FORMULARY (Complete List of Covered Drugs)

Please read: This document contains information about the drugs we cover in this plan. For more recent information or if you have other questions, please call AARP MedicareComplete Plans Customer Service at:

Toll-Free 1-800-643-4845, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.MyAARPMedicare.com

Formulary ID Number 00017009, Version 11 Y0066_160617_131835_FINAL_M04 Approved Last updated August 1, 2016 2

2 This Comprehensive Formulary is a complete list of the drugs covered by our plan. It is current as of August 1, 2016. For an up-to-date formulary (drug list), please call us. Our contact information, along with the date we last updated the formulary, is on the cover. When this formulary (drug list) refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan” or “our plan,” it means AARP MedicareComplete Plans. This list of covered drugs is called a Formulary. We call it a “drug list” for short. Note to existing members: This complete drug list has changed since last year. Please review this document to make sure your drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. 3

3 The AARP MedicareComplete Plans COMPREHENSIVE FORMULARY (drug list)

A formulary (drug list) is a list of covered drugs selected by your plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in our drug list as long as the drug is: · Medically necessary · The prescription is filled at a plan network pharmacy · Other plan rules are followed For more information on how to fill your prescriptions, please review your Evidence of Coverage.

This document is a complete drug list of the drugs covered by your plan. For your drug to be covered by your plan, it must be included in the complete drug list. To find out if your drug is covered: 1. See if your drug is included in this complete drug list. 2. Visit your plan website. Use the online tools to look up your drugs. The information is updated on a regular basis. The web address is on the cover. 3. Or call UnitedHealthcare Customer Service. Our contact information is on the cover. In most cases, your prescription must also be filled at one of our network pharmacies. 4 The drug list may change We try to make as few changes to the drug list as possible during the plan year. · If there are changes to the drug list, such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements. · If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The drug list may change during the year if your plan: · Adds new drugs, including generic drugs, as they become available. · Removes a drug that has been found to be ineffective or unsafe. · Changes the requirements or limits for a drug. · Moves a drug into a different tier.

Generally, if you are taking a drug on the 2017 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 plan year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from the list, will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the plan year. We feel it is important for you to have access for the entire plan year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, during the plan year we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) declares a drug on our drug list to be unsafe, or if the drug’s manufacturer removes the drug from the market, your plan will immediately remove the drug from the drug list and notify members who take the drug. The enclosed drug list is current as of the date printed on the cover. To get updated information about the drugs covered by your plan, please call UnitedHealthcare Customer Service or visit our website using the information provided on the cover of this drug list.

4 5 Drug payment stages and drug tiers The amount you pay for a covered drug will depend on: · Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in. · The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a co- pay and/or co-insurance amount. The chart below shows the differences between the tiers. For more information about drug coverage and co-pay or co-insurance amounts for each tier, please review your Evidence of Coverage.

Drug Tier Includes

Tier 1: 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. In addition, Part D eligible compound medications are covered in Tier 4.

Tier 5: Unique and/or very high-cost drugs. Specialty tier

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call UnitedHealthcare Customer Service. Our contact information is on the cover.

5 6 How to use the drug list There are two ways to find your prescription drugs in this complete drug list: 1. Medical condition: Turn to the “Covered drugs by medical condition” section, which begins on page 12, to look for drugs based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Agents” category and look under “Dyslipidemics, HMG CoA Reductase Inhibitors.”

2. Alphabetical list (index): If you are not sure what category to look under, turn to the “Index of covered drugs” section, which begins on page 107. Find the name of your drug. The page number where you can find the drug will be next to it.

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

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Dummy 7 Required actions, restrictions or limits Some covered drugs may have additional requirements or limits on coverage. If your drug has any requirements or limits, there will be a code(s) in the “Required actions, restrictions or limits” column of the drug list. The codes and what they mean are shown below.

Utilization Management Restrictions PA - Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug for one co-pay/co-insurance or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. LA - Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy. MED - Morphine Equivalent Dose Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is calculated based on the number of opioid drugs prescribed for you over a period of time. This cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for those individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 7 2

8 You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the “Covered drugs by medical condition” section that begins on page 12. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, is on the cover. You and your doctor may ask the plan for an exception to these requirements, restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the, “How to request an exception to the AARP MedicareComplete Plans drug list” section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug. If your drug is not on the drug list If your drug is not included in this complete formulary (list of covered drugs), you should call UnitedHealthcare Customer Service and ask if your drug is covered. Our contact information, along with the date we last updated the drug list, is on the cover. If you learn that your plan does not cover your drug, you have two options: 1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the appropriate drugs from the list. 2. Ask your plan to make an exception and cover your drug. See next page for information about how to request an exception.

8 9 How to request an exception to the AARP MedicareComplete Plans drug list At times you may need to ask for drug coverage that’s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination). You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask us to make.

· Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. · Tiering exception: You can ask your plan to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. · Utilization exception: You can ask your plan to waive coverage restrictions or limits on your drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a quantity limit, you can ask your plan to waive the limit and cover more. Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects. Who can ask for a coverage decision You, your authorized representative or your doctor can ask for an initial coverage decision for a formulary exception, tiering exception or utilization restriction exception. When you are requesting a formulary exception, tiering exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. Receiving a coverage decision Generally, your plan will make a coverage decision within 72 hours after receiving your prescribing physician’s statement. You can request an expedited, or fast, decision if you or your doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a decision within 24 hours after your plan receives your doctor’s or prescribing physician’s supporting statement.

9 10 What to do while you talk to your doctor about changing your drugs or requesting an exception New or continuing members As a new or continuing member in your plan, you may be taking drugs that are not on the drug list. Or you may be taking a drug that is on the drug list but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that your plan covers, or request a formulary exception so your plan will cover the drug you are currently taking. While you talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days you are a member of your plan. For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited, your plan may cover at least a temporary 30-day supply (unless you have a prescription written for fewer days) from a network pharmacy. After you receive at least a 30-day supply, your plan will not pay for these drugs, even if you have been a member of your plan less than 90 days. Long-term care facility residents If you’re a resident of a long-term care facility, your plan may allow you to refill your prescription until you have been provided with at least a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is written for fewer days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a member of your plan. If you need a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of membership in the plan, your plan will cover at least a 31-day emergency supply of the drug (unless your prescription is written for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care. If this happens and your doctor prescribes a drug that is not on the drug list, or a drug that is on the drug list but your ability to get it is limited, your plan may cover a one-time supply of at least 30- days. You may also ask for a one-time emergency supply of at least 30-days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception.

10 11 Drugs with dosages other than a one-month supply Drugs packaged in an extended day supply Some drugs are packaged from the manufacturer to provide more than a one-month supply. When you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single prescription. For more information, please call UnitedHealthcare Customer Service using the information on the cover. Daily cost share for oral medications filled for less than a one-month supply Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than one month under applicable law. The daily cost share requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.

For more information For more information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please call us toll-free at 1-800-643-4845, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Or visit us online at www.MyAARPMedicare.com. If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.

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12 Covered drugs by medical condition The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered drugs,” which begins on page 107. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column of the chart lists which coverage level (Tier) your drug is in. The “Required Actions, Restrictions or Limits” column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 85-106. tRACK Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Analgesics Etodolac ER ER (Tablet

Nonsteroidal Anti-inflammatory Drugs Extended-Release 24 4 Celecoxib (Capsule) 4 QL Hour)

Flector Diclofenac Potassium Potassium Flector (Patch) 4 PA, QL Flurbiprofen (Tablet Immediate- 2 Flurbiprofen (Tablet) 2 Release) Ibuprofen (100mg/5ml Diclofenac Sodium Sodium Suspension, 400mg 3 PA 2 (1% Gel) Tablet, 600mg Tablet, Diclofenac Sodium DR Sodium DR 800mg Tablet)

Ketoprofen (Tablet Delayed- 2 Ketoprofen (Capsule 3 Release) Immediate-Release) Diclofenac Sodium ER Sodium ER Ketorolac Tromethamine

(Tablet Extended- 2 Tromethamine (15mg/

Release 24 Hour) ml Injection, 30mg/ml 4

Diflunisal Diflunisal (Tablet) 3 Injection, 60mg/2ml Etodolac (200mg Injection) Meloxicam (15mg Capsule, 300mg 1 Capsule, 400mg Tablet Tablet, 7.5mg Tablet) 3 Meloxicam (7.5mg/ Immediate-Release, 4 500mg Tablet 5ml Suspension)

Nabumetone Immediate-Release) Nabumetone (Tablet) 4

Bold type = Brand name drug Plain type = Generic drug 12 2tRACK 2

Last updated August 1, 2016 13 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Naproxen (125mg/5ml Hydromorphone HCl ER HCl Suspension, 250mg ER (16mg Tablet 5 QL, MED Tablet Immediate- Extended-Release 24

Release, 375mg Tablet 2 Hour Abuse-Deterrent) Immediate-Release, Hydromorphone HCl ER HCl 500mg Tablet ER (32mg Tablet Immediate-Release) Extended-Release 24 5 QL, MED Naproxen DR DR (Tablet Hour Abuse-

Delayed-Release) 2 Deterrent) (Generic EC-Naprosyn) Levorphanol Tartrate Tartrate

Piroxicam 4 QL, MED Piroxicam (Capsule) 3 (Tablet)

Methadone HCl Sulindac Sulindac (Tablet) 2 Methadone HCl (10mg Voltaren (Gel) 3 PA Tablet, 5mg Tablet, 10mg/5ml Oral 3 QL, MED Opioid Analgesics, Long-acting Solution, 5mg/5ml Oral Embeda (Capsule 3 QL, MED Solution) Extended-Release) Methadone HCl HCl Fentanyl 5 Fentanyl (100mcg/hr (10mg/ml Injection) Patch 72 Hour, Morphine Sulfate ER Sulfate ER 12mcg/hr Patch 72 (100mg Tablet Hour, 25mcg/hr Patch 4 QL, MED Extended-Release, 72 Hour, 50mcg/hr 15mg Tablet Extended- Patch 72 Hour, Release, 200mg Tablet 3 QL, MED 75mcg/hr Patch 72 Extended-Release, Hour) 30mg Tablet Extended- Hydromorphone HCl ER Hydromorphone HCl Release, 60mg Tablet ER (12mg Tablet Extended-Release) Extended-Release 24 (Generic MS Contin) Hour Abuse-Deterrent, 4 QL, MED Nucynta ER ER (Tablet 8mg Tablet Extended- Extended-Release 12 3 QL, MED Release 24 Hour Hour) Abuse-Deterrent)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 13 3tRACK 3

14 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Opana ER ER (Tablet Hydrocodone Bitartrate/Acetaminophen Extended-Release 12 Bitartrate/ 3 QL, MED Hour Abuse- Acetaminophen 3 QL, MED Deterrent) (7.5mg-325mg/15ml Tramadol HCl ER HCl ER Oral Solution) (100mg Tablet Hydrocodone/Hydrocodone/Acetaminophen Extended-Release 24 Acetaminophen Hour, 200mg Tablet (10mg-325mg Tablet, 3 QL, MED Extended-Release 24 4 QL, MED 2.5mg-325mg Tablet, Hour) (Generic Ultram 5mg-325mg Tablet, ER), (300mg Tablet 7.5mg-325mg Tablet) Extended-Release 24 Hydrocodone/Hydrocodone/Ibuprofen Hour) (Generic Ryzolt) Ibuprofen 3 QL, MED Opioid Analgesics, Short-acting (7.5mg-200mg Tablet) Abstral (Tablet Hydromorphone HCl HCl 5 PA, QL Sublingual) (10mg/ml Injection, 4 Acetaminophen/Acetaminophen/Codeine 50mg/5ml Injection) Codeine Hydromorphone HCl HCl 4 QL, MED (120mg-12mg/5ml (1mg/ml Liquid) Oral Solution, 2 QL, MED Hydromorphone HCl HCl 300mg-15mg Tablet, (2mg Tablet 300mg-30mg Tablet, Immediate-Release, 2 QL, MED 300mg-60mg Tablet) 4mg Tablet Immediate- Butorphanol Tartrate Tartrate Release, 8mg Tablet (10mg/ml Nasal 3 QL, MED Immediate-Release) Solution) Hydromorphone HCl HCl

Butorphanol Tartrate 4 Butorphanol Tartrate (2mg/ml Injection)

(1mg/ml Injection, 4 Lorcet (Tablet) 3 QL, MED

2mg/ml Injection) Lorcet Plus Lorcet Plus (Tablet) 3 QL, MED Codeine Sulfate

Codeine Sulfate Lortab 3 QL, MED Lortab (10mg-325mg (Tablet) Tablet, 5mg-325mg Duramorph 3 QL, MED Duramorph (Injection) 4 Tablet, 7.5mg-325mg Endocet (Tablet) 3 QL, MED Tablet)

Bold type = Brand name drug Plain type = Generic drug 14 4tRACK 4

Last updated August 1, 2016 15 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Morphine Sulfate Sulfate Oxycodone/Oxycodone/Acetaminophen (100mg/5ml Oral Acetaminophen Solution, 10mg/5ml 3 QL, MED (10mg-325mg Tablet, 3 QL, MED Oral Solution, 20mg/ 2.5mg-325mg Tablet, 5ml Oral Solution) 5mg-325mg Tablet, Morphine Sulfate Sulfate 7.5mg-325mg Tablet) (10mg/ml Injection, Oxycodone/Oxycodone/Acetaminophen 4 4mg/ml Injection, Acetaminophen 4 QL, MED 8mg/ml Injection) (325mg/5ml-5mg/5ml Morphine Sulfate Sulfate Oral Solution) (15mg Tablet Oxycodone/Aspirin 3 QL, MED Immediate-Release, 3 QL, MED (Tablet) 30mg Tablet Oxycodone/Ibuprofen 3 QL, MED Immediate-Release) (Tablet)

Morphine Sulfate Morphine Sulfate Tramadol HCl HCl (Tablet 4 2 QL, MED (2mg/ml Injection) Immediate-Release)

Nalbuphine HCl Nalbuphine HCl Tramadol HCl/Acetaminophen 4 Tramadol HCl/ (Injection) Acetaminophen 2 QL, MED Oxycodone HCl HCl (Tablet) (100mg/5ml 4 QL, MED Trezix (Capsule) 4 QL, MED Concentrate) Anesthetics Oxycodone HCl Oxycodone HCl (10mg Local Anesthetics

Tablet Immediate- Lidocaine Lidocaine (5% Release, 15mg Tablet 4 Ointment) Immediate-Release, Lidocaine 20mg Tablet Lidocaine (5% Patch) 4 PA, QL 2 QL, MED Lidocaine HCl HCl (0.5% Immediate-Release, 4 B/D, PA 30mg Tablet Injection, 2% Injection) Immediate-Release, Lidocaine HCl HCl (4% 2 5mg Tablet Immediate- External Solution)

Lidocaine HCl Release) Lidocaine HCl (Gel) 2

Oxycodone HCl Oxycodone HCl (5mg/ Lidocaine Viscous Viscous 3 QL, MED 2 5ml Oral Solution) (Solution)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 15 5tRACK 5

16 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Lidocaine/Prilocaine Chantix Continuing Month Pak Continuing 3 3 (2.5%-2.5% Cream) Month Pak (Tablet) Anti-Addiction/Substance Abuse Treatment Chantix Starting Month Pak Starting 3 Agents Month Pak (Tablet)

Nicotrol Inhaler Alcohol Deterrents/Anti-craving Nicotrol Inhaler 4 Acamprosate Calcium DR Calcium Antibacterials DR (Tablet Delayed- 4 Aminoglycosides Release) Amikacin Sulfate Sulfate Disulfiram 4 Disulfiram (Tablet) 4 (Injection)

Naltrexone HCl Naltrexone HCl Bethkis (Nebulized 3 5 B/D, PA, QL (Tablet) Solution)

Vivitrol Vivitrol (Injection) 5 PA Gentak (Ophthalmic 2 Opioid Dependence Treatments Ointment)

Gentamicin Sulfate Buprenorphine HCl HCl Gentamicin Sulfate 3 (0.3mg/ml Injection) (0.1% Cream, 0.1% Buprenorphine HCl Ointment, 0.3% Buprenorphine HCl 2 (2mg Tablet Ophthalmic Ointment, 3 PA, QL Sublingual, 8mg Tablet 0.3% Ophthalmic Sublingual) Solution)

Gentamicin Sulfate Buprenorphine HCl/Naloxone HCl Gentamicin Sulfate Buprenorphine HCl/ Naloxone HCl (Tablet 3 PA, QL (10mg/ml Injection, 4 Sublingual) 40mg/ml Injection)

Gentamicin Sulfate/0.9% Sodium Chloride Naloxone HCl HCl Gentamicin Sulfate/ 3 (Injection) 0.9% Sodium Chloride 4

Narcan (Injection) Narcan (Liquid) 3 Isotonic Gentamicin

Suboxone Isotonic Gentamicin Suboxone (Film) 4 PA, QL 4 (Injection) Smoking Cessation Agents Neomycin Sulfate Sulfate Buproban (Tablet 2 (Tablet) Extended-Release 12 2 Paromomycin Sulfate Sulfate 4 Hour) (Capsule) Chantix Chantix (Tablet) 3 Streptomycin Sulfate Sulfate 4 (Injection)

Bold type = Brand name drug Plain type = Generic drug 16 6tRACK 6

Last updated August 1, 2016 17 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

TOBI (Nebulized Clindamycin Palmitate HCl Palmitate 5 B/D, PA, QL 2 Solution) HCl (Oral Solution) TOBI Podhaler Podhaler Clindamycin Phosphate 5 PA, QL 3 (Capsule) Phosphate (2% Cream) Tobradex Clindamycin Phosphate

(Ophthalmic 3 Phosphate (300mg/

Ointment) 2ml Solution, 900mg/ 4 Tobramycin (Nebulized 6ml Solution, 600mg/ 5 B/D, PA, QL Solution) 4ml Injection)

Clindamycin Phosphate in D5W Tobramycin Sulfate Sulfate Clindamycin

(0.3% Ophthalmic 2 Phosphate in D5W 4 Solution) (Injection)

Colistimethate Sodium Tobramycin Sulfate Sulfate Colistimethate Sodium 4 (10mg/ml Injection, 4 (Injection)

Cubicin 80mg/2ml Injection) Cubicin (Injection) 5

Tobrex Tobrex (0.3% Dalvance 4 Dalvance (Injection) 5 PA Ophthalmic Ointment) Lincomycin HCl HCl 4 Antibacterials, Other (Injection)

Altabax Altabax (Ointment) 4 Linezolid (100mg/5ml

BACiiM 5 PA BACiiM (Injection) 4 Suspension)

Linezolid Bacitracin (50000unit Linezolid (600mg 4 5 PA, QL Injection) Tablet)

Linezolid Bacitracin (500unit/gm Linezolid (600mg/ 2 4 PA Ophthalmic Ointment) 300ml Injection)

Methenamine Hippurate Bactroban Nasal Nasal Methenamine 4 PA 4 (Ointment) Hippurate (Tablet)

Metronidazole Chloramphenicol Sodium Succinate Metronidazole (0.75%

Sodium Succinate 4 Cream, 0.75% Gel, 1% 4 (Injection) Gel, 0.75% Lotion)

Metronidazole Clindamycin HCl HCl Metronidazole (250mg Tablet Immediate- (Capsule Immediate- 2 2 Release) Release, 500mg Tablet Immediate-Release)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 17 7tRACK 7

18 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Metronidazole in NaCl 0.79% in NaCl Vancomycin HCl HCl 4 0.79% (Injection) (1000mg Injection,

Metronidazole Vaginal 4 Metronidazole Vaginal 10gm Injection, 500mg 3 (Gel) Injection)

Vancomycin HCl Mupirocin Mupirocin (2% Cream) 4 Vancomycin HCl Mupirocin (2% (125mg Capsule, 5 PA 2 Ointment) 250mg Capsule) Vandazole Neomycin/Polymyxin B Sulfates B Vandazole (Gel) 3 Xifaxan Sulfates (Irrigation 3 Xifaxan (Tablet) 5 PA Solution) Beta-lactam, Cephalosporins

Nitrofurantoin Nitrofurantoin Cefaclor 4 Cefaclor (250mg (Suspension) Capsule Immediate-

Nitrofurantoin Macrocrystals Nitrofurantoin Release, 500mg 2 Macrocrystals (100mg Capsule Immediate-

Capsule, 50mg 3 Release) Capsule) (Generic Cefadroxil (250mg/5ml Macrodantin) Suspension, 500mg/

Nitrofurantoin Monohydrate 2 Nitrofurantoin 5ml Suspension, Monohydrate (100mg 500mg Capsule)

3 Cefazolin Sodium Capsule) (Generic Cefazolin Sodium 4 Macrobid) (Injection)

Polymyxin B Sulfate Polymyxin B Sulfate Cefdinir 4 Cefdinir (125mg/5ml (Injection) Suspension, 250mg/

Sulfamylon 3 Sulfamylon (85mg/ 5ml Suspension, 4 gm Cream) 300mg Capsule)

Cefepime Synercid Synercid (Injection) 5 Cefepime (Injection) 4

Cefixime Tinidazole Tinidazole (Tablet) 4 Cefixime (Suspension) 4

Cefotaxime Sodium Trimethoprim Cefotaxime Sodium Trimethoprim (Tablet) 2 4 Tygacil Tygacil (Injection) 5 (Injection) Cefotetan Vancocin HCl HCl Cefotetan (Injection) 4 5 PA (Capsule)

Bold type = Brand name drug Plain type = Generic drug 18 8tRACK 8

Last updated August 1, 2016 19 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Cefoxitin Sodium Sodium Suprax (100mg Tablet

(10gm Injection, 1gm Chewable, 200mg 3 4 Injection, 2gm Tablet Chewable) Injection) Suprax (400mg

Cefpodoxime Proxetil Cefpodoxime Proxetil Capsule, 500mg/5ml 3 (100mg Tablet, 200mg Suspension)

Tazicef Tablet, 100mg/5ml 4 Tazicef (Injection) 4

Suspension, 50mg/5ml Zerbaxa Zerbaxa (Injection) 5 PA Suspension)

Cefprozil Beta-lactam, Other

Cefprozil (125mg/5ml Azactam in Iso-Osmotic Dextrose Suspension, 250mg/ Azactam in Iso-

5ml Suspension, 3 Osmotic Dextrose 4 250mg Tablet, 500mg (Injection) Aztreonam Tablet) Aztreonam (Injection) 4

Doribax Ceftazidime Ceftazidime (Injection) 4 Doribax (Injection) 3

Imipenem/Cilastatin Ceftriaxone Sodium Imipenem/Cilastatin Ceftriaxone Sodium 4 (10gm Injection, 1gm (Injection)

Invanz Injection, 2gm Invanz (Injection) 4 4 Meropenem Injection, 250mg Meropenem (Injection) 4 Injection, 500mg Beta-lactam, Penicillins Injection) Amoxicillin

Cefuroxime Axetil Amoxicillin (125mg Cefuroxime Axetil 2 Tablet Chewable, (Tablet)

Cefuroxime Sodium 250mg Tablet Cefuroxime Sodium 4 Chewable, 125mg/5ml (Injection) Suspension, 200mg/ Cephalexin Cephalexin (125mg/ 5ml Suspension,

5ml Suspension, 250mg/5ml 1 250mg/5ml Suspension, 400mg/ Suspension, 250mg 2 5ml Suspension, Capsule, 500mg 250mg Capsule, Capsule, 750mg 500mg Capsule, Capsule) 500mg Tablet, 875mg Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 19 9tRACK 9

20 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Amoxicillin/Amoxicillin/Clavulanate Potassium Ampicillin-Sulbactam Clavulanate Potassium (10gm-5gm Injection, 4 (200mg-28.5mg Tablet 1gm-0.5gm Injection, Chewable, 2gm-1gm Injection) 400mg-57mg Tablet Bactocill in Dextrose in Dextrose 4 Chewable, 200mg/ (Injection)

Bicillin C-R 5ml-28.5mg/5ml Bicillin C-R (Injection) 4

Suspension, 250mg/ Bicillin L-A Bicillin L-A (Injection) 5ml-62.5mg/5ml 4 Dicloxacillin Sodium Suspension, 400mg/ Dicloxacillin Sodium 2 5ml-57mg/5ml 2 (Capsule) Suspension, 600mg/ Nafcillin Sodium Sodium 4 5ml-42.9mg/5ml (10gm Injection) Suspension, Nafcillin Sodium Sodium (1gm 5 250mg-125mg Tablet Injection) Immediate-Release, Oxacillin Sodium Sodium 5 500mg-125mg Tablet (10gm Injection) Immediate-Release, Oxacillin Sodium Sodium (2gm 4 875mg-125mg Tablet Injection)

Immediate-Release) Penicillin G Potassium Penicillin G Potassium (Generic Augmentin) 5

Amoxicillin/Clavulanate Potassium ER (Injection)

Amoxicillin/ Penicillin G Procaine Penicillin G Procaine Clavulanate Potassium 4 4 (Injection) ER (Tablet Extended- Penicillin G Sodium G Sodium Release 12 Hour) 5 Ampicillin (Injection) Ampicillin (125mg/5ml Penicillin V Potassium Suspension, 250mg/ Penicillin V Potassium (125mg/5ml Oral 5ml Suspension, 2 250mg Capsule, Solution, 250mg/5ml 2 500mg Capsule) Oral Solution, 250mg

Ampicillin Sodium Tablet, 500mg Tablet) Ampicillin Sodium Piperacillin/Tazobactam (10gm Injection, Piperacillin/ 4 4 125mg Injection, 1gm Tazobactam (Injection) Injection) Macrolides

Bold type = Brand name drug Plain type = Generic drug 20 10tRACK 10

Last updated August 1, 2016 21 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Azasite (Ophthalmic Erythromycin (250mg 4 Solution) Capsule Delayed- 4 Azithromycin (100mg/ Release) 5ml Suspension, Erythromycin (5mg/gm 2 200mg/5ml Ophthalmic Ointment)

1 Erythromycin Base Suspension, 250mg Erythromycin Base 4 Tablet, 500mg Tablet, (Tablet) 600mg Tablet) Erythromycin Ethylsuccinate Azithromycin (500mg 4 4 Ethylsuccinate (Tablet) Injection) Ilotycin (Ophthalmic Clarithromycin 2 Clarithromycin Ointment)

(125mg/5ml Zmax 4 Zmax (Suspension) 4 Suspension, 250mg/ Quinolones 5ml Suspension) Avelox

Clarithromycin Avelox (400mg/ Clarithromycin (250mg 4 3 250ml-0.8% Injection) Tablet, 500mg Tablet) Besivance

Clarithromycin ER Besivance Clarithromycin ER 4 (Suspension) (Tablet Extended- 3 Ciloxan (0.3% Release 24 Hour) 4

Dificid Ointment)

Dificid (Tablet) 5 PA Ciprofloxacin

E.E.S. Granules Ciprofloxacin (250mg/ E.E.S. Granules 4 5ml Suspension, (Suspension) 500mg/5ml 4 EryPed 200 200 4 Suspension, 400mg/ (Suspension) 40ml Injection)

EryPed 400 EryPed 400 Ciprofloxacin ER ER 5 (Suspension) (Tablet Extended- 3 Ery-Tab (Tablet 4 Release 24 Hour) Delayed-Release) Erythrocin Lactobionate

Lactobionate 4 (Injection)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 21 11tRACK 11

22 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Ciprofloxacin HCl HCl Ofloxacin (0.3% Otic

(0.3% Ophthalmic Solution, 400mg 3 Solution, 100mg Tablet Tablet) Immediate-Release, Vigamox (Ophthalmic 250mg Tablet 4 2 Solution) Immediate-Release, Sulfonamides

500mg Tablet Silver Sulfadiazine Silver Sulfadiazine Immediate-Release, 3 (Cream)

750mg Tablet Sodium Sulfacetamide Sodium Sulfacetamide Immediate-Release) 2

Ciprofloxacin I.V. in D5W (Ophthalmic Solution)

Ciprofloxacin I.V. in SSD 4 D5W (Injection) SSD (Cream) 3

Sulfacetamide Sodium Gatifloxacin Sulfacetamide Sodium 3 2 (Ophthalmic Solution) (Ophthalmic Ointment) Sulfadiazine Levofloxacin (0.5% Sulfadiazine (Tablet) 4 3 Sulfamethoxazole/Trimethoprim Ophthalmic Solution) Sulfamethoxazole/ Levofloxacin (250mg Trimethoprim

Tablet, 500mg Tablet, 1 (200mg-40mg/5ml 2 750mg Tablet) Suspension, Levofloxacin (25mg/ml 400mg-80mg Tablet) Sulfamethoxazole/Trimethoprim Injection, 25mg/ml 4 Sulfamethoxazole/ Trimethoprim Oral Solution) 4 Levofloxacin in D5W in D5W (400mg-80mg/5ml 4 (Injection) Injection) Sulfamethoxazole/Trimethoprim DS Moxeza (Ophthalmic Sulfamethoxazole/ 4 Solution) Trimethoprim DS 2

Moxifloxacin HCl (Tablet) Moxifloxacin HCl 3 (400mg Tablet) Tetracyclines Demeclocycline HCl Moxifloxacin HCl HCl Demeclocycline HCl 4 (400mg/250ml 4 (Tablet) Doxy 100 Injection) Doxy 100 (Injection) 4

Doxycycline Ofloxacin (0.3% Doxycycline (25mg/ 2 4 Ophthalmic Solution) 5ml Suspension)

Bold type = Brand name drug Plain type = Generic drug 22 12tRACK 12

Last updated August 1, 2016 23 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Doxycycline Hyclate Hyclate Vibramycin (50mg/ 4 (100mg Capsule 5ml Syrup) Immediate-Release, Anticonvulsants 50mg Capsule Anticonvulsants, Other Immediate-Release, 3 BRIVIACT (100mg 100mg Tablet Tablet, 10mg Tablet, Immediate-Release, 25mg Tablet, 50mg 5 QL 20mg Tablet Tablet, 75mg Tablet, Immediate-Release) 10mg/ml Oral Doxycycline Hyclate Hyclate 4 Solution) (100mg Injection) BRIVIACT (50mg/5ml Doxycycline Monohydrate 4 QL Doxycycline Injection) Monohydrate (100mg Fycompa (0.5mg/ml Capsule, 50mg 3 Suspension, 10mg Capsule, 100mg Tablet, 12mg Tablet, 4 Tablet, 50mg Tablet, 2mg Tablet, 4mg 75mg Tablet) Tablet, 6mg Tablet, Minocycline HCl Minocycline HCl 8mg Tablet) (100mg Capsule Levetiracetam Immediate-Release, (1000mg Tablet 50mg Capsule 2 Immediate-Release, Immediate-Release, 250mg Tablet 75mg Capsule Immediate-Release,

Immediate-Release) 500mg Tablet 2 Minocycline HCl Minocycline HCl Immediate-Release, (100mg Tablet 750mg Tablet Immediate-Release, Immediate-Release, 50mg Tablet 4 100mg/ml Oral Immediate-Release, Solution) 75mg Tablet Immediate-Release) Tetracycline HCl HCl 4 (Capsule)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 23 13tRACK 13

24 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Levetiracetam Gabapentin (100mg (1000mg/100ml Capsule, 300mg

Injection, 1500mg/ Capsule, 400mg 2 4 100ml Injection, Capsule, 600mg 500mg/100ml Tablet, 800mg Tablet) Injection) Gabapentin (250mg/

Levetiracetam 3 Levetiracetam (500mg/ 5ml Oral Solution)

4 Gabitril 5ml Injection) Gabitril (12mg Tablet,

Levetiracetam ER 4 QL Levetiracetam ER 16mg Tablet)

(Tablet Extended- 3 Onfi (10mg Tablet, 5 QL Release 24 Hour) 20mg Tablet)

Potiga Potiga (Tablet) 5 QL Onfi (2.5mg/ml

Roweepra 5 Roweepra (Tablet) 2 Suspension)

Phenobarbital Spritam (Tablet Phenobarbital (100mg

Disintegrating 4 Tablet, 15mg Tablet, 16.2mg Tablet, 30mg Soluble) Calcium Channel Modifying Agents Tablet, 32.4mg Tablet, 2

Celontin 60mg Tablet, 64.8mg Celontin (Capsule) 4 Tablet, 97.2mg Tablet, Ethosuximide (250mg 20mg/5ml Elixir) Capsule, 250mg/5ml 3 Primidone Primidone (Tablet) 2

Oral Solution) Sabril

Zonisamide Sabril (500mg Packet, Zonisamide (Capsule) 2 5 PA, QL, LA 500mg Tablet)

Gamma-aminobutyric Acid (GABA) Tiagabine HCl Tiagabine HCl (Tablet) 4 Augmenting Agents Valproate Sodium

Diastat AcuDial Valproate Sodium Diastat AcuDial (Gel) 4 4 (100mg/ml Injection) Diastat Pediatric Diastat Pediatric (Gel) 4 Valproic Acid Acid (250mg Diazepam (10mg Gel, 4 Capsule, 250mg/5ml 2 2.5mg Gel, 20mg Gel) Syrup) Glutamate Reducing Agents Felbamate (400mg 4 Tablet, 600mg Tablet)

Bold type = Brand name drug Plain type = Generic drug 24 14tRACK 14

Last updated August 1, 2016 25 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Felbamate (600mg/ Banzel (200mg 5 5ml Suspension) Tablet, 400mg Tablet, 5 Felbatol (600mg/5ml 40mg/ml Suspension)

5 Carbamazepine Suspension) Carbamazepine Lamotrigine (100mg (100mg Tablet Chewable, 100mg/5ml Tablet Immediate- 3 Release, 150mg Tablet Suspension, 200mg Immediate-Release, Tablet Immediate- 2 200mg Tablet Release) Immediate-Release, Carbamazepine ER ER 25mg Tablet (100mg Capsule Immediate-Release) Extended-Release 12 Lamotrigine (25mg Hour, 200mg Capsule

Tablet Chewable, 5mg 3 Extended-Release 12 Tablet Chewable) Hour, 300mg Capsule Topiramate Extended-Release 12 Topiramate (100mg 3 Tablet Immediate- Hour, 100mg Tablet Release, 200mg Tablet Extended-Release 12 Immediate-Release, Hour, 200mg Tablet 25mg Tablet Extended-Release 12 Immediate-Release, Hour, 400mg Tablet

50mg Tablet 2 Extended-Release 12 Immediate-Release, Hour)

Dilantin 15mg Capsule Dilantin (Capsule) 3 Sprinkle Immediate- Dilantin INFATABS INFATABS 3 Release, 25mg (Tablet Chewable)

Epitol Capsule Sprinkle Epitol (Tablet) 3

Immediate-Release) Fosphenytoin Sodium Fosphenytoin Sodium 4 Sodium Channel Agents (Injection) Aptiom Aptiom (200mg Oxcarbazepine 4 QL Tablet) (150mg Tablet, 300mg 3 Aptiom Aptiom (400mg Tablet, 600mg Tablet) Tablet, 600mg Tablet, 5 QL 800mg Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 25 15tRACK 15

26 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Oxcarbazepine Galantamine HBr HBr

(300mg/5ml 4 (12mg Tablet, 4mg Suspension) Tablet, 8mg Tablet,

Peganone Peganone (Tablet) 4 16mg Capsule

Phenytek Extended-Release 24 Phenytek (Capsule) 3

Phenytoin Hour, 24mg Capsule 4 QL Phenytoin (125mg/5ml Extended-Release 24 Suspension, 50mg 2 Hour, 8mg Capsule Tablet Chewable) Extended-Release 24 Phenytoin Sodium Sodium 4 Hour, 4mg/ml Oral (Injection) Solution)

Phenytoin Sodium Extended Phenytoin Sodium Rivastigmine Tartrate 2 Rivastigmine Tartrate Extended (Capsule) (Capsule Immediate- 3 QL Vimpat (100mg Release) Tablet, 150mg Tablet, Rivastigmine Transdermal System 200mg Tablet, 50mg 4 QL Transdermal System 4 QL, ST Tablet, 10mg/ml Oral (Patch 24 Hour) Solution) N-methyl-D-aspartate (NMDA) Receptor Vimpat (200mg/20ml 4 PA Antagonist Injection) Memantine HCl HCl (10mg Antidementia Agents Tablet, 5mg Tablet, 3 PA, QL Cholinesterase Inhibitors 2mg/ml Oral Solution)

Donepezil HCl Donepezil HCl (Tablet Memantine HCl Titration Pak HCl 1 QL 4 PA Immediate-Release) Titration Pak (Tablet)

Donepezil HCl ODT Donepezil HCl ODT Namenda XR XR 2 QL (Tablet Dispersible) (Capsule Extended- 3 PA, QL Release 24 Hour) Namenda XR Titration Pack XR Titration Pack (Capsule 3 PA, QL Extended-Release 24 Hour) Antidepressants Antidepressants, Other

Bold type = Brand name drug Plain type = Generic drug 26 16tRACK 16

Last updated August 1, 2016 27 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Bupropion HCl HCl (Tablet Escitalopram Oxalate Oxalate 2 Immediate-Release) (5mg/5ml Oral 2 Bupropion HCl SR HCl SR Solution)

Fetzima (Tablet Extended- 2 Fetzima (Capsule Release 12 Hour) Extended-Release 24 4 QL, ST Bupropion HCl XL HCl XL Hour)

Fetzima Titration Pack (Tablet Extended- 2 Fetzima Titration Release 24 Hour) Pack (Capsule

Mirtazapine 4 ST Mirtazapine (Tablet Extended-Release 24 2 Immediate-Release) Hour Therapy Pack)

Fluoxetine DR Mirtazapine ODT ODT Fluoxetine DR 2 (Tablet Dispersible) (Capsule Delayed- 4 Monoamine Oxidase Inhibitors Release)

Fluoxetine HCl Emsam (Patch 24 Fluoxetine HCl (10mg 5 QL Hour) Capsule Immediate-

Marplan Release, 20mg Marplan (Tablet) 4 Capsule Immediate- Phenelzine Sulfate Sulfate 2 3 Release, 40mg (Tablet) Capsule Immediate- Tranylcypromine Sulfate 4 Release, 20mg/5ml Sulfate (Tablet) Oral Solution) SSRI/SNRI (Selective Serotonin Reuptake Fluvoxamine Maleate Maleate 3 Inhibitors/Serotonin and Norepinephrine (Tablet) Reuptake Inhibitors) Maprotiline HCl HCl Citalopram HBr HBr (10mg 4 (Tablet) Tablet, 20mg Tablet, 1 Nefazodone HCl HCl 3 40mg Tablet) (Tablet)

Citalopram HBr Citalopram HBr Paroxetine HCl HCl (Tablet 2 (10mg/5ml Oral 3 Immediate-Release)

Solution) Paxil Paxil (10mg/5ml Escitalopram Oxalate Oxalate 4 Suspension)

(10mg Tablet, 20mg 1 Pristiq Pristiq (Tablet Tablet, 5mg Tablet) Extended-Release 24 4 QL Hour)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 27 17tRACK 17

28 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Sertraline HCl HCl (100mg Doxepin HCl HCl (100mg

Tablet, 25mg Tablet, 1 Capsule, 10mg 50mg Tablet) Capsule, 150mg Sertraline HCl HCl (20mg/ Capsule, 25mg 4 4 ml Concentrate) Capsule, 50mg

Trazodone HCl Trazodone HCl (Tablet) 1 Capsule, 75mg

Trintellix Capsule, 10mg/ml Trintellix (Tablet) 4 QL Concentrate) Venlafaxine HCl Venlafaxine HCl Imipramine HCl HCl 4 (Tablet Immediate- 3 (Tablet)

Release) Imipramine Pamoate

Venlafaxine HCl ER Imipramine Pamoate 4 Venlafaxine HCl ER (Capsule)

(150mg Capsule Nortriptyline HCl Nortriptyline HCl Extended-Release 24 (10mg Capsule, 25mg Hour, 37.5mg Capsule 2 Capsule, 50mg Extended-Release 24 2 Capsule, 75mg Hour, 75mg Capsule Capsule, 10mg/5ml Extended-Release 24 Oral Solution)

Hour) Protriptyline HCl

Viibryd Protriptyline HCl Viibryd (Tablet) 4 QL 4 (Tablet) Viibryd Starter Pack Viibryd Starter Pack Trimipramine Maleate Maleate 4 QL 4 (Kit) (Capsule) Tricyclics Antiemetics Amitriptyline HCl HCl 4 Antiemetics, Other

(Tablet) Compro

Amoxapine Compro (Suppository) 4

Amoxapine (Tablet) 3 Hydroxyzine Pamoate

Clomipramine HCl Hydroxyzine Pamoate Clomipramine HCl 3 4 (Capsule)

(Capsule) Meclizine HCl

Desipramine HCl Meclizine HCl (Tablet) 2

Desipramine HCl Metoclopramide HCl 2 Metoclopramide HCl (Tablet) (10mg Tablet, 5mg 1 Tablet)

Bold type = Brand name drug Plain type = Generic drug 28 18tRACK 18

Last updated August 1, 2016 29 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Metoclopramide HCl HCl Ondansetron HCl HCl

(5mg/5ml Oral 2 (24mg Tablet, 4mg 2 B/D, PA Solution) Tablet, 8mg Tablet) Metoclopramide HCl HCl Ondansetron HCl HCl 4 4 (5mg/ml Injection) (4mg/2ml Injection)

Ondansetron HCl Perphenazine Perphenazine (Tablet) 4 Ondansetron HCl Prochlorperazine (4mg/5ml Oral 4 B/D, PA 4 (Suppository) Solution)

Ondansetron ODT Prochlorperazine Edisylate Ondansetron ODT 4 2 B/D, PA Edisylate (Injection) (Tablet Dispersible)

Sancuso Prochlorperazine Maleate Sancuso (Patch) 5 2 Maleate (Tablet) Antifungals Transderm-Scop Antifungals 4 (Patch 72 Hour) Abelcet (Injection) 5 B/D, PA Emetogenic Therapy Adjuncts AmBisome (Injection) 5 B/D, PA

Aloxi Aloxi (Injection) 5 Amphotericin B B Anzemet 4 B/D, PA Anzemet (100mg (Injection) 5 B/D, PA Cancidas Tablet, 50mg Tablet) Cancidas (Injection) 5

Cesamet Cesamet (Capsule) 5 PA Ciclopirox (0.77% Gel,

Dronabinol Dronabinol (Capsule) 4 PA, QL 0.77% Suspension, 1% 3 Emend (Pack, 125mg Shampoo) Capsule, 40mg Ciclopirox Nail Lacquer Nail 4 PA Capsule, 80mg Lacquer (External 3 Capsule) Solution) Emend (150mg Ciclopirox Olamine Olamine 4 3 Injection) (Cream) Granisetron HCl HCl Clotrimazole (1% (0.1mg/ml Injection, Cream, 1% External 4 2 1mg/ml Injection, Solution, 10mg 4mg/4ml Injection) Troche) Granisetron HCl HCl (1mg Econazole Nitrate Nitrate 4 B/D, PA, QL 4 Tablet) (Cream)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 29 19tRACK 19

30 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Mycamine Eraxis Eraxis (Injection) 5 Mycamine (100mg 5 Exelderm (1% Cream, Injection) 4 Mycamine (50mg 1% External Solution) 4 Fluconazole (100mg Injection) Naftifine HCl HCl (1% Tablet, 150mg Tablet, 4 200mg Tablet, 50mg Cream)

2 Naftifine HCl Tablet, 10mg/ml Naftifine HCl (2% 4 Suspension, 40mg/ml Cream) Suspension) Naftin (1% Gel, 2%

Fluconazole in NaCl 4 Fluconazole in NaCl Gel) 4 Natacyn (Injection) Natacyn (Suspension) 3

Flucytosine Flucytosine (Capsule) 5 Noxafil (100mg Tablet

Griseofulvin Microsize 5 PA, QL Griseofulvin Microsize Delayed-Release) (125mg/5ml Noxafil (40mg/ml 4 5 QL Suspension, 500mg Suspension)

Nyamyc Tablet) Nyamyc (Powder) 2 Griseofulvin Ultramicrosize

Griseofulvin Nystatin 4 Nystatin (Cream, Ultramicrosize (Tablet) Ointment, Powder, 2 Itraconazole Itraconazole (Capsule) 4 PA, QL Suspension, Tablet)

Jublia Jublia (External Nystop 4 Nystop (Powder) 2

Solution) ONMEL ONMEL (Tablet) 5 PA Ketoconazole

Ketoconazole (2% Oxiconazole Nitrate Oxiconazole Nitrate Cream, 2% Shampoo, 2 4 (Cream) 200mg Tablet) Oxistat

Ketoconazole Oxistat (1% Cream, Ketoconazole (2% 4 4 1% Lotion) Foam) Sporanox

Lamisil Sporanox (10mg/ml Lamisil (125mg 5 PA Oral Solution) Packet, 187.5mg 4 Terbinafine HCl HCl Packet) 2

Mentax (Tablet)

Mentax (Cream) 4 Terconazole

Miconazole 3 Terconazole (0.4% Miconazole 3 3 Cream, 0.8% Cream, 3 (Suppository) 80mg Suppository)

Bold type = Brand name drug Plain type = Generic drug 30 20tRACK 20

Last updated August 1, 2016 31 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Vfend (200mg Tablet, Rizatriptan Benzoate Benzoate

50mg Tablet, 40mg/ 5 (Tablet Immediate- 3 QL ml Suspension) Release) Voriconazole (200mg Rizatriptan Benzoate ODT Benzoate

Injection, 40mg/ml 5 ODT (Tablet 3 QL Suspension) Dispersible) Voriconazole (200mg Sumatriptan (Nasal 4 4 QL Tablet, 50mg Tablet) Solution)

Sumatriptan Succinate Zazole Zazole (Cream) 3 Sumatriptan Succinate Antigout Agents (100mg Tablet, 25mg 2 QL Antigout Agents Tablet, 50mg Tablet) Sumatriptan Succinate

Allopurinol Sumatriptan Succinate Allopurinol (Tablet) 1 4 QL

Colchicine (6mg/0.5ml Injection)

Colchicine (0.6mg Sumatriptan Succinate Refill Sumatriptan Tablet) (Generic 3 QL Succinate Refill 4 QL Colcrys) (Injection) Colcrys

Colcrys (Tablet) 3 PA, QL Sumavel DosePro Sumavel DosePro Probenecid 5 QL Probenecid (Tablet) 2 (Injection) Probenecid/Colchicine 2 Antimyasthenic Agents (Tablet) Parasympathomimetics

Uloric Uloric (Tablet) 3 ST Guanidine HCl HCl 3 Antimigraine Agents (Tablet) Ergot Alkaloids Mestinon (60mg/5ml

Cafergot 5 Cafergot (Tablet) 3 Syrup)

Pyridostigmine Bromide Dihydroergotamine Mesylate Pyridostigmine Bromide (180mg Mesylate (1mg/ml 5 4 Injection) Tablet Extended-

Migergot Migergot (Suppository) 5 Release, 60mg Tablet) Serotonin (5-HT) 1b/1d Receptor Agonists Antimycobacterials

Naratriptan HCl Antimycobacterials, Other Naratriptan HCl 3 QL Dapsone (Tablet) Dapsone (Tablet) 3

Rifabutin Rifabutin (Capsule) 4 Antituberculars

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 31 21tRACK 21

32 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Capastat Sulfate Capastat Sulfate Matulane (Capsule) 5 LA 4 (Injection) Melphalan HCl HCl Ethambutol HCl HCl 4 3 (Injection) Mustargen (Tablet) Mustargen (Injection) 5

Isoniazid

Isoniazid (100mg Treanda 2 Treanda (Injection) 5 PA Tablet, 300mg Tablet) Valchlor

Isoniazid Valchlor (Gel) 5 PA, LA Isoniazid (100mg/ml Zanosar Injection, 50mg/5ml 4 Zanosar (Injection) 4 Syrup) Antiandrogens

Paser Bicalutamide Paser (Packet) 4 Bicalutamide (Tablet) 2

Priftin Flutamide Priftin (Tablet) 4 Flutamide (Capsule) 3

Pyrazinamide Nilandron Pyrazinamide (Tablet) 4 Nilandron (Tablet) 5 Rifampin (150mg Xtandi (Capsule) 5 PA, QL

Capsule, 300mg 3 Zytiga (Tablet) 5 PA, QL Capsule) Antiangiogenic Agents Rifampin

Rifampin (600mg Pomalyst 4 Pomalyst (Capsule) 5 PA, QL Injection) Revlimid

Rifater Revlimid (Capsule) 5 PA, QL, LA Rifater (Tablet) 4

Thalomid

Sirturo Thalomid (Capsule) 5 PA, QL Sirturo (Tablet) 5 PA

Trecator Antiestrogens/Modifiers Trecator (Tablet) 4 Emcyt Emcyt (Capsule) 5 Antineoplastics Fareston Alkylating Agents Fareston (Tablet) 5

Faslodex BiCNU BiCNU (Injection) 5 Faslodex (Injection) 5

Soltamox Busulfex Soltamox (Oral Busulfex (Injection) 5 4

Cyclophosphamide Solution)

Cyclophosphamide Tamoxifen Citrate 4 B/D, PA Tamoxifen Citrate (Capsule) 2

Dacarbazine (Tablet) Dacarbazine (Injection) 4 Antimetabolites Gleostine

Gleostine (Capsule) 4 Adrucil Adrucil (Injection) 4 B/D, PA Hexalen

Hexalen (Capsule) 5 PA Alimta Alimta (Injection) 5 PA Ifosfamide

Ifosfamide (Injection) 4 Cladribine Cladribine (Injection) 5 B/D, PA Leukeran Leukeran (Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 32 22tRACK 22

Last updated August 1, 2016 33 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Clolar Dacogen Clolar (Injection) 5 Dacogen (Injection) 5 Cytarabine Aqueous Aqueous Daunorubicin HCl HCl 4 B/D, PA 4 (Injection) (Injection)

Droxia Decitabine Droxia (Capsule) 4 Decitabine (Injection) 5

Dexrazoxane Elitek Elitek (Injection) 5 Dexrazoxane 5 PA Fluorouracil (2.5gm/ (Injection) 4 B/D, PA Docefrez 50ml Injection) Docefrez (Injection) 5

Docetaxel Folotyn Folotyn (Injection) 5 Docetaxel (80mg/4ml 5 Gemcitabine HCl HCl Injection) 4 Docetaxel (80mg/8ml (Injection) 5 Gemzar Gemzar (Injection) 5 Injection) Doxil

Hydroxyurea Hydroxyurea (Capsule) 2 Doxil (Injection) 5

Doxorubicin HCl

Lonsurf Doxorubicin HCl Lonsurf (Tablet) 5 PA, QL 4 B/D, PA

Mercaptopurine (Injection)

Mercaptopurine Doxorubicin HCl Liposome 3 Doxorubicin HCl (Tablet) 5

Nipent Liposome (Injection)

Nipent (Injection) 5 Ellence Ellence (Injection) 5 Purixan

Purixan (Suspension) 5 PA Erwinaze Erwinaze (Injection) 5 Tabloid

Tabloid (Tablet) 5 PA Farydak Farydak (Capsule) 5 PA

Antineoplastics, Other Fludarabine Phosphate

Abraxane Fludarabine Phosphate 4 Abraxane (Injection) 5 PA (Injection)

Alecensa

Fusilev Alecensa (Capsule) 5 PA, QL Fusilev (Injection) 5

Amifostine Amifostine (Injection) 5 Halaven (Injection) 5 PA

Arranon Arranon (Injection) 5 Ibrance (Capsule) 5 PA, QL

Azacitidine Azacitidine (Injection) 5 PA Idamycin PFS PFS

Beleodaq 5 Beleodaq (Injection) 5 PA (Injection)

Idarubicin HCl Bleomycin Sulfate Sulfate Idarubicin HCl 4 B/D, PA 5 (Injection) (Injection)

Irinotecan Carboplatin Carboplatin (Injection) 4 Irinotecan (Injection) 4

Istodax Cisplatin Cisplatin (Injection) 4 Istodax (Injection) 5 PA

Jevtana Cosmegen Cosmegen (Injection) 5 Jevtana (Injection) 5 PA

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 33 23tRACK 23

34 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Leucovorin Calcium Calcium Venclexta Starting Pack Starting

(100mg Injection, 4 Pack (Tablet Therapy 5 PA 350mg Injection) Pack)

Leucovorin Calcium Leucovorin Calcium Vidaza (Injection) 5 PA (10mg Tablet, 15mg Vinblastine Sulfate Sulfate 3 4 B/D, PA Tablet, 25mg Tablet, (Injection) 5mg Tablet) Vincasar PFS PFS Levoleucovorin Calcium 4 B/D, PA 5 (Injection) Calcium (Injection) Vincristine Sulfate Sulfate Lynparza 4 B/D, PA Lynparza (Capsule) 5 PA, QL (Injection)

Mesna Vinorelbine Tartrate Mesna (Injection) 4 Vinorelbine Tartrate

Mesnex 4 Mesnex (400mg (Injection)

5 Zaltrap Tablet) Zaltrap (Injection) 5 PA

Mitomycin Mitomycin (Injection) 5 Zinecard (Injection) 5 PA

Mitoxantrone HCl Mitoxantrone HCl Zolinza 3 Zolinza (Capsule) 5 PA (Injection) Zydelig Zydelig (Tablet) 5 PA, QL Ninlaro

Ninlaro (Capsule) 5 PA, QL Zykadia Zykadia (Capsule) 5 PA, QL Oxaliplatin Oxaliplatin (Injection) 4 Aromatase Inhibitors, 3rd Generation Paclitaxel

Anastrozole Paclitaxel (Injection) 4 Anastrozole (Tablet) 1

Proleukin

Exemestane Proleukin (Injection) 5 PA Exemestane (Tablet) 3

Synribo

Letrozole Synribo (Injection) 5 PA Letrozole (Tablet) 2 Taxotere Taxotere (Injection) 5 Enzyme Inhibitors

Thiotepa Etopophos Thiotepa (Injection) 5 Etopophos (Injection) 5

Trisenox Etoposide Trisenox (Injection) 4 Etoposide (Injection) 3

Velcade

Hycamtin Velcade (Injection) 5 PA Hycamtin (Injection) 5

Venclexta Venclexta (100mg Toposar 5 PA, QL Toposar (Injection) 3

Tablet) Topotecan HCl

Venclexta Topotecan HCl Venclexta (10mg 5 4 PA, QL (Injection) Tablet, 50mg Tablet) Molecular Target Inhibitors Afinitor (Tablet) 5 PA

Bold type = Brand name drug Plain type = Generic drug 34 24tRACK 24

Last updated August 1, 2016 35 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Afinitor Disperz Afinitor Disperz Votrient (Tablet) 5 PA, QL 5 PA (Tablet Soluble) Xalkori (Capsule) 5 PA, LA

Bosulif Bosulif (Tablet) 5 PA, QL Zelboraf (Tablet) 5 PA, QL

Cabometyx Cabometyx (Tablet) 5 PA, QL Monoclonal Antibodies

Caprelsa Caprelsa (Tablet) 5 PA, LA Avastin (Injection) 5 PA

Cometriq Cometriq (Kit) 5 PA Cyramza (Injection) 5 PA

Cotellic Cotellic (Tablet) 5 PA, QL, LA Darzalex (Injection) 5 PA, LA

Erivedge Erivedge (Capsule) 5 PA, QL Empliciti (Injection) 5 PA

Gilotrif Gilotrif (Tablet) 5 PA Erbitux (Injection) 5 PA

Iclusig Iclusig (15mg Tablet) 5 PA, QL, LA Herceptin (Injection) 5 PA

Iclusig Iclusig (45mg Tablet) 5 PA, QL Kadcyla (Injection) 5 PA

Imatinib Mesylate Imatinib Mesylate Keytruda 5 PA, QL Keytruda (Injection) 5 PA

(Tablet) Opdivo

Imbruvica Opdivo (Injection) 5 PA

Imbruvica (Capsule) 5 PA, QL Perjeta

Inlyta Perjeta (Injection) 5 PA

Inlyta (Tablet) 5 PA, QL Rituxan

Iressa Rituxan (Injection) 5 PA

Iressa (Tablet) 5 PA, QL Sylvant

Jakafi Sylvant (Injection) 5 PA

Jakafi (Tablet) 5 PA, QL, LA Tagrisso

Lenvima Tagrisso (Tablet) 5 PA, QL, LA Lenvima (Capsule 5 PA Tecentriq Therapy Pack) Tecentriq (Injection) 5 PA

Vectibix Mekinist (Tablet) 5 PA Vectibix (Injection) 5 PA

Yervoy Nexavar (Tablet) 5 PA Yervoy (Injection) 5 PA Odomzo (Capsule) 5 PA, QL, LA Retinoids

Bexarotene Sprycel (Tablet) 5 PA, QL Bexarotene (Capsule) 5 PA

Panretin Stivarga (Tablet) 5 PA, QL Panretin (Gel) 5 PA

Targretin Sutent (Capsule) 5 PA, QL Targretin (1% Gel) 5 PA

Tretinoin

Tafinlar Tretinoin (10mg Tafinlar (Capsule) 5 PA 5 Capsule) Tarceva (Tablet) 5 PA, QL Antiparasitics Tasigna Tasigna (Capsule) 5 PA, QL Anthelmintics

Tykerb Tykerb (Tablet) 5 PA Albenza (Tablet) 5 QL

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 35 25tRACK 25

36 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Biltricide Malathion Biltricide (Tablet) 4 Malathion (Lotion) 4

Ivermectin Permethrin Ivermectin (Tablet) 3 Permethrin (Cream) 3 Antiprotozoals Antiparkinson Agents Alinia (100mg/5ml Anticholinergics

4 Benztropine Mesylate Suspension) Benztropine Mesylate

Alinia Alinia (500mg Tablet) 5 (0.5mg Tablet, 1mg 2 Atovaquone Tablet, 2mg Tablet) 5 Benztropine Mesylate Mesylate (Suspension) 4 Atovaquone/Proguanil HCl (1mg/ml Injection) Trihexyphenidyl HCl Trihexyphenidyl HCl HCl (Tablet) (Generic 3 Malarone) (0.4mg/ml Elixir, 2mg 3 Chloroquine Phosphate Tablet, 5mg Tablet) 2 Phosphate (Tablet) Antiparkinson Agents, Other

Amantadine HCl Coartem Amantadine HCl Coartem (Tablet) 4 DARAPRIM (100mg Capsule, 3 DARAPRIM (Tablet) 5

Hydroxychloroquine Sulfate 100mg Tablet)

Hydroxychloroquine Amantadine HCl 2 Amantadine HCl Sulfate (Tablet) 2

Mefloquine HCl (50mg/5ml Syrup)

Mefloquine HCl Entacapone 2 Entacapone (Tablet) 4 (Tablet)

Tolcapone

Mepron Mepron (Suspension) 5 Tolcapone (Tablet) 5 QL Nebupent (Inhalation Dopamine Agonists 4 B/D, PA, QL Apokyn Solution) Apokyn (Injection) 5 PA, QL

Bromocriptine Mesylate Pentam 300 300 Bromocriptine 4 (Injection) Mesylate (2.5mg 3 Primaquine Phosphate Phosphate Tablet, 5mg Capsule) 4 Neupro (Patch 24 (Tablet) 4 Quinine Sulfate Sulfate Hour) 4 PA Pramipexole Dihydrochloride (Capsule) Pramipexole Dihydrochloride Pediculicides/Scabicides 3 Eurax (Tablet Immediate- Eurax (10% Cream, 4 Release) 10% Lotion)

Lindane Lindane (Shampoo) 4

Bold type = Brand name drug Plain type = Generic drug 36 26tRACK 26

Last updated August 1, 2016 37 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Ropinirole HCl HCl (Tablet Chlorpromazine HCl HCl 2 Immediate-Release) (100mg Tablet, 10mg Tablet, 200mg Tablet, Dopamine Precursors/L-Amino Acid 4 Decarboxylase Inhibitors 25mg Tablet, 50mg

Carbidopa Carbidopa (Tablet) 5 Tablet, 50mg/2ml

Carbidopa/Levodopa Injection)

Carbidopa/Levodopa Fluphenazine Decanoate Fluphenazine (Tablet Immediate- 1 4 Release) Decanoate (Injection) Fluphenazine HCl Carbidopa/Levodopa ER Fluphenazine HCl (10mg Tablet, 1mg ER (Tablet Extended- 1 2 Release) Tablet, 2.5mg Tablet,

Carbidopa/Levodopa ODT 5mg Tablet)

Carbidopa/Levodopa Fluphenazine HCl Fluphenazine HCl ODT (Tablet 2 Dispersible) (2.5mg/5ml Elixir, 4

Carbidopa/Levodopa/Entacapone 2.5mg/ml Injection)

Carbidopa/Levodopa/ Fluphenazine HCl 4 Fluphenazine HCl Entacapone (Tablet) 3

Stalevo 100 (5mg/ml Concentrate)

Stalevo 100 (Tablet) 4 PA Haloperidol Haloperidol (0.5mg Stalevo 125 Stalevo 125 (Tablet) 4 PA Tablet, 10mg Tablet, Stalevo 150 150 (Tablet) 4 PA 1mg Tablet, 20mg 2 Stalevo 200 200 (Tablet) 4 PA Tablet, 2mg Tablet,

Stalevo 50 5mg Tablet, 2mg/ml Stalevo 50 (Tablet) 4 PA Concentrate) Stalevo 75

Stalevo 75 (Tablet) 4 PA Haloperidol Decanoate Haloperidol Decanoate 4 Monoamine Oxidase B (MAO-B) Inhibitors (Injection)

Azilect Azilect (Tablet) 3 Haloperidol Lactate Lactate

Selegiline HCl 4 Selegiline HCl (5mg (Injection)

3 Loxapine Succinate Capsule, 5mg Tablet) Loxapine Succinate Zelapar (Tablet (10mg Capsule, 5mg 2 QL 5 Dispersible) Capsule) Antipsychotics Loxapine Succinate Succinate

1st Generation/Typical (25mg Capsule, 50mg 2 Capsule)

Molindone HCl Molindone HCl (Tablet) 4

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 37 27tRACK 27

38 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Invega Trinza Pimozide Pimozide (Tablet) 4 Invega Trinza 5 PA Thioridazine HCl HCl (Injection) 3 Latuda (Tablet) Latuda (Tablet) 5 QL

Thiothixene Nuplazid Thiothixene (Capsule) 3 Nuplazid (Tablet) 5 PA, QL Trifluoperazine HCl HCl Olanzapine (10mg 3 4 (Tablet) Injection) 2nd Generation/Atypical Olanzapine (10mg Abilify Maintena Maintena Tablet Immediate- 5 (Injection) Release, 15mg Tablet Aripiprazole (Tablet) 4 QL Immediate-Release,

Aripiprazole ODT 2.5mg Tablet Aripiprazole ODT 5 QL Immediate-Release, 2 QL (Tablet Dispersible) 20mg Tablet Aristada Aristada (Injection) 5 Immediate-Release, Fanapt (10mg Tablet, 5mg Tablet Immediate- 12mg Tablet, 6mg 5 QL, ST Release, 7.5mg Tablet Tablet, 8mg Tablet) Immediate-Release)

Fanapt Fanapt (1mg Tablet, Olanzapine ODT ODT 4 QL 2mg Tablet, 4mg 4 QL, ST (Tablet Dispersible) Tablet) Paliperidone ER ER Fanapt Titration Pack Titration Pack (Tablet Extended- 5 QL 4 ST (Tablet) Release 24 Hour)

Geodon Geodon (20mg Quetiapine Fumarate Fumarate 4 Injection) (Tablet Immediate- 2 QL Invega Sustenna Sustenna Release) (117mg/0.75ml Rexulti (Tablet) 5 QL Injection, 156mg/ml Risperdal Consta Consta

Injection, 234mg/ 5 (12.5mg Injection, 4 1.5ml Injection, 25mg Injection)

78mg/0.5ml Risperdal Consta Risperdal Consta Injection) (37.5mg Injection, 5 Invega Sustenna Sustenna 50mg Injection) (39mg/0.25ml 4 Injection)

Bold type = Brand name drug Plain type = Generic drug 38 28tRACK 28

Last updated August 1, 2016 39 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Risperidone (0.25mg Clozapine ODT ODT Tablet Immediate- (100mg Tablet 3 QL Release, 0.5mg Tablet Dispersible, 25mg Immediate-Release, Tablet Dispersible) 1mg Tablet Immediate- Clozapine ODT 2 Clozapine ODT Release, 2mg Tablet (12.5mg Tablet 3 QL Immediate-Release, Dispersible, 150mg 3mg Tablet Immediate- Tablet Dispersible) Release, 4mg Tablet Clozapine ODT ODT Immediate-Release) (200mg Tablet 5 QL Risperidone (1mg/ml 4 Dispersible) Oral Solution) Fazaclo (100mg Risperidone ODT ODT 4 Tablet Dispersible, (Tablet Dispersible) 150mg Tablet 5 QL Saphris (Tablet Dispersible, 200mg 4 QL Sublingual) Tablet Dispersible) Seroquel XR XR (Tablet Versacloz 5 Extended-Release 24 3 QL (Suspension) Hour) Antivirals Vraylar (1.5mg Anti-cytomegalovirus (CMV) Agents

Cidofovir Capsule, 3mg Cidofovir (Injection) 5

Capsule, 4.5mg 5 QL, ST Ganciclovir Ganciclovir (Injection) 3 B/D, PA Capsule, 6mg Valcyte (450mg Capsule) 5 QL Vraylar (Capsule Tablet) 4 ST Valcyte (50mg/ml Therapy Pack) 5 Ziprasidone HCl HCl Oral Solution) 3 QL Valganciclovir (Capsule) Valganciclovir (Tablet) 5

Zirgan Zyprexa Relprevv Zyprexa Relprevv Zirgan (Gel) 4 5 (Injection) Anti-hepatitis B (HBV) Agents Treatment-Resistant Adefovir Dipivoxil Dipivoxil

Clozapine 5 Clozapine (Tablet (Tablet) 3 Immediate-Release)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 39 29tRACK 29

40 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Baraclude (0.05mg/ Antiherpetic Agents ml Oral Solution, Acyclovir (200mg 5 0.5mg Tablet, 1mg Capsule, 200mg/5ml 2 Tablet) Suspension)

Entecavir Acyclovir Entecavir (Tablet) 5 Acyclovir (400mg

Epivir HBV 1 Epivir HBV (5mg/ml Tablet, 800mg Tablet)

3 Acyclovir Oral Solution) Acyclovir (5%

Hepsera 4 QL Hepsera (Tablet) 5 Ointment)

Acyclovir Sodium Lamivudine (100mg Acyclovir Sodium 3 4 B/D, PA Tablet) (Injection)

Denavir Tyzeka Tyzeka (Tablet) 5 Denavir (Cream) 5 QL

Famciclovir Anti-hepatitis C (HCV) Agents Famciclovir (Tablet) 3 QL

Trifluridine Daklinza Trifluridine Daklinza (Tablet) 5 PA, QL 4 Harvoni (Tablet) 5 PA, QL (Ophthalmic Solution) Valacyclovir HCl

Intron A Valacyclovir HCl Intron A (Injection) 5 PA 3 QL (Tablet) Intron A w/Diluent A w/Diluent 5 PA Anti-HIV Agents, Integrase Inhibitors (Injection) (INSTI) Pegasys

Pegasys (Injection) 5 PA Evotaz Evotaz (Tablet) 5 QL Pegasys ProClick

Pegasys ProClick Genvoya 5 PA Genvoya (Tablet) 5 QL (Injection) Isentress

PegIntron Isentress (100mg PegIntron (Injection) 5 PA Packet, 100mg Tablet PegIntron REDIPEN REDIPEN 5 QL 5 PA Chewable, 400mg (Injection) Tablet)

Ribasphere Ribasphere (200mg Isentress (25mg 3 QL Tablet, 400mg Tablet, 3 Tablet Chewable)

600mg Tablet) Prezcobix Prezcobix (Tablet) Ribavirin 5 QL

Ribavirin (200mg Stribild 3 Stribild (Tablet) Tablet) 5 QL

Tivicay Sovaldi (Tablet) 5 PA, QL Tivicay (10mg Tablet) 4 QL

Tivicay

Sylatron Tivicay (25mg Tablet, Sylatron (Injection) 5 PA 5 QL 50mg Tablet) Zepatier

Zepatier (Tablet) 5 PA, QL Triumeq Triumeq (Tablet) 5 QL

Bold type = Brand name drug Plain type = Generic drug 40 30tRACK 30

Last updated August 1, 2016 41 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Tybost (Tablet) 4 QL Descovy (Tablet) 5 QL

Didanosine Vitekta (Tablet) 5 QL Didanosine (Capsule 3 QL Anti-HIV Agents, Non-nucleoside Reverse Delayed-Release) Transcriptase Inhibitors (NNRTI) Emtriva (10mg/ml Atripla (Tablet) 5 QL Oral Solution, 200mg 4 QL

Complera Capsule) Complera (Tablet) 5 QL Epzicom

Edurant Epzicom (Tablet) 5 QL

Edurant (Tablet) 5 QL Lamivudine

Intelence Lamivudine (10mg/ml Intelence (Tablet) 5 QL Oral Solution, 150mg 3 QL

Nevirapine Nevirapine (200mg Tablet, 300mg Tablet) Tablet Immediate- 3 QL Lamivudine/Lamivudine/Zidovudine 4 QL Release) Zidovudine (Tablet)

Nevirapine Nevirapine (50mg/ Retrovir IV Infusion IV Infusion 3 QL 4 5ml Suspension) (Injection)

Nevirapine ER Nevirapine ER (Tablet Stavudine (15mg Extended-Release 24 3 QL Capsule, 20mg Hour) Capsule, 30mg Odefsey 3 QL Odefsey (Tablet) 5 QL Capsule, 40mg Rescriptor (Tablet) 4 QL Capsule, 1mg/ml Oral Sustiva (200mg Solution)

Trizivir Capsule, 600mg 5 QL Trizivir (Tablet) 5 QL Tablet) Truvada (Tablet) 5 QL

Sustiva Sustiva (50mg Videx Pediatric Pediatric (Oral 4 QL 4 QL Capsule) Solution) Anti-HIV Agents, Nucleoside and Viread (150mg Tablet, Nucleotide Reverse Transcriptase 200mg Tablet, 250mg 5 QL Inhibitors (NRTI) Tablet, 300mg Tablet, Abacavir (Tablet) 4 QL 40mg/gm Powder)

Ziagen Abacavir Sulfate/Lamivudine/Zidovudine Ziagen (20mg/ml Oral Abacavir Sulfate/ 4 QL Lamivudine/ 5 QL Solution) Zidovudine (Tablet) Combivir (Tablet) 5 QL

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 41 31tRACK 31

42 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Zidovudine (100mg Prezista (75mg 4 QL Capsule, 300mg Tablet)

3 QL Reyataz Tablet, 50mg/5ml Reyataz (150mg Syrup) Capsule, 200mg Anti-HIV Agents, Other Capsule, 300mg 5 QL Fuzeon (Injection) 5 QL Capsule, 50mg

Selzentry Packet) Selzentry (Tablet) 5 QL Viracept (Tablet) 5 QL Anti-HIV Agents, Protease Inhibitors Aptivus (100mg/ml Anti-influenza Agents Relenza Diskhaler Diskhaler Oral Solution, 250mg 5 QL 3 QL Capsule) (Aerosol Powder)

Rimantadine HCl Crixivan Rimantadine HCl Crixivan (Capsule) 3 QL 4

Invirase (Tablet) Invirase (200mg Tamiflu Capsule, 500mg 5 QL Tamiflu (30mg Tablet) Capsule, 45mg

Kaletra Capsule, 75mg 4 QL Kaletra (100mg-25mg Capsule, 6mg/ml Tablet, 4 QL Suspension) 400mg-100mg/5ml Oral Solution) Antivirals

Virazole Kaletra (200mg-50mg Virazole (Inhalation 5 QL 5 Tablet) Solution) Lexiva (50mg/ml Anxiolytics 4 QL Suspension) Anxiolytics, Other

Buspirone HCl Lexiva (700mg Tablet) 5 QL Buspirone HCl (Tablet) 2

Hydroxyzine HCl Norvir (100mg Hydroxyzine HCl Capsule, 100mg (10mg Tablet, 25mg 4 QL 3 Tablet, 80mg/ml Oral Tablet, 50mg Tablet, Solution) 10mg/5ml Syrup)

Hydroxyzine HCl Prezista Hydroxyzine HCl Prezista (100mg/ml Suspension, 150mg (25mg/ml Injection, 4 5 QL Tablet, 600mg Tablet, 50mg/ml Injection) 800mg Tablet) Benzodiazepines

Bold type = Brand name drug Plain type = Generic drug 42 32tRACK 32

Last updated August 1, 2016 43 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Alprazolam (Tablet Lithium Carbonate Carbonate 1 QL Immediate-Release) (150mg Capsule Chlordiazepoxide HCl HCl Immediate-Release, 2 300mg Capsule (Capsule) Clonazepam (Tablet Immediate-Release, 2 2 QL Immediate-Release) 600mg Capsule

Clonazepam ODT Immediate-Release, Clonazepam ODT 4 QL 300mg Tablet (Tablet Dispersible)

Clorazepate Dipotassium Immediate-Release)

Clorazepate Lithium Carbonate ER 2 QL Lithium Carbonate ER Dipotassium (Tablet)

Diazepam (Tablet Extended- 2 Diazepam (10mg Release) Tablet, 2mg Tablet, 2 QL Blood Glucose Regulators 5mg Tablet)

Diazepam Antidiabetic Agents Diazepam (1mg/ml 2 Acarbose Oral Solution) Acarbose (Tablet) 1 QL

Avandia Diazepam Intensol Intensol Avandia (Tablet) 4 PA, QL

2 QL Bydureon (5mg/ml Concentrate) Bydureon (Injection) 3 QL

Lorazepam Lorazepam (Tablet) 1 QL Byetta (Injection) 4 QL

Lorazepam Intensol Lorazepam Intensol Cycloset 2 QL Cycloset (Tablet) 4 PA, QL (2mg/ml Concentrate) Glimepiride Glimepiride (Tablet) 1 QL

Bipolar Agents Glipizide Glipizide (Tablet 1 QL Mood Stabilizers Immediate-Release) Divalproex Sodium Divalproex Sodium Glipizide ER Glipizide ER (Tablet (Capsule Sprinkle 2 Extended-Release 24 1 QL Delayed-Release) Hour) Divalproex Sodium DR Divalproex Sodium DR Glipizide/Metformin HCl Glipizide/Metformin 1 QL (Tablet Delayed- 2 HCl (Tablet)

Release) Invokamet

Divalproex Sodium ER Invokamet (Tablet) 3 QL Divalproex Sodium ER Invokana (Tablet Extended- 2 Invokana (Tablet) 3 QL Janumet (Tablet Release 24 Hour) 3 QL Lithium (Oral Immediate-Release) 3 Solution)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 43 33tRACK 33

44 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Janumet XR XR (Tablet Repaglinide/Metformin HCl 4 QL Extended-Release 24 3 QL HCl (Tablet) Hour) Riomet (Oral Solution) 4 QL

Januvia Januvia (Tablet) 3 QL SymlinPen 120 120

Jardiance 5 PA Jardiance (Tablet) 3 QL (Injection)

SymlinPen 60 Jentadueto SymlinPen 60 Jentadueto (Tablet) 4 QL 5 PA Jentadueto XR XR (Injection)

Synjardy (Tablet Extended- 4 QL Synjardy (Tablet) 3 QL Release 24 Hour) Tradjenta (Tablet) 4 QL

Kombiglyze XR Kombiglyze XR Trulicity (Injection) 3 QL

(Tablet Extended- 3 QL Victoza Victoza (Injection) 3 QL Release 24 Hour)

Metformin HCl Glycemic Agents

Metformin HCl (Tablet GlucaGen HypoKit 1 QL GlucaGen HypoKit Immediate-Release) 4

Metformin HCl ER (Injection)

Metformin HCl ER Glucagon Emergency Kit Glucagon Emergency (500mg Tablet 3 Extended-Release 24 Kit (Injection) Proglycem Hour, 750mg Tablet 1 QL 5 Extended-Release 24 (Suspension) Hour) (Generic Insulins Glucophage XR) Humalog Cartridge Cartridge

Miglitol 3 Miglitol (Tablet) 4 QL (Injection)

Humalog KwikPen Nateglinide Humalog KwikPen Nateglinide (Tablet) 1 QL 3 Onglyza (Injection) Onglyza (Tablet) 3 QL Humalog Mix 50/50 KwikPen

Pioglitazone HCl Humalog Mix 50/50 Pioglitazone HCl 3 1 QL KwikPen (Injection)

(Tablet) Humalog Mix 50/50 Vial

Pioglitazone HCl/Glimepiride Humalog Mix 50/50 Pioglitazone HCl/ 3 1 QL Vial (Injection)

Glimepiride (Tablet) Humalog Mix 75/25 KwikPen

Pioglitazone HCl/Metformin HCl Humalog Mix 75/25 Pioglitazone HCl/ 3 1 QL KwikPen (Injection)

Metformin HCl (Tablet) Humalog Mix 75/25 Vial

Repaglinide Humalog Mix 75/25 Repaglinide (Tablet) 1 QL 3 Vial (Injection)

Bold type = Brand name drug Plain type = Generic drug 44 34tRACK 34

Last updated August 1, 2016 45 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Humalog Vial Vial Enoxaparin Sodium Sodium 3 (Injection) (100mg/ml Injection, Humulin 70/30 KwikPen 70/30 120mg/0.8ml Injection, 3 KwikPen (Injection) 150mg/ml Injection, Humulin 70/30 Vial 70/30 Vial 30mg/0.3ml Injection, 4 QL 3 (Injection) 40mg/0.4ml Injection,

Humulin N KwikPen 60mg/0.6ml Injection, Humulin N KwikPen 3 80mg/0.8ml Injection, (Injection)

Humulin N Vial 300mg/3ml Injection)

Humulin N Vial Fondaparinux Sodium 3 Fondaparinux Sodium (Injection)

Humulin R U-500 KwikPen (10mg/0.8ml Injection, Humulin R U-500 5 3 5mg/0.4ml Injection, KwikPen (Injection) 7.5mg/0.6ml Injection) Humulin R U-500 Vial

Humulin R U-500 Vial Fondaparinux Sodium Fondaparinux Sodium (Concentrated) 4 3 (2.5mg/0.5ml Injection)

(Injection) Heparin Sodium

Humulin R Vial Heparin Sodium Humulin R Vial 4 B/D, PA 3 (Injection)

(Injection) Heparin Sodium/D5W

Lantus SoloStar Heparin Sodium/D5W Lantus SoloStar 4 B/D, PA 3 (Injection)

(Injection) Jantoven

Lantus Vial Jantoven (Tablet) 1 Lantus Vial (Injection) 3 Pradaxa

Levemir FlexTouch Pradaxa (Capsule) 4 PA, QL Levemir FlexTouch 3 Warfarin Sodium Sodium (Injection) 1

Levemir Vial (Tablet) Levemir Vial 3 Xarelto (Injection) Xarelto (Tablet) 3 PA, QL

Xarelto Starter Pack Toujeo SoloStar SoloStar Xarelto Starter Pack 3 3 PA, QL (Injection) (Tablet Therapy Pack) Blood Products/Modifiers/Volume Expanders Blood Formation Modifiers Anagrelide HCl HCl Anticoagulants 2 Coumadin Coumadin (Tablet) 4 (Capsule) Eliquis (Tablet) 3 PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 45 35tRACK 35

46 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Aranesp Albumin Free Albumin Procrit (20000unit/ml Free (100mcg/0.5ml Injection, 40000unit/ 5 PA Injection, 100mcg/ml ml Injection) Injection, 150mcg/ Promacta (Tablet) 5 PA, QL

0.3ml Injection, Zarxio Zarxio (Injection) 5 200mcg/0.4ml Injection, 200mcg/ml Blood Products/Modifiers/Volume 5 PA Injection, 300mcg/ Expanders Argatroban (125mg/ 0.6ml Injection, 5 B/D, PA 300mcg/ml Injection, 125ml-0.9% Injection) 500mcg/ml Injection, Argatroban (250mg/ 5 B/D, PA 60mcg/0.3ml 2.5ml Injection) Injection, 60mcg/ml Coagulants Injection) Tranexamic Acid Acid Aranesp Albumin Free Aranesp Albumin (1000mg/10ml 3 Free (10mcg/0.4ml Injection) Injection, 25mcg/ Tranexamic Acid Acid 0.42ml Injection, 4 4 PA (650mg Tablet) 25mcg/ml Injection, Platelet Modifying Agents

40mcg/0.4ml Aggrenox Aggrenox (Capsule Injection, 40mcg/ml Extended-Release 12 3 PA, QL Injection) Hour) Granix

Granix (Injection) 5 PA Aspirin/Dipyridamole Aspirin/Dipyridamole Leukine Leukine (Injection) 5 PA (Capsule Extended- 3 QL Mozobil (Injection) 5 PA Release 12 Hour)

Brilinta Neulasta (Injection) 5 PA Brilinta (Tablet) 3 QL

Cilostazol Neupogen Neupogen (Injection) 5 PA Cilostazol (Tablet) 2

Clopidogrel Procrit (10000unit/ml Clopidogrel (75mg 2 QL Injection, 2000unit/ Tablet) ml Injection, Effient 4 PA Effient (Tablet) 3 QL 3000unit/ml Cardiovascular Agents Injection, 4000unit/ Alpha-adrenergic Agonists ml Injection)

Bold type = Brand name drug Plain type = Generic drug 46 36tRACK 36

Last updated August 1, 2016 47 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Clonidine HCl Clonidine HCl (0.1mg Valsartan (Tablet) 1 QL Tablet Immediate- Angiotensin-converting Enzyme (ACE) Release, 0.2mg Tablet 1 Inhibitors Immediate-Release, Benazepril HCl Benazepril HCl (Tablet) 1 QL 0.3mg Tablet Captopril Immediate-Release) Captopril (Tablet) 1 QL

Enalapril Maleate Clonidine HCl Enalapril Maleate Clonidine HCl (0.1mg/ 1 QL 24hr Patch Weekly, (Tablet) Epaned Epaned (Oral 0.2mg/24hr Patch 4 4 Weekly, 0.3mg/24hr Solution) Patch Weekly) Fosinopril Sodium Sodium

Methyldopa 1 QL Methyldopa (Tablet) 3 (Tablet)

Lisinopril Methyldopate HCl HCl Lisinopril (Tablet) 1 QL

4 Moexipril HCl (Injection) Moexipril HCl (15mg

Midodrine HCl 1 Midodrine HCl (Tablet) 3 Tablet) Moexipril HCl HCl (7.5mg Alpha-adrenergic Blocking Agents 1 QL Doxazosin Mesylate Mesylate Tablet) 2 Perindopril Erbumine Erbumine (Tablet) 1 QL Phenoxybenzamine HCl (Tablet) 5 Quinapril HCl HCl (Capsule) Quinapril HCl (Tablet) 1 QL

Ramipril Prazosin HCl Prazosin HCl (Capsule) 2 Ramipril (Capsule) 1 QL Angiotensin II Receptor Antagonists Trandolapril (Tablet) 1 QL Benicar (Tablet) 3 QL Antiarrhythmics

Amiodarone HCl Candesartan Cilexetil Cilexetil Amiodarone HCl 1 QL 1 (Tablet) (200mg Tablet)

Amiodarone HCl Edarbi Amiodarone HCl Edarbi (Tablet) 4 QL 4 Eprosartan Mesylate Mesylate (50mg/ml Injection) 1 QL Dofetilide (Tablet) Dofetilide (Capsule) 4

Flecainide Acetate Irbesartan Flecainide Acetate Irbesartan (Tablet) 1 QL 2 Losartan Potassium Potassium (Tablet) 1 QL Mexiletine HCl HCl (Tablet) 2 Telmisartan (Tablet) 1 QL (Capsule)

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48 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Labetalol HCl Multaq Labetalol HCl (100mg Multaq (Tablet) 3 QL Pacerone (200mg Tablet, 200mg Tablet, 2 1 Tablet) 300mg Tablet)

Labetalol HCl Procainamide HCl HCl Labetalol HCl (5mg/ml 4 4 (Injection) Injection)

Metoprolol Succinate ER Propafenone HCl HCl Metoprolol Succinate 2 (Tablet) ER (Tablet Extended- 1 Propafenone HCl ER HCl ER Release 24 Hour) Metoprolol Tartrate (Capsule Extended- 4 Metoprolol Tartrate Release 12 Hour) (100mg Tablet

Quinidine Gluconate Immediate-Release, Quinidine Gluconate 4 (Injection) 25mg Tablet 1

Quinidine Gluconate CR Immediate-Release, Quinidine Gluconate 50mg Tablet CR (Tablet Extended- 4 Immediate-Release)

Release) Metoprolol Tartrate

Quinidine Sulfate Metoprolol Tartrate Quinidine Sulfate 4 2 (1mg/ml Injection)

(Tablet) Nadolol

Sotalol HCl Nadolol (Tablet) 4 Sotalol HCl (AF) 2 Pindolol (Tablet) Pindolol (Tablet) 3

Propranolol HCl

Sotalol HCl Sotalol HCl (Tablet) 2 Propranolol HCl (10mg Tablet Immediate- Beta-adrenergic Blocking Agents

Acebutolol HCl Release, 20mg Tablet Acebutolol HCl 2 Immediate-Release, (Capsule) 40mg Tablet Atenolol Atenolol (Tablet) 1 Immediate-Release,

Betaxolol HCl Betaxolol HCl (10mg 60mg Tablet 2 3 Tablet, 20mg Tablet) Immediate-Release, Bisoprolol Fumarate Fumarate 80mg Tablet 2 (Tablet) Immediate-Release, Bystolic (Tablet) 3 QL 20mg/5ml Oral

Carvedilol Solution, 40mg/5ml Carvedilol (Tablet 1 Oral Solution)

Immediate-Release) Propranolol HCl Propranolol HCl (1mg/ 4 ml Injection)

Bold type = Brand name drug Plain type = Generic drug 48 38tRACK 38

Last updated August 1, 2016 49 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Propranolol HCl ER HCl ER Diltiazem HCl ER HCl ER

(Capsule Extended- 2 (120mg Capsule Release 24 Hour) Extended-Release 12 Timolol Maleate Maleate (10mg Hour, 60mg Capsule

Tablet, 20mg Tablet, 4 Extended-Release 12 5mg Tablet) Hour, 90mg Capsule Calcium Channel Blocking Agents Extended-Release 12

Afeditab CR Hour, 120mg Capsule Afeditab CR (Tablet Extended-Release 24 Extended-Release 24 2 QL 3 Hour, 300mg Capsule Hour)

Amlodipine Besylate Extended-Release 24 Amlodipine Besylate 1 Hour, 180mg Capsule (Tablet) Extended-Release 24 Cardene IV Cardene IV (Injection) 4 Hour, 360mg Capsule Cartia XT XT (Capsule Extended-Release 24

Extended-Release 24 3 Hour, 420mg Capsule Hour) Extended-Release 24 Diltiazem CD CD (Capsule Hour)

Dilt-XR Extended-Release 24 3 Dilt-XR (Capsule

Hour) Extended-Release 24 3 Diltiazem HCl HCl (100mg Hour)

Felodipine ER Injection, 50mg/10ml 4 Felodipine ER (Tablet

Injection) Extended-Release 24 3 Diltiazem HCl HCl (120mg Hour) Tablet Immediate- Matzim LA LA (180mg Release, 30mg Tablet Tablet Extended- Immediate-Release, Release 24 Hour, 2 60mg Tablet 240mg Tablet 3 Immediate-Release, Extended-Release 24 90mg Tablet Hour, 300mg Tablet Immediate-Release) Extended-Release 24 Hour)

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50 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Matzim LA LA (360mg Verapamil HCl ER HCl ER Tablet Extended- (100mg Capsule Release 24 Hour, Extended-Release 24 3 QL 420mg Tablet Hour, 120mg Capsule Extended-Release 24 Extended-Release 24 Hour) Hour, 180mg Capsule Nicardipine HCl HCl Extended-Release 24 4 3 (2.5mg/ml Injection) Hour, 200mg Capsule Nicardipine HCl HCl (20mg Extended-Release 24

Capsule, 30mg 3 Hour, 240mg Capsule Capsule) Extended-Release 24

Nifedical XL Hour, 300mg Capsule Nifedical XL (Tablet Extended-Release 24 Extended-Release 24 2 QL Hour) Hour) Verapamil HCl ER

Nifedipine ER Verapamil HCl ER Nifedipine ER (Tablet (120mg Tablet Extended-Release 24 2 QL Extended-Release, Hour)

Nimodipine 180mg Tablet 2 Nimodipine (Capsule) 5 Extended-Release, Taztia XT XT (Capsule 240mg Tablet Extended-Release 24 3 Extended-Release) Hour) Verapamil HCl SR HCl SR Verapamil HCl Verapamil HCl (120mg (Capsule Extended- 3 Tablet Immediate- Release 24 Hour) Release, 40mg Tablet 2 Cardiovascular Agents, Other Immediate-Release, Amiloride/Hydrochlorothiazide Amiloride/ 80mg Tablet Hydrochlorothiazide 2 Immediate-Release) (Tablet) Verapamil HCl

Verapamil HCl (2.5mg/ Amlodipine Besylate/Atorvastatin Calcium 4 Amlodipine Besylate/ ml Injection) Atorvastatin Calcium 1 QL (Tablet) Amlodipine Besylate/Benazepril HCl Besylate/ Benazepril HCl 1 QL (Capsule)

Bold type = Brand name drug Plain type = Generic drug 50 40tRACK 40

Last updated August 1, 2016 51 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Amlodipine Besylate/Valsartan Besylate/ Digoxin (0.25mg/ml 4 QL 4 Valsartan (Tablet) Injection) Amlodipine/Valsartan/Amlodipine/Valsartan/Hydrochlorothiazide Digoxin (125mcg 2 Hydrochlorothiazide 4 QL Tablet, 250mcg Tablet) (Tablet) Edarbyclor (Tablet) 4 QL

Atenolol/Chlorthalidone Atenolol/ Enalapril Maleate/Hydrochlorothiazide 1 Enalapril Maleate/ Chlorthalidone (Tablet) Hydrochlorothiazide 1 QL Azor (Tablet) 3 QL (Tablet)

Benazepril HCl/Hydrochlorothiazide Benazepril HCl/ Entresto (Tablet) 3 PA, QL Hydrochlorothiazide 1 QL Fosinopril Sodium/Hydrochlorothiazide Sodium/ (Tablet) Hydrochlorothiazide 1 QL Benicar HCT HCT (Tablet) 3 QL (Tablet)

Irbesartan/Hydrochlorothiazide BiDil (Tablet) 3 QL Irbesartan/ Bisoprolol Fumarate/Hydrochlorothiazide Fumarate/ Hydrochlorothiazide 1 QL

Hydrochlorothiazide 2 (Tablet) (10mg-6.25mg Tablet) Lanoxin (125mcg Bisoprolol Fumarate/Hydrochlorothiazide Tablet, 187.5mcg Bisoprolol Fumarate/ Hydrochlorothiazide Tablet, 250mcg 4 2 QL (2.5mg-6.25mg Tablet, Tablet, 62.5mcg 5mg-6.25mg Tablet) Tablet)

Lisinopril/Hydrochlorothiazide Candesartan Cilexetil/Hydrochlorothiazide Cilexetil/ Lisinopril/ Hydrochlorothiazide 1 QL Hydrochlorothiazide 1 QL (Tablet) (Tablet)

Losartan Potassium/Hydrochlorothiazide Captopril/Captopril/Hydrochlorothiazide Losartan Potassium/ Hydrochlorothiazide 1 QL Hydrochlorothiazide 1 QL (Tablet) (Tablet)

Methyldopa/Hydrochlorothiazide Clorpres Methyldopa/ Clorpres (Tablet) 4

Demser Hydrochlorothiazide 3 Demser (Capsule) 5 (Tablet) Digitek Digitek (Tablet) 2 Metoprolol/Metoprolol/Hydrochlorothiazide Digoxin (0.05mg/ml 4 Hydrochlorothiazide 3 Oral Solution) (Tablet)

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52 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Moexipril/Moexipril/Hydrochlorothiazide Triamterene/Triamterene/Hydrochlorothiazide Hydrochlorothiazide 1 QL Hydrochlorothiazide (Tablet) (37.5mg-25mg

Nadolol/Nadolol/Bendroflumethiazide Capsule, 50mg-25mg 2 Bendroflumethiazide 3 QL Capsule, 37.5mg-25mg (40mg-5mg Tablet) Tablet, 75mg-50mg Nadolol/Nadolol/Bendroflumethiazide Tablet) Tribenzor Bendroflumethiazide 3 Tribenzor (Tablet) 3 QL (80mg-5mg Tablet) Valsartan/Valsartan/Hydrochlorothiazide Northera (Capsule) 5 PA, QL Hydrochlorothiazide 1 QL Pentoxifylline ER ER (Tablet)

(Tablet Extended- 2 Diuretics, Carbonic Anhydrase Inhibitors Release) Acetazolamide (Tablet

Propranolol/Hydrochlorothiazide 3 Propranolol/ Immediate-Release)

Acetazolamide ER Hydrochlorothiazide 2 Acetazolamide ER

(Tablet) (Capsule Extended- 4 Quinapril/Quinapril/Hydrochlorothiazide Release 12 Hour) Hydrochlorothiazide 1 QL Acetazolamide Sodium Sodium 4 (Tablet) (Injection) Ranexa (Tablet Methazolamide 4 Extended-Release 12 3 QL (Tablet) Hour) Diuretics, Loop

Spironolactone/Hydrochlorothiazide Spironolactone/ Bumetanide (0.25mg/ 4 Hydrochlorothiazide 2 ml Injection) (Tablet) Bumetanide (0.5mg Telmisartan/Telmisartan/Amlodipine 1 QL Tablet, 1mg Tablet, 1 Amlodipine (Tablet) 2mg Tablet)

Telmisartan/Hydrochlorothiazide Edecrin Telmisartan/ Edecrin (Tablet) 5 Hydrochlorothiazide 1 QL Furosemide (10mg/ml 4 B/D, PA (Tablet) Injection) Furosemide (10mg/ml

Oral Solution, 8mg/ml 2 Oral Solution)

Bold type = Brand name drug Plain type = Generic drug 52 42tRACK 42

Last updated August 1, 2016 53 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Furosemide (20mg Fenofibrate Micronized Micronized

Tablet, 40mg Tablet, 1 (134mg Capsule, 3 80mg Tablet) 200mg Capsule, 67mg

Torsemide Torsemide (Tablet) 2 Capsule) Fenofibric Acid Acid Diuretics, Potassium-sparing 3 Amiloride HCl (Tablet) Amiloride HCl (Tablet) 2 Fenofibric Acid DR

Dyrenium Fenofibric Acid DR Dyrenium (Capsule) 4 (Capsule Delayed- 3 Eplerenone Eplerenone (Tablet) 3 Release)

Spironolactone Spironolactone Gemfibrozil 2 Gemfibrozil (Tablet) 2 (Tablet) Dyslipidemics, HMG CoA Reductase Diuretics, Thiazide Inhibitors

Chlorothiazide Chlorothiazide (Tablet) 2 Atorvastatin Calcium Calcium

Chlorothiazide Sodium 1 QL Chlorothiazide Sodium (Tablet) 4 B/D, PA (Injection) Crestor (Tablet) 3 QL

Chlorthalidone Chlorthalidone (Tablet) 2 Fluvastatin (Capsule

Diuril 1 QL Diuril (Suspension) 4 Immediate-Release)

Lovastatin Hydrochlorothiazide Lovastatin (Tablet Hydrochlorothiazide 1 QL (12.5mg Capsule, Immediate-Release)

1 Pravastatin Sodium 12.5mg Tablet, 25mg Pravastatin Sodium 1 QL Tablet, 50mg Tablet) (Tablet)

Indapamide Rosuvastatin Calcium Indapamide (Tablet) 2 Rosuvastatin Calcium 3 QL Methyclothiazide (Tablet)

3 Simvastatin (Tablet) Simvastatin (Tablet) 1 QL

Metolazone Metolazone (Tablet) 3 Dyslipidemics, Other Dyslipidemics, Fibric Acid Derivatives Cholestyramine Light Light 4 Fenofibrate (145mg (Packet) 3 Colestipol HCl Tablet, 48mg Tablet) Colestipol HCl (1gm 3 Fenofibrate (160mg Tablet) 1 Colestipol HCl Tablet, 54mg Tablet) Colestipol HCl (5gm 4 Granules) Juxtapid (Capsule) 5 PA

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54 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Isosorbide Dinitrate ER Kynamro Isosorbide Dinitrate ER Kynamro (Injection) 5 PA Niacin ER ER (Tablet (Tablet Extended- 2 4 Extended-Release) Release)

Isosorbide Mononitrate Niacor Isosorbide Mononitrate Niacor (Tablet) 2

Omega-3-Acid Ethyl Esters (Tablet Immediate- 2 Omega-3-Acid Ethyl Release)

Esters (Capsule) 4 QL Isosorbide Mononitrate ER Isosorbide Mononitrate (Generic Lovaza)

Praluent ER (Tablet Extended- 2 Praluent (Injection) 5 PA, QL, LA Release 24 Hour) Prevalite Prevalite (Powder) 4 Minitran (Patch 24 Repatha 2 Repatha (Injection) 5 PA, QL Hour)

Repatha SureClick Nitro-Bid Repatha SureClick Nitro-Bid (Ointment) 4 5 PA, QL Nitroglycerin (Injection) Nitroglycerin (Injection) 4 Vascepa Vascepa (Capsule) 4 Nitroglycerin Lingual Lingual Vytorin 1 Vytorin (Tablet) 4 QL (Translingual Solution) Welchol (3.75gm Nitroglycerin Transdermal

Packet, 625mg 3 Transdermal (Patch 24 2 Tablet) Hour) Zetia (Tablet) 3 QL Nitrostat (Tablet 3 Vasodilators, Direct-acting Arterial Sublingual) Hydralazine HCl HCl Central Nervous System Agents (100mg Tablet, 10mg Attention Deficit Hyperactivity Disorder 2 Tablet, 25mg Tablet, Agents, Amphetamines 50mg Tablet) Hydralazine HCl HCl 4 (20mg/ml Injection)

Minoxidil Minoxidil (Tablet) 2 Vasodilators, Direct-acting Arterial/Venous Isosorbide Dinitrate Dinitrate

(Tablet Immediate- 2 Release)

Bold type = Brand name drug Plain type = Generic drug 54 44tRACK 44

Last updated August 1, 2016 55 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Amphetamine/Amphetamine/Dextroamphetamine Dextroamphetamine Sulfate Dextroamphetamine Sulfate (10mg Tablet (10mg Capsule Immediate-Release, 4 QL Extended-Release 24 5mg Tablet Immediate- Hour, 15mg Capsule Release) Extended-Release 24 Dextroamphetamine Sulfate ER Hour, 20mg Capsule Sulfate ER (Capsule 4 QL Extended-Release 24 4 QL Extended-Release 24 Hour, 25mg Capsule Hour)

Vyvanse Extended-Release 24 Vyvanse (Capsule) 4 Hour, 30mg Capsule Attention Deficit Hyperactivity Disorder Extended-Release 24 Agents, Non-amphetamines Hour, 5mg Capsule Clonidine HCl ER Extended-Release 24 Clonidine HCl ER Hour) (Tablet Extended- 4 PA

Amphetamine/Dextroamphetamine Release 12 Hour) Amphetamine/ Dexmethylphenidate HCl Dextroamphetamine Dexmethylphenidate (10mg Tablet HCl (Tablet Immediate- 3 QL Immediate-Release, Release)

Dexmethylphenidate HCl ER 12.5mg Tablet Dexmethylphenidate HCl ER (Capsule Immediate-Release, 4 15mg Tablet Extended-Release 24 Immediate-Release, 3 QL Hour) 20mg Tablet Guanfacine ER ER (Tablet

Immediate-Release, Extended-Release 24 4 30mg Tablet Hour) Immediate-Release, Metadate ER ER (Tablet 4 QL 5mg Tablet Immediate- Extended-Release) Release, 7.5mg Tablet Immediate-Release) Dexedrine (10mg 4 QL Tablet, 5mg Tablet)

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56 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Methylphenidate HCl HCl Duloxetine HCl HCl (20mg (10mg Tablet Capsule Delayed- Immediate-Release, Release, 30mg 20mg Tablet Capsule Delayed- 3 QL 3 QL Immediate-Release, Release, 60mg 5mg Tablet Immediate- Capsule Delayed- Release) (Generic Release) Ritalin) Lyrica (100mg Methylphenidate HCl HCl Capsule, 150mg (10mg/5ml Oral Capsule, 200mg 4 QL Solution, 5mg/5ml Oral Capsule, 225mg Solution) Capsule, 25mg

Methylphenidate HCl ER 3 QL Methylphenidate HCl Capsule, 300mg ER (10mg Tablet Capsule, 50mg Extended-Release, 4 QL Capsule, 75mg 20mg Tablet Extended- Capsule, 20mg/ml Release) Oral Solution)

Savella Strattera (Capsule) 4 QL, ST Savella (Tablet) 3

Savella Titration Pack Central Nervous System, Other Savella Titration Pack 3 Namzaric (Capsule Multiple Sclerosis Agents Extended-Release 24 3 PA, QL Ampyra (Tablet Hour) Extended-Release 12 5 PA, QL Nuedexta (Capsule) 4 PA Hour)

Aubagio Rilutek Rilutek (Tablet) 5 Aubagio (Tablet) 5 PA, QL

Avonex Riluzole Riluzole (Tablet) 3 Avonex (Injection) 5 PA

Avonex Pen Tetrabenazine Avonex Pen Tetrabenazine (Tablet) 5 PA, QL 5 PA Xenazine (Injection) Xenazine (Tablet) 5 PA, QL, LA Betaseron (Injection) 5 PA Fibromyalgia Agents Copaxone (Injection) 5 PA Gilenya (Capsule) 5 PA, QL Glatopa (Injection) 5 PA Rebif (Injection) 5 PA

Bold type = Brand name drug Plain type = Generic drug 56 46tRACK 46

Last updated August 1, 2016 57 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Rebif Rebidose Rebidose Calcipotriene (0.005% 5 PA (Injection) Cream, 0.005% 4 Rebif Rebidose Titration Pack Rebidose External Solution) Titration Pack 5 PA Calcitriol (3mcg/gm 4 (Injection) Ointment)

Rebif Titration Pack Rebif Titration Pack Carac (Cream) 5 PA 5 PA (Injection) Claravis (Capsule) 4 PA

Tecfidera Tecfidera (Capsule Clindamycin Phosphate 5 PA, QL Clindamycin Delayed-Release) Phosphate (1% Tecfidera Starter Pack Starter 5 PA External Solution, 1% 3 Pack Gel, 1% Lotion, 1% Tysabri (Injection) 5 PA Swab) Clindamycin/Benzoyl Peroxide Dental and Oral Agents Dental and Oral Agents Peroxide (1%-5% Gel) 4 Chlorhexidine Gluconate Oral Rinse (Generic BenzaClin) Clotrimazole/Betamethasone Dipropionate Gluconate Oral Rinse 2 Clotrimazole/ Betamethasone (Solution) 3 Kepivance Kepivance (Injection) 5 Dipropionate

Periogard (1%-0.05% Cream)

Periogard (Solution) 2 Clotrimazole/Betamethasone Dipropionate

Pilocarpine HCl Clotrimazole/ Pilocarpine HCl (5mg Betamethasone 4 4 Tablet, 7.5mg Tablet) Dipropionate Triamcinolone in Orabase in 3 (1%-0.05% Lotion) Orabase (Paste) Cortisporin

Dermatological Agents (0.5%-0.5% Cream, 4 Dermatological Agents 1%-0.5% Ointment)

8-MOP Diclofenac Sodium 8-MOP (Capsule) 4 Diclofenac Sodium 5 PA Acitretin Acitretin (Capsule) 4 (3% Gel)

Doxepin HCl Adapalene (0.1% Doxepin HCl (Cream) 3

4 Elidel Cream, 0.1% Gel) Elidel (Cream) 4 ST

Ammonium Lactate Ery Ammonium Lactate Ery (2% Pad) 3 (12% Cream, 12% 3 Erythromycin (2% 2 Lotion) External Solution)

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58 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Tretinoin Erythromycin Erythromycin (2% Gel) 4 Tretinoin (0.01% Gel, Erythromycin/Benzoyl Peroxide 0.025% Gel, 0.025% 4 4 PA Peroxide (Gel) Cream, 0.05% Cream, Fluorouracil (0.5% 0.1% Cream) 5 Tretinoin Microsphere Microsphere Cream) 4 PA Fluorouracil (2% (Gel) Uvadex External Solution, 5% 3 Uvadex (Injection) 4 External Solution) Zyclara (Cream) 5 PA

Fluorouracil Fluorouracil (5% Zyclara Pump Pump 4 5 PA Cream) (Cream)

Imiquimod Imiquimod (Cream) 4 Enzyme Replacement/Modifiers

Methoxsalen Methoxsalen (Capsule) 5 Enzyme Replacement/Modifiers

Adagen Mirvaso (Gel) 4 PA Adagen (Injection) 5 LA

Aldurazyme Oxsoralen Ultra Ultra Aldurazyme 5 5 (Capsule) (Injection)

Buphenyl Picato Buphenyl (3gm/tsp Picato (Gel) 3 Podofilox Powder, 500mg Podofilox (External 5 3 Tablet) Solution) Cerezyme

PRUDOXIN Cerezyme (Injection) PRUDOXIN (Cream) 3 5 PA Creon

Regranex Creon (Capsule Regranex (Gel) 5 PA 3 Delayed-Release) Santyl

Santyl (Ointment) 4 Cystadane Cystadane (Powder) 5 Selenium Sulfide

Selenium Sulfide Cystagon 2 Cystagon (Capsule) 4 LA (Lotion) Elaprase Solaraze Elaprase (Injection) Solaraze (Gel) 5 PA 5

Elelyso

Soriatane Elelyso (Injection) Soriatane (Capsule) 5 5 PA, LA Fabrazyme Tacrolimus (0.03% Fabrazyme (Injection) 5

Kuvan Ointment, 0.1% 4 ST Kuvan (100mg Packet, 500mg Ointment) 5 Tazorac (0.05% Packet, 100mg Tablet 4 PA Cream, 0.1% Cream) Soluble)

Lumizyme Lumizyme (Injection) 5

Bold type = Brand name drug Plain type = Generic drug 58 48tRACK 48

Last updated August 1, 2016 59 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Naglazyme Naglazyme (Injection) 5 Gastrointestinal Agents, Other

Chenodal Orfadin Orfadin (10mg Chenodal (Tablet) 5 Capsule, 2mg Cholbam (Capsule) 5 PA Capsule, 5mg 5 LA Cromolyn Sodium Sodium

Capsule, 4mg/ml (100mg/5ml 4 Suspension) Concentrate) Procysbi Procysbi (Capsule Diphenoxylate/Atropine 5 Diphenoxylate/ Delayed-Release) Atropine

RAVICTI RAVICTI (Liquid) 5 QL (2.5mg-0.025mg

Sodium Phenylbutyrate 4 Sodium Phenylbutyrate Tablet, 5 (Powder) 2.5mg-0.025mg/5ml Strensiq (Injection) 5 PA, LA Liquid)

Gattex Sucraid (Oral Gattex (Injection) 5 PA

5 LA Loperamide HCl Solution) Loperamide HCl 2 VPRIV (Injection) 5 PA (Capsule)

Relistor Zavesca (Capsule) 5 PA, LA Relistor (Injection) 5 PA

Serostim Zenpep (Capsule Serostim (Injection) 5 PA

3 Ursodiol Delayed-Release) Ursodiol (250mg

Gastrointestinal Agents Tablet, 500mg Tablet, 4 Antispasmodics, Gastrointestinal 300mg Capsule)

Zorbtive Atropine Sulfate Sulfate Zorbtive (Injection) 5 PA 4 (Injection) Histamine2 (H2) Receptor Antagonists

Cuvposa Cimetidine Cuvposa (Oral Cimetidine (Tablet) 2 4 Solution) Cimetidine HCl HCl (Oral Dicyclomine HCl 2 Dicyclomine HCl Solution) (10mg Capsule, 10mg/ Famotidine (20mg 2 2 5ml Oral Solution, Tablet, 40mg Tablet) 20mg Tablet) Famotidine (20mg/2ml Glycopyrrolate (4mg/ 5 Injection, 40mg/5ml 4 20ml Injection) Suspension)

Methscopolamine Bromide Methscopolamine Famotidine Premixed Premixed 4 4 Bromide (Tablet) (Injection)

You can find information on what the symbols and abbreviations in this table mean by going to page 7. 59 49tRACK 49

60 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Ranitidine HCl HCl (150mg PEG-3350/NaCl/Na Bicarbonate/KCl 2 Tablet, 300mg Tablet) Bicarbonate/KCl (Oral

Ranitidine HCl 3 Ranitidine HCl Solution) (Generic

(150mg/6ml Injection, 4 NuLYTELY) 15mg/ml Syrup) Polyethylene Glycol 3350 Powder Glycol

Irritable Bowel Syndrome Agents 3350 Powder (Generic 2 Alosetron HCl HCl (Tablet) 5 PA MiraLAX)

Suprep Bowel Prep

Amitiza Suprep Bowel Prep Amitiza (Capsule) 3 QL 3 (Oral Solution) Linzess

Linzess (Capsule) 3 QL TriLyte TriLyte (Oral Solution) 1 Lotronex (Tablet) 5 PA Protectants Laxatives Carafate (1gm/10ml Constulose (Oral 4 2 Suspension) Solution) Misoprostol Misoprostol (Tablet) 3 Enulose

Enulose (Oral Solution) 2 Sucralfate Sucralfate (Tablet) 2 GaviLyte-C (Oral 2 Proton Pump Inhibitors

Solution) Dexilant

GaviLyte-G Dexilant (Capsule GaviLyte-G (Oral 4 QL 2 Delayed-Release)

Solution) Esomeprazole Magnesium

GaviLyte-H Esomeprazole GaviLyte-H (Kit) 3 Magnesium (Capsule GaviLyte-N/Flavor Pack 3 QL 1 Delayed-Release) Pack (Oral Solution) (Generic Nexium)

Generlac Generlac (Oral Esomeprazole Sodium Sodium 2 4 Solution) (Injection)

Lactulose Lactulose (Oral Nexium 2 Nexium (10mg Solution) Packet, 2.5mg PEG-3350/Electrolytes PEG-3350/ Packet, 20mg Packet, 3 Electrolytes (Oral 3 40mg Packet, 5mg Solution) (Generic Packet) GoLYTELY)

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Last updated August 1, 2016 61 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Nexium (20mg Benign Prostatic Hypertrophy Agents Capsule Delayed- Alfuzosin HCl ER HCl ER

Release, 40mg 3 QL (Tablet Extended- 2 Capsule Delayed- Release 24 Hour) Release) Finasteride (5mg Omeprazole Omeprazole (10mg Tablet) (Generic 1 Capsule Delayed- Proscar) Release, 40mg 2 QL Rapaflo (Capsule) 3 QL

Capsule Delayed- Tamsulosin HCl Tamsulosin HCl Release) 1

Omeprazole (Capsule)

Omeprazole (20mg Terazosin HCl Terazosin HCl Capsule Delayed- 2 2 (Capsule) Release)

Pantoprazole Sodium Genitourinary Agents, Other Pantoprazole Sodium Bethanechol Chloride (20mg Tablet Delayed- Bethanechol Chloride 1 QL 2 Release, 40mg Tablet (Tablet) Delayed-Release) Cuprimine (Capsule) 5 PA

Depen Titratabs Prilosec (10mg Depen Titratabs 5 Packet, 2.5mg 4 PA (Tablet)

Elmiron Packet) Elmiron (Capsule) 4

Lithostat Genitourinary Agents Lithostat (Tablet) 5 Antispasmodics, Urinary Phosphate Binders

Myrbetriq Myrbetriq (Tablet Calcium Acetate Acetate 3 Extended-Release 24 3 (Capsule)

Hour) Eliphos

Oxybutynin Chloride Eliphos (Tablet) 4

Oxybutynin Chloride Fosrenol Fosrenol (1000mg (5mg Tablet 2 Packet, 750mg Immediate-Release, Packet, 1000mg 5mg/5ml Syrup)

Oxybutynin Chloride ER Tablet Chewable, 5 Oxybutynin Chloride 500mg Tablet ER (Tablet Extended- 3 QL Chewable, 750mg Release 24 Hour) Tablet Chewable) Vesicare

Vesicare (Tablet) 3 QL PhosLo PhosLo (Capsule) 3

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62 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Phoslyra (Oral Betamethasone Valerate 3 Solution) Valerate (0.1% Cream, 4 Renagel (Tablet) 3 ST 0.1% Lotion, 0.1% Renvela (0.8gm Ointment) Clobetasol Propionate Packet, 2.4gm Clobetasol Propionate 3 Packet, 800mg (0.05% External 3 Tablet) Solution)

Clobetasol Propionate Velphoro (Tablet Clobetasol Propionate 5 (0.05% Gel, 0.05% Chewable) 4 Hormonal Agents, Stimulant/Replacement/ Ointment, 0.05% Modifying (Adrenal) Shampoo) Clobetasol Propionate E Propionate Hormonal Agents, Stimulant/Replacement/ 4 Modifying (Adrenal) E (Cream) Cordran Tape

A-Hydrocort A-Hydrocort (Injection) 4 Cordran Tape (Tape) 4

Cormax Scalp Application

Ala Cort Cormax Scalp Ala Cort (Cream) 2

Alclometasone Dipropionate Application (External 3 Alclometasone Solution)

Dipropionate (0.05% Cortisone Acetate 3 Cortisone Acetate Cream, 0.05% 4 (Tablet) Ointment) Depo-Medrol

Augmented Betamethasone Dipropionate Depo-Medrol (20mg/ Augmented 4 ml Injection) Betamethasone 4 Desonide (0.05% Dipropionate (0.05% 4 Cream) Ointment)

Desoximetasone Augmented Betamethasone Dipropionate Desoximetasone Augmented Betamethasone (0.05% Cream, 0.25% 4

Dipropionate (0.05% 3 Cream)

Dexamethasone Gel, 0.05% Lotion, Dexamethasone 0.05% Ointment) (0.5mg Tablet, 0.75mg

Betamethasone Dipropionate Tablet, 1.5mg Tablet, Betamethasone Dipropionate (0.05% 1mg Tablet, 2mg 2 4 Cream, 0.05% Lotion, Tablet, 4mg Tablet, 0.05% Ointment) 6mg Tablet, 0.5mg/ 5ml Elixir)

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Last updated August 1, 2016 63 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Dexamethasone Intensol Hydrocortisone (10mg

Intensol (1mg/ml 2 Tablet, 20mg Tablet, 3 Concentrate) 5mg Tablet, 2.5% Dexamethasone Sodium Phosphate Lotion) Sodium Phosphate Hydrocortisone Butyrate 4 (10mg/ml Injection, Butyrate (0.1% 3 120mg/30ml Injection) Ointment) Fludrocortisone Acetate Hydrocortisone Valerate 2 Acetate (Tablet) Valerate (0.2% Cream, 4 Fluocinolone Acetonide 0.2% Ointment)

Kenalog-10 Acetonide (0.01% Kenalog-10 (Injection) 4

Cream, 0.025% Cream, Kenalog-40 4 Kenalog-40 (Injection) 4

0.01% External Methylprednisolone Methylprednisolone Solution, 0.025% 2 (Tablet)

Ointment) Methylprednisolone Acetate

Fluocinolone Acetonide Body Methylprednisolone Fluocinolone 4 4 Acetate (Injection)

Acetonide Body (Oil) Methylprednisolone Dose Pack

Fluocinonide Methylprednisolone Fluocinonide (0.05% Dose Pack (Tablet 2 External Solution, 3 Therapy Pack)

0.05% Gel, 0.05% Methylprednisolone Sodium Succinate Methylprednisolone Ointment)

Fluocinonide-E Sodium Succinate 4 Fluocinonide-E 3 (Injection)

(Cream) Mometasone Furoate

Fluticasone Propionate Mometasone Furoate Fluticasone Propionate (0.1% Cream, 0.1% (0.005% Ointment, 3 3 External Solution, 0.1% 0.05% Cream)

Halobetasol Propionate Ointment)

Halobetasol Prednicarbate Prednicarbate (0.1% Propionate (0.05% 4 4 Cream)

Cream, 0.05% Prednicarbate Prednicarbate (0.1% Ointment) 4

Hydrocortisone Ointment) Hydrocortisone (1% Cream, 2.5% Cream, 2 1% Ointment, 2.5% Ointment)

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64 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Prednisolone Sodium Phosphate Sodium Chorionic Gonadotropin Phosphate (15mg/5ml Gonadotropin 4 PA Oral Solution, 25mg/ (Injection)

2 Desmopressin Acetate 5ml Oral Solution, Desmopressin

5mg/5ml Oral Acetate (0.01% Nasal 3 Solution) Rhinal Tube Solution)

Prednisone Prednisone (10mg Desmopressin Acetate Acetate Tablet, 1mg Tablet, (0.01% Nasal Spray 4 2.5mg Tablet, 20mg 1 Solution, 4mcg/ml Tablet, 50mg Tablet, Injection) 5mg Tablet) Desmopressin Acetate Acetate Prednisone (5mg/5ml 2 (0.1mg Tablet, 0.2mg 3 Oral Solution) Tablet)

Prednisone Intensol Prednisone Intensol Genotropin 2 Genotropin (12mg (5mg/ml Concentrate) Injection, 5mg 5 PA

Solu-Cortef Solu-Cortef (Injection) 4 Injection)

Genotropin Miniquick Solu-Medrol (2gm Genotropin Miniquick 4 4 PA Injection) (0.2mg Injection)

Genotropin Miniquick Triamcinolone Acetonide Genotropin Miniquick Acetonide (0.025% (0.4mg Injection, Cream, 0.1% Cream, 0.6mg Injection,

0.5% Cream, 0.025% 3 0.8mg Injection, 1.2mg Injection, Ointment, 0.1% 5 PA Ointment, 0.5% 1.4mg Injection, Ointment) 1.6mg Injection, Triamcinolone Acetonide 1.8mg Injection, 1mg

Acetonide (0.025% 4 Injection, 2mg Lotion, 0.1% Lotion) Injection)

Humatrope

Triderm Triderm (Cream) 3 Humatrope (Injection) 5 PA Humatrope Combo Pack Combo Hormonal Agents, Stimulant/Replacement/ 5 PA Modifying (Pituitary) Pack (Injection)

Increlex Hormonal Agents, Stimulant/Replacement/ Increlex (Injection) 5 PA Modifying (Pituitary)

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Last updated August 1, 2016 65 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Norditropin FlexPro FlexPro Testosterone Cypionate 5 PA 4 (Injection) Cypionate (Injection)

Testosterone Enanthate Novarel (Injection) 4 PA Testosterone 4 Nutropin AQ AQ Enanthate (Injection) 5 PA (Injection) Estrogens

Amethia Pregnyl w/Diluent Benzyl Alcohol/NaCl Pregnyl w/Diluent Amethia (Tablet) 4

Amethyst Benzyl Alcohol/NaCl 4 PA Amethyst (Tablet) 4

(Injection) Apri Apri (Tablet) 4 Saizen

Saizen (Injection) 5 PA Aranelle Aranelle (Tablet) 4 Zomacton

Zomacton (10mg Ashlyna 5 PA Ashlyna (Tablet) 4 Injection) Aubra Hormonal Agents, Stimulant/Replacement/ Aubra (Tablet) 4

Aviane Modifying (Prostaglandins) Aviane (Tablet) 4

Balziva Hormonal Agents, Stimulant/Replacement/ Balziva (Tablet) 4

Bekyree Modifying (Prostaglandins) Bekyree (Tablet) 4

Korlym

Blisovi 24 Fe Korlym (Tablet) 5 PA, QL Blisovi 24 Fe (Tablet) 4 Hormonal Agents, Stimulant/Replacement/ Blisovi Fe 1.5/30 Fe 1.5/30 4 Modifying (Sex Hormones/Modifiers) (Tablet)

Androgens Blisovi Fe 1/20 Blisovi Fe 1/20 (Tablet) 4 Anadrol-50

Anadrol-50 (Tablet) 5 PA Briellyn Briellyn (Tablet) 4 Androderm

Androderm (Patch 24 Climara Pro 3 PA, QL Climara Pro (Patch Hour) 4 Weekly) AndroGel

AndroGel (1.62% Cryselle-28 3 PA Cryselle-28 (Tablet) 4 Packet Gel) Cyclafem AndroGel Pump Pump Cyclafem (Tablet) 4 3 PA Delyla (1.62% Gel) Delyla (Tablet) 4

Depo-Estradiol Danazol Depo-Estradiol Danazol (Capsule) 4 4 Oxandrolone (10mg (Injection) 4 PA, QL Desogestrel/Ethinyl Estradiol Tablet) 4 Oxandrolone (2.5mg Estradiol (Tablet) 3 PA, QL Drospirenone/Ethinyl Estradiol Tablet) 4 Estradiol (Tablet)

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66 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Duavee Juleber Duavee (Tablet) 4 Juleber (Tablet) 4

Elestrin Junel 1.5/30 Elestrin (Gel) 4 Junel 1.5/30 (Tablet) 4

Emoquette Junel 1/20 Emoquette (Tablet) 4 Junel 1/20 (Tablet) 4

Junel Fe 1.5/30 Enpresse-28 Enpresse-28 (Tablet) 4 Junel Fe 1.5/30 4 Estrace (0.1mg/gm (Tablet) 4 Junel Fe 1/20 Cream) Junel Fe 1/20 (Tablet) 4

Estradiol Junel Fe 24 Estradiol (0.025mg/ Junel Fe 24 (Tablet) 4 24hr Patch Weekly, Kaitlib Fe Fe (Tablet 4 0.05mg/24hr Patch Chewable)

Weekly, 0.06mg/24hr Kariva Kariva (Tablet) 4 Patch Weekly, 3 QL Kelnor 1/35 0.075mg/24hr Patch Kelnor 1/35 (Tablet) 4

Kimidess Weekly, 0.1mg/24hr Kimidess (Tablet) 4

LARIN 1.5/30 Patch Weekly, LARIN 1.5/30 (Tablet) 4

37.5mcg/24hr Patch LARIN 1/20 LARIN 1/20 (Tablet) 4

Weekly) LARIN Fe 1.5/30

Estradiol LARIN Fe 1.5/30 Estradiol (0.5mg 4 (Tablet) Tablet, 1mg Tablet, 3 LARIN Fe 1/20 2mg Tablet) (Generic LARIN Fe 1/20 (Tablet) 4 Layolis Fe Fe (Tablet Estrace) 4 Estradiol Valerate Valerate Chewable) 4 Leena (Injection) Leena (Tablet) 4

Estring Lessina Estring (Ring) 4 Lessina (Tablet) 4

Falmina Levonest Falmina (Tablet) 4 Levonest (Tablet) 4

Levonorgestrel and Ethinyl Estradiol Femring Levonorgestrel and Femring (Ring) 4 Gianvi Gianvi (Tablet) 4 Ethinyl Estradiol 4

Gildagia (Tablet)

Gildagia (Tablet) 4 Levonorgestrel/Ethinyl Estradiol

Gildess 1.5/30 Levonorgestrel/Ethinyl 4 Gildess 1.5/30 (Tablet) 4 Estradiol (Tablet)

Gildess 24 Fe Gildess 24 Fe (Tablet) 4 Levora 0.15/30-28 0.15/30-28

Introvale 4 Introvale (Tablet) 4 (Tablet)

Lomedia 24 Fe Jinteli Jinteli (Tablet) 4 Lomedia 24 Fe (Tablet) 4

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Nortrel 0.5/35 Loryna Loryna (Tablet) 4 Nortrel 0.5/35 (28) 4 Lutera Lutera (Tablet) 4 (Tablet) Nortrel 1/35

Marlissa Marlissa (Tablet) 4 Nortrel 1/35 (Tablet) 4 Nortrel 7/7/7

Menest Menest (Tablet) 3 Nortrel 7/7/7 (Tablet) 4 NuvaRing Microgestin 1.5/30 1.5/30 NuvaRing (Ring) 4 4 Ocella (Tablet) Ocella (Tablet) 4

Microgestin 1/20 Ogestrel Microgestin 1/20 Ogestrel (Tablet) 4 4 Orsythia (Tablet) Orsythia (Tablet) 4

Microgestin Fe Microgestin Fe Pimtrea 4 Pimtrea (Tablet) 4

(Tablet) Pirmella 1/35

Microgestin Fe 1.5/30 Pirmella 1/35 (Tablet) 4 Microgestin Fe 1.5/30 4 Portia-28 (Tablet) Portia-28 (Tablet) 4

Premarin

MonoNessa MonoNessa (Tablet) 4 Premarin (0.3mg

Necon 0.5/35-28 Tablet, 0.45mg Necon 0.5/35-28 4 Tablet, 0.625mg 4 QL (Tablet) Tablet, 0.9mg Tablet, Necon 1/35 Necon 1/35 (Tablet) 4 1.25mg Tablet)

Necon 1/50-28 Necon 1/50-28 Premarin (Vaginal 4 3 (Tablet) Cream)

Necon 10/11-28 Necon 10/11-28 Premphase 4 Premphase (Tablet) 4

(Tablet) Prempro

Necon 7/7/7 Prempro (Tablet) 4 QL

Necon 7/7/7 (Tablet) 4 Previfem

Nikki Previfem (Tablet) 4

Nikki (Tablet) 4 Quasense

Norethindrone & Ethinyl Estradiol Ferrous Fumarate Quasense (Tablet) 4 Norethindrone & Reclipsen Ethinyl Estradiol Reclipsen (Tablet) 4 4 Setlakin Ferrous Fumarate Setlakin (Tablet) 4

Sprintec 28 (Tablet Chewable) Sprintec 28 (Tablet) 4

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Sronyx Norethindrone Sronyx (Tablet) 4

Acetate/Ethinyl Tarina Fe 1/20 4 Tarina Fe 1/20 (Tablet) 4 Estradiol/Ferrous Tri-Legest Fe Fumarate (Tablet) Tri-Legest Fe (Tablet) 4

Tri-Lo-Estarylla Norgestimate/Ethinyl Estradiol Norgestimate/Ethinyl Tri-Lo-Estarylla (Tablet) 4

4 Tri-Lo-Sprintec Estradiol (Tablet) Tri-Lo-Sprintec (Tablet) 4

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68 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Medroxyprogesterone Acetate Trinessa Trinessa (Tablet) 4 Medroxyprogesterone

Tri-Previfem Acetate (10mg Tablet, Tri-Previfem (Tablet) 4 2

Tri-Sprintec 2.5mg Tablet, 5mg Tri-Sprintec (Tablet) 4 Tablet) Trivora-28 Trivora-28 (Tablet) 4 Medroxyprogesterone Acetate Vagifem Vagifem (Tablet) 4 QL Acetate (150mg/ml 4

Velivet Velivet (Tablet) 4 Injection)

Megace ES Vestura Megace ES Vestura (Tablet) 4 5

Vienva (Suspension)

Vienva (Tablet) 4 Megestrol Acetate

Vyfemla Megestrol Acetate Vyfemla (Tablet) 4 (20mg Tablet, 40mg WYMZYA Fe Fe (Tablet 3 4 Tablet, 40mg/ml Chewable) Suspension)

Xulane Xulane (Patch Weekly) 4 Megestrol Acetate Acetate

Zenchent Zenchent (Tablet) 4 (625mg/5ml 4 Zenchent Fe Fe (Tablet Suspension) 4 Nora-BE Chewable) Nora-BE (Tablet) 3

Norethindrone Zovia 1/35E Zovia 1/35E (Tablet) 4 Norethindrone (Tablet) 3

Norethindrone Acetate Zovia 1/50E Norethindrone Acetate Zovia 1/50E (Tablet) 4 2 Progestins (Tablet) Norlyroc Camila Camila (Tablet) 3 Norlyroc (Tablet) 3

Progesterone Crinone Progesterone Crinone (Gel) 4 PA 2 PA

Deblitane (Capsule)

Deblitane (Tablet) 3 Sharobel

Depo-Provera Sharobel (Tablet) 3 Depo-Provera 4 Selective Estrogen Receptor Modifying (Injection)

Errin Agents

Errin (Tablet) 3 Raloxifene HCl

Hydroxyprogesterone Caproate Raloxifene HCl (Tablet) 3 QL Hydroxyprogesterone 5 PA Hormonal Agents, Stimulant/Replacement/ Caproate (Injection)

Jolivette Modifying (Thyroid) Jolivette (Tablet) 3 Hormonal Agents, Stimulant/Replacement/ Lyza Lyza (Tablet) 3 Modifying (Thyroid) Makena (Injection) 5 PA

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Last updated August 1, 2016 69 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Levothyroxine Sodium Hormonal Agents, Suppressant (Pituitary)

Cabergoline Sodium (100mcg 5 Cabergoline (Tablet) 3

Injection) Egrifta Egrifta (Injection) 5 PA Levothyroxine Sodium

Levothyroxine Sodium Firmagon Firmagon (120mg (100mcg Tablet, 5 PA Injection)

112mcg Tablet, Firmagon Firmagon (80mg 125mcg Tablet, 4 PA 137mcg Tablet, Injection) Leuprolide Acetate Acetate 150mcg Tablet, 1 4 PA 175mcg Tablet, (Injection) 200mcg Tablet, 25mcg Lupaneta Pack Pack (Kit) 5 PA Tablet, 300mcg Tablet, Lupron Depot Depot 5 PA 50mcg Tablet, 75mcg (Injection) Tablet, 88mcg Tablet) Lupron Depot-PED Depot-PED Levoxyl 5 PA Levoxyl (Tablet) 3 (Injection)

Liothyronine Sodium Liothyronine Sodium Octreotide Acetate Acetate 4 5 PA (10mcg/ml Injection) (1000mcg/ml Injection)

Liothyronine Sodium Liothyronine Sodium Octreotide Acetate Octreotide Acetate (25mcg Tablet, 50mcg 2 (100mcg/ml Injection, Tablet, 5mcg Tablet) 200mcg/ml Injection, 4 PA

Synthroid Synthroid (Tablet) 3 500mcg/ml Injection,

Unithroid Unithroid (Tablet) 3 50mcg/ml Injection) Sandostatin LAR Depot LAR Hormonal Agents, Suppressant (Adrenal) 5 PA Depot (Injection) Hormonal Agents, Suppressant (Adrenal) Signifor

Lysodren Signifor (Injection) 5 PA Lysodren (Tablet) 3 Somatuline Depot Depot Hormonal Agents, Suppressant (Parathyroid) 5 PA (Injection)

Hormonal Agents, Suppressant Somavert Somavert (Injection) 5 PA, QL (Parathyroid) Synarel

Sensipar Sensipar (30mg Synarel (Nasal 3 QL 5 Tablet) Solution) Trelstar Mixject Sensipar (60mg Trelstar Mixject 5 QL 5 PA Tablet, 90mg Tablet) (Injection) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid)

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70 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Antithyroid Agents Enbrel (Injection) 5 PA

Methimazole Enbrel SureClick Methimazole (Tablet) 2 Enbrel SureClick

Propylthiouracil 5 PA Propylthiouracil (Injection)

2 Gengraf (Tablet) Gengraf (100mg Capsule, 25mg Immunological Agents 3 B/D, PA Angioedema (HAE) Agents Capsule, 100mg/ml

Berinert Oral Solution) Berinert (Injection) 5 PA, LA Humira

Cinryze Humira (Injection) 5 PA Cinryze (Injection) 5 PA, LA Humira Pediatric Crohns Disease Starter Pack

Firazyr Humira Pediatric Firazyr (Injection) 5 PA, QL Crohns Disease Ruconest 5 PA Ruconest (Injection) 5 PA Starter Pack Immune Suppressants (Injection) Azathioprine (100mg Humira Pen Pen 5 B/D, PA 5 PA Injection) (Injection) Azathioprine (50mg Humira Pen Crohns Disease Starter Pack Pen Crohns 2 B/D, PA Tablet) Disease Starter Pack 5 PA Cellcept (200mg/ml (Injection) Suspension, 250mg Kineret (Injection) 5 PA 5 PA Methotrexate Capsule, 500mg Methotrexate (Tablet) 2

Tablet) Methotrexate Sodium

Cellcept Intravenous Methotrexate Sodium Cellcept Intravenous 4 4 PA (Injection)

(Injection) Mycophenolate Mofetil Mycophenolate Mofetil Cimzia Cimzia (Injection) 5 PA (200mg/ml 5 PA Cyclosporine (100mg Suspension) Capsule, 25mg 3 B/D, PA Mycophenolate Mofetil Mofetil Capsule) (250mg Capsule, 3 PA Cyclosporine (50mg/ 4 500mg Tablet) ml Injection) Mycophenolic Acid DR Acid DR Cyclosporine Modified Modified (Tablet Delayed- 4 B/D, PA (100mg Capsule, Release) 25mg Capsule, 50mg 3 B/D, PA Nulojix (Injection) 5 PA Capsule, 100mg/ml Oral Solution)

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Last updated August 1, 2016 71 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Orencia Atgam Orencia (125mg/ml Atgam (Injection) 5 Injection, 250mg 5 PA BIVIGAM (Injection) 5 PA

Injection) Carimune Nanofiltered

Prograf Carimune Prograf (5mg/ml 4 PA Nanofiltered 5 PA Injection) (Injection) Rapamune Rapamune (1mg Flebogamma DIF DIF 5 PA Tablet, 2mg Tablet, 5 B/D, PA (Injection)

1mg/ml Oral Solution) Gamastan S/D Gamastan S/D Remicade 3 PA Remicade (Injection) 5 PA (Injection)

Sandimmune Sandimmune (100mg Gammagard Liquid Liquid 5 B/D, PA 5 PA Capsule) (Injection)

Sandimmune Sandimmune Gammaked (Injection) 5 PA

(100mg/ml Oral 4 B/D, PA Gammaplex Gammaplex Solution) 5 PA (Injection) Simponi

Simponi (Injection) 5 PA Gamunex-C Gamunex-C Simponi Aria Aria 5 PA 5 PA (Injection) (Injection) Octagam Octagam (Injection) 5 PA Sirolimus

Sirolimus (0.5mg Privigen 4 B/D, PA Privigen (Injection) 5 PA Tablet, 1mg Tablet) Thymoglobulin

Sirolimus Thymoglobulin Sirolimus (2mg Tablet) 5 B/D, PA 5 (Injection) Stelara

Stelara (Injection) 5 PA Varizig Varizig (Injection) 3 Tacrolimus (0.5mg Immunomodulators Capsule, 1mg Capsule, 3 PA Actemra 5mg Capsule) Actemra (162mg/

Torisel 0.9ml Injection, Torisel (Injection) 5 200mg/10ml Trexall 5 PA Trexall (Tablet) 4 Injection, 400mg/ Xeljanz (Tablet) 5 PA, QL 20ml Injection, 80mg/ Xeljanz XR XR (Tablet 4ml Injection)

Actimmune Extended-Release 24 5 PA, QL Actimmune (Injection) 5 Hour) Arcalyst (Injection) 5 PA, LA

Zortress Zortress (Tablet) 5 PA Benlysta (Injection) 5 PA Immunizing Agents, Passive

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72 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Ilaris Ixiaro Ilaris (Injection) 5 PA, QL, LA Ixiaro (Injection) 3

Leflunomide Menactra Leflunomide (Tablet) 2 Menactra (Injection) 3 Otezla (Tablet MENHIBRIX 3 Therapy Pack, 30mg 5 PA (Injection) Tablet) Menomune-A/C/Y/Menomune-A/C/Y/W-135

Ridaura 3 Ridaura (Capsule) 5 W-135 (Injection)

Menveo Simulect Simulect (Injection) 5 Menveo (Injection) 3

M-M-R II Synagis Synagis (Injection) 5 PA M-M-R II (Injection) 3

Pedvax HIB Vaccines Pedvax HIB (Injection) 3

ActHIB ProQuad ActHIB (Injection) 3 ProQuad (Injection) 3

Adacel Quadracel Adacel (Injection) 3 Quadracel (Injection) 3

BCG Vaccine BCG Vaccine Rabavert (Injection) 3 B/D, PA 3 (Injection) Recombivax HB HB Bexsero 3 B/D, PA Bexsero (Injection) 3 (Injection)

Boostrix Rotarix Boostrix (Injection) 3 Rotarix (Suspension) 3

RotaTeq Cervarix Cervarix (Injection) 4 RotaTeq (Oral 3 Daptacel Daptacel (Injection) 3 Solution) Tenivac Diphtheria/Tetanus Toxoids Adsorbed Pediatric Tenivac (Injection) 3 Tetanus/Diphtheria Toxoids-Adsorbed Adult Tetanus/Diphtheria Toxoids Adsorbed 3 Pediatric (Injection) Toxoids-Adsorbed 3 Engerix-B (Injection) 3 B/D, PA Adult (Injection) Trumenba

Gardasil Gardasil (Injection) 3 Trumenba (Injection) 3 Twinrix

Gardasil 9 Gardasil 9 (Injection) 3 Twinrix (Injection) 3 Typhim Vi

Havrix Havrix (Injection) 3 Typhim Vi (Injection) 3 VAQTA

Hiberix Hiberix (Injection) 3 VAQTA (Injection) 3 Varivax Imovax Rabies Rabies Varivax (Injection) 3 3 B/D, PA YF-Vax (H.D.C.V.) (Injection) YF-Vax (Injection) 3

Infanrix Zostavax Infanrix (Injection) 3 Zostavax (Injection) 4 PA IPOL Inactivated IPV Inactivated IPV Inflammatory Bowel Disease Agents 3 (Injection) Aminosalicylates

Bold type = Brand name drug Plain type = Generic drug 72 62tRACK 62

Last updated August 1, 2016 73 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Apriso (Capsule Sulfasalazine (500mg Extended-Release 24 3 QL Tablet Delayed- 2 Hour) Release, 500mg Tablet Balsalazide Disodium Disodium Immediate-Release) 4 (Capsule) Metabolic Bone Disease Agents

Canasa Canasa (Suppository) 5 Metabolic Bone Disease Agents

Alendronate Sodium Dipentum Dipentum (Capsule) 5 Alendronate Sodium Lialda (Tablet (10mg Tablet, 35mg 3 QL Delayed-Release) Tablet, 40mg Tablet, 1 QL

Mesalamine 5mg Tablet, 70mg Mesalamine (Kit) 4 Tablet) Pentasa Pentasa (Capsule Alendronate Sodium Sodium 4 QL Extended-Release) (70mg/75ml Oral 4

sfRowasa sfRowasa (Enema) 5 QL Solution) Glucocorticoids Binosto (Tablet

Budesonide 4 QL Budesonide (3mg Effervescent)

Capsule Delayed- 4 Calcitonin-Salmon 3 QL Release) (Nasal Solution)

Colocort Calcitriol Colocort (Enema) 4 Calcitriol (0.25mcg Entocort EC EC (Capsule Capsule, 0.5mcg 5 2 B/D, PA Delayed-Release) Capsule, 1mcg/ml Oral Hydrocortisone Solution) 4 Calcitriol (1mcg/ml (100mg/60ml Enema) 4 B/D, PA Procto-Med HC HC Injection) 2 Doxercalciferol (Cream) Doxercalciferol

Procto-Pak (0.5mcg Capsule, Procto-Pak (Cream) 2 4 B/D, PA, QL

Proctosol HC 1mcg Capsule, 2.5mcg Proctosol HC (Cream) 2 Capsule) Proctozone-HC Doxercalciferol Proctozone-HC Doxercalciferol (4mcg/ 2 4 B/D, PA (Cream) 2ml Injection) Uceris Uceris (9mg Tablet Etidronate Disodium Disodium 4 Extended-Release 24 5 ST (Tablet)

Hour) Forteo Forteo (Injection) 5 PA, QL Sulfonamides

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74 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Hectorol Hectorol (1mcg Zometa (Injection) 5 B/D, PA Capsule, 2.5mcg 5 B/D, PA, QL Miscellaneous Therapeutic Agents Capsule) Miscellaneous Therapeutic Agents Ibandronate Sodium

Ibandronate Sodium Alcohol Prep Pads 3 QL Alcohol Prep Pads 3 (150mg Tablet) Botox

Ibandronate Sodium Botox (Injection) 4 PA, QL Ibandronate Sodium 4 B/D, PA Fomepizole (3mg/3ml Injection) Fomepizole (Injection) 5

Gauze Miacalcin (200unit/ml Gauze (Non-medicated 5 PA 3 Injection) 2X2)

Insulin Syringes, Needles Natpara Insulin Syringes, Natpara (Injection) 5 PA 3 Pamidronate Disodium Disodium Needles 4 B/D, PA Kanuma (Injection) Kanuma (Injection) 5 PA

Methylergonovine Maleate Paricalcitol Methylergonovine Paricalcitol (1mcg 5 Capsule, 2mcg 4 B/D, PA, QL Maleate (Tablet) Capsule) Myalept (Injection) 5 PA

Paricalcitol Paricalcitol (2mcg/ml Sterile Water Irrigation Water 3 Injection, 5mcg/ml 4 B/D, PA Irrigation (Solution) Injection) Ophthalmic Agents Paricalcitol (4mcg 4 B/D, PA Ophthalmic Agents, Other Capsule) Bacitracin/Polymyxin B B Prolia 2 Prolia (Injection) 4 PA (Ophthalmic Ointment)

Risedronate Sodium Risedronate Sodium Blephamide 3 QL 4 (Tablet) (Suspension)

Xgeva Xgeva (Injection) 5 PA Blephamide S.O.P. S.O.P.

Zemplar 4 Zemplar (2mcg/ml (Ointment)

4 B/D, PA Cystaran Injection) Cystaran (Ophthalmic

Zemplar 5 Zemplar (5mcg/ml Solution)

5 B/D, PA Lacrisert Injection) Lacrisert (Insert) 4

Zoledronic Acid Zoledronic Acid (4mg/ Lastacaft (Ophthalmic 4 B/D, PA 3 5ml Injection) Solution)

Zoledronic Acid Zoledronic Acid (5mg/ Naphazoline HCl HCl 4 PA 2 100ml Injection) (Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug 74 64tRACK 64

Last updated August 1, 2016 75 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Neomycin/Bacitracin/Neomycin/Bacitracin/Polymyxin Tobradex ST ST 3 Polymyxin (Ointment) (Ophthalmic 4 Neomycin/Polymyxin/Neomycin/Polymyxin/Bacitracin/Hydrocortisone Suspension) Bacitracin/ Tobramycin/Tobramycin/Dexamethasone 3 Hydrocortisone Dexamethasone 3 (Ophthalmic Ointment) (Ophthalmic Neomycin/Polymyxin/Neomycin/Polymyxin/Dexamethasone Suspension) Dexamethasone (0.1% Ophthalmic Anti-allergy Agents

Ophthalmic Ointment, 2 Alocril (Ophthalmic 4 0.1% Ophthalmic Solution) Suspension) Alomide (Ophthalmic Neomycin/Polymyxin/Neomycin/Polymyxin/Gramicidin 4 Solution) Gramicidin 3 Azelastine HCl HCl (0.05% 4 (Ophthalmic Solution) Ophthalmic Solution)

Neomycin/Polymyxin/Hydrocortisone Neomycin/Polymyxin/ Bepreve (Ophthalmic Hydrocortisone (1% 4 4 Solution) Ophthalmic Cromolyn Sodium Cromolyn Sodium (4% Suspension) 2 Ophthalmic Solution) Polymyxin B Sulfate/Trimethoprim Sulfate

Polymyxin B Sulfate/ Epinastine HCl Epinastine HCl Trimethoprim Sulfate 2 3 (Ophthalmic Solution)

(Ophthalmic Solution) Olopatadine HCl

Pred-G Olopatadine HCl 3 Pred-G (Suspension) 4 (Ophthalmic Solution)

Pred-G S.O.P. Pred-G S.O.P. Pataday (Ophthalmic 4 3 (Ointment) Solution)

Proparacaine HCl Proparacaine HCl Patanol (Ophthalmic 2 3 (Ophthalmic Solution) Solution)

Restasis Restasis (Emulsion) 3 QL Pazeo (Ophthalmic Sulfacetamide Sodium/Prednisolone Sodium Phosphate 3 Sulfacetamide Solution) Sodium/Prednisolone 2 Ophthalmic Antiglaucoma Agents Sodium Phosphate Alphagan P P (0.1% 3 (Ophthalmic Solution) Ophthalmic Solution) Apraclonidine 3 (Ophthalmic Solution)

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76 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Timolol Maleate Azopt Azopt (Suspension) 3 Timolol Maleate Betaxolol HCl HCl (0.5% (0.25% Ophthalmic 3 2 Ophthalmic Solution) Solution, 0.5% Betimol (Ophthalmic Ophthalmic Solution) 4 Timolol Maleate Ophthalmic Gel Forming Maleate Solution) Brimonidine Tartrate Ophthalmic Gel Brimonidine Tartrate 3 Forming (Solution) (0.2% Ophthalmic 2 Solution) Ophthalmic Anti-inflammatories

Dexamethasone Sodium Phosphate Carteolol HCl HCl Dexamethasone 2 Sodium Phosphate (Ophthalmic Solution) 2 Combigan (0.1% Ophthalmic 3 (Ophthalmic Solution) Solution) Diclofenac Sodium

Dorzolamide HCl Diclofenac Sodium Dorzolamide HCl 2 (Ophthalmic Solution) (0.1% Ophthalmic 2

Dorzolamide HCl/Timolol Maleate Solution)

Dorzolamide HCl/ Durezol

Timolol Maleate 2 Durezol (Emulsion) 3 Flarex (Ophthalmic Solution) Flarex (Suspension) 4

Fluorometholone Levobunolol HCl HCl Fluorometholone 2 (Ophthalmic Solution) (Ophthalmic 3 Metipranolol Suspension) 2 Flurbiprofen Sodium (Ophthalmic Solution) Flurbiprofen Sodium 2 Phospholine Iodide Iodide (Ophthalmic Solution)

4 FML (Ophthalmic Solution) FML (Ointment) 4

Pilocarpine HCl Pilocarpine HCl (1% FML Forte Forte 4 Ophthalmic Solution, (Suspension) Ilevro 2% Ophthalmic 3 Ilevro (Suspension) 3

Solution, 4% Ketorolac Tromethamine Ketorolac Ophthalmic Solution) Tromethamine (0.4% Simbrinza 3 Ophthalmic Solution, 3 (Suspension) 0.5% Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug 76 66tRACK 66

Last updated August 1, 2016 77 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Lotemax (0.5% Gel, Ciprodex (Otic 3 0.5% Ointment, 0.5% 4 Suspension) Suspension) Coly-Mycin S S

Nevanac 4 Nevanac (Suspension)

3 Fluocinolone Acetonide (Suspension) Fluocinolone

Pred Mild Pred Mild Acetonide (0.01% Otic 4 4 (Suspension) Oil) Prednisolone Acetate Acetate Hydrocortisone/Acetic Acid 3 (Ophthalmic 3 Acid (Otic Solution) Suspension) Neomycin/Polymyxin/Neomycin/Polymyxin/Hydrocortisone Prednisolone Sodium Phosphate Sodium Hydrocortisone (1% 3 Phosphate (1% 2 Otic Solution, 1% Otic Ophthalmic Solution) Suspension) Prolensa (Ophthalmic Respiratory Tract/Pulmonary Agents 4 Solution) Antihistamines

Vexol Azelastine HCl Vexol (Suspension) 4 Azelastine HCl (0.1% 3 QL Ophthalmic Prostaglandin and Prostamide Nasal Solution) Analogs Azelastine HCl HCl (0.15%

Latanoprost 3 Latanoprost Nasal Solution)

1 Cetirizine HCl (Ophthalmic Solution) Cetirizine HCl (Syrup) 2

Lumigan Lumigan (Ophthalmic Cyproheptadine HCl HCl 3 4 Solution) (4mg Tablet)

Travatan Z Travatan Z Diphenhydramine HCl HCl 3 4 B/D, PA (Ophthalmic Solution) (50mg/ml Injection)

Travoprost Travoprost Levocetirizine Dihydrochloride 3 Levocetirizine (Ophthalmic Solution) Dihydrochloride (5mg 1 QL Otic Agents Tablet) Otic Agents Phenadoz

Acetic Acid 4 Acetic Acid (Otic (Suppository)

2 Phenergan Solution) Phenergan (12.5mg

Cipro HC HC Suppository, 25mg 4 4 (Suspension) Suppository)

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78 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Promethazine HCl HCl Antileukotrienes (12.5mg Suppository, Montelukast Sodium Sodium 1 QL 25mg Suppository, 4 (10mg Tablet) 25mg/ml Injection, Montelukast Sodium Sodium 50mg/ml Injection) (4mg Packet, 4mg Promethazine HCl 2 QL Promethazine HCl Tablet Chewable, 5mg (12.5mg Tablet, 25mg 3 Tablet Chewable) Tablet, 50mg Tablet, Zafirlukast (Tablet) 3 QL

6.25mg/5ml Syrup) Zyflo

Promethegan Zyflo (Tablet) 5 ST

Promethegan (25mg Zyflo CR 4 Suppository) Zyflo CR (Tablet Extended-Release 12 5 ST Anti-inflammatories, Inhaled Hour) Corticosteroids

Arnuity Ellipta Bronchodilators, Anticholinergic Arnuity Ellipta 3 QL Atrovent HFA HFA (Aerosol Powder) 4

Budesonide (Aerosol Solution)

Budesonide (0.25mg/ Incruse Ellipta Incruse Ellipta 2ml Suspension, 3 QL 0.5mg/2ml 4 B/D, PA (Aerosol Powder) Ipratropium Bromide Suspension, 1mg/2ml Ipratropium Bromide Suspension) (0.02% Inhalation 2 B/D, PA Flovent Diskus Diskus Solution) 3 QL Ipratropium Bromide Bromide (Aerosol Powder) Flovent HFA HFA (Aerosol) 3 QL (0.03% Nasal Solution, 2

Flunisolide 0.06% Nasal Solution)

Flunisolide (Nasal Spiriva HandiHaler 1 Spiriva HandiHaler Solution) 3 QL

Fluticasone Propionate (Capsule)

Fluticasone Propionate Spiriva Respimat Spiriva Respimat (50mcg/act 2 3 QL (Aerosol Solution) Suspension)

Mometasone Furoate Bronchodilators, Sympathomimetic Mometasone Furoate

(50mcg/act 4 Suspension) Nasonex 4 PA (Suspension)

Bold type = Brand name drug Plain type = Generic drug 78 68tRACK 68

Last updated August 1, 2016 79 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Albuterol Sulfate Sulfate Kalydeco (50mg 5 PA, QL (0.083% Nebulized Packet, 75mg Packet) Solution, 0.5% Orkambi (Tablet) 5 PA, QL, LA Nebulized Solution, 2 B/D, PA Phosphodiesterase Inhibitors, Airways 0.63mg/3ml Nebulized Disease

Solution, 1.25mg/3ml Aminophylline Aminophylline Nebulized Solution) 4

Albuterol Sulfate (Injection)

Albuterol Sulfate (2mg Daliresp Daliresp (Tablet) Tablet Immediate- 4 PA, QL 4 Theophylline (Oral Release, 4mg Tablet 2 Immediate-Release) Solution)

Theophylline CR Brovana (Nebulized Theophylline CR 4 B/D, PA, QL Solution) (Tablet Extended- 2

EpiPen EpiPen (Injection) 3 Release 12 Hour) Theophylline ER

Levalbuterol Theophylline ER Levalbuterol 4 B/D, PA (300mg Tablet (Nebulized Solution)

Metaproterenol Sulfate Extended-Release 12 Metaproterenol Sulfate Hour, 450mg Tablet

(10mg Tablet, 20mg Extended-Release 12 4 2 Tablet, 10mg/5ml Hour, 400mg Tablet Syrup) Extended-Release 24 Perforomist 4 B/D, PA, QL Hour, 600mg Tablet (Nebulized Solution) Extended-Release 24 ProAir HFA HFA (Aerosol 3 Hour) Solution) Pulmonary Antihypertensives

ProAir RespiClick ProAir RespiClick Adcirca 3 Adcirca (Tablet) 5 PA, QL

(Aerosol Powder) Adempas

Serevent Diskus Adempas (Tablet) 5 PA Serevent Diskus 3 QL Letairis (Aerosol Powder) Letairis (Tablet) 5 PA, QL, LA

Opsumit Terbutaline Sulfate Sulfate Opsumit (Tablet) 5 PA, LA 5 Orenitram (1mg/ml Injection) Orenitram (0.125mg Cystic Fibrosis Agents Tablet Extended- 4 PA, QL Cayston (Inhalation Release) 5 PA, LA Solution)

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80 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Orenitram (0.25mg Cromolyn Sodium Sodium Tablet Extended- (20mg/2ml Nebulized 3 B/D, PA 5 PA, QL Release, 1mg Tablet Solution) Extended-Release) Dulera (Aerosol) 4 PA, QL

Orenitram Orenitram (2.5mg Esbriet (Capsule) 5 PA, QL, LA

Tablet Extended- 5 PA Glassia Glassia (Injection) 5 PA, LA Release) Kalydeco

Remodulin Kalydeco (150mg Remodulin (Injection) 5 PA, LA 5 PA, QL Tablet) Revatio

Revatio (10mg/ Ofev 5 PA Ofev (Capsule) 5 PA, QL, LA 12.5ml Injection)

Prolastin-C Revatio (20mg Tablet) 5 PA, QL Prolastin-C (Injection) 5 PA, LA

Pulmozyme Sildenafil (10mg/ Pulmozyme 5 PA 5 B/D, PA, QL 12.5ml Injection) (Inhalation Solution) Stiolto Respimat

Sildenafil Stiolto Respimat Sildenafil (20mg 3 QL Tablet) (Generic 3 PA, QL (Aerosol Solution)

Symbicort Revatio) Symbicort (Aerosol) 3 QL

Zemaira Tracleer (Tablet) 5 PA, QL Zemaira (Injection) 5 PA, LA Tyvaso (Inhalation Respiratory Tract/Pulmonary Agents

5 PA, QL Combivent Respimat Solution) Combivent Respimat

Ventavis 3 Ventavis (Inhalation (Aerosol Solution)

5 PA, QL, LA Dymista Solution) Dymista (Suspension) 4 Respiratory Tract Agents, Other Ipratropium Bromide/Albuterol Sulfate Bromide/ Acetylcysteine Albuterol Sulfate 1 B/D, PA 2 B/D, PA (Inhalation Solution) (Inhalation Solution) Advair Diskus Diskus Xolair (Injection) 5 PA 3 QL (Aerosol Powder) Skeletal Muscle Relaxants Advair HFA HFA (Aerosol) 3 QL Skeletal Muscle Relaxants

Anoro Ellipta Baclofen Anoro Ellipta (Aerosol 3 QL Baclofen (Tablet) 2 Powder) Cyclobenzaprine HCl HCl Aralast NP 4 PA, HRM Aralast NP (Injection) 5 PA, LA (7.5mg Tablet)

Breo Ellipta Breo Ellipta (Aerosol Dantrolene Sodium Sodium 3 QL 4 Powder) (Capsule)

Bold type = Brand name drug Plain type = Generic drug 80 70tRACK 70

Last updated August 1, 2016 81 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Gablofen (10000mcg/ Electrolyte/Mineral Modifiers

Chemet 20ml Injection, 4 B/D, PA Chemet (Capsule) 4 50mcg/ml Injection) Exjade (Tablet Gablofen (40000mcg/ 5 PA 5 B/D, PA Soluble) 20ml Injection) Ferriprox (100mg/ml Lioresal Intrathecal Lioresal Intrathecal Oral Solution, 500mg 5 PA (0.05mg/ml Injection, 4 B/D, PA Tablet)

10mg/20ml Injection) Jadenu Jadenu (Tablet) 5 PA Lioresal Intrathecal

Lioresal Intrathecal Kionex 5 B/D, PA Kionex (Powder) 3 (10mg/5ml Injection)

Samsca Orphenadrine Citrate Citrate Samsca (Tablet) 5 PA, QL 4 Sodium Polystyrene Sulfonate Polystyrene (Injection) 3 Tizanidine HCl HCl (2mg Sulfonate (Suspension) 2 Syprine Tablet, 4mg Tablet) Syprine (Capsule) 5 PA Sleep Disorder Agents Electrolyte/Mineral Replacement GABA Receptor Modulators Ammonium Chloride Chloride

Temazepam 4 Temazepam (15mg (Injection) Capsule, 30mg 3 QL Carbaglu (Tablet) 5 LA

Isolyte-S Capsule) Isolyte-S (Injection) 4

Zaleplon Zaleplon (Capsule) 3 QL, HRM Klor-Con 10 10 (Tablet Zolpidem Tartrate 3 Zolpidem Tartrate Extended-Release) (10mg Tablet Klor-Con 8 8 (Tablet 3 Immediate-Release, 4 QL, HRM Extended-Release) 5mg Tablet Immediate- Klor-Con M15 M15 (Tablet 3 Release) Extended-Release) Sleep Disorders, Other Klor-Con M20 M20 (Tablet Belsomra 2 Belsomra (Tablet) 3 QL Extended-Release)

Hetlioz Hetlioz (Capsule) 5 PA, QL Klor-Con Sprinkle Sprinkle

Modafinil (Tablet) 4 PA, QL (Capsule Extended- 3 Rozerem (Tablet) 4 QL Release) Magnesium Sulfate

Xyrem Magnesium Sulfate Xyrem (Oral Solution) 5 PA, QL, LA (1gm/2ml-50% 4 Therapeutic Nutrients/Minerals/Electrolytes Injection)

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82 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Magnesium Sulfate Sulfate Potassium Chloride ER Chloride ER

(5gm/10ml-50% 4 (10meq Capsule Injection) Extended-Release,

Normosol-R 8meq Capsule 3 4 (Injection) Extended-Release, Physiolyte (Irrigation 8meq Tablet Extended- 4 Solution) Release)

Potassium Chloride ER Microencapsulated Physiosol Irrigation Irrigation Potassium Chloride ER 4 (Solution) Microencapsulated

Plasma-Lyte A (10meq Tablet Plasma-Lyte A 2 4 Extended-Release, (Injection)

Plasma-Lyte-148 20meq Tablet Plasma-Lyte-148 4 Extended-Release)

(Injection) Potassium Citrate ER

Potassium Chloride Potassium Citrate ER Potassium Chloride (Tablet Extended- 3 (10% Oral Solution, 3 Release)

20% Oral Solution) Sodium Chloride

Potassium Chloride Sodium Chloride (0.9% Potassium Chloride 4 Injection)

(10meq/100ml Sodium Chloride Sodium Chloride Injection, 20meq/ 4 B/D, PA (2.5meq/ml Injection, 100ml Injection, 4 3% Injection, 5% 40meq/100ml Injection) Injection) Sodium Chloride 0.45% Viaflex

Potassium Chloride Sodium Chloride Potassium Chloride 4 B/D, PA 0.45% Viaflex 4 (2meq/ml Injection)

Potassium Chloride 0.15% /NaCl 0.45% Viaflex (Injection)

Potassium Chloride Sodium Chloride 0.9% Sodium Chloride 0.15% /NaCl 0.45% 4 B/D, PA 0.9% (Irrigation 3 Viaflex (Injection)

Potassium Chloride 0.15%/NaCl 0.9% Solution)

Potassium Chloride Sodium Fluoride Sodium Fluoride 0.15%/NaCl 0.9% 4 B/D, PA 2 (Tablet) (Injection)

Potassium Chloride 0.3%/ NaCl 0.9% Therapeutic Nutrients/Minerals/ Potassium Chloride Electrolytes 0.3%/ NaCl 0.9% 4 B/D, PA (Injection)

Bold type = Brand name drug Plain type = Generic drug 82 72tRACK 72

Last updated August 1, 2016 83 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

Aminosyn 7%/Electrolytes 7%/ Dextrose 5%/NaCl 0.33% 5%/NaCl 4 Electrolytes 4 B/D, PA 0.33% (Injection) (Injection) Dextrose 5%/NaCl 0.45% 5%/NaCl

Aminosyn 8.5%/Electrolytes 4 Aminosyn 8.5%/ 0.45% (Injection) Electrolytes 4 B/D, PA Dextrose 5%/NaCl 0.9% 5%/NaCl 4 (Injection) 0.9% (Injection)

Aminosyn II Aminosyn II (10% Dextrose 5%/Potassium Chloride 0.15% 5%/ Injection, 7% 4 B/D, PA Potassium Chloride 4 B/D, PA Injection) 0.15% (Injection)

Aminosyn II 8.5%/Electrolytes Aminosyn II 8.5%/ FreAmine HBC 6.9% HBC 6.9% 4 B/D, PA Electrolytes 4 B/D, PA (Injection) (Injection) HepatAmine Aminosyn-HBC 4 B/D, PA 4 B/D, PA (Injection) (Injection) Intralipid (Injection) 4 B/D, PA

Aminosyn-PF Aminosyn-PF Ionosol-B/Dextrose 5% 4 B/D, PA 4 (Injection) 5% (Injection) Aminosyn-RF Aminosyn-RF Ionosol-MB/Dextrose 5% 4 B/D, PA 4 (Injection) 5% (Injection) Dextrose 10%

Isolyte-P/Dextrose 5% Dextrose 10% Isolyte-P/Dextrose 5% 4 4 (Injection) (Injection) Dextrose 10%/NaCl 0.2%

KCl 0.075%/D5W/NaCl 0.45% Dextrose 10%/NaCl KCl 0.075%/D5W/ 4 0.2% (Injection) NaCl 0.45% 4 Dextrose 10%/NaCl 0.45% 10%/NaCl 4 (Injection) 0.45% (Injection) KCl 0.15%/D5W/LR 0.15%/D5W/LR Dextrose 2.5%/Sodium Chloride 0.45% 2.5%/ 4 (Injection) Sodium Chloride 4 KCl 0.15%/D5W/NaCl 0.2% 0.15%/D5W/NaCl 4 0.45% (Injection) 0.2% (Injection) Dextrose 5%

KCl 0.15%/D5W/NaCl 0.225% Dextrose 5% KCl 0.15%/D5W/NaCl 4 4 (Injection) 0.225% (Injection) Dextrose 5%/NaCl 0.2%

KCl 0.15%/D5W/NaCl 0.9% Dextrose 5%/NaCl KCl 0.15%/D5W/NaCl 4 4 0.2% (Injection) 0.9% (Injection) Dextrose 5%/NaCl 0.225%

KCl 0.3%/D5W/NaCl 0.45% Dextrose 5%/NaCl KCl 0.3%/D5W/NaCl 4 4 0.225% (Injection) 0.45% (Injection)

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84 Last updated August 1, 2016 Required Required Drug Actions, Drug Actions, Drug Name Drug Name Tier Restrictions Tier Restrictions or Limits or Limits

KCl 0.3%/D5W/NaCl 0.9% 0.3%/D5W/NaCl Potassium Chloride 0.15% D5W/NaCl 0.45% Chloride 4 0.9% (Injection) 0.15% D5W/NaCl 4 Lactated Ringers Dextrose 5% Viaflex Ringers 0.45% (Injection)

Potassium Chloride 0.22% D5W/NaCl 0.45% Dextrose 5% Viaflex 4 Potassium Chloride

(Injection) 0.22% D5W/NaCl 4 Lactated Ringers Irrigation Ringers 0.45% (Injection)

3 Potassium Chloride 0.3%/D5W Irrigation (Solution) Potassium Chloride

Lactated Ringers Viaflex 4 B/D, PA Lactated Ringers 0.3%/D5W (Injection)

4 Premasol Viaflex (Injection) Premasol (Injection) 4 B/D, PA

Levocarnitine Levocarnitine (1gm/ Procalamine 4 B/D, PA 10ml Oral Solution, 3 B/D, PA (Injection) 330mg Tablet) Prosol (Injection) 4 B/D, PA

Nephramine

Nephramine Ringers Injection 4 B/D, PA Ringers Injection 4

(Injection) Ringers Irrigation

Normosol-M in D5W Ringers Irrigation Normosol-M in D5W 3 4 (Solution)

(Injection) Sodium Lactate

Normosol-R in D5W Sodium Lactate Normosol-R in D5W 4 4 (Injection)

(Injection) TPN Electrolytes

Nutrilipid TPN Electrolytes 4 Nutrilipid (Injection) 4 B/D, PA (Injection)

Plasma-Lyte-56/D5W

Plasma-Lyte-56/D5W Travasol 4 Travasol (Injection) 4 B/D, PA

(Injection) Trophamine

Plenamine Trophamine (10% 4 B/D, PA Plenamine (Injection) 4 B/D, PA Injection)

Potassium Chloride 0.15% D5W/NaCl 0.33%

Potassium Chloride VP-PNV-DHA VP-PNV-DHA (Capsule) 2 0.15% D5W/NaCl 4 0.33% (Injection)

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85 Drugs with a quantity limit (QL) This list shows drugs that have a quantity limit. Your plan will cover only a certain amount of these drugs for one co-pay/co-insurance or will only cover these drugs for a certain number of days. These limits may be in place to ensure your safety. Drugs are listed in alphabetical order in the chart below. Some drugs come in many strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. For more information about quantity limits, talk to your doctor or pharmacist. You can also call us. Our contact information, along with the date we last updated the drug list, is on the cover.

Drug Name Quantity Limit

Abacavir (Tablet) Maximum of 3 tablets per day Abacavir Sulfate/Lamivudine/Zidovudine Maximum of 3 tablets per day (Tablet) 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 140 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 Aggrenox (Capsule Extended-Release 12 Maximum of 2 capsules per day Hour) Albenza (Tablet) Maximum of 16 tablets per day Alecensa (Capsule) Maximum of 8 capsules per day Alendronate Sodium (10mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 5mg Tablet) Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days Alprazolam (0.25mg Tablet Immediate-Release, 0.5mg Tablet Immediate-Release, 1mg Tablet Maximum of 4 tablets per day Immediate-Release) Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day

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Drug Name Quantity Limit

Amitiza (Capsule) Maximum of 2 capsules per day Amlodipine Besylate/Atorvastatin Calcium Maximum of 1 tablet per day (Tablet) Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day Amlodipine/Valsartan/Hydrochlorothiazide Maximum of 1 tablet per day (Tablet) Amphetamine/Dextroamphetamine (10mg Capsule Extended-Release 24 Hour, 15mg Capsule Extended-Release 24 Hour, 20mg Capsule Extended-Release 24 Hour, 25mg Maximum of 2 capsules per day Capsule Extended-Release 24 Hour, 30mg Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour) Amphetamine/Dextroamphetamine (10mg Tablet Immediate-Release, 12.5mg Tablet Immediate-Release, 15mg Tablet Immediate- Maximum of 2 tablets per day Release, 30mg Tablet Immediate-Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Amphetamine/Dextroamphetamine (20mg Maximum of 3 tablets per day Tablet Immediate-Release) Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Androderm (Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Apokyn (Injection) Maximum of 2 cartridges (6 ml) per day Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day Aptiom (200mg Tablet, 400mg Tablet, 800mg Maximum of 1 tablet per day Tablet) Aptiom (600mg Tablet) Maximum of 2 tablets per day Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day Aptivus (250mg Capsule) Maximum of 6 capsules per day Aripiprazole (Tablet) Maximum of 1 tablet per day Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day Arnuity Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Aspirin/Dipyridamole (Capsule Extended- Maximum of 2 capsules per day Release 12 Hour) Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day

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Drug Name Quantity Limit

Atripla (Tablet) Maximum of 2 tablets per day Aubagio (Tablet) Maximum of 1 tablet per day Avandia (2mg Tablet) Maximum of 4 tablets per day Avandia (4mg Tablet) Maximum of 2 tablets per day Azelastine HCl (0.1% Nasal Solution) Maximum of 2 bottles (60 ml) per 30 days Azor (Tablet) Maximum of 1 tablet per day Belsomra (Tablet) Maximum of 1 tablet per day Benazepril HCl (Tablet) Maximum of 2 tablets per day Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Benicar (20mg Tablet, 40mg Tablet) Maximum of 1 tablet per day Benicar (5mg Tablet) Maximum of 2 tablets per day Benicar HCT (Tablet) Maximum of 1 tablet per day Bethkis (Nebulized Solution) Maximum of 8 ml (2 ampules) per day BiDil (Tablet) Maximum of 6 tablets per day Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days Bisoprolol Fumarate/Hydrochlorothiazide Maximum of 2 tablets per day (2.5mg-6.25mg Tablet, 5mg-6.25mg Tablet) Bosulif (100mg Tablet) Maximum of 6 tablets per day Bosulif (500mg Tablet) Maximum of 1 tablet per day Botox (Injection) Maximum of 9 vials per 30 days Breo Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days Brilinta (Tablet) Maximum of 2 tablets per day BRIVIACT (100mg Tablet, 10mg Tablet, Maximum of 2 tablets per day 25mg Tablet, 50mg Tablet, 75mg Tablet) BRIVIACT (10mg/ml Oral Solution) Maximum of 20 ml per day BRIVIACT (50mg/5ml Intravenous Solution) Maximum of 20 ml per day Brovana (Nebulized Solution) Maximum of 2 vials (4 ml) per day Buprenorphine HCl (2mg Tablet Sublingual, Maximum of 3 tablets per day 8mg Tablet Sublingual) Buprenorphine HCl/Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Butorphanol Tartrate (10mg/ml Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Bydureon (2mg Pen injector) Maximum of 4 pens per 28 days Bydureon (2mg Suspension Extended- Maximum of 4 vials per 28 days Release) Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days

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Drug Name Quantity Limit 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 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 Clonazepam (0.5mg Tablet Immediate-Release, Maximum of 4 tablets per day 1mg Tablet Immediate-Release) Clonazepam (2mg Tablet Immediate-Release) Maximum of 10 tablets per day Clonazepam ODT (0.125mg Tablet Dispersible, 0.25mg Tablet Dispersible, 0.5mg Tablet Maximum of 4 tablets per day Dispersible, 1mg Tablet Dispersible) Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel (75mg Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (Tablet) Maximum of 6 tablets per day Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day Colcrys (Tablet) Maximum of 4 tablets per day

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Drug Name Quantity Limit

Combivir (Tablet) Maximum of 3 tablets per day Complera (Tablet) Maximum of 2 tablets per day Cotellic (Tablet) Maximum of 3 tablets per day Crestor (Tablet) Maximum of 1 tablet 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 Dexedrine (Tablet) Maximum of 6 tablets per day 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 Immediate-Release, 5mg Tablet Immediate- Maximum of 6 tablets per day Release) Dextroamphetamine Sulfate ER (10mg Capsule Maximum of 6 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (15mg Capsule Maximum of 4 capsules per day Extended-Release 24 Hour) Dextroamphetamine Sulfate ER (5mg Capsule Maximum of 3 capsules per day Extended-Release 24 Hour) Diazepam (10mg Tablet, 2mg Tablet, 5mg Maximum of 4 tablets per day Tablet) Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day Donepezil HCl (10mg Tablet Immediate- Maximum of 2 tablets per day Release) Donepezil HCl (23mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release) Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day Doxercalciferol (1mcg Capsule, 2.5mcg Maximum of 4 capsules per day Capsule) Dronabinol (Capsule) Maximum of 4 capsules per day Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days

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Drug Name Quantity Limit Duloxetine HCl (20mg Capsule Delayed- Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day Capsule Delayed-Release) Edarbi (Tablet) Maximum of 1 tablet per day Edarbyclor (Tablet) Maximum of 1 tablet per day Edurant (Tablet) Maximum of 2 tablets per day Effient (Tablet) Maximum of 1 tablet per day Eliquis (Tablet) Maximum of 2 tablets per day Embeda (100mg-4mg Capsule Extended- Maximum of 3 capsules per day Release) Embeda (20mg-0.8mg Capsule Extended- Release, 80mg-3.2mg Capsule Extended- Maximum of 4 capsules per day Release) Embeda (30mg-1.2mg Capsule Extended- Release, 50mg-2mg Capsule Extended- Maximum of 2 capsules per day Release) Embeda (60mg-2.4mg Capsule Extended- Maximum of 6 capsules per day Release) Emsam (Patch 24 Hour) Maximum of 1 patch per day Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day Emtriva (200mg Capsule) Maximum of 2 capsules per day Enalapril Maleate (Tablet) Maximum of 2 tablets per day Enalapril Maleate/Hydrochlorothiazide Maximum of 2 tablets per day (10mg-25mg Tablet) Enalapril Maleate/Hydrochlorothiazide Maximum of 1 tablet per day (5mg-12.5mg Tablet) Endocet (Tablet) Maximum of 12 tablets per day Enoxaparin Sodium (100mg/ml Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150mg/ml Subcutaneous Solution) Enoxaparin Sodium (120mg/0.8ml Subcutaneous Solution, 80mg/0.8ml Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day Enoxaparin Sodium (30mg/0.3ml Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (40mg/0.4ml Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60mg/0.6ml Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution)

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Drug Name Quantity Limit

Entresto (Tablet) Maximum of 2 tablets per day Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day Epzicom (Tablet) Maximum of 2 tablets per day Erivedge (Capsule) Maximum of 1 capsule per day Esbriet (Capsule) Maximum of 9 capsules per day Esomeprazole Magnesium (20mg Capsule Maximum of 3 capsules per day Delayed-Release) (Generic Nexium) Esomeprazole Magnesium (40mg Capsule Maximum of 2 capsules per day Delayed-Release) (Generic Nexium) Estradiol (0.025mg/24hr Patch Weekly, 0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch Weekly, 0.075mg/24hr Patch Weekly, 0.1mg/ Maximum of 4 patches per 28 days 24hr Patch Weekly, 37.5mcg/24hr Patch Weekly) Evotaz (Tablet) Maximum of 2 tablets per day Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day Famciclovir (500mg Tablet) Maximum of 3 tablets per day Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Fazaclo (100mg Tablet Dispersible) Maximum of 9 tablets per day Fazaclo (150mg Tablet Dispersible) Maximum of 6 tablets per day Fazaclo (200mg Tablet Dispersible) Maximum of 4 tablets per day Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Hour, Maximum of 15 patches per 30 days 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour) Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day Firazyr (Injection) Maximum of 9 ml per day Flector (Patch) Maximum of 2 patches per day Maximum of 2 inhalers (120 blisters) per 30 Flovent Diskus (Aerosol Powder) days Flovent HFA (110mcg/act Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Flovent HFA (220mcg/act Aerosol) Maximum of 2 inhalers (24 grams) per 30 days Flovent HFA (44mcg/act Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day Forteo (Injection) Maximum of 1 pen (2.4 ml) per 28 days

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Drug Name Quantity Limit

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 Gabitril (12mg Tablet) Maximum of 4 tablets per day Gabitril (16mg Tablet) Maximum of 3 tablets per day Galantamine HBr (12mg Tablet, 4mg Tablet, Maximum of 2 tablets per day 8mg Tablet) Galantamine HBr (16mg Capsule Extended- Release 24 Hour, 24mg Capsule Extended- Maximum of 1 capsule per day Release 24 Hour, 8mg Capsule Extended- Release 24 Hour) Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days 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 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) Granisetron HCl (1mg Tablet) Maximum of 2 tablets per day Harvoni (Tablet) Maximum of 1 tablet per day Hectorol (1mcg Capsule, 2.5mcg Capsule) Maximum of 4 capsules per day Hetlioz (Capsule) Maximum of 1 capsule per day Hydrocodone Bitartrate/Acetaminophen Maximum of 180 ml per day (7.5mg-325mg/15ml Oral Solution) Hydrocodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Maximum of 12 tablets per day Tablet, 7.5mg-325mg Tablet) Hydrocodone/Ibuprofen (7.5mg-200mg Tablet) Maximum of 5 tablets per day

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Drug Name Quantity Limit

Hydromorphone HCl (1mg/ml Liquid) Maximum of 90 ml per day Hydromorphone HCl (2mg Tablet Immediate- Maximum of 8 tablets per day Release, 4mg Tablet Immediate-Release) Hydromorphone HCl (8mg Tablet Immediate- Maximum of 11 tablets per day Release) Hydromorphone HCl ER (12mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 16mg Tablet Extended-Release 24 Hour Abuse- Maximum of 2 tablets per day Deterrent, 8mg Tablet Extended-Release 24 Hour Abuse-Deterrent) Hydromorphone HCl ER (32mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour Abuse-Deterrent) Ibandronate Sodium (150mg Tablet) Maximum of 1 tablet per 28 days Ibrance (Capsule) Maximum of 1 capsule per day Iclusig (15mg Tablet) Maximum of 2 tablets per day Iclusig (45mg Tablet) Maximum of 1 tablet per day Ilaris (Injection) Maximum of 2 doses per 28 days Imatinib Mesylate (Tablet) Maximum of 3 tablets per day Imbruvica (Capsule) Maximum of 4 capsules per day Incruse Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days Inlyta (Tablet) Maximum of 4 tablets per day Intelence (100mg Tablet) Maximum of 2 tablets per day Intelence (200mg Tablet) Maximum of 3 tablets per day Intelence (25mg Tablet) Maximum of 6 tablets per day Invirase (200mg Capsule) Maximum of 15 capsules per day Invirase (500mg Tablet) Maximum of 6 tablets per day Invokamet (Tablet) Maximum of 2 tablets per day Invokana (Tablet) Maximum of 1 tablet per day Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day Irbesartan (75mg Tablet) Maximum of 3 tablets per day Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day Iressa (Tablet) Maximum of 2 tablets per day Isentress (100mg Packet) Maximum of 4 packets per day Isentress (100mg Tablet Chewable, 25mg Maximum of 9 tablets per day Tablet Chewable) Isentress (400mg Tablet) Maximum of 6 tablets per day Itraconazole (Capsule) Maximum of 4 capsules per day

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Drug Name Quantity Limit

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) Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day Kaletra (400mg-100mg/5ml Oral Solution) Maximum of 16 ml per day Kalydeco (150mg Tablet) Maximum of 2 tablets per day Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day 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 Latuda (120mg Tablet, 20mg Tablet, 40mg Maximum of 1 tablet per day Tablet, 60mg Tablet) Latuda (80mg Tablet) Maximum of 2 tablets per day Letairis (Tablet) Maximum of 1 tablet per day Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day Lexiva (50mg/ml Suspension) Maximum of 90 ml per day Lexiva (700mg Tablet) Maximum of 6 tablets per day Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day Lidocaine (5% Patch) Maximum of 3 patches per day Linezolid (600mg Tablet) Maximum of 2 tablets per day

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Drug Name Quantity Limit

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) Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day Lorazepam (2mg Tablet) Maximum of 5 tablets per day Lorazepam Intensol (2mg/ml Concentrate) Maximum of 5 ml per day Lorcet (Tablet) Maximum of 12 tablets per day Lorcet Plus (Tablet) Maximum of 12 tablets per day Lortab (Tablet) Maximum of 12 tablets per day Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day Losartan Potassium (25mg Tablet, 50mg Maximum of 2 tablets per day Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 1 tablet per day (100mg-12.5mg Tablet, 100mg-25mg Tablet) Losartan Potassium/Hydrochlorothiazide Maximum of 2 tablets per day (50mg-12.5mg Tablet) Lovastatin (10mg Tablet Immediate-Release, Maximum of 1 tablet per day 20mg Tablet Immediate-Release) Lovastatin (40mg Tablet Immediate-Release) Maximum of 2 tablets per day Loxapine Succinate (10mg Capsule, 5mg Maximum of 4 capsules per day Capsule) Lynparza (Capsule) Maximum of 16 capsules per day Lyrica (100mg Capsule, 150mg Capsule, 200mg Capsule, 25mg Capsule, 50mg Maximum of 3 capsules per day Capsule, 75mg Capsule) Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Matzim LA (360mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour, 420mg Tablet Extended-Release 24 Hour) Memantine HCl (10mg Tablet) Maximum of 2 tablets per day Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day

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Drug Name Quantity Limit

Memantine HCl (5mg Tablet) Maximum of 3 tablets per day Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day Metformin HCl (1000mg Tablet Immediate- Maximum of 2.5 tablets per day Release) Metformin HCl (500mg Tablet Immediate- Maximum of 5 tablets per day Release) Metformin HCl (850mg Tablet Immediate- Maximum of 3 tablets per day Release) Metformin HCl ER (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- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 3 tablets per day Tablet Immediate-Release) (Generic Ritalin) Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day Methylphenidate HCl (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 (7.5mg Tablet) Maximum of 2 tablets per day Moexipril/Hydrochlorothiazide (15mg-12.5mg Maximum of 2 tablets per day Tablet, 15mg-25mg Tablet) Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Maximum of 1 tablet per day Tablet) Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day Montelukast Sodium (4mg Packet) Maximum of 1 packet per day

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Drug Name Quantity Limit Montelukast Sodium (4mg Tablet Chewable, Maximum of 1 tablet per day 5mg Tablet Chewable) Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 18 ml per day Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 120 ml per day Morphine Sulfate (15mg Tablet Immediate- Maximum of 8 tablets per day Release) Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 90 ml per day Morphine Sulfate (30mg Tablet Immediate- Maximum of 12 tablets per day Release) Morphine Sulfate ER (100mg 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 Nadolol/Bendroflumethiazide (40mg-5mg Maximum of 1 tablet per day Tablet) Namenda XR (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Namenda XR Titration Pack (Capsule Maximum of 1 capsule per day Extended-Release 24 Hour) Namzaric (Capsule Extended-Release 24 Maximum of 1 capsule per day Hour) Naratriptan HCl (Tablet) Maximum of 9 tablets per 30 days Nateglinide (120mg Tablet) Maximum of 3 tablets per day Nateglinide (60mg Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution) Maximum of 300 mg (1 vial) in 28 days Nevirapine (200mg Tablet Immediate-Release) Maximum of 3 tablets per day Nevirapine (50mg/5ml Suspension) Maximum of 60 ml per day Nevirapine ER (100mg Tablet Extended-Release Maximum of 3 tablets per day 24 Hour) Nevirapine ER (400mg Tablet Extended-Release Maximum of 2 tablets per day 24 Hour) Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Nifedical XL (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day

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Drug Name Quantity Limit 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 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 Nucynta ER (Tablet Extended-Release 12 Maximum of 2 tablets per day Hour) Nuplazid (Tablet) Maximum of 2 tablets per day Odefsey (Tablet) Maximum of 2 tablets per day Odomzo (Capsule) Maximum of 1 capsule per day Ofev (Capsule) Maximum of 2 capsules per day Olanzapine (10mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 2.5mg Tablet Immediate-Release, 20mg Tablet Immediate- Maximum of 1 tablet per day Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate-Release) Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day Omega-3-Acid Ethyl Esters (Capsule) (Generic Maximum of 4 capsules per day Lovaza) Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day Onglyza (Tablet) Maximum of 1 tablet per day Opana ER (10mg Tablet Extended-Release 12 Hour Abuse-Deterrent, 15mg Tablet Extended-Release 12 Hour Abuse-Deterrent, 20mg Tablet Extended-Release 12 Hour Maximum of 2 tablets per day Abuse-Deterrent, 5mg Tablet Extended- Release 12 Hour Abuse-Deterrent, 7.5mg Tablet Extended-Release 12 Hour Abuse- Deterrent) Opana ER (30mg Tablet Extended-Release 12 Maximum of 4 tablets per day Hour Abuse-Deterrent)

Bold type = Brand name drug Plain type = Generic drug

98 99

Drug Name Quantity Limit Opana ER (40mg Tablet Extended-Release 12 Maximum of 3 tablets per day Hour Abuse-Deterrent) Orenitram (0.125mg Tablet Extended- Release, 0.25mg Tablet Extended-Release, Maximum of 6 tablets per day 1mg Tablet Extended-Release) Orkambi (Tablet) Maximum of 112 tablets per 28 days Oxandrolone (10mg Tablet) Maximum of 2 tablets per day Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10mg Tablet Extended-Release 24 Hour, 15mg Tablet Maximum of 2 tablets per day Extended-Release 24 Hour) Oxybutynin Chloride ER (5mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Oxycodone HCl (100mg/5ml Concentrate) Maximum of 12 ml per day Oxycodone HCl (10mg Tablet Immediate- Release, 20mg Tablet Immediate-Release, 5mg Maximum of 12 tablets per day Tablet Immediate-Release) Oxycodone HCl (15mg Tablet Immediate- Maximum of 16 tablets per day Release) Oxycodone HCl (30mg Tablet Immediate- Maximum of 8 tablets per day Release) Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 240 ml per day Oxycodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Maximum of 12 tablets per day Tablet, 7.5mg-325mg Tablet) Oxycodone/Acetaminophen (325mg/5ml-5mg/ Maximum of 60 ml per day 5ml Oral Solution) Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day 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)

Bold type = Brand name drug Plain type = Generic drug

99 100

Drug Name Quantity Limit

Paricalcitol (1mcg Capsule) Maximum of 1 capsule per day Paricalcitol (2mcg Capsule) Maximum of 2 capsules per day Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day 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 Potiga (200mg Tablet, 300mg Tablet, 400mg Maximum of 3 tablets per day Tablet) Potiga (50mg Tablet) Maximum of 9 tablets per day Pradaxa (Capsule) Maximum of 2 capsules per day Praluent (150mg/ml Solution Pen injector, Maximum of 2 pens (2 ml) per 28 days 75mg/ml Solution Pen injector) Praluent (150mg/ml Solution Prefilled Maximum of 2 syringes (2 ml) per 28 days Syringe, 75mg/ml Solution Prefilled Syringe) 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) 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 Pristiq (100mg Tablet Extended-Release 24 Maximum of 4 tablets per day Hour) Pristiq (25mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Promacta (12.5mg Tablet, 25mg Tablet) Maximum of 1 tablet per day Promacta (50mg Tablet, 75mg Tablet) Maximum of 2 tablets per day Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day

Bold type = Brand name drug Plain type = Generic drug

100 101

Drug Name Quantity Limit Quetiapine Fumarate (100mg Tablet Immediate- Release, 200mg Tablet Immediate-Release, Maximum of 3 tablets per day 50mg Tablet Immediate-Release) Quetiapine Fumarate (25mg Tablet Immediate- Maximum of 4 tablets per day Release) Quetiapine Fumarate (300mg Tablet Immediate- Maximum of 2 tablets per day Release, 400mg Tablet Immediate-Release) Quinapril HCl (Tablet) Maximum of 2 tablets per day Quinapril/Hydrochlorothiazide (10mg-12.5mg Maximum of 1 tablet per day Tablet) Quinapril/Hydrochlorothiazide (20mg-12.5mg Maximum of 2 tablets per day Tablet, 20mg-25mg Tablet) Raloxifene HCl (Tablet) Maximum of 1 tablet per day Ramipril (Capsule) Maximum of 2 capsules per day Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day Rapaflo (Capsule) Maximum of 1 capsule per day RAVICTI (Liquid) Maximum of 17.5 ml per day Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days 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 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 Revatio (20mg Tablet) Maximum of 3 tablets per day Revlimid (Capsule) Maximum of 1 capsule per day Rexulti (Tablet) Maximum of 1 tablet per day Reyataz (150mg Capsule, 300mg Capsule) Maximum of 2 capsules per day Reyataz (200mg Capsule) Maximum of 3 capsules per day Reyataz (50mg Packet) Maximum of 8 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Risedronate Sodium (150mg Tablet) Maximum of 1 tablet per 30 days Risedronate Sodium (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day Risedronate Sodium (35mg Tablet) Maximum of 4 tablets per 28 days

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101 102

Drug Name Quantity Limit Rivastigmine Tartrate (Capsule Immediate- Maximum of 2 capsules per day Release) Rivastigmine Transdermal System (Patch 24 Maximum of 1 patch per day Hour) Rizatriptan Benzoate (Tablet Immediate- Maximum of 12 tablets per 30 days Release) Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day Rozerem (Tablet) Maximum of 1 tablet per day Sabril (500mg Packet) Maximum of 6 packets per day Sabril (500mg Tablet) Maximum of 6 tablets per day Samsca (Tablet) Maximum of 2 tablets per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Selzentry (150mg Tablet) Maximum of 3 tablets per day Selzentry (300mg Tablet) Maximum of 6 tablets per day Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day Sensipar (90mg Tablet) Maximum of 4 tablets per day Maximum of 1 inhaler (60 inhalations) per 30 Serevent Diskus (Aerosol Powder) days Seroquel XR (150mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) Seroquel XR (300mg Tablet Extended- Release 24 Hour, 400mg Tablet Extended- Maximum of 2 tablets per day Release 24 Hour, 50mg Tablet Extended- Release 24 Hour) sfRowasa (Enema) Maximum of 1 bottle (60 ml) per day Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day Simvastatin (Tablet) Maximum of 1 tablet per day 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

Bold type = Brand name drug Plain type = Generic drug

102 103

Drug Name Quantity Limit Stavudine (15mg Capsule, 30mg Capsule, Maximum of 3 capsules per day 40mg Capsule) Stavudine (1mg/ml Oral Solution) Maximum of 120 ml per day Stavudine (20mg Capsule) Maximum of 2 capsules per day Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days Stivarga (Tablet) Maximum of 4 tablets per day Strattera (100mg Capsule, 60mg Capsule, Maximum of 1 capsule per day 80mg Capsule) Strattera (10mg Capsule, 18mg Capsule, Maximum of 2 capsules per day 25mg Capsule, 40mg Capsule) Stribild (Tablet) Maximum of 2 tablets per day Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 sublingual films per day Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 sublingual films per day Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100mg Tablet, 25mg Maximum of 9 tablets per 30 days Tablet, 50mg Tablet) Sumatriptan Succinate (6mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Auto injector) Sumatriptan Succinate (6mg/0.5ml Solution Maximum of 12 injections (6 ml) per 30 days Prefilled Syringe) Sumatriptan Succinate (6mg/0.5ml Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days Sumavel DosePro (Injection) Maximum of 12 injections (6 ml) per 30 days Sustiva (200mg Capsule) Maximum of 3 capsules per day Sustiva (50mg Capsule) Maximum of 9 capsules per day Sustiva (600mg Tablet) Maximum of 2 tablets per day Sutent (12.5mg Capsule, 25mg Capsule, Maximum of 1 capsule per day 50mg Capsule) Sutent (37.5mg Capsule) Maximum of 2 tablets per day Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Synjardy (Tablet) Maximum of 2 tablets per day Tagrisso (Tablet) Maximum of 1 tablet per day Tamiflu (30mg Capsule, 45mg Capsule, Maximum of 2 capsules per day 75mg Capsule) Tamiflu (6mg/ml Suspension) Maximum of 26 ml per day Tarceva (100mg Tablet, 150mg Tablet) Maximum of 1 tablet per day Tarceva (25mg Tablet) Maximum of 3 tablets per day

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Drug Name Quantity Limit

Tasigna (150mg Capsule) Maximum of 5 capsules per day Tasigna (200mg Capsule) Maximum of 4 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 (Tablet) Maximum of 1 tablet per day Temazepam (15mg Capsule, 30mg Capsule) Maximum of 1 capsule per day Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day Thalomid (100mg Capsule, 50mg Capsule) Maximum of 1 capsule per day Thalomid (150mg Capsule, 200mg Capsule) Maximum of 2 tablets per day Tivicay (10mg Tablet, 25mg Tablet) Maximum of 2 tablets per day Tivicay (50mg Tablet) Maximum of 3 tablets per day TOBI (Nebulized Solution) Maximum of 10 ml (2 ampules) per day TOBI Podhaler (Capsule) Maximum of 8 capsules per day Tobramycin (Nebulized Solution) Maximum of 10 ml (2 ampules) per day Tolcapone (Tablet) Maximum of 6 tablets per day Tracleer (Tablet) Maximum of 2 tablets per day Tradjenta (Tablet) Maximum of 1 tablet per day Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day Tramadol HCl ER (100mg Tablet Extended- Release 24 Hour, 200mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) (Generic Ultram ER) Tramadol HCl ER (300mg Tablet Extended- Maximum of 1 tablet per day Release 24 Hour) (Generic Ryzolt) Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day Trandolapril (4mg Tablet) Maximum of 2 tablets per day Trezix (Capsule) Maximum of 10 capsules per day Tribenzor (Tablet) Maximum of 1 tablet per day Trintellix (Tablet) Maximum of 1 tablet per day Triumeq (Tablet) Maximum of 2 tablets per day Trizivir (Tablet) Maximum of 3 tablets per day 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 Tyvaso (Inhalation Solution) Maximum of 4 ampules per day

Bold type = Brand name drug Plain type = Generic drug

104 105

Drug Name Quantity Limit

Vagifem (Tablet) Maximum of 1 tablet per day Valacyclovir HCl (1000mg Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day Valcyte (450mg Tablet) Maximum of 4 tablets per day 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 Venclexta (100mg Tablet) Maximum of 4 tablets per day Venclexta (10mg Tablet) Maximum of 2 tablets per day Venclexta (50mg Tablet) Maximum of 1 tablet per day Ventavis (10mcg/ml Inhalation Solution) Maximum of 7 ml per day Ventavis (20mcg/ml Inhalation Solution) Maximum of 3 ml per day Vesicare (Tablet) Maximum of 1 tablet per day Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days Videx Pediatric (Oral Solution) Maximum of 30 ml per day Viibryd (Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Kit) Maximum of 1 tablet per day Vimpat (100mg Tablet, 150mg Tablet, 200mg Maximum of 2 tablets per day Tablet, 50mg Tablet) Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day Viracept (250mg Tablet) Maximum of 15 tablets per day Viracept (625mg Tablet) Maximum of 6 tablets per day Viread (150mg Tablet) Maximum of 1 tablet per day Viread (200mg Tablet, 250mg Tablet, 300mg Maximum of 2 tablets per day Tablet) Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days Vitekta (Tablet) Maximum of 2 tablets per day Votrient (Tablet) Maximum of 4 tablets per day Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg Maximum of 1 capsule per day Capsule, 6mg Capsule) Vytorin (Tablet) Maximum of 1 tablet per day 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

Bold type = Brand name drug Plain type = Generic drug

105 106

Drug Name Quantity Limit Xeljanz XR (Tablet Extended-Release 24 Maximum of 1 tablet per day Hour) Xenazine (12.5mg Tablet) Maximum of 3 tablets per day Xenazine (25mg Tablet) Maximum of 4 tablets per day Xtandi (Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Zafirlukast (Tablet) Maximum of 2 tablets per day Zaleplon (Capsule) Maximum of 90 days of use per year Zelboraf (Tablet) Maximum of 8 tablets per day Zepatier (Tablet) Maximum of 1 tablet per day Zetia (Tablet) Maximum of 1 tablet per day Ziagen (Oral Solution) Maximum of 48 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 Ziprasidone HCl (Capsule) Maximum of 2 capsules per day Zolpidem Tartrate (10mg Tablet Immediate- Maximum of 90 days of use per year Release, 5mg Tablet Immediate-Release) Zydelig (Tablet) Maximum of 2 tablets per day Zykadia (Capsule) Maximum of 5 capsules per day Zytiga (Tablet) Maximum of 4 tablets per day

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Bold type = Brand name drug Plain type = Generic drug

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107 trackIndex of covered drugs

# Advair Diskus...... 80 Amiloride/ 8-MOP...... 57 Advair HFA...... 80 Hydrochlorothiazide...... 50 A Afeditab CR...... 49 Aminophylline...... 79 A-Hydrocort...... 62 Afinitor...... 34 Aminosyn 7%/Electrolytes ...... 83 Abacavir...... 41 Afinitor Disperz...... 35 Aminosyn 8.5%/Electrolytes Abacavir Sulfate/Lamivudine/ Aggrenox...... 46 ...... 83 Zidovudine...... 41 Ala Cort...... 62 Aminosyn II...... 83 Abelcet...... 29 Albenza...... 35 Aminosyn II 8.5%/Electrolytes Abilify Maintena...... 38 Albuterol Sulfate...... 79 ...... 83 Abraxane...... 33 Alclometasone Dipropionate Aminosyn-HBC...... 83 Abstral...... 14 ...... 62 Aminosyn-PF...... 83 Acamprosate Calcium DR...16 Alcohol Prep Pads...... 74 Aminosyn-RF...... 83 Acarbose...... 43 Aldurazyme...... 58 Amiodarone HCl...... 47 Acebutolol HCl...... 48 Alecensa...... 33 Amitiza...... 60 Acetaminophen/Codeine....14 Alendronate Sodium...... 73 Amitriptyline HCl...... 28 Acetazolamide...... 52 Alfuzosin HCl ER...... 61 Amlodipine Besylate...... 49 Acetazolamide ER...... 52 Alimta...... 32 Amlodipine Besylate/ Acetazolamide Sodium...... 52 Alinia...... 36 Atorvastatin Calcium...... 50 Acetic Acid...... 77 Allopurinol...... 31 Amlodipine Besylate/ Acetylcysteine...... 80 Alocril...... 75 Benazepril HCl...... 50 Acitretin...... 57 Alomide...... 75 Amlodipine Besylate/ Valsartan...... 51 Actemra...... 71 Alosetron HCl...... 60 Amlodipine/Valsartan/ ActHIB...... 72 Aloxi...... 29 Hydrochlorothiazide...... 51 Actimmune...... 71 Alphagan P...... 75 Ammonium Chloride...... 81 Acyclovir...... 40 Alprazolam...... 43 Ammonium Lactate...... 57 Acyclovir Sodium...... 40 Altabax...... 17 Amoxapine...... 28 Adacel...... 72 Amantadine HCl...... 36 Amoxicillin...... 19 Adagen...... 58 AmBisome...... 29 Amoxicillin/Clavulanate Adapalene...... 57 Amethia...... 65 Potassium...... 20 Adcirca...... 79 Amethyst...... 65 Amoxicillin/Clavulanate Adefovir Dipivoxil...... 39 Amifostine...... 33 Potassium ER...... 20 Adempas...... 79 Amikacin Sulfate...... 16 Amphetamine/ Adrucil...... 32 Amiloride HCl...... 53 Dextroamphetamine...... 55 Amphotericin B...... 29 107 Tracked

108

Ampicillin...... 20 Atovaquone...... 36 Balziva...... 65 Ampicillin Sodium...... 20 Atovaquone/Proguanil HCl Banzel...... 25 Ampicillin-Sulbactam...... 20 ...... 36 Baraclude...... 40 Ampyra...... 56 Atripla...... 41 BCG Vaccine...... 72 Anadrol-50...... 65 Atropine Sulfate...... 59 Bekyree...... 65 Anagrelide HCl...... 45 Atrovent HFA...... 78 Beleodaq...... 33 Anastrozole...... 34 Aubagio...... 56 Belsomra...... 81 Androderm...... 65 Aubra...... 65 Benazepril HCl...... 47 AndroGel...... 65 Augmented Betamethasone Benazepril HCl/ Dipropionate...... 62 AndroGel Pump...... 65 Hydrochlorothiazide...... 51 Avandia...... 43 Anoro Ellipta...... 80 Benicar...... 47 Avastin...... 35 Anzemet...... 29 Benicar HCT...... 51 Avelox...... 21 Apokyn...... 36 Benlysta...... 71 Aviane...... 65 Apraclonidine...... 75 Benztropine Mesylate...... 36 Avonex...... 56 Apri...... 65 Bepreve...... 75 Avonex Pen...... 56 Apriso...... 73 Berinert...... 70 Azacitidine...... 33 Aptiom...... 25 Besivance...... 21 Azactam in Iso-Osmotic Aptivus...... 42 Betamethasone Dipropionate Dextrose...... 19 ...... 62 Aralast NP...... 80 Azasite...... 21 Betamethasone Valerate..... 62 Aranelle...... 65 Azathioprine...... 70 Betaseron...... 56 Aranesp Albumin Free...... 46 Azelastine HCl...... 75, 77 Betaxolol HCl...... 48, 76 Arcalyst...... 71 Azilect...... 37 Bethanechol Chloride...... 61 Argatroban...... 46 Azithromycin...... 21 Bethkis...... 16 Aripiprazole...... 38 Azopt...... 76 Betimol...... 76 Aripiprazole ODT...... 38 Azor...... 51 Bexarotene...... 35 Aristada...... 38 Aztreonam...... 19 Bexsero...... 72 Arnuity Ellipta...... 78 B Bicalutamide...... 32 Arranon...... 33 BACiiM...... 17 Bicillin C-R...... 20 Ashlyna...... 65 Bacitracin...... 17 Bicillin L-A...... 20 Aspirin/Dipyridamole...... 46 Bacitracin/Polymyxin B...... 74 BiCNU...... 32 Atenolol...... 48 Baclofen...... 80 BiDil...... 51 Atenolol/Chlorthalidone...... 51 Bactocill in Dextrose...... 20 Biltricide...... 36 Atgam...... 71 Bactroban Nasal...... 17 Binosto...... 73 Atorvastatin Calcium...... 53 Balsalazide Disodium...... 73 108 Tracked

109

Bisoprolol Fumarate...... 48 Byetta...... 43 Carimune Nanofiltered...... 71 Bisoprolol Fumarate/ Bystolic...... 48 Carteolol HCl...... 76 Hydrochlorothiazide...... 51 C Cartia XT...... 49 BIVIGAM...... 71 Cabergoline...... 69 Carvedilol...... 48 Bleomycin Sulfate...... 33 Cabometyx...... 35 Cayston...... 79 Blephamide...... 74 Cafergot...... 31 Cefaclor...... 18 Blephamide S.O.P...... 74 Calcipotriene...... 57 Cefadroxil...... 18 Blisovi 24 Fe...... 65 Calcitonin-Salmon...... 73 Cefazolin Sodium...... 18 Blisovi Fe 1.5/30...... 65 Calcitriol...... 57, 73 Cefdinir...... 18 Blisovi Fe 1/20...... 65 Calcium Acetate...... 61 Cefepime...... 18 Boostrix...... 72 Camila...... 68 Cefixime...... 18 Bosulif...... 35 Canasa...... 73 Cefotaxime Sodium...... 18 Botox...... 74 Cancidas...... 29 Cefotetan...... 18 Breo Ellipta...... 80 Candesartan Cilexetil...... 47 Cefoxitin Sodium...... 19 Briellyn...... 65 Candesartan Cilexetil/ Cefpodoxime Proxetil...... 19 Brilinta...... 46 Hydrochlorothiazide...... 51 Cefprozil...... 19 Brimonidine Tartrate...... 76 Capastat Sulfate...... 32 Ceftazidime...... 19 BRIVIACT...... 23 Caprelsa...... 35 Ceftriaxone Sodium...... 19 Bromocriptine Mesylate...... 36 Captopril...... 47 Cefuroxime Axetil...... 19 Brovana...... 79 Captopril/Hydrochlorothiazide Cefuroxime Sodium...... 19 ...... 51 Budesonide...... 73, 78 Celecoxib...... 12 Carac...... 57 Bumetanide...... 52 Cellcept...... 70 Carafate...... 60 Buphenyl...... 58 Cellcept Intravenous...... 70 Carbaglu...... 81 Buprenorphine HCl...... 16 Celontin...... 24 Carbamazepine...... 25 Buprenorphine HCl/Naloxone Cephalexin...... 19 HCl...... 16 Carbamazepine ER...... 25 Cerezyme...... 58 Buproban...... 16 Carbidopa...... 37 Cervarix...... 72 Bupropion HCl...... 27 Carbidopa/Levodopa...... 37 Cesamet...... 29 Bupropion HCl SR...... 27 Carbidopa/Levodopa ER.....37 Cetirizine HCl...... 77 Bupropion HCl XL...... 27 Carbidopa/Levodopa ODT Chantix...... 16 Buspirone HCl...... 42 ...... 37 Chantix Continuing Month Carbidopa/Levodopa/ Busulfex...... 32 Pak...... 16 Entacapone...... 37 Butorphanol Tartrate...... 14 Chantix Starting Month Pak Carboplatin...... 33 Bydureon...... 43 ...... 16 Cardene IV...... 49

109 Tracked

110

Chemet...... 81 Claravis...... 57 Colocort...... 73 Chenodal...... 59 Clarithromycin...... 21 Coly-Mycin S...... 77 Chloramphenicol Sodium Clarithromycin ER...... 21 Combigan...... 76 Succinate...... 17 Climara Pro...... 65 Combivent Respimat...... 80 Chlordiazepoxide HCl...... 43 Clindamycin HCl...... 17 Combivir...... 41 Chlorhexidine Gluconate Oral Clindamycin Palmitate HCl Cometriq...... 35 Rinse...... 57 ...... 17 Complera...... 41 Chloroquine Phosphate...... 36 Clindamycin Phosphate...... 17, Compro...... 28 Chlorothiazide...... 53 57 Constulose...... 60 Chlorothiazide Sodium...... 53 Clindamycin Phosphate in Copaxone...... 56 Chlorpromazine HCl...... 37 D5W...... 17 Cordran Tape...... 62 Chlorthalidone...... 53 Clindamycin/Benzoyl Peroxide...... 57 Cormax Scalp Application...62 Cholbam...... 59 Clobetasol Propionate...... 62 Cortisone Acetate...... 62 Cholestyramine Light...... 53 Clobetasol Propionate E...... 62 Cortisporin...... 57 Chorionic Gonadotropin...... 64 Clolar...... 33 Cosmegen...... 33 Ciclopirox...... 29 Clomipramine HCl...... 28 Cotellic...... 35 Ciclopirox Nail Lacquer...... 29 Clonazepam...... 43 Coumadin...... 45 Ciclopirox Olamine...... 29 Clonazepam ODT...... 43 Creon...... 58 Cidofovir...... 39 Clonidine HCl...... 47 Crestor...... 53 Cilostazol...... 46 Clonidine HCl ER...... 55 Crinone...... 68 Ciloxan...... 21 Clopidogrel...... 46 Crixivan...... 42 Cimetidine...... 59 Clorazepate Dipotassium.... 43 Cromolyn Sodium....59, 75, 80 Cimetidine HCl...... 59 Clorpres...... 51 Cryselle-28...... 65 Cimzia...... 70 Clotrimazole...... 29 Cubicin...... 17 Cinryze...... 70 Clotrimazole/Betamethasone Cuprimine...... 61 Cipro HC...... 77 Dipropionate...... 57 Cuvposa...... 59 Ciprodex...... 77 Clozapine...... 39 Cyclafem...... 65 Ciprofloxacin...... 21 Clozapine ODT...... 39 Cyclobenzaprine HCl...... 80 Ciprofloxacin ER...... 21 Coartem...... 36 Cyclophosphamide...... 32 Ciprofloxacin HCl...... 22 Codeine Sulfate...... 14 Cycloset...... 43 Ciprofloxacin I.V. in D5W.....22 Colchicine...... 31 Cyclosporine...... 70 Cisplatin...... 33 Colcrys...... 31 Cyclosporine Modified...... 70 Citalopram HBr...... 27 Colestipol HCl...... 53 Cyproheptadine HCl...... 77 Cladribine...... 32 Colistimethate Sodium...... 17 Cyramza...... 35

110 Tracked

111

Cystadane...... 58 Dexamethasone...... 62 Diclofenac Sodium DR...... 12 Cystagon...... 58 Dexamethasone Intensol..... 63 Diclofenac Sodium ER...... 12 Cystaran...... 74 Dexamethasone Sodium Dicloxacillin Sodium...... 20 Cytarabine Aqueous...... 33 Phosphate...... 63, 76 Dicyclomine HCl...... 59 D Dexedrine...... 55 Didanosine...... 41 Dacarbazine...... 32 Dexilant...... 60 Dificid...... 21 Dacogen...... 33 Dexmethylphenidate HCl.....55 Diflunisal...... 12 Daklinza...... 40 Dexmethylphenidate HCl ER Digitek...... 51 ...... 55 Daliresp...... 79 Digoxin...... 51 Dexrazoxane...... 33 Dalvance...... 17 Dihydroergotamine Mesylate Dextroamphetamine Sulfate Danazol...... 65 ...... 31 ...... 55 Dantrolene Sodium...... 80 Dilantin...... 25 Dextroamphetamine Sulfate Dilantin INFATABS...... 25 Dapsone...... 31 ER...... 55 Dilt-XR...... 49 Daptacel...... 72 Dextrose 10%...... 83 Diltiazem CD...... 49 DARAPRIM...... 36 Dextrose 10%/NaCl 0.2%.... 83 Diltiazem HCl...... 49 Darzalex...... 35 Dextrose 10%/NaCl 0.45% Daunorubicin HCl...... 33 ...... 83 Diltiazem HCl ER...... 49 Deblitane...... 68 Dextrose 2.5%/Sodium Dipentum...... 73 Chloride 0.45%...... 83 Decitabine...... 33 Diphenhydramine HCl...... 77 Dextrose 5%...... 83 Delyla...... 65 Diphenoxylate/Atropine...... 59 Dextrose 5%/NaCl 0.2%...... 83 Demeclocycline HCl...... 22 Diphtheria/Tetanus Toxoids Dextrose 5%/NaCl 0.225% Adsorbed Pediatric...... 72 Demser...... 51 ...... 83 Disulfiram...... 16 Denavir...... 40 Dextrose 5%/NaCl 0.33%.... 83 Diuril...... 53 Depen Titratabs...... 61 Dextrose 5%/NaCl 0.45%.... 83 Divalproex Sodium...... 43 Depo-Estradiol...... 65 Dextrose 5%/NaCl 0.9%...... 83 Divalproex Sodium DR...... 43 Depo-Medrol...... 62 Dextrose 5%/Potassium Divalproex Sodium ER...... 43 Depo-Provera...... 68 Chloride 0.15%...... 83 Docefrez...... 33 Descovy...... 41 Diastat AcuDial...... 24 Docetaxel...... 33 Desipramine HCl...... 28 Diastat Pediatric...... 24 Dofetilide...... 47 Desmopressin Acetate...... 64 Diazepam...... 24, 43 Donepezil HCl...... 26 Desogestrel/Ethinyl Estradiol Diazepam Intensol...... 43 ...... 65 Donepezil HCl ODT...... 26 Diclofenac Potassium...... 12 Desonide...... 62 Doribax...... 19 Diclofenac Sodium...... 12, 57, Dorzolamide HCl...... 76 Desoximetasone...... 62 76

111 Tracked

112

Dorzolamide HCl/Timolol Elestrin...... 66 Eprosartan Mesylate...... 47 Maleate...... 76 Elidel...... 57 Epzicom...... 41 Doxazosin Mesylate...... 47 Eliphos...... 61 Eraxis...... 30 Doxepin HCl...... 28, 57 Eliquis...... 45 Erbitux...... 35 Doxercalciferol...... 73 Elitek...... 33 Erivedge...... 35 Doxil...... 33 Ellence...... 33 Errin...... 68 Doxorubicin HCl...... 33 Elmiron...... 61 Erwinaze...... 33 Doxorubicin HCl Liposome Embeda...... 13 Ery...... 57 ...... 33 Emcyt...... 32 Ery-Tab...... 21 Doxy 100...... 22 Emend...... 29 EryPed 200...... 21 Doxycycline...... 22 Emoquette...... 66 EryPed 400...... 21 Doxycycline Hyclate...... 23 Empliciti...... 35 Erythrocin Lactobionate...... 21 Doxycycline Monohydrate... 23 Emsam...... 27 Erythromycin...... 21, 57, 58 Dronabinol...... 29 Emtriva...... 41 Erythromycin Base...... 21 Drospirenone/Ethinyl Enalapril Maleate...... 47 Erythromycin Ethylsuccinate Estradiol...... 65 Enalapril Maleate/ ...... 21 Droxia...... 33 Hydrochlorothiazide...... 51 Erythromycin/Benzoyl Duavee...... 66 Enbrel...... 70 Peroxide...... 58 Dulera...... 80 Enbrel SureClick...... 70 Esbriet...... 80 Duloxetine HCl...... 56 Endocet...... 14 Escitalopram Oxalate...... 27 Duramorph...... 14 Engerix-B...... 72 Esomeprazole Magnesium Durezol...... 76 ...... 60 Enoxaparin Sodium...... 45 Dymista...... 80 Esomeprazole Sodium...... 60 Enpresse-28...... 66 Dyrenium...... 53 Estrace...... 66 Entacapone...... 36 E Estradiol...... 66 Entecavir...... 40 E.E.S. Granules...... 21 Estradiol Valerate...... 66 Entocort EC...... 73 Econazole Nitrate...... 29 Estring...... 66 Entresto...... 51 Edarbi...... 47 Ethambutol HCl...... 32 Enulose...... 60 Edarbyclor...... 51 Ethosuximide...... 24 Epaned...... 47 Edecrin...... 52 Etidronate Disodium...... 73 Epinastine HCl...... 75 Edurant...... 41 Etodolac...... 12 EpiPen...... 79 Effient...... 46 Etodolac ER...... 12 Epitol...... 25 Egrifta...... 69 Etopophos...... 34 Epivir HBV...... 40 Elaprase...... 58 Etoposide...... 34 Eplerenone...... 53 Elelyso...... 58 Eurax...... 36 112 Tracked

113

Evotaz...... 40 Flector...... 12 Fosinopril Sodium/ Exelderm...... 30 Flovent Diskus...... 78 Hydrochlorothiazide...... 51 Exemestane...... 34 Flovent HFA...... 78 Fosphenytoin Sodium...... 25 Exjade...... 81 Fluconazole...... 30 Fosrenol...... 61 F Fluconazole in NaCl...... 30 FreAmine HBC 6.9%...... 83 Fabrazyme...... 58 Flucytosine...... 30 Furosemide...... 52, 53 Falmina...... 66 Fludarabine Phosphate...... 33 Fusilev...... 33 Famciclovir...... 40 Fludrocortisone Acetate...... 63 Fuzeon...... 42 Famotidine...... 59 Flunisolide...... 78 Fycompa...... 23 Famotidine Premixed...... 59 Fluocinolone Acetonide...... 63, G Fanapt...... 38 77 Gabapentin...... 24 Fanapt Titration Pack...... 38 Fluocinolone Acetonide Body Gabitril...... 24 ...... 63 Fareston...... 32 Gablofen...... 81 Fluocinonide...... 63 Farydak...... 33 Galantamine HBr...... 26 Fluocinonide-E...... 63 Faslodex...... 32 Gamastan S/D...... 71 Fluorometholone...... 76 Fazaclo...... 39 Gammagard Liquid...... 71 Fluorouracil...... 33, 58 Felbamate...... 24, 25 Gammaked...... 71 Fluoxetine DR...... 27 Felbatol...... 25 Gammaplex...... 71 Fluoxetine HCl...... 27 Felodipine ER...... 49 Gamunex-C...... 71 Fluphenazine Decanoate.....37 Femring...... 66 Ganciclovir...... 39 Fluphenazine HCl...... 37 Fenofibrate...... 53 Gardasil...... 72 Flurbiprofen...... 12 Fenofibrate Micronized...... 53 Gardasil 9...... 72 Flurbiprofen Sodium...... 76 Fenofibric Acid...... 53 Gatifloxacin...... 22 Flutamide...... 32 Fenofibric Acid DR...... 53 Gattex...... 59 Fluticasone Propionate...... 63, Fentanyl...... 13 Gauze...... 74 78 Ferriprox...... 81 GaviLyte-C...... 60 Fluvastatin...... 53 Fetzima...... 27 GaviLyte-G...... 60 Fluvoxamine Maleate...... 27 Fetzima Titration Pack...... 27 GaviLyte-H...... 60 FML...... 76 Finasteride...... 61 GaviLyte-N/Flavor Pack...... 60 FML Forte...... 76 Firazyr...... 70 Gemcitabine HCl...... 33 Folotyn...... 33 Firmagon...... 69 Gemfibrozil...... 53 Fomepizole...... 74 Flarex...... 76 Gemzar...... 33 Fondaparinux Sodium...... 45 Flebogamma DIF...... 71 Generlac...... 60 Forteo...... 73 Flecainide Acetate...... 47 Gengraf...... 70 Fosinopril Sodium...... 47 113 Tracked

114

Genotropin...... 64 Haloperidol...... 37 Humulin R U-500 KwikPen Genotropin Miniquick...... 64 Haloperidol Decanoate...... 37 ...... 45 Gentak...... 16 Haloperidol Lactate...... 37 Humulin R U-500 Vial...... 45 Gentamicin Sulfate...... 16 Harvoni...... 40 Humulin R Vial...... 45 Gentamicin Sulfate/0.9% Havrix...... 72 Hycamtin...... 34 Sodium Chloride...... 16 Hectorol...... 74 Hydralazine HCl...... 54 Genvoya...... 40 Heparin Sodium...... 45 Hydrochlorothiazide...... 53 Geodon...... 38 Heparin Sodium/D5W...... 45 Hydrocodone Bitartrate/ Acetaminophen...... 14 Gianvi...... 66 HepatAmine...... 83 Hydrocodone/Acetaminophen Gildagia...... 66 Hepsera...... 40 ...... 14 Gildess 1.5/30...... 66 Herceptin...... 35 Hydrocodone/Ibuprofen...... 14 Gildess 24 Fe...... 66 Hetlioz...... 81 Hydrocortisone...... 63, 73 Gilenya...... 56 Hexalen...... 32 Hydrocortisone Butyrate...... 63 Gilotrif...... 35 Hiberix...... 72 Hydrocortisone Valerate...... 63 Glassia...... 80 Humalog Cartridge...... 44 Hydrocortisone/Acetic Acid Glatopa...... 56 Humalog KwikPen...... 44 ...... 77 Gleostine...... 32 Humalog Mix 50/50 KwikPen Hydromorphone HCl...... 14 Glimepiride...... 43 ...... 44 Hydromorphone HCl ER...... 13 Glipizide...... 43 Humalog Mix 50/50 Vial...... 44 Hydroxychloroquine Sulfate Glipizide ER...... 43 Humalog Mix 75/25 KwikPen ...... 36 ...... 44 Glipizide/Metformin HCl...... 43 Hydroxyprogesterone GlucaGen HypoKit...... 44 Humalog Mix 75/25 Vial...... 44 Caproate...... 68 Glucagon Emergency Kit.....44 Humalog Vial...... 45 Hydroxyurea...... 33 Glycopyrrolate...... 59 Humatrope...... 64 Hydroxyzine HCl...... 42 Granisetron HCl...... 29 Humatrope Combo Pack.....64 Hydroxyzine Pamoate...... 28 Granix...... 46 Humira...... 70 I Griseofulvin Microsize...... 30 Humira Pediatric Crohns Ibandronate Sodium...... 74 Disease Starter Pack...... 70 Griseofulvin Ultramicrosize Ibrance...... 33 Humira Pen...... 70 ...... 30 Ibuprofen...... 12 Humira Pen Crohns Disease Guanfacine ER...... 55 Iclusig...... 35 Starter Pack...... 70 Guanidine HCl...... 31 Idamycin PFS...... 33 Humulin 70/30 KwikPen...... 45 H Idarubicin HCl...... 33 Humulin 70/30 Vial...... 45 Halaven...... 33 Ifosfamide...... 32 Humulin N KwikPen...... 45 Halobetasol Propionate...... 63 Ilaris...... 72 Humulin N Vial...... 45

114 Tracked

115

Ilevro...... 76 Irbesartan/ Junel 1/20...... 66 Ilotycin...... 21 Hydrochlorothiazide...... 51 Junel Fe 1.5/30...... 66 Imatinib Mesylate...... 35 Iressa...... 35 Junel Fe 1/20...... 66 Imbruvica...... 35 Irinotecan...... 33 Junel Fe 24...... 66 Imipenem/Cilastatin...... 19 Isentress...... 40 Juxtapid...... 53 Imipramine HCl...... 28 Isolyte-P/Dextrose 5%...... 83 K Imipramine Pamoate...... 28 Isolyte-S...... 81 Kadcyla...... 35 Imiquimod...... 58 Isoniazid...... 32 Kaitlib Fe...... 66 Imovax Rabies...... 72 Isosorbide Dinitrate...... 54 Kaletra...... 42 Increlex...... 64 Isosorbide Dinitrate ER...... 54 Kalydeco...... 79, 80 Incruse Ellipta...... 78 Isosorbide Mononitrate...... 54 Kanuma...... 74 Indapamide...... 53 Isosorbide Mononitrate ER Kariva...... 66 ...... 54 Infanrix...... 72 KCl 0.075%/D5W/NaCl 0.45% Isotonic Gentamicin...... 16 Inlyta...... 35 ...... 83 Istodax...... 33 Insulin Syringes, Needles.... 74 KCl 0.15%/D5W/LR...... 83 Itraconazole...... 30 Intelence...... 41 KCl 0.15%/D5W/NaCl 0.2% Ivermectin...... 36 ...... 83 Intralipid...... 83 Ixiaro...... 72 KCl 0.15%/D5W/NaCl 0.225% Intron A...... 40 J ...... 83 Intron A w/Diluent...... 40 Jadenu...... 81 KCl 0.15%/D5W/NaCl 0.9% Introvale...... 66 ...... 83 Jakafi...... 35 Invanz...... 19 KCl 0.3%/D5W/NaCl 0.45% Jantoven...... 45 Invega Sustenna...... 38 ...... 83 Janumet...... 43 Invega Trinza...... 38 KCl 0.3%/D5W/NaCl 0.9% Janumet XR...... 44 ...... 84 Invirase...... 42 Januvia...... 44 Kelnor 1/35...... 66 Invokamet...... 43 Jardiance...... 44 Kenalog-10...... 63 Invokana...... 43 Jentadueto...... 44 Kenalog-40...... 63 Ionosol-B/Dextrose 5%...... 83 Jentadueto XR...... 44 Kepivance...... 57 Ionosol-MB/Dextrose 5%.....83 Jevtana...... 33 Ketoconazole...... 30 IPOL Inactivated IPV...... 72 Jinteli...... 66 Ketoprofen...... 12 Ipratropium Bromide...... 78 Jolivette...... 68 Ketorolac Tromethamine.... 12, Ipratropium Bromide/ 76 Albuterol Sulfate...... 80 Jublia...... 30 Keytruda...... 35 Irbesartan...... 47 Juleber...... 66 Junel 1.5/30...... 66 Kimidess...... 66 Kineret...... 70 115 Tracked

116

Kionex...... 81 Leena...... 66 Lidocaine Viscous...... 15 Klor-Con 10...... 81 Leflunomide...... 72 Lidocaine/Prilocaine...... 16 Klor-Con 8...... 81 Lenvima...... 35 Lincomycin HCl...... 17 Klor-Con M15...... 81 Lessina...... 66 Lindane...... 36 Klor-Con M20...... 81 Letairis...... 79 Linezolid...... 17 Klor-Con Sprinkle...... 81 Letrozole...... 34 Linzess...... 60 Kombiglyze XR...... 44 Leucovorin Calcium...... 34 Lioresal Intrathecal...... 81 Korlym...... 65 Leukeran...... 32 Liothyronine Sodium...... 69 Kuvan...... 58 Leukine...... 46 Lisinopril...... 47 Kynamro...... 54 Leuprolide Acetate...... 69 Lisinopril/Hydrochlorothiazide L Levalbuterol...... 79 ...... 51 Labetalol HCl...... 48 Levemir FlexTouch...... 45 Lithium...... 43 Lacrisert...... 74 Levemir Vial...... 45 Lithium Carbonate...... 43 Lactated Ringers Dextrose 5% Levetiracetam...... 23, 24 Lithium Carbonate ER...... 43 Viaflex...... 84 Levetiracetam ER...... 24 Lithostat...... 61 Lactated Ringers Irrigation Levobunolol HCl...... 76 Lomedia 24 Fe...... 66 ...... 84 Levocarnitine...... 84 Lonsurf...... 33 Lactated Ringers Viaflex...... 84 Levocetirizine Dihydrochloride Loperamide HCl...... 59 Lactulose...... 60 ...... 77 Lorazepam...... 43 Lamisil...... 30 Levofloxacin...... 22 Lorazepam Intensol...... 43 Lamivudine...... 40, 41 Levofloxacin in D5W...... 22 Lorcet...... 14 Lamivudine/Zidovudine...... 41 Levoleucovorin Calcium...... 34 Lorcet Plus...... 14 Lamotrigine...... 25 Levonest...... 66 Lortab...... 14 Lanoxin...... 51 Levonorgestrel and Ethinyl Loryna...... 67 Lantus SoloStar...... 45 Estradiol...... 66 Losartan Potassium...... 47 Lantus Vial...... 45 Levonorgestrel/Ethinyl Losartan Potassium/ LARIN 1.5/30...... 66 Estradiol...... 66 Hydrochlorothiazide...... 51 LARIN 1/20...... 66 Levora 0.15/30-28...... 66 Lotemax...... 77 LARIN Fe 1.5/30...... 66 Levorphanol Tartrate...... 13 Lotronex...... 60 LARIN Fe 1/20...... 66 Levothyroxine Sodium...... 69 Lovastatin...... 53 Lastacaft...... 74 Levoxyl...... 69 Loxapine Succinate...... 37 Latanoprost...... 77 Lexiva...... 42 Lumigan...... 77 Latuda...... 38 Lialda...... 73 Lumizyme...... 58 Layolis Fe...... 66 Lidocaine...... 15 Lupaneta Pack...... 69 Lidocaine HCl...... 15 116 Tracked

117

Lupron Depot...... 69 Menveo...... 72 Methylprednisolone Sodium Lupron Depot-PED...... 69 Mepron...... 36 Succinate...... 63 Lutera...... 67 Mercaptopurine...... 33 Metipranolol...... 76 Lynparza...... 34 Meropenem...... 19 Metoclopramide HCl...... 28, 29 Lyrica...... 56 Mesalamine...... 73 Metolazone...... 53 Lysodren...... 69 Mesna...... 34 Metoprolol Succinate ER.....48 Lyza...... 68 Mesnex...... 34 Metoprolol Tartrate...... 48 M Mestinon...... 31 Metoprolol/ Hydrochlorothiazide...... 51 M-M-R II...... 72 Metadate ER...... 55 Metronidazole...... 17 Magnesium Sulfate...... 81, 82 Metaproterenol Sulfate...... 79 Metronidazole in NaCl 0.79% Makena...... 68 Metformin HCl...... 44 ...... 18 Malathion...... 36 Metformin HCl ER...... 44 Metronidazole Vaginal...... 18 Maprotiline HCl...... 27 Methadone HCl...... 13 Mexiletine HCl...... 47 Marlissa...... 67 Methazolamide...... 52 Miacalcin...... 74 Marplan...... 27 Methenamine Hippurate...... 17 Miconazole 3...... 30 Matulane...... 32 Methimazole...... 70 Microgestin 1.5/30...... 67 Matzim LA...... 49, 50 Methotrexate...... 70 Microgestin 1/20...... 67 Meclizine HCl...... 28 Methotrexate Sodium...... 70 Microgestin Fe...... 67 Medroxyprogesterone Acetate Methoxsalen...... 58 Microgestin Fe 1.5/30...... 67 ...... 68 Methscopolamine Bromide Midodrine HCl...... 47 Mefloquine HCl...... 36 ...... 59 Migergot...... 31 Megace ES...... 68 Methyclothiazide...... 53 Miglitol...... 44 Megestrol Acetate...... 68 Methyldopa...... 47 Minitran...... 54 Mekinist...... 35 Methyldopa/ Minocycline HCl...... 23 Meloxicam...... 12 Hydrochlorothiazide...... 51 Minoxidil...... 54 Melphalan HCl...... 32 Methyldopate HCl...... 47 Mirtazapine...... 27 Memantine HCl...... 26 Methylergonovine Maleate ...... 74 Mirtazapine ODT...... 27 Memantine HCl Titration Pak ...... 26 Methylphenidate HCl...... 56 Mirvaso...... 58 Menactra...... 72 Methylphenidate HCl ER..... 56 Misoprostol...... 60 Menest...... 67 Methylprednisolone...... 63 Mitomycin...... 34 MENHIBRIX...... 72 Methylprednisolone Acetate Mitoxantrone HCl...... 34 ...... 63 Menomune-A/C/Y/W-135....72 Modafinil...... 81 Methylprednisolone Dose Mentax...... 30 Moexipril HCl...... 47 Pack...... 63

117 Tracked

118

Moexipril/Hydrochlorothiazide Naphazoline HCl...... 74 Nevirapine ER...... 41 ...... 52 Naproxen...... 13 Nexavar...... 35 Molindone HCl...... 37 Naproxen DR...... 13 Nexium...... 60, 61 Mometasone Furoate.....63, 78 Naratriptan HCl...... 31 Niacin ER...... 54 MonoNessa...... 67 Narcan...... 16 Niacor...... 54 Montelukast Sodium...... 78 Nasonex...... 78 Nicardipine HCl...... 50 Morphine Sulfate...... 15 Natacyn...... 30 Nicotrol Inhaler...... 16 Morphine Sulfate ER...... 13 Nateglinide...... 44 Nifedical XL...... 50 Moxeza...... 22 Natpara...... 74 Nifedipine ER...... 50 Moxifloxacin HCl...... 22 Nebupent...... 36 Nikki...... 67 Mozobil...... 46 Necon 0.5/35-28...... 67 Nilandron...... 32 Multaq...... 48 Necon 1/35...... 67 Nimodipine...... 50 Mupirocin...... 18 Necon 1/50-28...... 67 Ninlaro...... 34 Mustargen...... 32 Necon 10/11-28...... 67 Nipent...... 33 Myalept...... 74 Necon 7/7/7...... 67 Nitro-Bid...... 54 Mycamine...... 30 Nefazodone HCl...... 27 Nitrofurantoin...... 18 Mycophenolate Mofetil...... 70 Neomycin Sulfate...... 16 Nitrofurantoin Macrocrystals Mycophenolic Acid DR...... 70 Neomycin/Bacitracin/ ...... 18 Myrbetriq...... 61 Polymyxin...... 75 Nitrofurantoin Monohydrate N Neomycin/Polymyxin B ...... 18 Nabumetone...... 12 Sulfates...... 18 Nitroglycerin...... 54 Nadolol...... 48 Neomycin/Polymyxin/ Nitroglycerin Lingual...... 54 Bacitracin/Hydrocortisone Nadolol/Bendroflumethiazide Nitroglycerin Transdermal... 54 ...... 75 ...... 52 Nitrostat...... 54 Neomycin/Polymyxin/ Nafcillin Sodium...... 20 Nora-BE...... 68 Dexamethasone...... 75 Naftifine HCl...... 30 Norditropin FlexPro...... 65 Neomycin/Polymyxin/ Naftin...... 30 Gramicidin...... 75 Norethindrone...... 68 Naglazyme...... 59 Neomycin/Polymyxin/ Norethindrone & Ethinyl Nalbuphine HCl...... 15 Hydrocortisone...... 75, 77 Estradiol Ferrous Fumarate ...... 67 Naloxone HCl...... 16 Nephramine...... 84 Norethindrone Acetate...... 68 Naltrexone HCl...... 16 Neulasta...... 46 Norethindrone Acetate/Ethinyl Namenda XR...... 26 Neupogen...... 46 Estradiol/Ferrous Fumarate Namenda XR Titration Pack Neupro...... 36 ...... 67 ...... 26 Nevanac...... 77 Norgestimate/Ethinyl Estradiol Namzaric...... 56 Nevirapine...... 41 ...... 67 118 Tracked

119

Norlyroc...... 68 Omega-3-Acid Ethyl Esters Paclitaxel...... 34 Normosol-M in D5W...... 84 ...... 54 Paliperidone ER...... 38 Normosol-R...... 82 Omeprazole...... 61 Pamidronate Disodium...... 74 Normosol-R in D5W...... 84 Ondansetron HCl...... 29 Panretin...... 35 Northera...... 52 Ondansetron ODT...... 29 Pantoprazole Sodium...... 61 Nortrel 0.5/35...... 67 Onfi...... 24 Paricalcitol...... 74 Nortrel 1/35...... 67 Onglyza...... 44 Paromomycin Sulfate...... 16 Nortrel 7/7/7...... 67 ONMEL...... 30 Paroxetine HCl...... 27 Nortriptyline HCl...... 28 Opana ER...... 14 Paser...... 32 Norvir...... 42 Opdivo...... 35 Pataday...... 75 Novarel...... 65 Opsumit...... 79 Patanol...... 75 Noxafil...... 30 Orencia...... 71 Paxil...... 27 Nucynta ER...... 13 Orenitram...... 79, 80 Pazeo...... 75 Nuedexta...... 56 Orfadin...... 59 Pedvax HIB...... 72 Nulojix...... 70 Orkambi...... 79 PEG-3350/Electrolytes...... 60 Nuplazid...... 38 Orphenadrine Citrate...... 81 PEG-3350/NaCl/Na Nutrilipid...... 84 Orsythia...... 67 Bicarbonate/KCl...... 60 Nutropin AQ...... 65 Otezla...... 72 Peganone...... 26 NuvaRing...... 67 Oxacillin Sodium...... 20 Pegasys...... 40 Nyamyc...... 30 Oxaliplatin...... 34 Pegasys ProClick...... 40 Nystatin...... 30 Oxandrolone...... 65 PegIntron...... 40 Nystop...... 30 Oxcarbazepine...... 25, 26 PegIntron REDIPEN...... 40 O Oxiconazole Nitrate...... 30 Penicillin G Potassium...... 20 Ocella...... 67 Oxistat...... 30 Penicillin G Procaine...... 20 Octagam...... 71 Oxsoralen Ultra...... 58 Penicillin G Sodium...... 20 Octreotide Acetate...... 69 Oxybutynin Chloride...... 61 Penicillin V Potassium...... 20 Odefsey...... 41 Oxybutynin Chloride ER...... 61 Pentam 300...... 36 Odomzo...... 35 Oxycodone HCl...... 15 Pentasa...... 73 Ofev...... 80 Oxycodone/Acetaminophen Pentoxifylline ER...... 52 ...... 15 Ofloxacin...... 22 Perforomist...... 79 Oxycodone/Aspirin...... 15 Ogestrel...... 67 Perindopril Erbumine...... 47 Oxycodone/Ibuprofen...... 15 Olanzapine...... 38 Periogard...... 57 P Olanzapine ODT...... 38 Perjeta...... 35 Pacerone...... 48 Olopatadine HCl...... 75 Permethrin...... 36

119 Tracked

120

Perphenazine...... 29 Polyethylene Glycol 3350 Prednicarbate...... 63 Phenadoz...... 77 Powder...... 60 Prednisolone Acetate...... 77 Phenelzine Sulfate...... 27 Polymyxin B Sulfate...... 18 Prednisolone Sodium Phenergan...... 77 Polymyxin B Sulfate/ Phosphate...... 64, 77 Trimethoprim Sulfate...... 75 Phenobarbital...... 24 Prednisone...... 64 Pomalyst...... 32 Phenoxybenzamine HCl...... 47 Prednisone Intensol...... 64 Portia-28...... 67 Phenytek...... 26 Pregnyl w/Diluent Benzyl Potassium Chloride...... 82 Alcohol/NaCl...... 65 Phenytoin...... 26 Potassium Chloride 0.15% / Premarin...... 67 Phenytoin Sodium...... 26 NaCl 0.45% Viaflex...... 82 Premasol...... 84 Phenytoin Sodium Extended Potassium Chloride 0.15% ...... 26 Premphase...... 67 D5W/NaCl 0.33%...... 84 PhosLo...... 61 Prempro...... 67 Potassium Chloride 0.15% Prevalite...... 54 Phoslyra...... 62 D5W/NaCl 0.45%...... 84 Previfem...... 67 Phospholine Iodide...... 76 Potassium Chloride 0.15%/ Physiolyte...... 82 NaCl 0.9%...... 82 Prezcobix...... 40 Physiosol Irrigation...... 82 Potassium Chloride 0.22% Prezista...... 42 D5W/NaCl 0.45%...... 84 Picato...... 58 Priftin...... 32 Potassium Chloride 0.3%/ Pilocarpine HCl...... 57, 76 Prilosec...... 61 NaCl 0.9%...... 82 Pimozide...... 38 Primaquine Phosphate...... 36 Potassium Chloride 0.3%/ Primidone...... 24 Pimtrea...... 67 D5W...... 84 Pristiq...... 27 Pindolol...... 48 Potassium Chloride ER...... 82 Privigen...... 71 Pioglitazone HCl...... 44 Potassium Chloride ER Pioglitazone HCl/Glimepiride Microencapsulated...... 82 ProAir HFA...... 79 ...... 44 Potassium Citrate ER...... 82 ProAir RespiClick...... 79 Pioglitazone HCl/Metformin Potiga...... 24 Probenecid...... 31 HCl...... 44 Pradaxa...... 45 Probenecid/Colchicine...... 31 Piperacillin/Tazobactam...... 20 Praluent...... 54 Procainamide HCl...... 48 Pirmella 1/35...... 67 Pramipexole Dihydrochloride Procalamine...... 84 Piroxicam...... 13 ...... 36 Prochlorperazine...... 29 Plasma-Lyte A...... 82 Pravastatin Sodium...... 53 Prochlorperazine Edisylate Plasma-Lyte-148...... 82 Prazosin HCl...... 47 ...... 29 Plasma-Lyte-56/D5W...... 84 Pred Mild...... 77 Prochlorperazine Maleate....29 Plenamine...... 84 Pred-G...... 75 Procrit...... 46 Podofilox...... 58 Pred-G S.O.P...... 75 Procto-Med HC...... 73 Procto-Pak...... 73 120 Tracked

121

Proctosol HC...... 73 Quinapril/Hydrochlorothiazide Restasis...... 75 Proctozone-HC...... 73 ...... 52 Retrovir IV Infusion...... 41 Procysbi...... 59 Quinidine Gluconate...... 48 Revatio...... 80 Progesterone...... 68 Quinidine Gluconate CR...... 48 Revlimid...... 32 Proglycem...... 44 Quinidine Sulfate...... 48 Rexulti...... 38 Prograf...... 71 Quinine Sulfate...... 36 Reyataz...... 42 Prolastin-C...... 80 R Ribasphere...... 40 Prolensa...... 77 Rabavert...... 72 Ribavirin...... 40 Proleukin...... 34 Raloxifene HCl...... 68 Ridaura...... 72 Prolia...... 74 Ramipril...... 47 Rifabutin...... 31 Promacta...... 46 Ranexa...... 52 Rifampin...... 32 Promethazine HCl...... 78 Ranitidine HCl...... 60 Rifater...... 32 Promethegan...... 78 Rapaflo...... 61 Rilutek...... 56 Propafenone HCl...... 48 Rapamune...... 71 Riluzole...... 56 Propafenone HCl ER...... 48 RAVICTI...... 59 Rimantadine HCl...... 42 Proparacaine HCl...... 75 Rebif...... 56 Ringers Injection...... 84 Propranolol HCl...... 48 Rebif Rebidose...... 57 Ringers Irrigation...... 84 Propranolol HCl ER...... 49 Rebif Rebidose Titration Pack Riomet...... 44 ...... 57 Propranolol/ Risedronate Sodium...... 74 Rebif Titration Pack...... 57 Hydrochlorothiazide...... 52 Risperdal Consta...... 38 Reclipsen...... 67 Propylthiouracil...... 70 Risperidone...... 39 Recombivax HB...... 72 ProQuad...... 72 Risperidone ODT...... 39 Regranex...... 58 Prosol...... 84 Rituxan...... 35 Relenza Diskhaler...... 42 Protriptyline HCl...... 28 Rivastigmine Tartrate...... 26 Relistor...... 59 PRUDOXIN...... 58 Rivastigmine Transdermal Pulmozyme...... 80 Remicade...... 71 System...... 26 Purixan...... 33 Remodulin...... 80 Rizatriptan Benzoate...... 31 Pyrazinamide...... 32 Renagel...... 62 Rizatriptan Benzoate ODT...31 Pyridostigmine Bromide...... 31 Renvela...... 62 Ropinirole HCl...... 37 Q Repaglinide...... 44 Rosuvastatin Calcium...... 53 Quadracel...... 72 Repaglinide/Metformin HCl Rotarix...... 72 ...... 44 Quasense...... 67 RotaTeq...... 72 Repatha...... 54 Quetiapine Fumarate...... 38 Roweepra...... 24 Repatha SureClick...... 54 Quinapril HCl...... 47 Rozerem...... 81 Rescriptor...... 41 121 Tracked

122

Ruconest...... 70 Sodium Chloride 0.45% Stavudine...... 41 S Viaflex...... 82 Stelara...... 71 Sabril...... 24 Sodium Chloride 0.9%...... 82 Sterile Water Irrigation...... 74 Saizen...... 65 Sodium Fluoride...... 82 Stiolto Respimat...... 80 Samsca...... 81 Sodium Lactate...... 84 Stivarga...... 35 Sancuso...... 29 Sodium Phenylbutyrate...... 59 Strattera...... 56 Sandimmune...... 71 Sodium Polystyrene Sulfonate Strensiq...... 59 ...... 81 Sandostatin LAR Depot...... 69 Streptomycin Sulfate...... 16 Sodium Sulfacetamide...... 22 Santyl...... 58 Stribild...... 40 Solaraze...... 58 Saphris...... 39 Suboxone...... 16 Soltamox...... 32 Savella...... 56 Sucraid...... 59 Solu-Cortef...... 64 Savella Titration Pack...... 56 Sucralfate...... 60 Solu-Medrol...... 64 Selegiline HCl...... 37 Sulfacetamide Sodium...... 22 Somatuline Depot...... 69 Selenium Sulfide...... 58 Sulfacetamide Sodium/ Somavert...... 69 Selzentry...... 42 Prednisolone Sodium Soriatane...... 58 Phosphate...... 75 Sensipar...... 69 Sotalol HCl...... 48 Sulfadiazine...... 22 Serevent Diskus...... 79 Sovaldi...... 40 Sulfamethoxazole/ Seroquel XR...... 39 Spiriva HandiHaler...... 78 Trimethoprim...... 22 Serostim...... 59 Spiriva Respimat...... 78 Sulfamethoxazole/ Sertraline HCl...... 28 Trimethoprim DS...... 22 Spironolactone...... 53 Setlakin...... 67 Sulfamylon...... 18 Spironolactone/ sfRowasa...... 73 Hydrochlorothiazide...... 52 Sulfasalazine...... 73 Sharobel...... 68 Sporanox...... 30 Sulindac...... 13 Signifor...... 69 Sprintec 28...... 67 Sumatriptan...... 31 Sildenafil...... 80 Spritam...... 24 Sumatriptan Succinate...... 31 Silver Sulfadiazine...... 22 Sprycel...... 35 Sumatriptan Succinate Refill Simbrinza...... 76 ...... 31 Sronyx...... 67 Simponi...... 71 Sumavel DosePro...... 31 SSD...... 22 Simponi Aria...... 71 Suprax...... 19 Stalevo 100...... 37 Simulect...... 72 Suprep Bowel Prep...... 60 Stalevo 125...... 37 Simvastatin...... 53 Sustiva...... 41 Stalevo 150...... 37 Sirolimus...... 71 Sutent...... 35 Stalevo 200...... 37 Sirturo...... 32 Sylatron...... 40 Stalevo 50...... 37 Sodium Chloride...... 82 Sylvant...... 35 Stalevo 75...... 37 122 Tracked

123

Symbicort...... 80 Tenivac...... 72 Tolcapone...... 36 SymlinPen 120...... 44 Terazosin HCl...... 61 Topiramate...... 25 SymlinPen 60...... 44 Terbinafine HCl...... 30 Toposar...... 34 Synagis...... 72 Terbutaline Sulfate...... 79 Topotecan HCl...... 34 Synarel...... 69 Terconazole...... 30 Torisel...... 71 Synercid...... 18 Testosterone Cypionate...... 65 Torsemide...... 53 Synjardy...... 44 Testosterone Enanthate...... 65 Toujeo SoloStar...... 45 Synribo...... 34 Tetanus/Diphtheria Toxoids- TPN Electrolytes...... 84 Synthroid...... 69 Adsorbed Adult...... 72 Tracleer...... 80 Syprine...... 81 Tetrabenazine...... 56 Tradjenta...... 44 T Tetracycline HCl...... 23 Tramadol HCl...... 15 Tabloid...... 33 Thalomid...... 32 Tramadol HCl ER...... 14 Tacrolimus...... 58, 71 Theophylline...... 79 Tramadol HCl/ Tafinlar...... 35 Theophylline CR...... 79 Acetaminophen...... 15 Tagrisso...... 35 Theophylline ER...... 79 Trandolapril...... 47 Tamiflu...... 42 Thioridazine HCl...... 38 Tranexamic Acid...... 46 Tamoxifen Citrate...... 32 Thiotepa...... 34 Transderm-Scop...... 29 Tamsulosin HCl...... 61 Thiothixene...... 38 Tranylcypromine Sulfate...... 27 Tarceva...... 35 Thymoglobulin...... 71 Travasol...... 84 Targretin...... 35 Tiagabine HCl...... 24 Travatan Z...... 77 Tarina Fe 1/20...... 67 Timolol Maleate...... 49, 76 Travoprost...... 77 Tasigna...... 35 Timolol Maleate Ophthalmic Trazodone HCl...... 28 Gel Forming...... 76 Taxotere...... 34 Treanda...... 32 Tinidazole...... 18 Tazicef...... 19 Trecator...... 32 Tivicay...... 40 Tazorac...... 58 Trelstar Mixject...... 69 Tizanidine HCl...... 81 Taztia XT...... 50 Tretinoin...... 35, 58 TOBI...... 17 Tecentriq...... 35 Tretinoin Microsphere...... 58 TOBI Podhaler...... 17 Tecfidera...... 57 Trexall...... 71 Tobradex...... 17 Tecfidera Starter Pack...... 57 Trezix...... 15 Tobradex ST...... 75 Telmisartan...... 47 Tri-Legest Fe...... 67 Tobramycin...... 17 Telmisartan/Amlodipine...... 52 Tri-Lo-Estarylla...... 67 Tobramycin Sulfate...... 17 Telmisartan/ Tri-Lo-Sprintec...... 67 Hydrochlorothiazide...... 52 Tobramycin/Dexamethasone Tri-Previfem...... 68 ...... 75 Temazepam...... 81 Tri-Sprintec...... 68 Tobrex...... 17 123 Tracked

124

Triamcinolone Acetonide.... 64 Ursodiol...... 59 Vestura...... 68 Triamcinolone in Orabase... 57 Uvadex...... 58 Vexol...... 77 Triamterene/ V Vfend...... 31 Hydrochlorothiazide...... 52 Vagifem...... 68 Vibramycin...... 23 Tribenzor...... 52 Valacyclovir HCl...... 40 Victoza...... 44 Triderm...... 64 Valchlor...... 32 Vidaza...... 34 Trifluoperazine HCl...... 38 Valcyte...... 39 Videx Pediatric...... 41 Trifluridine...... 40 Valganciclovir...... 39 Vienva...... 68 Trihexyphenidyl HCl...... 36 Valproate Sodium...... 24 Vigamox...... 22 TriLyte...... 60 Valproic Acid...... 24 Viibryd...... 28 Trimethoprim...... 18 Valsartan...... 47 Viibryd Starter Pack...... 28 Trimipramine Maleate...... 28 Valsartan/Hydrochlorothiazide Vimpat...... 26 Trinessa...... 68 ...... 52 Vinblastine Sulfate...... 34 Trintellix...... 28 Vancocin HCl...... 18 Vincasar PFS...... 34 Trisenox...... 34 Vancomycin HCl...... 18 Vincristine Sulfate...... 34 Triumeq...... 40 Vandazole...... 18 Vinorelbine Tartrate...... 34 Trivora-28...... 68 VAQTA...... 72 Viracept...... 42 Trizivir...... 41 Varivax...... 72 Virazole...... 42 Trophamine...... 84 Varizig...... 71 Viread...... 41 Trulicity...... 44 Vascepa...... 54 Vitekta...... 41 Trumenba...... 72 Vectibix...... 35 Vivitrol...... 16 Truvada...... 41 Velcade...... 34 Voltaren...... 13 Twinrix...... 72 Velivet...... 68 Voriconazole...... 31 Tybost...... 41 Velphoro...... 62 Votrient...... 35 Tygacil...... 18 Venclexta...... 34 VP-PNV-DHA...... 84 Tykerb...... 35 Venclexta Starting Pack...... 34 VPRIV...... 59 Typhim Vi...... 72 Venlafaxine HCl...... 28 Vraylar...... 39 Tysabri...... 57 Venlafaxine HCl ER...... 28 Vyfemla...... 68 Tyvaso...... 80 Ventavis...... 80 Vytorin...... 54 Tyzeka...... 40 Verapamil HCl...... 50 Vyvanse...... 55 U Verapamil HCl ER...... 50 W Uceris...... 73 Verapamil HCl SR...... 50 Warfarin Sodium...... 45 Uloric...... 31 Versacloz...... 39 Welchol...... 54 Unithroid...... 69 Vesicare...... 61 WYMZYA Fe...... 68

124 Tracked

125

X Zanosar...... 32 Zoledronic Acid...... 74 Xalkori...... 35 Zarxio...... 46 Zolinza...... 34 Xarelto...... 45 Zavesca...... 59 Zolpidem Tartrate...... 81 Xarelto Starter Pack...... 45 Zazole...... 31 Zomacton...... 65 Xeljanz...... 71 Zelapar...... 37 Zometa...... 74 Xeljanz XR...... 71 Zelboraf...... 35 Zonisamide...... 24 Xenazine...... 56 Zemaira...... 80 Zorbtive...... 59 Xgeva...... 74 Zemplar...... 74 Zortress...... 71 Xifaxan...... 18 Zenchent...... 68 Zostavax...... 72 Xolair...... 80 Zenchent Fe...... 68 Zovia 1/35E...... 68 Xtandi...... 32 Zenpep...... 59 Zovia 1/50E...... 68 Xulane...... 68 Zepatier...... 40 Zyclara...... 58 Xyrem...... 81 Zerbaxa...... 19 Zyclara Pump...... 58 Y Zetia...... 54 Zydelig...... 34 Yervoy...... 35 Ziagen...... 41 Zyflo...... 78 YF-Vax...... 72 Zidovudine...... 42 Zyflo CR...... 78 Z Zinecard...... 34 Zykadia...... 34 Zafirlukast...... 78 Ziprasidone HCl...... 39 Zyprexa Relprevv...... 39 Zaleplon...... 81 Zirgan...... 39 Zytiga...... 32 Zaltrap...... 34 Zmax...... 21

125 For more recent information or if you have other questions, please call AARP MedicareComplete Plans Customer Service at: Toll-Free 1-800-643-4845, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.MyAARPMedicare.com

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary. This information is available for free in other languages. Please call our UnitedHealthcare Customer Service number listed above. Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente de UnitedHealthcare al número indicado arriba. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. The AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP.

AAEX17HM3881498_000 Last updated August 1, 2016