1

2018
COMPLETE DRUG LIST
(FORMULARY)
Prescription drug list information

UnitedHealthcare Dual Complete® (HMO SNP)

UnitedHealthcare Dual Complete® (HMO-POS SNP)
UnitedHealthcare Dual Complete® Focus (HMO SNP)
UnitedHealthcare Dual Complete® (PPO SNP)

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

Toll-Free 1-866-480-1086, TTY 711

8 a.m. - 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Formulary ID Number 00018044, Version 20

Y0066_170602_215911_FINAL_M53.10 Approved Last updated November 1, 2018
2 11

TABLE OF CONTENTS
What is a drug list?......................................................................................................................................3
Note to existing members.......................................................................................................................... 3
How do I use the drug list?.........................................................................................................................4
What are generic drugs?............................................................................................................................ 4
What is a compounded drug?....................................................................................................................4
Drug payment stage and drug tiers...........................................................................................................5
Getting Extra Help.......................................................................................................................................5
Are there any rules or limits on my drug coverage?................................................................................ 6
What if my drug is not on this list?.............................................................................................................8
How can I get an exception?......................................................................................................................8
Can I get my drug while I wait for an exception?......................................................................................9
Can the drug list change?........................................................................................................................ 10
Drugs with dosages other than a 1-month supply..................................................................................11
Covered drugs by name (Drug index).................................................................................................... 12
Covered drugs by medical condition...................................................................................................... 32
Covered drugs with a quantity limit (QL).............................................................................................. 102

Questions?

If you have questions, we’re here to help. Call Customer Service at:
Toll-Free 1-866-480-1086, TTY 711
8 a.m. - 8 p.m. local time, 7 days a week
 2 3
What is a drug list?
A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team
of health care providers work together in selecting drugs that are needed for well-rounded care
and treatment.
Your plan will generally cover the drugs listed in our drug list as long as:
· The drug is medically necessary
· The prescription is filled at a network pharmacy
· 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 November 1, 2018.
For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our
contact information is on the cover.
This drug list has changed since last year. Please review this document to make sure your
prescription drugs are still covered. In most cases, you must use network pharmacies to have your
prescriptions covered by the plan.
When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to
“plan,” “our plan,” or “your plan,” it means UnitedHealthcare Dual Complete.
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 12–31 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
.......32–101 to look for drugs based on your medical conditions. For example, if you have a heart
.......condition, you should look in the category Cardiovascular Agents. This is where you will find
.......drugs that treat heart conditions.

Can’t find your drug?

Check the complete drug list by visiting our plan website at
www.UHCCommunityPlan.com. You can use online tools to look up your
drugs. This information is updated on a regular basis.

What are generic drugs?

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

What is a compounded drug?

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

· Your drug’s tier. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier.
The chart below shows your cost-sharing amount.
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 Your Cost-Sharing Amount

Tier 1 “Covered Drugs” 25% coinsurance

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.
 1

6 5
Dummy

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 32. The codes and
what they mean are shown below and on the next page.
You can also get more information about the coverage rules and/or limits applied to specific
covered drugs by visiting our website. We have posted online documents that explain our prior
authorization and step therapy restrictions. If you would like a copy sent to you, please call
Customer Service. Our contact information is on the cover.
Coverage Rules and Limits
PA - Prior authorization
The plan requires you or your doctor to get prior approval for certain drugs. This means the plan
needs more information from your doctor to make sure the drug is being used correctly for a
medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.
QL - Quantity limits
The plan will cover only a certain amount of this drug for 1 copay/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.
LA - Limited access
Drugs are considered “limited access” if the FDA says the drug can be given out only by certain
facilities or doctors. These drugs may require extra handling, provider coordination or patient
education that can’t be done at a network pharmacy.

MED - Morphine equivalent dose

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional edit is called a cumulative morphine equivalent dose (MED). The MED is
calculated based on the number of opioid drugs prescribed for you over a period of time. This
cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids
for 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.
For Track Refered Purpose

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

How can I get an exception?

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

Types of exceptions you can ask for

· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved,
this drug will be covered at a pre-determined cost-sharing level. You will not be able to ask us to
provide the drug at a lower cost-sharing level.
· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For
example, if your drug has a quantity limit, you can ask the plan to change the limit and cover
more.
The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as
effective in treating your condition or would cause adverse medical effects.
Who can ask for an exception?
You, your authorized representative or your doctor can ask for an exception by calling Customer
Service. Your doctor must give us a supporting statement with the reason for the exception.
How long does it take to get an exception?
After we get the statement from your doctor supporting your request for an exception, we’ll give
you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor
believes that your health could be seriously harmed by waiting 72 hours. If your expedited request
is approved, we’ll give you a decision within 24 hours after we get your doctor’s supporting
statement.
 8 9
Can I get my drug while I wait for an exception?
As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s
not on our drug list or if it has rules or limits. For example, you may need a prior authorization from
us before you can fill your prescription. During the time when you are getting a temporary supply,
you should talk with your doctor to decide if there is a similar drug on the drug list you can take
instead. If you and your doctor decide this is the only drug that will work for you, you will need to
ask for an exception. We may cover your drug in certain cases during the first 90 days of your
membership.
The following chart shows how much of your drug we may cover while you ask for an exception.

If you... And you are… You can ask for…

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
were a member last year and it’s the in a nursing home or long- at least a 98-day
first 90 days of your plan year term care facility temporary supply

have been in the plan for more than 90 in a nursing home or at least a 31-day
days long-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,
any time during the year in a nursing home or long- at least a 31-day
term care facility temporary supply

The prescription must be filled at a network pharmacy. Also, if your prescription is written for fewer
days, you can refill it multiple times. This is so you can get your full temporary supply.
We will not pay for more of your drug after you get this temporary or emergency supply unless you
receive authorization from the plan.
10 9
Can the drug list change?
We try to change the drug list as little as possible during the plan year. Occasionally we may need
to make changes for safety or other reasons.
The drug list may change during the year if your plan:
· Adds new drugs, including generic drugs, as they become available.
· Removes a drug that has been found to be ineffective or unsafe.
· Changes the coverage rules or limits for a drug.
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 102-125.
We’ll tell you about any changes
If a drug you are taking is removed from the drug list during the plan year we’ll include an update in
your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about any changes to our
drug list at least 60 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 a 60-day supply of the drug so you have time to
talk with your doctor. To get updated information about the drugs covered by your plan, please call
Customer Service or go to www.UHCCommunityPlan.com to look it up online.
 10 11
Drugs with dosages other than a 1-month supply
Drugs packaged in an extended day supply
Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When
you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.
For more information, please call Customer Service. Our contact information is on the cover.
Daily cost-sharing for oral 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, we’re here to help. Call
Customer Service toll-free at 1-866-480-1086, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Or visit us online at www.UHCCommunityPlan.com.
If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov
or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.
Tracked
12

12 12
track
Covered drugs by name (Drug index)

A Advair HFA............................100 Amiloride/Hydrochlorothiazide

Abacavir.................................. 59 Afeditab CR............................ 66 ...............................................67
Abacavir Sulfate/Lamivudine/ Afinitor.....................................52 Aminophylline.........................99
Zidovudine............................59 Afinitor Disperz....................... 52 Aminosyn 7%/Electrolytes.....75
Abacavir/Lamivudine.............59 Ala-Cort................................... 82 Aminosyn 8.5%/Electrolytes
Abelcet.................................... 47 Albenza................................... 53 ...............................................75
Abilify Maintena......................55 Albuterol Sulfate.....................98 Aminosyn II............................. 75
Abraxane.................................50 Alclometasone Dipropionate Aminosyn II 8.5%/Electrolytes
...............................................75
Abstral..................................... 34 ...............................................82
Aminosyn-HBC....................... 75
Acamprosate Calcium DR..... 35 Alcohol Prep Pads..................94
Aminosyn-PF...........................75
Acarbose.................................61 Aldurazyme............................. 80
Aminosyn-RF.......................... 75
Acebutolol HCl....................... 66 Alecensa................................. 52
Amiodarone HCl.....................65
Acetaminophen/Codeine...... 34 Alendronate Sodium.............. 93
Amitiza.....................................79
Acetazolamide........................69 Alfuzosin HCl ER.................... 81
Amitriptyline HCl.....................46
Acetazolamide ER..................69 Alimta...................................... 50
Amlodipine Besylate.............. 66
Acetazolamide Sodium..........69 Alinia........................................54
Amlodipine Besylate/
Acetic Acid..............................97 Aliqopa.................................... 52
Atorvastatin Calcium............67
Acetylcysteine...................... 100 Allopurinol...............................48
Amlodipine Besylate/
Acitretin................................... 74 Alocril...................................... 95 Benazepril HCl..................... 68
Actemra...................................91 Alomide................................... 95 Amlodipine Besylate/Valsartan
ActHIB..................................... 92 Alosetron HCl......................... 79 ...............................................68
Actimmune..............................91 Aloxi.........................................46 Amlodipine/Olmesartan
Medoxomil............................68
Acyclovir..................................58 Alphagan P............................. 95
Amlodipine/Valsartan/
Acyclovir Sodium................... 58 Alprazolam.............................. 61
Hydrochlorothiazide............ 68
Adacel..................................... 92 Altavera................................... 85
Ammonium Lactate................74
Adagen....................................80 Alunbrig...................................52
Amoxapine..............................46
Adapalene...............................74 Alyacen 1/35.......................... 85
Amoxicillin...............................39
Adcirca.................................... 99 Amantadine HCl..................... 54
Amoxicillin/Clavulanate
Adefovir Dipivoxil....................57 AmBisome.............................. 47 Potassium.............................39
Adempas.................................99 Amethia................................... 85 Amoxicillin/Clavulanate
Adriamycin..............................50 Amethia Lo..............................85 Potassium ER.......................39
Adrucil..................................... 50 Amikacin Sulfate.................... 36 Amphetamine/
Advair Diskus........................100 Amiloride HCl......................... 69 Dextroamphetamine......71, 72
Amphotericin B.......................47
Tracked
13

13 13

Ampicillin................................. 39 Atgam...................................... 91 Bactroban Nasal..................... 36

Ampicillin Sodium...................39 Atomoxetine............................ 72 Balsalazide Disodium............. 92
Ampicillin-Sulbactam..............39 Atorvastatin Calcium.............. 70 Balziva......................................85
Ampyra.................................... 73 Atovaquone............................. 54 Banzel...................................... 43
Anadrol-50............................... 84 Atovaquone/Proguanil HCl....54 Baraclude................................ 57
Anagrelide HCl........................64 Atripla.......................................58 Bavencio..................................53
Anastrozole............................. 52 Atropine Sulfate................ 78, 94 BCG Vaccine...........................92
Androderm.............................. 84 Atrovent HFA........................... 98 Bekyree....................................85
AndroGel................................. 84 Aubagio................................... 73 Beleodaq................................. 52
AndroGel Pump...................... 84 Aubra....................................... 85 Belsomra............................... 100
Anoro Ellipta..........................100 Augmented Betamethasone Benazepril HCl........................ 65
Anzemet...................................46 Dipropionate......................... 82 Benazepril HCl/
Apokyn.....................................54 Auryxia..................................... 78 Hydrochlorothiazide............. 68
Apraclonidine.......................... 95 Austedo................................... 72 Benlysta................................... 91
Aprepitant................................47 Avandia.................................... 61 Benznidazole...........................54
Apri...........................................85 Avastin..................................... 53 Benztropine Mesylate.............54
Apriso.......................................92 Aviane...................................... 85 Bepreve................................... 95
Aptiom..................................... 43 Avonex..................................... 73 Berinert.................................... 89
Aptivus..................................... 60 Avonex Pen............................. 73 Besivance................................ 40
Aralast NP................................80 Azacitidine............................... 64 Betamethasone Dipropionate
............................................... 82
Aranelle....................................85 Azactam...................................38
Betamethasone Valerate........ 82
Aranesp Albumin Free............64 Azasite..................................... 39
Betaseron................................ 73
Arcalyst.................................... 91 Azathioprine............................ 90
Betaxolol HCl.................... 66, 95
Argatroban.............................. 63 Azelastine HCl...................95, 97
Bethanechol Chloride.............81
Aripiprazole............................. 55 Azilect...................................... 55
Bethkis..................................... 99
Aripiprazole ODT.................... 56 Azithromycin........................... 40
Betimol.....................................95
Aristada....................................56 Azopt........................................95
Bevespi Aerosphere............. 100
Arnuity Ellipta.......................... 97 Aztreonam............................... 38
B Bexarotene.............................. 53
Arranon.................................... 50
Bexsero....................................92
Ashlyna.................................... 85 BACiiM.....................................36
Bicalutamide........................... 50
Aspirin/Dipyridamole..............64 Bacitracin.................................36
Bicillin C-R............................... 39
Atazanavir Sulfate................... 60 Bacitracin/Polymyxin B.......... 94
Bicillin L-A................................39
Atenolol....................................66 Baclofen................................ 100
BiCNU...................................... 49
Atenolol/Chlorthalidone......... 68 Bactocill in Dextrose...............39
Tracked
14

14 14

BiDil..........................................68 Bupropion HCl XL...................44 Carbaglu.................................. 75

Biktarvy.................................... 59 Buspirone HCl.........................60 Carbamazepine.......................43
Biltricide...................................54 Busulfan...................................49 Carbamazepine ER.................43
Binosto.....................................93 Busulfex................................... 49 Carbidopa................................54
Bisoprolol Fumarate............... 66 Butalbital/Acetaminophen/ Carbidopa/Levodopa............. 55
Bisoprolol Fumarate/ Caffeine................................. 32 Carbidopa/Levodopa ER....... 55
Hydrochlorothiazide............. 68 Butalbital/Aspirin/Caffeine.... 32 Carbidopa/Levodopa ODT.... 55
BIVIGAM.................................. 91 Butorphanol Tartrate.............. 34 Carbidopa/Levodopa/
Bleomycin Sulfate...................50 Bydureon Bcise.......................61 Entacapone...........................55
Blephamide............................. 94 Bydureon Pen......................... 61 Carboplatin..............................50
Blephamide S.O.P.................. 94 Bydureon Vial..........................61 Cardene IV...............................66
Blisovi 24 Fe............................ 85 Byetta.......................................61 Carimune Nanofiltered........... 91
Blisovi Fe 1.5/30..................... 85 Bystolic.................................... 66 Carteolol HCl........................... 95
Blisovi Fe 1/20........................ 85 C Cartia XT.................................. 66
Boostrix....................................92 Cabergoline.............................89 Carvedilol.................................66
Bortezomib.............................. 50 Cabometyx.............................. 52 Caspofungin Acetate..............47
Bosulif...................................... 52 Calcipotriene........................... 74 Cayston....................................99
Botox........................................94 Calcitonin-Salmon...................93 Caziant..................................... 85
Breo Ellipta............................ 100 Calcitriol............................ 74, 93 Cefaclor................................... 38
Briellyn..................................... 85 Calcium Acetate......................78 Cefadroxil................................ 38
Brilinta......................................64 Calquence............................... 52 Cefazolin Sodium....................38
Brimonidine Tartrate...............95 Camila......................................88 Cefdinir.................................... 38
Briviact..................................... 42 Camrese Lo............................. 85 Cefepime................................. 38
Bromocriptine Mesylate......... 54 Canasa.....................................92 Cefixime...................................38
Brovana....................................98 Cancidas..................................47 Cefotaxime Sodium................ 38
Budesonide.......................93, 97 Candesartan Cilexetil............. 65 Cefotetan................................. 38
Budesonide ER....................... 93 Candesartan Cilexetil/ Cefoxitin Sodium.................... 38
Bumetanide............................. 69 Hydrochlorothiazide............. 68 Cefpodoxime Proxetil............. 38
Buphenyl................................. 80 Capastat Sulfate......................49 Cefprozil.................................. 38
Buprenorphine HCl.................35 Caprelsa.................................. 52 Ceftazidime............................. 38
Buprenorphine HCl/Naloxone Captopril.................................. 65 Ceftriaxone Sodium................38
HCl......................................... 36 Captopril/Hydrochlorothiazide Cefuroxime Axetil....................38
Bupropion HCl........................ 44 ............................................... 68
Cefuroxime Sodium................38
Bupropion HCl SR............ 36, 44 Carac........................................74
Celecoxib.................................32
Carafate................................... 80
Tracked
15

15 15

Cellcept....................................90 Cimetidine HCl........................ 79 Clozapine.................................57

Celontin................................... 42 Cimzia...................................... 90 Clozapine ODT........................57
Cephalexin...............................38 Cinryze..................................... 89 Coartem................................... 54
Cerezyme.................................80 Cipro HC..................................97 Codeine Sulfate...................... 34
Cesamet.................................. 47 Ciprodex.................................. 97 Colchicine................................48
Cetirizine HCl.......................... 97 Ciprofloxacin........................... 40 Colcrys.....................................48
Chantix.....................................36 Ciprofloxacin ER..................... 40 Colesevelam HCl.................... 70
Chantix Continuing Month Pak Ciprofloxacin HCl....................40 Colestipol HCl......................... 70
............................................... 36 Ciprofloxacin I.V. in D5W....... 40 Colistimethate Sodium........... 37
Chantix Starting Month Pak... 36 Cisplatin...................................51 Colocort................................... 93
Chemet.................................... 78 Citalopram HBr....................... 45 Coly-Mycin S............................97
Chenodal................................. 78 Cladribine................................ 50 Combigan................................ 95
Chloramphenicol Sodium Claravis.................................... 74 Combivent Respimat............100
Succinate.............................. 36
Clarithromycin.........................40 Combivir.................................. 59
Chlordiazepoxide HCl............ 61
Clarithromycin ER...................40 Cometriq..................................52
Chlorhexidine Gluconate Oral
Climara Pro..............................85 Complera................................. 58
Rinse......................................73
Clindamycin HCl..................... 36 Compro....................................46
Chloroquine Phosphate......... 54
Clindamycin Palmitate HCl.... 36 Constulose.............................. 79
Chlorothiazide......................... 70
Clindamycin Phosphate... 37, 74 Copaxone................................ 73
Chlorothiazide Sodium...........70
Clindamycin Phosphate in D5W Cordran....................................82
Chlorpromazine HCl............... 55
............................................... 37 Corlanor...................................68
Chlorthalidone.........................70
Clindamycin/Benzoyl Peroxide Cortisone Acetate................... 82
Chlorzoxazone...................... 100 ............................................... 74
Cortisporin...............................74
Cholbam.................................. 80 Clobetasol Propionate............82
Cosentyx..................................74
Cholestyramine....................... 70 Clofarabine.............................. 50
Cosentyx Sensoready Pen..... 74
Cholestyramine Light............. 70 Clomipramine HCl.................. 46
Cosmegen............................... 51
Chorionic Gonadotropin........ 84 Clonazepam............................ 61
Cosopt PF................................95
Ciclopirox................................ 47 Clonazepam ODT................... 61
Cotellic.....................................52
Ciclopirox Nail Lacquer..........47 Clonidine HCl.......................... 65
Coumadin................................ 63
Ciclopirox Olamine................. 47 Clonidine HCl ER.................... 72
Creon....................................... 80
Cidofovir.................................. 57 Clopidogrel..............................64
Crinone.................................... 88
Cilostazol................................. 64 Clorazepate Dipotassium....... 61
Crixivan.................................... 60
Ciloxan..................................... 40 Clotrimazole............................ 47
Cromolyn Sodium...... 78, 95, 99
Cimduo.................................... 59 Clotrimazole/Betamethasone
Cryselle-28...............................85
Cimetidine............................... 79 Dipropionate......................... 74
Tracked
16

16 16

Cubicin.....................................37 Demser.................................... 68 Dextrose 5%/NaCl 0.225%.... 75

Cuprimine................................ 81 Denavir.....................................58 Dextrose 5%/NaCl 0.33%.......75
Cuvposa...................................78 Depen Titratabs...................... 81 Dextrose 5%/NaCl 0.45%.......75
Cyclafem..................................85 Depo-Estradiol.........................85 Dextrose 5%/NaCl 0.9%.........75
Cyclobenzaprine HCl........... 100 Depo-Medrol........................... 82 Diastat AcuDial........................42
Cyclophosphamide.................50 Depo-Provera.......................... 88 Diastat Pediatric......................42
Cycloset................................... 61 Descovy................................... 59 Diazepam.................................61
Cyclosporine........................... 90 Desipramine HCl.....................46 Diazepam Intensol.................. 61
Cyclosporine Modified........... 90 Desmopressin Acetate........... 84 Diclofenac Potassium.............32
Cyproheptadine HCl............... 97 Desogestrel/Ethinyl Estradiol Diclofenac Sodium.....32, 74, 96
Cyramza...................................52 ............................................... 85 Diclofenac Sodium DR........... 32
Cystadane................................80 Desonide................................. 82 Diclofenac Sodium ER........... 32
Cystagon..................................80 Desoximetasone..................... 82 Dicloxacillin Sodium............... 39
Cystaran...................................94 Desvenlafaxine ER..................45 Dicyclomine HCl..................... 78
Cytarabine Aqueous............... 50 Dexamethasone...................... 82 Didanosine.............................. 59
D Dexamethasone Intensol........82 Dificid.......................................40
Dacarbazine............................ 50 Dexamethasone Sodium Diflunisal.................................. 32
Phosphate.......................82, 96
Dacogen.................................. 51 Digitek......................................68
Dexilant.................................... 80
Dactinomycin.......................... 51 Digox........................................68
Dexmethylphenidate HCl....... 72
Daklinza................................... 58 Digoxin.....................................68
Dexmethylphenidate HCl ER
Daliresp....................................99 Dihydroergotamine Mesylate
............................................... 72
Dalvance.................................. 37 ............................................... 48
Dexrazoxane............................51
Danazol....................................84 Dilantin.....................................43
Dextroamphetamine Sulfate
Dantrolene Sodium...............100 Dilantin INFATABS..................43
............................................... 72
Dapsone.................................. 49 Dilt-XR...................................... 67
Dextroamphetamine Sulfate ER
Daptacel.................................. 92 ............................................... 72 Diltiazem HCl...........................67
Daptomycin............................. 37 Dextrose 10%.......................... 75 Diltiazem HCl ER.....................67
DARAPRIM..............................54 Dextrose 10%/NaCl 0.2%.......75 Dipentum................................. 92
Darzalex................................... 53 Dextrose 10%/NaCl 0.45%.... 75 Diphenhydramine HCl............ 97
Daunorubicin HCl................... 51 Dextrose 2.5%/NaCl 0.45%... 75 Diphenoxylate/Atropine......... 79
Deblitane................................. 88 Dextrose 5%............................ 75 Diphtheria/Tetanus Toxoids
Adsorbed Pediatric.............. 92
Decitabine............................... 51 Dextrose 5%/Lactated Ringers
............................................... 75 Disulfiram.................................35
Delyla....................................... 85
Dextrose 5%/NaCl 0.2%.........75 Diuril.........................................70
Demeclocycline HCl............... 41
Tracked
17

17 17

Divalproex Sodium................. 61 E Enpresse-28............................ 85

Divalproex Sodium DR........... 61 E.E.S. Granules....................... 40 Enskyce................................... 85
Divalproex Sodium ER........... 61 Econazole Nitrate....................47 Entacapone............................. 54
Docetaxel.................................51 Edarbi.......................................65 Entecavir.................................. 57
Dofetilide................................. 65 Edarbyclor............................... 68 Entocort EC............................. 93
Donepezil HCl......................... 44 Edecrin.....................................69 Entresto................................... 68
Donepezil HCl ODT................ 44 Edurant.................................... 58 Enulose.................................... 79
Doripenem...............................38 Efavirenz.................................. 58 Envarsus XR............................ 90
Dorzolamide HCl.....................95 Egrifta.......................................89 Epclusa.................................... 58
Dorzolamide HCl/Timolol Elaprase...................................80 Epinastine HCl.........................95
Maleate..................................95 Elelyso......................................80 Epinephrine............................. 98
Doxazosin Mesylate................65 Elestrin..................................... 85 EpiPen..................................... 98
Doxepin HCl...................... 46, 74 Elidel........................................ 74 Epirubicin HCl......................... 51
Doxercalciferol........................ 93 Eliquis...................................... 63 Epitol........................................ 43
Doxil......................................... 51 Eliquis Starter Pack................ 63 Epivir HBV............................... 57
Doxorubicin HCl......................51 Elitek........................................ 53 Eplerenone.............................. 69
Doxorubicin HCl Liposome....51 Ellence..................................... 51 Eprosartan Mesylate...............65
Doxy 100..................................41 Elmiron.....................................81 Epzicom...................................59
Doxycycline............................. 41 Embeda................................... 33 Eraxis....................................... 47
Doxycycline Hyclate............... 41 Emcyt....................................... 50 Erbitux......................................53
Doxycycline Monohydrate......41 Emend......................................47 Ergotamine Tartrate/Caffeine
Dronabinol...............................47 Emend Tripack........................47 ............................................... 49
Drospirenone/Ethinyl Estradiol Emoquette............................... 85 Erivedge...................................52
............................................... 85 Erleada.....................................50
Empliciti................................... 53
Droxia.......................................50 Errin..........................................88
Emsam.....................................44
Duavee.....................................85 Erwinaze.................................. 51
Emtriva..................................... 59
Dulera.................................... 100 Ery............................................ 74
Enalapril Maleate.................... 65
Duloxetine HCl........................ 73 Ery-Tab.....................................40
Enalapril Maleate/
Duramorph.............................. 34 Hydrochlorothiazide............. 68 EryPed 200.............................. 40
Durezol.....................................96 Enbrel.......................................90 EryPed 400.............................. 40
Dutasteride.............................. 81 Enbrel SureClick..................... 90 Erythrocin Lactobionate......... 40
Dymista..................................100 Endocet................................... 34 Erythromycin..................... 40, 74
Dyrenium................................. 69 Engerix-B................................. 92 Erythromycin Base..................40
Dysport.................................... 94 Enoxaparin Sodium................ 63
Tracked
18

18 18

Erythromycin Ethylsuccinate Famotidine...............................79 Fluconazole in NaCl................47

............................................... 40 Famotidine Premixed............. 79 Flucytosine.............................. 47
Erythromycin/Benzoyl Peroxide Fanapt......................................56 Fludarabine Phosphate.......... 51
............................................... 74
Fanapt Titration Pack............. 56 Fludrocortisone Acetate.........82
Esbriet......................................99
Fareston...................................50 Flunisolide............................... 97
Escitalopram Oxalate............. 45
Farydak.................................... 52 Fluocinolone Acetonide... 82, 97
Esomeprazole Magnesium.... 80
Faslodex.................................. 50 Fluocinolone Acetonide Scalp
Esomeprazole Sodium........... 80
Fazaclo.....................................57 ............................................... 82
Estarylla................................... 85
Felbamate................................43 Fluocinonide............................82
Estrace.....................................85
Felbatol.................................... 43 Fluocinonide Emulsified Base
Estradiol...................................85 ............................................... 82
Felodipine ER..........................67
Estradiol Valerate....................85 Fluorometholone.....................96
Femring....................................86
Estring......................................85 Fluorouracil....................... 50, 74
Femynor...................................86
Ethacrynic Acid....................... 69 Fluoxetine DR..........................45
Fenofibrate.............................. 70
Ethambutol HCl.......................49 Fluoxetine HCl.........................45
Fenofibrate Micronized.......... 70
Ethosuximide...........................42 Fluphenazine Decanoate....... 55
Fenofibric Acid........................70
Ethynodiol Diacetate/Ethinyl Fluphenazine HCl................... 55
Fenofibric Acid DR................. 70
Estradiol................................ 85 Flurbiprofen.............................32
Fentanyl................................... 33
Etidronate Disodium............... 93 Flurbiprofen Sodium...............96
Fentanyl Citrate Oral
Etodolac...................................32
Transmucosal....................... 34 Flutamide.................................50
Etodolac ER.............................32
Ferriprox.................................. 78 Fluticasone Propionate.... 82, 97
Etopophos............................... 52
Fetzima.................................... 45 Fluticasone Propionate/
Etoposide................................ 52 Salmeterol...........................100
Fetzima Titration Pack............45
Eurax........................................ 54 Fluvastatin............................... 70
Finacea.................................... 74
Evotaz...................................... 60 Fluvoxamine Maleate..............45
Finasteride...............................81
Exelderm..................................47 FML.......................................... 96
Firazyr...................................... 90
Exemestane.............................52 FML Forte................................ 96
Firmagon................................. 89
Exjade...................................... 78 Folotyn..................................... 50
Flarex....................................... 96
Exondys 51..............................80 Fomepizole..............................94
Flebogamma DIF.................... 91
Ezetimibe................................. 70 Fondaparinux Sodium............ 63
Flecainide Acetate.................. 65
Ezetimibe/Simvastatin............70 Forteo.......................................93
Flector......................................32
F Fosamprenavir Calcium......... 60
Flovent Diskus.........................97
Fabrazyme............................... 80 Fosinopril Sodium...................65
Flovent HFA.............................97
Falmina.................................... 86 Fosinopril Sodium/
Fluconazole............................. 47
Famciclovir.............................. 58 Hydrochlorothiazide............. 68
Tracked
19

19 19

Fosphenytoin Sodium............ 43 Genotropin Miniquick.............84 Haloperidol Lactate................ 55

Fosrenol...................................78 Gentak..................................... 36 Harvoni.....................................58
FreAmine HBC 6.9%...............75 Gentamicin Sulfate................. 36 Havrix....................................... 92
Furosemide............................. 69 Gentamicin Sulfate/0.9% Heparin Sodium...................... 63
Fusilev......................................51 Sodium Chloride...................36 Heparin Sodium/D5W............ 64
Fuzeon..................................... 59 Genvoya...................................58 HepatAmine............................ 76
Fyavolv..................................... 86 Geodon....................................56 Hepsera................................... 57
Fycompa..................................43 Gianvi....................................... 86 Herceptin................................. 53
G Gilenya..................................... 73 Hetlioz....................................100
Gabapentin..............................42 Gilotrif...................................... 52 Hexalen....................................50
Gabitril..................................... 42 Glassia..................................... 80 Hiberix......................................92
Galantamine HBr.................... 44 Glatiramer Acetate..................73 Humalog Cartridge................. 62
Galantamine HBr ER.............. 44 Glatopa.................................... 73 Humalog Junior KwikPen.......62
Gamastan S/D.........................91 Gleostine................................. 50 Humalog KwikPen.................. 62
Gammagard Liquid.................91 Glimepiride.............................. 61 Humalog Mix 50/50 KwikPen
Gammagard S/D IGA Less Glipizide...................................61 ............................................... 63
Than 1 mcg/ml..................... 91 Glipizide ER.............................61 Humalog Mix 50/50 Vial.........63
Gammaked..............................91 Glipizide/Metformin HCl........ 61 Humalog Mix 75/25 KwikPen
Gammaplex............................. 91 GlucaGen HypoKit.................. 62 ............................................... 63
Gamunex-C..............................91 Glucagon Emergency Kit....... 62 Humalog Mix 75/25 Vial.........63
Ganciclovir...............................57 Glycopyrrolate.........................78 Humalog Vial........................... 63
Gardasil 9................................ 92 Glyxambi..................................61 Humatrope.............................. 84
Gatifloxacin..............................40 Granisetron HCl...................... 47 Humatrope Combo Pack....... 84
Gattex.......................................79 Granix.......................................64 Humira..................................... 90
Gauze.......................................94 Griseofulvin Microsize............ 48 Humira Pediatric Crohns
Disease Starter Pack............90
GaviLyte-C............................... 79 Griseofulvin Ultramicrosize.... 48
Humira Pen..............................90
GaviLyte-G............................... 79 Guanfacine ER........................ 72
Humira Pen Crohns Disease
GaviLyte-N/Flavor Pack..........79 Guanidine HCl.........................49
Starter Pack.......................... 90
Gemcitabine HCl.....................50 H Humulin 70/30 KwikPen........ 63
Gemfibrozil.............................. 70 Haegarda................................. 90
Humulin 70/30 Vial................. 63
Gemzar.................................... 50 Halaven.................................... 51
Humulin N KwikPen................63
Generlac.................................. 79 Halobetasol Propionate..........83
Humulin N Vial........................ 63
Gengraf....................................90 Haloperidol.............................. 55
Humulin R U-500 KwikPen.....63
Genotropin.............................. 84 Haloperidol Decanoate.......... 55
Humulin R U-500 Vial..............63
Tracked
20

20 20

Humulin R Vial.........................63 Imbruvica................................. 52 Irbesartan/Hydrochlorothiazide

Hycamtin..................................52 Imfinzi.......................................53 ............................................... 68
Hydralazine HCl...................... 71 Imipenem/Cilastatin............... 38 Iressa........................................52
Hydrochlorothiazide............... 70 Imipramine HCl....................... 46 Irinotecan.................................51
Hydrocodone/Acetaminophen Imipramine Pamoate.............. 46 Isentress.................................. 58
............................................... 34 Imiquimod............................... 74 Isentress HD............................ 58
Hydrocodone/Ibuprofen........ 34 Imovax Rabies.........................92 Isibloom................................... 86
Hydrocortisone................. 83, 93 Incassia....................................88 Isolyte-P/Dextrose 5%............ 76
Hydrocortisone Butyrate........ 83 Increlex.................................... 84 Isolyte-S................................... 76
Hydrocortisone Valerate.........83 Incruse Ellipta..........................98 Isoniazid...................................49
Hydrocortisone/Acetic Acid Indapamide............................. 70 Isosorbide Dinitrate................ 71
............................................... 97 Isosorbide Dinitrate ER.......... 71
Indomethacin.......................... 32
Hydromorphone HCl.............. 34 Isosorbide Mononitrate.......... 71
Infanrix..................................... 92
Hydromorphone HCl ER........ 33 Isosorbide Mononitrate ER.... 71
Ingrezza................................... 73
Hydroxychloroquine Sulfate Isotonic Gentamicin................36
Inlyta.........................................52
............................................... 54
Insulin Syringes, Needles.......94 Isotretinoin...............................74
Hydroxyprogesterone Caproate
Istodax..................................... 51
............................................... 88 Intelence.................................. 58
Itraconazole.............................48
Hydroxyurea............................ 50 Intralipid...................................76
Ivermectin................................ 54
Hydroxyzine HCl..................... 60 Intron A.................................... 58
Ixiaro........................................ 92
Hydroxyzine Pamoate.............46 Introvale................................... 86
Hysingla ER............................. 33 Invanz.......................................38
J
I Invega Sustenna..................... 56 Jadenu..................................... 78
Jadenu Sprinkle...................... 78
Ibandronate Sodium...............93 Invega Trinza........................... 56
Jakafi........................................52
Ibrance.....................................52 Invirase.....................................60
Jantoven.................................. 64
Ibu............................................ 32 Invokamet................................ 61
Janumet................................... 62
Ibuprofen................................. 32 Invokamet XR.......................... 62
Janumet XR............................. 62
Iclusig.......................................52 Invokana.................................. 62
Januvia.....................................62
Idamycin PFS.......................... 51 Ionosol-MB/Dextrose 5%....... 76
Jardiance................................. 62
Idarubicin HCl......................... 51 IPOL Inactivated IPV............... 92
Jentadueto...............................62
Idhifa........................................ 52 Ipratropium Bromide.............. 98
Jentadueto XR.........................62
Ifosfamide................................50 Ipratropium Bromide/Albuterol
Sulfate................................. 100 Jevtana.....................................52
Ilaris..........................................91
Irbesartan................................ 65 Jinteli........................................86
Ilevro........................................ 96
Jolivette....................................88
Imatinib Mesylate....................52
Tracked
21

21 21

Jublia........................................48 Kinrix........................................ 92 Larin 1/20................................ 86

Juleber..................................... 86 Kionex...................................... 78 Larin Fe 1.5/30........................86
Juluca...................................... 58 Kisqali...................................... 51 Larin Fe 1/20...........................86
Junel 1.5/30............................ 86 Kisqali Femara 200 Dose....... 51 Larissia.....................................86
Junel 1/20............................... 86 Kisqali Femara 400 Dose....... 51 Lartruvo....................................53
Junel Fe 1.5/30....................... 86 Kisqali Femara 600 Dose....... 51 Lastacaft.................................. 94
Junel Fe 1/20.......................... 86 Klor-Con...................................76 Latanoprost............................. 96
Junel Fe 24.............................. 86 Klor-Con 10..............................76 Latuda......................................56
Juxtapid................................... 70 Klor-Con 8................................76 Layolis Fe.................................86
K Klor-Con M10.......................... 76 Leena....................................... 86
Kadcyla.................................... 53 Klor-Con M15.......................... 76 Leflunomide............................ 91
Kaitlib Fe..................................86 Klor-Con M20.......................... 76 Lenvima................................... 53
Kaletra......................................60 Klor-Con Sprinkle....................76 Lessina.....................................86
Kalydeco..................................99 Kombiglyze XR........................62 Letairis..................................... 99
Kanuma................................... 81 Korlym......................................84 Letrozole..................................52
Kariva....................................... 86 Kurvelo.....................................86 Leucovorin Calcium................51
KCl 0.075%/D5W/NaCl 0.45% Kuvan....................................... 81 Leukeran..................................50
............................................... 76 Kynamro.................................. 70 Leukine.................................... 64
KCl 0.15%/D5W/NaCl 0.2%...76 Kyprolis.................................... 52 Leuprolide Acetate................. 89
KCl 0.15%/D5W/NaCl 0.45% L Levalbuterol.............................98
............................................... 76
Labetalol HCl...........................66 Levemir FlexTouch................. 63
KCl 0.15%/D5W/NaCl 0.9%...76
Lacrisert...................................94 Levemir Vial............................. 63
KCl 0.3%/D5W/NaCl 0.45%...76
Lactated Ringers Irrigation.... 76 Levetiracetam..........................42
KCl 0.3%/D5W/NaCl 0.9%.....76
Lactated Ringers Viaflex........ 76 Levetiracetam ER....................42
Kelnor 1/35............................. 86
Lactulose................................. 79 Levobunolol HCl..................... 96
Kelnor 1/50............................. 86
Lamivudine........................57, 59 Levocarnitine...........................76
Kenalog-10.............................. 83
Lamivudine/Zidovudine......... 59 Levocetirizine Dihydrochloride
Kenalog-40.............................. 83
Lamotrigine............................. 43 ............................................... 97
Kepivance................................73
Lanoxin.................................... 68 Levofloxacin............................ 40
Ketoconazole.......................... 48
Lansoprazole...........................80 Levofloxacin in D5W...............40
Ketorolac Tromethamine...... 32,
Lanthanum Carbonate........... 78 Levoleucovorin........................51
96
Lantus SoloStar.......................63 Levonest.................................. 86
Keytruda.................................. 53
Lantus Vial............................... 63 Levonorgestrel and Ethinyl
Kimidess.................................. 86 Estradiol................................ 86
Larin 1.5/30............................. 86
Kineret......................................90
Tracked
22

22 22

Levonorgestrel/Ethinyl Estradiol Losartan Potassium................ 65 Megestrol Acetate...................88

............................................... 86 Losartan Potassium/ Mekinist................................... 53
Levora 0.15/30-28...................86 Hydrochlorothiazide............. 68 Melodetta 24 Fe...................... 86
Levorphanol Tartrate.............. 33 Lotemax................................... 96 Meloxicam............................... 32
Levothyroxine Sodium............89 Lotronex...................................79 Melphalan HCl.........................50
Levoxyl.....................................89 Lovastatin................................ 70 Memantine HCl....................... 44
Lexiva.......................................60 Low-Ogestrel........................... 86 Memantine HCl ER................. 44
Lialda....................................... 93 Loxapine Succinate................ 55 Memantine HCl Titration Pak
Lidocaine................................. 35 Lumigan...................................96 ............................................... 44
Lidocaine HCl..........................35 Lumizyme................................ 81 Menactra..................................92
Lidocaine Viscous...................35 Lupaneta Pack........................ 89 Menest..................................... 86
Lidocaine/Prilocaine.............. 35 Lupron Depot.......................... 89 Mentax..................................... 48
Lincomycin HCl.......................37 Lupron Depot-Ped.................. 89 Menveo.................................... 92
Lindane....................................54 Lutera.......................................86 Mepron.................................... 54
Linezolid.................................. 37 Lynparza.................................. 53 Mercaptopurine...................... 50
Linzess.....................................79 Lyrica....................................... 73 Meropenem............................. 38
Lioresal Intrathecal............... 100 Lysodren..................................89 Mesalamine............................. 93
Liothyronine Sodium.............. 89 Lyza..........................................88 Mesalamine DR.......................93
Lisinopril.................................. 65 M Mesna...................................... 53
Lisinopril/Hydrochlorothiazide M-M-R II....................................92 Mesnex.................................... 53
............................................... 68 Magnesium Sulfate.................76 Mestinon..................................49
Lithium..................................... 61 Makena.................................... 88 Metadate ER............................72
Lithium Carbonate.................. 61 Malathion.................................54 Metaproterenol Sulfate...........98
Lithium Carbonate ER............ 61 Maprotiline HCl....................... 45 Metformin HCl.........................62
Lithostat................................... 81 Marlissa................................... 86 Metformin HCl ER...................62
Livalo........................................70 Marplan....................................45 Methadone HCl....................... 33
Lonsurf.....................................51 Matulane..................................50 Methazolamide........................69
Loperamide HCl......................79 Matzim LA................................67 Methenamine Hippurate........ 37
Lopinavir/Ritonavir................. 60 Mavyret.................................... 58 Methimazole............................89
Lorazepam...............................61 Meclizine HCl.......................... 46 Methotrexate........................... 90
Lorcet.......................................34 Medroxyprogesterone Acetate Methotrexate Sodium............. 90
Lorcet HD................................ 34 ............................................... 88 Methoxsalen............................ 74
Lorcet Plus.............................. 34 Mefloquine HCl....................... 54 Methscopolamine Bromide....78
Loryna...................................... 86 Megace ES.............................. 88 Methyclothiazide.....................70
Tracked
23

23 23

Methyldopa..............................65 Miglustat.................................. 81 N
Methyldopa/ Mili............................................87 Nabumetone........................... 32
Hydrochlorothiazide............. 68 Minitran....................................71 Nadolol.................................... 66
Methyldopate HCl................... 65 Minocycline HCl......................41 Nadolol/Bendroflumethiazide
Methylphenidate HCl..............72 Minoxidil.................................. 71 ............................................... 68
Methylphenidate HCl ER........72 Mirtazapine..............................44 Nafcillin Sodium......................39
Methylprednisolone................ 83 Mirtazapine ODT..................... 44 Naftifine HCl............................ 48
Methylprednisolone Acetate Mirvaso.................................... 74 Naftin........................................48
............................................... 83 Naglazyme...............................81
Misoprostol..............................80
Methylprednisolone Dose Pack Nalbuphine HCl.......................35
Mitomycin................................ 51
............................................... 83
Mitoxantrone HCl....................51 Naloxone HCl.......................... 36
Methylprednisolone Sodium
Naltrexone HCl........................35
Succinate.............................. 83 Modafinil................................101
Namenda XR........................... 44
Metipranolol............................ 96 Moexipril HCl...........................65
Namenda XR Titration Pack...44
Metoclopramide HCl.............. 46 Moexipril/Hydrochlorothiazide
............................................... 68 Namzaric..................................73
Metolazone..............................70
Mometasone Furoate....... 83, 97 Naproxen................................. 33
Metoprolol Succinate ER....... 66
MonoNessa............................. 87 Naproxen DR...........................33
Metoprolol Tartrate................. 66
Montelukast Sodium...............98 Naratriptan HCl....................... 49
Metoprolol/Hydrochlorothiazide
............................................... 68 Morphine Sulfate.............. 34, 35 Narcan..................................... 36
Metronidazole......................... 37 Morphine Sulfate ER.............. 33 Natacyn....................................48
Metronidazole in NaCl 0.79% Moxeza.................................... 40 Nateglinide.............................. 62
............................................... 37 Moxifloxacin HCl/Sodium HCl Natpara.................................... 93
Metronidazole Vaginal............37 ............................................... 41 Nebupent.................................54
Mexiletine HCl......................... 65 Moxifloxacin HCl..................... 41 Necon 0.5/35-28..................... 87
Miacalcin................................. 93 Mozobil.................................... 64 Necon 7/7/7............................87
Mibelas 24 Fe..........................86 Multaq......................................65 Nefazodone HCl......................45
Miconazole 3........................... 48 Mupirocin................................ 37 Neomycin Sulfate....................36
Microgestin 1.5/30................. 86 Mustargen............................... 50 Neomycin/Bacitracin/
Microgestin 1/20.....................86 Myalept.................................... 79 Polymyxin.............................. 94
Microgestin Fe........................ 86 Mycamine................................ 48 Neomycin/Polymyxin B
Sulfates..................................37
Microgestin Fe 1.5/30............ 87 Mycophenolate Mofetil...........90
Neomycin/Polymyxin/
Midodrine HCl......................... 65 Mycophenolic Acid DR...........90
Bacitracin/Hydrocortisone
Migergot.................................. 49 Mylotarg...................................53 ............................................... 94
Miglitol..................................... 62 Myrbetriq................................. 81
Tracked
24

24 24

Neomycin/Polymyxin/ Nitroglycerin Transdermal..... 71 NuvaRing................................. 87

Dexamethasone....................94 Nitrostat................................... 71 Nyamyc.................................... 48
Neomycin/Polymyxin/ Nora-BE....................................88 Nymalize.................................. 67
Gramicidin.............................94
Norditropin FlexPro................ 84 Nystatin....................................48
Neomycin/Polymyxin/
Norethindrone......................... 88 Nystop......................................48
Hydrocortisone...............94, 97
Norethindrone Acetate........... 88 O
Nephramine.............................76
Norethindrone Acetate/Ethinyl Ocaliva..................................... 81
Nerlynx.....................................53
Estradiol................................ 87 Ocella.......................................87
Neulasta...................................64
Norethindrone Acetate/Ethinyl Octagam.................................. 91
Neupogen................................64 Estradiol/Ferrous Fumarate
Octreotide Acetate..................89
Neupro.....................................54 ............................................... 87
Odefsey................................... 59
Nevanac...................................96 Norethindrone/Ethinyl
Odomzo................................... 53
Nevirapine............................... 58 Estradiol/Ferrous Fumarate
............................................... 87 Ofev........................................100
Nevirapine ER......................... 59
Norgestimate/Ethinyl Estradiol Ofloxacin..................................41
Nexavar....................................53
............................................... 87
Ogestrel................................... 87
Nexium.....................................80
Norlyroc................................... 88
Olanzapine.............................. 56
Niacin ER.................................70
Normosol-M in D5W............... 76
Olanzapine ODT......................56
Niacor...................................... 70
Normosol-R............................. 76
Olmesartan Medoxomil.......... 65
Nicardipine HCl.......................67
Normosol-R in D5W................ 76
Olmesartan Medoxomil/
Nicotrol.................................... 36
Northera...................................65 Amlodipine/
Nicotrol NS.............................. 36 Hydrochlorothiazide............. 69
Nortrel 0.5/35..........................87
Nifedipine ER.......................... 67 Olmesartan Medoxomil/
Nortrel 1/35............................. 87
Nikki......................................... 87 Hydrochlorothiazide............. 69
Nortrel 7/7/7........................... 87
Nilandron................................. 50 Olopatadine HCl..................... 95
Nortriptyline HCl......................46
Nilutamide............................... 50 Omega-3-Acid Ethyl Esters.....70
Norvir....................................... 60
Nimodipine.............................. 67 Omeprazole.............................80
Novarel.....................................84
Ninlaro..................................... 51 Ondansetron HCl.................... 47
Noxafil...................................... 48
Nipent...................................... 50 Ondansetron ODT.................. 47
Nucala....................................100
Nitro-Bid...................................71 Onfi...........................................42
Nucynta ER..............................33
Nitrofurantoin.......................... 37 Onglyza....................................62
Nuedexta................................. 73
Nitrofurantoin Macrocrystals Opdivo..................................... 53
Nulojix...................................... 90
............................................... 37 Opsumit................................... 99
Nuplazid...................................56
Nitrofurantoin Monohydrate...37 Orencia.................................... 90
Nutrilipid.................................. 76
Nitroglycerin............................ 71 Orencia Clickject.....................90
Nutropin AQ............................ 84
Nitroglycerin Lingual.............. 71 Orenitram.................................99
Tracked
25

25 25

Orfadin..................................... 81 Pazeo....................................... 95 Physiolyte................................ 76

Orkambi................................... 99 Pediarix.................................... 92 Physiosol Irrigation................. 76
Orphenadrine Citrate............100 Pedvax HIB.............................. 92 Picato....................................... 74
Orsythia....................................87 PEG 3350/Electrolytes........... 79 Pilocarpine HCl.................73, 96
Oseltamivir Phosphate........... 60 PEG-3350/Electrolytes........... 79 Pimozide..................................55
Osphena.................................. 88 PEG-3350/NaCl/Na Pimtrea.....................................87
Otezla.......................................92 Bicarbonate/KCl...................79 Pindolol....................................66
Oxacillin Sodium..................... 39 Peganone................................ 43 Pioglitazone HCl..................... 62
Oxaliplatin................................51 Pegasys................................... 58 Pioglitazone HCl/Glimepiride
Oxandrolone..................... 84, 85 Pegasys ProClick.................... 58 ............................................... 62
Oxcarbazepine........................ 43 Penicillin G Potassium............39 Pioglitazone HCl/Metformin
HCl......................................... 62
Oxiconazole Nitrate................ 48 Penicillin G Procaine.............. 39
Piperacillin/Tazobactam........ 39
Oxistat......................................48 Penicillin G Sodium................ 39
Pirmella 1/35...........................87
Oxsoralen Ultra....................... 74 Penicillin V Potassium............ 39
Piroxicam.................................33
Oxybutynin Chloride............... 81 Pentam 300............................. 54
Plasma-Lyte A......................... 76
Oxybutynin Chloride ER......... 81 Pentasa.................................... 93
Plasma-Lyte-148......................76
Oxycodone HCl.......................35 Pentoxifylline ER..................... 69
Oxycodone/Acetaminophen Perforomist..............................98 Plenamine................................76
............................................... 35 Perindopril Erbumine..............65 Podofilox..................................74
Oxycodone/Aspirin.................35 Periogard................................. 73 Polyethylene Glycol 3350
Powder.................................. 79
Oxycodone/Ibuprofen............ 35 Perjeta......................................53
Polymyxin B Sulfate................37
P Permethrin...............................54
Polymyxin B Sulfate/
Pacerone................................. 65 Perphenazine.......................... 46
Trimethoprim Sulfate........... 95
Paclitaxel................................. 51 Phenadoz.................................97
Pomalyst.................................. 50
Paliperidone ER...................... 56 Phenelzine Sulfate.................. 45
Portia-28.................................. 87
Palonosetron HCl....................47 Phenobarbital..........................42
Potassium Chloride.......... 76, 77
Pamidronate Disodium...........94 Phenoxybenzamine HCl.........65
Potassium Chloride CR.......... 77
Panretin................................... 53 Phenytek..................................44
Potassium Chloride ER.......... 77
Pantoprazole Sodium............. 80 Phenytoin.................................44
Potassium Chloride/Dextrose
Paricalcitol............................... 94 Phenytoin Sodium.................. 44 ............................................... 77
Paromomycin Sulfate............. 36 Phenytoin Sodium Extended Potassium Chloride/Dextrose/
Paroxetine HCl........................ 45 ............................................... 44 Lactated Ringers.................. 77
Paser........................................ 49 Phoslyra................................... 78 Potassium Chloride/Dextrose/
Sodium Chloride...................77
Paxil..........................................45 Phospholine Iodide.................96
Tracked
26

26 26

Potassium Chloride/Sodium Privigen.................................... 91 ProQuad.................................. 92

Chloride.................................77 ProAir HFA...............................98 Prosol.......................................77
Potassium Citrate ER..............77 ProAir RespiClick....................98 Protriptyline HCl......................46
Pradaxa....................................64 Probenecid.............................. 48 Prudoxin.................................. 75
Praluent................................... 70 Probenecid/Colchicine.......... 48 Pulmozyme............................100
Pramipexole Dihydrochloride Procainamide HCl...................65 Purixan.....................................50
............................................... 54
Procalamine............................ 77 Pyrazinamide...........................49
Prasugrel................................. 64
Prochlorperazine.....................46 Pyridostigmine Bromide.........49
Pravastatin Sodium.................70
Prochlorperazine Edisylate.... 46 Pyridostigmine Bromide ER...49
Prazosin HCl............................65
Prochlorperazine Maleate...... 46 Q
Pred Mild................................. 96
Procrit...................................... 64 Quadracel................................ 92
Pred-G......................................95
Procto-Med HC....................... 93 Quasense.................................87
Pred-G S.O.P........................... 95
Procto-Pak............................... 93 Quetiapine Fumarate.............. 56
Prednicarbate..........................83
Proctosol HC........................... 93 Quetiapine Fumarate ER........56
Prednisolone........................... 83
Proctozone-HC........................93 Quinapril HCl...........................65
Prednisolone Acetate............. 96
Procysbi...................................81 Quinapril/Hydrochlorothiazide
Prednisolone Sodium ............................................... 69
Progesterone...........................88
Phosphate.......................83, 96
Proglycem............................... 62 Quinidine Gluconate...............66
Prednisone.............................. 83
Prograf..................................... 90 Quinidine Gluconate CR........ 66
Prednisone Intensol................83
Prolastin-C............................... 81 Quinidine Sulfate.................... 66
Pregnyl w/Diluent Benzyl
Quinine Sulfate........................54
Alcohol/NaCl........................ 84 Prolensa...................................96
Premarin.................................. 87 Proleukin..................................51 R
Rabavert.................................. 92
Premasol..................................77 Prolia........................................ 94
Rabeprazole Sodium..............80
Premphase.............................. 87 Promacta................................. 64
Raloxifene HCl........................ 88
Prempro...................................87 Promethazine HCl...................97
Ramipril................................... 65
Prevalite................................... 70 Promethegan...........................97
Ranexa.....................................69
Previfem...................................87 Propafenone HCl.................... 65
Ranitidine HCl......................... 79
Prezcobix.................................60 Propafenone HCl ER.............. 66
Rapaflo.................................... 81
Prezista.................................... 60 Proparacaine HCl....................95
Rapamune............................... 91
Priftin........................................49 Propranolol HCl...................... 66
Rasagiline Mesylate................55
Prilosec.................................... 80 Propranolol HCl ER................ 66
Ravicti...................................... 81
Primaquine Phosphate...........54 Propranolol/
Hydrochlorothiazide............. 69 Rayaldee..................................94
Primidone................................ 42
Propylthiouracil....................... 89 Rebif.........................................73
Pristiq....................................... 45
Tracked
27

27 27

Rebif Rebidose....................... 73 Riluzole.................................... 73 Sandimmune........................... 91

Rebif Rebidose Titration Pack Rimantadine HCl.....................60 Sandostatin LAR Depot..........89
............................................... 73 Ringers Injection..................... 77 Santyl....................................... 75
Rebif Titration Pack................ 73 Ringers Irrigation.................... 77 Saphris.....................................56
Reclipsen.................................87 Riomet..................................... 62 Savella......................................73
Recombivax HB...................... 92 Risedronate Sodium...............94 Savella Titration Pack............. 73
Regranex................................. 75 Risperdal Consta.................... 56 Scopolamine........................... 46
Relenza Diskhaler................... 60 Risperidone............................. 56 Selegiline HCl..........................55
Relistor.....................................79 Risperidone ODT.................... 56 Selenium Sulfide.....................75
Remicade................................ 91 Ritonavir...................................60 Selzentry............................59, 60
Remodulin............................... 99 Rituxan.....................................53 Sensipar...................................94
Renagel................................... 78 Rivastigmine Tartrate............. 44 Serevent Diskus...................... 98
Renvela.................................... 78 Rivastigmine Transdermal Seroquel XR............................ 57
Repaglinide............................. 62 System...................................44 Serostim...................................79
Repaglinide/Metformin HCl...62 Rizatriptan Benzoate.............. 49 Sertraline HCl.......................... 45
Repatha................................... 70 Rizatriptan Benzoate ODT..... 49 Setlakin.................................... 87
Repatha Pushtronex System Ropinirole HCl.........................54 Sevelamer Carbonate.............78
............................................... 70 Rosuvastatin Calcium.............70
Sharobel.................................. 88
Repatha SureClick..................70 Rotarix......................................92
Shingrix....................................92
Rescriptor................................ 59 RotaTeq................................... 92
Signifor.................................... 89
Restasis................................... 95 Rowasa.................................... 93
Sildenafil.................................. 99
Retrovir IV Infusion................. 59 Roweepra................................ 42
Silver Sulfadiazine...................41
Revatio.....................................99 Roweepra XR.......................... 42
Simbrinza.................................96
Revlimid................................... 50 Rozerem................................ 101
Simponi....................................91
Rexulti...................................... 56 Rubraca................................... 52
Simponi Aria............................91
Reyataz.................................... 60 Ruconest................................. 90
Simulect...................................92
Rhopressa............................... 95 Rydapt..................................... 53
Simvastatin.............................. 70
Ribasphere.............................. 58 S Sirolimus..................................91
Ribavirin...................................58 Sabril........................................42
Sirturo...................................... 49
Ridaura.................................... 92 Saizen...................................... 84
Sodium Chloride..................... 77
Rifabutin.................................. 49 Saizenprep Reconstitution Kit
Sodium Chloride 0.9%...........77
Rifampin.................................. 49 ............................................... 84
Sodium Chloride 0.45%......... 77
Rifater...................................... 49 Samsca.................................... 78
Sodium Fluoride......................77
Rilutek......................................73 Sancuso...................................47
Sodium Lactate.......................77
Tracked
28

28 28

Sodium Phenylbutyrate.......... 81 Stiolto Respimat................... 100 SymlinPen 60.......................... 62

Sodium Polystyrene Sulfonate Stivarga....................................53 Synagis.................................... 92
............................................... 78 Strensiq....................................81 Synarel..................................... 89
Sodium Sulfacetamide........... 41 Streptomycin Sulfate.............. 36 Synercid...................................37
Soliqua 100/33....................... 62 Stribild......................................58 Synjardy................................... 62
Soltamox..................................50 Suboxone................................ 36 Synjardy XR............................. 62
Solu-Cortef...............................83 Sucraid.....................................81 Synribo.....................................51
Solu-Medrol............................. 83 Sucralfate................................ 80 Synthroid................................. 89
Somatuline Depot................... 89 Sulfacetamide Sodium........... 41 Syprine.....................................78
Somavert................................. 89 Sulfacetamide Sodium/ T
Soriatane................................. 75 Prednisolone Sodium Tabloid.....................................50
Sotalol HCl...............................66 Phosphate............................. 95
Tacrolimus........................ 75, 91
Sovaldi..................................... 58 Sulfadiazine............................. 41
Tafinlar..................................... 53
Spiriva HandiHaler.................. 98 Sulfamethoxazole/
Tagrisso................................... 53
Trimethoprim........................ 41
Spiriva Respimat.....................98 Tamiflu..................................... 60
Sulfamethoxazole/
Spironolactone........................69
Trimethoprim DS.................. 41 Tamoxifen Citrate................... 50
Spironolactone/
Sulfamylon...............................37 Tamsulosin HCl.......................81
Hydrochlorothiazide............. 69
Sulfasalazine........................... 93 Tarceva.................................... 53
Sporanox................................. 48
Sulindac...................................33 Targretin.................................. 53
Sprintec 28.............................. 87
Sumatriptan.............................49 Tarina Fe 1/20.........................87
Spritam.................................... 42
Sumatriptan Succinate........... 49 Tasigna.................................... 53
Sprycel.....................................53
Sumatriptan Succinate Refill Taxotere...................................51
SPS.......................................... 78
............................................... 49 Tazarotene...............................75
Sronyx...................................... 87
Suprax......................................38 Tazicef..................................... 38
SSD.......................................... 41
Suprep Bowel Prep Kit........... 79 Tazorac.................................... 75
Stalevo 100..............................55
Sustiva..................................... 59 Taztia XT.................................. 67
Stalevo 125..............................55
Sutent.......................................53 Tecentriq................................. 53
Stalevo 150..............................55
Syeda....................................... 87 Tecfidera..................................73
Stalevo 200..............................55
Sylatron....................................58 Tecfidera Starter Pack............73
Stalevo 50................................55
Sylvant..................................... 92 Telmisartan..............................65
Stalevo 75................................55
Symbicort.............................. 100 Telmisartan/Amlodipine.........69
Stavudine.................................59
Symfi........................................ 59 Telmisartan/
Stelara......................................75
Symfi Lo...................................59 Hydrochlorothiazide............. 69
Sterile Water Irrigation............94
SymlinPen 120........................ 62 Temazepam.......................... 100
Tracked
29

29 29

Tenivac.................................... 92 Tobramycin/Dexamethasone Tri-Legest Fe............................87

Tenofovir Disoproxil Fumarate ............................................... 95 Tri-Lo-Estarylla.........................87
............................................... 59 Tobrex......................................36 Tri-Lo-Sprintec.........................87
Terazosin HCl..........................81 Tolcapone................................54 Tri-Mili...................................... 87
Terbinafine HCl....................... 48 Topiramate.............................. 43 Tri-Previfem............................. 87
Terbutaline Sulfate..................98 Toposar....................................52 Tri-Sprintec.............................. 87
Terconazole.............................48 Topotecan HCl........................ 52 Tri-Vylibra.................................87
Testosterone Cypionate......... 85 Torisel...................................... 91 Triamcinolone Acetonide...... 83,
Testosterone Enanthate......... 85 Torsemide............................... 69 84, 98
Tetanus/Diphtheria Toxoids- Toujeo Max Solostar...............63 Triamcinolone Acetonide
Adsorbed Adult.................... 92 Toujeo SoloStar...................... 63 Dental Paste..........................74
Tetrabenazine......................... 73 TPN Electrolytes..................... 77 Triamterene/
Tetracycline HCl......................41 Tracleer....................................99 Hydrochlorothiazide............. 69
Thalomid..................................50 Tradjenta................................. 62 Triderm.................................... 84
Theophylline............................99 Tramadol HCl.......................... 35 Trientine HCl........................... 78
Theophylline CR..................... 99 Tramadol HCl ER.................... 33 Trifluoperazine HCl.................55
Theophylline ER......................99 Tramadol HCl/Acetaminophen Trifluridine............................... 58
Thioridazine HCl..................... 55 ............................................... 35 Trihexyphenidyl HCl............... 54
Thiotepa...................................51 Trandolapril............................. 65 TriLyte...................................... 80
Thiothixene..............................55 Tranexamic Acid..................... 64 Trimethoprim...........................37
Thymoglobulin........................ 91 Transderm-Scop..................... 46 Trimipramine Maleate............ 46
Tiagabine HCl......................... 42 Tranylcypromine Sulfate........ 45 Trinessa................................... 87
Tigecycline.............................. 37 Travasol................................... 77 Trintellix................................... 45
Timolol Maleate................ 66, 96 Travatan Z................................96 Trisenox................................... 51
Timolol Maleate Ophthalmic Trazodone HCl........................ 45 Triumeq................................... 58
Gel Forming.......................... 96 Treanda................................... 50 Trivora-28.................................87
Tinidazole................................ 37 Trecator................................... 49 Trizivir.......................................59
Tivicay...................................... 58 Trelegy Ellipta....................... 100 Trophamine............................. 77
Tizanidine HCl.......................100 Trelstar Mixject........................89 Trulicity.................................... 62
TOBI......................................... 99 Tresiba FlexTouch.................. 63 Trumenba................................ 92
TOBI Podhaler.........................99 Tretinoin............................ 53, 75 Truvada....................................59
Tobradex................................. 95 Tretinoin Microsphere............ 75 Twinrix......................................92
Tobradex ST............................95 Trexall...................................... 91 Tybost...................................... 58
Tobramycin............................. 99 Trezix....................................... 35 Tygacil..................................... 37
Tobramycin Sulfate.................36 Tykerb...................................... 53
Tracked
30

30 30

Tymlos..................................... 94 Venclexta Starting Pack......... 53 Vraylar...................................... 57

Typhim Vi.................................92 Venlafaxine HCl.......................45 Vyfemla.................................... 88
Tysabri..................................... 73 Venlafaxine HCl ER.................46 Vylibra...................................... 88
U Ventavis................................... 99 Vyvanse....................................72
Uceris.......................................93 Verapamil HCl......................... 67 Vyxeos..................................... 52
Uloric........................................48 Verapamil HCl ER................... 67 Vyzulta..................................... 96
Unithroid.................................. 89 Verapamil HCl SR................... 67 W
Ursodiol................................... 79 Versacloz................................. 57 Warfarin Sodium..................... 64
V Verzenio...................................52 Welchol.................................... 71
Valacyclovir HCl...................... 58 Vesicare................................... 81 Wymzya Fe.............................. 88
Valchlor....................................50 Vfend........................................48 X
Valcyte..................................... 57 Vibramycin...............................41 Xalkori...................................... 53
Valganciclovir.......................... 57 Victoza..................................... 62 Xarelto......................................64
Valganciclovir Hydrochlorde Vidaza...................................... 64 Xarelto Starter Pack................64
............................................... 57 Videx EC.................................. 59 Xatmep.....................................91
Valproate Sodium................... 42 Videx Pediatric........................ 59 Xeljanz..................................... 91
Valproic Acid........................... 43 Vienva...................................... 88 Xeljanz XR............................... 91
Valsartan..................................65 Vigabatrin................................ 43 Xenazine.................................. 73
Valsartan/Hydrochlorothiazide Viibryd......................................46 Xgeva....................................... 94
............................................... 69
Viibryd Starter Pack................ 46 Xifaxan..................................... 79
Vancocin HCl.......................... 37
Vimpat......................................44 Xiidra........................................ 95
Vancomycin HCl..................... 37
Vinblastine Sulfate.................. 52 Xolair........................................ 92
Vandazole................................37
Vincasar PFS........................... 52 Xtampza ER.............................33
VAQTA..................................... 92
Vincristine Sulfate................... 52 Xtandi.......................................50
Varivax..................................... 92
Vinorelbine Tartrate................ 52 Xulane...................................... 88
Varizig...................................... 91
Viracept....................................60 Xyrem.....................................101
Vascepa................................... 71
Viramune................................. 59 Y
Vectibix.................................... 53
Viread.......................................59 Yervoy...................................... 53
Velcade.................................... 51
Vivitrol...................................... 35 YF-Vax...................................... 92
Velivet...................................... 88
Voriconazole............................48 Yondelis................................... 50
Velphoro.................................. 78
Vosevi...................................... 58 Yuvafem...................................88
Veltassa................................... 78
Votrient.................................... 53 Z
Vemlidy.................................... 58
VP-PNV-DHA............................78 Zafirlukast................................98
Venclexta................................. 53
VPRIV.......................................81 Zaleplon.................................100
Tracked
31

31 31

Zaltrap......................................52 Ziagen...................................... 59 Zorbtive....................................79

Zanosar....................................50 Zidovudine...............................59 Zortress....................................91
Zarah........................................88 Zileuton ER..............................98 Zostavax.................................. 92
Zarxio....................................... 64 Zinecard...................................52 Zovia 1/35E............................. 88
Zavesca................................... 81 Zioptan.....................................97 Zyclara Pump.......................... 75
Zejula....................................... 52 Ziprasidone HCl...................... 57 Zydelig..................................... 53
Zelapar.....................................55 Zirgan.......................................57 Zyflo......................................... 98
Zelboraf................................... 53 Zoledronic Acid.......................94 Zyflo CR...................................98
Zemaira....................................81 Zolinza..................................... 52 Zykadia.................................... 53
Zenchent................................. 88 Zolpidem Tartrate................. 100 Zyprexa Relprevv.................... 57
Zenpep.................................... 81 Zomacton................................ 84 Zytiga....................................... 50
Zerbaxa....................................38 Zometa.....................................94
Zerit.......................................... 59 Zonisamide..............................42
31 32
32 tRACK

Covered drugs by medical condition 1

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 12-31.
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. Your plan has 1 tier named
“Covered Drugs.” All covered drugs are in this Tier. 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
102-125.
tRACK

Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Analgesics Etodolac (200mg
Etodolac

Analgesics Capsule, 300mg

Capsule, 400mg Tablet
Butalbital/ 1
Butalbital/Acetaminophen/Caffeine

Immediate-Release,
Acetaminophen/
500mg Tablet
Caffeine 1 QL
Immediate-Release)
(50mg-325mg-40mg
Etodolac ER (Tablet
Etodolac ER

Tablet)
Extended-Release 24 1
Butalbital/Aspirin/
Butalbital/Aspirin/Caffeine

Hour)
Caffeine
1 QL Flector (Patch)
Flector

1 PA, QL
(50mg-325mg-40mg
Capsule) Flurbiprofen (Tablet)
Flurbiprofen

1
Nonsteroidal Anti-inflammatory Drugs Ibu (Tablet)
Ibu

1
Celecoxib (Capsule) 1 QL
Celecoxib

Ibuprofen (100mg/5ml
Ibuprofen

Diclofenac Potassium Suspension, 400mg

Diclofenac Potassium

1 1
(Tablet) Tablet, 600mg Tablet,
Diclofenac Sodium
Diclofenac Sodium

800mg Tablet)
1 PA
(1% Gel) Indomethacin (25mg
Indomethacin

Diclofenac Sodium DR
Diclofenac Sodium DR

Capsule, 50mg 1
(Tablet Delayed- 1 Capsule)
Release) Ketorolac
Ketorolac Tromethamine

Diclofenac Sodium ER
Diclofenac Sodium ER

Tromethamine (15mg/
(Tablet Extended- 1 ml Injection, 30mg/ml 1
Release 24 Hour) Injection, 60mg/2ml
Injection)
Diflunisal (Tablet) 1
Diflunisal

Meloxicam (Tablet) 1
Meloxicam

Nabumetone (Tablet) 1
Nabumetone

You can find information on what the abbreviations in this table mean on pages 6 - 7.
32 33
Last updated November 1, 2018
tRACK
33
2
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Naproxen (125mg/5ml Hysingla ER (Tablet
Naproxen Hysingla ER

Suspension, 250mg Extended-Release 24

Tablet Immediate-
Release, 375mg Tablet
Immediate-Release,
1 QL, MED
Hour Abuse-
1 Deterrent)
Levorphanol Tartrate
Levorphanol Tartrate

500mg Tablet 1 QL, MED

(Tablet)
Immediate-Release)
Methadone HCl (10mg
Methadone HCl

Naproxen DR (Tablet
Naproxen DR

Tablet, 5mg Tablet,

Delayed-Release) 1
10mg/5ml Oral 1 QL, MED
(Generic EC-Naprosyn)
Solution, 5mg/5ml Oral
Piroxicam (Capsule) 1
Piroxicam

Solution)
Sulindac (Tablet) 1
Sulindac

Methadone HCl
Methadone HCl

1
Opioid Analgesics, Long-acting (10mg/ml Injection)
Morphine Sulfate ER
Morphine Sulfate ER

Embeda (Capsule
Embeda

1 QL, MED (100mg Tablet

Extended-Release)
Fentanyl (100mcg/hr
Fentanyl
Extended-Release,
15mg Tablet Extended-
Patch 72 Hour,
Release, 200mg Tablet
12mcg/hr Patch 72 1 QL, MED
Extended-Release,
Hour, 25mcg/hr Patch
1 QL, MED 30mg Tablet Extended-
72 Hour, 50mcg/hr
Release, 60mg Tablet
Patch 72 Hour,
Extended-Release)
75mcg/hr Patch 72
(Generic MS Contin)
Hour)
Nucynta ER (Tablet
Nucynta ER

Hydromorphone HCl
Hydromorphone HCl ER

ER (12mg Tablet Extended-Release 12 1 QL, MED

Extended-Release 24 Hour)
Hour Abuse-Deterrent, 1 QL, MED Tramadol HCl ER
Tramadol HCl ER

8mg Tablet Extended- (100mg Tablet

Release 24 Hour Extended-Release 24
Abuse-Deterrent) Hour, 200mg Tablet
1 QL, MED
Hydromorphone HCl
Hydromorphone HCl ER

Extended-Release 24
ER (16mg Tablet Hour, 300mg Tablet
1 QL, MED Extended-Release 24
Extended-Release 24
Hour Abuse-Deterrent) Hour)
Xtampza ER (Capsule
Xtampza ER

Hydromorphone HCl
Hydromorphone HCl ER

ER (32mg Tablet Extended-Release 12

1 QL, MED 1 QL, MED
Extended-Release 24 Hour Abuse-
Hour Abuse-Deterrent) Deterrent)

Bold type = Brand name drug Plain type = Generic drug

33 34
34 tRACK
Last updated November 1, 2018
3
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Opioid Analgesics, Short-acting Hydrocodone/
Hydrocodone/Acetaminophen

Abstral (Tablet
Abstral

Acetaminophen
1 PA, QL (10mg-325mg Tablet,
Sublingual)
2.5mg-325mg Tablet,
Acetaminophen/ 1 QL, MED
Acetaminophen/Codeine

5mg-325mg Tablet,
Codeine 7.5mg-325mg Tablet,
(120mg-12mg/5ml 7.5mg-325mg/15ml
Oral Solution, 1 QL, MED Oral Solution)
300mg-15mg Tablet,
Hydrocodone/
Hydrocodone/Ibuprofen

300mg-30mg Tablet,
300mg-60mg Tablet) Ibuprofen 1 QL, MED
(7.5mg-200mg Tablet)
Butorphanol Tartrate
Butorphanol Tartrate

Hydromorphone HCl
Hydromorphone HCl

(10mg/ml Nasal 1 QL, MED

Solution) (10mg/ml Injection, 1
50mg/5ml Injection)
Butorphanol Tartrate
Butorphanol Tartrate

Hydromorphone HCl
Hydromorphone HCl

(1mg/ml Injection, 1 1 QL, MED

2mg/ml Injection) (1mg/ml Liquid)
Hydromorphone HCl
Hydromorphone HCl

Codeine Sulfate
Codeine Sulfate

1 QL, MED (2mg Tablet

(Tablet)
Immediate-Release,
Duramorph (Injection) 1
Duramorph

1 QL, MED
4mg Tablet Immediate-
Endocet (Tablet) 1 QL, MED Release, 8mg Tablet
Endocet

Fentanyl Citrate Oral

Fentanyl Citrate Oral Transmucosal

Immediate-Release)
Transmucosal Hydromorphone HCl
Hydromorphone HCl

1
(1200mcg Lozenge on (2mg/ml Injection)
a Handle, 1600mcg Lorcet (Tablet)
Lorcet

1 QL, MED
1 PA, QL
Lozenge on a Handle,
Lorcet HD (Tablet) 1 QL, MED
Lorcet HD

600mcg Lozenge on a
Handle, 800mcg Lorcet Plus (Tablet) 1 QL, MED
Lorcet Plus

Lozenge on a Handle) Morphine Sulfate

Morphine Sulfate

Fentanyl Citrate Oral (100mg/5ml Oral

Fentanyl Citrate Oral Transmucosal

Transmucosal Solution, 10mg/5ml 1 QL, MED

(200mcg Lozenge on a 1 PA, QL Oral Solution, 20mg/
Handle, 400mcg 5ml Oral Solution)
Lozenge on a Handle) Morphine Sulfate
Morphine Sulfate

(10mg/ml Injection,
1
4mg/ml Injection,
8mg/ml Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
34 35
Last updated November 1, 2018 tRACK
35
4
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Morphine Sulfate Trezix (Capsule) 1 QL, MED
Morphine Sulfate
Trezix

(15mg Tablet Anesthetics

Immediate-Release, 1 QL, MED Local Anesthetics
30mg Tablet
Lidocaine (5%
Lidocaine

Immediate-Release) 1
Ointment)
Morphine Sulfate
Morphine Sulfate

Lidocaine (5% Patch) 1 PA, QL

Lidocaine

(2mg/ml Injection, 1
Lidocaine HCl (0.5%
Lidocaine HCl

5mg/ml Injection)
Injection, 1% Injection, 1 B/D, PA
Nalbuphine HCl
Nalbuphine HCl

1 2% Injection)
(Injection)
Lidocaine HCl (4%
Lidocaine HCl

Oxycodone HCl 1
Oxycodone HCl

External Solution)
(100mg/5ml 1 QL, MED
Lidocaine HCl (Gel) 1
Lidocaine HCl

Concentrate)
Lidocaine Viscous
Lidocaine Viscous

Oxycodone HCl (10mg

Oxycodone HCl

1
Tablet Immediate- (Solution)
Release, 15mg Tablet Lidocaine/Prilocaine
Lidocaine/Prilocaine

Immediate-Release, 1
(Cream)
20mg Tablet Anti-Addiction/Substance Abuse Treatment
1 QL, MED
Immediate-Release, Agents
30mg Tablet
Immediate-Release, Alcohol Deterrents/Anti-craving
5mg Tablet Immediate- Acamprosate Calcium
Acamprosate Calcium DR

Release) DR (Tablet Delayed- 1

Oxycodone HCl (5mg/
Oxycodone HCl

Release)
1 QL, MED
5ml Oral Solution) Disulfiram (Tablet) 1
Disulfiram

Oxycodone/ Naltrexone HCl

Oxycodone/Acetaminophen Naltrexone HCl

1
Acetaminophen 1 QL, MED (Tablet)
(Tablet) Vivitrol (Injection)
Vivitrol

1
Oxycodone/Aspirin
Oxycodone/Aspirin

1 QL, MED Opioid Dependence Treatments

(Tablet)
Buprenorphine HCl
Buprenorphine HCl

Oxycodone/Ibuprofen
Oxycodone/Ibuprofen

1
1 QL, MED (0.3mg/ml Injection)
(Tablet)
Buprenorphine HCl
Buprenorphine HCl

Tramadol HCl (Tablet

Tramadol HCl

1 QL, MED (2mg Tablet

Immediate-Release) 1 QL
Sublingual, 8mg Tablet
Tramadol HCl/ Sublingual)
Tramadol HCl/Acetaminophen

Acetaminophen 1 QL, MED

(Tablet)

Bold type = Brand name drug Plain type = Generic drug

35 36
36 tRACK
Last updated November 1, 2018
5
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Buprenorphine HCl/ Gentamicin Sulfate/
Buprenorphine HCl/Naloxone HCl Gentamicin Sulfate/0.9% Sodium Chloride

Naloxone HCl (Tablet 1 QL 0.9% Sodium Chloride 1

Sublingual) (Injection)
1 QL Isotonic Gentamicin
Isotonic Gentamicin

Suboxone (Film)
Suboxone

1
Opioid Reversal Agents (Injection)
Neomycin Sulfate
Neomycin Sulfate

Naloxone HCl 1
Naloxone HCl

1 (Tablet)
(Injection)
Paromomycin Sulfate
Paromomycin Sulfate

Narcan (Liquid) 1 1
Narcan

(Capsule)
Smoking Cessation Agents
Streptomycin Sulfate
Streptomycin Sulfate

Bupropion HCl SR
Bupropion HCl SR

1
(Injection)
(150mg Tablet
Tobramycin Sulfate
Tobramycin Sulfate

Extended-Release 12 1
(0.3% Ophthalmic 1
Hour Smoking-
Solution)
Deterrent)
Tobramycin Sulfate
Tobramycin Sulfate

Chantix (Tablet) 1
Chantix

(10mg/ml Injection, 1
Chantix Continuing
Chantix Continuing Month Pak

1 80mg/2ml Injection)
Month Pak (Tablet) Tobrex (0.3%
Tobrex

Chantix Starting
Chantix Starting Month Pak

1
1 Ophthalmic Ointment)
Month Pak (Tablet) Antibacterials, Other
Nicotrol (Inhaler) 1
Nicotrol

BACiiM (Injection) 1
BACiiM

Nicotrol NS (Nasal
Nicotrol NS

Bacitracin (50000unit
Bacitracin

1 1
Solution) Injection)
Antibacterials Bacitracin (500unit/gm
Bacitracin

1
Aminoglycosides Ophthalmic Ointment)
Amikacin Sulfate Bactroban Nasal
Amikacin Sulfate Bactroban Nasal

1 1 PA
(Injection) (Ointment)
Gentak (Ophthalmic Chloramphenicol
Gentak
Chloramphenicol Sodium Succinate

1
Ointment) Sodium Succinate 1
Gentamicin Sulfate
Gentamicin Sulfate

(Injection)
(0.1% Cream, 0.1% Clindamycin HCl
Clindamycin HCl

1
Ointment, 0.3% (Capsule Immediate- 1
Ophthalmic Solution) Release)
Gentamicin Sulfate Clindamycin Palmitate
Gentamicin Sulfate
Clindamycin Palmitate HCl

1 1
(40mg/ml Injection) HCl (Oral Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
36 37
Last updated November 1, 2018 tRACK
37
6
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Clindamycin Mupirocin (2% Cream) 1
Clindamycin Phosphate
Mupirocin

1
Phosphate (2% Cream) Mupirocin (2%
Mupirocin

Clindamycin 1
Ointment)
Clindamycin Phosphate

Phosphate (300mg/ Neomycin/Polymyxin B

Neomycin/Polymyxin B Sulfates

2ml Injection, 600mg/ 1 Sulfates (Irrigation 1

4ml Injection, 900mg/ Solution)
6ml Injection)
Nitrofurantoin
Nitrofurantoin

Clindamycin
Clindamycin Phosphate in D5W

1
(Suspension)
Phosphate in D5W 1
Nitrofurantoin
Nitrofurantoin Macrocrystals

(Injection)
Macrocrystals (100mg
Colistimethate Sodium
Colistimethate Sodium

1 Capsule, 50mg 1
(Injection) Capsule) (Generic
Cubicin (Injection) 1 Macrodantin)
Cubicin

1 PA Nitrofurantoin
Nitrofurantoin Monohydrate

Dalvance (Injection)
Dalvance

Daptomycin (Injection) 1 Monohydrate (100mg

1
Daptomycin

Capsule) (Generic
Lincomycin HCl
Lincomycin HCl

1 Macrobid)
(Injection)
Polymyxin B Sulfate
Polymyxin B Sulfate

Linezolid (100mg/5ml
Linezolid

1
1 PA (Injection)
Suspension)
Sulfamylon (85mg/
Sulfamylon

Linezolid (600mg
Linezolid

1
1 PA, QL gm Cream)
Tablet)
Synercid (Injection) 1
Synercid

Linezolid (600mg/
Linezolid

1 PA Tigecycline (Injection)
Tigecycline

1
300ml Injection)
Methenamine Tinidazole (Tablet) 1
Tinidazole
Methenamine Hippurate

1
Hippurate (Tablet) Trimethoprim (Tablet)
Trimethoprim

1
Metronidazole (0.75%
Metronidazole

Tygacil (Injection) 1
Tygacil

Cream, 0.75% Gel, 1% 1

Vancocin HCl
Vancocin HCl

Gel, 0.75% Lotion) 1

(Capsule)
Metronidazole (250mg
Metronidazole

Vancomycin HCl
Vancomycin HCl

Tablet Immediate-
1 (10gm Injection, 1gm
Release, 500mg Tablet
Immediate-Release) Injection, 500mg
1
Injection, 125mg
Metronidazole in NaCl
Metronidazole in NaCl 0.79%

1 Capsule, 250mg
0.79% (Injection)
Capsule)
Metronidazole Vaginal
Metronidazole Vaginal

1 Vandazole (Gel) 1
Vandazole

(Gel)
Beta-lactam, Cephalosporins

Bold type = Brand name drug Plain type = Generic drug

37 38
38 tRACK
Last updated November 1, 2018
7
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Cefaclor (250mg Ceftriaxone Sodium
Cefaclor Ceftriaxone Sodium

Capsule Immediate- (10gm Injection, 1gm

Release, 500mg 1 Injection, 250mg
1
Capsule Immediate- Injection, 2gm
Release) Injection, 500mg
Cefadroxil (250mg/5ml
Cefadroxil

Injection)
Suspension, 500mg/ Cefuroxime Axetil
Cefuroxime Axetil

1 1
5ml Suspension, (Tablet)
500mg Capsule) Cefuroxime Sodium
Cefuroxime Sodium

Cefazolin Sodium (1.5gm Injection,

Cefazolin Sodium

1 1
(Injection) 7.5gm Injection,
Cefdinir (125mg/5ml
Cefdinir

750mg Injection)
Suspension, 250mg/ Cephalexin (125mg/
Cephalexin

1
5ml Suspension, 5ml Suspension,
300mg Capsule) 250mg/5ml
Cefepime (Injection)
Cefepime

1 Suspension, 250mg 1
Capsule, 500mg
Cefixime (Suspension) 1
Cefixime

Capsule, 750mg
Cefotaxime Sodium Capsule)
Cefotaxime Sodium

1
(Injection) Suprax (100mg Tablet
Suprax

Cefotetan (Injection) 1 Chewable, 200mg 1

Cefotetan

Cefoxitin Sodium
Cefoxitin Sodium

Tablet Chewable)
(10gm Injection, 1gm Suprax (400mg
Suprax

1
Injection, 2gm Capsule, 500mg/5ml 1
Injection) Suspension)
Cefpodoxime Proxetil Tazicef (Injection) 1
Cefpodoxime Proxetil
Tazicef

(100mg Tablet, 200mg

Zerbaxa (Injection) 1 PA
Zerbaxa

Tablet, 100mg/5ml 1
Suspension, 50mg/5ml Beta-lactam, Other
Suspension) Azactam (Injection)
Azactam

1
Cefprozil (125mg/5ml
Cefprozil

Aztreonam (Injection) 1
Aztreonam

Suspension, 250mg/
Doripenem (Injection) 1
Doripenem

5ml Suspension, 1
250mg Tablet, 500mg Imipenem/Cilastatin
Imipenem/Cilastatin

1
Tablet) (Injection)
Ceftazidime (Injection) 1 Invanz (Injection) 1
Invanz
Ceftazidime

Meropenem (Injection) 1
Meropenem

Beta-lactam, Penicillins

You can find information on what the abbreviations in this table mean on pages 6 - 7.
38 39
Last updated November 1, 2018 tRACK
39
8
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Amoxicillin (125mg Ampicillin Sodium
Amoxicillin Ampicillin Sodium

Tablet Chewable, (10gm Injection,

1
250mg Tablet 125mg Injection, 1gm
Chewable, 125mg/5ml Injection)
Suspension, 200mg/ Ampicillin-Sulbactam
Ampicillin-Sulbactam

5ml Suspension, 1
(Injection)
250mg/5ml 1
Bactocill in Dextrose
Bactocill in Dextrose

Suspension, 400mg/ 1
5ml Suspension, (Injection)
250mg Capsule, Bicillin C-R (Injection) 1
Bicillin C-R

500mg Capsule, Bicillin L-A (Injection)

Bicillin L-A

1
500mg Tablet, 875mg
Dicloxacillin Sodium
Dicloxacillin Sodium

Tablet) 1
(Capsule)
Amoxicillin/
Amoxicillin/Clavulanate Potassium

Nafcillin Sodium
Nafcillin Sodium

Clavulanate Potassium
(200mg-28.5mg Tablet (10gm Injection, 1gm 1
Chewable, Injection)
Oxacillin Sodium
Oxacillin Sodium

400mg-57mg Tablet 1
Chewable, 200mg/ (10gm Injection)
5ml-28.5mg/5ml Oxacillin Sodium (1gm
Oxacillin Sodium

Suspension, 250mg/ Injection, 2gm 1

5ml-62.5mg/5ml Injection)
Suspension, 400mg/ Penicillin G Potassium
Penicillin G Potassium

5ml-57mg/5ml 1 1
(Injection)
Suspension, 600mg/
Penicillin G Procaine
Penicillin G Procaine

5ml-42.9mg/5ml 1
Suspension, (Injection)
Penicillin G Sodium
Penicillin G Sodium

250mg-125mg Tablet 1
Immediate-Release, (Injection)
500mg-125mg Tablet Penicillin V Potassium
Penicillin V Potassium

Immediate-Release, (125mg/5ml Oral

875mg-125mg Tablet Solution, 250mg/5ml 1
Immediate-Release) Oral Solution, 250mg
(Generic Augmentin) Tablet, 500mg Tablet)
Amoxicillin/ Piperacillin/
Amoxicillin/Clavulanate Potassium ER
Piperacillin/Tazobactam

Clavulanate Potassium 1
1 Tazobactam (Injection)
ER (Tablet Extended- Macrolides
Release 12 Hour)
Azasite (Ophthalmic
Azasite

Ampicillin (Capsule)
Ampicillin

1 1
Solution)

Bold type = Brand name drug Plain type = Generic drug

39 40
40 tRACK
Last updated November 1, 2018
9
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Azithromycin (100mg/ Erythromycin
Azithromycin Erythromycin Ethylsuccinate

5ml Suspension, Ethylsuccinate

200mg/5ml (200mg/5ml 1
1
Suspension, 250mg Suspension, 400mg
Tablet, 500mg Tablet, Tablet)
600mg Tablet) Quinolones
Azithromycin (500mg
Azithromycin

Besivance
Besivance

1 1
Injection) (Suspension)
Clarithromycin
Clarithromycin

Ciloxan (0.3%
Ciloxan

(125mg/5ml 1
1 Ointment)
Suspension, 250mg/
Ciprofloxacin (Oral
Ciprofloxacin

5ml Suspension) 1
Suspension)
Clarithromycin (250mg
Clarithromycin

1 Ciprofloxacin ER
Ciprofloxacin ER

Tablet, 500mg Tablet)

(Tablet Extended- 1
Clarithromycin ER
Clarithromycin ER

Release 24 Hour)
(Tablet Extended- 1
Ciprofloxacin HCl
Ciprofloxacin HCl

Release 24 Hour)
(0.3% Ophthalmic 1
Dificid (Tablet) 1
Dificid

Solution)
E.E.S. Granules
E.E.S. Granules

Ciprofloxacin HCl
Ciprofloxacin HCl

1
(Suspension) (Tablet Immediate- 1
Ery-Tab (Tablet Release)
Ery-Tab

1
Delayed-Release) Ciprofloxacin I.V. in
Ciprofloxacin I.V. in D5W

1
EryPed 200 D5W (Injection)
EryPed 200

1
(Suspension) Gatifloxacin
Gatifloxacin

1
EryPed 400
EryPed 400

(Ophthalmic Solution)
1
(Suspension) Levofloxacin (0.5%
Levofloxacin

1
Erythrocin
Erythrocin Lactobionate

Ophthalmic Solution)
Lactobionate 1 Levofloxacin (250mg
Levofloxacin

(Injection) Tablet, 500mg Tablet, 1

Erythromycin (250mg
Erythromycin

750mg Tablet)
Capsule Delayed- 1 Levofloxacin (25mg/ml
Levofloxacin

Release) Injection, 25mg/ml 1

Erythromycin (5mg/gm
Erythromycin

Oral Solution)
1
Ophthalmic Ointment) Levofloxacin in D5W
Levofloxacin in D5W

1
Erythromycin Base
Erythromycin Base

(Injection)
1
(Tablet) Moxeza (Ophthalmic
Moxeza

1
Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
40 41
Last updated November 1, 2018 tRACK
41
10
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Moxifloxacin HCl/ Doxy 100 (Injection) 1
Moxifloxacin HCl/Sodium HCl
Doxy 100

Sodium HCl 1 Doxycycline (25mg/

Doxycycline

(Injection) 1
5ml Suspension)
Moxifloxacin HCl
Moxifloxacin HCl

Doxycycline Hyclate
Doxycycline Hyclate

1
(Ophthalmic Solution) (100mg Capsule,
Moxifloxacin HCl 50mg Capsule, 100mg
Moxifloxacin HCl

1 Tablet Immediate-
(Tablet)
Ofloxacin (0.3%
Ofloxacin

Release, 150mg Tablet

1 1
Ophthalmic Solution) Immediate-Release,
75mg Tablet
Ofloxacin (0.3% Otic
Ofloxacin

Immediate-Release,
Solution, 300mg 1 20mg Tablet
Tablet, 400mg Tablet) Immediate-Release)
Sulfonamides Doxycycline
Doxycycline Monohydrate

Silver Sulfadiazine
Silver Sulfadiazine

1 Monohydrate (100mg
(Cream) Capsule, 50mg
1
Sodium Sulfacetamide
Sodium Sulfacetamide

Capsule, 100mg
1 Tablet, 50mg Tablet,
(Ophthalmic Solution)
SSD (Cream)
SSD

1 75mg Tablet)
Minocycline HCl
Minocycline HCl

Sulfacetamide Sodium
Sulfacetamide Sodium

1 (100mg Capsule,
(Ophthalmic Ointment) 1
50mg Capsule, 75mg
Sulfadiazine (Tablet) 1
Sulfadiazine

Capsule)
Sulfamethoxazole/ Minocycline HCl
Sulfamethoxazole/Trimethoprim
Minocycline HCl

Trimethoprim (100mg Tablet

(200mg-40mg/5ml 1 Immediate-Release,
Suspension, 50mg Tablet 1
400mg-80mg Tablet) Immediate-Release,
Sulfamethoxazole/
Sulfamethoxazole/Trimethoprim

75mg Tablet
Trimethoprim Immediate-Release)
1
(400mg-80mg/5ml Tetracycline HCl
Tetracycline HCl

Injection) 1
(Capsule)
Sulfamethoxazole/
Sulfamethoxazole/Trimethoprim DS

Vibramycin (50mg/
Vibramycin

Trimethoprim DS 1 1
5ml Syrup)
(Tablet)
Anticonvulsants
Tetracyclines
Anticonvulsants, Other
Demeclocycline HCl
Demeclocycline HCl

1
(Tablet)

Bold type = Brand name drug Plain type = Generic drug

41 42
42 tRACK
Last updated November 1, 2018
11
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Briviact (100mg 1
Briviact

Celontin (Capsule)
Celontin

Tablet, 10mg Tablet, Ethosuximide (250mg

Ethosuximide

25mg Tablet, 50mg Capsule, 250mg/5ml 1

1 QL
Tablet, 75mg Tablet, Oral Solution)
10mg/ml Oral Zonisamide (Capsule)
Zonisamide

1
Solution)
Gamma-aminobutyric Acid (GABA)
Briviact (50mg/5ml
Briviact

1 QL Augmenting Agents
Injection)
Diastat AcuDial (Gel) 1
Diastat AcuDial

Levetiracetam
Levetiracetam

Diastat Pediatric (Gel) 1

Diastat Pediatric

(1000mg Tablet
Immediate-Release, Gabapentin (100mg
Gabapentin

250mg Tablet Capsule, 300mg

Immediate-Release, Capsule, 400mg 1
500mg Tablet 1 Capsule, 600mg
Immediate-Release, Tablet, 800mg Tablet)
750mg Tablet Gabapentin (250mg/
Gabapentin

Immediate-Release, 1
5ml Oral Solution)
100mg/ml Oral
Gabitril (12mg Tablet,
Gabitril

Solution) 1
16mg Tablet)
Levetiracetam
Levetiracetam

Onfi (10mg Tablet,

Onfi

(1000mg/100ml 1 QL
Injection, 1500mg/ 20mg Tablet)
100ml Injection, 1 Onfi (2.5mg/ml
Onfi

1
500mg/100ml Suspension)
Injection, 500mg/5ml Phenobarbital (100mg
Phenobarbital

Injection) Tablet, 15mg Tablet,

Levetiracetam ER 16.2mg Tablet, 30mg
Levetiracetam ER

(Tablet Extended- 1 Tablet, 32.4mg Tablet, 1

Release 24 Hour) 60mg Tablet, 64.8mg
Roweepra (Tablet)
Roweepra

1 Tablet, 97.2mg Tablet,

20mg/5ml Elixir)
Roweepra XR (Tablet
Roweepra XR

Primidone (Tablet) 1
Primidone

Extended-Release 24 1
Hour) Sabril (500mg Packet,
Sabril

1 PA, QL, LA
Spritam (Tablet
Spritam

500mg Tablet)
Disintegrating 1 Tiagabine HCl (Tablet) 1
Tiagabine HCl

Soluble) Valproate Sodium

Valproate Sodium

Calcium Channel Modifying Agents 1

(100mg/ml Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
42 43
Last updated November 1, 2018
tRACK
43
12
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Valproic Acid (250mg 1 QL
Valproic Acid

Aptiom (Tablet)
Aptiom

Capsule, 250mg/5ml 1 Banzel (200mg

Banzel

Oral Solution)
Tablet, 400mg Tablet, 1
Vigabatrin (Packet) 1 PA, QL
Vigabatrin

40mg/ml Suspension)
Glutamate Reducing Agents Carbamazepine
Carbamazepine

Felbamate (400mg (100mg Tablet

Felbamate

1 Chewable, 100mg/5ml
Tablet, 600mg Tablet) 1
Felbamate (600mg/
Felbamate

Suspension, 200mg
1 Tablet Immediate-
5ml Suspension)
Release)
Felbatol (600mg/5ml
Felbatol

1 Carbamazepine ER
Carbamazepine ER

Suspension)
(100mg Capsule
Fycompa (0.5mg/ml
Fycompa

Extended-Release 12
Suspension, 10mg Hour, 200mg Capsule
Tablet, 12mg Tablet, Extended-Release 12
1
2mg Tablet, 4mg Hour, 300mg Capsule
Tablet, 6mg Tablet, Extended-Release 12
1
8mg Tablet) Hour, 100mg Tablet
Lamotrigine (100mg
Lamotrigine

Extended-Release 12
Tablet Immediate- Hour, 200mg Tablet
Release, 150mg Tablet Extended-Release 12
Immediate-Release, Hour, 400mg Tablet
1 Extended-Release 12
200mg Tablet
Immediate-Release, Hour)
25mg Tablet Dilantin (Capsule) 1
Dilantin

Immediate-Release) Dilantin INFATABS

Dilantin INFATABS

1
Lamotrigine (25mg (Tablet Chewable)
Lamotrigine

Tablet Chewable, 5mg 1 Epitol (Tablet)

Epitol

1
Tablet Chewable)
Fosphenytoin Sodium
Fosphenytoin Sodium

Topiramate (100mg
Topiramate

1
(Injection)
Tablet, 200mg Tablet,
Oxcarbazepine
Oxcarbazepine

25mg Tablet, 50mg

Tablet, 15mg Capsule (150mg Tablet, 300mg 1
1 Tablet, 600mg Tablet)
Sprinkle Immediate-
Release, 25mg Oxcarbazepine
Oxcarbazepine

Capsule Sprinkle (300mg/5ml 1

Immediate-Release) Suspension)
Sodium Channel Agents Peganone (Tablet) 1
Peganone

Bold type = Brand name drug Plain type = Generic drug

43 44
44 tRACK
Last updated November 1, 2018
13
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Phenytek (Capsule) 1 Memantine HCl (10mg
Memantine HCl
Phenytek

Phenytoin (125mg/5ml
Phenytoin

Tablet, 5mg Tablet, 1 PA, QL

Suspension, 50mg 1 2mg/ml Oral Solution)
Tablet Chewable) Memantine HCl ER
Memantine HCl ER

Phenytoin Sodium
Phenytoin Sodium

(Capsule Extended- 1 PA, QL

1 Release 24 Hour)
(Injection)
Memantine HCl
Memantine HCl Titration Pak

Phenytoin Sodium
Phenytoin Sodium Extended

1 1 PA
Extended (Capsule) Titration Pak (Tablet)
Namenda XR
Namenda XR

Vimpat (100mg
Vimpat

Tablet, 150mg Tablet, (Capsule Extended- 1 PA, QL

200mg Tablet, 50mg 1 QL Release 24 Hour)
Namenda XR Titration
Namenda XR Titration Pack

Tablet, 10mg/ml Oral

Solution) Pack (Capsule
1 PA, QL
Vimpat (200mg/20ml
Vimpat

Extended-Release 24
1 Hour)
Injection)
Antidementia Agents Antidepressants
Cholinesterase Inhibitors Antidepressants, Other
Bupropion HCl (Tablet
Bupropion HCl

Donepezil HCl (Tablet) 1 QL

Donepezil HCl

1
Immediate-Release)
Donepezil HCl ODT
Donepezil HCl ODT

1 QL Bupropion HCl SR
Bupropion HCl SR

(Tablet Dispersible)
(100mg Tablet
Galantamine HBr
Galantamine HBr

Extended-Release 12
(12mg Tablet, 4mg Hour, 150mg Tablet
1 QL 1
Tablet, 8mg Tablet, Extended-Release 12
4mg/ml Oral Solution) Hour, 200mg Tablet
Galantamine HBr ER Extended-Release 12
Galantamine HBr ER

(Capsule Extended- 1 QL Hour)

Release 24 Hour) Bupropion HCl XL
Bupropion HCl XL

Rivastigmine Tartrate (Tablet Extended- 1

Rivastigmine Tartrate

1 QL
(Capsule) Release 24 Hour)
Rivastigmine
Rivastigmine Transdermal System

Mirtazapine (Tablet) 1
Mirtazapine

Transdermal System 1 QL, ST

Mirtazapine ODT
Mirtazapine ODT

(Patch 24 Hour) 1
(Tablet Dispersible)
N-methyl-D-aspartate (NMDA) Receptor
Monoamine Oxidase Inhibitors
Antagonist
Emsam (Patch 24
Emsam

1 QL
Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
44 45
Last updated November 1, 2018
tRACK
45
14
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 Fluoxetine DR
Fluoxetine DR

Marplan (Tablet)
Marplan

Phenelzine Sulfate
Phenelzine Sulfate

(Capsule Delayed- 1
1 Release)
(Tablet)
Fluoxetine HCl (10mg
Fluoxetine HCl

Tranylcypromine
Tranylcypromine Sulfate

1 Capsule Immediate-
Sulfate (Tablet)
Release, 20mg
SSRI/SNRI (Selective Serotonin Reuptake Capsule Immediate-
Inhibitors/Serotonin and Norepinephrine 1
Release, 40mg
Reuptake Inhibitors) Capsule Immediate-
Citalopram HBr (10mg Release, 20mg/5ml
Citalopram HBr

Tablet, 20mg Tablet, 1 Oral Solution)

40mg Tablet) Fluvoxamine Maleate
Fluvoxamine Maleate

1
Citalopram HBr (Tablet)
Citalopram HBr

(10mg/5ml Oral 1 Maprotiline HCl

Maprotiline HCl

Solution) 1
(Tablet)
Desvenlafaxine ER
Desvenlafaxine ER

Nefazodone HCl
Nefazodone HCl

(100mg Tablet 1
(Tablet)
Extended-Release 24 Paroxetine HCl (Tablet
Paroxetine HCl

Hour, 25mg Tablet 1

1 QL Immediate-Release)
Extended-Release 24
Paxil (10mg/5ml
Paxil

Hour, 50mg Tablet 1

Extended-Release 24 Suspension)
Hour) (Generic Pristiq) Pristiq (Tablet
Pristiq

Escitalopram Oxalate
Escitalopram Oxalate

Extended-Release 24 1 PA, QL
(10mg Tablet, 20mg 1 Hour)
Tablet, 5mg Tablet) Sertraline HCl (100mg
Sertraline HCl

Escitalopram Oxalate Tablet, 25mg Tablet, 1

Escitalopram Oxalate

(5mg/5ml Oral 1 50mg Tablet)

Solution) Sertraline HCl (20mg/
Sertraline HCl

1
Fetzima (Capsule ml Concentrate)
Fetzima

Extended-Release 24 1 QL, ST Trazodone HCl (Tablet)

Trazodone HCl

1
Hour) Trintellix (Tablet)
Trintellix

1 QL
Fetzima Titration
Fetzima Titration Pack

Venlafaxine HCl
Venlafaxine HCl

Pack (Capsule (Tablet Immediate- 1

1 ST
Extended-Release 24 Release)
Hour Therapy Pack)

Bold type = Brand name drug Plain type = Generic drug

45 46
46 tRACK
Last updated November 1, 2018
15
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Venlafaxine HCl ER Protriptyline HCl
Venlafaxine HCl ER Protriptyline HCl

1
(150mg Capsule (Tablet)
Extended-Release 24 Trimipramine Maleate
Trimipramine Maleate

Hour, 37.5mg Capsule 1

1 (Capsule)
Extended-Release 24
Antiemetics
Hour, 75mg Capsule
Extended-Release 24 Antiemetics, Other
Hour) Compro (Suppository) 1
Compro

Viibryd (Tablet) 1 QL Hydroxyzine Pamoate

Viibryd
Hydroxyzine Pamoate

1
Viibryd Starter Pack
Viibryd Starter Pack

(Capsule)
1 QL
Meclizine HCl (Tablet) 1
Meclizine HCl

(Kit)
Tricyclics Metoclopramide HCl
Metoclopramide HCl

Amitriptyline HCl
Amitriptyline HCl

(10mg Tablet, 5mg 1

1 Tablet)
(Tablet)
Metoclopramide HCl
Metoclopramide HCl

Amoxapine (Tablet) 1
Amoxapine

(5mg/5ml Oral 1
Clomipramine HCl
Clomipramine HCl

1 Solution)
(Capsule)
Metoclopramide HCl
Metoclopramide HCl

Desipramine HCl 1
Desipramine HCl

1 (5mg/ml Injection)
(Tablet)
Perphenazine (Tablet) 1
Perphenazine

Doxepin HCl (100mg

Doxepin HCl

Prochlorperazine
Prochlorperazine

Capsule, 10mg 1
Capsule, 150mg (Suppository)
Capsule, 25mg Prochlorperazine
Prochlorperazine Edisylate

1 1
Capsule, 50mg Edisylate (Injection)
Capsule, 75mg Prochlorperazine
Prochlorperazine Maleate

Capsule, 10mg/ml 1
Maleate (Tablet)
Concentrate)
Scopolamine (Patch 72
Scopolamine

Imipramine HCl
Imipramine HCl

1
1 Hour)
(Tablet)
Transderm-Scop
Transderm-Scop

Imipramine Pamoate
Imipramine Pamoate

1
1 (Patch 72 Hour)
(Capsule)
Emetogenic Therapy Adjuncts
Nortriptyline HCl
Nortriptyline HCl

Aloxi (Injection) 1
Aloxi

(10mg Capsule, 25mg

Capsule, 50mg Anzemet (100mg
Anzemet

1 1 B/D, PA
Capsule, 75mg Tablet)
Capsule, 10mg/5ml Anzemet (50mg
Anzemet

Oral Solution) 1 B/D, PA

Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
46 47
Last updated November 1, 2018
tRACK
47
16
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Aprepitant (Therapy Antifungals
Aprepitant

1 PA
Pack, Capsule) Abelcet (Injection)
Abelcet

1 B/D, PA
Cesamet (Capsule) 1 PA
Cesamet

AmBisome (Injection) 1 B/D, PA

AmBisome

Dronabinol (Capsule) 1 PA
Dronabinol

Amphotericin B
Amphotericin B

1 B/D, PA
Emend (125mg (Injection)
Emend

Capsule, 40mg Cancidas (Injection)

Cancidas

1
Capsule, 80mg 1 PA Caspofungin Acetate
Caspofungin Acetate

Capsule, 125mg 1
(Injection)
Suspension)
Ciclopirox (0.77% Gel,
Ciclopirox

Emend (150mg
Emend

1 0.77% Suspension, 1% 1
Injection) Shampoo)
Emend Tripack
Emend Tripack

Ciclopirox Nail
Ciclopirox Nail Lacquer

1 PA
(Capsule) Lacquer (External 1
Granisetron HCl
Granisetron HCl

Solution)
(0.1mg/ml Injection, Ciclopirox Olamine
Ciclopirox Olamine

1 1
1mg/ml Injection, (Cream)
4mg/4ml Injection) Clotrimazole (1%
Clotrimazole

Granisetron HCl (1mg Cream, 1% External

Granisetron HCl

1 B/D, PA, QL 1
Tablet) Solution, 10mg
Ondansetron HCl
Ondansetron HCl

Lozenge)
(24mg Tablet, 4mg 1 B/D, PA Econazole Nitrate
Econazole Nitrate

Tablet, 8mg Tablet) 1

(Cream)
Ondansetron HCl 1
Ondansetron HCl

Eraxis (Injection)
Eraxis

1
(4mg/2ml Injection) Exelderm (1% Cream,
Exelderm

Ondansetron HCl
Ondansetron HCl

1
1% External Solution)
(4mg/5ml Oral 1 B/D, PA
Fluconazole (100mg
Fluconazole

Solution)
Tablet, 150mg Tablet,
Ondansetron ODT
Ondansetron ODT

1 B/D, PA 200mg Tablet, 50mg

(Tablet Dispersible) 1
Tablet, 10mg/ml
Palonosetron HCl Suspension, 40mg/ml
Palonosetron HCl

(0.25mg/2ml 1 Suspension)
Injection) Fluconazole in NaCl
Fluconazole in NaCl

1
Palonosetron HCl
Palonosetron HCl

(Injection)
1
(0.25mg/5ml Injection) Flucytosine (Capsule)
Flucytosine

1
Sancuso (Patch) 1
Sancuso

Antifungals

Bold type = Brand name drug Plain type = Generic drug

47 48
48 tRACK
Last updated November 1, 2018
17
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Griseofulvin Microsize Oxiconazole Nitrate
Griseofulvin Microsize Oxiconazole Nitrate

1
(125mg/5ml (Cream)
1
Suspension, 500mg Oxistat (1% Lotion)
Oxistat

1
Tablet)
Sporanox (10mg/ml
Sporanox

Griseofulvin 1 PA
Griseofulvin Ultramicrosize

1 Oral Solution)
Ultramicrosize (Tablet)
Terbinafine HCl
Terbinafine HCl

Itraconazole (Capsule) 1 PA, QL 1

Itraconazole

(Tablet)
Jublia (External
Jublia

Terconazole (0.4%
Terconazole

1
Solution) Cream, 0.8% Cream, 1
Ketoconazole (2% 80mg Suppository)
Ketoconazole

Cream, 2% Shampoo, 1 Vfend (200mg Tablet,

Vfend

200mg Tablet) 50mg Tablet, 40mg/ 1

Ketoconazole (2%
Ketoconazole

1 ml Suspension)
Foam) Voriconazole (200mg
Voriconazole

Mentax (Cream) 1 Injection, 40mg/ml 1

Mentax

Miconazole 3
Miconazole 3

Suspension)
1
(Suppository) Voriconazole (200mg
Voriconazole

1
Mycamine (Injection)
Mycamine

1 Tablet, 50mg Tablet)

Naftifine HCl (1%
Naftifine HCl

Antigout Agents
1
Cream) Antigout Agents
Naftifine HCl (2% Allopurinol (Tablet) 1
Naftifine HCl Allopurinol

1
Cream) Colchicine (0.6mg
Colchicine

Naftin (1% Gel, 2%

Naftin

1 Capsule, 0.6mg 1 QL
Gel) Tablet)
Natacyn (Suspension) 1
Natacyn

Colcrys (Tablet) 1 PA, QL

Colcrys

Noxafil (100mg Tablet

Noxafil

Probenecid (Tablet) 1
Probenecid

1 PA, QL
Delayed-Release) Probenecid/Colchicine
Probenecid/Colchicine

Noxafil (40mg/ml
Noxafil

1
1 QL (Tablet)
Suspension) Uloric (Tablet)
Uloric

1 ST
Nyamyc (Powder) 1
Nyamyc

Antimigraine Agents
Nystatin (Cream,
Nystatin

Ergot Alkaloids
Ointment, Powder, 1
Dihydroergotamine
Dihydroergotamine Mesylate

Suspension, Tablet)
Mesylate (1mg/ml 1
Nystop (Powder) 1
Nystop

Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
48 49
Last updated November 1, 2018 tRACK
49
18
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Ergotamine Tartrate/ Pyridostigmine
Ergotamine Tartrate/Caffeine Pyridostigmine Bromide ER

1
Caffeine (Tablet) Bromide ER (Tablet 1
Migergot (Suppository) 1
Migergot

Extended-Release)
Serotonin (5-HT) 1b/1d Receptor Agonists Antimycobacterials
Naratriptan HCl
Naratriptan HCl

Antimycobacterials, Other
1 QL Dapsone (Tablet) 1
(Tablet)
Dapsone

Rizatriptan Benzoate Rifabutin (Capsule) 1

Rizatriptan Benzoate
Rifabutin

1 QL
(Tablet) Antituberculars
Rizatriptan Benzoate
Rizatriptan Benzoate ODT

Capastat Sulfate
Capastat Sulfate

ODT (Tablet 1 QL 1
(Injection)
Dispersible)
Ethambutol HCl
Ethambutol HCl

Sumatriptan (Nasal 1
Sumatriptan

1 QL (Tablet)
Solution)
Isoniazid (100mg
Isoniazid

Sumatriptan Succinate 1
Sumatriptan Succinate

Tablet, 300mg Tablet)

(100mg Tablet, 25mg 1 QL
Isoniazid (100mg/ml
Isoniazid

Tablet, 50mg Tablet)

Injection, 50mg/5ml 1
Sumatriptan Succinate
Sumatriptan Succinate

Syrup)
(4mg/0.5ml Injection, 1 QL
Paser (Packet) 1
Paser

6mg/0.5ml Injection)
Priftin (Tablet) 1
Priftin

Sumatriptan
Sumatriptan Succinate

Succinate (6mg/ 1 QL Pyrazinamide (Tablet)

Pyrazinamide

1
0.5ml Injection) Rifampin (150mg
Rifampin

Sumatriptan Capsule, 300mg 1

Sumatriptan Succinate Refill

Succinate Refill 1 QL Capsule)

(Injection) Rifampin (600mg
Rifampin

1
Antimyasthenic Agents Injection)
Parasympathomimetics Rifater (Tablet) 1
Rifater

Guanidine HCl 1 PA
Guanidine HCl

Sirturo (Tablet)
Sirturo

1
(Tablet) Trecator (Tablet)
Trecator

1
Mestinon (60mg/5ml
Mestinon

1 Antineoplastics
Syrup)
Alkylating Agents
Pyridostigmine
Pyridostigmine Bromide

BiCNU (Injection) 1
BiCNU

Bromide (Tablet 1
Immediate-Release) Busulfan (Injection) 1
Busulfan

Busulfex (Injection) 1
Busulfex

Bold type = Brand name drug Plain type = Generic drug

49 50
50 tRACK
Last updated November 1, 2018
19
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Cyclophosphamide Soltamox (Oral
Cyclophosphamide Soltamox

1 B/D, PA 1
(Capsule) Solution)
Dacarbazine (Injection) 1 Tamoxifen Citrate
Tamoxifen Citrate
Dacarbazine

1
Gleostine (Capsule)
Gleostine

1 (Tablet)
Antimetabolites
Hexalen (Capsule) 1 PA
Hexalen

Adrucil (Injection) 1 B/D, PA

Adrucil

Ifosfamide (Injection) 1
Ifosfamide

Alimta (Injection) 1 PA
Alimta

Leukeran (Tablet) 1
Leukeran

Cladribine (Injection) 1 B/D, PA

Cladribine

Matulane (Capsule) 1 LA
Matulane

Clofarabine (Injection) 1
Clofarabine

Melphalan HCl
Melphalan HCl

1 Cytarabine Aqueous
Cytarabine Aqueous

(Injection) 1 B/D, PA
(Injection)
Mustargen (Injection) 1
Mustargen

Droxia (Capsule) 1
Droxia

Treanda (Injection) 1 PA
Treanda

Fluorouracil (5gm/
Fluorouracil

Valchlor (Gel)
Valchlor

1 PA, LA 1 B/D, PA
100ml Injection)
Yondelis (Injection) 1 PA
Yondelis

Folotyn (Injection) 1
Folotyn

Zanosar (Injection) 1
Zanosar

Gemcitabine HCl
Gemcitabine HCl

1
Antiandrogens (Injection)
Bicalutamide (Tablet) 1 Gemzar (Injection) 1
Gemzar
Bicalutamide

1 PA, QL Hydroxyurea (Capsule) 1

Hydroxyurea

Erleada (Tablet)
Erleada

Flutamide (Capsule) 1 Mercaptopurine

Mercaptopurine
Flutamide

1
(Tablet)
Nilandron (Tablet) 1
Nilandron

Nipent (Injection) 1
Nipent

Nilutamide (Tablet) 1
Nilutamide

Purixan (Suspension) 1 PA
Purixan

Xtandi (Capsule) 1 PA, QL

Xtandi

Tabloid (Tablet) 1 PA
Tabloid

Zytiga (Tablet) 1 PA, QL

Zytiga

Antineoplastics, Other
Antiangiogenic Agents
Abraxane (Injection) 1 PA
Abraxane

Pomalyst (Capsule) 1 PA, QL

Pomalyst

Adriamycin (Injection) 1 B/D, PA

Adriamycin

Revlimid (Capsule) 1 PA, QL, LA

Revlimid

Arranon (Injection) 1
Arranon

Thalomid (Capsule) 1 PA, QL

Thalomid

Bleomycin Sulfate
Bleomycin Sulfate

Antiestrogens/Modifiers 1 B/D, PA
(Injection)
Emcyt (Capsule) 1
Emcyt

Bortezomib
Bortezomib

Fareston (Tablet)
Fareston

1 1 PA
(Injection)
Faslodex (Injection) 1 Carboplatin (Injection) 1
Faslodex
Carboplatin

You can find information on what the abbreviations in this table mean on pages 6 - 7.
50 51
Last updated November 1, 2018
tRACK
51
20
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Cisplatin (Injection) 1 Kisqali (Tablet) 1 PA, QL
Cisplatin Kisqali

1 Kisqali Femara 200

Kisqali Femara 200 Dose

Cosmegen (Injection)
Cosmegen

Dacogen (Injection)
Dacogen

1 Dose (Tablet Therapy 1 PA, QL

Pack)
Dactinomycin
Dactinomycin

1 Kisqali Femara 400

Kisqali Femara 400 Dose

(Injection)
Dose (Tablet Therapy 1 PA, QL
Daunorubicin HCl
Daunorubicin HCl

1 Pack)
(Injection)
Kisqali Femara 600
Kisqali Femara 600 Dose

Decitabine (Injection) 1
Decitabine

Dose (Tablet Therapy 1 PA, QL

Dexrazoxane
Dexrazoxane

1 PA Pack)
(Injection)
Leucovorin Calcium
Leucovorin Calcium

Docetaxel (160mg/
Docetaxel

1 (100mg Injection, 1
16ml Injection) 350mg Injection)
Docetaxel (80mg/4ml
Docetaxel

1 Leucovorin Calcium
Leucovorin Calcium

Injection) (10mg Tablet, 15mg

1 1
Doxil (Injection) Tablet, 25mg Tablet,
Doxil

Doxorubicin HCl
Doxorubicin HCl

5mg Tablet)
1 B/D, PA
(Injection) Levoleucovorin
Levoleucovorin

1
Doxorubicin HCl
Doxorubicin HCl Liposome

(Injection)
1
Liposome (Injection) Lonsurf (Tablet) 1 PA, QL
Lonsurf

Ellence (Injection) 1 Mitomycin (Injection) 1

Ellence
Mitomycin

Epirubicin HCl Mitoxantrone HCl

Epirubicin HCl
Mitoxantrone HCl

1 1
(Injection) (Injection)
Erwinaze (Injection) 1 1 PA, QL
Erwinaze

Ninlaro (Capsule)
Ninlaro

Fludarabine Phosphate Oxaliplatin (100mg

Fludarabine Phosphate
Oxaliplatin

1
(Injection) Vial, 100mg/20ml 1
Fusilev (Injection)
Fusilev

1 Injection)
Paclitaxel (Injection) 1
Paclitaxel

Halaven (Injection) 1 PA
Halaven

Proleukin (Injection) 1 PA
Proleukin

Idamycin PFS
Idamycin PFS

1
(Injection) Synribo (Injection) 1 PA
Synribo

Idarubicin HCl
Idarubicin HCl

Taxotere (Injection) 1
Taxotere

1
(Injection)
Thiotepa (Injection) 1
Thiotepa

Irinotecan (Injection) 1
Irinotecan

Trisenox (Injection) 1
Trisenox

Istodax (Overfill)
Istodax

1 PA Velcade (Injection)
Velcade

1 PA
(Injection)

Bold type = Brand name drug Plain type = Generic drug

51 52
52 tRACK
Last updated November 1, 2018
21
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Verzenio (Tablet) 1 PA, QL Alecensa (Capsule) 1 PA, QL
Verzenio Alecensa

Vinblastine Sulfate Alunbrig (Tablet

Vinblastine Sulfate Alunbrig

1 B/D, PA
(Injection) Therapy Pack, 180mg
1 PA, QL
Vincasar PFS Tablet, 30mg Tablet,
Vincasar PFS

1 B/D, PA
(Injection) 90mg Tablet)
Vincristine Sulfate 1 PA
Vincristine Sulfate

Beleodaq (Injection)
Beleodaq

1 B/D, PA
(Injection) Bosulif (Tablet)
Bosulif

1 PA, QL
Vinorelbine Tartrate
Vinorelbine Tartrate

1 Cabometyx (Tablet) 1 PA, QL

Cabometyx

(Injection)
Calquence (Capsule) 1 PA, QL
Calquence

Vyxeos (Injection) 1 PA
Vyxeos

Caprelsa (Tablet) 1 PA, LA

Caprelsa

Zaltrap (Injection) 1 PA
Zaltrap

Cometriq (Kit) 1 PA
Cometriq

Zinecard (Injection) 1 PA
Zinecard

Cotellic (Tablet) 1 PA, QL, LA

Cotellic

Zolinza (Capsule) 1 PA
Zolinza

Cyramza (Injection) 1 PA
Cyramza

Aromatase Inhibitors, 3rd Generation

Erivedge (Capsule) 1 PA, QL
Erivedge

Anastrozole (Tablet) 1
Anastrozole

Farydak (Capsule) 1 PA
Farydak

Exemestane (Tablet) 1
Exemestane

Gilotrif (Tablet) 1 PA
Gilotrif

Letrozole (Tablet) 1
Letrozole

Ibrance (Capsule) 1 PA, QL

Ibrance

Enzyme Inhibitors
Iclusig (Tablet) 1 PA, QL, LA
Iclusig

Aliqopa (Injection) 1 PA
Aliqopa

Idhifa (Tablet) 1 PA, QL

Idhifa

Etopophos (Injection) 1
Etopophos

Imatinib Mesylate
Imatinib Mesylate

Etoposide (Injection) 1
Etoposide

1 PA, QL
(Tablet)
Hycamtin (Injection) 1
Hycamtin

Imbruvica (140mg
Imbruvica

Kyprolis (Injection) 1 PA
Kyprolis

Capsule, 70mg
Rubraca (Tablet) 1 PA, QL
Rubraca

Capsule, 140mg
1 PA, QL
Toposar (Injection)
Toposar

1 Tablet, 280mg Tablet,

Topotecan HCl
Topotecan HCl

420mg Tablet, 560mg

1 Tablet)
(Injection)
Inlyta (Tablet) 1 PA, QL
Inlyta

Zejula (Capsule) 1 PA, QL

Zejula

Iressa (Tablet) 1 PA, QL

Iressa

Molecular Target Inhibitors

Jakafi (Tablet) 1 PA, QL, LA
Jakafi

Afinitor (Tablet) 1 PA
Afinitor

Jevtana (Injection) 1 PA
Jevtana

Afinitor Disperz
Afinitor Disperz

1 PA
(Tablet Soluble)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
52 53
Last updated November 1, 2018
tRACK
53
22
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Lenvima (Capsule 1 PA
Lenvima

Avastin (Injection)
Avastin

1 PA
Therapy Pack) Bavencio (Injection)
Bavencio

1 PA
Lynparza (100mg
Lynparza

Darzalex (Injection) 1 PA, LA

Darzalex

Tablet, 150mg Tablet, 1 PA, QL

Empliciti (Injection) 1 PA
Empliciti

50mg Capsule)
Erbitux (Injection) 1 PA
Erbitux

Mekinist (Tablet) 1 PA
Mekinist

Herceptin (Injection) 1 PA
Herceptin

Nerlynx (Tablet) 1 PA, QL

Nerlynx

Imfinzi (Injection) 1 PA
Imfinzi

Nexavar (Tablet) 1 PA
Nexavar

Kadcyla (Injection) 1 PA
Kadcyla

Odomzo (Capsule) 1 PA, QL, LA

Odomzo

Keytruda (Injection) 1 PA
Keytruda

Rydapt (Capsule) 1 PA, QL

Rydapt

Lartruvo (Injection) 1 PA
Lartruvo

Sprycel (Tablet) 1 PA, QL

Sprycel

Mylotarg (Injection) 1 PA
Mylotarg

Stivarga (Tablet) 1 PA, QL

Stivarga

Opdivo (Injection) 1 PA
Opdivo

Sutent (Capsule) 1 PA, QL

Sutent

Perjeta (Injection) 1 PA
Perjeta

Tafinlar (Capsule) 1 PA
Tafinlar

Rituxan (Injection) 1 PA
Rituxan

Tagrisso (Tablet) 1 PA, QL, LA

Tagrisso

Tecentriq (Injection) 1 PA
Tecentriq

Tarceva (Tablet) 1 PA, QL

Tarceva

Vectibix (Injection) 1 PA
Vectibix

Tasigna (Capsule) 1 PA, QL

Tasigna

Yervoy (Injection) 1 PA
Yervoy

Tykerb (Tablet) 1 PA
Tykerb

Venclexta (100mg
Venclexta

Retinoids
1 PA, QL
Bexarotene (Capsule) 1 PA
Bexarotene

Tablet, 50mg Tablet)

Venclexta (10mg 1
Venclexta

Panretin (Gel)
Panretin

1 PA, QL
Tablet) Targretin (1% Gel)
Targretin

1 PA
Venclexta Starting
Venclexta Starting Pack

Tretinoin (10mg
Tretinoin

Pack (Tablet Therapy 1 PA 1

Capsule)
Pack) Treatment Adjuncts
Votrient (Tablet) 1 PA, QL
Votrient

Elitek (Injection) 1
Elitek

Xalkori (Capsule) 1 PA, LA

Xalkori

Mesna (Injection) 1
Mesna

Zelboraf (Tablet) 1 PA, QL

Zelboraf

Mesnex (400mg
Mesnex

Zydelig (Tablet)
Zydelig

1 PA, QL 1
Tablet)
Zykadia (Capsule) 1 PA, QL Antiparasitics
Zykadia

Monoclonal Antibody/Antibody-Drug Anthelmintics

Conjugate Albenza (Tablet)
Albenza

1 QL

Bold type = Brand name drug Plain type = Generic drug

53 54
54 tRACK
Last updated November 1, 2018
23
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Biltricide (Tablet) 1 Permethrin (Cream) 1
Biltricide Permethrin

Ivermectin (Tablet) 1 Antiparkinson Agents

Ivermectin

Antiprotozoals Anticholinergics
Benztropine Mesylate
Benztropine Mesylate

Alinia (100mg/5ml
Alinia

Suspension, 500mg 1 (0.5mg Tablet, 1mg 1

Tablet) Tablet, 2mg Tablet)
Benztropine Mesylate
Benztropine Mesylate

Atovaquone
Atovaquone

1 1
(Suspension) (1mg/ml Injection)
Trihexyphenidyl HCl
Trihexyphenidyl HCl

Atovaquone/Proguanil
Atovaquone/Proguanil HCl

HCl (Tablet) (Generic 1 (0.4mg/ml Elixir, 2mg 1

Malarone) Tablet, 5mg Tablet)
Benznidazole (Tablet)
Benznidazole

1 Antiparkinson Agents, Other

Amantadine HCl
Amantadine HCl

Chloroquine
Chloroquine Phosphate

1 (100mg Capsule, 1
Phosphate (Tablet)
100mg Tablet)
Coartem (Tablet) 1
Coartem

Amantadine HCl
Amantadine HCl

DARAPRIM (Tablet)
DARAPRIM

1 1
(50mg/5ml Syrup)
Hydroxychloroquine
Hydroxychloroquine Sulfate

Entacapone (Tablet) 1
Entacapone

1
Sulfate (Tablet)
Tolcapone (Tablet) 1 QL
Tolcapone

Mefloquine HCl
Mefloquine HCl

1 Dopamine Agonists
(Tablet)
Apokyn (Injection) 1 PA, QL
Apokyn

Mepron (Suspension) 1
Mepron

Bromocriptine
Bromocriptine Mesylate

Nebupent (Inhalation
Nebupent

1 B/D, PA, QL Mesylate (2.5mg 1

Solution)
Tablet, 5mg Capsule)
Pentam 300
Pentam 300

1 Neupro (Patch 24
Neupro

(Injection) 1
Hour)
Primaquine Phosphate
Primaquine Phosphate

1 Pramipexole
Pramipexole Dihydrochloride

(Tablet)
Dihydrochloride
Quinine Sulfate
Quinine Sulfate

1
1 PA (Tablet Immediate-
(Capsule) Release)
Pediculicides/Scabicides Ropinirole HCl (Tablet
Ropinirole HCl

1
Eurax (10% Cream, Immediate-Release)
Eurax

1
10% Lotion) Dopamine Precursors/L-Amino Acid
Lindane (Shampoo) 1 Decarboxylase Inhibitors
Lindane

Malathion (Lotion) 1 Carbidopa (Tablet) 1

Carbidopa
Malathion

You can find information on what the abbreviations in this table mean on pages 6 - 7.
54 55
Last updated November 1, 2018 tRACK
55
24
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Carbidopa/Levodopa Fluphenazine HCl
Carbidopa/Levodopa Fluphenazine HCl

(Tablet Immediate- 1 (10mg Tablet, 1mg

1
Release) Tablet, 2.5mg Tablet,
Carbidopa/Levodopa
Carbidopa/Levodopa ER

5mg Tablet)
ER (Tablet Extended- 1 Fluphenazine HCl
Fluphenazine HCl

Release) (2.5mg/5ml Elixir, 1

Carbidopa/Levodopa
Carbidopa/Levodopa ODT

2.5mg/ml Injection)
ODT (Tablet 1 Fluphenazine HCl
Fluphenazine HCl

1
Dispersible) (5mg/ml Concentrate)
Carbidopa/Levodopa/ Haloperidol (0.5mg
Carbidopa/Levodopa/Entacapone Haloperidol

1
Entacapone (Tablet) Tablet, 10mg Tablet,
1 PA 1mg Tablet, 20mg
Stalevo 100 (Tablet) 1
Stalevo 100

Tablet, 2mg Tablet,

Stalevo 125 (Tablet) 1 PA
Stalevo 125

5mg Tablet, 2mg/ml

Stalevo 150 (Tablet)
Stalevo 150

1 PA Concentrate)
Haloperidol Decanoate
Haloperidol Decanoate

Stalevo 200 (Tablet) 1 PA

Stalevo 200

1
(Injection)
Stalevo 50 (Tablet) 1 PA
Stalevo 50

Haloperidol Lactate
Haloperidol Lactate

Stalevo 75 (Tablet)
Stalevo 75

1 PA 1
(Injection)
Monoamine Oxidase B (MAO-B) Inhibitors Loxapine Succinate
Loxapine Succinate

1
Azilect (0.5mg Tablet) 1 PA (Capsule)
Azilect

Rasagiline Mesylate Pimozide (Tablet) 1

Pimozide
Rasagiline Mesylate

1
(Tablet) Thioridazine HCl
Thioridazine HCl

1
Selegiline HCl (5mg (Tablet)
Selegiline HCl

1
Capsule, 5mg Tablet) Thiothixene (Capsule)
Thiothixene

1
Zelapar (Tablet
Zelapar

Trifluoperazine HCl
Trifluoperazine HCl

1 1
Dispersible) (Tablet)
Antipsychotics 2nd Generation/Atypical
1st Generation/Typical Abilify Maintena
Abilify Maintena

Chlorpromazine HCl
Chlorpromazine HCl
1
(Injection)
(100mg Tablet, 10mg Aripiprazole (10mg
Aripiprazole

Tablet, 200mg Tablet, Tablet, 15mg Tablet,

1
25mg Tablet, 50mg 20mg Tablet, 2mg
Tablet, 50mg/2ml 1 QL
Tablet, 30mg Tablet,
Injection) 5mg Tablet, 1mg/ml
Fluphenazine Oral Solution)
Fluphenazine Decanoate

1
Decanoate (Injection)

Bold type = Brand name drug Plain type = Generic drug

55 56
56 tRACK
Last updated November 1, 2018
25
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Aripiprazole ODT Paliperidone ER
Aripiprazole ODT Paliperidone ER

1 QL
(Tablet Dispersible) (1.5mg Tablet
Aristada (Injection)
Aristada

1 Extended-Release 24
Hour, 3mg Tablet
Fanapt (10mg Tablet,
Fanapt

1 QL
Extended-Release 24
12mg Tablet, 6mg 1 QL, ST Hour, 6mg Tablet
Tablet, 8mg Tablet) Extended-Release 24
Fanapt (1mg Tablet, Hour)
Fanapt

2mg Tablet, 4mg 1 QL, ST Paliperidone ER (9mg

Paliperidone ER

Tablet) Tablet Extended- 1 QL

Fanapt Titration Pack
Fanapt Titration Pack

Release 24 Hour)
1 ST
Quetiapine Fumarate
Quetiapine Fumarate

(Tablet)
Geodon (20mg
Geodon

(Tablet Immediate- 1 QL
1 Release)
Injection)
Quetiapine Fumarate
Quetiapine Fumarate ER

Invega Sustenna
Invega Sustenna

ER (Tablet Extended- 1 QL
(117mg/0.75ml
Release 24 Hour)
Injection, 156mg/ml
Rexulti (Tablet) 1 QL
Rexulti

Injection, 234mg/ 1
Risperdal Consta
Risperdal Consta

1.5ml Injection,
78mg/0.5ml (12.5mg Injection, 1
Injection) 25mg Injection)
Risperdal Consta
Risperdal Consta

Invega Sustenna
Invega Sustenna

(39mg/0.25ml 1 (37.5mg Injection, 1

Injection) 50mg Injection)
Risperidone (0.25mg
Risperidone

Invega Trinza
Invega Trinza

1 PA Tablet, 0.5mg Tablet,

(Injection)
1mg Tablet, 2mg 1
Latuda (Tablet) 1 QL
Latuda

Tablet, 3mg Tablet,

Nuplazid (Tablet) 1 PA, QL 4mg Tablet)
Nuplazid

Olanzapine (10mg Risperidone (1mg/ml

Olanzapine Risperidone

1 1
Injection) Oral Solution)
Olanzapine (10mg Risperidone ODT
Olanzapine Risperidone ODT

1
Tablet, 15mg Tablet, (Tablet Dispersible)
2.5mg Tablet, 20mg 1 QL Saphris (Tablet
Saphris

Tablet, 5mg Tablet, 1 QL

Sublingual)
7.5mg Tablet)
Olanzapine ODT
Olanzapine ODT

1 QL
(Tablet Dispersible)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
56 57
Last updated November 1, 2018
tRACK
57
26
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Seroquel XR (150mg Clozapine ODT
Seroquel XR Clozapine ODT

Tablet Extended- (200mg Tablet 1 QL

Release 24 Hour, Dispersible)
200mg Tablet Fazaclo (100mg
Fazaclo

Extended-Release 24 Tablet Dispersible,

1 PA, QL
Hour, 300mg Tablet 150mg Tablet 1 QL
Extended-Release 24 Dispersible, 200mg
Hour, 50mg Tablet Tablet Dispersible)
Extended-Release 24 Versacloz
Versacloz

Hour) 1
(Suspension)
Seroquel XR (400mg
Seroquel XR

Antivirals
Tablet Extended- 1 PA, QL
Anti-cytomegalovirus (CMV) Agents
Release 24 Hour)
Cidofovir (Injection) 1
Cidofovir

Vraylar (1.5mg
Vraylar

Ganciclovir (500mg
Ganciclovir

Capsule, 3mg 1 B/D, PA

Capsule, 4.5mg 1 QL, ST Injection)
Valcyte (450mg
Valcyte

Capsule, 6mg 1 QL
Capsule) Tablet)
Valganciclovir (Tablet) 1 QL
Valganciclovir

Vraylar (Capsule
Vraylar

1 ST
Therapy Pack) Valganciclovir
Valganciclovir Hydrochlorde

Ziprasidone HCl
Ziprasidone HCl

Hydrochlorde (Oral 1 QL
1 QL Solution)
(Capsule)
Zirgan (Gel) 1
Zirgan

Zyprexa Relprevv
Zyprexa Relprevv

1
(Injection) Anti-hepatitis B (HBV) Agents
Treatment-Resistant Adefovir Dipivoxil
Adefovir Dipivoxil

1
Clozapine (100mg
Clozapine

(Tablet)
Tablet, 25mg Tablet, Baraclude (0.05mg/
Baraclude

1
50mg Tablet, 200mg ml Oral Solution,
Tablet) 1
0.5mg Tablet, 1mg
Clozapine ODT
Clozapine ODT

Tablet)
(100mg Tablet Entecavir (Tablet) 1
1 QL
Entecavir

Dispersible, 25mg
Epivir HBV (5mg/ml
Epivir HBV

Tablet Dispersible) 1
Oral Solution)
Clozapine ODT
Clozapine ODT

Hepsera (Tablet) 1
Hepsera

(12.5mg Tablet
1 QL
Lamivudine (100mg
Lamivudine

Dispersible, 150mg 1
Tablet Dispersible) Tablet)

Bold type = Brand name drug Plain type = Generic drug

57 58
58 tRACK
Last updated November 1, 2018
27
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 QL Valacyclovir HCl
Valacyclovir HCl

Vemlidy (Tablet)
Vemlidy

1 QL
Anti-hepatitis C (HCV) Agents, Other (Tablet)
Intron A (Injection)
Intron A

1 PA Anti-HIV Agents, Integrase Inhibitors (INSTI)

Genvoya (Tablet) 1 QL
Genvoya

Pegasys (Injection) 1 PA
Pegasys

Isentress (100mg
Isentress

Pegasys ProClick
Pegasys ProClick

1 PA Packet, 25mg Tablet 1 QL

(Injection)
Chewable)
Ribasphere (200mg
Ribasphere

Isentress (100mg
Isentress

Tablet, 400mg Tablet, 1

600mg Tablet) Tablet Chewable, 1 QL
400mg Tablet)
Ribavirin (200mg
Ribavirin

1 Isentress HD (Tablet)
Isentress HD

1 QL
Tablet)
1 PA Stribild (Tablet) 1 QL
Stribild

Sylatron (Injection)
Sylatron

Anti-hepatitis C (HCV) Direct Acting Agents Tivicay (10mg Tablet) 1 QL

Tivicay

1 PA, QL Tivicay (25mg Tablet,

Tivicay

Daklinza (Tablet)
Daklinza

1 QL
Epclusa (Tablet)
Epclusa

1 PA, QL 50mg Tablet)

Triumeq (Tablet) 1 QL
Triumeq

Harvoni (Tablet) 1 PA, QL

Harvoni

Tybost (Tablet) 1 QL
Tybost

Mavyret (Tablet) 1 PA, QL

Mavyret

Sovaldi (Tablet)
Sovaldi

1 PA, QL Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors (NNRTI)
Vosevi (Tablet) 1 PA, QL
Vosevi

Atripla (Tablet) 1 QL
Atripla

Antiherpetic Agents
Complera (Tablet) 1 QL
Complera

Acyclovir (200mg
Acyclovir

Edurant (Tablet) 1 QL
Edurant

Capsule, 200mg/5ml 1
Suspension) Efavirenz (200mg
Efavirenz

Acyclovir (400mg
Acyclovir

Capsule, 600mg 1 QL
1 Tablet)
Tablet, 800mg Tablet)
Efavirenz (50mg
Efavirenz

Acyclovir (5%
Acyclovir

1 QL 1 QL
Ointment) Capsule)
Intelence (100mg
Intelence

Acyclovir Sodium
Acyclovir Sodium

1 B/D, PA 1 QL
(Injection) Tablet, 200mg Tablet)
1 QL Intelence (25mg
Intelence

Denavir (Cream)
Denavir

1 QL
Famciclovir (Tablet)
Famciclovir

1 QL Tablet)
Juluca (Tablet) 1 QL
Juluca

Trifluridine
Trifluridine

1 Nevirapine (Tablet) 1 QL
(Ophthalmic Solution)
Nevirapine

You can find information on what the abbreviations in this table mean on pages 6 - 7.
58 59
Last updated November 1, 2018 tRACK
59
28
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Nevirapine ER (Tablet Lamivudine (10mg/ml
Nevirapine ER Lamivudine

Extended-Release 24 1 QL Oral Solution, 150mg 1 QL

Hour) Tablet, 300mg Tablet)
1 QL Lamivudine/
Lamivudine/Zidovudine

Odefsey (Tablet)
Odefsey

1 QL
Rescriptor (Tablet)
Rescriptor

1 QL Zidovudine (Tablet)
Retrovir IV Infusion
Retrovir IV Infusion

Sustiva (200mg 1
Sustiva

(Injection)
Capsule, 600mg 1 QL
Stavudine (Capsule) 1 QL
Stavudine

Tablet)
Tenofovir Disoproxil
Tenofovir Disoproxil Fumarate

Sustiva (50mg
Sustiva

1 QL 1 QL
Capsule) Fumarate (Tablet)
Trizivir (Tablet) 1 QL
Trizivir

Symfi (Tablet) 1 QL
Symfi

Truvada (Tablet) 1 QL
Truvada

Symfi Lo (Tablet) 1 QL
Symfi Lo

Videx EC (125mg
Videx EC

Viramune (50mg/5ml
Viramune

1 QL Capsule Delayed- 1 QL
Suspension)
Release)
Anti-HIV Agents, Nucleoside and Nucleotide
Videx Pediatric (Oral
Videx Pediatric

Reverse Transcriptase Inhibitors (NRTI) 1 QL

Solution)
Abacavir (20mg/ml
Abacavir

Viread (150mg Tablet,

Viread

Oral Solution, 300mg 1 QL

Tablet) 200mg Tablet, 250mg
1 QL
Abacavir Sulfate/
Abacavir Sulfate/Lamivudine/Zidovudine

Tablet, 300mg Tablet,

Lamivudine/ 1 QL 40mg/gm Powder)
Zidovudine (Tablet) Zerit (1mg/ml Oral
Zerit

1 QL
Abacavir/Lamivudine Solution)
Abacavir/Lamivudine

1 QL
(Tablet) Ziagen (20mg/ml Oral
Ziagen

1 QL
Biktarvy (Tablet) 1 QL Solution)
Biktarvy

Zidovudine (100mg
Zidovudine

Cimduo (Tablet) 1 QL
Cimduo

Capsule, 300mg
Combivir (Tablet) 1 QL 1 QL
Combivir

Tablet, 50mg/5ml
Descovy (Tablet) 1 QL Syrup)
Descovy

Didanosine (Capsule Anti-HIV Agents, Other

Didanosine

1 QL
Delayed-Release) Fuzeon (Injection)
Fuzeon

1 QL
Emtriva (10mg/ml
Emtriva

Selzentry (150mg
Selzentry

Oral Solution, 200mg 1 QL Tablet, 300mg Tablet,

Capsule) 1 QL
75mg Tablet, 20mg/
Epzicom (Tablet) 1 QL
Epzicom

ml Oral Solution)

Bold type = Brand name drug Plain type = Generic drug

59 60
60 tRACK
Last updated November 1, 2018
29
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Selzentry (25mg Prezista (100mg/ml
Selzentry Prezista

1 QL
Tablet) Suspension, 150mg
1 QL
Anti-HIV Agents, Protease Inhibitors Tablet, 600mg Tablet,
Aptivus (100mg/ml
Aptivus

800mg Tablet)
Prezista (75mg
Prezista

Oral Solution, 250mg 1 QL 1 QL

Capsule) Tablet)
Reyataz (150mg
Reyataz

Atazanavir Sulfate
Atazanavir Sulfate

1 QL
(Capsule) Capsule, 200mg
Crixivan (Capsule)
Crixivan

1 QL Capsule, 300mg 1 QL
Capsule, 50mg
Evotaz (Tablet) 1 QL
Evotaz

Packet)
Fosamprenavir
Fosamprenavir Calcium

1 QL Ritonavir (Tablet) 1 QL
Ritonavir

Calcium (Tablet)
Viracept (Tablet) 1 QL
Viracept

Invirase (200mg
Invirase

Capsule, 500mg 1 QL Anti-influenza Agents

Tablet) Oseltamivir Phosphate
Oseltamivir Phosphate

Kaletra (100mg-25mg
Kaletra

(30mg Capsule, 45mg

Tablet, Capsule, 75mg 1 QL
1 QL Capsule, 6mg/ml
400mg-100mg/5ml
Suspension)
Oral Solution)
Relenza Diskhaler
Relenza Diskhaler

Kaletra (200mg-50mg 1 QL
Kaletra

1 QL (Aerosol Powder)
Tablet)
Rimantadine HCl
Rimantadine HCl

Lexiva (50mg/ml 1
Lexiva

1 QL (Tablet)
Suspension)
Tamiflu (6mg/ml
Tamiflu

Lexiva (700mg Tablet) 1

Lexiva

QL 1 QL
Suspension)
Lopinavir/Ritonavir
Lopinavir/Ritonavir

1 QL Anxiolytics
(Oral Solution)
Anxiolytics, Other
Norvir (100mg
Norvir

Buspirone HCl (Tablet) 1

Buspirone HCl

Capsule, 100mg
Hydroxyzine HCl
Hydroxyzine HCl

Packet, 100mg 1 QL 1
Tablet, 80mg/ml Oral (10mg/5ml Syrup)
Hydroxyzine HCl
Hydroxyzine HCl

Solution)
Prezcobix (Tablet)
Prezcobix

1 QL (25mg/ml Injection, 1 B/D, PA

50mg/ml Injection)
Hydroxyzine HCl
Hydroxyzine HCl

1
(Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
60 61
Last updated November 1, 2018
tRACK
61
30
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Benzodiazepines Lithium Carbonate
Lithium Carbonate

Alprazolam (Tablet
Alprazolam

(150mg Capsule
1 QL Immediate-Release,
Immediate-Release)
300mg Capsule
Chlordiazepoxide HCl
Chlordiazepoxide HCl

1 Immediate-Release, 1
(Capsule)
600mg Capsule
Clonazepam (Tablet) 1 QL
Clonazepam

Immediate-Release,
Clonazepam ODT
Clonazepam ODT

300mg Tablet
1 QL Immediate-Release)
(Tablet Dispersible)
Clorazepate Lithium Carbonate ER
Lithium Carbonate ER
Clorazepate Dipotassium

1 QL (Tablet Extended- 1
Dipotassium (Tablet)
Diazepam (10mg
Diazepam

Release)
Tablet, 2mg Tablet, 1 QL Blood Glucose Regulators
5mg Tablet) Antidiabetic Agents
Diazepam (5mg/5ml
Diazepam

Acarbose (Tablet) 1 QL
Acarbose

1
Oral Solution)
Avandia (Tablet) 1 PA, QL
Avandia

Diazepam Intensol
Diazepam Intensol

1 QL Bydureon Bcise (Auto

Bydureon Bcise

(5mg/ml Concentrate) 1 QL
injector)
Lorazepam (0.5mg
Lorazepam

Bydureon Pen
Bydureon Pen

Tablet, 1mg Tablet, 1 QL 1 QL

2mg Tablet) (Injection)
Bydureon Vial
Bydureon Vial

Lorazepam (2mg/ml
Lorazepam

1 QL 1 QL
Concentrate) (Injection)
Bipolar Agents Byetta (Injection) 1 QL
Byetta

Mood Stabilizers Cycloset (Tablet) 1 PA, QL

Cycloset

Divalproex Sodium
Divalproex Sodium

Glimepiride (Tablet) 1 QL
Glimepiride

(Capsule Sprinkle 1
Glipizide (Tablet
Glipizide

Delayed-Release) 1 QL
Immediate-Release)
Divalproex Sodium DR
Divalproex Sodium DR

Glipizide ER (Tablet
Glipizide ER

(Tablet Delayed- 1
Extended-Release 24 1 QL
Release)
Hour)
Divalproex Sodium ER
Divalproex Sodium ER

Glipizide/Metformin
Glipizide/Metformin HCl

(Tablet Extended- 1 1 QL
HCl (Tablet)
Release 24 Hour)
Glyxambi (Tablet) 1 QL
Glyxambi

Lithium (Oral
Lithium

1 Invokamet (Tablet)
Invokamet

1 QL
Solution)

Bold type = Brand name drug Plain type = Generic drug

61 62
62 tRACK
Last updated November 1, 2018
31
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Invokamet XR (Tablet Pioglitazone HCl/
Invokamet XR Pioglitazone HCl/Metformin HCl

1 QL
Extended-Release 24 1 QL Metformin HCl (Tablet)
Hour) Repaglinide (Tablet) 1 QL
Repaglinide

Invokana (Tablet) 1 QL Repaglinide/Metformin

Invokana
Repaglinide/Metformin HCl

1 QL
Janumet (Tablet
Janumet

HCl (Tablet)
1 QL
Immediate-Release) Riomet (Oral Solution) 1 QL
Riomet

Janumet XR (Tablet
Janumet XR

Soliqua 100/33
Soliqua 100/33

1 QL
Extended-Release 24 1 QL (Injection)
Hour) SymlinPen 120
SymlinPen 120

1 PA
Januvia (Tablet) 1 QL
Januvia

(Injection)
1 QL SymlinPen 60
SymlinPen 60

Jardiance (Tablet)
Jardiance

1 PA
Jentadueto (Tablet)
Jentadueto

1 QL (Injection)
Synjardy (Tablet) 1 QL
Synjardy

Jentadueto XR
Jentadueto XR

1 QL Synjardy XR (Tablet
Synjardy XR

(Tablet Extended-
Release 24 Hour) Extended-Release 24 1 QL
Kombiglyze XR
Kombiglyze XR

Hour)
1 QL Tradjenta (Tablet) 1 QL
Tradjenta

(Tablet Extended-
Release 24 Hour) Trulicity (Injection)
Trulicity

1 QL
Metformin HCl (Tablet
Metformin HCl

Victoza (Injection) 1 QL
Victoza

1 QL
Immediate-Release)
Glycemic Agents
Metformin HCl ER
Metformin HCl ER

GlucaGen HypoKit
GlucaGen HypoKit

(500mg Tablet 1
Extended-Release 24 (Injection)
Hour, 750mg Tablet 1 QL Glucagon Emergency
Glucagon Emergency Kit

1
Extended-Release 24 Kit (Injection)
Hour) (Generic Proglycem
Proglycem

Glucophage XR) 1
(Suspension)
Miglitol (Tablet) 1 QL
Miglitol

Insulins
Nateglinide (Tablet) 1 QL
Nateglinide

Humalog Cartridge
Humalog Cartridge

1
Onglyza (Tablet) 1 QL (Injection)
Onglyza

Pioglitazone HCl Humalog Junior

Humalog Junior KwikPen
Pioglitazone HCl

1 QL 1
(Tablet) KwikPen (Injection)
Pioglitazone HCl/ Humalog KwikPen
Pioglitazone HCl/Glimepiride Humalog KwikPen

1 QL 1
Glimepiride (Tablet) (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
62 63
Last updated November 1, 2018tRACK
63
32
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Humalog Mix 50/50 Toujeo SoloStar
Humalog Mix 50/50 KwikPen Toujeo SoloStar

1 1
KwikPen (Injection) (Injection)
Humalog Mix 50/50 Tresiba FlexTouch
Humalog Mix 50/50 Vial Tresiba FlexTouch

1 1
Vial (Injection) (Injection)
Humalog Mix 75/25 Blood Products/Modifiers/Volume Expanders
Humalog Mix 75/25 KwikPen

1
KwikPen (Injection) Anticoagulants
Humalog Mix 75/25
Humalog Mix 75/25 Vial

Argatroban (125mg/
Argatroban

1 1 B/D, PA
Vial (Injection) 125ml-0.9% Injection)
Humalog Vial
Humalog Vial

Argatroban (250mg/
Argatroban

1 1 B/D, PA
(Injection) 2.5ml Injection)
Humulin 70/30 1
Humulin 70/30 KwikPen

Coumadin (Tablet)
Coumadin

1
KwikPen (Injection) Eliquis (Tablet)
Eliquis

1 QL
Humulin 70/30 Vial
Humulin 70/30 Vial

1 Eliquis Starter Pack

Eliquis Starter Pack

(Injection) 1 QL
(Tablet)
Humulin N KwikPen
Humulin N KwikPen

1 Enoxaparin Sodium
Enoxaparin Sodium

(Injection) (100mg/ml Injection,

Humulin N Vial 120mg/0.8ml Injection,
Humulin N Vial

1
(Injection) 150mg/ml Injection,
Humulin R U-500
Humulin R U-500 KwikPen

30mg/0.3ml Injection, 1 QL
1 40mg/0.4ml Injection,
KwikPen (Injection)
60mg/0.6ml Injection,
Humulin R U-500 Vial
Humulin R U-500 Vial

80mg/0.8ml Injection,
(Concentrated) 1 300mg/3ml Injection)
(Injection)
Fondaparinux Sodium
Fondaparinux Sodium

Humulin R Vial
Humulin R Vial

1 (10mg/0.8ml Injection,
(Injection) 1
5mg/0.4ml Injection,
Lantus SoloStar 7.5mg/0.6ml Injection)
Lantus SoloStar

1
(Injection) Fondaparinux Sodium
Fondaparinux Sodium

1
Lantus Vial (Injection)
Lantus Vial

1 (2.5mg/0.5ml Injection)
Heparin Sodium
Heparin Sodium

Levemir FlexTouch
Levemir FlexTouch

1 (10000unit/ml
(Injection)
Injection, 20000unit/ml 1
Levemir Vial
Levemir Vial

1 Injection, 5000unit/ml
(Injection) Injection)
Toujeo Max Solostar
Toujeo Max Solostar

Heparin Sodium
Heparin Sodium

1 1 B/D, PA
(Injection) (1000unit/ml Injection)

Bold type = Brand name drug Plain type = Generic drug

63 64
64 tRACK
Last updated November 1, 2018
33
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Heparin Sodium/D5W 1 ST
Heparin Sodium/D5W

Granix (Injection)
Granix

1
(Injection) Leukine (Injection)
Leukine

1 PA
Jantoven (Tablet) 1
Jantoven

Mozobil (Injection) 1
Mozobil

Pradaxa (Capsule) 1 QL
Pradaxa

Neulasta (Injection) 1 PA
Neulasta

Warfarin Sodium
Warfarin Sodium

1 Neupogen (Injection) 1 ST
Neupogen

(Tablet)
Procrit (10000unit/ml
Procrit

Xarelto (Tablet) 1 QL
Xarelto

Injection, 2000unit/
Xarelto Starter Pack
Xarelto Starter Pack

1 QL ml Injection,
(Tablet Therapy Pack) 1 PA
3000unit/ml
Blood Formation Modifiers Injection, 4000unit/
Anagrelide HCl
Anagrelide HCl

ml Injection)
1
(Capsule) Procrit (20000unit/ml
Procrit

Aranesp Albumin 1 PA
Aranesp Albumin Free

Injection, 40000unit/
Free (100mcg/0.5ml ml Injection)
Injection, 100mcg/ml Promacta (Tablet)
Promacta

1 PA, QL
Injection, 150mcg/
Vidaza (Injection) 1 PA
Vidaza

0.3ml Injection,
Zarxio (Solution
Zarxio

200mcg/0.4ml 1
Injection, 200mcg/ml Prefilled Syringe)
1 PA Hemostasis Agents
Injection, 300mcg/
Tranexamic Acid
Tranexamic Acid

0.6ml Injection,
300mcg/ml Injection, (1000mg/10ml 1
500mcg/ml Injection, Injection)
Tranexamic Acid
Tranexamic Acid

60mcg/0.3ml 1
Injection, 60mcg/ml (650mg Tablet)
Injection) Platelet Modifying Agents
Aranesp Albumin Aspirin/Dipyridamole
Aranesp Albumin Free Aspirin/Dipyridamole

Free (10mcg/0.4ml (Capsule Extended- 1 QL

Injection, 25mcg/ Release 12 Hour)
0.42ml Injection, Brilinta (Tablet) 1 QL
Brilinta

1 PA
25mcg/ml Injection, Cilostazol (Tablet)
Cilostazol

1
40mcg/0.4ml
Clopidogrel (75mg
Clopidogrel

Injection, 40mcg/ml 1 QL
Tablet)
Injection)
Prasugrel (Tablet) 1 QL
Prasugrel

Azacitidine (Injection) 1 PA
Azacitidine

Cardiovascular Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7.
64 65
Last updated November 1, 2018
tRACK
65
34
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Alpha-adrenergic Agonists Valsartan (Tablet) 1 QL
Valsartan

Clonidine HCl (0.1mg Angiotensin-converting Enzyme (ACE)

Clonidine HCl

Tablet Immediate- Inhibitors

Release, 0.2mg Tablet
1 Benazepril HCl (Tablet) 1 QL
Benazepril HCl

Immediate-Release,
0.3mg Tablet Captopril (Tablet) 1 QL
Captopril

Immediate-Release) Enalapril Maleate

Enalapril Maleate

1 QL
Clonidine HCl (0.1mg/ (Tablet)
Clonidine HCl

24hr Patch Weekly, Fosinopril Sodium

Fosinopril Sodium

0.2mg/24hr Patch 1 1 QL
(Tablet)
Weekly, 0.3mg/24hr
Lisinopril (Tablet) 1 QL
Lisinopril

Patch Weekly)
Moexipril HCl (Tablet) 1 QL
Moexipril HCl

Methyldopa (Tablet) 1
Methyldopa

Perindopril Erbumine
Perindopril Erbumine

Methyldopate HCl 1 QL
Methyldopate HCl

1 (Tablet)
(Injection)
Quinapril HCl (Tablet) 1 QL
Quinapril HCl

Midodrine HCl (Tablet) 1

Midodrine HCl

Ramipril (Capsule) 1 QL
Ramipril

Northera (Capsule) 1 PA, QL

Northera

Trandolapril (Tablet) 1 QL
Trandolapril

Alpha-adrenergic Blocking Agents

Doxazosin Mesylate
Doxazosin Mesylate

Antiarrhythmics
1 Amiodarone HCl
(Tablet)
Amiodarone HCl

1
Phenoxybenzamine
Phenoxybenzamine HCl

(200mg Tablet)
1 Amiodarone HCl
HCl (Capsule)
Amiodarone HCl

1
Prazosin HCl (Capsule) 1
Prazosin HCl

(50mg/ml Injection)
Dofetilide (Capsule) 1
Dofetilide

Angiotensin II Receptor Antagonists

Flecainide Acetate
Flecainide Acetate

Candesartan Cilexetil
Candesartan Cilexetil

1 QL 1
(Tablet) (Tablet)
Mexiletine HCl
Mexiletine HCl

Edarbi (Tablet) 1 QL 1
Edarbi

(Capsule)
Eprosartan Mesylate
Eprosartan Mesylate

1 QL Multaq (Tablet)
Multaq

1 QL
(Tablet)
Pacerone (200mg
Pacerone

Irbesartan (Tablet) 1 QL 1
Irbesartan

Tablet)
Losartan Potassium
Losartan Potassium

1 QL Procainamide HCl
Procainamide HCl

(Tablet) 1
(Injection)
Olmesartan Medoxomil
Olmesartan Medoxomil

1 QL Propafenone HCl
Propafenone HCl

(Tablet) 1
(Tablet)
Telmisartan (Tablet) 1 QL
Telmisartan

Bold type = Brand name drug Plain type = Generic drug

65 66
66 tRACK
Last updated November 1, 2018
35
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Propafenone HCl ER Metoprolol Tartrate
Propafenone HCl ER Metoprolol Tartrate

(Capsule Extended- 1 (100mg Tablet

Release 12 Hour) Immediate-Release,
Quinidine Gluconate
Quinidine Gluconate

25mg Tablet 1
1 Immediate-Release,
(Injection)
50mg Tablet
Quinidine Gluconate
Quinidine Gluconate CR

Immediate-Release)
CR (Tablet Extended- 1
Metoprolol Tartrate
Metoprolol Tartrate

Release) 1
(5mg/5ml Injection)
Quinidine Sulfate
Quinidine Sulfate

1 Nadolol (Tablet)
Nadolol

1
(Tablet)
Pindolol (Tablet) 1
Pindolol

Sotalol HCl (AF)

Sotalol HCl

1
(Tablet) Propranolol HCl
Propranolol HCl

Sotalol HCl (Tablet)

Sotalol HCl

1 (20mg/5ml Oral
1
Solution, 40mg/5ml
Beta-adrenergic Blocking Agents
Oral Solution)
Acebutolol HCl
Acebutolol HCl

1 Propranolol HCl (1mg/

Propranolol HCl

(Capsule) 1
ml Injection)
Atenolol (Tablet) 1
Atenolol

Propranolol HCl
Propranolol HCl

Betaxolol HCl (10mg

Betaxolol HCl

1 (Tablet Immediate- 1
Tablet, 20mg Tablet) Release)
Bisoprolol Fumarate
Bisoprolol Fumarate

Propranolol HCl ER
Propranolol HCl ER

1
(Tablet) (Capsule Extended- 1
Bystolic (Tablet)
Bystolic

1 QL Release 24 Hour)
Timolol Maleate (10mg
Timolol Maleate

Carvedilol (Tablet) 1
Carvedilol

Tablet, 20mg Tablet, 1

Labetalol HCl (100mg
Labetalol HCl

5mg Tablet)
Tablet, 200mg Tablet, 1
300mg Tablet) Calcium Channel Blocking Agents
Afeditab CR (Tablet
Afeditab CR

Labetalol HCl (5mg/ml

Labetalol HCl

1 Extended-Release 24 1 QL
Injection)
Hour)
Metoprolol Succinate
Metoprolol Succinate ER

Amlodipine Besylate
Amlodipine Besylate

ER (Tablet Extended- 1 1
Release 24 Hour) (Tablet)
Cardene IV (Injection) 1
Cardene IV

Cartia XT (Capsule
Cartia XT

Extended-Release 24 1
Hour)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
66 67
Last updated November 1, 2018
tRACK
67
36
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Dilt-XR (Capsule Verapamil HCl (120mg
Dilt-XR Verapamil HCl

Extended-Release 24 1 Tablet Immediate-

Hour) Release, 40mg Tablet
1
Diltiazem HCl (100mg
Diltiazem HCl

Immediate-Release,
Injection, 50mg/10ml 1 80mg Tablet
Injection) Immediate-Release)
Verapamil HCl (2.5mg/
Verapamil HCl

Diltiazem HCl (120mg

Diltiazem HCl

1
Tablet Immediate- ml Injection)
Release, 30mg Tablet Verapamil HCl ER
Verapamil HCl ER

Immediate-Release, (100mg Capsule

1
60mg Tablet Extended-Release 24
Immediate-Release, Hour, 120mg Capsule
90mg Tablet Extended-Release 24
Immediate-Release) Hour, 180mg Capsule
Diltiazem HCl ER
Diltiazem HCl ER

Extended-Release 24
1
(Capsule Extended- 1 Hour, 200mg Capsule
Release) Extended-Release 24
Hour, 240mg Capsule
Felodipine ER (Tablet
Felodipine ER

Extended-Release 24
Extended-Release 24 1
Hour, 300mg Capsule
Hour)
Extended-Release 24
Matzim LA (Tablet
Matzim LA

Hour)
Extended-Release 24 1
Verapamil HCl ER
Verapamil HCl ER

Hour)
(120mg Tablet
Nicardipine HCl
Nicardipine HCl

1 Extended-Release,
(2.5mg/ml Injection) 180mg Tablet 1
Nicardipine HCl (20mg Extended-Release,
Nicardipine HCl

Capsule, 30mg 1 240mg Tablet

Capsule) Extended-Release)
Nifedipine ER (Tablet Verapamil HCl SR
Nifedipine ER Verapamil HCl SR

Extended-Release 24 1 QL (Capsule Extended- 1

Hour) Release 24 Hour)
Nimodipine (Capsule) 1 Cardiovascular Agents, Other
Nimodipine

Nymalize (Oral Amiloride/

Nymalize
Amiloride/Hydrochlorothiazide

1
Solution) Hydrochlorothiazide 1
Taztia XT (Capsule
Taztia XT

(Tablet)
Extended-Release 24 1 Amlodipine Besylate/
Amlodipine Besylate/Atorvastatin Calcium

Hour) Atorvastatin Calcium 1 QL

(Tablet)

Bold type = Brand name drug Plain type = Generic drug

67 68
68 tRACK
Last updated November 1, 2018
37
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Amlodipine Besylate/ 1 QL
Amlodipine Besylate/Benazepril HCl

Edarbyclor (Tablet)
Edarbyclor

Benazepril HCl 1 QL Enalapril Maleate/

Enalapril Maleate/Hydrochlorothiazide

(Capsule) Hydrochlorothiazide 1 QL
Amlodipine Besylate/ (Tablet)
Amlodipine Besylate/Valsartan

1 QL
Valsartan (Tablet) Entresto (Tablet)
Entresto

1 QL
Amlodipine/
Amlodipine/Olmesartan Medoxomil

Fosinopril Sodium/
Fosinopril Sodium/Hydrochlorothiazide

Olmesartan Medoxomil 1 QL
Hydrochlorothiazide 1 QL
(Tablet)
(Tablet)
Amlodipine/Valsartan/
Amlodipine/Valsartan/Hydrochlorothiazide

Irbesartan/
Irbesartan/Hydrochlorothiazide

Hydrochlorothiazide 1 QL
Hydrochlorothiazide 1 QL
(Tablet)
(Tablet)
Atenolol/
Atenolol/Chlorthalidone

1 Lanoxin (125mcg
Lanoxin

Chlorthalidone (Tablet)
Tablet, 250mcg
Benazepril HCl/
Benazepril HCl/Hydrochlorothiazide

1
Tablet, 62.5mcg
Hydrochlorothiazide 1 QL
Tablet)
(Tablet)
Lisinopril/
Lisinopril/Hydrochlorothiazide

BiDil (Tablet) 1 QL
BiDil

Hydrochlorothiazide 1 QL
Bisoprolol Fumarate/
Bisoprolol Fumarate/Hydrochlorothiazide

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

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

(Tablet)
Hydrochlorothiazide 1 QL Methyldopa/
Methyldopa/Hydrochlorothiazide

(Tablet) Hydrochlorothiazide 1
Captopril/
Captopril/Hydrochlorothiazide

(Tablet)
Hydrochlorothiazide 1 QL Metoprolol/
Metoprolol/Hydrochlorothiazide

(Tablet) Hydrochlorothiazide 1
Corlanor (Tablet) 1 PA, QL (Tablet)
Corlanor

1 Moexipril/
Moexipril/Hydrochlorothiazide

Demser (Capsule)
Demser

Digitek (Tablet)
Digitek

1 Hydrochlorothiazide 1 QL
(Tablet)
Digox (Tablet) 1
Digox

Nadolol/
Nadolol/Bendroflumethiazide

Digoxin (0.05mg/ml
Digoxin

1 Bendroflumethiazide 1
Oral Solution) (Tablet)
Digoxin (0.25mg/ml
Digoxin

1
Injection)
Digoxin (125mcg
Digoxin

1
Tablet, 250mcg Tablet)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
68 69
Last updated November 1, 2018 tRACK
69
38
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Olmesartan Diuretics, Carbonic Anhydrase Inhibitors
Olmesartan Medoxomil/Amlodipine/Hydrochlorothiazide

Medoxomil/ Acetazolamide (Tablet

Acetazolamide

Amlodipine/ 1 QL 1
Immediate-Release)
Hydrochlorothiazide
Acetazolamide ER
Acetazolamide ER

(Tablet)
(Capsule Extended- 1
Olmesartan
Olmesartan Medoxomil/Hydrochlorothiazide

Release 12 Hour)
Medoxomil/
1 QL Acetazolamide Sodium
Acetazolamide Sodium

Hydrochlorothiazide 1
(Injection)
(Tablet)
Methazolamide
Methazolamide

Pentoxifylline ER 1
Pentoxifylline ER

(Tablet)
(Tablet Extended- 1
Release) Diuretics, Loop
Bumetanide (0.25mg/
Bumetanide

Propranolol/
Propranolol/Hydrochlorothiazide

1
Hydrochlorothiazide 1 ml Injection)
(Tablet) Bumetanide (0.5mg
Bumetanide

Quinapril/
Quinapril/Hydrochlorothiazide

Tablet, 1mg Tablet, 1

Hydrochlorothiazide 1 QL 2mg Tablet)
(Tablet) Edecrin (Tablet) 1
Edecrin

Ranexa (Tablet Ethacrynic Acid

Ranexa
Ethacrynic Acid

1
Extended-Release 12 1 QL (Tablet)
Hour) Furosemide (10mg/ml
Furosemide

1 B/D, PA
Spironolactone/ Injection)
Spironolactone/Hydrochlorothiazide

Hydrochlorothiazide 1 Furosemide (10mg/ml

Furosemide

(Tablet) Oral Solution, 8mg/ml 1

Telmisartan/ Oral Solution)
Telmisartan/Amlodipine

1 QL
Amlodipine (Tablet) Furosemide (20mg
Furosemide

Telmisartan/ Tablet, 40mg Tablet, 1

Telmisartan/Hydrochlorothiazide

Hydrochlorothiazide 1 QL 80mg Tablet)

(Tablet) Torsemide (Tablet)
Torsemide

1
Triamterene/
Triamterene/Hydrochlorothiazide

Diuretics, Potassium-sparing
Hydrochlorothiazide
Amiloride HCl (Tablet) 1
Amiloride HCl

(37.5mg-25mg Tablet,
1
75mg-50mg Tablet, Dyrenium (Capsule) 1
Dyrenium

37.5mg-25mg Eplerenone (Tablet)

Eplerenone

1
Capsule)
Spironolactone
Spironolactone

Valsartan/
Valsartan/Hydrochlorothiazide

1
(Tablet)
Hydrochlorothiazide 1 QL
(Tablet) Diuretics, Thiazide

Bold type = Brand name drug Plain type = Generic drug

69 70
70 tRACK
Last updated November 1, 2018
39
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Chlorothiazide (Tablet) 1 Pravastatin Sodium
Pravastatin Sodium
Chlorothiazide

1 QL
Chlorothiazide Sodium
Chlorothiazide Sodium

(Tablet)
1 B/D, PA Rosuvastatin Calcium
(Injection)
Rosuvastatin Calcium

1 QL
Chlorthalidone (Tablet) 1
Chlorthalidone
(Tablet)
Simvastatin (Tablet) 1 QL
Simvastatin

Diuril (Suspension) 1
Diuril

Dyslipidemics, Other
Hydrochlorothiazide
Hydrochlorothiazide

Cholestyramine
Cholestyramine

(12.5mg Capsule, 1
1 (Packet)
12.5mg Tablet, 25mg
Tablet, 50mg Tablet) Cholestyramine Light
Cholestyramine Light

1
Indapamide (Tablet)
Indapamide

1 (Powder)
Colesevelam HCl
Colesevelam HCl

Methyclothiazide 1
Methyclothiazide

1 (Tablet)
(Tablet)
Colestipol HCl (1gm
Colestipol HCl

Metolazone (Tablet) 1 1
Metolazone

Tablet)
Dyslipidemics, Fibric Acid Derivatives
Colestipol HCl (5gm
Colestipol HCl

Fenofibrate (145mg
Fenofibrate

1
1 Packet)
Tablet, 48mg Tablet)
Ezetimibe (Tablet) 1 QL
Ezetimibe

Fenofibrate (160mg
Fenofibrate

1 Ezetimibe/Simvastatin
Ezetimibe/Simvastatin

Tablet, 54mg Tablet) 1 QL

(Tablet)
Fenofibrate Micronized
Fenofibrate Micronized

1 Juxtapid (Capsule)
Juxtapid

1 PA, LA
(Capsule)
Kynamro (Injection) 1 PA, LA
Kynamro

Fenofibric Acid
Fenofibric Acid

1
(Tablet) Niacin ER (Tablet
Niacin ER

1
Fenofibric Acid DR
Fenofibric Acid DR

Extended-Release)
(Capsule Delayed- 1 Niacor (Tablet) 1
Niacor

Release) Omega-3-Acid Ethyl

Omega-3-Acid Ethyl Esters

Gemfibrozil (Tablet) 1 Esters (Capsule) 1 QL

Gemfibrozil

Dyslipidemics, HMG CoA Reductase (Generic Lovaza)

Inhibitors Praluent (Injection) 1 PA, QL
Praluent

Atorvastatin Calcium Prevalite (Packet) 1

Atorvastatin Calcium
Prevalite

1 QL
(Tablet)
Repatha (Injection) 1 PA, QL
Repatha

Fluvastatin (Capsule
Fluvastatin

1 QL Repatha Pushtronex
Repatha Pushtronex System

Immediate-Release) 1 PA, QL
System (Injection)
Livalo (Tablet) 1 QL
Livalo

Repatha SureClick
Repatha SureClick

Lovastatin (Tablet)
Lovastatin

1 QL 1 PA, QL
(Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
70 71
Last updated November 1, 2018tRACK
71
40
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 Nitroglycerin Lingual
Nitroglycerin Lingual

Vascepa (Capsule)
Vascepa

1
Welchol (3.75gm
Welchol

(Translingual Solution)
Nitroglycerin
Nitroglycerin Transdermal

Packet, 625mg 1
Tablet) Transdermal (Patch 24 1
Hour)
Vasodilators, Direct-acting Arterial
Nitrostat (Tablet
Nitrostat

Hydralazine HCl 1
Hydralazine HCl

Sublingual)
(100mg Tablet, 10mg
1 Central Nervous System Agents
Tablet, 25mg Tablet,
50mg Tablet) Attention Deficit Hyperactivity Disorder
Hydralazine HCl
Hydralazine HCl

Agents, Amphetamines
1
(20mg/ml Injection) Amphetamine/
Amphetamine/Dextroamphetamine

Minoxidil (Tablet)
Minoxidil

1 Dextroamphetamine
(10mg Capsule
Vasodilators, Direct-acting Arterial/Venous
Extended-Release 24
Isosorbide Dinitrate
Isosorbide Dinitrate

Hour, 15mg Capsule

(Tablet Immediate- 1 Extended-Release 24
Release) Hour, 20mg Capsule
Isosorbide Dinitrate ER Extended-Release 24 1 QL
Isosorbide Dinitrate ER

(Tablet Extended- 1 Hour, 25mg Capsule

Release) Extended-Release 24
Isosorbide Mononitrate
Isosorbide Mononitrate

Hour, 30mg Capsule

(Tablet Immediate- 1 Extended-Release 24
Release) Hour, 5mg Capsule
Extended-Release 24
Isosorbide Mononitrate
Isosorbide Mononitrate ER

Hour)
ER (Tablet Extended- 1
Release 24 Hour)
Minitran (Patch 24
Minitran

1
Hour)
Nitro-Bid (Ointment) 1
Nitro-Bid

Nitroglycerin (0.3mg
Nitroglycerin

Tablet Sublingual,
0.4mg Tablet 1
Sublingual, 0.6mg
Tablet Sublingual)
Nitroglycerin (5mg/ml
Nitroglycerin

1
Injection)

Bold type = Brand name drug Plain type = Generic drug

71 72
72 tRACK
Last updated November 1, 2018
41
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Amphetamine/ Attention Deficit Hyperactivity Disorder
Amphetamine/Dextroamphetamine

Dextroamphetamine Agents, Non-amphetamines

(10mg Tablet Atomoxetine (Capsule) 1
Atomoxetine

QL
Immediate-Release,
Clonidine HCl ER
Clonidine HCl ER

12.5mg Tablet
Immediate-Release, (Tablet Extended- 1 PA
15mg Tablet Release 12 Hour)
Immediate-Release, 1 QL Dexmethylphenidate
Dexmethylphenidate HCl

20mg Tablet HCl (Tablet Immediate- 1 QL

Immediate-Release, Release)
30mg Tablet Dexmethylphenidate
Dexmethylphenidate HCl ER

Immediate-Release, HCl ER (Capsule

5mg Tablet Immediate- 1
Extended-Release 24
Release, 7.5mg Tablet Hour)
Immediate-Release)
Guanfacine ER (Tablet
Guanfacine ER

Dextroamphetamine
Dextroamphetamine Sulfate

Extended-Release 24 1
Sulfate (10mg Tablet, 1 QL Hour)
5mg Tablet)
Metadate ER (Tablet
Metadate ER

Dextroamphetamine
Dextroamphetamine Sulfate ER

1 QL
Extended-Release)
Sulfate ER (Capsule
1 QL Methylphenidate HCl
Methylphenidate HCl

Extended-Release 24
(10mg Tablet
Hour)
Immediate-Release,
Vyvanse (10mg
Vyvanse

20mg Tablet
1 QL
Capsule, 20mg Immediate-Release,
Capsule, 30mg 5mg Tablet Immediate-
Capsule, 40mg Release) (Generic
Capsule, 50mg Ritalin)
Capsule, 60mg Methylphenidate HCl
Methylphenidate HCl

Capsule, 70mg (10mg/5ml Oral

1 QL
Capsule, 10mg Tablet Solution, 5mg/5ml Oral
1 Solution)
Chewable, 20mg
Methylphenidate HCl
Methylphenidate HCl ER

Tablet Chewable,
30mg Tablet ER (10mg Tablet
Chewable, 40mg Extended-Release, 1 QL
Tablet Chewable, 20mg Tablet Extended-
Release)
50mg Tablet
Chewable, 60mg Central Nervous System, Other
Austedo (Tablet) 1 PA, QL
Austedo

Tablet Chewable)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
72 73
Last updated November 1, 2018
tRACK
73
42
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Ingrezza (Capsule) 1 PA, QL Avonex (Injection) 1
Ingrezza Avonex

Namzaric (Therapy Avonex Pen

Namzaric Avonex Pen

1
Pack, Capsule (Injection)
1 PA, QL
Extended-Release 24 Betaseron (Injection)
Betaseron

1
Hour)
Copaxone (Injection) 1
Copaxone

Nuedexta (Capsule) 1 PA
Nuedexta

Gilenya (Capsule) 1 QL
Gilenya

Rilutek (Tablet) 1
Rilutek

Glatiramer Acetate
Glatiramer Acetate

Riluzole (Tablet) 1 (Solution Prefilled 1

Riluzole

Tetrabenazine (Tablet)
Tetrabenazine

1 PA, QL Syringe)
Glatopa (Injection) 1
Glatopa

Xenazine (Tablet) 1 PA, QL, LA

Xenazine

Rebif (Injection) 1
Rebif

Fibromyalgia Agents
Rebif Rebidose
Rebif Rebidose

Duloxetine HCl (20mg

Duloxetine HCl

1
Capsule Delayed- (Injection)
Release, 30mg Rebif Rebidose
Rebif Rebidose Titration Pack

Capsule Delayed- 1 QL Titration Pack 1

Release, 60mg (Injection)
Capsule Delayed-
Rebif Titration Pack
Rebif Titration Pack

Release) 1
(Injection)
Lyrica (100mg
Lyrica

Tecfidera (Capsule
Tecfidera

Capsule, 150mg 1 QL
Capsule, 200mg Delayed-Release)
Tecfidera Starter
Tecfidera Starter Pack

Capsule, 225mg 1
Capsule, 25mg Pack
1 QL
Tysabri (Injection) 1 PA
Tysabri

Capsule, 300mg
Capsule, 50mg Dental and Oral Agents
Capsule, 75mg Dental and Oral Agents
Capsule, 20mg/ml
Chlorhexidine
Chlorhexidine Gluconate Oral Rinse

Oral Solution) Gluconate Oral Rinse 1

Savella (Tablet) 1 (Solution)
Savella

Savella Titration Pack 1 1

Savella Titration Pack

Kepivance (Injection)
Kepivance

Multiple Sclerosis Agents Periogard (Solution)

Periogard

1
Ampyra (Tablet
Ampyra

Pilocarpine HCl (5mg

Pilocarpine HCl

1 QL 1
Extended-Release 12 Tablet, 7.5mg Tablet)
Hour)
Aubagio (Tablet) 1 QL
Aubagio

Bold type = Brand name drug Plain type = Generic drug

73 74
74 tRACK
Last updated November 1, 2018
43
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Triamcinolone Cortisporin
Triamcinolone Acetonide Dental Paste Cortisporin

Acetonide Dental 1 (0.5%-0.5% Cream, 1

Paste (Paste) 1%-0.5% Ointment)
Dermatological Agents Cosentyx (Injection)
Cosentyx

1 PA
Dermatological Agents Cosentyx Sensoready
Cosentyx Sensoready Pen

1 PA
Acitretin (Capsule) 1
Acitretin

Pen (Injection)
Adapalene (0.1% Diclofenac Sodium
Adapalene Diclofenac Sodium

1 1 PA
Cream, 0.1% Gel) (3% Gel)
Ammonium Lactate 1 PA
Ammonium Lactate

Doxepin HCl (Cream)

Doxepin HCl

(12% Cream, 12% 1 Elidel (Cream)

Elidel

1 ST
Lotion)
Ery (2% Pad) 1
Ery

Calcipotriene (0.005%
Calcipotriene

Cream, 0.005% 1 Erythromycin (2%

Erythromycin

1
External Solution) External Solution)
Erythromycin (2% Gel) 1
Erythromycin

Calcitriol (3mcg/gm
Calcitriol

1
Ointment) Erythromycin/Benzoyl
Erythromycin/Benzoyl Peroxide

1
Carac (Cream)
Carac

1 PA Peroxide (Gel)
Finacea (15% Foam,
Finacea

Claravis (Capsule) 1 PA
Claravis

1
15% Gel)
Clindamycin
Clindamycin Phosphate

Fluorouracil (0.5%
Fluorouracil

Phosphate (1% 1
External Solution, 1% 1 Cream)
Gel, 1% Lotion, 1% Fluorouracil (2%
Fluorouracil

Swab) External Solution, 5% 1

Clindamycin/Benzoyl
Clindamycin/Benzoyl Peroxide

External Solution)
Peroxide (1%-5% Gel) 1 Fluorouracil (5%
Fluorouracil

(Generic BenzaClin) 1
Cream)
Clotrimazole/ Imiquimod (Cream) 1
Clotrimazole/Betamethasone Dipropionate
Imiquimod

Betamethasone
1 Isotretinoin (Capsule) 1 PA
Isotretinoin

Dipropionate
(1%-0.05% Cream) Methoxsalen (Capsule) 1
Methoxsalen

Clotrimazole/ Mirvaso (Gel) 1

Clotrimazole/Betamethasone Dipropionate Mirvaso

Betamethasone Oxsoralen Ultra

Oxsoralen Ultra

1 1
Dipropionate (Capsule)
(1%-0.05% Lotion)
Picato (Gel) 1
Picato

Podofilox (External
Podofilox

1
Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
74 75
Last updated November 1, 2018 tRACK
75
44
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 PA Aminosyn II 8.5%/
Aminosyn II 8.5%/Electrolytes

Prudoxin (Cream)
Prudoxin

Regranex (Gel)
Regranex

1 PA Electrolytes 1 B/D, PA
(Injection)
Santyl (Ointment) 1
Santyl

Aminosyn-HBC
Aminosyn-HBC

Selenium Sulfide
Selenium Sulfide

1 B/D, PA
1 (Injection)
(Lotion)
Aminosyn-PF
Aminosyn-PF

Soriatane (Capsule) 1 1 B/D, PA

Soriatane

(Injection)
Stelara (130mg/26ml
Stelara

Aminosyn-RF
Aminosyn-RF

Injection, 45mg/ 1 B/D, PA

1 PA (Injection)
0.5ml Injection,
Carbaglu (Tablet) 1 LA
Carbaglu

90mg/ml Injection)
Dextrose 10%
Dextrose 10%

Tacrolimus (0.03% 1
Tacrolimus

Ointment, 0.1% 1 ST (Injection)

Ointment) Dextrose 10%/NaCl
Dextrose 10%/NaCl 0.2%

1
Tazarotene (Cream)
Tazarotene

1 PA 0.2% (Injection)
Dextrose 10%/NaCl
Dextrose 10%/NaCl 0.45%

Tazorac (0.05%
Tazorac

1
Cream, 0.1% Cream, 1 PA 0.45% (Injection)
Dextrose 2.5%/NaCl
Dextrose 2.5%/NaCl 0.45%

0.05% Gel, 0.1% Gel) 1

Tretinoin (0.01% Gel,
Tretinoin

0.45% (Injection)
0.025% Gel, 0.025% Dextrose 5%
Dextrose 5%

1 PA 1
Cream, 0.05% Cream, (Injection)
0.1% Cream) Dextrose 5%/
Dextrose 5%/Lactated Ringers

Tretinoin Microsphere 1
Tretinoin Microsphere

Lactated Ringers
1 PA
(Gel) (Injection)
Zyclara Pump
Zyclara Pump

Dextrose 5%/NaCl
Dextrose 5%/NaCl 0.2%

1 PA 1
(Cream) 0.2% (Injection)
Electrolytes/Minerals/Metals/Vitamins Dextrose 5%/NaCl
Dextrose 5%/NaCl 0.225%

1
Electrolyte/Mineral Replacement 0.225% (Injection)
Dextrose 5%/NaCl
Dextrose 5%/NaCl 0.33%

Aminosyn 7%/
Aminosyn 7%/Electrolytes

1
Electrolytes 1 B/D, PA 0.33% (Injection)
(Injection) Dextrose 5%/NaCl
Dextrose 5%/NaCl 0.45%

1
Aminosyn 8.5%/ 0.45% (Injection)
Aminosyn 8.5%/Electrolytes

Electrolytes 1 B/D, PA Dextrose 5%/NaCl

Dextrose 5%/NaCl 0.9%

1
(Injection) 0.9% (Injection)
Aminosyn II (10%
Aminosyn II

FreAmine HBC 6.9%

FreAmine HBC 6.9%

1 B/D, PA 1 B/D, PA
Injection) (Injection)

Bold type = Brand name drug Plain type = Generic drug

75 76
76 tRACK
Last updated November 1, 2018
45
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
HepatAmine Lactated Ringers
HepatAmine Lactated Ringers Irrigation

1 B/D, PA 1
(Injection) Irrigation (Solution)
1 B/D, PA Lactated Ringers
Lactated Ringers Viaflex

Intralipid (Injection)
Intralipid

1
Ionosol-MB/Dextrose
Ionosol-MB/Dextrose 5%

Viaflex (Injection)
1 Levocarnitine (1gm/
Levocarnitine

5% (Injection)
Isolyte-P/Dextrose 5%
Isolyte-P/Dextrose 5%

10ml Oral Solution, 1

1 330mg Tablet)
(Injection)
Magnesium Sulfate
Magnesium Sulfate

Isolyte-S (Injection) 1
Isolyte-S

(1gm/2ml-50% 1
KCl 0.075%/D5W/
KCl 0.075%/D5W/NaCl 0.45%

Injection)
NaCl 0.45% 1
Magnesium Sulfate
Magnesium Sulfate

(Injection) (5gm/10ml-50% 1
KCl 0.15%/D5W/NaCl
KCl 0.15%/D5W/NaCl 0.2%

1 Injection)
0.2% (Injection) Nephramine
Nephramine

KCl 0.15%/D5W/NaCl
KCl 0.15%/D5W/NaCl 0.45%

1 B/D, PA
1 (Injection)
0.45% (Injection) Normosol-M in D5W
Normosol-M in D5W

KCl 0.15%/D5W/NaCl
KCl 0.15%/D5W/NaCl 0.9%

1
1 (Injection)
0.9% (Injection) Normosol-R
Normosol-R

KCl 0.3%/D5W/NaCl
KCl 0.3%/D5W/NaCl 0.45%

1
1 (Injection)
0.45% (Injection) Normosol-R in D5W
Normosol-R in D5W

KCl 0.3%/D5W/NaCl
KCl 0.3%/D5W/NaCl 0.9%

1
1 (Injection)
0.9% (Injection) Nutrilipid (Injection)
Nutrilipid

1 B/D, PA
Klor-Con (Packet) 1
Klor-Con

Physiolyte (Irrigation
Physiolyte

Klor-Con 10 (Tablet
Klor-Con 10

1
1 Solution)
Extended-Release) Physiosol Irrigation
Physiosol Irrigation

Klor-Con 8 (Tablet
Klor-Con 8

1
1 (Solution)
Extended-Release) Plasma-Lyte A
Plasma-Lyte A

Klor-Con M10 (Tablet

Klor-Con M10

1
1 (Injection)
Extended-Release) Plasma-Lyte-148
Plasma-Lyte-148

Klor-Con M15 (Tablet

Klor-Con M15

1
1 (Injection)
Extended-Release)
Plenamine (Injection) 1 B/D, PA
Plenamine

Klor-Con M20 (Tablet

Klor-Con M20

1 Potassium Chloride
Potassium Chloride

Extended-Release)
(10% Oral Solution, 1
Klor-Con Sprinkle
Klor-Con Sprinkle

(Capsule Extended- 1 20% Oral Solution)

Release)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
76 77
Last updated November 1, 2018 tRACK
77
46
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Potassium Chloride Potassium Chloride/
Potassium Chloride Potassium Chloride/Sodium Chloride

(10meq/100ml Sodium Chloride

Injection, 20meq/ (20meq/L-0.9% 1 B/D, PA
1 B/D, PA
100ml Injection, Injection, 40meq/
40meq/100ml L-0.9% Injection)
Injection) Potassium Citrate ER
Potassium Citrate ER

Potassium Chloride (Tablet Extended- 1

Potassium Chloride

1 B/D, PA Release)
(2meq/ml Injection)
Potassium Chloride CR Premasol (Injection) 1 B/D, PA
Potassium Chloride CR Premasol

(Tablet Extended- 1 Procalamine

Procalamine

Release) 1 B/D, PA
(Injection)
Potassium Chloride ER
Potassium Chloride ER

Prosol (Injection) 1 B/D, PA

Prosol

(10meq Capsule
Ringers Injection 1
Ringers Injection

Extended-Release, 1
8meq Capsule Ringers Irrigation
Ringers Irrigation

Extended-Release) 1
(Solution)
Potassium Chloride ER
Potassium Chloride ER

Sodium Chloride
Sodium Chloride 0.9%

(10meq Tablet 0.9% (Irrigation 1

Extended-Release, Solution)
20meq Tablet 1
Sodium Chloride
Sodium Chloride

Extended-Release,
8meq Tablet Extended- (0.9% Injection, 1
Release) 2.5meq/ml Injection)
Sodium Chloride (3%
Sodium Chloride

Potassium Chloride/
Potassium Chloride/Dextrose

1 B/D, PA Injection, 5% 1 B/D, PA

Dextrose (Injection)
Potassium Chloride/
Potassium Chloride/Dextrose/Lactated Ringers

Injection)
Sodium Chloride
Sodium Chloride 0.45%

Dextrose/Lactated 1 1
Ringers (Injection) 0.45% (Injection)
Sodium Fluoride
Sodium Fluoride

Potassium Chloride/
Potassium Chloride/Dextrose/Sodium Chloride

1
Dextrose/Sodium 1 (Tablet)
Sodium Lactate
Sodium Lactate

Chloride (Injection) 1
Potassium Chloride/
Potassium Chloride/Sodium Chloride

(Injection)
Sodium Chloride TPN Electrolytes
TPN Electrolytes

1 B/D, PA 1
(20meq/L-0.45% (Injection)
Injection) Travasol (Injection)
Travasol

1 B/D, PA
Trophamine (10%
Trophamine

1 B/D, PA
Injection)

Bold type = Brand name drug Plain type = Generic drug

77 78
78 tRACK
Last updated November 1, 2018
47
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Electrolyte/Mineral/Metal Modifiers Renagel (Tablet) 1 ST
Renagel

Chemet (Capsule) 1
Chemet

Renvela (0.8gm
Renvela

Exjade (Tablet
Exjade

Packet, 2.4gm 1
1 PA Packet)
Soluble)
Sevelamer Carbonate
Sevelamer Carbonate

Ferriprox (100mg/ml
Ferriprox

Oral Solution, 500mg 1 PA (0.8gm Packet, 2.4gm 1

Tablet) Packet, 800mg Tablet)
Velphoro (Tablet
Velphoro

Jadenu (Tablet) 1 PA
Jadenu

1
Chewable)
Jadenu Sprinkle
Jadenu Sprinkle

1 PA Vitamins
(Packet)
VP-PNV-DHA (Capsule) 1
VP-PNV-DHA

Kionex (Suspension) 1
Kionex

Gastrointestinal Agents
Samsca (Tablet) 1 PA, QL
Samsca

Antispasmodics, Gastrointestinal
Sodium Polystyrene
Sodium Polystyrene Sulfonate

1 Atropine Sulfate
Atropine Sulfate

Sulfonate (Powder)
(0.25mg/5ml 1
SPS (Suspension) 1
SPS

Injection)
Syprine (Capsule) 1 PA, QL
Syprine

Cuvposa (Oral
Cuvposa

Trientine HCl (Capsule) 1

Trientine HCl

PA, QL 1
Solution)
Veltassa (Packet) 1 QL Dicyclomine HCl
Veltassa
Dicyclomine HCl

Phosphate Binders (10mg Capsule, 10mg/ 1

5ml Oral Solution)
Auryxia (Tablet) 1 PA
Auryxia

Dicyclomine HCl
Dicyclomine HCl

Calcium Acetate 1
Calcium Acetate

(Tablet)
(667mg Capsule, 1
Glycopyrrolate (4mg/
Glycopyrrolate

667mg Tablet) 1
20ml Injection)
Fosrenol (1000mg
Fosrenol

Methscopolamine
Methscopolamine Bromide

Packet, 750mg 1
Bromide (Tablet)
Packet, 1000mg
Tablet Chewable, 1 Gastrointestinal Agents, Other
Chenodal (Tablet) 1
Chenodal

500mg Tablet
Chewable, 750mg Cromolyn Sodium
Cromolyn Sodium

Tablet Chewable) (100mg/5ml 1

Lanthanum Carbonate
Lanthanum Carbonate

Concentrate)
1
(Tablet Chewable)
Phoslyra (Oral
Phoslyra

1
Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
78 79
Last updated November 1, 2018
tRACK
79
48
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Diphenoxylate/ Alosetron HCl (Tablet) 1 PA
Diphenoxylate/Atropine
Alosetron HCl

Atropine Amitiza (Capsule)

Amitiza

1 QL
(2.5mg-0.025mg
1 Linzess (Capsule)
Linzess

1 QL
Tablet,
2.5mg-0.025mg/5ml Lotronex (Tablet)
Lotronex

1 PA
Liquid)
Xifaxan (Tablet) 1 PA
Xifaxan

Gattex (Injection) 1 PA
Gattex

Laxatives
Loperamide HCl
Loperamide HCl

1 Constulose (Oral
Constulose

(Capsule) 1
Solution)
Myalept (Injection) 1 PA
Myalept

Enulose (Oral Solution) 1

Enulose

Relistor (12mg/0.6ml
Relistor

GaviLyte-C (Oral
GaviLyte-C

Injection, 8mg/0.4ml 1 PA 1
Solution)
Injection)
GaviLyte-G (Oral
GaviLyte-G

Serostim (Injection)
Serostim

1 PA 1
Solution)
Ursodiol (250mg
Ursodiol

GaviLyte-N/Flavor
GaviLyte-N/Flavor Pack

1 1
Tablet, 500mg Tablet) Pack (Oral Solution)
Ursodiol (300mg
Ursodiol

Generlac (Oral
Generlac

1 1
Capsule) Solution)
Zorbtive (Injection) 1 PA Lactulose (Oral
Zorbtive
Lactulose

1
Histamine2 (H2) Receptor Antagonists Solution)
PEG 3350/
PEG 3350/Electrolytes

Cimetidine (Tablet) 1
Cimetidine

Electrolytes (Oral 1
Cimetidine HCl (Oral
Cimetidine HCl

1 Solution)
Solution)
PEG-3350/
PEG-3350/Electrolytes

Famotidine (20mg
Famotidine

1 Electrolytes (Oral
Tablet, 40mg Tablet) 1
Famotidine (20mg/2ml
Famotidine
Solution) (Generic
Injection, 40mg/5ml 1 GoLYTELY)
Suspension) PEG-3350/NaCl/Na
PEG-3350/NaCl/Na Bicarbonate/KCl

Famotidine Premixed
Famotidine Premixed

Bicarbonate/KCl (Oral
1 1
(Injection) Solution) (Generic
NuLYTELY)
Ranitidine HCl (150mg
Ranitidine HCl

1 Polyethylene Glycol
Polyethylene Glycol 3350 Powder

Tablet, 300mg Tablet)

3350 Powder (Generic 1
Ranitidine HCl (50mg/
Ranitidine HCl

MiraLAX)
2ml Injection, 75mg/ 1
Suprep Bowel Prep
Suprep Bowel Prep Kit

5ml Syrup) 1
Kit (Oral Solution)
Irritable Bowel Syndrome Agents

Bold type = Brand name drug Plain type = Generic drug

79 80
80 tRACK
Last updated November 1, 2018
49
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
TriLyte (Oral Solution) 1 Omeprazole (20mg
Omeprazole
TriLyte

Protectants Capsule Delayed- 1

Release)
Carafate (1gm/10ml
Carafate

1 Pantoprazole Sodium
Pantoprazole Sodium

Suspension)
(20mg Tablet Delayed-
Misoprostol (Tablet)
Misoprostol

1 1 QL
Release, 40mg Tablet
Sucralfate (Tablet)
Sucralfate

1 Delayed-Release)
Proton Pump Inhibitors Prilosec (Packet) 1 PA
Prilosec

Rabeprazole Sodium
Rabeprazole Sodium

Dexilant (Capsule
Dexilant

1 QL (Tablet Delayed- 1
Delayed-Release)
Esomeprazole
Esomeprazole Magnesium
Release)
Magnesium (Capsule Genetic or Enzyme Disorder: Replacement,
1 QL Modifiers, Treatment
Delayed-Release)
(Generic Nexium) Genetic or Enzyme Disorder: Replacement,
Esomeprazole Sodium Modifiers, Treatment
Esomeprazole Sodium

1
(Injection) Adagen (Injection)
Adagen

1 LA
Lansoprazole (15mg
Lansoprazole

Aldurazyme
Aldurazyme

Capsule Delayed- 1
(Injection)
Release, 30mg 1 QL
Aralast NP (Injection) 1 PA, LA
Aralast NP

Capsule Delayed-
Release) Buphenyl (3gm/tsp
Buphenyl

Nexium (10mg Powder, 500mg 1

Nexium

Packet, 2.5mg Tablet)

Packet, 20mg Packet, 1 Cerezyme (Injection)
Cerezyme

1 PA
40mg Packet, 5mg Cholbam (Capsule)
Cholbam

1 PA
Packet)
Creon (Capsule
Creon

Nexium (20mg 1
Nexium

Delayed-Release)
Capsule Delayed-
Cystadane (Powder) 1
Cystadane

Release, 40mg 1 QL
Cystagon (Capsule) 1 LA
Cystagon

Capsule Delayed-
Release) Elaprase (Injection) 1
Elaprase

Omeprazole (10mg
Omeprazole

Elelyso (Injection) 1 PA, LA

Elelyso

Capsule Delayed-
Exondys 51
Exondys 51

Release, 40mg 1 QL 1 PA, LA

Capsule Delayed- (Injection)
Release) Fabrazyme (Injection) 1
Fabrazyme

Glassia (Injection) 1 PA, LA

Glassia

You can find information on what the abbreviations in this table mean on pages 6 - 7.
80 81
Last updated November 1, 2018
tRACK
81
50
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 PA Myrbetriq (Tablet
Myrbetriq

Kanuma (Injection)
Kanuma

Kuvan (100mg
Kuvan

Extended-Release 24 1
Packet, 500mg Hour)
1 Oxybutynin Chloride
Oxybutynin Chloride

Packet, 100mg Tablet

Soluble) (5mg Tablet
1
Immediate-Release,
Lumizyme (Injection) 1
Lumizyme

5mg/5ml Syrup)
Miglustat (Capsule) 1 PA, LA
Miglustat

Oxybutynin Chloride
Oxybutynin Chloride ER

Naglazyme (Injection) 1 ER (Tablet Extended- 1 QL

Naglazyme

Ocaliva (Tablet)
Ocaliva

1 PA, QL Release 24 Hour)

Vesicare (Tablet) 1 QL
Vesicare

Orfadin (10mg
Orfadin

Capsule, 20mg Benign Prostatic Hypertrophy Agents

Capsule, 2mg Alfuzosin HCl ER
Alfuzosin HCl ER

1 LA
Capsule, 5mg (Tablet Extended- 1
Capsule, 4mg/ml Release 24 Hour)
Suspension) Dutasteride (Capsule) 1
Dutasteride

Procysbi (Capsule Finasteride (5mg

Procysbi
Finasteride

1
Delayed-Release) Tablet) (Generic 1
Prolastin-C (Injection)
Prolastin-C

1 PA, LA Proscar)
Rapaflo (Capsule) 1 QL
Rapaflo

Ravicti (Liquid) 1 QL
Ravicti

Tamsulosin HCl
Tamsulosin HCl

Sodium Phenylbutyrate 1
Sodium Phenylbutyrate

(3gm/TSP Powder, 1 (Capsule)

500mg Tablet) Terazosin HCl
Terazosin HCl

1
Strensiq (Injection)
Strensiq

1 PA, LA (Capsule)
Genitourinary Agents, Other
Sucraid (Oral
Sucraid

1 LA Bethanechol Chloride
Bethanechol Chloride

Solution) 1
(Tablet)
VPRIV (Injection) 1 PA
VPRIV

Cuprimine (Capsule) 1 PA
Cuprimine

Zavesca (Capsule) 1 PA, LA

Zavesca

Depen Titratabs
Depen Titratabs

Zemaira (Injection)
Zemaira

1 PA, LA 1
(Tablet)
Zenpep (Capsule
Zenpep

Elmiron (Capsule) 1
Elmiron

1
Delayed-Release)
Lithostat (Tablet) 1
Lithostat

Genitourinary Agents
Hormonal Agents, Stimulant/Replacement/
Antispasmodics, Urinary
Modifying (Adrenal)

Bold type = Brand name drug Plain type = Generic drug

81 82
82 tRACK
Last updated November 1, 2018
51
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Hormonal Agents, Stimulant/Replacement/ Desoximetasone
Desoximetasone

Modifying (Adrenal) (0.05% Cream, 0.25% 1

Ala-Cort (Cream)
Ala-Cort

1 Cream)
Dexamethasone
Dexamethasone

Alclometasone
Alclometasone Dipropionate

(0.5mg Tablet, 0.75mg

Dipropionate (0.05%
1 Tablet, 1.5mg Tablet,
Cream, 0.05%
1mg Tablet, 2mg 1
Ointment)
Tablet, 4mg Tablet,
Augmented
Augmented Betamethasone Dipropionate

6mg Tablet, 0.5mg/

Betamethasone 5ml Elixir)
Dipropionate (0.05%
1 Dexamethasone
Dexamethasone Intensol

Cream, 0.05% Gel,

0.05% Lotion, 0.05% Intensol (1mg/ml 1
Ointment) Concentrate)
Dexamethasone
Dexamethasone Sodium Phosphate

Betamethasone
Betamethasone Dipropionate

Sodium Phosphate
Dipropionate (0.05% 1
1 (10mg/ml Injection,
Cream, 0.05% Lotion,
120mg/30ml Injection)
0.05% Ointment)
Fludrocortisone
Fludrocortisone Acetate

Betamethasone 1
Betamethasone Valerate

Acetate (Tablet)
Valerate (0.1% Cream,
1 Fluocinolone
Fluocinolone Acetonide

0.1% Lotion, 0.1%

Ointment) Acetonide (0.01%
Clobetasol Propionate Cream, 0.025% Cream,
1
Clobetasol Propionate

0.01% External
(0.05% Cream, 0.05%
1 Solution, 0.025%
Gel, 0.05% Ointment,
Ointment)
0.05% Shampoo)
Fluocinolone
Fluocinolone Acetonide Scalp

Clobetasol Propionate 1
Clobetasol Propionate

(0.05% External 1 Acetonide Scalp (Oil)

Fluocinonide (0.05%
Fluocinonide

Solution)
External Solution,
Cordran (Tape) 1 1
Cordran

0.05% Gel, 0.05%

Cortisone Acetate
Cortisone Acetate

1 Ointment)
(Tablet) Fluocinonide
Fluocinonide Emulsified Base

Depo-Medrol (20mg/
Depo-Medrol

1 Emulsified Base 1
ml Injection) (Cream)
Desonide (0.05% Fluticasone Propionate
Desonide
Fluticasone Propionate

1
Ointment) (0.005% Ointment, 1
0.05% Cream)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
82 83
Last updated November 1, 2018 tRACK
83
52
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Halobetasol Prednicarbate (0.1%
Halobetasol Propionate Prednicarbate

1
Propionate (0.05% Ointment)
1
Cream, 0.05% Prednisolone (15mg/
Prednisolone

Ointment) 1
5ml Oral Solution)
Hydrocortisone (1%
Hydrocortisone

Prednisolone Sodium
Prednisolone Sodium Phosphate

Cream, 2.5% Cream, Phosphate (10mg/5ml

1
1% Ointment, 2.5% Oral Solution, 20mg/
Ointment) 5ml Oral Solution, 1
Hydrocortisone (10mg 25mg/5ml Oral
Hydrocortisone

Tablet, 20mg Tablet, Solution, 5mg/5ml Oral

1
5mg Tablet, 2.5% Solution)
Lotion) Prednisone (10mg
Prednisone

Hydrocortisone Tablet Therapy Pack,

Hydrocortisone Butyrate

Butyrate (0.1% 1 5mg Tablet Therapy

Ointment) Pack, 10mg Tablet,
1
Hydrocortisone
Hydrocortisone Valerate

1mg Tablet, 2.5mg

Valerate (0.2% Cream, 1 Tablet, 20mg Tablet,
0.2% Ointment) 50mg Tablet, 5mg
Tablet)
Kenalog-10 (Injection) 1
Kenalog-10

Prednisone (5mg/5ml
Prednisone

Kenalog-40 (Injection)
Kenalog-40

1 1
Oral Solution)
Methylprednisolone
Methylprednisolone

Prednisone Intensol
Prednisone Intensol

1 1
(Tablet) (5mg/ml Concentrate)
Methylprednisolone
Methylprednisolone Acetate

Solu-Cortef (Injection) 1
Solu-Cortef

1
Acetate (Injection)
Solu-Medrol (2gm
Solu-Medrol

Methylprednisolone 1
Methylprednisolone Dose Pack

Injection)
Dose Pack (Tablet 1
Triamcinolone
Triamcinolone Acetonide

Therapy Pack)
Acetonide (0.025%
Methylprednisolone
Methylprednisolone Sodium Succinate

Cream, 0.1% Cream,

Sodium Succinate 1
0.5% Cream, 0.025% 1
(Injection)
Ointment, 0.1%
Mometasone Furoate
Mometasone Furoate

Ointment, 0.5%
(0.1% Cream, 0.1% Ointment)
1
External Solution, 0.1%
Triamcinolone
Triamcinolone Acetonide

Ointment)
Acetonide (0.025% 1
Prednicarbate (0.1%
Prednicarbate

1 Lotion, 0.1% Lotion)

Cream)

Bold type = Brand name drug Plain type = Generic drug

83 84
84 tRACK
Last updated November 1, 2018
53
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Triamcinolone 1 PA
Triamcinolone Acetonide

Increlex (Injection)
Increlex

Acetonide (40mg/ml 1 Norditropin FlexPro

Norditropin FlexPro

Injection) 1 PA
(Injection)
Triderm (Cream) 1
Triderm

Novarel (Injection) 1 PA
Novarel

Hormonal Agents, Stimulant/Replacement/

Nutropin AQ
Nutropin AQ

Modifying (Pituitary) 1 PA
(Injection)
Hormonal Agents, Stimulant/Replacement/
Pregnyl w/Diluent
Pregnyl w/Diluent Benzyl Alcohol/NaCl

Modifying (Pituitary)
Benzyl Alcohol/NaCl 1 PA
Chorionic
Chorionic Gonadotropin

(Injection)
Gonadotropin 1 PA
Saizen (Injection) 1 PA
Saizen

(Injection)
Saizenprep
Saizenprep Reconstitution Kit

Desmopressin Acetate
Desmopressin Acetate

(0.01% Nasal Spray Reconstitution Kit 1 PA

1 (Injection)
Solution, 4mcg/ml
Injection) Zomacton (10mg
Zomacton

1 PA
Desmopressin Acetate
Desmopressin Acetate

Injection)
(0.1mg Tablet, 0.2mg 1 Hormonal Agents, Stimulant/Replacement/
Tablet) Modifying (Prostaglandins)
Genotropin (12mg Hormonal Agents, Stimulant/Replacement/
Genotropin

Injection, 5mg 1 PA Modifying (Prostaglandins)

Injection) Korlym (Tablet)
Korlym

1 PA, QL
Genotropin Miniquick
Genotropin Miniquick

1 PA Hormonal Agents, Stimulant/Replacement/

(0.2mg Injection) Modifying (Sex Hormones/Modifiers)
Genotropin Miniquick
Genotropin Miniquick

Androgens
(0.4mg Injection,
Anadrol-50 (Tablet) 1 PA
Anadrol-50

0.6mg Injection,
Androderm (Patch 24
Androderm

0.8mg Injection, 1 QL
1.2mg Injection, Hour)
1 PA AndroGel (1.62%
AndroGel

1.4mg Injection, 1
1.6mg Injection, Packet Gel)
1.8mg Injection, 1mg AndroGel Pump
AndroGel Pump

1
Injection, 2mg (1.62% Gel)
Injection) Danazol (Capsule)
Danazol

1
Humatrope (Injection) 1 PA
Humatrope

Oxandrolone (10mg
Oxandrolone

1 PA, QL
Humatrope Combo Tablet)
Humatrope Combo Pack

1 PA
Pack (Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
84 85
Last updated November 1, 2018
tRACK
85
54
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Oxandrolone (2.5mg Desogestrel/Ethinyl
Oxandrolone Desogestrel/Ethinyl Estradiol

1 PA, QL 1
Tablet) Estradiol (Tablet)
Testosterone Drospirenone/Ethinyl
Testosterone Cypionate Drospirenone/Ethinyl Estradiol

1 1
Cypionate (Injection) Estradiol (Tablet)
Testosterone 1
Testosterone Enanthate

Duavee (Tablet)
Duavee

1
Enanthate (Injection) Elestrin (Gel)
Elestrin

1
Estrogens
Emoquette (Tablet) 1
Emoquette

Altavera (Tablet) 1
Altavera

Enpresse-28 (Tablet) 1
Enpresse-28

Alyacen 1/35 (Tablet) 1

Alyacen 1/35

Enskyce (Tablet) 1
Enskyce

Amethia (Tablet) 1
Amethia

Estarylla (Tablet) 1
Estarylla

Amethia Lo (Tablet) 1
Amethia Lo

Estrace (0.1mg/gm
Estrace

Apri (Tablet)
Apri

1 1
Cream)
Aranelle (Tablet) 1 Estradiol (0.025mg/
Aranelle
Estradiol

Ashlyna (Tablet)
Ashlyna

1 24hr Patch Weekly,

0.05mg/24hr Patch
Aubra (Tablet) 1
Aubra

Weekly, 0.06mg/24hr
Aviane (Tablet) 1 Patch Weekly,
Aviane

1 QL
Balziva (Tablet)
Balziva

1 0.075mg/24hr Patch
Weekly, 0.1mg/24hr
Bekyree (Tablet) 1
Bekyree

Patch Weekly,
Blisovi 24 Fe (Tablet)
Blisovi 24 Fe

1 37.5mcg/24hr Patch
Blisovi Fe 1.5/30
Blisovi Fe 1.5/30
Weekly)
1 Estradiol (0.1mg/gm
Estradiol

(Tablet) 1
Cream)
Blisovi Fe 1/20 (Tablet) 1
Blisovi Fe 1/20

Estradiol (0.5mg
Estradiol

Briellyn (Tablet) 1
Briellyn

Tablet, 1mg Tablet,

1
Camrese Lo (Tablet) 1 2mg Tablet) (Generic
Camrese Lo

Caziant (Tablet)
Caziant

1 Estrace)
Estradiol (10mcg
Estradiol

Climara Pro (Patch 1 QL

Climara Pro

1 Tablet)
Weekly)
Estradiol Valerate
Estradiol Valerate

Cryselle-28 (Tablet) 1 1
Cryselle-28

(Injection)
Cyclafem (Tablet) 1
Cyclafem

Estring (Ring) 1
Estring

Delyla (Tablet) 1
Delyla

Ethynodiol Diacetate/
Ethynodiol Diacetate/Ethinyl Estradiol

Depo-Estradiol Ethinyl Estradiol 1

Depo-Estradiol

1
(Injection) (Tablet)

Bold type = Brand name drug Plain type = Generic drug

85 86
86 tRACK
Last updated November 1, 2018
55
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Falmina (Tablet) 1 Leena (Tablet) 1
Falmina Leena

Femring (Ring) 1 Lessina (Tablet) 1

Femring Lessina

Femynor (Tablet) 1 Levonest (Tablet) 1

Femynor Levonest

Fyavolv (1mg-5mcg Levonorgestrel and

Fyavolv Levonorgestrel and Ethinyl Estradiol

1
Tablet) Ethinyl Estradiol 1
Gianvi (Tablet)
Gianvi

1 (90mcg-20mcg Tablet)
Levonorgestrel/Ethinyl
Levonorgestrel/Ethinyl Estradiol

Introvale (Tablet) 1
Introvale

Estradiol
Isibloom (Tablet) 1
Isibloom

(0.15mg-0.03mg
Jinteli (Tablet)
Jinteli

1 Tablet, 0.1mg-20mcg
Tablet,
Juleber (Tablet) 1
Juleber

0.05mg-30mcg/ 1
Junel 1.5/30 (Tablet) 1 0.075mg-40mcg/
Junel 1.5/30

Junel 1/20 (Tablet)

Junel 1/20

1 0.125mg-30mcg
Tablet,
Junel Fe 1.5/30
Junel Fe 1.5/30

1 0.15mg-0.03mg/
(Tablet) 0.01mg Tablet)
Junel Fe 1/20 (Tablet) 1
Junel Fe 1/20

Levora 0.15/30-28
Levora 0.15/30-28

1
Junel Fe 24 (Tablet) 1 (Tablet)
Junel Fe 24

Kaitlib Fe (Tablet Loryna (Tablet) 1

Kaitlib Fe Loryna

1
Chewable) Low-Ogestrel (Tablet)
Low-Ogestrel

1
Kariva (Tablet) 1
Kariva

Lutera (Tablet) 1
Lutera

Kelnor 1/35 (Tablet) 1

Kelnor 1/35

Marlissa (Tablet) 1
Marlissa

Kelnor 1/50 (Tablet) 1

Kelnor 1/50

Melodetta 24 Fe
Melodetta 24 Fe

1
Kimidess (Tablet) 1 (Tablet Chewable)
Kimidess

Kurvelo (Tablet) 1 Menest (Tablet) 1

Kurvelo Menest

Larin 1.5/30 (Tablet) 1 Mibelas 24 Fe (Tablet

Mibelas 24 Fe
Larin 1.5/30

1
Larin 1/20 (Tablet)
Larin 1/20

1 Chewable)
Microgestin 1.5/30
Microgestin 1.5/30

Larin Fe 1.5/30 1
Larin Fe 1.5/30

1 (Tablet)
(Tablet)
Microgestin 1/20
Microgestin 1/20

Larin Fe 1/20 (Tablet) 1 1

Larin Fe 1/20

(Tablet)
Larissia (Tablet) 1
Larissia

Microgestin Fe
Microgestin Fe

Layolis Fe (Tablet
Layolis Fe

1
1 (Tablet)
Chewable)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
86 87
Last updated November 1, 2018 tRACK
87
56
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Microgestin Fe 1.5/30 Ogestrel (Tablet) 1
Microgestin Fe 1.5/30
Ogestrel

1
(Tablet) Orsythia (Tablet)
Orsythia

1
Mili (Tablet) 1
Mili

Pimtrea (Tablet) 1
Pimtrea

MonoNessa (Tablet) 1
MonoNessa

Pirmella 1/35 (Tablet) 1

Pirmella 1/35

Necon 0.5/35-28
Necon 0.5/35-28

1 Portia-28 (Tablet) 1
Portia-28

(Tablet)
Premarin (0.3mg
Premarin

Necon 7/7/7 (Tablet) 1

Necon 7/7/7

Tablet, 0.45mg
Nikki (Tablet) 1
Nikki

Tablet, 0.625mg 1 QL
Norethindrone
Norethindrone Acetate/Ethinyl Estradiol

Tablet, 0.9mg Tablet,

Acetate/Ethinyl 1.25mg Tablet)
Estradiol (1mg-20mcg 1 Premarin (Vaginal
Premarin

Tablet, 1mg-5mcg 1
Cream)
Tablet)
Premphase (Tablet) 1 QL
Premphase

Norethindrone
Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Prempro (Tablet) 1 QL
Prempro

Acetate/Ethinyl
Estradiol/Ferrous Previfem (Tablet) 1
Previfem

1
Fumarate Quasense (Tablet)
Quasense

1
(1mg-20mcg-75mg
Reclipsen (Tablet) 1
Reclipsen

Tablet Chewable)
Setlakin (Tablet) 1
Setlakin

Norethindrone
Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

Acetate/Ethinyl Sprintec 28 (Tablet) 1

Sprintec 28

1
Estradiol/Ferrous Sronyx (Tablet)
Sronyx

1
Fumarate (Tablet)
Syeda (Tablet) 1
Syeda

Norethindrone/Ethinyl
Norethindrone/Ethinyl Estradiol/Ferrous Fumarate

Estradiol/Ferrous Tarina Fe 1/20 (Tablet) 1

Tarina Fe 1/20

1
Fumarate (Tablet Tri-Legest Fe (Tablet)
Tri-Legest Fe

1
Chewable)
Tri-Lo-Estarylla (Tablet) 1
Tri-Lo-Estarylla

Norgestimate/Ethinyl
Norgestimate/Ethinyl Estradiol

1 Tri-Lo-Sprintec (Tablet)
Tri-Lo-Sprintec

1
Estradiol (Tablet)
Tri-Mili (Tablet) 1
Tri-Mili

Nortrel 0.5/35 (28)

Nortrel 0.5/35

1
(Tablet) Tri-Previfem (Tablet)
Tri-Previfem

1
Nortrel 1/35 (Tablet) 1
Nortrel 1/35

Tri-Sprintec (Tablet) 1
Tri-Sprintec

Nortrel 7/7/7 (Tablet) 1

Nortrel 7/7/7

Tri-Vylibra (Tablet) 1
Tri-Vylibra

NuvaRing (Ring) 1
NuvaRing

Trinessa (Tablet) 1
Trinessa

Ocella (Tablet) 1
Ocella

Trivora-28 (Tablet) 1
Trivora-28

Bold type = Brand name drug Plain type = Generic drug

87 88
88 tRACK
Last updated November 1, 2018
57
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Velivet (Tablet) 1 Medroxyprogesterone
Medroxyprogesterone Acetate
Velivet

Vienva (Tablet)
Vienva

1 Acetate (150mg/ml
1
Injection Prefilled
Vyfemla (Tablet) 1
Vyfemla

Syringe)
Vylibra (Tablet) 1
Vylibra

Medroxyprogesterone
Medroxyprogesterone Acetate

Wymzya Fe (Tablet Acetate (150mg/ml 1

Wymzya Fe

1
Chewable) Injection)
Xulane (Patch Weekly) 1 Megace ES
Xulane Megace ES

1
Yuvafem (Tablet)
Yuvafem

1 QL (Suspension)
Megestrol Acetate
Megestrol Acetate

Zarah (Tablet) 1
Zarah

(20mg Tablet, 40mg

Zenchent (Tablet)
Zenchent

1 1
Tablet, 40mg/ml
Zovia 1/35E (Tablet)
Zovia 1/35E

1 Suspension)
Megestrol Acetate
Megestrol Acetate

Progestins
(625mg/5ml 1
Camila (Tablet) 1
Camila

Suspension)
Crinone (Gel) 1 PA
Crinone

Nora-BE (Tablet) 1
Nora-BE

Deblitane (Tablet) 1
Deblitane

Norethindrone
Norethindrone

1
Depo-Provera (0.35mg Tablet)
Depo-Provera

1
(Injection) Norethindrone Acetate
Norethindrone Acetate

1
Errin (Tablet) 1 (5mg Tablet)
Errin

Hydroxyprogesterone Norlyroc (Tablet) 1

Norlyroc
Hydroxyprogesterone Caproate

1 PA
Caproate (Injection) Progesterone
Progesterone

1
Incassia (Tablet) 1 (Capsule)
Incassia

1 Sharobel (Tablet) 1
Sharobel

Jolivette (Tablet)
Jolivette

Lyza (Tablet)
Lyza

1 Selective Estrogen Receptor Modifying

Makena (250mg/ml
Makena

Agents
Osphena (Tablet) 1 PA, QL
Osphena

Injection, 275mg/ 1 PA
1.1ml Injection) Raloxifene HCl (Tablet) 1 QL
Raloxifene HCl

Medroxyprogesterone
Medroxyprogesterone Acetate

Hormonal Agents, Stimulant/Replacement/

Acetate (10mg Tablet, Modifying (Thyroid)
1
2.5mg Tablet, 5mg
Hormonal Agents, Stimulant/Replacement/
Tablet)
Modifying (Thyroid)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
88 89
Last updated November 1, 2018
tRACK
89
58
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Levothyroxine 1 PA
Levothyroxine Sodium

Lupaneta Pack (Kit)

Lupaneta Pack

Sodium (100mcg 1 Lupron Depot (1-

Lupron Depot

Injection) 1 PA
Month) (Injection)
Levothyroxine Sodium
Levothyroxine Sodium

Lupron Depot (3-

Lupron Depot

(100mcg Tablet, 1 PA
Month) (Injection)
112mcg Tablet,
Lupron Depot (4-
Lupron Depot

125mcg Tablet, 1 PA
137mcg Tablet, Month) (Injection)
150mcg Tablet, 1 Lupron Depot (6-
Lupron Depot

1 PA
175mcg Tablet, Month) (Injection)
200mcg Tablet, 25mcg Lupron Depot-Ped (1-
Lupron Depot-Ped

Tablet, 300mcg Tablet, 1 PA

Month) (Injection)
50mcg Tablet, 75mcg
Lupron Depot-Ped (3-
Lupron Depot-Ped

Tablet, 88mcg Tablet) 1 PA

Month) (Injection)
Levoxyl (Tablet) 1
Levoxyl

Octreotide Acetate
Octreotide Acetate

Liothyronine Sodium
Liothyronine Sodium

1 PA
1 (Injection)
(10mcg/ml Injection)
Sandostatin LAR
Sandostatin LAR Depot

Liothyronine Sodium 1 PA
Liothyronine Sodium

Depot (Injection)
(25mcg Tablet, 50mcg 1
Signifor (Injection) 1 PA
Signifor

Tablet, 5mcg Tablet)

Somatuline Depot
Somatuline Depot

Synthroid (Tablet) 1
Synthroid

1
(Injection)
Unithroid (Tablet) 1
Unithroid

Somavert (Injection) 1 PA, QL

Somavert

Hormonal Agents, Suppressant (Adrenal)

Synarel (Nasal
Synarel

Hormonal Agents, Suppressant (Adrenal) 1

Solution)
Lysodren (Tablet) 1
Lysodren

Trelstar Mixject
Trelstar Mixject

Hormonal Agents, Suppressant (Pituitary) 1 PA

(Injection)
Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid)
Cabergoline (Tablet) 1
Cabergoline

Antithyroid Agents
Egrifta (Injection) 1 PA
Egrifta

Methimazole (Tablet) 1
Methimazole

Firmagon (120mg
Firmagon

Propylthiouracil
Propylthiouracil

1 PA 1
Injection) (Tablet)
Firmagon (80mg
Firmagon

1 PA Immunological Agents
Injection) Angioedema Agents
Leuprolide Acetate
Leuprolide Acetate

1 PA Berinert (Injection) 1 PA, LA

Berinert

(Injection)
Cinryze (Injection) 1 PA, LA
Cinryze

Bold type = Brand name drug Plain type = Generic drug

89 90
90 tRACK
Last updated November 1, 2018
59
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 PA, QL Humira Pediatric
Humira Pediatric Crohns Disease Starter Pack

Firazyr (Injection)
Firazyr

Haegarda (Injection)
Haegarda

1 PA Crohns Disease
1 PA
Starter Pack
Ruconest (Injection) 1 PA
Ruconest

(Injection)
Immune Suppressants Humira Pen
Humira Pen

Azathioprine (100mg
Azathioprine

1 PA
1 B/D, PA (Injection)
Injection)
Humira Pen Crohns
Humira Pen Crohns Disease Starter Pack

Azathioprine (50mg
Azathioprine

1 B/D, PA Disease Starter Pack 1 PA

Tablet) (Injection)
Cellcept (200mg/ml
Cellcept

Kineret (Injection) 1 PA
Kineret

Suspension, 250mg
1 PA Methotrexate (Tablet)
Methotrexate

1
Capsule, 500mg
Methotrexate Sodium
Methotrexate Sodium

Tablet) 1
Cimzia (Injection)
Cimzia

1 PA (Injection)
Mycophenolate Mofetil
Mycophenolate Mofetil

Cyclosporine (100mg
Cyclosporine

(200mg/ml 1 PA
Capsule, 25mg 1 B/D, PA
Suspension)
Capsule)
Mycophenolate Mofetil
Mycophenolate Mofetil

Cyclosporine (50mg/
Cyclosporine

1 (250mg Capsule, 1 PA
ml Injection)
500mg Tablet)
Cyclosporine Modified
Cyclosporine Modified

Mycophenolate Mofetil
Mycophenolate Mofetil

(100mg Capsule,
25mg Capsule, 50mg
1 PA
(500mg Injection)
1 B/D, PA
Mycophenolic Acid DR
Mycophenolic Acid DR

Capsule, 100mg/ml
Oral Solution) (Tablet Delayed- 1 B/D, PA
Release)
Enbrel (Injection) 1 PA
Enbrel

Nulojix (Injection) 1 PA
Nulojix

Enbrel SureClick
Enbrel SureClick

1 PA Orencia (125mg/ml
Orencia

(Injection)
Injection, 50mg/
Envarsus XR (Tablet
Envarsus XR

0.4ml Injection,
Extended-Release 24 1 PA 1 PA
87.5mg/0.7ml
Hour)
Injection, 250mg
Gengraf (100mg
Gengraf

Injection)
Capsule, 25mg
1 B/D, PA Orencia Clickject
Orencia Clickject

Capsule, 100mg/ml 1 PA
Oral Solution) (Injection)
Prograf (5mg/ml
Prograf

Humira (Injection) 1 PA
Humira

1 PA
Injection)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
90 91
Last updated November 1, 2018
tRACK
91
60
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Rapamune (1mg Gamastan S/D
Rapamune Gamastan S/D

1 PA
Tablet, 2mg Tablet, 1 B/D, PA (Injection)
1mg/ml Oral Solution) Gammagard Liquid
Gammagard Liquid

1 PA
Remicade (Injection) 1 PA (Injection)
Remicade

Gammagard S/D IGA

Gammagard S/D IGA Less Than 1 mcg/ml

Sandimmune (100mg
Sandimmune

1 B/D, PA Less Than 1 mcg/ml 1 PA

Capsule)
Sandimmune
Sandimmune

(Injection)
1 B/D, PA Gammaked (Injection) 1 PA
Gammaked

(100mg/ml Oral
Solution) Gammaplex
Gammaplex

1 PA
Simponi (Injection) 1 PA (Injection)
Simponi

Gamunex-C
Gamunex-C

Simponi Aria
Simponi Aria

1 PA 1 PA
(Injection) (Injection)
Sirolimus (Tablet) 1 B/D, PA Octagam (Injection) 1 PA
Octagam
Sirolimus

Tacrolimus (0.5mg Privigen (Injection) 1 PA

Privigen
Tacrolimus

Capsule, 1mg Capsule, 1 PA Thymoglobulin

Thymoglobulin

5mg Capsule) 1
(Injection)
Torisel (Injection) 1
Torisel

Varizig (Injection) 1
Varizig

Trexall (Tablet) 1
Trexall

Immunomodulators
Xatmep (Oral
Xatmep

Actemra (162mg/
Actemra

1 PA
Solution) 0.9ml Injection,
Xeljanz (10mg Tablet, 1 PA
Xeljanz

200mg/10ml
1 PA, QL
5mg Tablet) Injection, 400mg/
Xeljanz XR (Tablet 20ml Injection)
Xeljanz XR

Extended-Release 24 1 PA, QL Actemra (80mg/4ml

Actemra

1 PA
Hour) Injection)
Zortress (Tablet) 1 PA 1
Zortress

Actimmune (Injection)
Actimmune

Immunizing Agents, Passive Arcalyst (Injection)

Arcalyst

1 PA, LA
Atgam (Injection) 1
Atgam

Benlysta (120mg
Benlysta

BIVIGAM (Injection)
BIVIGAM

1 PA Injection, 400mg
1 PA
Carimune
Carimune Nanofiltered

Injection, 200mg/ml
Nanofiltered 1 PA Injection)
Ilaris (Injection) 1 PA, QL, LA
Ilaris

(Injection)
Leflunomide (Tablet) 1
Leflunomide

Flebogamma DIF
Flebogamma DIF

1 PA
(Injection)

Bold type = Brand name drug Plain type = Generic drug

91 92
92 tRACK
Last updated November 1, 2018
61
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Otezla (Tablet 1
Otezla

Menveo (Injection)
Menveo

Therapy Pack, 30mg 1 PA Pediarix (Injection)

Pediarix

1
Tablet)
Pedvax HIB (Injection) 1
Pedvax HIB

Ridaura (Capsule) 1
Ridaura

ProQuad (Injection) 1
ProQuad

Simulect (Injection) 1
Simulect

Quadracel (Injection) 1
Quadracel

Sylvant (Injection) 1 PA
Sylvant

Rabavert (Injection) 1 B/D, PA

Rabavert

Synagis (Injection) 1 PA
Synagis

Recombivax HB
Recombivax HB

Xolair (Injection)
Xolair

1 PA 1 B/D, PA
(Injection)
Vaccines Rotarix (Suspension)
Rotarix

1
ActHIB (Injection) 1
ActHIB

RotaTeq (Oral
RotaTeq

1
Adacel (Injection) 1
Adacel

Solution)
BCG Vaccine 1 PA
BCG Vaccine

Shingrix (Injection)
Shingrix

1
(Injection) Tenivac (Injection)
Tenivac

1
Bexsero (Injection) 1
Bexsero

Tetanus/Diphtheria
Tetanus/Diphtheria Toxoids-Adsorbed Adult

Boostrix (Injection) 1 1
Boostrix

Toxoids-Adsorbed
Daptacel (Injection)
Daptacel

1 Adult (Injection)
Trumenba (Injection) 1
Trumenba

Diphtheria/Tetanus
Diphtheria/Tetanus Toxoids Adsorbed Pediatric

Toxoids Adsorbed 1 Twinrix (Injection) 1

Twinrix

Pediatric (Injection) Typhim Vi (Injection)

Typhim Vi

1
Engerix-B (Injection) 1 B/D, PA
Engerix-B

VAQTA (Injection) 1
VAQTA

Gardasil 9 (Injection) 1
Gardasil 9

Varivax (Injection) 1
Varivax

Havrix (Injection) 1
Havrix

YF-Vax (Injection) 1
YF-Vax

Hiberix (Injection) 1
Hiberix

Zostavax (Injection) 1 PA
Zostavax

Imovax Rabies
Imovax Rabies

1 B/D, PA Inflammatory Bowel Disease Agents

(H.D.C.V.) (Injection)
Aminosalicylates
Infanrix (Injection) 1
Infanrix

Apriso (Capsule
Apriso

IPOL Inactivated IPV

IPOL Inactivated IPV

1 Extended-Release 24 1 QL
(Injection) Hour)
Ixiaro (Injection) 1
Ixiaro

Balsalazide Disodium
Balsalazide Disodium

1
Kinrix (Injection)
Kinrix

1 (Capsule)
Canasa (Suppository) 1
Canasa

M-M-R II (Injection) 1
M-M-R II

Dipentum (Capsule) 1
Dipentum

Menactra (Injection) 1
Menactra

You can find information on what the abbreviations in this table mean on pages 6 - 7.
92 93
Last updated November 1, 2018
tRACK
93
62
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Lialda (Tablet Metabolic Bone Disease Agents
Lialda

1 QL
Delayed-Release) Metabolic Bone Disease Agents
Mesalamine (Enema) 1 Alendronate Sodium
Mesalamine
Alendronate Sodium

Mesalamine DR
Mesalamine DR

(10mg Tablet, 35mg

(1.2gm Tablet Delayed- 1 QL Tablet, 40mg Tablet, 1 QL
Release) 5mg Tablet, 70mg
Tablet)
Pentasa (Capsule
Pentasa

1 QL Alendronate Sodium
Alendronate Sodium

Extended-Release)
(70mg/75ml Oral 1
Rowasa (Kit) 1
Rowasa

Solution)
Glucocorticoids Binosto (Tablet
Binosto

Budesonide (3mg
Budesonide

1 QL
Effervescent)
Capsule Delayed- 1 Calcitonin-Salmon
Calcitonin-Salmon

Release) 1 QL
(Nasal Solution)
Budesonide ER (Tablet
Budesonide ER

Calcitriol (0.25mcg
Calcitriol

Extended-Release 24 1 ST Capsule, 0.5mcg

Hour) 1 B/D, PA
Capsule, 1mcg/ml Oral
Colocort (Enema) 1 Solution)
Colocort

Entocort EC (Capsule Calcitriol (1mcg/ml

Entocort EC
Calcitriol

1 1 B/D, PA
Delayed-Release) Injection)
Doxercalciferol
Doxercalciferol

Hydrocortisone
Hydrocortisone

1 (0.5mcg Capsule,
(100mg/60ml Enema) 1 B/D, PA, QL
Procto-Med HC
Procto-Med HC

1mcg Capsule, 2.5mcg

1 Capsule)
(Cream)
Doxercalciferol (4mcg/
Doxercalciferol

Procto-Pak (Cream) 1 1 B/D, PA

Procto-Pak

2ml Injection)
Proctosol HC (Cream) 1
Proctosol HC

Etidronate Disodium
Etidronate Disodium

Proctozone-HC
Proctozone-HC

1
1 (Tablet)
(Cream)
Forteo (Injection) 1 PA, QL
Forteo

Uceris (9mg Tablet

Uceris

Ibandronate Sodium
Ibandronate Sodium

Extended-Release 24 1 ST 1 QL
(150mg Tablet)
Hour)
Ibandronate Sodium
Ibandronate Sodium

Sulfonamides 1 B/D, PA
(3mg/3ml Injection)
Sulfasalazine (500mg
Sulfasalazine

Miacalcin (200unit/ml
Miacalcin

Tablet Delayed- 1 PA
1 Injection)
Release, 500mg Tablet
Natpara (Injection) 1 PA
Natpara

Immediate-Release)

Bold type = Brand name drug Plain type = Generic drug

93 94
94 tRACK
Last updated November 1, 2018
63
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Pamidronate Disodium Sterile Water
Pamidronate Disodium Sterile Water Irrigation

1 B/D, PA 1
(Injection) Irrigation (Solution)
Paricalcitol (1mcg Ophthalmic Agents
Paricalcitol

Capsule, 2mcg Ophthalmic Agents, Other

Capsule, 4mcg
1 B/D, PA Atropine Sulfate (1%
Atropine Sulfate

Capsule, 2mcg/ml 1
Injection, 5mcg/ml Ophthalmic Solution)
Injection) Bacitracin/Polymyxin B
Bacitracin/Polymyxin B

1
Prolia (Injection)
Prolia

1 (Ophthalmic Ointment)
Blephamide
Blephamide

Rayaldee (Capsule 1
Rayaldee

1 QL (Suspension)
Extended-Release)
Blephamide S.O.P.
Blephamide S.O.P.

Risedronate Sodium 1
Risedronate Sodium

(Tablet Immediate- 1 QL (Ointment)

Cystaran (Ophthalmic
Cystaran

Release) 1
Sensipar (30mg
Sensipar

Solution)
1 B/D, PA, QL Lacrisert (Insert)
Lacrisert

1
Tablet)
Lastacaft (Ophthalmic
Lastacaft

Sensipar (60mg
Sensipar

1 B/D, PA, QL 1
Tablet, 90mg Tablet) Solution)
1 PA, QL Neomycin/Bacitracin/
Neomycin/Bacitracin/Polymyxin

Tymlos (Injection)
Tymlos

1
Polymyxin (Ointment)
Xgeva (Injection) 1 PA
Xgeva

Neomycin/Polymyxin/
Neomycin/Polymyxin/Bacitracin/Hydrocortisone

Zoledronic Acid (4mg/

Zoledronic Acid

1 B/D, PA Bacitracin/
5ml Injection) 1
Hydrocortisone
Zoledronic Acid (5mg/
Zoledronic Acid

1 PA (Ophthalmic Ointment)
100ml Injection)
Neomycin/Polymyxin/
Neomycin/Polymyxin/Dexamethasone

Zometa (Injection) 1 B/D, PA

Zometa

Dexamethasone (0.1%
Miscellaneous Therapeutic Agents Ophthalmic Ointment, 1
Miscellaneous Therapeutic Agents 0.1% Ophthalmic
Suspension)
Alcohol Prep Pads 1
Alcohol Prep Pads

Neomycin/Polymyxin/
Neomycin/Polymyxin/Gramicidin

Botox (Injection) 1 PA, QL

Botox

Gramicidin 1
Dysport (Injection)
Dysport

1 PA (Ophthalmic Solution)
Neomycin/Polymyxin/
Neomycin/Polymyxin/Hydrocortisone

Fomepizole (Injection) 1
Fomepizole

Hydrocortisone (1%
Gauze (Non-medicated
Gauze

1
1 Ophthalmic
2X2) Suspension)
Insulin Syringes,
Insulin Syringes, Needles

1
Needles

You can find information on what the abbreviations in this table mean on pages 6 - 7.
94 95
Last updated November 1, 2018 tRACK
95
64
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Polymyxin B Sulfate/ Cromolyn Sodium (4%
Polymyxin B Sulfate/Trimethoprim Sulfate Cromolyn Sodium

1
Trimethoprim Sulfate 1 Ophthalmic Solution)
(Ophthalmic Solution) Epinastine HCl
Epinastine HCl

1
Pred-G (Suspension) 1 (Ophthalmic Solution)
Pred-G

Olopatadine HCl
Olopatadine HCl

Pred-G S.O.P.
Pred-G S.O.P.

1 1
(Ointment) (Ophthalmic Solution)
Pazeo (Ophthalmic
Pazeo

Proparacaine HCl
Proparacaine HCl

1 1
(Ophthalmic Solution) Solution)
Restasis (Emulsion)
Restasis

1 QL Ophthalmic Antiglaucoma Agents

Alphagan P (0.1%
Alphagan P

Rhopressa
Rhopressa

1 ST 1
(Ophthalmic Solution) Ophthalmic Solution)
Apraclonidine
Apraclonidine

Sulfacetamide
Sulfacetamide Sodium/Prednisolone Sodium Phosphate

1
Sodium/Prednisolone (Ophthalmic Solution)
1
Sodium Phosphate Azopt (Suspension) 1
Azopt

(Ophthalmic Solution) Betaxolol HCl (0.5%

Betaxolol HCl

Tobradex (0.3%-0.1% 1
Ophthalmic Solution)
Tobradex

1
Ophthalmic Ointment) Betimol (Ophthalmic
Betimol

Tobradex ST
Tobradex ST
1
Solution)
(Ophthalmic 1 Brimonidine Tartrate
Brimonidine Tartrate

Suspension) (0.15% Ophthalmic 1

Tobramycin/
Tobramycin/Dexamethasone

Solution)
Dexamethasone Brimonidine Tartrate
1
Brimonidine Tartrate

(Ophthalmic (0.2% Ophthalmic 1

Suspension) Solution)
Xiidra (Ophthalmic
Xiidra

Carteolol HCl
Carteolol HCl

1 QL 1
Solution) (Ophthalmic Solution)
Ophthalmic Anti-allergy Agents Combigan
Combigan

Alocril (Ophthalmic
Alocril
1
1 (Ophthalmic Solution)
Solution) Cosopt PF
Cosopt PF

Alomide (Ophthalmic
Alomide
1
1 (Ophthalmic Solution)
Solution) Dorzolamide HCl
Dorzolamide HCl

Azelastine HCl (0.05% 1

(Ophthalmic Solution)
Azelastine HCl

1
Ophthalmic Solution) Dorzolamide HCl/
Dorzolamide HCl/Timolol Maleate

Bepreve (Ophthalmic Timolol Maleate 1

Bepreve

1
Solution) (Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug

95 96
96 tRACK
Last updated November 1, 2018
65
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Levobunolol HCl 1
Levobunolol HCl

FML (Ointment)
FML

1
(Ophthalmic Solution) FML Forte
FML Forte

Metipranolol
Metipranolol

1
1 (Suspension)
(Ophthalmic Solution)
Ilevro (Suspension) 1
Ilevro

Phospholine Iodide
Phospholine Iodide

1 Ketorolac
Ketorolac Tromethamine

(Ophthalmic Solution)
Tromethamine (0.4%
Pilocarpine HCl (1%
Pilocarpine HCl

Ophthalmic Solution, 1
Ophthalmic Solution, 0.5% Ophthalmic
2% Ophthalmic 1 Solution)
Solution, 4% Lotemax (0.5% Gel,
Lotemax

Ophthalmic Solution) 0.5% Ointment, 0.5% 1

Simbrinza
Simbrinza

Suspension)
1
(Suspension) Nevanac
Nevanac

1
Timolol Maleate
Timolol Maleate

(Suspension)
(0.25% Ophthalmic Pred Mild
Pred Mild

Solution, 0.5% 1 1
(Suspension)
Ophthalmic Solution)
Prednisolone Acetate
Prednisolone Acetate

(Generic Timoptic)
(Ophthalmic 1
Timolol Maleate
Timolol Maleate Ophthalmic Gel Forming

Suspension)
Ophthalmic Gel 1
Prednisolone Sodium
Prednisolone Sodium Phosphate

Forming (Solution)
Phosphate (1% 1
Ophthalmic Anti-inflammatories Ophthalmic Solution)
Dexamethasone
Dexamethasone Sodium Phosphate

Prolensa (Ophthalmic
Prolensa

Sodium Phosphate 1
1 Solution)
(0.1% Ophthalmic
Solution) Ophthalmic Prostaglandin and Prostamide
Diclofenac Sodium
Diclofenac Sodium
Analogs
Latanoprost
Latanoprost

(0.1% Ophthalmic 1 1
Solution) (Ophthalmic Solution)
Lumigan (Ophthalmic
Lumigan

Durezol (Emulsion) 1
Durezol

1
Solution)
Flarex (Suspension) 1
Flarex

Travatan Z
Travatan Z

Fluorometholone 1
Fluorometholone

(Ophthalmic Solution)
(Ophthalmic 1
Vyzulta (Ophthalmic
Vyzulta

Suspension) 1
Solution)
Flurbiprofen Sodium
Flurbiprofen Sodium

1
(Ophthalmic Solution)

You can find information on what the abbreviations in this table mean on pages 6 - 7.
96 97
Last updated November 1, 2018 tRACK
97
66
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Zioptan (Ophthalmic Phenadoz
Zioptan Phenadoz

1 1
Solution) (Suppository)
Otic Agents Promethazine HCl
Promethazine HCl

Otic Agents (12.5mg Suppository,

25mg Suppository, 1
Acetic Acid (Otic
Acetic Acid

1 25mg/ml Injection,
Solution) 50mg/ml Injection)
Cipro HC
Cipro HC

1 Promethazine HCl
Promethazine HCl

(Suspension) 1
(6.25mg/5ml Syrup)
Ciprodex (Otic
Ciprodex

Promethazine HCl
Promethazine HCl

1 1
Suspension) (Tablet)
Coly-Mycin S
Coly-Mycin S

Promethegan (25mg
Promethegan

1 1
(Suspension) Suppository)
Fluocinolone Anti-inflammatories, Inhaled Corticosteroids
Fluocinolone Acetonide

Acetonide (0.01% Otic 1 Arnuity Ellipta

Arnuity Ellipta

Oil)
(100mcg/act Aerosol
Hydrocortisone/Acetic
Hydrocortisone/Acetic Acid

1 Powder, 200mcg/act
Acid (Otic Solution) 1 QL
Aerosol Powder,
Neomycin/Polymyxin/
Neomycin/Polymyxin/Hydrocortisone

50mcg/act Aerosol
Hydrocortisone (1% Powder)
1
Otic Solution, 1% Otic
Budesonide (0.25mg/
Budesonide

Suspension)
2ml Suspension,
Respiratory Tract/Pulmonary Agents 0.5mg/2ml 1 B/D, PA
Antihistamines Suspension, 1mg/2ml
Azelastine HCl (0.1%
Azelastine HCl

Suspension)
Nasal Solution, 0.15% 1 Flovent Diskus
Flovent Diskus

Nasal Solution) 1 QL
(Aerosol Powder)
Cetirizine HCl (Oral
Cetirizine HCl

Flovent HFA (Aerosol) 1 QL

Flovent HFA

1
Solution)
Flunisolide (Nasal
Flunisolide

Cyproheptadine HCl
Cyproheptadine HCl

1
Solution)
(2mg/5ml Syrup, 4mg 1
Fluticasone Propionate
Fluticasone Propionate

Tablet)
(50mcg/act 1
Diphenhydramine HCl
Diphenhydramine HCl

1 B/D, PA Suspension)
(50mg/ml Injection)
Mometasone Furoate
Mometasone Furoate

Levocetirizine
Levocetirizine Dihydrochloride

(50mcg/act 1
Dihydrochloride (5mg 1 QL Suspension)
Tablet)

Bold type = Brand name drug Plain type = Generic drug

97 98
98 tRACK
Last updated November 1, 2018
67
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Triamcinolone Albuterol Sulfate
Triamcinolone Acetonide Albuterol Sulfate

Acetonide (55mcg/ 1 (0.083% Nebulized

act Aerosol) Solution, 0.5%
Antileukotrienes Nebulized Solution, 1 B/D, PA
0.63mg/3ml Nebulized
Montelukast Sodium
Montelukast Sodium

1 QL Solution, 1.25mg/3ml
(10mg Tablet) Nebulized Solution)
Montelukast Sodium
Montelukast Sodium

Albuterol Sulfate (2mg

Albuterol Sulfate

(4mg Packet, 4mg Tablet Immediate-

1 QL 1
Tablet Chewable, 5mg Release, 4mg Tablet
Tablet Chewable) Immediate-Release)
Zafirlukast (Tablet) 1 QL
Zafirlukast

Brovana (Nebulized
Brovana

1 B/D, PA, QL
Zileuton ER (Tablet
Zileuton ER

Solution)
Extended-Release 12 1 ST Epinephrine (0.15mg/
Epinephrine

Hour) 0.3ml Injection,

Zyflo (Tablet) 1 ST
Zyflo

0.3mg/0.3ml 1 QL
Zyflo CR (Tablet Injection) (Generic
Zyflo CR

Extended-Release 12 1 ST EpiPen)
Hour) EpiPen (Injection)
EpiPen

1 QL
Bronchodilators, Anticholinergic Levalbuterol
Levalbuterol

1 B/D, PA
Atrovent HFA (Nebulized Solution)
Atrovent HFA

1
(Aerosol Solution) Metaproterenol Sulfate
Metaproterenol Sulfate

Incruse Ellipta
Incruse Ellipta

(10mg Tablet, 20mg

1 QL 1
(Aerosol Powder) Tablet, 10mg/5ml
Syrup)
Ipratropium Bromide
Ipratropium Bromide

Perforomist
Perforomist

(0.02% Inhalation 1 B/D, PA 1 B/D, PA, QL

Solution) (Nebulized Solution)
Ipratropium Bromide ProAir HFA (Aerosol
ProAir HFA
Ipratropium Bromide

1
(0.03% Nasal Solution, 1 Solution)
0.06% Nasal Solution) ProAir RespiClick
ProAir RespiClick

1
Spiriva HandiHaler
Spiriva HandiHaler

(Aerosol Powder)
1 QL
(Capsule) Serevent Diskus
Serevent Diskus

1 QL
Spiriva Respimat
Spiriva Respimat

(Aerosol Powder)
1 QL
(Aerosol Solution) Terbutaline Sulfate
Terbutaline Sulfate

1
Bronchodilators, Sympathomimetic (1mg/ml Injection)
Cystic Fibrosis Agents

You can find information on what the abbreviations in this table mean on pages 6 - 7.
98 99
Last updated November 1, 2018
tRACK
99
68
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
Bethkis (Nebulized Pulmonary Antihypertensives
Bethkis

1 B/D, PA, QL
Solution) Adcirca (Tablet)
Adcirca

1 PA, QL
Cayston (Inhalation
Cayston

Adempas (Tablet) 1 PA
Adempas

1 PA, LA
Solution)
Letairis (Tablet) 1 PA, QL, LA
Letairis

Kalydeco (150mg
Kalydeco

Opsumit (Tablet) 1 PA, LA

Opsumit

Tablet, 50mg Packet, 1 PA, QL

Orenitram (0.125mg
Orenitram

75mg Packet)
Orkambi (Tablet)
Orkambi

1 PA, QL, LA Tablet Extended- 1 PA

Release)
TOBI (Nebulized
TOBI

1 B/D, PA, QL Orenitram (0.25mg

Orenitram

Solution)
Tablet Extended-
TOBI Podhaler
TOBI Podhaler

1 PA, QL Release, 1mg Tablet

(Capsule)
Extended-Release,
Tobramycin (Nebulized
Tobramycin

1 PA
1 B/D, PA, QL 2.5mg Tablet
Solution) Extended-Release,
Mast Cell Stabilizers 5mg Tablet Extended-
Cromolyn Sodium
Cromolyn Sodium

Release)
(20mg/2ml Nebulized 1 B/D, PA Remodulin (Injection)
Remodulin

1 PA, LA
Solution)
Revatio (10mg/
Revatio

Phosphodiesterase Inhibitors, Airways 1 PA

12.5ml Injection)
Disease
Revatio (20mg Tablet) 1 PA, QL
Revatio

Aminophylline
Aminophylline

1 Sildenafil (10mg/
Sildenafil

(Injection) 1 PA
12.5ml Injection)
Daliresp (Tablet) 1 PA, QL
Daliresp

Sildenafil (20mg
Sildenafil

Theophylline (Oral
Theophylline

1 Tablet) (Generic 1 PA, QL

Solution)
Revatio)
Theophylline CR
Theophylline CR

Tracleer (125mg
Tracleer

(Tablet Extended- 1
Release 12 Hour) Tablet, 62.5mg
1 PA, QL
Tablet, 32mg Tablet
Theophylline ER
Theophylline ER

Soluble)
(300mg Tablet
Ventavis (Inhalation
Ventavis

Extended-Release 12 1 PA, QL, LA

Hour, 400mg Tablet Solution)
1
Extended-Release 24 Pulmonary Fibrosis Agents
Hour, 600mg Tablet Esbriet (267mg
Esbriet

Extended-Release 24 Capsule, 267mg 1 PA, QL, LA

Hour)
Tablet, 801mg Tablet)

Bold type = Brand name drug Plain type = Generic drug

99 100
100 tRACK
Last updated November 1, 2018
69
Coverage Coverage
Drug Rules or Drug Rules or
Drug Name Drug Name
Tier Limits on Tier Limits on
use use
1 PA, QL, LA Baclofen (10mg Tablet,
Baclofen

Ofev (Capsule)
Ofev

Respiratory Tract Agents, Other 20mg Tablet, 5mg 1

Tablet)
Acetylcysteine
Acetylcysteine

1 B/D, PA Chlorzoxazone (500mg

Chlorzoxazone

(Inhalation Solution) 1
Tablet)
Advair Diskus
Advair Diskus

1 QL Cyclobenzaprine HCl
Cyclobenzaprine HCl

(Aerosol Powder)
(10mg Tablet, 5mg 1
Advair HFA (Aerosol) 1 QL
Advair HFA

Tablet)
Anoro Ellipta (Aerosol
Anoro Ellipta

Cyclobenzaprine HCl
Cyclobenzaprine HCl

1 QL 1
Powder) (7.5mg Tablet)
Bevespi Aerosphere Dantrolene Sodium
Bevespi Aerosphere
Dantrolene Sodium

1 QL 1
(Aerosol) (Capsule)
Lioresal Intrathecal
Lioresal Intrathecal

Breo Ellipta (Aerosol

Breo Ellipta

1 QL
Powder) (2000mcg/ml 1 B/D, PA
Combivent Respimat
Combivent Respimat

Injection)
1
Lioresal Intrathecal
Lioresal Intrathecal

(Aerosol Solution)
Dulera (Aerosol)
Dulera

1 QL (500mcg/ml 1 B/D, PA
Injection)
Dymista (Suspension) 1
Dymista

Orphenadrine Citrate
Orphenadrine Citrate

Fluticasone 1
Fluticasone Propionate/Salmeterol

(Injection)
Propionate/
1 QL Tizanidine HCl (2mg
Tizanidine HCl

Salmeterol (Aerosol 1
Tablet, 4mg Tablet)
Powder)
Sleep Disorder Agents
Ipratropium Bromide/
Ipratropium Bromide/Albuterol Sulfate

Albuterol Sulfate 1 B/D, PA GABA Receptor Modulators

(Inhalation Solution) Temazepam (15mg
Temazepam

Nucala (Injection)
Nucala

1 PA, QL, LA Capsule, 30mg 1 QL

Capsule)
Pulmozyme
Pulmozyme

1 B/D, PA, QL Zaleplon (Capsule) 1 QL

Zaleplon

(Inhalation Solution)
Zolpidem Tartrate
Zolpidem Tartrate

Stiolto Respimat
Stiolto Respimat

1 QL (10mg Tablet
(Aerosol Solution)
Immediate-Release, 1 QL
Symbicort (Aerosol) 1 QL
Symbicort

5mg Tablet Immediate-

Trelegy Ellipta
Trelegy Ellipta

Release)
1 QL
(Aerosol Powder) Sleep Disorders, Other
Skeletal Muscle Relaxants Belsomra (Tablet) 1 QL
Belsomra

Skeletal Muscle Relaxants Hetlioz (Capsule)

Hetlioz

1 PA, QL

You can find information on what the abbreviations in this table mean on pages 6 - 7.
100 101
Last updated November 1, 2018
tRACK
101
70
Modafinil (Tablet) 1 PA, QL
Modafinil

Rozerem (Tablet) 1 QL
Rozerem

Xyrem (Oral Solution) 1 PA, QL, LA

Xyrem

Bold type = Brand name drug Plain type = Generic drug

 1 track

102102
Covered drugs with a quantity limit (QL)
1
This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each
strength may have a different quantity limit. If quantity limits for a drug vary by strength, the
different strengths are listed on separate lines. These limits may be in place to ensure your safety.
Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain
number of days. For more information about quantity limits, talk with your doctor or pharmacist.
You can also call Customer Service. Our contact information is on the cover.
Drugs are listed in alphabetical order in the chart below.
track

Drug Name Quantity Limit

Abacavir (20mg/ml Oral Solution)
Abacavir (300mg Tablet)
Abacavir Sulfate/Lamivudine/Zidovudine
(Tablet)
Abacavir/Lamivudine (Tablet)
Abstral (Tablet Sublingual)
Acarbose (100mg Tablet)
Acarbose (25mg Tablet)
Acarbose (50mg Tablet)
Acetaminophen/Codeine (120mg-12mg/5ml
Oral Solution)
Acetaminophen/Codeine (300mg-15mg Tablet,
300mg-30mg Tablet, 300mg-60mg Tablet)
Acyclovir (5% Ointment)
Adcirca (Tablet)
Advair Diskus (Aerosol Powder)
Advair HFA (Aerosol)
Afeditab CR (Tablet Extended-Release 24 Hour)
Albenza (Tablet)
Alecensa (Capsule)
Alendronate Sodium (10mg Tablet, 40mg
Tablet, 5mg Tablet)
Alendronate Sodium (35mg Tablet)
Alendronate Sodium (70mg Tablet)
Alprazolam (0.25mg Tablet Immediate-Release,
0.5mg Tablet Immediate-Release)
Alprazolam (1mg Tablet Immediate-Release)
Alprazolam (2mg Tablet Immediate-Release)
Alunbrig (180mg Tablet, 90mg Tablet)
Maximum of 48 ml per day
Maximum of 3 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 3 tablets per day
Maximum of 12 tablets per day
Maximum of 6 tablets per day
Maximum of 150 ml per day
Maximum of 13 tablets per day
Maximum of 1 tube (30 grams) per 30 days
Maximum of 2 tablets per day
Maximum of 1 inhaler (60 blisters) per 30 days
Maximum of 1 inhaler (12 grams) per 30 days
Maximum of 2 tablets per day
Maximum of 16 tablets per day
Maximum of 8 capsules per day
Maximum of 1 tablet per day
Maximum of 8 tablets per 28 days
Maximum of 4 tablets per 28 days
Maximum of 4 tablets per day
Maximum of 4 tablets per day
Maximum of 5 tablets per day
Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug

 2

Last103
updated November 1, 2018 103
2
Drug Name Quantity Limit
Alunbrig (30mg Tablet) Maximum of 6 tablets per day
Alunbrig (Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days
Amitiza (Capsule) Maximum of 2 capsules per day
Amlodipine Besylate/Atorvastatin Calcium
Maximum of 1 tablet per day
(Tablet)
Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day
Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day
Amlodipine/Olmesartan Medoxomil (Tablet) Maximum of 1 tablet per day
Amlodipine/Valsartan/Hydrochlorothiazide
Maximum of 1 tablet per day
(Tablet)
Amphetamine/Dextroamphetamine (10mg
Capsule Extended-Release 24 Hour, 15mg
Capsule Extended-Release 24 Hour, 20mg
Capsule Extended-Release 24 Hour, 25mg Maximum of 2 capsules per day
Capsule Extended-Release 24 Hour, 30mg
Capsule Extended-Release 24 Hour, 5mg
Capsule Extended-Release 24 Hour)
Amphetamine/Dextroamphetamine (10mg
Tablet Immediate-Release, 12.5mg Tablet
Immediate-Release, 15mg Tablet Immediate-
Maximum of 2 tablets per day
Release, 30mg Tablet Immediate-Release, 5mg
Tablet Immediate-Release, 7.5mg Tablet
Immediate-Release)
Amphetamine/Dextroamphetamine (20mg
Maximum of 3 tablets per day
Tablet Immediate-Release)
Ampyra (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day
Androderm (Patch 24 Hour) Maximum of 1 patch per day
Anoro Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days
Apokyn (Injection) Maximum of 3 ml per day
Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day
Aptiom (200mg Tablet, 400mg Tablet) Maximum of 1 tablet per day
Aptiom (600mg Tablet, 800mg Tablet) Maximum of 2 tablets per day
Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day
Aptivus (250mg Capsule) Maximum of 6 capsules per day
Aripiprazole (10mg Tablet, 15mg Tablet, 20mg
Maximum of 1 tablet per day
Tablet, 2mg Tablet, 30mg Tablet, 5mg Tablet)
Aripiprazole (1mg/ml Oral Solution) Maximum of 25 ml per day
Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day
Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug


104104
3
Drug Name
Arnuity Ellipta (100mcg/act Aerosol Powder,
200mcg/act Aerosol Powder)
Arnuity Ellipta (50mcg/act Aerosol Powder)
Aspirin/Dipyridamole (Capsule Extended-
Release 12 Hour)
Atazanavir Sulfate (150mg Capsule, 300mg
Capsule)
Atazanavir Sulfate (200mg Capsule)
Atomoxetine (100mg Capsule, 60mg Capsule,
80mg Capsule)
Atomoxetine (10mg Capsule, 18mg Capsule,
25mg Capsule, 40mg Capsule)
Atorvastatin Calcium (Tablet)
Atripla (Tablet)
Aubagio (Tablet)
Austedo (Tablet)
Avandia (2mg Tablet)
Avandia (4mg Tablet)
Belsomra (Tablet)
Benazepril HCl (Tablet)
Benazepril HCl/Hydrochlorothiazide (Tablet)
Bethkis (Nebulized Solution)
Bevespi Aerosphere (Aerosol)
BiDil (Tablet)
Biktarvy (Tablet)
Binosto (Tablet Effervescent)
Bisoprolol Fumarate/Hydrochlorothiazide
(Tablet)
Bosulif (100mg Tablet)
Bosulif (400mg Tablet, 500mg Tablet)
Botox (Injection)
Breo Ellipta (Aerosol Powder)
Brilinta (Tablet)
Briviact (100mg Tablet, 10mg Tablet, 25mg
Tablet, 50mg Tablet, 75mg Tablet)
Briviact (10mg/ml Oral Solution)
Briviact (50mg/5ml Intravenous Solution)
Brovana (Nebulized Solution)
Bold type = Brand name drug Plain type = Generic drug
3
Last updated November 1, 2018
Quantity Limit
Maximum of 1 inhaler (30 blisters) per 30 days
Maximum of 1 inhaler (30 blisters) per 30 days
Maximum of 2 capsules per day
Maximum of 2 capsules per day
Maximum of 3 capsules per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 8 ml (2 ampules) per day
Maximum of 1 inhaler (10.7 grams) per 30 days
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per 28 days
Maximum of 2 tablets per day
Maximum of 6 tablets per day
Maximum of 1 tablet per day
Maximum of 9 vials per 30 days
Maximum of 1 inhaler (60 blisters) per 30 days
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 20 ml per day
Maximum of 20 ml per day
Maximum of 2 vials (4 ml) per day

Last105
updated November 1, 2018
4
Drug Name
Buprenorphine HCl (2mg Tablet Sublingual,
8mg Tablet Sublingual)
Buprenorphine HCl/Naloxone HCl (Tablet
Sublingual)
Butalbital/Acetaminophen/Caffeine (Tablet)
Butalbital/Aspirin/Caffeine (Capsule)
Butorphanol Tartrate (10mg/ml Nasal Solution)
Bydureon Bcise (Auto injector)
Bydureon Pen (Injection)
Bydureon Vial (Injection)
Byetta (10mcg/0.04ml Solution Pen injector)
Byetta (5mcg/0.02ml Solution Pen injector)
Bystolic (10mg Tablet, 2.5mg Tablet, 5mg
Tablet)
Bystolic (20mg Tablet)
Cabometyx (20mg Tablet, 60mg Tablet)
Cabometyx (40mg Tablet)
Calcitonin-Salmon (Nasal Solution)
Calquence (Capsule)
Candesartan Cilexetil (16mg Tablet, 32mg
Tablet, 4mg Tablet)
Candesartan Cilexetil (8mg Tablet)
Candesartan Cilexetil/Hydrochlorothiazide
(Tablet)
Captopril (100mg Tablet)
Captopril (12.5mg Tablet, 25mg Tablet)
Captopril (50mg Tablet)
Captopril/Hydrochlorothiazide (25mg-15mg
Tablet, 50mg-15mg Tablet)
Captopril/Hydrochlorothiazide (25mg-25mg
Tablet, 50mg-25mg Tablet)
Celecoxib (Capsule)
Cimduo (Tablet)
Clonazepam (0.5mg Tablet, 1mg Tablet)
Clonazepam (2mg Tablet)
Clonazepam ODT (0.125mg Tablet Dispersible,
0.25mg Tablet Dispersible, 0.5mg Tablet
Dispersible, 1mg Tablet Dispersible)
Bold type = Brand name drug Plain type = Generic drug
4
105
Quantity Limit
Maximum of 3 tablets per day
Maximum of 3 tablets per day
Maximum of 6 tablets per day
Maximum of 6 capsules per day
Maximum of 2 bottles (5 ml) per 30 days
Maximum of 4 pens (3.4 ml) per 28 days
Maximum of 4 pens per 28 days
Maximum of 4 vials per 28 days
Maximum of 1 pen (2.4 ml) per 30 days
Maximum of 1 pen (1.2 ml) per 30 days
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 bottle per 28 days
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 3 tablets per day
Maximum of 9 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 10 tablets per day
Maximum of 4 tablets per day

106106
5
Drug Name
Clonazepam ODT (2mg Tablet Dispersible)
Clopidogrel (75mg Tablet)
Clorazepate Dipotassium (15mg Tablet)
Clorazepate Dipotassium (3.75mg Tablet)
Clorazepate Dipotassium (7.5mg Tablet)
Clozapine ODT (100mg Tablet Dispersible)
Clozapine ODT (12.5mg Tablet Dispersible)
Clozapine ODT (150mg Tablet Dispersible)
Clozapine ODT (200mg Tablet Dispersible)
Clozapine ODT (25mg Tablet Dispersible)
Codeine Sulfate (Tablet)
Colchicine (0.6mg Capsule) (Generic
Mitigare)
Colchicine (0.6mg Tablet) (Generic Colcrys)
Colcrys (Tablet)
Combivir (Tablet)
Complera (Tablet)
Corlanor (Tablet)
Cotellic (Tablet)
Crixivan (Capsule)
Cycloset (Tablet)
Daklinza (Tablet)
Daliresp (Tablet)
Denavir (Cream)
Descovy (Tablet)
Desvenlafaxine ER (100mg Tablet Extended-
Release 24 Hour) (Generic Pristiq)
Desvenlafaxine ER (25mg Tablet Extended-
Release 24 Hour, 50mg Tablet Extended-
Release 24 Hour) (Generic Pristiq)
Dexilant (Capsule Delayed-Release)
Dexmethylphenidate HCl (Tablet Immediate-
Release)
Dextroamphetamine Sulfate (10mg Tablet, 5mg
Tablet)
Dextroamphetamine Sulfate ER (10mg Capsule
Extended-Release 24 Hour)
Bold type = Brand name drug Plain type = Generic drug
5
Last updated November 1, 2018
Quantity Limit
Maximum of 10 tablets per day
Maximum of 4 tablets per day
Maximum of 6 tablets per day
Maximum of 24 tablets per day
Maximum of 12 tablets per day
Maximum of 9 tablets per day
Maximum of 2 tablets per day
Maximum of 6 tablets per day
Maximum of 4 tablets per day
Maximum of 3 tablets per day
Maximum of 6 tablets per day
Maximum of 4 capsules per day
Maximum of 4 tablets per day
Maximum of 4 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 9 capsules per day
Maximum of 6 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tube (5 grams) per 30 days
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 2 tablets per day
Maximum of 6 tablets per day
Maximum of 6 capsules per day
 6

Last107
updated November 1, 2018 107
6
Drug Name Quantity Limit
Dextroamphetamine Sulfate ER (15mg Capsule
Maximum of 4 capsules per day
Extended-Release 24 Hour)
Dextroamphetamine Sulfate ER (5mg Capsule
Maximum of 3 capsules per day
Extended-Release 24 Hour)
Diazepam (10mg Tablet, 2mg Tablet, 5mg
Maximum of 4 tablets per day
Tablet)
Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day
Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day
Donepezil HCl (10mg Tablet) Maximum of 2 tablets per day
Donepezil HCl (23mg Tablet, 5mg Tablet) Maximum of 1 tablet per day
Donepezil HCl ODT (10mg Tablet Dispersible) Maximum of 2 tablets per day
Donepezil HCl ODT (5mg Tablet Dispersible) Maximum of 1 tablet per day
Doxercalciferol (0.5mcg Capsule) Maximum of 3 capsules per day
Doxercalciferol (1mcg Capsule, 2.5mcg
Maximum of 4 capsules per day
Capsule)
Dulera (Aerosol) Maximum of 1 inhaler (13 grams) per 30 days
Duloxetine HCl (20mg Capsule Delayed-
Release, 30mg Capsule Delayed-Release, 60mg Maximum of 2 capsules per day
Capsule Delayed-Release)
Edarbi (Tablet) Maximum of 1 tablet per day
Edarbyclor (Tablet) Maximum of 1 tablet per day
Edurant (Tablet) Maximum of 2 tablets per day
Efavirenz (200mg Capsule) Maximum of 3 capsules per day
Efavirenz (50mg Capsule) Maximum of 9 capsules per day
Efavirenz (600mg Tablet) Maximum of 2 tablets per day
Eliquis (Tablet) Maximum of 2 tablets per day
Eliquis Starter Pack (Tablet) Maximum of 1 pack (74 tablets) per 30 days
Embeda (100mg-4mg Capsule Extended-
Maximum of 3 capsules per day
Release)
Embeda (20mg-0.8mg Capsule Extended-
Release, 80mg-3.2mg Capsule Extended- Maximum of 4 capsules per day
Release)
Embeda (30mg-1.2mg Capsule Extended-
Release, 50mg-2mg Capsule Extended- Maximum of 2 capsules per day
Release)
Embeda (60mg-2.4mg Capsule Extended-
Maximum of 6 capsules per day
Release)
Emsam (Patch 24 Hour) Maximum of 1 patch per day
Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day

Bold type = Brand name drug Plain type = Generic drug

 7

108108 Last updated November 1, 2018

7
Drug Name Quantity Limit
Emtriva (200mg Capsule) Maximum of 2 capsules per day
Enalapril Maleate (Tablet) Maximum of 2 tablets per day
Enalapril Maleate/Hydrochlorothiazide
Maximum of 2 tablets per day
(10mg-25mg Tablet)
Enalapril Maleate/Hydrochlorothiazide
Maximum of 1 tablet per day
(5mg-12.5mg Tablet)
Endocet (Tablet) Maximum of 12 tablets per day
Enoxaparin Sodium (100mg/ml Subcutaneous
Maximum of 2 syringes (2 ml) per day
Solution, 150mg/ml Subcutaneous Solution)
Enoxaparin Sodium (120mg/0.8ml
Subcutaneous Solution, 80mg/0.8ml Maximum of 2 syringes (1.6 ml) per day
Subcutaneous Solution)
Enoxaparin Sodium (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day
Enoxaparin Sodium (30mg/0.3ml
Maximum of 2 syringes (0.6 ml) per day
Subcutaneous Solution)
Enoxaparin Sodium (40mg/0.4ml
Maximum of 2 syringes (0.8 ml) per day
Subcutaneous Solution)
Enoxaparin Sodium (60mg/0.6ml
Maximum of 2 syringes (1.2 ml) per day
Subcutaneous Solution)
Entresto (Tablet) Maximum of 2 tablets per day
Epclusa (Tablet) Maximum of 1 tablet per day
Epinephrine (Injection) (Generic EpiPen) Maximum of 4 pens (2 boxes) per 30 days
EpiPen (Injection) Maximum of 4 pens (2 boxes) per 30 days
Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day
Epzicom (Tablet) Maximum of 2 tablets per day
Erivedge (Capsule) Maximum of 1 capsule per day
Erleada (Tablet) Maximum of 4 tablets per day
Esbriet (267mg Capsule) Maximum of 9 capsules per day
Esbriet (267mg Tablet) Maximum of 9 tablets per day
Esbriet (801mg Tablet) Maximum of 3 tablets per day
Esomeprazole Magnesium (20mg Capsule
Maximum of 3 capsules per day
Delayed-Release) (Generic Nexium)
Esomeprazole Magnesium (40mg Capsule
Maximum of 2 capsules per day
Delayed-Release) (Generic Nexium)
Estradiol (0.025mg/24hr Patch Weekly,
0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch
Weekly, 0.075mg/24hr Patch Weekly, 0.1mg/ Maximum of 4 patches per 28 days
24hr Patch Weekly, 37.5mcg/24hr Patch
Weekly)

Bold type = Brand name drug Plain type = Generic drug


Last109
updated November 1, 2018
8
Drug Name
Estradiol (10mcg Tablet)
Evotaz (Tablet)
Ezetimibe (Tablet)
Ezetimibe/Simvastatin (Tablet)
Famciclovir (125mg Tablet, 250mg Tablet)
Famciclovir (500mg Tablet)
Fanapt (10mg Tablet, 12mg Tablet, 1mg
Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet,
8mg Tablet)
Fazaclo (100mg Tablet Dispersible)
Fazaclo (150mg Tablet Dispersible)
Fazaclo (200mg Tablet Dispersible)
Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr
Patch 72 Hour, 25mcg/hr Patch 72 Hour,
50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72
Hour)
Fentanyl Citrate Oral Transmucosal (1200mcg
Lozenge on a Handle, 1600mcg Lozenge on a
Handle, 200mcg Lozenge on a Handle, 400mcg
Lozenge on a Handle, 600mcg Lozenge on a
Handle, 800mcg Lozenge on a Handle)
Fetzima (Capsule Extended-Release 24 Hour)
Firazyr (Injection)
Flector (Patch)
Flovent Diskus (Aerosol Powder)
Flovent HFA (110mcg/act Aerosol)
Flovent HFA (220mcg/act Aerosol)
Flovent HFA (44mcg/act Aerosol)
Fluticasone Propionate/Salmeterol (Aerosol
Powder)
Fluvastatin (20mg Capsule Immediate-Release)
Fluvastatin (40mg Capsule Immediate-Release)
Forteo (Injection)
Fosamprenavir Calcium (Tablet)
Fosinopril Sodium (Tablet)
Fosinopril Sodium/Hydrochlorothiazide (Tablet)
Fuzeon (Injection)
Bold type = Brand name drug Plain type = Generic drug
8
109
Quantity Limit
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 9 tablets per day
Maximum of 6 tablets per day
Maximum of 4 tablets per day
Maximum of 15 patches per 30 days
Maximum of 4 lozenges per day
Maximum of 1 capsule per day
Maximum of 9 ml per day
Maximum of 2 patches per day
Maximum of 2 inhalers (120 blisters) per 30
days
Maximum of 1 inhaler (12 grams) per 30 days
Maximum of 2 inhalers (24 grams) per 30 days
Maximum of 1 inhaler (10.6 grams) per 30 days
Maximum of 1 inhaler per 30 days
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 1 pen (2.4 ml) per 28 days
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 3 vials per day
 9

110110 Last updated November 1, 2018

9
Drug Name Quantity Limit
Galantamine HBr (12mg Tablet, 4mg Tablet,
Maximum of 2 tablets per day
8mg Tablet)
Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days
Galantamine HBr ER (Capsule Extended-
Maximum of 1 capsule per day
Release 24 Hour)
Genvoya (Tablet) Maximum of 2 tablets per day
Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days
Glimepiride (1mg Tablet) Maximum of 8 tablets per day
Glimepiride (2mg Tablet) Maximum of 4 tablets per day
Glimepiride (4mg Tablet) Maximum of 2 tablets per day
Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day
Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day
Glipizide ER (10mg Tablet Extended-Release 24
Maximum of 2 tablets per day
Hour)
Glipizide ER (2.5mg Tablet Extended-Release
Maximum of 8 tablets per day
24 Hour)
Glipizide ER (5mg Tablet Extended-Release 24
Maximum of 4 tablets per day
Hour)
Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day
Glipizide/Metformin HCl (2.5mg-500mg Tablet,
Maximum of 4 tablets per day
5mg-500mg Tablet)
Glyxambi (Tablet) Maximum of 1 tablet per day
Granisetron HCl (1mg Tablet) Maximum of 2 tablets per day
Harvoni (Tablet) Maximum of 1 tablet per day
Hetlioz (Capsule) Maximum of 1 capsule per day
Hydrocodone Bitartrate/Acetaminophen
Maximum of 12 tablets per day
(2.5mg-325mg Tablet)
Hydrocodone Bitartrate/Acetaminophen
Maximum of 180 ml per day
(7.5mg-325mg/15ml Oral Solution)
Hydrocodone/Acetaminophen (Tablet) Maximum of 12 tablets per day
Hydrocodone/Ibuprofen (7.5mg-200mg Tablet) Maximum of 5 tablets per day
Hydromorphone HCl (1mg/ml Liquid) Maximum of 90 ml per day
Hydromorphone HCl (2mg Tablet Immediate-
Maximum of 8 tablets per day
Release, 4mg Tablet Immediate-Release)
Hydromorphone HCl (8mg Tablet Immediate-
Maximum of 11 tablets per day
Release)
Hydromorphone HCl ER (Tablet Extended-
Maximum of 2 tablets per day
Release 24 Hour Abuse-Deterrent)

Bold type = Brand name drug Plain type = Generic drug


Last111
updated November 1, 2018
10
Drug Name
Hysingla ER (Tablet Extended-Release 24
Hour Abuse-Deterrent)
Ibandronate Sodium (150mg Tablet)
Ibrance (Capsule)
Iclusig (15mg Tablet)
Iclusig (45mg Tablet)
Idhifa (Tablet)
Ilaris (Injection)
Imatinib Mesylate (Tablet)
Imbruvica (140mg Capsule)
Imbruvica (140mg Tablet, 280mg Tablet,
420mg Tablet, 560mg Tablet)
Imbruvica (70mg Capsule)
Incruse Ellipta (Aerosol Powder)
Ingrezza (40mg Capsule)
Ingrezza (80mg Capsule)
Inlyta (Tablet)
Intelence (100mg Tablet)
Intelence (200mg Tablet)
Intelence (25mg Tablet)
Invirase (200mg Capsule)
Invirase (500mg Tablet)
Invokamet (Tablet)
Invokamet XR (Tablet Extended-Release 24
Hour)
Invokana (Tablet)
Irbesartan (150mg Tablet, 300mg Tablet)
Irbesartan (75mg Tablet)
Irbesartan/Hydrochlorothiazide (Tablet)
Iressa (Tablet)
Isentress (100mg Packet)
Isentress (100mg Tablet Chewable, 25mg
Tablet Chewable)
Isentress (400mg Tablet)
Isentress HD (Tablet)
Itraconazole (Capsule)
Jakafi (Tablet)
Bold type = Brand name drug Plain type = Generic drug
10
111
Quantity Limit
Maximum of 1 tablet per day
Maximum of 1 tablet per 28 days
Maximum of 1 capsule per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 vials per 28 days
Maximum of 3 tablets per day
Maximum of 4 capsules per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 1 inhaler (30 blisters) per 30 days
Maximum of 2 capsules per day
Maximum of 1 capsule per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 6 tablets per day
Maximum of 15 capsules per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 4 packets per day
Maximum of 9 tablets per day
Maximum of 6 tablets per day
Maximum of 3 tablets per day
Maximum of 4 capsules per day
Maximum of 2 tablets per day
 11

112112 Last updated November 1, 2018

11
Drug Name Quantity Limit
Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day
Janumet XR (Tablet Extended-Release 24
Maximum of 2 tablets per day
Hour)
Januvia (Tablet) Maximum of 1 tablet per day
Jardiance (Tablet) Maximum of 1 tablet per day
Jentadueto (Tablet) Maximum of 2 tablets per day
Jentadueto XR (2.5mg-1000mg Tablet
Maximum of 2 tablets per day
Extended-Release 24 Hour)
Jentadueto XR (5mg-1000mg Tablet
Maximum of 1 tablet per day
Extended-Release 24 Hour)
Juluca (Tablet) Maximum of 2 tablets per day
Kaletra (100mg-25mg Tablet) Maximum of 10 tablets per day
Kaletra (200mg-50mg Tablet) Maximum of 6 tablets per day
Kaletra (400mg-100mg/5ml Oral Solution) Maximum of 16 ml per day
Kalydeco (150mg Tablet) Maximum of 2 tablets per day
Kalydeco (50mg Packet, 75mg Packet) Maximum of 2 packets per day
Kisqali (Tablet) Maximum of 3 tablets per day
Kisqali Femara 200 Dose (Tablet Therapy
Maximum of 1 pack (91 tablets) per 28 days
Pack)
Kisqali Femara 400 Dose (Tablet Therapy
Maximum of 1 pack (91 tablets) per 28 days
Pack)
Kisqali Femara 600 Dose (Tablet Therapy
Maximum of 1 pack (91 tablets) per 28 days
Pack)
Kombiglyze XR (2.5mg-1000mg Tablet
Maximum of 2 tablets per day
Extended-Release 24 Hour)
Kombiglyze XR (5mg-1000mg Tablet
Extended-Release 24 Hour, 5mg-500mg Maximum of 1 tablet per day
Tablet Extended-Release 24 Hour)
Korlym (Tablet) Maximum of 4 tablets per day
Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day
Lamivudine (150mg Tablet) Maximum of 3 tablets per day
Lamivudine (300mg Tablet) Maximum of 2 tablets per day
Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day
Lansoprazole (15mg Capsule Delayed-Release,
Maximum of 2 capsules per day
30mg Capsule Delayed-Release)
Latuda (120mg Tablet, 20mg Tablet, 40mg
Maximum of 1 tablet per day
Tablet, 60mg Tablet)
Latuda (80mg Tablet) Maximum of 2 tablets per day
Letairis (Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug


Last113
updated November 1, 2018
12
Drug Name
Levocetirizine Dihydrochloride (5mg Tablet)
Levorphanol Tartrate (Tablet)
Lexiva (50mg/ml Suspension)
Lexiva (700mg Tablet)
Lialda (Tablet Delayed-Release)
Lidocaine (5% Patch)
Linezolid (600mg Tablet)
Linzess (Capsule)
Lisinopril (Tablet)
Lisinopril/Hydrochlorothiazide (10mg-12.5mg
Tablet)
Lisinopril/Hydrochlorothiazide (20mg-12.5mg
Tablet)
Lisinopril/Hydrochlorothiazide (20mg-25mg
Tablet)
Livalo (Tablet)
Lonsurf (6.14mg-15mg Tablet)
Lonsurf (8.19mg-20mg Tablet)
Lopinavir/Ritonavir (Oral Solution)
Lorazepam (0.5mg Tablet, 1mg Tablet)
Lorazepam (2mg Tablet)
Lorazepam (2mg/ml Concentrate)
Lorcet (Tablet)
Lorcet HD (Tablet)
Lorcet Plus (Tablet)
Losartan Potassium (100mg Tablet)
Losartan Potassium (25mg Tablet, 50mg
Tablet)
Losartan Potassium/Hydrochlorothiazide
(100mg-12.5mg Tablet, 100mg-25mg Tablet)
Losartan Potassium/Hydrochlorothiazide
(50mg-12.5mg Tablet)
Lovastatin (10mg Tablet, 20mg Tablet)
Lovastatin (40mg Tablet)
Lynparza (100mg Tablet, 150mg Tablet)
Lynparza (50mg Capsule)
Bold type = Brand name drug Plain type = Generic drug
12
113
Quantity Limit
Maximum of 1 tablet per day
Maximum of 6 tablets per day
Maximum of 90 ml per day
Maximum of 6 tablets per day
Maximum of 4 tablets per day
Maximum of 3 patches per day
Maximum of 2 tablets per day
Maximum of 1 capsule per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 10 tablets per day
Maximum of 8 tablets per day
Maximum of 16 ml per day
Maximum of 4 tablets per day
Maximum of 5 tablets per day
Maximum of 5 ml per day
Maximum of 12 tablets per day
Maximum of 12 tablets per day
Maximum of 12 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 16 capsules per day
 13

114114 Last updated November 1, 2018

13
Drug Name Quantity Limit
Lyrica (100mg Capsule, 150mg Capsule,
200mg Capsule, 25mg Capsule, 50mg Maximum of 3 capsules per day
Capsule, 75mg Capsule)
Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day
Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day
Mavyret (Tablet) Maximum of 3 tablets per day
Memantine HCl (10mg Tablet) Maximum of 2 tablets per day
Memantine HCl (2mg/ml Oral Solution) Maximum of 10 ml per day
Memantine HCl (5mg Tablet) Maximum of 3 tablets per day
Memantine HCl ER (Capsule Extended-Release
Maximum of 1 capsule per day
24 Hour)
Mesalamine DR (1.2GM Tablet Delayed-
Maximum of 4 tablets per day
Release)
Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day
Metformin HCl (1000mg Tablet Immediate-
Maximum of 2.5 tablets per day
Release)
Metformin HCl (850mg Tablet Immediate-
Maximum of 3 tablets per day
Release)
Metformin HCl (500mg Tablet Immediate-
Maximum of 5 tablets per day
Release)
Metformin HCl ER (500mg Tablet Extended-
Maximum of 4 tablets per day
Release 24 Hour) (Generic Glucophage XR)
Metformin HCl ER (750mg Tablet Extended-
Maximum of 2 tablets per day
Release 24 Hour) (Generic Glucophage XR)
Methadone HCl (10mg Tablet) Maximum of 12 tablets per day
Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day
Methadone HCl (5mg Tablet) Maximum of 8 tablets per day
Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day
Methylphenidate HCl (10mg Tablet Immediate-
Maximum of 3 tablets per day
Release) (Generic Ritalin)
Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day
Methylphenidate HCl (20mg Tablet Immediate-
Release, 5mg Tablet Immediate-Release) Maximum of 3 tablets per day
(Generic Ritalin)
Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day
Methylphenidate HCl ER (10mg Tablet
Maximum of 4 tablets per day
Extended-Release)
Methylphenidate HCl ER (20mg Tablet
Maximum of 3 tablets per day
Extended-Release)

Bold type = Brand name drug Plain type = Generic drug

 14

Last115
updated November 1, 2018 115
14
Drug Name Quantity Limit
Miglitol (100mg Tablet) Maximum of 3 tablets per day
Miglitol (25mg Tablet) Maximum of 12 tablets per day
Miglitol (50mg Tablet) Maximum of 6 tablets per day
Modafinil (100mg Tablet) Maximum of 1 tablet per day
Modafinil (200mg Tablet) Maximum of 2 tablets per day
Moexipril HCl (Tablet) Maximum of 2 tablets per day
Moexipril/Hydrochlorothiazide (15mg-12.5mg
Maximum of 2 tablets per day
Tablet, 15mg-25mg Tablet)
Moexipril/Hydrochlorothiazide (7.5mg-12.5mg
Maximum of 1 tablet per day
Tablet)
Montelukast Sodium (10mg Tablet) Maximum of 1 tablet per day
Montelukast Sodium (4mg Packet) Maximum of 1 packet per day
Montelukast Sodium (4mg Tablet Chewable,
Maximum of 1 tablet per day
5mg Tablet Chewable)
Morphine Sulfate (100mg/5ml Oral Solution) Maximum of 18 ml per day
Morphine Sulfate (10mg/5ml Oral Solution) Maximum of 120 ml per day
Morphine Sulfate (15mg Tablet Immediate-
Maximum of 8 tablets per day
Release)
Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 90 ml per day
Morphine Sulfate (30mg Tablet Immediate-
Maximum of 12 tablets per day
Release)
Morphine Sulfate ER (100mg Tablet Extended-
Release, 15mg Tablet Extended-Release) Maximum of 3 tablets per day
(Generic MS Contin)
Morphine Sulfate ER (200mg Tablet Extended-
Maximum of 2 tablets per day
Release) (Generic MS Contin)
Morphine Sulfate ER (30mg Tablet Extended-
Release, 60mg Tablet Extended-Release) Maximum of 4 tablets per day
(Generic MS Contin)
Multaq (Tablet) Maximum of 2 tablets per day
Namenda XR (Capsule Extended-Release 24
Maximum of 1 capsule per day
Hour)
Namenda XR Titration Pack (Capsule
Maximum of 1 capsule per day
Extended-Release 24 Hour)
Namzaric (Capsule Extended-Release 24
Maximum of 1 capsule per day
Hour)
Namzaric (Therapy Pack, Capsule Extended-
Maximum of 1 capsule per day
Release 24 Hour)
Naratriptan HCl (Tablet) Maximum of 12 tablets per 30 days

Bold type = Brand name drug Plain type = Generic drug


116116
15
Drug Name
Nateglinide (120mg Tablet)
Nateglinide (60mg Tablet)
Nebupent (Inhalation Solution)
Nerlynx (Tablet)
Nevirapine (Tablet)
Nevirapine ER (100mg Tablet Extended-Release
24 Hour)
Nevirapine ER (400mg Tablet Extended-Release
24 Hour)
Nexium (20mg Capsule Delayed-Release)
Nexium (40mg Capsule Delayed-Release)
Nifedipine ER (Tablet Extended-Release 24
Hour)
Ninlaro (Capsule)
Northera (100mg Capsule)
Northera (200mg Capsule, 300mg Capsule)
Norvir (100mg Capsule)
Norvir (100mg Packet)
Norvir (100mg Tablet)
Norvir (80mg/ml Oral Solution)
Noxafil (100mg Tablet Delayed-Release)
Noxafil (40mg/ml Suspension)
Nucala (Injection)
Nucynta ER (Tablet Extended-Release 12
Hour)
Nuplazid (Tablet)
Ocaliva (Tablet)
Odefsey (Tablet)
Odomzo (Capsule)
Ofev (Capsule)
Olanzapine (10mg Tablet, 15mg Tablet, 2.5mg
Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Tablet)
Olanzapine ODT (Tablet Dispersible)
Olmesartan Medoxomil (20mg Tablet, 40mg
Tablet)
Olmesartan Medoxomil (5mg Tablet)
Olmesartan Medoxomil/Amlodipine/
Hydrochlorothiazide (Tablet)
Bold type = Brand name drug Plain type = Generic drug
15
Last updated November 1, 2018
Quantity Limit
Maximum of 3 tablets per day
Maximum of 6 tablets per day
Maximum of 300 mg (1 vial) in 28 days
Maximum of 6 tablets per day
Maximum of 3 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 3 capsules per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 3 capsules per 28 days
Maximum of 3 capsules per day
Maximum of 6 capsules per day
Maximum of 18 capsules per day
Maximum of 18 packets per day
Maximum of 18 tablets per day
Maximum of 24 ml per day
Maximum of 8 tablets per day
Maximum of 20 ml per day
Maximum of 3 vials per 28 days
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
 16

Last117
updated November 1, 2018 117
16
Drug Name Quantity Limit
Olmesartan Medoxomil/Hydrochlorothiazide
Maximum of 1 tablet per day
(Tablet)
Omega-3-Acid Ethyl Esters (Capsule) (Generic
Maximum of 4 capsules per day
Lovaza)
Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day
Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day
Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day
Onglyza (Tablet) Maximum of 1 tablet per day
Orkambi (Tablet) Maximum of 112 tablets per 28 days
Oseltamivir Phosphate (30mg Capsule, 45mg
Maximum of 2 capsules per day
Capsule, 75mg Capsule)
Oseltamivir Phosphate (6mg/ml Suspension) Maximum of 26 ml per day
Osphena (Tablet) Maximum of 1 tablet per day
Oxandrolone (10mg Tablet) Maximum of 2 tablets per day
Oxandrolone (2.5mg Tablet) Maximum of 4 tablets per day
Oxybutynin Chloride ER (10mg Tablet
Extended-Release 24 Hour, 15mg Tablet Maximum of 2 tablets per day
Extended-Release 24 Hour)
Oxybutynin Chloride ER (5mg Tablet Extended-
Maximum of 1 tablet per day
Release 24 Hour)
Oxycodone HCl (100mg/5ml Concentrate) Maximum of 12 ml per day
Oxycodone HCl (10mg Tablet Immediate-
Maximum of 12 tablets per day
Release, 20mg Tablet Immediate-Release)
Oxycodone HCl (15mg Tablet Immediate-
Maximum of 16 tablets per day
Release)
Oxycodone HCl (30mg Tablet Immediate-
Maximum of 8 tablets per day
Release)
Oxycodone HCl (5mg Tablet Immediate-
Maximum of 12 tablets per day
Release)
Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 240 ml per day
Oxycodone/Acetaminophen (Tablet) Maximum of 12 tablets per day
Oxycodone/Aspirin (Tablet) Maximum of 12 tablets per day
Oxycodone/Ibuprofen (Tablet) Maximum of 4 tablets per day
Paliperidone ER (1.5mg Tablet Extended-
Release 24 Hour, 3mg Tablet Extended-Release
Maximum of 1 tablet per day
24 Hour, 9mg Tablet Extended-Release 24
Hour)
Paliperidone ER (6mg Tablet Extended-Release
Maximum of 2 tablets per day
24 Hour)

Bold type = Brand name drug Plain type = Generic drug


118118
17
Drug Name
Pantoprazole Sodium (20mg Tablet Delayed-
Release)
Pantoprazole Sodium (40mg Tablet Delayed-
Release)
Pentasa (250mg Capsule Extended-Release)
Pentasa (500mg Capsule Extended-Release)
Perforomist (Nebulized Solution)
Perindopril Erbumine (Tablet)
Pioglitazone HCl (15mg Tablet)
Pioglitazone HCl (30mg Tablet, 45mg Tablet)
Pioglitazone HCl/Glimepiride (Tablet)
Pioglitazone HCl/Metformin HCl (Tablet)
Pomalyst (Capsule)
Pradaxa (Capsule)
Praluent (Injection)
Prasugrel (Tablet)
Pravastatin Sodium (Tablet)
Premarin (0.3mg Tablet, 0.45mg Tablet,
0.625mg Tablet, 0.9mg Tablet, 1.25mg
Tablet)
Premphase (Tablet)
Prempro (Tablet)
Prezcobix (Tablet)
Prezista (100mg/ml Suspension)
Prezista (150mg Tablet)
Prezista (600mg Tablet, 800mg Tablet)
Prezista (75mg Tablet)
Pristiq (100mg Tablet Extended-Release 24
Hour)
Pristiq (25mg Tablet Extended-Release 24
Hour, 50mg Tablet Extended-Release 24
Hour)
Promacta (12.5mg Tablet, 25mg Tablet)
Promacta (50mg Tablet, 75mg Tablet)
Pulmozyme (Inhalation Solution)
Quetiapine Fumarate (100mg Tablet Immediate-
Release, 200mg Tablet Immediate-Release,
50mg Tablet Immediate-Release)
Bold type = Brand name drug Plain type = Generic drug
17
Last updated November 1, 2018
Quantity Limit
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 12 capsules per day
Maximum of 8 capsules per day
Maximum of 2 vials (4 ml) per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 2 pens (2 ml) per 28 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 60 ml per day
Maximum of 6 tablets per day
Maximum of 3 tablets per day
Maximum of 7 tablets per day
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 5 ml (2 ampules) per day
Maximum of 3 tablets per day

Last119
updated November 1, 2018
18
Drug Name
Quetiapine Fumarate (25mg Tablet Immediate-
Release)
Quetiapine Fumarate (300mg Tablet Immediate-
Release, 400mg Tablet Immediate-Release)
Quetiapine Fumarate ER (150mg Tablet
Extended-Release 24 Hour, 200mg Tablet
Extended-Release 24 Hour)
Quetiapine Fumarate ER (300mg Tablet
Extended-Release 24 Hour, 400mg Tablet
Extended-Release 24 Hour, 50mg Tablet
Extended-Release 24 Hour)
Quinapril HCl (Tablet)
Quinapril/Hydrochlorothiazide (10mg-12.5mg
Tablet)
Quinapril/Hydrochlorothiazide (20mg-12.5mg
Tablet, 20mg-25mg Tablet)
Raloxifene HCl (Tablet)
Ramipril (Capsule)
Ranexa (Tablet Extended-Release 12 Hour)
Rapaflo (Capsule)
Ravicti (Liquid)
Rayaldee (Capsule Extended-Release)
Relenza Diskhaler (Aerosol Powder)
Repaglinide (0.5mg Tablet)
Repaglinide (1mg Tablet)
Repaglinide (2mg Tablet)
Repaglinide/Metformin HCl (Tablet)
Repatha (Injection)
Repatha Pushtronex System (Injection)
Repatha SureClick (Injection)
Rescriptor (Tablet)
Restasis (Emulsion)
Revatio (20mg Tablet)
Revlimid (Capsule)
Rexulti (Tablet)
Reyataz (150mg Capsule, 300mg Capsule)
Reyataz (200mg Capsule)
Reyataz (50mg Packet)
Bold type = Brand name drug Plain type = Generic drug
18
119
Quantity Limit
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 1 capsule per day
Maximum of 17.5 ml per day
Maximum of 2 capsules per day
Maximum of 3 inhalers (60 blisters) per 30 days
Maximum of 32 tablets per day
Maximum of 16 tablets per day
Maximum of 8 tablets per day
Maximum of 5 tablets per day
Maximum of 3 syringes (3 ml) per 28 days
Maximum of 1 cartridge (3.5 ml) per 28 days
Maximum of 3 pens (3 ml) per 28 days
Maximum of 9 tablets per day
Maximum of 2 vials per day
Maximum of 3 tablets per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Maximum of 2 capsules per day
Maximum of 3 capsules per day
Maximum of 8 packets per day

120120
19
Drug Name
Riomet (Oral Solution)
Risedronate Sodium (150mg Tablet)
Risedronate Sodium (30mg Tablet, 5mg Tablet)
Risedronate Sodium (35mg Tablet)
Ritonavir (Tablet)
Rivastigmine Tartrate (Capsule)
Rivastigmine Transdermal System (Patch 24
Hour)
Rizatriptan Benzoate (Tablet)
Rizatriptan Benzoate ODT (Tablet Dispersible)
Rosuvastatin Calcium (Tablet)
Rozerem (Tablet)
Rubraca (Tablet)
Rydapt (Capsule)
Sabril (500mg Packet)
Sabril (500mg Tablet)
Samsca (Tablet)
Saphris (Tablet Sublingual)
Selzentry (150mg Tablet, 75mg Tablet)
Selzentry (20mg/ml Oral Solution)
Selzentry (25mg Tablet, 300mg Tablet)
Sensipar (30mg Tablet, 60mg Tablet)
Sensipar (90mg Tablet)
Serevent Diskus (Aerosol Powder)
Seroquel XR (150mg Tablet Extended-
Release 24 Hour, 200mg Tablet Extended-
Release 24 Hour)
Seroquel XR (300mg Tablet Extended-
Release 24 Hour, 400mg Tablet Extended-
Release 24 Hour, 50mg Tablet Extended-
Release 24 Hour)
Sildenafil (20mg Tablet) (Generic Revatio)
Simvastatin (Tablet)
Soliqua 100/33 (Injection)
Somavert (Injection)
Sovaldi (Tablet)
Spiriva HandiHaler (Capsule)
Bold type = Brand name drug Plain type = Generic drug
19
Last updated November 1, 2018
Quantity Limit
Maximum of 25.5 ml per day
Maximum of 1 tablet per 30 days
Maximum of 1 tablet per day
Maximum of 4 tablets per 28 days
Maximum of 18 tablets per day
Maximum of 2 capsules per day
Maximum of 1 patch per day
Maximum of 12 tablets per 30 days
Maximum of 12 tablets per 30 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 8 capsules per day
Maximum of 6 packets per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 92 ml per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 1 inhaler (60 inhalations) per 30
days
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 18 ml (6 pens) per 30 days
Maximum of 1 vial per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
 20

Last121
updated November 1, 2018 121
20
Drug Name Quantity Limit
Spiriva Respimat (Aerosol Solution) (Retail
Maximum of 1 inhaler (4 grams) per 30 days
Pack)
Sprycel (100mg Tablet, 140mg Tablet, 70mg
Maximum of 1 tablet per day
Tablet)
Sprycel (20mg Tablet, 50mg Tablet) Maximum of 3 tablets per day
Sprycel (80mg Tablet) Maximum of 2 tablets per day
Stavudine (15mg Capsule, 30mg Capsule,
Maximum of 3 capsules per day
40mg Capsule)
Stavudine (20mg Capsule) Maximum of 2 capsules per day
Stiolto Respimat (Aerosol Solution) (Retail
Maximum of 1 inhaler (4 grams) per 30 days
Pack)
Stivarga (Tablet) Maximum of 4 tablets per day
Stribild (Tablet) Maximum of 2 tablets per day
Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 films per day
Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 films per day
Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days
Sumatriptan Succinate (100mg Tablet, 25mg
Maximum of 12 tablets per 30 days
Tablet, 50mg Tablet)
Sumatriptan Succinate (4mg/0.5ml Solution
Maximum of 12 injections (6 ml) per 30 days
Auto injector, 6mg/0.5ml Solution Auto injector)
Sumatriptan Succinate (6mg/0.5ml Solution
Maximum of 12 injections (6 ml) per 30 days
Auto injector)
Sumatriptan Succinate (6mg/0.5ml
Maximum of 12 injections (6 ml) per 30 days
Subcutaneous Solution)
Sumatriptan Succinate Refill (Injection) Maximum of 12 injections (6 ml) per 30 days
Sustiva (200mg Capsule) Maximum of 3 capsules per day
Sustiva (50mg Capsule) Maximum of 9 capsules per day
Sustiva (600mg Tablet) Maximum of 2 tablets per day
Sutent (12.5mg Capsule, 25mg Capsule,
Maximum of 1 capsule per day
50mg Capsule)
Sutent (37.5mg Capsule) Maximum of 2 capsules per day
Symbicort (Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days
Symfi (Tablet) Maximum of 2 tablets per day
Symfi Lo (Tablet) Maximum of 2 tablets per day
Synjardy (Tablet) Maximum of 2 tablets per day
Synjardy XR (10mg-1000mg Tablet Extended-
Release 24 Hour, 25mg-1000mg Tablet Maximum of 1 tablet per day
Extended-Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug


122122
21
Drug Name
Synjardy XR (12.5mg-1000mg Tablet
Extended-Release 24 Hour, 5mg-1000mg
Tablet Extended-Release 24 Hour)
Syprine (Capsule)
Tagrisso (Tablet)
Tamiflu (Suspension)
Tarceva (100mg Tablet, 150mg Tablet)
Tarceva (25mg Tablet)
Tasigna (150mg Capsule)
Tasigna (200mg Capsule)
Tasigna (50mg Capsule)
Tecfidera (Capsule Delayed-Release)
Telmisartan (Tablet)
Telmisartan/Amlodipine (Tablet)
Telmisartan/Hydrochlorothiazide (40mg-12.5mg
Tablet, 80mg-25mg Tablet)
Telmisartan/Hydrochlorothiazide (80mg-12.5mg
Tablet)
Temazepam (15mg Capsule, 30mg Capsule)
Tenofovir Disoproxil Fumarate (Tablet)
Tetrabenazine (12.5mg Tablet)
Tetrabenazine (25mg Tablet)
Thalomid (100mg Capsule, 50mg Capsule)
Thalomid (150mg Capsule, 200mg Capsule)
Tivicay (10mg Tablet, 25mg Tablet)
Tivicay (50mg Tablet)
TOBI (Nebulized Solution)
TOBI Podhaler (Capsule)
Tobramycin (Nebulized Solution)
Tolcapone (Tablet)
Tracleer (125mg Tablet, 62.5mg Tablet)
Tracleer (32mg Tablet Soluble)
Tradjenta (Tablet)
Tramadol HCl (Tablet Immediate-Release)
Tramadol HCl ER (Tablet Extended-Release 24
Hour)
Tramadol HCl/Acetaminophen (Tablet)
Bold type = Brand name drug Plain type = Generic drug
21
Last updated November 1, 2018
Quantity Limit
Maximum of 2 tablets per day
Maximum of 8 capsules per day
Maximum of 1 tablet per day
Maximum of 26 ml per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 5 capsules per day
Maximum of 4 capsules per day
Maximum of 14 capsules per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 capsule per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 4 tablets per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 10 ml (2 ampules) per day
Maximum of 8 capsules per day
Maximum of 10 ml (2 ampules) per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 8 tablets per day
Maximum of 1 tablet per day
Maximum of 12 tablets per day
 22

Last123
updated November 1, 2018 123
22
Drug Name Quantity Limit
Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day
Trandolapril (4mg Tablet) Maximum of 2 tablets per day
Trelegy Ellipta (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days
Trezix (Capsule) Maximum of 10 capsules per day
Trientine HCl (Capsule) Maximum of 8 capsules per day
Trintellix (Tablet) Maximum of 1 tablet per day
Triumeq (Tablet) Maximum of 2 tablets per day
Trizivir (Tablet) Maximum of 3 tablets per day
Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days
Truvada (Tablet) Maximum of 2 tablets per day
Tybost (Tablet) Maximum of 2 tablets per day
Tymlos (Injection) Maximum of 1.56 ml per 30 days
Valacyclovir HCl (1gm Tablet) Maximum of 4 tablets per day
Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day
Valcyte (Tablet) Maximum of 4 tablets per day
Valganciclovir (Tablet) Maximum of 4 tablets per day
Valganciclovir Hydrochlorde (Oral Solution) Maximum of 36 ml per day
Valsartan (160mg Tablet, 40mg Tablet, 80mg
Maximum of 2 tablets per day
Tablet)
Valsartan (320mg Tablet) Maximum of 1 tablet per day
Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Veltassa (Packet) Maximum of 1 packet per day
Vemlidy (Tablet) Maximum of 1 tablet per day
Venclexta (100mg Tablet) Maximum of 4 tablets per day
Venclexta (10mg Tablet) Maximum of 2 tablets per day
Venclexta (50mg Tablet) Maximum of 1 tablet per day
Ventavis (10mcg/ml Inhalation Solution) Maximum of 7 ml per day
Ventavis (20mcg/ml Inhalation Solution) Maximum of 3 ml per day
Verzenio (Tablet) Maximum of 2 tablets per day
Vesicare (Tablet) Maximum of 1 tablet per day
Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days
Videx EC (125mg Capsule Delayed-Release) Maximum of 2 capsules per day
Videx Pediatric (Oral Solution) Maximum of 30 ml per day
Vigabatrin (Packet) Maximum of 6 packets per day
Viibryd (Tablet) Maximum of 1 tablet per day
Viibryd Starter Pack (Kit) Maximum of 1 pack (30 tablets) per 30 days

Bold type = Brand name drug Plain type = Generic drug


124124
23
Drug Name
Vimpat (100mg Tablet, 150mg Tablet, 200mg
Tablet, 50mg Tablet)
Vimpat (10mg/ml Oral Solution)
Viracept (250mg Tablet)
Viracept (625mg Tablet)
Viramune (Suspension)
Viread (150mg Tablet)
Viread (200mg Tablet, 250mg Tablet, 300mg
Tablet)
Viread (40mg/gm Powder)
Vosevi (Tablet)
Votrient (Tablet)
Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg
Capsule, 6mg Capsule)
Xarelto (10mg Tablet, 20mg Tablet)
Xarelto (15mg Tablet)
Xarelto Starter Pack (Tablet Therapy Pack)
Xeljanz (10mg Tablet)
Xeljanz (5mg Tablet)
Xeljanz XR (Tablet Extended-Release 24
Hour)
Xenazine (12.5mg Tablet)
Xenazine (25mg Tablet)
Xiidra (Ophthalmic Solution)
Xtampza ER (13.5mg Capsule Extended-
Release 12 Hour Abuse-Deterrent, 18mg
Capsule Extended-Release 12 Hour Abuse-
Deterrent, 9mg Capsule Extended-Release 12
Hour Abuse-Deterrent)
Xtampza ER (27mg Capsule Extended-
Release 12 Hour Abuse-Deterrent, 36mg
Capsule Extended-Release 12 Hour Abuse-
Deterrent)
Xtandi (Capsule)
Xyrem (Oral Solution)
Yuvafem (Tablet)
Zafirlukast (Tablet)
Zaleplon (10mg Capsule)
Bold type = Brand name drug Plain type = Generic drug
23
Last updated November 1, 2018
Quantity Limit
Maximum of 2 tablets per day
Maximum of 40 ml per day
Maximum of 15 tablets per day
Maximum of 6 tablets per day
Maximum of 60 ml per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 6 bottles (360 grams) per 30 days
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 pack (51 tablets) per 30 days
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 4 tablets per day
Maximum of 2 vials per day
Maximum of 3 capsules per day
Maximum of 6 capsules per day
Maximum of 4 capsules per day
Maximum of 18 ml per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 capsules per day
 24

Last125
updated November 1, 2018 125
24
Drug Name Quantity Limit
Zaleplon (5mg Capsule) Maximum of 1 capsule per day
Zejula (Capsule) Maximum of 3 capsules per day
Zelboraf (Tablet) Maximum of 8 tablets per day
Zerit (Oral Solution) Maximum of 120 ml per day
Ziagen (Oral Solution) Maximum of 48 ml per day
Zidovudine (100mg Capsule) Maximum of 8 capsules per day
Zidovudine (300mg Tablet) Maximum of 3 tablets per day
Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day
Ziprasidone HCl (Capsule) Maximum of 2 capsules per day
Zolpidem Tartrate (10mg Tablet Immediate-
Maximum of 1 tablet per day
Release, 5mg Tablet Immediate-Release)
Zydelig (Tablet) Maximum of 2 tablets per day
Zykadia (Capsule) Maximum of 5 capsules per day
Zytiga (250mg Tablet) Maximum of 4 tablets per day
track
Zytiga (500mg Tablet) Maximum of 2 tablets per day

Bold type = Brand name drug Plain type = Generic drug

126126
Required information
Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change on
January 1 of each year, and from time to time during the plan year. You will receive notice when
necessary.
ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to
you. Please call Customer Service. Our contact information is on the cover.
ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición.
Llame a Servicio al Cliente. Nuestra información de contacto se encuentra en la portada.
This document is available for free in other languages. Please call Customer Service. Our contact
information is on the cover.
Esta documento está disponible sin costo en otros idiomas. Llame a Servicio al Cliente. Nuestra
información de contacto se encuentra en la portada.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract and a contract with the State
Medicaid Program. 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 1-866-480-1086, TTY 711

8 a.m. - 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

UHEX18HM4106416_011 Last updated November 1, 2018