_2EQJ8_AAEX24HM0153015

Complete Drug List

(Formulary) 2024

AARP® Medicare Advantage from UHC AR-0001 (HMO-POS)

AARP® Medicare Advantage from UHC AR-0002 (HMO-POS)

AARP® Medicare Advantage from UHC AR-0003 (HMO-POS)

AARP® Medicare Advantage from UHC MS-0001 (HMO-POS)

AARP® Medicare Advantage from UHC TC-0002 (HMO-POS)

AARP® Medicare Advantage from UHC TC-0003 (HMO-POS)

AARP® Medicare Advantage from UHC TN-0003 (HMO-POS)

AARP® Medicare Advantage from UHC TN-0004 (HMO-POS)

AARP® Medicare Advantage from UHC TN-0005 (HMO-POS)

AARP® Medicare Advantage from UHC TN-0006 (HMO-POS)

Important notes: This document has information about the drugs covered by this plan. For

more up-to-date information or if you have any questions, please callUnitedHealthcare

Customer Service at:

Formulary ID Number 00024004, Version 13

Y0066_070823_162534_C v86.02

Last updated February 1, 2024

Toll-free 1-877-370-4874, TTY 711

8 a.m.-8 p.m.: 7 Days Oct-Mar; M-F Apr-Sept

myAARPMedicare.com

What is a Drug List? ................................................................................................................................... 3

Note to existing members: ......................................................................................................................... 3

How can I f nd a drug on the Drug List? ................................................................................................... 4

What are generic drugs? ........................................................................................................................... 4

What is a compounded drug? .................................................................................................................. 4

Drug payment stage and drug tiers ......................................................................................................... 5

Getting Extra Help ......................................................................................................................................5

Are there any rules or limits on my drug coverage? ................................................................................ 6

What if my drug is not on this list? ............................................................................................................8

How can I get an exception? .................................................................................................................... 8

Can I get my drug while I wait for an exception? .................................................................................... 9

Can the Drug List change? ......................................................................................................................10

Drugs with dosages other than a 1-month supply .................................................................................11

Covered drugs by name (Drug index) ....................................................................................................12

Covered drugs by category .....................................................................................................................31

Covered drugs with a quantity limit (QL) .............................................................................................100

Additional covered drugs ......................................................................................................................135

Table of contents

Questions?

If you have questions, we’re here to help. Call UnitedHealthcare Customer Service at:

Toll- free 1-877-370-4874, TTY 711

8 a.m.-8 p.m.: 7 Days Oct-Mar; M-F Apr-Sept

What is a Drug List?

A Drug List, or Formulary, is a list of prescription drugs covered by your plan. Your plan and a team

of health care providers work together in selecting drugs that are needed for well-rounded care and

treatment.

Your plan will generally cover the drugs listed in our Drug List as long as:

l The drug is used for a medically accepted indication

l The prescription is filled at a network pharmacy, and

l Other plan rules are followed



For more information about your drug coverage, please review your Evidence of Coverage.

Note to existing members:

This complete list of prescription drugs covered by your plan is current as of February 1, 2024.

To get updated information about the covered drugs or if you have questions, please call

UnitedHealthcare Customer Service. Our contact information is on the cover.

This Drug List has changed since last year. Please review this document to make sure your

prescription drugs are still covered. In most cases, you must use network pharmacies to have your

prescriptions covered by the plan.

When this Drug List refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to

“plan,” “our plan,” or “your plan,” it means AARP Medicare Advantage from UHC.

Important message about what you pay for vaccines - Some vaccines are considered medical

benefits. Other vaccines are considered Part D drugs. Our plan covers most adult Part D vaccines

at no cost to you, even if you haven’t paid your deductible. Call UnitedHealthcare Customer Service

for more information.

Important message about what you pay for insulin - You will pay a maximum of $35for each

1-month supply of Part D covered insulin drug through all drug payment stages, except

Catastrophic drug payment stage, where you pay $0.

How can I find a drug on the Drug List?

There are 2 ways to find your prescription drugs in this Drug List:

1. By name. Turn to the section “Covered drugs by name (Drug index)” on pages 12-30

to see the list of drug names in alphabetical order. Find the name of your drug. The page

number where you can find the drug will be next to it.

2. By medical condition. Turn to the section “Covered drugs by category” on pages 31-99.

The drugs in this Drug List are grouped into categories depending on the type of medical

condition they are used to treat. For example, if you have a heart condition, you should look

in the category Cardiovascular Agents. This is where you will find drugs that treat heart

conditions.

Can’t find your drug?

Check the complete Drug List by visiting our plan website at

myAARPMedicare.com. You can use online tools to look up your drugs. This

information is updated on a regular basis.

What are generic drugs?

Generic drugs have the same active ingredients as brand name drugs. They usually cost less than

brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers

both brand name and generic drugs.

Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then

review the Drug List to make sure you are getting the drug you need for the least amount of money.

The Drug List shows brand name (B) drugs in bold type (for example, Humalog) and generic (G)

drugs in plain type (for example, Simvastatin).

What is a compounded drug?

A compounded drug is created by a pharmacist by combining or mixing ingredients to create a

prescription medication customized to the needs of an individual patient. Compounded drugs may

be Part D eligible. For more information about compounded drugs, please review your Evidence of

Coverage.

Drug payment stage and drug tiers

The amount you pay for a covered prescription drug will depend on:

l Your drug payment stage. Your plan has different stages of drug coverage. When you fill a

prescription, the amount you pay depends on the coverage stage you’re in.

l Your drug’s tier. Each covered drug is in 1 of 5 drug tiers. Each tier has a copay or

coinsurance amount. The chart below shows the differences between the tiers.

If you need help or have any questions about your drug costs, please review your Evidence of

Coverage or call UnitedHealthcare Customer Service. Our contact information is on the cover.

Drug tier Includes

Tier 1:

Preferred Generic

Lower-cost, commonly used generic drugs.

Tier 2:

Generic

Many generic drugs.

Tier 3:

Preferred Brand

Covered Insulin Drugs*

Many common brand name drugs, called

preferred brands and some higher-cost generic

drugs.

Insulin drugs with $35 max copay.

Tier 4:

Non-preferred Drug

Non-preferred generic and non-preferred brand

name drugs.

Tier 5:

Specialty Tier

Unique and/or very high-cost brand and generic

drugs.

* You will pay a maximum of $35 for each 1-month supply of Part D covered insulin drug through

all drug payment stages, except Catastrophic drug payment stage, where you pay $0.

In addition, your plan has added coverage of some prescription drugs that are not normally

covered under Medicare Part D. Please see the section “Additional covered drugs” on page 135

for a list of these drugs.

Getting Extra Help

If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may

be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for

people who get Extra Help paying for prescription drugs (also called a Low Income Subsidy (LIS)

Rider). Please read it to learn about your costs. You can also call UnitedHealthcare Customer

Service. Our contact information is on the cover.

Are there any rules or limits on my drug coverage?

Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug

has any coverage rules or limits, there will be a code(s) in the “Coverage rules or limits on use”

column of the “Covered drugs by category” chart starting on page 31. The codes and what

they mean are shown below and on the next page.

You can also get more information about the coverage rules and/or limits applied to specific

covered drugs by visiting our website. We have posted online documents that explain our prior

authorization and step therapy restrictions. If you would like a copy sent to you, please call

UnitedHealthcare Customer Service. Our contact information is on the cover.

Coverage rules and limits

PA - Prior authorization

The plan requires you or your doctor to get prior approval for certain drugs. This means the plan

needs more information from your doctor to make sure the drug is being used and covered

correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare

Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs) depending on

how it is used. If you don’t get prior approval, the plan may not cover the drug.

QL - Quantity limits

The plan will cover only a certain amount of this drug for 1 copay or over a certain number of days.

These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes

more than this amount or thinks the limit is not right for your situation, you or your doctor can ask

the plan to cover the additional quantity.

ST - Step therapy

There may be effective, lower-cost drugs that treat the same medical condition as this drug. You

may be required to try 1 or more of these other drugs before the plan will cover your drug. If you

have already tried other drugs or your doctor thinks they are not right for you, you or your doctor

can ask the plan to cover this drug.

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your

drug. See the section “How can I get an exception?” on page 8 or see your Evidence of

Coverage to learn more.

If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules

or limits, you may have to pay the full cost of the drug.

Other special coverage rules

B/D - Medicare Part B or Part D

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

outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide

the plan with more information about how this drug will be used to make sure it’s correctly covered

by Medicare.

LA - Limited access

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

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

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

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.

What if my drug is not on this list?

If your drug is not included in this Drug List, we may still cover it. Call UnitedHealthcare Customer

Service to ask if it’s covered. Our contact information, along with the date we last updated the Drug

List, is on the cover.

If you find out that your drug is not covered, you can do either of the following options:

1. Ask UnitedHealthcare Customer Service for a list of similar drugs that are covered by the

plan. When you get the list, show it to your doctor and ask them to prescribe a covered drug.

2. Ask the plan to make an exception and cover your drug. Review the next section for more

exception information.

How can I get an exception?

Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This

is called asking for an exception. When you do, the plan will review your request and give you a

coverage decision known as a coverage determination.

Types of exceptions you can ask for

l Drug List exception: Ask the plan to cover your drug even if it’s not on the Drug List. If

approved, this drug will be covered at a pre-determined cost-sharing level. You will not be

able to ask us to provide the drug at a lower cost-sharing level.

l Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For

example, if your drug has a quantity limit, you can ask the plan to change the limit and cover

more.

l Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if

this drug is not on the Specialty Tier. If approved this would lower the amount you pay

out-of-pocket for your drug.

The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as

effective in treating your condition or would cause adverse medical effects.

Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling

UnitedHealthcare Customer Service. Your doctor must give us a supporting statement with the

reason for the exception.

How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give

you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor

believes that your health could be seriously harmed by waiting 72 hours. If your request for an

expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s

supporting statement.

Can I get my drug while I wait for an exception?

As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s

not on our Drug List or if it has rules or limits. For example, you may need a prior authorization from

us before you can fill your prescription. During the time when you are getting a temporary supply,

you should talk with your doctor to decide if there is a similar drug on the Drug List you can take

instead. If you and your doctor decide this is the only drug that will work for you, you will need to

ask for an exception. For more information about exceptions, please review your Evidence of

Coverage.

We may cover your drug in certain cases during the first 90 days of your membership. The

following chart shows how much of your drug we may cover while you ask for an exception.

If you... And you are… We may cover…

are a new member in the first 90 days

of your membership

were a member last year and it’s the first

90 days of your plan year

not in a nursing home or

long-term care facility

at least a 30-day

temporary supply

in a nursing home or

long-term care facility

at least a 31-day

temporary supply

have been in the plan for more than

90 days

in a nursing home or

long-term care facility and

need a supply right away

at least a 31-day

emergency supply

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

not in a nursing home or

long-term care facility

at least a 30-day

temporary supply

in a nursing home or

long-term care facility

at least a 31-day

temporary supply

The prescription must be filled at a network pharmacy. If your prescription is written for fewer days,

we’ll allow refills to provide at least the day supply listed in the chart above. Note: The long-term

care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

We will not pay for more of your drug after you get this temporary or emergency supply unless you

receive authorization from the plan.

Can the Drug List change?

Most changes in drug coverage happen on January 1. We may need to make changes during the

plan year for safety or other reasons that can affect you. We must follow the Medicare rules in

making these changes.

Changes that can affect you this year

l New generic drugs. We may immediately remove a brand name drug on our Drug List if we

are replacing it with a new generic drug that will appear on the same or lower cost-sharing

tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may

decide to keep the brand name drug on our Drug List, but immediately move it to a different

cost-sharing tier or add new restrictions.

If you are currently taking that brand name drug, we may not tell you in advance before we

make that change, but we will later provide you with information about the specific change(s)

we have made.

l Other changes. We may make other changes that affect members currently taking a drug.

For instance, we may add a generic drug that is not new to the market to replace a brand

name drug currently on the Drug List, or add new restrictions to the brand name drug or

move it to a different cost-sharing tier or both. Or we may make changes based on new

clinical guidelines. If we remove drugs from our Drug List, add prior authorization, quantity

limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier,

we must notify affected members of the change.

We will notify members at least 30 days before the change becomes effective, or when the

member requests a refill of the drug, at which time the member will receive at least a 30-day

supply of the drug.

If we add new generic drugs or make other changes, you or your prescriber can ask us to

make an exception and continue to cover the brand name drug for you. The notice we

provide you will also include information on how to request an exception, and you can also

find information in the section “How can I get an exception?” on page 8.

l Drugs removed from the market. If the Food and Drug Administration (FDA) says a drug

you are taking is not effective or is unsafe, we will let you know and take it off the Drug List

right away.



Changes that will not affect you if you are currently taking the drug

Usually, if you’re taking a drug on this Drug List that was covered at the beginning of the year, we

will not remove or reduce coverage during the year except as described above. You will not get a

notice this year about changes that do not affect you. However, on January 1 of the next year these

changes will affect you, therefore it is important to check the Drug List for any changes to drugs for

the new plan year.

Drugs with dosages other than a 1-month supply

Drugs packaged in an extended day supply

Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When

you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.

For more information, please call Customer Service. Our contact information is on the cover.

Daily cost-sharing for oral medications filled for less than a 1-month supply

A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of

certain drugs for you and you are required to pay a copay. A daily cost-sharing rate is the copay

divided by the number of days in a month’s supply.

Daily cost-sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)

when dispensed for a supply of less than 1-month under applicable law. The daily cost-sharing

requirements do not apply to either of the following:

  1. Solid oral doses of antibiotics

  2. Solid oral doses that are dispensed in their original container or are usually dispensed

     in their original packaging to help patients comply with usage and dosage directions

For more information

For more detailed information about your plan’s prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about your plan’s prescription drug coverage, please call UnitedHealthcare

Customer Service. Our contact information, along with the date we last updated the Drug List, is on

the cover.

If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov

or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.

Covered drugs by name (Drug index)

Abacavir Sulfate . .....................57

Abacavir Sulfate -Lamivudine .

.....................................................57

Abelcet . .....................................44

Abilify Maintena . ......................53

Abiraterone Acetate . ..............46

Abrysvo . ....................................90

Acamprosate Calcium . ..........33

Acarbose . .................................59

Accutane . .................................71

Acebutolol HCl . .......................64

Acetaminophen -Caffeine

-Dihydrocodeine . ....................32

Acetaminophen -Codeine . ...32

Acetazolamide . .......................66

Acetazolamide ER . .................66

Acetic Acid . ..............................95

Acetylcysteine . ........................98

Acitretin . ....................................71

ActHIB . ......................................90

Actemra . ...................................87

Actemra ACTPen . ...................87

Actimmune . ..............................88

Acyclovir . ..................................56

Acyclovir Sodium . ...................56

Adacel . ......................................90

Adapalene . ...............................71

Adefovir Dipivoxil . ...................55

Adempas . .................................97

Advair Diskus . ..........................98

Advair HFA . ..............................98

Aimovig . ....................................45

Ala -Cort . ...................................71

Albendazole . ............................51

Albuterol Sulfate . ....................97

Albuterol Sulfate HFA . ...........97

Alclometasone Dipropionate .

.....................................................71

Alcohol Prep Pads. ..................92

Alecensa . ..................................48

Alendronate Sodium . .............92

Alfuzosin HCl ER . ...................79

Aliskiren Fumarate . ................66

Allopurinol . ...............................45

Alomide . ....................................93

Alosetron HCl . .........................77

Alphagan P . .............................95

Alprazolam . ..............................58

Altavera . ....................................81

Alunbrig . ...................................48

Alyacen 1/35 . ..........................81

Alyq . ...........................................97

Amantadine HCl . ....................52

Ambrisentan . ...........................97

Amethia . ....................................81

Amikacin Sulfate . ....................34

Amiloride HCl . .........................67

Amiloride -Hydrochlorothiazide

. ....................................................66

Amiodarone HCl . ....................64

Amitriptyline HCl . ....................43

Amlodipine Besylate . .............65

Amlodipine -Atorvastatin . ......66

Amlodipine -Benazepril . ........66

Amlodipine -Olmesartan . ......66

Amlodipine -Valsartan . ..........66

Amlodipine -Valsartan -HCTZ .

.....................................................66

Ammonium Lactate . ..............71

Amnesteem . .............................71

Amoxapine . ..............................43

Amoxicillin . ...............................36

Amoxicillin -Potassium

Clavulanate . .............................36

Amoxicillin -Potassium

Clavulanate ER . .......................36

Amphetamine

-Dextroamphetamine . ............69

Amphetamine

-Dextroamphetamine ER . .....69

Amphotericin B . ......................44

Amphotericin B Liposome . ..44

Ampicillin . .................................36

Ampicillin Sodium . .................36

Ampicillin -Sulbactam Sodium .

.....................................................37

Anagrelide HCl . .......................62

Anastrozole . .............................48

Anoro Ellipta . ...........................98

Anzemet . ...................................44

Apraclonidine HCl . .................95

Aprepitant . ................................44

Apri . ............................................81

Apriso . .......................................91

Aptiom . ......................................40

Index

Aptivus . .....................................57

Aralast NP . ...............................78

Aranelle . ....................................81

Aranesp . ...................................62

Arcalyst . ....................................87

Arexvy . .......................................90

Arformoterol Tartrate . ............97

Aripiprazole . .............................53

Aripiprazole ODT . ...................53

Aristada . ....................................53

Aristada Initio . ..........................53

Armodafinil . ..............................99

Arnuity Ellipta . ..........................96

Asenapine Maleate . ...............53

Ashlyna . ....................................81

Aspirin -Dipyridamole ER . .....63

Atazanavir Sulfate . ..................57

Atenolol . ....................................64

Atenolol -Chlorthalidone . ......66

Atomoxetine HCl . ...................69

Atorvastatin Calcium . .............67

Atovaquone . .............................51

Atovaquone -Proguanil HCl . 51

Atropine Sulfate . .....................93

Atrovent HFA . ..........................96

Aubra EQ . .................................81

Austedo . ....................................69

Auvelity . .....................................42

Aviane . .......................................81

Avonex Pen . .............................70

Avonex Prefilled . .....................70

Ayvakit . ......................................48

Azathioprine . ............................88

Azelaic Acid . ............................71

Azelastine HCl . ........................96

Azelastine -Fluticasone . .........96

Azithromycin . ...........................37

Aztreonam . ...............................34

BCG Vaccine . ..........................90

BIVIGAM . ..................................87

BRIVIACT . ................................39

Bacitracin . ................................93

Bacitracin -Polymyxin B . .......93

Baclofen . ...................................55

Balsalazide Disodium . ...........91

Balversa . ...................................48

Balziva . ......................................81

Baqsimi One Pack . ................60

Baraclude . ................................55

Belsomra . .................................99

Benazepril HCl . .......................64

Benazepril

-Hydrochlorothiazide . .............66

Benlysta . ...................................87

Benznidazole . ..........................51

Benzoyl Peroxide

-Erythromycin . ..........................71

Benztropine Mesylate . ...........52

Bepotastine Besilate . .............93

Bepreve . ....................................93

Berinert . ....................................86

Besivance . ................................93

Besremi . ....................................88

Betaine . .....................................78

Betamethasone Dipropionate .

.....................................................72

Betamethasone Dipropionate

Aug . ...........................................72

Betamethasone Valerate . .....72

Betaseron . ................................70

Betaxolol HCl . ..........................95

Bethanechol Chloride . ..........80

Betimol . .....................................95

Bevespi Aerosphere . .............98

Bexarotene . ..............................51

Bexsero . ....................................90

Bicalutamide . ...........................46

Bicillin C -R . ..............................37

Bicillin C -R 900/300 . ............37

Bicillin L -A . ...............................37

Biktarvy . ....................................56

Bisoprolol Fumarate . .............64

Bisoprolol -Hydrochlorothiazide

. ....................................................66

Blisovi 24 Fe . ...........................81

Blisovi Fe 1.5/30 . ...................81

Boostrix . ....................................90

Bosentan . .................................97

Bosulif . ......................................48

Braftovi . .....................................48

Breo Ellipta . ..............................98

Breztri Aerosphere . ................98

Briellyn . .....................................81

Brilinta . ......................................63

Brimonidine Tartrate . .............95

Brimonidine Tartrate -Timolol .

.....................................................93

Brinzolamide . ...........................95

Bromocriptine Mesylate . .......52

Bronchitol . ................................98

Brukinsa . ...................................48

Budesonide . ............................96

Budesonide ER . ......................92

Bumetanide . ............................67

Buprenorphine . .......................32

Buprenorphine HCl . ...............33

Buprenorphine HCl -Naloxone

HCl . ............................................33

Bupropion HCl . .......................42

Bupropion HCl SR . ................42

Bupropion HCl XL . .................42

Buspirone HCl . ........................58

Butalbital -Acetaminophen

-Caffeine . ...................................32

Butalbital -Aspirin -Caffeine . .32

Butorphanol Tartrate . ............32

Bydureon BCise . .....................59

Byetta 10MCG Pen . ...............59

Byetta 5MCG Pen . .................59

Cabergoline . ............................86

Cablivi . .......................................63

Cabometyx . ..............................48

Calcipotriene . ..........................73

Calcitonin Salmon . .................92

Calcitriol . ...................................92

Calcium Acetate . ....................76

Calquence . ...............................48

Camila . ......................................85

Camrese Lo . ............................81

Candesartan Cilexetil . ............63

Candesartan Cilexetil -HCTZ .

.....................................................66

Caplyta . .....................................53

Caprelsa . ...................................48

Captopril . ..................................64

Carbamazepine . .....................41

Carbamazepine ER . ...............41

Carbidopa . ...............................52

Carbidopa -Levodopa . ...........52

Carbidopa -Levodopa ER . ....52

Carbidopa -Levodopa ODT . .52

Carbidopa -Levodopa

-Entacapone . ............................52

Carglumic Acid . ......................74

Carteolol HCl . ..........................95

Cartia XT . ..................................65

Carvedilol . .................................64

Cayston . ....................................97

Cefaclor . ...................................35

Cefadroxil . ................................35

Cefazolin Sodium . ..................35

Cefdinir . ....................................35

Cefepime HCl . .........................35

Cefixime . ...................................35

Cefotetan Disodium . ..............35

Cefoxitin Sodium . ...................35

Cefpodoxime Proxetil . ...........35

Cefprozil . ...................................36

Ceftazidime . .............................36

Ceftriaxone Sodium . ..............36

Cefuroxime Axetil . ..................36

Cefuroxime Sodium . ..............36

Celecoxib . .................................31

Cephalexin . ..............................36

Cetirizine HCl . ..........................96

Chemet . ....................................76

Chenodal . .................................77

Chlordiazepoxide HCl . ..........58

Chlorhexidine Gluconate . .....71

Chloroquine Phosphate . .......51

Chlorpromazine HCl . .............53

Chlorthalidone . ........................67

Chlorzoxazone . .......................99

Cholbam . ..................................78

Cholestyramine . ......................68

Cholestyramine Light . ............68

Ciclopirox . ................................73

Ciclopirox Olamine . ................74

Cilostazol . .................................63

Ciloxan . .....................................94

Cimduo . ....................................57

Cimetidine . ...............................78

Cimzia . ......................................88

Cimzia Prefilled . ......................88

Cinacalcet HCl . .......................92

Cinryze . .....................................86

Cipro HC . ..................................95

Ciprofloxacin HCl . ..................94

Ciprofloxacin in D5W . ............38

Ciprofloxacin -Dexamethasone

. ....................................................95

Citalopram Hydrobromide . ...42

Claravis . ....................................71

Clarithromycin . ........................37

Clarithromycin ER . .................37

Clenpiq . .....................................77

Climara Pro . .............................81

Clindacin ETZ . .........................74

Clindamycin HCl . ....................34

Clindamycin Palmitate HCl . .34

Clindamycin Phosphate . .......74

Clindamycin Phosphate in

D5W . ..........................................34

Clindamycin Phosphate

-Benzoyl Peroxide . ..................71

Clobazam . ................................40

Clobetasol Propionate . ..........72

Clobetasol Propionate

Emollient Base . .......................72

Clodan . ......................................72

Clomipramine HCl . .................43

Clonazepam . ...........................58

Clonazepam ODT . ..................58

Clonidine . .................................63

Clonidine HCl . .........................63

Clonidine HCl ER . ..................69

Clopidogrel Bisulfate . ............63

Clorazepate Dipotassium . ....58

Clotrimazole . ............................74

Clotrimazole -Betamethasone .

.....................................................73

Clozapine . ................................55

Clozapine ODT . .......................55

Coartem . ...................................51

Codeine Sulfate . .....................32

Colchicine . ...............................45

Colchicine -Probenecid . ........45

Colesevelam HCl . ...................68

Colestipol HCl . ........................68

Colistimethate Sodium . .........34

Combigan . ................................93

Combivent Respimat . ............98

Cometriq . ..................................48

Complera . .................................56

Compro . ....................................43

Constulose . ..............................77

Copiktra . ...................................48

Cordran . ....................................72

Corlanor . ...................................66

Cosentyx . ..................................87

Cosentyx Sensoready . ...........87

Cosentyx UnoReady . .............87

Cotellic . .....................................48

Creon . ........................................78

Crinone . ....................................85

Cromolyn Sodium . .................97

Cryselle -28 . .............................81

Cyclobenzaprine HCl . ............99

Cyclophosphamide . ...............46

Cycloset . ...................................59

Cyclosporine . ...........................88

Cyclosporine Modified . .........88

Cyltezo . .....................................88

Cyltezo -CD/UC/HS Starter . .88

Cyltezo -Psoriasis Starter . .....88

Cyproheptadine HCl . .............96

Cyred EQ . .................................81

Cystagon . .................................78

Cystaran . ...................................93

Dalfampridine ER . ..................70

Danazol . ....................................80

Dantrolene Sodium . ...............55

Dapsone . ..................................46

Daptacel . ...................................90

Daptomycin . .............................34

Darunavir . .................................57

Daurismo . .................................48

Deblitane . .................................85

Deferasirox . ..............................76

Deferasirox Granules . ............76

Deferiprone . .............................76

Delstrigo . ...................................56

Demeclocycline HCl . .............38

Depo -Estradiol . .......................81

Depo -SubQ Provera 104 . ....85

Descovy . ...................................57

Desipramine HCl . ...................43

Desloratadine . .........................96

Desmopressin Acetate . .........80

Desmopressin Acetate Spray .

.....................................................80

Desogestrel -Ethinyl Estradiol .

.....................................................81

Desonide . .................................72

Desoximetasone . ....................72

Desvenlafaxine Succinate ER .

.....................................................42

Dexamethasone . .....................80

Dexamethasone Sodium

Phosphate . ...............................94

Dexlansoprazole . ....................78

Dexmethylphenidate HCl . .....69

Dexmethylphenidate HCl ER .

.....................................................69

Dextroamphetamine Sulfate .

.....................................................69

Dextroamphetamine Sulfate ER

. ....................................................69

Dextrose . ...................................74

Dextrose -NaCl . .......................75

Diacomit . ...................................40

Diazepam . ................................59

Diazepam Intensol . .................58

Diazoxide . .................................60

Diclofenac Epolamine . ..........31

Diclofenac Potassium . ...........31

Diclofenac Sodium . ................94

Diclofenac Sodium ER . .........31

Dicloxacillin Sodium . .............37

Dicyclomine HCl . ....................77

Dificid . .......................................37

Diflunisal . ..................................31

Digoxin . .....................................66

Dihydroergotamine Mesylate .

.....................................................45

Dilantin . .....................................41

Dilantin INFATABS . ................41

Dilt -XR . .....................................65

Diltiazem HCl . ..........................65

Diltiazem HCl ER . ...................65

Diltiazem HCl ER Beads . ......65

Diltiazem HCl ER Coated

Beads . .......................................65

Dimethyl Fumarate . ................70

Dimethyl Fumarate Starter

Pack . ..........................................70

Dipentum . .................................91

Diphenoxylate -Atropine . .......77

Diphtheria -Tetanus Toxoids

DT . ..............................................90

Disulfiram . .................................33

Diuril . ..........................................67

Divalproex Sodium . ................59

Divalproex Sodium ER . .........59

Dofetilide . ..................................64

Dolishale . ..................................81

Donepezil HCl . ........................41

Donepezil HCl ODT . ..............41

Doptelet . ...................................63

Dorzolamide HCl . ...................95

Dorzolamide HCl -Timolol

Maleate . ....................................93

Dorzolamide HCl -Timolol

Maleate Preservative Free . ...93

Dovato . ......................................56

Doxazosin Mesylate . ..............63

Doxepin HCl . ...........................72

Doxercalciferol . .......................92

Doxy 100 . .................................38

Doxycycline Hyclate . ..............38

Doxycycline Monohydrate . ...38

Dronabinol . ...............................44

Drospirenone -Ethinyl Estradiol

. ....................................................81

Droxia . .......................................47

Droxidopa . ................................63

Duavee . .....................................81

Dulera . .......................................98

Duloxetine HCl . .......................70

Dupixent . ..................................87

Dutasteride . ..............................79

Dymista . ....................................96

Econazole Nitrate . ..................74

Edarbi . .......................................63

Edarbyclor . ...............................66

Edurant . ....................................56

Efavirenz . ..................................56

Efavirenz -Emtricitabine

-Tenofovir . .................................56

Efavirenz -Lamivudine

-Tenofovir . .................................56

Elestrin . .....................................81

Eligard . ......................................86

Eliquis . .......................................62

Eliquis Starter Pack . ...............62

Elmiron . .....................................80

EluRyng . ...................................81

Emcyt . .......................................47

Emgality . ...................................45

Emsam . .....................................42

Emtricitabine . ...........................57

Emtricitabine -Tenofovir

Disoproxil Fumarate . ..............57

Emtriva . .....................................57

Enalapril Maleate . ...................64

Enalapril -Hydrochlorothiazide .

.....................................................66

Enbrel . .......................................88

Enbrel Mini . ..............................88

Enbrel SureClick . ....................88

Endari . .......................................75

Endocet . ...................................32

Engerix -B . ................................90

EnilloRing . ................................81

Enoxaparin Sodium . ..............62

Enpresse -28 . ..........................81

Enskyce . ...................................81

Entacapone . .............................52

Entecavir . ..................................55

Entresto . ....................................66

Enulose . ....................................77

Envarsus XR . ...........................88

Epclusa . ....................................55

Epidiolex . ..................................39

Epinastine HCl . .......................93

Epinephrine . ............................97

Epitol . .........................................41

Eplerenone . ..............................67

Eprontia . ...................................39

Ergotamine -Caffeine . ............45

Erivedge . ...................................48

Erleada . .....................................46

Erlotinib HCl . ............................48

Errin . ..........................................85

Ertapenem Sodium . ...............37

Ery . .............................................74

Erythrocin Lactobionate . .......37

Erythromycin . ...........................94

Erythromycin Base . ................38

Erythromycin Ethylsuccinate .

.....................................................38

Escitalopram Oxalate . ............42

Esomeprazole Magnesium . .78

Estarylla . ....................................81

Estradiol . ...................................81

Estradiol Valerate . ...................81

Estring . ......................................81

Eszopiclone . ............................99

Ethacrynic Acid . ......................67

Ethambutol HCl . .....................46

Ethosuximide . ..........................40

Ethynodiol Diacetate -Ethinyl

Estradiol . ...................................81

Etodolac . ...................................31

Etodolac ER . ............................31

Etonogestrel -Ethinyl Estradiol .

.....................................................81

Etravirine . ..................................56

Euthyrox . ...................................85

Everolimus . ...............................88

Evotaz . .......................................57

Exemestane . ............................48

Exkivity . .....................................49

Ezetimibe . .................................68

Ezetimibe -Simvastatin . .........68

FML Forte . ................................94

Falmina . ....................................82

Famciclovir . ..............................56

Famotidine . ..............................78

Fanapt . ......................................53

Fanapt Titration Pack . ...........53

Farxiga . .....................................59

Fasenra . ....................................98

Fasenra Pen . ............................98

Febuxostat . ...............................45

Felbamate . ...............................39

Felodipine ER . .........................65

Femring . ....................................82

Fenofibrate . ..............................67

Fenofibrate Micronized . ........67

Fenofibric Acid . .......................67

Fentanyl . ...................................32

Fentanyl Citrate . ......................32

Fetzima . .....................................42

Fetzima Titration . ....................42

Finacea . ....................................71

Finasteride . ...............................79

Fingolimod HCl . ......................70

Fintepla . ....................................39

Finzala . ......................................82

Firmagon . .................................86

Flac . ...........................................95

Flarex . ........................................94

Flebogamma DIF . ...................87

Flecainide Acetate . .................64

Fluconazole . .............................44

Fluconazole in Sodium

Chloride . ...................................44

Flucytosine . ..............................44

Fludrocortisone Acetate . .......80

Flunisolide . ...............................96

Fluocinolone Acetonide . .......95

Fluocinolone Acetonide Scalp .

.....................................................72

Fluocinonide . ...........................72

Fluocinonide Emulsified Base .

.....................................................72

Fluorometholone . ...................94

Fluorouracil . .............................73

Fluoxetine HCl . ........................42

Fluphenazine Decanoate . .....53

Fluphenazine HCl . ..................53

Flurbiprofen . ............................31

Flurbiprofen Sodium . .............94

Fluticasone Propionate . ........96

Fluticasone -Salmeterol . ........99

Fluvastatin Sodium . ................68

Fluvastatin Sodium ER . .........67

Fluvoxamine Maleate . ............42

Fondaparinux Sodium . ..........62

Formoterol Fumarate . ............97

Forteo . .......................................92

Fosamprenavir Calcium . .......57

Fosinopril Sodium . .................64

Fosinopril Sodium -HCTZ . ....66

Fotivda . ......................................47

Fruzaqla . ...................................49

Furosemide . .............................67

Fuzeon . .....................................57

Fyavolv . .....................................82

Fycompa . ..................................39

Gabapentin . .............................40

Galantamine Hydrobromide .

.....................................................41

Galantamine Hydrobromide ER

. ....................................................41

Gammagard . ............................87

Gammagard S/D Less IgA . ..87

Gammaked . .............................87

Gammaplex . ............................87

Gamunex -C . ............................87

Gardasil 9 . ................................90

Gatifloxacin . .............................94

Gauze . .......................................92

GaviLyte -C . ..............................77

GaviLyte -G . ..............................77

Gavreto . ....................................49

Gefitinib . ....................................49

Gemfibrozil . ..............................67

Gemtesa . ..................................79

Generlac . ..................................77

Gengraf . ....................................88

Genotropin . ..............................80

Genotropin MiniQuick . ..........80

Gentamicin Sulfate . ................94

Gentamicin Sulfate -0.9%

Sodium Chloride . ....................34

Genvoya . ...................................56

Gilotrif . .......................................49

Glatiramer Acetate . ................70

Glatopa . ....................................70

Gleostine . .................................46

Glimepiride . ..............................59

Glipizide . ...................................59

Glipizide ER . ............................59

Glipizide -Metformin HCl . ......59

GlucaGen HypoKit . ................60

Glucagon . .................................60

Glycopyrrolate . ........................77

Glyxambi . ..................................59

Granisetron HCl . .....................44

Griseofulvin Microsize . ..........44

Griseofulvin Ultramicrosize . ..44

Guanfacine HCl ER . ...............69

Gvoke HypoPen 2 -Pack . .....60

Gvoke Kit . .................................60

Gvoke PFS . ..............................60

Haegarda . .................................86

Hailey 24 Fe . ............................82

Halobetasol Propionate . .......72

Haloette . ....................................82

Haloperidol . ..............................53

Haloperidol Decanoate . ........53

Haloperidol Lactate . ...............53

Havrix . ........................................90

Heparin Sodium . .....................62

Heplisav -B . ..............................90

Hiberix . ......................................90

Humalog . ..................................61

Humalog Junior KwikPen . ....61

Humalog KwikPen . ................61

Humalog Mix 50/50 . .............61

Humalog Mix 50/50 KwikPen .

.....................................................61

Humalog Mix 75/25 . .............61

Humalog Mix 75/25 KwikPen .

.....................................................61

Humira . .....................................89

Humira Pediatric Crohns Start .

.....................................................89

Humira Pen . .............................89

Humira Pen Crohn's

Disease/Ulcerative

Colitis/Hidradenitis

Suppurativa Starter . ...............89

Humira Pen Psoriasis Starter .

.....................................................89

Humira Pen Psoriasis/Uveitis

Starter . .......................................89

Humira Pen -Pediatric UC Start

. ....................................................89

Humulin 70/30 . ......................61

Humulin 70/30 KwikPen . .....61

Humulin N . ...............................61

Humulin N KwikPen . ..............61

Humulin R . ...............................61

Humulin R U -500 . .................61

Humulin R U -500 KwikPen . 61

Hydralazine HCl . .....................68

Hydrochlorothiazide . ..............67

Hydrocodone -Acetaminophen

. ....................................................33

Hydrocodone -Ibuprofen . .....33

Hydrocortisone . .......................92

Hydrocortisone Butyrate . ......72

Hydrocortisone Valerate . ......73

Hydrocortisone -Acetic Acid .

.....................................................95

Hydromorphone HCl . ............33

Hydromorphone HCl ER . .....32

Hydromorphone HCl

Preservative Free . ...................33

Hydroxychloroquine Sulfate . 51

Hydroxyurea . ...........................47

Hydroxyzine HCl . ....................58

Hydroxyzine Pamoate . ..........58

IDHIFA . ......................................47

IPOL . ..........................................90

Ibandronate Sodium . .............92

Ibrance . .....................................49

Ibu . .............................................31

Ibuprofen . .................................31

Icatibant Acetate . ....................86

Iclevia . ........................................82

Iclusig . .......................................49

Ilevro . .........................................94

Imatinib Mesylate . ...................49

Imbruvica . .................................49

Imipenem -Cilastatin . .............37

Imipramine HCl . ......................43

Imipramine Pamoate . ............43

Imiquimod . ...............................73

Imovax Rabies . ........................90

Impavido . ..................................51

Imvexxy Maintenance Pack . 82

Imvexxy Starter Pack . ............82

Inbrija . ........................................52

Incassia . ....................................85

Increlex . .....................................80

Incruse Ellipta . .........................96

Indapamide . .............................67

Indomethacin . .........................31

Infanrix . ......................................90

Ingrezza . ...................................69

Inlyta . .........................................49

Inqovi . ........................................49

Inrebic . ......................................49

Insulin Lispro . ..........................61

Insulin Lispro Junior KwikPen .

.....................................................61

Insulin Lispro Prot & Lispro . .61

Insulin Syringes, Needles. .....92

Intelence . ..................................56

Intralipid . ...................................75

Introvale . ...................................82

Invega Hafyera . .......................54

Invega Sustenna . ....................54

Invega Trinza . ..........................54

Ipratropium Bromide . ............96

Ipratropium -Albuterol . ...........99

Irbesartan . ................................63

Irbesartan -Hydrochlorothiazide

. ....................................................66

Isentress . ...................................56

Isentress HD . ...........................56

Isibloom . ...................................82

Isolyte -P in D5W . ....................75

Isolyte -S pH 7.4 . .....................75

Isoniazid . ...................................46

Isosorbide Dinitrate . ...............68

Isosorbide Dinitrate

-Hydralazine . ............................66

Isosorbide Mononitrate . ........69

Isosorbide Mononitrate ER . .69

Isotretinoin . ...............................71

Isturisa . ......................................85

Itraconazole . ............................44

Ivermectin . ................................51

Ixiaro . .........................................90

Jakafi . ........................................49

Jantoven . ..................................62

Janumet . ...................................59

Janumet XR . ............................59

Januvia . .....................................59

Jardiance . .................................59

Jasmiel . .....................................82

Jaypirca . ....................................49

Jentadueto . ..............................59

Jentadueto XR . .......................59

Jinteli . ........................................82

Jublia . ........................................74

Juleber . .....................................82

Juluca . .......................................56

Junel 1.5/30 . ...........................82

Junel 1/20 . ...............................82

Junel Fe 1.5/30 . .....................82

Junel Fe 1/20 . .........................82

Junel Fe 24 . .............................82

Jynneos . ....................................90

KCl in Dextrose -NaCl . ...........75

KCl -Lactated Ringers -D5W .

.....................................................75

Kaitlib Fe . ..................................82

Kalydeco . ..................................97

Kariva . ........................................82

Kelnor 1/35 . ............................82

Kelnor 1/50 . ............................82

Kerendia . ..................................66

Kesimpta . ..................................70

Ketoconazole . ..........................74

Ketoprofen . ..............................31

Ketorolac Tromethamine . .....94

Kinrix . .........................................90

Kisqali . .......................................49

Kisqali Femara . ........................49

Klor -Con . ..................................75

Klor -Con 10 . ...........................75

Klor -Con 8 . ..............................75

Klor -Con M10 . ........................75

Klor -Con M15 . ........................75

Klor -Con M20 . ........................75

Korlym . ......................................80

Koselugo . .................................49

Kourzeq . ...................................71

Krazati . ......................................47

Kurvelo . .....................................82

LARIN 1.5/30 . .........................82

LARIN 1/20 . ............................82

LARIN Fe 1.5/30 . ...................82

LARIN Fe 1/20 . .......................82

Labetalol HCl . ..........................64

Lacosamide . ............................41

Lacrisert . ...................................93

Lactulose . .................................77

Lagevrio . ...................................92

Lamivudine . .............................57

Lamivudine -Zidovudine . ......57

Lamotrigine . .............................39

Lanoxin . ....................................66

Lansoprazole . ..........................78

Lantus . ......................................61

Lantus SoloStar . ......................61

Lapatinib Ditosylate . ...............49

Latanoprost . .............................95

Layolis Fe . ................................82

Leena . .......................................82

Leflunomide . ............................89

Lenalidomide . ..........................47

Lenvima 10MG Daily Dose . .49

Lenvima 12MG Daily Dose . .49

Lenvima 14MG Daily Dose . .49

Lenvima 18MG Daily Dose . .49

Lenvima 20MG Daily Dose . .49

Lenvima 24MG Daily Dose . .49

Lenvima 4MG Daily Dose . ....50

Lenvima 8MG Daily Dose . ....50

Lessina . .....................................82

Letrozole . ..................................48

Leucovorin Calcium . ..............51

Leukeran . .................................46

Leuprolide Acetate . ................86

Levalbuterol HCl . ....................97

Levalbuterol Tartrate . .............97

Levemir . ....................................61

Levemir FlexPen . ....................61

Levetiracetam . .........................39

Levetiracetam ER . ..................39

Levobunolol HCl . ....................95

Levocarnitine . ..........................78

Levocetirizine Dihydrochloride .

.....................................................96

Levofloxacin . ............................94

Levofloxacin in D5W . .............38

Levonest . ..................................82

Levonorgestrel -Ethinyl

Estradiol . ...................................82

Levonorgestrel -Ethinyl

Estradiol & Ethinyl Estradiol . 82

Levonorgestrel -Ethinyl

Estradiol 91 -Day . ...................82

Levonorgestrel -Ethinyl

Estradiol Triphasic . .................83

Levora 0.15/30 . ......................83

Levothyroxine Sodium . .........85

Levoxyl . .....................................85

Lexiva . .......................................58

Lidocaine . .................................33

Lidocaine HCl . .........................33

Lidocaine Viscous . .................33

Lidocaine -Prilocaine . ............33

Linezolid . ..................................35

Linzess . .....................................77

Liothyronine Sodium . ............85

Lisdexamfetamine Dimesylate .

.....................................................69

Lisinopril . ..................................64

Lisinopril -Hydrochlorothiazide .

.....................................................66

Lithium . .....................................59

Lithium Carbonate . ................59

Lithium Carbonate ER . ..........59

Livalo . ........................................68

Lokelma . ...................................76

Lonsurf . .....................................47

Loperamide HCl . ....................77

Lopinavir -Ritonavir . ................58

Lorazepam . ..............................59

Lorazepam Intensol . ..............59

Lorbrena . ..................................50

Loryna . ......................................83

Losartan Potassium . ..............63

Losartan Potassium -HCTZ . .66

Lotemax . ...................................94

Lotemax SM . ............................94

Loteprednol Etabonate . ........95

Lovastatin . ................................68

Low -Ogestrel . .........................83

Loxapine Succinate . ..............53

Lubiprostone . ..........................77

Lumakras . .................................47

Lumigan . ...................................95

Lupron Depot . .........................86

Lupron Depot -Ped . ...............86

Lurasidone HCl . ......................54

Lutera . .......................................83

Lybalvi . ......................................54

Lyleq . .........................................85

Lynparza . ..................................50

Lysodren . ..................................85

Lytgobi . .....................................50

Lyumjev . ....................................61

Lyumjev KwikPen . ..................61

Lyza . ...........................................85

M -M -R II . ..................................90

Magnesium Sulfate . ...............75

Malathion . .................................73

Maraviroc . .................................57

Marlissa . ....................................83

Marplan . ....................................42

Matulane . ..................................46

Matzim LA . ...............................65

Mavyret . ....................................55

Mayzent . ...................................70

Mayzent Starter Pack . ...........70

Meclizine HCl . .........................43

Medroxyprogesterone Acetate .

.....................................................85

Mefloquine HCl . ......................52

Megestrol Acetate . .................85

Mekinist . ....................................50

Mektovi . ....................................50

Meloxicam . ...............................31

Memantine HCl . ......................41

Memantine HCl ER . ...............41

Memantine HCl Titration Pak .

.....................................................42

MenQuadfi . ..............................90

Menactra . ..................................90

Menest . .....................................83

Menveo . ....................................90

Mercaptopurine . .....................47

Meropenem . ............................37

Mesalamine . .............................91

Mesalamine ER . ......................91

Mesnex . ....................................51

Metformin HCl . ........................60

Metformin HCl ER . .................60

Methadone HCl . ......................32

Methazolamide . ......................95

Methenamine Hippurate . ......35

Methimazole . ...........................86

Methocarbamol . ......................99

Methotrexate Sodium . ...........89

Methoxsalen Rapid . ...............73

Methscopolamine Bromide . 77

Methsuximide . .........................40

Methylphenidate HCl . ............69

Methylphenidate HCl ER . .....69

Methylprednisolone . ..............80

Metoclopramide HCl . ............43

Metolazone . .............................67

Metoprolol Succinate ER . .....65

Metoprolol Tartrate . ................65

Metoprolol

-Hydrochlorothiazide . .............66

Metronidazole . .........................35

Metyrosine . ...............................66

Mexiletine HCl . ........................64

Mibelas 24 Fe . .........................83

Micafungin Sodium . ...............44

Miconazole 3 . ..........................44

Microgestin 1.5/30 . ...............83

Microgestin 1/20 . ...................83

Microgestin 24 Fe . .................83

Microgestin Fe 1.5/30 . ..........83

Microgestin Fe 1/20 . .............83

Midodrine HCl . ........................63

Miglitol . ......................................60

Miglustat . ..................................78

Mili . .............................................83

Minocycline HCl . .....................38

Minoxidil . ..................................68

Mirtazapine . .............................42

Mirtazapine ODT . ....................42

Misoprostol . .............................78

Modafinil . ..................................99

Moexipril HCl . ..........................64

Molindone HCl . .......................53

Mometasone Furoate . ...........96

Montelukast Sodium . .............96

Morphine Sulfate . ...................33

Morphine Sulfate ER . .............32

Motegrity . ..................................77

Mounjaro . .................................60

Movantik . ..................................77

Moxifloxacin HCl . ....................94

Moxifloxacin HCl in NaCl . .....38

Multaq . ......................................64

Multiple Electrolytes Type 1 pH

5.5 . .............................................75

Mupirocin . ................................74

Mupirocin Calcium . ................74

Mycophenolate Mofetil . .........89

Mycophenolate Sodium . .......89

Myrbetriq . .................................79

Nabumetone . ...........................31

Nadolol . .....................................65

Nafcillin Sodium . .....................37

Naftifine HCl . ............................74

Naftin . ........................................74

Naloxone HCl . .........................34

Naltrexone HCl . .......................33

Namzaric . .................................41

Naproxen . .................................31

Naproxen DR . ..........................31

Naratriptan HCl . ......................45

Narcan . ......................................34

Natacyn . ....................................94

Nateglinide . ..............................60

Natpara . ....................................92

Nayzilam . ..................................40

Nebivolol HCl . ..........................65

Necon 0.5/35 . .........................83

Nefazodone HCl . ....................42

Neo -Polycin . ............................94

Neo -Polycin HC . ....................93

Neomycin Sulfate . ..................34

Neomycin -Bacitracin

-Polymyxin . ...............................94

Neomycin -Polymyxin

-Bacitracin -Hydrocortisone . .93

Neomycin -Polymyxin

-Dexamethasone . ....................93

Neomycin -Polymyxin

-Gramicidin . ..............................94

Neomycin -Polymyxin -HC . ...96

Nerlynx . .....................................50

Neuac . .......................................71

Neulasta . ...................................62

Neupro . .....................................52

Nevirapine . ...............................56

Nevirapine ER . ........................56

Niacin . .......................................68

Niacin ER . .................................68

Niacor . .......................................68

Nicardipine HCl . ......................65

Nicotrol . .....................................34

Nicotrol NS . ..............................34

Nifedipine ER . .........................65

Nifedipine ER Osmotic Release

. ....................................................65

Nikki . ..........................................83

Nilutamide . ...............................46

Nimodipine . ..............................65

Ninlaro . ......................................47

Nitazoxanide . ...........................52

Nitisinone . .................................78

Nitro -Bid . ..................................69

Nitrofurantoin Macrocrystal . .35

Nitrofurantoin Monohydrate . 35

Nitroglycerin . ............................69

Nitrostat . ....................................69

Nizatidine . .................................78

Nora -BE . ..................................85

Norethindrone . ........................85

Norethindrone Acetate . .........85

Norethindrone Acetate -Ethinyl

Estradiol . ...................................83

Norethindrone Acetate -Ethinyl

Estradiol -Fe . ............................83

Norethindrone -Ethinyl

Estradiol -Fe . ............................83

Norgestimate -Ethinyl Estradiol

. ....................................................83

Norgestimate -Ethinyl Estradiol

Triphasic . ..................................83

Nortrel 0.5/35 . ........................83

Nortrel 1/35 . ............................83

Nortrel 7/7/7 . ..........................83

Nortriptyline HCl . ....................43

Norvir . ........................................58

Noxafil . ......................................44

Nubeqa . ....................................46

Nucala . ......................................99

Nuedexta . .................................70

Nuplazid . ...................................54

Nurtec ODT . .............................45

Nutrilipid . ..................................75

Nyamyc . ....................................74

Nylia 1/35 . ................................83

Nylia 7/7/7 . ..............................83

Nymyo . ......................................83

Nystatin . ....................................74

Nystop . ......................................74

Ocella . .......................................83

Octagam . ..................................87

Octreotide Acetate . ................86

Odefsey . ....................................57

Odomzo . ...................................50

Ofev . ..........................................98

Ofloxacin . ..................................96

Ojjaara . ......................................50

Olanzapine . ..............................54

Olanzapine ODT . ....................54

Olmesartan Medoxomil . ........63

Olmesartan Medoxomil -HCTZ .

.....................................................66

Olmesartan -Amlodipine -HCTZ

. ....................................................66

Omega -3 -Acid Ethyl Esters .

.....................................................68

Omeprazole . ............................78

Ondansetron HCl . ...................44

Ondansetron ODT . .................44

Onureg . .....................................47

Opsumit . ...................................98

Orencia . ....................................87

Orencia ClickJect . ..................87

Orenitram . ................................98

Orenitram Month 1 . ................98

Orenitram Month 2 . ................98

Orenitram Month 3 . ................98

Orgovyx . ....................................86

Orkambi . ...................................97

Orserdu . ....................................47

Oseltamivir Phosphate . .........58

Osphena . ..................................85

Otezla . .......................................87

Oxacillin Sodium . ....................37

Oxacillin Sodium in Dextrose .

.....................................................37

Oxcarbazepine . .......................41

Oxybutynin Chloride . .............79

Oxybutynin Chloride ER . ......79

Oxycodone HCl . ......................33

Oxycodone -Acetaminophen .

.....................................................33

Ozempic . ..................................60

PEG -3350 -Electrolytes . .......77

PEG -3350 -NaCl -Na

Bicarbonate -KCl . ....................77

Pacerone . .................................64

Paliperidone ER . .....................54

Panretin . ....................................51

Pantoprazole Sodium . ...........78

Panzyga . ...................................87

Paricalcitol . ...............................92

Paromomycin Sulfate . ...........34

Paroxetine HCl . .......................43

Paxlovid . ...................................93

Pazopanib HCl . .......................50

Pediarix . ....................................90

Pedvax HIB . .............................90

Pegasys . ...................................88

Pemazyre . .................................47

Penicillamine . ..........................80

Penicillin G Potassium . .........37

Penicillin G Sodium . ...............37

Penicillin V Potassium . ..........37

Pentacel . ...................................90

Pentamidine Isethionate . ......52

Pentasa . ....................................91

Pentoxifylline ER . ....................66

Perforomist . ..............................97

Perindopril Erbumine . ...........64

Periogard . .................................71

Permethrin . ..............................73

Perphenazine . .........................43

Perseris . ....................................54

Phenelzine Sulfate . .................42

Phenobarbital . .........................40

Phenytek . ..................................41

Phenytoin . ................................41

Phenytoin Sodium Extended .

.....................................................41

Pifeltro . ......................................56

Pilocarpine HCl . ......................95

Pimecrolimus . ..........................73

Pimozide . ..................................53

Pimtrea . .....................................83

Pindolol . ....................................65

Pioglitazone HCl . ....................60

Pioglitazone HCl -Glimepiride .

.....................................................60

Pioglitazone HCl -Metformin

HCl . ............................................60

Piperacillin -Tazobactam . .....37

Piqray . .......................................50

Pirfenidone . ..............................98

Piroxicam . .................................31

Plasma -Lyte 148 . ...................75

Plasma -Lyte A . .......................75

Plenamine . ...............................75

Podofilox . ..................................73

Polycin . ......................................94

Polymyxin B Sulfate . ..............35

Polymyxin B -Trimethoprim . .94

Pomalyst . ..................................47

Portia -28 . .................................84

Posaconazole . .........................44

Potassium Chloride . ...............75

Potassium Chloride ER . ........75

Potassium Chloride

Microencapsulated ER . .........75

Potassium Chloride in Dextrose

5% . .............................................76

Potassium Chloride in NaCl . 75

Potassium Citrate ER . ............75

Praluent . ....................................68

Pramipexole Dihydrochloride .

.....................................................52

Prasugrel HCl . .........................63

Pravastatin Sodium . ...............68

Praziquantel . ............................51

Prazosin HCl . ...........................63

PreHevbrio . ..............................90

Pred Mild . .................................95

Prednisolone . ..........................80

Prednisolone Acetate . ...........95

Prednisolone Sodium

Phosphate . ...............................95

Prednisone . ..............................80

Prednisone Intensol . ..............80

Pregabalin . ...............................70

Premarin . ..................................84

Premasol . .................................76

Premphase . ..............................84

Prempro . ...................................84

Prenatal . ....................................76

Prevalite . ...................................68

Prevymis . ..................................55

Prezcobix . .................................58

Prezista . ....................................58

Priftin . ........................................46

Primaquine Phosphate . ........52

Primidone . ................................40

Priorix . .......................................91

Privigen . ....................................87

ProQuad . ..................................91

Probenecid . .............................45

Prochlorperazine . ...................43

Prochlorperazine Maleate . ...43

Procrit . .......................................63

Procto -Med HC . .....................92

Proctosol HC . ..........................92

Proctozone -HC . .....................92

Progesterone . ..........................85

Prograf . .....................................89

Prolastin -C . ..............................78

Prolensa . ...................................95

Prolia . .........................................92

Promacta . .................................63

Promethazine HCl . .................43

Promethegan . ..........................44

Propafenone HCl . ...................64

Propafenone HCl ER . ............64

Propranolol HCl . .....................65

Propranolol HCl ER . ...............65

Propylthiouracil . ......................86

Prosol . .......................................76

Protriptyline HCl . .....................43

Pulmozyme . .............................97

Purixan . .....................................47

Pyrazinamide . ..........................46

Pyridostigmine Bromide . ......46

Pyridostigmine Bromide ER . 46

Pyrimethamine . .......................52

Pyrukynd . ..................................63

Pyrukynd Taper Pack . ...........63

Qinlock . .....................................47

Quadracel . ................................91

Quetiapine Fumarate . ............54

Quetiapine Fumarate ER . .....54

Quinapril HCl . ..........................64

Quinidine Gluconate ER . ......64

Quinidine Sulfate . ...................64

Quinine Sulfate . .......................52

Qulipta . ......................................45

Quviviq . .....................................70

Qvar RediHaler . .......................96

RabAvert . ..................................91

Rabeprazole Sodium . ............78

Raloxifene HCl . .......................85

Ramelteon . ...............................99

Ramipril . ....................................64

Ranolazine ER . ........................66

Rasagiline Mesylate . ..............52

Rasuvo . .....................................89

Rayaldee . ..................................92

Rebif . .........................................70

Rebif Rebidose . ......................70

Rebif Rebidose Titration Pack .

.....................................................70

Rebif Titration Pack . ..............71

Reclipsen . .................................84

Recombivax HB . .....................91

Rectiv . ........................................69

Regranex . .................................73

Relenza Diskhaler . ..................58

Relistor . .....................................77

Repaglinide . .............................60

Repatha . ...................................68

Repatha Pushtronex System .

.....................................................68

Repatha SureClick . ................68

Restasis MultiDose . ................93

Restasis Single -Use Vials . ....93

Retacrit . .....................................63

Retevmo . ..................................47

Revcovi . ....................................78

Revlimid . ...................................47

Rexulti . ......................................54

Reyataz . ....................................58

Rezlidhia . ..................................50

Rhopressa . ...............................95

Ribavirin . ...................................55

Ridaura . ....................................87

Rifabutin . ..................................46

Rifampin . ..................................46

Riluzole . ....................................70

Rimantadine HCl . ...................58

Rinvoq . ......................................87

Risedronate Sodium . .............92

Risperdal Consta . ...................54

Risperidone . ............................54

Risperidone ODT . ...................54

Ritonavir . ...................................58

Rivastigmine . ...........................41

Rivastigmine Tartrate . ............41

Rivelsa . ......................................84

Rizatriptan Benzoate . ............45

Rizatriptan Benzoate ODT . ...45

Rocklatan . ................................93

Roflumilast . ..............................97

Ropinirole HCl . ........................52

Rosuvastatin Calcium . ...........68

RotaTeq . ...................................91

Rotarix . ......................................91

Roweepra . ................................39

Rozlytrek . ..................................50

Rubraca . ...................................50

Rufinamide . ..............................41

Rukobia . ...................................57

Rybelsus . ..................................60

Rydapt . ......................................50

Rytary . .......................................52

SPS . ...........................................76

SSD . ...........................................73

Sajazir . .......................................86

Sancuso . ...................................44

Sandimmune . ..........................89

Santyl . ........................................73

Sapropterin Dihydrochloride .

.....................................................79

Savella . ......................................70

Savella Titration Pack . ...........70

Scemblix . ..................................50

Scopolamine . ...........................44

Secuado . ..................................54

Selegiline HCl . .........................53

Selenium Sulfide . ....................73

Selzentry . ..................................57

Serevent Diskus . .....................97

Sertraline HCl . .........................43

Setlakin . ....................................84

Sevelamer Carbonate . ...........76

Sharobel . ..................................85

Shingrix . ....................................91

Signifor . .....................................86

Sildenafil Citrate . .....................98

Silodosin . ..................................79

Silver Sulfadiazine . .................73

Simbrinza . ................................95

Simponi . ....................................89

Simvastatin . ..............................68

Sirolimus . ..................................89

Sirturo . .......................................46

Skyclarys . ..................................70

Skyrizi . .......................................88

Skyrizi Pen . ...............................87

Sodium Chloride . ....................76

Sodium Fluoride . ....................76

Sodium Oxybate . ....................99

Sodium Phenylbutyrate . ........79

Sodium Polystyrene Sulfonate .

.....................................................76

Sodium Sulfate -Potassium

Sulfate -Magnesium Sulfate . 77

Sofosbuvir -Velpatasvir . .........55

Solifenacin Succinate . ...........79

Soliqua . .....................................60

Soltamox . ..................................47

Somavert . .................................86

Sorafenib Tosylate . .................50

Sorine . .......................................64

Sotalol HCl . ..............................64

Spiriva HandiHaler . ................96

Spiriva Respimat . ....................96

Spironolactone . .......................67

Spironolactone -HCTZ . .........66

Sprintec 28 . .............................84

Spritam ODT . ...........................39

Sprycel . .....................................50

Sronyx . ......................................84

Stelara . ......................................88

Stiolto Respimat . .....................99

Stivarga . ....................................50

Streptomycin Sulfate . ............34

Stribild . ......................................56

Suboxone . ................................33

Subvenite . .................................39

Sucraid . .....................................79

Sucralfate . ................................78

Suflave . ......................................77

Sulfacetamide Sodium . .........94

Sulfacetamide -Prednisolone .

.....................................................93

Sulfadiazine . .............................38

Sulfamethoxazole

-Trimethoprim . .........................38

Sulfamylon . ..............................74

Sulfasalazine . ...........................91

Sulindac . ...................................31

Sumatriptan . ............................45

Sumatriptan Succinate . .........45

Sunitinib Malate . .....................50

Sunlenca . ..................................57

Sutab . ........................................77

Syeda . .......................................84

Symbicort . ................................99

Sympazan . ................................40

Symtuza . ...................................58

Synarel . .....................................86

Synjardy . ...................................60

Synthroid . .................................85

TDVAX . ......................................91

TPN Electrolytes . ....................76

Tabloid . .....................................47

Tabrecta . ...................................47

Tacrolimus . ..............................89

Tadalafil . ...................................98

Tafinlar . .....................................50

Tagrisso . ...................................50

Talzenna . ..................................50

Tamoxifen Citrate . ..................47

Tamsulosin HCl . ......................79

Tarina 24 Fe . ...........................84

Tarina Fe 1/20 EQ . ................84

Tasigna . ....................................50

Tasimelteon . ............................99

Tazarotene . ..............................71

Tazicef . ......................................36

Taztia XT . ..................................65

Tazverik . ....................................47

Teflaro . ......................................36

Telmisartan . .............................63

Telmisartan -Amlodipine . ......67

Telmisartan -HCTZ . ................67

Temazepam . ............................99

Tenivac . .....................................91

Tenofovir Disoproxil Fumarate .

.....................................................57

Tepmetko . ................................50

Terazosin HCl . .........................79

Terbinafine HCl . ......................45

Terconazole . ............................45

Teriflunomide . .........................71

Teriparatide . .............................92

Testosterone . ...........................81

Testosterone Cypionate . .......80

Testosterone Enanthate . .......80

Tetrabenazine . .........................70

Tetracycline HCl . ....................39

Thalomid . ..................................47

Theophylline . ...........................97

Theophylline ER . ....................97

Thioridazine HCl . ....................53

Thiothixene . .............................53

Tiadylt ER . ................................65

Tiagabine HCl . ........................40

Tibsovo . ....................................50

Ticovac . .....................................91

Tigecycline . ..............................35

Tilia Fe . ......................................84

Timolol Maleate . .....................95

Timolol Maleate Ophthalmic

Gel Forming . ............................95

Tinidazole . ................................35

Tivicay . ......................................56

Tivicay PD . ................................56

Tizanidine HCl . ........................55

Tobi Podhaler . .........................97

TobraDex . .................................93

TobraDex ST . ..........................93

Tobramycin . .............................97

Tobramycin Sulfate . ...............34

Tobramycin -Dexamethasone .

.....................................................93

Tobrex . ......................................94

Tolterodine Tartrate . ..............79

Tolterodine Tartrate ER . ........79

Topiramate . ..............................39

Toremifene Citrate . ................47

Torsemide . ...............................67

Toujeo Max SoloStar . ............61

Toujeo SoloStar . .....................61

Tracleer . ....................................98

Tradjenta . .................................60

Tramadol HCl . .........................33

Tramadol HCl ER . ..................32

Tramadol -Acetaminophen . .33

Trandolapril . .............................64

Trandolapril -Verapamil HCl ER

. ....................................................67

Tranexamic Acid . ....................63

Tranylcypromine Sulfate . ......42

Travasol . ...................................76

Travoprost . ...............................95

Trazodone HCl . .......................43

Trecator . ...................................46

Trelegy Ellipta . .........................99

Trelstar Mixject . .......................86

Tresiba . .....................................62

Tresiba FlexTouch . .................61

Tretinoin . ...................................71

Tretinoin Microsphere . ..........71

Trexall . .......................................89

Tri -Estarylla . .............................84

Tri -Legest Fe . ..........................84

Tri -Lo -Estarylla . ......................84

Tri -Lo -Sprintec . ......................84

Tri -Mili . ......................................84

Tri -Nymyo . ...............................84

Tri -Sprintec . .............................84

Tri -VyLibra . ..............................84

Tri -VyLibra Lo . ........................84

Triamcinolone Acetonide . ....73

Triamterene . .............................67

Triamterene -HCTZ . ...............67

Triderm . ....................................73

Trientine HCl . ...........................76

Trifluoperazine HCl . ...............53

Trifluridine . ...............................94

Trihexyphenidyl HCl . ..............52

Trijardy XR . ...............................60

Trimethoprim . ..........................35

Trimipramine Maleate . ..........43

Trintellix . ....................................43

Triumeq . ...................................57

Triumeq PD . .............................57

Trivora . ......................................84

Trizivir . .......................................57

TrophAmine . ............................76

Trospium Chloride . ................79

Trulance . ...................................77

Trulicity . .....................................60

Trumenba . ................................91

Truqap . ......................................50

Tukysa . ......................................47

Turalio . ......................................50

Turqoz . ......................................84

Twinrix . ......................................91

Tyblume . ...................................84

Tybost . .......................................57

Tymlos . ......................................92

Typhim VI . ................................91

Tyrvaya . .....................................93

Ubrelvy . .....................................45

Udenyca . ...................................63

Unithroid . ..................................85

Ursodiol . ....................................77

Valacyclovir HCl . .....................56

Valchlor . ....................................46

Valganciclovir HCl . .................55

Valproic Acid . ..........................39

Valsartan . ..................................63

Valsartan -Hydrochlorothiazide

. ....................................................67

Valtoco 10MG Dose . .............40

Valtoco 15MG Dose . .............40

Valtoco 20MG Dose . .............40

Valtoco 5MG Dose . ................40

Vancomycin HCl . ....................35

Vanflyta . ....................................50

Vaqta . ........................................91

Varenicline Tartrate . ...............34

Varivax . ......................................91

Vascepa . ...................................68

Velivet . .......................................84

Velphoro . ..................................76

Veltassa . ....................................76

Vemlidy . ....................................55

Venclexta . .................................51

Venclexta Starting Pack . .......51

Venlafaxine Besylate ER . ......43

Venlafaxine HCl . .....................43

Venlafaxine HCl ER . ...............43

Ventavis . ...................................98

Ventolin HFA . ...........................97

Verapamil HCl . ........................65

Verapamil HCl ER . .................65

Verquvo . ....................................69

Versacloz . .................................55

Verzenio . ...................................51

Vestura . .....................................84

Vibramycin . ..............................39

Vienva . .......................................84

Vigabatrin . ................................40

Vigadrone . ................................40

Viibryd . ......................................43

Vilazodone HCl . ......................43

Viracept . ....................................58

Viread . .......................................57

Vitrakvi . ......................................51

Vivitrol . .......................................33

Vizimpro . ...................................51

Vonjo . ........................................47

Voriconazole . ...........................45

Vosevi . .......................................55

Votrient . .....................................51

Vowst . ........................................77

Vraylar . ......................................54

Vumerity . ...................................71

VyLibra . .....................................84

Vyfemla . ....................................84

Vyndamax . ...............................79

Vyndaqel . ..................................79

Vyvanse . ....................................69

Vyzulta . ......................................95

Warfarin Sodium . ....................62

Welireg . .....................................51

Wixela Inhub . ...........................99

Wymzya Fe . ..............................84

Xalkori . ......................................51

Xarelto . ......................................62

Xarelto Starter Pack . ..............62

Xatmep . .....................................89

Xcopri . .......................................40

Xeljanz . ......................................88

Xeljanz XR . ...............................88

Xermelo . ....................................77

Xgeva . ........................................92

Xifaxan . ......................................35

Xigduo XR . ...............................60

Xiidra . .........................................93

Xofluza . .....................................58

Xolair . .........................................88

Xospata . ....................................51

Xpovio . ......................................48

Xtampza ER . ............................32

Xtandi . .......................................47

Xulane . ......................................84

YF -VAX . ....................................91

Yuflyma 1 -Pen Kit . .................89

Yuflyma 2 -Syringe Kit . ..........90

Yuvafem . ...................................84

Zafemy . .....................................84

Zafirlukast . ................................96

Zaleplon . ...................................99

Zarxio . ........................................63

Zejula . ........................................51

Zelboraf . ....................................51

Zemaira . ....................................79

Zenatane . ..................................71

Zenpep . .....................................79

Zidovudine . ..............................57

Ziprasidone HCl . .....................54

Ziprasidone Mesylate . ...........55

Zirgan . .......................................55

Zokinvy . .....................................79

Zolinza . ......................................48

Zolpidem Tartrate . ..................99

Zonisade . ..................................41

Zonisamide . .............................41

Zovia 1/35 . ...............................84

Ztalmy . .......................................40

Zurzuvae . ..................................42

Zydelig . .....................................51

Zykadia . ....................................51

Zyprexa Relprevv . ...................55

Covered drugs by category

The list below has information about the drugs covered by this plan. If you have trouble finding

your drug, turn to the “Covered drugs by name (Drug index)” on pages 12-30.

The first column lists the drug name, which may include the dosage form and strength. Brand

name (B) drugs are listed in bold type (for example, Humalog) and generic (G) drugs are listed in

plain type (for example, Simvastatin). The (B) or (G) identifier is listed in the “Brand or Generic”

column. The information in the “Coverage rules or limits on use” column lists any special

requirements for coverage of your drug. If quantity limits (QL) apply to a drug, the restriction

amounts are shown in the chart on pages 100-134.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Analgesics

Nonsteroidal Anti-inflammatory Drugs

Celecoxib (Oral Capsule) G 2 QL

Diclofenac Epolamine (External Patch) B 4 PA; QL

Diclofenac Potassium (50MG Oral Tablet) G 2

Diclofenac Sodium ER (Oral Tablet Extended Release 24

Hour)

G 2

Diclofenac Sodium (1% External Gel) G 3

Diclofenac Sodium (Oral Tablet Delayed Release) G 2

Diflunisal (Oral Tablet) G 3

Etodolac ER (Oral Tablet Extended Release 24 Hour) G 4

Etodolac (Oral Capsule) G 3

Etodolac (Oral Tablet Immediate Release) G 3

Flurbiprofen (100MG Oral Tablet) G 2

Ibu (600MG Oral Tablet, 800MG Oral Tablet) G 2

Ibuprofen (Oral Suspension) G 2

Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet,

800MG Oral Tablet)

G 2

Indomethacin (25MG Oral Capsule Immediate Release,

50MG Oral Capsule Immediate Release)

G 2

Ketoprofen (50MG Oral Capsule Immediate Release) G 3

Meloxicam (Oral Tablet) G 1

Nabumetone (Oral Tablet) G 2

Naproxen (Oral Suspension) G 5 DL

Naproxen (Oral Tablet Immediate Release) G 2

Naproxen DR (Oral Tablet Delayed Release) (Generic

EC-Naprosyn)

G 2

Piroxicam (Oral Capsule) G 3

Sulindac (Oral Tablet) G 2

Opioid Analgesics, Long-acting

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Buprenorphine (Transdermal Patch Weekly) G 4 7D; DL; QL

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)

G 4 7D; MME; DL; QL

Hydromorphone HCl ER (Oral Tablet Extended Release

24 Hour)

G 4 7D; MME; DL; QL

Methadone HCl (Oral Solution) G 3 7D; MME; DL; QL

Methadone HCl (Oral Tablet) G 3 7D; MME; DL; QL

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)

G 3 7D; MME; DL; QL

Morphine Sulfate ER (200MG Oral Tablet Extended

Release) (Generic MS Contin)

G 4 7D; MME; DL; QL

Tramadol HCl (ER Biphasic) (Oral Tablet Extended

Release 24 Hour)

G 3 7D; MME; DL; QL

Tramadol HCl ER (Oral Tablet Extended Release 24

Hour)

G 3 7D; MME; DL; QL

Xtampza ER (Oral Capsule ER 12 Hour

Abuse-Deterrent)

B 4 7D; MME; DL; QL

Opioid Analgesics, Short-acting

Acetaminophen-Caffeine-Dihydrocodeine (Oral Capsule) G 4 7D; MME; DL; QL

Acetaminophen-Codeine (120-12MG/5ML Oral Solution) G 2 7D; MME; DL; QL

Acetaminophen-Codeine (300-15MG Oral Tablet,

300-30MG Oral Tablet, 300-60MG Oral Tablet)

G 2 7D; MME; DL; QL

Butalbital-Acetaminophen-Caffeine (Oral Tablet) G 3 QL

Butalbital-Aspirin-Caffeine (Oral Capsule) G 3 QL

Butorphanol Tartrate (Nasal Solution) G 3 7D; MME; DL; QL

Codeine Sulfate (Oral Tablet) G 4 7D; MME; DL; QL

Endocet (Oral Tablet) G 3 7D; MME; DL; QL

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)

G 5 PA; DL; QL

Fentanyl Citrate (200MCG Buccal Lozenge On A Handle) G 4 PA; DL; QL

Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral

Solution)

G 3 7D; MME; DL; QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Hydrocodone-Acetaminophen (10-325MG Oral Tablet,

5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

G 3 7D; MME; DL; QL

Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet) G 3 7D; MME; DL; QL

Hydromorphone HCl (1MG/ML Oral Liquid) G 4 7D; MME; DL; QL

Hydromorphone HCl (2MG Oral Tablet Immediate

Release, 4MG Oral Tablet Immediate Release, 8MG Oral

Tablet Immediate Release)

G 2 7D; MME; DL; QL

Hydromorphone HCl Preservative Free (10MG/ML

Injection Solution, 50MG/5ML Injection Solution)

G 4 7D; DL

Morphine Sulfate (Concentrate) (20MG/ML Oral

Solution)

G 3 7D; MME; DL; QL

Morphine Sulfate (Oral Solution) G 3 7D; MME; DL; QL

Morphine Sulfate (Oral Tablet Immediate Release) G 3 7D; MME; DL; QL

Oxycodone HCl (Oral Concentrate) G 4 7D; MME; DL; QL

Oxycodone HCl (Oral Solution) G 4 7D; MME; DL; QL

Oxycodone HCl (Oral Tablet Immediate Release) G 2 7D; MME; DL; QL

Oxycodone-Acetaminophen (10-325MG Oral Tablet,

2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG

Oral Tablet)

G 3 7D; MME; DL; QL

Tramadol HCl (50MG Oral Tablet Immediate Release) G 2 7D; MME; DL; QL

Tramadol-Acetaminophen (Oral Tablet) G 2 7D; MME; DL; QL

Anesthetics

Local Anesthetics

Lidocaine (5% External Ointment) G 3 QL

Lidocaine (5% External Patch) G 4 PA; QL

Lidocaine HCl (4% External Solution) G 4

Lidocaine Viscous (2% Mouth/Throat Solution) G 1

Lidocaine-Prilocaine (External Cream) G 3

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

Acamprosate Calcium (Oral Tablet Delayed Release) G 4

Disulfiram (Oral Tablet) G 3

Naltrexone HCl (Oral Tablet) G 3

Vivitrol (Intramuscular Suspension Reconstituted) B 5 DL

Opioid Dependence

Buprenorphine HCl (Tablet Sublingual) G 2 QL

Buprenorphine HCl-Naloxone HCl (Sublingual Film) G 4 QL

Buprenorphine HCl-Naloxone HCl (Tablet Sublingual) G 2 QL

Suboxone (Sublingual Film) B 4 QL

Opioid Reversal Agents

Last updated February 1, 2024 33

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Naloxone HCl (0.4MG/ML Injection Solution) G 2

Naloxone HCl (Injection Solution Cartridge) G 2

Naloxone HCl (Injection Solution Prefilled Syringe) G 2

Naloxone HCl (Nasal Liquid) G 3

Narcan (Nasal Liquid) B 3

Smoking Cessation Agents

Bupropion HCl SR (150MG Oral Tablet Extended

Release 12 Hour Smoking-Deterrent)

G 2

Nicotrol (Inhalation Inhaler) B 4

Nicotrol NS (Nasal Solution) B 4

Varenicline Tartrate (Starter) (Oral Tablet Therapy Pack) G 3

Varenicline Tartrate (Oral Tablet) G 3

Antibacterials

Aminoglycosides

Amikacin Sulfate (500MG/2ML Injection Solution) G 4

Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous

Solution)

G 4

Gentamicin Sulfate (40MG/ML Injection Solution) G 4

Neomycin Sulfate (Oral Tablet) G 2

Paromomycin Sulfate (250MG Oral Capsule) G 4

Streptomycin Sulfate (Intramuscular Solution

Reconstituted)

G 5 DL

Tobramycin Sulfate (10MG/ML Injection Solution,

80MG/2ML Injection Solution)

G 4

Antibacterials, Other

Aztreonam (Injection Solution Reconstituted) G 4

Clindamycin HCl (Oral Capsule) G 2

Clindamycin Palmitate HCl (Oral Solution Reconstituted) G 4

Clindamycin Phosphate in D5W (Intravenous Solution) G 4

Clindamycin Phosphate (600MG/4ML Injection Solution,

900MG/6ML Injection Solution)

G 4

Clindamycin Phosphate (Vaginal Cream) G 3

Colistimethate Sodium (CBA) (Injection Solution

Reconstituted)

G 5 DL

Daptomycin (Intravenous Solution Reconstituted) G 5 DL

Linezolid (Intravenous Solution) G 4

Linezolid (Oral Suspension Reconstituted) G 5 DL; QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Linezolid (Oral Tablet) G 4 QL

Methenamine Hippurate (Oral Tablet) G 3

Metronidazole (External Cream) G 3

Metronidazole (0.75% External Gel) G 3

Metronidazole (1% External Gel) G 4

Metronidazole (External Lotion) G 4

Metronidazole (Intravenous Solution) G 4

Metronidazole (Oral Tablet) G 2

Metronidazole (Vaginal Gel) G 3

Nitrofurantoin Macrocrystal (100MG Oral Capsule, 50MG

Oral Capsule) (Generic Macrodantin)

G 3

Nitrofurantoin Monohydrate (Generic Macrobid) G 3

Polymyxin B Sulfate (Injection Solution Reconstituted) G 4

Tigecycline (Intravenous Solution Reconstituted) G 5 DL

Tinidazole (Oral Tablet) G 4

Trimethoprim (Oral Tablet) G 2

Vancomycin HCl (10GM Intravenous Solution

Reconstituted, 1GM Intravenous Solution Reconstituted,

500MG Intravenous Solution Reconstituted, 750MG

Intravenous Solution Reconstituted)

G 4

Vancomycin HCl (Oral Capsule) G 4 QL

Xifaxan (200MG Oral Tablet) B 4 PA

Xifaxan (550MG Oral Tablet) B 5 PA; DL

Beta-lactam, Cephalosporins

Cefaclor (Oral Capsule) G 3

Cefadroxil (Oral Capsule) G 2

Cefadroxil (Oral Suspension Reconstituted) G 2

Cefazolin Sodium (10GM Injection Solution

Reconstituted, 1GM Injection Solution Reconstituted,

500MG Injection Solution Reconstituted)

G 4

Cefdinir (Oral Capsule) G 3

Cefdinir (Oral Suspension Reconstituted) G 3

Cefepime HCl (Injection Solution Reconstituted) G 4

Cefepime HCl (2GM Intravenous Solution Reconstituted) G 4

Cefixime (Oral Capsule) G 3

Cefixime (Oral Suspension Reconstituted) G 4

Cefotetan Disodium (Injection Solution Reconstituted) G 4

Cefoxitin Sodium (Intravenous Solution Reconstituted) G 4

Cefpodoxime Proxetil (Oral Suspension Reconstituted) G 4

Cefpodoxime Proxetil (Oral Tablet) G 4

Last updated February 1, 2024 35

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Cefprozil (Oral Suspension Reconstituted) G 3

Cefprozil (Oral Tablet) G 3

Ceftazidime (Injection Solution Reconstituted) G 4

Ceftazidime (Intravenous Solution Reconstituted) G 4

Ceftriaxone Sodium (1GM Injection Solution

Reconstituted, 250MG Injection Solution Reconstituted,

2GM Injection Solution Reconstituted, 500MG Injection

Solution Reconstituted)

G 4

Ceftriaxone Sodium (10GM Intravenous Solution

Reconstituted)

G 4

Cefuroxime Axetil (Oral Tablet) G 2

Cefuroxime Sodium (Injection Solution Reconstituted) G 4

Cefuroxime Sodium (Intravenous Solution Reconstituted) G 4

Cephalexin (250MG Oral Capsule, 500MG Oral Capsule) G 2

Cephalexin (750MG Oral Capsule) G 3

Cephalexin (Oral Suspension Reconstituted) G 2

Tazicef (Injection Solution Reconstituted) G 4

Tazicef (2GM Intravenous Solution Reconstituted, 6GM

Intravenous Solution Reconstituted)

G 4

Teflaro (Intravenous Solution Reconstituted) B 5 DL

Beta-lactam, Penicillins

Amoxicillin (Oral Capsule) G 1

Amoxicillin (Oral Suspension Reconstituted) G 1

Amoxicillin (Oral Tablet Immediate Release) G 1

Amoxicillin (Oral Tablet Chewable) G 1

Amoxicillin-Potassium Clavulanate ER (Oral Tablet

Extended Release 12 Hour)

G 4

Amoxicillin-Potassium Clavulanate (Oral Suspension

Reconstituted)

G 2

Amoxicillin-Potassium Clavulanate (Oral Tablet

Immediate Release)

G 2

Amoxicillin-Potassium Clavulanate (Oral Tablet

Chewable)

G 2

Ampicillin (Oral Capsule) G 2

Ampicillin Sodium (125MG Injection Solution

Reconstituted, 1GM Injection Solution Reconstituted)

G 4

Ampicillin Sodium (10GM Intravenous Solution

Reconstituted)

G 4

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Ampicillin-Sulbactam Sodium (Injection Solution

Reconstituted)

G 4

Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous

Solution Reconstituted)

G 4

Bicillin C-R 900/300 (Intramuscular Suspension) B 4

Bicillin C-R (Intramuscular Suspension) B 4

Bicillin L-A (Intramuscular Suspension Prefilled

Syringe)

B 4

Dicloxacillin Sodium (Oral Capsule) G 2

Nafcillin Sodium (Injection Solution Reconstituted) G 4

Nafcillin Sodium (10GM Intravenous Solution

Reconstituted)

G 4

Oxacillin Sodium in Dextrose (Intravenous Solution) B 4

Oxacillin Sodium (Injection Solution Reconstituted) G 4

Oxacillin Sodium (Intravenous Solution Reconstituted) G 4

Penicillin G Potassium (20000000UNIT Injection Solution

Reconstituted)

G 4

Penicillin G Sodium (Injection Solution Reconstituted) G 4

Penicillin V Potassium (Oral Solution Reconstituted) G 2

Penicillin V Potassium (Oral Tablet) G 2

Piperacillin-Tazobactam (2.25 (2-0.25)GM Intravenous

Solution Reconstituted, 3.375 (3-0.375)GM Intravenous

Solution Reconstituted, 4.5 (4-0.5)GM Intravenous

Solution Reconstituted, 40.5 (36-4.5)GM Intravenous

Solution Reconstituted)

G 4

Carbapenems

Ertapenem Sodium (Injection Solution Reconstituted) G 4

Imipenem-Cilastatin (Intravenous Solution Reconstituted) G 4

Meropenem (1GM Intravenous Solution Reconstituted,

500MG Intravenous Solution Reconstituted)

G 4

Macrolides

Azithromycin (Intravenous Solution Reconstituted) G 4

Azithromycin (Oral Suspension Reconstituted) G 1

Azithromycin (Oral Tablet) G 1

Clarithromycin ER (Oral Tablet Extended Release 24

Hour)

G 4

Clarithromycin (Oral Suspension Reconstituted) G 4

Clarithromycin (Oral Tablet Immediate Release) G 3

Dificid (Oral Suspension Reconstituted) B 5 DL

Dificid (Oral Tablet) B 5 DL

Erythrocin Lactobionate (Intravenous Solution

Reconstituted)

B 4

Last updated February 1, 2024 37

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Erythromycin Base (Oral Capsule Delayed Release

Particles)

G 4

Erythromycin Base (Oral Tablet Immediate Release) G 4

Erythromycin Ethylsuccinate (200MG/5ML Oral

Suspension Reconstituted)

G 4

Erythromycin Ethylsuccinate (Oral Tablet) G 4

Erythromycin (Oral Tablet Delayed Release) G 4

Quinolones

Ciprofloxacin HCl (250MG Oral Tablet Immediate

Release, 500MG Oral Tablet Immediate Release, 750MG

Oral Tablet Immediate Release)

G 2

Ciprofloxacin in D5W (200MG/100ML Intravenous

Solution)

G 4

Levofloxacin in D5W (500MG/100ML Intravenous

Solution, 750MG/150ML Intravenous Solution)

G 4

Levofloxacin (Oral Solution) G 4

Levofloxacin (Oral Tablet) G 1

Moxifloxacin HCl in NaCl (Intravenous Solution) G 4

Moxifloxacin HCl (Oral Tablet) G 3

Ofloxacin (Oral Tablet) G 3

Sulfonamides

Sulfadiazine (Oral Tablet) G 4

Sulfamethoxazole-Trimethoprim (Oral Suspension) G 3

Sulfamethoxazole-Trimethoprim (Oral Tablet) G 2

Tetracyclines

Demeclocycline HCl (Oral Tablet) G 4

Doxy 100 (Intravenous Solution Reconstituted) G 4

Doxycycline Hyclate (Oral Capsule) G 3

Doxycycline Hyclate (100MG Oral Tablet Immediate

Release, 20MG Oral Tablet Immediate Release)

G 3

Doxycycline Monohydrate (100MG Oral Capsule, 50MG

Oral Capsule)

G 3

Doxycycline Monohydrate (Oral Suspension

Reconstituted)

G 4

Doxycycline Monohydrate (100MG Oral Tablet, 50MG

Oral Tablet, 75MG Oral Tablet)

G 3

Minocycline HCl (Oral Capsule) G 2

Minocycline HCl (Oral Tablet Immediate Release) G 4

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Tetracycline HCl (Oral Capsule) G 4

Vibramycin (50MG/5ML Oral Syrup) B 4

Anticonvulsants

Anticonvulsants, Other

BRIVIACT (Oral Solution) B 5 PA; DL; QL

BRIVIACT (Oral Tablet) B 5 PA; DL; QL

Epidiolex (Oral Solution) B 5 PA; DL

Eprontia (Oral Solution) B 4

Felbamate (Oral Suspension) G 4

Felbamate (Oral Tablet) G 4

Fintepla (Oral Solution) B 5 PA; DL; QL

Fycompa (Oral Suspension) B 5 DL; QL

Fycompa (10MG Oral Tablet, 12MG Oral Tablet, 4MG

Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet)

B 5 DL; QL

Fycompa (2MG Oral Tablet) B 4 QL

Lamotrigine (100MG Oral Tablet Immediate Release,

150MG Oral Tablet Immediate Release, 200MG Oral

Tablet Immediate Release, 25MG Oral Tablet Immediate

Release)

G 2

Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral

Tablet Chewable)

G 3

Levetiracetam ER (Oral Tablet Extended Release 24

Hour)

G 3

Levetiracetam (Oral Solution) G 2

Levetiracetam (Oral Tablet Immediate Release) G 2

Roweepra (Oral Tablet Immediate Release) G 2

Spritam ODT (Oral Tablet Disintegrating Soluble) B 4

Subvenite (100MG Oral Tablet, 150MG Oral Tablet,

200MG Oral Tablet, 25MG Oral Tablet)

G 2

Topiramate (Oral Capsule Sprinkle Immediate Release) G 1

Topiramate (Oral Tablet) G 1

Valproic Acid (Oral Capsule) G 2

Valproic Acid (Oral Solution) G 2

Xcopri (250MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Xcopri (350MG Daily Dose) (150MG & 200MG Oral

Tablet Therapy Pack)

B 5 PA; DL; QL

Xcopri (100MG Oral Tablet, 150MG Oral Tablet,

200MG Oral Tablet, 50MG Oral Tablet)

B 5 PA; DL; QL

Xcopri (14 x 12.5MG & 14 x 25MG Oral Tablet

Therapy Pack)

B 4 PA; QL

Last updated February 1, 2024 39

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Xcopri (14 x 150MG & 14 x 200MG Oral Tablet

Therapy Pack, 14 x 50MG & 14 x 100MG Oral Tablet

Therapy Pack)

B 5 PA; DL; QL

Calcium Channel Modifying Agents

Ethosuximide (Oral Capsule) G 3

Ethosuximide (Oral Solution) G 3

Methsuximide (Oral Capsule) G 4

Gamma-aminobutyric Acid (GABA) Augmenting Agents

Clobazam (Oral Suspension) G 4 PA; QL

Clobazam (Oral Tablet) G 4 PA; QL

Diacomit (Oral Capsule) B 5 DL; QL

Diacomit (Oral Packet) B 5 DL; QL

Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG

Rectal Gel)

G 4 QL

Gabapentin (Oral Capsule) G 2

Gabapentin (250MG/5ML Oral Solution) G 3

Gabapentin (600MG Oral Tablet, 800MG Oral Tablet) G 2

Nayzilam (Nasal Solution) B 4 PA; QL

Phenobarbital (Oral Elixir) G 2

Phenobarbital (Oral Tablet) G 2

Primidone (Oral Tablet) G 2

Sympazan (Oral Film) B 5 PA; DL; QL

Tiagabine HCl (Oral Tablet) G 4

Valtoco 10MG Dose (Nasal Liquid) B 5 PA; DL; QL

Valtoco 15MG Dose (Nasal Liquid Therapy Pack) B 5 PA; DL; QL

Valtoco 20MG Dose (Nasal Liquid Therapy Pack) B 5 PA; DL; QL

Valtoco 5MG Dose (Nasal Liquid) B 5 PA; DL; QL

Vigabatrin (Oral Packet) G 5 PA; DL; QL

Vigabatrin (Oral Tablet) G 5 PA; DL; QL

Vigadrone (Oral Packet) G 5 PA; DL; QL

Vigadrone (Oral Tablet) G 5 PA; DL; QL

Ztalmy (Oral Suspension) B 5 PA; DL

Sodium Channel Agents

Aptiom (Oral Tablet) B 5 DL; QL

Carbamazepine ER (Oral Capsule Extended Release 12

Hour)

G 3

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Carbamazepine ER (Oral Tablet Extended Release 12

Hour)

G 3

Carbamazepine (Oral Suspension) G 3

Carbamazepine (Oral Tablet Immediate Release) G 3

Carbamazepine (Oral Tablet Chewable) G 3

Dilantin INFATABS (Oral Tablet Chewable) B 3

Dilantin (Oral Capsule) B 3

Epitol (Oral Tablet) G 3

Lacosamide (Oral Solution) G 4 QL

Lacosamide (Oral Tablet) G 4 QL

Oxcarbazepine (Oral Suspension) G 4

Oxcarbazepine (Oral Tablet) G 3

Phenytek (Oral Capsule) G 2

Phenytoin (125MG/5ML Oral Suspension) G 2

Phenytoin (Oral Tablet Chewable) G 2

Phenytoin Sodium Extended (Oral Capsule) G 2

Rufinamide (Oral Suspension) G 5 DL

Rufinamide (200MG Oral Tablet) G 4

Rufinamide (400MG Oral Tablet) G 5 DL

Zonisade (Oral Suspension) B 4 ST

Zonisamide (Oral Capsule) G 2

Antidementia Agents

Antidementia Agents, Other

Namzaric (Oral Capsule ER 24 Hour Therapy Pack) B 3 PA; QL

Namzaric (Oral Capsule Extended Release 24 Hour) B 3 PA; QL

Cholinesterase Inhibitors

Donepezil HCl (Oral Tablet) G 1 QL

Donepezil HCl ODT (Oral Tablet Dispersible) G 2 QL

Galantamine Hydrobromide ER (Oral Capsule Extended

Release 24 Hour)

G 4 QL

Galantamine Hydrobromide (Oral Solution) G 4 QL

Galantamine Hydrobromide (Oral Tablet) G 4 QL

Rivastigmine Tartrate (Oral Capsule) G 3 QL

Rivastigmine (Transdermal Patch 24 Hour) G 4 ST; QL

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

Memantine HCl ER (Oral Capsule Extended Release 24

Hour)

G 3 PA; QL

Memantine HCl (Oral Solution) G 4 PA; QL

Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet) G 2 PA; QL

Last updated February 1, 2024 41

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Memantine HCl Titration Pak (Oral Tablet) G 3 PA; QL

Antidepressants

Antidepressants, Other

Auvelity (Oral Tablet Extended Release) B 5 DL

Bupropion HCl SR (Oral Tablet Extended Release 12

Hour)

G 2

Bupropion HCl XL (150MG Oral Tablet Extended

Release 24 Hour, 300MG Oral Tablet Extended Release

24 Hour)

G 2

Bupropion HCl (Oral Tablet Immediate Release) G 2

Mirtazapine (Oral Tablet) G 2

Mirtazapine ODT (Oral Tablet Dispersible) G 2

Zurzuvae (Oral Capsule) B 5 PA; DL; QL

Monoamine Oxidase Inhibitors

Emsam (Transdermal Patch 24 Hour) B 5 DL; QL

Marplan (Oral Tablet) B 4

Phenelzine Sulfate (Oral Tablet) G 3

Tranylcypromine Sulfate (Oral Tablet) G 4

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

Inhibitors)

Citalopram Hydrobromide (Oral Capsule) B 4

Citalopram Hydrobromide (Oral Solution) G 3

Citalopram Hydrobromide (Oral Tablet) G 1

Desvenlafaxine Succinate ER (Oral Tablet Extended

Release 24 Hour) (Generic Pristiq)

G 3 QL

Escitalopram Oxalate (Oral Solution) G 2

Escitalopram Oxalate (Oral Tablet) G 1

Fetzima (Oral Capsule Extended Release 24 Hour) B 4 ST; QL

Fetzima Titration (Oral Capsule ER 24 Hour Therapy

Pack)

B 4 ST; QL

Fluoxetine HCl (10MG Oral Capsule Immediate Release,

20MG Oral Capsule Immediate Release, 40MG Oral

Capsule Immediate Release)

G 1

Fluoxetine HCl (90MG Oral Capsule Delayed Release) G 4

Fluoxetine HCl (20MG/5ML Oral Solution) G 2

Fluvoxamine Maleate (Oral Tablet) G 3

Nefazodone HCl (Oral Tablet) G 4

Paroxetine HCl (Oral Suspension) G 4

Last updated February 1, 2024

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Paroxetine HCl (Oral Tablet Immediate Release) G 2

Sertraline HCl (Oral Concentrate) G 4

Sertraline HCl (Oral Tablet) G 1

Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet,

50MG Oral Tablet)

G 1

Trazodone HCl (300MG Oral Tablet) G 2

Trintellix (Oral Tablet) B 4 QL

Venlafaxine Besylate ER (Oral Tablet Extended

Release 24 Hour)

B 4

Venlafaxine HCl ER (Oral Capsule Extended Release 24

Hour)

G 2

Venlafaxine HCl (Oral Tablet Immediate Release) G 3

Viibryd (Oral Tablet) B 4 QL

Vilazodone HCl (Oral Tablet) G 4 QL

Tricyclics

Amitriptyline HCl (Oral Tablet) G 4

Amoxapine (Oral Tablet) G 3

Clomipramine HCl (Oral Capsule) G 4

Desipramine HCl (Oral Tablet) G 3

Doxepin HCl (Oral Capsule) G 3

Doxepin HCl (Oral Concentrate) G 3

Imipramine HCl (Oral Tablet) G 4

Imipramine Pamoate (Oral Capsule) G 4

Nortriptyline HCl (Oral Capsule) G 2

Nortriptyline HCl (Oral Solution) G 2

Protriptyline HCl (Oral Tablet) G 4

Trimipramine Maleate (Oral Capsule) G 4

Antiemetics

Antiemetics, Other

Compro (Rectal Suppository) G 4

Meclizine HCl (12.5MG Oral Tablet, 25MG Oral Tablet) G 2

Metoclopramide HCl (5MG/5ML Oral Solution) G 2

Metoclopramide HCl (Oral Tablet) G 1

Perphenazine (Oral Tablet) G 4

Prochlorperazine Maleate (Oral Tablet) G 2

Prochlorperazine (Rectal Suppository) G 4

Promethazine HCl (Oral Syrup) G 3

Promethazine HCl (Oral Tablet) G 3

Promethazine HCl (Rectal Suppository) G 4 QL

Last updated February 1, 2024 43

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Promethegan (25MG Rectal Suppository) G 4 QL

Scopolamine (Transdermal Patch 72 Hour) G 4

Emetogenic Therapy Adjuncts

Anzemet (Oral Tablet) B 4 B/D,PA; QL

Aprepitant (Oral Therapy Pack, Oral Capsule) G 4 PA; QL

Dronabinol (Oral Capsule) G 4 PA

Granisetron HCl (Oral Tablet) G 4 B/D,PA; QL

Ondansetron HCl (Oral Solution) G 4 B/D,PA; QL

Ondansetron HCl (4MG Oral Tablet, 8MG Oral Tablet) G 2 B/D,PA; QL

Ondansetron ODT (Oral Tablet Dispersible) G 2 B/D,PA; QL

Sancuso (Transdermal Patch) B 5 DL; QL

Antifungals

Abelcet (Intravenous Suspension) B 4 B/D,PA

Amphotericin B (Intravenous Solution Reconstituted) G 4 B/D,PA

Amphotericin B Liposome (Intravenous Suspension

Reconstituted)

G 5 B/D,PA; DL

Clotrimazole (Mouth/Throat Troche) G 2

Fluconazole in Sodium Chloride (200-0.9MG/100ML-%

Intravenous Solution, 400-0.9MG/200ML-% Intravenous

Solution)

G 4

Fluconazole (Oral Suspension Reconstituted) G 2

Fluconazole (Oral Tablet) G 2

Flucytosine (Oral Capsule) G 5 DL

Griseofulvin Microsize (Oral Suspension) G 4

Griseofulvin Microsize (Oral Tablet) G 4

Griseofulvin Ultramicrosize (Oral Tablet) G 4

Itraconazole (Oral Capsule) G 4 PA; QL

Ketoconazole (Oral Tablet) G 2

Micafungin Sodium (Intravenous Solution Reconstituted) G 4

Miconazole 3 (Vaginal Suppository) G 3

Noxafil (Oral Suspension) B 5 DL; QL

Nystatin (Mouth/Throat Suspension) G 2

Nystatin (Oral Tablet) G 2

Posaconazole (Oral Suspension) G 5 DL; QL

Posaconazole (Oral Tablet Delayed Release) G 5 PA; DL; QL

Last updated February 1, 2024

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Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Terbinafine HCl (Oral Tablet) G 2 QL

Terconazole (Vaginal Cream) G 3

Terconazole (Vaginal Suppository) G 3

Voriconazole (Intravenous Solution Reconstituted) G 5 PA; DL

Voriconazole (Oral Suspension Reconstituted) G 5 DL; QL

Voriconazole (Oral Tablet) G 4 QL

Antigout Agents

Allopurinol (100MG Oral Tablet, 300MG Oral Tablet) G 1

Colchicine (0.6MG Oral Capsule) (Brand Equivalent

Mitigare)

B 3 QL

Colchicine (0.6MG Oral Tablet) (Generic Colcrys) G 3 QL

Colchicine-Probenecid (Oral Tablet) G 3

Febuxostat (Oral Tablet) G 3 ST

Probenecid (Oral Tablet) G 3

Antimigraine Agents

Acute

Naratriptan HCl (Oral Tablet) G 3 QL

Nurtec ODT (Oral Tablet Dispersible) B 5 PA; DL; QL

Rizatriptan Benzoate (Oral Tablet) G 3 QL

Rizatriptan Benzoate ODT (Oral Tablet Dispersible) G 3 QL

Sumatriptan (Nasal Solution) G 4 QL

Sumatriptan Succinate (Oral Tablet) G 2 QL

Sumatriptan Succinate (Subcutaneous Solution

Auto-Injector)

G 4 QL

Sumatriptan Succinate (Subcutaneous Solution) G 4 QL

Ubrelvy (Oral Tablet) B 5 PA; DL; QL

Ergot Alkaloids

Dihydroergotamine Mesylate (Nasal Solution) G 5 PA; DL; QL

Ergotamine-Caffeine (Oral Tablet) G 3

Prophylactic

Aimovig (Subcutaneous Solution Auto-Injector) B 4 PA; QL

Emgality (300MG Dose) (100MG/ML Subcutaneous

Solution Prefilled Syringe)

B 4 PA; QL

Emgality (Subcutaneous Solution Auto-Injector) B 4 PA; QL

Emgality (120MG/ML Subcutaneous Solution Prefilled

Syringe)

B 4 PA; QL

Qulipta (Oral Tablet) B 5 PA; DL; QL

Timolol Maleate (Oral Tablet) G 3

Antimyasthenic Agents

Last updated February 1, 2024 45

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Parasympathomimetics

Pyridostigmine Bromide ER (Oral Tablet Extended

Release)

G 4

Pyridostigmine Bromide (60MG Oral Tablet Immediate

Release)

G 3

Antimycobacterials

Antimycobacterials, Other

Dapsone (Oral Tablet) G 3

Rifabutin (Oral Capsule) G 4

Antituberculars

Ethambutol HCl (Oral Tablet) G 3

Isoniazid (Oral Syrup) G 4

Isoniazid (Oral Tablet) G 2

Priftin (Oral Tablet) B 4

Pyrazinamide (Oral Tablet) G 4

Rifampin (Intravenous Solution Reconstituted) G 4

Rifampin (Oral Capsule) G 3

Sirturo (Oral Tablet) B 5 PA; DL

Trecator (Oral Tablet) B 4

Antineoplastics

Alkylating Agents

Cyclophosphamide (Oral Capsule) G 3 B/D,PA

Cyclophosphamide (Oral Tablet) B 3 B/D,PA

Gleostine (100MG Oral Capsule) B 5 DL

Gleostine (10MG Oral Capsule, 40MG Oral Capsule) B 4

Leukeran (Oral Tablet) B 5 DL

Matulane (Oral Capsule) B 5 DL

Valchlor (External Gel) B 5 PA; DL; QL

Antiandrogens

Abiraterone Acetate (250MG Oral Tablet) G 4 PA; QL

Abiraterone Acetate (500MG Oral Tablet) G 5 PA; DL; QL

Bicalutamide (Oral Tablet) G 2

Erleada (Oral Tablet) B 5 PA; DL; QL

Nilutamide (Oral Tablet) G 5 DL

Nubeqa (Oral Tablet) B 5 PA; DL; QL

Xtandi (Oral Capsule) B 5 PA; DL; QL

Last updated February 1, 2024

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Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Xtandi (Oral Tablet) B 5 PA; DL; QL

Antiangiogenic Agents

Fotivda (Oral Capsule) B 5 PA; DL; QL

Lenalidomide (Oral Capsule) G 5 PA; DL; QL

Pomalyst (Oral Capsule) B 5 PA; DL; QL

Qinlock (Oral Tablet) B 5 PA; DL; QL

Revlimid (Oral Capsule) B 5 PA; DL; QL

Tabrecta (Oral Tablet) B 5 PA; DL; QL

Thalomid (Oral Capsule) B 5 PA; DL; QL

Antiestrogens/Modifiers

Emcyt (Oral Capsule) B 4

Orserdu (Oral Tablet) B 5 PA; DL; QL

Soltamox (Oral Solution) B 5 DL

Tamoxifen Citrate (Oral Tablet) G 2

Toremifene Citrate (Oral Tablet) G 5 DL

Antimetabolites

Droxia (Oral Capsule) B 4

Hydroxyurea (Oral Capsule) G 2

Mercaptopurine (Oral Tablet) G 3

Onureg (Oral Tablet) B 5 PA; DL; QL

Purixan (Oral Suspension) B 5 PA; DL

Tabloid (Oral Tablet) B 5 PA; DL

Antineoplastics, Other

IDHIFA (Oral Tablet) B 5 PA; DL; QL

Krazati (Oral Tablet) B 5 PA; DL; QL

Lonsurf (Oral Tablet) B 5 PA; DL; QL

Lumakras (Oral Tablet) B 5 PA; DL; QL

Ninlaro (Oral Capsule) B 5 PA; DL; QL

Pemazyre (Oral Tablet) B 5 PA; DL; QL

Retevmo (Oral Capsule) B 5 PA; DL; QL

Tazverik (Oral Tablet) B 5 PA; DL; QL

Tukysa (Oral Tablet) B 5 PA; DL; QL

Vonjo (Oral Capsule) B 5 PA; DL; QL

Xpovio (100MG Once Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Xpovio (40MG Once Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Xpovio (40MG Twice Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Last updated February 1, 2024 47

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Xpovio (60MG Once Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Xpovio (60MG Twice Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Xpovio (80MG Once Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Xpovio (80MG Twice Weekly) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Zolinza (Oral Capsule) B 5 PA; DL

Aromatase Inhibitors, 3rd Generation

Anastrozole (Oral Tablet) G 1

Exemestane (Oral Tablet) G 4

Letrozole (Oral Tablet) G 2

Molecular Target Inhibitors

Alecensa (Oral Capsule) B 5 PA; DL; QL

Alunbrig (Oral Tablet) B 5 PA; DL; QL

Alunbrig (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Ayvakit (Oral Tablet) B 5 PA; DL; QL

Balversa (Oral Tablet) B 5 PA; DL; QL

Bosulif (Oral Tablet) B 5 PA; DL; QL

Braftovi (Oral Capsule) B 5 PA; DL

Brukinsa (Oral Capsule) B 5 PA; DL; QL

Cabometyx (Oral Tablet) B 5 PA; DL; QL

Calquence (100MG Oral Capsule) B 5 PA; DL; QL

Calquence (Oral Tablet) B 5 PA; DL; QL

Caprelsa (Oral Tablet) B 5 PA; DL

Cometriq (100MG Daily Dose) (Oral Kit) B 5 PA; DL; QL

Cometriq (140MG Daily Dose) (Oral Kit) B 5 PA; DL; QL

Cometriq (60MG Daily Dose) (Oral Kit) B 5 PA; DL; QL

Copiktra (Oral Capsule) B 5 PA; DL; QL

Cotellic (Oral Tablet) B 5 PA; DL; QL

Daurismo (Oral Tablet) B 5 PA; DL; QL

Erivedge (Oral Capsule) B 5 PA; DL

Erlotinib HCl (Oral Tablet) G 5 PA; DL; QL

Everolimus (10MG Oral Tablet, 2.5MG Oral Tablet, 5MG

Oral Tablet, 7.5MG Oral Tablet)

G 5 PA; DL

Everolimus (Oral Tablet Soluble) G 5 PA; DL

Last updated February 1, 2024

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Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Exkivity (Oral Capsule) B 5 PA; DL; QL

Fruzaqla (Oral Capsule) B 5 PA; DL; QL

Gavreto (Oral Capsule) B 5 PA; DL; QL

Gefitinib (Oral Tablet) G 5 PA; DL; QL

Gilotrif (Oral Tablet) B 5 PA; DL

Ibrance (Oral Capsule) B 5 PA; DL; QL

Ibrance (Oral Tablet) B 5 PA; DL; QL

Iclusig (Oral Tablet) B 5 PA; DL; QL

Imatinib Mesylate (Oral Tablet) G 3 PA; QL

Imbruvica (Oral Capsule) B 5 PA; DL; QL

Imbruvica (Oral Suspension) B 5 PA; DL; QL

Imbruvica (140MG Oral Tablet, 280MG Oral Tablet,

420MG Oral Tablet)

B 5 PA; DL; QL

Inlyta (Oral Tablet) B 5 PA; DL; QL

Inqovi (Oral Tablet) B 5 PA; DL; QL

Inrebic (Oral Capsule) B 5 PA; DL; QL

Jakafi (Oral Tablet) B 5 PA; DL; QL

Jaypirca (Oral Tablet) B 5 PA; DL; QL

Kisqali (200MG Dose) (Oral Tablet) B 5 PA; DL; QL

Kisqali (400MG Dose) (Oral Tablet) B 5 PA; DL; QL

Kisqali (600MG Dose) (Oral Tablet) B 5 PA; DL; QL

Kisqali Femara (200MG Dose) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Kisqali Femara (400MG Dose) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Kisqali Femara (600MG Dose) (Oral Tablet Therapy

Pack)

B 5 PA; DL; QL

Koselugo (Oral Capsule) B 5 PA; DL; QL

Lapatinib Ditosylate (Oral Tablet) G 5 PA; DL

Lenvima 10MG Daily Dose (Oral Capsule Therapy

Pack)

B 5 PA; DL

Lenvima 12MG Daily Dose (Oral Capsule Therapy

Pack)

B 5 PA; DL

Lenvima 14MG Daily Dose (Oral Capsule Therapy

Pack)

B 5 PA; DL

Lenvima 18MG Daily Dose (Oral Capsule Therapy

Pack)

B 5 PA; DL

Lenvima 20MG Daily Dose (Oral Capsule Therapy

Pack)

B 5 PA; DL

Lenvima 24MG Daily Dose (Oral Capsule Therapy

Pack)

B 5 PA; DL

Last updated February 1, 2024 49

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Lenvima 4MG Daily Dose (Oral Capsule Therapy Pack) B 5 PA; DL

Lenvima 8MG Daily Dose (Oral Capsule Therapy Pack) B 5 PA; DL

Lorbrena (Oral Tablet) B 5 PA; DL; QL

Lynparza (Oral Tablet) B 5 PA; DL; QL

Lytgobi (12MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Lytgobi (16MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Lytgobi (20MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Mekinist (Oral Solution Reconstituted) B 5 PA; DL

Mekinist (Oral Tablet) B 5 PA; DL

Mektovi (Oral Tablet) B 5 PA; DL

Nerlynx (Oral Tablet) B 5 PA; DL; QL

Odomzo (Oral Capsule) B 5 PA; DL

Ojjaara (Oral Tablet) B 5 PA; DL; QL

Pazopanib HCl (Oral Tablet) G 5 PA; DL; QL

Piqray (200MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Piqray (250MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Piqray (300MG Daily Dose) (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Rezlidhia (Oral Capsule) B 5 PA; DL; QL

Rozlytrek (Oral Capsule) B 5 PA; DL; QL

Rubraca (Oral Tablet) B 5 PA; DL; QL

Rydapt (Oral Capsule) B 5 PA; DL; QL

Scemblix (Oral Tablet) B 5 PA; DL; QL

Sorafenib Tosylate (Oral Tablet) G 5 PA; DL

Sprycel (Oral Tablet) B 5 PA; DL; QL

Stivarga (Oral Tablet) B 5 PA; DL; QL

Sunitinib Malate (Oral Capsule) G 5 PA; DL; QL

Tafinlar (Oral Capsule) B 5 PA; DL

Tafinlar (Oral Tablet Soluble) B 5 PA; DL

Tagrisso (Oral Tablet) B 5 PA; DL; QL

Talzenna (Oral Capsule) B 5 PA; DL; QL

Tasigna (Oral Capsule) B 5 PA; DL; QL

Tepmetko (Oral Tablet) B 5 PA; DL; QL

Tibsovo (Oral Tablet) B 5 PA; DL; QL

Truqap (Oral Tablet) B 5 PA; DL; QL

Turalio (125MG Oral Capsule) B 5 PA; DL; QL

Vanflyta (Oral Tablet) B 5 PA; DL; QL

Last updated February 1, 2024

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Venclexta (100MG Oral Tablet, 50MG Oral Tablet) B 5 PA; DL; QL

Venclexta (10MG Oral Tablet) B 3 PA; QL

Venclexta Starting Pack (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Verzenio (Oral Tablet) B 5 PA; DL; QL

Vitrakvi (Oral Capsule) B 5 PA; DL; QL

Vitrakvi (Oral Solution) B 5 PA; DL; QL

Vizimpro (Oral Tablet) B 5 PA; DL; QL

Votrient (Oral Tablet) B 5 PA; DL; QL

Welireg (Oral Tablet) B 5 PA; DL; QL

Xalkori (Oral Capsule) B 5 PA; DL

Xospata (Oral Tablet) B 5 PA; DL; QL

Zejula (100MG Oral Capsule) B 5 PA; DL; QL

Zejula (Oral Tablet) B 5 PA; DL; QL

Zelboraf (Oral Tablet) B 5 PA; DL

Zydelig (Oral Tablet) B 5 PA; DL; QL

Zykadia (Oral Tablet) B 5 PA; DL; QL

Retinoids

Bexarotene (External Gel) G 5 PA; DL; QL

Bexarotene (Oral Capsule) G 5 PA; DL

Panretin (External Gel) B 5 PA; DL

Tretinoin (Oral Capsule) G 5 DL

Treatment Adjuncts

Leucovorin Calcium (10MG Oral Tablet, 15MG Oral

Tablet, 5MG Oral Tablet)

G 3

Leucovorin Calcium (25MG Oral Tablet) G 4

Mesnex (Oral Tablet) B 4

Antiparasitics

Anthelmintics

Albendazole (Oral Tablet) G 4 QL

Ivermectin (Oral Tablet) G 3 PA

Praziquantel (Oral Tablet) G 4

Antiprotozoals

Atovaquone (Oral Suspension) G 5 DL; QL

Atovaquone-Proguanil HCl (Oral Tablet) G 3

Benznidazole (Oral Tablet) B 4

Chloroquine Phosphate (Oral Tablet) G 4 QL

Coartem (Oral Tablet) B 4

Hydroxychloroquine Sulfate (200MG Oral Tablet) G 2 QL

Impavido (Oral Capsule) B 5 DL

Last updated February 1, 2024 51

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Mefloquine HCl (Oral Tablet) G 2

Nitazoxanide (Oral Tablet) G 5 DL; QL

Pentamidine Isethionate (Inhalation Solution

Reconstituted)

G 4 B/D,PA; QL

Pentamidine Isethionate (Injection Solution

Reconstituted)

G 4

Primaquine Phosphate (Oral Tablet) G 4

Pyrimethamine (Oral Tablet) G 5 DL

Quinine Sulfate (Oral Capsule) G 4 PA

Antiparkinson Agents

Anticholinergics

Benztropine Mesylate (Oral Tablet) G 2

Trihexyphenidyl HCl (Oral Solution) G 2

Trihexyphenidyl HCl (Oral Tablet) G 2

Antiparkinson Agents, Other

Amantadine HCl (Oral Capsule) G 3

Amantadine HCl (Oral Solution) G 2

Amantadine HCl (Oral Tablet) G 3

Carbidopa-Levodopa-Entacapone (Oral Tablet) G 4

Entacapone (Oral Tablet) G 4

Dopamine Agonists

Bromocriptine Mesylate (Oral Capsule) G 3

Bromocriptine Mesylate (Oral Tablet) G 3

Neupro (Transdermal Patch 24 Hour) B 4

Pramipexole Dihydrochloride (Oral Tablet Immediate

Release)

G 2

Ropinirole HCl (Oral Tablet Immediate Release) G 2

Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors

Carbidopa (Oral Tablet) G 4

Carbidopa-Levodopa ER (Oral Tablet Extended Release) G 1

Carbidopa-Levodopa (Oral Tablet Immediate Release) G 1

Carbidopa-Levodopa ODT (Oral Tablet Dispersible) G 2

Inbrija (Inhalation Capsule) B 5 PA; DL

Rytary (Oral Capsule Extended Release) B 4 ST

Monoamine Oxidase B (MAO-B) Inhibitors

Rasagiline Mesylate (Oral Tablet) G 4

Last updated February 1, 2024

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Selegiline HCl (Oral Capsule) G 3

Selegiline HCl (Oral Tablet) G 3

Antipsychotics

1st Generation/Typical

Chlorpromazine HCl (Oral Concentrate) G 4

Chlorpromazine HCl (Oral Tablet) G 4

Fluphenazine Decanoate (Injection Solution) G 4

Fluphenazine HCl (2.5MG/ML Injection Solution) G 4

Fluphenazine HCl (5MG/ML Oral Concentrate) G 3

Fluphenazine HCl (2.5MG/5ML Oral Elixir) G 4

Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet,

2.5MG Oral Tablet, 5MG Oral Tablet)

G 2

Haloperidol Decanoate (Intramuscular Solution) G 4

Haloperidol Lactate (Injection Solution) G 4

Haloperidol Lactate (Oral Concentrate) G 2

Haloperidol (Oral Tablet) G 2

Loxapine Succinate (Oral Capsule) G 2

Molindone HCl (Oral Tablet) G 4

Pimozide (Oral Tablet) G 4

Thioridazine HCl (Oral Tablet) G 3

Thiothixene (Oral Capsule) G 3

Trifluoperazine HCl (Oral Tablet) G 3

2nd Generation/Atypical

Abilify Maintena (Intramuscular Prefilled Syringe) B 5 DL

Abilify Maintena (Intramuscular Suspension

Reconstituted ER)

B 5 DL

Aripiprazole (1MG/ML Oral Solution) G 4 QL

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet,

20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet,

5MG Oral Tablet)

G 3 QL

Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG

Oral Tablet Dispersible)

G 5 DL; QL

Aristada Initio (Intramuscular Prefilled Syringe) B 5 DL

Aristada (Intramuscular Prefilled Syringe) B 5 DL

Asenapine Maleate (Tablet Sublingual) G 4 QL

Caplyta (Oral Capsule) B 5 PA; DL; QL

Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 1MG

Oral Tablet, 2MG Oral Tablet, 4MG Oral Tablet, 6MG

Oral Tablet, 8MG Oral Tablet)

B 5 ST; DL; QL

Fanapt Titration Pack (Oral Tablet) B 4 ST; QL

Last updated February 1, 2024 53

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Invega Hafyera (Intramuscular Suspension Prefilled

Syringe)

B 5 DL

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)

B 5 DL

Invega Sustenna (39MG/0.25ML Intramuscular

Suspension Prefilled Syringe)

B 4

Invega Trinza (Intramuscular Suspension Prefilled

Syringe)

B 5 DL

Lurasidone HCl (Oral Tablet) G 3 QL

Lybalvi (Oral Tablet) B 5 ST; DL; QL

Nuplazid (Oral Capsule) B 5 PA; DL; QL

Nuplazid (Oral Tablet) B 5 PA; DL; QL

Olanzapine (Intramuscular Solution Reconstituted) G 4

Olanzapine (Oral Tablet) G 2 QL

Olanzapine ODT (Oral Tablet Dispersible) G 4 QL

Paliperidone ER (Oral Tablet Extended Release 24 Hour) G 4 QL

Perseris (Subcutaneous Prefilled Syringe) B 5 DL

Quetiapine Fumarate ER (Oral Tablet Extended Release

24 Hour)

G 3 QL

Quetiapine Fumarate (Oral Tablet Immediate Release) G 2 QL

Rexulti (Oral Tablet) B 5 DL; QL

Risperdal Consta (12.5MG Intramuscular Suspension

Reconstituted ER, 25MG Intramuscular Suspension

Reconstituted ER)

B 4

Risperdal Consta (37.5MG Intramuscular Suspension

Reconstituted ER, 50MG Intramuscular Suspension

Reconstituted ER)

B 5 DL

Risperidone (Oral Solution) G 4

Risperidone (Oral Tablet) G 2

Risperidone ODT (Oral Tablet Dispersible) G 4

Secuado (Transdermal Patch 24 Hour) B 5 ST; DL; QL

Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule,

4.5MG Oral Capsule, 6MG Oral Capsule)

B 5 PA; DL; QL

Vraylar (Oral Capsule Therapy Pack) B 4 PA; QL

Ziprasidone HCl (Oral Capsule) G 3 QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Ziprasidone Mesylate (Intramuscular Solution

Reconstituted)

G 4

Zyprexa Relprevv (210MG Intramuscular Suspension

Reconstituted)

B 5 DL

Treatment-Resistant

Clozapine (100MG Oral Tablet, 200MG Oral Tablet,

25MG Oral Tablet, 50MG Oral Tablet)

G 3

Clozapine ODT (100MG Oral Tablet Dispersible, 12.5MG

Oral Tablet Dispersible, 150MG Oral Tablet Dispersible,

200MG Oral Tablet Dispersible, 25MG Oral Tablet

Dispersible)

G 4 QL

Versacloz (Oral Suspension) B 5 DL

Antispasticity Agents

Baclofen (Oral Tablet) G 2

Dantrolene Sodium (Oral Capsule) G 4

Tizanidine HCl (Oral Tablet) G 2

Antivirals

Anti-cytomegalovirus (CMV) Agents

Prevymis (Oral Tablet) B 5 PA; DL; QL

Valganciclovir HCl (Oral Solution Reconstituted) G 5 DL; QL

Valganciclovir HCl (Oral Tablet) G 3 QL

Zirgan (Ophthalmic Gel) B 4

Anti-hepatitis B (HBV) Agents

Adefovir Dipivoxil (Oral Tablet) G 4

Baraclude (Oral Solution) B 4

Entecavir (Oral Tablet) G 4

Lamivudine (100MG Oral Tablet) G 3

Vemlidy (Oral Tablet) B 5 DL; QL

Anti-hepatitis C (HCV) Agents

Epclusa (Oral Packet) B 5 PA; DL; QL

Epclusa (Oral Tablet) B 5 PA; DL; QL

Mavyret (Oral Packet) B 5 PA; DL; QL

Mavyret (Oral Tablet) B 5 PA; DL; QL

Ribavirin (Oral Tablet) G 3

Sofosbuvir-Velpatasvir (Oral Tablet) B 5 PA; DL; QL

Vosevi (Oral Tablet) B 5 PA; DL; QL

Antiherpetic Agents

Acyclovir (External Ointment) G 4 QL

Acyclovir (Oral Capsule) G 2

Last updated February 1, 2024 55

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Acyclovir (Oral Suspension) G 3

Acyclovir (Oral Tablet) G 1

Acyclovir Sodium (Intravenous Solution) G 4 B/D,PA

Famciclovir (Oral Tablet) G 3 QL

Valacyclovir HCl (Oral Tablet) G 3 QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

Biktarvy (Oral Tablet) B 5 DL; QL

Dovato (Oral Tablet) B 5 DL; QL

Genvoya (Oral Tablet) B 5 DL; QL

Isentress HD (Oral Tablet) B 5 DL; QL

Isentress (Oral Packet) B 4 QL

Isentress (Oral Tablet) B 5 DL; QL

Isentress (100MG Oral Tablet Chewable) B 4 QL

Isentress (25MG Oral Tablet Chewable) B 3 QL

Juluca (Oral Tablet) B 5 DL; QL

Stribild (Oral Tablet) B 5 DL; QL

Tivicay (10MG Oral Tablet, 25MG Oral Tablet) B 4 QL

Tivicay (50MG Oral Tablet) B 5 DL; QL

Tivicay PD (Oral Tablet Soluble) B 5 DL; QL

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

Complera (Oral Tablet) B 5 DL; QL

Delstrigo (Oral Tablet) B 5 DL; QL

Edurant (Oral Tablet) B 5 DL; QL

Efavirenz (200MG Oral Capsule, 50MG Oral Capsule) G 4 QL

Efavirenz (Oral Tablet) G 4 QL

Efavirenz-Emtricitabine-Tenofovir (Oral Tablet) G 4 QL

Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G 5 DL; QL

Etravirine (Oral Tablet) G 5 DL; QL

Intelence (25MG Oral Tablet) B 4 QL

Nevirapine ER (400MG Oral Tablet Extended Release 24

Hour)

G 4 QL

Nevirapine (Oral Suspension) G 4 QL

Nevirapine (Oral Tablet Immediate Release) G 3 QL

Pifeltro (Oral Tablet) B 5 DL; QL

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

Abacavir Sulfate (Oral Solution) G 4 QL

Last updated February 1, 2024

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Abacavir Sulfate (Oral Tablet) G 4 QL

Abacavir Sulfate-Lamivudine (Oral Tablet) G 4 QL

Cimduo (Oral Tablet) B 5 DL; QL

Descovy (Oral Tablet) B 5 DL; QL

Emtricitabine (Oral Capsule) G 4 QL

Emtricitabine-Tenofovir Disoproxil Fumarate

(100MG-150MG Oral Tablet, 133MG-200MG Oral Tablet,

167MG-250MG Oral Tablet)

G 5 DL; QL

Emtricitabine-Tenofovir Disoproxil Fumarate

(200MG-300MG Oral Tablet)

G 4 QL

Emtriva (Oral Solution) B 4 QL

Lamivudine (10MG/ML Oral Solution) G 3 QL

Lamivudine (150MG Oral Tablet, 300MG Oral Tablet) G 3 QL

Lamivudine-Zidovudine (Oral Tablet) G 4 QL

Odefsey (Oral Tablet) B 5 DL; QL

Tenofovir Disoproxil Fumarate (Oral Tablet) G 4 QL

Triumeq (Oral Tablet) B 5 DL; QL

Triumeq PD (Oral Tablet Soluble) B 5 DL; QL

Trizivir (300-150-300MG Oral Tablet) B 5 DL; QL

Viread (Oral Powder) B 5 DL; QL

Viread (150MG Oral Tablet, 200MG Oral Tablet,

250MG Oral Tablet)

B 5 DL; QL

Zidovudine (Oral Capsule) G 3 QL

Zidovudine (Oral Syrup) G 3 QL

Zidovudine (Oral Tablet) G 3 QL

Anti-HIV Agents, Other

Fuzeon (Subcutaneous Solution Reconstituted) B 5 DL; QL

Maraviroc (Oral Tablet) G 5 DL; QL

Rukobia (Oral Tablet Extended Release 12 Hour) B 5 DL; QL

Selzentry (Oral Solution) B 5 DL; QL

Selzentry (25MG Oral Tablet) B 3 QL

Selzentry (75MG Oral Tablet) B 5 DL; QL

Sunlenca (Oral Tablet Therapy Pack) B 5 DL; QL

Tybost (Oral Tablet) B 4 QL

Anti-HIV Agents, Protease Inhibitors

Aptivus (Oral Capsule) B 5 DL; QL

Atazanavir Sulfate (Oral Capsule) G 4 QL

Darunavir (Oral Tablet) G 5 DL; QL

Evotaz (Oral Tablet) B 5 DL; QL

Fosamprenavir Calcium (Oral Tablet) G 5 DL; QL

Last updated February 1, 2024 57

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Lexiva (Oral Suspension) B 4 QL

Lopinavir-Ritonavir (Oral Solution) G 4 QL

Lopinavir-Ritonavir (Oral Tablet) G 4 QL

Norvir (Oral Packet) B 4 QL

Prezcobix (Oral Tablet) B 5 DL; QL

Prezista (Oral Suspension) B 5 DL; QL

Prezista (150MG Oral Tablet) B 5 DL; QL

Prezista (75MG Oral Tablet) B 4 QL

Reyataz (Oral Packet) B 5 DL; QL

Ritonavir (Oral Tablet) G 3 QL

Symtuza (Oral Tablet) B 5 DL; QL

Viracept (Oral Tablet) B 5 DL; QL

Anti-influenza Agents

Oseltamivir Phosphate (Oral Capsule) G 3 QL

Oseltamivir Phosphate (Oral Suspension Reconstituted) G 3 QL

Relenza Diskhaler (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Rimantadine HCl (Oral Tablet) G 4

Xofluza (40MG Dose) (Oral Tablet Therapy Pack) B 3 QL

Xofluza (80MG Dose) (Oral Tablet Therapy Pack) B 3 QL

Anxiolytics

Anxiolytics, Other

Buspirone HCl (Oral Tablet) G 2

Hydroxyzine HCl (Oral Syrup) G 3

Hydroxyzine HCl (Oral Tablet) G 3

Hydroxyzine Pamoate (Oral Capsule) G 3

Benzodiazepines

Alprazolam (Oral Tablet Immediate Release) G 1 QL

Chlordiazepoxide HCl (Oral Capsule) G 2

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG

Oral Tablet)

G 2 QL

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)

G 4 QL

Clorazepate Dipotassium (Oral Tablet) G 3 QL

Diazepam Intensol (Oral Concentrate) G 2 QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Diazepam (5MG/5ML Oral Solution) G 2

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG

Oral Tablet)

G 2 QL

Lorazepam Intensol (Oral Concentrate) G 2 QL

Lorazepam (Oral Tablet) G 1 QL

Bipolar Agents

Mood Stabilizers

Divalproex Sodium ER (Oral Tablet Extended Release 24

Hour)

G 2

Divalproex Sodium (Oral Capsule Delayed Release

Sprinkle)

G 2

Divalproex Sodium (Oral Tablet Delayed Release) G 2

Lithium Carbonate ER (Oral Tablet Extended Release) G 2

Lithium Carbonate (Oral Capsule) G 2

Lithium Carbonate (Oral Tablet Immediate Release) G 2

Lithium (Oral Solution) G 3

Blood Glucose Regulators

Antidiabetic Agents

Acarbose (Oral Tablet) G 1 QL

Bydureon BCise (Subcutaneous Auto-Injector) B 3 PA; QL

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)

B 4 PA; QL

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)

B 4 PA; QL

Cycloset (Oral Tablet) B 4 PA; QL

Farxiga (Oral Tablet) B 3 QL

Glimepiride (Oral Tablet) G 1 QL

Glipizide ER (Oral Tablet Extended Release 24 Hour) G 1 QL

Glipizide (10MG Oral Tablet Immediate Release, 5MG

Oral Tablet Immediate Release)

G 1 QL

Glipizide-Metformin HCl (Oral Tablet) G 1 QL

Glyxambi (Oral Tablet) B 3 QL

Janumet (Oral Tablet Immediate Release) B 3 QL

Janumet XR (Oral Tablet Extended Release 24 Hour) B 3 QL

Januvia (Oral Tablet) B 3 QL

Jardiance (Oral Tablet) B 3 QL

Jentadueto (2.5-1000MG Oral Tablet, 2.5-500MG Oral

Tablet)

B 3 QL

Jentadueto XR (Oral Tablet Extended Release 24

Hour)

B 3 QL

Last updated February 1, 2024 59

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Metformin HCl ER (Oral Tablet Extended Release 24

Hour) (Generic Glucophage XR)

G 1 QL

Metformin HCl (Oral Solution) G 1 QL

Metformin HCl (1000MG Oral Tablet Immediate Release,

500MG Oral Tablet Immediate Release, 850MG Oral

Tablet Immediate Release)

G 1 QL

Miglitol (Oral Tablet) G 4 QL

Mounjaro (Subcutaneous Solution Pen-Injector) B 3 PA; QL

Nateglinide (Oral Tablet) G 1 QL

Ozempic (0.25MG/DOSE or 0.5MG/DOSE) (2MG/3ML

Subcutaneous Solution Pen-Injector)

B 3 PA; QL

Ozempic (1MG/DOSE) (4MG/3ML Subcutaneous

Solution Pen-Injector)

B 3 PA; QL

Ozempic (2MG/DOSE) (8MG/3ML Subcutaneous

Solution Pen-Injector)

B 3 PA; QL

Pioglitazone HCl (Oral Tablet) G 1 QL

Pioglitazone HCl-Glimepiride (Oral Tablet) G 1 QL

Pioglitazone HCl-Metformin HCl (Oral Tablet) G 1 QL

Repaglinide (Oral Tablet) G 1 QL

Rybelsus (Oral Tablet) B 3 PA; QL

Soliqua (Subcutaneous Solution Pen-Injector) B 3 PA; QL

Synjardy (Oral Tablet Immediate Release) B 3 QL

Tradjenta (Oral Tablet) B 3 QL

Trijardy XR (Oral Tablet Extended Release 24 Hour) B 3 QL

Trulicity (Subcutaneous Solution Pen-Injector) B 3 PA; QL

Xigduo XR (Oral Tablet Extended Release 24 Hour) B 3 QL

Glycemic Agents

Baqsimi One Pack (Nasal Powder) B 3

Diazoxide (Oral Suspension) G 4

GlucaGen HypoKit (Injection Solution Reconstituted) B 4

Glucagon (Injection Kit) (Lilly) B 3

Gvoke HypoPen 2-Pack (Subcutaneous Solution

Auto-Injector)

B 3

Gvoke Kit (Subcutaneous Solution) B 3

Gvoke PFS (Subcutaneous Solution Prefilled Syringe) B 3

Insulins

Humalog (Injection Solution) B 3

Last updated February 1, 2024

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Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Humalog Junior KwikPen (Subcutaneous Solution

Pen-Injector)

B 3

Humalog KwikPen (Subcutaneous Solution

Pen-Injector)

B 3

Humalog Mix 50/50 KwikPen (Subcutaneous

Suspension Pen-Injector)

B 3

Humalog Mix 50/50 (Subcutaneous Suspension) B 3

Humalog Mix 75/25 KwikPen (Subcutaneous

Suspension Pen-Injector)

B 3

Humalog Mix 75/25 (Subcutaneous Suspension) B 3

Humalog (Subcutaneous Solution Cartridge) B 3

Humulin 70/30 KwikPen (Subcutaneous Suspension

Pen-Injector)

B 3

Humulin 70/30 (Subcutaneous Suspension) B 3

Humulin N KwikPen (Subcutaneous Suspension

Pen-Injector)

B 3

Humulin N (Subcutaneous Suspension) B 3

Humulin R (Injection Solution) B 3

Humulin R U-500 (Concentrated) (Subcutaneous

Solution)

B 3

Humulin R U-500 KwikPen (Subcutaneous Solution

Pen-Injector)

B 3

Insulin Lispro (1 Unit Dial) (Subcutaneous Solution

Pen-Injector) (Brand Equivalent Humalog)

B 3

Insulin Lispro (Injection Solution) (Brand Equivalent

Humalog)

B 3

Insulin Lispro Junior KwikPen (Subcutaneous Solution

Pen-Injector) (Brand Equivalent Humalog)

B 3

Insulin Lispro Prot & Lispro (Subcutaneous

Suspension Pen-Injector) (Brand Equivalent Humalog)

B 3

Lantus SoloStar (Subcutaneous Solution Pen-Injector) B 3

Lantus (Subcutaneous Solution) B 3

Levemir FlexPen (Subcutaneous Solution

Pen-Injector)

B 3

Levemir (Subcutaneous Solution) B 3

Lyumjev (Injection Solution) B 3

Lyumjev KwikPen (Subcutaneous Solution

Pen-Injector)

B 3

Toujeo Max SoloStar (Subcutaneous Solution

Pen-Injector)

B 3

Toujeo SoloStar (Subcutaneous Solution Pen-Injector) B 3

Tresiba FlexTouch (Subcutaneous Solution

Pen-Injector)

B 3

Last updated February 1, 2024 61

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Tresiba (Subcutaneous Solution) B 3

Blood Products and Modifiers

Anticoagulants

Eliquis (Oral Tablet) B 3 QL

Eliquis Starter Pack (Oral Tablet) B 3 QL

Enoxaparin Sodium (Injection Solution Prefilled Syringe) G 4 QL

Fondaparinux Sodium (10MG/0.8ML Subcutaneous

Solution, 5MG/0.4ML Subcutaneous Solution,

7.5MG/0.6ML Subcutaneous Solution)

G 5 DL

Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous

Solution)

G 4

Heparin Sodium (10000UNIT/ML Injection Solution,

20000UNIT/ML Injection Solution, 5000UNIT/ML

Injection Solution)

G 3

Heparin Sodium (1000UNIT/ML Injection Solution) G 3 B/D,PA

Jantoven (Oral Tablet) G 1

Warfarin Sodium (Oral Tablet) G 1

Xarelto (Oral Tablet) B 3 QL

Xarelto Starter Pack (Oral Tablet Therapy Pack) B 3 QL

Blood Products and Modifiers, Other

Anagrelide HCl (Oral Capsule) G 3

Aranesp (Albumin Free) (100MCG/ML Injection

Solution, 200MCG/ML Injection Solution)

B 5 PA; DL

Aranesp (Albumin Free) (25MCG/ML Injection

Solution, 40MCG/ML Injection Solution, 60MCG/ML

Injection Solution)

B 4 PA

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)

B 5 PA; DL

Aranesp (Albumin Free) (10MCG/0.4ML Injection

Solution Prefilled Syringe, 25MCG/0.42ML Injection

Solution Prefilled Syringe, 40MCG/0.4ML Injection

Solution Prefilled Syringe, 60MCG/0.3ML Injection

Solution Prefilled Syringe)

B 4 PA

Neulasta (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Procrit (10000UNIT/ML Injection Solution,

2000UNIT/ML Injection Solution, 3000UNIT/ML

Injection Solution, 4000UNIT/ML Injection Solution)

B 4 PA

Last updated February 1, 2024

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Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Procrit (20000UNIT/ML Injection Solution,

40000UNIT/ML Injection Solution)

B 5 PA; DL

Promacta (Oral Packet) B 5 PA; DL; QL

Promacta (Oral Tablet) B 5 PA; DL; QL

Pyrukynd (Oral Tablet) B 5 PA; DL; QL

Pyrukynd Taper Pack (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Retacrit (Injection Solution) B 4 PA

Udenyca (Subcutaneous Solution Auto-Injector) B 5 PA; DL

Udenyca (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Zarxio (Injection Solution Prefilled Syringe) B 5 DL

Hemostasis Agents

Tranexamic Acid (Oral Tablet) G 3

Platelet Modifying Agents

Aspirin-Dipyridamole ER (Oral Capsule Extended

Release 12 Hour)

G 3 QL

Brilinta (Oral Tablet) B 3 QL

Cablivi (Injection Kit) B 5 PA; DL; QL

Cilostazol (Oral Tablet) G 2

Clopidogrel Bisulfate (75MG Oral Tablet) G 1 QL

Doptelet (Oral Tablet) B 5 PA; DL; QL

Prasugrel HCl (Oral Tablet) G 3 QL

Cardiovascular Agents

Alpha-adrenergic Agonists

Clonidine HCl (Oral Tablet Immediate Release) G 1

Clonidine (Transdermal Patch Weekly) G 4

Droxidopa (100MG Oral Capsule, 200MG Oral Capsule) G 4 PA; QL

Droxidopa (300MG Oral Capsule) G 5 PA; DL; QL

Midodrine HCl (Oral Tablet) G 3

Alpha-adrenergic Blocking Agents

Doxazosin Mesylate (Oral Tablet) G 1

Prazosin HCl (Oral Capsule) G 2

Angiotensin II Receptor Antagonists

Candesartan Cilexetil (Oral Tablet) G 1 QL

Edarbi (Oral Tablet) B 4 QL

Irbesartan (Oral Tablet) G 1 QL

Losartan Potassium (Oral Tablet) G 1 QL

Olmesartan Medoxomil (Oral Tablet) G 1 QL

Telmisartan (Oral Tablet) G 1 QL

Valsartan (Oral Tablet) G 1 QL

Last updated February 1, 2024 63

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Angiotensin-converting Enzyme (ACE) Inhibitors

Benazepril HCl (Oral Tablet) G 1 QL

Captopril (Oral Tablet) G 1 QL

Enalapril Maleate (Oral Solution) G 4

Enalapril Maleate (Oral Tablet) G 1 QL

Fosinopril Sodium (Oral Tablet) G 1 QL

Lisinopril (Oral Tablet) G 1 QL

Moexipril HCl (Oral Tablet) G 1 QL

Perindopril Erbumine (Oral Tablet) G 1 QL

Quinapril HCl (Oral Tablet) G 1 QL

Ramipril (Oral Capsule) G 1 QL

Trandolapril (Oral Tablet) G 1 QL

Antiarrhythmics

Amiodarone HCl (200MG Oral Tablet) G 1

Dofetilide (Oral Capsule) G 3 QL

Flecainide Acetate (Oral Tablet) G 2

Mexiletine HCl (Oral Capsule) G 3

Multaq (Oral Tablet) B 3 QL

Pacerone (200MG Oral Tablet) B 1

Propafenone HCl ER (Oral Capsule Extended Release 12

Hour)

G 4

Propafenone HCl (Oral Tablet) G 2

Quinidine Gluconate ER (Oral Tablet Extended Release) G 4

Quinidine Sulfate (Oral Tablet) G 2

Sorine (120MG Oral Tablet, 160MG Oral Tablet, 240MG

Oral Tablet, 80MG Oral Tablet)

G 2

Sotalol HCl (AF) (Oral Tablet) G 2

Sotalol HCl (Oral Tablet) G 2

Beta-adrenergic Blocking Agents

Acebutolol HCl (Oral Capsule) G 2

Atenolol (Oral Tablet) G 1

Betaxolol HCl (Oral Tablet) G 3

Bisoprolol Fumarate (Oral Tablet) G 2

Carvedilol (Oral Tablet) G 1

Labetalol HCl (Oral Tablet) G 1

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Metoprolol Succinate ER (Oral Tablet Extended Release

24 Hour)

G 1

Metoprolol Tartrate (Oral Tablet) G 1

Nadolol (Oral Tablet) G 4

Nebivolol HCl (Oral Tablet) G 3 QL

Pindolol (Oral Tablet) G 3

Propranolol HCl ER (Oral Capsule Extended Release 24

Hour)

G 2

Propranolol HCl (Oral Solution) G 2

Propranolol HCl (Oral Tablet) G 1

Calcium Channel Blocking Agents, Dihydropyridines

Amlodipine Besylate (Oral Tablet) G 1

Felodipine ER (Oral Tablet Extended Release 24 Hour) G 2

Nicardipine HCl (Oral Capsule) G 4

Nifedipine ER (Oral Tablet Extended Release 24 Hour) G 1 QL

Nifedipine ER Osmotic Release (Oral Tablet Extended

Release 24 Hour)

G 1 QL

Nimodipine (Oral Capsule) G 4

Calcium Channel Blocking Agents, Nondihydropyridines

Cartia XT (Oral Capsule Extended Release 24 Hour) G 2

Diltiazem HCl ER Beads (360MG Oral Capsule Extended

Release 24 Hour, 420MG Oral Capsule Extended

Release 24 Hour)

G 2

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)

G 2

Diltiazem HCl ER (Oral Capsule Extended Release 12

Hour)

G 2

Diltiazem HCl ER (Oral Tablet Extended Release 24

Hour)

G 2

Diltiazem HCl (Oral Tablet Immediate Release) G 2

Dilt-XR (Oral Capsule Extended Release 24 Hour) G 2

Matzim LA (Oral Tablet Extended Release 24 Hour) G 2

Taztia XT (Oral Capsule Extended Release 24 Hour) G 2

Tiadylt ER (Oral Capsule Extended Release 24 Hour) G 2

Verapamil HCl ER (Oral Capsule Extended Release 24

Hour)

G 3

Verapamil HCl ER (Oral Tablet Extended Release) G 2

Verapamil HCl (Oral Tablet Immediate Release) G 1

Cardiovascular Agents, Other

Last updated February 1, 2024 65

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Acetazolamide ER (Oral Capsule Extended Release 12

Hour)

G 4

Acetazolamide (Oral Tablet) G 3

Aliskiren Fumarate (Oral Tablet) G 1 QL

Amiloride-Hydrochlorothiazide (Oral Tablet) G 2

Amlodipine-Atorvastatin (Oral Tablet) G 1 QL

Amlodipine-Benazepril (Oral Capsule) G 1 QL

Amlodipine-Olmesartan (Oral Tablet) G 1 QL

Amlodipine-Valsartan (Oral Tablet) G 1 QL

Amlodipine-Valsartan-HCTZ (Oral Tablet) G 1 QL

Atenolol-Chlorthalidone (Oral Tablet) G 1

Benazepril-Hydrochlorothiazide (Oral Tablet) G 1 QL

Bisoprolol-Hydrochlorothiazide (Oral Tablet) G 2 QL

Candesartan Cilexetil-HCTZ (Oral Tablet) G 1 QL

Corlanor (Oral Solution) B 4 PA; QL

Corlanor (Oral Tablet) B 4 PA; QL

Digoxin (Oral Solution) G 3

Digoxin (125MCG Oral Tablet, 250MCG Oral Tablet) G 2

Digoxin (62.5MCG Oral Tablet) G 4

Edarbyclor (Oral Tablet) B 4 QL

Enalapril-Hydrochlorothiazide (Oral Tablet) G 1 QL

Entresto (Oral Tablet) B 3 QL

Fosinopril Sodium-HCTZ (Oral Tablet) G 1 QL

Irbesartan-Hydrochlorothiazide (Oral Tablet) G 1 QL

Isosorbide Dinitrate-Hydralazine (Oral Tablet) G 3 QL

Kerendia (Oral Tablet) B 4 PA; QL

Lanoxin (Oral Tablet) B 4

Lisinopril-Hydrochlorothiazide (Oral Tablet) G 1 QL

Losartan Potassium-HCTZ (Oral Tablet) G 1 QL

Metoprolol-Hydrochlorothiazide (Oral Tablet) G 2

Metyrosine (Oral Capsule) G 5 DL

Olmesartan Medoxomil-HCTZ (Oral Tablet) G 1 QL

Olmesartan-Amlodipine-HCTZ (Oral Tablet) G 1 QL

Pentoxifylline ER (Oral Tablet Extended Release) G 2

Ranolazine ER (Oral Tablet Extended Release 12 Hour) G 3 QL

Spironolactone-HCTZ (Oral Tablet) G 2

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Telmisartan-Amlodipine (Oral Tablet) G 1 QL

Telmisartan-HCTZ (Oral Tablet) G 1 QL

Trandolapril-Verapamil HCl ER (Oral Tablet Extended

Release)

G 1 QL

Triamterene-HCTZ (Oral Capsule) G 1

Triamterene-HCTZ (Oral Tablet) G 1

Valsartan-Hydrochlorothiazide (Oral Tablet) G 1 QL

Diuretics, Loop

Bumetanide (Injection Solution) G 4

Bumetanide (Oral Tablet) G 1

Ethacrynic Acid (Oral Tablet) G 4 QL

Furosemide (Injection Solution) G 4 B/D,PA

Furosemide (Oral Solution) G 1

Furosemide (Oral Tablet) G 1

Torsemide (Oral Tablet) G 2

Diuretics, Potassium-sparing

Amiloride HCl (Oral Tablet) G 2

Eplerenone (Oral Tablet) G 3

Spironolactone (Oral Tablet) G 1

Triamterene (Oral Capsule) G 4

Diuretics, Thiazide

Chlorthalidone (Oral Tablet) G 2

Diuril (Oral Suspension) B 4

Hydrochlorothiazide (Oral Capsule) G 1

Hydrochlorothiazide (Oral Tablet) G 1

Indapamide (Oral Tablet) G 1

Metolazone (Oral Tablet) G 1

Dyslipidemics, Fibric Acid Derivatives

Fenofibrate Micronized (134MG Oral Capsule, 200MG

Oral Capsule, 43MG Oral Capsule, 67MG Oral Capsule)

G 2

Fenofibrate (50MG Oral Capsule) G 2

Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet) G 2

Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet) G 1

Fenofibric Acid (Oral Capsule Delayed Release) G 3

Gemfibrozil (Oral Tablet) G 2

Dyslipidemics, HMG CoA Reductase Inhibitors

Atorvastatin Calcium (Oral Tablet) G 1 QL

Fluvastatin Sodium ER (Oral Tablet Extended Release 24

Hour)

G 1 QL

Last updated February 1, 2024 67

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Fluvastatin Sodium (Oral Capsule) G 1 QL

Livalo (Oral Tablet) B 3 QL

Lovastatin (Oral Tablet) G 1 QL

Pravastatin Sodium (Oral Tablet) G 1 QL

Rosuvastatin Calcium (Oral Tablet) G 1 QL

Simvastatin (Oral Tablet) G 1 QL

Dyslipidemics, Other

Cholestyramine Light (Oral Packet) G 4

Cholestyramine (Oral Packet) G 4

Colesevelam HCl (Oral Packet) G 3

Colesevelam HCl (Oral Tablet) G 3

Colestipol HCl (Oral Packet) G 4

Colestipol HCl (Oral Tablet) G 3

Ezetimibe (Oral Tablet) G 1 QL

Ezetimibe-Simvastatin (Oral Tablet) G 1 QL

Niacin (Antihyperlipidemic) (Oral Tablet Immediate

Release)

G 4

Niacin ER (Antihyperlipidemic) (Oral Tablet Extended

Release)

G 3

Niacor (Oral Tablet) G 4

Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic

Lovaza)

G 4 QL

Praluent (Subcutaneous Solution Auto-Injector) B 3 PA; QL

Prevalite (Oral Packet) G 4

Repatha Pushtronex System (Subcutaneous Solution

Cartridge)

B 3 PA; QL

Repatha (Subcutaneous Solution Prefilled Syringe) B 3 PA; QL

Repatha SureClick (Subcutaneous Solution

Auto-Injector)

B 3 PA; QL

Vascepa (Oral Capsule) B 3

Vasodilators, Direct-acting Arterial

Hydralazine HCl (Oral Tablet) G 1

Minoxidil (Oral Tablet) G 2

Vasodilators, Direct-acting Arterial/Venous

Isosorbide Dinitrate (10MG Oral Tablet Immediate

Release, 20MG Oral Tablet Immediate Release, 30MG

Oral Tablet Immediate Release, 5MG Oral Tablet

Immediate Release)

G 2

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Isosorbide Mononitrate ER (Oral Tablet Extended

Release 24 Hour)

G 1

Isosorbide Mononitrate (Oral Tablet Immediate Release) G 1

Nitro-Bid (Transdermal Ointment) B 4

Nitroglycerin (Tablet Sublingual) G 2

Nitroglycerin (Transdermal Patch 24 Hour) G 2

Nitroglycerin (Translingual Solution) G 3

Nitrostat (Tablet Sublingual) B 3

Rectiv (Rectal Ointment) B 4 QL

Verquvo (Oral Tablet) B 3 PA; QL

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

Amphetamine-Dextroamphetamine ER (Oral Capsule

Extended Release 24 Hour)

G 4 QL

Amphetamine-Dextroamphetamine (Oral Tablet) G 3 QL

Dextroamphetamine Sulfate ER (Oral Capsule Extended

Release 24 Hour)

G 4 QL

Dextroamphetamine Sulfate (10MG Oral Tablet, 15MG

Oral Tablet, 20MG Oral Tablet, 30MG Oral Tablet, 5MG

Oral Tablet)

G 4 QL

Lisdexamfetamine Dimesylate (Oral Capsule) G 4

Vyvanse (Oral Capsule) B 4

Vyvanse (Oral Tablet Chewable) B 4

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

Atomoxetine HCl (Oral Capsule) G 4 QL

Clonidine HCl ER (Oral Tablet Extended Release 12

Hour)

G 3 PA

Dexmethylphenidate HCl ER (Oral Capsule Extended

Release 24 Hour)

G 4

Dexmethylphenidate HCl (Oral Tablet) G 3 QL

Guanfacine HCl ER (Oral Tablet Extended Release 24

Hour)

G 4

Methylphenidate HCl ER (10MG Oral Tablet Extended

Release, 20MG Oral Tablet Extended Release)

G 4 QL

Methylphenidate HCl (Oral Solution) G 4 QL

Methylphenidate HCl (Oral Tablet Immediate Release)

(Generic Ritalin)

G 3 QL

Central Nervous System, Other

Austedo (Oral Tablet) B 5 PA; DL; QL

Ingrezza (Oral Capsule) B 5 PA; DL; QL

Ingrezza (Oral Capsule Therapy Pack) B 5 PA; DL; QL

Last updated February 1, 2024 69

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Nuedexta (Oral Capsule) B 5 PA; DL; QL

Quviviq (Oral Tablet) B 4 QL

Riluzole (Oral Tablet) G 3

Skyclarys (Oral Capsule) B 5 PA; DL; QL

Tetrabenazine (12.5MG Oral Tablet) G 4 PA; QL

Tetrabenazine (25MG Oral Tablet) G 5 PA; DL; QL

Fibromyalgia Agents

Duloxetine HCl (20MG Oral Capsule Delayed Release

Particles, 30MG Oral Capsule Delayed Release Particles,

60MG Oral Capsule Delayed Release Particles)

G 2 QL

Pregabalin (Oral Capsule) G 3 QL

Pregabalin (Oral Solution) G 3 QL

Savella (Oral Tablet) B 3

Savella Titration Pack (Oral Tablet) B 3

Multiple Sclerosis Agents

Avonex Pen (Intramuscular Auto-Injector Kit) B 5 DL; QL

Avonex Prefilled (Intramuscular Prefilled Syringe Kit) B 5 DL; QL

Betaseron (Subcutaneous Kit) B 5 DL; QL

Dalfampridine ER (Oral Tablet Extended Release 12

Hour)

G 3 QL

Dimethyl Fumarate (Oral Capsule Delayed Release) G 4 QL

Dimethyl Fumarate Starter Pack (Oral Capsule Delayed

Release Therapy Pack)

G 4 QL

Fingolimod HCl (Oral Capsule) G 5 DL; QL

Glatiramer Acetate (Subcutaneous Solution Prefilled

Syringe)

G 5 DL; QL

Glatopa (Subcutaneous Solution Prefilled Syringe) G 5 DL; QL

Kesimpta (Subcutaneous Solution Auto-Injector) B 5 DL

Mayzent (Oral Tablet) B 5 DL; QL

Mayzent Starter Pack (12 x 0.25MG Oral Tablet

Therapy Pack)

B 5 DL; QL

Mayzent Starter Pack (7 x 0.25MG Oral Tablet

Therapy Pack)

B 4 QL

Rebif Rebidose (Subcutaneous Solution Auto-Injector) B 5 ST; DL; QL

Rebif Rebidose Titration Pack (Subcutaneous

Solution Auto-Injector)

B 5 ST; DL; QL

Rebif (Subcutaneous Solution Prefilled Syringe) B 5 ST; DL; QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Rebif Titration Pack (Subcutaneous Solution Prefilled

Syringe)

B 5 ST; DL; QL

Teriflunomide (Oral Tablet) G 5 DL; QL

Vumerity (Oral Capsule Delayed Release)

(Maintenance Dose Bottle)

B 5 ST; DL; QL

Dental and Oral Agents

Chlorhexidine Gluconate (Mouth Solution) G 1

Kourzeq (Mouth/Throat Paste) G 3

Periogard (Mouth Solution) G 1

Pilocarpine HCl (Oral Tablet) G 4

Triamcinolone Acetonide (Dental Paste) G 3

Dermatological Agents

Acne and Rosacea Agents

Accutane (Oral Capsule) G 4 PA

Acitretin (Oral Capsule) G 4

Adapalene (External Cream) G 4

Adapalene (0.3% External Gel) G 3

Amnesteem (Oral Capsule) G 4 PA

Azelaic Acid (External Gel) G 4 QL

Benzoyl Peroxide-Erythromycin (External Gel) G 3

Claravis (Oral Capsule) G 4 PA

Clindamycin Phosphate-Benzoyl Peroxide (1-5% External

Gel, 1.2-5% External Gel)

G 4

Finacea (External Foam) B 4 QL

Isotretinoin (Oral Capsule) G 4 PA

Neuac (External Gel) G 4

Tazarotene (External Cream) G 4 PA; QL

Tretinoin (External Cream) G 4 PA

Tretinoin (0.01% External Gel, 0.025% External Gel) G 4 PA

Tretinoin Microsphere (0.04% External Gel, 0.1% External

Gel)

G 4 PA

Zenatane (Oral Capsule) G 4 PA

Dermatitis and Pruritus Agents

Ala-Cort (External Cream) G 2

Alclometasone Dipropionate (External Cream) G 3

Alclometasone Dipropionate (External Ointment) G 3

Ammonium Lactate (External Cream) G 3

Ammonium Lactate (External Lotion) G 3

Betamethasone Dipropionate Aug (External Cream) G 3

Last updated February 1, 2024 71

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Betamethasone Dipropionate Aug (External Gel) G 3

Betamethasone Dipropionate Aug (External Lotion) G 3

Betamethasone Dipropionate Aug (External Ointment) G 3

Betamethasone Dipropionate (External Cream) G 3

Betamethasone Dipropionate (External Lotion) G 3

Betamethasone Dipropionate (External Ointment) G 3

Betamethasone Valerate (External Cream) G 3

Betamethasone Valerate (External Lotion) G 3

Betamethasone Valerate (External Ointment) G 3

Clobetasol Propionate Emollient Base (External Cream) G 4

Clobetasol Propionate (External Cream) G 4

Clobetasol Propionate (External Gel) G 4

Clobetasol Propionate (External Ointment) G 4

Clobetasol Propionate (External Shampoo) G 4

Clobetasol Propionate (External Solution) G 3

Clodan (External Shampoo) G 4

Cordran (External Tape) B 4

Desonide (External Ointment) G 4 QL

Desoximetasone (External Cream) G 4 QL

Doxepin HCl (External Cream) G 4 PA; QL

Fluocinolone Acetonide (External Cream) G 3

Fluocinolone Acetonide (External Ointment) G 3

Fluocinolone Acetonide (External Solution) G 3

Fluocinolone Acetonide Scalp (External Oil) G 4

Fluocinonide Emulsified Base (External Cream) G 3 QL

Fluocinonide (0.05% External Cream) G 3 QL

Fluocinonide (External Gel) G 3 QL

Fluocinonide (External Ointment) G 3 QL

Fluocinonide (External Solution) G 3 QL

Fluticasone Propionate (External Cream) G 3

Fluticasone Propionate (External Ointment) G 3

Halobetasol Propionate (External Cream) G 4

Halobetasol Propionate (External Ointment) G 4

Hydrocortisone Butyrate (External Ointment) G 3

Hydrocortisone (1% External Cream) G 2

Hydrocortisone (2.5% External Lotion) G 3

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Hydrocortisone (1% External Ointment, 2.5% External

Ointment)

G 2

Hydrocortisone Valerate (External Cream) G 4

Hydrocortisone Valerate (External Ointment) G 4

Mometasone Furoate (External Cream) G 2

Mometasone Furoate (External Ointment) G 2

Mometasone Furoate (External Solution) G 2

Pimecrolimus (External Cream) G 4 ST; QL

Selenium Sulfide (External Lotion) G 2

Tacrolimus (External Ointment) G 4 ST

Triamcinolone Acetonide (External Cream) G 2

Triamcinolone Acetonide (External Lotion) G 2

Triamcinolone Acetonide (0.025% External Ointment,

0.1% External Ointment, 0.5% External Ointment)

G 2

Triderm (External Cream) G 2

Dermatological Agents, Other

Calcipotriene (External Cream) G 4 QL

Calcipotriene (External Ointment) G 4 QL

Calcipotriene (External Solution) G 3

Calcitriol (External Ointment) G 4

Clotrimazole-Betamethasone (External Cream) G 3 QL

Clotrimazole-Betamethasone (External Lotion) G 4

Diclofenac Sodium (3% External Gel) G 4 PA; QL

Fluorouracil (5% External Cream) G 4 QL

Fluorouracil (External Solution) G 3

Imiquimod (5% External Cream) G 4 QL

Methoxsalen Rapid (Oral Capsule) G 5 DL

Podofilox (External Solution) G 3

Regranex (External Gel) B 5 PA; DL

Santyl (External Ointment) B 4

Silver Sulfadiazine (External Cream) G 3

SSD (External Cream) G 3

Pediculicides/Scabicides

Malathion (External Lotion) G 4

Permethrin (External Cream) G 3

Topical Anti-infectives

Ciclopirox (External Gel) G 3

Ciclopirox (External Shampoo) G 3

Ciclopirox (External Solution) G 3

Last updated February 1, 2024 73

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Ciclopirox Olamine (External Cream) G 3

Ciclopirox Olamine (External Suspension) G 3

Clindacin ETZ (External Swab) G 3 QL

Clindamycin Phosphate (External Gel) G 3 QL

Clindamycin Phosphate (External Lotion) G 3 QL

Clindamycin Phosphate (External Solution) G 3 QL

Clindamycin Phosphate (External Swab) G 3 QL

Clotrimazole (External Cream) G 2

Clotrimazole (External Solution) G 2

Econazole Nitrate (External Cream) G 4 QL

Ery (External Pad) G 3

Erythromycin (External Gel) G 4

Erythromycin (External Solution) G 2

Gentamicin Sulfate (External Cream) G 3

Gentamicin Sulfate (External Ointment) G 3

Jublia (External Solution) B 4

Ketoconazole (External Cream) G 2 QL

Ketoconazole (External Shampoo) G 2

Mupirocin Calcium (External Cream) G 4

Mupirocin (External Ointment) G 2 QL

Naftifine HCl (External Cream) G 4

Naftifine HCl (2% External Gel) G 4

Naftin (2% External Gel) B 4

Nyamyc (External Powder) G 2 QL

Nystatin (External Cream) G 2

Nystatin (External Ointment) G 2

Nystatin (External Powder) G 2 QL

Nystop (External Powder) G 2 QL

Sulfamylon (External Cream) B 4

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

Carglumic Acid (Oral Tablet Soluble) G 5 DL

Dextrose (10% Intravenous Solution) G 4

Dextrose (5% Intravenous Solution) G 4 B/D,PA

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Dextrose-NaCl (10-0.2% Intravenous Solution, 10-0.45%

Intravenous Solution, 2.5-0.45% Intravenous Solution,

5-0.2% Intravenous Solution, 5-0.45% Intravenous

Solution)

G 4

Dextrose-NaCl (5-0.9% Intravenous Solution) G 4 B/D,PA

Endari (Oral Packet) B 5 PA; DL

Intralipid (Intravenous Emulsion) B 4 B/D,PA

Isolyte-P in D5W (Intravenous Solution) B 4

Isolyte-S pH 7.4 (Intravenous Solution) B 4

KCl in Dextrose-NaCl (Intravenous Solution) G 4

KCl-Lactated Ringers-D5W (Intravenous Solution) G 4

Klor-Con 10 (Oral Tablet Extended Release) G 2

Klor-Con M10 (Oral Tablet Extended Release) G 2

Klor-Con M15 (Oral Tablet Extended Release) G 2

Klor-Con M20 (Oral Tablet Extended Release) G 2

Klor-Con (Oral Packet) G 3

Klor-Con 8 (Oral Tablet Extended Release) G 2

Magnesium Sulfate (Injection Solution) G 4

Multiple Electrolytes Type 1 pH 5.5 (Intravenous

Solution)

G 4

Nutrilipid (Intravenous Emulsion) B 4 B/D,PA

Plasma-Lyte 148 (Intravenous Solution) B 4

Plasma-Lyte A (Intravenous Solution) B 4

Plenamine (Intravenous Solution) B 4 B/D,PA

Potassium Chloride Microencapsulated ER (Oral Tablet

Extended Release)

G 1

Potassium Chloride ER (Oral Capsule Extended Release) G 1

Potassium Chloride ER (10MEQ Oral Tablet Extended

Release, 20MEQ Oral Tablet Extended Release, 8MEQ

Oral Tablet Extended Release)

G 1

Potassium Chloride in NaCl (20-0.45MEQ/L-%

Intravenous Solution, 20-0.9MEQ/L-% Intravenous

Solution, 40-0.9MEQ/L-% Intravenous Solution)

G 4 B/D,PA

Potassium Chloride (10MEQ/100ML Intravenous

Solution, 20MEQ/100ML Intravenous Solution,

2MEQ/ML (30ML) Intravenous Solution, 2MEQ/ML

(20ML) Intravenous Solution, 40MEQ/100ML Intravenous

Solution)

G 4 B/D,PA

Potassium Chloride (Oral Packet) G 3

Potassium Chloride (20MEQ/15ML(10%) Oral Solution,

40MEQ/15ML(20%) Oral Solution)

G 3

Potassium Citrate ER (Oral Tablet Extended Release) G 3

Last updated February 1, 2024 75

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Potassium Chloride in Dextrose 5% (20MEQ/L

Intravenous Solution)

G 4 B/D,PA

Premasol (Intravenous Solution) B 4 B/D,PA

Prosol (Intravenous Solution) B 4 B/D,PA

Sodium Chloride (0.45% Intravenous Solution) G 4

Sodium Chloride (0.9% Intravenous Solution, 3%

Intravenous Solution, 5% Intravenous Solution)

G 4 B/D,PA

Sodium Chloride (Irrigation Solution) G 3

Sodium Fluoride (Oral Tablet) G 1

TPN Electrolytes (Intravenous Concentrate) B 4

Travasol (Intravenous Solution) B 4 B/D,PA

TrophAmine (Intravenous Solution) B 4 B/D,PA

Electrolyte/Mineral/Metal Modifiers

Chemet (Oral Capsule) B 5 DL

Deferasirox Granules (Oral Packet) G 5 PA; DL

Deferasirox (Oral Tablet) (Generic Jadenu) G 3 PA

Deferasirox (125MG Oral Tablet Soluble) (Generic

Exjade)

G 4 PA

Deferasirox (250MG Oral Tablet Soluble, 500MG Oral

Tablet Soluble) (Generic Exjade)

G 5 PA; DL

Deferiprone (Oral Tablet) G 5 PA; DL

Trientine HCl (250MG Oral Capsule) G 5 PA; DL; QL

Phosphate Binders

Calcium Acetate (Phosphate Binder) (Oral Capsule) G 3

Calcium Acetate (667MG Oral Tablet) G 3

Sevelamer Carbonate (Oral Packet) G 4

Sevelamer Carbonate (Oral Tablet) (Generic Renvela) G 4

Velphoro (Oral Tablet Chewable) B 5 DL

Potassium Binders

Lokelma (Oral Packet) B 4 QL

Sodium Polystyrene Sulfonate (Oral Powder) G 3

SPS (Oral Suspension) G 3

Veltassa (Oral Packet) B 4 QL

Vitamins

Prenatal (27-1MG Oral Tablet) G 3

Gastrointestinal Agents

Anti-Constipation Agents

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Constulose (Oral Solution) G 2

Enulose (Oral Solution) G 2

Generlac (Oral Solution) G 2

Lactulose (Oral Solution) G 2

Linzess (Oral Capsule) B 3 QL

Lubiprostone (Oral Capsule) G 3 QL

Motegrity (Oral Tablet) B 4 QL

Movantik (Oral Tablet) B 3 QL

Relistor (Oral Tablet) B 5 PA; DL; QL

Relistor (Subcutaneous Solution) B 5 PA; DL

Trulance (Oral Tablet) B 4 QL

Anti-Diarrheal Agents

Alosetron HCl (Oral Tablet) G 5 PA; DL

Diphenoxylate-Atropine (Oral Liquid) G 4

Diphenoxylate-Atropine (Oral Tablet) G 4

Loperamide HCl (Oral Capsule) G 2

Xermelo (Oral Tablet) B 5 PA; DL; QL

Antispasmodics, Gastrointestinal

Dicyclomine HCl (Oral Capsule) G 2

Dicyclomine HCl (Oral Solution) G 2

Dicyclomine HCl (Oral Tablet) G 2

Glycopyrrolate (Oral Solution) (Generic Cuvposa) G 4 PA

Methscopolamine Bromide (Oral Tablet) G 4

Gastrointestinal Agents, Other

Chenodal (Oral Tablet) B 5 PA; DL

Clenpiq (Oral Solution) B 3

GaviLyte-C (Oral Solution Reconstituted) G 2

GaviLyte-G (Oral Solution Reconstituted) G 2

Sodium Sulfate-Potassium Sulfate-Magnesium Sulfate

(Oral Solution)

G 3

PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution)

(Generic NuLYTELY)

G 2

PEG-3350-Electrolytes (Oral Solution) (Generic

GoLYTELY)

G 2

Suflave (Oral Solution Reconstituted) B 4

Sutab (Oral Tablet) B 3

Ursodiol (300MG Oral Capsule) G 3

Ursodiol (Oral Tablet) G 4

Vowst (Oral Capsule) B 5 PA; DL

Last updated February 1, 2024 77

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Histamine2 (H2) Receptor Antagonists

Cimetidine (Oral Tablet) G 3

Famotidine (Oral Suspension Reconstituted) G 4

Famotidine (20MG Oral Tablet, 40MG Oral Tablet) G 2

Nizatidine (Oral Capsule) G 3

Protectants

Misoprostol (Oral Tablet) G 3

Sucralfate (Oral Suspension) G 4

Sucralfate (Oral Tablet) G 2

Proton Pump Inhibitors

Dexlansoprazole (Oral Capsule Delayed Release) G 4 QL

Esomeprazole Magnesium (Oral Capsule Delayed

Release) (Generic Nexium)

G 3 QL

Esomeprazole Magnesium (Oral Packet) G 3

Lansoprazole (Oral Capsule Delayed Release) G 2 QL

Omeprazole (10MG Oral Capsule Delayed Release) G 2 QL

Omeprazole (20MG Oral Capsule Delayed Release,

40MG Oral Capsule Delayed Release)

G 2

Pantoprazole Sodium (Oral Tablet Delayed Release) G 1 QL

Rabeprazole Sodium (Oral Tablet Delayed Release) G 3

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment

Aralast NP (1000MG Intravenous Solution

Reconstituted)

B 5 PA; DL

Betaine (Oral Powder) G 5 DL

Cholbam (Oral Capsule) B 5 PA; DL

Creon (Oral Capsule Delayed Release Particles) B 3

Cromolyn Sodium (Oral Concentrate) G 3

Cystagon (Oral Capsule) B 4

Levocarnitine (Oral Solution) G 3

Levocarnitine (Oral Tablet) G 3

Miglustat (Oral Capsule) G 5 PA; DL

Nitisinone (Oral Capsule) G 5 DL

Prolastin-C (Intravenous Solution Reconstituted) B 5 PA; DL

Revcovi (Intramuscular Solution) B 5 PA; DL

Sapropterin Dihydrochloride (Oral Packet) G 5 DL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Sapropterin Dihydrochloride (Oral Tablet) G 5 DL

Sodium Phenylbutyrate (Oral Powder) G 5 DL

Sodium Phenylbutyrate (Oral Tablet) G 5 DL

Sucraid (Oral Solution) B 5 DL

Vyndamax (Oral Capsule) B 5 PA; DL; QL

Vyndaqel (Oral Capsule) B 5 PA; DL; QL

Zemaira (1000MG Intravenous Solution

Reconstituted)

B 5 PA; DL

Zenpep (10000-32000UNIT Oral Capsule Delayed

Release Particles, 15000-47000UNIT Oral Capsule

Delayed Release Particles, 20000-63000UNIT Oral

Capsule Delayed Release Particles, 25000-79000UNIT

Oral Capsule Delayed Release Particles,

3000-10000UNIT Oral Capsule Delayed Release

Particles, 40000-126000UNIT Oral Capsule Delayed

Release Particles, 5000-24000UNIT Oral Capsule

Delayed Release Particles)

B 3

Zokinvy (Oral Capsule) B 5 PA; DL; QL

Genitourinary Agents

Antispasmodics, Urinary

Gemtesa (Oral Tablet) B 4

Myrbetriq (Oral Suspension Reconstituted ER) B 3

Myrbetriq (Oral Tablet Extended Release 24 Hour) B 3

Oxybutynin Chloride ER (Oral Tablet Extended Release

24 Hour)

G 1 QL

Oxybutynin Chloride (Oral Solution) G 2

Oxybutynin Chloride (5MG Oral Tablet Immediate

Release)

G 2

Solifenacin Succinate (Oral Tablet) G 3 QL

Tolterodine Tartrate ER (Oral Capsule Extended Release

24 Hour)

G 4

Tolterodine Tartrate (Oral Tablet) G 3

Trospium Chloride (Oral Tablet) G 3

Benign Prostatic Hypertrophy Agents

Alfuzosin HCl ER (Oral Tablet Extended Release 24

Hour)

G 2

Dutasteride (Oral Capsule) G 2 QL

Finasteride (5MG Oral Tablet) (Generic Proscar) G 1

Silodosin (Oral Capsule) G 3 QL

Tamsulosin HCl (Oral Capsule) G 1

Terazosin HCl (Oral Capsule) G 1

Genitourinary Agents, Other

Last updated February 1, 2024 79

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Bethanechol Chloride (Oral Tablet) G 2

Elmiron (Oral Capsule) B 5 DL

Penicillamine (Oral Tablet) G 5 DL

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Dexamethasone (Oral Solution) G 2

Dexamethasone (Oral Tablet) G 2

Fludrocortisone Acetate (Oral Tablet) G 2

Hydrocortisone (Oral Tablet) G 3

Methylprednisolone (Oral Tablet) G 2

Methylprednisolone (Oral Tablet Therapy Pack) G 2

Prednisolone (Oral Solution) G 2

Prednisolone Sodium Phosphate (25MG/5ML Oral

Solution, 6.7MG/5ML Oral Solution)

G 2

Prednisone Intensol (Oral Concentrate) G 2

Prednisone (5MG/5ML Oral Solution) G 2

Prednisone (Oral Tablet) G 1

Prednisone (Oral Tablet Therapy Pack) G 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Desmopressin Acetate (Oral Tablet) G 3

Desmopressin Acetate Spray (Nasal Solution) G 4

Genotropin MiniQuick (Subcutaneous Prefilled

Syringe)

B 5 PA; DL

Genotropin (Subcutaneous Cartridge) B 5 PA; DL

Increlex (Subcutaneous Solution) B 5 PA; DL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Korlym (Oral Tablet) B 5 PA; DL; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Androgens

Danazol (Oral Capsule) G 4

Testosterone Cypionate (Intramuscular Solution) G 2

Testosterone Enanthate (Intramuscular Solution) G 3

Testosterone (25MG/2.5GM 1% Transdermal Gel,

50MG/5GM 1% Transdermal Gel), Testosterone Pump

(1% Transdermal Gel)

G 3

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Testosterone (20.25MG/1.25GM 1.62% Transdermal

Gel, 40.5MG/2.5GM 1.62% Transdermal Gel),

Testosterone Pump (1.62% Transdermal Gel)

G 4

Estrogens

Altavera (Oral Tablet) G 4

Alyacen 1/35 (Oral Tablet) G 4

Amethia (Oral Tablet) G 4

Apri (Oral Tablet) G 4

Aranelle (Oral Tablet) G 4

Ashlyna (Oral Tablet) G 4

Aubra EQ (Oral Tablet) G 4

Aviane (Oral Tablet) G 4

Balziva (Oral Tablet) G 4

Blisovi 24 Fe (Oral Tablet) G 4

Blisovi Fe 1.5/30 (Oral Tablet) G 4

Briellyn (Oral Tablet) G 4

Camrese Lo (Oral Tablet) G 4

Climara Pro (Transdermal Patch Weekly) B 4

Cryselle-28 (Oral Tablet) G 4

Cyred EQ (Oral Tablet) G 4

Depo-Estradiol (Intramuscular Oil) B 4

Desogestrel-Ethinyl Estradiol (Oral Tablet) G 4

Dolishale (Oral Tablet) G 4

Drospirenone-Ethinyl Estradiol (Oral Tablet) G 4

Duavee (Oral Tablet) B 4

Elestrin (Transdermal Gel) B 4

EluRyng (Vaginal Ring) G 4

EnilloRing (Vaginal Ring) G 4

Enpresse-28 (Oral Tablet) G 4

Enskyce (Oral Tablet) G 4

Estarylla (Oral Tablet) G 4

Estradiol (Oral Tablet) G 1

Estradiol (Transdermal Patch Weekly) G 3 QL

Estradiol (Vaginal Cream) G 3

Estradiol (Vaginal Tablet) G 4 QL

Estradiol Valerate (Intramuscular Oil) G 4

Estring (Vaginal Ring) B 4

Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet) G 4

Etonogestrel-Ethinyl Estradiol (Vaginal Ring) G 4

Last updated February 1, 2024 81

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Falmina (Oral Tablet) G 4

Femring (Vaginal Ring) B 4

Finzala (Oral Tablet Chewable) G 4

Fyavolv (Oral Tablet) G 4

Hailey 24 Fe (Oral Tablet) G 4

Haloette (Vaginal Ring) G 4

Iclevia (Oral Tablet) G 4

Imvexxy Maintenance Pack (Vaginal Insert) B 3 PA; QL

Imvexxy Starter Pack (Vaginal Insert) B 3 PA; QL

Introvale (Oral Tablet) G 4

Isibloom (Oral Tablet) G 4

Jasmiel (Oral Tablet) G 4

Jinteli (Oral Tablet) G 4

Juleber (Oral Tablet) G 4

Junel 1.5/30 (Oral Tablet) G 4

Junel 1/20 (Oral Tablet) G 4

Junel Fe 1.5/30 (Oral Tablet) G 4

Junel Fe 1/20 (Oral Tablet) G 4

Junel Fe 24 (Oral Tablet) G 4

Kaitlib Fe (Oral Tablet Chewable) G 4

Kariva (Oral Tablet) G 4

Kelnor 1/35 (Oral Tablet) G 4

Kelnor 1/50 (Oral Tablet) G 4

Kurvelo (Oral Tablet) G 4

LARIN 1.5/30 (Oral Tablet) G 4

LARIN 1/20 (Oral Tablet) G 4

LARIN Fe 1.5/30 (Oral Tablet) G 4

LARIN Fe 1/20 (Oral Tablet) G 4

Layolis Fe (Oral Tablet Chewable) G 4

Leena (Oral Tablet) G 4

Lessina (Oral Tablet) G 4

Levonest (Oral Tablet) G 4

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral

Tablet)

G 4

Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet) G 4

Levonorgestrel-Ethinyl Estradiol (Oral Tablet) G 4

Last updated February 1, 2024

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Levonorgestrel-Ethinyl Estradiol Triphasic (Oral Tablet) G 4

Levora 0.15/30 (28) (Oral Tablet) G 4

Loryna (Oral Tablet) G 4

Low-Ogestrel (Oral Tablet) G 4

Lutera (Oral Tablet) G 4

Marlissa (Oral Tablet) G 4

Menest (Oral Tablet) B 3

Mibelas 24 Fe (Oral Tablet Chewable) G 4

Microgestin 1.5/30 (Oral Tablet) G 4

Microgestin 1/20 (Oral Tablet) G 4

Microgestin 24 Fe (Oral Tablet) G 4

Microgestin Fe 1.5/30 (Oral Tablet) G 4

Microgestin Fe 1/20 (Oral Tablet) G 4

Mili (Oral Tablet) G 4

Necon 0.5/35 (28) (Oral Tablet) G 4

Nikki (Oral Tablet) G 4

Norethindrone Acetate-Ethinyl Estradiol-Fe

(1-20MG-MCG Oral Tablet)

G 4

Norethindrone Acetate-Ethinyl Estradiol-Fe

(1-20MG-MCG Oral Tablet Chewable)

G 4

Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG

Oral Tablet)

G 4

Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG

Oral Tablet, 1-5MG-MCG Oral Tablet)

G 4

Norethindrone-Ethinyl Estradiol-Fe

(1-20MG-MCG/1-30MG-MCG/1-35MG-MCG Oral Tablet)

G 4

Norethindrone Acetate-Ethinyl Estradiol-Fe

(0.4-35MG-MCG Oral Tablet Chewable, 0.8-25MG-MCG

Oral Tablet Chewable)

G 4

Norgestimate-Ethinyl Estradiol (Oral Tablet) G 4

Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet) G 4

Nortrel 0.5/35 (28) (Oral Tablet) G 4

Nortrel 1/35 (21) (Oral Tablet) G 4

Nortrel 1/35 (28) (Oral Tablet) G 4

Nortrel 7/7/7 (Oral Tablet) G 4

Nylia 1/35 (Oral Tablet) G 4

Nylia 7/7/7 (Oral Tablet) G 4

Nymyo (Oral Tablet) G 4

Ocella (Oral Tablet) G 4

Pimtrea (Oral Tablet) G 4

Last updated February 1, 2024 83

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Portia-28 (Oral Tablet) G 4

Premarin (Oral Tablet) B 4 QL

Premarin (Vaginal Cream) B 3

Premphase (Oral Tablet) B 4 QL

Prempro (Oral Tablet) B 4 QL

Reclipsen (Oral Tablet) G 4

Rivelsa (Oral Tablet) G 4

Setlakin (Oral Tablet) G 4

Sprintec 28 (Oral Tablet) G 4

Sronyx (Oral Tablet) G 4

Syeda (Oral Tablet) G 4

Tarina 24 Fe (Oral Tablet) G 4

Tarina Fe 1/20 EQ (Oral Tablet) G 4

Tilia Fe (Oral Tablet) G 4

Tri-Estarylla (Oral Tablet) G 4

Tri-Legest Fe (Oral Tablet) G 4

Tri-Lo-Estarylla (Oral Tablet) G 4

Tri-Lo-Sprintec (Oral Tablet) G 4

Tri-Mili (Oral Tablet) G 4

Tri-Nymyo (Oral Tablet) G 4

Tri-Sprintec (Oral Tablet) G 4

Trivora (28) (Oral Tablet) G 4

Tri-VyLibra Lo (Oral Tablet) G 4

Tri-VyLibra (Oral Tablet) G 4

Turqoz (Oral Tablet) G 4

Tyblume (Oral Tablet Chewable) G 4

Velivet (Oral Tablet) G 4

Vestura (Oral Tablet) G 4

Vienva (Oral Tablet) G 4

Vyfemla (Oral Tablet) G 4

VyLibra (Oral Tablet) G 4

Wymzya Fe (Oral Tablet Chewable) G 4

Xulane (Transdermal Patch Weekly) G 4

Yuvafem (Vaginal Tablet) G 4 QL

Zafemy (Transdermal Patch Weekly) G 4

Zovia 1/35 (28) (Oral Tablet) G 4

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Progestins

Camila (Oral Tablet) G 4

Crinone (Vaginal Gel) B 4 PA

Deblitane (Oral Tablet) G 4

Depo-SubQ Provera 104 (Subcutaneous Suspension

Prefilled Syringe)

B 4

Errin (Oral Tablet) G 4

Incassia (Oral Tablet) G 4

Lyleq (Oral Tablet) G 4

Lyza (Oral Tablet) G 4

Medroxyprogesterone Acetate (Intramuscular

Suspension)

G 4

Medroxyprogesterone Acetate (Intramuscular

Suspension Prefilled Syringe)

G 4

Medroxyprogesterone Acetate (Oral Tablet) G 2

Megestrol Acetate (40MG/ML Oral Suspension) G 3

Megestrol Acetate (625MG/5ML Oral Suspension) G 4

Megestrol Acetate (Oral Tablet) G 3

Nora-BE (Oral Tablet) G 4

Norethindrone Acetate (5MG Oral Tablet) G 2

Norethindrone (0.35MG Oral Tablet) G 4

Progesterone (Oral Capsule) G 2

Sharobel (Oral Tablet) G 4

Selective Estrogen Receptor Modifying Agents

Osphena (Oral Tablet) B 3 PA; QL

Raloxifene HCl (Oral Tablet) G 2 QL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Euthyrox (Oral Tablet) G 3

Levothyroxine Sodium (Oral Tablet) G 1

Levoxyl (Oral Tablet) G 3

Liothyronine Sodium (Oral Tablet) G 2

Synthroid (Oral Tablet) B 3

Unithroid (Oral Tablet) G 3

Hormonal Agents, Suppressant (Adrenal)

Isturisa (Oral Tablet) B 5 PA; DL

Lysodren (Oral Tablet) B 5 DL

Hormonal Agents, Suppressant (Pituitary)

Last updated February 1, 2024 85

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Hormonal Agents, Suppressant (Pituitary)

Cabergoline (Oral Tablet) G 3

Eligard (Subcutaneous Kit) B 4 PA; QL

Firmagon (240MG Dose) (120MG/Vial Subcutaneous

Solution Reconstituted)

B 5 PA; DL; QL

Firmagon (80MG Subcutaneous Solution

Reconstituted)

B 4 PA; QL

Leuprolide Acetate (Subcutaneous Injection Kit) G 4 PA; QL

Lupron Depot (1-Month) (Intramuscular Kit) B 5 PA; DL; QL

Lupron Depot (3-Month) (Intramuscular Kit) B 5 PA; DL; QL

Lupron Depot (4-Month) (Intramuscular Kit) B 5 PA; DL; QL

Lupron Depot (6-Month) (Intramuscular Kit) B 5 PA; DL; QL

Lupron Depot-Ped (1-Month) (7.5MG Intramuscular

Kit)

B 5 PA; DL; QL

Lupron Depot-Ped (3-Month) (11.25MG Intramuscular

Kit)

B 5 PA; DL; QL

Lupron Depot-Ped (6-Month) (Intramuscular Kit) B 5 PA; DL; QL

Octreotide Acetate (Injection Solution) G 4 PA

Orgovyx (Oral Tablet) B 5 PA; DL; QL

Signifor (Subcutaneous Solution) B 5 PA; DL

Somavert (Subcutaneous Solution Reconstituted) B 5 PA; DL; QL

Synarel (Nasal Solution) B 5 DL; QL

Trelstar Mixject (Intramuscular Suspension

Reconstituted)

B 4 PA; QL

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

Methimazole (Oral Tablet) G 1

Propylthiouracil (Oral Tablet) G 2

Immunological Agents

Angioedema Agents

Berinert (Intravenous Kit) B 5 PA; DL

Cinryze (Intravenous Solution Reconstituted) B 5 PA; DL

Haegarda (Subcutaneous Solution Reconstituted) B 5 PA; DL

Icatibant Acetate (Subcutaneous Solution Prefilled

Syringe)

G 5 PA; DL; QL

Sajazir (Subcutaneous Solution Prefilled Syringe) G 5 PA; DL; QL

Immunoglobulins

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

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You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

BIVIGAM (5GM/50ML Intravenous Solution) B 5 PA; DL

Flebogamma DIF (5GM/50ML Intravenous Solution) B 5 PA; DL

Gammagard (2.5GM/25ML Injection Solution) B 5 PA; DL

Gammagard S/D Less IgA (Intravenous Solution

Reconstituted)

B 5 PA; DL

Gammaked (1GM/10ML Injection Solution) B 5 PA; DL

Gammaplex (10GM/100ML Intravenous Solution,

10GM/200ML Intravenous Solution, 20GM/200ML

Intravenous Solution, 5GM/50ML Intravenous

Solution)

B 5 PA; DL

Gamunex-C (1GM/10ML Injection Solution) B 5 PA; DL

Octagam (1GM/20ML Intravenous Solution,

2GM/20ML Intravenous Solution)

B 5 PA; DL

Panzyga (Intravenous Solution) B 5 PA; DL

Privigen (20GM/200ML Intravenous Solution) B 5 PA; DL

Immunological Agents, Other

Actemra ACTPen (Subcutaneous Solution

Auto-Injector)

B 5 PA; DL; QL

Actemra (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Arcalyst (Subcutaneous Solution Reconstituted) B 5 PA; DL

Benlysta (Subcutaneous Solution Auto-Injector) B 5 PA; DL

Benlysta (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Cosentyx (300MG Dose) (Subcutaneous Solution

Prefilled Syringe)

B 5 PA; DL; QL

Cosentyx Sensoready (300MG) (Subcutaneous

Solution Auto-Injector)

B 5 PA; DL; QL

Cosentyx (75MG/0.5ML Subcutaneous Solution

Prefilled Syringe)

B 5 PA; DL; QL

Cosentyx UnoReady (Subcutaneous Solution

Auto-Injector)

B 5 PA; DL; QL

Dupixent (Subcutaneous Solution Pen-Injector) B 5 PA; DL; QL

Dupixent (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Orencia ClickJect (Subcutaneous Solution

Auto-Injector)

B 5 PA; DL; QL

Orencia (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Otezla (Oral Tablet) B 5 PA; DL; QL

Otezla (Oral Tablet Therapy Pack) B 5 PA; DL; QL

Ridaura (Oral Capsule) B 5 DL

Rinvoq (Oral Tablet Extended Release 24 Hour) B 5 PA; DL; QL

Skyrizi Pen (Subcutaneous Solution Auto-Injector) B 5 PA; DL; QL

Skyrizi (Subcutaneous Solution Cartridge) B 5 PA; DL; QL

Last updated February 1, 2024 87

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Skyrizi (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Stelara (Subcutaneous Solution) B 5 PA; DL; QL

Stelara (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Xeljanz (Oral Solution) B 5 PA; DL; QL

Xeljanz (Oral Tablet Immediate Release) B 5 PA; DL; QL

Xeljanz XR (Oral Tablet Extended Release 24 Hour) B 5 PA; DL; QL

Xolair (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Xolair (Subcutaneous Solution Reconstituted) B 5 PA; DL

Immunostimulants

Actimmune (Subcutaneous Solution) B 5 DL

Besremi (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Pegasys (Subcutaneous Solution) B 5 PA; DL

Pegasys (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Immunosuppressants

Azathioprine (50MG Oral Tablet) G 2 B/D,PA

Cimzia (Subcutaneous Kit) B 5 PA; DL; QL

Cimzia Prefilled (2 X 200MG/ML Subcutaneous

Prefilled Syringe Kit)

B 5 PA; DL; QL

Cyclosporine Modified (Oral Capsule) G 3 B/D,PA

Cyclosporine Modified (Oral Solution) G 3 B/D,PA

Cyclosporine (Oral Capsule) G 3 B/D,PA

Cyltezo (Subcutaneous Auto-Injector Kit) B 5 PA; DL; QL

Cyltezo (Subcutaneous Prefilled Syringe Kit) B 5 PA; DL; QL

Cyltezo-CD/UC/HS Starter (Subcutaneous

Auto-Injector Kit)

B 5 PA; DL

Cyltezo-Psoriasis Starter (Subcutaneous Auto-Injector

Kit)

B 5 PA; DL

Enbrel Mini (Subcutaneous Solution Cartridge) B 5 PA; DL; QL

Enbrel (Subcutaneous Solution) B 5 PA; DL; QL

Enbrel (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Enbrel SureClick (Subcutaneous Solution

Auto-Injector)

B 5 PA; DL; QL

Envarsus XR (Oral Tablet Extended Release 24 Hour) B 4 B/D,PA

Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet,

0.75MG Oral Tablet, 1MG Oral Tablet)

G 5 B/D,PA; DL

Gengraf (Oral Capsule) G 3 B/D,PA

Gengraf (Oral Solution) G 3 B/D,PA

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Humira (2 Pen) (40MG/0.4ML Subcutaneous

Pen-Injector Kit, 80MG/0.8ML Subcutaneous

Pen-Injector Kit)

B 5 PA; DL; QL

Humira (2 Syringe) (10MG/0.1ML Subcutaneous

Prefilled Syringe Kit, 20MG/0.2ML Subcutaneous

Prefilled Syringe Kit, 40MG/0.4ML Subcutaneous

Prefilled Syringe Kit)

B 5 PA; DL; QL

Humira Pediatric Crohns Start (Subcutaneous

Prefilled Syringe Kit)

B 5 PA; DL; QL

Humira Pen (40MG/0.8ML Subcutaneous Pen-Injector

Kit)

B 5 PA; DL; QL

Humira Pen-Pediatric UC Start (Subcutaneous

Pen-Injector Kit)

B 5 PA; DL

Humira Pen Psoriasis Starter (Subcutaneous

Pen-Injector Kit)

B 5 PA; DL

Humira Pen Psoriasis/Uveitis Starter (Subcutaneous

Pen-Injector Kit)

B 5 PA; DL; QL

Humira (40MG/0.8ML Subcutaneous Prefilled Syringe

Kit)

B 5 PA; DL; QL

Humira Pen Crohn's Disease/Ulcerative

Colitis/Hidradenitis Suppurativa Starter

(Subcutaneous Pen-Injector Kit)

B 5 PA; DL

Leflunomide (Oral Tablet) G 2

Methotrexate Sodium (50MG/2ML Injection Solution

Prefilled Syringe)

G 2

Methotrexate Sodium (50MG/2ML Injection Solution) G 2

Methotrexate Sodium (Oral Tablet) G 1

Mycophenolate Mofetil (Oral Capsule) G 3 B/D,PA

Mycophenolate Mofetil (Oral Suspension Reconstituted) G 5 B/D,PA; DL

Mycophenolate Mofetil (Oral Tablet) G 3 B/D,PA

Mycophenolate Sodium (Oral Tablet Delayed Release) G 4 B/D,PA

Prograf (Oral Packet) B 4 B/D,PA

Rasuvo (Subcutaneous Solution Auto-Injector) B 4 PA

Sandimmune (Oral Solution) B 4 B/D,PA

Simponi (Subcutaneous Solution Auto-Injector) B 5 PA; DL; QL

Simponi (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Sirolimus (Oral Solution) G 5 B/D,PA; DL

Sirolimus (Oral Tablet) G 4 B/D,PA

Tacrolimus (Oral Capsule) G 3 B/D,PA

Trexall (Oral Tablet) B 4

Xatmep (Oral Solution) B 4 PA

Yuflyma 1-Pen Kit (Subcutaneous Auto-Injector Kit) B 5 PA; DL

Last updated February 1, 2024 89

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Yuflyma 2-Syringe Kit (Subcutaneous Prefilled Syringe

Kit)

B 5 PA; DL

Vaccines

Abrysvo (Intramuscular Solution Reconstituted) B 3 PA; QL

ActHIB (Intramuscular Solution Reconstituted) B 3 QL

Adacel (Intramuscular Suspension) B 3 QL

Arexvy (Intramuscular Suspension Reconstituted) B 3 PA; QL

BCG Vaccine (Injection Solution Reconstituted) B 3 QL

Bexsero (Intramuscular Suspension Prefilled Syringe) B 3 QL

Boostrix (Intramuscular Suspension) B 3 QL

Boostrix (Intramuscular Suspension Prefilled Syringe) B 3 QL

Daptacel (Intramuscular Suspension) B 3 QL

Diphtheria-Tetanus Toxoids DT (25-5LFU/0.5ML

Intramuscular Suspension)

B 3 QL

Engerix-B (Injection Suspension) B 3 B/D,PA; QL

Engerix-B (Injection Suspension Prefilled Syringe) B 3 B/D,PA; QL

Gardasil 9 (Intramuscular Suspension) B 3 QL

Gardasil 9 (Intramuscular Suspension Prefilled

Syringe)

B 3 QL

Havrix (Intramuscular Suspension) B 3 QL

Heplisav-B (Intramuscular Solution Prefilled Syringe) B 3 B/D,PA; QL

Hiberix (Injection Solution Reconstituted) B 3 QL

Imovax Rabies (Intramuscular Suspension

Reconstituted)

B 3 B/D,PA; QL

Infanrix (Intramuscular Suspension) B 3 QL

IPOL (Injection) B 3 QL

Ixiaro (Intramuscular Suspension) B 3 QL

Jynneos (Subcutaneous Suspension) B 3 QL

Kinrix (Intramuscular Suspension Prefilled Syringe) B 3 QL

Menactra (Intramuscular Solution) B 3 QL

MenQuadfi (Intramuscular Solution) B 3 QL

Menveo (Intramuscular Solution Reconstituted) B 3 QL

M-M-R II (Injection Solution Reconstituted) B 3 QL

Pediarix (Intramuscular Suspension Prefilled Syringe) B 3 QL

Pedvax HIB (Intramuscular Suspension) B 3 QL

Pentacel (Intramuscular Suspension Reconstituted) B 3 QL

PreHevbrio (Intramuscular Suspension) B 3 B/D,PA; QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Priorix (Subcutaneous Suspension Reconstituted) B 3 QL

ProQuad (Subcutaneous Suspension Reconstituted) B 3 QL

Quadracel (Intramuscular Suspension) B 3 QL

Quadracel (Intramuscular Suspension Prefilled

Syringe)

B 3 QL

RabAvert (Intramuscular Suspension Reconstituted) B 3 B/D,PA; QL

Recombivax HB (Injection Suspension) B 3 B/D,PA; QL

Recombivax HB (Injection Suspension Prefilled

Syringe)

B 3 B/D,PA; QL

Rotarix (Oral Suspension) B 3 QL

Rotarix (Oral Suspension Reconstituted) B 3 QL

RotaTeq (Oral Solution) B 3 QL

Shingrix (Intramuscular Suspension Reconstituted) B 3 PA; QL

TDVAX (Intramuscular Suspension) B 3 QL

Tenivac (Intramuscular Injectable) B 3 QL

Ticovac (Intramuscular Suspension Prefilled Syringe) B 3 QL

Trumenba (Intramuscular Suspension Prefilled

Syringe)

B 3 QL

Twinrix (Intramuscular Suspension Prefilled Syringe) B 3 QL

Typhim VI (Intramuscular Solution) B 3 QL

Typhim VI (Intramuscular Solution Prefilled Syringe) B 3 QL

Vaqta (Intramuscular Suspension) B 3 QL

Varivax (Subcutaneous Injectable) B 3 QL

YF-VAX (Subcutaneous Injectable) B 3 QL

Inflammatory Bowel Disease Agents

Aminosalicylates

Apriso (Oral Capsule Extended Release 24 Hour) B 3 QL

Balsalazide Disodium (Oral Capsule) G 4

Dipentum (Oral Capsule) B 5 DL

Mesalamine ER (500MG Oral Capsule Extended

Release) (Generic Pentasa)

G 4 QL

Mesalamine ER (0.375GM Oral Capsule Extended

Release 24 Hour) (Generic Apriso)

G 3 QL

Mesalamine (1.2GM Oral Tablet Delayed Release)

(Generic Lialda)

G 3 QL

Mesalamine (Rectal Enema) G 4 QL

Mesalamine (Rectal Suppository) G 4 QL

Pentasa (Oral Capsule Extended Release) B 4 QL

Sulfasalazine (Oral Tablet Immediate Release) G 2

Sulfasalazine (Oral Tablet Delayed Release) G 2

Last updated February 1, 2024 91

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Glucocorticoids

Budesonide ER (Oral Tablet Extended Release 24 Hour) G 5 ST; DL

Budesonide (Oral Capsule Delayed Release Particles) G 4

Hydrocortisone (Perianal) (2.5% External Cream) G 2

Hydrocortisone (Rectal Enema) G 4

Procto-Med HC (External Cream) G 2

Proctosol HC (External Cream) G 2

Proctozone-HC (External Cream) G 2

Metabolic Bone Disease Agents

Alendronate Sodium (Oral Solution) G 4

Alendronate Sodium (10MG Oral Tablet, 35MG Oral

Tablet, 70MG Oral Tablet)

G 1 QL

Calcitonin Salmon (Nasal Solution) G 3 QL

Calcitriol (Oral Capsule) G 2 B/D,PA

Calcitriol (Oral Solution) G 2 B/D,PA

Cinacalcet HCl (Oral Tablet) G 4 B/D,PA; QL

Doxercalciferol (Oral Capsule) G 4 B/D,PA

Forteo (Subcutaneous Solution Pen-Injector) B 5 PA; DL; QL

Ibandronate Sodium (Oral Tablet) G 2 QL

Natpara (100MCG Subcutaneous Cartridge, 25MCG

Subcutaneous Cartridge, 50MCG Subcutaneous

Cartridge, 75MCG Subcutaneous Cartridge)

B 5 PA; DL

Paricalcitol (Oral Capsule) G 4 B/D,PA

Prolia (Subcutaneous Solution Prefilled Syringe) B 4 QL

Rayaldee (Oral Capsule Extended Release) B 5 DL; QL

Risedronate Sodium (Oral Tablet Immediate Release) G 3 QL

Teriparatide (Recombinant) (620MCG/2.48ML

Subcutaneous Solution Pen-Injector)

B 5 PA; DL; QL

Tymlos (Subcutaneous Solution Pen-Injector) B 5 PA; DL; QL

Xgeva (Subcutaneous Solution) B 5 PA; DL

Miscellaneous Therapeutic Agents

Alcohol Prep Pads B 3

Gauze (Non-medicated 2X2 Pad) B 3

Insulin Syringes, Needles B 3

Lagevrio (Oral Capsule) B 5 DL; QL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Paxlovid (150/100MG) (Oral Tablet Therapy Pack) B 5 DL; QL

Paxlovid (300/100MG) (Oral Tablet Therapy Pack) B 5 DL; QL

Ophthalmic Agents

Ophthalmic Agents, Other

Atropine Sulfate (1% Ophthalmic Solution) G 3

Neomycin-Polymyxin-Bacitracin-Hydrocortisone

(Ophthalmic Ointment)

G 3

Brimonidine Tartrate-Timolol (Ophthalmic Solution) G 3

Combigan (Ophthalmic Solution) B 3

Cystaran (Ophthalmic Solution) B 5 DL

Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution) G 1

Dorzolamide HCl-Timolol Maleate Preservative Free

(Ophthalmic Solution)

G 4

Lacrisert (Ophthalmic Insert) B 4

Neomycin-Polymyxin-Dexamethasone (Ophthalmic

Ointment)

G 2

Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1

Ophthalmic Suspension)

G 2

Neomycin-Polymyxin-HC (Ophthalmic Suspension) G 4

Neo-Polycin HC (Ophthalmic Ointment) G 3

Restasis MultiDose (Ophthalmic Emulsion) B 3 QL

Restasis Single-Use Vials (Ophthalmic Emulsion) B 3 QL

Rocklatan (Ophthalmic Solution) B 3 ST

Sulfacetamide-Prednisolone (Ophthalmic Solution) G 2

TobraDex (Ophthalmic Ointment) B 3

TobraDex ST (Ophthalmic Suspension) B 4

Tobramycin-Dexamethasone (Ophthalmic Suspension) G 3

Tyrvaya (Nasal Solution) B 4 QL

Xiidra (Ophthalmic Solution) B 4 QL

Ophthalmic Anti-allergy Agents

Alomide (Ophthalmic Solution) B 4

Azelastine HCl (Ophthalmic Solution) G 3

Bepotastine Besilate (Ophthalmic Solution) G 4

Bepreve (Ophthalmic Solution) B 4

Cromolyn Sodium (Ophthalmic Solution) G 2

Epinastine HCl (Ophthalmic Solution) G 3

Ophthalmic Anti-Infectives

Bacitracin (Ophthalmic Ointment) G 2

Bacitracin-Polymyxin B (Ophthalmic Ointment) G 2

Besivance (Ophthalmic Suspension) B 4

Last updated February 1, 2024 93

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Ciloxan (Ophthalmic Ointment) B 4

Ciprofloxacin HCl (Ophthalmic Solution) G 2

Erythromycin (Ophthalmic Ointment) G 2

Gatifloxacin (Ophthalmic Solution) G 3

Gentamicin Sulfate (Ophthalmic Solution) G 2

Levofloxacin (0.5% Ophthalmic Solution) G 3

Moxifloxacin HCl (Ophthalmic Solution) (Generic

Vigamox)

G 4

Natacyn (Ophthalmic Suspension) B 4

Neomycin-Bacitracin-Polymyxin (5-400-10000

Ophthalmic Ointment)

G 3

Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution) G 3

Neo-Polycin (Ophthalmic Ointment) G 3

Ofloxacin (Ophthalmic Solution) G 2

Polycin (Ophthalmic Ointment) G 2

Polymyxin B-Trimethoprim (Ophthalmic Solution) G 2

Sulfacetamide Sodium (Ophthalmic Ointment) G 2

Sulfacetamide Sodium (Ophthalmic Solution) G 2

Tobramycin (Ophthalmic Solution) G 2

Tobrex (Ophthalmic Ointment) B 4

Trifluridine (Ophthalmic Solution) G 3

Ophthalmic Anti-inflammatories

Dexamethasone Sodium Phosphate (Ophthalmic

Solution)

G 2

Diclofenac Sodium (Ophthalmic Solution) G 2

Flarex (Ophthalmic Suspension) B 4

Fluorometholone (Ophthalmic Suspension) G 3

Flurbiprofen Sodium (Ophthalmic Solution) G 2

FML Forte (Ophthalmic Suspension) B 4

Ilevro (Ophthalmic Suspension) B 3

Ketorolac Tromethamine (Ophthalmic Solution) G 3

Lotemax (Ophthalmic Gel) B 4

Lotemax (Ophthalmic Ointment) B 4

Lotemax (Ophthalmic Suspension) B 4

Lotemax SM (Ophthalmic Gel) B 4

Loteprednol Etabonate (Ophthalmic Gel) G 4

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Loteprednol Etabonate (Ophthalmic Suspension) G 4

Pred Mild (Ophthalmic Suspension) B 4

Prednisolone Acetate (Ophthalmic Suspension) G 3

Prednisolone Sodium Phosphate (1% Ophthalmic

Solution)

G 2

Prolensa (Ophthalmic Solution) B 4

Ophthalmic Beta-Adrenergic Blocking Agents

Betaxolol HCl (Ophthalmic Solution) G 3

Betimol (Ophthalmic Solution) B 4

Carteolol HCl (Ophthalmic Solution) G 2

Levobunolol HCl (Ophthalmic Solution) G 2

Timolol Maleate Ophthalmic Gel Forming (Ophthalmic

Solution) (Generic Timoptic-XE)

G 3

Timolol Maleate (Ophthalmic Solution) (Generic

Timoptic)

G 1

Ophthalmic Intraocular Pressure Lowering Agents, Other

Alphagan P (0.1% Ophthalmic Solution) B 3

Apraclonidine HCl (Ophthalmic Solution) G 3

Brimonidine Tartrate (0.15% Ophthalmic Solution) G 4

Brimonidine Tartrate (0.2% Ophthalmic Solution) G 1

Brinzolamide (Ophthalmic Suspension) G 3

Dorzolamide HCl (Ophthalmic Solution) G 2

Methazolamide (Oral Tablet) G 4

Pilocarpine HCl (Ophthalmic Solution) G 3

Rhopressa (Ophthalmic Solution) B 3 ST

Simbrinza (Ophthalmic Suspension) B 3

Ophthalmic Prostaglandin and Prostamide Analogs

Latanoprost (Ophthalmic Solution) G 1

Lumigan (Ophthalmic Solution) B 3

Travoprost (BAK Free) (Ophthalmic Solution) G 3

Vyzulta (Ophthalmic Solution) B 4

Otic Agents

Acetic Acid (Otic Solution) G 2

Cipro HC (Otic Suspension) B 4

Ciprofloxacin-Dexamethasone (Otic Suspension) G 4

Flac (Otic Oil) G 4

Fluocinolone Acetonide (Otic Oil) G 4

Hydrocortisone-Acetic Acid (Otic Solution) G 3

Last updated February 1, 2024 95

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Neomycin-Polymyxin-HC (1% Otic Solution) G 3

Neomycin-Polymyxin-HC (Otic Suspension) G 3

Ofloxacin (Otic Solution) G 3

Respiratory Tract/Pulmonary Agents

Antihistamines

Azelastine HCl (0.1% Nasal Solution) G 3

Azelastine-Fluticasone (Nasal Suspension) G 4

Cetirizine HCl (1MG/ML Oral Solution) G 2

Cyproheptadine HCl (Oral Syrup) G 4

Cyproheptadine HCl (Oral Tablet) G 4

Desloratadine (Oral Tablet) G 3

Dymista (Nasal Suspension) B 4

Levocetirizine Dihydrochloride (Oral Tablet) G 1 QL

Anti-inflammatories, Inhaled Corticosteroids

Arnuity Ellipta (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Budesonide (Inhalation Suspension) G 4 B/D,PA

Flunisolide (Nasal Solution) G 1

Fluticasone Propionate (Nasal Suspension) G 2

Mometasone Furoate (Nasal Suspension) G 4

Qvar RediHaler (Inhalation Aerosol Breath Activated) B 3 QL

Antileukotrienes

Montelukast Sodium (Oral Packet) G 2 QL

Montelukast Sodium (Oral Tablet) G 1 QL

Montelukast Sodium (Oral Tablet Chewable) G 2 QL

Zafirlukast (Oral Tablet) G 3 QL

Bronchodilators, Anticholinergic

Atrovent HFA (Inhalation Aerosol Solution) B 4

Incruse Ellipta (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Ipratropium Bromide (Inhalation Solution) G 2 B/D,PA

Ipratropium Bromide (Nasal Solution) G 2

Spiriva HandiHaler (Inhalation Capsule) B 3 QL

Spiriva Respimat (Inhalation Aerosol Solution) B 3 QL

Bronchodilators, Sympathomimetic

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

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)

G 2

Albuterol Sulfate (Inhalation Nebulization Solution) G 2 B/D,PA

Albuterol Sulfate (Oral Syrup) G 4

Albuterol Sulfate (Oral Tablet Immediate Release) G 4

Arformoterol Tartrate (Inhalation Nebulization Solution) G 4 B/D,PA; QL

Epinephrine (Injection Solution Auto-Injector) G 3 QL

Formoterol Fumarate (Inhalation Nebulization Solution) G 4 B/D,PA; QL

Levalbuterol HCl (Inhalation Nebulization Solution) G 4 B/D,PA

Levalbuterol Tartrate (Inhalation Aerosol) B 3

Perforomist (Inhalation Nebulization Solution) B 4 B/D,PA; QL

Serevent Diskus (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Ventolin HFA (Inhalation Aerosol Solution) B 3

Cystic Fibrosis Agents

Cayston (Inhalation Solution Reconstituted) B 5 PA; DL

Kalydeco (13.4MG Oral Packet, 25MG Oral Packet,

50MG Oral Packet, 75MG Oral Packet)

B 5 PA; DL; QL

Kalydeco (Oral Tablet) B 5 PA; DL; QL

Orkambi (Oral Packet) B 5 PA; DL; QL

Orkambi (Oral Tablet) B 5 PA; DL; QL

Pulmozyme (Inhalation Solution) B 5 B/D,PA; DL; QL

Tobi Podhaler (Inhalation Capsule) B 5 PA; DL; QL

Tobramycin (300MG/5ML Inhalation Nebulization

Solution)

G 5 B/D,PA; DL; QL

Mast Cell Stabilizers

Cromolyn Sodium (Inhalation Nebulization Solution) G 4 B/D,PA

Phosphodiesterase Inhibitors, Airways Disease

Roflumilast (Oral Tablet) G 4 PA; QL

Theophylline ER (300MG Oral Tablet Extended Release

12 Hour, 450MG Oral Tablet Extended Release 12 Hour)

G 2

Theophylline ER (Oral Tablet Extended Release 24 Hour) G 2

Theophylline (Oral Solution) G 2

Pulmonary Antihypertensives

Adempas (Oral Tablet) B 5 PA; DL

Alyq (Oral Tablet) G 4 PA; QL

Ambrisentan (Oral Tablet) G 5 PA; DL; QL

Bosentan (Oral Tablet) G 5 PA; DL; QL

Last updated February 1, 2024 97

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

Opsumit (Oral Tablet) B 5 PA; DL

Orenitram Month 1 (Oral Tablet Extended Release

Therapy Pack)

B 5 PA; DL; QL

Orenitram Month 2 (Oral Tablet Extended Release

Therapy Pack)

B 5 PA; DL; QL

Orenitram Month 3 (Oral Tablet Extended Release

Therapy Pack)

B 5 PA; DL; QL

Orenitram (0.125MG Oral Tablet Extended Release) B 4 PA

Orenitram (0.25MG Oral Tablet Extended Release,

1MG Oral Tablet Extended Release, 2.5MG Oral

Tablet Extended Release, 5MG Oral Tablet Extended

Release)

B 5 PA; DL

Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio) G 3 PA; QL

Tadalafil (PAH) (20MG Oral Tablet) (Generic Adcirca) G 4 PA; QL

Tracleer (Oral Tablet Soluble) B 5 PA; DL; QL

Ventavis (Inhalation Solution) B 5 PA; DL; QL

Pulmonary Fibrosis Agents

Ofev (Oral Capsule) B 5 PA; DL; QL

Pirfenidone (Oral Capsule) G 5 PA; DL; QL

Pirfenidone (Oral Tablet) G 5 PA; DL; QL

Respiratory Tract Agents, Other

Acetylcysteine (Inhalation Solution) G 2 B/D,PA

Advair Diskus (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Advair HFA (Inhalation Aerosol) B 3 QL

Anoro Ellipta (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Bevespi Aerosphere (Inhalation Aerosol) B 3 QL

Breo Ellipta (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Breztri Aerosphere (Inhalation Aerosol) B 3 QL

Bronchitol (Inhalation Capsule) B 5 PA; DL; QL

Combivent Respimat (Inhalation Aerosol Solution) B 3 QL

Dulera (Inhalation Aerosol) B 4 QL

Fasenra Pen (Subcutaneous Solution Auto-Injector) B 5 PA; DL

Fasenra (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL

Last updated February 1, 2024

¨ We provide additional coverage of this prescription drug in the coverage gap. Refer to your

Evidence of Coverage for more information.

You can find information on what the abbreviations in this table mean on pages 6-7.

Drug name

Brand

Generic

Drug

tier

Coverage rules

or limits on use

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)

G 3 QL

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)

B 3 QL

Ipratropium-Albuterol (Inhalation Solution) G 1 B/D,PA

Nucala (Subcutaneous Solution Auto-Injector) B 5 PA; DL; QL

Nucala (Subcutaneous Solution Prefilled Syringe) B 5 PA; DL; QL

Nucala (Subcutaneous Solution Reconstituted) B 5 PA; DL; QL

Stiolto Respimat (Inhalation Aerosol Solution) B 3 QL

Symbicort (Inhalation Aerosol) B 3 QL

Trelegy Ellipta (Inhalation Aerosol Powder Breath

Activated)

B 3 QL

Wixela Inhub (Inhalation Aerosol Powder Breath

Activated) (Generic Advair)

G 3 QL

Skeletal Muscle Relaxants

Chlorzoxazone (500MG Oral Tablet) G 3

Cyclobenzaprine HCl (10MG Oral Tablet, 5MG Oral

Tablet)

G 2

Cyclobenzaprine HCl (7.5MG Oral Tablet) G 4

Methocarbamol (500MG Oral Tablet, 750MG Oral Tablet) G 3

Sleep Disorder Agents

Sleep Promoting Agents

Belsomra (Oral Tablet) B 3 QL

Eszopiclone (Oral Tablet) G 3 QL

Ramelteon (Oral Tablet) G 4 QL

Tasimelteon (Oral Capsule) G 5 PA; DL; QL

Temazepam (15MG Oral Capsule, 30MG Oral Capsule) G 2 QL

Zaleplon (Oral Capsule) G 3 QL

Zolpidem Tartrate (Oral Tablet Immediate Release) G 2 QL

Wakefulness Promoting Agents

Armodafinil (Oral Tablet) G 4 PA; QL

Modafinil (Oral Tablet) G 3 PA; QL

Sodium Oxybate (Oral Solution) B 5 PA; DL; QL

Last updated February 1, 2024 99

Covered drugs with a quantity limit (QL)

This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each

strength may have a different quantity limit. If quantity limits for a drug vary by strength, the

different strengths are listed on separate lines. These limits may be in place to ensure your safety.

Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain

number of days. For more information about quantity limits, talk with your doctor or pharmacist.

You can also call UnitedHealthcare Customer Service. Our contact information is on the cover.

Drugs are listed in alphabetical order in the chart below. Brand name (B) drugs are listed in bold

type (for example, Humalog) and generic (G) drugs are listed in plain type (for example,

Simvastatin). The (B) or (G) identifier is listed in the “Brand or Generic” column.

Drug name

Brand

Generic

Quantity limit

Abacavir Sulfate (Oral Solution) G Maximum of 32 ml per day

Abacavir Sulfate (Oral Tablet) G Maximum of 2 tablets per day

Abacavir Sulfate-Lamivudine (Oral Tablet) G Maximum of 1 tablet per day

Abiraterone Acetate (250MG Oral Tablet) G Maximum of 4 tablets per day

Abiraterone Acetate (500MG Oral Tablet) G Maximum of 2 tablets per day

Abrysvo (Intramuscular Solution Reconstituted) B 1 vaccination dose (0.5 ml) per

day

Acarbose (100MG Oral Tablet) G Maximum of 3 tablets per day

Acarbose (25MG Oral Tablet) G Maximum of 12 tablets per day

Acarbose (50MG Oral Tablet) G Maximum of 6 tablets per day

Acetaminophen-Caffeine-Dihydrocodeine (Oral

Capsule)

G Maximum of 10 capsules per day

Acetaminophen-Codeine (120-12MG/5ML Oral

Solution)

G Maximum of 150 ml per day

Acetaminophen-Codeine (300-15MG Oral Tablet,

300-30MG Oral Tablet, 300-60MG Oral Tablet)

G Maximum of 13 tablets per day

Actemra ACTPen (Subcutaneous Solution

Auto-Injector)

B Maximum of 4 pens (3.6 ml) per

28 days

Actemra (Subcutaneous Solution Prefilled

Syringe)

B Maximum of 4 syringes (3.6 ml)

per 28 days

ActHIB (Intramuscular Solution Reconstituted) B 1 vaccination dose (1 injection)

per day

Acyclovir (External Ointment) G Maximum of 1 tube (30 grams) per

30 days

Adacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Advair Diskus (Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler (60 blisters)

per 30 days

Advair HFA (Inhalation Aerosol) B Maximum of 1 inhaler (12 grams)

per 30 days

100

Drug name

Brand

Generic

Quantity limit

Aimovig (Subcutaneous Solution Auto-Injector) B Maximum of 1 pen (1 ml) per 28

days

Albendazole (Oral Tablet) G Maximum of 16 tablets per day

Alecensa (Oral Capsule) B Maximum of 8 capsules per day

Alendronate Sodium (10MG Oral Tablet) G Maximum of 1 tablet per day

Alendronate Sodium (35MG Oral Tablet) G Maximum of 8 tablets per 28 days

Alendronate Sodium (70MG Oral Tablet) G Maximum of 4 tablets per 28 days

Aliskiren Fumarate (Oral Tablet) G Maximum of 1 tablet per day

Alprazolam (0.25MG Oral Tablet Immediate

Release, 0.5MG Oral Tablet Immediate Release,

1MG Oral Tablet Immediate Release)

G Maximum of 4 tablets per day

Alprazolam (2MG Oral Tablet Immediate Release) G Maximum of 5 tablets per day

Alunbrig (180MG Oral Tablet, 90MG Oral Tablet) B Maximum of 1 tablet per day

Alunbrig (30MG Oral Tablet) B Maximum of 4 tablets per day

Alunbrig (Oral Tablet Therapy Pack) B Maximum of 2 packs (60 tablets)

per year

Alyq (Oral Tablet) G Maximum of 2 tablets per day

Ambrisentan (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Atorvastatin (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Benazepril (Oral Capsule) G Maximum of 1 capsule per day

Amlodipine-Olmesartan (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Valsartan (Oral Tablet) G Maximum of 1 tablet per day

Amlodipine-Valsartan-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Amphetamine-Dextroamphetamine ER (Oral

Capsule Extended Release 24 Hour)

G 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)

G Maximum of 2 tablets per day

Amphetamine-Dextroamphetamine (20MG Oral

Tablet)

G Maximum of 3 tablets per day

Anoro Ellipta (Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler (60 blisters)

per 30 days

Anzemet (Oral Tablet) B Maximum of 2 tablets per day

Aprepitant (125MG Oral Capsule) G Maximum of 2 capsules per 28

days

Aprepitant (40MG Oral Capsule, 80MG Oral

Capsule)

G Maximum of 4 capsules per 28

days

Aprepitant (80 & 125MG Oral Capsule) G Maximum of 6 capsules (2 packs)

per 28 days

Apriso (Oral Capsule Extended Release 24 Hour) B Maximum of 4 capsules per day

Aptiom (200MG Oral Tablet, 400MG Oral Tablet) B Maximum of 1 tablet per day

Last updated February 1, 2024 101

Drug name

Brand

Generic

Quantity limit

Aptiom (600MG Oral Tablet, 800MG Oral Tablet) B Maximum of 2 tablets per day

Aptivus (Oral Capsule) B Maximum of 4 capsules per day

Arexvy (Intramuscular Suspension Reconstituted) B 1 vaccination dose (0.5 ml) per

day

Arformoterol Tartrate (Inhalation Nebulization

Solution)

G Maximum of 2 vials (4 ml) per day

Aripiprazole (1MG/ML Oral Solution) G 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)

G Maximum of 1 tablet per day

Aripiprazole ODT (10MG Oral Tablet Dispersible,

15MG Oral Tablet Dispersible)

G Maximum of 2 tablets per day

Armodafinil (150MG Oral Tablet, 200MG Oral

Tablet, 250MG Oral Tablet)

G Maximum of 1 tablet per day

Armodafinil (50MG Oral Tablet) G Maximum of 2 tablets per day

Arnuity Ellipta (Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler (30 blisters)

per 30 days

Asenapine Maleate (Tablet Sublingual) G Maximum of 2 tablets per day

Aspirin-Dipyridamole ER (Oral Capsule Extended

Release 12 Hour)

G Maximum of 2 capsules per day

Atazanavir Sulfate (150MG Oral Capsule, 300MG

Oral Capsule)

G Maximum of 1 capsule per day

Atazanavir Sulfate (200MG Oral Capsule) G Maximum of 2 capsules per day

Atomoxetine HCl (100MG Oral Capsule, 60MG Oral

Capsule, 80MG Oral Capsule)

G Maximum of 1 capsule per day

Atomoxetine HCl (10MG Oral Capsule, 18MG Oral

Capsule, 25MG Oral Capsule, 40MG Oral Capsule)

G Maximum of 2 capsules per day

Atorvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day

Atovaquone (Oral Suspension) G Maximum of 14 ml per day

Austedo (Oral Tablet) B Maximum of 4 tablets per day

Avonex Pen (Intramuscular Auto-Injector Kit) B Maximum of 1 kit per 28 days

Avonex Prefilled (Intramuscular Prefilled Syringe

Kit)

B Maximum of 1 kit per 28 days

Ayvakit (Oral Tablet) B Maximum of 1 tablet per day

Azelaic Acid (External Gel) G Maximum of 50 grams per 30 days

Balversa (3MG Oral Tablet) B Maximum of 3 tablets per day

Balversa (4MG Oral Tablet) B Maximum of 2 tablets per day

Balversa (5MG Oral Tablet) B Maximum of 1 tablet per day

BCG Vaccine (Injection Solution Reconstituted) B 1 vaccination dose (1 vial) per day

Belsomra (Oral Tablet) B Maximum of 1 tablet per day

Benazepril HCl (Oral Tablet) G Maximum of 2 tablets per day

Benazepril-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Last updated February 1, 2024102

Drug name

Brand

Generic

Quantity limit

Betaseron (Subcutaneous Kit) B Maximum of 1 kit (15 vials) per 30

days

Bevespi Aerosphere (Inhalation Aerosol) B Maximum of 1 inhaler (10.7 grams)

per 30 days

Bexarotene (External Gel) G Maximum of 60 grams per 30 days

Bexsero (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Biktarvy (Oral Tablet) B Maximum of 1 tablet per day

Bisoprolol-Hydrochlorothiazide (Oral Tablet) G Maximum of 2 tablets per day

Boostrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Boostrix (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Bosentan (Oral Tablet) G Maximum of 2 tablets per day

Bosulif (100MG Oral Tablet) B Maximum of 6 tablets per day

Bosulif (400MG Oral Tablet, 500MG Oral Tablet) B Maximum of 1 tablet per day

Breo Ellipta (Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler (60 blisters)

per 30 days

Breztri Aerosphere (120 Inhalation Aerosol) B Maximum of 1 inhaler (10.7 grams)

per 30 days

Brilinta (Oral Tablet) B Maximum of 2 tablets per day

BRIVIACT (10MG/ML Oral Solution) B Maximum of 20 ml per day

BRIVIACT (100MG Oral Tablet, 10MG Oral Tablet,

25MG Oral Tablet, 50MG Oral Tablet, 75MG Oral

Tablet)

B Maximum of 2 tablets per day

Bronchitol (Inhalation Capsule) B Maximum of 20 capsules per day

Brukinsa (Oral Capsule) B Maximum of 4 capsules per day

Buprenorphine HCl (Tablet Sublingual) G Maximum of 3 tablets per day

Buprenorphine HCl-Naloxone HCl (12-3MG

Sublingual Film)

G Maximum of 2 films per day

Buprenorphine HCl-Naloxone HCl (2-0.5MG

Sublingual Film, 4-1MG Sublingual Film, 8-2MG

Sublingual Film)

G Maximum of 3 films per day

Buprenorphine HCl-Naloxone HCl (Tablet

Sublingual)

G Maximum of 3 tablets per day

Buprenorphine (Transdermal Patch Weekly) G Maximum of 4 patches per 28

days

Butalbital-Acetaminophen-Caffeine (Oral Tablet) G Maximum of 6 tablets per day

Butalbital-Aspirin-Caffeine (Oral Capsule) G Maximum of 6 capsules per day

Butorphanol Tartrate (Nasal Solution) G Maximum of 2 bottles (5 ml) per

30 days

Bydureon BCise (Subcutaneous Auto-Injector) B Maximum of 4 pens (3.4 ml) per

28 days

Last updated February 1, 2024 103

Drug name

Brand

Generic

Quantity limit

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)

B Maximum of 1 pen (2.4 ml) per 30

days

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)

B Maximum of 1 pen (1.2 ml) per 30

days

Cablivi (Injection Kit) B Maximum of 1 kit per day

Cabometyx (20MG Oral Tablet, 60MG Oral Tablet) B Maximum of 1 tablet per day

Cabometyx (40MG Oral Tablet) B Maximum of 2 tablets per day

Calcipotriene (External Cream) G Maximum of 120 grams per 30

days

Calcipotriene (External Ointment) G Maximum of 120 grams per 30

days

Calcitonin Salmon (Nasal Solution) G Maximum of 1 bottle per 28 days

Calquence (100MG Oral Capsule) B Maximum of 2 capsules per day

Calquence (Oral Tablet) B Maximum of 2 tablets per day

Candesartan Cilexetil (16MG Oral Tablet, 32MG Oral

Tablet, 4MG Oral Tablet)

G Maximum of 1 tablet per day

Candesartan Cilexetil (8MG Oral Tablet) G Maximum of 3 tablets per day

Candesartan Cilexetil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Caplyta (Oral Capsule) B Maximum of 1 capsule per day

Captopril (100MG Oral Tablet) G Maximum of 4 tablets per day

Captopril (12.5MG Oral Tablet, 25MG Oral Tablet) G Maximum of 3 tablets per day

Captopril (50MG Oral Tablet) G Maximum of 9 tablets per day

Celecoxib (Oral Capsule) G Maximum of 2 capsules per day

Chloroquine Phosphate (Oral Tablet) G Maximum of 2 tablets per day

Cimduo (Oral Tablet) B Maximum of 1 tablet per day

Cimzia (Subcutaneous Kit) B Maximum of 2 kits per 28 days

Cimzia Prefilled (2 X 200MG/ML Subcutaneous

Prefilled Syringe Kit)

B Maximum of 2 kits per 28 days

Cinacalcet HCl (30MG Oral Tablet, 60MG Oral

Tablet)

G Maximum of 2 tablets per day

Cinacalcet HCl (90MG Oral Tablet) G Maximum of 4 tablets per day

Clindacin ETZ (External Swab) G Maximum of 69 pads per 30 days

Clindamycin Phosphate (External Gel) G Maximum of 75 grams per 30 days

Clindamycin Phosphate (External Lotion) G Maximum of 60 ml per 30 days

Clindamycin Phosphate (External Solution) G Maximum of 60 ml per 30 days

Clindamycin Phosphate (External Swab) G Maximum of 69 pads per 30 days

Clobazam (2.5MG/ML Oral Suspension) G Maximum of 16 ml per day

Clobazam (10MG Oral Tablet, 20MG Oral Tablet) G Maximum of 2 tablets per day

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet) G Maximum of 4 tablets per day

Clonazepam (2MG Oral Tablet) G Maximum of 10 tablets per day

Last updated February 1, 2024104

Drug name

Brand

Generic

Quantity limit

Clonazepam ODT (0.125MG Oral Tablet Dispersible,

0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet

Dispersible, 1MG Oral Tablet Dispersible)

G Maximum of 4 tablets per day

Clonazepam ODT (2MG Oral Tablet Dispersible) G Maximum of 10 tablets per day

Clopidogrel Bisulfate (75MG Oral Tablet) G Maximum of 1 tablet per day

Clorazepate Dipotassium (15MG Oral Tablet) G Maximum of 6 tablets per day

Clorazepate Dipotassium (3.75MG Oral Tablet) G Maximum of 24 tablets per day

Clorazepate Dipotassium (7.5MG Oral Tablet) G Maximum of 12 tablets per day

Clotrimazole-Betamethasone (External Cream) G Maximum of 90 grams per 30 days

Clozapine ODT (100MG Oral Tablet Dispersible) G Maximum of 9 tablets per day

Clozapine ODT (12.5MG Oral Tablet Dispersible) G Maximum of 2 tablets per day

Clozapine ODT (150MG Oral Tablet Dispersible) G Maximum of 6 tablets per day

Clozapine ODT (200MG Oral Tablet Dispersible) G Maximum of 4 tablets per day

Clozapine ODT (25MG Oral Tablet Dispersible) G Maximum of 3 tablets per day

Codeine Sulfate (Oral Tablet) G Maximum of 6 tablets per day

Colchicine (0.6MG Oral Capsule) (Brand

Equivalent Mitigare)

B Maximum of 4 capsules per day

Colchicine (0.6MG Oral Tablet) (Generic Colcrys) G Maximum of 4 tablets per day

Combivent Respimat (Inhalation Aerosol Solution) B Maximum of 1 inhaler (4 grams)

per 20 days

Cometriq (100MG Daily Dose) (Oral Kit) B Maximum of 1 carton (56

capsules) per 28 days

Cometriq (140MG Daily Dose) (Oral Kit) B Maximum of 1 carton (112

capsules) per 28 days

Cometriq (60MG Daily Dose) (Oral Kit) B Maximum of 1 carton (84

capsules) per 28 days

Complera (Oral Tablet) B Maximum of 1 tablet per day

Copiktra (Oral Capsule) B Maximum of 2 capsules per day

Corlanor (Oral Solution) B Maximum of 15 ml per day

Corlanor (Oral Tablet) B Maximum of 2 tablets per day

Cosentyx (300MG Dose) (Subcutaneous Solution

Prefilled Syringe)

B Maximum of 10 syringes (10 ml)

per 30 days

Cosentyx Sensoready (300MG) (Subcutaneous

Solution Auto-Injector)

B Maximum of 10 pens (10 ml) per

30 days

Cosentyx (75MG/0.5ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 20 syringes (10 ml)

per 30 days

Cosentyx UnoReady (Subcutaneous Solution

Auto-Injector)

B Maximum of 5 pens (10 ml) per 30

days

Cotellic (Oral Tablet) B Maximum of 3 tablets per day

Cycloset (Oral Tablet) B Maximum of 6 tablets per day

Cyltezo (Subcutaneous Auto-Injector Kit) B Maximum of 4 pens per 28 days

Last updated February 1, 2024 105

Drug name

Brand

Generic

Quantity limit

Cyltezo (10MG/0.2ML Subcutaneous Prefilled

Syringe Kit, 20MG/0.4ML Subcutaneous Prefilled

Syringe Kit)

B Maximum of 2 syringes per 28

days

Cyltezo (40MG/0.8ML Subcutaneous Prefilled

Syringe Kit)

B Maximum of 4 syringes per 28

days

Dalfampridine ER (Oral Tablet Extended Release 12

Hour)

G Maximum of 2 tablets per day

Daptacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Darunavir (600MG Oral Tablet) G Maximum of 2 tablets per day

Darunavir (800MG Oral Tablet) G Maximum of 1 tablet per day

Daurismo (100MG Oral Tablet) B Maximum of 1 tablet per day

Daurismo (25MG Oral Tablet) B Maximum of 2 tablets per day

Delstrigo (Oral Tablet) B Maximum of 1 tablet per day

Descovy (Oral Tablet) B Maximum of 1 tablet per day

Desonide (External Ointment) G Maximum of 120 grams per 30

days

Desoximetasone (External Cream) G Maximum of 100 grams per 30

days

Desvenlafaxine Succinate ER (100MG Oral Tablet

Extended Release 24 Hour) (Generic Pristiq)

G 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)

G Maximum of 1 tablet per day

Dexlansoprazole (Oral Capsule Delayed Release) G Maximum of 1 capsule per day

Dexmethylphenidate HCl (Oral Tablet) G Maximum of 2 tablets per day

Dextroamphetamine Sulfate ER (10MG Oral Capsule

Extended Release 24 Hour)

G Maximum of 6 capsules per day

Dextroamphetamine Sulfate ER (15MG Oral Capsule

Extended Release 24 Hour)

G Maximum of 4 capsules per day

Dextroamphetamine Sulfate ER (5MG Oral Capsule

Extended Release 24 Hour)

G Maximum of 3 capsules per day

Dextroamphetamine Sulfate (10MG Oral Tablet,

5MG Oral Tablet)

G Maximum of 6 tablets per day

Dextroamphetamine Sulfate (15MG Oral Tablet,

20MG Oral Tablet)

G Maximum of 3 tablets per day

Dextroamphetamine Sulfate (30MG Oral Tablet) G Maximum of 2 tablets per day

Diacomit (250MG Oral Capsule) B Maximum of 12 capsules per day

Diacomit (500MG Oral Capsule) B Maximum of 6 capsules per day

Diacomit (250MG Oral Packet) B Maximum of 12 packets per day

Diacomit (500MG Oral Packet) B Maximum of 6 packets per day

Diazepam Intensol (Oral Concentrate) G Maximum of 8 ml per day

Last updated February 1, 2024106

Drug name

Brand

Generic

Quantity limit

Diazepam (10MG Oral Tablet, 2MG Oral Tablet,

5MG Oral Tablet)

G Maximum of 4 tablets per day

Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel,

20MG Rectal Gel)

G Maximum of 5 packages per 30

days

Diclofenac Epolamine (External Patch) B Maximum of 2 patches per day

Diclofenac Sodium (3% External Gel) G Maximum of 100 grams per 30

days

Dihydroergotamine Mesylate (Nasal Solution) G Maximum of 16 vials (16 ml) per

28 days

Dimethyl Fumarate (120MG Oral Capsule Delayed

Release)

G Maximum of 2 capsules per day

Dimethyl Fumarate (240MG Oral Capsule Delayed

Release)

G Maximum of 2 capsules per day

Dimethyl Fumarate Starter Pack (Oral Capsule

Delayed Release Therapy Pack)

G Maximum of 2 packs (120

capsules) per year

Diphtheria-Tetanus Toxoids DT (25-5LFU/0.5ML

Intramuscular Suspension)

B 1 vaccination dose (0.5 ml) per

day

Dofetilide (125MCG Oral Capsule) G Maximum of 6 capsules per day

Dofetilide (250MCG Oral Capsule, 500MCG Oral

Capsule)

G Maximum of 2 capsules per day

Donepezil HCl (10MG Oral Tablet) G Maximum of 2 tablets per day

Donepezil HCl (23MG Oral Tablet, 5MG Oral Tablet) G Maximum of 1 tablet per day

Donepezil HCl ODT (10MG Oral Tablet Dispersible) G Maximum of 2 tablets per day

Donepezil HCl ODT (5MG Oral Tablet Dispersible) G Maximum of 1 tablet per day

Doptelet (Oral Tablet) B Maximum of 3 tablets per day

Dovato (Oral Tablet) B Maximum of 1 tablet per day

Doxepin HCl (External Cream) G Maximum of 90 grams per 30 days

Droxidopa (100MG Oral Capsule) G Maximum of 3 capsules per day

Droxidopa (200MG Oral Capsule, 300MG Oral

Capsule)

G Maximum of 6 capsules per day

Dulera (120 Inhalation Aerosol) B Maximum of 1 inhaler (13 grams)

per 30 days

Duloxetine HCl (20MG Oral Capsule Delayed

Release Particles)

G Maximum of 4 capsules per day

Duloxetine HCl (30MG Oral Capsule Delayed

Release Particles)

G Maximum of 3 capsules per day

Duloxetine HCl (60MG Oral Capsule Delayed

Release Particles)

G Maximum of 2 capsules per day

Dupixent (200MG/1.14ML Subcutaneous

Solution Pen-Injector)

B Maximum of 4 pens (4.56 ml) per

28 days

Dupixent (300MG/2ML Subcutaneous Solution

Pen-Injector)

B Maximum of 4 pens (8 ml) per 28

days

Last updated February 1, 2024 107

Drug name

Brand

Generic

Quantity limit

Dupixent (100MG/0.67ML Subcutaneous

Solution Prefilled Syringe)

B Maximum of 2 syringes (1.34 ml)

per 28 days

Dupixent (200MG/1.14ML Subcutaneous

Solution Prefilled Syringe)

B Maximum of 4 syringes (4.56 ml)

per 28 days

Dupixent (300MG/2ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 4 syringes (8 ml) per

28 days

Dutasteride (Oral Capsule) G Maximum of 1 capsule per day

Econazole Nitrate (External Cream) G Maximum of 90 grams per 30 days

Edarbi (Oral Tablet) B Maximum of 1 tablet per day

Edarbyclor (Oral Tablet) B Maximum of 1 tablet per day

Edurant (Oral Tablet) B Maximum of 1 tablet per day

Efavirenz (200MG Oral Capsule, 50MG Oral

Capsule)

G Maximum of 3 capsules per day

Efavirenz (Oral Tablet) G Maximum of 1 tablet per day

Efavirenz-Emtricitabine-Tenofovir (Oral Tablet) G Maximum of 1 tablet per day

Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G Maximum of 1 tablet per day

Eligard (22.5MG Subcutaneous Kit) B Maximum of 1 kit per 84 days

Eligard (30MG Subcutaneous Kit) B Maximum of 1 kit per 112 days

Eligard (45MG Subcutaneous Kit) B Maximum of 1 kit per 168 days

Eligard (7.5MG Subcutaneous Kit) B Maximum of 1 kit per 28 days

Eliquis (Oral Tablet) B Maximum of 2 tablets per day

Eliquis Starter Pack (Oral Tablet) B Maximum of 2 packs (148 tablets)

per year

Emgality (300MG Dose) (100MG/ML

Subcutaneous Solution Prefilled Syringe)

B Maximum of 3 syringes or pens (3

ml) per 28 days

Emgality (Subcutaneous Solution Auto-Injector) B Maximum of 2 syringes or pens (2

ml) per 28 days

Emgality (120MG/ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 2 syringes or pens (2

ml) per 28 days

Emsam (Transdermal Patch 24 Hour) B Maximum of 1 patch per day

Emtricitabine (Oral Capsule) G Maximum of 1 capsule per day

Emtricitabine-Tenofovir Disoproxil Fumarate (Oral

Tablet)

G Maximum of 1 tablet per day

Emtriva (Oral Solution) B Maximum of 5 bottles (850 ml) per

30 days

Enalapril Maleate (Oral Tablet) G Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (10-25MG Oral Tablet) G Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (5-12.5MG Oral

Tablet)

G Maximum of 1 tablet per day

Enbrel Mini (Subcutaneous Solution Cartridge) B Maximum of 8 cartridges per 28

days

Last updated February 1, 2024108

Drug name

Brand

Generic

Quantity limit

Enbrel (Subcutaneous Solution) B Maximum of 8 vials (4 ml) per 28

days

Enbrel (25MG/0.5ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 8 syringes (4 ml) per

28 days

Enbrel (50MG/ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 8 syringes (8 ml) per

28 days

Enbrel SureClick (Subcutaneous Solution

Auto-Injector)

B Maximum of 8 pens per 28 days

Endocet (Oral Tablet) G Maximum of 12 tablets per day

Engerix-B (Injection Suspension) B 1 vaccination dose (1 ml) per day

Engerix-B (10MCG/0.5ML Injection Suspension

Prefilled Syringe)

B 1 vaccination dose (0.5 ml) per

day

Engerix-B (20MCG/ML Injection Suspension

Prefilled Syringe)

B 1 vaccination dose (1 ml) per day

Enoxaparin Sodium (100MG/ML Injection Solution

Prefilled Syringe, 150MG/ML Injection Solution

Prefilled Syringe)

G Maximum of 2 syringes (2 ml) per

day

Enoxaparin Sodium (120MG/0.8ML Injection

Solution Prefilled Syringe, 80MG/0.8ML Injection

Solution Prefilled Syringe)

G Maximum of 2 syringes (1.6 ml)

per day

Enoxaparin Sodium (30MG/0.3ML Injection Solution

Prefilled Syringe)

G Maximum of 2 syringes (0.6 ml)

per day

Enoxaparin Sodium (40MG/0.4ML Injection Solution

Prefilled Syringe)

G Maximum of 2 syringes (0.8 ml)

per day

Enoxaparin Sodium (60MG/0.6ML Injection Solution

Prefilled Syringe)

G Maximum of 2 syringes (1.2 ml)

per day

Entresto (Oral Tablet) B Maximum of 2 tablets per day

Epclusa (Oral Packet) B Maximum of 1 carton (28 packets)

per 28 days

Epclusa (Oral Tablet) B Maximum of 1 tablet per day

Epinephrine (Injection Solution Auto-Injector) G Maximum of 4 pens (2 boxes) per

30 days

Erleada (240MG Oral Tablet) B Maximum of 1 tablet per day

Erleada (60MG Oral Tablet) B Maximum of 4 tablets per day

Erlotinib HCl (100MG Oral Tablet, 150MG Oral

Tablet)

G Maximum of 1 tablet per day

Erlotinib HCl (25MG Oral Tablet) G Maximum of 3 tablets per day

Esomeprazole Magnesium (20MG Oral Capsule

Delayed Release) (Generic Nexium)

G Maximum of 3 capsules per day

Esomeprazole Magnesium (40MG Oral Capsule

Delayed Release) (Generic Nexium)

G Maximum of 2 capsules per day

Estradiol (Transdermal Patch Weekly) G Maximum of 4 patches per 28

days

Last updated February 1, 2024 109

Drug name

Brand

Generic

Quantity limit

Estradiol (Vaginal Tablet) G Maximum of 18 tablets per 28

days

Eszopiclone (Oral Tablet) G Maximum of 1 tablet per day

Ethacrynic Acid (Oral Tablet) G Maximum of 16 tablets per day

Etravirine (Oral Tablet) G Maximum of 2 tablets per day

Evotaz (Oral Tablet) B Maximum of 1 tablet per day

Exkivity (Oral Capsule) B Maximum of 4 capsules per day

Ezetimibe (Oral Tablet) G Maximum of 1 tablet per day

Ezetimibe-Simvastatin (Oral Tablet) G Maximum of 1 tablet per day

Famciclovir (125MG Oral Tablet, 250MG Oral

Tablet)

G Maximum of 2 tablets per day

Famciclovir (500MG Oral Tablet) G 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)

B Maximum of 2 tablets per day

Fanapt Titration Pack (Oral Tablet) B Maximum of 2 packs per year

Farxiga (Oral Tablet) B Maximum of 1 tablet per day

Fentanyl Citrate (Buccal Lozenge On A Handle) G 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)

G Maximum of 15 patches per 30

days

Fetzima (Oral Capsule Extended Release 24

Hour)

B Maximum of 1 capsule per day

Fetzima Titration (Oral Capsule ER 24 Hour

Therapy Pack)

B Maximum of 2 packs (56

capsules) per year

Finacea (External Foam) B Maximum of 50 grams per 30 days

Fingolimod HCl (Oral Capsule) G Maximum of 1 capsule per day

Fintepla (Oral Solution) B Maximum of 12 ml per day

Firmagon (240MG Dose) (120MG/Vial

Subcutaneous Solution Reconstituted)

B Maximum of 2 kits (4 vials) per 365

days

Firmagon (80MG Subcutaneous Solution

Reconstituted)

B Maximum of 1 kit per 28 days

Fluocinonide Emulsified Base (External Cream) G Maximum of 60 grams per 30 days

Fluocinonide (0.05% External Cream) G Maximum of 60 grams per 30 days

Fluocinonide (External Gel) G Maximum of 60 grams per 30 days

Fluocinonide (External Ointment) G Maximum of 60 grams per 30 days

Fluocinonide (External Solution) G Maximum of 60 ml per 30 days

Fluorouracil (5% External Cream) G Maximum of 40 grams per 30 days

Last updated February 1, 2024110

Drug name

Brand

Generic

Quantity limit

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)

G 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)

B Maximum of 1 inhaler per 30 days

Fluvastatin Sodium ER (Oral Tablet Extended

Release 24 Hour)

G Maximum of 1 tablet per day

Fluvastatin Sodium (20MG Oral Capsule) G Maximum of 1 capsule per day

Fluvastatin Sodium (40MG Oral Capsule) G Maximum of 2 capsules per day

Formoterol Fumarate (Inhalation Nebulization

Solution)

G Maximum of 2 vials (4 ml) per day

Forteo (Subcutaneous Solution Pen-Injector) B Maximum of 1 pen (2.4 ml) per 28

days

Fosamprenavir Calcium (Oral Tablet) G Maximum of 4 tablets per day

Fosinopril Sodium (Oral Tablet) G Maximum of 2 tablets per day

Fosinopril Sodium-HCTZ (Oral Tablet) G Maximum of 4 tablets per day

Fotivda (Oral Capsule) B Maximum of 21 capsules per 28

days

Fruzaqla (1MG Oral Capsule) B Maximum of 84 capsules per 28

days

Fruzaqla (5MG Oral Capsule) B Maximum of 21 capsules per 28

days

Fuzeon (Subcutaneous Solution Reconstituted) B Maximum of 2 vials per day

Fycompa (Oral Suspension) B Maximum of 24 ml per day

Fycompa (Oral Tablet) B Maximum of 1 tablet per day

Galantamine Hydrobromide ER (Oral Capsule

Extended Release 24 Hour)

G Maximum of 1 capsule per day

Galantamine Hydrobromide (Oral Solution) G Maximum of 2 bottles (200 ml) per

30 days

Galantamine Hydrobromide (Oral Tablet) G Maximum of 2 tablets per day

Gardasil 9 (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Gardasil 9 (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Gavreto (Oral Capsule) B Maximum of 4 capsules per day

Gefitinib (Oral Tablet) G Maximum of 2 tablets per day

Genvoya (Oral Tablet) B Maximum of 1 tablet per day

Last updated February 1, 2024 111

Drug name

Brand

Generic

Quantity limit

Glatiramer Acetate (20MG/ML Subcutaneous

Solution Prefilled Syringe)

G Maximum of 1 syringe (1 ml) per

day

Glatiramer Acetate (40MG/ML Subcutaneous

Solution Prefilled Syringe)

G Maximum of 12 syringes (12 ml)

per 28 days

Glatopa (20MG/ML Subcutaneous Solution Prefilled

Syringe)

G Maximum of 1 syringe (1 ml) per

day

Glatopa (40MG/ML Subcutaneous Solution Prefilled

Syringe)

G Maximum of 12 syringes (12 ml)

per 28 days

Glimepiride (1MG Oral Tablet) G Maximum of 8 tablets per day

Glimepiride (2MG Oral Tablet) G Maximum of 4 tablets per day

Glimepiride (4MG Oral Tablet) G Maximum of 2 tablets per day

Glipizide ER (10MG Oral Tablet Extended Release

24 Hour)

G Maximum of 2 tablets per day

Glipizide ER (2.5MG Oral Tablet Extended Release

24 Hour)

G Maximum of 8 tablets per day

Glipizide ER (5MG Oral Tablet Extended Release 24

Hour)

G Maximum of 4 tablets per day

Glipizide (10MG Oral Tablet Immediate Release) G Maximum of 4 tablets per day

Glipizide (5MG Oral Tablet Immediate Release) G Maximum of 8 tablets per day

Glipizide-Metformin HCl (2.5-250MG Oral Tablet) G Maximum of 8 tablets per day

Glipizide-Metformin HCl (2.5-500MG Oral Tablet,

5-500MG Oral Tablet)

G Maximum of 4 tablets per day

Glyxambi (Oral Tablet) B Maximum of 1 tablet per day

Granisetron HCl (Oral Tablet) G Maximum of 2 tablets per day

Havrix (1440EL U/ML Intramuscular Suspension) B Maximum of 2 vaccines per

lifetime

Havrix (720EL U/0.5ML Intramuscular

Suspension)

B Maximum of 2 vaccines per

lifetime

Heplisav-B (Intramuscular Solution Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Hiberix (Injection Solution Reconstituted) B 1 vaccination dose (1 injection)

per day

Humira (2 Pen) (40MG/0.4ML Subcutaneous

Pen-Injector Kit)

B Maximum of 2 kits (4 pens) per 28

days

Humira (2 Pen) (80MG/0.8ML Subcutaneous

Pen-Injector Kit)

B Maximum of 1 kit (2 pens) per 28

days

Humira (2 Syringe) (10MG/0.1ML Subcutaneous

Prefilled Syringe Kit, 20MG/0.2ML Subcutaneous

Prefilled Syringe Kit)

B Maximum of 1 kit (2 syringes) per

28 days

Humira (2 Syringe) (40MG/0.4ML Subcutaneous

Prefilled Syringe Kit)

B Maximum of 2 kits (4 syringes) per

28 days

Humira Pediatric Crohns Start (80MG/0.8ML &

40MG/0.4ML Subcutaneous Prefilled Syringe Kit)

B Maximum of 2 kits per year

Last updated February 1, 2024112

Drug name

Brand

Generic

Quantity limit

Humira Pediatric Crohns Start (80MG/0.8ML

Subcutaneous Prefilled Syringe Kit)

B Maximum of 2 kits per year

Humira Pen (40MG/0.8ML Subcutaneous

Pen-Injector Kit)

B Maximum of 1 kit (2 pens) per 28

days

Humira Pen Psoriasis/Uveitis Starter

(Subcutaneous Pen-Injector Kit)

B Maximum of 2 kits per year

Humira (40MG/0.8ML Subcutaneous Prefilled

Syringe Kit)

B Maximum of 1 kit (2 syringes) per

28 days

Hydrocodone-Acetaminophen (7.5-325MG/15ML

Oral Solution)

G Maximum of 180 ml per day

Hydrocodone-Acetaminophen (10-325MG Oral

Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral

Tablet)

G Maximum of 12 tablets per day

Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet) G Maximum of 5 tablets per day

Hydromorphone HCl ER (Oral Tablet Extended

Release 24 Hour)

G Maximum of 2 tablets per day

Hydromorphone HCl (1MG/ML Oral Liquid) G Maximum of 50 ml per day

Hydromorphone HCl (2MG Oral Tablet Immediate

Release, 4MG Oral Tablet Immediate Release)

G Maximum of 8 tablets per day

Hydromorphone HCl (8MG Oral Tablet Immediate

Release)

G Maximum of 6 tablets per day

Hydroxychloroquine Sulfate (200MG Oral Tablet) G Maximum of 3 tablets per day

Ibandronate Sodium (Oral Tablet) G Maximum of 1 tablet per 28 days

Ibrance (Oral Capsule) B Maximum of 1 capsule per day

Ibrance (Oral Tablet) B Maximum of 1 tablet per day

Icatibant Acetate (Subcutaneous Solution Prefilled

Syringe)

G Maximum of 12 syringes (36 ml)

per 30 days

Iclusig (Oral Tablet) B Maximum of 1 tablet per day

IDHIFA (Oral Tablet) B Maximum of 1 tablet per day

Imatinib Mesylate (Oral Tablet) G Maximum of 3 tablets per day

Imbruvica (140MG Oral Capsule) B Maximum of 4 capsules per day

Imbruvica (70MG Oral Capsule) B Maximum of 1 capsule per day

Imbruvica (Oral Suspension) B Maximum of 8 ml per day

Imbruvica (140MG Oral Tablet, 280MG Oral

Tablet, 420MG Oral Tablet)

B Maximum of 1 tablet per day

Imiquimod (5% External Cream) G Maximum of 24 packets per 30

days

Imovax Rabies (Intramuscular Suspension

Reconstituted)

B 1 vaccination dose (1 injection)

per day

Imvexxy Maintenance Pack (Vaginal Insert) B Maximum of 8 vaginal inserts per

28 days

Imvexxy Starter Pack (Vaginal Insert) B Maximum of 2 packs per year

Last updated February 1, 2024 113

Drug name

Brand

Generic

Quantity limit

Incruse Ellipta (Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler (30 blisters)

per 30 days

Infanrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Ingrezza (Oral Capsule) B Maximum of 1 capsule per day

Ingrezza (Oral Capsule Therapy Pack) B Maximum of 1 pack (28 capsules)

per 28 days

Inlyta (Oral Tablet) B Maximum of 4 tablets per day

Inqovi (Oral Tablet) B Maximum of 1 pack (5 tablets) per

28 days

Inrebic (Oral Capsule) B Maximum of 4 capsules per day

Intelence (25MG Oral Tablet) B Maximum of 4 tablets per day

IPOL (Injection) B 1 vaccination dose (0.5 ml) per

day

Irbesartan (150MG Oral Tablet, 300MG Oral Tablet) G Maximum of 1 tablet per day

Irbesartan (75MG Oral Tablet) G Maximum of 3 tablets per day

Irbesartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Isentress HD (Oral Tablet) B Maximum of 2 tablets per day

Isentress (Oral Packet) B Maximum of 2 packets per day

Isentress (Oral Tablet) B Maximum of 2 tablets per day

Isentress (Oral Tablet Chewable) B Maximum of 6 tablets per day

Isosorbide Dinitrate-Hydralazine (Oral Tablet) G Maximum of 6 tablets per day

Itraconazole (Oral Capsule) G Maximum of 4 capsules per day

Ixiaro (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Jakafi (Oral Tablet) B Maximum of 2 tablets per day

Janumet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Janumet XR (100-1000MG Oral Tablet Extended

Release 24 Hour, 50-500MG Oral Tablet Extended

Release 24 Hour)

B Maximum of 1 tablet per day

Janumet XR (50-1000MG Oral Tablet Extended

Release 24 Hour)

B Maximum of 2 tablets per day

Januvia (Oral Tablet) B Maximum of 1 tablet per day

Jardiance (Oral Tablet) B Maximum of 1 tablet per day

Jaypirca (100MG Oral Tablet) B Maximum of 3 tablets per day

Jaypirca (50MG Oral Tablet) B Maximum of 1 tablet per day

Jentadueto (2.5-1000MG Oral Tablet, 2.5-500MG

Oral Tablet)

B Maximum of 2 tablets per day

Jentadueto XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)

B Maximum of 2 tablets per day

Jentadueto XR (5-1000MG Oral Tablet Extended

Release 24 Hour)

B Maximum of 1 tablet per day

Last updated February 1, 2024114

Drug name

Brand

Generic

Quantity limit

Juluca (Oral Tablet) B Maximum of 1 tablet per day

Jynneos (Subcutaneous Suspension) B 1 vaccination dose (0.5 ml) per

day

Kalydeco (13.4MG Oral Packet, 25MG Oral

Packet, 50MG Oral Packet, 75MG Oral Packet)

B Maximum of 2 packets per day

Kalydeco (Oral Tablet) B Maximum of 2 tablets per day

Kerendia (Oral Tablet) B Maximum of 1 tablet per day

Ketoconazole (External Cream) G Maximum of 90 grams per 30 days

Kinrix (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Kisqali (200MG Dose) (Oral Tablet) B Maximum of 1 tablet per day

Kisqali (400MG Dose) (Oral Tablet) B Maximum of 2 tablets per day

Kisqali (600MG Dose) (Oral Tablet) B Maximum of 3 tablets per day

Kisqali Femara (200MG Dose) (Oral Tablet

Therapy Pack)

B Maximum of 1 pack (49 tablets)

per 28 days

Kisqali Femara (400MG Dose) (Oral Tablet

Therapy Pack)

B Maximum of 1 pack (70 tablets)

per 28 days

Kisqali Femara (600MG Dose) (Oral Tablet

Therapy Pack)

B Maximum of 1 pack (91 tablets)

per 28 days

Korlym (Oral Tablet) B Maximum of 4 tablets per day

Koselugo (10MG Oral Capsule) B Maximum of 8 capsules per day

Koselugo (25MG Oral Capsule) B Maximum of 4 capsules per day

Krazati (Oral Tablet) B Maximum of 6 tablets per day

Lacosamide (Oral Solution) G Maximum of 40 ml per day

Lacosamide (Oral Tablet) G Maximum of 2 tablets per day

Lagevrio (Oral Capsule) B Maximum of 8 capsules per day

and 40 capsules per prescription

Lamivudine (10MG/ML Oral Solution) G Maximum of 32 ml per day

Lamivudine (150MG Oral Tablet) G Maximum of 2 tablets per day

Lamivudine (300MG Oral Tablet) G Maximum of 1 tablet per day

Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Lansoprazole (Oral Capsule Delayed Release) G Maximum of 2 capsules per day

Lenalidomide (Oral Capsule) G Maximum of 1 capsule per day

Leuprolide Acetate (Subcutaneous Injection Kit) G Maximum of 2 kits per 28 days

Levocetirizine Dihydrochloride (Oral Tablet) G Maximum of 1 tablet per day

Lexiva (Oral Suspension) B Maximum of 60 ml per day

Lidocaine (5% External Ointment) G Maximum of 152 grams per 30

days

Lidocaine (5% External Patch) G Maximum of 3 patches per day

Linezolid (Oral Suspension Reconstituted) G Maximum of 60 ml per day

Linezolid (Oral Tablet) G Maximum of 2 tablets per day

Last updated February 1, 2024 115

Drug name

Brand

Generic

Quantity limit

Linzess (Oral Capsule) B Maximum of 1 capsule per day

Lisinopril (Oral Tablet) G Maximum of 2 tablets per day

Lisinopril-Hydrochlorothiazide (10-12.5MG Oral

Tablet)

G Maximum of 1 tablet per day

Lisinopril-Hydrochlorothiazide (20-12.5MG Oral

Tablet)

G Maximum of 4 tablets per day

Lisinopril-Hydrochlorothiazide (20-25MG Oral

Tablet)

G Maximum of 2 tablets per day

Livalo (Oral Tablet) B Maximum of 1 tablet per day

Lokelma (Oral Packet) B Maximum of 3 packets per day

Lonsurf (15-6.14MG Oral Tablet) B Maximum of 10 tablets per day

Lonsurf (20-8.19MG Oral Tablet) B Maximum of 8 tablets per day

Lopinavir-Ritonavir (Oral Solution) G Maximum of 3 bottles (480 ml) per

30 days

Lopinavir-Ritonavir (100-25MG Oral Tablet) G Maximum of 8 tablets per day

Lopinavir-Ritonavir (200-50MG Oral Tablet) G Maximum of 4 tablets per day

Lorazepam Intensol (Oral Concentrate) G Maximum of 5 ml per day

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet) G Maximum of 4 tablets per day

Lorazepam (2MG Oral Tablet) G Maximum of 5 tablets per day

Lorbrena (100MG Oral Tablet) B Maximum of 1 tablet per day

Lorbrena (25MG Oral Tablet) B Maximum of 3 tablets per day

Losartan Potassium (100MG Oral Tablet) G Maximum of 1 tablet per day

Losartan Potassium (25MG Oral Tablet, 50MG Oral

Tablet)

G Maximum of 2 tablets per day

Losartan Potassium-HCTZ (100-12.5MG Oral Tablet,

100-25MG Oral Tablet)

G Maximum of 1 tablet per day

Losartan Potassium-HCTZ (50-12.5MG Oral Tablet) G Maximum of 2 tablets per day

Lovastatin (10MG Oral Tablet, 20MG Oral Tablet) G Maximum of 1 tablet per day

Lovastatin (40MG Oral Tablet) G Maximum of 2 tablets per day

Lubiprostone (Oral Capsule) G Maximum of 2 capsules per day

Lumakras (120MG Oral Tablet) B Maximum of 8 tablets per day

Lumakras (320MG Oral Tablet) B Maximum of 3 tablets per day

Lupron Depot (1-Month) (Intramuscular Kit) B Maximum of 1 kit per 28 days

Lupron Depot (3-Month) (Intramuscular Kit) B Maximum of 1 kit per 84 days

Lupron Depot (4-Month) (Intramuscular Kit) B Maximum of 1 kit per 112 days

Lupron Depot (6-Month) (Intramuscular Kit) B Maximum of 1 kit per 168 days

Lupron Depot-Ped (1-Month) (7.5MG

Intramuscular Kit)

B Maximum of 1 kit per 28 days

Lupron Depot-Ped (3-Month) (11.25MG

Intramuscular Kit)

B Maximum of 1 kit per 84 days

Lupron Depot-Ped (6-Month) (Intramuscular Kit) B Maximum of 1 kit per 168 days

Last updated February 1, 2024116

Drug name

Brand

Generic

Quantity limit

Lurasidone HCl (120MG Oral Tablet, 20MG Oral

Tablet, 40MG Oral Tablet, 60MG Oral Tablet)

G Maximum of 1 tablet per day

Lurasidone HCl (80MG Oral Tablet) G Maximum of 2 tablets per day

Lybalvi (Oral Tablet) B Maximum of 1 tablet per day

Lynparza (Oral Tablet) B Maximum of 4 tablets per day

Lytgobi (12MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 4 packs (84 tablets)

per 28 days

Lytgobi (16MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 4 packs (112 tablets)

per 28 days

Lytgobi (20MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 4 packs (140 tablets)

per 28 days

Maraviroc (150MG Oral Tablet) G Maximum of 2 tablets per day

Maraviroc (300MG Oral Tablet) G Maximum of 4 tablets per day

Mavyret (Oral Packet) B Maximum of 5 cartons (140

packets) per 28 days

Mavyret (Oral Tablet) B Maximum of 3 tablets per day

Mayzent (0.25MG Oral Tablet) B Maximum of 4 tablets per day

Mayzent (1MG Oral Tablet, 2MG Oral Tablet) B Maximum of 1 tablet per day

Mayzent Starter Pack (12 x 0.25MG Oral Tablet

Therapy Pack)

B Maximum of 2 packs (24 tablets)

per year

Mayzent Starter Pack (7 x 0.25MG Oral Tablet

Therapy Pack)

B Maximum of 2 packs (14 tablets)

per year

Memantine HCl ER (Oral Capsule Extended Release

24 Hour)

G Maximum of 1 capsule per day

Memantine HCl (Oral Solution) G Maximum of 10 ml per day

Memantine HCl (10MG Oral Tablet) G Maximum of 2 tablets per day

Memantine HCl Titration Pak (Oral Tablet) G Maximum of 2 packs per year

Memantine HCl (5MG Oral Tablet) G Maximum of 3 tablets per day

Menactra (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per

day

MenQuadfi (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per

day

Menveo (Intramuscular Solution Reconstituted) B 1 vaccination dose (1 injection)

per day

Mesalamine ER (500MG Oral Capsule Extended

Release) (Generic Pentasa)

G Maximum of 8 capsules per day

Mesalamine ER (0.375GM Oral Capsule Extended

Release 24 Hour) (Generic Apriso)

G Maximum of 4 capsules per day

Mesalamine (1.2GM Oral Tablet Delayed Release)

(Generic Lialda)

G Maximum of 4 tablets per day

Mesalamine (Rectal Enema) G Maximum of 1 bottle (60 ml) per

day

Mesalamine (Rectal Suppository) G Maximum of 1 suppository per day

Last updated February 1, 2024 117

Drug name

Brand

Generic

Quantity limit

Metformin HCl ER (500MG Oral Tablet Extended

Release 24 Hour) (Generic Glucophage XR)

G Maximum of 4 tablets per day

Metformin HCl ER (750MG Oral Tablet Extended

Release 24 Hour) (Generic Glucophage XR)

G Maximum of 2 tablets per day

Metformin HCl (Oral Solution) G Maximum of 25.5 ml per day

Metformin HCl (1000MG Oral Tablet Immediate

Release)

G Maximum of 2.5 tablets per day

Metformin HCl (500MG Oral Tablet Immediate

Release)

G Maximum of 5 tablets per day

Metformin HCl (850MG Oral Tablet Immediate

Release)

G Maximum of 3 tablets per day

Methadone HCl (10MG/5ML Oral Solution) G Maximum of 60 ml per day

Methadone HCl (5MG/5ML Oral Solution) G Maximum of 120 ml per day

Methadone HCl (10MG Oral Tablet) G Maximum of 12 tablets per day

Methadone HCl (5MG Oral Tablet) G Maximum of 8 tablets per day

Methylphenidate HCl ER (10MG Oral Tablet

Extended Release)

G Maximum of 4 tablets per day

Methylphenidate HCl ER (20MG Oral Tablet

Extended Release)

G Maximum of 3 tablets per day

Methylphenidate HCl (10MG/5ML Oral Solution) G Maximum of 30 ml per day

Methylphenidate HCl (5MG/5ML Oral Solution) G Maximum of 60 ml per day

Methylphenidate HCl (Oral Tablet Immediate

Release) (Generic Ritalin)

G Maximum of 3 tablets per day

Miglitol (100MG Oral Tablet) G Maximum of 3 tablets per day

Miglitol (25MG Oral Tablet) G Maximum of 12 tablets per day

Miglitol (50MG Oral Tablet) G Maximum of 6 tablets per day

M-M-R II (Injection Solution Reconstituted) B 1 vaccination dose (1 injection)

per day

Modafinil (100MG Oral Tablet) G Maximum of 1 tablet per day

Modafinil (200MG Oral Tablet) G Maximum of 2 tablets per day

Moexipril HCl (Oral Tablet) G Maximum of 2 tablets per day

Montelukast Sodium (Oral Packet) G Maximum of 1 packet per day

Montelukast Sodium (Oral Tablet) G Maximum of 1 tablet per day

Montelukast Sodium (Oral Tablet Chewable) G Maximum of 1 tablet per day

Morphine Sulfate (Concentrate) (20MG/ML Oral

Solution)

G Maximum of 10 ml per day

Morphine Sulfate ER (100MG Oral Tablet Extended

Release, 15MG Oral Tablet Extended Release)

(Generic MS Contin)

G Maximum of 3 tablets per day

Morphine Sulfate ER (200MG Oral Tablet Extended

Release) (Generic MS Contin)

G Maximum of 2 tablets per day

Last updated February 1, 2024118

Drug name

Brand

Generic

Quantity limit

Morphine Sulfate ER (30MG Oral Tablet Extended

Release, 60MG Oral Tablet Extended Release)

(Generic MS Contin)

G Maximum of 4 tablets per day

Morphine Sulfate (10MG/5ML Oral Solution) G Maximum of 100 ml per day

Morphine Sulfate (20MG/5ML Oral Solution) G Maximum of 50 ml per day

Morphine Sulfate (15MG Oral Tablet Immediate

Release)

G Maximum of 8 tablets per day

Morphine Sulfate (30MG Oral Tablet Immediate

Release)

G Maximum of 6 tablets per day

Motegrity (Oral Tablet) B Maximum of 1 tablet per day

Mounjaro (Subcutaneous Solution Pen-Injector) B Maximum of 4 pens (2 ml) per 28

days

Movantik (Oral Tablet) B Maximum of 1 tablet per day

Multaq (Oral Tablet) B Maximum of 2 tablets per day

Mupirocin (External Ointment) G Maximum of 110 grams per 30

days

Namzaric (Oral Capsule ER 24 Hour Therapy

Pack)

B Maximum of 1 capsule per day

Namzaric (Oral Capsule Extended Release 24

Hour)

B Maximum of 1 capsule per day

Naratriptan HCl (Oral Tablet) G Maximum of 12 tablets per 30

days

Nateglinide (120MG Oral Tablet) G Maximum of 3 tablets per day

Nateglinide (60MG Oral Tablet) G Maximum of 6 tablets per day

Nayzilam (Nasal Solution) B Maximum of 10 devices per 30

days

Nebivolol HCl (10MG Oral Tablet, 2.5MG Oral

Tablet, 5MG Oral Tablet)

G Maximum of 1 tablet per day

Nebivolol HCl (20MG Oral Tablet) G Maximum of 2 tablets per day

Nerlynx (Oral Tablet) B Maximum of 6 tablets per day

Nevirapine ER (400MG Oral Tablet Extended

Release 24 Hour)

G Maximum of 1 tablet per day

Nevirapine (Oral Suspension) G Maximum of 40 ml per day

Nevirapine (Oral Tablet Immediate Release) G Maximum of 2 tablets per day

Nifedipine ER (Oral Tablet Extended Release 24

Hour)

G Maximum of 2 tablets per day

Nifedipine ER Osmotic Release (Oral Tablet

Extended Release 24 Hour)

G Maximum of 2 tablets per day

Ninlaro (Oral Capsule) B Maximum of 3 capsules per 28

days

Nitazoxanide (Oral Tablet) G Maximum of 2 tablets per day

Norvir (Oral Packet) B Maximum of 12 packets per day

Noxafil (Oral Suspension) B Maximum of 20 ml per day

Last updated February 1, 2024 119

Drug name

Brand

Generic

Quantity limit

Nubeqa (Oral Tablet) B Maximum of 4 tablets per day

Nucala (Subcutaneous Solution Auto-Injector) B Maximum of 3 ml per 28 days

Nucala (100MG/ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 3 ml per 28 days

Nucala (40MG/0.4ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 0.4 ml per 28 days

Nucala (Subcutaneous Solution Reconstituted) B Maximum of 3 vials per 28 days

Nuedexta (Oral Capsule) B Maximum of 2 capsules per day

Nuplazid (Oral Capsule) B Maximum of 1 capsule per day

Nuplazid (Oral Tablet) B Maximum of 1 tablet per day

Nurtec ODT (Oral Tablet Dispersible) B Maximum of 18 tablets per 30

days

Nyamyc (External Powder) G Maximum of 120 grams per 30

days

Nystatin (External Powder) G Maximum of 120 grams per 30

days

Nystop (External Powder) G Maximum of 120 grams per 30

days

Odefsey (Oral Tablet) B Maximum of 1 tablet per day

Ofev (Oral Capsule) B Maximum of 2 capsules per day

Ojjaara (Oral Tablet) B Maximum of 1 tablet per day

Olanzapine (10MG Oral Tablet, 2.5MG Oral Tablet,

5MG Oral Tablet, 7.5MG Oral Tablet)

G Maximum of 2 tablets per day

Olanzapine (15MG Oral Tablet, 20MG Oral Tablet) G Maximum of 1 tablet per day

Olanzapine ODT (10MG Oral Tablet Dispersible,

5MG Oral Tablet Dispersible)

G Maximum of 2 tablets per day

Olanzapine ODT (15MG Oral Tablet Dispersible,

20MG Oral Tablet Dispersible)

G Maximum of 1 tablet per day

Olmesartan Medoxomil (20MG Oral Tablet, 40MG

Oral Tablet)

G Maximum of 1 tablet per day

Olmesartan Medoxomil (5MG Oral Tablet) G Maximum of 2 tablets per day

Olmesartan Medoxomil-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Olmesartan-Amlodipine-HCTZ (Oral Tablet) G Maximum of 1 tablet per day

Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic

Lovaza)

G Maximum of 4 capsules per day

Omeprazole (10MG Oral Capsule Delayed Release) G Maximum of 3 capsules per day

Ondansetron HCl (Oral Solution) G Maximum of 30 ml per day

Ondansetron HCl (4MG Oral Tablet) G Maximum of 6 tablets per day

Ondansetron HCl (8MG Oral Tablet) G Maximum of 3 tablets per day

Ondansetron ODT (4MG Oral Tablet Dispersible) G Maximum of 6 tablets per day

Ondansetron ODT (8MG Oral Tablet Dispersible) G Maximum of 3 tablets per day

Last updated February 1, 2024120

Drug name

Brand

Generic

Quantity limit

Onureg (Oral Tablet) B Maximum of 14 tablets per 28

days

Orencia ClickJect (Subcutaneous Solution

Auto-Injector)

B Maximum of 4 pens (4 ml) per 28

days

Orencia (125MG/ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 4 syringes (4 ml) per

28 days

Orencia (50MG/0.4ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 4 syringes (1.6 ml)

per 28 days

Orencia (87.5MG/0.7ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 4 syringes (2.8 ml)

per 28 days

Orenitram Month 1 (Oral Tablet Extended Release

Therapy Pack)

B Maximum of 2 packs (336 tablets)

per year

Orenitram Month 2 (Oral Tablet Extended Release

Therapy Pack)

B Maximum of 2 packs (672 tablets)

per year

Orenitram Month 3 (Oral Tablet Extended Release

Therapy Pack)

B Maximum of 2 packs (504 tablets)

per year

Orgovyx (Oral Tablet) B Maximum of 30 tablets per 28

days

Orkambi (Oral Packet) B Maximum of 56 packets per 28

days

Orkambi (Oral Tablet) B Maximum of 4 tablets per day

Orserdu (345MG Oral Tablet) B Maximum of 1 tablet per day

Orserdu (86MG Oral Tablet) B Maximum of 3 tablets per day

Oseltamivir Phosphate (Oral Capsule) G Maximum of 2 capsules per day

Oseltamivir Phosphate (Oral Suspension

Reconstituted)

G Maximum of 26 ml per day

Osphena (Oral Tablet) B Maximum of 1 tablet per day

Otezla (Oral Tablet) B Maximum of 2 tablets per day

Otezla (Oral Tablet Therapy Pack) B Maximum of 2 kits per year

Oxybutynin Chloride ER (10MG Oral Tablet

Extended Release 24 Hour)

G Maximum of 3 tablets per day

Oxybutynin Chloride ER (15MG Oral Tablet

Extended Release 24 Hour)

G Maximum of 2 tablets per day

Oxybutynin Chloride ER (5MG Oral Tablet Extended

Release 24 Hour)

G Maximum of 1 tablet per day

Oxycodone HCl (Oral Concentrate) G Maximum of 6 ml per day

Oxycodone HCl (Oral Solution) G Maximum of 130 ml per day

Oxycodone HCl (10MG Oral Tablet Immediate

Release, 5MG Oral Tablet Immediate Release)

G Maximum of 12 tablets per day

Oxycodone HCl (15MG Oral Tablet Immediate

Release)

G Maximum of 8 tablets per day

Oxycodone HCl (20MG Oral Tablet Immediate

Release, 30MG Oral Tablet Immediate Release)

G Maximum of 6 tablets per day

Last updated February 1, 2024 121

Drug name

Brand

Generic

Quantity limit

Oxycodone-Acetaminophen (10-325MG Oral Tablet,

2.5-325MG Oral Tablet, 5-325MG Oral Tablet,

7.5-325MG Oral Tablet)

G Maximum of 12 tablets per day

Ozempic (0.25MG/DOSE or 0.5MG/DOSE)

(2MG/3ML Subcutaneous Solution Pen-Injector)

B Maximum of 1 pen (3 ml) per 28

days

Ozempic (1MG/DOSE) (4MG/3ML Subcutaneous

Solution Pen-Injector)

B Maximum of 1 pen (3 ml) per 28

days

Ozempic (2MG/DOSE) (8MG/3ML Subcutaneous

Solution Pen-Injector)

B 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)

G Maximum of 1 tablet per day

Paliperidone ER (6MG Oral Tablet Extended

Release 24 Hour)

G Maximum of 2 tablets per day

Pantoprazole Sodium (20MG Oral Tablet Delayed

Release)

G Maximum of 3 tablets per day

Pantoprazole Sodium (40MG Oral Tablet Delayed

Release)

G Maximum of 2 tablets per day

Paxlovid (150/100MG) (Oral Tablet Therapy Pack) B Maximum of 4 tablets per day and

20 tablets per prescription

Paxlovid (300/100MG) (Oral Tablet Therapy Pack) B Maximum of 6 tablets per day and

30 tablets per prescription

Pazopanib HCl (Oral Tablet) G Maximum of 4 tablets per day

Pediarix (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Pedvax HIB (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Pemazyre (Oral Tablet) B Maximum of 14 tablets per 21

days

Pentacel (Intramuscular Suspension

Reconstituted)

B 1 vaccination dose (1 injection)

per day

Pentamidine Isethionate (Inhalation Solution

Reconstituted)

G Maximum of 1 vial (300 mg) per 28

days

Pentasa (250MG Oral Capsule Extended Release) B Maximum of 16 capsules per day

Pentasa (500MG Oral Capsule Extended Release) B Maximum of 8 capsules per day

Perforomist (Inhalation Nebulization Solution) B Maximum of 2 vials (4 ml) per day

Perindopril Erbumine (Oral Tablet) G Maximum of 2 tablets per day

Pifeltro (Oral Tablet) B Maximum of 1 tablet per day

Pimecrolimus (External Cream) G Maximum of 100 grams per 30

days

Pioglitazone HCl (Oral Tablet) G Maximum of 1 tablet per day

Pioglitazone HCl-Glimepiride (Oral Tablet) G Maximum of 1 tablet per day

Pioglitazone HCl-Metformin HCl (Oral Tablet) G Maximum of 3 tablets per day

Last updated February 1, 2024122

Drug name

Brand

Generic

Quantity limit

Piqray (200MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 1 tablet per day

Piqray (250MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 2 tablets per day

Piqray (300MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 2 tablets per day

Pirfenidone (Oral Capsule) G Maximum of 9 capsules per day

Pirfenidone (267MG Oral Tablet) G Maximum of 6 tablets per day

Pirfenidone (534MG Oral Tablet, 801MG Oral

Tablet)

G Maximum of 3 tablets per day

Pomalyst (Oral Capsule) B Maximum of 1 capsule per day

Posaconazole (Oral Suspension) G Maximum of 20 ml per day

Posaconazole (Oral Tablet Delayed Release) G Maximum of 6 tablets per day

Praluent (Subcutaneous Solution Auto-Injector) B Maximum of 2 pens (2 ml) per 28

days

Prasugrel HCl (Oral Tablet) G Maximum of 1 tablet per day

Pravastatin Sodium (Oral Tablet) G Maximum of 1 tablet per day

Pregabalin (100MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule, 75MG Oral Capsule)

G Maximum of 4 capsules per day

Pregabalin (150MG Oral Capsule, 200MG Oral

Capsule)

G Maximum of 3 capsules per day

Pregabalin (225MG Oral Capsule, 300MG Oral

Capsule)

G Maximum of 2 capsules per day

Pregabalin (Oral Solution) G Maximum of 30 ml per day

PreHevbrio (Intramuscular Suspension) B 1 vaccination dose (1 ml) per day

Premarin (Oral Tablet) B Maximum of 1 tablet per day

Premphase (Oral Tablet) B Maximum of 1 tablet per day

Prempro (Oral Tablet) B Maximum of 1 tablet per day

Prevymis (Oral Tablet) B Maximum of 1 tablet per day

Prezcobix (Oral Tablet) B Maximum of 1 tablet per day

Prezista (Oral Suspension) B Maximum of 2 bottles (400 ml) per

30 days

Prezista (150MG Oral Tablet) B Maximum of 6 tablets per day

Prezista (75MG Oral Tablet) B Maximum of 10 tablets per day

Priorix (Subcutaneous Suspension Reconstituted) B 1 vaccination dose (1 injection)

per day

Prolia (Subcutaneous Solution Prefilled Syringe) B Maximum of 1 syringe per 180

days

Promacta (Oral Packet) B Maximum of 6 packets per day

Promacta (12.5MG Oral Tablet, 25MG Oral

Tablet)

B Maximum of 1 tablet per day

Promacta (50MG Oral Tablet, 75MG Oral Tablet) B Maximum of 2 tablets per day

Last updated February 1, 2024 123

Drug name

Brand

Generic

Quantity limit

Promethazine HCl (12.5MG Rectal Suppository) G Maximum of 6 suppositories per

day

Promethazine HCl (25MG Rectal Suppository) G Maximum of 4 suppositories per

day

Promethegan (25MG Rectal Suppository) G Maximum of 4 suppositories per

day

ProQuad (Subcutaneous Suspension

Reconstituted)

B 1 vaccination dose (1 injection)

per day

Pulmozyme (Inhalation Solution) B Maximum of 2 ampules (5 ml) per

day

Pyrukynd (20MG Oral Tablet, 5MG Oral Tablet) B Maximum of 1 pack (56 tablets)

per 28 days

Pyrukynd (50MG Oral Tablet) B Maximum of 2 packs (112 tablets)

per 28 days

Pyrukynd Taper Pack (5MG Oral Tablet Therapy

Pack)

B 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)

B Maximum of 1 pack (14 tablets)

per 14 days

Qinlock (Oral Tablet) B Maximum of 3 tablets per day

Quadracel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Quadracel (Intramuscular Suspension Prefilled

Syringe)

B 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)

G 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)

G Maximum of 2 tablets per day

Quetiapine Fumarate (100MG Oral Tablet Immediate

Release, 150MG Oral Tablet Immediate Release,

200MG Oral Tablet Immediate Release, 50MG Oral

Tablet Immediate Release)

G Maximum of 3 tablets per day

Quetiapine Fumarate (25MG Oral Tablet Immediate

Release)

G Maximum of 4 tablets per day

Quetiapine Fumarate (300MG Oral Tablet Immediate

Release, 400MG Oral Tablet Immediate Release)

G Maximum of 2 tablets per day

Quinapril HCl (Oral Tablet) G Maximum of 2 tablets per day

Qulipta (Oral Tablet) B Maximum of 1 tablet per day

Quviviq (Oral Tablet) B Maximum of 1 tablet per day

Qvar RediHaler (Inhalation Aerosol Breath

Activated)

B Maximum of 2 inhalers (21.2

grams) per 30 days

Last updated February 1, 2024124

Drug name

Brand

Generic

Quantity limit

RabAvert (Intramuscular Suspension

Reconstituted)

B 1 vaccination dose (1 injection)

per day

Raloxifene HCl (Oral Tablet) G Maximum of 1 tablet per day

Ramelteon (Oral Tablet) G Maximum of 1 tablet per day

Ramipril (Oral Capsule) G Maximum of 2 capsules per day

Ranolazine ER (Oral Tablet Extended Release 12

Hour)

G Maximum of 2 tablets per day

Rayaldee (Oral Capsule Extended Release) B Maximum of 2 capsules per day

Rebif Rebidose (Subcutaneous Solution

Auto-Injector)

B Maximum of 12 pens (6 ml) per 28

days

Rebif Rebidose Titration Pack (Subcutaneous

Solution Auto-Injector)

B Maximum of 2 packs per year

Rebif (Subcutaneous Solution Prefilled Syringe) B Maximum of 12 syringes (6 ml) per

28 days

Rebif Titration Pack (Subcutaneous Solution

Prefilled Syringe)

B Maximum of 2 packs per year

Recombivax HB (10MCG/ML Injection

Suspension, 40MCG/ML Injection Suspension)

B 1 vaccination dose (1 ml) per day

Recombivax HB (5MCG/0.5ML Injection

Suspension)

B 1 vaccination dose (0.5 ml) per

day

Recombivax HB (10MCG/ML Injection

Suspension Prefilled Syringe)

B 1 vaccination dose (1 ml) per day

Recombivax HB (5MCG/0.5ML Injection

Suspension Prefilled Syringe)

B 1 vaccination dose (0.5 ml) per

day

Rectiv (Rectal Ointment) B Maximum of 30 grams per 30 days

Relenza Diskhaler (Inhalation Aerosol Powder

Breath Activated)

B Maximum of 3 inhalers (60

blisters) per 30 days

Relistor (Oral Tablet) B Maximum of 3 tablets per day

Repaglinide (0.5MG Oral Tablet) G Maximum of 32 tablets per day

Repaglinide (1MG Oral Tablet) G Maximum of 16 tablets per day

Repaglinide (2MG Oral Tablet) G Maximum of 8 tablets per day

Repatha Pushtronex System (Subcutaneous

Solution Cartridge)

B Maximum of 2 cartridges (7 ml)

per 28 days

Repatha (Subcutaneous Solution Prefilled

Syringe)

B Maximum of 3 syringes (3 ml) per

28 days

Repatha SureClick (Subcutaneous Solution

Auto-Injector)

B Maximum of 3 pens (3 ml) per 28

days

Restasis MultiDose (Ophthalmic Emulsion) B Maximum of 1 bottle (5.5 ml) per

25 days

Restasis Single-Use Vials (Ophthalmic Emulsion) B Maximum of 2 vials per day

Retevmo (40MG Oral Capsule) B Maximum of 6 capsules per day

Retevmo (80MG Oral Capsule) B Maximum of 4 capsules per day

Revlimid (Oral Capsule) B Maximum of 1 capsule per day

Last updated February 1, 2024 125

Drug name

Brand

Generic

Quantity limit

Rexulti (Oral Tablet) B Maximum of 1 tablet per day

Reyataz (Oral Packet) B Maximum of 6 packets per day

Rezlidhia (Oral Capsule) B Maximum of 2 capsules per day

Rinvoq (Oral Tablet Extended Release 24 Hour) B Maximum of 1 tablet per day

Risedronate Sodium (150MG Oral Tablet Immediate

Release)

G Maximum of 1 tablet per 30 days

Risedronate Sodium (30MG Oral Tablet Immediate

Release, 5MG Oral Tablet Immediate Release)

G 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)

G Maximum of 4 tablets per 28 days

Ritonavir (Oral Tablet) G Maximum of 12 tablets per day

Rivastigmine Tartrate (Oral Capsule) G Maximum of 2 capsules per day

Rivastigmine (Transdermal Patch 24 Hour) G Maximum of 1 patch per day

Rizatriptan Benzoate (Oral Tablet) G Maximum of 12 tablets per 30

days

Rizatriptan Benzoate ODT (Oral Tablet Dispersible) G Maximum of 12 tablets per 30

days

Roflumilast (250MCG Oral Tablet) G Maximum of 1 tablet per day

Roflumilast (500MCG Oral Tablet) G Maximum of 1 tablet per day

Rosuvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day

Rotarix (Oral Suspension) B 1 vaccination dose (1.5 ml) per

day

Rotarix (Oral Suspension Reconstituted) B 1 vaccination dose (1 ml) per day

RotaTeq (Oral Solution) B 1 vaccination dose (2 ml) per day

Rozlytrek (100MG Oral Capsule) B Maximum of 5 capsules per day

Rozlytrek (200MG Oral Capsule) B Maximum of 3 capsules per day

Rubraca (Oral Tablet) B Maximum of 4 tablets per day

Rukobia (Oral Tablet Extended Release 12 Hour) B Maximum of 2 tablets per day

Rybelsus (Oral Tablet) B Maximum of 1 tablet per day

Rydapt (Oral Capsule) B Maximum of 8 capsules per day

Sajazir (Subcutaneous Solution Prefilled Syringe) G Maximum of 12 syringes (36 ml)

per 30 days

Sancuso (Transdermal Patch) B Maximum of 4 patches per 28

days

Scemblix (20MG Oral Tablet) B Maximum of 2 tablets per day

Scemblix (40MG Oral Tablet) B Maximum of 10 tablets per day

Secuado (Transdermal Patch 24 Hour) B Maximum of 1 patch per day

Selzentry (Oral Solution) B Maximum of 8 bottles (1840 ml)

per 30 days

Selzentry (25MG Oral Tablet) B Maximum of 16 tablets per day

Last updated February 1, 2024126

Drug name

Brand

Generic

Quantity limit

Selzentry (75MG Oral Tablet) B Maximum of 2 tablets per day

Serevent Diskus (60 Inhalation Aerosol Powder

Breath Activated)

B Maximum of 1 inhaler (60

inhalations) per 30 days

Shingrix (Intramuscular Suspension

Reconstituted)

B 1 vaccination dose (1 injection)

per day

Sildenafil Citrate (20MG Oral Tablet) (Generic

Revatio)

G Maximum of 3 tablets per day

Silodosin (Oral Capsule) G Maximum of 1 capsule per day

Simponi (100MG/ML Subcutaneous Solution

Auto-Injector)

B Maximum of 3 syringes (3 ml) per

28 days

Simponi (50MG/0.5ML Subcutaneous Solution

Auto-Injector)

B Maximum of 1 syringe (0.5 ml) per

30 days

Simponi (100MG/ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 3 syringes (3 ml) per

28 days

Simponi (50MG/0.5ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 1 syringe (0.5 ml) per

30 days

Simvastatin (Oral Tablet) G Maximum of 1 tablet per day

Skyclarys (Oral Capsule) B Maximum of 3 capsules per day

Skyrizi Pen (Subcutaneous Solution Auto-Injector) B Maximum of 1 pen (1 ml) per 28

days

Skyrizi (180MG/1.2ML Subcutaneous Solution

Cartridge)

B Maximum of 1 cartridge (1.2 ml)

per 56 days

Skyrizi (360MG/2.4ML Subcutaneous Solution

Cartridge)

B Maximum of 1 cartridge (2.4 ml)

per 56 days

Skyrizi (Subcutaneous Solution Prefilled Syringe) B Maximum of 1 syringe (1 ml) per

28 days

Sodium Oxybate (Oral Solution) B Maximum of 18 ml per day

Sofosbuvir-Velpatasvir (Oral Tablet) B Maximum of 1 tablet per day

Solifenacin Succinate (Oral Tablet) G Maximum of 1 tablet per day

Soliqua (Subcutaneous Solution Pen-Injector) B Maximum of 5 pens (15 ml) per 25

days

Somavert (Subcutaneous Solution Reconstituted) B Maximum of 1 vial per day

Spiriva HandiHaler (Inhalation Capsule) B Maximum of 1 capsule per day

Spiriva Respimat (Inhalation Aerosol Solution) B Maximum of 1 inhaler (4 grams)

per 30 days

Sprycel (100MG Oral Tablet, 140MG Oral Tablet,

70MG Oral Tablet)

B Maximum of 1 tablet per day

Sprycel (20MG Oral Tablet, 50MG Oral Tablet) B Maximum of 3 tablets per day

Sprycel (80MG Oral Tablet) B Maximum of 2 tablets per day

Stelara (Subcutaneous Solution) B Maximum of 6 vials (3 ml) per 84

days

Stelara (45MG/0.5ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 6 syringes (3 ml) per

84 days

Last updated February 1, 2024 127

Drug name

Brand

Generic

Quantity limit

Stelara (90MG/ML Subcutaneous Solution

Prefilled Syringe)

B Maximum of 3 syringes (3 ml) per

84 days

Stiolto Respimat (Inhalation Aerosol Solution) B Maximum of 1 inhaler (4 grams)

per 30 days

Stivarga (Oral Tablet) B Maximum of 4 tablets per day

Stribild (Oral Tablet) B Maximum of 1 tablet per day

Suboxone (12-3MG Sublingual Film) B Maximum of 2 films per day

Suboxone (2-0.5MG Sublingual Film, 4-1MG

Sublingual Film, 8-2MG Sublingual Film)

B Maximum of 3 films per day

Sumatriptan (Nasal Solution) G Maximum of 12 devices per 30

days

Sumatriptan Succinate (Oral Tablet) G Maximum of 12 tablets per 30

days

Sumatriptan Succinate Refill (Subcutaneous

Solution Cartridge)

G Maximum of 12 injections (6 ml)

per 30 days

Sumatriptan Succinate (Subcutaneous Solution) G Maximum of 12 injections (6 ml)

per 30 days

Sumatriptan Succinate (Subcutaneous Solution

Auto-Injector)

G Maximum of 12 injections (6 ml)

per 30 days

Sunitinib Malate (12.5MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule)

G Maximum of 1 capsule per day

Sunitinib Malate (37.5MG Oral Capsule) G Maximum of 2 capsules per day

Sunlenca (4 x 300MG Oral Tablet Therapy Pack) B Maximum of 2 packs (8 tablets)

per year

Sunlenca (5 x 300MG Oral Tablet Therapy Pack) B Maximum of 2 packs (10 tablets)

per year

Symbicort (120 Inhalation Aerosol) B Maximum of 1 inhaler (10.2 grams)

per 30 days

Sympazan (Oral Film) B Maximum of 2 films per day

Symtuza (Oral Tablet) B Maximum of 1 tablet per day

Synarel (Nasal Solution) B Maximum of 4 bottles (32 ml) per

26 days

Synjardy (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Tabrecta (Oral Tablet) B Maximum of 4 tablets per day

Tadalafil (PAH) (20MG Oral Tablet) (Generic

Adcirca)

G Maximum of 2 tablets per day

Tagrisso (Oral Tablet) B Maximum of 1 tablet per day

Talzenna (0.1MG Oral Capsule, 0.35MG Oral

Capsule, 0.5MG Oral Capsule, 0.75MG Oral

Capsule, 1MG Oral Capsule)

B Maximum of 1 capsule per day

Talzenna (0.25MG Oral Capsule) B Maximum of 3 capsules per day

Tasigna (150MG Oral Capsule) B Maximum of 5 capsules per day

Tasigna (200MG Oral Capsule) B Maximum of 4 capsules per day

Last updated February 1, 2024128

Drug name

Brand

Generic

Quantity limit

Tasigna (50MG Oral Capsule) B Maximum of 14 capsules per day

Tasimelteon (Oral Capsule) G Maximum of 1 capsule per day

Tazarotene (External Cream) G Maximum of 60 grams per 30 days

Tazverik (Oral Tablet) B Maximum of 8 tablets per day

TDVAX (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per

day

Telmisartan (Oral Tablet) G Maximum of 1 tablet per day

Telmisartan-Amlodipine (Oral Tablet) G Maximum of 1 tablet per day

Telmisartan-HCTZ (40-12.5MG Oral Tablet, 80-25MG

Oral Tablet)

G Maximum of 1 tablet per day

Telmisartan-HCTZ (80-12.5MG Oral Tablet) G Maximum of 2 tablets per day

Temazepam (15MG Oral Capsule, 30MG Oral

Capsule)

G Maximum of 1 capsule per day

Tenivac (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per

day

Tenofovir Disoproxil Fumarate (Oral Tablet) G Maximum of 1 tablet per day

Tepmetko (Oral Tablet) B Maximum of 2 tablets per day

Terbinafine HCl (Oral Tablet) G Maximum of 2 tablets per day

Teriflunomide (Oral Tablet) G Maximum of 1 tablet per day

Teriparatide (Recombinant) (620MCG/2.48ML

Subcutaneous Solution Pen-Injector)

B Maximum of 1 pen (2.48 ml) per

28 days

Tetrabenazine (12.5MG Oral Tablet) G Maximum of 3 tablets per day

Tetrabenazine (25MG Oral Tablet) G Maximum of 4 tablets per day

Thalomid (100MG Oral Capsule, 50MG Oral

Capsule)

B Maximum of 1 capsule per day

Thalomid (150MG Oral Capsule, 200MG Oral

Capsule)

B Maximum of 2 capsules per day

Tibsovo (Oral Tablet) B Maximum of 2 tablets per day

Ticovac (1.2MCG/0.25ML Intramuscular

Suspension Prefilled Syringe)

B 1 vaccination dose (0.25 ml) per

day

Ticovac (2.4MCG/0.5ML Intramuscular

Suspension Prefilled Syringe)

B 1 vaccination dose (0.5 ml) per

day

Tivicay (10MG Oral Tablet, 25MG Oral Tablet) B Maximum of 1 tablet per day

Tivicay (50MG Oral Tablet) B Maximum of 2 tablets per day

Tivicay PD (Oral Tablet Soluble) B Maximum of 6 tablets per day

Tobi Podhaler (Inhalation Capsule) B Maximum of 8 capsules per day

Tobramycin (300MG/5ML Inhalation Nebulization

Solution)

G Maximum of 2 ampules (10 ml) per

day

Tracleer (Oral Tablet Soluble) B Maximum of 8 tablets per day

Tradjenta (Oral Tablet) B Maximum of 1 tablet per day

Tramadol HCl (ER Biphasic) (Oral Tablet Extended

Release 24 Hour)

G Maximum of 1 tablet per day

Last updated February 1, 2024 129

Drug name

Brand

Generic

Quantity limit

Tramadol HCl ER (Oral Tablet Extended Release 24

Hour)

G Maximum of 1 tablet per day

Tramadol HCl (50MG Oral Tablet Immediate

Release)

G Maximum of 8 tablets per day

Tramadol-Acetaminophen (Oral Tablet) G Maximum of 8 tablets per day

Trandolapril (1MG Oral Tablet, 2MG Oral Tablet) G Maximum of 1 tablet per day

Trandolapril (4MG Oral Tablet) G Maximum of 2 tablets per day

Trandolapril-Verapamil HCl ER (Oral Tablet

Extended Release)

G Maximum of 1 tablet per day

Trelegy Ellipta (Inhalation Aerosol Powder Breath

Activated)

B Maximum of 1 inhaler (60 blisters)

per 30 days

Trelstar Mixject (11.25MG Intramuscular

Suspension Reconstituted)

B Maximum of 1 vial per 84 days

Trelstar Mixject (22.5MG Intramuscular

Suspension Reconstituted)

B Maximum of 1 vial per 168 days

Trelstar Mixject (3.75MG Intramuscular

Suspension Reconstituted)

B Maximum of 1 vial per 28 days

Trientine HCl (250MG Oral Capsule) G 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)

B 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)

B Maximum of 2 tablets per day

Trintellix (Oral Tablet) B Maximum of 1 tablet per day

Triumeq (Oral Tablet) B Maximum of 1 tablet per day

Triumeq PD (Oral Tablet Soluble) B Maximum of 6 tablets per day

Trizivir (300-150-300MG Oral Tablet) B Maximum of 2 tablets per day

Trulance (Oral Tablet) B Maximum of 1 tablet per day

Trulicity (Subcutaneous Solution Pen-Injector) B Maximum of 4 pens (2 ml) per 28

days

Trumenba (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Truqap (Oral Tablet) B Maximum of 64 tablets per 28

days

Tukysa (150MG Oral Tablet) B Maximum of 4 tablets per day

Tukysa (50MG Oral Tablet) B Maximum of 12 tablets per day

Turalio (125MG Oral Capsule) B Maximum of 4 capsules per day

Twinrix (Intramuscular Suspension Prefilled

Syringe)

B 1 vaccination dose (1 ml) per day

Tybost (Oral Tablet) B Maximum of 1 tablet per day

Tymlos (Subcutaneous Solution Pen-Injector) B Maximum of 1.56 ml per 30 days

Last updated February 1, 2024130

Drug name

Brand

Generic

Quantity limit

Typhim VI (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per

day

Typhim VI (Intramuscular Solution Prefilled

Syringe)

B 1 vaccination dose (0.5 ml) per

day

Tyrvaya (Nasal Solution) B Maximum of 2 bottles (8.4 ml) per

30 days

Ubrelvy (Oral Tablet) B Maximum of 16 tablets per 30

days

Valacyclovir HCl (1GM Oral Tablet) G Maximum of 4 tablets per day

Valacyclovir HCl (500MG Oral Tablet) G Maximum of 2 tablets per day

Valchlor (External Gel) B Maximum of 60 grams per 30 days

Valganciclovir HCl (Oral Solution Reconstituted) G Maximum of 36 ml per day

Valganciclovir HCl (Oral Tablet) G Maximum of 4 tablets per day

Valsartan (160MG Oral Tablet, 40MG Oral Tablet,

80MG Oral Tablet)

G Maximum of 2 tablets per day

Valsartan (320MG Oral Tablet) G Maximum of 1 tablet per day

Valsartan-Hydrochlorothiazide (Oral Tablet) G Maximum of 1 tablet per day

Valtoco 10MG Dose (Nasal Liquid) B Maximum of 10 blister packs (10

spray devices) per 30 days

Valtoco 15MG Dose (Nasal Liquid Therapy Pack) B Maximum of 10 blister packs (20

spray devices) per 30 days

Valtoco 20MG Dose (Nasal Liquid Therapy Pack) B Maximum of 10 blister packs (20

spray devices) per 30 days

Valtoco 5MG Dose (Nasal Liquid) B Maximum of 10 blister packs (10

spray devices) per 30 days

Vancomycin HCl (125MG Oral Capsule) G Maximum of 4 capsules per day

Vancomycin HCl (250MG Oral Capsule) G Maximum of 8 capsules per day

Vanflyta (Oral Tablet) B Maximum of 2 tablets per day

VAQTA (25UNIT/0.5ML Intramuscular

Suspension, 25UNIT/0.5ML 0.5ML Intramuscular

Suspension)

B Maximum of 2 vaccines per

lifetime

VAQTA (50UNIT/ML Intramuscular Suspension,

50UNIT/ML 1ML Intramuscular Suspension)

B Maximum of 2 vaccines per

lifetime

Varivax (Subcutaneous Injectable) B 1 vaccination dose (1 injection)

per day

Veltassa (Oral Packet) B Maximum of 1 packet per day

Vemlidy (Oral Tablet) B Maximum of 1 tablet per day

Venclexta (100MG Oral Tablet) B Maximum of 6 tablets per day

Venclexta (10MG Oral Tablet) B Maximum of 2 tablets per day

Venclexta (50MG Oral Tablet) B Maximum of 1 tablet per day

Venclexta Starting Pack (Oral Tablet Therapy

Pack)

B Maximum of 2 packs per year

Last updated February 1, 2024 131

Drug name

Brand

Generic

Quantity limit

Ventavis (10MCG/ML Inhalation Solution) B Maximum of 7 ml per day

Ventavis (20MCG/ML Inhalation Solution) B Maximum of 3 ml per day

Verquvo (Oral Tablet) B Maximum of 1 tablet per day

Verzenio (Oral Tablet) B Maximum of 2 tablets per day

Vigabatrin (Oral Packet) G Maximum of 6 packets per day

Vigabatrin (Oral Tablet) G Maximum of 6 tablets per day

Vigadrone (Oral Packet) G Maximum of 6 packets per day

Vigadrone (Oral Tablet) G Maximum of 6 tablets per day

Viibryd (Oral Tablet) B Maximum of 1 tablet per day

Vilazodone HCl (Oral Tablet) G Maximum of 1 tablet per day

Viracept (250MG Oral Tablet) B Maximum of 10 tablets per day

Viracept (625MG Oral Tablet) B Maximum of 4 tablets per day

Viread (Oral Powder) B Maximum of 4 bottles (240 grams)

per 30 days

Viread (150MG Oral Tablet, 200MG Oral Tablet,

250MG Oral Tablet)

B Maximum of 1 tablet per day

Vitrakvi (100MG Oral Capsule) B Maximum of 4 capsules per day

Vitrakvi (25MG Oral Capsule) B Maximum of 6 capsules per day

Vitrakvi (Oral Solution) B Maximum of 20 ml per day

Vizimpro (Oral Tablet) B Maximum of 1 tablet per day

Vonjo (Oral Capsule) B Maximum of 4 capsules per day

Voriconazole (Oral Suspension Reconstituted) G Maximum of 20 ml per day

Voriconazole (200MG Oral Tablet) G Maximum of 4 tablets per day

Voriconazole (50MG Oral Tablet) G Maximum of 16 tablets per day

Vosevi (Oral Tablet) B Maximum of 1 tablet per day

Votrient (Oral Tablet) B Maximum of 4 tablets per day

Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule,

4.5MG Oral Capsule, 6MG Oral Capsule)

B Maximum of 1 capsule per day

Vraylar (Oral Capsule Therapy Pack) B Maximum of 2 packs (14

capsules) per year

Vumerity (Oral Capsule Delayed Release)

(Maintenance Dose Bottle)

B Maximum of 4 capsules per day

Vyndamax (Oral Capsule) B Maximum of 1 capsule per day

Vyndaqel (Oral Capsule) B Maximum of 4 capsules per day

Welireg (Oral Tablet) B Maximum of 3 tablets per day

Wixela Inhub (Inhalation Aerosol Powder Breath

Activated) (Generic Advair)

G Maximum of 1 inhaler (60 blisters)

per 30 days

Xarelto (10MG Oral Tablet, 20MG Oral Tablet) B Maximum of 1 tablet per day

Xarelto (15MG Oral Tablet, 2.5MG Oral Tablet) B Maximum of 2 tablets per day

Xarelto Starter Pack (Oral Tablet Therapy Pack) B Maximum of 2 packs per year

Last updated February 1, 2024132

Drug name

Brand

Generic

Quantity limit

Xcopri (250MG Daily Dose) (Oral Tablet Therapy

Pack)

B Maximum of 1 pack (56 tablets)

per 28 days

Xcopri (350MG Daily Dose) (150MG & 200MG

Oral Tablet Therapy Pack)

B Maximum of 1 pack (56 tablets)

per 28 days

Xcopri (100MG Oral Tablet, 50MG Oral Tablet) B Maximum of 1 tablet per day

Xcopri (150MG Oral Tablet, 200MG Oral Tablet) B 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)

B Maximum of 2 packs per year

Xeljanz (Oral Solution) B Maximum of 10 ml per day

Xeljanz (Oral Tablet Immediate Release) B Maximum of 2 tablets per day

Xeljanz XR (Oral Tablet Extended Release 24

Hour)

B Maximum of 1 tablet per day

Xermelo (Oral Tablet) B 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)

B Maximum of 1 tablet per day

Xigduo XR (2.5-1000MG Oral Tablet Extended

Release 24 Hour, 5-1000MG Oral Tablet Extended

Release 24 Hour)

B Maximum of 2 tablets per day

Xiidra (Ophthalmic Solution) B Maximum of 2 vials per day

Xofluza (40MG Dose) (Oral Tablet Therapy Pack) B Maximum of 2 tablets per 30 days

Xofluza (80MG Dose) (Oral Tablet Therapy Pack) B Maximum of 1 tablet per 30 days

Xospata (Oral Tablet) B Maximum of 3 tablets per day

Xpovio (100MG Once Weekly) (Oral Tablet

Therapy Pack)

B Maximum of 8 tablets per 28 days

Xpovio (40MG Once Weekly) (Oral Tablet Therapy

Pack)

B Maximum of 4 tablets per 28 days

Xpovio (40MG Twice Weekly) (Oral Tablet

Therapy Pack)

B Maximum of 8 tablets per 28 days

Xpovio (60MG Once Weekly) (Oral Tablet Therapy

Pack)

B Maximum of 4 tablets per 28 days

Xpovio (60MG Twice Weekly) (Oral Tablet

Therapy Pack)

B Maximum of 24 tablets per 28

days

Xpovio (80MG Once Weekly) (Oral Tablet Therapy

Pack)

B Maximum of 8 tablets per 28 days

Xpovio (80MG Twice Weekly) (Oral Tablet

Therapy Pack)

B 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)

B Maximum of 3 capsules per day

Last updated February 1, 2024 133

Drug name

Brand

Generic

Quantity limit

Xtampza ER (27MG Oral Capsule ER 12 Hour

Abuse-Deterrent, 36MG Oral Capsule ER 12 Hour

Abuse-Deterrent)

B Maximum of 6 capsules per day

Xtandi (Oral Capsule) B Maximum of 4 capsules per day

Xtandi (40MG Oral Tablet) B Maximum of 4 tablets per day

Xtandi (80MG Oral Tablet) B Maximum of 2 tablets per day

YF-VAX (Subcutaneous Injectable) B 1 vaccination dose (1 injection)

per day

Yuvafem (Vaginal Tablet) G Maximum of 18 tablets per 28

days

Zafirlukast (Oral Tablet) G Maximum of 2 tablets per day

Zaleplon (10MG Oral Capsule) G Maximum of 2 capsules per day

Zaleplon (5MG Oral Capsule) G Maximum of 1 capsule per day

Zejula (100MG Oral Capsule) B Maximum of 3 capsules per day

Zejula (Oral Tablet) B Maximum of 1 tablet per day

Zidovudine (Oral Capsule) G Maximum of 6 capsules per day

Zidovudine (Oral Syrup) G Maximum of 64 ml per day

Zidovudine (Oral Tablet) G Maximum of 2 tablets per day

Ziprasidone HCl (Oral Capsule) G Maximum of 2 capsules per day

Zokinvy (Oral Capsule) B Maximum of 4 capsules per day

Zolpidem Tartrate (Oral Tablet Immediate Release) G Maximum of 1 tablet per day

Zurzuvae (20MG Oral Capsule, 25MG Oral

Capsule)

B Maximum of 28 capsules per 14

days

Zurzuvae (30MG Oral Capsule) B Maximum of 14 capsules per 14

days

Zydelig (Oral Tablet) B Maximum of 2 tablets per day

Zykadia (Oral Tablet) B Maximum of 3 tablets per day

Last updated February 1, 2024134

Additional covered drugs

Your plan has additional coverage for the prescription drugs listed below. These drugs are not

normally covered in a Medicare Advantage plan with prescription drug coverage. The amount you

pay for these drugs does not count toward your total drug costs. If you get Extra Help to pay for

your prescriptions, it does not apply to these drugs.

Drug name Drug tier Restrictions

Vitamins

Folic Acid (1mg tablet) 2

Cyanocobalamin (1000mcg/ml vial) 2

Ergocalciferol (50000mcg capsule) 2

Erectile Dysfunction

Sildenafil (25mg tablet) 2 Maximum of 4 tablets per 30 days

Sildenafil (50mg tablet) 2 Maximum of 4 tablets per 30 days

Sildenafil (100mg tablet) 2 Maximum of 4 tablets per 30 days

135

Required information

Benefits, Drug List (Formulary), pharmacy network and/or copays/coinsurance may change on

January 1 of each year, and from time to time during the plan year. You will receive notice when

necessary.

This information is available for free in other languages. Please call our UnitedHealthcare Customer

Service number located on the cover.

Esta información esta disponible sin costo en otros idiomas. Llame a nuestro número de Servicio al

Cliente de UnitedHealthcare que se encuentra en la portada.

UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual

property. These fees are used for the general purposes of AARP. AARP and its affiliates are not

insurers.

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

disability in health programs and activities. UnitedHealthcare provides free services to help you

communicate with us such as letters in other languages, braille, large print, audio, or you can ask

for an interpreter. For more information, please call our UnitedHealthcare Customer Service

number located on the cover.

136

For more up-to-date information or if you have other questions, please call UnitedHealthcare

Customer Service at:

AAEX24HM0153015_002

Last updated February 1, 2024

Toll-free 1-877-370-4874, TTY711

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