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Home , Formulary (pharmacy), List of antiandrogens, Tolvaptan

Complete List (Formulary) 2021

UnitedHealthcare® Group Medicare Advantage (PPO) Illinois Department of Central Management Services College Program (CIP)

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

Toll-free 1-888-223-1092, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday

www.UHCRetiree.com/soi

Formulary ID Number 00021068, Version 23 Y0066_052820_104500_C Last updated September 1, 2021 Table Of Contents

What is a drug list?...... 3 Note to existing members:...... 3 How do I use the drug list?...... 4 What are generic drugs?...... 4 What is a compounded drug?...... 4 Drug payment stage and drug tiers...... 5 Getting Extra Help...... 5 Are there any rules or limits on my drug coverage?...... 6 What if my drug is not on this list?...... 8 How can I get an exception?...... 8 Can I get my drug while I wait for an exception?...... 9 Can the drug list change?...... 10 Drugs with dosages other than a 1-month supply...... 11 Covered drugs by name (Drug index)...... 12 Covered drugs by medical condition...... 40 Covered drugs with a quantity limit (QL)...... 157 3 What is a drug list? A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team of providers work together in selecting drugs that are needed for well-rounded care and treatment. Your plan will generally cover the drugs listed in our drug list as long as: · The drug is used for a medically accepted indication, · The prescription is filled at a network pharmacy and · Other plan rules are followed. For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members: This complete list of prescription drugs covered by your plan is current as of September 1, 2021. For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our contact information is on the cover. This drug list has changed since last year. Please review this document to make sure your prescription drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage. 4 How do I use the drug list? There are 2 ways to find your prescription drugs in this drug list: 1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–39 to see the ...... list of drug names in alphabetical order. Find the name of your drug. The page number where ...... you can find the drug will be next to it. 2. By medical condition. Turn to section “Covered drugs by medical condition” on pages ...... 40–156 to look for drugs based on your medical conditions. For example, if you have a heart ...... condition, you should look in the category Cardiovascular Agents. This is where you will find ...... drugs that treat heart conditions.

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

What is a compounded drug? A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription customized to the needs of an individual patient. Compounded drugs may be Part D eligible. For more information about compounded drugs, please review your Evidence of Coverage. 5 Drug payment stage and drug tiers The amount you pay for a covered will depend on: · Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in.

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

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

Getting Extra Help If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call Customer Service. Our contact information is on the cover. 6 Are there any rules or limits on my drug coverage? Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use” column of the “Covered drugs by medical condition” chart starting on page 40. The codes and what they mean are shown below and on the next page. You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call Customer Service. Our contact information is on the cover. Coverage Rules and Limits

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

B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. HRM - High-risk medication This drug is known as a high-risk medication (HRM) for patients 65 years and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. LA - Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy. MME - Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 7D - 7-Day limit An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan. DL - Dispensing limit Dispensing limits apply to this drug. This drug is limited to a 1-month supply per prescription.

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

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

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

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

If we make other changes We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the Drug List; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our Drug List, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive at least a 30 day supply of the drug. If we add new generic drugs or make other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section “How can I get an exception?” on page 8. If we remove a drug from the list If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe, we will let you know and take it off the drug list right away. Changes that will not affect you if you are currently taking the drug Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we will not remove or reduce coverage during the year except as described above. You will not get a notice this year about changes that do not affect you. However, on January 1 of the next year these changes will affect you, therefore it is important to check the Drug List for any changes to drugs for the new plan year. 11 Drugs with dosages other than a 1-month supply Drugs packaged in an extended day supply Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription. For more information, please call Customer Service. Our contact information is on the cover. Daily cost sharing for oral medications filled for less than a 1-month supply A daily cost sharing rate may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost sharing rate is the copayment divided by the number of days in a month’s supply. Daily cost sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than 1-month under applicable law. The daily cost sharing requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.

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

A Acticlate...... 54 Aimovig...... 67 Abacavir Sulfate...... 83 Actimmune...... 139 AirDuo Digihaler...... 154 Abacavir Sulfate-Lamivudine Actiq...... 44 AirDuo RespiClick 113/14 ...... 83 Actonel...... 143 ...... 154 Abacavir-Lamivudine- Actoplus Met...... 86 AirDuo RespiClick 232/14 Zidovudine...... 83 ...... 154 Actos...... 86 Abelcet...... 64 AirDuo RespiClick 55/14.... 154 Acular...... 147 Abilify...... 77 Ajovy...... 67 Acular LS...... 147 Abilify Maintena...... 77 Aklief...... 109 Acuvail...... 147 Abilify MyCite...... 77 Ala Scalp...... 110 Acyclovir...... 81 ...... 69 Ala-Cort...... 110 Acyclovir ...... 81 Absorica...... 108 Albendazole...... 74 Aczone...... 115 Absorica LD...... 108 Albenza...... 74 Adacel...... 141 Acamprosate ...... 46 Albuterol Sulfate...... 151 Adapalene...... 108, 109 Acanya...... 108 Albuterol Sulfate HFA...... 151 Adapalene-Benzoyl Peroxide Acarbose...... 86 ...... 109 Alclometasone Dipropionate ...... 110 Accolate...... 151 Adcirca...... 153 Alcohol Prep Pads...... 144 Accupril...... 95 Adderall...... 104 Aldactazide...... 99 Accuretic...... 98 Adderall XR...... 104 Aldactone...... 101 Accutane...... 108 Adefovir Dipivoxil...... 81 Aldara...... 114 Acebutolol HCl...... 96 Adempas...... 153 Alecensa...... 71 Acetaminophen-Caffeine- Adlyxin...... 86 Dihydrocodeine...... 44 Alendronate Sodium...... 143 Adlyxin Starter Pack...... 86 Acetaminophen-Codeine...... 44 Alfuzosin HCl ER...... 126 Admelog...... 89 ...... 98 Alinia...... 74 Admelog SoloStar...... 89 Acetazolamide ER...... 98 Aliskiren Fumarate...... 99 Advair Diskus...... 154 Acetic Acid...... 149 Alkindi Sprinkle...... 127 Advair HFA...... 154 Acetylcysteine...... 154 Allopurinol...... 66 Adzenys ER...... 104 Aciphex...... 123 Almotriptan Malate...... 66 Adzenys XR-ODT...... 104 Acitretin...... 108 Alocril...... 146 Aemcolo...... 48 Actemra...... 138 Alogliptin Benzoate...... 86 Afinitor...... 70 Actemra ACTPen...... 138 Alogliptin-Metformin HCl...... 86 Afinitor Disperz...... 70 Acthar...... 127 Alogliptin-Pioglitazone...... 86 Afrezza...... 89 ActHIB...... 141 Alomide...... 146 Agrylin...... 92 13

Alora...... 130 Amlodipine Besylate...... 97 AndroGel Pump...... 129 Alosetron HCl...... 121 Amlodipine-Atorvastatin...... 99 Annovera...... 130 Alphagan P...... 148 Amlodipine-Benazepril...... 99 Anoro Ellipta...... 154 Alprazolam...... 85 Amlodipine-Olmesartan...... 99 Antara...... 101 Alprazolam ER...... 85 Amlodipine-Valsartan...... 99 Anusol-HC...... 143 Alprazolam Intensol...... 85 Amlodipine-Valsartan-HCTZ ApexiCon E...... 110 Alprazolam ODT...... 85 ...... 99 Apidra...... 89 Alrex...... 147 Ammonium Lactate...... 110 Apidra SoloStar...... 89 Altabax...... 115 Amnesteem...... 109 Aplenzin...... 61 Altace...... 95 Amoxapine...... 63 Apokyn...... 75 Altavera...... 130 Amoxicillin...... 51 Apraclonidine HCl...... 148 Altoprev...... 102 Amoxicillin-Clarithromycin- Aprepitant...... 64 Lansoprazole...... 121 Altreno...... 109 Apri...... 130 Amoxicillin-Potassium Alunbrig...... 71 Apriso...... 142 Clavulanate...... 51 Alvesco...... 150 Aptensio XR...... 105 Amoxicillin-Potassium Alyacen 1/35...... 130 Clavulanate ER...... 51 Aptiom...... 59 Alyq...... 153 Amphetamine ER...... 104 Aptivus...... 84 Amantadine HCl...... 75 Amphetamine Sulfate...... 104 Aralast NP...... 124 Amaryl...... 86 Amphetamine- Aranelle...... 130 Ambien...... 155 Dextroamphetamine...... 104 Aranesp...... 92, 93 AmBisome...... 64 Amphetamine- Arava...... 139 Dextroamphetamine ER.... 104 ...... 153 Arazlo...... 109 Amphotericin B...... 64 Amcinonide...... 110 Arcalyst...... 138 Ampicillin...... 51 Amerge...... 66 Aricept...... 60 Ampicillin Sodium...... 51 Amethia...... 130 Arikayce...... 47 Ampicillin-Sulbactam Sodium Amikacin Sulfate...... 47 Arimidex...... 70 ...... 51 HCl...... 101 Aripiprazole...... 77 Ampyra...... 107 Amiloride- Aripiprazole ODT...... 77 Amzeeq...... 115 ...... 99 Aristada...... 77 Anafranil...... 63 Aminosyn II...... 117 Aristada Initio...... 77 Anagrelide HCl...... 92 Aminosyn-PF...... 117 Arixtra...... 91 ...... 70 Amiodarone HCl...... 95 Armodafinil...... 155 Ancobon...... 64 Amitiza...... 120 ArmonAir Digihaler...... 150 Androderm...... 129 Amitriptyline HCl...... 63 Arnuity Ellipta...... 150 AndroGel...... 129 14

Aromasin...... 70 Avonex Pen...... 107 Basaglar KwikPen...... 89 Arthrotec...... 40 Avonex Prefilled...... 107 Baxdela...... 54 Asacol HD...... 142 Avycaz...... 50 BCG Vaccine...... 141 Asenapine Maleate...... 77 Aygestin...... 134 Beconase AQ...... 150 Ashlyna...... 130 Ayvakit...... 71 Belbuca...... 42 Asmanex...... 150 Azactam...... 48 Belsomra...... 155 Asmanex HFA...... 150 Azasan...... 139 Benazepril HCl...... 95 Aspirin-Dipyridamole ER...... 94 Azasite...... 146 Benazepril-Hydrochlorothiazide Astagraf XL...... 139 Azathioprine...... 139 ...... 99 Atacand...... 95 Azelaic Acid...... 109 Benicar...... 95 Atacand HCT...... 99 Azelastine HCl...... 146, 149 Benicar HCT...... 99 Atazanavir Sulfate...... 84 Azelastine-Fluticasone...... 149 Benlysta...... 138 Atelvia...... 143 Azelex...... 109 BenzaClin with Pump...... 109 Atenolol...... 96 Azilect...... 76 Benzamycin...... 109 Atenolol-Chlorthalidone...... 99 Azithromycin...... 53 Benznidazole...... 74 Ativan...... 85 Azopt...... 148 Benzoyl Peroxide-Erythromycin ...... 109 Atomoxetine HCl...... 105 Azor...... 99 Benztropine Mesylate...... 75 Atorvastatin Calcium...... 102 Aztreonam...... 48 Bepotastine Besilate...... 146 Atovaquone...... 74 Azulfidine...... 142 Bepreve...... 146 Atovaquone-Proguanil HCl.... 74 Azulfidine EN-tabs...... 142 Berinert...... 137 Atralin...... 109 B Beser...... 110 Atripla...... 82 Bacitracin...... 146 Besivance...... 146 Atropine Sulfate...... 145 Bacitracin-Polymyxin B...... 146 Betamethasone Dipropionate Atrovent HFA...... 151 Baclofen...... 80 ...... 110 Aubagio...... 107 Bactrim...... 54 Betamethasone Dipropionate Aubra EQ...... 130 Bactrim DS...... 54 Aug...... 110 Auryxia...... 120 Bafiertam...... 107 Betamethasone Valerate.... 110, Austedo...... 106 Balcoltra...... 130 111 Avalide...... 99 Balsalazide Disodium...... 142 Betapace AF...... 96 Avapro...... 95 Balversa...... 71 Betaseron...... 107 Aveed...... 129 Balziva...... 130 Betaxolol HCl...... 96, 148 Aviane...... 130 Banzel...... 59 Bethanechol Chloride...... 126 Avita...... 109 Baqsimi Two Pack...... 88 Bethkis...... 152 Avodart...... 126 Baraclude...... 81 Betimol...... 148 15

Betoptic-S...... 148 Bromfenac Sodium...... 147 Calcipotriene...... 114 Bevespi Aerosphere...... 154 Mesylate...75, 76 Calcipotriene-Betamethasone Bexarotene...... 73 BromSite...... 147 ...... 114 Bexsero...... 141 Bronchitol...... 154 Salmon...... 143 Beyaz...... 130 Brovana...... 151 Calcitriol...... 114, 144 ...... 69 Brukinsa...... 71 Calcium Acetate...... 120 Bicillin C-R...... 52 Bryhali...... 111 Calquence...... 71 Bicillin C-R 900/300...... 51 Budesonide...... 143, 150 Cambia...... 40 Bicillin L-A...... 52 Budesonide ER...... 143 Camila...... 134 BiDil...... 99 Budesonide-Formoterol Camrese Lo...... 130 Biktarvy...... 82 Fumarate...... 154 Canasa...... 142 Biltricide...... 74 ...... 101 Cancidas...... 64 Bimatoprost...... 149 Buphenyl...... 124 Candesartan Cilexetil...... 95 Bisoprolol Fumarate...... 96 Buprenorphine...... 42 Candesartan Cilexetil-HCTZ ...... 99 Bisoprolol-Hydrochlorothiazide Buprenorphine HCl...... 47 ...... 99 Buprenorphine HCl-Naloxone Capex...... 111 BIVIGAM...... 137 HCl...... 47 Caplyta...... 77 Bleph-10...... 146 Bupropion HCl...... 61 Caprelsa...... 71 Blephamide...... 145 Bupropion HCl ER...... 61 Captopril...... 95 Blephamide S.O.P...... 145 Bupropion HCl SR...... 47, 61 Carac...... 114 Blisovi 24 Fe...... 130 Bupropion HCl XL...... 61 Carafate...... 123 Blisovi Fe 1.5/30...... 130 Buspirone HCl...... 85 Carbaglu...... 117 Boniva...... 143 Butorphanol Tartrate...... 44 Carbamazepine...... 59 Boostrix...... 141 Butrans...... 42 Carbamazepine ER...... 59 ...... 153 Bydureon BCise...... 86 Carbatrol...... 59 Bosulif...... 71 Byetta 10MCG Pen...... 87 Carbidopa...... 76 Braftovi...... 71 Byetta 5MCG Pen...... 87 Carbidopa-Levodopa...... 76 Breo Ellipta...... 154 Bystolic...... 96 Carbidopa-Levodopa ER...... 76 Breztri Aerosphere...... 154 C Carbidopa-Levodopa ODT.....76 Briellyn...... 130 ...... 136 Carbidopa-Levodopa- Entacapone...... 75 Brilinta...... 94 Cablivi...... 94 Cardizem...... 97 Brimonidine Tartrate...... 148 Cabometyx...... 71 Cardizem CD...... 97 Brinzolamide...... 148 Caduet...... 99 Cardizem LA...... 97 BRIVIACT...... 55 Cafergot...... 67 Calan SR...... 97 Cardura...... 94 16

Cardura XL...... 126 Cephalexin...... 50, 51 Cipro...... 54 Carnitor...... 124 Cequa...... 145 Cipro HC...... 149 CaroSpir...... 101 Cerdelga...... 124 Ciprodex...... 149 Carteolol HCl...... 148 Cetirizine HCl...... 149 Ciprofloxacin HCl...54, 146, 149 Cartia XT...... 97 Cetraxal...... 149 Ciprofloxacin in D5W...... 54 Carvedilol...... 96 Cevimeline HCl...... 108 Ciprofloxacin-Dexamethasone Carvedilol Phosphate ER...... 96 Chantix...... 47 ...... 149 Casodex...... 69 Chantix Continuing Month Pak Ciprofloxacin-Fluocinolone PF ...... 149 Caspofungin Acetate...... 64 ...... 47 Citalopram Hydrobromide.....62 Catapres-TTS-1...... 94 Chantix Starting Month Pak...47 Claravis...... 109 Catapres-TTS-2...... 94 Chemet...... 119 Clarinex...... 149 Catapres-TTS-3...... 94 Chenodal...... 121 Clarinex-D 12 Hour...... 154 Cayston...... 152 Chlordiazepoxide HCl...... 85 Clarithromycin...... 53 Caziant...... 130 Chlordiazepoxide-Clidinium ...... 121 Clarithromycin ER...... 53 Cefaclor...... 50 Chlorhexidine Gluconate.....108 Clenpiq...... 121 Cefaclor ER...... 50 Chloroquine Phosphate...... 74 Cleocin...... 48 Cefadroxil...... 50 HCl...... 76 Cleocin Phosphate...... 48 Cefazolin Sodium...... 50 Chlorthalidone...... 101 Cleocin-T...... 116 Cefdinir...... 50 Chlorzoxazone...... 155 Climara Pro...... 130 Cefepime HCl...... 50 Cholbam...... 124 Clindacin-P...... 116 Cefixime...... 50 Cholestyramine...... 102 Clindagel...... 116 Cefotetan Disodium...... 50 Cholestyramine Light...... 102 Clindamycin HCl...... 48 Cefoxitin Sodium...... 50 Cialis...... 126 Clindamycin Palmitate HCl....48 Cefpodoxime Proxetil...... 50 Ciclopirox...... 115, 116 Clindamycin Phosphate...... 48, Cefprozil...... 50 Ciclopirox Olamine...... 116 116 Ceftazidime...... 50 Cilostazol...... 94 Clindamycin Phosphate in D5W Ceftriaxone Sodium...... 50 ...... 48 Ciloxan...... 146 Cefuroxime Axetil...... 50 Clindamycin Phosphate- Cimduo...... 83 Cefuroxime Sodium...... 50 Benzoyl Peroxide...... 109 ...... 122 Celebrex...... 40 Clindamycin-Tretinoin...... 109 Cimetidine HCl...... 122 Celecoxib...... 40 Clindesse...... 48 Cimzia...... 139 Celexa...... 62 Clinimix E/Dextrose...... 117 Cimzia Prefilled...... 139 Cellcept...... 139 Clinimix/Dextrose...... 117 Cinacalcet HCl...... 144 Celontin...... 58 Clinisol SF...... 117 Cinryze...... 137 17

Clobazam...... 58 Combigan...... 145 Cuprimine...... 126 Clobetasol Propionate...... 111 Combivent Respimat...... 154 Cutivate...... 111 Clobetasol Propionate Combivir...... 83 Cuvposa...... 121 Emollient Base...... 111 Cometriq...... 71 Cyclafem 1/35...... 130 Clobetasol Propionate Complera...... 82 Cyclafem 7/7/7...... 130 Emulsion...... 111 Compro...... 63 Cyclobenzaprine HCl...... 155 Clobex...... 111 Comtan...... 75 Cyclophosphamide...... 68, 69 Clobex Spray...... 111 Concerta...... 105 Cycloset...... 87 Clocortolone Pivalate...... 111 Condylox...... 114 Cyclosporine...... 139 Clodan...... 111 Constulose...... 120 Cyclosporine Modified...... 139 Cloderm...... 111 ConZip...... 42 Cymbalta...... 106 Clomipramine HCl...... 63 Copaxone...... 107 HCl...... 149 Clonazepam...... 85 Copiktra...... 71 Cyred EQ...... 130 Clonazepam ODT...... 85 Cordran...... 111 Cystadane...... 124 Clonidine...... 94 Coreg...... 96 Cystadrops...... 145 Clonidine HCl...... 94 Coreg CR...... 96 Cystagon...... 124 Clonidine HCl ER...... 105 Corgard...... 96 Cystaran...... 145 Clopidogrel Bisulfate...... 94 Corlanor...... 99 Cytomel...... 135 Clorazepate Dipotassium...... 85 Cortef...... 127 Cytotec...... 123 Clotrimazole...... 64, 116 Cosentyx...... 138 D Clotrimazole-Betamethasone Cosentyx Sensoready...... 138 Dalfampridine ER...... 107 ...... 114 Cosopt...... 145 Daliresp...... 153 Clovique...... 119 Cosopt PF...... 145 Dalvance...... 48 Clozapine...... 80 Cotellic...... 71 ...... 129 Clozapine ODT...... 80 Cotempla XR-ODT...... 105 Dantrium...... 80 Clozaril...... 80 Cozaar...... 95 Dantrolene Sodium...... 80 Coartem...... 74 Creon...... 124 Dapsone...... 68, 116 Codeine Sulfate...... 44 Cresemba...... 64 Daptacel...... 141 Colazal...... 142 Crestor...... 102 Daptomycin...... 48 Colchicine...... 66 Crinone...... 134 DARAPRIM...... 74 Colcrys...... 66 Cromolyn Sodium...... 124, 146, Darifenacin Hydrobromide ER Colesevelam HCl...... 102 153 ...... 125 Colestid...... 102 Cryselle-28...... 130 Daurismo...... 71 Colestipol HCl...... 102 Cubicin...... 48 Daypro...... 40 Colistimethate Sodium...... 48 18

Daytrana...... 105 Desoximetasone...... 111 Dicyclomine HCl...... 121 DayVigo...... 155 Desoxyn...... 104 Differin...... 109 DDAVP...... 128 Desvenlafaxine ER...... 62 Dificid...... 53 Deblitane...... 135 Desvenlafaxine Succinate ER Diflorasone Diacetate...... 112 Deferasirox...... 119 ...... 62 Diflucan...... 65 Deferasirox Granules...... 119 Detrol...... 125 Diflunisal...... 40 Deferiprone...... 119 Detrol LA...... 125 Digitek...... 99 Delestrogen...... 130 Dexabliss...... 127 Digox...... 99 Delstrigo...... 82 Dexamethasone...... 127 Digoxin...... 99 Delzicol...... 142 Dexamethasone Sodium Dihydroergotamine Mesylate Phosphate...... 147 HCl...... 54 ...... 67 Dexedrine...... 104 Demser...... 99 Dilantin...... 59 Dexilant...... 123 Denavir...... 81 Dilantin INFATABS...... 59 Dexmethylphenidate HCl.....105 Depakote...... 86 Dilaudid...... 44, 45 Dexmethylphenidate HCl ER Depakote ER...... 86 Dilt-XR...... 98 ...... 105 Depakote Sprinkles...... 86 Diltiazem HCl...... 98 Dextroamphetamine Sulfate Diltiazem HCl ER...... 98 Depen Titratabs...... 126 ...... 104, 105 Diltiazem HCl ER Beads...... 98 Depo-...... 130 Dextroamphetamine Sulfate ER Depo-Provera...... 135 ...... 104 Diltiazem HCl ER Coated Beads...... 98 Depo-SubQ Provera 104...... 135 Dextrose...... 118 Dimethyl Fumarate...... 107 Depo-...... 129 Dextrose-NaCl...... 118 Dimethyl Fumarate Starter Pack Derma-Smoothe/FS Scalp...111 Diacomit...... 58 ...... 107 DermOtic...... 149 Diastat AcuDial...... 58 Diovan...... 95 Descovy...... 83 Diastat Pediatric...... 58 Diovan HCT...... 99 Desipramine HCl...... 63 Diazepam...... 58, 85 Dipentum...... 143 Desloratadine...... 150 Diazepam Intensol...... 85 Diphenoxylate-Atropine...... 121 Desloratadine ODT...... 150 Diazoxide...... 89 Diphtheria-Tetanus Toxoids DT Acetate...... 128 Dibenzyline...... 94 ...... 141 Desmopressin Acetate Spray Diclofenac Epolamine...... 40 Diprolene...... 112 ...... 128 Diclofenac Potassium...... 40 Disulfiram...... 46 -Ethinyl Estradiol Diclofenac Sodium...... 40, 114, Ditropan XL...... 125 ...... 130 147 Diuril...... 101 Desonate...... 111 Diclofenac Sodium ER...... 40 Divalproex Sodium...... 86 Desonide...... 111 Diclofenac-Misoprostol...... 40 Divalproex Sodium ER...... 86 DesOwen...... 111 Dicloxacillin Sodium...... 52 19

Dofetilide...... 96 Duloxetine HCl...... 106 Emcyt...... 69 Dojolvi...... 144 Duobrii...... 114 Emend...... 64 Dolishale...... 130 Duopa...... 76 Emend Tri-Pack...... 64 Donepezil HCl...... 60 Dupixent...... 138 Emflaza...... 127 Donepezil HCl ODT...... 60 Durezol...... 147 Emgality...... 67, 68 Doptelet...... 94 ...... 126 Emoquette...... 130 Doryx...... 54 Dutasteride-Tamsulosin HCl Emsam...... 61 Doryx MPC...... 54 ...... 126 Emtricitabine...... 83 Dorzolamide HCl...... 148 DUTOPROL...... 99 Emtricitabine-Tenofovir Dorzolamide HCl-Timolol Dyanavel XR...... 105 Disoproxil Fumarate...... 83 Maleate...... 145 Dymista...... 150 Emtriva...... 83 Dorzolamide HCl-Timolol Dyrenium...... 101 Emverm...... 74 Maleate Preservative Free E Enalapril Maleate...... 95 ...... 145 E.E.S. Granules...... 53 Enalapril-Hydrochlorothiazide Dotti...... 130 Econazole Nitrate...... 116 ...... 99 Dovato...... 82 Edarbi...... 95 Enbrel...... 139, 140 Dovonex...... 114 Edarbyclor...... 99 Enbrel Mini...... 139 Doxazosin Mesylate...... 94 Edecrin...... 101 Enbrel SureClick...... 140 Doxepin HCl...... 63, 112, 155 Edurant...... 82 Endari...... 118 Doxercalciferol...... 144 Efavirenz...... 82 Endocet...... 45 Doxy 100...... 54 Efavirenz-Emtricitabine- Engerix-B...... 141 Doxycycline Hyclate...... 54, 55 Tenofovir...... 82 Enoxaparin Sodium...... 91 Doxycycline Monohydrate..... 55 Efavirenz-Lamivudine-Tenofovir Enpresse-28...... 131 Drizalma Sprinkle...... 106 ...... 82 Enskyce...... 131 Dronabinol...... 64 Effexor XR...... 62 Enspryng...... 140 -Ethinyl Estradiol Efudex...... 114 Enstilar...... 114 ...... 130 Egrifta SV...... 128 Entacapone...... 75 Drospirenone-Ethinyl Estradiol- Elestrin...... 130 Entecavir...... 81 Levomefolate...... 130 Eletriptan Hydrobromide...... 66 Entocort EC...... 143 Droxia...... 69 Elidel...... 112 Entresto...... 99 Droxidopa...... 94 Eligard...... 136 Enulose...... 120 Duaklir Pressair...... 154 Eliquis...... 91 Envarsus XR...... 140 Duetact...... 87 Eliquis Starter Pack...... 91 Epclusa...... 81 Duexis...... 40 Elmiron...... 126 Epidiolex...... 55 Dulera...... 154 EluRyng...... 130 Epiduo...... 109 20

Epiduo Forte...... 109 Estarylla...... 131 Ezetimibe-Simvastatin...... 102 Epinastine HCl...... 146 Estrace...... 131 F Epinephrine...... 152 Estradiol...... 131 Fabior...... 109 EpiPen 2-Pak...... 152 Estradiol Valerate...... 131 Falmina...... 131 EpiPen Jr 2-Pak...... 152 Estring...... 131 Famciclovir...... 81 Epitol...... 59 Ethacrynic Acid...... 101 Famotidine...... 122 Epivir...... 83 Ethambutol HCl...... 68 Fanapt...... 77, 78 Epivir HBV...... 81 Ethosuximide...... 58 Fanapt Titration Pack...... 78 ...... 101 Ethynodiol Diacetate-Ethinyl Fareston...... 69 Epogen...... 93 Estradiol...... 131 Farxiga...... 87 Epzicom...... 83 Etodolac...... 40 Farydak...... 71 Equetro...... 86 Etodolac ER...... 40 Fasenra...... 154 Eraxis...... 65 -Ethinyl Estradiol Fasenra Pen...... 154 ...... 131 Ergotamine-Caffeine...... 67 Fayosim...... 131 Eucrisa...... 112 Erivedge...... 71 Febuxostat...... 66 Euthyrox...... 135 Erleada...... 69 Felbamate...... 55, 56 Evekeo...... 105 Erlotinib HCl...... 71 Felbatol...... 56 Evekeo ODT...... 105 Errin...... 135 Feldene...... 40 Evenity...... 144 Ertaczo...... 116 Felodipine ER...... 97 ...... 71, 140 Ertapenem Sodium...... 52 Femara...... 70 Evista...... 135 Ery...... 116 Femring...... 131 Evoclin...... 116 Ery-Tab...... 53 Femynor...... 131 Evotaz...... 84 Erygel...... 116 Fenofibrate...... 101 Evoxac...... 108 EryPed 200...... 53 Fenofibrate Micronized...... 101 Evrysdi...... 124 EryPed 400...... 53 Fenofibric Acid...... 101 Exelon...... 60 Erythrocin Lactobionate...... 53 Fenoglide...... 102 ...... 70 Erythrocin Stearate...... 53 Fenoprofen Calcium...... 40 Exforge...... 99 Erythromycin...... 116, 146 Fentanyl...... 42 Exforge HCT...... 99 Erythromycin Base...... 53 Fentanyl Citrate...... 45 Exjade...... 119 Erythromycin Ethylsuccinate Fentora...... 45 Extavia...... 107 ...... 53 Ferriprox...... 119 Extina...... 116 Esbriet...... 153 Fetzima...... 62 Eysuvis...... 147 Escitalopram Oxalate...... 62 Fetzima Titration...... 62 Ezallor Sprinkle...... 102 Esomeprazole Fexmid...... 155 ...... 123 Ezetimibe...... 102 21

Fiasp...... 89 Fluoroplex...... 114 Fragmin...... 92 Fiasp FlexTouch...... 89 Fluorouracil...... 114 Frova...... 66 Fiasp PenFill...... 89 Fluoxetine HCl...... 62 Frovatriptan Succinate...... 66 Finacea...... 109 Fluphenazine Decanoate...... 76 Fulphila...... 93 ...... 126 Fluphenazine HCl...... 77 ...... 101 Fintepla...... 56 Flurandrenolide...... 112 Fuzeon...... 84 Firazyr...... 137 Flurbiprofen...... 40 Fyavolv...... 131 Firdapse...... 106 Flurbiprofen Sodium...... 147 Fycompa...... 56 Firmagon...... 136 ...... 69 G Firvanq...... 48 Fluticasone Propionate...... 112, Gabapentin...... 58 Flac...... 149 150 Gabitril...... 58 Flagyl...... 48 Fluticasone-Salmeterol...... 154 Galafold...... 124 Flarex...... 147 Fluvastatin Sodium...... 102 Galantamine Hydrobromide Flavoxate HCl...... 125 Fluvastatin Sodium ER...... 102 ...... 60 Flebogamma DIF...... 137 Fluvoxamine Maleate...... 62 Galantamine Hydrobromide ER ...... 60 Flecainide Acetate...... 96 Fluvoxamine Maleate ER...... 62 Gammagard...... 137 Flector...... 40 FML...... 147 FML Forte...... 147 Gammagard S/D Less IgA FloLipid...... 102 ...... 137 FML Liquifilm...... 147 Flomax...... 126 Gammaked...... 137 Focalin...... 105 Flovent Diskus...... 150 Gammaplex...... 137 Focalin XR...... 105 Flovent HFA...... 150 Gamunex-C...... 137 Fondaparinux Sodium...... 91 Fluconazole...... 65 Gardasil 9...... 141 Forfivo XL...... 61 Fluconazole in Sodium Gastrocrom...... 124 Chloride...... 65 Fortamet...... 87 Gatifloxacin...... 146 Flucytosine...... 65 Forteo...... 144 Gattex...... 121 Fludrocortisone Acetate...... 127 Fortesta...... 129 Gauze...... 144 Flunisolide...... 150 Fosamax...... 144 GaviLyte-C...... 121 Fluocinolone Acetonide...... 112, Fosamax Plus D...... 144 GaviLyte-G...... 122 149 Fosamprenavir Calcium...... 84 GaviLyte-N with Flavor Pack Fluocinolone Acetonide Scalp Fosfomycin Tromethamine....48 ...... 112 ...... 122 Fosinopril Sodium...... 95 Fluocinonide...... 112 Gavreto...... 71 Fosinopril Sodium-HCTZ...... 99 Fluocinonide Emulsified Base Gelnique...... 125 Fosrenol...... 120 ...... 112 Gemfibrozil...... 102 Fotivda...... 69 Fluorometholone...... 147 Gemmily...... 131 22

Gemtesa...... 125 Granisetron HCl...... 64 Humalog Mix 50/50...... 89 Generess Fe...... 131 Granix...... 93 Humalog Mix 50/50 KwikPen Generlac...... 121 Grastek...... 138 ...... 89 Gengraf...... 140 Griseofulvin Microsize...... 65 Humalog Mix 75/25...... 89 Genotropin...... 128 Griseofulvin Ultramicrosize....65 Humalog Mix 75/25 KwikPen ...... 89 Genotropin MiniQuick...... 128 Gvoke HypoPen 2-Pack...... 89 Humatin...... 47 Gentak...... 146 Gvoke PFS...... 89 Humatrope...... 128 Gentamicin Sulfate...... 47, 116, Gynazole-1...... 65 Humira...... 140 146 H Humira Pediatric Crohns Start Gentamicin Sulfate-0.9% Haegarda...... 137 Sodium Chloride...... 47 ...... 140 Hailey 24 Fe...... 131 Genvoya...... 82 Humira Pen...... 140 Halcinonide...... 112 Geodon...... 78 Humira Pen Crohns Disease Haldol...... 77 Starter...... 140 Gilenya...... 107 Haldol Decanoate...... 77 Humira Pen Psoriasis Starter Gilotrif...... 71 Halobetasol Propionate...... 112 ...... 140 Gimoti...... 63 Halog...... 112 Humira Pen-Pediatric UC Start Glassia...... 124 ...... 77 ...... 140 Glatiramer Acetate...... 107 Haloperidol Decanoate...... 77 Humulin 70/30...... 90 Glatopa...... 107 Haloperidol Lactate...... 77 Humulin 70/30 KwikPen...... 89 Gleevec...... 71 Harvoni...... 81 Humulin N...... 90 Glimepiride...... 87 Havrix...... 141 Humulin N KwikPen...... 90 Glipizide...... 87 Helidac Therapy...... 122 Humulin R...... 90 Glipizide ER...... 87 Hemady...... 127 Humulin R U-500...... 90 Glipizide-Metformin HCl...... 87 Heparin Sodium...... 92 Humulin R U-500 KwikPen.....90 Gloperba...... 66 HepatAmine...... 118 Hydralazine HCl...... 103 GlucaGen HypoKit...... 89 Hepsera...... 81 Hydrea...... 69 ...... 89 Hetlioz...... 155 Hydrochlorothiazide...... 101 Glucotrol XL...... 87 Hetlioz LQ...... 155 Hydrocodone Bitartrate ER... 42 Glumetza...... 87 Hiberix...... 141 Hydrocodone-Acetaminophen Glycopyrrolate...... 121 ...... 45 Hiprex...... 48 Glyxambi...... 87 Hydrocodone-Ibuprofen...... 45 Horizant...... 106 Gocovri...... 75 Hydrocortisone... 112, 113, 127, Humalog...... 89 143 GoLYTELY...... 122 Humalog Junior KwikPen...... 89 Hydrocortisone Acetate- GoNitro...... 103 Humalog KwikPen...... 89 Pramoxine...... 115 Gralise...... 106 23

Hydrocortisone Butyrate...... 112 Imitrex STATdose System..... 66 Intralipid...... 118 Hydrocortisone Valerate...... 113 Imovax Rabies...... 141 Intrarosa...... 129 Hydrocortisone-Acetic Acid Impavido...... 74 Intron A...... 139 ...... 149 Impeklo...... 113 Introvale...... 131 Hydromorphone HCl...... 45 Imuran...... 140 Invanz...... 52 Hydromorphone HCl ER...... 42 Imvexxy Maintenance Pack Invega...... 78 Hydromorphone HCl ...... 131 Invega Sustenna...... 78 Preservative Free...... 45 Imvexxy Starter Pack...... 131 Invega Trinza...... 78 Hydroxychloroquine Sulfate Inbrija...... 76 Inveltys...... 147 ...... 74 Incassia...... 135 Invirase...... 84 Hydroxyurea...... 69 Increlex...... 128 Invokamet...... 87 Hydroxyzine HCl...... 85 Incruse Ellipta...... 151 Invokamet XR...... 87 Hydroxyzine Pamoate...... 85 ...... 101 Invokana...... 87 Hysingla ER...... 42, 43 Inderal LA...... 96 Iopidine...... 148 Hyzaar...... 99 Indocin...... 41 I IPOL...... 142 Infanrix...... 142 Ibandronate Sodium...... 144 Ipratropium Bromide...... 151 Ingrezza...... 106 Ibrance...... 71 Ipratropium-Albuterol...... 154 Inlyta...... 71 Ibu...... 40 Irbesartan...... 95 InnoPran XL...... 96 Ibuprofen...... 40, 41 Irbesartan-Hydrochlorothiazide Inqovi...... 71 ...... 100 Acetate...... 137 Inrebic...... 71 Iressa...... 71 Iclevia...... 131 Inspra...... 101 Isentress...... 82 Iclusig...... 71 Aspart...... 90 Isentress HD...... 82 Icosapent Ethyl...... 103 FlexPen...... 90 Isibloom...... 131 IDHIFA...... 70 Insulin Aspart PenFill...... 90 Isolyte-P in D5W...... 118 Ilevro...... 147 Insulin Aspart Prot & Aspart Isolyte-S...... 118 Ilumya...... 138 ...... 90 Isoniazid...... 68 Imatinib Mesylate...... 71 Insulin Aspart Prot & Aspart Isopto Carpine...... 148 Imbruvica...... 71 FlexPen...... 90 Isordil Titradose...... 103 Imipenem-Cilastatin...... 52 ...... 90 Isosorbide Dinitrate...... 104 Imipramine HCl...... 63 Insulin Lispro Junior KwikPen Isosorbide Mononitrate...... 104 Imipramine Pamoate...... 63 ...... 90 Isosorbide Mononitrate ER Insulin Lispro Prot & Lispro... 90 Imiquimod...... 115 ...... 104 Insulin Syringes, Needles.... 144 Imitrex...... 66 Isotretinoin...... 109 Intelence...... 82 Imitrex STATdose Refill...... 66 Isradipine...... 97 24

Istalol...... 148 Kaletra...... 84 Klor-Con M20...... 118 Isturisa...... 136 Kalydeco...... 152 Kombiglyze XR...... 87 Itraconazole...... 65 Kapvay...... 105 Korlym...... 129 Ivermectin...... 74, 115 Kariva...... 131 Koselugo...... 72 Ixiaro...... 142 Katerzia...... 97 Krintafel...... 74 J Kazano...... 87 Kristalose...... 121 Jadenu...... 119 KCl in Dextrose-NaCl...... 118 Kurvelo...... 132 Jadenu Sprinkle...... 120 KCl-Lactated Ringers-D5W Kuvan...... 124 Jakafi...... 71 ...... 118 Kynmobi...... 76 Jalyn...... 126 Kelnor 1/35...... 131 L Jantoven...... 92 Kelnor 1/50...... 132 Labetalol HCl...... 96 Janumet...... 87 Kenalog...... 113 Lacrisert...... 145 Janumet XR...... 87 Keppra...... 56 Lactulose...... 121 Januvia...... 87 Keppra XR...... 56 Lamictal...... 56 Jardiance...... 87 Kerydin...... 116 Lamictal ODT...... 56 Jasmiel...... 131 Kesimpta...... 107 Lamictal Starter...... 56 Jatenzo...... 129 ...... 65, 116 Lamictal XR...... 56 Jentadueto...... 87 Ketodan...... 116 Lamivudine...... 81, 83 Jentadueto XR...... 87 Ketoprofen...... 41 Lamivudine-Zidovudine...... 83 Jinteli...... 131 Ketoprofen ER...... 41 Lamotrigine...... 56 Jornay PM...... 105 Ketorolac Tromethamine...... 41, Lamotrigine ER...... 56 147 Jublia...... 116 Lamotrigine ODT...... 56 Keveyis...... 124 Juleber...... 131 Lamotrigine Starter Kit-Blue Kevzara...... 138 Juluca...... 82 ...... 56 Kineret...... 138 Junel 1.5/30...... 131 Lamotrigine Starter Kit-Green Kinrix...... 142 ...... 56 Junel 1/20...... 131 Kisqali...... 72 Lamotrigine Starter Kit-Orange Junel Fe 1.5/30...... 131 Kisqali Femara...... 72 ...... 57 Junel Fe 1/20...... 131 Klaron...... 116 Lampit...... 74 Junel Fe 24...... 131 Klonopin...... 85 Lanoxin...... 100 Juxtapid...... 103 Klor-Con...... 118 Lansoprazole...... 123 Jynarque...... 120 Klor-Con 10...... 118 Lansoprazole ODT...... 123 K Klor-Con 8...... 118 Lanthanum Carbonate...... 120 K-Tab...... 118 Klor-Con M10...... 118 Lantus...... 90 Kaitlib Fe...... 131 Klor-Con M15...... 118 Lantus SoloStar...... 90 25

Lapatinib Ditosylate...... 72 Levemir FlexTouch...... 90 Liothyronine Sodium...... 135 LARIN 1.5/30...... 132 Levetiracetam...... 57 Lipitor...... 102 LARIN 1/20...... 132 Levetiracetam ER...... 57 Lipofen...... 102 LARIN Fe 1.5/30...... 132 Levo-T...... 135 Lisinopril...... 95 LARIN Fe 1/20...... 132 Levobunolol HCl...... 148 Lisinopril-Hydrochlorothiazide Larissia...... 132 Levocarnitine...... 124 ...... 100 Lasix...... 101 Levocetirizine Dihydrochloride ...... 86 Lastacaft...... 146 ...... 150 ...... 86 Latanoprost...... 149 Levofloxacin...... 54, 146 Lithium Carbonate ER...... 86 Latuda...... 78 Levofloxacin in D5W...... 54 Lithobid...... 86 Layolis Fe...... 132 Levonest...... 132 Lithostat...... 127 Lazanda...... 45 -Ethinyl Estradiol Livalo...... 102 ...... 132 Ledipasvir-Sofosbuvir...... 81 Lo Loestrin Fe...... 132 Levonorgestrel-Ethinyl Estradiol Leena...... 132 Locoid...... 113 & Ethinyl Estradiol...... 132 Leflunomide...... 140 Locoid Lipocream...... 113 Levonorgestrel-Ethinyl Estradiol Lodine...... 41 Lenvima 10MG Daily Dose.... 72 91-Day...... 132 Lodosyn...... 76 Lenvima 12MG Daily Dose.... 72 Levora 0.15/30...... 132 Loestrin 1.5/30...... 132 Lenvima 14MG Daily Dose.... 72 Levorphanol Tartrate...... 43 Loestrin 1/20...... 132 Lenvima 18MG Daily Dose.... 72 Levothyroxine Sodium...... 135 Loestrin Fe 1.5/30...... 132 Lenvima 20MG Daily Dose.... 72 Levoxyl...... 135 Loestrin Fe 1/20...... 132 Lenvima 24MG Daily Dose.... 72 Lexapro...... 62 Lokelma...... 120 Lenvima 4MG Daily Dose...... 72 Lexette...... 113 Lomotil...... 121 Lenvima 8MG Daily Dose...... 72 Lexiva...... 84 Lonhala Magnair...... 151 Lescol XL...... 102 Lialda...... 143 Lonsurf...... 70 Lessina...... 132 Librax...... 121 Loperamide HCl...... 121 Letairis...... 153 Licart...... 41 Lopid...... 102 Letrozole...... 70 Lidocaine...... 46 Lopinavir-Ritonavir...... 84 Leucovorin Calcium...... 74 Lidocaine HCl...... 46 Lopressor...... 96 Leukeran...... 69 Lidocaine Viscous...... 46 Loprox...... 116 Leukine...... 93 Lidocaine-Prilocaine...... 46 Lorazepam...... 85 Leuprolide Acetate...... 136 Lidoderm...... 46 Lorazepam Intensol...... 85 Levalbuterol HCl...... 152 Lindane...... 115 Lorbrena...... 72 Levalbuterol Tartrate...... 152 Linezolid...... 48 Loryna...... 132 Levemir...... 90 Linzess...... 121 26

Losartan Potassium...... 95 M Memantine HCl...... 61 Losartan Potassium-HCTZ...100 M-M-R II...... 142 Memantine HCl ER...... 61 LoSeasonique...... 132 Macrobid...... 48 Memantine HCl Titration Pak Lotemax...... 147 Macrodantin...... 48 ...... 61 Lotemax SM...... 147 Mafenide Acetate...... 117 Menactra...... 142 Lotensin...... 95 Magnesium Sulfate...... 118 Menest...... 132 Loteprednol Etabonate...... 147 Malarone...... 74 MenQuadfi...... 142 Lotrel...... 100 Malathion...... 115 Mentax...... 117 Lotronex...... 121 Marinol...... 64 Menveo...... 142 Lovastatin...... 102 Marlissa...... 132 Mepron...... 74 Lovaza...... 103 Marplan...... 61 Mercaptopurine...... 69 Lovenox...... 92 Matulane...... 69 Meropenem...... 52, 53 Low-Ogestrel...... 132 Matzim LA...... 98 Merrem...... 53 Loxapine Succinate...... 77 Mavenclad...... 107 Merzee...... 132 Lubiprostone...... 121 Mavyret...... 81 Mesalamine...... 143 Lucemyra...... 47 Maxalt...... 66 Mesalamine ER...... 143 Luliconazole...... 116 Maxalt-MLT...... 66 Mesnex...... 74 Lumigan...... 149 Maxidex...... 147 Mestinon...... 68 Lupaneta Pack...... 136 Maxitrol...... 145 Metformin HCl...... 88 Lupkynis...... 140 Maxzide...... 100 Metformin HCl ER...... 87 Lupron Depot...... 136 Maxzide-25...... 100 Methadone HCl...... 43 Lutera...... 132 Mayzent...... 107 Methamphetamine HCl...... 105 Luxiq...... 113 Mayzent Starter Pack...... 107 Methazolamide...... 148 Luzu...... 117 Meclizine HCl...... 63 Methenamine Hippurate...... 48 Lyleq...... 135 Meclofenamate Sodium...... 41 Methimazole...... 137 Lyllana...... 132 Medrol...... 127 Methitest...... 129 Lynparza...... 72 Medroxyprogesterone Acetate Methotrexate...... 140 Lyrica...... 106, 107 ...... 135 Methotrexate Sodium...... 140 Lyrica CR...... 106 Mefenamic Acid...... 41 Methoxsalen Rapid...... 115 Lysodren...... 136 Mefloquine HCl...... 74 Methscopolamine Bromide ...... 121 Lysteda...... 94 ...... 135 Methyldopa...... 94 Lyumjev...... 90 Mekinist...... 72 Methylin...... 105 Lyumjev KwikPen...... 90 Mektovi...... 72 Methylphenidate HCl...... 106 Lyza...... 135 Meloxicam...... 41 Methylphenidate HCl CD.....105 27

Methylphenidate HCl ER..... 105 Mili...... 132 Moxifloxacin HCl in NaCl...... 54 Methylphenidate HCl ER Millipred...... 127 MS Contin...... 43 Osmotic Release...... 105 Minastrin 24 Fe...... 132 Mulpleta...... 93 Methylphenidate HCl LA...... 105 Minipress...... 94 Multaq...... 96 Methylprednisolone...... 127 Minitran...... 104 Mupirocin...... 117 ...... 129 Minivelle...... 133 Mupirocin Calcium...... 117 HCl...... 63 Minocycline HCl...... 55 Myalept...... 122 Metoclopramide HCl ODT..... 63 Minocycline HCl ER...... 55 Myambutol...... 68 ...... 101 Minolira...... 55 Mycamine...... 65 Metoprolol Succinate ER...... 97 Minoxidil...... 103 Mycapssa...... 136 Metoprolol Tartrate...... 97 Mirapex...... 76 Mycobutin...... 68 Metoprolol-Hydrochlorothiazide Mirapex ER...... 76 Mycophenolate Mofetil...... 140 ...... 100 Mirtazapine...... 61 Mycophenolate Sodium...... 140 MetroCream...... 48 Mirtazapine ODT...... 61 Mydayis...... 105 Metrogel...... 48 Mirvaso...... 109 Myfortic...... 140 MetroLotion...... 48 Misoprostol...... 123 Myorisan...... 109 Metronidazole...... 48, 49 Mitigare...... 66 Myrbetriq...... 125 Metronidazole in NaCl 0.79% Mobic...... 41 Mysoline...... 58 ...... 49 Modafinil...... 155 Mytesi...... 121 Metyrosine...... 100 Moexipril HCl...... 95 N Mexiletine HCl...... 96 Molindone HCl...... 77 Nabumetone...... 41 Mibelas 24 Fe...... 132 Mometasone Furoate...... 113, Nadolol...... 97 Micafungin Sodium...... 65 150 Nafcillin Sodium...... 52 Micardis...... 95 Mondoxyne NL...... 55 Naftifine HCl...... 117 Micardis HCT...... 100 Montelukast Sodium...... 151 Naftin...... 117 Miconazole 3...... 65 Monurol...... 49 Nalfon...... 41 Microgestin 1.5/30...... 132 Morphine Sulfate...... 45 Naloxone HCl...... 47 Microgestin 1/20...... 132 Morphine Sulfate ER...... 43 Naltrexone HCl...... 47 Microgestin Fe 1.5/30...... 132 Morphine Sulfate ER Beads Namenda...... 61 Microgestin Fe 1/20...... 132 ...... 43 Namenda Titration Pak...... 61 Midodrine HCl...... 94 Motegrity...... 121 Namenda XR...... 61 Migergot...... 67 Movantik...... 121 Namzaric...... 60 Miglitol...... 88 MoviPrep...... 122 Naprelan...... 41 Miglustat...... 124 Moxeza...... 146 Naproxen...... 41 Migranal...... 67 Moxifloxacin HCl...... 54, 146 28

Naproxen DR...... 41 Neupogen...... 93 Nitrolingual...... 104 Naproxen Sodium...... 41 Neupro...... 76 Nitrostat...... 104 Naproxen Sodium ER...... 41 Neurontin...... 58 Nityr...... 124 Naproxen-Esomeprazole...... 41 Nevanac...... 147 Nivestym...... 93 Naratriptan HCl...... 66 Nevirapine...... 82 Nizatidine...... 122 Narcan...... 47 Nevirapine ER...... 82 Nocdurna...... 128 Nardil...... 61 Nexavar...... 72 Nolix...... 113 Nasonex...... 150 Nexium...... 123 Nora-BE...... 135 Natacyn...... 146 Nexletol...... 103 Norditropin FlexPro...... 128 Natazia...... 133 Nexlizet...... 103 Norethindrone...... 135 Nateglinide...... 88 Nextstellis...... 133 Norethindrone Acetate...... 135 Natesto...... 129 Niacin ER...... 103 Norethindrone Acetate-Ethinyl Natpara...... 144 Niacor...... 103 Estradiol...... 133 Natroba...... 115 Niaspan...... 103 Norethindrone Acetate-Ethinyl Estradiol-Fe...... 133 Nayzilam...... 58 Nicardipine HCl...... 97 Norgestimate-Ethinyl Estradiol Nebupent...... 74 Nicotrol...... 47 ...... 133 Necon 0.5/35...... 133 Nicotrol NS...... 47 Norgestimate-Ethinyl Estradiol Nefazodone HCl...... 62 Nifedipine ER...... 97 Triphasic...... 133 Neo-Synalar...... 115 Nifedipine ER Osmotic Release Noritate...... 49 ...... 97 Neomycin Sulfate...... 47 Norpramin...... 63 Nikki...... 133 Neomycin-Bacitracin-Polymyxin Northera...... 94 ...... 146 Nilandron...... 69 Nortrel 0.5/35...... 133 Neomycin-Polymyxin- ...... 69 Nortrel 1/35...... 133 Bacitracin-Hydrocortisone Nimodipine...... 97 ...... 145 Nortrel 7/7/7...... 133 Ninlaro...... 70 Neomycin-Polymyxin- Nortriptyline HCl...... 63 Nisoldipine ER...... 97 Dexamethasone...... 145 Norvasc...... 97 Nitazoxanide...... 74 Neomycin-Polymyxin- Norvir...... 84 Nitisinone...... 124 Gramicidin...... 146 Nourianz...... 75 Nitro-Bid...... 104 Neomycin-Polymyxin-HC.... 145, Novolin 70/30...... 91 149 Nitro-Dur...... 104 Novolin 70/30 FlexPen...... 90 Neoral...... 140 Nitrofurantoin...... 49 Novolin N...... 91 Nerlynx...... 72 Nitrofurantoin Macrocrystal...49 Novolin N FlexPen...... 91 Nesina...... 88 Nitrofurantoin Monohydrate Novolin R...... 91 Neuac...... 109 ...... 49 Novolin R FlexPen...... 91 Neulasta...... 93 Nitroglycerin...... 104 29

NovoLog...... 91 Octreotide Acetate...... 136 Opsumit...... 153 NovoLog FlexPen...... 91 Ocuflox...... 146 Oracea...... 55 NovoLog Mix 70/30...... 91 Odactra...... 138 Oralair 300IR...... 138 NovoLog Mix 70/30 FlexPen Odefsey...... 83 Orapred ODT...... 127 ...... 91 Odomzo...... 72 Oravig...... 65 NovoLog PenFill...... 91 Ofev...... 154 Orencia...... 138 Noxafil...... 65 Ofloxacin...... 54, 146, 149 Orencia ClickJect...... 138 Nubeqa...... 69 Olanzapine...... 78 Orenitram...... 153 Nucala...... 154 Olanzapine ODT...... 78 Orfadin...... 124 Nucynta...... 45 Olanzapine-Fluoxetine HCl.... 61 Orgovyx...... 136 Nucynta ER...... 43 Olmesartan Medoxomil...... 95 Oriahnn...... 136 Nuedexta...... 106 Olmesartan Medoxomil-HCTZ Orilissa...... 137 NuLYTELY Lemon-Lime...... 122 ...... 100 Orkambi...... 152 Nuplazid...... 78 Olmesartan-Amlodipine-HCTZ Orladeyo...... 137 ...... 100 Nurtec ODT...... 66 Orsythia...... 133 Olopatadine HCl...... 146, 150 Nutrilipid...... 118 Ortikos...... 143 Olumiant...... 138 Nutropin AQ NuSpin 10...... 128 Oseltamivir Phosphate...... 84 Olux...... 113 Nutropin AQ NuSpin 20...... 128 Oseni...... 88 Olux-E...... 113 Nutropin AQ NuSpin 5...... 128 Osmolex ER...... 75 Omeclamox-Pak...... 122 NuvaRing...... 133 OsmoPrep...... 122 Omega-3-Acid Ethyl Esters Nuvigil...... 155 Osphena...... 135 ...... 103 Nuzyra...... 55 Otezla...... 138 Omeprazole...... 123 Nyamyc...... 117 Otovel...... 149 Omeprazole-Sodium Nylia 7/7/7...... 133 Bicarbonate...... 123 Otrexup...... 140 Nymalize...... 97 Omnaris...... 150 Ovide...... 115 Nymyo...... 133 Omnitrope...... 128 Oxacillin Sodium...... 52 Nystatin...... 65, 117 Ondansetron HCl...... 64 Oxacillin Sodium in Dextrose Nystatin-Triamcinolone...... 115 ...... 52 Ondansetron ODT...... 64 Nystop...... 117 ...... 129 Onexton...... 109 Nyvepria...... 93 Oxaprozin...... 41 Onfi...... 58 O Oxazepam...... 85 Ongentys...... 75 Ocaliva...... 122 Oxbryta...... 93 Onglyza...... 88 Ocella...... 133 Oxcarbazepine...... 59 Onureg...... 69 Octagam...... 137 Oxervate...... 145 Onzetra Xsail...... 66 30

Oxiconazole Nitrate...... 117 PEG-3350-NaCl-Na Picato...... 115 Oxistat...... 117 Bicarbonate-KCl...... 122 Pifeltro...... 82 Oxtellar XR...... 59 PEG-KCl-NaCl-NaSulf-Na Asc-C Pilocarpine HCl...... 108, 148 ...... 122 Oxybutynin Chloride...... 125 Pimecrolimus...... 113 Pegasys...... 139 Oxybutynin Chloride ER...... 125 Pimozide...... 77 Pemazyre...... 70 Oxycodone HCl...... 45, 46 Pimtrea...... 133 Penicillamine...... 127 Oxycodone HCl ER...... 43 Pindolol...... 97 Penicillin G Potassium...... 52 Oxycodone-Acetaminophen Pioglitazone HCl...... 88 Penicillin G Potassium in ...... 46 Pioglitazone HCl-Glimepiride Dextrose...... 52 OxyContin...... 44 ...... 88 Penicillin G Procaine...... 52 Oxymorphone HCl...... 46 Pioglitazone HCl-Metformin HCl Penicillin G Sodium...... 52 Oxymorphone HCl ER...... 44 ...... 88 Penicillin V Potassium...... 52 Oxytrol...... 126 Piperacillin-Tazobactam...... 52 Pennsaid...... 41 Ozempic...... 88 Piqray...... 72, 73 PENTAM 300...... 74 P Pirmella 1/35...... 133 Pentamidine Isethionate...... 75 Pacerone...... 96 Piroxicam...... 41 Pentasa...... 143 Paliperidone ER...... 78 Plaquenil...... 75 Pentoxifylline ER...... 100 Palynziq...... 124 Plasma-Lyte 148...... 118 Pepcid...... 122, 123 Pamelor...... 63 Plasma-Lyte A...... 118 Percocet...... 46 Pancreaze...... 124 Plavix...... 94 Perforomist...... 152 Pandel...... 113 Plegridy...... 107 Perindopril Erbumine...... 95 Pantoprazole Sodium...... 123 Plenamine...... 118 Periogard...... 108 Panzyga...... 137 Plenvu...... 122 Permethrin...... 115 Paricalcitol...... 144 Pliaglis...... 46 Perphenazine...... 63 Parlodel...... 76 Podofilox...... 115 Perseris...... 78 Parnate...... 61 Polymyxin B Sulfate...... 49 Pertzye...... 125 Paromomycin Sulfate...... 47 Polymyxin B-Trimethoprim Phenelzine Sulfate...... 61 ...... 146 Paroxetine HCl...... 62 Phenobarbital...... 58 Polytrim...... 146 Paser...... 68 Phenoxybenzamine HCl...... 94 Pomalyst...... 69 Patanase...... 150 Phenytek...... 60 Portia-28...... 133 Paxil...... 62 Phenytoin...... 60 Posaconazole...... 65 Pediarix...... 142 Phenytoin Sodium Extended Potassium Chloride...... 119 Pedvax HIB...... 142 ...... 60 Potassium Chloride CR...... 118 PEG-3350-Electrolytes...... 122 Phoslyra...... 120 Potassium Chloride ER...... 118 31

Potassium Chloride in Dextrose Previfem...... 133 Promacta...... 93 ...... 118 Prevymis...... 80 Promethazine HCl...... 64 Potassium Chloride in NaCl Prezcobix...... 84 Prometrium...... 135 ...... 118, 119 Prezista...... 84 Propafenone HCl...... 96 Potassium Citrate ER...... 119 Priftin...... 68 Propafenone HCl ER...... 96 Pradaxa...... 92 Prilosec...... 123 Proparacaine HCl...... 145 Praluent...... 103 Primaquine Phosphate...... 75 Propranolol HCl...... 97 Pramipexole Dihydrochloride Primaxin IV...... 53 Propranolol HCl ER...... 97 ...... 76 Primidone...... 58 Propylthiouracil...... 137 Pramipexole Dihydrochloride ER...... 76 Prinivil...... 95 ProQuad...... 142 Prasugrel HCl...... 94 Pristiq...... 62 Proscar...... 126 Pravastatin Sodium...... 102 Privigen...... 138 Prosol...... 119 Praziquantel...... 74 ProAir HFA...... 152 Protonix...... 123 Prazosin HCl...... 94 ProAir RespiClick...... 152 Protopic...... 113 Pred Forte...... 147 Probenecid...... 66 Protriptyline HCl...... 63 Pred Mild...... 148 Probenecid-Colchicine...... 66 Proventil HFA...... 152 Pred-G...... 145 Procalamine...... 119 Provera...... 135 Pred-G S.O.P...... 145 Procardia XL...... 97 Provigil...... 155 Prednicarbate...... 113 ProCentra...... 105 Prozac...... 62 Prednisolone...... 127 Prochlorperazine...... 63 PRUDOXIN...... 113 Prednisolone Acetate...... 148 Prochlorperazine Maleate...... 63 Psorcon...... 113 Prednisolone Sodium Procrit...... 93 Pulmicort...... 150 Phosphate...... 127, 148 Procto-Med HC...... 143 Pulmicort Flexhaler...... 150 Prednisolone Sodium Procto-Pak...... 143 Pulmozyme...... 152 Phosphate ODT...... 127 Proctosol HC...... 143 Purixan...... 70 Prednisone...... 127, 128 Proctozone-HC...... 143 Pylera...... 122 Prednisone Intensol...... 127 Procysbi...... 125 Pyrazinamide...... 68 Pregabalin...... 107 ...... 135 Pyridostigmine Bromide...... 68 Pregabalin ER...... 107 Proglycem...... 89 Pyridostigmine Bromide ER Premarin...... 133 Prograf...... 140, 141 ...... 68 Premasol...... 119 Prolastin-C...... 125 Pyrimethamine...... 75 Pretomanid...... 68 Prolate...... 46 Q Prevacid...... 123 Prolensa...... 148 Qbrelis...... 95 Prevacid SoluTab...... 123 Prolia...... 144 Qbrexza...... 115 Prevalite...... 103 32

Qinlock...... 69 Rayaldee...... 144 Retin-A Micro Pump...... 110 Qnasl...... 151 Rayos...... 128 Retrovir...... 83 Qnasl Childrens...... 150 Razadyne ER...... 60 Revatio...... 153 Qtern...... 88 Rebif...... 108 Revlimid...... 69 Quadracel...... 142 Rebif Rebidose...... 108 Rexulti...... 78 Qualaquin...... 75 Rebif Rebidose Titration Pack Reyataz...... 84 Quartette...... 133 ...... 108 Reyvow...... 67 Qudexy XR...... 57 Rebif Titration Pack...... 108 Rhofade...... 110 Questran...... 103 Reclipsen...... 133 Rhopressa...... 148 Questran Light...... 103 Recombivax HB...... 142 Ribavirin...... 81 Quetiapine Fumarate...... 78 Rectiv...... 104 Ridaura...... 138 Quetiapine Fumarate ER...... 78 RediTrex...... 141 Rifabutin...... 68 QuilliChew ER...... 106 Reglan...... 64 Rifampin...... 68 Quillivant XR...... 106 Regranex...... 115 Rilutek...... 106 Quinapril HCl...... 95 Relafen DS...... 41 Riluzole...... 106 Quinapril-Hydrochlorothiazide Relenza Diskhaler...... 85 Rimantadine HCl...... 85 ...... 100 Relexxii...... 106 Rinvoq...... 138 Quinidine Gluconate ER...... 96 Relistor...... 121 Riomet...... 88 Quinidine Sulfate...... 96 Relpax...... 66 Risedronate Sodium...... 144 Quinine Sulfate...... 75 Reltone...... 122 Risperdal...... 79 QVAR RediHaler...... 151 Remeron...... 61 Risperdal Consta...... 78 R Remeron SolTab...... 61 ...... 79 RabAvert...... 142 Renagel...... 120 Risperidone ODT...... 79 Rabeprazole Sodium...... 123 Renvela...... 120 Ritalin...... 106 Raloxifene HCl...... 135 Repaglinide...... 88 Ritalin LA...... 106 Ramelteon...... 155 Repatha...... 103 Ritonavir...... 84 Ramipril...... 95 Repatha Pushtronex System Rivastigmine...... 60 ...... 103 Ranexa...... 100 Rivastigmine Tartrate...... 60 Repatha SureClick...... 103 Ranolazine ER...... 100 Rivelsa...... 133 Restasis Single-Use Vials.....145 Rapaflo...... 126 Rizatriptan Benzoate...... 67 Restoril...... 155 Rapamune...... 141 Rizatriptan Benzoate ODT..... 67 Retacrit...... 93 Rasagiline Mesylate...... 76 Rocaltrol...... 144 Retevmo...... 70 Rasuvo...... 141 Rocklatan...... 145 Retin-A...... 109 RAVICTI...... 125 Ropinirole HCl...... 76 Retin-A Micro...... 109 33

Ropinirole HCl ER...... 76 Savella...... 107 Singulair...... 151 Rosuvastatin Calcium...... 102 Savella Titration Pack...... 107 ...... 141 Roszet...... 103 Scopolamine...... 64 Sirturo...... 68 Rotarix...... 142 Seasonique...... 133 Sitavig...... 81 RotaTeq...... 142 Secuado...... 79 Sivextro...... 49 Rowasa...... 143 Segluromet...... 88 Skyrizi...... 138 Roweepra...... 57 Selegiline HCl...... 76 Skyrizi Pen...... 138 Roxicodone...... 46 Selenium Sulfide...... 113 Slynd...... 135 Rozerem...... 155 Selzentry...... 84 Sodium Chloride...... 119 Rozlytrek...... 73 Semglee...... 91 Sodium Fluoride...... 119 Rubraca...... 73 Sensipar...... 144 Sodium Phenylbutyrate...... 125 Ruconest...... 137 Serevent Diskus...... 152 Sodium Polystyrene Sulfonate Rufinamide...... 60 Seroquel...... 79 ...... 120 Rukobia...... 84 Seroquel XR...... 79 Sofosbuvir-Velpatasvir...... 81 Ruzurgi...... 106 Serostim...... 129 Solifenacin Succinate...... 126 Rybelsus...... 88 Sertraline HCl...... 62 Soliqua...... 88 Rydapt...... 73 Setlakin...... 133 Solodyn...... 55 Rytary...... 76 Sevelamer Carbonate...... 120 Solosec...... 49 Rythmol SR...... 96 Sevelamer HCl...... 120 Soltamox...... 69 S Seysara...... 55 Somavert...... 137 Sabril...... 59 Sharobel...... 135 Soolantra...... 115 Safyral...... 133 Shingrix...... 142 Soriatane...... 110 Saizen...... 128 Signifor...... 137 Sorilux...... 115 Saizenprep...... 128 Siklos...... 93 Sorine...... 96 Salagen...... 108 Sildenafil Citrate...... 153 Sotalol HCl...... 96 Samsca...... 120 Silenor...... 155 Sotalol HCl AF...... 96 Sancuso...... 64 Siliq...... 138 Sotylize...... 96 Sandimmune...... 141 Silodosin...... 126 Sovaldi...... 81 Sandostatin...... 137 Silvadene...... 115 Spinosad...... 115 Santyl...... 115 Silver Sulfadiazine...... 115 Spiriva HandiHaler...... 151 Saphris...... 79 Simbrinza...... 149 Spiriva Respimat...... 151 Sapropterin Dihydrochloride Simponi...... 141 ...... 101 ...... 125 Simvastatin...... 102 Spironolactone-HCTZ...... 100 Savaysa...... 92 Sinemet...... 76 Sporanox...... 65 34

Sprintec 28...... 133 Sulfamylon...... 117 T Spritam ODT...... 57 Sulfasalazine...... 143 Tabloid...... 70 Sprix...... 41 Sulindac...... 41 Tabrecta...... 69 Sprycel...... 73 Sumatriptan...... 67 Taclonex...... 115 SPS...... 120 Sumatriptan Succinate...... 67 Tacrolimus...... 113, 141 Sronyx...... 133 Sumatriptan Succinate Refill Tadalafil...... 126, 153 SSD...... 115 ...... 67 Tafinlar...... 73 Stalevo 100...... 75 Sumatriptan-Naproxen Sodium Tagrisso...... 73 ...... 67 Stalevo 125...... 75 Takhzyro...... 137 Sunosi...... 155 Stalevo 150...... 75 Talicia...... 122 Suprax...... 51 Stalevo 200...... 75 Taltz...... 139 Suprep Bowel Prep Kit...... 122 Stalevo 50...... 75 Talzenna...... 73 Sustiva...... 82 Stalevo 75...... 75 Tamiflu...... 85 Sutab...... 122 Steglatro...... 88 Citrate...... 69 Sutent...... 73 Steglujan...... 88 Tamsulosin HCl...... 126 Syeda...... 134 Stelara...... 139 Tapazole...... 137 Symbicort...... 155 Stiolto Respimat...... 154 TaperDex 12-Day...... 128 Symbyax...... 61 Stivarga...... 73 TaperDex 6-Day...... 128 Symdeko...... 152 Strattera...... 106 TaperDex 7-Day...... 128 Symfi...... 83 Streptomycin Sulfate...... 47 Tarceva...... 73 Symfi Lo...... 82 Stribild...... 82 TARGADOX...... 55 Symjepi...... 152 Striverdi Respimat...... 152 Targretin...... 73, 74 SymlinPen 120...... 88 Stromectol...... 74 Tarina 24 Fe...... 134 SymlinPen 60...... 88 Suboxone...... 47 Tarina Fe 1/20 EQ...... 134 Sympazan...... 59 Subsys...... 46 Tasigna...... 73 Symproic...... 121 Sucraid...... 125 Tasmar...... 75 Symtuza...... 84 Sucralfate...... 123 Tavaborole...... 117 Synalar...... 113 Sular...... 97 Tavalisse...... 94 Synarel...... 137 Sulfacetamide Sodium...... 117, Tazarotene...... 110 Syndros...... 64 146, 147 Tazicef...... 51 Synjardy...... 88 Sulfacetamide-Prednisolone Tazorac...... 110 ...... 145 Synjardy XR...... 88 Taztia XT...... 98 Sulfadiazine...... 54 Synribo...... 70 Tazverik...... 70 Sulfamethoxazole- Synthroid...... 136 TDVAX...... 142 Trimethoprim...... 54 Syprine...... 120 35

Tecfidera...... 108 Thalomid...... 69 Tobramycin...... 147, 152 Tecfidera Starter Pack...... 108 Theo-24...... 153 Tobramycin Sulfate...... 47 Teflaro...... 51 Theophylline...... 153 Tobramycin-Dexamethasone Tegretol...... 60 Theophylline ER...... 153 ...... 145 Tegretol XR...... 60 Thiola...... 127 Tobrex...... 147 Tegsedi...... 125 Thiola EC...... 127 Tolcapone...... 75 Tekturna...... 100 Thioridazine HCl...... 77 Tolsura...... 65 Tekturna HCT...... 100 Thiothixene...... 77 Tolterodine Tartrate...... 126 Telmisartan...... 95 Thyquidity...... 136 Tolterodine Tartrate ER...... 126 Telmisartan-Amlodipine...... 100 Tiadylt ER...... 98 Tolvaptan...... 120 Telmisartan-HCTZ...... 100 Tiagabine HCl...... 59 Topamax...... 57 Temazepam...... 155 Tiazac...... 98 Topamax Sprinkle...... 57 Temixys...... 83 Tibsovo...... 73 Topicort...... 113 Temovate...... 113 Tigecycline...... 49 Topicort Spray...... 113 Tenivac...... 142 Tiglutik...... 106 Topiramate...... 57 Tenofovir Disoproxil Fumarate Tikosyn...... 96 Topiramate ER...... 57 ...... 83 Tilia Fe...... 134 Toprol XL...... 97 Tenoretic 100...... 100 Timolol Maleate...... 68, 148 Toremifene Citrate...... 69 Tenoretic 50...... 100 Timolol Maleate Ophthalmic Torsemide...... 101 Tenormin...... 97 Gel Forming...... 148 Tosymra...... 67 Tepmetko...... 73 Timolol Maleate PF...... 148 Toujeo Max SoloStar...... 91 Terazosin HCl...... 126 Timoptic Ocudose...... 148 Toujeo SoloStar...... 91 Terbinafine HCl...... 65 Timoptic-XE...... 148 Tovet...... 113 Terbutaline Sulfate...... 152 Tinidazole...... 49 Toviaz...... 126 Terconazole...... 65 Tiopronin...... 127 TPN Electrolytes...... 119 ...... 144 Tirosint...... 136 Tracleer...... 153 Testim...... 129 Tirosint-SOL...... 136 Tradjenta...... 88 Testosterone...... 129 Tivicay...... 82 Tramadol HCl...... 46 ...... 129 Tivicay PD...... 82 Tramadol HCl ER...... 44 ...... 129 Tizanidine HCl...... 80 Tramadol-Acetaminophen..... 46 Testosterone Pump...... 129 TOBI...... 152 Trandolapril...... 95 Tetrabenazine...... 106 TOBI Podhaler...... 152 Trandolapril-Verapamil HCl ER Tetracycline HCl...... 55 TobraDex...... 145 ...... 100 Texacort...... 113 TobraDex ST...... 145 Tranexamic Acid...... 94 Transderm-Scop...... 64 36

Tranxene-T...... 85 Triderm...... 114 Tykerb...... 73 Tranylcypromine Sulfate...... 61 Trientine HCl...... 120 Tymlos...... 144 Travasol...... 119 Trifluoperazine HCl...... 77 Typhim Vi...... 142 Travatan Z...... 149 Trifluridine...... 147 U Travoprost...... 149 Trihexyphenidyl HCl...... 75 Ubrelvy...... 67 Trazodone HCl...... 62 Trijardy XR...... 88 Uceris...... 143 Trecator...... 68 Trikafta...... 153 Udenyca...... 93 Trelegy Ellipta...... 155 Trileptal...... 60 Ukoniq...... 73 Trelstar Mixject...... 137 Trilipix...... 102 Uloric...... 66 Tremfya...... 139 TriLyte...... 122 Ultracet...... 46 Tresiba...... 91 Trimethobenzamide HCl...... 64 Ultram...... 46 Tresiba FlexTouch...... 91 Trimethoprim...... 49 Ultravate...... 114 Tretinoin...... 74, 110 Trimipramine Maleate...... 63 Unasyn...... 52 Tretinoin Microsphere...... 110 Trintellix...... 63 Unithroid...... 136 Trexall...... 141 Triumeq...... 83 Uptravi...... 153 Treximet...... 67 Trivora...... 134 Urocit-K 10...... 119 Trezix...... 46 Trizivir...... 83 Urocit-K 15...... 119 Tri-Estarylla...... 134 Trokendi XR...... 57 Urocit-K 5...... 119 Tri-Legest Fe...... 134 TrophAmine...... 119 Uroxatral...... 126 Tri-Lo-Estarylla...... 134 Trospium Chloride...... 126 Urso 250...... 122 Tri-Lo-Sprintec...... 134 Trospium Chloride ER...... 126 Urso Forte...... 122 Tri-Mili...... 134 Trulance...... 121 Ursodiol...... 122 Tri-Nymyo...... 134 Trulicity...... 88 V Tri-Previfem...... 134 Trumenba...... 142 Vabomere...... 53 Tri-Sprintec...... 134 Trusopt...... 149 Vagifem...... 134 Tri-VyLibra...... 134 Truvada...... 83 Valacyclovir HCl...... 81 Tri-VyLibra Lo...... 134 Tudorza Pressair...... 151 Valchlor...... 69 Triamcinolone Acetonide... 108, Tukysa...... 70 Valcyte...... 80 113, 114 Turalio...... 73 Valganciclovir HCl...... 80 ...... 101 Twinrix...... 142 Valium...... 86 Triamterene-HCTZ...... 100 Twynsta...... 100 Valproic Acid...... 57 Trianex...... 114 Tybost...... 84 Valsartan...... 95 Tribenzor...... 100 Tydemy...... 134 Valsartan-Hydrochlorothiazide ...... 100 Tricor...... 102 Tygacil...... 49 Valtoco 10 MG Dose...... 59 37

Valtoco 15 MG Dose...... 59 Verelan PM...... 98 Voriconazole...... 65, 66 Valtoco 20 MG Dose...... 59 Verquvo...... 104 Vosevi...... 81 Valtoco 5 MG Dose...... 59 Versacloz...... 80 Votrient...... 73 Valtrex...... 81 Verzenio...... 73 VP-PNV-DHA...... 120 Vancocin...... 49 Vesicare...... 126 Vraylar...... 79 Vancocin HCl...... 49 Vesicare LS...... 126 Vumerity...... 108 Vancomycin HCl...... 49 Vestura...... 134 Vyfemla...... 134 Vandazole...... 49 Vfend...... 65 VyLibra...... 134 Vanos...... 114 Vfend IV...... 65 Vyndamax...... 125 VAQTA...... 142 Viberzi...... 121 Vyndaqel...... 125 Varivax...... 142 Vibramycin...... 55 Vytorin...... 103 Varizig...... 138 Victoza...... 88 Vyvanse...... 105 Varubi...... 64 Viekira Pak...... 81 Vyzulta...... 149 Vascepa...... 103 Vienva...... 134 W Vaseretic...... 100 Vigabatrin...... 59 Wakix...... 156 Vasotec...... 95 Vigadrone...... 59 Warfarin Sodium...... 92 Vecamyl...... 100 Vigamox...... 147 Welchol...... 103 Vectical...... 115 Viibryd...... 63 Wellbutrin SR...... 61 Velivet...... 134 Viibryd Starter Pack...... 63 Wellbutrin XL...... 61 Velphoro...... 120 Vimovo...... 41 Wixela Inhub...... 155 Veltassa...... 120 Vimpat...... 60 WYMZYA Fe...... 134 Veltin...... 110 Viokace...... 125 X Vemlidy...... 81 Viracept...... 84 Xalatan...... 149 Venclexta...... 73 Viramune...... 83 Xalkori...... 73 Venclexta Starting Pack...... 73 Viramune XR...... 83 Xanax...... 86 Venlafaxine HCl...... 63 Viread...... 83 Xanax XR...... 86 Venlafaxine HCl ER...... 63 Vistaril...... 85 Xarelto...... 92 Ventavis...... 153 Vitrakvi...... 73 Xarelto Starter Pack...... 92 Ventolin HFA...... 152 Vivelle-Dot...... 134 Xatmep...... 141 Verapamil HCl...... 98 Vivitrol...... 47 Xcopri...... 57, 58 Verapamil HCl ER...... 98 Vivlodex...... 41 Xeljanz...... 139 Verdeso...... 114 Vizimpro...... 73 Xeljanz XR...... 139 Veregen...... 115 Vogelxo...... 129 Xelpros...... 149 Verelan...... 98 Vogelxo Pump...... 129 Xenazine...... 106 38

Xenleta...... 49 Zafirlukast...... 151 Zileuton ER...... 151 Xepi...... 117 Zaleplon...... 155 Zilxi...... 117 Xerese...... 115 Zanaflex...... 80 Zioptan...... 149 Xermelo...... 121 Zarah...... 134 Ziprasidone HCl...... 79 Xgeva...... 144 Zarontin...... 58 Ziprasidone Mesylate...... 79 Xhance...... 151 Zarxio...... 93 Zipsor...... 41 Xifaxan...... 49 Zavesca...... 125 Zirgan...... 80 Xigduo XR...... 88 Zegerid...... 123 Zithromax...... 53 Xiidra...... 145 Zejula...... 73 Zithromax Tri-Pak...... 53 Xofluza...... 85 Zelapar ODT...... 76 Zithromax Z-Pak...... 53 Xolair...... 139 Zelboraf...... 73 Zocor...... 102 Xolegel...... 117 Zemaira...... 125 Zolinza...... 70 Xopenex...... 152 Zembrace SymTouch...... 67 Zolmitriptan...... 67 Xopenex Concentrate...... 152 Zemdri...... 47 Zolmitriptan ODT...... 67 Xopenex HFA...... 152 Zemplar...... 144 Zoloft...... 63 Xospata...... 73 Zenatane...... 110 Zolpidem Tartrate...... 155 Xpovio...... 70 Zenpep...... 125 Zomacton...... 129 Xtampza ER...... 44 Zenzedi...... 105 Zomig...... 67 Xtandi...... 69 Zepatier...... 81 Zomig ZMT...... 67 Xulane...... 134 Zeposia...... 108 Zonalon...... 114 Xultophy...... 88 Zeposia 7-Day Starter Pack Zonegran...... 60 Xuriden...... 125 ...... 108 Zonisamide...... 60 Xyosted...... 130 Zeposia Starter Kit...... 108 Zontivity...... 92 Xyrem...... 156 Zerbaxa...... 51 Zorbtive...... 129 Xywav...... 155 Zerviate...... 146 Zortress...... 141 Y Zestoretic...... 100 Zorvolex...... 42 Yasmin 28...... 134 Zestril...... 95 Zosyn...... 52 YAZ...... 134 Zetia...... 103 Zovia 1/35E...... 134 YF-Vax...... 142 Zetonna...... 151 Zovirax...... 82 Yonsa...... 69 Ziac...... 100 ZTlido...... 46 Yupelri...... 151 Ziagen...... 83 Zubsolv...... 47 Yuvafem...... 134 Ziana...... 110 Zuplenz...... 64 Z Zidovudine...... 83 Zyclara Pump...... 115 Zafemy...... 134 Ziextenzo...... 94 Zydelig...... 73 39

Zyflo...... 151 Zymaxid...... 147 Zyprexa Zydis...... 80 Zykadia...... 73 Zypitamag...... 102 Zytiga...... 69 Zylet...... 145 Zyprexa...... 79 Zyvox...... 49 Zyloprim...... 66 Zyprexa Relprevv...... 80 40 Covered drugs by medical condition The list below has information about the drugs covered by this plan. If you have trouble finding your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-39. The first column lists the drug name, which may include the dosage form and strength. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The information in the “Coverage Rules or limits on use” column lists any special requirements for coverage of your drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 157-202.

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

A1 Analgesics B1 Anti-inflammatory Drugs

C1 Arth rote c Arthrotec (Oral Tablet Delayed Release) B 3

C1 Cam bia Cambia (Oral Packet) B 4

C1 Cele brex Celebrex (Oral Capsule) B 3 QL

C1 Cele coxi b Celecoxib (Oral Capsule) G 2 QL

C1 Day pro Daypro (Oral Tablet) B 3

C1 Dicl ofen ac Epol ami ne Diclofenac Epolamine (External Patch) G 3 PA; QL

C1 Dicl ofen ac Pota ssiu m Diclofenac Potassium (Oral Tablet) G 2

C1 Dicl ofen ac Sodi um ER Diclofenac Sodium ER (Oral Tablet Extended Release 24 G 1 Hour)

C1 Dicl ofen ac Sodi um Diclofenac Sodium (1% External Gel) G 2

C1 Dicl ofen ac Sodi um Diclofenac Sodium (External Solution) G 2 PA

C1 Dicl ofen ac Sodi um Diclofenac Sodium (Oral Tablet Delayed Release) G 1

C1 Dicl ofen ac- Mis opr osto l Diclofenac-Misoprostol (Oral Tablet Delayed Release) G 3

C1 Diflu nisal Diflunisal (Oral Tablet) G 2

C1 Due xis Duexis (Oral Tablet) B 4 ST

C1 Eto dola c ER Etodolac ER (Oral Tablet Extended Release 24 Hour) G 3

C1 Eto dola c Etodolac (Oral Capsule) G 2

C1 Eto dola c Etodolac (Oral Tablet Immediate Release) G 2

C1 Feld ene Feldene (Oral Capsule) B 3

C1 Fen opr ofen

Calc ium Fenoprofen Calcium (400MG Oral Capsule) G 3

C1 Fen opr ofen

Calc ium Fenoprofen Calcium (Oral Tablet) G 3

C1 Flec tor Flector (External Patch) B 3 PA; QL

C1 Flur bipr ofen Flurbiprofen (100MG Oral Tablet) G 2

C1 Ibu Ibu (600MG Oral Tablet, 800MG Oral Tablet) G 1

C1 Ibup rofe n Ibuprofen (Oral Suspension) G 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 41

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

C1 Ibup rofe n Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet, G 1 800MG Oral Tablet)

C1 Indo cin Indocin (Rectal Suppository) G 4

C1 Ket opr ofen ER Ketoprofen ER (Oral Capsule Extended Release 24 G 3 Hour)

C1 Ket opr ofen Ketoprofen (Oral Capsule Immediate Release) G 2

C1 Ket orol ac Tro met ham ine Ketorolac Tromethamine (Nasal Solution) G 4 LA

C1 Lica rt Licart (External Patch 24 Hour) B 3 PA; QL

C1 Lodi ne Lodine (Oral Tablet) G 4

C1 Mec lofe nam ate Sodi um Meclofenamate Sodium (Oral Capsule) G 3

C1 Mef ena mic Acid Mefenamic Acid (Oral Capsule) G 3

C1 Mel oxic am Meloxicam (Oral Capsule) G 3 QL

C1 Mel oxic am Meloxicam (Oral Tablet) G 1

C1 Mob ic Mobic (Oral Tablet) B 3

C1 Nab ume tone Nabumetone (Oral Tablet) G 2

C1 Nalf on Nalfon (Oral Capsule) B 3

C1 Nalf on Nalfon (Oral Tablet) G 3

C1 Nap rela n Naprelan (Oral Tablet Extended Release 24 Hour) B 4

C1 Nap roxe n Naproxen (Oral Suspension) G 4

C1 Nap roxe n Naproxen (Oral Tablet Immediate Release) G 1

C1 Nap roxe n DR Naproxen DR (Oral Tablet Delayed Release) (Generic G 1 EC-Naprosyn)

C1 Nap roxe n Sodi um ER Naproxen Sodium ER (375MG Oral Tablet Extended G 4 Release 24 Hour) (Generic Naprelan)

C1

Nap roxe n Sodi um ER Naproxen Sodium ER (500MG Oral Tablet Extended G 3 Release 24 Hour) (Generic Naprelan)

C1 Nap roxe n Sodi um Naproxen Sodium (275MG Oral Tablet Immediate G 2 Release, 550MG Oral Tablet Immediate Release)

C1 Nap roxe n- Eso mep razo le Naproxen-Esomeprazole (Oral Tablet Delayed Release) G 4 ST

C1 Oxa proz in Oxaprozin (Oral Tablet) G 3

C1 Pen nsai d Pennsaid (External Solution) B 4 PA

C1 Piro xica m Piroxicam (Oral Capsule) G 2

C1 Rela fen DS Relafen DS (Oral Tablet) G 4 ST

C1 Spri x Sprix (Nasal Solution) B 4 LA

C1 Suli nda c Sulindac (Oral Tablet) G 1

C1 Vim ovo Vimovo (Oral Tablet Delayed Release) B 4 ST

C1 Vivl ode x Vivlodex (Oral Capsule) B 4 QL

C1 Zips or Zipsor (Oral Capsule) B 4 ST 42 Last updated September 1, 2021

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

C1 Zorv olex Zorvolex (Oral Capsule) B 3 ST B1 Opioid Analgesics, Long-acting

C1 Belb uca Belbuca (150MCG Buccal Film, 300MCG Buccal Film, B 3 PA; 7D; DL; QL 450MCG Buccal Film, 75MCG Buccal Film)

C1 Belb uca Belbuca (600MCG Buccal Film, 750MCG Buccal Film, B 4 PA; 7D; DL; QL 900MCG Buccal Film)

C1 Bup reno rphi ne Buprenorphine (Transdermal Patch Weekly) G 2 7D; DL; QL

C1 Butr ans Butrans (Transdermal Patch Weekly) B 2 7D; DL; QL

C1 Con Zip ConZip (Oral Capsule Extended Release 24 Hour) B 3 7D; MME; DL; QL

C1 Fent anyl Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 37.5MCG/HR Transdermal Patch 72 Hour, 62.5MCG/HR G 3 7D; MME; DL; QL Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

C1 Fent anyl Fentanyl (12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR G 2 7D; MME; DL; QL Transdermal Patch 72 Hour)

C1 Fent anyl Fentanyl (87.5MCG/HR Transdermal Patch 72 Hour) G 4 7D; MME; DL; QL

C1 Hyd roco don e Bitar trate ER Hydrocodone Bitartrate ER (10MG Oral Capsule Extended Release 12 Hour, 15MG Oral Capsule Extended Release 12 Hour, 20MG Oral Capsule Extended Release 12 Hour, 30MG Oral Capsule G 3 7D; MME; DL; QL Extended Release 12 Hour, 40MG Oral Capsule Extended Release 12 Hour, 50MG Oral Capsule Extended Release 12 Hour)

C1 Hyd roco don e Bitar trate ER Hydrocodone Bitartrate ER (100MG Oral Tablet ER 24 PA; 7D; MME; DL; Hour Abuse-Deterrent, 120MG Oral Tablet ER 24 Hour G 4 QL Abuse-Deterrent)

C1 Hyd roco don e Bitar trate ER Hydrocodone Bitartrate ER (20MG Oral Tablet ER 24 Hour Abuse-Deterrent, 30MG Oral Tablet ER 24 Hour Abuse-Deterrent, 40MG Oral Tablet ER 24 Hour Abuse- PA; 7D; MME; DL; G 3 Deterrent, 60MG Oral Tablet ER 24 Hour Abuse- QL Deterrent, 80MG Oral Tablet ER 24 Hour Abuse- Deterrent)

C1 Hyd rom orph one HCl ER Hydromorphone HCl ER (Oral Tablet Extended Release G 3 7D; MME; DL; QL 24 Hour)

C1 Hysi ngla ER Hysingla ER (100MG Oral Tablet ER 24 Hour Abuse- Deterrent, 120MG Oral Tablet ER 24 Hour Abuse- PA; 7D; MME; DL; Deterrent, 60MG Oral Tablet ER 24 Hour Abuse- B 4 QL Deterrent, 80MG Oral Tablet ER 24 Hour Abuse- Deterrent)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 43

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

C1 Hysi ngla ER Hysingla ER (20MG Oral Tablet ER 24 Hour Abuse- Deterrent, 30MG Oral Tablet ER 24 Hour Abuse- PA; 7D; MME; DL; B 3 Deterrent, 40MG Oral Tablet ER 24 Hour Abuse- QL Deterrent)

C1 Lev orph anol

Tartr ate Levorphanol Tartrate (Oral Tablet) G 4 7D; MME; DL; QL

C1 Met had one HCl Methadone HCl (Oral Solution) G 1 7D; MME; DL; QL

C1 Met had one HCl Methadone HCl (Oral Tablet) G 1 7D; MME; DL; QL

C1 Mor phin e Sulf ate ER Bea ds Morphine Sulfate ER Beads (Oral Capsule Extended G 3 7D; MME; DL; QL Release 24 Hour) (Generic Avinza)

C1 Mor phin e Sulf ate ER Morphine Sulfate ER (100MG Oral Capsule Extended G 4 7D; MME; DL; QL Release 24 Hour) (Generic Kadian)

C1 Mor phin e Sulf ate ER Morphine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour, 20MG Oral Capsule Extended Release 24 Hour, 30MG Oral Capsule Extended Release 24 Hour, 40MG Oral Capsule Extended Release 24 Hour, G 3 7D; MME; DL; QL 50MG Oral Capsule Extended Release 24 Hour, 60MG Oral Capsule Extended Release 24 Hour, 80MG Oral Capsule Extended Release 24 Hour) (Generic Kadian)

C1 Mor phin e Sulf ate ER Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release, 30MG G 2 7D; MME; DL; QL Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)

C1 Mor phin e Sulf ate ER Morphine Sulfate ER (200MG Oral Tablet Extended G 3 7D; MME; DL; QL Release) (Generic MS Contin)

C1 MS Con tin MS Contin (100MG Oral Tablet Extended Release, 200MG Oral Tablet Extended Release, 30MG Oral B 4 7D; MME; DL; QL Tablet Extended Release, 60MG Oral Tablet Extended Release)

C1 MS Con tin MS Contin (15MG Oral Tablet Extended Release) B 3 7D; MME; DL; QL

C1 Nuc ynta ER Nucynta ER (Oral Tablet Extended Release 12 Hour) B 2 7D; MME; DL; QL

C1 Oxy cod one HCl ER Oxycodone HCl ER (10MG Oral Tablet ER 12 Hour Abuse-Deterrent, 15MG Oral Tablet ER 12 Hour Abuse- Deterrent, 20MG Oral Tablet ER 12 Hour Abuse- G 3 7D; MME; DL; QL Deterrent, 30MG Oral Tablet ER 12 Hour Abuse- Deterrent, 40MG Oral Tablet ER 12 Hour Abuse- Deterrent)

C1 Oxy cod one HCl ER Oxycodone HCl ER (60MG Oral Tablet ER 12 Hour Abuse-Deterrent, 80MG Oral Tablet ER 12 Hour Abuse- G 4 7D; MME; DL; QL Deterrent) 44 Last updated September 1, 2021

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

C1 Oxy Con tin OxyContin (10MG Oral Tablet ER 12 Hour Abuse- Deterrent, 15MG Oral Tablet ER 12 Hour Abuse- PA; 7D; MME; DL; B 3 Deterrent, 20MG Oral Tablet ER 12 Hour Abuse- QL Deterrent)

C1 Oxy Con tin OxyContin (30MG Oral Tablet ER 12 Hour Abuse- Deterrent, 40MG Oral Tablet ER 12 Hour Abuse- PA; 7D; MME; DL; Deterrent, 60MG Oral Tablet ER 12 Hour Abuse- B 4 QL Deterrent, 80MG Oral Tablet ER 12 Hour Abuse- Deterrent)

C1 Oxy mor pho ne HCl ER Oxymorphone HCl ER (Oral Tablet Extended Release 12 G 3 7D; MME; DL; QL Hour)

C1 Tra mad ol HCl ER Tramadol HCl ER (Biphasic) (100MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet G 2 7D; MME; DL; QL Extended Release 24 Hour)

C1 Tra mad ol HCl ER Tramadol HCl ER (Biphasic) (300MG Oral Tablet G 3 7D; MME; DL; QL Extended Release 24 Hour)

C1 Tra mad ol HCl ER Tramadol HCl ER (100MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended G 3 7D; MME; DL; QL Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

C1 Tra mad ol HCl ER Tramadol HCl ER (100MG Oral Tablet Extended Release G 2 7D; MME; DL; QL 24 Hour, 200MG Oral Tablet Extended Release 24 Hour)

C1 Tra mad ol HCl ER Tramadol HCl ER (300MG Oral Tablet Extended Release G 3 7D; MME; DL; QL 24 Hour)

C1 Xta mpz a ER Xtampza ER (Oral Capsule ER 12 Hour Abuse- B 2 7D; MME; DL; QL Deterrent) B1 Opioid Analgesics, Short-acting

C1 Acet ami nop hen- Caff eine - Dihy droc odei ne Acetaminophen-Caffeine-Dihydrocodeine (Oral Capsule) G 3 7D; MME; DL; QL

C1 Acet ami nop hen- Caff eine - Dihy droc odei ne Acetaminophen-Caffeine-Dihydrocodeine (Oral Tablet) G 3 7D; MME; DL; QL

C1 Acet ami nop hen- Cod eine Acetaminophen-Codeine (120-12MG/5ML Oral Solution) G 1 7D; MME; DL; QL

C1 Acet ami nop hen- Cod eine Acetaminophen-Codeine (300-15MG Oral Tablet, G 1 7D; MME; DL; QL 300-30MG Oral Tablet, 300-60MG Oral Tablet)

C1 Acti q Actiq (Buccal Lozenge On A Handle) B 4 PA; DL; QL

C1 But orph anol

Tartr ate Butorphanol Tartrate (Nasal Solution) G 2 7D; MME; DL; QL

C1 Cod eine

Sulf ate Codeine Sulfate (15MG Oral Tablet) B 2 7D; MME; DL; QL

C1 Cod eine

Sulf ate Codeine Sulfate (30MG Oral Tablet) G 2 7D; MME; DL; QL

C1 Cod eine

Sulf ate Codeine Sulfate (60MG Oral Tablet) G 3 7D; MME; DL; QL

C1 Dila udid Dilaudid (Oral Liquid) B 3 7D; MME; DL; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 45

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

C1 Dila udid Dilaudid (2MG Oral Tablet, 4MG Oral Tablet) B 3 7D; MME; DL; QL

C1 Dila udid Dilaudid (8MG Oral Tablet) B 4 7D; MME; DL; QL

C1 End ocet Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, G 2 7D; MME; DL; QL 7.5-325MG Oral Tablet)

C1 Fent anyl Citra te Fentanyl Citrate (1200MCG Buccal Lozenge On A Handle, 1600MCG Buccal Lozenge On A Handle, 400MCG Buccal Lozenge On A Handle, 600MCG Buccal G 4 PA; DL; QL Lozenge On A Handle, 800MCG Buccal Lozenge On A Handle)

C1 Fent anyl Citra te Fentanyl Citrate (200MCG Buccal Lozenge On A Handle) G 3 PA; DL; QL

C1 Fent anyl Citra te Fentanyl Citrate (100MCG Buccal Tablet, 200MCG Buccal Tablet, 400MCG Buccal Tablet, 600MCG Buccal G 4 PA; DL; QL Tablet, 800MCG Buccal Tablet)

C1 Fent ora Fentora (Buccal Tablet) B 4 PA; DL; QL

C1 Hyd roco don e- Acet ami nop hen Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral G 2 7D; MME; DL; QL Solution)

C1 Hyd roco don e- Acet ami nop hen Hydrocodone-Acetaminophen (10-300MG Oral Tablet, 10-325MG Oral Tablet, 5-300MG Oral Tablet, 5-325MG G 2 7D; MME; DL; QL Oral Tablet, 7.5-300MG Oral Tablet, 7.5-325MG Oral Tablet)

C1 Hyd roco don e- Ibup rofe n Hydrocodone-Ibuprofen (10-200MG Oral Tablet, G 3 7D; MME; DL; QL 5-200MG Oral Tablet)

C1 Hyd roco don e- Ibup rofe n Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet) G 2 7D; MME; DL; QL

C1 Hyd rom orph one HCl Hydromorphone HCl (1MG/ML Oral Liquid) G 2 7D; MME; DL; QL

C1 Hyd rom orph one HCl Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release, 8MG Oral G 1 7D; MME; DL; QL Tablet Immediate Release)

C1 Hyd rom orph one HCl Pres erva tive Free Hydromorphone HCl Preservative Free (10MG/ML G 3 DL Injection Solution, 50MG/5ML Injection Solution)

C1 Laza nda Lazanda (Nasal Solution) B 4 PA; DL; QL

C1 Mor phin e Sulf ate Morphine Sulfate (10MG/5ML Oral Solution, 100MG/ G 1 7D; MME; DL; QL 5ML Oral Solution, 20MG/5ML Oral Solution)

C1 Mor phin e Sulf ate Morphine Sulfate (Oral Tablet Immediate Release) G 2 7D; MME; DL; QL

C1 Nuc ynta Nucynta (100MG Oral Tablet Immediate Release) B 4 7D; MME; DL; QL

C1 Nuc ynta Nucynta (50MG Oral Tablet Immediate Release, B 3 7D; MME; DL; QL 75MG Oral Tablet Immediate Release)

C1 Oxy cod one HCl Oxycodone HCl (5MG Oral Capsule) G 2 7D; MME; DL; QL

C1 Oxy cod one HCl Oxycodone HCl (100MG/5ML Oral Concentrate) G 3 7D; MME; DL; QL

C1 Oxy cod one HCl Oxycodone HCl (5MG/5ML Oral Solution) G 2 7D; MME; DL; QL 46 Last updated September 1, 2021

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

C1 Oxy cod one HCl Oxycodone HCl (10MG Oral Tablet Immediate Release, 15MG Oral Tablet Immediate Release, 20MG Oral Tablet G 1 7D; MME; DL; QL Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)

C1 Oxy cod one- Acet ami nop hen Oxycodone-Acetaminophen (10-300MG Oral Tablet, G 4 7D; MME; DL; QL 5-300MG Oral Tablet)

C1 Oxy cod one- Acet ami nop hen Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, G 2 7D; MME; DL; QL 7.5-325MG Oral Tablet)

C1 Oxy mor pho ne HCl Oxymorphone HCl (Oral Tablet Immediate Release) G 3 7D; MME; DL; QL

C1 Perc ocet Percocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, G 4 7D; MME; DL; QL 7.5-325MG Oral Tablet)

C1 Perc ocet Percocet (2.5-325MG Oral Tablet) G 3 7D; MME; DL; QL

C1 Prol ate Prolate (Oral Tablet) G 4 7D; MME; DL; QL

C1 Roxi cod one Roxicodone (15MG Oral Tablet, 5MG Oral Tablet) B 3 7D; MME; DL; QL

C1 Roxi cod one Roxicodone (30MG Oral Tablet) B 4 7D; MME; DL; QL

C1 Sub sys Subsys (Sublingual Liquid) B 4 PA; DL; QL

C1 Tra mad ol HCl Tramadol HCl (100MG Oral Tablet Immediate Release) G 2 7D; MME; DL; QL

C1 Tra mad ol HCl Tramadol HCl (50MG Oral Tablet Immediate Release) G 1 7D; MME; DL; QL

C1 Tra mad ol- Acet ami nop hen Tramadol-Acetaminophen (Oral Tablet) G 1 7D; MME; DL; QL

C1 Trez ix Trezix (Oral Capsule) G 3 7D; MME; DL; QL

C1 Ultra cet Ultracet (Oral Tablet) B 3 7D; MME; DL; QL

C1 Ultra m Ultram (Oral Tablet Immediate Release) B 3 7D; MME; DL; QL A1 Anesthetics B1 Local Anesthetics

C1 Lido cain e Lidocaine (5% External Ointment) G 3 QL

C1 Lido cain e Lidocaine (5% External Patch) G 3 PA; QL

C1 Lido cain e HCl Lidocaine HCl (4% External Solution) G 2

C1 Lido cain e Visc ous Lidocaine Viscous (2% Mouth/Throat Solution) G 1

C1 Lido cain e- Prilo cain e Lidocaine-Prilocaine (External Cream) G 2

C1 Lido der m Lidoderm (External Patch) B 4 PA; QL

C1 Plia glis Pliaglis (External Cream) B 3

C1 ZTli do ZTlido (External Patch) B 3 PA; QL A1 Anti-Addiction/Substance Abuse Treatment Agents B1 Alcohol Deterrents/Anti-craving

C1 Aca mpr osat e Calc ium Acamprosate Calcium (Oral Tablet Delayed Release) G 3

C1 Disu lfira m Disulfiram (Oral Tablet) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 47

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

C1 Nalt rexo ne HCl Naltrexone HCl (Oral Tablet) G 2

C1 Vivit rol Vivitrol (Intramuscular Suspension Reconstituted) B 4 B1 Opioid Dependence

C1 Bup reno rphi ne HCl Buprenorphine HCl (Tablet Sublingual) G 1 QL

C1 Bup reno rphi ne HCl- Nalo xon e HCl Buprenorphine HCl-Naloxone HCl (Sublingual Film) G 3 QL

C1 Bup reno rphi ne HCl- Nalo xon e HCl Buprenorphine HCl-Naloxone HCl (Tablet Sublingual) G 1 QL

C1 Luc emy ra Lucemyra (Oral Tablet) B 4 QL

C1 Sub oxo ne Suboxone (Sublingual Film) B 3 QL

C1 Zub solv Zubsolv (Tablet Sublingual) B 3 QL B1 Opioid Reversal Agents

C1 Nalo xon e HCl Naloxone HCl (0.4MG/ML Injection Solution) G 1

C1 Nalo xon e HCl Naloxone HCl (Injection Solution Cartridge) G 1

C1 Nalo xon e HCl Naloxone HCl (Injection Solution Prefilled Syringe) G 1

C1 Nar can Narcan (Nasal Liquid) B 2 B1 Smoking Cessation Agents

C1 Bup ropi on HCl SR Bupropion HCl SR (150MG Oral Tablet Extended G 1 Release 12 Hour Smoking-Deterrent)

C1 Cha ntix Con tinui ng Mon th Pak Chantix Continuing Month Pak (Oral Tablet) B 2

C1 Cha ntix Chantix (Oral Tablet) B 2

C1 Cha ntix Start ing Mon th Pak Chantix Starting Month Pak (Oral Tablet) B 2

C1 Nico trol Nicotrol (Inhalation Inhaler) B 3

C1 Nico trol NS Nicotrol NS (Nasal Solution) B 3 A1 Antibacterials B1 Aminoglycosides

C1 Ami kaci n Sulf ate Amikacin Sulfate (500MG/2ML Injection Solution) G 2

C1 Arik ayce Arikayce (Inhalation Suspension) B 4 PA

C1 Gen tami cin Sulf ate- 0.9 % Sodi um Chlo ride Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous G 1 Solution)

C1 Gen tami cin Sulf ate Gentamicin Sulfate (40MG/ML Injection Solution) G 1

C1 Hu mati n Humatin (Oral Capsule) G 4

C1 Neo myci n Sulf ate Neomycin Sulfate (Oral Tablet) G 1

C1 Paro mo myci n Sulf ate Paromomycin Sulfate (Oral Capsule) G 3

C1 Stre pto myci n Sulf ate Streptomycin Sulfate (Intramuscular Solution G 4 Reconstituted)

C1 Tob ram ycin Sulf ate Tobramycin Sulfate (10MG/ML Injection Solution, G 3 80MG/2ML Injection Solution)

C1 Zem dri Zemdri (Intravenous Solution) B 4 B1 Antibacterials, Other 48 Last updated September 1, 2021

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

C1 Aem colo Aemcolo (Oral Tablet Delayed Release) B 3 PA

C1 Aza cta m Azactam (Injection Solution Reconstituted) B 3

C1 Aztr eon am Aztreonam (1GM Injection Solution Reconstituted) G 3

C1 Cleo cin Cleocin (Oral Capsule) B 3

C1 Cleo cin Cleocin (Oral Solution Reconstituted) G 3

C1 Cleo cin Pho sph ate Cleocin Phosphate (900MG/6ML Injection Solution) G 3

C1 Cleo cin Cleocin (Vaginal Cream) B 3

C1 Cleo cin Cleocin (Vaginal Suppository) B 3

C1 Clin dam ycin HCl Clindamycin HCl (Oral Capsule) G 1

C1 Clin dam ycin Pal mita te HCl Clindamycin Palmitate HCl (Oral Solution Reconstituted) G 3

C1 Clin dam ycin Pho sph ate in D5 W Clindamycin Phosphate in D5W (Intravenous Solution) G 2

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (300MG/2ML Injection Solution, 600MG/4ML Injection Solution, 900MG/6ML Injection G 2 Solution)

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (Vaginal Cream) G 2

C1 Clin des se Clindesse (Vaginal Cream) B 3

C1 Coli stim etha te Sodi um Colistimethate Sodium (CBA) (Injection Solution G 4 Reconstituted)

C1 Cubi cin Cubicin (Intravenous Solution Reconstituted) B 4

C1 Dalv anc e Dalvance (Intravenous Solution Reconstituted) B 4 PA

C1 Dap tom ycin Daptomycin (Intravenous Solution Reconstituted) G 4

C1 Firv anq Firvanq (Oral Solution Reconstituted) B 3

C1 Flag yl Flagyl (Oral Capsule) B 3

C1 Flag yl Flagyl (Oral Tablet) B 3

C1 Fosf omy cin Tro met ham ine Fosfomycin Tromethamine (Oral Packet) G 3

C1 Hipr ex Hiprex (Oral Tablet) B 3

C1 Line zoli d Linezolid (Intravenous Solution) G 3

C1 Line zoli d Linezolid (Oral Suspension Reconstituted) G 4

C1 Line zoli d Linezolid (Oral Tablet) G 3

C1 Mac robi d Macrobid (Oral Capsule) B 3 HRM

C1 Mac roda ntin Macrodantin (Oral Capsule) B 3 HRM

C1 Met hen ami ne Hip pura te Methenamine Hippurate (Oral Tablet) G 2

C1 Metr oCr eam MetroCream (External Cream) B 3

C1 Metr ogel Metrogel (External Gel) B 3

C1 Metr oLot MetroLotion (External Lotion) B 4

C1 Metr onid azol e Metronidazole (0.75% External Cream) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 49

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

C1 Metr onid azol e Metronidazole (0.75% External Gel, 1% External Gel) G 3

C1 Metr onid azol e Metronidazole (0.75% External Lotion) G 3

C1 Metr onid azol e in NaC l 0.79 % Metronidazole in NaCl 0.79% (Intravenous Solution) G 1

C1 Metr onid azol e Metronidazole (375MG Oral Capsule) G 3

C1 Metr onid azol e Metronidazole (250MG Oral Tablet, 500MG Oral Tablet) G 1

C1 Metr onid azol e Metronidazole (0.75% Vaginal Gel) G 2

C1 Mon urol Monurol (Oral Packet) B 3

C1 Nitr ofur anto in Mac rocr ystal Nitrofurantoin Macrocrystal (100MG Oral Capsule, G 2 HRM 50MG Oral Capsule) (Generic Macrodantin)

C1 Nitr ofur anto in Mac rocr ystal Nitrofurantoin Macrocrystal (25MG Oral Capsule) G 3 HRM (Generic Macrodantin)

C1 Nitr ofur anto in Mon ohy drat e Nitrofurantoin Monohydrate (Generic Macrobid) G 2 HRM

C1 Nitr ofur anto in Nitrofurantoin (Oral Suspension) G 3 HRM

C1 Nori tate Noritate (External Cream) B 4

C1 Poly myxi n B Sulf ate Polymyxin B Sulfate (Injection Solution Reconstituted) G 2

C1 Sive xtro Sivextro (Intravenous Solution Reconstituted) B 4 PA

C1 Sive xtro Sivextro (Oral Tablet) B 4 PA

C1 Solo sec Solosec (Oral Packet) B 3

C1 Tige cycli ne Tigecycline (Intravenous Solution Reconstituted) G 4

C1 Tini daz ole Tinidazole (Oral Tablet) G 2

C1 Trim etho prim Trimethoprim (Oral Tablet) G 1

C1 Tyg acil Tygacil (Intravenous Solution Reconstituted) B 4

C1 Van coci n HCl Vancocin HCl (125MG Oral Capsule) B 4 QL

C1 Van coci n Vancocin (250MG Oral Capsule) B 4 QL

C1 Van com ycin HCl Vancomycin HCl (10GM Intravenous Solution Reconstituted, 1GM Intravenous Solution Reconstituted, G 2 500MG Intravenous Solution Reconstituted, 750MG Intravenous Solution Reconstituted)

C1 Van com ycin HCl Vancomycin HCl (250MG Intravenous Solution B 2 Reconstituted)

C1 Van com ycin HCl Vancomycin HCl (Oral Capsule) G 3 QL

C1 Van com ycin HCl Vancomycin HCl (Oral Solution Reconstituted) G 3

C1 Van daz ole Vandazole (Vaginal Gel) B 2

C1 Xenl eta Xenleta (Oral Tablet) B 4 PA; QL

C1 Xifa xan Xifaxan (Oral Tablet) B 4 PA

C1 Zyv ox Zyvox (600MG/300ML Intravenous Solution) B 3

C1 Zyv ox Zyvox (Oral Suspension Reconstituted) B 4

C1 Zyv ox Zyvox (Oral Tablet) B 4 50 Last updated September 1, 2021

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

B1 Beta-lactam, Cephalosporins

C1 Avy caz Avycaz (Intravenous Solution Reconstituted) B 4 PA

C1 Cefa clor ER Cefaclor ER (Oral Tablet Extended Release 12 Hour) G 3

C1 Cefa clor Cefaclor (Oral Capsule) G 2

C1 Cefa clor Cefaclor (Oral Suspension Reconstituted) G 3

C1 Cefa drox il Cefadroxil (Oral Capsule) G 1

C1 Cefa drox il Cefadroxil (Oral Suspension Reconstituted) G 2

C1 Cefa drox il Cefadroxil (Oral Tablet) G 3

C1 Cefa zolin

Sodi um Cefazolin Sodium (10GM Injection Solution Reconstituted, 1GM Injection Solution Reconstituted, G 2 500MG Injection Solution Reconstituted)

C1 Cef dinir Cefdinir (Oral Capsule) G 2

C1 Cef dinir Cefdinir (Oral Suspension Reconstituted) G 2

C1 Cef epi me HCl Cefepime HCl (Injection Solution Reconstituted) G 3

C1 Cefi xim e Cefixime (Oral Capsule) G 2

C1 Cefi xim e Cefixime (Oral Suspension Reconstituted) G 3

C1 Cef otet an Diso diu m Cefotetan Disodium (Injection Solution Reconstituted) G 3

C1 Cef oxiti n Sodi um Cefoxitin Sodium (Injection Solution Reconstituted) G 2

C1 Cef oxiti n Sodi um Cefoxitin Sodium (Intravenous Solution Reconstituted) G 2

C1 Cef pod oxi me Prox etil Cefpodoxime Proxetil (Oral Suspension Reconstituted) G 3

C1 Cef pod oxi me Prox etil Cefpodoxime Proxetil (Oral Tablet) G 2

C1 Cef proz il Cefprozil (Oral Suspension Reconstituted) G 2

C1 Cef proz il Cefprozil (Oral Tablet) G 2

C1 Ceft azidi me Ceftazidime (Injection Solution Reconstituted) G 2

C1 Ceft riax one Sodi um Ceftriaxone Sodium (1GM Injection Solution G 1 Reconstituted, 250MG Injection Solution Reconstituted)

C1 Ceft riax one Sodi um Ceftriaxone Sodium (2GM Injection Solution G 2 Reconstituted, 500MG Injection Solution Reconstituted)

C1 Ceft riax one Sodi um Ceftriaxone Sodium (10GM Intravenous Solution G 2 Reconstituted)

C1 Cef urox ime Axet il Cefuroxime Axetil (Oral Tablet) G 1

C1 Cef urox ime Sodi um Cefuroxime Sodium (Injection Solution Reconstituted) G 1

C1 Cef urox ime Sodi um Cefuroxime Sodium (Intravenous Solution G 1 Reconstituted)

C1 Cep hale xin Cephalexin (250MG Oral Capsule, 500MG Oral Capsule) G 1

C1 Cep hale xin Cephalexin (750MG Oral Capsule) G 3

C1 Cep hale xin Cephalexin (Oral Suspension Reconstituted) G 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 51

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

C1 Cep hale xin Cephalexin (Oral Tablet) G 2

C1 Sup rax Suprax (Oral Capsule) B 2

C1 Sup rax Suprax (100MG/5ML Oral Suspension Reconstituted, G 3 200MG/5ML Oral Suspension Reconstituted)

C1 Sup rax Suprax (500MG/5ML Oral Suspension Reconstituted) B 3

C1 Sup rax Suprax (Oral Tablet Chewable) G 2

C1 Tazi cef Tazicef (Injection Solution Reconstituted) G 2

C1 Tefl aro Teflaro (Intravenous Solution Reconstituted) B 4

C1 Zer bax a Zerbaxa (Intravenous Solution Reconstituted) B 4 PA B1 Beta-lactam, Penicillins

C1 Am oxici llin Amoxicillin (Oral Capsule) G 1

C1 Am oxici llin Amoxicillin (Oral Suspension Reconstituted) G 1

C1 Am oxici llin Amoxicillin (Oral Tablet Immediate Release) G 1

C1 Am oxici llin Amoxicillin (Oral Tablet Chewable) G 1

C1 Am oxici llin- Pota ssiu m Clav ulan ate ER Amoxicillin-Potassium Clavulanate ER (Oral Tablet G 3 Extended Release 12 Hour)

C1 Am oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium Clavulanate (200-28.5MG/5ML Oral Suspension Reconstituted, 400-57MG/5ML Oral G 1 Suspension Reconstituted, 600-42.9MG/5ML Oral Suspension Reconstituted)

C1 Am oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium Clavulanate (250-62.5MG/5ML G 2 Oral Suspension Reconstituted)

C1 Am oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium Clavulanate (250-125MG Oral G 2 Tablet Immediate Release)

C1 Am oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium Clavulanate (500-125MG Oral Tablet Immediate Release, 875-125MG Oral Tablet G 1 Immediate Release)

C1 Am oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium Clavulanate (200-28.5MG Oral G 2 Tablet Chewable, 400-57MG Oral Tablet Chewable)

C1 Am picill in Ampicillin (Oral Capsule) G 1

C1 Am picill in Sodi um Ampicillin Sodium (125MG Injection Solution G 2 Reconstituted, 1GM Injection Solution Reconstituted)

C1 Am picill in Sodi um Ampicillin Sodium (10GM Intravenous Solution G 2 Reconstituted)

C1 Am picill in- Sulb acta m Sodi um Ampicillin-Sulbactam Sodium (Injection Solution G 2 Reconstituted)

C1 Am picill in- Sulb acta m Sodi um Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous G 2 Solution Reconstituted)

C1 Bicill in C- R 900/ 300 Bicillin C-R 900/300 (Intramuscular Suspension) B 3 52 Last updated September 1, 2021

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

C1 Bicill in C- R Bicillin C-R (Intramuscular Suspension) B 3

C1 Bicill in L- A Bicillin L-A (Intramuscular Suspension) B 3

C1 Dicl oxa cillin

Sodi um Dicloxacillin Sodium (250MG Oral Capsule) G 1

C1 Dicl oxa cillin

Sodi um Dicloxacillin Sodium (500MG Oral Capsule) G 2

C1 Nafc illin Sodi um Nafcillin Sodium (Injection Solution Reconstituted) G 3

C1 Nafc illin Sodi um Nafcillin Sodium (10GM Intravenous Solution G 3 Reconstituted)

C1 Oxa cillin

Sodi um in Dext rose Oxacillin Sodium in Dextrose (1GM/50ML Intravenous B 3 Solution)

C1 Oxa cillin

Sodi um in Dext rose Oxacillin Sodium in Dextrose (2GM/50ML Intravenous B 4 Solution)

C1 Oxa cillin

Sodi um Oxacillin Sodium (Injection Solution Reconstituted) G 3

C1 Oxa cillin

Sodi um Oxacillin Sodium (Intravenous Solution Reconstituted) G 3

C1 Peni cillin G Pota ssiu m in Dext rose Penicillin G Potassium in Dextrose (40000UNIT/ML

Intravenous Solution, 60000UNIT/ML Intravenous B 3 Solution)

C1 Peni cillin G Pota ssiu m Penicillin G Potassium (20000000UNIT Injection Solution G 3 Reconstituted)

C1 Peni cillin G Proc aine Penicillin G Procaine (Intramuscular Suspension) G 3

C1 Peni cillin G Sodi um Penicillin G Sodium (Injection Solution Reconstituted) G 4

C1 Peni cillin V Pota ssiu m Penicillin V Potassium (Oral Solution Reconstituted) G 1

C1 Peni cillin V Pota ssiu m Penicillin V Potassium (Oral Tablet) G 1

C1 Pipe racill in- Taz oba cta m Piperacillin-Tazobactam (2.25 (2-0.25)GM Intravenous Solution Reconstituted, 3.375 (3-0.375)GM Intravenous G 2 Solution Reconstituted)

C1 Pipe racill in- Taz oba cta m Piperacillin-Tazobactam (4.5 (4-0.5)GM Intravenous Solution Reconstituted, 40.5 (36-4.5)GM Intravenous G 3 Solution Reconstituted)

C1 Una syn Unasyn (3 (2-1)GM Injection Solution Reconstituted) B 3

C1 Una syn Unasyn (Intravenous Solution Reconstituted) B 3

C1 Zos yn Zosyn (2-0.25GM/50ML Intravenous Solution, B 3 3-0.375GM/50ML Intravenous Solution) B1 Carbapenems

C1 Erta pen em Sodi um Ertapenem Sodium (Injection Solution Reconstituted) G 3

C1 Imip ene m- Cila stati n Imipenem-Cilastatin (Intravenous Solution Reconstituted) G 3

C1 Inva nz Invanz (Injection Solution Reconstituted) B 4

C1 Mer ope nem Meropenem (1GM Intravenous Solution Reconstituted) G 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 53

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

C1 Mer ope nem Meropenem (500MG Intravenous Solution G 2 Reconstituted)

C1 Merr em Merrem (500MG Intravenous Solution Reconstituted) B 3

C1 Prim axin IV Primaxin IV (Intravenous Solution Reconstituted) B 3

C1 Vab ome re Vabomere (Intravenous Solution Reconstituted) B 4 B1 Macrolides

C1 Azit hro myci n Azithromycin (Intravenous Solution Reconstituted) G 1

C1 Azit hro myci n Azithromycin (Oral Packet) B 1

C1 Azit hro myci n Azithromycin (Oral Suspension Reconstituted) G 1

C1 Azit hro myci n Azithromycin (Oral Tablet) G 1

C1 Clari thro myci n ER Clarithromycin ER (Oral Tablet Extended Release 24 G 2 Hour)

C1 Clari thro myci n Clarithromycin (Oral Suspension Reconstituted) G 3

C1 Clari thro myci n Clarithromycin (Oral Tablet Immediate Release) G 2

C1 Dific id Dificid (Oral Suspension Reconstituted) B 4

C1 Dific id Dificid (Oral Tablet) B 4

C1 E.E. S. Gra nule s E.E.S. Granules (Oral Suspension Reconstituted) B 3

C1 EryP ed 200 EryPed 200 (Oral Suspension Reconstituted) B 3

C1 EryP ed 400 EryPed 400 (Oral Suspension Reconstituted) B 4

C1 Ery- Tab Ery-Tab (Oral Tablet Delayed Release) G 3

C1 Eryt hroc in Lact obio nate Erythrocin Lactobionate (Intravenous Solution G 3 Reconstituted)

C1 Eryt hroc in Stea rate Erythrocin Stearate (Oral Tablet) G 3

C1 Eryt hro myci n Bas e Erythromycin Base (Oral Capsule Delayed Release G 3 Particles)

C1 Eryt hro myci n Bas e Erythromycin Base (Oral Tablet Immediate Release) G 3

C1 Eryt hro myci n Bas e Erythromycin Base (Oral Tablet Delayed Release) G 3

C1 Eryt hro myci n Ethy lsuc cina te Erythromycin Ethylsuccinate (200MG/5ML Oral G 3 Suspension Reconstituted)

C1 Eryt hro myci n Ethy lsuc cina te Erythromycin Ethylsuccinate (400MG/5ML Oral G 4 Suspension Reconstituted)

C1 Eryt hro myci n Ethy lsuc cina te Erythromycin Ethylsuccinate (Oral Tablet) G 3

C1 Zithr oma x Zithromax (Intravenous Solution Reconstituted) B 3

C1 Zithr oma x Zithromax (Oral Packet) B 3

C1 Zithr oma x Zithromax (Oral Suspension Reconstituted) B 3

C1 Zithr oma x Zithromax (Oral Tablet) B 3

C1 Zithr oma x Tri- Pak Zithromax Tri-Pak (Oral Tablet) B 3

C1 Zithr oma x Z- Pak Zithromax Z-Pak (Oral Tablet) B 3 54 Last updated September 1, 2021

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

B1 Quinolones

C1 Bax dela Baxdela (Intravenous Solution Reconstituted) B 4

C1 Bax dela Baxdela (Oral Tablet) B 4

C1 Cipr o Cipro (Oral Suspension Reconstituted) B 3

C1 Cipr o Cipro (Oral Tablet Immediate Release) B 3

C1 Cipr oflo xaci n HCl Ciprofloxacin HCl (100MG Oral Tablet Immediate G 3 Release)

C1 Cipr oflo xaci n HCl Ciprofloxacin HCl (250MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 750MG G 1 Oral Tablet Immediate Release)

C1 Cipr oflo xaci n in D5 W Ciprofloxacin in D5W (200MG/100ML Intravenous G 1 Solution)

C1 Lev oflo xaci n in D5 W Levofloxacin in D5W (500MG/100ML Intravenous G 2 Solution, 750MG/150ML Intravenous Solution)

C1 Lev oflo xaci n Levofloxacin (25MG/ML Intravenous Solution) G 3

C1 Lev oflo xaci n Levofloxacin (25MG/ML Oral Solution) G 3

C1 Lev oflo xaci n Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet, G 1 750MG Oral Tablet)

C1 Mox iflox acin HCl in NaC l Moxifloxacin HCl in NaCl (Intravenous Solution) G 3

C1 Mox iflox acin HCl Moxifloxacin HCl (Oral Tablet) G 2

C1 Oflo xaci n Ofloxacin (Oral Tablet) G 3 B1 Sulfonamides

C1 Bact rim DS Bactrim DS (Oral Tablet) B 3

C1 Bact rim Bactrim (Oral Tablet) B 3

C1 Sulf adia zine Sulfadiazine (Oral Tablet) G 3

C1 Sulf ame thox azol e- Trim etho prim Sulfamethoxazole-Trimethoprim (Oral Suspension) G 2

C1 Sulf ame thox azol e- Trim etho prim Sulfamethoxazole-Trimethoprim (Oral Tablet) G 1 B1 Tetracyclines

C1 Acti clat e Acticlate (Oral Tablet) B 3

C1 De mec locy cline HCl Demeclocycline HCl (Oral Tablet) G 3

C1 Dor yx MP C Doryx MPC (Oral Tablet Delayed Release) B 3

C1 Dor yx Doryx (200MG Oral Tablet Delayed Release) B 4

C1 Dor yx Doryx (50MG Oral Tablet Delayed Release) B 3

C1 Dox y 100 Doxy 100 (Intravenous Solution Reconstituted) G 3

C1 Dox ycyc line Hycl ate Doxycycline Hyclate (Oral Capsule) G 2

C1 Dox ycyc line Hycl ate Doxycycline Hyclate (100MG Oral Tablet Immediate G 2 Release, 20MG Oral Tablet Immediate Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 55

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

C1 Dox ycyc line Hycl ate Doxycycline Hyclate (150MG Oral Tablet Immediate G 3 Release, 75MG Oral Tablet Immediate Release)

C1 Dox ycyc line Hycl ate Doxycycline Hyclate (100MG Oral Tablet Delayed Release, 150MG Oral Tablet Delayed Release, 200MG G 3 Oral Tablet Delayed Release, 50MG Oral Tablet Delayed Release, 75MG Oral Tablet Delayed Release)

C1 Dox ycyc line Hycl ate Doxycycline Hyclate (80MG Oral Tablet Delayed G 4 Release)

C1 Dox ycyc line Mon ohy drat e Doxycycline Monohydrate (100MG Oral Capsule, 50MG G 1 Oral Capsule)

C1 Dox ycyc line Mon ohy drat e Doxycycline Monohydrate (150MG Oral Capsule, 75MG G 3 Oral Capsule)

C1 Dox ycyc line Mon ohy drat e Doxycycline Monohydrate (Oral Suspension G 3 Reconstituted)

C1 Dox ycyc line Mon ohy drat e Doxycycline Monohydrate (Oral Tablet) G 2

C1 Min ocy cline HCl ER Minocycline HCl ER (Oral Tablet Extended Release 24 G 3 QL Hour)

C1 Min ocy cline HCl Minocycline HCl (Oral Capsule) G 1

C1 Min ocy cline HCl Minocycline HCl (Oral Tablet Immediate Release) G 3

C1 Min olira Minolira (Oral Tablet Extended Release 24 Hour) B 3 QL

C1 Mon dox yne NL Mondoxyne NL (100MG Oral Capsule) G 1

C1 Mon dox yne NL Mondoxyne NL (75MG Oral Capsule) G 3

C1 Nuz yra Nuzyra (Intravenous Solution Reconstituted) B 4 PA

C1 Nuz yra Nuzyra (Oral Tablet) B 4 PA; QL

C1 Ora cea Oracea (Oral Capsule Delayed Release) B 4

C1 Sey sara Seysara (Oral Tablet) B 4

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

C1 TAR GA DOX TARGADOX (Oral Tablet) G 3

C1 Tetr acyc line HCl Tetracycline HCl (Oral Capsule) G 3

C1 Vibr amy cin Vibramycin (Oral Capsule) B 3

C1 Vibr amy cin Vibramycin (Oral Suspension Reconstituted) B 3

C1 Vibr amy cin Vibramycin (50MG/5ML Oral Syrup) B 3 A1 Anticonvulsants B1 Anticonvulsants, Other

C1 BRI VIA CT BRIVIACT (Oral Solution) B 4 PA; QL

C1 BRI VIA CT BRIVIACT (Oral Tablet) B 4 PA; QL

C1 Epid iolex Epidiolex (Oral Solution) B 4 PA

C1 Felb ama te Felbamate (Oral Suspension) G 4 56 Last updated September 1, 2021

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

C1 Felb ama te Felbamate (Oral Tablet) G 3

C1 Felb atol Felbatol (Oral Suspension) B 4

C1 Felb atol Felbatol (Oral Tablet) B 4

C1 Fint epla Fintepla (Oral Solution) B 4 PA; QL

C1 Fyc omp a Fycompa (Oral Suspension) B 4 QL

C1 Fyc omp a Fycompa (Oral Tablet) B 4 QL

C1 Kep pra Keppra (Oral Solution) B 4

C1 Kep pra Keppra (1000MG Oral Tablet Immediate Release,

500MG Oral Tablet Immediate Release, 750MG Oral B 4 Tablet Immediate Release)

C1 Kep pra Keppra (250MG Oral Tablet Immediate Release) B 3

C1 Kep pra XR Keppra XR (Oral Tablet Extended Release 24 Hour) B 4

C1 Lam ictal ODT Lamictal ODT (Oral Tablet Dispersible) B 4

C1 Lam ictal Lamictal (Oral Tablet Immediate Release) B 4

C1 Lam ictal Lamictal (Oral Tablet Chewable) B 4

C1 Lam ictal Start er Lamictal Starter (35 Tablets Oral Kit, 49 Tablets Oral B 3 Kit)

C1 Lam ictal Start er Lamictal Starter (98 Tablets Oral Kit) B 4

C1 Lam ictal XR Lamictal XR (Oral Kit) B 3

C1 Lam ictal XR Lamictal XR (100MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 Hour, 250MG Oral Tablet Extended Release 24 Hour, 25MG B 4 Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour)

C1 Lam otrig ine ER Lamotrigine ER (Oral Tablet Extended Release 24 Hour) G 3

C1 Lam otrig ine ODT Lamotrigine ODT (25 & 50 & 100MG Oral Tablet G 3 Dispersible Kit)

C1 Lam otrig ine Lamotrigine (100MG Oral Tablet Immediate Release, 150MG Oral Tablet Immediate Release, 200MG Oral G 1 Tablet Immediate Release, 25MG Oral Tablet Immediate Release)

C1 Lam otrig ine Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral G 2 Tablet Chewable)

C1 Lam otrig ine ODT Lamotrigine ODT (Oral Tablet Dispersible) G 3

C1 Lam otrig ine Start er Kit- Blue Lamotrigine Starter Kit-Blue (Oral Kit) G 3

C1 Lam otrig ine Start er Kit- Gre en Lamotrigine Starter Kit-Green (Oral Kit) G 4

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 57

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

C1 Lam otrig ine Start er Kit- Ora nge Lamotrigine Starter Kit-Orange (Oral Kit) G 3

C1 Lev etira ceta m ER Levetiracetam ER (Oral Tablet Extended Release 24 G 2 Hour)

C1 Lev etira ceta m Levetiracetam (Oral Solution) G 1

C1 Lev etira ceta m Levetiracetam (Oral Tablet Immediate Release) G 1

C1 Qud exy XR Qudexy XR (100MG Oral Capsule ER 24 Hour Sprinkle, 25MG Oral Capsule ER 24 Hour Sprinkle, B 3 PA 50MG Oral Capsule ER 24 Hour Sprinkle)

C1 Qud exy XR Qudexy XR (150MG Oral Capsule ER 24 Hour B 4 PA Sprinkle, 200MG Oral Capsule ER 24 Hour Sprinkle)

C1 Row eepr a Roweepra (Oral Tablet Immediate Release) G 1

C1 Sprit am ODT Spritam ODT (Oral Tablet Disintegrating Soluble) B 3

C1 Top ama x Topamax (100MG Oral Tablet, 200MG Oral Tablet, B 4 50MG Oral Tablet)

C1 Top ama x Topamax (25MG Oral Tablet) B 3

C1 Top ama x Spri nkle Topamax Sprinkle (15MG Oral Capsule Sprinkle) B 3

C1 Top ama x Spri nkle Topamax Sprinkle (25MG Oral Capsule Sprinkle) B 4

C1 Topi ram ate ER Topiramate ER (100MG Oral Capsule ER 24 Hour Sprinkle, 25MG Oral Capsule ER 24 Hour Sprinkle, G 3 PA 50MG Oral Capsule ER 24 Hour Sprinkle)

C1 Topi ram ate ER Topiramate ER (150MG Oral Capsule ER 24 Hour G 4 PA Sprinkle, 200MG Oral Capsule ER 24 Hour Sprinkle)

C1 Topi ram ate Topiramate (Oral Capsule Sprinkle Immediate Release) G 2

C1 Topi ram ate Topiramate (Oral Tablet) G 1

C1 Trok endi XR Trokendi XR (100MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended Release 24 B 4 PA Hour)

C1 Trok endi XR Trokendi XR (25MG Oral Capsule Extended Release 24 Hour, 50MG Oral Capsule Extended Release 24 B 3 PA Hour)

C1 Valp roic Acid Valproic Acid (Oral Capsule) G 2

C1 Valp roic Acid Valproic Acid (Oral Solution) G 1

C1 Xco pri Xcopri (250MG Daily Dose) (Oral Tablet Therapy B 4 PA; QL Pack)

C1 Xco pri Xcopri (350MG Daily Dose) (Oral Tablet Therapy B 4 PA; QL Pack)

C1 Xco pri Xcopri (100MG Oral Tablet, 150MG Oral Tablet, B 3 PA; QL 50MG Oral Tablet)

C1 Xco pri Xcopri (200MG Oral Tablet) B 4 PA; QL 58 Last updated September 1, 2021

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

C1 Xco pri Xcopri (14x12.5MG & 14x25MG Oral Tablet Therapy B 3 PA; QL Pack)

C1 Xco pri Xcopri (14x150MG & 14x200MG Oral Tablet Therapy Pack, 14x50MG & 14x100MG Oral Tablet Therapy B 4 PA; QL Pack) B1 Calcium Channel Modifying Agents

C1 Celo ntin Celontin (Oral Capsule) B 3

C1 Etho suxi mid e Ethosuximide (Oral Capsule) G 2

C1 Etho suxi mid e Ethosuximide (Oral Solution) G 2

C1 Zaro ntin Zarontin (Oral Capsule) B 3

C1 Zaro ntin Zarontin (Oral Solution) G 3 B1 Gamma-aminobutyric Acid (GABA) Augmenting Agents

C1 Clo baz am Clobazam (Oral Suspension) G 3 PA; QL

C1 Clo baz am Clobazam (Oral Tablet) G 3 PA; QL

C1 Diac omit Diacomit (Oral Capsule) B 4 QL

C1 Diac omit Diacomit (Oral Packet) B 4 QL

C1 Dias tat Acu Dial Diastat AcuDial (Rectal Gel) B 3 QL

C1 Dias tat Pedi atric Diastat Pediatric (Rectal Gel) B 3 QL

C1 Diaz epa m Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG G 3 QL Rectal Gel)

C1 Gab ape ntin Gabapentin (Oral Capsule) G 1

C1 Gab ape ntin Gabapentin (250MG/5ML Oral Solution) G 2

C1 Gab ape ntin Gabapentin (Oral Tablet) G 1

C1 Gabi tril Gabitril (Oral Tablet) B 4

C1 Mys olin e Mysoline (Oral Tablet) B 4

C1 Nay zila m Nayzilam (Nasal Solution) B 3 QL

C1 Neu ronti n Neurontin (100MG Oral Capsule) B 3

C1 Neu ronti n Neurontin (300MG Oral Capsule, 400MG Oral B 4 Capsule)

C1 Neu ronti n Neurontin (Oral Solution) B 3

C1 Neu ronti n Neurontin (Oral Tablet) B 4

C1 Onfi Onfi (Oral Suspension) B 4 PA; QL

C1 Onfi Onfi (Oral Tablet) B 4 PA; QL

C1 Phe nob arbit al Phenobarbital (Oral Elixir) G 3 PA; HRM

C1 Phe nob arbit al Phenobarbital (Oral Tablet) G 3 PA; HRM

C1 Prim idon e Primidone (Oral Tablet) G 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 59

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

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

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

C1 Sym paz an Sympazan (10MG Oral Film, 20MG Oral Film) B 4 PA; QL

C1 Sym paz an Sympazan (5MG Oral Film) B 3 PA; QL

C1 Tiag abin e HCl Tiagabine HCl (Oral Tablet) G 3

C1 Valt oco 10 MG Dos e Valtoco 10 MG Dose (Nasal Liquid) B 3 QL

C1 Valt oco 15 MG Dos e Valtoco 15 MG Dose (Nasal Liquid Therapy Pack) B 3 QL

C1 Valt oco 20 MG Dos e Valtoco 20 MG Dose (Nasal Liquid Therapy Pack) B 3 QL

C1 Valt oco 5 MG Dos e Valtoco 5 MG Dose (Nasal Liquid) B 3 QL

C1 Viga batri n Vigabatrin (Oral Packet) G 4 PA; LA; QL

C1 Viga batri n Vigabatrin (Oral Tablet) G 4 PA; LA; QL

C1 Viga dron e Vigadrone (Oral Packet) G 4 PA; LA; QL B1 Sodium Channel Agents

C1 Apti om Aptiom (Oral Tablet) B 4 QL

C1 Ban zel Banzel (Oral Suspension) B 4

C1 Ban zel Banzel (Oral Tablet) B 4

C1 Car bam aze pine ER Carbamazepine ER (100MG Oral Capsule Extended Release 12 Hour, 200MG Oral Capsule Extended G 2 Release 12 Hour, 300MG Oral Capsule Extended Release 12 Hour)

C1 Car bam aze pine ER Carbamazepine ER (100MG Oral Tablet Extended Release 12 Hour, 200MG Oral Tablet Extended Release G 3 12 Hour, 400MG Oral Tablet Extended Release 12 Hour)

C1 Car bam aze pine Carbamazepine (Oral Suspension) G 2

C1 Car bam aze pine Carbamazepine (Oral Tablet Immediate Release) G 2

C1 Car bam aze pine Carbamazepine (Oral Tablet Chewable) G 2

C1 Car batr ol Carbatrol (Oral Capsule Extended Release 12 Hour) B 3

C1 Dila ntin INF ATA BS Dilantin INFATABS (Oral Tablet Chewable) G 2

C1 Dila ntin Dilantin (Oral Capsule) G 2

C1 Dila ntin Dilantin (Oral Suspension) B 3

C1 Epit ol Epitol (Oral Tablet) G 2

C1 Oxc arba zepi ne Oxcarbazepine (300MG/5ML Oral Suspension) G 3

C1 Oxc arba zepi ne Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet, G 2 600MG Oral Tablet)

C1 Oxt ellar XR Oxtellar XR (150MG Oral Tablet Extended Release 24 B 3 Hour, 300MG Oral Tablet Extended Release 24 Hour)

C1 Oxt ellar XR Oxtellar XR (600MG Oral Tablet Extended Release 24 B 4 Hour) 60 Last updated September 1, 2021

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

C1 Phe nyte k Phenytek (Oral Capsule) G 1

C1 Phe nyto in Phenytoin (125MG/5ML Oral Suspension) G 1

C1 Phe nyto in Phenytoin (Oral Tablet Chewable) G 1

C1 Phe nyto in Sodi um Exte nde d Phenytoin Sodium Extended (Oral Capsule) G 1

C1 Rufi nam ide Rufinamide (Oral Suspension) G 4

C1 Rufi nam ide Rufinamide (Oral Tablet) G 4

C1 Tegr etol Tegretol (Oral Suspension) B 3

C1 Tegr etol Tegretol (Oral Tablet Immediate Release) B 3

C1 Tegr etol XR Tegretol XR (Oral Tablet Extended Release 12 Hour) B 3

C1 Trile ptal Trileptal (Oral Suspension) B 4

C1 Trile ptal Trileptal (150MG Oral Tablet) B 3

C1 Trile ptal Trileptal (300MG Oral Tablet, 600MG Oral Tablet) B 4

C1 Vim pat Vimpat (Oral Solution) B 3 QL

C1 Vim pat Vimpat (Oral Tablet) B 3 QL

C1 Zon egra n Zonegran (Oral Capsule) B 4

C1 Zoni sami de Zonisamide (Oral Capsule) G 1 A1 Antidementia Agents B1 Antidementia Agents, Other

C1 Na mza ric Namzaric (Oral Capsule ER 24 Hour Therapy Pack) B 2 PA; QL

C1 Na mza ric Namzaric (Oral Capsule Extended Release 24 Hour) B 2 PA; QL B1 Cholinesterase Inhibitors

C1 Aric ept Aricept (Oral Tablet) B 3 QL

C1 Don epe zil HCl Donepezil HCl (10MG Oral Tablet, 5MG Oral Tablet) G 1 QL

C1 Don epe zil HCl Donepezil HCl (23MG Oral Tablet) G 2 QL

C1 Don epe zil HCl ODT Donepezil HCl ODT (Oral Tablet Dispersible) G 1 QL

C1 Exel on Exelon (Transdermal Patch 24 Hour) B 3 ST; QL

C1 Gala nta min e Hyd robr omi de ER Galantamine Hydrobromide ER (Oral Capsule Extended G 3 Release 24 Hour)

C1 Gala nta min e Hyd robr omi de Galantamine Hydrobromide (Oral Solution) G 3

C1 Gala nta min e Hyd robr omi de Galantamine Hydrobromide (Oral Tablet) G 2

C1 Raz ady ne ER Razadyne ER (Oral Capsule Extended Release 24 B 3 Hour)

C1 Riva stig min e Tartr ate Rivastigmine Tartrate (Oral Capsule) G 2

C1 Riva stig min e Rivastigmine (Transdermal Patch 24 Hour) G 3 ST; QL B1 N-methyl-D-aspartate (NMDA)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 61

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

C1 Me man tine HCl ER Memantine HCl ER (Oral Capsule Extended Release 24 G 3 PA; QL Hour)

C1 Me man tine HCl Memantine HCl (2MG/ML Oral Solution) G 3 PA; QL

C1 Me man tine HCl Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet) G 1 PA; QL

C1 Me man tine HCl Titra tion Pak Memantine HCl Titration Pak (Oral Tablet) B 1 PA

C1 Na men da Namenda (10MG Oral Tablet, 5MG Oral Tablet) B 3 PA; QL

C1 Na men da Titra tion Pak Namenda Titration Pak (Oral Tablet) B 3 PA

C1 Na men da XR Namenda XR (Oral Capsule Extended Release 24 B 3 PA; QL Hour) A1 Antidepressants B1 Antidepressants, Other

C1 Aple nzin Aplenzin (Oral Tablet Extended Release 24 Hour) B 4

C1 Bup ropi on HCl SR Bupropion HCl SR (Oral Tablet Extended Release 12 G 1 Hour)

C1 Bup ropi on HCl XL Bupropion HCl XL (150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release G 1 24 Hour)

C1 Bup ropi on HCl ER Bupropion HCl ER (XL) (450MG Oral Tablet Extended G 3 Release 24 Hour)

C1 Bup ropi on HCl Bupropion HCl (Oral Tablet Immediate Release) G 1

C1 Forfi vo XL Forfivo XL (Oral Tablet Extended Release 24 Hour) B 3

C1 Mirt aza pine Mirtazapine (Oral Tablet) G 1

C1 Mirt aza pine

ODT Mirtazapine ODT (Oral Tablet Dispersible) G 2

C1 Olan zapi ne- Fluo xeti ne HCl Olanzapine-Fluoxetine HCl (Oral Capsule) G 3

C1 Re mer on Remeron (Oral Tablet) B 3

C1 Re mer on SolT ab Remeron SolTab (Oral Tablet Dispersible) B 3

C1 Sym byax Symbyax (Oral Capsule) B 3

C1 Well butri n SR Wellbutrin SR (Oral Tablet Extended Release 12 Hour) B 3

C1 Well butri n XL Wellbutrin XL (Oral Tablet Extended Release 24 Hour) B 4 B1 Monoamine Oxidase Inhibitors

C1 Ems am Emsam (Transdermal Patch 24 Hour) B 4

C1 Mar plan Marplan (Oral Tablet) B 3

C1 Nar dil Nardil (Oral Tablet) B 3

C1 Parn ate Parnate (Oral Tablet) B 4

C1 Phe nelzi ne Sulf ate Phenelzine Sulfate (Oral Tablet) G 2

C1 Tran ylcy pro min e Sulf ate Tranylcypromine Sulfate (Oral Tablet) G 3 B1 SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) 62 Last updated September 1, 2021

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

C1 Cele xa Celexa (Oral Tablet) B 3

C1 Cital opra m Hyd robr omi de Citalopram Hydrobromide (Oral Solution) G 2

C1 Cital opra m Hyd robr omi de Citalopram Hydrobromide (Oral Tablet) G 1

C1 Des venl afaxi ne ER Desvenlafaxine ER (Oral Tablet Extended Release 24 B 3 Hour) (Brand Equivalent Khedezla)

C1 Des venl afaxi ne Suc cina te ER Desvenlafaxine Succinate ER (Oral Tablet Extended G 2 Release 24 Hour) (Generic Pristiq)

C1 Effe xor XR Effexor XR (Oral Capsule Extended Release 24 Hour) B 3

C1 Esci talo pra m Oxal ate Escitalopram Oxalate (Oral Solution) G 3

C1 Esci talo pra m Oxal ate Escitalopram Oxalate (Oral Tablet) G 1

C1 Fetz ima Fetzima (Oral Capsule Extended Release 24 Hour) B 3 ST

C1 Fetz ima Titra tion Fetzima Titration (Oral Capsule ER 24 Hour Therapy B 3 ST Pack)

C1 Fluo xeti ne HCl Fluoxetine HCl (PMDD) (Oral Tablet) G 3

C1 Fluo xeti ne HCl Fluoxetine HCl (10MG Oral Capsule Immediate Release, 20MG Oral Capsule Immediate Release, 40MG Oral G 1 Capsule Immediate Release)

C1 Fluo xeti ne HCl Fluoxetine HCl (90MG Oral Capsule Delayed Release) G 3

C1 Fluo xeti ne HCl Fluoxetine HCl (20MG/5ML Oral Solution) G 2

C1 Fluo xeti ne HCl Fluoxetine HCl (10MG Oral Tablet) G 1

C1 Fluo xeti ne HCl Fluoxetine HCl (20MG Oral Tablet, 60MG Oral Tablet) G 3

C1 Fluv oxa min e Mal eate ER Fluvoxamine Maleate ER (Oral Capsule Extended G 3 Release 24 Hour)

C1 Fluv oxa min e Mal eate Fluvoxamine Maleate (Oral Tablet) G 2

C1 Lex apro Lexapro (Oral Tablet) B 3

C1 Nef azo don e HCl Nefazodone HCl (Oral Tablet) G 3

C1 Paro xeti ne HCl Paroxetine HCl (Oral Tablet Immediate Release) G 1 PA; HRM

C1 Paxil Paxil (Oral Suspension) B 3 PA; HRM

C1 Paxil Paxil (Oral Tablet Immediate Release) B 3 PA; HRM

C1 Prist iq Pristiq (Oral Tablet Extended Release 24 Hour) B 3

C1 Proz ac Prozac (10MG Oral Capsule) B 3

C1 Proz ac Prozac (20MG Oral Capsule, 40MG Oral Capsule) B 4

C1 Sert ralin e HCl Sertraline HCl (Oral Concentrate) G 2

C1 Sert ralin e HCl Sertraline HCl (Oral Tablet) G 1

C1 Traz odo ne HCl Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet, G 1 50MG Oral Tablet)

C1 Traz odo ne HCl Trazodone HCl (300MG Oral Tablet) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 63

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

C1 Trint ellix Trintellix (Oral Tablet) B 3

C1 Venl afaxi ne HCl ER Venlafaxine HCl ER (Oral Capsule Extended Release 24 G 1 Hour)

C1 Venl afaxi ne HCl ER Venlafaxine HCl ER (Oral Tablet Extended Release 24 G 3 Hour)

C1 Venl afaxi ne HCl Venlafaxine HCl (Oral Tablet Immediate Release) G 1

C1 Viibr yd Viibryd (Oral Tablet) B 3

C1 Viibr yd Start er Pac k Viibryd Starter Pack (Oral Kit) B 3

C1 Zolo ft Zoloft (Oral Concentrate) B 3

C1 Zolo ft Zoloft (Oral Tablet) B 3 B1 Tricyclics

C1 Amit ripty line HCl Amitriptyline HCl (Oral Tablet) G 3 HRM

C1 Am oxa pine Amoxapine (Oral Tablet) G 2 PA; HRM

C1 Anaf ranil Anafranil (Oral Capsule) B 4 PA; HRM

C1 Clo mipr ami ne HCl Clomipramine HCl (Oral Capsule) G 3 PA; HRM

C1 Desi pra min e HCl Desipramine HCl (Oral Tablet) G 3 PA; HRM

C1 Dox epin HCl Doxepin HCl (Oral Capsule) G 3 PA; HRM

C1 Dox epin HCl Doxepin HCl (Oral Concentrate) G 3 PA; HRM

C1 Imip rami ne HCl Imipramine HCl (Oral Tablet) G 3 PA; HRM

C1 Imip rami ne Pam oate Imipramine Pamoate (Oral Capsule) G 3 PA; HRM

C1 Nor pra min Norpramin (Oral Tablet) B 3 PA; HRM

C1 Nort ripty line HCl Nortriptyline HCl (Oral Capsule) G 1 PA; HRM

C1 Nort ripty line HCl Nortriptyline HCl (Oral Solution) G 2 PA; HRM

C1 Pam elor Pamelor (Oral Capsule) B 4 PA; HRM

C1 Prot ripty line HCl Protriptyline HCl (Oral Tablet) G 3 PA; HRM

C1 Trim ipra min e Mal eate Trimipramine Maleate (Oral Capsule) G 3 PA; HRM A1 Antiemetics B1 Antiemetics, Other

C1 Co mpr o Compro (Rectal Suppository) G 3

C1 Gim oti Gimoti (Nasal Solution) B 4 PA

C1 Mec lizin e HCl Meclizine HCl (12.5MG Oral Tablet) G 1 HRM

C1 Met oclo pra mid e HCl Metoclopramide HCl (5MG/5ML Oral Solution) G 1

C1 Met oclo pra mid e HCl Metoclopramide HCl (Oral Tablet) G 1

C1 Met oclo pra mid e HCl ODT Metoclopramide HCl ODT (Oral Tablet Dispersible) G 3

C1 Per phe nazi ne Perphenazine (Oral Tablet) G 2

C1 Proc hlor pera zine Mal eate Prochlorperazine Maleate (Oral Tablet) G 1

C1 Proc hlor pera zine Prochlorperazine (Rectal Suppository) G 3 64 Last updated September 1, 2021

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

C1 Pro met hazi ne HCl Promethazine HCl (Oral Tablet) G 3 PA; HRM

C1 Pro met hazi ne HCl Promethazine HCl (12.5MG Rectal Suppository) G 3 PA; HRM

C1 Regl an Reglan (Oral Tablet) B 3

C1 Sco pola min e Scopolamine (Transdermal Patch 72 Hour) G 2 PA; HRM

C1 Tran sder m- Sco p Transderm-Scop (1.5MG) (Transdermal Patch 72 B 3 PA; HRM Hour)

C1 Trim etho ben zami de HCl Trimethobenzamide HCl (Oral Capsule) G 2 B/D, PA B1 Emetogenic Therapy Adjuncts

C1 Apr epit ant Aprepitant (Oral Therapy Pack, Oral Capsule) G 3 PA

C1 Dro nabi nol Dronabinol (Oral Capsule) G 3 PA

C1 Eme nd Emend (80MG Oral Capsule) B 3 PA

C1 Eme nd Emend (Oral Suspension Reconstituted) B 3 PA

C1 Eme nd Tri- Pac k Emend Tri-Pack (Oral Capsule) B 4 PA

C1 Gra nise tron HCl Granisetron HCl (Oral Tablet) G 2 B/D, PA

C1 Mari nol Marinol (10MG Oral Capsule, 5MG Oral Capsule) B 4 PA

C1 Mari nol Marinol (2.5MG Oral Capsule) B 3 PA

C1 Ond ans etro n HCl Ondansetron HCl (Oral Solution) G 2 B/D, PA

C1 Ond ans etro n HCl Ondansetron HCl (Oral Tablet) G 1 B/D, PA

C1 Ond ans etro n ODT Ondansetron ODT (Oral Tablet Dispersible) G 1 B/D, PA

C1 San cus o Sancuso (Transdermal Patch) B 4 QL

C1 Syn dros Syndros (Oral Solution) B 4 PA

C1 Varu bi Varubi (180 MG Dose) (Oral Tablet Therapy Pack) B 3 B/D, PA

C1 Zupl enz Zuplenz (Oral Film) B 4 B/D, PA A1 Antifungals B1 Antifungals

C1 Abel cet Abelcet (Intravenous Suspension) B 3 B/D, PA

C1 Am Biso me AmBisome (Intravenous Suspension Reconstituted) B 4 B/D, PA

C1 Am phot erici n B Amphotericin B (Intravenous Solution Reconstituted) G 3 B/D, PA

C1 Anc obo n Ancobon (Oral Capsule) B 4

C1 Can cida s Cancidas (Intravenous Solution Reconstituted) B 4

C1 Cas pofu ngin

Acet ate Caspofungin Acetate (50MG Intravenous Solution G 4 Reconstituted)

C1 Cas pofu ngin

Acet ate Caspofungin Acetate (70MG Intravenous Solution G 3 Reconstituted)

C1 Clot rima zole Clotrimazole (Mouth/Throat Troche) G 1

C1 Cres emb a Cresemba (Oral Capsule) B 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 65

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

C1 Diflu can Diflucan (Oral Suspension Reconstituted) B 3

C1 Diflu can Diflucan (100MG Oral Tablet, 150MG Oral Tablet, B 3 50MG Oral Tablet)

C1 Diflu can Diflucan (200MG Oral Tablet) B 4

C1 Erax is Eraxis (100MG Intravenous Solution Reconstituted) B 4

C1 Erax is Eraxis (50MG Intravenous Solution Reconstituted) B 3

C1 Fluc ona zole in Sodi um Chlo ride Fluconazole in Sodium Chloride (Intravenous Solution) G 2

C1 Fluc ona zole Fluconazole (Oral Suspension Reconstituted) G 2

C1 Fluc ona zole Fluconazole (Oral Tablet) G 1

C1 Fluc ytosi ne Flucytosine (Oral Capsule) G 4

C1 Gris eofu lvin Micr osiz e Griseofulvin Microsize (Oral Suspension) G 3

C1 Gris eofu lvin Micr osiz e Griseofulvin Microsize (Oral Tablet) G 3

C1 Gris eofu lvin Ultra micr osiz e Griseofulvin Ultramicrosize (Oral Tablet) G 3

C1 Gyn azol e-1 Gynazole-1 (Vaginal Cream) G 3

C1 Itrac ona zole Itraconazole (Oral Capsule) G 3 PA

C1 Itrac ona zole Itraconazole (Oral Solution) G 4 PA

C1 Ket oco naz ole Ketoconazole (Oral Tablet) G 1

C1 Mic afun gin Sodi um Micafungin Sodium (Intravenous Solution Reconstituted) G 3

C1 Mic ona zole 3 Miconazole 3 (Vaginal Suppository) G 2

C1 Myc ami ne Mycamine (Intravenous Solution Reconstituted) B 4

C1 Nox afil Noxafil (Oral Suspension) B 4 QL

C1 Nox afil Noxafil (Oral Tablet Delayed Release) B 4 PA; QL

C1 Nyst atin Nystatin (Mouth/Throat Suspension) G 1

C1 Nyst atin Nystatin (Oral Tablet) G 2

C1 Ora vig Oravig (Buccal Tablet) B 4

C1 Pos aco naz ole Posaconazole (Oral Tablet Delayed Release) G 4 PA; QL

C1 Spo rano x Sporanox (Oral Capsule) B 4 PA

C1 Spo rano x Sporanox (Oral Solution) B 4 PA

C1 Terb inafi ne HCl Terbinafine HCl (Oral Tablet) G 1

C1 Terc ona zole Terconazole (Vaginal Cream) G 2

C1 Terc ona zole Terconazole (Vaginal Suppository) G 2

C1 Tols ura Tolsura (Oral Capsule) B 4 PA

C1 Vfen d IV Vfend IV (Intravenous Solution Reconstituted) B 4

C1 Vfen d Vfend (Oral Suspension Reconstituted) B 4

C1 Vfen d Vfend (Oral Tablet) B 3

C1 Vori con azol e Voriconazole (Intravenous Solution Reconstituted) G 4

C1 Vori con azol e Voriconazole (Oral Suspension Reconstituted) G 4 66 Last updated September 1, 2021

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

C1 Vori con azol e Voriconazole (Oral Tablet) G 3 A1 Antigout Agents B1 Antigout Agents

C1 Allo puri nol Allopurinol (Oral Tablet) G 1

C1 Colc hicin e Colchicine (0.6MG Oral Capsule) (Brand Equivalent B 2 Mitigare)

C1 Colc hicin e Colchicine (0.6MG Oral Tablet) (Generic Colcrys) G 2

C1 Colc rys Colcrys (Oral Tablet) B 3 PA

C1 Feb uxo stat Febuxostat (Oral Tablet) G 3 ST

C1 Glo perb a Gloperba (Oral Solution) B 3 PA; QL

C1 Miti gare Mitigare (Oral Capsule) B 2

C1 Pro ben ecid Probenecid (Oral Tablet) G 1

C1 Pro ben ecid - Colc hicin e Probenecid-Colchicine (Oral Tablet) G 1

C1 Ulori c Uloric (Oral Tablet) B 3 ST

C1 Zylo prim Zyloprim (Oral Tablet) B 3 A1 Antimigraine Agents B1 Acute

C1 Alm otrip tan Mal ate Almotriptan Malate (Oral Tablet) G 3 ST; QL

C1 Ame rge Amerge (Oral Tablet) B 3 QL

C1 Eletr ipta n Hyd robr omi de Eletriptan Hydrobromide (Oral Tablet) G 3 ST; QL

C1 Frov a Frova (Oral Tablet) B 4 ST; QL

C1 Frov atrip tan Suc cina te Frovatriptan Succinate (Oral Tablet) G 3 ST; QL

C1 Imitr ex Imitrex (20MG/ACT Nasal Solution) B 4 QL

C1 Imitr ex Imitrex (5MG/ACT Nasal Solution) B 3 QL

C1 Imitr ex Imitrex (Oral Tablet) B 3 QL

C1 Imitr ex STA Tdo se Refil l Imitrex STATdose Refill (6MG/0.5ML Subcutaneous B 4 QL Solution Cartridge)

C1 Imitr ex STA Tdo se Syst em Imitrex STATdose System (4MG/0.5ML B 4 QL Subcutaneous Solution Auto-Injector)

C1 Imitr ex Imitrex (Subcutaneous Solution) B 4 QL

C1 Max alt Maxalt (Oral Tablet) B 3 QL

C1 Max alt- MLT Maxalt-MLT (Oral Tablet Dispersible) B 3 QL

C1 Nar atrip tan HCl Naratriptan HCl (Oral Tablet) G 2 QL

C1 Nurt ec ODT Nurtec ODT (Oral Tablet Dispersible) B 4 PA; QL

C1 Onz etra Xsail Onzetra Xsail (Nasal Exhaler Powder) B 4 QL

C1 Relp ax Relpax (Oral Tablet) B 3 ST; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 67

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

C1 Rey vow Reyvow (Oral Tablet) B 3 PA; QL

C1 Riza tript an Ben zoat e Rizatriptan Benzoate (Oral Tablet) G 2 QL

C1 Riza tript an Ben zoat e ODT Rizatriptan Benzoate ODT (Oral Tablet Dispersible) G 2 QL

C1 Sum atrip tan Sumatriptan (Nasal Solution) G 3 QL

C1 Sum atrip tan Suc cina te Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral G 1 QL Tablet, 50MG Oral Tablet)

C1 Sum atrip tan Suc cina te Refil l Sumatriptan Succinate Refill (Subcutaneous Solution G 3 QL Cartridge)

C1 Sum atrip tan Suc cina te Sumatriptan Succinate (6MG/0.5ML Subcutaneous G 3 QL Solution)

C1 Sum atrip tan Suc cina te Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/0.5ML Subcutaneous G 3 QL Solution Auto-Injector)

C1 Sum atrip tan- Nap roxe n Sodi um Sumatriptan-Naproxen Sodium (Oral Tablet) G 3 QL

C1 Tos ymr a Tosymra (Nasal Solution) B 3 QL

C1 Trex imet Treximet (Oral Tablet) B 4 QL

C1 Ubr elvy Ubrelvy (Oral Tablet) B 4 PA; QL

C1 Zem brac e Sym Tou ch Zembrace SymTouch (Subcutaneous Solution Auto- B 4 QL Injector)

C1 Zol mitri ptan Zolmitriptan (Oral Tablet) G 3 QL

C1 Zol mitri ptan

ODT Zolmitriptan ODT (Oral Tablet Dispersible) G 3 QL

C1 Zom ig Zomig (Nasal Solution) B 3 QL

C1 Zom ig Zomig (Oral Tablet) B 4 QL

C1 Zom ig ZMT Zomig ZMT (Oral Tablet Dispersible) B 4 QL B1 Ergot Alkaloids

C1 Cafe rgot Cafergot (Oral Tablet) G 3

C1 Dihy droe rgot ami ne Mes ylate Dihydroergotamine Mesylate (Nasal Solution) G 4 PA; QL

C1 Erg ota min e- Caff eine Ergotamine-Caffeine (Oral Tablet) G 2

C1 Mig ergo t Migergot (Rectal Suppository) G 4

C1 Migr anal Migranal (Nasal Solution) B 4 PA; QL B1 Prophylactic

C1 Aim ovig Aimovig (Subcutaneous Solution Auto-Injector) B 3 PA; QL

C1 Ajov y Ajovy (Subcutaneous Solution Auto-Injector) B 3 PA; QL

C1 Ajov y Ajovy (Subcutaneous Solution Prefilled Syringe) B 3 PA; QL

C1 Emg ality Emgality (300MG Dose) (100MG/ML Subcutaneous B 3 PA; QL Solution Prefilled Syringe)

C1 Emg ality Emgality (Subcutaneous Solution Auto-Injector) B 3 PA; QL 68 Last updated September 1, 2021

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

C1 Emg ality Emgality (120MG/ML Subcutaneous Solution B 3 PA; QL Prefilled Syringe)

C1 Tim olol Mal eate Timolol Maleate (Oral Tablet) G 2 A1 Antimyasthenic Agents B1 Parasympathomimetics

C1 Mes tino n Mestinon (Oral Solution) B 4

C1 Mes tino n Mestinon (Oral Tablet Immediate Release) B 4

C1 Mes tino n Mestinon (Oral Tablet Extended Release) B 4

C1 Pyri dost igmi ne Bro mid e ER Pyridostigmine Bromide ER (Oral Tablet Extended G 3 Release)

C1 Pyri dost igmi ne Bro mid e Pyridostigmine Bromide (Oral Solution) G 4

C1 Pyri dost igmi ne Bro mid e Pyridostigmine Bromide (30MG Oral Tablet Immediate G 3 Release)

C1 Pyri dost igmi ne Bro mid e Pyridostigmine Bromide (60MG Oral Tablet Immediate G 2 Release) A1 Antimycobacterials B1 Antimycobacterials, Other

C1 Dap son e Dapsone (Oral Tablet) G 2

C1 Myc obut in Mycobutin (Oral Capsule) B 4

C1 Rifa buti n Rifabutin (Oral Capsule) G 3 B1 Antituberculars

C1 Etha mbu tol HCl Ethambutol HCl (Oral Tablet) G 2

C1 Ison iazid Isoniazid (Oral Syrup) G 3

C1 Ison iazid Isoniazid (Oral Tablet) G 1

C1 Mya mbu tol Myambutol (Oral Tablet) B 3

C1 Pas er Paser (Oral Packet) G 3

C1 Pret oma nid Pretomanid (Oral Tablet) B 3

C1 Prifti n Priftin (Oral Tablet) B 3

C1 Pyra zina mid e Pyrazinamide (Oral Tablet) G 3

C1 Rifa mpi n Rifampin (600MG Intravenous Solution Reconstituted) G 3

C1 Rifa mpi n Rifampin (150MG Oral Capsule, 300MG Oral Capsule) G 2

C1 Sirtu ro Sirturo (Oral Tablet) B 4 PA; LA

C1 Trec ator Trecator (Oral Tablet) B 3 A1 Antineoplastics B1 Alkylating Agents

C1 Cycl oph osp ham ide Cyclophosphamide (Oral Capsule) G 2 B/D, PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 69

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

C1 Cycl oph osp ham ide Cyclophosphamide (25MG Oral Tablet) G 2 B/D, PA

C1 Cycl oph osp ham ide Cyclophosphamide (50MG Oral Tablet) B 2 B/D, PA

C1 Leu kera n Leukeran (Oral Tablet) B 4

C1 Mat ulan e Matulane (Oral Capsule) B 4 LA

C1 Valc hlor Valchlor (External Gel) B 4 PA; LA; QL B1

C1 Abir ater one Acet ate Abiraterone Acetate (Oral Tablet) G 4 PA

C1 Bica luta mid e Bicalutamide (Oral Tablet) G 1

C1 Cas ode x Casodex (Oral Tablet) B 4

C1 Erle ada Erleada (Oral Tablet) B 4 PA

C1 Flut ami de Flutamide (Oral Capsule) G 3

C1 Nila ndro n Nilandron (Oral Tablet) B 4

C1 Nilut ami de Nilutamide (Oral Tablet) G 4

C1 Nub eqa Nubeqa (Oral Tablet) B 4 PA; LA

C1 Xtan di Xtandi (Oral Capsule) B 4 PA; LA

C1 Xtan di Xtandi (Oral Tablet) B 4 PA

C1 Yon sa Yonsa (Oral Tablet) B 4 PA

C1 Zyti ga Zytiga (Oral Tablet) B 4 PA B1 Antiangiogenic Agents

C1 Foti vda Fotivda (Oral Capsule) B 4 PA; QL

C1 Pom alyst Pomalyst (Oral Capsule) B 4 PA

C1 Qinl ock Qinlock (Oral Tablet) B 4 PA; QL

C1 Revl imid Revlimid (Oral Capsule) B 4 PA; LA

C1 Tabr ecta Tabrecta (Oral Tablet) B 4 PA; QL

C1 Thal omi d Thalomid (Oral Capsule) B 4 PA; QL B1 /Modifiers

C1 Emc yt Emcyt (Oral Capsule) B 4

C1 Fare ston Fareston (Oral Tablet) B 4

C1 Solt amo x Soltamox (Oral Solution) B 4

C1 Tam oxif en Citra te Tamoxifen Citrate (Oral Tablet) G 1

C1 Tore mife ne Citra te Toremifene Citrate (Oral Tablet) G 4 B1 Antimetabolites

C1 Dro xia Droxia (Oral Capsule) B 3

C1 Hyd rea Hydrea (Oral Capsule) B 3

C1 Hyd roxy Hydroxyurea (Oral Capsule) G 1

C1 Mer capt opur ine Mercaptopurine (Oral Tablet) G 2

C1 Onu reg Onureg (Oral Tablet) B 4 PA; QL 70 Last updated September 1, 2021

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

C1 Puri xan Purixan (Oral Suspension) B 4 PA

C1 Tabl oid Tabloid (Oral Tablet) B 3 PA B1 Antineoplastics, Other

C1 IDHI FA IDHIFA (Oral Tablet) B 4 PA; LA

C1 Lon surf Lonsurf (Oral Tablet) B 4 PA; LA

C1 Ninl aro Ninlaro (Oral Capsule) B 4 PA

C1 Pem azyr e Pemazyre (Oral Tablet) B 4 PA; QL

C1 Ret evm o Retevmo (Oral Capsule) B 4 PA; QL

C1 Synr ibo Synribo (Subcutaneous Solution Reconstituted) B 4 PA

C1 Tazv erik Tazverik (Oral Tablet) B 4 PA; LA; QL

C1 Tuk ysa Tukysa (Oral Tablet) B 4 PA; QL

C1 Xpo vio Xpovio (100MG Once Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Xpo vio Xpovio (40MG Once Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Xpo vio Xpovio (40MG Twice Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Xpo vio Xpovio (60MG Once Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Xpo vio Xpovio (60MG Twice Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Xpo vio Xpovio (80MG Once Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Xpo vio Xpovio (80MG Twice Weekly) (Oral Tablet Therapy B 4 PA; LA; QL Pack)

C1 Zoli nza Zolinza (Oral Capsule) B 4 PA B1 Aromatase Inhibitors, 3rd Generation

C1 Ana stro zole Anastrozole (Oral Tablet) G 1

C1 Arim idex Arimidex (Oral Tablet) B 4

C1 Aro masi n Aromasin (Oral Tablet) B 4

C1 Exe mes tane Exemestane (Oral Tablet) G 3

C1 Fem ara Femara (Oral Tablet) B 4

C1 Letr ozol e Letrozole (Oral Tablet) G 1 B1 Molecular Target Inhibitors

C1 Afini tor Disp erz Afinitor Disperz (Oral Tablet Soluble) B 4 PA

C1 Afini tor Afinitor (Oral Tablet) B 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 71

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

C1 Alec ens a Alecensa (Oral Capsule) B 4 PA; LA

C1 Alun brig Alunbrig (Oral Tablet) B 4 PA; LA; QL

C1 Alun brig Alunbrig (Oral Tablet Therapy Pack) B 4 PA; LA; QL

C1 Ayv akit Ayvakit (100MG Oral Tablet, 200MG Oral Tablet, B 4 PA; LA; QL 300MG Oral Tablet)

C1 Balv ersa Balversa (Oral Tablet) B 4 PA; LA; QL

C1 Bos ulif Bosulif (Oral Tablet) B 4 PA

C1 Braf tovi Braftovi (Oral Capsule) B 4 PA

C1 Bruk insa Brukinsa (Oral Capsule) B 4 PA; LA; QL

C1 Cab ome tyx Cabometyx (Oral Tablet) B 4 PA; LA

C1 Calq uen ce Calquence (Oral Capsule) B 4 PA

C1 Cap rels a Caprelsa (Oral Tablet) B 4 PA; LA

C1 Co metr iq Cometriq (100MG Daily Dose) (Oral Kit) B 4 PA; LA

C1 Co metr iq Cometriq (140MG Daily Dose) (Oral Kit) B 4 PA; LA

C1 Co metr iq Cometriq (60MG Daily Dose) (Oral Kit) B 4 PA; LA

C1 Cop iktra Copiktra (Oral Capsule) B 4 PA; QL

C1 Cot ellic Cotellic (Oral Tablet) B 4 PA; LA

C1 Dau rism o Daurismo (Oral Tablet) B 4 PA; LA; QL

C1 Eriv edg e Erivedge (Oral Capsule) B 4 PA; LA

C1 Erlot inib HCl Erlotinib HCl (Oral Tablet) G 4 PA

C1 Ever olim us Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG G 4 PA Oral Tablet)

C1 Fary dak Farydak (Oral Capsule) B 4 PA

C1 Gavr eto Gavreto (Oral Capsule) B 4 PA; QL

C1 Gilot rif Gilotrif (Oral Tablet) B 4 PA; LA

C1 Glee vec Gleevec (Oral Tablet) B 4 PA; QL

C1 Ibra nce Ibrance (Oral Capsule) B 4 PA; LA

C1 Ibra nce Ibrance (Oral Tablet) B 4 PA; LA

C1 Iclus ig Iclusig (Oral Tablet) B 4 PA; LA

C1 Imat inib Mes ylate Imatinib Mesylate (Oral Tablet) G 4 PA; QL

C1 Imbr uvic a Imbruvica (Oral Capsule) B 4 PA; LA; QL

C1 Imbr uvic a Imbruvica (Oral Tablet) B 4 PA; QL

C1 Inlyt a Inlyta (Oral Tablet) B 4 PA; LA; QL

C1 Inqo vi Inqovi (Oral Tablet) B 4 PA; QL

C1 Inre bic Inrebic (Oral Capsule) B 4 PA; QL

C1 Ires sa Iressa (Oral Tablet) B 4 PA; LA; QL

C1 Jaka fi Jakafi (Oral Tablet) B 4 PA; LA; QL 72 Last updated September 1, 2021

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

C1 Kisq ali Kisqali (200MG Dose) (Oral Tablet) B 4 PA

C1 Kisq ali Kisqali (400MG Dose) (Oral Tablet) B 4 PA

C1 Kisq ali Kisqali (600MG Dose) (Oral Tablet) B 4 PA

C1 Kisq ali Fem ara Kisqali Femara (200MG Dose) (Oral Tablet Therapy B 4 PA Pack)

C1 Kisq ali Fem ara Kisqali Femara (400MG Dose) (Oral Tablet Therapy B 4 PA Pack)

C1 Kisq ali Fem ara Kisqali Femara (600MG Dose) (Oral Tablet Therapy B 4 PA Pack)

C1 Kos elug o Koselugo (Oral Capsule) B 4 PA; QL

C1 Lap atini b Dito sylat e Lapatinib Ditosylate (Oral Tablet) G 4 PA

C1 Len vima

10M G Dail y Dos e Lenvima 10MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

12M G Dail y Dos e Lenvima 12MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

14M G Dail y Dos e Lenvima 14MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

18M G Dail y Dos e Lenvima 18MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

20M G Dail y Dos e Lenvima 20MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

24M G Dail y Dos e Lenvima 24MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

4M G Dail y Dos e Lenvima 4MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Len vima

8M G Dail y Dos e Lenvima 8MG Daily Dose (Oral Capsule Therapy B 4 PA; LA Pack)

C1 Lorb rena Lorbrena (Oral Tablet) B 4 PA; LA; QL

C1 Lyn parz a Lynparza (Oral Tablet) B 4 PA; LA

C1 Mek inist Mekinist (Oral Tablet) B 4 PA; LA

C1 Mek tovi Mektovi (Oral Tablet) B 4 PA

C1 Nerl ynx Nerlynx (Oral Tablet) B 4 PA; LA; QL

C1 Nex avar Nexavar (Oral Tablet) B 4 PA; LA

C1 Odo mzo Odomzo (Oral Capsule) B 4 PA; LA; QL

C1 Piqr ay Piqray (200MG Daily Dose) (Oral Tablet Therapy B 4 PA; QL Pack)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 73

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

C1 Piqr ay Piqray (250MG Daily Dose) (Oral Tablet Therapy B 4 PA; QL Pack)

C1 Piqr ay Piqray (300MG Daily Dose) (Oral Tablet Therapy B 4 PA; QL Pack)

C1 Rozl ytre k Rozlytrek (Oral Capsule) B 4 PA; QL

C1 Rub raca Rubraca (Oral Tablet) B 4 PA; LA

C1 Ryd apt Rydapt (Oral Capsule) B 4 PA; QL

C1 Spry cel Sprycel (Oral Tablet) B 4 PA

C1 Stiv arga Stivarga (Oral Tablet) B 4 PA; LA

C1 Sute nt Sutent (Oral Capsule) B 4 PA

C1 Tafi nlar Tafinlar (Oral Capsule) B 4 PA; LA

C1 Tagr isso Tagrisso (Oral Tablet) B 4 PA; LA

C1 Talz enn a Talzenna (Oral Capsule) B 4 PA; LA; QL

C1 Tarc eva Tarceva (Oral Tablet) B 4 PA

C1 Tasi gna Tasigna (Oral Capsule) B 4 PA

C1 Tep met ko Tepmetko (Oral Tablet) B 4 PA; QL

C1 Tibs ovo Tibsovo (Oral Tablet) B 4 PA; QL

C1 Tura lio Turalio (Oral Capsule) B 4 PA; LA; QL

C1 Tyk erb Tykerb (Oral Tablet) B 4 PA; LA

C1 Uko niq Ukoniq (Oral Tablet) B 4 PA; QL

C1 Ven clext a Venclexta (100MG Oral Tablet, 50MG Oral Tablet) B 4 PA; LA

C1 Ven clext a Venclexta (10MG Oral Tablet) B 2 PA; LA

C1 Ven clext a Start ing Pac k Venclexta Starting Pack (Oral Tablet Therapy Pack) B 4 PA; LA

C1 Verz enio Verzenio (Oral Tablet) B 4 PA; LA

C1 Vitra kvi Vitrakvi (Oral Capsule) B 4 PA; LA; QL

C1 Vitra kvi Vitrakvi (Oral Solution) B 4 PA; LA; QL

C1 Vizi mpr o Vizimpro (Oral Tablet) B 4 PA; LA

C1 Votri ent Votrient (Oral Tablet) B 4 PA; LA

C1 Xalk ori Xalkori (Oral Capsule) B 4 PA; LA

C1 Xos pata Xospata (Oral Tablet) B 4 PA; QL

C1 Zeju la Zejula (Oral Capsule) B 4 PA; LA

C1 Zelb oraf Zelboraf (Oral Tablet) B 4 PA; LA; QL

C1 Zyd elig Zydelig (Oral Tablet) B 4 PA; LA

C1 Zyk adia Zykadia (Oral Tablet) B 4 PA B1 Retinoids

C1 Bex arot ene Bexarotene (Oral Capsule) G 4 PA

C1 Targ retin Targretin (External Gel) B 4 PA; QL 74 Last updated September 1, 2021

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

C1 Targ retin Targretin (Oral Capsule) B 4 PA

C1 Treti noin Tretinoin (Oral Capsule) G 4 B1 Treatment Adjuncts

C1 Leu cov orin Calc ium Leucovorin Calcium (10MG Oral Tablet, 15MG Oral G 2 Tablet)

C1 Leu cov orin Calc ium Leucovorin Calcium (25MG Oral Tablet) G 3

C1 Leu cov orin Calc ium Leucovorin Calcium (5MG Oral Tablet) G 1

C1 Mes nex Mesnex (Oral Tablet) B 4 A1 Antiparasitics B1 Anthelmintics

C1 Albe nda zole Albendazole (Oral Tablet) G 4 QL

C1 Albe nza Albenza (Oral Tablet) B 4 QL

C1 Biltri cide Biltricide (Oral Tablet) B 3

C1 Emv erm Emverm (Oral Tablet Chewable) G 4

C1 Iver mec tin Ivermectin (Oral Tablet) G 1

C1 Praz iqua ntel Praziquantel (Oral Tablet) G 3

C1 Stro mec tol Stromectol (Oral Tablet) B 3 B1 Antiprotozoals

C1 Alini a Alinia (Oral Suspension Reconstituted) B 4

C1 Alini a Alinia (Oral Tablet) B 4

C1 Atov aqu one Atovaquone (Oral Suspension) G 4

C1 Atov aqu one- Pro gua nil HCl Atovaquone-Proguanil HCl (Oral Tablet) G 2

C1 Ben znid azol e Benznidazole (Oral Tablet) B 3

C1 Chlo roqu ine Pho sph ate Chloroquine Phosphate (Oral Tablet) G 2 QL

C1 Coa rtem Coartem (Oral Tablet) B 3

C1 DAR APR IM DARAPRIM (Oral Tablet) B 4

C1 Hyd roxy chlo roqu ine Sulf ate Hydroxychloroquine Sulfate (Oral Tablet) G 1 QL

C1 Imp avid o Impavido (Oral Capsule) B 4

C1 Krint afel Krintafel (Oral Tablet) B 3

C1 Lam pit Lampit (Oral Tablet) B 3 PA

C1 Mal aron e Malarone (Oral Tablet) B 3

C1 Mefl oqui ne HCl Mefloquine HCl (Oral Tablet) G 1

C1 Mep ron Mepron (Oral Suspension) B 4

C1 Neb upe nt Nebupent (Inhalation Solution Reconstituted) B 3 B/D, PA; QL

C1 Nita zoxa nide Nitazoxanide (Oral Tablet) G 4

C1 PEN TA M 300 PENTAM 300 (Injection Solution Reconstituted) B 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 75

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

C1 Pent ami dine

Iset hion ate Pentamidine Isethionate (Inhalation Solution G 3 B/D, PA; QL Reconstituted)

C1 Pent ami dine

Iset hion ate Pentamidine Isethionate (Injection Solution G 3 Reconstituted)

C1 Plaq ueni l Plaquenil (Oral Tablet) B 3 QL

C1 Prim aqui ne Pho sph ate Primaquine Phosphate (Oral Tablet) G 2

C1 Pyri met ham ine Pyrimethamine (Oral Tablet) G 4

C1 Qual aqui n Qualaquin (Oral Capsule) B 3 PA

C1 Quin ine Sulf ate Quinine Sulfate (Oral Capsule) G 3 PA A1 Antiparkinson Agents B1 Anticholinergics

C1 Ben ztro pine

Mes ylate Benztropine Mesylate (Oral Tablet) G 2 PA; HRM

C1 Trih exy phe nidyl HCl Trihexyphenidyl HCl (Oral Solution) G 3 PA; HRM

C1 Trih exy phe nidyl HCl Trihexyphenidyl HCl (Oral Tablet) G 3 PA; HRM B1 Antiparkinson Agents, Other

C1 Ama ntad ine HCl Amantadine HCl (Oral Capsule) G 2

C1 Ama ntad ine HCl Amantadine HCl (Oral Syrup) G 1

C1 Ama ntad ine HCl Amantadine HCl (Oral Tablet) G 2

C1 Car bido pa- Lev odo pa- Enta cap one Carbidopa-Levodopa-Entacapone (Oral Tablet) G 3

C1 Co mta n Comtan (Oral Tablet) B 3

C1 Enta cap one Entacapone (Oral Tablet) G 3

C1 Goc ovri Gocovri (Oral Capsule Extended Release 24 Hour) B 4 PA

C1 Nou rian z Nourianz (Oral Tablet) B 4 PA; QL

C1 Ong enty s Ongentys (Oral Capsule) B 3 ST; QL

C1 Os mol ex ER Osmolex ER (Oral Tablet ER 24 Hour Therapy Pack) B 3 PA

C1 Os mol ex ER Osmolex ER (Oral Tablet Extended Release 24 Hour) B 3 PA

C1 Stal evo 100 Stalevo 100 (Oral Tablet) B 4

C1 Stal evo 125 Stalevo 125 (Oral Tablet) B 4

C1 Stal evo 150 Stalevo 150 (Oral Tablet) B 4

C1 Stal evo 200 Stalevo 200 (Oral Tablet) B 4

C1 Stal evo 50 Stalevo 50 (Oral Tablet) B 4

C1 Stal evo 75 Stalevo 75 (Oral Tablet) B 4

C1 Tas mar Tasmar (Oral Tablet) B 4 QL

C1 Tolc apo ne Tolcapone (Oral Tablet) G 4 QL B1 Dopamine Agonists

C1 Apo kyn Apokyn (Subcutaneous Solution Cartridge) B 4 PA; LA; QL

C1 Bro moc ripti ne Mes ylate Bromocriptine Mesylate (Oral Capsule) G 3 76 Last updated September 1, 2021

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

C1 Bro moc ripti ne Mes ylate Bromocriptine Mesylate (Oral Tablet) G 3

C1 Kyn mob i Kynmobi (10MG Sublingual Film, 15MG Sublingual Film, 20MG Sublingual Film, 25MG Sublingual Film, B 4 PA; QL 30MG Sublingual Film)

C1 Mira pex ER Mirapex ER (Oral Tablet Extended Release 24 Hour) B 3

C1 Mira pex Mirapex (Oral Tablet Immediate Release) B 3

C1 Neu pro Neupro (Transdermal Patch 24 Hour) B 3

C1 Parl odel Parlodel (Oral Capsule) B 3

C1 Parl odel Parlodel (Oral Tablet) B 3

C1 Pra mip exol e Dihy droc hlori de ER Pramipexole Dihydrochloride ER (Oral Tablet Extended G 3 Release 24 Hour)

C1 Pra mip exol e Dihy droc hlori de Pramipexole Dihydrochloride (Oral Tablet Immediate G 1 Release)

C1 Rop iniro le HCl ER Ropinirole HCl ER (Oral Tablet Extended Release 24 G 3 Hour)

C1 Rop iniro le HCl Ropinirole HCl (Oral Tablet Immediate Release) G 1 B1 Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors

C1 Car bido pa Carbidopa (Oral Tablet) G 3

C1 Car bido pa- Lev odo pa ER Carbidopa-Levodopa ER (Oral Tablet Extended Release) G 2

C1 Car bido pa- Lev odo pa Carbidopa-Levodopa (Oral Tablet Immediate Release) G 1

C1 Car bido pa- Lev odo pa ODT Carbidopa-Levodopa ODT (Oral Tablet Dispersible) G 3

C1 Duo pa Duopa (Enteral Suspension) B 4 PA

C1 Inbri ja Inbrija (Inhalation Capsule) B 4 PA; LA

C1 Lod osy n Lodosyn (Oral Tablet) B 4

C1

Ryta ry Rytary (Oral Capsule Extended Release) B 3 ST

C1 Sine met Sinemet (Oral Tablet Immediate Release) B 3 B1 Monoamine Oxidase B (MAO-B) Inhibitors

C1 Azil ect Azilect (Oral Tablet) B 4

C1 Ras agili ne Mes ylate Rasagiline Mesylate (Oral Tablet) G 3

C1 Sele gilin e HCl Selegiline HCl (Oral Capsule) G 2

C1 Sele gilin e HCl Selegiline HCl (Oral Tablet) G 2

C1 Zela par ODT Zelapar ODT (Oral Tablet Dispersible) B 4 A1 Antipsychotics B1 1st Generation/Typical

C1 Chlo rpro mazi ne HCl Chlorpromazine HCl (Oral Tablet) G 3

C1 Flup hen azin e Dec ano ate Fluphenazine Decanoate (Injection Solution) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 77

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

C1 Flup hen azin e HCl Fluphenazine HCl (2.5MG/ML Injection Solution) G 2

C1 Flup hen azin e HCl Fluphenazine HCl (5MG/ML Oral Concentrate) G 3

C1 Flup hen azin e HCl Fluphenazine HCl (2.5MG/5ML Oral Elixir) G 2

C1 Flup hen azin e HCl Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet, G 3 2.5MG Oral Tablet, 5MG Oral Tablet)

C1 Hald ol Dec ano ate Haldol Decanoate (Intramuscular Solution) B 3

C1 Hald ol Haldol (Injection Solution) B 3

C1 Halo peri dol Dec ano ate Haloperidol Decanoate (Intramuscular Solution) G 2

C1 Halo peri dol Lact ate Haloperidol Lactate (Injection Solution) G 1

C1 Halo peri dol Lact ate Haloperidol Lactate (Oral Concentrate) G 1

C1 Halo peri dol Haloperidol (Oral Tablet) G 1

C1 Lox apin e Suc cina te Loxapine Succinate (Oral Capsule) G 2

C1 Moli ndo ne HCl Molindone HCl (Oral Tablet) G 3

C1 Pim ozid e Pimozide (Oral Tablet) G 2

C1 Thio rida zine HCl Thioridazine HCl (Oral Tablet) G 2

C1 Thio thix ene Thiothixene (10MG Oral Capsule, 5MG Oral Capsule) G 3

C1 Thio thix ene Thiothixene (1MG Oral Capsule, 2MG Oral Capsule) G 2

C1 Trifl uop eraz ine HCl Trifluoperazine HCl (Oral Tablet) G 2 B1 2nd Generation/Atypical

C1 Abili fy Mai nten a Abilify Maintena (Intramuscular Prefilled Syringe) B 4

C1 Abili fy Mai nten a Abilify Maintena (Intramuscular Suspension B 4 Reconstituted ER)

C1 Abili fy MyC ite Abilify MyCite (Oral Tablet) B 4 ST; QL

C1 Abili fy Abilify (Oral Tablet) B 4 QL

C1 Aripi praz ole Aripiprazole (1MG/ML Oral Solution) G 3 QL

C1 Aripi praz ole Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, G 1 QL 5MG Oral Tablet)

C1 Aripi praz ole ODT Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG G 4 QL Oral Tablet Dispersible)

C1 Arist ada Initi o Aristada Initio (Intramuscular Prefilled Syringe) B 4

C1 Arist ada Aristada (Intramuscular Prefilled Syringe) B 4

C1 Ase napi ne Mal eate Asenapine Maleate (10MG Tablet Sublingual) G 3

C1 Ase napi ne Mal eate Asenapine Maleate (2.5MG Tablet Sublingual, 5MG G 4 Tablet Sublingual)

C1 Capl yta Caplyta (Oral Capsule) B 4 ST; QL

C1 Fan apt Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 4MG B 4 ST; QL Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet) 78 Last updated September 1, 2021

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

C1 Fan apt Fanapt (1MG Oral Tablet, 2MG Oral Tablet) B 3 ST; QL

C1 Fan apt Titra tion Pac k Fanapt Titration Pack (Oral Tablet) B 3 ST

C1 Geo don Geodon (Intramuscular Solution Reconstituted) B 3

C1 Geo don Geodon (Oral Capsule) B 4 QL

C1 Inve ga Invega (Oral Tablet Extended Release 24 Hour) B 4 PA; QL

C1 Inve ga Sust enn a Invega Sustenna (117MG/0.75ML Intramuscular Suspension Prefilled Syringe, 156MG/ML Intramuscular Suspension Prefilled Syringe, 234MG/ B 4 1.5ML Intramuscular Suspension Prefilled Syringe, 78MG/0.5ML Intramuscular Suspension Prefilled Syringe)

C1 Inve ga Sust enn a Invega Sustenna (39MG/0.25ML Intramuscular B 3 Suspension Prefilled Syringe)

C1 Inve ga Trin za Invega Trinza (Intramuscular Suspension Prefilled B 4 Syringe)

C1 Latu da Latuda (Oral Tablet) B 4 QL

C1 Nup lazid Nuplazid (Oral Capsule) B 4 PA; QL

C1 Nup lazid Nuplazid (Oral Tablet) B 4 PA; QL

C1 Olan zapi ne Olanzapine (10MG Intramuscular Solution G 3 Reconstituted)

C1 Olan zapi ne Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, G 1 QL 7.5MG Oral Tablet)

C1 Olan zapi ne ODT Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, G 2 QL 5MG Oral Tablet Dispersible)

C1 Pali peri don e ER Paliperidone ER (Oral Tablet Extended Release 24 Hour) G 3 QL

C1 Pers eris Perseris (Subcutaneous Prefilled Syringe) B 4

C1 Que tiapi ne Fum arat e ER Quetiapine Fumarate ER (Oral Tablet Extended Release G 2 QL 24 Hour)

C1 Que tiapi ne Fum arat e Quetiapine Fumarate (Oral Tablet Immediate Release) G 1 QL

C1 Rex ulti Rexulti (Oral Tablet) B 4 QL

C1 Risp erda l Con sta Risperdal Consta (12.5MG Intramuscular Suspension

Reconstituted ER, 25MG Intramuscular Suspension B 3 Reconstituted ER)

C1 Risp erda l Con sta Risperdal Consta (37.5MG Intramuscular Suspension

Reconstituted ER, 50MG Intramuscular Suspension B 4 Reconstituted ER)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 79

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

C1 Risp erda l Risperdal (1MG/ML Oral Solution) B 4

C1 Risp erda l Risperdal (0.5MG Oral Tablet) B 3

C1 Risp erda l Risperdal (1MG Oral Tablet, 2MG Oral Tablet, 3MG B 4 Oral Tablet, 4MG Oral Tablet)

C1 Risp erid one Risperidone (1MG/ML Oral Solution) G 2

C1 Risp erid one Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet, G 1 4MG Oral Tablet)

C1 Risp erid one ODT Risperidone ODT (0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet G 3 Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral Tablet Dispersible, 4MG Oral Tablet Dispersible)

C1 Sap hris Saphris (Tablet Sublingual) B 4

C1 Sec uad o Secuado (Transdermal Patch 24 Hour) B 4 PA; QL

C1 Ser oqu el Seroquel (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral B 3 QL Tablet Immediate Release, 50MG Oral Tablet Immediate Release)

C1 Ser oqu el Seroquel (300MG Oral Tablet Immediate Release, B 4 QL 400MG Oral Tablet Immediate Release)

C1 Ser oqu el XR Seroquel XR (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 B 3 QL Hour, 50MG Oral Tablet Extended Release 24 Hour)

C1 Ser oqu el XR Seroquel XR (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Extended Release 24 B 4 QL Hour)

C1 Vray lar Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule, B 4 ST; QL 4.5MG Oral Capsule, 6MG Oral Capsule)

C1 Vray lar Vraylar (Oral Capsule Therapy Pack) B 3 ST

C1 Zipr asid one HCl Ziprasidone HCl (Oral Capsule) G 2 QL

C1 Zipr asid one Mes ylate Ziprasidone Mesylate (Intramuscular Solution G 3 Reconstituted)

C1 Zypr exa Zyprexa (10MG Intramuscular Solution B 3 Reconstituted)

C1 Zypr exa Zyprexa (10MG Oral Tablet, 15MG Oral Tablet, 20MG B 4 QL Oral Tablet)

C1 Zypr exa Zyprexa (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG B 3 QL Oral Tablet) 80 Last updated September 1, 2021

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

C1 Zypr exa Relp revv Zyprexa Relprevv (210MG Intramuscular Suspension B 3 Reconstituted)

C1 Zypr exa Zydi s Zyprexa Zydis (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet B 4 QL Dispersible)

C1 Zypr exa Zydi s Zyprexa Zydis (5MG Oral Tablet Dispersible) B 3 QL B1 Treatment-Resistant

C1 Cloz apin e Clozapine (100MG Oral Tablet, 200MG Oral Tablet, G 2 25MG Oral Tablet, 50MG Oral Tablet)

C1 Cloz apin e ODT Clozapine ODT (100MG Oral Tablet Dispersible, 150MG G 3 Oral Tablet Dispersible, 200MG Oral Tablet Dispersible)

C1 Cloz apin e ODT Clozapine ODT (12.5MG Oral Tablet Dispersible, 25MG G 2 Oral Tablet Dispersible)

C1 Cloz aril Clozaril (100MG Oral Tablet, 200MG Oral Tablet) B 4

C1 Cloz aril Clozaril (25MG Oral Tablet, 50MG Oral Tablet) B 3

C1 Vers aclo z Versacloz (Oral Suspension) B 4 A1 Antispasticity Agents B1 Antispasticity Agents

C1 Bacl ofen Baclofen (Oral Tablet) G 1

C1 Dant rium Dantrium (Oral Capsule) B 3

C1 Dant role ne Sodi um Dantrolene Sodium (100MG Oral Capsule, 50MG Oral G 3 Capsule)

C1 Dant role ne Sodi um Dantrolene Sodium (25MG Oral Capsule) G 2

C1 Tiza nidi ne HCl Tizanidine HCl (2MG Oral Capsule, 4MG Oral Capsule, G 3 6MG Oral Capsule)

C1 Tiza nidi ne HCl Tizanidine HCl (2MG Oral Tablet, 4MG Oral Tablet) G 1

C1 Zan aflex Zanaflex (Oral Capsule) B 3

C1 Zan aflex Zanaflex (Oral Tablet) B 3 A1 Antivirals B1 Anti-cytomegalovirus (CMV) Agents

C1 Prev ymis Prevymis (Oral Tablet) B 4 PA; QL

C1 Valc yte Valcyte (Oral Solution Reconstituted) B 4 QL

C1 Valc yte Valcyte (Oral Tablet) B 4 QL

C1 Valg anci clovi r HCl Valganciclovir HCl (50MG/ML Oral Solution G 4 QL Reconstituted)

C1 Valg anci clovi r HCl Valganciclovir HCl (450MG Oral Tablet) G 2 QL

C1 Zirg an Zirgan (Ophthalmic Gel) B 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 81

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

B1 Anti-hepatitis B (HBV) Agents

C1 Ade fovir

Dipi voxil Adefovir Dipivoxil (Oral Tablet) G 4

C1 Bara clud e Baraclude (Oral Solution) B 4

C1 Bara clud e Baraclude (Oral Tablet) B 4

C1 Ente cavir Entecavir (Oral Tablet) G 3

C1 Epiv ir HBV Epivir HBV (Oral Solution) B 3

C1 Epiv ir HBV Epivir HBV (Oral Tablet) B 3

C1 Hep sera Hepsera (Oral Tablet) B 4

C1 Lam ivudi ne Lamivudine (100MG Oral Tablet) G 2

C1 Vem lidy Vemlidy (Oral Tablet) B 4 B1 Anti-hepatitis C (HCV) Agents

C1 Epcl usa Epclusa (Oral Tablet) B 4 PA; QL

C1 Harv oni Harvoni (Oral Packet) B 4 PA; QL

C1 Harv oni Harvoni (90-400MG Oral Tablet) B 4 PA; QL

C1 Ledi pasv ir- Sof osb uvir Ledipasvir-Sofosbuvir (Oral Tablet) G 4 PA; QL

C1 Mav yret Mavyret (Oral Tablet) B 4 PA; QL

C1 Riba virin Ribavirin (Oral Capsule) G 2

C1 Riba virin Ribavirin (Oral Tablet) G 2

C1 Sof osb uvir- Velp atas vir Sofosbuvir-Velpatasvir (Oral Tablet) G 4 PA; QL

C1 Sov aldi Sovaldi (Oral Packet) B 4 PA; QL

C1 Sov aldi Sovaldi (400MG Oral Tablet) B 4 PA; QL

C1 Viek ira Pak Viekira Pak (Oral Tablet Therapy Pack) B 4 PA; QL

C1 Vos evi Vosevi (Oral Tablet) B 4 PA; QL

C1 Zep atier Zepatier (Oral Tablet) B 4 PA; QL B1 Antiherpetic Agents

C1 Acy clovi r Acyclovir (External Cream) G 3

C1 Acy clovi r Acyclovir (External Ointment) G 3

C1 Acy clovi r Acyclovir (Oral Capsule) G 1

C1 Acy clovi r Acyclovir (Oral Suspension) G 3

C1 Acy clovi r Acyclovir (Oral Tablet) G 1

C1 Acy clovi r Sodi um Acyclovir Sodium (Intravenous Solution) G 3 B/D, PA

C1 Den avir Denavir (External Cream) B 4

C1 Fam ciclo vir Famciclovir (Oral Tablet) G 2

C1 Sita vig Sitavig (Buccal Tablet) B 3 ST

C1 Vala cycl ovir HCl Valacyclovir HCl (Oral Tablet) G 2 QL

C1 Valtr ex Valtrex (1GM Oral Tablet) B 4 QL

C1 Valtr ex Valtrex (500MG Oral Tablet) B 3 QL 82 Last updated September 1, 2021

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

C1 Zovi rax Zovirax (External Cream) B 4

C1 Zovi rax Zovirax (External Ointment) B 4

C1 Zovi rax Zovirax (Oral Suspension) B 3 B1 Anti-HIV Agents, Integrase Inhibitors (INSTI)

C1 Bikt arvy Biktarvy (Oral Tablet) B 4 QL

C1 Dov ato Dovato (Oral Tablet) B 4 QL

C1 Gen voya Genvoya (Oral Tablet) B 4 QL

C1 Isen tres s HD Isentress HD (Oral Tablet) B 4 QL

C1 Isen tres s Isentress (Oral Packet) B 3 QL

C1 Isen tres s Isentress (Oral Tablet) B 4 QL

C1 Isen tres s Isentress (100MG Oral Tablet Chewable) B 4 QL

C1 Isen tres s Isentress (25MG Oral Tablet Chewable) B 2 QL

C1 Julu ca Juluca (Oral Tablet) B 4 QL

C1 Strib ild Stribild (Oral Tablet) B 4 QL

C1 Tivic ay Tivicay (10MG Oral Tablet) B 3 QL

C1 Tivic ay Tivicay (25MG Oral Tablet, 50MG Oral Tablet) B 4 QL

C1 Tivic ay PD Tivicay PD (Oral Tablet Soluble) B 4 QL B1 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

C1 Atri pla Atripla (Oral Tablet) B 4 QL

C1 Co mpl era Complera (Oral Tablet) B 4 QL

C1 Dels trigo Delstrigo (Oral Tablet) B 4 QL

C1 Edu rant Edurant (Oral Tablet) B 4 QL

C1 Efav iren z Efavirenz (Oral Capsule) G 3 QL

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

C1 Efav iren z- Emt ricit abin e- Ten ofov ir Efavirenz-Emtricitabine-Tenofovir (Oral Tablet) G 4 QL

C1 Efav iren z- Lam ivudi ne- Ten ofov ir Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G 4 QL

C1 Intel enc e Intelence (100MG Oral Tablet, 200MG Oral Tablet) B 4 QL

C1 Intel enc e Intelence (25MG Oral Tablet) B 3 QL

C1 Nevi rapi ne ER Nevirapine ER (Oral Tablet Extended Release 24 Hour) G 3 QL

C1 Nevi rapi ne Nevirapine (Oral Suspension) G 3 QL

C1 Nevi rapi ne Nevirapine (Oral Tablet Immediate Release) G 2 QL

C1 Pifel tro Pifeltro (Oral Tablet) B 4 QL

C1 Sust iva Sustiva (Oral Capsule) B 3 QL

C1 Sust iva Sustiva (Oral Tablet) B 4 QL

C1 Sym fi Lo Symfi Lo (Oral Tablet) B 4 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 83

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

C1 Sym fi Symfi (Oral Tablet) B 4 QL

C1 Vira mun e Viramune (Oral Suspension) B 4 QL

C1 Vira mun e XR Viramune XR (Oral Tablet Extended Release 24 Hour) B 4 QL B1 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

C1 Aba cavir

Sulf ate Abacavir Sulfate (Oral Solution) G 3 QL

C1 Aba cavir

Sulf ate Abacavir Sulfate (Oral Tablet) G 3 QL

C1 Aba cavir

Sulf ate- Lam ivudi ne Abacavir Sulfate-Lamivudine (Oral Tablet) G 3 QL

C1 Aba cavir - Lam ivudi ne- Zido vudi ne Abacavir-Lamivudine-Zidovudine (Oral Tablet) G 4 QL

C1 Cim duo Cimduo (Oral Tablet) B 4 QL

C1 Co mbi vir Combivir (Oral Tablet) B 4 QL

C1 Des covy Descovy (Oral Tablet) B 4 QL

C1 Emt ricit abin e Emtricitabine (Oral Capsule) G 3 QL

C1 Emt ricit abin e- Ten ofov ir Diso prox il Fum Emtricitabine-Tenofovir Disoproxil Fumarate (Oral Tablet) G 4 QL arat e C1 Emt riva Emtriva (Oral Capsule) B 3 QL

C1 Emt riva Emtriva (Oral Solution) B 3 QL

C1 Epiv ir Epivir (Oral Solution) B 3 QL

C1 Epiv ir Epivir (Oral Tablet) B 3 QL

C1 Epzi com Epzicom (Oral Tablet) B 4 QL

C1 Lam ivudi ne Lamivudine (10MG/ML Oral Solution) G 2 QL

C1 Lam ivudi ne Lamivudine (150MG Oral Tablet, 300MG Oral Tablet) G 2 QL

C1 Lam ivudi ne- Zido vudi ne Lamivudine-Zidovudine (Oral Tablet) G 3 QL

C1 Ode fsey Odefsey (Oral Tablet) B 4 QL

C1 Retr ovir Retrovir (Oral Capsule) B 3 QL

C1 Retr ovir Retrovir (Oral Syrup) B 3 QL

C1 Tem ixys Temixys (Oral Tablet) B 4 QL

C1 Ten ofov ir Diso prox il Fum arat e Tenofovir Disoproxil Fumarate (Oral Tablet) G 2 QL

C1 Triu meq Triumeq (Oral Tablet) B 4 QL

C1 Trizi vir Trizivir (Oral Tablet) B 4 QL

C1 Truv ada Truvada (Oral Tablet) B 4 QL

C1 Vire ad Viread (Oral Powder) B 4 QL

C1 Vire ad Viread (Oral Tablet) B 4 QL

C1 Ziag en Ziagen (Oral Solution) B 3 QL

C1 Ziag en Ziagen (Oral Tablet) B 3 QL

C1 Zido vudi ne Zidovudine (Oral Capsule) G 3 QL

C1 Zido vudi ne Zidovudine (Oral Syrup) G 2 QL

C1 Zido vudi ne Zidovudine (Oral Tablet) G 2 QL B1 Anti-HIV Agents, Other 84 Last updated September 1, 2021

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

C1 Fuz eon Fuzeon (Subcutaneous Solution Reconstituted) B 4 QL

C1 Ruk obia Rukobia (Oral Tablet Extended Release 12 Hour) B 4 QL

C1 Selz entr y Selzentry (Oral Solution) B 4 QL

C1 Selz entr y Selzentry (150MG Oral Tablet, 300MG Oral Tablet, B 4 QL 75MG Oral Tablet)

C1 Selz entr y Selzentry (25MG Oral Tablet) B 2 QL

C1 Tyb ost Tybost (Oral Tablet) B 3 QL B1 Anti-HIV Agents, Protease Inhibitors

C1 Apti vus Aptivus (Oral Capsule) B 4 QL

C1 Ataz anav ir Sulf ate Atazanavir Sulfate (Oral Capsule) G 3 QL

C1 Evot az Evotaz (Oral Tablet) B 4 QL

C1 Fos amp rena vir Calc ium Fosamprenavir Calcium (Oral Tablet) G 4 QL

C1 Invir ase Invirase (Oral Tablet) B 4 QL

C1 Kale tra Kaletra (Oral Solution) B 3 QL

C1 Kale tra Kaletra (100-25MG Oral Tablet) B 3 QL

C1 Kale tra Kaletra (200-50MG Oral Tablet) B 4 QL

C1 Lexi va Lexiva (Oral Suspension) B 3 QL

C1 Lexi va Lexiva (Oral Tablet) B 4 QL

C1 Lopi navi r- Rito navi r Lopinavir-Ritonavir (Oral Solution) G 3 QL

C1 Nor vir Norvir (Oral Packet) B 3 QL

C1 Nor vir Norvir (Oral Solution) B 3 QL

C1 Nor vir Norvir (Oral Tablet) B 3 QL

C1 Prez cobi x Prezcobix (Oral Tablet) B 4 QL

C1 Prez ista Prezista (Oral Suspension) B 4 QL

C1 Prez ista Prezista (150MG Oral Tablet, 600MG Oral Tablet, B 4 QL 800MG Oral Tablet)

C1 Prez ista Prezista (75MG Oral Tablet) B 3 QL

C1 Rey ataz Reyataz (Oral Capsule) B 4 QL

C1 Rey ataz Reyataz (Oral Packet) B 4 QL

C1 Rito navi r Ritonavir (Oral Tablet) G 2 QL

C1 Sym tuza Symtuza (Oral Tablet) B 4 QL

C1 Vira cept Viracept (Oral Tablet) B 4 QL B1 Anti-influenza Agents

C1 Osel tami vir Pho sph ate Oseltamivir Phosphate (Oral Capsule) G 2

C1 Osel tami vir Pho sph ate Oseltamivir Phosphate (Oral Suspension Reconstituted) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 85

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

C1 Rele nza Disk hale r Relenza Diskhaler (Inhalation Aerosol Powder Breath B 2 Activated)

C1 Rim anta dine HCl Rimantadine HCl (Oral Tablet) G 3

C1 Tam iflu Tamiflu (Oral Capsule) B 3

C1 Tam iflu Tamiflu (Oral Suspension Reconstituted) B 3

C1 Xofl uza Xofluza (40MG Dose) (2 x 20MG Oral Tablet Therapy B 2 QL Pack)

C1 Xofl uza Xofluza (80MG Dose) (2 x 40MG Oral Tablet Therapy B 2 QL Pack) A1 Anxiolytics B1 Anxiolytics, Other

C1 Bus piro ne HCl Buspirone HCl (Oral Tablet) G 1

C1 Hyd roxy zine HCl Hydroxyzine HCl (Oral Syrup) G 3 PA; HRM

C1 Hyd roxy zine Pam oate Hydroxyzine Pamoate (Oral Capsule) G 3 PA; HRM

C1 Vist aril Vistaril (Oral Capsule) B 3 PA; HRM B1 Benzodiazepines

C1 Alpr azol am ER Alprazolam ER (Oral Tablet Extended Release 24 Hour) G 2 PA; QL

C1 Alpr azol am Inte nsol Alprazolam Intensol (Oral Concentrate) G 3 QL

C1 Alpr azol am Alprazolam (Oral Tablet Immediate Release) G 1 QL

C1 Alpr azol am ODT Alprazolam ODT (Oral Tablet Dispersible) G 3 QL

C1 Ativ an Ativan (Oral Tablet) B 4 QL

C1 Chlo rdia zep oxid e HCl Chlordiazepoxide HCl (Oral Capsule) G 1

C1 Clon aze pam Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG G 1 QL Oral Tablet)

C1 Clon aze pam

ODT Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet G 2 QL Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible)

C1 Clor aze pate

Dip otas siu m Clorazepate Dipotassium (Oral Tablet) G 3 QL

C1 Diaz epa m Inte nsol Diazepam Intensol (5MG/ML Oral Concentrate) G 2 QL

C1 Diaz epa m Diazepam (5MG/5ML Oral Solution) G 1

C1 Diaz epa m Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG G 1 QL Oral Tablet)

C1 Klon opin Klonopin (Oral Tablet) B 3 QL

C1 Lora zep am Inte nsol Lorazepam Intensol (Oral Concentrate) G 1 QL

C1 Lora zep am Lorazepam (Oral Tablet) G 1 QL

C1 Oxa zep am Oxazepam (Oral Capsule) G 2

C1 Tran xen e-T Tranxene-T (Oral Tablet) B 4 QL 86 Last updated September 1, 2021

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

C1 Vali um Valium (Oral Tablet) B 3 QL

C1 Xan ax Xanax (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, 1MG Oral B 3 QL Tablet Immediate Release)

C1 Xan ax Xanax (2MG Oral Tablet Immediate Release) B 4 QL

C1 Xan ax XR Xanax XR (Oral Tablet Extended Release 24 Hour) B 3 PA; QL A1 Bipolar Agents B1 Mood Stabilizers

C1 Dep akot e ER Depakote ER (Oral Tablet Extended Release 24 Hour) B 3

C1 Dep akot e Depakote (Oral Tablet Delayed Release) B 3

C1 Dep akot e Spri nkle s Depakote Sprinkles (Oral Capsule Delayed Release B 3 Sprinkle)

C1 Diva lpro ex Sodi um ER Divalproex Sodium ER (Oral Tablet Extended Release 24 G 1 Hour)

C1 Diva lpro ex Sodi um Divalproex Sodium (Oral Capsule Delayed Release G 2 Sprinkle)

C1 Diva lpro ex Sodi um Divalproex Sodium (Oral Tablet Delayed Release) G 1

C1 Equ etro Equetro (Oral Capsule Extended Release 12 Hour) B 3

C1 Lithi um Car bon ate ER Lithium Carbonate ER (Oral Tablet Extended Release) G 1

C1 Lithi um Car bon ate Lithium Carbonate (Oral Capsule) G 1

C1 Lithi um Car bon ate Lithium Carbonate (Oral Tablet Immediate Release) G 1

C1 Lithi um Lithium (8MEQ/5ML Oral Solution) B 2

C1 Lith obid Lithobid (Oral Tablet Extended Release) B 4 A1 Blood Glucose Regulators B1 Antidiabetic Agents

C1 Acar bos e Acarbose (Oral Tablet) G 1

C1 Acto plus Met Actoplus Met (Oral Tablet Immediate Release) B 3 QL

C1 Acto s Actos (Oral Tablet) B 3 QL

C1 Adly xin Start er Pac k Adlyxin Starter Pack (Subcutaneous Pen-Injector Kit) B 3 ST; QL

C1 Adly xin Adlyxin (Subcutaneous Solution Pen-Injector) B 3 ST; QL

C1 Alog lipti n Ben zoat e Alogliptin Benzoate (Oral Tablet) G 3 ST; QL

C1 Alog lipti n- Metf ormi n HCl Alogliptin-Metformin HCl (Oral Tablet) B 3 ST; QL

C1 Alog lipti n- Piog litaz one Alogliptin-Pioglitazone (Oral Tablet) G 3 ST; QL

C1 Ama ryl Amaryl (Oral Tablet) B 3 QL

C1 Byd ureo n BCis e Bydureon BCise (Subcutaneous Auto-Injector) B 3 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 87

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

C1 Byet ta 10M CG Pen Byetta 10MCG Pen (Subcutaneous Solution Pen- B 3 ST; QL Injector)

C1 Byet ta 5M CG Pen Byetta 5MCG Pen (Subcutaneous Solution Pen- B 3 ST; QL Injector)

C1 Cycl oset Cycloset (Oral Tablet) B 3 PA

C1 Due tact Duetact (Oral Tablet) B 3 QL

C1 Farx iga Farxiga (Oral Tablet) B 2 QL

C1 Fort ame t Fortamet (1000MG Oral Tablet Extended Release 24 B 4 PA; QL Hour, 500MG Oral Tablet Extended Release 24 Hour)

C1 Glim epiri de Glimepiride (Oral Tablet) G 1 QL

C1 Glipi zide ER Glipizide ER (Oral Tablet Extended Release 24 Hour) G 1 QL

C1 Glipi zide Glipizide (Oral Tablet Immediate Release) G 1 QL

C1 Glipi zide- Metf ormi n HCl Glipizide-Metformin HCl (Oral Tablet) G 2 QL

C1 Gluc otrol XL Glucotrol XL (Oral Tablet Extended Release 24 Hour) B 3 QL

C1 Glu met za Glumetza (Oral Tablet Extended Release 24 Hour) B 4 PA; QL

C1 Glyx amb i Glyxambi (Oral Tablet) B 2 QL

C1 Invo kam et Invokamet (Oral Tablet Immediate Release) B 3 ST; QL

C1 Invo kam et XR Invokamet XR (Oral Tablet Extended Release 24 B 3 ST; QL Hour)

C1 Invo kan a Invokana (Oral Tablet) B 3 ST; QL

C1 Jan ume t Janumet (Oral Tablet Immediate Release) B 2 QL

C1 Jan ume t XR Janumet XR (Oral Tablet Extended Release 24 Hour) B 2 QL

C1 Jan uvia Januvia (Oral Tablet) B 2 QL

C1 Jard ianc e Jardiance (Oral Tablet) B 2 QL

C1 Jent adu eto Jentadueto (Oral Tablet Immediate Release) B 2 QL

C1 Jent adu eto XR Jentadueto XR (Oral Tablet Extended Release 24 B 2 QL Hour)

C1 Kaz ano Kazano (Oral Tablet) B 3 ST; QL

C1 Ko mbi glyz e XR Kombiglyze XR (Oral Tablet Extended Release 24 B 3 QL Hour)

C1 Metf ormi n HCl ER Metformin HCl ER (1000MG Oral Tablet Extended Release 24 Hour, 500MG Oral Tablet Extended Release G 4 PA; QL 24 Hour) (Generic Glumetza)

C1 Metf ormi n HCl ER Metformin HCl ER (1000MG Oral Tablet Extended Release 24 Hour, 500MG Oral Tablet Extended Release G 3 PA; QL 24 Hour) (Generic Fortamet)

C1 Metf ormi n HCl ER Metformin HCl ER (Oral Tablet Extended Release 24 G 1 QL Hour) (Generic Glucophage XR) 88 Last updated September 1, 2021

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

C1 Metf ormi n HCl Metformin HCl (500MG/5ML Oral Solution) G 3 QL

C1 Metf ormi n HCl Metformin HCl (1000MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 850MG Oral G 1 QL Tablet Immediate Release)

C1 Migl itol Miglitol (Oral Tablet) G 3

C1 Nat egli nide Nateglinide (Oral Tablet) G 2 QL

C1 Nesi na Nesina (Oral Tablet) B 3 ST; QL

C1 Ong lyza Onglyza (Oral Tablet) B 3 QL

C1 Ose ni Oseni (Oral Tablet) B 3 ST; QL

C1 Oze mpi c Ozempic (0.25MG/DOSE or 0.5MG/DOSE) B 2 QL (Subcutaneous Solution Pen-Injector)

C1 Oze mpi c Ozempic (1MG/DOSE) (Subcutaneous Solution Pen- B 2 QL Injector)

C1 Piog litaz one HCl Pioglitazone HCl (Oral Tablet) G 1 QL

C1 Piog litaz one HCl- Glim epiri de Pioglitazone HCl-Glimepiride (Oral Tablet) G 3 QL

C1 Piog litaz one HCl- Metf ormi n HCl Pioglitazone HCl-Metformin HCl (Oral Tablet) G 3 QL

C1 Qter n Qtern (Oral Tablet) B 3 ST; QL

C1 Rep agli nide Repaglinide (Oral Tablet) G 1 QL

C1 Rio met Riomet (Oral Solution) B 3 QL

C1 Ryb elsu s Rybelsus (Oral Tablet) B 2 QL

C1 Segl uro met Segluromet (Oral Tablet) B 3 ST; QL

C1 Soli qua Soliqua (Subcutaneous Solution Pen-Injector) B 2 QL

C1 Steg latro Steglatro (Oral Tablet) B 3 ST; QL

C1 Steg lujan Steglujan (Oral Tablet) B 3 ST; QL

C1 Sym linP en 120 SymlinPen 120 (Subcutaneous Solution Pen-Injector) B 4 PA

C1 Sym linP en 60 SymlinPen 60 (Subcutaneous Solution Pen-Injector) B 4 PA

C1 Synj ardy Synjardy (Oral Tablet Immediate Release) B 2 QL

C1 Synj ardy XR Synjardy XR (Oral Tablet Extended Release 24 Hour) B 2 QL

C1 Trad jent a Tradjenta (Oral Tablet) B 2 QL

C1 Trija rdy XR Trijardy XR (Oral Tablet Extended Release 24 Hour) B 2 QL

C1 Truli city Trulicity (Subcutaneous Solution Pen-Injector) B 2 QL

C1 Vict oza Victoza (Subcutaneous Solution Pen-Injector) B 2 QL

C1 Xigd uo XR Xigduo XR (Oral Tablet Extended Release 24 Hour) B 2 QL

C1 Xult oph y Xultophy (Subcutaneous Solution Pen-Injector) B 3 ST; QL B1 Glycemic Agents

C1 Baq simi Two Pac k Baqsimi Two Pack (Nasal Powder) B 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 89

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

C1 Diaz oxid e Diazoxide (Oral Suspension) G 4

C1 Gluc aGe n Hyp oKit GlucaGen HypoKit (Injection Solution Reconstituted) B 3

C1 Gluc ago n Glucagon (Injection Kit) (Lilly) B 2

C1 Gvo ke Hyp oPe n 2- Pac k Gvoke HypoPen 2-Pack (Subcutaneous Solution Auto- B 2 Injector)

C1 Gvo ke PFS Gvoke PFS (Subcutaneous Solution Prefilled Syringe) B 2

C1 Pro glyc em Proglycem (Oral Suspension) B 4 B1

C1 Ad mel og Solo Star Admelog SoloStar (Subcutaneous Solution Pen- B 3 PA Injector)

C1 Ad mel og Admelog (Subcutaneous Solution) B 3 PA

C1 Afre zza Afrezza (12UNIT Inhalation Powder, 4 & 8 & 12UNIT Inhalation Powder, 4 & 8UNIT Inhalation Powder, 8 & B 4 PA 12UNIT Inhalation Powder)

C1 Afre zza Afrezza (4UNIT Inhalation Powder, 8UNIT Inhalation B 3 PA Powder)

C1 Apid ra Apidra (Injection Solution) B 3 PA

C1 Apid ra Solo Star Apidra SoloStar (Subcutaneous Solution Pen-Injector) B 3 PA

C1 Bas agla r Kwi kPe n Basaglar KwikPen (Subcutaneous Solution Pen- B 3 ST Injector)

C1 Fias p Flex Tou ch Fiasp FlexTouch (Subcutaneous Solution Pen- B 3 PA Injector)

C1 Fias p Pen Fill Fiasp PenFill (Subcutaneous Solution Cartridge) B 3 PA

C1 Fias p Fiasp (Subcutaneous Solution) B 3 PA

C1 Hu mal og Juni or Kwi kPe n Humalog Junior KwikPen (Subcutaneous Solution B 2 Pen-Injector)

C1 Hu mal og Kwi kPe n Humalog KwikPen (Subcutaneous Solution Pen- B 2 Injector)

C1 Hu mal og Mix 50/5 0 Kwi kPe n Humalog Mix 50/50 KwikPen (Subcutaneous B 2 Suspension Pen-Injector)

C1 Hu mal og Mix 50/5 0 Humalog Mix 50/50 (Subcutaneous Suspension) B 2

C1 Hu mal og Mix 75/2 5 Kwi kPe n Humalog Mix 75/25 KwikPen (Subcutaneous B 2 Suspension Pen-Injector)

C1 Hu mal og Mix 75/2 5 Humalog Mix 75/25 (Subcutaneous Suspension) B 2

C1 Hu mal og Humalog (Subcutaneous Solution) B 2

C1 Hu mal og Humalog (Subcutaneous Solution Cartridge) B 2

C1 Hu muli n 70/3 0 Kwi kPe n Humulin 70/30 KwikPen (Subcutaneous Suspension B 2 Pen-Injector) 90 Last updated September 1, 2021

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

C1 Hu muli n 70/3 0 Humulin 70/30 (Subcutaneous Suspension) B 2

C1 Hu muli n N Kwi kPe n Humulin N KwikPen (Subcutaneous Suspension Pen- B 2 Injector)

C1 Hu muli n N Humulin N (Subcutaneous Suspension) B 2

C1 Hu muli n R Humulin R (Injection Solution) B 2

C1 Hu muli n R U-50 0 Humulin R U-500 (Concentrated) (Subcutaneous B 2 Solution)

C1 Hu muli n R U-50 0 Kwi kPe n Humulin R U-500 KwikPen (Subcutaneous Solution B 2 Pen-Injector)

C1 Insul in Asp art Prot & Asp art Flex Pen Insulin Aspart Prot & Aspart FlexPen (Subcutaneous B 3 PA Suspension Pen-Injector) (Brand Equivalent Novolog)

C1 Insul in Asp art Flex Pen Insulin Aspart FlexPen (Subcutaneous Solution Pen- B 3 PA Injector) (Brand Equivalent Novolog)

C1 Insul in Asp art Pen Fill Insulin Aspart PenFill (Subcutaneous Solution B 3 PA Cartridge) (Brand Equivalent Novolog)

C1 Insul in Asp art Prot & Asp art Insulin Aspart Prot & Aspart (Subcutaneous B 3 PA Suspension) (Brand Equivalent Novolog)

C1 Insul in Asp art Insulin Aspart (Subcutaneous Solution) (Brand B 3 PA Equivalent Novolog)

C1 Insul in Lisp ro Insulin Lispro (1 Unit Dial) (Subcutaneous Solution B 2 Pen-Injector) (Brand Equivalent Humalog)

C1 Insul in Lisp ro Juni or Kwi kPe n Insulin Lispro Junior KwikPen (Subcutaneous B 2 Solution Pen-Injector) (Brand Equivalent Humalog)

C1 Insul in Lisp ro Prot & Lisp ro Insulin Lispro Prot & Lispro (Subcutaneous B 2 Suspension Pen-Injector) (Brand Equivalent Humalog)

C1 Insul in Lisp ro Insulin Lispro (Subcutaneous Solution) (Brand B 2 Equivalent Humalog)

C1 Lant us Solo Star Lantus SoloStar (Subcutaneous Solution Pen-Injector) B 2

C1 Lant us Lantus (Subcutaneous Solution) B 2

C1 Lev emir

Flex Tou ch Levemir FlexTouch (Subcutaneous Solution Pen- B 2 Injector)

C1 Lev emir Levemir (Subcutaneous Solution) B 2

C1 Lyu mje v Lyumjev (Injection Solution) B 2

C1 Lyu mje v Kwi kPe n Lyumjev KwikPen (Subcutaneous Solution Pen- B 2 Injector)

C1 Nov olin 70/3 0 Flex Pen Novolin 70/30 FlexPen (Subcutaneous Suspension B 3 PA Pen-Injector)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 91

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

C1 Nov olin 70/3 0 Novolin 70/30 (Subcutaneous Suspension) B 3 PA

C1 Nov olin N Flex Pen Novolin N FlexPen (Subcutaneous Suspension Pen- B 3 PA Injector)

C1 Nov olin N Novolin N (Subcutaneous Suspension) B 3 PA

C1 Nov olin R Flex Pen Novolin R FlexPen (Injection Solution Pen-Injector) B 3 PA

C1 Nov olin R Novolin R (Injection Solution) B 3 PA

C1 Nov oLo g Flex Pen NovoLog FlexPen (Subcutaneous Solution Pen- B 3 PA Injector)

C1 Nov oLo g Mix 70/3 0 Flex Pen NovoLog Mix 70/30 FlexPen (Subcutaneous B 3 PA Suspension Pen-Injector)

C1 Nov oLo g Mix 70/3 0 NovoLog Mix 70/30 (Subcutaneous Suspension) B 3 PA

C1 Nov oLo g Pen Fill NovoLog PenFill (Subcutaneous Solution Cartridge) B 3 PA

C1 Nov oLo g NovoLog (Subcutaneous Solution) B 3 PA

C1 Sem glee Semglee (Subcutaneous Solution) B 3 ST

C1 Sem glee Semglee (Subcutaneous Solution Pen-Injector) B 3 ST

C1 Touj eo Max Solo Star Toujeo Max SoloStar (Subcutaneous Solution Pen- B 2 Injector)

C1 Touj eo Solo Star Toujeo SoloStar (Subcutaneous Solution Pen-Injector) B 2

C1 Tres iba Flex Tou ch Tresiba FlexTouch (Subcutaneous Solution Pen- B 2 Injector)

C1 Tres iba Tresiba (Subcutaneous Solution) B 2 A1 Blood Products and Modifiers B1 Anticoagulants

C1 Arixt ra Arixtra (Subcutaneous Solution) B 4

C1 Eliq uis Eliquis (Oral Tablet) B 2 QL

C1 Eliq uis Start er Pac k Eliquis Starter Pack (Oral Tablet) B 2 QL

C1 Eno xap arin Sodi um Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 120MG/0.8ML Subcutaneous Solution, 150MG/ML Subcutaneous Solution, 60MG/0.6ML G 3 QL Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)

C1 Eno xap arin Sodi um Enoxaparin Sodium (30MG/0.3ML Subcutaneous G 2 QL Solution, 40MG/0.4ML Subcutaneous Solution)

C1 Fon dap arin ux Sodi um Fondaparinux Sodium (10MG/0.8ML Subcutaneous Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/ G 4 0.6ML Subcutaneous Solution)

C1 Fon dap arin ux Sodi um Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous G 3 Solution) 92 Last updated September 1, 2021

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

C1 Frag min Fragmin (10000UNIT/ML Subcutaneous Solution, 12500UNIT/0.5ML Subcutaneous Solution, 15000UNIT/0.6ML Subcutaneous Solution,

18000UNT/0.72ML Subcutaneous Solution, B 4 5000UNIT/0.2ML Subcutaneous Solution, 7500UNIT/ 0.3ML Subcutaneous Solution, 95000UNIT/3.8ML Subcutaneous Solution)

C1 Frag min Fragmin (2500UNIT/0.2ML Subcutaneous Solution) B 3

C1 Hep arin Sodi um Heparin Sodium (10000UNIT/ML Injection Solution, 20000UNIT/ML Injection Solution, 5000UNIT/ML G 2 Injection Solution)

C1 Hep arin Sodi um Heparin Sodium (1000UNIT/ML Injection Solution) G 2 B/D, PA

C1 Jant ove n Jantoven (Oral Tablet) G 1

C1 Lov eno x Lovenox (100MG/ML Subcutaneous Solution, 120MG/0.8ML Subcutaneous Solution, 60MG/0.6ML B 4 QL Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)

C1 Lov eno x Lovenox (150MG/ML Subcutaneous Solution, 30MG/ 0.3ML Subcutaneous Solution, 40MG/0.4ML B 3 QL Subcutaneous Solution)

C1 Prad axa Pradaxa (Oral Capsule) B 3 ST; QL

C1 Sav aysa Savaysa (Oral Tablet) B 3 ST; QL

C1 Warf arin Sodi um Warfarin Sodium (Oral Tablet) G 1

C1 Xare lto Xarelto (Oral Tablet) B 2 QL

C1 Xare lto Start er Pac k Xarelto Starter Pack (Oral Tablet Therapy Pack) B 2 QL

C1 Zont ivity Zontivity (Oral Tablet) B 3 PA B1 Blood Products and Modifiers, Other

C1 Agry lin Agrylin (Oral Capsule) B 3

C1 Ana greli de HCl Anagrelide HCl (Oral Capsule) G 2

C1 Aran esp Aranesp (Albumin Free) (100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 300MCG/ B 4 PA ML Injection Solution)

C1 Aran esp Aranesp (Albumin Free) (25MCG/ML Injection Solution, 40MCG/ML Injection Solution, 60MCG/ML B 3 PA Injection Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 93

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

C1 Aran esp Aranesp (Albumin Free) (100MCG/0.5ML Injection Solution Prefilled Syringe, 150MCG/0.3ML Injection Solution Prefilled Syringe, 200MCG/0.4ML Injection B 4 PA Solution Prefilled Syringe, 300MCG/0.6ML Injection Solution Prefilled Syringe, 500MCG/ML Injection Solution Prefilled Syringe)

C1 Aran esp Aranesp (Albumin Free) (10MCG/0.4ML Injection Solution Prefilled Syringe, 25MCG/0.42ML Injection Solution Prefilled Syringe, 40MCG/0.4ML Injection B 3 PA Solution Prefilled Syringe, 60MCG/0.3ML Injection Solution Prefilled Syringe)

C1 Epo gen Epogen (10000UNIT/ML Injection Solution, 2000UNIT/ML Injection Solution, 3000UNIT/ML B 3 PA Injection Solution, 4000UNIT/ML Injection Solution)

C1 Epo gen Epogen (20000UNIT/ML Injection Solution) B 4 PA

C1 Fulp hila Fulphila (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Gra nix Granix (Subcutaneous Solution) B 4 ST

C1 Gra nix Granix (Subcutaneous Solution Prefilled Syringe) B 4 ST

C1 Leu kine Leukine (Injection Solution Reconstituted) B 4 PA

C1 Mul plet a Mulpleta (Oral Tablet) B 4 PA

C1 Neul asta Neulasta (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Neu pog en Neupogen (Injection Solution) B 4 ST

C1 Neu pog en Neupogen (Injection Solution Prefilled Syringe) B 4 ST

C1 Nive sty m Nivestym (Injection Solution) B 4 ST

C1 Nive sty m Nivestym (Injection Solution Prefilled Syringe) B 4 ST

C1 Nyv epri a Nyvepria (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Oxb ryta Oxbryta (Oral Tablet) B 4 PA; QL

C1 Proc rit Procrit (10000UNIT/ML Injection Solution, 2000UNIT/ ML Injection Solution, 3000UNIT/ML Injection B 3 PA Solution, 4000UNIT/ML Injection Solution)

C1 Proc rit Procrit (20000UNIT/ML Injection Solution, B 4 PA 40000UNIT/ML Injection Solution)

C1 Pro mac ta Promacta (Oral Packet) B 4 PA; LA; QL

C1 Pro mac ta Promacta (Oral Tablet) B 4 PA; LA; QL

C1 Reta crit Retacrit (Injection Solution) B 3 PA

C1 Sikl os Siklos (Oral Tablet) B 4 PA

C1 Ude nyca Udenyca (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Zarx io Zarxio (Injection Solution Prefilled Syringe) B 4 94 Last updated September 1, 2021

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

C1 Ziex tenz o Ziextenzo (Subcutaneous Solution Prefilled Syringe) B 4 PA B1 Hemostasis Agents

C1 Lyst eda Lysteda (Oral Tablet) B 3

C1 Tran exa mic Acid Tranexamic Acid (Oral Tablet) G 2 B1 Platelet Modifying Agents

C1 Aspi rin- Dipy rida mol e ER Aspirin-Dipyridamole ER (Oral Capsule Extended G 3 QL Release 12 Hour)

C1 Brili nta Brilinta (Oral Tablet) B 2 QL

C1 Cabl ivi Cablivi (Injection Kit) B 4 PA; LA; QL

C1 Cilo staz ol Cilostazol (Oral Tablet) G 1

C1 Clo pido grel Bisu lfate Clopidogrel Bisulfate (75MG Oral Tablet) G 1 QL

C1 Dop telet Doptelet (Oral Tablet) B 4 PA

C1 Plavi x Plavix (Oral Tablet) B 3 QL

C1 Pras ugre l HCl Prasugrel HCl (Oral Tablet) G 2

C1 Tav aliss e Tavalisse (Oral Tablet) B 4 PA; QL A1 Cardiovascular Agents B1 Alpha-adrenergic Agonists

C1 Cata pres - TTS- 1 Catapres-TTS-1 (Transdermal Patch Weekly) B 3

C1 Cata pres - TTS- 2 Catapres-TTS-2 (Transdermal Patch Weekly) B 3

C1 Cata pres - TTS- 3 Catapres-TTS-3 (Transdermal Patch Weekly) B 3

C1 Clon idin e HCl Clonidine HCl (Oral Tablet Immediate Release) G 1

C1 Clon idin e Clonidine (0.1MG/24HR Transdermal Patch Weekly) G 2

C1 Clon idin e Clonidine (0.2MG/24HR Transdermal Patch Weekly, G 3 0.3MG/24HR Transdermal Patch Weekly)

C1 Dro xido pa Droxidopa (Oral Capsule) G 4 PA; QL

C1 Met hyld opa Methyldopa (Oral Tablet) G 3 PA; HRM

C1 Mid odri ne HCl Midodrine HCl (Oral Tablet) G 2

C1 Nort hera Northera (Oral Capsule) B 4 PA; LA; QL B1 Alpha-adrenergic Blocking Agents

C1 Car dura Cardura (Oral Tablet Immediate Release) B 3

C1 Dibe nzyli ne Dibenzyline (Oral Capsule) B 4

C1 Dox azos in Mes ylate Doxazosin Mesylate (Oral Tablet) G 1

C1 Mini pres s Minipress (Oral Capsule) B 3

C1 Phe nox ybe nza min e HCl Phenoxybenzamine HCl (Oral Capsule) G 4

C1 Praz osin HCl Prazosin HCl (Oral Capsule) G 1 B1 Angiotensin II Receptor Antagonists

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 95

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

C1 Atac and Atacand (Oral Tablet) B 3 QL

C1 Ava pro Avapro (Oral Tablet) B 3 QL

C1 Beni car Benicar (Oral Tablet) B 3 QL

C1 Can des arta n Cile xetil Candesartan Cilexetil (Oral Tablet) G 2 QL

C1 Coz aar Cozaar (Oral Tablet) B 3 QL

C1 Diov an Diovan (Oral Tablet) B 3 QL

C1 Edar bi Edarbi (Oral Tablet) B 3 QL

C1 Irbe sart an Irbesartan (Oral Tablet) G 1 QL

C1 Los arta n Pota ssiu m Losartan Potassium (Oral Tablet) G 1 QL

C1 Mic ardi s Micardis (Oral Tablet) B 3 QL

C1 Olm esar tan Med oxo mil Olmesartan Medoxomil (Oral Tablet) G 1 QL

C1 Tel misa rtan Telmisartan (Oral Tablet) G 1 QL

C1 Vals arta n Valsartan (Oral Tablet) G 1 QL B1 Angiotensin-converting Enzyme (ACE) Inhibitors

C1 Acc upril Accupril (Oral Tablet) B 3 QL

C1 Alta ce Altace (Oral Capsule) B 3 QL

C1 Ben aze pril HCl Benazepril HCl (Oral Tablet) G 1 QL

C1 Cap topri l Captopril (100MG Oral Tablet, 50MG Oral Tablet) G 3 QL

C1 Cap topri l Captopril (12.5MG Oral Tablet, 25MG Oral Tablet) G 2 QL

C1 Enal april

Mal eate Enalapril Maleate (Oral Tablet) G 1 QL

C1 Fosi nopr il Sodi um Fosinopril Sodium (Oral Tablet) G 1 QL

C1 Lisin opril Lisinopril (Oral Tablet) G 1 QL

C1 Lote nsin Lotensin (Oral Tablet) B 3 QL

C1 Moe xipril HCl Moexipril HCl (Oral Tablet) G 1 QL

C1 Peri ndo pril Erb umi ne Perindopril Erbumine (Oral Tablet) G 2 QL

C1 Prini vil Prinivil (Oral Tablet) B 3 QL

C1 Qbr elis Qbrelis (Oral Solution) B 4 QL

C1 Quin april HCl Quinapril HCl (Oral Tablet) G 1 QL

C1 Ram ipril Ramipril (Oral Capsule) G 1 QL

C1 Tran dola pril Trandolapril (Oral Tablet) G 1 QL

C1 Vas otec Vasotec (10MG Oral Tablet, 20MG Oral Tablet) B 4 QL

C1 Vas otec Vasotec (2.5MG Oral Tablet, 5MG Oral Tablet) B 3 QL

C1 Zest ril Zestril (Oral Tablet) B 3 QL B1 Antiarrhythmics

C1 Ami odar one HCl Amiodarone HCl (100MG Oral Tablet, 400MG Oral G 3 Tablet)

C1 Ami odar one HCl Amiodarone HCl (200MG Oral Tablet) G 1 96 Last updated September 1, 2021

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

C1 Beta pac e AF Betapace AF (120MG Oral Tablet, 160MG Oral Tablet) B 4

C1 Beta pac e AF Betapace AF (80MG Oral Tablet) B 3

C1 Dof etili de Dofetilide (Oral Capsule) G 2

C1 Flec aini de Acet ate Flecainide Acetate (Oral Tablet) G 1

C1 Mex iletin e HCl Mexiletine HCl (Oral Capsule) G 2

C1 Mult aq Multaq (Oral Tablet) B 2

C1 Pac eron e Pacerone (100MG Oral Tablet, 400MG Oral Tablet) G 3

C1 Pac eron e Pacerone (200MG Oral Tablet) G 1

C1 Pro pafe non e HCl ER Propafenone HCl ER (Oral Capsule Extended Release G 3 12 Hour)

C1 Pro pafe non e HCl Propafenone HCl (Oral Tablet) G 2

C1 Quin idin e Gluc onat e ER Quinidine Gluconate ER (Oral Tablet Extended Release) G 3

C1 Quin idin e Sulf ate Quinidine Sulfate (Oral Tablet) G 1

C1 Ryth mol SR Rythmol SR (Oral Capsule Extended Release 12 Hour) B 4

C1 Sori ne Sorine (Oral Tablet) G 1

C1 Sota lol HCl AF Sotalol HCl AF (Oral Tablet) G 1

C1 Sota lol HCl Sotalol HCl (Oral Tablet) G 1

C1 Soty lize Sotylize (Oral Solution) B 3 PA

C1 Tiko syn Tikosyn (Oral Capsule) B 3 B1 Beta-adrenergic Blocking Agents

C1 Ace buto lol HCl Acebutolol HCl (Oral Capsule) G 2

C1 Aten olol Atenolol (Oral Tablet) G 1

C1 Beta xolo l HCl Betaxolol HCl (Oral Tablet) G 2

C1 Biso prol ol Fum arat e Bisoprolol Fumarate (Oral Tablet) G 1

C1 Byst olic Bystolic (Oral Tablet) B 2 QL

C1 Carv edil ol Carvedilol (Oral Tablet) G 1

C1 Carv edil ol Pho sph ate ER Carvedilol Phosphate ER (Oral Capsule Extended G 3 Release 24 Hour)

C1 Cor eg CR Coreg CR (Oral Capsule Extended Release 24 Hour) B 3

C1 Cor eg Coreg (Oral Tablet) B 3

C1 Cor gard Corgard (Oral Tablet) B 3

C1 Inde ral LA Inderal LA (Oral Capsule Extended Release 24 Hour) B 4

C1 Inno Pran XL InnoPran XL (Oral Capsule Extended Release 24 B 4 Hour)

C1 Lab etal ol HCl Labetalol HCl (Oral Tablet) G 1

C1 Lopr ess or Lopressor (Oral Tablet) B 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 97

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

C1 Met opr olol Suc cina te ER Metoprolol Succinate ER (Oral Tablet Extended Release G 1 24 Hour)

C1 Met opr olol Tartr ate Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral G 1 Tablet, 50MG Oral Tablet)

C1 Met opr olol Tartr ate Metoprolol Tartrate (37.5MG Oral Tablet, 75MG Oral G 2 Tablet)

C1 Nad olol Nadolol (Oral Tablet) G 2

C1 Pind olol Pindolol (Oral Tablet) G 2

C1 Pro pran olol HCl ER Propranolol HCl ER (Oral Capsule Extended Release 24 G 2 Hour)

C1 Pro pran olol HCl Propranolol HCl (Oral Solution) G 1

C1 Pro pran olol HCl Propranolol HCl (Oral Tablet) G 1

C1 Ten ormi n Tenormin (Oral Tablet) B 3

C1 Top rol XL Toprol XL (Oral Tablet Extended Release 24 Hour) B 3 B1 Calcium Channel Blocking Agents, Dihydropyridines

C1 Aml odip ine Bes ylate Amlodipine Besylate (Oral Tablet) G 1

C1 Felo dipi ne ER Felodipine ER (Oral Tablet Extended Release 24 Hour) G 1

C1 Isra dipi ne Isradipine (Oral Capsule) G 3

C1 Kate rzia Katerzia (Oral Suspension) B 4 ST

C1 Nica rdipi ne HCl Nicardipine HCl (Oral Capsule) G 3

C1 Nife dipi ne ER Nifedipine ER (Oral Tablet Extended Release 24 Hour) G 1

C1 Nife dipi ne ER Os moti c Rele ase Nifedipine ER Osmotic Release (Oral Tablet Extended G 1 Release 24 Hour)

C1 Nim odip ine Nimodipine (Oral Capsule) G 3

C1 Niso ldipi ne ER Nisoldipine ER (Oral Tablet Extended Release 24 Hour) G 3

C1 Nor vasc Norvasc (Oral Tablet) B 3

C1 Nym alize Nymalize (6MG/ML Oral Solution) B 4

C1 Proc ardi a XL Procardia XL (Oral Tablet Extended Release 24 Hour) B 3

C1 Sula r Sular (Oral Tablet Extended Release 24 Hour) B 4 B1 Calcium Channel Blocking Agents, Nondihydropyridines

C1 Cala n SR Calan SR (Oral Tablet Extended Release) B 3

C1 Car dize m CD Cardizem CD (Oral Capsule Extended Release 24 B 4 Hour)

C1 Car dize m LA Cardizem LA (Oral Tablet Extended Release 24 Hour) B 3

C1 Car dize m Cardizem (Oral Tablet Immediate Release) B 4

C1 Carti a XT Cartia XT (Oral Capsule Extended Release 24 Hour) G 1 98 Last updated September 1, 2021

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

C1 Dilti aze m HCl ER Bea ds Diltiazem HCl ER Beads (360MG Oral Capsule Extended Release 24 Hour, 420MG Oral Capsule Extended G 1 Release 24 Hour)

C1 Dilti aze m HCl ER Coa ted Bea ds Diltiazem HCl ER Coated Beads (120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule G 1 Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

C1 Dilti aze m HCl ER Coa ted Bea ds Diltiazem HCl ER Coated Beads (180MG Oral Tablet Extended Release 24 Hour, 240MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet G 2 Extended Release 24 Hour, 360MG Oral Tablet Extended Release 24 Hour)

C1 Dilti aze m HCl ER Diltiazem HCl ER (Oral Capsule Extended Release 12 G 2 Hour)

C1 Dilti aze m HCl Diltiazem HCl (Oral Tablet Immediate Release) G 1

C1 Dilt- XR Dilt-XR (Oral Capsule Extended Release 24 Hour) G 1

C1 Mat zim LA Matzim LA (Oral Tablet Extended Release 24 Hour) G 2

C1 Tazt ia XT Taztia XT (Oral Capsule Extended Release 24 Hour) G 1

C1 Tiad ylt ER Tiadylt ER (Oral Capsule Extended Release 24 Hour) G 1

C1 Tiaz ac Tiazac (Oral Capsule Extended Release 24 Hour) B 3

C1 Vera pam il HCl ER Verapamil HCl ER (100MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended

Release 24 Hour, 300MG Oral Capsule Extended B 3 Release 24 Hour, 360MG Oral Capsule Extended Release 24 Hour)

C1 Vera pam il HCl ER Verapamil HCl ER (120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended G 2 Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour)

C1 Vera pam il HCl ER Verapamil HCl ER (Oral Tablet Extended Release) G 1

C1 Vera pam il HCl Verapamil HCl (Oral Tablet Immediate Release) G 1

C1 Vere lan Verelan (Oral Capsule Extended Release 24 Hour) B 3

C1 Vere lan PM Verelan PM (Oral Capsule Extended Release 24 Hour) B 3 B1 Cardiovascular Agents, Other

C1 Acc ureti c Accuretic (Oral Tablet) B 3 QL

C1 Acet azol ami de ER Acetazolamide ER (Oral Capsule Extended Release 12 G 2 Hour)

C1 Acet azol ami de Acetazolamide (Oral Tablet) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 99

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

C1 Alda ctazi de Aldactazide (Oral Tablet) B 3

C1 Alis kire n Fum arat e Aliskiren Fumarate (Oral Tablet) G 3 QL

C1 Amil orid e- Hyd roch lorot hiazi de Amiloride-Hydrochlorothiazide (Oral Tablet) G 1

C1 Aml odip ine- Ator vast atin Amlodipine-Atorvastatin (Oral Tablet) G 3 QL

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

C1 Aml odip ine- Olm esar tan Amlodipine-Olmesartan (Oral Tablet) G 2 QL

C1 Aml odip ine- Vals arta n Amlodipine-Valsartan (Oral Tablet) G 2 QL

C1 Aml odip ine- Vals arta n- HCT Z Amlodipine-Valsartan-HCTZ (Oral Tablet) G 3

C1 Atac and HCT Atacand HCT (Oral Tablet) B 3 QL

C1 Aten olol- Chlo rthal idon e Atenolol-Chlorthalidone (Oral Tablet) G 1

C1 Aval ide Avalide (Oral Tablet) B 3 QL

C1 Azor Azor (Oral Tablet) B 3 QL

C1 Ben aze pril- Hyd roch lorot hiazi de Benazepril-Hydrochlorothiazide (Oral Tablet) G 2 QL

C1 Beni car HCT Benicar HCT (Oral Tablet) B 3 QL

C1 BiDil BiDil (Oral Tablet) B 2

C1 Biso prol ol- Hyd roch lorot hiazi de Bisoprolol-Hydrochlorothiazide (Oral Tablet) G 1 QL

C1 Cad uet Caduet (Oral Tablet) B 3 QL

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

C1 Corl anor Corlanor (Oral Solution) B 3 PA; QL

C1 Corl anor Corlanor (Oral Tablet) B 3 PA; QL

C1 De mse r Demser (Oral Capsule) B 4

C1 Digit ek Digitek (125MCG Oral Tablet) G 3 HRM; QL

C1 Digit ek Digitek (250MCG Oral Tablet) G 3 PA; HRM

C1 Dig ox Digox (125MCG Oral Tablet) G 3 HRM; QL

C1 Dig ox Digox (250MCG Oral Tablet) G 3 PA; HRM

C1 Dig oxin Digoxin (Oral Solution) G 3 PA; HRM; QL

C1 Dig oxin Digoxin (125MCG Oral Tablet) G 3 HRM; QL

C1 Dig oxin Digoxin (250MCG Oral Tablet) G 3 PA; HRM

C1 Diov an HCT Diovan HCT (Oral Tablet) B 3 QL

C1 DUT OP ROL DUTOPROL (Oral Tablet Extended Release 24 Hour) B 3

C1 Edar bycl or Edarbyclor (Oral Tablet) B 3 QL

C1 Enal april - Hyd roch lorot hiazi de Enalapril-Hydrochlorothiazide (Oral Tablet) G 1 QL

C1 Entr esto Entresto (Oral Tablet) B 2 QL

C1 Exfo rge HCT Exforge HCT (Oral Tablet) B 3

C1 Exfo rge Exforge (Oral Tablet) B 3 QL

C1 Fosi nopr il Sodi um- HCT Z Fosinopril Sodium-HCTZ (Oral Tablet) G 2 QL

C1 Hyz aar Hyzaar (Oral Tablet) B 3 QL 100 Last updated September 1, 2021

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

C1 Irbe sart an- Hyd roch lorot hiazi de Irbesartan-Hydrochlorothiazide (Oral Tablet) G 1 QL

C1 Lan oxin Lanoxin (125MCG Oral Tablet, 62.5MCG Oral Tablet) B 3 HRM; QL

C1 Lan oxin Lanoxin (250MCG Oral Tablet) B 3 PA; HRM

C1 Lisin opril - Hyd roch lorot hiazi de Lisinopril-Hydrochlorothiazide (Oral Tablet) G 1 QL

C1 Los arta n Pota ssiu m- HCT Z Losartan Potassium-HCTZ (Oral Tablet) G 1 QL

C1 Lotr el Lotrel (Oral Capsule) B 3 QL

C1 Max zide Maxzide (Oral Tablet) B 3

C1 Max zide- 25 Maxzide-25 (Oral Tablet) B 3

C1 Met opr olol- Hyd roch lorot hiazi de Metoprolol-Hydrochlorothiazide (Oral Tablet) G 2

C1 Met yros ine Metyrosine (Oral Capsule) G 4

C1 Mic ardi s HCT Micardis HCT (Oral Tablet) B 3 QL

C1 Olm esar tan Med oxo mil- HCT Z Olmesartan Medoxomil-HCTZ (Oral Tablet) G 1 QL

C1 Olm esar tan- Aml odip ine- HCT Z Olmesartan-Amlodipine-HCTZ (Oral Tablet) G 3 QL

C1 Pent oxify lline ER Pentoxifylline ER (Oral Tablet Extended Release) G 1

C1 Quin april - Hyd roch lorot hiazi de Quinapril-Hydrochlorothiazide (Oral Tablet) G 1 QL

C1 Ran exa Ranexa (Oral Tablet Extended Release 12 Hour) B 3 ST

C1 Ran olazi ne ER Ranolazine ER (Oral Tablet Extended Release 12 Hour) G 2

C1 Spir onol acto ne- HCT Z Spironolactone-HCTZ (Oral Tablet) G 1

C1 Tekt urna

HCT Tekturna HCT (Oral Tablet) B 3 QL

C1 Tekt urna Tekturna (Oral Tablet) B 3 QL

C1 Tel misa rtan- Aml odip ine Telmisartan-Amlodipine (Oral Tablet) G 3 QL

C1 Tel misa rtan- HCT Z Telmisartan-HCTZ (Oral Tablet) G 3 QL

C1 Ten oreti c 100 Tenoretic 100 (Oral Tablet) B 3

C1 Ten oreti c 50 Tenoretic 50 (Oral Tablet) B 3

C1 Tran dola pril- Vera pam il HCl ER Trandolapril-Verapamil HCl ER (Oral Tablet Extended G 3 QL Release)

C1 Tria mter ene- HCT Z Triamterene-HCTZ (Oral Capsule) G 1

C1 Tria mter ene- HCT Z Triamterene-HCTZ (Oral Tablet) G 1

C1 Trib enz or Tribenzor (Oral Tablet) B 3 QL

C1 Twy nsta Twynsta (Oral Tablet) B 3 QL

C1 Vals arta n- Hyd roch lorot hiazi de Valsartan-Hydrochlorothiazide (Oral Tablet) G 1 QL

C1 Vas ereti c Vaseretic (Oral Tablet) B 3 QL

C1 Vec amyl Vecamyl (Oral Tablet) G 4 PA

C1 Zest oreti c Zestoretic (Oral Tablet) B 3 QL

C1 Ziac Ziac (Oral Tablet) B 3 QL B1 , Loop

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 101

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

C1 Bum etan ide Bumetanide (Injection Solution) G 1

C1 Bum etan ide Bumetanide (Oral Tablet) G 2

C1 Ede crin Edecrin (Oral Tablet) B 4

C1 Etha cryn ic Acid Ethacrynic Acid (Oral Tablet) G 3

C1 Furo sem ide Furosemide (Injection Solution) G 1 B/D, PA

C1 Furo sem ide Furosemide (Oral Solution) G 1

C1 Furo sem ide Furosemide (Oral Tablet) G 1

C1 Lasi x Lasix (Oral Tablet) B 3

C1 Tors emi de Torsemide (Oral Tablet) G 1 B1 Diuretics, Potassium-sparing

C1 Alda cton e Aldactone (Oral Tablet) B 3

C1 Amil orid e HCl Amiloride HCl (Oral Tablet) G 1

C1 Car oSpi r CaroSpir (Oral Suspension) B 3

C1 Dyre niu m Dyrenium (Oral Capsule) B 3

C1 Eple reno ne Eplerenone (25MG Oral Tablet) G 2

C1 Eple reno ne Eplerenone (50MG Oral Tablet) G 3

C1 Insp ra Inspra (Oral Tablet) B 3

C1 Spir onol acto ne Spironolactone (Oral Tablet) G 1

C1 Tria mter ene Triamterene (Oral Capsule) G 3 B1 Diuretics,

C1 Chlo rthal idon e Chlorthalidone (Oral Tablet) G 1

C1 Diuri l Diuril (Oral Suspension) B 3

C1 Hyd roch lorot hiazi de Hydrochlorothiazide (Oral Capsule) G 1

C1 Hyd roch lorot hiazi de Hydrochlorothiazide (Oral Tablet) G 1

C1 Inda pam ide Indapamide (Oral Tablet) G 1

C1 Met olaz one Metolazone (Oral Tablet) G 2 B1 Dyslipidemics, Fibric Acid Derivatives

C1 Anta ra Antara (Oral Capsule) B 3

C1 Fen ofibr ate Micr oniz ed Fenofibrate Micronized (130MG Oral Capsule) G 3

C1 Fen ofibr ate Micr oniz ed Fenofibrate Micronized (134MG Oral Capsule, 200MG G 2 Oral Capsule, 43MG Oral Capsule, 67MG Oral Capsule)

C1 Fen ofibr ate Fenofibrate (50MG Oral Capsule) G 2

C1 Fen ofibr ate Fenofibrate (150MG Oral Capsule) G 3

C1 Fen ofibr ate Fenofibrate (120MG Oral Tablet, 40MG Oral Tablet) G 3

C1 Fen ofibr ate Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet) G 2

C1 Fen ofibr ate Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet) G 1

C1 Fen ofibr ic Acid Fenofibric Acid (Oral Capsule Delayed Release) G 2 102 Last updated September 1, 2021

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

C1 Fen ogli de Fenoglide (120MG Oral Tablet) B 4

C1 Fen ogli de Fenoglide (40MG Oral Tablet) B 3

C1 Ge mfib rozil Gemfibrozil (Oral Tablet) G 1

C1 Lipo fen Lipofen (Oral Capsule) B 3

C1 Lopi d Lopid (Oral Tablet) B 3

C1 Tric or Tricor (Oral Tablet) B 3

C1 Trili pix Trilipix (Oral Capsule Delayed Release) B 3 B1 Dyslipidemics, HMG CoA Reductase Inhibitors

C1 Alto prev Altoprev (Oral Tablet Extended Release 24 Hour) B 4 QL

C1 Ator vast atin Calc ium Atorvastatin Calcium (Oral Tablet) G 1 QL

C1 Cres tor Crestor (Oral Tablet) B 3 QL

C1 Ezall or Spri nkle Ezallor Sprinkle (Oral Capsule Sprinkle) B 3 QL

C1 FloL ipid FloLipid (Oral Suspension) B 3 QL

C1 Fluv asta tin Sodi um ER Fluvastatin Sodium ER (Oral Tablet Extended Release 24 G 3 QL Hour)

C1 Fluv asta tin Sodi um Fluvastatin Sodium (Oral Capsule) G 3 QL

C1 Les col XL Lescol XL (Oral Tablet Extended Release 24 Hour) B 3 QL

C1 Lipit or Lipitor (Oral Tablet) B 3 QL

C1 Lival o Livalo (Oral Tablet) B 2 QL

C1 Lov asta tin Lovastatin (Oral Tablet) G 1 QL

C1 Prav asta tin Sodi um Pravastatin Sodium (Oral Tablet) G 1 QL

C1 Ros uvas tatin

Calc ium Rosuvastatin Calcium (Oral Tablet) G 1 QL

C1 Sim vast atin Simvastatin (Oral Tablet) G 1 QL

C1 Zoc or Zocor (Oral Tablet) B 3 QL

C1 Zypi tam ag Zypitamag (Oral Tablet) B 3 ST; QL B1 Dyslipidemics, Other

C1 Chol esty rami ne Ligh t Cholestyramine Light (Oral Powder) G 3

C1 Chol esty rami ne Cholestyramine (Oral Packet) G 3

C1 Cole seve lam HCl Colesevelam HCl (Oral Packet) G 3

C1 Cole seve lam HCl Colesevelam HCl (Oral Tablet) G 3

C1 Cole stid Colestid (Oral Packet) B 3

C1 Cole stid Colestid (Oral Tablet) B 3

C1 Cole stip ol HCl Colestipol HCl (Oral Packet) G 3

C1 Cole stip ol HCl Colestipol HCl (Oral Tablet) G 2

C1 Ezet imib e Ezetimibe (Oral Tablet) G 1

C1 Ezet imib e- Sim vast atin Ezetimibe-Simvastatin (Oral Tablet) G 3 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 103

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

C1 Icos ape nt Ethy l Icosapent Ethyl (Oral Capsule) G 3

C1 Juxt apid Juxtapid (10MG Oral Capsule, 20MG Oral Capsule, B 4 PA; LA 30MG Oral Capsule, 5MG Oral Capsule)

C1 Lov aza Lovaza (Oral Capsule) B 3

C1 Nexl etol Nexletol (Oral Tablet) B 3 PA; QL

C1 Nexl izet Nexlizet (Oral Tablet) B 3 PA; QL

C1 Niac in ER Niacin ER (Antihyperlipidemic) (1000MG Oral Tablet Extended Release, 750MG Oral Tablet Extended G 3 Release)

C1 Niac in ER Niacin ER (Antihyperlipidemic) (500MG Oral Tablet G 1 Extended Release)

C1 Niac or Niacor (Oral Tablet) G 3

C1 Nias pan Niaspan (Oral Tablet Extended Release) B 3

C1 Om ega- 3- Acid Ethy l Este rs Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic G 2 Lovaza)

C1 Pral uent Praluent (Subcutaneous Solution Auto-Injector) B 2 PA; LA; QL

C1 Prev alite Prevalite (Oral Packet) G 3

C1 Que stra n Ligh t Questran Light (Oral Powder) G 3

C1 Que stra n Questran (Oral Packet) G 3

C1 Rep atha

Pus htro nex Syst em Repatha Pushtronex System (Subcutaneous Solution B 2 PA; QL Cartridge)

C1 Rep atha Repatha (Subcutaneous Solution Prefilled Syringe) B 2 PA; QL

C1 Rep atha

Sure Clic k Repatha SureClick (Subcutaneous Solution Auto- B 2 PA; QL Injector)

C1 Ros zet Roszet (Oral Tablet) B 3 ST; QL

C1 Vas cep a Vascepa (Oral Capsule) B 3

C1 Vyto rin Vytorin (Oral Tablet) B 3 QL

C1 Wel chol Welchol (Oral Packet) B 3

C1 Wel chol Welchol (Oral Tablet) B 3

C1 Zeti a Zetia (Oral Tablet) B 3 B1 Vasodilators, Direct-acting Arterial

C1 Hyd ralaz ine HCl Hydralazine HCl (Oral Tablet) G 1

C1 Min oxid il Minoxidil (Oral Tablet) G 1 B1 Vasodilators, Direct-acting Arterial/Venous

C1 GoN itro GoNitro (Sublingual Packet) B 3

C1 Isor dil Titra dos e Isordil Titradose (Oral Tablet) B 4 104 Last updated September 1, 2021

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

C1 Isos orbi de Dinit rate Isosorbide Dinitrate (10MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG G 1 Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)

C1 Isos orbi de Dinit rate Isosorbide Dinitrate (40MG Oral Tablet Immediate G 4 Release)

C1 Isos orbi de Mon onitr ate ER Isosorbide Mononitrate ER (Oral Tablet Extended G 1 Release 24 Hour)

C1 Isos orbi de Mon onitr ate Isosorbide Mononitrate (Oral Tablet Immediate Release) G 1

C1 Mini tran Minitran (Transdermal Patch 24 Hour) G 1

C1 Nitr o- Bid Nitro-Bid (Transdermal Ointment) G 3

C1 Nitr o- Dur Nitro-Dur (Transdermal Patch 24 Hour) B 3

C1 Nitr ogly ceri n Nitroglycerin (Tablet Sublingual) G 1

C1 Nitr ogly ceri n Nitroglycerin (Transdermal Patch 24 Hour) G 1

C1 Nitr ogly ceri n Nitroglycerin (Translingual Solution) G 3

C1 Nitr olin gual Nitrolingual (Translingual Solution) B 3

C1 Nitr osta t Nitrostat (Tablet Sublingual) B 3

C1 Rect iv Rectiv (Rectal Ointment) B 3 QL

C1 Ver quv o Verquvo (Oral Tablet) B 3 PA; QL A1 Central Nervous System Agents B1 Attention Deficit Hyperactivity Disorder Agents, Amphetamines

C1 Add erall Adderall (20MG Oral Tablet, 5MG Oral Tablet, 7.5MG G 3 QL Oral Tablet)

C1 Add erall XR Adderall XR (Oral Capsule Extended Release 24 Hour) B 3 QL

C1 Adz enys ER Adzenys ER (Oral Suspension Extended Release) B 3 QL

C1 Adz enys XR- ODT Adzenys XR-ODT (Oral Tablet Extended Release B 3 QL Dispersible)

C1 Am phet ami ne ER Amphetamine ER (Oral Suspension Extended Release) G 3 QL

C1 Am phet ami ne Sulf ate Amphetamine Sulfate (Oral Tablet) G 3

C1 Am phet ami ne- Dext roa mph eta min e ER Amphetamine-Dextroamphetamine ER (Oral Capsule G 2 QL Extended Release 24 Hour)

C1 Am phet ami ne- Dext roa mph eta min e Amphetamine-Dextroamphetamine (Oral Tablet) G 2 QL

C1 Des oxy n Desoxyn (Oral Tablet) B 4 PA

C1 Dex edri ne Dexedrine (Oral Capsule Extended Release 24 Hour) B 4 QL

C1 Dext roa mph eta min e Sulf ate ER Dextroamphetamine Sulfate ER (Oral Capsule Extended G 3 QL Release 24 Hour)

C1 Dext roa mph eta min e Sulf ate Dextroamphetamine Sulfate (Oral Solution) G 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 105

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

C1 Dext roa mph eta min e Sulf ate Dextroamphetamine Sulfate (Oral Tablet) G 2 QL

C1 Dya nav el XR Dyanavel XR (Oral Suspension Extended Release) B 3 QL

C1 Eve keo ODT Evekeo ODT (Oral Tablet Dispersible) B 3

C1 Eve keo Evekeo (Oral Tablet) G 3

C1 Met ham phet ami ne HCl Methamphetamine HCl (Oral Tablet) G 4 PA

C1 Myd ayis Mydayis (Oral Capsule Extended Release 24 Hour) B 3 QL

C1 Pro Cen tra ProCentra (Oral Solution) G 3

C1 Vyv ans e Vyvanse (Oral Capsule) B 3

C1 Vyv ans e Vyvanse (Oral Tablet Chewable) B 3

C1 Zen zedi Zenzedi (Oral Tablet) G 3 QL B1 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

C1 Apt ensi o XR Aptensio XR (Oral Capsule Extended Release 24 B 3 QL Hour)

C1 Ato mox etin e HCl Atomoxetine HCl (Oral Capsule) G 3

C1 Clon idin e HCl ER Clonidine HCl ER (Oral Tablet Extended Release 12 G 3 PA Hour)

C1 Con cert a Concerta (Oral Tablet Extended Release) B 3 QL

C1 Cot emp la XR- ODT Cotempla XR-ODT (Oral Tablet Extended Release B 3 QL Dispersible)

C1 Dayt rana Daytrana (Transdermal Patch) B 3 QL

C1 Dex met hylp heni date HCl ER Dexmethylphenidate HCl ER (Oral Capsule Extended G 3 Release 24 Hour)

C1 Dex met hylp heni date HCl Dexmethylphenidate HCl (Oral Tablet) G 2 QL

C1 Foc alin Focalin (Oral Tablet) B 3 QL

C1 Foc alin XR Focalin XR (Oral Capsule Extended Release 24 Hour) B 3

C1 Jorn ay PM Jornay PM (Oral Capsule Extended Release 24 Hour) B 3 QL

C1 Kap vay Kapvay (Oral Tablet Extended Release 12 Hour) B 3 PA

C1 Met hylin Methylin (Oral Solution) B 3 QL

C1 Met hylp heni date HCl CD Methylphenidate HCl CD (Oral Capsule Extended G 3 Release) (Generic Metadate CD)

C1 Met hylp heni date HCl LA Methylphenidate HCl LA (Oral Capsule Extended G 3 Release 24 Hour) (Generic Ritalin LA)

C1 Met hylp heni date HCl ER Methylphenidate HCl ER (XR) (Oral Capsule Extended G 3 QL Release 24 Hour) (Brand Equivalent Aptensio XR)

C1 Met hylp heni date HCl ER Os moti c Rele ase Methylphenidate HCl ER Osmotic Release (Oral Tablet G 3 QL Extended Release)

C1 Met hylp heni date HCl ER Methylphenidate HCl ER (Oral Tablet Extended Release G 3 QL 24 Hour) 106 Last updated September 1, 2021

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

C1 Met hylp heni date HCl Methylphenidate HCl (Oral Solution) G 3 QL

C1 Met hylp heni date HCl Methylphenidate HCl (Oral Tablet Immediate Release) G 2 QL (Generic Ritalin)

C1 Met hylp heni date HCl Methylphenidate HCl (Oral Tablet Chewable) G 3 QL

C1 Quill iChe w ER QuilliChew ER (Oral Tablet Chewable Extended B 3 QL Release)

C1 Quill ivant XR Quillivant XR (Oral Suspension Reconstituted) B 3

C1 Rele xxii Relexxii (Oral Tablet Extended Release) G 3 QL

C1 Rital in LA Ritalin LA (Oral Capsule Extended Release 24 Hour) B 3

C1 Rital in Ritalin (Oral Tablet) B 3 QL

C1 Strat tera Strattera (Oral Capsule) B 3 B1 Central Nervous System, Other

C1 Aust edo Austedo (Oral Tablet) B 4 PA; LA; QL

C1 Fird aps e Firdapse (Oral Tablet) B 4 PA; LA; QL

C1 Grali se Gralise (Oral Tablet) B 3 PA

C1 Hori zant Horizant (Oral Tablet Extended Release) B 3 PA

C1 Ingr ezza Ingrezza (40MG Oral Capsule, 80MG Oral Capsule) B 4 PA; QL

C1 Ingr ezza Ingrezza (Oral Capsule Therapy Pack) B 4 PA; QL

C1 Nue dext a Nuedexta (Oral Capsule) B 3 PA; QL

C1 Rilut ek Rilutek (Oral Tablet) B 4

C1 Rilu zole Riluzole (Oral Tablet) G 2

C1 Ruz urgi Ruzurgi (Oral Tablet) B 4 PA; QL

C1 Tetr abe nazi ne Tetrabenazine (Oral Tablet) G 4 PA; LA

C1 Tigl utik Tiglutik (Oral Suspension) B 4 PA

C1 Xen azin e Xenazine (Oral Tablet) B 4 PA; LA B1 Fibromyalgia Agents

C1 Cym balt a Cymbalta (Oral Capsule Delayed Release Particles) B 3 QL

C1 Driz alm a Spri nkle Drizalma Sprinkle (Oral Capsule Delayed Release B 3 ST; QL Sprinkle)

C1 Dulo xeti ne HCl Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, G 1 QL 60MG Oral Capsule Delayed Release Particles)

C1 Dulo xeti ne HCl Duloxetine HCl (40MG Oral Capsule Delayed Release G 3 QL Particles)

C1 Lyri ca CR Lyrica CR (Oral Tablet Extended Release 24 Hour) B 3 PA; QL

C1 Lyri ca Lyrica (Oral Capsule) B 3 ST; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 107

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

C1 Lyri ca Lyrica (Oral Solution) B 3 ST; QL

C1 Pre gab alin ER Pregabalin ER (Oral Tablet Extended Release 24 Hour) G 3 PA; QL

C1 Pre gab alin Pregabalin (Oral Capsule) G 2 QL

C1 Pre gab alin Pregabalin (Oral Solution) G 2 QL

C1 Sav ella Savella (Oral Tablet) B 2

C1 Sav ella Titra tion Pac k Savella Titration Pack (Oral Tablet) B 2 B1 Multiple Sclerosis Agents

C1 Am pyra Ampyra (Oral Tablet Extended Release 12 Hour) B 4 QL

C1 Aub agio Aubagio (Oral Tablet) B 4 LA; QL

C1 Avo nex Pen Avonex Pen (Intramuscular Auto-Injector Kit) B 4

C1 Avo nex Prefi lled Avonex Prefilled (Intramuscular Prefilled Syringe Kit) B 4

C1 Bafi erta m Bafiertam (Oral Capsule Delayed Release) B 4 ST; QL

C1 Beta sero n Betaseron (Subcutaneous Kit) B 4

C1 Cop axo ne Copaxone (Subcutaneous Solution Prefilled Syringe) B 4

C1 Dalf amp ridin e ER Dalfampridine ER (Oral Tablet Extended Release 12 G 2 QL Hour)

C1 Dim ethy l Fum arat e Dimethyl Fumarate (120MG Oral Capsule Delayed G 4 QL Release, 240MG Oral Capsule Delayed Release)

C1 Dim ethy l Fum arat e Start er Pac k Dimethyl Fumarate Starter Pack (Oral Capsule) G 4

C1 Exta via Extavia (Subcutaneous Kit) B 4

C1 Gile nya Gilenya (0.5MG Oral Capsule) B 4 QL

C1 Glati ram er Acet ate Glatiramer Acetate (Subcutaneous Solution Prefilled G 4 Syringe)

C1 Glat opa Glatopa (Subcutaneous Solution Prefilled Syringe) G 4

C1 Kesi mpt a Kesimpta (Subcutaneous Solution Auto-Injector) B 4 PA

C1 Mav encl ad Mavenclad (10 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 Mav encl ad Mavenclad (4 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 Mav encl ad Mavenclad (5 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 Mav encl ad Mavenclad (6 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 Mav encl ad Mavenclad (7 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 Mav encl ad Mavenclad (8 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 Mav encl ad Mavenclad (9 Tabs) (Oral Tablet Therapy Pack) B 4 PA

C1 May zent Mayzent (0.25MG Oral Tablet, 2MG Oral Tablet) B 4 LA; QL

C1 May zent

Start er Pac k Mayzent Starter Pack (Oral Tablet Therapy Pack) B 4 LA

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

C1 Pleg ridy Plegridy (Subcutaneous Solution Prefilled Syringe) B 4 108 Last updated September 1, 2021

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

C1 Rebi f Rebi dos e Rebif Rebidose (Subcutaneous Solution Auto- B 4 ST Injector)

C1 Rebi f Rebi dos e Titra tion Pac k Rebif Rebidose Titration Pack (Subcutaneous B 4 ST Solution Auto-Injector)

C1 Rebi f Rebif (Subcutaneous Solution Prefilled Syringe) B 4 ST

C1 Rebi f Titra tion Pac k Rebif Titration Pack (Subcutaneous Solution Prefilled B 4 ST Syringe)

C1 Tecf ider a Start er Pac k Tecfidera Starter Pack (Oral) B 4 LA

C1 Tecf ider a Tecfidera (Oral Capsule Delayed Release) B 4 LA; QL

C1 Vum erity Vumerity (Oral Capsule Delayed Release) B 4 QL (Maintenance Dose Bottle)

C1 Zep osia 7- Day Start er Pac k Zeposia 7-Day Starter Pack (Oral Capsule Therapy B 4 QL Pack)

C1 Zep osia Zeposia (Oral Capsule) B 4 QL

C1 Zep osia Start er Kit Zeposia Starter Kit (Oral Capsule Therapy Pack) B 4 QL A1 Dental and Oral Agents B1 Dental and Oral Agents

C1 Cevi meli ne HCl Cevimeline HCl (Oral Capsule) G 3 ST

C1 Chlo rhex idin e Gluc onat e Chlorhexidine Gluconate (Mouth Solution) G 1

C1 Evo xac Evoxac (Oral Capsule) B 3 ST

C1 Peri ogar d Periogard (Mouth Solution) G 1

C1 Pilo carp ine HCl Pilocarpine HCl (Oral Tablet) G 3

C1 Sala gen Salagen (Oral Tablet) B 3

C1 Tria mci nolo ne Acet onid e Triamcinolone Acetonide (Dental Paste) G 2 A1 Dermatological Agents B1 Acne and Rosacea Agents

C1 Abs oric a LD Absorica LD (Oral Capsule) B 4 PA

C1 Abs oric a Absorica (Oral Capsule) B 4 PA

C1 Aca nya Acanya (External Gel) B 3 ST

C1 Acc utan e Accutane (20MG Oral Capsule, 30MG Oral Capsule, G 3 PA 40MG Oral Capsule)

C1 Acitr etin Acitretin (Oral Capsule) G 3

C1 Ada pale ne Adapalene (External Cream) G 3

C1 Ada pale ne Adapalene (0.1% External Gel) G 2

C1 Ada pale ne Adapalene (0.3% External Gel) G 3

C1 Ada pale ne Adapalene (External Pad) G 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 109

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

C1 Ada pale ne Adapalene (External Solution) G 4

C1 Ada pale ne- Ben zoyl Per oxid e Adapalene-Benzoyl Peroxide (External Gel) G 3 ST

C1 Akli ef Aklief (External Cream) B 3 PA

C1 Altre no Altreno (External Lotion) B 3 PA

C1 Amn este em Amnesteem (Oral Capsule) G 3 PA

C1 Araz lo Arazlo (External Lotion) B 3 PA

C1 Atral in Atralin (External Gel) B 3 PA

C1 Avit a Avita (External Cream) B 3 PA

C1 Avit a Avita (External Gel) B 3 PA

C1 Azel aic Acid Azelaic Acid (External Gel) G 3

C1 Azel ex Azelex (External Cream) B 3

C1 Ben zaCl in with Pum p BenzaClin with Pump (External Gel) B 3

C1 Ben zam ycin Benzamycin (External Gel) B 3

C1 Ben zoyl Per oxid e- Eryt hro myci n Benzoyl Peroxide-Erythromycin (External Gel) G 3

C1 Clar avis Claravis (Oral Capsule) G 3 PA

C1 Clin dam ycin Pho sph ate- Ben zoyl Per oxid e Clindamycin Phosphate-Benzoyl Peroxide (1.2-2.5% G 3 ST External Gel)

C1 Clin dam ycin Pho sph ate- Ben zoyl Per oxid e Clindamycin Phosphate-Benzoyl Peroxide (1-5% External G 3 Gel, 1.2-5% External Gel)

C1 Clin dam ycin- Treti noin Clindamycin-Tretinoin (External Gel) G 3 PA

C1 Diffe rin Differin (External Cream) B 3

C1 Diffe rin Differin (0.3% External Gel) B 3

C1 Diffe rin Differin (External Lotion) B 3

C1 Epid uo Epiduo (External Gel) B 3 ST

C1 Epid uo Fort e Epiduo Forte (External Gel) B 3 ST

C1 Fabi or Fabior (External Foam) B 3 PA

C1 Fina cea Finacea (External Foam) B 3

C1 Fina cea Finacea (External Gel) B 3

C1 Isotr etin oin Isotretinoin (Oral Capsule) G 3 PA

C1 Mirv aso Mirvaso (External Gel) B 3

C1 Myo risa n Myorisan (Oral Capsule) G 3 PA

C1 Neu ac Neuac (External Gel) G 3

C1 One xton Onexton (External Gel) B 3

C1 Reti n-A Retin-A (External Cream) B 3 PA

C1 Reti n-A Retin-A (External Gel) B 3 PA

C1 Reti n-A Micr o Retin-A Micro (External Gel) B 4 PA 110 Last updated September 1, 2021

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

C1 Reti n-A Micr o Pum p Retin-A Micro Pump (0.06% External Gel, 0.08% B 4 PA External Gel)

C1 Rho fade Rhofade (External Cream) B 3 PA

C1 Sori atan e Soriatane (Oral Capsule) B 4

C1 Taz arot ene Tazarotene (External Cream) G 3 PA

C1 Taz arot ene Tazarotene (External Foam) G 3 PA

C1 Taz orac Tazorac (External Cream) B 3 PA

C1 Taz orac Tazorac (0.05% External Gel) B 4 PA

C1 Taz orac Tazorac (0.1% External Gel) B 3 PA

C1 Treti noin Tretinoin (External Cream) G 3 PA

C1 Treti noin Tretinoin (External Gel) G 3 PA

C1 Treti noin

Micr osp here Tretinoin Microsphere (External Gel) G 3 PA

C1 Velti n Veltin (External Gel) B 4 PA

C1 Zen atan e Zenatane (Oral Capsule) G 3 PA

C1 Zian a Ziana (External Gel) B 4 PA B1 Dermatitis and Pruitus Agents

C1 Ala Scal p Ala Scalp (External Lotion) G 3

C1 Ala- Cort Ala-Cort (External Cream) G 1

C1 Alcl ome taso ne Dipr opio nate Alclometasone Dipropionate (External Cream) G 2

C1 Alcl ome taso ne Dipr opio nate Alclometasone Dipropionate (External Ointment) G 2

C1 Amc inon ide Amcinonide (External Cream) G 3

C1 Amc inon ide Amcinonide (External Lotion) G 3

C1 Amc inon ide Amcinonide (External Ointment) G 3

C1 Am mon ium Lact ate Ammonium Lactate (External Cream) G 1

C1 Am mon ium Lact ate Ammonium Lactate (External Lotion) G 1

C1 Ape xiCo n E ApexiCon E (External Cream) G 4 QL

C1 Bes er Beser (External Lotion) G 3

C1 Beta met has one Dipr opio nate Aug Betamethasone Dipropionate Aug (External Cream) G 1

C1 Beta met has one Dipr opio nate Aug Betamethasone Dipropionate Aug (External Gel) G 2

C1 Beta met has one Dipr opio nate Aug Betamethasone Dipropionate Aug (External Lotion) G 2

C1 Beta met has one Dipr opio nate Aug Betamethasone Dipropionate Aug (External Ointment) G 2

C1 Beta met has one Dipr opio nate Betamethasone Dipropionate (External Cream) G 2

C1 Beta met has one Dipr opio nate Betamethasone Dipropionate (External Lotion) G 2

C1 Beta met has one Dipr opio nate Betamethasone Dipropionate (External Ointment) G 2

C1 Beta met has one Vale rate Betamethasone Valerate (External Cream) G 2

C1 Beta met has one Vale rate Betamethasone Valerate (External Foam) G 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 111

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

C1 Beta met has one Vale rate Betamethasone Valerate (External Lotion) G 2

C1 Beta met has one Vale rate Betamethasone Valerate (External Ointment) G 2

C1 Bryh ali Bryhali (External Lotion) B 3

C1 Cap ex Capex (External Shampoo) B 3

C1 Clo beta sol Pro pion ate Emo llient

Bas e Clobetasol Propionate Emollient Base (External Cream) G 2

C1 Clo beta sol Pro pion ate Emu lsion Clobetasol Propionate Emulsion (External Foam) G 3

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Cream) G 2

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Foam) G 3 QL

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Gel) G 2

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Liquid Spray) G 3 QL

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Lotion) G 3 QL

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Ointment) G 2

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Shampoo) G 3

C1 Clo beta sol Pro pion ate Clobetasol Propionate (External Solution) G 2

C1 Clo bex Clobex (External Lotion) B 4 QL

C1 Clo bex Clobex (External Shampoo) B 4

C1 Clo bex Spra y Clobex Spray (External Liquid) B 4 QL

C1 Cloc ortol one Pival ate Clocortolone Pivalate (External Cream) G 3

C1 Clo dan Clodan (External Shampoo) G 3

C1 Clo der m Cloderm (External Cream) B 3

C1 Cor dran Cordran (0.025% External Cream) B 3

C1 Cor dran Cordran (0.05% External Cream) B 4

C1 Cor dran Cordran (External Lotion) B 3 QL

C1 Cor dran Cordran (External Ointment) B 4

C1 Cor dran Cordran (External Tape) B 4

C1 Cuti vate Cutivate (External Lotion) B 4

C1 Der ma- Smo othe /FS Scal p Derma-Smoothe/FS Scalp (External Oil) B 3

C1 Des onat e Desonate (External Gel) B 3 ST

C1 Des onid e Desonide (External Cream) G 2

C1 Des onid e Desonide (External Gel) G 3 ST

C1 Des onid e Desonide (External Lotion) G 3

C1 Des onid e Desonide (External Ointment) G 2

C1 Des Owe n DesOwen (External Cream) B 3

C1 Des oxi met aso ne Desoximetasone (External Cream) G 3 QL

C1 Des oxi met aso ne Desoximetasone (External Gel) G 3

C1 Des oxi met aso ne Desoximetasone (External Liquid) G 3

C1 Des oxi met aso ne Desoximetasone (External Ointment) G 3 112 Last updated September 1, 2021

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

C1 Diflo raso ne Diac etat e Diflorasone Diacetate (External Cream) G 3 QL

C1 Diflo raso ne Diac etat e Diflorasone Diacetate (External Ointment) G 4 ST; QL

C1 Dipr olen e Diprolene (External Ointment) B 3

C1 Dox epin HCl Doxepin HCl (External Cream) G 4 PA; QL

C1 Elid el Elidel (External Cream) B 3 ST; QL

C1 Eucr isa Eucrisa (External Ointment) B 3 PA; QL

C1 Fluo cino lone

Acet onid e Fluocinolone Acetonide (External Cream) G 2

C1 Fluo cino lone

Acet onid e Fluocinolone Acetonide (External Ointment) G 2

C1 Fluo cino lone

Acet onid e Fluocinolone Acetonide (External Solution) G 2

C1 Fluo cino lone

Acet onid e Scal p Fluocinolone Acetonide Scalp (External Oil) G 2

C1 Fluo cino nide

Emu lsifie d Bas e Fluocinonide Emulsified Base (External Cream) G 2

C1 Fluo cino nide Fluocinonide (0.05% External Cream) G 2

C1 Fluo cino nide Fluocinonide (0.1% External Cream) G 3

C1 Fluo cino nide Fluocinonide (External Gel) G 2

C1 Fluo cino nide Fluocinonide (External Ointment) G 2

C1 Fluo cino nide Fluocinonide (External Solution) G 2

C1 Flur andr enol ide Flurandrenolide (External Cream) G 3

C1 Flur andr enol ide Flurandrenolide (External Lotion) G 3 QL

C1 Flur andr enol ide Flurandrenolide (External Ointment) G 3

C1 Fluti cas one Pro pion ate Fluticasone Propionate (External Cream) G 2

C1 Fluti cas one Pro pion ate Fluticasone Propionate (External Lotion) G 3

C1 Fluti cas one Pro pion ate Fluticasone Propionate (External Ointment) G 2

C1 Halc inon ide Halcinonide (External Cream) G 3

C1 Halo beta sol Pro pion ate Halobetasol Propionate (External Cream) G 3

C1 Halo beta sol Pro pion ate Halobetasol Propionate (External Foam) B 4

C1 Halo beta sol Pro pion ate Halobetasol Propionate (External Ointment) G 3

C1 Halo g Halog (External Cream) B 4

C1 Halo g Halog (External Ointment) B 4

C1 Halo g Halog (External Solution) B 3

C1 Hyd roco rtiso ne Buty rate Hydrocortisone Butyrate (External Cream) G 3

C1 Hyd roco rtiso ne Buty rate Hydrocortisone Butyrate (External Lotion) G 3 QL

C1 Hyd roco rtiso ne Buty rate Hydrocortisone Butyrate (External Ointment) G 3

C1 Hyd roco rtiso ne Buty rate Hydrocortisone Butyrate (External Solution) G 3

C1 Hyd roco rtiso ne Hydrocortisone (1% External Cream, 2.5% External G 1 Cream)

C1 Hyd roco rtiso ne Hydrocortisone (2.5% External Lotion) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 113

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

C1 Hyd roco rtiso ne Hydrocortisone (1% External Ointment, 2.5% External G 1 Ointment)

C1 Hyd roco rtiso ne Vale rate Hydrocortisone Valerate (External Cream) G 3

C1 Hyd roco rtiso ne Vale rate Hydrocortisone Valerate (External Ointment) G 3

C1 Imp eklo Impeklo (External Lotion) B 3 QL

C1 Ken alog Kenalog (External Aerosol Solution) B 4

C1 Lex ette Lexette (External Foam) B 4

C1 Loc oid Locoid (External Lotion) B 4 QL

C1 Loc oid Lipo crea m Locoid Lipocream (External Cream) B 3

C1 Luxi q Luxiq (External Foam) B 3

C1 Mo met aso ne Furo ate Mometasone Furoate (External Cream) G 1

C1 Mo met aso ne Furo ate Mometasone Furoate (External Ointment) G 1

C1 Mo met aso ne Furo ate Mometasone Furoate (External Solution) G 1

C1 Noli x Nolix (External Cream) G 3

C1 Noli x Nolix (External Lotion) G 3 QL

C1 Olux Olux (External Foam) B 4 QL

C1 Olux -E Olux-E (External Foam) B 4 QL

C1 Pan del Pandel (External Cream) B 4

C1 Pim ecro limu s Pimecrolimus (External Cream) G 3 ST; QL

C1 Pre dnic arba te Prednicarbate (External Ointment) G 3

C1 Prot opic Protopic (External Ointment) B 3 ST

C1 PRU DOX IN PRUDOXIN (External Cream) B 4 PA; QL

C1 Psor con Psorcon (External Cream) G 3 QL

C1 Sele niu m Sulfi de Selenium Sulfide (External Lotion) G 1

C1 Syn alar Synalar (External Cream) B 3

C1 Tacr olim us Tacrolimus (External Ointment) G 3 ST

C1 Tem ovat e Temovate (External Cream) G 3

C1 Tex acor t Texacort (External Solution) G 3

C1 Topi cort Topicort (External Cream) G 3 QL

C1 Topi cort Topicort (External Gel) G 3

C1 Topi cort Topicort (0.05% External Ointment) B 3

C1 Topi cort Topicort (0.25% External Ointment) G 3

C1 Topi cort Spra y Topicort Spray (External Liquid) B 3

C1 Tov et Tovet (External Foam) G 3

C1 Tria mci nolo ne Acet onid e Triamcinolone Acetonide (External Aerosol Solution) G 3 (Generic Kenalog)

C1 Tria mci nolo ne Acet onid e Triamcinolone Acetonide (External Cream) G 1 114 Last updated September 1, 2021

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

C1 Tria mci nolo ne Acet onid e Triamcinolone Acetonide (External Lotion) G 2

C1 Tria mci nolo ne Acet onid e Triamcinolone Acetonide (0.025% External Ointment, G 1 0.1% External Ointment, 0.5% External Ointment)

C1 Tria mci nolo ne Acet onid e Triamcinolone Acetonide (0.05% External Ointment) G 3

C1 Tria nex Trianex (External Ointment) G 3

C1 Trid erm Triderm (0.1% External Cream) G 1

C1 Trid erm Triderm (0.5% External Cream) G 3

C1 Ultra vate Ultravate (External Lotion) B 4

C1 Van os Vanos (External Cream) B 4

C1 Ver des o Verdeso (External Foam) B 4 ST

C1 Zon alon Zonalon (External Cream) B 4 PA; QL B1 Dermatological Agents, Other

C1 Alda ra Aldara (External Cream) B 3 QL

C1 Calc ipotr iene Calcipotriene (External Cream) G 3

C1 Calc ipotr iene Calcipotriene (External Foam) B 4

C1 Calc ipotr iene Calcipotriene (External Ointment) G 3

C1 Calc ipotr iene Calcipotriene (External Solution) G 2

C1 Calc ipotr iene - Beta met has one Calcipotriene-Betamethasone (0.005-0.064% External G 3 Ointment)

C1 Calc ipotr iene - Beta met has one Calcipotriene-Betamethasone (0.005-0.064% External G 4 Suspension)

C1 Calc itriol Calcitriol (External Ointment) B 3

C1 Cara c Carac (External Cream) B 4

C1 Clot rima zole- Beta met has one Clotrimazole-Betamethasone (External Cream) G 2

C1 Clot rima zole- Beta met has one Clotrimazole-Betamethasone (External Lotion) G 3

C1 Con dylo x Condylox (External Gel) B 4

C1 Dicl ofen ac Sodi um Diclofenac Sodium (3% External Gel) G 3 PA

C1 Dov one x Dovonex (External Cream) B 4

C1 Duo brii Duobrii (External Lotion) B 4 PA

C1 Efud ex Efudex (External Cream) B 3

C1 Enst ilar Enstilar (External Foam) B 4 PA

C1 Fluo ropl ex Fluoroplex (External Cream) B 4 PA

C1 Fluo rour acil Fluorouracil (0.5% External Cream) G 4

C1 Fluo rour acil Fluorouracil (5% External Cream) G 2

C1 Fluo rour acil Fluorouracil (External Solution) G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 115

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

C1 Hyd roco rtiso ne Acet ate- Pra mox ine Hydrocortisone Acetate-Pramoxine (1-1% External G 3 Cream)

C1 Imiq uim od Imiquimod (3.75% External Cream) B 4 PA

C1 Imiq uim od Imiquimod (5% External Cream) G 2 QL

C1 Met hox sale n Rapi d Methoxsalen Rapid (Oral Capsule) G 4

C1 Neo - Syn alar Neo-Synalar (External Cream) G 4

C1 Nyst atin- Tria mci nolo ne Nystatin-Triamcinolone (External Cream) G 2

C1 Nyst atin- Tria mci nolo ne Nystatin-Triamcinolone (External Ointment) G 2

C1 Pica to Picato (0.015% External Gel, 0.05% External Gel) B 2 QL

C1 Pod ofilo x Podofilox (External Solution) G 2

C1 Qbr exza Qbrexza (External Pad) B 3

C1 Reg rane x Regranex (External Gel) B 4 PA

C1 Sant yl Santyl (External Ointment) B 3

C1 Silva den e Silvadene (External Cream) B 3

C1 Silv er Sulf adia zine Silver Sulfadiazine (External Cream) G 1

C1 Soril ux Sorilux (External Foam) B 4

C1 SSD SSD (External Cream) B 1

C1 Tacl one x Taclonex (External Ointment) B 4

C1 Tacl one x Taclonex (External Suspension) B 4

C1 Vect ical Vectical (External Ointment) B 4

C1 Vere gen Veregen (External Ointment) B 4

C1 Xere se Xerese (External Cream) B 4 PA

C1 Zycl ara Pum p Zyclara Pump (External Cream) B 4 PA B1 Pediculicides/Scabicides

C1 Iver mec tin Ivermectin (External Lotion) G 3

C1 Lind ane Lindane (External Shampoo) G 3

C1 Mal athi on Malathion (External Lotion) G 3

C1 Natr oba Natroba (External Suspension) B 3

C1 Ovid e Ovide (External Lotion) G 3

C1 Per met hrin Permethrin (External Cream) G 2

C1 Sool antr a Soolantra (External Cream) B 3

C1 Spin osa d Spinosad (External Suspension) B 3 B1 Topical Anti-infectives

C1 Acz one Aczone (External Gel) B 3

C1 Alta bax Altabax (External Ointment) B 3

C1 Amz eeq Amzeeq (External Foam) B 3

C1 Cicl opir ox Ciclopirox (External Gel) G 2 116 Last updated September 1, 2021

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

C1 Cicl opir ox Ciclopirox (External Shampoo) G 2

C1 Cicl opir ox Ciclopirox (External Solution) G 2

C1 Cicl opir ox Ola min e Ciclopirox Olamine (External Cream) G 2

C1 Cicl opir ox Ola min e Ciclopirox Olamine (External Suspension) G 2

C1 Cleo cin- T Cleocin-T (External Lotion) B 3

C1 Clin daci n-P Clindacin-P (External Swab) G 2

C1 Clin dag el Clindagel (External Gel) B 4 QL

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (External Foam) G 3

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (External Gel) G 2 QL

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (External Lotion) G 2

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (External Solution) G 1

C1 Clin dam ycin Pho sph ate Clindamycin Phosphate (External Swab) G 2

C1 Clot rima zole Clotrimazole (External Cream) G 1

C1 Clot rima zole Clotrimazole (External Solution) G 2

C1 Dap son e Dapsone (External Gel) G 3

C1 Eco naz ole Nitr ate Econazole Nitrate (External Cream) G 2 QL

C1 Erta czo Ertaczo (External Cream) B 4

C1 Ery Ery (External Pad) G 2

C1 Eryg el Erygel (External Gel) B 3

C1 Eryt hro myci n Erythromycin (External Gel) G 3

C1 Eryt hro myci n Erythromycin (External Solution) G 2

C1 Evo clin Evoclin (External Foam) B 4

C1 Exti na Extina (External Foam) B 4 QL

C1 Gen tami cin Sulf ate Gentamicin Sulfate (External Cream) G 2

C1 Gen tami cin Sulf ate Gentamicin Sulfate (External Ointment) G 1

C1 Jubli a Jublia (External Solution) B 3

C1 Kery din Kerydin (External Solution) B 4 ST

C1 Ket oco naz ole Ketoconazole (External Cream) G 1 QL

C1 Ket oco naz ole Ketoconazole (External Foam) G 3 QL

C1 Ket oco naz ole Ketoconazole (External Shampoo) G 1

C1 Ket oda n Ketodan (External Foam) G 3 QL

C1 Klar on Klaron (External Lotion) B 3 PA

C1 Lopr ox Loprox (External Cream) B 3

C1 Lopr ox Loprox (External Shampoo) B 3

C1 Lulic ona zole Luliconazole (External Cream) B 3 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 117

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

C1 Luz u Luzu (External Cream) B 3 QL

C1 Maf enid e Acet ate Mafenide Acetate (External Packet) G 3

C1 Men tax Mentax (External Cream) B 3

C1 Mup iroci n Calc ium Mupirocin Calcium (External Cream) G 3

C1 Mup iroci n Mupirocin (External Ointment) G 1 QL

C1 Nafti fine HCl Naftifine HCl (External Cream) G 3

C1 Nafti n Naftin (External Gel) B 3

C1 Nya myc Nyamyc (External Powder) G 1 QL

C1 Nyst atin Nystatin (External Cream) G 1

C1 Nyst atin Nystatin (External Ointment) G 1

C1 Nyst atin Nystatin (External Powder) G 1 QL

C1 Nyst op Nystop (External Powder) G 1 QL

C1 Oxic ona zole

Nitr ate Oxiconazole Nitrate (External Cream) G 3 QL

C1 Oxis tat Oxistat (External Cream) B 4 QL

C1 Oxis tat Oxistat (External Lotion) B 4 QL

C1 Sulf acet ami de Sodi um Sulfacetamide Sodium (Acne) (External Lotion) G 3 PA

C1 Sulf amyl on Sulfamylon (External Cream) B 3

C1 Sulf amyl on Sulfamylon (External Packet) B 4

C1 Tav abor ole Tavaborole (External Solution) G 4 ST

C1 Xepi Xepi (External Cream) B 3

C1 Xole gel Xolegel (External Gel) B 4 PA; QL

C1 Zilxi Zilxi (External Foam) B 3 A1 Electrolytes/Minerals/Metals/Vitamins B1 Electrolyte/Mineral Replacement

C1 Ami nos yn II Aminosyn II (15% Intravenous Solution) B 3 B/D, PA

C1 Ami nos yn- PF Aminosyn-PF (7% Intravenous Solution) B 3 B/D, PA

C1 Car bagl u Carbaglu (Oral Tablet) B 4 LA

C1 Clini mix E/ Dext rose Clinimix E/Dextrose (2.75/5) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix E/ Dext rose Clinimix E/Dextrose (4.25/10) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix E/ Dext rose Clinimix E/Dextrose (4.25/5) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix E/ Dext rose Clinimix E/Dextrose (5/15) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix E/ Dext rose Clinimix E/Dextrose (5/20) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix/ Dext rose Clinimix/Dextrose (4.25/10) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix/ Dext rose Clinimix/Dextrose (4.25/5) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix/ Dext rose Clinimix/Dextrose (5/15) (Intravenous Solution) B 3 B/D, PA

C1 Clini mix/ Dext rose Clinimix/Dextrose (5/20) (Intravenous Solution) B 3 B/D, PA

C1 Clini sol SF Clinisol SF (Intravenous Solution) G 3 B/D, PA 118 Last updated September 1, 2021

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

C1 Dext rose Dextrose (10% Intravenous Solution) G 2

C1 Dext rose Dextrose (5% Intravenous Solution) G 2 B/D, PA

C1 Dext rose - NaC l Dextrose-NaCl (10-0.2% Intravenous Solution, 10-0.45% Intravenous Solution, 2.5-0.45% B 2 Intravenous Solution, 5-0.2% Intravenous Solution, 5-0.45% Intravenous Solution)

C1 Dext rose - NaC l Dextrose-NaCl (5-0.9% Intravenous Solution) B 2 B/D, PA

C1 End ari Endari (Oral Packet) B 4 PA

C1 Hep atA min e HepatAmine (8% Intravenous Solution) B 3 B/D, PA

C1 Intra lipid Intralipid (Intravenous Emulsion) B 3 B/D, PA

C1 Isoly te-P in D5 W Isolyte-P in D5W (Intravenous Solution) B 3

C1 Isoly te-S Isolyte-S (Intravenous Solution) B 3

C1 KCl in Dext rose - NaC l KCl in Dextrose-NaCl (Intravenous Solution) B 2

C1 KCl- Lact ated

Ring ers- D5 W KCl-Lactated Ringers-D5W (Intravenous Solution) B 2

C1 Klor- Con 10 Klor-Con 10 (Oral Tablet Extended Release) B 1

C1 Klor- Con M10 Klor-Con M10 (Oral Tablet Extended Release) G 1

C1 Klor- Con M15 Klor-Con M15 (Oral Tablet Extended Release) G 1

C1 Klor- Con M20 Klor-Con M20 (Oral Tablet Extended Release) G 1

C1 Klor- Con Klor-Con (Oral Packet) G 3

C1 Klor- Con 8 Klor-Con 8 (Oral Tablet Extended Release) B 1

C1 K- Tab K-Tab (Oral Tablet Extended Release) B 3

C1 Mag nesi um Sulf ate Magnesium Sulfate (50% Injection Solution) B 1

C1 Mag nesi um Sulf ate Magnesium Sulfate (50% (10ML Syringe) Injection G 1 Solution)

C1 Nutr ilipid Nutrilipid (Intravenous Emulsion) B 3 B/D, PA

C1 Plas ma- Lyte 148 Plasma-Lyte 148 (Intravenous Solution) B 3

C1 Plas ma- Lyte A Plasma-Lyte A (Intravenous Solution) B 3

C1 Plen ami ne Plenamine (Intravenous Solution) G 3 B/D, PA

C1 Pota ssiu m Chlo ride CR Potassium Chloride CR (Oral Tablet Extended Release) G 1

C1 Pota ssiu m Chlo ride ER Potassium Chloride ER (Oral Capsule Extended G 1 Release)

C1 Pota ssiu m Chlo ride in Dext rose Potassium Chloride in Dextrose (Intravenous B 2 B/D, PA Solution)

C1 Pota ssiu m Chlo ride in NaC l Potassium Chloride in NaCl (20-0.45MEQ/L-% G 2 B/D, PA Intravenous Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 119

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

C1 Pota ssiu m Chlo ride in NaC l Potassium Chloride in NaCl (20-0.9MEQ/L-% Intravenous Solution, 40-0.9MEQ/L-% Intravenous B 2 B/D, PA Solution)

C1 Pota ssiu m Chlo ride Potassium Chloride (10MEQ/100ML Intravenous Solution, 20MEQ/100ML Intravenous Solution, B 1 B/D, PA 40MEQ/100ML Intravenous Solution)

C1 Pota ssiu m Chlo ride Potassium Chloride (2MEQ/ML Intravenous Solution, G 1 B/D, PA 2MEQ/ML (20ML) Intravenous Solution)

C1 Pota ssiu m Chlo ride Potassium Chloride (Oral Packet) G 3

C1 Pota ssiu m Chlo ride Potassium Chloride (20 MEQ/15ML(10%) Oral Solution, G 3 40 MEQ/15ML(20%) Oral Solution)

C1 Pota ssiu m Citra te ER Potassium Citrate ER (Oral Tablet Extended Release) G 3

C1 Pre mas ol Premasol (Intravenous Solution) G 3 B/D, PA

C1 Proc ala min e Procalamine (Intravenous Solution) B 3 B/D, PA

C1 Pros ol Prosol (Intravenous Solution) B 3 B/D, PA

C1 Sodi um Chlo ride Sodium Chloride (0.45% Intravenous Solution) G 1

C1 Sodi um Chlo ride Sodium Chloride (0.9% Intravenous Solution, 3% G 1 B/D, PA Intravenous Solution)

C1 Sodi um Chlo ride Sodium Chloride (5% Intravenous Solution) B 1 B/D, PA

C1 Sodi um Chlo ride Sodium Chloride (Irrigation Solution) B 1

C1 Sodi um Fluo ride Sodium Fluoride (Oral Tablet) G 1

C1 TPN Elec troly tes TPN Electrolytes (Intravenous Concentrate) B 2

C1 Trav asol Travasol (Intravenous Solution) B 3 B/D, PA

C1 Tro phA min e TrophAmine (10% Intravenous Solution) B 3 B/D, PA

C1 Uro cit-K 10 Urocit-K 10 (Oral Tablet Extended Release) B 3

C1 Uro cit-K 15 Urocit-K 15 (Oral Tablet Extended Release) B 3

C1 Uro cit-K 5 Urocit-K 5 (Oral Tablet Extended Release) B 3 B1 Electrolyte/Mineral/Metal Modifiers

C1 Che met Chemet (Oral Capsule) B 4

C1 Clov ique Clovique (Oral Capsule) G 4 PA; QL

C1 Def eras irox Gra nule s Deferasirox Granules (Oral Packet) G 4 PA

C1 Def eras irox Deferasirox (Oral Tablet) (Generic Jadenu) G 4 PA

C1 Def eras irox Deferasirox (Oral Tablet Soluble) (Generic Exjade) G 4 PA

C1 Def eripr one Deferiprone (Oral Tablet) G 4 PA

C1 Exja de Exjade (Oral Tablet Soluble) B 4 PA

C1 Ferri prox Ferriprox (Oral Solution) B 4 PA

C1 Ferri prox Ferriprox (Oral Tablet) B 4 PA

C1 Jad enu Jadenu (Oral Tablet) B 4 PA 120 Last updated September 1, 2021

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

C1 Jad enu Spri nkle Jadenu Sprinkle (Oral Packet) B 4 PA

C1 Jyna rque Jynarque (Oral Tablet) B 4 PA

C1 Jyna rque Jynarque (Oral Tablet Therapy Pack) B 4 PA; QL

C1 Sam sca Samsca (Oral Tablet) B 4 PA

C1 Sypr ine Syprine (Oral Capsule) B 4 PA; QL

C1 Tolv apta n Tolvaptan (15MG Oral Tablet) B 4 PA

C1 Tolv apta n Tolvaptan (30MG Oral Tablet) G 4 PA

C1 Trie ntin e HCl Trientine HCl (Oral Capsule) G 4 PA; QL B1 Phosphate Binders

C1 Aury xia Auryxia (Oral Tablet) B 4 PA

C1 Calc ium Acet ate Calcium Acetate (Phosphate Binder) (Oral Capsule) G 2

C1 Calc ium Acet ate Calcium Acetate (Phosphate Binder) (Oral Tablet) G 2

C1 Fosr enol Fosrenol (Oral Packet) B 4

C1 Fosr enol Fosrenol (Oral Tablet Chewable) B 4

C1 Lant han um Car bon ate Lanthanum Carbonate (Oral Tablet Chewable) G 4

C1 Pho slyra Phoslyra (Oral Solution) B 2

C1 Ren agel Renagel (Oral Tablet) B 4

C1 Ren vela Renvela (Oral Packet) B 4

C1 Ren vela Renvela (Oral Tablet) B 4

C1 Sev ela mer Car bon ate Sevelamer Carbonate (Oral Packet) G 4

C1 Sev ela mer Car bon ate Sevelamer Carbonate (Oral Tablet) (Generic Renvela) G 2

C1 Sev ela mer HCl Sevelamer HCl (Oral Tablet) G 3

C1 Velp horo Velphoro (Oral Tablet Chewable) B 4 B1 Potassium Binders

C1 Lok elm a Lokelma (Oral Packet) B 3 QL

C1 Sodi um Poly styr ene Sulf onat e Sodium Polystyrene Sulfonate (Oral Powder) G 2

C1 SPS SPS (Oral Suspension) G 2

C1 Velt assa Veltassa (Oral Packet) B 4 QL B1 Vitamins

C1 VP- PNV - DHA VP-PNV-DHA (Oral Capsule) G 1 A1 Gastrointestinal Agents B1 Anti-Constipation Agents

C1 Amit iza Amitiza (Oral Capsule) B 2 QL

C1 Con stul ose Constulose (Oral Solution) G 1

C1 Enul ose Enulose (Oral Solution) G 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 121

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

C1 Gen erla c Generlac (Oral Solution) G 1

C1 Krist alos e Kristalose (Oral Packet) G 3

C1 Lact ulos e Lactulose (Oral Packet) G 3

C1 Lact ulos e Lactulose (10GM/15ML Oral Solution) G 1

C1 Linz ess Linzess (Oral Capsule) B 2 QL

C1 Lubi pros tone Lubiprostone (Oral Capsule) G 2 QL

C1 Mot egrit y Motegrity (Oral Tablet) B 3 ST; QL

C1 Mov anti k Movantik (Oral Tablet) B 3 PA; QL

C1 Reli stor Relistor (Oral Tablet) B 4 PA

C1 Reli stor Relistor (Subcutaneous Solution) B 4 PA

C1 Sym proi c Symproic (Oral Tablet) B 3 PA; QL

C1 Trul anc e Trulance (Oral Tablet) B 3 ST B1 Anti-Diarrheal Agents

C1 Alos etro n HCl Alosetron HCl (Oral Tablet) G 4 PA

C1 Diph eno xylat e- Atro pine Diphenoxylate-Atropine (Oral Liquid) G 3 PA; HRM

C1 Diph eno xylat e- Atro pine Diphenoxylate-Atropine (Oral Tablet) G 3 PA; HRM

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

C1 Lop era mid e HCl Loperamide HCl (Oral Capsule) G 1

C1 Lotr one x Lotronex (Oral Tablet) B 4 PA

C1 Myt esi Mytesi (Oral Tablet Delayed Release) B 3 PA

C1 Vibe rzi Viberzi (Oral Tablet) B 4 PA; QL

C1 Xer mel o Xermelo (Oral Tablet) B 4 PA; LA; QL B1 Antispasmodics, Gastrointestinal

C1 Chlo rdia zep oxid e- Clidi niu m Chlordiazepoxide-Clidinium (Oral Capsule) G 1 HRM

C1 Cuv pos a Cuvposa (Oral Solution) B 3 PA

C1 Dicy clo min e HCl Dicyclomine HCl (Oral Capsule) G 1 HRM

C1 Dicy clo min e HCl Dicyclomine HCl (Oral Solution) G 3 HRM

C1 Dicy clo min e HCl Dicyclomine HCl (Oral Tablet) G 1 HRM

C1 Glyc opyr rolat e Glycopyrrolate (1MG Oral Tablet, 2MG Oral Tablet) G 2 PA

C1 Libr ax Librax (Oral Capsule) B 3 HRM

C1 Met hsc opol ami ne Bro mid e Methscopolamine Bromide (Oral Tablet) G 3 B1 Gastrointestinal Agents, Other

C1 Am oxici llin- Clari thro myci n- Lan sopr azol e Amoxicillin-Clarithromycin-Lansoprazole (Oral) G 3

C1 Che nod al Chenodal (Oral Tablet) G 4 PA

C1 Clen piq Clenpiq (Oral Solution) B 2

C1 Gatt ex Gattex (Subcutaneous Kit) B 4 PA; LA

C1 Gavi Lyte -C GaviLyte-C (Oral Solution Reconstituted) G 1 122 Last updated September 1, 2021

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

C1 Gavi Lyte -G GaviLyte-G (Oral Solution Reconstituted) G 1

C1 Gavi Lyte -N with Flav or Pac k GaviLyte-N with Flavor Pack (Oral Solution G 1 Reconstituted)

C1 GoL YTE LY GoLYTELY (Oral Solution Reconstituted) B 3

C1 Heli dac Ther apy Helidac Therapy (Oral) G 4

C1 Mov iPre p MoviPrep (Oral Solution Reconstituted) B 3

C1 Myal ept Myalept (Subcutaneous Solution Reconstituted) B 4 PA; LA

C1 NuL YTE LY Lem on- Lim e NuLYTELY Lemon-Lime (Oral Solution Reconstituted) B 3

C1 Ocal iva Ocaliva (Oral Tablet) B 4 PA; QL

C1 Om ecla mox -Pak Omeclamox-Pak (Oral) B 4

C1 Os moP rep OsmoPrep (Oral Tablet) B 3

C1 PEG -335 0- NaC l-Na Bica rbon ate- KCl PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution) G 1 (Generic NuLYTELY)

C1 PEG -335 0- Elec troly tes PEG-3350-Electrolytes (Oral Solution) (Generic G 1 GoLYTELY)

C1 PEG -KCl- NaC l- NaS ulf- Na Asc- C PEG-KCl-NaCl-NaSulf-Na Asc-C (Oral Solution G 3 Reconstituted) (Generic MoviPrep)

C1 Plen vu Plenvu (Oral Solution Reconstituted) B 3

C1 Pyle ra Pylera (Oral Capsule) B 4

C1 Relt one Reltone (Oral Capsule) G 4

C1 Sup rep Bow el Pre p Kit Suprep Bowel Prep Kit (Oral Solution) B 2

C1 Suta b Sutab (Oral Tablet) B 3

C1 Talic ia Talicia (Oral Capsule Delayed Release) B 3

C1 TriL yte TriLyte (420GM Oral Solution Reconstituted) G 1

C1 Urs o 250 Urso 250 (Oral Tablet) B 3

C1 Urs o Fort e Urso Forte (Oral Tablet) B 3

C1 Urs odio l Ursodiol (Oral Capsule) G 2

C1 Urs odio l Ursodiol (Oral Tablet) G 3 B1 Histamine2 (H2) Receptor Antagonists

C1 Cim etidi ne HCl Cimetidine HCl (300MG/5ML Oral Solution) G 2

C1 Cim etidi ne Cimetidine (Oral Tablet) G 2

C1 Fam otidi ne Famotidine (Oral Suspension Reconstituted) G 3

C1 Fam otidi ne Famotidine (20MG Oral Tablet, 40MG Oral Tablet) G 1

C1 Niza tidin e Nizatidine (Oral Capsule) G 2

C1 Niza tidin e Nizatidine (Oral Solution) G 3

C1 Pep cid Pepcid (20MG Oral Tablet) G 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 123

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

C1 Pep cid Pepcid (40MG Oral Tablet) G 4 B1 Protectants

C1 Cara fate Carafate (Oral Suspension) B 3

C1 Cara fate Carafate (Oral Tablet) B 3

C1 Cyto tec Cytotec (Oral Tablet) B 3

C1 Mis opr osto l Misoprostol (Oral Tablet) G 2

C1 Sucr alfat e Sucralfate (Oral Suspension) G 3

C1 Sucr alfat e Sucralfate (Oral Tablet) G 1 B1 Proton Pump Inhibitors

C1 Acip hex Aciphex (Oral Tablet Delayed Release) B 3

C1 Dexi lant Dexilant (Oral Capsule Delayed Release) B 3 QL

C1 Eso mep razo le Mag nesi um Esomeprazole Magnesium (Oral Capsule Delayed G 2 QL Release) (Generic Nexium)

C1 Eso mep razo le Mag nesi um Esomeprazole Magnesium (Oral Packet) G 2

C1 Lan sopr azol e Lansoprazole (Oral Capsule Delayed Release) G 2 QL

C1 Lan sopr azol e ODT Lansoprazole ODT (Oral Tablet Delayed Release G 3 Dispersible)

C1 Nexi um Nexium (20MG Oral Capsule Delayed Release, 40MG B 2 QL Oral Capsule Delayed Release)

C1 Nexi um Nexium (10MG Oral Packet, 2.5MG Oral Packet,

20MG Oral Packet, 40MG Oral Packet, 5MG Oral B 2 Packet)

C1 Om epra zole Omeprazole (10MG Oral Capsule Delayed Release) G 1 QL

C1 Om epra zole Omeprazole (20MG Oral Capsule Delayed Release, G 1 40MG Oral Capsule Delayed Release)

C1 Om epra zole- Sodi um Bica rbon ate Omeprazole-Sodium Bicarbonate (Oral Capsule) G 3 PA

C1 Om epra zole- Sodi um Bica rbon ate Omeprazole-Sodium Bicarbonate (Oral Packet) G 4 PA

C1 Pant opra zole

Sodi um Pantoprazole Sodium (Oral Packet) G 3 ST

C1 Pant opra zole

Sodi um Pantoprazole Sodium (Oral Tablet Delayed Release) G 1 QL

C1 Prev acid Prevacid (Oral Capsule Delayed Release) B 3 QL

C1 Prev acid

Solu Tab Prevacid SoluTab (Oral Tablet Delayed Release B 3 Dispersible)

C1 Prilo sec Prilosec (Oral Packet) B 3 PA

C1 Prot onix Protonix (Oral Packet) B 3 ST

C1 Prot onix Protonix (Oral Tablet Delayed Release) B 3 QL

C1 Rab epra zole

Sodi um Rabeprazole Sodium (Oral Tablet Delayed Release) G 2

C1 Zeg erid Zegerid (Oral Capsule) B 4 PA

C1 Zeg erid Zegerid (Oral Packet) B 4 PA 124 Last updated September 1, 2021

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

A1 Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment B1 Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment

C1 Aral ast NP Aralast NP (1000MG Intravenous Solution B 4 PA; LA Reconstituted)

C1 Bup hen yl Buphenyl (Oral Powder) B 4

C1 Bup hen yl Buphenyl (Oral Tablet) B 4

C1 Car nitor Carnitor (Oral Solution) B 3

C1 Car nitor Carnitor (Oral Tablet) B 3

C1 Cer delg a Cerdelga (Oral Capsule) B 4 PA

C1 Chol bam Cholbam (Oral Capsule) B 4 PA

C1 Cre on Creon (Oral Capsule Delayed Release Particles) B 2

C1 Cro mol yn Sodi um Cromolyn Sodium (Oral Concentrate) G 2

C1 Cyst ada ne Cystadane (Oral Powder) B 4

C1 Cyst ago n Cystagon (Oral Capsule) B 3 LA

C1 Evry sdi Evrysdi (Oral Solution Reconstituted) B 4 PA; LA; QL

C1 Gala fold Galafold (Oral Capsule) B 4 LA

C1 Gast rocr om Gastrocrom (Oral Concentrate) B 4

C1 Glas sia Glassia (Intravenous Solution) B 4 PA; LA

C1 Kev eyis Keveyis (Oral Tablet) B 4 PA; QL

C1 Kuv an Kuvan (Oral Packet) B 4 LA

C1 Kuv an Kuvan (Oral Tablet) B 4 LA

C1 Lev ocar nitin e Levocarnitine (1GM/10ML Oral Solution) G 3

C1 Lev ocar nitin e Levocarnitine (330MG Oral Tablet) B 2

C1 Migl usta t Miglustat (Oral Capsule) G 4 PA; LA

C1 Nitis inon e Nitisinone (Oral Capsule) G 4

C1 Nityr Nityr (Oral Tablet) B 4 LA

C1 Orfa din Orfadin (Oral Capsule) B 4 LA

C1 Orfa din Orfadin (Oral Suspension) B 4 LA

C1 Paly nziq Palynziq (Subcutaneous Solution Prefilled Syringe) B 4 PA; QL

C1 Pan crea ze Pancreaze (10500-35500UNIT Oral Capsule Delayed Release Particles, 2600-8800UNIT Oral Capsule B 3 ST Delayed Release Particles, 4200-14200UNIT Oral Capsule Delayed Release Particles)

C1 Pan crea ze Pancreaze (16800-56800UNIT Oral Capsule Delayed Release Particles, 21000-54700UNIT Oral Capsule B 4 ST Delayed Release Particles)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 125

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

C1 Pert zye Pertzye (16000-57500UNIT Oral Capsule Delayed Release Particles, 24000-86250UNIT Oral Capsule B 4 ST Delayed Release Particles)

C1 Pert zye Pertzye (4000-14375UNIT Oral Capsule Delayed Release Particles, 8000-28750UNIT Oral Capsule B 3 ST Delayed Release Particles)

C1 Proc ysbi Procysbi (Oral Packet) B 4 LA

C1 Prol astin -C Prolastin-C (Intravenous Solution Reconstituted) B 4 PA; LA

C1 RAV ICTI RAVICTI (Oral Liquid) B 4 LA

C1 Sapr opte rin Dihy droc hlori de Sapropterin Dihydrochloride (Oral Packet) G 4

C1 Sapr opte rin Dihy droc hlori de Sapropterin Dihydrochloride (Oral Tablet) G 4

C1 Sodi um Phe nylb utyr ate Sodium Phenylbutyrate (Oral Powder) G 4

C1 Sodi um Phe nylb utyr ate Sodium Phenylbutyrate (Oral Tablet) G 4

C1 Sucr aid Sucraid (Oral Solution) B 4 LA

C1 Teg sedi Tegsedi (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA

C1 Viok ace Viokace (10440-39150UNIT Oral Tablet) B 3 ST

C1 Viok ace Viokace (20880-78300UNIT Oral Tablet) B 4 ST

C1 Vyn dam ax Vyndamax (Oral Capsule) B 4 PA; LA; QL

C1 Vyn daq el Vyndaqel (Oral Capsule) B 4 PA; LA; QL

C1 Xuri den Xuriden (Oral Packet) B 4 PA; LA

C1 Zav esca Zavesca (Oral Capsule) B 4 PA; LA

C1 Zem aira Zemaira (Intravenous Solution Reconstituted) B 4 PA; LA

C1 Zen pep Zenpep (Oral Capsule Delayed Release Particles) B 2 A1 Genitourinary Agents B1 Antispasmodics, Urinary

C1 Darif ena cin Hyd robr omi de ER Darifenacin Hydrobromide ER (Oral Tablet Extended G 3 ST; QL Release 24 Hour)

C1 Detr ol LA Detrol LA (Oral Capsule Extended Release 24 Hour) B 3

C1 Detr ol Detrol (Oral Tablet) B 3

C1 Ditr opa n XL Ditropan XL (Oral Tablet Extended Release 24 Hour) B 3

C1 Flav oxat e HCl Flavoxate HCl (Oral Tablet) G 2

C1 Geln ique Gelnique (Transdermal Gel) B 3

C1 Ge mte sa Gemtesa (Oral Tablet) B 3 ST

C1 Myr betri q Myrbetriq (Oral Tablet Extended Release 24 Hour) B 2

C1 Oxy buty nin Chlo ride ER Oxybutynin Chloride ER (Oral Tablet Extended Release G 2 24 Hour)

C1 Oxy buty nin Chlo ride Oxybutynin Chloride (Oral Syrup) G 1

C1 Oxy buty nin Chlo ride Oxybutynin Chloride (Oral Tablet Immediate Release) G 1 126 Last updated September 1, 2021

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

C1 Oxyt rol Oxytrol (Transdermal Patch Twice Weekly) B 4

C1 Solif ena cin Suc cina te Solifenacin Succinate (Oral Tablet) G 2 QL

C1 Tolt erod ine Tartr ate ER Tolterodine Tartrate ER (Oral Capsule Extended Release G 3 24 Hour)

C1 Tolt erod ine Tartr ate Tolterodine Tartrate (Oral Tablet) G 2

C1 Tovi az Toviaz (Oral Tablet Extended Release 24 Hour) B 3 ST; QL

C1 Tros piu m Chlo ride ER Trospium Chloride ER (Oral Capsule Extended Release G 3 24 Hour)

C1 Tros piu m Chlo ride Trospium Chloride (Oral Tablet) G 2

C1 Vesi care LS Vesicare LS (Oral Suspension) B 3 PA; QL

C1 Vesi care Vesicare (Oral Tablet) B 3 QL B1 Benign Prostatic Hypertrophy Agents

C1 Alfu zosi n HCl ER Alfuzosin HCl ER (Oral Tablet Extended Release 24 G 1 Hour)

C1 Avo dart Avodart (Oral Capsule) B 3

C1 Car dura XL Cardura XL (Oral Tablet Extended Release 24 Hour) B 3 QL

C1 Ciali s Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) B 3 PA; QL

C1 Duta steri de Dutasteride (Oral Capsule) G 2

C1 Duta steri de- Tam sulo sin HCl Dutasteride-Tamsulosin HCl (Oral Capsule) G 3

C1 Fina steri de Finasteride (5MG Oral Tablet) (Generic Proscar) G 1

C1 Flo max Flomax (Oral Capsule) B 3

C1 Jaly n Jalyn (Oral Capsule) B 3

C1 Pros car Proscar (Oral Tablet) B 3

C1 Rap aflo Rapaflo (Oral Capsule) B 3 ST; QL

C1 Silo dosi n Silodosin (Oral Capsule) G 2 QL

C1 Tad alafil Tadalafil (2.5MG Oral Tablet, 5MG Oral Tablet) G 3 PA; QL

C1 Tam sulo sin HCl Tamsulosin HCl (Oral Capsule) G 1

C1 Tera zosi n HCl Terazosin HCl (Oral Capsule) G 1

C1 Uro xatr al Uroxatral (Oral Tablet Extended Release 24 Hour) B 3 B1 Genitourinary Agents, Other

C1 Beth ane chol

Chlo ride Bethanechol Chloride (10MG Oral Tablet, 25MG Oral G 2 Tablet, 5MG Oral Tablet)

C1 Beth ane chol

Chlo ride Bethanechol Chloride (50MG Oral Tablet) G 3

C1 Cup rimi ne Cuprimine (Oral Capsule) B 4 PA

C1 Dep en Titra tabs Depen Titratabs (Oral Tablet) B 4

C1 Elmi ron Elmiron (Oral Capsule) B 4

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 127

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

C1 Lith osta t Lithostat (Oral Tablet) B 4

C1 Peni cilla min e Penicillamine (250MG Oral Capsule) G 4 PA

C1 Peni cilla min e Penicillamine (250MG Oral Tablet) G 4

C1 Thio la EC Thiola EC (Oral Tablet Delayed Release) B 4 LA

C1 Thio la Thiola (Oral Tablet Immediate Release) B 4 LA

C1 Tiop roni n Tiopronin (Oral Tablet) G 4 A1 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) B1 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

C1 Acth ar Acthar (Injection Gel) B 4 PA; LA

C1 Alki ndi Spri nkle Alkindi Sprinkle (Oral Capsule Sprinkle) B 4

C1 Cort ef Cortef (Oral Tablet) B 3

C1 Dex ablis s Dexabliss (Oral Tablet Therapy Pack) G 3

C1 Dex ame thas one Dexamethasone (Oral Elixir) G 1

C1 Dex ame thas one Dexamethasone (Oral Tablet) G 1

C1 Dex ame thas one Dexamethasone (Oral Tablet Therapy Pack) G 3

C1 Emfl aza Emflaza (Oral Suspension) B 4 PA; LA

C1 Emfl aza Emflaza (Oral Tablet) B 4 PA; LA

C1 Flud roco rtiso ne Acet ate Fludrocortisone Acetate (Oral Tablet) G 1

C1 He mad y Hemady (Oral Tablet) B 3

C1 Hyd roco rtiso ne Hydrocortisone (Oral Tablet) G 1

C1 Med rol Medrol (Oral Tablet) B 3

C1 Med rol Medrol (Oral Tablet Therapy Pack) B 3

C1 Met hylp redn isol one Methylprednisolone (Oral Tablet) G 1

C1 Met hylp redn isol one Methylprednisolone (Oral Tablet Therapy Pack) G 1

C1 Milli pred Millipred (Oral Tablet) G 3

C1 Ora pred

ODT Orapred ODT (Oral Tablet Dispersible) B 3

C1 Pre dnis olon e Prednisolone (Oral Solution) G 1

C1 Pre dnis olon e Sodi um Pho sph ate Prednisolone Sodium Phosphate (10MG/5ML Oral Solution, 20MG/5ML Oral Solution, 25MG/5ML Oral G 3 Solution, 6.7MG/5ML Oral Solution)

C1 Pre dnis olon e Sodi um Pho sph ate ODT Prednisolone Sodium Phosphate ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 30MG G 3 Oral Tablet Dispersible)

C1 Pre dnis one Inte nsol Prednisone Intensol (Oral Concentrate) G 3

C1 Pre dnis one Prednisone (5MG/5ML Oral Solution) G 3

C1 Pre dnis one Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG G 1 Oral Tablet) 128 Last updated September 1, 2021

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

C1 Pre dnis one Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG (48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet G 1 Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)

C1 Ray os Rayos (Oral Tablet Delayed Release) B 4 PA

C1 Tap erD ex 12- Day TaperDex 12-Day (Oral Tablet Therapy Pack) G 3

C1 Tap erD ex 6- Day TaperDex 6-Day (Oral Tablet Therapy Pack) G 3

C1 Tap erD ex 7- Day TaperDex 7-Day (Oral Tablet Therapy Pack) G 3 A1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) B1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

C1 DDA VP DDAVP (0.1MG Oral Tablet) B 3

C1 DDA VP DDAVP (0.2MG Oral Tablet) B 4

C1 Des mop ressi n Acet ate Desmopressin Acetate (Oral Tablet) G 2

C1 Des mop ressi n Acet ate Spra y Desmopressin Acetate Spray (Nasal Solution) G 3

C1 Egrif ta SV Egrifta SV (2MG Subcutaneous Solution B 4 PA; LA Reconstituted)

C1 Gen otro pin Mini Quic k Genotropin MiniQuick (Subcutaneous Solution B 4 PA Reconstituted)

C1 Gen otro pin Genotropin (12MG Subcutaneous Solution B 4 PA Reconstituted)

C1 Gen otro pin Genotropin (5MG Subcutaneous Solution B 3 PA Reconstituted)

C1 Hu matr ope Humatrope (Injection Solution Renconstituted), B 4 PA Humatrope Combo Pack (Injection)

C1 Incr elex Increlex (Subcutaneous Solution) B 4 PA; LA

C1 Noc durn a Nocdurna (Tablet Sublingual) B 3 PA

C1 Nor ditro pin Flex Pro Norditropin FlexPro (Subcutaneous Solution Pen- B 4 PA Injector)

C1 Nutr opin AQ NuS pin 10 Nutropin AQ NuSpin 10 (Subcutaneous Solution Pen- B 4 PA Injector)

C1 Nutr opin AQ NuS pin 20 Nutropin AQ NuSpin 20 (Subcutaneous Solution Pen- B 4 PA Injector)

C1 Nutr opin AQ NuS pin 5 Nutropin AQ NuSpin 5 (Subcutaneous Solution Pen- B 4 PA Injector)

C1 Om nitro pe Omnitrope (Subcutaneous Solution Cartridge) B 4 PA

C1 Om nitro pe Omnitrope (Subcutaneous Solution Reconstituted) B 4 PA

C1 Saiz en Saizen (Injection Solution Reconstituted) B 4 PA; LA

C1 Saiz enpr ep Saizenprep (Injection Solution Reconstituted) B 4 PA; LA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 129

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

C1 Ser osti m Serostim (Subcutaneous Solution Reconstituted) B 4 PA; LA

C1 Zom acto n Zomacton (10MG Subcutaneous Solution B 4 PA Reconstituted)

C1 Zom acto n Zomacton (5MG Subcutaneous Solution B 3 PA Reconstituted)

C1 Zor btiv e Zorbtive (Subcutaneous Solution Reconstituted) B 4 PA; LA A1 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) B1 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

C1 Korl ym Korlym (Oral Tablet) B 4 PA; LA A1 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) B1 Anabolic Steroids

C1 Oxa ndro lone Oxandrolone (10MG Oral Tablet) G 3

C1 Oxa ndro lone Oxandrolone (2.5MG Oral Tablet) G 2 B1

C1 And rode rm Androderm (Transdermal Patch 24 Hour) B 2

C1 And roG el Pum p AndroGel Pump (Transdermal Gel) B 4

C1 And roG el AndroGel (Transdermal Gel) B 4

C1 Ave ed Aveed (Intramuscular Solution) B 3 PA

C1 Dan azol Danazol (Oral Capsule) G 3

C1 Dep o- Test oste rone Depo-Testosterone (Intramuscular Solution) G 3

C1 Fort esta Fortesta (Transdermal Gel) B 3

C1 Intra rosa Intrarosa (Vaginal Insert) B 3 PA; QL

C1 Jate nzo Jatenzo (158MG Oral Capsule, 198MG Oral Capsule) B 3 PA

C1 Jate nzo Jatenzo (237MG Oral Capsule) B 4 PA

C1 Met hite st Methitest (Oral Tablet) G 4 PA

C1 Met hylt esto ster one Methyltestosterone (Oral Capsule) G 4 PA

C1 Nat esto Natesto (Nasal Gel) B 3

C1 Test im Testim (Transdermal Gel) B 4

C1 Test oste rone

Cypi onat e Testosterone Cypionate (Intramuscular Solution) G 1

C1 Test oste rone

Ena ntha te Testosterone Enanthate (Intramuscular Solution) G 2

C1 Test oste rone

Pum p Testosterone Pump (2% Transdermal Gel, 1% Transdermal Gel, 1.62% Transdermal Gel), Testosterone (20.25 MG/1.25GM 1.62% Transdermal Gel, 25 MG/ G 3 2.5GM 1% Transdermal Gel, 40.5 MG/2.5GM 1.62% Transdermal Gel, 50 MG/5GM 1% Transdermal Gel)

C1 Test oste rone Testosterone (Transdermal Solution) G 3

C1 Vog elxo

Pum p Vogelxo Pump (Transdermal Gel) B 3

C1 Vog elxo Vogelxo (Transdermal Gel) B 3 130 Last updated September 1, 2021

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

C1 Xyo sted Xyosted (Subcutaneous Solution Auto-Injector) B 3 PA B1

C1 Alor a Alora (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL

C1 Alta vera Altavera (Oral Tablet) G 3

C1 Alya cen 1/35 Alyacen 1/35 (Oral Tablet) G 3

C1 Ame thia Amethia (Oral Tablet) G 3

C1 Ann over a Annovera (Vaginal Ring) B 3 QL

C1 Apri Apri (Oral Tablet) G 3

C1 Aran elle Aranelle (Oral Tablet) G 3

C1 Ashl yna Ashlyna (Oral Tablet) G 3

C1 Aub ra EQ Aubra EQ (Oral Tablet) G 3

C1 Avia ne Aviane (Oral Tablet) G 3

C1 Balc oltra Balcoltra (Oral Tablet) B 3

C1 Balz iva Balziva (Oral Tablet) G 3

C1 Bey az Beyaz (Oral Tablet) B 3

C1 Blis ovi 24 Fe Blisovi 24 Fe (Oral Tablet) G 3

C1 Blis ovi Fe 1.5/ 30 Blisovi Fe 1.5/30 (Oral Tablet) G 3

C1 Briel lyn Briellyn (Oral Tablet) G 3

C1 Cam rese Lo Camrese Lo (Oral Tablet) G 3

C1 Cazi ant Caziant (Oral Tablet) G 3

C1 Clim ara Pro Climara Pro (Transdermal Patch Weekly) B 3 PA; HRM

C1 Crys elle- 28 Cryselle-28 (Oral Tablet) G 3

C1 Cycl afe m 1/35 Cyclafem 1/35 (Oral Tablet) G 3

C1 Cycl afe m 7/7/ 7 Cyclafem 7/7/7 (Oral Tablet) G 3

C1 Cyre d EQ Cyred EQ (Oral Tablet) G 3

C1 Dele stro gen Delestrogen (Intramuscular Oil) B 3

C1 Dep o- Estr adio l Depo-Estradiol (Intramuscular Oil) G 3

C1 Des oge strel - Ethi nyl Estr adio l Desogestrel-Ethinyl Estradiol (Oral Tablet) G 3

C1 Doli shal e Dolishale (Oral Tablet) G 3

C1 Dott i Dotti (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL

C1 Dro spir eno ne- Ethi nyl Estr adio l Drospirenone-Ethinyl Estradiol (Oral Tablet) G 3

C1 Dro spir eno ne- Ethi nyl Estr adio l- Lev ome Drospirenone-Ethinyl Estradiol-Levomefolate folat e G 3 (3-0.02-0.451MG Oral Tablet)

C1 Eles trin Elestrin (Transdermal Gel) B 3 PA; HRM

C1 Elu Ryn g EluRyng (Vaginal Ring) G 3

C1 Emo quet te Emoquette (Oral Tablet) G 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 131

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

C1 Enp ress e-28 Enpresse-28 (Oral Tablet) G 3

C1 Ens kyce Enskyce (Oral Tablet) G 3

C1 Esta rylla Estarylla (Oral Tablet) G 3

C1 Estr ace Estrace (Oral Tablet) G 3 PA; HRM

C1 Estr ace Estrace (Vaginal Cream) G 3

C1 Estr adio l Estradiol (Oral Tablet) G 3 PA; HRM

C1 Estr adio l Estradiol (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL

C1 Estr adio l Estradiol (Vaginal Cream) G 3

C1 Estr adio l Estradiol (Vaginal Tablet) G 3

C1 Estr adio l Vale rate Estradiol Valerate (Intramuscular Oil) G 2

C1 Estri ng Estring (Vaginal Ring) B 3

C1 Ethy nodi ol Diac etat e- Ethi nyl Estr adio l Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet) G 3

C1 Eton oge strel - Ethi nyl Estr adio l Etonogestrel-Ethinyl Estradiol (Vaginal Ring) G 3

C1 Fal min a Falmina (Oral Tablet) G 3

C1 Fay osi m Fayosim (Oral Tablet) G 3

C1 Fem ring Femring (Vaginal Ring) B 3

C1 Fem ynor Femynor (Oral Tablet) G 3

C1 Fyav olv Fyavolv (Oral Tablet) G 3 PA; HRM

C1 Ge mmi ly Gemmily (Oral Capsule) G 3

C1 Gen eres s Fe Generess Fe (Oral Tablet Chewable) B 3

C1 Hail ey 24 Fe Hailey 24 Fe (Oral Tablet) G 3

C1 Iclev ia Iclevia (Oral Tablet) G 3

C1 Imv exxy

Mai nten anc e Pac k Imvexxy Maintenance Pack (Vaginal Insert) B 2 PA

C1 Imv exxy

Start er Pac k Imvexxy Starter Pack (Vaginal Insert) B 2 PA

C1 Intro vale Introvale (Oral Tablet) G 3

C1 Isibl oom Isibloom (Oral Tablet) G 3

C1 Jas miel Jasmiel (Oral Tablet) G 3

C1 Jint eli Jinteli (Oral Tablet) G 3 PA; HRM

C1 Jule ber Juleber (Oral Tablet) G 3

C1 Jun el 1.5/ 30 Junel 1.5/30 (Oral Tablet) G 3

C1 Jun el 1/20 Junel 1/20 (Oral Tablet) G 3

C1 Jun el Fe 1.5/ 30 Junel Fe 1.5/30 (Oral Tablet) G 3

C1 Jun el Fe 1/20 Junel Fe 1/20 (Oral Tablet) G 3

C1 Jun el Fe 24 Junel Fe 24 (Oral Tablet) G 3

C1 Kaitl ib Fe Kaitlib Fe (Oral Tablet Chewable) G 3

C1 Kari va Kariva (Oral Tablet) G 3

C1 Keln or 1/35 Kelnor 1/35 (Oral Tablet) G 3 132 Last updated September 1, 2021

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

C1 Keln or 1/50 Kelnor 1/50 (Oral Tablet) G 3

C1 Kurv elo Kurvelo (Oral Tablet) G 3

C1 LAR IN 1.5/ 30 LARIN 1.5/30 (Oral Tablet) G 3

C1 LAR IN 1/20 LARIN 1/20 (Oral Tablet) G 3

C1 LAR IN Fe 1.5/ 30 LARIN Fe 1.5/30 (Oral Tablet) G 3

C1 LAR IN Fe 1/20 LARIN Fe 1/20 (Oral Tablet) G 3

C1 Lari ssia Larissia (Oral Tablet) G 3

C1 Lay olis Fe Layolis Fe (Oral Tablet Chewable) B 3

C1 Lee na Leena (Oral Tablet) G 3

C1 Less ina Lessina (Oral Tablet) G 3

C1 Lev one st Levonest (Oral Tablet) G 3

C1 Lev onor gest rel- Ethi nyl Estr adio l & Ethi nyl Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral Estr adio l G 3 Tablet)

C1 Lev onor gest rel- Ethi nyl Estr adio l 91- Day Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet) G 3

C1 Lev onor gest rel- Ethi nyl Estr adio l Levonorgestrel-Ethinyl Estradiol (Oral Tablet) G 3

C1 Lev ora 0.15 /30 Levora 0.15/30 (28) (Oral Tablet) G 3

C1 Lo Loe strin Fe Lo Loestrin Fe (Oral Tablet) B 3

C1 Loe strin

1.5/ 30 Loestrin 1.5/30 (21) (Oral Tablet) G 3

C1 Loe strin

1/20 Loestrin 1/20 (21) (Oral Tablet) G 3

C1 Loe strin Fe 1.5/ 30 Loestrin Fe 1.5/30 (Oral Tablet) G 3

C1 Loe strin Fe 1/20 Loestrin Fe 1/20 (Oral Tablet) G 3

C1 Lory na Loryna (Oral Tablet) G 3

C1 LoS eas oniq ue LoSeasonique (Oral Tablet) B 3

C1 Low - Oge strel Low-Ogestrel (Oral Tablet) G 3

C1 Lute ra Lutera (Oral Tablet) G 3

C1 Lylla na Lyllana (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL

C1 Marl issa Marlissa (Oral Tablet) G 3

C1 Men est Menest (Oral Tablet) G 3 PA; HRM

C1 Mer zee Merzee (Oral Capsule) B 3

C1 Mib elas 24 Fe Mibelas 24 Fe (Oral Tablet Chewable) G 3

C1 Micr oge stin 1.5/ 30 Microgestin 1.5/30 (Oral Tablet) G 3

C1 Micr oge stin 1/20 Microgestin 1/20 (Oral Tablet) G 3

C1 Micr oge stin Fe 1.5/ 30 Microgestin Fe 1.5/30 (Oral Tablet) G 3

C1 Micr oge stin Fe 1/20 Microgestin Fe 1/20 (Oral Tablet) G 3

C1 Mili Mili (Oral Tablet) G 3

C1 Min astri n 24 Fe Minastrin 24 Fe (Oral Tablet Chewable) B 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 133

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

C1 Mini velle Minivelle (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL

C1 Nata zia Natazia (Oral Tablet) B 3

C1 Nec on 0.5/ 35 Necon 0.5/35 (28) (Oral Tablet) G 3

C1 Next stelli s Nextstellis (Oral Tablet) B 3

C1 Nikk i Nikki (Oral Tablet) G 3

C1 Nor ethi ndro ne Acet ate- Ethi nyl Estr adio l Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG G 3 PA; HRM Oral Tablet, 1-5MG-MCG Oral Tablet)

C1 Nor ethi ndro ne Acet ate- Ethi nyl Estr adio l Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG G 3 Oral Tablet)

C1 Nor ethi ndro ne Acet ate- Ethi nyl Estr adio l-Fe Norethindrone Acetate-Ethinyl Estradiol-Fe (1-20MG- G 3 MCG Oral Tablet)

C1 Nor ethi ndro ne Acet ate- Ethi nyl Estr adio l-Fe Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG- MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet G 3 Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)

C1 Nor gest imat e- Ethi nyl Estr adio l Norgestimate-Ethinyl Estradiol (Oral Tablet) G 3

C1 Nor gest imat e- Ethi nyl Estr adio l Trip hasi Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet) G 3 c

C1 Nort rel 0.5/ 35 Nortrel 0.5/35 (28) (Oral Tablet) G 3

C1 Nort rel 1/35 Nortrel 1/35 (21) (Oral Tablet) G 3

C1 Nort rel 1/35 Nortrel 1/35 (28) (Oral Tablet) G 3

C1 Nort rel 7/7/ 7 Nortrel 7/7/7 (Oral Tablet) G 3

C1 Nuv aRin g NuvaRing (Vaginal Ring) B 3

C1 Nyli a 7/7/ 7 Nylia 7/7/7 (Oral Tablet) G 3

C1 Nym yo Nymyo (Oral Tablet) G 3

C1 Ocel la Ocella (Oral Tablet) G 3

C1 Orsy thia Orsythia (Oral Tablet) G 3

C1 Pimt rea Pimtrea (Oral Tablet) G 3

C1 Pirm ella 1/35 Pirmella 1/35 (Oral Tablet) G 3

C1 Porti a-28 Portia-28 (Oral Tablet) G 3

C1 Pre mari n Premarin (Vaginal Cream) B 2

C1 Prev ifem Previfem (Oral Tablet) G 3

C1 Qua rtett e Quartette (Oral Tablet) B 3

C1 Recl ipse n Reclipsen (Oral Tablet) G 3

C1 Rive lsa Rivelsa (Oral Tablet) G 3

C1 Safy ral Safyral (Oral Tablet) B 3

C1 Sea soni que Seasonique (Oral Tablet) B 3

C1 Setl akin Setlakin (Oral Tablet) G 3

C1 Spri ntec 28 Sprintec 28 (Oral Tablet) G 3

C1 Sro nyx Sronyx (Oral Tablet) G 3 134 Last updated September 1, 2021

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

C1 Sye da Syeda (Oral Tablet) G 3

C1 Tari na 24 Fe Tarina 24 Fe (Oral Tablet) G 3

C1 Tari na Fe 1/20 EQ Tarina Fe 1/20 EQ (Oral Tablet) G 3

C1 Tilia Fe Tilia Fe (Oral Tablet) G 3

C1 Tri- Esta rylla Tri-Estarylla (Oral Tablet) G 3

C1 Tri- Leg est Fe Tri-Legest Fe (Oral Tablet) G 3

C1 Tri- Lo- Esta rylla Tri-Lo-Estarylla (Oral Tablet) G 3

C1 Tri- Lo- Spri ntec Tri-Lo-Sprintec (Oral Tablet) G 3

C1 Tri- Mili Tri-Mili (Oral Tablet) G 3

C1 Tri- Nym yo Tri-Nymyo (Oral Tablet) G 3

C1 Tri- Prev ifem Tri-Previfem (Oral Tablet) G 3

C1 Tri- Spri ntec Tri-Sprintec (Oral Tablet) G 3

C1 Triv ora Trivora (28) (Oral Tablet) G 3

C1 Tri- VyLi bra Lo Tri-VyLibra Lo (Oral Tablet) G 3

C1 Tri- VyLi bra Tri-VyLibra (Oral Tablet) G 3

C1 Tyd emy Tydemy (Oral Tablet) G 3

C1 Vagi fem Vagifem (Vaginal Tablet) B 3

C1 Veli vet Velivet (Oral Tablet) G 3

C1 Vest ura Vestura (Oral Tablet) G 3

C1 Vien va Vienva (Oral Tablet) G 3

C1 Vive lle- Dot Vivelle-Dot (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL

C1 Vyfe mla Vyfemla (Oral Tablet) G 3

C1 VyLi bra VyLibra (Oral Tablet) G 3

C1 WY MZ YA Fe WYMZYA Fe (Oral Tablet Chewable) G 3

C1 Xula ne Xulane (Transdermal Patch Weekly) G 3

C1 Yas min 28 Yasmin 28 (Oral Tablet) B 3

C1 YAZ YAZ (Oral Tablet) B 3

C1 Yuv afe m Yuvafem (Vaginal Tablet) G 3

C1 Zafe my Zafemy (Transdermal Patch Weekly) G 3

C1 Zara h Zarah (Oral Tablet) G 3

C1 Zovi a 1/35 E Zovia 1/35E (28) (Oral Tablet) G 3 B1 Progestins

C1 Ayg esti n Aygestin (Oral Tablet) G 3

C1 Cam ila Camila (Oral Tablet) G 2

C1 Crin one Crinone (Vaginal Gel) B 3 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 135

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

C1 Debl itan e Deblitane (Oral Tablet) G 2

C1 Dep o- Prov era Depo-Provera (150MG/ML Intramuscular Suspension) B 3

C1 Dep o- Sub Q Prov era 104 Depo-SubQ Provera 104 (Subcutaneous Suspension B 3 Prefilled Syringe)

C1 Errin Errin (Oral Tablet) G 2

C1 Inca ssia Incassia (Oral Tablet) G 2

C1 Lyle q Lyleq (Oral Tablet) G 2

C1 Lyza Lyza (Oral Tablet) G 2

C1 Med roxy pro gest eron e Acet ate Medroxyprogesterone Acetate (Intramuscular G 1 Suspension)

C1 Med roxy pro gest eron e Acet ate Medroxyprogesterone Acetate (Intramuscular G 1 Suspension Prefilled Syringe)

C1 Med roxy pro gest eron e Acet ate Medroxyprogesterone Acetate (Oral Tablet) G 1

C1 Meg estr ol Acet ate Megestrol Acetate (40MG/ML Oral Suspension, 625MG/ G 3 PA; HRM 5ML Oral Suspension)

C1 Meg estr ol Acet ate Megestrol Acetate (Oral Tablet) G 3 PA; HRM

C1 Nor a-BE Nora-BE (Oral Tablet) G 2

C1 Nor ethi ndro ne Acet ate Norethindrone Acetate (5MG Oral Tablet) G 1

C1 Nor ethi ndro ne Norethindrone (0.35MG Oral Tablet) G 2

C1 Pro gest eron e Progesterone (Oral Capsule) G 2

C1 Pro metr ium Prometrium (Oral Capsule) B 3

C1 Prov era Provera (Oral Tablet) B 3

C1 Shar obel Sharobel (Oral Tablet) G 2

C1 Slyn d Slynd (Oral Tablet) B 3 B1 Selective Receptor Modifying Agents

C1 Evis ta Evista (Oral Tablet) B 3

C1 Osp hen a Osphena (Oral Tablet) B 2 PA; QL

C1 Ralo xife ne HCl Raloxifene HCl (Oral Tablet) G 2 A1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) B1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

C1 Cyto mel Cytomel (Oral Tablet) B 3

C1 Euth yrox Euthyrox (Oral Tablet) B 1

C1 Lev o-T Levo-T (Oral Tablet) B 1

C1 Lev othy roxi ne Sodi um Levothyroxine Sodium (Oral Capsule) G 3

C1 Lev othy roxi ne Sodi um Levothyroxine Sodium (Oral Tablet) G 1

C1 Lev oxyl Levoxyl (Oral Tablet) B 1

C1 Liot hyro nine

Sodi um Liothyronine Sodium (Oral Tablet) G 1 136 Last updated September 1, 2021

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

C1 Synt hroi d Synthroid (Oral Tablet) B 2

C1 Thy quid ity Thyquidity (Oral Solution) B 3

C1 Tiro sint Tirosint (Oral Capsule) B 3

C1 Tiro sint- SOL Tirosint-SOL (100MCG/ML Oral Solution, 112MCG/ ML Oral Solution, 125MCG/ML Oral Solution, 137MCG/ML Oral Solution, 13MCG/ML Oral Solution,

150MCG/ML Oral Solution, 175MCG/ML Oral B 3 Solution, 200MCG/ML Oral Solution, 25MCG/ML Oral Solution, 50MCG/ML Oral Solution, 75MCG/ML Oral Solution, 88MCG/ML Oral Solution)

C1 Unit hroi d Unithroid (Oral Tablet) B 1 A1 Hormonal Agents, Suppressant (Adrenal) B1 Hormonal Agents, Suppressant (Adrenal)

C1 Istur isa Isturisa (Oral Tablet) B 4 PA

C1 Lys odre n Lysodren (Oral Tablet) B 4 A1 Hormonal Agents, Suppressant (Pituitary) B1 Hormonal Agents, Suppressant (Pituitary)

C1 Cab ergo line Cabergoline (Oral Tablet) G 2

C1 Elig ard Eligard (Subcutaneous Kit) B 3 PA

C1 Firm ago n Firmagon (240MG Dose) (120MG/Vial Subcutaneous B 4 PA Solution Reconstituted)

C1 Firm ago n Firmagon (80MG Subcutaneous Solution B 3 PA Reconstituted)

C1 Leu proli de Acet ate Leuprolide Acetate (Injection Kit) G 3 PA

C1 Lup anet a Pac k Lupaneta Pack (Combination Kit) B 4 PA

C1 Lupr on Dep ot Lupron Depot (1-Month) (Intramuscular Kit) B 4 PA

C1 Lupr on Dep ot Lupron Depot (3-Month) (Intramuscular Kit) B 4 PA

C1 Lupr on Dep ot Lupron Depot (4-Month) (Intramuscular Kit) B 4 PA

C1 Lupr on Dep ot Lupron Depot (6-Month) (Intramuscular Kit) B 4 PA

C1 Myc apss a Mycapssa (Oral Capsule Delayed Release) B 4 PA; QL

C1 Octr eoti de Acet ate Octreotide Acetate (1000MCG/ML Injection Solution, G 4 PA 500MCG/ML Injection Solution)

C1 Octr eoti de Acet ate Octreotide Acetate (100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 50MCG/ML Injection G 3 PA Solution)

C1 Org ovyx Orgovyx (Oral Tablet) B 4 PA; QL

C1 Oria hnn Oriahnn (Oral Capsule Therapy Pack) B 4 PA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 137

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

C1 Orili ssa Orilissa (Oral Tablet) B 4 PA; QL

C1 San dost atin Sandostatin (Injection Solution) B 4 PA

C1 Sign ifor Signifor (Subcutaneous Solution) B 4 PA; LA

C1 Som aver t Somavert (Subcutaneous Solution Reconstituted) B 4 PA; LA; QL

C1 Syn arel Synarel (Nasal Solution) B 4

C1 Trel star Mixj ect Trelstar Mixject (Intramuscular Suspension B 4 PA Reconstituted) A1 Hormonal Agents, Suppressant (Thyroid) B1 Antithyroid Agents

C1 Met him azol e Methimazole (Oral Tablet) G 1

C1 Pro pylt hiou racil Propylthiouracil (Oral Tablet) G 1

C1 Tap azol e Tapazole (Oral Tablet) G 3 A1 Immunological Agents B1 Angioedema Agents

C1 Beri nert Berinert (Intravenous Kit) B 4 PA; LA

C1 Cinr yze Cinryze (Intravenous Solution Reconstituted) B 4 PA; LA

C1 Fira zyr Firazyr (Subcutaneous Solution) B 4 PA; QL

C1 Hae gard a Haegarda (Subcutaneous Solution Reconstituted) B 4 PA; LA

C1 Icati bant

Acet ate Icatibant Acetate (Subcutaneous Solution) G 4 PA; QL

C1 Orla dey o Orladeyo (Oral Capsule) B 4 PA; QL

C1 Ruc one st Ruconest (Intravenous Solution Reconstituted) B 4 PA; LA

C1 Tak hzyr o Takhzyro (Subcutaneous Solution) B 4 PA B1 Immunoglobulins

C1 BIVI GA M BIVIGAM (Intravenous Solution) B 4 PA

C1 Fleb oga mm a DIF Flebogamma DIF (5GM/50ML Intravenous Solution) B 4 PA

C1 Ga mm agar d Gammagard (2.5GM/25ML Injection Solution) B 4 PA

C1 Ga mm agar d S/ D Less IgA Gammagard S/D Less IgA (Intravenous Solution B 4 PA Reconstituted)

C1 Ga mm ake d Gammaked (1GM/10ML Injection Solution) B 4 PA

C1 Ga mm aple x Gammaplex (10GM/100ML Intravenous Solution, 10GM/200ML Intravenous Solution, 20GM/200ML B 4 PA Intravenous Solution, 5GM/50ML Intravenous Solution)

C1 Ga mun ex-C Gamunex-C (1GM/10ML Injection Solution) B 4 PA

C1 Oct aga m Octagam (1GM/20ML Intravenous Solution, 2GM/ B 4 PA 20ML Intravenous Solution)

C1 Pan zyga Panzyga (Intravenous Solution) B 4 PA 138 Last updated September 1, 2021

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

C1 Privi gen Privigen (20GM/200ML Intravenous Solution) B 4 PA

C1 Vari zig Varizig (Intramuscular Solution) B 4 B1 Immunological Agents, Other

C1 Acte mra ACT Pen Actemra ACTPen (Subcutaneous Solution Auto- B 4 PA Injector)

C1 Acte mra Actemra (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Arca lyst Arcalyst (Subcutaneous Solution Reconstituted) B 4 PA; LA

C1 Benl ysta Benlysta (Subcutaneous Solution Auto-Injector) B 4 PA

C1 Benl ysta Benlysta (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Cos enty x Cosentyx (300 MG Dose) (Subcutaneous Solution B 4 PA; LA Prefilled Syringe)

C1 Cos enty x Sen sore ady Cosentyx Sensoready (300 MG) (Subcutaneous B 4 PA; LA Solution Auto-Injector)

C1 Dupi xent Dupixent (300MG/2ML Subcutaneous Solution Pen- B 4 PA Injector)

C1 Dupi xent Dupixent (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Gras tek Grastek (Tablet Sublingual) B 2 PA

C1 Ilum ya Ilumya (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Kev zara Kevzara (Subcutaneous Solution Auto-Injector) B 4 PA

C1 Kev zara Kevzara (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Kine ret Kineret (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Oda ctra Odactra (Tablet Sublingual) B 3 PA

C1 Olu mia nt Olumiant (Oral Tablet) B 4 PA; QL

C1 Oral air 300I R Oralair 300IR (Tablet Sublingual) B 3 PA

C1 Ore ncia Clic kJec t Orencia ClickJect (Subcutaneous Solution Auto- B 4 PA Injector)

C1 Ore ncia Orencia (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Ote zla Otezla (Oral Tablet) B 4 PA; LA

C1 Ote zla Otezla (Oral Tablet Therapy Pack) B 4 PA; LA

C1 Rida ura Ridaura (Oral Capsule) B 4

C1 Rinv oq Rinvoq (Oral Tablet Extended Release 24 Hour) B 4 PA; QL

C1 Siliq Siliq (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Skyr izi Skyrizi (150 MG Dose) (Subcutaneous Prefilled B 4 PA Syringe Kit)

C1 Skyr izi Pen Skyrizi Pen (Subcutaneous Solution Auto-Injector) B 4 PA

C1 Skyr izi Skyrizi (Subcutaneous Solution Prefilled Syringe) B 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 139

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

C1 Stel ara Stelara (Subcutaneous Solution) B 4 PA

C1 Stel ara Stelara (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Talt z Taltz (Subcutaneous Solution Auto-Injector) B 4 PA; LA

C1 Talt z Taltz (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA

C1 Tre mfy a Tremfya (Subcutaneous Solution Pen-Injector) B 4 PA

C1 Tre mfy a Tremfya (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Xelj anz Xeljanz (Oral Solution) B 4 PA; QL

C1 Xelj anz Xeljanz (Oral Tablet Immediate Release) B 4 PA; QL

C1 Xelj anz XR Xeljanz XR (Oral Tablet Extended Release 24 Hour) B 4 PA; QL

C1 Xola ir Xolair (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA

C1 Xola ir Xolair (Subcutaneous Solution Reconstituted) B 4 PA; LA B1 Immunostimulants

C1 Acti mm une Actimmune (Subcutaneous Solution) B 4 LA

C1 Intro n A Intron A (Injection Solution) B 4 PA; LA

C1 Intro n A Intron A (Injection Solution Reconstituted) B 4 PA; LA

C1 Peg asys Pegasys (Subcutaneous Solution) B 4 PA B1 Immunosuppressants

C1 Arav a Arava (Oral Tablet) B 4

C1 Asta graf XL Astagraf XL (0.5MG Oral Capsule Extended Release 24 Hour, 1MG Oral Capsule Extended Release 24 B 3 B/D, PA Hour)

C1 Asta graf XL Astagraf XL (5MG Oral Capsule Extended Release 24 B 4 B/D, PA Hour)

C1 Aza san Azasan (100MG Oral Tablet) G 3 B/D, PA

C1 Aza san Azasan (75MG Oral Tablet) G 4 B/D, PA

C1 Azat hiop rine Azathioprine (Oral Tablet) G 1 B/D, PA

C1 Cell cept Cellcept (Oral Capsule) B 4 B/D, PA

C1 Cell cept Cellcept (Oral Suspension Reconstituted) B 4 B/D, PA

C1 Cell cept Cellcept (Oral Tablet) B 4 B/D, PA

C1 Cim zia Prefi lled Cimzia Prefilled (Subcutaneous Kit) B 4 PA

C1 Cim zia Cimzia (Subcutaneous Kit) B 4 PA

C1 Cycl osp orin e Mod ified Cyclosporine Modified (Oral Capsule) G 2 B/D, PA

C1 Cycl osp orin e Mod ified Cyclosporine Modified (Oral Solution) G 2 B/D, PA

C1 Cycl osp orin e Cyclosporine (Oral Capsule) G 3 B/D, PA

C1 Enb rel Mini Enbrel Mini (Subcutaneous Solution Cartridge) B 4 PA

C1 Enb rel Enbrel (Subcutaneous Solution) B 4 PA

C1 Enb rel Enbrel (Subcutaneous Solution Prefilled Syringe) B 4 PA 140 Last updated September 1, 2021

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

C1 Enb rel Enbrel (Subcutaneous Solution Reconstituted) B 4 PA

C1 Enb rel Sure Clic k Enbrel SureClick (Subcutaneous Solution Auto- B 4 PA Injector)

C1 Ens pryn g Enspryng (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Env arsu s XR Envarsus XR (Oral Tablet Extended Release 24 Hour) B 3 B/D, PA

C1 Ever olim us Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet, G 4 B/D, PA 0.75MG Oral Tablet)

C1 Gen graf Gengraf (Oral Capsule) G 2 B/D, PA

C1 Gen graf Gengraf (Oral Solution) G 2 B/D, PA

C1 Hu mira

Pedi atric

Cro hns Start Humira Pediatric Crohns Start (Subcutaneous B 4 PA Prefilled Syringe Kit)

C1 Hu mira Pen Humira Pen (Subcutaneous Pen-Injector Kit) B 4 PA

C1 Hu mira Pen Cro hns Dise ase Start er Humira Pen Crohns Disease Starter (Subcutaneous B 4 PA Pen-Injector Kit)

C1 Hu mira

Pen- Pedi atric UC Start Humira Pen-Pediatric UC Start (Subcutaneous Pen- B 4 PA Injector Kit)

C1 Hu mira Pen Psor iasis

Start er Humira Pen Psoriasis Starter (Subcutaneous Pen- B 4 PA Injector Kit)

C1 Hu mira Humira (Subcutaneous Prefilled Syringe Kit) B 4 PA

C1 Imur an Imuran (Oral Tablet) B 3 B/D, PA

C1 Lefl uno mid e Leflunomide (Oral Tablet) G 2

C1 Lup kyni s Lupkynis (Oral Capsule) B 4 PA; QL

C1 Met hotr exat e Methotrexate (Oral Tablet) G 1

C1 Met hotr exat e Sodi um Methotrexate Sodium (50MG/2ML Injection Solution G 1 Prefilled Syringe)

C1 Met hotr exat e Sodi um Methotrexate Sodium (50MG/2ML Injection Solution) G 1

C1 Myc oph enol ate Mof etil Mycophenolate Mofetil (Oral Capsule) G 2 B/D, PA

C1 Myc oph enol ate Mof etil Mycophenolate Mofetil (Oral Suspension Reconstituted) G 4 B/D, PA

C1 Myc oph enol ate Mof etil Mycophenolate Mofetil (Oral Tablet) G 2 B/D, PA

C1 Myc oph enol ate Sodi um Mycophenolate Sodium (Oral Tablet Delayed Release) G 3 B/D, PA

C1 Myf ortic Myfortic (180MG Oral Tablet Delayed Release) B 3 B/D, PA

C1 Myf ortic Myfortic (360MG Oral Tablet Delayed Release) B 4 B/D, PA

C1 Neo ral Neoral (Oral Capsule) B 3 B/D, PA

C1 Neo ral Neoral (Oral Solution) B 3 B/D, PA

C1 Otre xup Otrexup (Subcutaneous Solution Auto-Injector) B 3 PA

C1 Pro graf Prograf (0.5MG Oral Capsule) B 3 B/D, PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 141

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

C1 Pro graf Prograf (1MG Oral Capsule, 5MG Oral Capsule) B 4 B/D, PA

C1 Pro graf Prograf (Oral Packet) B 3 B/D, PA

C1 Rap amu ne Rapamune (Oral Solution) B 4 B/D, PA

C1 Rap amu ne Rapamune (0.5MG Oral Tablet) B 3 B/D, PA

C1 Rap amu ne Rapamune (1MG Oral Tablet, 2MG Oral Tablet) B 4 B/D, PA

C1 Ras uvo Rasuvo (Subcutaneous Solution Auto-Injector) B 3 PA

C1 Redi Trex RediTrex (Subcutaneous Solution Prefilled Syringe) B 3 PA

C1 San dim mun e Sandimmune (100MG Oral Capsule) B 4 B/D, PA

C1 San dim mun e Sandimmune (25MG Oral Capsule) B 3 B/D, PA

C1 San dim mun e Sandimmune (100MG/ML Oral Solution) B 4 B/D, PA

C1 Sim poni Simponi (Subcutaneous Solution Auto-Injector) B 4 PA

C1 Sim poni Simponi (Subcutaneous Solution Prefilled Syringe) B 4 PA

C1 Sirol imu s Sirolimus (Oral Solution) G 4 B/D, PA

C1 Sirol imu s Sirolimus (Oral Tablet) G 3 B/D, PA

C1 Tacr olim us Tacrolimus (0.5MG Oral Capsule, 1MG Oral Capsule) G 2 B/D, PA

C1 Tacr olim us Tacrolimus (5MG Oral Capsule) G 3 B/D, PA

C1 Trex all Trexall (Oral Tablet) G 3

C1 Xat mep Xatmep (Oral Solution) B 3 PA

C1 Zort ress Zortress (Oral Tablet) B 4 B/D, PA B1 Vaccines

C1 Act HIB ActHIB (Intramuscular Solution Reconstituted) B 2 QL

C1 Ada cel Adacel (Intramuscular Suspension) B 2 QL

C1 BC G Vac cine BCG Vaccine (Injection) B 2 QL

C1 Bex sero Bexsero (Intramuscular Suspension Prefilled Syringe) B 2 QL

C1 Boo strix Boostrix (5-2.5-18.5 Intramuscular Suspension, 5-2.5-18.5 (0.5ML Syringe) Intramuscular B 2 QL Suspension)

C1 Dap tace l Daptacel (Intramuscular Suspension) B 2 QL

C1 Diph theri a- Teta nus Tox oids DT Diphtheria-Tetanus Toxoids DT (Intramuscular B 2 QL Suspension)

C1 Eng erix- B Engerix-B (Injection Suspension) B 2 B/D, PA; QL

C1 Gar dasil 9 Gardasil 9 (Intramuscular Suspension) B 2 QL

C1 Gar dasil 9 Gardasil 9 (Intramuscular Suspension Prefilled B 2 QL Syringe)

C1 Havr ix Havrix (Intramuscular Suspension) B 2 QL

C1 Hibe rix Hiberix (Injection Solution Reconstituted) B 2 QL

C1 Imo vax Rabi es Imovax Rabies (Intramuscular Injectable) B 2 B/D, PA; QL 142 Last updated September 1, 2021

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

C1 Infa nrix Infanrix (Intramuscular Suspension) B 2 QL

C1 IPO L IPOL (Injection) B 2 QL

C1 Ixiar o Ixiaro (Intramuscular Suspension) B 2 QL

C1 Kinri x Kinrix (Intramuscular Suspension) B 2 QL

C1 Men actr a Menactra (Intramuscular Injectable) B 2 QL

C1 Men Qua dfi MenQuadfi (Intramuscular Injectable) B 2 QL

C1 Men veo Menveo (Intramuscular Solution Reconstituted) B 2 QL

C1 M- M-R II M-M-R II (Injection Solution Reconstituted) B 2 QL

C1 Pedi arix Pediarix (Intramuscular Suspension) B 2 QL

C1 Ped vax HIB Pedvax HIB (Intramuscular Suspension) B 2 QL

C1 Pro Qua d ProQuad (Subcutaneous Suspension Reconstituted) B 2 QL

C1 Qua drac el Quadracel (Intramuscular Suspension) B 2 QL

C1 Rab Aver t RabAvert (Intramuscular Suspension Reconstituted) B 2 B/D, PA; QL

C1 Rec omb ivax HB Recombivax HB (Injection Suspension) B 2 B/D, PA; QL

C1 Rot arix Rotarix (Oral Suspension Reconstituted) B 2 QL

C1 Rot aTe q RotaTeq (Oral Solution) B 2 QL

C1 Shin grix Shingrix (Intramuscular Suspension Reconstituted) B 2 PA; QL

C1 TDV AX TDVAX (Intramuscular Suspension) B 2 QL

C1 Teni vac Tenivac (Intramuscular Injectable) B 2 QL

C1 Tru men ba Trumenba (Intramuscular Suspension Prefilled B 2 QL Syringe)

C1 Twi nrix Twinrix (Intramuscular Suspension Prefilled Syringe) B 2 QL

C1 Typ him Vi Typhim Vi (Intramuscular Solution) B 2 QL

C1 VAQ TA VAQTA (Intramuscular Suspension) B 2 QL

C1 Vari vax Varivax (Subcutaneous Injectable) B 2 QL

C1 YF- Vax YF-Vax (Subcutaneous Injectable) B 2 QL A1 Inflammatory Bowel Disease Agents B1 Aminosalicylates

C1 Apri so Apriso (Oral Capsule Extended Release 24 Hour) B 2 QL

C1 Asa col HD Asacol HD (Oral Tablet Delayed Release) B 4 ST; QL

C1 Azul fidin e EN- tabs Azulfidine EN-tabs (Oral Tablet Delayed Release) B 3

C1 Azul fidin e Azulfidine (Oral Tablet Immediate Release) B 3

C1 Bals alazi de Diso diu m Balsalazide Disodium (Oral Capsule) G 3

C1 Can asa Canasa (Rectal Suppository) B 4 QL

C1 Cola zal Colazal (Oral Capsule) G 4

C1 Delz icol Delzicol (Oral Capsule Delayed Release) B 3 ST

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 143

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

C1 Dipe ntu m Dipentum (Oral Capsule) B 4

C1 Lial da Lialda (Oral Tablet Delayed Release) B 4 ST; QL

C1 Mes ala min e ER Mesalamine ER (0.375GM Oral Capsule Extended G 2 QL Release 24 Hour) (Generic Apriso)

C1 Mes ala min e Mesalamine (400MG Oral Capsule Delayed Release) G 3 ST (Generic Delzicol)

C1 Mes ala min e Mesalamine (1.2GM Oral Tablet Delayed Release) G 3 QL (Generic Lialda)

C1 Mes ala min e Mesalamine (800MG Oral Tablet Delayed Release) G 3 ST; QL (Generic Asacol)

C1 Mes ala min e Mesalamine (Rectal Enema) G 3

C1 Mes ala min e Mesalamine (Rectal Suppository) G 3 QL

C1 Pent asa Pentasa (Oral Capsule Extended Release) B 3 QL

C1 Row asa Rowasa (Rectal Kit) B 4

C1 Sulf asal azin e Sulfasalazine (Oral Tablet Immediate Release) G 1

C1 Sulf asal azin e Sulfasalazine (Oral Tablet Delayed Release) G 1 B1 Glucocorticoids

C1 Anu sol- HC Anusol-HC (External Cream) G 3

C1 Bud eso nide ER Budesonide ER (Oral Tablet Extended Release 24 Hour) G 4 ST

C1 Bud eso nide Budesonide (Oral Capsule Delayed Release Particles) G 3

C1 Ento cort EC Entocort EC (Oral Capsule Delayed Release Particles) B 4

C1 Hyd roco rtiso ne Hydrocortisone (Rectal Enema) G 3

C1 Orti kos Ortikos (Oral Capsule Extended Release 24 Hour) B 4 ST

C1 Proc to- Med HC Procto-Med HC (External Cream) G 1

C1 Proc to- Pak Procto-Pak (External Cream) G 1

C1 Proc toso l HC Proctosol HC (2.5% External Cream) G 1

C1 Proc tozo ne- HC Proctozone-HC (External Cream) G 1

C1 Uce ris Uceris (Oral Tablet Extended Release 24 Hour) B 4 ST

C1 Uce ris Uceris (Rectal Foam) B 3 A1 Metabolic Bone Disease Agents B1 Metabolic Bone Disease Agents

C1 Acto nel Actonel (Oral Tablet) B 3

C1 Alen dron ate Sodi um Alendronate Sodium (Oral Solution) G 3

C1 Alen dron ate Sodi um Alendronate Sodium (10MG Oral Tablet, 35MG Oral G 1 Tablet, 70MG Oral Tablet)

C1 Atel via Atelvia (Oral Tablet Delayed Release) B 3

C1 Boni va Boniva (Oral Tablet) B 3

C1 Calc itoni n Sal mon Calcitonin Salmon (Nasal Solution) G 2 144 Last updated September 1, 2021

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

C1 Calc itriol Calcitriol (Oral Capsule) G 1 B/D, PA

C1 Calc itriol Calcitriol (Oral Solution) G 3 B/D, PA

C1 Cina calc et HCl Cinacalcet HCl (30MG Oral Tablet) G 3 B/D, PA; QL

C1 Cina calc et HCl Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet) G 4 B/D, PA; QL

C1 Dox erca lcife rol Doxercalciferol (Oral Capsule) G 3 B/D, PA

C1 Eve nity Evenity (Subcutaneous Solution Prefilled Syringe) B 4 PA; QL

C1 Fort eo Forteo (Subcutaneous Solution Pen-Injector) B 4 PA

C1 Fos ama x Fosamax (Oral Tablet) B 3

C1 Fos ama x Plus D Fosamax Plus D (Oral Tablet) B 3

C1 Iban dron ate Sodi um Ibandronate Sodium (Oral Tablet) G 2

C1 Nat para Natpara (Subcutaneous Cartridge) B 4 PA; LA

C1 Pari calci tol Paricalcitol (Oral Capsule) G 3 B/D, PA

C1 Proli a Prolia (Subcutaneous Solution Prefilled Syringe) B 3 QL

C1 Ray alde e Rayaldee (Oral Capsule Extended Release) B 4 QL

C1 Rise dron ate Sodi um Risedronate Sodium (150MG Oral Tablet, 30MG Oral G 3 Tablet, 5MG Oral Tablet)

C1 Rise dron ate Sodi um Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Tablet Immediate G 2 Release, 35MG (4 PACK) Oral Tablet Immediate Release)

C1 Rise dron ate Sodi um Risedronate Sodium (Oral Tablet Delayed Release) G 3

C1 Roc altro l Rocaltrol (Oral Capsule) B 3 B/D, PA

C1 Roc altro l Rocaltrol (Oral Solution) B 3 B/D, PA

C1 Sen sipa r Sensipar (Oral Tablet) B 4 B/D, PA; QL

C1

Teri para tide Teriparatide (Recombinant) (Subcutaneous Solution B 4 PA Pen-Injector)

C1 Tym los Tymlos (Subcutaneous Solution Pen-Injector) B 4 PA

C1 Xge va Xgeva (Subcutaneous Solution) B 4 PA

C1 Zem plar Zemplar (1MCG Oral Capsule) B 3 B/D, PA

C1 Zem plar Zemplar (2MCG Oral Capsule) B 4 B/D, PA A1 Miscellaneous Therapeutic Agents B1 Miscellaneous Therapeutic Agents

C1 Alco hol Pre p Pad s Alcohol Prep Pads G 2

C1 Doj olvi Dojolvi (Oral Liquid) B 4 PA

C1 Gau ze Gauze (Non-medicated 2X2 Pad) G 2

C1 Insul in Syri nge s, Nee dles Insulin Syringes, Needles G 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 145

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

A1 Ophthalmic Agents B1 Ophthalmic Agents, Other

C1 Atro pine

Sulf ate Atropine Sulfate (1% Ophthalmic Solution) B 2

C1 Neo myci n- Poly myxi n- Baci traci n- Hyd roco Neomycin-Polymyxin-Bacitracin-Hydrocortisone rtiso ne G 2 (Ophthalmic Ointment)

C1 Blep ham ide Blephamide (Ophthalmic Suspension) B 3

C1 Blep ham ide S.O. P. Blephamide S.O.P. (Ophthalmic Ointment) G 3

C1 Ceq ua Cequa (Ophthalmic Solution) B 3 PA; QL

C1 Co mbi gan Combigan (Ophthalmic Solution) B 2

C1 Cos opt Cosopt (Ophthalmic Solution) B 3

C1 Cos opt PF Cosopt PF (Ophthalmic Solution) B 3

C1 Cyst adro ps Cystadrops (Ophthalmic Solution) B 4

C1 Cyst aran Cystaran (Ophthalmic Solution) B 4 LA

C1 Dor zola mid e HCl- Tim olol Mal eate Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution) G 1

C1 Dor zola mid e HCl- Tim olol Mal eate

Pres Dorzolamide HCl-Timolol Maleate Preservative Free erva tive Free G 3 (Ophthalmic Solution)

C1 Lacr isert Lacrisert (Ophthalmic Insert) B 3

C1 Maxi trol Maxitrol (Ophthalmic Ointment) B 3

C1 Maxi trol Maxitrol (Ophthalmic Suspension) B 3

C1 Neo myci n- Poly myxi n- Dex ame thas one Neomycin-Polymyxin-Dexamethasone (Ophthalmic G 1 Ointment)

C1 Neo myci n- Poly myxi n- Dex ame thas one Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 G 1 Ophthalmic Suspension)

C1 Neo myci n- Poly myxi n- HC Neomycin-Polymyxin-HC (Ophthalmic Suspension) G 3

C1

Oxe rvat e Oxervate (Ophthalmic Solution) B 4 PA; QL

C1 Pre d-G Pred-G (Ophthalmic Suspension) B 3

C1 Pre d-G S.O. P. Pred-G S.O.P. (Ophthalmic Ointment) B 3

C1 Pro para cain e HCl Proparacaine HCl (Ophthalmic Solution) G 1

C1 Rest asis Sing le- Use Vials Restasis Single-Use Vials (Ophthalmic Emulsion) B 2 QL

C1 Roc klata n Rocklatan (Ophthalmic Solution) B 2 ST

C1 Sulf acet ami de- Pre dnis olon e Sulfacetamide-Prednisolone (Ophthalmic Solution) G 1

C1 Tob raD ex TobraDex (Ophthalmic Ointment) B 2

C1 Tob raD ex TobraDex (Ophthalmic Suspension) B 3

C1 Tob raD ex ST TobraDex ST (Ophthalmic Suspension) B 3

C1 Tob ram ycin- Dex ame thas one Tobramycin-Dexamethasone (Ophthalmic Suspension) G 2

C1 Xiidr a Xiidra (Ophthalmic Solution) B 3 QL

C1 Zyle t Zylet (Ophthalmic Suspension) B 3 B1 Ophthalmic Anti-allergy Agents 146 Last updated September 1, 2021

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

C1 Aloc ril Alocril (Ophthalmic Solution) B 3

C1 Alo mid e Alomide (Ophthalmic Solution) B 3

C1 Azel astin e HCl Azelastine HCl (Ophthalmic Solution) G 1

C1 Bep otas tine Besi late Bepotastine Besilate (Ophthalmic Solution) G 3

C1 Bep reve Bepreve (Ophthalmic Solution) B 3

C1 Cro mol yn Sodi um Cromolyn Sodium (Ophthalmic Solution) G 1

C1 Epin astin e HCl Epinastine HCl (Ophthalmic Solution) G 2

C1 Last acaf t Lastacaft (Ophthalmic Solution) B 2

C1 Olo pata dine HCl Olopatadine HCl (Ophthalmic Solution) G 2

C1 Zerv iate Zerviate (Ophthalmic Solution) B 3 B1 Ophthalmic Anti-Infectives

C1 Aza site Azasite (Ophthalmic Solution) B 3

C1 Baci traci n Bacitracin (Ophthalmic Ointment) G 2

C1 Baci traci n- Poly myxi n B Bacitracin-Polymyxin B (Ophthalmic Ointment) G 1

C1 Besi vanc e Besivance (Ophthalmic Suspension) B 3

C1 Blep h-10 Bleph-10 (Ophthalmic Solution) G 3

C1 Cilo xan Ciloxan (Ophthalmic Ointment) B 3

C1 Cilo xan Ciloxan (Ophthalmic Solution) B 3

C1 Cipr oflo xaci n HCl Ciprofloxacin HCl (Ophthalmic Solution) G 1

C1 Eryt hro myci n Erythromycin (Ophthalmic Ointment) G 1

C1 Gatif loxa cin Gatifloxacin (Ophthalmic Solution) G 2

C1 Gen tak Gentak (Ophthalmic Ointment) G 1

C1 Gen tami cin Sulf ate Gentamicin Sulfate (Ophthalmic Solution) G 1

C1 Lev oflo xaci n Levofloxacin (0.5% Ophthalmic Solution) G 2

C1 Mox eza Moxeza (Ophthalmic Solution) B 3

C1 Mox iflox acin HCl Moxifloxacin HCl (Ophthalmic Solution) (Generic G 2 Vigamox)

C1 Nata cyn Natacyn (Ophthalmic Suspension) B 3

C1 Neo myci n- Baci traci n- Poly myxi n Neomycin-Bacitracin-Polymyxin (5-400-10000 G 2 Ophthalmic Ointment)

C1 Neo myci n- Poly myxi n- Gra mici din Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution) G 2

C1 Ocu flox Ocuflox (Ophthalmic Solution) B 3

C1 Oflo xaci n Ofloxacin (Ophthalmic Solution) G 1

C1 Poly myxi n B- Trim etho prim Polymyxin B-Trimethoprim (Ophthalmic Solution) G 1

C1 Poly trim Polytrim (Ophthalmic Solution) B 3

C1 Sulf acet ami de Sodi um Sulfacetamide Sodium (Ophthalmic Ointment) G 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 147

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

C1 Sulf acet ami de Sodi um Sulfacetamide Sodium (Ophthalmic Solution) G 1

C1 Tob ram ycin Tobramycin (Ophthalmic Solution) G 1

C1 Tob rex Tobrex (Ophthalmic Ointment) B 3

C1 Tob rex Tobrex (Ophthalmic Solution) B 3

C1 Trifl uridi ne Trifluridine (Ophthalmic Solution) G 2

C1 Viga mox Vigamox (Ophthalmic Solution) B 3

C1 Zym axid Zymaxid (Ophthalmic Solution) B 3 B1 Ophthalmic Anti-inflammatories

C1 Acul ar LS Acular LS (Ophthalmic Solution) B 3

C1 Acul ar Acular (Ophthalmic Solution) B 3

C1 Acu vail Acuvail (Ophthalmic Solution) B 3 ST

C1 Alre x Alrex (Ophthalmic Suspension) B 3

C1 Bro mfe nac Sodi um Bromfenac Sodium (Once-Daily) (Ophthalmic Solution) G 3

C1 Bro mSit e BromSite (Ophthalmic Solution) B 3 ST

C1 Dex ame thas one Sodi um Pho sph ate Dexamethasone Sodium Phosphate (Ophthalmic G 2 Solution)

C1 Dicl ofen ac Sodi um Diclofenac Sodium (Ophthalmic Solution) G 1

C1 Dur ezol Durezol (Ophthalmic Emulsion) B 3

C1 Eys uvis Eysuvis (Ophthalmic Suspension) B 3 PA

C1 Flar ex Flarex (Ophthalmic Suspension) B 3

C1 Fluo rom etho lone Fluorometholone (Ophthalmic Suspension) G 2

C1 Flur bipr ofen

Sodi um Flurbiprofen Sodium (Ophthalmic Solution) G 1

C1 FML Fort e FML Forte (Ophthalmic Suspension) B 3

C1 FML Liqu ifilm FML Liquifilm (Ophthalmic Suspension) B 3

C1 FML FML (Ophthalmic Ointment) B 3

C1 Ilevr o Ilevro (Ophthalmic Suspension) B 2

C1 Invel tys Inveltys (Ophthalmic Suspension) B 3

C1 Ket orol ac Tro met ham ine Ketorolac Tromethamine (Ophthalmic Solution) G 2

C1 Lote max Lotemax (Ophthalmic Gel) B 3

C1 Lote max Lotemax (Ophthalmic Ointment) B 3

C1 Lote max Lotemax (Ophthalmic Suspension) B 3

C1 Lote max SM Lotemax SM (Ophthalmic Gel) B 3

C1 Lote pred nol Etab onat e Loteprednol Etabonate (Ophthalmic Gel) G 3

C1 Lote pred nol Etab onat e Loteprednol Etabonate (Ophthalmic Suspension) G 3

C1 Maxi dex Maxidex (Ophthalmic Suspension) B 3

C1 Nev ana c Nevanac (Ophthalmic Suspension) B 3

C1 Pre d Fort e Pred Forte (Ophthalmic Suspension) B 3 148 Last updated September 1, 2021

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

C1 Pre d Mild Pred Mild (Ophthalmic Suspension) B 3

C1 Pre dnis olon e Acet ate Prednisolone Acetate (Ophthalmic Suspension) G 2

C1 Pre dnis olon e Sodi um Pho sph ate Prednisolone Sodium Phosphate (1% Ophthalmic G 1 Solution)

C1 Prol ens a Prolensa (Ophthalmic Solution) B 3 B1 Ophthalmic Beta-Adrenergic Blocking Agents

C1 Beta xolo l HCl Betaxolol HCl (Ophthalmic Solution) G 2

C1 Beti mol Betimol (Ophthalmic Solution) B 3

C1 Bet opti c-S Betoptic-S (Ophthalmic Suspension) B 3

C1 Cart eolo l HCl Carteolol HCl (Ophthalmic Solution) G 1

C1 Istal ol Istalol (Ophthalmic Solution) B 3

C1 Lev obu nolo l HCl Levobunolol HCl (Ophthalmic Solution) G 1

C1 Tim olol Mal eate

Oph thal mic Gel For min Timolol Maleate Ophthalmic Gel Forming (Ophthalmic g G 2 Solution) (Generic Timoptic-XE)

C1 Tim olol Mal eate Timolol Maleate (0.25% Ophthalmic Solution, 0.5% G 1 Ophthalmic Solution) (Generic Timoptic)

C1 Tim olol Mal eate Timolol Maleate (0.5% (DAILY) Ophthalmic Solution) G 3 (Generic Istalol)

C1 Tim olol Mal eate PF Timolol Maleate PF (Ophthalmic Solution) (Generic G 3 Timoptic Ocudose)

C1 Tim opti c Ocu dos e Timoptic Ocudose (Ophthalmic Solution) B 3

C1 Tim opti c-XE Timoptic-XE (Ophthalmic Gel Forming Solution) B 3 B1 Ophthalmic Intraocular Pressure Lowering Agents, Other

C1 Alph aga n P Alphagan P (0.1% Ophthalmic Solution) B 2

C1 Alph aga n P Alphagan P (0.15% Ophthalmic Solution) B 3

C1 Apr aclo nidi ne HCl Apraclonidine HCl (Ophthalmic Solution) G 2

C1 Azo pt Azopt (Ophthalmic Suspension) B 2

C1 Brim onid ine Tartr ate Brimonidine Tartrate (0.15% Ophthalmic Solution) B 3

C1 Brim onid ine Tartr ate Brimonidine Tartrate (0.2% Ophthalmic Solution) G 1

C1 Brin zola mid e Brinzolamide (Ophthalmic Suspension) G 2

C1 Dor zola mid e HCl Dorzolamide HCl (Ophthalmic Solution) G 1

C1 Iopi dine Iopidine (1% Ophthalmic Solution) B 4

C1 Isop to Car pine Isopto Carpine (Ophthalmic Solution) B 3

C1 Met haz ola mid e Methazolamide (Oral Tablet) G 3

C1 Pilo carp ine HCl Pilocarpine HCl (Ophthalmic Solution) G 2

C1 Rho pres sa Rhopressa (Ophthalmic Solution) B 2 ST

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 149

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

C1 Sim brin za Simbrinza (Ophthalmic Suspension) B 2

C1 Trus opt Trusopt (Ophthalmic Solution) B 3 B1 Ophthalmic Prostaglandin and Prostamide Analogs

C1 Bim atop rost Bimatoprost (Ophthalmic Solution) G 3

C1 Lata nopr ost Latanoprost (Ophthalmic Solution) G 1

C1 Lum igan Lumigan (Ophthalmic Solution) B 2

C1 Trav atan Z Travatan Z (Ophthalmic Solution) B 3

C1 Trav opr ost Travoprost (BAK Free) (Ophthalmic Solution) G 2

C1 Vyz ulta Vyzulta (Ophthalmic Solution) B 3

C1 Xala tan Xalatan (Ophthalmic Solution) B 3

C1 Xelp ros Xelpros (Ophthalmic Emulsion) B 3 ST

C1 Ziop tan Zioptan (Ophthalmic Solution) B 3 A1 Otic Agents B1 Otic Agents

C1 Acet ic Acid Acetic Acid (Otic Solution) G 1

C1 Cetr axal Cetraxal (Otic Solution) B 3

C1 Cipr o HC Cipro HC (Otic Suspension) B 3

C1 Cipr ode x Ciprodex (Otic Suspension) B 3

C1 Cipr oflo xaci n HCl Ciprofloxacin HCl (Otic Solution) B 3

C1 Cipr oflo xaci n- Dex ame thas one Ciprofloxacin-Dexamethasone (Otic Suspension) G 2

C1 Cipr oflo xaci n- Fluo cino lone PF Ciprofloxacin-Fluocinolone PF (Otic Solution) B 3

C1 Der mOt ic DermOtic (Otic Oil) B 3

C1 Flac Flac (Otic Oil) G 3

C1 Fluo cino lone

Acet onid e Fluocinolone Acetonide (Otic Oil) G 2

C1 Hyd roco rtiso ne- Acet ic Acid Hydrocortisone-Acetic Acid (Otic Solution) G 2

C1 Neo myci n- Poly myxi n- HC Neomycin-Polymyxin-HC (1% Otic Solution) G 2

C1 Neo myci n- Poly myxi n- HC Neomycin-Polymyxin-HC (Otic Suspension) G 2

C1 Oflo xaci n Ofloxacin (Otic Solution) G 2

C1 Oto vel Otovel (Otic Solution) B 3 A1 Respiratory Tract/Pulmonary Agents B1 Antihistamines

C1 Azel astin e HCl Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal G 2 Solution)

C1 Azel astin e- Fluti cas one Azelastine-Fluticasone (Nasal Suspension) G 3

C1 Ceti rizin e HCl Cetirizine HCl (1MG/ML Oral Solution) G 1

C1 Clari nex Clarinex (Oral Tablet) B 3

C1 Cyp rohe ptad ine HCl Cyproheptadine HCl (Oral Tablet) G 3 PA; HRM 150 Last updated September 1, 2021

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

C1 Desl orat adin e Desloratadine (Oral Tablet) G 2

C1 Desl orat adin e ODT Desloratadine ODT (Oral Tablet Dispersible) G 3

C1 Dym ista Dymista (Nasal Suspension) B 3

C1 Lev ocet irizin e Dihy droc hlori de Levocetirizine Dihydrochloride (Oral Solution) G 2

C1 Lev ocet irizin e Dihy droc hlori de Levocetirizine Dihydrochloride (Oral Tablet) G 1

C1 Olo pata dine HCl Olopatadine HCl (Nasal Solution) G 3

C1 Pata nas e Patanase (Nasal Solution) B 3 B1 Anti-inflammatories, Inhaled Corticosteroids

C1 Alve sco Alvesco (Inhalation Aerosol Solution) B 3 ST; QL

C1 Arm onAi r Digi hale r ArmonAir Digihaler (Inhalation Aerosol Powder Breath B 3 ST; QL Activated)

C1 Arn uity Ellip ta Arnuity Ellipta (Inhalation Aerosol Powder Breath B 2 QL Activated)

C1 Asm ane x Asmanex (120 Metered Doses) (Inhalation Aerosol B 3 ST; QL Powder Breath Activated)

C1 Asm ane x Asmanex (30 Metered Doses) (Inhalation Aerosol B 3 ST; QL Powder Breath Activated)

C1 Asm ane x Asmanex (60 Metered Doses) (Inhalation Aerosol B 3 ST; QL Powder Breath Activated)

C1 Asm ane x HFA Asmanex HFA (Inhalation Aerosol) B 3 ST; QL

C1 Bec ona se AQ Beconase AQ (Nasal Suspension) B 3 ST

C1 Bud eso nide Budesonide (Inhalation Suspension) G 3 B/D, PA

C1 Flov ent Disk us Flovent Diskus (Inhalation Aerosol Powder Breath B 2 Activated)

C1 Flov ent HFA Flovent HFA (Inhalation Aerosol) B 2 QL

C1 Flun isoli de Flunisolide (Nasal Solution) G 2

C1 Fluti cas one Pro pion ate Fluticasone Propionate (Nasal Suspension) G 1

C1 Mo met aso ne Furo ate Mometasone Furoate (Nasal Suspension) G 3

C1 Nas one x Nasonex (Nasal Suspension) B 3

C1 Om nari s Omnaris (Nasal Suspension) B 3 ST

C1 Pul mic ort Flex hale r Pulmicort Flexhaler (Inhalation Aerosol Powder B 3 ST Breath Activated)

C1 Pul mic ort Pulmicort (0.25MG/2ML Inhalation Suspension, B 3 B/D, PA 0.5MG/2ML Inhalation Suspension)

C1 Pul mic ort Pulmicort (1MG/2ML Inhalation Suspension) B 4 B/D, PA

C1 Qna sl Chil dren s Qnasl Childrens (Nasal Aerosol Solution) B 3 ST

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 151

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

C1 Qna sl Qnasl (Nasal Aerosol Solution) B 3 ST

C1 QVA R Redi Hale r QVAR RediHaler (Inhalation Aerosol Breath Activated) B 3 ST; QL

C1 Xha nce Xhance (Nasal Exhaler Suspension) B 3

C1 Zeto nna Zetonna (Nasal Aerosol Solution) B 3 ST B1 Antileukotrienes

C1 Acc olat e Accolate (Oral Tablet) B 3

C1 Mon telu kast Sodi um Montelukast Sodium (Oral Packet) G 2 QL

C1 Mon telu kast Sodi um Montelukast Sodium (Oral Tablet) G 1 QL

C1 Mon telu kast Sodi um Montelukast Sodium (Oral Tablet Chewable) G 1 QL

C1 Sing ulair Singulair (Oral Packet) B 3 QL

C1 Sing ulair Singulair (Oral Tablet) B 3 QL

C1 Sing ulair Singulair (Oral Tablet Chewable) B 3 QL

C1 Zafir luka st Zafirlukast (Oral Tablet) G 2

C1 Zile uton ER Zileuton ER (Oral Tablet Extended Release 12 Hour) G 4 ST

C1 Zyfl o Zyflo (Oral Tablet Immediate Release) B 4 ST B1 Bronchodilators, Anticholinergic

C1 Atro vent

HFA Atrovent HFA (Inhalation Aerosol Solution) B 3

C1 Incr use Ellip ta Incruse Ellipta (Inhalation Aerosol Powder Breath B 3 ST; QL Activated)

C1 Iprat ropi um Bro mid e Ipratropium Bromide (Inhalation Solution) G 1 B/D, PA

C1 Iprat ropi um Bro mid e Ipratropium Bromide (Nasal Solution) G 2

C1 Lon hala Mag nair Lonhala Magnair (Inhalation Solution) B 4 QL

C1 Spiri va Han diHa ler Spiriva HandiHaler (Inhalation Capsule) B 2 QL

C1 Spiri va Res pim at Spiriva Respimat (Inhalation Aerosol Solution) B 2 QL

C1 Tud orza

Pres sair Tudorza Pressair (Inhalation Aerosol Powder Breath B 3 ST Activated)

C1 Yup elri Yupelri (Inhalation Solution) B 4 B/D, PA; QL B1 Bronchodilators, Sympathomimetic

C1 Albu terol

Sulf ate HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT G 3 ST Inhalation Aerosol Solution) (Brand Equivalent Ventolin)

C1 Albu terol

Sulf ate HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT Inhalation Aerosol Solution (Generic Proair), 108 (90 G 2 Base)MCG/ACT Inhalation Aerosol Solution) (Generic Proventil)

C1 Albu terol

Sulf ate Albuterol Sulfate (Inhalation Nebulization Solution) G 1 B/D, PA

C1 Albu terol

Sulf ate Albuterol Sulfate (Oral Syrup) G 3

C1 Albu terol

Sulf ate Albuterol Sulfate (Oral Tablet Immediate Release) G 3

C1 Brov ana Brovana (Inhalation Nebulization Solution) B 4 PA; QL 152 Last updated September 1, 2021

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

C1 Epin ephr ine Epinephrine (Injection Solution Auto-Injector) G 2 QL

C1 EpiP en 2- Pak EpiPen 2-Pak (Injection Solution Auto-Injector) B 3 QL

C1 EpiP en Jr 2- Pak EpiPen Jr 2-Pak (Injection Solution Auto-Injector) B 3 QL

C1 Lev albu terol HCl Levalbuterol HCl (Inhalation Nebulization Solution) G 3 B/D, PA

C1 Lev albu terol

Tartr ate Levalbuterol Tartrate (Inhalation Aerosol) G 3 ST

C1 Perf oro mist Perforomist (Inhalation Nebulization Solution) B 3 B/D, PA; QL

C1 Pro Air HFA ProAir HFA (Inhalation Aerosol Solution) B 2

C1 Pro Air Res piCli ck ProAir RespiClick (Inhalation Aerosol Powder Breath B 2 Activated)

C1 Prov entil

HFA Proventil HFA (Inhalation Aerosol Solution) B 3 ST

C1 Sere vent

Disk us Serevent Diskus (Inhalation Aerosol Powder Breath B 2 QL Activated)

C1 Striv erdi Res pim at Striverdi Respimat (Inhalation Aerosol Solution) B 3 ST

C1 Sym jepi Symjepi (Injection Solution Prefilled Syringe) B 3 QL

C1 Terb utali ne Sulf ate Terbutaline Sulfate (Oral Tablet) G 3

C1 Vent olin HFA Ventolin HFA (Inhalation Aerosol Solution) B 3 ST

C1 Xop ene x Con cent rate Xopenex Concentrate (Inhalation Nebulization B 3 B/D, PA Solution)

C1 Xop ene x HFA Xopenex HFA (Inhalation Aerosol) B 3 ST

C1 Xop ene x Xopenex (0.31MG/3ML Inhalation Nebulization Solution, 0.63MG/3ML Inhalation Nebulization B 3 B/D, PA Solution)

C1 Xop ene x Xopenex (1.25MG/3ML Inhalation Nebulization B 4 B/D, PA Solution) B1 Cystic Fibrosis Agents

C1 Beth kis Bethkis (Inhalation Nebulization Solution) B 4 B/D, PA; QL

C1 Cay ston Cayston (Inhalation Solution Reconstituted) B 4 PA; LA

C1 Kaly dec o Kalydeco (Oral Packet) B 4 PA; LA

C1 Kaly dec o Kalydeco (Oral Tablet) B 4 PA; LA

C1 Ork amb i Orkambi (Oral Packet) B 4 PA; LA; QL

C1 Ork amb i Orkambi (Oral Tablet) B 4 PA; LA; QL

C1 Pul moz yme Pulmozyme (Inhalation Solution) B 4 B/D, PA; QL

C1 Sym dek o Symdeko (Oral Tablet Therapy Pack) B 4 PA; QL

C1 TOB I TOBI (Inhalation Nebulization Solution) B 4 B/D, PA; QL

C1 TOB I Pod hale r TOBI Podhaler (Inhalation Capsule) B 4 PA; QL

C1 Tob ram ycin Tobramycin (Inhalation Nebulization Solution) G 4 B/D, PA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 153

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

C1 Trik afta Trikafta (100-50-75 & 150MG Oral Tablet Therapy B 4 PA; LA; QL Pack) B1 Mast Cell Stabilizers

C1 Cro mol yn Sodi um Cromolyn Sodium (Inhalation Nebulization Solution) G 4 B/D, PA B1 Phosphodiesterase Inhibitors, Airways Disease

C1 Dalir esp Daliresp (Oral Tablet) B 3 PA

C1 The o-24 Theo-24 (Oral Capsule Extended Release 24 Hour) G 3

C1 The oph yllin e ER Theophylline ER (300MG Oral Tablet Extended Release G 3 12 Hour)

C1 The oph yllin e ER Theophylline ER (Oral Tablet Extended Release 24 Hour) G 1

C1 The oph yllin e Theophylline (Oral Solution) G 3 B1 Pulmonary Antihypertensives

C1 Adci rca Adcirca (Oral Tablet) B 4 PA

C1 Ade mpa s Adempas (Oral Tablet) B 4 PA; LA

C1 Alyq Alyq (Oral Tablet) G 3 PA

C1 Am bris enta n Ambrisentan (Oral Tablet) G 4 PA; LA; QL

C1 Bos enta n Bosentan (Oral Tablet) G 4 PA; LA; QL

C1 Leta iris Letairis (Oral Tablet) B 4 PA; LA; QL

C1 Ops umit Opsumit (Oral Tablet) B 4 PA; LA

C1 Ore nitra m Orenitram (0.125MG Oral Tablet Extended Release) B 3 PA; LA

C1 Ore nitra m Orenitram (0.25MG Oral Tablet Extended Release, 1MG Oral Tablet Extended Release, 2.5MG Oral B 4 PA; LA Tablet Extended Release, 5MG Oral Tablet Extended Release)

C1 Rev atio Revatio (Oral Suspension Reconstituted) B 4 PA

C1 Rev atio Revatio (Oral Tablet) B 4 PA

C1 Sild enaf il Citra te Sildenafil Citrate (Oral Suspension Reconstituted) G 4 PA

C1 Sild enaf il Citra te Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio) G 2 PA

C1 Tad alafil Tadalafil (PAH) (20MG Oral Tablet) G 3 PA

C1 Trac leer Tracleer (Oral Tablet) B 4 PA; LA; QL

C1 Trac leer Tracleer (Oral Tablet Soluble) B 4 PA; LA; QL

C1 Uptr avi Uptravi (Oral Tablet) B 4 PA; LA; QL

C1 Uptr avi Uptravi (Oral Tablet Therapy Pack) B 4 PA; LA

C1 Vent avis Ventavis (Inhalation Solution) B 4 PA; LA B1 Pulmonary Fibrosis Agents

C1 Esbr iet Esbriet (Oral Capsule) B 4 PA; LA; QL

C1 Esbr iet Esbriet (Oral Tablet) B 4 PA; LA; QL 154 Last updated September 1, 2021

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

C1 Ofe v Ofev (Oral Capsule) B 4 PA; LA; QL B1 Respiratory Tract Agents, Other

C1 Acet ylcy stei ne Acetylcysteine (Inhalation Solution) G 1 B/D, PA

C1 Adv air Disk us Advair Diskus (Inhalation Aerosol Powder Breath B 2 QL Activated)

C1 Adv air HFA Advair HFA (Inhalation Aerosol) B 2 QL

C1 AirD uo Digi hale r AirDuo Digihaler (Inhalation Aerosol Powder Breath B 3 ST; QL Activated)

C1 AirD uo Res piCli ck 113/ 14 AirDuo RespiClick 113/14 (Inhalation Aerosol Powder B 3 ST; QL Breath Activated)

C1 AirD uo Res piCli ck 232/ 14 AirDuo RespiClick 232/14 (Inhalation Aerosol Powder B 3 ST; QL Breath Activated)

C1 AirD uo Res piCli ck 55/1 4 AirDuo RespiClick 55/14 (Inhalation Aerosol Powder B 3 ST; QL Breath Activated)

C1 Ano ro Ellip ta Anoro Ellipta (Inhalation Aerosol Powder Breath B 2 QL Activated)

C1 Bev espi

Aer osp here Bevespi Aerosphere (Inhalation Aerosol) B 3 ST

C1 Bre o Ellip ta Breo Ellipta (Inhalation Aerosol Powder Breath B 2 QL Activated)

C1 Brez tri Aer osp here Breztri Aerosphere (Inhalation Aerosol) B 2 QL

C1 Bro nchi tol Bronchitol (Inhalation Capsule) B 4 PA; QL

C1 Bud eso nide - For mot erol Fum arat e Budesonide-Formoterol Fumarate (Inhalation Aerosol) G 3 ST; QL

C1 Clari nex- D 12 Hou r Clarinex-D 12 Hour (Oral Tablet Extended Release 12 B 3 Hour)

C1 Co mbi vent

Res pim at Combivent Respimat (Inhalation Aerosol Solution) B 2 QL

C1 Dua klir Pres sair Duaklir Pressair (Inhalation Aerosol Powder Breath B 4 ST; QL Activated)

C1 Dule ra Dulera (Inhalation Aerosol) B 3 QL

C1 Fas enra Pen Fasenra Pen (Subcutaneous Solution Auto-Injector) B 4 PA; LA

C1 Fas enra Fasenra (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA

C1 Fluti cas one- Sal met erol Fluticasone-Salmeterol (Inhalation Aerosol Powder G 2 QL Breath Activated)

C1 Iprat ropi um- Albu terol Ipratropium-Albuterol (Inhalation Solution) G 1 B/D, PA

C1 Nuc ala Nucala (Subcutaneous Solution Auto-Injector) B 4 PA; LA; QL

C1 Nuc ala Nucala (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA; QL

C1 Nuc ala Nucala (Subcutaneous Solution Reconstituted) B 4 PA; LA; QL

C1 Stiol to Res pim at Stiolto Respimat (Inhalation Aerosol Solution) B 2

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updated September 1, 2021 155

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

C1 Sym bico rt Symbicort (Inhalation Aerosol) B 2 QL

C1 Trel egy Ellip ta Trelegy Ellipta (Inhalation Aerosol Powder Breath B 2 QL Activated)

C1 Wix ela Inhu b Wixela Inhub (Inhalation Aerosol Powder Breath G 2 QL Activated) (Generic Advair) A1 Skeletal Muscle Relaxants B1 Skeletal Muscle Relaxants

C1 Chlo rzox azo ne Chlorzoxazone (500MG Oral Tablet) G 3 PA; HRM

C1 Cycl obe nza prin e HCl Cyclobenzaprine HCl (7.5MG Oral Tablet) G 3 PA; HRM

C1 Fex mid Fexmid (Oral Tablet) G 3 PA; HRM A1 Sleep Disorder Agents B1 Sleep Disorder Agents

C1 Xyw av Xywav (Oral Solution) B 4 PA; QL B1 Sleep Promoting Agents

C1 Am bien Ambien (Oral Tablet Immediate Release) B 3 PA; HRM; QL

C1 Bels omr a Belsomra (Oral Tablet) B 2 QL

C1 Day Vigo DayVigo (Oral Tablet) B 2 QL

C1 Dox epin HCl Doxepin HCl (Oral Tablet) G 3

C1 Hetli oz LQ Hetlioz LQ (Oral Suspension) B 4 PA; LA; QL

C1 Hetli oz Hetlioz (Oral Capsule) B 4 PA; LA; QL

C1 Ram elte on Ramelteon (Oral Tablet) G 3

C1 Rest oril Restoril (22.5MG Oral Capsule) B 4 HRM; QL

C1 Roz ere m Rozerem (Oral Tablet) B 3 ST

C1 Sile nor Silenor (Oral Tablet) B 3

C1 Tem aze pam Temazepam (15MG Oral Capsule, 30MG Oral Capsule) G 2 HRM; QL

C1 Tem aze pam Temazepam (22.5MG Oral Capsule, 7.5MG Oral G 3 HRM; QL Capsule)

C1 Zale plon Zaleplon (Oral Capsule) G 2 HRM; QL

C1 Zolp ide m Tartr ate Zolpidem Tartrate (Oral Tablet Immediate Release) G 3 PA; HRM; QL B1 Wakefulness Promoting Agents

C1 Arm odaf inil Armodafinil (Oral Tablet) G 2 PA; QL

C1 Mod afinil Modafinil (Oral Tablet) G 2 PA; QL

C1 Nuvi gil Nuvigil (150MG Oral Tablet, 200MG Oral Tablet, B 4 PA; QL 250MG Oral Tablet)

C1 Nuvi gil Nuvigil (50MG Oral Tablet) B 3 PA; QL

C1 Prov igil Provigil (Oral Tablet) B 4 PA; QL

C1 Sun osi Sunosi (Oral Tablet) B 3 PA; QL 156 Last updated September 1, 2021

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

C1 Wak ix Wakix (Oral Tablet) B 4 PA; QL

C1 Xyre m Xyrem (Oral Solution) B 4 PA; LA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. 157 Covered drugs with a quantity limit (QL) This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety. Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover. Drugs are listed in alphabetical order in the chart below. Brand name drugs in bold type (for example, Humalog) and generic drugs in plain type (for example, Simvastatin).

Brand Drug Name or Quantity Limit Generic

Abacavir Sulfate (Oral Solution) G Maximum of 32 ml per day Abacavir Sulfate (Oral Tablet) G Maximum of 2 tablets per day Abacavir Sulfate-Lamivudine (Oral Tablet) G Maximum of 1 tablet per day Abacavir-Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day Abilify MyCite (Oral Tablet) B Maximum of 1 tablet per day Abilify (Oral Tablet) B Maximum of 1 tablet per day Accupril (Oral Tablet) B Maximum of 2 tablets per day Accuretic (10-12.5MG Oral Tablet) B Maximum of 1 tablet per day Accuretic (20-12.5MG Oral Tablet, B Maximum of 2 tablets per day 20-25MG Oral Tablet) Acetaminophen-Caffeine-Dihydrocodeine G Maximum of 10 capsules per day (320.5-30-16MG Oral Capsule) Acetaminophen-Caffeine-Dihydrocodeine G Maximum of 10 tablets per day (325-30-16MG Oral Tablet) Acetaminophen-Codeine (120-12MG/5ML G Maximum of 150 ml per day Oral Solution) Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG G Maximum of 13 tablets per day Oral Tablet) ActHIB (Intramuscular Solution 1 vaccination dose (1 injection) per B Reconstituted) day Actiq (Buccal Lozenge On A Handle) B Maximum of 4 lozenges per day Actoplus Met (Oral Tablet Immediate B Maximum of 3 tablets per day Release) Actos (15MG Oral Tablet) B Maximum of 3 tablets per day Actos (30MG Oral Tablet, 45MG Oral B Maximum of 1 tablet per day Tablet) Adacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Adderall (20MG Oral Tablet) G Maximum of 3 tablets per day 158 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Adderall (5MG Oral Tablet, 7.5MG Oral G Maximum of 2 tablets per day Tablet) Adderall XR (Oral Capsule Extended B Maximum of 2 capsules per day Release 24 Hour) Adlyxin Starter Pack (Subcutaneous Pen- B Maximum of 1 kit (6 ml) per 28 days Injector Kit) Adlyxin (Subcutaneous Solution Pen- Maximum of 2 pens (6 ml) per 28 B Injector) days Advair Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per B Breath Activated) 30 days Maximum of 1 inhaler (12 grams) per Advair HFA (Inhalation Aerosol) B 30 days Adzenys ER (Oral Suspension Extended B Maximum of 15 ml per day Release) Adzenys XR-ODT (Oral Tablet Extended B Maximum of 1 tablet per day Release Dispersible) Aimovig (140MG/ML Subcutaneous B Maximum of 1 pen (1 ml) per 30 days Solution Auto-Injector) Aimovig (70MG/ML Subcutaneous Solution Maximum of 2 pens (2 ml) per 30 B Auto-Injector) days AirDuo Digihaler (Inhalation Aerosol B Maximum of 1 inhaler per 30 days Powder Breath Activated) AirDuo RespiClick 113/14 (Inhalation B Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) AirDuo RespiClick 232/14 (Inhalation B Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) AirDuo RespiClick 55/14 (Inhalation B Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) Ajovy (Subcutaneous Solution Auto- Maximum of 1 pen (1.5 ml) per 30 B Injector) days Ajovy (Subcutaneous Solution Prefilled Maximum of 1 syringe (1.5 ml) per 30 B Syringe) days Albendazole (Oral Tablet) G Maximum of 16 tablets per day Albenza (Oral Tablet) B Maximum of 16 tablets per day Aldara (External Cream) B Maximum of 24 grams per 30 days Aliskiren Fumarate (Oral Tablet) G Maximum of 1 tablet per day Almotriptan Malate (Oral Tablet) G Maximum of 12 tablets per 30 days Alogliptin Benzoate (Oral Tablet) G Maximum of 1 tablet per day Alogliptin-Metformin HCl (Oral Tablet) B Maximum of 2 tablets per day Alogliptin-Pioglitazone (Oral Tablet) G Maximum of 1 tablet per day Last updated September 1, 2021 159

Brand Drug Name or Quantity Limit Generic

Alora (Transdermal Patch Twice Weekly) B Maximum of 8 patches per 28 days Alprazolam ER (0.5MG Oral Tablet Extended Release 24 Hour, 1MG Oral Tablet Extended G Maximum of 1 tablet per day Release 24 Hour) Alprazolam ER (2MG Oral Tablet Extended G Maximum of 5 tablets per day Release 24 Hour) Alprazolam ER (3MG Oral Tablet Extended G Maximum of 3 tablets per day Release 24 Hour) Alprazolam Intensol (Oral Concentrate) G Maximum of 10 ml per day Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate G Maximum of 4 tablets per day Release, 1MG Oral Tablet Immediate Release) Alprazolam (2MG Oral Tablet Immediate G Maximum of 5 tablets per day Release) Alprazolam ODT (0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, G Maximum of 4 tablets per day 1MG Oral Tablet Dispersible) Alprazolam ODT (2MG Oral Tablet G Maximum of 5 tablets per day Dispersible) Altace (Oral Capsule) B Maximum of 2 capsules per day Altoprev (Oral Tablet Extended Release 24 B Maximum of 1 tablet per day Hour) Alunbrig (180MG Oral Tablet, 90MG Oral B Maximum of 1 tablet per day Tablet) Alunbrig (30MG Oral Tablet) B Maximum of 4 tablets per day Maximum of 1 pack (30 tablets) per Alunbrig (Oral Tablet Therapy Pack) B 30 days Alvesco (160MCG/ACT Inhalation Aerosol Maximum of 2 inhalers (12.2 grams) B Solution) per 30 days Alvesco (80MCG/ACT Inhalation Aerosol Maximum of 1 inhaler (6.1 grams) per B Solution) 30 days Amaryl (1MG Oral Tablet) B Maximum of 8 tablets per day Amaryl (2MG Oral Tablet) B Maximum of 4 tablets per day Amaryl (4MG Oral Tablet) B Maximum of 2 tablets per day Ambien (Oral Tablet Immediate Release) B Maximum of 1 tablet per day Ambrisentan (Oral Tablet) G Maximum of 1 tablet per day Amerge (Oral Tablet) B Maximum of 12 tablets per 30 days Amitiza (Oral Capsule) B Maximum of 2 capsules per day Amlodipine-Atorvastatin (Oral Tablet) G Maximum of 1 tablet per day 160 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Amlodipine-Benazepril (Oral Capsule) G Maximum of 1 capsule per day Amlodipine-Olmesartan (Oral Tablet) G Maximum of 1 tablet per day Amlodipine-Valsartan (Oral Tablet) G Maximum of 1 tablet per day Amphetamine ER (Oral Suspension Extended G Maximum of 15 ml per day Release) Amphetamine-Dextroamphetamine ER (Oral G Maximum of 2 capsules per day Capsule Extended Release 24 Hour) Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral G Maximum of 2 tablets per day Tablet, 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet) Amphetamine-Dextroamphetamine (20MG G Maximum of 3 tablets per day Oral Tablet) Ampyra (Oral Tablet Extended Release 12 B Maximum of 2 tablets per day Hour) Annovera (Vaginal Ring) B Maximum of 1 ring per 365 days Anoro Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per B Breath Activated) 30 days ApexiCon E (External Cream) G Maximum of 240 grams per 30 days Apokyn (Subcutaneous Solution Cartridge) B Maximum of 3 ml per day Apriso (Oral Capsule Extended Release 24 B Maximum of 4 capsules per day Hour) Aptensio XR (Oral Capsule Extended B Maximum of 1 capsule per day Release 24 Hour) Aptiom (200MG Oral Tablet, 400MG Oral B Maximum of 1 tablet per day Tablet) Aptiom (600MG Oral Tablet, 800MG Oral B Maximum of 2 tablets per day Tablet) Aptivus (Oral Capsule) B Maximum of 4 capsules per day Aricept (10MG Oral Tablet) B Maximum of 2 tablets per day Aricept (23MG Oral Tablet, 5MG Oral B Maximum of 1 tablet per day Tablet) Aripiprazole (1MG/ML Oral Solution) G Maximum of 25 ml per day Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, G Maximum of 1 tablet per day 30MG Oral Tablet, 5MG Oral Tablet) Aripiprazole ODT (10MG Oral Tablet G Maximum of 3 tablets per day Dispersible) Aripiprazole ODT (15MG Oral Tablet G Maximum of 2 tablets per day Dispersible) Last updated September 1, 2021 161

Brand Drug Name or Quantity Limit Generic

Armodafinil (150MG Oral Tablet, 200MG Oral G Maximum of 1 tablet per day Tablet, 250MG Oral Tablet) Armodafinil (50MG Oral Tablet) G Maximum of 2 tablets per day ArmonAir Digihaler (Inhalation Aerosol B Maximum of 1 inhaler per 30 days Powder Breath Activated) Arnuity Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per B Breath Activated) 30 days Asacol HD (Oral Tablet Delayed Release) B Maximum of 6 tablets per day Asmanex (120 Metered Doses) (Inhalation B Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) Asmanex (30 Metered Doses) (110MCG/ INH Inhalation Aerosol Powder Breath B Maximum of 2 inhalers per 30 days Activated) Asmanex (30 Metered Doses) (220MCG/ INH Inhalation Aerosol Powder Breath B Maximum of 1 inhaler per 30 days Activated) Asmanex (60 Metered Doses) (Inhalation B Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) Maximum of 1 inhaler (13 grams) per Asmanex HFA (Inhalation Aerosol) B 30 days Aspirin-Dipyridamole ER (Oral Capsule G Maximum of 2 capsules per day Extended Release 12 Hour) Atacand HCT (Oral Tablet) B Maximum of 1 tablet per day Atacand (16MG Oral Tablet, 32MG Oral B Maximum of 1 tablet per day Tablet, 4MG Oral Tablet) Atacand (8MG Oral Tablet) B Maximum of 3 tablets per day Atazanavir Sulfate (150MG Oral Capsule, G Maximum of 1 capsule per day 300MG Oral Capsule) Atazanavir Sulfate (200MG Oral Capsule) G Maximum of 2 capsules per day Ativan (0.5MG Oral Tablet, 1MG Oral B Maximum of 4 tablets per day Tablet) Ativan (2MG Oral Tablet) B Maximum of 5 tablets per day Atorvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day Atripla (Oral Tablet) B Maximum of 1 tablet per day Aubagio (Oral Tablet) B Maximum of 1 tablet per day Austedo (Oral Tablet) B Maximum of 4 tablets per day Avalide (Oral Tablet) B Maximum of 1 tablet per day Avapro (150MG Oral Tablet, 300MG Oral B Maximum of 1 tablet per day Tablet) Avapro (75MG Oral Tablet) B Maximum of 3 tablets per day 162 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Ayvakit (100MG Oral Tablet, 200MG Oral B Maximum of 1 tablet per day Tablet, 300MG Oral Tablet) Azor (Oral Tablet) B Maximum of 1 tablet per day Bafiertam (Oral Capsule Delayed Release) B Maximum of 4 capsules per day Balversa (3MG Oral Tablet) B Maximum of 3 tablets per day Balversa (4MG Oral Tablet) B Maximum of 2 tablets per day Balversa (5MG Oral Tablet) B Maximum of 1 tablet per day BCG Vaccine (Injection) B 1 vaccination dose (1 vial) per day Belbuca (Buccal Film) B Maximum of 2 films per day Belsomra (Oral Tablet) B Maximum of 1 tablet per day Benazepril HCl (Oral Tablet) G Maximum of 2 tablets per day Benazepril-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day Benicar HCT (Oral Tablet) B Maximum of 1 tablet per day Benicar (20MG Oral Tablet, 40MG Oral B Maximum of 1 tablet per day Tablet) Benicar (5MG Oral Tablet) B Maximum of 2 tablets per day Bethkis (Inhalation Nebulization Solution) B Maximum of 2 ampules (8 ml) per day Bexsero (Intramuscular Suspension B 1 vaccination dose (0.5 ml) per day Prefilled Syringe) Biktarvy (Oral Tablet) B Maximum of 1 tablet per day Bisoprolol-Hydrochlorothiazide (Oral Tablet) G Maximum of 2 tablets per day Boostrix (5-2.5-18.5 Intramuscular Suspension, 5-2.5-18.5 (0.5ML Syringe) B 1 vaccination dose (0.5 ml) per day Intramuscular Suspension) Bosentan (Oral Tablet) G Maximum of 2 tablets per day Breo Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per B Breath Activated) 30 days Maximum of 1 inhaler (10.7 grams) Breztri Aerosphere (120 Inhalation Aerosol) B per 30 days Brilinta (Oral Tablet) B Maximum of 2 tablets per day BRIVIACT (10MG/ML Oral Solution) B Maximum of 20 ml per day BRIVIACT (100MG Oral Tablet, 10MG Oral Tablet, 25MG Oral Tablet, 50MG Oral B Maximum of 2 tablets per day Tablet, 75MG Oral Tablet) Bronchitol (Inhalation Capsule) B Maximum of 20 capsules per day Brovana (Inhalation Nebulization Solution) B Maximum of 2 vials (4 ml) per day Brukinsa (Oral Capsule) B Maximum of 4 capsules per day Budesonide-Formoterol Fumarate (Inhalation Maximum of 1 inhaler (10.2 grams) G Aerosol) per 30 days Last updated September 1, 2021 163

Brand Drug Name or Quantity Limit Generic

Buprenorphine HCl (Tablet Sublingual) G Maximum of 3 tablets per day Buprenorphine HCl-Naloxone HCl (12-3MG G Maximum of 2 films per day Sublingual Film, 4-1MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (2-0.5MG G Maximum of 3 films per day Sublingual Film, 8-2MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (Tablet G Maximum of 3 tablets per day Sublingual) Buprenorphine (Transdermal Patch Weekly) G Maximum of 4 patches per 28 days Maximum of 2 bottles (5 ml) per 30 Butorphanol Tartrate (Nasal Solution) G days Butrans (Transdermal Patch Weekly) B Maximum of 4 patches per 28 days Bydureon BCise (Subcutaneous Auto- Maximum of 4 pens (3.4 ml) per 28 B Injector) days Byetta 10MCG Pen (Subcutaneous Solution Maximum of 1 pen (2.4 ml) per 30 B Pen-Injector) days Byetta 5MCG Pen (Subcutaneous Solution Maximum of 1 pen (1.2 ml) per 30 B Pen-Injector) days Bystolic (10MG Oral Tablet, 2.5MG Oral B Maximum of 1 tablet per day Tablet, 5MG Oral Tablet) Bystolic (20MG Oral Tablet) B Maximum of 2 tablets per day Cablivi (Injection Kit) B Maximum of 1 kit per day Caduet (Oral Tablet) B Maximum of 1 tablet per day Canasa (Rectal Suppository) B Maximum of 1 suppository per day Candesartan Cilexetil (16MG Oral Tablet, G Maximum of 1 tablet per day 32MG Oral Tablet, 4MG Oral Tablet) Candesartan Cilexetil (8MG Oral Tablet) G Maximum of 3 tablets per day Candesartan Cilexetil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day Caplyta (Oral Capsule) B Maximum of 1 capsule per day Captopril (100MG Oral Tablet) G Maximum of 4 tablets per day Captopril (12.5MG Oral Tablet, 25MG Oral G Maximum of 3 tablets per day Tablet) Captopril (50MG Oral Tablet) G Maximum of 9 tablets per day Cardura XL (Oral Tablet Extended Release B Maximum of 1 tablet per day 24 Hour) Celebrex (Oral Capsule) B Maximum of 2 capsules per day Celecoxib (Oral Capsule) G Maximum of 2 capsules per day Cequa (Ophthalmic Solution) B Maximum of 2 vials per day Chloroquine Phosphate (Oral Tablet) G Maximum of 2 tablets per day Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) B Maximum of 1 tablet per day 164 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Cimduo (Oral Tablet) B Maximum of 1 tablet per day Cinacalcet HCl (30MG Oral Tablet, 60MG G Maximum of 2 tablets per day Oral Tablet) Cinacalcet HCl (90MG Oral Tablet) G Maximum of 4 tablets per day Clindagel (External Gel) B Maximum of 75 ml per 30 days Clindamycin Phosphate (External Gel) G Maximum of 75 grams per 30 days Clobazam (2.5MG/ML Oral Suspension) G Maximum of 16 ml per day Clobazam (10MG Oral Tablet, 20MG Oral G Maximum of 2 tablets per day Tablet) Clobetasol Propionate (External Foam) G Maximum of 100 grams per 30 days Clobetasol Propionate (External Liquid Spray) G Maximum of 125 ml per 30 days Clobetasol Propionate (External Lotion) G Maximum of 118 ml per 30 days Clobex (External Lotion) B Maximum of 118 ml per 30 days Clobex Spray (External Liquid) B Maximum of 125 ml per 30 days Clonazepam (0.5MG Oral Tablet, 1MG Oral G Maximum of 4 tablets per day Tablet) Clonazepam (2MG Oral Tablet) G Maximum of 10 tablets per day Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, G Maximum of 4 tablets per day 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible) Clonazepam ODT (2MG Oral Tablet G Maximum of 10 tablets per day Dispersible) Clopidogrel Bisulfate (75MG Oral Tablet) G Maximum of 4 tablets per day Clorazepate Dipotassium (15MG Oral Tablet) G Maximum of 6 tablets per day Clorazepate Dipotassium (3.75MG Oral G Maximum of 24 tablets per day Tablet) Clorazepate Dipotassium (7.5MG Oral Tablet) G Maximum of 12 tablets per day Clovique (Oral Capsule) G Maximum of 8 capsules per day Codeine Sulfate (15MG Oral Tablet) B Maximum of 6 tablets per day Codeine Sulfate (30MG Oral Tablet, 60MG G Maximum of 6 tablets per day Oral Tablet) Combivent Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per B Solution) 20 days Combivir (Oral Tablet) B Maximum of 2 tablets per day Complera (Oral Tablet) B Maximum of 1 tablet per day Concerta (18MG Oral Tablet Extended B Maximum of 3 tablets per day Release) Last updated September 1, 2021 165

Brand Drug Name or Quantity Limit Generic Concerta (27MG Oral Tablet Extended Release, 36MG Oral Tablet Extended B Maximum of 2 tablets per day Release) Concerta (54MG Oral Tablet Extended B Maximum of 1 tablet per day Release) ConZip (Oral Capsule Extended Release 24 B Maximum of 1 capsule per day Hour) Copiktra (Oral Capsule) B Maximum of 2 capsules per day Cordran (External Lotion) B Maximum of 240 ml per 30 days Corlanor (Oral Solution) B Maximum of 15 ml per day Corlanor (Oral Tablet) B Maximum of 2 tablets per day Cotempla XR-ODT (Oral Tablet Extended B Maximum of 2 tablets per day Release Dispersible) Cozaar (100MG Oral Tablet) B Maximum of 1 tablet per day Cozaar (25MG Oral Tablet, 50MG Oral B Maximum of 2 tablets per day Tablet) Crestor (Oral Tablet) B Maximum of 1 tablet per day Cymbalta (20MG Oral Capsule Delayed B Maximum of 4 capsules per day Release Particles) Cymbalta (30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule B Maximum of 2 capsules per day Delayed Release Particles) Dalfampridine ER (Oral Tablet Extended G Maximum of 2 tablets per day Release 12 Hour) Daptacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Darifenacin Hydrobromide ER (Oral Tablet G Maximum of 1 tablet per day Extended Release 24 Hour) Daurismo (100MG Oral Tablet) B Maximum of 1 tablet per day Daurismo (25MG Oral Tablet) B Maximum of 2 tablets per day Daytrana (Transdermal Patch) B Maximum of 1 patch per day DayVigo (Oral Tablet) B Maximum of 1 tablet per day Delstrigo (Oral Tablet) B Maximum of 1 tablet per day Descovy (Oral Tablet) B Maximum of 1 tablet per day Desoximetasone (External Cream) G Maximum of 100 grams per 30 days Dexedrine (10MG Oral Capsule Extended B Maximum of 6 capsules per day Release 24 Hour) Dexedrine (15MG Oral Capsule Extended B Maximum of 4 capsules per day Release 24 Hour) Dexedrine (5MG Oral Capsule Extended B Maximum of 3 capsules per day Release 24 Hour) 166 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Dexilant (Oral Capsule Delayed Release) B Maximum of 1 capsule per day Dexmethylphenidate HCl (Oral Tablet) G Maximum of 2 tablets per day Dextroamphetamine Sulfate ER (10MG Oral G Maximum of 6 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (15MG Oral G Maximum of 4 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (5MG Oral G Maximum of 3 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate (Oral Tablet) G Maximum of 6 tablets per day Diacomit (250MG Oral Capsule) B Maximum of 12 capsules per day Diacomit (500MG Oral Capsule) B Maximum of 6 capsules per day Diacomit (250MG Oral Packet) B Maximum of 12 packets per day Diacomit (500MG Oral Packet) B Maximum of 6 packets per day Diastat AcuDial (Rectal Gel) B Maximum of 5 packages per 30 days Diastat Pediatric (Rectal Gel) B Maximum of 5 packages per 30 days Diazepam Intensol (5MG/ML Oral G Maximum of 8 ml per day Concentrate) Diazepam (10MG Oral Tablet, 2MG Oral G Maximum of 4 tablets per day Tablet, 5MG Oral Tablet) Diazepam (10MG Rectal Gel, 2.5MG Rectal G Maximum of 5 packages per 30 days Gel, 20MG Rectal Gel) Diclofenac Epolamine (External Patch) G Maximum of 2 patches per day Diflorasone Diacetate (External Cream) G Maximum of 240 grams per 30 days Diflorasone Diacetate (External Ointment) G Maximum of 240 grams per 30 days Digitek (125MCG Oral Tablet) G Maximum of 1 tablet per day Digox (125MCG Oral Tablet) G Maximum of 1 tablet per day Digoxin (Oral Solution) G Maximum of 5 ml per day Digoxin (125MCG Oral Tablet) G Maximum of 1 tablet per day Maximum of 16 vials (16 ml) per 28 Dihydroergotamine Mesylate (Nasal Solution) G days Dilaudid (Oral Liquid) B Maximum of 50 ml per day Dilaudid (2MG Oral Tablet, 4MG Oral B Maximum of 8 tablets per day Tablet) Dilaudid (8MG Oral Tablet) B Maximum of 6 tablets per day Dimethyl Fumarate (120MG Oral Capsule Delayed Release, 240MG Oral Capsule G Maximum of 2 capsules per day Delayed Release) Diovan HCT (Oral Tablet) B Maximum of 1 tablet per day Last updated September 1, 2021 167

Brand Drug Name or Quantity Limit Generic Diovan (160MG Oral Tablet, 40MG Oral B Maximum of 2 tablets per day Tablet, 80MG Oral Tablet) Diovan (320MG Oral Tablet) B Maximum of 1 tablet per day Diphtheria-Tetanus Toxoids DT B 1 vaccination dose (0.5 ml) per day (Intramuscular Suspension) Donepezil HCl (10MG Oral Tablet) G Maximum of 2 tablets per day Donepezil HCl (23MG Oral Tablet, 5MG Oral G Maximum of 1 tablet per day Tablet) Donepezil HCl ODT (10MG Oral Tablet G Maximum of 2 tablets per day Dispersible) Donepezil HCl ODT (5MG Oral Tablet G Maximum of 1 tablet per day Dispersible) Dotti (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days Dovato (Oral Tablet) B Maximum of 1 tablet per day Doxepin HCl (External Cream) G Maximum of 90 grams per 30 days Drizalma Sprinkle (20MG Oral Capsule Delayed Release Sprinkle, 30MG Oral B Maximum of 2 capsules per day Capsule Delayed Release Sprinkle, 60MG Oral Capsule Delayed Release Sprinkle) Drizalma Sprinkle (40MG Oral Capsule B Maximum of 3 capsules per day Delayed Release Sprinkle) Droxidopa (100MG Oral Capsule) G Maximum of 3 capsules per day Droxidopa (200MG Oral Capsule, 300MG G Maximum of 6 capsules per day Oral Capsule) Duaklir Pressair (Inhalation Aerosol Powder B Maximum of 1 inhaler per 30 days Breath Activated) Duetact (Oral Tablet) B Maximum of 1 tablet per day Maximum of 1 inhaler (13 grams) per Dulera (120 Inhalation Aerosol) B 30 days Duloxetine HCl (20MG Oral Capsule Delayed G Maximum of 4 capsules per day Release Particles) Duloxetine HCl (30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule G Maximum of 2 capsules per day Delayed Release Particles) Duloxetine HCl (40MG Oral Capsule Delayed G Maximum of 3 capsules per day Release Particles) Dyanavel XR (Oral Suspension Extended B Maximum of 8 ml per day Release) Econazole Nitrate (External Cream) G Maximum of 90 grams per 30 days Edarbi (Oral Tablet) B Maximum of 1 tablet per day 168 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Edarbyclor (Oral Tablet) B Maximum of 1 tablet per day Edurant (Oral Tablet) B Maximum of 1 tablet per day Efavirenz (Oral Capsule) G Maximum of 3 capsules per day Efavirenz (Oral Tablet) G Maximum of 1 tablet per day Efavirenz-Emtricitabine-Tenofovir (Oral Tablet) G Maximum of 1 tablet per day Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G Maximum of 1 tablet per day Eletriptan Hydrobromide (Oral Tablet) G Maximum of 12 tablets per 30 days Elidel (External Cream) B Maximum of 100 grams per 30 days Eliquis (Oral Tablet) B Maximum of 2 tablets per day Maximum of 1 pack (74 tablets) per Eliquis Starter Pack (Oral Tablet) B 30 days Emgality (300MG Dose) (100MG/ML Maximum of 3 syringes or pens (3 ml) B Subcutaneous Solution Prefilled Syringe) per 30 days Emgality (Subcutaneous Solution Auto- Maximum of 2 syringes or pens (2 ml) B Injector) per 30 days Emgality (120MG/ML Subcutaneous Maximum of 2 syringes or pens (2 ml) B Solution Prefilled Syringe) per 30 days Emtricitabine (Oral Capsule) G Maximum of 1 capsule per day Emtricitabine-Tenofovir Disoproxil Fumarate G Maximum of 1 tablet per day (Oral Tablet) Emtriva (Oral Capsule) B Maximum of 1 capsule per day Maximum of 5 bottles (850 ml) per 30 Emtriva (Oral Solution) B days Enalapril Maleate (Oral Tablet) G Maximum of 2 tablets per day Enalapril-Hydrochlorothiazide (10-25MG Oral G Maximum of 2 tablets per day Tablet) Enalapril-Hydrochlorothiazide (5-12.5MG Oral G Maximum of 1 tablet per day Tablet) Endocet (10-325MG Oral Tablet, 5-325MG G Maximum of 12 tablets per day Oral Tablet, 7.5-325MG Oral Tablet) Engerix-B (10MCG/0.5ML Injection B 1 vaccination dose (0.5 ml) per day Suspension) Engerix-B (20MCG/ML Injection B 1 vaccination dose (1 ml) per day Suspension) Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML G Maximum of 2 syringes (2 ml) per day Subcutaneous Solution) Enoxaparin Sodium (120MG/0.8ML Maximum of 2 syringes (1.6 ml) per Subcutaneous Solution, 80MG/0.8ML G day Subcutaneous Solution) Last updated September 1, 2021 169

Brand Drug Name or Quantity Limit Generic

Enoxaparin Sodium (30MG/0.3ML Maximum of 2 syringes (0.6 ml) per G Subcutaneous Solution) day Enoxaparin Sodium (40MG/0.4ML Maximum of 2 syringes (0.8 ml) per G Subcutaneous Solution) day Enoxaparin Sodium (60MG/0.6ML Maximum of 2 syringes (1.2 ml) per G Subcutaneous Solution) day Entresto (Oral Tablet) B Maximum of 2 tablets per day Epclusa (200-50MG Oral Tablet) B Maximum of 2 tablets per day Epclusa (400-100MG Oral Tablet) B Maximum of 1 tablet per day Maximum of 4 pens (2 boxes) per 30 Epinephrine (Injection Solution Auto-Injector) G days EpiPen 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 B Injector) days EpiPen Jr 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 B Injector) days Epivir (10MG/ML Oral Solution) B Maximum of 32 ml per day Epivir (150MG Oral Tablet) B Maximum of 2 tablets per day Epivir (300MG Oral Tablet) B Maximum of 1 tablet per day Epzicom (Oral Tablet) B Maximum of 1 tablet per day Esbriet (Oral Capsule) B Maximum of 9 capsules per day Esbriet (267MG Oral Tablet) B Maximum of 9 tablets per day Esbriet (801MG Oral Tablet) B Maximum of 3 tablets per day Esomeprazole Magnesium (20MG Oral G Maximum of 3 capsules per day Capsule Delayed Release) (Generic Nexium) Esomeprazole Magnesium (40MG Oral G Maximum of 2 capsules per day Capsule Delayed Release) (Generic Nexium) Estradiol (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days Eucrisa (External Ointment) B Maximum of 100 grams per 30 days Evenity (Subcutaneous Solution Prefilled Maximum of 2 syringes (2.34 ml) per B Syringe) 28 days Evotaz (Oral Tablet) B Maximum of 1 tablet per day Evrysdi (Oral Solution Reconstituted) B Maximum of 8 ml per day Exelon (Transdermal Patch 24 Hour) B Maximum of 1 patch per day Exforge (Oral Tablet) B Maximum of 1 tablet per day Extina (External Foam) B Maximum of 100 grams per 28 days Ezallor Sprinkle (Oral Capsule Sprinkle) B Maximum of 1 capsule per day Ezetimibe-Simvastatin (Oral Tablet) G Maximum of 1 tablet per day 170 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, B Maximum of 2 tablets per day 4MG Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet) Farxiga (Oral Tablet) B Maximum of 1 tablet per day Fentanyl Citrate (1200MCG Buccal Lozenge On A Handle, 1600MCG Buccal Lozenge On A Handle, 200MCG Buccal Lozenge On A Handle, 400MCG Buccal Lozenge On A G Maximum of 4 lozenges per day Handle, 600MCG Buccal Lozenge On A Handle, 800MCG Buccal Lozenge On A Handle) Fentanyl Citrate (100MCG Buccal Tablet, 200MCG Buccal Tablet, 400MCG Buccal G Maximum of 4 tablets per day Tablet, 600MCG Buccal Tablet, 800MCG Buccal Tablet) Fentanyl (Transdermal Patch 72 Hour) G Maximum of 15 patches per 30 days Fentora (Buccal Tablet) B Maximum of 4 tablets per day Fintepla (Oral Solution) B Maximum of 12 ml per day Firazyr (Subcutaneous Solution) B Maximum of 3 syringes (9 ml) per day Firdapse (Oral Tablet) B Maximum of 8 tablets per day Flector (External Patch) B Maximum of 2 patches per day FloLipid (20MG/5ML Oral Suspension) B Maximum of 5 ml per day FloLipid (40MG/5ML Oral Suspension) B Maximum of 10 ml per day Flovent HFA (110MCG/ACT Inhalation Maximum of 1 inhaler (12 grams) per B Aerosol) 30 days Flovent HFA (220MCG/ACT Inhalation Maximum of 2 inhalers (24 grams) B Aerosol) per 30 days Flovent HFA (44MCG/ACT Inhalation Maximum of 1 inhaler (10.6 grams) B Aerosol) per 30 days Flurandrenolide (External Lotion) G Maximum of 240 ml per 30 days Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Maximum of 1 inhaler (60 blisters) per G Powder Breath Activated, 500-50MCG/DOSE 30 days Inhalation Aerosol Powder Breath Activated) (Generic Advair) Last updated September 1, 2021 171

Brand Drug Name or Quantity Limit Generic

Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder G Maximum of 1 inhaler per 30 days Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo) Fluvastatin Sodium ER (Oral Tablet Extended G Maximum of 1 tablet per day Release 24 Hour) Fluvastatin Sodium (20MG Oral Capsule) G Maximum of 1 capsule per day Fluvastatin Sodium (40MG Oral Capsule) G Maximum of 2 capsules per day Focalin (Oral Tablet) B Maximum of 2 tablets per day Fortamet (1000MG Oral Tablet Extended B Maximum of 2 tablets per day Release 24 Hour) Fortamet (500MG Oral Tablet Extended B Maximum of 5 tablets per day Release 24 Hour) Fosamprenavir Calcium (Oral Tablet) G Maximum of 4 tablets per day Fosinopril Sodium (Oral Tablet) G Maximum of 2 tablets per day Fosinopril Sodium-HCTZ (Oral Tablet) G Maximum of 4 tablets per day Fotivda (Oral Capsule) B Maximum of 1 capsule per day Frova (Oral Tablet) B Maximum of 12 tablets per 30 days Frovatriptan Succinate (Oral Tablet) G Maximum of 12 tablets per 30 days Fuzeon (Subcutaneous Solution B Maximum of 2 vials per day Reconstituted) Fycompa (Oral Suspension) B Maximum of 24 ml per day Fycompa (Oral Tablet) B Maximum of 1 tablet per day Gardasil 9 (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Gardasil 9 (Intramuscular Suspension B 1 vaccination dose (0.5 ml) per day Prefilled Syringe) Gavreto (Oral Capsule) B Maximum of 4 capsules per day Genvoya (Oral Tablet) B Maximum of 1 tablet per day Geodon (Oral Capsule) B Maximum of 2 capsules per day Maximum of 1 pack (30 capsules) per Gilenya (0.5MG Oral Capsule) B 30 days Gleevec (Oral Tablet) B Maximum of 3 tablets per day Glimepiride (1MG Oral Tablet) G Maximum of 8 tablets per day Glimepiride (2MG Oral Tablet) G Maximum of 4 tablets per day Glimepiride (4MG Oral Tablet) G Maximum of 2 tablets per day Glipizide ER (10MG Oral Tablet Extended G Maximum of 2 tablets per day Release 24 Hour) 172 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Glipizide ER (2.5MG Oral Tablet Extended G Maximum of 8 tablets per day Release 24 Hour) Glipizide ER (5MG Oral Tablet Extended G Maximum of 4 tablets per day Release 24 Hour) Glipizide (10MG Oral Tablet Immediate G Maximum of 4 tablets per day Release) Glipizide (5MG Oral Tablet Immediate G Maximum of 8 tablets per day Release) Glipizide-Metformin HCl (2.5-250MG Oral G Maximum of 8 tablets per day Tablet) Glipizide-Metformin HCl (2.5-500MG Oral G Maximum of 4 tablets per day Tablet, 5-500MG Oral Tablet) Gloperba (Oral Solution) B Maximum of 20 ml per day Glucotrol XL (10MG Oral Tablet Extended B Maximum of 2 tablets per day Release 24 Hour) Glucotrol XL (2.5MG Oral Tablet Extended B Maximum of 8 tablets per day Release 24 Hour) Glucotrol XL (5MG Oral Tablet Extended B Maximum of 4 tablets per day Release 24 Hour) Glumetza (1000MG Oral Tablet Extended B Maximum of 2 tablets per day Release 24 Hour) Glumetza (500MG Oral Tablet Extended B Maximum of 4 tablets per day Release 24 Hour) Glyxambi (Oral Tablet) B Maximum of 1 tablet per day Maximum of 1 carton (28 packets) Harvoni (33.75-150MG Oral Packet) B per 28 days Maximum of 2 cartons (56 packets) Harvoni (45-200MG Oral Packet) B per 28 days Harvoni (90-400MG Oral Tablet) B Maximum of 1 tablet per day Havrix (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime Hetlioz LQ (Oral Suspension) B Maximum of 158 ml per 30 days Hetlioz (Oral Capsule) B Maximum of 1 capsule per day 1 vaccination dose (1 injection) per Hiberix (Injection Solution Reconstituted) B day Last updated September 1, 2021 173

Brand Drug Name or Quantity Limit Generic

Hydrocodone Bitartrate ER (10MG Oral Capsule Extended Release 12 Hour, 15MG Oral Capsule Extended Release 12 Hour, 20MG Oral Capsule Extended Release 12 G Maximum of 2 capsules per day Hour, 30MG Oral Capsule Extended Release 12 Hour, 40MG Oral Capsule Extended Release 12 Hour, 50MG Oral Capsule Extended Release 12 Hour) Hydrocodone Bitartrate ER (100MG Oral Tablet ER 24 Hour Abuse-Deterrent, 120MG Oral Tablet ER 24 Hour Abuse-Deterrent, 20MG Oral Tablet ER 24 Hour Abuse- Deterrent, 30MG Oral Tablet ER 24 Hour G Maximum of 1 tablet per day Abuse-Deterrent, 40MG Oral Tablet ER 24 Hour Abuse-Deterrent, 60MG Oral Tablet ER 24 Hour Abuse-Deterrent, 80MG Oral Tablet ER 24 Hour Abuse-Deterrent) Hydrocodone-Acetaminophen (7.5-325MG/ G Maximum of 180 ml per day 15ML Oral Solution) Hydrocodone-Acetaminophen (10-300MG Oral Tablet, 5-300MG Oral Tablet, 7.5-300MG G Maximum of 13 tablets per day Oral Tablet) Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG G Maximum of 12 tablets per day Oral Tablet) Hydrocodone-Ibuprofen (Oral Tablet) G Maximum of 5 tablets per day Hydrocortisone Butyrate (External Lotion) G Maximum of 118 ml per 30 days Hydromorphone HCl ER (Oral Tablet G Maximum of 2 tablets per day Extended Release 24 Hour) Hydromorphone HCl (1MG/ML Oral Liquid) G Maximum of 50 ml per day Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet G Maximum of 8 tablets per day Immediate Release) Hydromorphone HCl (8MG Oral Tablet G Maximum of 6 tablets per day Immediate Release) Hydroxychloroquine Sulfate (Oral Tablet) G Maximum of 3 tablets per day Hysingla ER (Oral Tablet ER 24 Hour B Maximum of 1 tablet per day Abuse-Deterrent) Hyzaar (100-12.5MG Oral Tablet, B Maximum of 1 tablet per day 100-25MG Oral Tablet) Hyzaar (50-12.5MG Oral Tablet) B Maximum of 2 tablets per day 174 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Icatibant Acetate (Subcutaneous Solution) G Maximum of 3 syringes (9 ml) per day Imatinib Mesylate (Oral Tablet) G Maximum of 3 tablets per day Imbruvica (140MG Oral Capsule) B Maximum of 4 capsules per day Imbruvica (70MG Oral Capsule) B Maximum of 1 capsule per day Imbruvica (Oral Tablet) B Maximum of 1 tablet per day Imiquimod (5% External Cream) G Maximum of 24 grams per 30 days Imitrex (Nasal Solution) B Maximum of 12 devices per 30 days Imitrex (Oral Tablet) B Maximum of 12 tablets per 30 days Imitrex STATdose Refill (6MG/0.5ML Maximum of 12 injections (6 ml) per B Subcutaneous Solution Cartridge) 30 days Imitrex STATdose System (4MG/0.5ML Maximum of 12 injections (6 ml) per B Subcutaneous Solution Auto-Injector) 30 days Maximum of 12 injections (6 ml) per Imitrex (Subcutaneous Solution) B 30 days 1 vaccination dose (1 injection) per Imovax Rabies (Intramuscular Injectable) B day Impeklo (External Lotion) B Maximum of 68 grams per 30 days Incruse Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per B Breath Activated) 30 days Infanrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Ingrezza (40MG Oral Capsule, 80MG Oral B Maximum of 1 capsule per day Capsule) Maximum of 1 pack (28 capsules) per Ingrezza (Oral Capsule Therapy Pack) B 28 days Inlyta (Oral Tablet) B Maximum of 4 tablets per day Maximum of 1 pack (5 tablets) per 28 Inqovi (Oral Tablet) B days Inrebic (Oral Capsule) B Maximum of 4 capsules per day Intelence (100MG Oral Tablet, 200MG Oral B Maximum of 2 tablets per day Tablet) Intelence (25MG Oral Tablet) B Maximum of 4 tablets per day Intrarosa (Vaginal Insert) B Maximum of 1 vaginal insert per day Invega (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet B Maximum of 1 tablet per day Extended Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour) Invega (6MG Oral Tablet Extended Release B Maximum of 2 tablets per day 24 Hour) Invirase (Oral Tablet) B Maximum of 4 tablets per day Last updated September 1, 2021 175

Brand Drug Name or Quantity Limit Generic

Invokamet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day Invokamet XR (Oral Tablet Extended B Maximum of 2 tablets per day Release 24 Hour) Invokana (Oral Tablet) B Maximum of 1 tablet per day IPOL (Injection) B 1 vaccination dose (0.5 ml) per day Irbesartan (150MG Oral Tablet, 300MG Oral G Maximum of 1 tablet per day Tablet) Irbesartan (75MG Oral Tablet) G Maximum of 3 tablets per day Irbesartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day Iressa (Oral Tablet) B Maximum of 2 tablets per day Isentress HD (Oral Tablet) B Maximum of 2 tablets per day Isentress (Oral Packet) B Maximum of 2 packets per day Isentress (Oral Tablet) B Maximum of 2 tablets per day Isentress (Oral Tablet Chewable) B Maximum of 6 tablets per day Ixiaro (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Jakafi (Oral Tablet) B Maximum of 2 tablets per day Janumet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day Janumet XR (100-1000MG Oral Tablet B Maximum of 1 tablet per day Extended Release 24 Hour) Janumet XR (50-1000MG Oral Tablet Extended Release 24 Hour, 50-500MG Oral B Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Januvia (Oral Tablet) B Maximum of 1 tablet per day Jardiance (Oral Tablet) B Maximum of 1 tablet per day Jentadueto (Oral Tablet Immediate B Maximum of 2 tablets per day Release) Jentadueto XR (2.5-1000MG Oral Tablet B Maximum of 2 tablets per day Extended Release 24 Hour) Jentadueto XR (5-1000MG Oral Tablet B Maximum of 1 tablet per day Extended Release 24 Hour) Jornay PM (Oral Capsule Extended Release B Maximum of 1 capsule per day 24 Hour) Juluca (Oral Tablet) B Maximum of 1 tablet per day Jynarque (Oral Tablet Therapy Pack) B Maximum of 2 tablets per day Maximum of 3 bottles (480 ml) per 30 Kaletra (Oral Solution) B days Kaletra (100-25MG Oral Tablet) B Maximum of 8 tablets per day Kaletra (200-50MG Oral Tablet) B Maximum of 4 tablets per day Kazano (Oral Tablet) B Maximum of 2 tablets per day 176 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Ketoconazole (External Cream) G Maximum of 90 grams per 30 days Ketoconazole (External Foam) G Maximum of 100 grams per 28 days Ketodan (External Foam) G Maximum of 100 grams per 28 days Keveyis (Oral Tablet) B Maximum of 4 tablets per day Kinrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Klonopin (0.5MG Oral Tablet, 1MG Oral B Maximum of 4 tablets per day Tablet) Klonopin (2MG Oral Tablet) B Maximum of 10 tablets per day Kombiglyze XR (2.5-1000MG Oral Tablet B Maximum of 2 tablets per day Extended Release 24 Hour) Kombiglyze XR (5-1000MG Oral Tablet Extended Release 24 Hour, 5-500MG Oral B Maximum of 1 tablet per day Tablet Extended Release 24 Hour) Koselugo (10MG Oral Capsule) B Maximum of 8 capsules per day Koselugo (25MG Oral Capsule) B Maximum of 4 capsules per day Kynmobi (10MG Sublingual Film, 15MG Sublingual Film, 20MG Sublingual Film, B Maximum of 5 films per day 25MG Sublingual Film, 30MG Sublingual Film) Lamivudine (10MG/ML Oral Solution) G Maximum of 32 ml per day Lamivudine (150MG Oral Tablet) G Maximum of 2 tablets per day Lamivudine (300MG Oral Tablet) G Maximum of 1 tablet per day Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day Lanoxin (125MCG Oral Tablet) B Maximum of 1 tablet per day Lanoxin (62.5MCG Oral Tablet) B Maximum of 2 tablets per day Lansoprazole (Oral Capsule Delayed G Maximum of 2 capsules per day Release) Latuda (120MG Oral Tablet, 20MG Oral Tablet, 40MG Oral Tablet, 60MG Oral B Maximum of 1 tablet per day Tablet) Latuda (80MG Oral Tablet) B Maximum of 2 tablets per day Lazanda (Nasal Solution) B Maximum of 30 bottles per 30 days Ledipasvir-Sofosbuvir (Oral Tablet) G Maximum of 1 tablet per day Lescol XL (Oral Tablet Extended Release B Maximum of 1 tablet per day 24 Hour) Letairis (Oral Tablet) B Maximum of 1 tablet per day Levorphanol Tartrate (Oral Tablet) G Maximum of 6 tablets per day Lexiva (Oral Suspension) B Maximum of 60 ml per day Lexiva (Oral Tablet) B Maximum of 4 tablets per day Last updated September 1, 2021 177

Brand Drug Name or Quantity Limit Generic

Lialda (Oral Tablet Delayed Release) B Maximum of 4 tablets per day Licart (External Patch 24 Hour) B Maximum of 1 patch per day Lidocaine (5% External Ointment) G Maximum of 152 grams per 30 days Lidocaine (5% External Patch) G Maximum of 3 patches per day Lidoderm (External Patch) B Maximum of 3 patches per day Linzess (Oral Capsule) B Maximum of 1 capsule per day Lipitor (Oral Tablet) B Maximum of 1 tablet per day Lisinopril (Oral Tablet) G Maximum of 2 tablets per day Lisinopril-Hydrochlorothiazide (10-12.5MG G Maximum of 1 tablet per day Oral Tablet) Lisinopril-Hydrochlorothiazide (20-12.5MG G Maximum of 4 tablets per day Oral Tablet) Lisinopril-Hydrochlorothiazide (20-25MG Oral G Maximum of 2 tablets per day Tablet) Livalo (Oral Tablet) B Maximum of 1 tablet per day Locoid (External Lotion) B Maximum of 118 ml per 30 days Lokelma (Oral Packet) B Maximum of 90 packets per 30 days Lonhala Magnair (Inhalation Solution) B Maximum of 2 vials (2 ml) per day Maximum of 3 bottles (480 ml) per 30 Lopinavir-Ritonavir (Oral Solution) G days Lorazepam Intensol (Oral Concentrate) G Maximum of 5 ml per day Lorazepam (0.5MG Oral Tablet, 1MG Oral G Maximum of 4 tablets per day Tablet) Lorazepam (2MG Oral Tablet) G Maximum of 5 tablets per day Lorbrena (100MG Oral Tablet) B Maximum of 1 tablet per day Lorbrena (25MG Oral Tablet) B Maximum of 3 tablets per day Losartan Potassium (100MG Oral Tablet) G Maximum of 1 tablet per day Losartan Potassium (25MG Oral Tablet, G Maximum of 2 tablets per day 50MG Oral Tablet) Losartan Potassium-HCTZ (100-12.5MG Oral G Maximum of 1 tablet per day Tablet, 100-25MG Oral Tablet) Losartan Potassium-HCTZ (50-12.5MG Oral G Maximum of 2 tablets per day Tablet) Lotensin (Oral Tablet) B Maximum of 2 tablets per day Lotrel (Oral Capsule) B Maximum of 1 capsule per day Lovastatin (10MG Oral Tablet, 20MG Oral G Maximum of 1 tablet per day Tablet) Lovastatin (40MG Oral Tablet) G Maximum of 2 tablets per day 178 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Lovenox (100MG/ML Subcutaneous Solution, 150MG/ML Subcutaneous B Maximum of 2 syringes (2 ml) per day Solution) Lovenox (120MG/0.8ML Subcutaneous Maximum of 2 syringes (1.6 ml) per Solution, 80MG/0.8ML Subcutaneous B day Solution) Lovenox (30MG/0.3ML Subcutaneous Maximum of 2 syringes (0.6 ml) per B Solution) day Lovenox (40MG/0.4ML Subcutaneous Maximum of 2 syringes (0.8 ml) per B Solution) day Lovenox (60MG/0.6ML Subcutaneous Maximum of 2 syringes (1.2 ml) per B Solution) day Lubiprostone (Oral Capsule) G Maximum of 2 capsules per day Lucemyra (Oral Tablet) B Maximum of 16 tablets per day Luliconazole (External Cream) B Maximum of 60 grams per 28 days Lupkynis (Oral Capsule) B Maximum of 6 capsules per day Luzu (External Cream) B Maximum of 60 grams per 28 days Lyllana (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days Lyrica CR (165MG Oral Tablet Extended Release 24 Hour, 82.5MG Oral Tablet B Maximum of 3 tablets per day Extended Release 24 Hour) Lyrica CR (330MG Oral Tablet Extended B Maximum of 2 tablets per day Release 24 Hour) Lyrica (100MG Oral Capsule, 150MG Oral Capsule, 25MG Oral Capsule, 50MG Oral B Maximum of 4 capsules per day Capsule, 75MG Oral Capsule) Lyrica (200MG Oral Capsule) B Maximum of 3 capsules per day Lyrica (225MG Oral Capsule, 300MG Oral B Maximum of 2 capsules per day Capsule) Lyrica (Oral Solution) B Maximum of 30 ml per day Mavyret (Oral Tablet) B Maximum of 3 tablets per day Maxalt (Oral Tablet) B Maximum of 12 tablets per 30 days Maxalt-MLT (Oral Tablet Dispersible) B Maximum of 12 tablets per 30 days Mayzent (0.25MG Oral Tablet) B Maximum of 8 tablets per day Mayzent (2MG Oral Tablet) B Maximum of 1 tablet per day Meloxicam (Oral Capsule) G Maximum of 1 capsule per day Memantine HCl ER (Oral Capsule Extended G Maximum of 1 capsule per day Release 24 Hour) Memantine HCl (2MG/ML Oral Solution) G Maximum of 10 ml per day Last updated September 1, 2021 179

Brand Drug Name or Quantity Limit Generic

Memantine HCl (10MG Oral Tablet) G Maximum of 2 tablets per day Memantine HCl (5MG Oral Tablet) G Maximum of 3 tablets per day Menactra (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day MenQuadfi (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day Menveo (Intramuscular Solution 1 vaccination dose (1 injection) per B Reconstituted) day Mesalamine ER (0.375GM Oral Capsule G Maximum of 4 capsules per day Extended Release 24 Hour) (Generic Apriso) Mesalamine (1.2GM Oral Tablet Delayed G Maximum of 4 tablets per day Release) (Generic Lialda) Mesalamine (800MG Oral Tablet Delayed G Maximum of 6 tablets per day Release) (Generic Asacol) Mesalamine (Rectal Suppository) G Maximum of 1 suppository per day Metformin HCl ER (1000MG Oral Tablet Extended Release 24 Hour) (Generic G Maximum of 2 tablets per day Glumetza) Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic G Maximum of 4 tablets per day Glumetza) Metformin HCl ER (1000MG Oral Tablet Extended Release 24 Hour) (Generic G Maximum of 2 tablets per day Fortamet) Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic G Maximum of 5 tablets per day Fortamet) Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic G Maximum of 4 tablets per day Glucophage XR) Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic G Maximum of 2 tablets per day Glucophage XR) Metformin HCl (500MG/5ML Oral Solution) G Maximum of 25.5 ml per day Metformin HCl (1000MG Oral Tablet G Maximum of 2.5 tablets per day Immediate Release) Metformin HCl (500MG Oral Tablet G Maximum of 5 tablets per day Immediate Release) Metformin HCl (850MG Oral Tablet G Maximum of 3 tablets per day Immediate Release) Methadone HCl (10MG/5ML Oral Solution) G Maximum of 60 ml per day Methadone HCl (5MG/5ML Oral Solution) G Maximum of 120 ml per day 180 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Methadone HCl (10MG Oral Tablet) G Maximum of 12 tablets per day Methadone HCl (5MG Oral Tablet) G Maximum of 8 tablets per day Methylin (10MG/5ML Oral Solution) B Maximum of 30 ml per day Methylin (5MG/5ML Oral Solution) B Maximum of 60 ml per day Methylphenidate HCl ER (XR) (Oral Capsule Extended Release 24 Hour) (Brand G Maximum of 1 capsule per day Equivalent Aptensio XR) Methylphenidate HCl ER (10MG Oral Tablet G Maximum of 4 tablets per day Extended Release) Methylphenidate HCl ER Osmotic Release (18MG Oral Tablet Extended Release) (Generic Concerta), Methylphenidate HCl ER G Maximum of 3 tablets per day (20MG Oral Tablet Extended Release) (Generic Metadate ER) Methylphenidate HCl ER (18MG Oral Tablet G Maximum of 3 tablets per day Extended Release 24 Hour) Methylphenidate HCl ER (27MG Oral Tablet Extended Release 24 Hour, 36MG Oral Tablet G Maximum of 2 tablets per day Extended Release 24 Hour) Methylphenidate HCl ER (54MG Oral Tablet G Maximum of 1 tablet per day Extended Release 24 Hour) Methylphenidate HCl ER Osmotic Release (27MG Oral Tablet Extended Release, 36MG G Maximum of 2 tablets per day Oral Tablet Extended Release) (Generic Concerta) Methylphenidate HCl ER Osmotic Release (54MG Oral Tablet Extended Release, 72MG G Maximum of 1 tablet per day Oral Tablet Extended Release) (Generic Concerta) Methylphenidate HCl (10MG/5ML Oral G Maximum of 30 ml per day Solution) Methylphenidate HCl (5MG/5ML Oral G Maximum of 60 ml per day Solution) Methylphenidate HCl (Oral Tablet Immediate G Maximum of 3 tablets per day Release) (Generic Ritalin) Methylphenidate HCl (10MG Oral Tablet G Maximum of 6 tablets per day Chewable) Methylphenidate HCl (2.5MG Oral Tablet G Maximum of 3 tablets per day Chewable, 5MG Oral Tablet Chewable) Micardis HCT (40-12.5MG Oral Tablet, B Maximum of 1 tablet per day 80-25MG Oral Tablet) Last updated September 1, 2021 181

Brand Drug Name or Quantity Limit Generic

Micardis HCT (80-12.5MG Oral Tablet) B Maximum of 2 tablets per day Micardis (Oral Tablet) B Maximum of 1 tablet per day Maximum of 16 vials (16 ml) per 28 Migranal (Nasal Solution) B days Minivelle (Transdermal Patch Twice B Maximum of 8 patches per 28 days Weekly) Minocycline HCl ER (Oral Tablet Extended G Maximum of 1 tablet per day Release 24 Hour) Minolira (Oral Tablet Extended Release 24 B Maximum of 1 tablet per day Hour) 1 vaccination dose (1 injection) per M-M-R II (Injection Solution Reconstituted) B day Modafinil (100MG Oral Tablet) G Maximum of 1 tablet per day Modafinil (200MG Oral Tablet) G Maximum of 2 tablets per day Moexipril HCl (Oral Tablet) G Maximum of 2 tablets per day Montelukast Sodium (Oral Packet) G Maximum of 1 packet per day Montelukast Sodium (Oral Tablet) G Maximum of 1 tablet per day Montelukast Sodium (Oral Tablet Chewable) G Maximum of 1 tablet per day Morphine Sulfate (100MG/5ML Oral Solution) G Maximum of 10 ml per day Morphine Sulfate ER Beads (120MG Oral Capsule Extended Release 24 Hour) (Generic G Maximum of 3 capsules per day Avinza) Morphine Sulfate ER Beads (30MG Oral Capsule Extended Release 24 Hour, 45MG Oral Capsule Extended Release 24 Hour, G Maximum of 2 capsules per day 60MG Oral Capsule Extended Release 24 Hour) (Generic Avinza) Morphine Sulfate ER Beads (75MG Oral Capsule Extended Release 24 Hour, 90MG G Maximum of 4 capsules per day Oral Capsule Extended Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (100MG Oral Capsule Extended Release 24 Hour, 60MG Oral Capsule Extended Release 24 Hour, 80MG G Maximum of 3 capsules per day Oral Capsule Extended Release 24 Hour) (Generic Kadian) 182 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Morphine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour, 20MG Oral Capsule Extended Release 24 Hour, 30MG Oral Capsule Extended Release 24 Hour, G Maximum of 2 capsules per day 40MG Oral Capsule Extended Release 24 Hour, 50MG Oral Capsule Extended Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet G Maximum of 3 tablets per day Extended Release) (Generic MS Contin) Morphine Sulfate ER (200MG Oral Tablet G Maximum of 2 tablets per day Extended Release) (Generic MS Contin) Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet G Maximum of 4 tablets per day Extended Release) (Generic MS Contin) Morphine Sulfate (10MG/5ML Oral Solution) G Maximum of 100 ml per day Morphine Sulfate (20MG/5ML Oral Solution) G Maximum of 50 ml per day Morphine Sulfate (15MG Oral Tablet G Maximum of 8 tablets per day Immediate Release) Morphine Sulfate (30MG Oral Tablet G Maximum of 6 tablets per day Immediate Release) Motegrity (Oral Tablet) B Maximum of 1 tablet per day Movantik (Oral Tablet) B Maximum of 1 tablet per day MS Contin (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended B Maximum of 3 tablets per day Release) MS Contin (200MG Oral Tablet Extended B Maximum of 2 tablets per day Release) MS Contin (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended B Maximum of 4 tablets per day Release) Mupirocin (External Ointment) G Maximum of 110 grams per 30 days Maximum of 112 capsules per 28 Mycapssa (Oral Capsule Delayed Release) B days Mydayis (12.5MG Oral Capsule Extended Release 24 Hour, 25MG Oral Capsule B Maximum of 2 capsules per day Extended Release 24 Hour) Mydayis (37.5MG Oral Capsule Extended Release 24 Hour, 50MG Oral Capsule B Maximum of 1 capsule per day Extended Release 24 Hour) Namenda (10MG Oral Tablet) B Maximum of 2 tablets per day Last updated September 1, 2021 183

Brand Drug Name or Quantity Limit Generic

Namenda (5MG Oral Tablet) B Maximum of 3 tablets per day Namenda XR (Oral Capsule Extended B Maximum of 1 capsule per day Release 24 Hour) Namzaric (Oral Capsule ER 24 Hour B Maximum of 1 capsule per day Therapy Pack) Namzaric (Oral Capsule Extended Release B Maximum of 1 capsule per day 24 Hour) Naratriptan HCl (Oral Tablet) G Maximum of 12 tablets per 30 days Nateglinide (120MG Oral Tablet) G Maximum of 3 tablets per day Nateglinide (60MG Oral Tablet) G Maximum of 6 tablets per day Nayzilam (Nasal Solution) B Maximum of 10 devices per 30 days Nebupent (Inhalation Solution Maximum of 1 vial (300 mg) per 28 B Reconstituted) days Nerlynx (Oral Tablet) B Maximum of 6 tablets per day Nesina (Oral Tablet) B Maximum of 1 tablet per day Nevirapine ER (100MG Oral Tablet Extended G Maximum of 2 tablets per day Release 24 Hour) Nevirapine ER (400MG Oral Tablet Extended G Maximum of 1 tablet per day Release 24 Hour) Nevirapine (Oral Suspension) G Maximum of 40 ml per day Nevirapine (Oral Tablet Immediate Release) G Maximum of 2 tablets per day Nexium (20MG Oral Capsule Delayed B Maximum of 3 capsules per day Release) Nexium (40MG Oral Capsule Delayed B Maximum of 2 capsules per day Release) Nexletol (Oral Tablet) B Maximum of 1 tablet per day Nexlizet (Oral Tablet) B Maximum of 1 tablet per day Nolix (External Lotion) G Maximum of 240 ml per 30 days Northera (100MG Oral Capsule) B Maximum of 3 capsules per day Northera (200MG Oral Capsule, 300MG B Maximum of 6 capsules per day Oral Capsule) Norvir (Oral Packet) B Maximum of 12 packets per day Norvir (Oral Solution) B Maximum of 16 ml per day Norvir (Oral Tablet) B Maximum of 12 tablets per day Nourianz (Oral Tablet) B Maximum of 1 tablet per day Noxafil (Oral Suspension) B Maximum of 20 ml per day Noxafil (Oral Tablet Delayed Release) B Maximum of 6 tablets per day Nucala (Subcutaneous Solution Auto- B Maximum of 3 ml per 28 days Injector) 184 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Nucala (Subcutaneous Solution Prefilled B Maximum of 3 ml per 28 days Syringe) Nucala (Subcutaneous Solution B Maximum of 3 vials per 28 days Reconstituted) Nucynta ER (Oral Tablet Extended Release B Maximum of 2 tablets per day 12 Hour) Nucynta (Oral Tablet Immediate Release) B Maximum of 6 tablets per day Nuedexta (Oral Capsule) B Maximum of 2 capsules per day Nuplazid (Oral Capsule) B Maximum of 1 capsule per day Nuplazid (Oral Tablet) B Maximum of 1 tablet per day Nurtec ODT (Oral Tablet Dispersible) B Maximum of 18 tablets per 30 days Nuvigil (150MG Oral Tablet, 200MG Oral B Maximum of 1 tablet per day Tablet, 250MG Oral Tablet) Nuvigil (50MG Oral Tablet) B Maximum of 2 tablets per day Nuzyra (Oral Tablet) B Maximum of 2 tablets per day Nyamyc (External Powder) G Maximum of 120 grams per 30 days Nystatin (External Powder) G Maximum of 120 grams per 30 days Nystop (External Powder) G Maximum of 120 grams per 30 days Ocaliva (Oral Tablet) B Maximum of 1 tablet per day Odefsey (Oral Tablet) B Maximum of 1 tablet per day Odomzo (Oral Capsule) B Maximum of 1 capsule per day Ofev (Oral Capsule) B Maximum of 2 capsules per day Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, G Maximum of 1 tablet per day 5MG Oral Tablet, 7.5MG Oral Tablet) Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, G Maximum of 1 tablet per day 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible) Olmesartan Medoxomil (20MG Oral Tablet, G Maximum of 1 tablet per day 40MG Oral Tablet) Olmesartan Medoxomil (5MG Oral Tablet) G Maximum of 2 tablets per day Olmesartan Medoxomil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day Olmesartan-Amlodipine-HCTZ (Oral Tablet) G Maximum of 1 tablet per day Olumiant (Oral Tablet) B Maximum of 1 tablet per day Olux (External Foam) B Maximum of 100 grams per 30 days Olux-E (External Foam) B Maximum of 100 grams per 30 days Omeprazole (10MG Oral Capsule Delayed G Maximum of 3 capsules per day Release) Last updated September 1, 2021 185

Brand Drug Name or Quantity Limit Generic

Onfi (Oral Suspension) B Maximum of 16 ml per day Onfi (Oral Tablet) B Maximum of 2 tablets per day Ongentys (Oral Capsule) B Maximum of 1 capsule per day Onglyza (Oral Tablet) B Maximum of 1 tablet per day Onureg (Oral Tablet) B Maximum of 14 tablets per 28 days Maximum of 1 kit (16 exhalers) per 30 Onzetra Xsail (Nasal Exhaler Powder) B days Orgovyx (Oral Tablet) B Maximum of 1 tablet per day Maximum of 1 pack (56 capsules) per Oriahnn (Oral Capsule Therapy Pack) B 28 days Orilissa (150MG Oral Tablet) B Maximum of 1 tablet per day Orilissa (200MG Oral Tablet) B Maximum of 2 tablets per day Orkambi (Oral Packet) B Maximum of 56 packets per 28 days Orkambi (Oral Tablet) B Maximum of 112 tablets per 28 days Orladeyo (Oral Capsule) B Maximum of 1 capsule per day Oseni (Oral Tablet) B Maximum of 1 tablet per day Osphena (Oral Tablet) B Maximum of 1 tablet per day Oxbryta (Oral Tablet) B Maximum of 5 tablets per day Oxervate (Ophthalmic Solution) B Maximum of 2 vials (2 ml) per day Oxiconazole Nitrate (External Cream) G Maximum of 90 grams per 30 days Oxistat (External Cream) B Maximum of 90 grams per 30 days Oxistat (External Lotion) B Maximum of 60 ml per 30 days Oxycodone HCl ER (Oral Tablet ER 12 Hour G Maximum of 3 tablets per day Abuse-Deterrent) Oxycodone HCl (5MG Oral Capsule) G Maximum of 12 capsules per day Oxycodone HCl (100MG/5ML Oral G Maximum of 6 ml per day Concentrate) Oxycodone HCl (5MG/5ML Oral Solution) G Maximum of 130 ml per day Oxycodone HCl (10MG Oral Tablet Immediate Release, 5MG Oral Tablet G Maximum of 12 tablets per day Immediate Release) Oxycodone HCl (15MG Oral Tablet G Maximum of 8 tablets per day Immediate Release) Oxycodone HCl (20MG Oral Tablet Immediate Release, 30MG Oral Tablet G Maximum of 6 tablets per day Immediate Release) Oxycodone-Acetaminophen (10-300MG Oral G Maximum of 13 tablets per day Tablet, 5-300MG Oral Tablet) 186 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral G Maximum of 12 tablets per day Tablet, 7.5-325MG Oral Tablet) OxyContin (Oral Tablet ER 12 Hour Abuse- B Maximum of 3 tablets per day Deterrent) Oxymorphone HCl ER (10MG Oral Tablet Extended Release 12 Hour, 15MG Oral Tablet Extended Release 12 Hour, 20MG Oral Tablet G Maximum of 2 tablets per day Extended Release 12 Hour, 5MG Oral Tablet Extended Release 12 Hour, 7.5MG Oral Tablet Extended Release 12 Hour) Oxymorphone HCl ER (30MG Oral Tablet G Maximum of 4 tablets per day Extended Release 12 Hour) Oxymorphone HCl ER (40MG Oral Tablet G Maximum of 3 tablets per day Extended Release 12 Hour) Oxymorphone HCl (Oral Tablet Immediate G Maximum of 6 tablets per day Release) Ozempic (0.25MG/DOSE or 0.5MG/DOSE) Maximum of 1 pen (1.5 ml) per 28 B (Subcutaneous Solution Pen-Injector) days Ozempic (1MG/DOSE) (2MG/1.5ML Maximum of 2 pens (3 ml) per 28 B Subcutaneous Solution Pen-Injector) days Ozempic (1MG/DOSE) (4MG/3ML B Maximum of 1 pen (3 ml) per 28 days Subcutaneous Solution Pen-Injector) Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet G Maximum of 1 tablet per day Extended Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour) Paliperidone ER (6MG Oral Tablet Extended G Maximum of 2 tablets per day Release 24 Hour) Palynziq (10MG/0.5ML Subcutaneous B Maximum of 28 syringes per 28 days Solution Prefilled Syringe) Palynziq (2.5MG/0.5ML Subcutaneous B Maximum of 8 syringes per 28 days Solution Prefilled Syringe) Palynziq (20MG/ML Subcutaneous B Maximum of 56 syringes per 28 days Solution Prefilled Syringe) Pantoprazole Sodium (20MG Oral Tablet G Maximum of 3 tablets per day Delayed Release) Pantoprazole Sodium (40MG Oral Tablet G Maximum of 2 tablets per day Delayed Release) Pediarix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Pedvax HIB (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Last updated September 1, 2021 187

Brand Drug Name or Quantity Limit Generic

Pemazyre (Oral Tablet) B Maximum of 1 tablet per day Pentamidine Isethionate (Inhalation Solution Maximum of 1 vial (300 mg) per 28 G Reconstituted) days Pentasa (250MG Oral Capsule Extended B Maximum of 12 capsules per day Release) Pentasa (500MG Oral Capsule Extended B Maximum of 8 capsules per day Release) Percocet (Oral Tablet) G Maximum of 12 tablets per day Perforomist (Inhalation Nebulization B Maximum of 2 vials (4 ml) per day Solution) Perindopril Erbumine (Oral Tablet) G Maximum of 2 tablets per day Picato (0.015% External Gel) B Maximum of 3 tubes per 30 days Picato (0.05% External Gel) B Maximum of 2 tubes per 30 days Pifeltro (Oral Tablet) B Maximum of 1 tablet per day Pimecrolimus (External Cream) G Maximum of 100 grams per 30 days Pioglitazone HCl (15MG Oral Tablet) G Maximum of 3 tablets per day Pioglitazone HCl (30MG Oral Tablet, 45MG G Maximum of 1 tablet per day Oral Tablet) Pioglitazone HCl-Glimepiride (Oral Tablet) G Maximum of 1 tablet per day Pioglitazone HCl-Metformin HCl (Oral Tablet) G Maximum of 3 tablets per day Piqray (200MG Daily Dose) (Oral Tablet B Maximum of 1 tablet per day Therapy Pack) Piqray (250MG Daily Dose) (Oral Tablet B Maximum of 2 tablets per day Therapy Pack) Piqray (300MG Daily Dose) (Oral Tablet B Maximum of 2 tablets per day Therapy Pack) Plaquenil (Oral Tablet) B Maximum of 3 tablets per day Plavix (Oral Tablet) B Maximum of 4 tablets per day Posaconazole (Oral Tablet Delayed Release) G Maximum of 6 tablets per day Pradaxa (Oral Capsule) B Maximum of 2 capsules per day Praluent (Subcutaneous Solution Auto- Maximum of 2 pens (2 ml) per 28 B Injector) days Pravastatin Sodium (Oral Tablet) G Maximum of 1 tablet per day Pregabalin ER (165MG Oral Tablet Extended Release 24 Hour, 82.5MG Oral Tablet G Maximum of 3 tablets per day Extended Release 24 Hour) Pregabalin ER (330MG Oral Tablet Extended G Maximum of 2 tablets per day Release 24 Hour) 188 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 25MG Oral Capsule, 50MG G Maximum of 4 capsules per day Oral Capsule, 75MG Oral Capsule) Pregabalin (200MG Oral Capsule) G Maximum of 3 capsules per day Pregabalin (225MG Oral Capsule, 300MG G Maximum of 2 capsules per day Oral Capsule) Pregabalin (Oral Solution) G Maximum of 30 ml per day Prevacid (Oral Capsule Delayed Release) B Maximum of 2 capsules per day Prevymis (Oral Tablet) B Maximum of 1 tablet per day Prezcobix (Oral Tablet) B Maximum of 1 tablet per day Maximum of 2 bottles (400 ml) per 30 Prezista (Oral Suspension) B days Prezista (150MG Oral Tablet) B Maximum of 6 tablets per day Prezista (600MG Oral Tablet, 75MG Oral B Maximum of 2 tablets per day Tablet) Prezista (800MG Oral Tablet) B Maximum of 1 tablet per day Prinivil (Oral Tablet) B Maximum of 2 tablets per day Prolate (Oral Tablet) G Maximum of 13 tablets per day Prolia (Subcutaneous Solution Prefilled B Maximum of 1 syringe per 180 days Syringe) Promacta (Oral Packet) B Maximum of 6 packets per day Promacta (12.5MG Oral Tablet, 25MG Oral B Maximum of 1 tablet per day Tablet) Promacta (50MG Oral Tablet, 75MG Oral B Maximum of 2 tablets per day Tablet) ProQuad (Subcutaneous Suspension 1 vaccination dose (1 injection) per B Reconstituted) day Protonix (20MG Oral Tablet Delayed B Maximum of 3 tablets per day Release) Protonix (40MG Oral Tablet Delayed B Maximum of 2 tablets per day Release) Provigil (100MG Oral Tablet) B Maximum of 1 tablet per day Provigil (200MG Oral Tablet) B Maximum of 2 tablets per day PRUDOXIN (External Cream) B Maximum of 90 grams per 30 days Psorcon (External Cream) G Maximum of 240 grams per 30 days Pulmozyme (Inhalation Solution) B Maximum of 2 ampules (5 ml) per day Qbrelis (Oral Solution) B Maximum of 80 ml per day Qinlock (Oral Tablet) B Maximum of 3 tablets per day Qtern (Oral Tablet) B Maximum of 1 tablet per day Last updated September 1, 2021 189

Brand Drug Name or Quantity Limit Generic

Quadracel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral G Maximum of 1 tablet per day Tablet Extended Release 24 Hour) Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral G Maximum of 2 tablets per day Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet G Maximum of 3 tablets per day Immediate Release, 50MG Oral Tablet Immediate Release) Quetiapine Fumarate (25MG Oral Tablet G Maximum of 4 tablets per day Immediate Release) Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet G Maximum of 2 tablets per day Immediate Release) QuilliChew ER (20MG Oral Tablet Chewable Extended Release, 40MG Oral B Maximum of 1 tablet per day Tablet Chewable Extended Release) QuilliChew ER (30MG Oral Tablet B Maximum of 2 tablets per day Chewable Extended Release) Quinapril HCl (Oral Tablet) G Maximum of 2 tablets per day Quinapril-Hydrochlorothiazide (10-12.5MG G Maximum of 1 tablet per day Oral Tablet) Quinapril-Hydrochlorothiazide (20-12.5MG G Maximum of 2 tablets per day Oral Tablet, 20-25MG Oral Tablet) QVAR RediHaler (Inhalation Aerosol Breath Maximum of 2 inhalers (21.2 grams) B Activated) per 30 days RabAvert (Intramuscular Suspension 1 vaccination dose (1 injection) per B Reconstituted) day Ramipril (Oral Capsule) G Maximum of 2 capsules per day Rapaflo (Oral Capsule) B Maximum of 1 capsule per day Rayaldee (Oral Capsule Extended Release) B Maximum of 2 capsules per day Recombivax HB (10MCG/ML Injection Suspension, 10MCG/ML (1ML Syringe) B 1 vaccination dose (1 ml) per day Injection Suspension, 40MCG/ML Injection Suspension) Recombivax HB (5MCG/0.5ML Injection B 1 vaccination dose (0.5 ml) per day Suspension) Rectiv (Rectal Ointment) B Maximum of 30 grams per 30 days 190 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Relexxii (Oral Tablet Extended Release) G Maximum of 1 tablet per day Relpax (Oral Tablet) B Maximum of 12 tablets per 30 days Repaglinide (0.5MG Oral Tablet) G Maximum of 32 tablets per day Repaglinide (1MG Oral Tablet) G Maximum of 16 tablets per day Repaglinide (2MG Oral Tablet) G Maximum of 8 tablets per day Repatha Pushtronex System Maximum of 1 cartridge (3.5 ml) per B (Subcutaneous Solution Cartridge) 28 days Repatha (Subcutaneous Solution Prefilled Maximum of 3 syringes (3 ml) per 28 B Syringe) days Repatha SureClick (Subcutaneous Solution Maximum of 3 pens (3 ml) per 28 B Auto-Injector) days Restasis Single-Use Vials (Ophthalmic B Maximum of 2 vials per day Emulsion) Restoril (22.5MG Oral Capsule) B Maximum of 1 capsule per day Retevmo (40MG Oral Capsule) B Maximum of 6 capsules per day Retevmo (80MG Oral Capsule) B Maximum of 4 capsules per day Retrovir (Oral Capsule) B Maximum of 6 capsules per day Retrovir (Oral Syrup) B Maximum of 64 ml per day Rexulti (Oral Tablet) B Maximum of 1 tablet per day Reyataz (150MG Oral Capsule, 300MG Oral B Maximum of 1 capsule per day Capsule) Reyataz (200MG Oral Capsule) B Maximum of 2 capsules per day Reyataz (Oral Packet) B Maximum of 6 packets per day Reyvow (100MG Oral Tablet) B Maximum of 8 tablets per 30 days Reyvow (50MG Oral Tablet) B Maximum of 4 tablets per 30 days Rinvoq (Oral Tablet Extended Release 24 B Maximum of 1 tablet per day Hour) Riomet (Oral Solution) B Maximum of 25.5 ml per day Ritalin (Oral Tablet) B Maximum of 3 tablets per day Ritonavir (Oral Tablet) G Maximum of 12 tablets per day Rivastigmine (Transdermal Patch 24 Hour) G Maximum of 1 patch per day Rizatriptan Benzoate (Oral Tablet) G Maximum of 12 tablets per 30 days Rizatriptan Benzoate ODT (Oral Tablet G Maximum of 12 tablets per 30 days Dispersible) Rosuvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day Roszet (Oral Tablet) B Maximum of 1 tablet per day Rotarix (Oral Suspension Reconstituted) B 1 vaccination dose (1 ml) per day RotaTeq (Oral Solution) B 1 vaccination dose (2 ml) per day Last updated September 1, 2021 191

Brand Drug Name or Quantity Limit Generic

Roxicodone (15MG Oral Tablet) B Maximum of 8 tablets per day Roxicodone (30MG Oral Tablet) B Maximum of 6 tablets per day Roxicodone (5MG Oral Tablet) B Maximum of 12 tablets per day Rozlytrek (100MG Oral Capsule) B Maximum of 5 capsules per day Rozlytrek (200MG Oral Capsule) B Maximum of 3 capsules per day Rukobia (Oral Tablet Extended Release 12 B Maximum of 2 tablets per day Hour) Ruzurgi (Oral Tablet) B Maximum of 10 tablets per day Rybelsus (Oral Tablet) B Maximum of 1 tablet per day Rydapt (Oral Capsule) B Maximum of 8 capsules per day Sabril (Oral Packet) B Maximum of 6 packets per day Sabril (Oral Tablet) B Maximum of 6 tablets per day Sancuso (Transdermal Patch) B Maximum of 4 patches per 28 days Savaysa (Oral Tablet) B Maximum of 1 tablet per day Secuado (Transdermal Patch 24 Hour) B Maximum of 1 patch per day Segluromet (2.5-1000MG Oral Tablet, 7.5-1000MG Oral Tablet, 7.5-500MG Oral B Maximum of 2 tablets per day Tablet) Segluromet (2.5-500MG Oral Tablet) B Maximum of 4 tablets per day Maximum of 8 bottles (1840 ml) per Selzentry (Oral Solution) B 30 days Selzentry (150MG Oral Tablet, 75MG Oral B Maximum of 2 tablets per day Tablet) Selzentry (25MG Oral Tablet, 300MG Oral B Maximum of 4 tablets per day Tablet) Sensipar (30MG Oral Tablet, 60MG Oral B Maximum of 2 tablets per day Tablet) Sensipar (90MG Oral Tablet) B Maximum of 4 tablets per day Serevent Diskus (60 Inhalation Aerosol Maximum of 1 inhaler (60 inhalations) B Powder Breath Activated) per 30 days Seroquel (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate B Maximum of 3 tablets per day Release, 50MG Oral Tablet Immediate Release) Seroquel (25MG Oral Tablet Immediate B Maximum of 4 tablets per day Release) Seroquel (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate B Maximum of 2 tablets per day Release) 192 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Seroquel XR (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet B Maximum of 1 tablet per day Extended Release 24 Hour) Seroquel XR (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet B Maximum of 2 tablets per day Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) Shingrix (Intramuscular Suspension 1 vaccination dose (1 injection) per B Reconstituted) day Silodosin (Oral Capsule) G Maximum of 1 capsule per day Simvastatin (Oral Tablet) G Maximum of 1 tablet per day Singulair (Oral Packet) B Maximum of 1 packet per day Singulair (Oral Tablet) B Maximum of 1 tablet per day Singulair (Oral Tablet Chewable) B Maximum of 1 tablet per day Sofosbuvir-Velpatasvir (Oral Tablet) G Maximum of 1 tablet per day Solifenacin Succinate (Oral Tablet) G Maximum of 1 tablet per day Soliqua (Subcutaneous Solution Pen- Maximum of 6 pens (18 ml) per 30 B Injector) days Solodyn (Oral Tablet Extended Release 24 B Maximum of 1 tablet per day Hour) Somavert (Subcutaneous Solution B Maximum of 1 vial per day Reconstituted) Maximum of 1 carton (28 packets) Sovaldi (150MG Oral Packet) B per 28 days Maximum of 2 cartons (56 packets) Sovaldi (200MG Oral Packet) B per 28 days Sovaldi (400MG Oral Tablet) B Maximum of 1 tablet per day Spiriva HandiHaler (Inhalation Capsule) B Maximum of 1 capsule per day Spiriva Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per B Solution) 30 days Steglatro (15MG Oral Tablet) B Maximum of 1 tablet per day Steglatro (5MG Oral Tablet) B Maximum of 2 tablets per day Steglujan (Oral Tablet) B Maximum of 1 tablet per day Stribild (Oral Tablet) B Maximum of 1 tablet per day Suboxone (12-3MG Sublingual Film, 4-1MG B Maximum of 2 films per day Sublingual Film) Suboxone (2-0.5MG Sublingual Film, B Maximum of 3 films per day 8-2MG Sublingual Film) Last updated September 1, 2021 193

Brand Drug Name or Quantity Limit Generic Subsys (100MCG Sublingual Liquid, 200MCG Sublingual Liquid, 400MCG B Maximum of 4 sprays per day Sublingual Liquid, 600MCG Sublingual Liquid, 800MCG Sublingual Liquid) Subsys (1200 (600 X 2)MCG Sublingual Liquid, 1600 (800 X 2)MCG Sublingual B Maximum of 8 sprays per day Liquid) Sumatriptan (Nasal Solution) G Maximum of 12 devices per 30 days Sumatriptan Succinate (100MG Oral Tablet, G Maximum of 12 tablets per 30 days 25MG Oral Tablet, 50MG Oral Tablet) Sumatriptan Succinate Refill (Subcutaneous Maximum of 12 injections (6 ml) per G Solution Cartridge) 30 days Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per G Subcutaneous Solution) 30 days Sumatriptan Succinate (4MG/0.5ML Maximum of 12 injections (6 ml) per Subcutaneous Solution Auto-Injector, 6MG/ G 30 days 0.5ML Subcutaneous Solution Auto-Injector) Sumatriptan-Naproxen Sodium (Oral Tablet) G Maximum of 9 tablets per 30 days Sunosi (Oral Tablet) B Maximum of 1 tablet per day Sustiva (Oral Capsule) B Maximum of 3 capsules per day Sustiva (Oral Tablet) B Maximum of 1 tablet per day Maximum of 1 inhaler (10.2 grams) Symbicort (120 Inhalation Aerosol) B per 30 days Maximum of 1 pack (56 tablets) per Symdeko (Oral Tablet Therapy Pack) B 28 days Symfi Lo (Oral Tablet) B Maximum of 1 tablet per day Symfi (Oral Tablet) B Maximum of 1 tablet per day Symjepi (Injection Solution Prefilled B Maximum of 4 syringes per 30 days Syringe) Sympazan (Oral Film) B Maximum of 2 films per day Symproic (Oral Tablet) B Maximum of 1 tablet per day Symtuza (Oral Tablet) B Maximum of 1 tablet per day Synjardy (Oral Tablet Immediate Release) B Maximum of 2 tablets per day Synjardy XR (10-1000MG Oral Tablet Extended Release 24 Hour, 25-1000MG B Maximum of 1 tablet per day Oral Tablet Extended Release 24 Hour) Synjardy XR (12.5-1000MG Oral Tablet Extended Release 24 Hour, 5-1000MG Oral B Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Syprine (Oral Capsule) B Maximum of 8 capsules per day 194 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Tabrecta (Oral Tablet) B Maximum of 4 tablets per day Tadalafil (2.5MG Oral Tablet, 5MG Oral G Maximum of 1 tablet per day Tablet) Talzenna (0.25MG Oral Capsule) B Maximum of 3 capsules per day Talzenna (1MG Oral Capsule) B Maximum of 1 capsule per day Targretin (External Gel) B Maximum of 60 grams per 30 days Tasmar (Oral Tablet) B Maximum of 6 tablets per day Tavalisse (Oral Tablet) B Maximum of 2 tablets per day Tazverik (Oral Tablet) B Maximum of 8 tablets per day TDVAX (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day Tecfidera (Oral Capsule Delayed Release) B Maximum of 2 capsules per day Tekturna HCT (Oral Tablet) B Maximum of 1 tablet per day Tekturna (Oral Tablet) B Maximum of 1 tablet per day Telmisartan (Oral Tablet) G Maximum of 1 tablet per day Telmisartan-Amlodipine (Oral Tablet) G Maximum of 1 tablet per day Telmisartan-HCTZ (40-12.5MG Oral Tablet, G Maximum of 1 tablet per day 80-25MG Oral Tablet) Telmisartan-HCTZ (80-12.5MG Oral Tablet) G Maximum of 2 tablets per day Temazepam (Oral Capsule) G Maximum of 1 capsule per day Temixys (Oral Tablet) B Maximum of 1 tablet per day Tenivac (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day Tenofovir Disoproxil Fumarate (Oral Tablet) G Maximum of 1 tablet per day Tepmetko (Oral Tablet) B Maximum of 2 tablets per day Thalomid (100MG Oral Capsule, 50MG Oral B Maximum of 1 capsule per day Capsule) Thalomid (150MG Oral Capsule, 200MG B Maximum of 2 capsules per day Oral Capsule) Tibsovo (Oral Tablet) B Maximum of 2 tablets per day Tivicay (10MG Oral Tablet, 25MG Oral B Maximum of 1 tablet per day Tablet) Tivicay (50MG Oral Tablet) B Maximum of 2 tablets per day Tivicay PD (Oral Tablet Soluble) B Maximum of 6 tablets per day Maximum of 2 ampules (10 ml) per TOBI (Inhalation Nebulization Solution) B day TOBI Podhaler (Inhalation Capsule) B Maximum of 8 capsules per day Tobramycin (300MG/4ML Inhalation G Maximum of 2 ampules (8 ml) per day Nebulization Solution) Tobramycin (300MG/5ML Inhalation Maximum of 2 ampules (10 ml) per G Nebulization Solution) day Last updated September 1, 2021 195

Brand Drug Name or Quantity Limit Generic

Tolcapone (Oral Tablet) G Maximum of 6 tablets per day Topicort (External Cream) G Maximum of 100 grams per 30 days Tosymra (Nasal Solution) B Maximum of 12 devices per 30 days Toviaz (Oral Tablet Extended Release 24 B Maximum of 1 tablet per day Hour) Tracleer (Oral Tablet) B Maximum of 2 tablets per day Tracleer (Oral Tablet Soluble) B Maximum of 8 tablets per day Tradjenta (Oral Tablet) B Maximum of 1 tablet per day Tramadol HCl ER (Biphasic) (Oral Tablet G Maximum of 1 tablet per day Extended Release 24 Hour) Tramadol HCl ER (100MG Oral Capsule Extended Release 24 Hour, 200MG Oral G Maximum of 1 capsule per day Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour) Tramadol HCl ER (100MG Oral Tablet Extended Release 24 Hour, 200MG Oral G Maximum of 1 tablet per day Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour) Tramadol HCl (100MG Oral Tablet Immediate G Maximum of 4 tablets per day Release) Tramadol HCl (50MG Oral Tablet Immediate G Maximum of 8 tablets per day Release) Tramadol-Acetaminophen (Oral Tablet) G Maximum of 8 tablets per day Trandolapril (1MG Oral Tablet, 2MG Oral G Maximum of 1 tablet per day Tablet) Trandolapril (4MG Oral Tablet) G Maximum of 2 tablets per day Trandolapril-Verapamil HCl ER (Oral Tablet G Maximum of 1 tablet per day Extended Release) Tranxene-T (Oral Tablet) B Maximum of 12 tablets per day Trelegy Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per B Breath Activated) 30 days Treximet (Oral Tablet) B Maximum of 9 tablets per 30 days Trezix (Oral Capsule) G Maximum of 10 capsules per day Tribenzor (Oral Tablet) B Maximum of 1 tablet per day Trientine HCl (Oral Capsule) G Maximum of 8 capsules per day Trijardy XR (10-5-1000MG Oral Tablet Extended Release 24 Hour, 25-5-1000MG B Maximum of 1 tablet per day Oral Tablet Extended Release 24 Hour) 196 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Trijardy XR (12.5-2.5-1000MG Oral Tablet Extended Release 24 Hour, 5-2.5-1000MG B Maximum of 2 tablets per day Oral Tablet Extended Release 24 Hour) Trikafta (100-50-75 & 150MG Oral Tablet Maximum of 1 pack (84 tablets) per B Therapy Pack) 28 days Triumeq (Oral Tablet) B Maximum of 1 tablet per day Trizivir (Oral Tablet) B Maximum of 2 tablets per day Trulicity (Subcutaneous Solution Pen- Maximum of 4 pens (2 ml) per 28 B Injector) days Trumenba (Intramuscular Suspension B 1 vaccination dose (0.5 ml) per day Prefilled Syringe) Truvada (Oral Tablet) B Maximum of 1 tablet per day Tukysa (150MG Oral Tablet) B Maximum of 4 tablets per day Tukysa (50MG Oral Tablet) B Maximum of 12 tablets per day Turalio (Oral Capsule) B Maximum of 4 capsules per day Twinrix (Intramuscular Suspension B 1 vaccination dose (1 ml) per day Prefilled Syringe) Twynsta (Oral Tablet) B Maximum of 1 tablet per day Tybost (Oral Tablet) B Maximum of 1 tablet per day Typhim Vi (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per day Ubrelvy (Oral Tablet) B Maximum of 16 tablets per 30 days Ukoniq (Oral Tablet) B Maximum of 4 tablets per day Ultracet (Oral Tablet) B Maximum of 8 tablets per day Ultram (Oral Tablet Immediate Release) B Maximum of 8 tablets per day Uptravi (1000MCG Oral Tablet, 1200MCG Oral Tablet, 1400MCG Oral Tablet, 1600MCG Oral Tablet, 400MCG Oral B Maximum of 2 tablets per day Tablet, 600MCG Oral Tablet, 800MCG Oral Tablet) Uptravi (200MCG Oral Tablet) B Maximum of 5 tablets per day Valacyclovir HCl (1GM Oral Tablet) G Maximum of 4 tablets per day Valacyclovir HCl (500MG Oral Tablet) G Maximum of 2 tablets per day Valchlor (External Gel) B Maximum of 60 grams per 30 days Valcyte (Oral Solution Reconstituted) B Maximum of 36 ml per day Valcyte (Oral Tablet) B Maximum of 4 tablets per day Valganciclovir HCl (50MG/ML Oral Solution G Maximum of 36 ml per day Reconstituted) Valganciclovir HCl (450MG Oral Tablet) G Maximum of 4 tablets per day Valium (Oral Tablet) B Maximum of 4 tablets per day Last updated September 1, 2021 197

Brand Drug Name or Quantity Limit Generic

Valsartan (160MG Oral Tablet, 40MG Oral G Maximum of 2 tablets per day Tablet, 80MG Oral Tablet) Valsartan (320MG Oral Tablet) G Maximum of 1 tablet per day Valsartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day Maximum of 10 blister packs (10 Valtoco 10 MG Dose (Nasal Liquid) B spray devices) per 30 days Valtoco 15 MG Dose (Nasal Liquid Therapy Maximum of 10 blister packs (20 B Pack) spray devices) per 30 days Valtoco 20 MG Dose (Nasal Liquid Therapy Maximum of 10 blister packs (20 B Pack) spray devices) per 30 days Maximum of 10 blister packs (10 Valtoco 5 MG Dose (Nasal Liquid) B spray devices) per 30 days Valtrex (1GM Oral Tablet) B Maximum of 4 tablets per day Valtrex (500MG Oral Tablet) B Maximum of 2 tablets per day Vancocin HCl (125MG Oral Capsule) B Maximum of 4 capsules per day Vancocin (250MG Oral Capsule) B Maximum of 8 capsules per day Vancomycin HCl (125MG Oral Capsule) G Maximum of 4 capsules per day Vancomycin HCl (250MG Oral Capsule) G Maximum of 8 capsules per day VAQTA (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime 1 vaccination dose (1 injection) per Varivax (Subcutaneous Injectable) B day Vaseretic (Oral Tablet) B Maximum of 2 tablets per day Vasotec (Oral Tablet) B Maximum of 2 tablets per day Veltassa (Oral Packet) B Maximum of 1 packet per day Verquvo (Oral Tablet) B Maximum of 1 tablet per day Vesicare LS (Oral Suspension) B Maximum of 10 ml per day Vesicare (Oral Tablet) B Maximum of 1 tablet per day Viberzi (Oral Tablet) B Maximum of 2 tablets per day Victoza (Subcutaneous Solution Pen- Maximum of 3 pens (9 ml) per 30 B Injector) days Maximum of 1 pack (112 tablets) per Viekira Pak (Oral Tablet Therapy Pack) B 28 days Vigabatrin (Oral Packet) G Maximum of 6 packets per day Vigabatrin (Oral Tablet) G Maximum of 6 tablets per day Vigadrone (Oral Packet) G Maximum of 6 packets per day Vimpat (Oral Solution) B Maximum of 40 ml per day Vimpat (Oral Tablet) B Maximum of 2 tablets per day Viracept (250MG Oral Tablet) B Maximum of 10 tablets per day Viracept (625MG Oral Tablet) B Maximum of 4 tablets per day 198 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic

Viramune (Oral Suspension) B Maximum of 40 ml per day Viramune XR (Oral Tablet Extended B Maximum of 1 tablet per day Release 24 Hour) Maximum of 4 bottles (240 grams) Viread (Oral Powder) B per 30 days Viread (Oral Tablet) B Maximum of 1 tablet per day Vitrakvi (100MG Oral Capsule) B Maximum of 4 capsules per day Vitrakvi (25MG Oral Capsule) B Maximum of 6 capsules per day Vitrakvi (Oral Solution) B Maximum of 20 ml per day Vivelle-Dot (Transdermal Patch Twice B Maximum of 8 patches per 28 days Weekly) Vivlodex (Oral Capsule) B Maximum of 1 capsule per day Vosevi (Oral Tablet) B Maximum of 1 tablet per day Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule, 4.5MG Oral Capsule, 6MG Oral B Maximum of 1 capsule per day Capsule) Vumerity (Oral Capsule Delayed Release) B Maximum of 4 capsules per day (Maintenance Dose Bottle) Vyndamax (Oral Capsule) B Maximum of 1 capsule per day Vyndaqel (Oral Capsule) B Maximum of 4 capsules per day Vytorin (Oral Tablet) B Maximum of 1 tablet per day Wakix (Oral Tablet) B Maximum of 2 tablets per day Wixela Inhub (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per G Breath Activated) (Generic Advair) 30 days Xanax (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate B Maximum of 4 tablets per day Release, 1MG Oral Tablet Immediate Release) Xanax (2MG Oral Tablet Immediate B Maximum of 5 tablets per day Release) Xanax XR (0.5MG Oral Tablet Extended Release 24 Hour, 1MG Oral Tablet B Maximum of 1 tablet per day Extended Release 24 Hour) Xanax XR (2MG Oral Tablet Extended B Maximum of 5 tablets per day Release 24 Hour) Xanax XR (3MG Oral Tablet Extended B Maximum of 3 tablets per day Release 24 Hour) Xarelto (10MG Oral Tablet, 20MG Oral B Maximum of 1 tablet per day Tablet) Last updated September 1, 2021 199

Brand Drug Name or Quantity Limit Generic Xarelto (15MG Oral Tablet, 2.5MG Oral B Maximum of 2 tablets per day Tablet) Xarelto Starter Pack (Oral Tablet Therapy Maximum of 1 pack (51 tablets) per B Pack) 30 days Xcopri (250MG Daily Dose) (Oral Tablet Maximum of 1 pack (56 tablets) per B Therapy Pack) 28 days Xcopri (350MG Daily Dose) (Oral Tablet Maximum of 1 pack (56 tablets) per B Therapy Pack) 28 days Xcopri (100MG Oral Tablet, 50MG Oral B Maximum of 1 tablet per day Tablet) Xcopri (150MG Oral Tablet, 200MG Oral B Maximum of 2 tablets per day Tablet) Maximum of 1 pack (28 tablets) per Xcopri (Oral Tablet Titration Therapy Pack) B 28 days Xeljanz (Oral Solution) B Maximum of 10 ml per day Xeljanz (Oral Tablet Immediate Release) B Maximum of 2 tablets per day Xeljanz XR (Oral Tablet Extended Release B Maximum of 1 tablet per day 24 Hour) Xenleta (Oral Tablet) B Maximum of 2 tablets per day Xermelo (Oral Tablet) B Maximum of 3 tablets per day Xigduo XR (10-1000MG Oral Tablet Extended Release 24 Hour, 10-500MG Oral Tablet Extended Release 24 Hour, B Maximum of 1 tablet per day 5-500MG Oral Tablet Extended Release 24 Hour) Xigduo XR (2.5-1000MG Oral Tablet Extended Release 24 Hour, 5-1000MG Oral B Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Xiidra (Ophthalmic Solution) B Maximum of 2 vials per day Xofluza (40MG Dose) (2 x 20MG Oral B Maximum of 2 tablets per 30 days Tablet Therapy Pack) Xofluza (80MG Dose) (2 x 40MG Oral B Maximum of 2 tablets per 30 days Tablet Therapy Pack) Xolegel (External Gel) B Maximum of 90 grams per 30 days Xospata (Oral Tablet) B Maximum of 3 tablets per day Xpovio (100MG Once Weekly) (20MG Oral B Maximum of 20 tablets per 28 days Tablet Therapy Pack) Xpovio (100MG Once Weekly) (50MG Oral B Maximum of 8 tablets per 28 days Tablet Therapy Pack) 200 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Xpovio (40MG Once Weekly) (20MG Oral B Maximum of 8 tablets per 28 days Tablet Therapy Pack) Xpovio (40MG Once Weekly) (40MG Oral B Maximum of 4 tablets per 28 days Tablet Therapy Pack) Xpovio (40MG Twice Weekly) (20MG Oral B Maximum of 16 tablets per 28 days Tablet Therapy Pack) Xpovio (40MG Twice Weekly) (40MG Oral B Maximum of 8 tablets per 28 days Tablet Therapy Pack) Xpovio (60MG Once Weekly) (20MG Oral B Maximum of 12 tablets per 28 days Tablet Therapy Pack) Xpovio (60MG Once Weekly) (60MG Oral B Maximum of 4 tablets per 28 days Tablet Therapy Pack) Xpovio (60MG Twice Weekly) (Oral Tablet B Maximum of 24 tablets per 28 days Therapy Pack) Xpovio (80MG Once Weekly) (20MG Oral B Maximum of 16 tablets per 28 days Tablet Therapy Pack) Xpovio (80MG Once Weekly) (40MG Oral B Maximum of 8 tablets per 28 days Tablet Therapy Pack) Xpovio (80MG Twice Weekly) (Oral Tablet B Maximum of 32 tablets per 28 days Therapy Pack) Xtampza ER (13.5MG Oral Capsule ER 12 Hour Abuse-Deterrent, 18MG Oral Capsule B Maximum of 3 capsules per day ER 12 Hour Abuse-Deterrent, 9MG Oral Capsule ER 12 Hour Abuse-Deterrent) Xtampza ER (27MG Oral Capsule ER 12 Hour Abuse-Deterrent, 36MG Oral Capsule B Maximum of 6 capsules per day ER 12 Hour Abuse-Deterrent) Xultophy (Subcutaneous Solution Pen- Maximum of 5 pens (15 ml) per 30 B Injector) days Xyrem (Oral Solution) B Maximum of 18 ml per day Xywav (Oral Solution) B Maximum of 18 ml per day 1 vaccination dose (1 injection) per YF-Vax (Subcutaneous Injectable) B day Yupelri (Inhalation Solution) B Maximum of 1 vial (3 ml) per day Zaleplon (10MG Oral Capsule) G Maximum of 2 capsules per day Zaleplon (5MG Oral Capsule) G Maximum of 1 capsule per day Zelboraf (Oral Tablet) B Maximum of 8 tablets per day Zembrace SymTouch (Subcutaneous Maximum of 16 syringes (8 ml) per 30 B Solution Auto-Injector) days Zenzedi (10MG Oral Tablet, 2.5MG Oral G Maximum of 6 tablets per day Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet) Last updated September 1, 2021 201

Brand Drug Name or Quantity Limit Generic

Zenzedi (15MG Oral Tablet, 20MG Oral G Maximum of 3 tablets per day Tablet) Zenzedi (30MG Oral Tablet) G Maximum of 2 tablets per day Zepatier (Oral Tablet) B Maximum of 1 tablet per day Zeposia 7-Day Starter Pack (Oral Capsule Maximum of 1 pack (7 capsules) per B Therapy Pack) 7 days Zeposia (Oral Capsule) B Maximum of 1 capsule per day Zeposia Starter Kit (Oral Capsule Therapy Maximum of 1 pack (37 capsules) per B Pack) 37 days Zestoretic (10-12.5MG Oral Tablet) B Maximum of 1 tablet per day Zestoretic (20-12.5MG Oral Tablet) B Maximum of 4 tablets per day Zestoretic (20-25MG Oral Tablet) B Maximum of 2 tablets per day Zestril (Oral Tablet) B Maximum of 2 tablets per day Ziac (Oral Tablet) B Maximum of 2 tablets per day Ziagen (Oral Solution) B Maximum of 32 ml per day Ziagen (Oral Tablet) B Maximum of 2 tablets per day Zidovudine (Oral Capsule) G Maximum of 6 capsules per day Zidovudine (Oral Syrup) G Maximum of 64 ml per day Zidovudine (Oral Tablet) G Maximum of 2 tablets per day Ziprasidone HCl (Oral Capsule) G Maximum of 2 capsules per day Zocor (Oral Tablet) B Maximum of 1 tablet per day Zolmitriptan (Oral Tablet) G Maximum of 12 tablets per 30 days Zolmitriptan ODT (Oral Tablet Dispersible) G Maximum of 12 tablets per 30 days Zolpidem Tartrate (Oral Tablet Immediate G Maximum of 1 tablet per day Release) Zomig (2.5MG Nasal Solution) B Maximum of 18 devices per 30 days Zomig (5MG Nasal Solution) B Maximum of 12 devices per 30 days Zomig (Oral Tablet) B Maximum of 12 tablets per 30 days Zomig ZMT (Oral Tablet Dispersible) B Maximum of 12 tablets per 30 days Zonalon (External Cream) B Maximum of 90 grams per 30 days ZTlido (External Patch) B Maximum of 3 patches per day Zubsolv (0.7-0.18MG Tablet Sublingual, 1.4-0.36MG Tablet Sublingual, 5.7-1.4MG B Maximum of 3 tablets per day Tablet Sublingual) Zubsolv (11.4-2.9MG Tablet Sublingual) B Maximum of 1 tablet per day Zubsolv (2.9-0.71MG Tablet Sublingual) B Maximum of 5 tablets per day Zubsolv (8.6-2.1MG Tablet Sublingual) B Maximum of 2 tablets per day Zypitamag (Oral Tablet) B Maximum of 1 tablet per day 202 Last updated September 1, 2021

Brand Drug Name or Quantity Limit Generic Zyprexa (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral B Maximum of 1 tablet per day Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet) Zyprexa Zydis (Oral Tablet Dispersible) B Maximum of 1 tablet per day 203 Required information Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change from time to time during each plan year. You will receive notice when necessary. This information is available for free in other languages. Please call our Customer Service number located on the cover.

UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws, and does not discriminate on the basis of race, color, national origin, age, disability, or sex. For more up-to-date information or if you have other questions, please call Customer Service at: Toll-free 1-888-223-1092, TTY 711 8 a.m. - 8 p.m. local time, Monday - Friday

www.UHCRetiree.com/soi

OVEX21PP4738358_010 Last updated September 1, 2021