20191 COMPLETE DRUG LIST (FORMULARY)

Prescription drug list information

Preferred Choice Broward (HMO)

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

Toll-free 1-866-231-7201, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.myPreferredCare.com

Formulary ID Number 00019086, Version 10 Y0066_180629_123918_v88.03_C Last updated October 1, 2018 TABLE2 11 OF CONTENTS What is a drug list?...... 3 Note to existing members...... 3 How do I use the drug list?...... 4 What are generic drugs?...... 4 What is a compounded drug?...... 4 Drug payment stage and drug tiers...... 5 Getting Extra Help...... 5 Are there any rules or limits on my drug coverage?...... 6 What if my drug is not on this list?...... 8 How can I get an exception?...... 8 Can I get my drug while I wait for an exception?...... 9 Can the drug list change?...... 10 Drugs with dosages other than a 1-month supply...... 11 Covered drugs by name (Drug index)...... 12 Covered drugs by medical condition...... 29 Covered drugs with a quantity limit (QL)...... 92 Additional covered drugs...... 115

Questions?

If you have questions, we’re here to help. Call Customer Service at: Toll-free 1-866-231-7201, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week 2 3 What is a drug list? A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team of health care providers work together in selecting drugs that are needed for well-rounded care and treatment. Your plan will generally cover the drugs listed in our drug list as long as: · The drug is used for a medically accepted indication, · The prescription is filled at a network pharmacy and · Other plan rules are followed. For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members: This complete list of prescription drugs covered by your plan is current as of October 1, 2018. For an up-to-date list of covered drugs or if you have questions, please call 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 Preferred Choice Broward. 4 3 How do I use the drug list? There are 2 ways to find your prescription drugs in this drug list: 1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–28 to see the ...... list of drug names in alphabetical order. Find the name of your drug. The page number where ...... you can find the drug will be next to it. 2. By medical condition. Turn to section “Covered drugs by medical condition” on pages ...... 29–91 to look for drugs based on your medical conditions. For example, if you have a heart ...... condition, you should look in the category Cardiovascular Agents. This is where you will find ...... drugs that treat heart conditions.

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

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

What is a compounded drug? A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription customized to the needs of an individual patient. Generally compounded drugs are non-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage determination from us to have your compounded drug covered. Compounded drugs may be Part D eligible. For more information about compounded drugs, please review your Evidence of Coverage. 4 5 Drug payment stage and drug tiers The amount you pay for a covered prescription drug will depend on: · Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in.

· Your drug’s tier. Each covered drug is in 1 of 5 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers. If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call Customer Service. Our contact information is on the cover.

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

In addition, your plan has added coverage of some prescription drugs that are not normally covered under Medicare Part D. Please see section “Additional covered drugs” on page 115 for a list of these drugs.

Getting Extra Help If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call Customer Service. Our contact information is on the cover. ..6 5 1 Are there any rules or limits on my drug coverage? Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug has any coverage rules or limits, there will be a code(s) in the “Coverage rules or limits on use” column of the “Covered drugs by medical condition” chart starting on page 29. The codes and what they mean are shown below and on the next page. You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call Customer Service. Our contact information is on the cover. Coverage Rules and Limits

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

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

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

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

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

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

After we get the statement from your doctor supporting your request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting 72 hours. If your expedited request is approved, we’ll give you a decision within 24 hours after we get your doctor’s supporting statement. 8 9 Can I get my drug while I wait for an exception? As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s not on our drug list or if it has rules or limits. For example, you may need a prior authorization from us before you can fill your prescription. During the time when you are getting a temporary supply, you should talk with your doctor to decide if there is a similar drug on the drug list you can take instead. If you and your doctor decide this is the only drug that will work for you, you will need to ask for an exception. We may cover your drug in certain cases during the first 90 days of your membership. The following chart shows how much of your drug we may cover while you ask for an exception.

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

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

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

We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You can find out if your drug has any rules or limits by looking in the chart on pages 92-114. We’ll tell you about any changes

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

For more information For more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan’s prescription drug coverage, we’re here to help. Call Customer Service toll-free at 1-866-231-7201, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Or visit us online at www.myPreferredCare.com. If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week. 12 12Tracked 12 Covered drugs by name (Drug index) track

A Albuterol Sulfate...... 89 Amiodarone HCl...... 59 Abacavir...... 53 Alclometasone Dipropionate Amitiza...... 72 Abacavir Sulfate/Lamivudine/ ...... 74 Amitriptyline HCl...... 42 Zidovudine...... 53 Alcohol Prep Pads...... 85 Amlodipine Besylate...... 60 Abacavir/Lamivudine...... 53 Alecensa...... 47 Amlodipine Besylate/ Abelcet...... 43 Alendronate Sodium...... 84 Atorvastatin Calcium...... 61 Abilify Maintena...... 50 Alfuzosin HCl ER...... 74 Amlodipine Besylate/ Abstral...... 31 Alinia...... 48 Benazepril HCl...... 61 Acamprosate Calcium DR.....32 Allopurinol...... 45 Amlodipine Besylate/Valsartan ...... 61 Acarbose...... 55 Alocril...... 85 Amlodipine/Olmesartan Acebutolol HCl...... 59 Alomide...... 85 Medoxomil...... 61 Acetaminophen/Codeine...... 31 Alosetron HCl...... 72 Amlodipine/Valsartan/ Acetazolamide...... 62 Alphagan P...... 86 Hydrochlorothiazide...... 61 Acetazolamide ER...... 63 Alprazolam...... 54 Ammonium Lactate...... 67 Acetic Acid...... 87 Altavera...... 77 Amoxapine...... 42 Acetylcysteine...... 90 Alunbrig...... 47 Amoxicillin...... 35 Acitretin...... 67 Alyacen 1/35...... 77 Amoxicillin/Clavulanate Actemra...... 82 Amantadine HCl...... 49 Potassium...... 36 ActHIB...... 83 AmBisome...... 43 Amoxicillin/Clavulanate Potassium ER...... 36 Actimmune...... 83 Amethia...... 77 Amphetamine/ Acyclovir...... 52 Amethia Lo...... 77 Dextroamphetamine...... 65 Acyclovir Sodium...... 52 Amikacin Sulfate...... 33 Amphotericin B...... 43 Adacel...... 83 Amiloride HCl...... 63 Ampicillin...... 36 Adapalene...... 67 Amiloride/Hydrochlorothiazide Ampicillin Sodium...... 36 Adcirca...... 89 ...... 61 Ampicillin-Sulbactam...... 36 Adefovir Dipivoxil...... 51 Aminosyn 7%/Electrolytes.... 68 Ampyra...... 66 Adempas...... 89 Aminosyn 8.5%/Electrolytes ...... 68 Anadrol-50...... 77 Advair Diskus...... 90 Aminosyn II...... 68 Anagrelide HCl...... 57 Advair HFA...... 90 Aminosyn II 8.5%/Electrolytes Anastrozole...... 47 Afeditab CR...... 60 ...... 68 Androderm...... 77 Afinitor...... 47 Aminosyn-HBC...... 68 Anoro Ellipta...... 90 Afinitor Disperz...... 47 Aminosyn-PF...... 68 Apokyn...... 49 Ala-Cort...... 74 Aminosyn-RF...... 68 Apraclonidine...... 86 Albenza...... 48 13Tracked 13 13 Aprepitant...... 43 Avonex Pen...... 66 Betimol...... 86 Apri...... 77 Azasite...... 36 Bevespi Aerosphere...... 90 Apriso...... 83 Azathioprine...... 81 Bexarotene...... 48 Aptiom...... 40 Azelastine HCl...... 86, 87 Bexsero...... 83 Aptivus...... 54 Azithromycin...... 36 Bicalutamide...... 46 Aralast NP...... 73 Azopt...... 86 Bicillin C-R...... 36 Aranelle...... 77 Aztreonam...... 35 Bicillin L-A...... 36 Aranesp Albumin Free...... 58 B BiDil...... 61 Arcalyst...... 83 Bacitracin...... 33 Biktarvy...... 53 Aripiprazole...... 50 Bacitracin/Polymyxin B...... 85 Biltricide...... 48 Aripiprazole ODT...... 50 Baclofen...... 90 Binosto...... 84 Aristada...... 50 Bactocill in Dextrose...... 36 Bisoprolol Fumarate...... 59 Arnuity Ellipta...... 88 Bactroban Nasal...... 33 Bisoprolol Fumarate/ Ashlyna...... 77 Balsalazide Disodium...... 83 Hydrochlorothiazide...... 61 Aspirin/Dipyridamole...... 58 Balziva...... 77 BIVIGAM...... 82 Atazanavir Sulfate...... 54 Banzel...... 40 Blephamide...... 85 Atenolol...... 59 Baraclude...... 51 Blephamide S.O.P...... 85 Atenolol/Chlorthalidone...... 61 BCG Vaccine...... 83 Blisovi 24 Fe...... 77 Atomoxetine...... 65 Belsomra...... 91 Blisovi Fe 1.5/30...... 77 Atorvastatin Calcium...... 63 Benazepril HCl...... 59 Blisovi Fe 1/20...... 77 Atovaquone...... 48 Benazepril HCl/ Boostrix...... 83 Atovaquone/Proguanil HCl....48 Hydrochlorothiazide...... 61 Bosulif...... 47 Atripla...... 52 Benlysta...... 83 Breo Ellipta...... 90 Atropine Sulfate...... 85 Benznidazole...... 48 Briellyn...... 77 Atrovent HFA...... 88 Benztropine Mesylate...... 49 Brilinta...... 58 Aubagio...... 66 Bepreve...... 86 Brimonidine Tartrate...... 86 Aubra...... 77 Berinert...... 81 Briviact...... 38 Augmented Betamethasone Besivance...... 37 Bromocriptine Mesylate...... 49 Dipropionate...... 74 Betamethasone Dipropionate Budesonide...... 84, 88 Auryxia...... 71 ...... 74 Budesonide ER...... 84 Austedo...... 66 Betamethasone Valerate...... 74 Bumetanide...... 63 Avandia...... 55 Betaseron...... 66 Buprenorphine HCl...... 32 Aviane...... 77 Betaxolol HCl...... 59, 86 Buprenorphine HCl/Naloxone Avonex...... 66 Bethanechol Chloride...... 74 HCl...... 32 Bethkis...... 89 Bupropion HCl...... 41 14 14Tracked 14 Bupropion HCl SR...... 32, 41 Carbidopa...... 49 Chantix Continuing Month Pak Bupropion HCl XL...... 41 Carbidopa/Levodopa...... 49 ...... 33 Buspirone HCl...... 54 Carbidopa/Levodopa ER...... 49 Chantix Starting Month Pak...33 Butalbital/Acetaminophen/ Carbidopa/Levodopa ODT....49 Chemet...... 71 Caffeine...... 29 Carbidopa/Levodopa/ Chenodal...... 71 Butalbital/Aspirin/Caffeine....29 Entacapone...... 49 Chlordiazepoxide HCl...... 54 Butorphanol Tartrate...... 31 Carimune Nanofiltered...... 82 Chlorhexidine Gluconate Oral Bydureon Bcise...... 55 Carteolol HCl...... 86 Rinse...... 67 Bydureon Pen...... 55 Cartia XT...... 60 Chloroquine Phosphate...... 48 Bydureon Vial...... 55 Carvedilol...... 59 Chlorothiazide...... 63 Byetta...... 55 Caspofungin Acetate...... 44 Chlorpromazine HCl...... 49 Bystolic...... 59 Cayston...... 89 Chlorthalidone...... 63 C Caziant...... 77 Chlorzoxazone...... 90 Cabergoline...... 81 Cefaclor...... 34 Cholbam...... 73 Cabometyx...... 47 Cefadroxil...... 34 Cholestyramine...... 64 Calcipotriene...... 67 Cefazolin Sodium...... 34 Cholestyramine Light...... 64 Calcitonin-Salmon...... 84 Cefdinir...... 34 Ciclopirox...... 44 Calcitriol...... 67, 84 Cefepime...... 34 Ciclopirox Nail Lacquer...... 44 Calcium Acetate...... 71 Cefixime...... 34 Ciclopirox Olamine...... 44 Calquence...... 47 Cefotaxime Sodium...... 34 Cilostazol...... 58 Camila...... 80 Cefotetan...... 34 Ciloxan...... 37 Camrese Lo...... 77 Cefoxitin Sodium...... 34 Cimduo...... 53 Canasa...... 83 Cefpodoxime Proxetil...... 35 Cimetidine...... 72 Candesartan Cilexetil...... 59 Cefprozil...... 35 Cimetidine HCl...... 72 Candesartan Cilexetil/ Ceftazidime...... 35 Cimzia...... 81 Hydrochlorothiazide...... 61 Ceftriaxone Sodium...... 35 Cinryze...... 81 Caprelsa...... 47 Cefuroxime Axetil...... 35 Cipro HC...... 87 Captopril...... 59 Cefuroxime Sodium...... 35 Ciprodex...... 87 Captopril/Hydrochlorothiazide Celecoxib...... 29 Ciprofloxacin...... 37 ...... 61 Celontin...... 39 Ciprofloxacin ER...... 37 Carac...... 67 Cephalexin...... 35 Ciprofloxacin HCl...... 37 Carafate...... 72 Cesamet...... 43 Ciprofloxacin I.V. in D5W...... 37 Carbaglu...... 68 Cetirizine HCl...... 87 Citalopram HBr...... 41 Carbamazepine...... 40 Chantix...... 33 Claravis...... 67 Carbamazepine ER...... 40 Clarithromycin...... 36, 37 15Tracked 15 15 Clarithromycin ER...... 37 Complera...... 52 Dantrolene Sodium...... 90 Climara Pro...... 77 Compro...... 43 Dapsone...... 46 Clindamycin HCl...... 33 Constulose...... 72 Daptacel...... 83 Clindamycin Palmitate HCl....33 Cordran...... 74 Daptomycin...... 33 Clindamycin Phosphate...33, 67 Corlanor...... 61 DARAPRIM...... 48 Clindamycin Phosphate in D5W Cortisone Acetate...... 75 Deblitane...... 80 ...... 33 Cortisporin...... 67 Delyla...... 77 Clindamycin/Benzoyl Peroxide Cosentyx...... 67 Demeclocycline HCl...... 38 ...... 67 Cosentyx Sensoready Pen.....67 Demser...... 61 Clobetasol Propionate...... 74 Cosopt PF...... 86 Denavir...... 52 Clobetasol Propionate E...... 74 Cotellic...... 47 Depen Titratabs...... 74 Clomipramine HCl...... 42 Coumadin...... 57 Depo-...... 77 Clonazepam...... 54 Creon...... 73 Depo-Provera...... 80 Clonazepam ODT...... 54 Crinone...... 80 Descovy...... 53 Clonidine HCl...... 58 Crixivan...... 54 Desipramine HCl...... 42 Clonidine HCl ER...... 65 Cromolyn Sodium...... 71, 86, 89 Desmopressin Acetate...... 76 Clopidogrel...... 58 Cryselle-28...... 77 Desogestrel/Ethinyl Estradiol Clorazepate Dipotassium...... 54 Cuprimine...... 74 ...... 77 Clotrimazole...... 44 Cuvposa...... 71 Desonide...... 75 Clotrimazole/Betamethasone Cyclafem...... 77 Desoximetasone...... 75 Dipropionate...... 67 Cyclobenzaprine HCl...... 90 Desvenlafaxine ER...... 42 Clozapine...... 51 Cyclophosphamide...... 46 Dexamethasone...... 75 Clozapine ODT...... 51 Cycloset...... 55 Dexamethasone Intensol...... 75 Coartem...... 48 Cyclosporine...... 81 Dexamethasone Sodium Codeine Sulfate...... 31 Phosphate...... 86 Cyclosporine Modified...... 81 Colchicine...... 45 Dexilant...... 72 Cyproheptadine HCl...... 87 Colcrys...... 45 Dexmethylphenidate HCl...... 65 Cystadane...... 73 Colesevelam HCl...... 64 Dexmethylphenidate HCl ER Cystagon...... 73 Colestipol HCl...... 64 ...... 65 Cystaran...... 85 Colistimethate Sodium...... 33 Dextroamphetamine Sulfate D Colocort...... 84 ...... 65 Daklinza...... 52 Coly-Mycin S...... 87 Dextroamphetamine Sulfate ER Daliresp...... 89 ...... 65 Combigan...... 86 Dalvance...... 33 Dextrose 10%...... 68 Combivent Respimat...... 90 ...... 77 Dextrose 10%/NaCl 0.2%...... 68 Cometriq...... 47 16 16Tracked 16 Dextrose 10%/NaCl 0.45%.... 68 Disulfiram...... 32 Edarbyclor...... 61 Dextrose 2.5%/NaCl 0.45%... 68 Diuril...... 63 Edurant...... 52 Dextrose 5%...... 68 Divalproex Sodium...... 55 ...... 52 Dextrose 5%/NaCl 0.2%...... 69 Divalproex Sodium DR...... 55 Egrifta...... 81 Dextrose 5%/NaCl 0.225%.... 69 Divalproex Sodium ER...... 55 Elestrin...... 77 Dextrose 5%/NaCl 0.33%...... 69 Dofetilide...... 59 Elidel...... 67 Dextrose 5%/NaCl 0.45%...... 69 Donepezil HCl...... 41 Eliquis...... 57 Dextrose 5%/NaCl 0.9%...... 69 Donepezil HCl ODT...... 41 Eliquis Starter Pack...... 57 Diastat AcuDial...... 39 Doripenem...... 35 Elmiron...... 74 Diastat Pediatric...... 39 Dorzolamide HCl...... 86 Embeda...... 30 Diazepam...... 55 Dorzolamide HCl/Timolol Emcyt...... 46 Diazepam Intensol...... 55 Maleate...... 86 Emend...... 43 Diclofenac Potassium...... 29 Doxazosin Mesylate...... 58 Emoquette...... 77 Diclofenac Sodium.... 29, 67, 86 Doxepin HCl...... 43, 67 Emsam...... 41 Diclofenac Sodium DR...... 29 Doxercalciferol...... 84 Emtriva...... 53 Diclofenac Sodium ER...... 29 Doxy 100...... 38 Enalapril Maleate...... 59 Dicloxacillin Sodium...... 36 Doxycycline...... 38 Enalapril Maleate/ Dicyclomine HCl...... 71 Doxycycline Hyclate...... 38 Hydrochlorothiazide...... 61 Didanosine...... 53 Doxycycline Monohydrate..... 38 Enbrel...... 81 Dificid...... 37 Dronabinol...... 43 Enbrel SureClick...... 81 Diflunisal...... 29 Drospirenone/Ethinyl Estradiol Endocet...... 31 ...... 77 Digitek...... 61 Engerix-B...... 83 Droxia...... 46 Digox...... 61 Enoxaparin Sodium...... 57 Duavee...... 77 Digoxin...... 61 Enpresse-28...... 77 Dulera...... 90 Dihydroergotamine Mesylate Enskyce...... 77 ...... 45 Duloxetine HCl...... 66 Entacapone...... 49 Dilantin...... 40 Duramorph...... 31 Entecavir...... 51 Dilantin INFATABS...... 40 Durezol...... 86 Entresto...... 61 Dilt-XR...... 60 Dutasteride...... 74 Enulose...... 72 Diltiazem HCl...... 60 Dymista...... 90 Envarsus XR...... 81 Diltiazem HCl ER...... 60 Dyrenium...... 63 Epclusa...... 52 Dipentum...... 84 E Epinastine HCl...... 86 Diphenoxylate/Atropine...... 71 E.E.S. Granules...... 37 Epinephrine...... 89 Diphtheria/Tetanus Toxoids Econazole Nitrate...... 44 EpiPen...... 89 Adsorbed Pediatric...... 83 Edarbi...... 59 17Tracked 17 17 Epitol...... 40 Etodolac ER...... 29 Flarex...... 86 Epivir HBV...... 52 Eurax...... 48 Flebogamma DIF...... 82 Eplerenone...... 63 Evotaz...... 54 Flecainide Acetate...... 59 Eprosartan Mesylate...... 59 Exelderm...... 44 Flector...... 29 Eraxis...... 44 Exemestane...... 47 Flovent Diskus...... 88 Ergotamine Tartrate/Caffeine Exjade...... 71 Flovent HFA...... 88 ...... 45 Ezetimibe...... 64 Fluconazole...... 44 Erivedge...... 47 Ezetimibe/Simvastatin...... 64 Fluconazole in NaCl...... 44 Erleada...... 46 F Flucytosine...... 44 Errin...... 80 Falmina...... 78 Fludrocortisone Acetate...... 75 Ery...... 67 Famciclovir...... 52 Flunisolide...... 88 Ery-Tab...... 37 Famotidine...... 72 Fluocinolone Acetonide...75, 87 EryPed 200...... 37 Fanapt...... 50 Fluocinolone Acetonide Scalp EryPed 400...... 37 Fanapt Titration Pack...... 50 ...... 75 Erythrocin Lactobionate...... 37 Fareston...... 46 Fluocinonide...... 75 Erythromycin...... 37, 67 Farydak...... 47 Fluocinonide Emulsified Base ...... 75 Erythromycin Base...... 37 Felbamate...... 39 Fluorometholone...... 87 Erythromycin Ethylsuccinate Felodipine ER...... 60 ...... 37 Fluorouracil...... 68 Femring...... 78 Erythromycin/Benzoyl Peroxide Fluoxetine DR...... 42 Femynor...... 78 ...... 67 Fluoxetine HCl...... 42 Fenofibrate...... 63 Esbriet...... 90 Fluphenazine Decanoate...... 49 Fenofibrate Micronized...... 63 Escitalopram Oxalate...... 42 Fluphenazine HCl...... 49, 50 Fenofibric Acid...... 63 Esomeprazole Magnesium.... 73 Flurbiprofen...... 29 Fenofibric Acid DR...... 63 Estarylla...... 77 Flurbiprofen Sodium...... 87 Fentanyl...... 30 Estradiol...... 77, 78 Flutamide...... 46 Fentanyl Citrate Oral ...... 78 Transmucosal...... 31 Fluticasone Propionate....75, 88 Estring...... 78 Ferriprox...... 71 Fluticasone Propionate/ Ethacrynic Acid...... 63 Salmeterol...... 90 Fetzima...... 42 Ethambutol HCl...... 46 Fluvastatin...... 63 Fetzima Titration Pack...... 42 Ethosuximide...... 39 Fluvoxamine Maleate...... 42 Finacea...... 67 Ethynodiol Diacetate/Ethinyl FML...... 87 Finasteride...... 74 Estradiol...... 78 FML Forte...... 87 Firazyr...... 81 Etidronate Disodium...... 84 Fondaparinux Sodium...... 57 Firmagon...... 81 Etodolac...... 29 Forteo...... 84 18 18Tracked 18 Fosamprenavir Calcium...... 54 Genvoya...... 52 Hiberix...... 83 Fosinopril Sodium...... 59 Geodon...... 50 Humalog Cartridge...... 56 Fosinopril Sodium/ Gianvi...... 78 Humalog Junior KwikPen...... 56 Hydrochlorothiazide...... 62 Gilenya...... 66 Humalog KwikPen...... 56 FreAmine HBC 6.9%...... 69 Gilotrif...... 47 Humalog Mix 50/50 KwikPen Furosemide...... 63 Glassia...... 73 ...... 56 Fuzeon...... 53 Glatiramer Acetate...... 66 Humalog Mix 50/50 Vial...... 56 Fyavolv...... 78 Glatopa...... 66 Humalog Mix 75/25 KwikPen ...... 56 Fycompa...... 39 Gleostine...... 46 Humalog Mix 75/25 Vial...... 56 G Glimepiride...... 55 Humalog Vial...... 57 Gabapentin...... 39 Glipizide...... 55 Humatrope...... 76 Galantamine HBr...... 41 Glipizide ER...... 55 Humatrope Combo Pack...... 76 Galantamine HBr ER...... 41 Glipizide/Metformin HCl...... 55 Humira...... 81 Gammagard Liquid...... 82 GlucaGen HypoKit...... 56 Humira Pediatric Crohns Gammagard S/D IGA Less Glucagon Emergency Kit...... 56 Than 1 mcg/ml...... 82 Disease Starter Pack...... 82 Glyxambi...... 55 Gammaked...... 82 Humira Pen...... 82 Granisetron HCl...... 43 Gammaplex...... 82 Humira Pen Crohns Disease Granix...... 58 Starter Pack...... 82 Gamunex-C...... 82 Griseofulvin Microsize...... 44 Humira Pen-Psoriasis Starter Gardasil 9...... 83 Griseofulvin Ultramicrosize....44 ...... 82 Gatifloxacin...... 37 Guanfacine ER...... 65 Humulin 70/30 KwikPen...... 57 Gattex...... 71 Guanidine HCl...... 45 Humulin 70/30 Vial...... 57 Gauze...... 85 H Humulin N KwikPen...... 57 GaviLyte-C...... 72 Haegarda...... 81 Humulin N Vial...... 57 GaviLyte-G...... 72 Halobetasol Propionate...... 75 Humulin R U-500 KwikPen.....57 GaviLyte-N/Flavor Pack...... 72 Haloperidol...... 50 Humulin R U-500 Vial...... 57 Gemfibrozil...... 63 Haloperidol Decanoate...... 50 Humulin R Vial...... 57 Generlac...... 72 Haloperidol Lactate...... 50 Hydralazine HCl...... 64 Gengraf...... 81 Harvoni...... 52 Hydrochlorothiazide...... 63 Genotropin...... 76 Havrix...... 83 Hydrocodone/Acetaminophen Genotropin Miniquick...... 76 ...... 31 Heparin Sodium...... 57 Gentak...... 33 Hydrocodone/Ibuprofen...... 31 HepatAmine...... 69 Gentamicin Sulfate...... 33 Hydrocortisone...... 75, 84 Hetlioz...... 91 Gentamicin Sulfate/0.9% Hydrocortisone Butyrate...... 75 Hexalen...... 46 Sodium Chloride...... 33 Hydrocortisone Valerate...... 75 19Tracked 19 19 Hydrocortisone/Acetic Acid Intralipid...... 69 J ...... 87 Intron A...... 52 Jadenu...... 71 Hydromorphone HCl...... 31 Introvale...... 78 Jadenu Sprinkle...... 71 Hydromorphone HCl ER...... 30 Invanz...... 35 Jakafi...... 47 Hydroxychloroquine Sulfate Invega Sustenna...... 50 Jantoven...... 57 ...... 48 Invega Trinza...... 50 Janumet...... 55 Hydroxyurea...... 46 Invirase...... 54 Janumet XR...... 55 Hydroxyzine HCl...... 54 Invokamet...... 55 Januvia...... 56 Hydroxyzine Pamoate...... 43 Invokamet XR...... 55 Jardiance...... 56 Hysingla ER...... 30 Invokana...... 55 Jentadueto...... 56 I Ionosol-MB/Dextrose 5%...... 69 Jentadueto XR...... 56 Ibandronate Sodium...... 84 IPOL Inactivated IPV...... 83 Jinteli...... 78 Ibrance...... 47 Ipratropium Bromide...... 88 Jolivette...... 80 Ibu...... 29 Ipratropium Bromide/Albuterol Jublia...... 44 Ibuprofen...... 29 Sulfate...... 90 Juleber...... 78 Iclusig...... 47 Irbesartan...... 59 Juluca...... 53 Idhifa...... 47 Irbesartan/Hydrochlorothiazide Junel 1.5/30...... 78 Ilevro...... 87 ...... 62 Junel 1/20...... 78 Imatinib Mesylate...... 47 Iressa...... 47 Junel Fe 1.5/30...... 78 Imbruvica...... 47 Isentress...... 52 Junel Fe 1/20...... 78 Imipenem/Cilastatin...... 35 Isentress HD...... 52 Junel Fe 24...... 78 Imipramine HCl...... 43 Isibloom...... 78 Juxtapid...... 64 Imipramine Pamoate...... 43 Isolyte-P/Dextrose 5%...... 69 K Imiquimod...... 68 Isolyte-S...... 69 Kaitlib Fe...... 78 Imovax Rabies...... 83 Isoniazid...... 46 Kaletra...... 54 Incassia...... 80 Isosorbide Dinitrate...... 64 Kalydeco...... 89 Increlex...... 76 Isosorbide Dinitrate ER...... 64 Kariva...... 78 Incruse Ellipta...... 88 Isosorbide Mononitrate...... 64 KCl 0.075%/D5W/NaCl 0.45% Indapamide...... 63 Isosorbide Mononitrate ER....64 ...... 69 Indomethacin...... 29 Isotonic Gentamicin...... 33 KCl 0.15%/D5W/NaCl 0.2% Infanrix...... 83 Isotretinoin...... 68 ...... 69 Ingrezza...... 66 Itraconazole...... 44 KCl 0.15%/D5W/NaCl 0.45% Inlyta...... 47 Ivermectin...... 48 ...... 69 Insulin Syringes, Needles...... 85 Ixiaro...... 83 KCl 0.15%/D5W/NaCl 0.9% ...... 69 Intelence...... 52, 53 20 20Tracked 20 KCl 0.3%/D5W/NaCl 0.45% Lanoxin...... 62 Levonest...... 78 ...... 69 Lansoprazole...... 73 Levonorgestrel and Ethinyl KCl 0.3%/D5W/NaCl 0.9%.... 69 Lanthanum Carbonate...... 71 Estradiol...... 78 Kelnor 1/35...... 78 Lantus SoloStar...... 57 Levonorgestrel/Ethinyl Estradiol...... 78 Kelnor 1/50...... 78 Lantus Vial...... 57 Levora 0.15/30-28...... 78 Ketoconazole...... 44 LARIN 1.5/30...... 78 Levorphanol Tartrate...... 30 Ketorolac Tromethamine...... 87 LARIN 1/20...... 78 Levothyroxine Sodium...... 80 Kimidess...... 78 LARIN Fe 1.5/30...... 78 Levoxyl...... 80 Kineret...... 82 LARIN Fe 1/20...... 78 Lexiva...... 54 Kinrix...... 83 Larissia...... 78 Lialda...... 84 Kionex...... 71 Lastacaft...... 85 Lidocaine...... 32 Kisqali...... 46 Latanoprost...... 87 Lidocaine HCl...... 32 Kisqali Femara 200 Dose...... 46 Latuda...... 50 Lidocaine Viscous...... 32 Kisqali Femara 400 Dose...... 47 Layolis Fe...... 78 Lidocaine/Prilocaine...... 32 Kisqali Femara 600 Dose...... 47 Leena...... 78 Lindane...... 48 Klor-Con...... 69 Leflunomide...... 83 Linezolid...... 33 Klor-Con 10...... 69 Lenvima...... 47 Linzess...... 72 Klor-Con 8...... 69 Lessina...... 78 Liothyronine Sodium...... 80 Klor-Con M10...... 69 Letrozole...... 47 Lisinopril...... 59 Klor-Con M15...... 69 Leucovorin Calcium...... 47 Lisinopril/Hydrochlorothiazide Klor-Con M20...... 69 Leukeran...... 46 ...... 62 Klor-Con Sprinkle...... 69 Leukine...... 58 Lithium...... 55 Kombiglyze XR...... 56 Leuprolide Acetate...... 81 Lithium Carbonate...... 55 Korlym...... 76 Levalbuterol...... 89 Lithium Carbonate ER...... 55 Kurvelo...... 78 Levemir FlexTouch...... 57 Lithostat...... 74 Kuvan...... 73 Levemir Vial...... 57 Livalo...... 63 Kynamro...... 64 Levetiracetam...... 39 Lonsurf...... 47 L Levetiracetam ER...... 39 Loperamide HCl...... 72 Labetalol HCl...... 59 Levobunolol HCl...... 86 Lopinavir/Ritonavir...... 54 Lacrisert...... 85 Levocarnitine...... 69 Lorazepam...... 55 Lactulose...... 72 Levocetirizine Dihydrochloride Lorcet...... 31 Lamivudine...... 52, 53 ...... 87 Lorcet HD...... 31 Lamivudine/Zidovudine...... 53 Levofloxacin...... 37 Lorcet Plus...... 31 Lamotrigine...... 40 Levofloxacin in D5W...... 37 Loryna...... 78 21Tracked 21 21 Losartan Potassium...... 59 Memantine HCl Titration Pak Metolazone...... 63 Losartan Potassium/ ...... 41 Metoprolol Succinate ER...... 60 Hydrochlorothiazide...... 62 Menactra...... 83 Metoprolol Tartrate...... 60 Lotemax...... 87 Menest...... 79 Metoprolol/ Lovastatin...... 63 Mentax...... 44 Hydrochlorothiazide...... 62 Low-Ogestrel...... 78 Menveo...... 83 Metronidazole...... 34 Loxapine Succinate...... 50 Mercaptopurine...... 46 Metronidazole in NaCl 0.79% Lumigan...... 87 Meropenem...... 35 ...... 34 Lupaneta Pack...... 81 Mesalamine...... 84 Metronidazole Vaginal...... 34 Lupron Depot...... 81 Mesalamine DR...... 84 Mexiletine HCl...... 59 Lutera...... 78 Mesnex...... 48 Mibelas 24 Fe...... 79 Lynparza...... 47 Mestinon...... 45 Miconazole 3...... 44 Lyrica...... 66 Metadate ER...... 65 Microgestin 1.5/30...... 79 Lysodren...... 81 Metaproterenol Sulfate...... 89 Microgestin 1/20...... 79 Lyza...... 80 Metformin HCl...... 56 Microgestin Fe...... 79 M Metformin HCl ER...... 56 Microgestin Fe 1.5/30...... 79 M-M-R II...... 83 Methadone HCl...... 30 Midodrine HCl...... 58 Magnesium Sulfate...... 69 Methazolamide...... 63 Migergot...... 45 Malathion...... 48 Methenamine Hippurate...... 34 Miglitol...... 56 Maprotiline HCl...... 42 Methimazole...... 81 Miglustat...... 73 Marlissa...... 78 Methotrexate...... 82 Mili...... 79 Marplan...... 41 Methotrexate Sodium...... 82 Minitran...... 64 Matulane...... 46 Methoxsalen...... 68 Minocycline HCl...... 38 Matzim LA...... 60 Methscopolamine Bromide... 71 Minoxidil...... 64 Mavyret...... 52 Methyclothiazide...... 63 Mirtazapine...... 41 Meclizine HCl...... 43 Methyldopa...... 58 Mirtazapine ODT...... 41 Medroxyprogesterone Acetate Methyldopa/ Mirvaso...... 68 ...... 80 Hydrochlorothiazide...... 62 Misoprostol...... 72 Mefloquine HCl...... 48 Methylphenidate HCl...... 66 Modafinil...... 91 Megestrol Acetate...... 80 Methylphenidate HCl ER...... 66 Moexipril HCl...... 59 Mekinist...... 47 Methylprednisolone...... 75 Moexipril/Hydrochlorothiazide Melodetta 24 Fe...... 79 Methylprednisolone Dose Pack ...... 62 Meloxicam...... 29 ...... 75 Mometasone Furoate...... 75, 88 Memantine HCl...... 41 Metipranolol...... 86 MonoNessa...... 79 Memantine HCl ER...... 41 Metoclopramide HCl...... 43 Montelukast Sodium...... 88 22 22Tracked 22 Morphine Sulfate...... 31 Neomycin Sulfate...... 33 Nitrofurantoin Monohydrate Morphine Sulfate ER...... 30 Neomycin/Bacitracin/ ...... 34 Moxeza...... 37 Polymyxin...... 85 Nitroglycerin...... 64 Moxifloxacin HCl/Sodium HCl Neomycin/Polymyxin/ Nitroglycerin Lingual...... 64 ...... 37 Bacitracin/Hydrocortisone Nitroglycerin Transdermal..... 64 ...... 85 Moxifloxacin HCl...... 37, 38 Nitrostat...... 64 Neomycin/Polymyxin/ Multaq...... 59 Nora-BE...... 80 Dexamethasone...... 85 Mupirocin...... 34 Norditropin FlexPro...... 76 Neomycin/Polymyxin/ Myalept...... 72 Gramicidin...... 85 Norethindrone...... 80 Mycamine...... 44 Neomycin/Polymyxin/ Norethindrone Acetate...... 80 Mycophenolate Mofetil...... 82 Hydrocortisone...... 85, 87 Norethindrone Acetate/Ethinyl Mycophenolic Acid DR...... 82 Nephramine...... 69 Estradiol...... 79 Myrbetriq...... 74 Nerlynx...... 47 Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate N Neulasta...... 58 ...... 79 Nabumetone...... 29 Neupogen...... 58 Norethindrone/Ethinyl Nadolol...... 60 Neupro...... 49 Estradiol/Ferrous Fumarate Nadolol/Bendroflumethiazide Nevirapine...... 53 ...... 79 ...... 62 Nevirapine ER...... 53 Norgestimate/Ethinyl Estradiol Nafcillin Sodium...... 36 Nexavar...... 47 ...... 79 Naftifine HCl...... 44 Nexium...... 73 Norlyroc...... 80 Naftin...... 44 ER...... 64 Normosol-M in D5W...... 69 Naloxone HCl...... 32 Niacor...... 64 Normosol-R...... 69 Naltrexone HCl...... 32 Nicardipine HCl...... 60 Normosol-R in D5W...... 69 Namzaric...... 66 Nicotrol...... 33 Northera...... 58 Naproxen...... 29, 30 Nicotrol NS...... 33 Nortrel 0.5/35...... 79 Naproxen DR...... 30 Nifedipine ER...... 60 Nortrel 1/35...... 79 Naratriptan HCl...... 45 Nikki...... 79 Nortrel 7/7/7...... 79 Narcan...... 32 Nilutamide...... 46 Nortriptyline HCl...... 43 Natacyn...... 44 Nimodipine...... 60 Norvir...... 54 Nateglinide...... 56 Ninlaro...... 47 Noxafil...... 44 Natpara...... 84 Nitro-Bid...... 64 Nucala...... 90 Nebupent...... 48 Nitrofurantoin...... 34 Nucynta ER...... 30 Necon 0.5/35-28...... 79 Nitrofurantoin Macrocrystals Nuedexta...... 66 Necon 7/7/7...... 79 ...... 34 Nuplazid...... 50 Nefazodone HCl...... 42 Nutrilipid...... 69 23Tracked 23 23 Nutropin AQ...... 76 Orfadin...... 73 PEG-3350/NaCl/Na NuvaRing...... 79 Orkambi...... 89 Bicarbonate/KCl...... 72 Nyamyc...... 44 Orsythia...... 79 Peganone...... 40 Nymalize...... 60 Oseltamivir Phosphate...... 54 Pegasys...... 52 Nystatin...... 44 Osphena...... 80 Pegasys ProClick...... 52 Nystop...... 44 Otezla...... 83 Penicillin G Potassium...... 36 O Oxacillin Sodium...... 36 Penicillin G Procaine...... 36 Ocaliva...... 73 Oxandrolone...... 77 Penicillin G Sodium...... 36 Ocella...... 79 Oxcarbazepine...... 40 Penicillin V Potassium...... 36 Octagam...... 82 Oxiconazole Nitrate...... 44 Pentam 300...... 48 Octreotide Acetate...... 81 Oxistat...... 44 Pentasa...... 84 Odefsey...... 53 Oxsoralen Ultra...... 68 Pentoxifylline ER...... 62 Odomzo...... 47 Oxybutynin Chloride...... 74 Perforomist...... 89 Ofev...... 90 Oxybutynin Chloride ER...... 74 Perindopril Erbumine...... 59 Ofloxacin...... 38 Oxycodone HCl...... 32 Periogard...... 67 Ogestrel...... 79 Oxycodone/Acetaminophen Permethrin...... 48 Olanzapine...... 50 ...... 32 Perphenazine...... 43 Olanzapine ODT...... 50 Oxycodone/Aspirin...... 32 Phenadoz...... 88 Olmesartan Medoxomil...... 59 Oxycodone/Ibuprofen...... 32 Phenelzine Sulfate...... 41 Olmesartan Medoxomil/ P Phenobarbital...... 39 Amlodipine/ Pacerone...... 59 Phenoxybenzamine HCl...... 59 Hydrochlorothiazide...... 62 Paliperidone ER...... 51 Phenytek...... 40 Olmesartan Medoxomil/ Panretin...... 48 ...... 40 Hydrochlorothiazide...... 62 Pantoprazole Sodium...... 73 Phenytoin Sodium Extended Olopatadine HCl...... 86 Paricalcitol...... 84 ...... 40 Omega-3-Acid Ethyl Esters.... 64 Paromomycin Sulfate...... 33 Phoslyra...... 71 Omeprazole...... 73 Paroxetine HCl...... 42 Phospholine Iodide...... 86 Ondansetron HCl...... 43 Paser...... 46 Picato...... 68 Ondansetron ODT...... 43 Paxil...... 42 Pilocarpine HCl...... 67, 86 Onfi...... 39 Pazeo...... 86 Pimozide...... 50 Onglyza...... 56 Pediarix...... 83 Pimtrea...... 79 Opsumit...... 89 Pedvax HIB...... 83 Pindolol...... 60 Orencia...... 82 PEG 3350/Electrolytes...... 72 Pioglitazone HCl...... 56 Orencia Clickject...... 82 PEG-3350/Electrolytes...... 72 Pioglitazone HCl/Glimepiride Orenitram...... 89, 90 ...... 56 24 24Tracked 24 Pioglitazone HCl/Metformin Pred-G...... 85 Progesterone...... 80 HCl...... 56 Pred-G S.O.P...... 85 Proglycem...... 56 Piperacillin/Tazobactam...... 36 Prednicarbate...... 75 Prolastin-C...... 73 Pirmella 1/35...... 79 Prednisolone...... 75 Prolensa...... 87 Piroxicam...... 30 Prednisolone Acetate...... 87 Prolia...... 84 Plasma-Lyte A...... 70 Prednisolone Sodium Promacta...... 58 Plasma-Lyte-148...... 70 Phosphate...... 75, 76, 87 Promethazine HCl...... 88 Plenamine...... 70 Prednisone...... 76 Promethegan...... 88 Podofilox...... 68 Prednisone Intensol...... 76 Propafenone HCl...... 59 Polyethylene Glycol 3350 Premarin...... 79 Propafenone HCl ER...... 59 Powder...... 72 Premasol...... 70 Proparacaine HCl...... 85 Polymyxin B Sulfate...... 34 Premphase...... 79 Propranolol HCl...... 60 Polymyxin B Sulfate/ Prempro...... 79 Propranolol HCl ER...... 60 Trimethoprim Sulfate...... 85 Prevalite...... 64 Propranolol/ Pomalyst...... 46 Previfem...... 79 Hydrochlorothiazide...... 62 Portia-28...... 79 Prezcobix...... 54 Propylthiouracil...... 81 Potassium Chloride...... 70 Prezista...... 54 ProQuad...... 83 Potassium Chloride CR...... 70 Priftin...... 46 Prosol...... 70 Potassium Chloride ER...... 70 Prilosec...... 73 Protriptyline HCl...... 43 Potassium Chloride/Dextrose Primaquine Phosphate...... 48 Prudoxin...... 68 ...... 70 Primidone...... 39 Pulmozyme...... 90 Potassium Chloride/Dextrose/ Lactated Ringers...... 70 Privigen...... 82 Purixan...... 46 Potassium Chloride/Dextrose/ ProAir HFA...... 89 Pyrazinamide...... 46 Sodium Chloride...... 70 ProAir RespiClick...... 89 Pyridostigmine Bromide...... 45 Potassium Chloride/Sodium Probenecid...... 45 Pyridostigmine Bromide ER Chloride...... 70 Probenecid/Colchicine...... 45 ...... 45 Potassium Citrate ER...... 70 Procalamine...... 70 Q Pradaxa...... 57 Prochlorperazine...... 43 Quadracel...... 83 Praluent...... 64 Prochlorperazine Maleate...... 43 Quasense...... 79 Pramipexole Dihydrochloride Procrit...... 58 Quetiapine Fumarate...... 51 ...... 49 Procto-Med HC...... 84 Quetiapine Fumarate ER...... 51 Prasugrel...... 58 Procto-Pak...... 84 Quinapril HCl...... 59 Pravastatin Sodium...... 63 Proctosol HC...... 84 Quinapril/Hydrochlorothiazide Prazosin HCl...... 59 ...... 62 Proctozone-HC...... 84 Pred Mild...... 87 Quinidine Gluconate CR...... 59 25Tracked 25 25 Quinidine Sulfate...... 59 Reyataz...... 54 Samsca...... 71 Quinine Sulfate...... 48 Rhopressa...... 85 Sancuso...... 43 R Ribasphere...... 52 Sandimmune...... 82 Rabavert...... 83 Ribavirin...... 52 Santyl...... 68 Rabeprazole Sodium...... 73 Ridaura...... 83 Saphris...... 51 HCl...... 80 Rifabutin...... 46 Savella...... 66 Ramipril...... 59 Rifampin...... 46 Savella Titration Pack...... 66 Ranexa...... 62 Rifater...... 46 Scopolamine...... 43 Ranitidine HCl...... 72 Riluzole...... 66 Selegiline HCl...... 49 Rapaflo...... 74 Rimantadine HCl...... 54 Selenium Sulfide...... 68 Rapamune...... 82 Riomet...... 56 Selzentry...... 53, 54 Rasagiline Mesylate...... 49 Risedronate Sodium...... 84 Sensipar...... 84 Ravicti...... 73 Risperdal Consta...... 51 Serevent Diskus...... 89 Rayaldee...... 84 Risperidone...... 51 Serostim...... 72 Rebif...... 66 Risperidone ODT...... 51 Sertraline HCl...... 42 Rebif Rebidose...... 66 Ritonavir...... 54 Setlakin...... 79 Rebif Rebidose Titration Pack Rivastigmine Tartrate...... 41 Sevelamer Carbonate...... 71 ...... 66 Rivastigmine Transdermal Sharobel...... 80 Rebif Titration Pack...... 66 System...... 41 Shingrix...... 83 Reclipsen...... 79 Rizatriptan Benzoate...... 45 Signifor...... 81 Recombivax HB...... 83 Rizatriptan Benzoate ODT..... 45 Sildenafil...... 90 Regranex...... 68 Ropinirole HCl...... 49 Silver Sulfadiazine...... 38 Relenza Diskhaler...... 54 Rosuvastatin Calcium...... 64 Simbrinza...... 86 Relistor...... 72 Rotarix...... 83 Simponi...... 82 Repaglinide...... 56 RotaTeq...... 83 Simvastatin...... 64 Repaglinide/Metformin HCl Roweepra...... 39 Sirolimus...... 82 ...... 56 Roweepra XR...... 39 Sirturo...... 46 Repatha...... 64 Rozerem...... 91 Sodium Chloride...... 70 Repatha Pushtronex System Rubraca...... 47 Sodium Chloride 0.9%...... 70 ...... 64 Ruconest...... 81 Sodium Chloride 0.45%...... 70 Repatha SureClick...... 64 Rydapt...... 47 Sodium Fluoride...... 71 Rescriptor...... 53 S Sodium Lactate...... 71 Restasis...... 85 Sabril...... 39 Sodium Phenylbutyrate...... 73 Revlimid...... 46 Saizen...... 76 Rexulti...... 51 26 26Tracked 26 Sodium Polystyrene Sulfonate Sucralfate...... 72 Tacrolimus...... 68, 82 ...... 71 Sulfacetamide Sodium...... 38 Tafinlar...... 48 Sodium Sulfacetamide...... 38 Sulfacetamide Sodium/ Tagrisso...... 48 Soliqua 100/33...... 56 Prednisolone Sodium Citrate...... 46 Phosphate...... 85 Soltamox...... 46 Tamsulosin HCl...... 74 Sulfadiazine...... 38 Somatuline Depot...... 81 Tarceva...... 48 Sulfamethoxazole/ Somavert...... 81 Targretin...... 48 Trimethoprim...... 38 Sotalol HCl...... 59 Tarina Fe 1/20...... 79 Sulfamethoxazole/ Sovaldi...... 52 Trimethoprim DS...... 38 Tasigna...... 48 Spiriva HandiHaler...... 88 Sulfamylon...... 34 Tazarotene...... 68 Spiriva Respimat...... 88 Sulfasalazine...... 84 Tazicef...... 35 ...... 63 Sulindac...... 30 Tazorac...... 68 Spironolactone/ Sumatriptan...... 45 Taztia XT...... 60 Hydrochlorothiazide...... 62 Sumatriptan Succinate...... 45 Tecfidera...... 67 Sporanox...... 45 Sumatriptan Succinate Refill Tecfidera Starter Pack...... 67 Sprintec 28...... 79 ...... 45 Telmisartan...... 59 Spritam...... 39 Suprax...... 35 Telmisartan/Amlodipine...... 62 Sprycel...... 48 Suprep Bowel Prep Kit...... 72 Telmisartan/ SPS...... 71 Sustiva...... 53 Hydrochlorothiazide...... 62 Sronyx...... 79 Sutent...... 48 Temazepam...... 91 SSD...... 38 Syeda...... 79 Tenivac...... 83 Stalevo 100...... 49 Sylatron...... 52 Tenofovir Disoproxil Fumarate Stalevo 125...... 49 ...... 53 Symbicort...... 90 Stalevo 150...... 49 Terazosin HCl...... 74 Symfi...... 53 Stalevo 200...... 49 Terbinafine HCl...... 45 Symfi Lo...... 53 Stalevo 50...... 49 Terconazole...... 45 SymlinPen 120...... 56 Stalevo 75...... 49 ...... 77 SymlinPen 60...... 56 Stavudine...... 53 ...... 77 Synarel...... 81 Stelara...... 68 ...... 77 Synjardy...... 56 Stiolto Respimat...... 90 Testosterone Pump...... 77 Synjardy XR...... 56 Stivarga...... 48 Tetanus/Diphtheria Toxoids- Synribo...... 47 Streptomycin Sulfate...... 33 Adsorbed Adult...... 83 Synthroid...... 80 Tetrabenazine...... 66 Stribild...... 52 T Suboxone...... 32 Tetracycline HCl...... 38 Tabloid...... 46 Sucraid...... 73 Thalomid...... 46 27Tracked 27 27 Theophylline...... 89 Tranylcypromine Sulfate...... 41 Triumeq...... 52 Theophylline CR...... 89 Travasol...... 71 Trivora-28...... 80 Theophylline ER...... 89 Travatan Z...... 87 Trophamine...... 71 Thioridazine HCl...... 50 Trazodone HCl...... 42 Trulicity...... 56 Thiothixene...... 50 Trecator...... 46 Trumenba...... 83 Tiagabine HCl...... 39 Trelegy Ellipta...... 90 Truvada...... 53 Tigecycline...... 34 Trelstar Mixject...... 81 Twinrix...... 83 Timolol Maleate...... 60, 86 Tresiba FlexTouch...... 57 Tybost...... 52 Timolol Maleate Ophthalmic Tretinoin...... 48, 68 Tykerb...... 48 Gel Forming...... 86 Tretinoin Microsphere...... 68 Tymlos...... 84 Tinidazole...... 34 Trexall...... 82 Typhim Vi...... 83 Tivicay...... 52 Trezix...... 32 U Tizanidine HCl...... 90 Tri-Legest Fe...... 79 Uloric...... 45 TOBI Podhaler...... 89 Tri-Lo-Estarylla...... 79 Unithroid...... 81 Tobradex...... 85 Tri-Lo-Sprintec...... 79 Ursodiol...... 72 Tobradex ST...... 85 Tri-Mili...... 79 V Tobramycin...... 89 Tri-Previfem...... 80 Valacyclovir HCl...... 52 Tobramycin Sulfate...... 33 Tri-Sprintec...... 80 Valchlor...... 46 Tobramycin/Dexamethasone Tri-Vylibra...... 80 Valganciclovir...... 51 ...... 85 Triamcinolone Acetonide...... 76, Valganciclovir Hydrochlorde Tobrex...... 33 88 ...... 51 Tolcapone...... 49 Triamcinolone Acetonide Valproic Acid...... 39 Topiramate...... 40 Dental Paste...... 67 Valsartan...... 59 Torsemide...... 63 Triamterene/ Valsartan/Hydrochlorothiazide Toujeo Max Solostar...... 57 Hydrochlorothiazide...... 62 ...... 62 Toujeo SoloStar...... 57 Triderm...... 76 Vancomycin HCl...... 34 TPN Electrolytes...... 71 Trientine HCl...... 71 Vandazole...... 34 Tracleer...... 90 Trifluoperazine HCl...... 50 VAQTA...... 83 Tradjenta...... 56 Trifluridine...... 52 Varivax...... 83 Tramadol HCl...... 32 Trihexyphenidyl HCl...... 49 Varizig...... 82 Tramadol HCl ER...... 30 TriLyte...... 72 Vascepa...... 64 Tramadol HCl/Acetaminophen Trimethoprim...... 34 Velivet...... 80 ...... 32 Trimipramine Maleate...... 43 Velphoro...... 71 Trandolapril...... 59 Trinessa...... 80 Veltassa...... 71 Tranexamic Acid...... 58 Trintellix...... 42 Vemlidy...... 52 28 28Tracked 28 Venclexta...... 48 Vyfemla...... 80 Zarah...... 80 Venclexta Starting Pack...... 48 Vylibra...... 80 Zarxio...... 58 Venlafaxine HCl...... 42 Vyvanse...... 65 Zejula...... 47 Venlafaxine HCl ER...... 42 Vyzulta...... 87 Zelapar...... 49 Ventavis...... 90 W Zelboraf...... 48 Verapamil HCl...... 60 Warfarin Sodium...... 57 Zemaira...... 73 Verapamil HCl ER...... 61 Welchol...... 64 Zenchent...... 80 Verapamil HCl SR...... 61 WYMZYA Fe...... 80 Zenpep...... 73 Versacloz...... 51 X Zerbaxa...... 35 Verzenio...... 47 Xalkori...... 48 Zerit...... 53 Vesicare...... 74 Xarelto...... 57 Zidovudine...... 53 Vibramycin...... 38 Xarelto Starter Pack...... 57 Zileuton ER...... 88 Victoza...... 56 Xatmep...... 82 Zioptan...... 87 Videx EC...... 53 Xeljanz...... 82 Ziprasidone HCl...... 51 Videx Pediatric...... 53 Xeljanz XR...... 82 Zirgan...... 51 Vienva...... 80 Xgeva...... 84 Zolinza...... 47 Vigabatrin...... 39 Xifaxan...... 72 Zolpidem Tartrate...... 91 Viibryd...... 42 Xiidra...... 85 Zonisamide...... 39 Viibryd Starter Pack...... 42 Xolair...... 83 Zorbtive...... 72 Vimpat...... 40 Xtampza ER...... 31 Zortress...... 82 Viracept...... 54 Xtandi...... 46 Zostavax...... 83 Viramune...... 53 Xulane...... 80 Zovia 1/35E...... 80 Viread...... 53 Xyrem...... 91 Zyclara Pump...... 68 Vivitrol...... 32 Y Zydelig...... 48 Voriconazole...... 45 YF-Vax...... 83 Zyflo...... 88 Vosevi...... 52 Yuvafem...... 80 Zykadia...... 48 Votrient...... 48 Z Zyprexa Relprevv...... 51 VP-PNV-DHA...... 71 Zafirlukast...... 88 Zytiga...... 46 Vraylar...... 51 Zaleplon...... 91 tRACK 29 29 Covered drugs by medical condition 128 The list below has information about the drugs covered by this plan. Find your medical condition to see what drugs are covered. If you have trouble finding your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-28. The first column lists the drug name, which may include the dosage form and strength. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column lists the drug tier or coverage level. The third column lists any rules or limits for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 92-114. tRACK

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

A1 EtodC1 Analgesics Etodolacolac (200mg AnalgesicsB1 Capsule, 300mg

ButalC1 bital/ Capsule, 400mg Tablet Acet Butalbital/amin ophe 3 n/ Caff eine Immediate-Release, Acetaminophen/ 500mg Tablet Caffeine 3 QL Immediate-Release) (50mg-325mg-40mg EtodC1 olac Tablet) EtodolacER ER (Tablet

ButalC1 bital/ Extended-Release 24 4 Aspir Butalbital/Aspirin/in/ Caff eine Hour) Caffeine FlectC1 3 QL or (50mg-325mg-40mg Flector (Patch) 4 PA, QL

FlurbC1 iprof Capsule) Flurbiprofenen (Tablet) 2 ¨ NonsteroidalB1 Anti-inflammatory Drugs IbuC1 (Tablet) 2 ¨

CeleC1 IbupC1 coxi rofe Celecoxibb (Capsule) 3 QL Ibuprofenn (100mg/5ml

DicloC1 fena c Suspension, 400mg DiclofenacPota Potassium ssiu ¨ m 2 ¨ 2 (Tablet) Tablet, 600mg Tablet,

DicloC1 fena 800mg Tablet) c SodiDiclofenac Sodium um IndoC1 meth 3 PA acin (1% Gel) Indomethacin (25mg

DicloC1 ¨ fena Capsule, 50mg 2 c DiclofenacSodi Sodium DR um DR Capsule) (Tablet Delayed- 2 ¨ MeloC1 xica Release) Meloxicamm (Tablet) 1 ¨

NabC1 DicloC1 umet fena one c Nabumetone (Tablet) 4 SodiDiclofenac Sodium ER um ER NaprC1 (Tablet Extended- 2 ¨ Naproxenoxen (125mg/5ml 4 Release 24 Hour) Suspension)

DifluC1 nisalDiflunisal (Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 30 tRACK 30 Last updated October 1, 2018 229 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

NaprC1 HysiC1 oxen ngla Naproxen (250mg HysinglaER ER (Tablet Tablet Immediate- Extended-Release 24 7D, DL, QL, Release, 375mg Tablet 3 2 ¨ Hour Abuse- MME Immediate-Release, Deterrent)

500mg Tablet LevoC1 rpha nol LevorphanolTartr Tartrate 7D, DL, QL, Immediate-Release) ate 5

C1 (Tablet) Napr MME oxen DR Naproxen DR (Tablet MethC1 adon e Delayed-Release) 2 ¨ MethadoneHCl HCl (10mg Tablet, 5mg Tablet, (Generic EC-Naprosyn) 7D, DL, QL,

PiroxC1 10mg/5ml Oral 3 icam Piroxicam (Capsule) 3 Solution, 5mg/5ml Oral MME SulinC1 Sulindacdac (Tablet) 2 ¨ Solution)

B1 MorC1 phin e Opioid Analgesics, Long-acting MorphineSulfa Sulfate ER te ER EmbC1 Embedaeda (Capsule 7D, DL, QL, (100mg Tablet 3 Extended-Release) MME Extended-Release,

FentC1 Fentanylanyl (100mcg/hr 15mg Tablet Extended- 7D, DL, QL, Release, 30mg Tablet 3 Patch 72 Hour, MME 12mcg/hr Patch 72 Extended-Release, Hour, 25mcg/hr Patch 7D, DL, QL, 60mg Tablet Extended- 4 Release) (Generic MS 72 Hour, 50mcg/hr MME Patch 72 Hour, Contin) MorC1 phin e MorphineSulfa Sulfate ER te 75mcg/hr Patch 72 ER (200mg Tablet 7D, DL, QL, Hour) 4 HydrC1 omo Extended-Release) MME rpho Hydromorphonene HCl HCl ER (12mg Tablet (Generic MS Contin) NucyC1 nta NucyntaER ER (Tablet Extended-Release 24 7D, DL, QL, Extended-Release 12 3 Hour Abuse-Deterrent, MME 8mg Tablet Extended- 7D, DL, QL, Hour) 4 TramC1 adol Release 24 Hour MME HCl TramadolER HCl ER Abuse-Deterrent,16mg (100mg Tablet Tablet Extended- Extended-Release 24 Release 24 Hour Hour, 200mg Tablet 7D, DL, QL, 3 Abuse-Deterrent) Extended-Release 24 MME

HydrC1 omo rpho Hydromorphonene HCl Hour, 300mg Tablet HCl ER (32mg Tablet 7D, DL, QL, Extended-Release 24 5 Extended-Release 24 MME Hour) Hour Abuse-Deterrent)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 31 31 330 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

XtamC1 HydrC1 pza omo ER rpho Xtampza ER (Capsule Hydromorphonene HCl HCl Extended-Release 12 7D, DL, QL, (10mg/ml Injection, 4 7D, DL 3 Hour Abuse- MME 50mg/5ml Injection)

HydrC1 omo rpho Deterrent) Hydromorphonene HCl 7D, DL, QL, HCl 4 OpioidB1 Analgesics, Short-acting (1mg/ml Liquid) MME

HydrC1 AbstC1 omo ral rpho Hydromorphonene HCl Abstral (Tablet HCl 5 DL, PA, QL Sublingual) (2mg Tablet

AcetC1 Immediate-Release, 7D, DL, QL, amin ophe Acetaminophen/n/ 2 Cod eine 4mg Tablet Immediate- MME ¨ Codeine Release, 8mg Tablet (120mg-12mg/5ml 7D, DL, QL, Immediate-Release) Oral Solution, 2 HydrC1 ¨ omo MME rpho Hydromorphonene HCl 300mg-15mg Tablet, HCl 4 7D, DL 300mg-30mg Tablet, (2mg/ml Injection)

300mg-60mg Tablet) LorcC1 7D, DL, QL, et

ButoC1 Lorcet (Tablet) 3 rpha nol ButorphanolTartr Tartrate MME ate 7D, DL, QL,

(10mg/ml Nasal 3 C1 Lorc 7D, DL, QL, et MME LorcetHD HD (Tablet) 3 Solution) MME

CodC1 eine Sulfa Codeinete Sulfate 7D, DL, QL, LorcC1 7D, DL, QL, et 3 LorcetPlus Plus (Tablet) 3 (Tablet) MME MME

DuraC1 mor MorC1 ph phin Duramorph (Injection) 4 7D, DL e MorphineSulfa Sulfate te

EndC1 7D, DL, QL, (100mg/5ml Oral ocet 7D, DL, QL, Endocet (Tablet) 3 Solution, 10mg/5ml 3 MME MME FentC1 anyl Oral Solution, 20mg/ Citra Fentanylte Citrate Oral Oral Tran smu cosa 5ml Oral Solution) Transmucosall 5 DL, PA, QL MorC1 phin e MorphineSulfa Sulfate (Lozenge on a Handle) te

HydrC1 ocod (10mg/ml Injection, one/ Hydrocodone/Acet amin 4 7D, DL ophe Acetaminophenn 4mg/ml Injection, (10mg-325mg Tablet, 8mg/ml Injection) MorC1 phin e MorphineSulfa Sulfate 2.5mg-325mg Tablet, 7D, DL, QL, te 3 5mg-325mg Tablet, MME (15mg Tablet 7D, DL, QL, 7.5mg-325mg Tablet, Immediate-Release, 3 MME 7.5mg-325mg/15ml 30mg Tablet Oral Solution) Immediate-Release)

HydrC1 ocod C1 one/ Mor Ibup phin Hydrocodone/ e rofe n MorphineSulfa Sulfate 7D, DL, QL, te Ibuprofen 3 MME (2mg/ml Injection, 4 7D, DL (7.5mg-200mg Tablet) 5mg/ml Injection)

Bold type = Brand name drug Plain type = Generic drug 32 tRACK 32 Last updated October 1, 2018 431 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

OxycC1 LidoC1 odon cain e e OxycodoneHCl HCl LidocaineHCl HCl (4% 7D, DL, QL, 2 ¨ (100mg/5ml 4 External Solution)

MME C1 Lido cain Concentrate) e ¨ LidocaineHCl HCl (Gel) 2

OxycC1 odon LidoC1 e cain OxycodoneHCl HCl (10mg e LidocaineVisc Viscous ous 2 ¨ Tablet Immediate- (Solution)

LidoC1 Release, 15mg Tablet cain e/ Lidocaine/PrilocainePrilo cain Immediate-Release, e 3 (Cream) 7D, DL, QL, 20mg Tablet A1 2 Immediate-Release, MME ¨ Anti-Addiction/Substance Abuse Treatment 30mg Tablet Agents Immediate-Release, AlcoholB1 Deterrents/Anti-craving

AcaC1 mpr 5mg Tablet Immediate- osat Acamprosatee Calcium Calci um DR Release) DR (Tablet Delayed- 4

OxycC1 odon e OxycodoneHCl HCl (5mg/ 7D, DL, QL, Release)

3 C1 Disul 5ml Oral Solution) MME Disulfiramfiram (Tablet) 3

OxycC1 odon NaltrC1 e/ exon Oxycodone/Acet e amin NaltrexoneHCl HCl ophe n 7D, DL, QL, Acetaminophen 3 3 MME (Tablet) VivitrC1 (Tablet) Vivitrolol (Injection) 5 OxycC1 odon e/ B1 Oxycodone/AspirinAspir 7D, DL, QL, in 3 Opioid Dependence Treatments

(Tablet) MME BuprC1 enor phin Buprenorphinee HCl HCl OxycC1 odon ¨ e/ 2 QL Oxycodone/IbuprofenIbup 7D, DL, QL, rofe n 3 (Tablet Sublingual) (Tablet) BuprC1 MME enor phin eBuprenorphine HCl/ HCl/ TramC1 Nalo adol xone TramadolHCl HCl (Tablet 7D, DL, QL, HCl ¨ 2 Naloxone HCl (Tablet 2 QL Immediate-Release) MME ¨ Sublingual)

TramC1 adol SubC1 HCl/ oxon TramadolAcet HCl/ e amin Suboxone (Film) 4 QL ophe n 7D, DL, QL, Acetaminophen 2 B1 MME ¨ Opioid Reversal Agents

(Tablet) NaloC1 xone Naloxone HCl HCl

C1 3 Trezi 7D, DL, QL, Trezixx (Capsule) 4 (Injection) MME NarcC1 Narcanan (Liquid) 3 A1

Anesthetics B1 Smoking Cessation Agents B1

Local Anesthetics BuprC1 opio n BupropionHCl HCl SR SR LidoC1 cain Lidocainee (5% 4 QL (150mg Tablet Ointment) Extended-Release 12 2 ¨

LidoC1 cain Lidocainee (5% Patch) 4 PA, QL Hour Smoking- Deterrent)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 33 33 532 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ChaC1 TobrC1 ntix amy cin Chantix (Tablet) 3 TobramycinSulfa Sulfate te ChaC1 ntix Cont (10mg/ml Injection, 4 Chantixinuin Continuing g Mont h Pak 3 Month Pak (Tablet) 80mg/2ml Injection) TobrC1 ex ChaC1 ntix Tobrex (0.3% Starti Chantixng Starting Mont h 4 Pak 3 Month Pak (Tablet) Ophthalmic Ointment)

B1

NicoC1 Nicotroltrol (Inhaler) 4 Antibacterials, Other BacitC1 racin NicoC1 trol Bacitracin (Ophthalmic NicotrolNS NS (Nasal ¨ 4 2 Solution) Ointment) BactC1 roba

A1 n BactrobanNasa Nasal Antibacterials l 4 PA

B1 (Ointment)

Aminoglycosides C1 Clind amy cin AmikC1 ClindamycinHCl HCl acin Sulfa Amikacinte Sulfate 4 (Capsule Immediate- 2 ¨ (Injection) Release) GentC1 ak ClindC1 Gentak (Ophthalmic amy cin ¨ ClindamycinPalm Palmitate 2 itate HCl 2 ¨ Ointment) HCl (Oral Solution) GentC1 amic in C1 Sulfa Clind Gentamicin Sulfate amy te cin ClindamycinPhos phat (0.1% Cream, 0.1% e 3 2 ¨ Phosphate (2% Cream)

Ointment, 0.3% C1 Clind amy cin ClindamycinPhos phat Ophthalmic Solution) e

GentC1 Phosphate (300mg/ amic in SulfaGentamicin Sulfate te 4 2ml Injection, 600mg/ 4 (40mg/ml Injection) 4ml Injection, 900mg/ GentC1 amic in GentamicinSulfa Sulfate/ te/ 0.9% 6ml Injection) Sodi um Chlo C1 ride Clind 0.9% Sodium Chloride 4 amy cin ClindamycinPhos phat e in D5W (Injection) Phosphate in D5W 4 IsotoC1 nic Gent Isotonicamic Gentamicin in 4 (Injection)

ColisC1 (Injection) timet hate ColistimethateSodi Sodium um NeoC1 myci n 4 NeomycinSulfa Sulfate te 2 ¨ (Injection)

DalvC1 (Tablet) Dalvanceance (Injection) 5 PA ParoC1 mom ycin DaptC1 Sulfa Paromomycin Sulfate omy te 4 Daptomycincin (Injection) 5

(Capsule) C1 Line zolid

StreC1 Linezolid (100mg/5ml ptom ycin StreptomycinSulfa Sulfate 5 PA te 5 Suspension)

(Injection) C1 Line zolid

TobrC1 Linezolid (600mg amy cin TobramycinSulfa Sulfate 4 PA, QL te ¨ Tablet) (0.3% Ophthalmic 2 C1 Line Linezolidzolid (600mg/ Solution) 4 PA 300ml Injection)

Bold type = Brand name drug Plain type = Generic drug 34 tRACK 34 Last updated October 1, 2018 633 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MethC1 VancC1 ena omy mine cin Methenamine VancomycinHCl HCl Hipp urate 4 Hippurate (Tablet) (1000mg Injection,

MetrC1 onid azol 10gm Injection, 500mg Metronidazolee (0.75% 4 Cream, 0.75% Gel, 1% 4 Injection, 125mg Gel, 0.75% Lotion) Capsule, 250mg

MetrC1 onid Capsule) azol Metronidazolee (250mg VanC1 dazo Tablet Immediate- Vandazolele (Gel) 3 2 ¨ B1 Release, 500mg Tablet Beta-lactam, Cephalosporins

CefaC1 Immediate-Release) Cefaclorclor (250mg

MetrC1 onid azol eMetronidazole in in NaCl Capsule Immediate- NaCl 0.79 % 4 0.79% (Injection) Release, 500mg 2 ¨

MetrC1 onid azol Capsule Immediate- Metronidazolee Vaginal Vagi nal 3 (Gel) Release)

CefaC1 droxi MupiC1 Mupirocinrocin (2% Cream) 4 Cefadroxill (250mg/5ml

MupiC1 rocin Suspension, 500mg/ Mupirocin (2% 2 ¨ 2 ¨ 5ml Suspension, Ointment)

C1 500mg Capsule) Nitro furan toin Nitrofurantoin CefaC1 zolin Sodi 4 Cefazolinum Sodium (Suspension) 4

C1 (Injection) Nitro furan toin NitrofurantoinMacr CefdC1 ocry inir stals Cefdinir (125mg/5ml Macrocrystals (100mg Suspension, 250mg/ Capsule, 50mg 3 3 5ml Suspension, Capsule) (Generic 300mg Capsule) Macrodantin) CefeC1 pime

NitroC1 furan Cefepime (Injection) 4 toin NitrofurantoinMon ohyd CefixC1 rate Monohydrate (100mg Cefiximeime (Suspension) 4 3 CefoC1 taxi me Capsule) (Generic CefotaximeSodi Sodium um 4 Macrobid) (Injection)

PolyC1 CefoC1 myxi tetan n B PolymyxinSulfa B Sulfate Cefotetan (Injection) 4 te 4 CefoC1 xitin (Injection) Sodi Cefoxitinum Sodium

SulfaC1 mylo Sulfamylonn (85mg/ (10gm Injection, 1gm 4 4 gm Cream) Injection, 2gm

TigeC1 cycli Injection) Tigecyclinene (Injection) 5

TinidC1 azol Tinidazolee (Tablet) 4

TrimC1 etho Trimethoprimprim (Tablet) 2 ¨

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 35 35 734 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CefpC1 ZerbC1 odox axa ime CefpodoximeProx Proxetil Zerbaxa (Injection) 4 PA etil

B1 (100mg Tablet, 200mg Beta-lactam, Other

AztreC1 Tablet, 100mg/5ml 4 ona Aztreonamm (Injection) 4

Suspension, 50mg/5ml C1 Dori pene Suspension) Doripenemm (Injection) 3 ImipC1 ene CefpC1 m/ rozil Imipenem/CilastatinCilas Cefprozil (125mg/5ml tatin 4 Suspension, 250mg/ (Injection) InvaC1 5ml Suspension, 3 Invanznz (Injection) 5

MerC1 open 250mg Tablet, 500mg Meropenemem (Injection) 4 Tablet) Beta-lactam,B1 Penicillins CeftC1 azidi me AmoC1 Ceftazidime (Injection) 4 xicilli Amoxicillinn (125mg CeftrC1 iaxo ne CeftriaxoneSodi Sodium um Tablet Chewable, (10gm Injection, 1gm 250mg Tablet Injection, 250mg 4 Chewable, 125mg/5ml Injection, 2gm Suspension, 200mg/ Injection, 500mg 5ml Suspension, Injection) 250mg/5ml 1 ¨

CefuC1 roxi me CefuroximeAxeti Axetil Suspension, 400mg/ l 2 ¨ (Tablet) 5ml Suspension,

CefuC1 roxi me 250mg Capsule, SodiCefuroxime Sodium um (1.5gm Injection, 500mg Capsule, 4 7.5gm Injection, 500mg Tablet, 875mg 750mg Injection) Tablet)

CepC1 hale Cephalexinxin (125mg/ 5ml Suspension, 250mg/5ml Suspension, 250mg 2 ¨ Capsule, 500mg Capsule, 750mg Capsule)

SuprC1 ax Suprax (100mg Tablet Chewable, 200mg 3 Tablet Chewable)

SuprC1 Supraxax (400mg

Capsule, 500mg/5ml 3 Suspension)

TaziC1 Tazicefcef (Injection) 4

Bold type = Brand name drug Plain type = Generic drug 36 tRACK 36 Last updated October 1, 2018 835 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AmoC1 DicloC1 xicilli xacill n/ in Amoxicillin/Clav DicloxacillinSodi Sodium ulan um ate ¨ Pota 2 ssiu Clavulanatem Potassium (Capsule)

NafciC1 llin (200mg-28.5mg Tablet Sodi Nafcillinum Sodium Chewable, (10gm Injection, 1gm 4 400mg-57mg Tablet Injection)

OxacC1 Chewable, 200mg/ illin Sodi Oxacillinum Sodium 5ml-28.5mg/5ml 4 (Injection)

Suspension, 250mg/ C1 Peni cillin G PenicillinPota G Potassium ssiu 5ml-62.5mg/5ml m 4 Suspension, 400mg/ (Injection) PeniC1 cillin G ¨ PenicillinProc G Procaine 5ml-57mg/5ml 2 aine 4 Suspension, 600mg/ (Injection)

PeniC1 cillin 5ml-42.9mg/5ml G PenicillinSodi G Sodium um 4 Suspension, (Injection)

PeniC1 250mg-125mg Tablet cillin V PenicillinPota V Potassium ssiu Immediate-Release, (125mg/5mlm Oral 500mg-125mg Tablet Solution, 250mg/5ml 2 ¨ Immediate-Release, Oral Solution, 250mg 875mg-125mg Tablet Tablet, 500mg Tablet)

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

AmoC1 Tazobactam (Injection) xicilli n/ Clav Amoxicillin/ B1 ulan ate Pota ssiu Macrolides m ERClavulanate Potassium AzasC1 4 Azasiteite (Ophthalmic ER (Tablet Extended- 4 Release 12 Hour) Solution)

C1 AmpC1 Azith icillin romy Ampicillin (Capsule) 2 ¨ Azithromycincin (100mg/

AmpC1 icillin 5ml Suspension, SodiAmpicillin Sodium um (10gm Injection, 200mg/5ml 4 1 ¨ 125mg Injection, 1gm Suspension, 250mg Injection) Tablet, 500mg Tablet,

AmpC1 600mg Tablet) icillin - Sulb Ampicillin-Sulbactam C1 acta Azith m romy 4 Azithromycincin (500mg (Injection) 4 BactC1 Injection) ocill in BactocillDext in Dextrose rose ClaritC1 hro 4 myci (Injection) Clarithromycinn

C1 Bicill (125mg/5ml in C- R 4 Bicillin C-R (Injection) 4 Suspension, 250mg/ BicillC1 in L- BicillinA L-A (Injection) 4 5ml Suspension)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 37 37 936 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ClaritC1 CiprC1 hro oflox myci acin Clarithromycinn (250mg Ciprofloxacin (Oral 3 4 Tablet, 500mg Tablet) Suspension)

ClaritC1 CiprC1 hro oflox myci acin Clarithromycinn ER ER CiprofloxacinER ER (Tablet Extended- 3 (Tablet Extended- 3 Release 24 Hour) Release 24 Hour)

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

E.E.C1 S. Gran (0.3% Ophthalmic E.E.S.ules Granules 4 (Suspension) Solution, 250mg Tablet

Ery-C1 Immediate-Release, Ery-TabTab (Tablet 2 ¨ 4 500mg Tablet Delayed-Release) Immediate-Release, EryPC1 ed EryPed200 200 4 750mg Tablet (Suspension) Immediate-Release)

EryPC1 ed CiprC1 400 oflox acin EryPed 400 HCl 5 Ciprofloxacin HCl (Suspension) (100mg Tablet 3

ErythC1 rocin Immediate-Release) ErythrocinLact obio nate CiprC1 oflox acin Lactobionate 4 CiprofloxacinI.V. I.V. in in D5W 4 (Injection) D5W (Injection)

ErythC1 GatifC1 romy loxa Erythromycincin (250mg Gatifloxacincin 3 Capsule Delayed- 4 (Ophthalmic Solution)

LevoC1 floxa Release) Levofloxacincin (0.5%

ErythC1 romy 3 Erythromycincin (5mg/gm Ophthalmic Solution) 2 ¨ LevoC1 floxa Ophthalmic Ointment) Levofloxacincin (250mg

ErythC1 romy cin BaseErythromycin Base Tablet, 500mg Tablet, 1 ¨ 4 (Tablet) 750mg Tablet)

ErythC1 LevoC1 romy floxa cin cin ErythromycinEthyl succ Levofloxacin (25mg/ml inate Ethylsuccinate Injection, 25mg/ml 4 (200mg/5ml 4 Oral Solution)

LevoC1 floxa Suspension, 400mg cin Levofloxacinin in D5W D5W 4 Tablet) (Injection)

B1

MoxC1 Quinolones Moxezaeza (Ophthalmic

BesiC1 vanc 4 Besivancee 4 Solution) MoxiC1 floxa (Suspension) cin MoxifloxacinHCl/ HCl/ Sodi um CiloxC1 HCl an 4 Ciloxan (0.3% Sodium HCl (Injection)

4 C1 Moxi floxa Ointment) cin MoxifloxacinHCl HCl 4 (Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug 38 tRACK 38 Last updated October 1, 2018 1037 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

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

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

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

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

MinoC1 SulfaC1 cycli diazi ne neSulfadiazine (Tablet) 4 MinocyclineHCl HCl

SulfaC1 meth (100mg Tablet oxaz Sulfamethoxazole/ole/ Trim etho Trimethoprimprim Immediate-Release, (200mg-40mg/5ml 2 ¨ 50mg Tablet 4 Suspension, Immediate-Release, 400mg-80mg Tablet) 75mg Tablet

SulfaC1 Immediate-Release) meth oxaz ole/ Sulfamethoxazole/ TetraC1 Trim etho cycli prim ne HCl DS Tetracycline HCl Trimethoprim DS 2 ¨ 4 (Tablet) (Capsule) VibraC1 myci B1 Vibramycinn (50mg/ Tetracyclines 4

DemC1 5ml Syrup) eclo cycli ne Demeclocycline HCl A1 HCl 4 (Tablet) Anticonvulsants

B1

DoxyC1 Doxy100 100 (Injection) 4 Anticonvulsants, Other BriviC1 act DoxyC1 cycli Doxycyclinene (25mg/ Briviact (100mg 4 5ml Suspension) Tablet, 10mg Tablet, 25mg Tablet, 50mg 5 QL Tablet, 75mg Tablet, 10mg/ml Oral Solution)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 39 39 1138 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LeveC1 GabC1 tirac apen Levetiracetametam Gabapentintin (250mg/ 3 (1000mg Tablet 5ml Oral Solution) Immediate-Release, OnfiC1 (10mg Tablet, 5 PA, QL 250mg Tablet 20mg Tablet)

Immediate-Release, OnfiC1 Onfi (2.5mg/ml 500mg Tablet 2 ¨ 5 PA Immediate-Release, Suspension) PheC1 noba 750mg Tablet Phenobarbitalrbital (100mg Immediate-Release, Tablet, 15mg Tablet, 100mg/ml Oral 16.2mg Tablet, 30mg Solution) Tablet, 32.4mg Tablet, 2 ¨

LeveC1 tirac 60mg Tablet, 64.8mg etam LevetiracetamER ER (Tablet Extended- 3 Tablet, 97.2mg Tablet, Release 24 Hour) 20mg/5ml Elixir) PrimiC1 done RowC1 ¨ eepr Primidone (Tablet) 2 Roweepraa (Tablet) 2 ¨ SabriC1 l RowC1 eepr Sabril (500mg Tablet) 5 PA, QL, LA aRoweepra XR XR (Tablet TiagC1 abin e Extended-Release 24 3 HClTiagabine HCl (Tablet) 4

ValprC1 oic Hour) ValproicAcid Acid (250mg

SpritC1 Spritamam (Tablet Capsule, 250mg/5ml 2 ¨

Disintegrating 4 Oral Solution)

VigaC1 batri Soluble) Vigabatrinn (Packet) 5 PA, QL, LA

B1 CalciumB1 Channel Modifying Agents Glutamate Reducing Agents

FelbC1 CeloC1 ntin amat Felbamatee (400mg Celontin (Capsule) 4 4 EthoC1 suxi Ethosuximidemide (250mg Tablet, 600mg Tablet) FelbC1 amat Felbamatee (600mg/ Capsule, 250mg/5ml 3 5 Oral Solution) 5ml Suspension)

FycoC1 ZoniC1 sami mpa Zonisamidede (Capsule) 2 ¨ Fycompa (0.5mg/ml Gamma-aminobutyricB1 Acid (GABA) Suspension, 10mg Tablet, 12mg Tablet, Augmenting Agents 4 DiastC1 at 2mg Tablet, 4mg Acu DiastatDial AcuDial (Gel) 4

DiastC1 Tablet, 6mg Tablet, at Pedi Diastatatric Pediatric (Gel) 4

GabC1 8mg Tablet) apen Gabapentintin (100mg Capsule, 300mg Capsule, 400mg 2 ¨ Capsule, 600mg Tablet, 800mg Tablet)

Bold type = Brand name drug Plain type = Generic drug 40 tRACK 40 Last updated October 1, 2018 1239 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LamC1 CarbC1 otrigi ama ne zepi Lamotrigine (100mg Carbamazepinene ER ER Tablet Immediate- (100mg Capsule Release, 150mg Tablet Extended-Release 12 Immediate-Release, Hour, 200mg Capsule 2 ¨ 200mg Tablet Extended-Release 12 Immediate-Release, Hour, 300mg Capsule 25mg Tablet Extended-Release 12 3 Immediate-Release) Hour, 100mg Tablet

LamC1 otrigi ne Extended-Release 12 Lamotrigine (25mg Tablet Chewable, 5mg 3 Hour, 200mg Tablet Tablet Chewable) Extended-Release 12

TopirC1 amat Hour, 400mg Tablet Topiramatee (Tablet Extended-Release 12 Immediate- Release, 2 ¨ Hour) Capsule Sprinkle DilanC1 Immediate-Release) Dilantintin (Capsule) 3

DilanC1

B1 tin INFA DilantinTAB INFATABS Sodium Channel Agents S 3

AptiC1 om (Tablet Chewable) Aptiom (Tablet) 5 QL EpitoC1 l

BanzC1 Banzelel (200mg Epitol (Tablet) 3 OxcaC1 rbaz epin Tablet, 400mg Tablet, 5 Oxcarbazepinee 40mg/ml Suspension) (150mg Tablet, 300mg 3

CarbC1 Tablet, 600mg Tablet) ama zepi ne Carbamazepine OxcaC1 rbaz epin (100mg Tablet Oxcarbazepinee Chewable, 100mg/5ml (300mg/5ml 4 3 Suspension, 200mg Suspension) PegaC1 Tablet Immediate- Peganonenone (Tablet) 4

PheC1 nyte Release) Phenytekk (Capsule) 2 ¨

PheC1 nytoi Phenytoinn (125mg/5ml Suspension, 50mg 2 ¨ Tablet Chewable)

PheC1 nytoi n PhenytoinSodi Sodium um Exte ¨ nded 2 Extended (Capsule)

VimpC1 Vimpatat (100mg Tablet, 150mg Tablet, 200mg Tablet, 50mg 4 QL Tablet, 10mg/ml Oral Solution)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 41 41 1340 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

A1 BuprC1 opio n Antidementia Agents BupropionHCl HCl SR SR CholinesteraseB1 Inhibitors (100mg Tablet

DonC1 epez Extended-Release 12 il ¨ DonepezilHCl HCl (Tablet) 1 QL

C1 Hour, 150mg Tablet Don epez ¨ il 2 HClDonepezil HCl ODT ODT 2 QL ¨ Extended-Release 12 (Tablet Dispersible) Hour, 200mg Tablet GalaC1 ntam ine HBrGalantamine HBr Extended-Release 12 (12mg Tablet, 4mg 4 QL Hour) BuprC1 opio Tablet, 8mg Tablet, n BupropionHCl HCl XL XL 4mg/ml Oral Solution) (Tablet Extended- 2 ¨ GalaC1 ntam ine GalantamineHBr HBr ER ER Release 24 Hour)

MirtaC1 zapi (Capsule Extended- 4 QL Mirtazapinene (Tablet) 2 ¨

Release 24 Hour) MirtaC1 zapi ne ODT C1 Mirtazapine ODT Riva stig ¨ mine 2 Rivastigmine Tartrate Tartr ate 3 QL (Tablet Dispersible) (Capsule) B1

C1 Monoamine Oxidase Inhibitors Riva stig mine Rivastigmine EmsC1 Tran am sder mal Syst Emsam (Patch 24 Transdermalem System 4 QL, ST 5 QL (Patch 24 Hour) Hour) MarC1 plan N-methyl-D-aspartateB1 (NMDA) Receptor Marplan (Tablet) 4 PheC1 nelzi ne PhenelzineSulfa Sulfate Antagonist te 3

MemC1 antin (Tablet) e MemantineHCl HCl (10mg TranC1 ¨ ylcyp 2 PA, QL romi Tranylcyprominene Sulfa Tablet, 5mg Tablet) te 4

MemC1 antin Sulfate (Tablet) e HClMemantine HCl (2mg/ 4 PA, QL B1 ml Oral Solution) SSRI/SNRI (Selective Serotonin Reuptake

MemC1 antin Inhibitors/Serotonin and Norepinephrine e HClMemantine HCl ER ER (Capsule Extended- 3 PA, QL Reuptake Inhibitors)

CitalC1 opra m Release 24 Hour) CitalopramHBr HBr (10mg

MemC1 antin ¨ e Tablet, 20mg Tablet, 1 HClMemantine HCl Titrat ion Pak 3 PA Titration Pak (Tablet) 40mg Tablet) CitalC1 opra A1 m Antidepressants CitalopramHBr HBr

B1 (10mg/5ml Oral 3 Antidepressants, Other Solution) BuprC1 opio n BupropionHCl HCl (Tablet 2 ¨ Immediate-Release)

Bold type = Brand name drug Plain type = Generic drug 42 tRACK 42 Last updated October 1, 2018 1441 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DesvC1 NefaC1 enlaf zodo axin ne Desvenlafaxinee ER ER NefazodoneHCl HCl 4 (100mg Tablet (Tablet)

ParoC1 xetin Extended-Release 24 e ParoxetineHCl HCl (Tablet Hour, 25mg Tablet 2 ¨ 4 QL Immediate-Release) Extended-Release 24 PaxilC1 (10mg/5ml Hour, 50mg Tablet 4 Suspension) Extended-Release 24 SertrC1 aline Hour) (Generic Pristiq) Sertraline HCl HCl (100mg

EscitC1 ¨ alopr Tablet, 25mg Tablet, 1 am EscitalopramOxal Oxalate ate (10mg Tablet, 20mg 1 ¨ 50mg Tablet) SertrC1 aline Sertraline HCl HCl (20mg/ Tablet, 5mg Tablet) 4

EscitC1 alopr ml Concentrate) am OxalEscitalopram Oxalate ate TrazC1 odon e ¨ (5mg/5ml Oral 2 ¨ TrazodoneHCl HCl (Tablet) 1

TrintC1 Solution) Trintellixellix (Tablet) 4 QL

FetziC1 VenlC1 ma afaxi ne Fetzima (Capsule VenlafaxineHCl HCl Extended-Release 24 4 QL, ST (Tablet Immediate- 3 Hour) Release)

VenlC1 FetziC1 afaxi ma ne Titrat VenlafaxineHCl HCl ER ionFetzima Titration ER Pack Pack (Capsule (150mg Capsule 4 ST Extended-Release 24 Extended-Release 24 Hour, 37.5mg Capsule Hour Therapy Pack) 2 ¨

C1 Extended-Release 24 Fluo xetin Fluoxetinee DR DR Hour, 75mg Capsule (Capsule Delayed- 4 Extended-Release 24 Release) Hour) FluoC1 xetin e ViibrC1 FluoxetineHCl HCl (10mg Viibrydyd (Tablet) 4 QL

Capsule Immediate- ViibrC1 yd Start Viibryder Starter Pack Release, 20mg Pack 4 QL Capsule Immediate- (Kit) 2 ¨ B1 Release, 40mg Tricyclics

AmitC1 riptyl ine Capsule Immediate- AmitriptylineHCl HCl 4 Release, 20mg/5ml (Tablet)

AmoC1 Oral Solution) xapi Amoxapinene (Tablet) 3 FluvC1 oxa mine CloC1 Fluvoxamine Maleate mipr Male amin ate Clomipraminee HCl 3 HCl 4 (Tablet) (Capsule) MapC1 rotili ne DesiC1 MaprotilineHCl HCl pram ine DesipramineHCl HCl 4 3 (Tablet) (Tablet)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 43 43 1542 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DoxeC1 ProcC1 pin hlorp HCl erazi Doxepin HCl (100mg Prochlorperazinene 4 Capsule, 10mg (Suppository)

ProcC1 hlorp Capsule, 150mg erazi Prochlorperazinene Male Capsule, 25mg ate 2 ¨ 3 Maleate (Tablet)

ScoC1 Capsule, 50mg pola Scopolaminemine (Patch 72 Capsule, 75mg 4 Hour)

Capsule, 10mg/ml B1 Concentrate) Emetogenic Therapy Adjuncts ApreC1 pitan ImiprC1 t amin e Aprepitant (Therapy ImipramineHCl HCl 4 (Tablet) Pack, 40mg Capsule, 4 PA

ImiprC1 80mg Capsule) amin e Pam Imipramine Pamoate C1 oate Apre pitan 4 Aprepitantt (125mg (Capsule) 5 PA NortrC1 Capsule) iptyli ne HCl Nortriptyline HCl C1 Cesa (10mg Capsule, 25mg Cesametmet (Capsule) 5 PA DronC1 abin Capsule, 50mg ¨ Dronabinolol (Capsule) 4 PA 2 C1 Eme Capsule, 75mg Emendnd (125mg 4 PA Capsule, 10mg/5ml Suspension)

GranC1 Oral Solution) isetr on GranisetronHCl HCl ProtrC1 iptyli ne 4 B/D, PA, QL HClProtriptyline HCl 4 (Tablet)

OndC1 (Tablet) anse tron OndansetronHCl HCl TrimiC1 pram ine TrimipramineMale Maleate ate 4 (24mg Tablet, 4mg 2 B/D, PA ¨ (Capsule) Tablet, 8mg Tablet)

A1

OndC1 anse Antiemetics tron HClOndansetron HCl Antiemetics,B1 Other (4mg/5ml Oral 4 B/D, PA

ComC1 Compropro (Suppository) 4 Solution)

OndC1 HydrC1 anse oxyzi tron ne OndansetronODT ODT HydroxyzinePam Pamoate oate 3 2 B/D, PA ¨ (Capsule) (Tablet Dispersible)

SancC1 MeclC1 uso izine MeclizineHCl HCl (Tablet) 2 ¨ Sancuso (Patch) 5

A1 MetoC1 clopr amid Antifungals eMetoclopramide HCl HCl (10mg Tablet, 5mg 1 ¨ AntifungalsB1

AbelC1 Tablet) Abelcetcet (Injection) 5 B/D, PA

MetoC1 clopr AmBC1 amid isom e Metoclopramide HCl e HCl AmBisome (Injection) 4 B/D, PA

¨ AmpC1 (5mg/5ml Oral 2 hote ricin AmphotericinB B Solution) 4 B/D, PA (Injection) PerpC1 hena zinePerphenazine (Tablet) 4

Bold type = Brand name drug Plain type = Generic drug 44 tRACK 44 Last updated October 1, 2018 1643 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CaspC1 GrisC1 ofun eoful gin vin CaspofunginAcet Acetate GriseofulvinUltra ate micr 5 osize 4 (Injection) Ultramicrosize (Tablet)

CicloC1 ItracC1 pirox onaz Ciclopirox (0.77% Gel, Itraconazoleole (Capsule) 4 PA, QL JubliC1 0.77% Suspension, 1% 3 Jubliaa (External 4 Shampoo) Solution) CicloC1 pirox Nail KetoC1 CiclopiroxLacq Nail cona uer Ketoconazolezole (2% Lacquer (External 3 Cream, 2% Shampoo, 2 ¨ Solution) 200mg Tablet) CicloC1 pirox KetoC1 CiclopiroxOla Olamine cona mine Ketoconazolezole (2% 3 4 (Cream) Foam) ClotrC1 imaz ole MentC1 Clotrimazole (1% Mentaxax (Cream) 4

Cream, 1% External MicoC1 nazo 2 ¨ Miconazolele 3 3 Solution, 10mg 3 Lozenge) (Suppository) MycC1 amin e EconC1 azol Mycamine (Injection) 5 e NitraEconazole Nitrate te NaftiC1 fine 4 NaftifineHCl HCl (1% (Cream) 4

EraxiC1 Eraxiss (100mg Cream) NaftiC1 fine 5 NaftifineHCl HCl (2% Injection) 4 EraxiC1 Cream) s Eraxis (50mg C1 Nafti 4 Naftinn (1% Gel, 2% Injection) 4

ExelC1 Gel) der m Exelderm (1% Cream, C1 Nata 4 cyn 1% External Solution) Natacyn (Suspension) 4 NoxaC1 fil FlucC1 onaz Noxafil (100mg Tablet Fluconazoleole (100mg 5 PA, QL Tablet, 150mg Tablet, Delayed-Release) NoxaC1 200mg Tablet, 50mg Noxafilfil (40mg/ml 2 ¨ 5 QL Tablet, 10mg/ml Suspension)

NyaC1 Suspension, 40mg/ml Nyamycmyc (Powder) 2 ¨

NystC1 Suspension) atin Nystatin (Cream, FlucC1 onaz ole inFluconazole in NaCl NaCl 4 Ointment, Powder, 2 ¨ (Injection) Suspension, Tablet) FlucC1 ytosi NystC1 ne Flucytosine (Capsule) 5 Nystopop (Powder) 2 ¨

GrisC1 eoful OxicC1 vin onaz Micr Griseofulvin Microsize ole osize OxiconazoleNitra Nitrate (125mg/5ml te 4 4 (Cream) OxistC1 Suspension, 500mg at Oxistat (1% Lotion) 4 Tablet)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 45 45 1744 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SporC1 B1 Sporanoxanox (10mg/ml Serotonin (5-HT) 1b/1d Receptor Agonists

5 PA C1 Nara tripta Oral Solution) n NaratriptanHCl HCl

TerbiC1 3 QL nafin e HCl (Tablet) Terbinafine HCl ¨ 2 RizatC1 ripta n (Tablet) RizatriptanBenz Benzoate oate

TercC1 3 QL onaz ole (Tablet) Terconazole (0.4% RizatC1 ripta n Cream, 0.8% Cream, 3 RizatriptanBenz Benzoate oate 80mg Suppository) ODT (Tablet 3 QL

VoricC1 onaz ole Dispersible) Voriconazole (200mg SumC1 atript Injection, 40mg/ml 5 Sumatriptanan (Nasal 4 QL Suspension) Solution)

VoricC1 onaz SumC1 ole atript an Voriconazole (200mg SumatriptanSucc Succinate 4 inate Tablet, 50mg Tablet) (100mg Tablet, 25mg 2 QL ¨ AntigoutA1 Agents Tablet, 50mg Tablet)

C1 B1 Sum atript an SuccSumatriptan Succinate Antigout Agents inate

AllopC1 urino (4mg/0.5ml Injection, 4 QL Allopurinoll (Tablet) 1 ¨

ColcC1 6mg/0.5ml Injection) hicin e

Colchicine (0.6mg C1 Sum atript an SumatriptanSucc Capsule) (Generic 3 QL inate Mitigare) Succinate (6mg/ 4 QL

ColcC1 0.5ml Injection) hicin e

Colchicine (0.6mg C1 Sum atript an SumatriptanSucc inate Tablet) (Generic 3 QL Refill Colcrys) Succinate Refill 4 QL

ColcC1 Colcrysrys (Tablet) 3 QL (Injection) A1

ProbC1 enec Antimyasthenic Agents Probenecidid (Tablet) 2 ¨ B1

ProbC1 enec Parasympathomimetics id/ ColcProbenecid/Colchicine hicin e ¨ GuaC1 2 nidin e GuanidineHCl HCl (Tablet) 3 UloriC1 cUloric (Tablet) 3 ST (Tablet)

MestC1 inon A1 Mestinon (60mg/5ml Antimigraine Agents 5 ErgotB1 Alkaloids Syrup) PyridC1 ostig mine DihyC1

droe Pyridostigmine Bro rgota mide Dihydroergotaminemine

Mes ylate Mesylate (Nasal 5 Bromide (Tablet 3 Solution) Immediate-Release) PyridC1 ostig mine ErgoC1

tami Pyridostigmine Bro ne mide Tartr Ergotamine Tartrate/ ER ate/ Caff eine 3 Caffeine (Tablet) Bromide ER (Tablet 4

C1 Extended-Release) Mige rgot

Migergot (Suppository) 5 A1 Antimycobacterials

Bold type = Brand name drug Plain type = Generic drug 46 tRACK 46 Last updated October 1, 2018 1845 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 ValcC1 Antimycobacterials, Other Valchlorhlor (Gel) 5 PA, LA

DapsC1 B1 Dapsoneone (Tablet) 3 Antiandrogens

RifaC1 BicalC1 butin utam Rifabutin (Capsule) 4 Bicalutamideide (Tablet) 2 ¨

B1 ErleaC1 Antituberculars Erleadada (Tablet) 5 PA, QL

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

IsoniC1 azid XtanC1 Isoniazid (100mg di 2 ¨ Xtandi (Capsule) 5 PA, QL, LA

ZytigC1 Tablet, 300mg Tablet) a Zytiga (Tablet) 5 PA, QL, LA IsoniC1 azid Isoniazid (50mg/5ml B1 4 Antiangiogenic Agents

Syrup) C1 Pom alyst PaseC1 Pomalyst (Capsule) 5 PA, QL r

Paser (Packet) 4 C1 Revli mid PriftiC1 Revlimid (Capsule) 5 PA, QL, LA n

Priftin (Tablet) 4 C1 Thal omid PyraC1 Thalomid (Capsule) 5 PA, QL zina mide

Pyrazinamide (Tablet) 4 B1

RifaC1 /Modifiers mpin

Rifampin (150mg C1 Emc yt Capsule, 300mg 3 Emcyt (Capsule) 5 FareC1 Capsule) Farestonston (Tablet) 5

SoltaC1 RifaC1 Rifampinmpin (600mg Soltamoxmox (Oral 4 5 Injection) Solution)

RifatC1 TamC1 er oxife n Rifater (Tablet) 4 TamoxifenCitra Citrate te ¨ C1 2 Sirtu Sirturoro (Tablet) 5 PA, LA (Tablet)

B1 TrecC1 Trecatorator (Tablet) 4 Antimetabolites

DroxiC1 AntineoplasticsA1 Droxiaa (Capsule) 4

HydrC1 B1 oxyu Alkylating Agents Hydroxyurearea (Capsule) 2 ¨

MercC1 CyclC1 apto opho purin spha Mercaptopurinee Cyclophosphamidemide 4 B/D, PA 3 (Capsule) (Tablet)

PurixC1 GleoC1 an stineGleostine (100mg Purixan (Suspension) 5 PA TablC1 Capsule, 40mg 4 Tabloidoid (Tablet) 4 PA Capsule) Antineoplastics,B1 Other

C1 Gleo KisqC1 Gleostinestine (10mg Kisqaliali (Tablet) 5 PA, QL 3 KisqC1 ali Capsule) Fem Kisqaliara Femara 200 200 Dose HexaC1 Hexalenlen (Capsule) 5 PA Dose (Tablet Therapy 5 PA, QL

LeukC1 Leukeraneran (Tablet) 5 Pack)

MatuC1 Matulanelane (Capsule) 5 LA

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 47 47 1946 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

KisqC1 CabC1 ali omet Fem yx Kisqaliara Femara 400 Cabometyx (Tablet) 5 PA, QL, LA 400 Dose

CalqC1 uenc Dose (Tablet Therapy 5 PA, QL eCalquence (Capsule) 5 PA, QL

CaprC1 Pack) Caprelsaelsa (Tablet) 5 PA, LA

KisqC1 ali C1 Fem Com araKisqali Femara 600 etriq 600 Dose Cometriq (Kit) 5 PA, LA

CoteC1 Dose (Tablet Therapy 5 PA, QL llicCotellic (Tablet) 5 PA, QL, LA

Pack) EriveC1 dge

C1 Erivedge (Capsule) 5 PA, QL, LA Leuc ovori n CalciLeucovorin Calcium FaryC1 um dak (10mg Tablet, 15mg 3 Farydak (Capsule) 5 PA GilotC1 Tablet, 5mg Tablet) Gilotrifrif (Tablet) 5 PA, LA

IbranC1 LeucC1 ce ovori n Ibrance (Capsule) 5 PA, QL, LA LeucovorinCalci Calcium um 4 IclusiC1 (25mg Tablet) gIclusig (Tablet) 5 PA, QL, LA

LonsC1 IdhifC1 Lonsurfurf (Tablet) 5 PA, QL, LA aIdhifa (Tablet) 5 PA, QL, LA

NinlaC1 ImatiC1 ro nib Mes Ninlaro (Capsule) 5 PA, QL ylateImatinib Mesylate

C1 5 PA, QL Synri boSynribo (Injection) 5 PA (Tablet)

ImbrC1 VerzC1 uvic Verzenioenio (Tablet) 5 PA, QL, LA Imbruvicaa (140mg

ZolinC1 Zolinzaza (Capsule) 5 PA Capsule, 70mg 5 PA, QL, LA

B1 Capsule) Aromatase Inhibitors, 3rd Generation ImbrC1 uvic a AnasC1 Imbruvica (140mg trozo Anastrozolele (Tablet) 1 ¨

ExeC1 Tablet, 280mg Tablet, mest ane 5 PA, QL Exemestane (Tablet) 4 420mg Tablet, 560mg LetrC1 ozol Letrozolee (Tablet) 2 ¨ Tablet)

B1

InlytC1 Enzyme Inhibitors Inlytaa (Tablet) 5 PA, QL, LA RubrC1 aca IressC1 Rubraca (Tablet) 5 PA, QL, LA aIressa (Tablet) 5 PA, QL, LA ZejulC1 a JakaC1 Zejula (Capsule) 5 PA, QL, LA fiJakafi (Tablet) 5 PA, QL, LA

B1

LenvC1 Molecular Target Inhibitors imaLenvima (Capsule AfinitC1 or 5 PA, LA Afinitor (Tablet) 5 PA Therapy Pack)

AfinitC1 or LynpC1 Disp arza Afinitorerz Disperz 5 PA Lynparza (100mg (Tablet Soluble) Tablet, 150mg Tablet, 5 PA, QL, LA

AlecC1 Alecensaensa (Capsule) 5 PA, QL, LA 50mg Capsule)

C1 Alun MekiC1 Alunbrigbrig (Tablet nistMekinist (Tablet) 5 PA, LA

NerlyC1 Therapy Pack, 180mg nx 5 PA, QL, LA Nerlynx (Tablet) 5 PA, QL, LA NexaC1 Tablet, 30mg Tablet, varNexavar (Tablet) 5 PA, LA

OdoC1 90mg Tablet) mzo Odomzo (Capsule) 5 PA, QL, LA BosuC1 lif

RydaC1 Bosulif (Tablet) 5 PA, QL pt Rydapt (Capsule) 5 PA, QL

Bold type = Brand name drug Plain type = Generic drug 48 tRACK 48 Last updated October 1, 2018 2047 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SpryC1 BiltriC1 Sprycelcel (Tablet) 5 PA, QL Biltricidecide (Tablet) 5

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

SuteC1 B1 Sutentnt (Capsule) 5 PA, QL Antiprotozoals

TafinC1 AliniC1 larTafinlar (Capsule) 5 PA, LA Aliniaa (100mg/5ml

TagriC1 Tagrissosso (Tablet) 5 PA, QL, LA Suspension, 500mg 5

TarcC1 Tarcevaeva (Tablet) 5 PA, QL, LA Tablet)

AtovC1 aquo C1 Tasi ne gna Atovaquone Tasigna (Capsule) 5 PA, QL 5 TykeC1 (Suspension) rbTykerb (Tablet) 5 PA, LA C1 Atov aquo ne/ VencC1 Atovaquone/ProguanilProg lexta uanil Venclexta (100mg HCl 5 PA, QL, LA HCl (Tablet) (Generic 3 Tablet, 50mg Tablet) Malarone) VencC1 lexta BenzC1 Venclexta (10mg nida 3 PA, QL, LA Benznidazolezole (Tablet) 4

Tablet) ChloC1 roqui ne Phos C1 Chloroquine Venc phat lexta e ¨ 2 VenclextaStarti Starting ng Pack Phosphate (Tablet)

CoarC1 Pack (Tablet Therapy tem 5 PA, LA Coartem (Tablet) 4

Pack) DARC1 APRI M

C1 DARAPRIM (Tablet) Votri 5 ent

Votrient (Tablet) 5 PA, QL, LA HydrC1 oxyc hloro quin XalkC1 Hydroxychloroquine e ori Sulfa ¨ te 2 Xalkori (Capsule) 5 PA, LA Sulfate (Tablet) ZelbC1 oraf MeflC1 Zelboraf (Tablet) 5 PA, QL, LA oqui ne MefloquineHCl HCl ZydeC1 ¨ lig 2 Zydelig (Tablet) 5 PA, QL, LA (Tablet)

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

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

BexaC1 PentC1 rote am Bexarotenene (Capsule) 5 PA Pentam300 300

C1 4 Panr Panretinetin (Gel) 5 (Injection)

PrimC1 TargC1 aqui retin ne PrimaquinePhos Phosphate Targretin (1% Gel) 5 PA phat e 4 TretiC1 Tretinoinnoin (10mg (Tablet) QuinC1 5 ine Sulfa Quininete Sulfate Capsule) 4 PA TreatmentB1 Adjuncts (Capsule) B1

MesC1 Mesnexnex (400mg Pediculicides/Scabicides EuraC1 5 Euraxx (10% Cream, Tablet) 4 AntiparasiticsA1 10% Lotion) LindC1 ane AnthelminticsB1 Lindane (Shampoo) 4 MalaC1 thion AlbeC1 Albenzanza (Tablet) 5 QL Malathion (Lotion) 4 PerC1 meth Permethrinrin (Cream) 3

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 49 49 2148 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

A1 CarbC1 idop a/ Antiparkinson Agents Carbidopa/LevodopaLevo dopa ER AnticholinergicsB1 ER (Tablet Extended- 1 ¨

BenzC1 tropi Release) ne BenztropineMes Mesylate ylate CarbC1 ¨ idop 2 a/ Carbidopa/LevodopaLevo dopa (Tablet) ODT

TriheC1 ¨ xyph ODT (Tablet 2 enid ylTrihexyphenidyl HCl HCl Dispersible) (0.4mg/ml Elixir, 2mg 2 ¨ CarbC1 idop a/ Carbidopa/Levodopa/Levo dopa Tablet, 5mg Tablet) / Enta 4 capo ne B1 Entacapone (Tablet) Antiparkinson Agents, Other StaleC1 vo 100 AmaC1 ntadi Stalevo 100 (Tablet) 5 PA ne AmantadineHCl HCl StaleC1 vo (100mg Capsule, 3 Stalevo125 125 (Tablet) 5 PA

StaleC1 vo 100mg Tablet) Stalevo150 150 (Tablet) 5 PA

AmaC1 StaleC1 ntadi vo ne 200 AmantadineHCl HCl Stalevo 200 (Tablet) 5 PA 2 ¨ StaleC1 vo (50mg/5ml Syrup) Stalevo50 50 (Tablet) 4 PA

EntaC1 capo StaleC1 ne vo Entacapone (Tablet) 4 Stalevo75 75 (Tablet) 5 PA

TolcC1

apon B1 Tolcaponee (Tablet) 5 QL Monoamine Oxidase B (MAO-B) Inhibitors

B1

RasaC1 gilin Dopamine Agonists e RasagilineMes Mesylate ylate ApoC1 4 Apokynkyn (Injection) 5 PA, QL, LA (Tablet)

BroC1 SeleC1 mocr gilin iptin e Bromocriptinee SelegilineHCl HCl (5mg Mes ylate 3 Mesylate (2.5mg 3 Capsule, 5mg Tablet)

ZelaC1 Tablet, 5mg Capsule) Zelaparpar (Tablet

NeuC1 pro 5 Neupro (Patch 24 Dispersible) 4 Hour) AntipsychoticsA1

PraC1

mipe B1 xole PramipexoleDihy droc hlori 1st Generation/Typical de

ChloC1 Dihydrochloride rpro mazi ¨ Chlorpromazinene HCl 2 HCl (Tablet Immediate- 4 (Tablet)

Release) C1 Flup hena zine RopiC1 FluphenazineDec nirol anoa e te HClRopinirole HCl (Tablet 4 2 ¨ Decanoate (Injection)

Immediate-Release) C1 Flup hena zine B1 FluphenazineHCl HCl Dopamine Precursors/L-Amino Acid (10mg Tablet, 1mg 2 ¨ Decarboxylase Inhibitors Tablet, 2.5mg Tablet, CarbC1 idop Carbidopaa (Tablet) 5 5mg Tablet)

CarbC1 idop FlupC1 a/ hena Levo zine Carbidopa/Levodopa HCl dopa Fluphenazine HCl (Tablet Immediate- 1 ¨ (2.5mg/5ml Elixir, 4 Release) 2.5mg/ml Injection)

Bold type = Brand name drug Plain type = Generic drug 50 tRACK 50 Last updated October 1, 2018 2249 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FlupC1 FanaC1 hena pt zine FluphenazineHCl HCl Fanapt (10mg Tablet, 3 (5mg/ml Concentrate) 12mg Tablet, 6mg 5 QL, ST

HaloC1 perid Haloperidolol (0.5mg Tablet, 8mg Tablet)

FanaC1 Tablet, 10mg Tablet, Fanaptpt (1mg Tablet, 1mg Tablet, 20mg 2 ¨ 2mg Tablet, 4mg 4 QL, ST Tablet, 2mg Tablet, Tablet)

5mg Tablet, 2mg/ml FanaC1 pt Titrat Fanaption Titration Pack Concentrate) Pack 4 ST

HaloC1 (Tablet) perid ol Dec Haloperidol Decanoate C1 anoa Geo te 4 Geodondon (20mg (Injection) 4

HaloC1 perid Injection) ol HaloperidolLact Lactate ate InveC1 ga 4 Sust (Injection) Invegaenna Sustenna

LoxaC1 pine (117mg/0.75ml Succ Loxapineinate Succinate 2 ¨ Injection, 156mg/ml (Capsule)

PimoC1 zidePimozide (Tablet) 4 Injection, 234mg/ 5

ThiorC1 1.5ml Injection, idazi ne ThioridazineHCl HCl 3 78mg/0.5ml (Tablet)

ThiotC1 Injection) hixe ne Thiothixene (Capsule) 3 InveC1 ga Sust enna TrifluC1 Invega Sustenna oper azin Trifluoperazinee HCl HCl 3 (39mg/0.25ml 4 (Tablet)

B1 Injection)

2nd Generation/Atypical InveC1 ga Trinz a C1 Invega Trinza Abilif y Main Abilifytena Maintena 5 5 (Injection)

(Injection) LatuC1 da

C1 Latuda (Tablet) 5 QL Aripi praz ole Aripiprazole (10mg NuplC1 azid Tablet, 15mg Tablet, Nuplazid (Tablet) 5 PA, QL OlanC1 zapi Olanzapinene (10mg 20mg Tablet, 2mg 3 QL 4 Tablet, 30mg Tablet, Injection)

OlanC1 zapi 5mg Tablet) Olanzapinene (10mg

AripiC1 praz Aripiprazoleole (1mg/ml Tablet, 15mg Tablet, 4 QL Oral Solution) 2.5mg Tablet, 20mg 2 QL ¨

AripiC1 praz Tablet, 5mg Tablet, ole AripiprazoleODT ODT 5 QL (Tablet Dispersible) 7.5mg Tablet) OlanC1 zapi ne AristC1 ODT ada Olanzapine ODT Aristada (Injection) 5 4 QL (Tablet Dispersible)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 51 51 2350 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PalipC1 ZipraC1 erido sido ne ne PaliperidoneER ER ZiprasidoneHCl HCl 3 QL (Tablet Extended- 4 QL (Capsule)

ZyprC1 exa Release 24 Hour) Relp Zyprexarevv Relprevv

QuetC1 iapin 4 e QuetiapineFum Fumarate arate (Injection) (Tablet Immediate- 2 QL ¨ Treatment-ResistantB1

Release) ClozC1 apin e

C1 Clozapine (100mg Quet iapin e FumQuetiapine Fumarate arate ER Tablet, 25mg Tablet, 3 ER (Tablet Extended- 3 QL 50mg Tablet, 200mg Release 24 Hour) Tablet) RexuC1 lti ClozC1 Rexulti (Tablet) 5 QL apin e ClozapineODT ODT RispC1 erdal

RisperdalCon Consta sta (100mg Tablet (12.5mg Injection, 4 Dispersible, 12.5mg 25mg Injection) Tablet Dispersible, 3 QL

RispC1 erdal 150mg Tablet

RisperdalCon Consta sta (37.5mg Injection, 5 Dispersible, 25mg Tablet Dispersible) 50mg Injection) ClozC1 apin e RispC1 ClozapineODT ODT erido Risperidonene (0.25mg (200mg Tablet 5 QL Tablet, 0.5mg Tablet, Dispersible) 1mg Tablet, 2mg 2 ¨ VersC1 aclo Versaclozz Tablet, 3mg Tablet, 5 4mg Tablet) (Suspension)

A1 RispC1 erido neRisperidone (1mg/ml Antivirals

4 B1 Oral Solution) Anti-cytomegalovirus (CMV) Agents

C1 Risp ValgC1 erido anci ne clovi ODT Risperidone ODT r 4 Valganciclovir (Tablet) 5 QL ValgC1 anci (Tablet Dispersible) clovi Valganciclovirr Hydr ochl C1 Sap orde Saphrishris (Tablet Hydrochlorde (Oral 5 QL 5 QL Sublingual) Solution)

C1 VraylC1 Zirga Vraylarar (1.5mg Zirgann (Gel) 4 Capsule, 3mg Anti-hepatitisB1 B (HBV) Agents

AdefC1 ovir Capsule, 4.5mg 5 QL, ST Dipiv Adefoviroxil Dipivoxil 5 Capsule, 6mg (Tablet)

BaraC1 clud Capsule) Baracludee (0.05mg/

VraylC1 arVraylar (Capsule 4 4 ST ml Oral Solution) EnteC1 Therapy Pack) Entecavircavir (Tablet) 4

Bold type = Brand name drug Plain type = Generic drug 52 tRACK 52 Last updated October 1, 2018 2451 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EpiviC1 DenC1 r avir EpivirHBV HBV (5mg/ml Denavir (Cream) 5 QL

4 C1 Fam ciclo Oral Solution) Famciclovirvir (Tablet) 3 QL

LamiC1 vudi TrifluC1 ne ridin Lamivudine (100mg Trifluridinee 3 3 Tablet) (Ophthalmic Solution)

VemlC1 idy ValaC1 cycl Vemlidy (Tablet) ovir 5 QL ValacyclovirHCl HCl

B1 3 QL Anti-hepatitis C (HCV) Agents, Other (Tablet)

B1 IntroC1 Intronn A A (Injection) 5 PA, LA Anti-HIV Agents, Integrase Inhibitors (INSTI)

C1 C1 Gen Pega voya Pegasyssys (Injection) 5 PA Genvoya (Tablet) 5 QL

C1 C1 Isent Pega ress sys ProC Pegasyslick ProClick Isentress (100mg 5 PA (Injection) Packet, 25mg Tablet 3 QL

RibaC1 sphe Ribaspherere (200mg Chewable)

IsentC1 Tablet, 400mg Tablet, 3 Isentressress (100mg 600mg Tablet) Tablet Chewable, 5 QL

RibaC1 Ribavirinvirin (200mg 400mg Tablet)

3 C1 Isent ress Tablet) IsentressHD HD (Tablet) 5 QL

SylatC1 ron StribiC1 Sylatron (Injection) 5 PA Stribildld (Tablet) 5 QL

B1 TivicC1 Anti-hepatitis C (HCV) Direct Acting Agents Tivicayay (10mg Tablet) 4 QL

DakliC1 nza TivicC1 Daklinza (Tablet) 5 PA, QL Tivicayay (25mg Tablet, EpclC1 5 QL usaEpclusa (Tablet) 5 PA, QL 50mg Tablet)

C1 Harv TriuC1 oniHarvoni (Tablet) 5 PA, QL Triumeqmeq (Tablet) 5 QL

C1 Mav TyboC1 yretMavyret (Tablet) 5 PA, QL Tybostst (Tablet) 4 QL

C1 Sova B1 ldiSovaldi (Tablet) 5 PA, QL Anti-HIV Agents, Non-nucleoside Reverse

VoseC1 viVosevi (Tablet) 5 PA, QL Transcriptase Inhibitors (NNRTI)

C1 B1 Atrip Antiherpetic Agents Atriplala (Tablet) 5 QL

C1 C1 Com Acyc plera lovir Complera (Tablet) 5 QL Acyclovir (200mg ¨ 2 EdurC1 Capsule) Edurantant (Tablet) 5 QL

AcycC1 lovir EfaviC1 Acyclovir (200mg/5ml renz 3 Efavirenz (200mg Suspension) Capsule, 600mg 5 QL

AcycC1 lovir Tablet) Acyclovir (400mg ¨ 1 EfaviC1 Tablet, 800mg Tablet) Efavirenzrenz (50mg

AcycC1 4 QL lovirAcyclovir (5% Capsule)

4 QL IntelC1 Ointment) Intelenceence (100mg

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

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 53 53 2552 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

IntelC1 EmtriC1 Intelenceence (25mg Emtrivava (10mg/ml 4 QL Tablet) Oral Solution, 200mg 4 QL

JuluC1 Julucaca (Tablet) 5 QL Capsule)

LamiC1 NevirC1 vudi apin ne Nevirapinee (Tablet) 3 QL Lamivudine (10mg/ml

NevirC1 apin Oral Solution, 150mg 3 QL Nevirapinee ER ER (Tablet Extended-Release 24 4 QL Tablet, 300mg Tablet) LamiC1 vudi ne/ Lamivudine/Zido Hour) vudi ne 4 QL OdefC1 Odefseysey (Tablet) 5 QL Zidovudine (Tablet) StavC1 udin RescC1 e ripto Stavudine (Capsule) 3 QL Rescriptorr (Tablet) 4 QL TenoC1 fovir SustiC1 Diso va Tenofovirproxi Disoproxil l Fum Sustiva (200mg arate 5 QL Fumarate (Tablet) Capsule, 600mg 5 QL TruvC1 Tablet) Truvadaada (Tablet) 5 QL VideC1 x EC SustiC1 Sustivava (50mg Videx EC (125mg 4 QL Capsule) Capsule Delayed- 4 QL

SymfC1 i Release) Symfi (Tablet) 5 QL VideC1 x Pedi SymfC1 atric i Lo Videx Pediatric (Oral Symfi Lo (Tablet) 5 QL 4 QL

ViraC1 Solution) mun e Viramune (50mg/5ml VireaC1 5 QL Vireadd (150mg Tablet, Suspension)

B1 200mg Tablet, 250mg Anti-HIV Agents, Nucleoside and Nucleotide 5 QL Tablet, 40mg/gm Reverse Transcriptase Inhibitors (NRTI) Powder) AbaC1 cavir Abacavir (20mg/ml ZeritC1 Zerit (1mg/ml Oral Oral Solution, 300mg 4 QL 4 QL Tablet) Solution) ZidoC1 vudi ne AbaC1 cavir Zidovudine (100mg

AbacavirSulfa Sulfate/ te/ Lami vudi ne/ Capsule, 300mg Zido Lamivudine/vudi 5 QL ne 3 QL Zidovudine (Tablet) Tablet, 50mg/5ml

C1 Syrup) Aba cavir / Lami Abacavir/Lamivudine B1 vudi ne 4 QL (Tablet) Anti-HIV Agents, Other FuzeC1 on BiktaC1 Biktarvyrvy (Tablet) 5 QL Fuzeon (Injection) 5 QL SelzC1 entry CimC1 Cimduoduo (Tablet) 5 QL Selzentry (150mg

DescC1 Tablet, 300mg Tablet, Descovyovy (Tablet) 5 QL 5 QL 75mg Tablet, 20mg/ DidaC1 nosi Didanosinene (Capsule 3 QL ml Oral Solution) Delayed-Release)

Bold type = Brand name drug Plain type = Generic drug 54 tRACK 54 Last updated October 1, 2018 2653 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SelzC1 ReyaC1 Selzentryentry (25mg Reyataztaz (50mg 3 QL 5 QL Tablet) Packet)

B1 RitoC1 Anti-HIV Agents, Protease Inhibitors Ritonavirnavir (Tablet) 4 QL

AptivC1 ViracC1 Aptivusus (100mg/ml Viraceptept (Tablet) 5 QL Oral Solution, 250mg 5 QL Anti-influenzaB1 Agents

OseltC1 amivi Capsule) r OseltamivirPhos Phosphate phat e AtazC1 anav ir AtazanavirSulfa Sulfate te 5 QL (30mg Capsule, 45mg (Capsule) Capsule, 75mg 3 QL

CrixiC1 Crixivanvan (Capsule) 3 QL Capsule, 6mg/ml

EvotC1 Evotazaz (Tablet) 5 QL Suspension) ReleC1 nza Disk FosaC1 haler mpr Relenza Diskhaler enav Fosamprenavirir Calci 3 QL um 5 QL Calcium (Tablet) (Aerosol Powder) RimaC1 ntadi InvirC1 ne ase RimantadineHCl HCl Invirase (200mg 4 Capsule, 500mg 5 QL (Tablet) A1 Tablet) Anxiolytics

B1

KaletC1 Kaletrara (100mg-25mg Anxiolytics, Other

BusC1 4 QL piron e ¨ Tablet) BuspironeHCl HCl (Tablet) 2

HydrC1 KaletC1 oxyzi ra ne Kaletra (200mg-50mg HydroxyzineHCl HCl 5 QL 3 Tablet) (10mg/5ml Syrup)

HydrC1 LexivC1 oxyzi a ne Lexiva (50mg/ml HydroxyzineHCl HCl 4 QL 3 Suspension) (Tablet)

B1

LopiC1 navir / Benzodiazepines Lopinavir/RitonavirRito navir AlprC1 4 QL azol Alprazolamam (Tablet (Oral Solution) 1 QL ¨ NorviC1 Norvirr (100mg Immediate-Release) ChloC1 rdiaz epox ideChlordiazepoxide HCl Capsule, 100mg HCl 2 ¨ Packet, 100mg 4 QL (Capsule)

ClonC1 azep Clonazepamam (Tablet Tablet, 80mg/ml Oral 2 QL ¨ Solution) Immediate-Release)

ClonC1 PrezC1 azep cobi am x ODTClonazepam ODT Prezcobix (Tablet) 5 QL 4 QL

PreziC1 Prezistasta (100mg/ml (Tablet Dispersible) ClorC1 azep ate ClorazepateDipo tassi Suspension, 600mg 5 QL um 2 QL ¨ Tablet, 800mg Tablet) Dipotassium (Tablet)

PreziC1 Prezistasta (150mg 4 QL Tablet, 75mg Tablet)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 55 55 2754 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DiazC1 LithiC1 epa um m Carb Diazepam (10mg Lithiumonat Carbonate ER e ER Tablet, 2mg Tablet, 2 QL ¨ (Tablet Extended- 2 ¨ 5mg Tablet) Release)

DiazC1 A1 epa mDiazepam (1mg/ml Blood Glucose Regulators 2 ¨ Oral Solution) AntidiabeticB1 Agents

DiazC1 epa AcarC1 m bose IntenDiazepam Intensol sol 2 QL ¨ Acarbose (Tablet) 1 QL ¨

AvanC1 (5mg/ml Concentrate) dia Avandia (Tablet) 4 PA, QL LoraC1 zepa m BydC1 Lorazepam (0.5mg ureo n BydureonBcis Bcise (Auto Tablet, 1mg Tablet, 1 QL ¨ e 3 QL injector) 2mg Tablet) BydC1 ureo n C1 Lora Pen zepa Bydureon Pen mLorazepam (2mg/ml 2 QL ¨ 3 QL Concentrate) (Injection) BydC1 ureo A1 n BydureonVial Vial Bipolar Agents 3 QL B1 (Injection) Mood Stabilizers ByettC1 a DivalC1 Byetta (Injection) 4 QL proe x DivalproexSodi Sodium um CyclC1 (Capsule Sprinkle 2 ¨ Cyclosetoset (Tablet) 4 PA, QL

GlimC1 epiri Delayed-Release) Glimepiridede (Tablet) 1 QL ¨

DivalC1 GlipiC1 proe zide x SodiDivalproex Sodium DR Glipizide (Tablet um DR 1 QL ¨ (Tablet Delayed- 2 ¨ Immediate-Release)

GlipiC1 zide Release) ERGlipizide ER (Tablet

DivalC1 proe x ¨ SodiDivalproex Sodium ER Extended-Release 24 1 QL um ER(Tablet Extended- 2 ¨ Hour)

GlipiC1 zide/ Release 24 Hour) Metf ormiGlipizide/Metformin n HCl C1 ¨ Lithi 1 QL umLithium (Oral HCl (Tablet)

3 C1 Glyx Solution) ambiGlyxambi (Tablet) 3 QL

LithiC1 C1 um Invo Carb kam Lithiumonat Carbonate et e Invokamet (Tablet) 3 QL

InvoC1 (150mg Capsule kam et InvokametXR XR (Tablet Immediate-Release, Extended-Release 24 3 QL 300mg Capsule Hour) Immediate-Release, 2 ¨ InvoC1 600mg Capsule Invokanakana (Tablet) 3 QL

JanuC1 Immediate-Release, Janumetmet (Tablet 3 QL 300mg Tablet Immediate-Release)

JanuC1 met Immediate-Release) JanumetXR XR (Tablet Extended-Release 24 3 QL Hour)

Bold type = Brand name drug Plain type = Generic drug 56 tRACK 56 Last updated October 1, 2018 2855 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

JanuC1 SymlC1 via inPe n Januvia (Tablet) 3 QL SymlinPen120 120

C1 5 PA Jardi Jardianceance (Tablet) 3 QL (Injection)

SymlC1 JentC1 inPe adue n 60 to SymlinPen 60 Jentadueto (Tablet) 4 QL 5 PA JentC1 adue to (Injection) JentaduetoXR XR

SynjC1 (Tablet Extended- 4 QL Synjardyardy (Tablet) 3 QL

SynjC1 ardy Release 24 Hour) SynjardyXR XR (Tablet

KomC1 bigly ze Extended-Release 24 KombiglyzeXR XR 3 QL (Tablet Extended- 3 QL Hour)

TradjC1 Release 24 Hour) Tradjentaenta (Tablet) 4 QL

MetfC1 TruliC1 ormi city n MetforminHCl HCl (Tablet Trulicity (Injection) 3 QL 1 QL ¨ VictoC1 Immediate-Release) Victozaza (Injection) 3 QL

MetfC1

ormi B1 n HClMetformin HCl ER ER Glycemic Agents

GlucC1 (500mg Tablet aGe n GlucaGenHyp HypoKit Extended-Release 24 oKit 4 (Injection) Hour, 750mg Tablet 1 QL ¨ GlucC1 agon

GlucagonEme Emergency rgen Extended-Release 24 cy Kit 3 Hour) (Generic Kit (Injection)

ProgC1 lyce Glucophage XR) Proglycemm

MigliC1 5 tolMiglitol (Tablet) 4 QL (Suspension)

NateC1 B1 glini Nateglinidede (Tablet) 1 QL ¨ Insulins

OnglC1 HumC1 yza alog Cartr Onglyza (Tablet) 3 QL Humalogidge Cartridge

C1 3 Piogl itazo ne (Injection) PioglitazoneHCl HCl ¨ 1 QL HumC1 alog Juni (Tablet) Humalogor Junior Kwik Pen

PioglC1 3 itazo ne HCl/Pioglitazone HCl/ KwikPen (Injection) Glim epiri ¨ de 1 QL HumC1 alog Kwik Glimepiride (Tablet) HumalogPen KwikPen

PioglC1 3 itazo ne HCl/Pioglitazone HCl/ (Injection) Metf ormi ¨ n 1 QL HCl HumC1 alog Metformin HCl (Tablet) Mix Humalog50/5 Mix 50/50 0 Kwik RepC1 Pen aglin 3 ideRepaglinide (Tablet) 1 QL ¨ KwikPen (Injection)

C1 Rep C1 aglin Hum ide/ alog Metf Mix Repaglinide/Metformin 50/5 ormi Humalog Mix 50/50 n 0 HCl 4 QL Vial 3 HCl (Tablet) Vial (Injection)

RioC1 met HumC1 alog Riomet (Oral Solution) 4 QL Mix Humalog75/2 Mix 75/25 5 Kwik SoliqC1 Pen 3 ua 100/ Soliqua33 100/33 KwikPen (Injection) 3 QL HumC1 alog (Injection) Mix Humalog75/2 Mix 75/25 5 Vial 3 Vial (Injection)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 57 57 2956 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

HumC1 EliquC1 alog is HumalogVial Vial Eliquis (Tablet) 3 QL

3 C1 Eliqu is (Injection) Start Eliquiser Starter Pack Pack

HumC1 3 QL ulin 70/3 Humulin0 70/30 (Tablet) Kwik Pen

3 C1 Enox apari KwikPen (Injection) n EnoxaparinSodi Sodium um

HumC1 4 QL ulin 70/3 Humulin0 70/30 Vial (Injection) Vial

3 FondC1 apari nux (Injection) FondaparinuxSodi Sodium um

HumC1 ulin N (10mg/0.8ml Injection, HumulinKwik N KwikPen Pen 3 5 (Injection) 5mg/0.4ml Injection,

HumC1 7.5mg/0.6ml Injection) ulin N HumulinVial N Vial FondC1 apari 3 nux FondaparinuxSodi Sodium (Injection) um 4

HumC1 (2.5mg/0.5ml Injection) ulin R U-50 C1 Humulin R U-500 Hep 0 Kwik arin Pen Sodi 3 um KwikPen (Injection) Heparin Sodium

C1 (10000unit/ml Hum ulin R HumulinU-50 R U-500 Vial 0 Vial Injection, 20000unit/ml 3 (Concentrated) 3 Injection, 5000unit/ml (Injection) Injection)

HumC1 ulin HepC1 R arin Vial Sodi Humulin R Vial Heparinum Sodium 3 3 B/D, PA (Injection) (1000unit/ml Injection)

C1 Lant JantC1 us oven Solo LantusStar SoloStar Jantoven (Tablet) 1 ¨ 3 PradC1 (Injection) Pradaxaaxa (Capsule) 4 QL

LantC1 us WarfC1 Vial arin Lantus Vial (Injection) 3 Sodi Warfarinum Sodium

C1 ¨ Leve 1 mir Flex LevemirTouc FlexTouch (Tablet) h

3 XarelC1 (Injection) Xareltoto (Tablet) 3 QL

C1 Leve C1 mir Xarel Vial to Start Levemir Vial Xareltoer Starter Pack 3 Pack 3 QL (Injection) (Tablet Therapy Pack)

C1 Touj B1 eo Max ToujeoSolo Max Solostar star 3 Blood Formation Modifiers AnaC1 greli (Injection) de AnagrelideHCl HCl ToujC1 3 eo Solo ToujeoStar SoloStar (Capsule) 3 (Injection)

TresiC1 ba Flex TresibaTouc FlexTouch h 3 (Injection) BloodA1 Products/Modifiers/Volume Expanders AnticoagulantsB1

CouC1 madi Coumadinn (Tablet) 4

Bold type = Brand name drug Plain type = Generic drug 58 tRACK 58 Last updated October 1, 2018 3057 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AranC1 ProC1 esp mact Albu a Aranespmin Albumin Promacta (Tablet) 5 PA, QL, LA Free

ZarxiC1 Free (100mcg/0.5ml oZarxio (Injection) 5 Injection, 100mcg/ml HemostasisB1 Agents

TranC1 Injection, 150mcg/ exa mic TranexamicAcid Acid 3 0.3ml Injection, (Tablet)

200mcg/0.4ml B1 Platelet Modifying Agents

Injection, 200mcg/ml AspirC1 in/ Dipy 5 PA Aspirin/Dipyridamolerida Injection, 300mcg/ mole (Capsule Extended- 3 QL 0.6ml Injection, Release 12 Hour)

300mcg/ml Injection, BrilinC1 Brilintata (Tablet) 3 QL 500mcg/ml Injection, CilosC1 tazol ¨ 60mcg/0.3ml Cilostazol (Tablet) 2 ClopiC1 dogr Clopidogrelel (75mg Injection, 60mcg/ml 2 QL ¨ Injection) Tablet) PrasC1 ugrel AranC1 esp Prasugrel (Tablet) 3 QL Albu Aranespmin Albumin Free

A1 Free (10mcg/0.4ml Cardiovascular Agents Injection, 25mcg/ Alpha-adrenergicB1 Agonists

CloniC1 dine 0.42ml Injection, HCl 4 PA Clonidine HCl (0.1mg 25mcg/ml Injection, Tablet Immediate- Release, 0.2mg Tablet 40mcg/0.4ml 1 ¨ Injection, 40mcg/ml Immediate-Release, Injection) 0.3mg Tablet

GranC1 Immediate-Release) Granixix (Injection) 5 ST CloniC1 dine HCl LeukC1 Clonidine HCl (0.1mg/ Leukineine (Injection) 5 PA 24hr Patch Weekly, NeulC1 asta Neulasta (Injection) 5 PA 0.2mg/24hr Patch 4

NeuC1 poge Neupogenn (Injection) 5 ST Weekly, 0.3mg/24hr

ProcC1 Procritrit (10000unit/ml Patch Weekly)

MethC1 yldo Injection, 2000unit/ Methyldopapa (Tablet) 3

MidoC1 drine ml Injection, Midodrine HCl HCl (Tablet) 3 4 PA NortC1 3000unit/ml Northerahera (Capsule) 5 PA, QL, LA Injection, 4000unit/ Alpha-adrenergicB1 Blocking Agents

ml Injection) DoxaC1 zosin

Mes C1 Doxazosin Mesylate Proc ylate rit 2 ¨ Procrit (20000unit/ml (Tablet) Injection, 40000unit/ 5 PA ml Injection)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 59 59 3158 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PheC1 AmioC1 noxy daro benz ne Phenoxybenzamineamin AmiodaroneHCl HCl e HCl 5 1 ¨ HCl (Capsule) (200mg Tablet)

PrazC1 DofeC1 osin tilide PrazosinHCl HCl (Capsule) 2 ¨ Dofetilide (Capsule) 4

B1 FlecC1 ainid e Angiotensin II Receptor Antagonists FlecainideAcet Acetate ate 2 ¨ CanC1 desa rtan (Tablet) CandesartanCilex Cilexetil etil

¨ C1 1 QL Mexi letin e (Tablet) MexiletineHCl HCl 3 EdarC1 biEdarbi (Tablet) 4 QL (Capsule)

MultC1 EproC1 aq sarta n Multaq (Tablet) 3 QL EprosartanMes Mesylate ylate

¨ C1 1 QL Pace (Tablet) Paceronerone (200mg 1 ¨ IrbesC1 artanIrbesartan (Tablet) 1 QL ¨ Tablet)

PropC1 LosaC1 afen rtan one Pota PropafenoneHCl HCl ssiuLosartan Potassium m 1 QL ¨ 2 ¨ (Tablet) (Tablet)

PropC1 OlmC1 afen esart one an PropafenoneHCl HCl ER MedOlmesartan Medoxomil ER oxo mil 2 QL ¨ (Tablet) (Capsule Extended- 4

TelmC1 isart Release 12 Hour) anTelmisartan (Tablet) 1 QL ¨ QuinC1 idine

ValsC1 Gluc artan Quinidine Gluconate onat Valsartan (Tablet) 1 QL ¨ e CR

B1 CR (Tablet Extended- 4 Angiotensin-converting Enzyme (ACE) Release)

QuinC1 Inhibitors idine

QuinidineSulfa Sulfate te BenC1 azep ¨ ril ¨ 2 BenazeprilHCl HCl (Tablet) 1 QL (Tablet)

CaptC1 opril SotalC1 ¨ ol Captopril (Tablet) 1 QL SotalolHCl HCl (AF)

C1 ¨ Enal 2 april Male ateEnalapril Maleate ¨ (Tablet) 1 QL C1 Sotal ol (Tablet) SotalolHCl HCl (Tablet) 2 ¨

FosiC1 nopri B1 l SodiFosinopril Sodium um 1 QL ¨ Beta-adrenergic Blocking Agents

AceC1 (Tablet) butol ol AcebutololHCl HCl LisinC1 opril 2 ¨ Lisinopril (Tablet) 1 QL ¨ (Capsule)

MoeC1 xipril AtenC1 MoexiprilHCl HCl (Tablet) 1 QL ¨ Atenolololol (Tablet) 1 ¨

PerinC1 dopri BetaC1 l xolol ErbuPerindopril Erbumine HCl mine Betaxolol HCl (10mg 1 QL ¨ 3 (Tablet) Tablet, 20mg Tablet)

QuinC1 april BisoC1 HCl ¨ prolo Quinapril HCl (Tablet) 1 QL l BisoprololFum Fumarate arate

C1 ¨ Rami 2 prilRamipril (Capsule) 1 QL ¨ (Tablet)

TranC1 BystC1 dola olic prilTrandolapril (Tablet) 1 QL ¨ Bystolic (Tablet) 3 QL

B1 CarvC1 edilo Antiarrhythmics Carvediloll (Tablet) 1 ¨

LabeC1 talol LabetalolHCl HCl (Tablet) 2 ¨

Bold type = Brand name drug Plain type = Generic drug 60 tRACK 60 Last updated October 1, 2018 3259 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MetoC1 Dilt-C1 prolo XR l MetoprololSucc Succinate Dilt-XR (Capsule inate ER (Tablet Extended- 1 ¨ Extended-Release 24 2 ¨ Release 24 Hour) Hour)

MetoC1 DiltiaC1 prolo zem l HCl TartrMetoprolol Tartrate Diltiazem HCl (Tablet ate 2 ¨ (100mg Tablet Immediate-Release)

DiltiaC1 zem Immediate-Release, HCl DiltiazemER HCl ER 25mg Tablet 1 ¨ (Capsule Extended- 2 ¨ Immediate-Release, Release)

FeloC1 50mg Tablet dipin Felodipinee ER ER (Tablet Immediate-Release) Extended-Release 24 2 ¨ NadC1 ololNadolol (Tablet) 4 Hour)

PindC1 olol MatzC1 im Pindolol (Tablet) 3 MatzimLA LA (Tablet

PropC1 ranol ol ¨ PropranololHCl HCl Extended-Release 24 2 (20mg/5ml Oral Hour) 2 ¨ NicaC1 rdipi Solution, 40mg/5ml ne NicardipineHCl HCl 3 Oral Solution) (Capsule)

PropC1 ranol NifeC1 ol dipin HClPropranolol HCl Nifedipinee ER ER (Tablet (Tablet Immediate- 2 ¨ Extended-Release 24 2 QL ¨ Release) Hour)

PropC1 ranol NimC1 ol odipi HClPropranolol HCl ER ne ER Nimodipine (Capsule) 4

¨ NymC1 (Capsule Extended- 2 Nymalizealize (Oral Release 24 Hour) 5

C1 Solution) Timo lol Male ateTimolol Maleate (10mg TaztiC1 Taztiaa XT XT (Capsule Tablet, 20mg Tablet, 4 ¨ 5mg Tablet) Extended-Release 24 2

B1 Hour)

Calcium Channel Blocking Agents VeraC1 pami l HCl

C1 Verapamil HCl (120mg Afed itab AfeditabCR CR (Tablet Tablet Immediate- Extended-Release 24 2 QL ¨ Release, 40mg Tablet 2 ¨ Hour) Immediate-Release, AmloC1 dipin e BesyAmlodipine Besylate late 1 ¨ 80mg Tablet (Tablet) Immediate-Release)

CartiC1 aCartia XT XT (Capsule Extended-Release 24 2 ¨ Hour)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 61 61 3360 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

VeraC1 AmloC1 pami dipin l HCl e/ VerapamilER HCl ER Amlodipine/Olm esart an Med oxo (100mg Capsule Olmesartanmil Medoxomil 2 QL ¨ Extended-Release 24 (Tablet)

AmloC1 dipin Hour, 120mg Capsule e/ ValsAmlodipine/Valsartan/ artan / Hydr ochl Extended-Release 24 orot hiaziHydrochlorothiazide 4 QL de Hour, 180mg Capsule (Tablet)

AtenC1 Extended-Release 24 olol/ Chlo Atenolol/rthali 3 done Hour, 200mg Capsule 1 ¨ Chlorthalidone (Tablet)

Extended-Release 24 C1 Ben azep ril BenazeprilHCl/ HCl/ Hydr Hour, 240mg Capsule ochl orot hiazi Extended-Release 24 Hydrochlorothiazidede 1 QL ¨ Hour, 300mg Capsule (Tablet) Extended-Release 24 BiDilC1 (Tablet) 3 QL

BisoC1 prolo Hour) l BisoprololFum Fumarate/ arate / Hydr VeraC1 pami ochl l HCl orot ¨ ER Hydrochlorothiazidehiazi 2 QL Verapamil HCl ER de (120mg Tablet (Tablet)

CanC1 desa Extended-Release, rtan CilexCandesartan Cilexetil/ etil/ Hydr ochl ¨ orot 180mg Tablet 2 hiazi ¨ deHydrochlorothiazide 1 QL Extended-Release, (Tablet)

CaptC1 240mg Tablet opril / HydrCaptopril/ ochl orot hiazi Extended-Release) deHydrochlorothiazide 1 QL ¨ VeraC1 pami l HCl SRVerapamil HCl SR (Tablet) CorlC1 (Capsule Extended- 3 anorCorlanor (Tablet) 4 PA, QL

DemC1 Release 24 Hour) ser Demser (Capsule) 5 B1

DigitC1 Cardiovascular Agents, Other Digitekek (Tablet) 2 ¨ AmilC1 oride / C1 Hydr Digo Amiloride/ x ochl orot ¨ hiazi Digox (Tablet) 2 de ¨ Hydrochlorothiazide 2 C1 Digo Digoxinxin (0.05mg/ml (Tablet) 3

AmloC1 dipin Oral Solution) e BesyAmlodipine Besylate/ late/ C1 Ator Digo vasta xin tin Calci ¨ Digoxin (125mcg umAtorvastatin Calcium 2 QL 2 ¨ (Tablet) Tablet, 250mcg Tablet)

EdarC1 AmloC1 bycl dipin or e Edarbyclor (Tablet) 4 QL BesyAmlodipine Besylate/ late/ Ben azep EnalC1 ril april HCl ¨ Male Benazepril HCl 1 QL Enalaprilate/ Maleate/ Hydr ochl orot hiazi (Capsule) Hydrochlorothiazidede 1 QL ¨

AmloC1 dipin e (Tablet) BesyAmlodipine Besylate/ late/ Vals artan 4 QL EntrC1 Valsartan (Tablet) estoEntresto (Tablet) 3 QL

Bold type = Brand name drug Plain type = Generic drug 62 tRACK 62 Last updated October 1, 2018 3461 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FosiC1 OlmC1 nopri esart l an FosinoprilSodi Sodium/ OlmesartanMed um/ oxo Hydr mil/ ochl Hydr orot ochl hiazi ¨ orot Hydrochlorothiazidede 1 QL Medoxomil/hiazi de 2 QL ¨ (Tablet) Hydrochlorothiazide

IrbesC1 artan / (Tablet) HydrIrbesartan/ ochl orot hiazi PentC1 de oxifyl ¨ line Hydrochlorothiazide 1 QL ERPentoxifylline ER (Tablet) (Tablet Extended- 2 ¨

LanoC1 xinLanoxin (125mcg Release)

PropC1 ranol ol/ Propranolol/Hydr Tablet, 250mcg ochl orot hiazi 4 de Tablet, 62.5mcg Hydrochlorothiazide 2 ¨ Tablet) (Tablet)

QuinC1 april C1 Lisin / opril Hydr / Quinapril/ ochl Lisinopril/Hydr orot ochl hiazi orot de hiazi Hydrochlorothiazidede 1 QL ¨ Hydrochlorothiazide 1 QL ¨ (Tablet) (Tablet)

RanC1 exa LosaC1 rtan Pota Ranexa (Tablet ssiuLosartan Potassium/ m/ Hydr ochl orot hiazi ¨ Extended-Release 12 3 QL deHydrochlorothiazide 1 QL (Tablet) Hour)

C1 C1 Spir Meth onol yldo acto pa/ ne/ Hydr Spironolactone/ Methyldopa/ Hydr ochl ochl orot orot hiazi hiazi deHydrochlorothiazide 3 Hydrochlorothiazidede 2 ¨ (Tablet) (Tablet)

TelmC1 MetoC1 isart prolo an/ l/ Amlo Hydr Telmisartan/ Metoprolol/ dipin ochl e orot ¨ hiazi 1 QL Hydrochlorothiazidede 2 ¨ Amlodipine (Tablet)

TelmC1 isart an/ (Tablet) HydrTelmisartan/ ochl orot hiazi MoeC1 de xipril / ¨ HydrMoexipril/ Hydrochlorothiazide 1 QL ochl orot hiazi deHydrochlorothiazide 1 QL ¨ (Tablet)

TriaC1 mter ene/ (Tablet) HydrTriamterene/ ochl orot hiazi NadC1 de olol/ Ben droflNadolol/ Hydrochlorothiazide umet hiazi de (37.5mg-25mg Tablet, Bendroflumethiazide 3 2 ¨ (Tablet) 75mg-50mg Tablet,

OlmC1 esart 25mg-37.5mg an OlmesartanMed oxo mil/ Amlo dipin Capsule) e/ Medoxomil/Hydr ochl orot ValsC1 hiazi artan de / ¨ Valsartan/Hydr Amlodipine/ 2 QL ochl orot hiazi Hydrochlorothiazide Hydrochlorothiazidede 1 QL ¨ (Tablet) (Tablet) Diuretics,B1 Carbonic Anhydrase Inhibitors

AcetC1 azol amid Acetazolamidee (Tablet 3 Immediate-Release)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 63 63 3562 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AcetC1 HydrC1 azol ochl amid orot Acetazolamidee ER ER Hydrochlorothiazidehiazi de (Capsule Extended- 4 (12.5mg Capsule, 1 ¨ Release 12 Hour) 12.5mg Tablet, 25mg

MethC1 azol amid Tablet, 50mg Tablet) Methazolamidee 4 IndaC1 pami (Tablet) Indapamidede (Tablet) 2 ¨

B1 MethC1 yclot hiazi Diuretics, Loop Methyclothiazidede 3 BumC1 etani Bumetanidede (0.25mg/ (Tablet) 4 MetoC1 lazo ml Injection) Metolazonene (Tablet) 3

BumC1 B1 etani Bumetanidede (0.5mg Dyslipidemics, Fibric Acid Derivatives

FenoC1 ¨ fibrat Tablet, 1mg Tablet, 1 Fenofibratee (145mg 3 2mg Tablet) Tablet, 48mg Tablet)

EthaC1 cryni FenoC1 c fibrat Acid Ethacrynic Acid Fenofibratee (160mg 5 1 ¨ (Tablet) Tablet, 54mg Tablet)

FuroC1 semi FenoC1 de fibrat Furosemide (10mg/ml e FenofibrateMicr Micronized oniz 4 B/D, PA ed 3 Injection) (Capsule)

FuroC1 semi FenoC1 de fibric Furosemide (10mg/ml Fenofibric Acid Acid 3 Oral Solution, 8mg/ml 2 ¨ (105mg Tablet)

Oral Solution) FenoC1 fibric Acid C1 Fenofibric Acid (35mg Furo semi de 3 Furosemide (20mg Tablet) ¨ Tablet, 40mg Tablet, 1 FenoC1 fibric Acid 80mg Tablet) FenofibricDR Acid DR

C1 (Capsule Delayed- 3 Tors emid eTorsemide (Tablet) 2 ¨ Release)

B1

GemC1 Diuretics, Potassium-sparing fibro Gemfibrozilzil (Tablet) 2 ¨ AmilC1 oride Amiloride HCl HCl (Tablet) 2 ¨ Dyslipidemics,B1 HMG CoA Reductase DyreC1 niumDyrenium (Capsule) 4 Inhibitors

EplerC1 enon AtorC1 e vasta Eplerenone (Tablet) 3 tin AtorvastatinCalci Calcium um

C1 ¨ Spir 1 QL onol acto Spironolactonene ¨ (Tablet) 2 C1 Fluv astat (Tablet) inFluvastatin (Capsule

B1 2 QL ¨ Diuretics, Thiazide Immediate-Release)

C1 ChloC1 Lival rothi o azid ¨ Chlorothiazidee (Tablet) 2 Livalo (Tablet) 3 QL

C1 ChloC1 Lova rthali stati doneChlorthalidone (Tablet) 2 ¨ Lovastatinn (Tablet) 1 QL ¨

C1 DiurilC1 Prav astat in SodiPravastatin Sodium Diuril (Suspension) um 4 1 QL ¨ (Tablet)

Bold type = Brand name drug Plain type = Generic drug 64 tRACK 64 Last updated October 1, 2018 3663 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

RosC1 WelcC1 uvas hol tatin RosuvastatinCalci Calcium Welchol (3.75gm um 1 QL ¨ 3 (Tablet) Packet)

C1 Simv B1 astat inSimvastatin (Tablet) 1 QL ¨ Vasodilators, Direct-acting Arterial

B1 HydrC1 alazi ne Dyslipidemics, Other HCl Hydralazine HCl ¨ CholC1 2 estyr amin Cholestyraminee (Tablet)

4 MinoC1 (Packet) Minoxidilxidil (Tablet) 2 ¨

C1 Chol B1 estyr amin Cholestyraminee Light Light 4 Vasodilators, Direct-acting Arterial/Venous IsosC1 (Powder) orbid e IsosorbideDinit Dinitrate rate ColeC1 sevel am ColesevelamHCl HCl ¨ 3 (Tablet Immediate- 2 (Tablet) Release)

C1 Cole C1 stipo Isos l HCl orbid e Colestipol HCl (1gm IsosorbideDinit Dinitrate ER rate 3 ER Tablet) (Tablet Extended- 2 ¨

ColeC1 stipo Colestipoll HCl HCl (5gm Release)

4 IsosC1 orbid e Packet) IsosorbideMon Mononitrate onitr ate

EzetiC1 Ezetimibemibe (Tablet) 2 QL ¨ (Tablet Immediate- 2 ¨

EzetiC1 mibe Release) / SimvEzetimibe/Simvastatin astat in IsosC1 3 QL orbid e IsosorbideMon Mononitrate (Tablet) onitr ate ER JuxtC1 ¨ Juxtapidapid (Capsule) 5 PA, LA ER (Tablet Extended- 2

KynaC1 Release 24 Hour) mro

Kynamro (Injection) 5 PA, LA MinitC1 ran

NiaciC1 Minitran (Patch 24 Niacinn ER ER (Tablet 2 ¨ 4 Hour)

Extended-Release) NitroC1 -Bid

NiacC1 Nitro-Bid (Ointment) 4 or ¨ Niacor (Tablet) 2 NitroC1 glyc erin

C1 Ome Nitroglycerin (Tablet ga-3- Acid EthylOmega-3-Acid Ethyl 3 Ester s Sublingual)

Esters (Capsule) 4 QL NitroC1 glyc erin NitroglycerinLing Lingual (Generic Lovaza) ual 1 ¨

PraluC1 (Translingual Solution) ent

Praluent (Injection) 5 PA, QL, LA NitroC1 glyc erin Tran PrevC1 Nitroglycerin sder alite Prevalite (Packet) 4 Transdermalmal (Patch 24 2 ¨ RepC1 Repathaatha (Injection) 5 PA, QL Hour)

RepC1 atha NitroC1 Push stat tronRepatha Pushtronex ex Nitrostat (Tablet Syst em 5 PA, QL 3 System (Injection) Sublingual)

RepC1 atha A1 Sure ClickRepatha SureClick 5 PA, QL Central Nervous System Agents (Injection) AttentionB1 Deficit Hyperactivity Disorder VascC1 epaVascepa (Capsule) 4 Agents, Amphetamines

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 65 65 3764 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AmpC1 VyvaC1 heta nse mine Amphetamine// Vyvanse (10mg Dext roam phet amin Dextroamphetaminee Capsule, 20mg (10mg Capsule Capsule, 30mg Extended-Release 24 Capsule, 40mg Hour, 15mg Capsule Capsule, 50mg Extended-Release 24 Capsule, 60mg Hour, 20mg Capsule Capsule, 70mg Extended-Release 24 4 QL Capsule, 10mg Tablet Hour, 25mg Capsule 4 Extended-Release 24 Chewable, 20mg Hour, 30mg Capsule Tablet Chewable, Extended-Release 24 30mg Tablet Hour, 5mg Capsule Chewable, 40mg Extended-Release 24 Tablet Chewable, Hour) 50mg Tablet

AmpC1 heta mine Amphetamine// Dext Chewable, 60mg roam phet amin Dextroamphetaminee Tablet Chewable) (10mg Tablet AttentionB1 Deficit Hyperactivity Disorder Immediate-Release, Agents, Non-amphetamines

12.5mg Tablet C1 Ato mox Immediate-Release, Atomoxetineetine (Capsule) 4 QL CloniC1 dine HCl 15mg Tablet ClonidineER HCl ER Immediate-Release, 3 QL (Tablet Extended- 4 PA 20mg Tablet Release 12 Hour)

DexC1 meth ylph Immediate-Release, Dexmethylphenidateenid ate 30mg Tablet HCl (Tablet Immediate- 3 QL Immediate-Release, Release)

DexC1 5mg Tablet Immediate- meth ylph Dexmethylphenidateenid ate HCl Release, 7.5mg Tablet HClER ER (Capsule 4 Immediate-Release) Extended-Release 24 DextC1 roam phet Dextroamphetamineamin e Hour) Sulfa te

GuaC1 Sulfate (10mg Tablet, 4 QL nfaci ne GuanfacineER ER (Tablet 5mg Tablet) Extended-Release 24 4 DextC1 roam phet Dextroamphetamineamin e Hour) Sulfa te ER MetaC1 Sulfate ER (Capsule date MetadateER ER (Tablet 4 QL 4 QL Extended-Release 24 Extended-Release) Hour)

Bold type = Brand name drug Plain type = Generic drug 66 tRACK 66 Last updated October 1, 2018 3865 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

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

MethC1 Capsule, 75mg ylph enid Methylphenidateate HCl HCl Capsule, 20mg/ml (10mg/5ml Oral 4 QL Solution, 5mg/5ml Oral Oral Solution) SaveC1 Solution) Savellalla (Tablet) 3

SaveC1 C1 Meth lla ylph Titrat enid Savellaion Titration Pack Methylphenidateate HCl Pack 3 HCl ER ER (10mg Tablet MultipleB1 Sclerosis Agents

AmpC1 Extended-Release, 4 QL Ampyrayra (Tablet 20mg Tablet Extended- Extended-Release 12 5 QL, LA Release)

B1 Hour)

Central Nervous System, Other AubC1 agio

AustC1 Aubagio (Tablet) 5 QL, LA edo

Austedo (Tablet) 5 PA, QL, LA AvonC1 ex

IngreC1 Avonex (Injection) 5 zza

Ingrezza (Capsule) 5 PA, QL AvonC1 ex Pen

C1 Nam Avonex Pen zaricNamzaric (Therapy 5 (Injection)

Pack, Capsule BetaC1 sero 3 PA, QL Betaseronn (Injection) Extended-Release 24 5 GileC1 Hour) Gilenyanya (Capsule) 5 QL GlatiC1 rame NueC1 r dext GlatiramerAcet Acetate aNuedexta (Capsule) 4 PA ate

RiluzC1 (Solution Prefilled 5 ole Riluzole (Tablet) 3 Syringe) TetraC1 bena zine GlatC1 Tetrabenazine (Tablet) 5 PA, QL, LA Glatopaopa (Injection) 5 B1

RebiC1 Fibromyalgia Agents Rebiff (Injection) 5 DuloC1 xetin e C1 HCl Rebi Duloxetine HCl (20mg f Rebi Rebifdose Rebidose Capsule Delayed- 5 (Injection) Release, 30mg RebiC1 f Rebi Rebifdose Rebidose ¨ Capsule Delayed- 2 QL Titrat ion Release, 60mg TitrationPack Pack 5 Capsule Delayed- (Injection)

RebiC1 f Release) Titrat Rebifion Titration Pack Pack 5 (Injection)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 67 67 3966 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

TecfiC1 ClindC1 dera amy cin Tecfidera (Capsule ClindamycinPhos phat 5 QL, LA e Delayed-Release) Phosphate (1% TecfiC1 dera External Solution, 1% 3 Start Tecfideraer Starter Pack 5 LA Pack Gel, 1% Lotion, 1%

A1 Swab)

Dental and Oral Agents ClindC1 amy cin/ Benz B1 Clindamycin/Benzoyl oyl Pero xide Dental and Oral Agents Peroxide (1%-5% Gel) 4 ChloC1 rhexi dine ChlorhexidineGluc onat (Generic BenzaClin) e Oral Rins e ¨ ClotrC1 Gluconate Oral Rinse 2 imaz ole/ Clotrimazole/Beta meth ason e (Solution) Dipr opio Betamethasonenate PerioC1 gard 3 Periogard (Solution) 2 ¨ Dipropionate

PilocC1 arpin e HClPilocarpine HCl (5mg (1%-0.05% Cream)

4 ClotrC1 imaz ole/ Tablet, 7.5mg Tablet) Clotrimazole/Beta meth ason e C1 Tria Dipr mcin opio olon nate Triamcinolonee Betamethasone Acet onid e 4 Dent al AcetonidePast Dental 3 Dipropionate e Paste (Paste) (1%-0.05% Lotion)

CortiC1 A1 spori Cortisporinn Dermatological Agents DermatologicalB1 Agents (0.5%-0.5% Cream, 4

AcitrC1 Acitretinetin (Capsule) 4 1%-0.5% Ointment) CoseC1 ntyx AdaC1 pale Cosentyx (Injection) 5 PA, LA Adapalenene (0.1% CoseC1 4 ntyx Sens oreaCosentyx Sensoready Cream) dy Pen 5 PA, LA AdaC1 pale Adapalenene (0.1% Gel) 3 Pen (Injection) DicloC1 fena AmC1 c moni Sodi um Diclofenac Sodium um AmmoniumLact Lactate ate 4 PA (12% Cream, 12% 3 (3% Gel) DoxeC1 pin Lotion) DoxepinHCl HCl (Cream) 5 PA, QL

C1 CalciC1 Elide potri l Calcipotrieneene (0.005% Elidel (Cream) 4 ST Cream, 0.005% EryC1 4 Ery (2% Pad) 3 ErythC1 External Solution, romy Erythromycincin (2% 2 ¨ 0.005% Ointment) External Solution) CalciC1 triol ErythC1 Calcitriol (3mcg/gm romy 4 Erythromycincin (2% Gel) 4

Ointment) ErythC1 romy cin/ Benz C1 Erythromycin/Benzoyl Cara oyl c Pero xide 4 Carac (Cream) 5 PA Peroxide (Gel) ClarC1 avis FinaC1 Claravis (Capsule) 4 PA Finaceacea (15% Foam, 4 15% Gel)

Bold type = Brand name drug Plain type = Generic drug 68 tRACK 68 Last updated October 1, 2018 4067 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FluorC1 TretiC1 oura noin cil Micr Fluorouracil (0.5% Tretinoinosph Microsphere 5 ere 4 PA Cream) (Gel)

FluorC1 ZyclC1 oura ara cil Pum Fluorouracil (2% Zyclarap Pump 5 PA External Solution, 5% 3 (Cream) External Solution) Electrolytes/Minerals/Metals/VitaminsA1 FluorC1 oura Fluorouracilcil (5% B1 4 Electrolyte/Mineral Replacement

Cream) AminC1 osyn 7%/ Elect C1 Aminosyn 7%/ Imiq rolyt uimo es Imiquimodd (Cream) 4 Electrolytes 4 B/D, PA IsotrC1 etino Isotretinoinin (Capsule) 4 PA (Injection) MethC1 oxsal C1 en Amin osyn Methoxsalen (Capsule) 5 Aminosyn8.5% 8.5%/ / Elect MirvC1 rolyt Mirvasoaso (Gel) 4 Electrolyteses 4 B/D, PA

OxsoC1 ralen

OxsoralenUltra Ultra (Injection)

5 C1 Amin osyn (Capsule) Aminosyn II II (10%

PicatC1 4 B/D, PA Picatoo (Gel) 3 Injection)

PodC1 AminC1 ofilo osyn x II Podofilox (External Aminosyn8.5% II 8.5%/ / Elect 3 rolyt Solution) Electrolyteses 4 B/D, PA

PrudC1 Prudoxinoxin (Cream) 4 PA, QL (Injection)

C1 RegrC1 Amin anex osyn - Regranex (Gel) 5 PA Aminosyn-HBCHBC 4 B/D, PA SantC1 Santylyl (Ointment) 4 (Injection)

AminC1 SeleC1 osyn nium -PF Aminosyn-PF SeleniumSulfi Sulfide de 2 ¨ 4 B/D, PA (Lotion) (Injection)

AminC1 C1 Stela osyn ra Aminosyn-RF-RF Stelara (Injection) 5 PA 4 B/D, PA TacrC1 olim Tacrolimusus (0.03% (Injection)

CarbC1 Ointment, 0.1% 4 ST Carbagluaglu (Tablet) 5 LA

DextC1 rose Ointment) 10%Dextrose 10%

TazaC1 rote 4 Tazarotenene (Cream) 4 PA (Injection)

TazoC1 DextC1 rac rose 10% Tazorac (0.05% Dextrose/ 10%/NaCl NaCl 4 PA 0.2% 4 Cream, 0.1% Gel) 0.2% (Injection)

TazoC1 DextC1 rac rose 10% Tazorac (0.05% Gel) 5 PA Dextrose/ 10%/NaCl NaCl 0.45 % TretiC1 4 Tretinoinnoin (0.01% Gel, 0.45% (Injection)

DextC1 rose 0.025% Gel, 0.025% 2.5% Dextrose/ 2.5%/NaCl NaCl 4 PA 0.45 % 4 Cream, 0.05% Cream, 0.45% (Injection)

DextC1 0.1% Cream) rose Dextrose5% 5% (Injection) 4 B/D, PA

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 69 69 4168 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DextC1 Klor-C1 rose Con 5%/ DextroseNaCl 5%/NaCl Klor-Con (Packet) 3 0.2%

4 C1 Klor- Con 0.2% (Injection) Klor-Con10 10 (Tablet

DextC1 3 rose 5%/ DextroseNaCl 5%/NaCl Extended-Release) 0.22 5%

4 C1 Klor- Con 0.225% (Injection) Klor-Con8 8 (Tablet

DextC1 3 rose 5%/ DextroseNaCl 5%/NaCl Extended-Release) 0.33 %

4 C1 Klor- Con 0.33% (Injection) M10 Klor-Con M10 (Tablet ¨ DextC1 2 rose 5%/ DextroseNaCl 5%/NaCl Extended-Release) 0.45 % 4 Klor-C1 Con 0.45% (Injection) Klor-ConM15 M15 (Tablet ¨ C1 2 Dext rose 5%/ Extended-Release) DextroseNaCl 5%/NaCl 0.9% 4 B/D, PA Klor-C1 Con 0.9% (Injection) Klor-ConM20 M20 (Tablet 2 ¨ FreAC1 mine Extended-Release) HBCFreAmine HBC 6.9% 6.9%

Klor-C1 4 B/D, PA Con Spri (Injection) Klor-Connkle Sprinkle

HepC1 atA (Capsule Extended- 3 mineHepatAmine 4 B/D, PA (Injection) Release) LevoC1 carni tine IntralC1 ipid Levocarnitine (1gm/ Intralipid (Injection) 4 B/D, PA 3

C1 10ml Oral Solution) Iono sol- MB/ DextIonosol-MB/Dextrose LevoC1 rose carni 5% 4 Levocarnitinetine (330mg 5% (Injection) 3

C1 Tablet) Isolyt e-P/ Dext Isolyte-P/Dextroserose 5% MagC1 5% nesi um 4 MagnesiumSulfa Sulfate (Injection) te

C1 (1gm/2ml-50% 4 Isolyt e-S Isolyte-S (Injection) 4 Injection) KClC1 0.07 5%/ MagC1 KClD5W 0.075%/D5W/ nesi / um NaCl Sulfa 0.45 Magnesium Sulfate te % NaCl 0.45% 4 (5gm/10ml-50% 4 (Injection) Injection)

KClC1 0.15 NepC1 %/ hram KClD5W 0.15%/D5W/NaCl ine / NaCl Nephramine 0.2% 4 4 B/D, PA 0.2% (Injection) (Injection)

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

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

KClC1 0.3% NorC1 / mos KClD5W 0.3%/D5W/NaCl ol-R / in NaCl Normosol-R in D5W D5W 0.45 % 4 4 0.45% (Injection) (Injection)

KClC1 0.3% NutriC1 / lipid KClD5W 0.3%/D5W/NaCl / NaCl Nutrilipid (Injection) 4 B/D, PA 0.9% 4 0.9% (Injection)

Bold type = Brand name drug Plain type = Generic drug 70 tRACK 70 Last updated October 1, 2018 4269 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PlasC1 PotaC1 ma- ssiu Lyte m Plasma-LyteA A PotassiumChlo Chloride/ ride/ Dext rose 4 / Lact ated (Injection) Dextrose/LactatedRing 4 ers

PlasC1 ma- Lyte- Ringers (Injection) Plasma-Lyte-148148

4 PotaC1 ssiu m (Injection) PotassiumChlo Chloride/ ride/ Dext rose PlenC1 / amin Sodi e um Dextrose/SodiumChlo 4 Plenamine (Injection) 4 B/D, PA ride

PotaC1 ssiu m Chloride (Injection) ChloPotassium Chloride ride

PotaC1 ssiu m PotassiumChlo Chloride/ (10% Oral Solution, 3 ride/ Sodi um Chlo Sodiumride Chloride 20% Oral Solution) 4 B/D, PA

PotaC1 ssiu (20meq/L-0.45% m PotassiumChlo Chloride ride Injection)

(10meq/100ml C1 Pota ssiu m PotassiumChlo Chloride/ ride/ Sodi Injection, 20meq/ um Chlo 4 B/D, PA ride 100ml Injection, Sodium Chloride 40meq/100ml (20meq/L-0.9% 4 B/D, PA Injection) Injection, 40meq/

PotaC1 L-0.9% Injection) ssiu m Chlo Potassium Chloride C1 ride Pota ssiu 4 B/D, PA m PotassiumCitra Citrate ER te (2meq/ml Injection) ER

PotaC1 (Tablet Extended- 3 ssiu m ChloPotassium Chloride CR ride CR ¨ Release) (Tablet Extended- 2 C1 Pre mas Release) Premasolol (Injection) 4 B/D, PA ProcC1 alam PotaC1 ine ssiu Procalamine m ChloPotassium Chloride ER ride ER 4 B/D, PA (10meq Capsule (Injection)

ProsC1 Extended-Release, 3 Prosolol (Injection) 4 B/D, PA

SodiC1 um 8meq Capsule Chlo Sodiumride Chloride 0.9% Extended-Release) 0.9% (Irrigation 3 PotaC1 ssiu m PotassiumChlo Chloride ER ride Solution) ER

SodiC1 (10meq Tablet um Chlo Sodiumride Chloride (0.9% 4 B/D, PA Extended-Release, Injection) ¨ 20meq Tablet 2 SodiC1 um Chlo Sodiumride Chloride Extended-Release, 4 8meq Tablet Extended- (2.5meq/ml Injection)

SodiC1 um Chlo Release) Sodiumride Chloride (3%

PotaC1 ssiu m Injection, 5% 4 B/D, PA ChloPotassium Chloride/ ride/ Dext rose 4 B/D, PA Dextrose (Injection) Injection)

SodiC1 um Chlo Sodiumride Chloride 0.45 % 4 0.45% (Injection)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 71 71 4370 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SodiC1 PhosC1 um lyra Fluor Sodiumide Fluoride Phoslyra (Oral 2 ¨ 3 (Tablet) Solution)

C1 Sodi C1 um Seve Lact lame ate r Sodium Lactate SevelamerCarb Carbonate onat 4 e (Injection) (0.8gm Packet, 2.4gm 5

TPNC1 Elect rolyt Packet) TPNes Electrolytes

SeveC1 4 lame r SevelamerCarb Carbonate (Injection) onat e 4 TravC1 Travasolasol (Injection) 4 B/D, PA (800mg Tablet) VelpC1 horo TropC1 hami Velphoro (Tablet neTrophamine (10% 4 B/D, PA 5 Injection) Chewable)

B1 Electrolyte/Mineral/MetalB1 Modifiers Vitamins VP-C1 PNV- CheC1 DHA ¨ Chemetmet (Capsule) 5 VP-PNV-DHA (Capsule) 2

A1

ExjaC1 Exjadede (Tablet Gastrointestinal Agents 5 PA B1 Soluble) Antispasmodics, Gastrointestinal

CuvC1 FerriC1 posa prox Cuvposa (Oral Ferriprox (100mg/ml 4 Oral Solution, 500mg 5 PA Solution)

DicyC1 clom ine Tablet) DicyclomineHCl HCl

JadeC1 Jadenunu (Tablet) 5 PA (10mg Capsule, 10mg/ 2 ¨

JadeC1 5ml Oral Solution) nu Spri Jadenunkle Sprinkle DicyC1 clom 5 PA ine DicyclomineHCl HCl (Packet) 2 ¨

KionC1 (Tablet) ex

Kionex (Suspension) 3 MethC1 scop olam ine C1 Sam Methscopolamine Bro sca mide 4 Samsca (Tablet) 5 PA, QL Bromide (Tablet) SodiC1 um

Poly B1 styreSodium Polystyrene ne Sulfo nate 3 Gastrointestinal Agents, Other

Sulfonate (Powder) CheC1 noda l SPSC1 Chenodal (Tablet) 5

SPS (Suspension) 3 CroC1 moly n Sodi TrienC1 Cromolyn Sodium um tine HCl Trientine HCl (Capsule) 5 PA, QL (100mg/5ml 4 VeltaC1 ssaVeltassa (Powder) 5 QL Concentrate)

B1 DiphC1 enox Phosphate Binders ylate Diphenoxylate// Atro pine AuryC1 Auryxiaxia (Tablet) 5 PA Atropine

CalciC1 um Acet (2.5mg-0.025mg Calciumate Acetate 4 (667mg Capsule, 3 Tablet, 667mg Tablet) 2.5mg-0.025mg/5ml

LantC1 Liquid) hanu m Carb Lanthanum Carbonate C1 onat Gatt e 5 ex (Tablet Chewable) Gattex (Injection) 5 PA, LA

Bold type = Brand name drug Plain type = Generic drug 72 tRACK 72 Last updated October 1, 2018 4471 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

LopeC1 EnulC1 rami ose de ¨ LoperamideHCl HCl Enulose (Oral Solution) 2 2 ¨ GaviC1 Lyte- (Capsule) GaviLyte-CC (Oral

C1 ¨ Myal 2 eptMyalept (Injection) 5 PA, LA Solution)

RelisC1 GaviC1 tor Lyte- Relistor (12mg/0.6ml GaviLyte-GG (Oral 2 ¨ Injection, 8mg/0.4ml 5 PA Solution)

GaviC1 Lyte- N/ Injection) GaviLyte-N/FlavorFlav or Pack ¨ C1 1 Relis Relistortor (150mg Pack (Oral Solution) 5 PA, QL GenC1 Tablet) Generlacerlac (Oral 2 ¨ SeroC1 stimSerostim (Injection) 5 PA, LA Solution)

LactC1 ulos C1 Urso e Ursodioldiol (250mg Lactulose (Oral 4 2 ¨ Tablet, 500mg Tablet) Solution)

PEGC1 3350 C1 Urso / diol PEGElect 3350/Electrolytes rolyt Ursodiol (300mg es 3 3 Capsule) (Oral Solution)

PEG-C1 3350 C1 Zorb / tive PEG-3350/ElectrolytesElect rolyt Zorbtive (Injection) 5 PA, LA es

B1 (Oral Solution) 3 Histamine2 (H2) Receptor Antagonists (Generic GoLYTELY) CimC1 etidi ne ¨ C1 Cimetidine (Tablet) 2 PEG- 3350 / PEG-3350/NaCl/NaNaCl CimC1 /Na etidi Bicar ne bona HCl te/ Cimetidine HCl (Oral Bicarbonate/KClKCl (Oral 2 ¨ 3 Solution) Solution) (Generic

FamC1 otidi neFamotidine (20mg NuLYTELY) 2 ¨ PolyC1 ethyl Tablet, 40mg Tablet) ene PolyethyleneGlyc Glycol ol 3350 FamC1 Pow otidi der neFamotidine (40mg/5ml 3350 Powder (Generic 2 ¨ 4 Suspension) MiraLAX)

RaniC1 SuprC1 tidin ep e Bow RanitidineHCl HCl (150mg Suprepel Bowel Prep Prep 2 ¨ Kit 3 Tablet, 300mg Tablet) Kit (Oral Solution)

RaniC1 tidin TriLyC1 e te HClRanitidine HCl (75mg/ ¨ 4 TriLyte (Oral Solution) 1 5ml Syrup) ProtectantsB1

B1

CaraC1 Irritable Bowel Syndrome Agents Carafatefate (1gm/10ml AlosC1 etro 4 n AlosetronHCl HCl (Tablet) 5 PA Suspension)

AmitiC1 za MisoC1 prost Amitiza (Capsule) 3 QL Misoprostolol (Tablet) 3

LinzC1 ess SucrC1 alfat Linzess (Capsule) 3 QL Sucralfatee (Tablet) 2 ¨

XifaxC1 Xifaxanan (Tablet) 5 PA ProtonB1 Pump Inhibitors

B1 DexilC1 Laxatives Dexilantant (Capsule

ConC1 stulo 4 QL Constulosese (Oral 2 ¨ Delayed-Release) Solution)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 73 73 4572 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EsoC1 A1 mep razol Esomeprazolee Genetic or Enzyme Disorder: Replacement, Mag nesi Magnesiumum (Capsule 3 QL Modifiers, Treatment Delayed-Release) GeneticB1 or Enzyme Disorder: Replacement, (Generic Nexium) Modifiers, Treatment LansC1 opra zole AralaC1 Lansoprazole (15mg st AralastNP NP (Injection) 5 PA, LA

Capsule Delayed- CholC1 bam Release, 30mg 3 QL Cholbam (Capsule) 5 PA CreoC1 Creonn (Capsule Capsule Delayed- 3 Release) Delayed-Release)

NexiC1 CystC1 um adan Nexium (10mg Cystadanee (Powder) 5

CystC1 Packet, 2.5mg agon Cystagon (Capsule) 4 LA GlasC1 Packet, 20mg Packet, 3 siaGlassia (Injection) 5 PA, LA

KuvaC1 40mg Packet, 5mg nKuvan (100mg Packet) Packet, 500mg NexiC1 um 5 LA Nexium (20mg Packet, 100mg Tablet Capsule Delayed- Soluble)

MiglC1 Release, 40mg 3 QL ustatMiglustat (Capsule) 5 PA, LA

Capsule Delayed- OcaliC1 vaOcaliva (Tablet) 5 PA, QL

Release) C1 Orfa din

OmeC1 Orfadin (10mg praz Omeprazoleole (10mg Capsule, 20mg Capsule Delayed- Capsule, 2mg Release, 40mg 2 QL ¨ 5 LA Capsule Delayed- Capsule, 5mg Release) Capsule, 4mg/ml

OmeC1 praz Suspension) oleOmeprazole (20mg ProlaC1 stin- Capsule Delayed- 2 ¨ CProlastin-C (Injection) 5 PA, LA

RaviC1 Release) ctiRavicti (Liquid) 5 QL, LA

PantC1 opra SodiC1 zole um Sodi Phe Pantoprazole Sodium nylb um Sodium Phenylbutyrate utyra te (20mg Tablet Delayed- 1 QL ¨ (3gm/TSP Powder, 5 Release, 40mg Tablet 500mg Tablet)

SucrC1 Delayed-Release) Sucraidaid (Oral PriloC1 sec 5 LA Prilosec (Packet) 4 PA Solution)

RabC1 epra ZemC1 zole aira RabeprazoleSodi Sodium um Zemaira (Injection) 5 PA, LA

ZenC1 (Tablet Delayed- 3 pepZenpep (Capsule Release) 3 Delayed-Release)

Bold type = Brand name drug Plain type = Generic drug 74 tRACK 74 Last updated October 1, 2018 4673 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

A1 ElmirC1 Genitourinary Agents Elmironon (Capsule) 5

B1 LithoC1 Antispasmodics, Urinary Lithostatstat (Tablet) 5

MyrbC1 A1 Myrbetriqetriq (Tablet Hormonal Agents, Stimulant/Replacement/

Extended-Release 24 3 Modifying (Adrenal) Hour) HormonalB1 Agents, Stimulant/Replacement/

OxybC1 utyni n OxybutyninChlo Chloride Modifying (Adrenal) ride

Ala-C1 (5mg Tablet Cort 2 ¨ Ala-Cort (Cream) 2 ¨

AlcloC1 Immediate-Release, meta sone Alclometasone Dipr opio 5mg/5ml Syrup) nate Dipropionate (0.05% OxybC1 utyni n 3 ChloOxybutynin Chloride ride ER Cream, 0.05% ER (Tablet Extended- 3 QL Ointment)

AugC1 Release 24 Hour) ment ed AugmentedBeta C1 meth Vesi ason care e Dipr Vesicare (Tablet) 3 QL opio Betamethasonenate BenignB1 Prostatic Hypertrophy Agents Dipropionate (0.05% 3 AlfuzC1 osin HCl Cream, 0.05% Gel, AlfuzosinER HCl ER (Tablet Extended- 2 ¨ 0.05% Lotion, 0.05% Release 24 Hour) Ointment)

BetaC1 DutaC1 meth steri ason de Betamethasonee Dipr Dutasteride (Capsule) 3 QL opio nate

FinaC1 steri Dipropionate (0.05% Finasteridede (5mg 4 Cream, 0.05% Lotion, Tablet) (Generic 1 ¨ 0.05% Ointment) Proscar) BetaC1 meth ason RapC1 e aflo Betamethasone Valer Rapaflo (4mg ate Valerate (0.1% Cream, Capsule, 8mg 4 3 QL 0.1% Lotion, 0.1% Capsule) Ointment) TamC1 sulo sin ClobC1 TamsulosinHCl HCl etas ol ¨ ClobetasolProp Propionate 1 ionat (Capsule) (0.05%e Cream, 0.05% TeraC1 zosin 4 TerazosinHCl HCl 2 ¨ Gel, 0.05% Ointment, (Capsule) 0.05% Shampoo)

B1 ClobC1 etas ol Genitourinary Agents, Other ClobetasolProp Propionate ionat e

C1 Beth anec hol BethanecholChlo Chloride (0.05% External 3 ride 2 ¨ (Tablet) Solution)

ClobC1 C1 Cupr etas imin ol e ClobetasolProp Propionate Cuprimine (Capsule) 5 PA ionat e E 4 DepC1 en E (Cream) Titrat Depenabs Titratabs CordC1 5 ran (Tablet) Cordran (Tape) 4

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 75 75 4774 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

CortiC1 HaloC1 sone beta sol CortisoneAcet Acetate HalobetasolProp ate ionat 4 e (Tablet) Propionate (0.05% 4 DesoC1 Desonidenide (0.05% Cream, 0.05% 4 Ointment) Ointment)

HydrC1 DesoC1 ocort xime ison taso Hydrocortisonee (1% Desoximetasonene Cream, 2.5% Cream, (0.05% Cream, 0.25% 4 2 ¨ Cream) 1% Ointment, 2.5%

DexaC1 meth Ointment) ason Dexamethasonee HydrC1 ocort ison (0.5mg Tablet, 0.75mg Hydrocortisonee (10mg Tablet, 20mg Tablet, Tablet, 1.5mg Tablet, 3 1mg Tablet, 2mg 2 ¨ 5mg Tablet, 2.5% Tablet, 4mg Tablet, Lotion)

HydrC1 ocort ison 6mg Tablet, 0.5mg/ Hydrocortisonee Buty rate 5ml Elixir) Butyrate (0.1% 3

DexaC1 meth ason Ointment) eDexamethasone Inten sol HydrC1 ocort ¨ ison Intensol (1mg/ml 2 Hydrocortisonee Valer ate Concentrate) Valerate (0.2% Cream, 4

FludrC1 ocort ison 0.2% Ointment) eFludrocortisone Acet ate ¨ C1 2 Meth ylpre dnis Acetate (Tablet) Methylprednisoloneolon e 2 ¨ FluoC1 cinol one (Tablet) AcetFluocinolone onid e MethC1 ylpre dnis Acetonide (0.01% Methylprednisoloneolon e Dose Cream, 0.025% Cream, DosePack Pack (Tablet 2 ¨ 4 0.01% External Therapy Pack)

MomC1 etas Solution, 0.025% one MometasoneFuro Furoate ate Ointment) (0.1% Cream, 0.1% FluoC1 3 cinol one FluocinoloneAcet External Solution, 0.1% onid e Scal 4 Acetonidep Scalp (Oil) Ointment)

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

FluoC1 cino PredC1 nide nisol FluocinonideEmul one sifie Sodi d Prednisolone Sodium um Base Phos phat Emulsified Base 3 Phosphatee (10mg/5ml 4 (Cream) Oral Solution, 20mg/

FlutiC1 caso ne FluticasoneProp Propionate 5ml Oral Solution) ionat e (0.005% Ointment, 3 0.05% Cream)

Bold type = Brand name drug Plain type = Generic drug 76 tRACK 76 Last updated October 1, 2018 4875 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PredC1 DesC1 nisol mop one ressi PrednisoloneSodi Sodium Desmopressinn Acetate um Acet Phos ate phat Phosphatee (25mg/5ml (0.1mg Tablet, 0.2mg 3 2 ¨ Oral Solution, 5mg/5ml Tablet)

GenC1 otro Oral Solution) Genotropinpin (12mg

PredC1 niso nePrednisone (10mg Injection, 5mg 5 PA Tablet Therapy Pack, Injection)

GenC1 5mg Tablet Therapy otro pin GenotropinMini Miniquick quic Pack, 10mg Tablet, k 4 PA 1 ¨ (0.2mg Injection) 1mg Tablet, 2.5mg GenC1 otro pin GenotropinMini Miniquick quic Tablet, 20mg Tablet, k 50mg Tablet, 5mg (0.4mg Injection, Tablet) 0.6mg Injection,

PredC1 niso ne 0.8mg Injection, Prednisone (5mg/5ml ¨ 2 1.2mg Injection, Oral Solution) 5 PA PredC1 niso ne 1.4mg Injection, IntenPrednisone Intensol sol 2 ¨ (5mg/ml Concentrate) 1.6mg Injection,

TriaC1 mcin 1.8mg Injection, 1mg olon eTriamcinolone Acet onid eAcetonide (0.025% Injection, 2mg Cream, 0.1% Cream, Injection)

HumC1 atro 0.5% Cream, 0.025% 2 ¨ Humatropepe (Injection) 5 PA

HumC1 Ointment, 0.1% atro pe HumatropeCom Combo bo Pack 5 PA Ointment, 0.5% Pack (Injection)

Ointment) IncreC1 lex

TriaC1 Increlex (Injection) 5 PA, LA mcin olon e Triamcinolone NordC1 Acet onid itropi e n FlexNorditropin FlexPro Acetonide (0.025% 3 Pro 5 PA Lotion, 0.1% Lotion) (Injection)

NutrC1

C1 opin Tride AQ rm Nutropin AQ Triderm (Cream) 2 ¨ 5 PA HormonalA1 Agents, Stimulant/Replacement/ (Injection) SaizC1 Modifying (Pituitary) Saizenen (Injection) 5 PA, LA

A1 HormonalB1 Agents, Stimulant/Replacement/ Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) Modifying (Prostaglandins)

B1

DesC1 mop ressi Hormonal Agents, Stimulant/Replacement/ Desmopressinn Acetate Acet ate (0.01% Nasal Spray 4 Modifying (Prostaglandins)

KorlyC1 Solution) Korlymm (Tablet) 5 PA, QL, LA HormonalA1 Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 77 77 4976 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 BriellC1 Androgens Briellynyn (Tablet) 4

AnaC1 CamC1 drol- rese Anadrol-5050 (Tablet) 5 PA CamreseLo Lo (Tablet) 4

AndrC1 CaziC1 oder ant Androdermm (Patch 24 Caziant (Tablet) 4

3 QL C1 Clim ara Hour) ClimaraPro Pro (Patch

DanC1 4 Danazolazol (Capsule) 4 Weekly)

OxaC1 CrysC1 ndrol elle- Oxandroloneone (10mg Cryselle-2828 (Tablet) 4 4 PA, QL CyclC1 Tablet) Cyclafemafem (Tablet) 4

OxaC1 ndrol DelylC1 oneOxandrolone (2.5mg a 3 PA, QL Delyla (Tablet) 4

DepC1 Tablet) o- Estra Depo-Estradioldiol TestC1 oster one 4 Testosterone (25mg/ (Injection)

DesoC1 2.5gm 1% Gel, 50mg/ 3 gestr el/ Desogestrel/EthinylEthin yl Estra 5gm 1% Gel) diol 4 Estradiol (Tablet) TestC1 oster one Cypi DrosC1 Testosterone piren onat e one/ Drospirenone/EthinylEthin 3 yl Estra Cypionate (Injection) diol 4 Estradiol (Tablet) TestC1 oster one Enan DuavC1 Testosterone ee thate 4 Duavee (Tablet) 4

Enanthate (Injection) C1 Elest rin TestC1 Elestrin (Gel) 4 oster one Pum Testosterone Pump C1 p Emo quett 3 e (1% Gel) Emoquette (Tablet) 4 EnprC1 esse- EstrogensB1 Enpresse-2828 (Tablet) 4 EnskC1 yce AltavC1 Altaveraera (Tablet) 4 Enskyce (Tablet) 4 EstarC1 ylla AlyaC1 cen Alyacen1/35 1/35 (Tablet) 4 Estarylla (Tablet) 4 EstraC1 diol AmeC1 Amethiathia (Tablet) 4 Estradiol (0.025mg/

AmeC1 24hr Patch Weekly, thia AmethiaLo Lo (Tablet) 4 0.05mg/24hr Patch ApriC1 Apri (Tablet) 4 Weekly, 0.06mg/24hr

AranC1 Aranelleelle (Tablet) 4 Patch Weekly, 3 QL AshlC1 Ashlynayna (Tablet) 4 0.075mg/24hr Patch

AubrC1 a Weekly, 0.1mg/24hr Aubra (Tablet) 4

C1 Patch Weekly, Avia Avianene (Tablet) 4 37.5mcg/24hr Patch BalziC1 Balzivava (Tablet) 4 Weekly)

C1 Bliso C1 Estra vi 24 diol BlisoviFe 24 Fe (Tablet) 4 Estradiol (0.1mg/gm

C1 4 Bliso vi Fe 1.5/ Cream) Blisovi30 Fe 1.5/30 4 (Tablet)

BlisoC1 vi Fe Blisovi1/20 Fe 1/20 (Tablet) 4

Bold type = Brand name drug Plain type = Generic drug 78 tRACK 78 Last updated October 1, 2018 5077 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

EstraC1 KurvC1 Estradioldiol (0.5mg Kurveloelo (Tablet) 4

LARIC1 N Tablet, 1mg Tablet, 1.5/ 3 LARIN30 1.5/30 (Tablet) 4 LARIC1 2mg Tablet) (Generic N LARIN1/20 1/20 (Tablet) 4

Estrace) C1 LARI N Fe 1.5/ EstraC1 LARIN30 Fe 1.5/30 Estradioldiol (10mcg 4 4 QL (Tablet)

Tablet) C1 LARI N Fe 1/20 EstraC1 LARIN Fe 1/20 (Tablet) 4 diol Valer ate Estradiol Valerate C1 Laris 4 sia (Injection) Larissia (Tablet) 4 LayoC1 lis Fe EstriC1 ng Layolis Fe (Tablet Estring (Ring) 4 4

EthyC1 nodi Chewable) ol EthynodiolDiac Diacetate/ etate / LeenC1 Ethin a yl Estra Leena (Tablet) 4 Ethinyldiol Estradiol 4

LessiC1 (Tablet) Lessinana (Tablet) 4

FalmC1 LevoC1 Falminaina (Tablet) 4 Levonestnest (Tablet) 4

FemrC1 LevoC1 ing norg estre Femring (Ring) 4 Levonorgestrell and and Ethin yl Estra FemC1 diol Femynorynor (Tablet) 4 Ethinyl Estradiol 4

FyavC1 Fyavolvolv (Tablet) 4 (90mcg-20mcg Tablet) LevoC1 norg estre GianC1 l/ vi Levonorgestrel/Ethinyl Ethin yl Gianvi (Tablet) 4 Estra diol

C1 Estradiol Intro Introvalevale (Tablet) 4 (0.15mg-30mcg Tablet, IsiblC1 Isibloomoom (Tablet) 4 0.1mg-20mcg Tablet,

JinteC1 Jintelili (Tablet) 4 0.05mg-30mcg/

JuleC1 Juleberber (Tablet) 4 0.075mg-40mcg/

C1 June 0.125mg-30mcg l 1.5/ 30 4 Junel 1.5/30 (Tablet) 4 Tablet, 0.1-0.02mg/ JuneC1 l Junel1/20 1/20 (Tablet) 4 0.01mg Tablet,

JuneC1 l Fe 1.5/ Junel30 Fe 1.5/30 0.15mg-0.03mg/ 4 (Tablet) 0.01mg Tablet,

JuneC1 l Fe Junel1/20 Fe 1/20 (Tablet) 4 0.15mg-0.02mg/

JuneC1 0.025mg/0.03mg/ l Fe Junel24 Fe 24 (Tablet) 4 0.01mg Tablet) KaitliC1 b Fe LevoC1 Kaitlib Fe (Tablet ra 0.15 Levora/30- 0.15/30-28 4 28 Chewable) 4 (Tablet) KarivC1 a LoryC1 Kariva (Tablet) 4 na Loryna (Tablet) 4 KelnC1 or 1/35 Low-C1 Kelnor 1/35 (Tablet) 4 Oge Low-Ogestrelstrel (Tablet) 4 KelnC1 or 1/50 LuteC1 Kelnor 1/50 (Tablet) 4 ra Lutera (Tablet) 4 KimiC1 dess MarliC1 Kimidess (Tablet) 4 ssa Marlissa (Tablet) 4

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 79 79 5178 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

MeloC1 NortrC1 detta el 24 0.5/ MelodettaFe 24 Fe Nortrel35 0.5/35 (28) 4 4 (Tablet Chewable) (Tablet)

MenC1 NortrC1 est el Menest (Tablet) 3 Nortrel1/35 1/35 (Tablet) 4

MibeC1 NortrC1 las el 24 7/7/ MibelasFe 24 Fe (Tablet Nortrel7 7/7/7 (Tablet) 4 4 NuvaC1 Chewable) NuvaRingRing (Ring) 4

MicrC1 oges OcellC1 tin a Microgestin1.5/ 1.5/30 30 4 Ocella (Tablet) 4 OgeC1 (Tablet) strel Ogestrel (Tablet) 4 MicrC1 oges tin 1/20 OrsyC1 Microgestin 1/20 thia 4 Orsythia (Tablet) 4

(Tablet) C1 Pimt rea MicrC1 Pimtrea (Tablet) 4 oges tin Fe Microgestin Fe (Tablet) 4 C1 Pirm ella 1/35 MicrC1 Pirmella 1/35 (Tablet) 4 oges tin Fe Microgestin Fe 1.5/30 C1 1.5/ Porti 30 4 a-28 (Tablet) Portia-28 (Tablet) 4 PreC1 mari MiliC1 n Mili (Tablet) 4 Premarin (0.3mg

MonC1 oNe Tablet, 0.45mg MonoNessassa (Tablet) 4

NecC1 Tablet, 0.625mg 4 QL on 0.5/ Necon35-2 0.5/35-28 8 4 Tablet, 0.9mg Tablet, (Tablet)

NecC1 1.25mg Tablet) on 7/7/ 7 Necon 7/7/7 (Tablet) 4 PreC1 mari n

C1 Nikki Premarin (Vaginal 3 Nikki (Tablet) 4 Cream) NoreC1 thind rone Acet PreC1 Norethindrone mph ate/ Ethin ase yl Premphase (Tablet) 4 QL Estra diol

Acetate/Ethinyl C1 Pre mpr Estradiol Premproo (Tablet) 4 QL PreviC1 4 fem (0.5mg-2.5mcg Tablet, Previfem (Tablet) 4

QuaC1 sens 1mg-20mcg Tablet, Quasensee (Tablet) 4

RecliC1 1mg-5mcg Tablet) Reclipsenpsen (Tablet) 4 NoreC1 thind rone SetlaC1 NorethindroneAcet kin ate/ Ethin yl Setlakin (Tablet) 4 Estra diol/ Ferr Acetate/Ethinyl SpriC1 ous Fum ntec arate 28 Estradiol/Ferrous 4 Sprintec 28 (Tablet) 4 SronC1 Fumarate (Tablet, Sronyxyx (Tablet) 4

SyedC1 Tablet Chewable) Syedaa (Tablet) 4

NoreC1 TarinC1 thind a Fe rone 1/20 Norethindrone/Ethinyl/ Ethin Tarina Fe 1/20 (Tablet) 4 yl Estra diol/ Ferr Tri-C1 ous Lege Estradiol/Ferrous st Fe Fum arate 4 Tri-Legest Fe (Tablet) 4 Fumarate (Tablet Tri-C1 Lo- Estar Tri-Lo-Estaryllaylla (Tablet) 4 Chewable) Tri-C1 Lo- Spri NorgC1 ntec esti Tri-Lo-Sprintec (Tablet) 4 mate Norgestimate/Ethinyl/ Ethin Tri-C1 yl Estra 4 Mili Estradioldiol (Tablet) Tri-Mili (Tablet) 4

Bold type = Brand name drug Plain type = Generic drug 80 tRACK 80 Last updated October 1, 2018 5279 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

Tri-C1 MedC1 Previ roxy fem prog Tri-Previfem (Tablet) 4 Medroxyprogesteroneester one Acet ate Tri-C1 Spri ntec Acetate (150mg/ml Tri-Sprintec (Tablet) 4 4 Tri-C1 Vylib Injection Prefilled Tri-Vylibrara (Tablet) 4

C1 Syringe) Trine ssa Trinessa (Tablet) 4 MegC1 estro l Acet C1 Megestrol Acetate Trivo ate Trivora-28ra-28 (Tablet) 4 (20mg Tablet, 40mg VelivC1 et 3 Velivet (Tablet) 4 Tablet, 40mg/ml

VienC1 Vienvava (Tablet) 4 Suspension)

MegC1 VyfeC1 estro mla l MegestrolAcet Acetate Vyfemla (Tablet) 4 ate

VylibC1 Vylibrara (Tablet) 4 (625mg/5ml 4

WYC1 Suspension) MZY A Fe

C1 WYMZYA Fe (Tablet Nora 4 -BE Chewable) Nora-BE (Tablet) 3 NoreC1 thind XulaC1 rone ne Norethindrone Xulane (Patch Weekly) 4 3

YuvaC1 (0.35mg Tablet) fem

Yuvafem (Tablet) 4 QL NoreC1 thind rone Acet ZaraC1 Norethindrone Acetate ate h 2 ¨ Zarah (Tablet) 4 (5mg Tablet) ZencC1 hent NorlC1 Zenchent (Tablet) 4 Norlyrocyroc (Tablet) 3 ZoviC1 a 1/35 ProgC1 ZoviaE 1/35E (Tablet) 4 ester Progesteroneone B1 2 ¨ Progestins (Capsule)

CamiC1 la SharC1 Camila (Tablet) 3 Sharobelobel (Tablet) 3

CrinC1 Crinoneone (Gel) 4 PA SelectiveB1 Receptor Modifying

DebliC1 Deblitanetane (Tablet) 3 Agents

DepC1 OspC1 o- hena Prov Depo-Proveraera Osphena (Tablet) 3 PA, QL

4 C1 Ralo xifen (Injection) e RaloxifeneHCl HCl (Tablet) 3 QL

ErrinC1 Errin (Tablet) 3 HormonalA1 Agents, Stimulant/Replacement/

IncaC1 Incassiassia (Tablet) 3 Modifying (Thyroid)

JolivC1 B1 Jolivetteette (Tablet) 3 Hormonal Agents, Stimulant/Replacement/

LyzaC1 Lyza (Tablet) 3 Modifying (Thyroid)

LevoC1 MedC1 thyro roxy xine prog Sodi ester Levothyroxine Sodium Medroxyprogesterone um one Acet ¨ ate 1 (Tablet) Acetate (10mg Tablet, ¨ 2 LevoC1 2.5mg Tablet, 5mg Levoxylxyl (Tablet) 3

LiothC1 Tablet) yroni ne LiothyronineSodi Sodium um 2 ¨ (Tablet)

SyntC1 Synthroidhroid (Tablet) 3

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 81 81 5380 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

UnitC1 A1 Unithroidhroid (Tablet) 3 Hormonal Agents, Suppressant (Thyroid) HormonalA1 Agents, Suppressant (Adrenal) AntithyroidB1 Agents

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

LysoC1 PropC1 dren ylthi oura Lysodren (Tablet) 5 Propylthiouracilcil 2 ¨ HormonalA1 Agents, Suppressant (Pituitary) (Tablet)

A1 HormonalB1 Agents, Suppressant (Pituitary) Immunological Agents

B1 CabC1 ergol Cabergolineine (Tablet) 3 Angioedema Agents

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

CinryC1 FirmC1 ze Firmagonagon (120mg Cinryze (Injection) 5 PA, LA

FirazC1 5 PA yr Injection) Firazyr (Injection) 5 PA, QL, LA

HaeC1 FirmC1 gard agon Firmagon (80mg aHaegarda (Injection) 5 PA, LA

4 PA RucC1 ones Injection) tRuconest (Injection) 5 PA, LA

C1 Leup B1 rolid e LeuprolideAcet Acetate ate 4 PA Immune Suppressants AzatC1 hiopr (Injection) Azathioprineine (Tablet) 2 B/D, PA ¨

LupaC1 neta C1 Pack Cimz Lupaneta Pack (Kit) 5 PA iaCimzia (Injection) 5 PA

LuprC1 on C1 Dep Cycl ot ospo Lupron Depot (1- Cyclosporinerine 5 PA 3 B/D, PA Month) (Injection) (Capsule)

LuprC1 on CyclC1 Dep ospo Lupronot Depot (3- rine CyclosporineModi Modified 5 PA fied Month) (Injection) (100mg Capsule,

LuprC1 on Dep Lupronot Depot (4- 25mg Capsule, 50mg 3 B/D, PA 5 PA Month) (Injection) Capsule, 100mg/ml

LuprC1 on Oral Solution) Dep Lupronot Depot (6- EnbrC1 5 PA el Month) (Injection) Enbrel (Injection) 5 PA EnbrC1 el OctrC1 Sure eotid EnbrelClick SureClick e OctreotideAcet Acetate ate 4 PA 5 PA (Injection) (Injection)

EnvaC1 SigniC1 rsus Signiforfor (Injection) 5 PA, LA EnvarsusXR XR (Tablet

SomC1 atuli Extended-Release 24 4 B/D, PA ne SomatulineDep Depot ot 5 (Injection) Hour) GenC1 graf SomC1 Somavertavert (Injection) 5 PA, QL, LA Gengraf (100mg

SynaC1 Capsule, 25mg Synarelrel (Nasal 3 B/D, PA 5 Capsule, 100mg/ml Solution) Oral Solution) TrelsC1 tar Mixj HumC1 Trelstarect Mixject ira 5 PA Humira (Injection) 5 PA (Injection)

Bold type = Brand name drug Plain type = Generic drug 82 tRACK 82 Last updated October 1, 2018 5481 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

HumC1 TacrC1 ira olim Pedi us Humiraatric Pediatric Tacrolimus (0.5mg Croh ns Dise ase Start er Capsule, 1mg Capsule, 3 B/D, PA CrohnsPack Disease 5 PA Starter Pack 5mg Capsule)

TrexC1 (Injection) Trexallall (Tablet) 4

C1 HumC1 Xatm ira ep HumiraPen Pen Xatmep (Oral 5 PA 4 PA (Injection) Solution)

C1 HumC1 Xelja ira nz Pen HumiraCroh Pen Crohns Xeljanz (Tablet) 5 PA, QL ns Dise ase Start XeljaC1 er nz DiseasePack Starter Pack 5 PA XeljanzXR XR (Tablet (Injection) Extended-Release 24 5 PA, QL

HumC1 ira Pen- HumiraPsori Pen-Psoriasis Hour) asis Start er 5 PA ZortrC1 Starter (Injection) Zortressess (Tablet) 5 B/D, PA

C1 Kine B1 Kineretret (Injection) 5 PA Immunizing Agents, Passive

C1 Meth C1 otrex BIVI Methotrexateate (Tablet) 2 ¨ BIVIGAMGAM (Injection) 5 PA

C1 Meth C1 otrex Cari ate mun Sodi e Methotrexate Sodium Nan um Carimune ofilte 4 red (Injection) Nanofiltered 5 PA

MycC1 ophe nolat Mycophenolatee Mofetil Mofe (Injection) til

FlebC1 oga (200mg/ml 5 B/D, PA mma Flebogamma DIF DIF 5 PA Suspension) (Injection) MycC1 ophe nolat GamC1 eMycophenolate Mofetil mag Mofe ard til GammagardLiqui Liquid d 5 PA (250mg Capsule, 3 B/D, PA (Injection)

500mg Tablet) C1 Gam mag ard MycC1 GammagardS/D S/D IGA ophe IGA nolic Less Acid Than Mycophenolic Acid DR 1 DR mcg Less/ml Than 1 mcg/ml (Tablet Delayed- 4 B/D, PA 5 PA Release) (Injection) GamC1 mak OrenC1 ed ciaOrencia (Injection) 5 PA Gammaked (Injection) 5 PA GamC1 mapl OrenC1 ex cia Gammaplex Click Orenciaject Clickject 5 PA 5 PA (Injection) (Injection) GamC1 unex RapC1 -C amu Gamunex-C Rapamunene (1mg/ml 5 B/D, PA 5 PA Oral Solution) (Injection) OctaC1 gam SanC1 dim Octagam (Injection) 5 PA mun eSandimmune PriviC1 (100mg/ml Oral 4 B/D, PA Privigengen (Injection) 5 PA

VarizC1 Solution) Varizigig (Injection) 3

B1 SimpC1 oniSimponi (Injection) 5 PA Immunomodulators

ActeC1 SiroliC1 Sirolimusmus (Tablet) 4 B/D, PA Actemramra (Injection) 5 PA

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 83 83 5582 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

ActiC1 MenC1 mmu actra Actimmunene (Injection) 5 LA Menactra (Injection) 3

ArcalC1 MenC1 Arcalystyst (Injection) 5 PA, LA Menveoveo (Injection) 3

BenlC1 PediC1 Benlystaysta (Injection) 5 PA Pediarixarix (Injection) 3

LefluC1 PedvC1 nomi ax Leflunomidede (Tablet) 2 ¨ PedvaxHIB HIB (Injection) 3

OtezlC1 ProQC1 aOtezla (Tablet ProQuaduad (Injection) 3

QuaC1 drac Therapy Pack, 30mg 5 PA, LA Quadracelel (Injection) 3

RabC1 Tablet) Rabavertavert (Injection) 3 B/D, PA RidaC1 ura RecC1 ombi Ridaura (Capsule) 5 vax RecombivaxHB HB

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

B1 RotaC1 Vaccines Rotarixrix (Suspension) 3

ActHC1 IB RotaC1 ActHIB (Injection) 3 RotaTeqTeq (Oral

AdaC1 3 Adacelcel (Injection) 3 Solution)

BCGC1 ShinC1 Vacc grix BCGine Vaccine Shingrix (Injection) 3 PA

3 C1 Teni (Injection) Tenivacvac (Injection) 3

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

Boostrix (Injection) 3 Toxoids-AdsorbedAdul 3 t

DaptC1 Daptacelacel (Injection) 3 Adult (Injection)

TruC1 DiphC1 men theri ba a/ Trumenba (Injection) Diphtheria/TetanusTeta 3 nus Toxo ids TwinC1 Adso rix rbed

ToxoidsPedi Adsorbed 3 Twinrix (Injection) 3 atric

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

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

GardC1 asil 9 VarivC1 Gardasil 9 (Injection) 3 Varivaxax (Injection) 3

HavriC1 x YF-C1 Havrix (Injection) 3 YF-VaxVax (Injection) 3

HibeC1 rix ZostC1 Hiberix (Injection) 3 Zostavaxavax (Injection) 4 PA

ImovC1 ax A1 Rabi Imovaxes Rabies 3 B/D, PA Inflammatory Bowel Disease Agents (H.D.C.V.) (Injection) AminosalicylatesB1 InfanC1 rix AprisC1 Infanrix (Injection) 3 Aprisoo (Capsule

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

IxiarC1 o BalsC1 alazi Ixiaro (Injection) de 3 BalsalazideDiso Disodium dium

KinriC1 4 Kinrixx (Injection) 3 (Capsule)

C1 C1 Can M-M- asa M-M-RR II II (Injection) 3 Canasa (Suppository) 5

Bold type = Brand name drug Plain type = Generic drug 84 tRACK 84 Last updated October 1, 2018 5683 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

DipeC1 AlenC1 ntum dron ate Dipentum (Capsule) 5 AlendronateSodi Sodium um

LialdC1 Lialdaa (Tablet (10mg Tablet, 35mg 3 QL Delayed-Release) Tablet, 40mg Tablet, 1 QL ¨

MesC1 5mg Tablet, 70mg alam Mesalamineine (Enema) 4 QL Tablet) MesC1 alam ine C1 DR Alen Mesalamine DR dron ate SodiAlendronate Sodium um (1.2gm Tablet Delayed- 3 QL (70mg/75ml Oral 4 Release) Solution) PentC1 asa BinoC1 Pentasa (Capsule Binostosto (Tablet 4 QL 4 QL Extended-Release) Effervescent) B1

CalciC1 Glucocorticoids tonin - Calcitonin-SalmonSalm on BudC1 eson ide 3 QL Budesonide (3mg (Nasal Solution)

CalciC1 Capsule Delayed- 4 Calcitrioltriol (0.25mcg Release) Capsule, 0.5mcg BudC1 eson ¨ ide 2 B/D, PA BudesonideER ER (Tablet Capsule, 1mcg/ml Oral Extended-Release 24 5 ST Solution)

DoxeC1 Hour) rcalc iferolDoxercalciferol ColoC1 cort 4 B/D, PA, QL Colocort (Enema) 4 (Capsule)

HydrC1 ocort EtidrC1 ison onat Hydrocortisonee e EtidronateDiso Disodium 4 dium 4 (100mg/60ml Enema) (Tablet)

ProcC1 to- FortC1 Med eo Procto-MedHC HC 2 ¨ Forteo (Injection) 5 PA, QL

IbanC1 (Cream) dron ate IbandronateSodi Sodium um ProcC1 to- Pak 3 QL Procto-Pak (Cream) 2 ¨ (Tablet)

ProcC1 tosol NatpC1 ProctosolHC HC (Cream) 2 ¨ Natparaara (Injection) 5 PA, LA

ProcC1 tozo ParicC1 ne- alcit HCProctozone-HC ol 2 ¨ Paricalcitol (Capsule) 4 B/D, PA

ProliC1 (Cream) Proliaa (Injection) 4 QL B1

RayaC1 Sulfonamides Rayaldeeldee (Capsule SulfaC1 salaz ine 5 QL Sulfasalazine (500mg Extended-Release)

Tablet Delayed- RiseC1 dron ¨ ate 2 RisedronateSodi Sodium Release, 500mg Tablet um (Tablet Immediate- 3 QL Immediate-Release)

A1 Release)

Metabolic Bone Disease Agents SensC1 ipar

B1 Sensipar (Tablet) 5 B/D, PA, QL

Metabolic Bone Disease Agents TymlC1 Tymlosos (Injection) 5 PA, QL

XgevC1 Xgevaa (Injection) 5 PA MiscellaneousA1 Therapeutic Agents

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 85 85 5784 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

B1 NeoC1 myci n/ Miscellaneous Therapeutic Agents Neomycin/Polymyxin/Poly myxi n/ Hydr ocort AlcoC1 hol ison e Prep Hydrocortisone (1% AlcoholPads Prep Pads 3 4

GauC1 ze Ophthalmic Gauze (Non-medicated 3 Suspension) 2X2) PolyC1 myxi n B InsulC1 Sulfa in Polymyxin B Sulfate/ te/ Syrin Trim Insulinges, Syringes, etho Nee prim dles Sulfa ¨ 3 Trimethoprimte Sulfate 2 Needles

A1 (Ophthalmic Solution)

Ophthalmic Agents PredC1 -G

B1 Pred-G (Suspension) 4

Ophthalmic Agents, Other PredC1 -G S.O. P. C1 Pred-G S.O.P. Atro pine Sulfa Atropinete Sulfate 4 3 (Ointment)

(Ophthalmic Solution) PropC1 arac aine HCl C1 Proparacaine HCl Bacit racin ¨ / 2 Bacitracin/PolymyxinPoly B myxi n B 2 ¨ (Ophthalmic Solution) (Ophthalmic Ointment) RestC1 asis

C1 Restasis (Emulsion) 3 QL Blep hami de Blephamide RhoC1 pres 4 Rhopressasa (Suspension) 3 ST

C1 (Ophthalmic Solution) Blep hami de BlephamideS.O. S.O.P. SulfaC1 P. ceta mide 4 Sulfacetamide Sodi um/ (Ointment) Pred nisol one Sodi C1 Sodium/Prednisolone Cyst um aran Phos ¨ phat 2 Cystaran (Ophthalmic e 5 LA Sodium Phosphate Solution) (Ophthalmic Solution)

LacriC1 sert TobrC1 Lacrisert (Insert) 4 Tobradexadex (0.3%-0.1%

LastC1 acaft 3 Lastacaft (Ophthalmic Ophthalmic Ointment) 3 TobrC1 adex Solution) Tobradex ST ST NeoC1 myci n/ Neomycin/Bacitracin/Bacit racin (Ophthalmic 4 / Poly 3 myxi Polymyxinn (Ointment) Suspension)

NeoC1 myci TobrC1 n/ amy Neomycin/Polymyxin/Poly cin/ myxi Tobramycin/Dexa n/ meth Bacit ason racin e / Bacitracin/Hydr ocort Dexamethasone ison e 3 3 Hydrocortisone (Ophthalmic (Ophthalmic Ointment) Suspension)

NeoC1 myci XiidrC1 n/ a Neomycin/Polymyxin/Poly myxi Xiidra (Ophthalmic n/ Dexa meth ason 4 QL Dexamethasonee (0.1% Solution)

Ophthalmic Ointment, 2 ¨ B1 Ophthalmic Anti-allergy Agents

0.1% Ophthalmic C1 Aloc Alocrilril (Ophthalmic Suspension) 4

NeoC1 myci Solution) n/ PolyNeomycin/Polymyxin/ myxi n/ AlomC1 Gra ide mici din Alomide (Ophthalmic Gramicidin 3 4 (Ophthalmic Solution) Solution)

Bold type = Brand name drug Plain type = Generic drug 86 tRACK 86 Last updated October 1, 2018 5885 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AzelC1 DorzC1 astin olam e ide AzelastineHCl HCl (0.05% DorzolamideHCl HCl 3 2 ¨ Ophthalmic Solution) (Ophthalmic Solution)

BeprC1 DorzC1 eve olam ide Bepreve (Ophthalmic DorzolamideHCl/ HCl/ Timo lol Male 4 ate Solution) Timolol Maleate 2 ¨

CroC1 moly (Ophthalmic Solution) n CromolynSodi Sodium (4% um ¨ LevoC1 2 buno lol LevobunololHCl HCl Ophthalmic Solution) 2 ¨ EpinC1 astin (Ophthalmic Solution) e HClEpinastine HCl MetiC1 3 pran Metipranolololol (Ophthalmic Solution) 2 ¨ OlopC1 atadi (Ophthalmic Solution) ne OlopatadineHCl HCl PhosC1 3 pholi ne PhospholineIodid Iodide (Ophthalmic Solution) e 4 PazeC1 Pazeoo (Ophthalmic (Ophthalmic Solution)

PilocC1 3 arpin e Solution) PilocarpineHCl HCl (1% OphthalmicB1 Antiglaucoma Agents Ophthalmic Solution,

AlphC1 2% Ophthalmic 3 agan Alphagan P P (0.1% 3 Solution, 4% Ophthalmic Solution) Ophthalmic Solution) ApraC1 cloni dine SimbC1 Apraclonidine Simbrinzarinza 3 3 (Ophthalmic Solution) (Suspension) AzopC1 t TimoC1 Azopt (Suspension) 3 lol Male Timololate Maleate BetaC1 xolol Betaxolol HCl HCl (0.5% 3 (0.25% Ophthalmic Ophthalmic Solution) Solution, 0.5% 2 ¨

BetiC1 Betimolmol (Ophthalmic Ophthalmic Solution) 4 Solution) (Generic Timoptic)

TimoC1 C1 Brim lol onidi Male ne ate Tartr Timolol Maleate Brimonidine Tartrate Opht ate halm ic Gel For (0.15% Ophthalmic 4 Ophthalmicming Gel 3 Solution) Forming (Solution)

B1

BrimC1 onidi ne Ophthalmic Anti-inflammatories BrimonidineTartr Tartrate ate DexaC1 meth ason ¨ Dexamethasonee (0.2% Ophthalmic 2 Sodi um Phos phat Solution) Sodiume Phosphate 2 ¨

CartC1 eolol CarteololHCl HCl (Ophthalmic Solution) ¨ DicloC1 2 fena c DiclofenacSodi Sodium (Ophthalmic Solution) um

ComC1 biga ¨ nCombigan (0.1% Ophthalmic 2 3 (Ophthalmic Solution) Solution) DureC1 zol CosC1 opt Durezol (Emulsion) 3 CosoptPF PF FlareC1 4 x (Ophthalmic Solution) Flarex (Suspension) 4

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 87 87 5986 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

FluorC1 ZioptC1 omet an holo Fluorometholonene Zioptan (Ophthalmic 4 (Ophthalmic 3 Solution) Suspension) OticA1 Agents FlurbC1 iprof en B1 FlurbiprofenSodi Sodium um 2 ¨ Otic Agents

(Ophthalmic Solution) AcetiC1 c Acid

C1 Acetic Acid (Otic FML 2 ¨ FML (Ointment) 4 Solution) FMLC1 Fort e CiprC1 FML Forte Ciproo HC HC 4 4 (Suspension) (Suspension) IlevrC1 o CiprC1 Ilevro (Suspension) 3 Ciprodexodex (Otic KetoC1 rolac 3

KetorolacTro meth Suspension) amin e

Coly-C1 Tromethamine 3 Myci Coly-Mycinn S S (Ophthalmic Solution) 4 (Suspension) LoteC1 max Lotemax (0.5% Gel, FluoC1 cinol one FluocinoloneAcet onid e 0.5% Ointment, 0.5% 4 Acetonide (0.01% Otic 4 Suspension) Oil) PredC1 Mild HydrC1 Pred Mild ocort ison Hydrocortisone/Acetice/ Aceti 4 c Acid 3 (Suspension) Acid (Otic Solution)

PredC1 nisol NeoC1 one myci PrednisoloneAcet Acetate n/ ate Neomycin/Polymyxin/Poly myxi n/ Hydr ocort (Ophthalmic 3 ison Hydrocortisonee (1% 3 Suspension) Otic Solution, 1% Otic

PredC1 nisol one PrednisoloneSodi Sodium Suspension) um Phos phat e Phosphate (1% 2 ¨ RespiratoryA1 Tract/Pulmonary Agents

Ophthalmic Solution) B1 Antihistamines ProleC1 nsa AzelC1 Prolensa (Ophthalmic astin e 4 AzelastineHCl HCl (0.1% Solution) Nasal Solution, 0.15% 3 OphthalmicB1 Prostaglandin and Prostamide Nasal Solution)

CetirC1 izine Analogs CetirizineHCl HCl (Oral LataC1 ¨ nopr 2 Latanoprostost 1 ¨ Solution) CyprC1 ohep (Ophthalmic Solution) tadin Cyproheptadinee HCl HCl LumiC1 ganLumigan (Ophthalmic (2mg/5ml Syrup, 4mg 4 3 Solution) Tablet)

C1 TravC1 Levo atan cetiri Z zine LevocetirizineDihy Travatan Z droc hlori 3 de (Ophthalmic Solution) Dihydrochloride (5mg 1 QL ¨

VyzuC1 Vyzultalta (Ophthalmic Tablet) 4 Solution)

Bold type = Brand name drug Plain type = Generic drug 88 tRACK 88 Last updated October 1, 2018 6087 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

PheC1 TriaC1 nado mcin z olon Phenadoz Triamcinolonee Acet onid 4 e (Suppository) Acetonide (55mcg/act 4

ProC1 meth azin Aerosol) Promethazinee HCl HCl

B1 (12.5mg Suppository, 4 Antileukotrienes

MontC1 eluk 25mg Suppository) ast MontelukastSodi Sodium um

C1 ¨ Pro 1 QL meth azin Promethazinee HCl (10mg Tablet) HCl

MontC1 eluk (12.5mg Tablet, 25mg ast SodiMontelukast Sodium 3 um Tablet, 50mg Tablet, (4mg Packet, 4mg 2 QL ¨ 6.25mg/5ml Syrup) Tablet Chewable, 5mg

ProC1 meth Prometheganegan (25mg Tablet Chewable) 4 ZafirlC1 ukas Suppository) tZafirlukast (Tablet) 3 QL

B1

ZileuC1 ton Anti-inflammatories, Inhaled Corticosteroids ZileutonER ER (Tablet

ArnuC1 ity Ellipt Arnuitya Ellipta Extended-Release 12 5 ST (100mcg/act Aerosol Hour) Powder, 200mcg/act ZyfloC1 (Tablet) 5 ST 3 QL Aerosol Powder, Bronchodilators,B1 Anticholinergic

AtroC1 50mcg/act Aerosol vent AtroventHFA HFA 4 Powder) (Aerosol Solution) BudC1 eson ide IncruC1 Budesonide (0.25mg/ se Ellipt Incrusea Ellipta 3 QL 2ml Suspension, (Aerosol Powder)

0.5mg/2ml 4 B/D, PA C1 Iprat ropiu m IpratropiumBro Bromide Suspension, 1mg/2ml mide ¨ Suspension) (0.02% Inhalation 2 B/D, PA

FlovC1 Solution) ent Disk us Flovent Diskus C1 Iprat ropiu m 3 QL BroIpratropium Bromide mide (Aerosol Powder) ¨ C1 (0.03% Nasal Solution, 2 Flov ent FloventHFA HFA (Aerosol) 3 QL 0.06% Nasal Solution) FluniC1 solid e SpiriC1 Flunisolide (Nasal va Han ¨ SpirivadiHal HandiHaler 1 er 3 QL Solution) (Capsule) FlutiC1 caso ne SpiriC1 Prop Fluticasone Propionate va ionat Res e Spirivapima Respimat (50mcg/act 2 ¨ t 3 QL (Aerosol Solution) Suspension) B1

MomC1 etas Bronchodilators, Sympathomimetic one FuroMometasone Furoate ate (50mcg/act 4 Suspension)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 89 89 6188 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

AlbuC1 KalyC1 terol deco Sulfa Albuterolte Sulfate Kalydeco (150mg (0.083% Nebulized Tablet, 50mg Packet, 5 PA, QL, LA Solution, 0.5% 75mg Packet)

¨ OrkaC1 Nebulized Solution, 2 B/D, PA mbiOrkambi (Tablet) 5 PA, QL, LA

0.63mg/3ml Nebulized TOBIC1 Pod halerTOBI Podhaler Solution, 1.25mg/3ml 5 PA, QL Nebulized Solution) (Capsule)

TobrC1

C1 amy Albu cin terol Sulfa Tobramycin (Nebulized teAlbuterol Sulfate (2mg 5 B/D, PA, QL Tablet Immediate- Solution) 4 B1 Release, 4mg Tablet Mast Cell Stabilizers

CroC1 moly Immediate-Release) n CromolynSodi Sodium um

EpinC1 ephri Epinephrinene (0.15mg/ (20mg/2ml Nebulized 3 B/D, PA 0.3ml Injection, 0.3mg/ Solution)

3 QL B1 0.3ml Injection) Phosphodiesterase Inhibitors, Airways (Generic EpiPen) Disease

EpiPC1 en DalirC1 EpiPen (Injection) 3 QL Dalirespesp (Tablet) 4 PA, QL

LevaC1 lbute rol TheoC1 phylli Levalbuterol Theophyllinene (Oral 4 B/D, PA 2 ¨ (Nebulized Solution) Solution)

MetaC1 prot eren TheoC1 ol phylli Metaproterenol Sulfate ne Sulfa te TheophyllineCR CR (10mg Tablet, 20mg 4 (Tablet Extended- 2 ¨ Tablet, 10mg/5ml Release 12 Hour)

Syrup) TheoC1 phylli ne ER C1 Theophylline ER Perf oro Perforomistmist 4 B/D, PA, QL (300mg Tablet (Nebulized Solution) Extended-Release 12

ProAC1 ir HFAProAir HFA (Aerosol Hour, 400mg Tablet 3 2 ¨ Solution) Extended-Release 24

ProAC1 ir Hour, 600mg Tablet Res ProAirpiCli RespiClick ck 3 (Aerosol Powder) Extended-Release 24

C1 Hour) Sere vent Disk Sereventus Diskus B1 3 QL Pulmonary Antihypertensives

(Aerosol Powder) C1 Adci rca B1 Adcirca (Tablet) 5 PA, QL

Cystic Fibrosis Agents C1 Ade mpa s BethC1 Adempas (Tablet) 5 PA, LA kis

Bethkis (Nebulized C1 Ops 5 B/D, PA, QL umit Solution) Opsumit (Tablet) 5 PA, LA OrenC1 itram CaysC1 tonCayston (Inhalation Orenitram (0.125mg 5 PA, LA Solution) Tablet Extended- 4 PA, LA Release)

Bold type = Brand name drug Plain type = Generic drug 90 tRACK 90 Last updated October 1, 2018 6289 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

OrenC1 ComC1 itram bive nt Orenitram (0.25mg CombiventRes Respimat pima t 3 Tablet Extended- (Aerosol Solution)

DuleC1 Release, 1mg Tablet Dulerara (Aerosol) 4 QL

DymiC1 Extended-Release, sta 5 PA, LA Dymista (Suspension) 4

FlutiC1 2.5mg Tablet caso ne FluticasoneProp ionat e/ Salm Extended-Release, etero Propionate/Salmeteroll 3 QL 5mg Tablet Extended- (Aerosol Powder)

IpratC1 Release) ropiu m IpratropiumBro Bromide/ mide SildeC1 / nafil Albu terol Sulfa ¨ Sildenafil (20mg Albuterolte Sulfate 1 B/D, PA Tablet) (Generic 3 PA, QL (Inhalation Solution)

NucC1 Revatio) alaNucala (Injection) 5 PA, QL, LA TraclC1 eer PulmC1 Tracleer (125mg ozy mePulmozyme Tablet, 62.5mg 5 B/D, PA, QL 5 PA, QL, LA (Inhalation Solution)

Tablet, 32mg Tablet StioltC1 o Res Stioltopima Respimat Soluble) t 3 QL (Aerosol Solution) VentC1 avis Ventavis (Inhalation SymC1 bicor 5 PA, QL, LA Symbicortt (Aerosol) 3 QL

Solution) C1 Trele gy Ellipt a B1 Trelegy Ellipta Pulmonary Fibrosis Agents 3 QL (Aerosol Powder) EsbriC1 et Esbriet (267mg A1 Skeletal Muscle Relaxants

Capsule, 267mg 5 PA, QL, LA B1 Tablet, 801mg Tablet) Skeletal Muscle Relaxants BaclC1 ofen OfevC1 (Capsule) Baclofen (10mg Tablet, 5 PA, QL, LA ¨ B1 20mg Tablet, 5mg 2 Respiratory Tract Agents, Other Tablet) AcetC1 ylcys teine ChloC1 Acetylcysteine rzox azon ¨ Chlorzoxazonee (500mg 2 B/D, PA 3 (Inhalation Solution) Tablet) AdvaC1 ir Disk CyclC1 usAdvair Diskus oben zapri Cyclobenzaprinene HCl 3 QL HCl (Aerosol Powder) (10mg Tablet, 5mg 2 ¨

AdvaC1 ir AdvairHFA HFA (Aerosol) 3 QL Tablet)

AnorC1 CyclC1 o oben Ellipt zapri Anoroa Ellipta (Aerosol Cyclobenzaprinene HCl 3 QL HCl 4 Powder) (7.5mg Tablet)

DantC1 BeveC1 spi rolen Aero e Sodi sphe Dantrolene Sodium Bevespi Aerosphere um re 3 QL 4 (Aerosol) (Capsule)

TizaC1 BreoC1 nidin Ellipt e Breoa Ellipta (Aerosol TizanidineHCl HCl (2mg 3 QL 2 ¨ Powder) Tablet, 4mg Tablet)

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your Evidence of Coverage for more information. You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK October 1, 2018 91 91 6390 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

SleepA1 Disorder Agents SleepB1 Disorders, Other

B1 BelsC1 GABA Receptor Modulators Belsomraomra (Tablet) 3 QL

TemC1 HetliC1 azep oz Temazepamam (15mg Hetlioz (Capsule) 5 PA, QL, LA

ModC1 Capsule, 30mg 2 QL ¨ afinilModafinil (Tablet) 4 PA, QL

RozeC1 Capsule) rem Rozerem (Tablet) 4 QL ZaleC1 plon

XyreC1 Zaleplon (Capsule) 3 QL m Xyrem (Oral Solution) 5 PA, QL, LA ZolpiC1 dem Tartr Zolpidemate Tartrate (10mg Tablet Immediate-Release, 2 QL ¨ 5mg Tablet Immediate- Release)

Bold type = Brand name drug Plain type = Generic drug 92 92 1 1 track Covered drugs with a quantity limit (QL) This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety. Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover. Drugs are listed in alphabetical order in the chart below. track

Drug Name Quantity Limit Abacavir (20mg/ml Oral Solution) Maximum of 48 ml per day Abacavir (300mg Tablet) Maximum of 3 tablets per day Abacavir Sulfate/Lamivudine/Zidovudine Maximum of 3 tablets per day (Tablet) Abacavir/Lamivudine (Tablet) Maximum of 2 tablets per day Abstral (Tablet Sublingual) Maximum of 4 tablets per day Acarbose (100mg Tablet) Maximum of 3 tablets per day Acarbose (25mg Tablet) Maximum of 12 tablets per day Acarbose (50mg Tablet) Maximum of 6 tablets per day Acetaminophen/Codeine (120mg-12mg/5ml Maximum of 150 ml per day Oral Solution) Acetaminophen/Codeine (300mg-15mg Tablet, Maximum of 13 tablets per day 300mg-30mg Tablet, 300mg-60mg Tablet) Acyclovir (5% Ointment) Maximum of 1 tube (30 grams) per 30 days Adcirca (Tablet) Maximum of 2 tablets per day Advair Diskus (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Advair HFA (Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Afeditab CR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day Albenza (Tablet) Maximum of 16 tablets per day Alecensa (Capsule) Maximum of 8 capsules per day Alendronate Sodium (10mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 5mg Tablet) Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days Alprazolam (0.25mg Tablet Immediate-Release, Maximum of 4 tablets per day 0.5mg Tablet Immediate-Release) Alprazolam (1mg Tablet Immediate-Release) Maximum of 4 tablets per day Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day Alunbrig (180mg Tablet, 90mg Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last93 updated October 1, 2018 2 2 93 Drug Name Quantity Limit Alunbrig (30mg Tablet) Maximum of 4 tablets per day Alunbrig (Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days Amitiza (Capsule) Maximum of 2 capsules per day Amlodipine Besylate/Atorvastatin Calcium Maximum of 1 tablet per day (Tablet) Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day Amlodipine/Olmesartan Medoxomil (Tablet) Maximum of 1 tablet per day Amlodipine/Valsartan/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Amphetamine/Dextroamphetamine (10mg Capsule Extended-Release 24 Hour, 15mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 25mg Maximum of 2 capsules per day Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour) Amphetamine/Dextroamphetamine (10mg Tablet Immediate-Release, 12.5mg Tablet Immediate-Release, 15mg Tablet Immediate- Maximum of 2 tablets per day Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Amphetamine/Dextroamphetamine (20mg Maximum of 3 tablets per day Tablet Immediate-Release) Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Androderm (Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Apokyn (Injection) Maximum of 3 ml per day Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day Aptiom (200mg Tablet, 400mg Tablet) Maximum of 1 tablet per day Aptiom (600mg Tablet, 800mg Tablet) Maximum of 2 tablets per day Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day Aptivus (250mg Capsule) Maximum of 6 capsules per day Aripiprazole (10mg Tablet, 15mg Tablet, 20mg Maximum of 1 tablet per day Tablet, 2mg Tablet, 30mg Tablet, 5mg Tablet) Aripiprazole (1mg/ml Oral Solution) Maximum of 25 ml per day Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 94 94 3 3 Last updated October 1, 2018 Drug Name Quantity Limit Arnuity Ellipta (100mcg/act Aerosol Powder, Maximum of 1 inhaler (30 blisters) per 30 days 200mcg/act Aerosol Powder) Arnuity Ellipta (50mcg/act Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Aspirin/Dipyridamole (Capsule Extended- Maximum of 2 capsules per day Release 12 Hour) Atazanavir Sulfate (150mg Capsule, 300mg Maximum of 2 capsules per day Capsule) Atazanavir Sulfate (200mg Capsule) Maximum of 3 capsules per day Atomoxetine (100mg Capsule, 60mg Capsule, Maximum of 1 capsule per day 80mg Capsule) Atomoxetine (10mg Capsule, 18mg Capsule, Maximum of 2 capsules per day 25mg Capsule, 40mg Capsule) Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day Atripla (Tablet) Maximum of 2 tablets per day Aubagio (Tablet) Maximum of 1 tablet per day Austedo (Tablet) Maximum of 4 tablets per day Avandia (2mg Tablet) Maximum of 4 tablets per day Avandia (4mg Tablet) Maximum of 2 tablets per day Belsomra (Tablet) Maximum of 1 tablet per day Benazepril HCl (Tablet) Maximum of 2 tablets per day Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Bethkis (Nebulized Solution) Maximum of 8 ml (2 ampules) per day Bevespi Aerosphere (Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days BiDil (Tablet) Maximum of 6 tablets per day Biktarvy (Tablet) Maximum of 2 tablets per day Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days Bisoprolol Fumarate/Hydrochlorothiazide Maximum of 2 tablets per day (Tablet) Bosulif (100mg Tablet) Maximum of 6 tablets per day Bosulif (400mg Tablet, 500mg Tablet) Maximum of 1 tablet per day Breo Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Brilinta (Tablet) Maximum of 2 tablets per day Briviact (100mg Tablet, 10mg Tablet, 25mg Maximum of 2 tablets per day Tablet, 50mg Tablet, 75mg Tablet) Briviact (10mg/ml Oral Solution) Maximum of 20 ml per day Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day Buprenorphine HCl/Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual)

Bold type = Brand name drug Plain type = Generic drug Last95 updated October 1, 2018 4 4 95 Drug Name Quantity Limit Butalbital/Acetaminophen/Caffeine (Tablet) Maximum of 6 tablets per day Butalbital/Aspirin/Caffeine (Capsule) Maximum of 6 capsules per day Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Bydureon Bcise (Auto injector) Maximum of 4 pens (3.4 ml) per 28 days Bydureon Pen (Injection) Maximum of 4 pens per 28 days Bydureon Vial (Injection) Maximum of 4 vials per 28 days Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days Bystolic (10mg Tablet, 2.5mg Tablet, 5mg Maximum of 1 tablet per day Tablet) Bystolic (20mg Tablet) Maximum of 2 tablets per day Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day Cabometyx (40mg Tablet) Maximum of 2 tablets per day Calcitonin-Salmon (Nasal Solution) Maximum of 1 bottle per 28 days Calquence (Capsule) Maximum of 2 capsules per day Candesartan Cilexetil (16mg Tablet, 32mg Maximum of 1 tablet per day Tablet, 4mg Tablet) Candesartan Cilexetil (8mg Tablet) Maximum of 3 tablets per day Candesartan Cilexetil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Captopril (100mg Tablet) Maximum of 4 tablets per day Captopril (12.5mg Tablet, 25mg Tablet) Maximum of 3 tablets per day Captopril (50mg Tablet) Maximum of 9 tablets per day Captopril/Hydrochlorothiazide (25mg-15mg Maximum of 3 tablets per day Tablet, 50mg-15mg Tablet) Captopril/Hydrochlorothiazide (25mg-25mg Maximum of 2 tablets per day Tablet, 50mg-25mg Tablet) Celecoxib (Capsule) Maximum of 2 capsules per day Cimduo (Tablet) Maximum of 2 tablets per day Clonazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Clonazepam (2mg Tablet) Maximum of 10 tablets per day Clonazepam ODT (0.125mg Tablet Dispersible, 0.25mg Tablet Dispersible, 0.5mg Tablet Maximum of 4 tablets per day Dispersible, 1mg Tablet Dispersible) Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel (75mg Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day

Bold type = Brand name drug Plain type = Generic drug 96 96 5 5 Last updated October 1, 2018 Drug Name Quantity Limit Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (Tablet) Maximum of 6 tablets per day Colchicine (0.6mg Capsule) (Generic Maximum of 4 capsules per day Mitigare) Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day Colcrys (Tablet) Maximum of 4 tablets per day Complera (Tablet) Maximum of 2 tablets per day Corlanor (Tablet) Maximum of 2 tablets per day Cotellic (Tablet) Maximum of 3 tablets per day Crixivan (Capsule) Maximum of 9 capsules per day Cycloset (Tablet) Maximum of 6 tablets per day Daklinza (Tablet) Maximum of 1 tablet per day Daliresp (Tablet) Maximum of 1 tablet per day Denavir (Cream) Maximum of 1 tube (5 grams) per 30 days Descovy (Tablet) Maximum of 2 tablets per day Desvenlafaxine ER (100mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) Desvenlafaxine ER (25mg Tablet Extended- Release 24 Hour, 50mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Dexilant (Capsule Delayed-Release) Maximum of 1 capsule per day Dexmethylphenidate HCl (Tablet Immediate- Maximum of 2 tablets per day Release) Dextroamphetamine Sulfate (10mg Tablet, 5mg Maximum of 6 tablets per day Tablet) Dextroamphetamine Sulfate ER (10mg Capsule Maximum of 6 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (15mg Capsule Maximum of 4 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (5mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) Diazepam (10mg Tablet, 2mg Tablet, 5mg Maximum of 4 tablets per day Tablet) Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day

Bold type = Brand name drug Plain type = Generic drug Last97 updated October 1, 2018 6 6 97 Drug Name Quantity Limit Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day Donepezil HCl (10mg Tablet) Maximum of 2 tablets per day Donepezil HCl (23mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day Doxepin HCl (Cream) Maximum of 90 grams per 30 days Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day Doxercalciferol (1mcg Capsule, 2.5mcg Maximum of 4 capsules per day Capsule) Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Duloxetine HCl (20mg Capsule Delayed- Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day Capsule Delayed-Release) Dutasteride (Capsule) Maximum of 1 capsule per day Edarbi (Tablet) Maximum of 1 tablet per day Edarbyclor (Tablet) Maximum of 1 tablet per day Edurant (Tablet) Maximum of 2 tablets per day Efavirenz (200mg Capsule) Maximum of 3 capsules per day Efavirenz (50mg Capsule) Maximum of 9 capsules per day Efavirenz (600mg Tablet) Maximum of 2 tablets per day Eliquis (Tablet) Maximum of 2 tablets per day Eliquis Starter Pack (Tablet) Maximum of 1 pack (74 tablets) per 30 days Embeda (100mg-4mg Capsule Extended- Maximum of 3 capsules per day Release) Embeda (20mg-0.8mg Capsule Extended- Release, 80mg-3.2mg Capsule Extended- Maximum of 4 capsules per day Release) Embeda (30mg-1.2mg Capsule Extended- Release, 50mg-2mg Capsule Extended- Maximum of 2 capsules per day Release) Embeda (60mg-2.4mg Capsule Extended- Maximum of 6 capsules per day Release) Emsam (Patch 24 Hour) Maximum of 1 patch per day Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day Emtriva (200mg Capsule) Maximum of 2 capsules per day Enalapril Maleate (Tablet) Maximum of 2 tablets per day Enalapril Maleate/Hydrochlorothiazide Maximum of 2 tablets per day (10mg-25mg Tablet)

Bold type = Brand name drug Plain type = Generic drug 98 98 7 7 Last updated October 1, 2018 Drug Name Quantity Limit Enalapril Maleate/Hydrochlorothiazide Maximum of 1 tablet per day (5mg-12.5mg Tablet) Endocet (Tablet) Maximum of 12 tablets per day Enoxaparin Sodium (100mg/ml Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150mg/ml Subcutaneous Solution) Enoxaparin Sodium (120mg/0.8ml Subcutaneous Solution, 80mg/0.8ml Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (30mg/0.3ml Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (40mg/0.4ml Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60mg/0.6ml Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution) Entresto (Tablet) Maximum of 2 tablets per day Epclusa (Tablet) Maximum of 1 tablet per day Epinephrine (Injection) (Generic EpiPen) Maximum of 4 pens (2 boxes) per 30 days EpiPen (Injection) Maximum of 4 pens (2 boxes) per 30 days Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day Erivedge (Capsule) Maximum of 1 capsule per day Erleada (Tablet) Maximum of 4 tablets per day Esbriet (267mg Capsule) Maximum of 9 capsules per day Esbriet (267mg Tablet) Maximum of 9 tablets per day Esbriet (801mg Tablet) Maximum of 3 tablets per day Esomeprazole Magnesium (20mg Capsule Maximum of 3 capsules per day Delayed-Release) (Generic Nexium) Esomeprazole Magnesium (40mg Capsule Maximum of 2 capsules per day Delayed-Release) (Generic Nexium) Estradiol (0.025mg/24hr Patch Weekly, 0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch Weekly, 0.075mg/24hr Patch Weekly, 0.1mg/ Maximum of 4 patches per 28 days 24hr Patch Weekly, 37.5mcg/24hr Patch Weekly) Estradiol (10mcg Tablet) Maximum of 1 tablet per day Evotaz (Tablet) Maximum of 2 tablets per day Ezetimibe (Tablet) Maximum of 1 tablet per day Ezetimibe/Simvastatin (Tablet) Maximum of 1 tablet per day Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Famciclovir (500mg Tablet) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last99 updated October 1, 2018 8 8 99 Drug Name Quantity Limit Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Hour, Maximum of 15 patches per 30 days 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour) Fentanyl Citrate Oral Transmucosal (Lozenge Maximum of 4 lozenges per day on a Handle) Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Firazyr (Injection) Maximum of 9 ml per day Flector (Patch) Maximum of 2 patches per day Maximum of 2 inhalers (120 blisters) per 30 Flovent Diskus (Aerosol Powder) days Flovent HFA (110mcg/act Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Flovent HFA (220mcg/act Aerosol) Maximum of 2 inhalers (24 grams) per 30 days Flovent HFA (44mcg/act Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days Fluticasone Propionate/Salmeterol (Aerosol Maximum of 1 inhaler per 30 days Powder) Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day Forteo (Injection) Maximum of 1 pen (2.4 ml) per 28 days Fosamprenavir Calcium (Tablet) Maximum of 6 tablets per day Fosinopril Sodium (Tablet) Maximum of 2 tablets per day Fosinopril Sodium/Hydrochlorothiazide (Tablet) Maximum of 4 tablets per day Fuzeon (Injection) Maximum of 3 vials per day Galantamine HBr (12mg Tablet, 4mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days Galantamine HBr ER (Capsule Extended- Maximum of 1 capsule per day Release 24 Hour) Genvoya (Tablet) Maximum of 2 tablets per day Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days Glimepiride (1mg Tablet) Maximum of 8 tablets per day Glimepiride (2mg Tablet) Maximum of 4 tablets per day Glimepiride (4mg Tablet) Maximum of 2 tablets per day Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day

Bold type = Brand name drug Plain type = Generic drug 100100 9 9 Last updated October 1, 2018 Drug Name Quantity Limit Glipizide ER (10mg Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Glipizide ER (2.5mg Tablet Extended-Release Maximum of 8 tablets per day 24 Hour) Glipizide ER (5mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day Glipizide/Metformin HCl (2.5mg-500mg Tablet, Maximum of 4 tablets per day 5mg-500mg Tablet) Glyxambi (Tablet) Maximum of 1 tablet per day Granisetron HCl (Tablet) Maximum of 2 tablets per day Harvoni (Tablet) Maximum of 1 tablet per day Hetlioz (Capsule) Maximum of 1 capsule per day Hydrocodone Bitartrate/Acetaminophen Maximum of 12 tablets per day (2.5mg-325mg Tablet) Hydrocodone Bitartrate/Acetaminophen Maximum of 180 ml per day (7.5mg-325mg/15ml Oral Solution) Hydrocodone/Acetaminophen (Tablet) Maximum of 12 tablets per day Hydrocodone/Ibuprofen (7.5mg-200mg Tablet) Maximum of 5 tablets per day Hydromorphone HCl (1mg/ml Liquid) Maximum of 50 ml per day Hydromorphone HCl (2mg Tablet Immediate- Maximum of 8 tablets per day Release, 4mg Tablet Immediate-Release) Hydromorphone HCl (8mg Tablet Immediate- Maximum of 6 tablets per day Release) Hydromorphone HCl ER (Tablet Extended- Maximum of 2 tablets per day Release 24 Hour Abuse-Deterrent) Hysingla ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour Abuse-Deterrent) Ibandronate Sodium (Tablet) Maximum of 1 tablet per 28 days Ibrance (Capsule) Maximum of 1 capsule per day Iclusig (15mg Tablet) Maximum of 2 tablets per day Iclusig (45mg Tablet) Maximum of 1 tablet per day Idhifa (Tablet) Maximum of 1 tablet per day Imatinib Mesylate (Tablet) Maximum of 3 tablets per day Imbruvica (140mg Capsule) Maximum of 4 capsules per day Imbruvica (140mg Tablet, 280mg Tablet, Maximum of 1 tablet per day 420mg Tablet, 560mg Tablet) Imbruvica (70mg Capsule) Maximum of 1 capsule per day Incruse Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days

Bold type = Brand name drug Plain type = Generic drug Last101 updated October 1, 2018 10 10 101 Drug Name Quantity Limit Ingrezza (Capsule) Maximum of 1 capsule per day Inlyta (Tablet) Maximum of 4 tablets per day Intelence (100mg Tablet) Maximum of 2 tablets per day Intelence (200mg Tablet) Maximum of 3 tablets per day Intelence (25mg Tablet) Maximum of 6 tablets per day Invirase (200mg Capsule) Maximum of 15 capsules per day Invirase (500mg Tablet) Maximum of 6 tablets per day Invokamet (Tablet) Maximum of 2 tablets per day Invokamet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Invokana (Tablet) Maximum of 1 tablet per day Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Irbesartan (75mg Tablet) Maximum of 3 tablets per day Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Iressa (Tablet) Maximum of 2 tablets per day Isentress (100mg Packet) Maximum of 4 packets per day Isentress (100mg Tablet Chewable, 25mg Maximum of 9 tablets per day Tablet Chewable) Isentress (400mg Tablet) Maximum of 6 tablets per day Isentress HD (Tablet) Maximum of 3 tablets per day Itraconazole (Capsule) Maximum of 4 capsules per day Jakafi (Tablet) Maximum of 2 tablets per day Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day Janumet XR (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Januvia (Tablet) Maximum of 1 tablet per day Jardiance (Tablet) Maximum of 1 tablet per day Jentadueto (Tablet) Maximum of 2 tablets per day Jentadueto XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Jentadueto XR (5mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Juluca (Tablet) Maximum of 2 tablets per day Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day Kalydeco (150mg Tablet) Maximum of 2 tablets per day Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day Kisqali (Tablet) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug 102102 11 11 Last updated October 1, 2018 Drug Name Quantity Limit Kisqali Femara 200 Dose (Tablet Therapy Maximum of 1 pack (91 tablets) per 28 days Pack) Kisqali Femara 400 Dose (Tablet Therapy Maximum of 1 pack (91 tablets) per 28 days Pack) Kisqali Femara 600 Dose (Tablet Therapy Maximum of 1 pack (91 tablets) per 28 days Pack) Kombiglyze XR (2.5mg-1000mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Kombiglyze XR (5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-500mg Maximum of 1 tablet per day Tablet Extended-Release 24 Hour) Korlym (Tablet) Maximum of 4 tablets per day Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day Lamivudine (150mg Tablet) Maximum of 3 tablets per day Lamivudine (300mg Tablet) Maximum of 2 tablets per day Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day Lansoprazole (15mg Capsule Delayed-Release, Maximum of 2 capsules per day 30mg Capsule Delayed-Release) Latuda (120mg Tablet, 20mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 60mg Tablet) Latuda (80mg Tablet) Maximum of 2 tablets per day Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day Lexiva (Suspension) Maximum of 90 ml per day Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day Lidocaine (5% Ointment) Maximum of 150 grams per 30 days Lidocaine (5% Patch) Maximum of 3 patches per day Linezolid (600mg Tablet) Maximum of 2 tablets per day Linzess (Capsule) Maximum of 1 capsule per day Lisinopril (Tablet) Maximum of 2 tablets per day Lisinopril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-12.5mg Maximum of 4 tablets per day Tablet) Lisinopril/Hydrochlorothiazide (20mg-25mg Maximum of 2 tablets per day Tablet) Livalo (Tablet) Maximum of 1 tablet per day Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last103 updated October 1, 2018 12 12 103 Drug Name Quantity Limit Lopinavir/Ritonavir (Oral Solution) Maximum of 16 ml per day Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Lorazepam (2mg Tablet) Maximum of 5 tablets per day Lorazepam (2mg/ml Concentrate) Maximum of 5 ml per day Lorcet (Tablet) Maximum of 12 tablets per day Lorcet HD (Tablet) Maximum of 12 tablets per day Lorcet Plus (Tablet) Maximum of 12 tablets per day Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day Losartan Potassium (25mg Tablet, 50mg Maximum of 2 tablets per day Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 1 tablet per day (100mg-12.5mg Tablet, 100mg-25mg Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 2 tablets per day (50mg-12.5mg Tablet) Lovastatin (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day Lovastatin (40mg Tablet) Maximum of 2 tablets per day Lynparza (100mg Tablet, 150mg Tablet) Maximum of 4 tablets per day Lynparza (50mg Capsule) Maximum of 16 capsules per day Lyrica (100mg Capsule, 150mg Capsule, 200mg Capsule, 25mg Capsule, 50mg Maximum of 3 capsules per day Capsule, 75mg Capsule) Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Mavyret (Tablet) Maximum of 3 tablets per day Memantine HCl (10mg Tablet) Maximum of 2 tablets per day Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day Memantine HCl (5mg Tablet) Maximum of 3 tablets per day Memantine HCl ER (Capsule Extended-Release Maximum of 1 capsule per day 24 Hour) Mesalamine (Enema) Maximum of 1 bottle (60 ml) per day Mesalamine DR (1.2GM Tablet Delayed- Maximum of 4 tablets per day Release) Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day Metformin HCl (1000mg Tablet Immediate- Maximum of 2.5 tablets per day Release) Metformin HCl (850mg Tablet Immediate- Maximum of 3 tablets per day Release) Metformin HCl (500mg Tablet Immediate- Maximum of 5 tablets per day Release)

Bold type = Brand name drug Plain type = Generic drug 104104 13 13 Last updated October 1, 2018 Drug Name Quantity Limit Metformin HCl ER (500mg Tablet Extended- Maximum of 4 tablets per day Release 24 Hour) (Generic Glucophage XR) Metformin HCl ER (750mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour) (Generic Glucophage XR) Methadone HCl (10mg Tablet) Maximum of 12 tablets per day Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day Methadone HCl (5mg Tablet) Maximum of 8 tablets per day Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day Methylphenidate HCl (10mg Tablet Immediate- Maximum of 3 tablets per day Release) (Generic Ritalin) Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylphenidate HCl (20mg Tablet Immediate- Release, 5mg Tablet Immediate-Release) Maximum of 3 tablets per day (Generic Ritalin) Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day Methylphenidate HCl ER (10mg Tablet Maximum of 4 tablets per day Extended-Release) Methylphenidate HCl ER (20mg Tablet Maximum of 3 tablets per day Extended-Release) Miglitol (100mg Tablet) Maximum of 3 tablets per day Miglitol (25mg Tablet) Maximum of 12 tablets per day Miglitol (50mg Tablet) Maximum of 6 tablets per day Modafinil (100mg Tablet) Maximum of 1 tablet per day Modafinil (200mg Tablet) Maximum of 2 tablets per day Moexipril HCl (Tablet) Maximum of 2 tablets per day Moexipril/Hydrochlorothiazide (15mg-12.5mg Maximum of 2 tablets per day Tablet, 15mg-25mg Tablet) Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Maximum of 1 tablet per day Tablet) Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day Montelukast Sodium (4mg Packet) Maximum of 1 packet per day Montelukast Sodium (4mg Tablet Chewable, Maximum of 1 tablet per day 5mg Tablet Chewable) Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 10 ml per day Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 100 ml per day Morphine Sulfate (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 50 ml per day

Bold type = Brand name drug Plain type = Generic drug Last105 updated October 1, 2018 14 14 105 Drug Name Quantity Limit Morphine Sulfate (30mg Tablet Immediate- Maximum of 6 tablets per day Release) Morphine Sulfate ER (100mg Tablet Extended- Release, 15mg Tablet Extended-Release) Maximum of 3 tablets per day (Generic MS Contin) Morphine Sulfate ER (200mg Tablet Extended- Maximum of 2 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (30mg Tablet Extended- Release, 60mg Tablet Extended-Release) Maximum of 4 tablets per day (Generic MS Contin) Multaq (Tablet) Maximum of 2 tablets per day Namzaric (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Namzaric (Therapy Pack, Capsule Extended- Maximum of 1 capsule per day Release 24 Hour) Naratriptan HCl (Tablet) Maximum of 12 tablets per 30 days Nateglinide (120mg Tablet) Maximum of 3 tablets per day Nateglinide (60mg Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution) Maximum of 300 mg (1 vial) in 28 days Nerlynx (Tablet) Maximum of 6 tablets per day Nevirapine (Tablet) Maximum of 3 tablets per day Nevirapine ER (100mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Nevirapine ER (400mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Nifedipine ER (Tablet Extended-Release 24 Maximum of 2 tablets per day Hour) Ninlaro (Capsule) Maximum of 3 capsules per 28 days Northera (100mg Capsule) Maximum of 3 capsules per day Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day Norvir (100mg Capsule) Maximum of 18 capsules per day Norvir (100mg Packet) Maximum of 18 packets per day Norvir (100mg Tablet) Maximum of 18 tablets per day Norvir (80mg/ml Oral Solution) Maximum of 24 ml per day Noxafil (100mg Tablet Delayed-Release) Maximum of 8 tablets per day Noxafil (40mg/ml Suspension) Maximum of 20 ml per day Nucala (Injection) Maximum of 3 vials per 28 days

Bold type = Brand name drug Plain type = Generic drug 106106 15 15 Last updated October 1, 2018 Drug Name Quantity Limit Nucynta ER (Tablet Extended-Release 12 Maximum of 2 tablets per day Hour) Nuplazid (Tablet) Maximum of 2 tablets per day Ocaliva (Tablet) Maximum of 1 tablet per day Odefsey (Tablet) Maximum of 2 tablets per day Odomzo (Capsule) Maximum of 1 capsule per day Ofev (Capsule) Maximum of 2 capsules per day Olanzapine (10mg Tablet, 15mg Tablet, 2.5mg Maximum of 1 tablet per day Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Tablet) Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day Olmesartan Medoxomil (20mg Tablet, 40mg Maximum of 1 tablet per day Tablet) Olmesartan Medoxomil (5mg Tablet) Maximum of 2 tablets per day Olmesartan Medoxomil/Amlodipine/ Maximum of 1 tablet per day Hydrochlorothiazide (Tablet) Olmesartan Medoxomil/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Omega-3-Acid Ethyl Esters (Capsule) (Generic Maximum of 4 capsules per day Lovaza) Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day Onglyza (Tablet) Maximum of 1 tablet per day Orkambi (Tablet) Maximum of 112 tablets per 28 days Oseltamivir Phosphate (30mg Capsule, 45mg Maximum of 2 capsules per day Capsule, 75mg Capsule) Oseltamivir Phosphate (6mg/ml Suspension) Maximum of 26 ml per day Osphena (Tablet) Maximum of 1 tablet per day Oxandrolone (10mg Tablet) Maximum of 2 tablets per day Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10mg Tablet Maximum of 3 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (15mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (5mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Oxycodone HCl (100mg/5ml Concentrate) Maximum of 6 ml per day Oxycodone HCl (10mg Tablet Immediate- Maximum of 12 tablets per day Release)

Bold type = Brand name drug Plain type = Generic drug Last107 updated October 1, 2018 16 16 107 Drug Name Quantity Limit Oxycodone HCl (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Oxycodone HCl (20mg Tablet Immediate- Maximum of 6 tablets per day Release) Oxycodone HCl (30mg Tablet Immediate- Maximum of 6 tablets per day Release) Oxycodone HCl (5mg Tablet Immediate- Maximum of 12 tablets per day Release) Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 130 ml per day Oxycodone/Acetaminophen (Tablet) Maximum of 12 tablets per day Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day Paliperidone ER (1.5mg Tablet Extended- Release 24 Hour, 3mg Tablet Extended-Release Maximum of 1 tablet per day 24 Hour, 9mg Tablet Extended-Release 24 Hour) Paliperidone ER (6mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Pantoprazole Sodium (20mg Tablet Delayed- Maximum of 3 tablets per day Release) Pantoprazole Sodium (40mg Tablet Delayed- Maximum of 2 tablets per day Release) Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day Perindopril Erbumine (Tablet) Maximum of 2 tablets per day Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Glimepiride (Tablet) Maximum of 1 tablet per day Pioglitazone HCl/Metformin HCl (Tablet) Maximum of 3 tablets per day Pomalyst (Capsule) Maximum of 1 capsule per day Pradaxa (Capsule) Maximum of 2 capsules per day Praluent (150mg/ml Solution Pen injector, Maximum of 2 pens (2 ml) per 28 days 75mg/ml Solution Pen injector) Prasugrel (Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Tablet) Maximum of 1 tablet per day Premarin (0.3mg Tablet, 0.45mg Tablet, 0.625mg Tablet, 0.9mg Tablet, 1.25mg Maximum of 1 tablet per day Tablet)

Bold type = Brand name drug Plain type = Generic drug 108108 17 17 Last updated October 1, 2018 Drug Name Quantity Limit Premphase (Tablet) Maximum of 1 tablet per day Prempro (Tablet) Maximum of 1 tablet per day Prezcobix (Tablet) Maximum of 2 tablets per day Prezista (100mg/ml Suspension) Maximum of 60 ml per day Prezista (150mg Tablet) Maximum of 6 tablets per day Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day Prezista (75mg Tablet) Maximum of 7 tablets per day Prolia (Injection) Maximum of 1 syringe every 180 days Promacta (12.5mg Tablet, 25mg Tablet) Maximum of 1 tablet per day Promacta (50mg Tablet, 75mg Tablet) Maximum of 2 tablets per day Prudoxin (Cream) Maximum of 90 grams per 30 days Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day Quetiapine Fumarate (100mg Tablet Immediate- Release, 200mg Tablet Immediate-Release, Maximum of 3 tablets per day 50mg Tablet Immediate-Release) Quetiapine Fumarate (25mg Tablet Immediate- Maximum of 4 tablets per day Release) Quetiapine Fumarate (300mg Tablet Immediate- Maximum of 2 tablets per day Release, 400mg Tablet Immediate-Release) Quetiapine Fumarate ER (150mg Tablet Extended-Release 24 Hour, 200mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Quetiapine Fumarate ER (300mg Tablet Extended-Release 24 Hour, 400mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) Quinapril HCl (Tablet) Maximum of 2 tablets per day Quinapril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Quinapril/Hydrochlorothiazide (20mg-12.5mg Maximum of 2 tablets per day Tablet, 20mg-25mg Tablet) Raloxifene HCl (Tablet) Maximum of 1 tablet per day Ramipril (Capsule) Maximum of 2 capsules per day Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Rapaflo (4mg Capsule) Maximum of 1 capsule per day Rapaflo (8mg Capsule) Maximum of 1 capsule per day Ravicti (Liquid) Maximum of 17.5 ml per day Rayaldee (Capsule Extended-Release) Maximum of 2 capsules per day Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days

Bold type = Brand name drug Plain type = Generic drug Last109 updated October 1, 2018 18 18 109 Drug Name Quantity Limit Relistor (150mg Tablet) Maximum of 3 tablets per day Repaglinide (0.5mg Tablet) Maximum of 32 tablets per day Repaglinide (1mg Tablet) Maximum of 16 tablets per day Repaglinide (2mg Tablet) Maximum of 8 tablets per day Repaglinide/Metformin HCl (Tablet) Maximum of 5 tablets per day Repatha (Injection) Maximum of 3 syringes (3 ml) per 28 days Repatha Pushtronex System (Injection) Maximum of 1 cartridge (3.5 ml) per 28 days Repatha SureClick (Injection) Maximum of 3 pens (3 ml) per 28 days Rescriptor (Tablet) Maximum of 9 tablets per day Restasis (Emulsion) Maximum of 2 vials per day Revlimid (Capsule) Maximum of 1 capsule per day Rexulti (Tablet) Maximum of 1 tablet per day Reyataz (Packet) Maximum of 8 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Risedronate Sodium (150mg Tablet) Maximum of 1 tablet per 30 days Risedronate Sodium (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Risedronate Sodium (35mg Tablet) Maximum of 4 tablets per 28 days Ritonavir (Tablet) Maximum of 18 tablets per day Rivastigmine Tartrate (Capsule) Maximum of 2 capsules per day Rivastigmine Transdermal System (Patch 24 Maximum of 1 patch per day Hour) Rizatriptan Benzoate (Tablet) Maximum of 12 tablets per 30 days Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day Rozerem (Tablet) Maximum of 1 tablet per day Rubraca (Tablet) Maximum of 4 tablets per day Rydapt (Capsule) Maximum of 8 capsules per day Sabril (Tablet) Maximum of 6 tablets per day Samsca (Tablet) Maximum of 2 tablets per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Selzentry (150mg Tablet, 75mg Tablet) Maximum of 3 tablets per day Selzentry (20mg/ml Oral Solution) Maximum of 92 ml per day Selzentry (25mg Tablet, 300mg Tablet) Maximum of 6 tablets per day Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day Sensipar (90mg Tablet) Maximum of 4 tablets per day Maximum of 1 inhaler (60 inhalations) per 30 Serevent Diskus (Aerosol Powder) days

Bold type = Brand name drug Plain type = Generic drug 110110 19 19 Last updated October 1, 2018 Drug Name Quantity Limit Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day Simvastatin (Tablet) Maximum of 1 tablet per day Soliqua 100/33 (Injection) Maximum of 18 ml (6 pens) per 30 days Somavert (Injection) Maximum of 1 vial per day Sovaldi (Tablet) Maximum of 1 tablet per day Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Sprycel (100mg Tablet, 140mg Tablet, 70mg Maximum of 1 tablet per day Tablet) Sprycel (20mg Tablet, 50mg Tablet) Maximum of 3 tablets per day Sprycel (80mg Tablet) Maximum of 2 tablets per day Stavudine (15mg Capsule, 30mg Capsule, Maximum of 3 capsules per day 40mg Capsule) Stavudine (20mg Capsule) Maximum of 2 capsules per day Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Stivarga (Tablet) Maximum of 4 tablets per day Stribild (Tablet) Maximum of 2 tablets per day Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 films per day Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 films per day Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100mg Tablet, 25mg Maximum of 12 tablets per 30 days Tablet, 50mg Tablet) Sumatriptan Succinate (4mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Auto injector, 6mg/0.5ml Solution Auto injector) Sumatriptan Succinate (6mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Auto injector) Sumatriptan Succinate (6mg/0.5ml Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Sustiva (200mg Capsule) Maximum of 3 capsules per day Sustiva (50mg Capsule) Maximum of 9 capsules per day Sustiva (600mg Tablet) Maximum of 2 tablets per day Sutent (12.5mg Capsule, 25mg Capsule, Maximum of 1 capsule per day 50mg Capsule) Sutent (37.5mg Capsule) Maximum of 2 capsules per day Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Symfi (Tablet) Maximum of 2 tablets per day Symfi Lo (Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last111 updated October 1, 2018 20 20 111 Drug Name Quantity Limit Synjardy (Tablet) Maximum of 2 tablets per day Synjardy XR (10mg-1000mg Tablet Extended- Release 24 Hour, 25mg-1000mg Tablet Maximum of 1 tablet per day Extended-Release 24 Hour) Synjardy XR (12.5mg-1000mg Tablet Extended-Release 24 Hour, 5mg-1000mg Maximum of 2 tablets per day Tablet Extended-Release 24 Hour) Tagrisso (Tablet) Maximum of 1 tablet per day Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day Tarceva (25mg Tablet) Maximum of 3 tablets per day Tasigna (150mg Capsule) Maximum of 5 capsules per day Tasigna (200mg Capsule) Maximum of 4 capsules per day Tasigna (50mg Capsule) Maximum of 14 capsules per day Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day Telmisartan (Tablet) Maximum of 1 tablet per day Telmisartan/Amlodipine (Tablet) Maximum of 1 tablet per day Telmisartan/Hydrochlorothiazide (40mg-12.5mg Maximum of 1 tablet per day Tablet, 80mg-25mg Tablet) Telmisartan/Hydrochlorothiazide (80mg-12.5mg Maximum of 2 tablets per day Tablet) Temazepam (15mg Capsule, 30mg Capsule) Maximum of 1 capsule per day Tenofovir Disoproxil Fumarate (Tablet) Maximum of 2 tablets per day Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 capsules per day Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day Tivicay (50mg Tablet) Maximum of 3 tablets per day TOBI Podhaler (Capsule) Maximum of 8 capsules per day Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day Tolcapone (Tablet) Maximum of 6 tablets per day Tracleer (125mg Tablet, 62.5mg Tablet) Maximum of 2 tablets per day Tracleer (32mg Tablet Soluble) Maximum of 4 tablets per day Tradjenta (Tablet) Maximum of 1 tablet per day Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day Tramadol HCl ER (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day

Bold type = Brand name drug Plain type = Generic drug 112112 21 21 Last updated October 1, 2018 Drug Name Quantity Limit Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day Trandolapril (4mg Tablet) Maximum of 2 tablets per day Trelegy Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Trezix (Capsule) Maximum of 10 capsules per day Trientine HCl (Capsule) Maximum of 8 capsules per day Trintellix (Tablet) Maximum of 1 tablet per day Triumeq (Tablet) Maximum of 2 tablets per day Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days Truvada (Tablet) Maximum of 2 tablets per day Tybost (Tablet) Maximum of 2 tablets per day Tymlos (Injection) Maximum of 1.56 ml per 30 days Valacyclovir HCl (1gm Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day Valganciclovir (Tablet) Maximum of 4 tablets per day Valganciclovir Hydrochlorde (Oral Solution) Maximum of 36 ml per day Valsartan (160mg Tablet, 40mg Tablet, 80mg Maximum of 2 tablets per day Tablet) Valsartan (320mg Tablet) Maximum of 1 tablet per day Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Veltassa (Powder) Maximum of 1 packet per day Vemlidy (Tablet) Maximum of 1 tablet per day Venclexta (100mg Tablet) Maximum of 4 tablets per day Venclexta (10mg Tablet) Maximum of 2 tablets per day Venclexta (50mg Tablet) Maximum of 1 tablet per day Ventavis (10mcg/ml Inhalation Solution) Maximum of 7 ml per day Ventavis (20mcg/ml Inhalation Solution) Maximum of 3 ml per day Verzenio (Tablet) Maximum of 2 tablets per day Vesicare (Tablet) Maximum of 1 tablet per day Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days Videx EC (125mg Capsule Delayed-Release) Maximum of 2 capsules per day Videx Pediatric (Oral Solution) Maximum of 30 ml per day Vigabatrin (Packet) Maximum of 6 packets per day Viibryd (Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Kit) Maximum of 1 pack (30 tablets) per 30 days Vimpat (100mg Tablet, 150mg Tablet, 200mg Maximum of 2 tablets per day Tablet, 50mg Tablet) Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day

Bold type = Brand name drug Plain type = Generic drug Last113 updated October 1, 2018 22 22 113 Drug Name Quantity Limit Viracept (250mg Tablet) Maximum of 15 tablets per day Viracept (625mg Tablet) Maximum of 6 tablets per day Viramune (Suspension) Maximum of 60 ml per day Viread (150mg Tablet) Maximum of 1 tablet per day Viread (200mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days Vosevi (Tablet) Maximum of 1 tablet per day Votrient (Tablet) Maximum of 4 tablets per day Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg Maximum of 1 capsule per day Capsule, 6mg Capsule) Xarelto (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day Xarelto (15mg Tablet) Maximum of 2 tablets per day Xarelto Starter Pack (Tablet Therapy Pack) Maximum of 1 pack (51 tablets) per 30 days Xeljanz (Tablet) Maximum of 2 tablets per day Xeljanz XR (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xiidra (Ophthalmic Solution) Maximum of 2 vials per day Xtampza ER (13.5mg Capsule Extended- Release 12 Hour Abuse-Deterrent, 18mg Capsule Extended-Release 12 Hour Abuse- Maximum of 3 capsules per day Deterrent, 9mg Capsule Extended-Release 12 Hour Abuse-Deterrent) Xtampza ER (27mg Capsule Extended- Release 12 Hour Abuse-Deterrent, 36mg Maximum of 6 capsules per day Capsule Extended-Release 12 Hour Abuse- Deterrent) Xtandi (Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Yuvafem (Tablet) Maximum of 1 tablet per day Zafirlukast (Tablet) Maximum of 2 tablets per day Zaleplon (10mg Capsule) Maximum of 2 capsules per day Zaleplon (5mg Capsule) Maximum of 1 capsule per day Zejula (Capsule) Maximum of 3 capsules per day Zelboraf (Tablet) Maximum of 8 tablets per day Zerit (Oral Solution) Maximum of 120 ml per day Zidovudine (100mg Capsule) Maximum of 8 capsules per day Zidovudine (300mg Tablet) Maximum of 3 tablets per day Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day

Bold type = Brand name drug Plain type = Generic drug 114114 23 23 Last updated October 1, 2018 Drug Name Quantity Limit Ziprasidone HCl (Capsule) Maximum of 2 capsules per day Zolpidem Tartrate (10mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release) Zydelig (Tablet) Maximum of 2 tablets per day Zykadia (Capsule) Maximum of 5 capsules per day Zytiga (250mg Tablet) Maximum of 4 tablets per day Zytiga (500mg Tablet) Maximum of 2 tablets per day track

Bold type = Brand name drug Plain type = Generic drug 115 115 tRACK Additional covered drugs Your plan has additional coverage for the prescription drugs listed below. These drugs are not normally covered in a Medicare Advantage plan with prescription drug coverage. The amount you pay when you fill prescriptions for these drugs does not count toward your total drug costs. This means, the amount you pay doesn’t help you qualify for catastrophic coverage. Also, if you’re receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. Drug Name Drug Tier Restrictions VitaminsD1 FolicE1 Acid (1mg tablet) 2 CyanocobalaminE1 (1000mcg/ml vial) 2 ErectileD1 Dysfunction SildenafilE1 (25mg tablet) 2 Maximum of 4 tablets per 30 days SildenafilE1 (50mg tablet) 2 Maximum of 4 tablets per 30 days SildenafilE1 (100mg tablet) 2 Maximum of 4 tablets per 30 days

Bold type = Brand name drug Plain type = Generic drug 116116 0 Required information Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Please call Customer Service. Our contact information is on the cover. ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente. Nuestra información de contacto se encuentra en la portada. This document is available for free in other languages. Please call Customer Service. Our contact information is on the cover. Este documento está disponible sin costo en otros idiomas. Llame a Servicio al Cliente. Nuestra información de contacto se encuentra en la portada. Preferred Care Partners is insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. For more up-to-date information or if you have other questions, please call Customer Service at:

Toll-free 1-866-231-7201, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.myPreferredCare.com

PCFL19HM4310615_003 Last updated October 1, 2018