Download - Complete Drug List (Formulary) 2021
Complete Drug List(Formulary) 2021
UnitedHealthcare® Group Medicare Advantage (PPO)
Illinois Department of Central Management Services College Insurance Program (CIP)
Important Notes: This document has information about the drugs covered by this plan. For more
up-to-date information or if you have any questions, please call Customer Service at:
Toll-free 1-888-223-1092, TTY 7118 a.m. - 8 p.m. local time, Monday - Friday
www.UHCRetiree.com/soi
Formulary ID Number 00021068, Version 23
Y0066_052820_104500_C Last updated September 1, 2021
Table Of Contents
What is a drug list?......................................................................................................................................3
Note to existing members:......................................................................................................................... 3
How do I use the drug list?.........................................................................................................................4
What are generic drugs?............................................................................................................................ 4
What is a compounded drug?....................................................................................................................4
Drug payment stage and drug tiers...........................................................................................................5
Getting Extra Help.......................................................................................................................................5
Are there any rules or limits on my drug coverage?................................................................................ 6
What if my drug is not on this list?.............................................................................................................8
How can I get an exception?......................................................................................................................8
Can I get my drug while I wait for an exception?......................................................................................9
Can the drug list change?........................................................................................................................ 10
Drugs with dosages other than a 1-month supply..................................................................................11
Covered drugs by name (Drug index)....................................................................................................12
Covered drugs by medical condition...................................................................................................... 40
Covered drugs with a quantity limit (QL).............................................................................................. 157
3What is a drug list?
A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team
of health care providers work together in selecting drugs that are needed for well-rounded care and
treatment.
Your plan will generally cover the drugs listed in our drug list as long as:
· The drug is used for a medically accepted indication,
· The prescription is filled at a network pharmacy and
· Other plan rules are followed.
For more information about your drug coverage, please review your Evidence of Coverage.
Note to existing members:
This complete list of prescription drugs covered by your plan is current as of September 1, 2021.
For an up-to-date list of covered drugs or if you have questions, please call Customer Service. Our
contact information is on the cover.
This drug list has changed since last year. Please review this document to make sure your
prescription drugs are still covered. In most cases, you must use network pharmacies to have your
prescriptions covered by the plan.
When this drug list refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it refers to
“plan,” “our plan,” or “your plan,” it means UnitedHealthcare Group Medicare Advantage.
4
How do I use the drug list?
There are 2 ways to find your prescription drugs in this drug list:
1. By name. Turn to section “Covered drugs by name (Drug index)” on pages 12–39 to see the
.......list of drug names in alphabetical order. Find the name of your drug. The page number where
.......you can find the drug will be next to it.
2. By medical condition. Turn to section “Covered drugs by medical condition” on pages
.......40–156 to look for drugs based on your medical conditions. For example, if you have a heart
.......condition, you should look in the category Cardiovascular Agents. This is where you will find
.......drugs that treat heart conditions.
What are generic drugs?
Generic drugs have the same active ingredients as brand name drugs. They usually cost less than
brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers
both brand name and generic drugs.
Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then
review the drug list to make sure you are getting the drug you need for the least amount of money.
The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in
plain type (for example, Simvastatin).
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.
5
Drug payment stage and drug tiers
The amount you pay for a covered prescription drug will depend on:
· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the coverage stage you’re in.
· Your drug’s tier. Each covered drug is in 1 of 4 drug tiers. Each tier has a copay or coinsurance
amount. The chart below shows the differences between the tiers.
If you need help or have any questions about your drug costs, please review your Evidence of
Coverage or call Customer Service. Our contact information is on the cover.
Drug Tier Includes
Tier 1:
Preferred generic
Most generic drugs.
Tier 2:
Preferred brand
Many common brand name drugs, called preferred
brands and some higher-cost generic drugs.
Tier 3:
Non-preferred drug
Non-preferred generic and non-preferred brand name
drugs. In addition, Part D eligible compound medications
are covered in Tier 3.
Tier 4:
Specialty tier
Unique and/or very high-cost brand and generic 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” (LIS Rider). Please read it to learn about
your costs. You can also call Customer Service. Our contact information is on the cover.
6
Are there any rules or limits on my drug coverage?Yes, some drugs may have coverage rules or have limits on the amount you can get. If your drug
has any coverage rules or limits, there will be a code(s) in the “Coverage Rules or Limits on use”
column of the “Covered drugs by medical condition” chart starting on page 40. The codes and
what they mean are shown below and on the next page.
You can also get more information about the coverage rules and/or limits applied to specific
covered drugs by visiting our website. We have posted online documents that explain our prior
authorization and step therapy restrictions. If you would like a copy sent to you, please call
Customer Service. Our contact information is on the cover.
Coverage Rules and Limits
PA - Prior authorization
The plan requires you or your doctor to get prior approval for certain drugs. This means the plan
needs more information from your doctor to make sure the drug is being used and covered
correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare
Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs) depending on
how it is used. If you don’t get prior approval, the plan may not cover the drug.
QL - Quantity limits
The plan will cover only a certain amount of this drug for 1 copay/coinsurance or over a certain
number of days. These limits may be in place to ensure safe and effective use of the drug. If your
doctor prescribes more than this amount or thinks the limit is not right for your situation, you or
your doctor can ask the plan to cover the additional quantity.
ST - Step therapy
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You
may be required to try 1 or more of these other drugs before the plan will cover your drug. If you
have already tried other drugs or your doctor thinks they are not right for you, you or your doctor
can ask the plan to cover this drug.
7
Other Special Coverage Rules
B/D - Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and
outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide
the plan with more information about how this drug will be used to make sure it’s correctly
covered by Medicare.
HRM - High-risk medication
This drug is known as a high-risk medication (HRM) for patients 65 years and older. This drug
may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if
an alternative drug is available to treat your condition.
LA - Limited access
Drugs are considered “limited access” if the FDA says the drug can be given out only by certain
facilities or doctors. These drugs may require extra handling, provider coordination or patient
education that can’t be done at a network pharmacy.
MME - Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is
designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1
opioid drug for pain management. If your doctor prescribes more than this amount or thinks the
limit is not right for your situation, you or your doctor can ask the plan to cover the additional
quantity.
7D - 7-Day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members
with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For
members who are new to the plan and have a recent history of using opioids, the limit may be
overridden by having the pharmacy contact the plan.
DL - Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1-month supply per prescription.
You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your
drug. See section “How can I get an exception?" on page 8 or see your Evidence of Coverage to
learn more.
If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules
or limits, you may have to pay the full cost of the drug.
8
What if my drug is not on this list?
If your drug is not included in this drug list we may still cover it. Call Customer Service to ask if it’s
covered. Our contact information, along with the date we last updated the drug list is on the cover.
If you find out that your drug is not covered, you can do 1 of these things:
1. Ask Customer Service for a list of similar drugs that are covered by the plan. When you get
the list, show it to your doctor and ask him or her to prescribe a covered drug.
2. Ask the plan to make an exception and cover your drug. Review the next section for more
exception information.
How can I get an exception?
Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This
is called asking for an exception. When you do, the plan will review your request and give you a
coverage decision known as a coverage determination.
Types of exceptions you can ask for
· Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved,
this drug will be covered at a pre-determined cost sharing level. You will not be able to ask us to
provide the drug at a lower cost sharing level.
· Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For
example, if your drug has a quantity limit, you can ask the plan to change the limit and cover
more.
· Tiering exception: Ask the plan to cover your drug on our list at a lower cost sharing level if this
drug is not on the specialty tier.
The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as
effective in treating your condition or would cause adverse medical effects.
Who can ask for an exception?
You, your authorized representative or your doctor can ask for an exception by calling Customer
Service. Your doctor must give us a supporting statement with the reason for the exception.
How long does it take to get an exception?
After we get the statement from your doctor supporting your request for an exception, we’ll give
you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor
believes that your health could be seriously harmed by waiting 72 hours. If your request for an
expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s
supporting statement.
9
Can I get my drug while I wait for an exception?
As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s
not on our drug list or if it has rules or limits. For example, you may need a prior authorization from
us before you can fill your prescription. During the time when you are getting a temporary supply,
you should talk with your doctor to decide if there is a similar drug on the drug list you can take
instead. If you and your doctor decide this is the only drug that will work for you, you will need to
ask for an exception. We may cover your drug in certain cases during the first 90 days of your
membership.
The following chart shows how much of your drug we may cover while you ask for an exception.
If you... And you are… We may cover…
are a new member in the first 90 days of
your membership
OR
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. (Please note that the
long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
We will not pay for more of your drug after you get this temporary or emergency supply unless you
receive authorization from the plan.
10
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.
The drug list may change during the year if your plan:
· Adds new drugs, including generic drugs, as they become available.
· Removes a drug that has been found to be ineffective or unsafe.
· Changes the coverage rules or limits for a drug.
· Moves a drug into a different cost sharing tier.
If we add new generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new
generic drug that will appear on the same or lower cost sharing tier and with the same or fewer
restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug
on our Drug List, but immediately move it to a different cost sharing tier or add new restrictions. If
you are currently taking that brand name drug, we may not tell you in advance before we make that
change, but we will later provide you with information about the specific change(s) we have made.
If we make 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 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 at least 30
days before the change becomes effective, or at the time 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.
If we remove a drug from the list
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.
11
Drugs with dosages other than a 1-month supply
Drugs packaged in an extended day supply
Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When
you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription.
For more information, please call Customer Service. Our contact information is on the cover.
Daily cost sharing for oral medications filled for less than a 1-month supply
A daily cost sharing rate may apply when your doctor prescribes less than a full month’s supply of
certain drugs for you and you are required to pay a copayment. A daily cost sharing rate is the
copayment divided by the number of days in a month’s supply.
Daily cost sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)
when dispensed for a supply of less than 1-month under applicable law. The daily cost sharing
requirements do not apply to either of the following:
1. Solid oral doses of antibiotics.
2. Solid oral doses that are dispensed in their original container or are usually dispensed in their
original packaging to help patients comply with usage and dosage directions.
For more information
For more detailed information about your plan’s prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about your plan’s prescription drug coverage, please call Customer Service.
Our contact information, along with the date we last updated the drug list, is on the cover.
If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov
or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.
12
Covered drugs by name (Drug index)
A
Abacavir Sulfate..................... 83
Abacavir Sulfate-Lamivudine
.............................................. 83
Abacavir-Lamivudine-
Zidovudine........................... 83
Abelcet....................................64
Abilify...................................... 77
Abilify Maintena......................77
Abilify MyCite......................... 77
Abiraterone Acetate...............69
Absorica................................108
Absorica LD..........................108
Acamprosate Calcium........... 46
Acanya.................................. 108
Acarbose................................ 86
Accolate................................151
Accupril...................................95
Accuretic.................................98
Accutane.............................. 108
Acebutolol HCl....................... 96
Acetaminophen-Caffeine-
Dihydrocodeine................... 44
Acetaminophen-Codeine...... 44
Acetazolamide........................98
Acetazolamide ER..................98
Acetic Acid........................... 149
Acetylcysteine...................... 154
Aciphex.................................123
Acitretin................................ 108
Actemra................................ 138
Actemra ACTPen................. 138
Acthar................................... 127
ActHIB...................................141
Acticlate.................................. 54
Actimmune........................... 139
Actiq........................................44
Actonel..................................143
Actoplus Met.......................... 86
Actos....................................... 86
Acular....................................147
Acular LS.............................. 147
Acuvail.................................. 147
Acyclovir................................. 81
Acyclovir Sodium................... 81
Aczone..................................115
Adacel...................................141
Adapalene....................108, 109
Adapalene-Benzoyl Peroxide
............................................ 109
Adcirca..................................153
Adderall................................ 104
Adderall XR.......................... 104
Adefovir Dipivoxil................... 81
Adempas.............................. 153
Adlyxin.................................... 86
Adlyxin Starter Pack.............. 86
Admelog................................. 89
Admelog SoloStar..................89
Advair Diskus....................... 154
Advair HFA........................... 154
Adzenys ER.......................... 104
Adzenys XR-ODT................. 104
Aemcolo..................................48
Afinitor.....................................70
Afinitor Disperz.......................70
Afrezza.................................... 89
Agrylin.....................................92
Aimovig................................... 67
AirDuo Digihaler...................154
AirDuo RespiClick 113/14
............................................ 154
AirDuo RespiClick 232/14
............................................ 154
AirDuo RespiClick 55/14.... 154
Ajovy........................................67
Aklief..................................... 109
Ala Scalp...............................110
Ala-Cort.................................110
Albendazole............................74
Albenza................................... 74
Albuterol Sulfate.................. 151
Albuterol Sulfate HFA..........151
Alclometasone Dipropionate
............................................ 110
Alcohol Prep Pads............... 144
Aldactazide.............................99
Aldactone............................. 101
Aldara....................................114
Alecensa................................. 71
Alendronate Sodium............143
Alfuzosin HCl ER..................126
Alinia....................................... 74
Aliskiren Fumarate................. 99
Alkindi Sprinkle.................... 127
Allopurinol.............................. 66
Almotriptan Malate.................66
Alocril....................................146
Alogliptin Benzoate................86
Alogliptin-Metformin HCl....... 86
Alogliptin-Pioglitazone...........86
Alomide.................................146
13
Alora...................................... 130
Alosetron HCl........................121
Alphagan P........................... 148
Alprazolam.............................. 85
Alprazolam ER........................ 85
Alprazolam Intensol................85
Alprazolam ODT..................... 85
Alrex.......................................147
Altabax.................................. 115
Altace.......................................95
Altavera................................. 130
Altoprev................................. 102
Altreno...................................109
Alunbrig...................................71
Alvesco..................................150
Alyacen 1/35.........................130
Alyq........................................153
Amantadine HCl..................... 75
Amaryl..................................... 86
Ambien..................................155
AmBisome...............................64
Ambrisentan......................... 153
Amcinonide...........................110
Amerge....................................66
Amethia................................. 130
Amikacin Sulfate.....................47
Amiloride HCl........................101
Amiloride-Hydrochlorothiazide
...............................................99
Aminosyn II........................... 117
Aminosyn-PF.........................117
Amiodarone HCl..................... 95
Amitiza...................................120
Amitriptyline HCl.....................63
Amlodipine Besylate.............. 97
Amlodipine-Atorvastatin.........99
Amlodipine-Benazepril...........99
Amlodipine-Olmesartan......... 99
Amlodipine-Valsartan............. 99
Amlodipine-Valsartan-HCTZ
...............................................99
Ammonium Lactate..............110
Amnesteem...........................109
Amoxapine.............................. 63
Amoxicillin...............................51
Amoxicillin-Clarithromycin-
Lansoprazole......................121
Amoxicillin-Potassium
Clavulanate........................... 51
Amoxicillin-Potassium
Clavulanate ER..................... 51
Amphetamine ER................. 104
Amphetamine Sulfate.......... 104
Amphetamine-
Dextroamphetamine.......... 104
Amphetamine-
Dextroamphetamine ER.... 104
Amphotericin B.......................64
Ampicillin.................................51
Ampicillin Sodium.................. 51
Ampicillin-Sulbactam Sodium
...............................................51
Ampyra..................................107
Amzeeq................................. 115
Anafranil.................................. 63
Anagrelide HCl........................92
Anastrozole............................. 70
Ancobon..................................64
Androderm............................129
AndroGel...............................129
AndroGel Pump....................129
Annovera...............................130
Anoro Ellipta......................... 154
Antara....................................101
Anusol-HC............................. 143
ApexiCon E........................... 110
Apidra...................................... 89
Apidra SoloStar...................... 89
Aplenzin...................................61
Apokyn.................................... 75
Apraclonidine HCl................ 148
Aprepitant................................64
Apri........................................ 130
Apriso.................................... 142
Aptensio XR.......................... 105
Aptiom..................................... 59
Aptivus.....................................84
Aralast NP............................. 124
Aranelle................................. 130
Aranesp.............................92, 93
Arava..................................... 139
Arazlo.................................... 109
Arcalyst..................................138
Aricept..................................... 60
Arikayce...................................47
Arimidex.................................. 70
Aripiprazole.............................77
Aripiprazole ODT.................... 77
Aristada................................... 77
Aristada Initio.......................... 77
Arixtra...................................... 91
Armodafinil............................155
ArmonAir Digihaler...............150
Arnuity Ellipta........................150
14
Aromasin................................. 70
Arthrotec................................. 40
Asacol HD............................. 142
Asenapine Maleate.................77
Ashlyna..................................130
Asmanex............................... 150
Asmanex HFA.......................150
Aspirin-Dipyridamole ER........94
Astagraf XL........................... 139
Atacand................................... 95
Atacand HCT.......................... 99
Atazanavir Sulfate...................84
Atelvia....................................143
Atenolol................................... 96
Atenolol-Chlorthalidone......... 99
Ativan.......................................85
Atomoxetine HCl.................. 105
Atorvastatin Calcium............ 102
Atovaquone.............................74
Atovaquone-Proguanil HCl.... 74
Atralin.................................... 109
Atripla...................................... 82
Atropine Sulfate....................145
Atrovent HFA........................ 151
Aubagio.................................107
Aubra EQ...............................130
Auryxia...................................120
Austedo.................................106
Avalide.....................................99
Avapro..................................... 95
Aveed.................................... 129
Aviane....................................130
Avita.......................................109
Avodart..................................126
Avonex Pen...........................107
Avonex Prefilled....................107
Avycaz..................................... 50
Aygestin................................ 134
Ayvakit..................................... 71
Azactam.................................. 48
Azasan...................................139
Azasite...................................146
Azathioprine..........................139
Azelaic Acid.......................... 109
Azelastine HCl.............. 146, 149
Azelastine-Fluticasone......... 149
Azelex....................................109
Azilect...................................... 76
Azithromycin........................... 53
Azopt..................................... 148
Azor..........................................99
Aztreonam...............................48
Azulfidine.............................. 142
Azulfidine EN-tabs................ 142
B
Bacitracin.............................. 146
Bacitracin-Polymyxin B........ 146
Baclofen.................................. 80
Bactrim.................................... 54
Bactrim DS..............................54
Bafiertam...............................107
Balcoltra................................ 130
Balsalazide Disodium...........142
Balversa...................................71
Balziva................................... 130
Banzel......................................59
Baqsimi Two Pack..................88
Baraclude................................81
Basaglar KwikPen...................89
Baxdela....................................54
BCG Vaccine........................ 141
Beconase AQ........................150
Belbuca................................... 42
Belsomra...............................155
Benazepril HCl........................95
Benazepril-Hydrochlorothiazide
...............................................99
Benicar.................................... 95
Benicar HCT........................... 99
Benlysta.................................138
BenzaClin with Pump...........109
Benzamycin.......................... 109
Benznidazole.......................... 74
Benzoyl Peroxide-Erythromycin
.............................................109
Benztropine Mesylate............ 75
Bepotastine Besilate............ 146
Bepreve................................. 146
Berinert..................................137
Beser..................................... 110
Besivance..............................146
Betamethasone Dipropionate
.............................................110
Betamethasone Dipropionate
Aug......................................110
Betamethasone Valerate.... 110,
111
Betapace AF........................... 96
Betaseron..............................107
Betaxolol HCl..................96, 148
Bethanechol Chloride.......... 126
Bethkis.................................. 152
Betimol.................................. 148
15
Betoptic-S..............................148
Bevespi Aerosphere.............154
Bexarotene..............................73
Bexsero................................. 141
Beyaz.....................................130
Bicalutamide........................... 69
Bicillin C-R...............................52
Bicillin C-R 900/300............... 51
Bicillin L-A............................... 52
BiDil......................................... 99
Biktarvy....................................82
Biltricide.................................. 74
Bimatoprost.......................... 149
Bisoprolol Fumarate...............96
Bisoprolol-Hydrochlorothiazide
...............................................99
BIVIGAM................................137
Bleph-10................................ 146
Blephamide...........................145
Blephamide S.O.P................145
Blisovi 24 Fe..........................130
Blisovi Fe 1.5/30...................130
Boniva....................................143
Boostrix................................. 141
Bosentan...............................153
Bosulif......................................71
Braftovi.................................... 71
Breo Ellipta............................154
Breztri Aerosphere............... 154
Briellyn...................................130
Brilinta..................................... 94
Brimonidine Tartrate............ 148
Brinzolamide.........................148
BRIVIACT................................ 55
Bromfenac Sodium.............. 147
Bromocriptine Mesylate...75, 76
BromSite............................... 147
Bronchitol..............................154
Brovana................................. 151
Brukinsa.................................. 71
Bryhali................................... 111
Budesonide.................. 143, 150
Budesonide ER.....................143
Budesonide-Formoterol
Fumarate.............................154
Bumetanide.......................... 101
Buphenyl............................... 124
Buprenorphine........................42
Buprenorphine HCl................ 47
Buprenorphine HCl-Naloxone
HCl.........................................47
Bupropion HCl........................61
Bupropion HCl ER..................61
Bupropion HCl SR............47, 61
Bupropion HCl XL.................. 61
Buspirone HCl........................ 85
Butorphanol Tartrate..............44
Butrans.................................... 42
Bydureon BCise......................86
Byetta 10MCG Pen.................87
Byetta 5MCG Pen...................87
Bystolic....................................96
C
Cabergoline.......................... 136
Cablivi......................................94
Cabometyx..............................71
Caduet.....................................99
Cafergot...................................67
Calan SR................................. 97
Calcipotriene.........................114
Calcipotriene-Betamethasone
.............................................114
Calcitonin Salmon................ 143
Calcitriol........................114, 144
Calcium Acetate................... 120
Calquence...............................71
Cambia.................................... 40
Camila................................... 134
Camrese Lo.......................... 130
Canasa.................................. 142
Cancidas................................. 64
Candesartan Cilexetil............. 95
Candesartan Cilexetil-HCTZ
...............................................99
Capex.................................... 111
Caplyta.................................... 77
Caprelsa.................................. 71
Captopril..................................95
Carac..................................... 114
Carafate.................................123
Carbaglu................................117
Carbamazepine...................... 59
Carbamazepine ER................ 59
Carbatrol................................. 59
Carbidopa............................... 76
Carbidopa-Levodopa............. 76
Carbidopa-Levodopa ER....... 76
Carbidopa-Levodopa ODT.....76
Carbidopa-Levodopa-
Entacapone.......................... 75
Cardizem................................. 97
Cardizem CD...........................97
Cardizem LA........................... 97
Cardura................................... 94
16
Cardura XL............................126
Carnitor................................. 124
CaroSpir................................ 101
Carteolol HCl........................ 148
Cartia XT..................................97
Carvedilol................................ 96
Carvedilol Phosphate ER.......96
Casodex.................................. 69
Caspofungin Acetate............. 64
Catapres-TTS-1....................... 94
Catapres-TTS-2....................... 94
Catapres-TTS-3....................... 94
Cayston................................. 152
Caziant.................................. 130
Cefaclor...................................50
Cefaclor ER.............................50
Cefadroxil................................50
Cefazolin Sodium................... 50
Cefdinir....................................50
Cefepime HCl......................... 50
Cefixime.................................. 50
Cefotetan Disodium............... 50
Cefoxitin Sodium.................... 50
Cefpodoxime Proxetil.............50
Cefprozil.................................. 50
Ceftazidime............................. 50
Ceftriaxone Sodium................50
Cefuroxime Axetil................... 50
Cefuroxime Sodium............... 50
Celebrex.................................. 40
Celecoxib................................ 40
Celexa......................................62
Cellcept................................. 139
Celontin................................... 58
Cephalexin........................50, 51
Cequa....................................145
Cerdelga................................124
Cetirizine HCl........................149
Cetraxal................................. 149
Cevimeline HCl..................... 108
Chantix.................................... 47
Chantix Continuing Month Pak
...............................................47
Chantix Starting Month Pak...47
Chemet..................................119
Chenodal...............................121
Chlordiazepoxide HCl............ 85
Chlordiazepoxide-Clidinium
.............................................121
Chlorhexidine Gluconate.....108
Chloroquine Phosphate......... 74
Chlorpromazine HCl...............76
Chlorthalidone...................... 101
Chlorzoxazone......................155
Cholbam................................124
Cholestyramine.....................102
Cholestyramine Light........... 102
Cialis......................................126
Ciclopirox......................115, 116
Ciclopirox Olamine...............116
Cilostazol.................................94
Ciloxan.................................. 146
Cimduo....................................83
Cimetidine.............................122
Cimetidine HCl..................... 122
Cimzia....................................139
Cimzia Prefilled.....................139
Cinacalcet HCl......................144
Cinryze.................................. 137
Cipro........................................54
Cipro HC............................... 149
Ciprodex................................149
Ciprofloxacin HCl...54, 146, 149
Ciprofloxacin in D5W............. 54
Ciprofloxacin-Dexamethasone
.............................................149
Ciprofloxacin-Fluocinolone PF
.............................................149
Citalopram Hydrobromide..... 62
Claravis..................................109
Clarinex................................. 149
Clarinex-D 12 Hour............... 154
Clarithromycin.........................53
Clarithromycin ER...................53
Clenpiq..................................121
Cleocin.................................... 48
Cleocin Phosphate................. 48
Cleocin-T............................... 116
Climara Pro........................... 130
Clindacin-P............................116
Clindagel............................... 116
Clindamycin HCl.....................48
Clindamycin Palmitate HCl.... 48
Clindamycin Phosphate........48,
116
Clindamycin Phosphate in D5W
...............................................48
Clindamycin Phosphate-
Benzoyl Peroxide............... 109
Clindamycin-Tretinoin.......... 109
Clindesse.................................48
Clinimix E/Dextrose............. 117
Clinimix/Dextrose.................117
Clinisol SF............................. 117
17
Clobazam................................ 58
Clobetasol Propionate......... 111
Clobetasol Propionate
Emollient Base................... 111
Clobetasol Propionate
Emulsion............................. 111
Clobex................................... 111
Clobex Spray........................ 111
Clocortolone Pivalate........... 111
Clodan...................................111
Cloderm................................ 111
Clomipramine HCl.................. 63
Clonazepam............................85
Clonazepam ODT................... 85
Clonidine................................. 94
Clonidine HCl..........................94
Clonidine HCl ER..................105
Clopidogrel Bisulfate..............94
Clorazepate Dipotassium.......85
Clotrimazole....................64, 116
Clotrimazole-Betamethasone
.............................................114
Clovique................................ 119
Clozapine................................ 80
Clozapine ODT....................... 80
Clozaril.....................................80
Coartem...................................74
Codeine Sulfate...................... 44
Colazal...................................142
Colchicine............................... 66
Colcrys.....................................66
Colesevelam HCl.................. 102
Colestid................................. 102
Colestipol HCl.......................102
Colistimethate Sodium...........48
Combigan............................. 145
Combivent Respimat........... 154
Combivir.................................. 83
Cometriq................................. 71
Complera.................................82
Compro................................... 63
Comtan....................................75
Concerta................................105
Condylox............................... 114
Constulose............................120
ConZip.....................................42
Copaxone..............................107
Copiktra...................................71
Cordran................................. 111
Coreg.......................................96
Coreg CR................................ 96
Corgard................................... 96
Corlanor...................................99
Cortef.....................................127
Cosentyx............................... 138
Cosentyx Sensoready.......... 138
Cosopt...................................145
Cosopt PF............................. 145
Cotellic.....................................71
Cotempla XR-ODT................105
Cozaar..................................... 95
Creon.....................................124
Cresemba................................64
Crestor...................................102
Crinone..................................134
Cromolyn Sodium....... 124, 146,
153
Cryselle-28............................ 130
Cubicin.................................... 48
Cuprimine............................. 126
Cutivate................................. 111
Cuvposa................................ 121
Cyclafem 1/35...................... 130
Cyclafem 7/7/7.....................130
Cyclobenzaprine HCl........... 155
Cyclophosphamide..........68, 69
Cycloset...................................87
Cyclosporine.........................139
Cyclosporine Modified.........139
Cymbalta............................... 106
Cyproheptadine HCl............ 149
Cyred EQ...............................130
Cystadane............................. 124
Cystadrops............................145
Cystagon............................... 124
Cystaran................................ 145
Cytomel................................. 135
Cytotec.................................. 123
D
Dalfampridine ER................. 107
Daliresp................................. 153
Dalvance..................................48
Danazol................................. 129
Dantrium..................................80
Dantrolene Sodium................ 80
Dapsone..........................68, 116
Daptacel................................ 141
Daptomycin.............................48
DARAPRIM............................. 74
Darifenacin Hydrobromide ER
.............................................125
Daurismo.................................71
Daypro..................................... 40
18
Daytrana................................105
DayVigo.................................155
DDAVP.................................. 128
Deblitane...............................135
Deferasirox............................119
Deferasirox Granules........... 119
Deferiprone........................... 119
Delestrogen.......................... 130
Delstrigo.................................. 82
Delzicol..................................142
Demeclocycline HCl...............54
Demser.................................... 99
Denavir.................................... 81
Depakote.................................86
Depakote ER...........................86
Depakote Sprinkles................ 86
Depen Titratabs....................126
Depo-Estradiol...................... 130
Depo-Provera........................135
Depo-SubQ Provera 104......135
Depo-Testosterone...............129
Derma-Smoothe/FS Scalp...111
DermOtic...............................149
Descovy...................................83
Desipramine HCl.................... 63
Desloratadine........................150
Desloratadine ODT...............150
Desmopressin Acetate.........128
Desmopressin Acetate Spray
.............................................128
Desogestrel-Ethinyl Estradiol
.............................................130
Desonate...............................111
Desonide...............................111
DesOwen...............................111
Desoximetasone...................111
Desoxyn.................................104
Desvenlafaxine ER..................62
Desvenlafaxine Succinate ER
...............................................62
Detrol.....................................125
Detrol LA............................... 125
Dexabliss...............................127
Dexamethasone....................127
Dexamethasone Sodium
Phosphate.......................... 147
Dexedrine..............................104
Dexilant................................. 123
Dexmethylphenidate HCl.....105
Dexmethylphenidate HCl ER
.............................................105
Dextroamphetamine Sulfate
.................................... 104, 105
Dextroamphetamine Sulfate ER
.............................................104
Dextrose................................ 118
Dextrose-NaCl.......................118
Diacomit.................................. 58
Diastat AcuDial....................... 58
Diastat Pediatric......................58
Diazepam.......................... 58, 85
Diazepam Intensol..................85
Diazoxide.................................89
Dibenzyline..............................94
Diclofenac Epolamine............ 40
Diclofenac Potassium............ 40
Diclofenac Sodium........40, 114,
147
Diclofenac Sodium ER........... 40
Diclofenac-Misoprostol.......... 40
Dicloxacillin Sodium...............52
Dicyclomine HCl...................121
Differin...................................109
Dificid.......................................53
Diflorasone Diacetate...........112
Diflucan................................... 65
Diflunisal..................................40
Digitek..................................... 99
Digox....................................... 99
Digoxin.................................... 99
Dihydroergotamine Mesylate
...............................................67
Dilantin.................................... 59
Dilantin INFATABS................. 59
Dilaudid.............................44, 45
Dilt-XR......................................98
Diltiazem HCl.......................... 98
Diltiazem HCl ER.................... 98
Diltiazem HCl ER Beads........ 98
Diltiazem HCl ER Coated
Beads.................................... 98
Dimethyl Fumarate............... 107
Dimethyl Fumarate Starter Pack
.............................................107
Diovan......................................95
Diovan HCT.............................99
Dipentum...............................143
Diphenoxylate-Atropine....... 121
Diphtheria-Tetanus Toxoids DT
.............................................141
Diprolene...............................112
Disulfiram................................ 46
Ditropan XL........................... 125
Diuril...................................... 101
Divalproex Sodium................. 86
Divalproex Sodium ER........... 86
19
Dofetilide................................. 96
Dojolvi....................................144
Dolishale................................130
Donepezil HCl.........................60
Donepezil HCl ODT................ 60
Doptelet...................................94
Doryx....................................... 54
Doryx MPC.............................. 54
Dorzolamide HCl.................. 148
Dorzolamide HCl-Timolol
Maleate............................... 145
Dorzolamide HCl-Timolol
Maleate Preservative Free
.............................................145
Dotti....................................... 130
Dovato..................................... 82
Dovonex................................ 114
Doxazosin Mesylate............... 94
Doxepin HCl........... 63, 112, 155
Doxercalciferol......................144
Doxy 100................................. 54
Doxycycline Hyclate.........54, 55
Doxycycline Monohydrate..... 55
Drizalma Sprinkle................. 106
Dronabinol...............................64
Drospirenone-Ethinyl Estradiol
.............................................130
Drospirenone-Ethinyl Estradiol-
Levomefolate......................130
Droxia...................................... 69
Droxidopa................................94
Duaklir Pressair.................... 154
Duetact.................................... 87
Duexis......................................40
Dulera.................................... 154
Duloxetine HCl......................106
Duobrii...................................114
Duopa......................................76
Dupixent................................138
Durezol.................................. 147
Dutasteride............................126
Dutasteride-Tamsulosin HCl
.............................................126
DUTOPROL.............................99
Dyanavel XR..........................105
Dymista................................. 150
Dyrenium...............................101
E
E.E.S. Granules.......................53
Econazole Nitrate................. 116
Edarbi...................................... 95
Edarbyclor...............................99
Edecrin.................................. 101
Edurant....................................82
Efavirenz..................................82
Efavirenz-Emtricitabine-
Tenofovir...............................82
Efavirenz-Lamivudine-Tenofovir
...............................................82
Effexor XR............................... 62
Efudex................................... 114
Egrifta SV.............................. 128
Elestrin...................................130
Eletriptan Hydrobromide........66
Elidel......................................112
Eligard................................... 136
Eliquis...................................... 91
Eliquis Starter Pack................ 91
Elmiron.................................. 126
EluRyng.................................130
Emcyt.......................................69
Emend..................................... 64
Emend Tri-Pack...................... 64
Emflaza..................................127
Emgality............................ 67, 68
Emoquette.............................130
Emsam.....................................61
Emtricitabine...........................83
Emtricitabine-Tenofovir
Disoproxil Fumarate.............83
Emtriva.....................................83
Emverm................................... 74
Enalapril Maleate.................... 95
Enalapril-Hydrochlorothiazide
...............................................99
Enbrel............................139, 140
Enbrel Mini............................139
Enbrel SureClick...................140
Endari.................................... 118
Endocet................................... 45
Engerix-B...............................141
Enoxaparin Sodium................91
Enpresse-28.......................... 131
Enskyce.................................131
Enspryng............................... 140
Enstilar...................................114
Entacapone.............................75
Entecavir..................................81
Entocort EC...........................143
Entresto................................... 99
Enulose................................. 120
Envarsus XR..........................140
Epclusa....................................81
Epidiolex..................................55
Epiduo................................... 109
20
Epiduo Forte......................... 109
Epinastine HCl...................... 146
Epinephrine...........................152
EpiPen 2-Pak.........................152
EpiPen Jr 2-Pak.................... 152
Epitol........................................59
Epivir........................................83
Epivir HBV............................... 81
Eplerenone............................101
Epogen.................................... 93
Epzicom...................................83
Equetro....................................86
Eraxis....................................... 65
Ergotamine-Caffeine...............67
Erivedge.................................. 71
Erleada.................................... 69
Erlotinib HCl............................71
Errin....................................... 135
Ertaczo.................................. 116
Ertapenem Sodium................ 52
Ery..........................................116
Ery-Tab.................................... 53
Erygel.....................................116
EryPed 200..............................53
EryPed 400..............................53
Erythrocin Lactobionate.........53
Erythrocin Stearate.................53
Erythromycin................ 116, 146
Erythromycin Base................. 53
Erythromycin Ethylsuccinate
...............................................53
Esbriet................................... 153
Escitalopram Oxalate............. 62
Esomeprazole Magnesium
.............................................123
Estarylla.................................131
Estrace.................................. 131
Estradiol................................ 131
Estradiol Valerate................. 131
Estring................................... 131
Ethacrynic Acid.....................101
Ethambutol HCl...................... 68
Ethosuximide.......................... 58
Ethynodiol Diacetate-Ethinyl
Estradiol..............................131
Etodolac.................................. 40
Etodolac ER............................ 40
Etonogestrel-Ethinyl Estradiol
.............................................131
Eucrisa...................................112
Euthyrox................................ 135
Evekeo...................................105
Evekeo ODT..........................105
Evenity................................... 144
Everolimus...................... 71, 140
Evista..................................... 135
Evoclin...................................116
Evotaz...................................... 84
Evoxac...................................108
Evrysdi...................................124
Exelon......................................60
Exemestane............................ 70
Exforge.................................... 99
Exforge HCT........................... 99
Exjade....................................119
Extavia................................... 107
Extina.....................................116
Eysuvis.................................. 147
Ezallor Sprinkle.....................102
Ezetimibe.............................. 102
Ezetimibe-Simvastatin.......... 102
F
Fabior.................................... 109
Falmina..................................131
Famciclovir..............................81
Famotidine............................ 122
Fanapt............................... 77, 78
Fanapt Titration Pack............. 78
Fareston.................................. 69
Farxiga.....................................87
Farydak....................................71
Fasenra..................................154
Fasenra Pen..........................154
Fayosim.................................131
Febuxostat.............................. 66
Felbamate......................... 55, 56
Felbatol....................................56
Feldene....................................40
Felodipine ER......................... 97
Femara.................................... 70
Femring................................. 131
Femynor................................ 131
Fenofibrate............................101
Fenofibrate Micronized........101
Fenofibric Acid..................... 101
Fenoglide.............................. 102
Fenoprofen Calcium...............40
Fentanyl...................................42
Fentanyl Citrate.......................45
Fentora.................................... 45
Ferriprox................................119
Fetzima.................................... 62
Fetzima Titration..................... 62
Fexmid...................................155
21
Fiasp........................................ 89
Fiasp FlexTouch..................... 89
Fiasp PenFill............................89
Finacea..................................109
Finasteride............................ 126
Fintepla....................................56
Firazyr....................................137
Firdapse................................ 106
Firmagon...............................136
Firvanq.....................................48
Flac........................................ 149
Flagyl....................................... 48
Flarex.....................................147
Flavoxate HCl........................125
Flebogamma DIF..................137
Flecainide Acetate..................96
Flector......................................40
FloLipid................................. 102
Flomax...................................126
Flovent Diskus...................... 150
Flovent HFA.......................... 150
Fluconazole.............................65
Fluconazole in Sodium
Chloride................................ 65
Flucytosine..............................65
Fludrocortisone Acetate...... 127
Flunisolide.............................150
Fluocinolone Acetonide......112,
149
Fluocinolone Acetonide Scalp
.............................................112
Fluocinonide......................... 112
Fluocinonide Emulsified Base
.............................................112
Fluorometholone.................. 147
Fluoroplex............................. 114
Fluorouracil........................... 114
Fluoxetine HCl........................ 62
Fluphenazine Decanoate....... 76
Fluphenazine HCl................... 77
Flurandrenolide.................... 112
Flurbiprofen.............................40
Flurbiprofen Sodium............ 147
Flutamide................................ 69
Fluticasone Propionate.......112,
150
Fluticasone-Salmeterol........ 154
Fluvastatin Sodium...............102
Fluvastatin Sodium ER.........102
Fluvoxamine Maleate............. 62
Fluvoxamine Maleate ER....... 62
FML........................................147
FML Forte..............................147
FML Liquifilm........................ 147
Focalin...................................105
Focalin XR.............................105
Fondaparinux Sodium............91
Forfivo XL................................ 61
Fortamet.................................. 87
Forteo.................................... 144
Fortesta................................. 129
Fosamax................................144
Fosamax Plus D....................144
Fosamprenavir Calcium......... 84
Fosfomycin Tromethamine....48
Fosinopril Sodium.................. 95
Fosinopril Sodium-HCTZ....... 99
Fosrenol................................ 120
Fotivda.....................................69
Fragmin................................... 92
Frova........................................66
Frovatriptan Succinate........... 66
Fulphila....................................93
Furosemide...........................101
Fuzeon.....................................84
Fyavolv...................................131
Fycompa..................................56
G
Gabapentin............................. 58
Gabitril..................................... 58
Galafold.................................124
Galantamine Hydrobromide
...............................................60
Galantamine Hydrobromide ER
...............................................60
Gammagard..........................137
Gammagard S/D Less IgA
.............................................137
Gammaked........................... 137
Gammaplex...........................137
Gamunex-C........................... 137
Gardasil 9..............................141
Gastrocrom........................... 124
Gatifloxacin........................... 146
Gattex.................................... 121
Gauze.................................... 144
GaviLyte-C.............................121
GaviLyte-G.............................122
GaviLyte-N with Flavor Pack
.............................................122
Gavreto....................................71
Gelnique................................125
Gemfibrozil............................102
Gemmily................................ 131
22
Gemtesa................................125
Generess Fe..........................131
Generlac................................121
Gengraf................................. 140
Genotropin............................128
Genotropin MiniQuick..........128
Gentak...................................146
Gentamicin Sulfate........47, 116,
146
Gentamicin Sulfate-0.9%
Sodium Chloride.................. 47
Genvoya.................................. 82
Geodon....................................78
Gilenya.................................. 107
Gilotrif...................................... 71
Gimoti...................................... 63
Glassia...................................124
Glatiramer Acetate............... 107
Glatopa..................................107
Gleevec................................... 71
Glimepiride..............................87
Glipizide...................................87
Glipizide ER............................ 87
Glipizide-Metformin HCl.........87
Gloperba................................. 66
GlucaGen HypoKit..................89
Glucagon.................................89
Glucotrol XL............................ 87
Glumetza................................. 87
Glycopyrrolate...................... 121
Glyxambi................................. 87
Gocovri.................................... 75
GoLYTELY............................ 122
GoNitro..................................103
Gralise................................... 106
Granisetron HCl...................... 64
Granix...................................... 93
Grastek..................................138
Griseofulvin Microsize............65
Griseofulvin Ultramicrosize....65
Gvoke HypoPen 2-Pack......... 89
Gvoke PFS.............................. 89
Gynazole-1.............................. 65
H
Haegarda.............................. 137
Hailey 24 Fe.......................... 131
Halcinonide...........................112
Haldol...................................... 77
Haldol Decanoate...................77
Halobetasol Propionate....... 112
Halog..................................... 112
Haloperidol..............................77
Haloperidol Decanoate.......... 77
Haloperidol Lactate................ 77
Harvoni.................................... 81
Havrix.....................................141
Helidac Therapy................... 122
Hemady.................................127
Heparin Sodium......................92
HepatAmine.......................... 118
Hepsera...................................81
Hetlioz....................................155
Hetlioz LQ............................. 155
Hiberix................................... 141
Hiprex...................................... 48
Horizant.................................106
Humalog..................................89
Humalog Junior KwikPen...... 89
Humalog KwikPen.................. 89
Humalog Mix 50/50................89
Humalog Mix 50/50 KwikPen
...............................................89
Humalog Mix 75/25................89
Humalog Mix 75/25 KwikPen
...............................................89
Humatin...................................47
Humatrope............................ 128
Humira...................................140
Humira Pediatric Crohns Start
.............................................140
Humira Pen........................... 140
Humira Pen Crohns Disease
Starter................................. 140
Humira Pen Psoriasis Starter
.............................................140
Humira Pen-Pediatric UC Start
.............................................140
Humulin 70/30........................90
Humulin 70/30 KwikPen........ 89
Humulin N............................... 90
Humulin N KwikPen............... 90
Humulin R............................... 90
Humulin R U-500.................... 90
Humulin R U-500 KwikPen.....90
Hydralazine HCl....................103
Hydrea..................................... 69
Hydrochlorothiazide.............101
Hydrocodone Bitartrate ER... 42
Hydrocodone-Acetaminophen
...............................................45
Hydrocodone-Ibuprofen.........45
Hydrocortisone... 112, 113, 127,
143
Hydrocortisone Acetate-
Pramoxine...........................115
23
Hydrocortisone Butyrate......112
Hydrocortisone Valerate...... 113
Hydrocortisone-Acetic Acid
.............................................149
Hydromorphone HCl.............. 45
Hydromorphone HCl ER........ 42
Hydromorphone HCl
Preservative Free..................45
Hydroxychloroquine Sulfate
...............................................74
Hydroxyurea............................69
Hydroxyzine HCl..................... 85
Hydroxyzine Pamoate............ 85
Hysingla ER...................... 42, 43
Hyzaar......................................99
I
Ibandronate Sodium............ 144
Ibrance.................................... 71
Ibu............................................40
Ibuprofen.......................... 40, 41
Icatibant Acetate.................. 137
Iclevia.....................................131
Iclusig...................................... 71
Icosapent Ethyl..................... 103
IDHIFA..................................... 70
Ilevro...................................... 147
Ilumya.................................... 138
Imatinib Mesylate....................71
Imbruvica.................................71
Imipenem-Cilastatin................52
Imipramine HCl.......................63
Imipramine Pamoate.............. 63
Imiquimod............................. 115
Imitrex......................................66
Imitrex STATdose Refill......... 66
Imitrex STATdose System..... 66
Imovax Rabies...................... 141
Impavido..................................74
Impeklo..................................113
Imuran................................... 140
Imvexxy Maintenance Pack
.............................................131
Imvexxy Starter Pack............131
Inbrija.......................................76
Incassia................................. 135
Increlex..................................128
Incruse Ellipta....................... 151
Indapamide...........................101
Inderal LA................................96
Indocin.....................................41
Infanrix...................................142
Ingrezza.................................106
Inlyta........................................ 71
InnoPran XL............................ 96
Inqovi....................................... 71
Inrebic......................................71
Inspra.....................................101
Insulin Aspart.......................... 90
Insulin Aspart FlexPen........... 90
Insulin Aspart PenFill..............90
Insulin Aspart Prot & Aspart
...............................................90
Insulin Aspart Prot & Aspart
FlexPen................................. 90
Insulin Lispro...........................90
Insulin Lispro Junior KwikPen
...............................................90
Insulin Lispro Prot & Lispro... 90
Insulin Syringes, Needles.... 144
Intelence..................................82
Intralipid................................ 118
Intrarosa................................ 129
Intron A..................................139
Introvale.................................131
Invanz...................................... 52
Invega...................................... 78
Invega Sustenna..................... 78
Invega Trinza...........................78
Inveltys.................................. 147
Invirase.................................... 84
Invokamet................................87
Invokamet XR..........................87
Invokana.................................. 87
Iopidine................................. 148
IPOL.......................................142
Ipratropium Bromide............151
Ipratropium-Albuterol........... 154
Irbesartan................................ 95
Irbesartan-Hydrochlorothiazide
.............................................100
Iressa....................................... 71
Isentress.................................. 82
Isentress HD............................82
Isibloom.................................131
Isolyte-P in D5W....................118
Isolyte-S.................................118
Isoniazid.................................. 68
Isopto Carpine...................... 148
Isordil Titradose....................103
Isosorbide Dinitrate.............. 104
Isosorbide Mononitrate........104
Isosorbide Mononitrate ER
.............................................104
Isotretinoin............................ 109
Isradipine.................................97
24
Istalol..................................... 148
Isturisa................................... 136
Itraconazole.............................65
Ivermectin....................... 74, 115
Ixiaro......................................142
J
Jadenu...................................119
Jadenu Sprinkle....................120
Jakafi....................................... 71
Jalyn...................................... 126
Jantoven..................................92
Janumet...................................87
Janumet XR.............................87
Januvia.................................... 87
Jardiance.................................87
Jasmiel.................................. 131
Jatenzo..................................129
Jentadueto.............................. 87
Jentadueto XR........................ 87
Jinteli..................................... 131
Jornay PM............................. 105
Jublia..................................... 116
Juleber...................................131
Juluca...................................... 82
Junel 1.5/30..........................131
Junel 1/20.............................131
Junel Fe 1.5/30.....................131
Junel Fe 1/20........................131
Junel Fe 24........................... 131
Juxtapid.................................103
Jynarque............................... 120
K
K-Tab..................................... 118
Kaitlib Fe............................... 131
Kaletra..................................... 84
Kalydeco............................... 152
Kapvay...................................105
Kariva.....................................131
Katerzia....................................97
Kazano.....................................87
KCl in Dextrose-NaCl............118
KCl-Lactated Ringers-D5W
.............................................118
Kelnor 1/35........................... 131
Kelnor 1/50........................... 132
Kenalog................................. 113
Keppra.....................................56
Keppra XR...............................56
Kerydin.................................. 116
Kesimpta............................... 107
Ketoconazole..................65, 116
Ketodan.................................116
Ketoprofen.............................. 41
Ketoprofen ER........................ 41
Ketorolac Tromethamine...... 41,
147
Keveyis.................................. 124
Kevzara..................................138
Kineret................................... 138
Kinrix......................................142
Kisqali...................................... 72
Kisqali Femara........................ 72
Klaron.................................... 116
Klonopin.................................. 85
Klor-Con................................ 118
Klor-Con 10........................... 118
Klor-Con 8............................. 118
Klor-Con M10........................118
Klor-Con M15........................118
Klor-Con M20........................118
Kombiglyze XR....................... 87
Korlym................................... 129
Koselugo................................. 72
Krintafel................................... 74
Kristalose.............................. 121
Kurvelo.................................. 132
Kuvan.....................................124
Kynmobi.................................. 76
L
Labetalol HCl.......................... 96
Lacrisert................................ 145
Lactulose...............................121
Lamictal...................................56
Lamictal ODT.......................... 56
Lamictal Starter...................... 56
Lamictal XR.............................56
Lamivudine....................... 81, 83
Lamivudine-Zidovudine..........83
Lamotrigine............................. 56
Lamotrigine ER.......................56
Lamotrigine ODT.................... 56
Lamotrigine Starter Kit-Blue
...............................................56
Lamotrigine Starter Kit-Green
...............................................56
Lamotrigine Starter Kit-Orange
...............................................57
Lampit......................................74
Lanoxin..................................100
Lansoprazole........................ 123
Lansoprazole ODT............... 123
Lanthanum Carbonate.........120
Lantus......................................90
Lantus SoloStar...................... 90
25
Lapatinib Ditosylate................72
LARIN 1.5/30........................132
LARIN 1/20........................... 132
LARIN Fe 1.5/30...................132
LARIN Fe 1/20......................132
Larissia.................................. 132
Lasix...................................... 101
Lastacaft................................146
Latanoprost...........................149
Latuda......................................78
Layolis Fe.............................. 132
Lazanda...................................45
Ledipasvir-Sofosbuvir.............81
Leena.....................................132
Leflunomide..........................140
Lenvima 10MG Daily Dose.... 72
Lenvima 12MG Daily Dose.... 72
Lenvima 14MG Daily Dose.... 72
Lenvima 18MG Daily Dose.... 72
Lenvima 20MG Daily Dose.... 72
Lenvima 24MG Daily Dose.... 72
Lenvima 4MG Daily Dose...... 72
Lenvima 8MG Daily Dose...... 72
Lescol XL.............................. 102
Lessina.................................. 132
Letairis...................................153
Letrozole..................................70
Leucovorin Calcium............... 74
Leukeran................................. 69
Leukine....................................93
Leuprolide Acetate...............136
Levalbuterol HCl...................152
Levalbuterol Tartrate............152
Levemir....................................90
Levemir FlexTouch.................90
Levetiracetam......................... 57
Levetiracetam ER................... 57
Levo-T....................................135
Levobunolol HCl...................148
Levocarnitine........................ 124
Levocetirizine Dihydrochloride
.............................................150
Levofloxacin....................54, 146
Levofloxacin in D5W...............54
Levonest................................132
Levonorgestrel-Ethinyl Estradiol
.............................................132
Levonorgestrel-Ethinyl Estradiol
& Ethinyl Estradiol.............. 132
Levonorgestrel-Ethinyl Estradiol
91-Day................................. 132
Levora 0.15/30..................... 132
Levorphanol Tartrate..............43
Levothyroxine Sodium......... 135
Levoxyl.................................. 135
Lexapro................................... 62
Lexette...................................113
Lexiva.......................................84
Lialda.....................................143
Librax.....................................121
Licart........................................41
Lidocaine.................................46
Lidocaine HCl......................... 46
Lidocaine Viscous.................. 46
Lidocaine-Prilocaine...............46
Lidoderm.................................46
Lindane................................. 115
Linezolid.................................. 48
Linzess.................................. 121
Liothyronine Sodium............135
Lipitor.................................... 102
Lipofen.................................. 102
Lisinopril..................................95
Lisinopril-Hydrochlorothiazide
.............................................100
Lithium.....................................86
Lithium Carbonate..................86
Lithium Carbonate ER............86
Lithobid................................... 86
Lithostat................................ 127
Livalo..................................... 102
Lo Loestrin Fe.......................132
Locoid................................... 113
Locoid Lipocream................ 113
Lodine......................................41
Lodosyn...................................76
Loestrin 1.5/30..................... 132
Loestrin 1/20........................ 132
Loestrin Fe 1.5/30................ 132
Loestrin Fe 1/20................... 132
Lokelma.................................120
Lomotil.................................. 121
Lonhala Magnair...................151
Lonsurf.................................... 70
Loperamide HCl................... 121
Lopid..................................... 102
Lopinavir-Ritonavir..................84
Lopressor................................ 96
Loprox................................... 116
Lorazepam.............................. 85
Lorazepam Intensol................85
Lorbrena..................................72
Loryna................................... 132
26
Losartan Potassium................95
Losartan Potassium-HCTZ...100
LoSeasonique.......................132
Lotemax................................ 147
Lotemax SM..........................147
Lotensin...................................95
Loteprednol Etabonate........ 147
Lotrel..................................... 100
Lotronex................................ 121
Lovastatin..............................102
Lovaza................................... 103
Lovenox...................................92
Low-Ogestrel.........................132
Loxapine Succinate................77
Lubiprostone.........................121
Lucemyra................................ 47
Luliconazole..........................116
Lumigan................................ 149
Lupaneta Pack......................136
Lupkynis................................140
Lupron Depot........................136
Lutera.................................... 132
Luxiq......................................113
Luzu.......................................117
Lyleq......................................135
Lyllana................................... 132
Lynparza..................................72
Lyrica.............................106, 107
Lyrica CR...............................106
Lysodren............................... 136
Lysteda....................................94
Lyumjev................................... 90
Lyumjev KwikPen................... 90
Lyza....................................... 135
M
M-M-R II................................. 142
Macrobid................................. 48
Macrodantin............................48
Mafenide Acetate................. 117
Magnesium Sulfate.............. 118
Malarone................................. 74
Malathion.............................. 115
Marinol.....................................64
Marlissa................................. 132
Marplan................................... 61
Matulane..................................69
Matzim LA............................... 98
Mavenclad.............................107
Mavyret....................................81
Maxalt...................................... 66
Maxalt-MLT............................. 66
Maxidex.................................147
Maxitrol..................................145
Maxzide................................. 100
Maxzide-25............................100
Mayzent.................................107
Mayzent Starter Pack........... 107
Meclizine HCl..........................63
Meclofenamate Sodium.........41
Medrol................................... 127
Medroxyprogesterone Acetate
.............................................135
Mefenamic Acid......................41
Mefloquine HCl.......................74
Megestrol Acetate................ 135
Mekinist................................... 72
Mektovi....................................72
Meloxicam...............................41
Memantine HCl.......................61
Memantine HCl ER.................61
Memantine HCl Titration Pak
...............................................61
Menactra............................... 142
Menest...................................132
MenQuadfi............................ 142
Mentax...................................117
Menveo..................................142
Mepron.................................... 74
Mercaptopurine...................... 69
Meropenem...................... 52, 53
Merrem.................................... 53
Merzee...................................132
Mesalamine...........................143
Mesalamine ER.....................143
Mesnex.................................... 74
Mestinon..................................68
Metformin HCl.........................88
Metformin HCl ER...................87
Methadone HCl.......................43
Methamphetamine HCl........105
Methazolamide..................... 148
Methenamine Hippurate........ 48
Methimazole......................... 137
Methitest............................... 129
Methotrexate.........................140
Methotrexate Sodium...........140
Methoxsalen Rapid.............. 115
Methscopolamine Bromide
.............................................121
Methyldopa............................. 94
Methylin.................................105
Methylphenidate HCl........... 106
Methylphenidate HCl CD.....105
27
Methylphenidate HCl ER..... 105
Methylphenidate HCl ER
Osmotic Release................105
Methylphenidate HCl LA......105
Methylprednisolone............. 127
Methyltestosterone...............129
Metoclopramide HCl.............. 63
Metoclopramide HCl ODT..... 63
Metolazone........................... 101
Metoprolol Succinate ER.......97
Metoprolol Tartrate.................97
Metoprolol-Hydrochlorothiazide
.............................................100
MetroCream............................48
Metrogel.................................. 48
MetroLotion.............................48
Metronidazole...................48, 49
Metronidazole in NaCl 0.79%
...............................................49
Metyrosine............................ 100
Mexiletine HCl.........................96
Mibelas 24 Fe....................... 132
Micafungin Sodium................ 65
Micardis...................................95
Micardis HCT........................100
Miconazole 3...........................65
Microgestin 1.5/30...............132
Microgestin 1/20.................. 132
Microgestin Fe 1.5/30..........132
Microgestin Fe 1/20.............132
Midodrine HCl.........................94
Migergot.................................. 67
Miglitol.....................................88
Miglustat................................124
Migranal.................................. 67
Mili......................................... 132
Millipred................................ 127
Minastrin 24 Fe.....................132
Minipress.................................94
Minitran................................. 104
Minivelle................................ 133
Minocycline HCl......................55
Minocycline HCl ER................55
Minolira....................................55
Minoxidil................................103
Mirapex....................................76
Mirapex ER..............................76
Mirtazapine............................. 61
Mirtazapine ODT.....................61
Mirvaso..................................109
Misoprostol........................... 123
Mitigare................................... 66
Mobic.......................................41
Modafinil............................... 155
Moexipril HCl.......................... 95
Molindone HCl........................77
Mometasone Furoate..........113,
150
Mondoxyne NL....................... 55
Montelukast Sodium............ 151
Monurol................................... 49
Morphine Sulfate.................... 45
Morphine Sulfate ER.............. 43
Morphine Sulfate ER Beads
...............................................43
Motegrity............................... 121
Movantik................................121
MoviPrep...............................122
Moxeza..................................146
Moxifloxacin HCl............ 54, 146
Moxifloxacin HCl in NaCl....... 54
MS Contin............................... 43
Mulpleta...................................93
Multaq......................................96
Mupirocin.............................. 117
Mupirocin Calcium............... 117
Myalept..................................122
Myambutol.............................. 68
Mycamine................................65
Mycapssa..............................136
Mycobutin............................... 68
Mycophenolate Mofetil........ 140
Mycophenolate Sodium.......140
Mydayis................................. 105
Myfortic................................. 140
Myorisan................................109
Myrbetriq...............................125
Mysoline.................................. 58
Mytesi.................................... 121
N
Nabumetone........................... 41
Nadolol.................................... 97
Nafcillin Sodium..................... 52
Naftifine HCl..........................117
Naftin..................................... 117
Nalfon...................................... 41
Naloxone HCl..........................47
Naltrexone HCl....................... 47
Namenda.................................61
Namenda Titration Pak.......... 61
Namenda XR...........................61
Namzaric................................. 60
Naprelan..................................41
Naproxen.................................41
28
Naproxen DR.......................... 41
Naproxen Sodium.................. 41
Naproxen Sodium ER............ 41
Naproxen-Esomeprazole....... 41
Naratriptan HCl.......................66
Narcan..................................... 47
Nardil....................................... 61
Nasonex................................ 150
Natacyn................................. 146
Natazia...................................133
Nateglinide..............................88
Natesto.................................. 129
Natpara..................................144
Natroba................................. 115
Nayzilam..................................58
Nebupent................................ 74
Necon 0.5/35........................133
Nefazodone HCl..................... 62
Neo-Synalar...........................115
Neomycin Sulfate................... 47
Neomycin-Bacitracin-Polymyxin
.............................................146
Neomycin-Polymyxin-
Bacitracin-Hydrocortisone
.............................................145
Neomycin-Polymyxin-
Dexamethasone................. 145
Neomycin-Polymyxin-
Gramicidin.......................... 146
Neomycin-Polymyxin-HC.... 145,
149
Neoral....................................140
Nerlynx.................................... 72
Nesina......................................88
Neuac.................................... 109
Neulasta.................................. 93
Neupogen............................... 93
Neupro.....................................76
Neurontin................................ 58
Nevanac................................ 147
Nevirapine............................... 82
Nevirapine ER......................... 82
Nexavar................................... 72
Nexium.................................. 123
Nexletol................................. 103
Nexlizet..................................103
Nextstellis..............................133
Niacin ER.............................. 103
Niacor....................................103
Niaspan................................. 103
Nicardipine HCl...................... 97
Nicotrol....................................47
Nicotrol NS..............................47
Nifedipine ER..........................97
Nifedipine ER Osmotic Release
...............................................97
Nikki.......................................133
Nilandron.................................69
Nilutamide...............................69
Nimodipine..............................97
Ninlaro..................................... 70
Nisoldipine ER........................ 97
Nitazoxanide........................... 74
Nitisinone.............................. 124
Nitro-Bid................................ 104
Nitro-Dur................................104
Nitrofurantoin..........................49
Nitrofurantoin Macrocrystal...49
Nitrofurantoin Monohydrate
...............................................49
Nitroglycerin..........................104
Nitrolingual............................104
Nitrostat.................................104
Nityr....................................... 124
Nivestym..................................93
Nizatidine.............................. 122
Nocdurna.............................. 128
Nolix.......................................113
Nora-BE................................. 135
Norditropin FlexPro..............128
Norethindrone...................... 135
Norethindrone Acetate........ 135
Norethindrone Acetate-Ethinyl
Estradiol..............................133
Norethindrone Acetate-Ethinyl
Estradiol-Fe.........................133
Norgestimate-Ethinyl Estradiol
.............................................133
Norgestimate-Ethinyl Estradiol
Triphasic............................. 133
Noritate....................................49
Norpramin............................... 63
Northera.................................. 94
Nortrel 0.5/35....................... 133
Nortrel 1/35.......................... 133
Nortrel 7/7/7.........................133
Nortriptyline HCl..................... 63
Norvasc................................... 97
Norvir....................................... 84
Nourianz.................................. 75
Novolin 70/30......................... 91
Novolin 70/30 FlexPen...........90
Novolin N.................................91
Novolin N FlexPen.................. 91
Novolin R.................................91
Novolin R FlexPen.................. 91
29
NovoLog..................................91
NovoLog FlexPen................... 91
NovoLog Mix 70/30................91
NovoLog Mix 70/30 FlexPen
...............................................91
NovoLog PenFill..................... 91
Noxafil......................................65
Nubeqa....................................69
Nucala................................... 154
Nucynta................................... 45
Nucynta ER............................. 43
Nuedexta...............................106
NuLYTELY Lemon-Lime...... 122
Nuplazid.................................. 78
Nurtec ODT.............................66
Nutrilipid................................118
Nutropin AQ NuSpin 10.......128
Nutropin AQ NuSpin 20.......128
Nutropin AQ NuSpin 5......... 128
NuvaRing.............................. 133
Nuvigil....................................155
Nuzyra..................................... 55
Nyamyc................................. 117
Nylia 7/7/7............................ 133
Nymalize..................................97
Nymyo................................... 133
Nystatin........................... 65, 117
Nystatin-Triamcinolone........ 115
Nystop................................... 117
Nyvepria.................................. 93
O
Ocaliva...................................122
Ocella.................................... 133
Octagam................................137
Octreotide Acetate............... 136
Ocuflox.................................. 146
Odactra................................. 138
Odefsey................................... 83
Odomzo...................................72
Ofev....................................... 154
Ofloxacin................ 54, 146, 149
Olanzapine.............................. 78
Olanzapine ODT..................... 78
Olanzapine-Fluoxetine HCl.... 61
Olmesartan Medoxomil..........95
Olmesartan Medoxomil-HCTZ
.............................................100
Olmesartan-Amlodipine-HCTZ
.............................................100
Olopatadine HCl...........146, 150
Olumiant................................138
Olux....................................... 113
Olux-E.................................... 113
Omeclamox-Pak................... 122
Omega-3-Acid Ethyl Esters
.............................................103
Omeprazole.......................... 123
Omeprazole-Sodium
Bicarbonate........................ 123
Omnaris.................................150
Omnitrope.............................128
Ondansetron HCl....................64
Ondansetron ODT.................. 64
Onexton.................................109
Onfi.......................................... 58
Ongentys.................................75
Onglyza................................... 88
Onureg.................................... 69
Onzetra Xsail...........................66
Opsumit.................................153
Oracea.....................................55
Oralair 300IR.........................138
Orapred ODT........................ 127
Oravig...................................... 65
Orencia..................................138
Orencia ClickJect................. 138
Orenitram.............................. 153
Orfadin.................................. 124
Orgovyx................................. 136
Oriahnn..................................136
Orilissa...................................137
Orkambi................................ 152
Orladeyo................................137
Orsythia................................. 133
Ortikos...................................143
Oseltamivir Phosphate........... 84
Oseni....................................... 88
Osmolex ER............................ 75
OsmoPrep.............................122
Osphena................................135
Otezla.................................... 138
Otovel.................................... 149
Otrexup................................. 140
Ovide..................................... 115
Oxacillin Sodium.....................52
Oxacillin Sodium in Dextrose
...............................................52
Oxandrolone......................... 129
Oxaprozin................................41
Oxazepam............................... 85
Oxbryta.................................... 93
Oxcarbazepine........................59
Oxervate................................ 145
30
Oxiconazole Nitrate..............117
Oxistat................................... 117
Oxtellar XR.............................. 59
Oxybutynin Chloride............ 125
Oxybutynin Chloride ER...... 125
Oxycodone HCl................ 45, 46
Oxycodone HCl ER................ 43
Oxycodone-Acetaminophen
...............................................46
OxyContin............................... 44
Oxymorphone HCl..................46
Oxymorphone HCl ER............44
Oxytrol................................... 126
Ozempic.................................. 88
P
Pacerone................................. 96
Paliperidone ER......................78
Palynziq.................................124
Pamelor................................... 63
Pancreaze............................. 124
Pandel................................... 113
Pantoprazole Sodium...........123
Panzyga.................................137
Paricalcitol............................ 144
Parlodel................................... 76
Parnate.................................... 61
Paromomycin Sulfate.............47
Paroxetine HCl........................62
Paser........................................68
Patanase............................... 150
Paxil......................................... 62
Pediarix................................. 142
Pedvax HIB........................... 142
PEG-3350-Electrolytes......... 122
PEG-3350-NaCl-Na
Bicarbonate-KCl................. 122
PEG-KCl-NaCl-NaSulf-Na Asc-C
.............................................122
Pegasys.................................139
Pemazyre.................................70
Penicillamine.........................127
Penicillin G Potassium........... 52
Penicillin G Potassium in
Dextrose................................52
Penicillin G Procaine.............. 52
Penicillin G Sodium................52
Penicillin V Potassium............52
Pennsaid................................. 41
PENTAM 300.......................... 74
Pentamidine Isethionate........ 75
Pentasa................................. 143
Pentoxifylline ER...................100
Pepcid...........................122, 123
Percocet.................................. 46
Perforomist........................... 152
Perindopril Erbumine............. 95
Periogard.............................. 108
Permethrin............................ 115
Perphenazine..........................63
Perseris....................................78
Pertzye...................................125
Phenelzine Sulfate..................61
Phenobarbital......................... 58
Phenoxybenzamine HCl.........94
Phenytek................................. 60
Phenytoin................................ 60
Phenytoin Sodium Extended
...............................................60
Phoslyra................................ 120
Picato.................................... 115
Pifeltro..................................... 82
Pilocarpine HCl............ 108, 148
Pimecrolimus........................113
Pimozide..................................77
Pimtrea.................................. 133
Pindolol................................... 97
Pioglitazone HCl..................... 88
Pioglitazone HCl-Glimepiride
...............................................88
Pioglitazone HCl-Metformin HCl
...............................................88
Piperacillin-Tazobactam.........52
Piqray................................ 72, 73
Pirmella 1/35........................ 133
Piroxicam................................ 41
Plaquenil..................................75
Plasma-Lyte 148................... 118
Plasma-Lyte A....................... 118
Plavix....................................... 94
Plegridy................................. 107
Plenamine............................. 118
Plenvu....................................122
Pliaglis..................................... 46
Podofilox............................... 115
Polymyxin B Sulfate................49
Polymyxin B-Trimethoprim
.............................................146
Polytrim................................. 146
Pomalyst..................................69
Portia-28................................ 133
Posaconazole......................... 65
Potassium Chloride..............119
Potassium Chloride CR....... 118
Potassium Chloride ER........118
31
Potassium Chloride in Dextrose
.............................................118
Potassium Chloride in NaCl
.................................... 118, 119
Potassium Citrate ER........... 119
Pradaxa................................... 92
Praluent................................. 103
Pramipexole Dihydrochloride
...............................................76
Pramipexole Dihydrochloride
ER..........................................76
Prasugrel HCl..........................94
Pravastatin Sodium.............. 102
Praziquantel............................ 74
Prazosin HCl........................... 94
Pred Forte............................. 147
Pred Mild...............................148
Pred-G................................... 145
Pred-G S.O.P.........................145
Prednicarbate....................... 113
Prednisolone.........................127
Prednisolone Acetate...........148
Prednisolone Sodium
Phosphate.................. 127, 148
Prednisolone Sodium
Phosphate ODT..................127
Prednisone................... 127, 128
Prednisone Intensol............. 127
Pregabalin.............................107
Pregabalin ER.......................107
Premarin................................133
Premasol............................... 119
Pretomanid..............................68
Prevacid................................ 123
Prevacid SoluTab................. 123
Prevalite.................................103
Previfem................................ 133
Prevymis..................................80
Prezcobix................................ 84
Prezista....................................84
Priftin....................................... 68
Prilosec..................................123
Primaquine Phosphate...........75
Primaxin IV.............................. 53
Primidone................................58
Prinivil...................................... 95
Pristiq.......................................62
Privigen................................. 138
ProAir HFA............................ 152
ProAir RespiClick................. 152
Probenecid..............................66
Probenecid-Colchicine...........66
Procalamine..........................119
Procardia XL........................... 97
ProCentra..............................105
Prochlorperazine.................... 63
Prochlorperazine Maleate......63
Procrit...................................... 93
Procto-Med HC.....................143
Procto-Pak.............................143
Proctosol HC.........................143
Proctozone-HC..................... 143
Procysbi................................ 125
Progesterone........................ 135
Proglycem............................... 89
Prograf.......................... 140, 141
Prolastin-C.............................125
Prolate..................................... 46
Prolensa................................ 148
Prolia..................................... 144
Promacta.................................93
Promethazine HCl.................. 64
Prometrium........................... 135
Propafenone HCl....................96
Propafenone HCl ER..............96
Proparacaine HCl................. 145
Propranolol HCl...................... 97
Propranolol HCl ER................ 97
Propylthiouracil.....................137
ProQuad................................142
Proscar.................................. 126
Prosol.................................... 119
Protonix................................. 123
Protopic.................................113
Protriptyline HCl......................63
Proventil HFA........................152
Provera.................................. 135
Provigil...................................155
Prozac......................................62
PRUDOXIN............................113
Psorcon................................. 113
Pulmicort...............................150
Pulmicort Flexhaler.............. 150
Pulmozyme........................... 152
Purixan.................................... 70
Pylera.....................................122
Pyrazinamide.......................... 68
Pyridostigmine Bromide........ 68
Pyridostigmine Bromide ER
...............................................68
Pyrimethamine........................75
Q
Qbrelis..................................... 95
Qbrexza................................. 115
32
Qinlock.................................... 69
Qnasl..................................... 151
Qnasl Childrens.................... 150
Qtern........................................88
Quadracel............................. 142
Qualaquin................................75
Quartette............................... 133
Qudexy XR.............................. 57
Questran................................103
Questran Light...................... 103
Quetiapine Fumarate..............78
Quetiapine Fumarate ER........78
QuilliChew ER.......................106
Quillivant XR......................... 106
Quinapril HCl...........................95
Quinapril-Hydrochlorothiazide
.............................................100
Quinidine Gluconate ER........ 96
Quinidine Sulfate.................... 96
Quinine Sulfate....................... 75
QVAR RediHaler...................151
R
RabAvert............................... 142
Rabeprazole Sodium........... 123
Raloxifene HCl......................135
Ramelteon.............................155
Ramipril................................... 95
Ranexa.................................. 100
Ranolazine ER...................... 100
Rapaflo..................................126
Rapamune............................ 141
Rasagiline Mesylate............... 76
Rasuvo.................................. 141
RAVICTI.................................125
Rayaldee............................... 144
Rayos.....................................128
Razadyne ER.......................... 60
Rebif...................................... 108
Rebif Rebidose.....................108
Rebif Rebidose Titration Pack
.............................................108
Rebif Titration Pack..............108
Reclipsen.............................. 133
Recombivax HB....................142
Rectiv.....................................104
RediTrex................................141
Reglan..................................... 64
Regranex...............................115
Relafen DS.............................. 41
Relenza Diskhaler...................85
Relexxii..................................106
Relistor.................................. 121
Relpax......................................66
Reltone..................................122
Remeron..................................61
Remeron SolTab.................... 61
Renagel................................. 120
Renvela................................. 120
Repaglinide.............................88
Repatha.................................103
Repatha Pushtronex System
.............................................103
Repatha SureClick............... 103
Restasis Single-Use Vials.....145
Restoril.................................. 155
Retacrit.................................... 93
Retevmo.................................. 70
Retin-A...................................109
Retin-A Micro........................ 109
Retin-A Micro Pump.............110
Retrovir....................................83
Revatio.................................. 153
Revlimid...................................69
Rexulti......................................78
Reyataz....................................84
Reyvow.................................... 67
Rhofade.................................110
Rhopressa.............................148
Ribavirin.................................. 81
Ridaura..................................138
Rifabutin.................................. 68
Rifampin.................................. 68
Rilutek................................... 106
Riluzole..................................106
Rimantadine HCl.................... 85
Rinvoq................................... 138
Riomet..................................... 88
Risedronate Sodium............ 144
Risperdal................................. 79
Risperdal Consta....................78
Risperidone.............................79
Risperidone ODT....................79
Ritalin.....................................106
Ritalin LA...............................106
Ritonavir.................................. 84
Rivastigmine........................... 60
Rivastigmine Tartrate............. 60
Rivelsa................................... 133
Rizatriptan Benzoate..............67
Rizatriptan Benzoate ODT..... 67
Rocaltrol................................144
Rocklatan.............................. 145
Ropinirole HCl........................ 76
33
Ropinirole HCl ER.................. 76
Rosuvastatin Calcium.......... 102
Roszet................................... 103
Rotarix................................... 142
RotaTeq.................................142
Rowasa..................................143
Roweepra................................57
Roxicodone.............................46
Rozerem................................155
Rozlytrek................................. 73
Rubraca...................................73
Ruconest...............................137
Rufinamide..............................60
Rukobia................................... 84
Ruzurgi.................................. 106
Rybelsus..................................88
Rydapt..................................... 73
Rytary.......................................76
Rythmol SR............................. 96
S
Sabril........................................59
Safyral....................................133
Saizen....................................128
Saizenprep............................128
Salagen................................. 108
Samsca..................................120
Sancuso.................................. 64
Sandimmune........................ 141
Sandostatin...........................137
Santyl.....................................115
Saphris.................................... 79
Sapropterin Dihydrochloride
.............................................125
Savaysa................................... 92
Savella................................... 107
Savella Titration Pack...........107
Scopolamine...........................64
Seasonique........................... 133
Secuado.................................. 79
Segluromet..............................88
Selegiline HCl......................... 76
Selenium Sulfide.................. 113
Selzentry..................................84
Semglee.................................. 91
Sensipar................................ 144
Serevent Diskus....................152
Seroquel..................................79
Seroquel XR............................79
Serostim................................ 129
Sertraline HCl..........................62
Setlakin..................................133
Sevelamer Carbonate.......... 120
Sevelamer HCl......................120
Seysara....................................55
Sharobel................................135
Shingrix................................. 142
Signifor.................................. 137
Siklos....................................... 93
Sildenafil Citrate................... 153
Silenor................................... 155
Siliq........................................138
Silodosin............................... 126
Silvadene...............................115
Silver Sulfadiazine................ 115
Simbrinza.............................. 149
Simponi................................. 141
Simvastatin............................102
Sinemet................................... 76
Singulair................................ 151
Sirolimus............................... 141
Sirturo......................................68
Sitavig...................................... 81
Sivextro....................................49
Skyrizi.................................... 138
Skyrizi Pen............................ 138
Slynd......................................135
Sodium Chloride.................. 119
Sodium Fluoride................... 119
Sodium Phenylbutyrate........125
Sodium Polystyrene Sulfonate
.............................................120
Sofosbuvir-Velpatasvir............81
Solifenacin Succinate.......... 126
Soliqua.................................... 88
Solodyn................................... 55
Solosec....................................49
Soltamox................................. 69
Somavert............................... 137
Soolantra...............................115
Soriatane...............................110
Sorilux................................... 115
Sorine...................................... 96
Sotalol HCl.............................. 96
Sotalol HCl AF.........................96
Sotylize.................................... 96
Sovaldi.....................................81
Spinosad............................... 115
Spiriva HandiHaler............... 151
Spiriva Respimat.................. 151
Spironolactone..................... 101
Spironolactone-HCTZ.......... 100
Sporanox.................................65
34
Sprintec 28............................133
Spritam ODT........................... 57
Sprix.........................................41
Sprycel.....................................73
SPS........................................120
Sronyx................................... 133
SSD........................................115
Stalevo 100............................. 75
Stalevo 125............................. 75
Stalevo 150............................. 75
Stalevo 200............................. 75
Stalevo 50................................75
Stalevo 75................................75
Steglatro..................................88
Steglujan................................. 88
Stelara................................... 139
Stiolto Respimat................... 154
Stivarga....................................73
Strattera.................................106
Streptomycin Sulfate..............47
Stribild..................................... 82
Striverdi Respimat................152
Stromectol...............................74
Suboxone................................ 47
Subsys.....................................46
Sucraid.................................. 125
Sucralfate..............................123
Sular.........................................97
Sulfacetamide Sodium........117,
146, 147
Sulfacetamide-Prednisolone
.............................................145
Sulfadiazine.............................54
Sulfamethoxazole-
Trimethoprim........................54
Sulfamylon............................ 117
Sulfasalazine.........................143
Sulindac.................................. 41
Sumatriptan.............................67
Sumatriptan Succinate...........67
Sumatriptan Succinate Refill
...............................................67
Sumatriptan-Naproxen Sodium
...............................................67
Sunosi....................................155
Suprax..................................... 51
Suprep Bowel Prep Kit.........122
Sustiva..................................... 82
Sutab..................................... 122
Sutent...................................... 73
Syeda.....................................134
Symbicort..............................155
Symbyax..................................61
Symdeko............................... 152
Symfi........................................83
Symfi Lo.................................. 82
Symjepi..................................152
SymlinPen 120........................88
SymlinPen 60..........................88
Sympazan................................59
Symproic............................... 121
Symtuza...................................84
Synalar...................................113
Synarel.................................. 137
Syndros................................... 64
Synjardy...................................88
Synjardy XR.............................88
Synribo.................................... 70
Synthroid...............................136
Syprine.................................. 120
T
Tabloid.....................................70
Tabrecta.................................. 69
Taclonex................................115
Tacrolimus....................113, 141
Tadalafil........................ 126, 153
Tafinlar.....................................73
Tagrisso...................................73
Takhzyro................................137
Talicia.................................... 122
Taltz....................................... 139
Talzenna..................................73
Tamiflu.....................................85
Tamoxifen Citrate................... 69
Tamsulosin HCl.................... 126
Tapazole................................137
TaperDex 12-Day..................128
TaperDex 6-Day.................... 128
TaperDex 7-Day.................... 128
Tarceva....................................73
TARGADOX............................ 55
Targretin............................73, 74
Tarina 24 Fe..........................134
Tarina Fe 1/20 EQ................ 134
Tasigna....................................73
Tasmar.....................................75
Tavaborole............................ 117
Tavalisse..................................94
Tazarotene............................ 110
Tazicef..................................... 51
Tazorac..................................110
Taztia XT..................................98
Tazverik................................... 70
TDVAX................................... 142
35
Tecfidera............................... 108
Tecfidera Starter Pack......... 108
Teflaro..................................... 51
Tegretol................................... 60
Tegretol XR............................. 60
Tegsedi..................................125
Tekturna................................ 100
Tekturna HCT....................... 100
Telmisartan............................. 95
Telmisartan-Amlodipine.......100
Telmisartan-HCTZ................ 100
Temazepam.......................... 155
Temixys................................... 83
Temovate.............................. 113
Tenivac..................................142
Tenofovir Disoproxil Fumarate
...............................................83
Tenoretic 100........................100
Tenoretic 50..........................100
Tenormin................................. 97
Tepmetko................................ 73
Terazosin HCl....................... 126
Terbinafine HCl.......................65
Terbutaline Sulfate............... 152
Terconazole............................ 65
Teriparatide...........................144
Testim....................................129
Testosterone.........................129
Testosterone Cypionate.......129
Testosterone Enanthate.......129
Testosterone Pump..............129
Tetrabenazine.......................106
Tetracycline HCl..................... 55
Texacort................................ 113
Thalomid................................. 69
Theo-24................................. 153
Theophylline......................... 153
Theophylline ER................... 153
Thiola.....................................127
Thiola EC...............................127
Thioridazine HCl..................... 77
Thiothixene............................. 77
Thyquidity............................. 136
Tiadylt ER................................ 98
Tiagabine HCl......................... 59
Tiazac...................................... 98
Tibsovo....................................73
Tigecycline..............................49
Tiglutik...................................106
Tikosyn.................................... 96
Tilia Fe................................... 134
Timolol Maleate..............68, 148
Timolol Maleate Ophthalmic
Gel Forming........................148
Timolol Maleate PF.............. 148
Timoptic Ocudose................148
Timoptic-XE...........................148
Tinidazole................................49
Tiopronin...............................127
Tirosint.................................. 136
Tirosint-SOL.......................... 136
Tivicay......................................82
Tivicay PD............................... 82
Tizanidine HCl.........................80
TOBI...................................... 152
TOBI Podhaler...................... 152
TobraDex.............................. 145
TobraDex ST.........................145
Tobramycin...................147, 152
Tobramycin Sulfate................ 47
Tobramycin-Dexamethasone
.............................................145
Tobrex................................... 147
Tolcapone............................... 75
Tolsura.....................................65
Tolterodine Tartrate............. 126
Tolterodine Tartrate ER....... 126
Tolvaptan.............................. 120
Topamax................................. 57
Topamax Sprinkle.................. 57
Topicort.................................113
Topicort Spray...................... 113
Topiramate..............................57
Topiramate ER........................57
Toprol XL.................................97
Toremifene Citrate..................69
Torsemide.............................101
Tosymra...................................67
Toujeo Max SoloStar..............91
Toujeo SoloStar...................... 91
Tovet......................................113
Toviaz.................................... 126
TPN Electrolytes................... 119
Tracleer................................. 153
Tradjenta................................. 88
Tramadol HCl..........................46
Tramadol HCl ER....................44
Tramadol-Acetaminophen..... 46
Trandolapril.............................95
Trandolapril-Verapamil HCl ER
.............................................100
Tranexamic Acid.....................94
Transderm-Scop.....................64
36
Tranxene-T.............................. 85
Tranylcypromine Sulfate........ 61
Travasol.................................119
Travatan Z............................. 149
Travoprost.............................149
Trazodone HCl........................62
Trecator...................................68
Trelegy Ellipta....................... 155
Trelstar Mixject..................... 137
Tremfya................................. 139
Tresiba.....................................91
Tresiba FlexTouch..................91
Tretinoin..........................74, 110
Tretinoin Microsphere..........110
Trexall....................................141
Treximet.................................. 67
Trezix....................................... 46
Tri-Estarylla............................134
Tri-Legest Fe......................... 134
Tri-Lo-Estarylla...................... 134
Tri-Lo-Sprintec...................... 134
Tri-Mili....................................134
Tri-Nymyo..............................134
Tri-Previfem...........................134
Tri-Sprintec............................134
Tri-VyLibra.............................134
Tri-VyLibra Lo........................134
Triamcinolone Acetonide... 108,
113, 114
Triamterene...........................101
Triamterene-HCTZ................100
Trianex...................................114
Tribenzor...............................100
Tricor..................................... 102
Triderm..................................114
Trientine HCl.........................120
Trifluoperazine HCl.................77
Trifluridine.............................147
Trihexyphenidyl HCl............... 75
Trijardy XR...............................88
Trikafta.................................. 153
Trileptal....................................60
Trilipix....................................102
TriLyte....................................122
Trimethobenzamide HCl........64
Trimethoprim.......................... 49
Trimipramine Maleate............ 63
Trintellix................................... 63
Triumeq................................... 83
Trivora................................... 134
Trizivir...................................... 83
Trokendi XR............................ 57
TrophAmine.......................... 119
Trospium Chloride............... 126
Trospium Chloride ER......... 126
Trulance................................ 121
Trulicity....................................88
Trumenba..............................142
Trusopt.................................. 149
Truvada................................... 83
Tudorza Pressair.................. 151
Tukysa..................................... 70
Turalio......................................73
Twinrix................................... 142
Twynsta................................. 100
Tybost......................................84
Tydemy..................................134
Tygacil..................................... 49
Tykerb......................................73
Tymlos...................................144
Typhim Vi.............................. 142
U
Ubrelvy.................................... 67
Uceris.................................... 143
Udenyca.................................. 93
Ukoniq..................................... 73
Uloric....................................... 66
Ultracet.................................... 46
Ultram...................................... 46
Ultravate................................ 114
Unasyn.....................................52
Unithroid............................... 136
Uptravi................................... 153
Urocit-K 10............................ 119
Urocit-K 15............................ 119
Urocit-K 5.............................. 119
Uroxatral................................126
Urso 250................................122
Urso Forte............................. 122
Ursodiol.................................122
V
Vabomere................................53
Vagifem................................. 134
Valacyclovir HCl......................81
Valchlor................................... 69
Valcyte.....................................80
Valganciclovir HCl.................. 80
Valium......................................86
Valproic Acid...........................57
Valsartan..................................95
Valsartan-Hydrochlorothiazide
.............................................100
Valtoco 10 MG Dose.............. 59
37
Valtoco 15 MG Dose.............. 59
Valtoco 20 MG Dose.............. 59
Valtoco 5 MG Dose................ 59
Valtrex......................................81
Vancocin................................. 49
Vancocin HCl.......................... 49
Vancomycin HCl..................... 49
Vandazole................................49
Vanos.....................................114
VAQTA...................................142
Varivax...................................142
Varizig....................................138
Varubi...................................... 64
Vascepa................................ 103
Vaseretic............................... 100
Vasotec....................................95
Vecamyl.................................100
Vectical..................................115
Velivet.................................... 134
Velphoro................................120
Veltassa.................................120
Veltin......................................110
Vemlidy....................................81
Venclexta.................................73
Venclexta Starting Pack.........73
Venlafaxine HCl...................... 63
Venlafaxine HCl ER................ 63
Ventavis.................................153
Ventolin HFA.........................152
Verapamil HCl.........................98
Verapamil HCl ER...................98
Verdeso................................. 114
Veregen.................................115
Verelan.................................... 98
Verelan PM..............................98
Verquvo................................. 104
Versacloz.................................80
Verzenio.................................. 73
Vesicare.................................126
Vesicare LS...........................126
Vestura.................................. 134
Vfend....................................... 65
Vfend IV................................... 65
Viberzi....................................121
Vibramycin.............................. 55
Victoza.....................................88
Viekira Pak.............................. 81
Vienva....................................134
Vigabatrin................................ 59
Vigadrone................................59
Vigamox................................ 147
Viibryd......................................63
Viibryd Starter Pack................63
Vimovo.....................................41
Vimpat..................................... 60
Viokace..................................125
Viracept................................... 84
Viramune................................. 83
Viramune XR........................... 83
Viread...................................... 83
Vistaril...................................... 85
Vitrakvi.....................................73
Vivelle-Dot............................. 134
Vivitrol......................................47
Vivlodex................................... 41
Vizimpro.................................. 73
Vogelxo................................. 129
Vogelxo Pump...................... 129
Voriconazole.....................65, 66
Vosevi...................................... 81
Votrient.................................... 73
VP-PNV-DHA......................... 120
Vraylar......................................79
Vumerity................................ 108
Vyfemla..................................134
VyLibra.................................. 134
Vyndamax............................. 125
Vyndaqel............................... 125
Vytorin................................... 103
Vyvanse................................. 105
Vyzulta................................... 149
W
Wakix.....................................156
Warfarin Sodium.....................92
Welchol................................. 103
Wellbutrin SR.......................... 61
Wellbutrin XL...........................61
Wixela Inhub......................... 155
WYMZYA Fe..........................134
X
Xalatan...................................149
Xalkori......................................73
Xanax.......................................86
Xanax XR.................................86
Xarelto..................................... 92
Xarelto Starter Pack............... 92
Xatmep.................................. 141
Xcopri................................ 57, 58
Xeljanz................................... 139
Xeljanz XR............................. 139
Xelpros.................................. 149
Xenazine................................106
38
Xenleta.....................................49
Xepi........................................117
Xerese................................... 115
Xermelo................................. 121
Xgeva.....................................144
Xhance.................................. 151
Xifaxan.....................................49
Xigduo XR............................... 88
Xiidra..................................... 145
Xofluza.....................................85
Xolair......................................139
Xolegel...................................117
Xopenex................................ 152
Xopenex Concentrate.......... 152
Xopenex HFA........................152
Xospata................................... 73
Xpovio......................................70
Xtampza ER............................ 44
Xtandi.......................................69
Xulane....................................134
Xultophy.................................. 88
Xuriden.................................. 125
Xyosted................................. 130
Xyrem.................................... 156
Xywav.................................... 155
Y
Yasmin 28............................. 134
YAZ........................................134
YF-Vax....................................142
Yonsa.......................................69
Yupelri................................... 151
Yuvafem................................ 134
Z
Zafemy.................................. 134
Zafirlukast............................. 151
Zaleplon................................ 155
Zanaflex...................................80
Zarah..................................... 134
Zarontin................................... 58
Zarxio.......................................93
Zavesca................................. 125
Zegerid.................................. 123
Zejula.......................................73
Zelapar ODT........................... 76
Zelboraf................................... 73
Zemaira................................. 125
Zembrace SymTouch.............67
Zemdri..................................... 47
Zemplar................................. 144
Zenatane............................... 110
Zenpep..................................125
Zenzedi..................................105
Zepatier................................... 81
Zeposia..................................108
Zeposia 7-Day Starter Pack
.............................................108
Zeposia Starter Kit................108
Zerbaxa................................... 51
Zerviate..................................146
Zestoretic.............................. 100
Zestril.......................................95
Zetia.......................................103
Zetonna................................. 151
Ziac........................................100
Ziagen......................................83
Ziana......................................110
Zidovudine.............................. 83
Ziextenzo.................................94
Zileuton ER........................... 151
Zilxi........................................ 117
Zioptan.................................. 149
Ziprasidone HCl......................79
Ziprasidone Mesylate.............79
Zipsor...................................... 41
Zirgan...................................... 80
Zithromax................................ 53
Zithromax Tri-Pak................... 53
Zithromax Z-Pak..................... 53
Zocor..................................... 102
Zolinza..................................... 70
Zolmitriptan.............................67
Zolmitriptan ODT....................67
Zoloft....................................... 63
Zolpidem Tartrate.................155
Zomacton..............................129
Zomig...................................... 67
Zomig ZMT..............................67
Zonalon................................. 114
Zonegran.................................60
Zonisamide............................. 60
Zontivity................................... 92
Zorbtive................................. 129
Zortress................................. 141
Zorvolex...................................42
Zosyn.......................................52
Zovia 1/35E...........................134
Zovirax.....................................82
ZTlido...................................... 46
Zubsolv....................................47
Zuplenz....................................64
Zyclara Pump........................115
Zydelig.....................................73
39
Zyflo.......................................151
Zykadia....................................73
Zylet.......................................145
Zyloprim.................................. 66
Zymaxid.................................147
Zypitamag............................. 102
Zyprexa....................................79
Zyprexa Relprevv....................80
Zyprexa Zydis......................... 80
Zytiga.......................................69
Zyvox....................................... 49
40
Covered drugs by medical condition
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 12-39.
The first column lists the drug name, which may include the dosage form and strength. Brand
name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain
type (for example, Simvastatin). The 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 157-202.
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
A1
AnalgesicsB1
Nonsteroidal Anti-inflammatory DrugsC1
Arth
rote
c
Arthrotec (Oral Tablet Delayed Release) B 3
C1
Cam
bia
Cambia (Oral Packet) B 4
C1
Cele
brex
Celebrex (Oral Capsule) B 3 QL C1
Cele
coxi
b
Celecoxib (Oral Capsule) G 2 QL C1
Day
pro
Daypro (Oral Tablet) B 3
C1
Dicl
ofen
ac
Epol
ami
ne Diclofenac Epolamine (External Patch) G 3 PA; QL C1
Dicl
ofen
ac
Pota
ssiu
m Diclofenac Potassium (Oral Tablet) G 2
C1
Dicl
ofen
ac
Sodi
um
ER Diclofenac Sodium ER (Oral Tablet Extended Release 24
Hour)G 1
C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (1% External Gel) G 2
C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (External Solution) G 2 PA C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (Oral Tablet Delayed Release) G 1
C1
Dicl
ofen
ac-
Mis
opr
osto
l Diclofenac-Misoprostol (Oral Tablet Delayed Release) G 3
C1
Diflu
nisal
Diflunisal (Oral Tablet) G 2
C1
Due
xis
Duexis (Oral Tablet) B 4 ST C1
Eto
dola
c
ER
Etodolac ER (Oral Tablet Extended Release 24 Hour) G 3
C1
Eto
dola
c
Etodolac (Oral Capsule) G 2
C1
Eto
dola
c
Etodolac (Oral Tablet Immediate Release) G 2
C1
Feld
ene
Feldene (Oral Capsule) B 3
C1
Fen
opr
ofen
Calc
ium Fenoprofen Calcium (400MG Oral Capsule) G 3
C1
Fen
opr
ofen
Calc
ium Fenoprofen Calcium (Oral Tablet) G 3
C1
Flec
tor
Flector (External Patch) B 3 PA; QL C1
Flur
bipr
ofen
Flurbiprofen (100MG Oral Tablet) G 2
C1
Ibu
Ibu (600MG Oral Tablet, 800MG Oral Tablet) G 1
C1
Ibup
rofe
n
Ibuprofen (Oral Suspension) G 1
You can find information on what the abbreviations in this table mean on pages 6 - 7.
41Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Ibup
rofe
n
Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet,
800MG Oral Tablet)G 1
C1
Indo
cin
Indocin (Rectal Suppository) G 4
C1
Ket
opr
ofen
ER
Ketoprofen ER (Oral Capsule Extended Release 24
Hour)G 3
C1
Ket
opr
ofen
Ketoprofen (Oral Capsule Immediate Release) G 2
C1
Ket
orol
ac
Tro
met
ham
ine Ketorolac Tromethamine (Nasal Solution) G 4 LA C1
Lica
rt
Licart (External Patch 24 Hour) B 3 PA; QL C1
Lodi
ne
Lodine (Oral Tablet) G 4
C1
Mec
lofe
nam
ate
Sodi
um Meclofenamate Sodium (Oral Capsule) G 3
C1
Mef
ena
mic
Acid
Mefenamic Acid (Oral Capsule) G 3
C1
Mel
oxic
am
Meloxicam (Oral Capsule) G 3 QL C1
Mel
oxic
am
Meloxicam (Oral Tablet) G 1
C1
Mob
ic
Mobic (Oral Tablet) B 3
C1
Nab
ume
tone
Nabumetone (Oral Tablet) G 2
C1
Nalf
on
Nalfon (Oral Capsule) B 3
C1
Nalf
on
Nalfon (Oral Tablet) G 3
C1
Nap
rela
n
Naprelan (Oral Tablet Extended Release 24 Hour) B 4
C1
Nap
roxe
n
Naproxen (Oral Suspension) G 4
C1
Nap
roxe
n
Naproxen (Oral Tablet Immediate Release) G 1
C1
Nap
roxe
n
DR
Naproxen DR (Oral Tablet Delayed Release) (Generic
EC-Naprosyn)G 1
C1
Nap
roxe
n
Sodi
um
ER Naproxen Sodium ER (375MG Oral Tablet Extended
Release 24 Hour) (Generic Naprelan)G 4
C1
Nap
roxe
n
Sodi
um
ER Naproxen Sodium ER (500MG Oral Tablet Extended
Release 24 Hour) (Generic Naprelan)G 3
C1
Nap
roxe
n
Sodi
um Naproxen Sodium (275MG Oral Tablet Immediate
Release, 550MG Oral Tablet Immediate Release)G 2
C1
Nap
roxe
n-
Eso
mep
razo
le Naproxen-Esomeprazole (Oral Tablet Delayed Release) G 4 ST C1
Oxa
proz
in
Oxaprozin (Oral Tablet) G 3
C1
Pen
nsai
d
Pennsaid (External Solution) B 4 PA C1
Piro
xica
m
Piroxicam (Oral Capsule) G 2
C1
Rela
fen
DS
Relafen DS (Oral Tablet) G 4 ST C1
Spri
x
Sprix (Nasal Solution) B 4 LA C1
Suli
nda
c
Sulindac (Oral Tablet) G 1
C1
Vim
ovo
Vimovo (Oral Tablet Delayed Release) B 4 ST C1
Vivl
ode
x
Vivlodex (Oral Capsule) B 4 QL C1
Zips
or
Zipsor (Oral Capsule) B 4 ST
42 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Zorv
olex
Zorvolex (Oral Capsule) B 3 ST B1
Opioid Analgesics, Long-actingC1
Belb
uca
Belbuca (150MCG Buccal Film, 300MCG Buccal Film,
450MCG Buccal Film, 75MCG Buccal Film)B 3 PA; 7D; DL; QL
C1
Belb
uca
Belbuca (600MCG Buccal Film, 750MCG Buccal Film,
900MCG Buccal Film)B 4 PA; 7D; DL; QL
C1
Bup
reno
rphi
ne
Buprenorphine (Transdermal Patch Weekly) G 2 7D; DL; QL C1
Butr
ans
Butrans (Transdermal Patch Weekly) B 2 7D; DL; QL C1
Con
Zip
ConZip (Oral Capsule Extended Release 24 Hour) B 3 7D; MME; DL; QL C1
Fent
anyl
Fentanyl (100MCG/HR Transdermal Patch 72 Hour,
37.5MCG/HR Transdermal Patch 72 Hour, 62.5MCG/HR
Transdermal Patch 72 Hour, 75MCG/HR Transdermal
Patch 72 Hour)
G 3 7D; MME; DL; QL
C1
Fent
anyl
Fentanyl (12MCG/HR Transdermal Patch 72 Hour,
25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR
Transdermal Patch 72 Hour)
G 2 7D; MME; DL; QL
C1
Fent
anyl
Fentanyl (87.5MCG/HR Transdermal Patch 72 Hour) G 4 7D; MME; DL; QL C1
Hyd
roco
don
e
Bitar
trate
ER Hydrocodone Bitartrate ER (10MG Oral Capsule
Extended Release 12 Hour, 15MG Oral Capsule
Extended Release 12 Hour, 20MG Oral Capsule
Extended Release 12 Hour, 30MG Oral Capsule
Extended Release 12 Hour, 40MG Oral Capsule
Extended Release 12 Hour, 50MG Oral Capsule
Extended Release 12 Hour)
G 3 7D; MME; DL; QL
C1
Hyd
roco
don
e
Bitar
trate
ER Hydrocodone Bitartrate ER (100MG Oral Tablet ER 24
Hour Abuse-Deterrent, 120MG Oral Tablet ER 24 Hour
Abuse-Deterrent)
G 4PA; 7D; MME; DL;
QL C1
Hyd
roco
don
e
Bitar
trate
ER Hydrocodone Bitartrate ER (20MG Oral Tablet ER 24
Hour Abuse-Deterrent, 30MG Oral Tablet ER 24 Hour
Abuse-Deterrent, 40MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 60MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 80MG Oral Tablet ER 24 Hour Abuse-
Deterrent)
G 3PA; 7D; MME; DL;
QL
C1
Hyd
rom
orph
one
HCl
ER Hydromorphone HCl ER (Oral Tablet Extended Release
24 Hour)G 3 7D; MME; DL; QL
C1
Hysi
ngla
ER
Hysingla ER (100MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 120MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 60MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 80MG Oral Tablet ER 24 Hour Abuse-
Deterrent)
B 4PA; 7D; MME; DL;
QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
43Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Hysi
ngla
ER
Hysingla ER (20MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 30MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 40MG Oral Tablet ER 24 Hour Abuse-
Deterrent)
B 3PA; 7D; MME; DL;
QL
C1
Lev
orph
anol
Tartr
ate Levorphanol Tartrate (Oral Tablet) G 4 7D; MME; DL; QL C1
Met
had
one
HCl
Methadone HCl (Oral Solution) G 1 7D; MME; DL; QL C1
Met
had
one
HCl
Methadone HCl (Oral Tablet) G 1 7D; MME; DL; QL C1
Mor
phin
e
Sulf
ate
ER
Bea
ds Morphine Sulfate ER Beads (Oral Capsule Extended
Release 24 Hour) (Generic Avinza)G 3 7D; MME; DL; QL
C1
Mor
phin
e
Sulf
ate
ER Morphine Sulfate ER (100MG Oral Capsule Extended
Release 24 Hour) (Generic Kadian)G 4 7D; MME; DL; QL
C1
Mor
phin
e
Sulf
ate
ER Morphine Sulfate ER (10MG Oral Capsule Extended
Release 24 Hour, 20MG Oral Capsule Extended Release
24 Hour, 30MG Oral Capsule Extended Release 24
Hour, 40MG Oral Capsule Extended Release 24 Hour,
50MG Oral Capsule Extended Release 24 Hour, 60MG
Oral Capsule Extended Release 24 Hour, 80MG Oral
Capsule Extended Release 24 Hour) (Generic Kadian)
G 3 7D; MME; DL; QL
C1
Mor
phin
e
Sulf
ate
ER 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 2 7D; MME; DL; QL
C1
Mor
phin
e
Sulf
ate
ER Morphine Sulfate ER (200MG Oral Tablet Extended
Release) (Generic MS Contin)G 3 7D; MME; DL; QL
C1
MS
Con
tin
MS Contin (100MG Oral Tablet Extended Release,
200MG Oral Tablet Extended Release, 30MG Oral
Tablet Extended Release, 60MG Oral Tablet Extended
Release)
B 4 7D; MME; DL; QL
C1
MS
Con
tin
MS Contin (15MG Oral Tablet Extended Release) B 3 7D; MME; DL; QL C1
Nuc
ynta
ER
Nucynta ER (Oral Tablet Extended Release 12 Hour) B 2 7D; MME; DL; QL C1
Oxy
cod
one
HCl
ER Oxycodone HCl ER (10MG Oral Tablet ER 12 Hour
Abuse-Deterrent, 15MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 20MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 30MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 40MG Oral Tablet ER 12 Hour Abuse-
Deterrent)
G 3 7D; MME; DL; QL
C1
Oxy
cod
one
HCl
ER Oxycodone HCl ER (60MG Oral Tablet ER 12 Hour
Abuse-Deterrent, 80MG Oral Tablet ER 12 Hour Abuse-
Deterrent)
G 4 7D; MME; DL; QL
44 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Oxy
Con
tin
OxyContin (10MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 15MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 20MG Oral Tablet ER 12 Hour Abuse-
Deterrent)
B 3PA; 7D; MME; DL;
QL
C1
Oxy
Con
tin
OxyContin (30MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 40MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 60MG Oral Tablet ER 12 Hour Abuse-
Deterrent, 80MG Oral Tablet ER 12 Hour Abuse-
Deterrent)
B 4PA; 7D; MME; DL;
QL
C1
Oxy
mor
pho
ne
HCl
ER Oxymorphone HCl ER (Oral Tablet Extended Release 12
Hour)G 3 7D; MME; DL; QL
C1
Tra
mad
ol
HCl
ER Tramadol HCl ER (Biphasic) (100MG Oral Tablet
Extended Release 24 Hour, 200MG Oral Tablet
Extended Release 24 Hour)
G 2 7D; MME; DL; QL
C1
Tra
mad
ol
HCl
ER Tramadol HCl ER (Biphasic) (300MG Oral Tablet
Extended Release 24 Hour)G 3 7D; MME; DL; QL
C1
Tra
mad
ol
HCl
ER Tramadol HCl ER (100MG Oral Capsule Extended
Release 24 Hour, 200MG Oral Capsule Extended
Release 24 Hour, 300MG Oral Capsule Extended
Release 24 Hour)
G 3 7D; MME; DL; QL
C1
Tra
mad
ol
HCl
ER Tramadol HCl ER (100MG Oral Tablet Extended Release
24 Hour, 200MG Oral Tablet Extended Release 24 Hour)G 2 7D; MME; DL; QL
C1
Tra
mad
ol
HCl
ER Tramadol HCl ER (300MG Oral Tablet Extended Release
24 Hour)G 3 7D; MME; DL; QL
C1
Xta
mpz
a
ER
Xtampza ER (Oral Capsule ER 12 Hour Abuse-
Deterrent)B 2 7D; MME; DL; QL
B1
Opioid Analgesics, Short-actingC1
Acet
ami
nop
hen-
Caff
eine
-
Dihy
droc
odei
ne
Acetaminophen-Caffeine-Dihydrocodeine (Oral Capsule) G 3 7D; MME; DL; QL C1
Acet
ami
nop
hen-
Caff
eine
-
Dihy
droc
odei
ne
Acetaminophen-Caffeine-Dihydrocodeine (Oral Tablet) G 3 7D; MME; DL; QL C1
Acet
ami
nop
hen-
Cod
eine Acetaminophen-Codeine (120-12MG/5ML Oral Solution) G 1 7D; MME; DL; QL C1
Acet
ami
nop
hen-
Cod
eine Acetaminophen-Codeine (300-15MG Oral Tablet,
300-30MG Oral Tablet, 300-60MG Oral Tablet)G 1 7D; MME; DL; QL
C1
Acti
q
Actiq (Buccal Lozenge On A Handle) B 4 PA; DL; QL C1
But
orph
anol
Tartr
ate Butorphanol Tartrate (Nasal Solution) G 2 7D; MME; DL; QL C1
Cod
eine
Sulf
ate Codeine Sulfate (15MG Oral Tablet) B 2 7D; MME; DL; QL C1
Cod
eine
Sulf
ate Codeine Sulfate (30MG Oral Tablet) G 2 7D; MME; DL; QL C1
Cod
eine
Sulf
ate Codeine Sulfate (60MG Oral Tablet) G 3 7D; MME; DL; QL C1
Dila
udid
Dilaudid (Oral Liquid) B 3 7D; MME; DL; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
45Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Dila
udid
Dilaudid (2MG Oral Tablet, 4MG Oral Tablet) B 3 7D; MME; DL; QL C1
Dila
udid
Dilaudid (8MG Oral Tablet) B 4 7D; MME; DL; QL C1
End
ocet
Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet,
7.5-325MG Oral Tablet)G 2 7D; MME; DL; QL
C1
Fent
anyl
Citra
te
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 4 PA; DL; QL
C1
Fent
anyl
Citra
te
Fentanyl Citrate (200MCG Buccal Lozenge On A Handle) G 3 PA; DL; QL C1
Fent
anyl
Citra
te
Fentanyl Citrate (100MCG Buccal Tablet, 200MCG
Buccal Tablet, 400MCG Buccal Tablet, 600MCG Buccal
Tablet, 800MCG Buccal Tablet)
G 4 PA; DL; QL
C1
Fent
ora
Fentora (Buccal Tablet) B 4 PA; DL; QL C1
Hyd
roco
don
e-
Acet
ami
nop
hen Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral
Solution)G 2 7D; MME; DL; QL
C1
Hyd
roco
don
e-
Acet
ami
nop
hen Hydrocodone-Acetaminophen (10-300MG Oral Tablet,
10-325MG Oral Tablet, 5-300MG Oral Tablet, 5-325MG
Oral Tablet, 7.5-300MG Oral Tablet, 7.5-325MG Oral
Tablet)
G 2 7D; MME; DL; QL
C1
Hyd
roco
don
e-
Ibup
rofe
n Hydrocodone-Ibuprofen (10-200MG Oral Tablet,
5-200MG Oral Tablet)G 3 7D; MME; DL; QL
C1
Hyd
roco
don
e-
Ibup
rofe
n Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet) G 2 7D; MME; DL; QL C1
Hyd
rom
orph
one
HCl Hydromorphone HCl (1MG/ML Oral Liquid) G 2 7D; MME; DL; QL C1
Hyd
rom
orph
one
HCl Hydromorphone HCl (2MG Oral Tablet Immediate
Release, 4MG Oral Tablet Immediate Release, 8MG Oral
Tablet Immediate Release)
G 1 7D; MME; DL; QL
C1
Hyd
rom
orph
one
HCl
Pres
erva
tive
Free Hydromorphone HCl Preservative Free (10MG/ML
Injection Solution, 50MG/5ML Injection Solution)G 3 DL
C1
Laza
nda
Lazanda (Nasal Solution) B 4 PA; DL; QL C1
Mor
phin
e
Sulf
ate Morphine Sulfate (10MG/5ML Oral Solution, 100MG/
5ML Oral Solution, 20MG/5ML Oral Solution)G 1 7D; MME; DL; QL
C1
Mor
phin
e
Sulf
ate Morphine Sulfate (Oral Tablet Immediate Release) G 2 7D; MME; DL; QL C1
Nuc
ynta
Nucynta (100MG Oral Tablet Immediate Release) B 4 7D; MME; DL; QL C1
Nuc
ynta
Nucynta (50MG Oral Tablet Immediate Release,
75MG Oral Tablet Immediate Release)B 3 7D; MME; DL; QL
C1
Oxy
cod
one
HCl
Oxycodone HCl (5MG Oral Capsule) G 2 7D; MME; DL; QL C1
Oxy
cod
one
HCl
Oxycodone HCl (100MG/5ML Oral Concentrate) G 3 7D; MME; DL; QL C1
Oxy
cod
one
HCl
Oxycodone HCl (5MG/5ML Oral Solution) G 2 7D; MME; DL; QL
46 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Oxy
cod
one
HCl
Oxycodone HCl (10MG Oral Tablet Immediate Release,
15MG Oral Tablet Immediate Release, 20MG Oral Tablet
Immediate Release, 30MG Oral Tablet Immediate
Release, 5MG Oral Tablet Immediate Release)
G 1 7D; MME; DL; QL
C1
Oxy
cod
one-
Acet
ami
nop
hen Oxycodone-Acetaminophen (10-300MG Oral Tablet,
5-300MG Oral Tablet)G 4 7D; MME; DL; QL
C1
Oxy
cod
one-
Acet
ami
nop
hen Oxycodone-Acetaminophen (10-325MG Oral Tablet,
2.5-325MG Oral Tablet, 5-325MG Oral Tablet,
7.5-325MG Oral Tablet)
G 2 7D; MME; DL; QL
C1
Oxy
mor
pho
ne
HCl Oxymorphone HCl (Oral Tablet Immediate Release) G 3 7D; MME; DL; QL C1
Perc
ocet
Percocet (10-325MG Oral Tablet, 5-325MG Oral Tablet,
7.5-325MG Oral Tablet)G 4 7D; MME; DL; QL
C1
Perc
ocet
Percocet (2.5-325MG Oral Tablet) G 3 7D; MME; DL; QL C1
Prol
ate
Prolate (Oral Tablet) G 4 7D; MME; DL; QL C1
Roxi
cod
one
Roxicodone (15MG Oral Tablet, 5MG Oral Tablet) B 3 7D; MME; DL; QL C1
Roxi
cod
one
Roxicodone (30MG Oral Tablet) B 4 7D; MME; DL; QL C1
Sub
sys
Subsys (Sublingual Liquid) B 4 PA; DL; QL C1
Tra
mad
ol
HCl
Tramadol HCl (100MG Oral Tablet Immediate Release) G 2 7D; MME; DL; QL C1
Tra
mad
ol
HCl
Tramadol HCl (50MG Oral Tablet Immediate Release) G 1 7D; MME; DL; QL C1
Tra
mad
ol-
Acet
ami
nop
hen Tramadol-Acetaminophen (Oral Tablet) G 1 7D; MME; DL; QL C1
Trez
ix
Trezix (Oral Capsule) G 3 7D; MME; DL; QL C1
Ultra
cet
Ultracet (Oral Tablet) B 3 7D; MME; DL; QL C1
Ultra
m
Ultram (Oral Tablet Immediate Release) B 3 7D; MME; DL; QL A1
AnestheticsB1
Local AnestheticsC1
Lido
cain
e
Lidocaine (5% External Ointment) G 3 QL C1
Lido
cain
e
Lidocaine (5% External Patch) G 3 PA; QL C1
Lido
cain
e
HCl
Lidocaine HCl (4% External Solution) G 2
C1
Lido
cain
e
Visc
ous Lidocaine Viscous (2% Mouth/Throat Solution) G 1
C1
Lido
cain
e-
Prilo
cain
e Lidocaine-Prilocaine (External Cream) G 2
C1
Lido
der
m
Lidoderm (External Patch) B 4 PA; QL C1
Plia
glis
Pliaglis (External Cream) B 3
C1
ZTli
do
ZTlido (External Patch) B 3 PA; QL A1
Anti-Addiction/Substance Abuse Treatment AgentsB1
Alcohol Deterrents/Anti-cravingC1
Aca
mpr
osat
e
Calc
ium Acamprosate Calcium (Oral Tablet Delayed Release) G 3
C1
Disu
lfira
m
Disulfiram (Oral Tablet) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
47Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Nalt
rexo
ne
HCl
Naltrexone HCl (Oral Tablet) G 2
C1
Vivit
rol
Vivitrol (Intramuscular Suspension Reconstituted) B 4
B1
Opioid DependenceC1
Bup
reno
rphi
ne
HCl Buprenorphine HCl (Tablet Sublingual) G 1 QL C1
Bup
reno
rphi
ne
HCl-
Nalo
xon
e
HCl Buprenorphine HCl-Naloxone HCl (Sublingual Film) G 3 QL C1
Bup
reno
rphi
ne
HCl-
Nalo
xon
e
HCl Buprenorphine HCl-Naloxone HCl (Tablet Sublingual) G 1 QL C1
Luc
emy
ra
Lucemyra (Oral Tablet) B 4 QL C1
Sub
oxo
ne
Suboxone (Sublingual Film) B 3 QL C1
Zub
solv
Zubsolv (Tablet Sublingual) B 3 QL B1
Opioid Reversal AgentsC1
Nalo
xon
e
HCl
Naloxone HCl (0.4MG/ML Injection Solution) G 1
C1
Nalo
xon
e
HCl
Naloxone HCl (Injection Solution Cartridge) G 1
C1
Nalo
xon
e
HCl
Naloxone HCl (Injection Solution Prefilled Syringe) G 1
C1
Nar
can
Narcan (Nasal Liquid) B 2
B1
Smoking Cessation AgentsC1
Bup
ropi
on
HCl
SR Bupropion HCl SR (150MG Oral Tablet Extended
Release 12 Hour Smoking-Deterrent)G 1
C1
Cha
ntix
Con
tinui
ng
Mon
th
Pak Chantix Continuing Month Pak (Oral Tablet) B 2
C1
Cha
ntix
Chantix (Oral Tablet) B 2
C1
Cha
ntix
Start
ing
Mon
th
Pak Chantix Starting Month Pak (Oral Tablet) B 2
C1
Nico
trol
Nicotrol (Inhalation Inhaler) B 3
C1
Nico
trol
NS
Nicotrol NS (Nasal Solution) B 3
A1
AntibacterialsB1
AminoglycosidesC1
Ami
kaci
n
Sulf
ate Amikacin Sulfate (500MG/2ML Injection Solution) G 2
C1
Arik
ayce
Arikayce (Inhalation Suspension) B 4 PA C1
Gen
tami
cin
Sulf
ate-
0.9
%
Sodi
um
Chlo
ride
Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous
Solution)G 1
C1
Gen
tami
cin
Sulf
ate Gentamicin Sulfate (40MG/ML Injection Solution) G 1
C1
Hu
mati
n
Humatin (Oral Capsule) G 4
C1
Neo
myci
n
Sulf
ate Neomycin Sulfate (Oral Tablet) G 1
C1
Paro
mo
myci
n
Sulf
ate Paromomycin Sulfate (Oral Capsule) G 3
C1
Stre
pto
myci
n
Sulf
ate Streptomycin Sulfate (Intramuscular Solution
Reconstituted)G 4
C1
Tob
ram
ycin
Sulf
ate Tobramycin Sulfate (10MG/ML Injection Solution,
80MG/2ML Injection Solution)G 3
C1
Zem
dri
Zemdri (Intravenous Solution) B 4
B1
Antibacterials, Other
48 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Aem
colo
Aemcolo (Oral Tablet Delayed Release) B 3 PA C1
Aza
cta
m
Azactam (Injection Solution Reconstituted) B 3
C1
Aztr
eon
am
Aztreonam (1GM Injection Solution Reconstituted) G 3
C1
Cleo
cin
Cleocin (Oral Capsule) B 3
C1
Cleo
cin
Cleocin (Oral Solution Reconstituted) G 3
C1
Cleo
cin
Pho
sph
ate Cleocin Phosphate (900MG/6ML Injection Solution) G 3
C1
Cleo
cin
Cleocin (Vaginal Cream) B 3
C1
Cleo
cin
Cleocin (Vaginal Suppository) B 3
C1
Clin
dam
ycin
HCl
Clindamycin HCl (Oral Capsule) G 1
C1
Clin
dam
ycin
Pal
mita
te
HCl Clindamycin Palmitate HCl (Oral Solution Reconstituted) G 3
C1
Clin
dam
ycin
Pho
sph
ate
in
D5
W Clindamycin Phosphate in D5W (Intravenous Solution) G 2
C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (300MG/2ML Injection Solution,
600MG/4ML Injection Solution, 900MG/6ML Injection
Solution)
G 2
C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (Vaginal Cream) G 2
C1
Clin
des
se
Clindesse (Vaginal Cream) B 3
C1
Coli
stim
etha
te
Sodi
um Colistimethate Sodium (CBA) (Injection Solution
Reconstituted)G 4
C1
Cubi
cin
Cubicin (Intravenous Solution Reconstituted) B 4
C1
Dalv
anc
e
Dalvance (Intravenous Solution Reconstituted) B 4 PA C1
Dap
tom
ycin
Daptomycin (Intravenous Solution Reconstituted) G 4
C1
Firv
anq
Firvanq (Oral Solution Reconstituted) B 3
C1
Flag
yl
Flagyl (Oral Capsule) B 3
C1
Flag
yl
Flagyl (Oral Tablet) B 3
C1
Fosf
omy
cin
Tro
met
ham
ine Fosfomycin Tromethamine (Oral Packet) G 3
C1
Hipr
ex
Hiprex (Oral Tablet) B 3
C1
Line
zoli
d
Linezolid (Intravenous Solution) G 3
C1
Line
zoli
d
Linezolid (Oral Suspension Reconstituted) G 4
C1
Line
zoli
d
Linezolid (Oral Tablet) G 3
C1
Mac
robi
d
Macrobid (Oral Capsule) B 3 HRM C1
Mac
roda
ntin
Macrodantin (Oral Capsule) B 3 HRM C1
Met
hen
ami
ne
Hip
pura
te Methenamine Hippurate (Oral Tablet) G 2
C1
Metr
oCr
eam
MetroCream (External Cream) B 3
C1
Metr
ogel
Metrogel (External Gel) B 3
C1
Metr
oLot
ion
MetroLotion (External Lotion) B 4
C1
Metr
onid
azol
e
Metronidazole (0.75% External Cream) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
49Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Metr
onid
azol
e
Metronidazole (0.75% External Gel, 1% External Gel) G 3
C1
Metr
onid
azol
e
Metronidazole (0.75% External Lotion) G 3
C1
Metr
onid
azol
e in
NaC
l
0.79
% Metronidazole in NaCl 0.79% (Intravenous Solution) G 1
C1
Metr
onid
azol
e
Metronidazole (375MG Oral Capsule) G 3
C1
Metr
onid
azol
e
Metronidazole (250MG Oral Tablet, 500MG Oral Tablet) G 1
C1
Metr
onid
azol
e
Metronidazole (0.75% Vaginal Gel) G 2
C1
Mon
urol
Monurol (Oral Packet) B 3
C1
Nitr
ofur
anto
in
Mac
rocr
ystal Nitrofurantoin Macrocrystal (100MG Oral Capsule,
50MG Oral Capsule) (Generic Macrodantin)G 2 HRM
C1
Nitr
ofur
anto
in
Mac
rocr
ystal Nitrofurantoin Macrocrystal (25MG Oral Capsule)
(Generic Macrodantin)G 3 HRM
C1
Nitr
ofur
anto
in
Mon
ohy
drat
e Nitrofurantoin Monohydrate (Generic Macrobid) G 2 HRM C1
Nitr
ofur
anto
in
Nitrofurantoin (Oral Suspension) G 3 HRM C1
Nori
tate
Noritate (External Cream) B 4
C1
Poly
myxi
n B
Sulf
ate Polymyxin B Sulfate (Injection Solution Reconstituted) G 2
C1
Sive
xtro
Sivextro (Intravenous Solution Reconstituted) B 4 PA C1
Sive
xtro
Sivextro (Oral Tablet) B 4 PA C1
Solo
sec
Solosec (Oral Packet) B 3
C1
Tige
cycli
ne
Tigecycline (Intravenous Solution Reconstituted) G 4
C1
Tini
daz
ole
Tinidazole (Oral Tablet) G 2
C1
Trim
etho
prim
Trimethoprim (Oral Tablet) G 1
C1
Tyg
acil
Tygacil (Intravenous Solution Reconstituted) B 4
C1
Van
coci
n
HCl
Vancocin HCl (125MG Oral Capsule) B 4 QL C1
Van
coci
n
Vancocin (250MG Oral Capsule) B 4 QL C1
Van
com
ycin
HCl
Vancomycin HCl (10GM Intravenous Solution
Reconstituted, 1GM Intravenous Solution Reconstituted,
500MG Intravenous Solution Reconstituted, 750MG
Intravenous Solution Reconstituted)
G 2
C1
Van
com
ycin
HCl
Vancomycin HCl (250MG Intravenous Solution
Reconstituted)B 2
C1
Van
com
ycin
HCl
Vancomycin HCl (Oral Capsule) G 3 QL C1
Van
com
ycin
HCl
Vancomycin HCl (Oral Solution Reconstituted) G 3
C1
Van
daz
ole
Vandazole (Vaginal Gel) B 2
C1
Xenl
eta
Xenleta (Oral Tablet) B 4 PA; QL C1
Xifa
xan
Xifaxan (Oral Tablet) B 4 PA C1
Zyv
ox
Zyvox (600MG/300ML Intravenous Solution) B 3
C1
Zyv
ox
Zyvox (Oral Suspension Reconstituted) B 4
C1
Zyv
ox
Zyvox (Oral Tablet) B 4
50 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
B1
Beta-lactam, CephalosporinsC1
Avy
caz
Avycaz (Intravenous Solution Reconstituted) B 4 PA C1
Cefa
clor
ER
Cefaclor ER (Oral Tablet Extended Release 12 Hour) G 3
C1
Cefa
clor
Cefaclor (Oral Capsule) G 2
C1
Cefa
clor
Cefaclor (Oral Suspension Reconstituted) G 3
C1
Cefa
drox
il
Cefadroxil (Oral Capsule) G 1
C1
Cefa
drox
il
Cefadroxil (Oral Suspension Reconstituted) G 2
C1
Cefa
drox
il
Cefadroxil (Oral Tablet) G 3
C1
Cefa
zolin
Sodi
um Cefazolin Sodium (10GM Injection Solution
Reconstituted, 1GM Injection Solution Reconstituted,
500MG Injection Solution Reconstituted)
G 2
C1
Cef
dinir
Cefdinir (Oral Capsule) G 2
C1
Cef
dinir
Cefdinir (Oral Suspension Reconstituted) G 2
C1
Cef
epi
me
HCl
Cefepime HCl (Injection Solution Reconstituted) G 3
C1
Cefi
xim
e
Cefixime (Oral Capsule) G 2
C1
Cefi
xim
e
Cefixime (Oral Suspension Reconstituted) G 3
C1
Cef
otet
an
Diso
diu
m Cefotetan Disodium (Injection Solution Reconstituted) G 3
C1
Cef
oxiti
n
Sodi
um Cefoxitin Sodium (Injection Solution Reconstituted) G 2
C1
Cef
oxiti
n
Sodi
um Cefoxitin Sodium (Intravenous Solution Reconstituted) G 2
C1
Cef
pod
oxi
me
Prox
etil Cefpodoxime Proxetil (Oral Suspension Reconstituted) G 3
C1
Cef
pod
oxi
me
Prox
etil Cefpodoxime Proxetil (Oral Tablet) G 2
C1
Cef
proz
il
Cefprozil (Oral Suspension Reconstituted) G 2
C1
Cef
proz
il
Cefprozil (Oral Tablet) G 2
C1
Ceft
azidi
me
Ceftazidime (Injection Solution Reconstituted) G 2
C1
Ceft
riax
one
Sodi
um Ceftriaxone Sodium (1GM Injection Solution
Reconstituted, 250MG Injection Solution Reconstituted)G 1
C1
Ceft
riax
one
Sodi
um Ceftriaxone Sodium (2GM Injection Solution
Reconstituted, 500MG Injection Solution Reconstituted)G 2
C1
Ceft
riax
one
Sodi
um Ceftriaxone Sodium (10GM Intravenous Solution
Reconstituted)G 2
C1
Cef
urox
ime
Axet
il Cefuroxime Axetil (Oral Tablet) G 1
C1
Cef
urox
ime
Sodi
um Cefuroxime Sodium (Injection Solution Reconstituted) G 1
C1
Cef
urox
ime
Sodi
um Cefuroxime Sodium (Intravenous Solution
Reconstituted)G 1
C1
Cep
hale
xin
Cephalexin (250MG Oral Capsule, 500MG Oral Capsule) G 1
C1
Cep
hale
xin
Cephalexin (750MG Oral Capsule) G 3
C1
Cep
hale
xin
Cephalexin (Oral Suspension Reconstituted) G 1
You can find information on what the abbreviations in this table mean on pages 6 - 7.
51Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Cep
hale
xin
Cephalexin (Oral Tablet) G 2
C1
Sup
rax
Suprax (Oral Capsule) B 2
C1
Sup
rax
Suprax (100MG/5ML Oral Suspension Reconstituted,
200MG/5ML Oral Suspension Reconstituted)G 3
C1
Sup
rax
Suprax (500MG/5ML Oral Suspension Reconstituted) B 3
C1
Sup
rax
Suprax (Oral Tablet Chewable) G 2
C1
Tazi
cef
Tazicef (Injection Solution Reconstituted) G 2
C1
Tefl
aro
Teflaro (Intravenous Solution Reconstituted) B 4
C1
Zer
bax
a
Zerbaxa (Intravenous Solution Reconstituted) B 4 PA B1
Beta-lactam, PenicillinsC1
Am
oxici
llin
Amoxicillin (Oral Capsule) G 1
C1
Am
oxici
llin
Amoxicillin (Oral Suspension Reconstituted) G 1
C1
Am
oxici
llin
Amoxicillin (Oral Tablet Immediate Release) G 1
C1
Am
oxici
llin
Amoxicillin (Oral Tablet Chewable) G 1
C1
Am
oxici
llin-
Pota
ssiu
m
Clav
ulan
ate
ERAmoxicillin-Potassium Clavulanate ER (Oral Tablet
Extended Release 12 Hour)G 3
C1
Am
oxici
llin-
Pota
ssiu
m
Clav
ulan
ate Amoxicillin-Potassium Clavulanate (200-28.5MG/5ML
Oral Suspension Reconstituted, 400-57MG/5ML Oral
Suspension Reconstituted, 600-42.9MG/5ML Oral
Suspension Reconstituted)
G 1
C1
Am
oxici
llin-
Pota
ssiu
m
Clav
ulan
ate Amoxicillin-Potassium Clavulanate (250-62.5MG/5ML
Oral Suspension Reconstituted)G 2
C1
Am
oxici
llin-
Pota
ssiu
m
Clav
ulan
ate Amoxicillin-Potassium Clavulanate (250-125MG Oral
Tablet Immediate Release)G 2
C1
Am
oxici
llin-
Pota
ssiu
m
Clav
ulan
ate Amoxicillin-Potassium Clavulanate (500-125MG Oral
Tablet Immediate Release, 875-125MG Oral Tablet
Immediate Release)
G 1
C1
Am
oxici
llin-
Pota
ssiu
m
Clav
ulan
ate Amoxicillin-Potassium Clavulanate (200-28.5MG Oral
Tablet Chewable, 400-57MG Oral Tablet Chewable)G 2
C1
Am
picill
in
Ampicillin (Oral Capsule) G 1
C1
Am
picill
in
Sodi
um Ampicillin Sodium (125MG Injection Solution
Reconstituted, 1GM Injection Solution Reconstituted)G 2
C1
Am
picill
in
Sodi
um Ampicillin Sodium (10GM Intravenous Solution
Reconstituted)G 2
C1
Am
picill
in-
Sulb
acta
m
Sodi
um Ampicillin-Sulbactam Sodium (Injection Solution
Reconstituted)G 2
C1
Am
picill
in-
Sulb
acta
m
Sodi
um Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous
Solution Reconstituted)G 2
C1
Bicill
in C-
R
900/
300 Bicillin C-R 900/300 (Intramuscular Suspension) B 3
52 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Bicill
in C-
R
Bicillin C-R (Intramuscular Suspension) B 3
C1
Bicill
in L-
A
Bicillin L-A (Intramuscular Suspension) B 3
C1
Dicl
oxa
cillin
Sodi
um Dicloxacillin Sodium (250MG Oral Capsule) G 1
C1
Dicl
oxa
cillin
Sodi
um Dicloxacillin Sodium (500MG Oral Capsule) G 2
C1
Nafc
illin
Sodi
um
Nafcillin Sodium (Injection Solution Reconstituted) G 3
C1
Nafc
illin
Sodi
um
Nafcillin Sodium (10GM Intravenous Solution
Reconstituted)G 3
C1
Oxa
cillin
Sodi
um
in
Dext
rose Oxacillin Sodium in Dextrose (1GM/50ML Intravenous
Solution)B 3
C1
Oxa
cillin
Sodi
um
in
Dext
rose Oxacillin Sodium in Dextrose (2GM/50ML Intravenous
Solution)B 4
C1
Oxa
cillin
Sodi
um Oxacillin Sodium (Injection Solution Reconstituted) G 3
C1
Oxa
cillin
Sodi
um Oxacillin Sodium (Intravenous Solution Reconstituted) G 3
C1
Peni
cillin
G
Pota
ssiu
m in
Dext
rose Penicillin G Potassium in Dextrose (40000UNIT/ML
Intravenous Solution, 60000UNIT/ML Intravenous
Solution)
B 3
C1
Peni
cillin
G
Pota
ssiu
m Penicillin G Potassium (20000000UNIT Injection Solution
Reconstituted)G 3
C1
Peni
cillin
G
Proc
aine Penicillin G Procaine (Intramuscular Suspension) G 3
C1
Peni
cillin
G
Sodi
um Penicillin G Sodium (Injection Solution Reconstituted) G 4
C1
Peni
cillin
V
Pota
ssiu
m Penicillin V Potassium (Oral Solution Reconstituted) G 1
C1
Peni
cillin
V
Pota
ssiu
m Penicillin V Potassium (Oral Tablet) G 1
C1
Pipe
racill
in-
Taz
oba
cta
m Piperacillin-Tazobactam (2.25 (2-0.25)GM Intravenous
Solution Reconstituted, 3.375 (3-0.375)GM Intravenous
Solution Reconstituted)
G 2
C1
Pipe
racill
in-
Taz
oba
cta
m Piperacillin-Tazobactam (4.5 (4-0.5)GM Intravenous
Solution Reconstituted, 40.5 (36-4.5)GM Intravenous
Solution Reconstituted)
G 3
C1
Una
syn
Unasyn (3 (2-1)GM Injection Solution Reconstituted) B 3
C1
Una
syn
Unasyn (Intravenous Solution Reconstituted) B 3
C1
Zos
yn
Zosyn (2-0.25GM/50ML Intravenous Solution,
3-0.375GM/50ML Intravenous Solution)B 3
B1
CarbapenemsC1
Erta
pen
em
Sodi
um Ertapenem Sodium (Injection Solution Reconstituted) G 3
C1
Imip
ene
m-
Cila
stati
n Imipenem-Cilastatin (Intravenous Solution Reconstituted) G 3
C1
Inva
nz
Invanz (Injection Solution Reconstituted) B 4
C1
Mer
ope
nem
Meropenem (1GM Intravenous Solution Reconstituted) G 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
53Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Mer
ope
nem
Meropenem (500MG Intravenous Solution
Reconstituted)G 2
C1
Merr
em
Merrem (500MG Intravenous Solution Reconstituted) B 3
C1
Prim
axin
IV
Primaxin IV (Intravenous Solution Reconstituted) B 3
C1
Vab
ome
re
Vabomere (Intravenous Solution Reconstituted) B 4
B1
MacrolidesC1
Azit
hro
myci
n
Azithromycin (Intravenous Solution Reconstituted) G 1
C1
Azit
hro
myci
n
Azithromycin (Oral Packet) B 1
C1
Azit
hro
myci
n
Azithromycin (Oral Suspension Reconstituted) G 1
C1
Azit
hro
myci
n
Azithromycin (Oral Tablet) G 1
C1
Clari
thro
myci
n
ER Clarithromycin ER (Oral Tablet Extended Release 24
Hour)G 2
C1
Clari
thro
myci
n
Clarithromycin (Oral Suspension Reconstituted) G 3
C1
Clari
thro
myci
n
Clarithromycin (Oral Tablet Immediate Release) G 2
C1
Dific
id
Dificid (Oral Suspension Reconstituted) B 4
C1
Dific
id
Dificid (Oral Tablet) B 4
C1
E.E.
S.
Gra
nule
s E.E.S. Granules (Oral Suspension Reconstituted) B 3
C1
EryP
ed
200
EryPed 200 (Oral Suspension Reconstituted) B 3
C1
EryP
ed
400
EryPed 400 (Oral Suspension Reconstituted) B 4
C1
Ery-
Tab
Ery-Tab (Oral Tablet Delayed Release) G 3
C1
Eryt
hroc
in
Lact
obio
nate Erythrocin Lactobionate (Intravenous Solution
Reconstituted)G 3
C1
Eryt
hroc
in
Stea
rate Erythrocin Stearate (Oral Tablet) G 3
C1
Eryt
hro
myci
n
Bas
e Erythromycin Base (Oral Capsule Delayed Release
Particles)G 3
C1
Eryt
hro
myci
n
Bas
e Erythromycin Base (Oral Tablet Immediate Release) G 3
C1
Eryt
hro
myci
n
Bas
e Erythromycin Base (Oral Tablet Delayed Release) G 3
C1
Eryt
hro
myci
n
Ethy
lsuc
cina
te Erythromycin Ethylsuccinate (200MG/5ML Oral
Suspension Reconstituted)G 3
C1
Eryt
hro
myci
n
Ethy
lsuc
cina
te Erythromycin Ethylsuccinate (400MG/5ML Oral
Suspension Reconstituted)G 4
C1
Eryt
hro
myci
n
Ethy
lsuc
cina
te Erythromycin Ethylsuccinate (Oral Tablet) G 3
C1
Zithr
oma
x
Zithromax (Intravenous Solution Reconstituted) B 3
C1
Zithr
oma
x
Zithromax (Oral Packet) B 3
C1
Zithr
oma
x
Zithromax (Oral Suspension Reconstituted) B 3
C1
Zithr
oma
x
Zithromax (Oral Tablet) B 3
C1
Zithr
oma
x
Tri-
Pak Zithromax Tri-Pak (Oral Tablet) B 3
C1
Zithr
oma
x Z-
Pak
Zithromax Z-Pak (Oral Tablet) B 3
54 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
B1
QuinolonesC1
Bax
dela
Baxdela (Intravenous Solution Reconstituted) B 4
C1
Bax
dela
Baxdela (Oral Tablet) B 4
C1
Cipr
o
Cipro (Oral Suspension Reconstituted) B 3
C1
Cipr
o
Cipro (Oral Tablet Immediate Release) B 3
C1
Cipr
oflo
xaci
n
HCl Ciprofloxacin HCl (100MG Oral Tablet Immediate
Release)G 3
C1
Cipr
oflo
xaci
n
HCl Ciprofloxacin HCl (250MG Oral Tablet Immediate
Release, 500MG Oral Tablet Immediate Release, 750MG
Oral Tablet Immediate Release)
G 1
C1
Cipr
oflo
xaci
n in
D5
W Ciprofloxacin in D5W (200MG/100ML Intravenous
Solution)G 1
C1
Lev
oflo
xaci
n in
D5
W Levofloxacin in D5W (500MG/100ML Intravenous
Solution, 750MG/150ML Intravenous Solution)G 2
C1
Lev
oflo
xaci
n
Levofloxacin (25MG/ML Intravenous Solution) G 3
C1
Lev
oflo
xaci
n
Levofloxacin (25MG/ML Oral Solution) G 3
C1
Lev
oflo
xaci
n
Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet,
750MG Oral Tablet)G 1
C1
Mox
iflox
acin
HCl
in
NaC
l Moxifloxacin HCl in NaCl (Intravenous Solution) G 3
C1
Mox
iflox
acin
HCl
Moxifloxacin HCl (Oral Tablet) G 2
C1
Oflo
xaci
n
Ofloxacin (Oral Tablet) G 3
B1
SulfonamidesC1
Bact
rim
DS
Bactrim DS (Oral Tablet) B 3
C1
Bact
rim
Bactrim (Oral Tablet) B 3
C1
Sulf
adia
zine
Sulfadiazine (Oral Tablet) G 3
C1
Sulf
ame
thox
azol
e-
Trim
etho
prim Sulfamethoxazole-Trimethoprim (Oral Suspension) G 2
C1
Sulf
ame
thox
azol
e-
Trim
etho
prim Sulfamethoxazole-Trimethoprim (Oral Tablet) G 1
B1
TetracyclinesC1
Acti
clat
e
Acticlate (Oral Tablet) B 3
C1
De
mec
locy
cline
HCl Demeclocycline HCl (Oral Tablet) G 3
C1
Dor
yx
MP
C
Doryx MPC (Oral Tablet Delayed Release) B 3
C1
Dor
yx
Doryx (200MG Oral Tablet Delayed Release) B 4
C1
Dor
yx
Doryx (50MG Oral Tablet Delayed Release) B 3
C1
Dox
y
100
Doxy 100 (Intravenous Solution Reconstituted) G 3
C1
Dox
ycyc
line
Hycl
ate Doxycycline Hyclate (Oral Capsule) G 2
C1
Dox
ycyc
line
Hycl
ate Doxycycline Hyclate (100MG Oral Tablet Immediate
Release, 20MG Oral Tablet Immediate Release)G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
55Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Dox
ycyc
line
Hycl
ate Doxycycline Hyclate (150MG Oral Tablet Immediate
Release, 75MG Oral Tablet Immediate Release)G 3
C1
Dox
ycyc
line
Hycl
ate Doxycycline Hyclate (100MG Oral Tablet Delayed
Release, 150MG Oral Tablet Delayed Release, 200MG
Oral Tablet Delayed Release, 50MG Oral Tablet Delayed
Release, 75MG Oral Tablet Delayed Release)
G 3
C1
Dox
ycyc
line
Hycl
ate Doxycycline Hyclate (80MG Oral Tablet Delayed
Release)G 4
C1
Dox
ycyc
line
Mon
ohy
drat
e Doxycycline Monohydrate (100MG Oral Capsule, 50MG
Oral Capsule)G 1
C1
Dox
ycyc
line
Mon
ohy
drat
e Doxycycline Monohydrate (150MG Oral Capsule, 75MG
Oral Capsule)G 3
C1
Dox
ycyc
line
Mon
ohy
drat
e Doxycycline Monohydrate (Oral Suspension
Reconstituted)G 3
C1
Dox
ycyc
line
Mon
ohy
drat
e Doxycycline Monohydrate (Oral Tablet) G 2
C1
Min
ocy
cline
HCl
ER Minocycline HCl ER (Oral Tablet Extended Release 24
Hour)G 3 QL
C1
Min
ocy
cline
HCl
Minocycline HCl (Oral Capsule) G 1
C1
Min
ocy
cline
HCl
Minocycline HCl (Oral Tablet Immediate Release) G 3
C1
Min
olira
Minolira (Oral Tablet Extended Release 24 Hour) B 3 QL C1
Mon
dox
yne
NL
Mondoxyne NL (100MG Oral Capsule) G 1
C1
Mon
dox
yne
NL
Mondoxyne NL (75MG Oral Capsule) G 3
C1
Nuz
yra
Nuzyra (Intravenous Solution Reconstituted) B 4 PA C1
Nuz
yra
Nuzyra (Oral Tablet) B 4 PA; QL C1
Ora
cea
Oracea (Oral Capsule Delayed Release) B 4
C1
Sey
sara
Seysara (Oral Tablet) B 4
C1
Solo
dyn
Solodyn (Oral Tablet Extended Release 24 Hour) B 4 QL C1
TAR
GA
DOX
TARGADOX (Oral Tablet) G 3
C1
Tetr
acyc
line
HCl
Tetracycline HCl (Oral Capsule) G 3
C1
Vibr
amy
cin
Vibramycin (Oral Capsule) B 3
C1
Vibr
amy
cin
Vibramycin (Oral Suspension Reconstituted) B 3
C1
Vibr
amy
cin
Vibramycin (50MG/5ML Oral Syrup) B 3
A1
AnticonvulsantsB1
Anticonvulsants, OtherC1
BRI
VIA
CT
BRIVIACT (Oral Solution) B 4 PA; QL C1
BRI
VIA
CT
BRIVIACT (Oral Tablet) B 4 PA; QL C1
Epid
iolex
Epidiolex (Oral Solution) B 4 PA C1
Felb
ama
te
Felbamate (Oral Suspension) G 4
56 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Felb
ama
te
Felbamate (Oral Tablet) G 3
C1
Felb
atol
Felbatol (Oral Suspension) B 4
C1
Felb
atol
Felbatol (Oral Tablet) B 4
C1
Fint
epla
Fintepla (Oral Solution) B 4 PA; QL C1
Fyc
omp
a
Fycompa (Oral Suspension) B 4 QL C1
Fyc
omp
a
Fycompa (Oral Tablet) B 4 QL C1
Kep
pra
Keppra (Oral Solution) B 4
C1
Kep
pra
Keppra (1000MG Oral Tablet Immediate Release,
500MG Oral Tablet Immediate Release, 750MG Oral
Tablet Immediate Release)
B 4
C1
Kep
pra
Keppra (250MG Oral Tablet Immediate Release) B 3
C1
Kep
pra
XR
Keppra XR (Oral Tablet Extended Release 24 Hour) B 4
C1
Lam
ictal
ODT
Lamictal ODT (Oral Tablet Dispersible) B 4
C1
Lam
ictal
Lamictal (Oral Tablet Immediate Release) B 4
C1
Lam
ictal
Lamictal (Oral Tablet Chewable) B 4
C1
Lam
ictal
Start
er
Lamictal Starter (35 Tablets Oral Kit, 49 Tablets Oral
Kit)B 3
C1
Lam
ictal
Start
er
Lamictal Starter (98 Tablets Oral Kit) B 4
C1
Lam
ictal
XR
Lamictal XR (Oral Kit) B 3
C1
Lam
ictal
XR
Lamictal XR (100MG Oral Tablet Extended Release 24
Hour, 200MG Oral Tablet Extended Release 24 Hour,
250MG Oral Tablet Extended Release 24 Hour, 25MG
Oral Tablet Extended Release 24 Hour, 300MG Oral
Tablet Extended Release 24 Hour, 50MG Oral Tablet
Extended Release 24 Hour)
B 4
C1
Lam
otrig
ine
ER
Lamotrigine ER (Oral Tablet Extended Release 24 Hour) G 3
C1
Lam
otrig
ine
ODT
Lamotrigine ODT (25 & 50 & 100MG Oral Tablet
Dispersible Kit)G 3
C1
Lam
otrig
ine
Lamotrigine (100MG Oral Tablet Immediate Release,
150MG Oral Tablet Immediate Release, 200MG Oral
Tablet Immediate Release, 25MG Oral Tablet Immediate
Release)
G 1
C1
Lam
otrig
ine
Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral
Tablet Chewable)G 2
C1
Lam
otrig
ine
ODT
Lamotrigine ODT (Oral Tablet Dispersible) G 3
C1
Lam
otrig
ine
Start
er
Kit-
Blue Lamotrigine Starter Kit-Blue (Oral Kit) G 3
C1
Lam
otrig
ine
Start
er
Kit-
Gre
en Lamotrigine Starter Kit-Green (Oral Kit) G 4
You can find information on what the abbreviations in this table mean on pages 6 - 7.
57Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Lam
otrig
ine
Start
er
Kit-
Ora
nge Lamotrigine Starter Kit-Orange (Oral Kit) G 3
C1
Lev
etira
ceta
m
ER Levetiracetam ER (Oral Tablet Extended Release 24
Hour)G 2
C1
Lev
etira
ceta
m
Levetiracetam (Oral Solution) G 1
C1
Lev
etira
ceta
m
Levetiracetam (Oral Tablet Immediate Release) G 1
C1
Qud
exy
XR
Qudexy XR (100MG Oral Capsule ER 24 Hour
Sprinkle, 25MG Oral Capsule ER 24 Hour Sprinkle,
50MG Oral Capsule ER 24 Hour Sprinkle)
B 3 PA
C1
Qud
exy
XR
Qudexy XR (150MG Oral Capsule ER 24 Hour
Sprinkle, 200MG Oral Capsule ER 24 Hour Sprinkle)B 4 PA
C1
Row
eepr
a
Roweepra (Oral Tablet Immediate Release) G 1
C1
Sprit
am
ODT
Spritam ODT (Oral Tablet Disintegrating Soluble) B 3
C1
Top
ama
x
Topamax (100MG Oral Tablet, 200MG Oral Tablet,
50MG Oral Tablet)B 4
C1
Top
ama
x
Topamax (25MG Oral Tablet) B 3
C1
Top
ama
x
Spri
nkle Topamax Sprinkle (15MG Oral Capsule Sprinkle) B 3
C1
Top
ama
x
Spri
nkle Topamax Sprinkle (25MG Oral Capsule Sprinkle) B 4
C1
Topi
ram
ate
ER
Topiramate ER (100MG Oral Capsule ER 24 Hour
Sprinkle, 25MG Oral Capsule ER 24 Hour Sprinkle,
50MG Oral Capsule ER 24 Hour Sprinkle)
G 3 PA
C1
Topi
ram
ate
ER
Topiramate ER (150MG Oral Capsule ER 24 Hour
Sprinkle, 200MG Oral Capsule ER 24 Hour Sprinkle)G 4 PA
C1
Topi
ram
ate
Topiramate (Oral Capsule Sprinkle Immediate Release) G 2
C1
Topi
ram
ate
Topiramate (Oral Tablet) G 1
C1
Trok
endi
XR
Trokendi XR (100MG Oral Capsule Extended Release
24 Hour, 200MG Oral Capsule Extended Release 24
Hour)
B 4 PA
C1
Trok
endi
XR
Trokendi XR (25MG Oral Capsule Extended Release
24 Hour, 50MG Oral Capsule Extended Release 24
Hour)
B 3 PA
C1
Valp
roic
Acid
Valproic Acid (Oral Capsule) G 2
C1
Valp
roic
Acid
Valproic Acid (Oral Solution) G 1
C1
Xco
pri
Xcopri (250MG Daily Dose) (Oral Tablet Therapy
Pack)B 4 PA; QL
C1
Xco
pri
Xcopri (350MG Daily Dose) (Oral Tablet Therapy
Pack)B 4 PA; QL
C1
Xco
pri
Xcopri (100MG Oral Tablet, 150MG Oral Tablet,
50MG Oral Tablet)B 3 PA; QL
C1
Xco
pri
Xcopri (200MG Oral Tablet) B 4 PA; QL
58 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Xco
pri
Xcopri (14x12.5MG & 14x25MG Oral Tablet Therapy
Pack)B 3 PA; QL
C1
Xco
pri
Xcopri (14x150MG & 14x200MG Oral Tablet Therapy
Pack, 14x50MG & 14x100MG Oral Tablet Therapy
Pack)
B 4 PA; QL
B1
Calcium Channel Modifying AgentsC1
Celo
ntin
Celontin (Oral Capsule) B 3
C1
Etho
suxi
mid
e
Ethosuximide (Oral Capsule) G 2
C1
Etho
suxi
mid
e
Ethosuximide (Oral Solution) G 2
C1
Zaro
ntin
Zarontin (Oral Capsule) B 3
C1
Zaro
ntin
Zarontin (Oral Solution) G 3
B1
Gamma-aminobutyric Acid (GABA) Augmenting AgentsC1
Clo
baz
am
Clobazam (Oral Suspension) G 3 PA; QL C1
Clo
baz
am
Clobazam (Oral Tablet) G 3 PA; QL C1
Diac
omit
Diacomit (Oral Capsule) B 4 QL C1
Diac
omit
Diacomit (Oral Packet) B 4 QL C1
Dias
tat
Acu
Dial
Diastat AcuDial (Rectal Gel) B 3 QL C1
Dias
tat
Pedi
atric
Diastat Pediatric (Rectal Gel) B 3 QL C1
Diaz
epa
m
Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG
Rectal Gel)G 3 QL
C1
Gab
ape
ntin
Gabapentin (Oral Capsule) G 1
C1
Gab
ape
ntin
Gabapentin (250MG/5ML Oral Solution) G 2
C1
Gab
ape
ntin
Gabapentin (Oral Tablet) G 1
C1
Gabi
tril
Gabitril (Oral Tablet) B 4
C1
Mys
olin
e
Mysoline (Oral Tablet) B 4
C1
Nay
zila
m
Nayzilam (Nasal Solution) B 3 QL C1
Neu
ronti
n
Neurontin (100MG Oral Capsule) B 3
C1
Neu
ronti
n
Neurontin (300MG Oral Capsule, 400MG Oral
Capsule)B 4
C1
Neu
ronti
n
Neurontin (Oral Solution) B 3
C1
Neu
ronti
n
Neurontin (Oral Tablet) B 4
C1
Onfi
Onfi (Oral Suspension) B 4 PA; QL C1
Onfi
Onfi (Oral Tablet) B 4 PA; QL C1
Phe
nob
arbit
al
Phenobarbital (Oral Elixir) G 3 PA; HRM C1
Phe
nob
arbit
al
Phenobarbital (Oral Tablet) G 3 PA; HRM C1
Prim
idon
e
Primidone (Oral Tablet) G 1
You can find information on what the abbreviations in this table mean on pages 6 - 7.
59Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Sabr
il
Sabril (Oral Packet) B 4 PA; LA; QL C1
Sabr
il
Sabril (Oral Tablet) B 4 PA; LA; QL C1
Sym
paz
an
Sympazan (10MG Oral Film, 20MG Oral Film) B 4 PA; QL C1
Sym
paz
an
Sympazan (5MG Oral Film) B 3 PA; QL C1
Tiag
abin
e
HCl
Tiagabine HCl (Oral Tablet) G 3
C1
Valt
oco
10
MG
Dos
e Valtoco 10 MG Dose (Nasal Liquid) B 3 QL C1
Valt
oco
15
MG
Dos
e Valtoco 15 MG Dose (Nasal Liquid Therapy Pack) B 3 QL C1
Valt
oco
20
MG
Dos
e Valtoco 20 MG Dose (Nasal Liquid Therapy Pack) B 3 QL C1
Valt
oco
5
MG
Dos
e Valtoco 5 MG Dose (Nasal Liquid) B 3 QL C1
Viga
batri
n
Vigabatrin (Oral Packet) G 4 PA; LA; QL C1
Viga
batri
n
Vigabatrin (Oral Tablet) G 4 PA; LA; QL C1
Viga
dron
e
Vigadrone (Oral Packet) G 4 PA; LA; QL B1
Sodium Channel AgentsC1
Apti
om
Aptiom (Oral Tablet) B 4 QL C1
Ban
zel
Banzel (Oral Suspension) B 4
C1
Ban
zel
Banzel (Oral Tablet) B 4
C1
Car
bam
aze
pine
ER Carbamazepine ER (100MG Oral Capsule Extended
Release 12 Hour, 200MG Oral Capsule Extended
Release 12 Hour, 300MG Oral Capsule Extended
Release 12 Hour)
G 2
C1
Car
bam
aze
pine
ER Carbamazepine ER (100MG Oral Tablet Extended
Release 12 Hour, 200MG Oral Tablet Extended Release
12 Hour, 400MG Oral Tablet Extended Release 12 Hour)
G 3
C1
Car
bam
aze
pine
Carbamazepine (Oral Suspension) G 2
C1
Car
bam
aze
pine
Carbamazepine (Oral Tablet Immediate Release) G 2
C1
Car
bam
aze
pine
Carbamazepine (Oral Tablet Chewable) G 2
C1
Car
batr
ol
Carbatrol (Oral Capsule Extended Release 12 Hour) B 3
C1
Dila
ntin
INF
ATA
BS Dilantin INFATABS (Oral Tablet Chewable) G 2
C1
Dila
ntin
Dilantin (Oral Capsule) G 2
C1
Dila
ntin
Dilantin (Oral Suspension) B 3
C1
Epit
ol
Epitol (Oral Tablet) G 2
C1
Oxc
arba
zepi
ne
Oxcarbazepine (300MG/5ML Oral Suspension) G 3
C1
Oxc
arba
zepi
ne
Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet,
600MG Oral Tablet)G 2
C1
Oxt
ellar
XR
Oxtellar XR (150MG Oral Tablet Extended Release 24
Hour, 300MG Oral Tablet Extended Release 24 Hour)B 3
C1
Oxt
ellar
XR
Oxtellar XR (600MG Oral Tablet Extended Release 24
Hour)B 4
60 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Phe
nyte
k
Phenytek (Oral Capsule) G 1
C1
Phe
nyto
in
Phenytoin (125MG/5ML Oral Suspension) G 1
C1
Phe
nyto
in
Phenytoin (Oral Tablet Chewable) G 1
C1
Phe
nyto
in
Sodi
um
Exte
nde
d Phenytoin Sodium Extended (Oral Capsule) G 1
C1
Rufi
nam
ide
Rufinamide (Oral Suspension) G 4
C1
Rufi
nam
ide
Rufinamide (Oral Tablet) G 4
C1
Tegr
etol
Tegretol (Oral Suspension) B 3
C1
Tegr
etol
Tegretol (Oral Tablet Immediate Release) B 3
C1
Tegr
etol
XR
Tegretol XR (Oral Tablet Extended Release 12 Hour) B 3
C1
Trile
ptal
Trileptal (Oral Suspension) B 4
C1
Trile
ptal
Trileptal (150MG Oral Tablet) B 3
C1
Trile
ptal
Trileptal (300MG Oral Tablet, 600MG Oral Tablet) B 4
C1
Vim
pat
Vimpat (Oral Solution) B 3 QL C1
Vim
pat
Vimpat (Oral Tablet) B 3 QL C1
Zon
egra
n
Zonegran (Oral Capsule) B 4
C1
Zoni
sami
de
Zonisamide (Oral Capsule) G 1
A1
Antidementia AgentsB1
Antidementia Agents, OtherC1
Na
mza
ric
Namzaric (Oral Capsule ER 24 Hour Therapy Pack) B 2 PA; QL C1
Na
mza
ric
Namzaric (Oral Capsule Extended Release 24 Hour) B 2 PA; QL B1
Cholinesterase InhibitorsC1
Aric
ept
Aricept (Oral Tablet) B 3 QL C1
Don
epe
zil
HCl
Donepezil HCl (10MG Oral Tablet, 5MG Oral Tablet) G 1 QL C1
Don
epe
zil
HCl
Donepezil HCl (23MG Oral Tablet) G 2 QL C1
Don
epe
zil
HCl
ODT Donepezil HCl ODT (Oral Tablet Dispersible) G 1 QL C1
Exel
on
Exelon (Transdermal Patch 24 Hour) B 3 ST; QL C1
Gala
nta
min
e
Hyd
robr
omi
de
ER Galantamine Hydrobromide ER (Oral Capsule Extended
Release 24 Hour)G 3
C1
Gala
nta
min
e
Hyd
robr
omi
de Galantamine Hydrobromide (Oral Solution) G 3
C1
Gala
nta
min
e
Hyd
robr
omi
de Galantamine Hydrobromide (Oral Tablet) G 2
C1
Raz
ady
ne
ER
Razadyne ER (Oral Capsule Extended Release 24
Hour)B 3
C1
Riva
stig
min
e
Tartr
ate Rivastigmine Tartrate (Oral Capsule) G 2
C1
Riva
stig
min
e
Rivastigmine (Transdermal Patch 24 Hour) G 3 ST; QL B1
N-methyl-D-aspartate (NMDA) Receptor Antagonist
You can find information on what the abbreviations in this table mean on pages 6 - 7.
61Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Me
man
tine
HCl
ER Memantine HCl ER (Oral Capsule Extended Release 24
Hour)G 3 PA; QL
C1
Me
man
tine
HCl
Memantine HCl (2MG/ML Oral Solution) G 3 PA; QL C1
Me
man
tine
HCl
Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet) G 1 PA; QL C1
Me
man
tine
HCl
Titra
tion
Pak Memantine HCl Titration Pak (Oral Tablet) B 1 PA C1
Na
men
da
Namenda (10MG Oral Tablet, 5MG Oral Tablet) B 3 PA; QL C1
Na
men
da
Titra
tion
Pak Namenda Titration Pak (Oral Tablet) B 3 PA C1
Na
men
da
XR
Namenda XR (Oral Capsule Extended Release 24
Hour)B 3 PA; QL
A1
AntidepressantsB1
Antidepressants, OtherC1
Aple
nzin
Aplenzin (Oral Tablet Extended Release 24 Hour) B 4
C1
Bup
ropi
on
HCl
SR Bupropion HCl SR (Oral Tablet Extended Release 12
Hour)G 1
C1
Bup
ropi
on
HCl
XL Bupropion HCl XL (150MG Oral Tablet Extended
Release 24 Hour, 300MG Oral Tablet Extended Release
24 Hour)
G 1
C1
Bup
ropi
on
HCl
ER Bupropion HCl ER (XL) (450MG Oral Tablet Extended
Release 24 Hour)G 3
C1
Bup
ropi
on
HCl
Bupropion HCl (Oral Tablet Immediate Release) G 1
C1
Forfi
vo
XL
Forfivo XL (Oral Tablet Extended Release 24 Hour) B 3
C1
Mirt
aza
pine
Mirtazapine (Oral Tablet) G 1
C1
Mirt
aza
pine
ODT Mirtazapine ODT (Oral Tablet Dispersible) G 2
C1
Olan
zapi
ne-
Fluo
xeti
ne
HCl Olanzapine-Fluoxetine HCl (Oral Capsule) G 3
C1
Re
mer
on
Remeron (Oral Tablet) B 3
C1
Re
mer
on
SolT
ab Remeron SolTab (Oral Tablet Dispersible) B 3
C1
Sym
byax
Symbyax (Oral Capsule) B 3
C1
Well
butri
n
SR
Wellbutrin SR (Oral Tablet Extended Release 12 Hour) B 3
C1
Well
butri
n XL
Wellbutrin XL (Oral Tablet Extended Release 24 Hour) B 4
B1
Monoamine Oxidase InhibitorsC1
Ems
am
Emsam (Transdermal Patch 24 Hour) B 4
C1
Mar
plan
Marplan (Oral Tablet) B 3
C1
Nar
dil
Nardil (Oral Tablet) B 3
C1
Parn
ate
Parnate (Oral Tablet) B 4
C1
Phe
nelzi
ne
Sulf
ate Phenelzine Sulfate (Oral Tablet) G 2
C1
Tran
ylcy
pro
min
e
Sulf
ate Tranylcypromine Sulfate (Oral Tablet) G 3
B1
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine
Reuptake Inhibitors)
62 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Cele
xa
Celexa (Oral Tablet) B 3
C1
Cital
opra
m
Hyd
robr
omi
de Citalopram Hydrobromide (Oral Solution) G 2
C1
Cital
opra
m
Hyd
robr
omi
de Citalopram Hydrobromide (Oral Tablet) G 1
C1
Des
venl
afaxi
ne
ER Desvenlafaxine ER (Oral Tablet Extended Release 24
Hour) (Brand Equivalent Khedezla)B 3
C1
Des
venl
afaxi
ne
Suc
cina
te
ER Desvenlafaxine Succinate ER (Oral Tablet Extended
Release 24 Hour) (Generic Pristiq)G 2
C1
Effe
xor
XR
Effexor XR (Oral Capsule Extended Release 24 Hour) B 3
C1
Esci
talo
pra
m
Oxal
ate Escitalopram Oxalate (Oral Solution) G 3
C1
Esci
talo
pra
m
Oxal
ate Escitalopram Oxalate (Oral Tablet) G 1
C1
Fetz
ima
Fetzima (Oral Capsule Extended Release 24 Hour) B 3 ST C1
Fetz
ima
Titra
tion
Fetzima Titration (Oral Capsule ER 24 Hour Therapy
Pack)B 3 ST
C1
Fluo
xeti
ne
HCl
Fluoxetine HCl (PMDD) (Oral Tablet) G 3
C1
Fluo
xeti
ne
HCl
Fluoxetine HCl (10MG Oral Capsule Immediate Release,
20MG Oral Capsule Immediate Release, 40MG Oral
Capsule Immediate Release)
G 1
C1
Fluo
xeti
ne
HCl
Fluoxetine HCl (90MG Oral Capsule Delayed Release) G 3
C1
Fluo
xeti
ne
HCl
Fluoxetine HCl (20MG/5ML Oral Solution) G 2
C1
Fluo
xeti
ne
HCl
Fluoxetine HCl (10MG Oral Tablet) G 1
C1
Fluo
xeti
ne
HCl
Fluoxetine HCl (20MG Oral Tablet, 60MG Oral Tablet) G 3
C1
Fluv
oxa
min
e
Mal
eate
ER Fluvoxamine Maleate ER (Oral Capsule Extended
Release 24 Hour)G 3
C1
Fluv
oxa
min
e
Mal
eate Fluvoxamine Maleate (Oral Tablet) G 2
C1
Lex
apro
Lexapro (Oral Tablet) B 3
C1
Nef
azo
don
e
HCl Nefazodone HCl (Oral Tablet) G 3
C1
Paro
xeti
ne
HCl
Paroxetine HCl (Oral Tablet Immediate Release) G 1 PA; HRM C1
Paxil
Paxil (Oral Suspension) B 3 PA; HRM C1
Paxil
Paxil (Oral Tablet Immediate Release) B 3 PA; HRM C1
Prist
iq
Pristiq (Oral Tablet Extended Release 24 Hour) B 3
C1
Proz
ac
Prozac (10MG Oral Capsule) B 3
C1
Proz
ac
Prozac (20MG Oral Capsule, 40MG Oral Capsule) B 4
C1
Sert
ralin
e
HCl
Sertraline HCl (Oral Concentrate) G 2
C1
Sert
ralin
e
HCl
Sertraline HCl (Oral Tablet) G 1
C1
Traz
odo
ne
HCl
Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet,
50MG Oral Tablet)G 1
C1
Traz
odo
ne
HCl
Trazodone HCl (300MG Oral Tablet) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
63Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Trint
ellix
Trintellix (Oral Tablet) B 3
C1
Venl
afaxi
ne
HCl
ER Venlafaxine HCl ER (Oral Capsule Extended Release 24
Hour)G 1
C1
Venl
afaxi
ne
HCl
ER Venlafaxine HCl ER (Oral Tablet Extended Release 24
Hour)G 3
C1
Venl
afaxi
ne
HCl
Venlafaxine HCl (Oral Tablet Immediate Release) G 1
C1
Viibr
yd
Viibryd (Oral Tablet) B 3
C1
Viibr
yd
Start
er
Pac
k Viibryd Starter Pack (Oral Kit) B 3
C1
Zolo
ft
Zoloft (Oral Concentrate) B 3
C1
Zolo
ft
Zoloft (Oral Tablet) B 3
B1
TricyclicsC1
Amit
ripty
line
HCl
Amitriptyline HCl (Oral Tablet) G 3 HRM C1
Am
oxa
pine
Amoxapine (Oral Tablet) G 2 PA; HRM C1
Anaf
ranil
Anafranil (Oral Capsule) B 4 PA; HRM C1
Clo
mipr
ami
ne
HCl Clomipramine HCl (Oral Capsule) G 3 PA; HRM C1
Desi
pra
min
e
HCl Desipramine HCl (Oral Tablet) G 3 PA; HRM C1
Dox
epin
HCl
Doxepin HCl (Oral Capsule) G 3 PA; HRM C1
Dox
epin
HCl
Doxepin HCl (Oral Concentrate) G 3 PA; HRM C1
Imip
rami
ne
HCl
Imipramine HCl (Oral Tablet) G 3 PA; HRM C1
Imip
rami
ne
Pam
oate Imipramine Pamoate (Oral Capsule) G 3 PA; HRM C1
Nor
pra
min
Norpramin (Oral Tablet) B 3 PA; HRM C1
Nort
ripty
line
HCl
Nortriptyline HCl (Oral Capsule) G 1 PA; HRM C1
Nort
ripty
line
HCl
Nortriptyline HCl (Oral Solution) G 2 PA; HRM C1
Pam
elor
Pamelor (Oral Capsule) B 4 PA; HRM C1
Prot
ripty
line
HCl
Protriptyline HCl (Oral Tablet) G 3 PA; HRM C1
Trim
ipra
min
e
Mal
eate Trimipramine Maleate (Oral Capsule) G 3 PA; HRM A1
AntiemeticsB1
Antiemetics, OtherC1
Co
mpr
o
Compro (Rectal Suppository) G 3
C1
Gim
oti
Gimoti (Nasal Solution) B 4 PA C1
Mec
lizin
e
HCl
Meclizine HCl (12.5MG Oral Tablet) G 1 HRM C1
Met
oclo
pra
mid
e
HCl Metoclopramide HCl (5MG/5ML Oral Solution) G 1
C1
Met
oclo
pra
mid
e
HCl Metoclopramide HCl (Oral Tablet) G 1
C1
Met
oclo
pra
mid
e
HCl
ODT Metoclopramide HCl ODT (Oral Tablet Dispersible) G 3
C1
Per
phe
nazi
ne
Perphenazine (Oral Tablet) G 2
C1
Proc
hlor
pera
zine
Mal
eate Prochlorperazine Maleate (Oral Tablet) G 1
C1
Proc
hlor
pera
zine
Prochlorperazine (Rectal Suppository) G 3
64 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pro
met
hazi
ne
HCl Promethazine HCl (Oral Tablet) G 3 PA; HRM C1
Pro
met
hazi
ne
HCl Promethazine HCl (12.5MG Rectal Suppository) G 3 PA; HRM C1
Regl
an
Reglan (Oral Tablet) B 3
C1
Sco
pola
min
e
Scopolamine (Transdermal Patch 72 Hour) G 2 PA; HRM C1
Tran
sder
m-
Sco
p Transderm-Scop (1.5MG) (Transdermal Patch 72
Hour)B 3 PA; HRM
C1
Trim
etho
ben
zami
de
HCl Trimethobenzamide HCl (Oral Capsule) G 2 B/D, PA B1
Emetogenic Therapy AdjunctsC1
Apr
epit
ant
Aprepitant (Oral Therapy Pack, Oral Capsule) G 3 PA C1
Dro
nabi
nol
Dronabinol (Oral Capsule) G 3 PA C1
Eme
nd
Emend (80MG Oral Capsule) B 3 PA C1
Eme
nd
Emend (Oral Suspension Reconstituted) B 3 PA C1
Eme
nd
Tri-
Pac
k Emend Tri-Pack (Oral Capsule) B 4 PA C1
Gra
nise
tron
HCl
Granisetron HCl (Oral Tablet) G 2 B/D, PA C1
Mari
nol
Marinol (10MG Oral Capsule, 5MG Oral Capsule) B 4 PA C1
Mari
nol
Marinol (2.5MG Oral Capsule) B 3 PA C1
Ond
ans
etro
n
HCl Ondansetron HCl (Oral Solution) G 2 B/D, PA C1
Ond
ans
etro
n
HCl Ondansetron HCl (Oral Tablet) G 1 B/D, PA C1
Ond
ans
etro
n
ODT Ondansetron ODT (Oral Tablet Dispersible) G 1 B/D, PA C1
San
cus
o
Sancuso (Transdermal Patch) B 4 QL C1
Syn
dros
Syndros (Oral Solution) B 4 PA C1
Varu
bi
Varubi (180 MG Dose) (Oral Tablet Therapy Pack) B 3 B/D, PA C1
Zupl
enz
Zuplenz (Oral Film) B 4 B/D, PA A1
AntifungalsB1
AntifungalsC1
Abel
cet
Abelcet (Intravenous Suspension) B 3 B/D, PA C1
Am
Biso
me
AmBisome (Intravenous Suspension Reconstituted) B 4 B/D, PA C1
Am
phot
erici
n B
Amphotericin B (Intravenous Solution Reconstituted) G 3 B/D, PA C1
Anc
obo
n
Ancobon (Oral Capsule) B 4
C1
Can
cida
s
Cancidas (Intravenous Solution Reconstituted) B 4
C1
Cas
pofu
ngin
Acet
ate Caspofungin Acetate (50MG Intravenous Solution
Reconstituted)G 4
C1
Cas
pofu
ngin
Acet
ate Caspofungin Acetate (70MG Intravenous Solution
Reconstituted)G 3
C1
Clot
rima
zole
Clotrimazole (Mouth/Throat Troche) G 1
C1
Cres
emb
a
Cresemba (Oral Capsule) B 4 PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
65Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Diflu
can
Diflucan (Oral Suspension Reconstituted) B 3
C1
Diflu
can
Diflucan (100MG Oral Tablet, 150MG Oral Tablet,
50MG Oral Tablet)B 3
C1
Diflu
can
Diflucan (200MG Oral Tablet) B 4
C1
Erax
is
Eraxis (100MG Intravenous Solution Reconstituted) B 4
C1
Erax
is
Eraxis (50MG Intravenous Solution Reconstituted) B 3
C1
Fluc
ona
zole
in
Sodi
um
Chlo
ride Fluconazole in Sodium Chloride (Intravenous Solution) G 2
C1
Fluc
ona
zole
Fluconazole (Oral Suspension Reconstituted) G 2
C1
Fluc
ona
zole
Fluconazole (Oral Tablet) G 1
C1
Fluc
ytosi
ne
Flucytosine (Oral Capsule) G 4
C1
Gris
eofu
lvin
Micr
osiz
e Griseofulvin Microsize (Oral Suspension) G 3
C1
Gris
eofu
lvin
Micr
osiz
e Griseofulvin Microsize (Oral Tablet) G 3
C1
Gris
eofu
lvin
Ultra
micr
osiz
e Griseofulvin Ultramicrosize (Oral Tablet) G 3
C1
Gyn
azol
e-1
Gynazole-1 (Vaginal Cream) G 3
C1
Itrac
ona
zole
Itraconazole (Oral Capsule) G 3 PA C1
Itrac
ona
zole
Itraconazole (Oral Solution) G 4 PA C1
Ket
oco
naz
ole
Ketoconazole (Oral Tablet) G 1
C1
Mic
afun
gin
Sodi
um Micafungin Sodium (Intravenous Solution Reconstituted) G 3
C1
Mic
ona
zole
3
Miconazole 3 (Vaginal Suppository) G 2
C1
Myc
ami
ne
Mycamine (Intravenous Solution Reconstituted) B 4
C1
Nox
afil
Noxafil (Oral Suspension) B 4 QL C1
Nox
afil
Noxafil (Oral Tablet Delayed Release) B 4 PA; QL C1
Nyst
atin
Nystatin (Mouth/Throat Suspension) G 1
C1
Nyst
atin
Nystatin (Oral Tablet) G 2
C1
Ora
vig
Oravig (Buccal Tablet) B 4
C1
Pos
aco
naz
ole
Posaconazole (Oral Tablet Delayed Release) G 4 PA; QL C1
Spo
rano
x
Sporanox (Oral Capsule) B 4 PA C1
Spo
rano
x
Sporanox (Oral Solution) B 4 PA C1
Terb
inafi
ne
HCl
Terbinafine HCl (Oral Tablet) G 1
C1
Terc
ona
zole
Terconazole (Vaginal Cream) G 2
C1
Terc
ona
zole
Terconazole (Vaginal Suppository) G 2
C1
Tols
ura
Tolsura (Oral Capsule) B 4 PA C1
Vfen
d IV
Vfend IV (Intravenous Solution Reconstituted) B 4
C1
Vfen
d
Vfend (Oral Suspension Reconstituted) B 4
C1
Vfen
d
Vfend (Oral Tablet) B 3
C1
Vori
con
azol
e
Voriconazole (Intravenous Solution Reconstituted) G 4
C1
Vori
con
azol
e
Voriconazole (Oral Suspension Reconstituted) G 4
66 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Vori
con
azol
e
Voriconazole (Oral Tablet) G 3
A1
Antigout AgentsB1
Antigout AgentsC1
Allo
puri
nol
Allopurinol (Oral Tablet) G 1
C1
Colc
hicin
e
Colchicine (0.6MG Oral Capsule) (Brand Equivalent
Mitigare)B 2
C1
Colc
hicin
e
Colchicine (0.6MG Oral Tablet) (Generic Colcrys) G 2
C1
Colc
rys
Colcrys (Oral Tablet) B 3 PA C1
Feb
uxo
stat
Febuxostat (Oral Tablet) G 3 ST C1
Glo
perb
a
Gloperba (Oral Solution) B 3 PA; QL C1
Miti
gare
Mitigare (Oral Capsule) B 2
C1
Pro
ben
ecid
Probenecid (Oral Tablet) G 1
C1
Pro
ben
ecid
-
Colc
hicin
e Probenecid-Colchicine (Oral Tablet) G 1
C1
Ulori
c
Uloric (Oral Tablet) B 3 ST C1
Zylo
prim
Zyloprim (Oral Tablet) B 3
A1
Antimigraine AgentsB1
AcuteC1
Alm
otrip
tan
Mal
ate Almotriptan Malate (Oral Tablet) G 3 ST; QL C1
Ame
rge
Amerge (Oral Tablet) B 3 QL C1
Eletr
ipta
n
Hyd
robr
omi
de Eletriptan Hydrobromide (Oral Tablet) G 3 ST; QL C1
Frov
a
Frova (Oral Tablet) B 4 ST; QL C1
Frov
atrip
tan
Suc
cina
te Frovatriptan Succinate (Oral Tablet) G 3 ST; QL C1
Imitr
ex
Imitrex (20MG/ACT Nasal Solution) B 4 QL C1
Imitr
ex
Imitrex (5MG/ACT Nasal Solution) B 3 QL C1
Imitr
ex
Imitrex (Oral Tablet) B 3 QL C1
Imitr
ex
STA
Tdo
se
Refil
l Imitrex STATdose Refill (6MG/0.5ML Subcutaneous
Solution Cartridge)B 4 QL
C1
Imitr
ex
STA
Tdo
se
Syst
em Imitrex STATdose System (4MG/0.5ML
Subcutaneous Solution Auto-Injector)B 4 QL
C1
Imitr
ex
Imitrex (Subcutaneous Solution) B 4 QL C1
Max
alt
Maxalt (Oral Tablet) B 3 QL C1
Max
alt-
MLT
Maxalt-MLT (Oral Tablet Dispersible) B 3 QL C1
Nar
atrip
tan
HCl
Naratriptan HCl (Oral Tablet) G 2 QL C1
Nurt
ec
ODT
Nurtec ODT (Oral Tablet Dispersible) B 4 PA; QL C1
Onz
etra
Xsail
Onzetra Xsail (Nasal Exhaler Powder) B 4 QL C1
Relp
ax
Relpax (Oral Tablet) B 3 ST; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
67Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Rey
vow
Reyvow (Oral Tablet) B 3 PA; QL C1
Riza
tript
an
Ben
zoat
e Rizatriptan Benzoate (Oral Tablet) G 2 QL C1
Riza
tript
an
Ben
zoat
e
ODT Rizatriptan Benzoate ODT (Oral Tablet Dispersible) G 2 QL C1
Sum
atrip
tan
Sumatriptan (Nasal Solution) G 3 QL C1
Sum
atrip
tan
Suc
cina
te Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral
Tablet, 50MG Oral Tablet)G 1 QL
C1
Sum
atrip
tan
Suc
cina
te
Refil
l Sumatriptan Succinate Refill (Subcutaneous Solution
Cartridge)G 3 QL
C1
Sum
atrip
tan
Suc
cina
te Sumatriptan Succinate (6MG/0.5ML Subcutaneous
Solution)G 3 QL
C1
Sum
atrip
tan
Suc
cina
te Sumatriptan Succinate (4MG/0.5ML Subcutaneous
Solution Auto-Injector, 6MG/0.5ML Subcutaneous
Solution Auto-Injector)
G 3 QL
C1
Sum
atrip
tan-
Nap
roxe
n
Sodi
um Sumatriptan-Naproxen Sodium (Oral Tablet) G 3 QL C1
Tos
ymr
a
Tosymra (Nasal Solution) B 3 QL C1
Trex
imet
Treximet (Oral Tablet) B 4 QL C1
Ubr
elvy
Ubrelvy (Oral Tablet) B 4 PA; QL C1
Zem
brac
e
Sym
Tou
ch Zembrace SymTouch (Subcutaneous Solution Auto-
Injector)B 4 QL
C1
Zol
mitri
ptan
Zolmitriptan (Oral Tablet) G 3 QL C1
Zol
mitri
ptan
ODT Zolmitriptan ODT (Oral Tablet Dispersible) G 3 QL C1
Zom
ig
Zomig (Nasal Solution) B 3 QL C1
Zom
ig
Zomig (Oral Tablet) B 4 QL C1
Zom
ig
ZMT
Zomig ZMT (Oral Tablet Dispersible) B 4 QL B1
Ergot AlkaloidsC1
Cafe
rgot
Cafergot (Oral Tablet) G 3
C1
Dihy
droe
rgot
ami
ne
Mes
ylate Dihydroergotamine Mesylate (Nasal Solution) G 4 PA; QL C1
Erg
ota
min
e-
Caff
eine Ergotamine-Caffeine (Oral Tablet) G 2
C1
Mig
ergo
t
Migergot (Rectal Suppository) G 4
C1
Migr
anal
Migranal (Nasal Solution) B 4 PA; QL B1
ProphylacticC1
Aim
ovig
Aimovig (Subcutaneous Solution Auto-Injector) B 3 PA; QL C1
Ajov
y
Ajovy (Subcutaneous Solution Auto-Injector) B 3 PA; QL C1
Ajov
y
Ajovy (Subcutaneous Solution Prefilled Syringe) B 3 PA; QL C1
Emg
ality
Emgality (300MG Dose) (100MG/ML Subcutaneous
Solution Prefilled Syringe)B 3 PA; QL
C1
Emg
ality
Emgality (Subcutaneous Solution Auto-Injector) B 3 PA; QL
68 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Emg
ality
Emgality (120MG/ML Subcutaneous Solution
Prefilled Syringe)B 3 PA; QL
C1
Tim
olol
Mal
eate
Timolol Maleate (Oral Tablet) G 2
A1
Antimyasthenic AgentsB1
ParasympathomimeticsC1
Mes
tino
n
Mestinon (Oral Solution) B 4
C1
Mes
tino
n
Mestinon (Oral Tablet Immediate Release) B 4
C1
Mes
tino
n
Mestinon (Oral Tablet Extended Release) B 4
C1
Pyri
dost
igmi
ne
Bro
mid
e
ER Pyridostigmine Bromide ER (Oral Tablet Extended
Release)G 3
C1
Pyri
dost
igmi
ne
Bro
mid
e Pyridostigmine Bromide (Oral Solution) G 4
C1
Pyri
dost
igmi
ne
Bro
mid
e Pyridostigmine Bromide (30MG Oral Tablet Immediate
Release)G 3
C1
Pyri
dost
igmi
ne
Bro
mid
e Pyridostigmine Bromide (60MG Oral Tablet Immediate
Release)G 2
A1
AntimycobacterialsB1
Antimycobacterials, OtherC1
Dap
son
e
Dapsone (Oral Tablet) G 2
C1
Myc
obut
in
Mycobutin (Oral Capsule) B 4
C1
Rifa
buti
n
Rifabutin (Oral Capsule) G 3
B1
AntitubercularsC1
Etha
mbu
tol
HCl
Ethambutol HCl (Oral Tablet) G 2
C1
Ison
iazid
Isoniazid (Oral Syrup) G 3
C1
Ison
iazid
Isoniazid (Oral Tablet) G 1
C1
Mya
mbu
tol
Myambutol (Oral Tablet) B 3
C1
Pas
er
Paser (Oral Packet) G 3
C1
Pret
oma
nid
Pretomanid (Oral Tablet) B 3
C1
Prifti
n
Priftin (Oral Tablet) B 3
C1
Pyra
zina
mid
e
Pyrazinamide (Oral Tablet) G 3
C1
Rifa
mpi
n
Rifampin (600MG Intravenous Solution Reconstituted) G 3
C1
Rifa
mpi
n
Rifampin (150MG Oral Capsule, 300MG Oral Capsule) G 2
C1
Sirtu
ro
Sirturo (Oral Tablet) B 4 PA; LA C1
Trec
ator
Trecator (Oral Tablet) B 3
A1
AntineoplasticsB1
Alkylating AgentsC1
Cycl
oph
osp
ham
ide Cyclophosphamide (Oral Capsule) G 2 B/D, PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
69Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Cycl
oph
osp
ham
ide Cyclophosphamide (25MG Oral Tablet) G 2 B/D, PA C1
Cycl
oph
osp
ham
ide Cyclophosphamide (50MG Oral Tablet) B 2 B/D, PA C1
Leu
kera
n
Leukeran (Oral Tablet) B 4
C1
Mat
ulan
e
Matulane (Oral Capsule) B 4 LA C1
Valc
hlor
Valchlor (External Gel) B 4 PA; LA; QL B1
AntiandrogensC1
Abir
ater
one
Acet
ate Abiraterone Acetate (Oral Tablet) G 4 PA C1
Bica
luta
mid
e
Bicalutamide (Oral Tablet) G 1
C1
Cas
ode
x
Casodex (Oral Tablet) B 4
C1
Erle
ada
Erleada (Oral Tablet) B 4 PA C1
Flut
ami
de
Flutamide (Oral Capsule) G 3
C1
Nila
ndro
n
Nilandron (Oral Tablet) B 4
C1
Nilut
ami
de
Nilutamide (Oral Tablet) G 4
C1
Nub
eqa
Nubeqa (Oral Tablet) B 4 PA; LA C1
Xtan
di
Xtandi (Oral Capsule) B 4 PA; LA C1
Xtan
di
Xtandi (Oral Tablet) B 4 PA C1
Yon
sa
Yonsa (Oral Tablet) B 4 PA C1
Zyti
ga
Zytiga (Oral Tablet) B 4 PA B1
Antiangiogenic AgentsC1
Foti
vda
Fotivda (Oral Capsule) B 4 PA; QL C1
Pom
alyst
Pomalyst (Oral Capsule) B 4 PA C1
Qinl
ock
Qinlock (Oral Tablet) B 4 PA; QL C1
Revl
imid
Revlimid (Oral Capsule) B 4 PA; LA C1
Tabr
ecta
Tabrecta (Oral Tablet) B 4 PA; QL C1
Thal
omi
d
Thalomid (Oral Capsule) B 4 PA; QL B1
Antiestrogens/ModifiersC1
Emc
yt
Emcyt (Oral Capsule) B 4
C1
Fare
ston
Fareston (Oral Tablet) B 4
C1
Solt
amo
x
Soltamox (Oral Solution) B 4
C1
Tam
oxif
en
Citra
te Tamoxifen Citrate (Oral Tablet) G 1
C1
Tore
mife
ne
Citra
te Toremifene Citrate (Oral Tablet) G 4
B1
AntimetabolitesC1
Dro
xia
Droxia (Oral Capsule) B 3
C1
Hyd
rea
Hydrea (Oral Capsule) B 3
C1
Hyd
roxy
urea
Hydroxyurea (Oral Capsule) G 1
C1
Mer
capt
opur
ine
Mercaptopurine (Oral Tablet) G 2
C1
Onu
reg
Onureg (Oral Tablet) B 4 PA; QL
70 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Puri
xan
Purixan (Oral Suspension) B 4 PA C1
Tabl
oid
Tabloid (Oral Tablet) B 3 PA B1
Antineoplastics, OtherC1
IDHI
FA
IDHIFA (Oral Tablet) B 4 PA; LA C1
Lon
surf
Lonsurf (Oral Tablet) B 4 PA; LA C1
Ninl
aro
Ninlaro (Oral Capsule) B 4 PA C1
Pem
azyr
e
Pemazyre (Oral Tablet) B 4 PA; QL C1
Ret
evm
o
Retevmo (Oral Capsule) B 4 PA; QL C1
Synr
ibo
Synribo (Subcutaneous Solution Reconstituted) B 4 PA C1
Tazv
erik
Tazverik (Oral Tablet) B 4 PA; LA; QL C1
Tuk
ysa
Tukysa (Oral Tablet) B 4 PA; QL C1
Xpo
vio
Xpovio (100MG Once Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Xpo
vio
Xpovio (40MG Once Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Xpo
vio
Xpovio (40MG Twice Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Xpo
vio
Xpovio (60MG Once Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Xpo
vio
Xpovio (60MG Twice Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Xpo
vio
Xpovio (80MG Once Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Xpo
vio
Xpovio (80MG Twice Weekly) (Oral Tablet Therapy
Pack)B 4 PA; LA; QL
C1
Zoli
nza
Zolinza (Oral Capsule) B 4 PA B1
Aromatase Inhibitors, 3rd GenerationC1
Ana
stro
zole
Anastrozole (Oral Tablet) G 1
C1
Arim
idex
Arimidex (Oral Tablet) B 4
C1
Aro
masi
n
Aromasin (Oral Tablet) B 4
C1
Exe
mes
tane
Exemestane (Oral Tablet) G 3
C1
Fem
ara
Femara (Oral Tablet) B 4
C1
Letr
ozol
e
Letrozole (Oral Tablet) G 1
B1
Molecular Target InhibitorsC1
Afini
tor
Disp
erz
Afinitor Disperz (Oral Tablet Soluble) B 4 PA C1
Afini
tor
Afinitor (Oral Tablet) B 4 PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
71Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Alec
ens
a
Alecensa (Oral Capsule) B 4 PA; LA C1
Alun
brig
Alunbrig (Oral Tablet) B 4 PA; LA; QL C1
Alun
brig
Alunbrig (Oral Tablet Therapy Pack) B 4 PA; LA; QL C1
Ayv
akit
Ayvakit (100MG Oral Tablet, 200MG Oral Tablet,
300MG Oral Tablet)B 4 PA; LA; QL
C1
Balv
ersa
Balversa (Oral Tablet) B 4 PA; LA; QL C1
Bos
ulif
Bosulif (Oral Tablet) B 4 PA C1
Braf
tovi
Braftovi (Oral Capsule) B 4 PA C1
Bruk
insa
Brukinsa (Oral Capsule) B 4 PA; LA; QL C1
Cab
ome
tyx
Cabometyx (Oral Tablet) B 4 PA; LA C1
Calq
uen
ce
Calquence (Oral Capsule) B 4 PA C1
Cap
rels
a
Caprelsa (Oral Tablet) B 4 PA; LA C1
Co
metr
iq
Cometriq (100MG Daily Dose) (Oral Kit) B 4 PA; LA C1
Co
metr
iq
Cometriq (140MG Daily Dose) (Oral Kit) B 4 PA; LA C1
Co
metr
iq
Cometriq (60MG Daily Dose) (Oral Kit) B 4 PA; LA C1
Cop
iktra
Copiktra (Oral Capsule) B 4 PA; QL C1
Cot
ellic
Cotellic (Oral Tablet) B 4 PA; LA C1
Dau
rism
o
Daurismo (Oral Tablet) B 4 PA; LA; QL C1
Eriv
edg
e
Erivedge (Oral Capsule) B 4 PA; LA C1
Erlot
inib
HCl
Erlotinib HCl (Oral Tablet) G 4 PA C1
Ever
olim
us
Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG
Oral Tablet)G 4 PA
C1
Fary
dak
Farydak (Oral Capsule) B 4 PA C1
Gavr
eto
Gavreto (Oral Capsule) B 4 PA; QL C1
Gilot
rif
Gilotrif (Oral Tablet) B 4 PA; LA C1
Glee
vec
Gleevec (Oral Tablet) B 4 PA; QL C1
Ibra
nce
Ibrance (Oral Capsule) B 4 PA; LA C1
Ibra
nce
Ibrance (Oral Tablet) B 4 PA; LA C1
Iclus
ig
Iclusig (Oral Tablet) B 4 PA; LA C1
Imat
inib
Mes
ylate
Imatinib Mesylate (Oral Tablet) G 4 PA; QL C1
Imbr
uvic
a
Imbruvica (Oral Capsule) B 4 PA; LA; QL C1
Imbr
uvic
a
Imbruvica (Oral Tablet) B 4 PA; QL C1
Inlyt
a
Inlyta (Oral Tablet) B 4 PA; LA; QL C1
Inqo
vi
Inqovi (Oral Tablet) B 4 PA; QL C1
Inre
bic
Inrebic (Oral Capsule) B 4 PA; QL C1
Ires
sa
Iressa (Oral Tablet) B 4 PA; LA; QL C1
Jaka
fi
Jakafi (Oral Tablet) B 4 PA; LA; QL
72 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Kisq
ali
Kisqali (200MG Dose) (Oral Tablet) B 4 PA C1
Kisq
ali
Kisqali (400MG Dose) (Oral Tablet) B 4 PA C1
Kisq
ali
Kisqali (600MG Dose) (Oral Tablet) B 4 PA C1
Kisq
ali
Fem
ara
Kisqali Femara (200MG Dose) (Oral Tablet Therapy
Pack)B 4 PA
C1
Kisq
ali
Fem
ara
Kisqali Femara (400MG Dose) (Oral Tablet Therapy
Pack)B 4 PA
C1
Kisq
ali
Fem
ara
Kisqali Femara (600MG Dose) (Oral Tablet Therapy
Pack)B 4 PA
C1
Kos
elug
o
Koselugo (Oral Capsule) B 4 PA; QL C1
Lap
atini
b
Dito
sylat
e Lapatinib Ditosylate (Oral Tablet) G 4 PA C1
Len
vima
10M
G
Dail
y
Dos
e Lenvima 10MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
12M
G
Dail
y
Dos
e Lenvima 12MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
14M
G
Dail
y
Dos
e Lenvima 14MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
18M
G
Dail
y
Dos
e Lenvima 18MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
20M
G
Dail
y
Dos
e Lenvima 20MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
24M
G
Dail
y
Dos
e Lenvima 24MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
4M
G
Dail
y
Dos
e Lenvima 4MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Len
vima
8M
G
Dail
y
Dos
e Lenvima 8MG Daily Dose (Oral Capsule Therapy
Pack)B 4 PA; LA
C1
Lorb
rena
Lorbrena (Oral Tablet) B 4 PA; LA; QL C1
Lyn
parz
a
Lynparza (Oral Tablet) B 4 PA; LA C1
Mek
inist
Mekinist (Oral Tablet) B 4 PA; LA C1
Mek
tovi
Mektovi (Oral Tablet) B 4 PA C1
Nerl
ynx
Nerlynx (Oral Tablet) B 4 PA; LA; QL C1
Nex
avar
Nexavar (Oral Tablet) B 4 PA; LA C1
Odo
mzo
Odomzo (Oral Capsule) B 4 PA; LA; QL C1
Piqr
ay
Piqray (200MG Daily Dose) (Oral Tablet Therapy
Pack)B 4 PA; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
73Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Piqr
ay
Piqray (250MG Daily Dose) (Oral Tablet Therapy
Pack)B 4 PA; QL
C1
Piqr
ay
Piqray (300MG Daily Dose) (Oral Tablet Therapy
Pack)B 4 PA; QL
C1
Rozl
ytre
k
Rozlytrek (Oral Capsule) B 4 PA; QL C1
Rub
raca
Rubraca (Oral Tablet) B 4 PA; LA C1
Ryd
apt
Rydapt (Oral Capsule) B 4 PA; QL C1
Spry
cel
Sprycel (Oral Tablet) B 4 PA C1
Stiv
arga
Stivarga (Oral Tablet) B 4 PA; LA C1
Sute
nt
Sutent (Oral Capsule) B 4 PA C1
Tafi
nlar
Tafinlar (Oral Capsule) B 4 PA; LA C1
Tagr
isso
Tagrisso (Oral Tablet) B 4 PA; LA C1
Talz
enn
a
Talzenna (Oral Capsule) B 4 PA; LA; QL C1
Tarc
eva
Tarceva (Oral Tablet) B 4 PA C1
Tasi
gna
Tasigna (Oral Capsule) B 4 PA C1
Tep
met
ko
Tepmetko (Oral Tablet) B 4 PA; QL C1
Tibs
ovo
Tibsovo (Oral Tablet) B 4 PA; QL C1
Tura
lio
Turalio (Oral Capsule) B 4 PA; LA; QL C1
Tyk
erb
Tykerb (Oral Tablet) B 4 PA; LA C1
Uko
niq
Ukoniq (Oral Tablet) B 4 PA; QL C1
Ven
clext
a
Venclexta (100MG Oral Tablet, 50MG Oral Tablet) B 4 PA; LA C1
Ven
clext
a
Venclexta (10MG Oral Tablet) B 2 PA; LA C1
Ven
clext
a
Start
ing
Pac
k Venclexta Starting Pack (Oral Tablet Therapy Pack) B 4 PA; LA C1
Verz
enio
Verzenio (Oral Tablet) B 4 PA; LA C1
Vitra
kvi
Vitrakvi (Oral Capsule) B 4 PA; LA; QL C1
Vitra
kvi
Vitrakvi (Oral Solution) B 4 PA; LA; QL C1
Vizi
mpr
o
Vizimpro (Oral Tablet) B 4 PA; LA C1
Votri
ent
Votrient (Oral Tablet) B 4 PA; LA C1
Xalk
ori
Xalkori (Oral Capsule) B 4 PA; LA C1
Xos
pata
Xospata (Oral Tablet) B 4 PA; QL C1
Zeju
la
Zejula (Oral Capsule) B 4 PA; LA C1
Zelb
oraf
Zelboraf (Oral Tablet) B 4 PA; LA; QL C1
Zyd
elig
Zydelig (Oral Tablet) B 4 PA; LA C1
Zyk
adia
Zykadia (Oral Tablet) B 4 PA B1
RetinoidsC1
Bex
arot
ene
Bexarotene (Oral Capsule) G 4 PA C1
Targ
retin
Targretin (External Gel) B 4 PA; QL
74 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Targ
retin
Targretin (Oral Capsule) B 4 PA C1
Treti
noin
Tretinoin (Oral Capsule) G 4
B1
Treatment AdjunctsC1
Leu
cov
orin
Calc
ium Leucovorin Calcium (10MG Oral Tablet, 15MG Oral
Tablet)G 2
C1
Leu
cov
orin
Calc
ium Leucovorin Calcium (25MG Oral Tablet) G 3
C1
Leu
cov
orin
Calc
ium Leucovorin Calcium (5MG Oral Tablet) G 1
C1
Mes
nex
Mesnex (Oral Tablet) B 4
A1
AntiparasiticsB1
AnthelminticsC1
Albe
nda
zole
Albendazole (Oral Tablet) G 4 QL C1
Albe
nza
Albenza (Oral Tablet) B 4 QL C1
Biltri
cide
Biltricide (Oral Tablet) B 3
C1
Emv
erm
Emverm (Oral Tablet Chewable) G 4
C1
Iver
mec
tin
Ivermectin (Oral Tablet) G 1
C1
Praz
iqua
ntel
Praziquantel (Oral Tablet) G 3
C1
Stro
mec
tol
Stromectol (Oral Tablet) B 3
B1
AntiprotozoalsC1
Alini
a
Alinia (Oral Suspension Reconstituted) B 4
C1
Alini
a
Alinia (Oral Tablet) B 4
C1
Atov
aqu
one
Atovaquone (Oral Suspension) G 4
C1
Atov
aqu
one-
Pro
gua
nil
HCl Atovaquone-Proguanil HCl (Oral Tablet) G 2
C1
Ben
znid
azol
e
Benznidazole (Oral Tablet) B 3
C1
Chlo
roqu
ine
Pho
sph
ate Chloroquine Phosphate (Oral Tablet) G 2 QL C1
Coa
rtem
Coartem (Oral Tablet) B 3
C1
DAR
APR
IM
DARAPRIM (Oral Tablet) B 4
C1
Hyd
roxy
chlo
roqu
ine
Sulf
ate Hydroxychloroquine Sulfate (Oral Tablet) G 1 QL C1
Imp
avid
o
Impavido (Oral Capsule) B 4
C1
Krint
afel
Krintafel (Oral Tablet) B 3
C1
Lam
pit
Lampit (Oral Tablet) B 3 PA C1
Mal
aron
e
Malarone (Oral Tablet) B 3
C1
Mefl
oqui
ne
HCl
Mefloquine HCl (Oral Tablet) G 1
C1
Mep
ron
Mepron (Oral Suspension) B 4
C1
Neb
upe
nt
Nebupent (Inhalation Solution Reconstituted) B 3 B/D, PA; QL C1
Nita
zoxa
nide
Nitazoxanide (Oral Tablet) G 4
C1
PEN
TA
M
300
PENTAM 300 (Injection Solution Reconstituted) B 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
75Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pent
ami
dine
Iset
hion
ate Pentamidine Isethionate (Inhalation Solution
Reconstituted)G 3 B/D, PA; QL
C1
Pent
ami
dine
Iset
hion
ate Pentamidine Isethionate (Injection Solution
Reconstituted)G 3
C1
Plaq
ueni
l
Plaquenil (Oral Tablet) B 3 QL C1
Prim
aqui
ne
Pho
sph
ate Primaquine Phosphate (Oral Tablet) G 2
C1
Pyri
met
ham
ine
Pyrimethamine (Oral Tablet) G 4
C1
Qual
aqui
n
Qualaquin (Oral Capsule) B 3 PA C1
Quin
ine
Sulf
ate
Quinine Sulfate (Oral Capsule) G 3 PA A1
Antiparkinson AgentsB1
AnticholinergicsC1
Ben
ztro
pine
Mes
ylate Benztropine Mesylate (Oral Tablet) G 2 PA; HRM C1
Trih
exy
phe
nidyl
HCl Trihexyphenidyl HCl (Oral Solution) G 3 PA; HRM C1
Trih
exy
phe
nidyl
HCl Trihexyphenidyl HCl (Oral Tablet) G 3 PA; HRM B1
Antiparkinson Agents, OtherC1
Ama
ntad
ine
HCl
Amantadine HCl (Oral Capsule) G 2
C1
Ama
ntad
ine
HCl
Amantadine HCl (Oral Syrup) G 1
C1
Ama
ntad
ine
HCl
Amantadine HCl (Oral Tablet) G 2
C1
Car
bido
pa-
Lev
odo
pa-
Enta
cap
one Carbidopa-Levodopa-Entacapone (Oral Tablet) G 3
C1
Co
mta
n
Comtan (Oral Tablet) B 3
C1
Enta
cap
one
Entacapone (Oral Tablet) G 3
C1
Goc
ovri
Gocovri (Oral Capsule Extended Release 24 Hour) B 4 PA C1
Nou
rian
z
Nourianz (Oral Tablet) B 4 PA; QL C1
Ong
enty
s
Ongentys (Oral Capsule) B 3 ST; QL C1
Os
mol
ex
ER
Osmolex ER (Oral Tablet ER 24 Hour Therapy Pack) B 3 PA C1
Os
mol
ex
ER
Osmolex ER (Oral Tablet Extended Release 24 Hour) B 3 PA C1
Stal
evo
100
Stalevo 100 (Oral Tablet) B 4
C1
Stal
evo
125
Stalevo 125 (Oral Tablet) B 4
C1
Stal
evo
150
Stalevo 150 (Oral Tablet) B 4
C1
Stal
evo
200
Stalevo 200 (Oral Tablet) B 4
C1
Stal
evo
50
Stalevo 50 (Oral Tablet) B 4
C1
Stal
evo
75
Stalevo 75 (Oral Tablet) B 4
C1
Tas
mar
Tasmar (Oral Tablet) B 4 QL C1
Tolc
apo
ne
Tolcapone (Oral Tablet) G 4 QL B1
Dopamine AgonistsC1
Apo
kyn
Apokyn (Subcutaneous Solution Cartridge) B 4 PA; LA; QL C1
Bro
moc
ripti
ne
Mes
ylate Bromocriptine Mesylate (Oral Capsule) G 3
76 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Bro
moc
ripti
ne
Mes
ylate Bromocriptine Mesylate (Oral Tablet) G 3
C1
Kyn
mob
i
Kynmobi (10MG Sublingual Film, 15MG Sublingual
Film, 20MG Sublingual Film, 25MG Sublingual Film,
30MG Sublingual Film)
B 4 PA; QL
C1
Mira
pex
ER
Mirapex ER (Oral Tablet Extended Release 24 Hour) B 3
C1
Mira
pex
Mirapex (Oral Tablet Immediate Release) B 3
C1
Neu
pro
Neupro (Transdermal Patch 24 Hour) B 3
C1
Parl
odel
Parlodel (Oral Capsule) B 3
C1
Parl
odel
Parlodel (Oral Tablet) B 3
C1
Pra
mip
exol
e
Dihy
droc
hlori
de
ER Pramipexole Dihydrochloride ER (Oral Tablet Extended
Release 24 Hour)G 3
C1
Pra
mip
exol
e
Dihy
droc
hlori
de Pramipexole Dihydrochloride (Oral Tablet Immediate
Release)G 1
C1
Rop
iniro
le
HCl
ER Ropinirole HCl ER (Oral Tablet Extended Release 24
Hour)G 3
C1
Rop
iniro
le
HCl
Ropinirole HCl (Oral Tablet Immediate Release) G 1
B1
Dopamine Precursors and/or L-Amino Acid Decarboxylase InhibitorsC1
Car
bido
pa
Carbidopa (Oral Tablet) G 3
C1
Car
bido
pa-
Lev
odo
pa
ER Carbidopa-Levodopa ER (Oral Tablet Extended Release) G 2
C1
Car
bido
pa-
Lev
odo
pa Carbidopa-Levodopa (Oral Tablet Immediate Release) G 1
C1
Car
bido
pa-
Lev
odo
pa
ODT Carbidopa-Levodopa ODT (Oral Tablet Dispersible) G 3
C1
Duo
pa
Duopa (Enteral Suspension) B 4 PA C1
Inbri
ja
Inbrija (Inhalation Capsule) B 4 PA; LA C1
Lod
osy
n
Lodosyn (Oral Tablet) B 4
C1
Ryta
ry
Rytary (Oral Capsule Extended Release) B 3 ST C1
Sine
met
Sinemet (Oral Tablet Immediate Release) B 3
B1
Monoamine Oxidase B (MAO-B) InhibitorsC1
Azil
ect
Azilect (Oral Tablet) B 4
C1
Ras
agili
ne
Mes
ylate Rasagiline Mesylate (Oral Tablet) G 3
C1
Sele
gilin
e
HCl
Selegiline HCl (Oral Capsule) G 2
C1
Sele
gilin
e
HCl
Selegiline HCl (Oral Tablet) G 2
C1
Zela
par
ODT
Zelapar ODT (Oral Tablet Dispersible) B 4
A1
AntipsychoticsB1
1st Generation/TypicalC1
Chlo
rpro
mazi
ne
HCl Chlorpromazine HCl (Oral Tablet) G 3
C1
Flup
hen
azin
e
Dec
ano
ate Fluphenazine Decanoate (Injection Solution) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
77Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Flup
hen
azin
e
HCl Fluphenazine HCl (2.5MG/ML Injection Solution) G 2
C1
Flup
hen
azin
e
HCl Fluphenazine HCl (5MG/ML Oral Concentrate) G 3
C1
Flup
hen
azin
e
HCl Fluphenazine HCl (2.5MG/5ML Oral Elixir) G 2
C1
Flup
hen
azin
e
HCl Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet,
2.5MG Oral Tablet, 5MG Oral Tablet)G 3
C1
Hald
ol
Dec
ano
ate Haldol Decanoate (Intramuscular Solution) B 3
C1
Hald
ol
Haldol (Injection Solution) B 3
C1
Halo
peri
dol
Dec
ano
ate Haloperidol Decanoate (Intramuscular Solution) G 2
C1
Halo
peri
dol
Lact
ate Haloperidol Lactate (Injection Solution) G 1
C1
Halo
peri
dol
Lact
ate Haloperidol Lactate (Oral Concentrate) G 1
C1
Halo
peri
dol
Haloperidol (Oral Tablet) G 1
C1
Lox
apin
e
Suc
cina
te Loxapine Succinate (Oral Capsule) G 2
C1
Moli
ndo
ne
HCl
Molindone HCl (Oral Tablet) G 3
C1
Pim
ozid
e
Pimozide (Oral Tablet) G 2
C1
Thio
rida
zine
HCl
Thioridazine HCl (Oral Tablet) G 2
C1
Thio
thix
ene
Thiothixene (10MG Oral Capsule, 5MG Oral Capsule) G 3
C1
Thio
thix
ene
Thiothixene (1MG Oral Capsule, 2MG Oral Capsule) G 2
C1
Trifl
uop
eraz
ine
HCl Trifluoperazine HCl (Oral Tablet) G 2
B1
2nd Generation/AtypicalC1
Abili
fy
Mai
nten
a Abilify Maintena (Intramuscular Prefilled Syringe) B 4
C1
Abili
fy
Mai
nten
a Abilify Maintena (Intramuscular Suspension
Reconstituted ER)B 4
C1
Abili
fy
MyC
ite
Abilify MyCite (Oral Tablet) B 4 ST; QL C1
Abili
fy
Abilify (Oral Tablet) B 4 QL C1
Aripi
praz
ole
Aripiprazole (1MG/ML Oral Solution) G 3 QL C1
Aripi
praz
ole
Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet,
20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet,
5MG Oral Tablet)
G 1 QL
C1
Aripi
praz
ole
ODT
Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG
Oral Tablet Dispersible)G 4 QL
C1
Arist
ada
Initi
o
Aristada Initio (Intramuscular Prefilled Syringe) B 4
C1
Arist
ada
Aristada (Intramuscular Prefilled Syringe) B 4
C1
Ase
napi
ne
Mal
eate Asenapine Maleate (10MG Tablet Sublingual) G 3
C1
Ase
napi
ne
Mal
eate Asenapine Maleate (2.5MG Tablet Sublingual, 5MG
Tablet Sublingual)G 4
C1
Capl
yta
Caplyta (Oral Capsule) B 4 ST; QL C1
Fan
apt
Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 4MG
Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet)B 4 ST; QL
78 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Fan
apt
Fanapt (1MG Oral Tablet, 2MG Oral Tablet) B 3 ST; QL C1
Fan
apt
Titra
tion
Pac
k Fanapt Titration Pack (Oral Tablet) B 3 ST C1
Geo
don
Geodon (Intramuscular Solution Reconstituted) B 3
C1
Geo
don
Geodon (Oral Capsule) B 4 QL C1
Inve
ga
Invega (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1
Inve
ga
Sust
enn
a 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 4
C1
Inve
ga
Sust
enn
a Invega Sustenna (39MG/0.25ML Intramuscular
Suspension Prefilled Syringe)B 3
C1
Inve
ga
Trin
za
Invega Trinza (Intramuscular Suspension Prefilled
Syringe)B 4
C1
Latu
da
Latuda (Oral Tablet) B 4 QL C1
Nup
lazid
Nuplazid (Oral Capsule) B 4 PA; QL C1
Nup
lazid
Nuplazid (Oral Tablet) B 4 PA; QL C1
Olan
zapi
ne
Olanzapine (10MG Intramuscular Solution
Reconstituted)G 3
C1
Olan
zapi
ne
Olanzapine (10MG Oral Tablet, 15MG Oral Tablet,
2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet,
7.5MG Oral Tablet)
G 1 QL
C1
Olan
zapi
ne
ODT
Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG
Oral Tablet Dispersible, 20MG Oral Tablet Dispersible,
5MG Oral Tablet Dispersible)
G 2 QL
C1
Pali
peri
don
e
ER Paliperidone ER (Oral Tablet Extended Release 24 Hour) G 3 QL C1
Pers
eris
Perseris (Subcutaneous Prefilled Syringe) B 4
C1
Que
tiapi
ne
Fum
arat
e
ER Quetiapine Fumarate ER (Oral Tablet Extended Release
24 Hour)G 2 QL
C1
Que
tiapi
ne
Fum
arat
e Quetiapine Fumarate (Oral Tablet Immediate Release) G 1 QL C1
Rex
ulti
Rexulti (Oral Tablet) B 4 QL C1
Risp
erda
l
Con
sta Risperdal Consta (12.5MG Intramuscular Suspension
Reconstituted ER, 25MG Intramuscular Suspension
Reconstituted ER)
B 3
C1
Risp
erda
l
Con
sta Risperdal Consta (37.5MG Intramuscular Suspension
Reconstituted ER, 50MG Intramuscular Suspension
Reconstituted ER)
B 4
You can find information on what the abbreviations in this table mean on pages 6 - 7.
79Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Risp
erda
l
Risperdal (1MG/ML Oral Solution) B 4
C1
Risp
erda
l
Risperdal (0.5MG Oral Tablet) B 3
C1
Risp
erda
l
Risperdal (1MG Oral Tablet, 2MG Oral Tablet, 3MG
Oral Tablet, 4MG Oral Tablet)B 4
C1
Risp
erid
one
Risperidone (1MG/ML Oral Solution) G 2
C1
Risp
erid
one
Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet,
1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet,
4MG Oral Tablet)
G 1
C1
Risp
erid
one
ODT
Risperidone ODT (0.25MG Oral Tablet Dispersible,
0.5MG Oral Tablet Dispersible, 1MG Oral Tablet
Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral
Tablet Dispersible, 4MG Oral Tablet Dispersible)
G 3
C1
Sap
hris
Saphris (Tablet Sublingual) B 4
C1
Sec
uad
o
Secuado (Transdermal Patch 24 Hour) B 4 PA; QL C1
Ser
oqu
el
Seroquel (100MG Oral Tablet Immediate Release,
200MG Oral Tablet Immediate Release, 25MG Oral
Tablet Immediate Release, 50MG Oral Tablet
Immediate Release)
B 3 QL
C1
Ser
oqu
el
Seroquel (300MG Oral Tablet Immediate Release,
400MG Oral Tablet Immediate Release)B 4 QL
C1
Ser
oqu
el
XR
Seroquel XR (150MG Oral Tablet Extended Release
24 Hour, 200MG Oral Tablet Extended Release 24
Hour, 50MG Oral Tablet Extended Release 24 Hour)
B 3 QL
C1
Ser
oqu
el
XR
Seroquel XR (300MG Oral Tablet Extended Release
24 Hour, 400MG Oral Tablet Extended Release 24
Hour)
B 4 QL
C1
Vray
lar
Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule,
4.5MG Oral Capsule, 6MG Oral Capsule)B 4 ST; QL
C1
Vray
lar
Vraylar (Oral Capsule Therapy Pack) B 3 ST C1
Zipr
asid
one
HCl
Ziprasidone HCl (Oral Capsule) G 2 QL C1
Zipr
asid
one
Mes
ylate Ziprasidone Mesylate (Intramuscular Solution
Reconstituted)G 3
C1
Zypr
exa
Zyprexa (10MG Intramuscular Solution
Reconstituted)B 3
C1
Zypr
exa
Zyprexa (10MG Oral Tablet, 15MG Oral Tablet, 20MG
Oral Tablet)B 4 QL
C1
Zypr
exa
Zyprexa (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG
Oral Tablet)B 3 QL
80 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Zypr
exa
Relp
revv
Zyprexa Relprevv (210MG Intramuscular Suspension
Reconstituted)B 3
C1
Zypr
exa
Zydi
s
Zyprexa Zydis (10MG Oral Tablet Dispersible, 15MG
Oral Tablet Dispersible, 20MG Oral Tablet
Dispersible)
B 4 QL
C1
Zypr
exa
Zydi
s
Zyprexa Zydis (5MG Oral Tablet Dispersible) B 3 QL B1
Treatment-ResistantC1
Cloz
apin
e
Clozapine (100MG Oral Tablet, 200MG Oral Tablet,
25MG Oral Tablet, 50MG Oral Tablet)G 2
C1
Cloz
apin
e
ODT
Clozapine ODT (100MG Oral Tablet Dispersible, 150MG
Oral Tablet Dispersible, 200MG Oral Tablet Dispersible)G 3
C1
Cloz
apin
e
ODT
Clozapine ODT (12.5MG Oral Tablet Dispersible, 25MG
Oral Tablet Dispersible)G 2
C1
Cloz
aril
Clozaril (100MG Oral Tablet, 200MG Oral Tablet) B 4
C1
Cloz
aril
Clozaril (25MG Oral Tablet, 50MG Oral Tablet) B 3
C1
Vers
aclo
z
Versacloz (Oral Suspension) B 4
A1
Antispasticity AgentsB1
Antispasticity AgentsC1
Bacl
ofen
Baclofen (Oral Tablet) G 1
C1
Dant
rium
Dantrium (Oral Capsule) B 3
C1
Dant
role
ne
Sodi
um Dantrolene Sodium (100MG Oral Capsule, 50MG Oral
Capsule)G 3
C1
Dant
role
ne
Sodi
um Dantrolene Sodium (25MG Oral Capsule) G 2
C1
Tiza
nidi
ne
HCl
Tizanidine HCl (2MG Oral Capsule, 4MG Oral Capsule,
6MG Oral Capsule)G 3
C1
Tiza
nidi
ne
HCl
Tizanidine HCl (2MG Oral Tablet, 4MG Oral Tablet) G 1
C1
Zan
aflex
Zanaflex (Oral Capsule) B 3
C1
Zan
aflex
Zanaflex (Oral Tablet) B 3
A1
AntiviralsB1
Anti-cytomegalovirus (CMV) AgentsC1
Prev
ymis
Prevymis (Oral Tablet) B 4 PA; QL C1
Valc
yte
Valcyte (Oral Solution Reconstituted) B 4 QL C1
Valc
yte
Valcyte (Oral Tablet) B 4 QL C1
Valg
anci
clovi
r
HCl Valganciclovir HCl (50MG/ML Oral Solution
Reconstituted)G 4 QL
C1
Valg
anci
clovi
r
HCl Valganciclovir HCl (450MG Oral Tablet) G 2 QL C1
Zirg
an
Zirgan (Ophthalmic Gel) B 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
81Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
B1
Anti-hepatitis B (HBV) AgentsC1
Ade
fovir
Dipi
voxil Adefovir Dipivoxil (Oral Tablet) G 4
C1
Bara
clud
e
Baraclude (Oral Solution) B 4
C1
Bara
clud
e
Baraclude (Oral Tablet) B 4
C1
Ente
cavir
Entecavir (Oral Tablet) G 3
C1
Epiv
ir
HBV
Epivir HBV (Oral Solution) B 3
C1
Epiv
ir
HBV
Epivir HBV (Oral Tablet) B 3
C1
Hep
sera
Hepsera (Oral Tablet) B 4
C1
Lam
ivudi
ne
Lamivudine (100MG Oral Tablet) G 2
C1
Vem
lidy
Vemlidy (Oral Tablet) B 4
B1
Anti-hepatitis C (HCV) AgentsC1
Epcl
usa
Epclusa (Oral Tablet) B 4 PA; QL C1
Harv
oni
Harvoni (Oral Packet) B 4 PA; QL C1
Harv
oni
Harvoni (90-400MG Oral Tablet) B 4 PA; QL C1
Ledi
pasv
ir-
Sof
osb
uvir Ledipasvir-Sofosbuvir (Oral Tablet) G 4 PA; QL C1
Mav
yret
Mavyret (Oral Tablet) B 4 PA; QL C1
Riba
virin
Ribavirin (Oral Capsule) G 2
C1
Riba
virin
Ribavirin (Oral Tablet) G 2
C1
Sof
osb
uvir-
Velp
atas
vir Sofosbuvir-Velpatasvir (Oral Tablet) G 4 PA; QL C1
Sov
aldi
Sovaldi (Oral Packet) B 4 PA; QL C1
Sov
aldi
Sovaldi (400MG Oral Tablet) B 4 PA; QL C1
Viek
ira
Pak
Viekira Pak (Oral Tablet Therapy Pack) B 4 PA; QL C1
Vos
evi
Vosevi (Oral Tablet) B 4 PA; QL C1
Zep
atier
Zepatier (Oral Tablet) B 4 PA; QL B1
Antiherpetic AgentsC1
Acy
clovi
r
Acyclovir (External Cream) G 3
C1
Acy
clovi
r
Acyclovir (External Ointment) G 3
C1
Acy
clovi
r
Acyclovir (Oral Capsule) G 1
C1
Acy
clovi
r
Acyclovir (Oral Suspension) G 3
C1
Acy
clovi
r
Acyclovir (Oral Tablet) G 1
C1
Acy
clovi
r
Sodi
um Acyclovir Sodium (Intravenous Solution) G 3 B/D, PA C1
Den
avir
Denavir (External Cream) B 4
C1
Fam
ciclo
vir
Famciclovir (Oral Tablet) G 2
C1
Sita
vig
Sitavig (Buccal Tablet) B 3 ST C1
Vala
cycl
ovir
HCl
Valacyclovir HCl (Oral Tablet) G 2 QL C1
Valtr
ex
Valtrex (1GM Oral Tablet) B 4 QL C1
Valtr
ex
Valtrex (500MG Oral Tablet) B 3 QL
82 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Zovi
rax
Zovirax (External Cream) B 4
C1
Zovi
rax
Zovirax (External Ointment) B 4
C1
Zovi
rax
Zovirax (Oral Suspension) B 3
B1
Anti-HIV Agents, Integrase Inhibitors (INSTI)C1
Bikt
arvy
Biktarvy (Oral Tablet) B 4 QL C1
Dov
ato
Dovato (Oral Tablet) B 4 QL C1
Gen
voya
Genvoya (Oral Tablet) B 4 QL C1
Isen
tres
s
HD
Isentress HD (Oral Tablet) B 4 QL C1
Isen
tres
s
Isentress (Oral Packet) B 3 QL C1
Isen
tres
s
Isentress (Oral Tablet) B 4 QL C1
Isen
tres
s
Isentress (100MG Oral Tablet Chewable) B 4 QL C1
Isen
tres
s
Isentress (25MG Oral Tablet Chewable) B 2 QL C1
Julu
ca
Juluca (Oral Tablet) B 4 QL C1
Strib
ild
Stribild (Oral Tablet) B 4 QL C1
Tivic
ay
Tivicay (10MG Oral Tablet) B 3 QL C1
Tivic
ay
Tivicay (25MG Oral Tablet, 50MG Oral Tablet) B 4 QL C1
Tivic
ay
PD
Tivicay PD (Oral Tablet Soluble) B 4 QL B1
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)C1
Atri
pla
Atripla (Oral Tablet) B 4 QL C1
Co
mpl
era
Complera (Oral Tablet) B 4 QL C1
Dels
trigo
Delstrigo (Oral Tablet) B 4 QL C1
Edu
rant
Edurant (Oral Tablet) B 4 QL C1
Efav
iren
z
Efavirenz (Oral Capsule) G 3 QL C1
Efav
iren
z
Efavirenz (Oral Tablet) G 3 QL C1
Efav
iren
z-
Emt
ricit
abin
e-
Ten
ofov
irEfavirenz-Emtricitabine-Tenofovir (Oral Tablet) G 4 QL
C1
Efav
iren
z-
Lam
ivudi
ne-
Ten
ofov
ir Efavirenz-Lamivudine-Tenofovir (Oral Tablet) G 4 QL C1
Intel
enc
e
Intelence (100MG Oral Tablet, 200MG Oral Tablet) B 4 QL C1
Intel
enc
e
Intelence (25MG Oral Tablet) B 3 QL C1
Nevi
rapi
ne
ER
Nevirapine ER (Oral Tablet Extended Release 24 Hour) G 3 QL C1
Nevi
rapi
ne
Nevirapine (Oral Suspension) G 3 QL C1
Nevi
rapi
ne
Nevirapine (Oral Tablet Immediate Release) G 2 QL C1
Pifel
tro
Pifeltro (Oral Tablet) B 4 QL C1
Sust
iva
Sustiva (Oral Capsule) B 3 QL C1
Sust
iva
Sustiva (Oral Tablet) B 4 QL C1
Sym
fi Lo
Symfi Lo (Oral Tablet) B 4 QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
83Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Sym
fi
Symfi (Oral Tablet) B 4 QL C1
Vira
mun
e
Viramune (Oral Suspension) B 4 QL C1
Vira
mun
e
XR
Viramune XR (Oral Tablet Extended Release 24 Hour) B 4 QL B1
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)C1
Aba
cavir
Sulf
ate Abacavir Sulfate (Oral Solution) G 3 QL C1
Aba
cavir
Sulf
ate Abacavir Sulfate (Oral Tablet) G 3 QL C1
Aba
cavir
Sulf
ate-
Lam
ivudi
ne Abacavir Sulfate-Lamivudine (Oral Tablet) G 3 QL C1
Aba
cavir
-
Lam
ivudi
ne-
Zido
vudi
ne Abacavir-Lamivudine-Zidovudine (Oral Tablet) G 4 QL C1
Cim
duo
Cimduo (Oral Tablet) B 4 QL C1
Co
mbi
vir
Combivir (Oral Tablet) B 4 QL C1
Des
covy
Descovy (Oral Tablet) B 4 QL C1
Emt
ricit
abin
e
Emtricitabine (Oral Capsule) G 3 QL C1
Emt
ricit
abin
e-
Ten
ofov
ir
Diso
prox
il
Fum
arat
e
Emtricitabine-Tenofovir Disoproxil Fumarate (Oral Tablet) G 4 QL C1
Emt
riva
Emtriva (Oral Capsule) B 3 QL C1
Emt
riva
Emtriva (Oral Solution) B 3 QL C1
Epiv
ir
Epivir (Oral Solution) B 3 QL C1
Epiv
ir
Epivir (Oral Tablet) B 3 QL C1
Epzi
com
Epzicom (Oral Tablet) B 4 QL C1
Lam
ivudi
ne
Lamivudine (10MG/ML Oral Solution) G 2 QL C1
Lam
ivudi
ne
Lamivudine (150MG Oral Tablet, 300MG Oral Tablet) G 2 QL C1
Lam
ivudi
ne-
Zido
vudi
ne Lamivudine-Zidovudine (Oral Tablet) G 3 QL C1
Ode
fsey
Odefsey (Oral Tablet) B 4 QL C1
Retr
ovir
Retrovir (Oral Capsule) B 3 QL C1
Retr
ovir
Retrovir (Oral Syrup) B 3 QL C1
Tem
ixys
Temixys (Oral Tablet) B 4 QL C1
Ten
ofov
ir
Diso
prox
il
Fum
arat
e Tenofovir Disoproxil Fumarate (Oral Tablet) G 2 QL C1
Triu
meq
Triumeq (Oral Tablet) B 4 QL C1
Trizi
vir
Trizivir (Oral Tablet) B 4 QL C1
Truv
ada
Truvada (Oral Tablet) B 4 QL C1
Vire
ad
Viread (Oral Powder) B 4 QL C1
Vire
ad
Viread (Oral Tablet) B 4 QL C1
Ziag
en
Ziagen (Oral Solution) B 3 QL C1
Ziag
en
Ziagen (Oral Tablet) B 3 QL C1
Zido
vudi
ne
Zidovudine (Oral Capsule) G 3 QL C1
Zido
vudi
ne
Zidovudine (Oral Syrup) G 2 QL C1
Zido
vudi
ne
Zidovudine (Oral Tablet) G 2 QL B1
Anti-HIV Agents, Other
84 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Fuz
eon
Fuzeon (Subcutaneous Solution Reconstituted) B 4 QL C1
Ruk
obia
Rukobia (Oral Tablet Extended Release 12 Hour) B 4 QL C1
Selz
entr
y
Selzentry (Oral Solution) B 4 QL C1
Selz
entr
y
Selzentry (150MG Oral Tablet, 300MG Oral Tablet,
75MG Oral Tablet)B 4 QL
C1
Selz
entr
y
Selzentry (25MG Oral Tablet) B 2 QL C1
Tyb
ost
Tybost (Oral Tablet) B 3 QL B1
Anti-HIV Agents, Protease InhibitorsC1
Apti
vus
Aptivus (Oral Capsule) B 4 QL C1
Ataz
anav
ir
Sulf
ate Atazanavir Sulfate (Oral Capsule) G 3 QL C1
Evot
az
Evotaz (Oral Tablet) B 4 QL C1
Fos
amp
rena
vir
Calc
ium Fosamprenavir Calcium (Oral Tablet) G 4 QL C1
Invir
ase
Invirase (Oral Tablet) B 4 QL C1
Kale
tra
Kaletra (Oral Solution) B 3 QL C1
Kale
tra
Kaletra (100-25MG Oral Tablet) B 3 QL C1
Kale
tra
Kaletra (200-50MG Oral Tablet) B 4 QL C1
Lexi
va
Lexiva (Oral Suspension) B 3 QL C1
Lexi
va
Lexiva (Oral Tablet) B 4 QL C1
Lopi
navi
r-
Rito
navi
r Lopinavir-Ritonavir (Oral Solution) G 3 QL C1
Nor
vir
Norvir (Oral Packet) B 3 QL C1
Nor
vir
Norvir (Oral Solution) B 3 QL C1
Nor
vir
Norvir (Oral Tablet) B 3 QL C1
Prez
cobi
x
Prezcobix (Oral Tablet) B 4 QL C1
Prez
ista
Prezista (Oral Suspension) B 4 QL C1
Prez
ista
Prezista (150MG Oral Tablet, 600MG Oral Tablet,
800MG Oral Tablet)B 4 QL
C1
Prez
ista
Prezista (75MG Oral Tablet) B 3 QL C1
Rey
ataz
Reyataz (Oral Capsule) B 4 QL C1
Rey
ataz
Reyataz (Oral Packet) B 4 QL C1
Rito
navi
r
Ritonavir (Oral Tablet) G 2 QL C1
Sym
tuza
Symtuza (Oral Tablet) B 4 QL C1
Vira
cept
Viracept (Oral Tablet) B 4 QL B1
Anti-influenza AgentsC1
Osel
tami
vir
Pho
sph
ate Oseltamivir Phosphate (Oral Capsule) G 2
C1
Osel
tami
vir
Pho
sph
ate Oseltamivir Phosphate (Oral Suspension Reconstituted) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
85Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Rele
nza
Disk
hale
r Relenza Diskhaler (Inhalation Aerosol Powder Breath
Activated)B 2
C1
Rim
anta
dine
HCl
Rimantadine HCl (Oral Tablet) G 3
C1
Tam
iflu
Tamiflu (Oral Capsule) B 3
C1
Tam
iflu
Tamiflu (Oral Suspension Reconstituted) B 3
C1
Xofl
uza
Xofluza (40MG Dose) (2 x 20MG Oral Tablet Therapy
Pack)B 2 QL
C1
Xofl
uza
Xofluza (80MG Dose) (2 x 40MG Oral Tablet Therapy
Pack)B 2 QL
A1
AnxiolyticsB1
Anxiolytics, OtherC1
Bus
piro
ne
HCl
Buspirone HCl (Oral Tablet) G 1
C1
Hyd
roxy
zine
HCl
Hydroxyzine HCl (Oral Syrup) G 3 PA; HRM C1
Hyd
roxy
zine
Pam
oate Hydroxyzine Pamoate (Oral Capsule) G 3 PA; HRM C1
Vist
aril
Vistaril (Oral Capsule) B 3 PA; HRM B1
BenzodiazepinesC1
Alpr
azol
am
ER
Alprazolam ER (Oral Tablet Extended Release 24 Hour) G 2 PA; QL C1
Alpr
azol
am
Inte
nsol Alprazolam Intensol (Oral Concentrate) G 3 QL C1
Alpr
azol
am
Alprazolam (Oral Tablet Immediate Release) G 1 QL C1
Alpr
azol
am
ODT
Alprazolam ODT (Oral Tablet Dispersible) G 3 QL C1
Ativ
an
Ativan (Oral Tablet) B 4 QL C1
Chlo
rdia
zep
oxid
e
HCl Chlordiazepoxide HCl (Oral Capsule) G 1
C1
Clon
aze
pam
Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG
Oral Tablet)G 1 QL
C1
Clon
aze
pam
ODT Clonazepam ODT (0.125MG Oral Tablet Dispersible,
0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet
Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral
Tablet Dispersible)
G 2 QL
C1
Clor
aze
pate
Dip
otas
siu
m Clorazepate Dipotassium (Oral Tablet) G 3 QL C1
Diaz
epa
m
Inte
nsol Diazepam Intensol (5MG/ML Oral Concentrate) G 2 QL C1
Diaz
epa
m
Diazepam (5MG/5ML Oral Solution) G 1
C1
Diaz
epa
m
Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG
Oral Tablet)G 1 QL
C1
Klon
opin
Klonopin (Oral Tablet) B 3 QL C1
Lora
zep
am
Inte
nsol Lorazepam Intensol (Oral Concentrate) G 1 QL C1
Lora
zep
am
Lorazepam (Oral Tablet) G 1 QL C1
Oxa
zep
am
Oxazepam (Oral Capsule) G 2
C1
Tran
xen
e-T
Tranxene-T (Oral Tablet) B 4 QL
86 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Vali
um
Valium (Oral Tablet) B 3 QL C1
Xan
ax
Xanax (0.25MG Oral Tablet Immediate Release,
0.5MG Oral Tablet Immediate Release, 1MG Oral
Tablet Immediate Release)
B 3 QL
C1
Xan
ax
Xanax (2MG Oral Tablet Immediate Release) B 4 QL C1
Xan
ax
XR
Xanax XR (Oral Tablet Extended Release 24 Hour) B 3 PA; QL A1
Bipolar AgentsB1
Mood StabilizersC1
Dep
akot
e
ER
Depakote ER (Oral Tablet Extended Release 24 Hour) B 3
C1
Dep
akot
e
Depakote (Oral Tablet Delayed Release) B 3
C1
Dep
akot
e
Spri
nkle
s Depakote Sprinkles (Oral Capsule Delayed Release
Sprinkle)B 3
C1
Diva
lpro
ex
Sodi
um
ER Divalproex Sodium ER (Oral Tablet Extended Release 24
Hour)G 1
C1
Diva
lpro
ex
Sodi
um Divalproex Sodium (Oral Capsule Delayed Release
Sprinkle)G 2
C1
Diva
lpro
ex
Sodi
um Divalproex Sodium (Oral Tablet Delayed Release) G 1
C1
Equ
etro
Equetro (Oral Capsule Extended Release 12 Hour) B 3
C1
Lithi
um
Car
bon
ate
ER Lithium Carbonate ER (Oral Tablet Extended Release) G 1
C1
Lithi
um
Car
bon
ate Lithium Carbonate (Oral Capsule) G 1
C1
Lithi
um
Car
bon
ate Lithium Carbonate (Oral Tablet Immediate Release) G 1
C1
Lithi
um
Lithium (8MEQ/5ML Oral Solution) B 2
C1
Lith
obid
Lithobid (Oral Tablet Extended Release) B 4
A1
Blood Glucose RegulatorsB1
Antidiabetic AgentsC1
Acar
bos
e
Acarbose (Oral Tablet) G 1
C1
Acto
plus
Met
Actoplus Met (Oral Tablet Immediate Release) B 3 QL C1
Acto
s
Actos (Oral Tablet) B 3 QL C1
Adly
xin
Start
er
Pac
k Adlyxin Starter Pack (Subcutaneous Pen-Injector Kit) B 3 ST; QL C1
Adly
xin
Adlyxin (Subcutaneous Solution Pen-Injector) B 3 ST; QL C1
Alog
lipti
n
Ben
zoat
e Alogliptin Benzoate (Oral Tablet) G 3 ST; QL C1
Alog
lipti
n-
Metf
ormi
n
HCl Alogliptin-Metformin HCl (Oral Tablet) B 3 ST; QL C1
Alog
lipti
n-
Piog
litaz
one Alogliptin-Pioglitazone (Oral Tablet) G 3 ST; QL C1
Ama
ryl
Amaryl (Oral Tablet) B 3 QL C1
Byd
ureo
n
BCis
e Bydureon BCise (Subcutaneous Auto-Injector) B 3 QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
87Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Byet
ta
10M
CG
Pen Byetta 10MCG Pen (Subcutaneous Solution Pen-
Injector)B 3 ST; QL
C1
Byet
ta
5M
CG
Pen Byetta 5MCG Pen (Subcutaneous Solution Pen-
Injector)B 3 ST; QL
C1
Cycl
oset
Cycloset (Oral Tablet) B 3 PA C1
Due
tact
Duetact (Oral Tablet) B 3 QL C1
Farx
iga
Farxiga (Oral Tablet) B 2 QL C1
Fort
ame
t
Fortamet (1000MG Oral Tablet Extended Release 24
Hour, 500MG Oral Tablet Extended Release 24 Hour)B 4 PA; QL
C1
Glim
epiri
de
Glimepiride (Oral Tablet) G 1 QL C1
Glipi
zide
ER
Glipizide ER (Oral Tablet Extended Release 24 Hour) G 1 QL C1
Glipi
zide
Glipizide (Oral Tablet Immediate Release) G 1 QL C1
Glipi
zide-
Metf
ormi
n
HCl Glipizide-Metformin HCl (Oral Tablet) G 2 QL C1
Gluc
otrol
XL
Glucotrol XL (Oral Tablet Extended Release 24 Hour) B 3 QL C1
Glu
met
za
Glumetza (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1
Glyx
amb
i
Glyxambi (Oral Tablet) B 2 QL C1
Invo
kam
et
Invokamet (Oral Tablet Immediate Release) B 3 ST; QL C1
Invo
kam
et
XR
Invokamet XR (Oral Tablet Extended Release 24
Hour)B 3 ST; QL
C1
Invo
kan
a
Invokana (Oral Tablet) B 3 ST; QL C1
Jan
ume
t
Janumet (Oral Tablet Immediate Release) B 2 QL C1
Jan
ume
t XR
Janumet XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1
Jan
uvia
Januvia (Oral Tablet) B 2 QL C1
Jard
ianc
e
Jardiance (Oral Tablet) B 2 QL C1
Jent
adu
eto
Jentadueto (Oral Tablet Immediate Release) B 2 QL C1
Jent
adu
eto
XR
Jentadueto XR (Oral Tablet Extended Release 24
Hour)B 2 QL
C1
Kaz
ano
Kazano (Oral Tablet) B 3 ST; QL C1
Ko
mbi
glyz
e
XR Kombiglyze XR (Oral Tablet Extended Release 24
Hour)B 3 QL
C1
Metf
ormi
n
HCl
ER Metformin HCl ER (1000MG Oral Tablet Extended
Release 24 Hour, 500MG Oral Tablet Extended Release
24 Hour) (Generic Glumetza)
G 4 PA; QL
C1
Metf
ormi
n
HCl
ER Metformin HCl ER (1000MG Oral Tablet Extended
Release 24 Hour, 500MG Oral Tablet Extended Release
24 Hour) (Generic Fortamet)
G 3 PA; QL
C1
Metf
ormi
n
HCl
ER Metformin HCl ER (Oral Tablet Extended Release 24
Hour) (Generic Glucophage XR)G 1 QL
88 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Metf
ormi
n
HCl
Metformin HCl (500MG/5ML Oral Solution) G 3 QL C1
Metf
ormi
n
HCl
Metformin HCl (1000MG Oral Tablet Immediate Release,
500MG Oral Tablet Immediate Release, 850MG Oral
Tablet Immediate Release)
G 1 QL
C1
Migl
itol
Miglitol (Oral Tablet) G 3
C1
Nat
egli
nide
Nateglinide (Oral Tablet) G 2 QL C1
Nesi
na
Nesina (Oral Tablet) B 3 ST; QL C1
Ong
lyza
Onglyza (Oral Tablet) B 3 QL C1
Ose
ni
Oseni (Oral Tablet) B 3 ST; QL C1
Oze
mpi
c
Ozempic (0.25MG/DOSE or 0.5MG/DOSE)
(Subcutaneous Solution Pen-Injector)B 2 QL
C1
Oze
mpi
c
Ozempic (1MG/DOSE) (Subcutaneous Solution Pen-
Injector)B 2 QL
C1
Piog
litaz
one
HCl
Pioglitazone HCl (Oral Tablet) G 1 QL C1
Piog
litaz
one
HCl-
Glim
epiri
de Pioglitazone HCl-Glimepiride (Oral Tablet) G 3 QL C1
Piog
litaz
one
HCl-
Metf
ormi
n
HCl Pioglitazone HCl-Metformin HCl (Oral Tablet) G 3 QL C1
Qter
n
Qtern (Oral Tablet) B 3 ST; QL C1
Rep
agli
nide
Repaglinide (Oral Tablet) G 1 QL C1
Rio
met
Riomet (Oral Solution) B 3 QL C1
Ryb
elsu
s
Rybelsus (Oral Tablet) B 2 QL C1
Segl
uro
met
Segluromet (Oral Tablet) B 3 ST; QL C1
Soli
qua
Soliqua (Subcutaneous Solution Pen-Injector) B 2 QL C1
Steg
latro
Steglatro (Oral Tablet) B 3 ST; QL C1
Steg
lujan
Steglujan (Oral Tablet) B 3 ST; QL C1
Sym
linP
en
120
SymlinPen 120 (Subcutaneous Solution Pen-Injector) B 4 PA C1
Sym
linP
en
60
SymlinPen 60 (Subcutaneous Solution Pen-Injector) B 4 PA C1
Synj
ardy
Synjardy (Oral Tablet Immediate Release) B 2 QL C1
Synj
ardy
XR
Synjardy XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1
Trad
jent
a
Tradjenta (Oral Tablet) B 2 QL C1
Trija
rdy
XR
Trijardy XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1
Truli
city
Trulicity (Subcutaneous Solution Pen-Injector) B 2 QL C1
Vict
oza
Victoza (Subcutaneous Solution Pen-Injector) B 2 QL C1
Xigd
uo
XR
Xigduo XR (Oral Tablet Extended Release 24 Hour) B 2 QL C1
Xult
oph
y
Xultophy (Subcutaneous Solution Pen-Injector) B 3 ST; QL B1
Glycemic AgentsC1
Baq
simi
Two
Pac
k Baqsimi Two Pack (Nasal Powder) B 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
89Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Diaz
oxid
e
Diazoxide (Oral Suspension) G 4
C1
Gluc
aGe
n
Hyp
oKit GlucaGen HypoKit (Injection Solution Reconstituted) B 3
C1
Gluc
ago
n
Glucagon (Injection Kit) (Lilly) B 2
C1
Gvo
ke
Hyp
oPe
n 2-
Pac
k Gvoke HypoPen 2-Pack (Subcutaneous Solution Auto-
Injector)B 2
C1
Gvo
ke
PFS
Gvoke PFS (Subcutaneous Solution Prefilled Syringe) B 2
C1
Pro
glyc
em
Proglycem (Oral Suspension) B 4
B1
InsulinsC1
Ad
mel
og
Solo
Star Admelog SoloStar (Subcutaneous Solution Pen-
Injector)B 3 PA
C1
Ad
mel
og
Admelog (Subcutaneous Solution) B 3 PA C1
Afre
zza
Afrezza (12UNIT Inhalation Powder, 4 & 8 & 12UNIT
Inhalation Powder, 4 & 8UNIT Inhalation Powder, 8 &
12UNIT Inhalation Powder)
B 4 PA
C1
Afre
zza
Afrezza (4UNIT Inhalation Powder, 8UNIT Inhalation
Powder)B 3 PA
C1
Apid
ra
Apidra (Injection Solution) B 3 PA C1
Apid
ra
Solo
Star
Apidra SoloStar (Subcutaneous Solution Pen-Injector) B 3 PA C1
Bas
agla
r
Kwi
kPe
n Basaglar KwikPen (Subcutaneous Solution Pen-
Injector)B 3 ST
C1
Fias
p
Flex
Tou
ch Fiasp FlexTouch (Subcutaneous Solution Pen-
Injector)B 3 PA
C1
Fias
p
Pen
Fill
Fiasp PenFill (Subcutaneous Solution Cartridge) B 3 PA C1
Fias
p
Fiasp (Subcutaneous Solution) B 3 PA C1
Hu
mal
og
Juni
or
Kwi
kPe
n Humalog Junior KwikPen (Subcutaneous Solution
Pen-Injector)B 2
C1
Hu
mal
og
Kwi
kPe
n Humalog KwikPen (Subcutaneous Solution Pen-
Injector)B 2
C1
Hu
mal
og
Mix
50/5
0
Kwi
kPe
n Humalog Mix 50/50 KwikPen (Subcutaneous
Suspension Pen-Injector)B 2
C1
Hu
mal
og
Mix
50/5
0 Humalog Mix 50/50 (Subcutaneous Suspension) B 2
C1
Hu
mal
og
Mix
75/2
5
Kwi
kPe
n Humalog Mix 75/25 KwikPen (Subcutaneous
Suspension Pen-Injector)B 2
C1
Hu
mal
og
Mix
75/2
5 Humalog Mix 75/25 (Subcutaneous Suspension) B 2
C1
Hu
mal
og
Humalog (Subcutaneous Solution) B 2
C1
Hu
mal
og
Humalog (Subcutaneous Solution Cartridge) B 2
C1
Hu
muli
n
70/3
0
Kwi
kPe
n Humulin 70/30 KwikPen (Subcutaneous Suspension
Pen-Injector)B 2
90 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Hu
muli
n
70/3
0 Humulin 70/30 (Subcutaneous Suspension) B 2
C1
Hu
muli
n N
Kwi
kPe
n Humulin N KwikPen (Subcutaneous Suspension Pen-
Injector)B 2
C1
Hu
muli
n N
Humulin N (Subcutaneous Suspension) B 2
C1
Hu
muli
n R
Humulin R (Injection Solution) B 2
C1
Hu
muli
n R
U-50
0 Humulin R U-500 (Concentrated) (Subcutaneous
Solution)B 2
C1
Hu
muli
n R
U-50
0
Kwi
kPe
n Humulin R U-500 KwikPen (Subcutaneous Solution
Pen-Injector)B 2
C1
Insul
in
Asp
art
Prot
&
Asp
art
Flex
PenInsulin Aspart Prot & Aspart FlexPen (Subcutaneous
Suspension Pen-Injector) (Brand Equivalent Novolog)B 3 PA
C1
Insul
in
Asp
art
Flex
Pen Insulin Aspart FlexPen (Subcutaneous Solution Pen-
Injector) (Brand Equivalent Novolog)B 3 PA
C1
Insul
in
Asp
art
Pen
Fill Insulin Aspart PenFill (Subcutaneous Solution
Cartridge) (Brand Equivalent Novolog)B 3 PA
C1
Insul
in
Asp
art
Prot
&
Asp
art Insulin Aspart Prot & Aspart (Subcutaneous
Suspension) (Brand Equivalent Novolog)B 3 PA
C1
Insul
in
Asp
art
Insulin Aspart (Subcutaneous Solution) (Brand
Equivalent Novolog)B 3 PA
C1
Insul
in
Lisp
ro
Insulin Lispro (1 Unit Dial) (Subcutaneous Solution
Pen-Injector) (Brand Equivalent Humalog)B 2
C1
Insul
in
Lisp
ro
Juni
or
Kwi
kPe
n Insulin Lispro Junior KwikPen (Subcutaneous
Solution Pen-Injector) (Brand Equivalent Humalog)B 2
C1
Insul
in
Lisp
ro
Prot
&
Lisp
ro Insulin Lispro Prot & Lispro (Subcutaneous
Suspension Pen-Injector) (Brand Equivalent Humalog)B 2
C1
Insul
in
Lisp
ro
Insulin Lispro (Subcutaneous Solution) (Brand
Equivalent Humalog)B 2
C1
Lant
us
Solo
Star
Lantus SoloStar (Subcutaneous Solution Pen-Injector) B 2
C1
Lant
us
Lantus (Subcutaneous Solution) B 2
C1
Lev
emir
Flex
Tou
ch Levemir FlexTouch (Subcutaneous Solution Pen-
Injector)B 2
C1
Lev
emir
Levemir (Subcutaneous Solution) B 2
C1
Lyu
mje
v
Lyumjev (Injection Solution) B 2
C1
Lyu
mje
v
Kwi
kPe
n Lyumjev KwikPen (Subcutaneous Solution Pen-
Injector)B 2
C1
Nov
olin
70/3
0
Flex
Pen Novolin 70/30 FlexPen (Subcutaneous Suspension
Pen-Injector)B 3 PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
91Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Nov
olin
70/3
0
Novolin 70/30 (Subcutaneous Suspension) B 3 PA C1
Nov
olin
N
Flex
Pen Novolin N FlexPen (Subcutaneous Suspension Pen-
Injector)B 3 PA
C1
Nov
olin
N
Novolin N (Subcutaneous Suspension) B 3 PA C1
Nov
olin
R
Flex
Pen Novolin R FlexPen (Injection Solution Pen-Injector) B 3 PA C1
Nov
olin
R
Novolin R (Injection Solution) B 3 PA C1
Nov
oLo
g
Flex
Pen NovoLog FlexPen (Subcutaneous Solution Pen-
Injector)B 3 PA
C1
Nov
oLo
g
Mix
70/3
0
Flex
Pen NovoLog Mix 70/30 FlexPen (Subcutaneous
Suspension Pen-Injector)B 3 PA
C1
Nov
oLo
g
Mix
70/3
0 NovoLog Mix 70/30 (Subcutaneous Suspension) B 3 PA C1
Nov
oLo
g
Pen
Fill NovoLog PenFill (Subcutaneous Solution Cartridge) B 3 PA C1
Nov
oLo
g
NovoLog (Subcutaneous Solution) B 3 PA C1
Sem
glee
Semglee (Subcutaneous Solution) B 3 ST C1
Sem
glee
Semglee (Subcutaneous Solution Pen-Injector) B 3 ST C1
Touj
eo
Max
Solo
Star Toujeo Max SoloStar (Subcutaneous Solution Pen-
Injector)B 2
C1
Touj
eo
Solo
Star
Toujeo SoloStar (Subcutaneous Solution Pen-Injector) B 2
C1
Tres
iba
Flex
Tou
ch Tresiba FlexTouch (Subcutaneous Solution Pen-
Injector)B 2
C1
Tres
iba
Tresiba (Subcutaneous Solution) B 2
A1
Blood Products and ModifiersB1
AnticoagulantsC1
Arixt
ra
Arixtra (Subcutaneous Solution) B 4
C1
Eliq
uis
Eliquis (Oral Tablet) B 2 QL C1
Eliq
uis
Start
er
Pac
k Eliquis Starter Pack (Oral Tablet) B 2 QL C1
Eno
xap
arin
Sodi
um Enoxaparin Sodium (100MG/ML Subcutaneous
Solution, 120MG/0.8ML Subcutaneous Solution,
150MG/ML Subcutaneous Solution, 60MG/0.6ML
Subcutaneous Solution, 80MG/0.8ML Subcutaneous
Solution)
G 3 QL
C1
Eno
xap
arin
Sodi
um Enoxaparin Sodium (30MG/0.3ML Subcutaneous
Solution, 40MG/0.4ML Subcutaneous Solution)G 2 QL
C1
Fon
dap
arin
ux
Sodi
um Fondaparinux Sodium (10MG/0.8ML Subcutaneous
Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/
0.6ML Subcutaneous Solution)
G 4
C1
Fon
dap
arin
ux
Sodi
um Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous
Solution)G 3
92 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Frag
min
Fragmin (10000UNIT/ML Subcutaneous Solution,
12500UNIT/0.5ML Subcutaneous Solution,
15000UNIT/0.6ML Subcutaneous Solution,
18000UNT/0.72ML Subcutaneous Solution,
5000UNIT/0.2ML Subcutaneous Solution, 7500UNIT/
0.3ML Subcutaneous Solution, 95000UNIT/3.8ML
Subcutaneous Solution)
B 4
C1
Frag
min
Fragmin (2500UNIT/0.2ML Subcutaneous Solution) B 3
C1
Hep
arin
Sodi
um
Heparin Sodium (10000UNIT/ML Injection Solution,
20000UNIT/ML Injection Solution, 5000UNIT/ML
Injection Solution)
G 2
C1
Hep
arin
Sodi
um
Heparin Sodium (1000UNIT/ML Injection Solution) G 2 B/D, PA C1
Jant
ove
n
Jantoven (Oral Tablet) G 1
C1
Lov
eno
x
Lovenox (100MG/ML Subcutaneous Solution,
120MG/0.8ML Subcutaneous Solution, 60MG/0.6ML
Subcutaneous Solution, 80MG/0.8ML Subcutaneous
Solution)
B 4 QL
C1
Lov
eno
x
Lovenox (150MG/ML Subcutaneous Solution, 30MG/
0.3ML Subcutaneous Solution, 40MG/0.4ML
Subcutaneous Solution)
B 3 QL
C1
Prad
axa
Pradaxa (Oral Capsule) B 3 ST; QL C1
Sav
aysa
Savaysa (Oral Tablet) B 3 ST; QL C1
Warf
arin
Sodi
um
Warfarin Sodium (Oral Tablet) G 1
C1
Xare
lto
Xarelto (Oral Tablet) B 2 QL C1
Xare
lto
Start
er
Pac
k Xarelto Starter Pack (Oral Tablet Therapy Pack) B 2 QL C1
Zont
ivity
Zontivity (Oral Tablet) B 3 PA B1
Blood Products and Modifiers, OtherC1
Agry
lin
Agrylin (Oral Capsule) B 3
C1
Ana
greli
de
HCl
Anagrelide HCl (Oral Capsule) G 2
C1
Aran
esp
Aranesp (Albumin Free) (100MCG/ML Injection
Solution, 200MCG/ML Injection Solution, 300MCG/
ML Injection Solution)
B 4 PA
C1
Aran
esp
Aranesp (Albumin Free) (25MCG/ML Injection
Solution, 40MCG/ML Injection Solution, 60MCG/ML
Injection Solution)
B 3 PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
93Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Aran
esp
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 4 PA
C1
Aran
esp
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 3 PA
C1
Epo
gen
Epogen (10000UNIT/ML Injection Solution,
2000UNIT/ML Injection Solution, 3000UNIT/ML
Injection Solution, 4000UNIT/ML Injection Solution)
B 3 PA
C1
Epo
gen
Epogen (20000UNIT/ML Injection Solution) B 4 PA C1
Fulp
hila
Fulphila (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Gra
nix
Granix (Subcutaneous Solution) B 4 ST C1
Gra
nix
Granix (Subcutaneous Solution Prefilled Syringe) B 4 ST C1
Leu
kine
Leukine (Injection Solution Reconstituted) B 4 PA C1
Mul
plet
a
Mulpleta (Oral Tablet) B 4 PA C1
Neul
asta
Neulasta (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Neu
pog
en
Neupogen (Injection Solution) B 4 ST C1
Neu
pog
en
Neupogen (Injection Solution Prefilled Syringe) B 4 ST C1
Nive
sty
m
Nivestym (Injection Solution) B 4 ST C1
Nive
sty
m
Nivestym (Injection Solution Prefilled Syringe) B 4 ST C1
Nyv
epri
a
Nyvepria (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Oxb
ryta
Oxbryta (Oral Tablet) B 4 PA; QL C1
Proc
rit
Procrit (10000UNIT/ML Injection Solution, 2000UNIT/
ML Injection Solution, 3000UNIT/ML Injection
Solution, 4000UNIT/ML Injection Solution)
B 3 PA
C1
Proc
rit
Procrit (20000UNIT/ML Injection Solution,
40000UNIT/ML Injection Solution)B 4 PA
C1
Pro
mac
ta
Promacta (Oral Packet) B 4 PA; LA; QL C1
Pro
mac
ta
Promacta (Oral Tablet) B 4 PA; LA; QL C1
Reta
crit
Retacrit (Injection Solution) B 3 PA C1
Sikl
os
Siklos (Oral Tablet) B 4 PA C1
Ude
nyca
Udenyca (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Zarx
io
Zarxio (Injection Solution Prefilled Syringe) B 4
94 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Ziex
tenz
o
Ziextenzo (Subcutaneous Solution Prefilled Syringe) B 4 PA B1
Hemostasis AgentsC1
Lyst
eda
Lysteda (Oral Tablet) B 3
C1
Tran
exa
mic
Acid
Tranexamic Acid (Oral Tablet) G 2
B1
Platelet Modifying AgentsC1
Aspi
rin-
Dipy
rida
mol
e
ER Aspirin-Dipyridamole ER (Oral Capsule Extended
Release 12 Hour)G 3 QL
C1
Brili
nta
Brilinta (Oral Tablet) B 2 QL C1
Cabl
ivi
Cablivi (Injection Kit) B 4 PA; LA; QL C1
Cilo
staz
ol
Cilostazol (Oral Tablet) G 1
C1
Clo
pido
grel
Bisu
lfate Clopidogrel Bisulfate (75MG Oral Tablet) G 1 QL C1
Dop
telet
Doptelet (Oral Tablet) B 4 PA C1
Plavi
x
Plavix (Oral Tablet) B 3 QL C1
Pras
ugre
l
HCl
Prasugrel HCl (Oral Tablet) G 2
C1
Tav
aliss
e
Tavalisse (Oral Tablet) B 4 PA; QL A1
Cardiovascular AgentsB1
Alpha-adrenergic AgonistsC1
Cata
pres
-
TTS-
1 Catapres-TTS-1 (Transdermal Patch Weekly) B 3
C1
Cata
pres
-
TTS-
2 Catapres-TTS-2 (Transdermal Patch Weekly) B 3
C1
Cata
pres
-
TTS-
3 Catapres-TTS-3 (Transdermal Patch Weekly) B 3
C1
Clon
idin
e
HCl
Clonidine HCl (Oral Tablet Immediate Release) G 1
C1
Clon
idin
e
Clonidine (0.1MG/24HR Transdermal Patch Weekly) G 2
C1
Clon
idin
e
Clonidine (0.2MG/24HR Transdermal Patch Weekly,
0.3MG/24HR Transdermal Patch Weekly)G 3
C1
Dro
xido
pa
Droxidopa (Oral Capsule) G 4 PA; QL C1
Met
hyld
opa
Methyldopa (Oral Tablet) G 3 PA; HRM C1
Mid
odri
ne
HCl
Midodrine HCl (Oral Tablet) G 2
C1
Nort
hera
Northera (Oral Capsule) B 4 PA; LA; QL B1
Alpha-adrenergic Blocking AgentsC1
Car
dura
Cardura (Oral Tablet Immediate Release) B 3
C1
Dibe
nzyli
ne
Dibenzyline (Oral Capsule) B 4
C1
Dox
azos
in
Mes
ylate Doxazosin Mesylate (Oral Tablet) G 1
C1
Mini
pres
s
Minipress (Oral Capsule) B 3
C1
Phe
nox
ybe
nza
min
e
HCl Phenoxybenzamine HCl (Oral Capsule) G 4
C1
Praz
osin
HCl
Prazosin HCl (Oral Capsule) G 1
B1
Angiotensin II Receptor Antagonists
You can find information on what the abbreviations in this table mean on pages 6 - 7.
95Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Atac
and
Atacand (Oral Tablet) B 3 QL C1
Ava
pro
Avapro (Oral Tablet) B 3 QL C1
Beni
car
Benicar (Oral Tablet) B 3 QL C1
Can
des
arta
n
Cile
xetil Candesartan Cilexetil (Oral Tablet) G 2 QL C1
Coz
aar
Cozaar (Oral Tablet) B 3 QL C1
Diov
an
Diovan (Oral Tablet) B 3 QL C1
Edar
bi
Edarbi (Oral Tablet) B 3 QL C1
Irbe
sart
an
Irbesartan (Oral Tablet) G 1 QL C1
Los
arta
n
Pota
ssiu
m Losartan Potassium (Oral Tablet) G 1 QL C1
Mic
ardi
s
Micardis (Oral Tablet) B 3 QL C1
Olm
esar
tan
Med
oxo
mil Olmesartan Medoxomil (Oral Tablet) G 1 QL C1
Tel
misa
rtan
Telmisartan (Oral Tablet) G 1 QL C1
Vals
arta
n
Valsartan (Oral Tablet) G 1 QL B1
Angiotensin-converting Enzyme (ACE) InhibitorsC1
Acc
upril
Accupril (Oral Tablet) B 3 QL C1
Alta
ce
Altace (Oral Capsule) B 3 QL C1
Ben
aze
pril
HCl
Benazepril HCl (Oral Tablet) G 1 QL C1
Cap
topri
l
Captopril (100MG Oral Tablet, 50MG Oral Tablet) G 3 QL C1
Cap
topri
l
Captopril (12.5MG Oral Tablet, 25MG Oral Tablet) G 2 QL C1
Enal
april
Mal
eate Enalapril Maleate (Oral Tablet) G 1 QL C1
Fosi
nopr
il
Sodi
um Fosinopril Sodium (Oral Tablet) G 1 QL C1
Lisin
opril
Lisinopril (Oral Tablet) G 1 QL C1
Lote
nsin
Lotensin (Oral Tablet) B 3 QL C1
Moe
xipril
HCl
Moexipril HCl (Oral Tablet) G 1 QL C1
Peri
ndo
pril
Erb
umi
ne Perindopril Erbumine (Oral Tablet) G 2 QL C1
Prini
vil
Prinivil (Oral Tablet) B 3 QL C1
Qbr
elis
Qbrelis (Oral Solution) B 4 QL C1
Quin
april
HCl
Quinapril HCl (Oral Tablet) G 1 QL C1
Ram
ipril
Ramipril (Oral Capsule) G 1 QL C1
Tran
dola
pril
Trandolapril (Oral Tablet) G 1 QL C1
Vas
otec
Vasotec (10MG Oral Tablet, 20MG Oral Tablet) B 4 QL C1
Vas
otec
Vasotec (2.5MG Oral Tablet, 5MG Oral Tablet) B 3 QL C1
Zest
ril
Zestril (Oral Tablet) B 3 QL B1
AntiarrhythmicsC1
Ami
odar
one
HCl
Amiodarone HCl (100MG Oral Tablet, 400MG Oral
Tablet)G 3
C1
Ami
odar
one
HCl
Amiodarone HCl (200MG Oral Tablet) G 1
96 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Beta
pac
e AF
Betapace AF (120MG Oral Tablet, 160MG Oral Tablet) B 4
C1
Beta
pac
e AF
Betapace AF (80MG Oral Tablet) B 3
C1
Dof
etili
de
Dofetilide (Oral Capsule) G 2
C1
Flec
aini
de
Acet
ate Flecainide Acetate (Oral Tablet) G 1
C1
Mex
iletin
e
HCl
Mexiletine HCl (Oral Capsule) G 2
C1
Mult
aq
Multaq (Oral Tablet) B 2
C1
Pac
eron
e
Pacerone (100MG Oral Tablet, 400MG Oral Tablet) G 3
C1
Pac
eron
e
Pacerone (200MG Oral Tablet) G 1
C1
Pro
pafe
non
e
HCl
ER Propafenone HCl ER (Oral Capsule Extended Release
12 Hour)G 3
C1
Pro
pafe
non
e
HCl Propafenone HCl (Oral Tablet) G 2
C1
Quin
idin
e
Gluc
onat
e
ER Quinidine Gluconate ER (Oral Tablet Extended Release) G 3
C1
Quin
idin
e
Sulf
ate Quinidine Sulfate (Oral Tablet) G 1
C1
Ryth
mol
SR
Rythmol SR (Oral Capsule Extended Release 12 Hour) B 4
C1
Sori
ne
Sorine (Oral Tablet) G 1
C1
Sota
lol
HCl
AF
Sotalol HCl AF (Oral Tablet) G 1
C1
Sota
lol
HCl
Sotalol HCl (Oral Tablet) G 1
C1
Soty
lize
Sotylize (Oral Solution) B 3 PA C1
Tiko
syn
Tikosyn (Oral Capsule) B 3
B1
Beta-adrenergic Blocking AgentsC1
Ace
buto
lol
HCl
Acebutolol HCl (Oral Capsule) G 2
C1
Aten
olol
Atenolol (Oral Tablet) G 1
C1
Beta
xolo
l
HCl
Betaxolol HCl (Oral Tablet) G 2
C1
Biso
prol
ol
Fum
arat
e Bisoprolol Fumarate (Oral Tablet) G 1
C1
Byst
olic
Bystolic (Oral Tablet) B 2 QL C1
Carv
edil
ol
Carvedilol (Oral Tablet) G 1
C1
Carv
edil
ol
Pho
sph
ate
ER Carvedilol Phosphate ER (Oral Capsule Extended
Release 24 Hour)G 3
C1
Cor
eg
CR
Coreg CR (Oral Capsule Extended Release 24 Hour) B 3
C1
Cor
eg
Coreg (Oral Tablet) B 3
C1
Cor
gard
Corgard (Oral Tablet) B 3
C1
Inde
ral
LA
Inderal LA (Oral Capsule Extended Release 24 Hour) B 4
C1
Inno
Pran
XL
InnoPran XL (Oral Capsule Extended Release 24
Hour)B 4
C1
Lab
etal
ol
HCl
Labetalol HCl (Oral Tablet) G 1
C1
Lopr
ess
or
Lopressor (Oral Tablet) B 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
97Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Met
opr
olol
Suc
cina
te
ER Metoprolol Succinate ER (Oral Tablet Extended Release
24 Hour)G 1
C1
Met
opr
olol
Tartr
ate Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral
Tablet, 50MG Oral Tablet)G 1
C1
Met
opr
olol
Tartr
ate Metoprolol Tartrate (37.5MG Oral Tablet, 75MG Oral
Tablet)G 2
C1
Nad
olol
Nadolol (Oral Tablet) G 2
C1
Pind
olol
Pindolol (Oral Tablet) G 2
C1
Pro
pran
olol
HCl
ER Propranolol HCl ER (Oral Capsule Extended Release 24
Hour)G 2
C1
Pro
pran
olol
HCl
Propranolol HCl (Oral Solution) G 1
C1
Pro
pran
olol
HCl
Propranolol HCl (Oral Tablet) G 1
C1
Ten
ormi
n
Tenormin (Oral Tablet) B 3
C1
Top
rol
XL
Toprol XL (Oral Tablet Extended Release 24 Hour) B 3
B1
Calcium Channel Blocking Agents, DihydropyridinesC1
Aml
odip
ine
Bes
ylate Amlodipine Besylate (Oral Tablet) G 1
C1
Felo
dipi
ne
ER
Felodipine ER (Oral Tablet Extended Release 24 Hour) G 1
C1
Isra
dipi
ne
Isradipine (Oral Capsule) G 3
C1
Kate
rzia
Katerzia (Oral Suspension) B 4 ST C1
Nica
rdipi
ne
HCl
Nicardipine HCl (Oral Capsule) G 3
C1
Nife
dipi
ne
ER
Nifedipine ER (Oral Tablet Extended Release 24 Hour) G 1
C1
Nife
dipi
ne
ER
Os
moti
c
Rele
ase Nifedipine ER Osmotic Release (Oral Tablet Extended
Release 24 Hour)G 1
C1
Nim
odip
ine
Nimodipine (Oral Capsule) G 3
C1
Niso
ldipi
ne
ER
Nisoldipine ER (Oral Tablet Extended Release 24 Hour) G 3
C1
Nor
vasc
Norvasc (Oral Tablet) B 3
C1
Nym
alize
Nymalize (6MG/ML Oral Solution) B 4
C1
Proc
ardi
a XL
Procardia XL (Oral Tablet Extended Release 24 Hour) B 3
C1
Sula
r
Sular (Oral Tablet Extended Release 24 Hour) B 4
B1
Calcium Channel Blocking Agents, NondihydropyridinesC1
Cala
n
SR
Calan SR (Oral Tablet Extended Release) B 3
C1
Car
dize
m
CD
Cardizem CD (Oral Capsule Extended Release 24
Hour)B 4
C1
Car
dize
m
LA
Cardizem LA (Oral Tablet Extended Release 24 Hour) B 3
C1
Car
dize
m
Cardizem (Oral Tablet Immediate Release) B 4
C1
Carti
a XT
Cartia XT (Oral Capsule Extended Release 24 Hour) G 1
98 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Dilti
aze
m
HCl
ER
Bea
ds Diltiazem HCl ER Beads (360MG Oral Capsule Extended
Release 24 Hour, 420MG Oral Capsule Extended
Release 24 Hour)
G 1
C1
Dilti
aze
m
HCl
ER
Coa
ted
Bea
ds 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 1
C1
Dilti
aze
m
HCl
ER
Coa
ted
Bea
ds Diltiazem HCl ER Coated Beads (180MG Oral Tablet
Extended Release 24 Hour, 240MG Oral Tablet
Extended Release 24 Hour, 300MG Oral Tablet
Extended Release 24 Hour, 360MG Oral Tablet
Extended Release 24 Hour)
G 2
C1
Dilti
aze
m
HCl
ER Diltiazem HCl ER (Oral Capsule Extended Release 12
Hour)G 2
C1
Dilti
aze
m
HCl
Diltiazem HCl (Oral Tablet Immediate Release) G 1
C1
Dilt-
XR
Dilt-XR (Oral Capsule Extended Release 24 Hour) G 1
C1
Mat
zim
LA
Matzim LA (Oral Tablet Extended Release 24 Hour) G 2
C1
Tazt
ia
XT
Taztia XT (Oral Capsule Extended Release 24 Hour) G 1
C1
Tiad
ylt
ER
Tiadylt ER (Oral Capsule Extended Release 24 Hour) G 1
C1
Tiaz
ac
Tiazac (Oral Capsule Extended Release 24 Hour) B 3
C1
Vera
pam
il
HCl
ER Verapamil HCl ER (100MG Oral Capsule Extended
Release 24 Hour, 200MG Oral Capsule Extended
Release 24 Hour, 300MG Oral Capsule Extended
Release 24 Hour, 360MG Oral Capsule Extended
Release 24 Hour)
B 3
C1
Vera
pam
il
HCl
ER Verapamil HCl ER (120MG Oral Capsule Extended
Release 24 Hour, 180MG Oral Capsule Extended
Release 24 Hour, 240MG Oral Capsule Extended
Release 24 Hour)
G 2
C1
Vera
pam
il
HCl
ER Verapamil HCl ER (Oral Tablet Extended Release) G 1
C1
Vera
pam
il
HCl
Verapamil HCl (Oral Tablet Immediate Release) G 1
C1
Vere
lan
Verelan (Oral Capsule Extended Release 24 Hour) B 3
C1
Vere
lan
PM
Verelan PM (Oral Capsule Extended Release 24 Hour) B 3
B1
Cardiovascular Agents, OtherC1
Acc
ureti
c
Accuretic (Oral Tablet) B 3 QL C1
Acet
azol
ami
de
ER Acetazolamide ER (Oral Capsule Extended Release 12
Hour)G 2
C1
Acet
azol
ami
de
Acetazolamide (Oral Tablet) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
99Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Alda
ctazi
de
Aldactazide (Oral Tablet) B 3
C1
Alis
kire
n
Fum
arat
e Aliskiren Fumarate (Oral Tablet) G 3 QL C1
Amil
orid
e-
Hyd
roch
lorot
hiazi
de Amiloride-Hydrochlorothiazide (Oral Tablet) G 1
C1
Aml
odip
ine-
Ator
vast
atin Amlodipine-Atorvastatin (Oral Tablet) G 3 QL C1
Aml
odip
ine-
Ben
aze
pril Amlodipine-Benazepril (Oral Capsule) G 1 QL C1
Aml
odip
ine-
Olm
esar
tan Amlodipine-Olmesartan (Oral Tablet) G 2 QL C1
Aml
odip
ine-
Vals
arta
n Amlodipine-Valsartan (Oral Tablet) G 2 QL C1
Aml
odip
ine-
Vals
arta
n-
HCT
Z Amlodipine-Valsartan-HCTZ (Oral Tablet) G 3
C1
Atac
and
HCT
Atacand HCT (Oral Tablet) B 3 QL C1
Aten
olol-
Chlo
rthal
idon
e Atenolol-Chlorthalidone (Oral Tablet) G 1
C1
Aval
ide
Avalide (Oral Tablet) B 3 QL C1
Azor
Azor (Oral Tablet) B 3 QL C1
Ben
aze
pril-
Hyd
roch
lorot
hiazi
de Benazepril-Hydrochlorothiazide (Oral Tablet) G 2 QL C1
Beni
car
HCT
Benicar HCT (Oral Tablet) B 3 QL C1
BiDil
BiDil (Oral Tablet) B 2
C1
Biso
prol
ol-
Hyd
roch
lorot
hiazi
de Bisoprolol-Hydrochlorothiazide (Oral Tablet) G 1 QL C1
Cad
uet
Caduet (Oral Tablet) B 3 QL C1
Can
des
arta
n
Cile
xetil-
HCT
Z Candesartan Cilexetil-HCTZ (Oral Tablet) G 3 QL C1
Corl
anor
Corlanor (Oral Solution) B 3 PA; QL C1
Corl
anor
Corlanor (Oral Tablet) B 3 PA; QL C1
De
mse
r
Demser (Oral Capsule) B 4
C1
Digit
ek
Digitek (125MCG Oral Tablet) G 3 HRM; QL C1
Digit
ek
Digitek (250MCG Oral Tablet) G 3 PA; HRM C1
Dig
ox
Digox (125MCG Oral Tablet) G 3 HRM; QL C1
Dig
ox
Digox (250MCG Oral Tablet) G 3 PA; HRM C1
Dig
oxin
Digoxin (Oral Solution) G 3 PA; HRM; QL C1
Dig
oxin
Digoxin (125MCG Oral Tablet) G 3 HRM; QL C1
Dig
oxin
Digoxin (250MCG Oral Tablet) G 3 PA; HRM C1
Diov
an
HCT
Diovan HCT (Oral Tablet) B 3 QL C1
DUT
OP
ROL
DUTOPROL (Oral Tablet Extended Release 24 Hour) B 3
C1
Edar
bycl
or
Edarbyclor (Oral Tablet) B 3 QL C1
Enal
april
-
Hyd
roch
lorot
hiazi
de Enalapril-Hydrochlorothiazide (Oral Tablet) G 1 QL C1
Entr
esto
Entresto (Oral Tablet) B 2 QL C1
Exfo
rge
HCT
Exforge HCT (Oral Tablet) B 3
C1
Exfo
rge
Exforge (Oral Tablet) B 3 QL C1
Fosi
nopr
il
Sodi
um-
HCT
Z Fosinopril Sodium-HCTZ (Oral Tablet) G 2 QL C1
Hyz
aar
Hyzaar (Oral Tablet) B 3 QL
100 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Irbe
sart
an-
Hyd
roch
lorot
hiazi
de Irbesartan-Hydrochlorothiazide (Oral Tablet) G 1 QL C1
Lan
oxin
Lanoxin (125MCG Oral Tablet, 62.5MCG Oral Tablet) B 3 HRM; QL C1
Lan
oxin
Lanoxin (250MCG Oral Tablet) B 3 PA; HRM C1
Lisin
opril
-
Hyd
roch
lorot
hiazi
de Lisinopril-Hydrochlorothiazide (Oral Tablet) G 1 QL C1
Los
arta
n
Pota
ssiu
m-
HCT
Z Losartan Potassium-HCTZ (Oral Tablet) G 1 QL C1
Lotr
el
Lotrel (Oral Capsule) B 3 QL C1
Max
zide
Maxzide (Oral Tablet) B 3
C1
Max
zide-
25
Maxzide-25 (Oral Tablet) B 3
C1
Met
opr
olol-
Hyd
roch
lorot
hiazi
de Metoprolol-Hydrochlorothiazide (Oral Tablet) G 2
C1
Met
yros
ine
Metyrosine (Oral Capsule) G 4
C1
Mic
ardi
s
HCT
Micardis HCT (Oral Tablet) B 3 QL C1
Olm
esar
tan
Med
oxo
mil-
HCT
Z Olmesartan Medoxomil-HCTZ (Oral Tablet) G 1 QL C1
Olm
esar
tan-
Aml
odip
ine-
HCT
Z Olmesartan-Amlodipine-HCTZ (Oral Tablet) G 3 QL C1
Pent
oxify
lline
ER
Pentoxifylline ER (Oral Tablet Extended Release) G 1
C1
Quin
april
-
Hyd
roch
lorot
hiazi
de Quinapril-Hydrochlorothiazide (Oral Tablet) G 1 QL C1
Ran
exa
Ranexa (Oral Tablet Extended Release 12 Hour) B 3 ST C1
Ran
olazi
ne
ER
Ranolazine ER (Oral Tablet Extended Release 12 Hour) G 2
C1
Spir
onol
acto
ne-
HCT
Z Spironolactone-HCTZ (Oral Tablet) G 1
C1
Tekt
urna
HCT
Tekturna HCT (Oral Tablet) B 3 QL C1
Tekt
urna
Tekturna (Oral Tablet) B 3 QL C1
Tel
misa
rtan-
Aml
odip
ine Telmisartan-Amlodipine (Oral Tablet) G 3 QL C1
Tel
misa
rtan-
HCT
Z Telmisartan-HCTZ (Oral Tablet) G 3 QL C1
Ten
oreti
c
100
Tenoretic 100 (Oral Tablet) B 3
C1
Ten
oreti
c 50
Tenoretic 50 (Oral Tablet) B 3
C1
Tran
dola
pril-
Vera
pam
il
HCl
ER Trandolapril-Verapamil HCl ER (Oral Tablet Extended
Release)G 3 QL
C1
Tria
mter
ene-
HCT
Z Triamterene-HCTZ (Oral Capsule) G 1
C1
Tria
mter
ene-
HCT
Z Triamterene-HCTZ (Oral Tablet) G 1
C1
Trib
enz
or
Tribenzor (Oral Tablet) B 3 QL C1
Twy
nsta
Twynsta (Oral Tablet) B 3 QL C1
Vals
arta
n-
Hyd
roch
lorot
hiazi
de Valsartan-Hydrochlorothiazide (Oral Tablet) G 1 QL C1
Vas
ereti
c
Vaseretic (Oral Tablet) B 3 QL C1
Vec
amyl
Vecamyl (Oral Tablet) G 4 PA C1
Zest
oreti
c
Zestoretic (Oral Tablet) B 3 QL C1
Ziac
Ziac (Oral Tablet) B 3 QL B1
Diuretics, Loop
You can find information on what the abbreviations in this table mean on pages 6 - 7.
101Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Bum
etan
ide
Bumetanide (Injection Solution) G 1
C1
Bum
etan
ide
Bumetanide (Oral Tablet) G 2
C1
Ede
crin
Edecrin (Oral Tablet) B 4
C1
Etha
cryn
ic
Acid
Ethacrynic Acid (Oral Tablet) G 3
C1
Furo
sem
ide
Furosemide (Injection Solution) G 1 B/D, PA C1
Furo
sem
ide
Furosemide (Oral Solution) G 1
C1
Furo
sem
ide
Furosemide (Oral Tablet) G 1
C1
Lasi
x
Lasix (Oral Tablet) B 3
C1
Tors
emi
de
Torsemide (Oral Tablet) G 1
B1
Diuretics, Potassium-sparingC1
Alda
cton
e
Aldactone (Oral Tablet) B 3
C1
Amil
orid
e
HCl
Amiloride HCl (Oral Tablet) G 1
C1
Car
oSpi
r
CaroSpir (Oral Suspension) B 3
C1
Dyre
niu
m
Dyrenium (Oral Capsule) B 3
C1
Eple
reno
ne
Eplerenone (25MG Oral Tablet) G 2
C1
Eple
reno
ne
Eplerenone (50MG Oral Tablet) G 3
C1
Insp
ra
Inspra (Oral Tablet) B 3
C1
Spir
onol
acto
ne
Spironolactone (Oral Tablet) G 1
C1
Tria
mter
ene
Triamterene (Oral Capsule) G 3
B1
Diuretics, ThiazideC1
Chlo
rthal
idon
e
Chlorthalidone (Oral Tablet) G 1
C1
Diuri
l
Diuril (Oral Suspension) B 3
C1
Hyd
roch
lorot
hiazi
de Hydrochlorothiazide (Oral Capsule) G 1
C1
Hyd
roch
lorot
hiazi
de Hydrochlorothiazide (Oral Tablet) G 1
C1
Inda
pam
ide
Indapamide (Oral Tablet) G 1
C1
Met
olaz
one
Metolazone (Oral Tablet) G 2
B1
Dyslipidemics, Fibric Acid DerivativesC1
Anta
ra
Antara (Oral Capsule) B 3
C1
Fen
ofibr
ate
Micr
oniz
ed Fenofibrate Micronized (130MG Oral Capsule) G 3
C1
Fen
ofibr
ate
Micr
oniz
ed Fenofibrate Micronized (134MG Oral Capsule, 200MG
Oral Capsule, 43MG Oral Capsule, 67MG Oral Capsule)G 2
C1
Fen
ofibr
ate
Fenofibrate (50MG Oral Capsule) G 2
C1
Fen
ofibr
ate
Fenofibrate (150MG Oral Capsule) G 3
C1
Fen
ofibr
ate
Fenofibrate (120MG Oral Tablet, 40MG Oral Tablet) G 3
C1
Fen
ofibr
ate
Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet) G 2
C1
Fen
ofibr
ate
Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet) G 1
C1
Fen
ofibr
ic
Acid
Fenofibric Acid (Oral Capsule Delayed Release) G 2
102 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Fen
ogli
de
Fenoglide (120MG Oral Tablet) B 4
C1
Fen
ogli
de
Fenoglide (40MG Oral Tablet) B 3
C1
Ge
mfib
rozil
Gemfibrozil (Oral Tablet) G 1
C1
Lipo
fen
Lipofen (Oral Capsule) B 3
C1
Lopi
d
Lopid (Oral Tablet) B 3
C1
Tric
or
Tricor (Oral Tablet) B 3
C1
Trili
pix
Trilipix (Oral Capsule Delayed Release) B 3
B1
Dyslipidemics, HMG CoA Reductase InhibitorsC1
Alto
prev
Altoprev (Oral Tablet Extended Release 24 Hour) B 4 QL C1
Ator
vast
atin
Calc
ium Atorvastatin Calcium (Oral Tablet) G 1 QL C1
Cres
tor
Crestor (Oral Tablet) B 3 QL C1
Ezall
or
Spri
nkle
Ezallor Sprinkle (Oral Capsule Sprinkle) B 3 QL C1
FloL
ipid
FloLipid (Oral Suspension) B 3 QL C1
Fluv
asta
tin
Sodi
um
ER Fluvastatin Sodium ER (Oral Tablet Extended Release 24
Hour)G 3 QL
C1
Fluv
asta
tin
Sodi
um Fluvastatin Sodium (Oral Capsule) G 3 QL C1
Les
col
XL
Lescol XL (Oral Tablet Extended Release 24 Hour) B 3 QL C1
Lipit
or
Lipitor (Oral Tablet) B 3 QL C1
Lival
o
Livalo (Oral Tablet) B 2 QL C1
Lov
asta
tin
Lovastatin (Oral Tablet) G 1 QL C1
Prav
asta
tin
Sodi
um Pravastatin Sodium (Oral Tablet) G 1 QL C1
Ros
uvas
tatin
Calc
ium Rosuvastatin Calcium (Oral Tablet) G 1 QL C1
Sim
vast
atin
Simvastatin (Oral Tablet) G 1 QL C1
Zoc
or
Zocor (Oral Tablet) B 3 QL C1
Zypi
tam
ag
Zypitamag (Oral Tablet) B 3 ST; QL B1
Dyslipidemics, OtherC1
Chol
esty
rami
ne
Ligh
t Cholestyramine Light (Oral Powder) G 3
C1
Chol
esty
rami
ne
Cholestyramine (Oral Packet) G 3
C1
Cole
seve
lam
HCl
Colesevelam HCl (Oral Packet) G 3
C1
Cole
seve
lam
HCl
Colesevelam HCl (Oral Tablet) G 3
C1
Cole
stid
Colestid (Oral Packet) B 3
C1
Cole
stid
Colestid (Oral Tablet) B 3
C1
Cole
stip
ol
HCl
Colestipol HCl (Oral Packet) G 3
C1
Cole
stip
ol
HCl
Colestipol HCl (Oral Tablet) G 2
C1
Ezet
imib
e
Ezetimibe (Oral Tablet) G 1
C1
Ezet
imib
e-
Sim
vast
atin Ezetimibe-Simvastatin (Oral Tablet) G 3 QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
103Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Icos
ape
nt
Ethy
l Icosapent Ethyl (Oral Capsule) G 3
C1
Juxt
apid
Juxtapid (10MG Oral Capsule, 20MG Oral Capsule,
30MG Oral Capsule, 5MG Oral Capsule)B 4 PA; LA
C1
Lov
aza
Lovaza (Oral Capsule) B 3
C1
Nexl
etol
Nexletol (Oral Tablet) B 3 PA; QL C1
Nexl
izet
Nexlizet (Oral Tablet) B 3 PA; QL C1
Niac
in
ER
Niacin ER (Antihyperlipidemic) (1000MG Oral Tablet
Extended Release, 750MG Oral Tablet Extended
Release)
G 3
C1
Niac
in
ER
Niacin ER (Antihyperlipidemic) (500MG Oral Tablet
Extended Release)G 1
C1
Niac
or
Niacor (Oral Tablet) G 3
C1
Nias
pan
Niaspan (Oral Tablet Extended Release) B 3
C1
Om
ega-
3-
Acid
Ethy
l
Este
rs Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic
Lovaza)G 2
C1
Pral
uent
Praluent (Subcutaneous Solution Auto-Injector) B 2 PA; LA; QL C1
Prev
alite
Prevalite (Oral Packet) G 3
C1
Que
stra
n
Ligh
t Questran Light (Oral Powder) G 3
C1
Que
stra
n
Questran (Oral Packet) G 3
C1
Rep
atha
Pus
htro
nex
Syst
em Repatha Pushtronex System (Subcutaneous Solution
Cartridge)B 2 PA; QL
C1
Rep
atha
Repatha (Subcutaneous Solution Prefilled Syringe) B 2 PA; QL C1
Rep
atha
Sure
Clic
k Repatha SureClick (Subcutaneous Solution Auto-
Injector)B 2 PA; QL
C1
Ros
zet
Roszet (Oral Tablet) B 3 ST; QL C1
Vas
cep
a
Vascepa (Oral Capsule) B 3
C1
Vyto
rin
Vytorin (Oral Tablet) B 3 QL C1
Wel
chol
Welchol (Oral Packet) B 3
C1
Wel
chol
Welchol (Oral Tablet) B 3
C1
Zeti
a
Zetia (Oral Tablet) B 3
B1
Vasodilators, Direct-acting ArterialC1
Hyd
ralaz
ine
HCl
Hydralazine HCl (Oral Tablet) G 1
C1
Min
oxid
il
Minoxidil (Oral Tablet) G 1
B1
Vasodilators, Direct-acting Arterial/VenousC1
GoN
itro
GoNitro (Sublingual Packet) B 3
C1
Isor
dil
Titra
dos
e Isordil Titradose (Oral Tablet) B 4
104 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Isos
orbi
de
Dinit
rate Isosorbide Dinitrate (10MG Oral Tablet Immediate
Release, 20MG Oral Tablet Immediate Release, 30MG
Oral Tablet Immediate Release, 5MG Oral Tablet
Immediate Release)
G 1
C1
Isos
orbi
de
Dinit
rate Isosorbide Dinitrate (40MG Oral Tablet Immediate
Release)G 4
C1
Isos
orbi
de
Mon
onitr
ate
ER Isosorbide Mononitrate ER (Oral Tablet Extended
Release 24 Hour)G 1
C1
Isos
orbi
de
Mon
onitr
ate Isosorbide Mononitrate (Oral Tablet Immediate Release) G 1
C1
Mini
tran
Minitran (Transdermal Patch 24 Hour) G 1
C1
Nitr
o-
Bid
Nitro-Bid (Transdermal Ointment) G 3
C1
Nitr
o-
Dur
Nitro-Dur (Transdermal Patch 24 Hour) B 3
C1
Nitr
ogly
ceri
n
Nitroglycerin (Tablet Sublingual) G 1
C1
Nitr
ogly
ceri
n
Nitroglycerin (Transdermal Patch 24 Hour) G 1
C1
Nitr
ogly
ceri
n
Nitroglycerin (Translingual Solution) G 3
C1
Nitr
olin
gual
Nitrolingual (Translingual Solution) B 3
C1
Nitr
osta
t
Nitrostat (Tablet Sublingual) B 3
C1
Rect
iv
Rectiv (Rectal Ointment) B 3 QL C1
Ver
quv
o
Verquvo (Oral Tablet) B 3 PA; QL A1
Central Nervous System AgentsB1
Attention Deficit Hyperactivity Disorder Agents, AmphetaminesC1
Add
erall
Adderall (20MG Oral Tablet, 5MG Oral Tablet, 7.5MG
Oral Tablet)G 3 QL
C1
Add
erall
XR
Adderall XR (Oral Capsule Extended Release 24 Hour) B 3 QL C1
Adz
enys
ER
Adzenys ER (Oral Suspension Extended Release) B 3 QL C1
Adz
enys
XR-
ODT
Adzenys XR-ODT (Oral Tablet Extended Release
Dispersible)B 3 QL
C1
Am
phet
ami
ne
ER Amphetamine ER (Oral Suspension Extended Release) G 3 QL C1
Am
phet
ami
ne
Sulf
ate Amphetamine Sulfate (Oral Tablet) G 3
C1
Am
phet
ami
ne-
Dext
roa
mph
eta
min
e
ER
Amphetamine-Dextroamphetamine ER (Oral Capsule
Extended Release 24 Hour)G 2 QL
C1
Am
phet
ami
ne-
Dext
roa
mph
eta
min
eAmphetamine-Dextroamphetamine (Oral Tablet) G 2 QL
C1
Des
oxy
n
Desoxyn (Oral Tablet) B 4 PA C1
Dex
edri
ne
Dexedrine (Oral Capsule Extended Release 24 Hour) B 4 QL C1
Dext
roa
mph
eta
min
e
Sulf
ate
ER Dextroamphetamine Sulfate ER (Oral Capsule Extended
Release 24 Hour)G 3 QL
C1
Dext
roa
mph
eta
min
e
Sulf
ate Dextroamphetamine Sulfate (Oral Solution) G 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
105Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Dext
roa
mph
eta
min
e
Sulf
ate Dextroamphetamine Sulfate (Oral Tablet) G 2 QL C1
Dya
nav
el
XR
Dyanavel XR (Oral Suspension Extended Release) B 3 QL C1
Eve
keo
ODT
Evekeo ODT (Oral Tablet Dispersible) B 3
C1
Eve
keo
Evekeo (Oral Tablet) G 3
C1
Met
ham
phet
ami
ne
HCl Methamphetamine HCl (Oral Tablet) G 4 PA C1
Myd
ayis
Mydayis (Oral Capsule Extended Release 24 Hour) B 3 QL C1
Pro
Cen
tra
ProCentra (Oral Solution) G 3
C1
Vyv
ans
e
Vyvanse (Oral Capsule) B 3
C1
Vyv
ans
e
Vyvanse (Oral Tablet Chewable) B 3
C1
Zen
zedi
Zenzedi (Oral Tablet) G 3 QL B1
Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesC1
Apt
ensi
o
XR
Aptensio XR (Oral Capsule Extended Release 24
Hour)B 3 QL
C1
Ato
mox
etin
e
HCl Atomoxetine HCl (Oral Capsule) G 3
C1
Clon
idin
e
HCl
ER Clonidine HCl ER (Oral Tablet Extended Release 12
Hour)G 3 PA
C1
Con
cert
a
Concerta (Oral Tablet Extended Release) B 3 QL C1
Cot
emp
la
XR-
ODT Cotempla XR-ODT (Oral Tablet Extended Release
Dispersible)B 3 QL
C1
Dayt
rana
Daytrana (Transdermal Patch) B 3 QL C1
Dex
met
hylp
heni
date
HCl
ER Dexmethylphenidate HCl ER (Oral Capsule Extended
Release 24 Hour)G 3
C1
Dex
met
hylp
heni
date
HCl Dexmethylphenidate HCl (Oral Tablet) G 2 QL C1
Foc
alin
Focalin (Oral Tablet) B 3 QL C1
Foc
alin
XR
Focalin XR (Oral Capsule Extended Release 24 Hour) B 3
C1
Jorn
ay
PM
Jornay PM (Oral Capsule Extended Release 24 Hour) B 3 QL C1
Kap
vay
Kapvay (Oral Tablet Extended Release 12 Hour) B 3 PA C1
Met
hylin
Methylin (Oral Solution) B 3 QL C1
Met
hylp
heni
date
HCl
CD Methylphenidate HCl CD (Oral Capsule Extended
Release) (Generic Metadate CD)G 3
C1
Met
hylp
heni
date
HCl
LA Methylphenidate HCl LA (Oral Capsule Extended
Release 24 Hour) (Generic Ritalin LA)G 3
C1
Met
hylp
heni
date
HCl
ER Methylphenidate HCl ER (XR) (Oral Capsule Extended
Release 24 Hour) (Brand Equivalent Aptensio XR)G 3 QL
C1
Met
hylp
heni
date
HCl
ER
Os
moti
c
Rele
ase
Methylphenidate HCl ER Osmotic Release (Oral Tablet
Extended Release)G 3 QL
C1
Met
hylp
heni
date
HCl
ER Methylphenidate HCl ER (Oral Tablet Extended Release
24 Hour)G 3 QL
106 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Met
hylp
heni
date
HCl Methylphenidate HCl (Oral Solution) G 3 QL C1
Met
hylp
heni
date
HCl Methylphenidate HCl (Oral Tablet Immediate Release)
(Generic Ritalin)G 2 QL
C1
Met
hylp
heni
date
HCl Methylphenidate HCl (Oral Tablet Chewable) G 3 QL C1
Quill
iChe
w
ER
QuilliChew ER (Oral Tablet Chewable Extended
Release)B 3 QL
C1
Quill
ivant
XR
Quillivant XR (Oral Suspension Reconstituted) B 3
C1
Rele
xxii
Relexxii (Oral Tablet Extended Release) G 3 QL C1
Rital
in
LA
Ritalin LA (Oral Capsule Extended Release 24 Hour) B 3
C1
Rital
in
Ritalin (Oral Tablet) B 3 QL C1
Strat
tera
Strattera (Oral Capsule) B 3
B1
Central Nervous System, OtherC1
Aust
edo
Austedo (Oral Tablet) B 4 PA; LA; QL C1
Fird
aps
e
Firdapse (Oral Tablet) B 4 PA; LA; QL C1
Grali
se
Gralise (Oral Tablet) B 3 PA C1
Hori
zant
Horizant (Oral Tablet Extended Release) B 3 PA C1
Ingr
ezza
Ingrezza (40MG Oral Capsule, 80MG Oral Capsule) B 4 PA; QL C1
Ingr
ezza
Ingrezza (Oral Capsule Therapy Pack) B 4 PA; QL C1
Nue
dext
a
Nuedexta (Oral Capsule) B 3 PA; QL C1
Rilut
ek
Rilutek (Oral Tablet) B 4
C1
Rilu
zole
Riluzole (Oral Tablet) G 2
C1
Ruz
urgi
Ruzurgi (Oral Tablet) B 4 PA; QL C1
Tetr
abe
nazi
ne
Tetrabenazine (Oral Tablet) G 4 PA; LA C1
Tigl
utik
Tiglutik (Oral Suspension) B 4 PA C1
Xen
azin
e
Xenazine (Oral Tablet) B 4 PA; LA B1
Fibromyalgia AgentsC1
Cym
balt
a
Cymbalta (Oral Capsule Delayed Release Particles) B 3 QL C1
Driz
alm
a
Spri
nkle Drizalma Sprinkle (Oral Capsule Delayed Release
Sprinkle)B 3 ST; QL
C1
Dulo
xeti
ne
HCl
Duloxetine HCl (20MG Oral Capsule Delayed Release
Particles, 30MG Oral Capsule Delayed Release Particles,
60MG Oral Capsule Delayed Release Particles)
G 1 QL
C1
Dulo
xeti
ne
HCl
Duloxetine HCl (40MG Oral Capsule Delayed Release
Particles)G 3 QL
C1
Lyri
ca
CR
Lyrica CR (Oral Tablet Extended Release 24 Hour) B 3 PA; QL C1
Lyri
ca
Lyrica (Oral Capsule) B 3 ST; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
107Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Lyri
ca
Lyrica (Oral Solution) B 3 ST; QL C1
Pre
gab
alin
ER
Pregabalin ER (Oral Tablet Extended Release 24 Hour) G 3 PA; QL C1
Pre
gab
alin
Pregabalin (Oral Capsule) G 2 QL C1
Pre
gab
alin
Pregabalin (Oral Solution) G 2 QL C1
Sav
ella
Savella (Oral Tablet) B 2
C1
Sav
ella
Titra
tion
Pac
k Savella Titration Pack (Oral Tablet) B 2
B1
Multiple Sclerosis AgentsC1
Am
pyra
Ampyra (Oral Tablet Extended Release 12 Hour) B 4 QL C1
Aub
agio
Aubagio (Oral Tablet) B 4 LA; QL C1
Avo
nex
Pen
Avonex Pen (Intramuscular Auto-Injector Kit) B 4
C1
Avo
nex
Prefi
lled
Avonex Prefilled (Intramuscular Prefilled Syringe Kit) B 4
C1
Bafi
erta
m
Bafiertam (Oral Capsule Delayed Release) B 4 ST; QL C1
Beta
sero
n
Betaseron (Subcutaneous Kit) B 4
C1
Cop
axo
ne
Copaxone (Subcutaneous Solution Prefilled Syringe) B 4
C1
Dalf
amp
ridin
e
ER Dalfampridine ER (Oral Tablet Extended Release 12
Hour)G 2 QL
C1
Dim
ethy
l
Fum
arat
e Dimethyl Fumarate (120MG Oral Capsule Delayed
Release, 240MG Oral Capsule Delayed Release)G 4 QL
C1
Dim
ethy
l
Fum
arat
e
Start
er
Pac
kDimethyl Fumarate Starter Pack (Oral Capsule) G 4
C1
Exta
via
Extavia (Subcutaneous Kit) B 4
C1
Gile
nya
Gilenya (0.5MG Oral Capsule) B 4 QL C1
Glati
ram
er
Acet
ate Glatiramer Acetate (Subcutaneous Solution Prefilled
Syringe)G 4
C1
Glat
opa
Glatopa (Subcutaneous Solution Prefilled Syringe) G 4
C1
Kesi
mpt
a
Kesimpta (Subcutaneous Solution Auto-Injector) B 4 PA C1
Mav
encl
ad
Mavenclad (10 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
Mav
encl
ad
Mavenclad (4 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
Mav
encl
ad
Mavenclad (5 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
Mav
encl
ad
Mavenclad (6 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
Mav
encl
ad
Mavenclad (7 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
Mav
encl
ad
Mavenclad (8 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
Mav
encl
ad
Mavenclad (9 Tabs) (Oral Tablet Therapy Pack) B 4 PA C1
May
zent
Mayzent (0.25MG Oral Tablet, 2MG Oral Tablet) B 4 LA; QL C1
May
zent
Start
er
Pac
k Mayzent Starter Pack (Oral Tablet Therapy Pack) B 4 LA C1
Pleg
ridy
Plegridy (Subcutaneous Solution Pen-Injector) B 4
C1
Pleg
ridy
Plegridy (Subcutaneous Solution Prefilled Syringe) B 4
108 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Rebi
f
Rebi
dos
e Rebif Rebidose (Subcutaneous Solution Auto-
Injector)B 4 ST
C1
Rebi
f
Rebi
dos
e
Titra
tion
Pac
k Rebif Rebidose Titration Pack (Subcutaneous
Solution Auto-Injector)B 4 ST
C1
Rebi
f
Rebif (Subcutaneous Solution Prefilled Syringe) B 4 ST C1
Rebi
f
Titra
tion
Pac
k Rebif Titration Pack (Subcutaneous Solution Prefilled
Syringe)B 4 ST
C1
Tecf
ider
a
Start
er
Pac
k Tecfidera Starter Pack (Oral) B 4 LA C1
Tecf
ider
a
Tecfidera (Oral Capsule Delayed Release) B 4 LA; QL C1
Vum
erity
Vumerity (Oral Capsule Delayed Release)
(Maintenance Dose Bottle)B 4 QL
C1
Zep
osia
7-
Day
Start
er
Pac
k Zeposia 7-Day Starter Pack (Oral Capsule Therapy
Pack)B 4 QL
C1
Zep
osia
Zeposia (Oral Capsule) B 4 QL C1
Zep
osia
Start
er
Kit Zeposia Starter Kit (Oral Capsule Therapy Pack) B 4 QL A1
Dental and Oral AgentsB1
Dental and Oral AgentsC1
Cevi
meli
ne
HCl
Cevimeline HCl (Oral Capsule) G 3 ST C1
Chlo
rhex
idin
e
Gluc
onat
e Chlorhexidine Gluconate (Mouth Solution) G 1
C1
Evo
xac
Evoxac (Oral Capsule) B 3 ST C1
Peri
ogar
d
Periogard (Mouth Solution) G 1
C1
Pilo
carp
ine
HCl
Pilocarpine HCl (Oral Tablet) G 3
C1
Sala
gen
Salagen (Oral Tablet) B 3
C1
Tria
mci
nolo
ne
Acet
onid
e Triamcinolone Acetonide (Dental Paste) G 2
A1
Dermatological AgentsB1
Acne and Rosacea AgentsC1
Abs
oric
a LD
Absorica LD (Oral Capsule) B 4 PA C1
Abs
oric
a
Absorica (Oral Capsule) B 4 PA C1
Aca
nya
Acanya (External Gel) B 3 ST C1
Acc
utan
e
Accutane (20MG Oral Capsule, 30MG Oral Capsule,
40MG Oral Capsule)G 3 PA
C1
Acitr
etin
Acitretin (Oral Capsule) G 3
C1
Ada
pale
ne
Adapalene (External Cream) G 3
C1
Ada
pale
ne
Adapalene (0.1% External Gel) G 2
C1
Ada
pale
ne
Adapalene (0.3% External Gel) G 3
C1
Ada
pale
ne
Adapalene (External Pad) G 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
109Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Ada
pale
ne
Adapalene (External Solution) G 4
C1
Ada
pale
ne-
Ben
zoyl
Per
oxid
e Adapalene-Benzoyl Peroxide (External Gel) G 3 ST C1
Akli
ef
Aklief (External Cream) B 3 PA C1
Altre
no
Altreno (External Lotion) B 3 PA C1
Amn
este
em
Amnesteem (Oral Capsule) G 3 PA C1
Araz
lo
Arazlo (External Lotion) B 3 PA C1
Atral
in
Atralin (External Gel) B 3 PA C1
Avit
a
Avita (External Cream) B 3 PA C1
Avit
a
Avita (External Gel) B 3 PA C1
Azel
aic
Acid
Azelaic Acid (External Gel) G 3
C1
Azel
ex
Azelex (External Cream) B 3
C1
Ben
zaCl
in
with
Pum
p BenzaClin with Pump (External Gel) B 3
C1
Ben
zam
ycin
Benzamycin (External Gel) B 3
C1
Ben
zoyl
Per
oxid
e-
Eryt
hro
myci
n Benzoyl Peroxide-Erythromycin (External Gel) G 3
C1
Clar
avis
Claravis (Oral Capsule) G 3 PA C1
Clin
dam
ycin
Pho
sph
ate-
Ben
zoyl
Per
oxid
e
Clindamycin Phosphate-Benzoyl Peroxide (1.2-2.5%
External Gel)G 3 ST
C1
Clin
dam
ycin
Pho
sph
ate-
Ben
zoyl
Per
oxid
e
Clindamycin Phosphate-Benzoyl Peroxide (1-5% External
Gel, 1.2-5% External Gel)G 3
C1
Clin
dam
ycin-
Treti
noin Clindamycin-Tretinoin (External Gel) G 3 PA C1
Diffe
rin
Differin (External Cream) B 3
C1
Diffe
rin
Differin (0.3% External Gel) B 3
C1
Diffe
rin
Differin (External Lotion) B 3
C1
Epid
uo
Epiduo (External Gel) B 3 ST C1
Epid
uo
Fort
e
Epiduo Forte (External Gel) B 3 ST C1
Fabi
or
Fabior (External Foam) B 3 PA C1
Fina
cea
Finacea (External Foam) B 3
C1
Fina
cea
Finacea (External Gel) B 3
C1
Isotr
etin
oin
Isotretinoin (Oral Capsule) G 3 PA C1
Mirv
aso
Mirvaso (External Gel) B 3
C1
Myo
risa
n
Myorisan (Oral Capsule) G 3 PA C1
Neu
ac
Neuac (External Gel) G 3
C1
One
xton
Onexton (External Gel) B 3
C1
Reti
n-A
Retin-A (External Cream) B 3 PA C1
Reti
n-A
Retin-A (External Gel) B 3 PA C1
Reti
n-A
Micr
o
Retin-A Micro (External Gel) B 4 PA
110 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Reti
n-A
Micr
o
Pum
p Retin-A Micro Pump (0.06% External Gel, 0.08%
External Gel)B 4 PA
C1
Rho
fade
Rhofade (External Cream) B 3 PA C1
Sori
atan
e
Soriatane (Oral Capsule) B 4
C1
Taz
arot
ene
Tazarotene (External Cream) G 3 PA C1
Taz
arot
ene
Tazarotene (External Foam) G 3 PA C1
Taz
orac
Tazorac (External Cream) B 3 PA C1
Taz
orac
Tazorac (0.05% External Gel) B 4 PA C1
Taz
orac
Tazorac (0.1% External Gel) B 3 PA C1
Treti
noin
Tretinoin (External Cream) G 3 PA C1
Treti
noin
Tretinoin (External Gel) G 3 PA C1
Treti
noin
Micr
osp
here Tretinoin Microsphere (External Gel) G 3 PA C1
Velti
n
Veltin (External Gel) B 4 PA C1
Zen
atan
e
Zenatane (Oral Capsule) G 3 PA C1
Zian
a
Ziana (External Gel) B 4 PA B1
Dermatitis and Pruitus AgentsC1
Ala
Scal
p
Ala Scalp (External Lotion) G 3
C1
Ala-
Cort
Ala-Cort (External Cream) G 1
C1
Alcl
ome
taso
ne
Dipr
opio
nate Alclometasone Dipropionate (External Cream) G 2
C1
Alcl
ome
taso
ne
Dipr
opio
nate Alclometasone Dipropionate (External Ointment) G 2
C1
Amc
inon
ide
Amcinonide (External Cream) G 3
C1
Amc
inon
ide
Amcinonide (External Lotion) G 3
C1
Amc
inon
ide
Amcinonide (External Ointment) G 3
C1
Am
mon
ium
Lact
ate Ammonium Lactate (External Cream) G 1
C1
Am
mon
ium
Lact
ate Ammonium Lactate (External Lotion) G 1
C1
Ape
xiCo
n E
ApexiCon E (External Cream) G 4 QL C1
Bes
er
Beser (External Lotion) G 3
C1
Beta
met
has
one
Dipr
opio
nate
Aug Betamethasone Dipropionate Aug (External Cream) G 1
C1
Beta
met
has
one
Dipr
opio
nate
Aug Betamethasone Dipropionate Aug (External Gel) G 2
C1
Beta
met
has
one
Dipr
opio
nate
Aug Betamethasone Dipropionate Aug (External Lotion) G 2
C1
Beta
met
has
one
Dipr
opio
nate
Aug Betamethasone Dipropionate Aug (External Ointment) G 2
C1
Beta
met
has
one
Dipr
opio
nate Betamethasone Dipropionate (External Cream) G 2
C1
Beta
met
has
one
Dipr
opio
nate Betamethasone Dipropionate (External Lotion) G 2
C1
Beta
met
has
one
Dipr
opio
nate Betamethasone Dipropionate (External Ointment) G 2
C1
Beta
met
has
one
Vale
rate Betamethasone Valerate (External Cream) G 2
C1
Beta
met
has
one
Vale
rate Betamethasone Valerate (External Foam) G 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
111Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Beta
met
has
one
Vale
rate Betamethasone Valerate (External Lotion) G 2
C1
Beta
met
has
one
Vale
rate Betamethasone Valerate (External Ointment) G 2
C1
Bryh
ali
Bryhali (External Lotion) B 3
C1
Cap
ex
Capex (External Shampoo) B 3
C1
Clo
beta
sol
Pro
pion
ate
Emo
llient
Bas
e
Clobetasol Propionate Emollient Base (External Cream) G 2
C1
Clo
beta
sol
Pro
pion
ate
Emu
lsion Clobetasol Propionate Emulsion (External Foam) G 3
C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Cream) G 2
C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Foam) G 3 QL C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Gel) G 2
C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Liquid Spray) G 3 QL C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Lotion) G 3 QL C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Ointment) G 2
C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Shampoo) G 3
C1
Clo
beta
sol
Pro
pion
ate Clobetasol Propionate (External Solution) G 2
C1
Clo
bex
Clobex (External Lotion) B 4 QL C1
Clo
bex
Clobex (External Shampoo) B 4
C1
Clo
bex
Spra
y
Clobex Spray (External Liquid) B 4 QL C1
Cloc
ortol
one
Pival
ate Clocortolone Pivalate (External Cream) G 3
C1
Clo
dan
Clodan (External Shampoo) G 3
C1
Clo
der
m
Cloderm (External Cream) B 3
C1
Cor
dran
Cordran (0.025% External Cream) B 3
C1
Cor
dran
Cordran (0.05% External Cream) B 4
C1
Cor
dran
Cordran (External Lotion) B 3 QL C1
Cor
dran
Cordran (External Ointment) B 4
C1
Cor
dran
Cordran (External Tape) B 4
C1
Cuti
vate
Cutivate (External Lotion) B 4
C1
Der
ma-
Smo
othe
/FS
Scal
p Derma-Smoothe/FS Scalp (External Oil) B 3
C1
Des
onat
e
Desonate (External Gel) B 3 ST C1
Des
onid
e
Desonide (External Cream) G 2
C1
Des
onid
e
Desonide (External Gel) G 3 ST C1
Des
onid
e
Desonide (External Lotion) G 3
C1
Des
onid
e
Desonide (External Ointment) G 2
C1
Des
Owe
n
DesOwen (External Cream) B 3
C1
Des
oxi
met
aso
ne Desoximetasone (External Cream) G 3 QL C1
Des
oxi
met
aso
ne Desoximetasone (External Gel) G 3
C1
Des
oxi
met
aso
ne Desoximetasone (External Liquid) G 3
C1
Des
oxi
met
aso
ne Desoximetasone (External Ointment) G 3
112 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Diflo
raso
ne
Diac
etat
e Diflorasone Diacetate (External Cream) G 3 QL C1
Diflo
raso
ne
Diac
etat
e Diflorasone Diacetate (External Ointment) G 4 ST; QL C1
Dipr
olen
e
Diprolene (External Ointment) B 3
C1
Dox
epin
HCl
Doxepin HCl (External Cream) G 4 PA; QL C1
Elid
el
Elidel (External Cream) B 3 ST; QL C1
Eucr
isa
Eucrisa (External Ointment) B 3 PA; QL C1
Fluo
cino
lone
Acet
onid
e Fluocinolone Acetonide (External Cream) G 2
C1
Fluo
cino
lone
Acet
onid
e Fluocinolone Acetonide (External Ointment) G 2
C1
Fluo
cino
lone
Acet
onid
e Fluocinolone Acetonide (External Solution) G 2
C1
Fluo
cino
lone
Acet
onid
e
Scal
p Fluocinolone Acetonide Scalp (External Oil) G 2
C1
Fluo
cino
nide
Emu
lsifie
d
Bas
e Fluocinonide Emulsified Base (External Cream) G 2
C1
Fluo
cino
nide
Fluocinonide (0.05% External Cream) G 2
C1
Fluo
cino
nide
Fluocinonide (0.1% External Cream) G 3
C1
Fluo
cino
nide
Fluocinonide (External Gel) G 2
C1
Fluo
cino
nide
Fluocinonide (External Ointment) G 2
C1
Fluo
cino
nide
Fluocinonide (External Solution) G 2
C1
Flur
andr
enol
ide
Flurandrenolide (External Cream) G 3
C1
Flur
andr
enol
ide
Flurandrenolide (External Lotion) G 3 QL C1
Flur
andr
enol
ide
Flurandrenolide (External Ointment) G 3
C1
Fluti
cas
one
Pro
pion
ate Fluticasone Propionate (External Cream) G 2
C1
Fluti
cas
one
Pro
pion
ate Fluticasone Propionate (External Lotion) G 3
C1
Fluti
cas
one
Pro
pion
ate Fluticasone Propionate (External Ointment) G 2
C1
Halc
inon
ide
Halcinonide (External Cream) G 3
C1
Halo
beta
sol
Pro
pion
ate Halobetasol Propionate (External Cream) G 3
C1
Halo
beta
sol
Pro
pion
ate Halobetasol Propionate (External Foam) B 4
C1
Halo
beta
sol
Pro
pion
ate Halobetasol Propionate (External Ointment) G 3
C1
Halo
g
Halog (External Cream) B 4
C1
Halo
g
Halog (External Ointment) B 4
C1
Halo
g
Halog (External Solution) B 3
C1
Hyd
roco
rtiso
ne
Buty
rate Hydrocortisone Butyrate (External Cream) G 3
C1
Hyd
roco
rtiso
ne
Buty
rate Hydrocortisone Butyrate (External Lotion) G 3 QL C1
Hyd
roco
rtiso
ne
Buty
rate Hydrocortisone Butyrate (External Ointment) G 3
C1
Hyd
roco
rtiso
ne
Buty
rate Hydrocortisone Butyrate (External Solution) G 3
C1
Hyd
roco
rtiso
ne
Hydrocortisone (1% External Cream, 2.5% External
Cream)G 1
C1
Hyd
roco
rtiso
ne
Hydrocortisone (2.5% External Lotion) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
113Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Hyd
roco
rtiso
ne
Hydrocortisone (1% External Ointment, 2.5% External
Ointment)G 1
C1
Hyd
roco
rtiso
ne
Vale
rate Hydrocortisone Valerate (External Cream) G 3
C1
Hyd
roco
rtiso
ne
Vale
rate Hydrocortisone Valerate (External Ointment) G 3
C1
Imp
eklo
Impeklo (External Lotion) B 3 QL C1
Ken
alog
Kenalog (External Aerosol Solution) B 4
C1
Lex
ette
Lexette (External Foam) B 4
C1
Loc
oid
Locoid (External Lotion) B 4 QL C1
Loc
oid
Lipo
crea
m Locoid Lipocream (External Cream) B 3
C1
Luxi
q
Luxiq (External Foam) B 3
C1
Mo
met
aso
ne
Furo
ate Mometasone Furoate (External Cream) G 1
C1
Mo
met
aso
ne
Furo
ate Mometasone Furoate (External Ointment) G 1
C1
Mo
met
aso
ne
Furo
ate Mometasone Furoate (External Solution) G 1
C1
Noli
x
Nolix (External Cream) G 3
C1
Noli
x
Nolix (External Lotion) G 3 QL C1
Olux
Olux (External Foam) B 4 QL C1
Olux
-E
Olux-E (External Foam) B 4 QL C1
Pan
del
Pandel (External Cream) B 4
C1
Pim
ecro
limu
s
Pimecrolimus (External Cream) G 3 ST; QL C1
Pre
dnic
arba
te
Prednicarbate (External Ointment) G 3
C1
Prot
opic
Protopic (External Ointment) B 3 ST C1
PRU
DOX
IN
PRUDOXIN (External Cream) B 4 PA; QL C1
Psor
con
Psorcon (External Cream) G 3 QL C1
Sele
niu
m
Sulfi
de Selenium Sulfide (External Lotion) G 1
C1
Syn
alar
Synalar (External Cream) B 3
C1
Tacr
olim
us
Tacrolimus (External Ointment) G 3 ST C1
Tem
ovat
e
Temovate (External Cream) G 3
C1
Tex
acor
t
Texacort (External Solution) G 3
C1
Topi
cort
Topicort (External Cream) G 3 QL C1
Topi
cort
Topicort (External Gel) G 3
C1
Topi
cort
Topicort (0.05% External Ointment) B 3
C1
Topi
cort
Topicort (0.25% External Ointment) G 3
C1
Topi
cort
Spra
y
Topicort Spray (External Liquid) B 3
C1
Tov
et
Tovet (External Foam) G 3
C1
Tria
mci
nolo
ne
Acet
onid
e Triamcinolone Acetonide (External Aerosol Solution)
(Generic Kenalog)G 3
C1
Tria
mci
nolo
ne
Acet
onid
e Triamcinolone Acetonide (External Cream) G 1
114 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Tria
mci
nolo
ne
Acet
onid
e Triamcinolone Acetonide (External Lotion) G 2
C1
Tria
mci
nolo
ne
Acet
onid
e Triamcinolone Acetonide (0.025% External Ointment,
0.1% External Ointment, 0.5% External Ointment)G 1
C1
Tria
mci
nolo
ne
Acet
onid
e Triamcinolone Acetonide (0.05% External Ointment) G 3
C1
Tria
nex
Trianex (External Ointment) G 3
C1
Trid
erm
Triderm (0.1% External Cream) G 1
C1
Trid
erm
Triderm (0.5% External Cream) G 3
C1
Ultra
vate
Ultravate (External Lotion) B 4
C1
Van
os
Vanos (External Cream) B 4
C1
Ver
des
o
Verdeso (External Foam) B 4 ST C1
Zon
alon
Zonalon (External Cream) B 4 PA; QL B1
Dermatological Agents, OtherC1
Alda
ra
Aldara (External Cream) B 3 QL C1
Calc
ipotr
iene
Calcipotriene (External Cream) G 3
C1
Calc
ipotr
iene
Calcipotriene (External Foam) B 4
C1
Calc
ipotr
iene
Calcipotriene (External Ointment) G 3
C1
Calc
ipotr
iene
Calcipotriene (External Solution) G 2
C1
Calc
ipotr
iene
-
Beta
met
has
one Calcipotriene-Betamethasone (0.005-0.064% External
Ointment)G 3
C1
Calc
ipotr
iene
-
Beta
met
has
one Calcipotriene-Betamethasone (0.005-0.064% External
Suspension)G 4
C1
Calc
itriol
Calcitriol (External Ointment) B 3
C1
Cara
c
Carac (External Cream) B 4
C1
Clot
rima
zole-
Beta
met
has
one Clotrimazole-Betamethasone (External Cream) G 2
C1
Clot
rima
zole-
Beta
met
has
one Clotrimazole-Betamethasone (External Lotion) G 3
C1
Con
dylo
x
Condylox (External Gel) B 4
C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (3% External Gel) G 3 PA C1
Dov
one
x
Dovonex (External Cream) B 4
C1
Duo
brii
Duobrii (External Lotion) B 4 PA C1
Efud
ex
Efudex (External Cream) B 3
C1
Enst
ilar
Enstilar (External Foam) B 4 PA C1
Fluo
ropl
ex
Fluoroplex (External Cream) B 4 PA C1
Fluo
rour
acil
Fluorouracil (0.5% External Cream) G 4
C1
Fluo
rour
acil
Fluorouracil (5% External Cream) G 2
C1
Fluo
rour
acil
Fluorouracil (External Solution) G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
115Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Hyd
roco
rtiso
ne
Acet
ate-
Pra
mox
ine Hydrocortisone Acetate-Pramoxine (1-1% External
Cream)G 3
C1
Imiq
uim
od
Imiquimod (3.75% External Cream) B 4 PA C1
Imiq
uim
od
Imiquimod (5% External Cream) G 2 QL C1
Met
hox
sale
n
Rapi
d Methoxsalen Rapid (Oral Capsule) G 4
C1
Neo
-
Syn
alar
Neo-Synalar (External Cream) G 4
C1
Nyst
atin-
Tria
mci
nolo
ne Nystatin-Triamcinolone (External Cream) G 2
C1
Nyst
atin-
Tria
mci
nolo
ne Nystatin-Triamcinolone (External Ointment) G 2
C1
Pica
to
Picato (0.015% External Gel, 0.05% External Gel) B 2 QL C1
Pod
ofilo
x
Podofilox (External Solution) G 2
C1
Qbr
exza
Qbrexza (External Pad) B 3
C1
Reg
rane
x
Regranex (External Gel) B 4 PA C1
Sant
yl
Santyl (External Ointment) B 3
C1
Silva
den
e
Silvadene (External Cream) B 3
C1
Silv
er
Sulf
adia
zine Silver Sulfadiazine (External Cream) G 1
C1
Soril
ux
Sorilux (External Foam) B 4
C1
SSD
SSD (External Cream) B 1
C1
Tacl
one
x
Taclonex (External Ointment) B 4
C1
Tacl
one
x
Taclonex (External Suspension) B 4
C1
Vect
ical
Vectical (External Ointment) B 4
C1
Vere
gen
Veregen (External Ointment) B 4
C1
Xere
se
Xerese (External Cream) B 4 PA C1
Zycl
ara
Pum
p
Zyclara Pump (External Cream) B 4 PA B1
Pediculicides/ScabicidesC1
Iver
mec
tin
Ivermectin (External Lotion) G 3
C1
Lind
ane
Lindane (External Shampoo) G 3
C1
Mal
athi
on
Malathion (External Lotion) G 3
C1
Natr
oba
Natroba (External Suspension) B 3
C1
Ovid
e
Ovide (External Lotion) G 3
C1
Per
met
hrin
Permethrin (External Cream) G 2
C1
Sool
antr
a
Soolantra (External Cream) B 3
C1
Spin
osa
d
Spinosad (External Suspension) B 3
B1
Topical Anti-infectivesC1
Acz
one
Aczone (External Gel) B 3
C1
Alta
bax
Altabax (External Ointment) B 3
C1
Amz
eeq
Amzeeq (External Foam) B 3
C1
Cicl
opir
ox
Ciclopirox (External Gel) G 2
116 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Cicl
opir
ox
Ciclopirox (External Shampoo) G 2
C1
Cicl
opir
ox
Ciclopirox (External Solution) G 2
C1
Cicl
opir
ox
Ola
min
e Ciclopirox Olamine (External Cream) G 2
C1
Cicl
opir
ox
Ola
min
e Ciclopirox Olamine (External Suspension) G 2
C1
Cleo
cin-
T
Cleocin-T (External Lotion) B 3
C1
Clin
daci
n-P
Clindacin-P (External Swab) G 2
C1
Clin
dag
el
Clindagel (External Gel) B 4 QL C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (External Foam) G 3
C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (External Gel) G 2 QL C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (External Lotion) G 2
C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (External Solution) G 1
C1
Clin
dam
ycin
Pho
sph
ate Clindamycin Phosphate (External Swab) G 2
C1
Clot
rima
zole
Clotrimazole (External Cream) G 1
C1
Clot
rima
zole
Clotrimazole (External Solution) G 2
C1
Dap
son
e
Dapsone (External Gel) G 3
C1
Eco
naz
ole
Nitr
ate Econazole Nitrate (External Cream) G 2 QL C1
Erta
czo
Ertaczo (External Cream) B 4
C1
Ery
Ery (External Pad) G 2
C1
Eryg
el
Erygel (External Gel) B 3
C1
Eryt
hro
myci
n
Erythromycin (External Gel) G 3
C1
Eryt
hro
myci
n
Erythromycin (External Solution) G 2
C1
Evo
clin
Evoclin (External Foam) B 4
C1
Exti
na
Extina (External Foam) B 4 QL C1
Gen
tami
cin
Sulf
ate Gentamicin Sulfate (External Cream) G 2
C1
Gen
tami
cin
Sulf
ate Gentamicin Sulfate (External Ointment) G 1
C1
Jubli
a
Jublia (External Solution) B 3
C1
Kery
din
Kerydin (External Solution) B 4 ST C1
Ket
oco
naz
ole
Ketoconazole (External Cream) G 1 QL C1
Ket
oco
naz
ole
Ketoconazole (External Foam) G 3 QL C1
Ket
oco
naz
ole
Ketoconazole (External Shampoo) G 1
C1
Ket
oda
n
Ketodan (External Foam) G 3 QL C1
Klar
on
Klaron (External Lotion) B 3 PA C1
Lopr
ox
Loprox (External Cream) B 3
C1
Lopr
ox
Loprox (External Shampoo) B 3
C1
Lulic
ona
zole
Luliconazole (External Cream) B 3 QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
117Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Luz
u
Luzu (External Cream) B 3 QL C1
Maf
enid
e
Acet
ate Mafenide Acetate (External Packet) G 3
C1
Men
tax
Mentax (External Cream) B 3
C1
Mup
iroci
n
Calc
ium Mupirocin Calcium (External Cream) G 3
C1
Mup
iroci
n
Mupirocin (External Ointment) G 1 QL C1
Nafti
fine
HCl
Naftifine HCl (External Cream) G 3
C1
Nafti
n
Naftin (External Gel) B 3
C1
Nya
myc
Nyamyc (External Powder) G 1 QL C1
Nyst
atin
Nystatin (External Cream) G 1
C1
Nyst
atin
Nystatin (External Ointment) G 1
C1
Nyst
atin
Nystatin (External Powder) G 1 QL C1
Nyst
op
Nystop (External Powder) G 1 QL C1
Oxic
ona
zole
Nitr
ate Oxiconazole Nitrate (External Cream) G 3 QL C1
Oxis
tat
Oxistat (External Cream) B 4 QL C1
Oxis
tat
Oxistat (External Lotion) B 4 QL C1
Sulf
acet
ami
de
Sodi
um Sulfacetamide Sodium (Acne) (External Lotion) G 3 PA C1
Sulf
amyl
on
Sulfamylon (External Cream) B 3
C1
Sulf
amyl
on
Sulfamylon (External Packet) B 4
C1
Tav
abor
ole
Tavaborole (External Solution) G 4 ST C1
Xepi
Xepi (External Cream) B 3
C1
Xole
gel
Xolegel (External Gel) B 4 PA; QL C1
Zilxi
Zilxi (External Foam) B 3
A1
Electrolytes/Minerals/Metals/VitaminsB1
Electrolyte/Mineral ReplacementC1
Ami
nos
yn II
Aminosyn II (15% Intravenous Solution) B 3 B/D, PA C1
Ami
nos
yn-
PF
Aminosyn-PF (7% Intravenous Solution) B 3 B/D, PA C1
Car
bagl
u
Carbaglu (Oral Tablet) B 4 LA C1
Clini
mix
E/
Dext
rose Clinimix E/Dextrose (2.75/5) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix
E/
Dext
rose Clinimix E/Dextrose (4.25/10) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix
E/
Dext
rose Clinimix E/Dextrose (4.25/5) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix
E/
Dext
rose Clinimix E/Dextrose (5/15) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix
E/
Dext
rose Clinimix E/Dextrose (5/20) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix/
Dext
rose
Clinimix/Dextrose (4.25/10) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix/
Dext
rose
Clinimix/Dextrose (4.25/5) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix/
Dext
rose
Clinimix/Dextrose (5/15) (Intravenous Solution) B 3 B/D, PA C1
Clini
mix/
Dext
rose
Clinimix/Dextrose (5/20) (Intravenous Solution) B 3 B/D, PA C1
Clini
sol
SF
Clinisol SF (Intravenous Solution) G 3 B/D, PA
118 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Dext
rose
Dextrose (10% Intravenous Solution) G 2
C1
Dext
rose
Dextrose (5% Intravenous Solution) G 2 B/D, PA C1
Dext
rose
-
NaC
l 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)
B 2
C1
Dext
rose
-
NaC
l Dextrose-NaCl (5-0.9% Intravenous Solution) B 2 B/D, PA C1
End
ari
Endari (Oral Packet) B 4 PA C1
Hep
atA
min
e
HepatAmine (8% Intravenous Solution) B 3 B/D, PA C1
Intra
lipid
Intralipid (Intravenous Emulsion) B 3 B/D, PA C1
Isoly
te-P
in
D5
W Isolyte-P in D5W (Intravenous Solution) B 3
C1
Isoly
te-S
Isolyte-S (Intravenous Solution) B 3
C1
KCl
in
Dext
rose
-
NaC
l KCl in Dextrose-NaCl (Intravenous Solution) B 2
C1
KCl-
Lact
ated
Ring
ers-
D5
W KCl-Lactated Ringers-D5W (Intravenous Solution) B 2
C1
Klor-
Con
10
Klor-Con 10 (Oral Tablet Extended Release) B 1
C1
Klor-
Con
M10
Klor-Con M10 (Oral Tablet Extended Release) G 1
C1
Klor-
Con
M15
Klor-Con M15 (Oral Tablet Extended Release) G 1
C1
Klor-
Con
M20
Klor-Con M20 (Oral Tablet Extended Release) G 1
C1
Klor-
Con
Klor-Con (Oral Packet) G 3
C1
Klor-
Con
8
Klor-Con 8 (Oral Tablet Extended Release) B 1
C1
K-
Tab
K-Tab (Oral Tablet Extended Release) B 3
C1
Mag
nesi
um
Sulf
ate Magnesium Sulfate (50% Injection Solution) B 1
C1
Mag
nesi
um
Sulf
ate Magnesium Sulfate (50% (10ML Syringe) Injection
Solution)G 1
C1
Nutr
ilipid
Nutrilipid (Intravenous Emulsion) B 3 B/D, PA C1
Plas
ma-
Lyte
148
Plasma-Lyte 148 (Intravenous Solution) B 3
C1
Plas
ma-
Lyte
A
Plasma-Lyte A (Intravenous Solution) B 3
C1
Plen
ami
ne
Plenamine (Intravenous Solution) G 3 B/D, PA C1
Pota
ssiu
m
Chlo
ride
CR Potassium Chloride CR (Oral Tablet Extended Release) G 1
C1
Pota
ssiu
m
Chlo
ride
ER Potassium Chloride ER (Oral Capsule Extended
Release)G 1
C1
Pota
ssiu
m
Chlo
ride
in
Dext
rose Potassium Chloride in Dextrose (Intravenous
Solution)B 2 B/D, PA
C1
Pota
ssiu
m
Chlo
ride
in
NaC
l Potassium Chloride in NaCl (20-0.45MEQ/L-%
Intravenous Solution)G 2 B/D, PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
119Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pota
ssiu
m
Chlo
ride
in
NaC
l Potassium Chloride in NaCl (20-0.9MEQ/L-%
Intravenous Solution, 40-0.9MEQ/L-% Intravenous
Solution)
B 2 B/D, PA
C1
Pota
ssiu
m
Chlo
ride Potassium Chloride (10MEQ/100ML Intravenous
Solution, 20MEQ/100ML Intravenous Solution,
40MEQ/100ML Intravenous Solution)
B 1 B/D, PA
C1
Pota
ssiu
m
Chlo
ride Potassium Chloride (2MEQ/ML Intravenous Solution,
2MEQ/ML (20ML) Intravenous Solution)G 1 B/D, PA
C1
Pota
ssiu
m
Chlo
ride Potassium Chloride (Oral Packet) G 3
C1
Pota
ssiu
m
Chlo
ride Potassium Chloride (20 MEQ/15ML(10%) Oral Solution,
40 MEQ/15ML(20%) Oral Solution)G 3
C1
Pota
ssiu
m
Citra
te
ER Potassium Citrate ER (Oral Tablet Extended Release) G 3
C1
Pre
mas
ol
Premasol (Intravenous Solution) G 3 B/D, PA C1
Proc
ala
min
e
Procalamine (Intravenous Solution) B 3 B/D, PA C1
Pros
ol
Prosol (Intravenous Solution) B 3 B/D, PA C1
Sodi
um
Chlo
ride
Sodium Chloride (0.45% Intravenous Solution) G 1
C1
Sodi
um
Chlo
ride
Sodium Chloride (0.9% Intravenous Solution, 3%
Intravenous Solution)G 1 B/D, PA
C1
Sodi
um
Chlo
ride
Sodium Chloride (5% Intravenous Solution) B 1 B/D, PA C1
Sodi
um
Chlo
ride
Sodium Chloride (Irrigation Solution) B 1
C1
Sodi
um
Fluo
ride
Sodium Fluoride (Oral Tablet) G 1
C1
TPN
Elec
troly
tes
TPN Electrolytes (Intravenous Concentrate) B 2
C1
Trav
asol
Travasol (Intravenous Solution) B 3 B/D, PA C1
Tro
phA
min
e
TrophAmine (10% Intravenous Solution) B 3 B/D, PA C1
Uro
cit-K
10
Urocit-K 10 (Oral Tablet Extended Release) B 3
C1
Uro
cit-K
15
Urocit-K 15 (Oral Tablet Extended Release) B 3
C1
Uro
cit-K
5
Urocit-K 5 (Oral Tablet Extended Release) B 3
B1
Electrolyte/Mineral/Metal ModifiersC1
Che
met
Chemet (Oral Capsule) B 4
C1
Clov
ique
Clovique (Oral Capsule) G 4 PA; QL C1
Def
eras
irox
Gra
nule
s Deferasirox Granules (Oral Packet) G 4 PA C1
Def
eras
irox
Deferasirox (Oral Tablet) (Generic Jadenu) G 4 PA C1
Def
eras
irox
Deferasirox (Oral Tablet Soluble) (Generic Exjade) G 4 PA C1
Def
eripr
one
Deferiprone (Oral Tablet) G 4 PA C1
Exja
de
Exjade (Oral Tablet Soluble) B 4 PA C1
Ferri
prox
Ferriprox (Oral Solution) B 4 PA C1
Ferri
prox
Ferriprox (Oral Tablet) B 4 PA C1
Jad
enu
Jadenu (Oral Tablet) B 4 PA
120 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Jad
enu
Spri
nkle
Jadenu Sprinkle (Oral Packet) B 4 PA C1
Jyna
rque
Jynarque (Oral Tablet) B 4 PA C1
Jyna
rque
Jynarque (Oral Tablet Therapy Pack) B 4 PA; QL C1
Sam
sca
Samsca (Oral Tablet) B 4 PA C1
Sypr
ine
Syprine (Oral Capsule) B 4 PA; QL C1
Tolv
apta
n
Tolvaptan (15MG Oral Tablet) B 4 PA C1
Tolv
apta
n
Tolvaptan (30MG Oral Tablet) G 4 PA C1
Trie
ntin
e
HCl
Trientine HCl (Oral Capsule) G 4 PA; QL B1
Phosphate BindersC1
Aury
xia
Auryxia (Oral Tablet) B 4 PA C1
Calc
ium
Acet
ate
Calcium Acetate (Phosphate Binder) (Oral Capsule) G 2
C1
Calc
ium
Acet
ate
Calcium Acetate (Phosphate Binder) (Oral Tablet) G 2
C1
Fosr
enol
Fosrenol (Oral Packet) B 4
C1
Fosr
enol
Fosrenol (Oral Tablet Chewable) B 4
C1
Lant
han
um
Car
bon
ate Lanthanum Carbonate (Oral Tablet Chewable) G 4
C1
Pho
slyra
Phoslyra (Oral Solution) B 2
C1
Ren
agel
Renagel (Oral Tablet) B 4
C1
Ren
vela
Renvela (Oral Packet) B 4
C1
Ren
vela
Renvela (Oral Tablet) B 4
C1
Sev
ela
mer
Car
bon
ate Sevelamer Carbonate (Oral Packet) G 4
C1
Sev
ela
mer
Car
bon
ate Sevelamer Carbonate (Oral Tablet) (Generic Renvela) G 2
C1
Sev
ela
mer
HCl
Sevelamer HCl (Oral Tablet) G 3
C1
Velp
horo
Velphoro (Oral Tablet Chewable) B 4
B1
Potassium BindersC1
Lok
elm
a
Lokelma (Oral Packet) B 3 QL C1
Sodi
um
Poly
styr
ene
Sulf
onat
e Sodium Polystyrene Sulfonate (Oral Powder) G 2
C1
SPS
SPS (Oral Suspension) G 2
C1
Velt
assa
Veltassa (Oral Packet) B 4 QL B1
VitaminsC1
VP-
PNV
-
DHA
VP-PNV-DHA (Oral Capsule) G 1
A1
Gastrointestinal AgentsB1
Anti-Constipation AgentsC1
Amit
iza
Amitiza (Oral Capsule) B 2 QL C1
Con
stul
ose
Constulose (Oral Solution) G 1
C1
Enul
ose
Enulose (Oral Solution) G 1
You can find information on what the abbreviations in this table mean on pages 6 - 7.
121Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Gen
erla
c
Generlac (Oral Solution) G 1
C1
Krist
alos
e
Kristalose (Oral Packet) G 3
C1
Lact
ulos
e
Lactulose (Oral Packet) G 3
C1
Lact
ulos
e
Lactulose (10GM/15ML Oral Solution) G 1
C1
Linz
ess
Linzess (Oral Capsule) B 2 QL C1
Lubi
pros
tone
Lubiprostone (Oral Capsule) G 2 QL C1
Mot
egrit
y
Motegrity (Oral Tablet) B 3 ST; QL C1
Mov
anti
k
Movantik (Oral Tablet) B 3 PA; QL C1
Reli
stor
Relistor (Oral Tablet) B 4 PA C1
Reli
stor
Relistor (Subcutaneous Solution) B 4 PA C1
Sym
proi
c
Symproic (Oral Tablet) B 3 PA; QL C1
Trul
anc
e
Trulance (Oral Tablet) B 3 ST B1
Anti-Diarrheal AgentsC1
Alos
etro
n
HCl
Alosetron HCl (Oral Tablet) G 4 PA C1
Diph
eno
xylat
e-
Atro
pine Diphenoxylate-Atropine (Oral Liquid) G 3 PA; HRM C1
Diph
eno
xylat
e-
Atro
pine Diphenoxylate-Atropine (Oral Tablet) G 3 PA; HRM C1
Lom
otil
Lomotil (Oral Tablet) B 3 PA; HRM C1
Lop
era
mid
e
HCl Loperamide HCl (Oral Capsule) G 1
C1
Lotr
one
x
Lotronex (Oral Tablet) B 4 PA C1
Myt
esi
Mytesi (Oral Tablet Delayed Release) B 3 PA C1
Vibe
rzi
Viberzi (Oral Tablet) B 4 PA; QL C1
Xer
mel
o
Xermelo (Oral Tablet) B 4 PA; LA; QL B1
Antispasmodics, GastrointestinalC1
Chlo
rdia
zep
oxid
e-
Clidi
niu
m Chlordiazepoxide-Clidinium (Oral Capsule) G 1 HRM C1
Cuv
pos
a
Cuvposa (Oral Solution) B 3 PA C1
Dicy
clo
min
e
HCl Dicyclomine HCl (Oral Capsule) G 1 HRM C1
Dicy
clo
min
e
HCl Dicyclomine HCl (Oral Solution) G 3 HRM C1
Dicy
clo
min
e
HCl Dicyclomine HCl (Oral Tablet) G 1 HRM C1
Glyc
opyr
rolat
e
Glycopyrrolate (1MG Oral Tablet, 2MG Oral Tablet) G 2 PA C1
Libr
ax
Librax (Oral Capsule) B 3 HRM C1
Met
hsc
opol
ami
ne
Bro
mid
e Methscopolamine Bromide (Oral Tablet) G 3
B1
Gastrointestinal Agents, OtherC1
Am
oxici
llin-
Clari
thro
myci
n-
Lan
sopr
azol
e
Amoxicillin-Clarithromycin-Lansoprazole (Oral) G 3
C1
Che
nod
al
Chenodal (Oral Tablet) G 4 PA C1
Clen
piq
Clenpiq (Oral Solution) B 2
C1
Gatt
ex
Gattex (Subcutaneous Kit) B 4 PA; LA C1
Gavi
Lyte
-C
GaviLyte-C (Oral Solution Reconstituted) G 1
122 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Gavi
Lyte
-G
GaviLyte-G (Oral Solution Reconstituted) G 1
C1
Gavi
Lyte
-N
with
Flav
or
Pac
k GaviLyte-N with Flavor Pack (Oral Solution
Reconstituted)G 1
C1
GoL
YTE
LY
GoLYTELY (Oral Solution Reconstituted) B 3
C1
Heli
dac
Ther
apy
Helidac Therapy (Oral) G 4
C1
Mov
iPre
p
MoviPrep (Oral Solution Reconstituted) B 3
C1
Myal
ept
Myalept (Subcutaneous Solution Reconstituted) B 4 PA; LA C1
NuL
YTE
LY
Lem
on-
Lim
e NuLYTELY Lemon-Lime (Oral Solution Reconstituted) B 3
C1
Ocal
iva
Ocaliva (Oral Tablet) B 4 PA; QL C1
Om
ecla
mox
-Pak
Omeclamox-Pak (Oral) B 4
C1
Os
moP
rep
OsmoPrep (Oral Tablet) B 3
C1
PEG
-335
0-
NaC
l-Na
Bica
rbon
ate-
KCl PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution)
(Generic NuLYTELY)G 1
C1
PEG
-335
0-
Elec
troly
tes PEG-3350-Electrolytes (Oral Solution) (Generic
GoLYTELY)G 1
C1
PEG
-KCl-
NaC
l-
NaS
ulf-
Na
Asc-
C PEG-KCl-NaCl-NaSulf-Na Asc-C (Oral Solution
Reconstituted) (Generic MoviPrep)G 3
C1
Plen
vu
Plenvu (Oral Solution Reconstituted) B 3
C1
Pyle
ra
Pylera (Oral Capsule) B 4
C1
Relt
one
Reltone (Oral Capsule) G 4
C1
Sup
rep
Bow
el
Pre
p Kit Suprep Bowel Prep Kit (Oral Solution) B 2
C1
Suta
b
Sutab (Oral Tablet) B 3
C1
Talic
ia
Talicia (Oral Capsule Delayed Release) B 3
C1
TriL
yte
TriLyte (420GM Oral Solution Reconstituted) G 1
C1
Urs
o
250
Urso 250 (Oral Tablet) B 3
C1
Urs
o
Fort
e
Urso Forte (Oral Tablet) B 3
C1
Urs
odio
l
Ursodiol (Oral Capsule) G 2
C1
Urs
odio
l
Ursodiol (Oral Tablet) G 3
B1
Histamine2 (H2) Receptor AntagonistsC1
Cim
etidi
ne
HCl
Cimetidine HCl (300MG/5ML Oral Solution) G 2
C1
Cim
etidi
ne
Cimetidine (Oral Tablet) G 2
C1
Fam
otidi
ne
Famotidine (Oral Suspension Reconstituted) G 3
C1
Fam
otidi
ne
Famotidine (20MG Oral Tablet, 40MG Oral Tablet) G 1
C1
Niza
tidin
e
Nizatidine (Oral Capsule) G 2
C1
Niza
tidin
e
Nizatidine (Oral Solution) G 3
C1
Pep
cid
Pepcid (20MG Oral Tablet) G 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
123Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pep
cid
Pepcid (40MG Oral Tablet) G 4
B1
ProtectantsC1
Cara
fate
Carafate (Oral Suspension) B 3
C1
Cara
fate
Carafate (Oral Tablet) B 3
C1
Cyto
tec
Cytotec (Oral Tablet) B 3
C1
Mis
opr
osto
l
Misoprostol (Oral Tablet) G 2
C1
Sucr
alfat
e
Sucralfate (Oral Suspension) G 3
C1
Sucr
alfat
e
Sucralfate (Oral Tablet) G 1
B1
Proton Pump InhibitorsC1
Acip
hex
Aciphex (Oral Tablet Delayed Release) B 3
C1
Dexi
lant
Dexilant (Oral Capsule Delayed Release) B 3 QL C1
Eso
mep
razo
le
Mag
nesi
um Esomeprazole Magnesium (Oral Capsule Delayed
Release) (Generic Nexium)G 2 QL
C1
Eso
mep
razo
le
Mag
nesi
um Esomeprazole Magnesium (Oral Packet) G 2
C1
Lan
sopr
azol
e
Lansoprazole (Oral Capsule Delayed Release) G 2 QL C1
Lan
sopr
azol
e
ODT Lansoprazole ODT (Oral Tablet Delayed Release
Dispersible)G 3
C1
Nexi
um
Nexium (20MG Oral Capsule Delayed Release, 40MG
Oral Capsule Delayed Release)B 2 QL
C1
Nexi
um
Nexium (10MG Oral Packet, 2.5MG Oral Packet,
20MG Oral Packet, 40MG Oral Packet, 5MG Oral
Packet)
B 2
C1
Om
epra
zole
Omeprazole (10MG Oral Capsule Delayed Release) G 1 QL C1
Om
epra
zole
Omeprazole (20MG Oral Capsule Delayed Release,
40MG Oral Capsule Delayed Release)G 1
C1
Om
epra
zole-
Sodi
um
Bica
rbon
ate Omeprazole-Sodium Bicarbonate (Oral Capsule) G 3 PA C1
Om
epra
zole-
Sodi
um
Bica
rbon
ate Omeprazole-Sodium Bicarbonate (Oral Packet) G 4 PA C1
Pant
opra
zole
Sodi
um Pantoprazole Sodium (Oral Packet) G 3 ST C1
Pant
opra
zole
Sodi
um Pantoprazole Sodium (Oral Tablet Delayed Release) G 1 QL C1
Prev
acid
Prevacid (Oral Capsule Delayed Release) B 3 QL C1
Prev
acid
Solu
Tab Prevacid SoluTab (Oral Tablet Delayed Release
Dispersible)B 3
C1
Prilo
sec
Prilosec (Oral Packet) B 3 PA C1
Prot
onix
Protonix (Oral Packet) B 3 ST C1
Prot
onix
Protonix (Oral Tablet Delayed Release) B 3 QL C1
Rab
epra
zole
Sodi
um Rabeprazole Sodium (Oral Tablet Delayed Release) G 2
C1
Zeg
erid
Zegerid (Oral Capsule) B 4 PA C1
Zeg
erid
Zegerid (Oral Packet) B 4 PA
124 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
A1
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentB1
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentC1
Aral
ast
NP
Aralast NP (1000MG Intravenous Solution
Reconstituted)B 4 PA; LA
C1
Bup
hen
yl
Buphenyl (Oral Powder) B 4
C1
Bup
hen
yl
Buphenyl (Oral Tablet) B 4
C1
Car
nitor
Carnitor (Oral Solution) B 3
C1
Car
nitor
Carnitor (Oral Tablet) B 3
C1
Cer
delg
a
Cerdelga (Oral Capsule) B 4 PA C1
Chol
bam
Cholbam (Oral Capsule) B 4 PA C1
Cre
on
Creon (Oral Capsule Delayed Release Particles) B 2
C1
Cro
mol
yn
Sodi
um Cromolyn Sodium (Oral Concentrate) G 2
C1
Cyst
ada
ne
Cystadane (Oral Powder) B 4
C1
Cyst
ago
n
Cystagon (Oral Capsule) B 3 LA C1
Evry
sdi
Evrysdi (Oral Solution Reconstituted) B 4 PA; LA; QL C1
Gala
fold
Galafold (Oral Capsule) B 4 LA C1
Gast
rocr
om
Gastrocrom (Oral Concentrate) B 4
C1
Glas
sia
Glassia (Intravenous Solution) B 4 PA; LA C1
Kev
eyis
Keveyis (Oral Tablet) B 4 PA; QL C1
Kuv
an
Kuvan (Oral Packet) B 4 LA C1
Kuv
an
Kuvan (Oral Tablet) B 4 LA C1
Lev
ocar
nitin
e
Levocarnitine (1GM/10ML Oral Solution) G 3
C1
Lev
ocar
nitin
e
Levocarnitine (330MG Oral Tablet) B 2
C1
Migl
usta
t
Miglustat (Oral Capsule) G 4 PA; LA C1
Nitis
inon
e
Nitisinone (Oral Capsule) G 4
C1
Nityr
Nityr (Oral Tablet) B 4 LA C1
Orfa
din
Orfadin (Oral Capsule) B 4 LA C1
Orfa
din
Orfadin (Oral Suspension) B 4 LA C1
Paly
nziq
Palynziq (Subcutaneous Solution Prefilled Syringe) B 4 PA; QL C1
Pan
crea
ze
Pancreaze (10500-35500UNIT Oral Capsule Delayed
Release Particles, 2600-8800UNIT Oral Capsule
Delayed Release Particles, 4200-14200UNIT Oral
Capsule Delayed Release Particles)
B 3 ST
C1
Pan
crea
ze
Pancreaze (16800-56800UNIT Oral Capsule Delayed
Release Particles, 21000-54700UNIT Oral Capsule
Delayed Release Particles)
B 4 ST
You can find information on what the abbreviations in this table mean on pages 6 - 7.
125Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pert
zye
Pertzye (16000-57500UNIT Oral Capsule Delayed
Release Particles, 24000-86250UNIT Oral Capsule
Delayed Release Particles)
B 4 ST
C1
Pert
zye
Pertzye (4000-14375UNIT Oral Capsule Delayed
Release Particles, 8000-28750UNIT Oral Capsule
Delayed Release Particles)
B 3 ST
C1
Proc
ysbi
Procysbi (Oral Packet) B 4 LA C1
Prol
astin
-C
Prolastin-C (Intravenous Solution Reconstituted) B 4 PA; LA C1
RAV
ICTI
RAVICTI (Oral Liquid) B 4 LA C1
Sapr
opte
rin
Dihy
droc
hlori
de Sapropterin Dihydrochloride (Oral Packet) G 4
C1
Sapr
opte
rin
Dihy
droc
hlori
de Sapropterin Dihydrochloride (Oral Tablet) G 4
C1
Sodi
um
Phe
nylb
utyr
ate Sodium Phenylbutyrate (Oral Powder) G 4
C1
Sodi
um
Phe
nylb
utyr
ate Sodium Phenylbutyrate (Oral Tablet) G 4
C1
Sucr
aid
Sucraid (Oral Solution) B 4 LA C1
Teg
sedi
Tegsedi (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1
Viok
ace
Viokace (10440-39150UNIT Oral Tablet) B 3 ST C1
Viok
ace
Viokace (20880-78300UNIT Oral Tablet) B 4 ST C1
Vyn
dam
ax
Vyndamax (Oral Capsule) B 4 PA; LA; QL C1
Vyn
daq
el
Vyndaqel (Oral Capsule) B 4 PA; LA; QL C1
Xuri
den
Xuriden (Oral Packet) B 4 PA; LA C1
Zav
esca
Zavesca (Oral Capsule) B 4 PA; LA C1
Zem
aira
Zemaira (Intravenous Solution Reconstituted) B 4 PA; LA C1
Zen
pep
Zenpep (Oral Capsule Delayed Release Particles) B 2
A1
Genitourinary AgentsB1
Antispasmodics, UrinaryC1
Darif
ena
cin
Hyd
robr
omi
de
ER Darifenacin Hydrobromide ER (Oral Tablet Extended
Release 24 Hour)G 3 ST; QL
C1
Detr
ol
LA
Detrol LA (Oral Capsule Extended Release 24 Hour) B 3
C1
Detr
ol
Detrol (Oral Tablet) B 3
C1
Ditr
opa
n XL
Ditropan XL (Oral Tablet Extended Release 24 Hour) B 3
C1
Flav
oxat
e
HCl
Flavoxate HCl (Oral Tablet) G 2
C1
Geln
ique
Gelnique (Transdermal Gel) B 3
C1
Ge
mte
sa
Gemtesa (Oral Tablet) B 3 ST C1
Myr
betri
q
Myrbetriq (Oral Tablet Extended Release 24 Hour) B 2
C1
Oxy
buty
nin
Chlo
ride
ER Oxybutynin Chloride ER (Oral Tablet Extended Release
24 Hour)G 2
C1
Oxy
buty
nin
Chlo
ride Oxybutynin Chloride (Oral Syrup) G 1
C1
Oxy
buty
nin
Chlo
ride Oxybutynin Chloride (Oral Tablet Immediate Release) G 1
126 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Oxyt
rol
Oxytrol (Transdermal Patch Twice Weekly) B 4
C1
Solif
ena
cin
Suc
cina
te Solifenacin Succinate (Oral Tablet) G 2 QL C1
Tolt
erod
ine
Tartr
ate
ER Tolterodine Tartrate ER (Oral Capsule Extended Release
24 Hour)G 3
C1
Tolt
erod
ine
Tartr
ate Tolterodine Tartrate (Oral Tablet) G 2
C1
Tovi
az
Toviaz (Oral Tablet Extended Release 24 Hour) B 3 ST; QL C1
Tros
piu
m
Chlo
ride
ER Trospium Chloride ER (Oral Capsule Extended Release
24 Hour)G 3
C1
Tros
piu
m
Chlo
ride Trospium Chloride (Oral Tablet) G 2
C1
Vesi
care
LS
Vesicare LS (Oral Suspension) B 3 PA; QL C1
Vesi
care
Vesicare (Oral Tablet) B 3 QL B1
Benign Prostatic Hypertrophy AgentsC1
Alfu
zosi
n
HCl
ER Alfuzosin HCl ER (Oral Tablet Extended Release 24
Hour)G 1
C1
Avo
dart
Avodart (Oral Capsule) B 3
C1
Car
dura
XL
Cardura XL (Oral Tablet Extended Release 24 Hour) B 3 QL C1
Ciali
s
Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) B 3 PA; QL C1
Duta
steri
de
Dutasteride (Oral Capsule) G 2
C1
Duta
steri
de-
Tam
sulo
sin
HCl Dutasteride-Tamsulosin HCl (Oral Capsule) G 3
C1
Fina
steri
de
Finasteride (5MG Oral Tablet) (Generic Proscar) G 1
C1
Flo
max
Flomax (Oral Capsule) B 3
C1
Jaly
n
Jalyn (Oral Capsule) B 3
C1
Pros
car
Proscar (Oral Tablet) B 3
C1
Rap
aflo
Rapaflo (Oral Capsule) B 3 ST; QL C1
Silo
dosi
n
Silodosin (Oral Capsule) G 2 QL C1
Tad
alafil
Tadalafil (2.5MG Oral Tablet, 5MG Oral Tablet) G 3 PA; QL C1
Tam
sulo
sin
HCl
Tamsulosin HCl (Oral Capsule) G 1
C1
Tera
zosi
n
HCl
Terazosin HCl (Oral Capsule) G 1
C1
Uro
xatr
al
Uroxatral (Oral Tablet Extended Release 24 Hour) B 3
B1
Genitourinary Agents, OtherC1
Beth
ane
chol
Chlo
ride Bethanechol Chloride (10MG Oral Tablet, 25MG Oral
Tablet, 5MG Oral Tablet)G 2
C1
Beth
ane
chol
Chlo
ride Bethanechol Chloride (50MG Oral Tablet) G 3
C1
Cup
rimi
ne
Cuprimine (Oral Capsule) B 4 PA C1
Dep
en
Titra
tabs
Depen Titratabs (Oral Tablet) B 4
C1
Elmi
ron
Elmiron (Oral Capsule) B 4
You can find information on what the abbreviations in this table mean on pages 6 - 7.
127Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Lith
osta
t
Lithostat (Oral Tablet) B 4
C1
Peni
cilla
min
e
Penicillamine (250MG Oral Capsule) G 4 PA C1
Peni
cilla
min
e
Penicillamine (250MG Oral Tablet) G 4
C1
Thio
la
EC
Thiola EC (Oral Tablet Delayed Release) B 4 LA C1
Thio
la
Thiola (Oral Tablet Immediate Release) B 4 LA C1
Tiop
roni
n
Tiopronin (Oral Tablet) G 4
A1
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)B1
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)C1
Acth
ar
Acthar (Injection Gel) B 4 PA; LA C1
Alki
ndi
Spri
nkle
Alkindi Sprinkle (Oral Capsule Sprinkle) B 4
C1
Cort
ef
Cortef (Oral Tablet) B 3
C1
Dex
ablis
s
Dexabliss (Oral Tablet Therapy Pack) G 3
C1
Dex
ame
thas
one
Dexamethasone (Oral Elixir) G 1
C1
Dex
ame
thas
one
Dexamethasone (Oral Tablet) G 1
C1
Dex
ame
thas
one
Dexamethasone (Oral Tablet Therapy Pack) G 3
C1
Emfl
aza
Emflaza (Oral Suspension) B 4 PA; LA C1
Emfl
aza
Emflaza (Oral Tablet) B 4 PA; LA C1
Flud
roco
rtiso
ne
Acet
ate Fludrocortisone Acetate (Oral Tablet) G 1
C1
He
mad
y
Hemady (Oral Tablet) B 3
C1
Hyd
roco
rtiso
ne
Hydrocortisone (Oral Tablet) G 1
C1
Med
rol
Medrol (Oral Tablet) B 3
C1
Med
rol
Medrol (Oral Tablet Therapy Pack) B 3
C1
Met
hylp
redn
isol
one Methylprednisolone (Oral Tablet) G 1
C1
Met
hylp
redn
isol
one Methylprednisolone (Oral Tablet Therapy Pack) G 1
C1
Milli
pred
Millipred (Oral Tablet) G 3
C1
Ora
pred
ODT
Orapred ODT (Oral Tablet Dispersible) B 3
C1
Pre
dnis
olon
e
Prednisolone (Oral Solution) G 1
C1
Pre
dnis
olon
e
Sodi
um
Pho
sph
ate Prednisolone Sodium Phosphate (10MG/5ML Oral
Solution, 20MG/5ML Oral Solution, 25MG/5ML Oral
Solution, 6.7MG/5ML Oral Solution)
G 3
C1
Pre
dnis
olon
e
Sodi
um
Pho
sph
ate
ODTPrednisolone Sodium Phosphate ODT (10MG Oral
Tablet Dispersible, 15MG Oral Tablet Dispersible, 30MG
Oral Tablet Dispersible)
G 3
C1
Pre
dnis
one
Inte
nsol Prednisone Intensol (Oral Concentrate) G 3
C1
Pre
dnis
one
Prednisone (5MG/5ML Oral Solution) G 3
C1
Pre
dnis
one
Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG
Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG
Oral Tablet)
G 1
128 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pre
dnis
one
Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG
(48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet
Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)
G 1
C1
Ray
os
Rayos (Oral Tablet Delayed Release) B 4 PA C1
Tap
erD
ex
12-
Day TaperDex 12-Day (Oral Tablet Therapy Pack) G 3
C1
Tap
erD
ex 6-
Day
TaperDex 6-Day (Oral Tablet Therapy Pack) G 3
C1
Tap
erD
ex 7-
Day
TaperDex 7-Day (Oral Tablet Therapy Pack) G 3
A1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)B1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)C1
DDA
VP
DDAVP (0.1MG Oral Tablet) B 3
C1
DDA
VP
DDAVP (0.2MG Oral Tablet) B 4
C1
Des
mop
ressi
n
Acet
ate Desmopressin Acetate (Oral Tablet) G 2
C1
Des
mop
ressi
n
Acet
ate
Spra
y Desmopressin Acetate Spray (Nasal Solution) G 3
C1
Egrif
ta
SV
Egrifta SV (2MG Subcutaneous Solution
Reconstituted)B 4 PA; LA
C1
Gen
otro
pin
Mini
Quic
k Genotropin MiniQuick (Subcutaneous Solution
Reconstituted)B 4 PA
C1
Gen
otro
pin
Genotropin (12MG Subcutaneous Solution
Reconstituted)B 4 PA
C1
Gen
otro
pin
Genotropin (5MG Subcutaneous Solution
Reconstituted)B 3 PA
C1
Hu
matr
ope
Humatrope (Injection Solution Renconstituted),
Humatrope Combo Pack (Injection)B 4 PA
C1
Incr
elex
Increlex (Subcutaneous Solution) B 4 PA; LA C1
Noc
durn
a
Nocdurna (Tablet Sublingual) B 3 PA C1
Nor
ditro
pin
Flex
Pro Norditropin FlexPro (Subcutaneous Solution Pen-
Injector)B 4 PA
C1
Nutr
opin
AQ
NuS
pin
10 Nutropin AQ NuSpin 10 (Subcutaneous Solution Pen-
Injector)B 4 PA
C1
Nutr
opin
AQ
NuS
pin
20 Nutropin AQ NuSpin 20 (Subcutaneous Solution Pen-
Injector)B 4 PA
C1
Nutr
opin
AQ
NuS
pin
5 Nutropin AQ NuSpin 5 (Subcutaneous Solution Pen-
Injector)B 4 PA
C1
Om
nitro
pe
Omnitrope (Subcutaneous Solution Cartridge) B 4 PA C1
Om
nitro
pe
Omnitrope (Subcutaneous Solution Reconstituted) B 4 PA C1
Saiz
en
Saizen (Injection Solution Reconstituted) B 4 PA; LA C1
Saiz
enpr
ep
Saizenprep (Injection Solution Reconstituted) B 4 PA; LA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
129Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Ser
osti
m
Serostim (Subcutaneous Solution Reconstituted) B 4 PA; LA C1
Zom
acto
n
Zomacton (10MG Subcutaneous Solution
Reconstituted)B 4 PA
C1
Zom
acto
n
Zomacton (5MG Subcutaneous Solution
Reconstituted)B 3 PA
C1
Zor
btiv
e
Zorbtive (Subcutaneous Solution Reconstituted) B 4 PA; LA A1
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)B1
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)C1
Korl
ym
Korlym (Oral Tablet) B 4 PA; LA A1
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)B1
Anabolic SteroidsC1
Oxa
ndro
lone
Oxandrolone (10MG Oral Tablet) G 3
C1
Oxa
ndro
lone
Oxandrolone (2.5MG Oral Tablet) G 2
B1
AndrogensC1
And
rode
rm
Androderm (Transdermal Patch 24 Hour) B 2
C1
And
roG
el
Pum
p AndroGel Pump (Transdermal Gel) B 4
C1
And
roG
el
AndroGel (Transdermal Gel) B 4
C1
Ave
ed
Aveed (Intramuscular Solution) B 3 PA C1
Dan
azol
Danazol (Oral Capsule) G 3
C1
Dep
o-
Test
oste
rone Depo-Testosterone (Intramuscular Solution) G 3
C1
Fort
esta
Fortesta (Transdermal Gel) B 3
C1
Intra
rosa
Intrarosa (Vaginal Insert) B 3 PA; QL C1
Jate
nzo
Jatenzo (158MG Oral Capsule, 198MG Oral Capsule) B 3 PA C1
Jate
nzo
Jatenzo (237MG Oral Capsule) B 4 PA C1
Met
hite
st
Methitest (Oral Tablet) G 4 PA C1
Met
hylt
esto
ster
one Methyltestosterone (Oral Capsule) G 4 PA C1
Nat
esto
Natesto (Nasal Gel) B 3
C1
Test
im
Testim (Transdermal Gel) B 4
C1
Test
oste
rone
Cypi
onat
e Testosterone Cypionate (Intramuscular Solution) G 1
C1
Test
oste
rone
Ena
ntha
te Testosterone Enanthate (Intramuscular Solution) G 2
C1
Test
oste
rone
Pum
p Testosterone Pump (2% Transdermal Gel, 1%
Transdermal Gel, 1.62% Transdermal Gel), Testosterone
(20.25 MG/1.25GM 1.62% Transdermal Gel, 25 MG/
2.5GM 1% Transdermal Gel, 40.5 MG/2.5GM 1.62%
Transdermal Gel, 50 MG/5GM 1% Transdermal Gel)
G 3
C1
Test
oste
rone
Testosterone (Transdermal Solution) G 3
C1
Vog
elxo
Pum
p Vogelxo Pump (Transdermal Gel) B 3
C1
Vog
elxo
Vogelxo (Transdermal Gel) B 3
130 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Xyo
sted
Xyosted (Subcutaneous Solution Auto-Injector) B 3 PA B1
EstrogensC1
Alor
a
Alora (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL C1
Alta
vera
Altavera (Oral Tablet) G 3
C1
Alya
cen
1/35
Alyacen 1/35 (Oral Tablet) G 3
C1
Ame
thia
Amethia (Oral Tablet) G 3
C1
Ann
over
a
Annovera (Vaginal Ring) B 3 QL C1
Apri
Apri (Oral Tablet) G 3
C1
Aran
elle
Aranelle (Oral Tablet) G 3
C1
Ashl
yna
Ashlyna (Oral Tablet) G 3
C1
Aub
ra
EQ
Aubra EQ (Oral Tablet) G 3
C1
Avia
ne
Aviane (Oral Tablet) G 3
C1
Balc
oltra
Balcoltra (Oral Tablet) B 3
C1
Balz
iva
Balziva (Oral Tablet) G 3
C1
Bey
az
Beyaz (Oral Tablet) B 3
C1
Blis
ovi
24
Fe
Blisovi 24 Fe (Oral Tablet) G 3
C1
Blis
ovi
Fe
1.5/
30 Blisovi Fe 1.5/30 (Oral Tablet) G 3
C1
Briel
lyn
Briellyn (Oral Tablet) G 3
C1
Cam
rese
Lo
Camrese Lo (Oral Tablet) G 3
C1
Cazi
ant
Caziant (Oral Tablet) G 3
C1
Clim
ara
Pro
Climara Pro (Transdermal Patch Weekly) B 3 PA; HRM C1
Crys
elle-
28
Cryselle-28 (Oral Tablet) G 3
C1
Cycl
afe
m
1/35
Cyclafem 1/35 (Oral Tablet) G 3
C1
Cycl
afe
m
7/7/
7 Cyclafem 7/7/7 (Oral Tablet) G 3
C1
Cyre
d
EQ
Cyred EQ (Oral Tablet) G 3
C1
Dele
stro
gen
Delestrogen (Intramuscular Oil) B 3
C1
Dep
o-
Estr
adio
l Depo-Estradiol (Intramuscular Oil) G 3
C1
Des
oge
strel
-
Ethi
nyl
Estr
adio
l Desogestrel-Ethinyl Estradiol (Oral Tablet) G 3
C1
Doli
shal
e
Dolishale (Oral Tablet) G 3
C1
Dott
i
Dotti (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL C1
Dro
spir
eno
ne-
Ethi
nyl
Estr
adio
l Drospirenone-Ethinyl Estradiol (Oral Tablet) G 3
C1
Dro
spir
eno
ne-
Ethi
nyl
Estr
adio
l-
Lev
ome
folat
e
Drospirenone-Ethinyl Estradiol-Levomefolate
(3-0.02-0.451MG Oral Tablet)G 3
C1
Eles
trin
Elestrin (Transdermal Gel) B 3 PA; HRM C1
Elu
Ryn
g
EluRyng (Vaginal Ring) G 3
C1
Emo
quet
te
Emoquette (Oral Tablet) G 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
131Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Enp
ress
e-28
Enpresse-28 (Oral Tablet) G 3
C1
Ens
kyce
Enskyce (Oral Tablet) G 3
C1
Esta
rylla
Estarylla (Oral Tablet) G 3
C1
Estr
ace
Estrace (Oral Tablet) G 3 PA; HRM C1
Estr
ace
Estrace (Vaginal Cream) G 3
C1
Estr
adio
l
Estradiol (Oral Tablet) G 3 PA; HRM C1
Estr
adio
l
Estradiol (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL C1
Estr
adio
l
Estradiol (Vaginal Cream) G 3
C1
Estr
adio
l
Estradiol (Vaginal Tablet) G 3
C1
Estr
adio
l
Vale
rate Estradiol Valerate (Intramuscular Oil) G 2
C1
Estri
ng
Estring (Vaginal Ring) B 3
C1
Ethy
nodi
ol
Diac
etat
e-
Ethi
nyl
Estr
adio
l
Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet) G 3
C1
Eton
oge
strel
-
Ethi
nyl
Estr
adio
l Etonogestrel-Ethinyl Estradiol (Vaginal Ring) G 3
C1
Fal
min
a
Falmina (Oral Tablet) G 3
C1
Fay
osi
m
Fayosim (Oral Tablet) G 3
C1
Fem
ring
Femring (Vaginal Ring) B 3
C1
Fem
ynor
Femynor (Oral Tablet) G 3
C1
Fyav
olv
Fyavolv (Oral Tablet) G 3 PA; HRM C1
Ge
mmi
ly
Gemmily (Oral Capsule) G 3
C1
Gen
eres
s Fe
Generess Fe (Oral Tablet Chewable) B 3
C1
Hail
ey
24
Fe
Hailey 24 Fe (Oral Tablet) G 3
C1
Iclev
ia
Iclevia (Oral Tablet) G 3
C1
Imv
exxy
Mai
nten
anc
e
Pac
k Imvexxy Maintenance Pack (Vaginal Insert) B 2 PA C1
Imv
exxy
Start
er
Pac
k Imvexxy Starter Pack (Vaginal Insert) B 2 PA C1
Intro
vale
Introvale (Oral Tablet) G 3
C1
Isibl
oom
Isibloom (Oral Tablet) G 3
C1
Jas
miel
Jasmiel (Oral Tablet) G 3
C1
Jint
eli
Jinteli (Oral Tablet) G 3 PA; HRM C1
Jule
ber
Juleber (Oral Tablet) G 3
C1
Jun
el
1.5/
30
Junel 1.5/30 (Oral Tablet) G 3
C1
Jun
el
1/20
Junel 1/20 (Oral Tablet) G 3
C1
Jun
el
Fe
1.5/
30 Junel Fe 1.5/30 (Oral Tablet) G 3
C1
Jun
el
Fe
1/20
Junel Fe 1/20 (Oral Tablet) G 3
C1
Jun
el
Fe
24
Junel Fe 24 (Oral Tablet) G 3
C1
Kaitl
ib
Fe
Kaitlib Fe (Oral Tablet Chewable) G 3
C1
Kari
va
Kariva (Oral Tablet) G 3
C1
Keln
or
1/35
Kelnor 1/35 (Oral Tablet) G 3
132 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Keln
or
1/50
Kelnor 1/50 (Oral Tablet) G 3
C1
Kurv
elo
Kurvelo (Oral Tablet) G 3
C1
LAR
IN
1.5/
30
LARIN 1.5/30 (Oral Tablet) G 3
C1
LAR
IN
1/20
LARIN 1/20 (Oral Tablet) G 3
C1
LAR
IN
Fe
1.5/
30 LARIN Fe 1.5/30 (Oral Tablet) G 3
C1
LAR
IN
Fe
1/20
LARIN Fe 1/20 (Oral Tablet) G 3
C1
Lari
ssia
Larissia (Oral Tablet) G 3
C1
Lay
olis
Fe
Layolis Fe (Oral Tablet Chewable) B 3
C1
Lee
na
Leena (Oral Tablet) G 3
C1
Less
ina
Lessina (Oral Tablet) G 3
C1
Lev
one
st
Levonest (Oral Tablet) G 3
C1
Lev
onor
gest
rel-
Ethi
nyl
Estr
adio
l &
Ethi
nyl
Estr
adio
l
Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral
Tablet)G 3
C1
Lev
onor
gest
rel-
Ethi
nyl
Estr
adio
l 91-
DayLevonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet) G 3
C1
Lev
onor
gest
rel-
Ethi
nyl
Estr
adio
l Levonorgestrel-Ethinyl Estradiol (Oral Tablet) G 3
C1
Lev
ora
0.15
/30
Levora 0.15/30 (28) (Oral Tablet) G 3
C1
Lo
Loe
strin
Fe
Lo Loestrin Fe (Oral Tablet) B 3
C1
Loe
strin
1.5/
30 Loestrin 1.5/30 (21) (Oral Tablet) G 3
C1
Loe
strin
1/20
Loestrin 1/20 (21) (Oral Tablet) G 3
C1
Loe
strin
Fe
1.5/
30 Loestrin Fe 1.5/30 (Oral Tablet) G 3
C1
Loe
strin
Fe
1/20
Loestrin Fe 1/20 (Oral Tablet) G 3
C1
Lory
na
Loryna (Oral Tablet) G 3
C1
LoS
eas
oniq
ue
LoSeasonique (Oral Tablet) B 3
C1
Low
-
Oge
strel
Low-Ogestrel (Oral Tablet) G 3
C1
Lute
ra
Lutera (Oral Tablet) G 3
C1
Lylla
na
Lyllana (Transdermal Patch Twice Weekly) G 3 PA; HRM; QL C1
Marl
issa
Marlissa (Oral Tablet) G 3
C1
Men
est
Menest (Oral Tablet) G 3 PA; HRM C1
Mer
zee
Merzee (Oral Capsule) B 3
C1
Mib
elas
24
Fe
Mibelas 24 Fe (Oral Tablet Chewable) G 3
C1
Micr
oge
stin
1.5/
30 Microgestin 1.5/30 (Oral Tablet) G 3
C1
Micr
oge
stin
1/20
Microgestin 1/20 (Oral Tablet) G 3
C1
Micr
oge
stin
Fe
1.5/
30 Microgestin Fe 1.5/30 (Oral Tablet) G 3
C1
Micr
oge
stin
Fe
1/20 Microgestin Fe 1/20 (Oral Tablet) G 3
C1
Mili
Mili (Oral Tablet) G 3
C1
Min
astri
n 24
Fe
Minastrin 24 Fe (Oral Tablet Chewable) B 3
You can find information on what the abbreviations in this table mean on pages 6 - 7.
133Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Mini
velle
Minivelle (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL C1
Nata
zia
Natazia (Oral Tablet) B 3
C1
Nec
on
0.5/
35
Necon 0.5/35 (28) (Oral Tablet) G 3
C1
Next
stelli
s
Nextstellis (Oral Tablet) B 3
C1
Nikk
i
Nikki (Oral Tablet) G 3
C1
Nor
ethi
ndro
ne
Acet
ate-
Ethi
nyl
Estr
adio
l
Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG
Oral Tablet, 1-5MG-MCG Oral Tablet)G 3 PA; HRM
C1
Nor
ethi
ndro
ne
Acet
ate-
Ethi
nyl
Estr
adio
l
Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG
Oral Tablet)G 3
C1
Nor
ethi
ndro
ne
Acet
ate-
Ethi
nyl
Estr
adio
l-Fe
Norethindrone Acetate-Ethinyl Estradiol-Fe (1-20MG-
MCG Oral Tablet)G 3
C1
Nor
ethi
ndro
ne
Acet
ate-
Ethi
nyl
Estr
adio
l-Fe
Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG-
MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet
Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)
G 3
C1
Nor
gest
imat
e-
Ethi
nyl
Estr
adio
l Norgestimate-Ethinyl Estradiol (Oral Tablet) G 3
C1
Nor
gest
imat
e-
Ethi
nyl
Estr
adio
l
Trip
hasi
c
Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet) G 3
C1
Nort
rel
0.5/
35
Nortrel 0.5/35 (28) (Oral Tablet) G 3
C1
Nort
rel
1/35
Nortrel 1/35 (21) (Oral Tablet) G 3
C1
Nort
rel
1/35
Nortrel 1/35 (28) (Oral Tablet) G 3
C1
Nort
rel
7/7/
7
Nortrel 7/7/7 (Oral Tablet) G 3
C1
Nuv
aRin
g
NuvaRing (Vaginal Ring) B 3
C1
Nyli
a
7/7/
7
Nylia 7/7/7 (Oral Tablet) G 3
C1
Nym
yo
Nymyo (Oral Tablet) G 3
C1
Ocel
la
Ocella (Oral Tablet) G 3
C1
Orsy
thia
Orsythia (Oral Tablet) G 3
C1
Pimt
rea
Pimtrea (Oral Tablet) G 3
C1
Pirm
ella
1/35
Pirmella 1/35 (Oral Tablet) G 3
C1
Porti
a-28
Portia-28 (Oral Tablet) G 3
C1
Pre
mari
n
Premarin (Vaginal Cream) B 2
C1
Prev
ifem
Previfem (Oral Tablet) G 3
C1
Qua
rtett
e
Quartette (Oral Tablet) B 3
C1
Recl
ipse
n
Reclipsen (Oral Tablet) G 3
C1
Rive
lsa
Rivelsa (Oral Tablet) G 3
C1
Safy
ral
Safyral (Oral Tablet) B 3
C1
Sea
soni
que
Seasonique (Oral Tablet) B 3
C1
Setl
akin
Setlakin (Oral Tablet) G 3
C1
Spri
ntec
28
Sprintec 28 (Oral Tablet) G 3
C1
Sro
nyx
Sronyx (Oral Tablet) G 3
134 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Sye
da
Syeda (Oral Tablet) G 3
C1
Tari
na
24
Fe
Tarina 24 Fe (Oral Tablet) G 3
C1
Tari
na
Fe
1/20
EQ Tarina Fe 1/20 EQ (Oral Tablet) G 3
C1
Tilia
Fe
Tilia Fe (Oral Tablet) G 3
C1
Tri-
Esta
rylla
Tri-Estarylla (Oral Tablet) G 3
C1
Tri-
Leg
est
Fe
Tri-Legest Fe (Oral Tablet) G 3
C1
Tri-
Lo-
Esta
rylla
Tri-Lo-Estarylla (Oral Tablet) G 3
C1
Tri-
Lo-
Spri
ntec
Tri-Lo-Sprintec (Oral Tablet) G 3
C1
Tri-
Mili
Tri-Mili (Oral Tablet) G 3
C1
Tri-
Nym
yo
Tri-Nymyo (Oral Tablet) G 3
C1
Tri-
Prev
ifem
Tri-Previfem (Oral Tablet) G 3
C1
Tri-
Spri
ntec
Tri-Sprintec (Oral Tablet) G 3
C1
Triv
ora
Trivora (28) (Oral Tablet) G 3
C1
Tri-
VyLi
bra
Lo
Tri-VyLibra Lo (Oral Tablet) G 3
C1
Tri-
VyLi
bra
Tri-VyLibra (Oral Tablet) G 3
C1
Tyd
emy
Tydemy (Oral Tablet) G 3
C1
Vagi
fem
Vagifem (Vaginal Tablet) B 3
C1
Veli
vet
Velivet (Oral Tablet) G 3
C1
Vest
ura
Vestura (Oral Tablet) G 3
C1
Vien
va
Vienva (Oral Tablet) G 3
C1
Vive
lle-
Dot
Vivelle-Dot (Transdermal Patch Twice Weekly) B 3 PA; HRM; QL C1
Vyfe
mla
Vyfemla (Oral Tablet) G 3
C1
VyLi
bra
VyLibra (Oral Tablet) G 3
C1
WY
MZ
YA
Fe
WYMZYA Fe (Oral Tablet Chewable) G 3
C1
Xula
ne
Xulane (Transdermal Patch Weekly) G 3
C1
Yas
min
28
Yasmin 28 (Oral Tablet) B 3
C1
YAZ
YAZ (Oral Tablet) B 3
C1
Yuv
afe
m
Yuvafem (Vaginal Tablet) G 3
C1
Zafe
my
Zafemy (Transdermal Patch Weekly) G 3
C1
Zara
h
Zarah (Oral Tablet) G 3
C1
Zovi
a
1/35
E
Zovia 1/35E (28) (Oral Tablet) G 3
B1
ProgestinsC1
Ayg
esti
n
Aygestin (Oral Tablet) G 3
C1
Cam
ila
Camila (Oral Tablet) G 2
C1
Crin
one
Crinone (Vaginal Gel) B 3 PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
135Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Debl
itan
e
Deblitane (Oral Tablet) G 2
C1
Dep
o-
Prov
era
Depo-Provera (150MG/ML Intramuscular Suspension) B 3
C1
Dep
o-
Sub
Q
Prov
era
104 Depo-SubQ Provera 104 (Subcutaneous Suspension
Prefilled Syringe)B 3
C1
Errin
Errin (Oral Tablet) G 2
C1
Inca
ssia
Incassia (Oral Tablet) G 2
C1
Lyle
q
Lyleq (Oral Tablet) G 2
C1
Lyza
Lyza (Oral Tablet) G 2
C1
Med
roxy
pro
gest
eron
e
Acet
ate Medroxyprogesterone Acetate (Intramuscular
Suspension)G 1
C1
Med
roxy
pro
gest
eron
e
Acet
ate Medroxyprogesterone Acetate (Intramuscular
Suspension Prefilled Syringe)G 1
C1
Med
roxy
pro
gest
eron
e
Acet
ate Medroxyprogesterone Acetate (Oral Tablet) G 1
C1
Meg
estr
ol
Acet
ate Megestrol Acetate (40MG/ML Oral Suspension, 625MG/
5ML Oral Suspension)G 3 PA; HRM
C1
Meg
estr
ol
Acet
ate Megestrol Acetate (Oral Tablet) G 3 PA; HRM C1
Nor
a-BE
Nora-BE (Oral Tablet) G 2
C1
Nor
ethi
ndro
ne
Acet
ate Norethindrone Acetate (5MG Oral Tablet) G 1
C1
Nor
ethi
ndro
ne
Norethindrone (0.35MG Oral Tablet) G 2
C1
Pro
gest
eron
e
Progesterone (Oral Capsule) G 2
C1
Pro
metr
ium
Prometrium (Oral Capsule) B 3
C1
Prov
era
Provera (Oral Tablet) B 3
C1
Shar
obel
Sharobel (Oral Tablet) G 2
C1
Slyn
d
Slynd (Oral Tablet) B 3
B1
Selective Estrogen Receptor Modifying AgentsC1
Evis
ta
Evista (Oral Tablet) B 3
C1
Osp
hen
a
Osphena (Oral Tablet) B 2 PA; QL C1
Ralo
xife
ne
HCl
Raloxifene HCl (Oral Tablet) G 2
A1
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)B1
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)C1
Cyto
mel
Cytomel (Oral Tablet) B 3
C1
Euth
yrox
Euthyrox (Oral Tablet) B 1
C1
Lev
o-T
Levo-T (Oral Tablet) B 1
C1
Lev
othy
roxi
ne
Sodi
um Levothyroxine Sodium (Oral Capsule) G 3
C1
Lev
othy
roxi
ne
Sodi
um Levothyroxine Sodium (Oral Tablet) G 1
C1
Lev
oxyl
Levoxyl (Oral Tablet) B 1
C1
Liot
hyro
nine
Sodi
um Liothyronine Sodium (Oral Tablet) G 1
136 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Synt
hroi
d
Synthroid (Oral Tablet) B 2
C1
Thy
quid
ity
Thyquidity (Oral Solution) B 3
C1
Tiro
sint
Tirosint (Oral Capsule) B 3
C1
Tiro
sint-
SOL
Tirosint-SOL (100MCG/ML Oral Solution, 112MCG/
ML Oral Solution, 125MCG/ML Oral Solution,
137MCG/ML Oral Solution, 13MCG/ML Oral Solution,
150MCG/ML Oral Solution, 175MCG/ML Oral
Solution, 200MCG/ML Oral Solution, 25MCG/ML Oral
Solution, 50MCG/ML Oral Solution, 75MCG/ML Oral
Solution, 88MCG/ML Oral Solution)
B 3
C1
Unit
hroi
d
Unithroid (Oral Tablet) B 1
A1
Hormonal Agents, Suppressant (Adrenal)B1
Hormonal Agents, Suppressant (Adrenal)C1
Istur
isa
Isturisa (Oral Tablet) B 4 PA C1
Lys
odre
n
Lysodren (Oral Tablet) B 4
A1
Hormonal Agents, Suppressant (Pituitary)B1
Hormonal Agents, Suppressant (Pituitary)C1
Cab
ergo
line
Cabergoline (Oral Tablet) G 2
C1
Elig
ard
Eligard (Subcutaneous Kit) B 3 PA C1
Firm
ago
n
Firmagon (240MG Dose) (120MG/Vial Subcutaneous
Solution Reconstituted)B 4 PA
C1
Firm
ago
n
Firmagon (80MG Subcutaneous Solution
Reconstituted)B 3 PA
C1
Leu
proli
de
Acet
ate Leuprolide Acetate (Injection Kit) G 3 PA C1
Lup
anet
a
Pac
k Lupaneta Pack (Combination Kit) B 4 PA C1
Lupr
on
Dep
ot
Lupron Depot (1-Month) (Intramuscular Kit) B 4 PA C1
Lupr
on
Dep
ot
Lupron Depot (3-Month) (Intramuscular Kit) B 4 PA C1
Lupr
on
Dep
ot
Lupron Depot (4-Month) (Intramuscular Kit) B 4 PA C1
Lupr
on
Dep
ot
Lupron Depot (6-Month) (Intramuscular Kit) B 4 PA C1
Myc
apss
a
Mycapssa (Oral Capsule Delayed Release) B 4 PA; QL C1
Octr
eoti
de
Acet
ate Octreotide Acetate (1000MCG/ML Injection Solution,
500MCG/ML Injection Solution)G 4 PA
C1
Octr
eoti
de
Acet
ate Octreotide Acetate (100MCG/ML Injection Solution,
200MCG/ML Injection Solution, 50MCG/ML Injection
Solution)
G 3 PA
C1
Org
ovyx
Orgovyx (Oral Tablet) B 4 PA; QL C1
Oria
hnn
Oriahnn (Oral Capsule Therapy Pack) B 4 PA; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
137Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Orili
ssa
Orilissa (Oral Tablet) B 4 PA; QL C1
San
dost
atin
Sandostatin (Injection Solution) B 4 PA C1
Sign
ifor
Signifor (Subcutaneous Solution) B 4 PA; LA C1
Som
aver
t
Somavert (Subcutaneous Solution Reconstituted) B 4 PA; LA; QL C1
Syn
arel
Synarel (Nasal Solution) B 4
C1
Trel
star
Mixj
ect
Trelstar Mixject (Intramuscular Suspension
Reconstituted)B 4 PA
A1
Hormonal Agents, Suppressant (Thyroid)B1
Antithyroid AgentsC1
Met
him
azol
e
Methimazole (Oral Tablet) G 1
C1
Pro
pylt
hiou
racil
Propylthiouracil (Oral Tablet) G 1
C1
Tap
azol
e
Tapazole (Oral Tablet) G 3
A1
Immunological AgentsB1
Angioedema AgentsC1
Beri
nert
Berinert (Intravenous Kit) B 4 PA; LA C1
Cinr
yze
Cinryze (Intravenous Solution Reconstituted) B 4 PA; LA C1
Fira
zyr
Firazyr (Subcutaneous Solution) B 4 PA; QL C1
Hae
gard
a
Haegarda (Subcutaneous Solution Reconstituted) B 4 PA; LA C1
Icati
bant
Acet
ate Icatibant Acetate (Subcutaneous Solution) G 4 PA; QL C1
Orla
dey
o
Orladeyo (Oral Capsule) B 4 PA; QL C1
Ruc
one
st
Ruconest (Intravenous Solution Reconstituted) B 4 PA; LA C1
Tak
hzyr
o
Takhzyro (Subcutaneous Solution) B 4 PA B1
ImmunoglobulinsC1
BIVI
GA
M
BIVIGAM (Intravenous Solution) B 4 PA C1
Fleb
oga
mm
a
DIF Flebogamma DIF (5GM/50ML Intravenous Solution) B 4 PA C1
Ga
mm
agar
d
Gammagard (2.5GM/25ML Injection Solution) B 4 PA C1
Ga
mm
agar
d S/
D
Less
IgA Gammagard S/D Less IgA (Intravenous Solution
Reconstituted)B 4 PA
C1
Ga
mm
ake
d
Gammaked (1GM/10ML Injection Solution) B 4 PA C1
Ga
mm
aple
x
Gammaplex (10GM/100ML Intravenous Solution,
10GM/200ML Intravenous Solution, 20GM/200ML
Intravenous Solution, 5GM/50ML Intravenous
Solution)
B 4 PA
C1
Ga
mun
ex-C
Gamunex-C (1GM/10ML Injection Solution) B 4 PA C1
Oct
aga
m
Octagam (1GM/20ML Intravenous Solution, 2GM/
20ML Intravenous Solution)B 4 PA
C1
Pan
zyga
Panzyga (Intravenous Solution) B 4 PA
138 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Privi
gen
Privigen (20GM/200ML Intravenous Solution) B 4 PA C1
Vari
zig
Varizig (Intramuscular Solution) B 4
B1
Immunological Agents, OtherC1
Acte
mra
ACT
Pen
Actemra ACTPen (Subcutaneous Solution Auto-
Injector)B 4 PA
C1
Acte
mra
Actemra (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Arca
lyst
Arcalyst (Subcutaneous Solution Reconstituted) B 4 PA; LA C1
Benl
ysta
Benlysta (Subcutaneous Solution Auto-Injector) B 4 PA C1
Benl
ysta
Benlysta (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Cos
enty
x
Cosentyx (300 MG Dose) (Subcutaneous Solution
Prefilled Syringe)B 4 PA; LA
C1
Cos
enty
x
Sen
sore
ady Cosentyx Sensoready (300 MG) (Subcutaneous
Solution Auto-Injector)B 4 PA; LA
C1
Dupi
xent
Dupixent (300MG/2ML Subcutaneous Solution Pen-
Injector)B 4 PA
C1
Dupi
xent
Dupixent (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Gras
tek
Grastek (Tablet Sublingual) B 2 PA C1
Ilum
ya
Ilumya (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Kev
zara
Kevzara (Subcutaneous Solution Auto-Injector) B 4 PA C1
Kev
zara
Kevzara (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Kine
ret
Kineret (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Oda
ctra
Odactra (Tablet Sublingual) B 3 PA C1
Olu
mia
nt
Olumiant (Oral Tablet) B 4 PA; QL C1
Oral
air
300I
R
Oralair 300IR (Tablet Sublingual) B 3 PA C1
Ore
ncia
Clic
kJec
t Orencia ClickJect (Subcutaneous Solution Auto-
Injector)B 4 PA
C1
Ore
ncia
Orencia (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Ote
zla
Otezla (Oral Tablet) B 4 PA; LA C1
Ote
zla
Otezla (Oral Tablet Therapy Pack) B 4 PA; LA C1
Rida
ura
Ridaura (Oral Capsule) B 4
C1
Rinv
oq
Rinvoq (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1
Siliq
Siliq (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Skyr
izi
Skyrizi (150 MG Dose) (Subcutaneous Prefilled
Syringe Kit)B 4 PA
C1
Skyr
izi
Pen
Skyrizi Pen (Subcutaneous Solution Auto-Injector) B 4 PA C1
Skyr
izi
Skyrizi (Subcutaneous Solution Prefilled Syringe) B 4 PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
139Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Stel
ara
Stelara (Subcutaneous Solution) B 4 PA C1
Stel
ara
Stelara (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Talt
z
Taltz (Subcutaneous Solution Auto-Injector) B 4 PA; LA C1
Talt
z
Taltz (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1
Tre
mfy
a
Tremfya (Subcutaneous Solution Pen-Injector) B 4 PA C1
Tre
mfy
a
Tremfya (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Xelj
anz
Xeljanz (Oral Solution) B 4 PA; QL C1
Xelj
anz
Xeljanz (Oral Tablet Immediate Release) B 4 PA; QL C1
Xelj
anz
XR
Xeljanz XR (Oral Tablet Extended Release 24 Hour) B 4 PA; QL C1
Xola
ir
Xolair (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1
Xola
ir
Xolair (Subcutaneous Solution Reconstituted) B 4 PA; LA B1
ImmunostimulantsC1
Acti
mm
une
Actimmune (Subcutaneous Solution) B 4 LA C1
Intro
n A
Intron A (Injection Solution) B 4 PA; LA C1
Intro
n A
Intron A (Injection Solution Reconstituted) B 4 PA; LA C1
Peg
asys
Pegasys (Subcutaneous Solution) B 4 PA B1
ImmunosuppressantsC1
Arav
a
Arava (Oral Tablet) B 4
C1
Asta
graf
XL
Astagraf XL (0.5MG Oral Capsule Extended Release
24 Hour, 1MG Oral Capsule Extended Release 24
Hour)
B 3 B/D, PA
C1
Asta
graf
XL
Astagraf XL (5MG Oral Capsule Extended Release 24
Hour)B 4 B/D, PA
C1
Aza
san
Azasan (100MG Oral Tablet) G 3 B/D, PA C1
Aza
san
Azasan (75MG Oral Tablet) G 4 B/D, PA C1
Azat
hiop
rine
Azathioprine (Oral Tablet) G 1 B/D, PA C1
Cell
cept
Cellcept (Oral Capsule) B 4 B/D, PA C1
Cell
cept
Cellcept (Oral Suspension Reconstituted) B 4 B/D, PA C1
Cell
cept
Cellcept (Oral Tablet) B 4 B/D, PA C1
Cim
zia
Prefi
lled
Cimzia Prefilled (Subcutaneous Kit) B 4 PA C1
Cim
zia
Cimzia (Subcutaneous Kit) B 4 PA C1
Cycl
osp
orin
e
Mod
ified Cyclosporine Modified (Oral Capsule) G 2 B/D, PA C1
Cycl
osp
orin
e
Mod
ified Cyclosporine Modified (Oral Solution) G 2 B/D, PA C1
Cycl
osp
orin
e
Cyclosporine (Oral Capsule) G 3 B/D, PA C1
Enb
rel
Mini
Enbrel Mini (Subcutaneous Solution Cartridge) B 4 PA C1
Enb
rel
Enbrel (Subcutaneous Solution) B 4 PA C1
Enb
rel
Enbrel (Subcutaneous Solution Prefilled Syringe) B 4 PA
140 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Enb
rel
Enbrel (Subcutaneous Solution Reconstituted) B 4 PA C1
Enb
rel
Sure
Clic
k Enbrel SureClick (Subcutaneous Solution Auto-
Injector)B 4 PA
C1
Ens
pryn
g
Enspryng (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Env
arsu
s XR
Envarsus XR (Oral Tablet Extended Release 24 Hour) B 3 B/D, PA C1
Ever
olim
us
Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet,
0.75MG Oral Tablet)G 4 B/D, PA
C1
Gen
graf
Gengraf (Oral Capsule) G 2 B/D, PA C1
Gen
graf
Gengraf (Oral Solution) G 2 B/D, PA C1
Hu
mira
Pedi
atric
Cro
hns
Start Humira Pediatric Crohns Start (Subcutaneous
Prefilled Syringe Kit)B 4 PA
C1
Hu
mira
Pen
Humira Pen (Subcutaneous Pen-Injector Kit) B 4 PA C1
Hu
mira
Pen
Cro
hns
Dise
ase
Start
er Humira Pen Crohns Disease Starter (Subcutaneous
Pen-Injector Kit)B 4 PA
C1
Hu
mira
Pen-
Pedi
atric
UC
Start Humira Pen-Pediatric UC Start (Subcutaneous Pen-
Injector Kit)B 4 PA
C1
Hu
mira
Pen
Psor
iasis
Start
er Humira Pen Psoriasis Starter (Subcutaneous Pen-
Injector Kit)B 4 PA
C1
Hu
mira
Humira (Subcutaneous Prefilled Syringe Kit) B 4 PA C1
Imur
an
Imuran (Oral Tablet) B 3 B/D, PA C1
Lefl
uno
mid
e
Leflunomide (Oral Tablet) G 2
C1
Lup
kyni
s
Lupkynis (Oral Capsule) B 4 PA; QL C1
Met
hotr
exat
e
Methotrexate (Oral Tablet) G 1
C1
Met
hotr
exat
e
Sodi
um Methotrexate Sodium (50MG/2ML Injection Solution
Prefilled Syringe)G 1
C1
Met
hotr
exat
e
Sodi
um Methotrexate Sodium (50MG/2ML Injection Solution) G 1
C1
Myc
oph
enol
ate
Mof
etil Mycophenolate Mofetil (Oral Capsule) G 2 B/D, PA C1
Myc
oph
enol
ate
Mof
etil Mycophenolate Mofetil (Oral Suspension Reconstituted) G 4 B/D, PA C1
Myc
oph
enol
ate
Mof
etil Mycophenolate Mofetil (Oral Tablet) G 2 B/D, PA C1
Myc
oph
enol
ate
Sodi
um Mycophenolate Sodium (Oral Tablet Delayed Release) G 3 B/D, PA C1
Myf
ortic
Myfortic (180MG Oral Tablet Delayed Release) B 3 B/D, PA C1
Myf
ortic
Myfortic (360MG Oral Tablet Delayed Release) B 4 B/D, PA C1
Neo
ral
Neoral (Oral Capsule) B 3 B/D, PA C1
Neo
ral
Neoral (Oral Solution) B 3 B/D, PA C1
Otre
xup
Otrexup (Subcutaneous Solution Auto-Injector) B 3 PA C1
Pro
graf
Prograf (0.5MG Oral Capsule) B 3 B/D, PA
You can find information on what the abbreviations in this table mean on pages 6 - 7.
141Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pro
graf
Prograf (1MG Oral Capsule, 5MG Oral Capsule) B 4 B/D, PA C1
Pro
graf
Prograf (Oral Packet) B 3 B/D, PA C1
Rap
amu
ne
Rapamune (Oral Solution) B 4 B/D, PA C1
Rap
amu
ne
Rapamune (0.5MG Oral Tablet) B 3 B/D, PA C1
Rap
amu
ne
Rapamune (1MG Oral Tablet, 2MG Oral Tablet) B 4 B/D, PA C1
Ras
uvo
Rasuvo (Subcutaneous Solution Auto-Injector) B 3 PA C1
Redi
Trex
RediTrex (Subcutaneous Solution Prefilled Syringe) B 3 PA C1
San
dim
mun
e
Sandimmune (100MG Oral Capsule) B 4 B/D, PA C1
San
dim
mun
e
Sandimmune (25MG Oral Capsule) B 3 B/D, PA C1
San
dim
mun
e
Sandimmune (100MG/ML Oral Solution) B 4 B/D, PA C1
Sim
poni
Simponi (Subcutaneous Solution Auto-Injector) B 4 PA C1
Sim
poni
Simponi (Subcutaneous Solution Prefilled Syringe) B 4 PA C1
Sirol
imu
s
Sirolimus (Oral Solution) G 4 B/D, PA C1
Sirol
imu
s
Sirolimus (Oral Tablet) G 3 B/D, PA C1
Tacr
olim
us
Tacrolimus (0.5MG Oral Capsule, 1MG Oral Capsule) G 2 B/D, PA C1
Tacr
olim
us
Tacrolimus (5MG Oral Capsule) G 3 B/D, PA C1
Trex
all
Trexall (Oral Tablet) G 3
C1
Xat
mep
Xatmep (Oral Solution) B 3 PA C1
Zort
ress
Zortress (Oral Tablet) B 4 B/D, PA B1
VaccinesC1
Act
HIB
ActHIB (Intramuscular Solution Reconstituted) B 2 QL C1
Ada
cel
Adacel (Intramuscular Suspension) B 2 QL C1
BC
G
Vac
cine
BCG Vaccine (Injection) B 2 QL C1
Bex
sero
Bexsero (Intramuscular Suspension Prefilled Syringe) B 2 QL C1
Boo
strix
Boostrix (5-2.5-18.5 Intramuscular Suspension,
5-2.5-18.5 (0.5ML Syringe) Intramuscular
Suspension)
B 2 QL
C1
Dap
tace
l
Daptacel (Intramuscular Suspension) B 2 QL C1
Diph
theri
a-
Teta
nus
Tox
oids
DT Diphtheria-Tetanus Toxoids DT (Intramuscular
Suspension)B 2 QL
C1
Eng
erix-
B
Engerix-B (Injection Suspension) B 2 B/D, PA; QL C1
Gar
dasil
9
Gardasil 9 (Intramuscular Suspension) B 2 QL C1
Gar
dasil
9
Gardasil 9 (Intramuscular Suspension Prefilled
Syringe)B 2 QL
C1
Havr
ix
Havrix (Intramuscular Suspension) B 2 QL C1
Hibe
rix
Hiberix (Injection Solution Reconstituted) B 2 QL C1
Imo
vax
Rabi
es
Imovax Rabies (Intramuscular Injectable) B 2 B/D, PA; QL
142 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Infa
nrix
Infanrix (Intramuscular Suspension) B 2 QL C1
IPO
L
IPOL (Injection) B 2 QL C1
Ixiar
o
Ixiaro (Intramuscular Suspension) B 2 QL C1
Kinri
x
Kinrix (Intramuscular Suspension) B 2 QL C1
Men
actr
a
Menactra (Intramuscular Injectable) B 2 QL C1
Men
Qua
dfi
MenQuadfi (Intramuscular Injectable) B 2 QL C1
Men
veo
Menveo (Intramuscular Solution Reconstituted) B 2 QL C1
M-
M-R
II
M-M-R II (Injection Solution Reconstituted) B 2 QL C1
Pedi
arix
Pediarix (Intramuscular Suspension) B 2 QL C1
Ped
vax
HIB
Pedvax HIB (Intramuscular Suspension) B 2 QL C1
Pro
Qua
d
ProQuad (Subcutaneous Suspension Reconstituted) B 2 QL C1
Qua
drac
el
Quadracel (Intramuscular Suspension) B 2 QL C1
Rab
Aver
t
RabAvert (Intramuscular Suspension Reconstituted) B 2 B/D, PA; QL C1
Rec
omb
ivax
HB
Recombivax HB (Injection Suspension) B 2 B/D, PA; QL C1
Rot
arix
Rotarix (Oral Suspension Reconstituted) B 2 QL C1
Rot
aTe
q
RotaTeq (Oral Solution) B 2 QL C1
Shin
grix
Shingrix (Intramuscular Suspension Reconstituted) B 2 PA; QL C1
TDV
AX
TDVAX (Intramuscular Suspension) B 2 QL C1
Teni
vac
Tenivac (Intramuscular Injectable) B 2 QL C1
Tru
men
ba
Trumenba (Intramuscular Suspension Prefilled
Syringe)B 2 QL
C1
Twi
nrix
Twinrix (Intramuscular Suspension Prefilled Syringe) B 2 QL C1
Typ
him
Vi
Typhim Vi (Intramuscular Solution) B 2 QL C1
VAQ
TA
VAQTA (Intramuscular Suspension) B 2 QL C1
Vari
vax
Varivax (Subcutaneous Injectable) B 2 QL C1
YF-
Vax
YF-Vax (Subcutaneous Injectable) B 2 QL A1
Inflammatory Bowel Disease AgentsB1
AminosalicylatesC1
Apri
so
Apriso (Oral Capsule Extended Release 24 Hour) B 2 QL C1
Asa
col
HD
Asacol HD (Oral Tablet Delayed Release) B 4 ST; QL C1
Azul
fidin
e
EN-
tabs Azulfidine EN-tabs (Oral Tablet Delayed Release) B 3
C1
Azul
fidin
e
Azulfidine (Oral Tablet Immediate Release) B 3
C1
Bals
alazi
de
Diso
diu
m Balsalazide Disodium (Oral Capsule) G 3
C1
Can
asa
Canasa (Rectal Suppository) B 4 QL C1
Cola
zal
Colazal (Oral Capsule) G 4
C1
Delz
icol
Delzicol (Oral Capsule Delayed Release) B 3 ST
You can find information on what the abbreviations in this table mean on pages 6 - 7.
143Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Dipe
ntu
m
Dipentum (Oral Capsule) B 4
C1
Lial
da
Lialda (Oral Tablet Delayed Release) B 4 ST; QL C1
Mes
ala
min
e
ER Mesalamine ER (0.375GM Oral Capsule Extended
Release 24 Hour) (Generic Apriso)G 2 QL
C1
Mes
ala
min
e
Mesalamine (400MG Oral Capsule Delayed Release)
(Generic Delzicol)G 3 ST
C1
Mes
ala
min
e
Mesalamine (1.2GM Oral Tablet Delayed Release)
(Generic Lialda)G 3 QL
C1
Mes
ala
min
e
Mesalamine (800MG Oral Tablet Delayed Release)
(Generic Asacol)G 3 ST; QL
C1
Mes
ala
min
e
Mesalamine (Rectal Enema) G 3
C1
Mes
ala
min
e
Mesalamine (Rectal Suppository) G 3 QL C1
Pent
asa
Pentasa (Oral Capsule Extended Release) B 3 QL C1
Row
asa
Rowasa (Rectal Kit) B 4
C1
Sulf
asal
azin
e
Sulfasalazine (Oral Tablet Immediate Release) G 1
C1
Sulf
asal
azin
e
Sulfasalazine (Oral Tablet Delayed Release) G 1
B1
GlucocorticoidsC1
Anu
sol-
HC
Anusol-HC (External Cream) G 3
C1
Bud
eso
nide
ER
Budesonide ER (Oral Tablet Extended Release 24 Hour) G 4 ST C1
Bud
eso
nide
Budesonide (Oral Capsule Delayed Release Particles) G 3
C1
Ento
cort
EC
Entocort EC (Oral Capsule Delayed Release Particles) B 4
C1
Hyd
roco
rtiso
ne
Hydrocortisone (Rectal Enema) G 3
C1
Orti
kos
Ortikos (Oral Capsule Extended Release 24 Hour) B 4 ST C1
Proc
to-
Med
HC
Procto-Med HC (External Cream) G 1
C1
Proc
to-
Pak
Procto-Pak (External Cream) G 1
C1
Proc
toso
l HC
Proctosol HC (2.5% External Cream) G 1
C1
Proc
tozo
ne-
HC
Proctozone-HC (External Cream) G 1
C1
Uce
ris
Uceris (Oral Tablet Extended Release 24 Hour) B 4 ST C1
Uce
ris
Uceris (Rectal Foam) B 3
A1
Metabolic Bone Disease AgentsB1
Metabolic Bone Disease AgentsC1
Acto
nel
Actonel (Oral Tablet) B 3
C1
Alen
dron
ate
Sodi
um Alendronate Sodium (Oral Solution) G 3
C1
Alen
dron
ate
Sodi
um Alendronate Sodium (10MG Oral Tablet, 35MG Oral
Tablet, 70MG Oral Tablet)G 1
C1
Atel
via
Atelvia (Oral Tablet Delayed Release) B 3
C1
Boni
va
Boniva (Oral Tablet) B 3
C1
Calc
itoni
n
Sal
mon Calcitonin Salmon (Nasal Solution) G 2
144 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Calc
itriol
Calcitriol (Oral Capsule) G 1 B/D, PA C1
Calc
itriol
Calcitriol (Oral Solution) G 3 B/D, PA C1
Cina
calc
et
HCl
Cinacalcet HCl (30MG Oral Tablet) G 3 B/D, PA; QL C1
Cina
calc
et
HCl
Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet) G 4 B/D, PA; QL C1
Dox
erca
lcife
rol
Doxercalciferol (Oral Capsule) G 3 B/D, PA C1
Eve
nity
Evenity (Subcutaneous Solution Prefilled Syringe) B 4 PA; QL C1
Fort
eo
Forteo (Subcutaneous Solution Pen-Injector) B 4 PA C1
Fos
ama
x
Fosamax (Oral Tablet) B 3
C1
Fos
ama
x
Plus
D Fosamax Plus D (Oral Tablet) B 3
C1
Iban
dron
ate
Sodi
um Ibandronate Sodium (Oral Tablet) G 2
C1
Nat
para
Natpara (Subcutaneous Cartridge) B 4 PA; LA C1
Pari
calci
tol
Paricalcitol (Oral Capsule) G 3 B/D, PA C1
Proli
a
Prolia (Subcutaneous Solution Prefilled Syringe) B 3 QL C1
Ray
alde
e
Rayaldee (Oral Capsule Extended Release) B 4 QL C1
Rise
dron
ate
Sodi
um Risedronate Sodium (150MG Oral Tablet, 30MG Oral
Tablet, 5MG Oral Tablet)G 3
C1
Rise
dron
ate
Sodi
um Risedronate Sodium (35MG Oral Tablet Immediate
Release, 35MG (12 PACK) Oral Tablet Immediate
Release, 35MG (4 PACK) Oral Tablet Immediate
Release)
G 2
C1
Rise
dron
ate
Sodi
um Risedronate Sodium (Oral Tablet Delayed Release) G 3
C1
Roc
altro
l
Rocaltrol (Oral Capsule) B 3 B/D, PA C1
Roc
altro
l
Rocaltrol (Oral Solution) B 3 B/D, PA C1
Sen
sipa
r
Sensipar (Oral Tablet) B 4 B/D, PA; QL C1
Teri
para
tide
Teriparatide (Recombinant) (Subcutaneous Solution
Pen-Injector)B 4 PA
C1
Tym
los
Tymlos (Subcutaneous Solution Pen-Injector) B 4 PA C1
Xge
va
Xgeva (Subcutaneous Solution) B 4 PA C1
Zem
plar
Zemplar (1MCG Oral Capsule) B 3 B/D, PA C1
Zem
plar
Zemplar (2MCG Oral Capsule) B 4 B/D, PA A1
Miscellaneous Therapeutic AgentsB1
Miscellaneous Therapeutic AgentsC1
Alco
hol
Pre
p
Pad
s Alcohol Prep Pads G 2
C1
Doj
olvi
Dojolvi (Oral Liquid) B 4 PA C1
Gau
ze
Gauze (Non-medicated 2X2 Pad) G 2
C1
Insul
in
Syri
nge
s,
Nee
dles Insulin Syringes, Needles G 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
145Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
A1
Ophthalmic AgentsB1
Ophthalmic Agents, OtherC1
Atro
pine
Sulf
ate Atropine Sulfate (1% Ophthalmic Solution) B 2
C1
Neo
myci
n-
Poly
myxi
n-
Baci
traci
n-
Hyd
roco
rtiso
ne
Neomycin-Polymyxin-Bacitracin-Hydrocortisone
(Ophthalmic Ointment)G 2
C1
Blep
ham
ide
Blephamide (Ophthalmic Suspension) B 3
C1
Blep
ham
ide
S.O.
P. Blephamide S.O.P. (Ophthalmic Ointment) G 3
C1
Ceq
ua
Cequa (Ophthalmic Solution) B 3 PA; QL C1
Co
mbi
gan
Combigan (Ophthalmic Solution) B 2
C1
Cos
opt
Cosopt (Ophthalmic Solution) B 3
C1
Cos
opt
PF
Cosopt PF (Ophthalmic Solution) B 3
C1
Cyst
adro
ps
Cystadrops (Ophthalmic Solution) B 4
C1
Cyst
aran
Cystaran (Ophthalmic Solution) B 4 LA C1
Dor
zola
mid
e
HCl-
Tim
olol
Mal
eate Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution) G 1
C1
Dor
zola
mid
e
HCl-
Tim
olol
Mal
eate
Pres
erva
tive
Free
Dorzolamide HCl-Timolol Maleate Preservative Free
(Ophthalmic Solution)G 3
C1
Lacr
isert
Lacrisert (Ophthalmic Insert) B 3
C1
Maxi
trol
Maxitrol (Ophthalmic Ointment) B 3
C1
Maxi
trol
Maxitrol (Ophthalmic Suspension) B 3
C1
Neo
myci
n-
Poly
myxi
n-
Dex
ame
thas
oneNeomycin-Polymyxin-Dexamethasone (Ophthalmic
Ointment)G 1
C1
Neo
myci
n-
Poly
myxi
n-
Dex
ame
thas
oneNeomycin-Polymyxin-Dexamethasone (3.5-10000-0.1
Ophthalmic Suspension)G 1
C1
Neo
myci
n-
Poly
myxi
n-
HC Neomycin-Polymyxin-HC (Ophthalmic Suspension) G 3
C1
Oxe
rvat
e
Oxervate (Ophthalmic Solution) B 4 PA; QL C1
Pre
d-G
Pred-G (Ophthalmic Suspension) B 3
C1
Pre
d-G
S.O.
P.
Pred-G S.O.P. (Ophthalmic Ointment) B 3
C1
Pro
para
cain
e
HCl Proparacaine HCl (Ophthalmic Solution) G 1
C1
Rest
asis
Sing
le-
Use
Vials Restasis Single-Use Vials (Ophthalmic Emulsion) B 2 QL C1
Roc
klata
n
Rocklatan (Ophthalmic Solution) B 2 ST C1
Sulf
acet
ami
de-
Pre
dnis
olon
e Sulfacetamide-Prednisolone (Ophthalmic Solution) G 1
C1
Tob
raD
ex
TobraDex (Ophthalmic Ointment) B 2
C1
Tob
raD
ex
TobraDex (Ophthalmic Suspension) B 3
C1
Tob
raD
ex
ST
TobraDex ST (Ophthalmic Suspension) B 3
C1
Tob
ram
ycin-
Dex
ame
thas
one Tobramycin-Dexamethasone (Ophthalmic Suspension) G 2
C1
Xiidr
a
Xiidra (Ophthalmic Solution) B 3 QL C1
Zyle
t
Zylet (Ophthalmic Suspension) B 3
B1
Ophthalmic Anti-allergy Agents
146 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Aloc
ril
Alocril (Ophthalmic Solution) B 3
C1
Alo
mid
e
Alomide (Ophthalmic Solution) B 3
C1
Azel
astin
e
HCl
Azelastine HCl (Ophthalmic Solution) G 1
C1
Bep
otas
tine
Besi
late Bepotastine Besilate (Ophthalmic Solution) G 3
C1
Bep
reve
Bepreve (Ophthalmic Solution) B 3
C1
Cro
mol
yn
Sodi
um Cromolyn Sodium (Ophthalmic Solution) G 1
C1
Epin
astin
e
HCl
Epinastine HCl (Ophthalmic Solution) G 2
C1
Last
acaf
t
Lastacaft (Ophthalmic Solution) B 2
C1
Olo
pata
dine
HCl
Olopatadine HCl (Ophthalmic Solution) G 2
C1
Zerv
iate
Zerviate (Ophthalmic Solution) B 3
B1
Ophthalmic Anti-InfectivesC1
Aza
site
Azasite (Ophthalmic Solution) B 3
C1
Baci
traci
n
Bacitracin (Ophthalmic Ointment) G 2
C1
Baci
traci
n-
Poly
myxi
n B Bacitracin-Polymyxin B (Ophthalmic Ointment) G 1
C1
Besi
vanc
e
Besivance (Ophthalmic Suspension) B 3
C1
Blep
h-10
Bleph-10 (Ophthalmic Solution) G 3
C1
Cilo
xan
Ciloxan (Ophthalmic Ointment) B 3
C1
Cilo
xan
Ciloxan (Ophthalmic Solution) B 3
C1
Cipr
oflo
xaci
n
HCl Ciprofloxacin HCl (Ophthalmic Solution) G 1
C1
Eryt
hro
myci
n
Erythromycin (Ophthalmic Ointment) G 1
C1
Gatif
loxa
cin
Gatifloxacin (Ophthalmic Solution) G 2
C1
Gen
tak
Gentak (Ophthalmic Ointment) G 1
C1
Gen
tami
cin
Sulf
ate Gentamicin Sulfate (Ophthalmic Solution) G 1
C1
Lev
oflo
xaci
n
Levofloxacin (0.5% Ophthalmic Solution) G 2
C1
Mox
eza
Moxeza (Ophthalmic Solution) B 3
C1
Mox
iflox
acin
HCl
Moxifloxacin HCl (Ophthalmic Solution) (Generic
Vigamox)G 2
C1
Nata
cyn
Natacyn (Ophthalmic Suspension) B 3
C1
Neo
myci
n-
Baci
traci
n-
Poly
myxi
n Neomycin-Bacitracin-Polymyxin (5-400-10000
Ophthalmic Ointment)G 2
C1
Neo
myci
n-
Poly
myxi
n-
Gra
mici
din Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution) G 2
C1
Ocu
flox
Ocuflox (Ophthalmic Solution) B 3
C1
Oflo
xaci
n
Ofloxacin (Ophthalmic Solution) G 1
C1
Poly
myxi
n B-
Trim
etho
prim Polymyxin B-Trimethoprim (Ophthalmic Solution) G 1
C1
Poly
trim
Polytrim (Ophthalmic Solution) B 3
C1
Sulf
acet
ami
de
Sodi
um Sulfacetamide Sodium (Ophthalmic Ointment) G 1
You can find information on what the abbreviations in this table mean on pages 6 - 7.
147Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Sulf
acet
ami
de
Sodi
um Sulfacetamide Sodium (Ophthalmic Solution) G 1
C1
Tob
ram
ycin
Tobramycin (Ophthalmic Solution) G 1
C1
Tob
rex
Tobrex (Ophthalmic Ointment) B 3
C1
Tob
rex
Tobrex (Ophthalmic Solution) B 3
C1
Trifl
uridi
ne
Trifluridine (Ophthalmic Solution) G 2
C1
Viga
mox
Vigamox (Ophthalmic Solution) B 3
C1
Zym
axid
Zymaxid (Ophthalmic Solution) B 3
B1
Ophthalmic Anti-inflammatoriesC1
Acul
ar
LS
Acular LS (Ophthalmic Solution) B 3
C1
Acul
ar
Acular (Ophthalmic Solution) B 3
C1
Acu
vail
Acuvail (Ophthalmic Solution) B 3 ST C1
Alre
x
Alrex (Ophthalmic Suspension) B 3
C1
Bro
mfe
nac
Sodi
um Bromfenac Sodium (Once-Daily) (Ophthalmic Solution) G 3
C1
Bro
mSit
e
BromSite (Ophthalmic Solution) B 3 ST C1
Dex
ame
thas
one
Sodi
um
Pho
sph
ate Dexamethasone Sodium Phosphate (Ophthalmic
Solution)G 2
C1
Dicl
ofen
ac
Sodi
um Diclofenac Sodium (Ophthalmic Solution) G 1
C1
Dur
ezol
Durezol (Ophthalmic Emulsion) B 3
C1
Eys
uvis
Eysuvis (Ophthalmic Suspension) B 3 PA C1
Flar
ex
Flarex (Ophthalmic Suspension) B 3
C1
Fluo
rom
etho
lone
Fluorometholone (Ophthalmic Suspension) G 2
C1
Flur
bipr
ofen
Sodi
um Flurbiprofen Sodium (Ophthalmic Solution) G 1
C1
FML
Fort
e
FML Forte (Ophthalmic Suspension) B 3
C1
FML
Liqu
ifilm
FML Liquifilm (Ophthalmic Suspension) B 3
C1
FML
FML (Ophthalmic Ointment) B 3
C1
Ilevr
o
Ilevro (Ophthalmic Suspension) B 2
C1
Invel
tys
Inveltys (Ophthalmic Suspension) B 3
C1
Ket
orol
ac
Tro
met
ham
ine Ketorolac Tromethamine (Ophthalmic Solution) G 2
C1
Lote
max
Lotemax (Ophthalmic Gel) B 3
C1
Lote
max
Lotemax (Ophthalmic Ointment) B 3
C1
Lote
max
Lotemax (Ophthalmic Suspension) B 3
C1
Lote
max
SM
Lotemax SM (Ophthalmic Gel) B 3
C1
Lote
pred
nol
Etab
onat
e Loteprednol Etabonate (Ophthalmic Gel) G 3
C1
Lote
pred
nol
Etab
onat
e Loteprednol Etabonate (Ophthalmic Suspension) G 3
C1
Maxi
dex
Maxidex (Ophthalmic Suspension) B 3
C1
Nev
ana
c
Nevanac (Ophthalmic Suspension) B 3
C1
Pre
d
Fort
e
Pred Forte (Ophthalmic Suspension) B 3
148 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Pre
d
Mild
Pred Mild (Ophthalmic Suspension) B 3
C1
Pre
dnis
olon
e
Acet
ate Prednisolone Acetate (Ophthalmic Suspension) G 2
C1
Pre
dnis
olon
e
Sodi
um
Pho
sph
ate Prednisolone Sodium Phosphate (1% Ophthalmic
Solution)G 1
C1
Prol
ens
a
Prolensa (Ophthalmic Solution) B 3
B1
Ophthalmic Beta-Adrenergic Blocking AgentsC1
Beta
xolo
l
HCl
Betaxolol HCl (Ophthalmic Solution) G 2
C1
Beti
mol
Betimol (Ophthalmic Solution) B 3
C1
Bet
opti
c-S
Betoptic-S (Ophthalmic Suspension) B 3
C1
Cart
eolo
l
HCl
Carteolol HCl (Ophthalmic Solution) G 1
C1
Istal
ol
Istalol (Ophthalmic Solution) B 3
C1
Lev
obu
nolo
l
HCl Levobunolol HCl (Ophthalmic Solution) G 1
C1
Tim
olol
Mal
eate
Oph
thal
mic
Gel
For
min
g
Timolol Maleate Ophthalmic Gel Forming (Ophthalmic
Solution) (Generic Timoptic-XE)G 2
C1
Tim
olol
Mal
eate
Timolol Maleate (0.25% Ophthalmic Solution, 0.5%
Ophthalmic Solution) (Generic Timoptic)G 1
C1
Tim
olol
Mal
eate
Timolol Maleate (0.5% (DAILY) Ophthalmic Solution)
(Generic Istalol)G 3
C1
Tim
olol
Mal
eate
PF Timolol Maleate PF (Ophthalmic Solution) (Generic
Timoptic Ocudose)G 3
C1
Tim
opti
c
Ocu
dos
e Timoptic Ocudose (Ophthalmic Solution) B 3
C1
Tim
opti
c-XE
Timoptic-XE (Ophthalmic Gel Forming Solution) B 3
B1
Ophthalmic Intraocular Pressure Lowering Agents, OtherC1
Alph
aga
n P
Alphagan P (0.1% Ophthalmic Solution) B 2
C1
Alph
aga
n P
Alphagan P (0.15% Ophthalmic Solution) B 3
C1
Apr
aclo
nidi
ne
HCl Apraclonidine HCl (Ophthalmic Solution) G 2
C1
Azo
pt
Azopt (Ophthalmic Suspension) B 2
C1
Brim
onid
ine
Tartr
ate Brimonidine Tartrate (0.15% Ophthalmic Solution) B 3
C1
Brim
onid
ine
Tartr
ate Brimonidine Tartrate (0.2% Ophthalmic Solution) G 1
C1
Brin
zola
mid
e
Brinzolamide (Ophthalmic Suspension) G 2
C1
Dor
zola
mid
e
HCl Dorzolamide HCl (Ophthalmic Solution) G 1
C1
Iopi
dine
Iopidine (1% Ophthalmic Solution) B 4
C1
Isop
to
Car
pine
Isopto Carpine (Ophthalmic Solution) B 3
C1
Met
haz
ola
mid
e Methazolamide (Oral Tablet) G 3
C1
Pilo
carp
ine
HCl
Pilocarpine HCl (Ophthalmic Solution) G 2
C1
Rho
pres
sa
Rhopressa (Ophthalmic Solution) B 2 ST
You can find information on what the abbreviations in this table mean on pages 6 - 7.
149Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Sim
brin
za
Simbrinza (Ophthalmic Suspension) B 2
C1
Trus
opt
Trusopt (Ophthalmic Solution) B 3
B1
Ophthalmic Prostaglandin and Prostamide AnalogsC1
Bim
atop
rost
Bimatoprost (Ophthalmic Solution) G 3
C1
Lata
nopr
ost
Latanoprost (Ophthalmic Solution) G 1
C1
Lum
igan
Lumigan (Ophthalmic Solution) B 2
C1
Trav
atan
Z
Travatan Z (Ophthalmic Solution) B 3
C1
Trav
opr
ost
Travoprost (BAK Free) (Ophthalmic Solution) G 2
C1
Vyz
ulta
Vyzulta (Ophthalmic Solution) B 3
C1
Xala
tan
Xalatan (Ophthalmic Solution) B 3
C1
Xelp
ros
Xelpros (Ophthalmic Emulsion) B 3 ST C1
Ziop
tan
Zioptan (Ophthalmic Solution) B 3
A1
Otic AgentsB1
Otic AgentsC1
Acet
ic
Acid
Acetic Acid (Otic Solution) G 1
C1
Cetr
axal
Cetraxal (Otic Solution) B 3
C1
Cipr
o
HC
Cipro HC (Otic Suspension) B 3
C1
Cipr
ode
x
Ciprodex (Otic Suspension) B 3
C1
Cipr
oflo
xaci
n
HCl Ciprofloxacin HCl (Otic Solution) B 3
C1
Cipr
oflo
xaci
n-
Dex
ame
thas
one Ciprofloxacin-Dexamethasone (Otic Suspension) G 2
C1
Cipr
oflo
xaci
n-
Fluo
cino
lone
PF Ciprofloxacin-Fluocinolone PF (Otic Solution) B 3
C1
Der
mOt
ic
DermOtic (Otic Oil) B 3
C1
Flac
Flac (Otic Oil) G 3
C1
Fluo
cino
lone
Acet
onid
e Fluocinolone Acetonide (Otic Oil) G 2
C1
Hyd
roco
rtiso
ne-
Acet
ic
Acid Hydrocortisone-Acetic Acid (Otic Solution) G 2
C1
Neo
myci
n-
Poly
myxi
n-
HC Neomycin-Polymyxin-HC (1% Otic Solution) G 2
C1
Neo
myci
n-
Poly
myxi
n-
HC Neomycin-Polymyxin-HC (Otic Suspension) G 2
C1
Oflo
xaci
n
Ofloxacin (Otic Solution) G 2
C1
Oto
vel
Otovel (Otic Solution) B 3
A1
Respiratory Tract/Pulmonary AgentsB1
AntihistaminesC1
Azel
astin
e
HCl
Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal
Solution)G 2
C1
Azel
astin
e-
Fluti
cas
one Azelastine-Fluticasone (Nasal Suspension) G 3
C1
Ceti
rizin
e
HCl
Cetirizine HCl (1MG/ML Oral Solution) G 1
C1
Clari
nex
Clarinex (Oral Tablet) B 3
C1
Cyp
rohe
ptad
ine
HCl Cyproheptadine HCl (Oral Tablet) G 3 PA; HRM
150 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Desl
orat
adin
e
Desloratadine (Oral Tablet) G 2
C1
Desl
orat
adin
e
ODT Desloratadine ODT (Oral Tablet Dispersible) G 3
C1
Dym
ista
Dymista (Nasal Suspension) B 3
C1
Lev
ocet
irizin
e
Dihy
droc
hlori
de Levocetirizine Dihydrochloride (Oral Solution) G 2
C1
Lev
ocet
irizin
e
Dihy
droc
hlori
de Levocetirizine Dihydrochloride (Oral Tablet) G 1
C1
Olo
pata
dine
HCl
Olopatadine HCl (Nasal Solution) G 3
C1
Pata
nas
e
Patanase (Nasal Solution) B 3
B1
Anti-inflammatories, Inhaled CorticosteroidsC1
Alve
sco
Alvesco (Inhalation Aerosol Solution) B 3 ST; QL C1
Arm
onAi
r
Digi
hale
r ArmonAir Digihaler (Inhalation Aerosol Powder Breath
Activated)B 3 ST; QL
C1
Arn
uity
Ellip
ta
Arnuity Ellipta (Inhalation Aerosol Powder Breath
Activated)B 2 QL
C1
Asm
ane
x
Asmanex (120 Metered Doses) (Inhalation Aerosol
Powder Breath Activated)B 3 ST; QL
C1
Asm
ane
x
Asmanex (30 Metered Doses) (Inhalation Aerosol
Powder Breath Activated)B 3 ST; QL
C1
Asm
ane
x
Asmanex (60 Metered Doses) (Inhalation Aerosol
Powder Breath Activated)B 3 ST; QL
C1
Asm
ane
x
HFA
Asmanex HFA (Inhalation Aerosol) B 3 ST; QL C1
Bec
ona
se
AQ
Beconase AQ (Nasal Suspension) B 3 ST C1
Bud
eso
nide
Budesonide (Inhalation Suspension) G 3 B/D, PA C1
Flov
ent
Disk
us
Flovent Diskus (Inhalation Aerosol Powder Breath
Activated)B 2
C1
Flov
ent
HFA
Flovent HFA (Inhalation Aerosol) B 2 QL C1
Flun
isoli
de
Flunisolide (Nasal Solution) G 2
C1
Fluti
cas
one
Pro
pion
ate Fluticasone Propionate (Nasal Suspension) G 1
C1
Mo
met
aso
ne
Furo
ate Mometasone Furoate (Nasal Suspension) G 3
C1
Nas
one
x
Nasonex (Nasal Suspension) B 3
C1
Om
nari
s
Omnaris (Nasal Suspension) B 3 ST C1
Pul
mic
ort
Flex
hale
r Pulmicort Flexhaler (Inhalation Aerosol Powder
Breath Activated)B 3 ST
C1
Pul
mic
ort
Pulmicort (0.25MG/2ML Inhalation Suspension,
0.5MG/2ML Inhalation Suspension)B 3 B/D, PA
C1
Pul
mic
ort
Pulmicort (1MG/2ML Inhalation Suspension) B 4 B/D, PA C1
Qna
sl
Chil
dren
s Qnasl Childrens (Nasal Aerosol Solution) B 3 ST
You can find information on what the abbreviations in this table mean on pages 6 - 7.
151Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Qna
sl
Qnasl (Nasal Aerosol Solution) B 3 ST C1
QVA
R
Redi
Hale
r QVAR RediHaler (Inhalation Aerosol Breath Activated) B 3 ST; QL C1
Xha
nce
Xhance (Nasal Exhaler Suspension) B 3
C1
Zeto
nna
Zetonna (Nasal Aerosol Solution) B 3 ST B1
AntileukotrienesC1
Acc
olat
e
Accolate (Oral Tablet) B 3
C1
Mon
telu
kast
Sodi
um Montelukast Sodium (Oral Packet) G 2 QL C1
Mon
telu
kast
Sodi
um Montelukast Sodium (Oral Tablet) G 1 QL C1
Mon
telu
kast
Sodi
um Montelukast Sodium (Oral Tablet Chewable) G 1 QL C1
Sing
ulair
Singulair (Oral Packet) B 3 QL C1
Sing
ulair
Singulair (Oral Tablet) B 3 QL C1
Sing
ulair
Singulair (Oral Tablet Chewable) B 3 QL C1
Zafir
luka
st
Zafirlukast (Oral Tablet) G 2
C1
Zile
uton
ER
Zileuton ER (Oral Tablet Extended Release 12 Hour) G 4 ST C1
Zyfl
o
Zyflo (Oral Tablet Immediate Release) B 4 ST B1
Bronchodilators, AnticholinergicC1
Atro
vent
HFA
Atrovent HFA (Inhalation Aerosol Solution) B 3
C1
Incr
use
Ellip
ta
Incruse Ellipta (Inhalation Aerosol Powder Breath
Activated)B 3 ST; QL
C1
Iprat
ropi
um
Bro
mid
e Ipratropium Bromide (Inhalation Solution) G 1 B/D, PA C1
Iprat
ropi
um
Bro
mid
e Ipratropium Bromide (Nasal Solution) G 2
C1
Lon
hala
Mag
nair
Lonhala Magnair (Inhalation Solution) B 4 QL C1
Spiri
va
Han
diHa
ler Spiriva HandiHaler (Inhalation Capsule) B 2 QL C1
Spiri
va
Res
pim
at Spiriva Respimat (Inhalation Aerosol Solution) B 2 QL C1
Tud
orza
Pres
sair Tudorza Pressair (Inhalation Aerosol Powder Breath
Activated)B 3 ST
C1
Yup
elri
Yupelri (Inhalation Solution) B 4 B/D, PA; QL B1
Bronchodilators, SympathomimeticC1
Albu
terol
Sulf
ate
HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT
Inhalation Aerosol Solution) (Brand Equivalent Ventolin)G 3 ST
C1
Albu
terol
Sulf
ate
HFA Albuterol Sulfate HFA (108 (90 Base)MCG/ACT
Inhalation Aerosol Solution (Generic Proair), 108 (90
Base)MCG/ACT Inhalation Aerosol Solution) (Generic
Proventil)
G 2
C1
Albu
terol
Sulf
ate Albuterol Sulfate (Inhalation Nebulization Solution) G 1 B/D, PA C1
Albu
terol
Sulf
ate Albuterol Sulfate (Oral Syrup) G 3
C1
Albu
terol
Sulf
ate Albuterol Sulfate (Oral Tablet Immediate Release) G 3
C1
Brov
ana
Brovana (Inhalation Nebulization Solution) B 4 PA; QL
152 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Epin
ephr
ine
Epinephrine (Injection Solution Auto-Injector) G 2 QL C1
EpiP
en
2-
Pak
EpiPen 2-Pak (Injection Solution Auto-Injector) B 3 QL C1
EpiP
en
Jr 2-
Pak
EpiPen Jr 2-Pak (Injection Solution Auto-Injector) B 3 QL C1
Lev
albu
terol
HCl
Levalbuterol HCl (Inhalation Nebulization Solution) G 3 B/D, PA C1
Lev
albu
terol
Tartr
ate Levalbuterol Tartrate (Inhalation Aerosol) G 3 ST C1
Perf
oro
mist
Perforomist (Inhalation Nebulization Solution) B 3 B/D, PA; QL C1
Pro
Air
HFA
ProAir HFA (Inhalation Aerosol Solution) B 2
C1
Pro
Air
Res
piCli
ck ProAir RespiClick (Inhalation Aerosol Powder Breath
Activated)B 2
C1
Prov
entil
HFA
Proventil HFA (Inhalation Aerosol Solution) B 3 ST C1
Sere
vent
Disk
us Serevent Diskus (Inhalation Aerosol Powder Breath
Activated)B 2 QL
C1
Striv
erdi
Res
pim
at Striverdi Respimat (Inhalation Aerosol Solution) B 3 ST C1
Sym
jepi
Symjepi (Injection Solution Prefilled Syringe) B 3 QL C1
Terb
utali
ne
Sulf
ate Terbutaline Sulfate (Oral Tablet) G 3
C1
Vent
olin
HFA
Ventolin HFA (Inhalation Aerosol Solution) B 3 ST C1
Xop
ene
x
Con
cent
rate Xopenex Concentrate (Inhalation Nebulization
Solution)B 3 B/D, PA
C1
Xop
ene
x
HFA
Xopenex HFA (Inhalation Aerosol) B 3 ST C1
Xop
ene
x
Xopenex (0.31MG/3ML Inhalation Nebulization
Solution, 0.63MG/3ML Inhalation Nebulization
Solution)
B 3 B/D, PA
C1
Xop
ene
x
Xopenex (1.25MG/3ML Inhalation Nebulization
Solution)B 4 B/D, PA
B1
Cystic Fibrosis AgentsC1
Beth
kis
Bethkis (Inhalation Nebulization Solution) B 4 B/D, PA; QL C1
Cay
ston
Cayston (Inhalation Solution Reconstituted) B 4 PA; LA C1
Kaly
dec
o
Kalydeco (Oral Packet) B 4 PA; LA C1
Kaly
dec
o
Kalydeco (Oral Tablet) B 4 PA; LA C1
Ork
amb
i
Orkambi (Oral Packet) B 4 PA; LA; QL C1
Ork
amb
i
Orkambi (Oral Tablet) B 4 PA; LA; QL C1
Pul
moz
yme
Pulmozyme (Inhalation Solution) B 4 B/D, PA; QL C1
Sym
dek
o
Symdeko (Oral Tablet Therapy Pack) B 4 PA; QL C1
TOB
I
TOBI (Inhalation Nebulization Solution) B 4 B/D, PA; QL C1
TOB
I
Pod
hale
r TOBI Podhaler (Inhalation Capsule) B 4 PA; QL C1
Tob
ram
ycin
Tobramycin (Inhalation Nebulization Solution) G 4 B/D, PA; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
153Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Trik
afta
Trikafta (100-50-75 & 150MG Oral Tablet Therapy
Pack)B 4 PA; LA; QL
B1
Mast Cell StabilizersC1
Cro
mol
yn
Sodi
um Cromolyn Sodium (Inhalation Nebulization Solution) G 4 B/D, PA B1
Phosphodiesterase Inhibitors, Airways DiseaseC1
Dalir
esp
Daliresp (Oral Tablet) B 3 PA C1
The
o-24
Theo-24 (Oral Capsule Extended Release 24 Hour) G 3
C1
The
oph
yllin
e
ER Theophylline ER (300MG Oral Tablet Extended Release
12 Hour)G 3
C1
The
oph
yllin
e
ER Theophylline ER (Oral Tablet Extended Release 24 Hour) G 1
C1
The
oph
yllin
e
Theophylline (Oral Solution) G 3
B1
Pulmonary AntihypertensivesC1
Adci
rca
Adcirca (Oral Tablet) B 4 PA C1
Ade
mpa
s
Adempas (Oral Tablet) B 4 PA; LA C1
Alyq
Alyq (Oral Tablet) G 3 PA C1
Am
bris
enta
n
Ambrisentan (Oral Tablet) G 4 PA; LA; QL C1
Bos
enta
n
Bosentan (Oral Tablet) G 4 PA; LA; QL C1
Leta
iris
Letairis (Oral Tablet) B 4 PA; LA; QL C1
Ops
umit
Opsumit (Oral Tablet) B 4 PA; LA C1
Ore
nitra
m
Orenitram (0.125MG Oral Tablet Extended Release) B 3 PA; LA C1
Ore
nitra
m
Orenitram (0.25MG Oral Tablet Extended Release,
1MG Oral Tablet Extended Release, 2.5MG Oral
Tablet Extended Release, 5MG Oral Tablet Extended
Release)
B 4 PA; LA
C1
Rev
atio
Revatio (Oral Suspension Reconstituted) B 4 PA C1
Rev
atio
Revatio (Oral Tablet) B 4 PA C1
Sild
enaf
il
Citra
te Sildenafil Citrate (Oral Suspension Reconstituted) G 4 PA C1
Sild
enaf
il
Citra
te Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio) G 2 PA C1
Tad
alafil
Tadalafil (PAH) (20MG Oral Tablet) G 3 PA C1
Trac
leer
Tracleer (Oral Tablet) B 4 PA; LA; QL C1
Trac
leer
Tracleer (Oral Tablet Soluble) B 4 PA; LA; QL C1
Uptr
avi
Uptravi (Oral Tablet) B 4 PA; LA; QL C1
Uptr
avi
Uptravi (Oral Tablet Therapy Pack) B 4 PA; LA C1
Vent
avis
Ventavis (Inhalation Solution) B 4 PA; LA B1
Pulmonary Fibrosis AgentsC1
Esbr
iet
Esbriet (Oral Capsule) B 4 PA; LA; QL C1
Esbr
iet
Esbriet (Oral Tablet) B 4 PA; LA; QL
154 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Ofe
v
Ofev (Oral Capsule) B 4 PA; LA; QL B1
Respiratory Tract Agents, OtherC1
Acet
ylcy
stei
ne
Acetylcysteine (Inhalation Solution) G 1 B/D, PA C1
Adv
air
Disk
us
Advair Diskus (Inhalation Aerosol Powder Breath
Activated)B 2 QL
C1
Adv
air
HFA
Advair HFA (Inhalation Aerosol) B 2 QL C1
AirD
uo
Digi
hale
r AirDuo Digihaler (Inhalation Aerosol Powder Breath
Activated)B 3 ST; QL
C1
AirD
uo
Res
piCli
ck
113/
14 AirDuo RespiClick 113/14 (Inhalation Aerosol Powder
Breath Activated)B 3 ST; QL
C1
AirD
uo
Res
piCli
ck
232/
14 AirDuo RespiClick 232/14 (Inhalation Aerosol Powder
Breath Activated)B 3 ST; QL
C1
AirD
uo
Res
piCli
ck
55/1
4 AirDuo RespiClick 55/14 (Inhalation Aerosol Powder
Breath Activated)B 3 ST; QL
C1
Ano
ro
Ellip
ta
Anoro Ellipta (Inhalation Aerosol Powder Breath
Activated)B 2 QL
C1
Bev
espi
Aer
osp
here Bevespi Aerosphere (Inhalation Aerosol) B 3 ST C1
Bre
o
Ellip
ta
Breo Ellipta (Inhalation Aerosol Powder Breath
Activated)B 2 QL
C1
Brez
tri
Aer
osp
here Breztri Aerosphere (Inhalation Aerosol) B 2 QL C1
Bro
nchi
tol
Bronchitol (Inhalation Capsule) B 4 PA; QL C1
Bud
eso
nide
-
For
mot
erol
Fum
arat
eBudesonide-Formoterol Fumarate (Inhalation Aerosol) G 3 ST; QL
C1
Clari
nex-
D 12
Hou
r Clarinex-D 12 Hour (Oral Tablet Extended Release 12
Hour)B 3
C1
Co
mbi
vent
Res
pim
at Combivent Respimat (Inhalation Aerosol Solution) B 2 QL C1
Dua
klir
Pres
sair
Duaklir Pressair (Inhalation Aerosol Powder Breath
Activated)B 4 ST; QL
C1
Dule
ra
Dulera (Inhalation Aerosol) B 3 QL C1
Fas
enra
Pen
Fasenra Pen (Subcutaneous Solution Auto-Injector) B 4 PA; LA C1
Fas
enra
Fasenra (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA C1
Fluti
cas
one-
Sal
met
erol Fluticasone-Salmeterol (Inhalation Aerosol Powder
Breath Activated)G 2 QL
C1
Iprat
ropi
um-
Albu
terol Ipratropium-Albuterol (Inhalation Solution) G 1 B/D, PA C1
Nuc
ala
Nucala (Subcutaneous Solution Auto-Injector) B 4 PA; LA; QL C1
Nuc
ala
Nucala (Subcutaneous Solution Prefilled Syringe) B 4 PA; LA; QL C1
Nuc
ala
Nucala (Subcutaneous Solution Reconstituted) B 4 PA; LA; QL C1
Stiol
to
Res
pim
at Stiolto Respimat (Inhalation Aerosol Solution) B 2
You can find information on what the abbreviations in this table mean on pages 6 - 7.
155Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Sym
bico
rt
Symbicort (Inhalation Aerosol) B 2 QL C1
Trel
egy
Ellip
ta
Trelegy Ellipta (Inhalation Aerosol Powder Breath
Activated)B 2 QL
C1
Wix
ela
Inhu
b
Wixela Inhub (Inhalation Aerosol Powder Breath
Activated) (Generic Advair)G 2 QL
A1
Skeletal Muscle RelaxantsB1
Skeletal Muscle RelaxantsC1
Chlo
rzox
azo
ne
Chlorzoxazone (500MG Oral Tablet) G 3 PA; HRM C1
Cycl
obe
nza
prin
e
HCl Cyclobenzaprine HCl (7.5MG Oral Tablet) G 3 PA; HRM C1
Fex
mid
Fexmid (Oral Tablet) G 3 PA; HRM A1
Sleep Disorder AgentsB1
Sleep Disorder AgentsC1
Xyw
av
Xywav (Oral Solution) B 4 PA; QL B1
Sleep Promoting AgentsC1
Am
bien
Ambien (Oral Tablet Immediate Release) B 3 PA; HRM; QL C1
Bels
omr
a
Belsomra (Oral Tablet) B 2 QL C1
Day
Vigo
DayVigo (Oral Tablet) B 2 QL C1
Dox
epin
HCl
Doxepin HCl (Oral Tablet) G 3
C1
Hetli
oz
LQ
Hetlioz LQ (Oral Suspension) B 4 PA; LA; QL C1
Hetli
oz
Hetlioz (Oral Capsule) B 4 PA; LA; QL C1
Ram
elte
on
Ramelteon (Oral Tablet) G 3
C1
Rest
oril
Restoril (22.5MG Oral Capsule) B 4 HRM; QL C1
Roz
ere
m
Rozerem (Oral Tablet) B 3 ST C1
Sile
nor
Silenor (Oral Tablet) B 3
C1
Tem
aze
pam
Temazepam (15MG Oral Capsule, 30MG Oral Capsule) G 2 HRM; QL C1
Tem
aze
pam
Temazepam (22.5MG Oral Capsule, 7.5MG Oral
Capsule)G 3 HRM; QL
C1
Zale
plon
Zaleplon (Oral Capsule) G 2 HRM; QL C1
Zolp
ide
m
Tartr
ate Zolpidem Tartrate (Oral Tablet Immediate Release) G 3 PA; HRM; QL B1
Wakefulness Promoting AgentsC1
Arm
odaf
inil
Armodafinil (Oral Tablet) G 2 PA; QL C1
Mod
afinil
Modafinil (Oral Tablet) G 2 PA; QL C1
Nuvi
gil
Nuvigil (150MG Oral Tablet, 200MG Oral Tablet,
250MG Oral Tablet)B 4 PA; QL
C1
Nuvi
gil
Nuvigil (50MG Oral Tablet) B 3 PA; QL C1
Prov
igil
Provigil (Oral Tablet) B 4 PA; QL C1
Sun
osi
Sunosi (Oral Tablet) B 3 PA; QL
156 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Drug
Tier
Coverage Rules
or Limits on use
C1
Wak
ix
Wakix (Oral Tablet) B 4 PA; QL C1
Xyre
m
Xyrem (Oral Solution) B 4 PA; LA; QL
You can find information on what the abbreviations in this table mean on pages 6 - 7.
157
Covered drugs with a quantity limit (QL)
This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each
strength may have a different quantity limit. If quantity limits for a drug vary by strength, the
different strengths are listed on separate lines. These limits may be in place to ensure your safety.
Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain
number of days. For more information about quantity limits, talk with your doctor or pharmacist.
You can also call Customer Service. Our contact information is on the cover.
Drugs are listed in alphabetical order in the chart below. Brand name drugs in bold type (for
example, Humalog) and generic drugs in plain type (for example, Simvastatin).
Drug Name
Brand
or
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
Abacavir-Lamivudine-Zidovudine (Oral Tablet) G Maximum of 2 tablets per day
Abilify MyCite (Oral Tablet) B Maximum of 1 tablet per day
Abilify (Oral Tablet) B Maximum of 1 tablet per day
Accupril (Oral Tablet) B Maximum of 2 tablets per day
Accuretic (10-12.5MG Oral Tablet) B Maximum of 1 tablet per day
Accuretic (20-12.5MG Oral Tablet,
20-25MG Oral Tablet)B Maximum of 2 tablets per day
Acetaminophen-Caffeine-Dihydrocodeine
(320.5-30-16MG Oral Capsule)G Maximum of 10 capsules per day
Acetaminophen-Caffeine-Dihydrocodeine
(325-30-16MG Oral Tablet)G Maximum of 10 tablets 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
ActHIB (Intramuscular Solution
Reconstituted)B
1 vaccination dose (1 injection) per
day
Actiq (Buccal Lozenge On A Handle) B Maximum of 4 lozenges per day
Actoplus Met (Oral Tablet Immediate
Release)B Maximum of 3 tablets per day
Actos (15MG Oral Tablet) B Maximum of 3 tablets per day
Actos (30MG Oral Tablet, 45MG Oral
Tablet)B Maximum of 1 tablet per day
Adacel (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day
Adderall (20MG Oral Tablet) G Maximum of 3 tablets per day
158 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Adderall (5MG Oral Tablet, 7.5MG Oral
Tablet)G Maximum of 2 tablets per day
Adderall XR (Oral Capsule Extended
Release 24 Hour)B Maximum of 2 capsules per day
Adlyxin Starter Pack (Subcutaneous Pen-
Injector Kit)B Maximum of 1 kit (6 ml) per 28 days
Adlyxin (Subcutaneous Solution Pen-
Injector)B
Maximum of 2 pens (6 ml) per 28
days
Advair Diskus (Inhalation Aerosol Powder
Breath Activated)B
Maximum of 1 inhaler (60 blisters) per
30 days
Advair HFA (Inhalation Aerosol) BMaximum of 1 inhaler (12 grams) per
30 days
Adzenys ER (Oral Suspension Extended
Release)B Maximum of 15 ml per day
Adzenys XR-ODT (Oral Tablet Extended
Release Dispersible)B Maximum of 1 tablet per day
Aimovig (140MG/ML Subcutaneous
Solution Auto-Injector)B Maximum of 1 pen (1 ml) per 30 days
Aimovig (70MG/ML Subcutaneous Solution
Auto-Injector)B
Maximum of 2 pens (2 ml) per 30
days
AirDuo Digihaler (Inhalation Aerosol
Powder Breath Activated)B Maximum of 1 inhaler per 30 days
AirDuo RespiClick 113/14 (Inhalation
Aerosol Powder Breath Activated)B Maximum of 1 inhaler per 30 days
AirDuo RespiClick 232/14 (Inhalation
Aerosol Powder Breath Activated)B Maximum of 1 inhaler per 30 days
AirDuo RespiClick 55/14 (Inhalation
Aerosol Powder Breath Activated)B Maximum of 1 inhaler per 30 days
Ajovy (Subcutaneous Solution Auto-
Injector)B
Maximum of 1 pen (1.5 ml) per 30
days
Ajovy (Subcutaneous Solution Prefilled
Syringe)B
Maximum of 1 syringe (1.5 ml) per 30
days
Albendazole (Oral Tablet) G Maximum of 16 tablets per day
Albenza (Oral Tablet) B Maximum of 16 tablets per day
Aldara (External Cream) B Maximum of 24 grams per 30 days
Aliskiren Fumarate (Oral Tablet) G Maximum of 1 tablet per day
Almotriptan Malate (Oral Tablet) G Maximum of 12 tablets per 30 days
Alogliptin Benzoate (Oral Tablet) G Maximum of 1 tablet per day
Alogliptin-Metformin HCl (Oral Tablet) B Maximum of 2 tablets per day
Alogliptin-Pioglitazone (Oral Tablet) G Maximum of 1 tablet per day
159Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Alora (Transdermal Patch Twice Weekly) B Maximum of 8 patches per 28 days
Alprazolam ER (0.5MG Oral Tablet Extended
Release 24 Hour, 1MG Oral Tablet Extended
Release 24 Hour)
G Maximum of 1 tablet per day
Alprazolam ER (2MG Oral Tablet Extended
Release 24 Hour)G Maximum of 5 tablets per day
Alprazolam ER (3MG Oral Tablet Extended
Release 24 Hour)G Maximum of 3 tablets per day
Alprazolam Intensol (Oral Concentrate) G Maximum of 10 ml 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
Alprazolam ODT (0.25MG Oral Tablet
Dispersible, 0.5MG Oral Tablet Dispersible,
1MG Oral Tablet Dispersible)
G Maximum of 4 tablets per day
Alprazolam ODT (2MG Oral Tablet
Dispersible)G Maximum of 5 tablets per day
Altace (Oral Capsule) B Maximum of 2 capsules per day
Altoprev (Oral Tablet Extended Release 24
Hour)B Maximum of 1 tablet 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) BMaximum of 1 pack (30 tablets) per
30 days
Alvesco (160MCG/ACT Inhalation Aerosol
Solution)B
Maximum of 2 inhalers (12.2 grams)
per 30 days
Alvesco (80MCG/ACT Inhalation Aerosol
Solution)B
Maximum of 1 inhaler (6.1 grams) per
30 days
Amaryl (1MG Oral Tablet) B Maximum of 8 tablets per day
Amaryl (2MG Oral Tablet) B Maximum of 4 tablets per day
Amaryl (4MG Oral Tablet) B Maximum of 2 tablets per day
Ambien (Oral Tablet Immediate Release) B Maximum of 1 tablet per day
Ambrisentan (Oral Tablet) G Maximum of 1 tablet per day
Amerge (Oral Tablet) B Maximum of 12 tablets per 30 days
Amitiza (Oral Capsule) B Maximum of 2 capsules per day
Amlodipine-Atorvastatin (Oral Tablet) G Maximum of 1 tablet per day
160 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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
Amphetamine ER (Oral Suspension Extended
Release)G Maximum of 15 ml 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
Ampyra (Oral Tablet Extended Release 12
Hour)B Maximum of 2 tablets per day
Annovera (Vaginal Ring) B Maximum of 1 ring per 365 days
Anoro Ellipta (Inhalation Aerosol Powder
Breath Activated)B
Maximum of 1 inhaler (60 blisters) per
30 days
ApexiCon E (External Cream) G Maximum of 240 grams per 30 days
Apokyn (Subcutaneous Solution Cartridge) B Maximum of 3 ml per day
Apriso (Oral Capsule Extended Release 24
Hour)B Maximum of 4 capsules per day
Aptensio XR (Oral Capsule Extended
Release 24 Hour)B Maximum of 1 capsule per day
Aptiom (200MG Oral Tablet, 400MG Oral
Tablet)B Maximum of 1 tablet per day
Aptiom (600MG Oral Tablet, 800MG Oral
Tablet)B Maximum of 2 tablets per day
Aptivus (Oral Capsule) B Maximum of 4 capsules per day
Aricept (10MG Oral Tablet) B Maximum of 2 tablets per day
Aricept (23MG Oral Tablet, 5MG Oral
Tablet)B Maximum of 1 tablet 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)G Maximum of 3 tablets per day
Aripiprazole ODT (15MG Oral Tablet
Dispersible)G Maximum of 2 tablets per day
161Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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
ArmonAir Digihaler (Inhalation Aerosol
Powder Breath Activated)B Maximum of 1 inhaler per 30 days
Arnuity Ellipta (Inhalation Aerosol Powder
Breath Activated)B
Maximum of 1 inhaler (30 blisters) per
30 days
Asacol HD (Oral Tablet Delayed Release) B Maximum of 6 tablets per day
Asmanex (120 Metered Doses) (Inhalation
Aerosol Powder Breath Activated)B Maximum of 1 inhaler per 30 days
Asmanex (30 Metered Doses) (110MCG/
INH Inhalation Aerosol Powder Breath
Activated)
B Maximum of 2 inhalers per 30 days
Asmanex (30 Metered Doses) (220MCG/
INH Inhalation Aerosol Powder Breath
Activated)
B Maximum of 1 inhaler per 30 days
Asmanex (60 Metered Doses) (Inhalation
Aerosol Powder Breath Activated)B Maximum of 1 inhaler per 30 days
Asmanex HFA (Inhalation Aerosol) BMaximum of 1 inhaler (13 grams) per
30 days
Aspirin-Dipyridamole ER (Oral Capsule
Extended Release 12 Hour)G Maximum of 2 capsules per day
Atacand HCT (Oral Tablet) B Maximum of 1 tablet per day
Atacand (16MG Oral Tablet, 32MG Oral
Tablet, 4MG Oral Tablet)B Maximum of 1 tablet per day
Atacand (8MG Oral Tablet) B Maximum of 3 tablets 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
Ativan (0.5MG Oral Tablet, 1MG Oral
Tablet)B Maximum of 4 tablets per day
Ativan (2MG Oral Tablet) B Maximum of 5 tablets per day
Atorvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day
Atripla (Oral Tablet) B Maximum of 1 tablet per day
Aubagio (Oral Tablet) B Maximum of 1 tablet per day
Austedo (Oral Tablet) B Maximum of 4 tablets per day
Avalide (Oral Tablet) B Maximum of 1 tablet per day
Avapro (150MG Oral Tablet, 300MG Oral
Tablet)B Maximum of 1 tablet per day
Avapro (75MG Oral Tablet) B Maximum of 3 tablets per day
162 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Ayvakit (100MG Oral Tablet, 200MG Oral
Tablet, 300MG Oral Tablet)B Maximum of 1 tablet per day
Azor (Oral Tablet) B Maximum of 1 tablet per day
Bafiertam (Oral Capsule Delayed Release) B Maximum of 4 capsules per day
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) B 1 vaccination dose (1 vial) per day
Belbuca (Buccal Film) B Maximum of 2 films 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
Benicar HCT (Oral Tablet) B Maximum of 1 tablet per day
Benicar (20MG Oral Tablet, 40MG Oral
Tablet)B Maximum of 1 tablet per day
Benicar (5MG Oral Tablet) B Maximum of 2 tablets per day
Bethkis (Inhalation Nebulization Solution) B Maximum of 2 ampules (8 ml) per day
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 (5-2.5-18.5 Intramuscular
Suspension, 5-2.5-18.5 (0.5ML Syringe)
Intramuscular Suspension)
B 1 vaccination dose (0.5 ml) per day
Bosentan (Oral Tablet) G Maximum of 2 tablets per day
Breo Ellipta (Inhalation Aerosol Powder
Breath Activated)B
Maximum of 1 inhaler (60 blisters) per
30 days
Breztri Aerosphere (120 Inhalation Aerosol) BMaximum 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
Brovana (Inhalation Nebulization Solution) B Maximum of 2 vials (4 ml) per day
Brukinsa (Oral Capsule) B Maximum of 4 capsules per day
Budesonide-Formoterol Fumarate (Inhalation
Aerosol)G
Maximum of 1 inhaler (10.2 grams)
per 30 days
163Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Buprenorphine HCl (Tablet Sublingual) G Maximum of 3 tablets per day
Buprenorphine HCl-Naloxone HCl (12-3MG
Sublingual Film, 4-1MG Sublingual Film)G Maximum of 2 films per day
Buprenorphine HCl-Naloxone HCl (2-0.5MG
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
Butorphanol Tartrate (Nasal Solution) GMaximum of 2 bottles (5 ml) per 30
days
Butrans (Transdermal Patch Weekly) B Maximum of 4 patches per 28 days
Bydureon BCise (Subcutaneous Auto-
Injector)B
Maximum of 4 pens (3.4 ml) per 28
days
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
Bystolic (10MG Oral Tablet, 2.5MG Oral
Tablet, 5MG Oral Tablet)B Maximum of 1 tablet per day
Bystolic (20MG Oral Tablet) B Maximum of 2 tablets per day
Cablivi (Injection Kit) B Maximum of 1 kit per day
Caduet (Oral Tablet) B Maximum of 1 tablet per day
Canasa (Rectal Suppository) B Maximum of 1 suppository 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
Cardura XL (Oral Tablet Extended Release
24 Hour)B Maximum of 1 tablet per day
Celebrex (Oral Capsule) B Maximum of 2 capsules per day
Celecoxib (Oral Capsule) G Maximum of 2 capsules per day
Cequa (Ophthalmic Solution) B Maximum of 2 vials per day
Chloroquine Phosphate (Oral Tablet) G Maximum of 2 tablets per day
Cialis (2.5MG Oral Tablet, 5MG Oral Tablet) B Maximum of 1 tablet per day
164 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Cimduo (Oral Tablet) B Maximum of 1 tablet per day
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
Clindagel (External Gel) B Maximum of 75 ml per 30 days
Clindamycin Phosphate (External Gel) G Maximum of 75 grams 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
Clobetasol Propionate (External Foam) G Maximum of 100 grams per 30 days
Clobetasol Propionate (External Liquid Spray) G Maximum of 125 ml per 30 days
Clobetasol Propionate (External Lotion) G Maximum of 118 ml per 30 days
Clobex (External Lotion) B Maximum of 118 ml per 30 days
Clobex Spray (External Liquid) B Maximum of 125 ml per 30 days
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
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 4 tablets 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
Clovique (Oral Capsule) G Maximum of 8 capsules per day
Codeine Sulfate (15MG Oral Tablet) B Maximum of 6 tablets per day
Codeine Sulfate (30MG Oral Tablet, 60MG
Oral Tablet)G Maximum of 6 tablets per day
Combivent Respimat (Inhalation Aerosol
Solution)B
Maximum of 1 inhaler (4 grams) per
20 days
Combivir (Oral Tablet) B Maximum of 2 tablets per day
Complera (Oral Tablet) B Maximum of 1 tablet per day
Concerta (18MG Oral Tablet Extended
Release)B Maximum of 3 tablets per day
165Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Concerta (27MG Oral Tablet Extended
Release, 36MG Oral Tablet Extended
Release)
B Maximum of 2 tablets per day
Concerta (54MG Oral Tablet Extended
Release)B Maximum of 1 tablet per day
ConZip (Oral Capsule Extended Release 24
Hour)B Maximum of 1 capsule per day
Copiktra (Oral Capsule) B Maximum of 2 capsules per day
Cordran (External Lotion) B Maximum of 240 ml per 30 days
Corlanor (Oral Solution) B Maximum of 15 ml per day
Corlanor (Oral Tablet) B Maximum of 2 tablets per day
Cotempla XR-ODT (Oral Tablet Extended
Release Dispersible)B Maximum of 2 tablets per day
Cozaar (100MG Oral Tablet) B Maximum of 1 tablet per day
Cozaar (25MG Oral Tablet, 50MG Oral
Tablet)B Maximum of 2 tablets per day
Crestor (Oral Tablet) B Maximum of 1 tablet per day
Cymbalta (20MG Oral Capsule Delayed
Release Particles)B Maximum of 4 capsules per day
Cymbalta (30MG Oral Capsule Delayed
Release Particles, 60MG Oral Capsule
Delayed Release Particles)
B Maximum of 2 capsules per day
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
Darifenacin Hydrobromide ER (Oral Tablet
Extended Release 24 Hour)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
Daytrana (Transdermal Patch) B Maximum of 1 patch per day
DayVigo (Oral Tablet) B Maximum of 1 tablet per day
Delstrigo (Oral Tablet) B Maximum of 1 tablet per day
Descovy (Oral Tablet) B Maximum of 1 tablet per day
Desoximetasone (External Cream) G Maximum of 100 grams per 30 days
Dexedrine (10MG Oral Capsule Extended
Release 24 Hour)B Maximum of 6 capsules per day
Dexedrine (15MG Oral Capsule Extended
Release 24 Hour)B Maximum of 4 capsules per day
Dexedrine (5MG Oral Capsule Extended
Release 24 Hour)B Maximum of 3 capsules per day
166 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Dexilant (Oral Capsule Delayed Release) B 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 (Oral Tablet) G Maximum of 6 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
Diastat AcuDial (Rectal Gel) B Maximum of 5 packages per 30 days
Diastat Pediatric (Rectal Gel) B Maximum of 5 packages per 30 days
Diazepam Intensol (5MG/ML Oral
Concentrate)G Maximum of 8 ml per day
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) G Maximum of 2 patches per day
Diflorasone Diacetate (External Cream) G Maximum of 240 grams per 30 days
Diflorasone Diacetate (External Ointment) G Maximum of 240 grams per 30 days
Digitek (125MCG Oral Tablet) G Maximum of 1 tablet per day
Digox (125MCG Oral Tablet) G Maximum of 1 tablet per day
Digoxin (Oral Solution) G Maximum of 5 ml per day
Digoxin (125MCG Oral Tablet) G Maximum of 1 tablet per day
Dihydroergotamine Mesylate (Nasal Solution) GMaximum of 16 vials (16 ml) per 28
days
Dilaudid (Oral Liquid) B Maximum of 50 ml per day
Dilaudid (2MG Oral Tablet, 4MG Oral
Tablet)B Maximum of 8 tablets per day
Dilaudid (8MG Oral Tablet) B Maximum of 6 tablets per day
Dimethyl Fumarate (120MG Oral Capsule
Delayed Release, 240MG Oral Capsule
Delayed Release)
G Maximum of 2 capsules per day
Diovan HCT (Oral Tablet) B Maximum of 1 tablet per day
167Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Diovan (160MG Oral Tablet, 40MG Oral
Tablet, 80MG Oral Tablet)B Maximum of 2 tablets per day
Diovan (320MG Oral Tablet) B Maximum of 1 tablet per day
Diphtheria-Tetanus Toxoids DT
(Intramuscular Suspension)B 1 vaccination dose (0.5 ml) 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
Dotti (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days
Dovato (Oral Tablet) B Maximum of 1 tablet per day
Doxepin HCl (External Cream) G Maximum of 90 grams per 30 days
Drizalma Sprinkle (20MG Oral Capsule
Delayed Release Sprinkle, 30MG Oral
Capsule Delayed Release Sprinkle, 60MG
Oral Capsule Delayed Release Sprinkle)
B Maximum of 2 capsules per day
Drizalma Sprinkle (40MG Oral Capsule
Delayed Release Sprinkle)B Maximum of 3 capsules per day
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
Duaklir Pressair (Inhalation Aerosol Powder
Breath Activated)B Maximum of 1 inhaler per 30 days
Duetact (Oral Tablet) B Maximum of 1 tablet per day
Dulera (120 Inhalation Aerosol) BMaximum 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, 60MG Oral Capsule
Delayed Release Particles)
G Maximum of 2 capsules per day
Duloxetine HCl (40MG Oral Capsule Delayed
Release Particles)G Maximum of 3 capsules per day
Dyanavel XR (Oral Suspension Extended
Release)B Maximum of 8 ml per day
Econazole Nitrate (External Cream) G Maximum of 90 grams per 30 days
Edarbi (Oral Tablet) B Maximum of 1 tablet per day
168 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Edarbyclor (Oral Tablet) B Maximum of 1 tablet per day
Edurant (Oral Tablet) B Maximum of 1 tablet per day
Efavirenz (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
Eletriptan Hydrobromide (Oral Tablet) G Maximum of 12 tablets per 30 days
Elidel (External Cream) B Maximum of 100 grams per 30 days
Eliquis (Oral Tablet) B Maximum of 2 tablets per day
Eliquis Starter Pack (Oral Tablet) BMaximum of 1 pack (74 tablets) per
30 days
Emgality (300MG Dose) (100MG/ML
Subcutaneous Solution Prefilled Syringe)B
Maximum of 3 syringes or pens (3 ml)
per 30 days
Emgality (Subcutaneous Solution Auto-
Injector)B
Maximum of 2 syringes or pens (2 ml)
per 30 days
Emgality (120MG/ML Subcutaneous
Solution Prefilled Syringe)B
Maximum of 2 syringes or pens (2 ml)
per 30 days
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 Capsule) B Maximum of 1 capsule per day
Emtriva (Oral Solution) BMaximum 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
Endocet (10-325MG Oral Tablet, 5-325MG
Oral Tablet, 7.5-325MG Oral Tablet)G Maximum of 12 tablets per day
Engerix-B (10MCG/0.5ML Injection
Suspension)B 1 vaccination dose (0.5 ml) per day
Engerix-B (20MCG/ML Injection
Suspension)B 1 vaccination dose (1 ml) per day
Enoxaparin Sodium (100MG/ML
Subcutaneous Solution, 150MG/ML
Subcutaneous Solution)
G Maximum of 2 syringes (2 ml) per day
Enoxaparin Sodium (120MG/0.8ML
Subcutaneous Solution, 80MG/0.8ML
Subcutaneous Solution)
GMaximum of 2 syringes (1.6 ml) per
day
169Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Enoxaparin Sodium (30MG/0.3ML
Subcutaneous Solution)G
Maximum of 2 syringes (0.6 ml) per
day
Enoxaparin Sodium (40MG/0.4ML
Subcutaneous Solution)G
Maximum of 2 syringes (0.8 ml) per
day
Enoxaparin Sodium (60MG/0.6ML
Subcutaneous Solution)G
Maximum of 2 syringes (1.2 ml) per
day
Entresto (Oral Tablet) B Maximum of 2 tablets per day
Epclusa (200-50MG Oral Tablet) B Maximum of 2 tablets per day
Epclusa (400-100MG Oral Tablet) B Maximum of 1 tablet per day
Epinephrine (Injection Solution Auto-Injector) GMaximum of 4 pens (2 boxes) per 30
days
EpiPen 2-Pak (Injection Solution Auto-
Injector)B
Maximum of 4 pens (2 boxes) per 30
days
EpiPen Jr 2-Pak (Injection Solution Auto-
Injector)B
Maximum of 4 pens (2 boxes) per 30
days
Epivir (10MG/ML Oral Solution) B Maximum of 32 ml per day
Epivir (150MG Oral Tablet) B Maximum of 2 tablets per day
Epivir (300MG Oral Tablet) B Maximum of 1 tablet per day
Epzicom (Oral Tablet) B Maximum of 1 tablet per day
Esbriet (Oral Capsule) B Maximum of 9 capsules per day
Esbriet (267MG Oral Tablet) B Maximum of 9 tablets per day
Esbriet (801MG Oral Tablet) B 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 Twice Weekly) G Maximum of 8 patches per 28 days
Eucrisa (External Ointment) B Maximum of 100 grams per 30 days
Evenity (Subcutaneous Solution Prefilled
Syringe)B
Maximum of 2 syringes (2.34 ml) per
28 days
Evotaz (Oral Tablet) B Maximum of 1 tablet per day
Evrysdi (Oral Solution Reconstituted) B Maximum of 8 ml per day
Exelon (Transdermal Patch 24 Hour) B Maximum of 1 patch per day
Exforge (Oral Tablet) B Maximum of 1 tablet per day
Extina (External Foam) B Maximum of 100 grams per 28 days
Ezallor Sprinkle (Oral Capsule Sprinkle) B Maximum of 1 capsule per day
Ezetimibe-Simvastatin (Oral Tablet) G Maximum of 1 tablet per day
170 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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
Farxiga (Oral Tablet) B Maximum of 1 tablet per day
Fentanyl Citrate (1200MCG Buccal Lozenge
On A Handle, 1600MCG Buccal Lozenge On
A Handle, 200MCG Buccal Lozenge On A
Handle, 400MCG Buccal Lozenge On A
Handle, 600MCG Buccal Lozenge On A
Handle, 800MCG Buccal Lozenge On A
Handle)
G Maximum of 4 lozenges per day
Fentanyl Citrate (100MCG Buccal Tablet,
200MCG Buccal Tablet, 400MCG Buccal
Tablet, 600MCG Buccal Tablet, 800MCG
Buccal Tablet)
G Maximum of 4 tablets per day
Fentanyl (Transdermal Patch 72 Hour) G Maximum of 15 patches per 30 days
Fentora (Buccal Tablet) B Maximum of 4 tablets per day
Fintepla (Oral Solution) B Maximum of 12 ml per day
Firazyr (Subcutaneous Solution) B Maximum of 3 syringes (9 ml) per day
Firdapse (Oral Tablet) B Maximum of 8 tablets per day
Flector (External Patch) B Maximum of 2 patches per day
FloLipid (20MG/5ML Oral Suspension) B Maximum of 5 ml per day
FloLipid (40MG/5ML Oral Suspension) B Maximum of 10 ml per day
Flovent HFA (110MCG/ACT Inhalation
Aerosol)B
Maximum of 1 inhaler (12 grams) per
30 days
Flovent HFA (220MCG/ACT Inhalation
Aerosol)B
Maximum of 2 inhalers (24 grams)
per 30 days
Flovent HFA (44MCG/ACT Inhalation
Aerosol)B
Maximum of 1 inhaler (10.6 grams)
per 30 days
Flurandrenolide (External Lotion) G Maximum of 240 ml per 30 days
Fluticasone-Salmeterol (100-50MCG/DOSE
Inhalation Aerosol Powder Breath Activated,
250-50MCG/DOSE Inhalation Aerosol
Powder Breath Activated, 500-50MCG/DOSE
Inhalation Aerosol Powder Breath Activated)
(Generic Advair)
GMaximum of 1 inhaler (60 blisters) per
30 days
171Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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)
G 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
Focalin (Oral Tablet) B Maximum of 2 tablets per day
Fortamet (1000MG Oral Tablet Extended
Release 24 Hour)B Maximum of 2 tablets per day
Fortamet (500MG Oral Tablet Extended
Release 24 Hour)B Maximum of 5 tablets per day
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 1 capsule per day
Frova (Oral Tablet) B Maximum of 12 tablets per 30 days
Frovatriptan Succinate (Oral Tablet) G Maximum of 12 tablets per 30 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
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
Genvoya (Oral Tablet) B Maximum of 1 tablet per day
Geodon (Oral Capsule) B Maximum of 2 capsules per day
Gilenya (0.5MG Oral Capsule) BMaximum of 1 pack (30 capsules) per
30 days
Gleevec (Oral Tablet) B Maximum of 3 tablets per day
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
172 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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
Gloperba (Oral Solution) B Maximum of 20 ml per day
Glucotrol XL (10MG Oral Tablet Extended
Release 24 Hour)B Maximum of 2 tablets per day
Glucotrol XL (2.5MG Oral Tablet Extended
Release 24 Hour)B Maximum of 8 tablets per day
Glucotrol XL (5MG Oral Tablet Extended
Release 24 Hour)B Maximum of 4 tablets per day
Glumetza (1000MG Oral Tablet Extended
Release 24 Hour)B Maximum of 2 tablets per day
Glumetza (500MG Oral Tablet Extended
Release 24 Hour)B Maximum of 4 tablets per day
Glyxambi (Oral Tablet) B Maximum of 1 tablet per day
Harvoni (33.75-150MG Oral Packet) BMaximum of 1 carton (28 packets)
per 28 days
Harvoni (45-200MG Oral Packet) BMaximum of 2 cartons (56 packets)
per 28 days
Harvoni (90-400MG Oral Tablet) B Maximum of 1 tablet per day
Havrix (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime
Hetlioz LQ (Oral Suspension) B Maximum of 158 ml per 30 days
Hetlioz (Oral Capsule) B Maximum of 1 capsule per day
Hiberix (Injection Solution Reconstituted) B1 vaccination dose (1 injection) per
day
173Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Hydrocodone Bitartrate ER (10MG Oral
Capsule Extended Release 12 Hour, 15MG
Oral Capsule Extended Release 12 Hour,
20MG Oral Capsule Extended Release 12
Hour, 30MG Oral Capsule Extended Release
12 Hour, 40MG Oral Capsule Extended
Release 12 Hour, 50MG Oral Capsule
Extended Release 12 Hour)
G Maximum of 2 capsules per day
Hydrocodone Bitartrate ER (100MG Oral
Tablet ER 24 Hour Abuse-Deterrent, 120MG
Oral Tablet ER 24 Hour Abuse-Deterrent,
20MG Oral Tablet ER 24 Hour Abuse-
Deterrent, 30MG Oral Tablet ER 24 Hour
Abuse-Deterrent, 40MG Oral Tablet ER 24
Hour Abuse-Deterrent, 60MG Oral Tablet ER
24 Hour Abuse-Deterrent, 80MG Oral Tablet
ER 24 Hour Abuse-Deterrent)
G Maximum of 1 tablet per day
Hydrocodone-Acetaminophen (7.5-325MG/
15ML Oral Solution)G Maximum of 180 ml per day
Hydrocodone-Acetaminophen (10-300MG
Oral Tablet, 5-300MG Oral Tablet, 7.5-300MG
Oral Tablet)
G Maximum of 13 tablets 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 (Oral Tablet) G Maximum of 5 tablets per day
Hydrocortisone Butyrate (External Lotion) G Maximum of 118 ml per 30 days
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 (Oral Tablet) G Maximum of 3 tablets per day
Hysingla ER (Oral Tablet ER 24 Hour
Abuse-Deterrent)B Maximum of 1 tablet per day
Hyzaar (100-12.5MG Oral Tablet,
100-25MG Oral Tablet)B Maximum of 1 tablet per day
Hyzaar (50-12.5MG Oral Tablet) B Maximum of 2 tablets per day
174 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Icatibant Acetate (Subcutaneous Solution) G Maximum of 3 syringes (9 ml) 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 Tablet) B Maximum of 1 tablet per day
Imiquimod (5% External Cream) G Maximum of 24 grams per 30 days
Imitrex (Nasal Solution) B Maximum of 12 devices per 30 days
Imitrex (Oral Tablet) B Maximum of 12 tablets per 30 days
Imitrex STATdose Refill (6MG/0.5ML
Subcutaneous Solution Cartridge)B
Maximum of 12 injections (6 ml) per
30 days
Imitrex STATdose System (4MG/0.5ML
Subcutaneous Solution Auto-Injector)B
Maximum of 12 injections (6 ml) per
30 days
Imitrex (Subcutaneous Solution) BMaximum of 12 injections (6 ml) per
30 days
Imovax Rabies (Intramuscular Injectable) B1 vaccination dose (1 injection) per
day
Impeklo (External Lotion) B Maximum of 68 grams per 30 days
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 (40MG Oral Capsule, 80MG Oral
Capsule)B Maximum of 1 capsule per day
Ingrezza (Oral Capsule Therapy Pack) BMaximum of 1 pack (28 capsules) per
28 days
Inlyta (Oral Tablet) B Maximum of 4 tablets per day
Inqovi (Oral Tablet) BMaximum of 1 pack (5 tablets) per 28
days
Inrebic (Oral Capsule) B Maximum of 4 capsules per day
Intelence (100MG Oral Tablet, 200MG Oral
Tablet)B Maximum of 2 tablets per day
Intelence (25MG Oral Tablet) B Maximum of 4 tablets per day
Intrarosa (Vaginal Insert) B Maximum of 1 vaginal insert per day
Invega (1.5MG Oral Tablet Extended
Release 24 Hour, 3MG Oral Tablet
Extended Release 24 Hour, 9MG Oral
Tablet Extended Release 24 Hour)
B Maximum of 1 tablet per day
Invega (6MG Oral Tablet Extended Release
24 Hour)B Maximum of 2 tablets per day
Invirase (Oral Tablet) B Maximum of 4 tablets per day
175Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Invokamet (Oral Tablet Immediate Release) B Maximum of 2 tablets per day
Invokamet XR (Oral Tablet Extended
Release 24 Hour)B Maximum of 2 tablets per day
Invokana (Oral Tablet) B Maximum of 1 tablet 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
Iressa (Oral Tablet) B Maximum of 2 tablets 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
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)B Maximum of 1 tablet per day
Janumet XR (50-1000MG Oral Tablet
Extended Release 24 Hour, 50-500MG 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
Jentadueto (Oral Tablet Immediate
Release)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
Jornay PM (Oral Capsule Extended Release
24 Hour)B Maximum of 1 capsule per day
Juluca (Oral Tablet) B Maximum of 1 tablet per day
Jynarque (Oral Tablet Therapy Pack) B Maximum of 2 tablets per day
Kaletra (Oral Solution) BMaximum of 3 bottles (480 ml) per 30
days
Kaletra (100-25MG Oral Tablet) B Maximum of 8 tablets per day
Kaletra (200-50MG Oral Tablet) B Maximum of 4 tablets per day
Kazano (Oral Tablet) B Maximum of 2 tablets per day
176 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Ketoconazole (External Cream) G Maximum of 90 grams per 30 days
Ketoconazole (External Foam) G Maximum of 100 grams per 28 days
Ketodan (External Foam) G Maximum of 100 grams per 28 days
Keveyis (Oral Tablet) B Maximum of 4 tablets per day
Kinrix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day
Klonopin (0.5MG Oral Tablet, 1MG Oral
Tablet)B Maximum of 4 tablets per day
Klonopin (2MG Oral Tablet) B Maximum of 10 tablets per day
Kombiglyze XR (2.5-1000MG Oral Tablet
Extended Release 24 Hour)B Maximum of 2 tablets per day
Kombiglyze XR (5-1000MG Oral Tablet
Extended Release 24 Hour, 5-500MG Oral
Tablet Extended Release 24 Hour)
B Maximum of 1 tablet per day
Koselugo (10MG Oral Capsule) B Maximum of 8 capsules per day
Koselugo (25MG Oral Capsule) B Maximum of 4 capsules per day
Kynmobi (10MG Sublingual Film, 15MG
Sublingual Film, 20MG Sublingual Film,
25MG Sublingual Film, 30MG Sublingual
Film)
B Maximum of 5 films per day
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
Lanoxin (125MCG Oral Tablet) B Maximum of 1 tablet per day
Lanoxin (62.5MCG Oral Tablet) B Maximum of 2 tablets per day
Lansoprazole (Oral Capsule Delayed
Release)G Maximum of 2 capsules per day
Latuda (120MG Oral Tablet, 20MG Oral
Tablet, 40MG Oral Tablet, 60MG Oral
Tablet)
B Maximum of 1 tablet per day
Latuda (80MG Oral Tablet) B Maximum of 2 tablets per day
Lazanda (Nasal Solution) B Maximum of 30 bottles per 30 days
Ledipasvir-Sofosbuvir (Oral Tablet) G Maximum of 1 tablet per day
Lescol XL (Oral Tablet Extended Release
24 Hour)B Maximum of 1 tablet per day
Letairis (Oral Tablet) B Maximum of 1 tablet per day
Levorphanol Tartrate (Oral Tablet) G Maximum of 6 tablets per day
Lexiva (Oral Suspension) B Maximum of 60 ml per day
Lexiva (Oral Tablet) B Maximum of 4 tablets per day
177Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Lialda (Oral Tablet Delayed Release) B Maximum of 4 tablets per day
Licart (External Patch 24 Hour) B Maximum of 1 patch 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
Lidoderm (External Patch) B Maximum of 3 patches per day
Linzess (Oral Capsule) B Maximum of 1 capsule per day
Lipitor (Oral Tablet) B Maximum of 1 tablet 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
Locoid (External Lotion) B Maximum of 118 ml per 30 days
Lokelma (Oral Packet) B Maximum of 90 packets per 30 days
Lonhala Magnair (Inhalation Solution) B Maximum of 2 vials (2 ml) per day
Lopinavir-Ritonavir (Oral Solution) GMaximum of 3 bottles (480 ml) per 30
days
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
Lotensin (Oral Tablet) B Maximum of 2 tablets per day
Lotrel (Oral Capsule) B Maximum of 1 capsule 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
178 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Lovenox (100MG/ML Subcutaneous
Solution, 150MG/ML Subcutaneous
Solution)
B Maximum of 2 syringes (2 ml) per day
Lovenox (120MG/0.8ML Subcutaneous
Solution, 80MG/0.8ML Subcutaneous
Solution)
BMaximum of 2 syringes (1.6 ml) per
day
Lovenox (30MG/0.3ML Subcutaneous
Solution)B
Maximum of 2 syringes (0.6 ml) per
day
Lovenox (40MG/0.4ML Subcutaneous
Solution)B
Maximum of 2 syringes (0.8 ml) per
day
Lovenox (60MG/0.6ML Subcutaneous
Solution)B
Maximum of 2 syringes (1.2 ml) per
day
Lubiprostone (Oral Capsule) G Maximum of 2 capsules per day
Lucemyra (Oral Tablet) B Maximum of 16 tablets per day
Luliconazole (External Cream) B Maximum of 60 grams per 28 days
Lupkynis (Oral Capsule) B Maximum of 6 capsules per day
Luzu (External Cream) B Maximum of 60 grams per 28 days
Lyllana (Transdermal Patch Twice Weekly) G Maximum of 8 patches per 28 days
Lyrica CR (165MG Oral Tablet Extended
Release 24 Hour, 82.5MG Oral Tablet
Extended Release 24 Hour)
B Maximum of 3 tablets per day
Lyrica CR (330MG Oral Tablet Extended
Release 24 Hour)B Maximum of 2 tablets per day
Lyrica (100MG Oral Capsule, 150MG Oral
Capsule, 25MG Oral Capsule, 50MG Oral
Capsule, 75MG Oral Capsule)
B Maximum of 4 capsules per day
Lyrica (200MG Oral Capsule) B Maximum of 3 capsules per day
Lyrica (225MG Oral Capsule, 300MG Oral
Capsule)B Maximum of 2 capsules per day
Lyrica (Oral Solution) B Maximum of 30 ml per day
Mavyret (Oral Tablet) B Maximum of 3 tablets per day
Maxalt (Oral Tablet) B Maximum of 12 tablets per 30 days
Maxalt-MLT (Oral Tablet Dispersible) B Maximum of 12 tablets per 30 days
Mayzent (0.25MG Oral Tablet) B Maximum of 8 tablets per day
Mayzent (2MG Oral Tablet) B Maximum of 1 tablet per day
Meloxicam (Oral Capsule) G Maximum of 1 capsule per day
Memantine HCl ER (Oral Capsule Extended
Release 24 Hour)G Maximum of 1 capsule per day
Memantine HCl (2MG/ML Oral Solution) G Maximum of 10 ml per day
179Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Memantine HCl (10MG Oral Tablet) G Maximum of 2 tablets per day
Memantine HCl (5MG Oral Tablet) G Maximum of 3 tablets per day
Menactra (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day
MenQuadfi (Intramuscular Injectable) B 1 vaccination dose (0.5 ml) per day
Menveo (Intramuscular Solution
Reconstituted)B
1 vaccination dose (1 injection) 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 (800MG Oral Tablet Delayed
Release) (Generic Asacol)G Maximum of 6 tablets per day
Mesalamine (Rectal Suppository) G Maximum of 1 suppository per day
Metformin HCl ER (1000MG Oral Tablet
Extended Release 24 Hour) (Generic
Glumetza)
G Maximum of 2 tablets per day
Metformin HCl ER (500MG Oral Tablet
Extended Release 24 Hour) (Generic
Glumetza)
G Maximum of 4 tablets per day
Metformin HCl ER (1000MG Oral Tablet
Extended Release 24 Hour) (Generic
Fortamet)
G Maximum of 2 tablets per day
Metformin HCl ER (500MG Oral Tablet
Extended Release 24 Hour) (Generic
Fortamet)
G Maximum of 5 tablets per day
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 (500MG/5ML 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
180 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Methadone HCl (10MG Oral Tablet) G Maximum of 12 tablets per day
Methadone HCl (5MG Oral Tablet) G Maximum of 8 tablets per day
Methylin (10MG/5ML Oral Solution) B Maximum of 30 ml per day
Methylin (5MG/5ML Oral Solution) B Maximum of 60 ml per day
Methylphenidate HCl ER (XR) (Oral Capsule
Extended Release 24 Hour) (Brand
Equivalent Aptensio XR)
G Maximum of 1 capsule per day
Methylphenidate HCl ER (10MG Oral Tablet
Extended Release)G Maximum of 4 tablets per day
Methylphenidate HCl ER Osmotic Release
(18MG Oral Tablet Extended Release)
(Generic Concerta), Methylphenidate HCl ER
(20MG Oral Tablet Extended Release)
(Generic Metadate ER)
G Maximum of 3 tablets per day
Methylphenidate HCl ER (18MG Oral Tablet
Extended Release 24 Hour)G Maximum of 3 tablets per day
Methylphenidate HCl ER (27MG Oral Tablet
Extended Release 24 Hour, 36MG Oral Tablet
Extended Release 24 Hour)
G Maximum of 2 tablets per day
Methylphenidate HCl ER (54MG Oral Tablet
Extended Release 24 Hour)G Maximum of 1 tablet per day
Methylphenidate HCl ER Osmotic Release
(27MG Oral Tablet Extended Release, 36MG
Oral Tablet Extended Release) (Generic
Concerta)
G Maximum of 2 tablets per day
Methylphenidate HCl ER Osmotic Release
(54MG Oral Tablet Extended Release, 72MG
Oral Tablet Extended Release) (Generic
Concerta)
G Maximum of 1 tablet 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
Methylphenidate HCl (10MG Oral Tablet
Chewable)G Maximum of 6 tablets per day
Methylphenidate HCl (2.5MG Oral Tablet
Chewable, 5MG Oral Tablet Chewable)G Maximum of 3 tablets per day
Micardis HCT (40-12.5MG Oral Tablet,
80-25MG Oral Tablet)B Maximum of 1 tablet per day
181Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Micardis HCT (80-12.5MG Oral Tablet) B Maximum of 2 tablets per day
Micardis (Oral Tablet) B Maximum of 1 tablet per day
Migranal (Nasal Solution) BMaximum of 16 vials (16 ml) per 28
days
Minivelle (Transdermal Patch Twice
Weekly)B Maximum of 8 patches per 28 days
Minocycline HCl ER (Oral Tablet Extended
Release 24 Hour)G Maximum of 1 tablet per day
Minolira (Oral Tablet Extended Release 24
Hour)B Maximum of 1 tablet per day
M-M-R II (Injection Solution Reconstituted) B1 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 (100MG/5ML Oral Solution) G Maximum of 10 ml per day
Morphine Sulfate ER Beads (120MG Oral
Capsule Extended Release 24 Hour) (Generic
Avinza)
G Maximum of 3 capsules per day
Morphine Sulfate ER Beads (30MG Oral
Capsule Extended Release 24 Hour, 45MG
Oral Capsule Extended Release 24 Hour,
60MG Oral Capsule Extended Release 24
Hour) (Generic Avinza)
G Maximum of 2 capsules per day
Morphine Sulfate ER Beads (75MG Oral
Capsule Extended Release 24 Hour, 90MG
Oral Capsule Extended Release 24 Hour)
(Generic Avinza)
G Maximum of 4 capsules per day
Morphine Sulfate ER (100MG Oral Capsule
Extended Release 24 Hour, 60MG Oral
Capsule Extended Release 24 Hour, 80MG
Oral Capsule Extended Release 24 Hour)
(Generic Kadian)
G Maximum of 3 capsules per day
182 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Morphine Sulfate ER (10MG Oral Capsule
Extended Release 24 Hour, 20MG Oral
Capsule Extended Release 24 Hour, 30MG
Oral Capsule Extended Release 24 Hour,
40MG Oral Capsule Extended Release 24
Hour, 50MG Oral Capsule Extended Release
24 Hour) (Generic Kadian)
G Maximum of 2 capsules 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
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
Movantik (Oral Tablet) B Maximum of 1 tablet per day
MS Contin (100MG Oral Tablet Extended
Release, 15MG Oral Tablet Extended
Release)
B Maximum of 3 tablets per day
MS Contin (200MG Oral Tablet Extended
Release)B Maximum of 2 tablets per day
MS Contin (30MG Oral Tablet Extended
Release, 60MG Oral Tablet Extended
Release)
B Maximum of 4 tablets per day
Mupirocin (External Ointment) G Maximum of 110 grams per 30 days
Mycapssa (Oral Capsule Delayed Release) BMaximum of 112 capsules per 28
days
Mydayis (12.5MG Oral Capsule Extended
Release 24 Hour, 25MG Oral Capsule
Extended Release 24 Hour)
B Maximum of 2 capsules per day
Mydayis (37.5MG Oral Capsule Extended
Release 24 Hour, 50MG Oral Capsule
Extended Release 24 Hour)
B Maximum of 1 capsule per day
Namenda (10MG Oral Tablet) B Maximum of 2 tablets per day
183Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Namenda (5MG Oral Tablet) B Maximum of 3 tablets per day
Namenda XR (Oral Capsule Extended
Release 24 Hour)B Maximum of 1 capsule per day
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
Nebupent (Inhalation Solution
Reconstituted)B
Maximum of 1 vial (300 mg) per 28
days
Nerlynx (Oral Tablet) B Maximum of 6 tablets per day
Nesina (Oral Tablet) B Maximum of 1 tablet per day
Nevirapine ER (100MG Oral Tablet Extended
Release 24 Hour)G Maximum of 2 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
Nexium (20MG Oral Capsule Delayed
Release)B Maximum of 3 capsules per day
Nexium (40MG Oral Capsule Delayed
Release)B Maximum of 2 capsules per day
Nexletol (Oral Tablet) B Maximum of 1 tablet per day
Nexlizet (Oral Tablet) B Maximum of 1 tablet per day
Nolix (External Lotion) G Maximum of 240 ml per 30 days
Northera (100MG Oral Capsule) B Maximum of 3 capsules per day
Northera (200MG Oral Capsule, 300MG
Oral Capsule)B Maximum of 6 capsules per day
Norvir (Oral Packet) B Maximum of 12 packets per day
Norvir (Oral Solution) B Maximum of 16 ml per day
Norvir (Oral Tablet) B Maximum of 12 tablets per day
Nourianz (Oral Tablet) B Maximum of 1 tablet per day
Noxafil (Oral Suspension) B Maximum of 20 ml per day
Noxafil (Oral Tablet Delayed Release) B Maximum of 6 tablets per day
Nucala (Subcutaneous Solution Auto-
Injector)B Maximum of 3 ml per 28 days
184 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Nucala (Subcutaneous Solution Prefilled
Syringe)B Maximum of 3 ml per 28 days
Nucala (Subcutaneous Solution
Reconstituted)B Maximum of 3 vials per 28 days
Nucynta ER (Oral Tablet Extended Release
12 Hour)B Maximum of 2 tablets per day
Nucynta (Oral Tablet Immediate Release) B Maximum of 6 tablets per day
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
Nuvigil (150MG Oral Tablet, 200MG Oral
Tablet, 250MG Oral Tablet)B Maximum of 1 tablet per day
Nuvigil (50MG Oral Tablet) B Maximum of 2 tablets per day
Nuzyra (Oral Tablet) B Maximum of 2 tablets per day
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
Ocaliva (Oral Tablet) B Maximum of 1 tablet per day
Odefsey (Oral Tablet) B Maximum of 1 tablet per day
Odomzo (Oral Capsule) B Maximum of 1 capsule per day
Ofev (Oral Capsule) B Maximum of 2 capsules per day
Olanzapine (10MG Oral Tablet, 15MG Oral
Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet,
5MG Oral Tablet, 7.5MG Oral Tablet)
G Maximum of 1 tablet per day
Olanzapine ODT (10MG Oral Tablet
Dispersible, 15MG Oral Tablet Dispersible,
20MG Oral Tablet Dispersible, 5MG 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
Olumiant (Oral Tablet) B Maximum of 1 tablet per day
Olux (External Foam) B Maximum of 100 grams per 30 days
Olux-E (External Foam) B Maximum of 100 grams per 30 days
Omeprazole (10MG Oral Capsule Delayed
Release)G Maximum of 3 capsules per day
185Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Onfi (Oral Suspension) B Maximum of 16 ml per day
Onfi (Oral Tablet) B Maximum of 2 tablets per day
Ongentys (Oral Capsule) B Maximum of 1 capsule per day
Onglyza (Oral Tablet) B Maximum of 1 tablet per day
Onureg (Oral Tablet) B Maximum of 14 tablets per 28 days
Onzetra Xsail (Nasal Exhaler Powder) BMaximum of 1 kit (16 exhalers) per 30
days
Orgovyx (Oral Tablet) B Maximum of 1 tablet per day
Oriahnn (Oral Capsule Therapy Pack) BMaximum of 1 pack (56 capsules) per
28 days
Orilissa (150MG Oral Tablet) B Maximum of 1 tablet per day
Orilissa (200MG Oral Tablet) B Maximum of 2 tablets per day
Orkambi (Oral Packet) B Maximum of 56 packets per 28 days
Orkambi (Oral Tablet) B Maximum of 112 tablets per 28 days
Orladeyo (Oral Capsule) B Maximum of 1 capsule per day
Oseni (Oral Tablet) B Maximum of 1 tablet per day
Osphena (Oral Tablet) B Maximum of 1 tablet per day
Oxbryta (Oral Tablet) B Maximum of 5 tablets per day
Oxervate (Ophthalmic Solution) B Maximum of 2 vials (2 ml) per day
Oxiconazole Nitrate (External Cream) G Maximum of 90 grams per 30 days
Oxistat (External Cream) B Maximum of 90 grams per 30 days
Oxistat (External Lotion) B Maximum of 60 ml per 30 days
Oxycodone HCl ER (Oral Tablet ER 12 Hour
Abuse-Deterrent)G Maximum of 3 tablets per day
Oxycodone HCl (5MG Oral Capsule) G Maximum of 12 capsules per day
Oxycodone HCl (100MG/5ML Oral
Concentrate)G Maximum of 6 ml per day
Oxycodone HCl (5MG/5ML 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
Oxycodone-Acetaminophen (10-300MG Oral
Tablet, 5-300MG Oral Tablet)G Maximum of 13 tablets per day
186 Last updated September 1, 2021
Drug Name
Brand
or
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
OxyContin (Oral Tablet ER 12 Hour Abuse-
Deterrent)B Maximum of 3 tablets per day
Oxymorphone HCl ER (10MG Oral Tablet
Extended Release 12 Hour, 15MG Oral Tablet
Extended Release 12 Hour, 20MG Oral Tablet
Extended Release 12 Hour, 5MG Oral Tablet
Extended Release 12 Hour, 7.5MG Oral
Tablet Extended Release 12 Hour)
G Maximum of 2 tablets per day
Oxymorphone HCl ER (30MG Oral Tablet
Extended Release 12 Hour)G Maximum of 4 tablets per day
Oxymorphone HCl ER (40MG Oral Tablet
Extended Release 12 Hour)G Maximum of 3 tablets per day
Oxymorphone HCl (Oral Tablet Immediate
Release)G Maximum of 6 tablets per day
Ozempic (0.25MG/DOSE or 0.5MG/DOSE)
(Subcutaneous Solution Pen-Injector)B
Maximum of 1 pen (1.5 ml) per 28
days
Ozempic (1MG/DOSE) (2MG/1.5ML
Subcutaneous Solution Pen-Injector)B
Maximum of 2 pens (3 ml) per 28
days
Ozempic (1MG/DOSE) (4MG/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
Palynziq (10MG/0.5ML Subcutaneous
Solution Prefilled Syringe)B Maximum of 28 syringes per 28 days
Palynziq (2.5MG/0.5ML Subcutaneous
Solution Prefilled Syringe)B Maximum of 8 syringes per 28 days
Palynziq (20MG/ML Subcutaneous
Solution Prefilled Syringe)B Maximum of 56 syringes per 28 days
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
Pediarix (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day
Pedvax HIB (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day
187Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Pemazyre (Oral Tablet) B Maximum of 1 tablet 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 12 capsules per day
Pentasa (500MG Oral Capsule Extended
Release)B Maximum of 8 capsules per day
Percocet (Oral Tablet) G Maximum of 12 tablets 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
Picato (0.015% External Gel) B Maximum of 3 tubes per 30 days
Picato (0.05% External Gel) B Maximum of 2 tubes per 30 days
Pifeltro (Oral Tablet) B Maximum of 1 tablet per day
Pimecrolimus (External Cream) G Maximum of 100 grams per 30 days
Pioglitazone HCl (15MG Oral Tablet) G Maximum of 3 tablets per day
Pioglitazone HCl (30MG Oral Tablet, 45MG
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
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
Plaquenil (Oral Tablet) B Maximum of 3 tablets per day
Plavix (Oral Tablet) B Maximum of 4 tablets per day
Posaconazole (Oral Tablet Delayed Release) G Maximum of 6 tablets per day
Pradaxa (Oral Capsule) B Maximum of 2 capsules per day
Praluent (Subcutaneous Solution Auto-
Injector)B
Maximum of 2 pens (2 ml) per 28
days
Pravastatin Sodium (Oral Tablet) G Maximum of 1 tablet per day
Pregabalin ER (165MG Oral Tablet Extended
Release 24 Hour, 82.5MG Oral Tablet
Extended Release 24 Hour)
G Maximum of 3 tablets per day
Pregabalin ER (330MG Oral Tablet Extended
Release 24 Hour)G Maximum of 2 tablets per day
188 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Pregabalin (100MG Oral Capsule, 150MG
Oral Capsule, 25MG Oral Capsule, 50MG
Oral Capsule, 75MG Oral Capsule)
G Maximum of 4 capsules per day
Pregabalin (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
Prevacid (Oral Capsule Delayed Release) B Maximum of 2 capsules 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) BMaximum of 2 bottles (400 ml) per 30
days
Prezista (150MG Oral Tablet) B Maximum of 6 tablets per day
Prezista (600MG Oral Tablet, 75MG Oral
Tablet)B Maximum of 2 tablets per day
Prezista (800MG Oral Tablet) B Maximum of 1 tablet per day
Prinivil (Oral Tablet) B Maximum of 2 tablets per day
Prolate (Oral Tablet) G Maximum of 13 tablets 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
ProQuad (Subcutaneous Suspension
Reconstituted)B
1 vaccination dose (1 injection) per
day
Protonix (20MG Oral Tablet Delayed
Release)B Maximum of 3 tablets per day
Protonix (40MG Oral Tablet Delayed
Release)B Maximum of 2 tablets per day
Provigil (100MG Oral Tablet) B Maximum of 1 tablet per day
Provigil (200MG Oral Tablet) B Maximum of 2 tablets per day
PRUDOXIN (External Cream) B Maximum of 90 grams per 30 days
Psorcon (External Cream) G Maximum of 240 grams per 30 days
Pulmozyme (Inhalation Solution) B Maximum of 2 ampules (5 ml) per day
Qbrelis (Oral Solution) B Maximum of 80 ml per day
Qinlock (Oral Tablet) B Maximum of 3 tablets per day
Qtern (Oral Tablet) B Maximum of 1 tablet per day
189Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Quadracel (Intramuscular Suspension) 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, 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
QuilliChew ER (20MG Oral Tablet
Chewable Extended Release, 40MG Oral
Tablet Chewable Extended Release)
B Maximum of 1 tablet per day
QuilliChew ER (30MG Oral Tablet
Chewable Extended Release)B Maximum of 2 tablets per day
Quinapril HCl (Oral Tablet) G Maximum of 2 tablets per day
Quinapril-Hydrochlorothiazide (10-12.5MG
Oral Tablet)G Maximum of 1 tablet per day
Quinapril-Hydrochlorothiazide (20-12.5MG
Oral Tablet, 20-25MG Oral Tablet)G Maximum of 2 tablets per day
QVAR RediHaler (Inhalation Aerosol Breath
Activated)B
Maximum of 2 inhalers (21.2 grams)
per 30 days
RabAvert (Intramuscular Suspension
Reconstituted)B
1 vaccination dose (1 injection) per
day
Ramipril (Oral Capsule) G Maximum of 2 capsules per day
Rapaflo (Oral Capsule) B Maximum of 1 capsule per day
Rayaldee (Oral Capsule Extended Release) B Maximum of 2 capsules per day
Recombivax HB (10MCG/ML Injection
Suspension, 10MCG/ML (1ML Syringe)
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
Rectiv (Rectal Ointment) B Maximum of 30 grams per 30 days
190 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Relexxii (Oral Tablet Extended Release) G Maximum of 1 tablet per day
Relpax (Oral Tablet) B Maximum of 12 tablets per 30 days
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 1 cartridge (3.5 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 Single-Use Vials (Ophthalmic
Emulsion)B Maximum of 2 vials per day
Restoril (22.5MG Oral Capsule) B Maximum of 1 capsule per day
Retevmo (40MG Oral Capsule) B Maximum of 6 capsules per day
Retevmo (80MG Oral Capsule) B Maximum of 4 capsules per day
Retrovir (Oral Capsule) B Maximum of 6 capsules per day
Retrovir (Oral Syrup) B Maximum of 64 ml per day
Rexulti (Oral Tablet) B Maximum of 1 tablet per day
Reyataz (150MG Oral Capsule, 300MG Oral
Capsule)B Maximum of 1 capsule per day
Reyataz (200MG Oral Capsule) B Maximum of 2 capsules per day
Reyataz (Oral Packet) B Maximum of 6 packets per day
Reyvow (100MG Oral Tablet) B Maximum of 8 tablets per 30 days
Reyvow (50MG Oral Tablet) B Maximum of 4 tablets per 30 days
Rinvoq (Oral Tablet Extended Release 24
Hour)B Maximum of 1 tablet per day
Riomet (Oral Solution) B Maximum of 25.5 ml per day
Ritalin (Oral Tablet) B Maximum of 3 tablets per day
Ritonavir (Oral Tablet) G Maximum of 12 tablets 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
Rosuvastatin Calcium (Oral Tablet) G Maximum of 1 tablet per day
Roszet (Oral Tablet) B Maximum of 1 tablet 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
191Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Roxicodone (15MG Oral Tablet) B Maximum of 8 tablets per day
Roxicodone (30MG Oral Tablet) B Maximum of 6 tablets per day
Roxicodone (5MG Oral Tablet) B Maximum of 12 tablets per day
Rozlytrek (100MG Oral Capsule) B Maximum of 5 capsules per day
Rozlytrek (200MG Oral Capsule) B Maximum of 3 capsules per day
Rukobia (Oral Tablet Extended Release 12
Hour)B Maximum of 2 tablets per day
Ruzurgi (Oral Tablet) B Maximum of 10 tablets per day
Rybelsus (Oral Tablet) B Maximum of 1 tablet per day
Rydapt (Oral Capsule) B Maximum of 8 capsules per day
Sabril (Oral Packet) B Maximum of 6 packets per day
Sabril (Oral Tablet) B Maximum of 6 tablets per day
Sancuso (Transdermal Patch) B Maximum of 4 patches per 28 days
Savaysa (Oral Tablet) B Maximum of 1 tablet per day
Secuado (Transdermal Patch 24 Hour) B Maximum of 1 patch per day
Segluromet (2.5-1000MG Oral Tablet,
7.5-1000MG Oral Tablet, 7.5-500MG Oral
Tablet)
B Maximum of 2 tablets per day
Segluromet (2.5-500MG Oral Tablet) B Maximum of 4 tablets per day
Selzentry (Oral Solution) BMaximum of 8 bottles (1840 ml) per
30 days
Selzentry (150MG Oral Tablet, 75MG Oral
Tablet)B Maximum of 2 tablets per day
Selzentry (25MG Oral Tablet, 300MG Oral
Tablet)B Maximum of 4 tablets per day
Sensipar (30MG Oral Tablet, 60MG Oral
Tablet)B Maximum of 2 tablets per day
Sensipar (90MG Oral Tablet) B Maximum of 4 tablets per day
Serevent Diskus (60 Inhalation Aerosol
Powder Breath Activated)B
Maximum of 1 inhaler (60 inhalations)
per 30 days
Seroquel (100MG Oral Tablet Immediate
Release, 200MG Oral Tablet Immediate
Release, 50MG Oral Tablet Immediate
Release)
B Maximum of 3 tablets per day
Seroquel (25MG Oral Tablet Immediate
Release)B Maximum of 4 tablets per day
Seroquel (300MG Oral Tablet Immediate
Release, 400MG Oral Tablet Immediate
Release)
B Maximum of 2 tablets per day
192 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Seroquel XR (150MG Oral Tablet Extended
Release 24 Hour, 200MG Oral Tablet
Extended Release 24 Hour)
B Maximum of 1 tablet per day
Seroquel XR (300MG Oral Tablet Extended
Release 24 Hour, 400MG Oral Tablet
Extended Release 24 Hour, 50MG Oral
Tablet Extended Release 24 Hour)
B Maximum of 2 tablets per day
Shingrix (Intramuscular Suspension
Reconstituted)B
1 vaccination dose (1 injection) per
day
Silodosin (Oral Capsule) G Maximum of 1 capsule per day
Simvastatin (Oral Tablet) G Maximum of 1 tablet per day
Singulair (Oral Packet) B Maximum of 1 packet per day
Singulair (Oral Tablet) B Maximum of 1 tablet per day
Singulair (Oral Tablet Chewable) B Maximum of 1 tablet per day
Sofosbuvir-Velpatasvir (Oral Tablet) G 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 6 pens (18 ml) per 30
days
Solodyn (Oral Tablet Extended Release 24
Hour)B Maximum of 1 tablet per day
Somavert (Subcutaneous Solution
Reconstituted)B Maximum of 1 vial per day
Sovaldi (150MG Oral Packet) BMaximum of 1 carton (28 packets)
per 28 days
Sovaldi (200MG Oral Packet) BMaximum of 2 cartons (56 packets)
per 28 days
Sovaldi (400MG Oral Tablet) B Maximum of 1 tablet 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
Steglatro (15MG Oral Tablet) B Maximum of 1 tablet per day
Steglatro (5MG Oral Tablet) B Maximum of 2 tablets per day
Steglujan (Oral Tablet) B Maximum of 1 tablet per day
Stribild (Oral Tablet) B Maximum of 1 tablet per day
Suboxone (12-3MG Sublingual Film, 4-1MG
Sublingual Film)B Maximum of 2 films per day
Suboxone (2-0.5MG Sublingual Film,
8-2MG Sublingual Film)B Maximum of 3 films per day
193Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Subsys (100MCG Sublingual Liquid,
200MCG Sublingual Liquid, 400MCG
Sublingual Liquid, 600MCG Sublingual
Liquid, 800MCG Sublingual Liquid)
B Maximum of 4 sprays per day
Subsys (1200 (600 X 2)MCG Sublingual
Liquid, 1600 (800 X 2)MCG Sublingual
Liquid)
B Maximum of 8 sprays per day
Sumatriptan (Nasal Solution) G Maximum of 12 devices per 30 days
Sumatriptan Succinate (100MG Oral Tablet,
25MG Oral Tablet, 50MG 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 (6MG/0.5ML
Subcutaneous Solution)G
Maximum of 12 injections (6 ml) per
30 days
Sumatriptan Succinate (4MG/0.5ML
Subcutaneous Solution Auto-Injector, 6MG/
0.5ML Subcutaneous Solution Auto-Injector)
GMaximum of 12 injections (6 ml) per
30 days
Sumatriptan-Naproxen Sodium (Oral Tablet) G Maximum of 9 tablets per 30 days
Sunosi (Oral Tablet) B Maximum of 1 tablet per day
Sustiva (Oral Capsule) B Maximum of 3 capsules per day
Sustiva (Oral Tablet) B Maximum of 1 tablet per day
Symbicort (120 Inhalation Aerosol) BMaximum of 1 inhaler (10.2 grams)
per 30 days
Symdeko (Oral Tablet Therapy Pack) BMaximum of 1 pack (56 tablets) per
28 days
Symfi Lo (Oral Tablet) B Maximum of 1 tablet per day
Symfi (Oral Tablet) B Maximum of 1 tablet per day
Symjepi (Injection Solution Prefilled
Syringe)B Maximum of 4 syringes per 30 days
Sympazan (Oral Film) B Maximum of 2 films per day
Symproic (Oral Tablet) B Maximum of 1 tablet per day
Symtuza (Oral Tablet) B Maximum of 1 tablet per day
Synjardy (Oral Tablet Immediate Release) B Maximum of 2 tablets per day
Synjardy XR (10-1000MG Oral Tablet
Extended Release 24 Hour, 25-1000MG
Oral Tablet Extended Release 24 Hour)
B Maximum of 1 tablet per day
Synjardy XR (12.5-1000MG Oral Tablet
Extended Release 24 Hour, 5-1000MG Oral
Tablet Extended Release 24 Hour)
B Maximum of 2 tablets per day
Syprine (Oral Capsule) B Maximum of 8 capsules per day
194 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Tabrecta (Oral Tablet) B Maximum of 4 tablets per day
Tadalafil (2.5MG Oral Tablet, 5MG Oral
Tablet)G Maximum of 1 tablet per day
Talzenna (0.25MG Oral Capsule) B Maximum of 3 capsules per day
Talzenna (1MG Oral Capsule) B Maximum of 1 capsule per day
Targretin (External Gel) B Maximum of 60 grams per 30 days
Tasmar (Oral Tablet) B Maximum of 6 tablets per day
Tavalisse (Oral Tablet) B Maximum of 2 tablets per day
Tazverik (Oral Tablet) B Maximum of 8 tablets per day
TDVAX (Intramuscular Suspension) B 1 vaccination dose (0.5 ml) per day
Tecfidera (Oral Capsule Delayed Release) B Maximum of 2 capsules per day
Tekturna HCT (Oral Tablet) B Maximum of 1 tablet per day
Tekturna (Oral Tablet) B Maximum of 1 tablet 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 (Oral Capsule) G Maximum of 1 capsule per day
Temixys (Oral Tablet) B Maximum of 1 tablet 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
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
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 (Inhalation Nebulization Solution) BMaximum of 2 ampules (10 ml) per
day
TOBI Podhaler (Inhalation Capsule) B Maximum of 8 capsules per day
Tobramycin (300MG/4ML Inhalation
Nebulization Solution)G Maximum of 2 ampules (8 ml) per day
Tobramycin (300MG/5ML Inhalation
Nebulization Solution)G
Maximum of 2 ampules (10 ml) per
day
195Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Tolcapone (Oral Tablet) G Maximum of 6 tablets per day
Topicort (External Cream) G Maximum of 100 grams per 30 days
Tosymra (Nasal Solution) B Maximum of 12 devices per 30 days
Toviaz (Oral Tablet Extended Release 24
Hour)B Maximum of 1 tablet per day
Tracleer (Oral Tablet) B Maximum of 2 tablets 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
Tramadol HCl ER (100MG Oral Capsule
Extended Release 24 Hour, 200MG Oral
Capsule Extended Release 24 Hour, 300MG
Oral Capsule Extended Release 24 Hour)
G Maximum of 1 capsule per day
Tramadol HCl ER (100MG Oral Tablet
Extended Release 24 Hour, 200MG Oral
Tablet Extended Release 24 Hour, 300MG
Oral Tablet Extended Release 24 Hour)
G Maximum of 1 tablet per day
Tramadol HCl (100MG Oral Tablet Immediate
Release)G Maximum of 4 tablets 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
Tranxene-T (Oral Tablet) B Maximum of 12 tablets per day
Trelegy Ellipta (Inhalation Aerosol Powder
Breath Activated)B
Maximum of 1 inhaler (60 blisters) per
30 days
Treximet (Oral Tablet) B Maximum of 9 tablets per 30 days
Trezix (Oral Capsule) G Maximum of 10 capsules per day
Tribenzor (Oral Tablet) B Maximum of 1 tablet per day
Trientine HCl (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
196 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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
Trikafta (100-50-75 & 150MG Oral Tablet
Therapy Pack)B
Maximum of 1 pack (84 tablets) per
28 days
Triumeq (Oral Tablet) B Maximum of 1 tablet per day
Trizivir (Oral Tablet) B Maximum of 2 tablets 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
Truvada (Oral Tablet) B Maximum of 1 tablet per day
Tukysa (150MG Oral Tablet) B Maximum of 4 tablets per day
Tukysa (50MG Oral Tablet) B Maximum of 12 tablets per day
Turalio (Oral Capsule) B Maximum of 4 capsules per day
Twinrix (Intramuscular Suspension
Prefilled Syringe)B 1 vaccination dose (1 ml) per day
Twynsta (Oral Tablet) B Maximum of 1 tablet per day
Tybost (Oral Tablet) B Maximum of 1 tablet per day
Typhim Vi (Intramuscular Solution) B 1 vaccination dose (0.5 ml) per day
Ubrelvy (Oral Tablet) B Maximum of 16 tablets per 30 days
Ukoniq (Oral Tablet) B Maximum of 4 tablets per day
Ultracet (Oral Tablet) B Maximum of 8 tablets per day
Ultram (Oral Tablet Immediate Release) B Maximum of 8 tablets per day
Uptravi (1000MCG Oral Tablet, 1200MCG
Oral Tablet, 1400MCG Oral Tablet,
1600MCG Oral Tablet, 400MCG Oral
Tablet, 600MCG Oral Tablet, 800MCG Oral
Tablet)
B Maximum of 2 tablets per day
Uptravi (200MCG Oral Tablet) B Maximum of 5 tablets per day
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
Valcyte (Oral Solution Reconstituted) B Maximum of 36 ml per day
Valcyte (Oral Tablet) B Maximum of 4 tablets per day
Valganciclovir HCl (50MG/ML Oral Solution
Reconstituted)G Maximum of 36 ml per day
Valganciclovir HCl (450MG Oral Tablet) G Maximum of 4 tablets per day
Valium (Oral Tablet) B Maximum of 4 tablets per day
197Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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 10 MG Dose (Nasal Liquid) BMaximum of 10 blister packs (10
spray devices) per 30 days
Valtoco 15 MG Dose (Nasal Liquid Therapy
Pack)B
Maximum of 10 blister packs (20
spray devices) per 30 days
Valtoco 20 MG Dose (Nasal Liquid Therapy
Pack)B
Maximum of 10 blister packs (20
spray devices) per 30 days
Valtoco 5 MG Dose (Nasal Liquid) BMaximum of 10 blister packs (10
spray devices) per 30 days
Valtrex (1GM Oral Tablet) B Maximum of 4 tablets per day
Valtrex (500MG Oral Tablet) B Maximum of 2 tablets per day
Vancocin HCl (125MG Oral Capsule) B Maximum of 4 capsules per day
Vancocin (250MG Oral Capsule) B Maximum of 8 capsules per day
Vancomycin HCl (125MG Oral Capsule) G Maximum of 4 capsules per day
Vancomycin HCl (250MG Oral Capsule) G Maximum of 8 capsules per day
VAQTA (Intramuscular Suspension) B Maximum of 2 vaccines per lifetime
Varivax (Subcutaneous Injectable) B1 vaccination dose (1 injection) per
day
Vaseretic (Oral Tablet) B Maximum of 2 tablets per day
Vasotec (Oral Tablet) B Maximum of 2 tablets per day
Veltassa (Oral Packet) B Maximum of 1 packet per day
Verquvo (Oral Tablet) B Maximum of 1 tablet per day
Vesicare LS (Oral Suspension) B Maximum of 10 ml per day
Vesicare (Oral Tablet) B Maximum of 1 tablet per day
Viberzi (Oral Tablet) B Maximum of 2 tablets per day
Victoza (Subcutaneous Solution Pen-
Injector)B
Maximum of 3 pens (9 ml) per 30
days
Viekira Pak (Oral Tablet Therapy Pack) BMaximum of 1 pack (112 tablets) per
28 days
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
Vimpat (Oral Solution) B Maximum of 40 ml per day
Vimpat (Oral Tablet) B Maximum of 2 tablets per day
Viracept (250MG Oral Tablet) B Maximum of 10 tablets per day
Viracept (625MG Oral Tablet) B Maximum of 4 tablets per day
198 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Viramune (Oral Suspension) B Maximum of 40 ml per day
Viramune XR (Oral Tablet Extended
Release 24 Hour)B Maximum of 1 tablet per day
Viread (Oral Powder) BMaximum of 4 bottles (240 grams)
per 30 days
Viread (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
Vivelle-Dot (Transdermal Patch Twice
Weekly)B Maximum of 8 patches per 28 days
Vivlodex (Oral Capsule) B Maximum of 1 capsule per day
Vosevi (Oral Tablet) B Maximum of 1 tablet per day
Vraylar (1.5MG Oral Capsule, 3MG Oral
Capsule, 4.5MG Oral Capsule, 6MG Oral
Capsule)
B Maximum of 1 capsule per day
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
Vytorin (Oral Tablet) B Maximum of 1 tablet per day
Wakix (Oral Tablet) B Maximum of 2 tablets per day
Wixela Inhub (Inhalation Aerosol Powder
Breath Activated) (Generic Advair)G
Maximum of 1 inhaler (60 blisters) per
30 days
Xanax (0.25MG Oral Tablet Immediate
Release, 0.5MG Oral Tablet Immediate
Release, 1MG Oral Tablet Immediate
Release)
B Maximum of 4 tablets per day
Xanax (2MG Oral Tablet Immediate
Release)B Maximum of 5 tablets per day
Xanax XR (0.5MG Oral Tablet Extended
Release 24 Hour, 1MG Oral Tablet
Extended Release 24 Hour)
B Maximum of 1 tablet per day
Xanax XR (2MG Oral Tablet Extended
Release 24 Hour)B Maximum of 5 tablets per day
Xanax XR (3MG Oral Tablet Extended
Release 24 Hour)B Maximum of 3 tablets per day
Xarelto (10MG Oral Tablet, 20MG Oral
Tablet)B Maximum of 1 tablet per day
199Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
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 1 pack (51 tablets) per
30 days
Xcopri (250MG Daily Dose) (Oral Tablet
Therapy Pack)B
Maximum of 1 pack (56 tablets) per
28 days
Xcopri (350MG Daily Dose) (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 (Oral Tablet Titration Therapy Pack) BMaximum of 1 pack (28 tablets) per
28 days
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
Xenleta (Oral Tablet) B Maximum of 2 tablets 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) (2 x 20MG Oral
Tablet Therapy Pack)B Maximum of 2 tablets per 30 days
Xofluza (80MG Dose) (2 x 40MG Oral
Tablet Therapy Pack)B Maximum of 2 tablets per 30 days
Xolegel (External Gel) B Maximum of 90 grams per 30 days
Xospata (Oral Tablet) B Maximum of 3 tablets per day
Xpovio (100MG Once Weekly) (20MG Oral
Tablet Therapy Pack)B Maximum of 20 tablets per 28 days
Xpovio (100MG Once Weekly) (50MG Oral
Tablet Therapy Pack)B Maximum of 8 tablets per 28 days
200 Last updated September 1, 2021
Drug Name
Brand
or
Generic
Quantity Limit
Xpovio (40MG Once Weekly) (20MG Oral
Tablet Therapy Pack)B Maximum of 8 tablets per 28 days
Xpovio (40MG Once Weekly) (40MG Oral
Tablet Therapy Pack)B Maximum of 4 tablets per 28 days
Xpovio (40MG Twice Weekly) (20MG Oral
Tablet Therapy Pack)B Maximum of 16 tablets per 28 days
Xpovio (40MG Twice Weekly) (40MG Oral
Tablet Therapy Pack)B Maximum of 8 tablets per 28 days
Xpovio (60MG Once Weekly) (20MG Oral
Tablet Therapy Pack)B Maximum of 12 tablets per 28 days
Xpovio (60MG Once Weekly) (60MG 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) (20MG Oral
Tablet Therapy Pack)B Maximum of 16 tablets per 28 days
Xpovio (80MG Once Weekly) (40MG 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
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
Xultophy (Subcutaneous Solution Pen-
Injector)B
Maximum of 5 pens (15 ml) per 30
days
Xyrem (Oral Solution) B Maximum of 18 ml per day
Xywav (Oral Solution) B Maximum of 18 ml per day
YF-Vax (Subcutaneous Injectable) B1 vaccination dose (1 injection) per
day
Yupelri (Inhalation Solution) B Maximum of 1 vial (3 ml) per day
Zaleplon (10MG Oral Capsule) G Maximum of 2 capsules per day
Zaleplon (5MG Oral Capsule) G Maximum of 1 capsule per day
Zelboraf (Oral Tablet) B Maximum of 8 tablets per day
Zembrace SymTouch (Subcutaneous
Solution Auto-Injector)B
Maximum of 16 syringes (8 ml) per 30
days
Zenzedi (10MG Oral Tablet, 2.5MG Oral
Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)G Maximum of 6 tablets per day
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Drug Name
Brand
or
Generic
Quantity Limit
Zenzedi (15MG Oral Tablet, 20MG Oral
Tablet)G Maximum of 3 tablets per day
Zenzedi (30MG Oral Tablet) G Maximum of 2 tablets per day
Zepatier (Oral Tablet) B Maximum of 1 tablet per day
Zeposia 7-Day Starter Pack (Oral Capsule
Therapy Pack)B
Maximum of 1 pack (7 capsules) per
7 days
Zeposia (Oral Capsule) B Maximum of 1 capsule per day
Zeposia Starter Kit (Oral Capsule Therapy
Pack)B
Maximum of 1 pack (37 capsules) per
37 days
Zestoretic (10-12.5MG Oral Tablet) B Maximum of 1 tablet per day
Zestoretic (20-12.5MG Oral Tablet) B Maximum of 4 tablets per day
Zestoretic (20-25MG Oral Tablet) B Maximum of 2 tablets per day
Zestril (Oral Tablet) B Maximum of 2 tablets per day
Ziac (Oral Tablet) B Maximum of 2 tablets per day
Ziagen (Oral Solution) B Maximum of 32 ml per day
Ziagen (Oral Tablet) B Maximum of 2 tablets 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
Zocor (Oral Tablet) B Maximum of 1 tablet per day
Zolmitriptan (Oral Tablet) G Maximum of 12 tablets per 30 days
Zolmitriptan ODT (Oral Tablet Dispersible) G Maximum of 12 tablets per 30 days
Zolpidem Tartrate (Oral Tablet Immediate
Release)G Maximum of 1 tablet per day
Zomig (2.5MG Nasal Solution) B Maximum of 18 devices per 30 days
Zomig (5MG Nasal Solution) B Maximum of 12 devices per 30 days
Zomig (Oral Tablet) B Maximum of 12 tablets per 30 days
Zomig ZMT (Oral Tablet Dispersible) B Maximum of 12 tablets per 30 days
Zonalon (External Cream) B Maximum of 90 grams per 30 days
ZTlido (External Patch) B Maximum of 3 patches per day
Zubsolv (0.7-0.18MG Tablet Sublingual,
1.4-0.36MG Tablet Sublingual, 5.7-1.4MG
Tablet Sublingual)
B Maximum of 3 tablets per day
Zubsolv (11.4-2.9MG Tablet Sublingual) B Maximum of 1 tablet per day
Zubsolv (2.9-0.71MG Tablet Sublingual) B Maximum of 5 tablets per day
Zubsolv (8.6-2.1MG Tablet Sublingual) B Maximum of 2 tablets per day
Zypitamag (Oral Tablet) B Maximum of 1 tablet per day
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Drug Name
Brand
or
Generic
Quantity Limit
Zyprexa (10MG Oral Tablet, 15MG Oral
Tablet, 2.5MG Oral Tablet, 20MG Oral
Tablet, 5MG Oral Tablet, 7.5MG Oral
Tablet)
B Maximum of 1 tablet per day
Zyprexa Zydis (Oral Tablet Dispersible) B Maximum of 1 tablet per day
Required information
Benefits, drug list (formulary), pharmacy network and/or copayments/coinsurance may change
from time to time during each plan year. You will receive notice when necessary.
This information is available for free in other languages. Please call our Customer Service number
located on the cover.
UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws, and does
not discriminate on the basis of race, color, national origin, age, disability, or sex.
203
For more up-to-date information or if you have other questions, please call Customer Service at:
Toll-free 1-888-223-1092, TTY 7118 a.m. - 8 p.m. local time, Monday - Friday
www.UHCRetiree.com/soi
OVEX21PP4738358_010 Last updated September 1, 2021