tablet) 1 Elestrin (Gel) 3 PA, HRM
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 93 83tRACK 83
94 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Emoquette Gianvi Emoquette (Tablet) 1 Gianvi (Tablet) 1
Enpresse-28 Gildagia Enpresse-28 (Tablet) 1 Gildagia (Tablet) 1
Estrace Gildess 1.5/30 Estrace (0.1mg/gm Gildess 1.5/30 (Tablet) 1 3 Gildess 24 Fe Cream) Gildess 24 Fe (Tablet) 1
Estrace
Introvale Estrace (0.5mg Tablet, Introvale (Tablet) 1
1mg Tablet, 2mg 3 PA, HRM Jinteli Tablet) Jinteli (Tablet) 1 PA, HRM
Juleber Estradiol (0.025mg/ Juleber (Tablet) 1
Junel 1.5/30 24hr Patch Twice Junel 1.5/30 (Tablet) 1
Junel 1/20 Weekly, 0.0375mg/ Junel 1/20 (Tablet) 1
24hr Patch Twice Junel Fe 1.5/30 Junel Fe 1.5/30 Weekly, 0.05mg/24hr PA, QL, 1 1 (Tablet)
Patch Twice Weekly, HRM Junel Fe 1/20 0.075mg/24hr Patch Junel Fe 1/20 (Tablet) 1
Junel Fe 24 Twice Weekly, 0.1mg/ Junel Fe 24 (Tablet) 1 24hr Patch Twice Kaitlib Fe Fe (Tablet 1 Weekly) Chewable)
Estradiol Kariva Estradiol (0.5mg Kariva (Tablet) 1
Tablet, 1mg Tablet, Kelnor 1/35 1 PA, HRM Kelnor 1/35 (Tablet) 1
2mg Tablet) (Generic Kimidess Estrace) Kimidess (Tablet) 1
LARIN 1.5/30 Estradiol Valerate Valerate LARIN 1.5/30 (Tablet) 1
1 LARIN 1/20 (Injection) LARIN 1/20 (Tablet) 1
Estring LARIN Fe 1.5/30 Estring (Ring) 3 LARIN Fe 1.5/30 1 Falmina Falmina (Tablet) 1 (Tablet)
LARIN Fe 1/20 Femcon Fe Fe (Tablet LARIN Fe 1/20 (Tablet) 1 3 Layolis Fe Chewable) Layolis Fe (Tablet 1 Femhrt Low Dose Low Dose Chewable)
3 PA, HRM Leena (Tablet) Leena (Tablet) 1
Femring Lessina Femring (Ring) 3 Lessina (Tablet) 1
Fyavolv Levonest Fyavolv (Tablet) 1 PA, HRM Levonest (Tablet) 1 Generess Fe Fe (Tablet 3 Chewable)
Bold type = Brand name drug Plain type = Generic drug 94 84tRACK 84
Last updated August 1, 2016 95 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Levonorgestrel and Ethinyl Estradiol and Minastrin 24 Fe 24 Fe 3 Ethinyl Estradiol 1 (Tablet Chewable) (Tablet) Minivelle (Patch PA, QL,
Levonorgestrel/Ethinyl Estradiol 3 Levonorgestrel/Ethinyl Twice Weekly) HRM 1 Modicon Estradiol (Tablet) Modicon (Tablet) 3
Levora 0.15/30-28 Levora 0.15/30-28 MonoNessa 1 MonoNessa (Tablet) 1
(Tablet) Natazia
Lo Loestrin Fe Natazia (Tablet) 3
Lo Loestrin Fe Necon 0.5/35-28 3 Necon 0.5/35-28 (Tablet) 1
Loestrin 1.5/30-21 (Tablet)
Loestrin 1.5/30-21 Necon 1/35 3 (Tablet) Necon 1/35 (Tablet) 1
Necon 1/50-28 Loestrin 1/20-21 1/20-21 Necon 1/50-28 3 1 (Tablet) (Tablet)
Necon 10/11-28 Loestrin Fe 1.5/30 Fe 1.5/30 Necon 10/11-28 3 1 (Tablet) (Tablet)
Necon 7/7/7 Loestrin Fe 1/20 Fe 1/20 Necon 7/7/7 (Tablet) 1
3 Nikki (Tablet) Nikki (Tablet) 1
Lomedia 24 Fe Norethindrone & Ethinyl Estradiol Ferrous Fumarate Lomedia 24 Fe (Tablet) 1 Norethindrone &
Loryna Ethinyl Estradiol Loryna (Tablet) 1 1 LoSeasonique Ferrous Fumarate LoSeasonique 3 (Tablet Chewable) (Tablet) Norethindrone Acetate/Ethinyl Estradiol
Lutera Norethindrone Lutera (Tablet) 1 Acetate/Ethinyl 1 PA, HRM Marlissa Marlissa (Tablet) 1 Estradiol (Tablet)
Menest Menest (Tablet) 3 PA, HRM Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate Microgestin 1.5/30 1.5/30 Acetate/Ethinyl 1 1 (Tablet) Estradiol/Ferrous Microgestin 1/20 1/20 Fumarate (Tablet) 1 Norgestimate/Ethinyl Estradiol (Tablet) Norgestimate/Ethinyl 1 Microgestin Fe Fe Estradiol (Tablet)
1 Norinyl 1+35 (Tablet) Norinyl 1+35 (Tablet) 3
Microgestin Fe 1.5/30 Norinyl 1+50 Microgestin Fe 1.5/30 1 Norinyl 1+50 (Tablet) 3 (Tablet)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 95 85tRACK 85
96 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Nortrel 0.5/35 Seasonique Nortrel 0.5/35 (28) Seasonique (Tablet) 3 1 Setlakin (Tablet) Setlakin (Tablet) 1 Nortrel 1/35
Sprintec 28 Nortrel 1/35 (Tablet) 1 Sprintec 28 (Tablet) 1 Nortrel 7/7/7
Sronyx Nortrel 7/7/7 (Tablet) 1 Sronyx (Tablet) 1 NuvaRing
Tarina Fe 1/20 NuvaRing (Ring) 3 Tarina Fe 1/20 (Tablet) 1 Ocella
Tri-Legest Fe Ocella (Tablet) 1 Tri-Legest Fe (Tablet) 1 Ogestrel
Tri-Lo-Estarylla Ogestrel (Tablet) 1 Tri-Lo-Estarylla (Tablet) 1 Orsythia
Tri-Lo-Sprintec Orsythia (Tablet) 1 Tri-Lo-Sprintec (Tablet) 1
Ortho Tri-Cyclen
Ortho Tri-Cyclen Trinessa 3 Trinessa (Tablet) 1 (Tablet) Tri-Norinyl 28
Ortho Tri-Cyclen Lo Tri-Norinyl 28 (Tablet) 3 Ortho Tri-Cyclen Lo 3 Tri-Previfem (Tablet) Tri-Previfem (Tablet) 1
Tri-Sprintec Ortho-Cyclen Ortho-Cyclen (Tablet) 3 Tri-Sprintec (Tablet) 1
Trivora-28 Ortho-Novum 1/35 1/35 Trivora-28 (Tablet) 1
3 Vagifem (Tablet) Vagifem (Tablet) 3 QL
Ortho-Novum 7/7/7 Ortho-Novum 7/7/7 Velivet 3 Velivet (Tablet) 1
(Tablet) Vestura Vestura (Tablet) 1 Ovcon-35
Ovcon-35 (Tablet) 3 Vienva Vienva (Tablet) 1 Pimtrea
Pimtrea (Tablet) 1 Vivelle-Dot Vivelle-Dot (Patch PA, QL, Pirmella 1/35 3 Pirmella 1/35 (Tablet) 1 Twice Weekly) HRM
Portia-28 Vyfemla Portia-28 (Tablet) 1 Vyfemla (Tablet) 1
Premarin Premarin (25mg WYMZYA Fe Fe (Tablet 3 1 Injection) Chewable)
Premarin Premarin (Vaginal Xulane 2 Xulane (Patch Weekly) 1
Cream) Yasmin 28 Yasmin 28 (Tablet) 3 Previfem
Previfem (Tablet) 1 Yaz Yaz (Tablet) 3 Quartette
Quartette (Tablet) 3 Zenchent Zenchent (Tablet) 1 Quasense
Quasense (Tablet) 1 Zenchent Fe Zenchent Fe (Tablet Reclipsen 1 Reclipsen (Tablet) 1 Chewable)
Safyral Zovia 1/35E Safyral (Tablet) 3 Zovia 1/35E (Tablet) 1
Bold type = Brand name drug Plain type = Generic drug 96 86tRACK 86
Last updated August 1, 2016 97 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Megestrol Acetate Zovia 1/50E Zovia 1/50E (Tablet) 1 Megestrol Acetate Progestins (20mg Tablet, 40mg
Aygestin Tablet, 40mg/ml 1 PA, HRM Aygestin (Tablet) 3 Suspension, 625mg/ Camila Camila (Tablet) 1 5ml Suspension)
Crinone Nora-BE Crinone (Gel) 3 PA Nora-BE (Tablet) 1
Deblitane Norethindrone Deblitane (Tablet) 1 Norethindrone (Tablet) 1
Depo-Provera Depo-Provera Norethindrone Acetate Acetate 3 1 (Injection) (Tablet)
Depo-Provera Contraceptive Depo-Provera Norlyroc Norlyroc (Tablet) 1
Contraceptive 3 Nor-QD Nor-QD (Tablet) 3 (Injection) Ortho Micronor
Depo-SubQ Provera104 Ortho Micronor Depo-SubQ 3 (Tablet) Provera104 3 Progesterone (Injection) 1 PA Errin (Capsule) Errin (Tablet) 1 Prometrium
Hydroxyprogesterone Caproate Prometrium (Capsule) 3 PA Hydroxyprogesterone 1 PA Provera Caproate (Injection) Provera (Tablet) 3
Sharobel Jolivette Jolivette (Tablet) 1 Sharobel (Tablet) 1
Lyza Lyza (Tablet) 1 Selective Estrogen Receptor Modifying
Makena Agents Makena (Injection) 4 PA Evista
Medroxyprogesterone Acetate Evista (Tablet) 3 QL Medroxyprogesterone Raloxifene HCl Acetate (10mg Tablet, Raloxifene HCl (Tablet) 1 QL
2.5mg Tablet, 5mg 1 Hormonal Agents, Stimulant/Replacement/ Tablet, 150mg/ml Modifying (Thyroid) Injection) Hormonal Agents, Stimulant/Replacement/ Megace ES ES Modifying (Thyroid)
4 PA, HRM Cytomel (Suspension) Cytomel (Tablet) 3
Megace Oral Megace Oral Levothyroxine Sodium 3 PA, HRM (Suspension) Sodium (100mcg 1 Injection)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 97 87tRACK 87
98 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Levothyroxine Sodium Sodium Hormonal Agents, Suppressant (Pituitary)
Cabergoline (100mcg Tablet, Cabergoline (Tablet) 1
112mcg Tablet, Egrifta Egrifta (Injection) 4 PA
125mcg Tablet, Eligard 137mcg Tablet, Eligard (22.5mg Injection, 30mg 150mcg Tablet, 1 3 PA 175mcg Tablet, Injection, 7.5mg 200mcg Tablet, 25mcg Injection) Eligard (45mg Tablet, 300mcg Tablet, 4 PA 50mcg Tablet, 75mcg Injection) Tablet, 88mcg Tablet) Firmagon (120mg 4 PA Levoxyl Levoxyl (Tablet) 1 Injection)
Firmagon Liothyronine Sodium Firmagon (80mg Liothyronine Sodium 3 PA (10mcg/ml Injection, Injection) 1 Leuprolide Acetate Acetate 25mcg Tablet, 50mcg 1 PA Tablet, 5mcg Tablet) (Injection)
Lupaneta Pack Synthroid Synthroid (Tablet) 2 Lupaneta Pack (Kit) 4 PA
Lupron Depot Thyrolar Lupron Depot Thyrolar (Tablet) 2 4 PA Tirosint (Injection) Tirosint (Capsule) 3 Lupron Depot-PED
Triostat Lupron Depot-PED Triostat (Injection) 3 4 PA (Injection) Unithroid Unithroid (Tablet) 1 Octreotide Acetate Acetate 1 PA Hormonal Agents, Suppressant (Adrenal) (Injection) Hormonal Agents, Suppressant (Adrenal) Sandostatin
Lysodren 4 PA Lysodren (Tablet) 2 (Injection) Sandostatin LAR Depot LAR Hormonal Agents, Suppressant (Parathyroid) 4 PA Hormonal Agents, Suppressant Depot (Injection) (Parathyroid) Signifor (Injection) 4 PA
Sensipar Sensipar (30mg Signifor LAR LAR 2 QL 4 PA Tablet) (Injection)
Sensipar Sensipar (60mg Somatuline Depot Depot 4 QL 4 PA Tablet, 90mg Tablet) (Injection) Hormonal Agents, Suppressant (Pituitary) Somavert (Injection) 4 PA, QL
Bold type = Brand name drug Plain type = Generic drug 98 88tRACK 88
Last updated August 1, 2016 99 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Synarel (Nasal Cellcept (200mg/ml 4 Solution) Suspension, 250mg
Trelstar Mixject 4 PA Trelstar Mixject Capsule, 500mg 4 PA (Injection) Tablet) Cellcept Intravenous Intravenous Hormonal Agents, Suppressant (Thyroid) 3 PA Antithyroid Agents (Injection)
Cimzia
Methimazole Methimazole (Tablet) 1 Cimzia (Injection) 4 PA
Cosentyx Propylthiouracil Cosentyx (Injection) 4 PA
1 Cosentyx Sensoready Pen (Tablet) Cosentyx Sensoready 4 PA Tapazole Tapazole (Tablet) 3 Pen (Injection)
Cyclosporine Immunological Agents Cyclosporine (100mg Angioedema (HAE) Agents Capsule, 25mg 1 B/D, PA
Berinert Capsule)
Berinert (Injection) 4 PA, LA Cyclosporine Cyclosporine (50mg/ Cinryze 1 Cinryze (Injection) 4 PA, LA ml Injection)
Firazyr Firazyr (Injection) 4 PA, QL Cyclosporine Modified Modified Ruconest (Injection) 4 PA (100mg Capsule, Immune Suppressants 25mg Capsule, 50mg 1 B/D, PA Astagraf XL XL (0.5mg Capsule, 100mg/ml Capsule Extended- Oral Solution)
Enbrel Release 24 Hour, Enbrel (Injection) 4 PA
3 PA Enbrel SureClick 1mg Capsule Enbrel SureClick 4 PA Extended-Release 24 (Injection) Hour) Envarsus XR XR (Tablet Astagraf XL XL (5mg Extended-Release 24 3 PA Capsule Extended- 4 PA Hour) Release 24 Hour) Gengraf (100mg Azasan (Tablet) 3 B/D, PA Capsule, 25mg 1 B/D, PA Azathioprine (100mg Capsule, 100mg/ml 1 B/D, PA Injection, 50mg Tablet) Oral Solution) Humira (Injection) 4 PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 99 89tRACK 89
100 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Humira Pediatric Crohns Disease Starter Pack Pediatric Orencia (125mg/ml Crohns Disease Injection, 250mg 4 PA 4 PA Starter Pack Injection) (Injection) Otrexup (Injection) 3 PA
Humira Pen Humira Pen Prograf 4 PA Prograf (0.5mg (Injection) Capsule, 1mg Humira Pen Crohns Disease Starter Pack 3 PA Humira Pen Crohns Capsule, 5mg/ml Disease Starter Pack 4 PA Injection) (Injection) Prograf (5mg Imuran 4 PA Imuran (Tablet) 3 B/D, PA Capsule)
Rapamune Kineret (Injection) 4 PA Rapamune (0.5mg 3 B/D, PA Methotrexate Methotrexate (Tablet) 1 Tablet)
Rapamune Methotrexate Sodium Sodium Rapamune (1mg 1 (Injection) Tablet, 2mg Tablet, 4 B/D, PA
Mycophenolate Mofetil 1mg/ml Oral Solution) Mycophenolate Mofetil Rasuvo (200mg/ml Rasuvo (Injection) 3 PA Suspension, 250mg 1 PA Remicade (Injection) 4 PA
Rheumatrex Capsule, 500mg Rheumatrex (Tablet) 3 Tablet) Sandimmune (100mg Mycophenolic Acid DR 4 B/D, PA Mycophenolic Acid DR Capsule) (Tablet Delayed- 1 B/D, PA Sandimmune Release) (100mg/ml Oral Myfortic 3 B/D, PA Myfortic (180mg Solution, 25mg Tablet Delayed- 3 B/D, PA Capsule) Release) Sandimmune (50mg/ Myfortic 3 Myfortic (360mg ml Injection)
Tablet Delayed- 4 B/D, PA Simponi Simponi (Injection) 4 PA Release) Simponi Aria
Neoral Simponi Aria Neoral (100mg 4 PA (Injection) Capsule, 25mg 3 B/D, PA Sirolimus Capsule, 100mg/ml Sirolimus (Tablet) 1 B/D, PA Oral Solution) Stelara (Injection) 4 PA Nulojix (Injection) 4 PA
Bold type = Brand name drug Plain type = Generic drug 100 90tRACK 90
Last updated August 1, 2016 101 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Tacrolimus (0.5mg Thymoglobulin 4 Capsule, 1mg Capsule, 1 PA (Injection)
Varizig 5mg Capsule) Varizig (Injection) 2
Torisel Torisel (Injection) 4 Immunomodulators
Trexall Actemra Trexall (Tablet) 3 Actemra (162mg/ Xeljanz (Tablet) 4 PA, QL 0.9ml Injection,
Xeljanz XR 200mg/10ml Xeljanz XR (Tablet 4 PA Extended-Release 24 4 PA, QL Injection, 400mg/ Hour) 20ml Injection, 80mg/
Zortress 4ml Injection) Zortress (Tablet) 4 PA Actimmune Actimmune (Injection) 4 Immunizing Agents, Passive Arava
Atgam Arava (Tablet) 4 Atgam (Injection) 4 Arcalyst
BIVIGAM Arcalyst (Injection) 4 PA, LA BIVIGAM (Injection) 4 PA Benlysta
Carimune Nanofiltered Benlysta (Injection) 4 PA Carimune
Ilaris Nanofiltered 4 PA Ilaris (Injection) 4 PA, QL, LA
Leflunomide (Injection) Leflunomide (Tablet) 1
Flebogamma DIF Flebogamma DIF Otezla 4 PA Otezla (Tablet (Injection) Therapy Pack, 30mg 4 PA Gamastan S/D S/D Tablet)
2 PA Ridaura (Injection) Ridaura (Capsule) 4
Gammagard Liquid Gammagard Liquid Simulect 4 PA Simulect (Injection) 4
(Injection) Synagis Synagis (Injection) 4 PA Gammaked (Injection) 4 PA Vaccines Gammaplex
Gammaplex ActHIB 4 PA ActHIB (Injection) 2 (Injection) Adacel Gamunex-C Adacel (Injection) 2 4 PA BCG Vaccine Vaccine (Injection) 2 Hyperrab S/D S/D (Injection) 3 B/D, PA Bexsero (Injection) Bexsero (Injection) 2
Boostrix Octagam Octagam (Injection) 4 PA Boostrix (Injection) 2
Cervarix Privigen Privigen (Injection) 4 PA Cervarix (Injection) 3
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102 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
RotaTeq Daptacel Daptacel (Injection) 2 RotaTeq (Oral 2 Diphtheria/Tetanus Toxoids Adsorbed Pediatric Solution) Tenivac Toxoids Adsorbed 1 Tenivac (Injection) 2 Pediatric (Injection) Tetanus/Diphtheria Toxoids-Adsorbed Adult
Engerix-B Engerix-B (Injection) 2 B/D, PA Toxoids-Adsorbed 1
Gardasil Gardasil (Injection) 2 Adult (Injection) Trumenba
Gardasil 9 Gardasil 9 (Injection) 2 Trumenba (Injection) 2 Twinrix
Havrix Havrix (Injection) 2 Twinrix (Injection) 2 Typhim Vi
Hiberix Hiberix (Injection) 2 Typhim Vi (Injection) 2 VAQTA Imovax Rabies Rabies VAQTA (Injection) 2 2 B/D, PA Varivax (H.D.C.V.) (Injection) Varivax (Injection) 2
Infanrix YF-Vax Infanrix (Injection) 2 YF-Vax (Injection) 2 IPOL Inactivated IPV Inactivated IPV Zostavax (Injection) 3 PA 2 (Injection) Inflammatory Bowel Disease Agents
Ixiaro Ixiaro (Injection) 2 Aminosalicylates
Menactra Apriso Menactra (Injection) 2 Apriso (Capsule MENHIBRIX Extended-Release 24 2 QL 2 (Injection) Hour)
Asacol HD Menomune-A/C/Y/Menomune-A/C/Y/W-135 Asacol HD (Tablet 2 3 ST W-135 (Injection) Delayed-Release)
Balsalazide Disodium Menveo Balsalazide Disodium Menveo (Injection) 2 1 M-M-R II (Capsule) M-M-R II (Injection) 2 Canasa
Pedvax HIB Canasa (Suppository) 4 Pedvax HIB (Injection) 2 Colazal
ProQuad Colazal (Capsule) 4 ProQuad (Injection) 2 Delzicol
Quadracel Delzicol (Capsule Quadracel (Injection) 2 3 ST Delayed-Release)
Rabavert
Dipentum Rabavert (Injection) 2 B/D, PA Dipentum (Capsule) 4
Recombivax HB
Recombivax HB Giazo 2 B/D, PA Giazo (Tablet) 3
(Injection) Lialda
Rotarix Lialda (Tablet Rotarix (Suspension) 2 2 QL Delayed-Release)
Mesalamine Mesalamine (Kit) 1
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Pentasa (Capsule Sulfasalazine (500mg 3 QL Extended-Release) Tablet Delayed- 1 sfRowasa (Enema) 4 QL Release, 500mg Tablet Glucocorticoids Immediate-Release)
Anusol-HC Metabolic Bone Disease Agents Anusol-HC (Cream) 3
Budesonide Metabolic Bone Disease Agents Budesonide (3mg Actonel Capsule Delayed- 1 Actonel (Tablet) 3 QL Release) Alendronate Sodium Sodium
Colocort Colocort (Enema) 1 (10mg Tablet, 35mg
Entocort EC Tablet, 40mg Tablet, 1 QL Entocort EC (Capsule 4 5mg Tablet, 70mg Delayed-Release) Tablet) Hydrocortisone
Hydrocortisone Alendronate Sodium 1 Alendronate Sodium (100mg/60ml Enema) (70mg/75ml Oral 1 Procto-Med HC HC 1 Solution) (Cream) Atelvia Atelvia (Tablet Procto-Pak 3 QL Procto-Pak (Cream) 1 Delayed-Release)
Proctosol HC Proctosol HC (Cream) 1 Binosto (Tablet
Proctozone-HC 3 QL Proctozone-HC Effervescent)
1 Boniva (Cream) Boniva (150mg
Uceris 3 QL Uceris (2mg/act Tablet)
3 Boniva Foam) Boniva (3mg/3ml
Uceris 3 B/D, PA Uceris (9mg Tablet Injection) Extended-Release 24 4 ST Calcitonin-Salmon 1 QL Hour) (Nasal Solution) Sulfonamides Calcitriol (0.25mcg
Azulfidine Azulfidine (Tablet) 3 Capsule, 0.5mcg Azulfidine EN-Tabs EN-Tabs Capsule, 1mcg/ml 1 B/D, PA
(Tablet Delayed- 3 Injection, 1mcg/ml Release) Oral Solution)
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104 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Doxercalciferol Paricalcitol (1mcg (0.5mcg Capsule, Capsule, 2mcg 1 B/D, PA, QL 1 B/D, PA, QL 1mcg Capsule, 2.5mcg Capsule) Capsule) Paricalcitol (2mcg/ml Doxercalciferol (4mcg/ Injection, 5mcg/ml 3 B/D, PA 1 B/D, PA 2ml Injection) Injection) Etidronate Disodium Disodium Paricalcitol (4mcg 1 1 B/D, PA (Tablet) Capsule) Forteo (Injection) 4 PA, QL Prolia (Injection) 3 PA
Fortical Fortical (Nasal Reclast (Injection) 3 PA 3 QL Solution) Risedronate Sodium Sodium Fosamax 1 QL Fosamax (Tablet) 3 QL (Tablet) Fosamax Plus D Plus D Risedronate Sodium DR Sodium 3 QL (Tablet) DR (Tablet Delayed- 1 QL Hectorol (0.5mcg Release)
3 B/D, PA, QL Rocaltrol Capsule) Rocaltrol (0.25mcg Hectorol Capsule, 0.5mcg Hectorol (1mcg 3 B/D, PA Capsule, 2.5mcg 4 B/D, PA, QL Capsule, 1mcg/ml Capsule) Oral Solution)
Xgeva Hectorol (4mcg/2ml Xgeva (Injection) 4 PA
3 B/D, PA Zemplar Injection) Zemplar (1mcg Ibandronate Sodium Sodium Capsule, 2mcg 3 B/D, PA, QL 1 QL (150mg Tablet) Capsule)
Zemplar Ibandronate Sodium Sodium Zemplar (2mcg/ml 1 B/D, PA 3 B/D, PA (3mg/3ml Injection) Injection)
Zemplar Miacalcin (200unit/ Zemplar (5mcg/ml 3 QL 4 B/D, PA ACT Nasal Solution) Injection)
Zoledronic Acid Miacalcin (200unit/ml Zoledronic Acid (4mg/ 4 PA 1 B/D, PA Injection) 5ml Injection)
Zoledronic Acid Natpara (Injection) Zoledronic Acid (5mg/ 4 PA 1 PA Pamidronate Disodium Disodium 100ml Injection) 1 B/D, PA Zometa (Injection) Zometa (Injection) 4 B/D, PA Miscellaneous Therapeutic Agents
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Miscellaneous Therapeutic Agents Lastacaft (Ophthalmic 2 Alcohol Prep Pads Alcohol Prep Pads 2 Solution)
Maxitrol Botox Maxitrol (0.1% Botox (Injection) 3 PA, QL
Dysport Ointment, 0.1% 3 Dysport (Injection) 3 PA Suspension) Fomepizole Fomepizole (Injection) 1 Naphazoline HCl HCl Gauze (Non-medicated 1 2 (Ophthalmic Solution) 2X2) Neomycin/Bacitracin/Neomycin/Bacitracin/Polymyxin Insulin Syringes, Needles Syringes, 1 2 Polymyxin (Ointment) Needles Neomycin/Polymyxin/Neomycin/Polymyxin/Bacitracin/Hydrocortisone Kanuma (Injection) 4 PA Bacitracin/
Methylergonovine Maleate 1 Methylergonovine Hydrocortisone 1 Maleate (Tablet) (Ophthalmic Ointment)
Neomycin/Polymyxin/Dexamethasone Myalept (Injection) 4 PA Neomycin/Polymyxin/ Sterile Water Irrigation Water Dexamethasone (0.1% 1 Irrigation (Solution) Ophthalmic Ointment, 1
Xeomin 0.1% Ophthalmic Xeomin (Injection) 3 PA Suspension) Ophthalmic Agents Neomycin/Polymyxin/Neomycin/Polymyxin/Gramicidin
Ophthalmic Agents, Other Gramicidin 1 Alcaine (Ophthalmic 3 (Ophthalmic Solution) Solution) Neomycin/Polymyxin/Neomycin/Polymyxin/Hydrocortisone Atropine Sulfate Sulfate (1% Hydrocortisone (1% 1 1 Ophthalmic Solution) Ophthalmic Bacitracin/Polymyxin B B Suspension)
1 Neosporin (Ophthalmic Ointment) Neosporin (Ophthalmic
Blephamide 3 Blephamide Solution)
3 Polymyxin B Sulfate/Trimethoprim Sulfate (Suspension) Polymyxin B Sulfate/
Blephamide S.O.P. Blephamide S.O.P. Trimethoprim Sulfate 1 3 (Ointment) (Ophthalmic Solution) Cystaran (Ophthalmic Polytrim (Ophthalmic 4 3 Solution) Solution)
Lacrisert Pred-G Lacrisert (Insert) 3 Pred-G (Suspension) 3
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106 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Pred-G S.O.P. S.O.P. Emadine (Ophthalmic 3 3 (Ointment) Solution) Proparacaine HCl HCl Epinastine HCl HCl 1 1 (Ophthalmic Solution) (Ophthalmic Solution)
Olopatadine HCl Restasis (Emulsion) 2 QL Olopatadine HCl (0.1% 1 Sulfacetamide Sodium/Prednisolone Sodium Phosphate Ophthalmic Solution) Sodium/Prednisolone Pataday (Ophthalmic 1 2 Sodium Phosphate Solution) (Ophthalmic Solution) Patanol (Ophthalmic
Tobradex 2 Tobradex (0.3%-0.1% Solution)
Pazeo Ophthalmic 3 Pazeo (Ophthalmic 2 Suspension) Solution) Tobradex ST ST Ophthalmic Antiglaucoma Agents (Ophthalmic 3 Alphagan P P (0.1% 2 Suspension) Ophthalmic Solution)
Tobramycin/Dexamethasone Tobramycin/ Alphagan P P (0.15% Dexamethasone 3 1 Ophthalmic Solution) (Ophthalmic Apraclonidine 1 Suspension) (Ophthalmic Solution) Zylet Azopt Zylet (Suspension) 3 Azopt (Suspension) 2 Ophthalmic Anti-allergy Agents Betagan (Ophthalmic Alocril (Ophthalmic 3 3 Solution) Solution) Betaxolol HCl HCl (0.5% Alomide (Ophthalmic 1 3 Ophthalmic Solution) Solution) Betimol (Ophthalmic Azelastine HCl HCl (0.05% 3 1 Solution) Ophthalmic Solution) Betoptic-S Bepreve (Ophthalmic 3 3 (Suspension) Solution) Brimonidine Tartrate Tartrate Cromolyn Sodium Sodium (4% 1 (0.15% Ophthalmic 1 Ophthalmic Solution) Solution) Elestat (Ophthalmic 3 Solution)
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Brimonidine Tartrate Tartrate Timolol Maleate Maleate
(0.2% Ophthalmic 1 (0.25% Ophthalmic 1 Solution) Solution, 0.5% Carteolol HCl HCl Ophthalmic Solution)
1 Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) Timolol Maleate
Combigan Ophthalmic Gel 1 2 (Ophthalmic Solution) Forming (Solution)
Timoptic Ocudose Cosopt (Ophthalmic Timoptic Ocudose 3 3 Solution) (Ophthalmic Solution)
Timoptic-XE Dorzolamide HCl HCl Timoptic-XE (Gel 1 3 (Ophthalmic Solution) Form Solution)
Trusopt Dorzolamide HCl/Timolol Maleate HCl/ Trusopt (Ophthalmic 3 Timolol Maleate 1 Solution) (Ophthalmic Solution) Ophthalmic Anti-inflammatories Iopidine (Ophthalmic Acular (Ophthalmic 3 3 Solution) Solution) Isopto Carpine Carpine Acular LS LS 3 3 (Ophthalmic Solution) (Ophthalmic Solution) Istalol (Ophthalmic Acuvail (Ophthalmic 3 3 ST Solution) Solution)
Levobunolol HCl Alrex Levobunolol HCl Alrex (Suspension) 3 1 (Ophthalmic Solution) Bromfenac Metipranolol 1 1 (Ophthalmic Solution) (Ophthalmic Solution) Dexamethasone Sodium Phosphate Phospholine Iodide Iodide Sodium Phosphate 3 1 (Ophthalmic Solution) (0.1% Ophthalmic Pilocarpine HCl HCl (1% Solution) Ophthalmic Solution, Diclofenac Sodium Sodium
2% Ophthalmic 1 (0.1% Ophthalmic 1 Solution, 4% Solution)
Durezol Ophthalmic Solution) Durezol (Emulsion) 2
Simbrinza
Simbrinza Flarex 2 Flarex (Suspension) 3 (Suspension)
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108 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Fluorometholone Prednisolone Sodium Phosphate Sodium
(Ophthalmic 1 Phosphate (1% 1 Suspension) Ophthalmic Solution) Flurbiprofen Sodium Sodium Prolensa (Ophthalmic 1 3 (Ophthalmic Solution) Solution)
FML Vexol FML (Ointment) 3 Vexol (Suspension) 3 FML Forte Forte Ophthalmic Prostaglandin and Prostamide 3 (Suspension) Analogs FML Liquifilm Liquifilm Bimatoprost 3 1 (Suspension) (Ophthalmic Solution)
Latanoprost Ilevro Ilevro (Suspension) 2 Latanoprost 1 Ketorolac Tromethamine (Ophthalmic Solution) Tromethamine (0.4% Lumigan (Ophthalmic 2 Ophthalmic Solution, 1 Solution) 0.5% Ophthalmic Travatan Z Z 2 Solution) (Ophthalmic Solution)
Lotemax Lotemax (0.5% Gel, Travoprost 1 0.5% Ointment, 0.5% 3 (Ophthalmic Solution) Suspension) Xalatan (Ophthalmic
Maxidex 3 Maxidex (Suspension) 3 Solution)
Zioptan Nevanac Zioptan (Ophthalmic 2 3 ST (Suspension) Solution) Ocufen (Ophthalmic Otic Agents 3 Solution) Otic Agents
Omnipred Omnipred Acetasol HC HC (Otic 3 3 (Suspension) Solution)
Pred Forte Pred Forte Acetic Acid Acid (Otic 3 1 (Suspension) Solution)
Pred Mild Pred Mild Cipro HC HC 3 3 (Suspension) (Suspension)
Prednisolone Acetate Prednisolone Acetate Ciprodex (Otic 2 (Ophthalmic 1 Suspension) Suspension)
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Coly-Mycin S S Levocetirizine Dihydrochloride 3 (Suspension) Dihydrochloride (5mg 1 QL Fluocinolone Acetonide Tablet)
Olopatadine HCl Acetonide (0.01% Otic 1 Olopatadine HCl (0.6% 1 Oil) Nasal Solution) Hydrocortisone/Acetic Acid Patanase (Nasal 1 3 Acid (Otic Solution) Solution) Neomycin/Polymyxin/Neomycin/Polymyxin/Hydrocortisone Phenadoz (12.5mg 1 PA, HRM Hydrocortisone (1% Suppository)
1 Phenergan Otic Solution, 1% Otic Phenergan (12.5mg 1 PA, HRM Suspension) Suppository) Respiratory Tract/Pulmonary Agents Promethazine HCl HCl Antihistamines (12.5mg Suppository,
Astepro 1 PA, HRM Astepro (Nasal 12.5mg Tablet, 25mg 3 Solution) Tablet, 50mg Tablet)
Xyzal Azelastine HCl HCl (0.1% Xyzal (2.5mg/5ml 1 QL 3 Nasal Solution) Oral Solution)
Xyzal Azelastine HCl HCl (0.15% Xyzal (5mg Tablet) 3 QL 1 Nasal Solution) Anti-inflammatories, Inhaled
Cetirizine HCl Cetirizine HCl (Syrup) 1 Corticosteroids
Aerospan Clarinex (0.5mg/ml Aerospan (Aerosol 3 3 QL, ST Syrup, 5mg Tablet) Solution)
Alvesco Cyproheptadine HCl HCl Alvesco (Aerosol 1 PA, HRM 3 QL, ST (4mg Tablet) Solution)
Arnuity Ellipta Desloratadine Arnuity Ellipta Desloratadine (Tablet) 1 2 QL Desloratadine ODT ODT (Aerosol Powder) 1 Asmanex HFA HFA (Tablet Dispersible) 3 QL, ST Diphenhydramine HCl HCl (Aerosol) 1 B/D, PA Asmanex Twisthaler 120 Metered Doses (50mg/ml Injection) Asmanex Twisthaler Levocetirizine Dihydrochloride 120 Metered Doses 3 QL, ST Dihydrochloride (Aerosol Powder) 1 (2.5mg/5ml Oral Solution)
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110 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Asmanex Twisthaler 30 Metered Doses Twisthaler Qnasl (Aerosol 3 ST 30 Metered Doses 3 QL, ST Solution) (Aerosol Powder) Qnasl Childrens Childrens
Asmanex Twisthaler 60 Metered Doses 3 ST Asmanex Twisthaler (Aerosol Solution) 60 Metered Doses 3 QL, ST QVAR (Aerosol 3 QL, ST (Aerosol Powder) Solution)
Beconase AQ Beconase AQ Veramyst 3 ST 3 ST (Suspension) (Suspension)
Budesonide Budesonide (0.25mg/ Zetonna (Aerosol 3 ST 2ml Suspension, Solution) 0.5mg/2ml 1 B/D, PA Antileukotrienes
Suspension, 1mg/2ml Accolate Accolate (Tablet) 3 QL Suspension) Montelukast Sodium
Budesonide Montelukast Sodium Budesonide (32mcg/ 1 (10mg Tablet, 4mg act Suspension)
Flovent Diskus Packet, 4mg Tablet 1 QL Flovent Diskus 2 QL Chewable, 5mg Tablet (Aerosol Powder) Chewable)
Flovent HFA Flovent HFA (Aerosol) 2 QL Singulair (10mg Flunisolide (Nasal 1 Tablet, 4mg Packet, Solution) 4mg Tablet 3 QL Fluticasone Propionate Propionate Chewable, 5mg
(50mcg/act 1 Tablet Chewable) Suspension) Zafirlukast (Tablet) 1 QL
Mometasone Furoate Mometasone Furoate Zyflo Zyflo (Tablet) 4 ST
(50mcg/act 1 Zyflo CR Zyflo CR (Tablet Suspension) Extended-Release 12 Nasonex 4 ST Nasonex 3 PA Hour) (Suspension) Bronchodilators, Anticholinergic Omnaris
Omnaris (Suspension) 3 ST Atrovent Atrovent (Nasal Pulmicort 3 3 B/D, PA Solution) (Suspension) Atrovent HFA HFA Pulmicort Flexhaler Flexhaler 3 3 QL, ST (Aerosol Solution) (Aerosol Powder)
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Incruse Ellipta Ellipta Brovana (Nebulized 2 QL 3 B/D, PA, QL (Aerosol Powder) Solution) Ipratropium Bromide Bromide Epinephrine 3 ST (0.02% Inhalation 1 B/D, PA (Injection)
EpiPen Solution) EpiPen (Injection) 2
Ipratropium Bromide Ipratropium Bromide Foradil Aerolizer Aerolizer 3 QL, ST (0.03% Nasal Solution, 1 (Capsule) 0.06% Nasal Solution) Levalbuterol Spiriva HandiHaler HandiHaler 1 B/D, PA 2 QL (Nebulized Solution) (Capsule) Metaproterenol Sulfate Sulfate Spiriva Respimat Spiriva Respimat (10mg Tablet, 20mg 2 QL 1 (Aerosol Solution) Tablet, 10mg/5ml Tudorza Pressair Pressair 3 ST Syrup) (Aerosol Powder) Perforomist 3 B/D, PA, QL Bronchodilators, Sympathomimetic (Nebulized Solution)
Adrenalin ProAir HFA Adrenalin (Injection) 3 ProAir HFA (Aerosol
Albuterol Sulfate 2 Albuterol Sulfate Solution) (0.083% Nebulized ProAir RespiClick RespiClick 2 Solution, 0.5% (Aerosol Powder) Nebulized Solution, 1 B/D, PA Proventil HFA HFA 3 ST 0.63mg/3ml Nebulized (Aerosol Solution) Solution, 1.25mg/3ml Serevent Diskus Diskus 2 QL Nebulized Solution) (Aerosol Powder)
Albuterol Sulfate Albuterol Sulfate (2mg Striverdi Respimat Respimat Tablet Immediate- 3 QL, ST (Aerosol Solution) Release, 4mg Tablet 1 Terbutaline Sulfate Terbutaline Sulfate Immediate-Release, (1mg/ml Injection, 2mg/5ml Syrup) 1 2.5mg Tablet, 5mg Albuterol Sulfate ER Sulfate ER Tablet) (Tablet Extended- 1 Ventolin HFA Ventolin HFA (Aerosol Release 12 Hour) 3 ST Solution) Arcapta Neohaler Neohaler 3 QL, ST (Capsule)
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112 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Vospire ER ER (Tablet Theophylline ER ER
Extended-Release 12 3 (300mg Tablet Hour) Extended-Release 12 Xopenex (Nebulized Hour, 450mg Tablet 3 B/D, PA Extended-Release 12 Solution) 1 Xopenex HFA HFA Hour, 400mg Tablet 3 ST (Aerosol) Extended-Release 24 Hour, 600mg Tablet Cystic Fibrosis Agents
Cayston Extended-Release 24 Cayston (Inhalation 4 PA, LA Hour) Solution)
Kalydeco Pulmonary Antihypertensives
Kalydeco (50mg Adcirca 4 PA, QL Packet, 75mg Packet) Adcirca (Tablet) 4 PA, QL
Adempas Orkambi (Tablet) 4 PA, QL, LA Adempas (Tablet) 4 PA
Letairis Phosphodiesterase Inhibitors, Airways Letairis (Tablet) 4 PA, QL, LA Disease Opsumit (Tablet) 4 PA, LA Aminophylline Orenitram (0.125mg 1 (Injection) Tablet Extended- 3 PA, QL Daliresp (Tablet) 3 PA, QL Release)
Orenitram
Elixophyllin Elixophyllin (Elixir) 3 Orenitram (0.25mg
Theo-24 Tablet Extended- Theo-24 (Capsule 4 PA, QL Release, 1mg Tablet Extended-Release 24 3 Extended-Release) Hour) Orenitram
Theophylline Orenitram (2.5mg Theophylline (Oral 1 Tablet Extended- 4 PA Solution)
Theophylline CR Release)
Theophylline CR Remodulin Remodulin (Injection) 4 PA, LA (Tablet Extended- 1 Revatio (10mg/ Release 12 Hour) 4 PA 12.5ml Injection) Revatio (10mg/ml Suspension, 20mg 4 PA, QL Tablet) Sildenafil (10mg/ 1 PA 12.5ml Injection)
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Sildenafil Sildenafil (20mg Dulera (Aerosol) 3 PA, QL Tablet) (Generic 1 PA, QL Esbriet (Capsule) 4 PA, QL, LA
Revatio) Glassia
Tracleer Glassia (Injection) 4 PA, LA
Tracleer (Tablet) 4 PA, QL Grastek
Tyvaso Grastek (Tablet Tyvaso (Inhalation 3 PA, QL 4 PA, QL Sublingual)
Solution) Kalydeco
Uptravi Kalydeco (150mg 4 PA, QL Uptravi (1000mcg Tablet)
Tablet, 1200mcg Ofev Ofev (Capsule) 4 PA, QL, LA Tablet, 1400mcg Oralair (Tablet Tablet, 1600mcg 3 PA, QL Tablet, 200mcg 4 PA, QL Sublingual) Tablet, 400mcg Prolastin-C (Injection) 4 PA, LA Tablet, 600mcg Pulmozyme 4 B/D, PA, QL Tablet, 800mcg (Inhalation Solution) Tablet) Ragwitek (Tablet Uptravi (Tablet 3 PA, QL 4 PA Sublingual) Semprex-D Therapy Pack) Semprex-D (Capsule) 3 Ventavis Ventavis (Inhalation Stiolto Respimat Respimat 4 PA, QL, LA 2 QL Solution) (Aerosol Solution)
Respiratory Tract Agents, Other Symbicort Symbicort (Aerosol) 2 QL Acetylcysteine
Acetylcysteine Zemaira 1 B/D, PA Zemaira (Injection) 4 PA, LA (Inhalation Solution) Advair Diskus Diskus Respiratory Tract/Pulmonary Agents 2 QL Clarinex-D 12 Hour 12 Hour (Aerosol Powder) Advair HFA (Tablet Extended- 3 Advair HFA (Aerosol) 2 QL
Anoro Ellipta Release)
Anoro Ellipta (Aerosol Combivent Respimat 2 QL Combivent Respimat Powder) 2 (Aerosol Solution) Aralast NP
Aralast NP (Injection) 4 PA, LA Dymista Dymista (Suspension) 3 Breo Ellipta
Breo Ellipta (Aerosol Ipratropium Bromide/Albuterol Sulfate 2 QL Ipratropium Bromide/ Powder)
Cromolyn Sodium Albuterol Sulfate 1 B/D, PA Cromolyn Sodium (Inhalation Solution)
(20mg/2ml Nebulized 1 B/D, PA Nucala Nucala (Injection) 4 PA, QL, LA Solution)
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114 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Xolair
Xolair (Injection) 4 PA Ambien PA, QL, Ambien (Tablet) 3 Skeletal Muscle Relaxants HRM
Sonata PA, QL, Skeletal Muscle Relaxants Sonata (Capsule) 3 Baclofen HRM Baclofen (Tablet) 1
Cyclobenzaprine HCl Zaleplon PA, QL, Cyclobenzaprine HCl Zaleplon (Capsule) 1 1 PA, HRM HRM (7.5mg Tablet) Zolpidem Tartrate
Dantrium Zolpidem Tartrate Dantrium (Capsule) 3 (10mg Tablet Dantrolene Sodium PA, QL, Dantrolene Sodium Immediate-Release, 1 1 HRM (Capsule) 5mg Tablet Immediate- Fexmid (Tablet) 3 PA, HRM Release) Gablofen (10000mcg/ Sleep Disorders, Other 20ml Injection, 3 B/D, PA Armodafinil (Tablet) 1 PA, QL
50mcg/ml Injection) Belsomra Belsomra (Tablet) 2 QL Gablofen
Gablofen (40000mcg/ Hetlioz 4 B/D, PA Hetlioz (Capsule) 4 PA, QL 20ml Injection)
Modafinil Lioresal Intrathecal Intrathecal Modafinil (Tablet) 1 PA, QL (0.05mg/ml Injection, 3 B/D, PA Nuvigil (Tablet) 3 PA, QL 10mg/20ml Injection) Provigil (Tablet) 4 PA, QL
Lioresal Intrathecal Lioresal Intrathecal Rozerem 4 B/D, PA Rozerem (Tablet) 3 QL
(10mg/5ml Injection) Xyrem
Orphenadrine Citrate Xyrem (Oral Solution) 4 PA, QL, LA Orphenadrine Citrate 1 PA, HRM Therapeutic Nutrients/Minerals/Electrolytes (Injection)
Tizanidine HCl Electrolyte/Mineral Modifiers Tizanidine HCl (2mg Chemet Capsule, 4mg Capsule, Chemet (Capsule) 3 1 Exjade 6mg Capsule, 2mg Exjade (Tablet 4 PA Tablet, 4mg Tablet) Soluble)
Ferriprox Zanaflex (2mg Ferriprox (100mg/ml Capsule, 4mg Oral Solution, 500mg 4 PA 3 Capsule, 6mg Tablet) Capsule, 4mg Tablet) Jadenu (Tablet) 4 PA
Kayexalate Sleep Disorder Agents Kayexalate (Powder) 4
Kionex GABA Receptor Modulators Kionex (Powder) 1
Bold type = Brand name drug Plain type = Generic drug 114 104tRACK 104
Last updated August 1, 2016 115 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Physiolyte Samsca (Tablet) 4 PA, QL Physiolyte (Irrigation 3 Sodium Polystyrene Sulfonate Polystyrene Solution) 1 Physiosol Irrigation Irrigation Sulfonate (Suspension) 3 Syprine (Capsule) 4 PA (Solution)
Plasma-Lyte A
Veltassa Plasma-Lyte A Veltassa (Packet) 3 QL 3 (Injection)
Electrolyte/Mineral Replacement Plasma-Lyte-148
Ammonium Chloride Plasma-Lyte-148 Ammonium Chloride 3 3 (Injection)
(Injection) Potassium Chloride Potassium Chloride Carbaglu Carbaglu (Tablet) 4 LA (10% Oral Solution, 1
Isolyte-S Isolyte-S (Injection) 3 20% Oral Solution) Klor-Con 10 10 (Tablet Potassium Chloride Chloride 1 Extended-Release) (10meq/100ml Klor-Con 8 8 (Tablet Injection, 20meq/ 1 1 B/D, PA Extended-Release) 100ml Injection, Klor-Con M15 M15 (Tablet 40meq/100ml 1 Extended-Release) Injection)
Potassium Chloride Klor-Con M20 M20 (Tablet Potassium Chloride 1 1 B/D, PA Extended-Release) (2meq/ml Injection)
Potassium Chloride 0.15% /NaCl 0.45% Viaflex Klor-Con Sprinkle Sprinkle Potassium Chloride
(Capsule Extended- 1 0.15% /NaCl 0.45% 1 B/D, PA Release) Viaflex (Injection)
Potassium Chloride 0.15%/NaCl 0.9% K-Tab (Tablet Potassium Chloride 3 Extended-Release) 0.15%/NaCl 0.9% 1 B/D, PA Magnesium Sulfate Sulfate (Injection) Potassium Chloride 0.3%/ NaCl 0.9% (1gm/2ml-50% 1 Potassium Chloride Injection) 0.3%/ NaCl 0.9% 1 B/D, PA
Magnesium Sulfate (Injection) Magnesium Sulfate
(5gm/10ml-50% 1 Injection) Normosol-R 1 (Injection)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 115 105tRACK 105
116 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Potassium Chloride ER Chloride ER Aminosyn 7%/Electrolytes 7%/ (10meq Capsule Electrolytes 3 B/D, PA Extended-Release, (Injection) 8meq Capsule Aminosyn 8.5%/Electrolytes 8.5%/ Extended-Release, Electrolytes 1 B/D, PA 10meq Tablet 1 (Injection) Extended-Release, Aminosyn II II 3 B/D, PA 20meq Tablet (Injection)
Extended-Release, Aminosyn II 8.5%/Electrolytes Aminosyn II 8.5%/ 8meq Tablet Extended- Electrolytes 1 B/D, PA Release) (Injection) Potassium Citrate ER
Potassium Citrate ER Aminosyn-HBC Aminosyn-HBC (Tablet Extended- 1 3 B/D, PA (Injection)
Release) Aminosyn-PF
Sodium Chloride Aminosyn-PF Sodium Chloride (0.9% 3 B/D, PA 1 (Injection)
Injection) Aminosyn-RF
Sodium Chloride Aminosyn-RF Sodium Chloride 3 B/D, PA (Injection)
(2.5meq/ml Injection, Carnitor 1 3% Injection, 5% Carnitor (1gm/10ml Oral Solution, 200mg/ Injection) 3 B/D, PA
Sodium Chloride 0.45% Viaflex ml Injection, 330mg Sodium Chloride Tablet)
0.45% Viaflex 1 Clinimix 2.75%/Dextrose 5% (Injection) Clinimix 2.75%/
Sodium Chloride 0.9% Dextrose 5% 3 B/D, PA Sodium Chloride (Injection)
0.9% (Irrigation 1 Clinimix 4.25%/Dextrose 10% Solution) Clinimix 4.25%/
Sodium Fluoride Dextrose 10% 3 B/D, PA Sodium Fluoride 1 (Injection)
(Tablet) Clinimix 4.25%/Dextrose 20%
Urocit-K Clinimix 4.25%/ Urocit-K (Tablet 3 Dextrose 20% 3 B/D, PA Extended-Release) (Injection)
Therapeutic Nutrients/Minerals/ Clinimix 4.25%/Dextrose 25% Clinimix 4.25%/ Electrolytes Dextrose 25% 3 B/D, PA (Injection)
Bold type = Brand name drug Plain type = Generic drug 116 106tRACK 106
Last updated August 1, 2016 117 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Clinimix 4.25%/Dextrose 5% 4.25%/ Clinisol SF 15% SF 15% 3 B/D, PA Dextrose 5% 3 B/D, PA (Injection) (Injection) Dextrose 10% 10%
Clinimix 5%/Dextrose 15% 1 Clinimix 5%/Dextrose (Injection)
3 B/D, PA Dextrose 10%/NaCl 0.2% 15% (Injection) Dextrose 10%/NaCl
Clinimix 5%/Dextrose 20% 1 Clinimix 5%/Dextrose 0.2% (Injection)
3 B/D, PA Dextrose 10%/NaCl 0.45% 20% (Injection) Dextrose 10%/NaCl
Clinimix 5%/Dextrose 25% 1 Clinimix 5%/Dextrose 0.45% (Injection)
3 B/D, PA Dextrose 2.5%/Sodium Chloride 0.45% 25% (Injection) Dextrose 2.5%/
Clinimix E 2.75%/Dextrose 10% Clinimix E 2.75%/ Sodium Chloride 1 Dextrose 10% 3 B/D, PA 0.45% (Injection) (Injection) Dextrose 5% 5%
Clinimix E 2.75%/Dextrose 5% 1 Clinimix E 2.75%/ (Injection) Dextrose 5% 3 B/D, PA Dextrose 5%/NaCl 0.2% 5%/NaCl 1 (Injection) 0.2% (Injection)
Clinimix E 4.25%/Dextrose 10% Clinimix E 4.25%/ Dextrose 5%/NaCl 0.225% 5%/NaCl 1 Dextrose 10% 3 B/D, PA 0.225% (Injection) (Injection) Dextrose 5%/NaCl 0.33% 5%/NaCl Clinimix E 4.25%/Dextrose 25% 1 Clinimix E 4.25%/ 0.33% (Injection) Dextrose 25% 3 B/D, PA Dextrose 5%/NaCl 0.45% 5%/NaCl 1 (Injection) 0.45% (Injection)
Clinimix E 4.25%/Dextrose 5% Clinimix E 4.25%/ Dextrose 5%/NaCl 0.9% 5%/NaCl 1 Dextrose 5% 3 B/D, PA 0.9% (Injection)
(Injection) Dextrose 5%/Potassium Chloride 0.15% Dextrose 5%/ Clinimix E 5%/Dextrose 15% Clinimix E 5%/ Potassium Chloride 1 B/D, PA Dextrose 15% 3 B/D, PA 0.15% (Injection)
(Injection) FreAmine HBC 6.9% FreAmine HBC 6.9% Clinimix E 5%/Dextrose 20% 3 B/D, PA Clinimix E 5%/ (Injection)
Dextrose 20% 3 B/D, PA HepatAmine HepatAmine (Injection) 1 B/D, PA (Injection) Clinimix E 5%/Dextrose 25%
Clinimix E 5%/ Intralipid Intralipid (20gm/ Dextrose 25% 3 B/D, PA 1 B/D, PA 100ml Injection) (Injection)
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 117 107tRACK 107
118 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Intralipid (30gm/ Nephramine 3 B/D, PA 3 B/D, PA 100ml Injection) (Injection) Ionosol-B/Dextrose 5% Normosol-M in D5W in D5W 3 1 5% (Injection) (Injection) Ionosol-MB/Dextrose 5% Normosol-R in D5W in D5W 3 1 5% (Injection) (Injection)
Isolyte-P/Dextrose 5% NutreStore Isolyte-P/Dextrose 5% NutreStore (Packet) 3 3 (Injection) Nutrilipid (Injection) 1 B/D, PA
KCl 0.075%/D5W/NaCl 0.45% KCl 0.075%/D5W/ Plasma-Lyte-56/D5W 3 NaCl 0.45% 1 (Injection)
(Injection) Plenamine
KCl 0.15%/D5W/LR Plenamine (Injection) 1 B/D, PA
KCl 0.15%/D5W/LR Potassium Chloride 0.15% D5W/NaCl 0.33% 1 Potassium Chloride (Injection)
KCl 0.15%/D5W/NaCl 0.2% 0.15% D5W/NaCl 1 KCl 0.15%/D5W/NaCl 1 0.33% (Injection)
0.2% (Injection) Potassium Chloride 0.15% D5W/NaCl 0.45%
KCl 0.15%/D5W/NaCl 0.225% Potassium Chloride KCl 0.15%/D5W/NaCl 1 0.15% D5W/NaCl 1 0.225% (Injection) 0.45% (Injection) KCl 0.15%/D5W/NaCl 0.9%
KCl 0.15%/D5W/NaCl Potassium Chloride 0.22% D5W/NaCl 0.45% 1 Potassium Chloride 0.9% (Injection) 0.22% D5W/NaCl 1 KCl 0.3%/D5W/NaCl 0.45% 0.3%/D5W/NaCl 1 0.45% (Injection) 0.45% (Injection) Potassium Chloride 0.3%/D5W Potassium Chloride KCl 0.3%/D5W/NaCl 0.9% 0.3%/D5W/NaCl 1 B/D, PA 1 0.3%/D5W (Injection) 0.9% (Injection) Premasol Premasol (10% Lactated Ringers Dextrose 5% Viaflex Ringers 3 B/D, PA Injection)
Dextrose 5% Viaflex 1 Premasol Premasol (6% (Injection) 1 B/D, PA Injection) Lactated Ringers Irrigation
Lactated Ringers Procalamine 1 Procalamine Irrigation (Solution) 3 B/D, PA (Injection) Lactated Ringers Viaflex
Lactated Ringers Prosol 1 Prosol (Injection) 3 B/D, PA Viaflex (Injection) Ringers Injection Levocarnitine (1gm/ Ringers Injection 1 Ringers Irrigation Irrigation 10ml Oral Solution, 1 B/D, PA 1 330mg Tablet) (Solution)
Bold type = Brand name drug Plain type = Generic drug 118 108tRACK 108
Last updated August 1, 2016 119 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits
Sodium Lactate Sodium Lactate Travasol (Injection) 3 B/D, PA 1 (Injection) Trophamine TPN Electrolytes Electrolytes 3 B/D, PA 1 (Injection) VP-PNV-DHA (Injection) VP-PNV-DHA (Capsule) 1
You can find information on what the symbols and abbreviations in this table mean by going to page 7. 119 track
120 Drugs with a quantity limit (QL) This list shows drugs that have a quantity limit. Your plan will cover only a certain amount of these drugs for one co-pay/co-insurance or will only cover these drugs for a certain number of days. These limits may be in place to ensure your safety. Drugs are listed in alphabetical order in the chart below. Some drugs come in many strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. For more information about quantity limits, talk to your doctor or pharmacist. You can also call us. Our contact information, along with the date we last updated the drug list, is on the cover.
Drug Name Quantity Limit
Abacavir (Tablet) Maximum of 3 tablets per day Abacavir Sulfate/Lamivudine/Zidovudine Maximum of 3 tablets per day (Tablet) Abilify (Tablet) Maximum of 1 tablet per day Abstral (Tablet Sublingual) Maximum of 4 tablets per day Acarbose (100mg Tablet) Maximum of 3 tablets per day Acarbose (25mg Tablet) Maximum of 12 tablets per day Acarbose (50mg Tablet) Maximum of 6 tablets per day Accolate (Tablet) Maximum of 2 tablets per day Accupril (Tablet) Maximum of 2 tablets per day Accuretic (10mg-12.5mg Tablet) Maximum of 1 tablet per day Accuretic (20mg-12.5mg Tablet, 20mg-25mg Maximum of 2 tablets per day Tablet) Acetaminophen/Codeine (120mg-12mg/5ml Maximum of 140 ml per day Oral Solution) Acetaminophen/Codeine (300mg-15mg Tablet, Maximum of 13 tablets per day 300mg-30mg Tablet, 300mg-60mg Tablet) Actiq (Lollipop) Maximum of 4 lozenges per day Actonel (150mg Tablet) Maximum of 1 tablet per 30 days Actonel (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Actonel (35mg Tablet) Maximum of 4 tablets per 28 days Actoplus Met (Tablet) Maximum of 3 tablets per day Actoplus Met XR (15mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Actoplus Met XR (30mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Actos (15mg Tablet) Maximum of 3 tablets per day Actos (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Acyclovir (5% Ointment) Maximum of 1 tube (30 grams) per 30 days Adalat CC (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day Adcirca (Tablet) Maximum of 2 tablets per day Adderall (20mg Tablet) Maximum of 3 tablets per day Adderall (5mg Tablet, 7.5mg Tablet) Maximum of 2 tablets per day Adderall XR (Capsule Extended-Release 24 Maximum of 2 capsules per day Hour) Advair Diskus (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Advair HFA (Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Adzenys XR-ODT (Tablet Extended-Release Maximum of 1 tablet per day Dispersible) Maximum of 2 inhalers (17.8 grams) per 30 Aerospan (Aerosol Solution) days Afeditab CR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day Aggrenox (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour) Albenza (Tablet) Maximum of 16 tablets per day Alecensa (Capsule) Maximum of 8 capsules per day Alendronate Sodium (10mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 5mg Tablet) Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days Almotriptan Malate (Tablet) Maximum of 12 tablets per 30 days Alogliptin (Tablet) Maximum of 1 tablet per day Alogliptin/Metformin HCl (Tablet) Maximum of 2 tablets per day Alogliptin/Pioglitazone (Tablet) Maximum of 1 tablet per day Alora (Patch Twice Weekly) Maximum of 8 patches per 28 days Alprazolam (0.25mg Tablet Immediate-Release, 0.5mg Tablet Immediate-Release, 1mg Tablet Maximum of 4 tablets per day Immediate-Release) Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day Alprazolam ER (1mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Alprazolam ER (2mg Tablet Extended-Release Maximum of 5 tablets per day 24 Hour) Alprazolam ER (3mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Alprazolam Intensol (1mg/ml Concentrate) Maximum of 10 ml per day
Bold type = Brand name drug Plain type = Generic drug
121 122
Drug Name Quantity Limit Alprazolam ODT (0.25mg Tablet Dispersible, 0.5mg Tablet Dispersible, 1mg Tablet Maximum of 4 tablets per day Dispersible) Alprazolam ODT (2mg Tablet Dispersible) Maximum of 5 tablets per day Alprazolam XR (0.5mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Altace (Capsule) Maximum of 2 capsules per day Altoprev (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Maximum of 2 inhalers (12.2 grams) per 30 Alvesco (160mcg/act Aerosol Solution) days Alvesco (80mcg/act Aerosol Solution) Maximum of 1 inhaler (6.1 grams) per 30 days Amaryl (1mg Tablet) Maximum of 8 tablets per day Amaryl (2mg Tablet) Maximum of 4 tablets per day Amaryl (4mg Tablet) Maximum of 2 tablets per day Ambien (Tablet) Maximum of 90 days of use per year Amerge (Tablet) Maximum of 9 tablets per 30 days Amitiza (Capsule) Maximum of 2 capsules per day Amlodipine Besylate/Atorvastatin Calcium Maximum of 1 tablet per day (Tablet) Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day Amlodipine/Valsartan/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Amphetamine/Dextroamphetamine (10mg Capsule Extended-Release 24 Hour, 15mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 25mg Maximum of 2 capsules per day Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour) Amphetamine/Dextroamphetamine (10mg Tablet Immediate-Release, 12.5mg Tablet Immediate-Release, 15mg Tablet Immediate- Maximum of 2 tablets per day Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Amphetamine/Dextroamphetamine (20mg Maximum of 3 tablets per day Tablet Immediate-Release) Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Androderm (Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Apokyn (Injection) Maximum of 2 cartridges (6 ml) per day Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day Aptensio XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Aptiom (200mg Tablet, 400mg Tablet, 800mg Maximum of 1 tablet per day Tablet) Aptiom (600mg Tablet) Maximum of 2 tablets per day Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day Aptivus (250mg Capsule) Maximum of 6 capsules per day Arcapta Neohaler (Capsule) Maximum of 1 capsule per day Aricept (10mg Tablet) Maximum of 2 tablets per day Aricept (23mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Aripiprazole (Tablet) Maximum of 1 tablet per day Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day Armodafinil (150mg Tablet, 200mg Tablet, Maximum of 1 tablet per day 250mg Tablet) Armodafinil (50mg Tablet) Maximum of 2 tablets per day Arnuity Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Asmanex HFA (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Asmanex Twisthaler 120 Metered Doses Maximum of 1 inhaler per 30 days (Aerosol Powder) Asmanex Twisthaler 30 Metered Doses Maximum of 2 inhalers per 30 days (110mcg/INH Aerosol Powder) Asmanex Twisthaler 30 Metered Doses Maximum of 1 inhaler per 30 days (220mcg/INH Aerosol Powder) Asmanex Twisthaler 60 Metered Doses Maximum of 1 inhaler per 30 days (Aerosol Powder) Aspirin/Dipyridamole (Capsule Extended- Maximum of 2 capsules per day Release 12 Hour) Atacand (16mg Tablet, 32mg Tablet, 4mg Maximum of 1 tablet per day Tablet) Atacand (8mg Tablet) Maximum of 3 tablets per day Atacand HCT (Tablet) Maximum of 1 tablet per day Atelvia (Tablet Delayed-Release) Maximum of 4 tablets per 28 days Ativan (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Ativan (2mg Tablet) Maximum of 5 tablets per day Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day Atripla (Tablet) Maximum of 2 tablets per day Aubagio (Tablet) Maximum of 1 tablet per day Avalide (Tablet) Maximum of 1 tablet per day Avandia (2mg Tablet) Maximum of 4 tablets per day Avandia (4mg Tablet) Maximum of 2 tablets per day Avapro (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Avapro (75mg Tablet) Maximum of 3 tablets per day Axert (12.5mg Tablet, 6.25mg Tablet) Maximum of 12 tablets per 30 days Axiron (Transdermal Solution) Maximum of 2 bottles (180 ml) per 30 days Azelastine HCl (0.1% Nasal Solution) Maximum of 2 bottles (60 ml) per 30 days Azor (Tablet) Maximum of 1 tablet per day Belbuca (Film) Maximum of 2 films per day Belsomra (Tablet) Maximum of 1 tablet per day Benazepril HCl (Tablet) Maximum of 2 tablets per day Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Benicar (20mg Tablet, 40mg Tablet) Maximum of 1 tablet per day Benicar (5mg Tablet) Maximum of 2 tablets per day Benicar HCT (Tablet) Maximum of 1 tablet per day Bethkis (Nebulized Solution) Maximum of 8 ml (2 ampules) per day BiDil (Tablet) Maximum of 6 tablets per day Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days Bisoprolol Fumarate/Hydrochlorothiazide Maximum of 2 tablets per day (2.5mg-6.25mg Tablet, 5mg-6.25mg Tablet) Boniva (150mg Tablet) Maximum of 1 tablet per 28 days Bosulif (100mg Tablet) Maximum of 6 tablets per day Bosulif (500mg Tablet) Maximum of 1 tablet per day Botox (Injection) Maximum of 9 vials per 30 days Breo Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Brilinta (Tablet) Maximum of 2 tablets per day BRIVIACT (100mg Tablet, 10mg Tablet, Maximum of 2 tablets per day 25mg Tablet, 50mg Tablet, 75mg Tablet) BRIVIACT (10mg/ml Oral Solution) Maximum of 20 ml per day BRIVIACT (50mg/5ml Intravenous Solution) Maximum of 20 ml per day Brovana (Nebulized Solution) Maximum of 2 vials (4 ml) per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Bunavail (Film) Maximum of 2 films per day Buprenorphine HCl (2mg Tablet Sublingual, Maximum of 3 tablets per day 8mg Tablet Sublingual) Buprenorphine HCl/Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Butorphanol Tartrate (10mg/ml Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Butrans (Patch Weekly) Maximum of 4 patches per 28 days Bydureon (2mg Pen injector) Maximum of 4 pens per 28 days Bydureon (2mg Suspension Extended- Maximum of 4 vials per 28 days Release) Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days Bystolic (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 1 tablet per day Tablet) Bystolic (20mg Tablet) Maximum of 2 tablets per day Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day Cabometyx (40mg Tablet) Maximum of 2 tablets per day Caduet (Tablet) Maximum of 1 tablet per day Calcitonin-Salmon (Nasal Solution) Maximum of 1 bottle per 28 days Candesartan Cilexetil (16mg Tablet, 32mg Maximum of 1 tablet per day Tablet, 4mg Tablet) Candesartan Cilexetil (8mg Tablet) Maximum of 3 tablets per day Candesartan Cilexetil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Capital/Codeine (Suspension) Maximum of 150 ml per day Captopril (100mg Tablet) Maximum of 4 tablets per day Captopril (12.5mg Tablet, 25mg Tablet) Maximum of 3 tablets per day Captopril (50mg Tablet) Maximum of 9 tablets per day Captopril/Hydrochlorothiazide (25mg-15mg Maximum of 3 tablets per day Tablet, 50mg-15mg Tablet) Captopril/Hydrochlorothiazide (25mg-25mg Maximum of 2 tablets per day Tablet, 50mg-25mg Tablet) Cardizem LA (360mg Tablet Extended- Release 24 Hour, 420mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Cardura XL (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Celebrex (Capsule) Maximum of 2 capsules per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Celecoxib (Capsule) Maximum of 2 capsules per day Cerdelga (Capsule) Maximum of 2 capsules per day Cialis (2.5mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Clonazepam (0.5mg Tablet Immediate-Release, Maximum of 4 tablets per day 1mg Tablet Immediate-Release) Clonazepam (2mg Tablet Immediate-Release) Maximum of 10 tablets per day Clonazepam ODT (0.125mg Tablet Dispersible, 0.25mg Tablet Dispersible, 0.5mg Tablet Maximum of 4 tablets per day Dispersible, 1mg Tablet Dispersible) Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel (300mg Tablet) Maximum of 1 tablet per day Clopidogrel (75mg Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (Tablet) Maximum of 6 tablets per day Colchicine (0.6mg Capsule) (Generic Maximum of 4 capsules per day Mitigare) Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day Colcrys (Tablet) Maximum of 4 tablets per day Combivir (Tablet) Maximum of 3 tablets per day Complera (Tablet) Maximum of 2 tablets per day Concerta (18mg Tablet Extended-Release) Maximum of 3 tablets per day Concerta (27mg Tablet Extended-Release, Maximum of 2 tablets per day 36mg Tablet Extended-Release) Concerta (54mg Tablet Extended-Release) Maximum of 1 tablet per day Conzip (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Corlanor (Tablet) Maximum of 2 tablets per day Corzide (40mg-5mg Tablet) Maximum of 1 tablet per day Cotellic (Tablet) Maximum of 3 tablets per day Cozaar (100mg Tablet) Maximum of 1 tablet per day Cozaar (25mg Tablet, 50mg Tablet) Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
126 127
Drug Name Quantity Limit
Crestor (Tablet) Maximum of 1 tablet per day Crixivan (Capsule) Maximum of 9 capsules per day Cycloset (Tablet) Maximum of 6 tablets per day Cymbalta (Capsule Delayed-Release) Maximum of 2 capsules per day Daklinza (Tablet) Maximum of 1 tablet per day Daliresp (Tablet) Maximum of 1 tablet per day Darifenacin HBr ER (Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Daytrana (Patch) Maximum of 1 patch per day Denavir (Cream) Maximum of 1 tube (5 grams) per 30 days Descovy (Tablet) Maximum of 2 tablets per day Desvenlafaxine ER (100mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) Desvenlafaxine ER (50mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Dexedrine (10mg Capsule Extended-Release Maximum of 6 capsules per day 24 Hour) Dexedrine (10mg Tablet, 5mg Tablet) Maximum of 6 tablets per day Dexedrine (15mg Capsule Extended-Release Maximum of 4 capsules per day 24 Hour) Dexedrine (5mg Capsule Extended-Release Maximum of 3 capsules per day 24 Hour) Dexilant (Capsule Delayed-Release) Maximum of 1 capsule per day Dexmethylphenidate HCl (Tablet Immediate- Maximum of 2 tablets per day Release) Dextroamphetamine Sulfate (Tablet Immediate- Maximum of 6 tablets per day Release) Dextroamphetamine Sulfate ER (10mg Capsule Maximum of 6 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (15mg Capsule Maximum of 4 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (5mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) Diazepam (10mg Tablet, 2mg Tablet, 5mg Maximum of 4 tablets per day Tablet) Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day Digitek (0.125mg Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Digoxin (0.05mg/ml Oral Solution) Maximum of 5 ml per day Digoxin (125mcg Tablet) Maximum of 1 tablet per day Dilaudid (1mg/ml Liquid) Maximum of 90 ml per day Dilaudid (2mg Tablet, 4mg Tablet) Maximum of 8 tablets per day Dilaudid (8mg Tablet) Maximum of 11 tablets per day Diovan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Diovan (320mg Tablet) Maximum of 1 tablet per day Diovan HCT (Tablet) Maximum of 1 tablet per day Ditropan XL (10mg Tablet Extended-Release 24 Hour, 15mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Ditropan XL (5mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour) Dolophine (10mg Tablet) Maximum of 12 tablets per day Dolophine (5mg Tablet) Maximum of 8 tablets per day Donepezil HCl (10mg Tablet Immediate- Maximum of 2 tablets per day Release) Donepezil HCl (23mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release) Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day Doxercalciferol (1mcg Capsule, 2.5mcg Maximum of 4 capsules per day Capsule) Dronabinol (Capsule) Maximum of 4 capsules per day Duetact (Tablet) Maximum of 1 tablet per day Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Duloxetine HCl (20mg Capsule Delayed- Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day Capsule Delayed-Release) Duloxetine HCl (40mg Capsule Delayed- Maximum of 3 capsules per day Release) Duragesic (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Maximum of 15 patches per 30 days Hour, 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour) Edarbi (Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit
Edarbyclor (Tablet) Maximum of 1 tablet per day Edurant (Tablet) Maximum of 2 tablets per day Effient (Tablet) Maximum of 1 tablet per day Eliquis (Tablet) Maximum of 2 tablets per day Embeda (100mg-4mg Capsule Extended- Maximum of 3 capsules per day Release) Embeda (20mg-0.8mg Capsule Extended- Release, 80mg-3.2mg Capsule Extended- Maximum of 4 capsules per day Release) Embeda (30mg-1.2mg Capsule Extended- Release, 50mg-2mg Capsule Extended- Maximum of 2 capsules per day Release) Embeda (60mg-2.4mg Capsule Extended- Maximum of 6 capsules per day Release) Emsam (Patch 24 Hour) Maximum of 1 patch per day Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day Emtriva (200mg Capsule) Maximum of 2 capsules per day Enablex (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Enalapril Maleate (Tablet) Maximum of 2 tablets per day Enalapril Maleate/Hydrochlorothiazide Maximum of 2 tablets per day (10mg-25mg Tablet) Enalapril Maleate/Hydrochlorothiazide Maximum of 1 tablet per day (5mg-12.5mg Tablet) Endocet (Tablet) Maximum of 12 tablets per day Enoxaparin Sodium (100mg/ml Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150mg/ml Subcutaneous Solution) Enoxaparin Sodium (120mg/0.8ml Subcutaneous Solution, 80mg/0.8ml Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day Enoxaparin Sodium (30mg/0.3ml Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (40mg/0.4ml Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60mg/0.6ml Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution) Entresto (Tablet) Maximum of 2 tablets per day Epivir (10mg/ml Oral Solution) Maximum of 48 ml per day Epivir (150mg Tablet) Maximum of 3 tablets per day
Bold type = Brand name drug Plain type = Generic drug
129 130
Drug Name Quantity Limit
Epivir (300mg Tablet) Maximum of 2 tablets per day Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day Epzicom (Tablet) Maximum of 2 tablets per day Erivedge (Capsule) Maximum of 1 capsule per day Esbriet (Capsule) Maximum of 9 capsules per day Esomeprazole Magnesium (20mg Capsule Maximum of 3 capsules per day Delayed-Release) (Generic Nexium) Esomeprazole Magnesium (40mg Capsule Maximum of 2 capsules per day Delayed-Release) (Generic Nexium) Estradiol (0.025mg/24hr Patch Twice Weekly, 0.0375mg/24hr Patch Twice Weekly, 0.05mg/ Maximum of 8 patches per 28 days 24hr Patch Twice Weekly, 0.075mg/24hr Patch Twice Weekly, 0.1mg/24hr Patch Twice Weekly) Evista (Tablet) Maximum of 1 tablet per day Evotaz (Tablet) Maximum of 2 tablets per day Exalgo (12mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 16mg Tablet Extended-Release 24 Hour Abuse-Deterrent, Maximum of 2 tablets per day 32mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 8mg Tablet Extended- Release 24 Hour Abuse-Deterrent) Exelon (1.5mg Capsule, 3mg Capsule, 4.5mg Maximum of 2 capsules per day Capsule, 6mg Capsule) Exelon (13.3mg/24hr Patch 24 Hour, 4.6mg/ 24hr Patch 24 Hour, 9.5mg/24hr Patch 24 Maximum of 1 patch per day Hour) Exforge (Tablet) Maximum of 1 tablet per day Exforge HCT (Tablet) Maximum of 1 tablet per day Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Famciclovir (500mg Tablet) Maximum of 3 tablets per day Famvir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Famvir (500mg Tablet) Maximum of 3 tablets per day Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Farxiga (Tablet) Maximum of 1 tablet per day Fazaclo (100mg Tablet Dispersible) Maximum of 9 tablets per day Fazaclo (12.5mg Tablet Dispersible) Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
130 131
Drug Name Quantity Limit
Fazaclo (150mg Tablet Dispersible) Maximum of 6 tablets per day Fazaclo (200mg Tablet Dispersible) Maximum of 4 tablets per day Fazaclo (25mg Tablet Dispersible) Maximum of 3 tablets per day Fentanyl (Patch 72 Hour) Maximum of 15 patches per 30 days Fentanyl Citrate Oral Transmucosal (Lollipop) Maximum of 4 lozenges per day Fentora (Tablet) Maximum of 4 tablets per day Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Firazyr (Injection) Maximum of 9 ml per day Flector (Patch) Maximum of 2 patches per day Maximum of 2 inhalers (120 blisters) per 30 Flovent Diskus (Aerosol Powder) days Flovent HFA (110mcg/act Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Flovent HFA (220mcg/act Aerosol) Maximum of 2 inhalers (24 grams) per 30 days Flovent HFA (44mcg/act Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day Fluvastatin Sodium ER (Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Focalin (Tablet) Maximum of 2 tablets per day Foradil Aerolizer (Capsule) Maximum of 2 capsules per day Fortamet (1000mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Fortamet (500mg Tablet Extended-Release Maximum of 5 tablets per day 24 Hour) Forteo (Injection) Maximum of 1 pen (2.4 ml) per 28 days Fortical (Nasal Solution) Maximum of 1 bottle per 28 days Fosamax (Tablet) Maximum of 4 tablets per 28 days Fosamax Plus D (Tablet) Maximum of 4 tablets per 28 days Fosinopril Sodium (Tablet) Maximum of 2 tablets per day Fosinopril Sodium/Hydrochlorothiazide (Tablet) Maximum of 4 tablets per day Frova (Tablet) Maximum of 9 tablets per 30 days Frovatriptan Succinate (Tablet) Maximum of 9 tablets per 30 days Fuzeon (Injection) Maximum of 3 vials per day Gabitril (12mg Tablet) Maximum of 4 tablets per day Gabitril (16mg Tablet) Maximum of 3 tablets per day Galantamine HBr (12mg Tablet, 4mg Tablet, Maximum of 2 tablets per day 8mg Tablet)
Bold type = Brand name drug Plain type = Generic drug
131 132
Drug Name Quantity Limit Galantamine HBr (16mg Capsule Extended- Release 24 Hour, 24mg Capsule Extended- Maximum of 1 capsule per day Release 24 Hour, 8mg Capsule Extended- Release 24 Hour) Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days Gelnique (10% Gel) Maximum of 1 packet per day Genvoya (Tablet) Maximum of 2 tablets per day Geodon (20mg Capsule, 40mg Capsule, Maximum of 2 capsules per day 60mg Capsule, 80mg Capsule) Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days Gleevec (Tablet) Maximum of 3 tablets per day Glimepiride (1mg Tablet) Maximum of 8 tablets per day Glimepiride (2mg Tablet) Maximum of 4 tablets per day Glimepiride (4mg Tablet) Maximum of 2 tablets per day Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day Glipizide ER (10mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Glipizide ER (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour) Glipizide ER (5mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day Glipizide/Metformin HCl (2.5mg-500mg Tablet, Maximum of 4 tablets per day 5mg-500mg Tablet) Glucophage (1000mg Tablet) Maximum of 2.5 tablets per day Glucophage (500mg Tablet) Maximum of 5 tablets per day Glucophage (850mg Tablet) Maximum of 3 tablets per day Glucophage XR (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) Glucophage XR (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Glucotrol (10mg Tablet) Maximum of 4 tablets per day Glucotrol (5mg Tablet) Maximum of 8 tablets per day Glucotrol XL (10mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Glucotrol XL (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour)
Bold type = Brand name drug Plain type = Generic drug
132 133
Drug Name Quantity Limit Glucotrol XL (5mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Glumetza (1000mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Glumetza (500mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour) Glyset (100mg Tablet) Maximum of 3 tablets per day Glyset (25mg Tablet) Maximum of 12 tablets per day Glyset (50mg Tablet) Maximum of 6 tablets per day Glyxambi (Tablet) Maximum of 1 tablet per day Granisetron HCl (1mg Tablet) Maximum of 2 tablets per day Grastek (Tablet Sublingual) Maximum of 1 tablet per day Harvoni (Tablet) Maximum of 1 tablet per day Hectorol (0.5mcg Capsule) Maximum of 3 capsules per day Hectorol (1mcg Capsule, 2.5mcg Capsule) Maximum of 4 capsules per day Hetlioz (Capsule) Maximum of 1 capsule per day Hycet (Oral Solution) Maximum of 180 ml per day Hydrocodone Bitartrate/Acetaminophen (10mg-300mg Tablet, 5mg-300mg Tablet, Maximum of 13 tablets per day 7.5mg-300mg Tablet) Hydrocodone Bitartrate/Acetaminophen Maximum of 180 ml per day (7.5mg-325mg/15ml Oral Solution) Hydrocodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Maximum of 12 tablets per day Tablet, 7.5mg-325mg Tablet) Hydrocodone/Ibuprofen (Tablet) Maximum of 5 tablets per day Hydromorphone HCl (1mg/ml Liquid) Maximum of 90 ml per day Hydromorphone HCl (2mg Tablet Immediate- Maximum of 8 tablets per day Release, 4mg Tablet Immediate-Release) Hydromorphone HCl (8mg Tablet Immediate- Maximum of 11 tablets per day Release) Hydromorphone HCl ER (12mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 16mg Tablet Extended-Release 24 Hour Abuse- Maximum of 2 tablets per day Deterrent, 8mg Tablet Extended-Release 24 Hour Abuse-Deterrent) Hydromorphone HCl ER (32mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour Abuse-Deterrent)
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit Hysingla ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour Abuse-Deterrent) Hyzaar (100mg-12.5mg Tablet, 100mg-25mg Maximum of 1 tablet per day Tablet) Hyzaar (50mg-12.5mg Tablet) Maximum of 2 tablets per day Ibandronate Sodium (150mg Tablet) Maximum of 1 tablet per 28 days Ibrance (Capsule) Maximum of 1 capsule per day Ibudone (Tablet) Maximum of 5 tablets per day Iclusig (15mg Tablet) Maximum of 2 tablets per day Iclusig (45mg Tablet) Maximum of 1 tablet per day Ilaris (Injection) Maximum of 2 doses per 28 days Imatinib Mesylate (Tablet) Maximum of 3 tablets per day Imbruvica (Capsule) Maximum of 4 capsules per day Imitrex (100mg Tablet, 25mg Tablet, 50mg Maximum of 9 tablets per 30 days Tablet) Imitrex (20mg/act Nasal Solution, 5mg/act Maximum of 12 devices per 30 days Nasal Solution) Imitrex (6mg/0.5ml Subcutaneous Solution) Maximum of 12 injections (6 ml) per 30 days Imitrex Statdose Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Incruse Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Inlyta (Tablet) Maximum of 4 tablets per day Intelence (100mg Tablet) Maximum of 2 tablets per day Intelence (200mg Tablet) Maximum of 3 tablets per day Intelence (25mg Tablet) Maximum of 6 tablets per day Invega (1.5mg Tablet Extended-Release 24 Hour, 3mg Tablet Extended-Release 24 Hour, Maximum of 1 tablet per day 9mg Tablet Extended-Release 24 Hour) Invega (6mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Invirase (200mg Capsule) Maximum of 15 capsules per day Invirase (500mg Tablet) Maximum of 6 tablets per day Invokamet (Tablet) Maximum of 2 tablets per day Invokana (Tablet) Maximum of 1 tablet per day Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Irbesartan (75mg Tablet) Maximum of 3 tablets per day Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Irenka (Capsule Delayed-Release) Maximum of 3 capsules per day
Bold type = Brand name drug Plain type = Generic drug
134 135
Drug Name Quantity Limit
Iressa (Tablet) Maximum of 2 tablets per day Isentress (100mg Packet) Maximum of 4 packets per day Isentress (100mg Tablet Chewable, 25mg Maximum of 9 tablets per day Tablet Chewable) Isentress (400mg Tablet) Maximum of 6 tablets per day Itraconazole (Capsule) Maximum of 4 capsules per day Jakafi (Tablet) Maximum of 2 tablets per day Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day Janumet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Januvia (Tablet) Maximum of 1 tablet per day Jardiance (Tablet) Maximum of 1 tablet per day Jentadueto (Tablet) Maximum of 2 tablets per day Jentadueto XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Jentadueto XR (5mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Kadian (100mg Capsule Extended-Release 24 Hour, 60mg Capsule Extended-Release 24 Maximum of 3 capsules per day Hour, 80mg Capsule Extended-Release 24 Hour) Kadian (10mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Maximum of 2 capsules per day Hour, 40mg Capsule Extended-Release 24 Hour, 50mg Capsule Extended-Release 24 Hour) Kadian (200mg Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day Kaletra (400mg-100mg/5ml Oral Solution) Maximum of 16 ml per day Kalydeco (150mg Tablet) Maximum of 2 tablets per day Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day Kazano (Tablet) Maximum of 2 tablets per day Keveyis (Tablet) Maximum of 4 tablets per day Khedezla (100mg Tablet Extended-Release Maximum of 4 tablets per day 24 Hour)
Bold type = Brand name drug Plain type = Generic drug
135 136
Drug Name Quantity Limit Khedezla (50mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Klonopin (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Klonopin (2mg Tablet) Maximum of 10 tablets per day Kombiglyze XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Kombiglyze XR (5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-500mg Maximum of 1 tablet per day Tablet Extended-Release 24 Hour) Korlym (Tablet) Maximum of 4 tablets per day Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day Lamivudine (150mg Tablet) Maximum of 3 tablets per day Lamivudine (300mg Tablet) Maximum of 2 tablets per day Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day Lanoxin (125mcg Tablet) Maximum of 1 tablet per day Lanoxin (62.5mcg Tablet) Maximum of 2 tablets per day Lansoprazole (Capsule Delayed-Release) Maximum of 2 capsules per day Latuda (120mg Tablet, 20mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 60mg Tablet) Latuda (80mg Tablet) Maximum of 2 tablets per day Lazanda (Nasal Solution) Maximum of 15 bottles (79.5 ml) per 30 days Lescol XL (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Letairis (Tablet) Maximum of 1 tablet per day Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day Lexiva (50mg/ml Suspension) Maximum of 90 ml per day Lexiva (700mg Tablet) Maximum of 6 tablets per day Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day Lidocaine (5% Patch) Maximum of 3 patches per day Lidoderm (Patch) Maximum of 3 patches per day Linezolid (600mg Tablet) Maximum of 2 tablets per day Linzess (Capsule) Maximum of 1 capsule per day Lipitor (Tablet) Maximum of 1 tablet per day Lisinopril (Tablet) Maximum of 2 tablets per day Lisinopril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet)
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit Lisinopril/Hydrochlorothiazide (20mg-12.5mg Maximum of 4 tablets per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-25mg Maximum of 2 tablets per day Tablet) Livalo (Tablet) Maximum of 1 tablet per day Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Lorazepam (2mg Tablet) Maximum of 5 tablets per day Lorazepam Intensol (2mg/ml Concentrate) Maximum of 5 ml per day Lorcet (Tablet) Maximum of 12 tablets per day Lorcet Plus (Tablet) Maximum of 12 tablets per day Lortab (Tablet) Maximum of 12 tablets per day Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day Losartan Potassium (25mg Tablet, 50mg Maximum of 2 tablets per day Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 1 tablet per day (100mg-12.5mg Tablet, 100mg-25mg Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 2 tablets per day (50mg-12.5mg Tablet) Lotensin (Tablet) Maximum of 2 tablets per day Lotrel (Capsule) Maximum of 1 capsule per day Lovastatin (10mg Tablet Immediate-Release, Maximum of 1 tablet per day 20mg Tablet Immediate-Release) Lovastatin (40mg Tablet Immediate-Release) Maximum of 2 tablets per day Lovaza (Capsule) Maximum of 4 capsules per day Lovenox (100mg/ml Subcutaneous Solution, Maximum of 2 syringes (2 ml) per day 150mg/ml Subcutaneous Solution) Lovenox (120mg/0.8ml Subcutaneous Solution, 80mg/0.8ml Subcutaneous Maximum of 2 syringes (1.6 ml) per day Solution) Lovenox (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day Lovenox (30mg/0.3ml Subcutaneous Maximum of 2 syringes (0.6 ml) per day Solution) Lovenox (40mg/0.4ml Subcutaneous Maximum of 2 syringes (0.8 ml) per day Solution) Lovenox (60mg/0.6ml Subcutaneous Maximum of 2 syringes (1.2 ml) per day Solution)
Bold type = Brand name drug Plain type = Generic drug
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Drug Name Quantity Limit Loxapine Succinate (10mg Capsule, 5mg Maximum of 4 capsules per day Capsule) Lynparza (Capsule) Maximum of 16 capsules per day Lyrica (100mg Capsule, 150mg Capsule, 200mg Capsule, 25mg Capsule, 50mg Maximum of 3 capsules per day Capsule, 75mg Capsule) Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Macrobid (Capsule) Maximum of 90 days of use per year Macrodantin (100mg Capsule) Maximum of 90 days of use per year Marinol (10mg Capsule, 2.5mg Capsule, 5mg Maximum of 4 capsules per day Capsule) Matzim LA (360mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour, 420mg Tablet Extended-Release 24 Hour) Mavik (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day Maxalt (Tablet) Maximum of 12 tablets per 30 days Maxalt-MLT (Tablet Dispersible) Maximum of 12 tablets per 30 days Memantine HCl (10mg Tablet) Maximum of 2 tablets per day Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day Memantine HCl (5mg Tablet) Maximum of 3 tablets per day Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day Metformin HCl (1000mg Tablet Immediate- Maximum of 2.5 tablets per day Release) Metformin HCl (500mg Tablet Immediate- Maximum of 5 tablets per day Release) Metformin HCl (850mg Tablet Immediate- Maximum of 3 tablets per day Release) Metformin HCl ER (1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Fortamet) Metformin HCl ER (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Glucophage XR) Metformin HCl ER (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Glucophage XR) Methadone HCl (10mg Tablet) Maximum of 12 tablets per day Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day Methadone HCl (5mg Tablet) Maximum of 8 tablets per day Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day Methylin (10mg/5ml Oral Solution) Maximum of 30 ml per day
Bold type = Brand name drug Plain type = Generic drug
138 139
Drug Name Quantity Limit
Methylin (5mg/5ml Oral Solution) Maximum of 60 ml per day Methylphenidate HCl (10mg Tablet Chewable) Maximum of 6 tablets per day Methylphenidate HCl (10mg Tablet Immediate- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 3 tablets per day Tablet Immediate-Release) (Generic Ritalin) Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylphenidate HCl (2.5mg Tablet Chewable, Maximum of 3 tablets per day 5mg Tablet Chewable) Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day Methylphenidate HCl ER (10mg Tablet Maximum of 4 tablets per day Extended-Release) Methylphenidate HCl ER (18mg Tablet Maximum of 3 tablets per day Extended-Release 24 Hour) Methylphenidate HCl ER (20mg Tablet Maximum of 3 tablets per day Extended-Release) Methylphenidate HCl ER (27mg Tablet Extended-Release 24 Hour, 36mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Methylphenidate HCl ER (54mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Miacalcin (200unit/ACT Nasal Solution) Maximum of 1 bottle per 28 days Micardis (Tablet) Maximum of 1 tablet per day Micardis HCT (Tablet) Maximum of 1 tablet per day Miglitol (100mg Tablet) Maximum of 3 tablets per day Miglitol (25mg Tablet) Maximum of 12 tablets per day Miglitol (50mg Tablet) Maximum of 6 tablets per day Minivelle (Patch Twice Weekly) Maximum of 8 patches per 28 days Mitigare (Capsule) Maximum of 4 capsules per day Modafinil (100mg Tablet) Maximum of 1 tablet per day Modafinil (200mg Tablet) Maximum of 2 tablets per day Moexipril HCl (7.5mg Tablet) Maximum of 2 tablets per day Moexipril/Hydrochlorothiazide (15mg-12.5mg Maximum of 2 tablets per day Tablet, 15mg-25mg Tablet) Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Maximum of 1 tablet per day Tablet) Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day Montelukast Sodium (4mg Packet) Maximum of 1 packet per day
Bold type = Brand name drug Plain type = Generic drug
139 140
Drug Name Quantity Limit Montelukast Sodium (4mg Tablet Chewable, Maximum of 1 tablet per day 5mg Tablet Chewable) Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 18 ml per day Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 120 ml per day Morphine Sulfate (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 90 ml per day Morphine Sulfate (30mg Tablet Immediate- Maximum of 12 tablets per day Release) Morphine Sulfate ER (100mg Capsule Extended-Release 24 Hour, 60mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour, 80mg Capsule Extended-Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (100mg Tablet Extended- Release, 15mg Tablet Extended-Release) Maximum of 3 tablets per day (Generic MS Contin) Morphine Sulfate ER (10mg Capsule Extended- Release 24 Hour, 20mg Capsule Extended- Release 24 Hour, 30mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour, 50mg Capsule Extended- Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (120mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (200mg Tablet Extended- Maximum of 2 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (30mg Capsule Extended- Release 24 Hour, 45mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour, 60mg Capsule Extended- Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (30mg Tablet Extended- Release, 60mg Tablet Extended-Release) Maximum of 4 tablets per day (Generic MS Contin) Morphine Sulfate ER (75mg Capsule Extended- Release 24 Hour, 90mg Capsule Extended- Maximum of 4 capsules per day Release 24 Hour) (Generic Avinza) Movantik (Tablet) Maximum of 1 tablet per day MS Contin (100mg Tablet Extended-Release, Maximum of 3 tablets per day 15mg Tablet Extended-Release) MS Contin (200mg Tablet Extended-Release) Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
140 141
Drug Name Quantity Limit MS Contin (30mg Tablet Extended-Release, Maximum of 4 tablets per day 60mg Tablet Extended-Release) Multaq (Tablet) Maximum of 2 tablets per day Nadolol/Bendroflumethiazide (40mg-5mg Maximum of 1 tablet per day Tablet) Namenda (10mg Tablet Immediate-Release) Maximum of 2 tablets per day Namenda (10mg/5ml Oral Solution) Maximum of 10 ml per day Namenda (5mg Tablet Immediate-Release) Maximum of 3 tablets per day Namenda XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Namenda XR Titration Pack (Capsule Maximum of 1 capsule per day Extended-Release 24 Hour) Namzaric (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Naratriptan HCl (Tablet) Maximum of 9 tablets per 30 days Nateglinide (120mg Tablet) Maximum of 3 tablets per day Nateglinide (60mg Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution) Maximum of 300 mg (1 vial) in 28 days Nesina (Tablet) Maximum of 1 tablet per day Nevirapine (200mg Tablet Immediate-Release) Maximum of 3 tablets per day Nevirapine (50mg/5ml Suspension) Maximum of 60 ml per day Nevirapine ER (100mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Nevirapine ER (400mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Nifedical XL (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day Nifedipine ER (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Ninlaro (Capsule) Maximum of 3 capsules per 28 days Nitrofurantoin Macrocrystals (100mg Capsule) Maximum of 90 days of use per year (Generic Macrodantin) Nitrofurantoin Monohydrate (100mg Capsule) Maximum of 90 days of use per year (Generic Macrobid) Norco (Tablet) Maximum of 12 tablets per day Northera (100mg Capsule) Maximum of 3 capsules per day Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day
Bold type = Brand name drug Plain type = Generic drug
141 142
Drug Name Quantity Limit
Norvir (100mg Capsule) Maximum of 18 capsules per day Norvir (100mg Tablet) Maximum of 18 tablets per day Norvir (80mg/ml Oral Solution) Maximum of 24 ml per day Noxafil (100mg Tablet Delayed-Release) Maximum of 8 tablets per day Noxafil (40mg/ml Suspension) Maximum of 20 ml per day Nucala (Injection) Maximum of 1 vial per 28 days Nucynta (100mg Tablet, 50mg Tablet, 75mg Maximum of 6 tablets per day Tablet) Nucynta ER (Tablet Extended-Release 12 Maximum of 2 tablets per day Hour) Nuplazid (Tablet) Maximum of 2 tablets per day Nuvigil (150mg Tablet, 200mg Tablet, 250mg Maximum of 1 tablet per day Tablet) Nuvigil (50mg Tablet) Maximum of 2 tablets per day Odefsey (Tablet) Maximum of 2 tablets per day Odomzo (Capsule) Maximum of 1 capsule per day Ofev (Capsule) Maximum of 2 capsules per day Olanzapine (10mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 2.5mg Tablet Immediate-Release, 20mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day Omega-3-Acid Ethyl Esters (Capsule) (Generic Maximum of 4 capsules per day Lovaza) Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day Onglyza (Tablet) Maximum of 1 tablet per day Onzetra Xsail (Exhaler Powder) Maximum of 1 kit (8 pouches) per 30 days Opana (10mg Tablet Immediate-Release, Maximum of 6 tablets per day 5mg Tablet Immediate-Release)
Bold type = Brand name drug Plain type = Generic drug
142 143
Drug Name Quantity Limit Opana ER (10mg Tablet Extended-Release 12 Hour Abuse-Deterrent, 15mg Tablet Extended-Release 12 Hour Abuse-Deterrent, 20mg Tablet Extended-Release 12 Hour Maximum of 2 tablets per day Abuse-Deterrent, 5mg Tablet Extended- Release 12 Hour Abuse-Deterrent, 7.5mg Tablet Extended-Release 12 Hour Abuse- Deterrent) Opana ER (30mg Tablet Extended-Release 12 Maximum of 4 tablets per day Hour Abuse-Deterrent) Opana ER (40mg Tablet Extended-Release 12 Maximum of 3 tablets per day Hour Abuse-Deterrent) Oralair (Tablet Sublingual) Maximum of 1 tablet per day Orenitram (0.125mg Tablet Extended- Release, 0.25mg Tablet Extended-Release, Maximum of 6 tablets per day 1mg Tablet Extended-Release) Orkambi (Tablet) Maximum of 112 tablets per 28 days Oseni (Tablet) Maximum of 1 tablet per day Oxandrolone (10mg Tablet) Maximum of 2 tablets per day Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10mg Tablet Extended-Release 24 Hour, 15mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (5mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Oxycodone HCl (100mg/5ml Concentrate) Maximum of 12 ml per day Oxycodone HCl (10mg Tablet Immediate- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 12 tablets per day Tablet Immediate-Release) Oxycodone HCl (15mg Tablet Immediate- Maximum of 16 tablets per day Release) Oxycodone HCl (30mg Tablet Immediate- Maximum of 8 tablets per day Release) Oxycodone HCl (5mg Capsule Immediate- Maximum of 12 capsules per day Release) Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 240 ml per day Oxycodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Maximum of 12 tablets per day Tablet, 7.5mg-325mg Tablet)
Bold type = Brand name drug Plain type = Generic drug
143 144
Drug Name Quantity Limit Oxycodone/Acetaminophen (325mg/5ml-5mg/ Maximum of 60 ml per day 5ml Oral Solution) Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day OxyContin (Tablet Extended-Release 12 Hour Maximum of 3 tablets per day Abuse-Deterrent) Oxymorphone HCl (Tablet Immediate-Release) Maximum of 6 tablets per day Oxymorphone HCl ER (10mg Tablet Extended- Release 12 Hour, 15mg Tablet Extended- Release 12 Hour, 20mg Tablet Extended- Maximum of 2 tablets per day Release 12 Hour, 5mg Tablet Extended-Release 12 Hour, 7.5mg Tablet Extended-Release 12 Hour) Oxymorphone HCl ER (30mg Tablet Extended- Maximum of 4 tablets per day Release 12 Hour) Oxymorphone HCl ER (40mg Tablet Extended- Maximum of 3 tablets per day Release 12 Hour) Paliperidone ER (1.5mg Tablet Extended- Release 24 Hour, 3mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour, 9mg Tablet Extended-Release 24 Hour) Paliperidone ER (6mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Pantoprazole Sodium (20mg Tablet Delayed- Maximum of 3 tablets per day Release) Pantoprazole Sodium (40mg Tablet Delayed- Maximum of 2 tablets per day Release) Paricalcitol (1mcg Capsule) Maximum of 1 capsule per day Paricalcitol (2mcg Capsule) Maximum of 2 capsules per day Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day Percocet (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Tablet, 7.5mg-325mg Maximum of 12 tablets per day Tablet) Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day Perindopril Erbumine (Tablet) Maximum of 2 tablets per day Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Glimepiride (Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
144 145
Drug Name Quantity Limit
Pioglitazone HCl/Metformin HCl (Tablet) Maximum of 3 tablets per day Plavix (300mg Tablet) Maximum of 1 tablet per day Plavix (75mg Tablet) Maximum of 4 tablets per day Pomalyst (Capsule) Maximum of 1 capsule per day Potiga (200mg Tablet, 300mg Tablet, 400mg Maximum of 3 tablets per day Tablet) Potiga (50mg Tablet) Maximum of 9 tablets per day Pradaxa (Capsule) Maximum of 2 capsules per day Praluent (150mg/ml Solution Pen injector, Maximum of 2 pens (2 ml) per 28 days 75mg/ml Solution Pen injector) Praluent (150mg/ml Solution Prefilled Maximum of 2 syringes (2 ml) per 28 days Syringe, 75mg/ml Solution Prefilled Syringe) Prandin (0.5mg Tablet) Maximum of 32 tablets per day Prandin (1mg Tablet) Maximum of 16 tablets per day Prandin (2mg Tablet) Maximum of 8 tablets per day Pravachol (Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Tablet) Maximum of 1 tablet per day Precose (100mg Tablet) Maximum of 3 tablets per day Precose (25mg Tablet) Maximum of 12 tablets per day Precose (50mg Tablet) Maximum of 6 tablets per day Prevacid (Capsule Delayed-Release) Maximum of 2 capsules per day Prezcobix (Tablet) Maximum of 2 tablets per day Prezista (100mg/ml Suspension) Maximum of 60 ml per day Prezista (150mg Tablet) Maximum of 6 tablets per day Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day Prezista (75mg Tablet) Maximum of 7 tablets per day Primlev (10mg-300mg Tablet, 5mg-300mg Maximum of 13 tablets per day Tablet, 7.5mg-300mg Tablet) Prinivil (Tablet) Maximum of 2 tablets per day Pristiq (100mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Pristiq (25mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Procardia XL (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Promacta (12.5mg Tablet, 25mg Tablet) Maximum of 1 tablet per day Promacta (50mg Tablet, 75mg Tablet) Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
145 146
Drug Name Quantity Limit
Protonix (20mg Tablet Delayed-Release) Maximum of 3 tablets per day Protonix (40mg Tablet Delayed-Release) Maximum of 2 tablets per day Provigil (100mg Tablet) Maximum of 1 tablet per day Provigil (200mg Tablet) Maximum of 2 tablets per day Pulmicort Flexhaler (Aerosol Powder) Maximum of 2 inhalers per 30 days Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day Quetiapine Fumarate (100mg Tablet Immediate- Release, 200mg Tablet Immediate-Release, Maximum of 3 tablets per day 50mg Tablet Immediate-Release) Quetiapine Fumarate (25mg Tablet Immediate- Maximum of 4 tablets per day Release) Quetiapine Fumarate (300mg Tablet Immediate- Maximum of 2 tablets per day Release, 400mg Tablet Immediate-Release) QuilliChew ER (20mg Tablet Chewable Extended-Release, 40mg Tablet Chewable Maximum of 1 tablet per day Extended-Release) QuilliChew ER (30mg Tablet Chewable Maximum of 2 tablets per day Extended-Release) Quinapril HCl (Tablet) Maximum of 2 tablets per day Quinapril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Quinapril/Hydrochlorothiazide (20mg-12.5mg Maximum of 2 tablets per day Tablet, 20mg-25mg Tablet) Maximum of 2 inhalers (17.4 grams) per 30 QVAR (Aerosol Solution) days Ragwitek (Tablet Sublingual) Maximum of 1 tablet per day Raloxifene HCl (Tablet) Maximum of 1 tablet per day Ramipril (Capsule) Maximum of 2 capsules per day Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Rapaflo (Capsule) Maximum of 1 capsule per day RAVICTI (Liquid) Maximum of 17.5 ml per day Razadyne (Tablet) Maximum of 2 tablets per day Razadyne ER (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days Relpax (Tablet) Maximum of 12 tablets per 30 days Repaglinide (0.5mg Tablet) Maximum of 32 tablets per day Repaglinide (1mg Tablet) Maximum of 16 tablets per day
Bold type = Brand name drug Plain type = Generic drug
146 147
Drug Name Quantity Limit
Repaglinide (2mg Tablet) Maximum of 8 tablets per day Repaglinide/Metformin HCl (Tablet) Maximum of 5 tablets per day Repatha (Injection) Maximum of 3 syringes (3 ml) per 28 days Repatha SureClick (Injection) Maximum of 3 pens (3 ml) per 28 days Reprexain (Tablet) Maximum of 5 tablets per day Rescriptor (Tablet) Maximum of 9 tablets per day Restasis (Emulsion) Maximum of 2 vials per day Retrovir (100mg Capsule) Maximum of 8 capsules per day Retrovir (50mg/5ml Syrup) Maximum of 96 ml per day Revatio (10mg/ml Suspension) Maximum of 6 ml per day Revatio (20mg Tablet) Maximum of 3 tablets per day Revlimid (Capsule) Maximum of 1 capsule per day Rexulti (Tablet) Maximum of 1 tablet per day Reyataz (150mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Reyataz (200mg Capsule) Maximum of 3 capsules per day Reyataz (50mg Packet) Maximum of 8 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Risedronate Sodium (150mg Tablet) Maximum of 1 tablet per 30 days Risedronate Sodium (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Risedronate Sodium (35mg Tablet) Maximum of 4 tablets per 28 days Risedronate Sodium DR (Tablet Delayed- Maximum of 4 tablets per 28 days Release) Ritalin (Tablet) Maximum of 3 tablets per day Rivastigmine Tartrate (Capsule Immediate- Maximum of 2 capsules per day Release) Rivastigmine Transdermal System (Patch 24 Maximum of 1 patch per day Hour) Rizatriptan Benzoate (Tablet Immediate- Maximum of 12 tablets per 30 days Release) Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day Roxicodone (15mg Tablet) Maximum of 16 tablets per day Roxicodone (30mg Tablet) Maximum of 8 tablets per day Roxicodone (5mg Tablet) Maximum of 12 tablets per day Rozerem (Tablet) Maximum of 1 tablet per day Sabril (500mg Packet) Maximum of 6 packets per day Sabril (500mg Tablet) Maximum of 6 tablets per day
Bold type = Brand name drug Plain type = Generic drug
147 148
Drug Name Quantity Limit
Samsca (Tablet) Maximum of 2 tablets per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Savaysa (Tablet) Maximum of 1 tablet per day Selzentry (150mg Tablet) Maximum of 3 tablets per day Selzentry (300mg Tablet) Maximum of 6 tablets per day Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day Sensipar (90mg Tablet) Maximum of 4 tablets per day Maximum of 1 inhaler (60 inhalations) per 30 Serevent Diskus (Aerosol Powder) days Seroquel (100mg Tablet, 200mg Tablet, Maximum of 3 tablets per day 50mg Tablet) Seroquel (25mg Tablet) Maximum of 4 tablets per day Seroquel (300mg Tablet, 400mg Tablet) Maximum of 2 tablets per day Seroquel XR (150mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Seroquel XR (300mg Tablet Extended- Release 24 Hour, 400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour, 50mg Tablet Extended- Release 24 Hour) sfRowasa (Enema) Maximum of 1 bottle (60 ml) per day Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day Simvastatin (Tablet) Maximum of 1 tablet per day Singulair (10mg Tablet) Maximum of 1 tablet per day Singulair (4mg Packet) Maximum of 1 packet per day Singulair (4mg Tablet Chewable, 5mg Tablet Maximum of 1 tablet per day Chewable) Somavert (Injection) Maximum of 1 vial per day Sonata (Capsule) Maximum of 90 days of use per year Sovaldi (Tablet) Maximum of 1 tablet per day Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Sporanox (100mg Capsule) Maximum of 4 capsules per day Sprycel (100mg Tablet, 140mg Tablet, 70mg Maximum of 1 tablet per day Tablet) Sprycel (20mg Tablet, 50mg Tablet) Maximum of 3 tablets per day Sprycel (80mg Tablet) Maximum of 2 tablets per day Starlix (120mg Tablet) Maximum of 3 tablets per day
Bold type = Brand name drug Plain type = Generic drug
148 149
Drug Name Quantity Limit
Starlix (60mg Tablet) Maximum of 6 tablets per day Stavudine (15mg Capsule, 30mg Capsule, Maximum of 3 capsules per day 40mg Capsule) Stavudine (1mg/ml Oral Solution) Maximum of 120 ml per day Stavudine (20mg Capsule) Maximum of 2 capsules per day Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Stivarga (Tablet) Maximum of 4 tablets per day Strattera (100mg Capsule, 60mg Capsule, Maximum of 1 capsule per day 80mg Capsule) Strattera (10mg Capsule, 18mg Capsule, Maximum of 2 capsules per day 25mg Capsule, 40mg Capsule) Stribild (Tablet) Maximum of 2 tablets per day Striverdi Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 sublingual films per day Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 sublingual films per day Subsys (Liquid) Maximum of 4 sprays per day Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100mg Tablet, 25mg Maximum of 9 tablets per 30 days Tablet, 50mg Tablet) Sumatriptan Succinate (6mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Auto injector) Sumatriptan Succinate (6mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Prefilled Syringe) Sumatriptan Succinate (6mg/0.5ml Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Sumavel DosePro (Injection) Maximum of 12 injections (6 ml) per 30 days Sustiva (200mg Capsule) Maximum of 3 capsules per day Sustiva (50mg Capsule) Maximum of 9 capsules per day Sustiva (600mg Tablet) Maximum of 2 tablets per day Sutent (12.5mg Capsule, 25mg Capsule, Maximum of 1 capsule per day 50mg Capsule) Sutent (37.5mg Capsule) Maximum of 2 tablets per day Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Synalgos-DC (Capsule) Maximum of 8 capsules per day Synjardy (Tablet) Maximum of 2 tablets per day Tagrisso (Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
149 150
Drug Name Quantity Limit Tamiflu (30mg Capsule, 45mg Capsule, Maximum of 2 capsules per day 75mg Capsule) Tamiflu (6mg/ml Suspension) Maximum of 26 ml per day Tanzeum (Injection) Maximum of 4 pens per 28 days Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day Tarceva (25mg Tablet) Maximum of 3 tablets per day Tarka (Tablet Extended-Release) Maximum of 1 tablet per day Tasigna (150mg Capsule) Maximum of 5 capsules per day Tasigna (200mg Capsule) Maximum of 4 capsules per day Tasmar (Tablet) Maximum of 6 tablets per day Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day Technivie (Tablet) Maximum of 2 tablets per day Tekturna (Tablet) Maximum of 1 tablet per day Tekturna HCT (Tablet) Maximum of 1 tablet per day Telmisartan (Tablet) Maximum of 1 tablet per day Telmisartan/Amlodipine (Tablet) Maximum of 1 tablet per day Telmisartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 tablets per day Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day Tivicay (50mg Tablet) Maximum of 3 tablets per day TOBI (Nebulized Solution) Maximum of 10 ml (2 ampules) per day TOBI Podhaler (Capsule) Maximum of 8 capsules per day Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day Tolazamide (250mg Tablet) Maximum of 4 tablets per day Tolazamide (500mg Tablet) Maximum of 2 tablets per day Tolbutamide (Tablet) Maximum of 6 tablets per day Tolcapone (Tablet) Maximum of 6 tablets per day Toviaz (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day Tracleer (Tablet) Maximum of 2 tablets per day Tradjenta (Tablet) Maximum of 1 tablet per day Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day
Bold type = Brand name drug Plain type = Generic drug
150 151
Drug Name Quantity Limit Tramadol HCl ER (100mg Capsule Extended- Release 24 Hour, 200mg Capsule Extended- Maximum of 1 capsule per day Release 24 Hour, 300mg Capsule Extended- Release 24 Hour) Tramadol HCl ER (100mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) (Generic Ultram ER) Tramadol HCl ER (300mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) (Generic Ryzolt) Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day Trandolapril (4mg Tablet) Maximum of 2 tablets per day Trandolapril/Verapamil HCl (Tablet Extended- Maximum of 1 tablet per day Release) Tranxene T (3.75mg Tablet) Maximum of 24 tablets per day Tranxene T (7.5mg Tablet) Maximum of 12 tablets per day Treximet (Tablet) Maximum of 9 tablets per 30 days Trezix (Capsule) Maximum of 10 capsules per day Tribenzor (Tablet) Maximum of 1 tablet per day Trintellix (Tablet) Maximum of 1 tablet per day Triumeq (Tablet) Maximum of 2 tablets per day Trizivir (Tablet) Maximum of 3 tablets per day Trokendi XR (100mg Capsule Extended- Release 24 Hour, 50mg Capsule Extended- Maximum of 3 capsules per day Release 24 Hour) Trokendi XR (200mg Capsule Extended- Release 24 Hour, 25mg Capsule Extended- Maximum of 2 capsules per day Release 24 Hour) Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days Truvada (Tablet) Maximum of 2 tablets per day Twynsta (Tablet) Maximum of 1 tablet per day Tybost (Tablet) Maximum of 2 tablets per day Tylenol/Codeine #3 (Tablet) Maximum of 13 tablets per day Tylenol/Codeine #4 (Tablet) Maximum of 13 tablets per day Tyvaso (Inhalation Solution) Maximum of 4 ampules per day Ultracet (Tablet) Maximum of 12 tablets per day Ultram (Tablet) Maximum of 8 tablets per day Ultram ER (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
151 152
Drug Name Quantity Limit Uptravi (1000mcg Tablet, 1200mcg Tablet, 1400mcg Tablet, 1600mcg Tablet, 200mcg Maximum of 2 tablets per day Tablet, 400mcg Tablet, 600mcg Tablet, 800mcg Tablet) Vagifem (Tablet) Maximum of 1 tablet per day Valacyclovir HCl (1000mg Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day Valcyte (450mg Tablet) Maximum of 4 tablets per day Valium (Tablet) Maximum of 4 tablets per day Valsartan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Valsartan (320mg Tablet) Maximum of 1 tablet per day Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Valtrex (1gm Tablet) Maximum of 4 tablets per day Valtrex (500mg Tablet) Maximum of 2 tablets per day Vasotec (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 2 tablets per day Tablet) Veltassa (Packet) Maximum of 1 packet per day Venclexta (100mg Tablet) Maximum of 4 tablets per day Venclexta (10mg Tablet) Maximum of 2 tablets per day Venclexta (50mg Tablet) Maximum of 1 tablet per day Ventavis (10mcg/ml Inhalation Solution) Maximum of 7 ml per day Ventavis (20mcg/ml Inhalation Solution) Maximum of 3 ml per day Vesicare (Tablet) Maximum of 1 tablet per day Viberzi (Tablet) Maximum of 2 tablets per day Vicodin (Tablet) Maximum of 13 tablets per day Vicodin ES (Tablet) Maximum of 13 tablets per day Vicodin HP (Tablet) Maximum of 13 tablets per day Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days Videx EC (Capsule Delayed-Release) Maximum of 2 capsules per day Videx Pediatric (Oral Solution) Maximum of 30 ml per day Viekira Pak (Tablet Therapy Pack) Maximum of 1 pack (112 tablets) per 28 days Viibryd (Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Kit) Maximum of 1 tablet per day Vimpat (100mg Tablet, 150mg Tablet, 200mg Maximum of 2 tablets per day Tablet, 50mg Tablet) Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day
Bold type = Brand name drug Plain type = Generic drug
152 153
Drug Name Quantity Limit
Viracept (250mg Tablet) Maximum of 15 tablets per day Viracept (625mg Tablet) Maximum of 6 tablets per day Viramune (200mg Tablet) Maximum of 3 tablets per day Viramune (50mg/5ml Suspension) Maximum of 60 ml per day Viramune XR (100mg Tablet Extended- Maximum of 3 tablets per day Release 24 Hour) Viramune XR (400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Viread (150mg Tablet) Maximum of 1 tablet per day Viread (200mg Tablet, 250mg Tablet, 300mg Maximum of 2 tablets per day Tablet) Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days Vitekta (Tablet) Maximum of 2 tablets per day Vivelle-Dot (Patch Twice Weekly) Maximum of 8 patches per 28 days Vivlodex (Capsule) Maximum of 1 capsule per day Votrient (Tablet) Maximum of 4 tablets per day Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg Maximum of 1 capsule per day Capsule, 6mg Capsule) Vytorin (Tablet) Maximum of 1 tablet per day Xanax (0.25mg Tablet, 0.5mg Tablet, 1mg Maximum of 4 tablets per day Tablet) Xanax (2mg Tablet) Maximum of 5 tablets per day Xanax XR (0.5mg Tablet Extended-Release 24 Hour, 1mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xanax XR (2mg Tablet Extended-Release 24 Maximum of 5 tablets per day Hour) Xanax XR (3mg Tablet Extended-Release 24 Maximum of 3 tablets per day Hour) Xarelto (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day Xarelto (15mg Tablet) Maximum of 2 tablets per day Xarelto Starter Pack (Tablet Therapy Pack) Maximum of 1 pack (51 tablets) per 30 days Xartemis XR (Tablet Extended-Release) Maximum of 12 tablets per day Xeljanz (Tablet) Maximum of 2 tablets per day Xeljanz XR (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xenazine (12.5mg Tablet) Maximum of 3 tablets per day Xenazine (25mg Tablet) Maximum of 4 tablets per day
Bold type = Brand name drug Plain type = Generic drug
153 154
Drug Name Quantity Limit
Xerese (Cream) Maximum of 1 tube (5 grams) per 30 days Xigduo XR (10mg-1000mg Tablet Extended- Release 24 Hour, 10mg-500mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour, 5mg-500mg Tablet Extended-Release 24 Hour) Xigduo XR (5mg-1000mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) Xodol (10mg-300mg Tablet, 5mg-300mg Tablet, Maximum of 13 tablets per day 7.5mg-300mg Tablet) Xtampza ER (Capsule Extended-Release 12 Maximum of 3 capsules per day Hour Abuse-Deterrent) Xtandi (Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Xyzal (5mg Tablet) Maximum of 1 tablet per day Zafirlukast (Tablet) Maximum of 2 tablets per day Zaleplon (Capsule) Maximum of 90 days of use per year Zamicet (Oral Solution) Maximum of 180 ml per day Zelboraf (Tablet) Maximum of 8 tablets per day Zembrace Symtouch (Injection) Maximum of 8 ml (16 syringes) per 30 days Zemplar (1mcg Capsule) Maximum of 1 capsule per day Zemplar (2mcg Capsule) Maximum of 2 capsules per day Zenzedi (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 6 tablets per day Tablet, 7.5mg Tablet) Zenzedi (15mg Tablet) Maximum of 4 tablets per day Zenzedi (20mg Tablet) Maximum of 3 tablets per day Zenzedi (30mg Tablet) Maximum of 2 tablets per day Zepatier (Tablet) Maximum of 1 tablet per day Zerit (15mg Capsule, 30mg Capsule, 40mg Maximum of 3 capsules per day Capsule) Zerit (1mg/ml Oral Solution) Maximum of 120 ml per day Zerit (20mg Capsule) Maximum of 2 capsules per day Zestoretic (10mg-12.5mg Tablet) Maximum of 1 tablet per day Zestoretic (20mg-12.5mg Tablet) Maximum of 4 tablets per day Zestril (Tablet) Maximum of 2 tablets per day Zetia (Tablet) Maximum of 1 tablet per day Ziac (Tablet) Maximum of 2 tablets per day Ziagen (20mg/ml Oral Solution) Maximum of 48 ml per day
Bold type = Brand name drug Plain type = Generic drug
154 155
Drug Name Quantity Limit
Ziagen (300mg Tablet) Maximum of 3 tablets per day Zidovudine (100mg Capsule) Maximum of 8 capsules per day Zidovudine (300mg Tablet) Maximum of 3 tablets per day Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day Ziprasidone HCl (Capsule) Maximum of 2 capsules per day Zocor (Tablet) Maximum of 1 tablet per day Zohydro ER (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour Abuse-Deterrent) Zolmitriptan (Tablet) Maximum of 12 tablets per 30 days Zolmitriptan ODT (2.5mg Tablet Dispersible) Maximum of 12 tablets per 30 days Zolmitriptan ODT (5mg Tablet Dispersible) Maximum of 9 tablets per 30 days Zolpidem Tartrate (10mg Tablet Immediate- Maximum of 90 days of use per year Release, 5mg Tablet Immediate-Release) Zomig (2.5mg Tablet, 5mg Tablet) Maximum of 12 tablets per 30 days Zomig Nasal Spray (2.5mg Solution) Maximum of 18 devices per 30 days Zomig Nasal Spray (5mg Solution) Maximum of 12 devices per 30 days Zomig ZMT (2.5mg Tablet Dispersible) Maximum of 12 tablets per 30 days Zomig ZMT (5mg Tablet Dispersible) Maximum of 9 tablets per 30 days Zontivity (Tablet) Maximum of 1 tablet per day Zovirax (5% Cream) Maximum of 1 tube (5 grams) per 30 days Zovirax (5% Ointment) Maximum of 1 tube (30 grams) per 30 days Zubsolv (1.4mg-0.36mg Tablet Sublingual, Maximum of 3 tablets per day 5.7mg-1.4mg Tablet Sublingual) Zubsolv (11.4mg-2.9mg Tablet Sublingual) Maximum of 1 tablet per day Zubsolv (2.9mg-0.71mg Tablet Sublingual) Maximum of 5 tablets per day Zubsolv (8.6mg-2.1mg Tablet Sublingual) Maximum of 2 tablets per day Zydelig (Tablet) Maximum of 2 tablets per day Zykadia (Capsule) Maximum of 5 capsules per day Zyprexa (10mg Tablet, 15mg Tablet, 2.5mg Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Maximum of 1 tablet per day Tablet) Zyprexa Zydis (10mg Tablet Dispersible, 15mg Tablet Dispersible, 20mg Tablet Maximum of 1 tablet per day Dispersible, 5mg Tablet Dispersible) Zytiga (Tablet) Maximum of 4 tablets per day Zyvox (600mg Tablet) Maximum of 2 tablets per day
track
Bold type = Brand name drug Plain type = Generic drug
155 Tracked
156 trackIndex of covered drugs
# Actimmune...... 101 Agrylin...... 62 8-MOP...... 79 Actiq...... 17 Akynzeo...... 39 A Actonel...... 103 Ala Cort...... 88 A-Hydrocort...... 88 Actoplus Met...... 59 Ala Scalp...... 88 Abacavir...... 56 Actoplus Met XR...... 59 Albenza...... 48 Abacavir Sulfate/Lamivudine/ Actos...... 59 Albuterol Sulfate...... 111 Zidovudine...... 56 Acular...... 107 Albuterol Sulfate ER...... 111 Abelcet...... 40 Acular LS...... 107 Alcaine...... 105 Abilify...... 51 Acuvail...... 107 Alclometasone Dipropionate Abilify Maintena...... 51 Acyclovir...... 54 ...... 88 Abraxane...... 45 Acyclovir Sodium...... 54 Alcohol Prep Pads...... 105 Absorica...... 79 Aczone...... 79 Aldactazide...... 70 Abstral...... 17 Adacel...... 101 Aldactone...... 73 Acamprosate Calcium DR...20 Adagen...... 82 Aldara...... 79 Acanya...... 79 Adalat CC...... 67 Aldurazyme...... 82 Acarbose...... 59 Adapalene...... 79 Alecensa...... 45 Accolate...... 110 Adcirca...... 112 Alendronate Sodium...... 103 Accupril...... 65 Adderall...... 75 Alfuzosin HCl ER...... 87 Accuretic...... 70 Adderall XR...... 75 Alimta...... 45 Acebutolol HCl...... 66 Adefovir Dipivoxil...... 54 Alinia...... 48 Acetaminophen/Codeine....17 Adempas...... 112 Alkeran...... 44 Acetasol HC...... 108 Adoxa...... 29 Allopurinol...... 42 Acetazolamide...... 72 Adrenalin...... 111 Almotriptan Malate...... 43 Acetazolamide ER...... 72 Adrucil...... 45 Alocril...... 106 Acetazolamide Sodium...... 72 Advair Diskus...... 113 Alogliptin...... 59 Acetic Acid...... 108 Advair HFA...... 113 Alogliptin/Metformin HCl.... 59 Acetylcysteine...... 113 Adzenys XR-ODT...... 75 Alogliptin/Pioglitazone...... 59 Aciphex...... 85 Aerospan...... 109 Alomide...... 106 Aciphex Sprinkle...... 85 Afeditab CR...... 67 Aloprim...... 42 Acitretin...... 79 Afinitor...... 47 Alora...... 93 Actemra...... 101 Afinitor Disperz...... 47 Alosetron HCl...... 84 ActHIB...... 101 Afrezza...... 61 Aloxi...... 39 Actigall...... 83 Aggrenox...... 63 Alphagan P...... 106
156 Tracked
157
Alprazolam...... 57 Amitiza...... 84 Antabuse...... 20 Alprazolam ER...... 57 Amitriptyline HCl...... 38 Antara...... 73 Alprazolam Intensol...... 57 Amlodipine Besylate...... 67 Anusol-HC...... 103 Alprazolam ODT...... 57 Amlodipine Besylate/ Anzemet...... 39 Alprazolam XR...... 58 Atorvastatin Calcium...... 70 ApexiCon E...... 88 Alrex...... 107 Amlodipine Besylate/ Apidra SoloStar...... 61 Benazepril HCl...... 70 Altabax...... 21 Apidra Vial...... 61 Amlodipine Besylate/ Altace...... 65 Aplenzin...... 36 Valsartan...... 70 Altoprev...... 74 Apokyn...... 49 Amlodipine/Valsartan/ Alvesco...... 109 Hydrochlorothiazide...... 70 Apraclonidine...... 106 Amantadine HCl...... 49 Ammonium Chloride...... 115 Apri...... 93 Amaryl...... 59 Ammonium Lactate...... 79 Apriso...... 102 Ambien...... 114 Amoxapine...... 38 Aptensio XR...... 76 AmBisome...... 40 Amoxicillin...... 25 Aptiom...... 34 Amcinonide...... 88 Amoxicillin/Clavulanate Aptivus...... 57 Amerge...... 43 Potassium...... 26 Aralast NP...... 113 Amethia...... 93 Amoxicillin/Clavulanate Aranelle...... 93 Potassium ER...... 26 Amethyst...... 93 Aranesp Albumin Free...... 63 Amphetamine/ Amifostine...... 45 Arava...... 101 Dextroamphetamine...... 76 Amikacin Sulfate...... 21 Arcalyst...... 101 Amphotericin B...... 40 Amiloride HCl...... 73 Arcapta Neohaler...... 111 Ampicillin...... 26 Amiloride/ Argatroban...... 63 Ampicillin Sodium...... 26 Hydrochlorothiazide...... 70 Aricept...... 35 Ampicillin-Sulbactam...... 26 Aminophylline...... 112 Arimidex...... 47 Ampyra...... 78 Aminosyn 7%/Electrolytes Aripiprazole...... 51 ...... 116 Anadrol-50...... 92 Aripiprazole ODT...... 51 Aminosyn 8.5%/Electrolytes Anafranil...... 38 Aristada...... 51 ...... 116 Anagrelide HCl...... 62 Arixtra...... 62 Aminosyn II...... 116 Anaprox DS...... 12 Armodafinil...... 114 Aminosyn II 8.5%/Electrolytes Anastrozole...... 47 ...... 116 Arnuity Ellipta...... 109 Ancobon...... 40 Aminosyn-HBC...... 116 Aromasin...... 47 Androderm...... 92 Aminosyn-PF...... 116 Arranon...... 45 AndroGel...... 92 Aminosyn-RF...... 116 Arthrotec 50...... 12 AndroGel Pump...... 92 Amiodarone HCl...... 65 Arthrotec 75...... 12 Anoro Ellipta...... 113 157 Tracked
158
Asacol HD...... 102 Avandia...... 59 Bacitracin/Polymyxin B..... 105 Ashlyna...... 93 Avapro...... 64 Baclofen...... 114 Asmanex HFA...... 109 Avastin...... 48 Bactocill in Dextrose...... 26 Asmanex Twisthaler 120 AVC...... 40 Bactrim...... 29 Metered Doses...... 109 Aveed...... 92 Bactrim DS...... 29 Asmanex Twisthaler 30 Avelox...... 28 Bactroban...... 21 Metered Doses...... 110 Avelox ABC Pack...... 28 Bactroban Nasal...... 21 Asmanex Twisthaler 60 Aviane...... 93 Balsalazide Disodium...... 102 Metered Doses...... 110 Avita...... 79 Balziva...... 93 Aspirin/Dipyridamole...... 64 Avodart...... 87 Banzel...... 34 Astagraf XL...... 99 Avonex...... 78 Baraclude...... 54 Astepro...... 109 Avonex Pen...... 78 BCG Vaccine...... 101 Atacand...... 64 Avycaz...... 24 Beconase AQ...... 110 Atacand HCT...... 70 Axert...... 43 Bekyree...... 93 Atelvia...... 103 Axiron...... 93 Belbuca...... 20 Atenolol...... 66 Aygestin...... 97 Beleodaq...... 45 Atenolol/Chlorthalidone...... 70 Azacitidine...... 45 Belsomra...... 114 Atgam...... 101 Azactam in Iso-Osmotic Benazepril HCl...... 65 Ativan...... 58 Dextrose...... 25 Benazepril HCl/ Atorvastatin Calcium...... 74 Azasan...... 99 Hydrochlorothiazide...... 70 Atovaquone...... 48 Azasite...... 27 Benicar...... 64 Atovaquone/Proguanil HCl Azathioprine...... 99 Benicar HCT...... 70 ...... 48 Azelastine HCl...... 106, 109 Benlysta...... 101 Atralin...... 79 Azelex...... 79 Bentyl...... 83 Atripla...... 55 Azilect...... 50 BenzaClin...... 79 Atropine Sulfate...... 83, 105 Azithromycin...... 27 Benzamycin...... 79 Atrovent...... 110 Azopt...... 106 Benztropine Mesylate...... 49 Atrovent HFA...... 110 Azor...... 70 Bepreve...... 106 Aubagio...... 78 Aztreonam...... 25 Berinert...... 99 Aubra...... 93 Azulfidine...... 103 Besivance...... 28 Augmented Betamethasone Dipropionate...... 88 Azulfidine EN-Tabs...... 103 Betagan...... 106 Augmentin...... 26 B Betamethasone Dipropionate ...... 88 Auryxia...... 87 BACiiM...... 21 Betamethasone Valerate..... 88 Avalide...... 70 Bacitracin...... 21
158 Tracked
159
Betapace...... 65 Breo Ellipta...... 113 Cafergot...... 42 Betaseron...... 78 Brevicon-28...... 93 Calan...... 67 Betaxolol HCl...... 66, 106 Briellyn...... 93 Calan SR...... 67 Bethanechol Chloride...... 87 Brilinta...... 64 Calcipotriene...... 79 Bethkis...... 21 Brimonidine Tartrate...... 106, Calcipotriene/Betamethasone Betimol...... 106 107 Dipropionate...... 80 Betoptic-S...... 106 Brisdelle...... 37 Calcitonin-Salmon...... 103 Bexarotene...... 48 BRIVIACT...... 30 Calcitriol...... 80, 103 Bexsero...... 101 Bromfenac...... 107 Calcium Acetate...... 87 Beyaz...... 93 Bromocriptine Mesylate...... 49 Cambia...... 12 Biaxin...... 27 Brovana...... 111 Camila...... 97 Bicalutamide...... 45 Budesonide...... 103, 110 Camptosar...... 45 Bicillin C-R...... 26 Bumetanide...... 72 Canasa...... 102 Bicillin L-A...... 26 Bunavail...... 20 Cancidas...... 40 BiCNU...... 44 Buphenyl...... 82 Candesartan Cilexetil...... 64 BiDil...... 70 Buprenex...... 20 Candesartan Cilexetil/ Hydrochlorothiazide...... 70 Biltricide...... 48 Buprenorphine HCl...... 20 Capastat Sulfate...... 44 Bimatoprost...... 108 Buprenorphine HCl/Naloxone HCl...... 20 Capex...... 88 Binosto...... 103 Buproban...... 20 Capital/Codeine...... 17 Bisoprolol Fumarate...... 66 Bupropion HCl...... 36 Caprelsa...... 47 Bisoprolol Fumarate/ Hydrochlorothiazide...... 70 Bupropion HCl SR...... 36 Captopril...... 65 BIVIGAM...... 101 Bupropion HCl XL...... 36 Captopril/Hydrochlorothiazide ...... 70 Bleomycin Sulfate...... 45 Buspirone HCl...... 57 Carac...... 80 Bleph-10...... 29 Busulfex...... 44 Carafate...... 85 Blephamide...... 105 Butorphanol Tartrate...... 17 Carbaglu...... 115 Blephamide S.O.P...... 105 Butrans...... 20 Carbamazepine...... 34 Blisovi 24 Fe...... 93 Bydureon...... 59 Carbamazepine ER...... 34 Blisovi Fe 1.5/30...... 93 Byetta...... 59 Carbatrol...... 34 Blisovi Fe 1/20...... 93 Bystolic...... 66 Carbidopa...... 50 Boniva...... 103 C Carbidopa/Levodopa...... 50 Boostrix...... 101 Cabergoline...... 98 Carbidopa/Levodopa ER.....50 Bosulif...... 47 Cabometyx...... 47 Carbidopa/Levodopa ODT Botox...... 105 Caduet...... 70 ...... 50
159 Tracked
160
Carbidopa/Levodopa/ Ceftin...... 24 Cholbam...... 83 Entacapone...... 50 Ceftriaxone Sodium...... 24 Cholestyramine Light...... 74 Carboplatin...... 45 Cefuroxime Axetil...... 24 Chorionic Gonadotropin...... 91 Cardene IV...... 67 Cefuroxime Sodium...... 24 Cialis...... 87 Cardizem...... 67 Celebrex...... 12 Ciclopirox...... 40 Cardizem CD...... 67 Celecoxib...... 12 Ciclopirox Nail Lacquer...... 40 Cardizem LA...... 67, 68 Celexa...... 37 Ciclopirox Olamine...... 40 Cardura...... 64 Cellcept...... 99 Cidofovir...... 53 Cardura XL...... 87 Cellcept Intravenous...... 99 Cilostazol...... 64 Carimune Nanofiltered...... 101 Celontin...... 31 Ciloxan...... 28 Carnitor...... 116 Cephalexin...... 25 Cimetidine...... 84 Carteolol HCl...... 107 Cerdelga...... 82 Cimetidine HCl...... 84 Cartia XT...... 68 Cerebyx...... 34 Cimzia...... 99 Carvedilol...... 66 Cerezyme...... 82 Cinryze...... 99 Casodex...... 45 Cervarix...... 101 Cipro...... 28 Catapres...... 64 Cesamet...... 39 Cipro HC...... 108 Catapres-TTS-1...... 64 Cetirizine HCl...... 109 Cipro I.V. in D5W...... 28 Catapres-TTS-2...... 64 Cevimeline HCl...... 79 Ciprodex...... 108 Catapres-TTS-3...... 64 Chantix...... 20 Ciprofloxacin...... 28 Cayston...... 112 Chantix Continuing Month Ciprofloxacin ER...... 28 Cedax...... 24 Pak...... 20 Ciprofloxacin HCl...... 28 Cefaclor...... 24 Chantix Starting Month Pak Ciprofloxacin I.V. in D5W.....28 ...... 21 Cefaclor ER...... 24 Cisplatin...... 45 Chemet...... 114 Cefadroxil...... 24 Citalopram HBr...... 37 Chenodal...... 83 Cefazolin Sodium...... 24 Cladribine...... 45 Chloramphenicol Sodium Cefdinir...... 24 Claforan...... 25 Succinate...... 21 Cefepime...... 24 Claravis...... 80 Chlordiazepoxide HCl...... 58 Cefixime...... 24 Clarinex...... 109 Chlorhexidine Gluconate Oral Cefotaxime Sodium...... 24 Rinse...... 79 Clarinex-D 12 Hour...... 113 Cefotetan...... 24 Chloroquine Phosphate...... 48 Clarithromycin...... 27 Cefoxitin Sodium...... 24 Chlorothiazide...... 73 Clarithromycin ER...... 27 Cefpodoxime Proxetil...... 24 Chlorothiazide Sodium...... 73 Cleocin...... 22 Cefprozil...... 24 Chlorpromazine HCl...... 50 Cleocin in D5W...... 22 Ceftazidime...... 24 Chlorthalidone...... 73
160 Tracked
161
Cleocin Pediatric Granules Clinimix E 2.75%/Dextrose 5% Codeine Sulfate...... 17 ...... 22 ...... 117 Cogentin...... 49 Cleocin Phosphate...... 22 Clinimix E 4.25%/Dextrose Colazal...... 102 10%...... 117 Cleocin-T...... 80 Colchicine...... 42 Clinimix E 4.25%/Dextrose Climara Pro...... 93 Colcrys...... 42 25%...... 117 Clindacin PAC...... 80 Colestid...... 74 Clinimix E 4.25%/Dextrose 5% Clindagel...... 80 ...... 117 Colestipol HCl...... 74 Clindamax...... 80 Clinimix E 5%/Dextrose 15% Colistimethate Sodium...... 22 Clindamycin HCl...... 22 ...... 117 Colocort...... 103 Clindamycin Palmitate HCl Clinimix E 5%/Dextrose 20% Coly-Mycin S...... 109 ...... 22 ...... 117 CoLyte-Flavor Packs...... 84 Clindamycin Phosphate...... 22, Clinimix E 5%/Dextrose 25% Combigan...... 107 80 ...... 117 Combivent Respimat...... 113 Clindamycin Phosphate in Clinisol SF 15%...... 117 D5W...... 22 Combivir...... 56 Clobetasol Propionate...... 88 Clindamycin/Benzoyl Cometriq...... 47 Clobetasol Propionate E...... 88 Peroxide...... 80 Complera...... 55 Clobex...... 88 Clindesse...... 22 Compro...... 39 Clodan...... 88 Clinimix 2.75%/Dextrose 5% Comtan...... 49 ...... 116 Cloderm Pump...... 88 Concerta...... 76 Clinimix 4.25%/Dextrose 10% Clolar...... 45 Condylox...... 80 ...... 116 Clomipramine HCl...... 38 Constulose...... 84 Clinimix 4.25%/Dextrose 20% Clonazepam...... 58 Conzip...... 14 ...... 116 Clonazepam ODT...... 58 Copaxone...... 79 Clinimix 4.25%/Dextrose 25% Clonidine HCl...... 64 ...... 116 Copegus...... 54 Clonidine HCl ER...... 76 Clinimix 4.25%/Dextrose 5% Cordran Tape...... 88 Clopidogrel...... 64 ...... 117 Coreg...... 66 Clorazepate Dipotassium.... 58 Clinimix 5%/Dextrose 15% Coreg CR...... 66 ...... 117 Clorpres...... 70 Corgard...... 66 Clinimix 5%/Dextrose 20% Clotrimazole...... 40 Corlanor...... 70 ...... 117 Clotrimazole/Betamethasone Cormax Scalp Application...88 Clinimix 5%/Dextrose 25% Dipropionate...... 80 ...... 117 Clozapine...... 53 Cortef...... 88 Clinimix E 2.75%/Dextrose Clozapine ODT...... 53 Cortisone Acetate...... 88 10%...... 117 Clozaril...... 53 Cortisporin...... 80 Coartem...... 48 Corzide...... 70
161 Tracked
162
Cosentyx...... 99 Cytomel...... 97 Depakote Sprinkles...... 58 Cosentyx Sensoready Pen...99 Cytotec...... 85 Depen Titratabs...... 87 Cosmegen...... 46 Cytovene...... 53 Depo-Estradiol...... 93 Cosopt...... 107 D Depo-Medrol...... 88 Cotellic...... 47 Dacarbazine...... 44 Depo-Provera...... 97 Coumadin...... 62 Dacogen...... 46 Depo-Provera Contraceptive Cozaar...... 64 Daklinza...... 54 ...... 97 Creon...... 82 Daliresp...... 112 Depo-SubQ Provera104...... 97 Cresemba...... 40 Dalvance...... 22 Depo-Testosterone...... 93 Crestor...... 74 Danazol...... 93 Dermatop...... 88 Crinone...... 97 Dantrium...... 114 Descovy...... 56 Crixivan...... 57 Dantrolene Sodium...... 114 Desipramine HCl...... 39 Cromolyn Sodium...... 83, 106, Dapsone...... 44 Desloratadine...... 109 113 Daptacel...... 102 Desloratadine ODT...... 109 Cryselle-28...... 93 DARAPRIM...... 48 Desmopressin Acetate...... 92 Cubicin...... 22 Darifenacin HBr ER...... 86 Desogen...... 93 Cuprimine...... 87 Darzalex...... 48 Desogestrel/Ethinyl Estradiol ...... 93 Cutivate...... 88 Daunorubicin HCl...... 46 Desonate...... 89 Cuvposa...... 83 Daypro...... 12 Desonide...... 89 Cyclafem...... 93 Daytrana...... 77 DesOwen...... 89 Cyclessa...... 93 DDAVP...... 91, 92 Desoximetasone...... 89 Cyclobenzaprine HCl...... 114 Deblitane...... 97 Desoxyn...... 76 Cyclophosphamide...... 44 Decitabine...... 46 Desvenlafaxine ER...... 37 Cycloset...... 59 Delestrogen...... 93 Detrol...... 86 Cyclosporine...... 99 Delyla...... 93 Detrol LA...... 86 Cyclosporine Modified...... 99 Delzicol...... 102 Dexamethasone...... 89 Cyklokapron...... 63 Demadex...... 72 Dexamethasone Intensol..... 89 Cymbalta...... 78 Demeclocycline HCl...... 29 Dexamethasone Sodium Cyproheptadine HCl...... 109 Demser...... 70 Phosphate...... 89, 107 Cyramza...... 48 Denavir...... 55 Dexedrine...... 76 Cystadane...... 82 Depacon...... 31 Dexilant...... 85 Cystagon...... 82 Depakene...... 31 Dexmethylphenidate HCl.....77 Cystaran...... 105 Depakote...... 58 Dexmethylphenidate HCl ER Cytarabine Aqueous...... 45 Depakote ER...... 58 ...... 77
162 Tracked
163
DexPak 13 Day...... 89 Diclofenac Sodium/ Divalproex Sodium DR...... 58 Dexrazoxane...... 46 Misoprostol...... 12 Divalproex Sodium ER...... 58 Dextroamphetamine Sulfate Dicloxacillin Sodium...... 26 Docefrez...... 46 ...... 76 Dicyclomine HCl...... 83 Docetaxel...... 46 Dextroamphetamine Sulfate Didanosine...... 56 Dofetilide...... 65 ER...... 76 Differin...... 80 Dolophine...... 14 Dextrose 10%...... 117 Dificid...... 27 Donepezil HCl...... 35 Dextrose 10%/NaCl 0.2% Diflorasone Diacetate...... 89 Donepezil HCl ODT...... 35 ...... 117 Diflucan...... 41 Doribax...... 25 Dextrose 10%/NaCl 0.45% Diflunisal...... 12 ...... 117 Dorzolamide HCl...... 107 Digitek...... 70 Dextrose 2.5%/Sodium Dorzolamide HCl/Timolol Chloride 0.45%...... 117 Digoxin...... 70 Maleate...... 107 Dextrose 5%...... 117 Dihydroergotamine Mesylate Dovonex...... 80 ...... 42, 43 Dextrose 5%/NaCl 0.2%.... 117 Doxazosin Mesylate...... 64 Dilantin...... 34 Dextrose 5%/NaCl 0.225% Doxepin HCl...... 39, 80 ...... 117 Dilantin INFATABS...... 34 Doxercalciferol...... 104 Dextrose 5%/NaCl 0.33% Dilantin-125...... 34 Doxil...... 46 ...... 117 Dilaudid...... 17 Doxorubicin HCl...... 46 Dextrose 5%/NaCl 0.45% Dilt-XR...... 68 Doxorubicin HCl Liposome ...... 117 Diltiazem CD...... 68 ...... 46 Dextrose 5%/NaCl 0.9%.... 117 Diltiazem HCl...... 68 Doxy 100...... 29 Dextrose 5%/Potassium Diltiazem HCl ER...... 68 Doxycycline...... 29 Chloride 0.15%...... 117 Diovan...... 64 Doxycycline Hyclate...... 29 Diamox...... 72 Diovan HCT...... 71 Doxycycline Hyclate DR...... 29 Diastat AcuDial...... 31 Dipentum...... 102 Doxycycline Monohydrate... 29 Diastat Pediatric...... 31 Diphenhydramine HCl...... 109 Dronabinol...... 40 Diazepam...... 31, 58 Diphenoxylate/Atropine...... 83 Drospirenone/Ethinyl Diazepam Intensol...... 58 Diphtheria/Tetanus Toxoids Estradiol...... 93 Dibenzyline...... 64 Adsorbed Pediatric...... 102 Droxia...... 45 Diclofenac Potassium...... 12 Diprolene...... 89 Duac...... 80 Diclofenac Sodium...... 12, 80, Diprolene AF...... 89 Duetact...... 59 107 Disulfiram...... 20 Duexis...... 12 Diclofenac Sodium DR...... 12 Ditropan XL...... 86 Dulera...... 113 Diclofenac Sodium ER...... 12 Diuril...... 73 Duloxetine HCl...... 78 Divalproex Sodium...... 58 Duopa...... 50 163 Tracked
164
Duragesic...... 14 Eliphos...... 87 Epiduo...... 80 Duramorph...... 17 Eliquis...... 62 Epiduo Forte...... 80 Durezol...... 107 Elitek...... 45 Epinastine HCl...... 106 Durlaza...... 64 Elixophyllin...... 112 Epinephrine...... 111 Dutasteride...... 87 Ellence...... 46 EpiPen...... 111 Dutasteride/Tamsulosin HCl Elmiron...... 87 Epitol...... 34 ...... 87 Elocon...... 89 Epivir...... 56 DUTOPROL...... 71 Emadine...... 106 Epivir HBV...... 54 Dyazide...... 71 Embeda...... 14 Eplerenone...... 73 Dymista...... 113 Emcyt...... 45 Epogen...... 63 Dyrenium...... 73 Emend...... 40 Eprosartan Mesylate...... 64 Dysport...... 105 Emoquette...... 94 Epzicom...... 56 E Empliciti...... 48 Equetro...... 58 E.E.S. 400...... 27 Emsam...... 36 Eraxis...... 41 E.E.S. Granules...... 27 Emtriva...... 56 Erbitux...... 48 EC-Naprosyn...... 12 Emverm...... 48 Ergomar...... 43 Econazole Nitrate...... 41 Enablex...... 86 Erivedge...... 47 Edarbi...... 64 Enalapril Maleate...... 65 Errin...... 97 Edarbyclor...... 71 Enalapril Maleate/ Ertaczo...... 41 Edecrin...... 72 Hydrochlorothiazide...... 71 Erwinaze...... 46 Edurant...... 55 Enbrel...... 99 Ery...... 80 Effexor XR...... 37 Enbrel SureClick...... 99 Ery-Tab...... 27 Effient...... 64 Endocet...... 17 Erygel...... 80 Efudex...... 80 Engerix-B...... 102 EryPed 200...... 27 Egrifta...... 98 Enoxaparin Sodium...... 62 EryPed 400...... 27 Elaprase...... 82 Enpresse-28...... 94 Erythrocin Lactobionate...... 27 Elavil...... 39 Enstilar...... 80 Erythrocin Stearate...... 27 Eldepryl...... 50 Entacapone...... 49 Erythromycin...... 27, 80 Elelyso...... 82 Entecavir...... 54 Erythromycin Base...... 27 Elestat...... 106 Entocort EC...... 103 Erythromycin Ethylsuccinate Elestrin...... 93 Entresto...... 71 ...... 27 Elidel...... 80 Enulose...... 84 Erythromycin/Benzoyl Eligard...... 98 Envarsus XR...... 99 Peroxide...... 80 Elimite...... 49 Epaned...... 65 Esbriet...... 113
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Escitalopram Oxalate...... 37 Falmina...... 94 Fibricor...... 73 Esomeprazole Magnesium Famciclovir...... 55 Finacea...... 80 ...... 85 Famotidine...... 84 Finasteride...... 87 Esomeprazole Sodium...... 85 Famotidine Premixed...... 84 Firazyr...... 99 Estrace...... 94 Famvir...... 55 Firmagon...... 98 Estradiol...... 94 Fanapt...... 51 Flagyl...... 22 Estradiol Valerate...... 94 Fanapt Titration Pack...... 51 Flarex...... 107 Estring...... 94 Fareston...... 45 Flavoxate HCl...... 86 Ethacrynate Sodium...... 72 Farxiga...... 59 Flebogamma DIF...... 101 Ethambutol HCl...... 44 Farydak...... 46 Flecainide Acetate...... 65 Ethosuximide...... 31 Faslodex...... 45 Flector...... 13 Etidronate Disodium...... 104 Fazaclo...... 53 Flomax...... 87 Etodolac...... 12 Felbamate...... 32 Flovent Diskus...... 110 Etodolac ER...... 12 Felbatol...... 32 Flovent HFA...... 110 Etopophos...... 47 Feldene...... 12 Fluconazole...... 41 Etoposide...... 47 Felodipine ER...... 68 Fluconazole in NaCl...... 41 Eurax...... 49 Femara...... 47 Flucytosine...... 41 Evista...... 97 Femcon Fe...... 94 Fludarabine Phosphate...... 46 Evoclin...... 80 Femhrt Low Dose...... 94 Fludrocortisone Acetate...... 89 Evotaz...... 55 Femring...... 94 Flumadine...... 57 Evoxac...... 79 Fenofibrate...... 73 Flunisolide...... 110 Evzio...... 20 Fenofibrate Micronized...... 73 Fluocinolone Acetonide...... 89, Exalgo...... 14 Fenofibric Acid...... 73 109 Exelderm...... 41 Fenofibric Acid DR...... 73 Fluocinolone Acetonide Body ...... 89 Exelon...... 35 Fenoglide...... 73 Fluocinonide...... 89 Exemestane...... 47 Fenoprofen Calcium...... 13 Fluocinonide-E...... 89 Exforge...... 71 Fentanyl...... 14 Fluorometholone...... 108 Exforge HCT...... 71 Fentanyl Citrate Oral Exjade...... 114 Transmucosal...... 17 Fluorouracil...... 45, 80 Extavia...... 79 Fentora...... 17 Fluoxetine DR...... 37 Extina...... 41 Ferriprox...... 114 Fluoxetine HCl...... 37 F Fetzima...... 37 Fluphenazine Decanoate.....50 Fabior...... 80 Fetzima Titration Pack...... 37 Fluphenazine HCl...... 50 Fabrazyme...... 82 Fexmid...... 114 Flurandrenolide...... 89
165 Tracked
166
Flurbiprofen...... 13 Frovatriptan Succinate...... 43 Gengraf...... 99 Flurbiprofen Sodium...... 108 Furadantin...... 22 Genotropin...... 92 Flutamide...... 45 Furosemide...... 72, 73 Genotropin Miniquick...... 92 Fluticasone Propionate...... 89, Fusilev...... 46 Gentak...... 21 110 Fuzeon...... 56 Gentamicin Sulfate...... 21 Fluvastatin...... 74 Fyavolv...... 94 Gentamicin Sulfate/0.9% Fluvastatin Sodium ER...... 74 Fycompa...... 30 Sodium Chloride...... 21 Fluvoxamine Maleate...... 37 G Genvoya...... 55 Fluvoxamine Maleate ER..... 37 Gabapentin...... 31 Geodon...... 51 FML...... 108 Gabitril...... 31 Gianvi...... 94 FML Forte...... 108 Gablofen...... 114 Giazo...... 102 FML Liquifilm...... 108 Galantamine HBr...... 35 Gildagia...... 94 Focalin...... 77 Gamastan S/D...... 101 Gildess 1.5/30...... 94 Focalin XR...... 77 Gammagard Liquid...... 101 Gildess 24 Fe...... 94 Folotyn...... 45 Gammaked...... 101 Gilenya...... 79 Fomepizole...... 105 Gammaplex...... 101 Gilotrif...... 47 Fondaparinux Sodium...... 62 Gamunex-C...... 101 Glassia...... 113 Foradil Aerolizer...... 111 Ganciclovir...... 53 Glatopa...... 79 Forfivo XL...... 36 Gardasil...... 102 Gleevec...... 47 Fortamet...... 59 Gardasil 9...... 102 Gleostine...... 44 Fortaz...... 25 Gastrocrom...... 83 Glimepiride...... 59 Forteo...... 104 Gatifloxacin...... 28 Glipizide...... 59 Fortesta...... 93 Gattex...... 83 Glipizide ER...... 59 Fortical...... 104 Gauze...... 105 Glipizide/Metformin HCl...... 59 Fosamax...... 104 GaviLyte-C...... 84 GlucaGen HypoKit...... 61 Fosamax Plus D...... 104 GaviLyte-G...... 84 Glucagon Emergency Kit.....61 Fosinopril Sodium...... 65 GaviLyte-H...... 84 Glucophage...... 59 Fosinopril Sodium/ GaviLyte-N/Flavor Pack...... 84 Glucophage XR...... 59 Hydrochlorothiazide...... 71 Gelnique...... 86 Glucotrol...... 59 Fosphenytoin Sodium...... 34 Gemcitabine HCl...... 45 Glucotrol XL...... 59 Fosrenol...... 87 Gemfibrozil...... 73 Glumetza...... 59 Fragmin...... 62 Gemzar...... 45 Glycopyrrolate...... 83 FreAmine HBC 6.9%...... 117 Generess Fe...... 94 Glyset...... 59 Frova...... 43 Generlac...... 84 Glyxambi...... 59
166 Tracked
167
GoLYTELY...... 84 Hiprex...... 22 Hydrocodone/Ibuprofen...... 18 Gralise...... 78 Horizant...... 78 Hydrocortisone...... 90, 103 Gralise Starter Pack...... 78 Humalog Cartridge...... 61 Hydrocortisone Butyrate...... 90 Granisetron HCl...... 40 Humalog KwikPen...... 61 Hydrocortisone Valerate...... 90 Granix...... 63 Humalog Mix 50/50 KwikPen Hydrocortisone/Acetic Acid Grastek...... 113 ...... 61 ...... 109 GRIS-PEG...... 41 Humalog Mix 50/50 Vial...... 61 Hydromorphone HCl...... 18 Griseofulvin Microsize...... 41 Humalog Mix 75/25 KwikPen Hydromorphone HCl ER...... 14 ...... 61 Griseofulvin Ultramicrosize Hydroxychloroquine Sulfate ...... 41 Humalog Mix 75/25 Vial...... 61 ...... 48 Guanidine HCl...... 44 Humalog Vial...... 61 Hydroxyprogesterone Caproate...... 97 Gynazole-1...... 41 Humatrope...... 92 Hydroxyurea...... 45 H Humatrope Combo Pack.....92 Hydroxyzine HCl...... 57 H.P. Acthar...... 89 Humira...... 99 Hydroxyzine Pamoate...... 39 Halaven...... 46 Humira Pediatric Crohns Disease Starter Pack...... 100 Hyperrab S/D...... 101 Haldol...... 50 Humira Pen...... 100 Hysingla ER...... 15 Haldol Decanoate 100...... 50 Humira Pen Crohns Disease Hyzaar...... 71 Haldol Decanoate 50...... 50 Starter Pack...... 100 I Halobetasol Propionate...... 90 Humulin 70/30 KwikPen...... 61 Ibandronate Sodium...... 104 Halog...... 90 Humulin 70/30 Vial...... 61 Ibrance...... 46 Haloperidol...... 51 Humulin N KwikPen...... 61 Ibudone...... 18 Haloperidol Decanoate...... 51 Humulin N Vial...... 61 Ibuprofen...... 13 Haloperidol Lactate...... 51 Humulin R U-500 KwikPen Iclusig...... 47 Harvoni...... 54 ...... 61 Idamycin PFS...... 46 Havrix...... 102 Humulin R U-500 Vial...... 61 Idarubicin HCl...... 46 Hectorol...... 104 Humulin R Vial...... 61 Ifex...... 44 Heparin Sodium...... 62 Hycamtin...... 47 Ifosfamide...... 44 Heparin Sodium/D5W...... 62 Hycet...... 17 Ilaris...... 101 HepatAmine...... 117 Hydralazine HCl...... 75 Ilevro...... 108 Hepsera...... 54 Hydrea...... 45 Ilotycin...... 27 Herceptin...... 48 Hydrochlorothiazide...... 73 Imatinib Mesylate...... 47 Hetlioz...... 114 Hydrocodone Bitartrate/ Imbruvica...... 47 Hexalen...... 44 Acetaminophen...... 18 Imipenem/Cilastatin...... 25 Hiberix...... 102 Hydrocodone/Acetaminophen ...... 18 Imipramine HCl...... 39 167 Tracked
168
Imipramine Pamoate...... 39 Ipratropium Bromide/ Jentadueto...... 60 Imiquimod...... 80 Albuterol Sulfate...... 113 Jentadueto XR...... 60 Imitrex...... 43 Irbesartan...... 64 Jevtana...... 46 Imitrex Statdose Refill...... 43 Irbesartan/ Jinteli...... 94 Hydrochlorothiazide...... 71 Imovax Rabies...... 102 Jolivette...... 97 Irenka...... 78 Imuran...... 100 Jublia...... 41 Iressa...... 47 Increlex...... 92 Juleber...... 94 Irinotecan...... 46 Incruse Ellipta...... 111 Junel 1.5/30...... 94 Isentress...... 55 Indapamide...... 73 Junel 1/20...... 94 Isolyte-P/Dextrose 5%...... 118 Inderal LA...... 66 Junel Fe 1.5/30...... 94 Isolyte-S...... 115 Infanrix...... 102 Junel Fe 1/20...... 94 Isoniazid...... 44 Inlyta...... 47 Junel Fe 24...... 94 Isopto Carpine...... 107 Innopran XL...... 66 Juxtapid...... 74 Isordil Titradose...... 75 Inspra...... 73 K Isosorbide Dinitrate...... 75 Insulin Syringes, Needles K-Tab...... 115 Isosorbide Dinitrate ER...... 75 ...... 105 Kadcyla...... 48 Isosorbide Mononitrate...... 75 Intelence...... 55 Kadian...... 15 Isosorbide Mononitrate ER Intralipid...... 117, 118 Kaitlib Fe...... 94 ...... 75 Intron A...... 54 Kaletra...... 57 Isotonic Gentamicin...... 21 Intron A w/Diluent...... 54 Kalydeco...... 112, 113 Isradipine...... 68 Introvale...... 94 Kanuma...... 105 Istalol...... 107 Invanz...... 25 Kapvay...... 77 Istodax...... 46 Invega...... 51 Kariva...... 94 Itraconazole...... 41 Invega Sustenna...... 51 Kayexalate...... 114 Ivermectin...... 48 Invega Trinza...... 51 Kazano...... 60 Ixiaro...... 102 Invirase...... 57 J KCl 0.075%/D5W/NaCl 0.45% Invokamet...... 59 ...... 118 Jadenu...... 114 Invokana...... 59 KCl 0.15%/D5W/LR...... 118 Jakafi...... 47 Ionosol-B/Dextrose 5%...... 118 KCl 0.15%/D5W/NaCl 0.2% Jalyn...... 87 Ionosol-MB/Dextrose 5%...118 ...... 118 Jantoven...... 62 Iopidine...... 107 KCl 0.15%/D5W/NaCl 0.225% Janumet...... 59 ...... 118 IPOL Inactivated IPV...... 102 Janumet XR...... 60 KCl 0.15%/D5W/NaCl 0.9% Ipratropium Bromide...... 111 Januvia...... 60 ...... 118 Jardiance...... 60 168 Tracked
169
KCl 0.3%/D5W/NaCl 0.45% Kynamro...... 74 Latuda...... 51 ...... 118 L Layolis Fe...... 94 KCl 0.3%/D5W/NaCl 0.9% Labetalol HCl...... 66 Lazanda...... 18 ...... 118 Lacrisert...... 105 Leena...... 94 Kelnor 1/35...... 94 Lactated Ringers Dextrose 5% Leflunomide...... 101 Kenalog...... 90 Viaflex...... 118 Lenvima...... 47 Kenalog-10...... 90 Lactated Ringers Irrigation Lescol XL...... 74 Kenalog-40...... 90 ...... 118 Lessina...... 94 Kepivance...... 79 Lactated Ringers Viaflex....118 Letairis...... 112 Keppra...... 30 Lactulose...... 84 Letrozole...... 47 Keppra XR...... 30 Lamictal...... 32 Leucovorin Calcium...... 46 Kerydin...... 41 Lamictal Chewable Leukeran...... 44 Ketek...... 27 Dispersible...... 32 Leukine...... 63 Ketoconazole...... 41 Lamictal ODT...... 32 Leuprolide Acetate...... 98 Ketoprofen...... 13 Lamictal Starter...... 32 Levalbuterol...... 111 Ketoprofen ER...... 13 Lamictal XR...... 32 Levaquin...... 28 Ketorolac Tromethamine.... 13, Lamisil...... 41 Levemir FlexTouch...... 61 108 Lamivudine...... 54, 56 Levemir Vial...... 61 Keveyis...... 72 Lamivudine/Zidovudine...... 56 Levetiracetam...... 31 Keytruda...... 48 Lamotrigine...... 33 Levetiracetam ER...... 31 Khedezla...... 37 Lamotrigine ER...... 33 Levobunolol HCl...... 107 Kimidess...... 94 Lamotrigine ODT...... 33 Levocarnitine...... 118 Kineret...... 100 Lanoxin...... 71 Levocetirizine Dihydrochloride Kionex...... 114 Lansoprazole...... 85 ...... 109 Klaron...... 81 Lansoprazole/Amoxicillin/ Levofloxacin...... 28 Klonopin...... 58 Clarithromycin...... 83 Levofloxacin in D5W...... 28 Klor-Con 10...... 115 Lantus SoloStar...... 61 Levoleucovorin Calcium...... 46 Klor-Con 8...... 115 Lantus Vial...... 61 Levonest...... 94 Klor-Con M15...... 115 LARIN 1.5/30...... 94 Levonorgestrel and Ethinyl LARIN 1/20...... 94 Klor-Con M20...... 115 Estradiol...... 95 LARIN Fe 1.5/30...... 94 Klor-Con Sprinkle...... 115 Levonorgestrel/Ethinyl Kombiglyze XR...... 60 LARIN Fe 1/20...... 94 Estradiol...... 95 Korlym...... 92 Lasix...... 73 Levora 0.15/30-28...... 95 Kristalose...... 84 Lastacaft...... 105 Levorphanol Tartrate...... 15 Kuvan...... 82 Latanoprost...... 108 Levothyroxine Sodium...97, 98 169 Tracked
170
Levoxyl...... 98 Lofibra...... 74 Lupron Depot-PED...... 98 Lexapro...... 37 LoKara...... 90 Lutera...... 95 Lexiva...... 57 Lomedia 24 Fe...... 95 Luzu...... 41 Lialda...... 102 Lomotil...... 83 Lynparza...... 46 Lidocaine...... 20 Lonsurf...... 45 Lyrica...... 78 Lidocaine HCl...... 20 Loperamide HCl...... 83 Lysodren...... 98 Lidocaine Viscous...... 20 Lopid...... 74 Lysteda...... 63 Lidocaine/Prilocaine...... 20 Lopressor...... 66 Lyza...... 97 Lidoderm...... 20 Lopressor HCT...... 71 M Lincocin...... 22 Loprox...... 41 M-M-R II...... 102 Lincomycin HCl...... 22 Loprox Shampoo...... 41 Macrobid...... 22 Lindane...... 49 Lorazepam...... 58 Macrodantin...... 22 Linezolid...... 22 Lorazepam Intensol...... 58 Magnesium Sulfate...... 115 Linzess...... 84 Lorcet...... 18 Makena...... 97 Lioresal Intrathecal...... 114 Lorcet Plus...... 18 Malarone...... 48 Liothyronine Sodium...... 98 Lortab...... 18 Malathion...... 49 Lipitor...... 74 Loryna...... 95 Maprotiline HCl...... 37 Lipofen...... 73 Losartan Potassium...... 64 Marinol...... 40 Lisinopril...... 65 Losartan Potassium/ Marlissa...... 95 Lisinopril/Hydrochlorothiazide Hydrochlorothiazide...... 71 Marplan...... 36 ...... 71 LoSeasonique...... 95 Matulane...... 44 Lithium...... 58 Lotemax...... 108 Matzim LA...... 68, 69 Lithium Carbonate...... 59 Lotensin...... 65 Mavik...... 65 Lithium Carbonate ER...... 59 Lotrel...... 71 Maxalt...... 43 Lithobid...... 59 Lotrisone...... 81 Maxalt-MLT...... 43 Lithostat...... 87 Lotronex...... 84 Maxidex...... 108 Livalo...... 74 Lovastatin...... 74 Maxipime...... 25 Lo Loestrin Fe...... 95 Lovaza...... 74 Maxitrol...... 105 Locoid...... 90 Lovenox...... 62 Maxzide...... 71 Lodosyn...... 50 Loxapine Succinate...... 51 Meclizine HCl...... 39 Loestrin 1.5/30-21...... 95 Lumigan...... 108 Meclofenamate Sodium...... 13 Loestrin 1/20-21...... 95 Lumizyme...... 82 Medrol...... 90 Loestrin Fe 1.5/30...... 95 Lupaneta Pack...... 98 Medrol Dosepak...... 90 Loestrin Fe 1/20...... 95 Lupron Depot...... 98
170 Tracked
171
Medroxyprogesterone Acetate Methamphetamine HCl...... 76 Metozolv ODT...... 39 ...... 97 Methazolamide...... 72 MetroCream...... 22 Mefenamic Acid...... 13 Methenamine Hippurate...... 22 MetroGel...... 22 Mefloquine HCl...... 48 Methimazole...... 99 MetroGel-Vaginal...... 22 Megace ES...... 97 Methitest...... 93 MetroLotion...... 22 Megace Oral...... 97 Methotrexate...... 100 Metronidazole...... 23 Megestrol Acetate...... 97 Methotrexate Sodium...... 100 Metronidazole in NaCl 0.79% Mekinist...... 47 Methoxsalen...... 81 ...... 23 Meloxicam...... 13 Methscopolamine Bromide Metronidazole Vaginal...... 23 Melphalan HCl...... 44 ...... 83 Mexiletine HCl...... 65 Memantine HCl...... 36 Methyclothiazide...... 73 Miacalcin...... 104 Memantine HCl Titration Pak Methyldopa...... 64 Micardis...... 64 ...... 36 Methyldopate HCl...... 64 Micardis HCT...... 71 Menactra...... 102 Methylergonovine Maleate Miconazole 3...... 41 Menest...... 95 ...... 105 Microgestin 1.5/30...... 95 MENHIBRIX...... 102 Methylin...... 77 Microgestin 1/20...... 95 Menomune-A/C/Y/W-135 Methylphenidate HCl...... 77 Microgestin Fe...... 95 ...... 102 Methylphenidate HCl CD.....77 Microgestin Fe 1.5/30...... 95 Mentax...... 41 Methylphenidate HCl ER.... 77, Microzide...... 73 Menveo...... 102 78 Midodrine HCl...... 64 Mepron...... 49 Methylprednisolone...... 90 Migergot...... 43 Mercaptopurine...... 45 Methylprednisolone Acetate Miglitol...... 60 Meropenem...... 25 ...... 90 Migranal...... 43 Merrem...... 25 Methylprednisolone Dose Pack...... 90 Millipred...... 90 Mesalamine...... 102 Methylprednisolone Sodium Minastrin 24 Fe...... 95 Mesna...... 46 Succinate...... 90 Minipress...... 64 Mesnex...... 46 Methyltestosterone...... 93 Minitran...... 75 Mestinon...... 44 Metipranolol...... 107 Minivelle...... 95 Mestinon Timespan...... 44 Metoclopramide HCl...... 39 Minocin...... 29 Metadate CD...... 77 Metoclopramide ODT...... 39 Minocycline HCl...... 30 Metadate ER...... 77 Metolazone...... 73 Minocycline HCl ER...... 30 Metaproterenol Sulfate...... 111 Metoprolol Succinate ER.....66 Minoxidil...... 75 Metformin HCl...... 60 Metoprolol Tartrate...... 67 Mirapex...... 49 Metformin HCl ER...... 60 Metoprolol/ Mirapex ER...... 49 Methadone HCl...... 15 Hydrochlorothiazide...... 71 171 Tracked
172
Mircera...... 63 Myalept...... 105 Naproxen Sodium CR...... 13 Mirtazapine...... 36 Myambutol...... 44 Naproxen Sodium ER...... 13 Mirtazapine ODT...... 36 Mycamine...... 41 Naratriptan HCl...... 43 Mirvaso...... 81 Mycobutin...... 44 Narcan...... 20 Misoprostol...... 85 Mycophenolate Mofetil...... 100 Nardil...... 36 Mitigare...... 42 Mycophenolic Acid DR...... 100 Nasonex...... 110 Mitomycin...... 46 Myfortic...... 100 Natacyn...... 41 Mitoxantrone HCl...... 46 Myorisan...... 81 Natazia...... 95 Mobic...... 13 Myrbetriq...... 86 Nateglinide...... 60 Modafinil...... 114 Mysoline...... 31 Natesto...... 93 Moderiba...... 54 N Natpara...... 104 Moderiba 1200 Dose Pack Nabumetone...... 13 Nebupent...... 49 ...... 54 Nadolol...... 67 Necon 0.5/35-28...... 95 Moderiba 800 Dose Pack.... 54 Nadolol/Bendroflumethiazide Necon 1/35...... 95 Modicon...... 95 ...... 71 Necon 1/50-28...... 95 Moexipril HCl...... 65 Nafcillin Sodium...... 26 Necon 10/11-28...... 95 Moexipril/Hydrochlorothiazide Naftifine HCl...... 41 Necon 7/7/7...... 95 ...... 71 Naftin...... 41 Nefazodone HCl...... 37 Molindone HCl...... 51 Naglazyme...... 82 Neo-Synalar...... 81 Mometasone Furoate...... 90, Nalbuphine HCl...... 18 Neomycin Sulfate...... 21 110 Naloxone HCl...... 20 Neomycin/Bacitracin/ MonoNessa...... 95 Naltrexone HCl...... 20 Polymyxin...... 105 Montelukast Sodium...... 110 Namenda...... 36 Neomycin/Polymyxin B Monurol...... 23 Namenda Titration Pak...... 36 Sulfates...... 23 Morphine Sulfate...... 18 Namenda XR...... 36 Neomycin/Polymyxin/ Morphine Sulfate ER...... 16 Bacitracin/Hydrocortisone Namenda XR Titration Pack ...... 105 Movantik...... 83 ...... 36 Neomycin/Polymyxin/ MoviPrep...... 84 Namzaric...... 78 Dexamethasone...... 105 Moxeza...... 28 Naphazoline HCl...... 105 Neomycin/Polymyxin/ Moxifloxacin HCl...... 28 Naprelan...... 13 Gramicidin...... 105 Mozobil...... 63 Naprosyn...... 13 Neomycin/Polymyxin/ MS Contin...... 16 Naproxen...... 13 Hydrocortisone...... 105, 109 Multaq...... 65 Naproxen DR...... 13 Neoral...... 100 Mupirocin...... 23 Naproxen Sodium...... 13 Neosporin...... 105 Mustargen...... 45 Nephramine...... 118 172 Tracked
173
Nesina...... 60 Nitrofurantoin Monohydrate Nortrel 1/35...... 96 Neuac...... 81 ...... 23 Nortrel 7/7/7...... 96 Neulasta...... 63 Nitroglycerin...... 75 Nortriptyline HCl...... 39 Neupogen...... 63 Nitroglycerin Lingual...... 75 Norvasc...... 69 Neupro...... 49 Nitroglycerin Transdermal... 75 Norvir...... 57 Neurontin...... 31, 32 Nitrolingual Pumpspray...... 75 Novarel...... 92 Nevanac...... 108 NitroMist...... 75 Novolin 70/30 Vial...... 61 Nevirapine...... 55 Nitrostat...... 75 Novolin N Vial...... 61 Nevirapine ER...... 55 Nizatidine...... 84 Novolin R Vial...... 61 Nexavar...... 47 Nizoral...... 41 NovoLog FlexPen...... 61 Nexium...... 85 Nor-QD...... 97 NovoLog Mix 70/30 Prefilled Nexium I.V...... 85 Nora-BE...... 97 FlexPen...... 61 Nexterone...... 65 Norco...... 18 NovoLog Mix 70/30 Vial...... 61 Niacin ER...... 74 Norditropin FlexPro...... 92 NovoLog PenFill...... 61 Niacor...... 74 Norethindrone...... 97 NovoLog Vial...... 61 Niaspan...... 74 Norethindrone & Ethinyl Noxafil...... 42 Estradiol Ferrous Fumarate Nicardipine HCl...... 69 Nucala...... 113 ...... 95 Nicotrol Inhaler...... 21 Nucynta...... 18 Norethindrone Acetate...... 97 Nicotrol NS...... 21 Nucynta ER...... 16 Norethindrone Acetate/Ethinyl Nuedexta...... 78 Nifedical XL...... 69 Estradiol...... 95 Nulojix...... 100 Nifedipine ER...... 69 Norethindrone Acetate/Ethinyl Nikki...... 95 Estradiol/Ferrous Fumarate NuLYTELY/Flavor Packs..... 84 ...... 95 Nilandron...... 45 Nuplazid...... 51 Norgestimate/Ethinyl Estradiol Nimodipine...... 69 NutreStore...... 118 ...... 95 Ninlaro...... 46 Nutrilipid...... 118 Norinyl 1+35...... 95 Nipent...... 45 Nutropin AQ...... 92 Norinyl 1+50...... 95 Nisoldipine...... 69 NuvaRing...... 96 Noritate...... 23 Nisoldipine ER...... 69 Nuvessa...... 23 Norlyroc...... 97 Nitro-Bid...... 75 Nuvigil...... 114 Normosol-M in D5W...... 118 Nitro-Dur...... 75 Nyamyc...... 42 Normosol-R...... 115 Nitrofurantoin...... 23 Nystatin...... 42 Normosol-R in D5W...... 118 Nitrofurantoin Macrocrystals Nystatin/Triamcinolone...... 42 Norpramin...... 39 ...... 23 Nystop...... 42 Northera...... 71 Nortrel 0.5/35...... 96 173 Tracked
174
O Opdivo...... 48 Oxsoralen Ultra...... 81 Ocella...... 96 Opsumit...... 112 Oxtellar XR...... 34 Octagam...... 101 Oracea...... 30 Oxybutynin Chloride...... 86 Octreotide Acetate...... 98 Oralair...... 113 Oxybutynin Chloride ER...... 86 Ocufen...... 108 Orap...... 51 Oxycodone HCl...... 19 Ocuflox...... 28 Orapred ODT...... 90 Oxycodone/Acetaminophen Odefsey...... 55 Oravig...... 42 ...... 19 Odomzo...... 47 Orbactiv...... 23 Oxycodone/Aspirin...... 19 Ofev...... 113 Orencia...... 100 Oxycodone/Ibuprofen...... 19 Ofloxacin...... 29 Orenitram...... 112 OxyContin...... 16 Ogestrel...... 96 Orfadin...... 82 Oxymorphone HCl...... 19 Olanzapine...... 52 Orkambi...... 112 Oxymorphone HCl ER...... 16 Olanzapine ODT...... 52 Orphenadrine Citrate...... 114 Oxytrol...... 86 Olanzapine/Fluoxetine...... 36 Orsythia...... 96 P Olopatadine HCl...... 106, 109 Ortho Micronor...... 97 Pacerone...... 65 Olux...... 90 Ortho Tri-Cyclen...... 96 Paclitaxel...... 46 Omeclamox-Pak...... 83 Ortho Tri-Cyclen Lo...... 96 Paliperidone ER...... 52 Omega-3-Acid Ethyl Esters Ortho-Cyclen...... 96 Pamelor...... 39 ...... 74 Ortho-Novum 1/35...... 96 Pamidronate Disodium...... 104 Omeprazole...... 85 Ortho-Novum 7/7/7...... 96 Pancreaze...... 82 Omeprazole/Sodium Oseni...... 60 Pandel...... 90 Bicarbonate...... 85 OsmoPrep...... 84 Panretin...... 48 Omnaris...... 110 Otezla...... 101 Pantoprazole Sodium.... 85, 86 Omnipred...... 108 Otrexup...... 100 Paricalcitol...... 104 Omnitrope...... 92 Ovcon-35...... 96 Parnate...... 36 Ondansetron HCl...... 40 Ovide...... 49 Paromomycin Sulfate...... 21 Ondansetron ODT...... 40 Oxacillin Sodium...... 26 Paroxetine HCl...... 37 Onexton...... 81 Oxaliplatin...... 46 Paser...... 44 Onfi...... 32 Oxandrolone...... 93 Pataday...... 106 Onglyza...... 60 Oxaprozin...... 13 Patanase...... 109 ONMEL...... 42 Oxazepam...... 58 Patanol...... 106 Onzetra Xsail...... 43 Oxcarbazepine...... 34 Paxil...... 37 Opana...... 18 Oxiconazole Nitrate...... 42 Pazeo...... 106 Opana ER...... 16 Oxistat...... 42 PCE...... 27
174 Tracked
175
Pedvax HIB...... 102 Phenytoin...... 35 Polymyxin B Sulfate/ PEG-3350/Electrolytes...... 85 Phenytoin Sodium...... 35 Trimethoprim Sulfate...... 105 PEG-3350/NaCl/Na Phenytoin Sodium Extended Polytrim...... 105 Bicarbonate/KCl...... 85 ...... 35 Pomalyst...... 45 Peganone...... 35 PhosLo...... 87 Portia-28...... 96 Pegasys...... 54 Phoslyra...... 87 Potassium Chloride...... 115 Pegasys ProClick...... 54 Phospholine Iodide...... 107 Potassium Chloride 0.15% / PegIntron...... 54 Physiolyte...... 115 NaCl 0.45% Viaflex...... 115 PegIntron REDIPEN...... 54 Physiosol Irrigation...... 115 Potassium Chloride 0.15% D5W/NaCl 0.33%...... 118 Penicillin G Potassium...... 26 Picato...... 81 Potassium Chloride 0.15% Penicillin G Potassium in Iso- Pilocarpine HCl...... 79, 107 D5W/NaCl 0.45%...... 118 Osmotic Dextrose...... 26 Pimozide...... 51 Potassium Chloride 0.15%/ Penicillin G Procaine...... 26 Pimtrea...... 96 NaCl 0.9%...... 115 Penicillin G Sodium...... 26 Pindolol...... 67 Potassium Chloride 0.22% Penicillin V Potassium...... 26 Pioglitazone HCl...... 60 D5W/NaCl 0.45%...... 118 Pennsaid...... 14 Pioglitazone HCl/Glimepiride Potassium Chloride 0.3%/ Pentam 300...... 49 ...... 60 NaCl 0.9%...... 115 Pentasa...... 103 Pioglitazone HCl/Metformin Potassium Chloride 0.3%/ D5W...... 118 Pentoxifylline ER...... 71 HCl...... 60 Potassium Chloride ER...... 116 Pepcid...... 84 Piperacillin/Tazobactam...... 26 Potassium Citrate ER...... 116 Percocet...... 19 Pirmella 1/35...... 96 Potiga...... 31 Perforomist...... 111 Piroxicam...... 14 Pradaxa...... 62 Perindopril Erbumine...... 65 Plaquenil...... 49 Praluent...... 74 Periogard...... 79 Plasma-Lyte A...... 115 Pramipexole Dihydrochloride Perjeta...... 48 Plasma-Lyte-148...... 115 ...... 49 Permethrin...... 49 Plasma-Lyte-56/D5W...... 118 Pramipexole Dihydrochloride Plavix...... 64 Perphenazine...... 39 ER...... 49 Plegridy...... 79 Pertzye...... 82 Prandin...... 60 Plegridy Starter Pack...... 79 Phenadoz...... 109 Pravachol...... 74 Plenamine...... 118 Phenelzine Sulfate...... 36 Pravastatin Sodium...... 74 Podofilox...... 81 Phenergan...... 109 Prazosin HCl...... 64 Polyethylene Glycol 3350 Phenobarbital...... 32 Precose...... 60 Powder...... 85 Phenoxybenzamine HCl...... 64 Pred Forte...... 108 Polymyxin B Sulfate...... 23 Phenytek...... 35 Pred Mild...... 108
175 Tracked
176
Pred-G...... 105 Procainamide HCl...... 65 Proscar...... 87 Pred-G S.O.P...... 106 Procalamine...... 118 Prosol...... 118 Prednicarbate...... 90 Procardia XL...... 69 Protonix...... 86 Prednisolone Acetate...... 108 ProCentra...... 76 Protopic...... 81 Prednisolone Sodium Prochlorperazine...... 39 Protriptyline HCl...... 39 Phosphate...... 90, 108 Prochlorperazine Edisylate Proventil HFA...... 111 Prednisolone Sodium ...... 39 Provera...... 97 Phosphate ODT...... 91 Prochlorperazine Maleate....39 Provigil...... 114 Prednisone...... 91 Procrit...... 63 Prozac...... 38 Prednisone Intensol...... 91 Procto-Med HC...... 103 Prozac Weekly...... 38 Pregnyl w/Diluent Benzyl Procto-Pak...... 103 PRUDOXIN...... 81 Alcohol/NaCl...... 92 Proctosol HC...... 103 Psorcon...... 91 Premarin...... 96 Proctozone-HC...... 103 Pulmicort...... 110 Premasol...... 118 Procysbi...... 82 Pulmicort Flexhaler...... 110 Prepopik...... 85 Progesterone...... 97 Pulmozyme...... 113 Prevacid...... 86 Proglycem...... 61 Purixan...... 45 Prevacid SoluTab...... 86 Prograf...... 100 Pylera...... 83 Prevalite...... 74 Prolastin-C...... 113 Pyrazinamide...... 44 Previfem...... 96 Prolensa...... 108 Pyridostigmine Bromide...... 44 Prevpac...... 83 Proleukin...... 46 Q Prezcobix...... 55 Prolia...... 104 Qnasl...... 110 Prezista...... 57 Promacta...... 63 Qnasl Childrens...... 110 Priftin...... 44 Promethazine HCl...... 109 Quadracel...... 102 Prilosec...... 86 Prometrium...... 97 Qualaquin...... 49 Primaquine Phosphate...... 49 Propafenone HCl...... 65 Quartette...... 96 Primaxin IV...... 25 Propafenone HCl ER...... 65 Quasense...... 96 Primidone...... 32 Propantheline Bromide...... 83 Qudexy XR...... 33 Primlev...... 19 Proparacaine HCl...... 106 Questran...... 74 Prinivil...... 65 Propranolol HCl...... 67 Quetiapine Fumarate...... 52 Pristiq...... 38 Propranolol HCl ER...... 67 QuilliChew ER...... 78 Privigen...... 101 Propranolol/ Quillivant XR...... 78 ProAir HFA...... 111 Hydrochlorothiazide...... 71 Quinapril HCl...... 65 ProAir RespiClick...... 111 Propylthiouracil...... 99 Quinapril/Hydrochlorothiazide Probenecid...... 42 ProQuad...... 102 ...... 71 Probenecid/Colchicine...... 42 176 Tracked
177
Quinidine Gluconate...... 65 Relpax...... 43 Rifampin...... 44 Quinidine Gluconate CR...... 66 Remeron...... 36 Rifater...... 44 Quinidine Sulfate...... 66 Remeron Soltab...... 36 Rilutek...... 78 Quinine Sulfate...... 49 Remicade...... 100 Riluzole...... 78 QVAR...... 110 Remodulin...... 112 Rimantadine HCl...... 57 R Renagel...... 87 Ringers Injection...... 118 Rabavert...... 102 Renvela...... 88 Ringers Irrigation...... 118 Rabeprazole Sodium...... 86 Repaglinide...... 60 Riomet...... 60 Ragwitek...... 113 Repaglinide/Metformin HCl Risedronate Sodium...... 104 Raloxifene HCl...... 97 ...... 60 Risedronate Sodium DR....104 Ramipril...... 65 Repatha...... 74 Risperdal...... 52 Ranexa...... 71 Repatha SureClick...... 74 Risperdal Consta...... 52 Ranitidine HCl...... 84 Reprexain...... 19 Risperdal M-Tab...... 52 Rapaflo...... 87 Requip...... 49 Risperidone...... 52 Rapamune...... 100 Requip XL...... 49 Risperidone ODT...... 52 Rasuvo...... 100 Rescriptor...... 55 Ritalin...... 78 RAVICTI...... 82 Restasis...... 106 Ritalin LA...... 78 Rayos...... 91 Retin-A...... 81 Rituxan...... 48 Razadyne...... 35 Retin-A Micro...... 81 Rivastigmine Tartrate...... 35 Razadyne ER...... 35 Retin-A Micro Pump...... 81 Rivastigmine Transdermal Rebetol...... 54 Retrovir...... 56 System...... 35 Rebif...... 79 Retrovir IV Infusion...... 56 Rizatriptan Benzoate...... 43 Rebif Rebidose...... 79 Revatio...... 112 Rizatriptan Benzoate ODT...43 Rebif Rebidose Titration Pack Revlimid...... 45 Robinul...... 83 ...... 79 Rexulti...... 52 Robinul Forte...... 83 Rebif Titration Pack...... 79 Reyataz...... 57 Rocaltrol...... 104 Reclast...... 104 Rheumatrex...... 100 Ropinirole ER...... 50 Reclipsen...... 96 Ribasphere...... 54 Ropinirole HCl...... 50 Recombivax HB...... 102 Ribasphere Ribapak...... 54 Rosuvastatin Calcium...... 74 Rectiv...... 75 Ribavirin...... 54 Rotarix...... 102 Reglan...... 39 Ridaura...... 101 RotaTeq...... 102 Regranex...... 81 Rifabutin...... 44 Roweepra...... 31 Relenza Diskhaler...... 57 Rifadin...... 44 Roxicodone...... 19 Relistor...... 83 Rifamate...... 44 Rozerem...... 114
177 Tracked
178
Ruconest...... 99 Sharobel...... 97 Somatuline Depot...... 98 Rytary...... 50 Signifor...... 98 Somavert...... 98 Rythmol...... 66 Signifor LAR...... 98 Sonata...... 114 Rythmol SR...... 66 Sildenafil...... 112, 113 Soolantra...... 81 S Silvadene...... 29 Soriatane...... 81 Sabril...... 32 Silver Sulfadiazine...... 29 Sorilux...... 81 Safyral...... 96 Simbrinza...... 107 Sorine...... 66 Saizen...... 92 Simponi...... 100 Sotalol HCl...... 66 Salagen...... 79 Simponi Aria...... 100 Sotylize...... 66 Samsca...... 115 Simulect...... 101 Sovaldi...... 54 Sancuso...... 40 Simvastatin...... 74 Spiriva HandiHaler...... 111 Sandimmune...... 100 Sinemet...... 50 Spiriva Respimat...... 111 Sandostatin...... 98 Sinemet CR...... 50 Spironolactone...... 73 Sandostatin LAR Depot...... 98 Singulair...... 110 Spironolactone/ Santyl...... 81 Sirolimus...... 100 Hydrochlorothiazide...... 72 Saphris...... 52 Sirturo...... 44 Sporanox...... 42 Sarafem...... 38 Sivextro...... 23 Sprintec 28...... 96 Savaysa...... 62 Sklice...... 48 Spritam...... 31 Savella...... 78 Sodium Chloride...... 116 Sprycel...... 47 Savella Titration Pack...... 78 Sodium Chloride 0.45% Sronyx...... 96 Seasonique...... 96 Viaflex...... 116 SSD...... 29 Sectral...... 67 Sodium Chloride 0.9%...... 116 Stalevo 100...... 50 Selegiline HCl...... 50 Sodium Diuril...... 73 Stalevo 125...... 50 Selenium Sulfide...... 81 Sodium Fluoride...... 116 Stalevo 150...... 50 Selzentry...... 56 Sodium Lactate...... 119 Stalevo 200...... 50 Semprex-D...... 113 Sodium Phenylbutyrate...... 82 Stalevo 50...... 50 Sensipar...... 98 Sodium Polystyrene Sulfonate Stalevo 75...... 50 ...... 115 Serevent Diskus...... 111 Starlix...... 60 Sodium Sulfacetamide...... 29 Seroquel...... 52 Stavudine...... 56 Solaraze...... 81 Seroquel XR...... 53 Stelara...... 100 Solodyn...... 30 Serostim...... 84 Sterile Water Irrigation...... 105 Soltamox...... 45 Sertraline HCl...... 38 Stimate...... 92 Solu-Cortef...... 91 Setlakin...... 96 Stiolto Respimat...... 113 Solu-Medrol...... 91 sfRowasa...... 103 Stivarga...... 47
178 Tracked
179
Strattera...... 78 Sylatron...... 54 Tazorac...... 81 Strensiq...... 82 Sylvant...... 48 Taztia XT...... 69 Streptomycin Sulfate...... 21 Symbicort...... 113 Tecentriq...... 48 Striant...... 93 Symbyax...... 36 Tecfidera...... 79 Stribild...... 55 SymlinPen 120...... 60 Tecfidera Starter Pack...... 79 Striverdi Respimat...... 111 SymlinPen 60...... 60 Technivie...... 54 Stromectol...... 48 Synagis...... 101 Teflaro...... 25 Suboxone...... 20 Synalar Cream Kit...... 91 Tegretol...... 35 Subsys...... 19 Synalgos-DC...... 19 Tegretol-XR...... 35 Sucraid...... 82 Synarel...... 99 Tekturna...... 72 Sucralfate...... 85 Synercid...... 23 Tekturna HCT...... 72 Sular...... 69 Synjardy...... 60 Telmisartan...... 64 Sulfacetamide Sodium...... 29, Synribo...... 46 Telmisartan/Amlodipine...... 72 81 Synthroid...... 98 Telmisartan/ Sulfacetamide Sodium/ Syprine...... 115 Hydrochlorothiazide...... 72 Prednisolone Sodium T Temovate...... 91 Phosphate...... 106 Tabloid...... 45 Tenivac...... 102 Sulfadiazine...... 29 Taclonex...... 81 Tenoretic 100...... 72 Sulfamethoxazole/ Tenoretic 50...... 72 Trimethoprim...... 29 Tacrolimus...... 81, 101 Tenormin...... 67 Sulfamethoxazole/ Tafinlar...... 48 Trimethoprim DS...... 29 Tagrisso...... 48 Terazol 3...... 42 Sulfamylon...... 23 Tamiflu...... 57 Terazol 7...... 42 Sulfasalazine...... 103 Tamoxifen Citrate...... 45 Terazosin HCl...... 87 Sulindac...... 14 Tamsulosin HCl...... 87 Terbinafine HCl...... 42 Sumatriptan...... 43 Tanzeum...... 60 Terbutaline Sulfate...... 111 Sumatriptan Succinate...... 43 Tapazole...... 99 Terconazole...... 42 Sumatriptan Succinate Refill Tarceva...... 48 Testim...... 93 ...... 43 Targretin...... 48 Testosterone...... 93 Sumavel DosePro...... 43 Tarina Fe 1/20...... 96 Testosterone Cypionate...... 93 Suprax...... 25 Tarka...... 72 Testosterone Enanthate...... 93 Suprep Bowel Prep...... 85 Tasigna...... 48 Testosterone Pump...... 93 Surmontil...... 39 Tasmar...... 49 Tetanus/Diphtheria Toxoids- Sustiva...... 55 Adsorbed Adult...... 102 Taxotere...... 46 Sutent...... 48 Tetrabenazine...... 78 Tazicef...... 25
179 Tracked
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Tetracycline HCl...... 30 Tofranil...... 39 Travasol...... 119 Thalomid...... 45 Tolak...... 81 Travatan Z...... 108 Theo-24...... 112 Tolazamide...... 60 Travoprost...... 108 Theophylline...... 112 Tolbutamide...... 60 Trazodone HCl...... 38 Theophylline CR...... 112 Tolcapone...... 49 Treanda...... 45 Theophylline ER...... 112 Tolmetin Sodium...... 14 Trecator...... 44 Thiola...... 87 Tolterodine Tartrate...... 86 Trelstar Mixject...... 99 Thioridazine HCl...... 51 Tolterodine Tartrate ER...... 86 Tresiba FlexTouch...... 62 Thiotepa...... 46 Topamax...... 33 Tretin-X...... 81 Thiothixene...... 51 Topamax Sprinkle...... 33 Tretinoin...... 48, 81 Thymoglobulin...... 101 Topicort...... 91 Tretinoin Microsphere...... 81 Thyrolar...... 98 Topiramate...... 33 Trexall...... 101 Tiagabine HCl...... 32 Topiramate ER...... 33 Treximet...... 43 Tiazac...... 69 Toposar...... 47 Trezix...... 19 Tikosyn...... 66 Topotecan HCl...... 47 Tri-Legest Fe...... 96 Timolol Maleate...... 67, 107 Toprol XL...... 67 Tri-Lo-Estarylla...... 96 Timolol Maleate Ophthalmic Torisel...... 101 Tri-Lo-Sprintec...... 96 Gel Forming...... 107 Torsemide...... 73 Tri-Norinyl 28...... 96 Timoptic Ocudose...... 107 Toujeo SoloStar...... 62 Tri-Previfem...... 96 Timoptic-XE...... 107 Toviaz...... 86 Tri-Sprintec...... 96 Tindamax...... 23 TPN Electrolytes...... 119 Triamcinolone Acetonide.... 91 Tinidazole...... 23 Tracleer...... 113 Triamcinolone in Orabase... 79 Tirosint...... 98 Tradjenta...... 60 Triamterene/ Tivicay...... 55 Tramadol HCl...... 19 Hydrochlorothiazide...... 72 Tizanidine HCl...... 114 Tramadol HCl ER...... 17 Trianex...... 91 TOBI...... 21 Tramadol HCl/ Tribenzor...... 72 TOBI Podhaler...... 21 Acetaminophen...... 19 Tricor...... 74 Tobradex...... 21, 106 Trandolapril...... 65 Triderm...... 91 Tobradex ST...... 106 Trandolapril/Verapamil HCl Trifluoperazine HCl...... 51 Tobramycin...... 21 ...... 72 Trifluridine...... 55 Tobramycin Sulfate...... 21 Tranexamic Acid...... 63 Triglide...... 74 Tobramycin/Dexamethasone Transderm-Scop...... 39 Trihexyphenidyl HCl...... 49 ...... 106 Tranxene T...... 58 Trileptal...... 35 Tobrex...... 21 Tranylcypromine Sulfate...... 36 Trilipix...... 74
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TriLyte...... 85 Ultram...... 19 Vascepa...... 74 Trimethoprim...... 23 Ultram ER...... 17 Vaseretic...... 72 Trimipramine Maleate...... 39 Ultravate...... 91 Vasotec...... 65 Trinessa...... 96 Unasyn...... 27 Vecamyl...... 72 Trintellix...... 38 Unasyn Bulk Pack...... 27 Vectibix...... 48 Triostat...... 98 Unithroid...... 98 Vectical...... 81 Trisenox...... 46 Uptravi...... 113 Velcade...... 46 Triumeq...... 55 Urecholine...... 87 Velivet...... 96 Trivora-28...... 96 Urocit-K...... 116 Velphoro...... 88 Trizivir...... 56 Uroxatral...... 87 Veltassa...... 115 Trokendi XR...... 34 Urso...... 84 Veltin...... 81 Trophamine...... 119 Ursodiol...... 84 Venclexta...... 46 Trospium Chloride...... 87 Uvadex...... 81 Venclexta Starting Pack...... 47 Trospium Chloride ER...... 87 V Venlafaxine HCl...... 38 Trulicity...... 60 Vagifem...... 96 Venlafaxine HCl ER...... 38 Trumenba...... 102 Valacyclovir HCl...... 55 Ventavis...... 113 Trusopt...... 107 Valchlor...... 45 Ventolin HFA...... 111 Truvada...... 56 Valcyte...... 53 Veramyst...... 110 Tudorza Pressair...... 111 Valganciclovir...... 54 Verapamil HCl...... 69 Twinrix...... 102 Valium...... 58 Verapamil HCl ER...... 69 Twynsta...... 72 Valproate Sodium...... 32 Verapamil HCl SR...... 69 Tybost...... 55 Valproic Acid...... 32 Veregen...... 81 Tygacil...... 23 Valsartan...... 64 Verelan...... 69 Tykerb...... 48 Valsartan/Hydrochlorothiazide Verelan PM...... 70 Tylenol/Codeine #3...... 19 ...... 72 Veripred 20...... 91 Tylenol/Codeine #4...... 19 Valtrex...... 55 Versacloz...... 53 Typhim Vi...... 102 Vancocin HCl...... 23 Vesicare...... 87 Tysabri...... 79 Vancomycin HCl...... 23 Vestura...... 96 Tyvaso...... 113 Vandazole...... 23 Vexol...... 108 Tyzeka...... 54 Vanos...... 91 Vfend...... 42 U VAQTA...... 102 Vfend IV...... 42 Uceris...... 103 Varivax...... 102 Viberzi...... 84 Uloric...... 42 Varizig...... 101 Vibramycin...... 30 Ultracet...... 19 Varubi...... 40 Vicodin...... 19
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Vicodin ES...... 19 Votrient...... 48 Xtandi...... 45 Vicodin HP...... 19 VP-PNV-DHA...... 119 Xulane...... 96 Victoza...... 60 VPRIV...... 83 Xylocaine...... 20 Vidaza...... 47 Vraylar...... 53 Xyrem...... 114 Videx EC...... 56 Vyfemla...... 96 Xyzal...... 109 Videx Pediatric...... 56 Vytorin...... 75 Y Viekira Pak...... 54 Vyvanse...... 76 Yasmin 28...... 96 Vienva...... 96 W Yaz...... 96 Vigamox...... 29 Warfarin Sodium...... 62 Yervoy...... 48 Viibryd...... 38 Welchol...... 75 YF-Vax...... 102 Viibryd Starter Pack...... 38 Wellbutrin SR...... 36 Z Vimovo...... 14 Wellbutrin XL...... 36 Zafirlukast...... 110 Vimpat...... 35 WYMZYA Fe...... 96 Zaleplon...... 114 Vinblastine Sulfate...... 47 X Zaltrap...... 47 Vincasar PFS...... 47 Xalatan...... 108 Zamicet...... 20 Vincristine Sulfate...... 47 Xalkori...... 48 Zanaflex...... 114 Vinorelbine Tartrate...... 47 Xanax...... 58 Zanosar...... 45 Viokace...... 82, 83 Xanax XR...... 58 Zantac...... 84 Viracept...... 57 Xarelto...... 62 Zarontin...... 31 Viramune...... 55 Xarelto Starter Pack...... 62 Zarxio...... 63 Viramune XR...... 56 Xartemis XR...... 17 Zavesca...... 83 Virazole...... 57 Xeljanz...... 101 Zazole...... 42 Viread...... 56 Xeljanz XR...... 101 Zebeta...... 67 Viroptic...... 55 Xenazine...... 78 Zegerid...... 86 Vistaril...... 39 Xeomin...... 105 Zelapar...... 50 Vitekta...... 55 Xerese...... 55 Zelboraf...... 48 Vivelle-Dot...... 96 Xgeva...... 104 Zemaira...... 113 Vivitrol...... 20 Xifaxan...... 23 Zembrace Symtouch...... 43 Vivlodex...... 14 Xigduo XR...... 60 Zemplar...... 104 Vogelxo...... 93 Xodol...... 20 Zenatane...... 81 Vogelxo Pump...... 93 Xolair...... 114 Zenchent...... 96 Voltaren...... 14 Xopenex...... 112 Zenchent Fe...... 96 Voriconazole...... 42 Xopenex HFA...... 112 Zenpep...... 83 Vospire ER...... 112 Xtampza ER...... 17 Zenzedi...... 76
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Zepatier...... 54 Zofran...... 40 Zosyn...... 27 Zerbaxa...... 25 Zofran ODT...... 40 Zovia 1/35E...... 96 Zerit...... 56 Zohydro ER...... 17 Zovia 1/50E...... 97 Zestoretic...... 72 Zoledronic Acid...... 104 Zovirax...... 55 Zestril...... 65 Zolinza...... 47 Zubsolv...... 20 Zetia...... 75 Zolmitriptan...... 43 Zuplenz...... 40 Zetonna...... 110 Zolmitriptan ODT...... 43 Zyban...... 21 Ziac...... 72 Zoloft...... 38 Zyclara...... 81 Ziagen...... 56 Zolpidem Tartrate...... 114 Zyclara Pump...... 81 Ziana...... 81 Zomacton...... 92 Zydelig...... 47 Zidovudine...... 56 Zometa...... 104 Zyflo...... 110 Zinacef...... 25 Zomig...... 43 Zyflo CR...... 110 Zinecard...... 47 Zomig Nasal Spray...... 43 Zykadia...... 47 Zioptan...... 108 Zomig ZMT...... 43 Zylet...... 106 Ziprasidone HCl...... 53 Zonalon...... 81 Zyloprim...... 42 Zipsor...... 14 Zonegran...... 31 Zymaxid...... 29 Zirgan...... 54 Zonisamide...... 31 Zyprexa...... 53 Zithromax...... 27 Zontivity...... 64 Zyprexa Relprevv...... 53 Zithromax Tri-Pak...... 28 Zorbtive...... 84 Zyprexa Zydis...... 53 Zithromax Z-Pak...... 28 Zortress...... 101 Zytiga...... 45 Zmax...... 28 Zorvolex...... 14 Zyvox...... 23, 24 Zocor...... 74 Zostavax...... 102
183 For more recent information or if you have other questions, please call UnitedHealthcare Group Medicare Advantage Customer Service at: Toll-Free 1-800-457-8506, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday
www.UHCRetiree.com
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change from time to time during each plan year. You will receive notice when necessary. This information is available for free in other languages. Please call our Customer Service number listed above. 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.
UHEX17HM3838339_000 Last updated August 1, 2016