formulary - uhccommunityplan.com · 2 2 this document includes a complete list of the drugs...
TRANSCRIPT
2016 Comprehensive
FORMULARY(Complete list of covered drugs)
UnitedHealthcare Dual Complete® (PPO SNP)
UnitedHealthcare Dual Complete® RP (Regional PPO SNP)
Please read: This document contains information about the drugs we cover in this plan.
For more recent information or if you have other questions, please contact UnitedHealthcare Dual
Complete Customer Service at:
Toll-Free 1-866-622-8054, TTY 711
8 a.m. to 8 p.m. local time, 7 days a week
www.UHCCommunityPlan.com
Medicare Approved Formulary File ID 00016005, Version 21
Y0066_150714_123219A_FINAL_M32.10 Approved Last updated November 1, 2016
1
2
2
This document includes a complete list of the drugs (formulary) for our plan and is current as of
November 1, 2016. For an updated formulary (drug list), please contact us. Our contact
information, along with the date we last updated the formulary, appears on the cover.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it
refers to “plan” or “our plan,” it means UnitedHealthcare Dual Complete.
Note to existing members: Our list of covered drugs is called a Formulary. We call it the "Drug List"
for short. This complete drug list has changed since last year. Please review this document to
make sure the plan still covers the drugs you take. You must generally use network pharmacies to
use your prescription drug benefit.
3
3
The UnitedHealthcare Dual Complete
COMPREHENSIVE FORMULARY (drug list)
A formulary is a list of covered drugs selected by your plan in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. We call it the "Drug List" for short. Your plan will generally cover the
drugs listed in our formulary (drug list) as long as the drug is medically necessary, the prescription
is filled at a plan network pharmacy and other plan rules are followed. For more information on
how to fill your prescriptions, please review your Evidence of Coverage.
This document is a complete drug list of the drugs covered by your plan.
For your drug to be covered by your plan, it must be included in the complete drug list. In most
cases, your prescription must also be filled at one of our network pharmacies.
To find out if your drug is covered:
1. See if your drug is included in this complete drug list.
2. Visit your plan website. Use the online tools to look up your drugs. The information is updated
on a regular basis. The Web address appears on the cover.
3. Call Customer Service. Our contact information appears on the cover.
4
4
When the drug list may changeWe try to make as few changes to the drug list as possible during the plan year. If there are
changes to the drug list, such as regular or necessary updates, members may see information in
their Explanation of Benefits (EOB) statements, member newsletters or other member mailings. If
there are changes to the drug list outside of regular or necessary updates, members may receive a
special mailing.
The drug list may change throughout the year when your plan:
· Adds a new drug as they become available, including new generic drugs.
· Removes a drug from the list because it has been found to be ineffective or unsafe.
· Changes the requirements or limits for a drug.
Generally, if you are taking a drug on the 2016 drug list that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except
when a new, less expensive generic drug becomes available or when new information about the
safety or effectiveness of a drug is released.
Other types of drug list changes, such as removing a drug from the drug list, will not affect
members who are currently taking the drug. For those members it will remain available at the
same cost for the remainder of the coverage year. We feel it is important for you to have access for
the entire coverage year to the list of drugs that were available when you chose your plan, except
when you can save additional money or your safety is a concern.
If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug during the coverage year we must notify affected members at least
60 days before the change becomes effective, or when the member requests a refill of the drug. At
this time the member will receive a 60-day supply of the drug.
If the Food and Drug Administration (FDA) declares a drug on our drug list to be unsafe, or if the
drug’s manufacturer removes the drug from the market, your plan will immediately remove the
drug from the drug list and notify members who take the drug. The enclosed drug list is current as
of the date printed on the cover. To get updated information about the drugs covered by your
plan, please call Customer Service or visit our website using the information provided on the
cover of this drug list.
5
5
Drug tiers and drug payment stagesThe amount you pay for a covered drug will depend on:
· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the coverage stage you’re in.
· The drug tier for your drug. Your plan has one tier named “Covered Drugs.” All covered drugs
are in this Tier. The chart below shows your cost-sharing amount.
For more information about drug coverage and cost-sharing amount, please review your Evidence
of Coverage.
Drug Tier Cost-Share
Tier 1 “Covered Drugs” 25% co-insurance
If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be
lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for
People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about
your costs. You can also contact Customer Service. Our contact information appears on the cover.
6
6
How to use the drug listThere are two ways to find your prescription drugs in this complete drug list:
1. Medical condition: Turn to the “Covered drugs by medical condition” section, whichbegins on page 12, to look for drugs based on your medical conditions. For example,if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Agents”category and look under “Dyslipidemics, HMG CoA Reductase Inhibitors.”
2. Alphabetical list (index): If you are not sure what category to look under, turn to the“Index of covered drugs” section, which begins on page 93. Find the name of yourdrug. The page number where you can find the drug will be next to it.
Generic drugsYour plan covers both brand name drugs and generic drugs. Generic drugs are approved by the
Food and Drug Administration (FDA) as having the same active ingredients as brand name drugs.
Generic drugs usually cost less than brand name drugs. Talk with your doctor to see if any of the
brand name drugs you take have generic versions.
The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in
plain type (for example, Simvastatin).
7
7Dummy
Required actions, restrictions or limitsSome covered drugs may have additional requirements or limits on coverage. If your drug has any
requirements or limits, there will be a code(s) in the “Required actions, restrictions or limits”
column of the drug list. The codes and what they mean are shown below.
Utilization Management Restrictions
PA - Prior authorization
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs
more information from your doctor to make sure the drug is being used correctly for a medical condition
covered by Medicare. If you don’t get approval, the plan may not cover the drug.
QL - Quantity limits
The plan will cover only a certain amount of this drug for one co-pay/co-insurance or over a certain number
of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes
more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to
cover the additional quantity.
ST - Step therapy
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be
required to try one or more of these other drugs before the plan will cover your drug. If you have already tried
other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this
drug.
Other Special Requirements for Coverage
B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient
health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more
information about how this drug will be used to make sure it’s correctly covered by Medicare.
HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may
cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative
drug is available to treat your condition.
Note: If you are 65 or older, you may need to get a prior authorization (PA) or formulary exception from the
health plan before the plan will cover a high risk medication (HRM). If you are under 65, the prior
authorization (PA) will not apply to you until the first time you get your prescription filled after turning 65.
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.
8
8
You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the “Covered drugs by medical condition” section that begins on page 12. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the cover.
You and your doctor may ask the plan for an exception to these requirements, restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the, “How to request an exception to the UnitedHealthcare Dual Complete drug list” section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug.
If your drug is not on the drug listIf your drug is not included in this complete formulary (list of covered drugs), you should contact
Customer Service and ask if your drug is covered. Our contact information, along with the date we
last updated the drug list, appears on the cover.
If you learn that your plan does not cover your drug, you have two options:
1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask
him or her to prescribe one of the appropriate drugs from the list.
2. Ask your plan to make an exception and cover your drug. See next page for information
about how to request an exception.
9
9
How to request an exception to the
UnitedHealthcare Dual Complete drug list
At times you may need to ask for drug coverage that’s not normally provided by your plan. When
you do, your plan will consider your request and respond with a coverage decision (coverage
determination).
You can ask your plan to make an exception to the coverage rules. There are several types of
exceptions that you can ask your plan to make.
· Formulary exception: You can ask your plan to cover your drug even if it is not on the drug
list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you
would not be able to ask us to provide the drug at a lower cost-sharing level.
· Utilization exception: You can ask your plan to waive coverage restrictions or limits on your
drug. For example, your plan limits the amount it will cover for certain drugs. If your drug
has a quantity limit, you can ask your plan to waive the limit and cover more.
Generally, your plan will approve your request for an exception only if the alternative drugs
included in your plan’s drug list or additional utilization restrictions would not be as effective in
treating your condition and/or would cause adverse medical effects.
Who can ask for a coverage decision
You, your authorized representative or your doctor can ask for an initial coverage decision for a
formulary exception or utilization restriction exception.
When you are requesting a formulary exception or utilization restriction exception, your
prescriber or physician should submit a statement supporting your request.
Receiving a coverage decision
Generally, your plan will make a coverage decision within 72 hours after receiving your
prescribing physician’s statement. You can request an expedited, or fast, decision if you or your
doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a
decision within 24 hours after your plan receives your doctor’s or prescribing physician’s
supporting statement.
10
10
What to do while you talk to your doctor about changing your drugs
or requesting an exception
New or continuing members
As a new or continuing member in your plan, you may be taking drugs that are not on the drug
list. Or you may be taking a drug that is on the drug list, but your ability to get it is limited. For
example, you may need prior authorization before you can fill your prescription. You should talk
to your doctor to decide if you should switch to an appropriate drug that your plan covers, or
request a formulary exception so your plan will cover the drug you are currently taking. While you
talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the
first 90 days you are a member of your plan.
For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited,
your plan may cover a temporary 30-day supply (unless you have a prescription written for fewer
days) from a network pharmacy. After your first 30-day supply, your plan will not pay for these
drugs, even if you have been a member of your plan less than 90 days.
Long-term care facility residents
If you’re a resident of a long-term care facility, your plan may allow you to refill your prescription
until we have provided you with a maximum of a 91- and may be up to a 98-day transition supply
of the drug consistent with dispensing increment (unless your prescription is written for fewer
days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a
member of your plan. If you need a drug that’s not on the drug list or if you have limited ability to
get your drugs, but you are past the first 90 days of membership in the plan, your plan will cover a
31-day emergency supply of the drug (unless your prescription is written for fewer days) while you
request a formulary exception.
Other transitions
You may have an unplanned transition, like a hospital discharge or a change in your level of care,
after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug
that’s not on the drug list, or if it’s difficult for you to get your drugs, you are required to use your
plan’s exception process. You may ask for a one-time emergency supply of up to 30 days to give
you time to talk to your doctor about other treatment options or to try to get a formulary
exception.
11
11
Drugs with dosages other than 30 days
Drugs packaged in an extended day supply
Some drugs are packaged from the manufacturer to provide greater than a 30-day supply. When
you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single
prescription. For more information, please contact Customer Service using the information on the
cover.
Daily cost share for oral medications filled for less than a 30-day supply
Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)
when dispensed for a supply of less than 30 days under applicable law. The daily cost share
requirements do not apply to either of the following:
1. Solid oral doses of antibiotics.
2. Solid oral doses that are dispensed in their original container or are usually dispensed in
their original packaging to help patients comply with usage and dosage directions.
For more informationFor more information about your plan’s prescription drug coverage, please review your Evidence
of Coverage and other plan materials. If you have questions about your plan, please call us toll-
free at 1-866-622-8054, TTY 711, 8 a.m. to 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.
1
Bold type = Brand name drug Plain type = Generic drug
1
12
1tRACK
12
Covered drugs by medical condition
The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered drugs,” which begins on page 93.
The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for
example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin).
The second column of the chart lists which coverage level (Tier) your drug is in. Your plan has one
tier named “Covered Drugs”. All covered drugs are in this Tier.
The “Required actions, restrictions or limits” column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages 74-92.tRACK
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Analgesics
Nonsteroidal Anti-inflammatory DrugsCelecoxib
Celecoxib (Capsule) 1 QL Diclofenac Potassium
Diclofenac Potassium
(Tablet Immediate-
Release)
1
Diclofenac Sodium
Diclofenac Sodium (1%
Gel)1 PA
Diclofenac Sodium DR
Diclofenac Sodium DR
(Tablet Delayed-Release)1
Diclofenac Sodium ER
Diclofenac Sodium ER
(Tablet Extended-Release
24 Hour)
1
Diflunisal
Diflunisal (Tablet) 1
Etodolac
Etodolac (200mg
Capsule, 300mg Capsule,
400mg Tablet Immediate-
Release, 500mg Tablet
Immediate-Release)
1
Etodolac ER
Etodolac ER (Tablet
Extended-Release 24
Hour)
1
Flector
Flector (Patch) 1 PA, QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Flurbiprofen
Flurbiprofen (Tablet) 1
Ibuprofen
Ibuprofen (100mg/5ml
Suspension, 400mg
Tablet, 600mg Tablet,
800mg Tablet)
1
Ketoprofen
Ketoprofen (Capsule
Immediate-Release)1
Ketorolac Tromethamine
Ketorolac Tromethamine
(15mg/ml Injection,
30mg/ml Injection,
60mg/2ml Injection)
1
Meloxicam
Meloxicam (15mg Tablet,
7.5mg Tablet)1
Meloxicam
Meloxicam (7.5mg/5ml
Suspension)1
Nabumetone
Nabumetone (Tablet) 1
Naproxen
Naproxen (125mg/5ml
Suspension, 250mg
Tablet Immediate-
Release, 375mg Tablet
Immediate-Release,
500mg Tablet Immediate-
Release)
1
2
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
2
13
2tRACK
13Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Naproxen DR
Naproxen DR (Tablet
Delayed-Release)
(Generic EC-Naprosyn)
1
Naproxen Sodium
Naproxen Sodium (Tablet
Immediate-Release)
(Generic Anaprox DS)
1
Oxaprozin
Oxaprozin (Tablet) 1
Piroxicam
Piroxicam (Capsule) 1
Sulindac
Sulindac (Tablet) 1
Voltaren
Voltaren (Gel) 1 PA
Opioid Analgesics, Long-actingEmbeda
Embeda (Capsule
Extended-Release)1 QL
Fentanyl
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)
1 QL
Hydromorphone HCl ER
Hydromorphone HCl ER
(12mg Tablet Extended-
Release 24 Hour Abuse-
Deterrent, 16mg Tablet
Extended-Release 24
Hour Abuse-Deterrent)
1 QL
Hydromorphone HCl ER
Hydromorphone HCl ER
(32mg Tablet Extended-
Release 24 Hour Abuse-
Deterrent)
1 QL
Hydromorphone HCl ER
Hydromorphone HCl ER
(8mg Tablet Extended-
Release 24 Hour Abuse-
Deterrent)
1 QL
Levorphanol Tartrate
Levorphanol Tartrate
(Tablet)1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Methadone HCl
Methadone HCl (10mg
Tablet, 5mg Tablet,
10mg/5ml Oral Solution,
5mg/5ml Oral Solution)
1 QL
Methadone HCl
Methadone HCl (10mg/
ml Injection)1
Morphine Sulfate ER
Morphine Sulfate ER
(Tablet Extended-Release)
(Generic MS Contin)
1 QL
Nucynta ER
Nucynta ER (Tablet
Extended-Release 12
Hour)
1 QL
Opana ER
Opana ER (Tablet
Extended-Release 12
Hour Abuse-Deterrent)
1 QL
Tramadol HCl ER
Tramadol HCl ER (100mg
Tablet Extended-Release
24 Hour, 200mg Tablet
Extended-Release 24
Hour) (Generic Ultram
ER), (300mg Tablet
Extended-Release 24
Hour) (Generic Ryzolt)
1 QL
Opioid Analgesics, Short-actingAbstral
Abstral (Tablet
Sublingual)1 PA, QL
Acetaminophen/Codeine
Acetaminophen/Codeine
(120mg-12mg/5ml Oral
Solution, 300mg-15mg
Tablet, 300mg-30mg
Tablet, 300mg-60mg
Tablet)
1 QL
Butorphanol Tartrate
Butorphanol Tartrate
(10mg/ml Nasal Solution)1 QL
Butorphanol Tartrate
Butorphanol Tartrate
(1mg/ml Injection, 2mg/
ml Injection)
1
Codeine Sulfate
Codeine Sulfate (Tablet) 1 QL
3
Bold type = Brand name drug Plain type = Generic drug
3
14
3tRACK
14 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Duramorph
Duramorph (Injection) 1
Endocet
Endocet (Tablet) 1 QL Hydrocodone Bitartrate/Acetaminophen
Hydrocodone Bitartrate/
Acetaminophen
(7.5mg-325mg/15ml Oral
Solution)
1 QL
Hydrocodone/Acetaminophen
Hydrocodone/
Acetaminophen
(10mg-325mg Tablet,
2.5mg-325mg Tablet,
5mg-325mg Tablet,
7.5mg-325mg Tablet)
1 QL
Hydrocodone/Ibuprofen
Hydrocodone/Ibuprofen
(7.5mg-200mg Tablet)1 QL
Hydromorphone HCl
Hydromorphone HCl
(1mg/ml Liquid)1 QL
Hydromorphone HCl
Hydromorphone HCl
(2mg Tablet Immediate-
Release, 4mg Tablet
Immediate-Release, 8mg
Tablet Immediate-
Release)
1 QL
Hydromorphone HCl
Hydromorphone HCl
(2mg/ml Injection)1
Hydromorphone HCl
Hydromorphone HCl
(500mg/50ml Injection)1
Lorcet
Lorcet (Tablet) 1 QL Lorcet HD
Lorcet HD (Tablet) 1 QL Lorcet Plus
Lorcet Plus (Tablet) 1 QL Lortab
Lortab (10mg-325mg
Tablet, 5mg-325mg
Tablet, 7.5mg-325mg
Tablet)
1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Morphine Sulfate
Morphine Sulfate
(100mg/5ml Oral
Solution, 10mg/5ml Oral
Solution, 20mg/5ml Oral
Solution)
1 QL
Morphine Sulfate
Morphine Sulfate
(10mg/ml Injection,
2mg/ml Injection, 4mg/
ml Injection, 8mg/ml
Injection)
1
Morphine Sulfate
Morphine Sulfate (15mg
Tablet Immediate-
Release, 30mg Tablet
Immediate-Release)
1 QL
Nalbuphine HCl
Nalbuphine HCl (Injection) 1
Oxycodone HCl
Oxycodone HCl (100mg/
5ml Concentrate, 5mg/
5ml Oral Solution)
1 QL
Oxycodone HCl
Oxycodone HCl (10mg
Tablet Immediate-
Release, 15mg Tablet
Immediate-Release, 20mg
Tablet Immediate-
Release, 30mg Tablet
Immediate-Release, 5mg
Tablet Immediate-
Release)
1 QL
Oxycodone/Acetaminophen
Oxycodone/
Acetaminophen
(10mg-325mg Tablet,
2.5mg-325mg Tablet,
5mg-325mg Tablet,
7.5mg-325mg Tablet)
1 QL
Oxycodone/Acetaminophen
Oxycodone/
Acetaminophen
(325mg-5mg/5ml Oral
Solution)
1 QL
4
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
4
15
4tRACK
15Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Oxycodone/Aspirin
Oxycodone/Aspirin
(Tablet)1 QL
Oxycodone/Ibuprofen
Oxycodone/Ibuprofen
(Tablet)1 QL
Tramadol HCl
Tramadol HCl (Tablet
Immediate-Release)1 QL
Tramadol HCl/Acetaminophen
Tramadol HCl/
Acetaminophen (Tablet)1 QL
Trezix
Trezix (Capsule) 1 QL
Anesthetics
Local AnestheticsLidocaine
Lidocaine (5% Ointment) 1
Lidocaine
Lidocaine (5% Patch) 1 PA, QL Lidocaine HCl
Lidocaine HCl (0.5%
Injection, 2% Injection)1 B/D, PA
Lidocaine HCl
Lidocaine HCl (4%
External Solution)1
Lidocaine HCl
Lidocaine HCl (Gel) 1
Lidocaine Viscous
Lidocaine Viscous
(Solution)1
Lidocaine/Prilocaine
Lidocaine/Prilocaine
(2.5%-2.5% Cream)1
Anti-Addiction/Substance Abuse Treatment
Agents
Alcohol Deterrents/Anti-cravingAcamprosate Calcium DR
Acamprosate Calcium DR
(Tablet Delayed-Release)1
Disulfiram
Disulfiram (Tablet) 1
Naltrexone HCl
Naltrexone HCl (Tablet) 1
Vivitrol
Vivitrol (Injection) 1 PA
Opioid Dependence TreatmentsBuprenorphine HCl
Buprenorphine HCl
(0.3mg/ml Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Buprenorphine HCl
Buprenorphine HCl (2mg
Tablet Sublingual, 8mg
Tablet Sublingual)
1 QL
Buprenorphine HCl/Naloxone HCl
Buprenorphine HCl/
Naloxone HCl (Tablet
Sublingual)
1 PA, QL
Naloxone HCl
Naloxone HCl (Injection) 1
Narcan
Narcan (Liquid) 1
Suboxone
Suboxone (Film) 1 PA, QL
Smoking Cessation AgentsBupropion HCl SR
Bupropion HCl SR
(150mg Tablet Extended-
Release 12 Hour)
1
Chantix
Chantix (Tablet) 1
Chantix Continuing Month Pak
Chantix Continuing
Month Pak (Tablet)1
Chantix Starting Month Pak
Chantix Starting Month
Pak (Tablet)1
Nicotrol Inhaler
Nicotrol Inhaler 1
Antibacterials
AminoglycosidesAmikacin Sulfate
Amikacin Sulfate
(Injection)1
Bethkis
Bethkis (Nebulized
Solution)1 B/D, PA
Gentak
Gentak (Ophthalmic
Ointment)1
Gentamicin Sulfate
Gentamicin Sulfate (0.1%
Cream, 0.1% Ointment,
0.3% Ophthalmic
Ointment, 0.3%
Ophthalmic Solution)
1
Gentamicin Sulfate
Gentamicin Sulfate
(10mg/ml Injection,
40mg/ml Injection)
1
5
Bold type = Brand name drug Plain type = Generic drug
5
16
5tRACK
16 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Gentamicin Sulfate/0.9% Sodium Chloride
Gentamicin Sulfate/0.9%
Sodium Chloride
(Injection)
1
Isotonic Gentamicin
Isotonic Gentamicin
(Injection)1
Neomycin Sulfate
Neomycin Sulfate (Tablet) 1
Paromomycin Sulfate
Paromomycin Sulfate
(Capsule)1
Streptomycin Sulfate
Streptomycin Sulfate
(Injection)1
TOBI
TOBI (Nebulized
Solution)1 B/D, PA
TOBI Podhaler
TOBI Podhaler
(Capsule)1 PA
Tobradex
Tobradex (Ophthalmic
Ointment)1
Tobramycin
Tobramycin (Nebulized
Solution)1 B/D, PA
Tobramycin Sulfate
Tobramycin Sulfate (0.3%
Ophthalmic Solution)1
Tobramycin Sulfate
Tobramycin Sulfate
(10mg/ml Injection,
80mg/2ml Injection)
1
Tobrex
Tobrex (0.3%
Ophthalmic Ointment)1
Antibacterials, OtherBACiiM
BACiiM (Injection) 1
Bacitracin
Bacitracin (50000unit
Injection)1
Bacitracin
Bacitracin (500unit/gm
Ophthalmic Ointment)1
Bactroban Nasal
Bactroban Nasal
(Ointment)1 PA
Chloramphenicol Sodium Succinate
Chloramphenicol Sodium
Succinate (Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Clindamycin HCl
Clindamycin HCl
(Capsule Immediate-
Release)
1
Clindamycin Palmitate HCl
Clindamycin Palmitate
HCl (Oral Solution)1
Clindamycin Phosphate
Clindamycin Phosphate
(2% Cream)1
Clindamycin Phosphate
Clindamycin Phosphate
(600mg/4ml Injection)1
Clindamycin Phosphate in D5W
Clindamycin Phosphate in
D5W (Injection)1
Colistimethate Sodium
Colistimethate Sodium
(Injection)1
Cubicin
Cubicin (Injection) 1
Dalvance
Dalvance (Injection) 1 PA Lincocin
Lincocin (Injection) 1
Lincomycin HCl
Lincomycin HCl (Injection) 1
Linezolid
Linezolid (100mg/5ml
Suspension, 600mg/
300ml Injection)
1 PA
Linezolid
Linezolid (600mg
Tablet)1 PA, QL
Methenamine Hippurate
Methenamine Hippurate
(Tablet)1
Metronidazole
Metronidazole (0.75%
Cream, 0.75% Gel, 1%
Gel, 0.75% Lotion)
1
Metronidazole
Metronidazole (250mg
Tablet Immediate-
Release, 500mg Tablet
Immediate-Release,
375mg Capsule
Immediate-Release)
1
Metronidazole in NaCl 0.79%
Metronidazole in NaCl
0.79% (Injection)1
6
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
6
17
6tRACK
17Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Metronidazole Vaginal
Metronidazole Vaginal
(Gel)1
Mupirocin
Mupirocin (2% Cream) 1
Mupirocin
Mupirocin (2% Ointment) 1
Neomycin/Polymyxin B Sulfates
Neomycin/Polymyxin B
Sulfates (Irrigation
Solution)
1
Nitrofurantoin
Nitrofurantoin
(Suspension)1
Nitrofurantoin Macrocrystals
Nitrofurantoin
Macrocrystals (100mg
Capsule, 50mg Capsule)
(Generic Macrodantin)
1
Nitrofurantoin Monohydrate
Nitrofurantoin
Monohydrate (100mg
Capsule) (Generic
Macrobid)
1
Polymyxin B Sulfate
Polymyxin B Sulfate
(Injection)1
Sulfamylon
Sulfamylon (85mg/gm
Cream)1
Synercid
Synercid (Injection) 1
Tinidazole
Tinidazole (Tablet) 1
Trimethoprim
Trimethoprim (Tablet) 1
Tygacil
Tygacil (Injection) 1
Vancocin HCl
Vancocin HCl (Capsule) 1 PA Vancomycin HCl
Vancomycin HCl
(1000mg Injection, 10gm
Injection, 500mg
Injection)
1
Vancomycin HCl
Vancomycin HCl (125mg
Capsule, 250mg Capsule)1 PA
Vandazole
Vandazole (Gel) 1
Xifaxan
Xifaxan (Tablet) 1 PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Zyvox
Zyvox (100mg/5ml
Suspension, 600mg/
300ml Injection)
1 PA
Zyvox
Zyvox (600mg Tablet) 1 PA, QL
Beta-lactam, CephalosporinsCefaclor
Cefaclor (250mg Capsule
Immediate-Release,
500mg Capsule
Immediate-Release)
1
Cefadroxil
Cefadroxil (250mg/5ml
Suspension, 500mg/5ml
Suspension, 500mg
Capsule)
1
Cefazolin Sodium
Cefazolin Sodium (10gm
Injection, 1gm Injection,
500mg Injection, 1gm/
50ml Injection)
1
Cefdinir
Cefdinir (125mg/5ml
Suspension, 250mg/5ml
Suspension, 300mg
Capsule)
1
Cefepime
Cefepime (1gm Injection,
2gm Injection)1
Cefepime/Dextrose
Cefepime/Dextrose
(1gm/50ml Injection,
2gm/50ml Injection)
1
Cefixime
Cefixime (Suspension) 1
Cefotaxime Sodium
Cefotaxime Sodium
(Injection)1
Cefotetan
Cefotetan (Injection) 1
Cefoxitin Sodium
Cefoxitin Sodium (10gm
Injection, 1gm Injection,
2gm Injection)
1
Cefoxitin Sodium
Cefoxitin Sodium
(1gm-4% Injection,
2gm-2.2% Injection)
1
7
Bold type = Brand name drug Plain type = Generic drug
7
18
7tRACK
18 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Cefpodoxime Proxetil
Cefpodoxime Proxetil
(100mg Tablet, 200mg
Tablet, 100mg/5ml
Suspension, 50mg/5ml
Suspension)
1
Cefprozil
Cefprozil (125mg/5ml
Suspension, 250mg/5ml
Suspension, 250mg
Tablet, 500mg Tablet)
1
Ceftazidime
Ceftazidime (Injection) 1
Ceftazidime/Dextrose
Ceftazidime/Dextrose
(Injection)1
Ceftriaxone Sodium
Ceftriaxone Sodium
(10gm Injection, 1gm
Injection, 2gm Injection,
250mg Injection, 500mg
Injection)
1
Cefuroxime Axetil
Cefuroxime Axetil (Tablet) 1
Cefuroxime Sodium
Cefuroxime Sodium
(Injection)1
Cephalexin
Cephalexin (125mg/5ml
Suspension, 250mg/5ml
Suspension, 250mg
Capsule, 500mg Capsule,
750mg Capsule)
1
Fortaz
Fortaz (1gm Injection,
2gm Injection, 2gm
Injection, 6gm Injection)
1
Suprax
Suprax (100mg Tablet
Chewable, 200mg Tablet
Chewable, 100mg/5ml
Suspension, 200mg/5ml
Suspension)
1
Suprax
Suprax (400mg
Capsule, 500mg/5ml
Suspension)
1
Tazicef
Tazicef (Injection) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Zerbaxa
Zerbaxa (Injection) 1 PA
Beta-lactam, OtherAzactam in Iso-Osmotic Dextrose
Azactam in Iso-Osmotic
Dextrose (Injection)1
Aztreonam
Aztreonam (Injection) 1
Doribax
Doribax (Injection) 1
Imipenem/Cilastatin
Imipenem/Cilastatin
(Injection)1
Invanz
Invanz (Injection) 1
Meropenem
Meropenem (Injection) 1
Beta-lactam, PenicillinsAmoxicillin
Amoxicillin (Capsule, Oral
Suspension, Tablet,
Tablet Chewable)
1
Amoxicillin/Clavulanate Potassium
Amoxicillin/Clavulanate
Potassium (Oral
Suspension, Tablet
Chewable, Tablet
Immediate-Release)
(Generic Augmentin)
1
Amoxicillin/Clavulanate Potassium ER
Amoxicillin/Clavulanate
Potassium ER (Tablet
Extended-Release 12
Hour)
1
Ampicillin
Ampicillin (125mg/5ml
Suspension, 250mg/5ml
Suspension, 250mg
Capsule, 500mg Capsule)
1
Ampicillin Sodium
Ampicillin Sodium (10gm
Injection, 125mg
Injection, 1gm Injection)
1
Ampicillin-Sulbactam
Ampicillin-Sulbactam
(10gm-5gm Injection,
1gm-0.5gm Injection,
2gm-1gm Injection)
1
8
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
8
19
8tRACK
19Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Bactocill in Dextrose
Bactocill in Dextrose
(1gm/50ml Injection)1
Bactocill in Dextrose
Bactocill in Dextrose
(2gm/50ml Injection)1
Bicillin C-R
Bicillin C-R (Injection) 1
Bicillin L-A
Bicillin L-A (Injection) 1
Dicloxacillin Sodium
Dicloxacillin Sodium
(Capsule)1
Nafcillin in Dextrose
Nafcillin in Dextrose
(Injection)1
Nafcillin Sodium
Nafcillin Sodium
(Injection)1
Oxacillin Sodium
Oxacillin Sodium (10gm
Injection)1
Oxacillin Sodium
Oxacillin Sodium (2gm
Injection)1
Penicillin G Potassium
Penicillin G Potassium
(Injection)1
Penicillin G Procaine
Penicillin G Procaine
(Injection)1
Penicillin G Sodium
Penicillin G Sodium
(Injection)1
Penicillin V Potassium
Penicillin V Potassium
(125mg/5ml Oral
Solution, 250mg/5ml Oral
Solution, 250mg Tablet,
500mg Tablet)
1
Piperacillin/Tazobactam
Piperacillin/Tazobactam
(Injection)1
MacrolidesAzasite
Azasite (Ophthalmic
Solution)1
Azithromycin
Azithromycin (100mg/5ml
Oral Suspension, 200mg/
5ml Oral Suspension,
250mg Tablet, 500mg
Tablet, 600mg Tablet)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Azithromycin
Azithromycin (500mg
Injection)1
Clarithromycin
Clarithromycin (125mg/
5ml Suspension, 250mg/
5ml Suspension, 250mg
Tablet, 500mg Tablet)
1
Clarithromycin ER
Clarithromycin ER (Tablet
Extended-Release 24
Hour)
1
Dificid
Dificid (Tablet) 1 PA E.E.S. 400
E.E.S. 400 (Tablet) 1
E.E.S. Granules
E.E.S. Granules
(Suspension)1
EryPed 200
EryPed 200
(Suspension)1
EryPed 400
EryPed 400
(Suspension)1
Ery-Tab
Ery-Tab (Tablet Delayed-
Release)1
Erythrocin Lactobionate
Erythrocin Lactobionate
(Injection)1
Erythromycin
Erythromycin (250mg
Capsule Delayed-Release)1
Erythromycin
Erythromycin (5mg/gm
Ophthalmic Ointment)1
Erythromycin Base
Erythromycin Base
(Tablet)1
Erythromycin Ethylsuccinate
Erythromycin
Ethylsuccinate (Tablet)1
Ilotycin
Ilotycin (Ophthalmic
Ointment)1
Zmax
Zmax (Suspension) 1
QuinolonesAvelox
Avelox (400mg/
250ml-0.8% Injection)1
Besivance
Besivance (Suspension) 1
9
Bold type = Brand name drug Plain type = Generic drug
9
20
9tRACK
20 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ciloxan
Ciloxan (0.3%
Ointment)1
Ciprofloxacin
Ciprofloxacin (250mg/
5ml Suspension, 500mg/
5ml Suspension, 400mg/
40ml Injection)
1
Ciprofloxacin ER
Ciprofloxacin ER (Tablet
Extended-Release 24
Hour)
1
Ciprofloxacin HCl
Ciprofloxacin HCl (0.3%
Ophthalmic Solution,
100mg Tablet Immediate-
Release, 250mg Tablet
Immediate-Release,
500mg Tablet Immediate-
Release, 750mg Tablet
Immediate-Release)
1
Ciprofloxacin I.V. in D5W
Ciprofloxacin I.V. in D5W
(Injection)1
Gatifloxacin
Gatifloxacin (Ophthalmic
Solution)1
Levofloxacin
Levofloxacin (0.5%
Ophthalmic Solution,
25mg/ml Oral Solution)
1
Levofloxacin
Levofloxacin (250mg
Tablet, 500mg Tablet,
750mg Tablet)
1
Levofloxacin
Levofloxacin (25mg/ml
Injection)1
Levofloxacin in D5W
Levofloxacin in D5W
(Injection)1
Moxeza
Moxeza (Ophthalmic
Solution)1
Moxifloxacin HCl
Moxifloxacin HCl (400mg
Tablet)1
Moxifloxacin HCl
Moxifloxacin HCl
(400mg/250ml
Injection)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ofloxacin
Ofloxacin (0.3%
Ophthalmic Solution,
0.3% Otic Solution,
400mg Tablet)
1
Vigamox
Vigamox (Ophthalmic
Solution)1
SulfonamidesSilver Sulfadiazine
Silver Sulfadiazine
(Cream)1
Sodium Sulfacetamide
Sodium Sulfacetamide
(10% Ophthalmic
Solution)
1
SSD
SSD (Cream) 1
Sulfacetamide Sodium
Sulfacetamide Sodium
(Ophthalmic Ointment)1
Sulfadiazine
Sulfadiazine (Tablet) 1
Sulfamethoxazole/Trimethoprim
Sulfamethoxazole/
Trimethoprim
(200mg-40mg/5ml
Suspension,
400mg-80mg Tablet)
1
Sulfamethoxazole/Trimethoprim
Sulfamethoxazole/
Trimethoprim
(400mg-80mg/5ml
Injection)
1
Sulfamethoxazole/Trimethoprim DS
Sulfamethoxazole/
Trimethoprim DS (Tablet)1
TetracyclinesDemeclocycline HCl
Demeclocycline HCl
(Tablet)1
Doxy 100
Doxy 100 (Injection) 1
Doxycycline
Doxycycline (150mg
Capsule, 75mg Capsule)1
Doxycycline
Doxycycline (25mg/5ml
Suspension)1
10
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
10
21
10tRACK
21Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Doxycycline Hyclate
Doxycycline Hyclate
(100mg Capsule
Immediate-Release, 50mg
Capsule Immediate-
Release)
1
Doxycycline Hyclate
Doxycycline Hyclate
(100mg Injection, 100mg
Tablet Immediate-
Release, 20mg Tablet
Immediate-Release)
1
Doxycycline Monohydrate
Doxycycline Monohydrate
(100mg Capsule, 50mg
Capsule, 100mg Tablet,
150mg Tablet, 50mg
Tablet, 75mg Tablet)
1
Minocycline HCl
Minocycline HCl (100mg
Capsule Immediate-
Release, 50mg Capsule
Immediate-Release, 75mg
Capsule Immediate-
Release)
1
Minocycline HCl
Minocycline HCl (100mg
Tablet Immediate-
Release, 50mg Tablet
Immediate-Release, 75mg
Tablet Immediate-
Release)
1
Tetracycline HCl
Tetracycline HCl
(Capsule)1
Vibramycin
Vibramycin (50mg/5ml
Syrup)1
Anticonvulsants
Anticonvulsants, OtherBRIVIACT
BRIVIACT (100mg
Tablet, 10mg Tablet,
25mg Tablet, 50mg
Tablet, 75mg Tablet,
10mg/ml Oral Solution)
1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
BRIVIACT
BRIVIACT (50mg/5ml
Injection)1 QL
Fycompa
Fycompa (Tablet, Oral
Suspension)1
Levetiracetam
Levetiracetam (1000mg
Tablet Immediate-
Release, 250mg Tablet
Immediate-Release,
500mg Tablet Immediate-
Release, 750mg Tablet
Immediate-Release,
100mg/ml Oral Solution)
1
Levetiracetam
Levetiracetam
(1000mg/100ml
Injection, 1500mg/
100ml Injection,
500mg/100ml
Injection)
1
Levetiracetam
Levetiracetam (500mg/
5ml Injection)1
Levetiracetam ER
Levetiracetam ER (Tablet
Extended-Release 24
Hour)
1
Potiga
Potiga (Tablet) 1 QL Roweepra
Roweepra (Tablet) 1
Spritam
Spritam (Tablet
Disintegrating Soluble)1
Calcium Channel Modifying AgentsCelontin
Celontin (Capsule) 1
Ethosuximide
Ethosuximide (250mg
Capsule, 250mg/5ml Oral
Solution)
1
Zonisamide
Zonisamide (Capsule) 1
Gamma-aminobutyric Acid (GABA)
Augmenting AgentsDiastat AcuDial
Diastat AcuDial (Gel) 1
11
Bold type = Brand name drug Plain type = Generic drug
11
22
11tRACK
22 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Diastat Pediatric
Diastat Pediatric (Gel) 1
Diazepam
Diazepam (10mg Gel,
2.5mg Gel, 20mg Gel)1
Divalproex Sodium
Divalproex Sodium
(Capsule Sprinkle
Delayed-Release)
1
Divalproex Sodium DR
Divalproex Sodium DR
(Tablet Delayed-Release)1
Divalproex Sodium ER
Divalproex Sodium ER
(Tablet Extended-Release
24 Hour)
1
Gabapentin
Gabapentin (100mg
Capsule, 300mg Capsule,
400mg Capsule, 600mg
Tablet, 800mg Tablet)
1
Gabapentin
Gabapentin (250mg/5ml
Oral Solution)1
Gabitril
Gabitril (12mg Tablet,
16mg Tablet)1 QL
Onfi
Onfi (10mg Tablet) 1 QL Onfi
Onfi (2.5mg/ml
Suspension)1
Onfi
Onfi (20mg Tablet) 1 QL Phenobarbital
Phenobarbital (100mg
Tablet, 15mg Tablet,
16.2mg Tablet, 30mg
Tablet, 32.4mg Tablet,
60mg Tablet, 64.8mg
Tablet, 97.2mg Tablet,
20mg/5ml Elixir)
1
Primidone
Primidone (Tablet) 1
Sabril
Sabril (500mg Packet,
500mg Tablet)1 PA, QL, LA
Tiagabine HCl
Tiagabine HCl (Tablet) 1
Valproate Sodium
Valproate Sodium
(100mg/ml Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Valproic Acid
Valproic Acid (250mg
Capsule, 250mg/5ml
Syrup)
1
Glutamate Reducing AgentsFelbamate
Felbamate (400mg
Tablet, 600mg Tablet)1
Felbamate
Felbamate (600mg/5ml
Suspension)1
Felbatol
Felbatol (600mg/5ml
Suspension)1
Lamotrigine
Lamotrigine (100mg
Tablet Immediate-
Release, 150mg Tablet
Immediate-Release,
200mg Tablet Immediate-
Release, 25mg Tablet
Immediate-Release)
1
Lamotrigine
Lamotrigine (25mg Tablet
Chewable, 5mg Tablet
Chewable)
1
Topiramate
Topiramate (100mg
Tablet Immediate-
Release, 200mg Tablet
Immediate-Release, 25mg
Tablet Immediate-
Release, 50mg Tablet
Immediate-Release, 15mg
Capsule Sprinkle
Immediate-Release, 25mg
Capsule Sprinkle
Immediate-Release)
1
Sodium Channel AgentsAptiom
Aptiom (200mg Tablet) 1 QL Aptiom
Aptiom (400mg Tablet,
600mg Tablet, 800mg
Tablet)
1 QL
12
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
12
23
12tRACK
23Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Banzel
Banzel (200mg Tablet,
400mg Tablet, 40mg/
ml Suspension)
1
Carbamazepine
Carbamazepine (100mg
Tablet Chewable,
100mg/5ml Suspension,
200mg Tablet Immediate-
Release)
1
Carbamazepine ER
Carbamazepine ER
(Capsule Extended-
Release 12 Hour, Tablet
Extended-Release 12
Hour)
1
Dilantin
Dilantin (Capsule) 1
Dilantin INFATABS
Dilantin INFATABS (Tablet
Chewable)1
Epitol
Epitol (Tablet) 1
Fosphenytoin Sodium
Fosphenytoin Sodium
(Injection)1
Oxcarbazepine
Oxcarbazepine (150mg
Tablet, 300mg Tablet,
600mg Tablet)
1
Oxcarbazepine
Oxcarbazepine (300mg/
5ml Suspension)1
Peganone
Peganone (Tablet) 1
Phenytek
Phenytek (Capsule) 1
Phenytoin
Phenytoin (125mg/5ml
Suspension, 50mg Tablet
Chewable)
1
Phenytoin Sodium
Phenytoin Sodium
(Injection)1
Phenytoin Sodium Extended
Phenytoin Sodium
Extended (Capsule)1
Tegretol-XR
Tegretol-XR (100mg
Tablet Extended-
Release 12 Hour)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Vimpat
Vimpat (100mg Tablet,
150mg Tablet, 200mg
Tablet, 50mg Tablet,
10mg/ml Oral Solution)
1 QL
Vimpat
Vimpat (200mg/20ml
Injection)1 PA
Antidementia Agents
Cholinesterase InhibitorsDonepezil HCl
Donepezil HCl (Tablet
Immediate-Release)1 QL
Donepezil HCl ODT
Donepezil HCl ODT
(Tablet Dispersible)1 QL
Exelon
Exelon (Patch 24 Hour) 1 QL, ST Galantamine HBr
Galantamine HBr (12mg
Tablet, 4mg Tablet, 8mg
Tablet, 16mg Capsule
Extended-Release 24
Hour, 24mg Capsule
Extended-Release 24
Hour, 8mg Capsule
Extended-Release 24
Hour, 4mg/ml Oral
Solution)
1 QL
Rivastigmine Tartrate
Rivastigmine Tartrate
(Capsule Immediate-
Release)
1 QL
Rivastigmine Transdermal System
Rivastigmine Transdermal
System (Patch 24 Hour)1 QL, ST
N-methyl-D-aspartate (NMDA) Receptor
AntagonistMemantine HCl
Memantine HCl (10mg
Tablet, 5mg Tablet, 2mg/
ml Oral Solution)
1 PA, QL
Memantine HCl Titration Pak
Memantine HCl
Titration Pak (Tablet)1 PA
13
Bold type = Brand name drug Plain type = Generic drug
13
24
13tRACK
24 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Namenda
Namenda (10mg Tablet
Immediate-Release,
5mg Tablet Immediate-
Release)
1 PA, QL
Namenda
Namenda (10mg/5ml
Oral Solution)1 PA, QL
Namenda Titration Pak
Namenda Titration Pak
(Tablet)1 PA
Namenda XR
Namenda XR (Capsule
Extended-Release 24
Hour)
1 PA, QL
Namenda XR Titration Pack
Namenda XR Titration
Pack (Capsule
Extended-Release 24
Hour)
1 PA, QL
Antidepressants
Antidepressants, OtherBupropion HCl
Bupropion HCl (Tablet
Immediate-Release)1
Bupropion HCl SR
Bupropion HCl SR (Tablet
Extended-Release 12
Hour)
1
Bupropion HCl XL
Bupropion HCl XL (Tablet
Extended-Release 24
Hour)
1
Mirtazapine
Mirtazapine (Tablet
Immediate-Release)1
Mirtazapine ODT
Mirtazapine ODT (Tablet
Dispersible)1
Monoamine Oxidase InhibitorsEmsam
Emsam (Patch 24 Hour) 1 QL Marplan
Marplan (Tablet) 1
Phenelzine Sulfate
Phenelzine Sulfate
(Tablet)1
Tranylcypromine Sulfate
Tranylcypromine Sulfate
(Tablet)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
SSRI/SNRI (Selective Serotonin Reuptake
Inhibitors/Serotonin and Norepinephrine
Reuptake Inhibitors)Citalopram HBr
Citalopram HBr (10mg
Tablet, 20mg Tablet,
40mg Tablet)
1
Citalopram HBr
Citalopram HBr (10mg/
5ml Oral Solution)1
Escitalopram Oxalate
Escitalopram Oxalate
(10mg Tablet, 20mg
Tablet, 5mg Tablet)
1
Escitalopram Oxalate
Escitalopram Oxalate
(5mg/5ml Oral Solution)1
Fetzima
Fetzima (Capsule
Extended-Release 24
Hour)
1 QL, ST
Fetzima Titration Pack
Fetzima Titration Pack
(Capsule Extended-
Release 24 Hour
Therapy Pack)
1 ST
Fluoxetine DR
Fluoxetine DR (Capsule
Delayed-Release)1
Fluoxetine HCl
Fluoxetine HCl (10mg
Capsule Immediate-
Release, 20mg Capsule
Immediate-Release, 40mg
Capsule Immediate-
Release, 20mg/5ml Oral
Solution)
1
Fluvoxamine Maleate
Fluvoxamine Maleate
(Tablet)1
Maprotiline HCl
Maprotiline HCl (Tablet) 1
Nefazodone HCl
Nefazodone HCl (Tablet) 1
Paroxetine HCl
Paroxetine HCl (Tablet
Immediate-Release)1
Paxil
Paxil (10mg/5ml
Suspension)1
14
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
14
25
14tRACK
25Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Pristiq
Pristiq (Tablet
Extended-Release 24
Hour)
1 QL
Sertraline HCl
Sertraline HCl (100mg
Tablet, 25mg Tablet,
50mg Tablet)
1
Sertraline HCl
Sertraline HCl (20mg/ml
Concentrate)1
Trazodone HCl
Trazodone HCl (Tablet) 1
Trintellix
Trintellix (Tablet) 1 QL Venlafaxine HCl
Venlafaxine HCl (Tablet
Immediate-Release)1
Venlafaxine HCl ER
Venlafaxine HCl ER
(150mg Capsule
Extended-Release 24
Hour, 37.5mg Capsule
Extended-Release 24
Hour, 75mg Capsule
Extended-Release 24
Hour)
1
Viibryd
Viibryd (Tablet) 1 QL Viibryd Starter Pack
Viibryd Starter Pack
(Kit)1 QL
TricyclicsAmitriptyline HCl
Amitriptyline HCl (Tablet) 1
Amoxapine
Amoxapine (Tablet) 1
Clomipramine HCl
Clomipramine HCl
(Capsule)1
Desipramine HCl
Desipramine HCl (Tablet) 1
Doxepin HCl
Doxepin HCl (100mg
Capsule, 10mg Capsule,
150mg Capsule, 25mg
Capsule, 50mg Capsule,
75mg Capsule, 10mg/ml
Concentrate)
1
Imipramine HCl
Imipramine HCl (Tablet) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Imipramine Pamoate
Imipramine Pamoate
(Capsule)1
Nortriptyline HCl
Nortriptyline HCl (10mg
Capsule, 25mg Capsule,
50mg Capsule, 75mg
Capsule, 10mg/5ml Oral
Solution)
1
Protriptyline HCl
Protriptyline HCl (Tablet) 1
Surmontil
Surmontil (Capsule) 1
Trimipramine Maleate
Trimipramine Maleate
(Capsule)1
Antiemetics
Antiemetics, OtherCompro
Compro (Suppository) 1
Hydroxyzine Pamoate
Hydroxyzine Pamoate
(Capsule)1
Meclizine HCl
Meclizine HCl (Tablet) 1
Metoclopramide HCl
Metoclopramide HCl
(10mg Tablet, 5mg
Tablet)
1
Metoclopramide HCl
Metoclopramide HCl
(5mg/5ml Oral Solution)1
Metoclopramide HCl
Metoclopramide HCl
(5mg/ml Injection)1
Perphenazine
Perphenazine (Tablet) 1
Prochlorperazine
Prochlorperazine
(Suppository)1
Prochlorperazine Edisylate
Prochlorperazine
Edisylate (Injection)1
Prochlorperazine Maleate
Prochlorperazine Maleate
(Tablet)1
Transderm-Scop
Transderm-Scop (Patch
72 Hour)1
Emetogenic Therapy AdjunctsAloxi
Aloxi (Injection) 1
15
Bold type = Brand name drug Plain type = Generic drug
15
26
15tRACK
26 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Anzemet
Anzemet (100mg
Tablet, 50mg Tablet)1 B/D, PA
Cesamet
Cesamet (Capsule) 1 PA Dronabinol
Dronabinol (10mg
Capsule)1 PA, QL
Dronabinol
Dronabinol (2.5mg
Capsule, 5mg Capsule)1 PA, QL
Emend
Emend (Pack, 125mg
Capsule, 40mg
Capsule, 80mg
Capsule, 125mg
Suspension)
1 PA
Emend
Emend (150mg
Injection)1
Granisetron HCl
Granisetron HCl (0.1mg/
ml Injection, 1mg/ml
Injection)
1
Granisetron HCl
Granisetron HCl (1mg
Tablet)1 B/D, PA, QL
Ondansetron HCl
Ondansetron HCl (24mg
Tablet, 4mg Tablet, 8mg
Tablet)
1 B/D, PA
Ondansetron HCl
Ondansetron HCl (4mg/
2ml Injection)1
Ondansetron HCl
Ondansetron HCl (4mg/
5ml Oral Solution)1 B/D, PA
Ondansetron ODT
Ondansetron ODT (Tablet
Dispersible)1 B/D, PA
Sancuso
Sancuso (Patch) 1
Antifungals
AntifungalsAbelcet
Abelcet (Injection) 1 B/D, PA AmBisome
AmBisome (Injection) 1 B/D, PA Amphotericin B
Amphotericin B (Injection) 1 B/D, PA Ancobon
Ancobon (Capsule) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Cancidas
Cancidas (Injection) 1
Ciclopirox
Ciclopirox (0.77% Gel,
0.77% Suspension, 1%
Shampoo)
1
Ciclopirox Nail Lacquer
Ciclopirox Nail Lacquer
(External Solution)1
Ciclopirox Olamine
Ciclopirox Olamine
(Cream)1
Clotrimazole
Clotrimazole (1% Cream,
1% External Solution,
10mg Troche)
1
Econazole Nitrate
Econazole Nitrate (Cream) 1
Eraxis
Eraxis (Injection) 1
Exelderm
Exelderm (1% Cream,
1% External Solution)1
Fluconazole
Fluconazole (100mg
Tablet, 150mg Tablet,
200mg Tablet, 50mg
Tablet, 10mg/ml
Suspension, 40mg/ml
Suspension)
1
Fluconazole in Dextrose
Fluconazole in Dextrose
(Injection)1
Fluconazole in NaCl
Fluconazole in NaCl
(Injection)1
Flucytosine
Flucytosine (Capsule) 1
Griseofulvin Microsize
Griseofulvin Microsize
(125mg/5ml Suspension,
500mg Tablet)
1
Griseofulvin Ultramicrosize
Griseofulvin
Ultramicrosize (Tablet)1
Itraconazole
Itraconazole (Capsule) 1 PA, QL Jublia
Jublia (External
Solution)1
16
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
16
27
16tRACK
27Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ketoconazole
Ketoconazole (2% Cream,
2% Shampoo, 200mg
Tablet)
1
Ketoconazole
Ketoconazole (2% Foam) 1
Mentax
Mentax (Cream) 1
Miconazole 3
Miconazole 3
(Suppository)1
Mycamine
Mycamine (Injection) 1
Naftifine HCl
Naftifine HCl (1%
Cream)1
Naftifine HCl
Naftifine HCl (2% Cream) 1
Naftin
Naftin (1% Gel, 2% Gel,
2% Cream)1
Natacyn
Natacyn (Suspension) 1
Noxafil
Noxafil (100mg Tablet
Delayed-Release)1 PA
Noxafil
Noxafil (40mg/ml
Suspension)1
Nyamyc
Nyamyc (Powder) 1
Nystatin
Nystatin (Cream,
Ointment, Powder,
Suspension, Tablet)
1
Nystop
Nystop (Powder) 1
ONMEL
ONMEL (Tablet) 1 PA Oxiconazole Nitrate
Oxiconazole Nitrate
(Cream)1
Oxistat
Oxistat (1% Cream, 1%
Lotion)1
Sporanox
Sporanox (10mg/ml
Oral Solution)1 PA
Terbinafine HCl
Terbinafine HCl (Tablet) 1
Terconazole
Terconazole (0.4%
Cream, 0.8% Cream,
80mg Suppository)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Vfend
Vfend (200mg Tablet,
50mg Tablet, 40mg/ml
Suspension)
1
Voriconazole
Voriconazole (200mg
Injection)1
Voriconazole
Voriconazole (200mg
Tablet, 50mg Tablet,
40mg/ml Suspension)
1
Zazole
Zazole (0.8% Cream) 1
Antigout Agents
Antigout AgentsAllopurinol
Allopurinol (Tablet) 1
Colchicine
Colchicine (0.6mg
Tablet) (Generic
Colcrys)
1 QL
Colcrys
Colcrys (Tablet) 1 QL Probenecid
Probenecid (Tablet) 1
Probenecid/Colchicine
Probenecid/Colchicine
(Tablet)1
Uloric
Uloric (Tablet) 1 ST
Antimigraine Agents
Ergot AlkaloidsDihydroergotamine Mesylate
Dihydroergotamine
Mesylate (1mg/ml
Injection)
1
Migergot
Migergot (Suppository) 1
Serotonin (5-HT) 1b/1d Receptor AgonistsNaratriptan HCl
Naratriptan HCl (Tablet) 1 QL Rizatriptan Benzoate
Rizatriptan Benzoate
(Tablet Immediate-
Release)
1 QL
Rizatriptan Benzoate ODT
Rizatriptan Benzoate ODT
(Tablet Dispersible)1 QL
Sumatriptan
Sumatriptan (Nasal
Solution)1 QL
17
Bold type = Brand name drug Plain type = Generic drug
17
28
17tRACK
28 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Sumatriptan Succinate
Sumatriptan Succinate
(100mg Tablet, 25mg
Tablet, 50mg Tablet)
1 QL
Sumatriptan Succinate
Sumatriptan Succinate
(4mg/0.5ml Solution
Auto injector)
1 QL
Sumatriptan Succinate
Sumatriptan Succinate
(6mg/0.5ml Injection)1 QL
Sumatriptan Succinate Refill
Sumatriptan Succinate
Refill (4mg/0.5ml
Injection)
1 QL
Sumatriptan Succinate Refill
Sumatriptan Succinate
Refill (6mg/0.5ml
Injection)
1 QL
Sumavel DosePro
Sumavel DosePro
(Injection)1
Antimyasthenic Agents
ParasympathomimeticsGuanidine HCl
Guanidine HCl (Tablet) 1
Mestinon
Mestinon (60mg/5ml
Syrup)1
Mestinon Timespan
Mestinon Timespan
(Tablet Extended-
Release)
1
Pyridostigmine Bromide
Pyridostigmine Bromide
(180mg Tablet Extended-
Release)
1
Pyridostigmine Bromide
Pyridostigmine Bromide
(60mg Tablet)1
Antimycobacterials
Antimycobacterials, OtherDapsone
Dapsone (Tablet) 1
Rifabutin
Rifabutin (Capsule) 1
AntitubercularsCapastat Sulfate
Capastat Sulfate
(Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ethambutol HCl
Ethambutol HCl (Tablet) 1
Isoniazid
Isoniazid (100mg Tablet,
300mg Tablet, 50mg/5ml
Syrup)
1
Isoniazid
Isoniazid (100mg/ml
Injection)1
Paser
Paser (Packet) 1
Priftin
Priftin (Tablet) 1
Pyrazinamide
Pyrazinamide (Tablet) 1
Rifampin
Rifampin (150mg
Capsule, 300mg Capsule)1
Rifampin
Rifampin (600mg
Injection)1
Rifater
Rifater (Tablet) 1
Sirturo
Sirturo (Tablet) 1 PA Trecator
Trecator (Tablet) 1
Antineoplastics
Alkylating AgentsBiCNU
BiCNU (Injection) 1
Busulfex
Busulfex (Injection) 1
Cyclophosphamide
Cyclophosphamide
(Capsule)1 B/D, PA
Dacarbazine
Dacarbazine (Injection) 1
Gleostine
Gleostine (Capsule) 1
Hexalen
Hexalen (Capsule) 1 PA Ifosfamide
Ifosfamide (Injection) 1
Leukeran
Leukeran (Tablet) 1
Matulane
Matulane (Capsule) 1 LA Melphalan HCl
Melphalan HCl (Injection) 1
Mustargen
Mustargen (Injection) 1
Treanda
Treanda (Injection) 1 PA Valchlor
Valchlor (Gel) 1 PA, LA
18
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
18
29
18tRACK
29Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Yondelis
Yondelis (Injection) 1 PA Zanosar
Zanosar (Injection) 1
Antiandrogens Bicalutamide
Bicalutamide (Tablet) 1
Flutamide
Flutamide (Capsule) 1
Nilandron
Nilandron (Tablet) 1
Nilutamide
Nilutamide (Tablet) 1
Xtandi
Xtandi (Capsule) 1 PA, QL Zytiga
Zytiga (Tablet) 1 PA, QL
Antiangiogenic AgentsPomalyst
Pomalyst (Capsule) 1 PA Revlimid
Revlimid (Capsule) 1 PA, LA Thalomid
Thalomid (Capsule) 1 PA
Antiestrogens/ModifiersEmcyt
Emcyt (Capsule) 1
Fareston
Fareston (Tablet) 1
Faslodex
Faslodex (Injection) 1
Soltamox
Soltamox (Oral
Solution)1
Tamoxifen Citrate
Tamoxifen Citrate (Tablet) 1
AntimetabolitesAdrucil
Adrucil (Injection) 1 B/D, PA Alimta
Alimta (Injection) 1 PA Cladribine
Cladribine (Injection) 1 B/D, PA Clolar
Clolar (Injection) 1
Cytarabine Aqueous
Cytarabine Aqueous
(Injection)1 B/D, PA
Droxia
Droxia (Capsule) 1
Elitek
Elitek (Injection) 1
Fluorouracil
Fluorouracil (2.5gm/50ml
Injection)1 B/D, PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Folotyn
Folotyn (Injection) 1
Gemcitabine HCl
Gemcitabine HCl
(Injection)1
Gemzar
Gemzar (Injection) 1
Hydroxyurea
Hydroxyurea (Capsule) 1
Lonsurf
Lonsurf (Tablet) 1 PA, QL Mercaptopurine
Mercaptopurine (Tablet) 1
Nipent
Nipent (Injection) 1
Purixan
Purixan (Suspension) 1 PA Tabloid
Tabloid (Tablet) 1 PA
Antineoplastics, OtherAbraxane
Abraxane (Injection) 1 PA Alecensa
Alecensa (Capsule) 1 PA, QL Amifostine
Amifostine (Injection) 1
Arranon
Arranon (Injection) 1
Azacitidine
Azacitidine (Injection) 1 PA Beleodaq
Beleodaq (Injection) 1 PA Bleomycin Sulfate
Bleomycin Sulfate
(Injection)1 B/D, PA
Carboplatin
Carboplatin (Injection) 1
Cisplatin
Cisplatin (Injection) 1
Cosmegen
Cosmegen (Injection) 1
Dacogen
Dacogen (Injection) 1
Daunorubicin HCl
Daunorubicin HCl
(Injection)1
Decitabine
Decitabine (Injection) 1
Dexrazoxane
Dexrazoxane (Injection) 1 PA Docefrez
Docefrez (Injection) 1
Docetaxel
Docetaxel (80mg/4ml
Injection)1
19
Bold type = Brand name drug Plain type = Generic drug
19
30
19tRACK
30 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Docetaxel
Docetaxel (80mg/8ml
Injection)1
Doxil
Doxil (Injection) 1
Doxorubicin HCl
Doxorubicin HCl
(Injection)1 B/D, PA
Doxorubicin HCl Liposome
Doxorubicin HCl
Liposome (Injection)1
Ellence
Ellence (Injection) 1
Epirubicin HCl
Epirubicin HCl (Injection) 1
Erwinaze
Erwinaze (Injection) 1
Farydak
Farydak (Capsule) 1 PA Fludarabine Phosphate
Fludarabine Phosphate
(Injection)1
Fusilev
Fusilev (Injection) 1
Halaven
Halaven (Injection) 1 PA Ibrance
Ibrance (Capsule) 1 PA, QL Idamycin PFS
Idamycin PFS
(Injection)1
Idarubicin HCl
Idarubicin HCl (Injection) 1
Irinotecan
Irinotecan (Injection) 1
Istodax
Istodax (Injection) 1 PA Ixempra Kit
Ixempra Kit (Injection) 1
Jevtana
Jevtana (Injection) 1 PA Leucovorin Calcium
Leucovorin Calcium
(100mg Injection, 350mg
Injection)
1
Leucovorin Calcium
Leucovorin Calcium
(10mg Tablet, 15mg
Tablet, 25mg Tablet, 5mg
Tablet)
1
Levoleucovorin Calcium
Levoleucovorin Calcium
(Injection)1
Lynparza
Lynparza (Capsule) 1 PA, QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Mesna
Mesna (Injection) 1
Mesnex
Mesnex (400mg Tablet) 1
Mitomycin
Mitomycin (Injection) 1
Mitoxantrone HCl
Mitoxantrone HCl
(Injection)1
Ninlaro
Ninlaro (Capsule) 1 PA, QL Oncaspar
Oncaspar (Injection) 1
Oxaliplatin
Oxaliplatin (Injection) 1
Paclitaxel
Paclitaxel (Injection) 1
Proleukin
Proleukin (Injection) 1 PA Synribo
Synribo (Injection) 1 PA Taxotere
Taxotere (Injection) 1
Thiotepa
Thiotepa (Injection) 1
Trisenox
Trisenox (Injection) 1
Velcade
Velcade (Injection) 1 PA Venclexta
Venclexta (100mg
Tablet)1 PA, QL
Venclexta
Venclexta (10mg
Tablet, 50mg Tablet)1 PA, QL
Venclexta Starting Pack
Venclexta Starting Pack
(Tablet Therapy Pack)1 PA
Vidaza
Vidaza (Injection) 1 PA Vinblastine Sulfate
Vinblastine Sulfate
(Injection)1 B/D, PA
Vincasar PFS
Vincasar PFS (Injection) 1 B/D, PA Vincristine Sulfate
Vincristine Sulfate
(Injection)1 B/D, PA
Vinorelbine Tartrate
Vinorelbine Tartrate
(Injection)1
Zaltrap
Zaltrap (Injection) 1 PA Zinecard
Zinecard (Injection) 1 PA Zolinza
Zolinza (Capsule) 1 PA
20
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
20
31
20tRACK
31Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Zydelig
Zydelig (Tablet) 1 PA, QL Zykadia
Zykadia (Capsule) 1 PA, QL
Aromatase Inhibitors, 3rd GenerationAnastrozole
Anastrozole (Tablet) 1
Exemestane
Exemestane (Tablet) 1
Letrozole
Letrozole (Tablet) 1
Enzyme InhibitorsEtopophos
Etopophos (Injection) 1
Etoposide
Etoposide (Injection) 1
Hycamtin
Hycamtin (Injection) 1
Toposar
Toposar (Injection) 1
Topotecan HCl
Topotecan HCl (Injection) 1
Molecular Target InhibitorsAfinitor
Afinitor (Tablet) 1 PA Afinitor Disperz
Afinitor Disperz (Tablet
Soluble)1 PA
Bosulif
Bosulif (Tablet) 1 PA Cabometyx
Cabometyx (Tablet) 1 PA, QL Caprelsa
Caprelsa (Tablet) 1 PA, LA Cometriq
Cometriq (Kit) 1 PA Cotellic
Cotellic (Tablet) 1 PA, QL, LA Erivedge
Erivedge (Capsule) 1 PA Gilotrif
Gilotrif (Tablet) 1 PA Iclusig
Iclusig (15mg Tablet) 1 PA, LA Iclusig
Iclusig (45mg Tablet) 1 PA Imatinib Mesylate
Imatinib Mesylate (Tablet) 1 PA Imbruvica
Imbruvica (Capsule) 1 PA Inlyta
Inlyta (Tablet) 1 PA Iressa
Iressa (Tablet) 1 PA, QL Jakafi
Jakafi (Tablet) 1 PA, LA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Lenvima
Lenvima (Capsule
Therapy Pack)1 PA
Mekinist
Mekinist (Tablet) 1 PA Nexavar
Nexavar (Tablet) 1 PA Odomzo
Odomzo (Capsule) 1 PA, QL, LA Sprycel
Sprycel (Tablet) 1 PA Stivarga
Stivarga (Tablet) 1 PA Sutent
Sutent (Capsule) 1 PA Tafinlar
Tafinlar (Capsule) 1 PA Tarceva
Tarceva (Tablet) 1 PA Tasigna
Tasigna (Capsule) 1 PA Tykerb
Tykerb (Tablet) 1 PA Votrient
Votrient (Tablet) 1 PA Xalkori
Xalkori (Capsule) 1 PA, LA Zelboraf
Zelboraf (Tablet) 1 PA
Monoclonal AntibodiesAvastin
Avastin (Injection) 1 PA Cyramza
Cyramza (Injection) 1 PA Darzalex
Darzalex (Injection) 1 PA, LA Empliciti
Empliciti (Injection) 1 PA Erbitux
Erbitux (Injection) 1 PA Herceptin
Herceptin (Injection) 1 PA Kadcyla
Kadcyla (Injection) 1 PA Keytruda
Keytruda (Injection) 1 PA Opdivo
Opdivo (Injection) 1 PA Perjeta
Perjeta (Injection) 1 PA Rituxan
Rituxan (Injection) 1 PA Sylvant
Sylvant (Injection) 1 PA Tagrisso
Tagrisso (Tablet) 1 PA, QL, LA Tecentriq
Tecentriq (Injection) 1 PA
21
Bold type = Brand name drug Plain type = Generic drug
21
32
21tRACK
32 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Vectibix
Vectibix (Injection) 1 PA Yervoy
Yervoy (Injection) 1 PA
RetinoidsBexarotene
Bexarotene (Capsule) 1 PA Panretin
Panretin (Gel) 1 PA Targretin
Targretin (1% Gel,
75mg Capsule)1 PA
Tretinoin
Tretinoin (10mg Capsule) 1
Antiparasitics
AnthelminticsAlbenza
Albenza (Tablet) 1
Biltricide
Biltricide (Tablet) 1
Ivermectin
Ivermectin (Tablet) 1
AntiprotozoalsAlinia
Alinia (100mg/5ml
Suspension, 500mg
Tablet)
1
Atovaquone
Atovaquone (Suspension) 1
Atovaquone/Proguanil HCl
Atovaquone/Proguanil
HCl (Tablet) (Generic
Malarone)
1
Chloroquine Phosphate
Chloroquine Phosphate
(Tablet)1
Coartem
Coartem (Tablet) 1
DARAPRIM
DARAPRIM (Tablet) 1
Hydroxychloroquine Sulfate
Hydroxychloroquine
Sulfate (Tablet)1
Mefloquine HCl
Mefloquine HCl (Tablet) 1
Mepron
Mepron (Suspension) 1
Nebupent
Nebupent (Inhalation
Solution)1 B/D, PA
Pentam 300
Pentam 300 (Injection) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Primaquine Phosphate
Primaquine Phosphate
(Tablet)1
Quinine Sulfate
Quinine Sulfate (Capsule) 1 PA
Pediculicides/ScabicidesEurax
Eurax (10% Cream, 10%
Lotion)1
Lindane
Lindane (Shampoo) 1
Malathion
Malathion (Lotion) 1
Permethrin
Permethrin (Cream) 1
Antiparkinson Agents
AnticholinergicsBenztropine Mesylate
Benztropine Mesylate
(0.5mg Tablet, 1mg
Tablet, 2mg Tablet)
1
Benztropine Mesylate
Benztropine Mesylate
(1mg/ml Injection)1
Trihexyphenidyl HCl
Trihexyphenidyl HCl
(0.4mg/ml Elixir, 2mg
Tablet, 5mg Tablet)
1
Antiparkinson Agents, OtherAmantadine HCl
Amantadine HCl (100mg
Capsule, 100mg Tablet,
50mg/5ml Syrup)
1
Entacapone
Entacapone (Tablet) 1
Tasmar
Tasmar (Tablet) 1
Tolcapone
Tolcapone (Tablet) 1
Dopamine AgonistsApokyn
Apokyn (Injection) 1 PA Bromocriptine Mesylate
Bromocriptine Mesylate
(2.5mg Tablet, 5mg
Capsule)
1
Pramipexole Dihydrochloride
Pramipexole
Dihydrochloride (Tablet
Immediate-Release)
1
22
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
22
33
22tRACK
33Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ropinirole HCl
Ropinirole HCl (Tablet
Immediate-Release)1
Dopamine Precursors/L-Amino Acid
Decarboxylase InhibitorsCarbidopa
Carbidopa (Tablet) 1
Carbidopa/Levodopa
Carbidopa/Levodopa
(Tablet Immediate-
Release)
1
Carbidopa/Levodopa ER
Carbidopa/Levodopa ER
(Tablet Extended-Release)1
Carbidopa/Levodopa ODT
Carbidopa/Levodopa
ODT (Tablet Dispersible)1
Carbidopa/Levodopa/Entacapone
Carbidopa/Levodopa/
Entacapone (Tablet)1
Monoamine Oxidase B (MAO-B) InhibitorsAzilect
Azilect (Tablet) 1
Selegiline HCl
Selegiline HCl (5mg
Capsule, 5mg Tablet)1
Zelapar
Zelapar (Tablet
Dispersible)1
Antipsychotics
1st Generation/TypicalChlorpromazine HCl
Chlorpromazine HCl
(100mg Tablet, 10mg
Tablet, 200mg Tablet,
25mg Tablet, 50mg
Tablet, 50mg/2ml
Injection)
1
Fluphenazine Decanoate
Fluphenazine Decanoate
(Injection)1
Fluphenazine HCl
Fluphenazine HCl (10mg
Tablet, 1mg Tablet, 2.5mg
Tablet, 5mg Tablet)
1
Fluphenazine HCl
Fluphenazine HCl
(2.5mg/5ml Elixir, 5mg/ml
Concentrate)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Fluphenazine HCl
Fluphenazine HCl
(2.5mg/ml Injection)1
Haloperidol
Haloperidol (0.5mg
Tablet, 10mg Tablet, 1mg
Tablet, 20mg Tablet, 2mg
Tablet, 5mg Tablet, 2mg/
ml Concentrate)
1
Haloperidol Decanoate
Haloperidol Decanoate
(Injection)1
Haloperidol Lactate
Haloperidol Lactate
(Injection)1
Loxapine Succinate
Loxapine Succinate
(10mg Capsule, 5mg
Capsule)
1 QL
Loxapine Succinate
Loxapine Succinate
(25mg Capsule, 50mg
Capsule)
1
Molindone HCl
Molindone HCl (Tablet) 1
Orap
Orap (Tablet) 1
Pimozide
Pimozide (Tablet) 1
Thioridazine HCl
Thioridazine HCl (Tablet) 1
Thiothixene
Thiothixene (Capsule) 1
Trifluoperazine HCl
Trifluoperazine HCl
(Tablet)1
2nd Generation/AtypicalAbilify Maintena
Abilify Maintena
(Injection)1
Aripiprazole
Aripiprazole (10mg Tablet,
15mg Tablet, 2mg Tablet,
5mg Tablet)
1 QL
Aripiprazole
Aripiprazole (20mg Tablet,
30mg Tablet)1 QL
Aripiprazole ODT
Aripiprazole ODT (Tablet
Dispersible)1 QL
Aristada
Aristada (Injection) 1
23
Bold type = Brand name drug Plain type = Generic drug
23
34
23tRACK
34 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Fanapt
Fanapt (10mg Tablet,
12mg Tablet, 6mg
Tablet, 8mg Tablet)
1 QL, ST
Fanapt
Fanapt (1mg Tablet,
2mg Tablet, 4mg
Tablet)
1 QL, ST
Fanapt Titration Pack
Fanapt Titration Pack
(Tablet)1 ST
Geodon
Geodon (20mg
Injection)1
Invega
Invega (Tablet
Extended-Release 24
Hour)
1 QL
Invega Sustenna
Invega Sustenna
(117mg/0.75ml
Injection, 156mg/ml
Injection, 234mg/1.5ml
Injection, 78mg/0.5ml
Injection)
1
Invega Sustenna
Invega Sustenna
(39mg/0.25ml
Injection)
1
Invega Trinza
Invega Trinza (Injection) 1 PA Latuda
Latuda (Tablet) 1 QL Nuplazid
Nuplazid (Tablet) 1 PA, QL Olanzapine
Olanzapine (10mg
Injection)1
Olanzapine
Olanzapine (10mg Tablet
Immediate-Release, 15mg
Tablet Immediate-
Release, 2.5mg Tablet
Immediate-Release, 20mg
Tablet Immediate-
Release, 5mg Tablet
Immediate-Release,
7.5mg Tablet Immediate-
Release)
1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Olanzapine ODT
Olanzapine ODT (Tablet
Dispersible)1 QL
Paliperidone ER
Paliperidone ER (Tablet
Extended-Release 24
Hour)
1 QL
Quetiapine Fumarate
Quetiapine Fumarate
(Tablet Immediate-
Release)
1 QL
Rexulti
Rexulti (Tablet) 1 QL Risperdal Consta
Risperdal Consta
(12.5mg Injection,
25mg Injection)
1
Risperdal Consta
Risperdal Consta
(37.5mg Injection,
50mg Injection)
1
Risperidone
Risperidone (Tablet
Immediate-Release)1
Risperidone
Risperidone (1mg/ml Oral
Solution)1
Risperidone ODT
Risperidone ODT (Tablet
Dispersible)1
Saphris
Saphris (Tablet
Sublingual)1 QL
Seroquel XR
Seroquel XR (Tablet
Extended-Release 24
Hour)
1 QL
Vraylar
Vraylar (1.5mg Capsule,
3mg Capsule, 4.5mg
Capsule, 6mg Capsule)
1 QL, ST
Vraylar
Vraylar (Capsule
Therapy Pack)1 ST
Ziprasidone HCl
Ziprasidone HCl
(Capsule)1 QL
Zyprexa Relprevv
Zyprexa Relprevv
(Injection)1
Treatment-Resistant
24
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
24
35
24tRACK
35Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Clozapine
Clozapine (Tablet
Immediate-Release)1
Clozapine ODT
Clozapine ODT (100mg
Tablet Dispersible,
12.5mg Tablet
Dispersible, 150mg
Tablet Dispersible,
25mg Tablet
Dispersible)
1 QL
Clozapine ODT
Clozapine ODT (200mg
Tablet Dispersible)1 QL
Fazaclo
Fazaclo (100mg Tablet
Dispersible, 150mg
Tablet Dispersible,
200mg Tablet
Dispersible)
1 QL
Versacloz
Versacloz (Suspension) 1
Antivirals
Anti-cytomegalovirus (CMV) AgentsCidofovir
Cidofovir (Injection) 1
Ganciclovir
Ganciclovir (Injection) 1 B/D, PA Valcyte
Valcyte (450mg Tablet,
50mg/ml Oral Solution)1
Valganciclovir
Valganciclovir (Tablet) 1
Zirgan
Zirgan (Gel) 1
Anti-hepatitis B (HBV) AgentsAdefovir Dipivoxil
Adefovir Dipivoxil (Tablet) 1
Baraclude
Baraclude (0.05mg/ml
Oral Solution, 0.5mg
Tablet, 1mg Tablet)
1
Entecavir
Entecavir (Tablet) 1
Epivir HBV
Epivir HBV (5mg/ml
Oral Solution)1
Hepsera
Hepsera (Tablet) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Lamivudine
Lamivudine (100mg
Tablet)1
Tyzeka
Tyzeka (Tablet) 1
Anti-hepatitis C (HCV) AgentsDaklinza
Daklinza (Tablet) 1 PA, QL Epclusa
Epclusa (Tablet) 1 PA, QL Harvoni
Harvoni (Tablet) 1 PA, QL Intron A
Intron A (Injection) 1 PA Intron A w/Diluent
Intron A w/Diluent
(Injection)1 PA
Olysio
Olysio (Capsule) 1 PA, QL Pegasys
Pegasys (Injection) 1 PA Pegasys ProClick
Pegasys ProClick
(Injection)1 PA
PegIntron
PegIntron (Injection) 1 PA PegIntron REDIPEN
PegIntron REDIPEN
(Injection)1 PA
Ribasphere
Ribasphere (200mg
Capsule)1
Ribasphere
Ribasphere (200mg
Tablet, 400mg Tablet)1
Ribasphere
Ribasphere (600mg
Tablet)1
Ribavirin
Ribavirin (200mg
Capsule)1
Ribavirin
Ribavirin (200mg Tablet) 1
Sovaldi
Sovaldi (Tablet) 1 PA, QL Sylatron
Sylatron (Injection) 1 PA Zepatier
Zepatier (Tablet) 1 PA, QL
Antiherpetic AgentsAcyclovir
Acyclovir (200mg
Capsule, 200mg/5ml
Suspension)
1
25
Bold type = Brand name drug Plain type = Generic drug
25
36
25tRACK
36 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Acyclovir
Acyclovir (400mg Tablet,
800mg Tablet)1
Acyclovir
Acyclovir (5% Ointment) 1 QL Acyclovir Sodium
Acyclovir Sodium
(Injection)1 B/D, PA
Denavir
Denavir (Cream) 1 QL Famciclovir
Famciclovir (Tablet) 1 QL Trifluridine
Trifluridine (Ophthalmic
Solution)1
Valacyclovir HCl
Valacyclovir HCl (Tablet) 1 QL Zovirax
Zovirax (5% Cream) 1 QL Zovirax
Zovirax (5% Ointment) 1 QL
Anti-HIV Agents, Integrase Inhibitors
(INSTI) Evotaz
Evotaz (Tablet) 1 QL Genvoya
Genvoya (Tablet) 1 QL Isentress
Isentress (100mg
Packet, 100mg Tablet
Chewable, 400mg
Tablet)
1 QL
Isentress
Isentress (25mg Tablet
Chewable)1 QL
Prezcobix
Prezcobix (Tablet) 1 QL Stribild
Stribild (Tablet) 1 QL Tivicay
Tivicay (25mg Tablet,
50mg Tablet)1 QL
Triumeq
Triumeq (Tablet) 1 QL Tybost
Tybost (Tablet) 1 QL Vitekta
Vitekta (Tablet) 1 QL
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTI)Atripla
Atripla (Tablet) 1 QL Complera
Complera (Tablet) 1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Edurant
Edurant (Tablet) 1 QL Intelence
Intelence (100mg
Tablet, 200mg Tablet)1 QL
Intelence
Intelence (25mg Tablet) 1 QL Nevirapine
Nevirapine (200mg Tablet
Immediate-Release)1 QL
Nevirapine
Nevirapine (50mg/5ml
Suspension)1 QL
Nevirapine ER
Nevirapine ER (Tablet
Extended-Release 24
Hour)
1 QL
Odefsey
Odefsey (Tablet) 1 QL Rescriptor
Rescriptor (Tablet) 1 QL Sustiva
Sustiva (200mg
Capsule, 600mg Tablet)1 QL
Sustiva
Sustiva (50mg Capsule) 1 QL Viramune
Viramune (50mg/5ml
Suspension)1 QL
Viramune XR
Viramune XR (100mg
Tablet Extended-
Release 24 Hour)
1 QL
Viramune XR
Viramune XR (400mg
Tablet Extended-
Release 24 Hour)
1 QL
Anti-HIV Agents, Nucleoside and
Nucleotide Reverse Transcriptase
Inhibitors (NRTI)Abacavir
Abacavir (Tablet) 1 QL Abacavir Sulfate/Lamivudine/Zidovudine
Abacavir Sulfate/
Lamivudine/Zidovudine
(Tablet)
1 QL
Combivir
Combivir (Tablet) 1 QL Descovy
Descovy (Tablet) 1 QL Didanosine
Didanosine (Capsule
Delayed-Release)1 QL
26
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
26
37
26tRACK
37Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Emtriva
Emtriva (10mg/ml Oral
Solution, 200mg
Capsule)
1 QL
Epivir
Epivir (10mg/ml Oral
Solution)1 QL
Epzicom
Epzicom (Tablet) 1 QL Lamivudine
Lamivudine (10mg/ml
Oral Solution, 150mg
Tablet, 300mg Tablet)
1 QL
Lamivudine/Zidovudine
Lamivudine/Zidovudine
(Tablet)1 QL
Retrovir IV Infusion
Retrovir IV Infusion
(Injection)1
Stavudine
Stavudine (15mg
Capsule, 20mg Capsule,
30mg Capsule, 40mg
Capsule, 1mg/ml Oral
Solution)
1 QL
Trizivir
Trizivir (Tablet) 1 QL Truvada
Truvada (Tablet) 1 QL Videx Pediatric
Videx Pediatric (Oral
Solution)1 QL
Viread
Viread (150mg Tablet,
200mg Tablet, 250mg
Tablet, 300mg Tablet,
40mg/gm Powder)
1 QL
Ziagen
Ziagen (20mg/ml Oral
Solution)1 QL
Zidovudine
Zidovudine (100mg
Capsule, 300mg Tablet,
50mg/5ml Syrup)
1 QL
Anti-HIV Agents, OtherFuzeon
Fuzeon (Injection) 1 QL Selzentry
Selzentry (Tablet) 1 QL Tivicay
Tivicay (10mg Tablet) 1 QL
Anti-HIV Agents, Protease Inhibitors
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Aptivus
Aptivus (100mg/ml Oral
Solution, 250mg
Capsule)
1 QL
Crixivan
Crixivan (Capsule) 1 QL Invirase
Invirase (200mg
Capsule, 500mg Tablet)1 QL
Kaletra
Kaletra (100mg-25mg
Tablet)1 QL
Kaletra
Kaletra (200mg-50mg
Tablet, 400mg-100mg/
5ml Oral Solution)
1 QL
Lexiva
Lexiva (50mg/ml
Suspension)1 QL
Lexiva
Lexiva (700mg Tablet) 1 QL Norvir
Norvir (100mg Capsule,
100mg Tablet, 80mg/
ml Oral Solution)
1 QL
Prezista
Prezista (100mg/ml
Suspension, 150mg
Tablet, 600mg Tablet,
800mg Tablet)
1 QL
Prezista
Prezista (75mg Tablet) 1 QL Reyataz
Reyataz (150mg
Capsule, 200mg
Capsule, 300mg
Capsule, 50mg Packet)
1 QL
Viracept
Viracept (Tablet) 1 QL
Anti-influenza AgentsRelenza Diskhaler
Relenza Diskhaler
(Aerosol Powder)1 QL
Rimantadine HCl
Rimantadine HCl (Tablet) 1
Tamiflu
Tamiflu (30mg Capsule,
45mg Capsule, 75mg
Capsule, 6mg/ml
Suspension)
1 QL
Antivirals
27
Bold type = Brand name drug Plain type = Generic drug
27
38
27tRACK
38 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Virazole
Virazole (Inhalation
Solution)1
Anxiolytics
Anxiolytics, OtherBuspirone HCl
Buspirone HCl (Tablet) 1
Hydroxyzine HCl
Hydroxyzine HCl (10mg
Tablet, 25mg Tablet,
50mg Tablet, 10mg/5ml
Syrup)
1
Hydroxyzine HCl
Hydroxyzine HCl (25mg/
ml Injection, 50mg/ml
Injection)
1
Benzodiazepines Alprazolam
Alprazolam (Tablet
Immediate-Release)1 QL
Chlordiazepoxide HCl
Chlordiazepoxide HCl
(Capsule)1
Clonazepam
Clonazepam (Tablet
Immediate-Release)1 QL
Clonazepam ODT
Clonazepam ODT (Tablet
Dispersible)1 QL
Clorazepate Dipotassium
Clorazepate Dipotassium
(Tablet)1 QL
Diazepam
Diazepam (10mg Tablet,
2mg Tablet, 5mg Tablet)1 QL
Diazepam
Diazepam (1mg/ml Oral
Solution)1
Diazepam Intensol
Diazepam Intensol (5mg/
ml Concentrate)1 QL
Lorazepam
Lorazepam (Tablet) 1 QL Lorazepam Intensol
Lorazepam Intensol
(2mg/ml Concentrate)1 QL
Bipolar Agents
Mood Stabilizers
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Equetro
Equetro (Capsule
Extended-Release 12
Hour)
1
Lithium
Lithium (Oral Solution) 1
Lithium Carbonate
Lithium Carbonate
(150mg Capsule
Immediate-Release,
300mg Capsule
Immediate-Release,
600mg Capsule
Immediate-Release,
300mg Tablet Immediate-
Release)
1
Lithium Carbonate ER
Lithium Carbonate ER
(Tablet Extended-Release)1
Blood Glucose Regulators
Antidiabetic AgentsAcarbose
Acarbose (Tablet) 1 QL Avandia
Avandia (Tablet) 1 PA, QL Bydureon Vial
Bydureon Vial
(Injection)1 QL
Bydureon Pen
Bydureon Pen
(Injection)1 QL
Byetta
Byetta (Injection) 1 QL Cycloset
Cycloset (Tablet) 1 PA, QL Glimepiride
Glimepiride (Tablet) 1 QL Glipizide
Glipizide (Tablet
Immediate-Release)1 QL
Glipizide ER
Glipizide ER (Tablet
Extended-Release 24
Hour)
1 QL
Glipizide/Metformin HCl
Glipizide/Metformin HCl
(Tablet)1 QL
Glyset
Glyset (Tablet) 1 QL Invokamet
Invokamet (Tablet) 1 QL
28
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
28
39
28tRACK
39Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Invokana
Invokana (Tablet) 1 QL Janumet
Janumet (Tablet
Immediate-Release)1 QL
Janumet XR
Janumet XR (Tablet
Extended-Release 24
Hour)
1 QL
Januvia
Januvia (Tablet) 1 QL Jardiance
Jardiance (Tablet) 1 QL Jentadueto
Jentadueto (Tablet) 1 QL Jentadueto XR
Jentadueto XR (Tablet
Extended-Release 24
Hour)
1 QL
Kazano
Kazano (Tablet) 1 QL Kombiglyze XR
Kombiglyze XR (Tablet
Extended-Release 24
Hour)
1 QL
Metformin HCl
Metformin HCl (Tablet
Immediate-Release)1 QL
Metformin HCl ER
Metformin HCl ER
(1000mg Tablet
Extended-Release 24
Hour) (Generic Fortamet),
(500mg Tablet Extended-
Release 24 Hour, 750mg
Tablet Extended-Release
24 Hour) (Generic
Glucophage XR)
1 QL
Miglitol
Miglitol (Tablet) 1 QL Nateglinide
Nateglinide (Tablet) 1 QL Nesina
Nesina (Tablet) 1 QL Onglyza
Onglyza (Tablet) 1 QL Oseni
Oseni (Tablet) 1 QL Pioglitazone HCl
Pioglitazone HCl (Tablet) 1 QL Pioglitazone HCl/Glimepiride
Pioglitazone HCl/
Glimepiride (Tablet)1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Pioglitazone HCl/Metformin HCl
Pioglitazone HCl/
Metformin HCl (Tablet)1 QL
Repaglinide
Repaglinide (Tablet) 1 QL Repaglinide/Metformin HCl
Repaglinide/Metformin
HCl (Tablet)1 QL
Riomet
Riomet (Oral Solution) 1 QL SymlinPen 120
SymlinPen 120
(Injection)1 PA
SymlinPen 60
SymlinPen 60
(Injection)1 PA
Synjardy
Synjardy (Tablet) 1 QL Tradjenta
Tradjenta (Tablet) 1 QL Trulicity
Trulicity (Injection) 1 QL Victoza
Victoza (Injection) 1 QL
Glycemic AgentsGlucaGen HypoKit
GlucaGen HypoKit
(Injection)1
Glucagon Emergency Kit
Glucagon Emergency
Kit (Injection)1
Proglycem
Proglycem
(Suspension)1
InsulinsHumalog Cartridge
Humalog Cartridge
(Injection)1
Humalog KwikPen
Humalog KwikPen
(Injection)1
Humalog Mix 50/50 KwikPen
Humalog Mix 50/50
KwikPen (Injection)1
Humalog Mix 50/50 Vial
Humalog Mix 50/50 Vial
(Injection)1
Humalog Mix 75/25 KwikPen
Humalog Mix 75/25
KwikPen (Injection)1
Humalog Mix 75/25 Vial
Humalog Mix 75/25 Vial
(Injection)1
Humalog Vial
Humalog Vial (Injection) 1
29
Bold type = Brand name drug Plain type = Generic drug
29
40
29tRACK
40 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Humulin 70/30 KwikPen
Humulin 70/30
KwikPen (Injection)1
Humulin 70/30 Vial
Humulin 70/30 Vial
(Injection)1
Humulin N KwikPen
Humulin N KwikPen
(Injection)1
Humulin N Vial
Humulin N Vial
(Injection)1
Humulin R U-500 KwikPen
Humulin R U-500
KwikPen (Injection)1
Humulin R U-500 Vial
Humulin R U-500 Vial
(Concentrated)
(Injection)
1
Humulin R Vial
Humulin R Vial
(Injection)1
Lantus SoloStar
Lantus SoloStar
(Injection)1
Lantus Vial
Lantus Vial (Injection) 1
Levemir FlexTouch
Levemir FlexTouch
(Injection)1
Levemir Vial
Levemir Vial (Injection) 1
Toujeo SoloStar
Toujeo SoloStar
(Injection)1
Blood Products/Modifiers/Volume Expanders
AnticoagulantsCoumadin
Coumadin (Tablet) 1
Eliquis
Eliquis (Tablet) 1 PA, QL Enoxaparin Sodium
Enoxaparin Sodium
(100mg/ml Injection,
120mg/0.8ml Injection,
150mg/ml Injection)
1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Enoxaparin Sodium
Enoxaparin Sodium
(300mg/3ml Injection,
30mg/0.3ml Injection,
40mg/0.4ml Injection,
60mg/0.6ml Injection,
80mg/0.8ml Injection)
1 QL
Fondaparinux Sodium
Fondaparinux Sodium
(10mg/0.8ml Injection,
5mg/0.4ml Injection,
7.5mg/0.6ml Injection)
1
Fondaparinux Sodium
Fondaparinux Sodium
(2.5mg/0.5ml Injection)1
Heparin Sodium
Heparin Sodium
(10000unit/ml Injection,
20000unit/ml Injection,
5000unit/ml Injection)
1
Heparin Sodium
Heparin Sodium
(1000unit/ml Injection)1 B/D, PA
Heparin Sodium/D5W
Heparin Sodium/D5W
(Injection)1
Jantoven
Jantoven (Tablet) 1
Pradaxa
Pradaxa (Capsule) 1 PA, QL Warfarin Sodium
Warfarin Sodium (Tablet) 1
Xarelto
Xarelto (Tablet) 1 PA, QL Xarelto Starter Pack
Xarelto Starter Pack
(Tablet Therapy Pack)1 PA, QL
Blood Formation ModifiersAnagrelide HCl
Anagrelide HCl (Capsule) 1
30
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
30
41
30tRACK
41Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Aranesp Albumin Free
Aranesp Albumin Free
(100mcg/0.5ml
Injection, 100mcg/ml
Injection, 150mcg/
0.3ml Injection,
200mcg/0.4ml
Injection, 200mcg/ml
Injection, 300mcg/
0.6ml Injection,
300mcg/ml Injection,
500mcg/ml Injection,
60mcg/0.3ml Injection,
60mcg/ml Injection)
1 PA
Aranesp Albumin Free
Aranesp Albumin Free
(10mcg/0.4ml Injection,
25mcg/0.42ml
Injection, 25mcg/ml
Injection, 40mcg/0.4ml
Injection, 40mcg/ml
Injection)
1 PA
Granix
Granix (Injection) 1 PA Leukine
Leukine (Injection) 1 PA Mozobil
Mozobil (Injection) 1 PA Neulasta
Neulasta (Injection) 1 PA Neupogen
Neupogen (Injection) 1 PA Procrit
Procrit (10000unit/ml
Injection, 2000unit/ml
Injection, 3000unit/ml
Injection, 4000unit/ml
Injection)
1 PA
Procrit
Procrit (20000unit/ml
Injection, 40000unit/ml
Injection)
1 PA
Promacta
Promacta (Tablet) 1 PA Zarxio
Zarxio (Injection) 1
Blood Products/Modifiers/Volume
Expanders
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Argatroban
Argatroban (Injection) 1 B/D, PA
CoagulantsTranexamic Acid
Tranexamic Acid
(1000mg/10ml Injection,
650mg Tablet)
1
Platelet Modifying AgentsAggrenox
Aggrenox (Capsule
Extended-Release 12
Hour)
1 QL
Aspirin/Dipyridamole
Aspirin/Dipyridamole
(Capsule Extended-
Release 12 Hour)
1 QL
Brilinta
Brilinta (Tablet) 1 QL Cilostazol
Cilostazol (Tablet) 1
Clopidogrel
Clopidogrel (75mg Tablet) 1 QL Effient
Effient (Tablet) 1 QL
Cardiovascular Agents
Alpha-adrenergic AgonistsClonidine HCl
Clonidine HCl (0.1mg
Tablet Immediate-
Release, 0.2mg Tablet
Immediate-Release,
0.3mg Tablet Immediate-
Release)
1
Clonidine HCl
Clonidine HCl (0.1mg/
24hr Patch Weekly,
0.2mg/24hr Patch
Weekly, 0.3mg/24hr
Patch Weekly)
1
Methyldopa
Methyldopa (Tablet) 1
Methyldopate HCl
Methyldopate HCl
(Injection)1
Midodrine HCl
Midodrine HCl (Tablet) 1
Alpha-adrenergic Blocking AgentsDibenzyline
Dibenzyline (Capsule) 1
31
Bold type = Brand name drug Plain type = Generic drug
31
42
31tRACK
42 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Doxazosin Mesylate
Doxazosin Mesylate
(Tablet)1
Phenoxybenzamine HCl
Phenoxybenzamine HCl
(Capsule)1
Prazosin HCl
Prazosin HCl (Capsule) 1
Angiotensin II Receptor AntagonistsBenicar
Benicar (Tablet) 1 QL Candesartan Cilexetil
Candesartan Cilexetil
(Tablet)1 QL
Edarbi
Edarbi (Tablet) 1 QL Eprosartan Mesylate
Eprosartan Mesylate
(Tablet)1 QL
Irbesartan
Irbesartan (Tablet) 1 QL Losartan Potassium
Losartan Potassium
(Tablet)1 QL
Telmisartan
Telmisartan (Tablet) 1 QL Valsartan
Valsartan (Tablet) 1 QL
Angiotensin-converting Enzyme (ACE)
InhibitorsBenazepril HCl
Benazepril HCl (Tablet) 1 QL Captopril
Captopril (Tablet) 1 QL Enalapril Maleate
Enalapril Maleate (Tablet) 1 QL Epaned
Epaned (Oral Solution) 1
Fosinopril Sodium
Fosinopril Sodium (Tablet) 1 QL Lisinopril
Lisinopril (Tablet) 1 QL Moexipril HCl
Moexipril HCl (Tablet) 1 QL Perindopril Erbumine
Perindopril Erbumine
(Tablet)1 QL
Quinapril HCl
Quinapril HCl (Tablet) 1 QL Ramipril
Ramipril (Capsule) 1 QL Trandolapril
Trandolapril (Tablet) 1 QL
Antiarrhythmics
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Amiodarone HCl
Amiodarone HCl (200mg
Tablet)1
Amiodarone HCl
Amiodarone HCl (50mg/
ml Injection)1
Dofetilide
Dofetilide (Capsule) 1
Flecainide Acetate
Flecainide Acetate
(Tablet)1
Mexiletine HCl
Mexiletine HCl (Capsule) 1
Multaq
Multaq (Tablet) 1 QL Pacerone
Pacerone (200mg Tablet) 1
Procainamide HCl
Procainamide HCl
(Injection)1
Propafenone HCl
Propafenone HCl (Tablet) 1
Propafenone HCl ER
Propafenone HCl ER
(Capsule Extended-
Release 12 Hour)
1
Quinidine Gluconate
Quinidine Gluconate
(Injection)1
Quinidine Gluconate CR
Quinidine Gluconate CR
(Tablet Extended-Release)1
Quinidine Sulfate
Quinidine Sulfate (Tablet) 1
Sotalol HCl
Sotalol HCl (AF) (Tablet) 1
Sotalol HCl
Sotalol HCl (Tablet) 1
Tikosyn
Tikosyn (Capsule) 1
Beta-adrenergic Blocking AgentsAcebutolol HCl
Acebutolol HCl (Capsule) 1
Atenolol
Atenolol (Tablet) 1
Betaxolol HCl
Betaxolol HCl (10mg
Tablet, 20mg Tablet)1
Bisoprolol Fumarate
Bisoprolol Fumarate
(Tablet)1
Bystolic
Bystolic (Tablet) 1 QL Carvedilol
Carvedilol (Tablet
Immediate-Release)1
32
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
32
43
32tRACK
43Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Labetalol HCl
Labetalol HCl (100mg
Tablet, 200mg Tablet,
300mg Tablet)
1
Labetalol HCl
Labetalol HCl (5mg/ml
Injection)1
Metoprolol Succinate ER
Metoprolol Succinate ER
(Tablet Extended-Release
24 Hour)
1
Metoprolol Tartrate
Metoprolol Tartrate
(100mg Tablet
Immediate-Release, 25mg
Tablet Immediate-
Release, 50mg Tablet
Immediate-Release)
1
Metoprolol Tartrate
Metoprolol Tartrate (1mg/
ml Injection)1
Nadolol
Nadolol (Tablet) 1
Pindolol
Pindolol (Tablet) 1
Propranolol HCl
Propranolol HCl (10mg
Tablet Immediate-
Release, 20mg Tablet
Immediate-Release, 40mg
Tablet Immediate-
Release, 60mg Tablet
Immediate-Release, 80mg
Tablet Immediate-
Release, 20mg/5ml Oral
Solution, 40mg/5ml Oral
Solution)
1
Propranolol HCl
Propranolol HCl (1mg/ml
Injection)1
Propranolol HCl ER
Propranolol HCl ER
(Capsule Extended-
Release 24 Hour)
1
Timolol Maleate
Timolol Maleate (10mg
Tablet, 20mg Tablet, 5mg
Tablet)
1
Calcium Channel Blocking Agents
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Afeditab CR
Afeditab CR (Tablet
Extended-Release 24
Hour)
1 QL
Amlodipine Besylate
Amlodipine Besylate
(Tablet)1
Cardene IV
Cardene IV (Injection) 1
Cartia XT
Cartia XT (Capsule
Extended-Release 24
Hour)
1
Diltiazem CD
Diltiazem CD (Capsule
Extended-Release 24
Hour)
1
Diltiazem HCl
Diltiazem HCl (100mg
Injection, 50mg/10ml
Injection)
1
Diltiazem HCl
Diltiazem HCl (Tablet
Immediate-Release)1
Diltiazem HCl ER
Diltiazem HCl ER
(Capsule Extended-
Release)
1
Dilt-XR
Dilt-XR (Capsule
Extended-Release 24
Hour)
1
Felodipine ER
Felodipine ER (Tablet
Extended-Release 24
Hour)
1
Matzim LA
Matzim LA (180mg Tablet
Extended-Release 24
Hour, 240mg Tablet
Extended-Release 24
Hour, 300mg Tablet
Extended-Release 24
Hour)
1
Matzim LA
Matzim LA (360mg Tablet
Extended-Release 24
Hour, 420mg Tablet
Extended-Release 24
Hour)
1 QL
33
Bold type = Brand name drug Plain type = Generic drug
33
44
33tRACK
44 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Nicardipine HCl
Nicardipine HCl (2.5mg/
ml Injection)1
Nicardipine HCl
Nicardipine HCl (20mg
Capsule, 30mg Capsule)1
Nifedical XL
Nifedical XL (Tablet
Extended-Release 24
Hour)
1 QL
Nifedipine ER
Nifedipine ER (Tablet
Extended-Release 24
Hour)
1 QL
Nimodipine
Nimodipine (Capsule) 1
Taztia XT
Taztia XT (Capsule
Extended-Release 24
Hour)
1
Verapamil HCl
Verapamil HCl (120mg
Tablet Immediate-
Release, 40mg Tablet
Immediate-Release, 80mg
Tablet Immediate-
Release)
1
Verapamil HCl
Verapamil HCl (2.5mg/ml
Injection)1
Verapamil HCl ER
Verapamil HCl ER
(100mg Capsule
Extended-Release 24
Hour, 120mg Capsule
Extended-Release 24
Hour, 180mg Capsule
Extended-Release 24
Hour, 200mg Capsule
Extended-Release 24
Hour, 240mg Capsule
Extended-Release 24
Hour, 300mg Capsule
Extended-Release 24
Hour)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Verapamil HCl ER
Verapamil HCl ER
(120mg Tablet Extended-
Release, 180mg Tablet
Extended-Release,
240mg Tablet Extended-
Release)
1
Verapamil HCl SR
Verapamil HCl SR
(Capsule Extended-
Release 24 Hour)
1
Cardiovascular Agents, OtherAmiloride/Hydrochlorothiazide
Amiloride/
Hydrochlorothiazide
(Tablet)
1
Amlodipine Besylate/Atorvastatin Calcium
Amlodipine Besylate/
Atorvastatin Calcium
(Tablet)
1 QL
Amlodipine Besylate/Benazepril HCl
Amlodipine Besylate/
Benazepril HCl (Capsule)1 QL
Amlodipine Besylate/Valsartan
Amlodipine Besylate/
Valsartan (Tablet)1 QL
Amlodipine/Valsartan/Hydrochlorothiazide
Amlodipine/Valsartan/
Hydrochlorothiazide
(Tablet)
1 QL
Atenolol/Chlorthalidone
Atenolol/Chlorthalidone
(Tablet)1
Azor
Azor (Tablet) 1 QL Benazepril HCl/Hydrochlorothiazide
Benazepril HCl/
Hydrochlorothiazide
(Tablet)
1 QL
Benicar HCT
Benicar HCT (Tablet) 1 QL BiDil
BiDil (Tablet) 1 QL Bisoprolol Fumarate/Hydrochlorothiazide
Bisoprolol Fumarate/
Hydrochlorothiazide
(Tablet)
1 QL
Candesartan Cilexetil/Hydrochlorothiazide
Candesartan Cilexetil/
Hydrochlorothiazide
(Tablet)
1 QL
34
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
34
45
34tRACK
45Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Captopril/Hydrochlorothiazide
Captopril/
Hydrochlorothiazide
(Tablet)
1 QL
Clorpres
Clorpres (Tablet) 1
Demser
Demser (Capsule) 1
Digitek
Digitek (Tablet) 1
Digoxin
Digoxin (0.05mg/ml
Oral Solution)1
Digoxin
Digoxin (0.25mg/ml
Injection)1
Digoxin
Digoxin (125mcg Tablet,
250mcg Tablet)1
Edarbyclor
Edarbyclor (Tablet) 1 QL Enalapril Maleate/Hydrochlorothiazide
Enalapril Maleate/
Hydrochlorothiazide
(Tablet)
1 QL
Entresto
Entresto (Tablet) 1 PA, QL Fosinopril Sodium/Hydrochlorothiazide
Fosinopril Sodium/
Hydrochlorothiazide
(Tablet)
1 QL
Irbesartan/Hydrochlorothiazide
Irbesartan/
Hydrochlorothiazide
(Tablet)
1 QL
Lanoxin
Lanoxin (125mcg
Tablet, 187.5mcg
Tablet, 250mcg Tablet,
62.5mcg Tablet)
1
Lisinopril/Hydrochlorothiazide
Lisinopril/
Hydrochlorothiazide
(Tablet)
1 QL
Losartan Potassium/Hydrochlorothiazide
Losartan Potassium/
Hydrochlorothiazide
(Tablet)
1 QL
Methyldopa/Hydrochlorothiazide
Methyldopa/
Hydrochlorothiazide
(Tablet)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Metoprolol/Hydrochlorothiazide
Metoprolol/
Hydrochlorothiazide
(Tablet)
1
Moexipril/Hydrochlorothiazide
Moexipril/
Hydrochlorothiazide
(Tablet)
1 QL
Nadolol/Bendroflumethiazide
Nadolol/
Bendroflumethiazide
(40mg-5mg Tablet)
1 QL
Nadolol/Bendroflumethiazide
Nadolol/
Bendroflumethiazide
(80mg-5mg Tablet)
1
Northera
Northera (Capsule) 1 PA, QL Pentoxifylline ER
Pentoxifylline ER (Tablet
Extended-Release)1
Propranolol/Hydrochlorothiazide
Propranolol/
Hydrochlorothiazide
(Tablet)
1
Quinapril/Hydrochlorothiazide
Quinapril/
Hydrochlorothiazide
(Tablet)
1 QL
Ranexa
Ranexa (Tablet
Extended-Release 12
Hour)
1 QL
Spironolactone/Hydrochlorothiazide
Spironolactone/
Hydrochlorothiazide
(Tablet)
1
Telmisartan/Amlodipine
Telmisartan/Amlodipine
(Tablet)1 QL
Telmisartan/Hydrochlorothiazide
Telmisartan/
Hydrochlorothiazide
(Tablet)
1 QL
Triamterene/Hydrochlorothiazide
Triamterene/
Hydrochlorothiazide
(37.5mg-25mg Capsule,
50mg-25mg Capsule,
37.5mg-25mg Tablet,
75mg-50mg Tablet)
1
35
Bold type = Brand name drug Plain type = Generic drug
35
46
35tRACK
46 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Tribenzor
Tribenzor (Tablet) 1 QL Valsartan/Hydrochlorothiazide
Valsartan/
Hydrochlorothiazide
(Tablet)
1 QL
Diuretics, Carbonic Anhydrase InhibitorsAcetazolamide
Acetazolamide (Tablet
Immediate-Release)1
Acetazolamide ER
Acetazolamide ER
(Capsule Extended-
Release 12 Hour)
1
Acetazolamide Sodium
Acetazolamide Sodium
(Injection)1
Diuretics, LoopBumetanide
Bumetanide (0.25mg/ml
Injection)1
Bumetanide
Bumetanide (0.5mg
Tablet, 1mg Tablet, 2mg
Tablet)
1
Edecrin
Edecrin (Tablet) 1
Furosemide
Furosemide (10mg/ml
Injection)1 B/D, PA
Furosemide
Furosemide (10mg/ml
Oral Solution, 8mg/ml
Oral Solution)
1
Furosemide
Furosemide (20mg
Tablet, 40mg Tablet,
80mg Tablet)
1
Torsemide
Torsemide (Tablet) 1
Diuretics, Potassium-sparingAmiloride HCl
Amiloride HCl (Tablet) 1
Dyrenium
Dyrenium (Capsule) 1
Eplerenone
Eplerenone (Tablet) 1
Spironolactone
Spironolactone (Tablet) 1
Diuretics, ThiazideChlorothiazide
Chlorothiazide (Tablet) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Chlorothiazide Sodium
Chlorothiazide Sodium
(Injection)1 B/D, PA
Chlorthalidone
Chlorthalidone (Tablet) 1
Diuril
Diuril (Suspension) 1
Hydrochlorothiazide
Hydrochlorothiazide
(12.5mg Capsule, 12.5mg
Tablet, 25mg Tablet,
50mg Tablet)
1
Indapamide
Indapamide (Tablet) 1
Methyclothiazide
Methyclothiazide (Tablet) 1
Metolazone
Metolazone (Tablet) 1
Dyslipidemics, Fibric Acid DerivativesFenofibrate
Fenofibrate (145mg
Tablet, 48mg Tablet)
(Generic Tricor), (160mg
Tablet, 54mg Tablet)
(Generic Lofibra)
1
Fenofibrate Micronized
Fenofibrate Micronized
(134mg Capsule, 200mg
Capsule, 67mg Capsule)
(Generic Lofibra)
1
Fenofibric Acid
Fenofibric Acid (Tablet) 1
Fenofibric Acid DR
Fenofibric Acid DR
(Capsule Delayed-
Release)
1
Gemfibrozil
Gemfibrozil (Tablet) 1
Dyslipidemics, HMG CoA Reductase
InhibitorsAtorvastatin Calcium
Atorvastatin Calcium
(Tablet)1 QL
Crestor
Crestor (Tablet) 1 QL Fluvastatin
Fluvastatin (Capsule
Immediate-Release)1 QL
Lovastatin
Lovastatin (Tablet
Immediate-Release)1 QL
36
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
36
47
36tRACK
47Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Pravastatin Sodium
Pravastatin Sodium
(Tablet)1 QL
Rosuvastatin Calcium
Rosuvastatin Calcium
(Tablet)1 QL
Simvastatin
Simvastatin (Tablet) 1 QL
Dyslipidemics, OtherCholestyramine Light
Cholestyramine Light
(4gm Packet, 4gm/dose
Powder)
1
Colestipol HCl
Colestipol HCl (1gm
Tablet, 5gm Granules)1
Juxtapid
Juxtapid (Capsule) 1 PA Kynamro
Kynamro (Injection) 1 PA Niacin ER
Niacin ER (Tablet
Extended-Release)1
Niacor
Niacor (Tablet) 1
Omega-3-Acid Ethyl Esters
Omega-3-Acid Ethyl
Esters (Capsule) (Generic
Lovaza)
1 QL
Praluent
Praluent (Injection) 1 PA, QL, LA Prevalite
Prevalite (Powder) 1
Repatha
Repatha (Injection) 1 PA, QL Repatha Pushtronex System
Repatha Pushtronex
System (Solution
Cartridge)
1 PA, QL
Repatha SureClick
Repatha SureClick
(Injection)1 PA, QL
Vascepa
Vascepa (Capsule) 1
Vytorin
Vytorin (Tablet) 1 QL Welchol
Welchol (3.75gm
Packet, 625mg Tablet)1
Zetia
Zetia (Tablet) 1 QL
Vasodilators, Direct-acting Arterial
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Hydralazine HCl
Hydralazine HCl (100mg
Tablet, 10mg Tablet,
25mg Tablet, 50mg
Tablet)
1
Hydralazine HCl
Hydralazine HCl (20mg/
ml Injection)1
Minoxidil
Minoxidil (Tablet) 1
Vasodilators, Direct-acting Arterial/VenousIsosorbide Dinitrate
Isosorbide Dinitrate
(Tablet Immediate-
Release)
1
Isosorbide Dinitrate ER
Isosorbide Dinitrate ER
(Tablet Extended-Release)1
Isosorbide Mononitrate
Isosorbide Mononitrate
(Tablet Immediate-
Release)
1
Isosorbide Mononitrate ER
Isosorbide Mononitrate
ER (Tablet Extended-
Release 24 Hour)
1
Minitran
Minitran (Patch 24 Hour) 1
Nitro-Bid
Nitro-Bid (Ointment) 1
Nitroglycerin
Nitroglycerin (Injection) 1
Nitroglycerin Lingual
Nitroglycerin Lingual
(Translingual Solution)1
Nitroglycerin Transdermal
Nitroglycerin Transdermal
(Patch 24 Hour)1
Nitrostat
Nitrostat (Tablet
Sublingual)1
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines
37
Bold type = Brand name drug Plain type = Generic drug
37
48
37tRACK
48 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Amphetamine/Dextroamphetamine
Amphetamine/
Dextroamphetamine
(10mg Capsule Extended-
Release 24 Hour, 15mg
Capsule Extended-
Release 24 Hour, 20mg
Capsule Extended-
Release 24 Hour, 25mg
Capsule Extended-
Release 24 Hour, 30mg
Capsule Extended-
Release 24 Hour, 5mg
Capsule Extended-
Release 24 Hour)
1 QL
Amphetamine/Dextroamphetamine
Amphetamine/
Dextroamphetamine
(10mg Tablet Immediate-
Release, 12.5mg Tablet
Immediate-Release, 15mg
Tablet Immediate-
Release, 20mg Tablet
Immediate-Release, 30mg
Tablet Immediate-
Release, 5mg Tablet
Immediate-Release,
7.5mg Tablet Immediate-
Release)
1 QL
Dexedrine
Dexedrine (Tablet) 1 QL Dextroamphetamine Sulfate
Dextroamphetamine
Sulfate (10mg Tablet
Immediate-Release, 5mg
Tablet Immediate-
Release)
1 QL
Dextroamphetamine Sulfate ER
Dextroamphetamine
Sulfate ER (Capsule
Extended-Release 24
Hour)
1 QL
Vyvanse
Vyvanse (Capsule) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetaminesClonidine HCl ER
Clonidine HCl ER (Tablet
Extended-Release 12
Hour)
1
Dexmethylphenidate HCl
Dexmethylphenidate HCl
(Tablet Immediate-
Release)
1 QL
Dexmethylphenidate HCl ER
Dexmethylphenidate HCl
ER (Capsule Extended-
Release 24 Hour)
1
Guanfacine ER
Guanfacine ER (Tablet
Extended-Release 24
Hour)
1
Metadate ER
Metadate ER (Tablet
Extended-Release)1 QL
Methylphenidate HCl
Methylphenidate HCl
(10mg Tablet Immediate-
Release, 20mg Tablet
Immediate-Release, 5mg
Tablet Immediate-
Release) (Generic Ritalin),
(10mg/5ml Oral Solution,
5mg/5ml Oral Solution)
1 QL
Methylphenidate HCl ER
Methylphenidate HCl ER
(10mg Tablet Extended-
Release, 20mg Tablet
Extended-Release)
1 QL
Strattera
Strattera (Capsule) 1 QL, ST
Central Nervous System, OtherNamzaric
Namzaric (Capsule
Extended-Release 24
Hour)
1 PA, QL
Nuedexta
Nuedexta (Capsule) 1 PA Rilutek
Rilutek (Tablet) 1
Riluzole
Riluzole (Tablet) 1
38
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
38
49
38tRACK
49Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Tetrabenazine
Tetrabenazine (Tablet) 1 PA, QL Xenazine
Xenazine (Tablet) 1 PA, QL, LA
Fibromyalgia AgentsDuloxetine HCl
Duloxetine HCl (20mg
Capsule Delayed-Release,
30mg Capsule Delayed-
Release, 60mg Capsule
Delayed-Release)
1 QL
Lyrica
Lyrica (100mg Capsule,
150mg Capsule, 200mg
Capsule, 225mg
Capsule, 25mg
Capsule, 300mg
Capsule, 50mg
Capsule, 75mg
Capsule, 20mg/ml Oral
Solution)
1 QL
Savella
Savella (Tablet) 1
Savella Titration Pack
Savella Titration Pack 1
Multiple Sclerosis AgentsAmpyra
Ampyra (Tablet
Extended-Release 12
Hour)
1 PA, QL
Aubagio
Aubagio (Tablet) 1 PA, QL Avonex
Avonex (Injection) 1 PA Avonex Pen
Avonex Pen (Injection) 1 PA Betaseron
Betaseron (Injection) 1 PA Copaxone
Copaxone (Injection) 1 PA Gilenya
Gilenya (Capsule) 1 PA, QL Glatopa
Glatopa (Injection) 1 PA Rebif
Rebif (Injection) 1 PA Rebif Rebidose
Rebif Rebidose
(Injection)1 PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Rebif Rebidose Titration Pack
Rebif Rebidose
Titration Pack
(Injection)
1 PA
Rebif Titration Pack
Rebif Titration Pack
(Injection)1 PA
Tecfidera
Tecfidera (Capsule
Delayed-Release)1 PA, QL
Tecfidera Starter Pack
Tecfidera Starter Pack 1 PA Tysabri
Tysabri (Injection) 1 PA
Dental and Oral Agents
Dental and Oral AgentsChlorhexidine Gluconate Oral Rinse
Chlorhexidine Gluconate
Oral Rinse (Solution)1
Kepivance
Kepivance (Injection) 1
Periogard
Periogard (Solution) 1
Pilocarpine HCl
Pilocarpine HCl (5mg
Tablet, 7.5mg Tablet)1
Triamcinolone in Orabase
Triamcinolone in Orabase
(Paste)1
Dermatological Agents
Dermatological Agents8-MOP
8-MOP (Capsule) 1
Acitretin
Acitretin (Capsule) 1
Adapalene
Adapalene (0.1% Cream,
0.1% Gel)1
Ammonium Lactate
Ammonium Lactate (12%
Cream, 12% Lotion)1
Avita
Avita (0.025% Cream,
0.025% Gel)1 PA
Calcipotriene
Calcipotriene (0.005%
Cream, 0.005% External
Solution)
1
Calcitriol
Calcitriol (3mcg/gm
Ointment)1
Carac
Carac (Cream) 1
39
Bold type = Brand name drug Plain type = Generic drug
39
50
39tRACK
50 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Claravis
Claravis (Capsule) 1 PA Clindamycin Phosphate
Clindamycin Phosphate
(1% External Solution, 1%
Gel, 1% Lotion, 1% Swab)
1
Clindamycin/Benzoyl Peroxide
Clindamycin/Benzoyl
Peroxide (1%-5% Gel)
(Generic BenzaClin)
1
Clotrimazole/Betamethasone Dipropionate
Clotrimazole/
Betamethasone
Dipropionate (1%-0.05%
Cream)
1
Clotrimazole/Betamethasone Dipropionate
Clotrimazole/
Betamethasone
Dipropionate (1%-0.05%
Lotion)
1
Cortisporin
Cortisporin (0.5%-0.5%
Cream, 1%-0.5%
Ointment)
1
Diclofenac Sodium
Diclofenac Sodium (3%
Gel)1 PA
Doxepin HCl
Doxepin HCl (Cream) 1
Elidel
Elidel (Cream) 1 ST Ery
Ery (2% Pad) 1
Erythromycin
Erythromycin (2% External
Solution)1
Erythromycin
Erythromycin (2% Gel) 1
Erythromycin/Benzoyl Peroxide
Erythromycin/Benzoyl
Peroxide (Gel)1
Fluorouracil
Fluorouracil (2% External
Solution, 5% External
Solution, 5% Cream)
1
Imiquimod
Imiquimod (Cream) 1
Methoxsalen
Methoxsalen (Capsule) 1
Mirvaso
Mirvaso (Gel) 1 PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Oxsoralen Ultra
Oxsoralen Ultra
(Capsule)1
Picato
Picato (Gel) 1
Podofilox
Podofilox (External
Solution)1
PRUDOXIN
PRUDOXIN (Cream) 1
Regranex
Regranex (Gel) 1 PA Santyl
Santyl (Ointment) 1
Selenium Sulfide
Selenium Sulfide (Lotion) 1
Solaraze
Solaraze (Gel) 1 PA Soriatane
Soriatane (Capsule) 1
Tacrolimus
Tacrolimus (0.03%
Ointment, 0.1% Ointment)1 ST
Tazorac
Tazorac (0.05% Cream,
0.1% Cream)1 PA
Tretinoin
Tretinoin (0.01% Gel,
0.025% Gel, 0.025%
Cream, 0.05% Cream,
0.1% Cream)
1 PA
Tretinoin Microsphere
Tretinoin Microsphere
(Gel)1 PA
Uvadex
Uvadex (Injection) 1
Zyclara
Zyclara (Cream) 1 PA Zyclara Pump
Zyclara Pump (Cream) 1 PA
Enzyme Replacement/Modifiers
Enzyme Replacement/ModifiersAdagen
Adagen (Injection) 1 LA Aldurazyme
Aldurazyme (Injection) 1
Buphenyl
Buphenyl (3gm/tsp
Powder, 500mg Tablet)1
Cerezyme
Cerezyme (Injection) 1 PA Creon
Creon (Capsule
Delayed-Release)1
40
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
40
51
40tRACK
51Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Cystadane
Cystadane (Powder) 1
Cystagon
Cystagon (Capsule) 1 LA Elaprase
Elaprase (Injection) 1
Elelyso
Elelyso (Injection) 1 PA, LA Fabrazyme
Fabrazyme (Injection) 1
Kuvan
Kuvan (100mg Packet,
500mg Packet, 100mg
Tablet Soluble)
1
Lumizyme
Lumizyme (Injection) 1
Naglazyme
Naglazyme (Injection) 1
Orfadin
Orfadin (Capsule, Oral
Suspension)1 LA
Procysbi
Procysbi (Capsule
Delayed-Release)1
RAVICTI
RAVICTI (Liquid) 1
Sodium Phenylbutyrate
Sodium Phenylbutyrate
(Powder)1
Strensiq
Strensiq (Injection) 1 PA, LA Sucraid
Sucraid (Oral Solution) 1 LA VPRIV
VPRIV (Injection) 1 PA Zavesca
Zavesca (Capsule) 1 PA, LA Zenpep
Zenpep (Capsule
Delayed-Release)1
Gastrointestinal Agents
Antispasmodics, GastrointestinalAtropine Sulfate
Atropine Sulfate
(Injection)1
Cuvposa
Cuvposa (Oral Solution) 1
Dicyclomine HCl
Dicyclomine HCl (10mg
Capsule, 10mg/5ml Oral
Solution, 20mg Tablet)
1
Glycopyrrolate
Glycopyrrolate (4mg/
20ml Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Methscopolamine Bromide
Methscopolamine
Bromide (Tablet)1
Gastrointestinal Agents, OtherChenodal
Chenodal (Tablet) 1
Cholbam
Cholbam (Capsule) 1 PA Cromolyn Sodium
Cromolyn Sodium
(100mg/5ml
Concentrate)
1
Diphenoxylate/Atropine
Diphenoxylate/Atropine
(2.5mg-0.025mg Tablet,
2.5mg-0.025mg/5ml
Liquid)
1
Gattex
Gattex (Injection) 1 PA Loperamide HCl
Loperamide HCl
(Capsule)1
Ocaliva
Ocaliva (Tablet) 1 PA, QL Relistor
Relistor (Injection) 1 PA Serostim
Serostim (Injection) 1 PA Ursodiol
Ursodiol (250mg Tablet,
500mg Tablet, 300mg
Capsule)
1
Zorbtive
Zorbtive (Injection) 1 PA
Histamine2 (H2) Receptor AntagonistsCimetidine
Cimetidine (Tablet) 1
Cimetidine HCl
Cimetidine HCl (Oral
Solution)1
Famotidine
Famotidine (20mg Tablet,
40mg Tablet)1
Famotidine
Famotidine (20mg/2ml
Injection, 40mg/5ml
Suspension)
1
Famotidine Premixed
Famotidine Premixed
(Injection)1
41
Bold type = Brand name drug Plain type = Generic drug
41
52
41tRACK
52 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ranitidine HCl
Ranitidine HCl (150mg
Capsule, 300mg Capsule,
15mg/ml Syrup)
1
Ranitidine HCl
Ranitidine HCl (150mg
Tablet, 300mg Tablet)1
Irritable Bowel Syndrome AgentsAlosetron HCl
Alosetron HCl (Tablet) 1 PA Amitiza
Amitiza (Capsule) 1 QL Linzess
Linzess (Capsule) 1 QL Lotronex
Lotronex (Tablet) 1 PA
LaxativesConstulose
Constulose (Oral Solution) 1
Enulose
Enulose (Oral Solution) 1
GaviLyte-C
GaviLyte-C (Oral Solution) 1
GaviLyte-G
GaviLyte-G (Oral Solution) 1
GaviLyte-H
GaviLyte-H (Kit) 1
GaviLyte-N/Flavor Pack
GaviLyte-N/Flavor Pack
(Oral Solution)1
Generlac
Generlac (Oral Solution) 1
Lactulose
Lactulose (Oral Solution) 1
PEG-3350/Electrolytes
PEG-3350/Electrolytes
(Oral Solution) (Generic
GoLYTELY)
1
PEG-3350/NaCl/Na Bicarbonate/KCl
PEG-3350/NaCl/Na
Bicarbonate/KCl (Oral
Solution) (Generic
NuLYTELY)
1
Polyethylene Glycol 3350 Powder
Polyethylene Glycol 3350
Powder (Generic
MiraLAX)
1
Suprep Bowel Prep
Suprep Bowel Prep
(Oral Solution)1
TriLyte
TriLyte (Oral Solution) 1
Protectants
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Carafate
Carafate (1gm/10ml
Suspension)1
Misoprostol
Misoprostol (Tablet) 1
Sucralfate
Sucralfate (Tablet) 1
Proton Pump InhibitorsDexilant
Dexilant (Capsule
Delayed-Release)1 QL
Esomeprazole Magnesium
Esomeprazole
Magnesium (Capsule
Delayed-Release)
(Generic Nexium)
1 QL
Esomeprazole Sodium
Esomeprazole Sodium
(Injection)1
Nexium
Nexium (10mg Packet,
2.5mg Packet, 20mg
Packet, 40mg Packet,
5mg Packet)
1
Nexium
Nexium (20mg Capsule
Delayed-Release, 40mg
Capsule Delayed-
Release)
1 QL
Omeprazole
Omeprazole (10mg
Capsule Delayed-Release,
40mg Capsule Delayed-
Release)
1 QL
Omeprazole
Omeprazole (20mg
Capsule Delayed-Release)1
Pantoprazole Sodium
Pantoprazole Sodium
(Tablet Delayed-Release)1 QL
Pantoprazole Sodium
Pantoprazole Sodium
(40mg Injection)1
Genitourinary Agents
Antispasmodics, UrinaryMyrbetriq
Myrbetriq (Tablet
Extended-Release 24
Hour)
1
42
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
42
53
42tRACK
53Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Oxybutynin Chloride
Oxybutynin Chloride (5mg
Tablet Immediate-
Release, 5mg/5ml Syrup)
1
Oxybutynin Chloride ER
Oxybutynin Chloride ER
(Tablet Extended-Release
24 Hour)
1 QL
Vesicare
Vesicare (Tablet) 1 QL
Benign Prostatic Hypertrophy AgentsAlfuzosin HCl ER
Alfuzosin HCl ER (Tablet
Extended-Release 24
Hour)
1
Finasteride
Finasteride (5mg Tablet)
(Generic Proscar)1
Rapaflo
Rapaflo (Capsule) 1 QL Tamsulosin HCl
Tamsulosin HCl (Capsule) 1
Terazosin HCl
Terazosin HCl (Capsule) 1
Genitourinary Agents, OtherBethanechol Chloride
Bethanechol Chloride
(Tablet)1
Cuprimine
Cuprimine (Capsule) 1 ST Depen Titratabs
Depen Titratabs
(Tablet)1
Elmiron
Elmiron (Capsule) 1
Lithostat
Lithostat (Tablet) 1
Phosphate BindersCalcium Acetate
Calcium Acetate
(Capsule)1
Eliphos
Eliphos (Tablet) 1
Fosrenol
Fosrenol (1000mg
Packet, 750mg Packet,
1000mg Tablet
Chewable, 500mg
Tablet Chewable,
750mg Tablet
Chewable)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
PhosLo
PhosLo (Capsule) 1
Phoslyra
Phoslyra (Oral Solution) 1
Renagel
Renagel (Tablet) 1 ST Renvela
Renvela (0.8gm Packet,
2.4gm Packet, 800mg
Tablet)
1
Velphoro
Velphoro (Tablet
Chewable)1
Hormonal Agents, Stimulant/Replacement/
Modifying (Adrenal)
Hormonal Agents, Stimulant/
Replacement/Modifying (Adrenal)A-Hydrocort
A-Hydrocort (Injection) 1
Ala Cort
Ala Cort (Cream) 1
Alclometasone Dipropionate
Alclometasone
Dipropionate (0.05%
Cream, 0.05% Ointment)
1
Augmented Betamethasone Dipropionate
Augmented
Betamethasone
Dipropionate (0.05%
Cream)
1
Augmented Betamethasone Dipropionate
Augmented
Betamethasone
Dipropionate (0.05% Gel,
0.05% Lotion, 0.05%
Ointment)
1
Betamethasone Dipropionate
Betamethasone
Dipropionate (0.05%
Cream, 0.05% Lotion,
0.05% Ointment)
1
Betamethasone Valerate
Betamethasone Valerate
(0.1% Cream, 0.1%
Lotion, 0.1% Ointment)
1
43
Bold type = Brand name drug Plain type = Generic drug
43
54
43tRACK
54 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Clobetasol Propionate
Clobetasol Propionate
(0.05% External Solution,
0.05% Gel, 0.05%
Ointment)
1
Clobetasol Propionate
Clobetasol Propionate
(0.05% Shampoo)1
Clobetasol Propionate E
Clobetasol Propionate E
(Cream)1
Cordran Tape
Cordran Tape (Tape) 1
Cormax Scalp Application
Cormax Scalp Application
(External Solution)1
Cortisone Acetate
Cortisone Acetate (Tablet) 1
Depo-Medrol
Depo-Medrol (20mg/ml
Injection)1
Desonide
Desonide (0.05%
Ointment)1
Desoximetasone
Desoximetasone (0.05%
Cream, 0.25% Cream)1
Dexamethasone
Dexamethasone (0.5mg
Tablet, 0.75mg Tablet,
1.5mg Tablet, 1mg Tablet,
2mg Tablet, 4mg Tablet,
6mg Tablet, 0.5mg/5ml
Elixir)
1
Dexamethasone Intensol
Dexamethasone Intensol
(1mg/ml Concentrate)1
Dexamethasone Sodium Phosphate
Dexamethasone Sodium
Phosphate (10mg/ml
Injection, 120mg/30ml
Injection)
1
Fludrocortisone Acetate
Fludrocortisone Acetate
(Tablet)1
Fluocinolone Acetonide
Fluocinolone Acetonide
(0.01% Cream, 0.025%
Cream, 0.01% External
Solution, 0.025%
Ointment)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Fluocinolone Acetonide Body
Fluocinolone Acetonide
Body (Oil)1
Fluocinonide
Fluocinonide (0.05%
Cream, 0.05% External
Solution, 0.05% Gel,
0.05% Ointment)
1
Fluocinonide
Fluocinonide (0.1%
Cream)1
Fluocinonide-E
Fluocinonide-E (Cream) 1
Fluticasone Propionate
Fluticasone Propionate
(0.005% Ointment, 0.05%
Cream)
1
Halobetasol Propionate
Halobetasol Propionate
(0.05% Cream, 0.05%
Ointment)
1
Hydrocortisone
Hydrocortisone (1%
Cream, 2.5% Cream, 1%
Ointment, 2.5% Ointment)
1
Hydrocortisone
Hydrocortisone (Tablet,
2.5% Lotion)1
Hydrocortisone Butyrate
Hydrocortisone Butyrate
(0.1% Ointment)1
Hydrocortisone Valerate
Hydrocortisone Valerate
(0.2% Cream, 0.2%
Ointment)
1
Kenalog-10
Kenalog-10 (Injection) 1
Kenalog-40
Kenalog-40 (Injection) 1
Methylprednisolone
Methylprednisolone
(Tablet)1
Methylprednisolone Acetate
Methylprednisolone
Acetate (Injection)1
Methylprednisolone Dose Pack
Methylprednisolone Dose
Pack (Tablet Therapy
Pack)
1
Methylprednisolone Sodium Succinate
Methylprednisolone
Sodium Succinate
(Injection)
1
44
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
44
55
44tRACK
55Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Millipred
Millipred (5mg Tablet) 1
Mometasone Furoate
Mometasone Furoate
(0.1% Cream, 0.1%
External Solution, 0.1%
Ointment)
1
Prednicarbate
Prednicarbate (0.1%
Cream)1
Prednicarbate
Prednicarbate (0.1%
Ointment)1
Prednisolone Sodium Phosphate
Prednisolone Sodium
Phosphate (15mg/5ml
Oral Solution, 25mg/5ml
Oral Solution, 5mg/5ml
Oral Solution)
1
Prednisone
Prednisone (10mg Tablet
Therapy Pack, 5mg
Tablet Therapy Pack,
10mg Tablet, 1mg Tablet,
2.5mg Tablet, 20mg
Tablet, 50mg Tablet, 5mg
Tablet)
1
Prednisone
Prednisone (5mg/5ml
Oral Solution)1
Prednisone Intensol
Prednisone Intensol
(5mg/ml Concentrate)1
Solu-Cortef
Solu-Cortef (Injection) 1
Solu-Medrol
Solu-Medrol (2gm
Injection)1
Triamcinolone Acetonide
Triamcinolone Acetonide
(0.025% Cream, 0.1%
Cream, 0.5% Cream,
0.025% Ointment, 0.1%
Ointment, 0.5% Ointment)
1
Triamcinolone Acetonide
Triamcinolone Acetonide
(0.025% Lotion, 0.1%
Lotion)
1
Triderm
Triderm (Cream) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Hormonal Agents, Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents, Stimulant/
Replacement/Modifying (Pituitary)Chorionic Gonadotropin
Chorionic Gonadotropin
(Injection)1 PA
Desmopressin Acetate
Desmopressin Acetate
(0.01% Nasal Rhinal
Tube Solution)
1
Desmopressin Acetate
Desmopressin Acetate
(0.01% Nasal Spray
Solution, 0.1mg Tablet,
0.2mg Tablet)
1
Desmopressin Acetate
Desmopressin Acetate
(4mcg/ml Injection)1
Genotropin
Genotropin (12mg
Injection, 5mg Injection)1 PA
Genotropin Miniquick
Genotropin Miniquick
(0.2mg Injection)1 PA
Genotropin Miniquick
Genotropin Miniquick
(0.4mg Injection, 0.6mg
Injection, 0.8mg
Injection, 1.2mg
Injection, 1.4mg
Injection, 1.6mg
Injection, 1.8mg
Injection, 1mg Injection,
2mg Injection)
1 PA
Humatrope
Humatrope (Injection) 1 PA Humatrope Combo Pack
Humatrope Combo
Pack (Injection)1 PA
Increlex
Increlex (Injection) 1 PA Norditropin FlexPro
Norditropin FlexPro
(Injection)1 PA
Novarel
Novarel (Injection) 1 PA Nutropin AQ
Nutropin AQ (Injection) 1 PA
45
Bold type = Brand name drug Plain type = Generic drug
45
56
45tRACK
56 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Omnitrope
Omnitrope (Injection) 1 PA Pregnyl w/Diluent Benzyl Alcohol/NaCl
Pregnyl w/Diluent
Benzyl Alcohol/NaCl
(Injection)
1 PA
Saizen
Saizen (Injection) 1 PA Zomacton
Zomacton (Injection) 1 PA
Hormonal Agents, Stimulant/Replacement/
Modifying (Prostaglandins)
Hormonal Agents, Stimulant/
Replacement/Modifying (Prostaglandins)Korlym
Korlym (Tablet) 1 PA, QL
Hormonal Agents, Stimulant/Replacement/
Modifying (Sex Hormones/Modifiers)
AndrogensAnadrol-50
Anadrol-50 (Tablet) 1 PA Androderm
Androderm (Patch 24
Hour)1 PA, QL
AndroGel
AndroGel (1.62%
Packet)1 PA
AndroGel Pump
AndroGel Pump (1.62%
Gel)1 PA
Danazol
Danazol (Capsule) 1
Oxandrolone
Oxandrolone (10mg
Tablet)1 PA, QL
Oxandrolone
Oxandrolone (2.5mg
Tablet)1 PA, QL
Testosterone Cypionate
Testosterone Cypionate
(Injection)1
Testosterone Enanthate
Testosterone Enanthate
(Injection)1
EstrogensAlora
Alora (Patch Twice
Weekly)1
Amethia
Amethia (Tablet) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Amethyst
Amethyst (Tablet) 1
Apri
Apri (Tablet) 1
Aranelle
Aranelle (Tablet) 1
Ashlyna
Ashlyna (Tablet) 1
Aubra
Aubra (Tablet) 1
Aviane
Aviane (Tablet) 1
Balziva
Balziva (Tablet) 1
Bekyree
Bekyree (Tablet) 1
Blisovi 24 Fe
Blisovi 24 Fe (Tablet) 1
Blisovi Fe 1.5/30
Blisovi Fe 1.5/30 (Tablet) 1
Blisovi Fe 1/20
Blisovi Fe 1/20 (Tablet) 1
Briellyn
Briellyn (Tablet) 1
Caziant
Caziant (Tablet) 1
Climara Pro
Climara Pro (Patch
Weekly)1
Cryselle-28
Cryselle-28 (Tablet) 1
Cyclafem
Cyclafem (Tablet) 1
Delyla
Delyla (Tablet) 1
Depo-Estradiol
Depo-Estradiol (Injection) 1
Desogestrel/Ethinyl Estradiol
Desogestrel/Ethinyl
Estradiol (Tablet)1
Drospirenone/Ethinyl Estradiol
Drospirenone/Ethinyl
Estradiol (Tablet)1
Duavee
Duavee (Tablet) 1
Elestrin
Elestrin (Gel) 1
Emoquette
Emoquette (Tablet) 1
Enpresse-28
Enpresse-28 (Tablet) 1
Estrace
Estrace (0.1mg/gm
Cream)1
46
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
46
57
46tRACK
57Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Estradiol
Estradiol (0.025mg/24hr
Patch Weekly, 0.05mg/
24hr Patch Weekly,
0.06mg/24hr Patch
Weekly, 0.075mg/24hr
Patch Weekly, 0.1mg/
24hr Patch Weekly,
37.5mcg/24hr Patch
Weekly, 0.5mg Tablet,
1mg Tablet, 2mg Tablet)
1
Estradiol Valerate
Estradiol Valerate
(Injection)1
Estring
Estring (Ring) 1
Falmina
Falmina (Tablet) 1
Femring
Femring (Ring) 1
Gianvi
Gianvi (Tablet) 1
Gildagia
Gildagia (Tablet) 1
Gildess 1.5/30
Gildess 1.5/30 (Tablet) 1
Gildess 24 Fe
Gildess 24 Fe (Tablet) 1
Introvale
Introvale (Tablet) 1
Jinteli
Jinteli (Tablet) 1
Juleber
Juleber (Tablet) 1
Junel 1.5/30
Junel 1.5/30 (Tablet) 1
Junel 1/20
Junel 1/20 (Tablet) 1
Junel Fe 1.5/30
Junel Fe 1.5/30 (Tablet) 1
Junel Fe 1/20
Junel Fe 1/20 (Tablet) 1
Junel Fe 24
Junel Fe 24 (Tablet) 1
Kaitlib Fe
Kaitlib Fe (Tablet
Chewable)1
Kariva
Kariva (Tablet) 1
Kelnor 1/35
Kelnor 1/35 (Tablet) 1
Kimidess
Kimidess (Tablet) 1
LARIN 1.5/30
LARIN 1.5/30 (Tablet) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
LARIN 1/20
LARIN 1/20 (Tablet) 1
LARIN Fe 1.5/30
LARIN Fe 1.5/30 (Tablet) 1
LARIN Fe 1/20
LARIN Fe 1/20 (Tablet) 1
Larissia
Larissia (Tablet) 1
Layolis Fe
Layolis Fe (Tablet
Chewable)1
Lessina
Lessina (Tablet) 1
Levonest
Levonest (Tablet) 1
Levonorgestrel and Ethinyl Estradiol
Levonorgestrel and
Ethinyl Estradiol (Tablet)1
Levonorgestrel/Ethinyl Estradiol
Levonorgestrel/Ethinyl
Estradiol (Tablet)1
Levora 0.15/30-28
Levora 0.15/30-28
(Tablet)1
Lomedia 24 Fe
Lomedia 24 Fe (Tablet) 1
Loryna
Loryna (Tablet) 1
Low-Ogestrel
Low-Ogestrel (Tablet) 1
Lutera
Lutera (Tablet) 1
Marlissa
Marlissa (Tablet) 1
Menest
Menest (Tablet) 1
Microgestin 1.5/30
Microgestin 1.5/30
(Tablet)1
Microgestin 1/20
Microgestin 1/20 (Tablet) 1
Microgestin Fe
Microgestin Fe (Tablet) 1
Microgestin Fe 1.5/30
Microgestin Fe 1.5/30
(Tablet)1
MonoNessa
MonoNessa (Tablet) 1
Necon 0.5/35-28
Necon 0.5/35-28 (Tablet) 1
Necon 1/35
Necon 1/35 (Tablet) 1
Necon 1/50-28
Necon 1/50-28 (Tablet) 1
Necon 10/11-28
Necon 10/11-28 (Tablet) 1
Necon 7/7/7
Necon 7/7/7 (Tablet) 1
47
Bold type = Brand name drug Plain type = Generic drug
47
58
47tRACK
58 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Nikki
Nikki (Tablet) 1
Norethindrone & Ethinyl Estradiol Ferrous Fumarate
Norethindrone & Ethinyl
Estradiol Ferrous
Fumarate (Tablet
Chewable)
1
Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate
Norethindrone Acetate/
Ethinyl Estradiol/Ferrous
Fumarate (Tablet)
1
Norgestimate/Ethinyl Estradiol
Norgestimate/Ethinyl
Estradiol (Tablet)1
Nortrel 0.5/35
Nortrel 0.5/35 (28)
(Tablet)1
Nortrel 1/35
Nortrel 1/35 (Tablet) 1
Nortrel 7/7/7
Nortrel 7/7/7 (Tablet) 1
NuvaRing
NuvaRing (Ring) 1
Ocella
Ocella (Tablet) 1
Ogestrel
Ogestrel (Tablet) 1
Orsythia
Orsythia (Tablet) 1
Pimtrea
Pimtrea (Tablet) 1
Pirmella 1/35
Pirmella 1/35 (Tablet) 1
Portia-28
Portia-28 (Tablet) 1
Premarin
Premarin (0.3mg
Tablet, 0.45mg Tablet,
0.625mg Tablet, 0.9mg
Tablet, 1.25mg Tablet)
1
Premarin
Premarin (Vaginal
Cream)1
Premphase
Premphase (Tablet) 1
Prempro
Prempro (Tablet) 1
Previfem
Previfem (Tablet) 1
Quasense
Quasense (Tablet) 1
Reclipsen
Reclipsen (Tablet) 1
Setlakin
Setlakin (Tablet) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Sprintec 28
Sprintec 28 (Tablet) 1
Sronyx
Sronyx (Tablet) 1
Tarina Fe 1/20
Tarina Fe 1/20 (Tablet) 1
Tri-Legest Fe
Tri-Legest Fe (Tablet) 1
Tri-Lo-Estarylla
Tri-Lo-Estarylla (Tablet) 1
Tri-Lo-Sprintec
Tri-Lo-Sprintec (Tablet) 1
Trinessa
Trinessa (Tablet) 1
Tri-Previfem
Tri-Previfem (Tablet) 1
Tri-Sprintec
Tri-Sprintec (Tablet) 1
Trivora-28
Trivora-28 (Tablet) 1
Vagifem
Vagifem (Tablet) 1 QL Velivet
Velivet (Tablet) 1
Vestura
Vestura (Tablet) 1
Vienva
Vienva (Tablet) 1
Vyfemla
Vyfemla (Tablet) 1
WYMZYA Fe
WYMZYA Fe (Tablet
Chewable)1
Xulane
Xulane (Patch Weekly) 1
Zenchent
Zenchent (Tablet) 1
Zenchent Fe
Zenchent Fe (Tablet
Chewable)1
Zovia 1/35E
Zovia 1/35E (Tablet) 1
Zovia 1/50E
Zovia 1/50E (Tablet) 1
ProgestinsCamila
Camila (Tablet) 1
Crinone
Crinone (Gel) 1
Deblitane
Deblitane (Tablet) 1
Depo-Provera
Depo-Provera
(Injection)1
Errin
Errin (Tablet) 1
48
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
48
59
48tRACK
59Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Hydroxyprogesterone Caproate
Hydroxyprogesterone
Caproate (Injection)1 PA
Jolivette
Jolivette (Tablet) 1
Lyza
Lyza (Tablet) 1
Makena
Makena (Injection) 1 PA Medroxyprogesterone Acetate
Medroxyprogesterone
Acetate (10mg Tablet,
2.5mg Tablet, 5mg
Tablet)
1
Medroxyprogesterone Acetate
Medroxyprogesterone
Acetate (150mg/ml
Injection)
1
Megace ES
Megace ES
(Suspension)1
Megestrol Acetate
Megestrol Acetate (20mg
Tablet, 40mg Tablet,
40mg/ml Suspension)
1
Megestrol Acetate
Megestrol Acetate
(625mg/5ml Suspension)1
Nora-BE
Nora-BE (Tablet) 1
Norethindrone
Norethindrone (Tablet) 1
Norethindrone Acetate
Norethindrone Acetate
(Tablet)1
Norlyroc
Norlyroc (Tablet) 1
Progesterone
Progesterone (Capsule) 1
Sharobel
Sharobel (Tablet) 1
Selective Estrogen Receptor Modifying
AgentsRaloxifene HCl
Raloxifene HCl (Tablet) 1 QL
Hormonal Agents, Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents, Stimulant/
Replacement/Modifying (Thyroid)
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Levothyroxine Sodium
Levothyroxine Sodium
(100mcg Injection)1
Levothyroxine Sodium
Levothyroxine Sodium
(100mcg Tablet, 112mcg
Tablet, 125mcg Tablet,
137mcg Tablet, 150mcg
Tablet, 175mcg Tablet,
200mcg Tablet, 25mcg
Tablet, 300mcg Tablet,
50mcg Tablet, 75mcg
Tablet, 88mcg Tablet)
1
Levoxyl
Levoxyl (Tablet) 1
Liothyronine Sodium
Liothyronine Sodium
(10mcg/ml Injection)1
Liothyronine Sodium
Liothyronine Sodium
(25mcg Tablet, 50mcg
Tablet, 5mcg Tablet)
1
Synthroid
Synthroid (Tablet) 1
Thyrolar
Thyrolar (Tablet) 1
Unithroid
Unithroid (Tablet) 1
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)Lysodren
Lysodren (Tablet) 1
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant
(Parathyroid)Sensipar
Sensipar (30mg Tablet) 1 QL Sensipar
Sensipar (60mg Tablet,
90mg Tablet)1 QL
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)Cabergoline
Cabergoline (Tablet) 1
Egrifta
Egrifta (Injection) 1 PA Firmagon
Firmagon (120mg
Injection)1 PA
49
Bold type = Brand name drug Plain type = Generic drug
49
60
49tRACK
60 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Firmagon
Firmagon (80mg
Injection)1 PA
Leuprolide Acetate
Leuprolide Acetate
(Injection)1 PA
Lupaneta Pack
Lupaneta Pack (Kit) 1 PA Lupron Depot
Lupron Depot
(Injection)1 PA
Lupron Depot-PED
Lupron Depot-PED
(Injection)1 PA
Octreotide Acetate
Octreotide Acetate
(1000mcg/ml Injection,
500mcg/ml Injection)
1 PA
Octreotide Acetate
Octreotide Acetate
(100mcg/ml Injection,
200mcg/ml Injection,
50mcg/ml Injection)
1 PA
Sandostatin LAR Depot
Sandostatin LAR Depot
(Injection)1 PA
Signifor
Signifor (Injection) 1 PA Somatuline Depot
Somatuline Depot
(Injection)1 PA
Somavert
Somavert (Injection) 1 PA Synarel
Synarel (Nasal Solution) 1
Trelstar Mixject
Trelstar Mixject
(Injection)1 PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid AgentsMethimazole
Methimazole (Tablet) 1
Propylthiouracil
Propylthiouracil (Tablet) 1
Immunological Agents
Angioedema (HAE) Agents Berinert
Berinert (Injection) 1 PA, LA Cinryze
Cinryze (Injection) 1 PA, LA Firazyr
Firazyr (Injection) 1 PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ruconest
Ruconest (Injection) 1 PA
Immune SuppressantsAzathioprine
Azathioprine (100mg
Injection)1 B/D, PA
Azathioprine
Azathioprine (50mg
Tablet)1 B/D, PA
Cellcept
Cellcept (200mg/ml
Suspension, 250mg
Capsule, 500mg Tablet)
1 PA
Cellcept Intravenous
Cellcept Intravenous
(Injection)1 PA
Cimzia
Cimzia (Injection) 1 PA Cyclosporine
Cyclosporine (100mg
Capsule, 25mg Capsule)1 B/D, PA
Cyclosporine
Cyclosporine (50mg/ml
Injection)1
Cyclosporine Modified
Cyclosporine Modified
(100mg Capsule, 25mg
Capsule, 50mg Capsule,
100mg/ml Oral Solution)
1 B/D, PA
Enbrel
Enbrel (Injection) 1 PA Enbrel SureClick
Enbrel SureClick
(Injection)1 PA
Gengraf
Gengraf (100mg Capsule,
25mg Capsule, 100mg/
ml Oral Solution, 50mg
Capsule)
1 B/D, PA
Humira
Humira (Injection) 1 PA Humira Pediatric Crohns Disease Starter Pack
Humira Pediatric
Crohns Disease Starter
Pack (Injection)
1 PA
Humira Pen
Humira Pen (Injection) 1 PA Humira Pen Crohns Disease Starter Pack
Humira Pen Crohns
Disease Starter Pack
(Injection)
1 PA
50
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
50
61
50tRACK
61Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Humira Pen-Psoriasis Starter
Humira Pen-Psoriasis
Starter (Injection)1 PA
Kineret
Kineret (Injection) 1 PA Methotrexate
Methotrexate (Tablet) 1
Methotrexate Sodium
Methotrexate Sodium
(Injection)1
Mycophenolate Mofetil
Mycophenolate Mofetil
(200mg/ml Suspension)1 PA
Mycophenolate Mofetil
Mycophenolate Mofetil
(250mg Capsule, 500mg
Tablet)
1 PA
Mycophenolic Acid DR
Mycophenolic Acid DR
(Tablet Delayed-Release)1 B/D, PA
Nulojix
Nulojix (Injection) 1 PA Orencia
Orencia (125mg/ml
Injection, 250mg
Injection)
1 PA
Orencia Clickject
Orencia Clickject
(Solution Auto injector)1 PA
Prograf
Prograf (5mg/ml
Injection)1 PA
Rapamune
Rapamune (1mg Tablet,
2mg Tablet, 1mg/ml
Oral Solution)
1 B/D, PA
Remicade
Remicade (Injection) 1 PA Sandimmune
Sandimmune (100mg
Capsule)1 B/D, PA
Sandimmune
Sandimmune (100mg/
ml Oral Solution)1 B/D, PA
Simponi
Simponi (Injection) 1 PA Simponi Aria
Simponi Aria (Injection) 1 PA Sirolimus
Sirolimus (0.5mg Tablet) 1 B/D, PA Sirolimus
Sirolimus (1mg Tablet,
2mg Tablet)1 B/D, PA
Stelara
Stelara (Injection) 1 PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Tacrolimus
Tacrolimus (0.5mg
Capsule, 1mg Capsule,
5mg Capsule)
1 PA
Torisel
Torisel (Injection) 1
Trexall
Trexall (Tablet) 1
Xeljanz
Xeljanz (Tablet) 1 PA, QL Xeljanz XR
Xeljanz XR (Tablet
Extended-Release 24
Hour)
1 PA, QL
Zinbryta
Zinbryta (Solution
Prefilled Syringe)1 PA
Zortress
Zortress (Tablet) 1 PA
Immunizing Agents, PassiveAtgam
Atgam (Injection) 1
BIVIGAM
BIVIGAM (Injection) 1 PA Carimune Nanofiltered
Carimune Nanofiltered
(Injection)1 PA
Flebogamma DIF
Flebogamma DIF
(Injection)1 PA
Gamastan S/D
Gamastan S/D
(Injection)1 PA
Gammagard Liquid
Gammagard Liquid
(Injection)1 PA
Gammaked
Gammaked (Injection) 1 PA Gammaplex
Gammaplex (Injection) 1 PA Gamunex-C
Gamunex-C (Injection) 1 PA Octagam
Octagam (Injection) 1 PA Privigen
Privigen (Injection) 1 PA Thymoglobulin
Thymoglobulin
(Injection)1
Varizig
Varizig (Injection) 1
Immunomodulators
51
Bold type = Brand name drug Plain type = Generic drug
51
62
51tRACK
62 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Actemra
Actemra (162mg/0.9ml
Injection, 200mg/10ml
Injection, 400mg/20ml
Injection, 80mg/4ml
Injection)
1 PA
Actimmune
Actimmune (Injection) 1
Arcalyst
Arcalyst (Injection) 1 PA, LA Benlysta
Benlysta (Injection) 1 PA Ilaris
Ilaris (Injection) 1 PA, LA Leflunomide
Leflunomide (Tablet) 1
Otezla
Otezla (Tablet Therapy
Pack, 30mg Tablet)1 PA
Ridaura
Ridaura (Capsule) 1
Simulect
Simulect (Injection) 1
Synagis
Synagis (Injection) 1 PA
VaccinesActHIB
ActHIB (Injection) 1
Adacel
Adacel (Injection) 1
BCG Vaccine
BCG Vaccine (Injection) 1
Bexsero
Bexsero (Injection) 1
Boostrix
Boostrix (Injection) 1
Cervarix
Cervarix (Injection) 1
Daptacel
Daptacel (Injection) 1
Diphtheria/Tetanus Toxoids Adsorbed Pediatric
Diphtheria/Tetanus
Toxoids Adsorbed
Pediatric (Injection)
1
Engerix-B
Engerix-B (Injection) 1 B/D, PA Gardasil
Gardasil (Injection) 1
Gardasil 9
Gardasil 9 (Injection) 1
Havrix
Havrix (Injection) 1
Hiberix
Hiberix (Injection) 1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Imovax Rabies
Imovax Rabies
(H.D.C.V.) (Injection)1 B/D, PA
Infanrix
Infanrix (Injection) 1
IPOL Inactivated IPV
IPOL Inactivated IPV
(Injection)1
Ixiaro
Ixiaro (Injection) 1
Menactra
Menactra (Injection) 1
MENHIBRIX
MENHIBRIX (Injection) 1
Menomune-A/C/Y/W-135
Menomune-A/C/Y/
W-135 (Injection)1
Menveo
Menveo (Injection) 1
M-M-R II
M-M-R II (Injection) 1
Pedvax HIB
Pedvax HIB (Injection) 1
ProQuad
ProQuad (Injection) 1
Quadracel
Quadracel (Injection) 1
Rabavert
Rabavert (Injection) 1 B/D, PA Recombivax HB
Recombivax HB
(Injection)1 B/D, PA
Rotarix
Rotarix (Suspension) 1
RotaTeq
RotaTeq (Oral Solution) 1
Tenivac
Tenivac (Injection) 1
Tetanus/Diphtheria Toxoids-Adsorbed Adult
Tetanus/Diphtheria
Toxoids-Adsorbed Adult
(Injection)
1
Trumenba
Trumenba (Injection) 1
Twinrix
Twinrix (Injection) 1
Typhim Vi
Typhim Vi (Injection) 1
VAQTA
VAQTA (Injection) 1
Varivax
Varivax (Injection) 1
YF-Vax
YF-Vax (Injection) 1
Zostavax
Zostavax (Injection) 1 PA
Inflammatory Bowel Disease Agents
52
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
52
63
52tRACK
63Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
AminosalicylatesApriso
Apriso (Capsule
Extended-Release 24
Hour)
1 QL
Balsalazide Disodium
Balsalazide Disodium
(Capsule)1
Canasa
Canasa (Suppository) 1
Dipentum
Dipentum (Capsule) 1
Giazo
Giazo (Tablet) 1
Lialda
Lialda (Tablet Delayed-
Release)1 QL
Mesalamine
Mesalamine (Kit) 1
Pentasa
Pentasa (Capsule
Extended-Release)1 QL
sfRowasa
sfRowasa (Enema) 1 QL
GlucocorticoidsBudesonide
Budesonide (3mg
Capsule Delayed-Release)1
Colocort
Colocort (Enema) 1
Entocort EC
Entocort EC (Capsule
Delayed-Release)1
Hydrocortisone
Hydrocortisone
(100mg/60ml Enema)1
Procto-Med HC
Procto-Med HC (Cream) 1
Procto-Pak
Procto-Pak (Cream) 1
Proctosol HC
Proctosol HC (Cream) 1
Proctozone-HC
Proctozone-HC (Cream) 1
Uceris
Uceris (9mg Tablet
Extended-Release 24
Hour)
1 ST
Sulfonamides
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Sulfasalazine
Sulfasalazine (500mg
Tablet Delayed-Release,
500mg Tablet Immediate-
Release)
1
Metabolic Bone Disease Agents
Metabolic Bone Disease AgentsActonel
Actonel (150mg Tablet) 1 QL Alendronate Sodium
Alendronate Sodium
(10mg Tablet, 35mg
Tablet, 40mg Tablet, 5mg
Tablet, 70mg Tablet)
1 QL
Alendronate Sodium
Alendronate Sodium
(70mg/75ml Oral
Solution)
1
Binosto
Binosto (Tablet
Effervescent)1 QL
Boniva
Boniva (3mg/3ml
Injection)1 B/D, PA
Calcitonin-Salmon
Calcitonin-Salmon (Nasal
Solution)1
Calcitriol
Calcitriol (0.25mcg
Capsule, 0.5mcg
Capsule, 1mcg/ml Oral
Solution)
1 B/D, PA
Calcitriol
Calcitriol (1mcg/ml
Injection)1 B/D, PA
Doxercalciferol
Doxercalciferol (0.5mcg
Capsule, 1mcg Capsule,
2.5mcg Capsule)
1 B/D, PA, QL
Doxercalciferol
Doxercalciferol (4mcg/
2ml Injection)1 B/D, PA
Etidronate Disodium
Etidronate Disodium
(Tablet)1
Forteo
Forteo (Injection) 1 PA, QL Hectorol
Hectorol (1mcg
Capsule, 2.5mcg
Capsule)
1 B/D, PA, QL
53
Bold type = Brand name drug Plain type = Generic drug
53
64
53tRACK
64 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ibandronate Sodium
Ibandronate Sodium
(150mg Tablet)1 QL
Ibandronate Sodium
Ibandronate Sodium
(3mg/3ml Injection)1 B/D, PA
Miacalcin
Miacalcin (200unit/ml
Injection)1 PA
Natpara
Natpara (Injection) 1 PA Pamidronate Disodium
Pamidronate Disodium
(Injection)1 B/D, PA
Paricalcitol
Paricalcitol (1mcg
Capsule, 2mcg Capsule)1 B/D, PA, QL
Paricalcitol
Paricalcitol (2mcg/ml
Injection, 5mcg/ml
Injection)
1 B/D, PA
Paricalcitol
Paricalcitol (4mcg
Capsule)1 B/D, PA
Prolia
Prolia (Injection) 1 PA Risedronate Sodium
Risedronate Sodium
(Tablet)1 QL
Xgeva
Xgeva (Injection) 1 PA Zemplar
Zemplar (2mcg/ml
Injection, 5mcg/ml
Injection)
1 B/D, PA
Zoledronic Acid
Zoledronic Acid (4mg/
5ml Injection)1 B/D, PA
Zoledronic Acid
Zoledronic Acid (5mg/
100ml Injection)1 PA
Zometa
Zometa (Injection) 1 B/D, PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic AgentsAlcohol Prep Pads
Alcohol Prep Pads 1
Botox
Botox (Injection) 1 PA, QL Fomepizole
Fomepizole (Injection) 1
Gauze
Gauze (Non-medicated
2X2)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Insulin Syringes, Needles
Insulin Syringes, Needles 1
Kanuma
Kanuma (Injection) 1 PA Methylergonovine Maleate
Methylergonovine
Maleate (Tablet)1
Myalept
Myalept (Injection) 1 PA Sterile Water Irrigation
Sterile Water Irrigation
(Solution)1
Ophthalmic Agents
Ophthalmic Agents, OtherBacitracin/Polymyxin B
Bacitracin/Polymyxin B
(Ophthalmic Ointment)1
Blephamide
Blephamide
(Suspension)1
Blephamide S.O.P.
Blephamide S.O.P.
(Ointment)1
Cystaran
Cystaran (Ophthalmic
Solution)1
Lacrisert
Lacrisert (Insert) 1
Lastacaft
Lastacaft (Ophthalmic
Solution)1
Neomycin/Bacitracin/Polymyxin
Neomycin/Bacitracin/
Polymyxin (Ointment)1
Neomycin/Polymyxin/Bacitracin/Hydrocortisone
Neomycin/Polymyxin/
Bacitracin/Hydrocortisone
(Ophthalmic Ointment)
1
Neomycin/Polymyxin/Dexamethasone
Neomycin/Polymyxin/
Dexamethasone (0.1%
Ophthalmic Ointment,
0.1% Ophthalmic
Suspension)
1
Neomycin/Polymyxin/Gramicidin
Neomycin/Polymyxin/
Gramicidin (Ophthalmic
Solution)
1
Neomycin/Polymyxin/Hydrocortisone
Neomycin/Polymyxin/
Hydrocortisone (1%
Ophthalmic Suspension)
1
54
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
54
65
54tRACK
65Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Polymyxin B Sulfate/Trimethoprim Sulfate
Polymyxin B Sulfate/
Trimethoprim Sulfate
(Ophthalmic Solution)
1
Pred-G
Pred-G (Suspension) 1
Pred-G S.O.P.
Pred-G S.O.P.
(Ointment)1
Proparacaine HCl
Proparacaine HCl
(Ophthalmic Solution)1
Restasis
Restasis (Emulsion) 1
Sulfacetamide Sodium/Prednisolone Sodium Phosphate
Sulfacetamide Sodium/
Prednisolone Sodium
Phosphate (Ophthalmic
Solution)
1
Tobradex ST
Tobradex ST
(Ophthalmic
Suspension)
1
Tobramycin/Dexamethasone
Tobramycin/
Dexamethasone
(Ophthalmic Suspension)
1
Ophthalmic Anti-allergy AgentsAlocril
Alocril (Ophthalmic
Solution)1
Alomide
Alomide (Ophthalmic
Solution)1
Azelastine HCl
Azelastine HCl (0.05%
Ophthalmic Solution)1
Bepreve
Bepreve (Ophthalmic
Solution)1
Cromolyn Sodium
Cromolyn Sodium (4%
Ophthalmic Solution)1
Epinastine HCl
Epinastine HCl
(Ophthalmic Solution)1
Olopatadine HCl
Olopatadine HCl
(Ophthalmic Solution)1
Pataday
Pataday (Ophthalmic
Solution)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Patanol
Patanol (Ophthalmic
Solution)1
Pazeo
Pazeo (Ophthalmic
Solution)1
Ophthalmic Antiglaucoma AgentsAlphagan P
Alphagan P (0.1%
Ophthalmic Solution)1
Apraclonidine
Apraclonidine
(Ophthalmic Solution)1
Azopt
Azopt (Suspension) 1
Betaxolol HCl
Betaxolol HCl (0.5%
Ophthalmic Solution)1
Betimol
Betimol (Ophthalmic
Solution)1
Brimonidine Tartrate
Brimonidine Tartrate
(0.15% Ophthalmic
Solution)
1
Brimonidine Tartrate
Brimonidine Tartrate
(0.2% Ophthalmic
Solution)
1
Carteolol HCl
Carteolol HCl (Ophthalmic
Solution)1
Combigan
Combigan (Ophthalmic
Solution)1
Dorzolamide HCl
Dorzolamide HCl
(Ophthalmic Solution)1
Dorzolamide HCl/Timolol Maleate
Dorzolamide HCl/Timolol
Maleate (Ophthalmic
Solution)
1
Levobunolol HCl
Levobunolol HCl
(Ophthalmic Solution)1
Methazolamide
Methazolamide (Tablet) 1
Metipranolol
Metipranolol (Ophthalmic
Solution)1
Phospholine Iodide
Phospholine Iodide
(Ophthalmic Solution)1
55
Bold type = Brand name drug Plain type = Generic drug
55
66
55tRACK
66 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Pilocarpine HCl
Pilocarpine HCl (1%
Ophthalmic Solution,
2% Ophthalmic
Solution, 4%
Ophthalmic Solution)
1
Simbrinza
Simbrinza (Suspension) 1
Timolol Maleate
Timolol Maleate (0.25%
Ophthalmic Solution,
0.5% Ophthalmic
Solution)
1
Timolol Maleate Ophthalmic Gel Forming
Timolol Maleate
Ophthalmic Gel
Forming (Solution)
1
Ophthalmic Anti-inflammatoriesDexamethasone Sodium Phosphate
Dexamethasone Sodium
Phosphate (0.1%
Ophthalmic Solution)
1
Diclofenac Sodium
Diclofenac Sodium (0.1%
Ophthalmic Solution)1
Durezol
Durezol (Emulsion) 1
Flarex
Flarex (Suspension) 1
Fluorometholone
Fluorometholone
(Ophthalmic
Suspension)
1
Flurbiprofen Sodium
Flurbiprofen Sodium
(Ophthalmic Solution)1
FML
FML (Ointment) 1
FML Forte
FML Forte (Suspension) 1
Ilevro
Ilevro (Suspension) 1
Ketorolac Tromethamine
Ketorolac Tromethamine
(0.4% Ophthalmic
Solution, 0.5%
Ophthalmic Solution)
1
Lotemax
Lotemax (0.5% Gel,
0.5% Ointment, 0.5%
Suspension)
1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Nevanac
Nevanac (Suspension) 1
Pred Mild
Pred Mild (Suspension) 1
Prednisolone Acetate
Prednisolone Acetate
(Ophthalmic
Suspension)
1
Prednisolone Sodium Phosphate
Prednisolone Sodium
Phosphate (1%
Ophthalmic Solution)
1
Prolensa
Prolensa (Ophthalmic
Solution)1
Vexol
Vexol (Suspension) 1
Ophthalmic Prostaglandin and Prostamide
AnalogsLatanoprost
Latanoprost (Ophthalmic
Solution)1
Lumigan
Lumigan (Ophthalmic
Solution)1
Travatan Z
Travatan Z (Ophthalmic
Solution)1
Travoprost
Travoprost (Ophthalmic
Solution)1
Otic Agents
Otic AgentsAcetic Acid
Acetic Acid (Otic Solution) 1
Cipro HC
Cipro HC (Suspension) 1
Ciprodex
Ciprodex (Otic
Suspension)1
Coly-Mycin S
Coly-Mycin S
(Suspension)1
Fluocinolone Acetonide
Fluocinolone Acetonide
(0.01% Otic Oil)1
Hydrocortisone/Acetic Acid
Hydrocortisone/Acetic
Acid (Otic Solution)1
56
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
56
67
56tRACK
67Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Neomycin/Polymyxin/Hydrocortisone
Neomycin/Polymyxin/
Hydrocortisone (1% Otic
Solution, 1% Otic
Suspension)
1
Respiratory Tract/Pulmonary Agents
AntihistaminesAzelastine HCl
Azelastine HCl (0.1%
Nasal Solution)1 QL
Azelastine HCl
Azelastine HCl (0.15%
Nasal Solution)1
Cetirizine HCl
Cetirizine HCl (Syrup) 1
Cyproheptadine HCl
Cyproheptadine HCl
(4mg Tablet)1
Diphenhydramine HCl
Diphenhydramine HCl
(50mg/ml Injection)1 B/D, PA
Levocetirizine Dihydrochloride
Levocetirizine
Dihydrochloride (5mg
Tablet)
1 QL
Phenadoz
Phenadoz (Suppository) 1
Phenergan
Phenergan (12.5mg
Suppository, 25mg
Suppository)
1
Promethazine HCl
Promethazine HCl
(12.5mg Suppository,
25mg Suppository,
25mg/ml Injection,
50mg/ml Injection)
1
Promethazine HCl
Promethazine HCl
(12.5mg Tablet, 25mg
Tablet, 50mg Tablet,
6.25mg/5ml Syrup)
1
Promethegan
Promethegan (25mg
Suppository)1
Anti-inflammatories, Inhaled
CorticosteroidsArnuity Ellipta
Arnuity Ellipta (Aerosol
Powder)1 QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Budesonide
Budesonide (0.25mg/2ml
Suspension, 0.5mg/2ml
Suspension, 1mg/2ml
Suspension)
1 B/D, PA
Flovent Diskus
Flovent Diskus (Aerosol
Powder)1 QL
Flovent HFA
Flovent HFA (Aerosol) 1
Flunisolide
Flunisolide (Nasal
Solution)1
Fluticasone Propionate
Fluticasone Propionate
(50mcg/ACT
Suspension)
1
Mometasone Furoate
Mometasone Furoate
(50mcg/ACT
Suspension)
1
Nasonex
Nasonex (Suspension) 1
Pulmicort
Pulmicort (1mg/2ml
Suspension)1 B/D, PA
AntileukotrienesMontelukast Sodium
Montelukast Sodium
(10mg Tablet)1 QL
Montelukast Sodium
Montelukast Sodium
(4mg Packet, 4mg Tablet
Chewable, 5mg Tablet
Chewable)
1 QL
Zafirlukast
Zafirlukast (Tablet) 1 QL Zyflo
Zyflo (Tablet) 1 ST Zyflo CR
Zyflo CR (Tablet
Extended-Release 12
Hour)
1 ST
Bronchodilators, AnticholinergicAtrovent HFA
Atrovent HFA (Aerosol
Solution)1
Ipratropium Bromide
Ipratropium Bromide
(0.02% Inhalation
Solution)
1 B/D, PA
57
Bold type = Brand name drug Plain type = Generic drug
57
68
57tRACK
68 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ipratropium Bromide
Ipratropium Bromide
(0.03% Nasal Solution,
0.06% Nasal Solution)
1
Spiriva HandiHaler
Spiriva HandiHaler
(Capsule)1 QL
Spiriva Respimat
Spiriva Respimat
(Aerosol Solution)1 QL
Bronchodilators, SympathomimeticAlbuterol Sulfate
Albuterol Sulfate (0.083%
Nebulized Solution, 0.5%
Nebulized Solution,
0.63mg/3ml Nebulized
Solution, 1.25mg/3ml
Nebulized Solution)
1 B/D, PA
Albuterol Sulfate
Albuterol Sulfate (2mg
Tablet Immediate-
Release, 4mg Tablet
Immediate-Release)
1
Brovana
Brovana (Nebulized
Solution)1 B/D, PA
EpiPen
EpiPen (Injection) 1
Levalbuterol
Levalbuterol (Nebulized
Solution)1 B/D, PA
Metaproterenol Sulfate
Metaproterenol Sulfate
(10mg Tablet, 20mg
Tablet, 10mg/5ml Syrup)
1
Perforomist
Perforomist (Nebulized
Solution)1 B/D, PA, QL
ProAir HFA
ProAir HFA (Aerosol
Solution)1
ProAir RespiClick
ProAir RespiClick
(Aerosol Powder)1
Serevent Diskus
Serevent Diskus
(Aerosol Powder)1 QL
Terbutaline Sulfate
Terbutaline Sulfate (1mg/
ml Injection)1
Cystic Fibrosis Agents
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Cayston
Cayston (Inhalation
Solution)1 PA, LA
Kalydeco
Kalydeco (50mg
Packet, 75mg Packet)1 PA, QL
Orkambi
Orkambi (Tablet) 1 PA, QL, LA
Phosphodiesterase Inhibitors, Airways
DiseaseAminophylline
Aminophylline (Injection) 1
Daliresp
Daliresp (Tablet) 1 PA, QL Theophylline
Theophylline (Oral
Solution)1
Theophylline CR
Theophylline CR (Tablet
Extended-Release 12
Hour)
1
Theophylline ER
Theophylline ER (300mg
Tablet Extended-Release
12 Hour, 450mg Tablet
Extended-Release 12
Hour, 400mg Tablet
Extended-Release 24
Hour, 600mg Tablet
Extended-Release 24
Hour)
1
Pulmonary AntihypertensivesAdcirca
Adcirca (Tablet) 1 PA, QL Adempas
Adempas (Tablet) 1 PA Letairis
Letairis (Tablet) 1 PA, LA Opsumit
Opsumit (Tablet) 1 PA, LA Orenitram
Orenitram (0.125mg
Tablet Extended-
Release)
1 PA, QL
Orenitram
Orenitram (0.25mg
Tablet Extended-
Release, 1mg Tablet
Extended-Release)
1 PA, QL
58
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
58
69
58tRACK
69Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Orenitram
Orenitram (2.5mg
Tablet Extended-
Release)
1 PA
Remodulin
Remodulin (Injection) 1 PA, LA Revatio
Revatio (10mg/12.5ml
Injection)1 PA
Revatio
Revatio (20mg Tablet) 1 PA, QL Sildenafil
Sildenafil (10mg/12.5ml
Injection)1 PA
Sildenafil
Sildenafil (20mg Tablet)
(Generic Revatio)1 PA, QL
Tracleer
Tracleer (Tablet) 1 PA, QL Tyvaso
Tyvaso (Inhalation
Solution)1 PA
Ventavis
Ventavis (Inhalation
Solution)1 PA, LA
Respiratory Tract Agents, OtherAcetylcysteine
Acetylcysteine (Inhalation
Solution)1 B/D, PA
Advair Diskus
Advair Diskus (Aerosol
Powder)1 QL
Advair HFA
Advair HFA (Aerosol) 1
Anoro Ellipta
Anoro Ellipta (Aerosol
Powder)1 QL
Aralast NP
Aralast NP (Injection) 1 PA, LA Breo Ellipta
Breo Ellipta (Aerosol
Powder)1
Cromolyn Sodium
Cromolyn Sodium (20mg/
2ml Nebulized Solution)1 B/D, PA
Dulera
Dulera (Aerosol) 1 PA Esbriet
Esbriet (Capsule) 1 PA, QL, LA Glassia
Glassia (Injection) 1 PA, LA Kalydeco
Kalydeco (150mg
Tablet)1 PA, QL
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ofev
Ofev (Capsule) 1 PA, QL, LA Prolastin-C
Prolastin-C (Injection) 1 PA, LA Pulmozyme
Pulmozyme (Inhalation
Solution)1 B/D, PA
Stiolto Respimat
Stiolto Respimat
(Aerosol Solution)1 QL
Symbicort
Symbicort (Aerosol) 1
Tyzine Pediatric Nasal Drops
Tyzine Pediatric Nasal
Drops (Nasal Solution)1
Zemaira
Zemaira (Injection) 1 PA, LA
Respiratory Tract/Pulmonary AgentsCombivent Respimat
Combivent Respimat
(Aerosol Solution)1
Dymista
Dymista (Suspension) 1
Ipratropium Bromide/Albuterol Sulfate
Ipratropium Bromide/
Albuterol Sulfate
(Inhalation Solution)
1 B/D, PA
Xolair
Xolair (Injection) 1 PA
Skeletal Muscle Relaxants
Skeletal Muscle RelaxantsBaclofen
Baclofen (Tablet) 1
Cyclobenzaprine HCl
Cyclobenzaprine HCl
(7.5mg Tablet)1 PA, HRM
Dantrolene Sodium
Dantrolene Sodium
(Capsule)1
Gablofen
Gablofen (10000mcg/
20ml Injection, 50mcg/
ml Injection)
1 B/D, PA
Gablofen
Gablofen (40000mcg/
20ml Injection)1 B/D, PA
Lioresal Intrathecal
Lioresal Intrathecal
(0.05mg/ml Injection,
10mg/20ml Injection)
1 B/D, PA
Lioresal Intrathecal
Lioresal Intrathecal
(10mg/5ml Injection)1 B/D, PA
59
Bold type = Brand name drug Plain type = Generic drug
59
70
59tRACK
70 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Orphenadrine Citrate
Orphenadrine Citrate
(Injection)1
Tizanidine HCl
Tizanidine HCl (2mg
Tablet, 4mg Tablet)1
Sleep Disorder Agents
GABA Receptor ModulatorsTemazepam
Temazepam (Capsule) 1 QL Zaleplon
Zaleplon (Capsule) 1 QL, HRM Zolpidem Tartrate
Zolpidem Tartrate (10mg
Tablet Immediate-
Release, 5mg Tablet
Immediate-Release)
1 QL, HRM
Sleep Disorders, OtherBelsomra
Belsomra (Tablet) 1 QL Hetlioz
Hetlioz (Capsule) 1 PA, QL Modafinil
Modafinil (Tablet) 1 PA, QL Rozerem
Rozerem (Tablet) 1 QL Xyrem
Xyrem (Oral Solution) 1 PA, QL, LA
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral ModifiersChemet
Chemet (Capsule) 1
Exjade
Exjade (Tablet Soluble) 1 PA Ferriprox
Ferriprox (100mg/ml
Oral Solution, 500mg
Tablet)
1 PA
Jadenu
Jadenu (Tablet) 1 PA Kionex
Kionex (Powder) 1
Samsca
Samsca (Tablet) 1 PA, QL Sodium Polystyrene Sulfonate
Sodium Polystyrene
Sulfonate (Suspension)1
SPS
SPS (Suspension) 1
Syprine
Syprine (Capsule) 1 ST
Electrolyte/Mineral Replacement
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Ammonium Chloride
Ammonium Chloride
(Injection)1
Carbaglu
Carbaglu (Tablet) 1 LA Isolyte-S
Isolyte-S (Injection) 1
Klor-Con 10
Klor-Con 10 (Tablet
Extended-Release)1
Klor-Con 8
Klor-Con 8 (Tablet
Extended-Release)1
Klor-Con M15
Klor-Con M15 (Tablet
Extended-Release)1
Klor-Con M20
Klor-Con M20 (Tablet
Extended-Release)1
Klor-Con Sprinkle
Klor-Con Sprinkle
(Capsule Extended-
Release)
1
K-Tab
K-Tab (10meq Tablet
Extended-Release,
8meq Tablet Extended-
Release)
1
Magnesium Sulfate
Magnesium Sulfate
(1gm/2ml-50%
Injection)
1
Magnesium Sulfate
Magnesium Sulfate (5gm/
10ml-50% Injection)1
Normosol-R
Normosol-R (Injection) 1
Physiolyte
Physiolyte (Irrigation
Solution)1
Physiosol Irrigation
Physiosol Irrigation
(Solution)1
Plasma-Lyte A
Plasma-Lyte A
(Injection)1
Plasma-Lyte-148
Plasma-Lyte-148
(Injection)1
Potassium Chloride
Potassium Chloride
(10% Oral Solution,
20% Oral Solution)
1
60
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
60
71
60tRACK
71Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Potassium Chloride
Potassium Chloride
(10meq/100ml
Injection, 20meq/100ml
Injection, 40meq/100ml
Injection)
1 B/D, PA
Potassium Chloride
Potassium Chloride
(2meq/ml Injection)1 B/D, PA
Potassium Chloride 0.15% /NaCl 0.45% Viaflex
Potassium Chloride
0.15% /NaCl 0.45%
Viaflex (Injection)
1 B/D, PA
Potassium Chloride 0.15%/NaCl 0.9%
Potassium Chloride
0.15%/NaCl 0.9%
(Injection)
1 B/D, PA
Potassium Chloride 0.3%/ NaCl 0.9%
Potassium Chloride
0.3%/ NaCl 0.9%
(Injection)
1 B/D, PA
Potassium Chloride ER
Potassium Chloride ER
(10meq Capsule
Extended-Release, 8meq
Capsule Extended-
Release, 8meq Tablet
Extended-Release)
1
Potassium Chloride ER Microencapsulated
Potassium Chloride ER
Microencapsulated
(10meq Tablet Extended-
Release, 20meq Tablet
Extended-Release)
1
Potassium Citrate ER
Potassium Citrate ER
(Tablet Extended-Release)1
Sodium Chloride
Sodium Chloride (0.9%
Injection)1
Sodium Chloride
Sodium Chloride
(2.5meq/ml Injection,
3% Injection, 5%
Injection)
1
Sodium Chloride 0.45%
Sodium Chloride 0.45%
(Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Sodium Chloride 0.9%
Sodium Chloride 0.9%
(Irrigation Solution)1
Sodium Fluoride
Sodium Fluoride (Tablet) 1
Therapeutic Nutrients/Minerals/
ElectrolytesAminosyn 7%/Electrolytes
Aminosyn 7%/
Electrolytes (Injection)1 B/D, PA
Aminosyn 8.5%/Electrolytes
Aminosyn 8.5%/
Electrolytes (Injection)1 B/D, PA
Aminosyn II
Aminosyn II (Injection) 1 B/D, PA Aminosyn II 8.5%/Electrolytes
Aminosyn II 8.5%/
Electrolytes (Injection)1 B/D, PA
Aminosyn M
Aminosyn M (Injection) 1 B/D, PA Aminosyn-HBC
Aminosyn-HBC
(Injection)1 B/D, PA
Aminosyn-PF
Aminosyn-PF (Injection) 1 B/D, PA Aminosyn-RF
Aminosyn-RF (Injection) 1 B/D, PA Clinisol SF 15%
Clinisol SF 15% (Injection) 1 B/D, PA Dextrose 10%
Dextrose 10%
(Injection)1
Dextrose 10%/NaCl 0.2%
Dextrose 10%/NaCl
0.2% (Injection)1
Dextrose 10%/NaCl 0.45%
Dextrose 10%/NaCl
0.45% (Injection)1
Dextrose 2.5%/NaCl 0.45%
Dextrose 2.5%/NaCl
0.45% (Injection)1
Dextrose 5%
Dextrose 5% (Injection) 1
Dextrose 5%/Lactated Ringers
Dextrose 5%/Lactated
Ringers (Injection)1
Dextrose 5%/NaCl 0.2%
Dextrose 5%/NaCl 0.2%
(Injection)1
Dextrose 5%/NaCl 0.225%
Dextrose 5%/NaCl
0.225% (Injection)1
Dextrose 5%/NaCl 0.33%
Dextrose 5%/NaCl
0.33% (Injection)1
61
Bold type = Brand name drug Plain type = Generic drug
61
72
61tRACK
72 Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Dextrose 5%/NaCl 0.45%
Dextrose 5%/NaCl
0.45% (Injection)1
Dextrose 5%/NaCl 0.9%
Dextrose 5%/NaCl 0.9%
(Injection)1
Dextrose 5%/Potassium Chloride 0.15%
Dextrose 5%/Potassium
Chloride 0.15%
(Injection)
1 B/D, PA
FreAmine HBC 6.9%
FreAmine HBC 6.9%
(Injection)1 B/D, PA
HepatAmine
HepatAmine (Injection) 1 B/D, PA Intralipid
Intralipid (Injection) 1 B/D, PA Ionosol-B/Dextrose 5%
Ionosol-B/Dextrose 5%
(Injection)1
Ionosol-MB/Dextrose 5%
Ionosol-MB/Dextrose
5% (Injection)1
Isolyte-P/Dextrose 5%
Isolyte-P/Dextrose 5%
(Injection)1
KCl 0.075%/D5W/NaCl 0.45%
KCl 0.075%/D5W/NaCl
0.45% (Injection)1
KCl 0.15%/D5W/LR
KCl 0.15%/D5W/LR
(Injection)1
KCl 0.15%/D5W/NaCl 0.2%
KCl 0.15%/D5W/NaCl
0.2% (Injection)1
KCl 0.15%/D5W/NaCl 0.225%
KCl 0.15%/D5W/NaCl
0.225% (Injection)1
KCl 0.15%/D5W/NaCl 0.9%
KCl 0.15%/D5W/NaCl
0.9% (Injection)1
KCl 0.3%/D5W/NaCl 0.45%
KCl 0.3%/D5W/NaCl
0.45% (Injection)1
KCl 0.3%/D5W/NaCl 0.9%
KCl 0.3%/D5W/NaCl
0.9% (Injection)1
Lactated Ringers Irrigation
Lactated Ringers
Irrigation (Solution)1
Lactated Ringers Viaflex
Lactated Ringers
Viaflex (Injection)1
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Levocarnitine
Levocarnitine (1gm/10ml
Oral Solution, 330mg
Tablet)
1 B/D, PA
Levocarnitine
Levocarnitine (200mg/ml
Injection)1 B/D, PA
Nephramine
Nephramine (Injection) 1 B/D, PA Normosol-M in D5W
Normosol-M in D5W
(Injection)1
Normosol-R in D5W
Normosol-R in D5W
(Injection)1
NutreStore
NutreStore (Packet) 1
Nutrilipid
Nutrilipid (Injection) 1 B/D, PA Plasma-Lyte-56/D5W
Plasma-Lyte-56/D5W
(Injection)1
Plenamine
Plenamine (Injection) 1 B/D, PA Potassium Chloride 0.15% D5W/NaCl 0.33%
Potassium Chloride
0.15% D5W/NaCl
0.33% (Injection)
1
Potassium Chloride 0.15% D5W/NaCl 0.45%
Potassium Chloride
0.15% D5W/NaCl
0.45% (Injection)
1
Potassium Chloride 0.22% D5W/NaCl 0.45%
Potassium Chloride
0.22% D5W/NaCl
0.45% (Injection)
1
Potassium Chloride 0.3%/D5W
Potassium Chloride
0.3%/D5W (Injection)1 B/D, PA
Premasol
Premasol (Injection) 1 B/D, PA Procalamine
Procalamine (Injection) 1 B/D, PA Prosol
Prosol (Injection) 1 B/D, PA Ringers Injection
Ringers Injection
(Injection)1
Ringers Irrigation
Ringers Irrigation
(Solution)1
Sodium Lactate
Sodium Lactate
(Injection)1
62
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
62
73
62tRACK
73Last updated November 1, 2016
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
TPN Electrolytes
TPN Electrolytes
(Injection)1
Travasol
Travasol (Injection) 1 B/D, PA
Drug NameDrug
Tier
Required
Actions,
Restrictions
or Limits
Trophamine
Trophamine (Injection) 1 B/D, PA VP-PNV-DHA
VP-PNV-DHA (Capsule) 1
track
Bold type = Brand name drug Plain type = Generic drug
74
74
Drugs with a quantity limit (QL)
This list shows drugs that have a quantity limit. Your plan will cover only a certain amount of
these drugs or will only cover these drugs for a certain number of days. These limits may be in
place to ensure your safety.
Drugs are listed in alphabetical order in the chart below. Some drugs come in many strengths.
Each strength may have a different quantity limit. If quantity limits for a drug vary by strength,
the different strengths are listed on separate lines.
For more information about quantity limits, talk to your doctor or pharmacist. You can also
contact us. Our contact information, along with the date we last updated the drug list, appears on
the cover.
Drug Name Quantity Limit
Abacavir (Tablet) Maximum of 3 tablets per day
Abacavir Sulfate/Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day
Abstral (Tablet Sublingual) Maximum of 4 tablets per day
Acarbose (100mg Tablet) Maximum of 3 tablets per day
Acarbose (25mg Tablet) Maximum of 12 tablets per day
Acarbose (50mg Tablet) Maximum of 6 tablets per day
Acetaminophen/Codeine (120mg-12mg/5ml Oral
Solution)Maximum of 140 ml per day
Acetaminophen/Codeine (300mg-15mg Tablet,
300mg-30mg Tablet, 300mg-60mg Tablet)Maximum of 13 tablets per day
Actonel (150mg Tablet) Maximum of 1 tablet per 30 days
Acyclovir (5% Ointment) Maximum of 1 tube (30 grams) per 30 days
Adcirca (Tablet) Maximum of 2 tablets per day
Advair Diskus (Aerosol Powder) Maximum of 1 inhaler (60 blisters) per 30 days
Afeditab CR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day
Aggrenox (Capsule Extended-Release 12 Hour) Maximum of 2 capsules per day
Alecensa (Capsule) Maximum of 8 capsules per day
Alendronate Sodium (10mg Tablet, 40mg Tablet, 5mg
Tablet)Maximum of 1 tablet per day
Alendronate Sodium (35mg Tablet) Maximum of 8 tablets per 28 days
Alendronate Sodium (70mg Tablet) Maximum of 4 tablets per 28 days
Alprazolam (0.25mg Tablet Immediate-Release, 0.5mg
Tablet Immediate-Release, 1mg Tablet Immediate-
Release)
Maximum of 4 tablets per day
Alprazolam (2mg Tablet Immediate-Release) Maximum of 5 tablets per day
Amitiza (Capsule) Maximum of 2 capsules per day
Amlodipine Besylate/Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day
Amlodipine Besylate/Benazepril HCl (Capsule) Maximum of 1 capsule per day
Bold type = Brand name drug Plain type = Generic drug
75
75
Drug Name Quantity Limit
Amlodipine Besylate/Valsartan (Tablet) Maximum of 1 tablet per day
Amlodipine/Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Amphetamine/Dextroamphetamine (10mg Capsule
Extended-Release 24 Hour, 15mg Capsule Extended-
Release 24 Hour, 20mg Capsule Extended-Release
24 Hour, 25mg Capsule Extended-Release 24 Hour,
30mg Capsule Extended-Release 24 Hour, 5mg
Capsule Extended-Release 24 Hour)
Maximum of 2 capsules per day
Amphetamine/Dextroamphetamine (10mg Tablet
Immediate-Release, 12.5mg Tablet Immediate-
Release, 15mg Tablet Immediate-Release, 30mg
Tablet Immediate-Release, 5mg Tablet Immediate-
Release, 7.5mg Tablet Immediate-Release)
Maximum of 2 tablets per day
Amphetamine/Dextroamphetamine (20mg Tablet
Immediate-Release)Maximum of 3 tablets per day
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
Apriso (Capsule Extended-Release 24 Hour) Maximum of 4 capsules per day
Aptiom (200mg Tablet, 400mg Tablet, 800mg
Tablet)Maximum of 1 tablet per day
Aptiom (600mg Tablet) Maximum of 2 tablets per day
Aptivus (100mg/ml Oral Solution) Maximum of 15 ml per day
Aptivus (250mg Capsule) Maximum of 6 capsules per day
Aripiprazole (10mg Tablet, 15mg Tablet, 20mg Tablet,
2mg Tablet, 30mg Tablet, 5mg Tablet)Maximum of 1 tablet per day
Aripiprazole ODT (10mg Tablet Dispersible) Maximum of 3 tablets per day
Aripiprazole ODT (15mg Tablet Dispersible) Maximum of 2 tablets per day
Arnuity Ellipta (Aerosol Powder) Maximum of 1 inhaler (30 blisters) per 30 days
Aspirin/Dipyridamole (Capsule Extended-Release
12 Hour)Maximum of 2 capsules per day
Atorvastatin Calcium (Tablet) Maximum of 1 tablet per day
Atripla (Tablet) Maximum of 2 tablets per day
Aubagio (Tablet) Maximum of 1 tablet per day
Avandia (2mg Tablet) Maximum of 4 tablets per day
Avandia (4mg Tablet) Maximum of 2 tablets per day
Azelastine HCl (0.1% Nasal Solution) Maximum of 2 bottles (60 ml) per 30 days
Azor (Tablet) Maximum of 1 tablet per day
Belsomra (Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
76
76
Drug Name Quantity Limit
Benazepril HCl (Tablet) Maximum of 2 tablets per day
Benazepril HCl/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Benicar (20mg Tablet, 40mg Tablet) Maximum of 1 tablet per day
Benicar (5mg Tablet) Maximum of 2 tablets per day
Benicar HCT (Tablet) Maximum of 1 tablet per day
BiDil (Tablet) Maximum of 6 tablets per day
Binosto (Tablet Effervescent) Maximum of 4 tablets per 28 days
Bisoprolol Fumarate/Hydrochlorothiazide (Tablet) Maximum of 2 tablets per day
Botox (Injection) Maximum of 9 vials per 30 days
Brilinta (Tablet) Maximum of 2 tablets per day
BRIVIACT (100mg Tablet, 10mg Tablet, 25mg
Tablet, 50mg Tablet, 75mg Tablet)Maximum of 2 tablets per day
BRIVIACT (10mg/ml Oral Solution) Maximum of 20 ml per day
BRIVIACT (50mg/5ml Intravenous Solution) Maximum of 4 vials (20 ml) per day
Buprenorphine HCl (2mg Tablet Sublingual, 8mg
Tablet Sublingual)Maximum of 3 tablets per day
Buprenorphine HCl/Naloxone HCl (Tablet Sublingual) Maximum of 3 tablets per day
Butorphanol Tartrate (10mg/ml Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days
Bydureon Vial (Injection) Maximum of 4 vials per 28 days
Bydureon Pen (Injection) Maximum of 4 pens per 28 days
Byetta (10mcg/0.04ml Solution Pen injector) Maximum of 1 pen (2.4 ml) per 30 days
Byetta (5mcg/0.02ml Solution Pen injector) Maximum of 1 pen (1.2 ml) per 30 days
Bystolic (10mg Tablet, 2.5mg Tablet, 5mg Tablet) Maximum of 1 tablet per day
Bystolic (20mg Tablet) Maximum of 2 tablets per day
Cabometyx (20mg Tablet, 60mg Tablet) Maximum of 1 tablet per day
Cabometyx (40mg Tablet) Maximum of 2 tablets per day
Candesartan Cilexetil (16mg Tablet, 32mg Tablet,
4mg Tablet)Maximum of 1 tablet per day
Candesartan Cilexetil (8mg Tablet) Maximum of 3 tablets per day
Candesartan Cilexetil/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Captopril (100mg Tablet) Maximum of 4 tablets per day
Captopril (12.5mg Tablet, 25mg Tablet) Maximum of 3 tablets per day
Captopril (50mg Tablet) Maximum of 9 tablets per day
Captopril/Hydrochlorothiazide (25mg-15mg Tablet,
50mg-15mg Tablet)Maximum of 3 tablets per day
Captopril/Hydrochlorothiazide (25mg-25mg Tablet,
50mg-25mg Tablet)Maximum of 2 tablets per day
Celecoxib (Capsule) Maximum of 2 capsules per day
Bold type = Brand name drug Plain type = Generic drug
77
77
Drug Name Quantity Limit
Clonazepam (0.5mg Tablet Immediate-Release, 1mg
Tablet Immediate-Release)Maximum of 4 tablets per day
Clonazepam (2mg Tablet Immediate-Release) Maximum of 10 tablets per day
Clonazepam ODT (0.125mg Tablet Dispersible,
0.25mg Tablet Dispersible, 0.5mg Tablet Dispersible,
1mg Tablet Dispersible)
Maximum of 4 tablets per day
Clonazepam ODT (2mg Tablet Dispersible) Maximum of 10 tablets per day
Clopidogrel (75mg Tablet) Maximum of 4 tablets per day
Clorazepate Dipotassium (15mg Tablet) Maximum of 6 tablets per day
Clorazepate Dipotassium (3.75mg Tablet) Maximum of 24 tablets per day
Clorazepate Dipotassium (7.5mg Tablet) Maximum of 12 tablets per day
Clozapine ODT (100mg Tablet Dispersible) Maximum of 9 tablets per day
Clozapine ODT (12.5mg Tablet Dispersible) Maximum of 2 tablets per day
Clozapine ODT (150mg Tablet Dispersible) Maximum of 6 tablets per day
Clozapine ODT (200mg Tablet Dispersible) Maximum of 4 tablets per day
Clozapine ODT (25mg Tablet Dispersible) Maximum of 3 tablets per day
Codeine Sulfate (Tablet) Maximum of 6 tablets per day
Colchicine (0.6mg Tablet) (Generic Colcrys) Maximum of 4 tablets per day
Colcrys (Tablet) Maximum of 4 tablets per day
Combivir (Tablet) Maximum of 3 tablets per day
Complera (Tablet) Maximum of 2 tablets per day
Cotellic (Tablet) Maximum of 3 tablets per day
Crestor (Tablet) Maximum of 1 tablet per day
Crixivan (Capsule) Maximum of 9 capsules per day
Cycloset (Tablet) Maximum of 6 tablets per day
Daklinza (Tablet) Maximum of 1 tablet per day
Daliresp (Tablet) Maximum of 1 tablet per day
Denavir (Cream) Maximum of 1 tube (5 grams) per 30 days
Descovy (Tablet) Maximum of 2 tablets per day
Dexedrine (Tablet) Maximum of 6 tablets per day
Dexilant (Capsule Delayed-Release) Maximum of 1 capsule per day
Dexmethylphenidate HCl (Tablet Immediate-Release) Maximum of 2 tablets per day
Dextroamphetamine Sulfate (10mg Tablet Immediate-
Release, 5mg Tablet Immediate-Release)Maximum of 6 tablets per day
Dextroamphetamine Sulfate ER (10mg Capsule
Extended-Release 24 Hour)Maximum of 6 capsules per day
Dextroamphetamine Sulfate ER (15mg Capsule
Extended-Release 24 Hour)Maximum of 4 capsules per day
Bold type = Brand name drug Plain type = Generic drug
78
78
Drug Name Quantity Limit
Dextroamphetamine Sulfate ER (5mg Capsule
Extended-Release 24 Hour)Maximum of 3 capsules per day
Diazepam (10mg Tablet, 2mg Tablet, 5mg Tablet) Maximum of 4 tablets per day
Diazepam Intensol (5mg/ml Concentrate) Maximum of 8 ml per day
Didanosine (Capsule Delayed-Release) Maximum of 2 capsules per day
Donepezil HCl (10mg Tablet Immediate-Release) Maximum of 2 tablets per day
Donepezil HCl (23mg Tablet Immediate-Release, 5mg
Tablet Immediate-Release)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) Maximum of 8 capsules per day
Doxercalciferol (2.5mcg Capsule) Maximum of 4 capsules per day
Dronabinol (10mg Capsule, 2.5mg Capsule, 5mg
Capsule)Maximum of 4 capsules per day
Duloxetine HCl (20mg Capsule Delayed-Release,
30mg Capsule Delayed-Release, 60mg Capsule
Delayed-Release)
Maximum of 2 capsules per day
Edarbi (Tablet) Maximum of 1 tablet per day
Edarbyclor (Tablet) Maximum of 1 tablet per day
Edurant (Tablet) Maximum of 2 tablets per day
Effient (Tablet) Maximum of 1 tablet per day
Eliquis (Tablet) Maximum of 2 tablets per day
Embeda (100mg-4mg Capsule Extended-Release) Maximum of 3 capsules per day
Embeda (20mg-0.8mg Capsule Extended-
Release, 80mg-3.2mg Capsule Extended-
Release)
Maximum of 4 capsules per day
Embeda (30mg-1.2mg Capsule Extended-
Release, 50mg-2mg Capsule Extended-Release)Maximum of 2 capsules per day
Embeda (60mg-2.4mg Capsule Extended-
Release)Maximum of 6 capsules per day
Emsam (Patch 24 Hour) Maximum of 1 patch per day
Emtriva (10mg/ml Oral Solution) Maximum of 42.5 ml per day
Emtriva (200mg Capsule) Maximum of 2 capsules per day
Enalapril Maleate (Tablet) Maximum of 2 tablets per day
Enalapril Maleate/Hydrochlorothiazide (10mg-25mg
Tablet)Maximum of 2 tablets per day
Enalapril Maleate/Hydrochlorothiazide (5mg-12.5mg
Tablet)Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
79
79
Drug Name Quantity Limit
Endocet (Tablet) Maximum of 12 tablets per day
Enoxaparin Sodium (100mg/ml Subcutaneous
Solution, 150mg/ml Subcutaneous Solution)Maximum of 2 syringes (2 ml) per day
Enoxaparin Sodium (120mg/0.8ml Subcutaneous
Solution, 80mg/0.8ml Subcutaneous Solution)Maximum of 2 syringes (1.6 ml) per day
Enoxaparin Sodium (300mg/3ml Solution) Maximum of 1 vial (3 ml) per day
Enoxaparin Sodium (30mg/0.3ml Subcutaneous
Solution)Maximum of 2 syringes (0.6 ml) per day
Enoxaparin Sodium (40mg/0.4ml Subcutaneous
Solution)Maximum of 2 syringes (0.8 ml) per day
Enoxaparin Sodium (60mg/0.6ml Subcutaneous
Solution)Maximum of 2 syringes (1.2 ml) per day
Entresto (Tablet) Maximum of 2 tablets per day
Epclusa (Tablet) Maximum of 1 tablet per day
Epivir (Oral Solution) Maximum of 48 ml per day
Eprosartan Mesylate (Tablet) Maximum of 1 tablet per day
Epzicom (Tablet) Maximum of 2 tablets per day
Esbriet (Capsule) Maximum of 9 capsules per day
Esomeprazole Magnesium (20mg Capsule Delayed-
Release) (Generic Nexium)Maximum of 3 capsules per day
Esomeprazole Magnesium (40mg Capsule Delayed-
Release) (Generic Nexium)Maximum of 2 capsules per day
Evotaz (Tablet) Maximum of 2 tablets per day
Exelon (Patch 24 Hour) Maximum of 1 patch per day
Famciclovir (125mg Tablet, 250mg Tablet) Maximum of 2 tablets per day
Famciclovir (500mg Tablet) Maximum of 3 tablets per day
Fanapt (10mg Tablet, 12mg Tablet, 1mg Tablet,
2mg Tablet, 4mg Tablet, 6mg Tablet, 8mg Tablet)Maximum of 2 tablets per day
Fazaclo (100mg Tablet Dispersible) Maximum of 9 tablets per day
Fazaclo (150mg Tablet Dispersible) Maximum of 6 tablets per day
Fazaclo (200mg Tablet Dispersible) Maximum of 4 tablets per day
Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr
Patch 72 Hour, 25mcg/hr Patch 72 Hour, 50mcg/hr
Patch 72 Hour, 75mcg/hr Patch 72 Hour)
Maximum of 15 patches per 30 days
Fetzima (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day
Flector (Patch) Maximum of 2 patches per day
Flovent Diskus (Aerosol Powder) Maximum of 2 inhalers (120 blisters) per 30 days
Fluvastatin (20mg Capsule Immediate-Release) Maximum of 1 capsule per day
Fluvastatin (40mg Capsule Immediate-Release) Maximum of 2 capsules per day
Bold type = Brand name drug Plain type = Generic drug
80
80
Drug Name Quantity Limit
Forteo (Injection) Maximum of 1 pen (2.4 ml) per 28 days
Fosinopril Sodium (Tablet) Maximum of 2 tablets per day
Fosinopril Sodium/Hydrochlorothiazide (Tablet) Maximum of 4 tablets per day
Fuzeon (Injection) Maximum of 3 vials per day
Gabitril (12mg Tablet) Maximum of 4 tablets per day
Gabitril (16mg Tablet) Maximum of 3 tablets per day
Galantamine HBr (12mg Tablet, 4mg Tablet, 8mg
Tablet)Maximum of 2 tablets per day
Galantamine HBr (16mg Capsule Extended-Release
24 Hour, 24mg Capsule Extended-Release 24 Hour,
8mg Capsule Extended-Release 24 Hour)
Maximum of 1 capsule per day
Galantamine HBr (4mg/ml Oral Solution) Maximum of 2 bottles (200 ml) per 30 days
Genvoya (Tablet) Maximum of 2 tablets per day
Gilenya (Capsule) Maximum of 1 pack (30 capsules) per 30 days
Glimepiride (1mg Tablet) Maximum of 8 tablets per day
Glimepiride (2mg Tablet) Maximum of 4 tablets per day
Glimepiride (4mg Tablet) Maximum of 2 tablets per day
Glipizide (10mg Tablet Immediate-Release) Maximum of 4 tablets per day
Glipizide (5mg Tablet Immediate-Release) Maximum of 8 tablets per day
Glipizide ER (10mg Tablet Extended-Release 24
Hour)Maximum of 2 tablets per day
Glipizide ER (2.5mg Tablet Extended-Release 24
Hour)Maximum of 8 tablets per day
Glipizide ER (5mg Tablet Extended-Release 24 Hour) Maximum of 4 tablets per day
Glipizide/Metformin HCl (2.5mg-250mg Tablet) Maximum of 8 tablets per day
Glipizide/Metformin HCl (2.5mg-500mg Tablet,
5mg-500mg Tablet)Maximum of 4 tablets per day
Glyset (100mg Tablet) Maximum of 3 tablets per day
Glyset (25mg Tablet) Maximum of 12 tablets per day
Glyset (50mg Tablet) Maximum of 6 tablets per day
Granisetron HCl (1mg Tablet) Maximum of 2 tablets per day
Harvoni (Tablet) Maximum of 1 tablet per day
Hectorol (1mcg Capsule) Maximum of 8 capsules per day
Hectorol (2.5mcg Capsule) Maximum of 4 capsules per day
Hetlioz (Capsule) Maximum of 1 capsule per day
Hydrocodone Bitartrate/Acetaminophen
(7.5mg-325mg/15ml Oral Solution)Maximum of 180 ml per day
Bold type = Brand name drug Plain type = Generic drug
81
81
Drug Name Quantity Limit
Hydrocodone/Acetaminophen (10mg-325mg Tablet,
2.5mg-325mg Tablet, 5mg-325mg Tablet,
7.5mg-325mg 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-Release,
4mg Tablet Immediate-Release)Maximum of 8 tablets per day
Hydromorphone HCl (8mg Tablet Immediate-Release) Maximum of 11 tablets per day
Hydromorphone HCl ER (12mg Tablet Extended-
Release 24 Hour Abuse-Deterrent, 16mg Tablet
Extended-Release 24 Hour Abuse-Deterrent, 8mg
Tablet Extended-Release 24 Hour Abuse-Deterrent)
Maximum of 2 tablets per day
Hydromorphone HCl ER (32mg Tablet Extended-
Release 24 Hour Abuse-Deterrent)Maximum of 2 tablets per day
Ibandronate Sodium (150mg Tablet) Maximum of 1 tablet per 28 days
Ibrance (Capsule) Maximum of 1 capsule per day
Intelence (100mg Tablet) Maximum of 2 tablets per day
Intelence (200mg Tablet) Maximum of 3 tablets per day
Intelence (25mg Tablet) Maximum of 6 tablets per day
Invega (1.5mg Tablet Extended-Release 24 Hour,
3mg Tablet Extended-Release 24 Hour, 9mg
Tablet Extended-Release 24 Hour)
Maximum of 1 tablet per day
Invega (6mg Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day
Invirase (200mg Capsule) Maximum of 15 capsules per day
Invirase (500mg Tablet) Maximum of 6 tablets per day
Invokamet (Tablet) Maximum of 2 tablets per day
Invokana (Tablet) Maximum of 1 tablet per day
Irbesartan (150mg Tablet, 300mg Tablet) Maximum of 1 tablet per day
Irbesartan (75mg Tablet) Maximum of 3 tablets per day
Irbesartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Iressa (Tablet) Maximum of 2 tablets per day
Isentress (100mg Packet) Maximum of 4 packets per day
Isentress (100mg Tablet Chewable, 25mg Tablet
Chewable)Maximum of 9 tablets per day
Isentress (400mg Tablet) Maximum of 6 tablets per day
Itraconazole (Capsule) Maximum of 4 capsules per day
Janumet (Tablet Immediate-Release) Maximum of 2 tablets per day
Janumet XR (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day
Januvia (Tablet) Maximum of 1 tablet per day
Bold type = Brand name drug Plain type = Generic drug
82
82
Drug Name Quantity Limit
Jardiance (Tablet) Maximum of 1 tablet per day
Jentadueto (Tablet) Maximum of 2 tablets per day
Jentadueto XR (2.5mg-1000mg Tablet Extended-
Release 24 Hour)Maximum of 2 tablets per day
Jentadueto XR (5mg-1000mg Tablet Extended-
Release 24 Hour)Maximum of 1 tablet 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
Kazano (Tablet) Maximum of 2 tablets per day
Kombiglyze XR (2.5mg-1000mg Tablet Extended-
Release 24 Hour)Maximum of 2 tablets per day
Kombiglyze XR (5mg-1000mg Tablet Extended-
Release 24 Hour, 5mg-500mg Tablet Extended-
Release 24 Hour)
Maximum of 1 tablet per day
Korlym (Tablet) Maximum of 4 tablets per day
Lamivudine (10mg/ml Oral Solution) Maximum of 48 ml per day
Lamivudine (150mg Tablet) Maximum of 3 tablets per day
Lamivudine (300mg Tablet) Maximum of 2 tablets per day
Lamivudine/Zidovudine (Tablet) Maximum of 3 tablets per day
Latuda (120mg Tablet, 20mg Tablet, 40mg
Tablet, 60mg Tablet)Maximum of 1 tablet per day
Latuda (80mg Tablet) Maximum of 2 tablets per day
Levocetirizine Dihydrochloride (5mg Tablet) Maximum of 1 tablet per day
Levorphanol Tartrate (Tablet) Maximum of 6 tablets per day
Lexiva (50mg/ml Suspension) Maximum of 90 ml per day
Lexiva (700mg Tablet) Maximum of 6 tablets per day
Lialda (Tablet Delayed-Release) Maximum of 4 tablets per day
Lidocaine (5% Patch) Maximum of 3 patches per day
Linezolid (600mg Tablet) Maximum of 2 tablets per day
Linzess (Capsule) Maximum of 1 capsule per day
Lisinopril (Tablet) Maximum of 2 tablets per day
Lisinopril/Hydrochlorothiazide (10mg-12.5mg Tablet) Maximum of 1 tablet per day
Lisinopril/Hydrochlorothiazide (20mg-12.5mg Tablet) Maximum of 4 tablets per day
Lisinopril/Hydrochlorothiazide (20mg-25mg Tablet) Maximum of 2 tablets per day
Lonsurf (6.14mg-15mg Tablet) Maximum of 10 tablets per day
Bold type = Brand name drug Plain type = Generic drug
83
83
Drug Name Quantity Limit
Lonsurf (8.19mg-20mg Tablet) Maximum of 8 tablets per day
Lorazepam (0.5mg Tablet, 1mg Tablet) Maximum of 4 tablets per day
Lorazepam (2mg Tablet) Maximum of 5 tablets per day
Lorazepam Intensol (2mg/ml Concentrate) Maximum of 5 ml per day
Lorcet (Tablet) Maximum of 12 tablets per day
Lorcet HD (Tablet) Maximum of 12 tablets per day
Lorcet Plus (Tablet) Maximum of 12 tablets per day
Lortab (Tablet) Maximum of 12 tablets per day
Losartan Potassium (100mg Tablet) Maximum of 1 tablet per day
Losartan Potassium (25mg Tablet, 50mg Tablet) Maximum of 2 tablets per day
Losartan Potassium/Hydrochlorothiazide
(100mg-12.5mg Tablet, 100mg-25mg Tablet)Maximum of 1 tablet per day
Losartan Potassium/Hydrochlorothiazide
(50mg-12.5mg Tablet)Maximum of 2 tablets per day
Lovastatin (10mg Tablet Immediate-Release, 20mg
Tablet Immediate-Release)Maximum of 1 tablet per day
Lovastatin (40mg Tablet Immediate-Release) Maximum of 2 tablets per day
Loxapine Succinate (10mg Capsule, 5mg Capsule) Maximum of 4 capsules per day
Lynparza (Capsule) Maximum of 16 capsules per day
Lyrica (100mg Capsule, 150mg Capsule, 200mg
Capsule, 25mg Capsule, 50mg Capsule, 75mg
Capsule)
Maximum of 3 capsules per day
Lyrica (20mg/ml Oral Solution) Maximum of 30 ml per day
Lyrica (225mg Capsule, 300mg Capsule) Maximum of 2 capsules per day
Matzim LA (360mg Tablet Extended-Release 24 Hour,
420mg Tablet Extended-Release 24 Hour)Maximum of 1 tablet 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
Metadate ER (Tablet Extended-Release) Maximum of 3 tablets per day
Metformin HCl (1000mg Tablet Immediate-Release) Maximum of 2.5 tablets per day
Metformin HCl (500mg Tablet Immediate-Release) Maximum of 5 tablets per day
Metformin HCl (850mg Tablet Immediate-Release) Maximum of 3 tablets per day
Metformin HCl ER (1000mg Tablet Extended-Release
24 Hour) (Generic Fortamet)Maximum of 2 tablets per day
Metformin HCl ER (500mg Tablet Extended-Release
24 Hour) (Generic Glucophage XR)Maximum of 4 tablets per day
Metformin HCl ER (750mg Tablet Extended-Release
24 Hour) (Generic Glucophage XR)Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
84
84
Drug Name Quantity Limit
Methadone HCl (10mg Tablet) Maximum of 12 tablets per day
Methadone HCl (10mg/5ml Oral Solution) Maximum of 60 ml per day
Methadone HCl (5mg Tablet) Maximum of 8 tablets per day
Methadone HCl (5mg/5ml Oral Solution) Maximum of 120 ml per day
Methylphenidate HCl (10mg Tablet Immediate-
Release, 20mg Tablet Immediate-Release, 5mg Tablet
Immediate-Release) (Generic Ritalin)
Maximum of 3 tablets per day
Methylphenidate HCl (10mg/5ml Oral Solution) Maximum of 30 ml per day
Methylphenidate HCl (5mg/5ml Oral Solution) Maximum of 60 ml per day
Methylphenidate HCl ER (10mg Tablet Extended-
Release)Maximum of 4 tablets per day
Methylphenidate HCl ER (20mg Tablet Extended-
Release)Maximum of 3 tablets per day
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 Tablet,
15mg-25mg Tablet)Maximum of 2 tablets per day
Moexipril/Hydrochlorothiazide (7.5mg-12.5mg Tablet) Maximum of 1 tablet per day
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, 5mg
Tablet Chewable)Maximum of 1 tablet per day
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-
Release)Maximum of 8 tablets per day
Morphine Sulfate (20mg/5ml Oral Solution) Maximum of 90 ml per day
Morphine Sulfate (30mg Tablet Immediate-
Release)Maximum of 12 tablets per day
Morphine Sulfate ER (100mg Tablet Extended-
Release, 15mg Tablet Extended-Release) (Generic
MS Contin)
Maximum of 3 tablets per day
Morphine Sulfate ER (200mg Tablet Extended-
Release) (Generic MS Contin)Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
85
85
Drug Name Quantity Limit
Morphine Sulfate ER (30mg Tablet Extended-Release,
60mg Tablet Extended-Release) (Generic MS Contin)Maximum of 4 tablets per day
Multaq (Tablet) Maximum of 2 tablets per day
Nadolol/Bendroflumethiazide (40mg-5mg Tablet) Maximum of 1 tablet per day
Namenda (10mg Tablet Immediate-Release) Maximum of 2 tablets per day
Namenda (10mg/5ml Oral Solution) Maximum of 10 ml per day
Namenda (5mg Tablet Immediate-Release) Maximum of 3 tablets per day
Namenda XR (Capsule Extended-Release 24
Hour)Maximum of 1 capsule per day
Namenda XR Titration Pack (Capsule Extended-
Release 24 Hour)Maximum of 1 capsule per day
Namzaric (Capsule Extended-Release 24 Hour) Maximum of 1 capsule per day
Naratriptan HCl (Tablet) Maximum of 9 tablets per 30 days
Nateglinide (120mg Tablet) Maximum of 3 tablets per day
Nateglinide (60mg Tablet) Maximum of 6 tablets per day
Nesina (Tablet) Maximum of 1 tablet per day
Nevirapine (200mg Tablet Immediate-Release) Maximum of 3 tablets per day
Nevirapine (50mg/5ml Suspension) Maximum of 60 ml per day
Nevirapine ER (100mg Tablet Extended-Release 24
Hour)Maximum of 3 tablets per day
Nevirapine ER (400mg Tablet Extended-Release 24
Hour)Maximum of 2 tablets per day
Nexium (20mg Capsule Delayed-Release) Maximum of 3 capsules per day
Nexium (40mg Capsule Delayed-Release) Maximum of 2 capsules per day
Nifedical XL (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day
Nifedipine ER (Tablet Extended-Release 24 Hour) Maximum of 2 tablets per day
Ninlaro (Capsule) Maximum of 3 capsules per 28 days
Northera (100mg Capsule) Maximum of 3 capsules per day
Northera (200mg Capsule, 300mg Capsule) Maximum of 6 capsules per day
Norvir (100mg Capsule) Maximum of 18 capsules per day
Norvir (100mg Tablet) Maximum of 18 tablets per day
Norvir (80mg/ml Oral Solution) Maximum of 24 ml per day
Nucynta ER (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day
Nuplazid (Tablet) Maximum of 2 tablets per day
Ocaliva (Tablet) Maximum of 1 tablet per day
Odefsey (Tablet) Maximum of 2 tablets per day
Odomzo (Capsule) Maximum of 1 capsule per day
Ofev (Capsule) Maximum of 2 capsules per day
Bold type = Brand name drug Plain type = Generic drug
86
86
Drug Name Quantity Limit
Olanzapine (10mg Tablet Immediate-Release, 15mg
Tablet Immediate-Release, 2.5mg Tablet Immediate-
Release, 20mg Tablet Immediate-Release, 5mg Tablet
Immediate-Release, 7.5mg Tablet Immediate-Release)
Maximum of 1 tablet per day
Olanzapine ODT (Tablet Dispersible) Maximum of 1 tablet per day
Olysio (Capsule) Maximum of 1 capsule per day
Omega-3-Acid Ethyl Esters (Capsule) (Generic
Lovaza)Maximum of 4 capsules per day
Omeprazole (10mg Capsule Delayed-Release) Maximum of 3 capsules per day
Omeprazole (40mg Capsule Delayed-Release) Maximum of 2 capsules per day
Onfi (10mg Tablet, 20mg Tablet) Maximum of 2 tablets per day
Onglyza (Tablet) Maximum of 1 tablet per day
Opana ER (10mg Tablet Extended-Release 12
Hour Abuse-Deterrent, 15mg Tablet Extended-
Release 12 Hour Abuse-Deterrent, 20mg Tablet
Extended-Release 12 Hour Abuse-Deterrent, 5mg
Tablet Extended-Release 12 Hour Abuse-
Deterrent, 7.5mg Tablet Extended-Release 12
Hour Abuse-Deterrent)
Maximum of 2 tablets per day
Opana ER (30mg Tablet Extended-Release 12
Hour Abuse-Deterrent)Maximum of 4 tablets per day
Opana ER (40mg Tablet Extended-Release 12
Hour Abuse-Deterrent)Maximum of 3 tablets per day
Orenitram (0.125mg Tablet Extended-Release,
0.25mg Tablet Extended-Release, 1mg Tablet
Extended-Release)
Maximum of 6 tablets per day
Orkambi (Tablet) Maximum of 112 tablets per 28 days
Oseni (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 Extended-Release 24
Hour)
Maximum of 2 tablets per day
Oxybutynin Chloride ER (5mg Tablet Extended-
Release 24 Hour)Maximum of 1 tablet per day
Oxycodone HCl (100mg/5ml Concentrate) Maximum of 12 ml per day
Oxycodone HCl (10mg Tablet Immediate-Release,
20mg Tablet Immediate-Release, 5mg Tablet
Immediate-Release)
Maximum of 12 tablets per day
Oxycodone HCl (15mg Tablet Immediate-Release) Maximum of 16 tablets per day
Oxycodone HCl (30mg Tablet Immediate-Release) Maximum of 8 tablets per day
Bold type = Brand name drug Plain type = Generic drug
87
87
Drug Name Quantity Limit
Oxycodone HCl (5mg/5ml Oral Solution) Maximum of 240 ml per day
Oxycodone/Acetaminophen (10mg-325mg Tablet,
2.5mg-325mg Tablet, 5mg-325mg Tablet,
7.5mg-325mg Tablet)
Maximum of 12 tablets per day
Oxycodone/Acetaminophen (325mg/5ml-5mg/5ml
Oral Solution)Maximum of 60 ml 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 24 Hour, 9mg
Tablet Extended-Release 24 Hour)
Maximum of 1 tablet per day
Paliperidone ER (6mg Tablet Extended-Release 24
Hour)Maximum of 2 tablets per day
Pantoprazole Sodium (20mg Tablet Delayed-Release) Maximum of 3 tablets per day
Pantoprazole Sodium (40mg Tablet Delayed-Release) Maximum of 2 tablets per day
Paricalcitol (1mcg Capsule) Maximum of 1 capsule per day
Paricalcitol (2mcg Capsule) Maximum of 2 capsules per day
Pentasa (250mg Capsule Extended-Release) Maximum of 12 capsules per day
Pentasa (500mg Capsule Extended-Release) Maximum of 8 capsules per day
Perforomist (Nebulized Solution) Maximum of 2 vials (4 ml) per day
Perindopril Erbumine (Tablet) Maximum of 2 tablets per day
Pioglitazone HCl (15mg Tablet) Maximum of 3 tablets per day
Pioglitazone HCl (30mg Tablet, 45mg Tablet) Maximum of 1 tablet per day
Pioglitazone HCl/Glimepiride (Tablet) Maximum of 1 tablet per day
Pioglitazone HCl/Metformin HCl (Tablet) Maximum of 3 tablets per day
Potiga (200mg Tablet, 300mg Tablet, 400mg
Tablet)Maximum of 3 tablets per day
Potiga (50mg Tablet) Maximum of 9 tablets per day
Pradaxa (Capsule) Maximum of 2 capsules per day
Praluent (150mg/ml Solution Pen injector, 75mg/
ml Solution Pen injector)Maximum of 2 pens (2 ml) per 28 days
Praluent (150mg/ml Solution Prefilled Syringe,
75mg/ml Solution Prefilled Syringe)Maximum of 2 syringes (2 ml) per 28 days
Pravastatin Sodium (Tablet) Maximum of 1 tablet per day
Prezcobix (Tablet) Maximum of 2 tablets per day
Prezista (100mg/ml Suspension) Maximum of 60 ml per day
Prezista (150mg Tablet) Maximum of 6 tablets per day
Prezista (600mg Tablet, 800mg Tablet) Maximum of 3 tablets per day
Prezista (75mg Tablet) Maximum of 7 tablets per day
Bold type = Brand name drug Plain type = Generic drug
88
88
Drug Name Quantity Limit
Pristiq (100mg Tablet Extended-Release 24 Hour) Maximum of 4 tablets per day
Pristiq (25mg Tablet Extended-Release 24 Hour,
50mg Tablet Extended-Release 24 Hour)Maximum of 1 tablet per day
Quetiapine Fumarate (100mg Tablet Immediate-
Release, 200mg Tablet Immediate-Release, 50mg
Tablet Immediate-Release)
Maximum of 3 tablets per day
Quetiapine Fumarate (25mg Tablet Immediate-
Release)Maximum of 4 tablets per day
Quetiapine Fumarate (300mg Tablet Immediate-
Release, 400mg Tablet Immediate-Release)Maximum of 2 tablets per day
Quinapril HCl (Tablet) Maximum of 2 tablets per day
Quinapril/Hydrochlorothiazide (10mg-12.5mg Tablet) Maximum of 1 tablet per day
Quinapril/Hydrochlorothiazide (20mg-12.5mg Tablet,
20mg-25mg Tablet)Maximum of 2 tablets per day
Raloxifene HCl (Tablet) Maximum of 1 tablet per day
Ramipril (Capsule) Maximum of 2 capsules per day
Ranexa (Tablet Extended-Release 12 Hour) Maximum of 2 tablets per day
Rapaflo (Capsule) Maximum of 1 capsule per day
Relenza Diskhaler (Aerosol Powder) Maximum of 3 inhalers (60 blisters) per 30 days
Repaglinide (0.5mg Tablet) Maximum of 32 tablets per day
Repaglinide (1mg Tablet) Maximum of 16 tablets per day
Repaglinide (2mg Tablet) Maximum of 8 tablets per day
Repaglinide/Metformin HCl (Tablet) Maximum of 5 tablets per day
Repatha (Injection) Maximum of 3 syringes (3 ml) per 28 days
Repatha Pushtronex System (Solution Cartridge) Maximum of 1 cartridge (3.5 ml) per 28 days
Repatha SureClick (Injection) Maximum of 3 pens (3 ml) per 28 days
Rescriptor (Tablet) Maximum of 9 tablets per day
Revatio (20mg Tablet) Maximum of 3 tablets per day
Rexulti (Tablet) Maximum of 1 tablet per day
Reyataz (150mg Capsule, 300mg Capsule) Maximum of 2 capsules per day
Reyataz (200mg Capsule) Maximum of 3 capsules per day
Reyataz (50mg Packet) Maximum of 8 packets per day
Riomet (Oral Solution) Maximum of 25.5 ml per day
Risedronate Sodium (150mg Tablet) Maximum of 1 tablet per 30 days
Risedronate Sodium (30mg Tablet, 5mg Tablet) Maximum of 1 tablet per day
Risedronate Sodium (35mg Tablet) Maximum of 4 tablets per 28 days
Rivastigmine Tartrate (Capsule Immediate-Release) Maximum of 2 capsules per day
Rivastigmine Transdermal System (Patch 24 Hour) Maximum of 1 patch per day
Bold type = Brand name drug Plain type = Generic drug
89
89
Drug Name Quantity Limit
Rizatriptan Benzoate (Tablet Immediate-Release) Maximum of 12 tablets per 30 days
Rizatriptan Benzoate ODT (Tablet Dispersible) Maximum of 12 tablets per 30 days
Rosuvastatin Calcium (Tablet) Maximum of 1 tablet per day
Rozerem (Tablet) Maximum of 1 tablet per day
Sabril (500mg Packet) Maximum of 6 packets per day
Sabril (500mg Tablet) Maximum of 6 tablets per day
Samsca (Tablet) Maximum of 2 tablets per day
Saphris (Tablet Sublingual) Maximum of 2 tablets per day
Selzentry (150mg Tablet) Maximum of 3 tablets per day
Selzentry (300mg Tablet) Maximum of 6 tablets per day
Sensipar (30mg Tablet, 60mg Tablet) Maximum of 2 tablets per day
Sensipar (90mg Tablet) Maximum of 4 tablets per day
Serevent Diskus (Aerosol Powder) Maximum of 1 inhaler (60 inhalations) per 30 days
Seroquel XR (150mg Tablet Extended-Release 24
Hour, 200mg Tablet Extended-Release 24 Hour)Maximum of 1 tablet per day
Seroquel XR (300mg Tablet Extended-Release 24
Hour, 400mg Tablet Extended-Release 24 Hour,
50mg Tablet Extended-Release 24 Hour)
Maximum of 2 tablets per day
sfRowasa (Enema) Maximum of 1 bottle (60 ml) per day
Sildenafil (20mg Tablet) (Generic Revatio) Maximum of 3 tablets per day
Simvastatin (Tablet) Maximum of 1 tablet per day
Sovaldi (Tablet) Maximum of 1 tablet per day
Spiriva HandiHaler (Capsule) Maximum of 1 capsule per day
Spiriva Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days
Stavudine (15mg Capsule, 30mg Capsule, 40mg
Capsule)Maximum of 3 capsules per day
Stavudine (1mg/ml Oral Solution) Maximum of 120 ml per day
Stavudine (20mg Capsule) Maximum of 2 capsules per day
Stiolto Respimat (Aerosol Solution) Maximum of 1 inhaler (4 grams) per 30 days
Strattera (100mg Capsule, 60mg Capsule, 80mg
Capsule)Maximum of 1 capsule per day
Strattera (10mg Capsule, 18mg Capsule, 25mg
Capsule, 40mg Capsule)Maximum of 2 capsules per day
Stribild (Tablet) Maximum of 2 tablets per day
Suboxone (12mg-3mg Film, 4mg-1mg Film) Maximum of 2 sublingual films per day
Suboxone (2mg-0.5mg Film, 8mg-2mg Film) Maximum of 3 sublingual films per day
Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days
Bold type = Brand name drug Plain type = Generic drug
90
90
Drug Name Quantity Limit
Sumatriptan Succinate (100mg Tablet, 25mg Tablet,
50mg Tablet)Maximum of 9 tablets per 30 days
Sumatriptan Succinate (4mg/0.5ml Solution Auto
injector)Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6mg/0.5ml Solution Auto
injector)Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6mg/0.5ml Subcutaneous
Solution)Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate Refill (4mg/0.5ml Solution
Cartridge)Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate Refill (6mg/0.5ml Solution
Cartridge)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
Synjardy (Tablet) Maximum of 2 tablets per day
Tagrisso (Tablet) Maximum of 1 tablet per day
Tamiflu (30mg Capsule, 45mg Capsule, 75mg
Capsule)Maximum of 2 capsules per day
Tamiflu (6mg/ml Suspension) Maximum of 26 ml per day
Tecfidera (Capsule Delayed-Release) Maximum of 2 capsules per day
Telmisartan (Tablet) Maximum of 1 tablet per day
Telmisartan/Amlodipine (Tablet) Maximum of 1 tablet per day
Telmisartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Temazepam (Capsule) Maximum of 1 capsule per day
Tetrabenazine (12.5mg Tablet) Maximum of 3 tablets per day
Tetrabenazine (25mg Tablet) Maximum of 4 tablets per day
Tivicay (10mg Tablet) Maximum of 2 tablets per day
Tivicay (25mg Tablet) Maximum of 2 tablets per day
Tivicay (50mg Tablet) Maximum of 3 tablets per day
Tracleer (Tablet) Maximum of 2 tablets per day
Tradjenta (Tablet) Maximum of 1 tablet per day
Tramadol HCl (Tablet Immediate-Release) Maximum of 8 tablets per day
Tramadol HCl ER (100mg Tablet Extended-Release
24 Hour, 200mg Tablet Extended-Release 24 Hour)
(Generic Ultram ER)
Maximum of 1 tablet per day
Tramadol HCl ER (300mg Tablet Extended-Release
24 Hour) (Generic Ryzolt)Maximum of 1 tablet per day
Tramadol HCl/Acetaminophen (Tablet) Maximum of 12 tablets per day
Bold type = Brand name drug Plain type = Generic drug
91
91
Drug Name Quantity Limit
Trandolapril (1mg Tablet, 2mg Tablet) Maximum of 1 tablet per day
Trandolapril (4mg Tablet) Maximum of 2 tablets per day
Trezix (Capsule) Maximum of 10 capsules per day
Tribenzor (Tablet) Maximum of 1 tablet per day
Trintellix (Tablet) Maximum of 1 tablet per day
Triumeq (Tablet) Maximum of 2 tablets per day
Trizivir (Tablet) Maximum of 3 tablets per day
Trulicity (Injection) Maximum of 4 pens (2 ml) per 28 days
Truvada (Tablet) Maximum of 2 tablets per day
Tybost (Tablet) Maximum of 2 tablets per day
Vagifem (Tablet) Maximum of 1 tablet per day
Valacyclovir HCl (1000mg Tablet) Maximum of 4 tablets per day
Valacyclovir HCl (500mg Tablet) Maximum of 2 tablets per day
Valsartan (160mg Tablet, 40mg Tablet, 80mg Tablet) Maximum of 2 tablets per day
Valsartan (320mg Tablet) Maximum of 1 tablet per day
Valsartan/Hydrochlorothiazide (Tablet) Maximum of 1 tablet per day
Venclexta (100mg Tablet) Maximum of 4 tablets per day
Venclexta (10mg Tablet) Maximum of 2 tablets per day
Venclexta (50mg Tablet) Maximum of 1 tablet per day
Vesicare (Tablet) Maximum of 1 tablet per day
Victoza (Injection) Maximum of 3 pens (9 ml) per 30 days
Videx Pediatric (Oral Solution) Maximum of 30 ml per day
Viibryd (Tablet) Maximum of 1 tablet per day
Viibryd Starter Pack (Kit) Maximum of 1 tablet per day
Vimpat (100mg Tablet, 150mg Tablet, 200mg
Tablet, 50mg Tablet)Maximum of 2 tablets per day
Vimpat (10mg/ml Oral Solution) Maximum of 40 ml per day
Viracept (250mg Tablet) Maximum of 15 tablets per day
Viracept (625mg Tablet) Maximum of 6 tablets per day
Viramune (Suspension) Maximum of 60 ml per day
Viramune XR (100mg Tablet Extended-Release
24 Hour)Maximum of 3 tablets per day
Viramune XR (400mg Tablet Extended-Release
24 Hour)Maximum of 2 tablets per day
Viread (150mg Tablet) Maximum of 1 tablet per day
Viread (200mg Tablet, 250mg Tablet, 300mg
Tablet)Maximum of 2 tablets per day
Bold type = Brand name drug Plain type = Generic drug
92
92
Drug Name Quantity Limit
Viread (40mg/gm Powder) Maximum of 6 bottles (360 grams) per 30 days
Vitekta (Tablet) Maximum of 2 tablets per day
Vraylar (1.5mg Capsule, 3mg Capsule, 4.5mg
Capsule, 6mg Capsule)Maximum of 1 capsule per day
Vytorin (Tablet) Maximum of 1 tablet per day
Xarelto (10mg Tablet, 20mg Tablet) Maximum of 1 tablet per day
Xarelto (15mg Tablet) Maximum of 2 tablets per day
Xarelto Starter Pack (Tablet Therapy Pack) Maximum of 1 pack (51 tablets) per 30 days
Xeljanz (Tablet) Maximum of 2 tablets per day
Xeljanz XR (Tablet Extended-Release 24 Hour) Maximum of 1 tablet per day
Xenazine (12.5mg Tablet) Maximum of 3 tablets per day
Xenazine (25mg Tablet) Maximum of 4 tablets per day
Xtandi (Capsule) Maximum of 4 capsules per day
Xyrem (Oral Solution) Maximum of 18 ml per day
Zafirlukast (Tablet) Maximum of 2 tablets per day
Zaleplon (Capsule) Maximum of 90 days of use per year
Zepatier (Tablet) Maximum of 1 tablet per day
Zetia (Tablet) Maximum of 1 tablet per day
Ziagen (Oral Solution) Maximum of 48 ml per day
Zidovudine (100mg Capsule) Maximum of 8 capsules per day
Zidovudine (300mg Tablet) Maximum of 3 tablets per day
Zidovudine (50mg/5ml Syrup) Maximum of 96 ml per day
Ziprasidone HCl (Capsule) Maximum of 2 capsules per day
Zolpidem Tartrate (Tablet Immediate-Release) Maximum of 90 days of use per year
Zovirax (5% Cream) Maximum of 1 tube (5 grams) per 30 days
Zovirax (5% Ointment) Maximum of 1 tube (30 grams) per 30 days
Zydelig (Tablet) Maximum of 2 tablets per day
Zykadia (Capsule) Maximum of 5 capsules per day
Zytiga (Tablet) Maximum of 4 tablets per day
Zyvox (600mg Tablet) Maximum of 2 tablets per daytrack
93
Tracked
93
trackIndex of covered drugs
#
8-MOP................................ 49
A
A-Hydrocort....................... 53
Abacavir............................. 36
Abacavir Sulfate/
Lamivudine/Zidovudine
......................................... 36
Abelcet............................... 26
Abilify Maintena................ 33
Abraxane............................29
Abstral................................ 13
Acamprosate Calcium DR
.......................................... 15
Acarbose.............................38
Acebutolol HCl.................. 42
Acetaminophen/Codeine...13
Acetazolamide...................46
Acetazolamide ER............. 46
Acetazolamide Sodium..... 46
Acetic Acid.........................66
Acetylcysteine................... 69
Acitretin.............................49
Actemra..............................62
ActHIB................................62
Actimmune........................ 62
Actonel...............................63
Acyclovir.......................35, 36
Acyclovir Sodium.............. 36
Adacel................................ 62
Adagen............................... 50
Adapalene..........................49
Adcirca...............................68
Adefovir Dipivoxil..............35
Adempas............................ 68
Adrucil............................... 29
Advair Diskus.................... 69
Advair HFA........................ 69
Afeditab CR........................43
Afinitor............................... 31
Afinitor Disperz..................31
Aggrenox............................ 41
Ala Cort.............................. 53
Albenza.............................. 32
Albuterol Sulfate................68
Alclometasone Dipropionate
..........................................53
Alcohol Prep Pads..............64
Aldurazyme....................... 50
Alecensa............................. 29
Alendronate Sodium......... 63
Alfuzosin HCl ER............... 53
Alimta................................ 29
Alinia..................................32
Allopurinol......................... 27
Alocril.................................65
Alomide..............................65
Alora...................................56
Alosetron HCl.....................52
Aloxi................................... 25
Alphagan P.........................65
Alprazolam.........................38
Amantadine HCl................ 32
AmBisome..........................26
Amethia............................. 56
Amethyst............................56
Amifostine......................... 29
Amikacin Sulfate................ 15
Amiloride HCl....................46
Amiloride/
Hydrochlorothiazide...... 44
Aminophylline...................68
Aminosyn 7%/Electrolytes
.......................................... 71
Aminosyn 8.5%/Electrolytes
.......................................... 71
Aminosyn II........................71
Aminosyn II 8.5%/
Electrolytes...................... 71
Aminosyn M....................... 71
Aminosyn-HBC.................. 71
Aminosyn-PF......................71
Aminosyn-RF..................... 71
Amiodarone HCl................42
Amitiza............................... 52
Amitriptyline HCl.............. 25
Amlodipine Besylate......... 43
Amlodipine Besylate/
Atorvastatin Calcium......44
Amlodipine Besylate/
Benazepril HCl................ 44
Amlodipine Besylate/
Valsartan......................... 44
Amlodipine/Valsartan/
Hydrochlorothiazide...... 44
Ammonium Chloride........ 70
Ammonium Lactate.......... 49
Amoxapine......................... 25
Amoxicillin.........................18
Amoxicillin/Clavulanate
Potassium.........................18
Amoxicillin/Clavulanate
Potassium ER................... 18
Amphetamine/
Dextroamphetamine.......48
Amphotericin B................. 26
94
Tracked
94
Ampicillin........................... 18
Ampicillin Sodium............. 18
Ampicillin-Sulbactam........ 18
Ampyra...............................49
Anadrol-50..........................56
Anagrelide HCl.................. 40
Anastrozole......................... 31
Ancobon............................. 26
Androderm......................... 56
AndroGel............................ 56
AndroGel Pump..................56
Anoro Ellipta...................... 69
Anzemet............................. 26
Apokyn............................... 32
Apraclonidine.....................65
Apri..................................... 56
Apriso................................. 63
Aptiom................................ 22
Aptivus................................37
Aralast NP...........................69
Aranelle.............................. 56
Aranesp Albumin Free....... 41
Arcalyst...............................62
Argatroban..........................41
Aripiprazole........................33
Aripiprazole ODT............... 33
Aristada.............................. 33
Arnuity Ellipta....................67
Arranon.............................. 29
Ashlyna...............................56
Aspirin/Dipyridamole........ 41
Atenolol.............................. 42
Atenolol/Chlorthalidone... 44
Atgam..................................61
Atorvastatin Calcium.........46
Atovaquone........................ 32
Atovaquone/Proguanil HCl
.......................................... 32
Atripla.................................36
Atropine Sulfate..................51
Atrovent HFA..................... 67
Aubagio.............................. 49
Aubra.................................. 56
Augmented Betamethasone
Dipropionate.................... 53
Avandia.............................. 38
Avastin................................ 31
Avelox................................. 19
Aviane.................................56
Avita................................... 49
Avonex............................... 49
Avonex Pen........................ 49
Azacitidine......................... 29
Azactam in Iso-Osmotic
Dextrose............................18
Azasite.................................19
Azathioprine...................... 60
Azelastine HCl.............. 65, 67
Azilect................................. 33
Azithromycin......................19
Azopt...................................65
Azor.................................... 44
Aztreonam.......................... 18
B
BACiiM................................16
Bacitracin............................16
Bacitracin/Polymyxin B.....64
Baclofen..............................69
Bactocill in Dextrose...........19
Bactroban Nasal..................16
Balsalazide Disodium.........63
Balziva................................ 56
Banzel................................. 23
Baraclude............................35
BCG Vaccine....................... 62
Bekyree............................... 56
Beleodaq............................. 29
Belsomra.............................70
Benazepril HCl................... 42
Benazepril HCl/
Hydrochlorothiazide....... 44
Benicar................................42
Benicar HCT.......................44
Benlysta.............................. 62
Benztropine Mesylate.........32
Bepreve............................... 65
Berinert.............................. 60
Besivance............................ 19
Betamethasone Dipropionate
.......................................... 53
Betamethasone Valerate.... 53
Betaseron........................... 49
Betaxolol HCl................ 42, 65
Bethanechol Chloride.........53
Bethkis................................ 15
Betimol............................... 65
Bexarotene..........................32
Bexsero............................... 62
Bicalutamide...................... 29
Bicillin C-R..........................19
Bicillin L-A.......................... 19
BiCNU................................. 28
BiDil....................................44
Biltricide............................. 32
Binosto................................63
Bisoprolol Fumarate.......... 42
95
Tracked
95
Bisoprolol Fumarate/
Hydrochlorothiazide....... 44
BIVIGAM.............................61
Bleomycin Sulfate.............. 29
Blephamide........................ 64
Blephamide S.O.P.............. 64
Blisovi 24 Fe........................56
Blisovi Fe 1.5/30..................56
Blisovi Fe 1/20.....................56
Boniva.................................63
Boostrix...............................62
Bosulif................................. 31
Botox.................................. 64
Breo Ellipta.........................69
Briellyn............................... 56
Brilinta................................ 41
Brimonidine Tartrate......... 65
BRIVIACT............................21
Bromocriptine Mesylate.....32
Brovana.............................. 68
Budesonide................... 63, 67
Bumetanide........................46
Buphenyl............................ 50
Buprenorphine HCl............ 15
Buprenorphine HCl/
Naloxone HCl................... 15
Bupropion HCl................... 24
Bupropion HCl SR......... 15, 24
Bupropion HCl XL..............24
Buspirone HCl.................... 38
Busulfex.............................. 28
Butorphanol Tartrate..........13
Bydureon Pen..................... 38
Bydureon Vial.....................38
Byetta..................................38
Bystolic............................... 42
C
Cabergoline........................ 59
Cabometyx.......................... 31
Calcipotriene......................49
Calcitonin-Salmon............. 63
Calcitriol....................... 49, 63
Calcium Acetate................. 53
Camila.................................58
Canasa................................ 63
Cancidas............................. 26
Candesartan Cilexetil.........42
Candesartan Cilexetil/
Hydrochlorothiazide....... 44
Capastat Sulfate..................28
Caprelsa...............................31
Captopril.............................42
Captopril/
Hydrochlorothiazide....... 45
Carac...................................49
Carafate...............................52
Carbaglu............................. 70
Carbamazepine...................23
Carbamazepine ER............. 23
Carbidopa........................... 33
Carbidopa/Levodopa..........33
Carbidopa/Levodopa ER.... 33
Carbidopa/Levodopa ODT
.......................................... 33
Carbidopa/Levodopa/
Entacapone...................... 33
Carboplatin.........................29
Cardene IV..........................43
Carimune Nanofiltered...... 61
Carteolol HCl...................... 65
Cartia XT.............................43
Carvedilol........................... 42
Cayston...............................68
Caziant................................56
Cefaclor............................... 17
Cefadroxil............................17
Cefazolin Sodium................17
Cefdinir............................... 17
Cefepime............................. 17
Cefepime/Dextrose............. 17
Cefixime.............................. 17
Cefotaxime Sodium............ 17
Cefotetan.............................17
Cefoxitin Sodium................ 17
Cefpodoxime Proxetil......... 18
Cefprozil..............................18
Ceftazidime.........................18
Ceftazidime/Dextrose.........18
Ceftriaxone Sodium............18
Cefuroxime Axetil...............18
Cefuroxime Sodium............18
Celecoxib.............................12
Cellcept.............................. 60
Cellcept Intravenous..........60
Celontin...............................21
Cephalexin.......................... 18
Cerezyme............................50
Cervarix.............................. 62
Cesamet.............................. 26
Cetirizine HCl..................... 67
Chantix................................15
Chantix Continuing Month
Pak.................................... 15
Chantix Starting Month Pak
...........................................15
Chemet............................... 70
Chenodal............................. 51
96
Tracked
96
Chloramphenicol Sodium
Succinate.......................... 16
Chlordiazepoxide HCl........ 38
Chlorhexidine Gluconate
Oral Rinse.........................49
Chloroquine Phosphate......32
Chlorothiazide................... 46
Chlorothiazide Sodium......46
Chlorpromazine HCl.......... 33
Chlorthalidone...................46
Cholbam..............................51
Cholestyramine Light........ 47
Chorionic Gonadotropin.... 55
Ciclopirox........................... 26
Ciclopirox Nail Lacquer..... 26
Ciclopirox Olamine............ 26
Cidofovir............................. 35
Cilostazol............................ 41
Ciloxan............................... 20
Cimetidine.......................... 51
Cimetidine HCl................... 51
Cimzia................................ 60
Cinryze............................... 60
Cipro HC.............................66
Ciprodex............................. 66
Ciprofloxacin......................20
Ciprofloxacin ER................ 20
Ciprofloxacin HCl.............. 20
Ciprofloxacin I.V. in D5W
..........................................20
Cisplatin............................. 29
Citalopram HBr.................. 24
Cladribine...........................29
Claravis...............................50
Clarithromycin................... 19
Clarithromycin ER..............19
Climara Pro.........................56
Clindamycin HCl................ 16
Clindamycin Palmitate HCl
.......................................... 16
Clindamycin Phosphate.... 16,
50
Clindamycin Phosphate in
D5W.................................. 16
Clindamycin/Benzoyl
Peroxide........................... 50
Clinisol SF 15%.................... 71
Clobetasol Propionate........ 54
Clobetasol Propionate E.....54
Clolar.................................. 29
Clomipramine HCl............. 25
Clonazepam........................38
Clonazepam ODT............... 38
Clonidine HCl..................... 41
Clonidine HCl ER............... 48
Clopidogrel......................... 41
Clorazepate Dipotassium... 38
Clorpres.............................. 45
Clotrimazole....................... 26
Clotrimazole/Betamethasone
Dipropionate....................50
Clozapine............................ 35
Clozapine ODT....................35
Coartem.............................. 32
Codeine Sulfate...................13
Colchicine........................... 27
Colcrys................................ 27
Colestipol HCl.................... 47
Colistimethate Sodium.......16
Colocort.............................. 63
Coly-Mycin S...................... 66
Combigan........................... 65
Combivent Respimat......... 69
Combivir.............................36
Cometriq............................. 31
Complera............................ 36
Compro............................... 25
Constulose.......................... 52
Copaxone............................49
Cordran Tape......................54
Cormax Scalp Application
..........................................54
Cortisone Acetate............... 54
Cortisporin......................... 50
Cosmegen........................... 29
Cotellic................................ 31
Coumadin.......................... 40
Creon.................................. 50
Crestor................................ 46
Crinone............................... 58
Crixivan.............................. 37
Cromolyn Sodium... 51, 65, 69
Cryselle-28.......................... 56
Cubicin................................16
Cuprimine...........................53
Cuvposa...............................51
Cyclafem.............................56
Cyclobenzaprine HCl......... 69
Cyclophosphamide............ 28
Cycloset.............................. 38
Cyclosporine...................... 60
Cyclosporine Modified...... 60
Cyproheptadine HCl.......... 67
Cyramza.............................. 31
Cystadane............................51
Cystagon..............................51
Cystaran............................. 64
97
Tracked
97
Cytarabine Aqueous...........29
D
Dacarbazine........................28
Dacogen.............................. 29
Daklinza..............................35
Daliresp.............................. 68
Dalvance............................. 16
Danazol...............................56
Dantrolene Sodium............69
Dapsone.............................. 28
Daptacel..............................62
DARAPRIM......................... 32
Darzalex.............................. 31
Daunorubicin HCl.............. 29
Deblitane............................ 58
Decitabine.......................... 29
Delyla..................................56
Demeclocycline HCl.......... 20
Demser............................... 45
Denavir............................... 36
Depen Titratabs.................. 53
Depo-Estradiol................... 56
Depo-Medrol...................... 54
Depo-Provera......................58
Descovy.............................. 36
Desipramine HCl................ 25
Desmopressin Acetate........55
Desogestrel/Ethinyl
Estradiol........................... 56
Desonide.............................54
Desoximetasone................. 54
Dexamethasone..................54
Dexamethasone Intensol... 54
Dexamethasone Sodium
Phosphate...................54, 66
Dexedrine........................... 48
Dexilant.............................. 52
Dexmethylphenidate HCl
..........................................48
Dexmethylphenidate HCl ER
..........................................48
Dexrazoxane....................... 29
Dextroamphetamine Sulfate
..........................................48
Dextroamphetamine Sulfate
ER..................................... 48
Dextrose 10%.......................71
Dextrose 10%/NaCl 0.2%.... 71
Dextrose 10%/NaCl 0.45%
...........................................71
Dextrose 2.5%/NaCl 0.45%
...........................................71
Dextrose 5%.........................71
Dextrose 5%/Lactated
Ringers.............................. 71
Dextrose 5%/NaCl 0.2%...... 71
Dextrose 5%/NaCl 0.225%...71
Dextrose 5%/NaCl 0.33%.... 71
Dextrose 5%/NaCl 0.45%....72
Dextrose 5%/NaCl 0.9%......72
Dextrose 5%/Potassium
Chloride 0.15%..................72
Diastat AcuDial................... 21
Diastat Pediatric................. 22
Diazepam...................... 22, 38
Diazepam Intensol............. 38
Dibenzyline........................ 41
Diclofenac Potassium......... 12
Diclofenac Sodium.......12, 50,
66
Diclofenac Sodium DR........12
Diclofenac Sodium ER........ 12
Dicloxacillin Sodium.......... 19
Dicyclomine HCl.................51
Didanosine......................... 36
Dificid................................. 19
Diflunisal.............................12
Digitek................................ 45
Digoxin............................... 45
Dihydroergotamine Mesylate
.......................................... 27
Dilantin...............................23
Dilantin INFATABS............ 23
Dilt-XR................................43
Diltiazem CD...................... 43
Diltiazem HCl.....................43
Diltiazem HCl ER............... 43
Dipentum........................... 63
Diphenhydramine HCl.......67
Diphenoxylate/Atropine.... 51
Diphtheria/Tetanus Toxoids
Adsorbed Pediatric.......... 62
Disulfiram........................... 15
Diuril.................................. 46
Divalproex Sodium.............22
Divalproex Sodium DR....... 22
Divalproex Sodium ER....... 22
Docefrez..............................29
Docetaxel...................... 29, 30
Dofetilide............................42
Donepezil HCl.....................23
Donepezil HCl ODT............ 23
Doribax................................18
Dorzolamide HCl................65
Dorzolamide HCl/Timolol
Maleate.............................65
Doxazosin Mesylate........... 42
Doxepin HCl..................25, 50
Doxercalciferol................... 63
98
Tracked
98
Doxil................................... 30
Doxorubicin HCl................ 30
Doxorubicin HCl Liposome
..........................................30
Doxy 100.............................20
Doxycycline........................20
Doxycycline Hyclate...........21
Doxycycline Monohydrate
...........................................21
Dronabinol......................... 26
Drospirenone/Ethinyl
Estradiol........................... 56
Droxia................................. 29
Duavee................................ 56
Dulera................................. 69
Duloxetine HCl...................49
Duramorph......................... 14
Durezol............................... 66
Dymista.............................. 69
Dyrenium........................... 46
E
E.E.S. 400............................19
E.E.S. Granules................... 19
Econazole Nitrate...............26
Edarbi................................. 42
Edarbyclor.......................... 45
Edecrin............................... 46
Edurant...............................36
Effient................................. 41
Egrifta................................. 59
Elaprase...............................51
Elelyso.................................51
Elestrin............................... 56
Elidel.................................. 50
Eliphos................................53
Eliquis................................ 40
Elitek...................................29
Ellence................................30
Elmiron...............................53
Embeda............................... 13
Emcyt..................................29
Emend................................ 26
Emoquette.......................... 56
Empliciti............................. 31
Emsam................................24
Emtriva............................... 37
Enalapril Maleate............... 42
Enalapril Maleate/
Hydrochlorothiazide....... 45
Enbrel.................................60
Enbrel SureClick................ 60
Endocet...............................14
Engerix-B............................62
Enoxaparin Sodium...........40
Enpresse-28........................ 56
Entacapone.........................32
Entecavir.............................35
Entocort EC........................ 63
Entresto.............................. 45
Enulose............................... 52
Epaned................................42
Epclusa............................... 35
Epinastine HCl................... 65
EpiPen................................ 68
Epirubicin HCl................... 30
Epitol.................................. 23
Epivir.................................. 37
Epivir HBV..........................35
Eplerenone.........................46
Eprosartan Mesylate.......... 42
Epzicom.............................. 37
Equetro............................... 38
Eraxis.................................. 26
Erbitux................................ 31
Erivedge.............................. 31
Errin....................................58
Erwinaze.............................30
Ery...................................... 50
Ery-Tab............................... 19
EryPed 200..........................19
EryPed 400......................... 19
Erythrocin Lactobionate.... 19
Erythromycin................19, 50
Erythromycin Base............. 19
Erythromycin
Ethylsuccinate..................19
Erythromycin/Benzoyl
Peroxide........................... 50
Esbriet................................ 69
Escitalopram Oxalate......... 24
Esomeprazole Magnesium
.......................................... 52
Esomeprazole Sodium........52
Estrace................................ 56
Estradiol..............................57
Estradiol Valerate............... 57
Estring.................................57
Ethambutol HCl................. 28
Ethosuximide......................21
Etidronate Disodium..........63
Etodolac.............................. 12
Etodolac ER.........................12
Etopophos........................... 31
Etoposide............................ 31
Eurax...................................32
Evotaz................................. 36
Exelderm............................ 26
99
Tracked
99
Exelon................................. 23
Exemestane.........................31
Exjade................................. 70
F
Fabrazyme.......................... 51
Falmina...............................57
Famciclovir.........................36
Famotidine..........................51
Famotidine Premixed......... 51
Fanapt.................................34
Fanapt Titration Pack........ 34
Fareston..............................29
Farydak...............................30
Faslodex..............................29
Fazaclo................................ 35
Felbamate........................... 22
Felbatol............................... 22
Felodipine ER.....................43
Femring.............................. 57
Fenofibrate.........................46
Fenofibrate Micronized..... 46
Fenofibric Acid.................. 46
Fenofibric Acid DR.............46
Fentanyl.............................. 13
Ferriprox.............................70
Fetzima...............................24
Fetzima Titration Pack.......24
Finasteride..........................53
Firazyr................................ 60
Firmagon...................... 59, 60
Flarex..................................66
Flebogamma DIF................ 61
Flecainide Acetate..............42
Flector................................. 12
Flovent Diskus....................67
Flovent HFA....................... 67
Fluconazole........................ 26
Fluconazole in Dextrose.....26
Fluconazole in NaCl........... 26
Flucytosine......................... 26
Fludarabine Phosphate......30
Fludrocortisone Acetate.... 54
Flunisolide..........................67
Fluocinolone Acetonide....54,
66
Fluocinolone Acetonide
Body................................. 54
Fluocinonide...................... 54
Fluocinonide-E.................. 54
Fluorometholone............... 66
Fluorouracil.................. 29, 50
Fluoxetine DR.....................24
Fluoxetine HCl................... 24
Fluphenazine Decanoate... 33
Fluphenazine HCl.............. 33
Flurbiprofen........................12
Flurbiprofen Sodium......... 66
Flutamide........................... 29
Fluticasone Propionate..... 54,
67
Fluvastatin......................... 46
Fluvoxamine Maleate.........24
FML.................................... 66
FML Forte........................... 66
Folotyn............................... 29
Fomepizole.........................64
Fondaparinux Sodium.......40
Fortaz.................................. 18
Forteo................................. 63
Fosinopril Sodium..............42
Fosinopril Sodium/
Hydrochlorothiazide....... 45
Fosphenytoin Sodium........ 23
Fosrenol.............................. 53
FreAmine HBC 6.9%...........72
Furosemide........................ 46
Fusilev................................ 30
Fuzeon................................ 37
Fycompa..............................21
G
Gabapentin......................... 22
Gabitril................................22
Gablofen............................. 69
Galantamine HBr............... 23
Gamastan S/D..................... 61
Gammagard Liquid.............61
Gammaked..........................61
Gammaplex.........................61
Gamunex-C......................... 61
Ganciclovir......................... 35
Gardasil.............................. 62
Gardasil 9............................62
Gatifloxacin........................20
Gattex.................................. 51
Gauze..................................64
GaviLyte-C.......................... 52
GaviLyte-G..........................52
GaviLyte-H......................... 52
GaviLyte-N/Flavor Pack..... 52
Gemcitabine HCl................ 29
Gemfibrozil........................ 46
Gemzar............................... 29
Generlac..............................52
Gengraf...............................60
Genotropin......................... 55
100
Tracked
100
Genotropin Miniquick........55
Gentak................................. 15
Gentamicin Sulfate............. 15
Gentamicin Sulfate/0.9%
Sodium Chloride.............. 16
Genvoya..............................36
Geodon............................... 34
Gianvi..................................57
Giazo...................................63
Gildagia...............................57
Gildess 1.5/30...................... 57
Gildess 24 Fe....................... 57
Gilenya............................... 49
Gilotrif.................................31
Glassia................................ 69
Glatopa............................... 49
Gleostine.............................28
Glimepiride........................ 38
Glipizide............................. 38
Glipizide ER........................38
Glipizide/Metformin HCl...38
GlucaGen HypoKit............. 39
Glucagon Emergency Kit... 39
Glycopyrrolate.................... 51
Glyset.................................. 38
Granisetron HCl................. 26
Granix................................. 41
Griseofulvin Microsize....... 26
Griseofulvin Ultramicrosize
.......................................... 26
Guanfacine ER................... 48
Guanidine HCl....................28
H
Halaven.............................. 30
Halobetasol Propionate..... 54
Haloperidol.........................33
Haloperidol Decanoate...... 33
Haloperidol Lactate............33
Harvoni...............................35
Havrix................................. 62
Hectorol..............................63
Heparin Sodium.................40
Heparin Sodium/D5W....... 40
HepatAmine....................... 72
Hepsera...............................35
Herceptin............................ 31
Hetlioz................................ 70
Hexalen...............................28
Hiberix................................62
Humalog Cartridge.............39
Humalog KwikPen............. 39
Humalog Mix 50/50 KwikPen
.......................................... 39
Humalog Mix 50/50 Vial.... 39
Humalog Mix 75/25 KwikPen
.......................................... 39
Humalog Mix 75/25 Vial..... 39
Humalog Vial..................... 39
Humatrope......................... 55
Humatrope Combo Pack.... 55
Humira............................... 60
Humira Pediatric Crohns
Disease Starter Pack.........60
Humira Pen........................60
Humira Pen Crohns Disease
Starter Pack......................60
Humira Pen-Psoriasis Starter
.......................................... 61
Humulin 70/30 KwikPen...40
Humulin 70/30 Vial........... 40
Humulin N KwikPen......... 40
Humulin N Vial..................40
Humulin R U-500 KwikPen
......................................... 40
Humulin R U-500 Vial.......40
Humulin R Vial.................. 40
Hycamtin............................ 31
Hydralazine HCl.................47
Hydrochlorothiazide......... 46
Hydrocodone Bitartrate/
Acetaminophen................14
Hydrocodone/
Acetaminophen................14
Hydrocodone/Ibuprofen.... 14
Hydrocortisone.............54, 63
Hydrocortisone Butyrate... 54
Hydrocortisone Valerate....54
Hydrocortisone/Acetic Acid
..........................................66
Hydromorphone HCl......... 14
Hydromorphone HCl ER.... 13
Hydroxychloroquine Sulfate
.......................................... 32
Hydroxyprogesterone
Caproate........................... 59
Hydroxyurea...................... 29
Hydroxyzine HCl................38
Hydroxyzine Pamoate........ 25
I
Ibandronate Sodium.......... 64
Ibrance............................... 30
Ibuprofen............................ 12
Iclusig..................................31
Idamycin PFS..................... 30
Idarubicin HCl................... 30
Ifosfamide...........................28
Ilaris....................................62
Ilevro.................................. 66
Ilotycin................................19
101
Tracked
101
Imatinib Mesylate...............31
Imbruvica............................31
Imipenem/Cilastatin.......... 18
Imipramine HCl..................25
Imipramine Pamoate..........25
Imiquimod......................... 50
Imovax Rabies.................... 62
Increlex............................... 55
Indapamide........................46
Infanrix...............................62
Inlyta................................... 31
Insulin Syringes, Needles
..........................................64
Intelence.............................36
Intralipid.............................72
Intron A...............................35
Intron A w/Diluent............. 35
Introvale............................. 57
Invanz................................. 18
Invega................................. 34
Invega Sustenna................. 34
Invega Trinza..................... 34
Invirase............................... 37
Invokamet.......................... 38
Invokana.............................39
Ionosol-B/Dextrose 5%....... 72
Ionosol-MB/Dextrose 5%....72
IPOL Inactivated IPV..........62
Ipratropium Bromide... 67, 68
Ipratropium Bromide/
Albuterol Sulfate..............69
Irbesartan........................... 42
Irbesartan/
Hydrochlorothiazide....... 45
Iressa................................... 31
Irinotecan...........................30
Isentress............................. 36
Isolyte-P/Dextrose 5%........ 72
Isolyte-S..............................70
Isoniazid............................. 28
Isosorbide Dinitrate........... 47
Isosorbide Dinitrate ER......47
Isosorbide Mononitrate......47
Isosorbide Mononitrate ER
.......................................... 47
Isotonic Gentamicin........... 16
Istodax................................30
Itraconazole........................26
Ivermectin.......................... 32
Ixempra Kit........................ 30
Ixiaro...................................62
J
Jadenu................................ 70
Jakafi...................................31
Jantoven............................ 40
Janumet..............................39
Janumet XR........................39
Januvia............................... 39
Jardiance............................ 39
Jentadueto..........................39
Jentadueto XR....................39
Jevtana............................... 30
Jinteli.................................. 57
Jolivette.............................. 59
Jublia.................................. 26
Juleber................................ 57
Junel 1.5/30.........................57
Junel 1/20............................57
Junel Fe 1.5/30.................... 57
Junel Fe 1/20.......................57
Junel Fe 24..........................57
Juxtapid..............................47
K
K-Tab.................................. 70
Kadcyla............................... 31
Kaitlib Fe.............................57
Kaletra.................................37
Kalydeco....................... 68, 69
Kanuma..............................64
Kariva..................................57
Kazano................................ 39
KCl 0.075%/D5W/NaCl
0.45%................................ 72
KCl 0.15%/D5W/LR............. 72
KCl 0.15%/D5W/NaCl 0.2%
.......................................... 72
KCl 0.15%/D5W/NaCl 0.225%
.......................................... 72
KCl 0.15%/D5W/NaCl 0.9%
.......................................... 72
KCl 0.3%/D5W/NaCl 0.45%
.......................................... 72
KCl 0.3%/D5W/NaCl 0.9%
.......................................... 72
Kelnor 1/35.......................... 57
Kenalog-10..........................54
Kenalog-40......................... 54
Kepivance...........................49
Ketoconazole...................... 27
Ketoprofen.......................... 12
Ketorolac Tromethamine
.....................................12, 66
Keytruda............................. 31
Kimidess............................. 57
Kineret................................ 61
Kionex................................ 70
Klor-Con 10.........................70
Klor-Con 8.......................... 70
102
Tracked
102
Klor-Con M15......................70
Klor-Con M20..................... 70
Klor-Con Sprinkle.............. 70
Kombiglyze XR...................39
Korlym................................56
Kuvan.................................. 51
Kynamro.............................47
L
Labetalol HCl......................43
Lacrisert............................. 64
Lactated Ringers Irrigation
.......................................... 72
Lactated Ringers Viaflex.... 72
Lactulose.............................52
Lamivudine................... 35, 37
Lamivudine/Zidovudine.... 37
Lamotrigine........................ 22
Lanoxin...............................45
Lantus SoloStar.................. 40
Lantus Vial......................... 40
LARIN 1.5/30.......................57
LARIN 1/20..........................57
LARIN Fe 1.5/30.................. 57
LARIN Fe 1/20.....................57
Larissia................................57
Lastacaft............................. 64
Latanoprost........................ 66
Latuda.................................34
Layolis Fe............................ 57
Leflunomide....................... 62
Lenvima.............................. 31
Lessina................................ 57
Letairis................................68
Letrozole............................. 31
Leucovorin Calcium...........30
Leukeran.............................28
Leukine............................... 41
Leuprolide Acetate.............60
Levalbuterol....................... 68
Levemir FlexTouch............40
Levemir Vial.......................40
Levetiracetam..................... 21
Levetiracetam ER................21
Levobunolol HCl................ 65
Levocarnitine......................72
Levocetirizine
Dihydrochloride...............67
Levofloxacin.......................20
Levofloxacin in D5W.......... 20
Levoleucovorin Calcium....30
Levonest..............................57
Levonorgestrel and Ethinyl
Estradiol........................... 57
Levonorgestrel/Ethinyl
Estradiol........................... 57
Levora 0.15/30-28............... 57
Levorphanol Tartrate..........13
Levothyroxine Sodium.......59
Levoxyl............................... 59
Lexiva..................................37
Lialda.................................. 63
Lidocaine............................ 15
Lidocaine HCl..................... 15
Lidocaine Viscous............... 15
Lidocaine/Prilocaine.......... 15
Lincocin.............................. 16
Lincomycin HCl..................16
Lindane...............................32
Linezolid............................. 16
Linzess................................ 52
Lioresal Intrathecal............69
Liothyronine Sodium......... 59
Lisinopril............................ 42
Lisinopril/
Hydrochlorothiazide....... 45
Lithium...............................38
Lithium Carbonate............. 38
Lithium Carbonate ER....... 38
Lithostat..............................53
Lomedia 24 Fe.....................57
Lonsurf............................... 29
Loperamide HCl..................51
Lorazepam..........................38
Lorazepam Intensol........... 38
Lorcet.................................. 14
Lorcet HD............................14
Lorcet Plus.......................... 14
Lortab..................................14
Loryna.................................57
Losartan Potassium............42
Losartan Potassium/
Hydrochlorothiazide....... 45
Lotemax..............................66
Lotronex..............................52
Lovastatin...........................46
Low-Ogestrel.......................57
Loxapine Succinate............ 33
Lumigan............................. 66
Lumizyme........................... 51
Lupaneta Pack....................60
Lupron Depot.....................60
Lupron Depot-PED............ 60
Lutera..................................57
Lynparza.............................30
Lyrica..................................49
Lysodren.............................59
Lyza.....................................59
103
Tracked
103
M
M-M-R II............................. 62
Magnesium Sulfate............ 70
Makena............................... 59
Malathion........................... 32
Maprotiline HCl................. 24
Marlissa...............................57
Marplan.............................. 24
Matulane.............................28
Matzim LA.......................... 43
Meclizine HCl..................... 25
Medroxyprogesterone
Acetate..............................59
Mefloquine HCl.................. 32
Megace ES...........................59
Megestrol Acetate...............59
Mekinist.............................. 31
Meloxicam...........................12
Melphalan HCl................... 28
Memantine HCl.................. 23
Memantine HCl Titration
Pak.................................... 23
Menactra.............................62
Menest................................ 57
MENHIBRIX....................... 62
Menomune-A/C/Y/W-135...62
Mentax................................ 27
Menveo............................... 62
Mepron............................... 32
Mercaptopurine..................29
Meropenem.........................18
Mesalamine........................ 63
Mesna................................. 30
Mesnex............................... 30
Mestinon.............................28
Mestinon Timespan........... 28
Metadate ER....................... 48
Metaproterenol Sulfate...... 68
Metformin HCl................... 39
Metformin HCl ER..............39
Methadone HCl...................13
Methazolamide...................65
Methenamine Hippurate....16
Methimazole...................... 60
Methotrexate...................... 61
Methotrexate Sodium.........61
Methoxsalen.......................50
Methscopolamine Bromide
...........................................51
Methyclothiazide............... 46
Methyldopa.........................41
Methyldopa/
Hydrochlorothiazide....... 45
Methyldopate HCl.............. 41
Methylergonovine Maleate
..........................................64
Methylphenidate HCl........ 48
Methylphenidate HCl ER...48
Methylprednisolone...........54
Methylprednisolone Acetate
..........................................54
Methylprednisolone Dose
Pack.................................. 54
Methylprednisolone Sodium
Succinate..........................54
Metipranolol.......................65
Metoclopramide HCl.......... 25
Metolazone.........................46
Metoprolol Succinate ER... 43
Metoprolol Tartrate............43
Metoprolol/
Hydrochlorothiazide....... 45
Metronidazole.....................16
Metronidazole in NaCl 0.79%
.......................................... 16
Metronidazole Vaginal....... 17
Mexiletine HCl................... 42
Miacalcin............................64
Miconazole 3.......................27
Microgestin 1.5/30.............. 57
Microgestin 1/20................. 57
Microgestin Fe.................... 57
Microgestin Fe 1.5/30..........57
Midodrine HCl....................41
Migergot..............................27
Miglitol............................... 39
Millipred............................. 55
Minitran..............................47
Minocycline HCl................. 21
Minoxidil............................ 47
Mirtazapine........................ 24
Mirtazapine ODT................24
Mirvaso...............................50
Misoprostol......................... 52
Mitomycin..........................30
Mitoxantrone HCl.............. 30
Modafinil............................ 70
Moexipril HCl..................... 42
Moexipril/
Hydrochlorothiazide....... 45
Molindone HCl................... 33
Mometasone Furoate.... 55, 67
MonoNessa......................... 57
Montelukast Sodium.......... 67
Morphine Sulfate................14
Morphine Sulfate ER.......... 13
Moxeza............................... 20
Moxifloxacin HCl............... 20
Mozobil............................... 41
104
Tracked
104
Multaq................................ 42
Mupirocin............................17
Mustargen...........................28
Myalept.............................. 64
Mycamine........................... 27
Mycophenolate Mofetil...... 61
Mycophenolic Acid DR.......61
Myrbetriq............................ 52
N
Nabumetone....................... 12
Nadolol............................... 43
Nadolol/
Bendroflumethiazide.......45
Nafcillin in Dextrose...........19
Nafcillin Sodium.................19
Naftifine HCl...................... 27
Naftin..................................27
Naglazyme.......................... 51
Nalbuphine HCl..................14
Naloxone HCl......................15
Naltrexone HCl................... 15
Namenda............................ 24
Namenda Titration Pak......24
Namenda XR...................... 24
Namenda XR Titration Pack
..........................................24
Namzaric............................ 48
Naproxen............................ 12
Naproxen DR.......................13
Naproxen Sodium...............13
Naratriptan HCl..................27
Narcan.................................15
Nasonex.............................. 67
Natacyn...............................27
Nateglinide.........................39
Natpara...............................64
Nebupent............................ 32
Necon 0.5/35-28.................. 57
Necon 1/35...........................57
Necon 1/50-28..................... 57
Necon 10/11-28.................... 57
Necon 7/7/7......................... 57
Nefazodone HCl................. 24
Neomycin Sulfate............... 16
Neomycin/Bacitracin/
Polymyxin........................64
Neomycin/Polymyxin B
Sulfates............................. 17
Neomycin/Polymyxin/
Bacitracin/Hydrocortisone
..........................................64
Neomycin/Polymyxin/
Dexamethasone............... 64
Neomycin/Polymyxin/
Gramicidin.......................64
Neomycin/Polymyxin/
Hydrocortisone.......... 64, 67
Nephramine........................72
Nesina.................................39
Neulasta..............................41
Neupogen........................... 41
Nevanac..............................66
Nevirapine..........................36
Nevirapine ER.................... 36
Nexavar............................... 31
Nexium............................... 52
Niacin ER............................47
Niacor................................. 47
Nicardipine HCl................. 44
Nicotrol Inhaler.................. 15
Nifedical XL....................... 44
Nifedipine ER.....................44
Nikki................................... 58
Nilandron........................... 29
Nilutamide......................... 29
Nimodipine........................44
Ninlaro............................... 30
Nipent.................................29
Nitro-Bid.............................47
Nitrofurantoin.................... 17
Nitrofurantoin Macrocrystals
...........................................17
Nitrofurantoin Monohydrate
...........................................17
Nitroglycerin...................... 47
Nitroglycerin Lingual.........47
Nitroglycerin Transdermal
.......................................... 47
Nitrostat............................. 47
Nora-BE.............................. 59
Norditropin FlexPro........... 55
Norethindrone................... 59
Norethindrone & Ethinyl
Estradiol Ferrous Fumarate
.......................................... 58
Norethindrone Acetate...... 59
Norethindrone Acetate/
Ethinyl Estradiol/Ferrous
Fumarate.......................... 58
Norgestimate/Ethinyl
Estradiol........................... 58
Norlyroc..............................59
Normosol-M in D5W...........72
Normosol-R........................ 70
Normosol-R in D5W............72
Northera............................. 45
Nortrel 0.5/35..................... 58
Nortrel 1/35......................... 58
Nortrel 7/7/7........................58
Nortriptyline HCl............... 25
105
Tracked
105
Norvir..................................37
Novarel............................... 55
Noxafil................................ 27
Nucynta ER......................... 13
Nuedexta............................ 48
Nulojix................................ 61
Nuplazid............................. 34
NutreStore.......................... 72
Nutrilipid............................ 72
Nutropin AQ....................... 55
NuvaRing............................58
Nyamyc...............................27
Nystatin.............................. 27
Nystop.................................27
O
Ocaliva................................ 51
Ocella.................................. 58
Octagam.............................. 61
Octreotide Acetate............. 60
Odefsey............................... 36
Odomzo...............................31
Ofev.................................... 69
Ofloxacin............................ 20
Ogestrel...............................58
Olanzapine......................... 34
Olanzapine ODT.................34
Olopatadine HCl.................65
Olysio.................................. 35
Omega-3-Acid Ethyl Esters
.......................................... 47
Omeprazole.........................52
Omnitrope.......................... 56
Oncaspar............................ 30
Ondansetron HCl............... 26
Ondansetron ODT.............. 26
Onfi..................................... 22
Onglyza...............................39
ONMEL............................... 27
Opana ER............................ 13
Opdivo.................................31
Opsumit..............................68
Orap.................................... 33
Orencia................................61
Orencia Clickject.................61
Orenitram..................... 68, 69
Orfadin................................ 51
Orkambi..............................68
Orphenadrine Citrate.........70
Orsythia.............................. 58
Oseni...................................39
Otezla..................................62
Oxacillin Sodium................ 19
Oxaliplatin..........................30
Oxandrolone.......................56
Oxaprozin............................13
Oxcarbazepine....................23
Oxiconazole Nitrate............27
Oxistat.................................27
Oxsoralen Ultra.................. 50
Oxybutynin Chloride..........53
Oxybutynin Chloride ER.... 53
Oxycodone HCl...................14
Oxycodone/Acetaminophen
.......................................... 14
Oxycodone/Aspirin.............15
Oxycodone/Ibuprofen........ 15
P
Pacerone............................. 42
Paclitaxel............................ 30
Paliperidone ER................. 34
Pamidronate Disodium......64
Panretin.............................. 32
Pantoprazole Sodium......... 52
Paricalcitol......................... 64
Paromomycin Sulfate......... 16
Paroxetine HCl................... 24
Paser................................... 28
Pataday............................... 65
Patanol................................65
Paxil.................................... 24
Pazeo...................................65
Pedvax HIB......................... 62
PEG-3350/Electrolytes....... 52
PEG-3350/NaCl/Na
Bicarbonate/KCl...............52
Peganone............................ 23
Pegasys................................35
Pegasys ProClick.................35
PegIntron............................ 35
PegIntron REDIPEN........... 35
Penicillin G Potassium....... 19
Penicillin G Procaine.......... 19
Penicillin G Sodium............19
Penicillin V Potassium....... 19
Pentam 300.........................32
Pentasa............................... 63
Pentoxifylline ER............... 45
Perforomist.........................68
Perindopril Erbumine........42
Periogard............................ 49
Perjeta................................. 31
Permethrin......................... 32
Perphenazine......................25
Phenadoz............................ 67
Phenelzine Sulfate............. 24
106
Tracked
106
Phenergan...........................67
Phenobarbital..................... 22
Phenoxybenzamine HCl.... 42
Phenytek.............................23
Phenytoin........................... 23
Phenytoin Sodium..............23
Phenytoin Sodium Extended
.......................................... 23
PhosLo................................ 53
Phoslyra.............................. 53
Phospholine Iodide............ 65
Physiolyte...........................70
Physiosol Irrigation............70
Picato..................................50
Pilocarpine HCl............ 49, 66
Pimozide.............................33
Pimtrea............................... 58
Pindolol.............................. 43
Pioglitazone HCl.................39
Pioglitazone HCl/
Glimepiride...................... 39
Pioglitazone HCl/Metformin
HCl....................................39
Piperacillin/Tazobactam.... 19
Pirmella 1/35....................... 58
Piroxicam............................ 13
Plasma-Lyte A.................... 70
Plasma-Lyte-148.................70
Plasma-Lyte-56/D5W..........72
Plenamine...........................72
Podofilox............................ 50
Polyethylene Glycol 3350
Powder..............................52
Polymyxin B Sulfate............17
Polymyxin B Sulfate/
Trimethoprim Sulfate...... 65
Pomalyst............................. 29
Portia-28............................. 58
Potassium Chloride.......70, 71
Potassium Chloride 0.15% /
NaCl 0.45% Viaflex........... 71
Potassium Chloride 0.15%
D5W/NaCl 0.33%.............. 72
Potassium Chloride 0.15%
D5W/NaCl 0.45%..............72
Potassium Chloride 0.15%/
NaCl 0.9%......................... 71
Potassium Chloride 0.22%
D5W/NaCl 0.45%..............72
Potassium Chloride 0.3%/
NaCl 0.9%......................... 71
Potassium Chloride 0.3%/
D5W.................................. 72
Potassium Chloride ER....... 71
Potassium Chloride ER
Microencapsulated........... 71
Potassium Citrate ER.......... 71
Potiga.................................. 21
Pradaxa.............................. 40
Praluent.............................. 47
Pramipexole
Dihydrochloride...............32
Pravastatin Sodium............47
Prazosin HCl.......................42
Pred Mild............................ 66
Pred-G.................................65
Pred-G S.O.P....................... 65
Prednicarbate..................... 55
Prednisolone Acetate......... 66
Prednisolone Sodium
Phosphate................... 55, 66
Prednisone..........................55
Prednisone Intensol........... 55
Pregnyl w/Diluent Benzyl
Alcohol/NaCl....................56
Premarin.............................58
Premasol............................. 72
Premphase.......................... 58
Prempro.............................. 58
Prevalite..............................47
Previfem............................. 58
Prezcobix............................ 36
Prezista............................... 37
Priftin..................................28
Primaquine Phosphate.......32
Primidone........................... 22
Pristiq..................................25
Privigen...............................61
ProAir HFA......................... 68
ProAir RespiClick............... 68
Probenecid..........................27
Probenecid/Colchicine.......27
Procainamide HCl.............. 42
Procalamine........................72
Prochlorperazine................ 25
Prochlorperazine Edisylate
.......................................... 25
Prochlorperazine Maleate
.......................................... 25
Procrit................................. 41
Procto-Med HC...................63
Procto-Pak.......................... 63
Proctosol HC.......................63
Proctozone-HC................... 63
Procysbi...............................51
Progesterone.......................59
Proglycem...........................39
Prograf................................ 61
Prolastin-C..........................69
107
Tracked
107
Prolensa..............................66
Proleukin............................30
Prolia.................................. 64
Promacta.............................41
Promethazine HCl.............. 67
Promethegan...................... 67
Propafenone HCl................42
Propafenone HCl ER.......... 42
Proparacaine HCl............... 65
Propranolol HCl................. 43
Propranolol HCl ER............43
Propranolol/
Hydrochlorothiazide....... 45
Propylthiouracil.................60
ProQuad..............................62
Prosol.................................. 72
Protriptyline HCl................ 25
PRUDOXIN.........................50
Pulmicort............................67
Pulmozyme........................ 69
Purixan............................... 29
Pyrazinamide..................... 28
Pyridostigmine Bromide.... 28
Q
Quadracel........................... 62
Quasense.............................58
Quetiapine Fumarate......... 34
Quinapril HCl..................... 42
Quinapril/
Hydrochlorothiazide....... 45
Quinidine Gluconate..........42
Quinidine Gluconate CR.... 42
Quinidine Sulfate............... 42
Quinine Sulfate...................32
R
Rabavert............................. 62
Raloxifene HCl................... 59
Ramipril..............................42
Ranexa................................ 45
Ranitidine HCl....................52
Rapaflo................................53
Rapamune...........................61
RAVICTI.............................. 51
Rebif................................... 49
Rebif Rebidose................... 49
Rebif Rebidose Titration
Pack..................................49
Rebif Titration Pack........... 49
Reclipsen............................ 58
Recombivax HB..................62
Regranex.............................50
Relenza Diskhaler...............37
Relistor................................ 51
Remicade............................ 61
Remodulin..........................69
Renagel............................... 53
Renvela............................... 53
Repaglinide........................ 39
Repaglinide/Metformin HCl
.......................................... 39
Repatha.............................. 47
Repatha Pushtronex System
.......................................... 47
Repatha SureClick..............47
Rescriptor........................... 36
Restasis............................... 65
Retrovir IV Infusion............37
Revatio............................... 69
Revlimid............................. 29
Rexulti................................ 34
Reyataz............................... 37
Ribasphere..........................35
Ribavirin............................. 35
Ridaura............................... 62
Rifabutin.............................28
Rifampin.............................28
Rifater................................. 28
Rilutek................................ 48
Riluzole.............................. 48
Rimantadine HCl................37
Ringers Injection................ 72
Ringers Irrigation............... 72
Riomet................................ 39
Risedronate Sodium.......... 64
Risperdal Consta................ 34
Risperidone........................ 34
Risperidone ODT................34
Rituxan................................31
Rivastigmine Tartrate........ 23
Rivastigmine Transdermal
System.............................. 23
Rizatriptan Benzoate..........27
Rizatriptan Benzoate ODT
.......................................... 27
Ropinirole HCl....................33
Rosuvastatin Calcium........ 47
Rotarix................................ 62
RotaTeq.............................. 62
Roweepra............................ 21
Rozerem............................. 70
Ruconest............................ 60
S
Sabril................................... 22
Saizen................................. 56
Samsca................................70
Sancuso...............................26
Sandimmune...................... 61
Sandostatin LAR Depot..... 60
108
Tracked
108
Santyl..................................50
Saphris................................34
Savella................................ 49
Savella Titration Pack........ 49
Selegiline HCl..................... 33
Selenium Sulfide................ 50
Selzentry............................. 37
Sensipar.............................. 59
Serevent Diskus..................68
Seroquel XR........................ 34
Serostim.............................. 51
Sertraline HCl..................... 25
Setlakin...............................58
sfRowasa.............................63
Sharobel..............................59
Signifor...............................60
Sildenafil............................ 69
Silver Sulfadiazine............. 20
Simbrinza........................... 66
Simponi...............................61
Simponi Aria.......................61
Simulect..............................62
Simvastatin.........................47
Sirolimus.............................61
Sirturo.................................28
Sodium Chloride................. 71
Sodium Chloride 0.45%...... 71
Sodium Chloride 0.9%........ 71
Sodium Fluoride................. 71
Sodium Lactate...................72
Sodium Phenylbutyrate......51
Sodium Polystyrene
Sulfonate.......................... 70
Sodium Sulfacetamide.......20
Solaraze.............................. 50
Soltamox.............................29
Solu-Cortef..........................55
Solu-Medrol........................ 55
Somatuline Depot.............. 60
Somavert............................ 60
Soriatane............................ 50
Sotalol HCl..........................42
Sovaldi................................ 35
Spiriva HandiHaler............ 68
Spiriva Respimat................ 68
Spironolactone...................46
Spironolactone/
Hydrochlorothiazide....... 45
Sporanox............................. 27
Sprintec 28.......................... 58
Spritam................................21
Sprycel.................................31
SPS...................................... 70
Sronyx.................................58
SSD..................................... 20
Stavudine............................37
Stelara................................. 61
Sterile Water Irrigation...... 64
Stiolto Respimat.................69
Stivarga............................... 31
Strattera..............................48
Strensiq............................... 51
Streptomycin Sulfate..........16
Stribild................................ 36
Suboxone.............................15
Sucraid................................ 51
Sucralfate............................52
Sulfacetamide Sodium.......20
Sulfacetamide Sodium/
Prednisolone Sodium
Phosphate.........................65
Sulfadiazine....................... 20
Sulfamethoxazole/
Trimethoprim.................. 20
Sulfamethoxazole/
Trimethoprim DS.............20
Sulfamylon..........................17
Sulfasalazine...................... 63
Sulindac.............................. 13
Sumatriptan........................27
Sumatriptan Succinate.......28
Sumatriptan Succinate Refill
.......................................... 28
Sumavel DosePro................28
Suprax................................. 18
Suprep Bowel Prep..............52
Surmontil............................25
Sustiva................................ 36
Sutent.................................. 31
Sylatron.............................. 35
Sylvant................................ 31
Symbicort........................... 69
SymlinPen 120.................... 39
SymlinPen 60..................... 39
Synagis................................62
Synarel............................... 60
Synercid.............................. 17
Synjardy..............................39
Synribo............................... 30
Synthroid............................59
Syprine............................... 70
T
Tabloid................................29
Tacrolimus.................... 50, 61
Tafinlar............................... 31
Tagrisso............................... 31
Tamiflu............................... 37
109
Tracked
109
Tamoxifen Citrate.............. 29
Tamsulosin HCl..................53
Tarceva................................31
Targretin............................. 32
Tarina Fe 1/20..................... 58
Tasigna................................31
Tasmar................................ 32
Taxotere............................. 30
Tazicef.................................18
Tazorac............................... 50
Taztia XT............................ 44
Tecentriq.............................31
Tecfidera............................ 49
Tecfidera Starter Pack........49
Tegretol-XR........................ 23
Telmisartan........................ 42
Telmisartan/Amlodipine... 45
Telmisartan/
Hydrochlorothiazide....... 45
Temazepam........................70
Tenivac............................... 62
Terazosin HCl..................... 53
Terbinafine HCl.................. 27
Terbutaline Sulfate............ 68
Terconazole........................ 27
Testosterone Cypionate..... 56
Testosterone Enanthate.....56
Tetanus/Diphtheria Toxoids-
Adsorbed Adult................ 62
Tetrabenazine.................... 49
Tetracycline HCl................. 21
Thalomid............................ 29
Theophylline...................... 68
Theophylline CR................ 68
Theophylline ER................ 68
Thioridazine HCl................ 33
Thiotepa............................. 30
Thiothixene........................ 33
Thymoglobulin................... 61
Thyrolar..............................59
Tiagabine HCl.....................22
Tikosyn...............................42
Timolol Maleate........... 43, 66
Timolol Maleate Ophthalmic
Gel Forming..................... 66
Tinidazole........................... 17
Tivicay...........................36, 37
Tizanidine HCl................... 70
TOBI.................................... 16
TOBI Podhaler.................... 16
Tobradex............................. 16
Tobradex ST........................65
Tobramycin........................ 16
Tobramycin Sulfate............ 16
Tobramycin/Dexamethasone
.......................................... 65
Tobrex................................. 16
Tolcapone........................... 32
Topiramate......................... 22
Toposar............................... 31
Topotecan HCl.................... 31
Torisel................................. 61
Torsemide.......................... 46
Toujeo SoloStar.................. 40
TPN Electrolytes.................73
Tracleer.............................. 69
Tradjenta............................ 39
Tramadol HCl..................... 15
Tramadol HCl ER................13
Tramadol HCl/
Acetaminophen................ 15
Trandolapril....................... 42
Tranexamic Acid................ 41
Transderm-Scop................. 25
Tranylcypromine Sulfate... 24
Travasol.............................. 73
Travatan Z.......................... 66
Travoprost.......................... 66
Trazodone HCl....................25
Treanda...............................28
Trecator.............................. 28
Trelstar Mixject.................. 60
Tretinoin....................... 32, 50
Tretinoin Microsphere.......50
Trexall................................. 61
Trezix.................................. 15
Tri-Legest Fe.......................58
Tri-Lo-Estarylla.................. 58
Tri-Lo-Sprintec...................58
Tri-Previfem....................... 58
Tri-Sprintec........................ 58
Triamcinolone Acetonide
.......................................... 55
Triamcinolone in Orabase
..........................................49
Triamterene/
Hydrochlorothiazide....... 45
Tribenzor............................46
Triderm...............................55
Trifluoperazine HCl........... 33
Trifluridine.........................36
Trihexyphenidyl HCl..........32
TriLyte................................ 52
Trimethoprim..................... 17
Trimipramine Maleate....... 25
Trinessa.............................. 58
Trintellix............................. 25
Trisenox..............................30
110
Tracked
110
Triumeq..............................36
Trivora-28........................... 58
Trizivir................................ 37
Trophamine........................ 73
Trulicity..............................39
Trumenba...........................62
Truvada...............................37
Twinrix............................... 62
Tybost................................. 36
Tygacil.................................17
Tykerb................................. 31
Typhim Vi...........................62
Tysabri................................49
Tyvaso................................ 69
Tyzeka.................................35
Tyzine Pediatric Nasal Drops
..........................................69
U
Uceris..................................63
Uloric.................................. 27
Unithroid............................59
Ursodiol...............................51
Uvadex................................50
V
Vagifem.............................. 58
Valacyclovir HCl.................36
Valchlor.............................. 28
Valcyte................................ 35
Valganciclovir.....................35
Valproate Sodium...............22
Valproic Acid...................... 22
Valsartan............................ 42
Valsartan/
Hydrochlorothiazide....... 46
Vancocin HCl...................... 17
Vancomycin HCl.................17
Vandazole........................... 17
VAQTA................................62
Varivax................................62
Varizig.................................61
Vascepa...............................47
Vectibix...............................32
Velcade............................... 30
Velivet.................................58
Velphoro............................. 53
Venclexta............................30
Venclexta Starting Pack..... 30
Venlafaxine HCl................. 25
Venlafaxine HCl ER............25
Ventavis..............................69
Verapamil HCl................... 44
Verapamil HCl ER..............44
Verapamil HCl SR.............. 44
Versacloz.............................35
Vesicare.............................. 53
Vestura................................58
Vexol...................................66
Vfend.................................. 27
Vibramycin......................... 21
Victoza................................39
Vidaza.................................30
Videx Pediatric................... 37
Vienva.................................58
Vigamox............................. 20
Viibryd................................ 25
Viibryd Starter Pack........... 25
Vimpat................................ 23
Vinblastine Sulfate.............30
Vincasar PFS.......................30
Vincristine Sulfate............. 30
Vinorelbine Tartrate.......... 30
Viracept.............................. 37
Viramune............................36
Viramune XR......................36
Virazole...............................38
Viread..................................37
Vitekta................................ 36
Vivitrol................................ 15
Voltaren.............................. 13
Voriconazole.......................27
Votrient............................... 31
VP-PNV-DHA......................73
VPRIV.................................. 51
Vraylar................................34
Vyfemla.............................. 58
Vytorin................................47
Vyvanse.............................. 48
W
Warfarin Sodium............... 40
Welchol...............................47
WYMZYA Fe........................58
X
Xalkori.................................31
Xarelto................................40
Xarelto Starter Pack........... 40
Xeljanz................................ 61
Xeljanz XR...........................61
Xenazine.............................49
Xgeva.................................. 64
Xifaxan................................ 17
Xolair.................................. 69
Xtandi................................. 29
Xulane.................................58
Xyrem................................. 70
Y
Yervoy................................. 32
111
Tracked
111
YF-Vax................................ 62
Yondelis..............................29
Z
Zafirlukast.......................... 67
Zaleplon..............................70
Zaltrap................................ 30
Zanosar............................... 29
Zarxio.................................. 41
Zavesca................................51
Zazole..................................27
Zelapar................................ 33
Zelboraf............................... 31
Zemaira.............................. 69
Zemplar.............................. 64
Zenchent.............................58
Zenchent Fe........................ 58
Zenpep................................ 51
Zepatier...............................35
Zerbaxa............................... 18
Zetia.................................... 47
Ziagen................................. 37
Zidovudine......................... 37
Zinbryta.............................. 61
Zinecard............................. 30
Ziprasidone HCl................. 34
Zirgan..................................35
Zmax................................... 19
Zoledronic Acid..................64
Zolinza................................30
Zolpidem Tartrate.............. 70
Zomacton............................56
Zometa............................... 64
Zonisamide......................... 21
Zorbtive...............................51
Zortress............................... 61
Zostavax..............................62
Zovia 1/35E..........................58
Zovia 1/50E......................... 58
Zovirax................................36
Zyclara................................50
Zyclara Pump..................... 50
Zydelig................................ 31
Zyflo....................................67
Zyflo CR.............................. 67
Zykadia................................31
Zyprexa Relprevv............... 34
Zytiga.................................. 29
Zyvox................................... 17
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or co-payments/co-insurance may change on
January 1, 2016, and from time to time during the plan year.
This information is available for free in other languages. Please call our Customer Service number
listed above.
Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al
número indicado arriba.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated
companies, a Medicare Advantage organization with a Medicare contract and a contract with the
State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with
Medicare.
UHHI16RP3711973_011 Last updated November 1, 2016
For more recent information or if you have other questions, please
contact UnitedHealthcare Dual Complete Customer Service at:
Toll-Free 1-866-622-8054, TTY 711
8 a.m. to 8 p.m. local time, 7 days a week
www.UHCCommunityPlan.com