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20201 COMPLETE LIST (FORMULARY)

Prescription drug list information

UnitedHealthcare® Group Medicare Advantage (PPO) North Carolina State Health Plan for Teachers and State Employees

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

Toll-free 1-866-747-1014, TTY 711 8 a.m. - 8 p.m. ET, Monday - Friday

www.UHCRetiree.com/ncshp

Formulary ID Number 00020062, Version 14 Y0066_190621_090130_C Last updated September 1, 2019 TABLE2 11 OF CONTENTS What is a drug list?...... 3 Note to existing members...... 3 How do I use the drug list?...... 4 What are generic drugs?...... 4 Drug tiers...... 5 Getting Extra Help...... 5 Are there any rules or limits on my drug coverage?...... 6 What if my drug is not on this list?...... 8 How can I get an exception?...... 8 Can I get my drug while I wait for an exception?...... 9 Can the drug list change?...... 10 Drugs with dosages other than a 1-month supply...... 11 Covered drugs by name (Drug index)...... 12 Covered drugs by medical condition...... 39 Covered drugs with a quantity limit (QL)...... 165 2 3 What is a drug list? A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team of health care providers work together in selecting drugs that are needed for well-rounded care and treatment. Your plan will generally cover the drugs listed in our drug list as long as: · The drug is used for a medically accepted indication, · The prescription is filled at a network pharmacy and · Other plan rules are followed. For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members: This complete list of prescription drugs covered by your plan is current as of September 1, 2019. For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our contact information is on the cover. This drug list has changed since last year. Please review this document to make sure your prescription drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan. When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to “plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage. 4 3 How do I use the drug list? There are 2 ways to find your prescription drugs in this drug list: 1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–38 to see the ...... list of drug names in alphabetical order. Find the name of your drug. The page number where ...... you can find the drug will be next to it. 2. By medical condition. Turn to section “Covered drugs by medical condition” on pages ...... 39–164 to look for drugs based on your medical conditions. For example, if you have a heart ...... condition, you should look in the category Cardiovascular Agents. This is where you will find ...... drugs that treat heart conditions.

What are generic drugs? Generic drugs have the same active ingredients as brand name drugs. They usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers both brand name and generic drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money. The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in plain type (for example, Simvastatin). 4 5 Drug tiers The amount you pay for a covered prescription drug will depend on: · Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers. If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call Customer Service. Our contact information is on the cover.

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

Getting Extra Help If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call Customer Service. Our contact information is on the cover. ..6 5 1 Are there any rules or limits on my drug coverage? Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use” column of the “Covered drugs by medical condition” chart starting on page 39. The codes and what they mean are shown below and on the next page. You can also get more information about the coverage rules and/or limits applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call Customer Service. Our contact information is on the cover. Coverage Rules and Limits

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

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

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

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

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

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

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

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

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

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

We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You can find out if your drug has any rules or limits by looking in the chart on pages 165-202. We’ll tell you about other changes

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

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

A Actoplus Met...... 91 AirDuo RespiClick 55/14.... 162 Abacavir Sulfate...... 88 Actos...... 91 Ajovy...... 72 Abacavir Sulfate-Lamivudine Acular...... 155 Aktipak...... 114 ...... 88 Acular LS...... 155 Ala Scalp...... 129 Abacavir-Lamivudine- Acuvail...... 155 Ala-Cort...... 129 Zidovudine...... 88 Acyclovir...... 86 Albendazole...... 78 Abelcet...... 68 Acyclovir Sodium...... 86 Albenza...... 78 Abilify...... 82 Aczone...... 114 Albuterol Sulfate...... 159 Abilify Maintena...... 81, 82 Adacel...... 148 Albuterol Sulfate ER...... 159 ...... 74 Adalat CC...... 102 Albuterol Sulfate HFA...... 159 Absorica...... 114 Adapalene...... 114 Alclometasone Dipropionate Abstral...... 44 Adapalene-Benzoyl Peroxide ...... 129 Acamprosate ...... 47 ...... 114 Alcohol Prep Pads...... 152 Acanya...... 114 Adcirca...... 161 Aldactazide...... 104 Acarbose...... 91 Adderall...... 110 Aldactone...... 106 Accolate...... 158 Adderall XR...... 110 Aldara...... 114 Accupril...... 100 Adefovir Dipivoxil...... 85 Alecensa...... 76 Accuretic...... 104 Adempas...... 161 Alendronate Sodium...... 151 Acebutolol HCl...... 101 Adlyxin...... 91 Alfuzosin HCl ER...... 128 Acetaminophen-Codeine...... 44 Adlyxin Starter Pack...... 91 Alinia...... 78 Acetazolamide...... 106 Advair Diskus...... 162 Aliskiren Fumarate...... 104 Acetazolamide ER...... 106 Advair HFA...... 162 Allopurinol...... 71 Acetic Acid...... 156 Adzenys ER...... 110 Almotriptan Malate...... 72 Acetylcysteine...... 162 Adzenys XR-ODT...... 110 Alocril...... 153 Aciphex...... 125 Afinitor...... 76 Alogliptin Benzoate...... 91 Acitretin...... 114 Afinitor Disperz...... 76 Alogliptin-Metformin HCl...... 91 Actemra...... 147 Afrezza...... 94 Alogliptin-Pioglitazone...... 91 Actemra ACTPen...... 147 Aggrenox...... 99 Alomide...... 153 Acthar...... 129 Agrylin...... 97 Alora...... 137 ActHIB...... 148 Aimovig...... 72 Alosetron HCl...... 124 Actigall...... 123 AirDuo RespiClick 113/14 Alphagan P...... 154 Actimmune...... 147 ...... 162 Alprazolam...... 90 Actiq...... 44 AirDuo RespiClick 232/14 Alprazolam ER...... 90 ...... 162 Actonel...... 151 Alprazolam Intensol...... 90 13Tracked 13 13 Alprazolam ODT...... 90 Ammonium Lactate...... 114 Apraclonidine HCl...... 154 Alrex...... 155 Amnesteem...... 114 Aprepitant...... 68 Altace...... 100 Amoxapine...... 67 Apri...... 137 Altavera...... 137 Amoxicillin...... 54 Apriso...... 150 Altoprev...... 108 Amoxicillin-Clarithromycin- Aptensio XR...... 110 Altreno...... 114 Lansoprazole...... 123 Aptiom...... 62 Alunbrig...... 76 Amoxicillin-Potassium Aptivus...... 89 Clavulanate...... 54 Alvesco...... 157 Aralast NP...... 126 Amoxicillin-Potassium Alyacen 1/35...... 137 Aranelle...... 137 Clavulanate ER...... 54 Alyq...... 161 Aranesp...... 97, 98 Amphetamine Sulfate...... 110 Amantadine HCl...... 79 Arava...... 147 Amphetamine- Amaryl...... 91 Dextroamphetamine...... 110 Arcalyst...... 147 Ambien...... 164 Amphetamine- Arcapta Neohaler...... 159 AmBisome...... 69 Dextroamphetamine ER.... 110 Aricept...... 64 ...... 161 Amphotericin B...... 69 Arikayce...... 48 Amcinonide...... 129 Ampicillin...... 54 Arimidex...... 76 Amerge...... 72 Ampicillin Sodium...... 54 Aripiprazole...... 82 Amethia...... 137 Ampicillin-Sulbactam Sodium Aripiprazole ODT...... 82 ...... 54 Amethia Lo...... 137 Aristada...... 82 Ampyra...... 112 Amikacin Sulfate...... 48 Aristada Initio...... 82 Anadrol-50...... 136 Amiloride HCl...... 107 Arixtra...... 95 Anafranil...... 67 Amiloride-Hydrochlorothiazide Armodafinil...... 164 Anagrelide HCl...... 97 ...... 104 Arnuity Ellipta...... 157 ...... 76 Aminosyn II...... 118 Aromasin...... 76 Ancobon...... 69 Aminosyn-PF...... 118 Arthrotec...... 39 Androderm...... 136 Amiodarone HCl...... 100 Asacol HD...... 150 AndroGel...... 136 Amitiza...... 124 Ashlyna...... 137 AndroGel Pump...... 136 Amitriptyline HCl...... 67 Asmanex...... 157 Anoro Ellipta...... 162 Amlodipine Besylate...... 102 Asmanex HFA...... 157 Antabuse...... 47 Amlodipine-Atorvastatin...... 104 Aspirin-Dipyridamole ER...... 99 Antara...... 107 Amlodipine-Benazepril...... 104 Astagraf XL...... 144 Anusol-HC...... 150 Amlodipine-Olmesartan...... 104 Astepro...... 156 ApexiCon E...... 129 Amlodipine-Valsartan...... 104 Atacand...... 100 Aplenzin...... 65 Amlodipine-Valsartan-HCTZ Atacand HCT...... 104 ...... 104 Apokyn...... 79 14 14Tracked 14 Atazanavir Sulfate...... 89 Azasite...... 55 Benicar...... 100 Atelvia...... 151 Azathioprine...... 144 Benicar HCT...... 104 Atenolol...... 101 Azelaic Acid...... 115 Benlysta...... 148 Atenolol-Chlorthalidone...... 104 Azelastine HCl...... 153, 157 BenzaClin with Pump...... 115 Ativan...... 90 Azelex...... 115 Benzamycin...... 115 Atomoxetine HCl...... 111 Azilect...... 81 Benznidazole...... 78 Atorvastatin Calcium...... 108 Azithromycin...... 55 Benzoyl Peroxide-Erythromycin Atovaquone...... 78 Azopt...... 154 ...... 115 Atovaquone-Proguanil HCl.... 78 Azor...... 104 Benztropine Mesylate...... 79 Atralin...... 114 Aztreonam...... 53 Bepreve...... 153 Atripla...... 87 Azulfidine...... 151 Berinert...... 144 Atropine Sulfate...... 152 Azulfidine EN-tabs...... 151 Beser...... 129 Atrovent HFA...... 158 B Besivance...... 56 Aubagio...... 112 Bacitracin...... 49 Betamethasone Dipropionate ...... 129, 130 Aubra...... 137 Bacitracin-Polymyxin B...... 152 Betamethasone Dipropionate Augmentin...... 54 Baclofen...... 163 Aug...... 129 Auryxia...... 122 Bactocill in Dextrose...... 54 Betamethasone Valerate..... 130 Austedo...... 112 Bactrim...... 57 Betapace AF...... 101 Avalide...... 104 Bactrim DS...... 57 Betaseron...... 113 Avandia...... 91 Bactroban...... 49 Betaxolol HCl...... 101, 154 Avapro...... 100 Balsalazide Disodium...... 150 Bethanechol Chloride...... 129 AVC Vaginal...... 69 Balversa...... 76 Bethkis...... 160 Aveed...... 136 Balziva...... 137 Betimol...... 154 Avelox...... 56 Banzel...... 63 Betoptic-S...... 154 Aviane...... 137 Baraclude...... 85 Bevespi Aerosphere...... 162 Avita...... 114, 115 Basaglar KwikPen...... 94 Bevyxxa...... 95 Avodart...... 128 Baxdela...... 56 Bexarotene...... 78 Avonex...... 112 BCG Vaccine...... 148 Bexsero...... 148 Avonex Pen...... 113 Beconase AQ...... 157 Beyaz...... 137 Avonex Prefilled...... 113 Belbuca...... 41 ...... 74 Avycaz...... 51 Belsomra...... 164 Bicillin C-R...... 54 Aygestin...... 141 Benazepril HCl...... 100 Bicillin C-R 900/300...... 54 Azactam...... 53 Benazepril-Hydrochlorothiazide Bicillin L-A...... 54 Azasan...... 144 ...... 104 BiDil...... 104 15Tracked 15 15 Biktarvy...... 88 Buprenorphine HCl...... 47 Candesartan Cilexetil...... 100 Biltricide...... 78 Buprenorphine HCl-Naloxone Candesartan Cilexetil-HCTZ Bimatoprost...... 156 HCl...... 47 ...... 104 Binosto...... 151 Bupropion HCl...... 65 Capex...... 130 Bisoprolol Fumarate...... 101 Bupropion HCl ER...... 65 Caprelsa...... 76 Bisoprolol-Hydrochlorothiazide Bupropion HCl SR...... 48, 65 Captopril...... 100 ...... 104 Bupropion HCl XL...... 65 Captopril-Hydrochlorothiazide BIVIGAM...... 147 Buspirone HCl...... 90 ...... 104 Bleph-10...... 57 Butorphanol Tartrate...... 44 Carac...... 115 Blephamide...... 152 Butrans...... 41 Carafate...... 125 Blephamide S.O.P...... 152 Bydureon...... 91 Carbaglu...... 118 Blisovi 24 Fe...... 137 Bydureon BCise...... 91 Carbamazepine...... 63 Blisovi Fe 1.5/30...... 137 Byetta 10MCG Pen...... 91 Carbamazepine ER...... 63 Boniva...... 151 Byetta 5MCG Pen...... 91 Carbatrol...... 63 Boostrix...... 148 Bystolic...... 101 Carbidopa...... 80 ...... 161 C Carbidopa-Levodopa...... 80 Bosulif...... 76 ...... 143 Carbidopa-Levodopa ER...... 80 Braftovi...... 76 Cablivi...... 99 Carbidopa-Levodopa ODT.....80 Breo Ellipta...... 162 Cabometyx...... 76 Carbidopa-Levodopa- Entacapone...... 80 Briellyn...... 137 Caduet...... 104 Cardizem...... 102 Brilinta...... 99 Cafergot...... 71 Cardizem CD...... 102 Brimonidine Tartrate...... 154 Calan...... 102 Cardizem LA...... 102 BRIVIACT...... 59 Calan SR...... 102 Cardura...... 99 Bromfenac Sodium...... 155 Calcipotriene...... 115 Cardura XL...... 128 Mesylate...... 79 Calcipotriene-Betamethasone Carnitor...... 118 BromSite...... 155 ...... 115 CaroSpir...... 107 Brovana...... 159 Salmon...... 151 Carteolol HCl...... 154 Bryhali...... 130 Calcitriol...... 115, 151 Cartia XT...... 102 Budesonide...... 150, 157 Calcium Acetate...... 122 Carvedilol...... 101 Budesonide ER...... 150 Calquence...... 76 Carvedilol Phosphate ER.....101 Bumetanide...... 106 Cambia...... 39 Casodex...... 74 Bunavail...... 47 Camila...... 141 Caspofungin Acetate...... 69 Buphenyl...... 126 Camrese Lo...... 137 Catapres...... 99 Buprenorphine...... 41 Canasa...... 150 Cancidas...... 69 Catapres-TTS-1...... 99 16 16Tracked 16 Catapres-TTS-2...... 99 Chemet...... 121 Clarithromycin ER...... 55 Catapres-TTS-3...... 99 Chenodal...... 123 Clenpiq...... 124 Cayston...... 160 Chlordiazepoxide HCl...... 90 Cleocin...... 49 Caziant...... 137 Chlorhexidine Gluconate.....114 Cleocin in D5W...... 49 Cefaclor...... 51, 52 Chloroquine Phosphate...... 78 Cleocin Phosphate...... 49 Cefaclor ER...... 51 Chlorothiazide...... 107 Cleocin-T...... 115 Cefadroxil...... 52 HCl...... 81 Climara Pro...... 137 Cefazolin Sodium...... 52 Chlorthalidone...... 107 Clindacin-P...... 115 Cefdinir...... 52 Cholbam...... 126 Clindagel...... 115 Cefepime HCl...... 52 Cholestyramine...... 108 Clindamycin HCl...... 49 Cefixime...... 52 Cholestyramine Light...... 108 Clindamycin Palmitate HCl....49 Cefotetan Disodium...... 52 Cialis...... 128 Clindamycin Phosphate...... 49, Cefoxitin Sodium...... 52 Ciclopirox...... 69 115 Cefpodoxime Proxetil...... 52 Ciclopirox Olamine...... 69 Clindamycin Phosphate in D5W ...... 49 Cefprozil...... 52 Cilostazol...... 99 Clindamycin Phosphate- Ceftazidime...... 52 Ciloxan...... 56 Benzoyl Peroxide...... 115 Ceftriaxone Sodium...... 52 Cimduo...... 88 Clindamycin-Tretinoin...... 115 Cefuroxime Axetil...... 52 ...... 124 Clindesse...... 49 Cefuroxime Sodium...... 52 Cimetidine HCl...... 124 Clinimix E/Dextrose..... 118, 119 Celebrex...... 39 Cimzia...... 144 Clinimix/Dextrose...... 119 Celecoxib...... 39 Cimzia Prefilled...... 144 Clinisol SF...... 119 Celexa...... 65 Cinacalcet HCl...... 151 Clobazam...... 60 Cellcept...... 144 Cinryze...... 144 Clobetasol Propionate...... 130 Celontin...... 60 Cipro...... 56, 57 Clobetasol Propionate Cephalexin...... 53 Cipro HC...... 156 Emollient Base...... 130 Cerdelga...... 126 Ciprodex...... 156 Clobetasol Propionate Cesamet...... 68 Ciprofloxacin...... 57 Emulsion...... 130 Cetirizine HCl...... 157 Ciprofloxacin HCl...... 57, 156 Clobex...... 130 Cetraxal...... 156 Ciprofloxacin in D5W...... 57 Clobex Spray...... 130 Cevimeline HCl...... 114 Citalopram Hydrobromide.....65 Clodan...... 130 Chantix...... 48 Claravis...... 115 Clomipramine HCl...... 67 Chantix Continuing Month Pak Clarinex...... 157 Clonazepam...... 90 ...... 48 Clarinex-D 12 Hour...... 162 Clonazepam ODT...... 90 Chantix Starting Month Pak...48 Clarithromycin...... 55 Clonidine...... 99 17Tracked 17 17 Clonidine HCl...... 99 Cordran...... 130 Cyclosporine Modified...... 145 Clonidine HCl ER...... 111 Coreg...... 101 Cymbalta...... 112 Clopidogrel Bisulfate...... 99 Coreg CR...... 101 HCl...... 157 Clorazepate Dipotassium...... 90 Corgard...... 101 Cyred...... 137 Clotrimazole...... 69 Corlanor...... 104 Cystadane...... 126 Clotrimazole-Betamethasone Cortef...... 130 Cystagon...... 126 ...... 115 Cortisone Acetate...... 130 Cystaran...... 152 Clozapine...... 85 Cortisporin...... 116 Cytomel...... 142 Clozapine ODT...... 85 Cosentyx...... 116 Cytotec...... 125 Clozaril...... 85 Cosentyx Sensoready...... 116 D Coartem...... 78 Cosopt...... 154 Daklinza...... 86 Codeine Sulfate...... 44 Cosopt PF...... 154 Dalfampridine ER...... 113 Colazal...... 150 Cotellic...... 76 Daliresp...... 161 Colchicine...... 71 Cotempla XR-ODT...... 111 Dalvance...... 50 Colcrys...... 71 Coumadin...... 95 ...... 136 Colesevelam HCl...... 108 Cozaar...... 100 Dantrium...... 163 Colestid...... 108 Creon...... 126 Dantrolene Sodium...... 163 Colestipol HCl...... 108 Cresemba...... 69 Dapsone...... 74, 116 Colistimethate Sodium...... 49 Crestor...... 108 Daptacel...... 148 Colocort...... 150 Crinone...... 141 Daptomycin...... 50 Colyte with Flavor Packs...... 124 Crixivan...... 89 DARAPRIM...... 78 Combigan...... 154 Cromolyn Sodium...... 123, 153, Darifenacin Hydrobromide ER Combivent Respimat...... 162 161 ...... 127 Combivir...... 88 Cryselle-28...... 137 Daurismo...... 76 Cometriq...... 76 Cubicin...... 49 Daypro...... 39 Complera...... 87 Cuprimine...... 129 Daytrana...... 111 Compro...... 67 Cutivate...... 130 DDAVP...... 134 Comtan...... 79 Cuvposa...... 122 DDAVP Rhinal Tube...... 134 Concerta...... 111 Cyclafem 1/35...... 137 Deblitane...... 141 Condylox...... 116 Cyclafem 7/7/7...... 137 Deferasirox...... 121 Constulose...... 124 Cyclobenzaprine HCl...... 163 Delestrogen...... 137 ConZip...... 41 Cyclophosphamide...... 74 Delstrigo...... 87 Copaxone...... 113 Cycloset...... 91 Delyla...... 137 Copiktra...... 75 Cyclosporine...... 145 Delzicol...... 150 18 18Tracked 18 Demeclocycline HCl...... 58 Dexedrine...... 110 Dihydroergotamine Mesylate Demser...... 104 Dexilant...... 125 ...... 72 Denavir...... 86 Dexmethylphenidate HCl.....111 Dilantin...... 63 Depakene...... 60 Dexmethylphenidate HCl ER Dilantin INFATABS...... 63 Depakote...... 91 ...... 111 Dilaudid...... 44 Depakote ER...... 91 DexPak 13 Day...... 131 Dilt-XR...... 103 Depakote Sprinkles...... 91 Dextroamphetamine Sulfate Diltiazem HCl...... 103 ...... 110 Depen Titratabs...... 129 Diltiazem HCl ER...... 103 Dextroamphetamine Sulfate ER Depo-...... 138 Diltiazem HCl ER Beads...... 102 ...... 110 Depo-Provera...... 141 Diltiazem HCl ER Coated Dextrose...... 119 Beads...... 102 Depo-SubQ Provera 104...... 141 Dextrose-NaCl...... 119 Diovan...... 100 Depo-...... 136 Diastat AcuDial...... 60 Diovan HCT...... 105 Descovy...... 88 Diastat Pediatric...... 60 Dipentum...... 150 Desipramine HCl...... 67 Diazepam...... 90 Diphenoxylate-Atropine...... 123 Desloratadine...... 157 Diazepam Intensol...... 90 Diphtheria-Tetanus Toxoids DT Desloratadine ODT...... 157 Dibenzyline...... 100 ...... 148 Desmopressin Acetate...... 134 Diclofenac Epolamine...... 39 Diprolene...... 131 Desmopressin Acetate Spray Diclofenac Potassium...... 39 Disulfiram...... 47 ...... 134 Diclofenac Sodium...... 39, 116, Ditropan XL...... 128 -Ethinyl Estradiol 155 ...... 138 Diuril...... 107 Diclofenac Sodium ER...... 39 Desonate...... 130 Divalproex Sodium...... 91 Diclofenac-Misoprostol...... 39 Desonide...... 130 Divalproex Sodium ER...... 91 Dicloxacillin Sodium...... 54 DesOwen...... 130 Dofetilide...... 101 Dicyclomine HCl...... 122 Desoximetasone...... 131 Dolophine...... 41 Didanosine...... 88 Desoxyn...... 110 Donepezil HCl...... 64 Differin...... 116 Desvenlafaxine ER...... 65 Donepezil HCl ODT...... 64 Dificid...... 55 Desvenlafaxine Succinate ER Doptelet...... 98 ...... 66 Diflorasone Diacetate...... 131 Doryx...... 58 Detrol...... 127 Diflucan...... 69 Doryx MPC...... 58 Detrol LA...... 127 Diflunisal...... 39 Dorzolamide HCl...... 154 Dexamethasone...... 131 Digitek...... 104 Dorzolamide HCl-Timolol Dexamethasone Intensol..... 131 Digox...... 104 Maleate...... 154 Dexamethasone Sodium Digoxin...... 104, 105 Dorzolamide HCl-Timolol Phosphate...... 155 Maleate Preservative Free ...... 154 19Tracked 19 19 Dotti...... 138 Dyazide...... 105 Emverm...... 78 Dovato...... 87 Dymista...... 162 Enablex...... 128 Dovonex...... 116 Dyrenium...... 107 Enalapril Maleate...... 100 Doxazosin Mesylate...... 100 E Enalapril-Hydrochlorothiazide Doxepin HCl...... 67, 116 E.E.S. 400...... 55 ...... 105 Doxercalciferol...... 151 E.E.S. Granules...... 56 Enbrel...... 145 Doxy 100...... 58 Econazole Nitrate...... 69 Enbrel SureClick...... 145 Doxycycline Hyclate...... 58 Edarbi...... 100 Endari...... 119 Doxycycline Monohydrate..... 58 Edarbyclor...... 105 Endocet...... 44 Dronabinol...... 68 Edecrin...... 106 Engerix-B...... 148 -Ethinyl Estradiol Edurant...... 87 Enoxaparin Sodium...... 96 ...... 138 Efavirenz...... 87 Enpresse-28...... 138 Drospirenone-Ethinyl Estradiol- Effexor XR...... 66 Enskyce...... 138 Levomefolate...... 138 Effient...... 99 Enstilar...... 116 Droxia...... 75 Efudex...... 116 Entacapone...... 79 Duac...... 116 Egrifta...... 143 Entecavir...... 85 Duetact...... 92 Elestrin...... 138 Entocort EC...... 150 Dulera...... 162 Eletriptan Hydrobromide...... 72 Entresto...... 105 Duloxetine HCl...... 112 Elidel...... 116 Enulose...... 124 Duobrii...... 116 Eligard...... 143 Envarsus XR...... 145 Duopa...... 80 Elimite...... 79 Epclusa...... 86 Dupixent...... 116, 145 Eliquis...... 95 Epidiolex...... 59 Duragesic-100...... 41 Eliquis Starter Pack...... 95 Epiduo...... 116 Duragesic-12...... 41 Elmiron...... 129 Epiduo Forte...... 116 Duragesic-25...... 41 Elocon...... 131 Epinastine HCl...... 153 Duragesic-50...... 41 Embeda...... 41 Epinephrine...... 159 Duragesic-75...... 41 Emcyt...... 75 EpiPen 2-Pak...... 159 Duramorph...... 44 Emend...... 68 EpiPen Jr 2-Pak...... 159 Durezol...... 155 Emend Tri-Pack...... 68 Epitol...... 63 ...... 128 Emflaza...... 131 Epivir...... 88 Dutasteride-Tamsulosin HCl Emgality...... 72 Epivir HBV...... 85 ...... 128 Emoquette...... 138 Eplerenone...... 107 DUTOPROL...... 105 Emsam...... 65 Epogen...... 98 Dvorah...... 44 Emtriva...... 88 Eprosartan Mesylate...... 100 Dyanavel XR...... 110 20 20Tracked 20 Epzicom...... 88 Ethynodiol Diacetate-Ethinyl Fayosim...... 138 Equetro...... 91 Estradiol...... 138 FazaClo...... 85 Eraxis...... 69 Etodolac...... 39 Felbamate...... 61 Ergotamine-Caffeine...... 72 Etodolac ER...... 39 Felbatol...... 61 Erivedge...... 76 Eucrisa...... 116 Feldene...... 39 Erleada...... 74 Eurax...... 79 Felodipine ER...... 103 Erlotinib HCl...... 76 Evekeo...... 110 Femara...... 76 Errin...... 141 Evista...... 142 Femring...... 138 Ertaczo...... 69 Evoclin...... 116 Femynor...... 138 Ertapenem Sodium...... 53 Evotaz...... 89 Fenofibrate...... 107 Ery...... 116 Evoxac...... 114 Fenofibrate Micronized...... 107 Ery-Tab...... 56 Evzio...... 48 Fenofibric Acid...... 107 Erygel...... 116 Exelderm...... 69 Fenoglide...... 107 EryPed 200...... 56 Exelon...... 64 Fenoprofen Calcium...... 39 EryPed 400...... 56 ...... 76 Fentanyl...... 41, 42 Erythrocin Lactobionate...... 56 Exforge...... 105 Fentanyl Citrate...... 44 Erythrocin Stearate...... 56 Exforge HCT...... 105 Fentora...... 44 Erythromycin...... 56, 116 Exjade...... 121 Ferriprox...... 121, 122 Erythromycin Base...... 56 Extavia...... 113 Fetzima...... 66 Erythromycin Ethylsuccinate Extina...... 69 Fetzima Titration...... 66 ...... 56 Ezallor Sprinkle...... 108 Fexmid...... 163 Esbriet...... 162 Ezetimibe...... 108 Fibricor...... 107 Escitalopram Oxalate...... 66 Ezetimibe-Simvastatin...... 108 Finacea...... 116 Esomeprazole F ...... 128 ...... 125 Fabior...... 116 Firazyr...... 144 Esomeprazole Strontium..... 125 Falmina...... 138 Firdapse...... 152 Estarylla...... 138 Famciclovir...... 86 Firmagon...... 143 Estrace...... 138 Famotidine...... 124 Firvanq...... 50 Estradiol...... 138 Fanapt...... 82 Flac...... 156 Estradiol Valerate...... 138 Fanapt Titration Pack...... 82 Flagyl...... 50 Estring...... 138 Fareston...... 75 Flarex...... 155 Ethacrynic Acid...... 106 Farxiga...... 92 Flavoxate HCl...... 128 Ethambutol HCl...... 74 Farydak...... 76 Flebogamma DIF...... 147 Ethosuximide...... 60 Fasenra...... 162 Flecainide Acetate...... 101 21Tracked 21 21 Flector...... 39 FML...... 155 Gammagard S/D Less IgA FloLipid...... 108 FML Forte...... 155 ...... 147 Flomax...... 128 FML Liquifilm...... 155 Gammaked...... 147 Flovent Diskus...... 157 Focalin...... 111 Gammaplex...... 147 Flovent HFA...... 157 Focalin XR...... 111 Gamunex-C...... 147 Fluconazole...... 70 Fondaparinux Sodium...... 96 Gardasil 9...... 148 Fluconazole in Sodium Forfivo XL...... 65 Gastrocrom...... 123 Chloride...... 69 Fortamet...... 92 Gatifloxacin...... 57 Flucytosine...... 70 Forteo...... 151 Gattex...... 123 Fludrocortisone Acetate...... 131 Fortesta...... 136 Gauze...... 152 Flumadine...... 89 Fosamax...... 151 GaviLyte-C...... 124 Flunisolide...... 157 Fosamax Plus D...... 151 GaviLyte-G...... 124 Fluocinolone Acetonide...... 131, Fosamprenavir Calcium...... 89 GaviLyte-N with Flavor Pack 156 ...... 124 Fosinopril Sodium...... 100 Fluocinolone Acetonide Scalp Gelnique Pump...... 128 Fosinopril Sodium-HCTZ..... 105 ...... 131 Gemfibrozil...... 107 Fosrenol...... 122 Fluocinonide...... 131 Generess Fe...... 138 Fragmin...... 96 Fluocinonide Emulsified Base Generlac...... 124 ...... 131 FreAmine HBC...... 119 Gengraf...... 145 Fluorometholone...... 155 Frova...... 72 Genotropin...... 135 Fluorouracil...... 116 Frovatriptan Succinate...... 72 Genotropin MiniQuick...... 134, Fulphila...... 98 Fluoxetine HCl...... 66 135 Furadantin...... 50 Fluphenazine Decanoate...... 81 Gentak...... 48 Furosemide...... 106 Fluphenazine HCl...... 81 Gentamicin Sulfate...... 48 Fuzeon...... 89 Flurandrenolide...... 131 Gentamicin Sulfate-0.9% Flurbiprofen...... 39 Fyavolv...... 138 Sodium Chloride...... 48 Flurbiprofen Sodium...... 155 Fycompa...... 61 Genvoya...... 87 ...... 74 G Geodon...... 82 Fluticasone Propionate...... 131, Gabapentin...... 60 Gianvi...... 138 132, 157 Gabitril...... 60 Gilenya...... 113 Fluticasone-Salmeterol...... 162, Galafold...... 126 Gilotrif...... 76 163 Galantamine Hydrobromide Glassia...... 126 Fluvastatin Sodium...... 108 ...... 64 Glatiramer Acetate...... 113 Fluvastatin Sodium ER...... 108 Galantamine Hydrobromide ER Glatopa...... 113 Fluvoxamine Maleate...... 66 ...... 64 Gleevec...... 76 Fluvoxamine Maleate ER...... 66 Gammagard...... 147 22 22Tracked 22 Gleostine...... 74 Decanoate...... 81 Humulin R U-500 KwikPen.....95 Glimepiride...... 92 Haloperidol Lactate...... 81 Hydralazine HCl...... 109 Glipizide...... 92 Harvoni...... 86 Hydrea...... 75 Glipizide ER...... 92 Havrix...... 148 Hydrochlorothiazide...... 107 Glipizide-Metformin HCl...... 92 Heparin Sodium...... 96 Hydrocodone-Acetaminophen GlucaGen HypoKit...... 94 HepatAmine...... 119 ...... 44, 45 Emergency...... 94 Hepsera...... 85 Hydrocodone-Ibuprofen...... 45 Glucophage...... 92 Hetlioz...... 164 Hydrocortisone...... 132, 151 Glucophage XR...... 92 Hiberix...... 148 Hydrocortisone Acetate- Pramoxine...... 150 Glucotrol...... 92 Hiprex...... 50 Hydrocortisone Butyrate...... 132 Glucotrol XL...... 92 Horizant...... 112 Hydrocortisone Valerate...... 132 Glumetza...... 92 Humalog...... 94 Hydrocortisone-Acetic Acid Glycopyrrolate...... 123 Humalog Junior KwikPen...... 94 ...... 156 Glyset...... 92 Humalog KwikPen...... 94 Hydromorphone HCl...... 45 Glyxambi...... 92 Humalog Mix 50/50...... 94 Hydromorphone HCl ER...... 42 Gocovri...... 79 Humalog Mix 50/50 KwikPen Hydromorphone HCl ...... 94 GoLYTELY...... 124 Preservative Free...... 45 Humalog Mix 75/25...... 94 GoNitro...... 109 Hydroxychloroquine Sulfate Gralise...... 112 Humalog Mix 75/25 KwikPen ...... 78 ...... 94 Gralise Starter...... 112 Hydroxyurea...... 75 Humatrope...... 135 Granisetron HCl...... 68 Hydroxyzine HCl...... 90 Humira...... 145 Granix...... 98 Hydroxyzine Pamoate...... 67 Humira Pediatric Crohns Start Griseofulvin Microsize...... 70 Hysingla ER...... 42 ...... 145 Griseofulvin Ultramicrosize....70 Hyzaar...... 105 Humira Pen...... 145 Guanidine HCl...... 73 I Humira Pen Crohns Disease Gynazole-1...... 70 Starter...... 145 Ibandronate Sodium...... 151 H Humira Pen Psoriasis Starter Ibrance...... 76 Haegarda...... 144 ...... 145 Ibu...... 39 Hailey 24 Fe...... 138 Humulin 70/30...... 95 Ibuprofen...... 40 Haldol...... 81 Humulin 70/30 KwikPen...... 95 Iclusig...... 76 Haldol Decanoate...... 81 Humulin N...... 95 IDHIFA...... 76 Halobetasol Propionate...... 132 Humulin N KwikPen...... 95 Ilevro...... 155 Halog...... 132 Humulin R...... 95 Ilumya...... 116 Haloperidol...... 81 Humulin R U-500...... 95 Imatinib Mesylate...... 76 23Tracked 23 23 Imbruvica...... 77 Invega Sustenna...... 82 J Imipenem-Cilastatin...... 53 Invega Trinza...... 83 Jadenu...... 122 Imipramine HCl...... 67 Inveltys...... 155 Jadenu Sprinkle...... 122 Imipramine Pamoate...... 67 Invirase...... 89 Jakafi...... 77 Imiquimod...... 117 Invokamet...... 92 Jalyn...... 128 Imiquimod Pump...... 117 Invokamet XR...... 92 Jantoven...... 96 Imitrex...... 72 Invokana...... 92 Janumet...... 92 Imitrex STATdose Refill...... 72 Ionosol-MB in D5W...... 119 Janumet XR...... 92 Imitrex STATdose System..... 72 Iopidine...... 154 Januvia...... 92 Imovax Rabies...... 149 IPOL...... 149 Jardiance...... 92 Impoyz...... 132 Ipratropium Bromide...... 158 Jasmiel...... 138 Imuran...... 145 Ipratropium-Albuterol...... 163 Jentadueto...... 92 Imvexxy Maintenance Pack Irbesartan...... 100 Jentadueto XR...... 92 ...... 138 Irbesartan-Hydrochlorothiazide Jinteli...... 138 Imvexxy Starter Pack...... 138 ...... 105 Jolivette...... 141 Inbrija...... 79 Iressa...... 77 Jublia...... 70 Incassia...... 141 Isentress...... 87 Juleber...... 138 Increlex...... 135 Isentress HD...... 87 Juluca...... 87 Incruse Ellipta...... 158 Isibloom...... 138 Junel 1.5/30...... 138 Indapamide...... 107 Isolyte-P in D5W...... 119 Junel 1/20...... 138 Inderal LA...... 101 Isolyte-S...... 119 Junel Fe 1.5/30...... 138 Infanrix...... 149 Isoniazid...... 74 Junel Fe 1/20...... 138 Ingrezza...... 112 Isopto Carpine...... 154 Junel Fe 24...... 138 Inlyta...... 77 Isordil Titradose...... 109 Juxtapid...... 108 InnoPran XL...... 101 Isosorbide Dinitrate...... 109 Jynarque...... 122 Inspra...... 107 Isosorbide Dinitrate ER...... 109 K Syringes, Needles.... 152 Isosorbide Mononitrate...... 109 K-Tab...... 120 Intelence...... 87 Isosorbide Mononitrate ER Kadian...... 42 ...... 109 Intralipid...... 119 Kaitlib Fe...... 139 Isotretinoin...... 117 Intrarosa...... 136 Kaletra...... 89 Isradipine...... 103 Intron A...... 86 Kalydeco...... 163 Istalol...... 154 Introvale...... 138 Kapvay...... 111 Itraconazole...... 70 Invanz...... 53 Kariva...... 139 Ivermectin...... 78 Invega...... 82 Kazano...... 92 Ixiaro...... 149 24 24Tracked 24 KCl in Dextrose-NaCl...... 119 Kurvelo...... 139 Latuda...... 83 KCl-Lactated Ringers-D5W Kuvan...... 126 Layolis Fe...... 139 ...... 120 L Lazanda...... 45 Kelnor 1/35...... 139 Labetalol HCl...... 101 Ledipasvir-Sofosbuvir...... 86 Kelnor 1/50...... 139 Lacrisert...... 152 Leena...... 139 Kenalog...... 132 Lactulose...... 124 Leflunomide...... 148 Keppra...... 59 Lamictal...... 61 Lenvima 10MG Daily Dose.... 77 Keppra XR...... 59 Lamictal ODT...... 61 Lenvima 12MG Daily Dose.... 77 Kerydin...... 70 Lamictal Starter...... 61 Lenvima 14MG Daily Dose.... 77 ...... 70 Lamictal XR...... 61 Lenvima 18MG Daily Dose.... 77 Ketoprofen...... 40 Lamivudine...... 85, 88 Lenvima 20MG Daily Dose.... 77 Ketoprofen ER...... 40 Lamivudine-Zidovudine...... 88 Lenvima 24MG Daily Dose.... 77 Ketorolac Tromethamine.....155 Lamotrigine...... 62 Lenvima 4MG Daily Dose...... 77 Keveyis...... 106 Lamotrigine ER...... 62 Lenvima 8MG Daily Dose...... 77 Kevzara...... 148 Lamotrigine ODT...... 62 Lescol XL...... 108 Khedezla...... 66 Lamotrigine Starter Kit-Blue Lessina...... 139 Kineret...... 145 ...... 62 Letairis...... 161 Kinrix...... 149 Lamotrigine Starter Kit-Green Letrozole...... 76 ...... 62 Kionex...... 122 Leucovorin Calcium...... 75 Lamotrigine Starter Kit-Orange Kisqali...... 75 Leukeran...... 74 ...... 62 Kisqali Femara...... 75 Leukine...... 98 Lanoxin...... 105 Klaron...... 117 Leuprolide Acetate...... 143 Lansoprazole...... 125 Klonopin...... 90 Levalbuterol HCl...... 159, 160 Lansoprazole ODT...... 125 Klor-Con...... 120 Levalbuterol Tartrate...... 160 Lanthanum Carbonate...... 122 Klor-Con 10...... 120 Levemir...... 95 Lantus...... 95 Klor-Con 8...... 120 Levemir FlexTouch...... 95 Lantus SoloStar...... 95 Klor-Con M10...... 120 Levetiracetam...... 59, 60 LARIN 1.5/30...... 139 Klor-Con M15...... 120 Levetiracetam ER...... 59 LARIN 1/20...... 139 Klor-Con M20...... 120 Levo-T...... 142 LARIN Fe 1.5/30...... 139 Klor-Con Sprinkle...... 120 Levobunolol HCl...... 154 LARIN Fe 1/20...... 139 Kombiglyze XR...... 92 Levocarnitine...... 120 Larissia...... 139 Korlym...... 136 Levocetirizine Dihydrochloride Lasix...... 106 Krintafel...... 78 ...... 157 Lastacaft...... 152 Kristalose...... 124 Levofloxacin...... 57 Latanoprost...... 156 25Tracked 25 25 Levofloxacin in D5W...... 57 Livalo...... 108 Lotrisone...... 117 Levonest...... 139 Lo Loestrin Fe...... 139 Lotronex...... 124 -Ethinyl Estradiol Locoid...... 132 Lovastatin...... 108 ...... 139 Locoid Lipocream...... 132 Lovaza...... 108 Levonorgestrel-Ethinyl Estradiol Lodine...... 40 Lovenox...... 97 & Ethinyl Estradiol...... 139 Lodosyn...... 80 Low-Ogestrel...... 139 Levonorgestrel-Ethinyl Estradiol Loestrin 1.5/30...... 139 Loxapine Succinate...... 81 91-Day...... 139 Loestrin 1/20...... 139 Lucemyra...... 152 Levora 0.15/30...... 139 Loestrin Fe 1.5/30...... 139 Luliconazole...... 70 Levorphanol Tartrate...... 42 Loestrin Fe 1/20...... 139 Lumigan...... 156 Levothyroxine Sodium...... 142 Lokelma...... 122 Lupaneta Pack...... 143 Levoxyl...... 142 Lomotil...... 123 Lupron Depot...... 143 Lexapro...... 66 Lonhala Magnair Refill Kit....158 Lutera...... 139 Lexette...... 132 Lonsurf...... 75 Luxiq...... 132 Lexiva...... 89 Loperamide HCl...... 123 Luzu...... 70 Lialda...... 150 Lopid...... 107 Lynparza...... 77 Lidocaine...... 47 Lopinavir-Ritonavir...... 89 Lyrica...... 112 Lidocaine HCl...... 47 Lopressor...... 102 Lyrica CR...... 112 Lidocaine Viscous...... 47 Lopressor HCT...... 105 Lysodren...... 143 Lidocaine-Prilocaine...... 47 Loprox...... 70 Lysteda...... 99 Lidoderm...... 47 Lorazepam...... 90 Lyza...... 142 Lindane...... 79 Lorbrena...... 75 M Linezolid...... 50 Lorcet...... 45 M-M-R II...... 149 Linzess...... 124 Lorcet HD...... 45 Macrobid...... 50 Liothyronine Sodium...... 142 Lorcet Plus...... 45 Macrodantin...... 50 Lipitor...... 108 Loryna...... 139 Mafenide Acetate...... 50 Lipofen...... 107 Losartan Potassium...... 100 Magnesium Sulfate...... 120 Lisinopril...... 100 Losartan Potassium-HCTZ...105 Malarone...... 78 Lisinopril-Hydrochlorothiazide ...... 105 LoSeasonique...... 139 Malathion...... 79 Lithium...... 91 Lotemax...... 155 Maprotiline HCl...... 66 Lithium Carbonate...... 91 Lotemax SM...... 155 Marinol...... 68 Lithium Carbonate ER...... 91 Lotensin...... 100 Marlissa...... 139 Lithobid...... 91 Loteprednol Etabonate...... 156 Marplan...... 65 Lithostat...... 129 Lotrel...... 105 Matulane...... 74 26 26Tracked 26 Matzim LA...... 103 Mesalamine...... 150 Metoprolol-Hydrochlorothiazide Mavenclad...... 113 Mesnex...... 78 ...... 105 Mavyret...... 86 Mestinon...... 73 MetroCream...... 50 Maxalt...... 72 Metadate ER...... 111 Metrogel...... 50 Maxalt-MLT...... 72 Metaproterenol Sulfate...... 160 MetroGel-Vaginal...... 50 Maxidex...... 156 Metformin HCl...... 93 MetroLotion...... 50 Maxipime...... 53 Metformin HCl ER...... 92, 93 Metronidazole...... 50 Maxitrol...... 152 Methadone HCl...... 42 Metronidazole in NaCl 0.79% ...... 50 Maxzide...... 105 Methamphetamine HCl...... 110 Mexiletine HCl...... 101 Maxzide-25...... 105 Methazolamide...... 106 Mibelas 24 Fe...... 139 Mayzent...... 113 Methenamine Hippurate...... 50 Micardis...... 100 Meclizine HCl...... 67 Methimazole...... 144 Micardis HCT...... 105 Meclofenamate Sodium...... 40 Methitest...... 136 Miconazole 3...... 70 Medrol...... 132 Methotrexate...... 145 MiCort-HC...... 132 Medroxyprogesterone Acetate Methotrexate Sodium...... 145 Microgestin 1.5/30...... 139 ...... 142 Methoxsalen Rapid...... 117 Microgestin 1/20...... 139 Mefenamic Acid...... 40 Methscopolamine Bromide Mefloquine HCl...... 78 ...... 123 Microgestin Fe 1.5/30...... 139 ...... 142 Methyclothiazide...... 107 Microgestin Fe 1/20...... 139 Mekinist...... 77 Methyldopa...... 99 Midodrine HCl...... 99 Mektovi...... 77 Methylin...... 111 Migergot...... 72 Melodetta 24 Fe...... 139 Methylphenidate HCl...... 111 Miglitol...... 93 Meloxicam...... 40 Methylphenidate HCl CD.....111 Miglustat...... 126 Memantine HCl...... 64 Methylphenidate HCl ER..... 111 Migranal...... 72 Memantine HCl ER...... 64 Methylphenidate HCl ER Mili...... 139 Memantine HCl Titration Pak Osmotic Release...... 111 Millipred...... 133 ...... 64 Methylphenidate HCl LA...... 111 Minastrin 24 Fe...... 139 Menactra...... 149 Methylprednisolone...... 132 Minipress...... 100 Menest...... 139 ...... 136 Minitran...... 109 Mentax...... 70 HCl...... 68 Minivelle...... 139 Menveo...... 149 Metoclopramide HCl ODT..... 68 Minocin...... 59 Mepron...... 78 Metolazone...... 107 Minocycline HCl...... 59 Mercaptopurine...... 75 Metoprolol Succinate ER.....102 Minocycline HCl ER...... 59 Meropenem...... 53 Metoprolol Tartrate...... 102 Minoxidil...... 109 Merrem...... 53 Mirapex...... 79 27Tracked 27 27 Mirapex ER...... 79 Mycamine...... 70 Nasonex...... 158 Mirtazapine...... 65 Mycobutin...... 74 Natacyn...... 70 Mirtazapine ODT...... 65 Mycophenolate Mofetil...... 145 Natazia...... 140 Mirvaso...... 117 Mycophenolate Sodium...... 146 Nateglinide...... 93 Misoprostol...... 125 Mydayis...... 110 Natpara...... 151 Mitigare...... 71 Myfortic...... 146 Natroba...... 79 Mobic...... 40 Myorisan...... 117 Nebupent...... 78 Modafinil...... 164 Myrbetriq...... 128 Necon 0.5/35...... 140 Moexipril HCl...... 100 Mysoline...... 60 Nefazodone HCl...... 66 Molindone HCl...... 81 Mytesi...... 123 Neo-Synalar...... 117 Mometasone Furoate...... 133, N Neomycin Sulfate...... 48 157 Nabumetone...... 40 Neomycin-Bacitracin-Polymyxin Mondoxyne NL...... 59 Nadolol...... 102 ...... 152 MonoNessa...... 140 Nadolol-Bendroflumethiazide Neomycin-Polymyxin- Montelukast Sodium...... 158 ...... 105 Bacitracin-Hydrocortisone ...... 152 Monurol...... 50 Nafcillin Sodium...... 54 Neomycin-Polymyxin- Morgidox...... 59 Naftifine HCl...... 70 Dexamethasone...... 153 MorphaBond ER...... 42 Naftin...... 70 Neomycin-Polymyxin- Morphine Sulfate...... 45 Nalfon...... 40 Gramicidin...... 153 Morphine Sulfate ER...... 42, 43 Naloxone HCl...... 48 Neomycin-Polymyxin-HC.... 153, Morphine Sulfate ER Beads Naltrexone HCl...... 47 156 ...... 42 Namenda...... 64 Neoral...... 146 Motegrity...... 123 Namenda Titration Pak...... 64 NephrAmine...... 120 Movantik...... 123 Namenda XR...... 64 Nerlynx...... 77 MoviPrep...... 124 Namenda XR Titration Pack Nesina...... 93 Moxeza...... 57 ...... 64 Neuac...... 117 Moxifloxacin HCl...... 57 Namzaric...... 112 Neulasta...... 98 Moxifloxacin HCl in NaCl...... 57 Naprelan...... 40 Neupogen...... 98 MS Contin...... 43 Naproxen...... 40 Neupro...... 80 Mulpleta...... 98 Naproxen DR...... 40 Neurontin...... 60 Multaq...... 101 Naproxen Sodium...... 40 Nevanac...... 156 Mupirocin...... 50 Naproxen Sodium ER...... 40 Nevirapine...... 87 Mupirocin Calcium...... 50 Naratriptan HCl...... 72 Nevirapine ER...... 87 Myalept...... 123 Narcan...... 48 Nexavar...... 77 Myambutol...... 74 Nardil...... 65 Nexium...... 125 28 28Tracked 28 Niacin ER...... 108 Norethindrone Acetate-Ethinyl Nuzyra...... 59 Niacor...... 108 Estradiol...... 140 Nyamyc...... 70 Niaspan...... 109 Norethindrone Acetate-Ethinyl Nymalize...... 103 Estradiol-Fe...... 140 Nicardipine HCl...... 103 Nystatin...... 70, 71 Norgestimate-Ethinyl Estradiol Nicotrol...... 48 Nystatin-Triamcinolone...... 71 ...... 140 Nicotrol NS...... 48 Nystop...... 71 Norgestimate-Ethinyl Estradiol Nifedipine ER...... 103 Triphasic...... 140 O Nifedipine ER Osmotic Release Noritate...... 51 Ocaliva...... 126 ...... 103 Norlyroc...... 142 Ocella...... 140 Nikki...... 140 Normosol-M in D5W...... 120 Octagam...... 147 Nilandron...... 74 Normosol-R in D5W...... 120 Octreotide Acetate...... 143 ...... 74 Normosol-R pH 7.4...... 120 Ocuflox...... 57 Nimodipine...... 103 Norpramin...... 67 Odefsey...... 87 Ninlaro...... 75 Northera...... 99 Odomzo...... 77 Nisoldipine ER...... 103 Nortrel 0.5/35...... 140 Ofev...... 162 Nitro-Bid...... 109 Nortrel 1/35...... 140 Ofloxacin...... 57 Nitro-Dur...... 109 Nortrel 7/7/7...... 140 Ogestrel...... 140 Nitrofurantoin...... 51 Nortriptyline HCl...... 67 Olanzapine...... 83 Nitrofurantoin Macrocrystal Norvasc...... 103 Olanzapine ODT...... 83 ...... 50, 51 Norvir...... 89 Olanzapine-Fluoxetine HCl.... 65 Nitrofurantoin Monohydrate Olmesartan Medoxomil...... 100 ...... 51 Noxafil...... 70 Olmesartan Medoxomil-HCTZ Nitroglycerin...... 109 Nucala...... 163 ...... 105 Nitrostat...... 109 Nucynta...... 45, 46 Olmesartan-Amlodipine-HCTZ Nucynta ER...... 43 Nityr...... 126 ...... 105 Nuedexta...... 112 Nivestym...... 98 Olopatadine HCl...... 153, 157 NuLYTELY with Flavor Packs Nizatidine...... 124 Olumiant...... 146 ...... 125 Nizoral...... 70 Olux...... 133 Nuplazid...... 83 Nocdurna...... 135 Olux-E...... 133 Nutrilipid...... 120 Nolix...... 133 Omeclamox-Pak...... 123 Nutropin AQ NuSpin 10...... 135 Nora-BE...... 142 Omega-3-Acid Ethyl Esters Nutropin AQ NuSpin 20...... 135 Norco...... 45 ...... 109 Nutropin AQ NuSpin 5...... 135 Norditropin FlexPro...... 135 Omeprazole...... 125, 126 NuvaRing...... 140 Norethindrone...... 142 Omnaris...... 158 Nuvigil...... 164 Norethindrone Acetate...... 142 Omnipred...... 156 29Tracked 29 29 Omnitrope...... 135 ...... 136 Parnate...... 65 Ondansetron HCl...... 68 Oxaprozin...... 40 Paromomycin Sulfate...... 49 Ondansetron ODT...... 68 Oxazepam...... 90 Paroxetine HCl...... 66 Onexton...... 117 Oxcarbazepine...... 63 Paser...... 74 Onfi...... 60 Oxervate...... 153 Pataday...... 153 Onglyza...... 93 Oxiconazole Nitrate...... 71 Patanase...... 157 Onzetra Xsail...... 72 Oxistat...... 71 Patanol...... 154 Opana...... 46 Oxsoralen Ultra...... 117 Paxil...... 66 Opsumit...... 161 Oxtellar XR...... 63 Pazeo...... 154 Oracea...... 59 Oxybutynin Chloride...... 128 Pediarix...... 149 Oralair 300IR...... 163 Oxybutynin Chloride ER...... 128 Pedvax HIB...... 149 Orapred ODT...... 133 Oxycodone HCl...... 46 PEG-3350-Electrolytes...... 125 Oravig...... 71 Oxycodone HCl ER...... 43 PEG-3350-NaCl-Na Orencia...... 146 Oxycodone-Acetaminophen Bicarbonate-KCl...... 125 Orencia ClickJect...... 146 ...... 46 Peganone...... 63 Orenitram...... 161 Oxycodone-Aspirin...... 46 Pegasys...... 86 Orfadin...... 126 Oxycodone-Ibuprofen...... 46 Pegasys ProClick...... 86 Orilissa...... 143 OxyContin...... 43 Penicillamine...... 129 Orkambi...... 160 Oxymorphone HCl...... 46 Penicillin G Potassium...... 55 Orsythia...... 140 Oxymorphone HCl ER...... 43 Penicillin G Potassium in Dextrose...... 55 Ortho Micronor...... 142 Oxytrol...... 128 Penicillin G Procaine...... 55 Ortho Tri-Cyclen Lo...... 140 Ozempic...... 93 Penicillin G Sodium...... 55 Ortho-Novum 1/35...... 140 P Penicillin V Potassium...... 55 Ortho-Novum 7/7/7...... 140 Pacerone...... 101 Pennsaid...... 40 Oseltamivir Phosphate...... 89 Paliperidone ER...... 83 PENTAM 300...... 78 Oseni...... 93 Palynziq...... 126 Pentasa...... 150 Osmolex ER...... 79 Pamelor...... 67 Pentoxifylline ER...... 105 OsmoPrep...... 125 Pancreaze...... 127 Pepcid...... 124 Osphena...... 142 Pandel...... 133 Percocet...... 46 Otezla...... 148 Panretin...... 78 Perforomist...... 160 Otovel...... 156 Pantoprazole Sodium...... 126 Perindopril Erbumine...... 100 Otrexup...... 146 Panzyga...... 147 Permethrin...... 79 Ovide...... 79 Paricalcitol...... 151, 152 Perphenazine...... 68 Oxacillin Sodium...... 55 Parlodel...... 80 Perseris...... 83 30 30Tracked 30 Pertzye...... 127 Pliaglis...... 47 Prednisolone Acetate...... 156 Phenadoz...... 157 Podofilox...... 117 Prednisolone Sodium Phenelzine Sulfate...... 65 Polymyxin B Sulfate...... 51 Phosphate...... 133, 156 Phenobarbital...... 60, 61 Polymyxin B-Trimethoprim Prednisolone Sodium Phosphate ODT...... 133 Phenoxybenzamine HCl...... 100 ...... 153 Prednisone...... 133 Phenytek...... 63 Polytrim...... 153 Prednisone Intensol...... 133 Phenytoin...... 63 Pomalyst...... 75 Premarin...... 140 Phenytoin Sodium Extended Portia-28...... 140 ...... 63 Potassium Chloride...... 121 Premasol...... 121 Phoslyra...... 122 Potassium Chloride CR...... 120 Prepopik...... 125 Phospholine Iodide...... 154 Potassium Chloride ER...... 120 Prevacid...... 126 Picato...... 117 Potassium Chloride in Dextrose Prevacid SoluTab...... 126 Pifeltro...... 87 ...... 120 Prevalite...... 109 Pilocarpine HCl...... 114, 154 Potassium Chloride in NaCl Previfem...... 140 ...... 120 Pimecrolimus...... 117 Prevymis...... 85 Potassium Citrate ER...... 121 Pimozide...... 81 Prezcobix...... 89 Pradaxa...... 97 Pimtrea...... 140 Prezista...... 89 Praluent...... 109 Pindolol...... 102 Priftin...... 74 Pramipexole Dihydrochloride Pioglitazone HCl...... 93 Prilosec...... 126 ...... 80 Pioglitazone HCl-Glimepiride Primaquine Phosphate...... 79 Pramipexole Dihydrochloride ...... 93 Primaxin IV...... 53 ER...... 80 Pioglitazone HCl-Metformin HCl Primidone...... 61 Prandin...... 93 ...... 93 Primlev...... 46 Prasugrel HCl...... 99 Piperacillin-Tazobactam...... 55 Prinivil...... 100 Pravachol...... 108 Piqray...... 75, 76 Pristiq...... 66 Pravastatin Sodium...... 108 Pirmella 1/35...... 140 Privigen...... 147 Praziquantel...... 78 Piroxicam...... 40 ProAir HFA...... 160 Prazosin HCl...... 100 Plaquenil...... 79 ProAir RespiClick...... 160 Precose...... 93 Plasma-Lyte 148...... 120 Probenecid...... 71 Pred Forte...... 156 Plasma-Lyte A...... 120 Probenecid-Colchicine...... 71 Pred Mild...... 156 Plavix...... 99 Procalamine...... 121 Pred-G...... 153 Plegridy...... 113 Procardia XL...... 103 Pred-G S.O.P...... 153 Plegridy Starter Pack...... 113 ProCentra...... 110 Prednicarbate...... 133 Plenamine...... 120 Prochlorperazine...... 68 Prednisolone...... 133 Plenvu...... 125 Prochlorperazine Maleate...... 68 31Tracked 31 31 Procrit...... 98 Pulmicort...... 158 Rabeprazole Sodium...... 126 Procto-Med HC...... 151 Pulmicort Flexhaler...... 158 Raloxifene HCl...... 142 Procto-Pak...... 151 Pulmozyme...... 163 Ramipril...... 100 Proctosol HC...... 151 Purixan...... 75 Ranexa...... 105 Proctozone-HC...... 151 Pylera...... 123 Ranitidine HCl...... 124 Micronized.... 142 Pyrazinamide...... 74 Ranolazine ER...... 105 Proglycem...... 94 Pyridostigmine Bromide...... 73, Rapaflo...... 128 Prograf...... 146 74 Rapamune...... 146 Prolastin-C...... 127 Pyridostigmine Bromide ER Rasagiline Mesylate...... 81 ...... 73 Prolensa...... 156 Rasuvo...... 146 Q Prolia...... 152 RAVICTI...... 127 Qbrelis...... 100 Promacta...... 98 Rayaldee...... 152 Qmiiz ODT...... 40 Promethazine HCl...... 157 Rayos...... 133 Qnasl...... 158 Prometrium...... 142 Razadyne...... 64 Qnasl Childrens...... 158 Propafenone HCl...... 101 Razadyne ER...... 64 Qtern...... 93 Propafenone HCl ER...... 101 Rebetol...... 86 Quadracel...... 149 Propantheline Bromide...... 123 Rebif...... 114 Qualaquin...... 79 Proparacaine HCl...... 153 Rebif Rebidose...... 113 Quartette...... 140 Propranolol HCl...... 102 Rebif Rebidose Titration Pack Qudexy XR...... 62 Propranolol HCl ER...... 102 ...... 114 Questran...... 109 Propranolol-HCTZ...... 105 Rebif Titration Pack...... 114 Questran Light...... 109 Propylthiouracil...... 144 Reclipsen...... 140 Quetiapine Fumarate...... 83 ProQuad...... 149 Recombivax HB...... 149 Quetiapine Fumarate ER...... 83 Proscar...... 128 Rectiv...... 110 QuilliChew ER...... 111 Prosol...... 121 Reglan...... 68 Quillivant XR...... 112 Protonix...... 126 Regranex...... 117 Quinapril HCl...... 100 Protopic...... 117 Relenza Diskhaler...... 89 Quinapril-Hydrochlorothiazide Protriptyline HCl...... 67 Relexxii...... 112 ...... 105 Proventil HFA...... 160 Relistor...... 123 Quinidine Gluconate ER...... 101 Provera...... 142 Relpax...... 72 Quinidine Sulfate...... 101 Provigil...... 164 Remeron...... 65 Quinine Sulfate...... 79 Prozac...... 66 Remeron SolTab...... 65 QVAR RediHaler...... 158 Renagel...... 122 PRUDOXIN...... 117 R Psorcon...... 133 Renvela...... 122 RabAvert...... 149 32 32Tracked 32 Repaglinide...... 93 Risedronate Sodium...... 152 Saizenprep...... 136 Repaglinide-Metformin HCl... 93 Risperdal...... 83 Salagen...... 114 Repatha...... 109 Risperdal Consta...... 83 Samsca...... 122 Repatha Pushtronex System ...... 83 Sancuso...... 68 ...... 109 Risperidone ODT...... 84 Sandimmune...... 146 Repatha SureClick...... 109 Ritalin...... 112 Sandostatin...... 143 Requip XL...... 80 Ritalin LA...... 112 Santyl...... 117 Rescriptor...... 87 Ritonavir...... 89 Saphris...... 84 Restasis...... 153 Rivastigmine...... 64 Sarafem...... 66 Restoril...... 164 Rivastigmine Tartrate...... 64 Savaysa...... 97 Retacrit...... 99 Rivelsa...... 140 Savella...... 112 Retin-A...... 117 Rizatriptan Benzoate...... 72 Savella Titration Pack...... 112 Retin-A Micro...... 117 Rizatriptan Benzoate ODT..... 73 Scopolamine...... 68 Retin-A Micro Pump...... 117 Rocaltrol...... 152 Seasonique...... 140 Retrovir...... 88 Rocklatan...... 154 Seebri Neohaler...... 158 Revatio...... 161 Ropinirole HCl...... 80 Segluromet...... 93 Revlimid...... 75 Ropinirole HCl ER...... 80 Selegiline HCl...... 81 Rexulti...... 83 Rosuvastatin Calcium...... 108 Selenium Sulfide...... 117 Reyataz...... 89 Rotarix...... 149 Selzentry...... 89 Rhofade...... 117 RotaTeq...... 149 Semprex-D...... 163 Rhopressa...... 153 Rowasa...... 150 Sensipar...... 152 Ribasphere...... 86 Roweepra...... 60 Serevent Diskus...... 160 Ribasphere RibaPak...... 86 Roweepra XR...... 60 Seroquel...... 84 Ribavirin...... 86 Roxicodone...... 46 Seroquel XR...... 84 Ridaura...... 148 Rozerem...... 164 Serostim...... 123 Rifabutin...... 74 Rubraca...... 76 Sertraline HCl...... 66 Rifadin...... 74 Ruconest...... 144 Setlakin...... 140 Rifamate...... 74 Rydapt...... 77 Sevelamer Carbonate...... 122 Rifampin...... 74 Rytary...... 80 Sevelamer HCl...... 122 Rifater...... 74 Rythmol SR...... 101 Sharobel...... 142 Rilutek...... 112 S Shingrix...... 149 Riluzole...... 112 Sabril...... 61 Signifor...... 143 Rimantadine HCl...... 90 Safyral...... 140 Sildenafil Citrate...... 161 Riomet...... 93 Saizen...... 135 Silenor...... 164 33Tracked 33 33 Siliq...... 117 Sotylize...... 101 Subsys...... 46 Silodosin...... 128 Sovaldi...... 86 Sucraid...... 127 Silvadene...... 57 Spiriva HandiHaler...... 158 Sucralfate...... 125 Silver Sulfadiazine...... 58 Spiriva Respimat...... 158 Sular...... 103 Simbrinza...... 154 ...... 107 Sulfacetamide Sodium...... 58, Simponi...... 146 Spironolactone-HCTZ...... 106 117 Simvastatin...... 108 Sporanox...... 71 Sulfacetamide-Prednisolone ...... 153 Sinemet...... 80 Sprintec 28...... 141 Sulfadiazine...... 58 Sinemet CR...... 80 Spritam...... 60 Sulfamethoxazole- Singulair...... 158 Sprycel...... 77 Trimethoprim...... 58 ...... 146 SPS...... 122 Sulfamylon...... 51 Sirturo...... 74 Sronyx...... 141 Sulfasalazine...... 151 Sivextro...... 51 SSD...... 58 Sulindac...... 40 Sklice...... 78 Stalevo 100...... 81 Sumatriptan...... 73 Sodium Chloride...... 121 Stalevo 125...... 81 Sumatriptan Succinate...... 73 Sodium Fluoride...... 121 Stalevo 150...... 81 Sumatriptan Succinate Refill Sodium Lactate...... 121 Stalevo 200...... 81 ...... 73 Sodium Phenylbutyrate...... 127 Stalevo 50...... 81 Suprax...... 53 Sodium Polystyrene Sulfonate Stalevo 75...... 81 Suprep Bowel Prep Kit...... 125 ...... 122 Starlix...... 93 Surmontil...... 67 Sofosbuvir-Velpatasvir...... 86 Stavudine...... 88 Sustiva...... 87 Solifenacin Succinate...... 128 Steglatro...... 93 Sutent...... 77 Soliqua...... 93 Steglujan...... 93 Syeda...... 141 Solodyn...... 59 Stelara...... 117 Sylatron...... 86 Solosec...... 51 Stimate...... 136 Symbicort...... 163 Soloxide...... 59 Stiolto Respimat...... 163 Symbyax...... 65 Soltamox...... 75 Stivarga...... 77 Symdeko...... 160 Somatuline Depot...... 144 Strattera...... 112 Symfi...... 88 Somavert...... 144 Streptomycin Sulfate...... 49 Symfi Lo...... 87 Soolantra...... 117 Striant...... 136 SymlinPen 120...... 93 Soriatane...... 117 Stribild...... 87 SymlinPen 60...... 93 Sorilux...... 117 Striverdi Respimat...... 160 Sympazan...... 61 Sorine...... 101 Stromectol...... 78 Symproic...... 123 Sotalol HCl...... 101 Suboxone...... 47 Symtuza...... 89 34 34Tracked 34 Synalar...... 133 Tazarotene...... 118 Thalomid...... 75 Synarel...... 144 Tazicef...... 53 Theo-24...... 161 Syndros...... 68 Tazorac...... 118 Theophylline...... 161 Synjardy...... 93 Taztia XT...... 103 Theophylline ER...... 161 Synjardy XR...... 93 TDVAX...... 149 Thiola...... 129 Synribo...... 76 Tecfidera...... 114 Thioridazine HCl...... 81 Synthroid...... 142 Tecfidera Starter Pack...... 114 Thiothixene...... 81 Syprine...... 122 Teflaro...... 53 Thyrolar-1...... 142 T Tegretol...... 63 Thyrolar-1/2...... 142 Tabloid...... 75 Tegretol XR...... 64 Thyrolar-1/4...... 142 Taclonex...... 118 Tegsedi...... 127 Thyrolar-2...... 142 Tacrolimus...... 118, 146 Tekturna...... 106 Thyrolar-3...... 142 Tadalafil...... 129, 161 Tekturna HCT...... 106 Tiagabine HCl...... 61 Tafinlar...... 77 Telmisartan...... 100 Tiazac...... 103 Tagrisso...... 77 Telmisartan-Amlodipine...... 106 Tibsovo...... 77 Takhzyro...... 144 Telmisartan-HCTZ...... 106 Tigan...... 68 Taltz...... 118 Temazepam...... 164 Tigecycline...... 51 Talzenna...... 76 Tenivac...... 149 Tiglutik...... 112 Tamiflu...... 90 Tenofovir Disoproxil Fumarate Tikosyn...... 101 Citrate...... 75 ...... 88 Timolol Maleate...... 72, 155 Tamsulosin HCl...... 129 Tenoretic 100...... 106 Timolol Maleate Ophthalmic Tapazole...... 144 Tenoretic 50...... 106 Gel Forming...... 154 TaperDex 12-Day...... 133 Tenormin...... 102 Timoptic Ocudose...... 155 TaperDex 6-Day...... 133 Terazosin HCl...... 129 Timoptic-XE...... 155 TaperDex 7-Day...... 133 Terbinafine HCl...... 71 Tinidazole...... 51 Tarceva...... 77 Terbutaline Sulfate...... 160 Tirosint...... 142 TARGADOX...... 59 Terconazole...... 71 Tirosint-SOL...... 142 Targretin...... 78 Testim...... 136 Tivicay...... 87 Tarina 24 Fe...... 141 Testosterone...... 137 Tizanidine HCl...... 163 Tarina Fe 1/20...... 141 ...... 137 TOBI...... 161 Tarka...... 106 ...... 137 TOBI Podhaler...... 161 Tasigna...... 77 Tetrabenazine...... 112 TobraDex...... 153 Tasmar...... 79 Tetracycline HCl...... 59 TobraDex ST...... 153 Tavalisse...... 99 Texacort...... 133 Tobramycin...... 49, 161 35Tracked 35 35 Tobramycin Sulfate...... 49 Transderm-Scop...... 68 Trifluoperazine HCl...... 81 Tobramycin-Dexamethasone Tranxene-T...... 90 Trifluridine...... 86 ...... 153 Tranylcypromine Sulfate...... 65 Triglide...... 107 Tobrex...... 49 Travasol...... 121 Trihexyphenidyl HCl...... 79 Tofranil...... 67 Travatan Z...... 156 Trileptal...... 64 Tolak...... 118 Trazodone HCl...... 67 Trilipix...... 107 Tolazamide...... 93 Trecator...... 74 TriLyte...... 125 Tolbutamide...... 93 Trelegy Ellipta...... 163 Trimethobenzamide HCl...... 68 Tolcapone...... 79 Trelstar Mixject...... 144 Trimethoprim...... 51 Tolmetin Sodium...... 40 Tremfya...... 118 Trimipramine Maleate...... 67 Tolsura...... 71 Tresiba...... 95 Trintellix...... 67 Tolterodine Tartrate...... 128 Tresiba FlexTouch...... 95 Triumeq...... 87 Tolterodine Tartrate ER...... 128 Tretinoin...... 78, 118 Trivora...... 141 Topamax...... 62 Tretinoin Microsphere...... 118 Trizivir...... 88 Topamax Sprinkle...... 62 Trexall...... 146 Trokendi XR...... 62 Topicort...... 133, 134 Trezix...... 46 TrophAmine...... 121 Topicort Spray...... 134 Tri-Estarylla...... 141 Trospium Chloride...... 128 Topiramate...... 62 Tri-Legest Fe...... 141 Trospium Chloride ER...... 128 Topiramate ER...... 62 Tri-Lo-Estarylla...... 141 Trulance...... 123 Toprol XL...... 102 Tri-Lo-Sprintec...... 141 Trulicity...... 94 Toremifene Citrate...... 75 Tri-Mili...... 141 Trumenba...... 149 Torsemide...... 106 Tri-Previfem...... 141 Trusopt...... 155 Toujeo Max SoloStar...... 95 Tri-Sprintec...... 141 Truvada...... 88 Toujeo SoloStar...... 95 Tri-VyLibra...... 141 Tudorza Pressair...... 159 Toviaz...... 128 Tri-VyLibra Lo...... 141 Twinrix...... 149 TPN Electrolytes...... 121 Triamcinolone Acetonide... 114, Twynsta...... 106 Tracleer...... 161 134 Tybost...... 87 Tradjenta...... 94 Triamterene-HCTZ...... 106 Tydemy...... 141 Tramadol HCl...... 46 Trianex...... 134 Tygacil...... 51 Tramadol HCl ER...... 43, 44 Tribenzor...... 106 Tykerb...... 77 Tramadol-Acetaminophen..... 46 Tricor...... 107 Tylenol with Codeine #3...... 46 Trandolapril...... 100 Triderm...... 134 Tylenol with Codeine #4...... 47 Trandolapril-Verapamil HCl ER Tridesilon...... 134 Tymlos...... 152 ...... 106 Trientine HCl...... 122 Typhim Vi...... 149 Tranexamic Acid...... 99 36 36Tracked 36 U Vandazole...... 51 Vicodin ES...... 47 Uceris...... 151 Vanos...... 134 Vicodin HP...... 47 Udenyca...... 99 VAQTA...... 150 Victoza...... 94 Uloric...... 71 Varivax...... 150 Videx...... 88 Ultracet...... 47 Varizig...... 147 Videx EC...... 88 Ultram...... 47 Varubi...... 68 Viekira Pak...... 86 Ultravate...... 134 Vascepa...... 109 Vienva...... 141 Unasyn...... 55 Vaseretic...... 106 Vigabatrin...... 61 Unithroid...... 143 Vasotec...... 100 Vigadrone...... 61 Uptravi...... 161, 162 Vecamyl...... 106 Vigamox...... 57 Urecholine...... 129 Vectical...... 118 Viibryd...... 67 Urocit-K 10...... 121 Velivet...... 141 Viibryd Starter Pack...... 67 Urocit-K 15...... 121 Velphoro...... 122 Vimpat...... 64 Urocit-K 5...... 121 Veltassa...... 122 Viokace...... 127 Uroxatral...... 129 Vemlidy...... 85 Viracept...... 89 Urso 250...... 123 Venclexta...... 77 Viramune...... 88 Urso Forte...... 123 Venclexta Starting Pack...... 77 Viramune XR...... 88 Ursodiol...... 123 Venlafaxine HCl...... 67 Viread...... 88 Utibron Neohaler...... 163 Venlafaxine HCl ER...... 67 Vistaril...... 68 V Ventavis...... 162 Vitrakvi...... 77 Vabomere...... 53 Ventolin HFA...... 160 Vivelle-Dot...... 141 Vagifem...... 141 Verapamil HCl...... 104 Vivitrol...... 47 Valacyclovir HCl...... 86 Verapamil HCl ER...... 103 Vivlodex...... 40 Valchlor...... 74 Veregen...... 118 Vizimpro...... 77 Valcyte...... 85 Verelan...... 104 Vogelxo...... 137 Valganciclovir HCl...... 85 Verelan PM...... 104 Vogelxo Pump...... 137 Valium...... 90 Versacloz...... 85 Voltaren...... 40 Valproic Acid...... 61 Verzenio...... 76 Voriconazole...... 71 Valsartan...... 100 Vesicare...... 128 Vosevi...... 86 Valsartan-Hydrochlorothiazide Vfend...... 71 Votrient...... 77 ...... 106 Vfend IV...... 71 VP-PNV-DHA...... 122 Valtrex...... 86 Viberzi...... 124 Vraylar...... 84 Vancocin HCl...... 51 Vibramycin...... 59 Vyfemla...... 141 Vancomycin HCl...... 51 Vicodin...... 47 VyLibra...... 141 37Tracked 37 37 Vytorin...... 109 Xopenex Concentrate...... 160 Zenzedi...... 110 Vyvanse...... 110 Xopenex HFA...... 160 Zepatier...... 86 Vyzulta...... 156 Xospata...... 77 Zerbaxa...... 53 W Xtampza ER...... 44 Zestoretic...... 106 Warfarin Sodium...... 97 Xtandi...... 75 Zestril...... 100 Welchol...... 109 Xulane...... 141 Zetia...... 109 Wellbutrin SR...... 65 Xultophy...... 94 Zetonna...... 158 Wellbutrin XL...... 65 Xuriden...... 127 Ziac...... 106 Wixela Inhub...... 163 Xyosted...... 137 Ziagen...... 88 WYMZYA Fe...... 141 Xyrem...... 164 Ziana...... 118 X Y Zidovudine...... 88 Xalatan...... 156 Yasmin 28...... 141 Zileuton ER...... 158 Xalkori...... 77 YAZ...... 141 Zioptan...... 156 Xanax...... 90 YF-Vax...... 150 Ziprasidone HCl...... 84 Xanax XR...... 90 Yonsa...... 75 Zipsor...... 40 Xarelto...... 97 Yosprala...... 126 Zirgan...... 85 Xarelto Starter Pack...... 97 Yupelri...... 159 Zithromax...... 56 Xatmep...... 147 Yuvafem...... 141 Zithromax Tri-Pak...... 56 Xeljanz...... 147 Z Zithromax Z-Pak...... 56 Xeljanz XR...... 147 Zafirlukast...... 158 Zocor...... 108 Xelpros...... 156 Zaleplon...... 164 Zofran...... 68 Xenazine...... 112 Zanaflex...... 163, 164 Zohydro ER...... 44 Xepi...... 57 Zarah...... 141 Zolinza...... 76 Xerese...... 87 Zarontin...... 60 Zolmitriptan...... 73 Xermelo...... 123 Zarxio...... 99 Zolmitriptan ODT...... 73 Xgeva...... 152 Zavesca...... 127 Zoloft...... 67 Xhance...... 158 Zejula...... 76 Zolpidem Tartrate...... 164 Xifaxan...... 124 Zelapar...... 81 Zomacton...... 136 Xigduo XR...... 94 Zelboraf...... 78 Zomig...... 73 Xiidra...... 153 Zemaira...... 127 Zomig ZMT...... 73 Ximino...... 59 Zembrace SymTouch...... 73 Zonalon...... 118 Xofluza...... 90 Zemplar...... 152 Zonegran...... 60 Xolair...... 148 Zenatane...... 118 Zonisamide...... 60 Xopenex...... 160 Zenpep...... 127 Zontivity...... 97 38 38Tracked 38 Zorbtive...... 123 Zuplenz...... 68 Zymaxid...... 57 Zortress...... 147 Zyban...... 48 Zypitamag...... 108 Zorvolex...... 41 Zyclara Pump...... 118 Zyprexa...... 84 Zostavax...... 150 Zydelig...... 78 Zyprexa Relprevv...... 84 Zosyn...... 55 Zyflo...... 158 Zyprexa Zydis...... 84, 85 Zovia 1/35E...... 141 Zyflo CR...... 158 Zytiga...... 75 Zovirax...... 87 Zykadia...... 78 Zyvox...... 51 ZTlido...... 47 Zylet...... 153 Zubsolv...... 48 Zyloprim...... 71 tRACK 39 39 Covered drugs by medical condition 138 The list below has information about the drugs covered by this plan. Find your medical condition to see what drugs are covered. If you have trouble finding your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-38. The first column lists the drug name, which may include the dosage form and strength. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column lists the drug tier or coverage level. The third column lists any rules or limits for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 165-202. tRACK

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

C1 Dicl ofen A1 ac- Mis opr osto Analgesics l Diclofenac-Misoprostol B1 Nonsteroidal Anti-inflammatory Drugs (Oral Tablet Delayed 1

C1 Arth rote c Release)

C1 Diflu Arthrotec (Oral Tablet nisal 3 Diflunisal (Oral Tablet) 1 Delayed Release) C1 Eto dola C1 c ER Cam bia Cambia (Oral Packet) 3 Etodolac ER (Oral C1 Cele brex Tablet Extended 1 Celebrex (Oral 3 QL Release 24 Hour) C1 Eto dola Capsule) c

C1 Cele coxi b Etodolac (Oral Celecoxib (Oral 1 1 QL Capsule) C1 Eto dola Capsule) c

C1 Day pro Etodolac (Oral Tablet Daypro (Oral Tablet) 3 1 C1 Immediate Release) Dicl ofen ac C1 Epol ami Feld ne Diclofenac Epolamine ene 3 PA; QL Feldene (Oral (Transdermal Patch) 3

C1 Dicl Capsule) ofen ac Pota C1 ssiu m Fen opr ofen

Calc Diclofenac Potassium ium 1 Fenoprofen Calcium (Oral Tablet) 3

C1 Dicl ofen (400MG Oral Capsule) ac Sodi C1 um ER Fen opr ofen

Calc Diclofenac Sodium ER ium Fenoprofen Calcium 3 (Oral Tablet Extended 1 (Oral Tablet)

C1 Flec Release 24 Hour) tor

C1 Dicl ofen ac Sodi Flector (Transdermal um Diclofenac Sodium 3 PA; QL Patch)

C1 Flur (Oral Tablet Delayed 1 bipr ofen Release) Flurbiprofen (Oral C1 1 Dicl ofen ac Sodi um Tablet) C1 Diclofenac Sodium Ibu 1 (1% Transdermal Gel) Ibu (600MG Oral C1 Dicl ofen ac Sodi um Tablet, 800MG Oral 1 Diclofenac Sodium 1 PA Tablet) (Transdermal Solution)

Bold type = Brand name drug Plain type = Generic drug 40 tRACK 40 Last updated September 1, 2019 239 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Ibup Nap rofe roxe n n Sodi um Ibuprofen (Oral ER Naproxen Sodium ER 1 Suspension) (375MG Oral Tablet

C1 Ibup rofe n Ibuprofen (400MG Extended Release 24 4 Oral Tablet, 600MG Hour) (Generic 1 Naprelan)

Oral Tablet, 800MG C1 Nap roxe n Sodi um Oral Tablet) ER Naproxen Sodium ER

C1 Ket opr ofen ER (500MG Oral Tablet Ketoprofen ER (Oral Capsule Extended 3 Extended Release 24 3 Release 24 Hour) Hour) (Generic

C1 Ket opr ofen Naprelan)

C1 Nap Ketoprofen (Oral roxe n Sodi um Capsule Immediate 1 Naproxen Sodium Release) (275MG Oral Tablet C1 Lodi ne Immediate Release, 1 Lodine (Oral Tablet) 4

C1 Mec lofe nam 550MG Oral Tablet ate Sodi um Meclofenamate 3 Immediate Release) C1 Oxa proz Sodium (Oral Capsule) in

C1 Mef ena mic Oxaprozin (Oral Acid Mefenamic Acid (Oral 1 3 Tablet) C1 Pen nsai Capsule) d

C1 Mel oxic Pennsaid am Meloxicam (Oral 1 (Transdermal 4 PA Tablet)

C1 Mob ic Solution) C1 Piro xica Mobic (Oral Tablet) 3 m

C1 Nab ume Piroxicam (Oral tone 1 Nabumetone (Oral Capsule)

1 C1 Qmii z Tablet) ODT

C1 Nalf on Qmiiz ODT (Oral Nalfon (Oral Tablet) 3 3 C1 Tablet Dispersible) Nap rela n C1 Suli nda Naprelan (Oral Tablet c Sulindac (Oral Tablet) 1 C1 Tol meti n Sodi Extended Release 24 4 um Tolmetin Sodium (Oral Hour) 3

C1 Nap Capsule) roxe n DR C1 Tol meti n Sodi Naproxen DR (Oral um Tolmetin Sodium Tablet Delayed 3 1 (600MG Oral Tablet) C1 Vivl ode Release) (Generic EC- x Vivlodex (Oral Naprosyn) 4 QL C1 Nap roxe n Capsule)

C1 Volt Naproxen (Oral aren 3 Suspension) Voltaren

C1 3 PA Nap roxe n (Transdermal Gel) C1 Naproxen (Oral Tablet Zips 1 or Immediate Release) Zipsor (Oral Capsule) 4 ST

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 41 41 340 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Zorv Dur olex age sic-1 Zorvolex (Oral 00 Duragesic-100 3 ST 7D; MME; Capsule) (Transdermal Patch 4

B1 DL; QL Opioid Analgesics, Long-acting 72 Hour) C1 C1 Dur age Belb sic-1 uca 2 Duragesic-12 Belbuca (150MCG 7D; MME; Buccal Film, 300MCG (Transdermal Patch 3 PA; 7D; DL; DL; QL Buccal Film, 450MCG 3 72 Hour) C1 Dur age sic-2 QL 5 Buccal Film, 75MCG Duragesic-25 7D; MME; Buccal Film) (Transdermal Patch 3

C1 Belb uca DL; QL Belbuca (600MCG 72 Hour) C1 Dur age sic-5 Buccal Film, 750MCG PA; 7D; DL; 0 Duragesic-50 4 7D; MME; Buccal Film, 900MCG QL (Transdermal Patch 4 DL; QL Buccal Film) 72 Hour)

C1 C1 Bup Dur reno age rphi sic-7 ne Buprenorphine 5 Duragesic-75 7D; MME; (10MCG/HR (Transdermal Patch 4 DL; QL Transdermal Patch 72 Hour)

C1 Emb Weekly, 15MCG/HR eda Embeda (Oral Transdermal Patch 7D; MME; 1 7D; DL; QL Capsule Extended 2 Weekly, 20MCG/HR DL; QL Release)

C1 Transdermal Patch Fent anyl Weekly, 5MCG/HR Fentanyl (100MCG/HR Transdermal Patch Transdermal Patch 72 Weekly) Hour, 12MCG/HR

C1 Bup reno rphi ne Buprenorphine Transdermal Patch 72 (7.5MCG/HR Hour, 25MCG/HR 7D; MME; 2 7D; DL; QL Transdermal Patch 72 1 Transdermal Patch DL; QL Weekly) Hour, 50MCG/HR

C1 Butr ans Transdermal Patch 72 Butrans (Transdermal 2 7D; DL; QL Hour, 75MCG/HR Patch Weekly)

C1 Transdermal Patch 72 Con Zip ConZip (Oral Capsule Hour)

C1 Fent 7D; MME; anyl Extended Release 24 3 DL; QL Fentanyl (37.5MCG/ 7D; MME; Hour) HR Transdermal Patch 3 C1 Dol ophi ne DL; QL Dolophine (Oral 7D; MME; 72 Hour) 3 Tablet) DL; QL

Bold type = Brand name drug Plain type = Generic drug 42 tRACK 42 Last updated September 1, 2019 441 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Fent Lev anyl orph anol

Tartr Fentanyl (62.5MCG/ ate Levorphanol Tartrate 7D; MME; 4 HR Transdermal Patch (Oral Tablet) DL; QL

C1 7D; MME; Met had one 72 Hour, 87.5MCG/HR 4 HCl Methadone HCl (Oral 7D; MME; DL; QL 1 Transdermal Patch 72 Solution) DL; QL

C1 Met had Hour) one HCl

C1 Hyd rom orph one Methadone HCl (Oral 7D; MME; HCl ER Hydromorphone HCl 1 7D; MME; Tablet) DL; QL

C1 Mor ER (Oral Tablet ER 24 3 pha Bon d Hour Abuse-Deterrent) DL; QL ER MorphaBond ER

C1 Hysi ngla ER Hysingla ER (Oral (100MG Oral Tablet 7D; MME; Tablet ER 24 Hour 2 ER 12 Hour Abuse- DL; QL Deterrent, 30MG Oral Abuse-Deterrent) 7D; MME; C1 Kadi an Tablet ER 12 Hour 4 Kadian (100MG Oral DL; QL Abuse-Deterrent, Capsule Extended 60MG Oral Tablet ER Release 24 Hour, 12 Hour Abuse- 200MG Oral Capsule Deterrent)

C1 Mor pha Extended Release 24 Bon d ER Hour, 40MG Oral MorphaBond ER (15MG Oral Tablet ER 7D; MME; Capsule Extended 3 Release 24 Hour, 7D; MME; 12 Hour Abuse- DL; QL 4 Deterrent)

C1 50MG Oral Capsule DL; QL Mor phin e Sulf ate ER Bea Extended Release 24 ds Morphine Sulfate ER Beads (Oral Capsule 7D; MME; Hour, 60MG Oral 3 Capsule Extended Extended Release 24 DL; QL Hour) (Generic Avinza)

C1 Mor Release 24 Hour, phin e Sulf ate 80MG Oral Capsule ER Morphine Sulfate ER (Oral Capsule 7D; MME; Extended Release 24 3 Extended Release 24 DL; QL Hour)

C1 Kadi Hour) (Generic Kadian) an Kadian (10MG Oral Capsule Extended Release 24 Hour, 20MG Oral Capsule 7D; MME; 3 Extended Release 24 DL; QL Hour, 30MG Oral Capsule Extended Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 43 43 542 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Mor Oxy phin cod e one Sulf HCl ate ER ER Morphine Sulfate ER Oxycodone HCl ER (100MG Oral Tablet (10MG Oral Tablet ER Extended Release, 12 Hour Abuse- 15MG Oral Tablet Deterrent, 15MG Oral Extended Release, 7D; MME; Tablet ER 12 Hour 1 30MG Oral Tablet DL; QL Abuse-Deterrent, Extended Release, 20MG Oral Tablet ER 7D; MME; 3 60MG Oral Tablet 12 Hour Abuse- DL; QL Extended Release) Deterrent, 30MG Oral (Generic MS Contin) Tablet ER 12 Hour

C1 Mor phin e Sulf ate ER Morphine Sulfate ER Abuse-Deterrent, (200MG Oral Tablet 7D; MME; 40MG Oral Tablet ER 3 Extended Release) DL; QL 12 Hour Abuse- Deterrent)

(Generic MS Contin) C1 Oxy C1 cod one MS HCl Con ER tin MS Contin (100MG Oxycodone HCl ER Oral Tablet Extended (60MG Oral Tablet ER 12 Hour Abuse- 7D; MME; Release, 200MG Oral 4 Deterrent, 80MG Oral Tablet Extended DL; QL 7D; MME; Tablet ER 12 Hour Release, 30MG Oral 4 DL; QL Abuse-Deterrent) C1 Oxy Con Tablet Extended tin OxyContin (Oral Release, 60MG Oral 7D; MME; Tablet ER 12 Hour 2 Tablet Extended DL; QL Abuse-Deterrent)

C1 Oxy mor Release) pho ne HCl C1 ER MS Con tin Oxymorphone HCl ER MS Contin (15MG 7D; MME; 7D; MME; (Oral Tablet Extended 3 Oral Tablet Extended 3 DL; QL DL; QL Release 12 Hour) C1 Tra mad ol HCl Release) ER

C1 Nuc ynta Tramadol HCl ER ER Nucynta ER (Oral 7D; MME; (Biphasic) (Oral Tablet 7D; MME; Tablet Extended 2 1 DL; QL Extended Release 24 DL; QL Release 12 Hour) Hour)

Bold type = Brand name drug Plain type = Generic drug 44 tRACK 44 Last updated September 1, 2019 643 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Tra Acti mad q ol HCl ER Tramadol HCl ER Actiq (Buccal (100MG Oral Capsule Lozenge On A 4 PA; DL; QL Extended Release 24 Handle)

C1 But orph anol

Tartr Hour, 200MG Oral ate 7D; MME; Butorphanol Tartrate 7D; MME; Capsule Extended 3 1 DL; QL (Nasal Solution) DL; QL

C1 Cod Release 24 Hour, eine

Sulf ate Codeine Sulfate (Oral 7D; MME; 300MG Oral Capsule 1 Extended Release 24 Tablet) DL; QL C1 Dila Hour) udid 7D; MME; C1 Tra mad ol Dilaudid (Oral Liquid) 3 HCl ER Tramadol HCl ER DL; QL C1 Dila (100MG Oral Tablet udid Dilaudid (2MG Oral 7D; MME; Extended Release 24 Tablet, 4MG Oral 3 DL; QL Hour, 200MG Oral 7D; MME; Tablet) C1 Dila Tablet Extended 1 udid DL; QL Dilaudid (8MG Oral 7D; MME; Release 24 Hour, 4 Tablet) DL; QL 300MG Oral Tablet C1 Dur amo rph Duramorph (Injection Extended Release 24 1 DL Hour) Solution)

C1 C1 Xta Dvo mpz rah a ER Xtampza ER (Oral ST; 7D; 7D; MME; Dvorah (Oral Tablet) 3 Capsule ER 12 Hour 3 MME; DL; DL; QL

C1 End Abuse-Deterrent) QL ocet Endocet (10-325MG C1 Zoh ydro ER Zohydro ER (Oral PA; 7D; Oral Tablet, 5-325MG 7D; MME; Oral Tablet, 1 Capsule ER 12 Hour 3 MME; DL; DL; QL Abuse-Deterrent) QL 7.5-325MG Oral

B1 Tablet)

C1 Fent Opioid Analgesics, Short-acting anyl Citra te C1 Abst ral Fentanyl Citrate Abstral (Tablet 4 PA; DL; QL (Buccal Lozenge On A 4 PA; DL; QL Sublingual)

C1 Acet Handle) ami nop hen- C1 Cod eine Fent anyl Citra Acetaminophen- 7D; MME; te Fentanyl Citrate Codeine (120-12MG/ 1 4 PA; DL; QL DL; QL (Buccal Tablet) C1 Fent 5ML Oral Solution) ora

C1 Acet ami nop Fentora (Buccal hen- Cod eine Acetaminophen- 4 PA; DL; QL Tablet)

C1 Hyd Codeine (300-15MG roco don e- Acet ami nop 7D; MME; hen Oral Tablet, 300-30MG 1 Hydrocodone- DL; QL Acetaminophen 7D; MME; Oral Tablet, 300-60MG 1 Oral Tablet) (7.5-325MG/15ML DL; QL Oral Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 45 45 744 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Hyd Lorc roco et don HD e- Acet ami nop hen Hydrocodone- Lorcet HD (Oral 7D; MME; 1 Acetaminophen Tablet) DL; QL

C1 Lorc (10-300MG Oral et 7D; MME; Lorcet (Oral Tablet) 1 Tablet, 10-325MG Oral DL; QL

C1 Lorc et Tablet, 5-300MG Oral 7D; MME; Plus 1 Lorcet Plus (Oral 7D; MME; Tablet, 5-325MG Oral DL; QL 1 Tablet) DL; QL

Tablet, 7.5-300MG C1 Mor phin e Sulf ate Oral Tablet, Morphine Sulfate 7D; MME; 7.5-325MG Oral (100MG/5ML Oral 1 DL; QL Tablet) Solution)

C1 C1 Hyd Mor roco phin don e e- Sulf Ibup ate rofe n Morphine Sulfate Hydrocodone- 7D; MME; Ibuprofen (10-200MG 3 (8MG/ML Intravenous DL; QL 1 DL Oral Tablet) Solution Prefilled

C1 Hyd roco don e- Ibup rofe n Syringe)

Hydrocodone- C1 Mor phin e Sulf ate Morphine Sulfate Ibuprofen (5-200MG 7D; MME; Oral Tablet, 1 (10MG/ML Injection DL; QL 1 DL 7.5-200MG Oral Solution, 4MG/ML Tablet) Injection Solution)

C1 C1 Hyd Mor rom phin orph e one Sulf HCl Hydromorphone HCl ate Morphine Sulfate (2MG/ML Injection 3 DL (2MG/ML Injection 1 DL Solution) Solution, 5MG/ML C1 Hyd rom orph one HCl Hydromorphone HCl 7D; MME; Injection Solution)

C1 Mor phin 1 e Sulf (1MG/ML Oral Liquid) DL; QL ate Morphine Sulfate (Oral 7D; MME; C1 Hyd rom orph one HCl 1 Hydromorphone HCl Solution) DL; QL

C1 Mor phin e Sulf (2MG Oral Tablet ate Morphine Sulfate 7D; MME; Immediate Release, 7D; MME; (Oral Tablet 1 4MG Oral Tablet 1 DL; QL DL; QL Immediate Release) C1 Nor Immediate Release, co 7D; MME; 8MG Oral Tablet Norco (Oral Tablet) 3 DL; QL

Immediate Release) C1 Nuc C1 ynta Hyd rom orph one HCl Pres erva tive Nucynta (100MG Oral Free Hydromorphone HCl 7D; MME; Tablet Immediate 4 Preservative Free DL; QL (10MG/ML Injection 3 DL Release) Solution, 50MG/5ML Injection Solution)

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

Bold type = Brand name drug Plain type = Generic drug 46 tRACK 46 Last updated September 1, 2019 845 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Nuc Oxy ynta mor pho ne Nucynta (50MG Oral HCl Oxymorphone HCl 7D; MME; Tablet Immediate (Oral Tablet Immediate 1 7D; MME; DL; QL Release, 75MG Oral 3 Release) C1 Perc DL; QL ocet Tablet Immediate Percocet (10-325MG Release) Oral Tablet, 5-325MG C1 7D; MME; Opa na Opana (10MG Oral Oral Tablet, 4 7D; MME; DL; QL Tablet Immediate 4 7.5-325MG Oral DL; QL Tablet)

C1 Perc Release) ocet

C1 Opa na Percocet (2.5-325MG 7D; MME; Opana (5MG Oral 3 7D; MME; Oral Tablet) DL; QL

C1 Prim Tablet Immediate 3 lev DL; QL 7D; MME; Release) Primlev (Oral Tablet) 4 C1 Oxy cod one HCl DL; QL

C1 Roxi cod Oxycodone HCl (5MG 7D; MME; one 1 Roxicodone (15MG Oral Capsule) DL; QL 7D; MME; C1 Oxy cod one HCl Oral Tablet, 5MG Oral 3 Oxycodone HCl DL; QL 7D; MME; Tablet)

C1 Roxi (100MG/5ML Oral 3 cod DL; QL one Concentrate) Roxicodone (30MG 7D; MME; C1 4 Oxy cod one HCl Oral Tablet) DL; QL

C1 Oxycodone HCl (5MG/ 7D; MME; Sub 1 sys 5ML Oral Solution) DL; QL Subsys (100MCG

C1 Oxy cod one HCl Oxycodone HCl Sublingual Liquid, (10MG Oral Tablet 200MCG Sublingual Liquid, 400MCG Immediate Release, 4 PA; DL; QL 15MG Oral Tablet Sublingual Liquid, 600MCG Sublingual Immediate Release, 7D; MME; 20MG Oral Tablet 1 Liquid, 800MCG DL; QL Immediate Release, Sublingual Liquid)

C1 Tra mad ol 30MG Oral Tablet HCl Tramadol HCl (Oral 7D; MME; Immediate Release, Tablet Immediate 1 DL; QL 5MG Oral Tablet Release)

C1 Tra mad Immediate Release) ol- Acet ami C1 nop hen Oxy cod one- Acet Tramadol- ami nop hen 7D; MME; Oxycodone- 7D; MME; Acetaminophen (Oral 1 Acetaminophen (Oral 1 DL; QL DL; QL Tablet) C1 Trez Tablet) ix

C1 Oxy cod one- Aspi 7D; MME; rin Oxycodone-Aspirin 7D; MME; Trezix (Oral Capsule) 3 1 DL; QL

C1 Tyle nol (Oral Tablet) DL; QL with Cod eine C1 #3 Oxy cod one- Ibup Tylenol with Codeine 7D; MME; rofe n Oxycodone-Ibuprofen 7D; MME; 3 1 #3 (Oral Tablet) DL; QL (Oral Tablet) DL; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 47 47 946 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 Tyle nol with A1 Cod eine #4 Tylenol with Codeine 7D; MME; Anti-Addiction/Substance Abuse Treatment 3 #4 (Oral Tablet) DL; QL Agents

C1 Ultra cet 7D; MME; B1 Alcohol Deterrents/Anti-craving

C1 Aca mpr Ultracet (Oral Tablet) 3 osat e Calc DL; QL ium Acamprosate Calcium C1 Ultra m 7D; MME; (Oral Tablet Delayed 1 Ultram (Oral Tablet) 3 DL; QL Release) C1

C1 Anta bus Vico e din ES 7D; MME; Antabuse (Oral Tablet) 3 Vicodin ES (Oral C1 Disu lfira 1 m Tablet) DL; QL Disulfiram (Oral Tablet) 1

C1 C1 Nalt Vico rexo din ne HP Vicodin HP (Oral 7D; MME; HCl Naltrexone HCl (Oral 1 1 Tablet) DL; QL Tablet) C1 C1 Vivit rol Vico din 7D; MME; Vivitrol Vicodin (Oral Tablet) 1 (Intramuscular DL; QL 4 A1 Anesthetics Suspension B1 Local Anesthetics Reconstituted) B1 C1 Lido cain e Opioid Dependence Treatments

C1 Lidocaine (5% External Bun 3 QL avail Ointment) Bunavail (Buccal

C1 Lido 3 ST; QL cain e Film) Lidocaine (5% External C1 Bup reno rphi ne 3 PA; QL HCl Patch) Buprenorphine HCl

C1 Lido 1 QL cain e HCl (Tablet Sublingual) Lidocaine HCl (4% C1 Bup reno rphi ne HCl- 1 Nalo xon e External Solution) HCl Buprenorphine HCl-

C1 Lido cain e HCl Lidocaine HCl Naloxone HCl 3 QL 1 (Sublingual Film) (External Gel) C1 Bup reno C1 rphi ne Lido HCl- cain Nalo e xon Visc e ous HCl Buprenorphine HCl- Lidocaine Viscous (2% Mouth/Throat 1 Naloxone HCl (Tablet 1 QL Sublingual) Solution) C1 Sub oxo C1 ne Lido cain e- Prilo cain e Lidocaine-Prilocaine Suboxone (Sublingual 1 3 QL (External Cream) Film)

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

C1 Plia glis Pliaglis (External 3 Cream)

C1 ZTli do ZTlido (External 3 PA; QL Patch)

Bold type = Brand name drug Plain type = Generic drug 48 tRACK 48 Last updated September 1, 2019 1047 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Zub Cha solv ntix Start ing Mon th Zubsolv (1.4-0.36MG Pak Chantix Starting

Tablet Sublingual, Month Pak (Oral 2 11.4-2.9MG Tablet Tablet)

C1 Nico Sublingual, trol Nicotrol (Inhalation 3 2.9-0.71MG Tablet Inhaler)

C1 3 QL Nico trol Sublingual, NS Nicotrol NS (Nasal 3 5.7-1.4MG Tablet Solution)

C1 Zyb Sublingual, an Zyban (150MG Oral

8.6-2.1MG Tablet Tablet Extended 3 Sublingual) Release 12 Hour) B1 Opioid Reversal Agents A1

C1 Evzi Antibacterials o Evzio (Injection B1 Aminoglycosides

C1 Ami kaci n Solution Auto- 4 ST Sulf ate Amikacin Sulfate Injector)

C1 Nalo xon (500MG/2ML Injection 1 e HCl Naloxone HCl (0.4MG/ Solution)

1 C1 Arik ML Injection Solution) ayce

C1 Nalo xon Arikayce (Inhalation e HCl 4 Naloxone HCl Suspension) C1 Gen (Injection Solution 1 tak Gentak (Ophthalmic Cartridge) 1 C1 Nalo xon e Ointment) HCl

C1 Gen tami cin Naloxone HCl Sulf ate- 0.9 % Sodi um Chlo (Injection Solution 1 ride Gentamicin Sulfate-0.9% Sodium Prefilled Syringe) 1 C1 Nar can Chloride (Intravenous Narcan (Nasal Liquid) 2 Solution)

B1 C1 Gen tami cin Sulf Smoking Cessation Agents ate C1 Gentamicin Sulfate Bup ropi on HCl SR 1 Bupropion HCl SR (External Cream)

C1 Gen tami cin Sulf (150MG Oral Tablet ate Gentamicin Sulfate 1 Extended Release 12 1 (External Ointment)

C1 Gen tami cin Hour Smoking- Sulf ate Deterrent) Gentamicin Sulfate

C1 Cha ntix Con (40MG/ML Injection 1 tinui ng Mon th Pak Chantix Continuing Solution) C1 Gen tami cin Sulf Month Pak (Oral 2 ate Gentamicin Sulfate Tablet) 1

C1 Cha (Ophthalmic Solution) ntix C1 Neo myci n Sulf Chantix (Oral Tablet) 2 ate Neomycin Sulfate (Oral 1 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 49 49 1148 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Paro Cleo mo cin myci n Sulf ate Paromomycin Sulfate Cleocin (Oral Solution 3 3 (Oral Capsule) Reconstituted)

C1 C1 Stre Cleo pto cin myci Pho n sph Sulf ate ate Streptomycin Sulfate Cleocin Phosphate (Intramuscular (900MG/6ML Injection 3 4 Solution Solution)

C1 Cleo Reconstituted) cin C1 Cleocin (Vaginal Tob ram ycin 3 Tobramycin Cream)

C1 1 Cleo (Ophthalmic Solution) cin C1 Cleocin (Vaginal Tob ram ycin Sulf ate 3 Tobramycin Sulfate Suppository)

C1 Clin dam ycin HCl (10MG/ML Injection Clindamycin HCl (Oral 3 1 Solution, 80MG/2ML Capsule)

C1 Clin dam Injection Solution) ycin Pal mita C1 te HCl Tob rex Clindamycin Palmitate Tobrex (Ophthalmic 2 HCl (Oral Solution 1 Ointment) C1 Reconstituted) Tob rex C1 Clin dam ycin Pho sph ate Tobrex (Ophthalmic in D5 3 W Clindamycin Solution) Phosphate in D5W 1 B1 Antibacterials, Other (Intravenous Solution)

C1 C1 Baci Clin traci dam n ycin Pho sph Bacitracin (Ophthalmic ate Clindamycin 1 Ointment) Phosphate (300MG/

C1 Bact roba n Bactroban (2% 2ML Injection Solution, 3 1 External Cream) 600MG/4ML Injection

C1 Bact roba n Solution, 900MG/6ML Bactroban (2% Nasal 3 PA Injection Solution) C1 Clin dam ycin Ointment) Pho sph ate C1 Cleo cin in Clindamycin D5 W Cleocin in D5W Phosphate (Vaginal 1 (300MG/50ML Cream)

C1 Clin des Intravenous Solution, se Clindesse (Vaginal 3 600MG/50ML 3 Cream)

C1 Coli stim etha Intravenous Solution, te Sodi um Colistimethate Sodium 900MG/50ML (CBA) (Injection Intravenous Solution) 4

C1 Cleo Solution cin Cleocin (150MG Oral Reconstituted) C1 Cubi Capsule, 75MG Oral 3 cin Cubicin (Intravenous Capsule)

C1 Solution 4 Cleo cin Cleocin (300MG Oral 4 Reconstituted) Capsule)

Bold type = Brand name drug Plain type = Generic drug 50 tRACK 50 Last updated September 1, 2019 1249 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Dalv Metr anc oGe e l- Vagi Dalvance nal MetroGel-Vaginal 3 (Intravenous Solution 4 PA (Vaginal Gel)

C1 Metr oLot Reconstituted) MetroLotion (External C1 Dap tom ycin 4 Daptomycin (350MG Lotion)

C1 Metr onid azol Intravenous Solution 4 e Metronidazole (0.75% 1 Reconstituted) External Cream)

C1 C1 Dap tom Metr ycin onid azol Daptomycin (500MG e Metronidazole (0.75% 1 Intravenous Solution 4 External Gel)

C1 Metr onid azol Reconstituted) e C1 Metronidazole (1% Firv anq 3 Firvanq (Oral Solution External Gel)

C1 Metr 3 onid azol Reconstituted) e Metronidazole (0.75% C1 Flag yl 1 Flagyl (Oral Capsule) 3 External Lotion)

C1 C1 Metr Flag onid yl azol e in NaC l 0.79 Flagyl (Oral Tablet) 3 % Metronidazole in NaCl C1 Fura dant in Furadantin (Oral 0.79% (Intravenous 1 4 HRM Solution) Suspension) C1 Metr onid azol C1 e Hipr ex Metronidazole (375MG Hiprex (Oral Tablet) 3 3 C1 Line zoli d Oral Capsule)

C1 Metr onid Linezolid (Intravenous azol 3 e Solution) Metronidazole (250MG

C1 Line zoli d Oral Tablet, 500MG 1 Linezolid (Oral Oral Tablet)

C1 Metr onid Suspension 4 azol e Metronidazole (0.75% Reconstituted) 1 C1 Line zoli d Vaginal Gel)

C1 Mon Linezolid (Oral Tablet) 1 urol

C1 Mac robi d Monurol (Oral Packet) 3

C1 Mup iroci Macrobid (Oral n Calc 3 HRM ium Mupirocin Calcium Capsule) 3

C1 Mac roda ntin (External Cream)

C1 Mup iroci Macrodantin (Oral n 3 HRM Mupirocin (External Capsule) 1

C1 Maf enid Ointment) e Acet ate C1 Nitr ofur anto in Mac Mafenide Acetate rocr 3 ystal Nitrofurantoin (External Packet)

C1 Met hen Macrocrystal (100MG ami ne Hip pura te Methenamine 1 Oral Capsule, 50MG 1 HRM Hippurate (Oral Tablet)

C1 Oral Capsule) (Generic Metr oCr eam MetroCream Macrodantin) 3 (External Cream)

C1 Metr ogel Metrogel (External 3 Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 51 51 1350 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Nitr Van ofur com anto ycin in HCl Mac rocr ystal Nitrofurantoin Vancomycin HCl Macrocrystal (25MG (10GM Intravenous 3 HRM Oral Capsule) (Generic Solution Macrodantin) Reconstituted, 1GM

C1 Nitr ofur anto in Mon ohy drat e Intravenous Solution Nitrofurantoin 1 Monohydrate (Generic 1 HRM Reconstituted, 500MG Macrobid) Intravenous Solution

C1 Nitr ofur anto in Reconstituted, 750MG Nitrofurantoin (Oral 3 HRM Intravenous Solution Suspension)

C1 Nori tate Reconstituted)

C1 Van com ycin Noritate (External HCl 4 Vancomycin HCl Cream)

C1 Poly myxi (250MG Intravenous n B Sulf ate 1 Polymyxin B Sulfate Solution (Injection Solution 1 Reconstituted)

C1 Van Reconstituted) com ycin HCl C1 Sive xtro Vancomycin HCl (Oral Sivextro (Intravenous 3 QL Capsule)

C1 Van daz Solution 4 PA ole Vandazole (Vaginal Reconstituted) 1 C1 Sive xtro Gel)

C1 Zyv Sivextro (Oral Tablet) 4 PA ox

C1 Solo sec Zyvox (600MG/ Solosec (Oral Packet) 3

C1 Sulf amyl 300ML Intravenous 4 on Sulfamylon (External 3 Solution) C1 Zyv Cream) ox

C1 Sulf amyl Zyvox (Oral on Sulfamylon (External 4 Suspension 4 Packet) C1 Reconstituted) Tige cycli ne C1 Zyv ox Tigecycline Zyvox (Oral Tablet) 4

(Intravenous Solution 4 B1 Beta-lactam, Cephalosporins

C1 Reconstituted) Avy caz

C1 Tini daz ole Tinidazole (Oral Avycaz (Intravenous 1 Tablet) Solution 4 PA

C1 Trim etho prim Reconstituted)

C1 Cefa Trimethoprim (Oral clor 1 ER Tablet) Cefaclor ER (Oral C1 Tyg acil Tablet Extended 1 Tygacil (Intravenous Release 12 Hour)

C1 Cefa Solution 4 clor Cefaclor (Oral Reconstituted) 1 C1 Van coci n Capsule) HCl Vancocin HCl (Oral 4 QL Capsule)

Bold type = Brand name drug Plain type = Generic drug 52 tRACK 52 Last updated September 1, 2019 1451 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Cefa Cef clor oxiti n Sodi um Cefaclor (Oral Cefoxitin Sodium Suspension 3 (Intravenous Solution 1 Reconstituted) Reconstituted)

C1 C1 Cefa Cef drox pod il oxi me Prox Cefadroxil (Oral etil Cefpodoxime Proxetil 1 Capsule) (Oral Suspension 3

C1 Cefa drox il Reconstituted)

Cefadroxil (Oral C1 Cef pod oxi me Prox Suspension 1 etil Cefpodoxime Proxetil 1 Reconstituted) (Oral Tablet)

C1 C1 Cefa Cef drox proz il Cefadroxil (Oral il Cefprozil (Oral 1 Tablet) Suspension 1

C1 Cefa zolin

Sodi um Reconstituted)

Cefazolin Sodium C1 Cef proz il (10GM Injection Cefprozil (Oral Tablet) 1

C1 Ceft azidi Solution me Ceftazidime (Injection Reconstituted, 1GM 1 Solution 1 Injection Solution Reconstituted)

C1 Ceft riax one Sodi Reconstituted, 500MG um Ceftriaxone Sodium Injection Solution (1GM Injection Reconstituted)

C1 Cef dinir Solution Cefdinir (Oral Capsule) 1

C1 Reconstituted, 250MG Cef dinir Cefdinir (Oral Injection Solution 1 Suspension 1 Reconstituted, 2GM Reconstituted) Injection Solution

C1 Cef epi me HCl Reconstituted, 500MG Cefepime HCl (Injection Solution 1 Injection Solution Reconstituted)

Reconstituted) C1 Ceft C1 riax one Cefi Sodi xim um e Cefixime (Oral Ceftriaxone Sodium (10GM Intravenous Suspension 3 1 Reconstituted) Solution

C1 Cef otet an Diso diu Reconstituted) m

C1 Cef Cefotetan Disodium urox ime Axet il Cefuroxime Axetil (Oral (1GM Injection 1 Tablet) Solution C1 Cef urox ime Sodi 1 um Reconstituted, 2GM Cefuroxime Sodium Injection Solution (Injection Solution 1 Reconstituted) Reconstituted)

C1 C1 Cef Cef oxiti urox n ime Sodi Sodi um um Cefoxitin Sodium Cefuroxime Sodium (Injection Solution 1 (Intravenous Solution 1 Reconstituted) Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 53 53 1552 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Cep Aza hale cta xin Cephalexin (Oral m Azactam (Injection 1 Capsule) Solution 3 C1 Cep hale xin Cephalexin (Oral Reconstituted)

C1 Aztr eon Suspension 1 am Aztreonam (1GM Reconstituted) Injection Solution 3 C1 Cep hale xin Cephalexin (Oral Reconstituted)

C1 Erta pen 1 em Sodi Tablet) um Ertapenem Sodium C1 Maxi pim e Maxipime (1GM (Injection Solution 3

Injection Solution 3 Reconstituted) C1 Imip ene m- Cila stati Reconstituted) n Imipenem-Cilastatin

C1 Maxi pim e Maxipime (2GM (250MG Intravenous 1 Intravenous Solution 3 Solution Reconstituted)

C1 Reconstituted) Imip ene m- C1 Cila stati Sup n rax Suprax (Oral Capsule) 2 Imipenem-Cilastatin

C1 Sup rax (500MG Intravenous 3 Suprax (100MG/5ML Solution Oral Suspension Reconstituted)

C1 Inva Reconstituted, nz 3 Invanz (Injection 200MG/5ML Oral Suspension Solution 4 Reconstituted)

Reconstituted) C1 Mer C1 ope nem Sup rax Suprax (500MG/5ML Meropenem (1GM

Oral Suspension 3 Intravenous Solution 3 Reconstituted)

C1 Reconstituted) Mer ope nem C1 Sup rax Suprax (Oral Tablet Meropenem (500MG 2 Chewable) Intravenous Solution 1

C1 Tazi cef Reconstituted)

C1 Merr Tazicef (Injection em Merrem (500MG Solution 1 Reconstituted) Intravenous Solution 3

C1 Tefl aro Reconstituted)

C1 Prim Teflaro (Intravenous axin IV Primaxin IV Solution 4 Reconstituted) (Intravenous Solution 3

C1 Zer bax a Reconstituted)

C1 Vab Zerbaxa (Intravenous ome re Vabomere Solution 4 PA Reconstituted) (Intravenous Solution 4

B1 Reconstituted) Beta-lactam, Other

Bold type = Brand name drug Plain type = Generic drug 54 tRACK 54 Last updated September 1, 2019 1653 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 Am picill B1 in Sodi Beta-lactam, Penicillins um Ampicillin Sodium

C1 Am oxici llin Amoxicillin (Oral (10GM Intravenous 1 1 Capsule) Solution

C1 Am oxici llin Reconstituted)

C1 Am Amoxicillin (Oral picill in- Sulb acta m Sodi Suspension 1 um Ampicillin-Sulbactam Reconstituted) Sodium (Injection C1 1 Am oxici llin Solution Amoxicillin (Oral 1 Reconstituted)

C1 Aug Tablet) men tin C1 Am oxici llin Augmentin Amoxicillin (Oral 1 (125-31.25MG/5ML Tablet Chewable) 4 C1 Am oxici llin- Pota ssiu Oral Suspension m Clav ulan ate ER Amoxicillin-Potassium Reconstituted) C1 Clavulanate ER (Oral Bact ocill in Dext 1 rose Bactocill in Dextrose Tablet Extended 3 Release 12 Hour) (Intravenous Solution) C1 C1 Bicill Am in C- oxici R llin- 900/ Pota 300 ssiu m Clav ulan ate Bicillin C-R 900/300 Amoxicillin-Potassium Clavulanate (Oral (Intramuscular 3 1 Suspension Suspension)

C1 Bicill in C- Reconstituted) R C1 Bicillin C-R Am oxici llin- Pota ssiu m Clav ulan ate Amoxicillin-Potassium (Intramuscular 3 Clavulanate (Oral Suspension)

1 C1 Bicill in L- Tablet Immediate A Bicillin L-A Release)

C1 Am oxici llin- (Intramuscular 3 Pota ssiu m Clav ulan ate Amoxicillin-Potassium Suspension)

C1 Dicl oxa Clavulanate (Oral 1 cillin

Sodi um Dicloxacillin Sodium Tablet Chewable) 1 C1 Am picill in (Oral Capsule)

C1 Nafc illin Ampicillin (Oral Sodi 1 um Capsule) Nafcillin Sodium (1GM

C1 Am picill in Sodi Injection Solution um Ampicillin Sodium Reconstituted, 2GM 3 (125MG Injection Injection Solution Solution 1 Reconstituted)

C1 Nafc illin Reconstituted, 1GM Sodi um Injection Solution Nafcillin Sodium (10GM Intravenous Reconstituted) 3 Solution Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 55 55 1754 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Oxa Zos cillin yn

Sodi um Oxacillin Sodium Zosyn (2-0.25GM/ (Injection Solution 3 50ML Intravenous

Reconstituted) Solution, 3-0.375GM/ 3 C1 Peni cillin G Pota ssiu m in Dext rose Penicillin G 50ML Intravenous Potassium in Solution)

C1 Zos Dextrose yn Zosyn (40.5 (40000UNIT/ML 2 (36-4.5)GM 3 Intravenous Solution, Intravenous Solution 60000UNIT/ML Reconstituted) Intravenous Solution) B1 C1 Macrolides Peni cillin G C1 Pota ssiu Aza m Penicillin G Potassium site Azasite (Ophthalmic (20000000UNIT 3 3 Solution) C1 Azit hro Injection Solution myci n Reconstituted) Azithromycin

C1 Peni cillin G Proc (Intravenous Solution 1 aine Penicillin G Procaine Reconstituted)

C1 Azit hro (Intramuscular 3 myci n Azithromycin (Oral Suspension) 1 C1 Peni cillin G Sodi um Packet)

C1 Azit Penicillin G Sodium hro myci n (Injection Solution 4 Azithromycin (Oral Reconstituted) Suspension 1

C1 Peni cillin V Pota ssiu Reconstituted) m

C1 Azit Penicillin V Potassium hro myci n Azithromycin (Oral (Oral Solution 1 1 Tablet)

Reconstituted) C1 Clari C1 thro myci Peni n cillin ER V Pota ssiu m Penicillin V Potassium Clarithromycin ER 1 (Oral Tablet) (Oral Tablet Extended 1

C1 Pipe racill in- Taz oba Release 24 Hour) cta m C1 Clari Piperacillin- thro myci n Tazobactam Clarithromycin (Oral 1 (Intravenous Solution Suspension 3 Reconstituted)

Reconstituted) C1 Clari C1 thro myci Una n syn Unasyn (15 (10-5)GM Clarithromycin (Oral Injection Solution Tablet Immediate 1 Release)

C1 Reconstituted, 3 Dific id 3 Dificid (Oral Tablet) 4 (2-1)GM Injection C1 E.E. S. 400 E.E.S. 400 (Oral Solution 3 Reconstituted) Tablet)

Bold type = Brand name drug Plain type = Generic drug 56 tRACK 56 Last updated September 1, 2019 1855 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 E.E. Eryt S. hro Gra myci nule n s E.E.S. Granules (Oral Erythromycin 1 Suspension 3 (Ophthalmic Ointment) C1 Zithr oma Reconstituted) x Zithromax

C1 EryP ed 200 EryPed 200 (Oral (Intravenous Solution 3

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

C1 EryP ed 400 3 EryPed 400 (Oral Packet) C1 Zithr oma x Suspension 4 Zithromax (Oral

Reconstituted) Suspension 3

C1 Ery- Tab Ery-Tab (Oral Tablet Reconstituted) C1 Zithr oma 3 x Delayed Release) Zithromax (250MG C1 Eryt hroc in Lact obio nate Erythrocin Oral Tablet, 500MG 3 Lactobionate Oral Tablet)

C1 3 Zithr oma x Tri- (Intravenous Solution Pak Zithromax Tri-Pak Reconstituted) 3

C1 Eryt (Oral Tablet) hroc in Stea C1 rate Zithr oma x Z- Erythrocin Stearate Pak 3 Zithromax Z-Pak (Oral (Oral Tablet) 3

C1 Eryt hro Tablet) myci n Bas e Erythromycin Base B1 Quinolones

C1 Avel (Oral Capsule Delayed 3 ox Release Particles) Avelox (400MG Oral C1 3 Eryt hro myci n Bas e Tablet)

C1 Erythromycin Base Bax dela Baxdela (Intravenous (Oral Tablet Immediate 3 Release) Solution 4

C1 Eryt hro myci n Ethy lsuc cina te Reconstituted)

Erythromycin C1 Bax dela Ethylsuccinate Baxdela (Oral Tablet) 4

C1 Besi vanc (200MG/5ML Oral 3 e Besivance

Suspension (Ophthalmic 3 Reconstituted)

C1 Eryt Suspension) hro myci n C1 Ethy lsuc Cilo cina xan te Erythromycin Ciloxan (Ophthalmic Ethylsuccinate 3 Ointment)

C1 Cilo (400MG/5ML Oral 4 xan Ciloxan (Ophthalmic Suspension 3 Reconstituted) Solution) C1

C1 Cipr o Eryt hro myci n Ethy lsuc cina te Cipro (Oral Erythromycin Ethylsuccinate (Oral 3 Suspension 3 Tablet) Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 57 57 1956 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Cipr Lev o oflo xaci n Cipro (Oral Tablet) 3 Levofloxacin (250MG

C1 Cipr oflo xaci n HCl Ciprofloxacin HCl Oral Tablet, 500MG 1 1 (Ophthalmic Solution) Oral Tablet, 750MG

C1 Cipr oflo xaci n HCl Oral Tablet)

C1 Mox Ciprofloxacin HCl eza Moxeza (Ophthalmic (100MG Oral Tablet 3 3 Immediate Release) Solution) C1 C1 Mox iflox Cipr acin oflo HCl xaci in n NaC HCl Ciprofloxacin HCl l Moxifloxacin HCl in (250MG Oral Tablet NaCl (Intravenous 3 Immediate Release, Solution) C1 Mox iflox acin 500MG Oral Tablet 1 HCl Moxifloxacin HCl 1 Immediate Release, (Ophthalmic Solution)

C1 Mox iflox acin 750MG Oral Tablet HCl Moxifloxacin HCl (Oral Immediate Release) 1 C1 Tablet) Cipr oflo xaci C1 n in D5 Ocu W Ciprofloxacin in D5W flox Ocuflox (Ophthalmic 3 (200MG/100ML 1 Solution)

C1 Oflo xaci Intravenous Solution) n

C1 Cipr oflo xaci n Ofloxacin (Ophthalmic 1 Ciprofloxacin (Oral Solution)

C1 Oflo xaci Suspension 1 n Ofloxacin (Oral Tablet) 1 Reconstituted) C1 Oflo xaci C1 n Gatif loxa cin Ofloxacin (Otic Gatifloxacin 1 1 Solution) (Ophthalmic Solution) C1 Viga mox C1 Lev oflo xaci n in D5 W Vigamox (Ophthalmic Levofloxacin in D5W 3 Solution)

(500MG/100ML C1 Xepi Intravenous Solution, 1 Xepi (External Cream) 3

C1 Zym 750MG/150ML axid Zymaxid (Ophthalmic Intravenous Solution) 3 C1 Solution) Lev oflo xaci n Levofloxacin (25MG/ B1 Sulfonamides C1 Bact rim ML Intravenous 3 DS Bactrim DS (Oral Solution) 3 C1 Lev oflo xaci Tablet) n

C1 Bact Levofloxacin (0.5% rim 1 Bactrim (Oral Tablet) 3

C1 Ophthalmic Solution) Blep h-10 C1 Lev oflo xaci n Bleph-10 (Ophthalmic Levofloxacin (25MG/ 3 1 Solution)

C1 ML Oral Solution) Silva den e Silvadene (External 3 Cream)

Bold type = Brand name drug Plain type = Generic drug 58 tRACK 58 Last updated September 1, 2019 2057 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Silv Dox er ycyc Sulf line adia Hycl zine Silver Sulfadiazine ate Doxycycline Hyclate 1 (External Cream) (100MG Oral Tablet

C1 SSD SSD (External Cream) 1 Immediate Release, 1

C1 Sulf acet ami de Sodi 20MG Oral Tablet um Sulfacetamide Sodium 1 Immediate Release)

C1 Dox (Ophthalmic Ointment) ycyc line Hycl C1 ate Sulf acet ami de Sodi Doxycycline Hyclate um Sulfacetamide Sodium 1 (150MG Oral Tablet (Ophthalmic Solution)

C1 Sulf adia zine Immediate Release, 3 Sulfadiazine (Oral 3 75MG Oral Tablet Tablet) C1 Immediate Release) Sulf ame thox C1 azol e- Dox Trim ycyc etho line prim Hycl Sulfamethoxazole- ate Doxycycline Hyclate Trimethoprim (Oral 1 (100MG Oral Tablet Suspension) C1 Delayed Release, Sulf ame thox azol e- Trim etho prim Sulfamethoxazole- 150MG Oral Tablet Trimethoprim (Oral 1 Delayed Release, Tablet) 200MG Oral Tablet 3 B1 Tetracyclines Delayed Release,

C1 De mec locy cline HCl Demeclocycline HCl 50MG Oral Tablet 3 (Oral Tablet) Delayed Release,

C1 Dor yx MP 75MG Oral Tablet C Doryx MPC (Oral Delayed Release) C1 Dox ycyc line Mon Tablet Delayed 3 ohy drat e Doxycycline Release)

C1 Dor Monohydrate (100MG yx Doryx (200MG Oral Oral Capsule, 150MG 1 Tablet Delayed 4 Oral Capsule, 50MG Release) Oral Capsule)

C1 C1 Dor Dox yx ycyc line Mon ohy drat Doryx (50MG Oral e Doxycycline

Tablet Delayed 3 Monohydrate (75MG 3 Release) Oral Capsule) C1

C1 Dox ycyc Dox line y Mon 100 ohy drat Doxy 100 (Intravenous e Doxycycline Monohydrate (Oral Solution 3 1 Reconstituted) Suspension

C1 Dox ycyc line Hycl ate Reconstituted) C1 Doxycycline Hyclate Dox ycyc line Mon ohy drat 1 e (Oral Capsule) Doxycycline Monohydrate (Oral 1 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 59 59 2158 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Min Vibr ocin amy Minocin (50MG Oral cin Vibramycin (50MG/ 3 3 Capsule) 5ML Oral Syrup)

C1 C1 Min Ximi ocy no cline HCl ER Minocycline HCl ER Ximino (Oral Capsule (Oral Tablet Extended 3 QL Extended Release 24 4 QL Release 24 Hour) Hour) C1 Min ocy cline HCl Minocycline HCl (Oral A1 1 Anticonvulsants Capsule) B1

C1 Min Anticonvulsants, Other ocy cline HCl C1 BRI VIA Minocycline HCl (Oral CT BRIVIACT (Oral Tablet Immediate 1 4 PA; QL Solution)

C1 BRI Release) VIA CT

C1 Mon dox yne NL BRIVIACT (Oral Mondoxyne NL 4 PA; QL Tablet)

C1 (100MG Oral Capsule, 1 Epid iolex 75MG Oral Capsule) Epidiolex (Oral

C1 Mor 4 PA gido x Solution) Morgidox (50MG Oral C1 Kep 1 pra Capsule) Keppra (Oral

C1 Nuz yra 4 Nuzyra (Intravenous Solution) C1 Kep Solution 4 PA pra Keppra (1000MG Oral Reconstituted) Tablet Immediate

C1 Nuz yra Nuzyra (Oral Tablet) 4 PA; QL Release, 500MG Oral

C1 Ora cea Oracea (Oral Capsule Tablet Immediate 4 3 Delayed Release) Release, 750MG Oral

C1 Solo dyn Tablet Immediate Solodyn (Oral Tablet Release)

C1 Kep Extended Release 24 4 QL pra Keppra (250MG Oral Hour) C1 Solo xide Tablet Immediate 3 Soloxide (Oral Tablet 3 Release)

C1 Delayed Release) Kep pra XR C1 TAR GA DOX TARGADOX (Oral Keppra XR (Oral 3 Tablet) Tablet Extended 4

C1 Tetr acyc line HCl Release 24 Hour) C1 Lev Tetracycline HCl (Oral etira ceta m 3 ER Capsule) Levetiracetam ER (Oral C1 Vibr amy cin Vibramycin (Oral Tablet Extended 1 3 Release 24 Hour)

C1 Lev etira Capsule) ceta m

C1 Vibr amy cin Levetiracetam (Oral Vibramycin (Oral 1 Solution) Suspension 3 Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 60 tRACK 60 Last updated September 1, 2019 2259 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Lev Clo etira baz ceta am m Levetiracetam (Oral Clobazam (2.5MG/ML 4 PA; QL Tablet Immediate 1 Oral Suspension)

C1 Clo baz Release) am

C1 Clobazam (10MG Oral Row eepr a 3 PA; QL Roweepra (Oral Tablet Tablet)

C1 Clo 1 baz Immediate Release) am

C1 Clobazam (20MG Oral Row eepr a XR 4 PA; QL Roweepra XR (Oral Tablet)

C1 Dep ake Tablet Extended 1 ne Depakene (Oral Release 24 Hour) 3 C1 Capsule) Sprit am C1 Dias tat Acu Spritam (1000MG Dial Diastat AcuDial 3 Oral Tablet (Rectal Gel)

C1 Dias tat Pedi Disintegrating atric Diastat Pediatric Soluble, 250MG Oral 3 (Rectal Gel)

C1 Gab ape Tablet Disintegrating ntin 3 Gabapentin (Oral Soluble, 500MG Oral 1 Capsule)

C1 Gab ape Tablet Disintegrating ntin Gabapentin (250MG/ Soluble, 750MG Oral 1 5ML Oral Solution)

C1 Gab Tablet Disintegrating ape ntin Gabapentin (Oral Soluble) 1

B1 Tablet)

C1 Gabi Calcium Channel Modifying Agents tril

C1 Celo ntin Gabitril (Oral Tablet) 4

C1 Mys olin Celontin (Oral e 3 Mysoline (Oral Tablet) 4

C1 Neu Capsule) ronti n

C1 Etho suxi mid e Neurontin (100MG Ethosuximide (Oral 3 1 Oral Capsule)

C1 Capsule) Neu ronti n C1 Etho suxi mid e Ethosuximide (Oral Neurontin (300MG 1 Solution) Oral Capsule, 400MG 4

C1 Zaro ntin Oral Capsule)

C1 Zarontin (Oral Neu ronti 3 n Capsule) Neurontin (Oral

C1 3 Zaro ntin Solution) C1 Zarontin (Oral Neu ronti 3 n Solution) Neurontin (Oral C1 4 Zon egra n Tablet) Zonegran (Oral C1 4 Onfi Capsule) Onfi (Oral C1 4 PA; QL Zoni sami de Suspension) Zonisamide (Oral C1 1 Onfi Capsule) Onfi (Oral Tablet) 4 PA; QL C1 Phe nob arbit B1 al Phenobarbital (Oral Gamma-aminobutyric Acid (GABA) 1 PA; HRM Augmenting Agents Elixir)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 61 61 2360 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Phe Lam nob ictal arbit al Phenobarbital (Oral Lamictal (100MG Oral 1 PA; HRM Tablet) Tablet Immediate C1 Prim idon e Primidone (Oral Release, 150MG Oral 1 Tablet) Tablet Immediate

C1 Sabr il Sabril (Oral Packet) 4 PA; LA; QL Release, 200MG Oral 4

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

C1 Sym paz an Sympazan (Oral Film) 4 PA; QL Release, 25MG Oral

C1 Tiag abin e HCl Tablet Immediate Tiagabine HCl (Oral 3 Release)

C1 Tablet) Lam ictal

C1 Valp roic Acid Lamictal (25MG Oral Valproic Acid (Oral 4 1 Tablet Chewable) Capsule) C1 Lam ictal C1 Valp roic Acid Lamictal (5MG Oral Valproic Acid (Oral 3 1 Tablet Chewable)

Solution) C1 Lam C1 ictal Start Viga er batri n Vigabatrin (Oral Lamictal Starter (35 4 PA; LA; QL Packet) Tablets Oral Kit, 49 3

C1 Viga batri n Tablets Oral Kit) Vigabatrin (Oral C1 Lam ictal Start 4 PA; LA; QL er Tablet) Lamictal Starter (98

C1 Viga dron 4 e Tablets Oral Kit)

Vigadrone (Oral C1 Lam ictal 4 PA; LA; QL XR Packet) Lamictal XR (Oral Kit) 3

C1 Lam ictal B1 Glutamate Reducing Agents XR Lamictal XR (100MG

C1 Felb ama te Felbamate (Oral Oral Tablet Extended 4 Suspension) Release 24 Hour,

C1 Felb ama te Felbamate (Oral 200MG Oral Tablet 3 Tablet) Extended Release 24

C1 Felb atol Felbatol (Oral Hour, 250MG Oral 4 Suspension) Tablet Extended

C1 Felb atol Release 24 Hour, Felbatol (Oral Tablet) 4 4 C1 Fyc omp a 25MG Oral Tablet Fycompa (Oral 4 Extended Release 24 Suspension)

C1 Fyc omp a Hour, 300MG Oral Fycompa (Oral 4 Tablet Extended Tablet)

C1 Lam Release 24 Hour, ictal ODT Lamictal ODT (Oral 4 50MG Oral Tablet Tablet Dispersible) Extended Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 62 tRACK 62 Last updated September 1, 2019 2461 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Lam Top otrig ama ine x ER Lamotrigine ER (Oral Topamax (100MG Tablet Extended 3 Oral Tablet, 200MG 4 Release 24 Hour) Oral Tablet, 50MG C1 Lam otrig ine Lamotrigine (100MG Oral Tablet)

C1 Top ama Oral Tablet Immediate x Topamax (25MG Oral 3 Release, 150MG Oral Tablet)

C1 Top ama x Tablet Immediate Spri nkle Topamax Sprinkle Release, 200MG Oral 1 Tablet Immediate (15MG Oral Capsule 3 Sprinkle)

Release, 25MG Oral C1 Top ama x Spri Tablet Immediate nkle Topamax Sprinkle

Release) (25MG Oral Capsule 4 C1 Lam otrig ine Lamotrigine (25MG Sprinkle)

C1 Topi ram ate Oral Tablet Chewable, ER 1 Topiramate ER (Oral 5MG Oral Tablet Capsule ER 24 Hour 3 PA Chewable) Sprinkle) C1 Lam C1 otrig ine Topi ODT ram Lamotrigine ODT (Oral ate 3 Topiramate (Oral Tablet Dispersible) Capsule Sprinkle 1 C1 Lam otrig ine Start er Kit- Blue Lamotrigine Starter Kit- Immediate Release)

C1 Topi ram 3 ate Blue (Oral Kit) Topiramate (Oral C1 Lam otrig ine Start 1 er Kit- Gre en Lamotrigine Starter Kit- Tablet)

C1 Trok endi 4 XR Green (Oral Kit) Trokendi XR (100MG C1 Lam otrig ine Start er Kit- Ora nge Lamotrigine Starter Kit- Oral Capsule 3 Orange (Oral Kit) Extended Release 24 C1 Qud exy XR 4 PA Qudexy XR (100MG Hour, 200MG Oral Oral Capsule ER 24 Capsule Extended Hour Sprinkle, 25MG Release 24 Hour)

C1 Trok endi Oral Capsule ER 24 3 PA XR Trokendi XR (25MG Hour Sprinkle, 50MG Oral Capsule Oral Capsule ER 24 Extended Release 24 3 PA Hour Sprinkle) Hour, 50MG Oral C1 Qud exy XR Qudexy XR (150MG Capsule Extended Oral Capsule ER 24 Release 24 Hour) Hour Sprinkle, 4 PA B1 Sodium Channel Agents

C1 Apti 200MG Oral Capsule om Aptiom (Oral Tablet) 4 QL ER 24 Hour Sprinkle)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 63 63 2562 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Ban Dila zel Banzel (Oral ntin Dilantin (Oral 4 3 Suspension) Suspension)

C1 C1 Ban Epit zel ol Banzel (Oral Tablet) 4 Epitol (Oral Tablet) 1

C1 C1 Car Oxc bam arba aze zepi pine ne ER Carbamazepine ER Oxcarbazepine (100MG Oral Capsule (300MG/5ML Oral 3 Extended Release 12 Suspension)

C1 Oxc arba zepi Hour, 200MG Oral ne Oxcarbazepine Capsule Extended 1 (150MG Oral Tablet, 1 Release 12 Hour, 300MG Oral Tablet, 300MG Oral Capsule 600MG Oral Tablet)

C1 Oxt ellar Extended Release 12 XR Oxtellar XR (150MG Hour)

C1 Car bam aze Oral Tablet Extended pine ER Carbamazepine ER Release 24 Hour, (100MG Oral Tablet 3 PA 300MG Oral Tablet Extended Release 12 1 Hour, 200MG Oral Extended Release 24 Hour) Tablet Extended C1 Oxt ellar Release 12 Hour) XR Oxtellar XR (600MG

C1 Car bam aze pine ER Carbamazepine ER Oral Tablet Extended 4 PA (400MG Oral Tablet Release 24 Hour) C1 Peg ano 3 ne Extended Release 12 Peganone (Oral 3 Hour) Tablet) C1 Car C1 bam aze Phe pine nyte Carbamazepine (Oral k Phenytek (Oral 1 1 Suspension) Capsule) C1 Car C1 bam aze Phe pine nyto Carbamazepine (Oral in Phenytoin (Oral 1 Tablet Immediate 1 Suspension)

C1 Phe nyto Release) in C1 Car Phenytoin (Oral Tablet bam aze pine 1 Carbamazepine (Oral Chewable) 1 C1 Phe nyto in Sodi um Tablet Chewable) Exte nde d C1 Car Phenytoin Sodium batr ol Carbatrol (Oral Extended (Oral 1 Capsule Extended 3 Capsule)

C1 Tegr Release 12 Hour) etol C1 Tegretol (Oral Dila ntin INF ATA BS 3 Dilantin INFATABS Suspension)

C1 2 Tegr (Oral Tablet Chewable) etol C1 Tegretol (Oral Tablet Dila ntin 3 Dilantin (Oral Capsule) 2 Immediate Release)

Bold type = Brand name drug Plain type = Generic drug 64 tRACK 64 Last updated September 1, 2019 2663 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Tegr Raz etol ady XR ne Tegretol XR (Oral ER Razadyne ER (Oral

Tablet Extended 3 Capsule Extended 3 Release 12 Hour) Release 24 Hour)

C1 C1 Trile Raz ptal ady Trileptal (Oral ne Razadyne (Oral 4 3 Suspension) Tablet)

C1 C1 Trile Riva ptal stig min e Tartr Trileptal (150MG Oral ate Rivastigmine Tartrate 3 1 Tablet) (Oral Capsule) C1 C1 Riva Trile stig ptal min Trileptal (300MG Oral e Rivastigmine

Tablet, 600MG Oral 4 (Transdermal Patch 24 3 ST; QL Tablet) Hour)

C1 B1 Vim pat Vimpat (Oral Solution) 3 QL N-methyl-D-aspartate (NMDA) Receptor

C1 Vim pat Antagonist

C1 Vimpat (Oral Tablet) 3 QL Me man tine HCl ER A1 Antidementia Agents Memantine HCl ER

B1 (Oral Capsule Cholinesterase Inhibitors 3 PA; QL C1 Extended Release 24 Aric ept Aricept (Oral Tablet) 3 QL Hour) C1 Don C1 epe Me zil man HCl tine Donepezil HCl (Oral HCl Memantine HCl (Oral 1 QL 3 PA; QL Tablet) Solution) C1 Don C1 epe Me zil man HCl tine ODT Donepezil HCl ODT HCl Memantine HCl (10MG (Oral Tablet 1 QL Oral Tablet, 5MG Oral 1 PA; QL Dispersible) Tablet) C1 Exel C1 on Me man tine HCl Titra tion Exelon (Transdermal Pak 3 ST; QL Memantine HCl Patch 24 Hour) Titration Pak (Oral 1 PA C1 Gala nta min e Hyd robr omi de ER Galantamine Tablet)

C1 Na men Hydrobromide ER da Namenda (Oral 3 PA; QL (Oral Capsule 1 Tablet)

C1 Na men da Titra Extended Release 24 tion Pak Namenda Titration Hour) 3 PA C1 Gala nta min e Pak (Oral Tablet) Hyd robr omi C1 de Na men Galantamine da XR Hydrobromide (Oral 3 Namenda XR (Oral Solution) Capsule Extended 3 PA; QL

C1 Gala nta min e Hyd robr Release 24 Hour) omi de C1 Galantamine Na men da XR Titra tion Pac Hydrobromide (Oral 1 k Namenda XR Titration Pack (Oral Tablet) 3 PA; QL Capsule Extended Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 65 65 2764 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 Sym byax A1 Antidepressants Symbyax (Oral

B1 3 Antidepressants, Other Capsule) C1 C1 Well butri Aple n nzin Aplenzin (Oral Tablet SR Wellbutrin SR (Oral

Extended Release 24 4 Tablet Extended 3 Hour) Release 12 Hour) C1 C1 Well butri Bup n XL ropi on HCl SR Wellbutrin XL (Oral Bupropion HCl SR (Oral Tablet Extended 1 Tablet Extended 4 Release 12 Hour) Release 24 Hour)

C1 Bup ropi on B1 HCl XL Bupropion HCl XL Monoamine Oxidase Inhibitors

C1 Ems (150MG Oral Tablet am Emsam (Transdermal Extended Release 24 4 1 Patch 24 Hour) C1 Mar Hour, 300MG Oral plan Marplan (Oral Tablet) 3

C1 Tablet Extended Nar dil Release 24 Hour) Nardil (Oral Tablet) 3 C1

C1 Parn ate Bup ropi on HCl ER Bupropion HCl ER (XL) Parnate (Oral Tablet) 4 C1 Phe nelzi ne Sulf (450MG Oral Tablet ate Phenelzine Sulfate 3 1 Extended Release 24 (Oral Tablet)

C1 Tran ylcy pro min e Sulf Hour) ate C1 Tranylcypromine Bup ropi on HCl 3 Bupropion HCl (Oral Sulfate (Oral Tablet) Tablet Immediate 1 B1 SSRI/SNRI (Selective Serotonin Reuptake Release)

C1 Forfi Inhibitors/Serotonin and Norepinephrine vo XL Forfivo XL (Oral Reuptake Inhibitors)

C1 Cele xa Tablet Extended 3 Celexa (Oral Tablet) 3

C1 Cital opra m Release 24 Hour) Hyd robr omi de C1 Mirt aza Citalopram pine Mirtazapine (Oral 1 Hydrobromide (Oral 1 Tablet) C1 Solution) Mirt aza pine C1

Cital ODT opra m Hyd robr omi Mirtazapine ODT (Oral de 1 Citalopram Tablet Dispersible) C1 Hydrobromide (Oral 1 Olan zapi ne- Fluo xeti ne HCl Olanzapine-Fluoxetine Tablet)

C1 3 Des venl afaxi ne HCl (Oral Capsule) ER C1 Desvenlafaxine ER Re mer on Remeron (Oral (Oral Tablet Extended 3 Tablet) Release 24 Hour) 3

C1 Re mer on SolT ab Remeron SolTab (Brand Equivalent

(Oral Tablet 3 Khedezla) Dispersible)

Bold type = Brand name drug Plain type = Generic drug 66 tRACK 66 Last updated September 1, 2019 2865 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Des Fluv venl oxa afaxi min ne e Suc Mal cina eate te ER ER Desvenlafaxine Fluvoxamine Maleate Succinate ER (Oral ER (Oral Capsule 3 Tablet Extended 1 Extended Release 24 Release 24 Hour) Hour)

C1 Fluv oxa min e Mal (Generic Pristiq) eate C1 Fluvoxamine Maleate Effe xor XR 1 Effexor XR (Oral (Oral Tablet)

C1 Khe dezl Capsule Extended 3 a Khedezla (Oral Tablet

Release 24 Hour) Extended Release 24 3 C1 Esci talo pra m Oxal ate Escitalopram Oxalate Hour)

C1 Lex 1 apro (Oral Solution)

C1 Lexapro (Oral Tablet) 3 Esci talo C1 pra m Map Oxal rotili ate ne Escitalopram Oxalate HCl 1 Maprotiline HCl (Oral (Oral Tablet) 1

C1 Tablet) Fetz ima C1 Nef azo don e Fetzima (Oral HCl Nefazodone HCl (Oral 1 Capsule Extended 3 ST Tablet)

C1 Paro xeti ne Release 24 Hour) HCl C1 Paroxetine HCl (Oral Fetz ima Titra tion Fetzima Titration Tablet Immediate 1 PA; HRM (Oral Capsule ER 24 3 ST Release)

C1 Hour Therapy Pack) Paxil Paxil (Oral C1 Fluo xeti ne HCl 3 PA; HRM Fluoxetine HCl (10MG Suspension)

C1 Oral Capsule Paxil Paxil (Oral Tablet 3 PA; HRM Immediate Release, Immediate Release) C1 Prist 20MG Oral Capsule 1 iq Pristiq (Oral Tablet Immediate Release, 40MG Oral Capsule Extended Release 24 3 Hour) Immediate Release) C1 Proz ac C1 Fluo xeti ne HCl Prozac (10MG Oral Fluoxetine HCl (90MG 3 Capsule)

Oral Capsule Delayed 1 C1 Proz Release) ac Prozac (20MG Oral

C1 Fluo xeti ne HCl Fluoxetine HCl (20MG/ Capsule, 40MG Oral 4 1 5ML Oral Solution) Capsule)

C1 C1 Fluo Sara xeti fem ne HCl Fluoxetine HCl (10MG Sarafem (Oral Tablet) 3

C1 Sert ralin e Oral Tablet, 20MG Oral 1 HCl Sertraline HCl (Oral 1 Tablet) Concentrate) C1 Fluo xeti C1 ne Sert HCl ralin e Fluoxetine HCl (60MG HCl Sertraline HCl (Oral 3 1 Oral Tablet) Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 67 67 2966 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Traz Dox odo epin ne HCl HCl Trazodone HCl (Oral Doxepin HCl (Oral 1 1 PA; HRM Tablet) Capsule)

C1 C1 Trint Dox ellix epin HCl Trintellix (Oral Tablet) 3 Doxepin HCl (Oral

C1 Venl afaxi 1 PA; HRM ne HCl ER Concentrate)

Venlafaxine HCl ER C1 Imip rami ne (Oral Capsule HCl Imipramine HCl (Oral 1 1 PA; HRM Extended Release 24 Tablet)

C1 Imip rami ne Pam Hour) oate

C1 Imipramine Pamoate Venl afaxi ne HCl ER 3 PA; HRM Venlafaxine HCl ER (Oral Capsule)

C1 Nor pra (Oral Tablet Extended 3 min Norpramin (Oral Release 24 Hour) 3 PA; HRM C1 Tablet) Venl afaxi ne C1 HCl Nort ripty line Venlafaxine HCl (Oral HCl Nortriptyline HCl (Oral 1 PA; HRM Tablet Immediate 1 Capsule)

C1 Nort ripty line Release) HCl

C1 Viibr yd Nortriptyline HCl (Oral Viibryd (Oral Tablet) 3 1 PA; HRM C1 Solution) Viibr yd Start C1 er Pac Pam k Viibryd Starter Pack elor 3 Pamelor (Oral (Oral Kit) 4 PA; HRM C1 Capsule) Zolo ft C1 Prot ripty line Zoloft (Oral Tablet) 3 HCl Protriptyline HCl (Oral B1 1 PA; HRM Tricyclics Tablet) C1 C1 Amit ripty Sur line mon HCl Amitriptyline HCl (Oral til 1 HRM Surmontil (100MG Tablet) Oral Capsule, 25MG C1 Am oxa pine 3 PA; HRM Amoxapine (Oral Oral Capsule, 50MG 1 PA; HRM Tablet) Oral Capsule) C1 Anaf C1 ranil Tofr Anafranil (Oral anil Tofranil (Oral Tablet) 4 PA; HRM

C1 4 PA; HRM Trim ipra min e Mal Capsule) eate

C1 Trimipramine Maleate Clo mipr ami ne HCl 3 PA; HRM Clomipramine HCl (Oral Capsule) 3 PA; HRM (Oral Capsule) A1 C1 Antiemetics Desi pra min e HCl Desipramine HCl B1 Antiemetics, Other

C1 Co mpr (100MG Oral Tablet, 3 PA; HRM o Compro (Rectal 150MG Oral Tablet) 1

C1 Desi pra Suppository) min e HCl C1 Hyd roxy zine Pam Desipramine HCl oate Hydroxyzine Pamoate (10MG Oral Tablet, 1 PA; HRM (Oral Capsule)

C1 Mec 25MG Oral Tablet, 1 PA; HRM lizin e HCl Meclizine HCl (12.5MG 50MG Oral Tablet, 1 HRM 75MG Oral Tablet) Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 68 tRACK 68 Last updated September 1, 2019 3067 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Met Eme oclo nd pra mid e HCl Metoclopramide HCl Emend (Oral (5MG/5ML Oral 1 Suspension 3 PA Solution) Reconstituted) C1

Met C1 oclo pra Eme mid nd e Tri- HCl Pac Metoclopramide HCl k 1 Emend Tri-Pack (Oral (Oral Tablet) 4 PA

C1 Capsule) Met oclo C1 pra mid Gra e nise HCl tron ODT Metoclopramide HCl HCl Granisetron HCl (Oral 1 B/D, PA ODT (Oral Tablet 3 Tablet)

C1 Mari Dispersible) nol

C1 Per phe Marinol (10MG Oral nazi ne Perphenazine (Oral 1 Capsule, 5MG Oral 4 PA Tablet)

C1 Proc Capsule) hlor pera zine Mal C1 eate Mari Prochlorperazine nol 1 Marinol (2.5MG Oral Maleate (Oral Tablet) 3 PA

C1 Proc hlor pera Capsule) zine C1 Ond ans etro Prochlorperazine n 1 HCl Ondansetron HCl (Oral (Rectal Suppository) 1 B/D, PA

C1 Regl an Solution) C1 Ond ans etro Reglan (Oral Tablet) 3 n HCl

C1 Sco pola min Ondansetron HCl (Oral e 1 B/D, PA Scopolamine Tablet)

C1 Ond ans etro (Transdermal Patch 72 1 PA; HRM n ODT Ondansetron ODT Hour)

C1 Tiga n (Oral Tablet 1 B/D, PA Tigan (Oral Capsule) 3 B/D, PA C1 Dispersible) Tran sder m- C1 Sco p San cus Transderm-Scop o Sancuso 4 (1.5MG) (Transdermal Patch)

3 PA; HRM C1 Syn (Transdermal Patch dros Syndros (Oral 72 Hour) 4 PA

C1 Trim Solution) etho ben zami de C1 HCl Varu Trimethobenzamide bi 1 B/D, PA Varubi (Oral Tablet) 3 B/D, PA

C1 Zofr HCl (Oral Capsule) an

C1 Vist aril Zofran (8MG Oral Vistaril (Oral Capsule) 3 PA; HRM 4 B/D, PA

B1 Tablet)

C1 Zupl Emetogenic Therapy Adjuncts enz

C1 Apr epit ant Zuplenz (Oral Film) 4 B/D, PA

Aprepitant (Oral A1 Antifungals Therapy Pack, Oral 3 PA B1 Antifungals

Capsule) C1 Abel C1 cet Ces ame t Cesamet (Oral Abelcet (Intravenous 4 PA 3 B/D, PA Capsule) Suspension)

C1 Dro nabi nol Dronabinol (Oral 3 PA Capsule)

C1 Eme nd Emend (Oral Capsule) 3 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 69 69 3168 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Am Clot Biso rima me AmBisome zole Clotrimazole (External 1 (Intravenous Solution) C1 Clot rima 4 B/D, PA zole Suspension Clotrimazole (Mouth/ 1 Reconstituted) Throat Lozenge)

C1 C1 Cres Am emb phot a erici n B Amphotericin B Cresemba (Oral 4 PA (Intravenous Solution 3 B/D, PA Capsule)

C1 Diflu Reconstituted) can C1 Diflucan (Oral Anc obo n Ancobon (Oral 4 Suspension 3 Capsule) Reconstituted) C1 AVC C1 Vagi nal Diflu AVC Vaginal (Vaginal can 3 Diflucan (100MG Oral Cream) Tablet, 150MG Oral C1 Can cida s 3 Cancidas Tablet, 50MG Oral

(Intravenous Solution 4 Tablet)

C1 Diflu Reconstituted) can Diflucan (200MG Oral C1 Cas pofu ngin 4 Acet ate Caspofungin Acetate Tablet)

C1 Eco naz ole Nitr (50MG Intravenous ate Econazole Nitrate 4 1 QL Solution (External Cream)

C1 Erax Reconstituted) is

C1 Cas pofu Eraxis (100MG ngin

Acet ate Caspofungin Acetate Intravenous Solution 4 (70MG Intravenous 3 Reconstituted) C1 Erax Solution is Eraxis (50MG Reconstituted) C1 Cicl opir ox Intravenous Solution 3 Ciclopirox (External 1 Reconstituted)

C1 Gel) Erta czo

C1 Cicl opir ox Ertaczo (External Ciclopirox (External 4 1 Cream) Shampoo) C1 Exel der C1 m Cicl opir ox Exelderm (External Ciclopirox (External 3 1 Cream)

Solution) C1 Exel C1 der m Cicl opir ox Ola min e Ciclopirox Olamine Exelderm (External 1 3 (External Cream) Solution) C1 C1 Exti na Cicl opir ox Ola min e Ciclopirox Olamine Extina (External 1 4 QL (External Suspension) Foam)

C1 C1 Fluc Clot ona rima zole zole in Sodi um Chlo Clotrimazole (External ride Fluconazole in Sodium 1 Cream) Chloride (Intravenous 1 Solution)

Bold type = Brand name drug Plain type = Generic drug 70 tRACK 70 Last updated September 1, 2019 3269 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Fluc Lopr ona ox zole Fluconazole (Oral Loprox (External 4 Suspension 1 Shampoo)

C1 Lulic ona Reconstituted) zole C1 Luliconazole Fluc ona zole 3 QL Fluconazole (Oral (External Cream) 1 C1 Luz Tablet) u

C1 Fluc Luzu (External ytosi ne 3 QL Flucytosine (Oral Cream)

4 C1 Men Capsule) tax

C1 Gris eofu Mentax (External lvin Micr osiz e Griseofulvin Microsize 3 1 Cream) C1 Mic ona zole (Oral Suspension) 3

C1 Gris eofu lvin Miconazole 3 (Vaginal Micr osiz e Griseofulvin Microsize 1 3 Suppository) C1 Myc ami (Oral Tablet) ne

C1 Gris eofu lvin Mycamine Ultra micr osiz e Griseofulvin (Intravenous Solution 4 Ultramicrosize (Oral 3 Reconstituted)

C1 Nafti Tablet) fine HCl C1 Gyn azol e-1 Naftifine HCl (External Gynazole-1 (Vaginal 3 3 Cream)

C1 Nafti Cream) n

C1 Itrac ona zole Naftin (External Itraconazole (Oral 3 3 PA Cream)

C1 Capsule) Nafti n C1 Itrac ona zole Naftin (External Gel) 3

C1 Itraconazole (Oral Nata 4 PA cyn Solution) Natacyn (Ophthalmic

C1 Jubli 3 a Suspension)

Jublia (External C1 Nizo 3 ral Solution) Nizoral (External

C1 Kery 3 din Shampoo)

Kerydin (External C1 Nox 4 ST afil Solution) Noxafil (Oral

C1 Ket 4 QL oco naz ole Suspension)

Ketoconazole (External C1 Nox 1 QL afil Cream) Noxafil (Oral Tablet

C1 Ket oco 4 PA; QL naz ole Ketoconazole (External Delayed Release) C1 Nya 3 QL myc Foam) Nyamyc (External

C1 Ket oco naz 1 ole Ketoconazole (External Powder) C1 Nyst 1 atin Shampoo) Nystatin (External

C1 Ket oco naz 1 ole Ketoconazole (Oral Cream) C1 Nyst 1 atin Tablet) Nystatin (External

C1 Lopr ox 1 Loprox (External Ointment) C1 Nyst 3 atin Cream) Nystatin (External 1 Powder)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 71 71 3370 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Nyst Vfen atin Nystatin (Mouth/ d Vfend (Oral 1 Throat Suspension) Suspension 4 C1 Nyst atin Nystatin (Oral Tablet) 1 Reconstituted)

C1 C1 Vfen Nyst d atin- Tria mci nolo ne Nystatin-Triamcinolone Vfend (Oral Tablet) 4

C1 Vori con 1 azol (External Cream) e Voriconazole C1 Nyst atin- Tria mci nolo ne Nystatin-Triamcinolone (Intravenous Solution 4 1 (External Ointment) Reconstituted)

C1 C1 Vori Nyst con op azol Nystop (External e Voriconazole (Oral 1 Powder) Suspension 4

C1 Ora vig Reconstituted) Oravig (Buccal C1 Vori con azol 4 e Tablet) Voriconazole (Oral C1 3 Oxic ona zole

Nitr ate Oxiconazole Nitrate Tablet) 3 QL A1 (External Cream) Antigout Agents

C1

Oxis B1 tat Oxistat (External Antigout Agents C1 Allo puri 4 QL nol Cream) Allopurinol (Oral

C1 Oxis tat 1 Tablet)

Oxistat (External C1 Colc hicin 4 QL e Lotion) Colchicine (0.6MG

C1 Spo rano x Sporanox (Oral Oral Capsule) (Brand 2 QL 4 PA Equivalent Mitigare)

Capsule) C1 Colc C1 hicin e Spo rano x Sporanox (Oral Colchicine (0.6MG 4 PA Solution) Oral Tablet) (Brand 2 QL

C1 Terb inafi ne HCl Equivalent Colcrys)

C1 Colc Terbinafine HCl (Oral rys 1 Colcrys (Oral Tablet) 3 PA; QL Tablet) C1 Miti gare C1 Terc ona zole Mitigare (Oral Terconazole (Vaginal 3 QL 1 Capsule)

Cream) C1 Pro C1 ben ecid Terc ona zole Probenecid (Oral Terconazole (Vaginal 1 1 Tablet)

Suppository) C1 Pro C1 ben ecid Tols - ura Colc hicin e Probenecid-Colchicine Tolsura (Oral 1 4 PA (Oral Tablet) Capsule) C1 Ulori c C1 Vfen d IV Uloric (Oral Tablet) 3 ST Vfend IV (Intravenous C1 Zylo prim Solution 4 Zyloprim (Oral Tablet) 3 Reconstituted) A1 Antimigraine Agents B1 Ergot Alkaloids

C1 Cafe rgot Cafergot (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 72 tRACK 72 Last updated September 1, 2019 3471 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Dihy Ame droe rge rgot ami ne Mes ylate Dihydroergotamine Amerge (Oral Tablet) 3 QL

C1 Eletr ipta n Hyd robr omi Mesylate (Nasal 4 de Eletriptan Solution)

C1 Hydrobromide (Oral 3 ST; QL Erg ota min e- Caff eine Ergotamine-Caffeine Tablet)

C1 Frov 1 a (Oral Tablet)

C1 Frova (Oral Tablet) 4 ST; QL Mig ergo C1 t Frov atrip tan Suc cina Migergot (Rectal te 4 Frovatriptan Succinate Suppository) 3 ST; QL

C1 (Oral Tablet) Migr anal C1 Imitr Migranal (Nasal ex Imitrex (Nasal 4 3 QL Solution) Solution)

C1 B1 Imitr Prophylactic ex

C1 Imitrex (Oral Tablet) 3 QL Aim ovig C1 Imitr ex STA Tdo se Refil Aimovig l Imitrex STATdose (Subcutaneous Refill (6MG/0.5ML 3 PA; QL 4 QL Solution Auto- Subcutaneous Injector)

C1 Solution Cartridge) Ajov y C1 Imitr ex STA Tdo se Syst Ajovy (Subcutaneous em Imitrex STATdose Solution Prefilled 3 PA; QL System (4MG/0.5ML Syringe)

C1 Subcutaneous 4 QL Emg ality Emgality (300 MG Solution Auto- Dose) (Subcutaneous Injector)

C1 Imitr 3 PA; QL ex Solution Prefilled Imitrex Syringe)

C1 (Subcutaneous 4 QL Emg ality Emgality Solution)

C1 Max (Subcutaneous alt Maxalt (Oral Tablet) 3 QL 3 PA; QL C1 Max alt- Solution Auto- MLT Maxalt-MLT (Oral Injector) 3 QL C1 Tablet Dispersible) Emg ality C1 Nar atrip tan Emgality HCl Naratriptan HCl (Oral 1 QL (Subcutaneous Tablet)

3 PA; QL C1 Onz etra Solution Prefilled Xsail Onzetra Xsail (Nasal Syringe) 4 QL

C1 Tim Exhaler Powder) olol Mal eate C1 Relp Timolol Maleate (Oral ax 1 Relpax (Oral Tablet) 3 ST; QL C1 Riza tript Tablet) an Ben zoat e

B1 Rizatriptan Benzoate Serotonin (5-HT) 1b/1d Receptor Agonists 1 QL

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

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 73 73 3572 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Riza Sum tript atrip an tan Ben Suc zoat cina e te ODT Rizatriptan Benzoate Sumatriptan Succinate ODT (Oral Tablet 1 QL (6MG/0.5ML Dispersible) Subcutaneous 3 QL

C1 Sum atrip tan Sumatriptan (Nasal Solution Prefilled 3 QL Syringe)

Solution) C1 Zem C1 brac e Sum Sym atrip Tou tan ch Suc cina te Sumatriptan Succinate Zembrace SymTouch (100MG Oral Tablet, (Subcutaneous 1 QL 4 QL 25MG Oral Tablet, Solution Auto- 50MG Oral Tablet) Injector)

C1 C1 Sum Zol atrip mitri tan ptan Suc cina te Refil l Sumatriptan Zolmitriptan (Oral 1 QL Succinate Refill Tablet)

C1 Zol mitri 3 QL ptan

(Subcutaneous ODT Zolmitriptan ODT (Oral 1 QL Solution Cartridge) Tablet Dispersible)

C1 C1 Sum Zom atrip ig tan Suc cina te Sumatriptan Succinate Zomig (Nasal 3 QL (6MG/0.5ML Solution)

C1 3 QL Zom Subcutaneous ig Zomig (Oral Tablet) 4 QL

C1 Zom ig Solution) ZMT

C1 Sum atrip tan Zomig ZMT (Oral Suc cina te 4 QL Sumatriptan Succinate Tablet Dispersible)

(4MG/0.5ML A1 3 QL Subcutaneous Antimyasthenic Agents Solution Auto-Injector) B1 Parasympathomimetics C1 C1 Gua nidi Sum ne atrip HCl tan Suc cina te Guanidine HCl (Oral Sumatriptan Succinate 3 (6MG/0.5ML Tablet)

C1 Mes tino n Subcutaneous 3 QL Mestinon (Oral Syrup) 4

C1 Mes tino Solution Auto-Injector) n Mestinon (Oral Tablet (Generic Imitrex) 4

C1 Sum atrip Immediate Release) tan Suc cina C1 te Mes tino Sumatriptan n Mestinon (Oral Tablet Succinate (6MG/ 4 Extended Release)

C1 Pyri dost 0.5ML Subcutaneous igmi ne Bro mid e 3 QL ER Solution Auto- Pyridostigmine Bromide ER (Oral Injector) (Generic 3 Tablet Extended Imitrex STATdose) Release)

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

Bold type = Brand name drug Plain type = Generic drug 74 tRACK 74 Last updated September 1, 2019 3673 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Pyri Rifa dost mpi igmi n ne Bro mid e Pyridostigmine Rifampin (Oral 1 Bromide (30MG Oral Capsule)

C1 Rifat 4 er Tablet Immediate Rifater (Oral Tablet) 4

C1 Sirtu Release) ro

C1 Pyri dost Sirturo (Oral Tablet) 4 PA; LA igmi ne Bro C1 mid e Trec Pyridostigmine ator Trecator (Oral Tablet) 3 Bromide (60MG Oral A1 1 Tablet Immediate Antineoplastics Release) B1 Alkylating Agents C1 Cycl oph osp A1 ham ide Cyclophosphamide Antimycobacterials 1 B/D, PA B1 (Oral Capsule) Antimycobacterials, Other C1 Gle osti C1 ne Dap son e Dapsone (Oral Tablet) 1 Gleostine (100MG

C1 4 Myc obut in Oral Capsule)

C1 Mycobutin (Oral Gle osti 4 ne Capsule) Gleostine (10MG Oral

C1 2 Rifa buti n Capsule) C1 Gle Rifabutin (Oral osti 3 ne Gleostine (40MG Oral Capsule) 3 B1 Capsule) Antituberculars C1 Leu kera C1 n Etha mbu tol HCl Leukeran (Oral Ethambutol HCl (Oral 4 1 Tablet)

Tablet) C1 Mat C1 ulan e Ison iazid Isoniazid (Oral Syrup) 3 Matulane (Oral C1 4 LA Ison iazid Capsule)

C1 Isoniazid (Oral Tablet) 1 Valc hlor

C1 Mya mbu tol Myambutol (400MG Valchlor (External 3 4 PA; LA Oral Tablet) Gel) B1 C1 Pas er

C1 Paser (Oral Packet) 3 Abir ater one C1 Acet ate Prifti n Abiraterone Acetate Priftin (Oral Tablet) 3 4 PA C1 Pyra zina mid (Oral Tablet) e

C1 Bica luta mid Pyrazinamide (Oral e 1 Bicalutamide (Oral Tablet) 1 C1 Rifa din Tablet)

C1 Cas ode Rifadin (150MG Oral x 3 Casodex (Oral Tablet) 4

C1 Erle Capsule) ada

C1 Rifa mat e Erleada (Oral Tablet) 4 PA; QL

C1 Flut Rifamate (Oral ami 3 de Capsule) Flutamide (Oral

C1 3 Rifa mpi n Capsule)

C1 Nila Rifampin (Intravenous ndro n Nilandron (Oral Solution 3 4 Reconstituted) Tablet) C1 Nilut ami de Nilutamide (Oral 4 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 75 75 3774 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Xtan Kisq di Xtandi (Oral Capsule) 4 PA; LA ali Kisqali (200MG Dose)

C1 Yon sa 4 PA Yonsa (Oral Tablet) 4 PA (Oral Tablet) C1 C1 Kisq ali Zyti ga Kisqali (400MG Dose) Zytiga (Oral Tablet) 4 PA 4 PA B1 (Oral Tablet) Antiangiogenic Agents C1 Kisq ali C1 Pom alyst Kisqali (600MG Dose) Pomalyst (Oral 4 PA 4 PA (Oral Tablet)

Capsule) C1 Kisq ali C1 Fem Revl ara imid Revlimid (Oral Kisqali Femara 4 PA; LA Capsule) (400MG Dose) (Oral 4 PA

C1 Thal omi d Tablet Therapy Pack)

C1 Thalomid (Oral Kisq ali Fem 4 PA; QL ara Capsule) Kisqali Femara B1 /Modifiers (600MG Dose) (Oral 4 PA

C1 Emc yt Tablet Therapy Pack)

C1 Kisq ali Emcyt (Oral Capsule) 4 Fem ara

C1 Fare ston Kisqali Femara Fareston (Oral Tablet) 4

C1 Solt amo (200MG Dose) (Oral 4 PA x Soltamox (Oral 4 Tablet Therapy Pack) C1 Leu cov orin Solution) Calc ium

C1 Tam oxif Leucovorin Calcium en Citra te Tamoxifen Citrate 1 (10MG Oral Tablet, (Oral Tablet) 1 C1 15MG Oral Tablet, Tore mife ne Citra te Toremifene Citrate 5MG Oral Tablet)

C1 4 Leu cov orin Calc (Oral Tablet) ium Leucovorin Calcium B1 3 Antimetabolites (25MG Oral Tablet) C1 C1 Dro xia Lon surf Droxia (Oral Capsule) 3 Lonsurf (Oral Tablet) 4 PA; LA C1 C1 Hyd rea Lorb Hydrea (Oral rena Lorbrena (Oral 3 4 PA; QL Capsule) Tablet)

C1 C1 Hyd roxy Ninl urea Hydroxyurea (Oral aro Ninlaro (Oral 1 4 PA; QL Capsule) Capsule) C1

Mer C1 capt opur Piqr ine Mercaptopurine (Oral ay 1 Piqray (200 MG Daily Tablet)

C1 Dose) (Oral Tablet 4 PA; QL Puri xan Purixan (Oral Therapy Pack)

C1 Piqr 4 PA ay Suspension)

C1 Piqray (250 MG Daily Tabl oid Tabloid (Oral Tablet) 3 PA Dose) (Oral Tablet 4 PA; QL B1 Antineoplastics, Other Therapy Pack)

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

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C1 C1 Piqr Alun ay Piqray (300 MG Daily brig Alunbrig (Oral Tablet 4 PA; LA; QL Dose) (Oral Tablet 4 PA; QL Therapy Pack)

C1 Bos Therapy Pack) ulif Bosulif (Oral Tablet) 4 PA C1 Synr C1 ibo Braf Synribo tovi Braftovi (Oral 4 PA (Subcutaneous Capsule)

C1 4 PA Cab ome Solution tyx Cabometyx (Oral Reconstituted) 4 PA; LA; QL

C1 Tablet) Verz enio C1 Calq uen Verzenio (Oral Tablet) 4 PA; LA ce C1 Calquence (Oral Zoli nza 4 PA; QL Zolinza (Oral Capsule)

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

B1 C1 Co metr Aromatase Inhibitors, 3rd Generation iq C1 Cometriq (100MG Ana stro zole 4 PA; LA Anastrozole (Oral Daily Dose) (Oral Kit) 1 C1 Co metr Tablet) iq C1 Cometriq (140MG Arim idex Arimidex (Oral Tablet) 4 4 PA; LA

C1 Daily Dose) (Oral Kit) Aro masi C1 n Co metr Aromasin (Oral iq 4 Cometriq (60MG Tablet) 4 PA; LA

C1 Daily Dose) (Oral Kit) Exe mes C1 tane Cot Exemestane (Oral ellic Cotellic (Oral Tablet) 4 PA; LA 3 C1 Dau rism Tablet) o

C1 Fem ara Daurismo (Oral Femara (Oral Tablet) 4 4 PA; LA; QL C1 Tablet) Letr ozol e C1 Eriv edg Letrozole (Oral Tablet) 1 e Erivedge (Oral B1 4 PA; LA; QL Enzyme Inhibitors Capsule) C1

Balv C1 ersa Erlot inib Balversa (Oral Tablet) 4 PA; QL HCl Erlotinib HCl (Oral C1 Rub raca 4 PA; QL Rubraca (Oral Tablet) 4 PA; LA Tablet)

C1 C1 Fary Talz dak enn a Talzenna (Oral Farydak (Oral 4 PA; LA; QL 4 PA Capsule) Capsule)

C1 C1 Gilot Zeju rif la Zejula (Oral Capsule) 4 PA; LA; QL Gilotrif (Oral Tablet) 4 PA; LA

C1 Glee vec B1 Molecular Target Inhibitors Gleevec (Oral Tablet) 4 PA; QL

C1 C1 Ibra Afini nce tor Disp erz Afinitor Disperz (Oral Ibrance (Oral 4 PA 4 PA; LA Tablet Soluble) Capsule)

C1 C1 Iclus Afini ig tor Afinitor (Oral Tablet) 4 PA Iclusig (Oral Tablet) 4 PA; LA

C1 C1 IDHI Alec FA ens a Alecensa (Oral IDHIFA (Oral Tablet) 4 PA; LA

C1 Imat inib 4 PA; LA Mes Capsule) ylate Imatinib Mesylate (Oral C1 Alun brig 4 PA; QL Alunbrig (Oral Tablet) 4 PA; LA; QL Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 77 77 3976 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Imbr Mek uvic tovi a Imbruvica (Oral Mektovi (Oral Tablet) 4 PA

C1 Nerl 4 PA; LA; QL ynx Capsule) Nerlynx (Oral Tablet) 4 PA; LA; QL C1 Imbr C1 uvic a Nex Imbruvica (Oral avar Nexavar (Oral Tablet) 4 PA; LA

C1 4 PA; QL Odo Tablet) mzo

C1 Odomzo (Oral Inlyt a 4 PA; LA; QL Inlyta (Oral Tablet) 4 PA; LA; QL Capsule) C1 Ires C1 sa Ryd Iressa (Oral Tablet) 4 PA; LA; QL apt Rydapt (Oral Capsule) 4 PA; QL C1 Jaka C1 fi Spry Jakafi (Oral Tablet) 4 PA; LA; QL cel Sprycel (Oral Tablet) 4 PA C1 Len C1 vima Stiv 10M arga G Dail y Dos e Lenvima 10MG Daily Stivarga (Oral Tablet) 4 PA; LA; QL

C1 Sute Dose (Oral Capsule 4 PA; LA nt Sutent (Oral Capsule) 4 PA

C1 Tafi Therapy Pack) nlar

C1 Len Tafinlar (Oral vima

12M G Dail y Dos 4 PA; LA e Lenvima 12MG Daily Capsule)

C1 Tagr Dose (Oral Capsule 4 PA; LA isso Tagrisso (Oral Tablet) 4 PA; LA

C1 Tarc Therapy Pack) eva

C1 Len vima Tarceva (Oral Tablet) 4 PA; LA; QL 14M G Dail C1 y Dos Tasi e Lenvima 14MG Daily gna Tasigna (Oral Dose (Oral Capsule 4 PA; LA 4 PA Capsule)

C1 Tibs Therapy Pack) ovo

C1 Len vima

18M Tibsovo (Oral Tablet) G 4 PA; QL Dail y Dos C1 e Tyk Lenvima 18MG Daily erb Tykerb (Oral Tablet) 4 PA; LA

C1 Dose (Oral Capsule 4 PA; LA Ven clext a Therapy Pack) Venclexta (100MG

C1 Len vima

20M G Dail Oral Tablet, 50MG 4 PA; LA y Dos e Lenvima 20MG Daily Oral Tablet)

C1 Dose (Oral Capsule 4 PA; LA Ven clext a Therapy Pack) Venclexta (10MG Oral C1 2 PA; LA Len vima

24M G Dail Tablet) y Dos e C1 Lenvima 24MG Daily Ven clext a Start ing Pac Dose (Oral Capsule 4 PA; LA k Venclexta Starting Therapy Pack) Pack (Oral Tablet 4 PA; LA

C1 Len vima

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

Therapy Pack) C1 Vitra C1 kvi Len vima

8M G Dail y Dos Vitrakvi (Oral e Lenvima 8MG Daily 4 PA; LA; QL Solution)

Dose (Oral Capsule 4 PA; LA C1 Vizi mpr Therapy Pack) o Vizimpro (Oral Tablet) 4 PA; LA C1 C1 Votri Lyn ent parz a Lynparza (Oral Votrient (Oral Tablet) 4 PA; LA; QL C1 Xalk 4 PA; LA ori Tablet) Xalkori (Oral Capsule) 4 PA; LA

C1 C1 Mek Xos inist Mekinist (Oral Tablet) 4 PA; LA pata Xospata (Oral Tablet) 4 PA; QL

Bold type = Brand name drug Plain type = Generic drug 78 tRACK 78 Last updated September 1, 2019 4077 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Zelb Stro oraf mec Zelboraf (Oral Tablet) 4 PA; LA; QL tol Stromectol (Oral

C1 Zyd elig 3 Zydelig (Oral Tablet) 4 PA; LA Tablet)

C1

Zyk B1 adia Zykadia (Oral Antiprotozoals C1 Alini 4 PA a Capsule) Alinia (Oral

C1 Zyk adia Zykadia (Oral Tablet) 4 PA Suspension 4 B1 Reconstituted) Retinoids C1 Alini a C1 Bex arot ene Alinia (Oral Tablet) 4 Bexarotene (Oral C1 Atov aqu 4 PA one Capsule) Atovaquone (Oral

C1 Panr etin 4 Suspension) Panretin (External C1 Atov aqu one- Pro gua 4 nil Gel) HCl Atovaquone-Proguanil C1 1 Targ retin HCl (Oral Tablet) Targretin (External C1 Ben znid azol 4 PA e Gel) Benznidazole (Oral C1 3 Targ retin Tablet) Targretin (Oral C1 Chlo roqu ine Pho sph 4 PA ate Capsule) Chloroquine C1 Treti noin Phosphate (Oral 1 Tretinoin (Oral 4 Tablet)

C1 Coa Capsule) rtem B1 Coartem (Oral Tablet) 3

C1 DAR Treatment Adjuncts APR IM C1 Mes nex DARAPRIM (Oral Mesnex (Oral Tablet) 4 4

A1 Tablet)

C1 Hyd roxy Antiparasitics chlo roqu ine Sulf ate B1 Hydroxychloroquine Anthelmintics 1

C1 Albe Sulfate (Oral Tablet) nda zole C1 Krint Albendazole (Oral afel 4 QL Krintafel (Oral Tablet) 3 C1 Mal aron Tablet) e

C1 Albe nza Malarone (Oral Albenza (Oral Tablet) 4 QL 3

C1 Biltri cide Tablet) C1

Mefl oqui ne Biltricide (Oral Tablet) 3 HCl

C1 Emv erm Mefloquine HCl (Oral 1 Emverm (Oral Tablet Tablet)

4 C1 Mep Chewable) ron

C1 Iver mec Mepron (Oral tin Ivermectin (Oral 4 1 Suspension) C1 Neb upe Tablet) nt

C1 Praz iqua ntel Nebupent (Inhalation Praziquantel (Oral 3 Solution 3 B/D, PA; QL Tablet)

C1 Skli ce Reconstituted)

C1 PEN TA M Sklice (External 300 3 PENTAM 300 Lotion) (Injection Solution 3 Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 79 79 4178 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Plaq Ama ueni ntad l ine Plaquenil (Oral HCl Amantadine HCl (Oral 3 1 Tablet) Capsule) C1 C1 Ama Prim ntad aqui ine ne HCl Pho sph ate Primaquine Phosphate Amantadine HCl (Oral 1 1 (Oral Tablet) Syrup) C1 C1 Ama Qual ntad aqui ine n Qualaquin (Oral HCl Amantadine HCl (Oral 3 PA 1 Capsule) Tablet) C1

C1 Co mta Quin n ine Sulf ate Quinine Sulfate (Oral Comtan (Oral Tablet) 4 C1 Enta cap 1 PA one Capsule) Entacapone (Oral

B1 3 Pediculicides/Scabicides Tablet) C1

C1 Goc ovri Elim ite Elimite (External Gocovri (Oral Capsule 3 Cream) Extended Release 24 4 PA

C1 Eura x Hour) Eurax (External C1 Os mol ex 3 ER Cream) Osmolex ER (Oral

C1 Eura x Eurax (External Tablet Extended 3 PA 3 Release 24 Hour) Lotion) C1 Tas mar C1 Lind ane Tasmar (Oral Tablet) 4 QL Lindane (External C1 Tolc apo 1 ne Shampoo) Tolcapone (Oral

C1 Mal 4 QL athi on Malathion (External Tablet) 3 B1 Lotion) Dopamine Agonists C1 C1 Apo Natr kyn oba Natroba (External Apokyn 3 Suspension) (Subcutaneous 4 PA; LA; QL

C1 Ovid e Solution Cartridge)

Ovide (External Lotion) 3 C1 Bro C1 moc ripti Per ne met Mes hrin Permethrin (External ylate Bromocriptine 1 Cream) Mesylate (Oral 3

A1 Capsule)

C1 Bro Antiparkinson Agents moc ripti ne Mes ylate B1 Bromocriptine Anticholinergics 1

C1 Ben ztro pine Mesylate (Oral Tablet)

Mes ylate C1 Inbri Benztropine Mesylate ja 1 PA; HRM Inbrija (Inhalation (Oral Tablet) 4 PA C1 Trih exy phe nidyl Capsule) HCl C1 Mira pex Trihexyphenidyl HCl ER 1 PA; HRM Mirapex ER (Oral (Oral Elixir) C1 Trih exy phe nidyl HCl Tablet Extended 3 Trihexyphenidyl HCl 1 PA; HRM Release 24 Hour)

C1 (Oral Tablet) Mira pex

B1 Mirapex (Oral Tablet Antiparkinson Agents, Other 3 Immediate Release)

Bold type = Brand name drug Plain type = Generic drug 80 tRACK 80 Last updated September 1, 2019 4279 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Neu Rop pro iniro le HCl Neupro (Transdermal ER Ropinirole HCl ER 3 Patch 24 Hour) (2MG Oral Tablet

C1 Parl odel Parlodel (Oral Extended Release 24 3 1 Capsule) Hour, 4MG Oral Tablet

C1 Parl odel Extended Release 24 Parlodel (Oral Tablet) 3 C1 Hour) Pra mip exol C1 e Dihy Rop droc iniro hlori le de HCl ER Pramipexole Ropinirole HCl (Oral Dihydrochloride ER 3 Tablet Immediate 1 (Oral Tablet Extended Release)

Release 24 Hour) B1

C1 Pra mip exol Dopamine Precursors/L-Amino Acid e Dihy droc hlori de Pramipexole Decarboxylase Inhibitors

C1 Car bido Dihydrochloride (Oral pa 1 Carbidopa (Oral Tablet Immediate 3 Tablet) Release) C1 Car bido C1 pa- Lev Req odo uip pa XL Requip XL (12MG ER Carbidopa-Levodopa Oral Tablet Extended ER (Oral Tablet 1 Extended Release)

C1 Car Release 24 Hour, bido pa- Lev odo 4 pa 8MG Oral Tablet Carbidopa-Levodopa Extended Release 24 (Oral Tablet Immediate 1 Release)

C1 Car bido Hour) pa- Lev odo C1 pa ODT Req uip XL Carbidopa-Levodopa Requip XL (4MG Oral ODT (Oral Tablet 1 Tablet Extended Dispersible)

C1 Car bido pa- Lev Release 24 Hour, odo pa- Enta cap 3 one Carbidopa-Levodopa- 6MG Oral Tablet Entacapone (Oral 3 Extended Release 24 Tablet)

C1 Duo Hour) pa

C1 Rop iniro Duopa (Enteral le HCl ER 4 PA Ropinirole HCl ER Suspension)

C1 Lod osy (12MG Oral Tablet n Lodosyn (Oral Tablet) 4

C1 Ryta Extended Release 24 ry Hour, 6MG Oral Tablet Rytary (Oral Capsule 3 3 Extended Release 24 Extended Release) C1 Sine met Hour, 8MG Oral Tablet CR Sinemet CR (Oral

Extended Release 24 Tablet Extended 3 Hour) Release)

C1 Sine met Sinemet (Oral Tablet 3 Immediate Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 81 81 4380 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Stal Flup evo hen 100 azin e Stalevo 100 (Oral HCl Fluphenazine HCl 4 1 Tablet) (Oral Elixir) C1 C1 Flup Stal hen evo azin 125 e Stalevo 125 (Oral HCl Fluphenazine HCl 4 1 Tablet) (Oral Tablet) C1

C1 Hald ol Stal Dec evo ano 150 Stalevo 150 (Oral ate Haldol Decanoate 4 Tablet) (Intramuscular 3

C1 Stal evo 200 Solution) Stalevo 200 (Oral C1 Hald 4 ol Tablet) Haldol (Injection

C1 Stal 3 evo 50 Solution) Stalevo 50 (Oral C1 Halo peri dol Dec ano 4 ate Tablet) Haloperidol Decanoate

C1 Stal evo 75 Stalevo 75 (Oral (Intramuscular 1 4 Solution)

C1 Halo Tablet) peri dol Lact ate B1 Haloperidol Lactate Monoamine Oxidase B (MAO-B) Inhibitors 1

C1 Azil ect (Injection Solution) C1 Halo peri dol Lact Azilect (Oral Tablet) 3 ate

C1 Ras agili Haloperidol Lactate ne Mes ylate 1 Rasagiline Mesylate (Oral Concentrate)

3 C1 Halo peri (Oral Tablet) dol

C1 Sele gilin Haloperidol (Oral e HCl 1 Selegiline HCl (Oral Tablet)

1 C1 Lox apin e Suc Capsule) cina te

C1 Sele gilin Loxapine Succinate e HCl 1 Selegiline HCl (Oral (Oral Capsule)

1 C1 Moli ndo ne Tablet) HCl

C1 Zela par Molindone HCl (Oral 3 Zelapar (Oral Tablet Tablet) 4 C1 Pim ozid e Dispersible) Pimozide (Oral Tablet) 1 A1 C1 Thio rida zine Antipsychotics HCl Thioridazine HCl (Oral B1 1 1st Generation/Typical Tablet) C1

Chlo C1 rpro mazi Thio ne thix HCl Chlorpromazine HCl ene Thiothixene (Oral 3 1 (Oral Tablet) Capsule) C1

Flup C1 hen azin Trifl e uop Dec eraz ano ine ate Fluphenazine HCl Trifluoperazine HCl 1 Decanoate (Injection 1 (Oral Tablet)

Solution) B1

C1 Flup 2nd Generation/Atypical hen azin e C1 HCl Abili fy Mai nten Fluphenazine HCl a 1 Abilify Maintena (Injection Solution)

C1 Flup hen (Intramuscular 4 azin e HCl Fluphenazine HCl 1 Prefilled Syringe) (Oral Concentrate)

Bold type = Brand name drug Plain type = Generic drug 82 tRACK 82 Last updated September 1, 2019 4481 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Abili Fan fy apt Mai Titra nten tion a Pac Abilify Maintena k Fanapt Titration Pack 3 ST (Intramuscular (Oral Tablet)

C1 Geo 4 don Suspension Geodon Reconstituted ER) (Intramuscular C1 Abili fy 3 Abilify (Oral Tablet) 4 QL Solution

C1 Aripi praz ole Aripiprazole (1MG/ML Reconstituted) C1 Geo 3 QL don Oral Solution) Geodon (Oral C1 Aripi praz ole 4 QL Aripiprazole (10MG Capsule)

C1 Inve Oral Tablet, 15MG Oral ga Invega (3MG Oral Tablet, 20MG Oral Tablet Extended Tablet, 2MG Oral 1 QL Release 24 Hour, Tablet, 30MG Oral 6MG Oral Tablet Tablet, 5MG Oral 4 PA; QL Extended Release 24 Tablet)

C1 Aripi praz ole ODT Hour, 9MG Oral Aripiprazole ODT Tablet Extended (10MG Oral Tablet Release 24 Hour)

C1 Dispersible, 15MG 4 QL Inve ga Sust enn Oral Tablet a Invega Sustenna Dispersible) (117MG/0.75ML

C1 Arist ada Initi o Aristada Initio Intramuscular

(Intramuscular 4 Suspension Prefilled Prefilled Syringe) Syringe, 156MG/ML

C1 Arist ada Aristada Intramuscular Suspension Prefilled (Intramuscular 4 4 Prefilled Syringe) Syringe, 234MG/

C1 Fan apt 1.5ML Intramuscular Fanapt (10MG Oral Suspension Prefilled Tablet, 12MG Oral Syringe, 78MG/ Tablet, 4MG Oral 4 ST; QL 0.5ML Intramuscular Tablet, 6MG Oral Suspension Prefilled Tablet, 8MG Oral Syringe)

C1 Inve Tablet) ga Sust enn C1 a Fan apt Invega Sustenna Fanapt (1MG Oral (39MG/0.25ML Tablet, 2MG Oral 3 ST; QL Intramuscular 3 Tablet) Suspension Prefilled Syringe)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 83 83 4582 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Inve Que ga tiapi Trin ne za Fum arat Invega Trinza e Quetiapine Fumarate (Intramuscular (Oral Tablet Immediate 1 QL 4 Suspension Prefilled Release) C1 Rex Syringe) ulti Rexulti (Oral Tablet) 4 QL

C1 C1 Risp Latu erda da l Con Latuda (Oral Tablet) 4 QL sta Risperdal Consta

C1 Nup lazid Nuplazid (Oral (12.5MG 4 PA; QL Capsule) Intramuscular 3

C1 Nup lazid Nuplazid (Oral Tablet) 4 PA; QL Suspension

C1 Olan zapi ne Reconstituted)

C1 Risp Olanzapine (10MG erda l Con sta Intramuscular Solution 3 Risperdal Consta Reconstituted) (25MG Intramuscular

C1 Olan zapi ne Olanzapine (10MG Suspension Oral Tablet, 15MG Oral Reconstituted, 37.5MG Tablet, 2.5MG Oral Tablet, 20MG Oral 1 QL Intramuscular 4 Tablet, 5MG Oral Suspension Tablet, 7.5MG Oral Reconstituted, 50MG Tablet)

C1 Intramuscular Olan zapi ne ODT Olanzapine ODT Suspension (10MG Oral Tablet Reconstituted)

C1 Risp erda Dispersible, 15MG l Risperdal (1MG/ML Oral Tablet 4 1 QL Oral Solution)

C1 Risp Dispersible, 20MG erda l Risperdal (0.25MG Oral Tablet Dispersible, 5MG Oral Oral Tablet, 0.5MG 3 Tablet Dispersible) Oral Tablet)

C1 C1 Risp Pali erda peri l don e ER Paliperidone ER (Oral Risperdal (1MG Oral Tablet Extended 3 QL Tablet, 2MG Oral

Release 24 Hour) Tablet, 3MG Oral 4 C1 Pers eris Perseris Tablet, 4MG Oral

(Subcutaneous 4 Tablet)

C1 Risp erid Prefilled Syringe) one Risperidone (Oral C1 Que tiapi ne Fum 1 arat e ER Quetiapine Fumarate Solution) C1 Risp erid ER (Oral Tablet one Risperidone (Oral 1 QL 1 Extended Release 24 Tablet) Hour)

Bold type = Brand name drug Plain type = Generic drug 84 tRACK 84 Last updated September 1, 2019 4683 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Risp Vray erid lar one ODT Risperidone ODT (Oral Vraylar (1.5MG Oral 1 Tablet Dispersible) Capsule, 3MG Oral C1 Sap hris Saphris (Tablet Capsule, 4.5MG Oral 4 ST; QL 4 Sublingual) Capsule, 6MG Oral

C1 Ser oqu el Seroquel (100MG Capsule) C1 Vray Oral Tablet lar Vraylar (Oral Capsule 3 ST Immediate Release, Therapy Pack)

C1 Zipr asid one 200MG Oral Tablet HCl Ziprasidone HCl (Oral 1 QL Immediate Release, 3 QL Capsule)

C1 Zypr 25MG Oral Tablet exa Zyprexa (10MG Immediate Release, Intramuscular 3 50MG Oral Tablet Solution Immediate Release) Reconstituted) C1 Ser C1 oqu el Zypr Seroquel (300MG exa Zyprexa (10MG Oral Oral Tablet Tablet, 2.5MG Oral Immediate Release, 4 QL Tablet, 5MG Oral 3 QL 400MG Oral Tablet Tablet, 7.5MG Oral Immediate Release) Tablet) C1 Ser C1 oqu el Zypr XR Seroquel XR (150MG exa Zyprexa (15MG Oral Oral Tablet Extended Tablet, 20MG Oral 4 QL Release 24 Hour, Tablet)

C1 Zypr exa Relp 200MG Oral Tablet revv Zyprexa Relprevv Extended Release 24 (210MG

Hour, 300MG Oral 3 QL Intramuscular 3 Tablet Extended Suspension Release 24 Hour, Reconstituted)

C1 Zypr exa Zydi 50MG Oral Tablet s Zyprexa Zydis (10MG Extended Release 24 Oral Tablet Hour)

C1 Ser Dispersible, 15MG oqu el XR Seroquel XR (400MG Oral Tablet 4 QL Oral Tablet Extended 4 QL Dispersible, 20MG Release 24 Hour) Oral Tablet Dispersible)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 85 85 4784 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Zypr Vers exa aclo Zydi z s Zyprexa Zydis (5MG Versacloz (Oral 4 Oral Tablet 3 QL Suspension) Dispersible) A1 Antivirals

B1 Treatment-Resistant B1 Anti-cytomegalovirus (CMV) Agents C1 Cloz C1 apin e Prev Clozapine (100MG ymis Prevymis (Oral 4 PA; QL Oral Tablet, 200MG Tablet) C1 Valc Oral Tablet, 25MG Oral 1 yte Valcyte (Oral Solution Tablet, 50MG Oral 4 QL Reconstituted)

C1 Valc Tablet) yte

C1 Cloz apin e ODT Valcyte (Oral Tablet) 4 QL

C1 Valg Clozapine ODT anci clovi r HCl Valganciclovir HCl (100MG Oral Tablet Dispersible, 150MG 3 (Oral Solution 4 QL Reconstituted)

Oral Tablet C1 Valg anci clovi r Dispersible) HCl Valganciclovir HCl

C1 Cloz apin 4 QL e ODT (Oral Tablet)

Clozapine ODT C1 Zirg (12.5MG Oral Tablet an Zirgan (Ophthalmic 3 Dispersible, 25MG 1 Gel) Oral Tablet B1 Anti-hepatitis B (HBV) Agents

C1 Ade fovir

Dispersible) Dipi voxil

C1 Cloz apin e Adefovir Dipivoxil (Oral ODT 4 Clozapine ODT Tablet)

C1 Bara clud (200MG Oral Tablet 4 e Baraclude (Oral Dispersible) 3 C1 Cloz aril Solution)

C1 Bara clud Clozaril (100MG Oral e 4 Baraclude (Oral Tablet) 4 C1 Cloz aril Tablet)

C1 Ente Clozaril (25MG Oral cavir 3 Entecavir (Oral Tablet) 3

C1 Tablet) Epiv ir HBV C1 Faza Clo Epivir HBV (Oral FazaClo (100MG Oral 3 Solution)

C1 Tablet Dispersible, Epiv ir HBV Epivir HBV (Oral 150MG Oral Tablet 3 4 Tablet)

Dispersible, 200MG C1 Hep sera Oral Tablet Hepsera (Oral Tablet) 4 C1 Lam ivudi Dispersible) ne Lamivudine (100MG

C1 Faza Clo 1 Oral Tablet)

FazaClo (12.5MG Oral C1 Vem Tablet Dispersible, lidy Vemlidy (Oral Tablet) 4 QL

3 B1 25MG Oral Tablet Anti-hepatitis C (HCV) Agents, Other Dispersible)

Bold type = Brand name drug Plain type = Generic drug 86 tRACK 86 Last updated September 1, 2019 4885 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Intro Ledi n A pasv ir- Sof osb Intron A (Injection uvir Ledipasvir-Sofosbuvir 4 PA; LA 4 PA; QL Solution) (Oral Tablet) C1 C1 Mav Intro yret n A Intron A (Injection Mavyret (Oral Tablet) 4 PA; QL C1 Sof osb uvir- Velp atas Solution 4 PA; LA vir Sofosbuvir-Velpatasvir 4 PA; QL Reconstituted) (Oral Tablet)

C1 C1 Sov Peg aldi asys

Pro Clic k Pegasys ProClick Sovaldi (Oral Tablet) 4 PA; QL

C1 Viek ira (Subcutaneous 4 PA Pak Viekira Pak (Oral 4 PA; QL Solution) Tablet Therapy Pack) C1 C1 Peg asys Vos Pegasys evi Vosevi (Oral Tablet) 4 PA; QL

C1 Zep (Subcutaneous 4 PA atier Zepatier (Oral Tablet) 4 PA; QL

Solution) B1

C1 Reb Antiherpetic Agents etol C1 Acy clovi Rebetol (Oral r 3 Acyclovir (External Solution) 3 C1 Cream) Riba sph ere C1 Acy clovi Ribasphere (Oral r 1 Acyclovir (External Capsule) 1 C1 Ointment) Riba sph ere C1 Acy clovi Ribasphere (600MG r 4 Acyclovir (Oral Oral Tablet) 1 C1 Capsule) Riba sph ere C1 Riba Acy Pak clovi Ribasphere RibaPak r 4 Acyclovir (Oral (600MG Oral Tablet) 3 C1 Suspension) Riba sph ere C1 Riba Acy Pak clovi r Ribasphere RibaPak Acyclovir (Oral Tablet) 1 C1 Acy clovi r Sodi (400 & 600MG Oral 4 um Acyclovir Sodium Tablet Therapy Pack) 3 B/D, PA

C1 Riba virin (Intravenous Solution)

C1 Den Ribavirin (Oral avir 1 Denavir (External Capsule) 4 C1 Riba virin Cream)

C1 Fam ciclo Ribavirin (Oral Tablet) 1 vir

C1 Syla tron Famciclovir (Oral Sylatron 1 4 PA Tablet) C1 Trifl uridi (Subcutaneous Kit) ne B1 Trifluridine Anti-hepatitis C (HCV) Direct Acting Agents 1 C1 (Ophthalmic Solution) Dakl inza C1 Vala cycl ovir Daklinza (30MG Oral HCl Valacyclovir HCl (Oral 1 QL Tablet, 60MG Oral 4 PA; QL Tablet)

C1 Valtr Tablet) ex C1 Valtrex (1GM Oral Epcl usa 4 QL Epclusa (Oral Tablet) 4 PA; QL Tablet) C1 Harv oni C1 Valtr Harvoni (Oral Tablet) 4 PA; QL ex Valtrex (500MG Oral 3 QL Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 87 87 4986 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Xere Tyb se Xerese (External ost Tybost (Oral Tablet) 3 QL

4 PA B1 Cream) Anti-HIV Agents, Non-nucleoside Reverse C1 Zovi rax Zovirax (External Transcriptase Inhibitors (NNRTI)

C1 Atri 4 pla Cream) Atripla (Oral Tablet) 4 QL C1 Zovi C1 rax Co mpl Zovirax (External era Complera (Oral 4 4 QL Ointment) Tablet) C1 Zovi C1 rax Dels Zovirax (Oral trigo Delstrigo (Oral 3 4 QL Capsule) Tablet) C1 Zovi C1 rax Edu Zovirax (Oral rant Edurant (Oral Tablet) 4 QL

C1 3 Efav iren Suspension) z C1 Efavirenz (Oral Zovi rax 3 QL Zovirax (800MG Oral Capsule)

C1 Efav 3 iren Tablet) z Efavirenz (Oral Tablet) 4 QL

C1 B1 Intel enc Anti-HIV Agents, Integrase Inhibitors (INSTI) e Intelence (100MG C1 Dov ato Dovato (Oral Tablet) 4 QL Oral Tablet, 200MG 4 QL

C1 Gen voya Genvoya (Oral Tablet) 4 QL Oral Tablet) C1 C1 Intel Isen enc tres e s HD Isentress HD (Oral Intelence (25MG Oral 4 QL 3 QL Tablet) Tablet) C1 C1 Julu Isen ca tres s Isentress (Oral Juluca (Oral Tablet) 4 QL C1 Nevi rapi ne 3 QL ER Packet) Nevirapine ER (Oral

C1 Isen tres s Isentress (Oral Tablet Extended 3 QL 4 QL Release 24 Hour)

Tablet) C1 Nevi C1 rapi ne Isen tres s Nevirapine (Oral Isentress (100MG 3 QL Suspension) Oral Tablet C1 4 QL Nevi rapi ne Chewable) Nevirapine (Oral Tablet

C1 1 QL Isen tres s Immediate Release)

C1 Isentress (25MG Oral Ode 2 QL fsey Odefsey (Oral Tablet) 4 QL Tablet Chewable) C1 Pifel tro C1 Strib ild Pifeltro (Oral Tablet) 4 QL Stribild (Oral Tablet) 4 QL C1 Res cript C1 or Tivic ay Rescriptor (Oral Tivicay (10MG Oral 3 QL 3 QL Tablet) Tablet) C1 Sust iva C1 Tivic ay Sustiva (Oral Tivicay (25MG Oral 3 QL Capsule) Tablet, 50MG Oral 4 QL C1 Sust iva Tablet) Sustiva (Oral Tablet) 4 QL C1

C1 Sym fi Lo Triu meq Triumeq (Oral Tablet) 4 QL Symfi Lo (Oral Tablet) 4 QL

Bold type = Brand name drug Plain type = Generic drug 88 tRACK 88 Last updated September 1, 2019 5087 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Sym Lam fi ivudi Symfi (Oral Tablet) 4 QL ne Lamivudine (10MG/ML

C1 Vira mun 1 QL e Oral Solution)

Viramune (Oral C1 Lam ivudi 4 QL ne Suspension) Lamivudine (150MG

C1 Vira mun e Viramune (Oral Tablet Oral Tablet, 300MG 1 QL 4 QL Oral Tablet)

C1 Immediate Release) Lam ivudi ne- C1 Zido vudi Vira ne mun e XR Viramune XR (Oral Lamivudine- Zidovudine (Oral 1 QL Tablet Extended 4 QL Tablet)

C1 Retr Release 24 Hour) ovir

B1 Retrovir (Oral Anti-HIV Agents, Nucleoside and Nucleotide 3 QL Capsule)

C1 Retr Reverse Transcriptase Inhibitors (NRTI) ovir

C1 Aba cavir

Sulf Retrovir (Oral Syrup) 3 QL ate

C1 Stav udin Abacavir Sulfate (Oral e 3 QL Stavudine (Oral Solution) 1 QL C1 Aba cavir

Sulf Capsule) ate C1 Ten ofov Abacavir Sulfate (Oral ir Diso prox il Fum arat 1 QL e Tenofovir Disoproxil Tablet) 3 QL C1 Aba cavir

Sulf Fumarate (Oral Tablet) ate- Lam ivudi C1 ne Trizi Abacavir Sulfate- vir Trizivir (Oral Tablet) 4 QL

C1 Lamivudine (Oral 3 QL Truv ada Tablet) Truvada (Oral Tablet) 4 QL C1 C1 Vide x EC Aba cavir - Lam ivudi ne- Zido vudi ne Abacavir-Lamivudine- Videx EC (Oral Zidovudine (Oral 4 QL Capsule Delayed 3 QL Tablet) Release)

C1 C1 Bikt arvy Vide Biktarvy (Oral Tablet) 4 QL x Videx (4GM Oral

C1 Cim duo Cimduo (Oral Tablet) 4 QL Solution 3 QL

C1 Co mbi vir Reconstituted)

Combivir (Oral Tablet) 4 QL C1 Vire C1 ad Des covy Viread (Oral Powder) 4 QL

Descovy (Oral Tablet) 4 QL C1 Vire C1 ad Dida nosi ne Viread (Oral Tablet) 4 QL

Didanosine (Oral C1 Ziag Capsule Delayed 1 QL en Ziagen (Oral Solution) 3 QL

C1 Ziag Release) en

C1 Ziagen (Oral Tablet) 3 QL Emt riva C1 Zido vudi Emtriva (Oral ne Zidovudine (Oral 3 QL 1 QL Capsule) Capsule) C1 Emt C1 riva Zido vudi Emtriva (Oral ne Zidovudine (Oral 3 QL 1 QL Solution) Syrup)

C1 C1 Epiv ir Zido vudi Epivir (Oral Solution) 3 QL ne Zidovudine (Oral

C1 Epiv ir 1 QL Epivir (Oral Tablet) 3 QL Tablet)

C1 Epzi B1 com Epzicom (Oral Tablet) 4 QL Anti-HIV Agents, Other

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 89 89 5188 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Fuz Lopi eon navi r- Rito navi Fuzeon r Lopinavir-Ritonavir 3 QL (Subcutaneous (Oral Solution) C1 Nor 4 QL vir Solution Norvir (Oral Packet) 3 QL

C1 Nor Reconstituted) vir Norvir (Oral Solution) 3 QL C1 Selz C1 entr y Nor Selzentry (Oral vir Norvir (Oral Tablet) 3 QL 4 QL C1 Prez cobi Solution) x C1 Prezcobix (Oral Selz entr y 4 QL Selzentry (150MG Tablet)

C1 Prez Oral Tablet, 300MG ista Prezista (Oral 4 QL 4 QL Oral Tablet, 75MG Suspension)

C1 Prez Oral Tablet) ista

C1 Selz entr Prezista (150MG Oral y Selzentry (25MG Oral 2 QL Tablet, 75MG Oral 3 QL Tablet) Tablet)

B1 C1 Prez Anti-HIV Agents, Protease Inhibitors ista C1 Prezista (600MG Oral Apti vus Aptivus (Oral 4 QL Tablet, 800MG Oral 4 QL Capsule) Tablet) C1 Apti C1 vus Rey Aptivus (Oral ataz Reyataz (Oral 4 QL 4 QL Solution) Capsule) C1 Ataz C1 anav ir Rey Sulf ataz ate Atazanavir Sulfate Reyataz (Oral Packet) 4 QL 4 QL C1 Rito navi (Oral Capsule) r

C1 Crixi Ritonavir (Oral Tablet) 1 QL van

C1 Sym Crixivan (Oral tuza 2 QL Symtuza (Oral Tablet) 4 QL C1 Vira Capsule) cept

C1 Evot az Viracept (Oral Tablet) 4 QL

Evotaz (Oral Tablet) 4 QL B1

C1 Fos amp rena Anti-influenza Agents vir Calc ium C1 Flu mad Fosamprenavir ine 4 QL Flumadine (Oral Calcium (Oral Tablet) 3 C1

Invir ase Tablet)

C1 Osel tami Invirase (Oral Tablet) 4 QL vir Pho sph C1 ate Kale tra Oseltamivir Phosphate Kaletra (Oral 1 3 QL (Oral Capsule) C1 Osel tami vir Solution) Pho sph ate C1 Kale tra Oseltamivir Phosphate Kaletra (100-25MG 3 QL (Oral Suspension 1 Oral Tablet)

C1 Reconstituted) Kale tra C1 Rele nza Disk hale Kaletra (200-50MG r 4 QL Relenza Diskhaler Oral Tablet) C1 (Inhalation Aerosol Lexi va 2 Lexiva (Oral Powder Breath 3 QL Suspension) Activated) C1 Lexi va Lexiva (Oral Tablet) 4 QL

Bold type = Brand name drug Plain type = Generic drug 90 tRACK 90 Last updated September 1, 2019 5289 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Rim Clor anta aze dine pate HCl Dip otas siu Rimantadine HCl (Oral m Clorazepate 1 Tablet) Dipotassium (Oral 1 QL

C1 Tam iflu Tablet) Tamiflu (Oral C1 Diaz epa m Inte 3 nsol Capsule) Diazepam Intensol

C1 Tam iflu Tamiflu (Oral (5MG/ML Oral 1 QL Concentrate)

C1 Suspension 3 Diaz epa m Reconstituted) Diazepam (5MG/5ML

C1 1 Xofl uza Oral Solution)

C1 Diaz Xofluza (Oral Tablet epa 2 QL m Therapy Pack) Diazepam (10MG Oral

A1 Tablet, 2MG Oral 1 QL Anxiolytics Tablet, 5MG Oral B1 Anxiolytics, Other Tablet) C1

Bus C1 piro ne Klon HCl Buspirone HCl (Oral opin Klonopin (Oral Tablet) 3 QL 1 C1 Lora zep Tablet) am

C1 Hyd Lorazepam (2MG/ML roxy zine HCl 1 QL Hydroxyzine HCl (Oral Oral Concentrate) 1 PA; HRM C1 Lora zep Syrup) am Lorazepam (Oral B1 1 QL Benzodiazepines Tablet) C1

Alpr C1 azol am Oxa ER zep Alprazolam ER (Oral am Oxazepam (Oral 1 Tablet Extended 1 PA; QL Capsule)

C1 Tran xen Release 24 Hour) e-T

C1 Alpr Tranxene-T (Oral azol am Inte nsol 3 QL Alprazolam Intensol Tablet)

1 QL C1 Vali (Oral Concentrate) um

C1 Alpr azol Valium (Oral Tablet) 3 QL am

C1 Xan Alprazolam (Oral ax Xanax (0.25MG Oral Tablet Immediate 1 QL Release) Tablet Immediate

C1 Alpr azol am ODT Release, 0.5MG Oral Alprazolam ODT (Oral 1 QL Tablet Immediate 3 QL Tablet Dispersible)

C1 Ativ an Release, 1MG Oral Ativan (Oral Tablet) 4 QL

C1 Chlo rdia Tablet Immediate zep oxid e HCl Chlordiazepoxide HCl 1 Release) C1 Xan (Oral Capsule) ax

C1 Clon aze pam Xanax (2MG Oral Clonazepam (Oral 1 QL Tablet Immediate 4 QL Tablet)

C1 Clon aze Release) pam

ODT C1 Xan ax Clonazepam ODT XR Xanax XR (Oral Tablet (Oral Tablet 1 QL Dispersible) Extended Release 24 3 PA; QL Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 91 91 5390 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

A1 Bipolar Agents A1 Blood Glucose Regulators B1 Mood Stabilizers B1 Antidiabetic Agents

C1 C1 Dep Acar akot bos e e ER Depakote ER (Oral Acarbose (Oral Tablet) 1

C1 Acto plus Tablet Extended 3 Met Actoplus Met (Oral Release 24 Hour) Tablet Immediate 3 QL C1 Dep akot e Depakote (Oral Tablet Release)

C1 Acto 3 s Delayed Release) Actos (Oral Tablet) 3 QL C1 Dep C1 akot e Adly Spri xin nkle Start s er Pac Depakote Sprinkles k Adlyxin Starter Pack (Oral Capsule 3 (Subcutaneous Pen- 3 ST; QL Delayed Release Injector Kit)

C1 Adly Sprinkle) xin

C1 Adlyxin Diva lpro ex Sodi um ER Divalproex Sodium ER (Subcutaneous 3 ST; QL (Oral Tablet Extended 1 Solution Pen-Injector)

C1 Alog lipti n Ben Release 24 Hour) zoat e

C1 Diva lpro Alogliptin Benzoate ex Sodi um 3 ST; QL Divalproex Sodium (Oral Tablet) C1 Alog lipti n- Metf (Oral Capsule Delayed 1 ormi n HCl Alogliptin-Metformin Release Sprinkle) 3 ST; QL

C1 Diva lpro ex HCl (Oral Tablet) Sodi um C1 Alog lipti n- Divalproex Sodium Piog litaz one Alogliptin-Pioglitazone (Oral Tablet Delayed 1 3 ST; QL (Oral Tablet)

C1 Ama Release) ryl

C1 Equ etro Amaryl (Oral Tablet) 3 QL

C1 Equetro (Oral Ava ndia Avandia (Oral Tablet) 3 PA; QL Capsule Extended 3 C1 Byd ureo n BCis Release 12 Hour) e Bydureon BCise

C1 Lithi um Car bon ate ER Lithium Carbonate ER (Subcutaneous Auto- 3 QL Injector)

(Oral Tablet Extended 1 C1 Byd ureo Release) n Bydureon

C1 Lithi um Car bon ate Lithium Carbonate (Subcutaneous Pen- 3 QL 1 (Oral Capsule) Injector)

C1 C1 Lithi Byet um ta Car 10M bon CG ate Pen Lithium Carbonate Byetta 10MCG Pen (Oral Tablet Immediate 1 (Subcutaneous 3 ST; QL Release) Solution Pen-Injector) C1 Lithi C1 um Byet ta 5M CG Lithium (Oral Pen 1 Byetta 5MCG Pen Solution) (Subcutaneous 3 ST; QL C1 Lith obid Lithobid (Oral Tablet Solution Pen-Injector)

C1 Cycl 4 oset Extended Release) Cycloset (Oral Tablet) 3 PA

Bold type = Brand name drug Plain type = Generic drug 92 tRACK 92 Last updated September 1, 2019 5491 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Due Invo tact kam et Duetact (Oral Tablet) 3 QL XR Invokamet XR (Oral

C1 Farx iga Farxiga (Oral Tablet) 3 ST; QL Tablet Extended 2 QL

C1 Fort ame t Release 24 Hour)

Fortamet (Oral Tablet C1 Invo kan Extended Release 24 4 PA; QL a Invokana (Oral Tablet) 2 QL C1 Jan ume Hour) t Janumet (Oral Tablet

C1 Glim epiri de 2 QL Glimepiride (Oral Immediate Release) C1 Jan ume 1 QL t XR Tablet) Janumet XR (Oral C1 Glipi zide ER Glipizide ER (Oral Tablet Extended 2 QL Tablet Extended 1 QL Release 24 Hour)

C1 Jan Release 24 Hour) uvia C1 Januvia (Oral Tablet) 2 QL Glipi zide C1 Jard ianc Glipizide (Oral Tablet e 1 QL Jardiance (Oral Immediate Release) 2 QL C1 Tablet) Glipi zide- Metf ormi C1 n Jent HCl adu Glipizide-Metformin eto 1 QL Jentadueto (Oral HCl (Oral Tablet)

C1 Gluc Tablet Immediate oph 2 QL age Glucophage (Oral Release)

C1 Jent adu eto Tablet Immediate XR 3 QL Jentadueto XR (Oral Release)

C1 Gluc Tablet Extended oph 2 QL age XR Glucophage XR (Oral Release 24 Hour)

C1 Kaz Tablet Extended 3 QL ano Kazano (Oral Tablet) 3 ST; QL

C1 Ko mbi glyz Release 24 Hour) e XR C1 Gluc otrol Kombiglyze XR (Oral Glucotrol (Oral Tablet 3 QL Tablet Extended 3 QL Immediate Release)

C1 Gluc Release 24 Hour) otrol XL C1 Metf ormi n HCl Glucotrol XL (Oral ER Metformin HCl ER Tablet Extended 3 QL (1000MG Oral Tablet Release 24 Hour)

C1 Extended Release 24 Glu met za Glumetza (Oral Tablet Hour, 500MG Oral 4 PA; QL Extended Release 24 4 PA; QL Tablet Extended Hour) Release 24 Hour)

C1 Glys et (Generic Glumetza) Glyset (Oral Tablet) C1 3 Metf ormi n C1 HCl ER Glyx amb i Glyxambi (Oral Metformin HCl ER 2 QL Tablet) (1000MG Oral Tablet

C1 Invo kam et Extended Release 24 4 PA; QL Invokamet (Oral Hour) (Generic Tablet Immediate 2 QL Fortamet) Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 93 93 5592 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Metf Qter ormi n n HCl ER Metformin HCl ER Qtern (Oral Tablet) 3 ST; QL

C1 Rep agli (500MG Oral Tablet nide Repaglinide (Oral 1 QL Extended Release 24 3 PA; QL Tablet)

C1 Rep agli nide - Hour) (Generic Metf ormi n HCl Repaglinide-Metformin Fortamet) 3 QL

C1 Metf ormi HCl (Oral Tablet) n HCl ER C1 Rio Metformin HCl ER met Riomet (Oral (Oral Tablet Extended 3 QL Solution)

C1 Segl Release 24 Hour) 1 QL uro met Segluromet (Oral (Generic Glucophage 3 ST; QL XR) Tablet) C1 C1 Soli qua Metf ormi n HCl Metformin HCl (Oral Soliqua Tablet Immediate 1 QL (Subcutaneous 2 QL Release) Solution Pen-Injector)

C1 C1 Migl itol Starl ix Miglitol (Oral Tablet) 1 Starlix (Oral Tablet) 3 QL C1 C1 Nat egli Steg nide Nateglinide (Oral latro Steglatro (Oral 1 QL 3 ST; QL Tablet) Tablet) C1 Nesi C1 na Steg Nesina (Oral Tablet) 3 ST; QL lujan Steglujan (Oral C1 Ong lyza 3 ST; QL Onglyza (Oral Tablet) 3 QL Tablet)

C1 C1 Ose Sym ni linP en Oseni (Oral Tablet) 3 ST; QL 120 SymlinPen 120

C1 Oze mpi c Ozempic (Subcutaneous 4 PA (Subcutaneous 2 QL Solution Pen-Injector) C1 Sym linP en Solution Pen-Injector) 60 SymlinPen 60

C1 Piog litaz one HCl Pioglitazone HCl (Oral (Subcutaneous 4 PA 1 QL Tablet) Solution Pen-Injector)

C1 C1 Synj Piog ardy litaz one HCl- Glim epiri de Pioglitazone HCl- Synjardy (Oral Tablet 2 QL Glimepiride (Oral 3 QL Immediate Release)

C1 Synj ardy Tablet) XR C1 Synjardy XR (Oral Piog litaz one HCl- Metf ormi n HCl Pioglitazone HCl- Tablet Extended 2 QL Metformin HCl (Oral 1 QL Release 24 Hour)

C1 Tola zami Tablet) de

C1 Pran din Tolazamide (250MG Prandin (1MG Oral 3 QL Oral Tablet, 500MG 1 QL Tablet)

C1 Oral Tablet) Pran din C1 Tolb uta mid Prandin (2MG Oral e 4 QL Tolbutamide (Oral Tablet) 1 QL

C1 Tablet) Prec ose Precose (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 94 tRACK 94 Last updated September 1, 2019 5693 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Trad Bas jent agla a r Kwi kPe Tradjenta (Oral n Basaglar KwikPen 2 QL Tablet) (Subcutaneous 3 ST

C1 Truli city Trulicity Solution Pen-Injector) C1 Hu mal og Juni or Kwi kPe (Subcutaneous 2 QL n Humalog Junior Solution Pen-Injector) KwikPen

C1 Vict oza 2 Victoza (Subcutaneous (Subcutaneous 2 QL Solution Pen-Injector) C1 Hu mal og Kwi kPe Solution Pen-Injector) n Humalog KwikPen

C1 Xigd uo XR Xigduo XR (Oral (Subcutaneous 2 Tablet Extended 3 ST; QL Solution Pen-Injector) C1 Hu mal og Mix 50/5 0 Kwi kPe Release 24 Hour) n Humalog Mix 50/50

C1 Xult oph y KwikPen Xultophy (Subcutaneous 3 ST; QL (Subcutaneous 2 Solution Pen-Injector) Suspension Pen- B1 Injector) Glycemic Agents C1 Hu mal C1 og Gluc Mix aGe 50/5 n 0 Hyp oKit GlucaGen HypoKit Humalog Mix 50/50

(Injection Solution 3 (Subcutaneous 2 Suspension)

Reconstituted) C1 Hu mal C1 og Gluc Mix ago 75/2 n 5 Eme Kwi rgen kPe cy Glucagon Emergency n Humalog Mix 75/25 2 KwikPen (Injection Kit) C1 Pro glyc em Proglycem (Oral (Subcutaneous 2 4 Suspension) Suspension Pen-

B1 Injector)

C1 Hu mal og Mix 75/2 C1 5 Afre zza Humalog Mix 75/25 Afrezza (12UNIT (Subcutaneous 2 Inhalation Powder, 4 Suspension)

C1 Hu mal & 8 & 12UNIT og Humalog Inhalation Powder, 4 4 PA & 8UNIT Inhalation (Subcutaneous 2 Solution)

C1 Powder, 8 & 12UNIT Hu mal og Humalog Inhalation Powder) C1 Afre zza Afrezza (4UNIT (Subcutaneous 2 Inhalation Powder, Solution Cartridge) 3 PA 8UNIT Inhalation Powder)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 95 95 5794 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Hu Lev muli emir n 70/3 0 Kwi kPe n Humulin 70/30 Levemir

KwikPen (Subcutaneous 2

(Subcutaneous 2 Solution)

C1 Touj eo Max Solo Suspension Pen- Star Toujeo Max SoloStar

Injector) (Subcutaneous 2 C1 Hu muli n 70/3 0 Humulin 70/30 Solution Pen-Injector)

C1 Touj eo Solo (Subcutaneous 2 Star Toujeo SoloStar

Suspension) (Subcutaneous 2 C1 Hu muli n N Kwi kPe n Humulin N KwikPen Solution Pen-Injector)

C1 Tres iba Flex Tou (Subcutaneous ch Tresiba FlexTouch 2 Suspension Pen- (Subcutaneous 2 Injector) Solution Pen-Injector) C1 Hu C1 muli n N Tres Humulin N iba Tresiba

(Subcutaneous 2 (Subcutaneous 2 Suspension) Solution) C1 Hu muli n R Humulin R (Injection A1 2 Blood Products/Modifiers/Volume Expanders Solution) B1 C1 Anticoagulants Hu muli n R C1 U-50 Arixt 0 Humulin R U-500 ra Arixtra (Concentrated) 2 (Subcutaneous 4 (Subcutaneous Solution)

C1 Bev Solution) yxxa

C1 Hu Bevyxxa (Oral muli n R U-50 0 Kwi kPe n 3 QL Humulin R U-500 Capsule)

C1 Cou mad in KwikPen Coumadin (Oral 2 2 (Subcutaneous Tablet)

C1 Eliq Solution Pen-Injector) uis

C1 Lant us Solo Eliquis (Oral Tablet) 2 QL Star

C1 Eliq uis Start Lantus SoloStar er Pac k Eliquis Starter Pack (Subcutaneous 2 2 QL (Oral Tablet) Solution Pen-Injector)

C1 Lant us Lantus

(Subcutaneous 2 Solution)

C1 Lev emir

Flex Tou ch Levemir FlexTouch

(Subcutaneous 2 Solution Pen-Injector)

Bold type = Brand name drug Plain type = Generic drug 96 tRACK 96 Last updated September 1, 2019 5895 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Eno Frag xap min arin Sodi um Enoxaparin Sodium Fragmin (10000UNIT/ (100MG/ML ML Subcutaneous Subcutaneous Solution, 12500UNIT/ Solution, 120MG/ 0.5ML Subcutaneous 0.8ML Subcutaneous Solution, 15000UNIT/ Solution, 150MG/ML 3 QL 0.6ML Subcutaneous Subcutaneous Solution, 18000UNT/ Solution, 60MG/0.6ML 0.72ML Subcutaneous 4 Solution, 80MG/0.8ML Subcutaneous Subcutaneous Solution, 5000UNIT/ Solution) 0.2ML Subcutaneous

C1 Eno xap arin Sodi um Enoxaparin Sodium Solution, 7500UNIT/ (30MG/0.3ML 0.3ML Subcutaneous Subcutaneous Solution, 95000UNIT/ 1 QL Solution, 40MG/0.4ML 3.8ML Subcutaneous Subcutaneous Solution)

C1 Frag Solution) min C1 Fragmin (2500UNIT/ Fon dap arin ux Sodi um Fondaparinux Sodium 0.2ML Subcutaneous 3 (10MG/0.8ML Solution)

C1 Hep arin Sodi Subcutaneous um Solution, 5MG/0.4ML Heparin Sodium 4 Subcutaneous (10000UNIT/ML Solution, 7.5MG/ Injection Solution, 0.6ML Subcutaneous 20000UNIT/ML 1 Solution) Injection Solution,

C1 Fon dap arin 5000UNIT/ML ux Sodi um Fondaparinux Sodium Injection Solution)

C1 Hep arin Sodi (2.5MG/0.5ML um 3 Subcutaneous Heparin Sodium Solution) (1000UNIT/ML 1 B/D, PA Injection Solution)

C1 Jant ove n Jantoven (Oral Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 97 97 5996 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Lov Aran eno esp x Lovenox (100MG/ML Aranesp (Albumin Subcutaneous Free) (100MCG/ML Solution, 120MG/ Injection Solution, 0.8ML Subcutaneous 200MCG/ML Solution, 60MG/ 4 QL Injection Solution, 4 PA 0.6ML Subcutaneous 300MCG/ML Solution, 80MG/ Injection Solution, 0.8ML Subcutaneous 60MCG/ML Injection Solution) Solution)

C1 C1 Lov Aran eno esp x Lovenox (150MG/ML Aranesp (Albumin Subcutaneous Free) (25MCG/ML Solution, 30MG/ Injection Solution, 3 PA 0.3ML Subcutaneous 3 QL 40MCG/ML Injection Solution, 40MG/ Solution)

C1 Aran 0.4ML Subcutaneous esp Aranesp (Albumin Solution) Free) (100MCG/ C1 Prad axa Pradaxa (Oral 0.5ML Injection 3 ST; QL Capsule) Solution Prefilled

C1 Sav aysa Savaysa (Oral Tablet) 3 ST; QL Syringe, 150MCG/

C1 Warf arin Sodi um Warfarin Sodium (Oral 0.3ML Injection 1 Tablet) Solution Prefilled

C1 Xare lto Xarelto (Oral Tablet) 2 QL Syringe, 200MCG/

C1 Xare lto Start er Pac 0.4ML Injection k Xarelto Starter Pack Solution Prefilled 4 PA (Oral Tablet Therapy 2 QL Syringe, 300MCG/ Pack)

C1 Zont ivity 0.6ML Injection Zontivity (Oral Tablet) 3 PA Solution Prefilled B1 Blood Formation Modifiers C1 Syringe, 500MCG/ML Agry lin Agrylin (Oral Capsule) 3 Injection Solution C1 Ana greli de HCl Anagrelide HCl Prefilled Syringe, 3 (0.5MG Oral Capsule) 60MCG/0.3ML C1 Ana greli de HCl Anagrelide HCl (1MG Injection Solution 1 Oral Capsule) Prefilled Syringe)

Bold type = Brand name drug Plain type = Generic drug 98 tRACK 98 Last updated September 1, 2019 6097 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Aran Mul esp plet Aranesp (Albumin a Mulpleta (Oral Tablet) 4 PA

C1 Neul Free) (10MCG/0.4ML asta Neulasta Injection Solution (Subcutaneous 4 PA Prefilled Syringe, Solution Prefilled 25MCG/0.42ML Syringe)

C1 3 PA Neu pog Injection Solution en Neupogen (Injection 4 ST Prefilled Syringe, Solution)

C1 Neu pog 40MCG/0.4ML en Neupogen (Injection Injection Solution Solution Prefilled 4 ST Prefilled Syringe)

C1 Dop Syringe) telet

C1 Nive sty Doptelet (Oral Tablet) 4 PA m

C1 Epo Nivestym (Injection gen 4 ST Epogen (10000UNIT/ Solution)

C1 Nive sty ML Injection Solution, m Nivestym (Injection 2000UNIT/ML Solution Prefilled 4 ST Injection Solution, 3 PA Syringe) C1 Proc 3000UNIT/ML rit Procrit (10000UNIT/ Injection Solution, ML Injection Solution, 4000UNIT/ML 2000UNIT/ML Injection Solution)

C1 Epo gen Injection Solution, Epogen (20000UNIT/ 3 PA 4 PA 3000UNIT/ML ML Injection Solution)

C1 Fulp Injection Solution, hila Fulphila 4000UNIT/ML (Subcutaneous Injection Solution)

4 PA C1 Proc Solution Prefilled rit Procrit (20000UNIT/ Syringe)

C1 Gra ML Injection Solution, nix 4 PA Granix 40000UNIT/ML (Subcutaneous 4 ST Injection Solution)

C1 Pro mac Solution) ta

C1 Gra Promacta (Oral nix 4 PA; LA; QL Granix Packet)

C1 Pro mac (Subcutaneous ta Promacta (Oral 4 ST 4 PA; LA; QL Solution Prefilled Tablet) Syringe)

C1 Leu kine Leukine (Injection Solution 4 PA Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 99 99 6198 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Reta Clo crit pido grel Bisu Retacrit (10000UNIT/ lfate Clopidogrel Bisulfate 1 QL ML Injection Solution, (75MG Oral Tablet) C1 Effie nt 2000UNIT/ML Effient (Oral Tablet) 3

C1 Plavi Injection Solution, x Plavix (Oral Tablet) 3 QL 3 PA C1 Pras ugre l 3000UNIT/ML HCl Prasugrel HCl (Oral 1 Injection Solution, Tablet) 4000UNIT/ML A1 Cardiovascular Agents

Injection Solution) B1

C1 Reta crit Alpha-adrenergic Agonists

C1 Cata Retacrit (40000UNIT/ pres 4 PA Catapres (Oral ML Injection Solution) 3

C1 Ude nyca Tablet)

C1 Cata pres - Udenyca TTS- 1 Catapres-TTS-1 (Subcutaneous 4 PA (Transdermal Patch 3 Solution Prefilled Weekly)

C1 Cata pres Syringe) - TTS- 2 C1 Zarx io Catapres-TTS-2 Zarxio (Injection (Transdermal Patch 3 Solution Prefilled 4 Weekly)

C1 Cata pres Syringe) - TTS- 3

B1 Catapres-TTS-3 Hemostasis Agents

C1 Lyst eda (Transdermal Patch 3 Lysteda (Oral Tablet) 3

C1 Tav Weekly) aliss e C1 Clon idin e Tavalisse (Oral HCl 4 PA; QL Clonidine HCl (Oral Tablet) C1 Tablet Immediate 1 Tran exa mic Acid Tranexamic Acid (Oral Release)

C1 1 Clon idin Tablet) e Clonidine B1 Platelet Modifying Agents (Transdermal Patch 1 C1 Agg reno x Aggrenox (Oral Weekly) C1 Met hyld Capsule Extended 3 QL opa Methyldopa (Oral 1 PA; HRM Release 12 Hour) Tablet) C1 C1 Mid odri Aspi ne rin- HCl Dipy rida mol e ER Midodrine HCl (Oral Aspirin-Dipyridamole 1 ER (Oral Capsule Tablet) C1 Nort 3 QL hera Extended Release 12 Northera (Oral 4 PA; LA; QL Hour) Capsule) C1 Brili nta Brilinta (Oral Tablet) 2 QL B1 Alpha-adrenergic Blocking Agents C1 Cabl ivi C1 Car Cablivi (Injection Kit) 4 PA; QL dura Cardura (Oral Tablet C1 Cilo staz ol 3 Cilostazol (Oral Tablet) 1 Immediate Release)

Bold type = Brand name drug Plain type = Generic drug 100 tRACK 100 Last updated September 1, 2019 6299 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Dibe Alta nzyli ce ne Dibenzyline (Oral Altace (Oral Capsule) 3 QL

C1 Ben aze 4 pril Capsule) HCl Benazepril HCl (Oral C1 Dox azos in Mes 1 QL ylate Doxazosin Mesylate Tablet) C1 Cap topri 1 l (Oral Tablet) Captopril (Oral Tablet) 1 QL C1 Mini C1 pres s Enal april

Mal Minipress (Oral eate Enalapril Maleate (Oral 3 1 QL Capsule) Tablet)

C1 C1 Phe nox Fosi ybe nopr nza il min Sodi e um HCl Phenoxybenzamine Fosinopril Sodium 4 1 QL HCl (Oral Capsule) (Oral Tablet)

C1 C1 Praz osin Lisin HCl Prazosin HCl (Oral opril Lisinopril (Oral Tablet) 1 QL

C1 Lote 1 nsin Capsule) Lotensin (Oral Tablet) 3 QL

B1 C1 Moe xipril Angiotensin II Receptor Antagonists HCl C1 Moexipril HCl (Oral Atac and 1 QL Atacand (Oral Tablet) 3 QL Tablet)

C1 C1 Ava pro Peri ndo pril Erb umi Avapro (Oral Tablet) 3 QL ne Perindopril Erbumine

C1 Beni car 1 QL Benicar (Oral Tablet) 3 QL (Oral Tablet) C1

C1 Prini vil Can des arta n Cile xetil Candesartan Cilexetil Prinivil (Oral Tablet) 3 QL C1 Qbr 1 QL elis (Oral Tablet) Qbrelis (Oral

C1 Coz aar 4 QL Cozaar (Oral Tablet) 3 QL Solution) C1 C1 Quin Diov april an Diovan (Oral Tablet) 3 QL HCl Quinapril HCl (Oral

C1 Edar 1 QL bi Tablet) Edarbi (Oral Tablet) 3 QL C1 Ram ipril C1 Epr osar tan Mes ylate Ramipril (Oral Eprosartan Mesylate 1 QL 1 QL Capsule) (Oral Tablet) C1 Tran dola C1 pril Irbe sart an Trandolapril (Oral Irbesartan (Oral Tablet) 1 QL 1 QL C1 Los arta n Pota Tablet) ssiu m C1 Vas Losartan Potassium otec 1 QL (Oral Tablet) Vasotec (10MG Oral

C1 Mic ardi s Tablet, 20MG Oral 4 QL Micardis (Oral Tablet) 3 QL

C1 Olm esar tan Med Tablet) oxo mil C1 Vas Olmesartan otec Medoxomil (Oral 1 QL Vasotec (2.5MG Oral Tablet) Tablet, 5MG Oral 3 QL

C1 Tel misa rtan Tablet)

C1 Telmisartan (Oral Zest 1 QL ril Tablet) Zestril (Oral Tablet) 3 QL

C1 B1 Vals arta n Valsartan (Oral Tablet) 1 QL Antiarrhythmics C1 Ami odar one HCl B1 Amiodarone HCl (Oral Angiotensin-converting Enzyme (ACE) 1 Inhibitors Tablet)

C1 Acc upril Accupril (Oral Tablet) 3 QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 101 101 63100 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Beta Sota pac lol e AF Betapace AF (120MG HCl Sotalol HCl (Oral 1 Oral Tablet, 160MG 4 Tablet) C1 Soty Oral Tablet) lize Sotylize (Oral

C1 Beta pac e AF 3 PA Betapace AF (80MG Solution) C1 Tiko 3 syn Oral Tablet) Tikosyn (Oral

C1 Dof etili de 3 Dofetilide (Oral Capsule)

3 B1 Capsule) Beta-adrenergic Blocking Agents C1 Flec C1 aini de Ace Acet buto ate lol Flecainide Acetate HCl Acebutolol HCl (Oral 1 1 (Oral Tablet) Capsule) C1 Mex C1 iletin e Aten HCl olol Mexiletine HCl (Oral Atenolol (Oral Tablet) 1 1 C1 Beta xolo l Capsule) HCl C1 Mult Betaxolol HCl (Oral aq 1 Multaq (Oral Tablet) 2 Tablet) C1 Pac C1 eron e Biso prol ol Fum arat Pacerone (100MG Oral e Bisoprolol Fumarate 1 Tablet, 400MG Oral 3 (Oral Tablet)

C1 Byst Tablet) olic C1 Bystolic (Oral Tablet) Pac 2 QL eron e C1 Carv edil Pacerone (200MG Oral ol 1 Carvedilol (Oral Tablet) 1 C1 Carv edil ol Tablet) Pho sph ate C1 ER Pro pafe non Carvedilol Phosphate e HCl ER Propafenone HCl ER ER (Oral Capsule (Oral Capsule 3 3 Extended Release 24 Extended Release 12 Hour)

C1 Cor eg Hour) CR

C1 Pro pafe non Coreg CR (Oral e HCl Propafenone HCl (Oral 1 Capsule Extended 3 Tablet)

C1 Quin idin e Release 24 Hour) Gluc onat e C1 ER Cor Quinidine Gluconate eg Coreg (Oral Tablet) 3

C1 Cor ER (Oral Tablet 3 gard Corgard (Oral Tablet) 3

Extended Release) C1 Inde C1 ral LA Quin idin e Sulf ate Quinidine Sulfate (Oral Inderal LA (Oral 1 Tablet) Capsule Extended 4

C1 Ryth mol SR Release 24 Hour)

Rythmol SR (Oral C1 Inno Pran XL InnoPran XL (Oral Capsule Extended 4 Release 12 Hour) Capsule Extended 4

C1 Sori ne Release 24 Hour)

Sorine (Oral Tablet) 1 C1 Lab C1 etal ol Sota HCl lol HCl Sotalol HCl (AF) Labetalol HCl (Oral 1 1 (120MG Oral Tablet) Tablet)

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C1 C1 Lopr Cala ess n or Lopressor (100MG SR Calan SR (120MG 3 Oral Tablet) Oral Tablet Extended

C1 Met opr olol Suc cina te ER Metoprolol Succinate Release, 240MG Oral 3 ER (Oral Tablet Tablet Extended 1 Extended Release 24 Release)

C1 Car dize m Hour) CD

C1 Cardizem CD (Oral Met opr olol Tartr ate Metoprolol Tartrate Capsule Extended 4 (100MG Oral Tablet, Release 24 Hour)

1 C1 Car dize m 25MG Oral Tablet, LA Cardizem LA (Oral 50MG Oral Tablet)

C1 Nad olol Tablet Extended 3 Nadolol (Oral Tablet) 1

C1 Pind Release 24 Hour) olol

C1 Car dize Pindolol (Oral Tablet) 1 m C1 Pro Cardizem (Oral Tablet pran olol HCl ER 4 Propranolol HCl ER Immediate Release)

C1 Carti (Oral Capsule a XT 1 Cartia XT (Oral Extended Release 24 Capsule Extended 1 Hour)

C1 Pro pran Release 24 Hour) olol HCl C1 Dilti aze m HCl Propranolol HCl (Oral ER Bea 1 ds Diltiazem HCl ER Solution)

C1 Pro pran Beads (360MG Oral olol HCl Propranolol HCl (Oral 1 Capsule Extended Tablet)

C1 Release 24 Hour, 1 Ten ormi n Tenormin (Oral 420MG Oral Capsule 3 Tablet) Extended Release 24

C1 Top rol XL Hour) Toprol XL (Oral Tablet C1 Dilti aze m HCl ER Coa ted Bea Extended Release 24 3 ds Diltiazem HCl ER Hour) Coated Beads (120MG

B1 Oral Capsule Extended Calcium Channel Blocking Agents

C1 Adal at Release 24 Hour, CC Adalat CC (Oral 180MG Oral Capsule Tablet Extended 3 Extended Release 24 1 Release 24 Hour) Hour, 240MG Oral C1 Aml odip ine Bes ylate Amlodipine Besylate Capsule Extended 1 (Oral Tablet) Release 24 Hour,

C1 Cala n Calan (Oral Tablet 300MG Oral Capsule 3 Immediate Release) Extended Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 103 103 65102 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Dilti Proc aze ardi m a XL HCl ER Diltiazem HCl ER (Oral Procardia XL (Oral

Capsule Extended 1 Tablet Extended 3 Release 12 Hour) Release 24 Hour) C1

Dilti C1 aze m Sula HCl Diltiazem HCl (Oral r Sular (Oral Tablet

Tablet Immediate 1 Extended Release 24 3 Release) C1 Hour) Dilt- XR C1 Tazt ia Dilt-XR (Oral Capsule XT Taztia XT (Oral Extended Release 24 1 Capsule Extended 1 Hour)

C1 Felo Release 24 Hour) dipi ne C1 ER Tiaz Felodipine ER (Oral ac Tiazac (Oral Capsule

Tablet Extended 1 Extended Release 24 3 Release 24 Hour)

C1 Isra dipi ne Hour)

C1 Vera pam il Isradipine (Oral HCl 1 ER Verapamil HCl ER Capsule)

C1 Mat zim LA (100MG Oral Capsule Matzim LA (Oral Tablet Extended Release 24 Extended Release 24 1 Hour, 120MG Oral Hour) C1 Capsule Extended Nica rdipi ne HCl Nicardipine HCl (Oral 1 Release 24 Hour, Capsule) 180MG Oral Capsule C1 Nife dipi ne ER Extended Release 24 Nifedipine ER (Oral 1 Tablet Extended 1 Hour, 200MG Oral Release 24 Hour) Capsule Extended

C1 Nife dipi ne ER Os moti Release 24 Hour, c Rele ase Nifedipine ER Osmotic Release (Oral Tablet 240MG Oral Capsule 1 Extended Release 24 Extended Release 24 Hour) Hour, 300MG Oral

C1 Nim odip ine Capsule Extended Nimodipine (Oral 3 Release 24 Hour) C1 Vera pam il Capsule) HCl ER C1 Niso ldipi ne Verapamil HCl ER ER Nisoldipine ER (Oral (360MG Oral Capsule Tablet Extended 3 1 Release 24 Hour) Extended Release 24

C1 Nor vasc Hour)

C1 Vera pam Norvasc (Oral Tablet) 3 il HCl ER C1 Nym alize Verapamil HCl ER Nymalize (60MG/ 4 (Oral Tablet Extended 1 20ML Oral Solution) Release)

Bold type = Brand name drug Plain type = Generic drug 104 tRACK 104 Last updated September 1, 2019 66103 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Vera Aten pam olol- il Chlo HCl rthal idon Verapamil HCl (Oral e Atenolol- Tablet Immediate 1 Chlorthalidone (Oral 1 Release) Tablet)

C1 C1 Vere Aval lan Verelan (Oral Capsule ide Avalide (Oral Tablet) 3 QL

C1 Azor Extended Release 24 3 Azor (Oral Tablet) 3 QL

C1 Ben aze pril- Hyd roch lorot Hour) hiazi de C1 Benazepril- Vere lan PM Verelan PM (Oral Hydrochlorothiazide 1 QL Capsule Extended 3 (Oral Tablet)

C1 Beni car Release 24 Hour) HCT Benicar HCT (Oral

B1 3 QL Cardiovascular Agents, Other Tablet)

C1 C1 BiDil Acc ureti c Accuretic (Oral BiDil (Oral Tablet) 2

C1 Biso prol 3 QL ol- Hyd roch lorot hiazi Tablet) de Bisoprolol- C1 Alda ctazi de Aldactazide (Oral Hydrochlorothiazide 1 QL 3 Tablet) (Oral Tablet) C1 Cad C1 uet Alis kire n Fum arat e Caduet (Oral Tablet) 3 QL

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

C1 Amil orid 1 QL e- Hyd roch lorot hiazi de HCTZ (Oral Tablet)

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

C1 Aml odip ine- Ator vast atin (Oral Tablet)

Amlodipine- C1 Corl Atorvastatin (Oral 3 QL anor Corlanor (Oral Tablet) 3 PA; QL

C1 De mse Tablet) r C1 Demser (Oral Aml odip ine- Ben aze pril 4 Amlodipine-Benazepril Capsule)

C1 1 QL Digit (Oral Capsule) ek C1 Digitek (125MCG Oral Aml odip ine- Olm esar tan 1 HRM; QL Amlodipine- Tablet)

C1 Digit Olmesartan (Oral 1 QL ek Digitek (250MCG Oral Tablet) 1 PA; HRM C1 Tablet) Aml odip ine- C1 Vals arta Dig n Amlodipine-Valsartan ox 1 QL Digox (125MCG Oral (Oral Tablet) 1 HRM; QL C1 Tablet) Aml odip ine- C1 Vals arta Dig n- ox HCT Z Amlodipine-Valsartan- 1 Digox (250MCG Oral HCTZ (Oral Tablet) 1 PA; HRM C1 Tablet) Atac and HCT C1 Dig Atacand HCT (Oral oxin Digoxin (Oral PA; HRM; 3 QL 1 Tablet) Solution) QL

C1 Dig oxin Digoxin (125MCG Oral 1 HRM; QL Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 105 105 67104 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Dig Los oxin arta n Pota ssiu m- HCT Digoxin (250MCG Oral Z Losartan Potassium- 1 PA; HRM 1 QL Tablet) HCTZ (Oral Tablet)

C1 C1 Diov Lotr an el HCT Diovan HCT (Oral Lotrel (Oral Capsule) 3 QL

C1 Max 3 QL zide Tablet) Maxzide (Oral Tablet) 3 C1 DUT C1 OP ROL Max zide- DUTOPROL (Oral 25 Maxzide-25 (Oral 3 Tablet Extended 3 Tablet)

C1 Met opr olol- Hyd roch lorot Release 24 Hour) hiazi de C1 Metoprolol- Dya zide Dyazide (Oral Hydrochlorothiazide 1 3 Capsule) (Oral Tablet)

C1 C1 Mic Edar ardi bycl s or Edarbyclor (Oral HCT Micardis HCT (Oral 3 QL 3 QL Tablet) Tablet)

C1 C1 Nad Enal olol- april Ben - drofl Hyd ume roch thiaz lorot ide hiazi de Enalapril- Nadolol- Hydrochlorothiazide 1 QL Bendroflumethiazide 1 (Oral Tablet) (40-5MG Oral Tablet)

C1 C1 Olm Entr esar esto tan Med oxo mil- HCT Entresto (Oral Tablet) 2 QL Z Olmesartan

C1 Exfo rge HCT Exforge HCT (Oral Medoxomil-HCTZ (Oral 1 QL 3 Tablet) Tablet) C1 Olm esar tan- C1 Aml Exfo odip rge ine- HCT Exforge (Oral Tablet) 3 QL Z Olmesartan-

C1 Fosi nopr il Sodi Amlodipine-HCTZ 1 QL um- HCT Z Fosinopril Sodium- 1 QL (Oral Tablet) C1 Pent oxify HCTZ (Oral Tablet) lline ER

C1 Hyz aar Pentoxifylline ER (Oral Hyzaar (Oral Tablet) 3 QL

C1 Irbe Tablet Extended 1 sart an- Hyd roch lorot hiazi de Irbesartan- Release)

C1 Pro pran olol- HCT Hydrochlorothiazide 1 QL Z Propranolol-HCTZ (Oral Tablet) 1

C1 Lan (Oral Tablet) oxin

C1 Quin april - Hyd roch Lanoxin (125MCG lorot hiazi de Quinapril- Oral Tablet, 62.5MCG 3 HRM; QL Hydrochlorothiazide 1 QL Oral Tablet)

C1 (Oral Tablet) Lan oxin C1 Ran Lanoxin (250MCG exa Ranexa (Oral Tablet 3 PA; HRM Oral Tablet) Extended Release 12 C1 3 Lisin opril - Hyd roch lorot hiazi de Lisinopril- Hour)

C1 Ran olazi ne Hydrochlorothiazide 1 QL ER Ranolazine ER (Oral (Oral Tablet) C1 Tablet Extended 1 Lopr ess or HCT Lopressor HCT (Oral Release 12 Hour) 3 Tablet)

Bold type = Brand name drug Plain type = Generic drug 106 tRACK 106 Last updated September 1, 2019 68105 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Spir Zest onol oreti acto c ne- HCT Z Spironolactone-HCTZ Zestoretic (Oral 1 3 QL (Oral Tablet) Tablet) C1 C1 Tark a Tarka (Oral Tablet Ziac Ziac (2.5-6.25MG 3 QL 3 QL Extended Release) Oral Tablet) C1 Tekt urna

HCT Tekturna HCT (Oral B1 Diuretics, Carbonic Anhydrase Inhibitors

C1 Acet 3 QL azol ami de Tablet) ER

C1 Acetazolamide ER Tekt urna Tekturna (Oral Tablet) 3 QL (Oral Capsule

C1 Tel misa 1 rtan- Aml odip ine Telmisartan- Extended Release 12 Hour)

Amlodipine (Oral 1 QL C1 Acet azol ami Tablet) de Acetazolamide (Oral

C1 Tel misa 1 rtan- HCT Z Tablet)

Telmisartan-HCTZ C1 Kev 1 QL eyis (Oral Tablet) Keveyis (Oral Tablet) 4 PA; QL

C1 C1 Ten Met oreti haz c ola 100 mid Tenoretic 100 (Oral e Methazolamide (Oral 3 3 Tablet) Tablet)

C1 Ten oreti B1 c 50 Tenoretic 50 (Oral Diuretics, Loop C1 Bum etan 3 ide Tablet) Bumetanide (Injection

C1 Tran dola pril- 1 Vera pam il HCl ER Trandolapril-Verapamil Solution) C1 Bum etan HCl ER (Oral Tablet 1 QL ide Bumetanide (Oral 1 Extended Release) Tablet)

C1 C1 Tria mter Ede ene- crin HCT Z Triamterene-HCTZ Edecrin (Oral Tablet) 4

C1 Etha 1 cryn ic (Oral Capsule) Acid C1 Ethacrynic Acid (Oral Tria mter ene- HCT Z 3 Triamterene-HCTZ Tablet)

C1 Furo 1 sem (Oral Tablet) ide C1 Furosemide (Injection Trib enz or 1 B/D, PA Tribenzor (Oral Solution)

C1 Furo 3 QL sem Tablet) ide Furosemide (Oral C1 Twy nsta 1 Twynsta (40-10MG Solution)

C1 Furo sem Oral Tablet, 40-5MG ide Furosemide (Oral 3 QL 1 Oral Tablet, 80-5MG Tablet)

C1 Lasi x Oral Tablet) Lasix (Oral Tablet) 3 C1 Vals C1 arta n- Tors Hyd emi roch de lorot hiazi de Valsartan- Torsemide (Oral 1 Hydrochlorothiazide 1 QL Tablet)

(Oral Tablet) B1

C1 Vas Diuretics, Potassium-sparing ereti c C1 Alda cton Vaseretic (Oral e 3 QL Aldactone (Oral Tablet) 3

C1 Vec Tablet) amyl Vecamyl (Oral Tablet) 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 107 107 69106 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Amil Fen orid ofibr e ate HCl Amiloride HCl (Oral Fenofibrate (150MG 1 Tablet) Oral Capsule, 50MG 1

C1 Car oSpi r Oral Capsule) CaroSpir (Oral C1 Fen ofibr 3 ate Suspension) Fenofibrate (120MG C1 Dyre niu m Dyrenium (Oral Oral Tablet, 40MG Oral 3 3 Tablet)

C1 Capsule) Fen ofibr ate C1 Eple reno ne Eplerenone (Oral Fenofibrate (145MG 1 Tablet) Oral Tablet, 160MG

C1 Insp ra Oral Tablet, 48MG Oral 1 Inspra (Oral Tablet) 3 C1 Tablet, 54MG Oral Spir onol acto ne Spironolactone (Oral Tablet)

C1 1 Fen ofibr ic Tablet) Acid Fenofibric Acid (Oral B1 Diuretics, Thiazide Capsule Delayed 1 C1 Chlo rothi azid e Chlorothiazide (Oral Release) C1 Fen ofibr ic 1 Acid Tablet) Fenofibric Acid C1 Chlo rthal idon e 1 Chlorthalidone (Oral (105MG Oral Tablet)

C1 Fen 1 ofibr ic Tablet) Acid C1 Fenofibric Acid (35MG Diuri l 1 Diuril (Oral Oral Tablet)

C1 Fen ogli 3 de Suspension) Fenoglide (120MG C1 Hyd roch lorot hiazi 4 de Hydrochlorothiazide Oral Tablet)

C1 Fen 1 ogli (Oral Capsule) de Fenoglide (40MG Oral C1 Hyd roch lorot hiazi de 3 Hydrochlorothiazide Tablet)

C1 1 Fibri (Oral Tablet) cor C1 Fibricor (Oral Tablet) 3 Inda pam ide C1 Ge mfib Indapamide (Oral rozil 1 Gemfibrozil (Oral Tablet) 1 C1 Tablet) Met hycl othi C1 azid e Lipo Methyclothiazide (5MG fen 1 Lipofen (Oral Oral Tablet) 3

C1 Met Capsule) olaz one C1 Lopi Metolazone (Oral d 1 Lopid (Oral Tablet) 3 C1 Tric Tablet) or

B1 Tricor (Oral Tablet) 3

C1 Trigl Dyslipidemics, Fibric Acid Derivatives ide

C1 Anta ra Triglide (Oral Tablet) 3

C1 Trili Antara (Oral Capsule) 2 pix

C1 Fen ofibr ate Micr Trilipix (Oral Capsule oniz ed Fenofibrate Micronized 3 1 Delayed Release)

(Oral Capsule) B1 Dyslipidemics, HMG CoA Reductase Inhibitors

Bold type = Brand name drug Plain type = Generic drug 108 tRACK 108 Last updated September 1, 2019 70107 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Alto Zoc prev Altoprev (Oral Tablet or Zocor (10MG Oral Extended Release 24 4 QL Tablet, 20MG Oral Hour) Tablet, 40MG Oral 3 QL

C1 Ator vast atin Calc ium Atorvastatin Calcium Tablet, 80MG Oral 1 QL (Oral Tablet) Tablet)

C1 C1 Zypi Cres tam tor Crestor (Oral Tablet) 3 QL ag Zypitamag (Oral

C1 Ezall or 3 ST; QL Spri nkle Ezallor Sprinkle (Oral Tablet) 3 QL B1 Capsule Sprinkle) Dyslipidemics, Other

C1 C1 Chol FloL esty ipid rami ne Ligh FloLipid (Oral t Cholestyramine Light 3 QL 1 Suspension) (Oral Powder) C1 C1 Chol esty Fluv rami asta ne tin Sodi um ER Cholestyramine (Oral Fluvastatin Sodium ER 1 (Oral Tablet Extended 3 QL Packet) C1 Cole seve lam Release 24 Hour) HCl Colesevelam HCl (Oral C1 Fluv asta tin 3 Sodi um Fluvastatin Sodium Packet) C1 Cole seve lam 1 QL HCl (Oral Capsule) Colesevelam HCl (Oral C1 Les col XL 3 Lescol XL (Oral Tablet) C1 Cole stid Tablet Extended 3 QL Colestid (Oral Packet) 3

C1 Cole stid Release 24 Hour) Colestid (Oral Tablet) 3 C1 Lipit C1 or Cole stip ol Lipitor (Oral Tablet) 3 QL HCl Colestipol HCl (Oral C1 Lival o 1 Livalo (Oral Tablet) 2 QL Packet) C1 C1 Cole Lov stip asta ol tin Lovastatin (Oral HCl Colestipol HCl (Oral 1 QL 1 Tablet) Tablet) C1 C1 Ezet Prav imib ach e ol Pravachol (Oral Ezetimibe (Oral Tablet) 1 C1 Ezet imib e- 3 QL Sim vast Tablet) atin Ezetimibe-Simvastatin

C1 Prav asta tin 1 QL Sodi um Pravastatin Sodium (Oral Tablet) C1 Juxt 1 QL apid (Oral Tablet) Juxtapid (Oral

C1 Ros uvas tatin 4 PA; LA

Calc ium Rosuvastatin Calcium Capsule) C1 Lov 1 QL aza (Oral Tablet) Lovaza (Oral Capsule) 3 C1 Sim C1 vast atin Niac in Simvastatin (Oral ER 1 QL Niacin ER Tablet) (Antihyperlipidemic) 1 (Oral Tablet Extended Release)

C1 Niac or Niacor (Oral Tablet) 1

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 109 109 71108 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 Nias pan Niaspan (Oral Tablet B1 Vasodilators, Direct-acting Arterial/Venous

C1 GoN 3 itro Extended Release) GoNitro (Sublingual C1 Om ega- 3- Acid 3 Ethy l Este rs Omega-3-Acid Ethyl Packet)

C1 Isor dil Titra dos Esters (Oral Capsule) 1 e Isordil Titradose (Oral (Generic Lovaza) 4 C1 Tablet) Pral uent C1 Isos orbi de Dinit rate Praluent ER Isosorbide Dinitrate ER (Subcutaneous 3 PA; LA; QL (Oral Tablet Extended 1 Solution Pen-Injector) Release) C1 Prev C1 alite Isos orbi de Dinit Prevalite (Oral Packet) 1 rate Isosorbide Dinitrate C1 Que stra n Ligh t Questran Light (Oral (Oral Tablet Immediate 1 3 Powder) Release) C1 C1 Isos Que orbi stra de n Mon onitr ate Questran (Oral Packet) 3 ER Isosorbide

C1 Rep atha

Pus htro nex Syst Mononitrate ER (Oral em Repatha Pushtronex 1 System Tablet Extended 3 PA; QL Release 24 Hour)

C1 Isos (Subcutaneous orbi de Mon onitr Solution Cartridge) ate Isosorbide

C1 Rep atha Mononitrate (Oral 1 Repatha Tablet Immediate (Subcutaneous Release)

3 PA; QL C1 Mini Solution Prefilled tran Minitran (Transdermal Syringe) 1

C1 Rep Patch 24 Hour) atha

Sure C1 Clic Nitr k o- Repatha SureClick Bid Nitro-Bid (Transdermal 2 (Subcutaneous Ointment) 3 PA; QL C1 Nitr o- Solution Auto- Dur Nitro-Dur Injector)

C1 Vas (Transdermal Patch 3 cep a Vascepa (Oral 24 Hour)

3 C1 Nitr ogly ceri Capsule) n C1 Vyto Nitroglycerin (Tablet rin 1 Vytorin (Oral Tablet) 3 QL Sublingual) C1

Wel C1 chol Nitr ogly ceri Welchol (Oral Packet) 3 n Nitroglycerin C1 Wel chol Welchol (Oral Tablet) 3 (Transdermal Patch 24 1

C1 Zeti a Hour) Zetia (Oral Tablet) 3 C1 Nitr ogly ceri n B1 Vasodilators, Direct-acting Arterial Nitroglycerin

C1 1 Hyd ralaz ine HCl (Translingual Solution)

C1 Nitr Hydralazine HCl (Oral osta 1 t Tablet) Nitrostat (Tablet

C1 3 Min oxid il Minoxidil (Oral Tablet) 1 Sublingual)

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C1 C1 Rect Dext iv roa mph eta min e Sulf ate Rectiv (Rectal ER Dextroamphetamine 3 Ointment) Sulfate ER (10MG Oral A1 Central Nervous System Agents Capsule Extended

B1 Release 24 Hour, 3 QL Attention Deficit Hyperactivity Disorder 15MG Oral Capsule Agents, Amphetamines C1 Extended Release 24 Add erall Adderall (20MG Oral Hour)

C1 Dext roa mph eta min e Tablet, 5MG Oral Sulf ate 3 QL ER Dextroamphetamine Tablet, 7.5MG Oral Sulfate ER (5MG Oral Tablet) 1 QL C1 Capsule Extended Add erall XR Adderall XR (Oral Release 24 Hour)

C1 Dext roa mph eta min e Sulf Capsule Extended 3 QL ate Dextroamphetamine 1 QL Release 24 Hour) Sulfate (Oral Tablet) C1

Adz C1 enys ER Dya nav el Adzenys ER (Oral XR Dyanavel XR (Oral Suspension Extended 3 QL Suspension Extended 3 QL Release) Release) C1

Adz C1 enys XR- Eve ODT keo Adzenys XR-ODT Evekeo (Oral Tablet) 3

C1 Met ham phet ami ne (Oral Tablet Extended 3 QL HCl Methamphetamine HCl Release Dispersible) 3 PA

C1 (Oral Tablet) Am phet C1 ami ne Myd Sulf ayis ate Amphetamine Sulfate 3 Mydayis (Oral (Oral Tablet) C1 Capsule Extended 3 QL Am phet ami ne- Dext roa mph eta min e ER Amphetamine- Release 24 Hour)

C1 Pro Cen Dextroamphetamine tra ProCentra (Oral 3 ER (Oral Capsule 1 QL Solution)

C1 Vyv ans Extended Release 24 e Vyvanse (Oral Hour) 3 C1 Am phet ami ne- Dext Capsule) roa mph eta C1 min e Vyv Amphetamine- ans e Vyvanse (Oral Tablet Dextroamphetamine 1 QL 3 (Oral Tablet) Chewable) C1

C1 Zen zedi Des oxy n Desoxyn (Oral Tablet) 4 PA Zenzedi (Oral Tablet) 3 QL

C1 Dex B1 edri ne Dexedrine (Oral Attention Deficit Hyperactivity Disorder Capsule Extended 4 QL Agents, Non-amphetamines C1 Apt ensi o Release 24 Hour) XR Aptensio XR (Oral Capsule Extended 3 QL Release 24 Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 111 111 73110 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Ato Met mox hylp etin heni e date HCl HCl Atomoxetine HCl (Oral LA Methylphenidate HCl 1 Capsule) LA (Oral Capsule

C1 Clon idin 3 e HCl ER Clonidine HCl ER (Oral Extended Release 24 Hour)

Tablet Extended 3 PA C1 Met hylp heni date HCl Release 12 Hour) ER Methylphenidate HCl

C1 Con cert a Concerta (Oral Tablet ER (10MG Oral Tablet 3 QL Extended Release) Extended Release, 1 QL

C1 Cot emp la XR- 20MG Oral Tablet ODT Cotempla XR-ODT Extended Release)

C1 Met hylp heni (Oral Tablet Extended 3 QL date HCl ER Os moti c Rele ase Methylphenidate HCl Release Dispersible)

C1 Dayt rana ER Osmotic Release Daytrana 3 QL (18MG Oral Tablet (Transdermal Patch) Extended Release, C1 Dex met hylp heni date HCl ER Dexmethylphenidate 27MG Oral Tablet HCl ER (Oral Capsule Extended Release, 3 3 QL Extended Release 24 36MG Oral Tablet Hour) Extended Release,

C1 Dex met hylp heni date HCl Dexmethylphenidate 54MG Oral Tablet 1 QL HCl (Oral Tablet) Extended Release,

C1 Foc alin 72MG Oral Tablet Focalin (Oral Tablet) 3 QL

C1 Foc alin Extended Release) XR

C1 Met hylp heni date Focalin XR (Oral HCl ER Methylphenidate HCl Capsule Extended 3 ER (Oral Tablet Release 24 Hour) 3 QL C1 Extended Release 24 Kap vay Kapvay (Oral Tablet Hour)

C1 Met hylp heni date Extended Release 12 3 PA HCl Methylphenidate HCl 1 QL Hour) (Oral Solution) C1 C1 Met adat Met e hylp ER heni date Metadate ER (Oral HCl Methylphenidate HCl Tablet Extended 1 QL (Oral Tablet Immediate 1 QL Release) Release) (Generic C1 Met hylin Methylin (Oral Ritalin) C1 Met hylp heni 3 QL date Solution) HCl Methylphenidate HCl

C1 Met hylp 3 QL heni date HCl CD (Oral Tablet Chewable)

Methylphenidate HCl C1 Quill iChe w CD (Oral Capsule 1 ER QuilliChew ER (Oral Extended Release) Tablet Chewable 3 QL Extended Release)

Bold type = Brand name drug Plain type = Generic drug 112 tRACK 112 Last updated September 1, 2019 74111 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Quill Tigl ivant utik XR Quillivant XR (Oral Tiglutik (Oral 4 PA Suspension 3 Suspension)

C1 Xen azin Reconstituted) e Xenazine (Oral C1 Rele xxii 4 PA; LA Relexxii (Oral Tablet Tablet) 3 QL Extended Release) B1

C1 Fibromyalgia Agents Rital in C1 LA Cym balt Ritalin LA (Oral a Cymbalta (Oral Capsule Extended 3 Capsule Delayed 3 QL Release 24 Hour)

C1 Release Particles) Rital in C1 Dulo xeti ne Ritalin (Oral Tablet) 3 QL HCl

C1 Duloxetine HCl (20MG Strat tera Strattera (Oral Oral Capsule Delayed 3 Capsule) Release Particles, B1 30MG Oral Capsule Central Nervous System, Other 1 QL C1 Aust edo Delayed Release Austedo (Oral Tablet) 4 PA; LA; QL

C1 Grali se Particles, 60MG Oral Gralise (Oral Tablet) 3 PA

C1 Capsule Delayed Grali se Start er Gralise Starter (Oral) 3 PA Release Particles)

C1 C1 Hori Dulo zant xeti ne Horizant (Oral Tablet HCl Duloxetine HCl (40MG 3 PA Extended Release) Oral Capsule Delayed 3 QL

C1 Ingr ezza Release Particles) Ingrezza (Oral C1 Lyri ca 4 PA; QL CR Capsule) Lyrica CR (Oral Tablet

C1 Ingr ezza Ingrezza (Oral Extended Release 24 3 PA; QL Hour) Capsule Therapy 4 PA; QL C1 Lyri ca Pack) Lyrica (Oral Capsule) 2 QL C1 Lyri C1 ca Na mza ric Namzaric (Oral Lyrica (Oral Solution) 2 QL C1 Sav ella Capsule ER 24 Hour 2 PA; QL Savella (Oral Tablet) 2 C1 Sav ella Titra tion Pac Therapy Pack) k Savella Titration Pack C1 Na mza ric 2 Namzaric (Oral (Oral Tablet) Capsule Extended 2 PA; QL B1 Multiple Sclerosis Agents

C1 Am Release 24 Hour) pyra Ampyra (Oral Tablet C1 Nue dext a Nuedexta (Oral Extended Release 12 4 QL 3 PA Capsule) Hour) C1 C1 Rilut ek Aub agio Rilutek (Oral Tablet) 4 Aubagio (Oral Tablet) 4 LA; QL C1 C1 Rilu zole Avo nex Riluzole (Oral Tablet) 1 Avonex (30MCG C1 Tetr abe nazi ne 4 Tetrabenazine (Oral Intramuscular Kit) 4 PA; LA Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 113 113 75112 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Avo Mav nex encl Pen Avonex Pen ad Mavenclad (5 Tabs)

(Intramuscular Auto- 4 (Oral Tablet Therapy 4 PA Injector Kit) Pack)

C1 C1 Avo Mav nex encl Prefi ad lled Avonex Prefilled Mavenclad (6 Tabs)

(Intramuscular 4 (Oral Tablet Therapy 4 PA Prefilled Syringe Kit) Pack)

C1 C1 Beta Mav sero encl n Betaseron ad Mavenclad (7 Tabs) 4 (Subcutaneous Kit) (Oral Tablet Therapy 4 PA

C1 Cop axo ne Copaxone Pack) C1 Mav encl (Subcutaneous ad Mavenclad (8 Tabs) 4 Solution Prefilled (Oral Tablet Therapy 4 PA Syringe) Pack)

C1 C1 Dalf Mav amp encl ridin ad e ER Dalfampridine ER (Oral Mavenclad (9 Tabs) Tablet Extended 4 QL (Oral Tablet Therapy 4 PA Release 12 Hour) Pack) C1

Exta C1 via May Extavia zent Mayzent (Oral Tablet) 4 QL

C1 4 Pleg ridy Start er Pac (Subcutaneous Kit) k C1 Plegridy Starter Pack Gile nya Gilenya (0.5MG Oral 4 QL (Subcutaneous 4 Capsule) Solution Pen-Injector) C1

Glati C1 ram er Pleg Acet ridy ate Start er Pac Glatiramer Acetate k Plegridy Starter Pack (Subcutaneous (Subcutaneous 4 4 Solution Prefilled Solution Prefilled Syringe)

C1 Glat Syringe) opa

C1 Pleg Glatopa ridy Plegridy (Subcutaneous 4 (Subcutaneous Solution Prefilled 4 Solution Pen-Injector)

C1 Syringe) Pleg ridy C1 Mav encl ad Mavenclad (10 Tabs) Plegridy (Subcutaneous (Oral Tablet Therapy 4 PA 4 Pack) Solution Prefilled

C1 Mav encl ad Syringe)

C1 Rebi Mavenclad (4 Tabs) f Rebi dos e (Oral Tablet Therapy 4 PA Rebif Rebidose (Subcutaneous Pack) 4 Solution Auto- Injector)

Bold type = Brand name drug Plain type = Generic drug 114 tRACK 114 Last updated September 1, 2019 76113 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Rebi Abs f oric Rebi a dos e Titra tion Pac k Rebif Rebidose Absorica (Oral 4 PA Titration Pack Capsule)

C1 Aca nya (Subcutaneous 4 Acanya (External Gel) 3 ST

C1 Acitr Solution Auto- etin Acitretin (Oral 3 Injector) Capsule) C1 Rebi C1 f Acz Rebif (Subcutaneous one Aczone (5% External 3 Solution Prefilled 4 Gel)

C1 Ada pale Syringe) ne C1 Adapalene (External Rebi f Titra tion Pac k 3 Rebif Titration Pack Cream)

C1 Ada pale (Subcutaneous ne Adapalene (0.1% 4 1 Solution Prefilled External Gel)

C1 Ada pale Syringe) ne C1 Adapalene (0.3% Tecf ider a Start er Pac 3 k Tecfidera Starter External Gel)

C1 Ada 4 LA pale Pack (Oral) ne Adapalene (External C1 Tecf ider a 3 Tecfidera (Oral Pad)

C1 Ada pale Capsule Delayed 4 LA; QL ne Adapalene (External 4 Release) Solution)

C1 Ada pale A1 ne- Ben zoyl Per oxid Dental and Oral Agents e Adapalene-Benzoyl

B1 3 ST Peroxide (External Gel)

Dental and Oral Agents C1 Akti C1 pak Cevi meli ne HCl Cevimeline HCl (Oral Aktipak (External 3 ST 3 ST Capsule) Packet) C1 C1 Alda ra Chlo rhex idin e Gluc onat e Aldara (External Chlorhexidine 3 Gluconate (Mouth 1 Cream)

C1 Altre Solution) no Altreno (External C1 Evo xac 3 PA Evoxac (Oral Capsule) 3 ST Lotion)

C1 C1 Pilo carp Am ine mon HCl ium Lact Pilocarpine HCl (Oral ate Ammonium Lactate 1 1 Tablet) (External Cream) C1 C1 Sala gen Am mon ium Lact Salagen (Oral Tablet) 3 ate Ammonium Lactate C1 Tria mci nolo 1 ne Acet onid e Triamcinolone (External Lotion) C1 Amn este em Acetonide (Dental 1 Amnesteem (Oral 3 PA Paste) Capsule)

C1 Atral A1 Dermatological Agents in Atralin (External Gel) 3 PA

C1 Avit B1 Dermatological Agents a Avita (External 1 PA Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 115 115 77114 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Avit Clin a daci Avita (External Gel) 1 PA n-P Clindacin-P (External

C1 Azel aic 1 Acid Swab) Azelaic Acid (External C1 Clin dag 3 el Gel) Clindagel (External

C1 Azel ex 4 Azelex (External Gel) C1 Clin dam ycin 3 Pho sph Cream) ate Clindamycin

C1 Ben zaCl in with Pum p BenzaClin with Pump Phosphate (External 3 3 Foam) (External Gel) C1 Clin dam C1 ycin Pho Ben sph zam ate ycin Benzamycin (External Clindamycin 3 Gel) Phosphate (External 1

C1 Ben zoyl Per Gel) oxid e- Eryt C1 hro myci Clin n dam ycin Benzoyl Peroxide- Pho sph ate Erythromycin (External 3 Clindamycin Gel) Phosphate (External 1

C1 Calc ipotr iene Lotion)

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

C1 Calc ipotr iene Phosphate (External 1 Calcipotriene (External 3 Solution) C1 Clin dam ycin Ointment) Pho sph ate C1 Calc ipotr iene Clindamycin Calcipotriene (External 1 Phosphate (External 1 Solution) C1 Swab) Calc ipotr iene C1 - Beta Clin met dam has ycin one Pho sph ate- Calcipotriene- Ben zoyl Per oxid e Clindamycin Betamethasone 3 Phosphate-Benzoyl (External Ointment) 3 ST C1 Peroxide (1.2-2.5% Calc itriol Calcitriol (External External Gel)

C1 3 Clin dam ycin Pho sph ate- Ben Ointment) zoyl Per oxid C1 e Clindamycin Cara c Carac (External Phosphate-Benzoyl 4 Cream) Peroxide (1-5% 1

C1 Clar avis Claravis (10MG Oral External Gel, 1.2-5% External Gel) Capsule, 20MG Oral C1 Clin dam ycin- Treti 3 PA noin Clindamycin-Tretinoin Capsule, 40MG Oral 3 PA Capsule) (External Gel) C1 C1 Clot Cleo rima cin- zole- T Beta met has Cleocin-T (External one Clotrimazole- 3 Gel) Betamethasone 1

C1 Cleo cin- T (External Cream) C1 Cleocin-T (External Clot rima zole- Beta met has 3 one Lotion) Clotrimazole- C1 Cleo cin- T Betamethasone 1 Cleocin-T (External 3 (External Lotion) Swab)

Bold type = Brand name drug Plain type = Generic drug 116 tRACK 116 Last updated September 1, 2019 78115 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Con Efud dylo ex x Condylox (External Efudex (External 3 3 Gel) Cream)

C1 C1 Cort Elid ispo el rin Cortisporin (External Elidel (External 3 3 ST Cream) Cream)

C1 C1 Cort Enst ispo ilar rin Cortisporin (External Enstilar (External 3 4 PA Ointment) Foam)

C1 C1 Cos Epid enty uo x Cosentyx (300 MG Epiduo (External Gel) 3 ST

C1 Epid uo Fort Dose) (Subcutaneous e Epiduo Forte 4 PA; LA 3 ST Solution Prefilled (External Gel)

C1 Syringe) Ery C1 Ery (External Pad) 1 Cos enty x C1 Sen Eryg sore el ady Cosentyx Sensoready Erygel (External Gel) 3

C1 Eryt hro myci (300 MG) n Erythromycin (External 1 (Subcutaneous 4 PA; LA Gel)

C1 Eryt hro myci Solution Auto- n Erythromycin (External Injector) 1

C1 Dap Solution) son e C1 Eucr Dapsone (External Gel) 3 isa

C1 Dicl Eucrisa (External ofen ac Sodi um 3 PA; QL Diclofenac Sodium Ointment)

3 PA C1 Evo (3% Transdermal Gel) clin

C1 Diffe rin Evoclin (External 4 Differin (External Foam)

3 C1 Fabi Cream) or

C1 Diffe rin Fabior (External Differin (External Gel) 3 3 PA C1 Foam) Diffe rin C1 Fina Differin (External cea 3 Finacea (External Lotion) 3 C1 Foam) Dov one x C1 Fina cea Dovonex (External Finacea (External Gel) 3

4 C1 Fluo rour Cream) acil

C1 Dox epin Fluorouracil (0.5% HCl 4 Doxepin HCl (External External Cream)

3 PA; QL C1 Fluo rour Cream) acil

C1 Dua c Fluorouracil (5% Duac (External Gel) 3 1

C1 External Cream) Duo brii C1 Fluo rour Duobrii (External acil Fluorouracil (External 4 PA 1 Lotion) Solution) C1 Dupi C1 xent Ilum Dupixent (300MG/ ya Ilumya 2ML Subcutaneous (Subcutaneous 4 PA 4 PA Solution Prefilled Solution Prefilled Syringe) Syringe)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 117 117 79116 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Imiq Reti uim n-A od Imiquimod (5% Retin-A (External 1 3 PA External Cream) Cream) C1 C1 Imiq uim Reti od n-A Pum p Imiquimod Pump Retin-A (External Gel) 3 PA

C1 Reti n-A Micr (3.75% External 4 PA o Retin-A Micro Cream) 4 PA

C1 Isotr (External Gel) etin oin C1 Reti n-A Micr o Pum Isotretinoin (Oral p 3 PA Retin-A Micro Pump Capsule)

C1 Klar on (0.06% External Gel, 4 PA Klaron (External 3 PA 0.08% External Gel) C1 Rho Lotion) fade

C1 Lotri son Rhofade (External e Lotrisone (External 3 PA 3 Cream) C1 Sant Cream) yl

C1 Met hox Santyl (External sale n Rapi d Methoxsalen Rapid 3 4 Ointment) C1 Sele niu m (Oral Capsule) Sulfi de C1 Mirv aso Selenium Sulfide Mirvaso (External Gel) 3 1

C1 Myo (External Lotion) risa n C1 Myorisan (Oral Siliq 3 PA Siliq (Subcutaneous Capsule)

C1 Neo Solution Prefilled - 4 PA Syn alar Neo-Synalar (External 4 Syringe) C1 Sool antr Cream) a

C1 Neu ac Soolantra (External Neuac (External Gel) 1 3

C1 One Cream) xton

C1 Sori atan Onexton (External e 3 Soriatane (Oral Gel) 4

C1 Oxs Capsule) oral en Ultra C1 Soril Oxsoralen Ultra (Oral ux 4 Sorilux (External Capsule) 4

C1 Pica Foam) to

C1 Stel Picato (External Gel) 2 ara

C1 Pim Stelara ecro limu s Pimecrolimus (External 3 ST (Subcutaneous 4 PA Cream) C1 Solution) Pod ofilo x C1 Stel Podofilox (External ara 1 Stelara Solution)

C1 Prot (Subcutaneous opic Protopic (External 4 PA 3 ST Solution Prefilled Ointment) C1 Syringe) PRU DOX IN C1 Sulf acet ami de Sodi PRUDOXIN (External um 3 PA; QL Sulfacetamide Sodium Cream)

C1 (Acne) (External 1 PA Reg rane x Regranex (External Lotion) 4 PA Gel)

Bold type = Brand name drug Plain type = Generic drug 118 tRACK 118 Last updated September 1, 2019 80117 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Tacl Treti one noin x Taclonex (External Tretinoin (0.05% 4 3 PA Ointment) External Gel) C1 C1 Treti Tacl noin one x Micr osp Taclonex (External here Tretinoin Microsphere 4 3 PA Suspension) (External Gel) C1

C1 Vect ical Tacr olim us Tacrolimus (External Vectical (External 3 ST 4 Ointment) Ointment) C1 C1 Vere Talt gen z Taltz (Subcutaneous Veregen (External 4 Solution Auto- 4 PA; LA Ointment) C1 Zen atan Injector) e Zenatane (Oral

C1 Talt z 3 PA Taltz (Subcutaneous Capsule) C1 Zian Solution Prefilled 4 PA; LA a Ziana (External Gel) 4 PA

C1 Zon Syringe) alon Zonalon (External C1 Taz arot ene 3 PA; QL Tazarotene (External Cream)

C1 Zycl ara 3 PA Pum Cream) p Zyclara Pump C1 Taz orac 4 PA Tazorac (External (External Cream) 3 PA Cream) A1 Electrolytes/Minerals/Metals/Vitamins C1 Taz orac Tazorac (0.05% B1 Electrolyte/Mineral Replacement 4 PA C1 Ami nos External Gel) yn II C1 Aminosyn II Taz orac 3 B/D, PA Tazorac (0.1% (Intravenous Solution) 3 PA C1 Ami nos yn- External Gel) PF C1 Aminosyn-PF Tola k 3 B/D, PA Tolak (External (Intravenous Solution) 3 C1 Car bagl Cream) u C1 Carbaglu (Oral Tre mfy a 4 LA Tremfya Tablet)

C1 Car (Subcutaneous 4 PA nitor Carnitor (Oral Solution Pen-Injector) 3 C1 Solution) Tre mfy a C1 Car nitor Tremfya Carnitor (Oral Tablet) 3

C1 Clini mix E/ Dext (Subcutaneous rose 4 PA Clinimix E/Dextrose Solution Prefilled (2.75/5) (Intravenous 3 B/D, PA Syringe)

C1 Treti noin Solution)

C1 Clini mix E/ Dext Tretinoin (External rose 1 PA Clinimix E/Dextrose Cream)

C1 Treti noin (4.25/10) 3 B/D, PA Tretinoin (0.01% (Intravenous Solution) External Gel, 0.025% 1 PA External Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 119 119 81118 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Clini Dext mix rose E/ - Dext NaC rose Clinimix E/Dextrose l Dextrose-NaCl (4.25/5) (Intravenous 3 B/D, PA (10-0.2% Intravenous Solution) Solution, 10-0.45%

C1 Clini mix E/ Dext rose Clinimix E/Dextrose Intravenous Solution, (5/15) (Intravenous 3 B/D, PA 2.5-0.45% Solution) Intravenous Solution,

C1 Clini 1 mix E/ Dext rose Clinimix E/Dextrose 5-0.2% Intravenous (5/20) (Intravenous 3 B/D, PA Solution, 5-0.225% Solution) Intravenous Solution,

C1 Clini mix/ Dext rose Clinimix/Dextrose 5-0.33% Intravenous (4.25/10) 3 B/D, PA Solution, 5-0.45% Intravenous Solution)

C1 (Intravenous Solution) Dext rose - C1 NaC l Clini mix/ Dext rose Clinimix/Dextrose Dextrose-NaCl (4.25/5) (Intravenous 3 B/D, PA (5-0.9% Intravenous 1 B/D, PA Solution)

C1 Solution) End ari

C1 Clini mix/ Dext rose Endari (Oral Packet) 4 PA

C1 Clinimix/Dextrose Fre Ami ne HBC FreAmine HBC (5/15) (Intravenous 3 B/D, PA 3 B/D, PA (Intravenous Solution)

Solution) C1 Hep atA C1 min Clini e mix/ Dext rose HepatAmine Clinimix/Dextrose 1 B/D, PA (Intravenous Solution) (5/20) (Intravenous 3 B/D, PA C1 Intra lipid Solution) Intralipid (20%

C1 Clini sol SF Clinisol SF Intravenous 1 B/D, PA 3 B/D, PA (Intravenous Solution) Emulsion) C1 Intra C1 lipid Dext rose Dextrose (10% Intralipid (30% 1 Intravenous Solution) Intravenous 3 B/D, PA

C1 Dext rose Emulsion) Dextrose (5% C1 Iono sol- MB in D5 1 B/D, PA W Ionosol-MB in D5W Intravenous Solution) 3 (Intravenous Solution)

C1 Isoly te-P in D5 W Isolyte-P in D5W 3 (Intravenous Solution)

C1 Isoly te-S Isolyte-S (Intravenous 3 Solution)

C1 KCl in Dext rose - NaC l KCl in Dextrose-NaCl 1 (Injection)

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C1 C1 KCl- Nep Lact hrA ated min e Ring ers- D5 W KCl-Lactated Ringers- NephrAmine 3 B/D, PA D5W (Intravenous 1 (Intravenous Solution)

C1 Nor mos ol-M in D5 Solution) W Normosol-M in D5W C1 Klor- Con 10 1 Klor-Con 10 (Oral (Intravenous Solution)

C1 Nor mos ol-R in D5 Tablet Extended 1 W Normosol-R in D5W 1 Release) (Intravenous Solution) C1 Klor- C1 Con M10 Nor mos ol-R pH Klor-Con M10 (Oral 7.4 Normosol-R pH 7.4 1 Tablet Extended 1 (Intravenous Solution)

C1 Nutr Release) ilipid

C1 Klor- Con Nutrilipid M15 Klor-Con M15 (Oral (Intravenous 1 B/D, PA Tablet Extended 1 Emulsion)

C1 Plas ma- Release) Lyte 148

C1 Klor- Con M20 Plasma-Lyte 148 Klor-Con M20 (Oral 3 (Intravenous Solution)

C1 Plas Tablet Extended 1 ma- Lyte A Release) Plasma-Lyte A C1 3 Klor- Con (Intravenous Solution)

C1 Klor-Con (Oral Packet) 3 Plen ami ne C1 Klor- Con 8 Plenamine Klor-Con 8 (Oral 1 B/D, PA (Intravenous Solution)

C1 Pota Tablet Extended 1 ssiu m Chlo ride Release) CR Potassium Chloride

C1 Klor- Con Spri nkle CR (Oral Tablet 1 Klor-Con Sprinkle Extended Release)

C1 Pota ssiu (8MEQ Oral Capsule 1 m Chlo ride Extended Release) ER Potassium Chloride ER

C1 K- Tab (Oral Capsule 1 K-Tab (Oral Tablet 3 Extended Release) C1 Pota ssiu m Extended Release) Chlo ride in C1 Dext rose Lev ocar nitin Potassium Chloride in e Levocarnitine (1GM/ 1 Dextrose (Intravenous 1 B/D, PA 10ML Oral Solution)

C1 Lev ocar Solution) nitin e C1 Pota ssiu m Chlo Levocarnitine ride in NaC 1 l Potassium Chloride in (330MG Oral Tablet)

C1 Mag NaCl (20-0.45MEQ/L- nesi um Sulf ate Magnesium Sulfate 1 B/D, PA % Intravenous (50% Injection 1 Solution)

C1 Pota ssiu m Chlo ride in NaC Solution) l

C1 Potassium Chloride in Mag nesi um Sulf ate Magnesium Sulfate NaCl (20-0.9MEQ/L-% (50% (10ML Syringe) 1 Intravenous Solution, 1 B/D, PA Injection Solution) 40-0.9MEQ/L-% Intravenous Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 121 121 83120 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Pota Sodi ssiu um m Chlo Chlo ride ride Potassium Chloride Sodium Chloride (3% (10MEQ/100ML Intravenous Solution, 1 B/D, PA Intravenous Solution, 5% Intravenous 20MEQ/100ML 1 B/D, PA Solution)

C1 Sodi um Chlo Intravenous Solution, ride Sodium Chloride 1 40MEQ/100ML (Irrigation Solution)

C1 Sodi um Fluo Intravenous Solution) ride C1 Sodium Fluoride (Oral Pota ssiu m Chlo ride 1 Potassium Chloride Tablet)

C1 Sodi um Lact (2MEQ/ML ate Sodium Lactate 1 Intravenous Solution, 1 B/D, PA (Intravenous Solution)

C1 TPN Elec troly 2MEQ/ML (20ML) tes TPN Electrolytes Intravenous Solution) 1 C1 Pota ssiu m Chlo (Intravenous Solution) ride

C1 Trav Potassium Chloride asol 3 (Oral Packet) Travasol (Intravenous

C1 3 B/D, PA Pota ssiu m Chlo ride Solution) C1 Tro Potassium Chloride phA min 3 e (Oral Solution) TrophAmine C1 3 B/D, PA Pota ssiu m Citra te ER (Intravenous Solution) Potassium Citrate ER C1 Uro cit-K 10 Urocit-K 10 (Oral (Oral Tablet Extended 1 Release) Tablet Extended 3

C1 Pre mas ol Premasol (10% Release) C1 Uro cit-K 3 B/D, PA 15 Intravenous Solution) Urocit-K 15 (Oral

C1 Pre mas ol Premasol (6% Tablet Extended 3 1 B/D, PA Intravenous Solution) Release)

C1 C1 Proc Uro ala cit-K min 5 e Procalamine Urocit-K 5 (Oral 3 B/D, PA (Intravenous Solution) Tablet Extended 3

C1

Pros ol Prosol (Intravenous Release)

3 B/D, PA B1 Solution) Electrolyte/Mineral/Metal Modifiers

C1 C1 Sodi Che um met Chlo ride Sodium Chloride Chemet (Oral 4 (0.45% Intravenous 1 Capsule)

C1 Def eras Solution) irox Deferasirox (Oral C1 Sodi um Chlo ride 4 PA Sodium Chloride (0.9% Tablet Soluble) C1 Exja 1 B/D, PA de Intravenous Solution) Exjade (Oral Tablet 4 PA Soluble)

C1 Ferri prox Ferriprox (Oral 4 PA Solution)

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C1 C1 Ferri Fosr prox Ferriprox (Oral enol Fosrenol (Oral 4 PA 4 Tablet) Packet)

C1 C1 Jad Fosr enu Jadenu (Oral Tablet) 4 PA enol Fosrenol (Oral Tablet

C1 Jad enu Spri 4 nkle Jadenu Sprinkle (Oral Chewable) C1 Lant han um 4 PA Car bon Packet) ate Lanthanum Carbonate

C1 Jyna rque 4 (Oral Tablet Chewable)

Jynarque (Oral C1 Pho 4 PA slyra Tablet) Phoslyra (Oral

C1 Jyna rque 2 Solution)

Jynarque (Oral Tablet C1 Ren 4 PA; QL agel Therapy Pack) Renagel (Oral Tablet) 4 C1 C1 Ren Kion vela ex Kionex (Oral Renvela (Oral Packet) 4 C1 Ren 1 vela Suspension) Renvela (Oral Tablet) 4 C1 Lok C1 elm a Sev ela mer Car bon Lokelma (Oral ate Sevelamer Carbonate 3 QL 4 Packet) (Oral Packet)

C1 C1 Sam sca Sev ela mer Car bon Samsca (Oral Tablet) 4 PA ate Sevelamer Carbonate

C1 Sodi um Poly styr ene Sulf onat e (Oral Tablet) (Generic 3 Sodium Polystyrene Sulfonate (Oral 1 Renvela) C1 Sev ela mer Powder) HCl Sevelamer HCl (Oral

C1 Sodi um Poly 3 styr ene Sulf onat e Sodium Polystyrene Tablet) C1 Velp horo Sulfonate (Oral 1 Velphoro (Oral Tablet 4 Suspension) Chewable) C1 SPS SPS (Oral Suspension) 1 B1 Vitamins C1 Sypr C1 ine VP- PNV - Syprine (Oral DHA VP-PNV-DHA (Oral 4 PA; QL 1 Capsule) Capsule)

C1 Trie ntin e A1 HCl Trientine HCl (Oral 4 PA; QL Gastrointestinal Agents Capsule) B1 C1 Antispasmodics, Gastrointestinal Velt assa C1 Cuv pos Veltassa (Oral Packet) 4 QL a Cuvposa (Oral B1 3 PA Phosphate Binders Solution) C1 Aury C1 xia Dicy clo min e Auryxia (Oral Tablet) 4 PA HCl Dicyclomine HCl (Oral C1 Calc ium Acet ate 1 HRM Calcium Acetate Capsule) C1 Dicy clo min e (Phosphate Binder) 1 HCl Dicyclomine HCl (Oral 1 HRM (Oral Capsule) Solution) C1 Calc C1 ium Acet Dicy ate clo min e Calcium Acetate HCl Dicyclomine HCl (Oral 1 HRM (Phosphate Binder) 1 Tablet) (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 123 123 85122 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Glyc Myal opyr ept rolat e Glycopyrrolate (1MG Myalept Oral Tablet, 2MG Oral 1 PA (Subcutaneous 4 PA; LA Tablet) Solution C1 Met hsc opol ami ne Bro mid e Methscopolamine Reconstituted)

C1 Myt 1 esi Bromide (Oral Tablet)

C1 Mytesi (Oral Tablet Pro pant heli ne Bro mid 4 PA e Propantheline Bromide Delayed Release)

C1 1 PA; HRM Om ecla mox (Oral Tablet) -Pak Omeclamox-Pak B1 4 Gastrointestinal Agents, Other (Oral) C1 Acti gall C1 Pyle ra Actigall (Oral Pylera (Oral Capsule) 4 4 C1 Reli Capsule) stor C1 Relistor (Oral Tablet) Am 4 PA oxici llin- C1 Clari thro Reli myci stor n- Lan sopr azol e Amoxicillin- Relistor Clarithromycin- 3 (Subcutaneous 4 PA Lansoprazole (Oral)

C1 Che nod al Solution) C1 Ser osti Chenodal (Oral Tablet) 4 m

C1 Cro mol yn Serostim Sodi um Cromolyn Sodium 1 (Subcutaneous (Oral Concentrate) 4 PA; LA

C1 Diph eno Solution xylat e- Atro pine Diphenoxylate- 1 PA; HRM Reconstituted) C1 Sym proi Atropine (Oral Liquid) c

C1 Diph eno xylat Symproic (Oral e- Atro pine Diphenoxylate- 3 PA; QL 1 PA; HRM Tablet)

C1 Trul anc Atropine (Oral Tablet) e

C1 Gast rocr om Trulance (Oral Tablet) 3 ST

C1 Urs o Gastrocrom (Oral 250 4 Urso 250 (Oral Concentrate) 3 C1 Gatt ex Tablet)

C1 Urs o Gattex Fort 4 PA; LA e Urso Forte (Oral (Subcutaneous Kit) 3 C1 Lom otil Tablet)

C1 Urs odio Lomotil (Oral Tablet) 3 PA; HRM l

C1 Lop era mid e Ursodiol (Oral HCl Loperamide HCl (Oral 1 1 Capsule)

C1 Urs odio Capsule) l C1 Mot egrit y Ursodiol (Oral Tablet) 3

C1 Xer mel Motegrity (Oral o 3 ST; QL Xermelo (Oral Tablet) 4 PA; LA; QL

C1 Tablet) Zor btiv e C1 Mov anti k Movantik (Oral Zorbtive 3 PA; QL (Subcutaneous Tablet) 4 PA; LA Solution Reconstituted) B1 Histamine2 (H2) Receptor Antagonists

Bold type = Brand name drug Plain type = Generic drug 124 tRACK 124 Last updated September 1, 2019 86123 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 Cim etidi ne B1 HCl Cimetidine HCl (Oral Laxatives

C1 Clen 1 piq Solution) C1 Clenpiq (Oral Cim etidi ne 2 Cimetidine (Oral Solution)

C1 1 Coly te with Flav or Pac Tablet) ks C1 Colyte with Flavor Fam otidi ne Famotidine (Oral Packs (Oral Solution 3 Suspension 1 Reconstituted)

C1 Con stul Reconstituted) ose

C1 Fam otidi Constulose (Oral ne 1 Famotidine (20MG Solution) C1 Enul Oral Tablet, 40MG Oral 1 ose Enulose (Oral Solution) 1

C1 Gavi Tablet) Lyte -C

C1 Niza tidin e GaviLyte-C (Oral Nizatidine (Oral 1 Solution 1 Capsule)

C1 Niza tidin Reconstituted) e

C1 Gavi Lyte Nizatidine (Oral -G 3 GaviLyte-G (Oral Solution)

C1 Pep cid Solution 1 Pepcid (20MG Oral Reconstituted)

3 C1 Gavi Lyte -N with Tablet) Flav or Pac C1 k Pep cid GaviLyte-N with Flavor Pepcid (40MG Oral 4 Pack (Oral Solution 1 Tablet) C1 Reconstituted) Rani tidin C1 e HCl Gen erla Ranitidine HCl (Oral c 1 Generlac (Oral Capsule) 1 C1 Solution) Rani tidin C1 e HCl GoL YTE Ranitidine HCl (75MG/ LY 1 GoLYTELY (Oral 5ML Oral Syrup) C1 Solution Rani 3 tidin e HCl Ranitidine HCl (150MG Reconstituted) C1 Krist alos Oral Tablet, 300MG 1 e Kristalose (Oral 3 Oral Tablet) Packet) B1 C1 Lact ulos Irritable Bowel Syndrome Agents e C1 Alos etro Lactulose (Oral n HCl 3 Alosetron HCl (Oral Packet) 4 PA C1 Lact ulos Tablet) e C1 Amit iza Lactulose (10GM/ 1 Amitiza (Oral 15ML Oral Solution) 2 QL C1 Mov iPre Capsule) p C1 MoviPrep (Oral Linz ess Linzess (Oral 2 QL Solution 3 Capsule) Reconstituted) C1 Lotr one x Lotronex (Oral Tablet) 4 PA

C1 Vibe rzi Viberzi (Oral Tablet) 4 PA; QL

C1 Xifa xan Xifaxan (Oral Tablet) 4 PA

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 125 125 87124 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 NuL Acip YTE hex LY with Flav or Pac ks NuLYTELY with Aciphex (Oral Tablet 3 Flavor Packs (Oral Delayed Release)

C1 Dexi 3 lant Solution Dexilant (Oral Reconstituted) Capsule Delayed 3 QL C1 Os moP rep OsmoPrep (Oral Release)

C1 Eso mep 3 razo le Mag nesi Tablet) um Esomeprazole C1 PEG -335 0- Elec troly tes PEG-3350-Electrolytes Magnesium (Oral (Oral Solution Capsule Delayed 1 QL 1 Reconstituted) Release) (Generic (Generic Colyte) Nexium) C1 C1 Eso PEG mep -335 razo 0- le NaC Stro l-Na ntiu Bica m rbon ate- KCl PEG-3350-NaCl-Na Esomeprazole Bicarbonate-KCl (Oral Strontium (Oral 1 3 QL Solution) (Generic Capsule Delayed NuLYTELY) Release) C1

PEG C1 -335 0- Lan Elec sopr troly azol tes PEG-3350-Electrolytes e Lansoprazole (Oral (Oral Solution) 1 Capsule Delayed 1 QL (Generic GoLYTELY) Release) C1

Plen C1 vu Lan sopr azol e Plenvu (Oral Solution ODT 3 Lansoprazole ODT Reconstituted) (Oral Tablet 3 C1 Pre popi k Prepopik (Oral Dispersible) C1 Nexi 3 um Packet) Nexium (20MG Oral

C1 Sup rep Bow el Pre p Kit Suprep Bowel Prep Capsule Delayed 2 Kit (Oral Solution) Release, 40MG Oral 2 QL

C1 TriL yte TriLyte (Oral Solution Capsule Delayed 1 Reconstituted) Release) C1 Nexi um B1 Protectants Nexium (10MG Oral

C1 Cara fate Carafate (Oral Packet, 2.5MG Oral 3 Suspension) Packet, 20MG Oral

C1 2 Cara fate Packet, 40MG Oral Carafate (Oral Tablet) 3

C1 Cyto tec Packet, 5MG Oral Cytotec (Oral Tablet) 3

C1 Mis opr Packet) osto l C1 Om epra Misoprostol (Oral zole 1 Omeprazole (10MG Tablet)

C1 Sucr alfat Oral Capsule Delayed 1 QL e Sucralfate (Oral Tablet) 1 Release) B1 Proton Pump Inhibitors

Bold type = Brand name drug Plain type = Generic drug 126 tRACK 126 Last updated September 1, 2019 88125 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Om Cer epra delg zole Omeprazole (20MG a Cerdelga (Oral 4 PA Oral Capsule Delayed Capsule) C1 Chol Release, 40MG Oral 1 bam Cholbam (Oral 4 PA Capsule Delayed Capsule)

C1 Cre Release) on

C1 Pant opra zole Creon (Oral Capsule Sodi um Pantoprazole Sodium Delayed Release 2 (Oral Tablet Delayed 1 QL Particles)

C1 Release) Cyst ada ne C1 Prev acid Cystadane (Oral Prevacid (Oral 4 Powder)

C1 Capsule Delayed 3 QL Cyst ago n Release) Cystagon (Oral C1 3 LA Prev acid

Solu Tab Capsule)

C1 Prevacid SoluTab Gala fold Galafold (Oral (Oral Tablet 3 4 LA Capsule)

Dispersible) C1 Glas C1 sia Prilo sec Prilosec (Oral Packet) 3 PA Glassia (Intravenous C1 4 PA; LA Prot onix Solution)

C1 Protonix (Oral Packet) 3 ST Kuv an

C1 Prot onix Kuvan (Oral Packet) 4 LA

C1 Protonix (Oral Tablet Kuv 3 QL an Delayed Release) Kuvan (Oral Tablet C1 4 LA Rab epra zole

Sodi um Soluble)

C1 Rabeprazole Sodium Migl usta t Miglustat (Oral (Oral Tablet Delayed 1 4 PA; LA Release) Capsule) C1

C1 Nityr Yos pral a Yosprala (Oral Tablet Nityr (Oral Tablet) 4 LA C1 Ocal 3 iva Delayed Release) Ocaliva (Oral Tablet) 4 PA; QL

C1 Orfa din A1 Genetic or Enzyme Disorder: Replacement, Orfadin (Oral 4 LA Modifiers, Treatment Capsule)

C1 Orfa din B1 Genetic or Enzyme Disorder: Replacement, Orfadin (Oral 4 LA Modifiers, Treatment Suspension)

C1 C1 Aral Paly ast nziq NP Aralast NP (1000MG Palynziq Intravenous Solution 4 PA; LA (Subcutaneous 4 PA; QL Reconstituted) Solution Prefilled

C1 Bup hen yl Buphenyl (Oral Syringe) 4 Powder)

C1 Bup hen yl Buphenyl (Oral 4 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 127 127 89126 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Pan Sodi crea um ze Phe nylb utyr Pancreaze ate Sodium (10500UNIT Oral Phenylbutyrate (Oral 4 Capsule Delayed Tablet) C1 Sucr Release Particles, aid Sucraid (Oral 4 LA 16800UNIT Oral Solution)

C1 Teg Capsule Delayed sedi Tegsedi Release Particles, 3 ST (Subcutaneous 4 PA; LA 2600UNIT Oral Solution Prefilled Capsule Delayed Syringe)

C1 Viok Release Particles, ace Viokace (10440UNIT 3 ST 4200UNIT Oral Oral Tablet)

C1 Viok Capsule Delayed ace Viokace (20880UNIT Release Particles) 4 ST

C1 Pan Oral Tablet) crea ze C1 Xuri Pancreaze den Xuriden (Oral Packet) 4 PA; LA

C1 Zav (21000UNIT Oral esca 4 ST Zavesca (Oral Capsule Delayed 4 PA; LA Capsule)

C1 Zem Release Particles) aira

C1 Pert zye Zemaira (Intravenous Pertzye (16000UNIT Solution 4 PA; LA Oral Capsule Delayed 4 ST Reconstituted)

C1 Zen Release Particles) pep

C1 Pert zye Zenpep (Oral Capsule Pertzye (4000UNIT Delayed Release 2 Oral Capsule Delayed Particles)

Release Particles, A1 3 ST 8000UNIT Oral Genitourinary Agents B1 Antispasmodics, Urinary Capsule Delayed C1 Darif ena cin Hyd robr omi de Release Particles) ER Darifenacin

C1 Prol astin -C Hydrobromide ER Prolastin-C 3 ST; QL (Oral Tablet Extended (Intravenous Solution 4 PA; LA Release 24 Hour)

C1 Detr ol Reconstituted) LA

C1 RAV ICTI Detrol LA (Oral RAVICTI (Oral Liquid) 4 LA

C1 Sodi um Capsule Extended Phe 3 nylb utyr ate Sodium Release 24 Hour)

C1 Detr Phenylbutyrate (Oral 4 ol Powder) Detrol (Oral Tablet) 3

Bold type = Brand name drug Plain type = Generic drug 128 tRACK 128 Last updated September 1, 2019 90127 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Ditr Tros opa piu n XL m Chlo ride Ditropan XL (Oral ER Trospium Chloride ER

(Oral Capsule Tablet Extended 3 1 Release 24 Hour) Extended Release 24

C1 Ena blex Hour)

C1 Enablex (Oral Tablet Tros piu m Chlo ride Trospium Chloride Extended Release 24 3 ST; QL 1 (Oral Tablet) Hour) C1 Vesi care C1 Flav oxat e HCl Flavoxate HCl (Oral Vesicare (Oral Tablet) 3 ST; QL 1 B1 Tablet) Benign Prostatic Hypertrophy Agents C1 C1 Alfu zosi Geln n ique HCl ER Pum p Gelnique Pump Alfuzosin HCl ER (Oral 3 (Transdermal Gel) Tablet Extended 1

C1 Myr betri q Release 24 Hour)

C1 Myrbetriq (Oral Avo dart Avodart (Oral Tablet Extended 2 3 Capsule) Release 24 Hour) C1 Car dura C1 XL Oxy buty nin Chlo ride ER Oxybutynin Chloride Cardura XL (Oral ER (Oral Tablet Tablet Extended 3 QL 1 Extended Release 24 Release 24 Hour) C1 Ciali Hour) s Cialis (2.5MG Oral C1 Oxy buty nin Chlo ride Oxybutynin Chloride Tablet, 5MG Oral 3 PA; QL 1 (Oral Syrup) Tablet)

C1 C1 Oxy buty Duta nin steri Chlo de ride Oxybutynin Chloride Dutasteride (Oral 1 (Oral Tablet Immediate 1 Capsule)

C1 Duta steri de- Tam sulo sin Release) HCl C1 Dutasteride- Oxyt rol Oxytrol (Transdermal Tamsulosin HCl (Oral 1 4 Patch Twice Weekly) Capsule)

C1 C1 Fina Solif steri ena de cin Suc cina te Solifenacin Succinate Finasteride (5MG Oral 1 QL (Oral Tablet) Tablet) (Generic 1

C1 Tolt erod ine Tartr ate ER Proscar) Tolterodine Tartrate C1 Flo ER (Oral Capsule max Flomax (Oral 1 3 Extended Release 24 Capsule)

C1 Jaly Hour) n C1 Jalyn (Oral Capsule) 3 Tolt erod ine C1 Tartr Pros ate car Tolterodine Tartrate Proscar (Oral Tablet) 3

1 C1 Rap (Oral Tablet) aflo

C1 Tovi az Rapaflo (Oral 3 QL Toviaz (Oral Tablet Capsule)

C1 Silo dosi Extended Release 24 3 ST; QL n Silodosin (Oral 1 QL Hour) Capsule)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 129 129 91128 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Tad Ala- alafil Tadalafil (2.5MG Oral Cort Ala-Cort (External 1 Tablet, 5MG Oral 3 PA; QL Cream)

C1 Alcl ome taso ne Dipr opio Tablet) nate

C1 Alclometasone Tam sulo sin HCl Tamsulosin HCl (Oral Dipropionate (External 1 1 Capsule) Cream)

C1 C1 Tera Alcl zosi ome n taso HCl ne Dipr opio Terazosin HCl (Oral nate Alclometasone 1 Capsule) Dipropionate (External 1

C1 Uro xatr al Ointment)

Uroxatral (Oral Tablet C1 Amc inon ide Amcinonide (External Extended Release 24 3 3 Hour) Cream) C1 Amc inon ide B1 Genitourinary Agents, Other Amcinonide (External C1 3 Beth ane chol

Chlo ride Lotion) C1 Bethanechol Chloride Amc inon 1 ide (Oral Tablet) Amcinonide (External C1 3 Cup rimi ne Ointment)

C1 Cuprimine (Oral Ape xiCo 4 PA n E Capsule) ApexiCon E (External

C1 4 Dep en Titra tabs Cream)

C1 Bes Depen Titratabs (Oral er 4 Beser (External Lotion) 3 Tablet) C1 Beta met has C1 one Elmi Dipr ron opio nate Elmiron (Oral Aug Betamethasone 4 Capsule) Dipropionate Aug 1

C1 Lith osta t (External Cream) C1 Beta met has Lithostat (Oral Tablet) 4 one Dipr opio C1 nate Aug Peni cilla min Betamethasone e Penicillamine (Oral 4 PA Dipropionate Aug 1 Capsule) C1 (External Gel) Thio la C1 Beta met has one Dipr opio Thiola (Oral Tablet nate 4 LA Aug Betamethasone Immediate Release)

C1 Dipropionate Aug 1 Ure chol ine Urecholine (Oral (External Lotion)

C1 Beta 3 met has one Dipr opio nate Tablet) Aug Betamethasone

A1 Hormonal Agents, Stimulant/Replacement/ Dipropionate Aug 1 Modifying (Adrenal) (External Ointment) C1 Beta met has B1 one Dipr opio Hormonal Agents, Stimulant/Replacement/ nate Betamethasone Modifying (Adrenal) Dipropionate (External 1

C1 Acth ar Cream)

C1 Acthar (Injection Gel) 4 PA; LA Beta met has C1 one Dipr Ala opio Scal nate p Ala Scalp (External Betamethasone 3 Lotion) Dipropionate (External 1 Lotion)

Bold type = Brand name drug Plain type = Generic drug 130 tRACK 130 Last updated September 1, 2019 92129 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Beta Clo met beta has sol one Pro Dipr pion opio ate nate Betamethasone Clobetasol Propionate 1 Dipropionate (External 1 (External Ointment)

C1 Clo beta sol Pro pion Ointment) ate C1 Clobetasol Propionate Beta met has one Vale 3 rate Betamethasone (External Shampoo)

C1 Clo beta sol Pro pion Valerate (External 1 ate Clobetasol Propionate Cream) 1

C1 (External Solution) Beta met C1 has one Clo Vale bex rate Betamethasone Clobex (External 3 Valerate (External 3 Lotion)

C1 Clo Foam) bex

C1 Beta met has Clobex (External one Vale rate 4 Betamethasone Shampoo)

C1 Clo bex Valerate (External 1 Spra y Clobex Spray Lotion) 4 C1 Beta met has one Vale (External Liquid) rate

C1 Clo Betamethasone dan Clodan (External Valerate (External 1 3 Shampoo)

Ointment) C1 Cor C1 dran Bryh ali Cordran (External Bryhali (External 4 3 Tape)

Lotion) C1 Cort C1 ef Cap ex Cortef (Oral Tablet) 3 Capex (External C1 Cort ison e Acet 3 ate Shampoo) Cortisone Acetate

C1 Clo 1 beta sol Pro pion ate Emo (Oral Tablet) llient

Bas C1 e Clobetasol Propionate Cuti vate Cutivate (External Emollient Base 1 4 (External Cream) Lotion)

C1 C1 Clo Des beta onat sol e Pro pion ate Emu lsion Clobetasol Propionate Desonate (External 3 Emulsion (External 3 Gel)

C1 Des onid Foam) e C1 Desonide (External Clo beta sol Pro pion ate 1 Clobetasol Propionate Cream)

C1 1 Des onid (External Cream) e C1 Desonide (External Clo beta sol Pro pion ate 3 Clobetasol Propionate Lotion)

C1 3 Des onid (External Foam) e C1 Desonide (External Clo beta sol Pro pion ate 1 Clobetasol Propionate Ointment)

C1 1 Des Owe (External Gel) n C1 DesOwen (External Clo beta sol Pro pion ate 3 Clobetasol Propionate Cream) 3 C1 Des Owe (External Liquid) n C1 Clo DesOwen (0.05% beta sol Pro pion ate Clobetasol Propionate 3 3 External Lotion) (External Lotion)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 131 131 93130 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Des Emfl oxi aza met aso ne Desoximetasone Emflaza (Oral Tablet) 4 PA; LA

C1 Flud roco rtiso ne Acet (0.05% External 3 ate Fludrocortisone Cream) 1

C1 Acetate (Oral Tablet) Des oxi C1 met aso Fluo ne cino lone

Acet onid Desoximetasone e Fluocinolone (0.25% External 1 Acetonide (External 1 Cream)

C1 Cream) Des oxi C1 met aso Fluo ne cino lone

Acet onid Desoximetasone e 3 Fluocinolone (External Gel)

C1 Acetonide (External 1 Des oxi met aso ne Desoximetasone Ointment)

C1 Fluo 3 cino lone

Acet onid (External Liquid) e

C1 Fluocinolone Des oxi met aso ne Desoximetasone Acetonide (External 1 3 (External Ointment) Solution)

C1 C1 Dex Fluo ame cino thas lone one Inte Acet nsol onid e Scal Dexamethasone p Fluocinolone Intensol (Oral 1 Acetonide Scalp 1 Concentrate) (External Oil)

C1 C1 Dex Fluo ame cino thas nide one Emu lsifie d Bas Dexamethasone (Oral e Fluocinonide 1 Elixir) Emulsified Base 1

C1 Dex ame thas one (External Cream) Dexamethasone (Oral C1 Fluo cino 1 nide Tablet) Fluocinonide (0.1%

C1 Dex ame 3 thas one External Cream) Dexamethasone (Oral C1 Fluo cino 3 nide Tablet Therapy Pack) Fluocinonide (External

C1 Dex Pak 1 13 Day Gel) DexPak 13 Day (Oral C1 Fluo cino 3 nide Tablet Therapy Pack) Fluocinonide (External

C1 Diflo raso 1 ne Diac etat e Ointment) Diflorasone Diacetate C1 Fluo cino 3 nide (External Cream) Fluocinonide (External

C1

Diflo raso 1 ne Diac etat e Solution) Diflorasone Diacetate C1 Flur andr enol 3 ide (External Ointment) Flurandrenolide

C1 Dipr olen 3 e (External Cream) Diprolene (External C1 Flur andr enol 3 ide Ointment) Flurandrenolide

C1 Eloc 3 on (External Lotion) Elocon (External C1 Flur andr enol 3 ide Cream) Flurandrenolide C1 3 Eloc on (External Ointment) C1 Elocon (0.1% External Fluti cas one Pro pion 3 ate Ointment) Fluticasone Propionate

C1 1 Emfl aza (External Cream) Emflaza (Oral 4 PA; LA Suspension)

Bold type = Brand name drug Plain type = Generic drug 132 tRACK 132 Last updated September 1, 2019 94131 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Fluti Hyd cas roco one rtiso Pro ne pion ate Fluticasone Propionate Hydrocortisone (1% 3 (External Lotion) External Ointment,

C1 Fluti cas 1 one Pro pion ate Fluticasone Propionate 2.5% External 1 Ointment)

(External Ointment) C1 Hyd C1 roco rtiso Halo ne beta sol Pro pion ate Hydrocortisone (Oral Halobetasol 1 Tablet)

Propionate (External 1 C1 Hyd roco rtiso ne Vale Cream) rate Hydrocortisone

C1 Halo beta sol Pro pion ate Halobetasol Valerate (External 1 Cream) Propionate (External 4 C1 Hyd roco rtiso ne Vale Foam) rate Hydrocortisone

C1 Halo beta sol Pro pion ate Halobetasol Valerate (External 1 Ointment)

C1 Propionate (External 1 Imp oyz Ointment) Impoyz (External

C1 Halo 3 g Cream) Halog (External C1 Ken 4 alog Cream) Kenalog (External

C1 Halo 4 g Aerosol Solution) Halog (External C1 Lex 4 ette Ointment) Lexette (External

C1 Hyd 4 roco rtiso ne Buty rate Foam) Hydrocortisone C1 Loc oid Locoid (External Butyrate (External 3 4 Cream) Lotion)

C1 C1 Hyd Loc roco oid rtiso ne Buty rate Hydrocortisone Locoid (External 3 Butyrate (External 3 Solution)

C1 Loc oid Lipo crea Lotion) m C1 Locoid Lipocream Hyd roco rtiso ne Buty rate 3 Hydrocortisone (External Cream)

C1 Luxi q Butyrate (External 1 Luxiq (External Foam) 3

C1 Med Ointment) rol

C1 Hyd roco rtiso ne Medrol (Oral Tablet) 3 Buty rate C1 Med Hydrocortisone rol Medrol (Oral Tablet Butyrate (External 1 3 Therapy Pack)

Solution) C1 Met C1 hylp redn Hyd isol roco one rtiso ne Methylprednisolone Hydrocortisone (1% 1 (Oral Tablet)

External Cream, 2.5% 1 C1 Met hylp redn isol External Cream) one Methylprednisolone

C1 Hyd roco rtiso ne Hydrocortisone (2.5% (Oral Tablet Therapy 1 1 Pack)

External Lotion) C1 MiC ort- HC MiCort-HC (External 3 Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 133 133 95132 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Milli Pre pred dnis olon e Sodi um Pho sph ate Millipred (Oral Tablet) 3 ODT Prednisolone Sodium

C1 Mo met aso ne Furo ate Mometasone Furoate Phosphate ODT 1 (External Cream) (10MG Oral Tablet

C1 Mo met aso ne Furo Dispersible, 15MG ate Mometasone Furoate 3 1 Oral Tablet (External Ointment)

C1 Mo met aso Dispersible, 30MG ne Furo ate Mometasone Furoate 1 Oral Tablet (External Solution) C1 Dispersible) Noli x C1 Pre dnis one Inte Nolix (External Cream) 3 nsol C1 Prednisone Intensol Noli x 3 Nolix (External Lotion) 3 (Oral Concentrate) C1 C1 Olux Pre dnis one Olux (External Foam) 4 Prednisone (5MG/5ML C1 Olux -E 1 Olux-E (External Oral Solution) C1 Pre dnis 4 one Foam) Prednisone (Oral

C1 Ora pred 1

ODT Tablet) Orapred ODT (Oral C1 Pre dnis 3 one Tablet Dispersible) Prednisone (Oral

C1 Pan 1 del Tablet Therapy Pack) Pandel (External C1 Psor 4 con Cream) Psorcon (External C1 3 Pre dnic arba te Cream) C1 Prednicarbate Ray 1 os (External Cream) Rayos (Oral Tablet C1 4 PA Pre dnic arba te Delayed Release) Prednicarbate C1 Syn 1 alar (External Ointment) Synalar (External

C1 Pre 3 dnis olon e Cream) Prednisolone (Oral C1 Tap erD ex 12- 1 Day Solution) TaperDex 12-Day (Oral

C1 Pre dnis 3 olon e Sodi um Pho sph Tablet Therapy Pack) ate Prednisolone Sodium C1 Tap erD ex 6- Phosphate (10MG/ Day TaperDex 6-Day (Oral 3 5ML Oral Solution, 3 Tablet Therapy Pack)

C1 Tap erD ex 7- 20MG/5ML Oral Day TaperDex 7-Day (Oral Solution) 3

C1 Tablet Therapy Pack) Pre dnis C1 olon e Tex Sodi acor um t Pho sph ate Prednisolone Sodium Texacort (External 3 Phosphate (25MG/ Solution) C1 Topi 5ML Oral Solution, 1 cort Topicort (External 3 6.7MG/5ML Oral Cream)

C1 Topi Solution) cort Topicort (External Gel) 3

C1 Topi cort Topicort (0.05% 3 External Ointment)

Bold type = Brand name drug Plain type = Generic drug 134 tRACK 134 Last updated September 1, 2019 96133 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Topi DDA cort Topicort (0.25% VP DDAVP (Nasal 3 4 External Ointment) Solution) C1 C1 Topi cort DDA Spra VP y Topicort Spray DDAVP (0.1MG Oral 3 3 (External Liquid) Tablet) C1 C1 Tria mci DDA nolo VP ne Acet onid e Triamcinolone DDAVP (0.2MG Oral 4 Acetonide (External Tablet) 3 C1 DDA VP Rhin al Tub Aerosol Solution) e DDAVP Rhinal Tube (Generic Kenalog) 3

C1 Tria mci (Nasal Solution) nolo ne Acet C1 onid e Des mop ressi n Triamcinolone Acet ate Desmopressin Acetate Acetonide (External 1 1 (Oral Tablet)

C1 Des Cream) mop ressi n C1 Acet ate Tria Spra mci y nolo ne Acet Desmopressin Acetate onid e Triamcinolone 3 Spray (Nasal Solution)

C1 Gen Acetonide (External 1 otro pin Mini Quic Lotion) k Genotropin MiniQuick

C1 Tria mci nolo ne Acet onid (0.2MG e Triamcinolone Acetonide (External 1 Subcutaneous 3 PA Ointment) Solution

C1 Tria nex Trianex (External Reconstituted) 4 Ointment)

C1 Trid erm Triderm (0.1% External 1 Cream)

C1 Trid esilo n Tridesilon (External 1 Cream)

C1 Ultra vate Ultravate (External 3 Cream)

C1 Ultra vate Ultravate (External 4 Lotion)

C1 Ultra vate Ultravate (External 3 Ointment)

C1 Van os Vanos (External 4 Cream) A1 Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) B1 Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 135 135 97134 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Gen Hu otro matr pin ope Mini Quic k Genotropin MiniQuick Humatrope (Injection (0.4MG Solution Subcutaneous Renconstituted), 4 PA Solution Humatrope Combo Reconstituted, 0.6MG Pack (Injection)

C1 Incr Subcutaneous elex Increlex Solution (Subcutaneous 4 PA; LA Reconstituted, 0.8MG Solution)

C1 Noc durn Subcutaneous a Nocdurna (Tablet 3 PA Solution Sublingual)

C1 Nor ditro pin Flex Reconstituted, 1.2MG Pro Norditropin FlexPro Subcutaneous (Subcutaneous 4 PA Solution Solution)

C1 Nutr opin AQ Reconstituted, 1.4MG NuS pin 10 Nutropin AQ NuSpin Subcutaneous 4 PA 10 (Subcutaneous 4 PA Solution Solution)

C1 Nutr Reconstituted, 1.6MG opin AQ NuS pin Subcutaneous 20 Nutropin AQ NuSpin Solution 20 (Subcutaneous 4 PA Solution)

C1 Reconstituted, 1.8MG Nutr opin AQ NuS pin Subcutaneous 5 Nutropin AQ NuSpin Solution 5 (Subcutaneous 4 PA Solution)

Reconstituted, 1MG C1 Om nitro Subcutaneous pe Omnitrope Solution (Subcutaneous 4 PA Reconstituted, 2MG Solution) C1 Om nitro Subcutaneous pe Omnitrope Solution (Subcutaneous 4 PA Reconstituted) Solution

C1 Gen otro pin Genotropin Reconstituted) C1 Saiz (Subcutaneous en Saizen (Injection 4 PA Solution Solution 4 PA; LA Reconstituted) Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 136 tRACK 136 Last updated September 1, 2019 98135 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Saiz And enpr roG ep Saizenprep (Injection el AndroGel (20.25 MG/ Solution 4 PA; LA 1.25GM 1.62% Reconstituted) Transdermal Gel,

C1 Stim ate Stimate (Nasal 40.5 MG/2.5GM 3 4 Solution) 1.62% Transdermal

C1 Zom acto n Zomacton (10MG Gel, 50 MG/5GM 1% Transdermal Gel)

Subcutaneous C1 And roG 4 PA el AndroGel (25 MG/ Solution Reconstituted) 2.5GM 1% 4

C1 Zom acto n Transdermal Gel)

Zomacton (5MG C1 Ave ed Subcutaneous Aveed (Intramuscular 3 PA 3 PA Solution Solution) C1 Dan azol Reconstituted) Danazol (100MG Oral A1 Hormonal Agents, Stimulant/Replacement/ Capsule, 200MG Oral 3 Capsule) Modifying (Prostaglandins) C1 Dan azol B1 Danazol (50MG Oral Hormonal Agents, Stimulant/Replacement/ 1 Capsule)

C1 Modifying (Prostaglandins) Dep o- Test C1 oste rone Korl ym Korlym (Oral Tablet) 4 PA; LA Depo-Testosterone

A1 (Intramuscular 3 Hormonal Agents, Stimulant/Replacement/ Solution)

C1 Fort Modifying (Sex Hormones/Modifiers) esta Fortesta B1 3 C1 (Transdermal Gel) Ana drol- 50 C1 Intra Anadrol-50 (Oral rosa 4 PA Intrarosa (Vaginal Tablet) 3 PA; QL C1 Insert) And rode rm C1 Met hite Androderm st Methitest (Oral Tablet) 4 PA C1 Met hylt esto ster (Transdermal Patch 2 one Methyltestosterone 24 Hour) 4 PA

C1 And (Oral Capsule) roG el Pum C1 p Oxa ndro lone AndroGel Pump Oxandrolone (10MG 3 3 PA (Transdermal Gel) Oral Tablet)

C1 Oxa ndro lone Oxandrolone (2.5MG 1 PA Oral Tablet)

C1 Stria nt Striant (Buccal) 4 PA

C1 Test im Testim (Transdermal 3 Gel)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 137 137 99136 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Test Alya oste cen rone 1/35

Cypi onat e Testosterone Alyacen 1/35 (Oral 1 Cypionate Tablet)

C1 Ame 1 thia (Intramuscular Lo Amethia Lo (Oral Solution) 1

C1 Tablet) Test oste C1 rone Ame Ena thia ntha te Testosterone Amethia (Oral Tablet) 1

C1 Enanthate Apri 1 Apri (Oral Tablet) 1

C1 Aran (Intramuscular elle Aranelle (Oral Tablet) 1 Solution) C1 Ashl yna C1 Test oste rone Ashlyna (Oral Tablet) 1 Testosterone (20.25 C1 Aub ra MG/1.25GM 1.62% Aubra (Oral Tablet) 1 C1 Avia ne Transdermal Gel, 25 Aviane (Oral Tablet) 1

C1 Balz iva MG/2.5GM 1% Balziva (Oral Tablet) 1

C1 Bey Transdermal Gel, 40.5 az Beyaz (Oral Tablet) 3

C1 MG/2.5GM 1.62% Blis ovi 24 Transdermal Gel, 50 Fe Blisovi 24 Fe (Oral 3 1 MG/5GM 1% Tablet) C1 Blis ovi Fe 1.5/ Transdermal Gel), 30 Blisovi Fe 1.5/30 (Oral 1 Testosterone Pump Tablet)

C1 Briel lyn (2% Transdermal Gel, Briellyn (Oral Tablet) 1

C1 Cam rese 1% Transdermal Gel, Lo Camrese Lo (Oral 1.62% Transdermal 1 Tablet)

C1 Cazi Gel) ant C1 Test oste rone Caziant (Oral Tablet) 1 C1 Clim Testosterone ara 3 Pro (Transdermal Solution) Climara Pro

C1 Vog elxo

Pum p Vogelxo Pump (Transdermal Patch 3 PA; HRM 3 Weekly) (Transdermal Gel) C1 Crys elle- C1 28 Vog elxo Cryselle-28 (Oral Vogelxo (Transdermal 1 3 Tablet)

C1 Gel) Cycl afe m 1/35 C1 Xyo sted Cyclafem 1/35 (Oral Xyosted 1 Tablet)

C1 Cycl (Subcutaneous afe m 7/7/ 3 PA 7 Cyclafem 7/7/7 (Oral Solution Auto- 1 Tablet)

C1 Cyre Injector) d B1 Cyred (Oral Tablet) 1

C1 Dele stro gen

C1 Alor a Delestrogen Alora (Transdermal PA; HRM; 3 3 (Intramuscular Oil)

C1 Dely Patch Twice Weekly) QL la C1 Alta vera Delyla (Oral Tablet) 1 Altavera (Oral Tablet) 1

Bold type = Brand name drug Plain type = Generic drug 138 tRACK 138 Last updated September 1, 2019 100137 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Dep Ethy o- nodi Estr ol adio Diac l etat e- Ethi nyl Estr adio Depo-Estradiol l Ethynodiol Diacetate- 3 (Intramuscular Oil) Ethinyl Estradiol (Oral 1

C1 Des oge strel - Ethi nyl Estr adio Tablet) l Desogestrel-Ethinyl C1 Fal min 1 a Estradiol (Oral Tablet) Falmina (Oral Tablet) 1

C1 C1 Dott Fay i osi m Dotti (Transdermal PA; HRM; Fayosim (Oral Tablet) 1

C1 Fem 1 ring Patch Twice Weekly) QL Femring (Vaginal C1 Dro spir eno ne- 3 Ethi nyl Estr adio l Drospirenone-Ethinyl Ring)

C1 Fem 1 ynor Estradiol (Oral Tablet)

C1 Femynor (Oral Tablet) 1 Dro spir C1 eno ne- Fyav Ethi olv nyl Estr adio l- Lev ome Drospirenone-Ethinyl folat e Fyavolv (Oral Tablet) 1 PA; HRM

C1 Gen eres Estradiol-Levomefolate s Fe 1 Generess Fe (Oral (3-0.02-0.451MG Oral 3 Tablet Chewable)

C1 Gian Tablet) vi C1 Eles trin Gianvi (Oral Tablet) 1

C1 Elestrin (Transdermal Hail ey 24 3 PA; HRM Fe Hailey 24 Fe (Oral Gel) 1 C1 Emo quet te Tablet)

C1 Imv exxy Emoquette (Oral Mai nten anc e Pac 1 k Tablet) Imvexxy Maintenance

C1 2 PA; QL Enp ress e-28 Pack (Vaginal Insert) C1 Imv Enpresse-28 (Oral exxy

Start er Pac 1 k Tablet) Imvexxy Starter Pack C1 2 PA; QL Ens kyce (Vaginal Insert) Enskyce (Oral Tablet) 1 C1 Intro vale C1 Esta rylla Introvale (Oral Tablet) 1 Estarylla (Oral Tablet) 1 C1 Isibl oom C1 Estr ace Isibloom (Oral Tablet) 1 Estrace (Oral Tablet) 3 PA; HRM C1 Jas miel C1 Estr ace Jasmiel (Oral Tablet) 1 Estrace (Vaginal C1 Jint 3 eli Cream) Jinteli (Oral Tablet) 1 PA; HRM C1 C1 Jule ber Estr adio l Estradiol (Oral Tablet) 1 PA; HRM Juleber (Oral Tablet) 1 C1 C1 Jun el Estr 1.5/ adio 30 l Estradiol (Transdermal PA; HRM; Junel 1.5/30 (Oral 1 1 Patch Twice Weekly) Tablet) QL C1 Jun C1 el 1/20 Estr adio l Junel 1/20 (Oral Estradiol (Vaginal 1 1 Tablet)

Cream) C1 Jun C1 el Fe Estr 1.5/ adio 30 l Junel Fe 1.5/30 (Oral Estradiol (Vaginal 1 3 Tablet)

Tablet) C1 Jun C1 el Fe Estr 1/20 adio l Vale rate Junel Fe 1/20 (Oral Estradiol Valerate 1 1 Tablet)

(Intramuscular Oil) C1 Jun C1 el Fe Estri 24 ng Junel Fe 24 (Oral Estring (Vaginal Ring) 3 1 Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 139 139 101138 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Kaitl Loe ib strin Fe 1.5/ Kaitlib Fe (Oral Tablet 30 Loestrin 1.5/30 (21) 1 3 Chewable) (Oral Tablet)

C1 C1 Kari Loe va strin

1/20 Kariva (Oral Tablet) 1 Loestrin 1/20 (21)

C1 Keln or 3 1/35 (Oral Tablet) Kelnor 1/35 (Oral C1 Loe strin Fe 1.5/ 1 30 Tablet) Loestrin Fe 1.5/30

C1 Keln or 3 1/50 (Oral Tablet) Kelnor 1/50 (Oral C1 Loe strin Fe 1 1/20 Tablet) Loestrin Fe 1/20 (Oral

C1 Kurv elo 3 Tablet)

Kurvelo (Oral Tablet) 1 C1 Lory C1 na LAR IN 1.5/ 30 Loryna (Oral Tablet) 1 LARIN 1.5/30 (Oral C1 LoS eas oniq 1 ue Tablet) LoSeasonique (Oral

C1 LAR IN 1/20 3 LARIN 1/20 (Oral Tablet) C1 Low - Oge 1 strel Tablet) Low-Ogestrel (Oral C1 LAR IN Fe 1 1.5/ 30 LARIN Fe 1.5/30 (Oral Tablet) C1 Lute 1 ra Tablet) Lutera (Oral Tablet) 1 C1 C1 LAR IN Marl Fe issa 1/20 LARIN Fe 1/20 (Oral Marlissa (Oral Tablet) 1

C1 1 Mel odet ta 24 Tablet) Fe C1 Melodetta 24 Fe (Oral Lari ssia 1 Larissia (Oral Tablet) 1 Tablet Chewable) C1 C1 Lay olis Men Fe Layolis Fe (Oral est Menest (Oral Tablet) 3 PA; HRM

C1 Mib 1 elas 24 Tablet Chewable) Fe C1 Mibelas 24 Fe (Oral Lee na 1 Leena (Oral Tablet) 1 Tablet Chewable)

C1 C1 Less Micr ina oge stin 1.5/ Lessina (Oral Tablet) 1 30 Microgestin 1.5/30

C1 Lev one 1 st (Oral Tablet)

Levonest (Oral Tablet) 1 C1 Micr C1 oge stin Lev 1/20 onor gest rel- Ethi nyl Estr adio Microgestin 1/20 (Oral l & Ethi nyl Levonorgestrel-Ethinyl Estr adio l 1 Tablet)

Estradiol & Ethinyl 1 C1 Micr oge stin Fe 1.5/ Estradiol (Oral Tablet) 30 Microgestin Fe 1.5/30

C1 Lev onor 1 gest rel- Ethi nyl Estr adio (Oral Tablet) l 91- Day Levonorgestrel-Ethinyl C1 Micr oge stin Fe Estradiol 91-Day (Oral 1 1/20 Microgestin Fe 1/20 1 Tablet) (Oral Tablet)

C1 C1 Lev Mili onor gest rel- Ethi nyl Estr adio l Levonorgestrel-Ethinyl Mili (Oral Tablet) 1

C1 Min 1 astri n 24 Estradiol (Oral Tablet) Fe C1 Minastrin 24 Fe (Oral Lev ora 0.15 /30 3 Levora 0.15/30 (28) Tablet Chewable)

C1 1 Mini (Oral Tablet) velle C1 Minivelle Lo Loe strin Fe PA; HRM; Lo Loestrin Fe (Oral (Transdermal Patch 3 3 QL Tablet) Twice Weekly)

Bold type = Brand name drug Plain type = Generic drug 140 tRACK 140 Last updated September 1, 2019 102139 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Mon Nort oNe rel ssa MonoNessa (Oral 1/35 Nortrel 1/35 (21) (Oral 1 1 Tablet) Tablet) C1 C1 Nort Nata rel zia 1/35 Natazia (Oral Tablet) 3 Nortrel 1/35 (28) (Oral

C1 Nec 1 on 0.5/ 35 Tablet) Necon 0.5/35 (28) C1 Nort rel 7/7/ 1 7 (Oral Tablet) Nortrel 7/7/7 (Oral

C1 Nikk 1 i Tablet) Nikki (Oral Tablet) 1 C1 Nuv aRin C1 g Nor ethi ndro ne Acet ate- Ethi NuvaRing (Vaginal nyl Estr adio l Norethindrone 3 Ring)

Acetate-Ethinyl C1 Ocel la Estradiol (0.5-2.5MG- Ocella (Oral Tablet) 1

C1 Oge 1 PA; HRM strel MCG Oral Tablet, Ogestrel (Oral Tablet) 1

C1 Orsy 1-5MG-MCG Oral thia Orsythia (Oral Tablet) 1

C1 Orth o Tablet) Tri- Cycl en C1 Lo Nor ethi ndro ne Ortho Tri-Cyclen Lo Acet ate- Ethi nyl Estr adio l Norethindrone 3 (Oral Tablet) C1 Orth Acetate-Ethinyl o- Nov um 1 1/35 Ortho-Novum 1/35 Estradiol (1-20MG- 3 MCG Oral Tablet) (28) (Oral Tablet) C1 C1 Orth o- Nor Nov ethi um ndro 7/7/ ne 7 Acet ate- Ethi nyl Estr Ortho-Novum 7/7/7 adio l-Fe Norethindrone 3 Acetate-Ethinyl (28) (Oral Tablet)

C1 Pimt 1 rea Estradiol-Fe (1-20MG- Pimtrea (Oral Tablet) 1

C1 Pirm ella MCG(24) Oral Tablet) 1/35 C1 Nor Pirmella 1/35 (Oral ethi ndro ne Acet ate- Ethi 1 nyl Estr adio l-Fe Norethindrone Tablet)

C1 Porti a-28 Acetate-Ethinyl Portia-28 (Oral Tablet) 1

C1 Pre mari Estradiol-Fe n Premarin (Vaginal (0.4-35MG-MCG Oral 2 Cream)

Tablet Chewable, 1 C1 Prev ifem 0.8-25MG-MCG Oral Previfem (Oral Tablet) 1

C1 Qua rtett Tablet Chewable, e Quartette (Oral 3 1-20MG-MCG(24) Oral Tablet)

C1 Recl ipse Tablet Chewable) n

C1 Nor gest imat Reclipsen (Oral Tablet) 1 e- Ethi nyl C1 Estr Rive adio lsa l Norgestimate-Ethinyl 1 Rivelsa (Oral Tablet) 1

C1 Safy Estradiol (Oral Tablet) ral C1 Nor gest imat e- Ethi Safyral (Oral Tablet) nyl 3 Estr adio C1 l Trip Sea hasi Norgestimate-Ethinyl soni c que Seasonique (Oral Estradiol Triphasic 1 3 (Oral Tablet) Tablet) C1 C1 Setl akin Nort rel 0.5/ 35 Nortrel 0.5/35 (28) Setlakin (Oral Tablet) 1 1 (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 141 141 103140 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Spri Vive ntec lle- 28 Sprintec 28 (Oral Dot Vivelle-Dot 1 PA; HRM; Tablet) (Transdermal Patch 3 C1 Sro nyx QL Sronyx (Oral Tablet) 1 Twice Weekly)

C1 C1 Vyfe Sye mla da Syeda (Oral Tablet) 1 Vyfemla (Oral Tablet) 1

C1 C1 VyLi Tari bra na 24 Fe Tarina 24 Fe (Oral VyLibra (Oral Tablet) 1

C1 WY MZ 1 YA Tablet) Fe WYMZYA Fe (Oral C1 Tari na Fe 1/20 1 Tarina Fe 1/20 (Oral Tablet Chewable)

C1 Xula 1 ne Tablet) Xulane (Transdermal C1 Tri- Esta rylla 1 Tri-Estarylla (Oral Patch Weekly)

C1 Yas min 1 28 Tablet) Yasmin 28 (Oral C1 Tri- Leg est Fe 3 Tri-Legest Fe (Oral Tablet)

C1 1 YAZ Tablet) C1 YAZ (Oral Tablet) 3 Tri- Lo- C1 Esta rylla Yuv afe Tri-Lo-Estarylla (Oral m 1 Yuvafem (Vaginal Tablet) 3 C1 Tablet) Tri- Lo- C1 Spri ntec Zara h Tri-Lo-Sprintec (Oral Zarah (Oral Tablet) 1

1 C1 Zovi a 1/35 Tablet) E

C1 Tri- Mili Zovia 1/35E (28) (Oral Tri-Mili (Oral Tablet) 1 1 C1 Tablet) Tri- Prev ifem Tri-Previfem (Oral B1 Progestins

1 C1 Ayg esti Tablet) n

C1 Tri- Spri Aygestin (Oral Tablet) 3 ntec

C1 Cam Tri-Sprintec (Oral ila 1 Camila (Oral Tablet) 1

C1 Crin Tablet) one

C1 Triv ora Crinone (Vaginal Gel) 3 PA

C1 Debl Trivora (28) (Oral itan e 1 Deblitane (Oral Tablet) 1

Tablet) C1 Dep C1 o- Prov Tri- era VyLi bra Lo Tri-VyLibra Lo (Oral Depo-Provera 1 Tablet) (Intramuscular 3

C1 Tri- VyLi bra Suspension) Tri-VyLibra (Oral C1 Dep o- Sub Q Prov 1 era Tablet) 104 Depo-SubQ Provera

C1 Tyd emy Tydemy (Oral Tablet) 1 104 (Subcutaneous C1 3 Vagi fem Vagifem (Vaginal Suspension Prefilled 3 Syringe) Tablet) C1 Errin

C1 Veli vet Errin (Oral Tablet) 1

C1 Velivet (Oral Tablet) 1 Inca ssia C1 Vien va Incassia (Oral Tablet) 1

C1 Vienva (Oral Tablet) 1 Joliv ette Jolivette (0.35MG 1 Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 142 tRACK 142 Last updated September 1, 2019 104141 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Lyza Evis ta Lyza (Oral Tablet) 1 Evista (Oral Tablet) 3

C1 C1 Med Osp roxy hen pro a gest eron e Acet ate Medroxyprogesterone Osphena (Oral Tablet) 2 PA; QL

C1 Ralo xife ne Acetate (Intramuscular 1 HCl Raloxifene HCl (Oral Suspension) 1

C1 Tablet) Med roxy pro gest eron e A1 Acet ate Medroxyprogesterone Hormonal Agents, Stimulant/Replacement/ Acetate (Intramuscular 1 Modifying (Thyroid)

Suspension Prefilled B1 Syringe) Hormonal Agents, Stimulant/Replacement/

C1 Med roxy pro gest Modifying (Thyroid) eron e Acet C1 ate Cyto Medroxyprogesterone mel 1 Cytomel (Oral Tablet) 3 Acetate (Oral Tablet) C1 Lev o-T C1 Meg estr ol Acet ate Levo-T (Oral Tablet) 1 Megestrol Acetate C1 Lev othy roxi ne Sodi um Levothyroxine Sodium (40MG/ML Oral 1 PA; HRM 1 Suspension) (Oral Tablet) C1 C1 Lev oxyl Meg estr ol Acet ate Megestrol Acetate Levoxyl (Oral Tablet) 1 C1 Liot hyro nine

Sodi (625MG/5ML Oral 3 PA; HRM um Liothyronine Sodium 1 Suspension) (Oral Tablet) C1 C1 Meg estr Synt ol hroi Acet d ate Megestrol Acetate Synthroid (Oral 1 PA; HRM 2 (Oral Tablet) Tablet) C1 Nor a-BE C1 Thyr olar- Nora-BE (Oral Tablet) 1 1 Thyrolar-1 (Oral C1 Nor ethi ndro ne Acet 2 ate Norethindrone Acetate Tablet)

C1 1 Thyr olar- (5MG Oral Tablet) 1/2 C1 Thyrolar-1/2 (Oral Nor ethi ndro ne 2 Norethindrone Tablet) 1 C1 Thyr olar- (0.35MG Oral Tablet) 1/4 C1 Norl Thyrolar-1/4 (Oral yroc Norlyroc (Oral Tablet) 1 2

C1 Tablet) Orth o C1 Micr onor Thyr olar- Ortho Micronor (Oral 2 3 Thyrolar-2 (Oral Tablet) 2

C1 Tablet) Pro gest C1 eron e Thyr Micr olar- oniz 3 ed Progesterone Thyrolar-3 (Oral 2 Micronized (Oral 1 Tablet)

C1 Tiro Capsule) sint

C1 Pro metr ium Tirosint (Oral Prometrium (Oral 3 3 Capsule) C1 Tiro sint- Capsule) SOL

C1 Prov era Tirosint-SOL (Oral Provera (Oral Tablet) 3 3

C1 Shar Solution) obel Sharobel (Oral Tablet) 1 B1 Selective Receptor Modifying Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 143 143 105142 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Unit Leu hroi proli d de Acet Unithroid (100MCG ate Leuprolide Acetate 3 PA Oral Tablet, 112MCG (Injection Kit) C1 Lup anet a Pac Oral Tablet, 125MCG k Lupaneta Pack 4 PA Oral Tablet, 150MCG (Combination Kit)

C1 Lupr on Dep Oral Tablet, 175MCG ot Lupron Depot (1- Oral Tablet, 200MCG 1 Month) 4 PA Oral Tablet, 25MCG (Intramuscular Kit)

C1 Lupr on Dep Oral Tablet, 300MCG ot Lupron Depot (3- Oral Tablet, 50MCG Month) 4 PA Oral Tablet, 75MCG (Intramuscular Kit)

C1 Lupr on Dep Oral Tablet, 88MCG ot Lupron Depot (4- Oral Tablet) Month) 4 PA A1 Hormonal Agents, Suppressant (Adrenal) (Intramuscular Kit)

B1 C1 Lupr on Dep Hormonal Agents, Suppressant (Adrenal) ot C1 Lupron Depot (6- Lys odre n Lysodren (Oral 4 Month) 4 PA Tablet) (Intramuscular Kit)

C1 A1 Octr eoti de Acet Hormonal Agents, Suppressant (Pituitary) ate Octreotide Acetate B1 Hormonal Agents, Suppressant (Pituitary) (1000MCG/ML

C1 Cab ergo line Cabergoline (Oral Injection Solution, 4 PA 1 Tablet) 500MCG/ML Injection

C1 Egrif ta Solution)

C1 Octr Egrifta eoti de Acet ate (Subcutaneous Octreotide Acetate 4 PA; LA Solution (100MCG/ML Injection Solution, 200MCG/ML Reconstituted) 3 PA

C1 Elig ard Injection Solution, Eligard 3 PA 50MCG/ML Injection (Subcutaneous Kit) Solution) C1 Firm C1 ago n Orili Firmagon (120MG ssa Orilissa (Oral Tablet) 4 PA; QL

C1 San dost Subcutaneous atin Sandostatin (Injection 4 PA 4 PA Solution Solution)

C1 Sign Reconstituted) ifor

C1 Firm Signifor ago n Firmagon (80MG (Subcutaneous 4 PA; LA Subcutaneous 3 PA Solution) Solution Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 144 tRACK 144 Last updated September 1, 2019 106143 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Som Ruc atuli one ne st Dep ot Somatuline Depot Ruconest

(Subcutaneous 4 (Intravenous Solution 4 PA; LA Solution) Reconstituted)

C1 C1 Som Tak aver hzyr t Somavert o Takhzyro (Subcutaneous (Subcutaneous 4 PA 4 PA; LA; QL Solution Solution) Reconstituted) B1 Immune Suppressants C1 Syn C1 arel Asta graf Synarel (Nasal XL 4 Astagraf XL (0.5MG Solution) Oral Capsule C1 Trel star Mixj ect Trelstar Mixject Extended Release 24 3 B/D, PA (Intramuscular Hour, 1MG Oral 4 PA Suspension Capsule Extended Reconstituted) Release 24 Hour)

C1 Asta graf A1 Hormonal Agents, Suppressant (Thyroid) XL Astagraf XL (5MG B1 Antithyroid Agents Oral Capsule

C1 Met 4 B/D, PA him azol e Methimazole (Oral Extended Release 24 1 Tablet) Hour) C1 Aza C1 san Pro pylt hiou racil Propylthiouracil (Oral Azasan (100MG Oral 1 3 B/D, PA Tablet) Tablet) C1 Aza C1 san Tap azol e Azasan (75MG Oral Tapazole (Oral Tablet) 3 4 B/D, PA A1 Tablet)

C1 Immunological Agents Azat hiop rine B1 Azathioprine (Oral Angioedema Agents 1 B/D, PA C1 Beri nert Tablet)

C1 Cell Berinert (Intravenous cept 4 PA; LA Cellcept (Oral Kit) 4 B/D, PA

C1 Cinr yze Capsule)

C1 Cell Cinryze (Intravenous cept Cellcept (Oral Solution 4 PA; LA Suspension 4 B/D, PA Reconstituted)

C1 Fira zyr Reconstituted)

C1 Cell Firazyr cept Cellcept (Oral Tablet) 4 B/D, PA

C1 Cim (Subcutaneous 4 PA; LA; QL zia Prefi lled Cimzia Prefilled Solution) 4 PA C1 Hae gard a (Subcutaneous Kit)

C1 Cim Haegarda zia (Subcutaneous Cimzia 4 PA; LA 4 PA Solution (Subcutaneous Kit) Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 145 145 107144 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Cycl Hu osp mira orin Pen e Mod ified Cyclosporine Modified Humira Pen 1 B/D, PA (Oral Capsule) (Subcutaneous Pen- 4 PA C1 Cycl osp orin e Mod ified Cyclosporine Modified Injector Kit)

C1 Hu mira 1 B/D, PA Pen Cro hns Dise ase Start (Oral Solution) er Humira Pen Crohns C1 Cycl osp orin e Cyclosporine (Oral Disease Starter 3 B/D, PA 4 PA Capsule) (Subcutaneous Pen- C1 Dupi xent Dupixent (200MG/ Injector Kit)

C1 Hu mira Pen Psor iasis

Start 1.14ML er Humira Pen Psoriasis Subcutaneous 4 PA Starter 4 PA Solution Prefilled (Subcutaneous Pen- Syringe) Injector Kit) C1 Enb C1 rel Hu Enbrel mira Humira (Subcutaneous 4 PA (Subcutaneous 4 PA Solution Prefilled Prefilled Syringe Kit)

C1 Imur Syringe) an

C1 Imuran (Oral Tablet) 3 B/D, PA Enb rel C1 Kine Enbrel ret Kineret (Subcutaneous (Subcutaneous 4 PA 4 PA Solution Solution Prefilled Reconstituted)

C1 Syringe) Enb rel C1 Sure Clic Met k hotr exat Enbrel SureClick e Methotrexate (Oral 1 (Subcutaneous Tablet)

C1 4 PA Met hotr exat e Sodi Solution Auto- um Methotrexate Sodium Injector) C1 (50MG/2ML Injection Env arsu s XR 1 Envarsus XR (Oral Solution Prefilled Tablet Extended 3 B/D, PA Syringe) C1 Met hotr exat e Sodi Release 24 Hour) um Methotrexate Sodium

C1 Gen graf Gengraf (Oral Capsule) 1 B/D, PA (50MG/2ML Injection 1

C1 Gen graf Solution)

C1 Gengraf (Oral Solution) 1 B/D, PA Myc oph enol C1 ate Mof Hu etil mira

Pedi atric Mycophenolate Mofetil Cro hns Start Humira Pediatric 1 B/D, PA (Oral Capsule)

C1 Myc Crohns Start oph enol ate Mof 4 PA etil (Subcutaneous Mycophenolate Mofetil Prefilled Syringe Kit) (Oral Suspension 4 B/D, PA Reconstituted)

C1 Myc oph enol ate Mof etil Mycophenolate Mofetil 1 B/D, PA (Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 146 tRACK 146 Last updated September 1, 2019 108145 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Myc Rap oph amu enol ne ate Sodi um Mycophenolate Rapamune (0.5MG 3 B/D, PA Sodium (Oral Tablet 3 B/D, PA Oral Tablet)

C1 Rap amu Delayed Release) ne C1 Rapamune (1MG Oral Myf ortic Myfortic (180MG Oral Tablet, 2MG Oral 4 B/D, PA Tablet Delayed 3 B/D, PA Tablet)

C1 Ras Release) uvo C1 Rasuvo Myf ortic Myfortic (360MG Oral (Subcutaneous 3 PA Tablet Delayed 4 B/D, PA Solution Auto- Release) Injector) C1

Neo C1 ral San dim mun Neoral (Oral Capsule) 3 B/D, PA e Sandimmune (100MG C1 Neo ral 4 B/D, PA Neoral (Oral Solution) 3 B/D, PA Oral Capsule)

C1 C1 Olu San mia dim nt mun Olumiant (Oral e Sandimmune (25MG 4 PA; QL 3 B/D, PA Tablet) Oral Capsule)

C1 C1 Ore San ncia dim Clic mun kJec e t Orencia ClickJect Sandimmune (Subcutaneous (100MG/ML Oral 4 B/D, PA 4 PA Solution Auto- Solution)

C1 Sim Injector) poni Simponi C1 Ore ncia Orencia (Subcutaneous 4 PA (Subcutaneous Solution Auto- 4 PA Solution Prefilled Injector)

C1 Sim Syringe) poni Simponi C1 Otre xup Otrexup (Subcutaneous 4 PA (Subcutaneous Solution Prefilled 3 PA Solution Auto- Syringe)

C1 Sirol imu Injector) s Sirolimus (Oral C1 Pro graf 4 B/D, PA Prograf (0.5MG Oral Solution)

C1 Sirol imu 3 B/D, PA s Capsule) Sirolimus (0.5MG Oral C1 Pro graf Prograf (1MG Oral Tablet, 1MG Oral 3 B/D, PA Tablet)

Capsule, 5MG Oral 4 B/D, PA C1 Sirol imu Capsule) s Sirolimus (2MG Oral

C1 Pro 4 B/D, PA graf Tablet) Prograf (Oral Packet) 4 B/D, PA C1 Tacr olim C1 us Rap amu ne Tacrolimus (Oral Rapamune (Oral 1 B/D, PA 4 B/D, PA Capsule)

C1 Solution) Trex all Trexall (Oral Tablet) 3

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 147 147 109146 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Xat Ga mep mun Xatmep (Oral ex-C Gamunex-C (1GM/ 3 PA Solution) 10ML Injection 4 PA

C1 Xelj anz Xeljanz (Oral Tablet Solution) C1 Oct aga 4 PA; QL m Immediate Release) Octagam (1GM/20ML

C1 Xelj anz XR Intravenous Solution, Xeljanz XR (Oral 4 PA Tablet Extended 4 PA; QL 2GM/20ML Release 24 Hour) Intravenous Solution) C1 C1 Pan zyga Zort ress Panzyga (Intravenous Zortress (Oral Tablet) 4 B/D, PA 4 PA B1 Solution) Immunizing Agents, Passive C1 Privi gen C1 BIVI GA M BIVIGAM (10GM/ Privigen (20GM/ 100ML Intravenous 4 PA 200ML Intravenous 4 PA Solution)

Solution) C1 Vari zig C1 Fleb oga mm a DIF Varizig (Intramuscular Flebogamma DIF 4 (5GM/50ML 4 PA Solution) Intravenous Solution) B1 Immunomodulators C1 C1 Acte mra Ga ACT mm Pen agar d Gammagard (2.5GM/ Actemra ACTPen (Subcutaneous 25ML Injection 4 PA 4 PA Solution) Solution Auto-

C1 Ga mm agar d S/ D Less IgA Injector)

Gammagard S/D C1 Acte mra Less IgA (Intravenous Actemra 4 PA (Subcutaneous Solution 4 PA Reconstituted) Solution Prefilled

C1 Ga mm ake d Syringe)

Gammaked (1GM/ C1 Acti mm 10ML Injection 4 PA une Actimmune Solution) (Subcutaneous 4 LA

C1 Ga mm aple x Solution)

Gammaplex (10GM/ C1 Arav a 100ML Intravenous Arava (Oral Tablet) 4 C1 Arca Solution, 10GM/ lyst Arcalyst 200ML Intravenous (Subcutaneous 4 PA 4 PA; LA Solution, 20GM/ Solution 200ML Intravenous Reconstituted) Solution, 5GM/50ML Intravenous Solution)

Bold type = Brand name drug Plain type = Generic drug 148 tRACK 148 Last updated September 1, 2019 110147 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Benl BC ysta G Vac Benlysta cine BCG Vaccine 1 (Subcutaneous (Injection)

C1 Bex 4 PA sero Solution Auto- Bexsero Injector) (Intramuscular C1 Benl ysta 1 Benlysta Suspension Prefilled (Subcutaneous Syringe)

C1 Boo 4 PA strix Solution Prefilled Boostrix (5-2.5-18.5 Syringe) Intramuscular C1 Kev zara Kevzara Suspension,

(Subcutaneous 5-2.5-18.5 (0.5ML 1 4 PA Solution Prefilled Syringe) Syringe) Intramuscular

C1 Lefl uno mid e Leflunomide (Oral Suspension) C1 Dap tace 1 l Tablet) Daptacel C1 Ote zla Otezla (Oral Tablet) 4 PA; LA (Intramuscular 1

C1 Ote zla Otezla (Oral Tablet Suspension) C1 Diph theri a- Teta 4 PA; LA nus Tox oids Therapy Pack) DT Diphtheria-Tetanus

C1 Rida ura Ridaura (Oral Toxoids DT 4 1 Capsule) (Intramuscular

C1 Xola ir Suspension) Xolair (Subcutaneous C1 Eng erix- B Engerix-B (Injection Solution Prefilled 4 PA; LA 1 B/D, PA Syringe) Suspension) C1 Gar C1 dasil Xola 9 ir Gardasil 9 Xolair (Subcutaneous Solution 4 PA; LA (Intramuscular 1 Reconstituted) Suspension) C1 Gar dasil 9 B1 Vaccines Gardasil 9

C1 Act HIB (Intramuscular ActHIB 1 (Intramuscular Suspension Prefilled 1 Syringe) Solution C1 Havr ix Reconstituted) Havrix (Intramuscular C1 1 PA Ada cel Suspension) Adacel C1 Hibe rix Hiberix (Injection (Intramuscular 1 Suspension) Solution 1 Reconstituted)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 149 149 111148 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Imo Rab vax Aver Rabi t es Imovax Rabies RabAvert (Intramuscular 1 B/D, PA (Intramuscular 1 B/D, PA Injectable) Suspension

C1 Infa nrix Infanrix Reconstituted) C1 Rec omb ivax HB (Intramuscular 1 Recombivax HB Suspension) (Injection 1 B/D, PA

C1 IPO L IPOL (Injection) 1 Suspension) C1 C1 Rot arix Ixiar o Ixiaro (Intramuscular Rotarix (Oral 2 Suspension) Suspension 1

C1 Kinri x Reconstituted)

Kinrix (Intramuscular C1 Rot aTe 1 q Suspension) RotaTeq (Oral

C1 Men 1 actr a Solution)

Menactra C1 Shin grix (Intramuscular 1 Shingrix Injectable) (Intramuscular

C1 Men 1 PA veo Menveo Suspension Reconstituted)

(Intramuscular C1 TDV 1 AX TDVAX Solution Reconstituted) (Intramuscular 1

C1 M- M-R II Suspension)

M-M-R II C1 Teni vac Tenivac (Subcutaneous 1 Injectable) (Intramuscular 1

C1 Pedi arix Injectable)

Pediarix C1 Tru men ba (Intramuscular 1 Trumenba Suspension) (Intramuscular

C1 Ped 1 vax HIB Pedvax HIB Suspension Prefilled Syringe) (Intramuscular 1 C1 Twi nrix Suspension) Twinrix

C1 Pro Qua d (Intramuscular ProQuad 1 (Subcutaneous Suspension Prefilled 1 Syringe)

Suspension C1 Typ him Reconstituted) Vi Typhim Vi C1 Qua drac el Quadracel (Intramuscular 2

(Intramuscular 1 Solution) Suspension)

Bold type = Brand name drug Plain type = Generic drug 150 tRACK 150 Last updated September 1, 2019 112149 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 VAQ Mes TA ala min VAQTA e Mesalamine (Oral (Intramuscular 1 PA Capsule Delayed 3 ST Suspension) Release) C1

C1 Mes ala Vari min vax Varivax e Mesalamine (1.2GM Oral Tablet Delayed (Subcutaneous 1 3 QL Injectable) Release) (Generic

C1 YF- Vax Lialda)

C1 Mes ala YF-Vax min e (Subcutaneous 2 Mesalamine (800MG Oral Tablet Delayed 3 ST; QL Injectable)

C1 Zost avax Release)

C1 Mes ala min Zostavax e Mesalamine (Rectal (Subcutaneous 3 3 PA Enema) C1 Mes ala min Suspension e Mesalamine (Rectal 4 Reconstituted) Suppository) A1 C1 Pent Inflammatory Bowel Disease Agents asa Pentasa (Oral B1 Aminosalicylates C1 Capsule Extended 3 QL Apri so Apriso (Oral Capsule Release)

C1 Row asa Extended Release 24 2 QL Rowasa (Rectal Kit) 4

Hour) B1

C1 Asa Glucocorticoids col HD C1 Anu sol- Asacol HD (Oral HC Anusol-HC (Rectal 3 Tablet Delayed 4 ST; QL Cream)

C1 Bud eso nide Release) ER

C1 Bals alazi Budesonide ER (Oral de Diso diu m Balsalazide Disodium 3 Tablet Extended 4 ST (Oral Capsule)

C1 Release 24 Hour) Can asa C1 Bud eso Canasa (Rectal nide 4 Budesonide (Oral Suppository) Capsule Delayed 3 C1 Cola zal Colazal (Oral Capsule) 4 Release Particles) C1 C1 Col Delz ocor icol t Colocort (Rectal Delzicol (Oral 1 Capsule Delayed 3 ST Enema) C1 Ento cort Release) EC Entocort EC (Oral

C1 Dipe ntu m Dipentum (Oral Capsule Delayed 4 4 Capsule) Release Particles) C1

C1 Hyd roco Lial rtiso da ne Acet ate- Pra mox Lialda (Oral Tablet ine Hydrocortisone 4 QL Delayed Release) Acetate-Pramoxine 1 (1-1% Rectal Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 151 151 113150 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Hyd Alen roco dron rtiso ate ne Sodi Hydrocortisone (Rectal um Alendronate Sodium 1 1 Enema) (Oral Tablet)

C1 C1 Proc Atel to- via Med HC Procto-Med HC (Rectal Atelvia (Oral Tablet 1 3 Cream) Delayed Release) C1 C1 Proc to- Bino Pak Procto-Pak (Rectal sto Binosto (Oral Tablet 1 3 Cream) Effervescent) C1

Proc C1 toso l HC Boni va Proctosol HC (Rectal Boniva (Oral Tablet) 3 1 C1 Calc itoni n Sal Cream) mon C1 Proc Calcitonin Salmon tozo ne- HC 1 Proctozone-HC (Rectal (Nasal Solution) 1 C1 Calc Cream) itriol

C1 Uce Calcitriol (Oral ris 1 B/D, PA Uceris (Oral Tablet Capsule)

C1 Calc Extended Release 24 4 ST itriol Calcitriol (Oral Hour) 1 B/D, PA

C1 Solution) Uce ris C1 Cina calc et Uceris (Rectal Foam) 3 HCl Cinacalcet HCl (30MG B1 3 B/D, PA; QL Sulfonamides Oral Tablet)

C1 C1 Azul Cina fidin calc e et EN- HCl tabs Azulfidine EN-tabs Cinacalcet HCl (60MG

(Oral Tablet Delayed 3 Oral Tablet, 90MG Oral 4 B/D, PA; QL Release) Tablet) C1

C1 Dox erca Azul lcife fidin rol e Doxercalciferol (Oral Azulfidine (Oral 3 B/D, PA Capsule) Tablet Immediate 3 C1 Fort eo Release) Forteo

C1 Sulf asal azin e (Subcutaneous 4 PA Sulfasalazine (Oral Tablet Immediate 1 Solution) C1 Fos ama x Release) Fosamax (Oral Tablet) 3

C1 C1 Sulf asal Fos azin ama e x Plus Sulfasalazine (Oral D Fosamax Plus D (Oral 3 Tablet Delayed 1 Tablet)

C1 Iban dron ate Sodi Release) um Ibandronate Sodium A1 1 Metabolic Bone Disease Agents (Oral Tablet)

C1

B1 Nat Metabolic Bone Disease Agents para Natpara C1 Acto nel Actonel (150MG Oral (Subcutaneous 4 PA; LA Tablet, 35MG Oral Cartridge)

C1 Pari calci 3 tol Tablet, 5MG Oral Paricalcitol (1MCG 1 B/D, PA Tablet) Oral Capsule)

C1 Alen dron ate Sodi um Alendronate Sodium 1 (Oral Solution)

Bold type = Brand name drug Plain type = Generic drug 152 tRACK 152 Last updated September 1, 2019 114151 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Pari Gau calci ze tol Paricalcitol (2MCG Gauze (Non-medicated 1 Oral Capsule, 4MCG 3 B/D, PA 2X2 Pad)

C1 Insul in Syri nge s, Nee Oral Capsule) dles C1 Insulin Syringes, Proli a 1 Prolia (Subcutaneous Needles

C1 Luc emy Solution Prefilled 3 QL ra Lucemyra (Oral 4 QL Syringe) Tablet) C1 Ray alde e Rayaldee (Oral A1 Ophthalmic Agents Capsule Extended 4 QL B1 Ophthalmic Agents, Other

C1 Atro pine

Sulf Release) ate

C1 Rise Atropine Sulfate dron ate Sodi um 1 Risedronate Sodium (Ophthalmic Solution) C1 Baci traci n- Poly (Oral Tablet Immediate 1 myxi n B Bacitracin-Polymyxin B Release) 1

C1 Rise dron (Ophthalmic Ointment) ate Sodi um C1 Neo myci n- Poly Risedronate Sodium myxi n- Baci traci n- Hyd roco Neomycin-Polymyxin- rtiso ne (Oral Tablet Delayed 1 Bacitracin- Release) 1 C1 Hydrocortisone Roc altro l Rocaltrol (Oral (Ophthalmic Ointment)

C1 Blep 3 B/D, PA ham Capsule) ide

C1 Blephamide Roc altro l Rocaltrol (Oral (Ophthalmic 3 B/D, PA 3 Solution) Suspension) C1 C1 Sen sipa Blep r ham ide S.O. Sensipar (Oral Tablet) 4 B/D, PA; QL P. Blephamide S.O.P. C1 Tym los 3 Tymlos (Ophthalmic Ointment) C1 Cyst (Subcutaneous 4 PA; QL aran Cystaran (Ophthalmic 4 LA Solution Pen-Injector) Solution)

C1 C1 Xge Lacr va Xgeva (Subcutaneous isert Lacrisert (Ophthalmic 4 PA 3 Solution) Insert)

C1 C1 Zem Last plar acaf Zemplar (1MCG Oral t Lastacaft 3 B/D, PA 2 Capsule) (Ophthalmic Solution)

C1 C1 Zem Maxi plar Zemplar (2MCG Oral trol Maxitrol (Ophthalmic 4 B/D, PA 3 Capsule) Ointment)

C1 Maxi trol A1 Miscellaneous Therapeutic Agents Maxitrol (Ophthalmic

B1 3 Miscellaneous Therapeutic Agents Suspension) C1 C1 Neo myci Alco n- hol Baci Pre traci p n- Pad Poly s myxi Alcohol Prep Pads 1 n Neomycin-Bacitracin-

C1 Fird aps e Polymyxin Firdapse (Oral Tablet) 4 PA; LA; QL 1 (5-400-10000 Ophthalmic Ointment)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 153 153 115152 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Neo Tob myci raD n- ex Poly myxi n- Dex ame thas one Neomycin-Polymyxin- TobraDex

Dexamethasone 1 (Ophthalmic 2 (Ophthalmic Ointment) Ointment) C1

Neo C1 myci n- Tob Poly raD myxi ex n- Dex ame thas one Neomycin-Polymyxin- TobraDex

Dexamethasone (Ophthalmic 3 (3.5-10000-0.1 1 Suspension)

C1 Tob raD ex Ophthalmic ST TobraDex ST Suspension) C1 Neo myci n- Poly (Ophthalmic 3 myxi n- Gra mici din Neomycin-Polymyxin- Suspension)

C1 Tob Gramicidin 1 ram ycin- Dex ame thas (Ophthalmic Solution) one Tobramycin-

C1 Neo myci n- Poly myxi n- Dexamethasone HC Neomycin-Polymyxin- 1 HC (Ophthalmic 1 (Ophthalmic Suspension)

C1 Xiidr Suspension) a

C1 Oxe rvat e Xiidra (Ophthalmic Oxervate (Ophthalmic 3 QL 4 PA; LA; QL Solution)

C1 Solution) Zyle t

C1 Poly myxi n B- Trim etho Zylet (Ophthalmic prim Polymyxin B- 3 Trimethoprim 1 Suspension) (Ophthalmic Solution) B1 Ophthalmic Anti-allergy Agents C1 C1 Aloc ril Poly trim Polytrim (Ophthalmic Alocril (Ophthalmic 3 3 Solution) Solution) C1 C1 Alo mid Pre e d-G Pred-G (Ophthalmic Alomide (Ophthalmic 3 3 Suspension) Solution) C1 C1 Azel astin Pre e d-G HCl S.O. P. Pred-G S.O.P. Azelastine HCl 1 (Ophthalmic (Ophthalmic Solution) 3 C1 Bep Ointment) reve Bepreve (Ophthalmic

C1 Pro para 3 cain e HCl Solution) Proparacaine HCl C1 Cro mol yn Sodi 1 um (Ophthalmic Solution) Cromolyn Sodium

C1 Rest asis 1 Restasis (Ophthalmic (Ophthalmic Solution) C1 Epin astin e 2 QL HCl Emulsion) Epinastine HCl

C1 Rho 1 pres sa (Ophthalmic Solution) Rhopressa C1 Olo pata dine 2 ST HCl (Ophthalmic Solution) Olopatadine HCl C1 1 Sulf acet ami de- Pre dnis (Ophthalmic Solution) olon e C1 Sulfacetamide- Pata day Pataday (Ophthalmic Prednisolone 1 3 (Ophthalmic Solution) Solution)

Bold type = Brand name drug Plain type = Generic drug 154 tRACK 154 Last updated September 1, 2019 116153 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Pata Dor nol zola mid e Patanol (Ophthalmic HCl Dorzolamide HCl 2 1 Solution) (Ophthalmic Solution) C1 C1 Dor Paz zola eo mid e HCl- Tim olol Mal Pazeo (Ophthalmic eate Dorzolamide HCl- 2 Solution) Timolol Maleate 1

B1 (Ophthalmic Solution)

C1 Ophthalmic Antiglaucoma Agents Dor zola mid C1 e HCl- Alph Tim aga olol n P Mal eate

Pres Dorzolamide HCl- erva tive Alphagan P (0.1% Free 2 Timolol Maleate Ophthalmic Solution) 1

C1 Alph aga Preservative Free n P Alphagan P (0.15% (Ophthalmic Solution) 3 C1 Iopi Ophthalmic Solution) dine C1 Apr Iopidine (1% aclo nidi ne HCl 4 Apraclonidine HCl Ophthalmic Solution)

1 C1 Isop to Car (Ophthalmic Solution) pine

C1 Azo pt Isopto Carpine Azopt (Ophthalmic 3 2 (Ophthalmic Solution) C1 Istal Suspension) ol

C1 Beta xolo Istalol (Ophthalmic l HCl Betaxolol HCl 3 1 Solution) C1 Lev obu nolo (Ophthalmic Solution) l HCl

C1 Beti mol Levobunolol HCl Betimol (Ophthalmic 1 3 (Ophthalmic Solution) C1 Pho sph olin e Solution) Iodi de

C1 Bet opti Phospholine Iodide c-S Betoptic-S (Ophthalmic Solution 3 (Ophthalmic 3 Reconstituted)

C1 Pilo carp ine Suspension) HCl

C1 Brim onid Pilocarpine HCl ine Tartr ate 1 Brimonidine Tartrate (Ophthalmic Solution)

C1 Roc klata (0.15% Ophthalmic 1 n Rocklatan Solution) 3 ST

C1 Brim (Ophthalmic Solution) onid ine Tartr C1 ate Sim brin Brimonidine Tartrate za Simbrinza (0.2% Ophthalmic 1 (Ophthalmic 2 Solution)

C1 Cart eolo l Suspension) HCl

C1 Tim olol Mal Carteolol HCl eate

Oph thal mic Gel 1 For min Timolol Maleate (Ophthalmic Solution) g

C1 Co mbi gan Ophthalmic Gel Combigan 2 Forming (Ophthalmic 1 (Ophthalmic Solution)

C1 Solution) (Generic Cos opt Cosopt (Ophthalmic Timoptic-XE) 3 Solution)

C1 Cos opt PF Cosopt PF 3 (Ophthalmic Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 155 155 117154 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Tim Dur olol ezol Mal eate Timolol Maleate Durezol (Ophthalmic 2 (0.25% Ophthalmic Emulsion) C1 Flar Solution, 0.5% 1 ex Flarex (Ophthalmic 3 Ophthalmic Solution) Suspension)

C1 Fluo rom (Generic Timoptic) etho lone

C1 Tim olol Mal eate Fluorometholone Timolol Maleate (0.5% (Ophthalmic 1 (DAILY) Ophthalmic 3 Suspension)

C1 Flur bipr Solution) ofen

Sodi C1 um Tim opti c Ocu Flurbiprofen Sodium dos e Timoptic Ocudose 1 3 (Ophthalmic Solution) C1 FML Fort (Ophthalmic Solution) e

C1 Tim opti c-XE FML Forte Timoptic-XE (Ophthalmic 3 (Ophthalmic Gel 3 Suspension)

C1 FML Liqu Forming Solution) ifilm

C1 Trus opt FML Liquifilm Trusopt (Ophthalmic 3 (Ophthalmic 3 Solution) Suspension) B1 C1 Ophthalmic Anti-inflammatories FML C1 Acul FML (Ophthalmic ar LS 3 Acular LS Ointment)

3 C1 Ilevr (Ophthalmic Solution) o C1 Acul Ilevro (Ophthalmic ar 2 Acular (Ophthalmic Suspension)

3 C1 Invel Solution) tys

C1 Acu Inveltys (Ophthalmic vail 3 ST Acuvail (Ophthalmic Suspension)

3 ST C1 Ket orol ac Tro met Solution) ham ine

C1 Alre Ketorolac x Alrex (Ophthalmic 3 Tromethamine 1 Suspension) (Ophthalmic Solution) C1 C1 Bro mfe Lote nac max Sodi um Bromfenac Sodium Lotemax (Ophthalmic 3 (Once-Daily) 1 Gel)

C1 Lote (Ophthalmic Solution) max C1 Bro Lotemax (Ophthalmic mSit e 3 BromSite Ointment)

3 ST C1 Lote (Ophthalmic Solution) max C1 Dex Lotemax (Ophthalmic ame thas one Sodi um Pho sph 3 ate Dexamethasone Suspension) C1 Lote max Sodium Phosphate 1 SM Lotemax SM (Ophthalmic Solution) 3

C1 Dicl ofen ac (Ophthalmic Gel) Sodi um Diclofenac Sodium 1 (Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug 156 tRACK 156 Last updated September 1, 2019 118155 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Lote Vyz pred ulta nol Etab onat e Loteprednol Etabonate Vyzulta (Ophthalmic 3 (Ophthalmic 3 Solution)

C1 Xala Suspension) tan C1 Xalatan (Ophthalmic Maxi dex 3 Maxidex (Ophthalmic Solution)

C1 3 Xelp Suspension) ros C1 Xelpros (Ophthalmic Nev ana c 3 ST Nevanac (Ophthalmic Emulsion)

C1 3 Ziop Suspension) tan C1 Zioptan (Ophthalmic Om nipr ed Omnipred (1% 3 Solution) Ophthalmic 3 A1 Otic Agents

Suspension) B1

C1 Pre d Otic Agents Fort e C1 Acet ic Pred Forte Acid Acetic Acid (Otic 1 (Ophthalmic 3 Solution)

C1 Cetr Suspension) axal

C1 Pre d Cetraxal (Otic Mild Pred Mild 3 Solution) C1 Cipr o (Ophthalmic 3 HC Cipro HC (Otic Suspension) 3

C1 Pre dnis Suspension) olon e Acet C1 ate Cipr ode Prednisolone Acetate x Ciprodex (Otic (Ophthalmic 1 2 Suspension)

C1 Suspension) Cipr oflo xaci C1 n HCl Pre dnis olon e Sodi um Ciprofloxacin HCl Pho sph ate Prednisolone Sodium 1 (Otic Solution) Phosphate (1% 1 C1 Flac Ophthalmic Solution) Flac (Otic Oil) 1 C1 C1 Fluo Prol cino ens lone a Acet onid Prolensa (Ophthalmic e Fluocinolone 3 1 Solution) Acetonide (Otic Oil) C1 Hyd roco rtiso ne- B1 Acet ic Acid Hydrocortisone-Acetic Ophthalmic Prostaglandin and Prostamide 1 Acid (Otic Solution)

Analogs C1 Neo C1 myci n- Bim Poly atop myxi rost n- HC Neomycin-Polymyxin- Bimatoprost 1 1 HC (1% Otic Solution)

(Ophthalmic Solution) C1 Neo C1 myci n- Lata Poly nopr myxi ost n- HC Neomycin-Polymyxin- Latanoprost 1 1 HC (Otic Suspension)

(Ophthalmic Solution) C1 Oto C1 vel Lum igan Lumigan (Ophthalmic Otovel (Otic Solution) 3 ST 2 A1 Solution) Respiratory Tract/Pulmonary Agents

C1 Trav B1 atan Z Travatan Z Antihistamines C1 Aste 3 pro (Ophthalmic Solution) Astepro (Nasal 3 Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 157 157 119156 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Azel Arn astin uity e Ellip HCl ta Azelastine HCl (0.1% Arnuity Ellipta Nasal Solution, 0.15% 1 (Inhalation Aerosol 2 QL Nasal Solution) Powder Breath C1 Ceti rizin e HCl Cetirizine HCl (1MG/ Activated)

C1 Asm 1 ane ML Oral Solution) x

C1 Asmanex (120 Clari nex Clarinex (Oral Syrup) 3 Metered Doses) C1 Clari nex Clarinex (Oral Tablet) 3 (Inhalation Aerosol 3 ST; QL

C1 Cyp rohe ptad ine HCl Cyproheptadine HCl Powder Breath 1 PA; HRM (Oral Tablet) Activated) C1 C1 Asm Desl ane orat x adin e Desloratadine (Oral Asmanex (30 Metered 1 Tablet) Doses) (Inhalation

C1 Desl orat adin 3 ST; QL e ODT Aerosol Powder Desloratadine ODT (Oral Tablet 1 Breath Activated)

C1 Asm ane Dispersible) x Asmanex (60 Metered C1 Lev ocet irizin e Dihy droc hlori de Levocetirizine Doses) (Inhalation 3 ST; QL Dihydrochloride (Oral 1 Aerosol Powder Solution)

C1 Breath Activated) Lev ocet C1 irizin e Asm Dihy ane droc x hlori HFA de Levocetirizine Asmanex HFA 3 ST; QL Dihydrochloride (Oral 1 (Inhalation Aerosol)

C1 Bec ona se Tablet) AQ

C1 Olo pata dine Beconase AQ (Nasal HCl Olopatadine HCl 3 ST 3 Suspension) C1 Bud eso (Nasal Solution) nide

C1 Pata nas e Budesonide (Inhalation Patanase (Nasal 3 B/D, PA 3 Suspension) C1 Flov ent Disk Solution) us

C1 Phe nad oz Flovent Diskus Phenadoz (12.5MG 1 PA; HRM (Inhalation Aerosol Rectal Suppository) 2

C1 Pro met Powder Breath hazi ne HCl Promethazine HCl 1 PA; HRM Activated) C1 Flov ent (Oral Tablet) HFA

C1 Pro met hazi Flovent HFA ne HCl Promethazine HCl 2 QL (Inhalation Aerosol)

C1 Flun (12.5MG Rectal 1 PA; HRM isoli de Flunisolide (Nasal Suppository) 1 B1 Solution)

C1 Fluti Anti-inflammatories, Inhaled Corticosteroids cas one Pro pion C1 ate Alve sco Fluticasone Propionate Alvesco (Inhalation 1 3 ST; QL (Nasal Suspension) C1 Mo met Aerosol Solution) aso ne Furo ate Mometasone Furoate 1 (Nasal Suspension)

Bold type = Brand name drug Plain type = Generic drug 158 tRACK 158 Last updated September 1, 2019 120157 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Nas Sing one ulair x Nasonex (Nasal Singulair (Oral Tablet 3 3 QL Suspension) Chewable)

C1 C1 Om Zafir nari luka s Omnaris (Nasal st Zafirlukast (Oral 3 ST 1 Suspension) Tablet) C1 C1 Zile Pul uton mic ER ort Flex hale r Pulmicort Flexhaler Zileuton ER (Oral (Inhalation Aerosol Tablet Extended 4 ST 3 ST Release 12 Hour)

Powder Breath C1 Zyfl o Activated) CR Zyflo CR (600MG Oral

C1 Pul mic ort Pulmicort (Inhalation Tablet Extended 4 ST 3 B/D, PA Release 12 Hour)

Suspension) C1 Zyfl o C1 Qna sl Chil dren s Zyflo (Oral Tablet Qnasl Childrens 4 ST (Nasal Aerosol 3 ST Immediate Release) Solution) B1 Bronchodilators, Anticholinergic C1 C1 Atro vent Qna sl Qnasl (Nasal Aerosol HFA Atrovent HFA 3 ST Solution) (Inhalation Aerosol 3

C1 QVA R Redi Hale r Solution)

QVAR RediHaler C1 Incr use Ellip (Inhalation Aerosol 3 ST; QL ta Incruse Ellipta Breath Activated) (Inhalation Aerosol

C1 Xha 2 QL nce Xhance (Nasal Powder Breath 3 Activated)

Exhaler Suspension) C1 Iprat ropi C1 um Zeto Bro nna mid e Ipratropium Bromide Zetonna (Nasal 1 B/D, PA 3 ST (Inhalation Solution) Aerosol Solution) C1 Iprat ropi um Bro mid e B1 Ipratropium Bromide Antileukotrienes 1 C1 Acc olat e (Nasal Solution)

C1 Lon hala Accolate (Oral Tablet) 3 Mag nair Refil C1 l Kit Mon telu kast Sodi Lonhala Magnair um Montelukast Sodium 1 QL Refill Kit (Inhalation 4 QL (Oral Packet)

C1 Mon telu kast Solution) Sodi um C1 See bri Neo Montelukast Sodium hale 1 QL r Seebri Neohaler (Oral Tablet) 3 ST C1 Mon telu kast Sodi (Inhalation Capsule) um

C1 Spiri va Montelukast Sodium Han diHa 1 QL ler (Oral Tablet Chewable) Spiriva HandiHaler

C1 2 QL Sing ulair (Inhalation Capsule)

C1 Spiri Singulair (Oral va Res pim 3 QL at Packet) Spiriva Respimat

C1 Sing ulair (Inhalation Aerosol 2 QL Singulair (Oral Tablet) 3 QL Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 159 159 121158 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Tud Brov orza ana

Pres sair Tudorza Pressair Brovana (Inhalation (Inhalation Aerosol Nebulization 4 PA; QL 3 ST Powder Breath Solution)

C1 Epin ephr Activated) ine Epinephrine (0.3MG/ C1 Yup elri Yupelri (Inhalation 0.3ML Injection 4 B/D, PA; QL Solution) Solution Auto-Injector) 3 ST; QL B1 Bronchodilators, Sympathomimetic (Brand Equivalent

C1 Albu terol Adrenaclick) Sulf ate ER C1 Epin ephr Albuterol Sulfate ER ine (Oral Tablet Extended 1 Epinephrine (0.15MG/ Release 12 Hour) 0.15ML Injection

C1 Albu terol Solution Auto-Injector) 3 ST; QL Sulf ate HFA Albuterol Sulfate HFA (Brand Equivalent (108 (90 Base)MCG/ Adrenaclick)

C1 Epin ephr ACT Inhalation ine 3 ST Epinephrine (0.15MG/ Aerosol Solution) 0.3ML Injection (Brand Equivalent Solution Auto-Injector, Proair) 0.3MG/0.3ML Injection 2 QL C1 Albu terol

Sulf ate HFA Albuterol Sulfate HFA Solution Auto-Injector) (108 (90 Base)MCG/ (Brand Equivalent ACT Inhalation Aerosol Epipen) C1 EpiP en 2- Solution) (Brand Pak EpiPen 2-Pak Equivalent Proventil), 3 ST (Injection Solution 3 ST; QL Albuterol Sulfate HFA Auto-Injector)

C1 EpiP en Jr 2- (108 (90 Base)MCG/ Pak EpiPen Jr 2-Pak ACT Inhalation Aerosol Solution) (Brand (Injection Solution 3 ST; QL Auto-Injector)

Equivalent Ventolin) C1 Lev C1 albu terol Albu HCl terol

Sulf ate Albuterol Sulfate Levalbuterol HCl (Inhalation 1 B/D, PA (0.31MG/3ML Nebulization Solution) Inhalation Nebulization

C1 Albu terol

Sulf ate Solution, 0.63MG/3ML Albuterol Sulfate (Oral 1 B/D, PA 1 Inhalation Nebulization Syrup)

C1 Albu terol Solution, 1.25MG/3ML

Sulf ate Albuterol Sulfate (Oral Inhalation Nebulization Tablet Immediate 3 Solution) Release)

C1 Arca pta Neo hale r Arcapta Neohaler 3 ST (Inhalation Capsule)

Bold type = Brand name drug Plain type = Generic drug 160 tRACK 160 Last updated September 1, 2019 122159 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Lev Vent albu olin terol HFA HCl Levalbuterol HCl Ventolin HFA (1.25MG/0.5ML 3 B/D, PA (Inhalation Aerosol 3 ST Inhalation Nebulization Solution)

C1 Xop ene x Con cent Solution) rate

C1 Lev Xopenex Concentrate albu terol

Tartr ate Levalbuterol Tartrate 3 ST (Inhalation (Inhalation Aerosol) 3 B/D, PA C1 Nebulization Met apro tere nol Sulf ate Metaproterenol Sulfate Solution)

1 C1 Xop ene x (Oral Syrup) HFA

C1 Met Xopenex HFA apro tere nol Sulf ate 3 ST Metaproterenol Sulfate (Inhalation Aerosol) C1 Xop ene (10MG Oral Tablet, 1 x Xopenex (0.31MG/ 20MG Oral Tablet)

C1 Perf oro mist 3ML Inhalation Perforomist Nebulization Solution, (Inhalation 3 B/D, PA; QL 0.63MG/3ML 3 B/D, PA Nebulization Inhalation Solution)

C1 Pro Air Nebulization HFA ProAir HFA Solution) C1 Xop ene (Inhalation Aerosol 2 x Xopenex (1.25MG/ Solution)

C1 Pro Air 3ML Inhalation Res piCli ck 4 B/D, PA ProAir RespiClick Nebulization (Inhalation Aerosol 2 Solution) Powder Breath B1 Cystic Fibrosis Agents

C1 Beth Activated) kis

C1 Prov entil

HFA Bethkis (Inhalation Proventil HFA Nebulization 4 B/D, PA; QL (Inhalation Aerosol 3 ST Solution)

C1 Cay Solution) ston

C1 Sere vent

Disk Cayston (Inhalation us Serevent Diskus Solution 4 PA; LA (Inhalation Aerosol 2 QL Reconstituted)

C1 Ork amb Powder Breath i Orkambi (Oral Activated) 4 PA; LA; QL C1 Striv erdi Res pim Packet) at C1 Ork amb Striverdi Respimat i Orkambi (Oral Tablet) 4 PA; LA; QL

C1 (Inhalation Aerosol Sym 3 ST dek o Solution) Symdeko (Oral Tablet

C1 4 PA; QL Terb utali ne Sulf ate Therapy Pack) Terbutaline Sulfate 3 (Oral Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 161 161 123160 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 TOB Alyq I TOBI (Inhalation Alyq (Oral Tablet) 4 PA

C1 Am bris enta Nebulization 4 B/D, PA; QL n Ambrisentan (Oral 4 PA; LA; QL Solution) Tablet)

C1 C1 TOB I Bos Pod enta hale n r TOBI Podhaler Bosentan (Oral Tablet) 4 PA; LA; QL

C1 Leta 4 PA; QL iris (Inhalation Capsule) Letairis (Oral Tablet) 4 PA; LA; QL C1 Tob C1 ram ycin Ops Tobramycin (Inhalation umit Opsumit (Oral Tablet) 4 PA; LA 4 B/D, PA; QL C1 Ore nitra Nebulization Solution) m Orenitram (0.125MG B1 Mast Cell Stabilizers C1 Oral Tablet Extended 3 PA; LA Cro mol yn Sodi um Cromolyn Sodium Release)

C1 Ore nitra (Inhalation 1 B/D, PA m Orenitram (0.25MG Nebulization Solution) Oral Tablet Extended B1 Phosphodiesterase Inhibitors, Airways Release, 1MG Oral Disease C1 Tablet Extended Dalir esp Daliresp (Oral Tablet) 3 PA Release, 2.5MG Oral 4 PA; LA C1 The o-24 Theo-24 (Oral Capsule Tablet Extended Extended Release 24 3 Release, 5MG Oral Hour) Tablet Extended C1 The oph yllin e ER Theophylline ER Release)

C1 Rev (100MG Oral Tablet atio Revatio (Oral Extended Release 12 Suspension 4 PA Hour, 200MG Oral Reconstituted)

C1 Rev Tablet Extended 1 atio Revatio (Oral Tablet) 4 PA Release 12 Hour, C1 Sild enaf il Citra 300MG Oral Tablet te Sildenafil Citrate (Oral Extended Release 12 Suspension 4 PA Hour) Reconstituted)

C1 C1 Sild The enaf oph il yllin Citra e te ER Theophylline ER (Oral Sildenafil Citrate Tablet Extended 1 (20MG Oral Tablet) 1 PA Release 24 Hour) (Generic Revatio)

C1 C1 Tad The alafil oph yllin e Theophylline (Oral Tadalafil (PAH) (20MG 1 4 PA Solution) Oral Tablet)

C1 Trac leer B1 Pulmonary Antihypertensives Tracleer (Oral Tablet) 4 PA; LA; QL

C1 C1 Trac Adci leer rca Adcirca (Oral Tablet) 4 PA Tracleer (Oral Tablet

C1 Ade mpa 4 PA; LA; QL s Adempas (Oral Soluble) C1 Uptr 4 PA; LA avi Tablet) Uptravi (Oral Tablet) 4 PA; LA; QL

Bold type = Brand name drug Plain type = Generic drug 162 tRACK 162 Last updated September 1, 2019 124161 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Uptr Bev avi espi

Aer osp Uptravi (Oral Tablet here Bevespi Aerosphere 4 PA; LA 3 ST Therapy Pack) (Inhalation Aerosol)

C1 C1 Vent Bre avis o Ellip Ventavis (Inhalation ta Breo Ellipta 4 PA; LA Solution) (Inhalation Aerosol

B1 2 QL Pulmonary Fibrosis Agents Powder Breath

C1 Esbr iet Activated) Esbriet (Oral Capsule) 4 PA; LA; QL C1 Clari nex- C1 D 12 Esbr Hou iet r Clarinex-D 12 Hour Esbriet (Oral Tablet) 4 PA; LA; QL C1 Ofe v Ofev (Oral Capsule) 4 PA; LA; QL (Oral Tablet Extended 3

B1 Release 12 Hour)

C1 Co mbi Respiratory Tract Agents, Other vent

Res C1 pim at Acet ylcy stei ne Combivent Respimat Acetylcysteine 1 B/D, PA (Inhalation Aerosol 2 QL (Inhalation Solution)

C1 Adv air Disk Solution) us

C1 Dule Advair Diskus ra Dulera (Inhalation (Inhalation Aerosol 3 QL 1 QL Aerosol)

C1 Dym Powder Breath ista Activated) Dymista (Nasal

C1 3 Adv air HFA Suspension)

C1 Fas Advair HFA enra 2 QL (Inhalation Aerosol) Fasenra

C1 AirD uo Res piCli ck (Subcutaneous 113/ 14 AirDuo RespiClick 4 PA; LA Solution Prefilled 113/14 (Inhalation 3 ST; QL Syringe)

C1 Fluti Aerosol Powder cas one- Sal met Breath Activated) erol Fluticasone-Salmeterol

C1 AirD uo Res piCli (100-50MCG/DOSE ck 232/ 14 AirDuo RespiClick Inhalation Aerosol 232/14 (Inhalation 3 ST; QL Powder Breath Aerosol Powder Activated, Breath Activated) 250-50MCG/DOSE C1 AirD uo Res piCli ck 55/1 4 Inhalation Aerosol AirDuo RespiClick 1 QL 55/14 (Inhalation Powder Breath 3 ST; QL Aerosol Powder Activated, Breath Activated) 500-50MCG/DOSE

C1 Ano ro Ellip ta Inhalation Aerosol Anoro Ellipta Powder Breath (Inhalation Aerosol 2 QL Activated) (Generic Powder Breath Advair) Activated)

You can find information on what the abbreviations in this table mean on pages 6 - 7. Last updatedtRACK September 1, 2019 163 163 125162 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 C1 Fluti Sem cas prex one- -D Sal met erol Fluticasone-Salmeterol Semprex-D (Oral 3 (113-14MCG/ACT Capsule)

C1 Stiol to Res pim Inhalation Aerosol at Stiolto Respimat

Powder Breath (Inhalation Aerosol 2 Activated, Solution)

C1 Sym 232-14MCG/ACT bico rt Symbicort (Inhalation Inhalation Aerosol 2 QL 2 QL Powder Breath Aerosol) C1 Trel egy Ellip Activated, 55-14MCG/ ta Trelegy Ellipta ACT Inhalation Aerosol (Inhalation Aerosol 2 QL Powder Breath Powder Breath Activated) (Brand Activated)

C1 Utib ron Neo Equivalent AirDuo) hale r

C1 Iprat ropi um- Utibron Neohaler Albu terol Ipratropium-Albuterol 3 ST 1 B/D, PA (Inhalation Capsule) C1 Wix ela (Inhalation Solution) Inhu b

C1 Kaly dec o Wixela Inhub Kalydeco (Oral 4 PA; LA (Inhalation Aerosol Packet) C1 Powder Breath 1 QL Kaly dec o Kalydeco (Oral 4 PA; LA Activated) (Generic Tablet) Advair)

C1 Nuc ala Nucala A1 Skeletal Muscle Relaxants (Subcutaneous B1 Skeletal Muscle Relaxants

C1 4 PA; LA; QL Bacl ofen Solution Auto- Baclofen (Oral Tablet) 1

C1 Cycl obe nza prin e Injector) HCl

C1 Nuc Cyclobenzaprine HCl ala 3 PA; HRM Nucala (7.5MG Oral Tablet)

C1 Dant (Subcutaneous rium Dantrium (Oral 4 PA; LA; QL 3 Solution Prefilled Capsule)

C1 Dant role ne Sodi Syringe) um

C1 Nuc ala Dantrolene Sodium 1 Nucala (Oral Capsule)

C1 Fex (Subcutaneous mid 4 PA; LA; QL Fexmid (Oral Tablet) 3 PA; HRM C1 Tiza nidi ne Solution HCl Tizanidine HCl (Oral Reconstituted) 1

C1 Oral air Capsule) 300I R C1 Tiza nidi ne Oralair 300IR (Tablet HCl 3 PA Tizanidine HCl (Oral Sublingual) 1 C1 Tablet) Pul moz yme C1 Zan Pulmozyme aflex Zanaflex (Oral 4 B/D, PA; QL 3 (Inhalation Solution) Capsule)

Bold type = Brand name drug Plain type = Generic drug 164 tRACK 164 Last updated September 1, 2019 126163 Coverage Coverage Drug Rules or Drug Rules or Drug Name Drug Name Tier Limits on Tier Limits on use use

C1 Zan aflex B1 Zanaflex (Oral Tablet) 3 Sleep Disorders, Other

C1 Arm odaf A1 Sleep Disorder Agents inil Armodafinil (Oral 1 PA; QL B1 Tablet)

GABA Receptor Modulators C1 Bels C1 omr a Am bien Belsomra (Oral Ambien (Oral Tablet PA; HRM; 2 QL 3 Tablet)

Immediate Release) QL C1 Hetli C1 oz Rest oril Hetlioz (Oral Capsule) 4 PA; LA; QL

Restoril (22.5MG Oral C1 Mod 4 HRM; QL afinil Capsule) Modafinil (Oral Tablet) 1 PA; QL C1 C1 Nuvi Tem gil aze pam Temazepam (15MG Nuvigil (150MG Oral Oral Capsule, 30MG Tablet, 200MG Oral 1 HRM; QL 4 PA; QL Oral Capsule, 7.5MG Tablet, 250MG Oral Oral Capsule) Tablet) C1

Tem C1 aze pam Nuvi Temazepam (22.5MG gil 3 HRM; QL Nuvigil (50MG Oral Oral Capsule) 3 PA; QL

C1 Tablet) Zale plon C1 Prov Zaleplon (Oral igil Provigil (Oral Tablet) 4 PA; QL

1 HRM; QL C1 Roz ere Capsule) m

C1 Zolp ide Rozerem (Oral Tablet) 3 m Tartr ate C1 Sile Zolpidem Tartrate nor PA; HRM; Silenor (Oral Tablet) 3

C1 Xyre (Oral Tablet Immediate 1 m QL Release) Xyrem (Oral Solution) 4 PA; LA; QL

You can find information on what the abbreviations in this table mean on pages 6 - 7. 165 1 1 track 165 Covered drugs with a quantity limit (QL) This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety. Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover. Drugs are listed in alphabetical order in the chart below. track

Drug Name Quantity Limit Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day Abilify (Oral Tablet) Maximum of 1 tablet per day Abstral (Tablet Sublingual) Maximum of 4 tablets per day Accupril (Oral Tablet) Maximum of 2 tablets per day Accuretic (10-12.5MG Oral Tablet) Maximum of 1 tablet per day Accuretic (20-12.5MG Oral Tablet, 20-25MG Maximum of 2 tablets per day Oral Tablet) Acetaminophen-Codeine (120-12MG/5ML Oral Maximum of 150 ml per day Solution) Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Maximum of 13 tablets per day Tablet) Actiq (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day Actoplus Met (Oral Tablet Immediate Maximum of 3 tablets per day Release) Actos (15MG Oral Tablet) Maximum of 3 tablets per day Actos (30MG Oral Tablet, 45MG Oral Tablet) Maximum of 1 tablet per day Adderall (20MG Oral Tablet) Maximum of 3 tablets per day Adderall (5MG Oral Tablet, 7.5MG Oral Tablet) Maximum of 2 tablets per day Adderall XR (Oral Capsule Extended Release Maximum of 2 capsules per day 24 Hour) Adlyxin Starter Pack (Subcutaneous Pen- Maximum of 6 ml (1 kit) per 28 days Injector Kit) Adlyxin (Subcutaneous Solution Pen-Injector) Maximum of 6 ml (2 pens) per 28 days Advair Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated)

Bold type = Brand name drug Plain type = Generic drug 166166 2 2 Last updated September 1, 2019 Drug Name Quantity Limit Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Adzenys ER (Oral Suspension Extended Maximum of 15 ml per day Release) Adzenys XR-ODT (Oral Tablet Extended Maximum of 1 tablet per day Release Dispersible) Aggrenox (Oral Capsule Extended Release 12 Maximum of 2 capsules per day Hour) Aimovig (140MG/ML Subcutaneous Solution Maximum of 1 ml (1 pen) per 30 days Auto-Injector) Aimovig (70MG/ML Subcutaneous Solution Maximum of 2 ml per 30 days Auto-Injector) AirDuo RespiClick 113/14 (Inhalation Aerosol Maximum of 1 inhaler per 30 days Powder Breath Activated) AirDuo RespiClick 232/14 (Inhalation Aerosol Maximum of 1 inhaler per 30 days Powder Breath Activated) AirDuo RespiClick 55/14 (Inhalation Aerosol Maximum of 1 inhaler per 30 days Powder Breath Activated) Ajovy (Subcutaneous Solution Prefilled Maximum of 1.5 ml (1 syringe) per 30 days Syringe) Albendazole (Oral Tablet) Maximum of 16 tablets per day Albenza (Oral Tablet) Maximum of 16 tablets per day Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day Almotriptan Malate (Oral Tablet) Maximum of 12 tablets per 30 days Alogliptin Benzoate (Oral Tablet) Maximum of 1 tablet per day Alogliptin-Metformin HCl (Oral Tablet) Maximum of 2 tablets per day Alogliptin-Pioglitazone (Oral Tablet) Maximum of 1 tablet per day Alora (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days Alprazolam ER (0.5MG Oral Tablet Extended Release 24 Hour, 1MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Alprazolam ER (2MG Oral Tablet Extended Maximum of 5 tablets per day Release 24 Hour) Alprazolam ER (3MG Oral Tablet Extended Maximum of 3 tablets per day Release 24 Hour) Alprazolam Intensol (Oral Concentrate) Maximum of 10 ml per day Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, Maximum of 4 tablets per day 1MG Oral Tablet Immediate Release) Alprazolam (2MG Oral Tablet Immediate Maximum of 5 tablets per day Release)

Bold type = Brand name drug Plain type = Generic drug Last167 updated September 1, 2019 3 3 167 Drug Name Quantity Limit Alprazolam ODT (0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, Maximum of 4 tablets per day 1MG Oral Tablet Dispersible) Alprazolam ODT (2MG Oral Tablet Dispersible) Maximum of 5 tablets per day Altace (Oral Capsule) Maximum of 2 capsules per day Altoprev (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Alunbrig (180MG Oral Tablet, 90MG Oral Maximum of 1 tablet per day Tablet) Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days Alvesco (160MCG/ACT Inhalation Aerosol Maximum of 2 inhalers (12.2 grams) per 30 Solution) days Alvesco (80MCG/ACT Inhalation Aerosol Maximum of 1 inhaler (6.1 grams) per 30 days Solution) Amaryl (1MG Oral Tablet) Maximum of 8 tablets per day Amaryl (2MG Oral Tablet) Maximum of 4 tablets per day Amaryl (4MG Oral Tablet) Maximum of 2 tablets per day Ambien (Oral Tablet Immediate Release) Maximum of 90 tablets per year Ambrisentan (Oral Tablet) Maximum of 1 tablet per day Amerge (Oral Tablet) Maximum of 12 tablets per 30 days Amitiza (Oral Capsule) Maximum of 2 capsules per day Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day Amphetamine-Dextroamphetamine ER (Oral Maximum of 2 capsules per day Capsule Extended Release 24 Hour) Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, Maximum of 2 tablets per day 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet) Amphetamine-Dextroamphetamine (20MG Oral Maximum of 3 tablets per day Tablet) Ampyra (Oral Tablet Extended Release 12 Maximum of 2 tablets per day Hour) Anoro Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day

Bold type = Brand name drug Plain type = Generic drug 168168 4 4 Last updated September 1, 2019 Drug Name Quantity Limit Apriso (Oral Capsule Extended Release 24 Maximum of 4 capsules per day Hour) Aptensio XR (Oral Capsule Extended Release Maximum of 1 capsule per day 24 Hour) Aptiom (200MG Oral Tablet, 400MG Oral Maximum of 1 tablet per day Tablet) Aptiom (600MG Oral Tablet, 800MG Oral Maximum of 2 tablets per day Tablet) Aptivus (Oral Capsule) Maximum of 4 capsules per day Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days Aricept (10MG Oral Tablet) Maximum of 2 tablets per day Aricept (23MG Oral Tablet, 5MG Oral Tablet) Maximum of 1 tablet per day Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, Maximum of 1 tablet per day 30MG Oral Tablet, 5MG Oral Tablet) Aripiprazole ODT (10MG Oral Tablet Maximum of 3 tablets per day Dispersible) Aripiprazole ODT (15MG Oral Tablet Maximum of 2 tablets per day Dispersible) Armodafinil (150MG Oral Tablet, 200MG Oral Maximum of 1 tablet per day Tablet, 250MG Oral Tablet) Armodafinil (50MG Oral Tablet) Maximum of 2 tablets per day Arnuity Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per 30 days Breath Activated) Asacol HD (Oral Tablet Delayed Release) Maximum of 6 tablets per day Asmanex (120 Metered Doses) (Inhalation Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) Asmanex (30 Metered Doses) (110MCG/INH Maximum of 2 inhalers per 30 days Inhalation Aerosol Powder Breath Activated) Asmanex (30 Metered Doses) (220MCG/INH Maximum of 1 inhaler per 30 days Inhalation Aerosol Powder Breath Activated) Asmanex (60 Metered Doses) (Inhalation Maximum of 1 inhaler per 30 days Aerosol Powder Breath Activated) Asmanex HFA (Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Aspirin-Dipyridamole ER (Oral Capsule Maximum of 2 capsules per day Extended Release 12 Hour) Atacand HCT (Oral Tablet) Maximum of 1 tablet per day Atacand (16MG Oral Tablet, 32MG Oral Maximum of 1 tablet per day Tablet, 4MG Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug Last169 updated September 1, 2019 5 5 169 Drug Name Quantity Limit Atacand (8MG Oral Tablet) Maximum of 3 tablets per day Atazanavir Sulfate (150MG Oral Capsule, Maximum of 1 capsule per day 300MG Oral Capsule) Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day Ativan (0.5MG Oral Tablet, 1MG Oral Tablet) Maximum of 4 tablets per day Ativan (2MG Oral Tablet) Maximum of 5 tablets per day Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day Atripla (Oral Tablet) Maximum of 1 tablet per day Aubagio (Oral Tablet) Maximum of 1 tablet per day Austedo (Oral Tablet) Maximum of 4 tablets per day Avalide (Oral Tablet) Maximum of 1 tablet per day Avandia (2MG Oral Tablet) Maximum of 4 tablets per day Avandia (4MG Oral Tablet) Maximum of 2 tablets per day Avapro (150MG Oral Tablet, 300MG Oral Maximum of 1 tablet per day Tablet) Avapro (75MG Oral Tablet) Maximum of 3 tablets per day Azor (Oral Tablet) Maximum of 1 tablet per day Balversa (3MG Oral Tablet) Maximum of 3 tablets per day Balversa (4MG Oral Tablet) Maximum of 2 tablets per day Balversa (5MG Oral Tablet) Maximum of 1 tablet per day Belbuca (Buccal Film) Maximum of 2 films per day Belsomra (Oral Tablet) Maximum of 1 tablet per day Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Benicar HCT (Oral Tablet) Maximum of 1 tablet per day Benicar (20MG Oral Tablet, 40MG Oral Maximum of 1 tablet per day Tablet) Benicar (5MG Oral Tablet) Maximum of 2 tablets per day Bethkis (Inhalation Nebulization Solution) Maximum of 8 ml (2 ampules) per day Bevyxxa (Oral Capsule) Maximum of 31 capsules per 30 days Biktarvy (Oral Tablet) Maximum of 1 tablet per day Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day Bosentan (Oral Tablet) Maximum of 2 tablets per day Breo Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Brilinta (Oral Tablet) Maximum of 2 tablets per day BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day

Bold type = Brand name drug Plain type = Generic drug 170170 6 6 Last updated September 1, 2019 Drug Name Quantity Limit BRIVIACT (100MG Oral Tablet, 10MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet, Maximum of 2 tablets per day 75MG Oral Tablet) Brovana (Inhalation Nebulization Solution) Maximum of 2 vials (4 ml) per day Bunavail (Buccal Film) Maximum of 2 films per day Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day Buprenorphine HCl-Naloxone HCl (12-3MG Maximum of 2 films per day Sublingual Film, 4-1MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (2-0.5MG Maximum of 3 films per day Sublingual Film, 8-2MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Butrans (Transdermal Patch Weekly) Maximum of 4 patches per 28 days Bydureon BCise (Subcutaneous Auto- Maximum of 4 pens (3.4 ml) per 28 days Injector) Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days Byetta 10MCG Pen (Subcutaneous Solution Maximum of 1 pen (2.4 ml) per 30 days Pen-Injector) Byetta 5MCG Pen (Subcutaneous Solution Maximum of 1 pen (1.2 ml) per 30 days Pen-Injector) Bystolic (10MG Oral Tablet, 2.5MG Oral Maximum of 1 tablet per day Tablet, 5MG Oral Tablet) Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day Cablivi (Injection Kit) Maximum of 1 kit per day Cabometyx (20MG Oral Tablet, 60MG Oral Maximum of 1 tablet per day Tablet) Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day Caduet (Oral Tablet) Maximum of 1 tablet per day Calquence (Oral Capsule) Maximum of 2 capsules per day Candesartan Cilexetil (16MG Oral Tablet, 32MG Maximum of 1 tablet per day Oral Tablet, 4MG Oral Tablet) Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day Captopril (100MG Oral Tablet) Maximum of 4 tablets per day Captopril (12.5MG Oral Tablet, 25MG Oral Maximum of 3 tablets per day Tablet) Captopril (50MG Oral Tablet) Maximum of 9 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last171 updated September 1, 2019 7 7 171 Drug Name Quantity Limit Captopril-Hydrochlorothiazide (25-15MG Oral Maximum of 3 tablets per day Tablet, 50-15MG Oral Tablet) Captopril-Hydrochlorothiazide (25-25MG Oral Maximum of 2 tablets per day Tablet, 50-25MG Oral Tablet) Cardura XL (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Celebrex (Oral Capsule) Maximum of 2 capsules per day Celecoxib (Oral Capsule) Maximum of 2 capsules per day Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) Maximum of 1 tablet per day Cimduo (Oral Tablet) Maximum of 1 tablet per day Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Maximum of 2 tablets per day Tablet) Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day Clobazam (10MG Oral Tablet, 20MG Oral Maximum of 2 tablets per day Tablet) Clonazepam (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, Maximum of 4 tablets per day 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible) Clonazepam ODT (2MG Oral Tablet Dispersible) Maximum of 10 tablets per day Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day Codeine Sulfate (Oral Tablet) Maximum of 6 tablets per day Colchicine (0.6MG Oral Capsule) (Brand Maximum of 4 capsules per day Equivalent Mitigare) Colchicine (0.6MG Oral Tablet) (Brand Maximum of 4 tablets per day Equivalent Colcrys) Colcrys (Oral Tablet) Maximum of 4 tablets per day Combivent Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 20 days Solution) Combivir (Oral Tablet) Maximum of 2 tablets per day Complera (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 172172 8 8 Last updated September 1, 2019 Drug Name Quantity Limit Concerta (18MG Oral Tablet Extended Maximum of 3 tablets per day Release) Concerta (27MG Oral Tablet Extended Release, 36MG Oral Tablet Extended Maximum of 2 tablets per day Release) Concerta (54MG Oral Tablet Extended Maximum of 1 tablet per day Release) ConZip (Oral Capsule Extended Release 24 Maximum of 1 capsule per day Hour) Copiktra (Oral Capsule) Maximum of 2 capsules per day Corlanor (Oral Tablet) Maximum of 2 tablets per day Cotempla XR-ODT (Oral Tablet Extended Maximum of 2 tablets per day Release Dispersible) Cozaar (100MG Oral Tablet) Maximum of 1 tablet per day Cozaar (25MG Oral Tablet, 50MG Oral Tablet) Maximum of 2 tablets per day Crestor (Oral Tablet) Maximum of 1 tablet per day Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day Cymbalta (Oral Capsule Delayed Release Maximum of 2 capsules per day Particles) Daklinza (30MG Oral Tablet, 60MG Oral Maximum of 1 tablet per day Tablet) Dalfampridine ER (Oral Tablet Extended Maximum of 2 tablets per day Release 12 Hour) Darifenacin Hydrobromide ER (Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day Daytrana (Transdermal Patch) Maximum of 1 patch per day Delstrigo (Oral Tablet) Maximum of 1 tablet per day Descovy (Oral Tablet) Maximum of 1 tablet per day Dexedrine (10MG Oral Capsule Extended Maximum of 6 capsules per day Release 24 Hour) Dexedrine (15MG Oral Capsule Extended Maximum of 4 capsules per day Release 24 Hour) Dexedrine (5MG Oral Capsule Extended Maximum of 3 capsules per day Release 24 Hour) Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last173 updated September 1, 2019 9 9 173 Drug Name Quantity Limit Dextroamphetamine Sulfate ER (10MG Oral Maximum of 6 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (15MG Oral Maximum of 4 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (5MG Oral Maximum of 3 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day Diazepam (10MG Oral Tablet, 2MG Oral Tablet, Maximum of 4 tablets per day 5MG Oral Tablet) Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day Didanosine (200MG Oral Capsule Delayed Maximum of 2 capsules per day Release) Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Maximum of 1 capsule per day Release) Digitek (125MCG Oral Tablet) Maximum of 1 tablet per day Digox (125MCG Oral Tablet) Maximum of 1 tablet per day Digoxin (Oral Solution) Maximum of 5 ml per day Digoxin (125MCG Oral Tablet) Maximum of 1 tablet per day Dilaudid (Oral Liquid) Maximum of 50 ml per day Dilaudid (2MG Oral Tablet, 4MG Oral Tablet) Maximum of 8 tablets per day Dilaudid (8MG Oral Tablet) Maximum of 6 tablets per day Diovan HCT (Oral Tablet) Maximum of 1 tablet per day Diovan (160MG Oral Tablet, 40MG Oral Maximum of 2 tablets per day Tablet, 80MG Oral Tablet) Diovan (320MG Oral Tablet) Maximum of 1 tablet per day Dolophine (10MG Oral Tablet) Maximum of 12 tablets per day Dolophine (5MG Oral Tablet) Maximum of 8 tablets per day Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day Donepezil HCl (23MG Oral Tablet, 5MG Oral Maximum of 1 tablet per day Tablet) Donepezil HCl ODT (10MG Oral Tablet Maximum of 2 tablets per day Dispersible) Donepezil HCl ODT (5MG Oral Tablet Maximum of 1 tablet per day Dispersible) Dotti (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days Dovato (Oral Tablet) Maximum of 1 tablet per day Doxepin HCl (External Cream) Maximum of 90 grams per 30 days

Bold type = Brand name drug Plain type = Generic drug 174174 10 10 Last updated September 1, 2019 Drug Name Quantity Limit Duetact (Oral Tablet) Maximum of 1 tablet per day Dulera (Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Maximum of 2 capsules per day Release Particles, 60MG Oral Capsule Delayed Release Particles) Duloxetine HCl (40MG Oral Capsule Delayed Maximum of 3 capsules per day Release Particles) Duragesic-100 (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days Duragesic-12 (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days Duragesic-25 (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days Duragesic-50 (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days Duragesic-75 (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days Dvorah (Oral Tablet) Maximum of 10 tablets per day Dyanavel XR (Oral Suspension Extended Maximum of 8 ml per day Release) Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days Edarbi (Oral Tablet) Maximum of 1 tablet per day Edarbyclor (Oral Tablet) Maximum of 1 tablet per day Edurant (Oral Tablet) Maximum of 1 tablet per day Efavirenz (Oral Capsule) Maximum of 3 capsules per day Efavirenz (Oral Tablet) Maximum of 1 tablet per day Eletriptan Hydrobromide (Oral Tablet) Maximum of 12 tablets per 30 days Eliquis (Oral Tablet) Maximum of 2 tablets per day Eliquis Starter Pack (Oral Tablet) Maximum of 1 pack (74 tablets) per 30 days Embeda (100-4MG Oral Capsule Extended Maximum of 3 capsules per day Release) Embeda (20-0.8MG Oral Capsule Extended Release, 80-3.2MG Oral Capsule Extended Maximum of 4 capsules per day Release) Embeda (30-1.2MG Oral Capsule Extended Release, 50-2MG Oral Capsule Extended Maximum of 2 capsules per day Release) Embeda (60-2.4MG Oral Capsule Extended Maximum of 6 capsules per day Release) Emgality (300 MG Dose) (Subcutaneous Maximum of 3 ml (3 syringes or pens) per 30 Solution Prefilled Syringe) days Emgality (Subcutaneous Solution Auto- Maximum of 2 ml (2 syringes or pens) per 30 Injector) days

Bold type = Brand name drug Plain type = Generic drug Last175 updated September 1, 2019 11 11 175 Drug Name Quantity Limit Emgality (120 MG Dose) (Subcutaneous Maximum of 2 ml (2 syringes or pens) per 30 Solution Prefilled Syringe) days Emtriva (Oral Capsule) Maximum of 1 capsule per day Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days Enablex (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day Enalapril-Hydrochlorothiazide (10-25MG Oral Maximum of 2 tablets per day Tablet) Enalapril-Hydrochlorothiazide (5-12.5MG Oral Maximum of 1 tablet per day Tablet) Endocet (10-325MG Oral Tablet, 5-325MG Oral Maximum of 12 tablets per day Tablet, 7.5-325MG Oral Tablet) Enoxaparin Sodium (100MG/ML Subcutaneous Maximum of 2 syringes (2 ml) per day Solution, 150MG/ML Subcutaneous Solution) Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (30MG/0.3ML Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (40MG/0.4ML Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60MG/0.6ML Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution) Entresto (Oral Tablet) Maximum of 2 tablets per day Epclusa (Oral Tablet) Maximum of 1 tablet per day Epinephrine (Injection Solution) Maximum of 4 pens (2 boxes) per 30 days Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days EpiPen 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 days Injector) EpiPen Jr 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 days Injector) Epivir (Oral Solution) Maximum of 32 ml per day Epivir (150MG Oral Tablet) Maximum of 2 tablets per day Epivir (300MG Oral Tablet) Maximum of 1 tablet per day Eprosartan Mesylate (Oral Tablet) Maximum of 1 tablet per day Epzicom (Oral Tablet) Maximum of 1 tablet per day Erivedge (Oral Capsule) Maximum of 1 capsule per day Erleada (Oral Tablet) Maximum of 4 tablets per day

Bold type = Brand name drug Plain type = Generic drug 176176 12 12 Last updated September 1, 2019 Drug Name Quantity Limit Erlotinib HCl (100MG Oral Tablet, 150MG Oral Maximum of 1 tablet per day Tablet) Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day Esbriet (Oral Capsule) Maximum of 9 capsules per day Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day Esomeprazole Magnesium (20MG Oral Capsule Maximum of 3 capsules per day Delayed Release) (Generic Nexium) Esomeprazole Magnesium (40MG Oral Capsule Maximum of 2 capsules per day Delayed Release) (Generic Nexium) Esomeprazole Strontium (Oral Capsule Maximum of 2 capsules per day Delayed Release) Estradiol (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days Eucrisa (External Ointment) Maximum of 60 grams per 30 days Evotaz (Oral Tablet) Maximum of 1 tablet per day Exelon (Transdermal Patch 24 Hour) Maximum of 1 patch per day Exforge (Oral Tablet) Maximum of 1 tablet per day Extina (External Foam) Maximum of 100 grams per 28 days Ezallor Sprinkle (Oral Capsule Sprinkle) Maximum of 1 capsule per day Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 4MG Oral Maximum of 2 tablets per day Tablet, 6MG Oral Tablet, 8MG Oral Tablet) Farxiga (Oral Tablet) Maximum of 1 tablet per day Fentanyl Citrate (1200MCG Buccal Lozenge On A Handle, 1600MCG Buccal Lozenge On A Handle, 200MCG Buccal Lozenge On A Handle, Maximum of 4 lozenges per day 400MCG Buccal Lozenge On A Handle, 600MCG Buccal Lozenge On A Handle, 800MCG Buccal Lozenge On A Handle) Fentanyl Citrate (100MCG Buccal Tablet, 200MCG Buccal Tablet, 400MCG Buccal Maximum of 4 tablets per day Tablet, 600MCG Buccal Tablet, 800MCG Buccal Tablet) Fentanyl (Transdermal Patch 72 Hour) Maximum of 15 patches per 30 days Fentora (Buccal Tablet) Maximum of 4 tablets per day Firazyr (Subcutaneous Solution) Maximum of 9 ml per day Firdapse (Oral Tablet) Maximum of 8 tablets per day Flector (Transdermal Patch) Maximum of 2 patches per day

Bold type = Brand name drug Plain type = Generic drug Last177 updated September 1, 2019 13 13 177 Drug Name Quantity Limit FloLipid (20MG/5ML Oral Suspension) Maximum of 5 ml per day FloLipid (40MG/5ML Oral Suspension) Maximum of 10 ml per day Flovent HFA (110MCG/ACT Inhalation Maximum of 1 inhaler (12 grams) per 30 days Aerosol) Flovent HFA (220MCG/ACT Inhalation Maximum of 2 inhalers (24 grams) per 30 days Aerosol) Flovent HFA (44MCG/ACT Inhalation Aerosol) Maximum of 1 inhaler (10.6 grams) per 30 days Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair) Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Maximum of 1 inhaler per 30 days Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo) Fluvastatin Sodium ER (Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day Focalin (Oral Tablet) Maximum of 2 tablets per day Fortamet (1000MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Fortamet (500MG Oral Tablet Extended Maximum of 5 tablets per day Release 24 Hour) Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day Frova (Oral Tablet) Maximum of 12 tablets per 30 days Frovatriptan Succinate (Oral Tablet) Maximum of 12 tablets per 30 days Fuzeon (Subcutaneous Solution Maximum of 2 vials per day Reconstituted) Genvoya (Oral Tablet) Maximum of 1 tablet per day Geodon (Oral Capsule) Maximum of 2 capsules per day Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days Gleevec (Oral Tablet) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug 178178 14 14 Last updated September 1, 2019 Drug Name Quantity Limit Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day Glimepiride (2MG Oral Tablet) Maximum of 4 tablets per day Glimepiride (4MG Oral Tablet) Maximum of 2 tablets per day Glipizide ER (10MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Glipizide ER (2.5MG Oral Tablet Extended Maximum of 8 tablets per day Release 24 Hour) Glipizide ER (5MG Oral Tablet Extended Maximum of 4 tablets per day Release 24 Hour) Glipizide (10MG Oral Tablet Immediate Maximum of 4 tablets per day Release) Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day Glipizide-Metformin HCl (2.5-250MG Oral Maximum of 8 tablets per day Tablet) Glipizide-Metformin HCl (2.5-500MG Oral Maximum of 4 tablets per day Tablet, 5-500MG Oral Tablet) Glucophage (1000MG Oral Tablet Immediate Maximum of 2.5 tablets per day Release) Glucophage (500MG Oral Tablet Immediate Maximum of 5 tablets per day Release) Glucophage (850MG Oral Tablet Immediate Maximum of 3 tablets per day Release) Glucophage XR (500MG Oral Tablet Maximum of 4 tablets per day Extended Release 24 Hour) Glucophage XR (750MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Glucotrol (10MG Oral Tablet Immediate Maximum of 4 tablets per day Release) Glucotrol (5MG Oral Tablet Immediate Maximum of 8 tablets per day Release) Glucotrol XL (10MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Glucotrol XL (2.5MG Oral Tablet Extended Maximum of 8 tablets per day Release 24 Hour) Glucotrol XL (5MG Oral Tablet Extended Maximum of 4 tablets per day Release 24 Hour) Glumetza (1000MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Glumetza (500MG Oral Tablet Extended Maximum of 4 tablets per day Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug Last179 updated September 1, 2019 15 15 179 Drug Name Quantity Limit Glyxambi (Oral Tablet) Maximum of 1 tablet per day Harvoni (Oral Tablet) Maximum of 1 tablet per day Hetlioz (Oral Capsule) Maximum of 1 capsule per day Hydrocodone-Acetaminophen (7.5-325MG/ Maximum of 180 ml per day 15ML Oral Solution) Hydrocodone-Acetaminophen (10-300MG Oral Tablet, 5-300MG Oral Tablet, 7.5-300MG Oral Maximum of 13 tablets per day Tablet) Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Maximum of 12 tablets per day Tablet) Hydrocodone-Ibuprofen (Oral Tablet) Maximum of 5 tablets per day Hydromorphone HCl ER (Oral Tablet ER 24 Maximum of 2 tablets per day Hour Abuse-Deterrent) Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Maximum of 8 tablets per day Release) Hydromorphone HCl (8MG Oral Tablet Maximum of 6 tablets per day Immediate Release) Hysingla ER (Oral Tablet ER 24 Hour Abuse- Maximum of 1 tablet per day Deterrent) Hyzaar (100-12.5MG Oral Tablet, 100-25MG Maximum of 1 tablet per day Oral Tablet) Hyzaar (50-12.5MG Oral Tablet) Maximum of 2 tablets per day Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day Imbruvica (Oral Tablet) Maximum of 1 tablet per day Imitrex (Nasal Solution) Maximum of 12 devices per 30 days Imitrex (Oral Tablet) Maximum of 12 tablets per 30 days Imitrex STATdose Refill (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution Cartridge) Imitrex STATdose System (4MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution Auto-Injector) Imitrex (Subcutaneous Solution) Maximum of 12 injections (6 ml) per 30 days Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Bold type = Brand name drug Plain type = Generic drug 180180 16 16 Last updated September 1, 2019 Drug Name Quantity Limit Incruse Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per 30 days Breath Activated) Ingrezza (Oral Capsule) Maximum of 1 capsule per day Ingrezza (Oral Capsule Therapy Pack) Maximum of 28 capsules (1 pack) per 28 days Inlyta (Oral Tablet) Maximum of 4 tablets per day Intelence (100MG Oral Tablet, 200MG Oral Maximum of 2 tablets per day Tablet) Intelence (25MG Oral Tablet) Maximum of 4 tablets per day Intrarosa (Vaginal Insert) Maximum of 1 vaginal insert per day Invega (3MG Oral Tablet Extended Release 24 Hour, 9MG Oral Tablet Extended Release Maximum of 1 tablet per day 24 Hour) Invega (6MG Oral Tablet Extended Release Maximum of 2 tablets per day 24 Hour) Invirase (Oral Tablet) Maximum of 4 tablets per day Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day Invokamet XR (Oral Tablet Extended Release Maximum of 2 tablets per day 24 Hour) Invokana (Oral Tablet) Maximum of 1 tablet per day Irbesartan (150MG Oral Tablet, 300MG Oral Maximum of 1 tablet per day Tablet) Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Iressa (Oral Tablet) Maximum of 2 tablets per day Isentress HD (Oral Tablet) Maximum of 2 tablets per day Isentress (Oral Packet) Maximum of 2 packets per day Isentress (Oral Tablet) Maximum of 2 tablets per day Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day Jakafi (Oral Tablet) Maximum of 2 tablets per day Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day Janumet XR (100-1000MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Janumet XR (50-1000MG Oral Tablet Extended Release 24 Hour, 50-500MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Januvia (Oral Tablet) Maximum of 1 tablet per day Jardiance (Oral Tablet) Maximum of 1 tablet per day Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last181 updated September 1, 2019 17 17 181 Drug Name Quantity Limit Jentadueto XR (2.5-1000MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Jentadueto XR (5-1000MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Juluca (Oral Tablet) Maximum of 1 tablet per day Jynarque (Oral Tablet Therapy Pack) Maximum of 2 tablets per day Kadian (100MG Oral Capsule Extended Release 24 Hour, 60MG Oral Capsule Maximum of 3 capsules per day Extended Release 24 Hour, 80MG Oral Capsule Extended Release 24 Hour) Kadian (10MG Oral Capsule Extended Release 24 Hour, 20MG Oral Capsule Extended Release 24 Hour, 30MG Oral Capsule Extended Release 24 Hour, 40MG Maximum of 2 capsules per day Oral Capsule Extended Release 24 Hour, 50MG Oral Capsule Extended Release 24 Hour) Kadian (200MG Oral Capsule Extended Maximum of 1 capsule per day Release 24 Hour) Kaletra (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days Kaletra (100-25MG Oral Tablet) Maximum of 2 tablets per day Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day Kazano (Oral Tablet) Maximum of 2 tablets per day Ketoconazole (External Cream) Maximum of 90 grams per 30 days Ketoconazole (External Foam) Maximum of 100 grams per 28 days Keveyis (Oral Tablet) Maximum of 4 tablets per day Klonopin (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Klonopin (2MG Oral Tablet) Maximum of 10 tablets per day Kombiglyze XR (2.5-1000MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Kombiglyze XR (5-1000MG Oral Tablet Extended Release 24 Hour, 5-500MG Oral Maximum of 1 tablet per day Tablet Extended Release 24 Hour) Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day Lanoxin (125MCG Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 182182 18 18 Last updated September 1, 2019 Drug Name Quantity Limit Lanoxin (62.5MCG Oral Tablet) Maximum of 2 tablets per day Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day Latuda (120MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet, 40MG Oral Tablet, 60MG Oral Tablet) Latuda (80MG Oral Tablet) Maximum of 2 tablets per day Lazanda (Nasal Solution) Maximum of 15 bottles (79.5 ml) per 30 days Ledipasvir-Sofosbuvir (Oral Tablet) Maximum of 1 tablet per day Lescol XL (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Letairis (Oral Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day Lexiva (Oral Suspension) Maximum of 60 ml per day Lexiva (Oral Tablet) Maximum of 4 tablets per day Lialda (Oral Tablet Delayed Release) Maximum of 4 tablets per day Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days Lidocaine (5% External Patch) Maximum of 3 patches per day Lidoderm (External Patch) Maximum of 3 patches per day Linzess (Oral Capsule) Maximum of 1 capsule per day Lipitor (Oral Tablet) Maximum of 1 tablet per day Lisinopril (Oral Tablet) Maximum of 2 tablets per day Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Maximum of 1 tablet per day Tablet) Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Maximum of 4 tablets per day Tablet) Lisinopril-Hydrochlorothiazide (20-25MG Oral Maximum of 2 tablets per day Tablet) Livalo (Oral Tablet) Maximum of 1 tablet per day Lokelma (Oral Packet) Maximum of 90 packets per 30 days Lonhala Magnair Refill Kit (Inhalation Maximum of 2 vials (2 ml) per day Solution) Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day Lorazepam (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day Lorcet HD (Oral Tablet) Maximum of 12 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last183 updated September 1, 2019 19 19 183 Drug Name Quantity Limit Lorcet (Oral Tablet) Maximum of 12 tablets per day Lorcet Plus (Oral Tablet) Maximum of 12 tablets per day Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day Losartan Potassium (25MG Oral Tablet, 50MG Maximum of 2 tablets per day Oral Tablet) Losartan Potassium-HCTZ (100-12.5MG Oral Maximum of 1 tablet per day Tablet, 100-25MG Oral Tablet) Losartan Potassium-HCTZ (50-12.5MG Oral Maximum of 2 tablets per day Tablet) Lotensin (Oral Tablet) Maximum of 2 tablets per day Lotrel (Oral Capsule) Maximum of 1 capsule per day Lovastatin (10MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet) Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day Lovenox (100MG/ML Subcutaneous Solution, Maximum of 2 syringes (2 ml) per day 150MG/ML Subcutaneous Solution) Lovenox (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Subcutaneous Maximum of 2 syringes (1.6 ml) per day Solution) Lovenox (30MG/0.3ML Subcutaneous Maximum of 2 syringes (0.6 ml) per day Solution) Lovenox (40MG/0.4ML Subcutaneous Maximum of 2 syringes (0.8 ml) per day Solution) Lovenox (60MG/0.6ML Subcutaneous Maximum of 2 syringes (1.2 ml) per day Solution) Lucemyra (Oral Tablet) Maximum of 16 tablets per day Luliconazole (External Cream) Maximum of 60 grams per 28 days Luzu (External Cream) Maximum of 60 grams per 28 days Lyrica CR (165MG Oral Tablet Extended Release 24 Hour, 82.5MG Oral Tablet Maximum of 3 tablets per day Extended Release 24 Hour) Lyrica CR (330MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Lyrica (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Maximum of 3 capsules per day Capsule, 50MG Oral Capsule, 75MG Oral Capsule) Lyrica (225MG Oral Capsule, 300MG Oral Maximum of 2 capsules per day Capsule) Lyrica (Oral Solution) Maximum of 30 ml per day

Bold type = Brand name drug Plain type = Generic drug 184184 20 20 Last updated September 1, 2019 Drug Name Quantity Limit Mavyret (Oral Tablet) Maximum of 3 tablets per day Maxalt (Oral Tablet) Maximum of 12 tablets per 30 days Maxalt-MLT (Oral Tablet Dispersible) Maximum of 12 tablets per 30 days Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day Memantine HCl ER (Oral Capsule Extended Maximum of 1 capsule per day Release 24 Hour) Memantine HCl (Oral Solution) Maximum of 10 ml per day Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day Mesalamine (1.2GM Oral Tablet Delayed Maximum of 4 tablets per day Release) (Generic Lialda) Mesalamine (800MG Oral Tablet Delayed Maximum of 6 tablets per day Release) Metadate ER (Oral Tablet Extended Release) Maximum of 3 tablets per day Metformin HCl ER (1000MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) (Generic Glumetza) Metformin HCl ER (500MG Oral Tablet Maximum of 4 tablets per day Extended Release 24 Hour) (Generic Glumetza) Metformin HCl ER (1000MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) (Generic Fortamet) Metformin HCl ER (500MG Oral Tablet Maximum of 5 tablets per day Extended Release 24 Hour) (Generic Fortamet) Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 4 tablets per day Glucophage XR) Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 2 tablets per day Glucophage XR) Metformin HCl (1000MG Oral Tablet Immediate Maximum of 2.5 tablets per day Release) Metformin HCl (500MG Oral Tablet Immediate Maximum of 5 tablets per day Release) Metformin HCl (850MG Oral Tablet Immediate Maximum of 3 tablets per day Release) Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day

Bold type = Brand name drug Plain type = Generic drug Last185 updated September 1, 2019 21 21 185 Drug Name Quantity Limit Methylin (10MG/5ML Oral Solution) Maximum of 30 ml per day Methylin (5MG/5ML Oral Solution) Maximum of 60 ml per day Methylphenidate HCl ER Osmotic Release Maximum of 4 tablets per day (10MG Oral Tablet Extended Release) Methylphenidate HCl ER Osmotic Release (18MG Oral Tablet Extended Release, 20MG Maximum of 3 tablets per day Oral Tablet Extended Release) Methylphenidate HCl ER (18MG Oral Tablet Maximum of 3 tablets per day Extended Release 24 Hour) Methylphenidate HCl ER (27MG Oral Tablet Extended Release 24 Hour, 36MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Methylphenidate HCl ER (54MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Methylphenidate HCl ER Osmotic Release (27MG Oral Tablet Extended Release, 36MG Maximum of 2 tablets per day Oral Tablet Extended Release) Methylphenidate HCl ER Osmotic Release (54MG Oral Tablet Extended Release, 72MG Maximum of 1 tablet per day Oral Tablet Extended Release) Methylphenidate HCl (10MG/5ML Oral Maximum of 30 ml per day Solution) Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day Methylphenidate HCl (Oral Tablet Immediate Maximum of 3 tablets per day Release) (Generic Ritalin) Methylphenidate HCl (10MG Oral Tablet Maximum of 6 tablets per day Chewable) Methylphenidate HCl (2.5MG Oral Tablet Maximum of 3 tablets per day Chewable, 5MG Oral Tablet Chewable) Micardis HCT (40-12.5MG Oral Tablet, Maximum of 1 tablet per day 80-25MG Oral Tablet) Micardis HCT (80-12.5MG Oral Tablet) Maximum of 2 tablets per day Micardis (Oral Tablet) Maximum of 1 tablet per day Minivelle (Transdermal Patch Twice Weekly) Maximum of 8 patches per 28 days Minocycline HCl ER (Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Mitigare (Oral Capsule) Maximum of 4 capsules per day Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug 186186 22 22 Last updated September 1, 2019 Drug Name Quantity Limit Montelukast Sodium (Oral Packet) Maximum of 1 packet per day Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day MorphaBond ER (100MG Oral Tablet ER 12 Hour Abuse-Deterrent, 60MG Oral Tablet ER Maximum of 3 tablets per day 12 Hour Abuse-Deterrent) MorphaBond ER (15MG Oral Tablet ER 12 Hour Abuse-Deterrent, 30MG Oral Tablet ER Maximum of 2 tablets per day 12 Hour Abuse-Deterrent) Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day Morphine Sulfate ER Beads (120MG Oral Capsule Extended Release 24 Hour) (Generic Maximum of 3 capsules per day Avinza) Morphine Sulfate ER Beads (30MG Oral Capsule Extended Release 24 Hour, 45MG Oral Capsule Extended Release 24 Hour, 60MG Oral Maximum of 2 capsules per day Capsule Extended Release 24 Hour) (Generic Avinza) Morphine Sulfate ER Beads (75MG Oral Capsule Extended Release 24 Hour, 90MG Oral Maximum of 4 capsules per day Capsule Extended Release 24 Hour) (Generic Avinza) Morphine Sulfate ER (100MG Oral Capsule Extended Release 24 Hour, 60MG Oral Capsule Maximum of 3 capsules per day Extended Release 24 Hour, 80MG Oral Capsule Extended Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour, 20MG Oral Capsule Extended Release 24 Hour, 30MG Oral Capsule Maximum of 2 capsules per day Extended Release 24 Hour, 40MG Oral Capsule Extended Release 24 Hour, 50MG Oral Capsule Extended Release 24 Hour) (Generic Kadian) Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Maximum of 3 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (200MG Oral Tablet Maximum of 2 tablets per day Extended Release) (Generic MS Contin) Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Maximum of 4 tablets per day Release) (Generic MS Contin) Morphine Sulfate (10MG/5ML Oral Solution) Maximum of 100 ml per day

Bold type = Brand name drug Plain type = Generic drug Last187 updated September 1, 2019 23 23 187 Drug Name Quantity Limit Morphine Sulfate (20MG/5ML Oral Solution) Maximum of 50 ml per day Morphine Sulfate (15MG Oral Tablet Maximum of 8 tablets per day Immediate Release) Morphine Sulfate (30MG Oral Tablet Maximum of 6 tablets per day Immediate Release) Motegrity (Oral Tablet) Maximum of 1 tablet per day Movantik (Oral Tablet) Maximum of 1 tablet per day MS Contin (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Maximum of 3 tablets per day Release) MS Contin (200MG Oral Tablet Extended Maximum of 2 tablets per day Release) MS Contin (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Maximum of 4 tablets per day Release) Mydayis (12.5MG Oral Capsule Extended Release 24 Hour, 25MG Oral Capsule Maximum of 2 capsules per day Extended Release 24 Hour) Mydayis (37.5MG Oral Capsule Extended Release 24 Hour, 50MG Oral Capsule Maximum of 1 capsule per day Extended Release 24 Hour) Namenda (10MG Oral Tablet) Maximum of 2 tablets per day Namenda (5MG Oral Tablet) Maximum of 3 tablets per day Namenda XR (Oral Capsule Extended Maximum of 1 capsule per day Release 24 Hour) Namenda XR Titration Pack (Oral Capsule Maximum of 1 capsule per day Extended Release 24 Hour) Namzaric (Oral Capsule ER 24 Hour Therapy Maximum of 1 capsule per day Pack) Namzaric (Oral Capsule Extended Release 24 Maximum of 1 capsule per day Hour) Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day Nebupent (Inhalation Solution Reconstituted) Maximum of 300 mg (1 vial) per 28 days Nerlynx (Oral Tablet) Maximum of 6 tablets per day Nesina (Oral Tablet) Maximum of 1 tablet per day Nevirapine ER (100MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 188188 24 24 Last updated September 1, 2019 Drug Name Quantity Limit Nevirapine ER (400MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Nevirapine (Oral Suspension) Maximum of 40 ml per day Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day Nexium (20MG Oral Capsule Delayed Maximum of 3 capsules per day Release) Nexium (40MG Oral Capsule Delayed Maximum of 2 capsules per day Release) Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days Norco (Oral Tablet) Maximum of 12 tablets per day Northera (100MG Oral Capsule) Maximum of 3 capsules per day Northera (200MG Oral Capsule, 300MG Oral Maximum of 6 capsules per day Capsule) Norvir (Oral Packet) Maximum of 12 packets per day Norvir (Oral Solution) Maximum of 16 ml per day Norvir (Oral Tablet) Maximum of 12 tablets per day Noxafil (Oral Suspension) Maximum of 20 ml per day Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day Nucala (Subcutaneous Solution Auto-Injector) Maximum of 3 ml per 28 days Nucala (Subcutaneous Solution Prefilled Maximum of 3 ml per 28 days Syringe) Nucala (Subcutaneous Solution Maximum of 3 vials per 28 days Reconstituted) Nucynta ER (Oral Tablet Extended Release Maximum of 2 tablets per day 12 Hour) Nucynta (Oral Tablet Immediate Release) Maximum of 6 tablets per day Nuplazid (Oral Capsule) Maximum of 1 capsule per day Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day Nuvigil (150MG Oral Tablet, 200MG Oral Maximum of 1 tablet per day Tablet, 250MG Oral Tablet) Nuvigil (50MG Oral Tablet) Maximum of 2 tablets per day Nuzyra (Oral Tablet) Maximum of 2 tablets per day Ocaliva (Oral Tablet) Maximum of 1 tablet per day Odefsey (Oral Tablet) Maximum of 1 tablet per day Odomzo (Oral Capsule) Maximum of 1 capsule per day Ofev (Oral Capsule) Maximum of 2 capsules per day Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, Maximum of 1 tablet per day 5MG Oral Tablet, 7.5MG Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug Last189 updated September 1, 2019 25 25 189 Drug Name Quantity Limit Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Maximum of 1 tablet per day Tablet Dispersible, 5MG Oral Tablet Dispersible) Olmesartan Medoxomil (20MG Oral Tablet, Maximum of 1 tablet per day 40MG Oral Tablet) Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day Olumiant (Oral Tablet) Maximum of 1 tablet per day Omeprazole (10MG Oral Capsule Delayed Maximum of 3 capsules per day Release) Onfi (Oral Suspension) Maximum of 16 ml per day Onfi (Oral Tablet) Maximum of 2 tablets per day Onglyza (Oral Tablet) Maximum of 1 tablet per day Onzetra Xsail (Nasal Exhaler Powder) Maximum of 1 kit (16 exhalers) per 30 days Opana (Oral Tablet Immediate Release) Maximum of 6 tablets per day Orilissa (150MG Oral Tablet) Maximum of 1 tablet per day Orilissa (200MG Oral Tablet) Maximum of 2 tablets per day Orkambi (Oral Packet) Maximum of 56 packets per 28 days Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days Oseni (Oral Tablet) Maximum of 1 tablet per day Osphena (Oral Tablet) Maximum of 1 tablet per day Oxervate (Ophthalmic Solution) Maximum of 2 ml (2 vials) per day Oxiconazole Nitrate (External Cream) Maximum of 90 grams per 30 days Oxistat (External Cream) Maximum of 90 grams per 30 days Oxistat (External Lotion) Maximum of 60 ml per 30 days Oxycodone HCl ER (Oral Tablet ER 12 Hour Maximum of 3 tablets per day Abuse-Deterrent) Oxycodone HCl (5MG Oral Capsule) Maximum of 12 capsules per day Oxycodone HCl (100MG/5ML Oral Maximum of 6 ml per day Concentrate) Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day Oxycodone HCl (10MG Oral Tablet Immediate Maximum of 12 tablets per day Release, 5MG Oral Tablet Immediate Release) Oxycodone HCl (15MG Oral Tablet Immediate Maximum of 8 tablets per day Release)

Bold type = Brand name drug Plain type = Generic drug 190190 26 26 Last updated September 1, 2019 Drug Name Quantity Limit Oxycodone HCl (20MG Oral Tablet Immediate Maximum of 6 tablets per day Release, 30MG Oral Tablet Immediate Release) Oxycodone-Acetaminophen (Oral Tablet) Maximum of 12 tablets per day Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day Oxycodone-Ibuprofen (Oral Tablet) Maximum of 4 tablets per day OxyContin (Oral Tablet ER 12 Hour Abuse- Maximum of 3 tablets per day Deterrent) Oxymorphone HCl ER (10MG Oral Tablet Extended Release 12 Hour, 15MG Oral Tablet Extended Release 12 Hour, 20MG Oral Tablet Maximum of 2 tablets per day Extended Release 12 Hour, 5MG Oral Tablet Extended Release 12 Hour, 7.5MG Oral Tablet Extended Release 12 Hour) Oxymorphone HCl ER (30MG Oral Tablet Maximum of 4 tablets per day Extended Release 12 Hour) Oxymorphone HCl ER (40MG Oral Tablet Maximum of 3 tablets per day Extended Release 12 Hour) Oxymorphone HCl (Oral Tablet Immediate Maximum of 6 tablets per day Release) Ozempic (0.25 or 0.5MG/DOSE Maximum of 1 pen (1.5 ml) per 28 days Subcutaneous Solution Pen-Injector) Ozempic (1MG/DOSE Subcutaneous Solution Maximum of 2 pens (3 ml) per 28 days Pen-Injector) Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour) Paliperidone ER (6MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Palynziq (10MG/0.5ML Subcutaneous Maximum of 28 syringes per 28 days Solution Prefilled Syringe) Palynziq (2.5MG/0.5ML Subcutaneous Maximum of 8 syringes per 28 days Solution Prefilled Syringe) Palynziq (20MG/ML Subcutaneous Solution Maximum of 56 syringes per 28 days Prefilled Syringe) Pantoprazole Sodium (20MG Oral Tablet Maximum of 3 tablets per day Delayed Release) Pantoprazole Sodium (40MG Oral Tablet Maximum of 2 tablets per day Delayed Release) Pentasa (250MG Oral Capsule Extended Maximum of 12 capsules per day Release)

Bold type = Brand name drug Plain type = Generic drug Last191 updated September 1, 2019 27 27 191 Drug Name Quantity Limit Pentasa (500MG Oral Capsule Extended Maximum of 8 capsules per day Release) Percocet (Oral Tablet) Maximum of 12 tablets per day Perforomist (Inhalation Nebulization Solution) Maximum of 2 vials (4 ml) per day Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day Pifeltro (Oral Tablet) Maximum of 1 tablet per day Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Maximum of 1 tablet per day Tablet) Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day Piqray (200 MG Daily Dose) (Oral Tablet Maximum of 1 tablet per day Therapy Pack) Piqray (250 MG Daily Dose) (Oral Tablet Maximum of 2 tablets per day Therapy Pack) Piqray (300 MG Daily Dose) (Oral Tablet Maximum of 2 tablets per day Therapy Pack) Plavix (Oral Tablet) Maximum of 4 tablets per day Pradaxa (Oral Capsule) Maximum of 2 capsules per day Praluent (Subcutaneous Solution Pen- Maximum of 2 pens (2 ml) per 28 days Injector) Prandin (1MG Oral Tablet) Maximum of 16 tablets per day Prandin (2MG Oral Tablet) Maximum of 8 tablets per day Pravachol (Oral Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day Prevacid (Oral Capsule Delayed Release) Maximum of 2 capsules per day Prevymis (Oral Tablet) Maximum of 1 tablet per day Prezcobix (Oral Tablet) Maximum of 1 tablet per day Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days Prezista (150MG Oral Tablet) Maximum of 6 tablets per day Prezista (600MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Prezista (800MG Oral Tablet) Maximum of 1 tablet per day Primlev (Oral Tablet) Maximum of 13 tablets per day Prinivil (Oral Tablet) Maximum of 2 tablets per day Prolia (Subcutaneous Solution Prefilled Maximum of 1 syringe per 180 days Syringe) Promacta (Oral Packet) Maximum of 6 packets per day

Bold type = Brand name drug Plain type = Generic drug 192192 28 28 Last updated September 1, 2019 Drug Name Quantity Limit Promacta (12.5MG Oral Tablet, 25MG Oral Maximum of 1 tablet per day Tablet) Promacta (50MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Protonix (20MG Oral Tablet Delayed Release) Maximum of 3 tablets per day Protonix (40MG Oral Tablet Delayed Release) Maximum of 2 tablets per day Provigil (100MG Oral Tablet) Maximum of 1 tablet per day Provigil (200MG Oral Tablet) Maximum of 2 tablets per day PRUDOXIN (External Cream) Maximum of 90 grams per 30 days Pulmozyme (Inhalation Solution) Maximum of 5 ml (2 ampules) per day Qbrelis (Oral Solution) Maximum of 80 ml per day Qtern (Oral Tablet) Maximum of 1 tablet per day Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Maximum of 3 tablets per day Immediate Release, 50MG Oral Tablet Immediate Release) Quetiapine Fumarate (25MG Oral Tablet Maximum of 4 tablets per day Immediate Release) Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Maximum of 2 tablets per day Immediate Release) QuilliChew ER (20MG Oral Tablet Chewable Extended Release, 40MG Oral Tablet Maximum of 1 tablet per day Chewable Extended Release) QuilliChew ER (30MG Oral Tablet Chewable Maximum of 2 tablets per day Extended Release) Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day Quinapril-Hydrochlorothiazide (10-12.5MG Oral Maximum of 1 tablet per day Tablet) Quinapril-Hydrochlorothiazide (20-12.5MG Oral Maximum of 2 tablets per day Tablet, 20-25MG Oral Tablet) QVAR RediHaler (Inhalation Aerosol Breath Maximum of 2 inhalers (21.2 grams) per 30 Activated) days

Bold type = Brand name drug Plain type = Generic drug Last193 updated September 1, 2019 29 29 193 Drug Name Quantity Limit Ramipril (Oral Capsule) Maximum of 2 capsules per day Rapaflo (Oral Capsule) Maximum of 1 capsule per day Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day Relexxii (Oral Tablet Extended Release) Maximum of 1 tablet per day Relpax (Oral Tablet) Maximum of 12 tablets per 30 days Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day Repaglinide-Metformin HCl (Oral Tablet) Maximum of 5 tablets per day Repatha Pushtronex System (Subcutaneous Maximum of 1 cartridge (3.5 ml) per 28 days Solution Cartridge) Repatha (Subcutaneous Solution Prefilled Maximum of 3 syringes (3 ml) per 28 days Syringe) Repatha SureClick (Subcutaneous Solution Maximum of 3 pens (3 ml) per 28 days Auto-Injector) Rescriptor (Oral Tablet) Maximum of 6 tablets per day Restasis (Ophthalmic Emulsion) Maximum of 2 vials per day Restoril (22.5MG Oral Capsule) Maximum of 1 capsule per day Retrovir (Oral Capsule) Maximum of 6 capsules per day Retrovir (Oral Syrup) Maximum of 64 ml per day Rexulti (Oral Tablet) Maximum of 1 tablet per day Reyataz (150MG Oral Capsule, 300MG Oral Maximum of 1 capsule per day Capsule) Reyataz (200MG Oral Capsule) Maximum of 2 capsules per day Reyataz (Oral Packet) Maximum of 6 packets per day Riomet (Oral Solution) Maximum of 25.5 ml per day Ritalin (Oral Tablet) Maximum of 3 tablets per day Ritonavir (Oral Tablet) Maximum of 12 tablets per day Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days Rizatriptan Benzoate ODT (Oral Tablet Maximum of 12 tablets per 30 days Dispersible) Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day Roxicodone (15MG Oral Tablet) Maximum of 8 tablets per day Roxicodone (30MG Oral Tablet) Maximum of 6 tablets per day Roxicodone (5MG Oral Tablet) Maximum of 12 tablets per day Rydapt (Oral Capsule) Maximum of 8 capsules per day Sabril (Oral Packet) Maximum of 6 packets per day

Bold type = Brand name drug Plain type = Generic drug 194194 30 30 Last updated September 1, 2019 Drug Name Quantity Limit Sabril (Oral Tablet) Maximum of 6 tablets per day Savaysa (Oral Tablet) Maximum of 1 tablet per day Segluromet (2.5-1000MG Oral Tablet, 7.5-1000MG Oral Tablet, 7.5-500MG Oral Maximum of 2 tablets per day Tablet) Segluromet (2.5-500MG Oral Tablet) Maximum of 4 tablets per day Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days Selzentry (150MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Selzentry (25MG Oral Tablet, 300MG Oral Maximum of 4 tablets per day Tablet) Sensipar (30MG Oral Tablet, 60MG Oral Maximum of 2 tablets per day Tablet) Sensipar (90MG Oral Tablet) Maximum of 4 tablets per day Serevent Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 inhalations) per 30 Breath Activated) days Seroquel (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Maximum of 3 tablets per day Release, 50MG Oral Tablet Immediate Release) Seroquel (25MG Oral Tablet Immediate Maximum of 4 tablets per day Release) Seroquel (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate Maximum of 2 tablets per day Release) Seroquel XR (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Seroquel XR (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) Silodosin (Oral Capsule) Maximum of 1 capsule per day Simvastatin (Oral Tablet) Maximum of 1 tablet per day Singulair (Oral Packet) Maximum of 1 packet per day Singulair (Oral Tablet) Maximum of 1 tablet per day Singulair (Oral Tablet Chewable) Maximum of 1 tablet per day Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day Soliqua (Subcutaneous Solution Pen-Injector) Maximum of 18 ml (6 pens) per 30 days

Bold type = Brand name drug Plain type = Generic drug Last195 updated September 1, 2019 31 31 195 Drug Name Quantity Limit Solodyn (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Somavert (Subcutaneous Solution Maximum of 1 vial per day Reconstituted) Sovaldi (Oral Tablet) Maximum of 1 tablet per day Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day Spiriva Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 30 days Solution) Starlix (120MG Oral Tablet) Maximum of 3 tablets per day Starlix (60MG Oral Tablet) Maximum of 6 tablets per day Stavudine (Oral Capsule) Maximum of 2 capsules per day Steglatro (15MG Oral Tablet) Maximum of 1 tablet per day Steglatro (5MG Oral Tablet) Maximum of 2 tablets per day Steglujan (Oral Tablet) Maximum of 1 tablet per day Stivarga (Oral Tablet) Maximum of 4 tablets per day Stribild (Oral Tablet) Maximum of 1 tablet per day Suboxone (12-3MG Sublingual Film, 4-1MG Maximum of 2 films per day Sublingual Film) Suboxone (2-0.5MG Sublingual Film, 8-2MG Maximum of 3 films per day Sublingual Film) Subsys (100MCG Sublingual Liquid, 200MCG Sublingual Liquid, 400MCG Sublingual Maximum of 4 sprays per day Liquid, 600MCG Sublingual Liquid, 800MCG Sublingual Liquid) Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100MG Oral Tablet, Maximum of 12 tablets per 30 days 25MG Oral Tablet, 50MG Oral Tablet) Sumatriptan Succinate Refill (Subcutaneous Maximum of 12 injections (6 ml) per 30 days Solution Cartridge) Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate (4MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution Auto-Injector) Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Auto-Injector) (Generic Maximum of 12 injections (6 ml) per 30 days Imitrex) Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Auto-Injector) Maximum of 12 injections (6 ml) per 30 days (Generic Imitrex STATdose)

Bold type = Brand name drug Plain type = Generic drug 196196 32 32 Last updated September 1, 2019 Drug Name Quantity Limit Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution Prefilled Syringe) Sustiva (Oral Capsule) Maximum of 3 capsules per day Sustiva (Oral Tablet) Maximum of 1 tablet per day Symbicort (Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Symdeko (Oral Tablet Therapy Pack) Maximum of 1 pack (56 tablets) per 28 days Symfi Lo (Oral Tablet) Maximum of 1 tablet per day Symfi (Oral Tablet) Maximum of 1 tablet per day Sympazan (Oral Film) Maximum of 2 films per day Symproic (Oral Tablet) Maximum of 1 tablet per day Symtuza (Oral Tablet) Maximum of 1 tablet per day Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day Synjardy XR (10-1000MG Oral Tablet Extended Release 24 Hour, 25-1000MG Oral Maximum of 1 tablet per day Tablet Extended Release 24 Hour) Synjardy XR (12.5-1000MG Oral Tablet Extended Release 24 Hour, 5-1000MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Syprine (Oral Capsule) Maximum of 8 capsules per day Tadalafil (2.5MG Oral Tablet, 5MG Oral Tablet) Maximum of 1 tablet per day Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day Tarceva (100MG Oral Tablet, 150MG Oral Maximum of 1 tablet per day Tablet) Tarceva (25MG Oral Tablet) Maximum of 3 tablets per day Tarka (Oral Tablet Extended Release) Maximum of 1 tablet per day Tasmar (Oral Tablet) Maximum of 6 tablets per day Tavalisse (Oral Tablet) Maximum of 2 tablets per day Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day Tekturna HCT (Oral Tablet) Maximum of 1 tablet per day Tekturna (Oral Tablet) Maximum of 1 tablet per day Telmisartan (Oral Tablet) Maximum of 1 tablet per day Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day Telmisartan-HCTZ (40-12.5MG Oral Tablet, Maximum of 1 tablet per day 80-25MG Oral Tablet) Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day Temazepam (Oral Capsule) Maximum of 1 capsule per day Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug Last197 updated September 1, 2019 33 33 197 Drug Name Quantity Limit Thalomid (100MG Oral Capsule, 50MG Oral Maximum of 1 capsule per day Capsule) Thalomid (150MG Oral Capsule, 200MG Oral Maximum of 2 capsules per day Capsule) Tibsovo (Oral Tablet) Maximum of 2 tablets per day Tivicay (10MG Oral Tablet, 25MG Oral Tablet) Maximum of 1 tablet per day Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day TOBI (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day Tobramycin (Inhalation Nebulization Solution) Maximum of 10 ml (2 ampules) per day Tolazamide (250MG Oral Tablet) Maximum of 4 tablets per day Tolazamide (500MG Oral Tablet) Maximum of 2 tablets per day Tolbutamide (Oral Tablet) Maximum of 6 tablets per day Tolcapone (Oral Tablet) Maximum of 6 tablets per day Toviaz (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Tracleer (Oral Tablet) Maximum of 2 tablets per day Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day Tradjenta (Oral Tablet) Maximum of 1 tablet per day Tramadol HCl ER (Biphasic) (Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Tramadol HCl ER (100MG Oral Capsule Extended Release 24 Hour, 200MG Oral Maximum of 1 capsule per day Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour) Tramadol HCl ER (100MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour) Tramadol HCl (Oral Tablet Immediate Release) Maximum of 8 tablets per day Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day Trandolapril (1MG Oral Tablet, 2MG Oral Maximum of 1 tablet per day Tablet) Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day Trandolapril-Verapamil HCl ER (Oral Tablet Maximum of 1 tablet per day Extended Release) Tranxene-T (Oral Tablet) Maximum of 12 tablets per day Trelegy Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated)

Bold type = Brand name drug Plain type = Generic drug 198198 34 34 Last updated September 1, 2019 Drug Name Quantity Limit Trezix (Oral Capsule) Maximum of 10 capsules per day Tribenzor (Oral Tablet) Maximum of 1 tablet per day Trientine HCl (Oral Capsule) Maximum of 8 capsules per day Triumeq (Oral Tablet) Maximum of 1 tablet per day Trizivir (Oral Tablet) Maximum of 2 tablets per day Trulicity (Subcutaneous Solution Pen- Maximum of 4 pens (2 ml) per 28 days Injector) Truvada (Oral Tablet) Maximum of 1 tablet per day Twynsta (40-10MG Oral Tablet, 40-5MG Oral Maximum of 1 tablet per day Tablet, 80-5MG Oral Tablet) Tybost (Oral Tablet) Maximum of 1 tablet per day Tylenol with Codeine #3 (Oral Tablet) Maximum of 13 tablets per day Tylenol with Codeine #4 (Oral Tablet) Maximum of 13 tablets per day Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days Ultracet (Oral Tablet) Maximum of 8 tablets per day Ultram (Oral Tablet) Maximum of 8 tablets per day Uptravi (1000MCG Oral Tablet, 1200MCG Oral Tablet, 1400MCG Oral Tablet, 1600MCG Maximum of 2 tablets per day Oral Tablet, 400MCG Oral Tablet, 600MCG Oral Tablet, 800MCG Oral Tablet) Uptravi (200MCG Oral Tablet) Maximum of 5 tablets per day Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day Valcyte (Oral Solution Reconstituted) Maximum of 36 ml per day Valcyte (Oral Tablet) Maximum of 4 tablets per day Valganciclovir HCl (50MG/ML Oral Solution Maximum of 36 ml per day Reconstituted) Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day Valium (Oral Tablet) Maximum of 4 tablets per day Valsartan (160MG Oral Tablet, 40MG Oral Maximum of 2 tablets per day Tablet, 80MG Oral Tablet) Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Valtrex (1GM Oral Tablet) Maximum of 4 tablets per day Valtrex (500MG Oral Tablet) Maximum of 2 tablets per day Vancocin HCl (125MG Oral Capsule) Maximum of 4 capsules per day Vancocin HCl (250MG Oral Capsule) Maximum of 8 capsules per day Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day

Bold type = Brand name drug Plain type = Generic drug Last199 updated September 1, 2019 35 35 199 Drug Name Quantity Limit Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day Vaseretic (Oral Tablet) Maximum of 2 tablets per day Vasotec (Oral Tablet) Maximum of 2 tablets per day Veltassa (Oral Packet) Maximum of 1 packet per day Vemlidy (Oral Tablet) Maximum of 1 tablet per day Vesicare (Oral Tablet) Maximum of 1 tablet per day Viberzi (Oral Tablet) Maximum of 2 tablets per day Vicodin ES (Oral Tablet) Maximum of 13 tablets per day Vicodin HP (Oral Tablet) Maximum of 13 tablets per day Vicodin (Oral Tablet) Maximum of 13 tablets per day Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days Videx EC (125MG Oral Capsule Delayed Release, 250MG Oral Capsule Delayed Maximum of 1 capsule per day Release, 400MG Oral Capsule Delayed Release) Videx EC (200MG Oral Capsule Delayed Maximum of 2 capsules per day Release) Videx (4GM Oral Solution Reconstituted) Maximum of 40 ml per day Viekira Pak (Oral Tablet Therapy Pack) Maximum of 1 pack (112 tablets) per 28 days Vigabatrin (Oral Packet) Maximum of 6 packets per day Vigabatrin (Oral Tablet) Maximum of 6 tablets per day Vigadrone (Oral Packet) Maximum of 6 packets per day Vimpat (Oral Solution) Maximum of 40 ml per day Vimpat (Oral Tablet) Maximum of 2 tablets per day Viracept (250MG Oral Tablet) Maximum of 10 tablets per day Viracept (625MG Oral Tablet) Maximum of 4 tablets per day Viramune (Oral Suspension) Maximum of 40 ml per day Viramune (Oral Tablet Immediate Release) Maximum of 2 tablets per day Viramune XR (Oral Tablet Extended Release Maximum of 1 tablet per day 24 Hour) Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days Viread (Oral Tablet) Maximum of 1 tablet per day Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day Vitrakvi (Oral Solution) Maximum of 20 ml per day Vivelle-Dot (Transdermal Patch Twice Maximum of 8 patches per 28 days Weekly) Vivlodex (Oral Capsule) Maximum of 1 capsule per day

Bold type = Brand name drug Plain type = Generic drug 200200 36 36 Last updated September 1, 2019 Drug Name Quantity Limit Vosevi (Oral Tablet) Maximum of 1 tablet per day Votrient (Oral Tablet) Maximum of 4 tablets per day Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule, 4.5MG Oral Capsule, 6MG Oral Maximum of 1 capsule per day Capsule) Vytorin (Oral Tablet) Maximum of 1 tablet per day Wixela Inhub (Inhalation Aerosol Powder Breath Maximum of 1 inhaler (60 blisters) per 30 days Activated) (Generic Advair) Xanax (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Maximum of 4 tablets per day Release, 1MG Oral Tablet Immediate Release) Xanax (2MG Oral Tablet Immediate Release) Maximum of 5 tablets per day Xanax XR (0.5MG Oral Tablet Extended Release 24 Hour, 1MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Xanax XR (2MG Oral Tablet Extended Maximum of 5 tablets per day Release 24 Hour) Xanax XR (3MG Oral Tablet Extended Maximum of 3 tablets per day Release 24 Hour) Xarelto (10MG Oral Tablet, 20MG Oral Tablet) Maximum of 1 tablet per day Xarelto (15MG Oral Tablet, 2.5MG Oral Maximum of 2 tablets per day Tablet) Xarelto Starter Pack (Oral Tablet Therapy Maximum of 1 pack (51 tablets) per 30 days Pack) Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day Xeljanz XR (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Xermelo (Oral Tablet) Maximum of 3 tablets per day Xigduo XR (10-1000MG Oral Tablet Extended Release 24 Hour, 10-500MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour, 5-500MG Oral Tablet Extended Release 24 Hour) Xigduo XR (2.5-1000MG Oral Tablet Extended Release 24 Hour, 5-1000MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Xiidra (Ophthalmic Solution) Maximum of 2 vials per day Ximino (Oral Capsule Extended Release 24 Maximum of 1 capsule per day Hour) Xofluza (Oral Tablet Therapy Pack) Maximum of 2 tablets per 30 days

Bold type = Brand name drug Plain type = Generic drug Last201 updated September 1, 2019 37 37 201 Drug Name Quantity Limit Xospata (Oral Tablet) Maximum of 3 tablets per day Xtampza ER (13.5MG Oral Capsule ER 12 Hour Abuse-Deterrent, 18MG Oral Capsule Maximum of 3 capsules per day ER 12 Hour Abuse-Deterrent, 9MG Oral Capsule ER 12 Hour Abuse-Deterrent) Xtampza ER (27MG Oral Capsule ER 12 Hour Abuse-Deterrent, 36MG Oral Capsule ER 12 Maximum of 6 capsules per day Hour Abuse-Deterrent) Xultophy (Subcutaneous Solution Pen- Maximum of 5 pens (15 ml) per 30 days Injector) Xyrem (Oral Solution) Maximum of 18 ml per day Yupelri (Inhalation Solution) Maximum of 1 vial (3 ml) per day Zaleplon (Oral Capsule) Maximum of 90 capsules per year Zejula (Oral Capsule) Maximum of 3 capsules per day Zelboraf (Oral Tablet) Maximum of 8 tablets per day Zembrace SymTouch (Subcutaneous Maximum of 8 ml (16 syringes) per 30 days Solution Auto-Injector) Zenzedi (10MG Oral Tablet, 2.5MG Oral Tablet, Maximum of 6 tablets per day 5MG Oral Tablet, 7.5MG Oral Tablet) Zenzedi (15MG Oral Tablet, 20MG Oral Tablet) Maximum of 3 tablets per day Zenzedi (30MG Oral Tablet) Maximum of 2 tablets per day Zepatier (Oral Tablet) Maximum of 1 tablet per day Zestoretic (10-12.5MG Oral Tablet) Maximum of 1 tablet per day Zestoretic (20-12.5MG Oral Tablet) Maximum of 4 tablets per day Zestoretic (20-25MG Oral Tablet) Maximum of 2 tablets per day Zestril (Oral Tablet) Maximum of 2 tablets per day Ziac (2.5-6.25MG Oral Tablet) Maximum of 2 tablets per day Ziagen (Oral Solution) Maximum of 32 ml per day Ziagen (Oral Tablet) Maximum of 2 tablets per day Zidovudine (Oral Capsule) Maximum of 6 capsules per day Zidovudine (Oral Syrup) Maximum of 64 ml per day Zidovudine (Oral Tablet) Maximum of 2 tablets per day Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day Zocor (10MG Oral Tablet, 20MG Oral Tablet, Maximum of 1 tablet per day 40MG Oral Tablet, 80MG Oral Tablet) Zohydro ER (Oral Capsule ER 12 Hour Abuse- Maximum of 2 capsules per day Deterrent) Zolmitriptan (Oral Tablet) Maximum of 12 tablets per 30 days

Bold type = Brand name drug Plain type = Generic drug 202202 38 38 Last updated September 1, 2019 Drug Name Quantity Limit Zolmitriptan ODT (Oral Tablet Dispersible) Maximum of 12 tablets per 30 days Zolpidem Tartrate (Oral Tablet Immediate Maximum of 90 tablets per year Release) Zomig (2.5MG Nasal Solution) Maximum of 18 devices per 30 days Zomig (5MG Nasal Solution) Maximum of 12 devices per 30 days Zomig (Oral Tablet) Maximum of 12 tablets per 30 days Zomig ZMT (Oral Tablet Dispersible) Maximum of 12 tablets per 30 days Zonalon (External Cream) Maximum of 90 grams per 30 days ZTlido (External Patch) Maximum of 3 patches per day Zubsolv (1.4-0.36MG Tablet Sublingual, Maximum of 3 tablets per day 5.7-1.4MG Tablet Sublingual) Zubsolv (11.4-2.9MG Tablet Sublingual) Maximum of 1 tablet per day Zubsolv (2.9-0.71MG Tablet Sublingual) Maximum of 5 tablets per day Zubsolv (8.6-2.1MG Tablet Sublingual) Maximum of 2 tablets per day Zypitamag (Oral Tablet) Maximum of 1 tablet per day Zyprexa (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, Maximum of 1 tablet per day 5MG Oral Tablet, 7.5MG Oral Tablet) Zyprexa Zydis (Oral Tablet Dispersible) Maximum of 1 tablet per day track

Bold type = Brand name drug Plain type = Generic drug 203 0 203 Required information Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change from time to time during each plan year. You will receive notice when necessary. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Please call Customer Service. Our contact information is on the cover. 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. For more up-to-date information or if you have other questions, please call Customer Service at:

Toll-free 1-866-747-1014, TTY 711 8 a.m. - 8 p.m. ET, Monday - Friday

www.UHCRetiree.com/ncshp

OVEX20PP4480423_000 Last updated September 1, 2019