List of Covered Drugs (Formulary) 2023

List of Covered Drugs

(Formulary) 2023

UnitedHealthcare Dual Complete® ONE (HMO D-SNP)

Important notes:

This document has information about the drugs covered by this plan. For more

recent information or if you have questions, please call Customer Service at:

Toll-free 1-800-514-4911, TTY 711

8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

myuhc.com/CommunityPlan

Formulary ID Number 00023003, Version 11

H3113_062422_103113_C v1.03

Last updated March 1, 2023

UnitedHealthcare Dual Complete® ONE (HMO D-SNP)

2023 List of Covered Drugs (Formulary)

Introduction

This document is called the List of Covered Drugs (also known as the Drug List). It tells you which

prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Dual

Complete ONE. The Drug List also tells you if there are any special rules or restrictions on any

drugs covered by UnitedHealthcare Dual Complete ONE. Key terms and their definitions appear in

the last chapter of the Evidence of Coverage.

Important Message About What You Pay for Vaccines

- Our plan covers most Part D vaccines at

no cost to you. Call Customer Service for more information.

Our contact information, along with the date we last updated the Drug List, appears on the front

and back cover pages.

Table of contents

A. Disclaimers..............................................................................................................................................4

B. Frequently Asked Questions (FAQ)...................................................................................................... 5

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered

Drugs the “Drug List” for short.)................................................................................................ 5

B2. Does the Drug List ever change?...............................................................................................5

B3. What happens when there is a change to the Drug List?........................................................ 6

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get

certain drugs?..............................................................................................................................7

B5. How will I know if the drug I want has limits or if there are any actions required to get the

drug?............................................................................................................................................ 8

B6. What happens if UnitedHealthcare Dual Complete ONE changes their rules about how

they cover some drugs (for example, prior authorization, quantity limits, and/or step

therapy restrictions)?.................................................................................................................. 8

B7. How can I find a drug on the Drug List?....................................................................................8

B8. What if the drug I want to take is not on the Drug List?........................................................... 8

B9. What if I am a new UnitedHealthcare Dual Complete ONE member and can’t find my drug

on the Drug List or have a problem getting my drug?............................................................. 9

B10. Can I ask for an exception to cover my drug?.......................................................................... 9

This section is continued on the next page.

B11. How can I ask for an exception?..............................................................................................10

B12. How long does it take to get an exception?............................................................................10

B13. What are generic drugs?.......................................................................................................... 10

B14. What are over-the-counter (OTC) drugs?................................................................................ 10

B15. Does UnitedHealthcare Dual Complete ONE cover non-drug OTC products?................... 11

B16. Can I get a long-term supply of drugs?................................................................................... 11

B17. What is my copay?.................................................................................................................... 11

C. Overview of the List of Covered Drugs...............................................................................................12

C1. List of Drugs by Drug Type.......................................................................................................12

C2. Covered Drugs with a quantity limit (QL)................................................................................ 97

C3. Over-the-counter (OTC) Medicaid Drug List......................................................................... 132

D. Index of Covered Drugs.....................................................................................................................166

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

A. Disclaimers

This is a list of drugs that members can get in UnitedHealthcare Dual Complete ONE.

v Members must use network plan providers, pharmacies, DME (Durable Medical Equipment)

suppliers, and follow the rules on referrals. Members will be enrolled into Medicare Part D

prescription drug coverage under the plan and will be automatically disenrolled from any other

Medicare Advantage or Medicare Part D prescription drug coverage.

v The Drug List (formulary) may change on January 1 of each year, and from time to time during

the plan year. You will receive notice when necessary.

v You can always check UnitedHealthcare Dual Complete ONE’s up-to-date List of Covered Drugs

online at myuhc.com/CommunityPlan or by calling Customer Service toll-free at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.

v This information is available for free in other languages. Call Customer Service toll-free at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.

v Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al

número gratuito 1-800-514-4911, TTY 711, de 8 a.m. a 8 p.m.: los 7 días de la semana, de

octubre a marzo; de lunes a viernes, de abril a septiembre.

v You can get this document for free in other formats, such as large print,

braille, or audio. Call Customer Service toll-free at 1-800-514-4911,

TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.

v You can call Customer Service and ask us to make a note in our system that you would like

materials in Spanish, large print, braille or audio now and in the future.

v UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws, and

does not discriminate on the basis of race, color, national origin, age, disability, or sex.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

B. Frequently Asked Questions (FAQ)

Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ

to learn more or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List

of Covered Drugs the “Drug List” for short.)

The drugs on the Drug List that starts on page 12 are the drugs covered by UnitedHealthcare Dual

Complete ONE. These drugs are available at pharmacies within our network. A pharmacy is in our

network if we have an agreement with them to work with us and provide you services. We refer to

these pharmacies as “network pharmacies.”

UnitedHealthcare Dual Complete ONE will cover all medically necessary drugs on the Drug

List if:

Your doctor or other prescriber says you need them to get better or stay healthy, and

o You fill the prescription at a UnitedHealthcare Dual Complete ONE network pharmacy.

· UnitedHealthcare Dual Complete ONE may have additional steps to access certain drugs.

Refer to question B4 for more information.

You can also find an up-to-date list of drugs we cover on our website at myuhc.com/

CommunityPlan or call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-

Mar; M-F Apr-Sept.

B2. Does the Drug List ever change?

Yes, and UnitedHealthcare Dual Complete ONE must follow Medicare and Medicaid rules when

making changes. We may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could:

· Decide to require or not require prior authorization for a drug. (Prior authorization is

permission from UnitedHealthcare Dual Complete ONE before you can get a drug.)

Add or change the amount of a drug you can get (called quantity limits).

Add or change step therapy restrictions on a drug. (Step therapy means you must try one

drug before we will cover another drug.)

For more information on these drug rules, refer to question B4.

If you are taking a drug that is covered at the beginning of the year, we will generally not remove or

change coverage of that drug during the rest of the year unless:

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

· A new, cheaper drug comes on the market that works as well as a drug on the Drug List

now, or

· We learn that a drug is not safe,

· A drug is removed from the market.

Questions B3 and B6 have more information on what happens when the Drug List changes.

· You can always check UnitedHealthcare Dual Complete ONE’s current Drug List online at

myuhc.com/CommunityPlan.

· You can also call Customer Service at

1-800-514-4911

, TTY

711

, 8am-8pm: 7 Days Oct-

Mar; M-F Apr-Sept to check the current Drug List.

B3. What happens when there is a change to the Drug List?

Some changes to the Drug List will happen immediately. For example:

· A new generic drug becomes available

. Sometimes, a new generic drug comes on the

market that works as well as a brand name drug on the Drug List now. When that happens,

we may remove the brand name drug and add the new generic drug. When we add the new

generic drug, we may also decide to keep the brand name drug on the list but change its

coverage rules or limits.

o We may not tell you before we make this change, but we will send you information about

the specific change we made once it happens.

o You or your provider can ask for an exception from these changes. We will send you a

notice with the steps you can take to ask for an exception. Refer to questions B10 - B12

for more information on exceptions.

· A drug is taken off the market. If the Food and Drug Administration (FDA) says a

drug you are taking is not safe or the drug’s manufacturer takes a drug off the

market, we will take it off the Drug List. If you are taking the drug, we will let you

know. Contact your doctor or other prescriber and ask about your other options.

We may make other changes that affect the drugs you take. We will tell you in advance about

these other changes to the Drug List. These changes might happen if:

The FDA provides new guidance or there are new clinical guidelines about a drug.

We add a generic drug that is not new to the market and

Replace a brand name drug currently on the Drug List or

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

· Change the coverage rules or limits for the brand name drug.

When these changes happen, we will:

· Tell you at least 30 days before we make the change to the Drug List

· Let you know and give you a 30-day supply of the drug after you ask for a refill.

This will give you time to talk to your doctor or other prescriber. They can help you decide:

· If there is a similar drug on the Drug List you can take instead

· Whether to ask for an exception from these changes. To learn more about exceptions, refer

to questions B10 - B12 for more information.

B4. Are there any restrictions or limits on drug coverage or any required actions

to take to get certain drugs?

Yes. Some drugs have coverage rules or have limits on the amount you can get. In some cases,

you, your doctor, or other prescriber must do something before you can get the drug. For example:

· Prior authorization: For some drugs, you, your doctor, or other prescriber must get

authorization from UnitedHealthcare Dual Complete ONE before you fill your

prescription. Prior authorization is different from a referral. UnitedHealthcare Dual

Complete ONE may not cover the drug if you don’t get authorization.

· Quantity limits: Sometimes UnitedHealthcare Dual Complete ONE limits the amount of

a drug you can get.

· Step therapy: Sometimes UnitedHealthcare Dual Complete ONE requires you to do step

therapy. This means you will have to try drugs in a certain order for your medical

condition. You might have to try one drug before we will cover another drug. If your

doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the

second.

You can find out if your drug has any additional requirements or limits by looking in the tables on

pages 14 - 96. You can also get more information by visiting our website at myuhc.com/

CommunityPlan. We have posted online documents that explain our prior authorization and step

therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception to these limits. This will give you time to talk to your doctor or other

prescriber. They can help you decide if there is a similar drug on the Drug List you can take instead

or whether to ask for an exception. Refer to questions B10 - B12 for more information about

exceptions.

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

B5. How will I know if the drug I want has limits or if there are any actions

required to get the drug?

The table of drugs on page 14 - 96 has a column labeled “Necessary actions, restrictions, or limits

on use.”

B6. What happens if UnitedHealthcare Dual Complete ONE changes their rules

about how they cover some drugs (for example, prior authorization, quantity

limits, and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior authorization, quantity limits,

and/or step therapy restrictions on a drug. Refer to question B3 for more information about this

advance notice and situations where we may not be able to tell you in advance when our rules

about drugs on the Drug List change.

B7. How can I find a drug on the Drug List?

There are two ways to find a drug:

· You can search alphabetically by the drug’s name,

· You can search by drug type.

To search alphabetically, use the Index of Covered Drugs section that begins on page 166. The

Index of Covered Drugs is an alphabetical list of all of the drugs included in the Drug List. Brand

name drugs and generic drugs are listed in the index. Look in the Index and find your drug. Next to

your drug, you will see the page number where you can find coverage information.

To search by drug type, find the section labeled “List of Drugs by Drug Type” on page 12. The

drugs in this section are grouped into categories by type. For example, if you are taking a medicine

for migraines, you should look in the “Antimigraine Agents” category. That is where you will find

drugs that treat migraines.

B8. What if the drug I want to take is not on the Drug List?

If you don’t find your drug on the Drug List, call Customer Service at 1-800-514-4911, TTY 711

and ask about it. If you learn that UnitedHealthcare Dual Complete ONE will not cover the drug, you

can do one of these things:

Ask Customer Service for a list of drugs like the one you want to take. Then show the list to

your doctor or other prescriber. They can prescribe a drug on the Drug List that is like the

one you want to take. Or

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

· You can ask the health plan to make an exception to cover your drug. Refer to questions

B10 - B12 for more information about exceptions.

B9. What if I am a new UnitedHealthcare Dual Complete ONE member and can’t

find my drug on the Drug List or have a problem getting my drug?

We can help. We may cover a temporary 30-day supply

your drug during the first 90 days you are

a member of UnitedHealthcare Dual Complete ONE. This will give you time to talk to your doctor or

other prescriber. They can help you decide if there is a similar drug on the Drug List you can take

instead, or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple refills to provide up to a

maximum of 30 days of medication.

We will cover a 30-day supply of your drug if:

· You are taking a drug that is not on our Drug List, or

· Health plan rules do not let you get the amount ordered by your prescriber, or

· The drug requires prior authorization by UnitedHealthcare Dual Complete ONE, or

· You are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug

List or if you cannot easily get the drug you need, we can help. If you have been in the plan for

more than 90 days, live in a long-term care facility, and need a supply right away:

· We will cover one 31-day supply of the drug you need (unless you have a prescription for

fewer days), whether or not you are a new UnitedHealthcare Dual Complete ONE member.

· This is in addition to the temporary supply during the first 90 days you are a member of

UnitedHealthcare Dual Complete ONE.

If you are going through a change in your level of care, such as being transferred from a hospital to

a long-term care facility, any time during the year, we may cover a temporary 31-day supply of the

drug you need. This will give you time to talk to your doctor or other prescriber about other

treatment options or to try to get an exception. Refer to questions B10 - B12 for more information

about exceptions.

We will not pay for more of your drug after you get a temporary supply unless you receive

authorization from the plan.

B10. Can I ask for an exception to cover my drug?

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

Yes. You can ask UnitedHealthcare Dual Complete ONE to make an exception to cover a drug that

is not on the Drug List.

You can also ask us to change the rules on your drug.

· For example, UnitedHealthcare Dual Complete ONE may limit the amount of a drug we will

cover. If your drug has a limit, you can ask us to change the limit and cover more.

· Other examples: You can ask us to drop step therapy restrictions or prior authorization

requirements.

B11. How can I ask for an exception?

To ask for an exception, call Customer Service. A Customer Service representative will work with

you and your provider to help you ask for an exception. You can also read Chapter 8 of the

Evidence of Coverage to learn more about exceptions.

B12. How long does it take to get an exception?

After we get a statement from your prescriber supporting your request for an exception, we will give

you a decision within 72 hours. Your doctor or other prescriber can fax or mail the statement to us.

Or your doctor or other prescriber can tell us on the phone, and then fax or mail the statement. If

you have questions, call Customer Service at 1-800-514-4911, TTY 711.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a

decision, you can ask for an expedited exception. This is a faster decision. If your prescriber

supports your request, we will give you a decision within 24 hours of getting your prescriber’s

supporting statement.

B13. What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost

less than the brand name drug and usually don’t have well-known names. Generic drugs are

approved by the Food and Drug Administration (FDA).

UnitedHealthcare Dual Complete ONE covers both brand name drugs and generic drugs.

B14. What are over-the-counter (OTC) drugs?

OTC stands for “over-the-counter.” UnitedHealthcare Dual Complete ONE offers some OTC drugs

through the NJ FamilyCare (Medicaid) portion of the plan’s coverage at no cost to you. You need a

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List starting on

page 132.

B15. Does UnitedHealthcare Dual Complete ONE cover non-drug OTC products?

Yes. UnitedHealthcare Dual Complete ONE covers some non-drug OTC products when they are

prescribed for you by your provider. These non-drug OTC products are listed in the Drug List.

B16. Can I get a long-term supply of drugs?

Yes. UnitedHealthcare Dual Complete ONE offers two ways to get a long-term supply of

“maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a

regular basis, for a chronic or long-term medical condition.)

· Retail pharmacy.

Some retail pharmacies in our network allow you to get a long-term

supply of maintenance drugs. Your Provider and Pharmacy Directory tells you which

pharmacies in our network can give you a long-term supply of maintenance drugs.

· Mail-order. For certain kinds of drugs, you can use the plan’s network mail-order services.

Our plan’s mail-order service allows you to get up to a 90-day supply. To get order forms

and information about filling your prescriptions by mail, please reference your Provider and

Pharmacy Directory to find the mail service pharmacies in our network.

For more information about getting a long-term supply of drugs, call Customer Service at

1-800-514-4911, TTY 711.

B17. What is my copay?

UnitedHealthcare Dual Complete ONE members have no copays for prescription and over-the-

counter (OTC) drugs and non-drug products as long as the member follows the plan’s rules. Refer

to questions B14 and B15 for more information about OTC drugs and non-drug products.

Tiers are groups of drugs on our Drug List. Your plan has 1 tier named “Covered Drugs.” All

covered drugs are in this tier.

Tier 1 Generic drugs have $0 copay.

Tier 1 Brand name drugs have $0 copay.

· OTCs have $0 copay.

If you have questions, call Customer Service at 1-800-514-4911, TTY 711.

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at

1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit myuhc.com/CommunityPlan.

This section is continued on the next page.

tRACK

C. Overview of the List of Covered Drugs

The List of Covered Drugs gives you information about the drugs covered by UnitedHealthcare

Dual Complete ONE. If you have trouble finding your drug in the list, turn to the Index of Covered

Drugs that begins on page 166. The index alphabetically lists all drugs covered by

UnitedHealthcare Dual Complete ONE.

C1. List of Drugs by Drug Type

The drugs in this section are grouped into categories by type. For example, if you are taking a

medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you

will find drugs that treat migraines.

The first column of the table lists the name of the drug. Generic drugs are listed in lower-case

italics (for example,

simvastatin

) and brand name drugs are capitalized (for example, HUMALOG).

The information in the “Necessary actions, restrictions, or limits on use” column tells you if

UnitedHealthcare Dual Complete ONE has any rules for covering your drug.

Coverage rules and limits

PA – Prior authorization

For some drugs, you, your doctor, or other prescriber must get authorization from

UnitedHealthcare Dual Complete ONE before you fill your prescription. Prior authorization is

different from a referral. UnitedHealthcare Dual Complete ONE may not cover the drug if you don’t

get authorization.

QL – Quantity limits

Sometimes UnitedHealthcare Dual Complete ONE limits the amount of a drug you can get.

ST – Step therapy

Sometimes UnitedHealthcare Dual Complete ONE requires you to do step therapy. This means

you will have to try drugs in a certain order for your medical condition. You might have to try one

drug before we will cover another drug. If your doctor or other prescriber thinks the first drug

doesn’t work for you, then we will cover the second.

tRACK

Other special coverage rules

B/D – Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either the Medicare Part B (doctor and

outpatient health care) or the Medicare Part D (prescription drugs) portion of the plan’s coverage.

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.

LA – Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain

facilities or doctors. These drugs may require extra handling, provider coordination or patient

education that can’t be done at a network pharmacy.

MME – Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of

pain. This additional limit is called a cumulative morphine milligram equivalent (MME) and is

designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1

opioid drug for pain management. If your doctor prescribes more than this amount or thinks the

limit is not right for your situation, you or your doctor can ask the plan to cover the additional

quantity.

7D – 7-day limit

An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members

with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For

members who are new to the plan and have a recent history of using opioids, the limit may be

overridden by the pharmacy when appropriate.

DL – Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a 1-month supply per prescription.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Analgesics

Nonsteroidal Anti-inflammatory Drugs

Celecoxib

celecoxib (oral capsule) $0 (Tier 1) QL

Diclofenac

Epolamine

diclofenac epolamine (external patch) $0 (Tier 1) PA; QL

Diclofenac

Potassium

diclofenac potassium (50mg oral tablet) $0 (Tier 1)

Diclofenac Sodium

diclofenac sodium er (oral tablet extended release

24 hour)

$0 (Tier 1)

Diclofenac Sodium

diclofenac sodium (1% external gel) $0 (Tier 1)

Diclofenac Sodium

diclofenac sodium (oral tablet delayed release) $0 (Tier 1)

Diflunisal

diflunisal (oral tablet) $0 (Tier 1)

Etodolac ER

etodolac er (oral tablet extended release 24 hour) $0 (Tier 1)

Etodolac

etodolac (oral capsule) $0 (Tier 1)

Etodolac

etodolac (oral tablet immediate release) $0 (Tier 1)

Flurbiprofen

flurbiprofen (100mg oral tablet) $0 (Tier 1)

Ibu

ibu (600mg oral tablet, 800mg oral tablet) $0 (Tier 1)

Ibuprofen

ibuprofen (oral suspension) $0 (Tier 1)

Ibuprofen

ibuprofen (400mg oral tablet, 600mg oral tablet,

800mg oral tablet)

$0 (Tier 1)

Indomethacin

indomethacin (25mg oral capsule immediate

release, 50mg oral capsule immediate release)

$0 (Tier 1)

Ketoprofen

ketoprofen (50mg oral capsule immediate release) $0 (Tier 1)

Meloxicam

meloxicam (oral tablet) $0 (Tier 1)

Nabumetone

nabumetone (oral tablet) $0 (Tier 1)

Naproxen

naproxen (oral suspension) $0 (Tier 1) DL

Naproxen

naproxen (oral tablet immediate release) $0 (Tier 1)

Naproxen DR

naproxen dr (oral tablet delayed release) (generic

ec-naprosyn)

$0 (Tier 1)

Piroxicam

piroxicam (oral capsule) $0 (Tier 1)

Sulindac

sulindac (oral tablet) $0 (Tier 1)

Opioid Analgesics, Long-acting

Buprenorphine

buprenorphine (transdermal patch weekly) $0 (Tier 1) 7D; DL; QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fentanyl

fentanyl (100mcg/hr transdermal patch 72 hour,

12mcg/hr transdermal patch 72 hour, 25mcg/hr

transdermal patch 72 hour, 50mcg/hr transdermal

patch 72 hour, 75mcg/hr transdermal patch 72

hour)

$0 (Tier 1) 7D; MME; DL; QL

Hydromorphone

HCl ER

hydromorphone hcl er (oral tablet extended

release 24 hour)

$0 (Tier 1) 7D; MME; DL; QL

Levorphanol

Tartrate

levorphanol tartrate (oral tablet) $0 (Tier 1) 7D; MME; DL; QL

Methadone HCl

methadone hcl (oral solution) $0 (Tier 1) 7D; MME; DL; QL

Methadone HCl

methadone hcl (oral tablet) $0 (Tier 1) 7D; MME; DL; QL

Morphine Sulfate

morphine sulfate er (100mg oral tablet extended

release, 15mg oral tablet extended release, 30mg

oral tablet extended release, 60mg oral tablet

extended release) (generic ms contin)

$0 (Tier 1) 7D; MME; DL; QL

Morphine Sulfate

morphine sulfate er (200mg oral tablet extended

release) (generic ms contin)

$0 (Tier 1) 7D; MME; DL; QL

Tramadol HCl ER

tramadol hcl er (biphasic) (oral tablet extended

release 24 hour)

$0 (Tier 1) 7D; MME; DL; QL

Tramadol HCl ER

tramadol hcl er (oral tablet extended release 24

hour)

$0 (Tier 1) 7D; MME; DL; QL

Xtampza ER

XTAMPZA ER (ORAL CAPSULE ER 12 HOUR

ABUSE-DETERRENT)

$0 (Tier 1) 7D; MME; DL; QL

Opioid Analgesics, Short-acting

Acetaminophen-

Caffeine-

Dihydrocodeine

acetaminophen-caffeine-dihydrocodeine (oral

capsule)

$0 (Tier 1) 7D; MME; DL; QL

Acetaminophen-

Codeine

acetaminophen-codeine (120-12mg/5ml oral

solution)

$0 (Tier 1) 7D; MME; DL; QL

Acetaminophen-

Codeine

acetaminophen-codeine (300-15mg oral tablet,

300-30mg oral tablet, 300-60mg oral tablet)

$0 (Tier 1) 7D; MME; DL; QL

Butalbital-

Acetaminophen-

Caffeine

butalbital-acetaminophen-caffeine (oral tablet) $0 (Tier 1) QL

Butalbital-Aspirin-

Caffeine

butalbital-aspirin-caffeine (oral capsule) $0 (Tier 1) QL

Butorphanol

Tartrate

butorphanol tartrate (nasal solution) $0 (Tier 1) 7D; MME; DL; QL

Codeine Sulfate

CODEINE SULFATE (15MG ORAL TABLET,

60MG ORAL TABLET)

$0 (Tier 1) 7D; MME; DL; QL

Codeine Sulfate

codeine sulfate (30mg oral tablet) $0 (Tier 1) 7D; MME; DL; QL

Endocet

endocet (10-325mg oral tablet, 5-325mg oral

tablet, 7.5-325mg oral tablet)

$0 (Tier 1) 7D; MME; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fentanyl Citrate

fentanyl citrate (1200mcg buccal lozenge on a

handle, 1600mcg buccal lozenge on a handle,

400mcg buccal lozenge on a handle, 600mcg

buccal lozenge on a handle, 800mcg buccal

lozenge on a handle)

$0 (Tier 1) PA; DL; QL

Fentanyl Citrate

fentanyl citrate (200mcg buccal lozenge on a

handle)

$0 (Tier 1) PA; DL; QL

Hydrocodone-

Acetaminophen

hydrocodone-acetaminophen (7.5-325mg/15ml

oral solution)

$0 (Tier 1) 7D; MME; DL; QL

Hydrocodone-

Acetaminophen

hydrocodone-acetaminophen (10-325mg oral

tablet, 5-325mg oral tablet, 7.5-325mg oral tablet)

$0 (Tier 1) 7D; MME; DL; QL

Hydrocodone-

Ibuprofen

hydrocodone-ibuprofen (7.5-200mg oral tablet) $0 (Tier 1) 7D; MME; DL; QL

Hydromorphone

HCl

hydromorphone hcl (1mg/ml oral liquid) $0 (Tier 1) 7D; MME; DL; QL

Hydromorphone

HCl

hydromorphone hcl (2mg oral tablet immediate

release, 4mg oral tablet immediate release, 8mg

oral tablet immediate release)

$0 (Tier 1) 7D; MME; DL; QL

Hydromorphone

HCl Preservative

Free

hydromorphone hcl preservative free (10mg/ml

injection solution, 50mg/5ml injection solution)

$0 (Tier 1) 7D; DL

Morphine Sulfate

morphine sulfate (concentrate) (20mg/ml oral

solution)

$0 (Tier 1) 7D; MME; DL; QL

Morphine Sulfate

morphine sulfate (10mg/5ml oral solution) $0 (Tier 1) 7D; MME; DL; QL

Morphine Sulfate

MORPHINE SULFATE (20MG/5ML ORAL

SOLUTION)

$0 (Tier 1) 7D; MME; DL; QL

Morphine Sulfate

morphine sulfate (oral tablet immediate release) $0 (Tier 1) 7D; MME; DL; QL

Oxycodone HCl

oxycodone hcl (100mg/5ml oral concentrate) $0 (Tier 1) 7D; MME; DL; QL

Oxycodone HCl

oxycodone hcl (5mg/5ml oral solution) $0 (Tier 1) 7D; MME; DL; QL

Oxycodone HCl

oxycodone hcl (10mg oral tablet immediate

release, 15mg oral tablet immediate release, 20mg

oral tablet immediate release, 30mg oral tablet

immediate release, 5mg oral tablet immediate

release)

$0 (Tier 1) 7D; MME; DL; QL

Oxycodone-

Acetaminophen

oxycodone-acetaminophen (10-325mg oral tablet,

2.5-325mg oral tablet, 5-325mg oral tablet,

7.5-325mg oral tablet)

$0 (Tier 1) 7D; MME; DL; QL

Tramadol HCl

tramadol hcl (50mg oral tablet immediate release) $0 (Tier 1) 7D; MME; DL; QL

Tramadol-

Acetaminophen

tramadol-acetaminophen (oral tablet) $0 (Tier 1) 7D; MME; DL; QL

Anesthetics

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Local Anesthetics

Lidocaine

lidocaine (5% external ointment) $0 (Tier 1) QL

Lidocaine

lidocaine (5% external patch) $0 (Tier 1) PA; QL

Lidocaine HCl

lidocaine hcl (4% external solution) $0 (Tier 1)

Lidocaine Viscous

lidocaine viscous (2% mouth/throat solution) $0 (Tier 1)

Lidocaine-Prilocaine

lidocaine-prilocaine (external cream) $0 (Tier 1)

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

Acamprosate

Calcium

acamprosate calcium (oral tablet delayed release) $0 (Tier 1)

Disulfiram

disulfiram (oral tablet) $0 (Tier 1)

Naltrexone HCl

naltrexone hcl (oral tablet) $0 (Tier 1)

Vivitrol

VIVITROL (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

$0 (Tier 1) DL

Opioid Dependence

Buprenorphine HCl

buprenorphine hcl (tablet sublingual) $0 (Tier 1) QL

Buprenorphine HCl-

Naloxone HCl

buprenorphine hcl-naloxone hcl (sublingual film) $0 (Tier 1) QL

Buprenorphine HCl-

Naloxone HCl

buprenorphine hcl-naloxone hcl (tablet sublingual) $0 (Tier 1) QL

Suboxone

SUBOXONE (SUBLINGUAL FILM) $0 (Tier 1) QL

Opioid Reversal Agents

Naloxone HCl

naloxone hcl (0.4mg/ml injection solution) $0 (Tier 1)

Naloxone HCl

naloxone hcl (injection solution cartridge) $0 (Tier 1)

Naloxone HCl

naloxone hcl (injection solution prefilled syringe) $0 (Tier 1)

Naloxone HCl

naloxone hcl (nasal liquid) $0 (Tier 1)

Narcan

NARCAN (NASAL LIQUID) $0 (Tier 1)

Smoking Cessation Agents

Bupropion HCl SR

bupropion hcl sr (150mg oral tablet extended

release 12 hour smoking-deterrent)

$0 (Tier 1)

Nicotrol

NICOTROL (INHALATION INHALER) $0 (Tier 1)

Nicotrol NS

NICOTROL NS (NASAL SOLUTION) $0 (Tier 1)

Varenicline Tartrate

varenicline tartrate (oral tablet) $0 (Tier 1)

Varenicline Tartrate

varenicline tartrate (oral tablet therapy pack) $0 (Tier 1)

Antibacterials

Aminoglycosides

Amikacin Sulfate

amikacin sulfate (500mg/2ml injection solution) $0 (Tier 1)

Gentamicin

Sulfate-0.9%

Sodium Chloride

gentamicin sulfate-0.9% sodium chloride

(intravenous solution)

$0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Gentamicin Sulfate

gentamicin sulfate (40mg/ml injection solution) $0 (Tier 1)

Neomycin Sulfate

neomycin sulfate (oral tablet) $0 (Tier 1)

Paromomycin

Sulfate

paromomycin sulfate (oral capsule) $0 (Tier 1)

Streptomycin

Sulfate

streptomycin sulfate (intramuscular solution

reconstituted)

$0 (Tier 1) DL

Tobramycin Sulfate

tobramycin sulfate (10mg/ml injection solution,

80mg/2ml injection solution)

$0 (Tier 1)

Antibacterials, Other

Aztreonam

aztreonam (injection solution reconstituted) $0 (Tier 1)

Clindamycin HCl

clindamycin hcl (oral capsule) $0 (Tier 1)

Clindamycin

Palmitate HCl

clindamycin palmitate hcl (oral solution

reconstituted)

$0 (Tier 1)

Clindamycin

Phosphate in D5W

clindamycin phosphate in d5w (intravenous

solution)

$0 (Tier 1)

Clindamycin

Phosphate

clindamycin phosphate (300mg/2ml injection

solution, 600mg/4ml injection solution, 900mg/

6ml injection solution)

$0 (Tier 1)

Clindamycin

Phosphate

clindamycin phosphate (vaginal cream) $0 (Tier 1)

Colistimethate

Sodium

colistimethate sodium (cba) (injection solution

reconstituted)

$0 (Tier 1) DL

Dalvance

DALVANCE (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Daptomycin

daptomycin (intravenous solution reconstituted) $0 (Tier 1) DL

Linezolid

linezolid (intravenous solution) $0 (Tier 1)

Linezolid

linezolid (oral suspension reconstituted) $0 (Tier 1) DL; QL

Linezolid

linezolid (oral tablet) $0 (Tier 1) QL

Methenamine

Hippurate

methenamine hippurate (oral tablet) $0 (Tier 1)

Metronidazole

metronidazole (0.75% external cream) $0 (Tier 1)

Metronidazole

metronidazole (0.75% external gel, 1% external

gel)

$0 (Tier 1)

Metronidazole

metronidazole (0.75% external lotion) $0 (Tier 1)

Metronidazole

metronidazole (500mg/100ml intravenous

solution)

$0 (Tier 1)

Metronidazole

metronidazole (250mg oral tablet, 500mg oral

tablet)

$0 (Tier 1)

Metronidazole

metronidazole (0.75% vaginal gel) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Nitrofurantoin

Macrocrystal

nitrofurantoin macrocrystal (100mg oral capsule,

50mg oral capsule) (generic macrodantin)

$0 (Tier 1)

Nitrofurantoin

Monohydrate

nitrofurantoin monohydrate (generic macrobid) $0 (Tier 1)

Nitrofurantoin

nitrofurantoin (oral suspension) $0 (Tier 1) DL

Polymyxin B Sulfate

polymyxin b sulfate (injection solution

reconstituted)

$0 (Tier 1)

Tigecycline

tigecycline (intravenous solution reconstituted) $0 (Tier 1) DL

Tinidazole

tinidazole (oral tablet) $0 (Tier 1)

Trimethoprim

trimethoprim (oral tablet) $0 (Tier 1)

Vancomycin HCl

vancomycin hcl (10gm intravenous solution

reconstituted, 1gm intravenous solution

reconstituted, 500mg intravenous solution

reconstituted, 750mg intravenous solution

reconstituted)

$0 (Tier 1)

Vancomycin HCl

vancomycin hcl (oral capsule) $0 (Tier 1) QL

Vandazole

VANDAZOLE (VAGINAL GEL) $0 (Tier 1)

Xifaxan

XIFAXAN (ORAL TABLET) $0 (Tier 1) PA; DL

Beta-lactam, Cephalosporins

Cefaclor

cefaclor (oral capsule) $0 (Tier 1)

Cefadroxil

cefadroxil (oral capsule) $0 (Tier 1)

Cefadroxil

cefadroxil (oral suspension reconstituted) $0 (Tier 1)

Cefazolin Sodium

cefazolin sodium (10gm injection solution

reconstituted, 1gm injection solution reconstituted,

500mg injection solution reconstituted)

$0 (Tier 1)

Cefdinir

cefdinir (oral capsule) $0 (Tier 1)

Cefdinir

cefdinir (oral suspension reconstituted) $0 (Tier 1)

Cefepime HCl

cefepime hcl (injection solution reconstituted) $0 (Tier 1)

Cefixime

cefixime (oral capsule) $0 (Tier 1)

Cefixime

cefixime (oral suspension reconstituted) $0 (Tier 1)

Cefotetan Disodium

cefotetan disodium (injection solution

reconstituted)

$0 (Tier 1)

Cefoxitin Sodium

cefoxitin sodium (intravenous solution

reconstituted)

$0 (Tier 1)

Cefpodoxime

Proxetil

cefpodoxime proxetil (oral suspension

reconstituted)

$0 (Tier 1)

Cefpodoxime

Proxetil

cefpodoxime proxetil (oral tablet) $0 (Tier 1)

Cefprozil

cefprozil (oral suspension reconstituted) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Cefprozil

cefprozil (oral tablet) $0 (Tier 1)

Ceftazidime

ceftazidime (injection solution reconstituted) $0 (Tier 1)

Ceftazidime

ceftazidime (intravenous solution reconstituted) $0 (Tier 1)

Ceftriaxone Sodium

ceftriaxone sodium (1gm injection solution

reconstituted, 250mg injection solution

reconstituted, 2gm injection solution reconstituted,

500mg injection solution reconstituted)

$0 (Tier 1)

Ceftriaxone Sodium

ceftriaxone sodium (10gm intravenous solution

reconstituted)

$0 (Tier 1)

Cefuroxime Axetil

cefuroxime axetil (oral tablet) $0 (Tier 1)

Cefuroxime Sodium

cefuroxime sodium (injection solution

reconstituted)

$0 (Tier 1)

Cefuroxime Sodium

cefuroxime sodium (intravenous solution

reconstituted)

$0 (Tier 1)

Cephalexin

cephalexin (250mg oral capsule, 500mg oral

capsule)

$0 (Tier 1)

Cephalexin

cephalexin (750mg oral capsule) $0 (Tier 1)

Cephalexin

cephalexin (oral suspension reconstituted) $0 (Tier 1)

Suprax

SUPRAX (500MG/5ML ORAL SUSPENSION

RECONSTITUTED)

$0 (Tier 1)

Suprax

suprax (oral tablet chewable) $0 (Tier 1)

Tazicef

tazicef (injection solution reconstituted) $0 (Tier 1)

Tazicef

tazicef (2gm intravenous solution reconstituted,

6gm intravenous solution reconstituted)

$0 (Tier 1)

Teflaro

TEFLARO (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) DL

Zerbaxa

ZERBAXA (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Beta-lactam, Penicillins

Amoxicillin

amoxicillin (oral capsule) $0 (Tier 1)

Amoxicillin

amoxicillin (oral suspension reconstituted) $0 (Tier 1)

Amoxicillin

amoxicillin (oral tablet immediate release) $0 (Tier 1)

Amoxicillin

amoxicillin (oral tablet chewable) $0 (Tier 1)

Amoxicillin-

Potassium

Clavulanate ER

amoxicillin-potassium clavulanate er (oral tablet

extended release 12 hour)

$0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Amoxicillin-

Potassium

Clavulanate

amoxicillin-potassium clavulanate (oral suspension

reconstituted)

$0 (Tier 1)

Amoxicillin-

Potassium

Clavulanate

amoxicillin-potassium clavulanate (oral tablet

immediate release)

$0 (Tier 1)

Amoxicillin-

Potassium

Clavulanate

amoxicillin-potassium clavulanate (oral tablet

chewable)

$0 (Tier 1)

Ampicillin

ampicillin (oral capsule) $0 (Tier 1)

Ampicillin Sodium

ampicillin sodium (125mg injection solution

reconstituted, 1gm injection solution reconstituted)

$0 (Tier 1)

Ampicillin Sodium

ampicillin sodium (10gm intravenous solution

reconstituted)

$0 (Tier 1)

Ampicillin-

Sulbactam Sodium

ampicillin-sulbactam sodium (injection solution

reconstituted)

$0 (Tier 1)

Ampicillin-

Sulbactam Sodium

ampicillin-sulbactam sodium (15 (10-5)gm

intravenous solution reconstituted)

$0 (Tier 1)

Bicillin C-R 900/300

BICILLIN C-R 900/300 (INTRAMUSCULAR

SUSPENSION)

$0 (Tier 1)

Bicillin C-R

BICILLIN C-R (INTRAMUSCULAR SUSPENSION) $0 (Tier 1)

Bicillin L-A

BICILLIN L-A (INTRAMUSCULAR SUSPENSION) $0 (Tier 1)

Bicillin L-A

BICILLIN L-A (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1)

Dicloxacillin Sodium

dicloxacillin sodium (oral capsule) $0 (Tier 1)

Nafcillin Sodium

nafcillin sodium (injection solution reconstituted) $0 (Tier 1)

Nafcillin Sodium

nafcillin sodium (10gm intravenous solution

reconstituted)

$0 (Tier 1)

Oxacillin Sodium in

Dextrose

OXACILLIN SODIUM IN DEXTROSE

(INTRAVENOUS SOLUTION)

$0 (Tier 1)

Oxacillin Sodium

oxacillin sodium (injection solution reconstituted) $0 (Tier 1)

Oxacillin Sodium

oxacillin sodium (intravenous solution

reconstituted)

$0 (Tier 1)

Penicillin G

Potassium

penicillin g potassium (20000000unit injection

solution reconstituted)

$0 (Tier 1)

Penicillin G

Procaine

penicillin g procaine (intramuscular suspension) $0 (Tier 1)

Penicillin G Sodium

penicillin g sodium (injection solution

reconstituted)

$0 (Tier 1)

Penicillin V

Potassium

penicillin v potassium (oral solution reconstituted) $0 (Tier 1)

Penicillin V

Potassium

penicillin v potassium (oral tablet) $0 (Tier 1)

Piperacillin-

Tazobactam

piperacillin-tazobactam (intravenous solution

reconstituted)

$0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Carbapenems

Ertapenem Sodium

ertapenem sodium (injection solution

reconstituted)

$0 (Tier 1)

Imipenem-Cilastatin

imipenem-cilastatin (intravenous solution

reconstituted)

$0 (Tier 1)

Meropenem

meropenem (intravenous solution reconstituted) $0 (Tier 1)

Macrolides

Azithromycin

azithromycin (intravenous solution reconstituted) $0 (Tier 1)

Azithromycin

azithromycin (oral suspension reconstituted) $0 (Tier 1)

Azithromycin

azithromycin (oral tablet) $0 (Tier 1)

Clarithromycin ER

clarithromycin er (oral tablet extended release 24

hour)

$0 (Tier 1)

Clarithromycin

clarithromycin (oral suspension reconstituted) $0 (Tier 1)

Clarithromycin

clarithromycin (oral tablet immediate release) $0 (Tier 1)

Dificid

DIFICID (ORAL SUSPENSION RECONSTITUTED) $0 (Tier 1) DL

Dificid

DIFICID (ORAL TABLET) $0 (Tier 1) DL

Erythrocin

Lactobionate

erythrocin lactobionate (intravenous solution

reconstituted)

$0 (Tier 1)

Erythromycin Base

erythromycin base (oral capsule delayed release

particles)

$0 (Tier 1)

Erythromycin Base

erythromycin base (oral tablet immediate release) $0 (Tier 1)

Erythromycin

Ethylsuccinate

erythromycin ethylsuccinate (200mg/5ml oral

suspension reconstituted)

$0 (Tier 1)

Erythromycin

Ethylsuccinate

erythromycin ethylsuccinate (oral tablet) $0 (Tier 1)

Erythromycin

erythromycin (oral tablet delayed release) $0 (Tier 1)

Quinolones

Ciprofloxacin HCl

ciprofloxacin hcl (100mg oral tablet immediate

release)

$0 (Tier 1)

Ciprofloxacin HCl

ciprofloxacin hcl (250mg oral tablet immediate

release, 500mg oral tablet immediate release,

750mg oral tablet immediate release)

$0 (Tier 1)

Ciprofloxacin in

D5W

ciprofloxacin in d5w (200mg/100ml intravenous

solution)

$0 (Tier 1)

Levofloxacin in

D5W

levofloxacin in d5w (500mg/100ml intravenous

solution, 750mg/150ml intravenous solution)

$0 (Tier 1)

Levofloxacin

levofloxacin (25mg/ml intravenous solution) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Levofloxacin

levofloxacin (25mg/ml oral solution) $0 (Tier 1)

Levofloxacin

levofloxacin (250mg oral tablet, 500mg oral tablet,

750mg oral tablet)

$0 (Tier 1)

Moxifloxacin HCl in

NaCl

moxifloxacin hcl in nacl (intravenous solution) $0 (Tier 1)

Moxifloxacin HCl

moxifloxacin hcl (oral tablet) $0 (Tier 1)

Ofloxacin

ofloxacin (oral tablet) $0 (Tier 1)

Sulfonamides

Sulfadiazine

sulfadiazine (oral tablet) $0 (Tier 1)

Sulfamethoxazole-

Trimethoprim

sulfamethoxazole-trimethoprim (oral suspension) $0 (Tier 1)

Sulfamethoxazole-

Trimethoprim

sulfamethoxazole-trimethoprim (oral tablet) $0 (Tier 1)

Tetracyclines

Demeclocycline

HCl

demeclocycline hcl (oral tablet) $0 (Tier 1)

Doxy 100

doxy 100 (intravenous solution reconstituted) $0 (Tier 1)

Doxycycline Hyclate

doxycycline hyclate (oral capsule) $0 (Tier 1)

Doxycycline Hyclate

doxycycline hyclate (100mg oral tablet immediate

release, 20mg oral tablet immediate release)

$0 (Tier 1)

Doxycycline

Monohydrate

doxycycline monohydrate (100mg oral capsule,

50mg oral capsule)

$0 (Tier 1)

Doxycycline

Monohydrate

doxycycline monohydrate (oral suspension

reconstituted)

$0 (Tier 1)

Doxycycline

Monohydrate

doxycycline monohydrate (100mg oral tablet,

50mg oral tablet, 75mg oral tablet)

$0 (Tier 1)

Minocycline HCl

minocycline hcl (oral capsule) $0 (Tier 1)

Minocycline HCl

minocycline hcl (oral tablet immediate release) $0 (Tier 1)

Tetracycline HCl

tetracycline hcl (oral capsule) $0 (Tier 1)

Vibramycin

VIBRAMYCIN (50MG/5ML ORAL SYRUP) $0 (Tier 1)

Anticonvulsants

Anticonvulsants, Other

BRIVIACT

BRIVIACT (ORAL SOLUTION) $0 (Tier 1) PA; DL; QL

BRIVIACT

BRIVIACT (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Epidiolex

EPIDIOLEX (ORAL SOLUTION) $0 (Tier 1) PA; DL

Eprontia

EPRONTIA (ORAL SOLUTION) $0 (Tier 1)

Felbamate

felbamate (oral suspension) $0 (Tier 1)

Felbamate

felbamate (oral tablet) $0 (Tier 1)

Fintepla

FINTEPLA (ORAL SOLUTION) $0 (Tier 1) PA; DL; QL

Fycompa

FYCOMPA (ORAL SUSPENSION) $0 (Tier 1) DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fycompa

FYCOMPA (10MG ORAL TABLET, 12MG ORAL

TABLET, 4MG ORAL TABLET, 6MG ORAL

TABLET, 8MG ORAL TABLET)

$0 (Tier 1) DL; QL

Fycompa

FYCOMPA (2MG ORAL TABLET) $0 (Tier 1) QL

Lamotrigine

lamotrigine (100mg oral tablet immediate release,

150mg oral tablet immediate release, 200mg oral

tablet immediate release, 25mg oral tablet

immediate release)

$0 (Tier 1)

Lamotrigine

lamotrigine (25mg oral tablet chewable, 5mg oral

tablet chewable)

$0 (Tier 1)

Levetiracetam ER

levetiracetam er (oral tablet extended release 24

hour)

$0 (Tier 1)

Levetiracetam

levetiracetam (oral solution) $0 (Tier 1)

Levetiracetam

levetiracetam (oral tablet immediate release) $0 (Tier 1)

Roweepra

roweepra (oral tablet immediate release) $0 (Tier 1)

Spritam ODT

SPRITAM ODT (ORAL TABLET

DISINTEGRATING SOLUBLE)

$0 (Tier 1)

Topiramate

topiramate (oral capsule sprinkle immediate

release)

$0 (Tier 1)

Topiramate

topiramate (oral tablet) $0 (Tier 1)

Valproic Acid

valproic acid (oral capsule) $0 (Tier 1)

Valproic Acid

valproic acid (oral solution) $0 (Tier 1)

Xcopri

XCOPRI (250MG DAILY DOSE) (100MG &

150MG ORAL TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xcopri

XCOPRI (350MG DAILY DOSE) (150MG &

200MG ORAL TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xcopri

XCOPRI (100MG ORAL TABLET, 150MG ORAL

TABLET, 200MG ORAL TABLET, 50MG ORAL

TABLET)

$0 (Tier 1) PA; DL; QL

Xcopri

XCOPRI (14 X 12.5MG & 14 X 25MG ORAL

TABLET THERAPY PACK)

$0 (Tier 1) PA; QL

Xcopri

XCOPRI (14 X 150MG & 14 X 200MG ORAL

TABLET THERAPY PACK, 14 X 50MG & 14 X

100MG ORAL TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Calcium Channel Modifying Agents

Celontin

CELONTIN (ORAL CAPSULE) $0 (Tier 1)

Ethosuximide

ethosuximide (oral capsule) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Ethosuximide

ethosuximide (oral solution) $0 (Tier 1)

Gamma-aminobutyric Acid (GABA) Augmenting Agents

Clobazam

clobazam (oral suspension) $0 (Tier 1) PA; QL

Clobazam

clobazam (oral tablet) $0 (Tier 1) PA; QL

Diacomit

DIACOMIT (ORAL CAPSULE) $0 (Tier 1) DL; QL

Diacomit

DIACOMIT (ORAL PACKET) $0 (Tier 1) DL; QL

Diazepam

diazepam (10mg rectal gel, 2.5mg rectal gel,

20mg rectal gel)

$0 (Tier 1) QL

Gabapentin

gabapentin (oral capsule) $0 (Tier 1)

Gabapentin

gabapentin (250mg/5ml oral solution) $0 (Tier 1)

Gabapentin

gabapentin (600mg oral tablet, 800mg oral tablet) $0 (Tier 1)

Nayzilam

NAYZILAM (NASAL SOLUTION) $0 (Tier 1) PA; QL

Phenobarbital

phenobarbital (oral elixir) $0 (Tier 1)

Phenobarbital

phenobarbital (oral tablet) $0 (Tier 1)

Primidone

primidone (oral tablet) $0 (Tier 1)

Sympazan

SYMPAZAN (ORAL FILM) $0 (Tier 1) PA; DL; QL

Tiagabine HCl

tiagabine hcl (oral tablet) $0 (Tier 1)

Valtoco 10MG Dose

VALTOCO 10MG DOSE (NASAL LIQUID) $0 (Tier 1) PA; DL; QL

Valtoco 15MG Dose

VALTOCO 15MG DOSE (NASAL LIQUID

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Valtoco 20MG Dose

VALTOCO 20MG DOSE (NASAL LIQUID

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Valtoco 5MG Dose

VALTOCO 5MG DOSE (NASAL LIQUID) $0 (Tier 1) PA; DL; QL

Vigabatrin

vigabatrin (oral packet) $0 (Tier 1) PA; DL; QL

Vigabatrin

vigabatrin (oral tablet) $0 (Tier 1) PA; DL; QL

Vigadrone

vigadrone (oral packet) $0 (Tier 1) PA; DL; QL

Sodium Channel Agents

Aptiom

APTIOM (ORAL TABLET) $0 (Tier 1) DL; QL

Carbamazepine ER

carbamazepine er (oral capsule extended release

12 hour)

$0 (Tier 1)

Carbamazepine ER

carbamazepine er (oral tablet extended release 12

hour)

$0 (Tier 1)

Carbamazepine

carbamazepine (oral suspension) $0 (Tier 1)

Carbamazepine

carbamazepine (oral tablet immediate release) $0 (Tier 1)

Carbamazepine

carbamazepine (oral tablet chewable) $0 (Tier 1)

Dilantin INFATABS

dilantin infatabs (oral tablet chewable) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Dilantin

dilantin (oral capsule) $0 (Tier 1)

Epitol

epitol (oral tablet) $0 (Tier 1)

Lacosamide

lacosamide (oral solution) $0 (Tier 1) QL

Lacosamide

lacosamide (oral tablet) $0 (Tier 1) QL

Oxcarbazepine

oxcarbazepine (300mg/5ml oral suspension) $0 (Tier 1)

Oxcarbazepine

oxcarbazepine (150mg oral tablet, 300mg oral

tablet, 600mg oral tablet)

$0 (Tier 1)

Phenytek

phenytek (oral capsule) $0 (Tier 1)

Phenytoin

phenytoin (125mg/5ml oral suspension) $0 (Tier 1)

Phenytoin

phenytoin (oral tablet chewable) $0 (Tier 1)

Phenytoin Sodium

Extended

phenytoin sodium extended (oral capsule) $0 (Tier 1)

Rufinamide

rufinamide (oral suspension) $0 (Tier 1) DL

Rufinamide

rufinamide (200mg oral tablet) $0 (Tier 1)

Rufinamide

rufinamide (400mg oral tablet) $0 (Tier 1) DL

Vimpat

VIMPAT (ORAL SOLUTION) $0 (Tier 1) QL

Vimpat

VIMPAT (ORAL TABLET) $0 (Tier 1) QL

Zonisade

ZONISADE (ORAL SUSPENSION) $0 (Tier 1) ST

Zonisamide

zonisamide (oral capsule) $0 (Tier 1)

Antidementia Agents

Antidementia Agents, Other

Namzaric

NAMZARIC (ORAL CAPSULE ER 24 HOUR

THERAPY PACK)

$0 (Tier 1) PA; QL

Namzaric

NAMZARIC (ORAL CAPSULE EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) PA; QL

Cholinesterase Inhibitors

Donepezil HCl

donepezil hcl (oral tablet) $0 (Tier 1) QL

Donepezil HCl ODT

donepezil hcl odt (oral tablet dispersible) $0 (Tier 1) QL

Galantamine

Hydrobromide ER

galantamine hydrobromide er (oral capsule

extended release 24 hour)

$0 (Tier 1) QL

Galantamine

Hydrobromide

galantamine hydrobromide (oral solution) $0 (Tier 1) QL

Galantamine

Hydrobromide

galantamine hydrobromide (oral tablet) $0 (Tier 1) QL

Rivastigmine

Tartrate

rivastigmine tartrate (oral capsule) $0 (Tier 1) QL

Rivastigmine

rivastigmine (transdermal patch 24 hour) $0 (Tier 1) ST; QL

N-methyl-D-aspartate (NMDA) Receptor Antagonist

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Memantine HCl ER

memantine hcl er (oral capsule extended release

24 hour)

$0 (Tier 1) PA; QL

Memantine HCl

memantine hcl (oral solution) $0 (Tier 1) PA; QL

Memantine HCl

memantine hcl (10mg oral tablet, 5mg oral tablet) $0 (Tier 1) PA; QL

Memantine HCl

Titration Pak

MEMANTINE HCL TITRATION PAK (ORAL

TABLET)

$0 (Tier 1) PA; QL

Antidepressants

Antidepressants, Other

Auvelity

AUVELITY (ORAL TABLET EXTENDED

RELEASE)

$0 (Tier 1)

Bupropion HCl SR

bupropion hcl sr (oral tablet extended release 12

hour)

$0 (Tier 1)

Bupropion HCl XL

bupropion hcl xl (150mg oral tablet extended

release 24 hour, 300mg oral tablet extended

release 24 hour)

$0 (Tier 1)

Bupropion HCl

bupropion hcl (oral tablet immediate release) $0 (Tier 1)

Mirtazapine

mirtazapine (oral tablet) $0 (Tier 1)

Mirtazapine ODT

mirtazapine odt (oral tablet dispersible) $0 (Tier 1)

Monoamine Oxidase Inhibitors

Emsam

EMSAM (TRANSDERMAL PATCH 24 HOUR) $0 (Tier 1) DL; QL

Marplan

MARPLAN (ORAL TABLET) $0 (Tier 1)

Phenelzine Sulfate

phenelzine sulfate (oral tablet) $0 (Tier 1)

Tranylcypromine

Sulfate

tranylcypromine sulfate (oral tablet) $0 (Tier 1)

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine

Reuptake Inhibitors)

Citalopram

Hydrobromide

CITALOPRAM HYDROBROMIDE (ORAL

CAPSULE)

$0 (Tier 1)

Citalopram

Hydrobromide

citalopram hydrobromide (oral solution) $0 (Tier 1)

Citalopram

Hydrobromide

citalopram hydrobromide (oral tablet) $0 (Tier 1)

Desvenlafaxine

Succinate ER

desvenlafaxine succinate er (oral tablet extended

release 24 hour) (generic pristiq)

$0 (Tier 1) QL

Escitalopram

Oxalate

escitalopram oxalate (oral solution) $0 (Tier 1)

Escitalopram

Oxalate

escitalopram oxalate (oral tablet) $0 (Tier 1)

Fetzima

FETZIMA (ORAL CAPSULE EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) ST; QL

Fetzima Titration

FETZIMA TITRATION (ORAL CAPSULE ER 24

HOUR THERAPY PACK)

$0 (Tier 1) ST; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fluoxetine HCl

fluoxetine hcl (10mg oral capsule immediate

release, 20mg oral capsule immediate release,

40mg oral capsule immediate release)

$0 (Tier 1)

Fluoxetine HCl

fluoxetine hcl (90mg oral capsule delayed release) $0 (Tier 1)

Fluoxetine HCl

fluoxetine hcl (20mg/5ml oral solution) $0 (Tier 1)

Fluvoxamine

Maleate

fluvoxamine maleate (oral tablet) $0 (Tier 1)

Nefazodone HCl

nefazodone hcl (oral tablet) $0 (Tier 1)

Paroxetine HCl

paroxetine hcl (10mg/5ml oral suspension) $0 (Tier 1)

Paroxetine HCl

paroxetine hcl (10mg oral tablet immediate

release, 20mg oral tablet immediate release, 30mg

oral tablet immediate release, 40mg oral tablet

immediate release)

$0 (Tier 1)

Sertraline HCl

sertraline hcl (oral concentrate) $0 (Tier 1)

Sertraline HCl

sertraline hcl (oral tablet) $0 (Tier 1)

Trazodone HCl

trazodone hcl (100mg oral tablet, 150mg oral

tablet, 50mg oral tablet)

$0 (Tier 1)

Trazodone HCl

trazodone hcl (300mg oral tablet) $0 (Tier 1)

Trintellix

TRINTELLIX (ORAL TABLET) $0 (Tier 1) QL

Venlafaxine

Besylate ER

VENLAFAXINE BESYLATE ER (ORAL TABLET

EXTENDED RELEASE 24 HOUR)

$0 (Tier 1)

Venlafaxine HCl ER

venlafaxine hcl er (oral capsule extended release

24 hour)

$0 (Tier 1)

Venlafaxine HCl

venlafaxine hcl (oral tablet immediate release) $0 (Tier 1)

Viibryd

VIIBRYD (ORAL TABLET) $0 (Tier 1) QL

Viibryd Starter Pack

VIIBRYD STARTER PACK (ORAL KIT) $0 (Tier 1) QL

Vilazodone HCl

vilazodone hcl (oral tablet) $0 (Tier 1) QL

Tricyclics

Amitriptyline HCl

amitriptyline hcl (oral tablet) $0 (Tier 1)

Amoxapine

amoxapine (oral tablet) $0 (Tier 1)

Clomipramine HCl

clomipramine hcl (oral capsule) $0 (Tier 1)

Desipramine HCl

desipramine hcl (oral tablet) $0 (Tier 1)

Doxepin HCl

doxepin hcl (oral capsule) $0 (Tier 1)

Doxepin HCl

doxepin hcl (oral concentrate) $0 (Tier 1)

Imipramine HCl

imipramine hcl (oral tablet) $0 (Tier 1)

Imipramine

Pamoate

imipramine pamoate (oral capsule) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Nortriptyline HCl

nortriptyline hcl (oral capsule) $0 (Tier 1)

Nortriptyline HCl

nortriptyline hcl (oral solution) $0 (Tier 1)

Protriptyline HCl

protriptyline hcl (oral tablet) $0 (Tier 1)

Trimipramine

Maleate

trimipramine maleate (oral capsule) $0 (Tier 1)

Antiemetics

Antiemetics, Other

Compro

compro (rectal suppository) $0 (Tier 1)

Meclizine HCl

meclizine hcl (12.5mg oral tablet, 25mg oral tablet) $0 (Tier 1)

Metoclopramide

HCl

metoclopramide hcl (5mg/5ml oral solution) $0 (Tier 1)

Metoclopramide

HCl

metoclopramide hcl (oral tablet) $0 (Tier 1)

Perphenazine

perphenazine (oral tablet) $0 (Tier 1)

Prochlorperazine

Maleate

prochlorperazine maleate (oral tablet) $0 (Tier 1)

Prochlorperazine

prochlorperazine (rectal suppository) $0 (Tier 1)

Promethazine HCl

promethazine hcl (oral syrup) $0 (Tier 1)

Promethazine HCl

promethazine hcl (oral tablet) $0 (Tier 1)

Promethazine HCl

promethazine hcl (rectal suppository) $0 (Tier 1) QL

Promethegan

promethegan (25mg rectal suppository) $0 (Tier 1) QL

Scopolamine

scopolamine (transdermal patch 72 hour) $0 (Tier 1)

Emetogenic Therapy Adjuncts

Anzemet

ANZEMET (ORAL TABLET) $0 (Tier 1) B/D, PA

Aprepitant

aprepitant (oral therapy pack, oral capsule) $0 (Tier 1) PA; QL

Dronabinol

dronabinol (oral capsule) $0 (Tier 1) PA

Granisetron HCl

granisetron hcl (oral tablet) $0 (Tier 1) B/D, PA; QL

Ondansetron HCl

ondansetron hcl (oral solution) $0 (Tier 1) B/D, PA

Ondansetron HCl

ondansetron hcl (4mg oral tablet, 8mg oral tablet) $0 (Tier 1) B/D, PA

Ondansetron ODT

ondansetron odt (oral tablet dispersible) $0 (Tier 1) B/D, PA

Sancuso

SANCUSO (TRANSDERMAL PATCH) $0 (Tier 1) DL; QL

Antifungals

Abelcet

ABELCET (INTRAVENOUS SUSPENSION) $0 (Tier 1) B/D, PA

AmBisome

AMBISOME (INTRAVENOUS SUSPENSION

RECONSTITUTED)

$0 (Tier 1) B/D, PA; DL

Amphotericin B

amphotericin b (intravenous solution reconstituted) $0 (Tier 1) B/D, PA

Clotrimazole

clotrimazole (mouth/throat troche) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fluconazole in

Sodium Chloride

fluconazole in sodium chloride (200-0.9mg/100ml-

% intravenous solution, 400-0.9mg/200ml-%

intravenous solution)

$0 (Tier 1)

Fluconazole

fluconazole (oral suspension reconstituted) $0 (Tier 1)

Fluconazole

fluconazole (oral tablet) $0 (Tier 1)

Flucytosine

flucytosine (oral capsule) $0 (Tier 1) DL

Griseofulvin

Microsize

griseofulvin microsize (oral suspension) $0 (Tier 1)

Griseofulvin

Microsize

griseofulvin microsize (oral tablet) $0 (Tier 1)

Griseofulvin

Ultramicrosize

griseofulvin ultramicrosize (oral tablet) $0 (Tier 1)

Itraconazole

itraconazole (oral capsule) $0 (Tier 1) PA; QL

Itraconazole

itraconazole (oral solution) $0 (Tier 1) PA; DL

Ketoconazole

ketoconazole (oral tablet) $0 (Tier 1)

Micafungin Sodium

micafungin sodium (intravenous solution

reconstituted)

$0 (Tier 1)

Miconazole 3

miconazole 3 (vaginal suppository) $0 (Tier 1)

Noxafil

NOXAFIL (ORAL SUSPENSION) $0 (Tier 1) DL; QL

Nystatin

nystatin (mouth/throat suspension) $0 (Tier 1)

Nystatin

nystatin (oral tablet) $0 (Tier 1)

Posaconazole

posaconazole (oral tablet delayed release) $0 (Tier 1) PA; DL; QL

Terbinafine HCl

terbinafine hcl (oral tablet) $0 (Tier 1)

Terconazole

terconazole (vaginal cream) $0 (Tier 1)

Terconazole

terconazole (vaginal suppository) $0 (Tier 1)

Voriconazole

voriconazole (intravenous solution reconstituted) $0 (Tier 1) PA; DL

Voriconazole

voriconazole (oral suspension reconstituted) $0 (Tier 1) DL; QL

Voriconazole

voriconazole (oral tablet) $0 (Tier 1) QL

Antigout Agents

Allopurinol

allopurinol (100mg oral tablet, 300mg oral tablet) $0 (Tier 1)

Colchicine

COLCHICINE (0.6MG ORAL CAPSULE) (BRAND

EQUIVALENT MITIGARE)

$0 (Tier 1) QL

Colchicine

colchicine (0.6mg oral tablet) (generic colcrys) $0 (Tier 1) QL

Febuxostat

febuxostat (oral tablet) $0 (Tier 1) ST

Probenecid

probenecid (oral tablet) $0 (Tier 1)

Probenecid-

Colchicine

probenecid-colchicine (oral tablet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Antimigraine Agents

Acute

Naratriptan HCl

naratriptan hcl (oral tablet) $0 (Tier 1) QL

Nurtec ODT

NURTEC ODT (ORAL TABLET DISPERSIBLE) $0 (Tier 1) PA; DL; QL

Rizatriptan

Benzoate

rizatriptan benzoate (oral tablet) $0 (Tier 1) QL

Rizatriptan

Benzoate ODT

rizatriptan benzoate odt (oral tablet dispersible) $0 (Tier 1) QL

Sumatriptan

sumatriptan (nasal solution) $0 (Tier 1) QL

Sumatriptan

Succinate

sumatriptan succinate (100mg oral tablet, 25mg

oral tablet, 50mg oral tablet)

$0 (Tier 1) QL

Sumatriptan

Succinate

sumatriptan succinate (4mg/0.5ml subcutaneous

solution auto-injector, 6mg/0.5ml subcutaneous

solution auto-injector)

$0 (Tier 1) QL

Sumatriptan

Succinate

sumatriptan succinate (6mg/0.5ml subcutaneous

solution)

$0 (Tier 1) QL

Ergot Alkaloids

Dihydroergotamine

Mesylate

dihydroergotamine mesylate (nasal solution) $0 (Tier 1) PA; DL; QL

Ergotamine-

Caffeine

ergotamine-caffeine (oral tablet) $0 (Tier 1)

Migergot

migergot (rectal suppository) $0 (Tier 1) DL

Prophylactic

Aimovig

AIMOVIG (SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

$0 (Tier 1) PA; QL

Emgality

EMGALITY (300MG DOSE) (100MG/ML

SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE)

$0 (Tier 1) PA; QL

Emgality

EMGALITY (SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

$0 (Tier 1) PA; QL

Emgality

EMGALITY (120MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

$0 (Tier 1) PA; QL

Timolol Maleate

timolol maleate (oral tablet) $0 (Tier 1)

Antimyasthenic Agents

Parasympathomimetics

Pyridostigmine

Bromide ER

pyridostigmine bromide er (oral tablet extended

release)

$0 (Tier 1)

Pyridostigmine

Bromide

pyridostigmine bromide (oral solution) $0 (Tier 1) DL

Pyridostigmine

Bromide

pyridostigmine bromide (60mg oral tablet

immediate release)

$0 (Tier 1)

Antimycobacterials

Antimycobacterials, Other

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Dapsone

dapsone (oral tablet) $0 (Tier 1)

Rifabutin

rifabutin (oral capsule) $0 (Tier 1)

Antituberculars

Ethambutol HCl

ethambutol hcl (oral tablet) $0 (Tier 1)

Isoniazid

isoniazid (oral syrup) $0 (Tier 1)

Isoniazid

isoniazid (oral tablet) $0 (Tier 1)

Priftin

PRIFTIN (ORAL TABLET) $0 (Tier 1)

Pyrazinamide

pyrazinamide (oral tablet) $0 (Tier 1)

Rifampin

rifampin (600mg intravenous solution

reconstituted)

$0 (Tier 1)

Rifampin

rifampin (150mg oral capsule, 300mg oral

capsule)

$0 (Tier 1)

Sirturo

SIRTURO (ORAL TABLET) $0 (Tier 1) PA; DL

Trecator

TRECATOR (ORAL TABLET) $0 (Tier 1)

Antineoplastics

Alkylating Agents

Cyclophosphamide

cyclophosphamide (oral capsule) $0 (Tier 1) B/D, PA

Cyclophosphamide

cyclophosphamide (25mg oral tablet) $0 (Tier 1) B/D, PA

Cyclophosphamide

CYCLOPHOSPHAMIDE (50MG ORAL TABLET) $0 (Tier 1) B/D, PA

Gleostine

GLEOSTINE (100MG ORAL CAPSULE) $0 (Tier 1) DL

Gleostine

GLEOSTINE (10MG ORAL CAPSULE, 40MG

ORAL CAPSULE)

$0 (Tier 1)

Leukeran

LEUKERAN (ORAL TABLET) $0 (Tier 1) DL

Matulane

MATULANE (ORAL CAPSULE) $0 (Tier 1) DL

Valchlor

VALCHLOR (EXTERNAL GEL) $0 (Tier 1) PA; DL; QL

Antiandrogens

Abiraterone Acetate

abiraterone acetate (250mg oral tablet) $0 (Tier 1) PA; QL

Abiraterone Acetate

abiraterone acetate (500mg oral tablet) $0 (Tier 1) PA; DL; QL

Bicalutamide

bicalutamide (oral tablet) $0 (Tier 1)

Erleada

ERLEADA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Nilutamide

nilutamide (oral tablet) $0 (Tier 1) DL

Nubeqa

NUBEQA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Xtandi

XTANDI (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Xtandi

XTANDI (ORAL TABLET) $0 (Tier 1) PA; DL; QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Antiangiogenic Agents

Fotivda

FOTIVDA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Lenalidomide

lenalidomide (oral capsule) $0 (Tier 1) PA; DL; QL

Pomalyst

POMALYST (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Qinlock

QINLOCK (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Revlimid

REVLIMID (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Tabrecta

TABRECTA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Thalomid

THALOMID (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Antiestrogens/Modifiers

Emcyt

EMCYT (ORAL CAPSULE) $0 (Tier 1)

Soltamox

SOLTAMOX (ORAL SOLUTION) $0 (Tier 1) DL

Tamoxifen Citrate

tamoxifen citrate (oral tablet) $0 (Tier 1)

Toremifene Citrate

toremifene citrate (oral tablet) $0 (Tier 1) DL

Antimetabolites

Droxia

DROXIA (ORAL CAPSULE) $0 (Tier 1)

Hydroxyurea

hydroxyurea (oral capsule) $0 (Tier 1)

Mercaptopurine

mercaptopurine (oral tablet) $0 (Tier 1)

Onureg

ONUREG (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Purixan

PURIXAN (ORAL SUSPENSION) $0 (Tier 1) PA; DL

Tabloid

TABLOID (ORAL TABLET) $0 (Tier 1) PA

Antineoplastics, Other

IDHIFA

IDHIFA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Lonsurf

LONSURF (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Lumakras

LUMAKRAS (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Ninlaro

NINLARO (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Pemazyre

PEMAZYRE (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Retevmo

RETEVMO (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Synribo

SYNRIBO (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Tazverik

TAZVERIK (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Truseltiq

TRUSELTIQ (100MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Truseltiq

TRUSELTIQ (125MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Truseltiq

TRUSELTIQ (50MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

$0 (Tier 1) PA; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Truseltiq

TRUSELTIQ (75MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Tukysa

TUKYSA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Vonjo

VONJO (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (100MG ONCE WEEKLY) (ORAL

TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (40MG ONCE WEEKLY) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (40MG TWICE WEEKLY) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (60MG ONCE WEEKLY) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (60MG TWICE WEEKLY) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (80MG ONCE WEEKLY) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Xpovio

XPOVIO (80MG TWICE WEEKLY) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Zolinza

ZOLINZA (ORAL CAPSULE) $0 (Tier 1) PA; DL

Aromatase Inhibitors, 3rd Generation

Anastrozole

anastrozole (oral tablet) $0 (Tier 1)

Exemestane

exemestane (oral tablet) $0 (Tier 1)

Letrozole

letrozole (oral tablet) $0 (Tier 1)

Molecular Target Inhibitors

Alecensa

ALECENSA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Alunbrig

ALUNBRIG (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Alunbrig

ALUNBRIG (ORAL TABLET THERAPY PACK) $0 (Tier 1) PA; DL; QL

Ayvakit

AYVAKIT (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Balversa

BALVERSA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Bosulif

BOSULIF (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Braftovi

BRAFTOVI (ORAL CAPSULE) $0 (Tier 1) PA; DL

Brukinsa

BRUKINSA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Cabometyx

CABOMETYX (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Calquence

CALQUENCE (100MG ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Calquence

CALQUENCE (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Caprelsa

CAPRELSA (ORAL TABLET) $0 (Tier 1) PA; DL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Cometriq

COMETRIQ (100MG DAILY DOSE) (ORAL KIT) $0 (Tier 1) PA; DL; QL

Cometriq

COMETRIQ (140MG DAILY DOSE) (ORAL KIT) $0 (Tier 1) PA; DL; QL

Cometriq

COMETRIQ (60MG DAILY DOSE) (ORAL KIT) $0 (Tier 1) PA; DL; QL

Copiktra

COPIKTRA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Cotellic

COTELLIC (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Daurismo

DAURISMO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Erivedge

ERIVEDGE (ORAL CAPSULE) $0 (Tier 1) PA; DL

Erlotinib HCl

erlotinib hcl (oral tablet) $0 (Tier 1) PA; DL; QL

Everolimus

everolimus (10mg oral tablet, 2.5mg oral tablet,

5mg oral tablet, 7.5mg oral tablet)

$0 (Tier 1) PA; DL

Everolimus

everolimus (oral tablet soluble) $0 (Tier 1) PA; DL

Exkivity

EXKIVITY (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Gavreto

GAVRETO (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Gilotrif

GILOTRIF (ORAL TABLET) $0 (Tier 1) PA; DL

Ibrance

IBRANCE (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Ibrance

IBRANCE (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Iclusig

ICLUSIG (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Imatinib Mesylate

imatinib mesylate (oral tablet) $0 (Tier 1) PA; DL; QL

Imbruvica

IMBRUVICA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Imbruvica

IMBRUVICA (ORAL SUSPENSION) $0 (Tier 1) PA; DL; QL

Imbruvica

IMBRUVICA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Inlyta

INLYTA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Inqovi

INQOVI (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Inrebic

INREBIC (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Iressa

IRESSA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Jakafi

JAKAFI (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Kisqali

KISQALI (200MG DOSE) (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Kisqali

KISQALI (400MG DOSE) (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Kisqali

KISQALI (600MG DOSE) (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Kisqali Femara

KISQALI FEMARA (200MG DOSE) (ORAL

TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Kisqali Femara

KISQALI FEMARA (400MG DOSE) (ORAL

TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Kisqali Femara

KISQALI FEMARA (600MG DOSE) (ORAL

TABLET THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Koselugo

KOSELUGO (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Lapatinib Ditosylate

lapatinib ditosylate (oral tablet) $0 (Tier 1) PA; DL

Lenvima 10MG

Daily Dose

LENVIMA 10MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 12MG

Daily Dose

LENVIMA 12MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 14MG

Daily Dose

LENVIMA 14MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 18MG

Daily Dose

LENVIMA 18MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 20MG

Daily Dose

LENVIMA 20MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 24MG

Daily Dose

LENVIMA 24MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 4MG Daily

Dose

LENVIMA 4MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lenvima 8MG Daily

Dose

LENVIMA 8MG DAILY DOSE (ORAL CAPSULE

THERAPY PACK)

$0 (Tier 1) PA; DL

Lorbrena

LORBRENA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Lynparza

LYNPARZA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Mekinist

MEKINIST (ORAL TABLET) $0 (Tier 1) PA; DL

Mektovi

MEKTOVI (ORAL TABLET) $0 (Tier 1) PA; DL

Nerlynx

NERLYNX (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Odomzo

ODOMZO (ORAL CAPSULE) $0 (Tier 1) PA; DL

Piqray

PIQRAY (200MG DAILY DOSE) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Piqray

PIQRAY (250MG DAILY DOSE) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Piqray

PIQRAY (300MG DAILY DOSE) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Rozlytrek

ROZLYTREK (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Rubraca

RUBRACA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Rydapt

RYDAPT (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Scemblix

SCEMBLIX (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Sorafenib Tosylate

sorafenib tosylate (oral tablet) $0 (Tier 1) PA; DL

Sprycel

SPRYCEL (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Stivarga

STIVARGA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Sunitinib Malate

sunitinib malate (oral capsule) $0 (Tier 1) PA; DL; QL

Tafinlar

TAFINLAR (ORAL CAPSULE) $0 (Tier 1) PA; DL

Tagrisso

TAGRISSO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Talzenna

TALZENNA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Tasigna

TASIGNA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Tepmetko

TEPMETKO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Tibsovo

TIBSOVO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Turalio

TURALIO (200MG ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Venclexta

VENCLEXTA (100MG ORAL TABLET, 50MG

ORAL TABLET)

$0 (Tier 1) PA; DL; QL

Venclexta

VENCLEXTA (10MG ORAL TABLET) $0 (Tier 1) PA; QL

Venclexta Starting

Pack

VENCLEXTA STARTING PACK (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Verzenio

VERZENIO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Vitrakvi

VITRAKVI (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Vitrakvi

VITRAKVI (ORAL SOLUTION) $0 (Tier 1) PA; DL; QL

Vizimpro

VIZIMPRO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Votrient

VOTRIENT (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Welireg

WELIREG (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Xalkori

XALKORI (ORAL CAPSULE) $0 (Tier 1) PA; DL

Xospata

XOSPATA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Zejula

ZEJULA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Zelboraf

ZELBORAF (ORAL TABLET) $0 (Tier 1) PA; DL

Zydelig

ZYDELIG (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Zykadia

ZYKADIA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Retinoids

Bexarotene

bexarotene (external gel) $0 (Tier 1) PA; DL; QL

Bexarotene

bexarotene (oral capsule) $0 (Tier 1) PA; DL

Panretin

PANRETIN (EXTERNAL GEL) $0 (Tier 1) PA; DL

Tretinoin

tretinoin (oral capsule) $0 (Tier 1) DL

Treatment Adjuncts

Leucovorin Calcium

leucovorin calcium (10mg oral tablet, 15mg oral

tablet, 5mg oral tablet)

$0 (Tier 1)

Leucovorin Calcium

leucovorin calcium (25mg oral tablet) $0 (Tier 1)

Mesnex

MESNEX (ORAL TABLET) $0 (Tier 1)

Antiparasitics

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Anthelmintics

Albendazole

albendazole (oral tablet) $0 (Tier 1) QL

Ivermectin

ivermectin (oral tablet) $0 (Tier 1) PA

Praziquantel

praziquantel (oral tablet) $0 (Tier 1)

Antiprotozoals

Atovaquone

atovaquone (oral suspension) $0 (Tier 1) DL; QL

Atovaquone-

Proguanil HCl

atovaquone-proguanil hcl (oral tablet) $0 (Tier 1)

Benznidazole

BENZNIDAZOLE (ORAL TABLET) $0 (Tier 1)

Chloroquine

Phosphate

chloroquine phosphate (oral tablet) $0 (Tier 1) QL

Coartem

COARTEM (ORAL TABLET) $0 (Tier 1)

Hydroxychloroquin

e Sulfate

hydroxychloroquine sulfate (200mg oral tablet) $0 (Tier 1) QL

Impavido

IMPAVIDO (ORAL CAPSULE) $0 (Tier 1) DL

Mefloquine HCl

mefloquine hcl (oral tablet) $0 (Tier 1)

Nitazoxanide

nitazoxanide (oral tablet) $0 (Tier 1) DL

Pentamidine

Isethionate

pentamidine isethionate (inhalation solution

reconstituted)

$0 (Tier 1) B/D, PA; QL

Pentamidine

Isethionate

pentamidine isethionate (injection solution

reconstituted)

$0 (Tier 1)

Primaquine

Phosphate

primaquine phosphate (oral tablet) $0 (Tier 1)

Pyrimethamine

pyrimethamine (oral tablet) $0 (Tier 1) DL

Quinine Sulfate

quinine sulfate (oral capsule) $0 (Tier 1) PA

Antiparkinson Agents

Anticholinergics

Benztropine

Mesylate

benztropine mesylate (oral tablet) $0 (Tier 1)

Trihexyphenidyl HCl

trihexyphenidyl hcl (oral solution) $0 (Tier 1)

Trihexyphenidyl HCl

trihexyphenidyl hcl (oral tablet) $0 (Tier 1)

Antiparkinson Agents, Other

Amantadine HCl

amantadine hcl (oral capsule) $0 (Tier 1)

Amantadine HCl

amantadine hcl (oral solution) $0 (Tier 1)

Amantadine HCl

amantadine hcl (oral tablet) $0 (Tier 1)

Carbidopa-

Levodopa-

Entacapone

carbidopa-levodopa-entacapone (oral tablet) $0 (Tier 1)

Entacapone

entacapone (oral tablet) $0 (Tier 1)

Tolcapone

tolcapone (oral tablet) $0 (Tier 1) DL; QL

Dopamine Agonists

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Apomorphine HCl

apomorphine hcl (subcutaneous solution

cartridge)

$0 (Tier 1) PA; DL; QL

Bromocriptine

Mesylate

bromocriptine mesylate (oral capsule) $0 (Tier 1)

Bromocriptine

Mesylate

bromocriptine mesylate (oral tablet) $0 (Tier 1)

Kynmobi

KYNMOBI (10MG SUBLINGUAL FILM, 15MG

SUBLINGUAL FILM, 20MG SUBLINGUAL FILM,

25MG SUBLINGUAL FILM, 30MG SUBLINGUAL

FILM)

$0 (Tier 1) PA; DL; QL

Neupro

NEUPRO (TRANSDERMAL PATCH 24 HOUR) $0 (Tier 1)

Pramipexole

Dihydrochloride

pramipexole dihydrochloride (oral tablet immediate

release)

$0 (Tier 1)

Ropinirole HCl

ropinirole hcl (oral tablet immediate release) $0 (Tier 1)

Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors

Carbidopa

carbidopa (oral tablet) $0 (Tier 1)

Carbidopa-

Levodopa ER

carbidopa-levodopa er (oral tablet extended

release)

$0 (Tier 1)

Carbidopa-

Levodopa

carbidopa-levodopa (oral tablet immediate release) $0 (Tier 1)

Carbidopa-

Levodopa ODT

carbidopa-levodopa odt (oral tablet dispersible) $0 (Tier 1)

Rytary

RYTARY (ORAL CAPSULE EXTENDED

RELEASE)

$0 (Tier 1) ST

Monoamine Oxidase B (MAO-B) Inhibitors

Rasagiline Mesylate

rasagiline mesylate (oral tablet) $0 (Tier 1)

Selegiline HCl

selegiline hcl (oral capsule) $0 (Tier 1)

Selegiline HCl

selegiline hcl (oral tablet) $0 (Tier 1)

Zelapar ODT

ZELAPAR ODT (ORAL TABLET DISPERSIBLE) $0 (Tier 1) DL

Antipsychotics

1st Generation/Typical

Chlorpromazine

HCl

chlorpromazine hcl (oral concentrate) $0 (Tier 1)

Chlorpromazine

HCl

chlorpromazine hcl (oral tablet) $0 (Tier 1)

Fluphenazine

Decanoate

fluphenazine decanoate (injection solution) $0 (Tier 1)

Fluphenazine HCl

fluphenazine hcl (2.5mg/ml injection solution) $0 (Tier 1)

Fluphenazine HCl

fluphenazine hcl (5mg/ml oral concentrate) $0 (Tier 1)

Fluphenazine HCl

fluphenazine hcl (2.5mg/5ml oral elixir) $0 (Tier 1)

Fluphenazine HCl

fluphenazine hcl (10mg oral tablet, 1mg oral tablet,

2.5mg oral tablet, 5mg oral tablet)

$0 (Tier 1)

Haloperidol

Decanoate

haloperidol decanoate (intramuscular solution) $0 (Tier 1)

Haloperidol Lactate

haloperidol lactate (injection solution) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Haloperidol Lactate

haloperidol lactate (oral concentrate) $0 (Tier 1)

Haloperidol

haloperidol (oral tablet) $0 (Tier 1)

Loxapine Succinate

loxapine succinate (oral capsule) $0 (Tier 1)

Molindone HCl

molindone hcl (oral tablet) $0 (Tier 1)

Pimozide

pimozide (oral tablet) $0 (Tier 1)

Thioridazine HCl

thioridazine hcl (oral tablet) $0 (Tier 1)

Thiothixene

thiothixene (oral capsule) $0 (Tier 1)

Trifluoperazine HCl

trifluoperazine hcl (oral tablet) $0 (Tier 1)

2nd Generation/Atypical

Abilify Maintena

ABILIFY MAINTENA (INTRAMUSCULAR

PREFILLED SYRINGE)

$0 (Tier 1) DL

Abilify Maintena

ABILIFY MAINTENA (INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER)

$0 (Tier 1) DL

Aripiprazole

aripiprazole (1mg/ml oral solution) $0 (Tier 1) QL

Aripiprazole

aripiprazole (10mg oral tablet, 15mg oral tablet,

20mg oral tablet, 2mg oral tablet, 30mg oral tablet,

5mg oral tablet)

$0 (Tier 1) QL

Aripiprazole ODT

aripiprazole odt (10mg oral tablet dispersible,

15mg oral tablet dispersible)

$0 (Tier 1) DL; QL

Aristada Initio

ARISTADA INITIO (INTRAMUSCULAR

PREFILLED SYRINGE)

$0 (Tier 1) DL

Aristada

ARISTADA (INTRAMUSCULAR PREFILLED

SYRINGE)

$0 (Tier 1) DL

Asenapine Maleate

asenapine maleate (tablet sublingual) $0 (Tier 1) QL

Caplyta

CAPLYTA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Fanapt

FANAPT (10MG ORAL TABLET, 12MG ORAL

TABLET, 1MG ORAL TABLET, 2MG ORAL

TABLET, 4MG ORAL TABLET, 6MG ORAL

TABLET, 8MG ORAL TABLET)

$0 (Tier 1) ST; DL; QL

Fanapt Titration

Pack

FANAPT TITRATION PACK (ORAL TABLET) $0 (Tier 1) ST; QL

Invega Hafyera

INVEGA HAFYERA (INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE)

$0 (Tier 1) DL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Invega Sustenna

INVEGA SUSTENNA (117MG/0.75ML

INTRAMUSCULAR SUSPENSION PREFILLED

SYRINGE, 156MG/ML INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE, 234MG/

1.5ML INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE, 78MG/0.5ML

INTRAMUSCULAR SUSPENSION PREFILLED

SYRINGE)

$0 (Tier 1) DL

Invega Sustenna

INVEGA SUSTENNA (39MG/0.25ML

INTRAMUSCULAR SUSPENSION PREFILLED

SYRINGE)

$0 (Tier 1)

Invega Trinza

INVEGA TRINZA (INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE)

$0 (Tier 1) DL

Latuda

LATUDA (ORAL TABLET) $0 (Tier 1) DL; QL

Lybalvi

LYBALVI (ORAL TABLET) $0 (Tier 1) ST; DL; QL

Nuplazid

NUPLAZID (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Nuplazid

NUPLAZID (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Olanzapine

olanzapine (10mg intramuscular solution

reconstituted)

$0 (Tier 1)

Olanzapine

olanzapine (10mg oral tablet, 15mg oral tablet,

2.5mg oral tablet, 20mg oral tablet, 5mg oral

tablet, 7.5mg oral tablet)

$0 (Tier 1) QL

Olanzapine ODT

olanzapine odt (10mg oral tablet dispersible, 15mg

oral tablet dispersible, 20mg oral tablet dispersible,

5mg oral tablet dispersible)

$0 (Tier 1) QL

Paliperidone ER

paliperidone er (oral tablet extended release 24

hour)

$0 (Tier 1) QL

Perseris

PERSERIS (SUBCUTANEOUS PREFILLED

SYRINGE)

$0 (Tier 1) DL

Quetiapine

Fumarate ER

quetiapine fumarate er (oral tablet extended

release 24 hour)

$0 (Tier 1) QL

Quetiapine

Fumarate

quetiapine fumarate (100mg oral tablet immediate

release, 200mg oral tablet immediate release,

25mg oral tablet immediate release, 300mg oral

tablet immediate release, 400mg oral tablet

immediate release, 50mg oral tablet immediate

release)

$0 (Tier 1) QL

Rexulti

REXULTI (ORAL TABLET) $0 (Tier 1) DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Risperdal Consta

RISPERDAL CONSTA (12.5MG

INTRAMUSCULAR SUSPENSION

RECONSTITUTED ER, 25MG INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER)

$0 (Tier 1)

Risperdal Consta

RISPERDAL CONSTA (37.5MG

INTRAMUSCULAR SUSPENSION

RECONSTITUTED ER, 50MG INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER)

$0 (Tier 1) DL

Risperidone

risperidone (1mg/ml oral solution) $0 (Tier 1)

Risperidone

risperidone (0.25mg oral tablet, 0.5mg oral tablet,

1mg oral tablet, 2mg oral tablet, 3mg oral tablet,

4mg oral tablet)

$0 (Tier 1)

Risperidone ODT

risperidone odt (0.25mg oral tablet dispersible,

0.5mg oral tablet dispersible, 1mg oral tablet

dispersible, 2mg oral tablet dispersible, 3mg oral

tablet dispersible, 4mg oral tablet dispersible)

$0 (Tier 1)

Secuado

SECUADO (TRANSDERMAL PATCH 24 HOUR) $0 (Tier 1) ST; DL; QL

Vraylar

VRAYLAR (1.5MG ORAL CAPSULE, 3MG ORAL

CAPSULE, 4.5MG ORAL CAPSULE, 6MG ORAL

CAPSULE)

$0 (Tier 1) ST; DL; QL

Vraylar

VRAYLAR (ORAL CAPSULE THERAPY PACK) $0 (Tier 1) ST; QL

Ziprasidone HCl

ziprasidone hcl (oral capsule) $0 (Tier 1) QL

Ziprasidone

Mesylate

ziprasidone mesylate (intramuscular solution

reconstituted)

$0 (Tier 1)

Zyprexa Relprevv

ZYPREXA RELPREVV (210MG

INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

$0 (Tier 1) DL

Treatment-Resistant

Clozapine

clozapine (100mg oral tablet, 200mg oral tablet,

25mg oral tablet, 50mg oral tablet)

$0 (Tier 1)

Clozapine ODT

clozapine odt (100mg oral tablet dispersible,

12.5mg oral tablet dispersible, 150mg oral tablet

dispersible, 200mg oral tablet dispersible, 25mg

oral tablet dispersible)

$0 (Tier 1) QL

Versacloz

VERSACLOZ (ORAL SUSPENSION) $0 (Tier 1) DL

Antispasticity Agents

Baclofen

baclofen (oral tablet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Dantrolene Sodium

dantrolene sodium (oral capsule) $0 (Tier 1)

Tizanidine HCl

tizanidine hcl (oral tablet) $0 (Tier 1)

Antivirals

Anti-cytomegalovirus (CMV) Agents

Prevymis

PREVYMIS (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Valganciclovir HCl

valganciclovir hcl (50mg/ml oral solution

reconstituted)

$0 (Tier 1) DL; QL

Valganciclovir HCl

valganciclovir hcl (450mg oral tablet) $0 (Tier 1) QL

Zirgan

ZIRGAN (OPHTHALMIC GEL) $0 (Tier 1)

Anti-hepatitis B (HBV) Agents

Adefovir Dipivoxil

adefovir dipivoxil (oral tablet) $0 (Tier 1)

Baraclude

BARACLUDE (ORAL SOLUTION) $0 (Tier 1) DL

Entecavir

entecavir (oral tablet) $0 (Tier 1)

Epivir HBV

EPIVIR HBV (ORAL SOLUTION) $0 (Tier 1)

Lamivudine

lamivudine (100mg oral tablet) $0 (Tier 1)

Vemlidy

VEMLIDY (ORAL TABLET) $0 (Tier 1) DL; QL

Anti-hepatitis C (HCV) Agents

Epclusa

EPCLUSA (ORAL PACKET) $0 (Tier 1) PA; DL; QL

Epclusa

EPCLUSA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Mavyret

MAVYRET (ORAL PACKET) $0 (Tier 1) PA; DL; QL

Mavyret

MAVYRET (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Ribavirin

ribavirin (oral tablet) $0 (Tier 1)

Sofosbuvir-

Velpatasvir

sofosbuvir-velpatasvir (oral tablet) $0 (Tier 1) PA; DL; QL

Sovaldi

SOVALDI (ORAL PACKET) $0 (Tier 1) PA; DL; QL

Sovaldi

SOVALDI (400MG ORAL TABLET) $0 (Tier 1) PA; DL; QL

Vosevi

VOSEVI (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Antiherpetic Agents

Acyclovir

acyclovir (external ointment) $0 (Tier 1) QL

Acyclovir

acyclovir (oral capsule) $0 (Tier 1)

Acyclovir

acyclovir (oral suspension) $0 (Tier 1)

Acyclovir

acyclovir (oral tablet) $0 (Tier 1)

Acyclovir Sodium

acyclovir sodium (intravenous solution) $0 (Tier 1) B/D, PA

Famciclovir

famciclovir (oral tablet) $0 (Tier 1) QL

Valacyclovir HCl

valacyclovir hcl (oral tablet) $0 (Tier 1) QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Biktarvy

BIKTARVY (ORAL TABLET) $0 (Tier 1) DL; QL

Dovato

DOVATO (ORAL TABLET) $0 (Tier 1) DL; QL

Genvoya

GENVOYA (ORAL TABLET) $0 (Tier 1) DL; QL

Isentress HD

ISENTRESS HD (ORAL TABLET) $0 (Tier 1) DL; QL

Isentress

ISENTRESS (ORAL PACKET) $0 (Tier 1) QL

Isentress

ISENTRESS (ORAL TABLET) $0 (Tier 1) DL; QL

Isentress

ISENTRESS (100MG ORAL TABLET

CHEWABLE)

$0 (Tier 1) QL

Isentress

ISENTRESS (25MG ORAL TABLET CHEWABLE) $0 (Tier 1) QL

Juluca

JULUCA (ORAL TABLET) $0 (Tier 1) DL; QL

Stribild

STRIBILD (ORAL TABLET) $0 (Tier 1) DL; QL

Tivicay

TIVICAY (10MG ORAL TABLET, 25MG ORAL

TABLET)

$0 (Tier 1) QL

Tivicay

TIVICAY (50MG ORAL TABLET) $0 (Tier 1) DL; QL

Tivicay PD

TIVICAY PD (ORAL TABLET SOLUBLE) $0 (Tier 1) DL; QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

Complera

COMPLERA (ORAL TABLET) $0 (Tier 1) DL; QL

Delstrigo

DELSTRIGO (ORAL TABLET) $0 (Tier 1) DL; QL

Edurant

EDURANT (ORAL TABLET) $0 (Tier 1) DL; QL

Efavirenz

efavirenz (oral capsule) $0 (Tier 1) QL

Efavirenz

efavirenz (oral tablet) $0 (Tier 1) QL

Efavirenz-

Emtricitabine-

Tenofovir

efavirenz-emtricitabine-tenofovir (oral tablet) $0 (Tier 1) DL; QL

Efavirenz-

Lamivudine-

Tenofovir

efavirenz-lamivudine-tenofovir (oral tablet) $0 (Tier 1) DL; QL

Etravirine

etravirine (oral tablet) $0 (Tier 1) DL; QL

Intelence

INTELENCE (25MG ORAL TABLET) $0 (Tier 1) QL

Nevirapine ER

nevirapine er (oral tablet extended release 24 hour) $0 (Tier 1) QL

Nevirapine

nevirapine (oral suspension) $0 (Tier 1) QL

Nevirapine

nevirapine (oral tablet immediate release) $0 (Tier 1) QL

Pifeltro

PIFELTRO (ORAL TABLET) $0 (Tier 1) DL; QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

Abacavir Sulfate

abacavir sulfate (oral solution) $0 (Tier 1) QL

Abacavir Sulfate

abacavir sulfate (oral tablet) $0 (Tier 1) QL

Abacavir Sulfate-

Lamivudine

abacavir sulfate-lamivudine (oral tablet) $0 (Tier 1) QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Cimduo

CIMDUO (ORAL TABLET) $0 (Tier 1) DL; QL

Descovy

DESCOVY (ORAL TABLET) $0 (Tier 1) DL; QL

Emtricitabine

emtricitabine (oral capsule) $0 (Tier 1) QL

Emtricitabine-

Tenofovir Disoproxil

Fumarate

emtricitabine-tenofovir disoproxil fumarate

(100-150mg oral tablet, 133-200mg oral tablet,

167-250mg oral tablet)

$0 (Tier 1) DL; QL

Emtricitabine-

Tenofovir Disoproxil

Fumarate

emtricitabine-tenofovir disoproxil fumarate

(200-300mg oral tablet)

$0 (Tier 1) QL

Emtriva

EMTRIVA (ORAL SOLUTION) $0 (Tier 1) QL

Lamivudine

lamivudine (10mg/ml oral solution) $0 (Tier 1) QL

Lamivudine

lamivudine (150mg oral tablet, 300mg oral tablet) $0 (Tier 1) QL

Lamivudine-

Zidovudine

lamivudine-zidovudine (oral tablet) $0 (Tier 1) QL

Odefsey

ODEFSEY (ORAL TABLET) $0 (Tier 1) DL; QL

Tenofovir Disoproxil

Fumarate

tenofovir disoproxil fumarate (oral tablet) $0 (Tier 1) QL

Triumeq

TRIUMEQ (ORAL TABLET) $0 (Tier 1) DL; QL

Triumeq PD

TRIUMEQ PD (ORAL TABLET SOLUBLE) $0 (Tier 1) DL; QL

Trizivir

TRIZIVIR (ORAL TABLET) $0 (Tier 1) DL; QL

Viread

VIREAD (ORAL POWDER) $0 (Tier 1) DL; QL

Viread

VIREAD (150MG ORAL TABLET, 200MG ORAL

TABLET, 250MG ORAL TABLET)

$0 (Tier 1) DL; QL

Zidovudine

zidovudine (oral capsule) $0 (Tier 1) QL

Zidovudine

zidovudine (oral syrup) $0 (Tier 1) QL

Zidovudine

zidovudine (oral tablet) $0 (Tier 1) QL

Anti-HIV Agents, Other

Fuzeon

FUZEON (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) DL; QL

Maraviroc

maraviroc (oral tablet) $0 (Tier 1) DL; QL

Rukobia

RUKOBIA (ORAL TABLET EXTENDED RELEASE

12 HOUR)

$0 (Tier 1) DL; QL

Selzentry

SELZENTRY (ORAL SOLUTION) $0 (Tier 1) DL; QL

Selzentry

SELZENTRY (25MG ORAL TABLET) $0 (Tier 1) QL

Selzentry

SELZENTRY (75MG ORAL TABLET) $0 (Tier 1) DL; QL

Tybost

TYBOST (ORAL TABLET) $0 (Tier 1) QL

Anti-HIV Agents, Protease Inhibitors

Aptivus

APTIVUS (ORAL CAPSULE) $0 (Tier 1) DL; QL

Atazanavir Sulfate

atazanavir sulfate (oral capsule) $0 (Tier 1) QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Evotaz

EVOTAZ (ORAL TABLET) $0 (Tier 1) DL; QL

Fosamprenavir

Calcium

fosamprenavir calcium (oral tablet) $0 (Tier 1) DL; QL

Lexiva

LEXIVA (ORAL SUSPENSION) $0 (Tier 1) QL

Lopinavir-Ritonavir

lopinavir-ritonavir (oral solution) $0 (Tier 1) QL

Lopinavir-Ritonavir

lopinavir-ritonavir (oral tablet) $0 (Tier 1) QL

Norvir

NORVIR (ORAL PACKET) $0 (Tier 1) QL

Norvir

NORVIR (ORAL SOLUTION) $0 (Tier 1) QL

Prezcobix

PREZCOBIX (ORAL TABLET) $0 (Tier 1) DL; QL

Prezista

PREZISTA (ORAL SUSPENSION) $0 (Tier 1) DL; QL

Prezista

PREZISTA (150MG ORAL TABLET, 600MG

ORAL TABLET, 800MG ORAL TABLET)

$0 (Tier 1) DL; QL

Prezista

PREZISTA (75MG ORAL TABLET) $0 (Tier 1) QL

Reyataz

REYATAZ (ORAL PACKET) $0 (Tier 1) DL; QL

Ritonavir

ritonavir (oral tablet) $0 (Tier 1) QL

Symtuza

SYMTUZA (ORAL TABLET) $0 (Tier 1) DL; QL

Viracept

VIRACEPT (ORAL TABLET) $0 (Tier 1) DL; QL

Anti-influenza Agents

Oseltamivir

Phosphate

oseltamivir phosphate (oral capsule) $0 (Tier 1) QL

Oseltamivir

Phosphate

oseltamivir phosphate (oral suspension

reconstituted)

$0 (Tier 1) QL

Relenza Diskhaler

RELENZA DISKHALER (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Rimantadine HCl

rimantadine hcl (oral tablet) $0 (Tier 1)

Xofluza

XOFLUZA (40MG DOSE) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) QL

Xofluza

XOFLUZA (80MG DOSE) (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) QL

Anxiolytics

Anxiolytics, Other

Buspirone HCl

buspirone hcl (oral tablet) $0 (Tier 1)

Hydroxyzine HCl

hydroxyzine hcl (oral syrup) $0 (Tier 1)

Hydroxyzine HCl

hydroxyzine hcl (oral tablet) $0 (Tier 1)

Hydroxyzine

Pamoate

hydroxyzine pamoate (oral capsule) $0 (Tier 1)

Benzodiazepines

Alprazolam

alprazolam (oral tablet immediate release) $0 (Tier 1) QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Chlordiazepoxide

HCl

chlordiazepoxide hcl (oral capsule) $0 (Tier 1)

Clonazepam

clonazepam (0.5mg oral tablet, 1mg oral tablet,

2mg oral tablet)

$0 (Tier 1) QL

Clonazepam ODT

clonazepam odt (0.125mg oral tablet dispersible,

0.25mg oral tablet dispersible, 0.5mg oral tablet

dispersible, 1mg oral tablet dispersible, 2mg oral

tablet dispersible)

$0 (Tier 1) QL

Clorazepate

Dipotassium

clorazepate dipotassium (oral tablet) $0 (Tier 1) QL

Diazepam Intensol

diazepam intensol (oral concentrate) $0 (Tier 1) QL

Diazepam

diazepam (5mg/5ml oral solution) $0 (Tier 1)

Diazepam

diazepam (10mg oral tablet, 2mg oral tablet, 5mg

oral tablet)

$0 (Tier 1) QL

Lorazepam Intensol

lorazepam intensol (oral concentrate) $0 (Tier 1) QL

Lorazepam

lorazepam (oral tablet) $0 (Tier 1) QL

Bipolar Agents

Mood Stabilizers

Divalproex Sodium

divalproex sodium er (oral tablet extended release

24 hour)

$0 (Tier 1)

Divalproex Sodium

divalproex sodium (oral capsule delayed release

sprinkle)

$0 (Tier 1)

Divalproex Sodium

divalproex sodium (oral tablet delayed release) $0 (Tier 1)

Lithium Carbonate

lithium carbonate er (oral tablet extended release) $0 (Tier 1)

Lithium Carbonate

lithium carbonate (oral capsule) $0 (Tier 1)

Lithium Carbonate

lithium carbonate (oral tablet immediate release) $0 (Tier 1)

Blood Glucose Regulators

Antidiabetic Agents

Acarbose

acarbose (oral tablet) $0 (Tier 1) QL

Bydureon BCise

BYDUREON BCISE (SUBCUTANEOUS AUTO-

INJECTOR)

$0 (Tier 1) QL

Byetta 10MCG Pen

BYETTA 10MCG PEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1) QL

Byetta 5MCG Pen

BYETTA 5MCG PEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1) QL

Cycloset

CYCLOSET (ORAL TABLET) $0 (Tier 1) PA; QL

Farxiga

FARXIGA (ORAL TABLET) $0 (Tier 1) QL

Glimepiride

glimepiride (oral tablet) $0 (Tier 1) QL

Glipizide ER

glipizide er (oral tablet extended release 24 hour) $0 (Tier 1) QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Glipizide

glipizide (oral tablet immediate release) $0 (Tier 1) QL

Glipizide-Metformin

HCl

glipizide-metformin hcl (oral tablet) $0 (Tier 1) QL

Glyxambi

GLYXAMBI (ORAL TABLET) $0 (Tier 1) QL

Janumet

JANUMET (ORAL TABLET IMMEDIATE

RELEASE)

$0 (Tier 1) QL

Janumet XR

JANUMET XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) QL

Januvia

JANUVIA (ORAL TABLET) $0 (Tier 1) QL

Jardiance

JARDIANCE (ORAL TABLET) $0 (Tier 1) QL

Jentadueto

JENTADUETO (ORAL TABLET IMMEDIATE

RELEASE)

$0 (Tier 1) QL

Jentadueto XR

JENTADUETO XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) QL

Metformin HCl ER

metformin hcl er (oral tablet extended release 24

hour) (generic glucophage xr)

$0 (Tier 1) QL

Metformin HCl

metformin hcl (oral solution) $0 (Tier 1) QL

Metformin HCl

metformin hcl (1000mg oral tablet immediate

release, 500mg oral tablet immediate release,

850mg oral tablet immediate release)

$0 (Tier 1) QL

Miglitol

miglitol (oral tablet) $0 (Tier 1) QL

Mounjaro

MOUNJARO (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) QL

Nateglinide

nateglinide (oral tablet) $0 (Tier 1) QL

Ozempic

OZEMPIC (0.25MG/DOSE OR 0.5MG/DOSE)

(2MG/1.5ML SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) QL

Ozempic

OZEMPIC (1MG/DOSE) (4MG/3ML

SUBCUTANEOUS SOLUTION PEN-INJECTOR)

$0 (Tier 1) QL

Ozempic

OZEMPIC (2MG/DOSE) (8MG/3ML

SUBCUTANEOUS SOLUTION PEN-INJECTOR)

$0 (Tier 1) QL

Pioglitazone HCl

pioglitazone hcl (oral tablet) $0 (Tier 1) QL

Pioglitazone HCl-

Glimepiride

pioglitazone hcl-glimepiride (oral tablet) $0 (Tier 1) QL

Pioglitazone HCl-

Metformin HCl

pioglitazone hcl-metformin hcl (oral tablet) $0 (Tier 1) QL

Repaglinide

repaglinide (oral tablet) $0 (Tier 1) QL

Rybelsus

RYBELSUS (ORAL TABLET) $0 (Tier 1) QL

Soliqua

SOLIQUA (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

SymlinPen 120

SYMLINPEN 120 (SUBCUTANEOUS SOLUTION

PEN-INJECTOR)

$0 (Tier 1) PA; DL

SymlinPen 60

SYMLINPEN 60 (SUBCUTANEOUS SOLUTION

PEN-INJECTOR)

$0 (Tier 1) PA; DL

Synjardy

SYNJARDY (ORAL TABLET IMMEDIATE

RELEASE)

$0 (Tier 1) QL

Synjardy XR

SYNJARDY XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) QL

Tradjenta

TRADJENTA (ORAL TABLET) $0 (Tier 1) QL

Trijardy XR

TRIJARDY XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) QL

Trulicity

TRULICITY (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) QL

Victoza

VICTOZA (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) QL

Xigduo XR

XIGDUO XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) QL

Glycemic Agents

Baqsimi One Pack

BAQSIMI ONE PACK (NASAL POWDER) $0 (Tier 1)

Diazoxide

diazoxide (oral suspension) $0 (Tier 1)

GlucaGen HypoKit

GLUCAGEN HYPOKIT (INJECTION SOLUTION

RECONSTITUTED)

$0 (Tier 1)

Glucagon

glucagon (injection kit) (lilly) $0 (Tier 1)

Gvoke HypoPen 2-

Pack

GVOKE HYPOPEN 2-PACK (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

$0 (Tier 1)

Gvoke Kit

GVOKE KIT (SUBCUTANEOUS SOLUTION) $0 (Tier 1)

Gvoke PFS

GVOKE PFS (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1)

Insulins

Humalog

HUMALOG (INJECTION SOLUTION) $0 (Tier 1)

Humalog Junior

KwikPen

HUMALOG JUNIOR KWIKPEN

(SUBCUTANEOUS SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Humalog KwikPen

HUMALOG KWIKPEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Humalog Mix 50/50

KwikPen

HUMALOG MIX 50/50 KWIKPEN

(SUBCUTANEOUS SUSPENSION PEN-

INJECTOR)

$0 (Tier 1)

Humalog Mix 50/50

HUMALOG MIX 50/50 (SUBCUTANEOUS

SUSPENSION)

$0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Humalog Mix 75/25

KwikPen

HUMALOG MIX 75/25 KWIKPEN

(SUBCUTANEOUS SUSPENSION PEN-

INJECTOR)

$0 (Tier 1)

Humalog Mix 75/25

HUMALOG MIX 75/25 (SUBCUTANEOUS

SUSPENSION)

$0 (Tier 1)

Humalog

HUMALOG (SUBCUTANEOUS SOLUTION

CARTRIDGE)

$0 (Tier 1)

Humulin 70/30

KwikPen

HUMULIN 70/30 KWIKPEN (SUBCUTANEOUS

SUSPENSION PEN-INJECTOR)

$0 (Tier 1)

Humulin 70/30

HUMULIN 70/30 (SUBCUTANEOUS

SUSPENSION)

$0 (Tier 1)

Humulin N KwikPen

HUMULIN N KWIKPEN (SUBCUTANEOUS

SUSPENSION PEN-INJECTOR)

$0 (Tier 1)

Humulin N

HUMULIN N (SUBCUTANEOUS SUSPENSION) $0 (Tier 1)

Humulin R

HUMULIN R (INJECTION SOLUTION) $0 (Tier 1)

Humulin R U-500

HUMULIN R U-500 (CONCENTRATED)

(SUBCUTANEOUS SOLUTION)

$0 (Tier 1)

Humulin R U-500

KwikPen

HUMULIN R U-500 KWIKPEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Insulin Lispro

INSULIN LISPRO (1 UNIT DIAL)

(SUBCUTANEOUS SOLUTION PEN-INJECTOR)

(BRAND EQUIVALENT HUMALOG)

$0 (Tier 1)

Insulin Lispro

INSULIN LISPRO (INJECTION SOLUTION)

(BRAND EQUIVALENT HUMALOG)

$0 (Tier 1)

Insulin Lispro Junior

KwikPen

INSULIN LISPRO JUNIOR KWIKPEN

(SUBCUTANEOUS SOLUTION PEN-INJECTOR)

(BRAND EQUIVALENT HUMALOG)

$0 (Tier 1)

Insulin Lispro Prot &

Lispro

INSULIN LISPRO PROT & LISPRO

(SUBCUTANEOUS SUSPENSION PEN-

INJECTOR) (BRAND EQUIVALENT HUMALOG)

$0 (Tier 1)

Lantus SoloStar

LANTUS SOLOSTAR (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Lantus

LANTUS (SUBCUTANEOUS SOLUTION) $0 (Tier 1)

Levemir FlexTouch

LEVEMIR FLEXTOUCH (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Levemir

LEVEMIR (SUBCUTANEOUS SOLUTION) $0 (Tier 1)

Lyumjev

LYUMJEV (INJECTION SOLUTION) $0 (Tier 1)

Lyumjev KwikPen

LYUMJEV KWIKPEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Toujeo Max

SoloStar

TOUJEO MAX SOLOSTAR (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Toujeo SoloStar

TOUJEO SOLOSTAR (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Tresiba FlexTouch

TRESIBA FLEXTOUCH (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

$0 (Tier 1)

Tresiba

TRESIBA (SUBCUTANEOUS SOLUTION) $0 (Tier 1)

Blood Products and Modifiers

Anticoagulants

Eliquis

ELIQUIS (ORAL TABLET) $0 (Tier 1) QL

Eliquis Starter Pack

ELIQUIS STARTER PACK (ORAL TABLET) $0 (Tier 1) QL

Enoxaparin Sodium

enoxaparin sodium (injection solution prefilled

syringe)

$0 (Tier 1) QL

Fondaparinux

Sodium

fondaparinux sodium (10mg/0.8ml subcutaneous

solution, 5mg/0.4ml subcutaneous solution,

7.5mg/0.6ml subcutaneous solution)

$0 (Tier 1) DL

Fondaparinux

Sodium

fondaparinux sodium (2.5mg/0.5ml subcutaneous

solution)

$0 (Tier 1)

Heparin Sodium

heparin sodium (10000unit/ml injection solution,

20000unit/ml injection solution, 5000unit/ml

injection solution)

$0 (Tier 1)

Heparin Sodium

heparin sodium (1000unit/ml injection solution) $0 (Tier 1) B/D, PA

Jantoven

jantoven (oral tablet) $0 (Tier 1)

Warfarin Sodium

warfarin sodium (oral tablet) $0 (Tier 1)

Xarelto

XARELTO (ORAL TABLET) $0 (Tier 1) QL

Xarelto Starter Pack

XARELTO STARTER PACK (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) QL

Blood Products and Modifiers, Other

Anagrelide HCl

anagrelide hcl (oral capsule) $0 (Tier 1)

Aranesp

ARANESP (ALBUMIN FREE) (100MCG/ML

INJECTION SOLUTION, 200MCG/ML INJECTION

SOLUTION)

$0 (Tier 1) PA; DL

Aranesp

ARANESP (ALBUMIN FREE) (25MCG/ML

INJECTION SOLUTION, 40MCG/ML INJECTION

SOLUTION, 60MCG/ML INJECTION SOLUTION)

$0 (Tier 1) PA

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Aranesp

ARANESP (ALBUMIN FREE) (100MCG/0.5ML

INJECTION SOLUTION PREFILLED SYRINGE,

150MCG/0.3ML INJECTION SOLUTION

PREFILLED SYRINGE, 200MCG/0.4ML

INJECTION SOLUTION PREFILLED SYRINGE,

300MCG/0.6ML INJECTION SOLUTION

PREFILLED SYRINGE, 500MCG/ML INJECTION

SOLUTION PREFILLED SYRINGE, 60MCG/

0.3ML INJECTION SOLUTION PREFILLED

SYRINGE)

$0 (Tier 1) PA; DL

Aranesp

ARANESP (ALBUMIN FREE) (10MCG/0.4ML

INJECTION SOLUTION PREFILLED SYRINGE,

25MCG/0.42ML INJECTION SOLUTION

PREFILLED SYRINGE, 40MCG/0.4ML

INJECTION SOLUTION PREFILLED SYRINGE)

$0 (Tier 1) PA

Leukine

LEUKINE (INJECTION SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Neulasta

NEULASTA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Procrit

PROCRIT (10000UNIT/ML INJECTION

SOLUTION, 2000UNIT/ML INJECTION

SOLUTION, 3000UNIT/ML INJECTION

SOLUTION, 4000UNIT/ML INJECTION

SOLUTION)

$0 (Tier 1) PA

Procrit

PROCRIT (20000UNIT/ML INJECTION

SOLUTION, 40000UNIT/ML INJECTION

SOLUTION)

$0 (Tier 1) PA; DL

Promacta

PROMACTA (ORAL PACKET) $0 (Tier 1) PA; DL; QL

Promacta

PROMACTA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Pyrukynd

PYRUKYND (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Pyrukynd Taper

Pack

PYRUKYND TAPER PACK (ORAL TABLET

THERAPY PACK)

$0 (Tier 1) PA; DL; QL

Retacrit

RETACRIT (INJECTION SOLUTION) $0 (Tier 1) PA

Zarxio

ZARXIO (INJECTION SOLUTION PREFILLED

SYRINGE)

$0 (Tier 1) DL

Ziextenzo

ZIEXTENZO (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Hemostasis Agents

Tranexamic Acid

tranexamic acid (oral tablet) $0 (Tier 1)

Platelet Modifying Agents

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Aspirin-

Dipyridamole ER

aspirin-dipyridamole er (oral capsule extended

release 12 hour)

$0 (Tier 1) QL

Brilinta

BRILINTA (ORAL TABLET) $0 (Tier 1) QL

Cablivi

CABLIVI (INJECTION KIT) $0 (Tier 1) PA; DL; QL

Cilostazol

cilostazol (oral tablet) $0 (Tier 1)

Clopidogrel

Bisulfate

clopidogrel bisulfate (75mg oral tablet) $0 (Tier 1) QL

Prasugrel HCl

prasugrel hcl (oral tablet) $0 (Tier 1) QL

Cardiovascular Agents

Alpha-adrenergic Agonists

Clonidine HCl

clonidine hcl (oral tablet immediate release) $0 (Tier 1)

Clonidine

clonidine (transdermal patch weekly) $0 (Tier 1)

Droxidopa

droxidopa (100mg oral capsule, 200mg oral

capsule)

$0 (Tier 1) PA; QL

Droxidopa

droxidopa (300mg oral capsule) $0 (Tier 1) PA; DL; QL

Midodrine HCl

midodrine hcl (oral tablet) $0 (Tier 1)

Alpha-adrenergic Blocking Agents

Doxazosin Mesylate

doxazosin mesylate (oral tablet) $0 (Tier 1)

Phenoxybenzamine

HCl

phenoxybenzamine hcl (oral capsule) $0 (Tier 1) DL

Prazosin HCl

prazosin hcl (oral capsule) $0 (Tier 1)

Angiotensin II Receptor Antagonists

Candesartan

Cilexetil

candesartan cilexetil (oral tablet) $0 (Tier 1) QL

Edarbi

EDARBI (ORAL TABLET) $0 (Tier 1) QL

Irbesartan

irbesartan (oral tablet) $0 (Tier 1) QL

Losartan Potassium

losartan potassium (oral tablet) $0 (Tier 1) QL

Olmesartan

Medoxomil

olmesartan medoxomil (oral tablet) $0 (Tier 1) QL

Telmisartan

telmisartan (oral tablet) $0 (Tier 1) QL

Valsartan

valsartan (oral tablet) $0 (Tier 1) QL

Angiotensin-converting Enzyme (ACE) Inhibitors

Benazepril HCl

benazepril hcl (oral tablet) $0 (Tier 1) QL

Captopril

captopril (oral tablet) $0 (Tier 1) QL

Enalapril Maleate

enalapril maleate (oral solution) $0 (Tier 1)

Enalapril Maleate

enalapril maleate (oral tablet) $0 (Tier 1) QL

Fosinopril Sodium

fosinopril sodium (oral tablet) $0 (Tier 1) QL

Lisinopril

lisinopril (oral tablet) $0 (Tier 1) QL

Moexipril HCl

moexipril hcl (oral tablet) $0 (Tier 1) QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Perindopril

Erbumine

perindopril erbumine (oral tablet) $0 (Tier 1) QL

Quinapril HCl

quinapril hcl (oral tablet) $0 (Tier 1) QL

Ramipril

ramipril (oral capsule) $0 (Tier 1) QL

Trandolapril

trandolapril (oral tablet) $0 (Tier 1) QL

Antiarrhythmics

Amiodarone HCl

amiodarone hcl (200mg oral tablet) $0 (Tier 1)

Dofetilide

dofetilide (oral capsule) $0 (Tier 1) QL

Flecainide Acetate

flecainide acetate (oral tablet) $0 (Tier 1)

Mexiletine HCl

mexiletine hcl (oral capsule) $0 (Tier 1)

Multaq

MULTAQ (ORAL TABLET) $0 (Tier 1) QL

Pacerone

pacerone (200mg oral tablet) $0 (Tier 1)

Propafenone HCl

propafenone hcl er (oral capsule extended release

12 hour)

$0 (Tier 1)

Propafenone HCl

propafenone hcl (oral tablet) $0 (Tier 1)

Quinidine

Gluconate ER

quinidine gluconate er (oral tablet extended

release)

$0 (Tier 1)

Quinidine Sulfate

quinidine sulfate (oral tablet) $0 (Tier 1)

Sorine

sorine (oral tablet) $0 (Tier 1)

Sotalol HCl AF

sotalol hcl af (oral tablet) $0 (Tier 1)

Sotalol HCl

sotalol hcl (oral tablet) $0 (Tier 1)

Beta-adrenergic Blocking Agents

Acebutolol HCl

acebutolol hcl (oral capsule) $0 (Tier 1)

Atenolol

atenolol (oral tablet) $0 (Tier 1)

Betaxolol HCl

betaxolol hcl (oral tablet) $0 (Tier 1)

Bisoprolol

Fumarate

bisoprolol fumarate (oral tablet) $0 (Tier 1)

Carvedilol

carvedilol (oral tablet) $0 (Tier 1)

Labetalol HCl

labetalol hcl (oral tablet) $0 (Tier 1)

Metoprolol

Succinate ER

metoprolol succinate er (oral tablet extended

release 24 hour)

$0 (Tier 1)

Metoprolol Tartrate

metoprolol tartrate (oral tablet) $0 (Tier 1)

Nadolol

nadolol (oral tablet) $0 (Tier 1)

Nebivolol HCl

nebivolol hcl (oral tablet) $0 (Tier 1) QL

Pindolol

pindolol (oral tablet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Propranolol HCl ER

propranolol hcl er (oral capsule extended release

24 hour)

$0 (Tier 1)

Propranolol HCl

propranolol hcl (oral solution) $0 (Tier 1)

Propranolol HCl

propranolol hcl (oral tablet) $0 (Tier 1)

Calcium Channel Blocking Agents, Dihydropyridines

Amlodipine

Besylate

amlodipine besylate (oral tablet) $0 (Tier 1)

Felodipine ER

felodipine er (oral tablet extended release 24 hour) $0 (Tier 1)

Nicardipine HCl

nicardipine hcl (oral capsule) $0 (Tier 1)

Nifedipine ER

nifedipine er (oral tablet extended release 24 hour) $0 (Tier 1) QL

Nifedipine ER

Osmotic Release

nifedipine er osmotic release (oral tablet extended

release 24 hour)

$0 (Tier 1) QL

Nimodipine

nimodipine (oral capsule) $0 (Tier 1)

Nymalize

NYMALIZE (ORAL SOLUTION) $0 (Tier 1) DL

Calcium Channel Blocking Agents, Nondihydropyridines

Cartia XT

cartia xt (oral capsule extended release 24 hour) $0 (Tier 1)

Diltiazem HCl ER

Beads

diltiazem hcl er beads (360mg oral capsule

extended release 24 hour, 420mg oral capsule

extended release 24 hour)

$0 (Tier 1)

Diltiazem HCl ER

Coated Beads

diltiazem hcl er coated beads (120mg oral capsule

extended release 24 hour, 180mg oral capsule

extended release 24 hour, 240mg oral capsule

extended release 24 hour, 300mg oral capsule

extended release 24 hour)

$0 (Tier 1)

Diltiazem HCl ER

Coated Beads

diltiazem hcl er coated beads (180mg oral tablet

extended release 24 hour, 240mg oral tablet

extended release 24 hour, 300mg oral tablet

extended release 24 hour, 360mg oral tablet

extended release 24 hour)

$0 (Tier 1)

Diltiazem HCl ER

diltiazem hcl er (oral capsule extended release 12

hour)

$0 (Tier 1)

Diltiazem HCl

diltiazem hcl (oral tablet immediate release) $0 (Tier 1)

Dilt-XR

dilt-xr (oral capsule extended release 24 hour) $0 (Tier 1)

Matzim LA

matzim la (oral tablet extended release 24 hour) $0 (Tier 1)

Taztia XT

taztia xt (oral capsule extended release 24 hour) $0 (Tier 1)

Tiadylt ER

tiadylt er (oral capsule extended release 24 hour) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Verapamil HCl ER

VERAPAMIL HCL ER (100MG ORAL CAPSULE

EXTENDED RELEASE 24 HOUR, 200MG ORAL

CAPSULE EXTENDED RELEASE 24 HOUR,

300MG ORAL CAPSULE EXTENDED RELEASE

24 HOUR, 360MG ORAL CAPSULE EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1)

Verapamil HCl ER

verapamil hcl er (120mg oral capsule extended

release 24 hour, 180mg oral capsule extended

release 24 hour, 240mg oral capsule extended

release 24 hour)

$0 (Tier 1)

Verapamil HCl ER

verapamil hcl er (oral tablet extended release) $0 (Tier 1)

Verapamil HCl

verapamil hcl (oral tablet immediate release) $0 (Tier 1)

Cardiovascular Agents, Other

Acetazolamide ER

acetazolamide er (oral capsule extended release

12 hour)

$0 (Tier 1)

Acetazolamide

acetazolamide (oral tablet) $0 (Tier 1)

Aliskiren Fumarate

aliskiren fumarate (oral tablet) $0 (Tier 1) QL

Amiloride-

Hydrochlorothiazid

amiloride-hydrochlorothiazide (oral tablet) $0 (Tier 1)

Amlodipine-

Atorvastatin

amlodipine-atorvastatin (oral tablet) $0 (Tier 1) QL

Amlodipine-

Benazepril

amlodipine-benazepril (oral capsule) $0 (Tier 1) QL

Amlodipine-

Olmesartan

amlodipine-olmesartan (oral tablet) $0 (Tier 1) QL

Amlodipine-

Valsartan

amlodipine-valsartan (oral tablet) $0 (Tier 1) QL

Amlodipine-

Valsartan-HCTZ

amlodipine-valsartan-hctz (oral tablet) $0 (Tier 1) QL

Atenolol-

Chlorthalidone

atenolol-chlorthalidone (oral tablet) $0 (Tier 1)

Benazepril-

Hydrochlorothiazid

benazepril-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Bisoprolol-

Hydrochlorothiazid

bisoprolol-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Candesartan

Cilexetil-HCTZ

candesartan cilexetil-hctz (oral tablet) $0 (Tier 1) QL

Corlanor

CORLANOR (ORAL SOLUTION) $0 (Tier 1) PA; QL

Corlanor

CORLANOR (ORAL TABLET) $0 (Tier 1) PA; QL

Demser

DEMSER (ORAL CAPSULE) $0 (Tier 1) DL

Digitek

digitek (250mcg oral tablet) $0 (Tier 1)

Digoxin

digoxin (oral solution) $0 (Tier 1)

Digoxin

digoxin (125mcg oral tablet, 250mcg oral tablet) $0 (Tier 1)

Digoxin

digoxin (62.5mcg oral tablet) $0 (Tier 1)

Edarbyclor

EDARBYCLOR (ORAL TABLET) $0 (Tier 1) QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Enalapril-

Hydrochlorothiazid

enalapril-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Entresto

ENTRESTO (ORAL TABLET) $0 (Tier 1) QL

Fosinopril Sodium-

HCTZ

fosinopril sodium-hctz (oral tablet) $0 (Tier 1) QL

Irbesartan-

Hydrochlorothiazid

irbesartan-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Isosorbide Dinitrate-

Hydralazine

isosorbide dinitrate-hydralazine (oral tablet) $0 (Tier 1) QL

Kerendia

KERENDIA (ORAL TABLET) $0 (Tier 1) PA; QL

Lanoxin

LANOXIN (ORAL TABLET) $0 (Tier 1)

Lisinopril-

Hydrochlorothiazid

lisinopril-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Losartan

Potassium-HCTZ

losartan potassium-hctz (oral tablet) $0 (Tier 1) QL

Metoprolol-

Hydrochlorothiazid

metoprolol-hydrochlorothiazide (oral tablet) $0 (Tier 1)

Metyrosine

metyrosine (oral capsule) $0 (Tier 1) DL

Olmesartan

Medoxomil-HCTZ

olmesartan medoxomil-hctz (oral tablet) $0 (Tier 1) QL

Olmesartan-

Amlodipine-HCTZ

olmesartan-amlodipine-hctz (oral tablet) $0 (Tier 1) QL

Pentoxifylline ER

pentoxifylline er (oral tablet extended release) $0 (Tier 1)

Quinapril-

Hydrochlorothiazid

quinapril-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Ranolazine ER

ranolazine er (oral tablet extended release 12 hour) $0 (Tier 1) QL

Spironolactone-

HCTZ

spironolactone-hctz (oral tablet) $0 (Tier 1)

Telmisartan-

Amlodipine

telmisartan-amlodipine (oral tablet) $0 (Tier 1) QL

Telmisartan-HCTZ

telmisartan-hctz (oral tablet) $0 (Tier 1) QL

Trandolapril-

Verapamil HCl ER

trandolapril-verapamil hcl er (oral tablet extended

release)

$0 (Tier 1) QL

Triamterene-HCTZ

triamterene-hctz (oral capsule) $0 (Tier 1)

Triamterene-HCTZ

triamterene-hctz (oral tablet) $0 (Tier 1)

Valsartan-

Hydrochlorothiazid

valsartan-hydrochlorothiazide (oral tablet) $0 (Tier 1) QL

Diuretics, Loop

Bumetanide

bumetanide (injection solution) $0 (Tier 1)

Bumetanide

bumetanide (oral tablet) $0 (Tier 1)

Ethacrynic Acid

ethacrynic acid (oral tablet) $0 (Tier 1)

Furosemide

furosemide (injection solution) $0 (Tier 1) B/D, PA

Furosemide

furosemide (oral solution) $0 (Tier 1)

Furosemide

furosemide (oral tablet) $0 (Tier 1)

Torsemide

torsemide (oral tablet) $0 (Tier 1)

Diuretics, Potassium-sparing

Amiloride HCl

amiloride hcl (oral tablet) $0 (Tier 1)

Eplerenone

eplerenone (oral tablet) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Spironolactone

spironolactone (oral tablet) $0 (Tier 1)

Triamterene

triamterene (oral capsule) $0 (Tier 1)

Diuretics, Thiazide

Chlorthalidone

chlorthalidone (oral tablet) $0 (Tier 1)

Diuril

DIURIL (ORAL SUSPENSION) $0 (Tier 1)

Hydrochlorothiazid

hydrochlorothiazide (oral capsule) $0 (Tier 1)

Hydrochlorothiazid

hydrochlorothiazide (oral tablet) $0 (Tier 1)

Indapamide

indapamide (oral tablet) $0 (Tier 1)

Metolazone

metolazone (oral tablet) $0 (Tier 1)

Dyslipidemics, Fibric Acid Derivatives

Fenofibrate

Micronized

fenofibrate micronized (134mg oral capsule,

200mg oral capsule, 43mg oral capsule, 67mg

oral capsule)

$0 (Tier 1)

Fenofibrate

fenofibrate (50mg oral capsule) $0 (Tier 1)

Fenofibrate

fenofibrate (145mg oral tablet, 48mg oral tablet) $0 (Tier 1)

Fenofibrate

fenofibrate (160mg oral tablet, 54mg oral tablet) $0 (Tier 1)

Fenofibric Acid

fenofibric acid (oral capsule delayed release) $0 (Tier 1)

Gemfibrozil

gemfibrozil (oral tablet) $0 (Tier 1)

Dyslipidemics, HMG CoA Reductase Inhibitors

Atorvastatin

Calcium

atorvastatin calcium (oral tablet) $0 (Tier 1) QL

Fluvastatin Sodium

fluvastatin sodium er (oral tablet extended release

24 hour)

$0 (Tier 1) QL

Fluvastatin Sodium

fluvastatin sodium (oral capsule) $0 (Tier 1) QL

Livalo

LIVALO (ORAL TABLET) $0 (Tier 1) QL

Lovastatin

lovastatin (oral tablet) $0 (Tier 1) QL

Pravastatin Sodium

pravastatin sodium (oral tablet) $0 (Tier 1) QL

Rosuvastatin

Calcium

rosuvastatin calcium (oral tablet) $0 (Tier 1) QL

Simvastatin

simvastatin (oral tablet) $0 (Tier 1) QL

Dyslipidemics, Other

Cholestyramine

Light

cholestyramine light (oral packet) $0 (Tier 1)

Cholestyramine

cholestyramine (oral packet) $0 (Tier 1)

Colesevelam HCl

colesevelam hcl (oral packet) $0 (Tier 1)

Colesevelam HCl

colesevelam hcl (oral tablet) $0 (Tier 1)

Colestipol HCl

colestipol hcl (oral packet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Colestipol HCl

colestipol hcl (oral tablet) $0 (Tier 1)

Ezetimibe

ezetimibe (oral tablet) $0 (Tier 1) QL

Ezetimibe-

Simvastatin

ezetimibe-simvastatin (oral tablet) $0 (Tier 1) QL

Icosapent Ethyl

icosapent ethyl (oral capsule) $0 (Tier 1)

Juxtapid

JUXTAPID (ORAL CAPSULE) $0 (Tier 1) PA; DL

Niacin

niacin (antihyperlipidemic) (oral tablet immediate

release)

$0 (Tier 1)

Niacin ER

niacin er (antihyperlipidemic) (oral tablet extended

release)

$0 (Tier 1)

Niacor

niacor (oral tablet) $0 (Tier 1)

Omega-3-Acid Ethyl

Esters

omega-3-acid ethyl esters (oral capsule) (generic

lovaza)

$0 (Tier 1) QL

Praluent

PRALUENT (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

$0 (Tier 1) PA; QL

Prevalite

prevalite (oral packet) $0 (Tier 1)

Repatha

Pushtronex System

REPATHA PUSHTRONEX SYSTEM

(SUBCUTANEOUS SOLUTION CARTRIDGE)

$0 (Tier 1) PA; QL

Repatha

REPATHA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; QL

Repatha SureClick

REPATHA SURECLICK (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

$0 (Tier 1) PA; QL

Vascepa

VASCEPA (ORAL CAPSULE) $0 (Tier 1)

Vasodilators, Direct-acting Arterial

Hydralazine HCl

hydralazine hcl (oral tablet) $0 (Tier 1)

Minoxidil

minoxidil (oral tablet) $0 (Tier 1)

Vasodilators, Direct-acting Arterial/Venous

Isosorbide Dinitrate

isosorbide dinitrate (10mg oral tablet immediate

release, 20mg oral tablet immediate release, 30mg

oral tablet immediate release, 5mg oral tablet

immediate release)

$0 (Tier 1)

Isosorbide

Mononitrate ER

isosorbide mononitrate er (oral tablet extended

release 24 hour)

$0 (Tier 1)

Isosorbide

Mononitrate

isosorbide mononitrate (oral tablet immediate

release)

$0 (Tier 1)

Nitro-Bid

nitro-bid (transdermal ointment) $0 (Tier 1)

Nitroglycerin

nitroglycerin (tablet sublingual) $0 (Tier 1)

Nitroglycerin

nitroglycerin (transdermal patch 24 hour) $0 (Tier 1)

Nitroglycerin

nitroglycerin (translingual solution) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Nitrostat

NITROSTAT (TABLET SUBLINGUAL) $0 (Tier 1)

Rectiv

RECTIV (RECTAL OINTMENT) $0 (Tier 1) QL

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

Amphetamine-

Dextroamphetamin

e ER

amphetamine-dextroamphetamine er (oral capsule

extended release 24 hour)

$0 (Tier 1) QL

Amphetamine-

Dextroamphetamin

amphetamine-dextroamphetamine (oral tablet) $0 (Tier 1) QL

Dextroamphetamin

e Sulfate ER

dextroamphetamine sulfate er (oral capsule

extended release 24 hour)

$0 (Tier 1) QL

Dextroamphetamin

e Sulfate

dextroamphetamine sulfate (oral tablet) $0 (Tier 1) QL

Vyvanse

VYVANSE (ORAL CAPSULE) $0 (Tier 1)

Vyvanse

VYVANSE (ORAL TABLET CHEWABLE) $0 (Tier 1)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

Atomoxetine HCl

atomoxetine hcl (oral capsule) $0 (Tier 1) QL

Clonidine HCl ER

clonidine hcl er (oral tablet extended release 12

hour)

$0 (Tier 1) PA

Dexmethylphenidat

e HCl ER

dexmethylphenidate hcl er (oral capsule extended

release 24 hour)

$0 (Tier 1)

Dexmethylphenidat

e HCl

dexmethylphenidate hcl (oral tablet) $0 (Tier 1) QL

Guanfacine HCl ER

guanfacine hcl er (oral tablet extended release 24

hour)

$0 (Tier 1)

Methylphenidate

HCl ER

methylphenidate hcl er (10mg oral tablet extended

release, 20mg oral tablet extended release)

$0 (Tier 1) QL

Methylphenidate

HCl

methylphenidate hcl (oral solution) $0 (Tier 1) QL

Methylphenidate

HCl

methylphenidate hcl (oral tablet immediate release)

(generic ritalin)

$0 (Tier 1) QL

Central Nervous System, Other

Austedo

AUSTEDO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Ingrezza

INGREZZA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Ingrezza

INGREZZA (ORAL CAPSULE THERAPY PACK) $0 (Tier 1) PA; DL; QL

Nuedexta

NUEDEXTA (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Riluzole

riluzole (oral tablet) $0 (Tier 1)

Tetrabenazine

tetrabenazine (12.5mg oral tablet) $0 (Tier 1) PA; QL

Tetrabenazine

tetrabenazine (25mg oral tablet) $0 (Tier 1) PA; DL; QL

Fibromyalgia Agents

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Drizalma Sprinkle

DRIZALMA SPRINKLE (ORAL CAPSULE

DELAYED RELEASE SPRINKLE)

$0 (Tier 1) ST; QL

Duloxetine HCl

duloxetine hcl (20mg oral capsule delayed release

particles, 30mg oral capsule delayed release

particles, 60mg oral capsule delayed release

particles)

$0 (Tier 1) QL

Pregabalin

pregabalin (oral capsule) $0 (Tier 1) QL

Pregabalin

pregabalin (oral solution) $0 (Tier 1) QL

Savella

SAVELLA (ORAL TABLET) $0 (Tier 1)

Savella Titration

Pack

SAVELLA TITRATION PACK (ORAL TABLET) $0 (Tier 1)

Multiple Sclerosis Agents

Aubagio

AUBAGIO (ORAL TABLET) $0 (Tier 1) DL; QL

Avonex Pen

AVONEX PEN (INTRAMUSCULAR AUTO-

INJECTOR KIT)

$0 (Tier 1) DL; QL

Avonex Prefilled

AVONEX PREFILLED (INTRAMUSCULAR

PREFILLED SYRINGE KIT)

$0 (Tier 1) DL; QL

Betaseron

BETASERON (SUBCUTANEOUS KIT) $0 (Tier 1) DL; QL

Dalfampridine ER

dalfampridine er (oral tablet extended release 12

hour)

$0 (Tier 1) QL

Dimethyl Fumarate

dimethyl fumarate (oral capsule delayed release) $0 (Tier 1) DL; QL

Dimethyl Fumarate

Starter Pack

dimethyl fumarate starter pack (oral capsule) $0 (Tier 1) DL; QL

Fingolimod HCl

fingolimod hcl (oral capsule) $0 (Tier 1) DL; QL

Gilenya

GILENYA (0.5MG ORAL CAPSULE) $0 (Tier 1) DL; QL

Glatiramer Acetate

glatiramer acetate (subcutaneous solution prefilled

syringe)

$0 (Tier 1) DL; QL

Glatopa

glatopa (subcutaneous solution prefilled syringe) $0 (Tier 1) DL; QL

Mayzent

MAYZENT (ORAL TABLET) $0 (Tier 1) DL; QL

Mayzent Starter

Pack

MAYZENT STARTER PACK (7 X 0.25MG ORAL

TABLET THERAPY PACK)

$0 (Tier 1) QL

Mayzent Starter

Pack

MAYZENT STARTER PACK (12 X 0.25MG ORAL

TABLET THERAPY PACK)

$0 (Tier 1) DL; QL

Rebif Rebidose

REBIF REBIDOSE (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

$0 (Tier 1) ST; DL; QL

Rebif Rebidose

Titration Pack

REBIF REBIDOSE TITRATION PACK

(SUBCUTANEOUS SOLUTION AUTO-INJECTOR)

$0 (Tier 1) ST; DL; QL

Rebif

REBIF (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) ST; DL; QL

Rebif Titration Pack

REBIF TITRATION PACK (SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

$0 (Tier 1) ST; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Vumerity

VUMERITY (ORAL CAPSULE DELAYED

RELEASE) (MAINTENANCE DOSE BOTTLE)

$0 (Tier 1) ST; DL; QL

Dental and Oral Agents

Chlorhexidine

Gluconate

chlorhexidine gluconate (mouth solution) $0 (Tier 1)

Periogard

periogard (mouth solution) $0 (Tier 1)

Pilocarpine HCl

pilocarpine hcl (oral tablet) $0 (Tier 1)

Triamcinolone

Acetonide

triamcinolone acetonide (dental paste) $0 (Tier 1)

Dermatological Agents

Acne and Rosacea Agents

Accutane

accutane (oral capsule) $0 (Tier 1) PA

Acitretin

acitretin (oral capsule) $0 (Tier 1)

Adapalene

adapalene (external cream) $0 (Tier 1)

Adapalene

adapalene (0.3% external gel) $0 (Tier 1)

Amnesteem

amnesteem (oral capsule) $0 (Tier 1) PA

Azelaic Acid

azelaic acid (external gel) $0 (Tier 1) QL

Benzoyl Peroxide-

Erythromycin

benzoyl peroxide-erythromycin (external gel) $0 (Tier 1)

Claravis

claravis (oral capsule) $0 (Tier 1) PA

Clindamycin

Phosphate-Benzoyl

Peroxide

clindamycin phosphate-benzoyl peroxide (1-5%

external gel, 1.2-5% external gel)

$0 (Tier 1)

Finacea

FINACEA (EXTERNAL FOAM) $0 (Tier 1) QL

Isotretinoin

isotretinoin (oral capsule) $0 (Tier 1) PA

Mirvaso

MIRVASO (EXTERNAL GEL) $0 (Tier 1)

Myorisan

myorisan (oral capsule) $0 (Tier 1) PA

Neuac

neuac (external gel) $0 (Tier 1)

Tazarotene

tazarotene (external cream) $0 (Tier 1) PA

Tretinoin

tretinoin (external cream) $0 (Tier 1) PA

Tretinoin

tretinoin (0.01% external gel, 0.025% external gel) $0 (Tier 1) PA

Tretinoin

Microsphere

tretinoin microsphere (external gel) $0 (Tier 1) PA

Zenatane

zenatane (oral capsule) $0 (Tier 1) PA

Dermatitis and Pruritus Agents

Ala-Cort

ala-cort (external cream) $0 (Tier 1)

Alclometasone

Dipropionate

alclometasone dipropionate (external cream) $0 (Tier 1)

Alclometasone

Dipropionate

alclometasone dipropionate (external ointment) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Ammonium Lactate

ammonium lactate (external cream) $0 (Tier 1)

Ammonium Lactate

ammonium lactate (external lotion) $0 (Tier 1)

Betamethasone

Dipropionate Aug

betamethasone dipropionate aug (external cream) $0 (Tier 1)

Betamethasone

Dipropionate Aug

betamethasone dipropionate aug (external gel) $0 (Tier 1)

Betamethasone

Dipropionate Aug

betamethasone dipropionate aug (external lotion) $0 (Tier 1)

Betamethasone

Dipropionate Aug

betamethasone dipropionate aug (external

ointment)

$0 (Tier 1)

Betamethasone

Dipropionate

betamethasone dipropionate (external cream) $0 (Tier 1)

Betamethasone

Dipropionate

betamethasone dipropionate (external lotion) $0 (Tier 1)

Betamethasone

Dipropionate

betamethasone dipropionate (external ointment) $0 (Tier 1)

Betamethasone

Valerate

betamethasone valerate (external cream) $0 (Tier 1)

Betamethasone

Valerate

betamethasone valerate (external lotion) $0 (Tier 1)

Betamethasone

Valerate

betamethasone valerate (external ointment) $0 (Tier 1)

Clobetasol

Propionate

Emollient Base

clobetasol propionate emollient base (external

cream)

$0 (Tier 1)

Clobetasol

Propionate

clobetasol propionate (external cream) $0 (Tier 1)

Clobetasol

Propionate

clobetasol propionate (external gel) $0 (Tier 1)

Clobetasol

Propionate

clobetasol propionate (external ointment) $0 (Tier 1)

Clobetasol

Propionate

clobetasol propionate (external shampoo) $0 (Tier 1)

Clobetasol

Propionate

clobetasol propionate (external solution) $0 (Tier 1)

Clodan

clodan (external shampoo) $0 (Tier 1)

Cordran

CORDRAN (EXTERNAL TAPE) $0 (Tier 1)

Desonide

desonide (external ointment) $0 (Tier 1) QL

Desoximetasone

desoximetasone (external cream) $0 (Tier 1) QL

Doxepin HCl

doxepin hcl (external cream) $0 (Tier 1) PA; QL

Fluocinolone

Acetonide

fluocinolone acetonide (external cream) $0 (Tier 1)

Fluocinolone

Acetonide

fluocinolone acetonide (external ointment) $0 (Tier 1)

Fluocinolone

Acetonide

fluocinolone acetonide (external solution) $0 (Tier 1)

Fluocinolone

Acetonide Scalp

fluocinolone acetonide scalp (external oil) $0 (Tier 1)

Fluocinonide

Emulsified Base

fluocinonide emulsified base (external cream) $0 (Tier 1) QL

Fluocinonide

fluocinonide (0.05% external cream) $0 (Tier 1) QL

Fluocinonide

fluocinonide (external gel) $0 (Tier 1) QL

Fluocinonide

fluocinonide (external ointment) $0 (Tier 1) QL

Fluocinonide

fluocinonide (external solution) $0 (Tier 1) QL

Fluticasone

Propionate

fluticasone propionate (external cream) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fluticasone

Propionate

fluticasone propionate (external ointment) $0 (Tier 1)

Halobetasol

Propionate

halobetasol propionate (external cream) $0 (Tier 1)

Halobetasol

Propionate

halobetasol propionate (external ointment) $0 (Tier 1)

Hydrocortisone

Butyrate

hydrocortisone butyrate (external ointment) $0 (Tier 1)

Hydrocortisone

hydrocortisone (1% external cream) $0 (Tier 1)

Hydrocortisone

hydrocortisone (2.5% external lotion) $0 (Tier 1)

Hydrocortisone

hydrocortisone (1% external ointment, 2.5%

external ointment)

$0 (Tier 1)

Hydrocortisone

Valerate

hydrocortisone valerate (external cream) $0 (Tier 1)

Hydrocortisone

Valerate

hydrocortisone valerate (external ointment) $0 (Tier 1)

Mometasone

Furoate

mometasone furoate (external cream) $0 (Tier 1)

Mometasone

Furoate

mometasone furoate (external ointment) $0 (Tier 1)

Mometasone

Furoate

mometasone furoate (external solution) $0 (Tier 1)

Pimecrolimus

pimecrolimus (external cream) $0 (Tier 1) ST; QL

Prednicarbate

prednicarbate (external ointment) $0 (Tier 1)

Selenium Sulfide

selenium sulfide (external lotion) $0 (Tier 1)

Tacrolimus

tacrolimus (external ointment) $0 (Tier 1) ST

Triamcinolone

Acetonide

triamcinolone acetonide (external cream) $0 (Tier 1)

Triamcinolone

Acetonide

triamcinolone acetonide (external lotion) $0 (Tier 1)

Triamcinolone

Acetonide

triamcinolone acetonide (0.025% external

ointment, 0.1% external ointment, 0.5% external

ointment)

$0 (Tier 1)

Triderm

triderm (external cream) $0 (Tier 1)

Dermatological Agents, Other

Calcipotriene

calcipotriene (external cream) $0 (Tier 1) QL

Calcipotriene

calcipotriene (external ointment) $0 (Tier 1) QL

Calcipotriene

calcipotriene (external solution) $0 (Tier 1)

Calcitriol

CALCITRIOL (EXTERNAL OINTMENT) $0 (Tier 1)

Clotrimazole-

Betamethasone

clotrimazole-betamethasone (external cream) $0 (Tier 1) QL

Clotrimazole-

Betamethasone

clotrimazole-betamethasone (external lotion) $0 (Tier 1)

Diclofenac Sodium

diclofenac sodium (3% external gel) $0 (Tier 1) PA; QL

Fluorouracil

fluorouracil (5% external cream) $0 (Tier 1) QL

Fluorouracil

fluorouracil (external solution) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Imiquimod

imiquimod (5% external cream) $0 (Tier 1) QL

Imiquimod Pump

imiquimod pump (3.75% external cream) $0 (Tier 1) PA; DL

Methoxsalen Rapid

methoxsalen rapid (oral capsule) $0 (Tier 1) DL

Podofilox

podofilox (external solution) $0 (Tier 1)

Regranex

REGRANEX (EXTERNAL GEL) $0 (Tier 1) PA; DL

Santyl

SANTYL (EXTERNAL OINTMENT) $0 (Tier 1)

Silver Sulfadiazine

silver sulfadiazine (external cream) $0 (Tier 1)

SSD

SSD (EXTERNAL CREAM) $0 (Tier 1)

Pediculicides/Scabicides

Crotan

crotan (external lotion) $0 (Tier 1)

Malathion

malathion (external lotion) $0 (Tier 1)

Permethrin

permethrin (external cream) $0 (Tier 1)

Topical Anti-infectives

Ciclopirox

ciclopirox (external gel) $0 (Tier 1)

Ciclopirox

ciclopirox (external shampoo) $0 (Tier 1)

Ciclopirox

ciclopirox (external solution) $0 (Tier 1)

Ciclopirox Olamine

ciclopirox olamine (external cream) $0 (Tier 1)

Ciclopirox Olamine

ciclopirox olamine (external suspension) $0 (Tier 1)

Clindacin ETZ

clindacin etz (external swab) $0 (Tier 1) QL

Clindamycin

Phosphate

clindamycin phosphate (external gel) $0 (Tier 1) QL

Clindamycin

Phosphate

clindamycin phosphate (external lotion) $0 (Tier 1) QL

Clindamycin

Phosphate

clindamycin phosphate (external solution) $0 (Tier 1) QL

Clindamycin

Phosphate

clindamycin phosphate (external swab) $0 (Tier 1) QL

Clotrimazole

clotrimazole (external cream) $0 (Tier 1)

Clotrimazole

clotrimazole (external solution) $0 (Tier 1)

Econazole Nitrate

econazole nitrate (external cream) $0 (Tier 1) QL

Ery

ery (external pad) $0 (Tier 1)

Erythromycin

erythromycin (external gel) $0 (Tier 1)

Erythromycin

erythromycin (external solution) $0 (Tier 1)

Gentamicin Sulfate

gentamicin sulfate (external cream) $0 (Tier 1)

Gentamicin Sulfate

gentamicin sulfate (external ointment) $0 (Tier 1)

Jublia

JUBLIA (EXTERNAL SOLUTION) $0 (Tier 1)

Ketoconazole

ketoconazole (external cream) $0 (Tier 1) QL

Ketoconazole

ketoconazole (external shampoo) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Mupirocin Calcium

mupirocin calcium (external cream) $0 (Tier 1)

Mupirocin

mupirocin (external ointment) $0 (Tier 1) QL

Naftifine HCl

naftifine hcl (external cream) $0 (Tier 1)

Naftin

NAFTIN (2% EXTERNAL GEL) $0 (Tier 1)

Nyamyc

nyamyc (external powder) $0 (Tier 1) QL

Nystatin

nystatin (external cream) $0 (Tier 1)

Nystatin

nystatin (external ointment) $0 (Tier 1)

Nystatin

nystatin (external powder) $0 (Tier 1) QL

Nystop

nystop (external powder) $0 (Tier 1) QL

Sulfamylon

SULFAMYLON (EXTERNAL CREAM) $0 (Tier 1)

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

Carglumic Acid

carglumic acid (oral tablet soluble) $0 (Tier 1) DL

Dextrose

dextrose (10% intravenous solution) $0 (Tier 1)

Dextrose

dextrose (5% intravenous solution) $0 (Tier 1) B/D, PA

Dextrose-NaCl

DEXTROSE-NACL (10-0.2% INTRAVENOUS

SOLUTION, 10-0.45% INTRAVENOUS

SOLUTION, 5-0.2% INTRAVENOUS SOLUTION)

$0 (Tier 1)

Dextrose-NaCl

dextrose-nacl (2.5-0.45% intravenous solution,

5-0.45% intravenous solution)

$0 (Tier 1)

Dextrose-NaCl

dextrose-nacl (5-0.9% intravenous solution) $0 (Tier 1) B/D, PA

Intralipid

INTRALIPID (INTRAVENOUS EMULSION) $0 (Tier 1) B/D, PA

Isolyte-P in D5W

ISOLYTE-P IN D5W (INTRAVENOUS SOLUTION) $0 (Tier 1)

Isolyte-S pH 7.4

ISOLYTE-S PH 7.4 (INTRAVENOUS SOLUTION) $0 (Tier 1)

KCl in Dextrose-

NaCl

KCL IN DEXTROSE-NACL (INTRAVENOUS

SOLUTION)

$0 (Tier 1)

KCl-Lactated

Ringers-D5W

KCL-LACTATED RINGERS-D5W (INTRAVENOUS

SOLUTION)

$0 (Tier 1)

Klor-Con 10

KLOR-CON 10 (ORAL TABLET EXTENDED

RELEASE)

$0 (Tier 1)

Klor-Con M10

klor-con m10 (oral tablet extended release) $0 (Tier 1)

Klor-Con M15

klor-con m15 (oral tablet extended release) $0 (Tier 1)

Klor-Con M20

klor-con m20 (oral tablet extended release) $0 (Tier 1)

Klor-Con

klor-con (oral packet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Klor-Con 8

KLOR-CON 8 (ORAL TABLET EXTENDED

RELEASE)

$0 (Tier 1)

Magnesium Sulfate

MAGNESIUM SULFATE (50% INJECTION

SOLUTION)

$0 (Tier 1)

Magnesium Sulfate

magnesium sulfate (50% (10ml syringe) injection

solution)

$0 (Tier 1)

Nutrilipid

NUTRILIPID (INTRAVENOUS EMULSION) $0 (Tier 1) B/D, PA

Plasma-Lyte 148

PLASMA-LYTE 148 (INTRAVENOUS SOLUTION) $0 (Tier 1)

Plasma-Lyte A

PLASMA-LYTE A (INTRAVENOUS SOLUTION) $0 (Tier 1)

Plenamine

plenamine (intravenous solution) $0 (Tier 1) B/D, PA

Potassium Chloride

potassium chloride cr (oral tablet extended

release)

$0 (Tier 1)

Potassium Chloride

potassium chloride er (oral capsule extended

release)

$0 (Tier 1)

Potassium Chloride

potassium chloride er (oral tablet extended

release)

$0 (Tier 1)

Potassium Chloride

in NaCl

potassium chloride in nacl (20-0.45meq/l-%

intravenous solution)

$0 (Tier 1) B/D, PA

Potassium Chloride

in NaCl

POTASSIUM CHLORIDE IN NACL (20-0.9MEQ/L-

% INTRAVENOUS SOLUTION, 40-0.9MEQ/L-%

INTRAVENOUS SOLUTION)

$0 (Tier 1) B/D, PA

Potassium Chloride

potassium chloride (10meq/100ml intravenous

solution, 20meq/100ml intravenous solution,

2meq/ml (30ml) intravenous solution, 2meq/ml

(20ml) intravenous solution, 40meq/100ml

intravenous solution)

$0 (Tier 1) B/D, PA

Potassium Chloride

potassium chloride (oral packet) $0 (Tier 1)

Potassium Chloride

potassium chloride (20meq/15ml(10%) oral

solution, 40meq/15ml(20%) oral solution)

$0 (Tier 1)

Potassium Citrate

potassium citrate er (oral tablet extended release) $0 (Tier 1)

Potassium Chloride

in Dextrose 5%

POTASSIUM CHLORIDE IN DEXTROSE 5%

(20MEQ/L INTRAVENOUS SOLUTION)

$0 (Tier 1) B/D, PA

Premasol

premasol (intravenous solution) $0 (Tier 1) B/D, PA

Prosol

PROSOL (INTRAVENOUS SOLUTION) $0 (Tier 1) B/D, PA

Sodium Chloride

sodium chloride (0.45% intravenous solution) $0 (Tier 1)

Sodium Chloride

sodium chloride (0.9% intravenous solution, 3%

intravenous solution)

$0 (Tier 1) B/D, PA

Sodium Chloride

SODIUM CHLORIDE (5% INTRAVENOUS

SOLUTION)

$0 (Tier 1) B/D, PA

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Sodium Chloride

SODIUM CHLORIDE (IRRIGATION SOLUTION) $0 (Tier 1)

Sodium Fluoride

sodium fluoride (oral tablet) $0 (Tier 1)

TPN Electrolytes

TPN ELECTROLYTES (INTRAVENOUS

CONCENTRATE)

$0 (Tier 1)

Travasol

TRAVASOL (INTRAVENOUS SOLUTION) $0 (Tier 1) B/D, PA

TrophAmine

TROPHAMINE (INTRAVENOUS SOLUTION) $0 (Tier 1) B/D, PA

Electrolyte/Mineral/Metal Modifiers

Chemet

CHEMET (ORAL CAPSULE) $0 (Tier 1) DL

Deferasirox

Granules

deferasirox granules (oral packet) $0 (Tier 1) PA; DL

Deferasirox

deferasirox (oral tablet) (generic jadenu) $0 (Tier 1) PA

Deferasirox

deferasirox (125mg oral tablet soluble) (generic

exjade)

$0 (Tier 1) PA

Deferasirox

deferasirox (250mg oral tablet soluble, 500mg oral

tablet soluble) (generic exjade)

$0 (Tier 1) PA; DL

Deferiprone

deferiprone (oral tablet) $0 (Tier 1) PA; DL

Ferriprox

FERRIPROX (ORAL SOLUTION) $0 (Tier 1) PA; DL

Trientine HCl

trientine hcl (oral capsule) $0 (Tier 1) PA; DL; QL

Phosphate Binders

Auryxia

AURYXIA (ORAL TABLET) $0 (Tier 1) PA; DL

Calcium Acetate

calcium acetate (phosphate binder) (oral capsule) $0 (Tier 1)

Calcium Acetate

calcium acetate (667mg oral tablet) $0 (Tier 1)

Lanthanum

Carbonate

lanthanum carbonate (oral tablet chewable) $0 (Tier 1) DL

Phoslyra

PHOSLYRA (ORAL SOLUTION) $0 (Tier 1)

Sevelamer

Carbonate

sevelamer carbonate (oral packet) $0 (Tier 1) DL

Sevelamer

Carbonate

sevelamer carbonate (oral tablet) (generic renvela) $0 (Tier 1)

Velphoro

VELPHORO (ORAL TABLET CHEWABLE) $0 (Tier 1) DL

Potassium Binders

Lokelma

LOKELMA (ORAL PACKET) $0 (Tier 1) QL

Sodium Polystyrene

Sulfonate

sodium polystyrene sulfonate (oral powder) $0 (Tier 1)

SPS

sps (oral suspension) $0 (Tier 1)

Veltassa

VELTASSA (ORAL PACKET) $0 (Tier 1) DL; QL

Vitamins

Prenatal

prenatal (27-1mg oral tablet) $0 (Tier 1)

Gastrointestinal Agents

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Anti-Constipation Agents

Constulose

constulose (oral solution) $0 (Tier 1)

Enulose

enulose (oral solution) $0 (Tier 1)

Generlac

generlac (oral solution) $0 (Tier 1)

Lactulose

lactulose (10gm/15ml oral solution) $0 (Tier 1)

Linzess

LINZESS (ORAL CAPSULE) $0 (Tier 1) QL

Lubiprostone

lubiprostone (oral capsule) $0 (Tier 1) QL

Motegrity

MOTEGRITY (ORAL TABLET) $0 (Tier 1) QL

Movantik

MOVANTIK (ORAL TABLET) $0 (Tier 1) QL

Relistor

RELISTOR (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Relistor

RELISTOR (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL

Trulance

TRULANCE (ORAL TABLET) $0 (Tier 1) QL

Anti-Diarrheal Agents

Alosetron HCl

alosetron hcl (oral tablet) $0 (Tier 1) PA; DL

Diphenoxylate-

Atropine

diphenoxylate-atropine (oral liquid) $0 (Tier 1)

Diphenoxylate-

Atropine

diphenoxylate-atropine (oral tablet) $0 (Tier 1)

Loperamide HCl

loperamide hcl (oral capsule) $0 (Tier 1)

Xermelo

XERMELO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Antispasmodics, Gastrointestinal

Dicyclomine HCl

dicyclomine hcl (oral capsule) $0 (Tier 1)

Dicyclomine HCl

dicyclomine hcl (oral solution) $0 (Tier 1)

Dicyclomine HCl

dicyclomine hcl (oral tablet) $0 (Tier 1)

Glycopyrrolate

glycopyrrolate (oral solution) (generic cuvposa) $0 (Tier 1) PA

Methscopolamine

Bromide

methscopolamine bromide (oral tablet) $0 (Tier 1)

Gastrointestinal Agents, Other

Chenodal

chenodal (oral tablet) $0 (Tier 1) PA; DL

Clenpiq

CLENPIQ (ORAL SOLUTION) $0 (Tier 1)

Gattex

GATTEX (SUBCUTANEOUS KIT) $0 (Tier 1) PA; DL

GaviLyte-C

gavilyte-c (oral solution reconstituted) $0 (Tier 1)

GaviLyte-G

gavilyte-g (oral solution reconstituted) $0 (Tier 1)

Myalept

MYALEPT (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Sodium Sulfate-

Potassium Sulfate-

Magnesium Sulfate

SODIUM SULFATE-POTASSIUM SULFATE-

MAGNESIUM SULFATE (ORAL SOLUTION)

$0 (Tier 1)

Ocaliva

OCALIVA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

PEG-3350-NaCl-Na

Bicarbonate-KCl

peg-3350-nacl-na bicarbonate-kcl (oral solution)

(generic nulytely)

$0 (Tier 1)

PEG-3350-

Electrolytes

peg-3350-electrolytes (oral solution) (generic

golytely)

$0 (Tier 1)

Suprep Bowel Prep

Kit

SUPREP BOWEL PREP KIT (ORAL SOLUTION) $0 (Tier 1)

Sutab

SUTAB (ORAL TABLET) $0 (Tier 1)

Ursodiol

ursodiol (300mg oral capsule) $0 (Tier 1)

Ursodiol

ursodiol (oral tablet) $0 (Tier 1)

Histamine2 (H2) Receptor Antagonists

Cimetidine HCl

cimetidine hcl (oral solution) $0 (Tier 1)

Cimetidine

cimetidine (oral tablet) $0 (Tier 1)

Famotidine

famotidine (oral suspension reconstituted) $0 (Tier 1)

Famotidine

famotidine (20mg oral tablet, 40mg oral tablet) $0 (Tier 1)

Nizatidine

nizatidine (oral capsule) $0 (Tier 1)

Protectants

Misoprostol

misoprostol (oral tablet) $0 (Tier 1)

Sucralfate

sucralfate (oral suspension) $0 (Tier 1)

Sucralfate

sucralfate (oral tablet) $0 (Tier 1)

Proton Pump Inhibitors

Dexilant

DEXILANT (ORAL CAPSULE DELAYED

RELEASE)

$0 (Tier 1) QL

Dexlansoprazole

dexlansoprazole (oral capsule delayed release) $0 (Tier 1) QL

Esomeprazole

Magnesium

esomeprazole magnesium (oral capsule delayed

release) (generic nexium)

$0 (Tier 1) QL

Esomeprazole

Magnesium

esomeprazole magnesium (oral packet) $0 (Tier 1)

Lansoprazole

lansoprazole (oral capsule delayed release) $0 (Tier 1) QL

Omeprazole

omeprazole (10mg oral capsule delayed release) $0 (Tier 1) QL

Omeprazole

omeprazole (20mg oral capsule delayed release,

40mg oral capsule delayed release)

$0 (Tier 1)

Pantoprazole

Sodium

pantoprazole sodium (oral tablet delayed release) $0 (Tier 1) QL

Rabeprazole

Sodium

rabeprazole sodium (oral tablet delayed release) $0 (Tier 1)

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment

Aralast NP

ARALAST NP (1000MG INTRAVENOUS

SOLUTION RECONSTITUTED)

$0 (Tier 1) PA; DL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Betaine

betaine (oral powder) $0 (Tier 1) DL

Cholbam

CHOLBAM (ORAL CAPSULE) $0 (Tier 1) PA; DL

Creon

CREON (ORAL CAPSULE DELAYED RELEASE

PARTICLES)

$0 (Tier 1)

Cromolyn Sodium

cromolyn sodium (oral concentrate) $0 (Tier 1)

Cystadane

CYSTADANE (ORAL POWDER) $0 (Tier 1) DL

Cystagon

CYSTAGON (ORAL CAPSULE) $0 (Tier 1)

Glassia

GLASSIA (INTRAVENOUS SOLUTION) $0 (Tier 1) PA; DL

Levocarnitine

levocarnitine (1gm/10ml oral solution) $0 (Tier 1)

Levocarnitine

LEVOCARNITINE (330MG ORAL TABLET) $0 (Tier 1)

Miglustat

miglustat (oral capsule) $0 (Tier 1) PA; DL

Nitisinone

nitisinone (oral capsule) $0 (Tier 1) DL

Orfadin

ORFADIN (20MG ORAL CAPSULE) $0 (Tier 1) DL

Orfadin

ORFADIN (ORAL SUSPENSION) $0 (Tier 1) DL

Procysbi

PROCYSBI (ORAL PACKET) $0 (Tier 1) DL

Prolastin-C

PROLASTIN-C (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

RAVICTI

RAVICTI (ORAL LIQUID) $0 (Tier 1) DL; QL

Revcovi

REVCOVI (INTRAMUSCULAR SOLUTION) $0 (Tier 1) PA; DL

Sapropterin

Dihydrochloride

sapropterin dihydrochloride (oral packet) $0 (Tier 1) DL

Sapropterin

Dihydrochloride

sapropterin dihydrochloride (oral tablet) $0 (Tier 1) DL

Sodium

Phenylbutyrate

sodium phenylbutyrate (oral powder) $0 (Tier 1) DL

Sodium

Phenylbutyrate

sodium phenylbutyrate (oral tablet) $0 (Tier 1) DL

Sucraid

SUCRAID (ORAL SOLUTION) $0 (Tier 1) DL

Tegsedi

TEGSEDI (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Vyndamax

VYNDAMAX (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Vyndaqel

VYNDAQEL (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Zemaira

ZEMAIRA (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Zenpep

ZENPEP (ORAL CAPSULE DELAYED RELEASE

PARTICLES)

$0 (Tier 1)

Genitourinary Agents

Antispasmodics, Urinary

Gemtesa

GEMTESA (ORAL TABLET) $0 (Tier 1)

Myrbetriq

MYRBETRIQ (ORAL SUSPENSION

RECONSTITUTED ER)

$0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Myrbetriq

MYRBETRIQ (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1)

Oxybutynin

Chloride ER

oxybutynin chloride er (oral tablet extended release

24 hour)

$0 (Tier 1) QL

Oxybutynin

Chloride

oxybutynin chloride (oral syrup) $0 (Tier 1)

Oxybutynin

Chloride

oxybutynin chloride (oral tablet immediate release) $0 (Tier 1)

Solifenacin

Succinate

solifenacin succinate (oral tablet) $0 (Tier 1) QL

Tolterodine Tartrate

tolterodine tartrate er (oral capsule extended

release 24 hour)

$0 (Tier 1)

Tolterodine Tartrate

tolterodine tartrate (oral tablet) $0 (Tier 1)

Trospium Chloride

trospium chloride (oral tablet) $0 (Tier 1)

Benign Prostatic Hypertrophy Agents

Alfuzosin HCl ER

alfuzosin hcl er (oral tablet extended release 24

hour)

$0 (Tier 1)

Dutasteride

dutasteride (oral capsule) $0 (Tier 1) QL

Finasteride

finasteride (5mg oral tablet) (generic proscar) $0 (Tier 1)

Silodosin

silodosin (oral capsule) $0 (Tier 1) QL

Tamsulosin HCl

tamsulosin hcl (oral capsule) $0 (Tier 1)

Terazosin HCl

terazosin hcl (oral capsule) $0 (Tier 1)

Genitourinary Agents, Other

Bethanechol

Chloride

bethanechol chloride (oral tablet) $0 (Tier 1)

Elmiron

ELMIRON (ORAL CAPSULE) $0 (Tier 1) DL

Lithostat

LITHOSTAT (ORAL TABLET) $0 (Tier 1) DL

Penicillamine

penicillamine (250mg oral capsule) $0 (Tier 1) PA; DL

Penicillamine

penicillamine (250mg oral tablet) $0 (Tier 1) DL

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Dexamethasone

dexamethasone (oral solution) $0 (Tier 1)

Dexamethasone

dexamethasone (oral tablet) $0 (Tier 1)

Fludrocortisone

Acetate

fludrocortisone acetate (oral tablet) $0 (Tier 1)

Hydrocortisone

hydrocortisone (oral tablet) $0 (Tier 1)

Methylprednisolone

methylprednisolone (oral tablet) $0 (Tier 1)

Methylprednisolone

methylprednisolone (oral tablet therapy pack) $0 (Tier 1)

Prednisolone

prednisolone (oral solution) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Prednisolone

Sodium Phosphate

prednisolone sodium phosphate (25mg/5ml oral

solution, 6.7mg/5ml oral solution)

$0 (Tier 1)

Prednisone Intensol

prednisone intensol (oral concentrate) $0 (Tier 1)

Prednisone

prednisone (5mg/5ml oral solution) $0 (Tier 1)

Prednisone

prednisone (10mg oral tablet, 1mg oral tablet,

2.5mg oral tablet, 20mg oral tablet, 50mg oral

tablet, 5mg oral tablet)

$0 (Tier 1)

Prednisone

prednisone (10mg (21) oral tablet therapy pack,

10mg (48) oral tablet therapy pack, 5mg (21) oral

tablet therapy pack, 5mg (48) oral tablet therapy

pack)

$0 (Tier 1)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Desmopressin

Acetate

desmopressin acetate (oral tablet) $0 (Tier 1)

Desmopressin

Acetate Spray

desmopressin acetate spray (nasal solution) $0 (Tier 1)

Egrifta SV

EGRIFTA SV (2MG SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Genotropin

MiniQuick

GENOTROPIN MINIQUICK (SUBCUTANEOUS

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Genotropin

GENOTROPIN (SUBCUTANEOUS CARTRIDGE) $0 (Tier 1) PA; DL

Increlex

INCRELEX (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL

Serostim

SEROSTIM (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Zorbtive

ZORBTIVE (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Korlym

KORLYM (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic Steroids

Oxandrolone

oxandrolone (10mg oral tablet) $0 (Tier 1) PA; QL

Oxandrolone

oxandrolone (2.5mg oral tablet) $0 (Tier 1) PA; QL

Androgens

Androderm

ANDRODERM (TRANSDERMAL PATCH 24

HOUR)

$0 (Tier 1) QL

Danazol

danazol (oral capsule) $0 (Tier 1)

Testosterone

Cypionate

testosterone cypionate (intramuscular solution) $0 (Tier 1)

Testosterone

Enanthate

testosterone enanthate (intramuscular solution) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Testosterone

testosterone (25mg/2.5gm 1% transdermal gel,

50mg/5gm 1% transdermal gel), testosterone

pump (1% transdermal gel)

$0 (Tier 1)

Testosterone

testosterone (20.25mg/1.25gm 1.62%

transdermal gel, 40.5mg/2.5gm 1.62%

transdermal gel), testosterone pump (1.62%

transdermal gel)

$0 (Tier 1)

Estrogens

Altavera

altavera (oral tablet) $0 (Tier 1)

Alyacen 1/35

alyacen 1/35 (oral tablet) $0 (Tier 1)

Amethia

amethia (oral tablet) $0 (Tier 1)

Apri

apri (oral tablet) $0 (Tier 1)

Aranelle

aranelle (oral tablet) $0 (Tier 1)

Ashlyna

ashlyna (oral tablet) $0 (Tier 1)

Aubra EQ

aubra eq (oral tablet) $0 (Tier 1)

Aviane

aviane (oral tablet) $0 (Tier 1)

Balziva

balziva (oral tablet) $0 (Tier 1)

Blisovi 24 Fe

blisovi 24 fe (oral tablet) $0 (Tier 1)

Blisovi Fe 1.5/30

blisovi fe 1.5/30 (oral tablet) $0 (Tier 1)

Briellyn

briellyn (oral tablet) $0 (Tier 1)

Camrese Lo

camrese lo (oral tablet) $0 (Tier 1)

Climara Pro

CLIMARA PRO (TRANSDERMAL PATCH

WEEKLY)

$0 (Tier 1)

Cryselle-28

cryselle-28 (oral tablet) $0 (Tier 1)

Cyred EQ

cyred eq (oral tablet) $0 (Tier 1)

Depo-Estradiol

depo-estradiol (intramuscular oil) $0 (Tier 1)

Desogestrel-Ethinyl

Estradiol

desogestrel-ethinyl estradiol (oral tablet) $0 (Tier 1)

Dolishale

dolishale (oral tablet) $0 (Tier 1)

Drospirenone-

Ethinyl Estradiol

drospirenone-ethinyl estradiol (oral tablet) $0 (Tier 1)

Duavee

DUAVEE (ORAL TABLET) $0 (Tier 1)

Elestrin

ELESTRIN (TRANSDERMAL GEL) $0 (Tier 1)

EluRyng

eluryng (vaginal ring) $0 (Tier 1)

Emoquette

emoquette (0.15-30mg-mcg oral tablet) $0 (Tier 1)

Enpresse-28

enpresse-28 (oral tablet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Enskyce

enskyce (oral tablet) $0 (Tier 1)

Estarylla

estarylla (oral tablet) $0 (Tier 1)

Estradiol

estradiol (oral tablet) $0 (Tier 1)

Estradiol

estradiol (transdermal patch weekly) $0 (Tier 1) QL

Estradiol

estradiol (vaginal cream) $0 (Tier 1)

Estradiol

estradiol (vaginal tablet) $0 (Tier 1) QL

Estradiol Valerate

estradiol valerate (20mg/ml intramuscular oil,

40mg/ml intramuscular oil)

$0 (Tier 1)

Estring

ESTRING (VAGINAL RING) $0 (Tier 1)

Ethynodiol

Diacetate-Ethinyl

Estradiol

ethynodiol diacetate-ethinyl estradiol (oral tablet) $0 (Tier 1)

Etonogestrel-Ethinyl

Estradiol

etonogestrel-ethinyl estradiol (vaginal ring) $0 (Tier 1)

Falmina

falmina (oral tablet) $0 (Tier 1)

Femring

FEMRING (VAGINAL RING) $0 (Tier 1)

Femynor

femynor (oral tablet) $0 (Tier 1)

Finzala

finzala (oral tablet chewable) $0 (Tier 1)

Fyavolv

fyavolv (oral tablet) $0 (Tier 1)

Hailey 24 Fe

hailey 24 fe (oral tablet) $0 (Tier 1)

Iclevia

iclevia (oral tablet) $0 (Tier 1)

Imvexxy

Maintenance Pack

IMVEXXY MAINTENANCE PACK (VAGINAL

INSERT)

$0 (Tier 1) PA; QL

Imvexxy Starter

Pack

IMVEXXY STARTER PACK (VAGINAL INSERT) $0 (Tier 1) PA; QL

Introvale

introvale (oral tablet) $0 (Tier 1)

Isibloom

isibloom (oral tablet) $0 (Tier 1)

Jasmiel

jasmiel (oral tablet) $0 (Tier 1)

Jinteli

jinteli (oral tablet) $0 (Tier 1)

Juleber

juleber (oral tablet) $0 (Tier 1)

Junel 1.5/30

junel 1.5/30 (oral tablet) $0 (Tier 1)

Junel 1/20

junel 1/20 (oral tablet) $0 (Tier 1)

Junel Fe 1.5/30

junel fe 1.5/30 (oral tablet) $0 (Tier 1)

Junel Fe 1/20

junel fe 1/20 (oral tablet) $0 (Tier 1)

Junel Fe 24

junel fe 24 (oral tablet) $0 (Tier 1)

Kaitlib Fe

kaitlib fe (oral tablet chewable) $0 (Tier 1)

Kariva

kariva (oral tablet) $0 (Tier 1)

Kelnor 1/35

kelnor 1/35 (oral tablet) $0 (Tier 1)

Kelnor 1/50

kelnor 1/50 (oral tablet) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Kurvelo

kurvelo (oral tablet) $0 (Tier 1)

LARIN 1.5/30

larin 1.5/30 (oral tablet) $0 (Tier 1)

LARIN 1/20

larin 1/20 (oral tablet) $0 (Tier 1)

LARIN Fe 1.5/30

larin fe 1.5/30 (oral tablet) $0 (Tier 1)

LARIN Fe 1/20

larin fe 1/20 (oral tablet) $0 (Tier 1)

Layolis Fe

LAYOLIS FE (ORAL TABLET CHEWABLE) $0 (Tier 1)

Leena

leena (oral tablet) $0 (Tier 1)

Lessina

lessina (oral tablet) $0 (Tier 1)

Levonest

levonest (oral tablet) $0 (Tier 1)

Levonorgestrel-

Ethinyl Estradiol &

Ethinyl Estradiol

levonorgestrel-ethinyl estradiol & ethinyl estradiol

(oral tablet)

$0 (Tier 1)

Levonorgestrel-

Ethinyl Estradiol 91-

Day

levonorgestrel-ethinyl estradiol 91-day (oral tablet) $0 (Tier 1)

Levonorgestrel-

Ethinyl Estradiol

levonorgestrel-ethinyl estradiol (oral tablet) $0 (Tier 1)

Levora 0.15/30

levora 0.15/30 (28) (oral tablet) $0 (Tier 1)

Loryna

loryna (oral tablet) $0 (Tier 1)

Low-Ogestrel

low-ogestrel (oral tablet) $0 (Tier 1)

Lutera

lutera (oral tablet) $0 (Tier 1)

Marlissa

marlissa (oral tablet) $0 (Tier 1)

Menest

menest (oral tablet) $0 (Tier 1)

Microgestin 1.5/30

microgestin 1.5/30 (oral tablet) $0 (Tier 1)

Microgestin 1/20

microgestin 1/20 (oral tablet) $0 (Tier 1)

Microgestin 24 Fe

microgestin 24 fe (oral tablet) $0 (Tier 1)

Microgestin Fe

1.5/30

microgestin fe 1.5/30 (oral tablet) $0 (Tier 1)

Microgestin Fe 1/20

microgestin fe 1/20 (oral tablet) $0 (Tier 1)

Mili

mili (oral tablet) $0 (Tier 1)

Necon 0.5/35

necon 0.5/35 (28) (oral tablet) $0 (Tier 1)

Nikki

nikki (oral tablet) $0 (Tier 1)

Norethindrone

Acetate-Ethinyl

Estradiol

norethindrone acetate-ethinyl estradiol (0.5-2.5mg-

mcg oral tablet, 1-20mg-mcg oral tablet, 1-5mg-

mcg oral tablet)

$0 (Tier 1)

Norethindrone

Acetate-Ethinyl

Estradiol-Fe

norethindrone acetate-ethinyl estradiol-fe (1-20mg-

mcg oral tablet)

$0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Norethindrone

Acetate-Ethinyl

Estradiol-Fe

norethindrone acetate-ethinyl estradiol-fe

(0.4-35mg-mcg oral tablet chewable, 0.8-25mg-

mcg oral tablet chewable, 1-20mg-mcg(24) oral

tablet chewable)

$0 (Tier 1)

Norethindrone-

Ethinyl Estradiol-Fe

norethindrone-ethinyl estradiol-fe (1-20mg-mcg/

1-30mg-mcg/1-35mg-mcg oral tablet)

$0 (Tier 1)

Norgestimate-

Ethinyl Estradiol

norgestimate-ethinyl estradiol (oral tablet) $0 (Tier 1)

Norgestimate-

Ethinyl Estradiol

Triphasic

norgestimate-ethinyl estradiol triphasic (oral tablet) $0 (Tier 1)

Nortrel 0.5/35

nortrel 0.5/35 (28) (oral tablet) $0 (Tier 1)

Nortrel 1/35

nortrel 1/35 (21) (oral tablet) $0 (Tier 1)

Nortrel 1/35

nortrel 1/35 (28) (oral tablet) $0 (Tier 1)

Nortrel 7/7/7

nortrel 7/7/7 (oral tablet) $0 (Tier 1)

Nylia 1/35

nylia 1/35 (oral tablet) $0 (Tier 1)

Nylia 7/7/7

nylia 7/7/7 (oral tablet) $0 (Tier 1)

Nymyo

nymyo (oral tablet) $0 (Tier 1)

Ocella

ocella (oral tablet) $0 (Tier 1)

Pimtrea

pimtrea (oral tablet) $0 (Tier 1)

Pirmella 1/35

pirmella 1/35 (oral tablet) $0 (Tier 1)

Portia-28

portia-28 (oral tablet) $0 (Tier 1)

Premarin

PREMARIN (ORAL TABLET) $0 (Tier 1) QL

Premarin

PREMARIN (VAGINAL CREAM) $0 (Tier 1)

Premphase

PREMPHASE (ORAL TABLET) $0 (Tier 1) QL

Prempro

PREMPRO (ORAL TABLET) $0 (Tier 1) QL

Reclipsen

reclipsen (oral tablet) $0 (Tier 1)

Rivelsa

rivelsa (oral tablet) $0 (Tier 1)

Setlakin

setlakin (oral tablet) $0 (Tier 1)

Sprintec 28

sprintec 28 (oral tablet) $0 (Tier 1)

Sronyx

sronyx (oral tablet) $0 (Tier 1)

Syeda

syeda (oral tablet) $0 (Tier 1)

Tarina 24 Fe

tarina 24 fe (oral tablet) $0 (Tier 1)

Tarina Fe 1/20 EQ

tarina fe 1/20 eq (oral tablet) $0 (Tier 1)

Tilia Fe

tilia fe (oral tablet) $0 (Tier 1)

Tri-Estarylla

tri-estarylla (oral tablet) $0 (Tier 1)

Tri-Legest Fe

tri-legest fe (oral tablet) $0 (Tier 1)

Tri-Lo-Estarylla

tri-lo-estarylla (oral tablet) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Tri-Lo-Sprintec

tri-lo-sprintec (oral tablet) $0 (Tier 1)

Tri-Mili

tri-mili (oral tablet) $0 (Tier 1)

Tri-Nymyo

tri-nymyo (oral tablet) $0 (Tier 1)

Tri-Sprintec

tri-sprintec (oral tablet) $0 (Tier 1)

Trivora

trivora (28) (oral tablet) $0 (Tier 1)

Tri-VyLibra Lo

tri-vylibra lo (oral tablet) $0 (Tier 1)

Tri-VyLibra

tri-vylibra (oral tablet) $0 (Tier 1)

Velivet

velivet (oral tablet) $0 (Tier 1)

Vestura

vestura (oral tablet) $0 (Tier 1)

Vienva

vienva (oral tablet) $0 (Tier 1)

Vyfemla

vyfemla (oral tablet) $0 (Tier 1)

VyLibra

vylibra (oral tablet) $0 (Tier 1)

WYMZYA Fe

wymzya fe (oral tablet chewable) $0 (Tier 1)

Xulane

xulane (transdermal patch weekly) $0 (Tier 1)

Yuvafem

yuvafem (vaginal tablet) $0 (Tier 1) QL

Zafemy

zafemy (transdermal patch weekly) $0 (Tier 1)

Zovia 1/35

zovia 1/35 (28) (oral tablet) $0 (Tier 1)

Progestins

Camila

camila (oral tablet) $0 (Tier 1)

Crinone

CRINONE (VAGINAL GEL) $0 (Tier 1) PA

Deblitane

deblitane (oral tablet) $0 (Tier 1)

Errin

errin (oral tablet) $0 (Tier 1)

Incassia

incassia (oral tablet) $0 (Tier 1)

Lyleq

lyleq (oral tablet) $0 (Tier 1)

Lyza

lyza (oral tablet) $0 (Tier 1)

Medroxyprogestero

ne Acetate

medroxyprogesterone acetate (150mg/ml

intramuscular suspension)

$0 (Tier 1)

Medroxyprogestero

ne Acetate

medroxyprogesterone acetate (150mg/ml

intramuscular suspension prefilled syringe)

$0 (Tier 1)

Medroxyprogestero

ne Acetate

medroxyprogesterone acetate (10mg oral tablet,

2.5mg oral tablet, 5mg oral tablet)

$0 (Tier 1)

Megestrol Acetate

megestrol acetate (40mg/ml oral suspension) $0 (Tier 1)

Megestrol Acetate

megestrol acetate (625mg/5ml oral suspension) $0 (Tier 1)

Megestrol Acetate

megestrol acetate (oral tablet) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Nora-BE

nora-be (oral tablet) $0 (Tier 1)

Norethindrone

Acetate

norethindrone acetate (5mg oral tablet) $0 (Tier 1)

Norethindrone

norethindrone (0.35mg oral tablet) $0 (Tier 1)

Progesterone

progesterone (oral capsule) $0 (Tier 1)

Sharobel

sharobel (oral tablet) $0 (Tier 1)

Selective Estrogen Receptor Modifying Agents

Osphena

OSPHENA (ORAL TABLET) $0 (Tier 1) PA; QL

Raloxifene HCl

raloxifene hcl (oral tablet) $0 (Tier 1) QL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Euthyrox

EUTHYROX (ORAL TABLET) $0 (Tier 1)

Levo-T

LEVO-T (ORAL TABLET) $0 (Tier 1)

Levothyroxine

Sodium

levothyroxine sodium (oral tablet) $0 (Tier 1)

Levoxyl

LEVOXYL (ORAL TABLET) $0 (Tier 1)

Liothyronine

Sodium

liothyronine sodium (oral tablet) $0 (Tier 1)

Synthroid

SYNTHROID (ORAL TABLET) $0 (Tier 1)

Unithroid

UNITHROID (ORAL TABLET) $0 (Tier 1)

Hormonal Agents, Suppressant (Adrenal)

Isturisa

ISTURISA (ORAL TABLET) $0 (Tier 1) PA; DL

Lysodren

LYSODREN (ORAL TABLET) $0 (Tier 1) DL

Hormonal Agents, Suppressant (Pituitary)

Cabergoline

cabergoline (oral tablet) $0 (Tier 1)

Firmagon

FIRMAGON (240MG DOSE) (120MG/VIAL

SUBCUTANEOUS SOLUTION RECONSTITUTED)

$0 (Tier 1) PA; DL

Firmagon

FIRMAGON (80MG SUBCUTANEOUS

SOLUTION RECONSTITUTED)

$0 (Tier 1) PA

Leuprolide Acetate

leuprolide acetate (injection kit) $0 (Tier 1) PA

Lupron Depot

LUPRON DEPOT (1-MONTH) (INTRAMUSCULAR

KIT)

$0 (Tier 1) PA; DL

Lupron Depot

LUPRON DEPOT (3-MONTH) (INTRAMUSCULAR

KIT)

$0 (Tier 1) PA; DL

Lupron Depot

LUPRON DEPOT (4-MONTH) (INTRAMUSCULAR

KIT)

$0 (Tier 1) PA; DL

Lupron Depot

LUPRON DEPOT (6-MONTH) (INTRAMUSCULAR

KIT)

$0 (Tier 1) PA; DL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Octreotide Acetate

octreotide acetate (injection solution) $0 (Tier 1) PA

Orgovyx

ORGOVYX (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Signifor

SIGNIFOR (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL

Somavert

SOMAVERT (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL; QL

Synarel

SYNAREL (NASAL SOLUTION) $0 (Tier 1) DL

Trelstar Mixject

TRELSTAR MIXJECT (INTRAMUSCULAR

SUSPENSION RECONSTITUTED)

$0 (Tier 1) PA; DL

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

Methimazole

methimazole (oral tablet) $0 (Tier 1)

Propylthiouracil

propylthiouracil (oral tablet) $0 (Tier 1)

Immunological Agents

Angioedema Agents

Berinert

BERINERT (INTRAVENOUS KIT) $0 (Tier 1) PA; DL

Cinryze

CINRYZE (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Haegarda

HAEGARDA (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Icatibant Acetate

icatibant acetate (subcutaneous solution) $0 (Tier 1) PA; DL; QL

Ruconest

RUCONEST (INTRAVENOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Sajazir

sajazir (subcutaneous solution) $0 (Tier 1) PA; DL; QL

Immunoglobulins

BIVIGAM

BIVIGAM (5GM/50ML INTRAVENOUS

SOLUTION)

$0 (Tier 1) PA; DL

Flebogamma DIF

FLEBOGAMMA DIF (5GM/50ML INTRAVENOUS

SOLUTION)

$0 (Tier 1) PA; DL

Gammagard

GAMMAGARD (2.5GM/25ML INJECTION

SOLUTION)

$0 (Tier 1) PA; DL

Gammagard S/D

Less IgA

GAMMAGARD S/D LESS IGA (INTRAVENOUS

SOLUTION RECONSTITUTED)

$0 (Tier 1) PA; DL

Gammaked

GAMMAKED (1GM/10ML INJECTION

SOLUTION)

$0 (Tier 1) PA; DL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Gammaplex

GAMMAPLEX (10GM/100ML INTRAVENOUS

SOLUTION, 10GM/200ML INTRAVENOUS

SOLUTION, 20GM/200ML INTRAVENOUS

SOLUTION, 5GM/50ML INTRAVENOUS

SOLUTION)

$0 (Tier 1) PA; DL

Gamunex-C

GAMUNEX-C (1GM/10ML INJECTION

SOLUTION)

$0 (Tier 1) PA; DL

Octagam

OCTAGAM (1GM/20ML INTRAVENOUS

SOLUTION, 2GM/20ML INTRAVENOUS

SOLUTION)

$0 (Tier 1) PA; DL

Panzyga

PANZYGA (INTRAVENOUS SOLUTION) $0 (Tier 1) PA; DL

Privigen

PRIVIGEN (20GM/200ML INTRAVENOUS

SOLUTION)

$0 (Tier 1) PA; DL

Immunological Agents, Other

Actemra ACTPen

ACTEMRA ACTPEN (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

$0 (Tier 1) PA; DL; QL

Actemra

ACTEMRA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Arcalyst

ARCALYST (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Benlysta

BENLYSTA (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

$0 (Tier 1) PA; DL

Benlysta

BENLYSTA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Cosentyx

COSENTYX (300MG DOSE) (SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Cosentyx

Sensoready

COSENTYX SENSOREADY (300MG)

(SUBCUTANEOUS SOLUTION AUTO-INJECTOR)

$0 (Tier 1) PA; DL; QL

Cosentyx

COSENTYX (75MG/0.5ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Dupixent

DUPIXENT (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) PA; DL; QL

Dupixent

DUPIXENT (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Kineret

KINERET (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Orencia ClickJect

ORENCIA CLICKJECT (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

$0 (Tier 1) PA; DL; QL

Orencia

ORENCIA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Otezla

OTEZLA (ORAL TABLET) $0 (Tier 1) PA; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Otezla

OTEZLA (ORAL TABLET THERAPY PACK) $0 (Tier 1) PA; DL; QL

Ridaura

RIDAURA (ORAL CAPSULE) $0 (Tier 1) DL

Rinvoq

RINVOQ (ORAL TABLET EXTENDED RELEASE

24 HOUR)

$0 (Tier 1) PA; DL; QL

Skyrizi Pen

SKYRIZI PEN (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

$0 (Tier 1) PA; DL; QL

Skyrizi

SKYRIZI (SUBCUTANEOUS SOLUTION

CARTRIDGE)

$0 (Tier 1) PA; DL; QL

Skyrizi

SKYRIZI (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Stelara

STELARA (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL; QL

Stelara

STELARA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Xeljanz

XELJANZ (ORAL SOLUTION) $0 (Tier 1) PA; DL; QL

Xeljanz

XELJANZ (ORAL TABLET IMMEDIATE RELEASE) $0 (Tier 1) PA; DL; QL

Xeljanz XR

XELJANZ XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) PA; DL; QL

Xolair

XOLAIR (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Xolair

XOLAIR (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Immunostimulants

Actimmune

ACTIMMUNE (SUBCUTANEOUS SOLUTION) $0 (Tier 1) DL

Besremi

BESREMI (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Pegasys

PEGASYS (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL

Pegasys

PEGASYS (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

Immunosuppressants

Azathioprine

azathioprine (50mg oral tablet) $0 (Tier 1) B/D, PA

Cimzia

CIMZIA (SUBCUTANEOUS KIT) $0 (Tier 1) PA; DL; QL

Cimzia Prefilled

CIMZIA PREFILLED (2 X 200MG/ML

SUBCUTANEOUS PREFILLED SYRINGE KIT)

$0 (Tier 1) PA; DL; QL

Cyclosporine

Modified

cyclosporine modified (oral capsule) $0 (Tier 1) B/D, PA

Cyclosporine

Modified

cyclosporine modified (oral solution) $0 (Tier 1) B/D, PA

Cyclosporine

cyclosporine (oral capsule) $0 (Tier 1) B/D, PA

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Enbrel Mini

ENBREL MINI (SUBCUTANEOUS SOLUTION

CARTRIDGE)

$0 (Tier 1) PA; DL; QL

Enbrel

ENBREL (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL; QL

Enbrel

ENBREL (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Enbrel SureClick

ENBREL SURECLICK (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

$0 (Tier 1) PA; DL; QL

Envarsus XR

ENVARSUS XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

$0 (Tier 1) B/D, PA

Everolimus

everolimus (0.25mg oral tablet, 0.5mg oral tablet,

0.75mg oral tablet, 1mg oral tablet)

$0 (Tier 1) B/D, PA; DL

Gengraf

gengraf (oral capsule) $0 (Tier 1) B/D, PA

Gengraf

gengraf (oral solution) $0 (Tier 1) B/D, PA

Humira Pediatric

Crohns Start

HUMIRA PEDIATRIC CROHNS START

(SUBCUTANEOUS PREFILLED SYRINGE KIT)

$0 (Tier 1) PA; DL; QL

Humira Pen

HUMIRA PEN (SUBCUTANEOUS PEN-INJECTOR

KIT)

$0 (Tier 1) PA; DL; QL

Humira Pen Crohns

Disease Starter

HUMIRA PEN CROHNS DISEASE STARTER

(SUBCUTANEOUS PEN-INJECTOR KIT)

$0 (Tier 1) PA; DL

Humira Pen-

Pediatric UC Start

HUMIRA PEN-PEDIATRIC UC START

(SUBCUTANEOUS PEN-INJECTOR KIT)

$0 (Tier 1) PA; DL

Humira Pen

Psoriasis Starter

HUMIRA PEN PSORIASIS STARTER (40MG/

0.8ML SUBCUTANEOUS PEN-INJECTOR KIT)

$0 (Tier 1) PA; DL

Humira Pen

Psoriasis Starter

HUMIRA PEN PSORIASIS STARTER (80MG/

0.8ML AND 40MG/0.4ML SUBCUTANEOUS

PEN-INJECTOR KIT)

$0 (Tier 1) PA; DL; QL

Humira

HUMIRA (SUBCUTANEOUS PREFILLED

SYRINGE KIT)

$0 (Tier 1) PA; DL; QL

Leflunomide

leflunomide (oral tablet) $0 (Tier 1)

Methotrexate

Sodium

methotrexate sodium (50mg/2ml injection solution

prefilled syringe)

$0 (Tier 1)

Methotrexate

Sodium

methotrexate sodium (50mg/2ml injection

solution)

$0 (Tier 1)

Methotrexate

Sodium

methotrexate sodium (oral tablet) $0 (Tier 1)

Mycophenolate

Mofetil

mycophenolate mofetil (oral capsule) $0 (Tier 1) B/D, PA

Mycophenolate

Mofetil

mycophenolate mofetil (oral suspension

reconstituted)

$0 (Tier 1) B/D, PA; DL

Mycophenolate

Mofetil

mycophenolate mofetil (oral tablet) $0 (Tier 1) B/D, PA

Mycophenolate

Sodium

mycophenolate sodium (oral tablet delayed

release)

$0 (Tier 1) B/D, PA

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Prograf

PROGRAF (ORAL PACKET) $0 (Tier 1) B/D, PA

Rasuvo

RASUVO (SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

$0 (Tier 1) PA

Sandimmune

SANDIMMUNE (ORAL SOLUTION) $0 (Tier 1) B/D, PA

Simponi

SIMPONI (SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

$0 (Tier 1) PA; DL; QL

Simponi

SIMPONI (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Sirolimus

sirolimus (oral solution) $0 (Tier 1) B/D, PA; DL

Sirolimus

sirolimus (oral tablet) $0 (Tier 1) B/D, PA

Tacrolimus

tacrolimus (oral capsule) $0 (Tier 1) B/D, PA

Trexall

trexall (oral tablet) $0 (Tier 1)

Xatmep

XATMEP (ORAL SOLUTION) $0 (Tier 1) PA

Vaccines

ActHIB

ACTHIB (INTRAMUSCULAR SOLUTION

RECONSTITUTED)

$0 (Tier 1) QL

Adacel

ADACEL (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

BCG Vaccine

BCG VACCINE (INJECTION SOLUTION

RECONSTITUTED)

$0 (Tier 1) QL

Bexsero

BEXSERO (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Boostrix

BOOSTRIX (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Boostrix

BOOSTRIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Daptacel

DAPTACEL (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Diphtheria-Tetanus

Toxoids DT

DIPHTHERIA-TETANUS TOXOIDS DT

(INTRAMUSCULAR SUSPENSION)

$0 (Tier 1) QL

Engerix-B

ENGERIX-B (INJECTION SUSPENSION) $0 (Tier 1) B/D, PA; QL

Engerix-B

ENGERIX-B (INJECTION SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) B/D, PA; QL

Gardasil 9

GARDASIL 9 (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Gardasil 9

GARDASIL 9 (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Havrix

HAVRIX (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Hiberix

HIBERIX (INJECTION SOLUTION

RECONSTITUTED)

$0 (Tier 1) QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Imovax Rabies

IMOVAX RABIES (INTRAMUSCULAR

SUSPENSION RECONSTITUTED)

$0 (Tier 1) B/D, PA; QL

Infanrix

INFANRIX (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

IPOL

IPOL (INJECTION) $0 (Tier 1) QL

Ixiaro

IXIARO (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Jynneos

JYNNEOS (SUBCUTANEOUS SUSPENSION) $0 (Tier 1) QL

Kinrix

KINRIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Menactra

MENACTRA (INTRAMUSCULAR SOLUTION) $0 (Tier 1) QL

MenQuadfi

MENQUADFI (INTRAMUSCULAR SOLUTION) $0 (Tier 1) QL

Menveo

MENVEO (INTRAMUSCULAR SOLUTION

RECONSTITUTED)

$0 (Tier 1) QL

M-M-R II

M-M-R II (INJECTION SOLUTION

RECONSTITUTED)

$0 (Tier 1) QL

Pediarix

PEDIARIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Pedvax HIB

PEDVAX HIB (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Pentacel

PENTACEL (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

$0 (Tier 1) QL

PreHevbrio

PREHEVBRIO (INTRAMUSCULAR

SUSPENSION)

$0 (Tier 1) B/D, PA; QL

Priorix

PRIORIX (SUBCUTANEOUS SUSPENSION

RECONSTITUTED)

$0 (Tier 1) QL

ProQuad

PROQUAD (SUBCUTANEOUS SUSPENSION

RECONSTITUTED)

$0 (Tier 1) QL

Quadracel

QUADRACEL (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Quadracel

QUADRACEL (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

RabAvert

RABAVERT (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

$0 (Tier 1) B/D, PA; QL

Recombivax HB

RECOMBIVAX HB (INJECTION SUSPENSION) $0 (Tier 1) B/D, PA; QL

Recombivax HB

RECOMBIVAX HB (INJECTION SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) B/D, PA; QL

Rotarix

ROTARIX (ORAL SUSPENSION

RECONSTITUTED)

$0 (Tier 1) QL

RotaTeq

ROTATEQ (ORAL SOLUTION) $0 (Tier 1) QL

Shingrix

SHINGRIX (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

$0 (Tier 1) PA; QL

TDVAX

TDVAX (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Tenivac

TENIVAC (INTRAMUSCULAR INJECTABLE) $0 (Tier 1) QL

Ticovac

TICOVAC (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Trumenba

TRUMENBA (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Twinrix

TWINRIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Typhim Vi

TYPHIM VI (INTRAMUSCULAR SOLUTION) $0 (Tier 1) QL

Typhim Vi

TYPHIM VI (INTRAMUSCULAR SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) QL

VAQTA

VAQTA (INTRAMUSCULAR SUSPENSION) $0 (Tier 1) QL

Varivax

VARIVAX (SUBCUTANEOUS INJECTABLE) $0 (Tier 1) QL

YF-Vax

YF-VAX (SUBCUTANEOUS INJECTABLE) $0 (Tier 1) QL

Inflammatory Bowel Disease Agents

Aminosalicylates

Apriso

APRISO (ORAL CAPSULE EXTENDED RELEASE

24 HOUR)

$0 (Tier 1) QL

Balsalazide

Disodium

balsalazide disodium (oral capsule) $0 (Tier 1)

Dipentum

DIPENTUM (ORAL CAPSULE) $0 (Tier 1) DL

Mesalamine ER

mesalamine er (500mg oral capsule extended

release) (generic pentasa)

$0 (Tier 1) QL

Mesalamine ER

mesalamine er (0.375gm oral capsule extended

release 24 hour) (generic apriso)

$0 (Tier 1) QL

Mesalamine

mesalamine (1.2gm oral tablet delayed release)

(generic lialda)

$0 (Tier 1) QL

Mesalamine

mesalamine (rectal enema) $0 (Tier 1) QL

Mesalamine

mesalamine (rectal suppository) $0 (Tier 1) QL

Pentasa

PENTASA (250MG ORAL CAPSULE EXTENDED

RELEASE)

$0 (Tier 1) QL

Sulfasalazine

sulfasalazine (oral tablet immediate release) $0 (Tier 1)

Sulfasalazine

sulfasalazine (oral tablet delayed release) $0 (Tier 1)

Glucocorticoids

Budesonide ER

budesonide er (oral tablet extended release 24

hour)

$0 (Tier 1) ST; DL

Budesonide

budesonide (oral capsule delayed release

particles)

$0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Hydrocortisone

hydrocortisone (perianal) (2.5% external cream) $0 (Tier 1)

Hydrocortisone

hydrocortisone (rectal enema) $0 (Tier 1)

Procto-Med HC

procto-med hc (external cream) $0 (Tier 1)

Procto-Pak

procto-pak (external cream) $0 (Tier 1)

Proctosol HC

proctosol hc (external cream) $0 (Tier 1)

Proctozone-HC

proctozone-hc (external cream) $0 (Tier 1)

Metabolic Bone Disease Agents

Alendronate

Sodium

alendronate sodium (oral solution) $0 (Tier 1)

Alendronate

Sodium

alendronate sodium (10mg oral tablet, 35mg oral

tablet, 70mg oral tablet)

$0 (Tier 1) QL

Calcitonin Salmon

calcitonin salmon (nasal solution) $0 (Tier 1) QL

Calcitriol

calcitriol (oral capsule) $0 (Tier 1) B/D, PA

Calcitriol

calcitriol (oral solution) $0 (Tier 1) B/D, PA

Cinacalcet HCl

cinacalcet hcl (oral tablet) $0 (Tier 1) B/D, PA; QL

Doxercalciferol

doxercalciferol (oral capsule) $0 (Tier 1) B/D, PA

Forteo

FORTEO (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) PA; DL; QL

Ibandronate

Sodium

ibandronate sodium (oral tablet) $0 (Tier 1) QL

Natpara

NATPARA (SUBCUTANEOUS CARTRIDGE) $0 (Tier 1) PA; DL

Paricalcitol

paricalcitol (oral capsule) $0 (Tier 1) B/D, PA

Prolia

PROLIA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) QL

Rayaldee

RAYALDEE (ORAL CAPSULE EXTENDED

RELEASE)

$0 (Tier 1) DL; QL

Risedronate

Sodium

risedronate sodium (oral tablet immediate release) $0 (Tier 1) QL

Teriparatide

TERIPARATIDE (RECOMBINANT)

(SUBCUTANEOUS SOLUTION PEN-INJECTOR)

$0 (Tier 1) PA; DL; QL

Tymlos

TYMLOS (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

$0 (Tier 1) PA; DL; QL

Xgeva

XGEVA (SUBCUTANEOUS SOLUTION) $0 (Tier 1) PA; DL

Miscellaneous Therapeutic Agents

Alcohol Prep Pads

alcohol prep pads $0 (Tier 1)

Gauze

gauze (non-medicated 2x2 pad) $0 (Tier 1)

Insulin Syringes,

Needles

insulin syringes, needles $0 (Tier 1)

Ophthalmic Agents

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Ophthalmic Agents, Other

Atropine Sulfate

atropine sulfate (1% ophthalmic solution) $0 (Tier 1)

Neomycin-

Polymyxin-

Bacitracin-

Hydrocortisone

neomycin-polymyxin-bacitracin-hydrocortisone

(ophthalmic ointment)

$0 (Tier 1)

Brimonidine

Tartrate-Timolol

brimonidine tartrate-timolol (ophthalmic solution) $0 (Tier 1)

Combigan

COMBIGAN (OPHTHALMIC SOLUTION) $0 (Tier 1)

Cystaran

CYSTARAN (OPHTHALMIC SOLUTION) $0 (Tier 1) DL

Dorzolamide HCl-

Timolol Maleate

dorzolamide hcl-timolol maleate (ophthalmic

solution)

$0 (Tier 1)

Dorzolamide HCl-

Timolol Maleate

Preservative Free

dorzolamide hcl-timolol maleate preservative free

(ophthalmic solution)

$0 (Tier 1)

Lacrisert

LACRISERT (OPHTHALMIC INSERT) $0 (Tier 1)

Neomycin-

Polymyxin-

Dexamethasone

neomycin-polymyxin-dexamethasone (ophthalmic

ointment)

$0 (Tier 1)

Neomycin-

Polymyxin-

Dexamethasone

neomycin-polymyxin-dexamethasone

(3.5-10000-0.1 ophthalmic suspension)

$0 (Tier 1)

Neomycin-

Polymyxin-HC

neomycin-polymyxin-hc (ophthalmic suspension) $0 (Tier 1)

Restasis MultiDose

RESTASIS MULTIDOSE (OPHTHALMIC

EMULSION)

$0 (Tier 1) QL

Restasis Single-Use

Vials

RESTASIS SINGLE-USE VIALS (OPHTHALMIC

EMULSION)

$0 (Tier 1) QL

Rocklatan

ROCKLATAN (OPHTHALMIC SOLUTION) $0 (Tier 1) ST

Sulfacetamide-

Prednisolone

sulfacetamide-prednisolone (ophthalmic solution) $0 (Tier 1)

TobraDex

TOBRADEX (OPHTHALMIC OINTMENT) $0 (Tier 1)

TobraDex ST

TOBRADEX ST (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Tobramycin-

Dexamethasone

tobramycin-dexamethasone (ophthalmic

suspension)

$0 (Tier 1)

Xiidra

XIIDRA (OPHTHALMIC SOLUTION) $0 (Tier 1) QL

Ophthalmic Anti-allergy Agents

Alocril

ALOCRIL (OPHTHALMIC SOLUTION) $0 (Tier 1)

Alomide

ALOMIDE (OPHTHALMIC SOLUTION) $0 (Tier 1)

Azelastine HCl

azelastine hcl (ophthalmic solution) $0 (Tier 1)

Bepotastine

Besilate

bepotastine besilate (ophthalmic solution) $0 (Tier 1)

Bepreve

BEPREVE (OPHTHALMIC SOLUTION) $0 (Tier 1)

Cromolyn Sodium

cromolyn sodium (ophthalmic solution) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Epinastine HCl

epinastine hcl (ophthalmic solution) $0 (Tier 1)

Olopatadine HCl

olopatadine hcl (ophthalmic solution) $0 (Tier 1)

Ophthalmic Anti-Infectives

Bacitracin

bacitracin (ophthalmic ointment) $0 (Tier 1)

Bacitracin-

Polymyxin B

bacitracin-polymyxin b (ophthalmic ointment) $0 (Tier 1)

Besivance

BESIVANCE (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Ciloxan

CILOXAN (OPHTHALMIC OINTMENT) $0 (Tier 1)

Ciprofloxacin HCl

ciprofloxacin hcl (ophthalmic solution) $0 (Tier 1)

Erythromycin

erythromycin (ophthalmic ointment) $0 (Tier 1)

Gatifloxacin

gatifloxacin (ophthalmic solution) $0 (Tier 1)

Gentak

gentak (ophthalmic ointment) $0 (Tier 1)

Gentamicin Sulfate

gentamicin sulfate (ophthalmic solution) $0 (Tier 1)

Levofloxacin

levofloxacin (0.5% ophthalmic solution) $0 (Tier 1)

Moxifloxacin HCl

moxifloxacin hcl (ophthalmic solution) (generic

vigamox)

$0 (Tier 1)

Natacyn

NATACYN (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Neomycin-

Bacitracin-

Polymyxin

neomycin-bacitracin-polymyxin (5-400-10000

ophthalmic ointment)

$0 (Tier 1)

Neomycin-

Polymyxin-

Gramicidin

neomycin-polymyxin-gramicidin (ophthalmic

solution)

$0 (Tier 1)

Ofloxacin

ofloxacin (ophthalmic solution) $0 (Tier 1)

Polymyxin B-

Trimethoprim

polymyxin b-trimethoprim (ophthalmic solution) $0 (Tier 1)

Sulfacetamide

Sodium

sulfacetamide sodium (ophthalmic ointment) $0 (Tier 1)

Sulfacetamide

Sodium

sulfacetamide sodium (ophthalmic solution) $0 (Tier 1)

Tobramycin

tobramycin (ophthalmic solution) $0 (Tier 1)

Tobrex

TOBREX (OPHTHALMIC OINTMENT) $0 (Tier 1)

Trifluridine

trifluridine (ophthalmic solution) $0 (Tier 1)

Ophthalmic Anti-inflammatories

Dexamethasone

Sodium Phosphate

dexamethasone sodium phosphate (ophthalmic

solution)

$0 (Tier 1)

Diclofenac Sodium

diclofenac sodium (ophthalmic solution) $0 (Tier 1)

Flarex

FLAREX (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Fluorometholone

fluorometholone (ophthalmic suspension) $0 (Tier 1)

Flurbiprofen

Sodium

flurbiprofen sodium (ophthalmic solution) $0 (Tier 1)

FML Forte

FML FORTE (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Ilevro

ILEVRO (OPHTHALMIC SUSPENSION) $0 (Tier 1)

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Ketorolac

Tromethamine

ketorolac tromethamine (ophthalmic solution) $0 (Tier 1)

Lotemax

LOTEMAX (OPHTHALMIC GEL) $0 (Tier 1)

Lotemax

LOTEMAX (OPHTHALMIC OINTMENT) $0 (Tier 1)

Lotemax

LOTEMAX (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Lotemax SM

LOTEMAX SM (OPHTHALMIC GEL) $0 (Tier 1)

Loteprednol

Etabonate

loteprednol etabonate (ophthalmic gel) $0 (Tier 1)

Loteprednol

Etabonate

loteprednol etabonate (ophthalmic suspension) $0 (Tier 1)

Pred Mild

PRED MILD (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Prednisolone

Acetate

prednisolone acetate (ophthalmic suspension) $0 (Tier 1)

Prednisolone

Sodium Phosphate

prednisolone sodium phosphate (1% ophthalmic

solution)

$0 (Tier 1)

Prolensa

PROLENSA (OPHTHALMIC SOLUTION) $0 (Tier 1)

Ophthalmic Beta-Adrenergic Blocking Agents

Betaxolol HCl

betaxolol hcl (ophthalmic solution) $0 (Tier 1)

Betimol

BETIMOL (OPHTHALMIC SOLUTION) $0 (Tier 1)

Carteolol HCl

carteolol hcl (ophthalmic solution) $0 (Tier 1)

Levobunolol HCl

levobunolol hcl (ophthalmic solution) $0 (Tier 1)

Timolol Maleate

Ophthalmic Gel

Forming

timolol maleate ophthalmic gel forming

(ophthalmic solution) (generic timoptic-xe)

$0 (Tier 1)

Timolol Maleate

timolol maleate (ophthalmic solution) (generic

timoptic)

$0 (Tier 1)

Ophthalmic Intraocular Pressure Lowering Agents, Other

Alphagan P

ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) $0 (Tier 1)

Apraclonidine HCl

apraclonidine hcl (ophthalmic solution) $0 (Tier 1)

Brimonidine

Tartrate

brimonidine tartrate (0.15% ophthalmic solution) $0 (Tier 1)

Brimonidine

Tartrate

brimonidine tartrate (0.2% ophthalmic solution) $0 (Tier 1)

Brinzolamide

brinzolamide (ophthalmic suspension) $0 (Tier 1)

Dorzolamide HCl

dorzolamide hcl (ophthalmic solution) $0 (Tier 1)

Methazolamide

methazolamide (oral tablet) $0 (Tier 1)

Pilocarpine HCl

pilocarpine hcl (ophthalmic solution) $0 (Tier 1)

Rhopressa

RHOPRESSA (OPHTHALMIC SOLUTION) $0 (Tier 1) ST

Simbrinza

SIMBRINZA (OPHTHALMIC SUSPENSION) $0 (Tier 1)

Ophthalmic Prostaglandin and Prostamide Analogs

Latanoprost

latanoprost (ophthalmic solution) $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Lumigan

LUMIGAN (OPHTHALMIC SOLUTION) $0 (Tier 1)

Travoprost

travoprost (bak free) (ophthalmic solution) $0 (Tier 1)

Vyzulta

VYZULTA (OPHTHALMIC SOLUTION) $0 (Tier 1)

Otic Agents

Acetic Acid

acetic acid (otic solution) $0 (Tier 1)

Cipro HC

CIPRO HC (OTIC SUSPENSION) $0 (Tier 1)

Ciprofloxacin-

Dexamethasone

ciprofloxacin-dexamethasone (otic suspension) $0 (Tier 1)

Flac

flac (otic oil) $0 (Tier 1)

Fluocinolone

Acetonide

fluocinolone acetonide (otic oil) $0 (Tier 1)

Hydrocortisone-

Acetic Acid

hydrocortisone-acetic acid (otic solution) $0 (Tier 1)

Neomycin-

Polymyxin-HC

neomycin-polymyxin-hc (1% otic solution) $0 (Tier 1)

Neomycin-

Polymyxin-HC

neomycin-polymyxin-hc (otic suspension) $0 (Tier 1)

Ofloxacin

ofloxacin (otic solution) $0 (Tier 1)

Respiratory Tract/Pulmonary Agents

Antihistamines

Azelastine HCl

azelastine hcl (0.1% nasal solution, 0.15% nasal

solution)

$0 (Tier 1)

Azelastine-

Fluticasone

azelastine-fluticasone (nasal suspension) $0 (Tier 1)

Cetirizine HCl

cetirizine hcl (1mg/ml oral solution) $0 (Tier 1)

Cyproheptadine

HCl

cyproheptadine hcl (oral syrup) $0 (Tier 1)

Cyproheptadine

HCl

cyproheptadine hcl (oral tablet) $0 (Tier 1)

Desloratadine

desloratadine (oral tablet) $0 (Tier 1)

Dymista

DYMISTA (NASAL SUSPENSION) $0 (Tier 1)

Levocetirizine

Dihydrochloride

levocetirizine dihydrochloride (oral tablet) $0 (Tier 1) QL

Anti-inflammatories, Inhaled Corticosteroids

Arnuity Ellipta

ARNUITY ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Budesonide

budesonide (inhalation suspension) $0 (Tier 1) B/D, PA

Flovent Diskus

FLOVENT DISKUS (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Flovent HFA

FLOVENT HFA (INHALATION AEROSOL) $0 (Tier 1) QL

Flunisolide

flunisolide (nasal solution) $0 (Tier 1)

Fluticasone

Propionate

fluticasone propionate (nasal suspension) $0 (Tier 1)

Mometasone

Furoate

mometasone furoate (nasal suspension) $0 (Tier 1)

Antileukotrienes

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Montelukast

Sodium

montelukast sodium (oral packet) $0 (Tier 1) QL

Montelukast

Sodium

montelukast sodium (oral tablet) $0 (Tier 1) QL

Montelukast

Sodium

montelukast sodium (oral tablet chewable) $0 (Tier 1) QL

Zafirlukast

zafirlukast (oral tablet) $0 (Tier 1) QL

Zileuton ER

zileuton er (oral tablet extended release 12 hour) $0 (Tier 1) ST; DL

Zyflo

ZYFLO (ORAL TABLET IMMEDIATE RELEASE) $0 (Tier 1) ST; DL

Bronchodilators, Anticholinergic

Atrovent HFA

ATROVENT HFA (INHALATION AEROSOL

SOLUTION)

$0 (Tier 1)

Incruse Ellipta

INCRUSE ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Ipratropium

Bromide

ipratropium bromide (inhalation solution) $0 (Tier 1) B/D, PA

Ipratropium

Bromide

ipratropium bromide (nasal solution) $0 (Tier 1)

Lonhala Magnair

LONHALA MAGNAIR (INHALATION SOLUTION) $0 (Tier 1) DL; QL

Spiriva HandiHaler

SPIRIVA HANDIHALER (INHALATION CAPSULE) $0 (Tier 1) QL

Spiriva Respimat

SPIRIVA RESPIMAT (INHALATION AEROSOL

SOLUTION)

$0 (Tier 1) QL

Bronchodilators, Sympathomimetic

Albuterol Sulfate

HFA

albuterol sulfate hfa (108 (90 base)mcg/act

inhalation aerosol solution) (generic proair),

albuterol sulfate hfa (108 (90 base)mcg/act

inhalation aerosol solution) (generic proventil)

$0 (Tier 1)

Albuterol Sulfate

albuterol sulfate (inhalation nebulization solution) $0 (Tier 1) B/D, PA

Albuterol Sulfate

albuterol sulfate (oral syrup) $0 (Tier 1)

Albuterol Sulfate

albuterol sulfate (oral tablet immediate release) $0 (Tier 1)

Epinephrine

epinephrine (injection solution auto-injector) $0 (Tier 1) QL

Formoterol

Fumarate

formoterol fumarate (inhalation nebulization

solution)

$0 (Tier 1) B/D, PA; QL

Levalbuterol HCl

levalbuterol hcl (inhalation nebulization solution) $0 (Tier 1) B/D, PA

Levalbuterol

Tartrate

levalbuterol tartrate (inhalation aerosol) $0 (Tier 1)

Perforomist

PERFOROMIST (INHALATION NEBULIZATION

SOLUTION)

$0 (Tier 1) B/D, PA; QL

ProAir RespiClick

PROAIR RESPICLICK (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1)

Serevent Diskus

SEREVENT DISKUS (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Cystic Fibrosis Agents

Cayston

CAYSTON (INHALATION SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL

Kalydeco

KALYDECO (ORAL PACKET) $0 (Tier 1) PA; DL; QL

Kalydeco

KALYDECO (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Orkambi

ORKAMBI (ORAL PACKET) $0 (Tier 1) PA; DL; QL

Orkambi

ORKAMBI (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Pulmozyme

PULMOZYME (INHALATION SOLUTION) $0 (Tier 1) B/D, PA; DL; QL

TOBI Podhaler

TOBI PODHALER (INHALATION CAPSULE) $0 (Tier 1) PA; DL; QL

Tobramycin

tobramycin (inhalation nebulization solution) $0 (Tier 1) B/D, PA; DL; QL

Mast Cell Stabilizers

Cromolyn Sodium

cromolyn sodium (inhalation nebulization solution) $0 (Tier 1) B/D, PA

Phosphodiesterase Inhibitors, Airways Disease

Daliresp

DALIRESP (ORAL TABLET) $0 (Tier 1) PA; QL

Roflumilast

roflumilast (oral tablet) $0 (Tier 1) PA; QL

Theophylline ER

theophylline er (oral tablet extended release 12

hour)

$0 (Tier 1)

Theophylline ER

theophylline er (oral tablet extended release 24

hour)

$0 (Tier 1)

Theophylline

theophylline (oral solution) $0 (Tier 1)

Pulmonary Antihypertensives

Adempas

ADEMPAS (ORAL TABLET) $0 (Tier 1) PA; DL

Alyq

alyq (oral tablet) $0 (Tier 1) PA; QL

Ambrisentan

ambrisentan (oral tablet) $0 (Tier 1) PA; DL; QL

Bosentan

bosentan (oral tablet) $0 (Tier 1) PA; DL; QL

Opsumit

OPSUMIT (ORAL TABLET) $0 (Tier 1) PA; DL

Orenitram

ORENITRAM (0.125MG ORAL TABLET

EXTENDED RELEASE)

$0 (Tier 1) PA

Orenitram

ORENITRAM (0.25MG ORAL TABLET

EXTENDED RELEASE, 1MG ORAL TABLET

EXTENDED RELEASE, 2.5MG ORAL TABLET

EXTENDED RELEASE, 5MG ORAL TABLET

EXTENDED RELEASE)

$0 (Tier 1) PA; DL

Sildenafil Citrate

sildenafil citrate (20mg oral tablet) (generic revatio) $0 (Tier 1) PA; QL

Tadalafil

tadalafil (pah) (20mg oral tablet) (generic adcirca) $0 (Tier 1) PA; QL

Tracleer

TRACLEER (ORAL TABLET SOLUBLE) $0 (Tier 1) PA; DL; QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Tyvaso DPI

Maintenance Kit

TYVASO DPI MAINTENANCE KIT (INHALATION

POWDER)

$0 (Tier 1) PA; DL; QL

Tyvaso DPI Titration

Kit

TYVASO DPI TITRATION KIT (INHALATION

POWDER)

$0 (Tier 1) PA; DL; QL

Ventavis

VENTAVIS (INHALATION SOLUTION) $0 (Tier 1) PA; DL; QL

Pulmonary Fibrosis Agents

Esbriet

ESBRIET (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Esbriet

ESBRIET (ORAL TABLET) $0 (Tier 1) PA; DL; QL

Ofev

OFEV (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Pirfenidone

pirfenidone (oral tablet) $0 (Tier 1) PA; DL; QL

Respiratory Tract Agents, Other

Acetylcysteine

acetylcysteine (inhalation solution) $0 (Tier 1) B/D, PA

Advair Diskus

ADVAIR DISKUS (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Advair HFA

ADVAIR HFA (INHALATION AEROSOL) $0 (Tier 1) QL

Anoro Ellipta

ANORO ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Bevespi

Aerosphere

BEVESPI AEROSPHERE (INHALATION

AEROSOL)

$0 (Tier 1) QL

Breo Ellipta

BREO ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Breztri Aerosphere

BREZTRI AEROSPHERE (INHALATION

AEROSOL)

$0 (Tier 1) QL

Combivent

Respimat

COMBIVENT RESPIMAT (INHALATION

AEROSOL SOLUTION)

$0 (Tier 1) QL

Dulera

DULERA (INHALATION AEROSOL) $0 (Tier 1) QL

Fasenra Pen

FASENRA PEN (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

$0 (Tier 1) PA; DL

Fasenra

FASENRA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Fluticasone-

Salmeterol

fluticasone-salmeterol (100-50mcg/dose inhalation

aerosol powder breath activated, 250-50mcg/dose

inhalation aerosol powder breath activated,

500-50mcg/dose inhalation aerosol powder breath

activated) (generic advair), fluticasone-salmeterol

(113-14mcg/act inhalation aerosol powder breath

activated, 232-14mcg/act inhalation aerosol

powder breath activated, 55-14mcg/act inhalation

aerosol powder breath activated) (brand equivalent

airduo respiclick)

$0 (Tier 1) QL

Ipratropium-

Albuterol

ipratropium-albuterol (inhalation solution) $0 (Tier 1) B/D, PA

Nucala

NUCALA (SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

$0 (Tier 1) PA; DL; QL

Nucala

NUCALA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

$0 (Tier 1) PA; DL; QL

Nucala

NUCALA (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

$0 (Tier 1) PA; DL; QL

Stiolto Respimat

STIOLTO RESPIMAT (INHALATION AEROSOL

SOLUTION)

$0 (Tier 1) QL

Symbicort

SYMBICORT (INHALATION AEROSOL) $0 (Tier 1) QL

Trelegy Ellipta

TRELEGY ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

$0 (Tier 1) QL

Wixela Inhub

wixela inhub (inhalation aerosol powder breath

activated) (generic advair)

$0 (Tier 1) QL

Skeletal Muscle Relaxants

Chlorzoxazone

chlorzoxazone (500mg oral tablet) $0 (Tier 1)

Cyclobenzaprine

HCl

cyclobenzaprine hcl (10mg oral tablet, 5mg oral

tablet)

$0 (Tier 1)

Cyclobenzaprine

HCl

cyclobenzaprine hcl (7.5mg oral tablet) $0 (Tier 1)

Methocarbamol

methocarbamol (500mg oral tablet, 750mg oral

tablet)

$0 (Tier 1) QL

Sleep Disorder Agents

Sleep Promoting Agents

Belsomra

BELSOMRA (ORAL TABLET) $0 (Tier 1) QL

Eszopiclone

eszopiclone (oral tablet) $0 (Tier 1) QL

Hetlioz LQ

HETLIOZ LQ (ORAL SUSPENSION) $0 (Tier 1) PA; DL; QL

Hetlioz

HETLIOZ (ORAL CAPSULE) $0 (Tier 1) PA; DL; QL

Ramelteon

ramelteon (oral tablet) $0 (Tier 1) QL

tRACK

Name of drug What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits

on use

Temazepam

temazepam (15mg oral capsule, 30mg oral

capsule)

$0 (Tier 1) QL

Zaleplon

zaleplon (oral capsule) $0 (Tier 1) QL

Zolpidem Tartrate

zolpidem tartrate (oral tablet immediate release) $0 (Tier 1) QL

Wakefulness Promoting Agents

Armodafinil

armodafinil (oral tablet) $0 (Tier 1) PA; QL

Modafinil

modafinil (oral tablet) $0 (Tier 1) PA; QL

Xyrem

XYREM (ORAL SOLUTION) $0 (Tier 1) PA; DL; QL

tRACK

You can find information on what the symbols and abbreviations in this table mean by referring to

pages 12 and 13.

C2. Covered Drugs with a quantity limit (QL)

This list shows Medicare Part D drugs that have a quantity limit. Some drugs come in several

strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by

strength, the different strengths are listed on separate lines. These limits may be in place to ensure

your safety.

Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain

number of days. For more information about quantity limits, talk with your doctor or pharmacist.

You can also call Customer Service. Our contact information is on the cover.

Drugs are listed in alphabetical order in the tables below.

Drug name Quantity limit

abacavir sulfate (oral solution) Maximum of 32 ml per day

abacavir sulfate (oral tablet) Maximum of 2 tablets per day

abacavir sulfate-lamivudine (oral tablet) Maximum of 1 tablet per day

abiraterone acetate (250mg oral tablet) Maximum of 4 tablets per day

abiraterone acetate (500mg oral tablet) Maximum of 2 tablets per day

acarbose (100mg oral tablet) Maximum of 3 tablets per day

acarbose (25mg oral tablet) Maximum of 12 tablets per day

acarbose (50mg oral tablet) Maximum of 6 tablets per day

acetaminophen-caffeine-dihydrocodeine (oral

capsule)

Maximum of 10 capsules per day

acetaminophen-codeine (120-12mg/5ml oral

solution)

Maximum of 150 ml per day

acetaminophen-codeine (300-15mg oral tablet,

300-30mg oral tablet, 300-60mg oral tablet)

Maximum of 13 tablets per day

ACTEMRA ACTPEN (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 4 pens (3.6 ml) per 28 days

ACTEMRA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

Maximum of 4 syringes (3.6 ml) per 28 days

ACTHIB (INTRAMUSCULAR SOLUTION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

acyclovir (external ointment) Maximum of 1 tube (30 grams) per 30 days

ADACEL (INTRAMUSCULAR SUSPENSION) 1 vaccination dose (0.5 ml) per day

ADVAIR DISKUS (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (60 blisters) per 30 days

ADVAIR HFA (INHALATION AEROSOL) Maximum of 1 inhaler (12 grams) per 30 days

AIMOVIG (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

Maximum of 1 pen (1 ml) per 30 days

albendazole (oral tablet) Maximum of 16 tablets per day

ALECENSA (ORAL CAPSULE) Maximum of 8 capsules per day

alendronate sodium (10mg oral tablet) Maximum of 1 tablet per day

Drug name Quantity limit

alendronate sodium (35mg oral tablet) Maximum of 8 tablets per 28 days

alendronate sodium (70mg oral tablet) Maximum of 4 tablets per 28 days

aliskiren fumarate (oral tablet) Maximum of 1 tablet per day

alprazolam (0.25mg oral tablet immediate

release, 0.5mg oral tablet immediate release,

1mg oral tablet immediate release)

Maximum of 4 tablets per day

alprazolam (2mg oral tablet immediate release) Maximum of 5 tablets per day

ALUNBRIG (180MG ORAL TABLET, 90MG

ORAL TABLET)

Maximum of 1 tablet per day

ALUNBRIG (30MG ORAL TABLET) Maximum of 4 tablets per day

ALUNBRIG (ORAL TABLET THERAPY PACK) Maximum of 2 packs (60 tablets) per year

alyq (oral tablet) Maximum of 2 tablets per day

ambrisentan (oral tablet) Maximum of 1 tablet per day

amlodipine-atorvastatin (oral tablet) Maximum of 1 tablet per day

amlodipine-benazepril (oral capsule) Maximum of 1 capsule per day

amlodipine-olmesartan (oral tablet) Maximum of 1 tablet per day

amlodipine-valsartan (oral tablet) Maximum of 1 tablet per day

amlodipine-valsartan-hctz (oral tablet) Maximum of 1 tablet per day

amphetamine-dextroamphetamine er (oral

capsule extended release 24 hour)

Maximum of 2 capsules per day

amphetamine-dextroamphetamine (10mg oral

tablet, 12.5mg oral tablet, 15mg oral tablet,

30mg oral tablet, 5mg oral tablet, 7.5mg oral

tablet)

Maximum of 2 tablets per day

amphetamine-dextroamphetamine (20mg oral

tablet)

Maximum of 3 tablets per day

ANDRODERM (TRANSDERMAL PATCH 24

HOUR)

Maximum of 1 patch per day

ANORO ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (60 blisters) per 30 days

apomorphine hcl (subcutaneous solution

cartridge)

Maximum of 2 ml per day

aprepitant (125mg oral capsule) Maximum of 2 capsules per 28 days

aprepitant (40mg oral capsule, 80mg oral

capsule)

Maximum of 4 capsules per 28 days

aprepitant (80 & 125mg oral capsule) Maximum of 6 capsules (2 packs) per 28 days

APRISO (ORAL CAPSULE EXTENDED

RELEASE 24 HOUR)

Maximum of 4 capsules per day

APTIOM (200MG ORAL TABLET, 400MG

ORAL TABLET)

Maximum of 1 tablet per day

APTIOM (600MG ORAL TABLET, 800MG

ORAL TABLET)

Maximum of 2 tablets per day

Drug name Quantity limit

APTIVUS (ORAL CAPSULE) Maximum of 4 capsules per day

aripiprazole (1mg/ml oral solution) Maximum of 25 ml per day

aripiprazole (10mg oral tablet, 15mg oral tablet,

20mg oral tablet, 2mg oral tablet, 30mg oral

tablet, 5mg oral tablet)

Maximum of 1 tablet per day

aripiprazole odt (10mg oral tablet dispersible,

15mg oral tablet dispersible)

Maximum of 2 tablets per day

armodafinil (150mg oral tablet, 200mg oral

tablet, 250mg oral tablet)

Maximum of 1 tablet per day

armodafinil (50mg oral tablet) Maximum of 2 tablets per day

ARNUITY ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (30 blisters) per 30 days

asenapine maleate (tablet sublingual) Maximum of 2 tablets per day

aspirin-dipyridamole er (oral capsule extended

release 12 hour)

Maximum of 2 capsules per day

atazanavir sulfate (150mg oral capsule, 300mg

oral capsule)

Maximum of 1 capsule per day

atazanavir sulfate (200mg oral capsule) Maximum of 2 capsules per day

atomoxetine hcl (100mg oral capsule, 60mg oral

capsule, 80mg oral capsule)

Maximum of 1 capsule per day

atomoxetine hcl (10mg oral capsule, 18mg oral

capsule, 25mg oral capsule, 40mg oral capsule)

Maximum of 2 capsules per day

atorvastatin calcium (oral tablet) Maximum of 1 tablet per day

atovaquone (oral suspension) Maximum of 14 ml per day

AUBAGIO (ORAL TABLET) Maximum of 1 tablet per day

AUSTEDO (ORAL TABLET) Maximum of 4 tablets per day

AVONEX PEN (INTRAMUSCULAR AUTO-

INJECTOR KIT)

Maximum of 1 kit per 28 days

AVONEX PREFILLED (INTRAMUSCULAR

PREFILLED SYRINGE KIT)

Maximum of 1 kit per 28 days

AYVAKIT (ORAL TABLET) Maximum of 1 tablet per day

azelaic acid (external gel) Maximum of 50 grams per 30 days

BALVERSA (3MG ORAL TABLET) Maximum of 3 tablets per day

BALVERSA (4MG ORAL TABLET) Maximum of 2 tablets per day

BALVERSA (5MG ORAL TABLET) Maximum of 1 tablet per day

BCG VACCINE (INJECTION SOLUTION

RECONSTITUTED)

1 vaccination dose (1 vial) per day

BELSOMRA (ORAL TABLET) Maximum of 1 tablet per day

benazepril hcl (oral tablet) Maximum of 2 tablets per day

benazepril-hydrochlorothiazide (oral tablet) Maximum of 1 tablet per day

BETASERON (SUBCUTANEOUS KIT) Maximum of 1 kit (15 vials) per 30 days

100

Drug name Quantity limit

BEVESPI AEROSPHERE (INHALATION

AEROSOL)

Maximum of 1 inhaler (10.7 grams) per 30 days

bexarotene (external gel) Maximum of 60 grams per 30 days

BEXSERO (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

BIKTARVY (ORAL TABLET) Maximum of 1 tablet per day

bisoprolol-hydrochlorothiazide (oral tablet) Maximum of 2 tablets per day

BOOSTRIX (INTRAMUSCULAR SUSPENSION) 1 vaccination dose (0.5 ml) per day

BOOSTRIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

bosentan (oral tablet) Maximum of 2 tablets per day

BOSULIF (100MG ORAL TABLET) Maximum of 6 tablets per day

BOSULIF (400MG ORAL TABLET, 500MG

ORAL TABLET)

Maximum of 1 tablet per day

BREO ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (60 blisters) per 30 days

BREZTRI AEROSPHERE (120 INHALATION

AEROSOL)

Maximum of 1 inhaler (10.7 grams) per 30 days

BRILINTA (ORAL TABLET) Maximum of 2 tablets per day

BRIVIACT (10MG/ML ORAL SOLUTION) Maximum of 20 ml per day

BRIVIACT (100MG ORAL TABLET, 10MG

ORAL TABLET, 25MG ORAL TABLET, 50MG

ORAL TABLET, 75MG ORAL TABLET)

Maximum of 2 tablets per day

BRUKINSA (ORAL CAPSULE) Maximum of 4 capsules per day

buprenorphine hcl (tablet sublingual) Maximum of 3 tablets per day

buprenorphine hcl-naloxone hcl (12-3mg

sublingual film, 4-1mg sublingual film)

Maximum of 2 films per day

buprenorphine hcl-naloxone hcl (2-0.5mg

sublingual film, 8-2mg sublingual film)

Maximum of 3 films per day

buprenorphine hcl-naloxone hcl (tablet

sublingual)

Maximum of 3 tablets per day

buprenorphine (transdermal patch weekly) Maximum of 4 patches per 28 days

butalbital-acetaminophen-caffeine (oral tablet) Maximum of 6 tablets per day

butalbital-aspirin-caffeine (oral capsule) Maximum of 6 capsules per day

butorphanol tartrate (nasal solution) Maximum of 2 bottles (5 ml) per 30 days

BYDUREON BCISE (SUBCUTANEOUS AUTO-

INJECTOR)

Maximum of 4 pens (3.4 ml) per 28 days

BYETTA 10MCG PEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

Maximum of 1 pen (2.4 ml) per 30 days

BYETTA 5MCG PEN (SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

Maximum of 1 pen (1.2 ml) per 30 days

CABLIVI (INJECTION KIT) Maximum of 1 kit per day

101

Drug name Quantity limit

CABOMETYX (20MG ORAL TABLET, 60MG

ORAL TABLET)

Maximum of 1 tablet per day

CABOMETYX (40MG ORAL TABLET) Maximum of 2 tablets per day

calcipotriene (external cream) Maximum of 120 grams per 30 days

calcipotriene (external ointment) Maximum of 120 grams per 30 days

calcitonin salmon (nasal solution) Maximum of 1 bottle per 28 days

CALQUENCE (100MG ORAL CAPSULE) Maximum of 2 capsules per day

CALQUENCE (ORAL TABLET) Maximum of 2 tablets per day

candesartan cilexetil (16mg oral tablet, 32mg

oral tablet, 4mg oral tablet)

Maximum of 1 tablet per day

candesartan cilexetil (8mg oral tablet) Maximum of 3 tablets per day

candesartan cilexetil-hctz (oral tablet) Maximum of 1 tablet per day

CAPLYTA (ORAL CAPSULE) Maximum of 1 capsule per day

captopril (100mg oral tablet) Maximum of 4 tablets per day

captopril (12.5mg oral tablet, 25mg oral tablet) Maximum of 3 tablets per day

captopril (50mg oral tablet) Maximum of 9 tablets per day

celecoxib (oral capsule) Maximum of 2 capsules per day

chloroquine phosphate (oral tablet) Maximum of 2 tablets per day

CIMDUO (ORAL TABLET) Maximum of 1 tablet per day

CIMZIA (SUBCUTANEOUS KIT) Maximum of 2 kits per 28 days

CIMZIA PREFILLED (2 X 200MG/ML

SUBCUTANEOUS PREFILLED SYRINGE KIT)

Maximum of 2 kits per 28 days

cinacalcet hcl (30mg oral tablet, 60mg oral

tablet)

Maximum of 2 tablets per day

cinacalcet hcl (90mg oral tablet) Maximum of 4 tablets per day

clindacin etz (external swab) Maximum of 69 pads per 30 days

clindamycin phosphate (external gel) Maximum of 75 grams per 30 days

clindamycin phosphate (external lotion) Maximum of 60 ml per 30 days

clindamycin phosphate (external solution) Maximum of 60 ml per 30 days

clindamycin phosphate (external swab) Maximum of 69 pads per 30 days

clobazam (2.5mg/ml oral suspension) Maximum of 16 ml per day

clobazam (10mg oral tablet, 20mg oral tablet) Maximum of 2 tablets per day

clonazepam (0.5mg oral tablet, 1mg oral tablet) Maximum of 4 tablets per day

clonazepam (2mg oral tablet) Maximum of 10 tablets per day

clonazepam odt (0.125mg oral tablet

dispersible, 0.25mg oral tablet dispersible,

0.5mg oral tablet dispersible, 1mg oral tablet

dispersible)

Maximum of 4 tablets per day

clonazepam odt (2mg oral tablet dispersible) Maximum of 10 tablets per day

clopidogrel bisulfate (75mg oral tablet) Maximum of 1 tablet per day

102

Drug name Quantity limit

clorazepate dipotassium (15mg oral tablet) Maximum of 6 tablets per day

clorazepate dipotassium (3.75mg oral tablet) Maximum of 24 tablets per day

clorazepate dipotassium (7.5mg oral tablet) Maximum of 12 tablets per day

clotrimazole-betamethasone (external cream) Maximum of 90 grams per 30 days

clozapine odt (100mg oral tablet dispersible) Maximum of 9 tablets per day

clozapine odt (12.5mg oral tablet dispersible) Maximum of 2 tablets per day

clozapine odt (150mg oral tablet dispersible) Maximum of 6 tablets per day

clozapine odt (200mg oral tablet dispersible) Maximum of 4 tablets per day

clozapine odt (25mg oral tablet dispersible) Maximum of 3 tablets per day

CODEINE SULFATE (15MG ORAL TABLET,

60MG ORAL TABLET)

Maximum of 6 tablets per day

codeine sulfate (30mg oral tablet) Maximum of 6 tablets per day

COLCHICINE (0.6MG ORAL CAPSULE)

(BRAND EQUIVALENT MITIGARE)

Maximum of 4 capsules per day

colchicine (0.6mg oral tablet) (generic colcrys) Maximum of 4 tablets per day

COMBIVENT RESPIMAT (INHALATION

AEROSOL SOLUTION)

Maximum of 1 inhaler (4 grams) per 20 days

COMETRIQ (100MG DAILY DOSE) (ORAL KIT) Maximum of 1 carton (56 capsules) per 28 days

COMETRIQ (140MG DAILY DOSE) (ORAL KIT)

Maximum of 1 carton (112 capsules) per 28

days

COMETRIQ (60MG DAILY DOSE) (ORAL KIT) Maximum of 1 carton (84 capsules) per 28 days

COMPLERA (ORAL TABLET) Maximum of 1 tablet per day

COPIKTRA (ORAL CAPSULE) Maximum of 2 capsules per day

CORLANOR (ORAL SOLUTION) Maximum of 15 ml per day

CORLANOR (ORAL TABLET) Maximum of 2 tablets per day

COSENTYX (300MG DOSE) (SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 10 syringes (10 ml) per 30 days

COSENTYX SENSOREADY (300MG)

(SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

Maximum of 10 pens (10 ml) per 30 days

COSENTYX (75MG/0.5ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 20 syringes (10 ml) per 30 days

COTELLIC (ORAL TABLET) Maximum of 3 tablets per day

CYCLOSET (ORAL TABLET) Maximum of 6 tablets per day

dalfampridine er (oral tablet extended release 12

hour)

Maximum of 2 tablets per day

DALIRESP (250MCG ORAL TABLET) Maximum of 1 tablet per day

DALIRESP (500MCG ORAL TABLET) Maximum of 1 tablet per day

DAPTACEL (INTRAMUSCULAR SUSPENSION) 1 vaccination dose (0.5 ml) per day

DAURISMO (100MG ORAL TABLET) Maximum of 1 tablet per day

DAURISMO (25MG ORAL TABLET) Maximum of 2 tablets per day

103

Drug name Quantity limit

DELSTRIGO (ORAL TABLET) Maximum of 1 tablet per day

DESCOVY (ORAL TABLET) Maximum of 1 tablet per day

desonide (external ointment) Maximum of 120 grams per 30 days

desoximetasone (external cream) Maximum of 100 grams per 30 days

desvenlafaxine succinate er (100mg oral tablet

extended release 24 hour) (generic pristiq)

Maximum of 4 tablets per day

desvenlafaxine succinate er (25mg oral tablet

extended release 24 hour, 50mg oral tablet

extended release 24 hour) (generic pristiq)

Maximum of 1 tablet per day

DEXILANT (ORAL CAPSULE DELAYED

RELEASE)

Maximum of 1 capsule per day

dexlansoprazole (oral capsule delayed release) Maximum of 1 capsule per day

dexmethylphenidate hcl (oral tablet) Maximum of 2 tablets per day

dextroamphetamine sulfate er (10mg oral

capsule extended release 24 hour)

Maximum of 6 capsules per day

dextroamphetamine sulfate er (15mg oral

capsule extended release 24 hour)

Maximum of 4 capsules per day

dextroamphetamine sulfate er (5mg oral capsule

extended release 24 hour)

Maximum of 3 capsules per day

dextroamphetamine sulfate (10mg oral tablet,

5mg oral tablet)

Maximum of 6 tablets per day

dextroamphetamine sulfate (15mg oral tablet,

20mg oral tablet)

Maximum of 3 tablets per day

dextroamphetamine sulfate (30mg oral tablet) Maximum of 2 tablets per day

DIACOMIT (250MG ORAL CAPSULE) Maximum of 12 capsules per day

DIACOMIT (500MG ORAL CAPSULE) Maximum of 6 capsules per day

DIACOMIT (250MG ORAL PACKET) Maximum of 12 packets per day

DIACOMIT (500MG ORAL PACKET) Maximum of 6 packets per day

diazepam intensol (oral concentrate) Maximum of 8 ml per day

diazepam (10mg oral tablet, 2mg oral tablet,

5mg oral tablet)

Maximum of 4 tablets per day

diazepam (10mg rectal gel, 2.5mg rectal gel,

20mg rectal gel)

Maximum of 5 packages per 30 days

diclofenac epolamine (external patch) Maximum of 2 patches per day

diclofenac sodium (3% external gel) Maximum of 100 grams per 30 days

dihydroergotamine mesylate (nasal solution) Maximum of 16 vials (16 ml) per 28 days

dimethyl fumarate (120mg oral capsule delayed

release)

Maximum of 2 capsules per day

dimethyl fumarate (240mg oral capsule delayed

release)

Maximum of 2 capsules per day

dimethyl fumarate starter pack (oral capsule) Maximum of 2 packs (120 capsules) per year

104

Drug name Quantity limit

DIPHTHERIA-TETANUS TOXOIDS DT

(INTRAMUSCULAR SUSPENSION)

1 vaccination dose (0.5 ml) per day

dofetilide (125mcg oral capsule) Maximum of 6 capsules per day

dofetilide (250mcg oral capsule, 500mcg oral

capsule)

Maximum of 2 capsules per day

donepezil hcl (10mg oral tablet) Maximum of 2 tablets per day

donepezil hcl (23mg oral tablet, 5mg oral tablet) Maximum of 1 tablet per day

donepezil hcl odt (10mg oral tablet dispersible) Maximum of 2 tablets per day

donepezil hcl odt (5mg oral tablet dispersible) Maximum of 1 tablet per day

DOVATO (ORAL TABLET) Maximum of 1 tablet per day

doxepin hcl (external cream) Maximum of 90 grams per 30 days

DRIZALMA SPRINKLE (20MG ORAL CAPSULE

DELAYED RELEASE SPRINKLE, 40MG ORAL

CAPSULE DELAYED RELEASE SPRINKLE,

60MG ORAL CAPSULE DELAYED RELEASE

SPRINKLE)

Maximum of 2 capsules per day

DRIZALMA SPRINKLE (30MG ORAL CAPSULE

DELAYED RELEASE SPRINKLE)

Maximum of 3 capsules per day

droxidopa (100mg oral capsule) Maximum of 3 capsules per day

droxidopa (200mg oral capsule, 300mg oral

capsule)

Maximum of 6 capsules per day

DULERA (120 INHALATION AEROSOL) Maximum of 1 inhaler (13 grams) per 30 days

duloxetine hcl (20mg oral capsule delayed

release particles)

Maximum of 4 capsules per day

duloxetine hcl (30mg oral capsule delayed

release particles)

Maximum of 3 capsules per day

duloxetine hcl (60mg oral capsule delayed

release particles)

Maximum of 2 capsules per day

DUPIXENT (200MG/1.14ML SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

Maximum of 4 pens (4.56 ml) per 28 days

DUPIXENT (300MG/2ML SUBCUTANEOUS

SOLUTION PEN-INJECTOR)

Maximum of 4 pens (8 ml) per 28 days

DUPIXENT (100MG/0.67ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 2 syringes (1.34 ml) per 28 days

DUPIXENT (200MG/1.14ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 4 syringes (4.56 ml) per 28 days

DUPIXENT (300MG/2ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 4 syringes (8 ml) per 28 days

dutasteride (oral capsule) Maximum of 1 capsule per day

econazole nitrate (external cream) Maximum of 90 grams per 30 days

EDARBI (ORAL TABLET) Maximum of 1 tablet per day

EDARBYCLOR (ORAL TABLET) Maximum of 1 tablet per day

105

Drug name Quantity limit

EDURANT (ORAL TABLET) Maximum of 1 tablet per day

efavirenz (oral capsule) Maximum of 3 capsules per day

efavirenz (oral tablet) Maximum of 1 tablet per day

efavirenz-emtricitabine-tenofovir (oral tablet) Maximum of 1 tablet per day

efavirenz-lamivudine-tenofovir (oral tablet) Maximum of 1 tablet per day

ELIQUIS (ORAL TABLET) Maximum of 2 tablets per day

ELIQUIS STARTER PACK (ORAL TABLET) Maximum of 2 packs (148 tablets) per year

EMGALITY (300MG DOSE) (100MG/ML

SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE)

Maximum of 3 syringes or pens (3 ml) per 30

days

EMGALITY (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

Maximum of 2 syringes or pens (2 ml) per 30

days

EMGALITY (120MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 2 syringes or pens (2 ml) per 30

days

EMSAM (TRANSDERMAL PATCH 24 HOUR) Maximum of 1 patch per day

emtricitabine (oral capsule) Maximum of 1 capsule per day

emtricitabine-tenofovir disoproxil fumarate (oral

tablet)

Maximum of 1 tablet per day

EMTRIVA (ORAL SOLUTION) Maximum of 5 bottles (850 ml) per 30 days

enalapril maleate (oral tablet) Maximum of 2 tablets per day

enalapril-hydrochlorothiazide (10-25mg oral

tablet)

Maximum of 2 tablets per day

enalapril-hydrochlorothiazide (5-12.5mg oral

tablet)

Maximum of 1 tablet per day

ENBREL MINI (SUBCUTANEOUS SOLUTION

CARTRIDGE)

Maximum of 8 cartridges per 28 days

ENBREL (SUBCUTANEOUS SOLUTION) Maximum of 8 vials (4 ml) per 28 days

ENBREL (25MG/0.5ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 8 syringes (4 ml) per 28 days

ENBREL (50MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 8 syringes (8 ml) per 28 days

ENBREL SURECLICK (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 8 pens per 28 days

endocet (10-325mg oral tablet, 5-325mg oral

tablet, 7.5-325mg oral tablet)

Maximum of 12 tablets per day

ENGERIX-B (INJECTION SUSPENSION) 1 vaccination dose (1 ml) per day

ENGERIX-B (10MCG/0.5ML INJECTION

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

ENGERIX-B (20MCG/ML INJECTION

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (1 ml) per day

106

Drug name Quantity limit

enoxaparin sodium (100mg/ml injection solution

prefilled syringe, 150mg/ml injection solution

prefilled syringe)

Maximum of 2 syringes (2 ml) per day

enoxaparin sodium (120mg/0.8ml injection

solution prefilled syringe, 80mg/0.8ml injection

solution prefilled syringe)

Maximum of 2 syringes (1.6 ml) per day

enoxaparin sodium (30mg/0.3ml injection

solution prefilled syringe)

Maximum of 2 syringes (0.6 ml) per day

enoxaparin sodium (40mg/0.4ml injection

solution prefilled syringe)

Maximum of 2 syringes (0.8 ml) per day

enoxaparin sodium (60mg/0.6ml injection

solution prefilled syringe)

Maximum of 2 syringes (1.2 ml) per day

ENTRESTO (ORAL TABLET) Maximum of 2 tablets per day

EPCLUSA (ORAL PACKET) Maximum of 1 carton (28 packets) per 28 days

EPCLUSA (ORAL TABLET) Maximum of 1 tablet per day

epinephrine (injection solution auto-injector) Maximum of 4 pens (2 boxes) per 30 days

ERLEADA (ORAL TABLET) Maximum of 4 tablets per day

erlotinib hcl (100mg oral tablet, 150mg oral

tablet)

Maximum of 1 tablet per day

erlotinib hcl (25mg oral tablet) Maximum of 3 tablets per day

ESBRIET (ORAL CAPSULE) Maximum of 9 capsules per day

ESBRIET (267MG ORAL TABLET) Maximum of 6 tablets per day

ESBRIET (801MG ORAL TABLET) Maximum of 3 tablets per day

esomeprazole magnesium (20mg oral capsule

delayed release) (generic nexium)

Maximum of 3 capsules per day

esomeprazole magnesium (40mg oral capsule

delayed release) (generic nexium)

Maximum of 2 capsules per day

estradiol (transdermal patch weekly) Maximum of 4 patches per 28 days

estradiol (vaginal tablet) Maximum of 18 tablets per 28 days

eszopiclone (oral tablet) Maximum of 90 tablets per year

etravirine (oral tablet) Maximum of 2 tablets per day

EVOTAZ (ORAL TABLET) Maximum of 1 tablet per day

EXKIVITY (ORAL CAPSULE) Maximum of 4 capsules per day

ezetimibe (oral tablet) Maximum of 1 tablet per day

ezetimibe-simvastatin (oral tablet) Maximum of 1 tablet per day

famciclovir (125mg oral tablet, 250mg oral

tablet)

Maximum of 2 tablets per day

famciclovir (500mg oral tablet) Maximum of 3 tablets per day

FANAPT (10MG ORAL TABLET, 12MG ORAL

TABLET, 1MG ORAL TABLET, 2MG ORAL

TABLET, 4MG ORAL TABLET, 6MG ORAL

TABLET, 8MG ORAL TABLET)

Maximum of 2 tablets per day

107

Drug name Quantity limit

FANAPT TITRATION PACK (ORAL TABLET) Maximum of 2 packs per year

FARXIGA (ORAL TABLET) Maximum of 1 tablet per day

fentanyl citrate (buccal lozenge on a handle) Maximum of 4 lozenges per day

fentanyl (100mcg/hr transdermal patch 72 hour,

12mcg/hr transdermal patch 72 hour, 25mcg/hr

transdermal patch 72 hour, 50mcg/hr

transdermal patch 72 hour, 75mcg/hr

transdermal patch 72 hour)

Maximum of 15 patches per 30 days

FETZIMA (ORAL CAPSULE EXTENDED

RELEASE 24 HOUR)

Maximum of 1 capsule per day

FETZIMA TITRATION (ORAL CAPSULE ER 24

HOUR THERAPY PACK)

Maximum of 2 packs (56 capsules) per year

FINACEA (EXTERNAL FOAM) Maximum of 50 grams per 30 days

fingolimod hcl (oral capsule) Maximum of 1 pack (30 capsules) per 30 days

FINTEPLA (ORAL SOLUTION) Maximum of 12 ml per day

FLOVENT DISKUS (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 2 inhalers (120 blisters) per 30

days

FLOVENT HFA (110MCG/ACT INHALATION

AEROSOL)

Maximum of 1 inhaler (12 grams) per 30 days

FLOVENT HFA (220MCG/ACT INHALATION

AEROSOL)

Maximum of 2 inhalers (24 grams) per 30 days

FLOVENT HFA (44MCG/ACT INHALATION

AEROSOL)

Maximum of 1 inhaler (10.6 grams) per 30 days

fluocinonide emulsified base (external cream) Maximum of 60 grams per 30 days

fluocinonide (0.05% external cream) Maximum of 60 grams per 30 days

fluocinonide (external gel) Maximum of 60 grams per 30 days

fluocinonide (external ointment) Maximum of 60 grams per 30 days

fluocinonide (external solution) Maximum of 60 ml per 30 days

fluorouracil (5% external cream) Maximum of 40 grams per 30 days

fluticasone-salmeterol (100-50mcg/act

inhalation aerosol powder breath activated,

250-50mcg/act inhalation aerosol powder

breath activated, 500-50mcg/act inhalation

aerosol powder breath activated) (generic

advair)

Maximum of 1 inhaler (60 blisters) per 30 days

fluticasone-salmeterol (113-14mcg/act

inhalation aerosol powder breath activated,

232-14mcg/act inhalation aerosol powder

breath activated, 55-14mcg/act inhalation

aerosol powder breath activated) (brand

equivalent airduo respiclick)

Maximum of 1 inhaler per 30 days

fluvastatin sodium er (oral tablet extended

release 24 hour)

Maximum of 1 tablet per day

108

Drug name Quantity limit

fluvastatin sodium (20mg oral capsule) Maximum of 1 capsule per day

fluvastatin sodium (40mg oral capsule) Maximum of 2 capsules per day

formoterol fumarate (inhalation nebulization

solution)

Maximum of 2 vials (4 ml) per day

FORTEO (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

Maximum of 1 pen (2.4 ml) per 28 days

fosamprenavir calcium (oral tablet) Maximum of 4 tablets per day

fosinopril sodium (oral tablet) Maximum of 2 tablets per day

fosinopril sodium-hctz (oral tablet) Maximum of 4 tablets per day

FOTIVDA (ORAL CAPSULE) Maximum of 21 capsules per 28 days

FUZEON (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

Maximum of 2 vials per day

FYCOMPA (ORAL SUSPENSION) Maximum of 24 ml per day

FYCOMPA (ORAL TABLET) Maximum of 1 tablet per day

galantamine hydrobromide er (oral capsule

extended release 24 hour)

Maximum of 1 capsule per day

galantamine hydrobromide (oral solution) Maximum of 2 bottles (200 ml) per 30 days

galantamine hydrobromide (oral tablet) Maximum of 2 tablets per day

GARDASIL 9 (INTRAMUSCULAR

SUSPENSION)

1 vaccination dose (0.5 ml) per day

GARDASIL 9 (INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

GAVRETO (ORAL CAPSULE) Maximum of 4 capsules per day

GENVOYA (ORAL TABLET) Maximum of 1 tablet per day

GILENYA (0.5MG ORAL CAPSULE) Maximum of 1 pack (30 capsules) per 30 days

glatiramer acetate (20mg/ml subcutaneous

solution prefilled syringe)

Maximum of 1 syringe (1 ml) per day

glatiramer acetate (40mg/ml subcutaneous

solution prefilled syringe)

Maximum of 12 syringes (12 ml) per 28 days

glatopa (20mg/ml subcutaneous solution

prefilled syringe)

Maximum of 1 syringe (1 ml) per day

glatopa (40mg/ml subcutaneous solution

prefilled syringe)

Maximum of 12 syringes (12 ml) per 28 days

glimepiride (1mg oral tablet) Maximum of 8 tablets per day

glimepiride (2mg oral tablet) Maximum of 4 tablets per day

glimepiride (4mg oral tablet) Maximum of 2 tablets per day

glipizide er (10mg oral tablet extended release

24 hour)

Maximum of 2 tablets per day

glipizide er (2.5mg oral tablet extended release

24 hour)

Maximum of 8 tablets per day

glipizide er (5mg oral tablet extended release 24

hour)

Maximum of 4 tablets per day

109

Drug name Quantity limit

glipizide (10mg oral tablet immediate release) Maximum of 4 tablets per day

glipizide (5mg oral tablet immediate release) Maximum of 8 tablets per day

glipizide-metformin hcl (2.5-250mg oral tablet) Maximum of 8 tablets per day

glipizide-metformin hcl (2.5-500mg oral tablet,

5-500mg oral tablet)

Maximum of 4 tablets per day

GLYXAMBI (ORAL TABLET) Maximum of 1 tablet per day

granisetron hcl (oral tablet) Maximum of 2 tablets per day

HAVRIX (1440EL U/ML INTRAMUSCULAR

SUSPENSION)

Maximum of 2 vaccines per lifetime

HAVRIX (720EL U/0.5ML INTRAMUSCULAR

SUSPENSION)

Maximum of 2 vaccines per lifetime

HETLIOZ LQ (ORAL SUSPENSION) Maximum of 158 ml per 30 days

HETLIOZ (ORAL CAPSULE) Maximum of 1 capsule per day

HIBERIX (INJECTION SOLUTION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

HUMIRA PEDIATRIC CROHNS START (80MG/

0.8ML & 40MG/0.4ML SUBCUTANEOUS

PREFILLED SYRINGE KIT)

Maximum of 2 kits per year

HUMIRA PEDIATRIC CROHNS START (80MG/

0.8ML SUBCUTANEOUS PREFILLED

SYRINGE KIT)

Maximum of 2 kits per year

HUMIRA PEN (40MG/0.4ML SUBCUTANEOUS

PEN-INJECTOR KIT)

Maximum of 2 kits (4 pens) per 28 days

HUMIRA PEN (40MG/0.8ML SUBCUTANEOUS

PEN-INJECTOR KIT, 80MG/0.8ML

SUBCUTANEOUS PEN-INJECTOR KIT)

Maximum of 1 kit (2 pens) per 28 days

HUMIRA PEN PSORIASIS STARTER (80MG/

0.8ML AND 40MG/0.4ML SUBCUTANEOUS

PEN-INJECTOR KIT)

Maximum of 2 kits per year

HUMIRA (10MG/0.1ML SUBCUTANEOUS

PREFILLED SYRINGE KIT, 20MG/0.2ML

SUBCUTANEOUS PREFILLED SYRINGE KIT,

40MG/0.8ML SUBCUTANEOUS PREFILLED

SYRINGE KIT)

Maximum of 1 kit (2 syringes) per 28 days

HUMIRA (40MG/0.4ML SUBCUTANEOUS

PREFILLED SYRINGE KIT)

Maximum of 2 kits (4 syringes) per 28 days

hydrocodone-acetaminophen (7.5-325mg/15ml

oral solution)

Maximum of 180 ml per day

hydrocodone-acetaminophen (10-325mg oral

tablet, 5-325mg oral tablet, 7.5-325mg oral

tablet)

Maximum of 12 tablets per day

hydrocodone-ibuprofen (7.5-200mg oral tablet) Maximum of 5 tablets per day

110

Drug name Quantity limit

hydromorphone hcl er (oral tablet extended

release 24 hour)

Maximum of 2 tablets per day

hydromorphone hcl (1mg/ml oral liquid) Maximum of 50 ml per day

hydromorphone hcl (2mg oral tablet immediate

release, 4mg oral tablet immediate release)

Maximum of 8 tablets per day

hydromorphone hcl (8mg oral tablet immediate

release)

Maximum of 6 tablets per day

hydroxychloroquine sulfate (200mg oral tablet) Maximum of 3 tablets per day

ibandronate sodium (oral tablet) Maximum of 1 tablet per 28 days

IBRANCE (ORAL CAPSULE) Maximum of 1 capsule per day

IBRANCE (ORAL TABLET) Maximum of 1 tablet per day

icatibant acetate (subcutaneous solution) Maximum of 6 syringes (18 ml) per 30 days

ICLUSIG (ORAL TABLET) Maximum of 1 tablet per day

IDHIFA (ORAL TABLET) Maximum of 1 tablet per day

imatinib mesylate (oral tablet) Maximum of 3 tablets per day

IMBRUVICA (140MG ORAL CAPSULE) Maximum of 4 capsules per day

IMBRUVICA (70MG ORAL CAPSULE) Maximum of 1 capsule per day

IMBRUVICA (ORAL SUSPENSION) Maximum of 8 ml per day

IMBRUVICA (ORAL TABLET) Maximum of 1 tablet per day

imiquimod (5% external cream) Maximum of 24 grams per 30 days

IMOVAX RABIES (INTRAMUSCULAR

SUSPENSION RECONSTITUTED)

1 vaccination dose (1 injection) per day

IMVEXXY MAINTENANCE PACK (VAGINAL

INSERT)

Maximum of 8 vaginal inserts per 28 days

IMVEXXY STARTER PACK (VAGINAL INSERT) Maximum of 2 packs per year

INCRUSE ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (30 blisters) per 30 days

INFANRIX (INTRAMUSCULAR SUSPENSION) 1 vaccination dose (0.5 ml) per day

INGREZZA (ORAL CAPSULE) Maximum of 1 capsule per day

INGREZZA (ORAL CAPSULE THERAPY PACK) Maximum of 1 pack (28 capsules) per 28 days

INLYTA (ORAL TABLET) Maximum of 4 tablets per day

INQOVI (ORAL TABLET) Maximum of 1 pack (5 tablets) per 28 days

INREBIC (ORAL CAPSULE) Maximum of 4 capsules per day

INTELENCE (25MG ORAL TABLET) Maximum of 4 tablets per day

IPOL (INJECTION) 1 vaccination dose (0.5 ml) per day

irbesartan (150mg oral tablet, 300mg oral

tablet)

Maximum of 1 tablet per day

irbesartan (75mg oral tablet) Maximum of 3 tablets per day

irbesartan-hydrochlorothiazide (oral tablet) Maximum of 1 tablet per day

IRESSA (ORAL TABLET) Maximum of 2 tablets per day

ISENTRESS HD (ORAL TABLET) Maximum of 2 tablets per day

111

Drug name Quantity limit

ISENTRESS (ORAL PACKET) Maximum of 2 packets per day

ISENTRESS (ORAL TABLET) Maximum of 2 tablets per day

ISENTRESS (ORAL TABLET CHEWABLE) Maximum of 6 tablets per day

isosorbide dinitrate-hydralazine (oral tablet) Maximum of 6 tablets per day

itraconazole (oral capsule) Maximum of 4 capsules per day

IXIARO (INTRAMUSCULAR SUSPENSION) 1 vaccination dose (0.5 ml) per day

JAKAFI (ORAL TABLET) Maximum of 2 tablets per day

JANUMET (ORAL TABLET IMMEDIATE

RELEASE)

Maximum of 2 tablets per day

JANUMET XR (100-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR, 50-500MG

ORAL TABLET EXTENDED RELEASE 24

HOUR)

Maximum of 1 tablet per day

JANUMET XR (50-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR)

Maximum of 2 tablets per day

JANUVIA (ORAL TABLET) Maximum of 1 tablet per day

JARDIANCE (ORAL TABLET) Maximum of 1 tablet per day

JENTADUETO (ORAL TABLET IMMEDIATE

RELEASE)

Maximum of 2 tablets per day

JENTADUETO XR (2.5-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR)

Maximum of 2 tablets per day

JENTADUETO XR (5-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR)

Maximum of 1 tablet per day

JULUCA (ORAL TABLET) Maximum of 1 tablet per day

JYNNEOS (SUBCUTANEOUS SUSPENSION) 1 vaccination dose (0.5 ml) per day

KALYDECO (ORAL PACKET) Maximum of 2 packets per day

KALYDECO (ORAL TABLET) Maximum of 2 tablets per day

KERENDIA (ORAL TABLET) Maximum of 1 tablet per day

ketoconazole (external cream) Maximum of 90 grams per 30 days

KINRIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

KISQALI (200MG DOSE) (ORAL TABLET) Maximum of 1 tablet per day

KISQALI (400MG DOSE) (ORAL TABLET) Maximum of 2 tablets per day

KISQALI (600MG DOSE) (ORAL TABLET) Maximum of 3 tablets per day

KISQALI FEMARA (200MG DOSE) (ORAL

TABLET THERAPY PACK)

Maximum of 1 pack (49 tablets) per 28 days

KISQALI FEMARA (400MG DOSE) (ORAL

TABLET THERAPY PACK)

Maximum of 1 pack (70 tablets) per 28 days

KISQALI FEMARA (600MG DOSE) (ORAL

TABLET THERAPY PACK)

Maximum of 1 pack (91 tablets) per 28 days

KORLYM (ORAL TABLET) Maximum of 4 tablets per day

112

Drug name Quantity limit

KOSELUGO (10MG ORAL CAPSULE) Maximum of 8 capsules per day

KOSELUGO (25MG ORAL CAPSULE) Maximum of 4 capsules per day

KYNMOBI (10MG SUBLINGUAL FILM, 15MG

SUBLINGUAL FILM, 20MG SUBLINGUAL

FILM, 25MG SUBLINGUAL FILM, 30MG

SUBLINGUAL FILM)

Maximum of 5 films per day

lacosamide (oral solution) Maximum of 40 ml per day

lacosamide (oral tablet) Maximum of 2 tablets per day

lamivudine (10mg/ml oral solution) Maximum of 32 ml per day

lamivudine (150mg oral tablet) Maximum of 2 tablets per day

lamivudine (300mg oral tablet) Maximum of 1 tablet per day

lamivudine-zidovudine (oral tablet) Maximum of 2 tablets per day

lansoprazole (oral capsule delayed release) Maximum of 2 capsules per day

LATUDA (120MG ORAL TABLET, 20MG ORAL

TABLET, 40MG ORAL TABLET, 60MG ORAL

TABLET)

Maximum of 1 tablet per day

LATUDA (80MG ORAL TABLET) Maximum of 2 tablets per day

lenalidomide (oral capsule) Maximum of 1 capsule per day

levocetirizine dihydrochloride (oral tablet) Maximum of 1 tablet per day

levorphanol tartrate (oral tablet) Maximum of 6 tablets per day

LEXIVA (ORAL SUSPENSION) Maximum of 60 ml per day

lidocaine (5% external ointment) Maximum of 152 grams per 30 days

lidocaine (5% external patch) Maximum of 3 patches per day

linezolid (oral suspension reconstituted) Maximum of 60 ml per day

linezolid (oral tablet) Maximum of 2 tablets per day

LINZESS (ORAL CAPSULE) Maximum of 1 capsule per day

lisinopril (oral tablet) Maximum of 2 tablets per day

lisinopril-hydrochlorothiazide (10-12.5mg oral

tablet)

Maximum of 1 tablet per day

lisinopril-hydrochlorothiazide (20-12.5mg oral

tablet)

Maximum of 4 tablets per day

lisinopril-hydrochlorothiazide (20-25mg oral

tablet)

Maximum of 2 tablets per day

LIVALO (ORAL TABLET) Maximum of 1 tablet per day

LOKELMA (ORAL PACKET) Maximum of 90 packets per 30 days

LONHALA MAGNAIR (INHALATION

SOLUTION)

Maximum of 2 vials (2 ml) per day

LONSURF (15-6.14MG ORAL TABLET) Maximum of 10 tablets per day

LONSURF (20-8.19MG ORAL TABLET) Maximum of 8 tablets per day

lopinavir-ritonavir (oral solution) Maximum of 3 bottles (480 ml) per 30 days

lopinavir-ritonavir (100-25mg oral tablet) Maximum of 8 tablets per day

113

Drug name Quantity limit

lopinavir-ritonavir (200-50mg oral tablet) Maximum of 4 tablets per day

lorazepam intensol (oral concentrate) Maximum of 5 ml per day

lorazepam (0.5mg oral tablet, 1mg oral tablet) Maximum of 4 tablets per day

lorazepam (2mg oral tablet) Maximum of 5 tablets per day

LORBRENA (100MG ORAL TABLET) Maximum of 1 tablet per day

LORBRENA (25MG ORAL TABLET) Maximum of 3 tablets per day

losartan potassium (100mg oral tablet) Maximum of 1 tablet per day

losartan potassium (25mg oral tablet, 50mg oral

tablet)

Maximum of 2 tablets per day

losartan potassium-hctz (100-12.5mg oral tablet,

100-25mg oral tablet)

Maximum of 1 tablet per day

losartan potassium-hctz (50-12.5mg oral tablet) Maximum of 2 tablets per day

lovastatin (10mg oral tablet, 20mg oral tablet) Maximum of 1 tablet per day

lovastatin (40mg oral tablet) Maximum of 2 tablets per day

lubiprostone (oral capsule) Maximum of 2 capsules per day

LUMAKRAS (ORAL TABLET) Maximum of 8 tablets per day

LYBALVI (ORAL TABLET) Maximum of 1 tablet per day

LYNPARZA (ORAL TABLET) Maximum of 4 tablets per day

maraviroc (150mg oral tablet) Maximum of 2 tablets per day

maraviroc (300mg oral tablet) Maximum of 4 tablets per day

MAVYRET (ORAL PACKET)

Maximum of 5 cartons (140 packets) per 28

days

MAVYRET (ORAL TABLET) Maximum of 3 tablets per day

MAYZENT (0.25MG ORAL TABLET) Maximum of 4 tablets per day

MAYZENT (1MG ORAL TABLET, 2MG ORAL

TABLET)

Maximum of 1 tablet per day

MAYZENT STARTER PACK (7 X 0.25MG ORAL

TABLET THERAPY PACK)

Maximum of 2 packs (14 tablets) per year

MAYZENT STARTER PACK (12 X 0.25MG

ORAL TABLET THERAPY PACK)

Maximum of 2 packs (24 tablets) per year

memantine hcl er (oral capsule extended release

24 hour)

Maximum of 1 capsule per day

memantine hcl (oral solution) Maximum of 10 ml per day

memantine hcl (10mg oral tablet) Maximum of 2 tablets per day

MEMANTINE HCL TITRATION PAK (ORAL

TABLET)

Maximum of 2 packs per year

memantine hcl (5mg oral tablet) Maximum of 3 tablets per day

MENACTRA (INTRAMUSCULAR SOLUTION) 1 vaccination dose (0.5 ml) per day

MENQUADFI (INTRAMUSCULAR SOLUTION) 1 vaccination dose (0.5 ml) per day

MENVEO (INTRAMUSCULAR SOLUTION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

114

Drug name Quantity limit

mesalamine er (500mg oral capsule extended

release) (generic pentasa)

Maximum of 8 capsules per day

mesalamine er (0.375gm oral capsule extended

release 24 hour) (generic apriso)

Maximum of 4 capsules per day

mesalamine (1.2gm oral tablet delayed release)

(generic lialda)

Maximum of 4 tablets per day

mesalamine (rectal enema) Maximum of 1 bottle (60 ml) per day

mesalamine (rectal suppository) Maximum of 1 suppository per day

metformin hcl er (500mg oral tablet extended

release 24 hour) (generic glucophage xr)

Maximum of 4 tablets per day

metformin hcl er (750mg oral tablet extended

release 24 hour) (generic glucophage xr)

Maximum of 2 tablets per day

metformin hcl (500mg/5ml oral solution) Maximum of 25.5 ml per day

metformin hcl (1000mg oral tablet immediate

release)

Maximum of 2.5 tablets per day

metformin hcl (500mg oral tablet immediate

release)

Maximum of 5 tablets per day

metformin hcl (850mg oral tablet immediate

release)

Maximum of 3 tablets per day

methadone hcl (10mg/5ml oral solution) Maximum of 60 ml per day

methadone hcl (5mg/5ml oral solution) Maximum of 120 ml per day

methadone hcl (10mg oral tablet) Maximum of 12 tablets per day

methadone hcl (5mg oral tablet) Maximum of 8 tablets per day

methocarbamol (500mg oral tablet, 750mg oral

tablet)

Maximum of 540 tablets per year

methylphenidate hcl er (10mg oral tablet

extended release)

Maximum of 4 tablets per day

methylphenidate hcl er (20mg oral tablet

extended release)

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 (oral tablet immediate

release) (generic ritalin)

Maximum of 3 tablets per day

miglitol (100mg oral tablet) Maximum of 3 tablets per day

miglitol (25mg oral tablet) Maximum of 12 tablets per day

miglitol (50mg oral tablet) Maximum of 6 tablets per day

M-M-R II (INJECTION SOLUTION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

modafinil (100mg oral tablet) Maximum of 1 tablet per day

modafinil (200mg oral tablet) Maximum of 2 tablets per day

moexipril hcl (oral tablet) Maximum of 2 tablets per day

montelukast sodium (oral packet) Maximum of 1 packet per day

115

Drug name Quantity limit

montelukast sodium (oral tablet) Maximum of 1 tablet per day

montelukast sodium (oral tablet chewable) Maximum of 1 tablet per day

morphine sulfate (concentrate) (20mg/ml oral

solution)

Maximum of 10 ml per day

morphine sulfate er (100mg oral tablet extended

release, 15mg oral tablet extended release)

(generic ms contin)

Maximum of 3 tablets per day

morphine sulfate er (200mg oral tablet extended

release) (generic ms contin)

Maximum of 2 tablets per day

morphine sulfate er (30mg oral tablet extended

release, 60mg oral tablet extended release)

(generic ms contin)

Maximum of 4 tablets per day

morphine sulfate (10mg/5ml oral solution) Maximum of 100 ml per day

MORPHINE SULFATE (20MG/5ML ORAL

SOLUTION)

Maximum of 50 ml per day

morphine sulfate (15mg oral tablet immediate

release)

Maximum of 8 tablets per day

morphine sulfate (30mg oral tablet immediate

release)

Maximum of 6 tablets per day

MOTEGRITY (ORAL TABLET) Maximum of 1 tablet per day

MOUNJARO (SUBCUTANEOUS SOLUTION

PEN-INJECTOR)

Maximum of 4 pens (2 ml) per 28 days

MOVANTIK (ORAL TABLET) Maximum of 1 tablet per day

MULTAQ (ORAL TABLET) Maximum of 2 tablets per day

mupirocin (external ointment) Maximum of 110 grams per 30 days

NAMZARIC (ORAL CAPSULE ER 24 HOUR

THERAPY PACK)

Maximum of 1 capsule per day

NAMZARIC (ORAL CAPSULE EXTENDED

RELEASE 24 HOUR)

Maximum of 1 capsule per day

naratriptan hcl (oral tablet) Maximum of 12 tablets per 30 days

nateglinide (120mg oral tablet) Maximum of 3 tablets per day

nateglinide (60mg oral tablet) Maximum of 6 tablets per day

NAYZILAM (NASAL SOLUTION) Maximum of 10 devices per 30 days

nebivolol hcl (10mg oral tablet, 2.5mg oral

tablet, 5mg oral tablet)

Maximum of 1 tablet per day

nebivolol hcl (20mg oral tablet) Maximum of 2 tablets per day

NERLYNX (ORAL TABLET) Maximum of 6 tablets per day

nevirapine er (100mg oral tablet extended

release 24 hour)

Maximum of 2 tablets per day

nevirapine er (400mg oral tablet extended

release 24 hour)

Maximum of 1 tablet per day

nevirapine (oral suspension) Maximum of 40 ml per day

116

Drug name Quantity limit

nevirapine (oral tablet immediate release) Maximum of 2 tablets per day

nifedipine er (oral tablet extended release 24

hour)

Maximum of 2 tablets per day

nifedipine er osmotic release (oral tablet

extended release 24 hour)

Maximum of 2 tablets per day

NINLARO (ORAL CAPSULE) Maximum of 3 capsules per 28 days

NORVIR (ORAL PACKET) Maximum of 12 packets per day

NORVIR (ORAL SOLUTION) Maximum of 16 ml per day

NOXAFIL (ORAL SUSPENSION) Maximum of 20 ml per day

NUBEQA (ORAL TABLET) Maximum of 4 tablets per day

NUCALA (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

Maximum of 3 ml per 28 days

NUCALA (100MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 3 ml per 28 days

NUCALA (40MG/0.4ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 0.4 ml per 28 days

NUCALA (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

Maximum of 3 vials per 28 days

NUEDEXTA (ORAL CAPSULE) Maximum of 2 capsules per day

NUPLAZID (ORAL CAPSULE) Maximum of 1 capsule per day

NUPLAZID (ORAL TABLET) Maximum of 1 tablet per day

NURTEC ODT (ORAL TABLET DISPERSIBLE) Maximum of 18 tablets per 30 days

nyamyc (external powder) Maximum of 120 grams per 30 days

nystatin (external powder) Maximum of 120 grams per 30 days

nystop (external powder) Maximum of 120 grams per 30 days

OCALIVA (ORAL TABLET) Maximum of 1 tablet per day

ODEFSEY (ORAL TABLET) Maximum of 1 tablet per day

OFEV (ORAL CAPSULE) Maximum of 2 capsules per day

olanzapine (10mg oral tablet, 2.5mg oral tablet,

5mg oral tablet, 7.5mg oral tablet)

Maximum of 2 tablets per day

olanzapine (15mg oral tablet, 20mg oral tablet) Maximum of 1 tablet per day

olanzapine odt (10mg oral tablet dispersible,

5mg oral tablet dispersible)

Maximum of 2 tablets per day

olanzapine odt (15mg oral tablet dispersible,

20mg oral tablet dispersible)

Maximum of 1 tablet per day

olmesartan medoxomil (20mg oral tablet, 40mg

oral tablet)

Maximum of 1 tablet per day

olmesartan medoxomil (5mg oral tablet) Maximum of 2 tablets per day

olmesartan medoxomil-hctz (oral tablet) Maximum of 1 tablet per day

olmesartan-amlodipine-hctz (oral tablet) Maximum of 1 tablet per day

117

Drug name Quantity limit

omega-3-acid ethyl esters (oral capsule) (generic

lovaza)

Maximum of 4 capsules per day

omeprazole (10mg oral capsule delayed release) Maximum of 3 capsules per day

ONUREG (ORAL TABLET) Maximum of 14 tablets per 28 days

ORENCIA CLICKJECT (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 4 syringes (4 ml) per 28 days

ORENCIA (125MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 4 syringes (4 ml) per 28 days

ORENCIA (50MG/0.4ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 4 syringes (1.6 ml) per 28 days

ORENCIA (87.5MG/0.7ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 4 syringes (2.8 ml) per 28 days

ORGOVYX (ORAL TABLET) Maximum of 30 tablets per 28 days

ORKAMBI (ORAL PACKET) Maximum of 56 packets per 28 days

ORKAMBI (ORAL TABLET) Maximum of 4 tablets per day

oseltamivir phosphate (oral capsule) Maximum of 2 capsules per day

oseltamivir phosphate (oral suspension

reconstituted)

Maximum of 26 ml per day

OSPHENA (ORAL TABLET) Maximum of 1 tablet per day

OTEZLA (ORAL TABLET) Maximum of 2 tablets per day

OTEZLA (ORAL TABLET THERAPY PACK) Maximum of 2 kits per year

oxandrolone (10mg oral tablet) Maximum of 2 tablets per day

oxandrolone (2.5mg oral tablet) Maximum of 4 tablets per day

oxybutynin chloride er (10mg oral tablet

extended release 24 hour)

Maximum of 3 tablets per day

oxybutynin chloride er (15mg oral tablet

extended release 24 hour)

Maximum of 2 tablets per day

oxybutynin chloride er (5mg oral tablet extended

release 24 hour)

Maximum of 1 tablet per day

oxycodone hcl (100mg/5ml oral concentrate) Maximum of 6 ml per day

oxycodone hcl (5mg/5ml oral solution) Maximum of 130 ml per day

oxycodone hcl (10mg oral tablet immediate

release, 5mg oral tablet immediate release)

Maximum of 12 tablets per day

oxycodone hcl (15mg oral tablet immediate

release)

Maximum of 8 tablets per day

oxycodone hcl (20mg oral tablet immediate

release, 30mg oral tablet immediate release)

Maximum of 6 tablets per day

oxycodone-acetaminophen (10-325mg oral

tablet, 2.5-325mg oral tablet, 5-325mg oral

tablet, 7.5-325mg oral tablet)

Maximum of 12 tablets per day

118

Drug name Quantity limit

OZEMPIC (0.25MG/DOSE OR 0.5MG/DOSE)

(2MG/1.5ML SUBCUTANEOUS SOLUTION

PEN-INJECTOR)

Maximum of 1 pen (1.5 ml) per 28 days

OZEMPIC (1MG/DOSE) (4MG/3ML

SUBCUTANEOUS SOLUTION PEN-INJECTOR)

Maximum of 1 pen (3 ml) per 28 days

OZEMPIC (2MG/DOSE) (8MG/3ML

SUBCUTANEOUS SOLUTION PEN-INJECTOR)

Maximum of 1 pen (3 ml) per 28 days

paliperidone er (1.5mg oral tablet extended

release 24 hour, 3mg oral tablet extended

release 24 hour, 9mg oral tablet extended

release 24 hour)

Maximum of 1 tablet per day

paliperidone er (6mg oral tablet extended

release 24 hour)

Maximum of 2 tablets per day

pantoprazole sodium (20mg oral tablet delayed

release)

Maximum of 3 tablets per day

pantoprazole sodium (40mg oral tablet delayed

release)

Maximum of 2 tablets per day

PEDIARIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

PEDVAX HIB (INTRAMUSCULAR

SUSPENSION)

1 vaccination dose (0.5 ml) per day

PEMAZYRE (ORAL TABLET) Maximum of 14 tablets per 21 days

PENTACEL (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

pentamidine isethionate (inhalation solution

reconstituted)

Maximum of 1 vial (300 mg) per 28 days

PENTASA (250MG ORAL CAPSULE

EXTENDED RELEASE)

Maximum of 16 capsules per day

PERFOROMIST (INHALATION NEBULIZATION

SOLUTION)

Maximum of 2 vials (4 ml) per day

perindopril erbumine (oral tablet) Maximum of 2 tablets per day

PIFELTRO (ORAL TABLET) Maximum of 1 tablet per day

pimecrolimus (external cream) Maximum of 100 grams per 30 days

pioglitazone hcl (oral tablet) Maximum of 1 tablet per day

pioglitazone hcl-glimepiride (oral tablet) Maximum of 1 tablet per day

pioglitazone hcl-metformin hcl (oral tablet) Maximum of 3 tablets per day

PIQRAY (200MG DAILY DOSE) (ORAL TABLET

THERAPY PACK)

Maximum of 1 tablet per day

PIQRAY (250MG DAILY DOSE) (ORAL TABLET

THERAPY PACK)

Maximum of 2 tablets per day

PIQRAY (300MG DAILY DOSE) (ORAL TABLET

THERAPY PACK)

Maximum of 2 tablets per day

pirfenidone (267mg oral tablet) Maximum of 6 tablets per day

119

Drug name Quantity limit

pirfenidone (534mg oral tablet, 801mg oral

tablet)

Maximum of 3 tablets per day

POMALYST (ORAL CAPSULE) Maximum of 1 capsule per day

posaconazole (oral tablet delayed release) Maximum of 6 tablets per day

PRALUENT (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

Maximum of 2 pens (2 ml) per 28 days

prasugrel hcl (oral tablet) Maximum of 1 tablet per day

pravastatin sodium (oral tablet) Maximum of 1 tablet per day

pregabalin (100mg oral capsule, 25mg oral

capsule, 50mg oral capsule, 75mg oral capsule)

Maximum of 4 capsules per day

pregabalin (150mg oral capsule, 200mg oral

capsule)

Maximum of 3 capsules per day

pregabalin (225mg oral capsule, 300mg oral

capsule)

Maximum of 2 capsules per day

pregabalin (oral solution) Maximum of 30 ml per day

PREHEVBRIO (INTRAMUSCULAR

SUSPENSION)

1 vaccination dose (1 ml) per day

PREMARIN (ORAL TABLET) Maximum of 1 tablet per day

PREMPHASE (ORAL TABLET) Maximum of 1 tablet per day

PREMPRO (ORAL TABLET) Maximum of 1 tablet per day

PREVYMIS (ORAL TABLET) Maximum of 1 tablet per day

PREZCOBIX (ORAL TABLET) Maximum of 1 tablet per day

PREZISTA (ORAL SUSPENSION) Maximum of 2 bottles (400 ml) per 30 days

PREZISTA (150MG ORAL TABLET) Maximum of 6 tablets per day

PREZISTA (600MG ORAL TABLET) Maximum of 2 tablets per day

PREZISTA (75MG ORAL TABLET) Maximum of 10 tablets per day

PREZISTA (800MG ORAL TABLET) Maximum of 1 tablet per day

PRIORIX (SUBCUTANEOUS SUSPENSION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

PROLIA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

Maximum of 1 syringe per 180 days

PROMACTA (ORAL PACKET) Maximum of 6 packets per day

PROMACTA (12.5MG ORAL TABLET, 25MG

ORAL TABLET)

Maximum of 1 tablet per day

PROMACTA (50MG ORAL TABLET, 75MG

ORAL TABLET)

Maximum of 2 tablets per day

promethazine hcl (12.5mg rectal suppository) Maximum of 6 suppositories per day

promethazine hcl (25mg rectal suppository) Maximum of 4 suppositories per day

promethegan (25mg rectal suppository) Maximum of 4 suppositories per day

PROQUAD (SUBCUTANEOUS SUSPENSION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

120

Drug name Quantity limit

PULMOZYME (INHALATION SOLUTION) Maximum of 2 ampules (5 ml) per day

PYRUKYND (20MG ORAL TABLET, 5MG

ORAL TABLET)

Maximum of 1 pack (56 tablets) per 28 days

PYRUKYND (50MG ORAL TABLET) Maximum of 2 packs (112 tablets) per 28 days

PYRUKYND TAPER PACK (5MG ORAL

TABLET THERAPY PACK)

Maximum of 1 pack (7 tablets) per 7 days

PYRUKYND TAPER PACK (7 X 20MG & 7 X

5MG ORAL TABLET THERAPY PACK, 7 X

50MG & 7 X 20MG ORAL TABLET THERAPY

PACK)

Maximum of 1 pack (14 tablets) per 14 days

QINLOCK (ORAL TABLET) Maximum of 3 tablets per day

QUADRACEL (INTRAMUSCULAR

SUSPENSION)

1 vaccination dose (0.5 ml) per day

QUADRACEL (INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

quetiapine fumarate er (150mg oral tablet

extended release 24 hour, 200mg oral tablet

extended release 24 hour)

Maximum of 1 tablet per day

quetiapine fumarate er (300mg oral tablet

extended release 24 hour, 400mg oral tablet

extended release 24 hour, 50mg oral tablet

extended release 24 hour)

Maximum of 2 tablets per day

quetiapine fumarate (100mg oral tablet

immediate release, 200mg oral tablet immediate

release, 50mg oral tablet immediate release)

Maximum of 3 tablets per day

quetiapine fumarate (25mg oral tablet

immediate release)

Maximum of 4 tablets per day

quetiapine fumarate (300mg oral tablet

immediate release, 400mg oral tablet immediate

release)

Maximum of 2 tablets per day

quinapril hcl (oral tablet) Maximum of 2 tablets per day

quinapril-hydrochlorothiazide (10-12.5mg oral

tablet)

Maximum of 1 tablet per day

quinapril-hydrochlorothiazide (20-12.5mg oral

tablet, 20-25mg oral tablet)

Maximum of 2 tablets per day

RABAVERT (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

raloxifene hcl (oral tablet) Maximum of 1 tablet per day

ramelteon (oral tablet) Maximum of 1 tablet per day

ramipril (oral capsule) Maximum of 2 capsules per day

ranolazine er (oral tablet extended release 12

hour)

Maximum of 2 tablets per day

RAVICTI (ORAL LIQUID) Maximum of 17.5 ml per day

121

Drug name Quantity limit

RAYALDEE (ORAL CAPSULE EXTENDED

RELEASE)

Maximum of 2 capsules per day

REBIF REBIDOSE (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 12 pens (6 ml) per 28 days

REBIF REBIDOSE TITRATION PACK

(SUBCUTANEOUS SOLUTION AUTO-

INJECTOR)

Maximum of 2 packs per year

REBIF (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

Maximum of 12 syringes (6 ml) per 28 days

REBIF TITRATION PACK (SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 2 packs per year

RECOMBIVAX HB (10MCG/ML INJECTION

SUSPENSION, 40MCG/ML INJECTION

SUSPENSION)

1 vaccination dose (1 ml) per day

RECOMBIVAX HB (5MCG/0.5ML INJECTION

SUSPENSION)

1 vaccination dose (0.5 ml) per day

RECOMBIVAX HB (10MCG/ML INJECTION

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (1 ml) per day

RECOMBIVAX HB (5MCG/0.5ML INJECTION

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

RECTIV (RECTAL OINTMENT) Maximum of 30 grams per 30 days

RELENZA DISKHALER (INHALATION

AEROSOL POWDER BREATH ACTIVATED)

Maximum of 3 inhalers (60 blisters) per 30 days

RELISTOR (ORAL TABLET) Maximum of 3 tablets per day

repaglinide (0.5mg oral tablet) Maximum of 32 tablets per day

repaglinide (1mg oral tablet) Maximum of 16 tablets per day

repaglinide (2mg oral tablet) Maximum of 8 tablets per day

REPATHA PUSHTRONEX SYSTEM

(SUBCUTANEOUS SOLUTION CARTRIDGE)

Maximum of 2 cartridges (7 ml) per 28 days

REPATHA (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

Maximum of 3 syringes (3 ml) per 28 days

REPATHA SURECLICK (SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 3 pens (3 ml) per 28 days

RESTASIS MULTIDOSE (OPHTHALMIC

EMULSION)

Maximum of 1 bottle (5.5 ml) per 25 days

RESTASIS SINGLE-USE VIALS (OPHTHALMIC

EMULSION)

Maximum of 2 vials per day

RETEVMO (40MG ORAL CAPSULE) Maximum of 6 capsules per day

RETEVMO (80MG ORAL CAPSULE) Maximum of 4 capsules per day

REVLIMID (ORAL CAPSULE) Maximum of 1 capsule per day

REXULTI (ORAL TABLET) Maximum of 1 tablet per day

REYATAZ (ORAL PACKET) Maximum of 6 packets per day

122

Drug name Quantity limit

RINVOQ (ORAL TABLET EXTENDED RELEASE

24 HOUR)

Maximum of 1 tablet per day

risedronate sodium (150mg oral tablet

immediate release)

Maximum of 1 tablet per 30 days

risedronate sodium (30mg oral tablet immediate

release, 5mg oral tablet immediate release)

Maximum of 1 tablet per day

risedronate sodium (35mg oral tablet immediate

release, 35mg (12 pack) oral tablet immediate

release, 35mg (4 pack) oral tablet immediate

release)

Maximum of 4 tablets per 28 days

ritonavir (oral tablet) Maximum of 12 tablets per day

rivastigmine tartrate (oral capsule) Maximum of 2 capsules per day

rivastigmine (transdermal patch 24 hour) Maximum of 1 patch per day

rizatriptan benzoate (oral tablet) Maximum of 12 tablets per 30 days

rizatriptan benzoate odt (oral tablet dispersible) Maximum of 12 tablets per 30 days

roflumilast (250mcg oral tablet) Maximum of 1 tablet per day

roflumilast (500mcg oral tablet) Maximum of 1 tablet per day

rosuvastatin calcium (oral tablet) Maximum of 1 tablet per day

ROTARIX (ORAL SUSPENSION

RECONSTITUTED)

1 vaccination dose (1 ml) per day

ROTATEQ (ORAL SOLUTION) 1 vaccination dose (2 ml) per day

ROZLYTREK (100MG ORAL CAPSULE) Maximum of 5 capsules per day

ROZLYTREK (200MG ORAL CAPSULE) Maximum of 3 capsules per day

RUBRACA (ORAL TABLET) Maximum of 4 tablets per day

RUKOBIA (ORAL TABLET EXTENDED

RELEASE 12 HOUR)

Maximum of 2 tablets per day

RYBELSUS (ORAL TABLET) Maximum of 1 tablet per day

RYDAPT (ORAL CAPSULE) Maximum of 8 capsules per day

sajazir (subcutaneous solution) Maximum of 6 syringes (18 ml) per 30 days

SANCUSO (TRANSDERMAL PATCH) Maximum of 4 patches per 28 days

SCEMBLIX (20MG ORAL TABLET) Maximum of 2 tablets per day

SCEMBLIX (40MG ORAL TABLET) Maximum of 10 tablets per day

SECUADO (TRANSDERMAL PATCH 24

HOUR)

Maximum of 1 patch per day

SELZENTRY (ORAL SOLUTION) Maximum of 8 bottles (1840 ml) per 30 days

SELZENTRY (25MG ORAL TABLET) Maximum of 4 tablets per day

SELZENTRY (75MG ORAL TABLET) Maximum of 2 tablets per day

SEREVENT DISKUS (60 INHALATION

AEROSOL POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (60 inhalations) per 30

days

SHINGRIX (INTRAMUSCULAR SUSPENSION

RECONSTITUTED)

1 vaccination dose (1 injection) per day

123

Drug name Quantity limit

sildenafil citrate (20mg oral tablet) (generic

revatio)

Maximum of 3 tablets per day

silodosin (oral capsule) Maximum of 1 capsule per day

SIMPONI (100MG/ML SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 3 syringes (3 ml) per 28 days

SIMPONI (50MG/0.5ML SUBCUTANEOUS

SOLUTION AUTO-INJECTOR)

Maximum of 1 syringe (0.5 ml) per 30 days

SIMPONI (100MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 3 syringes (3 ml) per 28 days

SIMPONI (50MG/0.5ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 1 syringe (0.5 ml) per 30 days

simvastatin (oral tablet) Maximum of 1 tablet per day

SKYRIZI PEN (SUBCUTANEOUS SOLUTION

AUTO-INJECTOR)

Maximum of 1 pen (1 ml) per 28 days

SKYRIZI (180MG/1.2ML SUBCUTANEOUS

SOLUTION CARTRIDGE)

Maximum of 1 cartridge (1.2 ml) per 56 days

SKYRIZI (360MG/2.4ML SUBCUTANEOUS

SOLUTION CARTRIDGE)

Maximum of 1 cartridge (2.4 ml) per 56 days

SKYRIZI (SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE)

Maximum of 1 syringe (1 ml) per 28 days

sofosbuvir-velpatasvir (oral tablet) Maximum of 1 tablet per day

solifenacin succinate (oral tablet) Maximum of 1 tablet per day

SOLIQUA (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

Maximum of 5 pens (15 ml) per 25 days

SOMAVERT (SUBCUTANEOUS SOLUTION

RECONSTITUTED)

Maximum of 1 vial per day

SOVALDI (150MG ORAL PACKET) Maximum of 1 carton (28 packets) per 28 days

SOVALDI (200MG ORAL PACKET) Maximum of 2 cartons (56 packets) per 28 days

SOVALDI (400MG ORAL TABLET) Maximum of 1 tablet per day

SPIRIVA HANDIHALER (INHALATION

CAPSULE)

Maximum of 1 capsule per day

SPIRIVA RESPIMAT (INHALATION AEROSOL

SOLUTION)

Maximum of 1 inhaler (4 grams) per 30 days

SPRYCEL (100MG ORAL TABLET, 140MG

ORAL TABLET, 70MG ORAL TABLET)

Maximum of 1 tablet per day

SPRYCEL (20MG ORAL TABLET, 50MG ORAL

TABLET)

Maximum of 3 tablets per day

SPRYCEL (80MG ORAL TABLET) Maximum of 2 tablets per day

STELARA (SUBCUTANEOUS SOLUTION) Maximum of 6 vials (3 ml) per 84 days

STELARA (45MG/0.5ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 6 syringes (3 ml) per 84 days

STELARA (90MG/ML SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE)

Maximum of 3 syringes (3 ml) per 84 days

124

Drug name Quantity limit

STIOLTO RESPIMAT (INHALATION AEROSOL

SOLUTION)

Maximum of 1 inhaler (4 grams) per 30 days

STIVARGA (ORAL TABLET) Maximum of 4 tablets per day

STRIBILD (ORAL TABLET) Maximum of 1 tablet per day

SUBOXONE (12-3MG SUBLINGUAL FILM,

4-1MG SUBLINGUAL FILM)

Maximum of 2 films per day

SUBOXONE (2-0.5MG SUBLINGUAL FILM,

8-2MG SUBLINGUAL FILM)

Maximum of 3 films per day

sumatriptan (nasal solution) Maximum of 12 devices per 30 days

sumatriptan succinate (100mg oral tablet, 25mg

oral tablet, 50mg oral tablet)

Maximum of 12 tablets per 30 days

sumatriptan succinate refill (subcutaneous

solution cartridge)

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 (4mg/0.5ml

subcutaneous solution auto-injector, 6mg/0.5ml

subcutaneous solution auto-injector)

Maximum of 12 injections (6 ml) per 30 days

sunitinib malate (12.5mg oral capsule, 25mg

oral capsule, 50mg oral capsule)

Maximum of 1 capsule per day

sunitinib malate (37.5mg oral capsule) Maximum of 2 capsules per day

SYMBICORT (120 INHALATION AEROSOL) Maximum of 1 inhaler (10.2 grams) per 30 days

SYMPAZAN (ORAL FILM) Maximum of 2 films per day

SYMTUZA (ORAL TABLET) Maximum of 1 tablet per day

SYNJARDY (ORAL TABLET IMMEDIATE

RELEASE)

Maximum of 2 tablets per day

SYNJARDY XR (10-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR, 25-1000MG

ORAL TABLET EXTENDED RELEASE 24

HOUR)

Maximum of 1 tablet per day

SYNJARDY XR (12.5-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR, 5-1000MG

ORAL TABLET EXTENDED RELEASE 24

HOUR)

Maximum of 2 tablets per day

TABRECTA (ORAL TABLET) Maximum of 4 tablets per day

tadalafil (pah) (20mg oral tablet) (generic

adcirca)

Maximum of 2 tablets per day

TAGRISSO (ORAL TABLET) Maximum of 1 tablet per day

TALZENNA (0.25MG ORAL CAPSULE) Maximum of 3 capsules per day

TALZENNA (0.5MG ORAL CAPSULE, 0.75MG

ORAL CAPSULE, 1MG ORAL CAPSULE)

Maximum of 1 capsule per day

TASIGNA (150MG ORAL CAPSULE) Maximum of 5 capsules per day

125

Drug name Quantity limit

TASIGNA (200MG ORAL CAPSULE) Maximum of 4 capsules per day

TASIGNA (50MG ORAL CAPSULE) Maximum of 14 capsules per day

TAZVERIK (ORAL TABLET) Maximum of 8 tablets per day

TDVAX (INTRAMUSCULAR SUSPENSION) 1 vaccination dose (0.5 ml) per day

telmisartan (oral tablet) Maximum of 1 tablet per day

telmisartan-amlodipine (oral tablet) Maximum of 1 tablet per day

telmisartan-hctz (40-12.5mg oral tablet,

80-25mg oral tablet)

Maximum of 1 tablet per day

telmisartan-hctz (80-12.5mg oral tablet) Maximum of 2 tablets per day

temazepam (15mg oral capsule, 30mg oral

capsule)

Maximum of 1 capsule per day

TENIVAC (INTRAMUSCULAR INJECTABLE) 1 vaccination dose (0.5 ml) per day

tenofovir disoproxil fumarate (oral tablet) Maximum of 1 tablet per day

TEPMETKO (ORAL TABLET) Maximum of 2 tablets per day

TERIPARATIDE (RECOMBINANT)

(SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

Maximum of 1 pen (2.48 ml) per 28 days

tetrabenazine (12.5mg oral tablet) Maximum of 3 tablets per day

tetrabenazine (25mg oral tablet) Maximum of 4 tablets per day

THALOMID (100MG ORAL CAPSULE, 50MG

ORAL CAPSULE)

Maximum of 1 capsule per day

THALOMID (150MG ORAL CAPSULE, 200MG

ORAL CAPSULE)

Maximum of 2 capsules per day

TIBSOVO (ORAL TABLET) Maximum of 2 tablets per day

TICOVAC (1.2MCG/0.25ML INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (0.25 ml) per day

TICOVAC (2.4MCG/0.5ML INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

TIVICAY (10MG ORAL TABLET, 25MG ORAL

TABLET)

Maximum of 1 tablet per day

TIVICAY (50MG ORAL TABLET) Maximum of 2 tablets per day

TIVICAY PD (ORAL TABLET SOLUBLE) Maximum of 6 tablets per day

TOBI PODHALER (INHALATION CAPSULE) Maximum of 8 capsules per day

tobramycin (300mg/4ml inhalation nebulization

solution)

Maximum of 2 ampules (8 ml) per day

tobramycin (300mg/5ml inhalation nebulization

solution)

Maximum of 2 ampules (10 ml) per day

tolcapone (oral tablet) Maximum of 6 tablets per day

TRACLEER (ORAL TABLET SOLUBLE) Maximum of 8 tablets per day

TRADJENTA (ORAL TABLET) Maximum of 1 tablet per day

tramadol hcl er (biphasic) (oral tablet extended

release 24 hour)

Maximum of 1 tablet per day

126

Drug name Quantity limit

tramadol hcl er (oral tablet extended release 24

hour)

Maximum of 1 tablet per day

tramadol hcl (50mg oral tablet immediate

release)

Maximum of 8 tablets per day

tramadol-acetaminophen (oral tablet) Maximum of 8 tablets per day

trandolapril (1mg oral tablet, 2mg oral tablet) Maximum of 1 tablet per day

trandolapril (4mg oral tablet) Maximum of 2 tablets per day

trandolapril-verapamil hcl er (oral tablet

extended release)

Maximum of 1 tablet per day

TRELEGY ELLIPTA (INHALATION AEROSOL

POWDER BREATH ACTIVATED)

Maximum of 1 inhaler (60 blisters) per 30 days

trientine hcl (oral capsule) Maximum of 8 capsules per day

TRIJARDY XR (10-5-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR, 25-5-1000MG

ORAL TABLET EXTENDED RELEASE 24

HOUR)

Maximum of 1 tablet per day

TRIJARDY XR (12.5-2.5-1000MG ORAL

TABLET EXTENDED RELEASE 24 HOUR,

5-2.5-1000MG ORAL TABLET EXTENDED

RELEASE 24 HOUR)

Maximum of 2 tablets per day

TRINTELLIX (ORAL TABLET) Maximum of 1 tablet per day

TRIUMEQ (ORAL TABLET) Maximum of 1 tablet per day

TRIUMEQ PD (ORAL TABLET SOLUBLE) Maximum of 6 tablets per day

TRIZIVIR (ORAL TABLET) Maximum of 2 tablets per day

TRULANCE (ORAL TABLET) Maximum of 1 tablet per day

TRULICITY (SUBCUTANEOUS SOLUTION

PEN-INJECTOR)

Maximum of 4 pens (2 ml) per 28 days

TRUMENBA (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

TRUSELTIQ (100MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

Maximum of 1 capsule per day

TRUSELTIQ (125MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

Maximum of 2 capsules per day

TRUSELTIQ (50MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

Maximum of 2 capsules per day

TRUSELTIQ (75MG DAILY DOSE) (ORAL

CAPSULE THERAPY PACK)

Maximum of 3 capsules per day

TUKYSA (150MG ORAL TABLET) Maximum of 4 tablets per day

TUKYSA (50MG ORAL TABLET) Maximum of 12 tablets per day

TURALIO (200MG ORAL CAPSULE) Maximum of 4 capsules per day

TWINRIX (INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE)

1 vaccination dose (1 ml) per day

127

Drug name Quantity limit

TYBOST (ORAL TABLET) Maximum of 1 tablet per day

TYMLOS (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

Maximum of 1.56 ml per 30 days

TYPHIM VI (INTRAMUSCULAR SOLUTION) 1 vaccination dose (0.5 ml) per day

TYPHIM VI (INTRAMUSCULAR SOLUTION

PREFILLED SYRINGE)

1 vaccination dose (0.5 ml) per day

TYVASO DPI MAINTENANCE KIT (112 X

32MCG & 112 X 48MCG INHALATION

POWDER)

Maximum of 1 kit (224 cartridges) per 28 days

TYVASO DPI MAINTENANCE KIT (16MCG

INHALATION POWDER, 32MCG INHALATION

POWDER, 48MCG INHALATION POWDER,

64MCG INHALATION POWDER)

Maximum of 1 kit (112 cartridges) per 28 days

TYVASO DPI TITRATION KIT (112 X 16MCG &

84 X 32MCG INHALATION POWDER)

Maximum of 2 kits (392 cartridges) per year

TYVASO DPI TITRATION KIT (112 X 16MCG &

112 X 32MCG & 28 X 48MCG INHALATION

POWDER)

Maximum of 2 kits (504 cartridges) per year

valacyclovir hcl (1gm oral tablet) Maximum of 4 tablets per day

valacyclovir hcl (500mg oral tablet) Maximum of 2 tablets per day

VALCHLOR (EXTERNAL GEL) Maximum of 60 grams per 30 days

valganciclovir hcl (50mg/ml oral solution

reconstituted)

Maximum of 36 ml per day

valganciclovir hcl (450mg oral tablet) Maximum of 4 tablets per day

valsartan (160mg oral tablet, 40mg oral tablet,

80mg oral tablet)

Maximum of 2 tablets per day

valsartan (320mg oral tablet) Maximum of 1 tablet per day

valsartan-hydrochlorothiazide (oral tablet) Maximum of 1 tablet per day

VALTOCO 10MG DOSE (NASAL LIQUID)

Maximum of 10 blister packs (10 spray devices)

per 30 days

VALTOCO 15MG DOSE (NASAL LIQUID

THERAPY PACK)

Maximum of 10 blister packs (20 spray devices)

per 30 days

VALTOCO 20MG DOSE (NASAL LIQUID

THERAPY PACK)

Maximum of 10 blister packs (20 spray devices)

per 30 days

VALTOCO 5MG DOSE (NASAL LIQUID)

Maximum of 10 blister packs (10 spray devices)

per 30 days

vancomycin hcl (125mg oral capsule) Maximum of 4 capsules per day

vancomycin hcl (250mg oral capsule) Maximum of 8 capsules per day

VAQTA (25UNIT/0.5ML INTRAMUSCULAR

SUSPENSION, 25UNIT/0.5ML 0.5ML

INTRAMUSCULAR SUSPENSION)

Maximum of 2 vaccines per lifetime

128

Drug name Quantity limit

VAQTA (50UNIT/ML INTRAMUSCULAR

SUSPENSION, 50UNIT/ML 1ML

INTRAMUSCULAR SUSPENSION)

Maximum of 2 vaccines per lifetime

VARIVAX (SUBCUTANEOUS INJECTABLE) 1 vaccination dose (1 injection) per day

VELTASSA (ORAL PACKET) Maximum of 1 packet per day

VEMLIDY (ORAL TABLET) Maximum of 1 tablet per day

VENCLEXTA (100MG ORAL TABLET) Maximum of 6 tablets per day

VENCLEXTA (10MG ORAL TABLET) Maximum of 2 tablets per day

VENCLEXTA (50MG ORAL TABLET) Maximum of 1 tablet per day

VENCLEXTA STARTING PACK (ORAL TABLET

THERAPY PACK)

Maximum of 2 packs per year

VENTAVIS (10MCG/ML INHALATION

SOLUTION)

Maximum of 7 ml per day

VENTAVIS (20MCG/ML INHALATION

SOLUTION)

Maximum of 3 ml per day

VERZENIO (ORAL TABLET) Maximum of 2 tablets per day

VICTOZA (SUBCUTANEOUS SOLUTION PEN-

INJECTOR)

Maximum of 3 pens (9 ml) per 30 days

vigabatrin (oral packet) Maximum of 6 packets per day

vigabatrin (oral tablet) Maximum of 6 tablets per day

vigadrone (oral packet) Maximum of 6 packets per day

VIIBRYD (ORAL TABLET) Maximum of 1 tablet per day

VIIBRYD STARTER PACK (ORAL KIT) Maximum of 2 packs (60 tablets) per year

vilazodone hcl (oral tablet) Maximum of 1 tablet per day

VIMPAT (ORAL SOLUTION) Maximum of 40 ml per day

VIMPAT (ORAL TABLET) Maximum of 2 tablets per day

VIRACEPT (250MG ORAL TABLET) Maximum of 10 tablets per day

VIRACEPT (625MG ORAL TABLET) Maximum of 4 tablets per day

VIREAD (ORAL POWDER) Maximum of 4 bottles (240 grams) per 30 days

VIREAD (150MG ORAL TABLET, 200MG ORAL

TABLET, 250MG ORAL TABLET)

Maximum of 1 tablet per day

VITRAKVI (100MG ORAL CAPSULE) Maximum of 4 capsules per day

VITRAKVI (25MG ORAL CAPSULE) Maximum of 6 capsules per day

VITRAKVI (ORAL SOLUTION) Maximum of 20 ml per day

VIZIMPRO (ORAL TABLET) Maximum of 1 tablet per day

VONJO (ORAL CAPSULE) Maximum of 4 capsules per day

voriconazole (oral suspension reconstituted) Maximum of 20 ml per day

voriconazole (200mg oral tablet) Maximum of 4 tablets per day

voriconazole (50mg oral tablet) Maximum of 16 tablets per day

VOSEVI (ORAL TABLET) Maximum of 1 tablet per day

129

Drug name Quantity limit

VOTRIENT (ORAL TABLET) Maximum of 4 tablets per day

VRAYLAR (1.5MG ORAL CAPSULE, 3MG

ORAL CAPSULE, 4.5MG ORAL CAPSULE,

6MG ORAL CAPSULE)

Maximum of 1 capsule per day

VRAYLAR (ORAL CAPSULE THERAPY PACK) Maximum of 2 packs (14 capsules) per year

VUMERITY (ORAL CAPSULE DELAYED

RELEASE) (MAINTENANCE DOSE BOTTLE)

Maximum of 4 capsules per day

VYNDAMAX (ORAL CAPSULE) Maximum of 1 capsule per day

VYNDAQEL (ORAL CAPSULE) Maximum of 4 capsules per day

WELIREG (ORAL TABLET) Maximum of 3 tablets per day

wixela inhub (inhalation aerosol powder breath

activated) (generic advair)

Maximum of 1 inhaler (60 blisters) per 30 days

XARELTO (10MG ORAL TABLET, 20MG ORAL

TABLET)

Maximum of 1 tablet per day

XARELTO (15MG ORAL TABLET, 2.5MG

ORAL TABLET)

Maximum of 2 tablets per day

XARELTO STARTER PACK (ORAL TABLET

THERAPY PACK)

Maximum of 2 packs per year

XCOPRI (250MG DAILY DOSE) (100MG &

150MG ORAL TABLET THERAPY PACK)

Maximum of 1 pack (56 tablets) per 28 days

XCOPRI (350MG DAILY DOSE) (150MG &

200MG ORAL TABLET THERAPY PACK)

Maximum of 1 pack (56 tablets) per 28 days

XCOPRI (100MG ORAL TABLET, 50MG ORAL

TABLET)

Maximum of 1 tablet per day

XCOPRI (150MG ORAL TABLET, 200MG

ORAL TABLET)

Maximum of 2 tablets per day

XCOPRI (14 X 12.5MG & 14 X 25MG ORAL

TABLET THERAPY PACK, 14 X 150MG & 14 X

200MG ORAL TABLET THERAPY PACK, 14 X

50MG & 14 X 100MG ORAL TABLET

THERAPY PACK)

Maximum of 2 packs per year

XELJANZ (ORAL SOLUTION) Maximum of 10 ml per day

XELJANZ (ORAL TABLET IMMEDIATE

RELEASE)

Maximum of 2 tablets per day

XELJANZ XR (ORAL TABLET EXTENDED

RELEASE 24 HOUR)

Maximum of 1 tablet per day

XERMELO (ORAL TABLET) Maximum of 3 tablets per day

XIGDUO XR (10-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR, 10-500MG

ORAL TABLET EXTENDED RELEASE 24

HOUR, 5-500MG ORAL TABLET EXTENDED

RELEASE 24 HOUR)

Maximum of 1 tablet per day

130

Drug name Quantity limit

XIGDUO XR (2.5-1000MG ORAL TABLET

EXTENDED RELEASE 24 HOUR, 5-1000MG

ORAL TABLET EXTENDED RELEASE 24

HOUR)

Maximum of 2 tablets per day

XIIDRA (OPHTHALMIC SOLUTION) Maximum of 2 vials per day

XOFLUZA (40MG DOSE) (ORAL TABLET

THERAPY PACK)

Maximum of 2 tablets per 30 days

XOFLUZA (80MG DOSE) (ORAL TABLET

THERAPY PACK)

Maximum of 1 tablet per 30 days

XOSPATA (ORAL TABLET) Maximum of 3 tablets per day

XPOVIO (100MG ONCE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 8 tablets per 28 days

XPOVIO (40MG ONCE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 4 tablets per 28 days

XPOVIO (40MG TWICE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 8 tablets per 28 days

XPOVIO (60MG ONCE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 4 tablets per 28 days

XPOVIO (60MG TWICE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 24 tablets per 28 days

XPOVIO (80MG ONCE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 8 tablets per 28 days

XPOVIO (80MG TWICE WEEKLY) (ORAL

TABLET THERAPY PACK)

Maximum of 32 tablets per 28 days

XTAMPZA ER (13.5MG ORAL CAPSULE ER 12

HOUR ABUSE-DETERRENT, 18MG ORAL

CAPSULE ER 12 HOUR ABUSE-DETERRENT,

9MG ORAL CAPSULE ER 12 HOUR ABUSE-

DETERRENT)

Maximum of 3 capsules per day

XTAMPZA ER (27MG ORAL CAPSULE ER 12

HOUR ABUSE-DETERRENT, 36MG ORAL

CAPSULE ER 12 HOUR ABUSE-DETERRENT)

Maximum of 6 capsules per day

XTANDI (ORAL CAPSULE) Maximum of 4 capsules per day

XTANDI (40MG ORAL TABLET) Maximum of 4 tablets per day

XTANDI (80MG ORAL TABLET) Maximum of 2 tablets per day

XYREM (ORAL SOLUTION) Maximum of 18 ml per day

YF-VAX (SUBCUTANEOUS INJECTABLE) 1 vaccination dose (1 injection) per day

yuvafem (vaginal tablet) Maximum of 18 tablets per 28 days

zafirlukast (oral tablet) Maximum of 2 tablets per day

zaleplon (10mg oral capsule) Maximum of 2 capsules per day

zaleplon (5mg oral capsule) Maximum of 1 capsule per day

ZEJULA (ORAL CAPSULE) Maximum of 3 capsules per day

131

Drug name Quantity limit

zidovudine (oral capsule) Maximum of 6 capsules per day

zidovudine (oral syrup) Maximum of 64 ml per day

zidovudine (oral tablet) Maximum of 2 tablets per day

ziprasidone hcl (oral capsule) Maximum of 2 capsules per day

zolpidem tartrate (oral tablet immediate release) Maximum of 1 tablet per day

ZYDELIG (ORAL TABLET) Maximum of 2 tablets per day

ZYKADIA (ORAL TABLET) Maximum of 3 tablets per day

132

C3. Over-the-counter (OTC) Medicaid Drug List

UnitedHealthcare Dual Complete ONE covers some prescription OTC drugs that aren’t normally

covered under our Medicare Part D benefit.

You need a prescription from your doctor to have drugs on this list covered. If your prescription is

for a brand name drug, you will get the generic version of the drug if it’s available, unless otherwise

prescribed or directed by your doctor.

Some of these drugs may need prior authorization. Please check with your doctor and the plan. If

the drug requires a prior authorization, you or your doctor will need to get approval from the plan

before the drug may be covered.

The list below shows the prescription OTC and Medicaid covered drugs.

tRACK

Drug name

Analgesics

8 hour arthritis pain reliever (tablet er)

8 hr arthritis pain relief (tablet er)

8hr muscle aches & pain (tablet er)

acetaminophen (suppository)

acetaminophen er (tablet er)

arthritis pain relief (tablet er)

arthritis pain reliever (tablet er)

childrens aspirin free (elixir)

childrens silapap (liquid)

ed-apap (liquid)

feverall adults (suppository)

feverall childrens (suppository)

gnp 8 hour arthritis relief (tablet er)

gnp 8 hour pain reliever (tablet er)

GNP ARTHRITIS PAIN RELIEF (TABLET ER)

goodsense arthritis pain (tablet er)

hm arthritis pain relief (tablet er)

hm pain relief (tablet er)

mapap (capsule)

mapap arthritis pain (tablet er)

medi-tabs childrens (elixir)

MIDOL (TABLET ER)

pain reliever/fever reducer childrens

(suppository)

px arthritis pain relief (tablet er)

Drug name

qc acetaminophen 8 hour arthritis pain (tablet

er)

qc acetaminophen 8 hour muscle aches & pain

(tablet er)

qc acetaminophen 8 hours (tablet er)

ra 8 hour pain relief (tablet er)

ra arthritis pain relief acetaminophen (tablet er)

sb arthritis pain relief (tablet er)

sm arthritis pain reliever (tablet er)

sm pain reliever extra strength (tablet er)

Nonsteroidal Anti-inflammatory Drugs

acetaminophen (suspension)

acetaminophen (tablet)

acetaminophen childrens (suspension)

acetaminophen extra strength (tablet)

acetaminophen infants (suspension)

adult aspirin regimen (tablet dr)

ADVIL JUNIOR STRENGTH (TABLET)

ALEVE (TABLET)

ALEVE ARTHRITIS (TABLET)

all day pain relief (tablet)

all day relief (tablet)

aspirin (suppository)

aspirin (tablet chewable)

aspirin (tablet dr)

aspirin (tablet)

ASPIRIN 81 (TABLET DR)

133

Drug name

aspirin 81 low dose (tablet chewable)

ASPIRIN ADULT (TABLET)

aspirin adult low dose (tablet dr)

aspirin childrens (tablet chewable)

aspirin ec (tablet dr)

aspirin ec low dose (tablet dr)

aspirin enteric coated adult low strength (tablet

dr)

aspirin low dose (tablet chewable)

aspirin low dose (tablet dr)

aspirin regular strength (tablet dr)

BAYER ADVANCED ASPIRIN EXTRA

STRENGTH (TABLET)

BAYER ADVANCED ASPIRIN REGULAR

STRENGTH (TABLET)

BAYER ASPIRIN (TABLET)

BAYER ASPIRIN EXTRA STRENGTH

(TABLET)

BAYER MIGRAINE (TABLET)

childrens acetaminophen (suspension)

CHILDRENS ASPIRIN LOW STRENGTH

(TABLET CHEWABLE)

ECOTRIN (TABLET DR)

ECOTRIN LOW STRENGTH (TABLET DR)

ECOTRIN REGULAR STRENGTH (TABLET

DR)

ECPIRIN (TABLET DR)

eql aspirin ec (tablet dr)

eql ibuprofen (tablet)

EXCEDRIN EXTRA STRENGTH (TABLET)

EXCEDRIN MIGRAINE (TABLET)

extraprin (tablet)

extraprin extra strength (tablet)

gnp acetaminophen (tablet)

gnp adult aspirin low strength (tablet

chewable)

gnp aspirin (tablet dr)

GNP ASPIRIN (TABLET)

gnp aspirin low dose (tablet dr)

gnp headache relief extra strength (tablet)

Drug name

gnp ibuprofen (tablet)

gnp ibuprofen childrens (tablet chewable)

gnp ibuprofen infants (suspension)

GNP IBUPROFEN JUNIOR STRENGTH

(TABLET CHEWABLE)

gnp infants pain/fever (suspension)

gnp migraine relief (tablet)

gnp naproxen (tablet)

gnp pain & fever childrens (suspension)

gnp pain & fever infants (suspension)

gnp pain relief (tablet)

gnp pain relief extra strength (tablet)

goodsense aspirin (tablet chewable)

goodsense aspirin (tablet)

GOODSENSE ASPIRIN ADULT LOW

STRENGTH (TABLET CHEWABLE)

goodsense ibuprofen (tablet)

goodsense ibuprofen infants (suspension)

GOODSENSE IBUPROFEN JUNIOR

STRENGTH (TABLET CHEWABLE)

goodsense migraine formula (tablet)

goodsense naproxen sodium (tablet)

goodsense pain & fever childrens (suspension)

goodsense pain & fever infants (suspension)

goodsense pain relief (tablet)

goodsense pain relief extra strength (tablet)

headache relief (tablet)

headache relief/extra strength (tablet)

hm aspirin (tablet chewable)

hm aspirin (tablet)

hm aspirin ec (tablet dr)

hm aspirin ec low dose (tablet dr)

hm ibuprofen (tablet)

hm ibuprofen ib (tablet)

HM IBUPROFEN INFANTS (SUSPENSION)

hm migraine relief (tablet)

hm naproxen sodium (tablet)

hm pain & fever childrens (suspension)

hm pain & fever infants (suspension)

hm pain relief extra strength (tablet)

134

Drug name

hm pain reliever (tablet)

ibu-200 (tablet)

ibuprofen (tablet)

ibuprofen 100 junior strength (tablet chewable)

ibuprofen 200 (tablet)

ibuprofen infants (suspension)

ibuprofen junior strength (tablet chewable)

ibuprofen pm (tablet)

infants ibuprofen (suspension)

infants pain & fever (suspension)

MIGRAINE FORMULA (TABLET)

migraine relief (tablet)

naproxen sodium (tablet)

NON-ASPIRIN CHILDRENS (SUSPENSION)

pain & fever childrens (suspension)

pain & fever childrens/dye-free (suspension)

pain & fever infants (suspension)

pain relief childrens (suspension)

pain relief extra strength (tablet)

pain reliever extra strength (tablet)

PAIN RELIEVER PLUS (TABLET)

PAMPRIN ALL DAY MAXIMUM STRENGTH

(TABLET)

PAMPRIN MAX (TABLET)

PEDIACARE CHILDREN (SUSPENSION)

PEDIACARE INFANTS (SUSPENSION)

PHARBETOL (TABLET)

PHARBETOL EXTRA STRENGTH (TABLET)

PROVIL (TABLET)

px all day relief (tablet)

px aspirin (tablet chewable)

px aspirin (tablet)

px childrens pain relief (suspension)

px enteric aspirin (tablet dr)

px headache relief added strength (tablet)

px ibuprofen (tablet)

px ibuprofen junior strength (tablet chewable)

px infants profen ib (suspension)

px migraine relief (tablet)

Drug name

px pain relief extra strength (tablet)

qc aspirin (tablet)

qc aspirin low dose (tablet dr)

QC CHEWABLE ASPIRIN LOW DOSE

(TABLET CHEWABLE)

qc enteric aspirin (tablet dr)

qc headache relief (tablet)

qc ibuprofen (tablet)

QC IBUPROFEN IB (TABLET)

qc naproxen sodium (tablet)

qc non-aspirin childrens (suspension)

qc non-aspirin extra strength (tablet)

qc pain relief (tablet)

qc pain relief childrens (suspension)

qc pain relief extra strength (tablet)

ra childrens fever reducer & pain reliever

(suspension)

ra fever reducer & pain reliever infants

(suspension)

ra fever reducer/pain reliever infants

(suspension)

ra ibuprofen (tablet)

ra pain relief acetaminophen (tablet)

ra pain relief aspirin (tablet)

ra pain relief ibuprofen (tablet)

ra pain reliever extra strength (tablet)

sb infants ibuprofen (suspension)

sb naproxen sodium (tablet)

sb pain reliever extra strength (tablet)

sm aspirin (tablet)

sm aspirin adult low strength (tablet chewable)

sm aspirin adult low strength (tablet dr)

sm aspirin low dose (tablet chewable)

sm childrens aspirin (tablet chewable)

sm ibuprofen (tablet)

sm ibuprofen ib (tablet chewable)

sm ibuprofen ib (tablet)

sm ibuprofen jr (tablet)

sm infants ibuprofen (suspension)

SM MIGRAINE RELIEF (TABLET)

135

Drug name

sm naproxen sodium (tablet)

sm pain & fever childrens (suspension)

sm pain & fever infants (suspension)

sm pain relief extra strength (tablet)

sm pain reliever (tablet)

sm pain reliever extra strength (tablet)

ST JOSEPH ASPIRIN (TABLET DR)

TACTINAL (TABLET)

TACTINAL EXTRA STRENGTH (TABLET)

wal-profen (tablet)

Anesthetics

Local Anesthetics

lidocaine (cream)

LIDOCAINE HYDROCHLORIDE (CREAM)

lidocaine topical anesthetic (cream)

Anti-Addiction/Substance Abuse Treatment

Agents

Smoking Cessation Agents

gnp nicotine gum (gum)

gnp nicotine mini lozenge (lozenge)

gnp nicotine polacrilex (gum)

gnp nicotine polacrilex (lozenge)

gnp nicotine polacrilex mini (lozenge)

gnp nicotine transdermal system (patch 24 hr)

gnp nicotine transdermal system step 2 (patch

24 hr)

goodsense nicotine (lozenge)

goodsense nicotine gum (gum)

goodsense nicotine polacrilex (lozenge)

goodsense nicotine polacrilex gum (gum)

hm nicotine polacrilex (gum)

hm nicotine polacrilex (lozenge)

hm nicotine transdermal system step 1 (patch

24 hr)

hm nicotine transdermal system step 2 (patch

24 hr)

hm nicotine transdermal system step 3 (patch

24 hr)

NICORETTE (GUM)

nicotine (gum)

Drug name

nicotine (patch 24 hr)

nicotine mini lozenge (lozenge)

nicotine polacrilex (gum)

nicotine polacrilex (lozenge)

nicotine step 1 (patch 24 hr)

nicotine step 3 (patch 24 hr)

nicotine transdermal system (kit)

nicotine transdermal system (patch 24 hr)

nicotine transdermal system step 1 (patch 24

hr)

nicotine transdermal system step 2 (patch 24

hr)

nicotine transdermal system step 3 (patch 24

hr)

px stop smoking aid (gum)

px stop smoking aid (lozenge)

ra nicotine (gum)

ra nicotine (patch 24 hr)

ra nicotine gum (gum)

ra nicotine transdermal system (patch 24 hr)

sm nicotine (gum)

sm nicotine (lozenge)

sm nicotine polacrilex (gum)

sm nicotine polacrilex (lozenge)

sm nicotine transdermal system/step 1/clear

(patch 24 hr)

sm nicotine transdermal system/step 2/clear

(patch 24 hr)

sm nicotine transdermal system/step 3/clear

(patch 24 hr)

Antibacterials

Antibacterials, Other

bacitracin (ointment)

bacitracin zinc (ointment)

BACITRAYCIN PLUS (OINTMENT)

DOUBLE ANTIBIOTIC (OINTMENT)

first aid antibiotic (ointment)

gnp bacitracin zinc (ointment)

gnp triple antibiotic (ointment)

hm bacitracin (ointment)

136

Drug name

hm double antibiotic (ointment)

LANABIOTIC (OINTMENT)

NEOSPORIN (OINTMENT)

px triple ointment (ointment)

ra bacitracin zinc first aid (ointment)

sm antibiotic (ointment)

sm double antibiotic (ointment)

sm triple antibiotic original strength (ointment)

triple antibiotic (ointment)

wal-sporin (ointment)

Antiemetics

Antiemetics, Other

anti-nausea (solution)

DRAMAMINE (TABLET)

driminate (tablet)

eql anti-nausea (solution)

FORMULA EM (SOLUTION)

gnp nausea relief (solution)

goodsense nausea relief (solution)

HM ANTI-NAUSEA (SOLUTION)

hm motion sickness (tablet)

sm anti-nausea (solution)

sm motion sickness (tablet)

TRAVEL SICKNESS (TABLET)

trav-tabs (tablet)

Antifungals

3 day vaginal (cream)

antifungal (cream)

antifungal powder (powder)

anti-fungal powder (powder)

athletes foot (cream)

athletes foot powder (powder)

athletes foot powder spray (aerosol powder)

athletes foot spray (aerosol)

BLIS-TO-SOL (LIQUID)

clotrimazole (cream)

clotrimazole 3 (cream)

clotrimazole-7 (cream)

Drug name

DESENEX (POWDER)

eql athletes foot (cream)

gnp clotrimazole 3 (cream)

gnp miconazole 3 (kit)

gnp miconazole 7 (cream)

gnp miconazorb af (powder)

gnp terbinafine hydrochloride (cream)

gnp tolnaftate (cream)

LOTRIMIN AF DEODORANT POWDER

(AEROSOL POWDER)

LOTRIMIN AF JOCK ITCH POWDER

(AEROSOL POWDER)

LOTRIMIN AF POWDER (AEROSOL

POWDER)

medicated anti-fungal (solution)

miconazole (cream)

miconazole 3 combination pack (kit)

miconazole 3 combo pack (kit)

miconazole 7 (cream)

miconazole 7 (suppository)

miconazole nitrate (cream)

odor control foot & sneaker spray (aerosol

powder)

ODOR EATERS ANTIFUNGAL (POWDER)

ODOR EATERS FOOT & SNEAKER SPRAY

(AEROSOL POWDER)

px athletic foot (cream)

px miconazole 3-day combo pack (kit)

qc 3 day vaginal cream (cream)

qc miconazole 7 (cream)

qc tolnaftate (cream)

ra foot care antifungal (cream)

ra miconazole 3 combination pack (kit)

sm 3-day vaginal (cream)

sm antifungal miconazole (cream)

sm antifungal tolnaftate (cream)

sm athletes foot (cream)

sm clotrimazole vaginal (cream)

sm miconazole 3 (kit)

sm miconazole 7 (cream)

137

Drug name

sm miconazole 7 (suppository)

terbinafine hcl (cream)

TINACTIN (AEROSOL POWDER)

TINACTIN DEODORANT (AEROSOL

POWDER)

TINACTIN JOCK ITCH (AEROSOL POWDER)

TINEACIDE (CREAM)

tolnaftate (aerosol powder)

tolnaftate (cream)

tolnaftate (powder)

VAGISTAT-3 (KIT)

ZEASORB-AF (POWDER)

Antiparasitics

Anthelmintics

pinworm medicine (suspension)

reeses pinworm medicine (suspension)

Antivirals

Antiherpetic Agents

docosanol (cream)

Blood Glucose Regulators

Glycemic Agents

cvs glucose (tablet chewable)

cvs soft glucose (tablet chewable)

DEX4 QUICK DISSOLVE GLUCOSE (TABLET

CHEWABLE)

glucose (tablet chewable)

gnp quick dissolve glucose (tablet chewable)

leader quick dissolve glucose (tablet chewable)

sm glucose (tablet chewable)

walgreens glucose (tablet chewable)

Dermatological Agents

Acne and Rosacea Agents

sodium sulfacetamide wash (liquid)

Dermatitis and Pruitus Agents

CORTIZONE-10 DIABETICS SKIN (LOTION)

CORTIZONE-10 ECZEMA (LOTION)

CORTIZONE-10 HYDRATENSIVEHEALING

(LOTION)

CORTIZONE-10 HYDRATENSIVESOOTHING

(LOTION)

Drug name

CORTIZONE-10 INTENSIVE HEALING

(CREAM)

CORTIZONE-10 PLUS (CREAM)

CORTIZONE-10/ALOE (CREAM)

gnp hydrocortisone (cream)

gnp hydrocortisone/aloe (cream)

hm hydrocortisone plus (cream)

hm hydrocortisone/aloe maximum strength

(cream)

hydrocortisone (cream)

hydrocortisone (ointment)

hydrocortisone/aloe (cream)

LAC-HYDRIN FIVE (LOTION)

px hydrocream (cream)

sm hydrocortisone plus (cream)

Dermatological Agents

capsaicin (cream)

capsaicin hp (cream)

CAPZASIN-HP (CREAM)

cvs capsaicin hp (cream)

Dermatological Agents, Other

advanced healing ointment/baby (ointment)

AQUA CARE (CREAM)

AQUA CARE (LOTION)

AQUAPHILIC (OINTMENT)

arthritis pain relieving (cream)

AVEENO BABY ECZEMA THERAPY

(PACKET)

AVEENO BABY SOOTHING

BATHTREATMENT (PACKET)

AVEENO SOOTHING BATH TREATMENT

(PACKET)

bp 10-1 (emulsion)

capsaicin (cream)

CLEAN & CLEAR ADVANTAGE ACNE

CONTROL 3-IN-1 FOAMING WASH (LIQUID)

CLEAN & CLEAR DEEP CLEANING

ASTRINGENT (LIQUID)

CLEARASIL DAILY CLEAN GENTLE

PREVENTION (LIQUID)

138

Drug name

corn and callus remover (liquid)

CVS ADVANCED HEALING OINTMENT

(OINTMENT)

daily face wash (liquid)

diaper rash (ointment)

diaper rash paste (paste)

DR SMITHS ADULT BARRIER (OINTMENT)

DR SMITHS DIAPER (OINTMENT)

dry skin treatment (ointment)

dry skin treatment advanced therapy (ointment)

DUOFILM (SOLUTION)

eql acne scrub pink grapefruit (liquid)

eql advanced healing ointment (ointment)

eql apricot scrub (liquid)

eql scalp relief maximum strength (liquid)

GETS-IT CORN AND CALLUS REMOVER

(LIQUID)

gnp wart remover (liquid)

GOLD BOND ULTIMATE HEALING

(OINTMENT)

gormel 10 (lotion)

gormel creme (cream)

hydrolatum (ointment)

LANAPHILIC (OINTMENT)

liquid corn & callus remover (liquid)

liquid wart remover (liquid)

natural oatmeal bath treatment (packet)

NUTRAPLUS (LOTION)

ointment base (ointment)

ra advanced healing (ointment)

ra renewal soothing bath treatment (packet)

ra wart remover ma ximum strength (liquid)

SARATOGA (OINTMENT)

SCALPICIN (LIQUID)

SELSUN BLUE 3-IN-1 TREATMENT (LIQUID)

sm oatmeal bath (packet)

sodium sulfacetamide/sulfur (cream)

sodium sulfacetamide/sulfur wash (liquid)

sss 10%-5% (cream)

SUMADAN WASH (LIQUID)

Drug name

urea (lotion)

urea 10 hydrating (cream)

UREA 10 HYDRATING (LOTION)

urea 20 intensive hydrating cream (cream)

ureacin-10 (lotion)

ureacin-20 (cream)

VANICREAM (OINTMENT)

wart remover maximum strength (liquid)

zinc oxide (ointment)

Pediculicides/Scabicides

eql lice killing maximum strength (shampoo)

gnp lice treatment (liquid)

gnp lice treatment (shampoo)

HM LICE KILLING MAXIMUM STRENGTH

(SHAMPOO)

HM LICE TREATMENT (LIQUID)

lice killing maximum strength (shampoo)

lice killing shampoo (shampoo)

lice treatment (lotion)

ra lice treatment (lotion)

sm lice killing maximum strength (shampoo)

sm lice treatment (lotion)

stop lice maximum strength (liquid)

topical anti-infectives

acne foaming wash (liquid)

acne maximum strength (cream)

acne medication 10 (gel)

acne medication 10 (lotion)

acne medication 5 (gel)

acne medication 5 (lotion)

acne treatment gel (gel)

benzoyl peroxide (gel)

BENZOYL PEROXIDE CLEANSER (LIQUID)

benzoyl peroxide wash (liquid)

CLEAN & CLEAR CONTINUOUS CONTROL

ACNE CLEANSER (CREAM)

CLEAN & CLEAR PERSA-GEL MAXIMUM

STRENGTH (GEL)

CLEARASIL DAILY CLEAR VANISHING ACNE

TREATMENT (CREAM)

139

Drug name

cvs acne (cream)

cvs acne control cleanser (cream)

GNP ACNE TREATMENT MAXIMUM

STRENGTH (CREAM)

PANOXYL CREAMY WASH (LIQUID)

PANOXYL FOAMING WASH (LIQUID)

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

ADVANCED CALCIUM/VITAMIN D/

MAGNESIUM (TABLET)

advantage care oral electrolyte pediatric

(solution)

bone density builder (tablet)

cal mag zinc +d3 (tablet)

CALCITRATE (TABLET)

calcium (tablet)

calcium + d3 (tablet)

calcium 1200 (tablet chewable)

calcium 500 + d (tablet)

calcium 500/d (tablet)

calcium 500/vitamin d (tablet)

calcium 500+d (tablet)

calcium 500+d high potency (tablet)

calcium 600 (tablet)

calcium 600 + d (tablet)

calcium 600 + minerals (tablet)

calcium 600 high potency (tablet)

calcium 600 with vitamin d (tablet)

calcium 600/vitamin d (tablet)

calcium 600/vitamin d3 (tablet)

calcium 600+d (tablet)

calcium 600+d high potency (tablet)

calcium 600+d plus minerals (tablet chewable)

calcium 600+d plus minerals (tablet)

calcium 600+d3 (tablet)

calcium 600+d3 plus minerals (tablet)

calcium carbonate (suspension)

calcium carbonate (tablet)

calcium citrate (tablet)

calcium citrate + (tablet)

Drug name

calcium citrate + d (tablet)

calcium citrate + d3 maximum (tablet)

calcium citrate +d (tablet)

calcium citrate plus (tablet)

calcium citrate plus magnesium & minerals

(tablet)

calcium citrate plus/magnesium (tablet)

calcium citrate/d3 (tablet)

calcium citrate/vitamin d (tablet)

calcium citrate/vitamin d3 (tablet)

calcium citrate+d3 (tablet)

calcium high potency (tablet)

calcium high potency + vitamin d (tablet)

calcium oyster shell (tablet)

calcium/magnesium/zinc (tablet)

calcium/vitamin d (tablet)

calcium/vitamin d/minerals (tablet chewable)

calcium/vitamin d3 (tablet)

cal-mag-zinc-d (tablet)

CALTRATE 600+D PLUS MINERALS

(TABLET)

CERALYTE 70 (SOLUTION)

CERASPORT (SOLUTION)

CERASPORT EX1 (SOLUTION)

chewable calcium (tablet chewable)

chewable calcium/d3 (wafer)

CITRACAL + D3 MAXIMUM (TABLET)

CITRACAL MAXIMUM PLUS (TABLET)

CITRACAL PLUS (TABLET)

cvs calcium 600 + d plus minerals (tablet)

CVS CALCIUM CITRATE+D3 (TABLET)

cvs calcium citrate+d3 w/magnesium (tablet)

cvs calcium/magnesium/zinc (tablet)

cvs electrolyte solution (solution)

cvs iron (tablet)

cvs magnesium (tablet)

cvs pediatric electrolyte (solution)

cvs pediatric electrolyte freezer pops (solution)

effer-k (tablet effervescent)

electrolyte solution (solution)

140

Drug name

ENFAMIL ENFALYTE (SOLUTION)

eq calcium citrate+d (tablet)

eql calcium citrate w/vitamin d (tablet)

eql calcium citrate/ vitamin d3 (tablet)

eql calcium soft chews (tablet chewable)

eql calcium/vitamin d (tablet)

eql iron supplement therapy (tablet)

eql natural zinc (tablet)

EZFE 200 (CAPSULE)

fe tabs (tablet dr)

ferate (tablet)

FER-IN-SOL (SOLUTION)

ferosul (tablet)

ferretts (tablet)

ferrex 150 (capsule)

ferrocite (tablet)

ferrous gluconate (tablet)

ferrous sulfate (elixir)

ferrous sulfate (solution)

ferrous sulfate (tablet dr)

ferrous sulfate (tablet)

gnp cal mag zinc +d3 (tablet)

gnp calcium (tablet)

gnp calcium citrate +d3 (tablet)

GNP CALCIUM PLUS 600 +D (TABLET)

gnp electrolyte solution (solution)

GNP PEDIATRIC ELECTROLYTE

(SOLUTION)

h-e-b oral electrolyte solution (solution)

HM CALCIUM/VITAMIN D (TABLET)

hm calcium/vitamin d/minerals (tablet)

HM PEDIATRIC ELECTROLYTE (SOLUTION)

iferex 150 forte (capsule)

iron (tablet)

iron high-potency (tablet)

iron supplement childrens (solution)

klor-con/ef (tablet effervescent)

kp calcium citrate+d (tablet)

kp calcium/magnesium/zinc (tablet)

Drug name

kp ferrous gluconate (tablet)

kp ferrous sulfate (tablet)

K-PHOS (TABLET)

K-PHOS NEUTRAL (TABLET)

magnesium (tablet)

magnesium glycinate (capsule)

magnesium oxide (tablet)

magnesium oxide 400 (tablet)

meijer ferrous sulfate (tablet)

mgo (tablet)

MULTI MEGA MINERALS (TABLET)

multisource calcium magnesium & d formula

(tablet)

NU-IRON 150 (CAPSULE)

oral electrolyte solutionfreezer pops pediatric

(solution)

ORALYTE (SOLUTION)

ORALYTE FREEZER POPS (SOLUTION)

OS-CAL CALCIUM + D3 (TABLET)

oysco 500+d (tablet)

oyster calcium (tablet)

oyster calcium/d3 (tablet)

oyster shell calcium (tablet)

oyster shell calcium + vitamin d (tablet)

oyster shell calcium 250+d (tablet)

oyster shell calcium 500 (tablet)

oyster shell calcium 500/d (tablet)

oyster shell calcium/d (tablet)

oyster shell calcium/d3 (tablet)

oyster shell calcium/vitamin d (tablet)

oyster shell calcium/vitamin d3 (tablet)

PEDIA VANCE (SOLUTION)

PEDIALYTE (SOLUTION)

PEDIALYTE FREEZER POPS (SOLUTION)

PEDIALYTE SINGLES (SOLUTION)

pediatric electrolyte (solution)

pediatric electrolyte freeze pops (solution)

pediatric electrolyte freezer pops (solution)

PHOSPHA 250 NEUTRAL (TABLET)

polysaccharide-iron complex (capsule)

141

Drug name

potassium citrate/citric acid (solution)

PROSTEON (TABLET)

px calcium&d (tablet)

qc calcium 500mg/d3 (tablet)

qc zinc (tablet)

ra calcium 600 (tablet)

ra calcium 600 plus vitamin d-3 & minerals

(tablet chewable)

ra calcium 600/vit d/minerals (tablet)

ra calcium citrate plus vitamin d (tablet)

ra calcium citrate plus vitamin d-3 (tablet)

ra calcium plus vitamin d (tablet)

ra calcium/minerals/vitamin d (tablet)

ra hi cal (tablet)

ra iron (tablet)

ra pediatric electrolyte (solution)

REHYDRALYTE (SOLUTION)

sb calcium + d (tablet)

sb oyster shell calcium (tablet)

sb pediatric electrolyte (solution)

sm calcium /vitamin d (tablet)

sm calcium 500/vitamin d3 (tablet)

sm calcium 600/vitamin d (tablet)

sm calcium citrate + d (tablet)

sm calcium citrate+ w/vitamin d (tablet)

sm calcium/magnesium/zinc (tablet)

sm calcium/vitamin d (tablet)

sm calcium/vitamin d3 (tablet)

sm iron (tablet)

sm magnesium (tablet)

sm oyster shell calcium/vitamin d (tablet)

sm pediatric electrolyte (solution)

sm zinc (tablet)

sodium citrate/citric acid (solution)

super calcium (tablet)

super calcium 600 + d3 (tablet)

super calcium 600+d3 400 (tablet)

THERACAL D2000 (TABLET)

THERACAL D4000 (TABLET)

Drug name

THERACAL RAPID REPLETION (TABLET)

VIRT-PHOS 250 NEUTRAL (TABLET)

zinc (tablet)

zinc chelated (tablet)

Electrolytes/Minerals/Metals/Vitamins

b-1 (tablet)

cvs b1 (tablet)

cvs b-1 (tablet)

qc vitamin b1 (tablet)

thiamine hcl (tablet)

thiamine hydrochloride (tablet)

vitamin b1 (tablet)

vitamin b-1 (tablet)

CALTRATE 600+D PLUS MINERALS

(TABLET)

Vitamins

50+ adult eye health (capsule)

a thru z advanced (tablet)

a thru z advanced adult formula (tablet)

a thru z high potency (tablet)

a thru z select (tablet)

a thru z select 50+ advanced formula (tablet)

a thru z select 50+ mens (tablet)

a thru z select advanced (tablet)

a thru z select ultimate womens (tablet)

a thru z ultimate mens (tablet)

a-10000 (capsule)

abc complete senior womens 50+ (tablet)

acerola c-500 (tablet chewable)

advanced diabetic multivitamin formula (tablet)

advanced eye health (capsule)

ALIVE DAILY SUPPORT PRENATAL

GUMMIES (TABLET CHEWABLE)

ALIVE ENERGY 50+ (TABLET)

alive gummies for children (tablet chewable)

ALIVE MENS ENERGY (TABLET)

alive multi-vitamin childrens chewable (tablet

chewable)

ALIVE ONCE DAILY WOMENS ULTRA

POTENCY (TABLET)

142

Drug name

ALIVE ULTRA POTENCY WOMENS 50+

(TABLET)

ALIVE WOMENS 50+ (TABLET)

ALIVE WOMENS ENERGY (TABLET)

ALPH-E (CAPSULE)

ALPH-E-MIXED (CAPSULE)

ALPH-E-MIXED 1000 (CAPSULE)

AMORYN MOOD BOOSTER (CAPSULE)

animal chews (tablet chewable)

ANIMAL SHAPES (TABLET CHEWABLE)

ANIMAL SHAPES/IRON (TABLET

CHEWABLE)

anti-oxidant (tablet)

antioxidant protection formula (tablet)

ascorbic acid (tablet)

ASCO-TABS-1000 (TABLET)

b complex (capsule)

b1 (tablet)

b-1 (tablet)

b12 (tablet er)

b-12 (tablet er)

b-12 tr (tablet er)

b-6 (tablet)

BACMIN (TABLET)

bariatric multivitamins/iron (capsule)

b-complex with b-12 (tablet)

BIO-35 GLUTEN-FREE (CAPSULE)

BIO-35 IRON FREE (CAPSULE)

bite-a-mins (tablet chewable)

bite-a-mins/iron (tablet chewable)

body/hair/skin/nails (capsule)

BURIED TREASURE ACTIVE 55PLUS

SENIOR COMPLEX (LIQUID)

c 1000 (tablet)

c 250 (tablet)

c 500 (tablet chewable)

c 500 (tablet)

c 500/rose hips (tablet)

c-1000 (tablet)

c-1000 prolonged release (tablet er)

Drug name

c-1000 sr (tablet er)

c-1000/rose hips (tablet)

c-1000/rose hips sr (tablet er)

c-1500/rose hips sr (tablet er)

c-250 (tablet chewable)

c-250 (tablet)

c-500 (tablet chewable)

c-500 (tablet)

c-500 prolonged release (tablet er)

c-500 sr (tablet er)

c-500/rose hips (tablet)

CAL-DAY 1000 (TABLET)

CELEBRATE MULTI-COMPLETE 18

(CAPSULE)

CELEBRATE MULTI-COMPLETE 45

(CAPSULE)

CELEBRATE MULTI-COMPLETE 60

(CAPSULE)

CELLULAR SECURITY (CAPSULE)

centravites (tablet)

centravites 50 plus (tablet)

CENTRUM KIDS (TABLET CHEWABLE)

cerovite jr (tablet chewable)

certa plus (tablet)

CERTAVITE SENIOR (TABLET)

chewable vitamin c (tablet chewable)

CHEW-C (TABLET CHEWABLE)

childrens animal shapes complete (tablet

chewable)

childrens chewable multivitamin (tablet

chewable)

childrens chewable multivitamin with iron

(tablet chewable)

childrens chewable vitamins (tablet chewable)

childrens gummies (tablet chewable)

companion (tablet)

complete multivitamin/multimineral

supplement (liquid)

coral calcium plus (capsule)

cvs b6 (tablet)

143

Drug name

cvs chewable c with rose hips (tablet

chewable)

cvs chewable childrens vitamin (tablet

chewable)

cvs childrens chewable complete (tablet

chewable)

cvs d3 (capsule)

cvs e (capsule)

cvs folic acid (tablet)

cvs gummy dinos (tablet chewable)

cvs gummy dinos childrens (tablet chewable)

cvs gummy multivitamin kids (tablet chewable)

cvs vitamin a (capsule)

cvs vitamin b12 tr (tablet er)

cvs vitamin b-12 tr (tablet er)

cvs vitamin c (tablet)

cvs vitamin c/rose hips (tablet)

cvs vitamin d3 (tablet chewable)

cvs vitamin e (capsule)

cyanocobalamin (solution)

d 1000 (capsule)

d 1000 (tablet chewable)

d 10000 (capsule)

d 5000 (capsule)

d-1000 (tablet)

d-1000 extra strength (tablet)

d2000 ultra strength (capsule)

d3 (capsule)

d3 (tablet chewable)

d3 (tablet)

d3 2000 (tablet)

d3 adult (tablet chewable)

d3 high potency (capsule)

d3 high potency (tablet)

d3 kids (tablet chewable)

d3 maximum strength (capsule)

d3 super strength (capsule)

d3 ultra strength (capsule)

d3-1000 (capsule)

d3-1000 (tablet)

Drug name

d-400 (tablet)

d-5000 (tablet)

daily betic (tablet)

daily mens health formula (tablet)

daily multiple vitamins (tablet)

daily multiple vitamins/minerals (tablet)

daily vitamin (tablet)

daily vitamin formula+ir on (tablet)

daily vitamin formula+iron (tablet)

daily vitamin formula+minerals (tablet)

daily vitamin plus (capsule)

daily vitamins (tablet)

daily womens health formula (tablet)

daily-vitamin (tablet)

daily-vitamin maximum formula (tablet)

daily-vitamin/iron (tablet)

daily-vite (tablet)

diabetes health formula (tablet)

DIALYVITE 800 (TABLET)

DIALYVITE VITAMIN D 5000 (CAPSULE)

DIALYVITE VITAMIN D3 MAX (TABLET)

DRISDOL (CAPSULE)

e 1000 (capsule)

e1000 (capsule)

e-1000 (capsule)

e200 (capsule)

e-200 (capsule)

e400 (capsule)

e-400 (capsule)

endur-acin (tablet er)

endur-c/rose hips (tablet er)

eql b-6 (tablet)

eql century (tablet)

eql century mature (tablet)

eql century mature adults50+ (tablet)

eql century mature men 50+ (tablet)

eql century mature women 50+ (tablet)

eql century mens (tablet)

eql century womens (tablet)

144

Drug name

eql childrens multivitamins/minerals (tablet

chewable)

eql gummies childrens (tablet chewable)

eql one daily mens (tablet)

eql one daily mens 50+ advanced (tablet)

eql one daily mens health formula (tablet)

eql one daily womens 50+ advanced (tablet)

eql prenatal formula (tablet)

eql vision formula (tablet)

eql vitamin b-12 tr (tablet er)

eql vitamin c (tablet)

eql vitamin c/rose hips (tablet)

eql vitamin d3 (capsule)

eql vitamin d3 gummies (tablet chewable)

eql vitamin e (capsule)

ESSENTIA (TABLET)

essential balance (tablet)

eye health (capsule)

EYE MULTIVITAMIN/LUTEIN (TABLET)

eye-vites (tablet)

FLINTSTONES COMPLETE (TABLET

CHEWABLE)

FLINTSTONES GUMMIES (TABLET

CHEWABLE)

FLINTSTONES GUMMIES COMPLETE

(TABLET CHEWABLE)

FLINTSTONES GUMMIES PLUS BONE

BUILDING SUPPORT (TABLET CHEWABLE)

FLINTSTONES GUMMIES PLUS IMMUNITY

SUPPORT/EXTRA C (TABLET CHEWABLE)

FLINTSTONES GUMMIES PLUS OMEGA-3

DHA (TABLET CHEWABLE)

FLINTSTONES PLUS CALCIUM (TABLET

CHEWABLE)

FLINTSTONES PLUS EXTRA C (TABLET

CHEWABLE)

FLINTSTONES SOUR GUMMIES (TABLET

CHEWABLE)

FLINTSTONES TODDLER/TASTISMOOTH

(TABLET CHEWABLE)

Drug name

FLINTSTONES W/IRON (TABLET

CHEWABLE)

FLINTSTONES/MY FIRST (TABLET

CHEWABLE)

folate (tablet)

folic acid (tablet)

fruity chews (tablet chewable)

fruity chews/iron (tablet chewable)

gerivite complete (tablet)

gnp childrens chewables/extra c (tablet

chewable)

gnp childrens chewables/iron (tablet

chewable)

gnp essential one daily (tablet)

gnp little ones childrens (tablet chewable)

GNP ONE DAILY PLUS IRON (TABLET)

gnp vitamin d-400 (tablet)

gummi bear multivitamin/mineral (tablet

chewable)

hair formula extra strength (tablet)

hair skin & nails advanced formula (tablet)

hair skin and nails formula (tablet)

hair vitamins (tablet)

hair/skin/nails (capsule)

hair/skin/nails (tablet)

healthy eyes (tablet)

healthy kids gummies (tablet chewable)

healthy kids overall hea lth multivitamins (tablet

chewable)

healthy kids vitamin d3 (tablet chewable)

high potency multivitamin (tablet)

hi-potency multi-vitamin/mineral supplement

(tablet)

hm complete men (tablet)

hm complete women (tablet)

HM MENS 50+ ADVANCED ONE DAILY

(TABLET)

HM ONE DAILY PRENATAL COMBO

(MISCELLANEOUS)

hm womens 50+ advanced one daily (tablet)

145

Drug name

kids first vitamin d3 gummies (tablet chewable)

kp folic acid (tablet)

kp niacin (tablet)

kp vitamin b-6 (tablet)

kp vitamin d (capsule)

kp vitamin d (tablet chewable)

kp vitamin d3 (capsule)

kp vitamin e (capsule)

land before time multivitamin/iron (tablet

chewable)

land before time multivitamin/vitamin c (tablet

chewable)

LIQUID C 500 (LIQUID)

little animals (tablet chewable)

little animals plus iron (tablet chewable)

lutein plus/zeaxanthin (tablet)

MEGA MULTI FOR MEN (TABLET)

mega multi for women (tablet)

megavite fruits & veggies (tablet)

megavite golden years 55+ (tablet)

meijer c (tablet)

mens 50+ advanced (capsule)

mens 50+ multi vitamin & mineral formula

(tablet)

mens daily formula/lycopene (capsule)

mens multi vitamin & mineral formula (tablet)

MEPHYTON (TABLET)

milltrium advanced formula with beta carotene

(tablet)

milltrium cardio (tablet)

milltrium senior (tablet)

multi complete (capsule)

multi complete/iron (tablet)

multi for her (capsule)

multi for her (tablet)

multi for her 50+ (capsule)

multi for her 50+ (tablet)

multi for him (capsule)

multi for him (tablet)

multi for him 50+ (tablet)

Drug name

multi prenatal (tablet)

multi vitamin (tablet)

multi vitamin daily (tablet)

multi vitamin with iron (tablet)

multi vitamin/d-3 (tablet)

multi-lean (tablet)

multiple vitamin (tablet)

multiple vitamins (tablet)

multiple vitamins essential (tablet)

multiple vitamins/iron (tablet)

multivitamin & mineral (liquid)

multivitamin (liquid)

multivitamin adults (tablet)

multivitamin adults 50+ (tablet)

multi-vitamin daily (tablet)

multivitamin gummies childrens (tablet

chewable)

multivitamin iron-free (tablet)

multivitamin men (tablet)

multivitamin men 50+ (tablet)

multivitamin women (tablet)

multivitamin women 50+ (tablet)

multivitamin/fluoride (tablet chewable)

multi-vitamin/menopausal formula (tablet)

multi-vitamins (tablet)

multi-vitamins/iron (tablet)

myamulti (tablet)

natural c/rose hips (tablet)

natural vitamin d-3 (tablet)

natural vitamin e (capsule)

NEPHRO-VITE (TABLET)

NEURO-K-250 VITAMIN B6 (TABLET)

NEURO-K-50 (TABLET)

niacin (tablet er)

niacin (tablet)

niacin er (tablet er)

niacin pr (tablet er)

niacin sr (capsule er)

niacin sr (tablet er)

146

Drug name

niacin time release (tablet er)

niacin timed release (tablet er)

niacin tr (capsule er)

niacin tr (tablet er)

NIACIN-50 (TABLET)

NOVAFERRUM PEDIATRIC MULTIVITAMIN

(LIQUID)

ocutabs (tablet)

ocutabs vision formula (tablet)

ocutabs/lutein (tablet)

OCUVITE EYE + MULTI (TABLET)

once daily (tablet)

ONE A DAY PRENATAL (TABLET

CHEWABLE)

ONE A DAY WOMENS PRENATAL/DHA

(MISCELLANEOUS)

ONE A DAY WOMENS PRENATAL1

(CAPSULE)

one daily 50 plus (tablet)

one daily adults 50+ (tablet)

one daily complete (tablet)

one daily complete for men (tablet)

ONE DAILY ESSENTIAL (TABLET)

one daily for men 50+ advanced (tablet)

one daily for men/lycopene (tablet)

one daily for women (tablet)

one daily for women 50+a dvanced (tablet)

one daily healthy weight (tablet)

one daily healthy weight advanced (tablet)

one daily maximum (tablet)

one daily mens (tablet)

one daily mens 50+ multivitamin (tablet)

one daily mens formula w/o iron (tablet)

one daily mens health/lycopene (tablet)

one daily multivitamin men (tablet)

one daily multivitamin mens 50+/lycopene

(tablet)

one daily multivitamin women (tablet)

one daily multivitamin/iron (tablet)

one daily multivitamin/iron-free (tablet)

Drug name

one daily womens (tablet)

one daily womens 50 plus (tablet)

one daily womens 50+ (tablet)

one daily/iron/calcium (tablet)

one daily/minerals (tablet)

ONE-A-DAY ENERGY (TABLET)

ONE-A-DAY ESSENTIAL (TABLET)

ONE-A-DAY MENOPAUSE FORMULA

(TABLET)

ONE-A-DAY MENS (TABLET)

ONE-A-DAY MENS 50+ (TABLET)

ONE-A-DAY MENS 50+ ADVANTAGE

(TABLET)

ONE-A-DAY MENS HEALTH FORMULA

(TABLET)

ONE-A-DAY MENS PRO EDGE (TABLET)

ONE-A-DAY PROACTIVE 65+ (TABLET)

ONE-A-DAY SCOOBY-DOO GUMMIES

(TABLET CHEWABLE)

ONE-A-DAY TEEN ADVANTAGE FOR HER

(TABLET)

ONE-A-DAY TEEN ADVANTAGE FOR HIM

(TABLET)

ONE-A-DAY VITACRAVES

GUMMIES+OMEGA-3 DHA (TABLET

CHEWABLE)

ONE-A-DAY WEIGHT SMART ADVANCED

(TABLET)

ONE-A-DAY WOMENS (TABLET)

ONE-A-DAY WOMENS 50+ ADVANTAGE

(TABLET)

ONE-A-DAY WOMENS 50+ HEALTHY

ADVANTAGE (TABLET)

ONE-A-DAY WOMENS ACTIVE MIND & BODY

(TABLET)

ONE-A-DAY WOMENS PETITES (TABLET)

ONE-A-DAY WOMENS PLUS HEALTHY SKIN

SUPPORT (TABLET)

ONE-A-DAY WOMENS PRENATAL

(MISCELLANEOUS)

147

Drug name

ONE-A-DAY/JOLLY RANCHER (TABLET

CHEWABLE)

optic-vites (tablet)

optic-vites with lutein (tablet)

OPTIMAL D3 (CAPSULE)

OPTIMAL D3 PACK (CAPSULE)

optimum pms (tablet)

phytonadione (tablet)

plain niacin (tablet)

poly-vitamin/iron drops (solution)

prenatal (tablet)

prenatal complete (tablet)

prenatal multi + dha (capsule)

prenatal multi +dha (capsule)

prenatal multivitamin (tablet)

PRENATAL MULTIVITAMIN + DHA

(MISCELLANEOUS)

prenatal multivitamin plus dha (capsule)

prenatal multivitamin plus dha (miscellaneous)

prenatal vitamin (tablet)

prenatal vitamins (tablet)

prenatal+dha (miscellaneous)

PRESERVISION AREDS 2 (CAPSULE)

PRESERVISION AREDS 2 + MULTI VITAMIN

(CAPSULE)

PRO-CAL (TABLET)

PROCERV HP (TABLET)

PRONUTRIENTS VITAMIN D3 (CAPSULE)

PRORENAL+D (TABLET)

PRORENAL+D/OMEGA-3 (CAPSULE)

PROTEGRA (CAPSULE)

pureway-c (tablet)

px advanced formula multivitamins/lycopene

(tablet)

px childrens vitamin (tablet chewable)

px complete senior multivitamins (tablet)

px folic acid (tablet)

px mens multivitamins (tablet)

px niacin (tablet)

px prenatal multivitamins (tablet)

Drug name

px vitamin a (capsule)

px vitamin c (tablet)

px vitamin e (capsule)

pyridoxine hcl (tablet)

pyridoxine hydrochloride (tablet)

qc c with rose hips (tablet)

qc folic acid (tablet)

qc hair skin & nails (tablet)

qc multi-vite (tablet)

QC OCUHEALTH VISION SUPPORT 2

(CAPSULE)

qc vitamin b12 (tablet er)

qc vitamin b6 (tablet)

qc vitamin c (tablet chewable)

qc vitamin c (tablet)

qc vitamin d3 (capsule)

qc vitamin d3 (tablet)

qc vitamin e (capsule)

QUFLORA PEDIATRIC (SOLUTION)

QUFLORA PEDIATRIC (TABLET CHEWABLE)

ra b-complex (tablet)

ra b-complex with b-12 (tablet)

RA CENTRAL-VITE (TABLET)

ra chewable vitamins complete childrens

(tablet chewable)

ra folic acid (tablet)

ra natural vitamin e (capsule)

ra niacin (tablet)

ra no flush niacin 500 (tablet)

ra one daily mens 50+ with vitamin d-3 (tablet)

ra vitamin a (capsule)

ra vitamin b-1 (tablet)

ra vitamin b-12 tr (tablet er)

ra vitamin b-6 (tablet)

ra vitamin c (tablet chewable)

ra vitamin c (tablet)

ra vitamin c tr (tablet er)

ra vitamin c/acerola (tablet chewable)

ra vitamin c/rose hips (tablet)

ra vitamin d-3 (capsule)

148

Drug name

ra vitamin d-3 (tablet)

ra vitamin e (capsule)

ra vitamin e natural (capsule)

radiance platinum vitamin d3 (tablet)

RENAL CAPS (CAPSULE)

renal-vite (tablet)

reno caps (capsule)

SAVISION (TABLET)

sb vitamin c (tablet)

sentry (tablet)

sentry senior (tablet)

SLO-NIACIN (TABLET ER)

sm animal shapes complete (tablet chewable)

sm animal shapes kids first (tablet chewable)

sm antioxidant vitamins (tablet)

sm chewable c (tablet chewable)

sm chewable vitamin c (tablet chewable)

sm complete (tablet)

sm complete 50+ (tablet)

sm complete 50+ ultimate mens (tablet)

sm complete 50+ ultimate womens (tablet)

sm folic acid (tablet)

sm hair/skin/nails (tablet)

sm multiple vitamins essential (tablet)

sm multiple vitamins/iron (tablet)

sm niacin cr (tablet er)

sm one daily mens (tablet)

sm one daily prenatal (miscellaneous)

sm one daily womens (tablet)

sm prenatal vitamins (tablet)

sm vit c/rose hips (tablet)

sm vitamin b1 (tablet)

sm vitamin b12 tr (tablet er)

sm vitamin b6 (tablet)

sm vitamin b-6 (tablet)

sm vitamin c (tablet chewable)

sm vitamin c (tablet)

sm vitamin c tr (tablet er)

sm vitamin c/rose hips (tablet)

Drug name

sm vitamin d (tablet)

sm vitamin d3 (capsule)

sm vitamin d3 (tablet)

sm vitamin d3 maximum strength (capsule)

sm vitamin e (capsule)

SMARTY PANTS KIDS COMPLETE AND

FIBER (TABLET CHEWABLE)

solo (tablet)

SPONGEBOB SQUAREPANTS GUMMIES

(TABLET CHEWABLE)

stress b complex/iron (tablet)

stress b-complex/antioxidants/zinc (tablet)

stress formula (tablet)

stress formula/iron (tablet)

stress formula/zinc (tablet)

STRESSTABS ADVANCED (TABLET)

STRESSTABS ENERGY (TABLET)

STROVITE FORTE (TABLET)

STROVITE ONE (TABLET)

sunkist vitamin c (tablet chewable)

super aytinal 50 plus (tablet)

super aytinal for active adults (tablet)

super multiple (capsule)

super multiple (tablet)

super vita-mins (tablet)

SYSTANE ICAPS AREDS2 (TABLET)

TAB-A-VITE (TABLET)

tab-a-vite w/beta carotene (tablet)

TAB-A-VITE/IRON (TABLET)

THERA (TABLET)

thera vital m (tablet)

thera vital-m (tablet)

THERABETIC MULTI-VITAMIN (TABLET)

THERA-D 2000 (TABLET)

THERA-D 4000 (TABLET)

THERA-D RAPID REPLETION (TABLET)

theradex "m" (tablet)

theradex "m"/beta carotene (tablet)

THERAGRAN-M (TABLET)

THERAGRAN-M ADVANCED (TABLET)

149

Drug name

THERAGRAN-M ADVANCED 50 PLUS

(TABLET)

THERAGRAN-M PREMIER (TABLET)

THERAGRAN-M PREMIER 50 PLUS

(TABLET)

thera-m (tablet)

thera-mill (tablet)

thera-mill m (tablet)

THERANATAL LACTATION ONE (CAPSULE)

THERANATAL ONE (CAPSULE)

therapeutic-m/lutein (tablet)

thrive for life womens (tablet)

triphrocaps (capsule)

ultra antioxidant formula (tablet)

ultra choice multivitamin kids (tablet chewable)

ULTRA PRENATAL + DHA (CAPSULE)

ultrachoice advanced formula (tablet)

ultrachoice advanced formula mature (tablet)

virt-caps (capsule)

vision vitamins (tablet)

visivites (tablet)

visivites/lutein (tablet)

vita hair (tablet)

vitabex plus (capsule)

VITAJOY DAILY D GUMMIES (TABLET

CHEWABLE)

vitamin a (capsule)

vitamin a (tablet)

vitamin b complex (tablet)

vitamin b1 (tablet)

vitamin b-1 (tablet)

vitamin b12 (tablet er)

vitamin b-12 cr (tablet er)

vitamin b12 tr (tablet er)

vitamin b-12 tr (tablet er)

vitamin b6 (tablet)

vitamin b-6 (tablet)

vitamin b-6 tr (tablet er)

vitamin b-complex (tablet)

vitamin c (tablet chewable)

Drug name

vitamin c (tablet)

vitamin c immune health (tablet chewable)

vitamin c plus bioflavonoids/wild rose hips

(tablet)

vitamin c plus wild rose hips (tablet chewable)

vitamin c tr (tablet er)

vitamin c/acerola (tablet chewable)

vitamin c/rose hips (tablet)

vitamin c/rose hips tr (tablet er)

vitamin d (capsule)

vitamin d (tablet)

vitamin d 400 (tablet chewable)

vitamin d high potency (capsule)

VITAMIN D-1000 (TABLET)

vitamin d-1000 maximum strength (tablet)

vitamin d3 (capsule)

vitamin d-3 (capsule)

vitamin d3 (tablet chewable)

vitamin d3 (tablet)

vitamin d-3 (tablet)

vitamin d3 400 (capsule)

vitamin d3 adult gummies (tablet chewable)

vitamin d3 complete (tablet)

vitamin d3 gummies (tablet chewable)

vitamin d3 gummies adult (tablet chewable)

vitamin d3 high potency (capsule)

vitamin d3 super strength (capsule)

vitamin d3 super strength (tablet)

vitamin d3 ultra strength (capsule)

vitamin e (capsule)

vitamin e (tablet chewable)

vitamin e blend (capsule)

vitamin e high potency (capsule)

vitamin e water soluble (capsule)

vitamin e/d-alpha (capsule)

vitamin e/d-alpha natural (capsule)

vitamin e/vitamin c/beta carotene (tablet)

VITAMIN E-200 (CAPSULE)

vitamin supplement e-1000 (capsule)

150

Drug name

vitamin supplement e-400 (capsule)

vitatrum (tablet)

vitatrum complete (tablet)

vitrum 50+ adult-multi iron free (tablet)

vitrum 50+ senior multi (tablet)

vitrum senior (tablet)

womens 50+ advanced (capsule)

womens 50+ multi vitamin & mineral formula

(tablet)

womens daily formula (tablet)

womens daily formula/folic acid/calcium/iron

(tablet)

womens multi (capsule)

womens multi vitamin & mineral formula (tablet)

zoo friends complete (tablet chewable)

ZOO FRIENDS MULTI GUMMIES (TABLET

CHEWABLE)

ZOO FRIENDS/EXTRA C (TABLET

CHEWABLE)

Gastrointestinal Agents

Anti-Constipation Agents

ALOPHEN (TABLET DR)

bisacodyl (suppository)

bisacodyl ec (tablet dr)

clearlax (powder)

COLACE (CAPSULE)

COLACE 2-IN-1 (TABLET)

COLACE CLEAR (CAPSULE)

CORRECTOL (TABLET DR)

CORRECTOL EXTRA GENTLE (CAPSULE)

docu (liquid)

docusate mini (enema)

docusate sodium (capsule)

DOCUSATE SODIUM (LIQUID)

docusate sodium extra strength (capsule)

docusate sodium/senna (tablet)

DOCUSIL (CAPSULE)

DOCUSOL MINI (ENEMA)

DOK (CAPSULE)

dss (capsule)

Drug name

DUCODYL (TABLET DR)

easy-lax (capsule)

easy-lax plus (tablet)

enema (enema)

enema disposable (enema)

enema mineral oil (enema)

enema mineral oil ready-to-use (enema)

enema ready-to-use (enema)

ENEMEEZ MINI (ENEMA)

eq enema (enema)

eql fiber therapy (powder)

eql fiber therapy (tablet)

eql laxative (tablet dr)

eql laxative maximum strength (tablet)

eql natural fiber (powder)

eql ready-to-use enema (enema)

eql senna laxative (tablet)

eql senna-s (tablet)

eql stool softener (capsule)

EVAC-U-GEN (TABLET)

FEENAMINT (TABLET DR)

fiber laxative (tablet)

fiber tabs (tablet)

fiber therapy (tablet)

fiber-lax (tablet)

FLEET BISACODYL (ENEMA)

FLEET ENEMA (ENEMA)

FLEET OIL (ENEMA)

FLEET PEDIATRIC (ENEMA)

gavilax (powder)

gentle laxative (suppository)

gentle laxative (tablet dr)

GLYCERIN (LIQUID)

glycerin adult (suppository)

glycerin children (suppository)

glycerin infants & children (suppository)

glycerin pediatric (suppository)

glycolax (powder)

GNP BISA-LAX (TABLET DR)

151

Drug name

gnp clearlax (powder)

GNP ENEMA (ENEMA)

GNP ENEMA MINERAL OIL LAXATIVE

(ENEMA)

gnp fiber therapy (tablet)

gnp fiber-caps (tablet)

gnp gentle laxative (suppository)

gnp gentle laxative (tablet dr)

gnp glycerin child (suppository)

GNP MAGNESIUM CITRATE (SOLUTION)

gnp milk of magnesia (suspension)

gnp mineral oil (oil)

gnp natural fiber (powder)

gnp senna lax (tablet)

gnp stool softener (capsule)

gnp stool softener/stimulant laxative (tablet)

gnp womens gentle laxative (tablet dr)

goodsense clearlax (powder)

GOODSENSE NATURAL FIBER (POWDER)

goodsense psyllium fiber (powder)

hm clearlax (powder)

hm enema mineral oil (enema)

hm enema saline laxative (enema)

hm fiber (powder)

hm fiber (tablet)

hm laxative (tablet dr)

hm milk of magnesia (suspension)

hm mineral oil (oil)

hm stool softener/stimulant laxative (tablet)

HYDROCIL INSTANT (POWDER)

konsyl daily fiber (powder)

magnesium citrate (solution)

METAMUCIL (CAPSULE)

METAMUCIL (PACKET)

METAMUCIL (POWDER)

METAMUCIL FIBER (PACKET)

METAMUCIL ORIGINAL TEXTURE

(POWDER)

METAMUCIL SMOOTH TEXTURE (POWDER)

Drug name

METAMUCIL SMOOTH TEXTURE SUGAR

FREE (POWDER)

milk of magnesia (suspension)

mineral oil (oil)

MIRALAX (POWDER)

natural fiber laxative (powder)

PEDIA-LAX (LIQUID)

PEDIA-LAX (SUPPOSITORY)

pediatric enema (enema)

peg3350 (powder)

PHILLIPS MILK OF MAGNESIA

(SUSPENSION)

PHILLIPS STOOL SOFTENER (CAPSULE)

polyethylene glycol 3350 (powder)

psyllium fiber (capsule)

px docusate sodium (capsule)

px fiber (capsule)

px fiber (tablet)

px laxative (tablet dr)

px milk of magnesia (suspension)

px vegetable laxative (tablet)

qc enema (enema)

qc gentle laxative (suppository)

qc magnesium citrate (solution)

qc milk of magnesia (suspension)

qc mineral oil heavy (oil)

QC NATURAL VEGETABLE LAXATIVE

(TABLET)

qc natura-lax (powder)

qc stool softener (capsule)

qc stool softener plus stimulant laxative (tablet)

ra col-rite (capsule)

ra laxative (tablet dr)

ra multihealth fiber supplement (powder)

reguloid (powder)

sb docusate sodium (capsule)

sb glycerin pediatric (suppository)

sb laxative (suppository)

sb magnesium citrate (solution)

sb polyethylene glycol 3 350 (powder)

152

Drug name

senexon (liquid)

senexon-s (tablet)

senna (liquid)

senna (syrup)

senna (tablet)

senna laxative (tablet)

senna plus (tablet)

senna-lax (tablet)

senna-s (tablet)

senna-tabs (tablet)

senna-time (tablet)

senna-time s (tablet)

SENNO (TABLET)

SENOKOT (TABLET)

SENOKOT S (TABLET)

silace (liquid)

SILACE (SYRUP)

sm clearlax (powder)

sm enema (enema)

sm fiber (powder)

sm fiber (tablet)

sm fiber laxative (tablet)

sm gentle laxative (tablet dr)

sm glycerin laxative pediatric (suppository)

SM LAXATIVE MAXIMUM STRENGTH

(TABLET)

sm magnesium citrate (solution)

sm milk of magnesia (suspension)

sm mineral oil (oil)

sm senna-s (tablet)

sm stool softener (capsule)

SM STOOL SOFTENER (TABLET)

smooth lax (powder)

soluble fiber (powder)

sorbitol (solution)

stimulant laxative (tablet)

stool softener (capsule)

stool softener (liquid)

stool softener plus laxative (tablet)

Drug name

SURFAK (CAPSULE)

vegetable laxative+stool softener (tablet)

VERACOLATE (TABLET DR)

Antispasmodics, Gastrointestinal

ANASPAZ (TABLET DISINTEGRATING)

ED-SPAZ (TABLET DISINTEGRATING)

hyoscyamine sulfate (elixir)

hyoscyamine sulfate (solution)

hyoscyamine sulfate (tab sublingual)

HYOSCYAMINE SULFATE (TABLET

DISINTEGRATING)

hyoscyamine sulfate (tablet)

LEVSIN/SL (TAB SUBLINGUAL)

Gastrointestinal Agents, Other

4x probiotic (tablet)

acid gone (suspension)

acid gone (tablet chewable)

acidophilus (capsule)

acidophilus (tablet)

acidophilus extra strength (capsule)

acidophilus probiotic (capsule)

acidophilus probiotic blend (tablet)

acidophilus/citrus pectin (tablet)

acidophilus/pectin (capsule)

ALIGN (TABLET CHEWABLE)

ALIGN JR FOR KIDS (TABLET CHEWABLE)

almacone double strength (suspension)

ALUMINUM/MAGNESIUM/SIMETHICONE

(SUSPENSION)

antacid & antigas (suspension)

antacid (suspension)

antacid + anti-gas liquid maximum strength

(suspension)

antacid anti-gas (suspension)

antacid anti-gas maximum strength

(suspension)

antacid calcium regular strength (tablet

chewable)

antacid extra strength (tablet chewable)

ANTACID FAST RELIEF (SUSPENSION)

153

Drug name

antacid flavor chews (tablet chewable)

antacid liquid (suspension)

antacid maximum (tablet chewable)

ANTACID PLUS ANTI-GAS FAST ACTING

(SUSPENSION)

antacid plus anti-gas relief (suspension)

antacid plus anti-gas relief maximum strength

(suspension)

antacid ultra strength (tablet chewable)

antacid/anti-gas (suspension)

anti-diarrheal (tablet)

BIOGAIA (TABLET CHEWABLE)

BIOGAIA GASTRUS (TABLET CHEWABLE)

BIOGAIA PROTECTIS BABY/VITAMIN D

(LIQUID)

biohm childrens probioticsupplement (tablet

chewable)

BIO-KULT INFANTIS (PACKET)

BISMATROL (SUSPENSION)

bismatrol (tablet chewable)

BISMATROL MAXIMUM STRENGTH

(SUSPENSION)

calcium antacid (tablet chewable)

calcium antacid extra strength (tablet

chewable)

calcium carbonate (tablet)

cal-gest antacid (tablet chewable)

childrens pepto (tablet chewable)

childrens probiotic (tablet chewable)

childrens soothe (tablet chewable)

comfort gel antacid anti-gas (suspension)

comfort gel antacid anti-gas maximum strength

(suspension)

comfort gel antacid& anti-gas (suspension)

CULTURELLE (CAPSULE)

CULTURELLE ADULT ULTIMATEBALANCE

(CAPSULE)

CULTURELLE BABY GROW THRIVE

(PACKET)

CULTURELLE DIGESTIVE HEALTH

(CAPSULE)

Drug name

CULTURELLE DIGESTIVE HEALTH

PROBIOTIC (CAPSULE)

CULTURELLE DIGESTIVE HEALTH WOMENS

HEALTHY BALANCE (CAPSULE)

CULTURELLE HEALTH & WELLNESS

(CAPSULE)

CULTURELLE IMMUNITY SUPPORT

FORMULA (CAPSULE)

CULTURELLE PROBIOTICS (TABLET

CHEWABLE)

CULTURELLE PROBIOTICS KIDS (TABLET

CHEWABLE)

CULTURELLE PRO-WELL (CAPSULE)

cvs acidophilus probioticformula (tablet)

cvs probiotic childrens (tablet chewable)

DIFF-STAT (PACKET)

digestive advantage probiotic gummies (tablet

chewable)

digestive health probiotic (capsule)

eql 2 in 1 probiotic (tablet)

eql 4x probiotic (tablet)

eql antacid (tablet chewable)

eql antacid ultra strength (tablet chewable)

eql digestive probiotic (capsule)

eql gas gone extra strength (tablet chewable)

eql gas relief (capsule)

eql probiotic acidophilus/pectin (capsule)

eql stomach relief (suspension)

FAST ACTING ANTACID PLUS ANTI-GAS

MAXIMUM STRENGTH (SUSPENSION)

FLORAJEN ACIDOPHILUS (CAPSULE)

FLORAJEN WOMEN (CAPSULE)

FLORASTOR (CAPSULE)

FLORASTOR BABY (PACKET)

FLORASTOR KIDS (PACKET)

GAS RELIEF (SUSPENSION)

GAS RELIEF (TABLET CHEWABLE)

gas relief extra strength (capsule)

gas relief extra strength (tablet chewable)

gas relief ultra strength (capsule)

154

Drug name

GERBER SOOTHE/VITAMIN D/PROBIOTIC

(LIQUID)

gnp antacid & anti-gas/regular strength

(suspension)

gnp antacid and anti-gas/maximum strength

(suspension)

gnp antacid anti-gas/maximum strength

(suspension)

gnp antacid extra strength (tablet chewable)

gnp antacid/regular strength (suspension)

gnp anti-diarrheal (tablet)

gnp anti-gas (capsule)

gnp gas relief (tablet chewable)

gnp gas relief extra strength (capsule)

gnp gas relief extra strength (tablet chewable)

gnp infant gas relief (suspension)

gnp pink bismuth (tablet chewable)

gnp pink bismuth (tablet)

gnp stomach relief (suspension)

GNP STOMACH RELIEF MAXIMUM

STRENGTH (SUSPENSION)

GOOD START GROW KIDS PROBIOTIC

(TABLET CHEWABLE)

goodsense antacid/regular strength (tablet

chewable)

goodsense gas relief extra strength (tablet

chewable)

goodsense stomach relief (tablet chewable)

HM ADVANCED ANTACID MAXIMUM

STRENGTH (SUSPENSION)

hm antacid (suspension)

hm antacid anti-gas extrastrength (suspension)

HM ANTACID/ANTIGAS (SUSPENSION)

hm anti-diarrheal (tablet)

HM CALCIUM ANTACID (TABLET

CHEWABLE)

hm calcium antacid extra strength (tablet

chewable)

hm gas relief (tablet chewable)

hm gas relief extra strength (capsule)

hm gas relief infants (suspension)

Drug name

hm probiotic digestive health (capsule)

HM STOMACH RELIEF (TABLET

CHEWABLE)

INFANTS GAS RELIEF (SUSPENSION)

infants simethicone (suspension)

KAOPECTATE (SUSPENSION)

KAOPECTATE (TABLET)

KAOPECTATE EXTRA STRENGTH

(SUSPENSION)

LACTINEX (PACKET)

lactobacillus extra strength (capsule)

loperamide hydrochloride (tablet)

mag-al plus (liquid)

mag-al plus xs (liquid)

magnesium oxide (tablet)

MI-ACID (SUSPENSION)

MI-ACID GAS RELIEF (TABLET CHEWABLE)

mintox maximum strength (suspension)

mintox plus (tablet chewable)

MYLANTA MAXIMUM STRENGTH

(SUSPENSION)

MYLICON INFANTS GAS RELIEF

(SUSPENSION)

MYLICON INFANTS GAS RELIEF DYE FREE

(SUSPENSION)

PEPTIC RELIEF (TABLET CHEWABLE)

PEPTO BISMOL (TABLET)

PEPTO-BISMOL (SUSPENSION)

PEPTO-BISMOL (TABLET CHEWABLE)

PEPTO-BISMOL MAX STRENGTH

(SUSPENSION)

PEPTO-BISMOL TO-GO (TABLET

CHEWABLE)

PHAZYME ULTRA STRENGTH (CAPSULE)

primadophilus (capsule)

probiotic (capsule)

probiotic acidophilus (capsule)

probiotic choclate bears childrens (tablet

chewable)

probiotic gold extra strength (capsule)

155

Drug name

probiotic gummies (tablet chewable)

probiotic packets childrens (packet)

probiotic/prebiotic (capsule)

PROBIOTIC-10 CHEWABLE (TABLET

CHEWABLE)

px antacid extra strength (tablet chewable)

px antacid maximum strength (suspension)

px antacid maximum strength (tablet

chewable)

px antacid regular strength (suspension)

px anti-diarrheal (tablet)

px calcium antacid regular strength (tablet

chewable)

px gas relief extra strength (capsule)

px gas relief infants (suspension)

px gas relief ultra strength (capsule)

px stomach relief (suspension)

px stomach relief (tablet chewable)

px stomach relief maximum strength

(suspension)

qc antacid (suspension)

qc antacid (tablet chewable)

qc antacid/anti-gas (suspension)

qc anti-diarrheal (tablet)

ra antacid (tablet chewable)

ra antacid ultra strength (tablet chewable)

ra digestive health (capsule)

ra probiotic gummies (tablet chewable)

RESTORE (PACKET)

sb antacid anti-gas (suspension)

SIMETHICONE (CAPSULE)

simethicone (tablet chewable)

simethicone extra strength (capsule)

sm 4x probiotic (tablet)

sm antacid advanced (suspension)

sm antacid advanced maxi mum strength

(suspension)

sm antacid/antigas (suspension)

sm anti-diarrheal (tablet)

Drug name

SM CALCIUM ANTACID (TABLET

CHEWABLE)

SM CALCIUM ANTACID EXTRA STRENGTH

(TABLET CHEWABLE)

sm gas relief (tablet chewable)

sm gas relief antiflatuent (capsule)

sm gas relief drops infants (suspension)

sm gas relief extra strength (capsule)

sm probiotic (capsule)

sm stomach relief (tablet chewable)

sm stomach relief (tablet)

SMARTY PANTS KIDS PROBIOTIC

COMPLETE (TABLET CHEWABLE)

sodium bicarbonate (tablet)

soothe (suspension)

triple probiotic (tablet)

UP4 PROBIOTICS (TABLET CHEWABLE)

UP4 PROBIOTICS KIDS CUBES (TABLET

CHEWABLE)

VSL#3 (PACKET)

VSL#3 DS (PACKET)

VSL#3 JUNIOR (PACKET)

Histamine2 (H2) Receptor Antagonists

acid reducer (tablet)

eql heartburn prevention (tablet)

gnp acid reducer (tablet)

heartburn relief (tablet)

hm famotidine (tablet)

PEPCID AC (TABLET)

px acid reducer (tablet)

qc acid controller (tablet)

sm acid reducer (tablet)

Proton Pump Inhibitors

acid reducer (capsule delayed release)

omeprazole magnesium (capsule delayed

release)

qc omeprazole magnesium (capsule delayed

release)

Genitourinary Agents

Genitourinary Agents, Other

156

Drug name

gnp urinary pain relief (tablet)

ra urinary pain relief (tablet)

sm urinary pain relief (tablet)

urinary pain relief (tablet)

VH ESSENTIALS UTI RELIEF MAXIMUM

STRENGTH (TABLET)

Hormonal Agents, Stimulant/Replacement/

Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/

Modifying (Pituitary)

OVIDREL (INJECTABLE)

Hormonal Agents, Stimulant/Replacement/

Modifying (Sex Hormones/Modifiers)

Progestins

econtra ez (tablet)

econtra one-step (tablet)

levonorgestrel (tablet)

my choice (tablet)

my way (tablet)

new day (tablet)

opcicon one-step (tablet)

option 2 (tablet)

PLAN B ONE-STEP (TABLET)

TAKE ACTION (TABLET)

Immunological Agents

Vaccines

VIVOTIF (CAPSULE DELAYED RELEASE)

Miscellaneous Therapeutic Agents

AIMSCO LUBRICATED (MISCELLANEOUS)

ASEPTO FEVER THERMOMETER ORAL

BULB (MISCELLANEOUS)

ASEPTO FEVER THERMOMETER SECURITY

BULB RECTAL (MISCELLANEOUS)

BD ASSURE IR THERMOMETER

(MISCELLANEOUS)

BD THERMOMETER ORAL CENTRIGRADE

(MISCELLANEOUS)

BD THERMOMETER RECTAL

CENTRIGRADE (MISCELLANEOUS)

Drug name

BD THERMOMETERS ASEPTO SECURITY

(MISCELLANEOUS)

BD THERMOMETERS ORAL-CARDED

(MISCELLANEOUS)

BD THERMOMETERS RECTAL

CENTRIGRADE (MISCELLANEOUS)

BD THERMOMETERS-ORL ASPT

(MISCELLANEOUS)

chewable acetaminophen childrens (tablet

chewable)

children's chewable acetaminophen (tablet

chewable)

childrens pain reliever (tablet chewable)

CLEVER CHOICE ULTRASONIC HUMIDIFIER

(MISCELLANEOUS)

COOL MIST HUMIDIFIER 1 GALLON

(MISCELLANEOUS)

COOL MIST HUMIDIFIER 2 GALLON

(MISCELLANEOUS)

COOL MIST HUMIDIFIER (MISCELLANEOUS)

COOL MIST HUMIDIFIER 0.8 GALLON

(MISCELLANEOUS)

COOL MIST HUMIDIFIER 1.2 GALLON

(MISCELLANEOUS)

COOL MIST HUMIDIFIER 1.3 GALLON

(MISCELLANEOUS)

CVS COOL MIST HUMIDIFIER

(MISCELLANEOUS)

CVS VAPORIZER 1 GALLON WARM STEAM

(MISCELLANEOUS)

DIGITAL THERMOMETER/TEMPLE TOUCH

MINI (MISCELLANEOUS)

DUREX EXTRA SENSITIVE (DEVICE)

EAR THERMOMETER (MISCELLANEOUS)

EVAPORATIVE HUMIDIFIER 1.5 GALLON

(MISCELLANEOUS)

EVAPORATIVE HUMIDIFIER 2 GALLON

(MISCELLANEOUS)

FANTASY LUBRICATED (MISCELLANEOUS)

FANTASY LUBRICATED/SPERMICIDE

(MISCELLANEOUS)

157

Drug name

FEVER STRIP FOREHEAD THERMOMETER

(MISCELLANEOUS)

gnp pain relief (tablet chewable)

gnp petroleum jelly (gel)

goodsense petroleum jelly (gel)

hm acetaminophen childrens (tablet chewable)

hm petroleum jelly (gel)

HOSPITAL HUMIDIFIER (MISCELLANEOUS)

HUMIDIFIER 1.25 GALLON

(MISCELLANEOUS)

HUMIDIFIER 2 GALLON (MISCELLANEOUS)

KAMELEON LUBRICATED

(MISCELLANEOUS)

KAZ HEALTHMIST HUMIDIFIER 1.2 GALLON

(MISCELLANEOUS)

KAZ HUMIDIFIER EVAPORATIVE 3000

(MISCELLANEOUS)

KAZ HUMIDIFIER EVAPORATIVE 3300

(MISCELLANEOUS)

KAZ HUMIDIFIER EVAPORATIVE 3400

(MISCELLANEOUS)

KAZ PERSONAL ULTRASONIC HUMIDIFIER

(MISCELLANEOUS)

KAZ VAPORIZER 1.0 GALLON

(MISCELLANEOUS)

KAZ VAPORIZER 2.2 GAL

(MISCELLANEOUS)

KAZ VICKS VAPORIZER V150

(MISCELLANEOUS)

KIMONO COLORS (DEVICE)

KIMONO LUBRICATED (MISCELLANEOUS)

KIMONO MICRO THIN (MISCELLANEOUS)

KIMONO MICRO THIN PLUS SPERMICIDE

LUBRICATED (MISCELLANEOUS)

KIMONO PLUS SPERMICIDE LUBRICATED

(MISCELLANEOUS)

KIMONO PLUS SPERMICIDE/LUBRICATED

(MISCELLANEOUS)

KIMONO PS LUBRICATED

(MISCELLANEOUS)

Drug name

KIMONO PS PLUS SPERMICIDE/

LUBRICATED (MISCELLANEOUS)

KIMONO SENSATION LUBRICATED

(MISCELLANEOUS)

KIMONO SENSATION PLUS SPERMICIDE

LUBRICATED (MISCELLANEOUS)

KIMONO SPECIAL (DEVICE)

mapap childrens (tablet chewable)

MAXX LUBRICATED (MISCELLANEOUS)

MAXX PLUS SPERMICIDE LUBRICATED

(MISCELLANEOUS)

OMNIFLEX DIAPHRAGM (DIAPHRAGM)

ORAL THERMOMETER (MISCELLANEOUS)

ORAL THERMOMETER/YELLOWLINE

(MISCELLANEOUS)

pain & fever childrens (tablet chewable)

PERSONAL ULTRASONIC HUMIDIFIER

(MISCELLANEOUS)

PERSONAL ULTRASONIC HUMIDIFIER/

COOL MIST (MISCELLANEOUS)

petrolatum (gel)

petrolatum white (gel)

petroleum jelly (gel)

PREMIUM CONDOMS LUBRICATED

(MISCELLANEOUS)

PURE COMFORT HUMIDIFIER

(MISCELLANEOUS)

PURELY PERSONAL ULTRASONIC

HUMIDIFIER (MISCELLANEOUS)

ra acetaminophen childrens (tablet chewable)

RA PETROLEUM JELLY (GEL)

REALITY LATEX CONDOMS/LUBRICATED

(MISCELLANEOUS)

REALITY LATEX/ULTRA TEXTURED

(DEVICE)

REALITY LATEX/ULTRA THIN (DEVICE)

RECTAL THERMOMETER

(MISCELLANEOUS)

SENTINEL THERMOMETER ORAL

(MISCELLANEOUS)

158

Drug name

SM HUMIDIFIER/COOL MIST

(MISCELLANEOUS)

sm petroleum jelly (gel)

TRUSTEX COLOR CONDOMS + LUBE

(MISCELLANEOUS)

TRUSTEX LUBRICATED (MISCELLANEOUS)

TRUSTEX LUBRICATED EXTRA LARGE

(MISCELLANEOUS)

TRUSTEX LUBRICATED EXTRA STRENGTH

(MISCELLANEOUS)

TRUSTEX LUBRICATED/RIBBED/STUDDED

(MISCELLANEOUS)

TRUSTEX LUBRICATED/SPERMICIDE

(MISCELLANEOUS)

TRUSTEX LUBRICATED/SPERMICIDE

EXTRA LARGE (MISCELLANEOUS)

TRUSTEX LUBRICATED/SPERMICIDE

EXTRA STRENGTH (MISCELLANEOUS)

TRUSTEX NATURAL CONDOMS +LUBE/

LUBRICATED (MISCELLANEOUS)

TRUSTEX NON-LUBRICATED

(MISCELLANEOUS)

TRUSTEX WITH NONOXYNOL-9/RIBBED/

STUDDED (MISCELLANEOUS)

TRUSTEX/RIA LUBRICATED

(MISCELLANEOUS)

TRUSTEX/RIA LUBRICATED SPERMICIDE

(MISCELLANEOUS)

TRUSTEX/RIA LUBRICATED/SPERMICIDE

(MISCELLANEOUS)

TRUSTEX/RIA NON-LUBRICATED

(MISCELLANEOUS)

ULTRASONIC COOL MIST HUMIDIFIER

(MISCELLANEOUS)

ULTRASONIC COOL MIST HUMIDIFIER 1.2

GALLON (MISCELLANEOUS)

ULTRASONIC HUMIDIFIER 1.5GALLON

(MISCELLANEOUS)

VAPORIZER 1 GALLON WARM STEAM

(MISCELLANEOUS)

VAPORIZER 1.2 GALLON

(MISCELLANEOUS)

Drug name

VAPORIZER 1.2 GALLON WARM STEAM

(MISCELLANEOUS)

VAPORIZER 1.7 GALLON

(MISCELLANEOUS)

VAPORIZER 3 GALLON (MISCELLANEOUS)

VASELINE (GEL)

VASELINE PURE ULTRA WHITEPETROLEUM

JELLY (GEL)

VICKS BABY THERMOMETER

(MISCELLANEOUS)

VICKS COOL MIST HUMIDIFIER

(MISCELLANEOUS)

VICKS COOL MIST HUMIDIFIER W/AIR-

FILTER/IDEAL FOR NURSERY

(MISCELLANEOUS)

VICKS GERMFREE COOL MOISTURE

HUMIDIFIER 1 GALLON (MISCELLANEOUS)

VICKS HUMIDIFIER 1.5 GALLON

(MISCELLANEOUS)

VICKS MINI FILTERFREE COOLMIST

HUMIDIFIER (MISCELLANEOUS)

VICKS NURSERY VAPORIZER 1GALLON

(MISCELLANEOUS)

VICKS THERMOMETER DISPOSABLE

(MISCELLANEOUS)

VICKS ULTRASONIC HUMIDIFIER

(MISCELLANEOUS)

VICKS VAPORIZER 1.9 GALLON

(MISCELLANEOUS)

VICKS VAPORIZER 2 GALLON

(MISCELLANEOUS)

VICKS WARM MIST HUMIDIFIER

(MISCELLANEOUS)

VICKS WARM MIST HUMIDIFIER 2 GALLON

(MISCELLANEOUS)

VICKS WATERLESS VAPORIZER

(MISCELLANEOUS)

VICKS WEARABLE THERMOMETER

(MISCELLANEOUS)

WARM MIST VAPORIZER

(MISCELLANEOUS)

white petrolatum (gel)

159

Drug name

WIDE-SEAL SILICONE DIAPHRAGM KIT 60

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 65

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 70

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 75

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 80

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 85

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 90

(DIAPHRAGM)

WIDE-SEAL SILICONE DIAPHRAGM KIT 95

(DIAPHRAGM)

Ophthalmic Agents

Ophthalmic Agents, Other

allergy eye drops (solution)

artificial tears (ointment)

artificial tears (solution)

atropine sulfate (ointment)

BION TEARS (SOLUTION)

cvs lubricant gel drops (gel)

eql eye drops ac (solution)

eye allergy relief (solution)

GENTEAL SEVERE (GEL)

GENTEAL SEVERE TEARS (GEL)

GENTEAL TEARS LIQUID DROPS

MODERATE (SOLUTION)

GENTEAL TEARS MILD (SOLUTION)

GENTEAL TEARS MODERATE PF

(SOLUTION)

GENTEAL TEARS NIGHT-TIME (OINTMENT)

gnp eye drops long lasting (solution)

gnp lubricating plus eye drops (solution)

goodsense lubricant eye drops (solution)

goodsense lubricating plus eye drops (solution)

hm lubricating plus (solution)

hm lubricating tears (solution)

just tears eye drops (solution)

Drug name

lubricant eye (ointment)

lubricant eye drops (solution)

lubricant eye fast acting (ointment)

lubricant eye nighttime (ointment)

lubricating eye drops (solution)

lubricating plus eye drops (solution)

lubrifresh p.m. (ointment)

MURO 128 (OINTMENT)

MURO 128 (SOLUTION)

NAPHCON-A (SOLUTION)

PURALUBE (OINTMENT)

ra lubricant eye drops (solution)

REFRESH LACRI-LUBE (OINTMENT)

REFRESH P.M. (OINTMENT)

REFRESH PLUS (SOLUTION)

REFRESH TEARS (SOLUTION)

relief drops (solution)

relief eye drops (solution)

RETAINE CMC (SOLUTION)

RETAINE HPMC (SOLUTION)

RETAINE PM (OINTMENT)

sm lubricant eye drops (solution)

sm lubricating plus (solution)

sm lubricating tears (solution)

sodium chloride (ointment)

sodium chloride (solution)

SOOTHE HYDRATION (SOLUTION)

SOOTHE NIGHTTIME DRY EYE THERAPY

(OINTMENT)

SOOTHE XP (SOLUTION)

SOOTHE XP/XTRA PROTECTION

(SOLUTION)

SYSTANE (SOLUTION)

SYSTANE COMPLETE (SOLUTION)

SYSTANE GEL (GEL)

SYSTANE HYDRATION PF (SOLUTION)

SYSTANE NIGHTTIME (OINTMENT)

SYSTANE PRESERVATIVE FREE

(SOLUTION)

SYSTANE ULTRA (SOLUTION)

160

Drug name

SYSTANE ULTRA PRESERVATIVE FREE

(SOLUTION)

Ophthalmic Anti-allergy Agents

eql advanced relief eye drops (solution)

eql eye drops (solution)

eql redness relief (solution)

eye drops (solution)

eye drops maximum relief (solution)

gnp eye drops (solution)

hm eye drops (solution)

hm eye drops advanced relief (solution)

px sterile eye drops (solution)

redness reliever eye drops (solution)

sm eye drops (solution)

Ophthalmic Anti-inflammatories

ALAWAY (SOLUTION)

ALAWAY CHILDRENS ALLERGY EYE ITCH

RELIEF (SOLUTION)

CLARITIN EYE (SOLUTION)

eye itch relief (solution)

ketotifen fumarate (solution)

ra eye itch relief (solution)

sm eye itch relief (solution)

ZADITOR (SOLUTION)

Otic Agents

DEBROX (SOLUTION)

ear drops (solution)

ear wax removal drops (solution)

ear wax removal kit (solution)

earwax removal (solution)

earwax removal kit (solution)

Respiratory Tract/Pulmonary Agents

Antihistamines

alertab (tablet)

ALKA-SELTZER PLUS ALLERGY FAST

RELIEF FORMULA (TABLET)

all day allergy (tablet)

ALL DAY ALLERGY D (TABLET ER 12HR)

all day allergy-d (tablet er 12hr)

Drug name

allergy & congestion relief (tablet er 12hr)

allergy childrens (liquid)

allergy childrens (syrup)

allergy relief (capsule)

allergy relief (tablet)

allergy relief childrens (liquid)

allergy relief d (tablet er 24hr)

allergy relief d-24 (tablet er 24hr)

allergy relief/nasal decongestant (tablet er

24hr)

allergy relief-d (tablet er 24hr)

banophen (capsule)

banophen (tablet)

BENADRYL ALLERGY (TABLET)

cetirizine hcl (tablet)

cetirizine hcl/pseudoephedrine hcl er (tablet er

12hr)

cetirizine hydrochloride (tablet)

CHILDRENS COLD & ALLERGY (ELIXIR)

childrens loratadine (solution)

childrens loratadine (syrup)

CHLOR-TRIMETON ALLERGY (TABLET ER)

CLARITIN (SYRUP)

CLARITIN (TABLET)

CLARITIN ALLERGY CHILDRENS (SYRUP)

CLARITIN REDITABS (TABLET

DISINTEGRATING)

CLARITIN-D 12 HOUR (TABLET ER 12HR)

CLARITIN-D 24 HOUR (TABLET ER 24HR)

complete allergy medicine (capsule)

complete allergy medicine (tablet)

diphenhist (capsule)

diphenhydramine hcl (capsule)

diphenhydramine hydrochloride (capsule)

diphenhydramine hydrochloride (liquid)

diphenhydramine hydrochloride (tablet)

ED A-HIST (LIQUID)

ed chlorped jr (syrup)

eql allergy (tablet)

gnp all day allergy (tablet)

161

Drug name

gnp all day allergy-d (tablet er 12hr)

gnp allergy & congestion relief (tablet er 24hr)

gnp allergy (tablet)

GNP ALLERGY ANTIHISTAMINECHILDRENS

(LIQUID)

gnp allergy relief (capsule)

gnp allergy relief (tablet chewable)

gnp childrens allergy (liquid)

gnp loratadine (syrup)

gnp loratadine (tablet disintegrating)

gnp loratadine (tablet)

gnp loratadine childrens (solution)

gnp sleep aid (tablet)

goodsense all day allergy (tablet)

goodsense allergy relief (tablet)

hm allergy complete-d (tablet er 12hr)

hm allergy relief & nasaldecongestant (tablet er

24hr)

hm allergy relief (capsule)

hm allergy relief (tablet)

HM ALLERGY RELIEF CHILDRENS (LIQUID)

hm cetirizine hydrochloride (tablet)

hm loratadine childrens (syrup)

HM SLEEP AID (TABLET)

LOHIST-D (LIQUID)

loratadine (tablet)

loratadine childrens (syrup)

loratadine-d 12hr (tablet er 12hr)

loratadine-d 24hr (tablet er 24hr)

nohist-lq (liquid)

PEDIACARE CHILDRENS ALLERGY (LIQUID)

pharbedryl (capsule)

px allergy (liquid)

px allergy (tablet)

px allergy relief (tablet disintegrating)

px allergy relief (tablet)

px allergy relief d (tablet er 12hr)

px allergy relief d (tablet er 24hr)

PX DAYHIST ALLERGY (TABLET)

px dibromm cold/allergy childrens (elixir)

Drug name

qc all day allergy (tablet)

qc loratadine-d (tablet er 24hr)

ra allergy relief & nasaldecongestant (tablet er

24hr)

ra allergy relief (tablet)

ra allergy relief 24 hour (tablet)

ra allergy/congestion relief (tablet er 12hr)

rynex pe (elixir)

rynex pse (liquid)

sb allergy relief (tablet disintegrating)

sb loratadine (tablet)

sb loratadine allergy relief (tablet)

siladryl allergy (liquid)

sleep aid (tablet)

sm all day allergy-d (tablet er 12hr)

sm allergy relief (liquid)

sm allergy relief (tablet)

SM COLD & ALLERGY CHILDRENS (ELIXIR)

sm loratadine (syrup)

sm loratadine (tablet)

sm lorata-dine d (tablet er 24hr)

sm loratadine d 12hr (tablet er 12hr)

SM SLEEP AID (TABLET)

sudogest sinus & allergy (tablet)

UNISOM SLEEPTABS (TABLET)

wal-dryl allergy (tablet)

wal-dryl allergy childrens (liquid)

wal-dryl allergy dye-freechildrens (liquid)

wal-itin (tablet disintegrating)

wal-itin (tablet)

wal-itin allergy relief reditabs (tablet

disintegrating)

wal-itin d (tablet er 12hr)

wal-itin d 24 hour (tablet er 24hr)

wal-som (tablet)

wal-zyr (tablet)

wal-zyr d (tablet er 12hr)

ZYRTEC ALLERGY (TABLET)

Anti-inflammatories, Inhaled

Corticosteroids

162

Drug name

allergy nasal spray 24 hour (aerosol)

gnp 24 hour nasal allerg y spray (aerosol)

goodsense nasal allergy spray (aerosol)

nasal allergy 24 hour (aerosol)

nasal allergy 24 hour multi-symptom (aerosol)

ra nasal allergy spray (aerosol)

triamcinolone acetonide (aerosol)

Mast Cell Stabilizers

cromolyn sodium (aerosol solution)

NASALCROM (AEROSOL SOLUTION)

Respiratory Tract Agents, Other

12 hour decongestant (tablet er 12hr)

12 hour nasal spray (solution)

AFRIN 12 HOUR (SOLUTION)

AFRIN ALL NIGHT NODRIP (SOLUTION)

AFRIN NASAL SPRAY (SOLUTION)

AFRIN NODRIP EXTRA MOISTURIZING

(SOLUTION)

AFRIN NODRIP ORIGINAL (SOLUTION)

AFRIN NODRIP SEVERE CONGESTION

(SOLUTION)

AFRIN NODRIP SINUS (SOLUTION)

AFRIN PUMP MIST (SOLUTION)

AFRIN SALINE NASAL MIST (SOLUTION)

anefrin nasal spray (solution)

anefrin nasal spray/no drip (solution)

aprodine (tablet)

AYR (SOLUTION)

AYR NASAL DROPS (SOLUTION)

BABY AYR SALINE (SOLUTION)

benzonatate (capsule)

bromphen/pseudoephedrine hcl/

dextromethorphan hbr (syrup)

bromphen/pseudoephedrine hcl/

dextromethorphan hydrobromide (syrup)

chest congestion relief (tablet)

childrens mucus relief cough (liquid)

codeine/guaifenesin (solution)

cold & cough childrens (liquid)

cold/cough childrens (liquid)

Drug name

cough & chest congestion dm (liquid)

COUGH & CHEST CONGESTION DM

(SYRUP)

cough & cold (tablet)

cough & cold hbp (tablet)

cough dm (susp extended release)

cough dm childrens (susp extended release)

cvs saline nasal spray (solution)

decongestant (tablet)

deep sea nasal spray (solution)

DELSYM (SUSP EXTENDED RELEASE)

DELSYM COUGH CHILDRENS (SUSP

EXTENDED RELEASE)

dextromethorphan polistirex (susp extended

release)

dimaphen dm cold & cough (liquid)

DURATION 12 HOUR (SOLUTION)

DURATION SPRAY (SOLUTION)

ed a-hist dm (liquid)

ed bron gp (liquid)

ENDACOF-DM (LIQUID)

eq saline nasal spray (solution)

eql nasal decongestant maximum strength

(tablet)

eql saline nasal spray (solution)

gnp cold & cough childrens (liquid)

gnp cough dm er (susp extended release)

gnp mucus er (tablet er 12hr)

gnp mucus relief dm max (liquid)

gnp nasal decongestant (tablet)

gnp nasal decongestant pe maximum strength

(tablet)

gnp nasal decongestant/maximum strength

(tablet)

gnp nasal spray (solution)

gnp nasal spray extra moisturizing (solution)

gnp nasal spray fast actiing (solution)

gnp no drip nasal spray (solution)

gnp pseudoephedrine hcl 12 hour (tablet er

12hr)

163

Drug name

gnp pseudoephedrine hcl er (tablet er 12hr)

gnp tab tussin (tablet)

gnp tussin cough long acting (syrup)

gnp tussin dm cough (liquid)

gnp tussin dm max (liquid)

gnp tussin mucus & chest congestion (liquid)

goodsense cough dm (susp extended release)

goodsense cough dm childrens (susp

extended release)

goodsense tussin cf (liquid)

goodsense tussin dm max (liquid)

guaiatussin ac (syrup)

guaifenesin (liquid)

guaifenesin (solution)

guaifenesin (tablet)

GUAIFENESIN ER (TABLET ER 12HR)

guaifenesin/codeine (solution)

GUAIFENESIN/DEXTROMETHORPHAN

(LIQUID)

guaifenesin/dextromethorphan hydrobromide

(syrup)

GUAIFENESIN/PSEUDOEPHEDRINE

HYDROCHLORIDE (TABLET ER 12HR)

guaifenesin-dm (syrup)

hm chest congestion relief (tablet)

hm cold & cough childrens (liquid)

hm cold & sinus relief (tablet)

hm cough dm (susp extended release)

HM MUCUS RELIEF D (TABLET ER 12HR)

hm nasal decongestant (tablet)

hm nasal decongestant 12 hour (tablet er

12hr)

hm nasal decongestant pe (tablet)

hm nasal spray (solution)

hm nose drops extra strength (solution)

hm sinus nasal spray (solution)

HM TUSSIN ADULT (LIQUID)

HM TUSSIN ADULT COUGH & CHEST

CONGESTION DM (LIQUID)

Drug name

hydrocodone bitartrate/homatropine

methylbromide (solution)

hydrocodone bitartrate/homatropine

methylbromide (tablet)

hydromet (solution)

ibuprofen cold & sinus (tablet)

m-clear wc (solution)

meijer saline nasal spray (solution)

MUCINEX (TABLET ER 12HR)

MUCINEX COUGH CHILDRENS (LIQUID)

MUCINEX D (TABLET ER 12HR)

MUCINEX D MAXIMUM STRENGTH (TABLET

ER 12HR)

MUCINEX DM (TABLET ER 12HR)

MUCINEX FAST-MAX DM MAX (LIQUID)

MUCINEX MAXIMUM STRENGTH (TABLET

ER 12HR)

mucosa (tablet)

mucus & chest congestion (liquid)

MUCUS & COUGH RELIEF CHILDRENS

(LIQUID)

mucus d (tablet er 12hr)

mucus relief (tablet er 12hr)

mucus relief (tablet)

mucus relief chest congestion (tablet)

mucus relief cough childrens (liquid)

mucus relief d (tablet er 12hr)

mucus relief dm (tablet er 12hr)

mucus relief dm maximum strength (liquid)

mucus relief er (tablet er 12hr)

mucus relief er 12 hour maximum strength

(tablet er 12hr)

nasal decongestant (tablet)

nasal decongestant maximum strength (tablet)

nasal decongestant pe (tablet)

nasal decongestant pe maximum strength

(tablet)

nasal decongestant spray (solution)

nasal four (solution)

NASAL MOIST (SOLUTION)

164

Drug name

nasal moisturizing spray (solution)

nasal relief (solution)

nasal spray 12 hour (solution)

nasal spray extra moisturizing 12 hour

(solution)

nasal spray no drip (solution)

NEO-SYNEPHRINE COLD+ALLERGY EXTRA

STRENGTH (SOLUTION)

no drip nasal spray (solution)

nohist-dm (liquid)

OCEAN FOR KIDS (SOLUTION)

OCEAN NASAL SPRAY (SOLUTION)

promethazine/codeine (solution)

promethazine/codeine (syrup)

promethazine/dextromethorphan (syrup)

promethazine/phenylephrine/codeine (syrup)

pseudoephedrine hcl (tablet)

pseudoephedrine hcl er (tablet er 12hr)

pseudoephedrine hydrochloride (tablet)

px dibromm dm cold/cough childrens (liquid)

px ibuprofen cold & sinus (tablet)

px nasal decongestant (tablet er 12hr)

px nasal decongestant (tablet)

px nasal decongestant pe (tablet)

px nasal four (solution)

px nasal spray extra moisturizing (solution)

px no drip nasal spray (solution)

px original nasal spray (solution)

px saline nasal spray (solution)

px tussin (solution)

px tussin cf (liquid)

px tussin dm (liquid)

px tussin max (syrup)

qc cough & cold hbp (tablet)

qc medifin 400 (tablet)

qc mucus relief (tablet er 12hr)

qc mucus relief er 12 hour maximum strength

(tablet er 12hr)

qc saline nasal relief (solution)

Drug name

qc suphedrine maximum strength (tablet er

12hr)

qc tussin cf (liquid)

qc tussin dm cough & chest congestion/adult

(liquid)

qc tussin mucus + chest congestion adult

(liquid)

QLEARQUIL (SOLUTION)

ra mucus relief (tablet er 12hr)

ra mucus relief d (tablet er 12hr)

ra mucus relief d maximumstrength (tablet er

12hr)

ra mucus relief dm (tablet er 12hr)

ra mucus relief maximum strength (tablet er

12hr)

ra saline nasal spray (solution)

robafen cf multi-symptom cold (liquid)

robafen dm cough (liquid)

ROBAFEN DM COUGH/CHEST

CONGESTION (LIQUID)

ROBAFEN DM PEAK COLD COUGH/CHEST

CONGESTION (LIQUID)

robafen mucus/chest congestion (liquid)

rynex dm (liquid)

saline mist (solution)

saline nasal spray (solution)

saline nasal spray infants/childrens (solution)

sb saline nose (solution)

scot-tussin dm (liquid)

scot-tussin expectorant (liquid)

siltussin dm das (liquid)

siltussin sa (syrup)

siltussin-dm (syrup)

sinus 12 hour (tablet er 12hr)

sinus nasal spray (solution)

sinus relief (solution)

sinus relief extra strength (solution)

sinus relief mist (solution)

sm 12 hour sinus decongestant (tablet er 12hr)

sm chest congestion relief (tablet)

165

Drug name

sm cold & cough dm childrens (liquid)

sm cold & sinus relief (tablet)

sm mucus relief (tablet er 12hr)

sm mucus relief cough childrens (liquid)

SM MUCUS RELIEF D (TABLET ER 12HR)

sm mucus relief maximum strength (tablet er

12hr)

sm mucus relief/12 hour (tablet er 12hr)

sm nasal decongestant maximum strength

(tablet)

sm nasal decongestant pe (tablet)

sm nasal spray (solution)

sm nasal spray 12 hour (solution)

sm nasal spray moisturizing (solution)

sm nasal spray saline (solution)

sm nasal spray sinus (solution)

sm nose drops nasal decongestant extra

strength (solution)

sm tussin cf (liquid)

sm tussin dm (syrup)

sm tussin dm cough/chest congestion (syrup)

sm tussin mucus + chest congestion adult

(liquid)

sodium chloride (solution)

soothing - 12 hour nasal decongestant

(solution)

sudogest (tablet)

sudogest 12 hour (tablet er 12hr)

sudogest maximum strength (tablet)

SUDOGEST PE (TABLET)

Drug name

suphedrine 12hour maximum strength (tablet

er 12hr)

TESSALON PERLES (CAPSULE)

tusnel diabetic (liquid)

tussin cf (liquid)

tussin cf multi-symptom cold (liquid)

tussin cough (syrup)

tussin dm (liquid)

tussin dm (syrup)

tussin dm cough + chest congestion (liquid)

tussin dm max (liquid)

TUSSIN DM MAX ADULT (LIQUID)

tussin dm maximum strength/adult (liquid)

tussin mucus & chest congestion adult (liquid)

tussin mucus + chest congestion (liquid)

tussin mucus + chest congestion (syrup)

tussin mucus + chest congestion adult (liquid)

tussin multi-symptom cold cf (liquid)

VICKS SINEX 12 HOUR DECONGESTANT

(SOLUTION)

VICKS SINEX MOISTURIZING (SOLUTION)

VICKS SINEX SEVERE (SOLUTION)

VICKS SINEX SEVERE NASAL

DECONGESTANT (SOLUTION)

VIRTUSSIN A/C (SOLUTION)

wal-phed d (tablet er 12hr)

wal-tussin chest congestion (liquid)

wal-tussin cough long acting (syrup)

wal-tussin dm cough & chest congestion

(liquid)

Tracked

166

track

D. Index of Covered Drugs

In this section, you can find a drug by searching for its name alphabetically. This will tell you the

page number where you can find additional coverage information for your drug.

Abacavir Sulfate..................... 44

Abacavir Sulfate-Lamivudine

...............................................44

Abelcet.................................... 29

Abilify Maintena...................... 40

Abiraterone Acetate............... 32

Acamprosate Calcium........... 17

Acarbose.................................47

Accutane................................. 62

Acebutolol HCl........................54

Acetaminophen-Caffeine-

Dihydrocodeine....................15

Acetaminophen-Codeine.......15

Acetazolamide........................ 56

Acetazolamide ER..................56

Acetic Acid..............................91

Acetylcysteine.........................94

Acitretin................................... 62

Actemra...................................81

Actemra ACTPen....................81

ActHIB..................................... 84

Actimmune..............................82

Acyclovir..................................43

Acyclovir Sodium....................43

Adacel..................................... 84

Adapalene...............................62

Adefovir Dipivoxil....................43

Adempas.................................93

Advair Diskus..........................94

Advair HFA..............................94

Aimovig................................... 31

Ala-Cort....................................62

Albendazole............................ 38

Albuterol Sulfate.....................92

Albuterol Sulfate HFA.............92

Alclometasone Dipropionate

...............................................62

Alcohol Prep Pads..................87

Alecensa..................................34

Alendronate Sodium.............. 87

Alfuzosin HCl ER.................... 72

Aliskiren Fumarate................. 56

Allopurinol...............................30

Alocril...................................... 88

Alomide................................... 88

Alosetron HCl..........................69

Alphagan P............................. 90

Alprazolam.............................. 46

Altavera................................... 74

Alunbrig...................................34

Alyacen 1/35...........................74

Alyq..........................................93

Amantadine HCl..................... 38

AmBisome...............................29

Ambrisentan............................93

Amethia................................... 74

Amikacin Sulfate.....................17

Amiloride HCl..........................57

Amiloride-Hydrochlorothiazide

...............................................56

Amiodarone HCl.....................54

Amitriptyline HCl.....................28

Amlodipine Besylate.............. 55

Amlodipine-Atorvastatin.........56

Amlodipine-Benazepril...........56

Amlodipine-Olmesartan......... 56

Amlodipine-Valsartan............. 56

Amlodipine-Valsartan-HCTZ

...............................................56

Ammonium Lactate................63

Amnesteem.............................62

Amoxapine..............................28

Amoxicillin...............................20

Amoxicillin-Potassium

Clavulanate...........................21

Amoxicillin-Potassium

Clavulanate ER.....................20

Amphetamine-

Dextroamphetamine............ 60

Amphetamine-

Dextroamphetamine ER...... 60

Amphotericin B.......................29

Ampicillin.................................21

Ampicillin Sodium.................. 21

Ampicillin-Sulbactam Sodium

...............................................21

Anagrelide HCl....................... 51

Anastrozole............................. 34

Androderm..............................73

Anoro Ellipta........................... 94

Anzemet.................................. 29

Tracked

167

Apomorphine HCl...................39

Apraclonidine HCl.................. 90

Aprepitant............................... 29

Apri.......................................... 74

Apriso...................................... 86

Aptiom.....................................25

Aptivus.....................................45

Aralast NP............................... 70

Aranelle................................... 74

Aranesp.............................51, 52

Arcalyst....................................81

Aripiprazole.............................40

Aripiprazole ODT....................40

Aristada................................... 40

Aristada Initio..........................40

Armodafinil..............................96

Arnuity Ellipta..........................91

Asenapine Maleate.................40

Ashlyna....................................74

Aspirin-Dipyridamole ER........53

Atazanavir Sulfate...................45

Atenolol................................... 54

Atenolol-Chlorthalidone......... 56

Atomoxetine HCl.................... 60

Atorvastatin Calcium.............. 58

Atovaquone.............................38

Atovaquone-Proguanil HCl.... 38

Atropine Sulfate......................88

Atrovent HFA.......................... 92

Aubagio...................................61

Aubra EQ.................................74

Auryxia.....................................68

Austedo...................................60

Auvelity....................................27

Aviane......................................74

Avonex Pen.............................61

Avonex Prefilled......................61

Ayvakit..................................... 34

Azathioprine............................82

Azelaic Acid............................ 62

Azelastine HCl.................. 88, 91

Azelastine-Fluticasone........... 91

Azithromycin........................... 22

Aztreonam...............................18

Bacitracin................................ 89

Bacitracin-Polymyxin B.......... 89

Baclofen.................................. 42

Balsalazide Disodium.............86

Balversa...................................34

Balziva..................................... 74

Baqsimi One Pack..................49

Baraclude................................43

BCG Vaccine.......................... 84

Belsomra................................. 95

Benazepril HCl........................53

Benazepril-Hydrochlorothiazide

...............................................56

Benlysta...................................81

Benznidazole.......................... 38

Benzoyl Peroxide-Erythromycin

...............................................62

Benztropine Mesylate............ 38

Bepotastine Besilate.............. 88

Bepreve................................... 88

Berinert....................................80

Besivance................................89

Besremi................................... 82

Betaine.................................... 71

Betamethasone Dipropionate

...............................................63

Betamethasone Dipropionate

Aug........................................63

Betamethasone Valerate....... 63

Betaseron................................61

Betaxolol HCl....................54, 90

Bethanechol Chloride............ 72

Betimol.................................... 90

Bevespi Aerosphere...............94

Bexarotene..............................37

Bexsero................................... 84

Bicalutamide...........................32

Bicillin C-R...............................21

Bicillin C-R 900/300............... 21

Bicillin L-A............................... 21

Biktarvy....................................44

Bisoprolol Fumarate...............54

Bisoprolol-Hydrochlorothiazide

...............................................56

BIVIGAM..................................80

Blisovi 24 Fe............................74

Blisovi Fe 1.5/30.....................74

Boostrix................................... 84

Bosentan................................. 93

Bosulif......................................34

Braftovi.................................... 34

Breo Ellipta..............................94

Breztri Aerosphere................. 94

Briellyn.....................................74

Brilinta..................................... 53

Brimonidine Tartrate.............. 90

Brimonidine Tartrate-Timolol

...............................................88

Tracked

168

Brinzolamide...........................90

BRIVIACT................................ 23

Bromocriptine Mesylate.........39

Brukinsa.................................. 34

Budesonide...................... 86, 91

Budesonide ER.......................86

Bumetanide.............................57

Buprenorphine........................14

Buprenorphine HCl................ 17

Buprenorphine HCl-Naloxone

HCl........................................ 17

Bupropion HCl........................27

Bupropion HCl SR........... 17, 27

Bupropion HCl XL.................. 27

Buspirone HCl........................ 46

Butalbital-Acetaminophen-

Caffeine.................................15

Butalbital-Aspirin-Caffeine..... 15

Butorphanol Tartrate..............15

Bydureon BCise..................... 47

Byetta 10MCG Pen.................47

Byetta 5MCG Pen...................47

Cabergoline............................ 79

Cablivi......................................53

Cabometyx..............................34

Calcipotriene...........................64

Calcitonin Salmon.................. 87

Calcitriol............................ 64, 87

Calcium Acetate..................... 68

Calquence...............................34

Camila..................................... 78

Camrese Lo.............................74

Candesartan Cilexetil............. 53

Candesartan Cilexetil-HCTZ

...............................................56

Caplyta.................................... 40

Caprelsa.................................. 34

Captopril..................................53

Carbamazepine...................... 25

Carbamazepine ER................ 25

Carbidopa............................... 39

Carbidopa-Levodopa............. 39

Carbidopa-Levodopa ER....... 39

Carbidopa-Levodopa ODT.... 39

Carbidopa-Levodopa-

Entacapone.......................... 38

Carglumic Acid.......................66

Carteolol HCl.......................... 90

Cartia XT..................................55

Carvedilol................................ 54

Cayston................................... 93

Cefaclor...................................19

Cefadroxil................................19

Cefazolin Sodium................... 19

Cefdinir....................................19

Cefepime HCl......................... 19

Cefixime.................................. 19

Cefotetan Disodium............... 19

Cefoxitin Sodium.................... 19

Cefpodoxime Proxetil.............19

Cefprozil............................19, 20

Ceftazidime.............................20

Ceftriaxone Sodium............... 20

Cefuroxime Axetil................... 20

Cefuroxime Sodium............... 20

Celecoxib................................ 14

Celontin................................... 24

Cephalexin.............................. 20

Cetirizine HCl.......................... 91

Chemet....................................68

Chenodal.................................69

Chlordiazepoxide HCl............ 47

Chlorhexidine Gluconate....... 62

Chloroquine Phosphate.........38

Chlorpromazine HCl...............39

Chlorthalidone........................ 58

Chlorzoxazone........................95

Cholbam..................................71

Cholestyramine.......................58

Cholestyramine Light............. 58

Ciclopirox................................ 65

Ciclopirox Olamine.................65

Cilostazol.................................53

Ciloxan.................................... 89

Cimduo....................................45

Cimetidine...............................70

Cimetidine HCl........................70

Cimzia......................................82

Cimzia Prefilled.......................82

Cinacalcet HCl........................87

Cinryze.................................... 80

Cipro HC................................. 91

Ciprofloxacin HCl............. 22, 89

Ciprofloxacin in D5W............. 22

Ciprofloxacin-Dexamethasone

...............................................91

Citalopram Hydrobromide.....27

Claravis....................................62

Clarithromycin........................ 22

Clarithromycin ER.................. 22

Clenpiq....................................69

Tracked

169

Climara Pro............................. 74

Clindacin ETZ......................... 65

Clindamycin HCl.....................18

Clindamycin Palmitate HCl....18

Clindamycin Phosphate........18,

Clindamycin Phosphate in D5W

...............................................18

Clindamycin Phosphate-

Benzoyl Peroxide................. 62

Clobazam................................ 25

Clobetasol Propionate........... 63

Clobetasol Propionate

Emollient Base..................... 63

Clodan.....................................63

Clomipramine HCl..................28

Clonazepam............................47

Clonazepam ODT...................47

Clonidine................................. 53

Clonidine HCl..........................53

Clonidine HCl ER....................60

Clopidogrel Bisulfate..............53

Clorazepate Dipotassium...... 47

Clotrimazole......................29, 65

Clotrimazole-Betamethasone

...............................................64

Clozapine................................ 42

Clozapine ODT....................... 42

Coartem.................................. 38

Codeine Sulfate......................15

Colchicine............................... 30

Colesevelam HCl.................... 58

Colestipol HCl...................58, 59

Colistimethate Sodium...........18

Combigan............................... 88

Combivent Respimat..............94

Cometriq................................. 35

Complera................................ 44

Compro................................... 29

Constulose..............................69

Copiktra...................................35

Cordran................................... 63

Corlanor.................................. 56

Cosentyx................................. 81

Cosentyx Sensoready............ 81

Cotellic.................................... 35

Creon.......................................71

Crinone....................................78

Cromolyn Sodium......71, 88, 93

Crotan......................................65

Cryselle-28.............................. 74

Cyclobenzaprine HCl............. 95

Cyclophosphamide................ 32

Cycloset.................................. 47

Cyclosporine...........................82

Cyclosporine Modified...........82

Cyproheptadine HCl.............. 91

Cyred EQ.................................74

Cystadane............................... 71

Cystagon................................. 71

Cystaran.................................. 88

Dalfampridine ER................... 61

Daliresp................................... 93

Dalvance..................................18

Danazol................................... 73

Dantrolene Sodium................ 43

Dapsone..................................32

Daptacel.................................. 84

Daptomycin.............................18

Daurismo.................................35

Deblitane................................. 78

Deferasirox..............................68

Deferasirox Granules............. 68

Deferiprone............................. 68

Delstrigo..................................44

Demeclocycline HCl...............23

Demser....................................56

Depo-Estradiol........................ 74

Descovy...................................45

Desipramine HCl.................... 28

Desloratadine..........................91

Desmopressin Acetate...........73

Desmopressin Acetate Spray

...............................................73

Desogestrel-Ethinyl Estradiol

...............................................74

Desonide.................................63

Desoximetasone.....................63

Desvenlafaxine Succinate ER

...............................................27

Dexamethasone......................72

Dexamethasone Sodium

Phosphate............................ 89

Dexilant................................... 70

Dexlansoprazole.....................70

Dexmethylphenidate HCl.......60

Dexmethylphenidate HCl ER

...............................................60

Dextroamphetamine Sulfate

...............................................60

Dextroamphetamine Sulfate ER

...............................................60

Dextrose.................................. 66

Tracked

170

Dextrose-NaCl.........................66

Diacomit.................................. 25

Diazepam..........................25, 47

Diazepam Intensol..................47

Diazoxide.................................49

Diclofenac Epolamine............14

Diclofenac Potassium............ 14

Diclofenac Sodium.... 14, 64, 89

Diclofenac Sodium ER...........14

Dicloxacillin Sodium...............21

Dicyclomine HCl.....................69

Dificid...................................... 22

Diflunisal..................................14

Digitek..................................... 56

Digoxin.................................... 56

Dihydroergotamine Mesylate

...............................................31

Dilantin.................................... 26

Dilantin INFATABS................. 25

Dilt-XR......................................55

Diltiazem HCl.......................... 55

Diltiazem HCl ER.................... 55

Diltiazem HCl ER Beads........ 55

Diltiazem HCl ER Coated

Beads....................................55

Dimethyl Fumarate................. 61

Dimethyl Fumarate Starter

Pack...................................... 61

Dipentum.................................86

Diphenoxylate-Atropine......... 69

Diphtheria-Tetanus Toxoids DT

...............................................84

Disulfiram................................ 17

Diuril........................................ 58

Divalproex Sodium................. 47

Divalproex Sodium ER........... 47

Dofetilide................................. 54

Dolishale..................................74

Donepezil HCl.........................26

Donepezil HCl ODT................26

Dorzolamide HCl.................... 90

Dorzolamide HCl-Timolol

Maleate................................. 88

Dorzolamide HCl-Timolol

Maleate Preservative Free...88

Dovato..................................... 44

Doxazosin Mesylate............... 53

Doxepin HCl..................... 28, 63

Doxercalciferol........................87

Doxy 100................................. 23

Doxycycline Hyclate............... 23

Doxycycline Monohydrate..... 23

Drizalma Sprinkle................... 61

Dronabinol.............................. 29

Drospirenone-Ethinyl Estradiol

...............................................74

Droxia...................................... 33

Droxidopa................................53

Duavee.................................... 74

Dulera...................................... 94

Duloxetine HCl........................61

Dupixent..................................81

Dutasteride..............................72

Dymista....................................91

Econazole Nitrate................... 65

Edarbi...................................... 53

Edarbyclor...............................56

Edurant....................................44

Efavirenz..................................44

Efavirenz-Emtricitabine-

Tenofovir...............................44

Efavirenz-Lamivudine-Tenofovir

...............................................44

Egrifta SV................................ 73

Elestrin.....................................74

Eliquis......................................51

Eliquis Starter Pack................ 51

Elmiron.................................... 72

EluRyng...................................74

Emcyt.......................................33

Emgality...................................31

Emoquette...............................74

Emsam.................................... 27

Emtricitabine...........................45

Emtricitabine-Tenofovir

Disoproxil Fumarate.............45

Emtriva.................................... 45

Enalapril Maleate....................53

Enalapril-Hydrochlorothiazide

...............................................57

Enbrel...................................... 83

Enbrel Mini..............................83

Enbrel SureClick.....................83

Endocet................................... 15

Engerix-B.................................84

Enoxaparin Sodium................51

Enpresse-28............................ 74

Enskyce...................................75

Entacapone.............................38

Entecavir................................. 43

Entresto................................... 57

Enulose....................................69

Envarsus XR............................83

Epclusa....................................43

Tracked

171

Epidiolex..................................23

Epinastine HCl........................ 89

Epinephrine.............................92

Epitol........................................26

Epivir HBV............................... 43

Eplerenone..............................57

Eprontia...................................23

Ergotamine-Caffeine.............. 31

Erivedge.................................. 35

Erleada.................................... 32

Erlotinib HCl............................35

Errin......................................... 78

Ertapenem Sodium................ 22

Ery............................................65

Erythrocin Lactobionate.........22

Erythromycin.............. 22, 65, 89

Erythromycin Base................. 22

Erythromycin Ethylsuccinate

...............................................22

Esbriet..................................... 94

Escitalopram Oxalate............. 27

Esomeprazole Magnesium....70

Estarylla...................................75

Estradiol.................................. 75

Estradiol Valerate................... 75

Estring..................................... 75

Eszopiclone.............................95

Ethacrynic Acid.......................57

Ethambutol HCl...................... 32

Ethosuximide....................24, 25

Ethynodiol Diacetate-Ethinyl

Estradiol................................75

Etodolac.................................. 14

Etodolac ER............................ 14

Etonogestrel-Ethinyl Estradiol

...............................................75

Etravirine................................. 44

Euthyrox.................................. 79

Everolimus........................ 35, 83

Evotaz......................................46

Exemestane............................ 34

Exkivity.....................................35

Ezetimibe................................ 59

Ezetimibe-Simvastatin............ 59

Falmina....................................75

Famciclovir..............................43

Famotidine.............................. 70

Fanapt..................................... 40

Fanapt Titration Pack.............40

Farxiga.....................................47

Fasenra....................................94

Fasenra Pen............................94

Febuxostat.............................. 30

Felbamate............................... 23

Felodipine ER......................... 55

Femring................................... 75

Femynor.................................. 75

Fenofibrate..............................58

Fenofibrate Micronized..........58

Fenofibric Acid....................... 58

Fentanyl...................................15

Fentanyl Citrate...................... 16

Ferriprox..................................68

Fetzima....................................27

Fetzima Titration.....................27

Finacea....................................62

Finasteride.............................. 72

Fingolimod HCl.......................61

Fintepla....................................23

Finzala..................................... 75

Firmagon................................. 79

Flac.......................................... 91

Flarex.......................................89

Flebogamma DIF.................... 80

Flecainide Acetate..................54

Flovent Diskus........................ 91

Flovent HFA............................ 91

Fluconazole.............................30

Fluconazole in Sodium

Chloride................................ 30

Flucytosine..............................30

Fludrocortisone Acetate........ 72

Flunisolide...............................91

Fluocinolone Acetonide...63, 91

Fluocinolone Acetonide Scalp

...............................................63

Fluocinonide........................... 63

Fluocinonide Emulsified Base

...............................................63

Fluorometholone.................... 89

Fluorouracil............................. 64

Fluoxetine HCl........................ 28

Fluphenazine Decanoate.......39

Fluphenazine HCl................... 39

Flurbiprofen............................ 14

Flurbiprofen Sodium.............. 89

Fluticasone Propionate...63, 64,

Fluticasone-Salmeterol.......... 95

Fluvastatin Sodium.................58

Fluvastatin Sodium ER...........58

Fluvoxamine Maleate............. 28

Tracked

172

FML Forte................................89

Fondaparinux Sodium............51

Formoterol Fumarate............. 92

Forteo...................................... 87

Fosamprenavir Calcium.........46

Fosinopril Sodium.................. 53

Fosinopril Sodium-HCTZ....... 57

Fotivda.....................................33

Furosemide.............................57

Fuzeon.....................................45

Fyavolv.....................................75

Fycompa........................... 23, 24

Gabapentin............................. 25

Galantamine Hydrobromide

...............................................26

Galantamine Hydrobromide ER

...............................................26

Gammagard............................80

Gammagard S/D Less IgA.... 80

Gammaked............................. 80

Gammaplex.............................81

Gamunex-C............................. 81

Gardasil 9................................84

Gatifloxacin............................. 89

Gattex...................................... 69

Gauze...................................... 87

GaviLyte-C...............................69

GaviLyte-G...............................69

Gavreto....................................35

Gemfibrozil..............................58

Gemtesa..................................71

Generlac..................................69

Gengraf................................... 83

Genotropin..............................73

Genotropin MiniQuick............73

Gentak.....................................89

Gentamicin Sulfate.... 18, 65, 89

Gentamicin Sulfate-0.9%

Sodium Chloride.................. 17

Genvoya.................................. 44

Gilenya.................................... 61

Gilotrif......................................35

Glassia.....................................71

Glatiramer Acetate................. 61

Glatopa....................................61

Gleostine................................. 32

Glimepiride..............................47

Glipizide.................................. 48

Glipizide ER............................ 47

Glipizide-Metformin HCl.........48

GlucaGen HypoKit..................49

Glucagon.................................49

Glycopyrrolate........................ 69

Glyxambi................................. 48

Granisetron HCl......................29

Griseofulvin Microsize............30

Griseofulvin Ultramicrosize....30

Guanfacine HCl ER................ 60

Gvoke HypoPen 2-Pack......... 49

Gvoke Kit.................................49

Gvoke PFS.............................. 49

Haegarda................................ 80

Hailey 24 Fe............................ 75

Halobetasol Propionate......... 64

Haloperidol............................. 40

Haloperidol Decanoate.......... 39

Haloperidol Lactate..........39, 40

Havrix.......................................84

Heparin Sodium......................51

Hetlioz......................................95

Hetlioz LQ................................95

Hiberix..................................... 84

Humalog........................... 49, 50

Humalog Junior KwikPen...... 49

Humalog KwikPen..................49

Humalog Mix 50/50............... 49

Humalog Mix 50/50 KwikPen

...............................................49

Humalog Mix 75/25............... 50

Humalog Mix 75/25 KwikPen

...............................................50

Humira.....................................83

Humira Pediatric Crohns Start

...............................................83

Humira Pen............................. 83

Humira Pen Crohns Disease

Starter................................... 83

Humira Pen Psoriasis Starter

...............................................83

Humira Pen-Pediatric UC Start

...............................................83

Humulin 70/30........................50

Humulin 70/30 KwikPen........50

Humulin N............................... 50

Humulin N KwikPen............... 50

Humulin R............................... 50

Humulin R U-500.................... 50

Humulin R U-500 KwikPen.... 50

Hydralazine HCl......................59

Hydrochlorothiazide...............58

Tracked

173

Hydrocodone-Acetaminophen

...............................................16

Hydrocodone-Ibuprofen.........16

Hydrocortisone.......... 64, 72, 87

Hydrocortisone Butyrate........64

Hydrocortisone Valerate........ 64

Hydrocortisone-Acetic Acid...91

Hydromorphone HCl..............16

Hydromorphone HCl ER........15

Hydromorphone HCl

Preservative Free................. 16

Hydroxychloroquine Sulfate

...............................................38

Hydroxyurea............................33

Hydroxyzine HCl..................... 46

Hydroxyzine Pamoate............ 46

Ibandronate Sodium.............. 87

Ibrance.................................... 35

Ibu............................................14

Ibuprofen.................................14

Icatibant Acetate.....................80

Iclevia.......................................75

Iclusig...................................... 35

Icosapent Ethyl....................... 59

IDHIFA..................................... 33

Ilevro........................................ 89

Imatinib Mesylate................... 35

Imbruvica.................................35

Imipenem-Cilastatin................22

Imipramine HCl.......................28

Imipramine Pamoate..............28

Imiquimod............................... 65

Imiquimod Pump....................65

Imovax Rabies........................ 85

Impavido..................................38

Imvexxy Maintenance Pack... 75

Imvexxy Starter Pack..............75

Incassia................................... 78

Increlex....................................73

Incruse Ellipta......................... 92

Indapamide.............................58

Indomethacin..........................14

Infanrix.....................................85

Ingrezza...................................60

Inlyta........................................ 35

Inqovi.......................................35

Inrebic......................................35

Insulin Lispro.......................... 50

Insulin Lispro Junior KwikPen

...............................................50

Insulin Lispro Prot & Lispro... 50

Insulin Syringes, Needles...... 87

Intelence..................................44

Intralipid.................................. 66

Introvale...................................75

Invega Hafyera........................40

Invega Sustenna.....................41

Invega Trinza...........................41

IPOL.........................................85

Ipratropium Bromide..............92

Ipratropium-Albuterol............. 95

Irbesartan................................ 53

Irbesartan-Hydrochlorothiazide

...............................................57

Iressa....................................... 35

Isentress..................................44

Isentress HD........................... 44

Isibloom...................................75

Isolyte-P in D5W......................66

Isolyte-S pH 7.4.......................66

Isoniazid.................................. 32

Isosorbide Dinitrate................ 59

Isosorbide Dinitrate-

Hydralazine...........................57

Isosorbide Mononitrate..........59

Isosorbide Mononitrate ER....59

Isotretinoin.............................. 62

Isturisa..................................... 79

Itraconazole............................ 30

Ivermectin................................38

Ixiaro........................................ 85

Jakafi....................................... 35

Jantoven..................................51

Janumet.................................. 48

Janumet XR............................ 48

Januvia.................................... 48

Jardiance.................................48

Jasmiel.................................... 75

Jentadueto.............................. 48

Jentadueto XR........................ 48

Jinteli....................................... 75

Jublia....................................... 65

Juleber.....................................75

Juluca...................................... 44

Junel 1.5/30............................75

Junel 1/20............................... 75

Junel Fe 1.5/30.......................75

Junel Fe 1/20..........................75

Junel Fe 24..............................75

Juxtapid...................................59

Jynneos................................... 85

Tracked

174

Kaitlib Fe................................. 75

Kalydeco................................. 93

Kariva.......................................75

KCl in Dextrose-NaCl..............66

KCl-Lactated Ringers-D5W....66

Kelnor 1/35............................. 75

Kelnor 1/50............................. 75

Kerendia..................................57

Ketoconazole....................30, 65

Ketoprofen.............................. 14

Ketorolac Tromethamine....... 90

Kineret..................................... 81

Kinrix........................................85

Kisqali......................................35

Kisqali Femara........................ 35

Klor-Con.................................. 66

Klor-Con 10............................. 66

Klor-Con 8............................... 67

Klor-Con M10..........................66

Klor-Con M15..........................66

Klor-Con M20..........................66

Korlym..................................... 73

Koselugo................................. 35

Kurvelo.................................... 76

Kynmobi.................................. 39

Labetalol HCl.......................... 54

Lacosamide............................ 26

Lacrisert.................................. 88

Lactulose.................................69

Lamivudine....................... 43, 45

Lamivudine-Zidovudine..........45

Lamotrigine.............................24

Lanoxin....................................57

Lansoprazole.......................... 70

Lanthanum Carbonate........... 68

Lantus......................................50

Lantus SoloStar...................... 50

Lapatinib Ditosylate................36

LARIN 1.5/30..........................76

LARIN 1/20............................. 76

LARIN Fe 1.5/30.....................76

LARIN Fe 1/20........................76

Latanoprost.............................90

Latuda..................................... 41

Layolis Fe................................ 76

Leena.......................................76

Leflunomide............................83

Lenalidomide.......................... 33

Lenvima 10MG Daily Dose.... 36

Lenvima 12MG Daily Dose.... 36

Lenvima 14MG Daily Dose.... 36

Lenvima 18MG Daily Dose.... 36

Lenvima 20MG Daily Dose.... 36

Lenvima 24MG Daily Dose.... 36

Lenvima 4MG Daily Dose...... 36

Lenvima 8MG Daily Dose...... 36

Lessina.................................... 76

Letrozole................................. 34

Leucovorin Calcium............... 37

Leukeran................................. 32

Leukine....................................52

Leuprolide Acetate.................79

Levalbuterol HCl.....................92

Levalbuterol Tartrate..............92

Levemir....................................50

Levemir FlexTouch.................50

Levetiracetam......................... 24

Levetiracetam ER................... 24

Levo-T......................................79

Levobunolol HCl.....................90

Levocarnitine.......................... 71

Levocetirizine Dihydrochloride

...............................................91

Levofloxacin............... 22, 23, 89

Levofloxacin in D5W.............. 22

Levonest..................................76

Levonorgestrel-Ethinyl Estradiol

...............................................76

Levonorgestrel-Ethinyl Estradiol

& Ethinyl Estradiol................ 76

Levonorgestrel-Ethinyl Estradiol

91-Day................................... 76

Levora 0.15/30....................... 76

Levorphanol Tartrate..............15

Levothyroxine Sodium........... 79

Levoxyl.................................... 79

Lexiva...................................... 46

Lidocaine.................................17

Lidocaine HCl......................... 17

Lidocaine Viscous.................. 17

Lidocaine-Prilocaine...............17

Linezolid..................................18

Linzess.................................... 69

Liothyronine Sodium..............79

Lisinopril..................................53

Lisinopril-Hydrochlorothiazide

...............................................57

Lithium Carbonate..................47

Lithium Carbonate ER............47

Lithostat...................................72

Livalo....................................... 58

Tracked

175

Lokelma...................................68

Lonhala Magnair.....................92

Lonsurf.................................... 33

Loperamide HCl..................... 69

Lopinavir-Ritonavir..................46

Lorazepam.............................. 47

Lorazepam Intensol................47

Lorbrena..................................36

Loryna......................................76

Losartan Potassium................53

Losartan Potassium-HCTZ.....57

Lotemax.................................. 90

Lotemax SM............................90

Loteprednol Etabonate.......... 90

Lovastatin................................58

Low-Ogestrel...........................76

Loxapine Succinate................40

Lubiprostone...........................69

Lumakras................................ 33

Lumigan.................................. 91

Lupron Depot..........................79

Lutera...................................... 76

Lybalvi..................................... 41

Lyleq........................................ 78

Lynparza..................................36

Lysodren................................. 79

Lyumjev................................... 50

Lyumjev KwikPen................... 50

Lyza......................................... 78

M-M-R II................................... 85

Magnesium Sulfate................ 67

Malathion................................ 65

Maraviroc................................ 45

Marlissa................................... 76

Marplan................................... 27

Matulane................................. 32

Matzim LA............................... 55

Mavyret....................................43

Mayzent...................................61

Mayzent Starter Pack............. 61

Meclizine HCl..........................29

Medroxyprogesterone Acetate

...............................................78

Mefloquine HCl.......................38

Megestrol Acetate.................. 78

Mekinist...................................36

Mektovi....................................36

Meloxicam...............................14

Memantine HCl.......................27

Memantine HCl ER.................27

Memantine HCl Titration Pak

...............................................27

Menactra................................. 85

Menest.....................................76

MenQuadfi.............................. 85

Menveo....................................85

Mercaptopurine...................... 33

Meropenem............................ 22

Mesalamine.............................86

Mesalamine ER.......................86

Mesnex....................................37

Metformin HCl........................ 48

Metformin HCl ER.................. 48

Methadone HCl...................... 15

Methazolamide....................... 90

Methenamine Hippurate........18

Methimazole........................... 80

Methocarbamol...................... 95

Methotrexate Sodium.............83

Methoxsalen Rapid................ 65

Methscopolamine Bromide... 69

Methylphenidate HCl............. 60

Methylphenidate HCl ER....... 60

Methylprednisolone............... 72

Metoclopramide HCl..............29

Metolazone............................. 58

Metoprolol Succinate ER.......54

Metoprolol Tartrate.................54

Metoprolol-Hydrochlorothiazide

...............................................57

Metronidazole.........................18

Metyrosine.............................. 57

Mexiletine HCl.........................54

Micafungin Sodium................ 30

Miconazole 3...........................30

Microgestin 1.5/30.................76

Microgestin 1/20.................... 76

Microgestin 24 Fe...................76

Microgestin Fe 1.5/30............76

Microgestin Fe 1/20...............76

Midodrine HCl.........................53

Migergot..................................31

Miglitol.....................................48

Miglustat..................................71

Mili........................................... 76

Minocycline HCl..................... 23

Minoxidil..................................59

Mirtazapine............................. 27

Mirtazapine ODT.................... 27

Mirvaso....................................62

Misoprostol............................. 70

Tracked

176

Modafinil................................. 96

Moexipril HCl.......................... 53

Molindone HCl........................40

Mometasone Furoate.......64, 91

Montelukast Sodium.............. 92

Morphine Sulfate.................... 16

Morphine Sulfate ER.............. 15

Motegrity................................. 69

Mounjaro................................. 48

Movantik..................................69

Moxifloxacin HCl.............. 23, 89

Moxifloxacin HCl in NaCl....... 23

Multaq..................................... 54

Mupirocin................................ 66

Mupirocin Calcium................. 66

Myalept....................................69

Mycophenolate Mofetil.......... 83

Mycophenolate Sodium.........83

Myorisan..................................62

Myrbetriq...........................71, 72

Nabumetone........................... 14

Nadolol.................................... 54

Nafcillin Sodium..................... 21

Naftifine HCl............................66

Naftin....................................... 66

Naloxone HCl..........................17

Naltrexone HCl....................... 17

Namzaric................................. 26

Naproxen.................................14

Naproxen DR.......................... 14

Naratriptan HCl.......................31

Narcan.....................................17

Natacyn................................... 89

Nateglinide..............................48

Natpara....................................87

Nayzilam..................................25

Nebivolol HCl..........................54

Necon 0.5/35..........................76

Nefazodone HCl..................... 28

Neomycin Sulfate................... 18

Neomycin-Bacitracin-Polymyxin

...............................................89

Neomycin-Polymyxin-

Bacitracin-Hydrocortisone...88

Neomycin-Polymyxin-

Dexamethasone................... 88

Neomycin-Polymyxin-

Gramicidin............................ 89

Neomycin-Polymyxin-HC...... 88,

Nerlynx.................................... 36

Neuac...................................... 62

Neulasta.................................. 52

Neupro.................................... 39

Nevirapine...............................44

Nevirapine ER.........................44

Niacin...................................... 59

Niacin ER................................ 59

Niacor...................................... 59

Nicardipine HCl...................... 55

Nicotrol....................................17

Nicotrol NS..............................17

Nifedipine ER..........................55

Nifedipine ER Osmotic Release

...............................................55

Nikki.........................................76

Nilutamide...............................32

Nimodipine..............................55

Ninlaro..................................... 33

Nitazoxanide........................... 38

Nitisinone................................ 71

Nitro-Bid.................................. 59

Nitrofurantoin..........................19

Nitrofurantoin Macrocrystal...19

Nitrofurantoin Monohydrate

...............................................19

Nitroglycerin............................59

Nitrostat...................................60

Nizatidine................................ 70

Nora-BE................................... 79

Norethindrone.........................79

Norethindrone Acetate.......... 79

Norethindrone Acetate-Ethinyl

Estradiol................................76

Norethindrone Acetate-Ethinyl

Estradiol-Fe.................... 76, 77

Norethindrone-Ethinyl Estradiol-

Fe...........................................77

Norgestimate-Ethinyl Estradiol

...............................................77

Norgestimate-Ethinyl Estradiol

Triphasic............................... 77

Nortrel 0.5/35......................... 77

Nortrel 1/35.............................77

Nortrel 7/7/7...........................77

Nortriptyline HCl..................... 29

Norvir....................................... 46

Noxafil..................................... 30

Nubeqa....................................32

Nucala..................................... 95

Nuedexta.................................60

Nuplazid.................................. 41

Nurtec ODT.............................31

Tracked

177

Nutrilipid..................................67

Nyamyc................................... 66

Nylia 1/35................................77

Nylia 7/7/7.............................. 77

Nymalize..................................55

Nymyo..................................... 77

Nystatin............................. 30, 66

Nystop..................................... 66

Ocaliva.....................................69

Ocella...................................... 77

Octagam..................................81

Octreotide Acetate................. 80

Odefsey................................... 45

Odomzo...................................36

Ofev......................................... 94

Ofloxacin.....................23, 89, 91

Olanzapine.............................. 41

Olanzapine ODT..................... 41

Olmesartan Medoxomil..........53

Olmesartan Medoxomil-HCTZ

...............................................57

Olmesartan-Amlodipine-HCTZ

...............................................57

Olopatadine HCl..................... 89

Omega-3-Acid Ethyl Esters.... 59

Omeprazole............................ 70

Ondansetron HCl....................29

Ondansetron ODT.................. 29

Onureg.................................... 33

Opsumit...................................93

Orencia....................................81

Orencia ClickJect................... 81

Orenitram................................ 93

Orfadin.....................................71

Orgovyx................................... 80

Orkambi...................................93

Oseltamivir Phosphate...........46

Osphena..................................79

Otezla................................ 81, 82

Oxacillin Sodium.................... 21

Oxacillin Sodium in Dextrose

...............................................21

Oxandrolone........................... 73

Oxcarbazepine....................... 26

Oxybutynin Chloride...............72

Oxybutynin Chloride ER........ 72

Oxycodone HCl...................... 16

Oxycodone-Acetaminophen

...............................................16

Ozempic..................................48

Pacerone.................................54

Paliperidone ER......................41

Panretin................................... 37

Pantoprazole Sodium.............70

Panzyga...................................81

Paricalcitol.............................. 87

Paromomycin Sulfate.............18

Paroxetine HCl........................28

Pediarix................................... 85

Pedvax HIB............................. 85

PEG-3350-Electrolytes........... 70

PEG-3350-NaCl-Na

Bicarbonate-KCl................... 70

Pegasys...................................82

Pemazyre................................ 33

Penicillamine...........................72

Penicillin G Potassium........... 21

Penicillin G Procaine..............21

Penicillin G Sodium................21

Penicillin V Potassium............21

Pentacel.................................. 85

Pentamidine Isethionate........ 38

Pentasa................................... 86

Pentoxifylline ER.....................57

Perforomist............................. 92

Perindopril Erbumine............. 54

Periogard................................ 62

Permethrin.............................. 65

Perphenazine..........................29

Perseris................................... 41

Phenelzine Sulfate..................27

Phenobarbital......................... 25

Phenoxybenzamine HCl........ 53

Phenytek................................. 26

Phenytoin................................ 26

Phenytoin Sodium Extended

...............................................26

Phoslyra...................................68

Pifeltro..................................... 44

Pilocarpine HCl................ 62, 90

Pimecrolimus..........................64

Pimozide................................. 40

Pimtrea.................................... 77

Pindolol................................... 54

Pioglitazone HCl..................... 48

Pioglitazone HCl-Glimepiride

...............................................48

Pioglitazone HCl-Metformin HCl

...............................................48

Piperacillin-Tazobactam.........21

Piqray...................................... 36

Pirfenidone..............................94

Tracked

178

Pirmella 1/35.......................... 77

Piroxicam................................ 14

Plasma-Lyte 148..................... 67

Plasma-Lyte A......................... 67

Plenamine............................... 67

Podofilox................................. 65

Polymyxin B Sulfate............... 19

Polymyxin B-Trimethoprim.... 89

Pomalyst..................................33

Portia-28.................................. 77

Posaconazole......................... 30

Potassium Chloride................67

Potassium Chloride CR..........67

Potassium Chloride ER..........67

Potassium Chloride in Dextrose

5%..........................................67

Potassium Chloride in NaCl

...............................................67

Potassium Citrate ER............. 67

Praluent................................... 59

Pramipexole Dihydrochloride

...............................................39

Prasugrel HCl..........................53

Pravastatin Sodium................ 58

Praziquantel............................ 38

Prazosin HCl........................... 53

Pred Mild.................................90

Prednicarbate......................... 64

Prednisolone...........................72

Prednisolone Acetate.............90

Prednisolone Sodium

Phosphate...................... 73, 90

Prednisone..............................73

Prednisone Intensol............... 73

Pregabalin...............................61

PreHevbrio.............................. 85

Premarin..................................77

Premasol................................. 67

Premphase..............................77

Prempro.................................. 77

Prenatal................................... 68

Prevalite...................................59

Prevymis..................................43

Prezcobix................................ 46

Prezista....................................46

Priftin....................................... 32

Primaquine Phosphate.......... 38

Primidone................................25

Priorix...................................... 85

Privigen................................... 81

ProAir RespiClick................... 92

Probenecid..............................30

Probenecid-Colchicine...........30

Prochlorperazine.................... 29

Prochlorperazine Maleate......29

Procrit......................................52

Procto-Med HC.......................87

Procto-Pak...............................87

Proctosol HC...........................87

Proctozone-HC....................... 87

Procysbi.................................. 71

Progesterone.......................... 79

Prograf.....................................84

Prolastin-C...............................71

Prolensa.................................. 90

Prolia....................................... 87

Promacta.................................52

Promethazine HCl.................. 29

Promethegan.......................... 29

Propafenone HCl....................54

Propafenone HCl ER..............54

Propranolol HCl...................... 55

Propranolol HCl ER................ 55

Propylthiouracil.......................80

ProQuad..................................85

Prosol...................................... 67

Protriptyline HCl..................... 29

Pulmozyme............................. 93

Purixan.................................... 33

Pyrazinamide.......................... 32

Pyridostigmine Bromide........ 31

Pyridostigmine Bromide ER

...............................................31

Pyrimethamine........................38

Pyrukynd................................. 52

Pyrukynd Taper Pack.............52

Qinlock.................................... 33

Quadracel................................85

Quetiapine Fumarate............. 41

Quetiapine Fumarate ER....... 41

Quinapril HCl.......................... 54

Quinapril-Hydrochlorothiazide

...............................................57

Quinidine Gluconate ER........ 54

Quinidine Sulfate.................... 54

Quinine Sulfate....................... 38

RabAvert................................. 85

Rabeprazole Sodium............. 70

Raloxifene HCl........................79

Ramelteon...............................95

Ramipril................................... 54

Tracked

179

Ranolazine ER........................ 57

Rasagiline Mesylate............... 39

Rasuvo.....................................84

RAVICTI...................................71

Rayaldee................................. 87

Rebif........................................ 61

Rebif Rebidose.......................61

Rebif Rebidose Titration Pack

...............................................61

Rebif Titration Pack................61

Reclipsen................................ 77

Recombivax HB......................85

Rectiv.......................................60

Regranex.................................65

Relenza Diskhaler...................46

Relistor.................................... 69

Repaglinide.............................48

Repatha...................................59

Repatha Pushtronex System

...............................................59

Repatha SureClick................. 59

Restasis MultiDose.................88

Restasis Single-Use Vials.......88

Retacrit....................................52

Retevmo.................................. 33

Revcovi....................................71

Revlimid.................................. 33

Rexulti......................................41

Reyataz....................................46

Rhopressa...............................90

Ribavirin.................................. 43

Ridaura....................................82

Rifabutin..................................32

Rifampin..................................32

Riluzole....................................60

Rimantadine HCl.................... 46

Rinvoq..................................... 82

Risedronate Sodium.............. 87

Risperdal Consta....................42

Risperidone.............................42

Risperidone ODT....................42

Ritonavir.................................. 46

Rivastigmine........................... 26

Rivastigmine Tartrate............. 26

Rivelsa..................................... 77

Rizatriptan Benzoate..............31

Rizatriptan Benzoate ODT..... 31

Rocklatan................................ 88

Roflumilast.............................. 93

Ropinirole HCl........................ 39

Rosuvastatin Calcium............ 58

Rotarix..................................... 85

RotaTeq...................................85

Roweepra................................24

Rozlytrek................................. 36

Rubraca...................................36

Ruconest.................................80

Rufinamide..............................26

Rukobia................................... 45

Rybelsus..................................48

Rydapt..................................... 36

Rytary...................................... 39

Sajazir......................................80

Sancuso.................................. 29

Sandimmune.......................... 84

Santyl.......................................65

Sapropterin Dihydrochloride

...............................................71

Savella..................................... 61

Savella Titration Pack.............61

Scemblix..................................36

Scopolamine...........................29

Secuado.................................. 42

Selegiline HCl......................... 39

Selenium Sulfide.................... 64

Selzentry..................................45

Serevent Diskus......................92

Serostim.................................. 73

Sertraline HCl..........................28

Setlakin....................................77

Sevelamer Carbonate............ 68

Sharobel..................................79

Shingrix................................... 85

Signifor.................................... 80

Sildenafil Citrate..................... 93

Silodosin................................. 72

Silver Sulfadiazine.................. 65

Simbrinza................................ 90

Simponi................................... 84

Simvastatin..............................58

Sirolimus................................. 84

Sirturo......................................32

Skyrizi...................................... 82

Skyrizi Pen.............................. 82

Sodium Chloride.............. 67, 68

Sodium Fluoride..................... 68

Sodium Phenylbutyrate..........71

Sodium Polystyrene Sulfonate

...............................................68

Tracked

180

Sodium Sulfate-Potassium

Sulfate-Magnesium Sulfate

...............................................69

Sofosbuvir-Velpatasvir............43

Solifenacin Succinate............ 72

Soliqua.................................... 48

Soltamox................................. 33

Somavert................................. 80

Sorafenib Tosylate................. 36

Sorine...................................... 54

Sotalol HCl.............................. 54

Sotalol HCl AF........................ 54

Sovaldi.....................................43

Spiriva HandiHaler..................92

Spiriva Respimat.................... 92

Spironolactone....................... 58

Spironolactone-HCTZ............ 57

Sprintec 28..............................77

Spritam ODT........................... 24

Sprycel.................................... 36

SPS..........................................68

Sronyx..................................... 77

SSD..........................................65

Stelara..................................... 82

Stiolto Respimat..................... 95

Stivarga................................... 36

Streptomycin Sulfate..............18

Stribild..................................... 44

Suboxone................................17

Sucraid.................................... 71

Sucralfate................................ 70

Sulfacetamide Sodium...........89

Sulfacetamide-Prednisolone

...............................................88

Sulfadiazine............................ 23

Sulfamethoxazole-

Trimethoprim........................23

Sulfamylon.............................. 66

Sulfasalazine...........................86

Sulindac.................................. 14

Sumatriptan............................ 31

Sumatriptan Succinate.......... 31

Sunitinib Malate......................37

Suprax..................................... 20

Suprep Bowel Prep Kit...........70

Sutab....................................... 70

Syeda.......................................77

Symbicort................................95

SymlinPen 120........................49

SymlinPen 60..........................49

Sympazan............................... 25

Symtuza...................................46

Synarel.....................................80

Synjardy.................................. 49

Synjardy XR............................ 49

Synribo.................................... 33

Synthroid.................................79

Tabloid.................................... 33

Tabrecta.................................. 33

Tacrolimus........................ 64, 84

Tadalafil...................................93

Tafinlar.....................................37

Tagrisso...................................37

Talzenna..................................37

Tamoxifen Citrate................... 33

Tamsulosin HCl...................... 72

Tarina 24 Fe............................ 77

Tarina Fe 1/20 EQ.................. 77

Tasigna....................................37

Tazarotene.............................. 62

Tazicef..................................... 20

Taztia XT................................. 55

Tazverik................................... 33

TDVAX..................................... 85

Teflaro..................................... 20

Tegsedi....................................71

Telmisartan............................. 53

Telmisartan-Amlodipine.........57

Telmisartan-HCTZ.................. 57

Temazepam............................ 96

Tenivac....................................86

Tenofovir Disoproxil Fumarate

...............................................45

Tepmetko................................37

Terazosin HCl......................... 72

Terbinafine HCl.......................30

Terconazole............................ 30

Teriparatide.............................87

Testosterone...........................74

Testosterone Cypionate.........73

Testosterone Enanthate.........73

Tetrabenazine.........................60

Tetracycline HCl..................... 23

Thalomid................................. 33

Theophylline........................... 93

Theophylline ER..................... 93

Thioridazine HCl..................... 40

Thiothixene............................. 40

Tiadylt ER................................55

Tiagabine HCl......................... 25

Tibsovo....................................37

Ticovac.................................... 86

Tracked

181

Tigecycline..............................19

Tilia Fe..................................... 77

Timolol Maleate................31, 90

Timolol Maleate Ophthalmic

Gel Forming..........................90

Tinidazole................................19

Tivicay......................................44

Tivicay PD............................... 44

Tizanidine HCl........................ 43

TOBI Podhaler........................ 93

TobraDex.................................88

TobraDex ST...........................88

Tobramycin.......................89, 93

Tobramycin Sulfate................ 18

Tobramycin-Dexamethasone

...............................................88

Tobrex..................................... 89

Tolcapone............................... 38

Tolterodine Tartrate............... 72

Tolterodine Tartrate ER......... 72

Topiramate..............................24

Toremifene Citrate................. 33

Torsemide............................... 57

Toujeo Max SoloStar..............51

Toujeo SoloStar......................51

TPN Electrolytes..................... 68

Tracleer................................... 93

Tradjenta................................. 49

Tramadol HCl..........................16

Tramadol HCl ER....................15

Tramadol-Acetaminophen..... 16

Trandolapril.............................54

Trandolapril-Verapamil HCl ER

...............................................57

Tranexamic Acid.....................52

Tranylcypromine Sulfate........27

Travasol...................................68

Travoprost...............................91

Trazodone HCl........................28

Trecator...................................32

Trelegy Ellipta......................... 95

Trelstar Mixject....................... 80

Tresiba.....................................51

Tresiba FlexTouch..................51

Tretinoin............................37, 62

Tretinoin Microsphere............62

Trexall......................................84

Tri-Estarylla..............................77

Tri-Legest Fe........................... 77

Tri-Lo-Estarylla........................ 77

Tri-Lo-Sprintec........................ 78

Tri-Mili......................................78

Tri-Nymyo................................ 78

Tri-Sprintec..............................78

Tri-VyLibra............................... 78

Tri-VyLibra Lo..........................78

Triamcinolone Acetonide..... 62,

Triamterene.............................58

Triamterene-HCTZ..................57

Triderm....................................64

Trientine HCl...........................68

Trifluoperazine HCl................ 40

Trifluridine............................... 89

Trihexyphenidyl HCl...............38

Trijardy XR.............................. 49

Trimethoprim.......................... 19

Trimipramine Maleate............ 29

Trintellix...................................28

Triumeq...................................45

Triumeq PD.............................45

Trivora..................................... 78

Trizivir...................................... 45

TrophAmine............................ 68

Trospium Chloride..................72

Trulance.................................. 69

Trulicity....................................49

Trumenba................................86

Truseltiq............................ 33, 34

Tukysa..................................... 34

Turalio..................................... 37

Twinrix..................................... 86

Tybost......................................45

Tymlos.....................................87

Typhim Vi................................ 86

Tyvaso DPI Maintenance Kit

...............................................94

Tyvaso DPI Titration Kit..........94

Unithroid..................................79

Ursodiol...................................70

Valacyclovir HCl......................43

Valchlor................................... 32

Valganciclovir HCl.................. 43

Valproic Acid...........................24

Valsartan................................. 53

Valsartan-Hydrochlorothiazide

...............................................57

Valtoco 10MG Dose............... 25

Valtoco 15MG Dose............... 25

Valtoco 20MG Dose............... 25

Valtoco 5MG Dose................. 25

Tracked

182

Vancomycin HCl.....................19

Vandazole............................... 19

VAQTA.....................................86

Varenicline Tartrate................ 17

Varivax.....................................86

Vascepa...................................59

Velivet...................................... 78

Velphoro..................................68

Veltassa...................................68

Vemlidy....................................43

Venclexta.................................37

Venclexta Starting Pack.........37

Venlafaxine Besylate ER........ 28

Venlafaxine HCl...................... 28

Venlafaxine HCl ER................ 28

Ventavis...................................94

Verapamil HCl.........................56

Verapamil HCl ER...................56

Versacloz.................................42

Verzenio.................................. 37

Vestura.................................... 78

Vibramycin.............................. 23

Victoza.....................................49

Vienva......................................78

Vigabatrin................................25

Vigadrone................................25

Viibryd..................................... 28

Viibryd Starter Pack................28

Vilazodone HCl....................... 28

Vimpat..................................... 26

Viracept................................... 46

Viread...................................... 45

Vitrakvi.....................................37

Vivitrol......................................17

Vizimpro.................................. 37

Vonjo....................................... 34

Voriconazole........................... 30

Vosevi...................................... 43

Votrient....................................37

Vraylar..................................... 42

Vumerity.................................. 62

Vyfemla....................................78

VyLibra.................................... 78

Vyndamax............................... 71

Vyndaqel................................. 71

Vyvanse................................... 60

Vyzulta..................................... 91

Warfarin Sodium.....................51

Welireg.................................... 37

Wixela Inhub........................... 95

WYMZYA Fe............................78

Xalkori......................................37

Xarelto..................................... 51

Xarelto Starter Pack............... 51

Xatmep.................................... 84

Xcopri...................................... 24

Xeljanz..................................... 82

Xeljanz XR............................... 82

Xermelo................................... 69

Xgeva.......................................87

Xifaxan.....................................19

Xigduo XR............................... 49

Xiidra........................................88

Xofluza.....................................46

Xolair........................................82

Xospata................................... 37

Xpovio......................................34

Xtampza ER............................ 15

Xtandi...................................... 32

Xulane......................................78

Xyrem...................................... 96

YF-Vax......................................86

Yuvafem.................................. 78

Zafemy.....................................78

Zafirlukast............................... 92

Zaleplon.................................. 96

Zarxio.......................................52

Zejula.......................................37

Zelapar ODT........................... 39

Zelboraf................................... 37

Zemaira................................... 71

Zenatane................................. 62

Zenpep.................................... 71

Zerbaxa................................... 20

Zidovudine.............................. 45

Ziextenzo.................................52

Zileuton ER............................. 92

Ziprasidone HCl......................42

Ziprasidone Mesylate.............42

Zirgan...................................... 43

Zolinza.....................................34

Zolpidem Tartrate...................96

Zonisade................................. 26

Zonisamide............................. 26

Zorbtive................................... 73

Zovia 1/35...............................78

Zydelig.....................................37

Zyflo.........................................92

Tracked

183

Zykadia....................................37 Zyprexa Relprevv....................42

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