2020 LIST OF COVERED DRUGS (FORMULARY)€¦ · H3113_190701_012345_C v01.06 Last updated June 1, 2020. . UnitedHealthcare Dual Complete® ONE (HMO D-SNP) 2020 . List of Covered Drugs

2020 LIST OF COVERED DRUGS (FORMULARY)

Prescription drug list information

UnitedHealthcare Dual Complete® ONE (HMO D-SNP)

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

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

www.UHCCommunityPlan.com

Formulary ID Number 00020047, Version 20 H3113_190701_012345_C v01.11

Last updated November 1, 2020


UnitedHealthcare Dual Complete® ONE (HMO D-SNP)

2020 List of Covered Drugs (Formulary)

IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Dual Complete ONE. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Dual Complete ONE. Key terms and their definitions appear in the last chapter of the Evidence of Coverage.

Our contact information, along with the date we last updated the Drug List, appears on the front and back cover pages.

Table of Contents

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

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

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of CoveredDrugs the �“Drug List” for short.)................................................................................................ 5

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

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

B4. Are there any restrictions or limits on drug coverage or any required actions to take to getcertain drugs?.............................................................................................................................. 7

B5. How will you know if the drug you want has limitations or if there are any actions requiredto get the drug?........................................................................................................................... 7

B6. What happens if we change our rules about how we cover some drugs (for example, priorauthorization (approval), quantity limits, and/or step therapy restrictions)?.......................... 8

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

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

B9. What if you are a new UnitedHealthcare Dual Complete ONE member and can’t find yourdrug on the Drug List or have a problem getting your drug?.................................................. 8

B10. Can you ask for an exception to cover your drug?...................................................................9

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

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

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

This section is continued on the next page.

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

B15. Does UnitedHealthcare Dual Complete ONE cover non-drug OTC products?................... 10

B16. Can you get a long-term supply of drugs?.............................................................................. 10

B17. What is your copay?..................................................................................................................11

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

C1. List of Drugs by Medical Condition......................................................................................... 12

C2. Covered drugs with a quantity limit (QL).................................................................................91

C3. Over-the-counter (OTC) Drug List.......................................................................................... 119

D. Index of Covered Drugs.....................................................................................................................152

If you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

information, visit www.UHCCommunityPlan.com.


A. Disclaimers

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

v Plans are insured through UnitedHealthcare Dual Complete® ONE (HMO D-SNP), a Medicare Advantage organization with a Medicare contract and a contract with the state Medicaid program. Enrollment in the plan depends on the plan’s contract renewal.

Members must use network plan providers, pharmacies, DME (Durable Medical Equipment) suppliers, and follow the rules on referrals. Members will be enrolled into Medicare Part D prescription drug coverage under the plan and will be automatically disenrolled from any other Medicare Advantage or Medicare Part D prescription drug coverage.

v The Drug List (formulary) may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary.

v You can always check UnitedHealthcare Dual Complete ONE’s up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com or by calling Customer Service toll-free at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.

v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free.

v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare Dual Complete ONE al 1-800-514-4911, TTY 711, de 8 a.m. a 8 p.m.: los 7 días de la semana, de octubre a marzo; de lunes a viernes, de abril a septiembre. La llamada es gratuita.

v You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.

v You can call Customer Service and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.

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B. Frequently Asked Questions (FAQ)

Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the Drug List that starts on page 12 are the drugs covered by UnitedHealthcare Dual Complete ONE. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

· UnitedHealthcare Dual Complete ONE will cover all medically necessary drugs on the Drug List if:

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

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

· UnitedHealthcare Dual Complete ONE may have additional steps to access certain drugs. See question B4 for more information.

You can also see an up-to-date list of drugs we cover on our website at www.UHCCommunityPlan.com or call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.

B2. Does the Drug List ever change?

Yes. UnitedHealthcare Dual Complete ONE may add or remove drugs on the Drug List during the year. We must follow Medicare rules in making these changes.

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

· Decide to require or not require prior authorization (approval) for a drug. (Prior authorization (approval) is permission from UnitedHealthcare Dual Complete ONE before you can get a drug.)

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

· Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:




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

· We learn that a drug is not safe, or

· A drug is removed from the market.

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

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

· You can also call Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept to check the current Drug List.

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

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

· A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

o We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.

o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.

· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

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

· We add a generic drug that is new to the market and

· Replace a brand name drug currently on the Drug List or

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

When these changes happen, we will:

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

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


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

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

· Whether to ask for an exception from these changes. To learn more about exceptions, see questions B10 - B12 for more information about exceptions.

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

Yes. Some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

· Prior authorization (approval): For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Dual Complete ONE before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Dual Complete ONE may not cover the drug if you don’t get authorization (approval).

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

· Step therapy: Sometimes UnitedHealthcare Dual Complete ONE requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 14 - 90. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception to these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug?

The Drug List on pages 14 - 90 has a column labeled “Necessary actions, restrictions, or limits on use.”




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B6. What happens if we change our rules about how we cover some drugs (for

example, prior authorization (approval), quantity limits, and/or step therapy

restrictions)?

In some cases, we will tell you in advance if we add or change prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

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

There are two ways to find a drug:

· You can search alphabetically (if you know how to spell the drug), or

· You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section that begins on page 152. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. To search by medical condition, find the section labeled “List of Drugs by Medical Condition” on page 12. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

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

If you don’t see your drug on the Drug List, call Customer Service at 1-800-514-4911, TTY 711 and ask about it. If you learn that UnitedHealthcare Dual Complete ONE will not cover the drug, you can do one of these things:

· Ask Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

· You can ask the health plan to make an exception to cover your drug. Please see questions B10 - B12 for more information about exceptions.

B9. What if you are a new UnitedHealthcare Dual Complete ONE member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Dual Complete ONE. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to ask for an exception.


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If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medication.

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

.

If

1-

in

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

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

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

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

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Dual Complete ONE member.

· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Dual Complete ONE.

If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a temporary 31-day supply of the drug you need. This will give you time to talk to your doctor or other prescriber about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions.

We will not pay for more of your drug after you get a temporary supply unless you receive authorization from the plan.

B10. Can you ask for an exception to cover your drug?

Yes. You can ask UnitedHealthcare Dual Complete ONE to make an exception to cover a drug that is not on the Drug List.

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

· For example, UnitedHealthcare Dual Complete ONE may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

· Other examples: You can ask us to drop step therapy restrictions or prior authorization (approval) requirements.

This section is continued on the next page

you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

formation, visit www.UHCCommunityPlan.com.

9

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

OTC stands for “over-the-counter.” UnitedHealthcare Dual Complete ONE offers some OTC drugs through the NJ FamilyCare (Medicaid) portion of the plan’s coverage at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List starting on page 119.

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

Yes. UnitedHealthcare Dual Complete ONE covers some non-drug OTC products when they are prescribed for you by your provider. These non-drug OTC products are listed in the Drug List.

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

Yes. UnitedHealthcare Dual Complete ONE offers two ways to get a long-term supply of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)

· Retail pharmacy. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider and Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs.

B11. How can you ask for an exception?

To ask for an exception, call Customer Service. A Customer Service representative will work with you and your provider to help you ask for an exception. You can also read Chapter 8 of the Evidence of Coverage to learn more about exceptions.

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

First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

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

· Mail-order. For certain kinds of drugs, you can use the plan’s network mail-order services. Our plan’s mail-order service allows you to get up to a 90-day supply. To get order forms


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

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

For more information about getting a long-term supply of drugs, call Customer Service at 1-800-514-4911, TTY 711.

I

I

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B17. What is your copay?

UnitedHealthcare Dual Complete ONE members have no copays for prescription and over-the-counter (OTC) drugs and non-drug products as long as the member follows the plan’s rules. See questions B14 and B15 for more information about OTC drugs and non-drug products.

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

· Tier 1 Generic drugs have $0 copay.

· Tier 1 Brand name drugs have $0 copay.

OTCs have $0 copay.

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

f you have questions, please call UnitedHealthcare Dual Complete ONE Customer Service at 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept. The call is free. For more

nformation, visit www.UHCCommunityPlan.com.

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C. Overview of the List of Covered Drugs

The List of Covered Drugs gives you information about the drugs covered by UnitedHealthcare Dual Complete ONE. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 152. The index alphabetically lists all drugs covered by UnitedHealthcare Dual Complete ONE.

C1. List of Drugs by Medical Condition

The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

The first column of the table lists the name of the drug. Generic drugs are listed in plain type (e.g., Simvastatin) and brand name drugs are in bold type (e.g., Humalog).

The second column lists the Medicare Part D drug tier. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier. As a member of this plan, you have no copays for

covered, prescribed drugs when obtained from network pharmacies.

The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Dual Complete ONE has any rules for covering your drug.

Coverage Rules and Limits

PA – Prior authorization (approval)

For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Dual Complete ONE before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Dual Complete ONE may not cover the drug if you don’t get authorization (approval).

QL – Quantity limits

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

ST – Step therapy

Sometimes UnitedHealthcare Dual Complete ONE requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

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2Other Special Coverage Rules

B/D – Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either the Medicare Part B (doctor and outpatient health care) or the Medicare Part D (prescription drugs) portion of the plan’s coverage. Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered.

LA – Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

MME – Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

7D – 7-Day limit

An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by 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.

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You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.

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A1

B1

C1Butalbital-Acetaminophen-Caffeine

C1Butalbital-Aspirin-Caffeine

B1

C1Celecoxib

C1Diclofenac Epolamine

C1Diclofenac Potassium

C1Diclofenac Sodium ER

C1Diclofenac Sodium

C1Diclofenac Sodium

C1Diflunisal

C1Etodolac ER

C1Etodolac

C1Etodolac

C1Flector

C1Flurbiprofen

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ibu

C1Ibuprofen

C1Ibuprofen

C1Indomethacin

C1Ketoprofen

C1Meloxicam

C1Nabumetone

C1Naproxen DR

C1Naproxen

C1Naproxen

C1Piroxicam

C1Sulindac

B1

C1Buprenorphine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Analgesics

Analgesics

Butalbital-Acetaminophen-Caffeine (Oral Tablet)

1 QL

Butalbital-Aspirin-Caffeine (Oral Capsule)

1 QL

Nonsteroidal Anti-inflammatory Drugs

Celecoxib (Oral Capsule)

1 QL

Diclofenac Epolamine (Transdermal Patch)

1 PA; QL

Diclofenac Potassium (Oral Tablet)

1

Diclofenac Sodium ER (Oral Tablet Extended Release 24 Hour)

1

Diclofenac Sodium (Oral Tablet Delayed Release)

1

Diclofenac Sodium (1% Transdermal Gel)

1

Diflunisal (Oral Tablet) 1

Etodolac ER (Oral Tablet Extended Release 24 Hour)

1

Etodolac (Oral Capsule)

1

Etodolac (Oral Tablet Immediate Release)

1

Flector (Transdermal

Patch)1 PA; QL

Flurbiprofen (100MG Oral Tablet)

1

Ibu (600MG Oral Tablet, 800MG Oral Tablet)

1

Ibuprofen (Oral Suspension)

1

Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet, 800MG Oral Tablet)

1

Indomethacin (25MG Oral Capsule Immediate Release, 50MG Oral Capsule Immediate Release)

1

Ketoprofen (Oral Capsule Immediate Release)

1

Meloxicam (Oral Tablet)

1

Nabumetone (Oral Tablet)

1

Naproxen DR (Oral Tablet Delayed Release) (Generic EC-Naprosyn)

1

Naproxen (Oral Suspension)

1

Naproxen (Oral Tablet Immediate Release)

1

Piroxicam (Oral Capsule)

1

Sulindac (Oral Tablet) 1

Opioid Analgesics, Long-acting

Buprenorphine (Transdermal Patch Weekly)

1 7D; DL; QL

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4

Bold type = Brand name drug Plain type = Generic drug

C1Fentanyl

C1Hydromorphone HCl ER

C1Hysingla ER

C1Levorphanol Tartrate

C1Methadone HCl

C1Methadone HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Morphine Sulfate ER

C1Morphine Sulfate ER

C1Nucynta ER

C1Tramadol HCl ER

C1Tramadol HCl ER

C1Xtampza ER

B1

C1Acetaminophen-Codeine

C1Acetaminophen-Codeine

C1Butorphanol Tartrate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

17D; MME;

DL; QL

Hydromorphone HCl ER (12MG Oral Tablet ER 24 Hour Abuse-Deterrent, 16MG Oral Tablet ER 24 Hour Abuse-Deterrent, 32MG Oral Tablet ER 24 Hour Abuse-Deterrent, 8MG Oral Tablet ER 24 Hour Abuse-Deterrent)

17D; MME;

DL; QL

Hysingla ER (Oral

Tablet ER 24 Hour

Abuse-Deterrent)

17D; MME;

DL; QL

Levorphanol Tartrate (Oral Tablet)

17D; MME;

DL; QL

Methadone HCl (Oral Solution)

17D; MME;

DL; QL

Methadone HCl (Oral Tablet)

17D; MME;

DL; QL

Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release, 30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)

17D; MME;

DL; QL

Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)

17D; MME;

DL; QL

Nucynta ER (Oral

Tablet Extended

Release 12 Hour)

17D; MME;

DL; QL

Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)

17D; MME;

DL; QL

Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)

17D; MME;

DL; QL

Xtampza ER (Oral

Capsule ER 12 Hour

Abuse-Deterrent)

17D; MME;

DL; QL

Opioid Analgesics, Short-acting

Acetaminophen-Codeine (120-12MG/ 5ML Oral Solution)

17D; MME;

DL; QL

Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)

17D; MME;

DL; QL

Butorphanol Tartrate (Nasal Solution)

17D; MME;

DL; QL

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C1Codeine Sulfate

C1Codeine Sulfate

C1Endocet

C1Fentanyl Citrate

C1Hydrocodone-Acetaminophen

C1Hydrocodone-Acetaminophen

C1Hydrocodone-Ibuprofen

C1Hydromorphone HCl

C1Hydromorphone HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Hydromorphone HCl Preservative Free

C1Morphine Sulfate

C1Morphine Sulfate

C1Oxycodone HCl

C1Oxycodone HCl

C1Oxycodone HCl

C1Oxycodone-Acetaminophen

C1Oxycodone-Aspirin

C1Tramadol HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Codeine Sulfate

(15MG Oral Tablet)1

7D; MME; DL; QL

Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet)

17D; MME;

DL; QL

Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

17D; MME;

DL; QL

Fentanyl Citrate (Buccal Lozenge On A Handle)

1 PA; DL; QL

Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)

17D; MME;

DL; QL

Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

17D; MME;

DL; QL

Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)

17D; MME;

DL; QL

Hydromorphone HCl (1MG/ML Oral Liquid)

17D; MME;

DL; QL

Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release, 8MG Oral Tablet Immediate Release)

17D; MME;

DL; QL

Hydromorphone HCl Preservative Free (10MG/ML Injection Solution, 50MG/5ML Injection Solution)

1 DL

Morphine Sulfate (Oral Solution)

17D; MME;

DL; QL

Morphine Sulfate

(Oral Tablet

Immediate Release)

17D; MME;

DL; QL

Oxycodone HCl (100MG/5ML Oral Concentrate)

17D; MME;

DL; QL

Oxycodone HCl (5MG/ 5ML Oral Solution)

17D; MME;

DL; QL

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)

17D; MME;

DL; QL

Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

17D; MME;

DL; QL

Oxycodone-Aspirin (Oral Tablet)

17D; MME;

DL; QL

Tramadol HCl (50MG Oral Tablet Immediate Release)

17D; MME;

DL; QL

tRACK16

6


C1Tramadol-Acetaminophen

C1Trezix

A1

B1

C1Lidocaine

C1Lidocaine

C1Lidocaine HCl

C1Lidocaine HCl

C1Lidocaine Viscous

C1Lidocaine-Prilocaine

A1

B1

C1Acamprosate Calcium

C1Disulfiram

C1Naltrexone HCl

C1Vivitrol

B1

C1Buprenorphine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Buprenorphine HCl-Naloxone HCl

C1Buprenorphine HCl-Naloxone HCl

C1Suboxone

B1

C1Naloxone HCl

C1Naloxone HCl

C1Naloxone HCl

C1Narcan

B1

C1Bupropion HCl SR

C1Chantix Continuing Month Pak

C1Chantix

C1Chantix Starting Month Pak

C1Nicotrol

C1Nicotrol NS

A1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Tramadol-Acetaminophen (Oral Tablet)

17D; MME;

DL; QL

Trezix (Oral Capsule) 17D; MME;

DL; QL

Anesthetics

Local Anesthetics

Lidocaine (5% External Ointment)

1 QL

Lidocaine (5% External Patch)

1 PA; QL

Lidocaine HCl (4% External Solution)

1

Lidocaine HCl (External Gel)

1

Lidocaine Viscous (2% Mouth/Throat Solution)

1

Lidocaine-Prilocaine (External Cream)

1

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

Acamprosate Calcium (Oral Tablet Delayed Release)

1

Disulfiram (Oral Tablet) 1

Naltrexone HCl (Oral Tablet)

1

Vivitrol (Intramuscular

Suspension

Reconstituted)

1

Opioid Dependence Treatments

Buprenorphine HCl (Tablet Sublingual)

1 QL

Buprenorphine HCl-Naloxone HCl (Sublingual Film)

1 QL

Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)

1 QL

Suboxone (Sublingual

Film)1 QL

Opioid Reversal Agents

Naloxone HCl (0.4MG/ ML Injection Solution)

1

Naloxone HCl (Injection Solution Cartridge)

1

Naloxone HCl (Injection Solution Prefilled Syringe)

1

Narcan (Nasal Liquid) 1

Smoking Cessation Agents

Bupropion HCl SR (150MG Oral Tablet Extended Release 12 Hour Smoking-Deterrent)

1

Chantix Continuing

Month Pak (Oral

Tablet)

1

Chantix (Oral Tablet) 1

Chantix Starting

Month Pak (Oral

Tablet)

1

Nicotrol (Inhalation

Inhaler)1

Nicotrol NS (Nasal

Solution)1

Antibacterials

tRACK 17

7


B1

C1Amikacin Sulfate

C1Gentak

C1Gentamicin Sulfate-0.9% Sodium Chloride

C1Gentamicin Sulfate




C1Neomycin Sulfate

C1Paromomycin Sulfate

C1Streptomycin Sulfate

C1Tobramycin

C1Tobramycin Sulfate

C1Tobrex

B1

C1Bacitracin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clindamycin HCl

C1Clindamycin Palmitate HCl

C1Clindamycin Phosphate in D5W

C1Clindamycin Phosphate


C1Colistimethate Sodium

C1Dalvance

C1Daptomycin

C1Daptomycin

C1Linezolid

C1Linezolid

C1Linezolid

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Aminoglycosides

Amikacin Sulfate (500MG/2ML Injection Solution)

1

Gentak (Ophthalmic Ointment)

1

Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous Solution)

1

Gentamicin Sulfate (External Cream)

1

Gentamicin Sulfate (External Ointment)

1

Gentamicin Sulfate (40MG/ML Injection Solution)

1

Gentamicin Sulfate (Ophthalmic Solution)

1

Neomycin Sulfate (Oral Tablet)

1

Paromomycin Sulfate (Oral Capsule)

1

Streptomycin Sulfate (Intramuscular Solution Reconstituted)

1

Tobramycin (Ophthalmic Solution)

1

Tobramycin Sulfate (10MG/ML Injection Solution, 80MG/2ML Injection Solution)

1

Tobrex (Ophthalmic

Ointment)1

Antibacterials, Other

Bacitracin (Ophthalmic Ointment)

1

Clindamycin HCl (Oral Capsule)

1

Clindamycin Palmitate HCl (Oral Solution Reconstituted)

1

Clindamycin Phosphate in D5W (Intravenous Solution)

1

Clindamycin Phosphate (300MG/ 2ML Injection Solution, 600MG/4ML Injection Solution, 900MG/6ML Injection Solution)

1

Clindamycin Phosphate (Vaginal Cream)

1

Colistimethate Sodium (CBA) (Injection Solution Reconstituted)

1

Dalvance (Intravenous

Solution

Reconstituted)

1 PA

Daptomycin (350MG

Intravenous Solution

Reconstituted)

1

Daptomycin (500MG Intravenous Solution Reconstituted)

1

Linezolid (Intravenous Solution)

1

Linezolid (Oral Suspension Reconstituted)

1

Linezolid (Oral Tablet) 1 QL

tRACK18

8


C1Methenamine Hippurate

C1Metronidazole

C1Metronidazole

C1Metronidazole

C1Metronidazole in NaCl 0.79%

C1Metronidazole

C1Metronidazole

C1Mupirocin Calcium

C1Mupirocin

C1Nitrofurantoin Macrocrystal

C1Nitrofurantoin Monohydrate

C1Nitrofurantoin

C1Polymyxin B Sulfate

C1Sulfamylon

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tigecycline

C1Tinidazole

C1Trimethoprim

C1Vancomycin HCl

C1Vancomycin HCl

C1Vancomycin HCl

C1Vandazole

B1

C1Cefaclor

C1Cefadroxil

C1Cefadroxil

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Methenamine Hippurate (Oral Tablet)

1

Metronidazole (0.75% External Cream)

1

Metronidazole (0.75% External Gel, 1% External Gel)

1

Metronidazole (0.75% External Lotion)

1

Metronidazole in NaCl 0.79% (Intravenous Solution)

1

Metronidazole (250MG Oral Tablet, 500MG Oral Tablet)

1

Metronidazole (0.75% Vaginal Gel)

1

Mupirocin Calcium (External Cream)

1

Mupirocin (External Ointment)

1

Nitrofurantoin Macrocrystal (100MG Oral Capsule, 50MG Oral Capsule) (Generic Macrodantin)

1

Nitrofurantoin Monohydrate (Generic Macrobid)

1

Nitrofurantoin (Oral Suspension)

1

Polymyxin B Sulfate (Injection Solution Reconstituted)

1

Sulfamylon (External

Cream)1

Tigecycline (Intravenous Solution Reconstituted)

1

Tinidazole (Oral Tablet) 1

Trimethoprim (Oral Tablet)

1

Vancomycin HCl (10GM Intravenous Solution Reconstituted, 1GM Intravenous Solution Reconstituted, 500MG Intravenous Solution Reconstituted, 750MG Intravenous Solution Reconstituted)

1

Vancomycin HCl

(250MG Intravenous

Solution

Reconstituted)

1

Vancomycin HCl (Oral Capsule)

1 QL

Vandazole (Vaginal

Gel)1

Beta-lactam, Cephalosporins

Cefaclor (Oral Capsule)

1

Cefadroxil (Oral Capsule)

1

Cefadroxil (Oral Suspension Reconstituted)

1

tRACK 19

9


C1Cefazolin Sodium

C1Cefdinir

C1Cefdinir

C1Cefepime HCl

C1Cefixime

C1Cefixime

C1Cefotetan Disodium

C1Cefoxitin Sodium

C1Cefoxitin Sodium

C1Cefpodoxime Proxetil

C1Cefpodoxime Proxetil

C1Cefprozil

C1Cefprozil

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ceftazidime

C1Ceftriaxone Sodium

C1Ceftriaxone Sodium

C1Cefuroxime Axetil

C1Cefuroxime Sodium

C1Cefuroxime Sodium

C1Cephalexin

C1Cephalexin

C1Suprax

C1Suprax

C1Suprax

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Cefazolin Sodium (10GM Injection Solution Reconstituted, 1GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

1

Cefdinir (Oral Capsule) 1

Cefdinir (Oral Suspension Reconstituted)

1

Cefepime HCl (Injection Solution Reconstituted)

1

Cefixime (Oral Capsule)

1

Cefixime (Oral Suspension Reconstituted)

1

Cefotetan Disodium (Injection Solution Reconstituted)

1

Cefoxitin Sodium (Injection Solution Reconstituted)

1

Cefoxitin Sodium (Intravenous Solution Reconstituted)

1

Cefpodoxime Proxetil (Oral Suspension Reconstituted)

1

Cefpodoxime Proxetil (Oral Tablet)

1

Cefprozil (Oral Suspension Reconstituted)

1

Cefprozil (Oral Tablet) 1

Ceftazidime (Injection Solution Reconstituted)

1

Ceftriaxone Sodium (1GM Injection Solution Reconstituted, 250MG Injection Solution Reconstituted, 2GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

1

Ceftriaxone Sodium (10GM Intravenous Solution Reconstituted)

1

Cefuroxime Axetil (Oral Tablet)

1

Cefuroxime Sodium (Injection Solution Reconstituted)

1

Cefuroxime Sodium (Intravenous Solution Reconstituted)

1

Cephalexin (Oral Capsule)

1

Cephalexin (Oral Suspension Reconstituted)

1

Suprax (Oral Capsule) 1

Suprax (500MG/5ML

Oral Suspension

Reconstituted)

1

Suprax (Oral Tablet Chewable)

1

tRACK20

10


C1Tazicef

C1Zerbaxa

B1

C1Aztreonam

C1Ertapenem Sodium

C1Imipenem-Cilastatin

C1Meropenem

B1

C1Amoxicillin

C1Amoxicillin

C1Amoxicillin

C1Amoxicillin

C1Amoxicillin-Potassium Clavulanate ER

C1Amoxicillin-Potassium Clavulanate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Amoxicillin-Potassium Clavulanate

C1Amoxicillin-Potassium Clavulanate

C1Ampicillin

C1Ampicillin Sodium

C1Ampicillin Sodium

C1Ampicillin-Sulbactam Sodium

C1Ampicillin-Sulbactam Sodium

C1Bicillin C-R 900/300

C1Bicillin C-R

C1Bicillin L-A

C1Dicloxacillin Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Tazicef (Injection Solution Reconstituted)

1

Zerbaxa (Intravenous

Solution

Reconstituted)

1 PA

Beta-lactam, Other

Aztreonam (1GM Injection Solution Reconstituted)

1

Ertapenem Sodium (Injection Solution Reconstituted)

1

Imipenem-Cilastatin (Intravenous Solution Reconstituted)

1

Meropenem (Intravenous Solution Reconstituted)

1

Beta-lactam, Penicillins

Amoxicillin (Oral Capsule)

1

Amoxicillin (Oral Suspension Reconstituted)

1

Amoxicillin (Oral Tablet Immediate Release)

1

Amoxicillin (Oral Tablet Chewable)

1

Amoxicillin-Potassium Clavulanate ER (Oral Tablet Extended Release 12 Hour)

1

Amoxicillin-Potassium Clavulanate (Oral Suspension Reconstituted)

1

Amoxicillin-Potassium Clavulanate (Oral Tablet Immediate Release)

1

Amoxicillin-Potassium Clavulanate (Oral Tablet Chewable)

1

Ampicillin (Oral Capsule)

1

Ampicillin Sodium (125MG Injection Solution Reconstituted, 1GM Injection Solution Reconstituted)

1

Ampicillin Sodium (10GM Intravenous Solution Reconstituted)

1

Ampicillin-Sulbactam Sodium (Injection Solution Reconstituted)

1

Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous Solution Reconstituted)

1

Bicillin C-R 900/300

(Intramuscular

Suspension)

1

Bicillin C-R

(Intramuscular

Suspension)

1

Bicillin L-A

(Intramuscular

Suspension)

1

Dicloxacillin Sodium (Oral Capsule)

1

tRACK 21

11


C1Nafcillin Sodium

C1Nafcillin Sodium

C1Oxacillin Sodium in Dextrose

C1Oxacillin Sodium

C1Oxacillin Sodium

C1Penicillin G Potassium

C1Penicillin G Procaine

C1Penicillin G Sodium

C1Penicillin V Potassium

C1Penicillin V Potassium

C1Piperacillin-Tazobactam

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Azasite

C1Azithromycin

C1Azithromycin

C1Azithromycin

C1Clarithromycin ER

C1Clarithromycin

C1Clarithromycin

C1Dificid

C1E.E.S. Granules

C1Erythrocin Lactobionate

C1Erythromycin Base

C1Erythromycin Base

C1Erythromycin Base

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nafcillin Sodium (1GM Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)

1

Nafcillin Sodium (10GM Intravenous Solution Reconstituted)

1

Oxacillin Sodium in

Dextrose (Intravenous

Solution)

1

Oxacillin Sodium (Injection Solution Reconstituted)

1

Oxacillin Sodium (Intravenous Solution Reconstituted)

1

Penicillin G Potassium (20000000UNIT Injection Solution Reconstituted)

1

Penicillin G Procaine (Intramuscular Suspension)

1

Penicillin G Sodium (Injection Solution Reconstituted)

1

Penicillin V Potassium (Oral Solution Reconstituted)

1

Penicillin V Potassium (Oral Tablet)

1

Piperacillin-Tazobactam (Intravenous Solution Reconstituted)

1

Macrolides

Azasite (Ophthalmic

Solution)1

Azithromycin (Intravenous Solution Reconstituted)

1

Azithromycin (Oral Suspension Reconstituted)

1

Azithromycin (Oral Tablet)

1

Clarithromycin ER (Oral Tablet Extended Release 24 Hour)

1

Clarithromycin (Oral Suspension Reconstituted)

1

Clarithromycin (Oral Tablet Immediate Release)

1

Dificid (Oral Tablet) 1

E.E.S. Granules (Oral

Suspension

Reconstituted)

1

Erythrocin Lactobionate (Intravenous Solution Reconstituted)

1

Erythromycin Base (Oral Capsule Delayed Release Particles)

1

Erythromycin Base (Oral Tablet Immediate Release)

1

Erythromycin Base (Oral Tablet Delayed Release)

1

tRACK22

12


C1Erythromycin Ethylsuccinate

C1Erythromycin Ethylsuccinate

C1Erythromycin

B1

C1Besivance

C1Ciloxan

C1Ciprofloxacin HCl

C1Ciprofloxacin HCl

C1Ciprofloxacin HCl

C1Ciprofloxacin in D5W

C1Gatifloxacin

C1Levofloxacin in D5W

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Levofloxacin

C1Levofloxacin

C1Levofloxacin

C1Levofloxacin

C1Moxifloxacin HCl in NaCl

C1Moxifloxacin HCl

C1Moxifloxacin HCl

C1Ofloxacin

C1Ofloxacin

C1Ofloxacin

B1

C1Silver Sulfadiazine

C1SSD

C1Sulfacetamide Sodium

C1Sulfacetamide Sodium

C1Sulfadiazine

C1Sulfamethoxazole-Trimethoprim

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Erythromycin Ethylsuccinate (200MG/5ML Oral Suspension Reconstituted)

1

Erythromycin Ethylsuccinate (Oral Tablet)

1

Erythromycin (Ophthalmic Ointment)

1

Quinolones

Besivance

(Ophthalmic

Suspension)

1

Ciloxan (Ophthalmic

Ointment)1

Ciprofloxacin HCl (Ophthalmic Solution)

1

Ciprofloxacin HCl (100MG Oral Tablet Immediate Release)

1

Ciprofloxacin HCl (250MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 750MG Oral Tablet Immediate Release)

1

Ciprofloxacin in D5W (200MG/100ML Intravenous Solution)

1

Gatifloxacin (Ophthalmic Solution)

1

Levofloxacin in D5W (500MG/100ML Intravenous Solution, 750MG/150ML Intravenous Solution)

1

Levofloxacin (25MG/ ML Intravenous Solution)

1

Levofloxacin (0.5% Ophthalmic Solution)

1

Levofloxacin (25MG/ ML Oral Solution)

1

Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet, 750MG Oral Tablet)

1

Moxifloxacin HCl in NaCl (Intravenous Solution)

1

Moxifloxacin HCl (Ophthalmic Solution) (Generic Vigamox)

1

Moxifloxacin HCl (Oral Tablet)

1

Ofloxacin (Ophthalmic Solution)

1

Ofloxacin (Oral Tablet) 1

Ofloxacin (Otic Solution)

1

Sulfonamides

Silver Sulfadiazine (External Cream)

1

SSD (External Cream) 1

Sulfacetamide Sodium (Ophthalmic Ointment)

1

Sulfacetamide Sodium (Ophthalmic Solution)

1

Sulfadiazine (Oral Tablet)

1

Sulfamethoxazole-Trimethoprim (Oral Suspension)

1

tRACK 23

13


C1Sulfamethoxazole-Trimethoprim

B1

C1Demeclocycline HCl

C1Doxy 100

C1Doxycycline Hyclate

C1Doxycycline Hyclate

C1Doxycycline Monohydrate



C1Minocycline HCl

C1Minocycline HCl

C1Tetracycline HCl

C1Vibramycin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useA1

B1

C1BRIVIACT

C1BRIVIACT

C1Epidiolex

C1Fintepla

C1Levetiracetam ER

C1Levetiracetam

C1Levetiracetam

C1Nayzilam

C1Roweepra

C1Roweepra XR

C1Spritam ODT

C1Xcopri

C1Xcopri

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Sulfamethoxazole-Trimethoprim (Oral Tablet)

1

Tetracyclines

Demeclocycline HCl (Oral Tablet)

1

Doxy 100 (Intravenous Solution Reconstituted)

1

Doxycycline Hyclate (Oral Capsule)

1

Doxycycline Hyclate (100MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release)

1

Doxycycline Monohydrate (100MG Oral Capsule, 50MG Oral Capsule)

1

Doxycycline Monohydrate (Oral Suspension Reconstituted)

1

Doxycycline Monohydrate (100MG Oral Tablet, 50MG Oral Tablet, 75MG Oral Tablet)

1

Minocycline HCl (Oral Capsule)

1

Minocycline HCl (Oral Tablet Immediate Release)

1

Tetracycline HCl (Oral Capsule)

1

Vibramycin (50MG/

5ML Oral Syrup)1

Anticonvulsants

Anticonvulsants, Other

BRIVIACT (Oral

Solution)1 PA; QL

BRIVIACT (Oral

Tablet)1 PA; QL

Epidiolex (Oral

Solution)1 PA

Fintepla (Oral

Solution)1 PA; QL

Levetiracetam ER (Oral Tablet Extended Release 24 Hour)

1

Levetiracetam (Oral Solution)

1

Levetiracetam (Oral Tablet Immediate Release)

1

Nayzilam (Nasal

Solution)1

Roweepra (Oral Tablet Immediate Release)

1

Roweepra XR (Oral Tablet Extended Release 24 Hour)

1

Spritam ODT (Oral

Tablet Disintegrating

Soluble)

1

Xcopri (250MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Xcopri (350MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

tRACK24

14


C1Xcopri

C1Xcopri

C1Xcopri

C1Xcopri

B1

C1Celontin

C1Ethosuximide

C1Ethosuximide

C1Zonisamide

B1

C1Clobazam

C1Clobazam

C1Clobazam

C1Diastat AcuDial

C1Diastat Pediatric

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Diazepam

C1Gabapentin

C1Gabapentin

C1Gabapentin

C1Phenobarbital

C1Phenobarbital

C1Primidone

C1Sympazan

C1Tiagabine HCl

C1Valproic Acid

C1Valproic Acid

C1Valtoco 10 MG Dose



C1Valtoco 5 MG Dose

C1Vigabatrin

C1Vigabatrin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Xcopri (100MG Oral

Tablet, 150MG Oral

Tablet, 50MG Oral

Tablet)

1 PA; QL

Xcopri (200MG Oral

Tablet)1 PA; QL

Xcopri (14x12.5MG &

14x25MG Oral Tablet

Therapy Pack)

1 PA; QL

Xcopri (14x150MG &

14x200MG Oral

Tablet Therapy Pack,

14x50MG &

14x100MG Oral

Tablet Therapy Pack)

1 PA; QL

Calcium Channel Modifying Agents

Celontin (Oral

Capsule)1

Ethosuximide (Oral Capsule)

1

Ethosuximide (Oral Solution)

1

Zonisamide (Oral Capsule)

1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

Clobazam (2.5MG/ML Oral Suspension)

1 PA; QL

Clobazam (10MG Oral Tablet)

1 PA; QL

Clobazam (20MG Oral Tablet)

1 PA; QL

Diastat AcuDial

(Rectal Gel)1

Diastat Pediatric

(Rectal Gel)1

Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG Rectal Gel)

1

Gabapentin (Oral Capsule)

1

Gabapentin (250MG/ 5ML Oral Solution)

1

Gabapentin (Oral Tablet)

1

Phenobarbital (Oral Elixir)

1

Phenobarbital (Oral Tablet)

1

Primidone (Oral Tablet) 1

Sympazan (Oral Film) 1 PA; QL

Tiagabine HCl (Oral Tablet)

1

Valproic Acid (Oral Capsule)

1

Valproic Acid (Oral Solution)

1

Valtoco 10 MG Dose

(Nasal Liquid)1 QL

Valtoco 15 MG Dose

(Nasal Liquid Therapy

Pack)

1 QL

Valtoco 20 MG Dose

(Nasal Liquid Therapy

Pack)

1 QL

Valtoco 5 MG Dose

(Nasal Liquid)1 QL

Vigabatrin (Oral Packet)

1 PA; LA; QL

Vigabatrin (Oral Tablet) 1 PA; LA; QL

tRACK 25

15


C1Vigadrone

B1

C1Felbamate

C1Felbamate

C1Fycompa

C1Fycompa

C1Lamotrigine

C1Lamotrigine

C1Topiramate

C1Topiramate

B1

C1Aptiom

C1Banzel

C1Banzel

C1Carbamazepine ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Carbamazepine ER

C1Carbamazepine

C1Carbamazepine

C1Carbamazepine

C1Dilantin INFATABS

C1Dilantin

C1Epitol

C1Oxcarbazepine

C1Oxcarbazepine

C1Peganone

C1Phenytek

C1Phenytoin

C1Phenytoin

C1Phenytoin Sodium Extended

C1Vimpat

C1Vimpat

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Vigadrone (Oral Packet)

1 PA; LA; QL

Glutamate Reducing Agents

Felbamate (Oral Suspension)

1

Felbamate (Oral Tablet)

1

Fycompa (Oral

Suspension)1

Fycompa (Oral Tablet) 1

Lamotrigine (100MG Oral Tablet Immediate Release, 150MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral Tablet Immediate Release)

1

Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral Tablet Chewable)

1

Topiramate (Oral Capsule Sprinkle Immediate Release)

1

Topiramate (Oral Tablet)

1

Sodium Channel Agents

Aptiom (Oral Tablet) 1 QL

Banzel (Oral

Suspension)1

Banzel (Oral Tablet) 1

Carbamazepine ER (Oral Capsule Extended Release 12 Hour)

1

Carbamazepine ER (Oral Tablet Extended Release 12 Hour)

1

Carbamazepine (Oral Suspension)

1

Carbamazepine (Oral Tablet Immediate Release)

1

Carbamazepine (Oral Tablet Chewable)

1

Dilantin INFATABS (Oral Tablet Chewable)

1

Dilantin (Oral Capsule) 1

Epitol (Oral Tablet) 1

Oxcarbazepine (300MG/5ML Oral Suspension)

1

Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet, 600MG Oral Tablet)

1

Peganone (Oral

Tablet)1

Phenytek (Oral Capsule)

1

Phenytoin (125MG/ 5ML Oral Suspension)

1

Phenytoin (Oral Tablet Chewable)

1

Phenytoin Sodium Extended (Oral Capsule)

1

Vimpat (Oral Solution) 1 QL

Vimpat (Oral Tablet) 1 QL

Antidementia Agents

Cholinesterase Inhibitors

tRACK26

16


C1Donepezil HCl

C1Donepezil HCl ODT

C1Galantamine Hydrobromide ER

C1Galantamine Hydrobromide

C1Galantamine Hydrobromide

C1Rivastigmine Tartrate

C1Rivastigmine

B1

C1Memantine HCl ER

C1Memantine HCl

C1Memantine HCl

C1Memantine HCl Titration Pak

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Bupropion HCl SR

C1Bupropion HCl XL

C1Bupropion HCl

C1Mirtazapine

C1Mirtazapine ODT

B1

C1Emsam

C1Marplan

C1Phenelzine Sulfate

C1Tranylcypromine Sulfate

B1

C1Citalopram Hydrobromide

C1Citalopram Hydrobromide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Donepezil HCl (Oral Tablet)

1 QL

Donepezil HCl ODT (Oral Tablet Dispersible)

1 QL

Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)

1 QL

Galantamine Hydrobromide (Oral Solution)

1 QL

Galantamine Hydrobromide (Oral Tablet)

1 QL

Rivastigmine Tartrate (Oral Capsule)

1 QL

Rivastigmine (Transdermal Patch 24 Hour)

1 ST; QL

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

Memantine HCl ER (Oral Capsule Extended Release 24 Hour)

1 PA; QL

Memantine HCl (2MG/ ML Oral Solution)

1 PA; QL

Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet)

1 PA; QL

Memantine HCl

Titration Pak (Oral

Tablet)

1 PA

Antidepressants

Antidepressants, Other

Bupropion HCl SR (Oral Tablet Extended Release 12 Hour)

1

Bupropion HCl XL (150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour)

1

Bupropion HCl (Oral Tablet Immediate Release)

1

Mirtazapine (Oral Tablet)

1

Mirtazapine ODT (Oral Tablet Dispersible)

1

Monoamine Oxidase Inhibitors

Emsam (Transdermal

Patch 24 Hour)1 QL

Marplan (Oral Tablet) 1

Phenelzine Sulfate (Oral Tablet)

1

Tranylcypromine Sulfate (Oral Tablet)

1

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

Citalopram Hydrobromide (Oral Solution)

1

Citalopram Hydrobromide (Oral Tablet)

1

tRACK 27

17


C1Desvenlafaxine Succinate ER

C1Escitalopram Oxalate

C1Escitalopram Oxalate

C1Fetzima

C1Fetzima Titration

C1Fluoxetine HCl

C1Fluoxetine HCl

C1Fluoxetine HCl

C1Fluvoxamine Maleate

C1Maprotiline HCl

C1Nefazodone HCl

C1Paroxetine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Paxil

C1Sertraline HCl

C1Sertraline HCl

C1Trazodone HCl

C1Trazodone HCl

C1Trintellix

C1Venlafaxine HCl ER

C1Venlafaxine HCl

C1Viibryd

C1Viibryd Starter Pack

B1

C1Amitriptyline HCl

C1Amoxapine

C1Clomipramine HCl

C1Desipramine HCl

C1Doxepin HCl

C1Doxepin HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Desvenlafaxine Succinate ER (Oral Tablet Extended Release 24 Hour) (Generic Pristiq)

1 QL

Escitalopram Oxalate (Oral Solution)

1

Escitalopram Oxalate (Oral Tablet)

1

Fetzima (Oral Capsule

Extended Release 24

Hour)

1 ST; QL

Fetzima Titration

(Oral Capsule ER 24

Hour Therapy Pack)

1 ST

Fluoxetine HCl (10MG Oral Capsule Immediate Release, 20MG Oral Capsule Immediate Release, 40MG Oral Capsule Immediate Release)

1

Fluoxetine HCl (90MG Oral Capsule Delayed Release)

1

Fluoxetine HCl (20MG/ 5ML Oral Solution)

1

Fluvoxamine Maleate (Oral Tablet)

1

Maprotiline HCl (Oral Tablet)

1

Nefazodone HCl (Oral Tablet)

1

Paroxetine HCl (Oral Tablet Immediate Release)

1

Paxil (Oral

Suspension)1

Sertraline HCl (Oral Concentrate)

1

Sertraline HCl (Oral Tablet)

1

Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet, 50MG Oral Tablet)

1

Trazodone HCl (300MG Oral Tablet)

1

Trintellix (Oral Tablet) 1 QL

Venlafaxine HCl ER (Oral Capsule Extended Release 24 Hour)

1

Venlafaxine HCl (Oral Tablet Immediate Release)

1

Viibryd (Oral Tablet) 1 QL

Viibryd Starter Pack

(Oral Kit)1 QL

Tricyclics

Amitriptyline HCl (Oral Tablet)

1

Amoxapine (Oral Tablet)

1

Clomipramine HCl (Oral Capsule)

1

Desipramine HCl (Oral Tablet)

1

Doxepin HCl (Oral Capsule)

1

Doxepin HCl (Oral Concentrate)

1

tRACK28

18


C1Imipramine HCl

C1Imipramine Pamoate

C1Nortriptyline HCl

C1Nortriptyline HCl

C1Protriptyline HCl

C1Trimipramine Maleate

A1

B1

C1Compro

C1Hydroxyzine Pamoate

C1Meclizine HCl

C1Metoclopramide HCl

C1Metoclopramide HCl

C1Perphenazine

C1Prochlorperazine Maleate

C1Prochlorperazine

C1Scopolamine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Transderm-Scop

B1

C1Aprepitant

C1Dronabinol

C1Granisetron HCl

C1Ondansetron HCl

C1Ondansetron HCl

C1Ondansetron ODT

C1Sancuso

A1

B1

C1Abelcet

C1AmBisome

C1Amphotericin B

C1Ciclopirox

C1Ciclopirox

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Imipramine HCl (Oral Tablet)

1

Imipramine Pamoate (Oral Capsule)

1

Nortriptyline HCl (Oral Capsule)

1

Nortriptyline HCl (Oral Solution)

1

Protriptyline HCl (Oral Tablet)

1

Trimipramine Maleate (Oral Capsule)

1

Antiemetics

Antiemetics, Other

Compro (Rectal Suppository)

1

Hydroxyzine Pamoate (Oral Capsule)

1

Meclizine HCl (Oral Tablet)

1

Metoclopramide HCl (10MG/10ML Oral Solution)

1

Metoclopramide HCl (Oral Tablet)

1

Perphenazine (Oral Tablet)

1

Prochlorperazine Maleate (Oral Tablet)

1

Prochlorperazine (Rectal Suppository)

1

Scopolamine (Transdermal Patch 72 Hour)

1

Transderm-Scop

(1.5MG) (Transdermal

Patch 72 Hour)

1

Emetogenic Therapy Adjuncts

Aprepitant (Oral Therapy Pack, Oral Capsule)

1 PA

Dronabinol (Oral Capsule)

1 PA

Granisetron HCl (Oral Tablet)

1 B/D, PA; QL

Ondansetron HCl (Oral Solution)

1 B/D, PA

Ondansetron HCl (Oral Tablet)

1 B/D, PA

Ondansetron ODT (Oral Tablet Dispersible)

1 B/D, PA

Sancuso

(Transdermal Patch)1

Antifungals

Antifungals

Abelcet (Intravenous

Suspension)1 B/D, PA

AmBisome

(Intravenous

Suspension

Reconstituted)

1 B/D, PA

Amphotericin B (Intravenous Solution Reconstituted)

1 B/D, PA

Ciclopirox (External Gel)

1

Ciclopirox (External Shampoo)

1

tRACK 29

19


C1Ciclopirox

C1Ciclopirox Olamine

C1Ciclopirox Olamine

C1Clotrimazole

C1Clotrimazole

C1Clotrimazole

C1Econazole Nitrate

C1Eraxis

C1Eraxis

C1Fluconazole in Sodium Chloride

C1Fluconazole

C1Fluconazole

C1Flucytosine

C1Griseofulvin Microsize

C1Griseofulvin Microsize

C1Griseofulvin Ultramicrosize

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Itraconazole

C1Itraconazole

C1Jublia

C1Ketoconazole

C1Ketoconazole

C1Ketoconazole

C1Mentax

C1Micafungin Sodium

C1Miconazole 3

C1Mycamine

C1Naftifine HCl

C1Naftin

C1Natacyn

C1Noxafil

C1Noxafil

C1Nyamyc

C1Nystatin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Ciclopirox (External Solution)

1

Ciclopirox Olamine (External Cream)

1

Ciclopirox Olamine (External Suspension)

1

Clotrimazole (External Cream)

1

Clotrimazole (External Solution)

1

Clotrimazole (Mouth/ Throat Troche)

1

Econazole Nitrate (External Cream)

1 QL

Eraxis (100MG


Reconstituted)

1

Eraxis (50MG


Reconstituted)

1

Fluconazole in Sodium Chloride (Intravenous Solution)

1

Fluconazole (Oral Suspension Reconstituted)

1

Fluconazole (Oral Tablet)

1

Flucytosine (Oral Capsule)

1

Griseofulvin Microsize (Oral Suspension)

1

Griseofulvin Microsize (Oral Tablet)

1

Griseofulvin Ultramicrosize (Oral Tablet)

1

Itraconazole (Oral Capsule)

1 PA; QL

Itraconazole (Oral Solution)

1 PA

Jublia (External

Solution)1

Ketoconazole (External Cream)

1 QL

Ketoconazole (External Shampoo)

1

Ketoconazole (Oral Tablet)

1

Mentax (External

Cream)1

Micafungin Sodium (Intravenous Solution Reconstituted)

1

Miconazole 3 (Vaginal Suppository)

1

Mycamine

(Intravenous Solution

Reconstituted)

1

Naftifine HCl (External Cream)

1

Naftin (External Gel) 1

Natacyn (Ophthalmic

Suspension)1

Noxafil (Oral

Suspension)1 QL

Noxafil (Oral Tablet

Delayed Release)1 PA; QL

Nyamyc (External Powder)

1

Nystatin (External Cream)

1

tRACK30

20


C1Nystatin

C1Nystatin

C1Nystatin

C1Nystatin

C1Nystop

C1Posaconazole

C1Terbinafine HCl

C1Terconazole

C1Terconazole

C1Voriconazole

C1Voriconazole

C1Voriconazole

A1

B1

C1Allopurinol

C1Colchicine

C1Colchicine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Colcrys

C1Febuxostat

C1Probenecid

C1Probenecid-Colchicine

A1

B1

C1Dihydroergotamine Mesylate

C1Ergotamine-Caffeine

C1Migergot

B1

C1Aimovig

C1Emgality

C1Emgality

C1Emgality

C1Timolol Maleate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nystatin (External Ointment)

1

Nystatin (External Powder)

1

Nystatin (Mouth/Throat Suspension)

1

Nystatin (Oral Tablet) 1

Nystop (External Powder)

1

Posaconazole (Oral Tablet Delayed Release)

1 PA; QL

Terbinafine HCl (Oral Tablet)

1

Terconazole (Vaginal Cream)

1

Terconazole (Vaginal Suppository)

1

Voriconazole (Intravenous Solution Reconstituted)

1

Voriconazole (Oral Suspension Reconstituted)

1

Voriconazole (Oral Tablet)

1

Antigout Agents

Antigout Agents

Allopurinol (Oral Tablet)

1

Colchicine (0.6MG

Oral Capsule) (Brand

Equivalent Mitigare)

1 QL

Colchicine (0.6MG Oral Tablet) (Generic Colcrys)

1 QL

Colcrys (Oral Tablet) 1 QL

Febuxostat (Oral Tablet)

1 ST

Probenecid (Oral Tablet)

1

Probenecid-Colchicine (Oral Tablet)

1

Antimigraine Agents

Ergot Alkaloids

Dihydroergotamine Mesylate (Nasal Solution)

1

Ergotamine-Caffeine (Oral Tablet)

1

Migergot (Rectal Suppository)

1

Prophylactic

Aimovig

(Subcutaneous

Solution Auto-

Injector)

1 PA; QL

Emgality (300MG

Dose) (100MG/ML

Subcutaneous

Solution Prefilled

Syringe)

1 PA; QL

Emgality

(Subcutaneous

Solution Auto-

Injector)

1 PA; QL

Emgality (120MG/ML

Subcutaneous

Solution Prefilled

Syringe)

1 PA; QL

Timolol Maleate (Oral Tablet)

1

tRACK 31

21


B1

C1Naratriptan HCl

C1Rizatriptan Benzoate

C1Rizatriptan Benzoate ODT

C1Sumatriptan

C1Sumatriptan Succinate

C1Sumatriptan Succinate Refill





Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useA1

B1

C1Guanidine HCl

C1Pyridostigmine Bromide ER

C1Pyridostigmine Bromide

C1Pyridostigmine Bromide

A1

B1

C1Dapsone

C1Rifabutin

B1

C1Ethambutol HCl

C1Isoniazid

C1Isoniazid

C1Paser

C1Priftin

C1Pyrazinamide

C1Rifampin

C1Rifampin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Serotonin (5-HT) 1b/1d Receptor Agonists

Naratriptan HCl (Oral Tablet)

1 QL

Rizatriptan Benzoate (Oral Tablet)

1 QL

Rizatriptan Benzoate ODT (Oral Tablet Dispersible)

1 QL

Sumatriptan (Nasal Solution)

1 QL

Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

1 QL

Sumatriptan

Succinate Refill

(Subcutaneous

Solution Cartridge)

1 QL

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)

1 QL

Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/ 0.5ML Subcutaneous Solution Auto-Injector)

1 QL

Sumatriptan

Succinate (6MG/

0.5ML Subcutaneous

Solution Auto-

Injector) (Generic

Imitrex STATdose)

1 QL

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)

1 QL

Antimyasthenic Agents

Parasympathomimetics

Guanidine HCl (Oral

Tablet)1

Pyridostigmine Bromide ER (Oral Tablet Extended Release)

1

Pyridostigmine Bromide (Oral Solution)

1

Pyridostigmine Bromide (60MG Oral Tablet Immediate Release)

1

Antimycobacterials

Antimycobacterials, Other

Dapsone (Oral Tablet) 1

Rifabutin (Oral Capsule)

1

Antituberculars

Ethambutol HCl (Oral Tablet)

1

Isoniazid (Oral Syrup) 1

Isoniazid (Oral Tablet) 1

Paser (Oral Packet) 1

Priftin (Oral Tablet) 1

Pyrazinamide (Oral Tablet)

1

Rifampin (600MG Intravenous Solution Reconstituted)

1

Rifampin (150MG Oral Capsule, 300MG Oral Capsule)

1

tRACK32

22


C1Sirturo

C1Trecator

A1

B1

C1Cyclophosphamide

C1Gleostine

C1Gleostine

C1Leukeran

C1Matulane

C1Valchlor

B1

C1Abiraterone Acetate

C1Bicalutamide

C1Erleada

C1Flutamide

C1Nilutamide

C1Nubeqa

C1Xtandi

B1

C1Pomalyst

C1Revlimid

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tabrecta

C1Thalomid

B1

C1Emcyt

C1Soltamox

C1Tamoxifen Citrate

C1Toremifene Citrate

B1

C1Droxia

C1Hydroxyurea

C1Mercaptopurine

C1Purixan

C1Tabloid

B1

C1Xpovio

C1Xpovio

C1Xpovio

C1Xpovio

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Sirturo (Oral Tablet) 1 PA; LA

Trecator (Oral Tablet) 1

Antineoplastics

Alkylating Agents

Cyclophosphamide (Oral Capsule)

1 B/D, PA

Gleostine (100MG

Oral Capsule)1

Gleostine (10MG Oral

Capsule, 40MG Oral

Capsule)

1

Leukeran (Oral

Tablet)1

Matulane (Oral

Capsule)1 LA

Valchlor (External

Gel)1 PA; LA

Antiandrogens

Abiraterone Acetate (Oral Tablet)

1 PA; QL

Bicalutamide (Oral Tablet)

1

Erleada (Oral Tablet) 1 PA; QL

Flutamide (Oral Capsule)

1

Nilutamide (Oral Tablet)

1

Nubeqa (Oral Tablet) 1 PA; QL

Xtandi (Oral Capsule) 1 PA; LA; QL

Antiangiogenic Agents

Pomalyst (Oral

Capsule)1 PA; QL

Revlimid (Oral

Capsule)1 PA; LA; QL

Tabrecta (Oral Tablet) 1 PA; QL

Thalomid (Oral

Capsule)1 PA; QL

Antiestrogens/Modifiers

Emcyt (Oral Capsule) 1

Soltamox (Oral

Solution)1

Tamoxifen Citrate (Oral Tablet)

1

Toremifene Citrate (Oral Tablet)

1

Antimetabolites

Droxia (Oral Capsule) 1

Hydroxyurea (Oral Capsule)

1

Mercaptopurine (Oral Tablet)

1

Purixan (Oral

Suspension)1 PA

Tabloid (Oral Tablet) 1 PA

Antineoplastics

Xpovio (100MG Once

Weekly) (Oral Tablet

Therapy Pack)

1 PA; QL

Xpovio (40 MG Once


Therapy Pack)

1 PA; QL

Xpovio (40 MG Twice


Therapy Pack)

1 PA; QL

Xpovio (60MG Once


Therapy Pack)

1 PA; QL

tRACK 33

23


C1Xpovio

C1Xpovio

C1Xpovio

B1

C1Copiktra

C1Inrebic

C1Kisqali

C1Kisqali

C1Kisqali

C1Kisqali Femara

C1Kisqali Femara

C1Kisqali Femara

C1Leucovorin Calcium

C1Leucovorin Calcium

C1Lonsurf

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Lorbrena

C1Ninlaro

C1Pemazyre

C1Piqray

C1Piqray

C1Piqray

C1Qinlock

C1Retevmo

C1Rozlytrek

C1Synribo

C1Tazverik

C1Tukysa

C1Verzenio

C1Zolinza

B1

C1Anastrozole

C1Exemestane

C1Letrozole

B1

C1Balversa

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Xpovio (60 MG Twice


Therapy Pack)

1 PA; QL

Xpovio (80MG Once


Therapy Pack)

1 PA; QL

Xpovio (80MG Twice


Therapy Pack)

1 PA; QL

Antineoplastics, Other

Copiktra (Oral

Capsule)1 PA; QL

Inrebic (Oral Capsule) 1 PA; QL

Kisqali (200MG Dose)

(Oral Tablet)1 PA; QL





Kisqali Femara

(400MG Dose) (Oral


1 PA; QL

Kisqali Femara

(600MG Dose) (Oral


1 PA; QL

Kisqali Femara

(200MG Dose) (Oral


1 PA; QL

Leucovorin Calcium (10MG Oral Tablet, 15MG Oral Tablet, 5MG Oral Tablet)

1

Leucovorin Calcium (25MG Oral Tablet)

1

Lonsurf (Oral Tablet) 1 PA; LA; QL

Lorbrena (Oral Tablet) 1 PA; QL

Ninlaro (Oral Capsule) 1 PA; QL

Pemazyre (Oral

Tablet)1 PA; QL

Piqray (200MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Piqray (250MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Piqray (300MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Qinlock (Oral Tablet) 1 PA; QL

Retevmo (Oral

Capsule)1 PA; QL

Rozlytrek (Oral

Capsule)1 PA; QL

Synribo

(Subcutaneous

Solution

Reconstituted)

1 PA

Tazverik (Oral Tablet) 1 PA; QL

Tukysa (Oral Tablet) 1 PA; QL

Verzenio (Oral Tablet) 1 PA; LA; QL

Zolinza (Oral Capsule) 1 PA

Aromatase Inhibitors, 3rd Generation

Anastrozole (Oral Tablet)

1

Exemestane (Oral Tablet)

1

Letrozole (Oral Tablet) 1

Enzyme Inhibitors

Balversa (Oral Tablet) 1 PA; QL

tRACK34

24


C1Rubraca

C1Talzenna

C1Zejula

B1

C1Afinitor Disperz

C1Afinitor

C1Alecensa

C1Alunbrig

C1Alunbrig

C1Ayvakit

C1Bosulif

C1Braftovi

C1Brukinsa

C1Cabometyx

C1Calquence

C1Caprelsa

C1Cometriq

C1Cometriq

C1Cometriq

C1Cotellic

C1Daurismo

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Erivedge

C1Erlotinib HCl

C1Everolimus

C1Farydak

C1Gilotrif

C1Ibrance

C1Ibrance

C1Iclusig

C1IDHIFA

C1Imatinib Mesylate

C1Imbruvica

C1Imbruvica

C1Inlyta

C1Inqovi

C1Iressa

C1Jakafi

C1Koselugo

C1Lenvima 10MG Daily Dose


Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Rubraca (Oral Tablet) 1 PA; LA; QL

Talzenna (Oral


Zejula (Oral Capsule) 1 PA; LA; QL

Molecular Target Inhibitors

Afinitor Disperz (Oral

Tablet Soluble)1 PA

Afinitor (Oral Tablet) 1 PA

Alecensa (Oral


Alunbrig (Oral Tablet) 1 PA; LA; QL

Alunbrig (Oral Tablet

Therapy Pack)1 PA; LA; QL

Ayvakit (Oral Tablet) 1 PA; LA; QL

Bosulif (Oral Tablet) 1 PA; QL

Braftovi (Oral

Capsule)1 PA

Brukinsa (Oral


Cabometyx (Oral

Tablet)1 PA; LA; QL

Calquence (Oral

Capsule)1 PA; QL

Caprelsa (Oral Tablet) 1 PA; LA

Cometriq (100MG

Daily Dose) (Oral Kit)1 PA; LA

Cometriq (140MG

Daily Dose) (Oral Kit)1 PA; LA

Cometriq (60MG Daily

Dose) (Oral Kit)1 PA; LA

Cotellic (Oral Tablet) 1 PA; LA; QL

Daurismo (Oral

Tablet)1 PA; LA; QL

Erivedge (Oral


Erlotinib HCl (Oral Tablet)

1 PA; QL

Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)

1 PA

Farydak (Oral

Capsule)1 PA

Gilotrif (Oral Tablet) 1 PA; LA

Ibrance (Oral


Ibrance (Oral Tablet) 1 PA; LA; QL

Iclusig (Oral Tablet) 1 PA; LA; QL

IDHIFA (Oral Tablet) 1 PA; LA; QL

Imatinib Mesylate (Oral Tablet)

1 PA; QL

Imbruvica (Oral


Imbruvica (Oral

Tablet)1 PA; QL

Inlyta (Oral Tablet) 1 PA; LA; QL

Inqovi (Oral Tablet) 1 PA; QL

Iressa (Oral Tablet) 1 PA; LA; QL

Jakafi (Oral Tablet) 1 PA; LA; QL

Koselugo (Oral

Capsule)1 PA; QL

Lenvima 10MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 12MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

tRACK 35

25








C1Lynparza

C1Mekinist

C1Mektovi

C1Nerlynx

C1Nexavar

C1Odomzo

C1Rydapt

C1Sprycel

C1Stivarga

C1Sutent

C1Tafinlar

C1Tagrisso

C1Tasigna

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tibsovo

C1Turalio

C1Tykerb

C1Venclexta

C1Venclexta

C1Venclexta Starting Pack

C1Vitrakvi

C1Vitrakvi

C1Vizimpro

C1Votrient

C1Xalkori

C1Xospata

C1Zelboraf

C1Zydelig

C1Zykadia

B1

C1Bexarotene

C1Panretin

C1Targretin

C1Tretinoin

B1

C1Mesnex

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Lenvima 14MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 18MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 20MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 24MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 4MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 8MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lynparza (Oral Tablet) 1 PA; LA; QL

Mekinist (Oral Tablet) 1 PA; LA

Mektovi (Oral Tablet) 1 PA

Nerlynx (Oral Tablet) 1 PA; LA; QL

Nexavar (Oral Tablet) 1 PA; LA

Odomzo (Oral


Rydapt (Oral Capsule) 1 PA; QL

Sprycel (Oral Tablet) 1 PA; QL

Stivarga (Oral Tablet) 1 PA; LA; QL

Sutent (Oral Capsule) 1 PA; QL

Tafinlar (Oral

Capsule)1 PA; LA

Tagrisso (Oral Tablet) 1 PA; LA; QL

Tasigna (Oral

Capsule)1 PA; QL

Tibsovo (Oral Tablet) 1 PA; QL

Turalio (Oral Capsule) 1 PA; LA; QL

Tykerb (Oral Tablet) 1 PA; LA

Venclexta (100MG

Oral Tablet, 50MG

Oral Tablet)

1 PA; LA; QL

Venclexta (10MG Oral

Tablet)1 PA; LA; QL

Venclexta Starting

Pack (Oral Tablet

Therapy Pack)

1 PA; LA

Vitrakvi (Oral


Vitrakvi (Oral

Solution)1 PA; LA; QL

Vizimpro (Oral Tablet) 1 PA; LA; QL

Votrient (Oral Tablet) 1 PA; LA; QL

Xalkori (Oral Capsule) 1 PA; LA

Xospata (Oral Tablet) 1 PA; QL

Zelboraf (Oral Tablet) 1 PA; LA; QL

Zydelig (Oral Tablet) 1 PA; LA; QL

Zykadia (Oral Tablet) 1 PA; QL

Retinoids

Bexarotene (Oral Capsule)

1 PA

Panretin (External

Gel)1

Targretin (External

Gel)1 PA

Tretinoin (Oral Capsule)

1

Treatment Adjuncts

Mesnex (Oral Tablet) 1

tRACK36

26


A1

B1

C1Albendazole

C1Ivermectin

C1Praziquantel

B1

C1Alinia

C1Alinia

C1Atovaquone

C1Atovaquone-Proguanil HCl

C1Benznidazole

C1Chloroquine Phosphate

C1Coartem

C1DARAPRIM

C1Hydroxychloroquine Sulfate

C1Mefloquine HCl

C1Nebupent

C1PENTAM 300

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Pentamidine Isethionate

C1Pentamidine Isethionate

C1Primaquine Phosphate

C1Pyrimethamine

C1Quinine Sulfate

B1

C1Lindane

C1Malathion

C1Permethrin

A1

B1

C1Benztropine Mesylate

C1Trihexyphenidyl HCl

C1Trihexyphenidyl HCl

B1

C1Amantadine HCl

C1Amantadine HCl

C1Amantadine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Antiparasitics

Anthelmintics

Albendazole (Oral Tablet)

1 QL

Ivermectin (Oral Tablet)

1

Praziquantel (Oral Tablet)

1

Antiprotozoals

Alinia (Oral

Suspension

Reconstituted)

1

Alinia (Oral Tablet) 1

Atovaquone (Oral Suspension)

1

Atovaquone-Proguanil HCl (Oral Tablet)

1

Benznidazole (Oral

Tablet)1

Chloroquine Phosphate (Oral Tablet)

1

Coartem (Oral Tablet) 1

DARAPRIM (Oral

Tablet)1

Hydroxychloroquine Sulfate (Oral Tablet)

1

Mefloquine HCl (Oral Tablet)

1

Nebupent (Inhalation

Solution

Reconstituted)

1 B/D, PA; QL

PENTAM 300

(Injection Solution

Reconstituted)

1

Pentamidine Isethionate (Inhalation Solution Reconstituted)

1 B/D, PA; QL

Pentamidine Isethionate (Injection Solution Reconstituted)

1

Primaquine Phosphate (Oral Tablet)

1

Pyrimethamine (Oral Tablet)

1

Quinine Sulfate (Oral Capsule)

1 PA

Pediculicides/Scabicides

Lindane (External Shampoo)

1

Malathion (External Lotion)

1

Permethrin (External Cream)

1

Antiparkinson Agents

Anticholinergics

Benztropine Mesylate (Oral Tablet)

1

Trihexyphenidyl HCl (Oral Solution)

1

Trihexyphenidyl HCl (Oral Tablet)

1

Antiparkinson Agents, Other

Amantadine HCl (Oral Capsule)

1

Amantadine HCl (Oral Syrup)

1

Amantadine HCl (Oral Tablet)

1

tRACK 37

27


C1Entacapone

C1Tolcapone

B1

C1Apokyn

C1Bromocriptine Mesylate

C1Bromocriptine Mesylate

C1Neupro

C1Pramipexole Dihydrochloride

C1Ropinirole HCl

B1

C1Carbidopa

C1Carbidopa-Levodopa ER

C1Carbidopa-Levodopa

C1Carbidopa-Levodopa ODT

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Carbidopa-Levodopa-Entacapone

C1Rytary

B1

C1Rasagiline Mesylate

C1Selegiline HCl

C1Selegiline HCl

C1Zelapar ODT

A1

B1

C1Chlorpromazine HCl

C1Fluphenazine Decanoate

C1Fluphenazine HCl

C1Fluphenazine HCl

C1Fluphenazine HCl

C1Fluphenazine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Entacapone (Oral Tablet)

1

Tolcapone (Oral Tablet)

1 QL

Dopamine Agonists

Apokyn

(Subcutaneous

Solution Cartridge)

1 PA; LA; QL

Bromocriptine Mesylate (Oral Capsule)

1

Bromocriptine Mesylate (Oral Tablet)

1

Neupro (Transdermal

Patch 24 Hour)1

Pramipexole Dihydrochloride (Oral Tablet Immediate Release)

1

Ropinirole HCl (Oral Tablet Immediate Release)

1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

Carbidopa (Oral Tablet)

1

Carbidopa-Levodopa ER (Oral Tablet Extended Release)

1

Carbidopa-Levodopa (Oral Tablet Immediate Release)

1

Carbidopa-Levodopa ODT (Oral Tablet Dispersible)

1

Carbidopa-Levodopa-Entacapone (Oral Tablet)

1

Rytary (Oral Capsule

Extended Release)1 ST

Monoamine Oxidase B (MAO-B) Inhibitors

Rasagiline Mesylate (Oral Tablet)

1

Selegiline HCl (Oral Capsule)

1

Selegiline HCl (Oral Tablet)

1

Zelapar ODT (Oral

Tablet Dispersible)1

Antipsychotics

1st Generation/Typical

Chlorpromazine HCl (Oral Tablet)

1

Fluphenazine Decanoate (Injection Solution)

1

Fluphenazine HCl (2.5MG/ML Injection Solution)

1

Fluphenazine HCl (5MG/ML Oral Concentrate)

1

Fluphenazine HCl (2.5MG/5ML Oral Elixir)

1

Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)

1

tRACK38

28


C1Haloperidol Decanoate

C1Haloperidol Lactate

C1Haloperidol Lactate

C1Haloperidol

C1Loxapine Succinate

C1Molindone HCl

C1Pimozide

C1Thioridazine HCl

C1Thiothixene

C1Trifluoperazine HCl

B1

C1Abilify Maintena

C1Abilify Maintena

C1Aripiprazole

C1Aripiprazole

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Aripiprazole ODT

C1Aristada Initio

C1Aristada

C1Caplyta

C1Fanapt

C1Fanapt

C1Fanapt Titration Pack

C1Geodon

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Haloperidol Decanoate (Intramuscular Solution)

1

Haloperidol Lactate (Injection Solution)

1

Haloperidol Lactate (Oral Concentrate)

1

Haloperidol (Oral Tablet)

1

Loxapine Succinate (Oral Capsule)

1

Molindone HCl (Oral Tablet)

1

Pimozide (Oral Tablet) 1

Thioridazine HCl (Oral Tablet)

1

Thiothixene (Oral Capsule)

1

Trifluoperazine HCl (Oral Tablet)

1

2nd Generation/Atypical

Abilify Maintena

(Intramuscular

Prefilled Syringe)

1

Abilify Maintena

(Intramuscular

Suspension

Reconstituted ER)

1

Aripiprazole (1MG/ML Oral Solution)

1 QL

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

1 QL

Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible)

1 QL

Aristada Initio

(Intramuscular

Prefilled Syringe)

1

Aristada

(Intramuscular

Prefilled Syringe)

1

Caplyta (Oral

Capsule)1 ST; QL

Fanapt (10MG Oral

Tablet, 12MG Oral

Tablet, 4MG Oral

Tablet, 6MG Oral

Tablet, 8MG Oral

Tablet)

1 ST; QL

Fanapt (1MG Oral

Tablet, 2MG Oral

Tablet)

1 ST; QL

Fanapt Titration Pack

(Oral Tablet)1 ST

Geodon

(Intramuscular

Solution

Reconstituted)

1

tRACK 39

29


C1Invega Sustenna

C1Invega Sustenna

C1Invega Trinza

C1Latuda

C1Nuplazid

C1Nuplazid

C1Olanzapine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Olanzapine

C1Olanzapine ODT

C1Paliperidone ER

C1Perseris

C1Quetiapine Fumarate ER

C1Quetiapine Fumarate

C1Rexulti

C1Risperdal Consta

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Invega Sustenna

(117MG/0.75ML

Intramuscular

Suspension Prefilled

Syringe, 156MG/ML

Intramuscular


Syringe, 234MG/

1.5ML Intramuscular


Syringe, 78MG/0.5ML

Intramuscular


Syringe)

1

Invega Sustenna

(39MG/0.25ML

Intramuscular


Syringe)

1

Invega Trinza

(Intramuscular


Syringe)

1

Latuda (Oral Tablet) 1 QL

Nuplazid (Oral

Capsule)1 PA; QL

Nuplazid (10MG Oral

Tablet)1 PA; QL

Olanzapine (10MG Intramuscular Solution Reconstituted)

1

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)

1 QL

Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)

1 QL

Paliperidone ER (Oral Tablet Extended Release 24 Hour)

1 QL

Perseris

(Subcutaneous

Prefilled Syringe)

1

Quetiapine Fumarate ER (Oral Tablet Extended Release 24 Hour)

1 QL

Quetiapine Fumarate (Oral Tablet Immediate Release)

1 QL

Rexulti (Oral Tablet) 1 QL

Risperdal Consta

(12.5MG

Intramuscular

Suspension

Reconstituted ER,

25MG Intramuscular

Suspension

Reconstituted ER)

1

tRACK40

30


C1Risperdal Consta

C1Risperidone

C1Risperidone

C1Risperidone ODT

C1Saphris

C1Secuado

C1Vraylar

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Vraylar

C1Ziprasidone HCl

C1Ziprasidone Mesylate

C1Zyprexa Relprevv

B1

C1Clozapine

C1Clozapine ODT

C1Versacloz

A1

B1

C1Valganciclovir HCl

C1Valganciclovir HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Risperdal Consta

(37.5MG

Intramuscular

Suspension

Reconstituted ER,

50MG Intramuscular

Suspension

Reconstituted ER)

1

Risperidone (1MG/ML Oral Solution)

1

Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet, 4MG Oral Tablet)

1

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)

1

Saphris (Tablet

Sublingual)1 QL

Secuado

(Transdermal Patch

24 Hour)

1 PA; QL

Vraylar (1.5MG Oral

Capsule, 3MG Oral

Capsule, 4.5MG Oral

Capsule, 6MG Oral

Capsule)

1 ST; QL

Vraylar (Oral Capsule

Therapy Pack)1 ST

Ziprasidone HCl (Oral Capsule)

1 QL

Ziprasidone Mesylate (Intramuscular Solution Reconstituted)

1

Zyprexa Relprevv

(210MG

Intramuscular

Suspension

Reconstituted)

1

Treatment-Resistant

Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

1

Clozapine ODT (100MG Oral Tablet Dispersible, 12.5MG Oral Tablet Dispersible, 150MG Oral Tablet Dispersible, 200MG Oral Tablet Dispersible, 25MG Oral Tablet Dispersible)

1 QL

Versacloz (Oral

Suspension)1

Antivirals

Anti-cytomegalovirus (CMV) Agents

Valganciclovir HCl (Oral Solution Reconstituted)

1 QL

Valganciclovir HCl (Oral Tablet)

1 QL

tRACK 41

31


C1Zirgan

B1

C1Adefovir Dipivoxil

C1Baraclude

C1Entecavir

C1Epivir HBV

C1Lamivudine

C1Vemlidy

B1

C1Intron A

C1Intron A

C1Pegasys ProClick

C1Pegasys

C1Ribavirin

B1

C1Epclusa

C1Mavyret

C1Sofosbuvir-Velpatasvir

C1Sovaldi

C1Sovaldi

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Vosevi

B1

C1Acyclovir

C1Acyclovir

C1Acyclovir

C1Acyclovir

C1Acyclovir Sodium

C1Denavir

C1Famciclovir

C1Trifluridine

C1Valacyclovir HCl

B1

C1Dovato

C1Genvoya

C1Isentress HD

C1Isentress

C1Isentress

C1Isentress

C1Isentress

C1Stribild

C1Tivicay

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Zirgan (Ophthalmic

Gel)1

Anti-hepatitis B (HBV) Agents

Adefovir Dipivoxil (Oral Tablet)

1

Baraclude (Oral

Solution)1

Entecavir (Oral Tablet) 1

Epivir HBV (Oral

Solution)1

Lamivudine (100MG Oral Tablet)

1

Vemlidy (Oral Tablet) 1 QL

Anti-hepatitis C (HCV) Agents, Other

Intron A (Injection

Solution)1 PA; LA

Intron A (Injection

Solution

Reconstituted)

1 PA; LA

Pegasys ProClick

(Subcutaneous

Solution)

1 PA

Pegasys

(Subcutaneous

Solution)

1 PA

Ribavirin (Oral Tablet) 1

Anti-hepatitis C (HCV) Direct Acting Agents

Epclusa (Oral Tablet) 1 PA; QL

Mavyret (Oral Tablet) 1 PA; QL

Sofosbuvir-Velpatasvir (Oral Tablet)

1 PA; QL

Sovaldi (Oral Packet) 1 PA; QL

Sovaldi (400MG Oral

Tablet)1 PA; QL

Vosevi (Oral Tablet) 1 PA; QL

Antiherpetic Agents

Acyclovir (External Ointment)

1 QL

Acyclovir (Oral Capsule)

1

Acyclovir (Oral Suspension)

1

Acyclovir (Oral Tablet) 1

Acyclovir Sodium (Intravenous Solution)

1 B/D, PA

Denavir (External

Cream)1 QL

Famciclovir (Oral Tablet)

1 QL

Trifluridine (Ophthalmic Solution)

1

Valacyclovir HCl (Oral Tablet)

1 QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

Dovato (Oral Tablet) 1 QL

Genvoya (Oral Tablet) 1 QL

Isentress HD (Oral

Tablet)1 QL

Isentress (Oral

Packet)1 QL

Isentress (Oral Tablet) 1 QL

Isentress (100MG

Oral Tablet Chewable)1 QL

Isentress (25MG Oral

Tablet Chewable)1 QL

Stribild (Oral Tablet) 1 QL

Tivicay (10MG Oral

Tablet)1 QL

tRACK42

32


C1Tivicay

C1Tivicay PD

C1Triumeq

C1Tybost

B1

C1Atripla

C1Complera

C1Delstrigo

C1Edurant

C1Efavirenz

C1Efavirenz

C1Intelence

C1Intelence

C1Juluca

C1Nevirapine ER

C1Nevirapine

C1Nevirapine

C1Odefsey

C1Pifeltro

C1Symfi Lo

C1Symfi

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useB1

C1Abacavir Sulfate

C1Abacavir Sulfate

C1Abacavir Sulfate-Lamivudine

C1Abacavir-Lamivudine-Zidovudine

C1Biktarvy

C1Cimduo

C1Descovy

C1Didanosine

C1Emtriva

C1Emtriva

C1Lamivudine

C1Lamivudine

C1Lamivudine-Zidovudine

C1Stavudine

C1Tenofovir Disoproxil Fumarate

C1Truvada

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Tivicay (25MG Oral

Tablet, 50MG Oral

Tablet)

1 QL

Tivicay PD (Oral

Tablet Soluble)1 QL

Triumeq (Oral Tablet) 1 QL

Tybost (Oral Tablet) 1 QL

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

Atripla (Oral Tablet) 1 QL

Complera (Oral

Tablet)1 QL

Delstrigo (Oral Tablet) 1 QL

Edurant (Oral Tablet) 1 QL

Efavirenz (Oral Capsule)

1 QL

Efavirenz (Oral Tablet) 1 QL

Intelence (100MG

Oral Tablet, 200MG

Oral Tablet)

1 QL

Intelence (25MG Oral

Tablet)1 QL

Juluca (Oral Tablet) 1 QL

Nevirapine ER (Oral Tablet Extended Release 24 Hour)

1 QL

Nevirapine (Oral Suspension)

1 QL

Nevirapine (Oral Tablet Immediate Release)

1 QL

Odefsey (Oral Tablet) 1 QL

Pifeltro (Oral Tablet) 1 QL

Symfi Lo (Oral Tablet) 1 QL

Symfi (Oral Tablet) 1 QL

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

Abacavir Sulfate (Oral Solution)

1 QL

Abacavir Sulfate (Oral Tablet)

1 QL

Abacavir Sulfate-Lamivudine (Oral Tablet)

1 QL

Abacavir-Lamivudine-Zidovudine (Oral Tablet)

1 QL

Biktarvy (Oral Tablet) 1 QL

Cimduo (Oral Tablet) 1 QL

Descovy (Oral Tablet) 1 QL

Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)

1 QL

Emtriva (Oral

Capsule)1 QL

Emtriva (Oral

Solution)1 QL

Lamivudine (10MG/ML Oral Solution)

1 QL

Lamivudine (150MG Oral Tablet, 300MG Oral Tablet)

1 QL

Lamivudine-Zidovudine (Oral Tablet)

1 QL

Stavudine (Oral Capsule)

1 QL

Tenofovir Disoproxil Fumarate (Oral Tablet)

1 QL

Truvada (Oral Tablet) 1 QL

tRACK 43

33


C1Viread

C1Viread

C1Zidovudine

C1Zidovudine

C1Zidovudine

B1

C1Fuzeon

C1Rukobia

C1Selzentry

C1Selzentry

C1Selzentry

B1

C1Aptivus

C1Aptivus

C1Atazanavir Sulfate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Crixivan

C1Evotaz

C1Fosamprenavir Calcium

C1Invirase

C1Kaletra

C1Kaletra

C1Lexiva

C1Lopinavir-Ritonavir

C1Norvir

C1Norvir

C1Prezcobix

C1Prezista

C1Prezista

C1Prezista

C1Reyataz

C1Ritonavir

C1Symtuza

C1Viracept

B1

C1Oseltamivir Phosphate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Viread (Oral Powder) 1 QL

Viread (150MG Oral

Tablet, 200MG Oral

Tablet, 250MG Oral

Tablet)

1 QL

Zidovudine (Oral Capsule)

1 QL

Zidovudine (Oral Syrup)

1 QL

Zidovudine (Oral Tablet)

1 QL

Anti-HIV Agents, Other

Fuzeon

(Subcutaneous

Solution

Reconstituted)

1 QL

Rukobia (Oral Tablet

Extended Release 12

Hour)

1 QL

Selzentry (Oral

Solution)1 QL

Selzentry (150MG

Oral Tablet, 300MG

Oral Tablet, 75MG

Oral Tablet)

1 QL

Selzentry (25MG Oral

Tablet)1 QL

Anti-HIV Agents, Protease Inhibitors

Aptivus (Oral

Capsule)1 QL

Aptivus (Oral

Solution)1 QL

Atazanavir Sulfate (Oral Capsule)

1 QL

Crixivan (Oral

Capsule)1 QL

Evotaz (Oral Tablet) 1 QL

Fosamprenavir Calcium (Oral Tablet)

1 QL

Invirase (Oral Tablet) 1 QL

Kaletra (100-25MG

Oral Tablet)1 QL

Kaletra (200-50MG

Oral Tablet)1 QL

Lexiva (Oral

Suspension)1 QL

Lopinavir-Ritonavir (Oral Solution)

1 QL

Norvir (Oral Packet) 1 QL

Norvir (Oral Solution) 1 QL

Prezcobix (Oral

Tablet)1 QL

Prezista (Oral

Suspension)1 QL

Prezista (150MG Oral

Tablet, 75MG Oral

Tablet)

1 QL

Prezista (600MG Oral

Tablet, 800MG Oral

Tablet)

1 QL

Reyataz (Oral Packet) 1 QL

Ritonavir (Oral Tablet) 1 QL

Symtuza (Oral Tablet) 1 QL

Viracept (Oral Tablet) 1 QL

Anti-influenza Agents

Oseltamivir Phosphate (Oral Capsule)

1 QL

tRACK44

34


C1Oseltamivir Phosphate

C1Relenza Diskhaler

C1Rimantadine HCl

C1Xofluza

C1Xofluza

A1

B1

C1Buspirone HCl

C1Hydroxyzine HCl

C1Hydroxyzine HCl

B1

C1Alprazolam

C1Chlordiazepoxide HCl

C1Clonazepam

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clonazepam ODT

C1Clorazepate Dipotassium

C1Diazepam Intensol

C1Diazepam

C1Diazepam

C1Lorazepam

C1Lorazepam

A1

B1

C1Divalproex Sodium ER

C1Divalproex Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Oseltamivir Phosphate (Oral Suspension Reconstituted)

1 QL

Relenza Diskhaler

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Rimantadine HCl (Oral Tablet)

1

Xofluza (40 MG Dose)

(Oral Tablet Therapy

Pack)

1 QL

Xofluza (80 MG Dose)


Pack)

1 QL

Anxiolytics

Anxiolytics, Other

Buspirone HCl (Oral Tablet)

1

Hydroxyzine HCl (Oral Syrup)

1

Hydroxyzine HCl (Oral Tablet)

1

Benzodiazepines

Alprazolam (Oral Tablet Immediate Release)

1 QL

Chlordiazepoxide HCl (Oral Capsule)

1

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

1 QL

Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible)

1 QL

Clorazepate Dipotassium (Oral Tablet)

1 QL

Diazepam Intensol (5MG/ML Oral Concentrate)

1 QL

Diazepam (5MG/5ML Oral Solution)

1

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)

1 QL

Lorazepam (2MG/ML Oral Concentrate)

1 QL

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

1 QL

Bipolar Agents

Mood Stabilizers

Divalproex Sodium ER (Oral Tablet Extended Release 24 Hour)

1

Divalproex Sodium (Oral Capsule Delayed Release Sprinkle)

1

tRACK 45

35


C1Divalproex Sodium

C1Lithium Carbonate ER

C1Lithium Carbonate

C1Lithium Carbonate

C1Lithium

A1

B1

C1Acarbose

C1Bydureon BCise

C1Bydureon

C1Byetta 10MCG Pen

C1Byetta 5MCG Pen

C1Cycloset

C1Glimepiride

C1Glipizide ER

C1Glipizide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Glipizide-Metformin HCl

C1Glyxambi

C1Invokamet

C1Invokamet XR

C1Invokana

C1Janumet

C1Janumet XR

C1Januvia

C1Jardiance

C1Jentadueto

C1Jentadueto XR

C1Metformin HCl ER

C1Metformin HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Divalproex Sodium (Oral Tablet Delayed Release)

1

Lithium Carbonate ER (Oral Tablet Extended Release)

1

Lithium Carbonate (Oral Capsule)

1

Lithium Carbonate (Oral Tablet Immediate Release)

1

Lithium (Oral

Solution)1

Blood Glucose Regulators

Antidiabetic Agents

Acarbose (Oral Tablet) 1 QL

Bydureon BCise

(Subcutaneous Auto-

Injector)

1 QL

Bydureon

(Subcutaneous Pen-

Injector)

1 QL

Byetta 10MCG Pen

(Subcutaneous

Solution Pen-Injector)

1 QL

Byetta 5MCG Pen

(Subcutaneous


1 QL

Cycloset (Oral Tablet) 1 PA; QL

Glimepiride (Oral Tablet)

1 QL

Glipizide ER (Oral Tablet Extended Release 24 Hour)

1 QL

Glipizide (Oral Tablet Immediate Release)

1 QL

Glipizide-Metformin HCl (Oral Tablet)

1 QL

Glyxambi (Oral

Tablet)1 QL

Invokamet (Oral

Tablet Immediate

Release)

1 QL

Invokamet XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Invokana (Oral Tablet) 1 QL

Janumet (Oral Tablet

Immediate Release)1 QL

Janumet XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Januvia (Oral Tablet) 1 QL

Jardiance (Oral

Tablet)1 QL

Jentadueto (Oral

Tablet Immediate

Release)

1 QL

Jentadueto XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Metformin HCl ER (Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)

1 QL

Metformin HCl (500MG/5ML Oral Solution)

1 QL

tRACK46

36


C1Metformin HCl

C1Miglitol

C1Nateglinide

C1Ozempic

C1Ozempic

C1Pioglitazone HCl

C1Pioglitazone HCl-Glimepiride

C1Pioglitazone HCl-Metformin HCl

C1Repaglinide

C1Riomet ER

C1Riomet

C1Rybelsus

C1Soliqua

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1SymlinPen 120

C1SymlinPen 60

C1Synjardy

C1Synjardy XR

C1Tradjenta

C1Trijardy XR

C1Trulicity

C1Victoza

B1

C1Baqsimi Two Pack

C1Diazoxide

C1GlucaGen HypoKit

C1Glucagon

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Metformin HCl (1000MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 850MG Oral Tablet Immediate Release)

1 QL

Miglitol (Oral Tablet) 1 QL

Nateglinide (Oral Tablet)

1 QL

Ozempic (0.25 or

0.5MG/DOSE)

(Subcutaneous


1 QL

Ozempic (1MG/

DOSE)

(Subcutaneous


1 QL

Pioglitazone HCl (Oral Tablet)

1 QL

Pioglitazone HCl-Glimepiride (Oral Tablet)

1 QL

Pioglitazone HCl-Metformin HCl (Oral Tablet)

1 QL

Repaglinide (Oral Tablet)

1 QL

Riomet ER (Oral

Suspension

Reconstituted ER)

1 QL

Riomet (Oral Solution) 1 QL

Rybelsus (Oral Tablet) 1 QL

Soliqua

(Subcutaneous


1 QL

SymlinPen 120

(Subcutaneous


1 PA

SymlinPen 60

(Subcutaneous


1 PA

Synjardy (Oral Tablet

Immediate Release)1 QL

Synjardy XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Tradjenta (Oral

Tablet)1 QL

Trijardy XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Trulicity (0.75MG/

0.5ML Subcutaneous

Solution Pen-Injector,

1.5MG/0.5ML

Subcutaneous


1 QL

Victoza

(Subcutaneous


1 QL

Glycemic Agents

Baqsimi Two Pack

(Nasal Powder)1

Diazoxide (Oral Suspension)

1

GlucaGen HypoKit

(Injection Solution

Reconstituted)

1

Glucagon (Injection

Kit) (Lilly)1

tRACK 47

37


C1Gvoke HypoPen 2-Pack

C1Gvoke PFS

C1Proglycem

B1

C1Humalog Junior KwikPen

C1Humalog KwikPen

C1Humalog Mix 50/50 KwikPen

C1Humalog Mix 50/50

C1Humalog Mix 75/25 KwikPen

C1Humalog Mix 75/25

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Humalog

C1Humalog

C1Humulin 70/30 KwikPen

C1Humulin 70/30

C1Humulin N KwikPen

C1Humulin N

C1Humulin R

C1Humulin R U-500

C1Humulin R U-500 KwikPen

C1Insulin Lispro

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Gvoke HypoPen 2-

Pack (Subcutaneous

Solution Auto-

Injector)

1

Gvoke PFS

(Subcutaneous

Solution Prefilled

Syringe)

1

Proglycem (Oral

Suspension)1

Insulins

Humalog Junior

KwikPen

(Subcutaneous


1

Humalog KwikPen

(Subcutaneous


1

Humalog Mix 50/50

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humalog Mix 50/50

(Subcutaneous

Suspension)

1

Humalog Mix 75/25

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humalog Mix 75/25

(Subcutaneous

Suspension)

1

Humalog

(Subcutaneous

Solution)

1

Humalog

(Subcutaneous

Solution Cartridge)

1

Humulin 70/30

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humulin 70/30

(Subcutaneous

Suspension)

1

Humulin N KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humulin N

(Subcutaneous

Suspension)

1

Humulin R (Injection

Solution)1

Humulin R U-500

(Concentrated)

(Subcutaneous

Solution)

1

Humulin R U-500

KwikPen

(Subcutaneous


1

Insulin Lispro (1 Unit

Dial) (Subcutaneous


(Brand Equivalent

Humalog)

1

tRACK48

38


C1Insulin Lispro Junior KwikPen

C1Insulin Lispro Prot & Lispro

C1Insulin Lispro

C1Lantus SoloStar

C1Lantus

C1Levemir FlexTouch

C1Levemir

C1Lyumjev

C1Lyumjev KwikPen

C1Toujeo Max SoloStar

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Toujeo SoloStar

C1Tresiba FlexTouch

C1Tresiba

A1

B1

C1Eliquis DVT/PE Starter Pack

C1Eliquis

C1Enoxaparin Sodium

C1Fondaparinux Sodium

C1Fondaparinux Sodium

C1Heparin Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Insulin Lispro Junior

KwikPen

(Subcutaneous


(Brand Equivalent

Humalog)

1

Insulin Lispro Prot &

Lispro (Subcutaneous

Suspension Pen-

Injector) (Brand

Equivalent Humalog)

1

Insulin Lispro

(Subcutaneous

Solution) (Brand

Equivalent Humalog)

1

Lantus SoloStar

(Subcutaneous


1

Lantus

(Subcutaneous

Solution)

1

Levemir FlexTouch

(Subcutaneous


1

Levemir

(Subcutaneous

Solution)

1

Lyumjev (Injection

Solution)1

Lyumjev KwikPen

(Subcutaneous


1

Toujeo Max SoloStar

(Subcutaneous


1

Toujeo SoloStar

(Subcutaneous


1

Tresiba FlexTouch

(Subcutaneous


1

Tresiba

(Subcutaneous

Solution)

1

Blood Products/Modifiers/Volume Expanders

Anticoagulants

Eliquis DVT/PE

Starter Pack (5MG

Oral Tablet)

1 QL

Eliquis (Oral Tablet) 1 QL

Enoxaparin Sodium (Subcutaneous Solution)

1 QL

Fondaparinux Sodium (10MG/0.8ML Subcutaneous Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/ 0.6ML Subcutaneous Solution)

1

Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous Solution)

1

Heparin Sodium (10000UNIT/ML Injection Solution, 20000UNIT/ML Injection Solution, 5000UNIT/ML Injection Solution)

1

tRACK 49

39


C1Heparin Sodium

C1Jantoven

C1Warfarin Sodium

C1Xarelto

C1Xarelto Starter Pack

B1

C1Anagrelide HCl

C1Aranesp

C1Aranesp

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Aranesp

C1Aranesp

C1Granix

C1Granix

C1Leukine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Heparin Sodium (1000UNIT/ML Injection Solution)

1 B/D, PA

Jantoven (Oral Tablet) 1

Warfarin Sodium (Oral Tablet)

1

Xarelto (Oral Tablet) 1 QL

Xarelto Starter Pack


Pack)

1 QL

Blood Formation Modifiers

Anagrelide HCl (Oral Capsule)

1

Aranesp (Albumin

Free) (100MCG/ML

Injection Solution,

200MCG/ML

Injection Solution,

300MCG/ML

Injection Solution,

60MCG/ML Injection

Solution)

1 PA

Aranesp (Albumin

Free) (25MCG/ML

Injection Solution,

40MCG/ML Injection

Solution)

1 PA

Aranesp (Albumin

Free) (100MCG/

0.5ML Injection

Solution Prefilled

Syringe, 150MCG/

0.3ML Injection

Solution Prefilled

Syringe, 200MCG/

0.4ML Injection

Solution Prefilled

Syringe, 300MCG/

0.6ML Injection

Solution Prefilled

Syringe, 500MCG/ML

Injection Solution

Prefilled Syringe,

60MCG/0.3ML

Injection Solution

Prefilled Syringe)

1 PA

Aranesp (Albumin

Free) (10MCG/0.4ML

Injection Solution

Prefilled Syringe,

25MCG/0.42ML

Injection Solution

Prefilled Syringe,

40MCG/0.4ML

Injection Solution

Prefilled Syringe)

1 PA

Granix (Subcutaneous

Solution)1 ST

Granix (Subcutaneous

Solution Prefilled

Syringe)

1 ST

Leukine (Injection

Solution

Reconstituted)

1 PA

tRACK50

40


C1Neulasta

C1Neupogen

C1Neupogen

C1Procrit

C1Procrit

C1Promacta

C1Promacta

C1Retacrit

C1Retacrit

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Udenyca

C1Zarxio

B1

C1Tranexamic Acid

B1

C1Aspirin-Dipyridamole ER

C1Brilinta

C1Cablivi

C1Cilostazol

C1Clopidogrel Bisulfate

C1Prasugrel HCl

A1

B1

C1Clonidine HCl

C1Clonidine

C1Methyldopa

C1Midodrine HCl

C1Northera

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Neulasta

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Neupogen (Injection

Solution)1 ST

Neupogen (Injection

Solution Prefilled

Syringe)

1 ST

Procrit (10000UNIT/

ML Injection Solution,

2000UNIT/ML

Injection Solution,

3000UNIT/ML

Injection Solution,

4000UNIT/ML

Injection Solution)

1 PA

Procrit (20000UNIT/


40000UNIT/ML

Injection Solution)

1 PA

Promacta (Oral

Packet)1 PA; LA; QL

Promacta (Oral

Tablet)1 PA; LA; QL

Retacrit (10000UNIT/


2000UNIT/ML

Injection Solution,

3000UNIT/ML

Injection Solution,

4000UNIT/ML

Injection Solution)

1 PA

Retacrit (40000UNIT/

ML Injection Solution)1 PA

Udenyca

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Zarxio (Injection

Solution Prefilled

Syringe)

1

Hemostasis Agents

Tranexamic Acid (Oral Tablet)

1

Platelet Modifying Agents

Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)

1 QL

Brilinta (Oral Tablet) 1 QL

Cablivi (Injection Kit) 1 PA; QL

Cilostazol (Oral Tablet) 1

Clopidogrel Bisulfate (75MG Oral Tablet)

1 QL

Prasugrel HCl (Oral Tablet)

1 QL

Cardiovascular Agents

Alpha-adrenergic Agonists

Clonidine HCl (Oral Tablet Immediate Release)

1

Clonidine (Transdermal Patch Weekly)

1

Methyldopa (Oral Tablet)

1

Midodrine HCl (Oral Tablet)

1

Northera (Oral


tRACK 51

41


B1

C1Doxazosin Mesylate

C1Phenoxybenzamine HCl

C1Prazosin HCl

B1

C1Candesartan Cilexetil

C1Edarbi

C1Irbesartan

C1Losartan Potassium

C1Olmesartan Medoxomil

C1Telmisartan

C1Valsartan

B1

C1Benazepril HCl

C1Captopril

C1Enalapril Maleate

C1Fosinopril Sodium

C1Lisinopril

C1Moexipril HCl

C1Perindopril Erbumine

C1Quinapril HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ramipril

C1Trandolapril

B1

C1Amiodarone HCl

C1Dofetilide

C1Flecainide Acetate

C1Mexiletine HCl

C1Multaq

C1Pacerone

C1Propafenone HCl ER

C1Propafenone HCl

C1Quinidine Gluconate ER

C1Quinidine Sulfate

C1Sotalol HCl AF

C1Sotalol HCl

B1

C1Acebutolol HCl

C1Atenolol

C1Betaxolol HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Alpha-adrenergic Blocking Agents

Doxazosin Mesylate (Oral Tablet)

1

Phenoxybenzamine HCl (Oral Capsule)

1

Prazosin HCl (Oral Capsule)

1

Angiotensin II Receptor Antagonists

Candesartan Cilexetil (Oral Tablet)

1 QL

Edarbi (Oral Tablet) 1 QL

Irbesartan (Oral Tablet) 1 QL

Losartan Potassium (Oral Tablet)

1 QL

Olmesartan Medoxomil (Oral Tablet)

1 QL

Telmisartan (Oral Tablet)

1 QL

Valsartan (Oral Tablet) 1 QL

Angiotensin-converting Enzyme (ACE) Inhibitors

Benazepril HCl (Oral Tablet)

1 QL

Captopril (Oral Tablet) 1 QL

Enalapril Maleate (Oral Tablet)

1 QL

Fosinopril Sodium (Oral Tablet)

1 QL

Lisinopril (Oral Tablet) 1 QL

Moexipril HCl (Oral Tablet)

1 QL

Perindopril Erbumine (Oral Tablet)

1 QL

Quinapril HCl (Oral Tablet)

1 QL

Ramipril (Oral Capsule) 1 QL

Trandolapril (Oral Tablet)

1 QL

Antiarrhythmics

Amiodarone HCl (200MG Oral Tablet)

1

Dofetilide (Oral Capsule)

1

Flecainide Acetate (Oral Tablet)

1

Mexiletine HCl (Oral Capsule)

1

Multaq (Oral Tablet) 1 QL

Pacerone (200MG Oral Tablet)

1

Propafenone HCl ER (Oral Capsule Extended Release 12 Hour)

1

Propafenone HCl (Oral Tablet)

1

Quinidine Gluconate ER (Oral Tablet Extended Release)

1

Quinidine Sulfate (Oral Tablet)

1

Sotalol HCl AF (Oral Tablet)

1

Sotalol HCl (Oral Tablet)

1

Beta-adrenergic Blocking Agents

Acebutolol HCl (Oral Capsule)

1

Atenolol (Oral Tablet) 1

Betaxolol HCl (Oral Tablet)

1

tRACK52

42


C1Bisoprolol Fumarate

C1Bystolic

C1Carvedilol

C1Labetalol HCl

C1Metoprolol Succinate ER

C1Metoprolol Tartrate

C1Nadolol

C1Pindolol

C1Propranolol HCl ER

C1Propranolol HCl

C1Propranolol HCl

B1

C1Amlodipine Besylate

C1Cartia XT

C1Diltiazem HCl ER Beads

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Diltiazem HCl ER Coated Beads

C1Diltiazem HCl ER

C1Diltiazem HCl

C1Dilt-XR

C1Felodipine ER

C1Matzim LA

C1Nicardipine HCl

C1Nifedipine ER

C1Nifedipine ER Osmotic Release

C1Nimodipine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Bisoprolol Fumarate (Oral Tablet)

1

Bystolic (Oral Tablet) 1 QL

Carvedilol (Oral Tablet) 1

Labetalol HCl (Oral Tablet)

1

Metoprolol Succinate ER (Oral Tablet Extended Release 24 Hour)

1

Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

1

Nadolol (Oral Tablet) 1

Pindolol (Oral Tablet) 1

Propranolol HCl ER (Oral Capsule Extended Release 24 Hour)

1

Propranolol HCl (Oral Solution)

1

Propranolol HCl (Oral Tablet)

1

Calcium Channel Blocking Agents

Amlodipine Besylate (Oral Tablet)

1

Cartia XT (Oral Capsule Extended Release 24 Hour)

1

Diltiazem HCl ER Beads (360MG Oral Capsule Extended Release 24 Hour, 420MG Oral Capsule Extended Release 24 Hour)

1

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)

1

Diltiazem HCl ER (Oral Capsule Extended Release 12 Hour)

1

Diltiazem HCl (Oral Tablet Immediate Release)

1

Dilt-XR (Oral Capsule Extended Release 24 Hour)

1

Felodipine ER (Oral Tablet Extended Release 24 Hour)

1

Matzim LA (Oral Tablet Extended Release 24 Hour)

1

Nicardipine HCl (Oral Capsule)

1

Nifedipine ER (Oral Tablet Extended Release 24 Hour)

1 QL

Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)

1 QL

Nimodipine (Oral Capsule)

1

tRACK 53

43


C1Nymalize

C1Taztia XT

C1Tiadylt ER

C1Verapamil HCl ER

C1Verapamil HCl ER

C1Verapamil HCl ER

C1Verapamil HCl

B1

C1Aliskiren Fumarate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Amiloride-Hydrochlorothiazide

C1Amlodipine-Atorvastatin

C1Amlodipine-Benazepril

C1Amlodipine-Olmesartan

C1Amlodipine-Valsartan

C1Amlodipine-Valsartan-HCTZ

C1Atenolol-Chlorthalidone

C1Benazepril-Hydrochlorothiazide

C1BiDil

C1Bisoprolol-Hydrochlorothiazide

C1Candesartan Cilexetil-HCTZ

C1Captopril-Hydrochlorothiazide

C1Corlanor

C1Corlanor

C1Demser

C1Digitek

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nymalize (6MG/ML

Oral Solution)1

Taztia XT (Oral Capsule Extended Release 24 Hour)

1

Tiadylt ER (Oral Capsule Extended Release 24 Hour)

1

Verapamil HCl ER (100MG Oral Capsule Extended Release 24 Hour, 120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

1

Verapamil HCl ER

(360MG Oral Capsule

Extended Release 24

Hour)

1

Verapamil HCl ER (Oral Tablet Extended Release)

1

Verapamil HCl (Oral Tablet Immediate Release)

1

Cardiovascular Agents, Other

Aliskiren Fumarate (Oral Tablet)

1 QL

Amiloride-Hydrochlorothiazide (Oral Tablet)

1

Amlodipine-Atorvastatin (Oral Tablet)

1 QL

Amlodipine-Benazepril (Oral Capsule)

1 QL

Amlodipine-Olmesartan (Oral Tablet)

1 QL

Amlodipine-Valsartan (Oral Tablet)

1 QL

Amlodipine-Valsartan-HCTZ (Oral Tablet)

1 QL

Atenolol-Chlorthalidone (Oral Tablet)

1

Benazepril-Hydrochlorothiazide (Oral Tablet)

1 QL

BiDil (Oral Tablet) 1 QL

Bisoprolol-Hydrochlorothiazide (Oral Tablet)

1 QL

Candesartan Cilexetil-HCTZ (Oral Tablet)

1 QL

Captopril-Hydrochlorothiazide (Oral Tablet)

1 QL

Corlanor (Oral

Solution)1 PA; QL

Corlanor (Oral Tablet) 1 PA; QL

Demser (Oral

Capsule)1

Digitek (Oral Tablet) 1

tRACK54

44


C1Digox

C1Digoxin

C1Digoxin

C1Edarbyclor

C1Enalapril-Hydrochlorothiazide

C1Entresto

C1Fosinopril Sodium-HCTZ

C1Irbesartan-Hydrochlorothiazide

C1Lanoxin

C1Lisinopril-Hydrochlorothiazide

C1Losartan Potassium-HCTZ

C1Methyldopa-Hydrochlorothiazide

C1Metoprolol-Hydrochlorothiazide

C1Olmesartan Medoxomil-HCTZ

C1Olmesartan-Amlodipine-HCTZ

C1Pentoxifylline ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Propranolol-HCTZ

C1Quinapril-Hydrochlorothiazide

C1Ranolazine ER

C1Spironolactone-HCTZ

C1Telmisartan-Amlodipine

C1Telmisartan-HCTZ

C1Triamterene-HCTZ

C1Triamterene-HCTZ

C1Valsartan-Hydrochlorothiazide

C1Vyndamax

C1Vyndaqel

B1

C1Acetazolamide ER

C1Acetazolamide

C1Methazolamide

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Digox (Oral Tablet) 1

Digoxin (Oral

Solution)1

Digoxin (Oral Tablet) 1

Edarbyclor (Oral

Tablet)1 QL

Enalapril-Hydrochlorothiazide (Oral Tablet)

1 QL

Entresto (Oral Tablet) 1 QL

Fosinopril Sodium-HCTZ (Oral Tablet)

1 QL

Irbesartan-Hydrochlorothiazide (Oral Tablet)

1 QL

Lanoxin (Oral Tablet) 1

Lisinopril-Hydrochlorothiazide (Oral Tablet)

1 QL

Losartan Potassium-HCTZ (Oral Tablet)

1 QL

Methyldopa-Hydrochlorothiazide (Oral Tablet)

1

Metoprolol-Hydrochlorothiazide (Oral Tablet)

1

Olmesartan Medoxomil-HCTZ (Oral Tablet)

1 QL

Olmesartan-Amlodipine-HCTZ (Oral Tablet)

1 QL

Pentoxifylline ER (Oral Tablet Extended Release)

1

Propranolol-HCTZ (Oral Tablet)

1

Quinapril-Hydrochlorothiazide (Oral Tablet)

1 QL

Ranolazine ER (Oral Tablet Extended Release 12 Hour)

1 QL

Spironolactone-HCTZ (Oral Tablet)

1

Telmisartan-Amlodipine (Oral Tablet)

1 QL

Telmisartan-HCTZ (Oral Tablet)

1 QL

Triamterene-HCTZ (Oral Capsule)

1

Triamterene-HCTZ (Oral Tablet)

1

Valsartan-Hydrochlorothiazide (Oral Tablet)

1 QL

Vyndamax (Oral

Capsule)1 PA; QL

Vyndaqel (Oral

Capsule)1 PA; QL

Diuretics, Carbonic Anhydrase Inhibitors

Acetazolamide ER (Oral Capsule Extended Release 12 Hour)

1

Acetazolamide (Oral Tablet)

1

Methazolamide (Oral Tablet)

1

Diuretics, Loop

tRACK 55

45


C1Bumetanide

C1Bumetanide

C1Ethacrynic Acid

C1Furosemide

C1Furosemide

C1Furosemide

C1Torsemide

B1

C1Amiloride HCl

C1Eplerenone

C1Spironolactone

C1Triamterene

B1

C1Chlorthalidone

C1Diuril

C1Hydrochlorothiazide

C1Hydrochlorothiazide

C1Indapamide

C1Metolazone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useB1

C1Fenofibrate Micronized

C1Fenofibrate

C1Fenofibrate

C1Fenofibric Acid

C1Gemfibrozil

B1

C1Atorvastatin Calcium

C1Fluvastatin Sodium

C1Livalo

C1Lovastatin

C1Pravastatin Sodium

C1Rosuvastatin Calcium

C1Simvastatin

B1

C1Cholestyramine Light

C1Cholestyramine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Bumetanide (Injection Solution)

1

Bumetanide (Oral Tablet)

1

Ethacrynic Acid (Oral Tablet)

1

Furosemide (Injection Solution)

1 B/D, PA

Furosemide (Oral Solution)

1

Furosemide (Oral Tablet)

1

Torsemide (Oral Tablet)

1

Diuretics, Potassium-sparing

Amiloride HCl (Oral Tablet)

1

Eplerenone (Oral Tablet)

1

Spironolactone (Oral Tablet)

1

Triamterene (Oral Capsule)

1

Diuretics, Thiazide

Chlorthalidone (Oral Tablet)

1

Diuril (Oral

Suspension)1

Hydrochlorothiazide (Oral Capsule)

1

Hydrochlorothiazide (Oral Tablet)

1

Indapamide (Oral Tablet)

1

Metolazone (Oral Tablet)

1

Dyslipidemics, Fibric Acid Derivatives

Fenofibrate Micronized (134MG Oral Capsule, 200MG Oral Capsule, 67MG Oral Capsule)

1

Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet)

1

Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet)

1

Fenofibric Acid (Oral Capsule Delayed Release)

1

Gemfibrozil (Oral Tablet)

1

Dyslipidemics, HMG CoA Reductase Inhibitors

Atorvastatin Calcium (Oral Tablet)

1 QL

Fluvastatin Sodium (Oral Capsule)

1 QL

Livalo (Oral Tablet) 1 QL

Lovastatin (Oral Tablet) 1 QL

Pravastatin Sodium (Oral Tablet)

1 QL

Rosuvastatin Calcium (Oral Tablet)

1 QL

Simvastatin (Oral Tablet)

1 QL

Dyslipidemics, Other

Cholestyramine Light (Oral Powder)

1

Cholestyramine (Oral Packet)

1

tRACK56

46


C1Colesevelam HCl

C1Colesevelam HCl

C1Colestipol HCl

C1Colestipol HCl

C1Ezetimibe

C1Ezetimibe-Simvastatin

C1Juxtapid

C1Niacin ER

C1Niacor

C1Omega-3-Acid Ethyl Esters

C1Praluent

C1Prevalite

C1Repatha Pushtronex System

C1Repatha

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Repatha SureClick

C1Vascepa

B1

C1Hydralazine HCl

C1Minoxidil

B1

C1Isosorbide Dinitrate

C1Isosorbide Mononitrate ER

C1Isosorbide Mononitrate

C1Minitran

C1Nitro-Bid

C1Nitroglycerin

C1Nitroglycerin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Colesevelam HCl (Oral Packet)

1

Colesevelam HCl (Oral Tablet)

1

Colestipol HCl (Oral Packet)

1

Colestipol HCl (Oral Tablet)

1

Ezetimibe (Oral Tablet) 1 QL

Ezetimibe-Simvastatin (Oral Tablet)

1 QL

Juxtapid (Oral

Capsule)1 PA; LA

Niacin ER (Antihyperlipidemic) (Oral Tablet Extended Release)

1

Niacor (Oral Tablet) 1

Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)

1 QL

Praluent

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA; QL

Prevalite (Oral Packet) 1

Repatha Pushtronex

System

(Subcutaneous

Solution Cartridge)

1 PA; QL

Repatha

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; QL

Repatha SureClick

(Subcutaneous

Solution Auto-

Injector)

1 PA; QL

Vascepa (Oral

Capsule)1

Vasodilators, Direct-acting Arterial

Hydralazine HCl (Oral Tablet)

1

Minoxidil (Oral Tablet) 1

Vasodilators, Direct-acting Arterial/Venous

Isosorbide Dinitrate (10MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)

1

Isosorbide Mononitrate ER (Oral Tablet Extended Release 24 Hour)

1

Isosorbide Mononitrate (Oral Tablet Immediate Release)

1

Minitran (Transdermal Patch 24 Hour)

1

Nitro-Bid (Transdermal Ointment)

1

Nitroglycerin (Tablet Sublingual)

1

Nitroglycerin (Transdermal Patch 24 Hour)

1

tRACK 57

47


C1Nitroglycerin

C1Nitrostat

C1Rectiv

A1

B1

C1Amphetamine-Dextroamphetamine ER

C1Amphetamine-Dextroamphetamine

C1Dextroamphetamine Sulfate ER

C1Dextroamphetamine Sulfate

C1Vyvanse

C1Vyvanse

B1

C1Atomoxetine HCl

C1Clonidine HCl ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Dexmethylphenidate HCl ER

C1Dexmethylphenidate HCl

C1Guanfacine HCl ER

C1Methylphenidate HCl ER

C1Methylphenidate HCl

C1Methylphenidate HCl

B1

C1Austedo

C1Ingrezza

C1Ingrezza

C1Namzaric

C1Namzaric

C1Nuedexta

C1Riluzole

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nitroglycerin (Translingual Solution)

1

Nitrostat (Tablet

Sublingual)1

Rectiv (Rectal

Ointment)1

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

1 QL

Amphetamine-Dextroamphetamine (Oral Tablet)

1 QL

Dextroamphetamine Sulfate ER (Oral Capsule Extended Release 24 Hour)

1 QL

Dextroamphetamine Sulfate (Oral Tablet)

1 QL

Vyvanse (Oral

Capsule)1

Vyvanse (Oral Tablet

Chewable)1

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

Atomoxetine HCl (Oral Capsule)

1 QL

Clonidine HCl ER (Oral Tablet Extended Release 12 Hour)

1 PA

Dexmethylphenidate HCl ER (Oral Capsule Extended Release 24 Hour)

1

Dexmethylphenidate HCl (Oral Tablet)

1 QL

Guanfacine HCl ER (Oral Tablet Extended Release 24 Hour)

1

Methylphenidate HCl ER (10MG Oral Tablet Extended Release, 20MG Oral Tablet Extended Release)

1 QL

Methylphenidate HCl (Oral Solution)

1 QL

Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)

1 QL

Central Nervous System, Other

Austedo (Oral Tablet) 1 PA; LA; QL

Ingrezza (Oral

Capsule)1 PA; QL

Ingrezza (Oral

Capsule Therapy

Pack)

1 PA; QL

Namzaric (Oral

Capsule ER 24 Hour

Therapy Pack)

1 PA; QL

Namzaric (Oral

Capsule Extended

Release 24 Hour)

1 PA; QL

Nuedexta (Oral

Capsule)1 PA

Riluzole (Oral Tablet) 1

tRACK58

48


C1Tetrabenazine

B1

C1Drizalma Sprinkle

C1Duloxetine HCl

C1Pregabalin

C1Pregabalin

C1Savella

C1Savella Titration Pack

B1

C1Ampyra

C1Aubagio

C1Avonex Pen

C1Avonex Prefilled

C1Betaseron

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Dalfampridine ER

C1Gilenya

C1Glatiramer Acetate

C1Glatopa

C1Mayzent

C1Rebif Rebidose

C1Rebif Rebidose Titration Pack

C1Rebif

C1Rebif Titration Pack

C1Tecfidera Starter Pack

C1Tecfidera

A1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Tetrabenazine (Oral Tablet)

1 PA; LA; QL

Fibromyalgia Agents

Drizalma Sprinkle

(Oral Capsule

Delayed Release

Sprinkle)

1 ST; QL

Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)

1 QL

Pregabalin (Oral Capsule)

1 QL

Pregabalin (Oral Solution)

1 QL

Savella (Oral Tablet) 1

Savella Titration Pack

(Oral Tablet)1

Multiple Sclerosis Agents

Ampyra (Oral Tablet

Extended Release 12

Hour)

1 QL

Aubagio (Oral Tablet) 1 LA; QL

Avonex Pen

(Intramuscular Auto-

Injector Kit)

1 QL

Avonex Prefilled

(Intramuscular

Prefilled Syringe Kit)

1 QL

Betaseron

(Subcutaneous Kit)1 QL

Dalfampridine ER (Oral Tablet Extended Release 12 Hour)

1 QL

Gilenya (0.5MG Oral

Capsule)1 QL

Glatiramer Acetate (Subcutaneous Solution Prefilled Syringe)

1 QL

Glatopa (Subcutaneous Solution Prefilled Syringe)

1 QL

Mayzent (Oral Tablet) 1 QL

Rebif Rebidose

(Subcutaneous

Solution Auto-

Injector)

1 QL

Rebif Rebidose

Titration Pack

(Subcutaneous

Solution Auto-

Injector)

1 QL

Rebif (Subcutaneous

Solution Prefilled

Syringe)

1 QL

Rebif Titration Pack

(Subcutaneous

Solution Prefilled

Syringe)

1 QL

Tecfidera Starter

Pack (Oral)1 LA

Tecfidera (Oral

Capsule Delayed

Release)

1 LA; QL

Dental and Oral Agents

tRACK 59

49


B1

C1Chlorhexidine Gluconate

C1Pilocarpine HCl

C1Triamcinolone Acetonide

A1

B1

C1Acitretin

C1Adapalene

C1Adapalene

C1Ammonium Lactate

C1Ammonium Lactate

C1Azelaic Acid

C1Benzoyl Peroxide-Erythromycin

C1Calcipotriene

C1Calcipotriene

C1Calcipotriene

C1Calcitriol

C1Carac

C1Claravis

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clindamycin Phosphate




C1Clindamycin Phosphate-Benzoyl Peroxide

C1Clotrimazole-Betamethasone

C1Clotrimazole-Betamethasone

C1Cortisporin

C1Cortisporin

C1Cosentyx

C1Cosentyx Sensoready

C1Diclofenac Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Dental and Oral Agents

Chlorhexidine Gluconate (Mouth Solution)

1

Pilocarpine HCl (Oral Tablet)

1

Triamcinolone Acetonide (Dental Paste)

1

Dermatological Agents

Dermatological Agents

Acitretin (Oral Capsule) 1

Adapalene (External Cream)

1

Adapalene (0.1% External Gel)

1

Ammonium Lactate (External Cream)

1

Ammonium Lactate (External Lotion)

1

Azelaic Acid (External Gel)

1

Benzoyl Peroxide-Erythromycin (External Gel)

1

Calcipotriene (External Cream)

1

Calcipotriene (External Ointment)

1

Calcipotriene (External Solution)

1

Calcitriol (External

Ointment)1

Carac (External

Cream)1 PA

Claravis (Oral Capsule) 1 PA

Clindamycin Phosphate (External Gel)

1

Clindamycin Phosphate (External Lotion)

1

Clindamycin Phosphate (External Solution)

1

Clindamycin Phosphate (External Swab)

1

Clindamycin Phosphate-Benzoyl Peroxide (1-5% External Gel)

1

Clotrimazole-Betamethasone (External Cream)

1

Clotrimazole-Betamethasone (External Lotion)

1

Cortisporin (External

Cream)1

Cortisporin (External

Ointment)1

Cosentyx (300 MG

Dose) (Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Cosentyx Sensoready

(300 MG)

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA

Diclofenac Sodium (3% Transdermal Gel)

1 PA

tRACK60

50


C1Doxepin HCl

C1Ery

C1Erythromycin

C1Erythromycin

C1Finacea

C1Fluorouracil

C1Fluorouracil

C1Fluorouracil

C1Imiquimod

C1Imiquimod Pump

C1Isotretinoin

C1Methoxsalen Rapid

C1Mirvaso

C1Oxsoralen Ultra

C1Picato

C1Pimecrolimus

C1Podofilox

C1Regranex

C1Santyl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Selenium Sulfide

C1Stelara

C1Stelara

C1Tacrolimus

C1Tazarotene

C1Tazorac

C1Tazorac

C1Tazorac

C1Tolak

C1Tretinoin

C1Tretinoin

C1Tretinoin Microsphere

C1Zyclara Pump

A1

B1

C1Aminosyn II

C1Aminosyn-PF

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Doxepin HCl (External Cream)

1 PA; QL

Ery (External Pad) 1

Erythromycin (External Gel)

1

Erythromycin (External Solution)

1

Finacea (External

Foam)1

Fluorouracil (0.5% External Cream)

1

Fluorouracil (5% External Cream)

1

Fluorouracil (External Solution)

1

Imiquimod (5% External Cream)

1

Imiquimod Pump (3.75% External Cream)

1 PA

Isotretinoin (Oral Capsule)

1 PA

Methoxsalen Rapid (Oral Capsule)

1

Mirvaso (External Gel) 1

Oxsoralen Ultra (Oral

Capsule)1

Picato (External Gel) 1

Pimecrolimus (External Cream)

1 ST

Podofilox (External Solution)

1

Regranex (External

Gel)1 PA

Santyl (External

Ointment)1

Selenium Sulfide (External Lotion)

1

Stelara

(Subcutaneous

Solution)

1 PA

Stelara

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Tacrolimus (External Ointment)

1 ST

Tazarotene (External Cream)

1 PA

Tazorac (0.05%

External Cream)1 PA

Tazorac (0.05%

External Gel)1 PA

Tazorac (0.1%

External Gel)1 PA

Tolak (External

Cream)1

Tretinoin (External Cream)

1 PA

Tretinoin (0.01% External Gel, 0.025% External Gel)

1 PA

Tretinoin Microsphere (External Gel)

1 PA

Zyclara Pump

(External Cream)1 PA

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

Aminosyn II

(Intravenous Solution)1 B/D, PA

Aminosyn-PF (7%

Intravenous Solution)1 B/D, PA

tRACK 61

51


C1Carbaglu

C1Dextrose

C1Dextrose

C1Dextrose-NaCl

C1Dextrose-NaCl

C1FreAmine HBC

C1HepatAmine

C1Intralipid

C1Isolyte-P in D5W

C1Isolyte-S

C1KCl in Dextrose-NaCl

C1KCl-Lactated Ringers-D5W

C1Klor-Con 10

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Klor-Con M10

C1Klor-Con M15

C1Klor-Con M20

C1Klor-Con

C1Klor-Con 8

C1Levocarnitine

C1Levocarnitine

C1Magnesium Sulfate

C1Magnesium Sulfate

C1NephrAmine

C1Normosol-M in D5W

C1Nutrilipid

C1Plasma-Lyte 148

C1Plasma-Lyte A

C1Plenamine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Carbaglu (Oral Tablet) 1 LA

Dextrose (10%

Intravenous Solution)1

Dextrose (5% Intravenous Solution)

1 B/D, PA

Dextrose-NaCl

(10-0.2% Intravenous

Solution, 10-0.45%

Intravenous Solution,

2.5-0.45%


5-0.2% Intravenous

Solution, 5-0.45%

Intravenous Solution)

1

Dextrose-NaCl

(5-0.9% Intravenous

Solution)

1 B/D, PA

FreAmine HBC


HepatAmine


Intralipid (Intravenous

Emulsion)1 B/D, PA

Isolyte-P in D5W

(Intravenous Solution)1

Isolyte-S (Intravenous

Solution)1

KCl in Dextrose-NaCl


KCl-Lactated Ringers-

D5W (Intravenous

Solution)

1

Klor-Con 10 (Oral

Tablet Extended

Release)

1

Klor-Con M10 (Oral Tablet Extended Release)

1


1


1

Klor-Con (Oral Packet) 1

Klor-Con 8 (Oral

Tablet Extended

Release)

1

Levocarnitine (1GM/ 10ML Oral Solution)

1

Levocarnitine (330MG

Oral Tablet)1

Magnesium Sulfate

(50% Injection

Solution)

1

Magnesium Sulfate (50% (10ML Syringe) Injection Solution)

1

NephrAmine


Normosol-M in D5W


Nutrilipid

(Intravenous

Emulsion)

1 B/D, PA

Plasma-Lyte 148


Plasma-Lyte A


Plenamine (Intravenous Solution)

1 B/D, PA

tRACK62

52


C1Potassium Chloride CR

C1Potassium Chloride ER

C1Potassium Chloride in Dextrose

C1Potassium Chloride in NaCl

C1Potassium Chloride in NaCl

C1Potassium Chloride




C1Potassium Citrate ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Premasol

C1Procalamine

C1Prosol

C1Sodium Chloride

C1Sodium Chloride

C1Sodium Chloride

C1Sodium Chloride

C1Sodium Fluoride

C1TPN Electrolytes

C1Travasol

C1TrophAmine

B1

C1Chemet

C1Clovique

C1Deferasirox Granules

C1Deferasirox

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Potassium Chloride CR (Oral Tablet Extended Release)

1

Potassium Chloride ER (Oral Capsule Extended Release)

1

Potassium Chloride in

Dextrose (Intravenous

Solution)

1 B/D, PA

Potassium Chloride in NaCl (20-0.45MEQ/L-% Intravenous Solution)

1 B/D, PA

Potassium Chloride in

NaCl (20-0.9MEQ/L-%


40-0.9MEQ/L-%


1 B/D, PA

Potassium Chloride

(10MEQ/100ML


20MEQ/100ML


40MEQ/100ML


1 B/D, PA

Potassium Chloride (2MEQ/ML Intravenous Solution, 2MEQ/ML (20ML) Intravenous Solution)

1 B/D, PA

Potassium Chloride (Oral Packet)

1

Potassium Chloride (Oral Solution)

1

Potassium Citrate ER (Oral Tablet Extended Release)

1

Premasol (Intravenous Solution)

1 B/D, PA

Procalamine


Prosol (Intravenous

Solution)1 B/D, PA

Sodium Chloride

(0.45% Intravenous

Solution)

1

Sodium Chloride (0.9% Intravenous Solution)

1 B/D, PA

Sodium Chloride (3%


5% Intravenous

Solution)

1 B/D, PA

Sodium Chloride

(Irrigation Solution)1

Sodium Fluoride (Oral Tablet)

1

TPN Electrolytes

(Intravenous

Concentrate)

1

Travasol (Intravenous

Solution)1 B/D, PA

TrophAmine (10%

Intravenous Solution)1 B/D, PA

Electrolyte/Mineral/Metal Modifiers

Chemet (Oral

Capsule)1

Clovique (Oral Capsule)

1 PA; QL

Deferasirox Granules (Oral Packet)

1 PA

Deferasirox (Oral Tablet) (Generic Jadenu)

1 PA

tRACK 63

53


C1Deferasirox

C1Ferriprox

C1Ferriprox

C1Jadenu

C1Jadenu Sprinkle

C1Kionex

C1Lokelma

C1Sodium Polystyrene Sulfonate

C1Sodium Polystyrene Sulfonate

C1SPS

C1Trientine HCl

C1Veltassa

B1

C1Auryxia

C1Calcium Acetate

C1Calcium Acetate

C1Lanthanum Carbonate

C1Phoslyra

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Sevelamer Carbonate

C1Sevelamer Carbonate

C1Velphoro

B1

C1VP-PNV-DHA

A1

B1

C1Cuvposa

C1Dicyclomine HCl

C1Dicyclomine HCl

C1Dicyclomine HCl

C1Methscopolamine Bromide

B1

C1Chenodal

C1Cromolyn Sodium

C1Diphenoxylate-Atropine

C1Diphenoxylate-Atropine

C1Gattex

C1Loperamide HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Deferasirox (Oral Tablet Soluble) (Generic Exjade)

1 PA

Ferriprox (Oral

Solution)1 PA

Ferriprox (Oral Tablet) 1 PA

Jadenu (Oral Tablet) 1 PA

Jadenu Sprinkle (Oral

Packet)1 PA

Kionex (Oral Suspension)

1

Lokelma (Oral Packet) 1 QL

Sodium Polystyrene Sulfonate (Oral Powder)

1

Sodium Polystyrene Sulfonate (Oral Suspension)

1

SPS (Oral Suspension) 1

Trientine HCl (Oral Capsule)

1 PA; QL

Veltassa (Oral Packet) 1 QL

Phosphate Binders

Auryxia (Oral Tablet) 1 PA

Calcium Acetate (Phosphate Binder) (Oral Capsule)

1

Calcium Acetate (Phosphate Binder) (Oral Tablet)

1

Lanthanum Carbonate (Oral Tablet Chewable)

1

Phoslyra (Oral

Solution)1

Sevelamer Carbonate (Oral Packet)

1

Sevelamer Carbonate (Oral Tablet) (Generic Renvela)

1

Velphoro (Oral Tablet

Chewable)1

Vitamins

VP-PNV-DHA (Oral Capsule)

1

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

Cuvposa (Oral

Solution)1 PA

Dicyclomine HCl (Oral Capsule)

1

Dicyclomine HCl (Oral Solution)

1

Dicyclomine HCl (Oral Tablet)

1

Methscopolamine Bromide (Oral Tablet)

1

Gastrointestinal Agents, Other

Chenodal (Oral Tablet) 1

Cromolyn Sodium (Oral Concentrate)

1

Diphenoxylate-Atropine (Oral Liquid)

1

Diphenoxylate-Atropine (Oral Tablet)

1

Gattex (Subcutaneous

Kit)1 PA; LA

Loperamide HCl (Oral Capsule)

1

tRACK64

54


C1Myalept

C1Relistor

C1Relistor

C1Serostim

C1Ursodiol

C1Ursodiol

C1Zorbtive

B1

C1Cimetidine HCl

C1Cimetidine

C1Famotidine

C1Famotidine

B1

C1Alosetron HCl

C1Amitiza

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Linzess

C1Xifaxan

B1

C1Clenpiq

C1Constulose

C1Enulose

C1GaviLyte-C

C1GaviLyte-G

C1GaviLyte-N with Flavor Pack

C1Generlac

C1Lactulose

C1PEG-3350-NaCl-Na Bicarbonate-KCl

C1PEG-3350-Electrolytes

C1Suprep Bowel Prep Kit

C1TriLyte

B1

C1Carafate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Myalept

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Relistor (Oral Tablet) 1 PA; QL

Relistor

(Subcutaneous

Solution)

1 PA

Serostim

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Ursodiol (Oral Capsule)

1

Ursodiol (Oral Tablet) 1

Zorbtive

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Histamine2 (H2) Receptor Antagonists

Cimetidine HCl (Oral Solution)

1

Cimetidine (Oral Tablet)

1

Famotidine (Oral Suspension Reconstituted)

1

Famotidine (20MG Oral Tablet, 40MG Oral Tablet)

1

Irritable Bowel Syndrome Agents

Alosetron HCl (Oral Tablet)

1 PA

Amitiza (Oral

Capsule)1 QL

Linzess (Oral

Capsule)1 QL

Xifaxan (Oral Tablet) 1 PA

Laxatives

Clenpiq (Oral

Solution)1

Constulose (Oral Solution)

1

Enulose (Oral Solution) 1

GaviLyte-C (Oral Solution Reconstituted)

1

GaviLyte-G (Oral Solution Reconstituted)

1

GaviLyte-N with Flavor Pack (Oral Solution Reconstituted)

1

Generlac (Oral Solution)

1

Lactulose (10GM/ 15ML Oral Solution)

1

PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution) (Generic NuLYTELY)

1

PEG-3350-Electrolytes (Oral Solution) (Generic GoLYTELY)

1

Suprep Bowel Prep

Kit (Oral Solution)1

TriLyte (Oral Solution Reconstituted)

1

Protectants

Carafate (Oral

Suspension)1

tRACK 65

55


C1Misoprostol

C1Sucralfate

C1Sucralfate

B1

C1Dexilant

C1Esomeprazole Magnesium

C1Lansoprazole

C1Omeprazole

C1Omeprazole

C1Pantoprazole Sodium

C1Prilosec

C1Rabeprazole Sodium

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Aralast NP

C1Cholbam

C1Creon

C1Cystadane

C1Cystagon

C1Glassia

C1Kuvan

C1Kuvan

C1Miglustat

C1Nitisinone

C1Ocaliva

C1Orfadin

C1Orfadin

C1Procysbi

C1Prolastin-C

C1RAVICTI

C1Sodium Phenylbutyrate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Misoprostol (Oral Tablet)

1

Sucralfate (Oral Suspension)

1

Sucralfate (Oral Tablet) 1

Proton Pump Inhibitors

Dexilant (Oral

Capsule Delayed

Release)

1 QL

Esomeprazole Magnesium (Oral Capsule Delayed Release) (Generic Nexium)

1 QL

Lansoprazole (Oral Capsule Delayed Release)

1 QL

Omeprazole (10MG Oral Capsule Delayed Release)

1 QL

Omeprazole (20MG Oral Capsule Delayed Release, 40MG Oral Capsule Delayed Release)

1

Pantoprazole Sodium (Oral Tablet Delayed Release)

1 QL

Prilosec (Oral Packet) 1 PA

Rabeprazole Sodium (Oral Tablet Delayed Release)

1

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Aralast NP (1000MG


Reconstituted)

1 PA; LA

Cholbam (Oral

Capsule)1 PA

Creon (Oral Capsule

Delayed Release

Particles)

1

Cystadane (Oral

Powder)1

Cystagon (Oral

Capsule)1 LA

Glassia (Intravenous

Solution)1 PA; LA

Kuvan (Oral Packet) 1 LA

Kuvan (Oral Tablet

Soluble)1 LA

Miglustat (Oral Capsule)

1 PA; LA

Nitisinone (Oral Capsule)

1

Ocaliva (Oral Tablet) 1 PA; QL

Orfadin (Oral

Capsule)1 LA

Orfadin (Oral

Suspension)1 LA

Procysbi (Oral

Packet)1 LA

Prolastin-C


Reconstituted)

1 PA; LA

RAVICTI (Oral Liquid) 1 LA; QL

Sodium Phenylbutyrate (Oral Powder)

1

tRACK66

56


C1Sodium Phenylbutyrate

C1Sucraid

C1Tegsedi

C1Zemaira

C1Zenpep

A1

B1

C1Myrbetriq

C1Oxybutynin Chloride ER

C1Oxybutynin Chloride

C1Oxybutynin Chloride

C1Solifenacin Succinate

B1

C1Alfuzosin HCl ER

C1Dutasteride

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Finasteride

C1Silodosin

C1Tamsulosin HCl

C1Terazosin HCl

B1

C1Bethanechol Chloride

C1Depen Titratabs

C1Elmiron

C1Lithostat

C1Penicillamine

C1Penicillamine

A1

B1

C1Ala-Cort

C1Alclometasone Dipropionate

C1Alclometasone Dipropionate

C1Betamethasone Dipropionate Aug

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Sodium Phenylbutyrate (Oral Tablet)

1

Sucraid (Oral

Solution)1 LA

Tegsedi

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Zemaira (Intravenous

Solution

Reconstituted)

1 PA; LA

Zenpep (Oral Capsule

Delayed Release

Particles)

1

Genitourinary Agents

Antispasmodics, Urinary

Myrbetriq (Oral Tablet

Extended Release 24

Hour)

1

Oxybutynin Chloride ER (Oral Tablet Extended Release 24 Hour)

1 QL

Oxybutynin Chloride (Oral Syrup)

1

Oxybutynin Chloride (Oral Tablet Immediate Release)

1

Solifenacin Succinate (Oral Tablet)

1 QL

Benign Prostatic Hypertrophy Agents

Alfuzosin HCl ER (Oral Tablet Extended Release 24 Hour)

1

Dutasteride (Oral Capsule)

1 QL

Finasteride (5MG Oral Tablet) (Generic Proscar)

1

Silodosin (Oral Capsule)

1 QL

Tamsulosin HCl (Oral Capsule)

1

Terazosin HCl (Oral Capsule)

1

Genitourinary Agents, Other

Bethanechol Chloride (Oral Tablet)

1

Depen Titratabs (Oral

Tablet)1

Elmiron (Oral

Capsule)1

Lithostat (Oral Tablet) 1

Penicillamine (250MG Oral Capsule)

1 PA

Penicillamine (250MG Oral Tablet)

1

Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Ala-Cort (1% External Cream)

1

Alclometasone Dipropionate (External Cream)

1

Alclometasone Dipropionate (External Ointment)

1

Betamethasone Dipropionate Aug (External Cream)

1

tRACK 67

57





C1Betamethasone Dipropionate



C1Betamethasone Valerate



C1Clobetasol Propionate Emollient Base

C1Clobetasol Propionate



Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clobetasol Propionate


C1Cordran

C1Cortisone Acetate

C1Desonide

C1Desoximetasone

C1Dexamethasone

C1Dexamethasone

C1Fludrocortisone Acetate

C1Fluocinolone Acetonide



C1Fluocinolone Acetonide Scalp

C1Fluocinonide Emulsified Base

C1Fluocinonide

C1Fluocinonide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Betamethasone Dipropionate Aug (External Gel)

1

Betamethasone Dipropionate Aug (External Lotion)

1

Betamethasone Dipropionate Aug (External Ointment)

1

Betamethasone Dipropionate (External Cream)

1

Betamethasone Dipropionate (External Lotion)

1

Betamethasone Dipropionate (External Ointment)

1

Betamethasone Valerate (External Cream)

1

Betamethasone Valerate (External Lotion)

1

Betamethasone Valerate (External Ointment)

1

Clobetasol Propionate Emollient Base (External Cream)

1

Clobetasol Propionate (External Cream)

1

Clobetasol Propionate (External Gel)

1

Clobetasol Propionate (External Ointment)

1

Clobetasol Propionate (External Shampoo)

1

Clobetasol Propionate (External Solution)

1

Cordran (External

Tape)1

Cortisone Acetate (Oral Tablet)

1

Desonide (External Ointment)

1

Desoximetasone (External Cream)

1

Dexamethasone (Oral Elixir)

1

Dexamethasone (Oral Tablet)

1

Fludrocortisone Acetate (Oral Tablet)

1

Fluocinolone Acetonide (External Cream)

1

Fluocinolone Acetonide (External Ointment)

1

Fluocinolone Acetonide (External Solution)

1

Fluocinolone Acetonide Scalp (External Oil)

1

Fluocinonide Emulsified Base (External Cream)

1

Fluocinonide (External Gel)

1

Fluocinonide (External Ointment)

1

tRACK68

58


C1Fluocinonide

C1Fluticasone Propionate


C1Halobetasol Propionate

C1Halobetasol Propionate

C1Hydrocortisone Butyrate

C1Hydrocortisone

C1Hydrocortisone

C1Hydrocortisone

C1Hydrocortisone

C1Hydrocortisone Valerate

C1Hydrocortisone Valerate

C1Methylprednisolone

C1Methylprednisolone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Mometasone Furoate

C1Mometasone Furoate


C1Prednicarbate

C1Prednicarbate

C1Prednisolone

C1Prednisolone Sodium Phosphate

C1Prednisone Intensol

C1Prednisone

C1Prednisone

C1Prednisone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Fluocinonide (External Solution)

1

Fluticasone Propionate (External Cream)

1

Fluticasone Propionate (External Ointment)

1

Halobetasol Propionate (External Cream)

1

Halobetasol Propionate (External Ointment)

1

Hydrocortisone Butyrate (External Ointment)

1

Hydrocortisone (1% External Cream, 2.5% External Cream)

1

Hydrocortisone (2.5% External Lotion)

1

Hydrocortisone (1% External Ointment, 2.5% External Ointment)

1

Hydrocortisone (Oral Tablet)

1

Hydrocortisone Valerate (External Cream)

1

Hydrocortisone Valerate (External Ointment)

1

Methylprednisolone (Oral Tablet)

1

Methylprednisolone (Oral Tablet Therapy Pack)

1

Mometasone Furoate (External Cream)

1

Mometasone Furoate (External Ointment)

1

Mometasone Furoate (External Solution)

1

Prednicarbate (External Cream)

1

Prednicarbate (External Ointment)

1

Prednisolone (Oral Solution)

1

Prednisolone Sodium Phosphate (25MG/ 5ML Oral Solution, 6.7MG/5ML Oral Solution)

1

Prednisone Intensol (Oral Concentrate)

1

Prednisone (5MG/5ML Oral Solution)

1

Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG Oral Tablet)

1

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)

1

tRACK 69

59





C1Triderm

A1

B1

C1Desmopressin Acetate

C1Desmopressin Acetate Spray

C1Genotropin MiniQuick

C1Genotropin

C1Humatrope

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Increlex

C1Norditropin FlexPro

C1Nutropin AQ NuSpin 10



C1Saizen

C1Saizenprep

A1

B1

C1Korlym

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Triamcinolone Acetonide (External Cream)

1

Triamcinolone Acetonide (External Lotion)

1

Triamcinolone Acetonide (0.025% External Ointment, 0.1% External Ointment, 0.5% External Ointment)

1

Triderm (0.1% External Cream)

1

Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Desmopressin Acetate (Oral Tablet)

1

Desmopressin Acetate Spray (Nasal Solution)

1

Genotropin MiniQuick

(Subcutaneous

Solution

Reconstituted)

1 PA

Genotropin

(Subcutaneous

Solution

Reconstituted)

1 PA

Humatrope (Injection

Solution

Renconstituted),

Humatrope Combo

Pack (Injection)

1 PA

Increlex

(Subcutaneous

Solution)

1 PA; LA

Norditropin FlexPro

(10MG/1.5ML

Subcutaneous

Solution, 15MG/

1.5ML Subcutaneous

Solution, 30MG/3ML

Subcutaneous

Solution, 5MG/1.5ML

Subcutaneous

Solution)

1 PA

Nutropin AQ NuSpin

10 (10MG/2ML

Subcutaneous

Solution)

1 PA

Nutropin AQ NuSpin

20 (20MG/2ML

Subcutaneous

Solution)

1 PA

Nutropin AQ NuSpin 5

(5MG/2ML

Subcutaneous

Solution)

1 PA

Saizen (Injection

Solution

Reconstituted)

1 PA; LA

Saizenprep (Injection

Solution

Reconstituted)

1 PA; LA

Hormonal Agents, Stimulant/Replacement/ Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Korlym (Oral Tablet) 1 PA; LA; QL

tRACK70

60


A1

B1

C1Anadrol-50

C1Androderm

C1Danazol

C1Oxandrolone

C1Oxandrolone

C1Testosterone Cypionate

C1Testosterone Enanthate

C1Testosterone

C1Testosterone

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Altavera

C1Alyacen 1/35

C1Amethia Lo

C1Amethia

C1Apri

C1Aranelle

C1Ashlyna

C1Aubra

C1Aviane

C1Balziva

C1Blisovi 24 Fe

C1Blisovi Fe 1.5/30

C1Briellyn

C1Camrese Lo

C1Caziant

C1Climara Pro

C1Cryselle-28

C1Cyclafem 1/35

C1Cyclafem 7/7/7

C1Cyred

C1Depo-Estradiol

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Hormonal Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers)

Androgens

Anadrol-50 (Oral

Tablet)1 PA

Androderm

(Transdermal Patch

24 Hour)

1 QL

Danazol (Oral Capsule) 1

Oxandrolone (10MG Oral Tablet)

1 PA; QL

Oxandrolone (2.5MG Oral Tablet)

1 PA; QL

Testosterone Cypionate (Intramuscular Solution)

1

Testosterone Enanthate (Intramuscular Solution)

1

Testosterone (25MG/ 2.5GM 1% Transdermal Gel, 50MG/5GM 1% Transdermal Gel), Testosterone Pump (1% Transdermal Gel)

1

Testosterone (20.25MG/1.25GM 1.62% Transdermal Gel, 40.5MG/2.5GM 1.62% Transdermal Gel), Testosterone Pump (1.62% Transdermal Gel)

1

Estrogens

Altavera (Oral Tablet) 1

Alyacen 1/35 (Oral Tablet)

1

Amethia Lo (Oral Tablet)

1

Amethia (Oral Tablet) 1

Apri (Oral Tablet) 1

Aranelle (Oral Tablet) 1

Ashlyna (Oral Tablet) 1

Aubra (Oral Tablet) 1

Aviane (Oral Tablet) 1

Balziva (Oral Tablet) 1

Blisovi 24 Fe (Oral Tablet)

1

Blisovi Fe 1.5/30 (Oral Tablet)

1

Briellyn (Oral Tablet) 1

Camrese Lo (Oral Tablet)

1

Caziant (Oral Tablet) 1

Climara Pro

(Transdermal Patch

Weekly)

1

Cryselle-28 (Oral Tablet)

1

Cyclafem 1/35 (Oral Tablet)

1

Cyclafem 7/7/7 (Oral Tablet)

1

Cyred (Oral Tablet) 1

Depo-Estradiol (Intramuscular Oil)

1

tRACK 71

61


C1Desogestrel-Ethinyl Estradiol

C1Drospirenone-Ethinyl Estradiol

C1Duavee

C1Elestrin

C1EluRyng

C1Emoquette

C1Enpresse-28

C1Enskyce

C1Estarylla

C1Estradiol

C1Estradiol

C1Estradiol

C1Estradiol

C1Estradiol Valerate

C1Estring

C1Ethynodiol Diacetate-Ethinyl Estradiol

C1Etonogestrel-Ethinyl Estradiol

C1Falmina

C1Fayosim

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Femring

C1Femynor

C1Fyavolv

C1Gianvi

C1Hailey 24 Fe

C1Imvexxy Maintenance Pack

C1Imvexxy Starter Pack

C1Introvale

C1Isibloom

C1Jasmiel

C1Jinteli

C1Juleber

C1Junel 1.5/30

C1Junel 1/20

C1Junel Fe 1.5/30

C1Junel Fe 1/20

C1Junel Fe 24

C1Kaitlib Fe

C1Kariva

C1Kelnor 1/35

C1Kelnor 1/50

C1Kurvelo

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Desogestrel-Ethinyl Estradiol (0.15-0.02/0.01MG (21/5) Oral Tablet)

1

Drospirenone-Ethinyl Estradiol (Oral Tablet)

1

Duavee (Oral Tablet) 1

Elestrin (Transdermal

Gel)1

EluRyng (Vaginal Ring) 1

Emoquette (Oral Tablet)

1

Enpresse-28 (Oral Tablet)

1

Enskyce (Oral Tablet) 1

Estarylla (Oral Tablet) 1

Estradiol (Oral Tablet) 1

Estradiol (Transdermal Patch Weekly)

1 QL

Estradiol (Vaginal Cream)

1

Estradiol (Vaginal Tablet)

1 QL

Estradiol Valerate (Intramuscular Oil)

1

Estring (Vaginal Ring) 1

Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet)

1

Etonogestrel-Ethinyl Estradiol (Vaginal Ring)

1

Falmina (Oral Tablet) 1

Fayosim (Oral Tablet) 1

Femring (Vaginal

Ring)1

Femynor (Oral Tablet) 1

Fyavolv (Oral Tablet) 1

Gianvi (Oral Tablet) 1

Hailey 24 Fe (Oral Tablet)

1

Imvexxy Maintenance

Pack (Vaginal Insert)1 PA; QL

Imvexxy Starter Pack

(Vaginal Insert)1 PA; QL

Introvale (Oral Tablet) 1

Isibloom (Oral Tablet) 1

Jasmiel (Oral Tablet) 1

Jinteli (Oral Tablet) 1

Juleber (Oral Tablet) 1

Junel 1.5/30 (Oral Tablet)

1

Junel 1/20 (Oral Tablet)

1

Junel Fe 1.5/30 (Oral Tablet)

1

Junel Fe 1/20 (Oral Tablet)

1

Junel Fe 24 (Oral Tablet)

1

Kaitlib Fe (Oral Tablet Chewable)

1

Kariva (Oral Tablet) 1

Kelnor 1/35 (Oral Tablet)

1

Kelnor 1/50 (Oral Tablet)

1

Kurvelo (Oral Tablet) 1

tRACK72

62


C1LARIN 1.5/30

C1LARIN 1/20

C1LARIN Fe 1.5/30

C1LARIN Fe 1/20

C1Larissia

C1Layolis Fe

C1Leena

C1Lessina

C1Levonest

C1Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol

C1Levonorgestrel-Ethinyl Estradiol 91-Day

C1Levonorgestrel-Ethinyl Estradiol

C1Levora 0.15/30

C1Loryna

C1Low-Ogestrel

C1Lutera

C1Marlissa

C1Melodetta 24 Fe

C1Menest

C1Mibelas 24 Fe

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Microgestin 1.5/30

C1Microgestin 1/20

C1Microgestin Fe 1.5/30

C1Microgestin Fe 1/20

C1Mili

C1Necon 0.5/35

C1Nikki

C1Norethindrone Acetate-Ethinyl Estradiol

C1Norethindrone Acetate-Ethinyl Estradiol

C1Norethindrone Acetate-Ethinyl Estradiol-Fe

C1Norgestimate-Ethinyl Estradiol

C1Norgestimate-Ethinyl Estradiol Triphasic

C1Nortrel 0.5/35

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

LARIN 1.5/30 (Oral Tablet)

1

LARIN 1/20 (Oral Tablet)

1

LARIN Fe 1.5/30 (Oral Tablet)

1

LARIN Fe 1/20 (Oral Tablet)

1

Larissia (Oral Tablet) 1

Layolis Fe (Oral

Tablet Chewable)1

Leena (Oral Tablet) 1

Lessina (Oral Tablet) 1

Levonest (Oral Tablet) 1

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral Tablet)

1

Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet)

1

Levonorgestrel-Ethinyl Estradiol (Oral Tablet)

1

Levora 0.15/30 (28) (Oral Tablet)

1

Loryna (Oral Tablet) 1

Low-Ogestrel (Oral Tablet)

1

Lutera (Oral Tablet) 1

Marlissa (Oral Tablet) 1

Melodetta 24 Fe (Oral Tablet Chewable)

1

Menest (Oral Tablet) 1

Mibelas 24 Fe (Oral Tablet Chewable)

1

Microgestin 1.5/30 (Oral Tablet)

1

Microgestin 1/20 (Oral Tablet)

1

Microgestin Fe 1.5/30 (Oral Tablet)

1

Microgestin Fe 1/20 (Oral Tablet)

1

Mili (Oral Tablet) 1

Necon 0.5/35 (28) (Oral Tablet)

1

Nikki (Oral Tablet) 1

Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG Oral Tablet, 1-5MG-MCG Oral Tablet)

1

Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG Oral Tablet)

1

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)

1

Norgestimate-Ethinyl Estradiol (Oral Tablet)

1

Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet)

1

Nortrel 0.5/35 (28) (Oral Tablet)

1

tRACK 73

63


C1Nortrel 1/35

C1Nortrel 1/35

C1Nortrel 7/7/7

C1Ocella

C1Orsythia

C1Pimtrea

C1Pirmella 1/35

C1Portia-28

C1Premarin

C1Premarin

C1Premphase

C1Prempro

C1Previfem

C1Reclipsen

C1Rivelsa

C1Setlakin

C1Sprintec 28

C1Sronyx

C1Syeda

C1Tarina 24 Fe

C1Tarina Fe 1/20

C1Tri-Estarylla

C1Tri-Legest Fe

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tri-Lo-Estarylla

C1Tri-Lo-Sprintec

C1Tri-Mili

C1Tri-Previfem

C1Tri-Sprintec

C1Trivora

C1Tri-VyLibra Lo

C1Tri-VyLibra

C1Velivet

C1Vienva

C1Vyfemla

C1VyLibra

C1WYMZYA Fe

C1Xulane

C1Yuvafem

C1Zarah

C1Zovia 1/35E

B1

C1Camila

C1Crinone

C1Deblitane

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nortrel 1/35 (21) (Oral Tablet)

1

Nortrel 1/35 (28) (Oral Tablet)

1

Nortrel 7/7/7 (Oral Tablet)

1

Ocella (Oral Tablet) 1

Orsythia (Oral Tablet) 1

Pimtrea (Oral Tablet) 1

Pirmella 1/35 (Oral Tablet)

1

Portia-28 (Oral Tablet) 1

Premarin (Oral Tablet) 1 QL

Premarin (Vaginal

Cream)1

Premphase (Oral

Tablet)1 QL

Prempro (Oral Tablet) 1 QL

Previfem (Oral Tablet) 1

Reclipsen (Oral Tablet) 1

Rivelsa (Oral Tablet) 1

Setlakin (Oral Tablet) 1

Sprintec 28 (Oral Tablet)

1

Sronyx (Oral Tablet) 1

Syeda (Oral Tablet) 1

Tarina 24 Fe (Oral Tablet)

1

Tarina Fe 1/20 (Oral Tablet)

1

Tri-Estarylla (Oral Tablet)

1

Tri-Legest Fe (Oral Tablet)

1

Tri-Lo-Estarylla (Oral Tablet)

1

Tri-Lo-Sprintec (Oral Tablet)

1

Tri-Mili (Oral Tablet) 1

Tri-Previfem (Oral Tablet)

1

Tri-Sprintec (Oral Tablet)

1

Trivora (28) (Oral Tablet)

1

Tri-VyLibra Lo (Oral Tablet)

1

Tri-VyLibra (Oral Tablet)

1

Velivet (Oral Tablet) 1

Vienva (Oral Tablet) 1

Vyfemla (Oral Tablet) 1

VyLibra (Oral Tablet) 1

WYMZYA Fe (Oral Tablet Chewable)

1

Xulane (Transdermal Patch Weekly)

1

Yuvafem (Vaginal Tablet)

1 QL

Zarah (Oral Tablet) 1

Zovia 1/35E (28) (Oral Tablet)

1

Progestins

Camila (Oral Tablet) 1

Crinone (Vaginal Gel) 1 PA

Deblitane (Oral Tablet) 1

tRACK74

64


C1Depo-Provera

C1Errin

C1Incassia

C1Lyza

C1Medroxyprogesterone Acetate



C1Megestrol Acetate

C1Megestrol Acetate

C1Megestrol Acetate

C1Nora-BE

C1Norethindrone Acetate

C1Norethindrone

C1Progesterone Micronized

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Sharobel

B1

C1Osphena

C1Raloxifene HCl

A1

B1

C1Euthyrox

C1Levo-T

C1Levothyroxine Sodium

C1Levoxyl

C1Liothyronine Sodium

C1Synthroid

C1Unithroid

A1

B1

C1Lysodren

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Depo-Provera

(400MG/ML

Intramuscular

Suspension)

1

Errin (Oral Tablet) 1

Incassia (Oral Tablet) 1

Lyza (Oral Tablet) 1

Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension)

1

Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension Prefilled Syringe)

1

Medroxyprogesterone Acetate (10MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)

1

Megestrol Acetate (40MG/ML Oral Suspension)

1

Megestrol Acetate (625MG/5ML Oral Suspension)

1

Megestrol Acetate (Oral Tablet)

1

Nora-BE (Oral Tablet) 1

Norethindrone Acetate (5MG Oral Tablet)

1

Norethindrone (0.35MG Oral Tablet)

1

Progesterone Micronized (Oral Capsule)

1

Sharobel (Oral Tablet) 1

Selective Estrogen Receptor Modifying Agents

Osphena (Oral Tablet) 1 PA; QL

Raloxifene HCl (Oral Tablet)

1 QL

Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Euthyrox (Oral Tablet) 1

Levo-T (Oral Tablet) 1

Levothyroxine Sodium (Oral Tablet)

1

Levoxyl (Oral Tablet) 1

Liothyronine Sodium (Oral Tablet)

1

Synthroid (Oral

Tablet)1

Unithroid (100MCG

Oral Tablet, 112MCG

Oral Tablet, 125MCG

Oral Tablet, 150MCG

Oral Tablet, 175MCG

Oral Tablet, 200MCG

Oral Tablet, 25MCG

Oral Tablet, 300MCG

Oral Tablet, 50MCG

Oral Tablet, 75MCG

Oral Tablet, 88MCG

Oral Tablet)

1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)

Lysodren (Oral

Tablet)1

tRACK 75

65


A1

B1

C1Cabergoline

C1Egrifta SV

C1Firmagon

C1Firmagon

C1Leuprolide Acetate

C1Lupaneta Pack

C1Lupron Depot

C1Lupron Depot

C1Lupron Depot

C1Lupron Depot

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Octreotide Acetate

C1Octreotide Acetate

C1Signifor

C1Somatuline Depot

C1Somavert

C1Synarel

C1Trelstar Mixject

A1

B1

C1Methimazole

C1Propylthiouracil

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

Cabergoline (Oral Tablet)

1

Egrifta SV (2MG

Subcutaneous

Solution

Reconstituted)

1 PA; LA

Firmagon (240MG

Dose) (120MG/Vial

Subcutaneous

Solution

Reconstituted)

1 PA

Firmagon (80MG

Subcutaneous

Solution

Reconstituted)

1 PA

Leuprolide Acetate (Injection Kit)

1 PA

Lupaneta Pack

(Combination Kit)1 PA

Lupron Depot (1-

Month)

(Intramuscular Kit)

1 PA

Lupron Depot (3-

Month)

(Intramuscular Kit)

1 PA

Lupron Depot (4-

Month)

(Intramuscular Kit)

1 PA

Lupron Depot (6-

Month)

(Intramuscular Kit)

1 PA

Octreotide Acetate (1000MCG/ML Injection Solution, 500MCG/ML Injection Solution)

1 PA

Octreotide Acetate (100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 50MCG/ML Injection Solution)

1 PA

Signifor

(Subcutaneous

Solution)

1 PA; LA

Somatuline Depot

(Subcutaneous

Solution)

1

Somavert

(Subcutaneous

Solution

Reconstituted)

1 PA; LA; QL

Synarel (Nasal

Solution)1

Trelstar Mixject

(Intramuscular

Suspension

Reconstituted)

1 PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

Methimazole (Oral Tablet)

1

Propylthiouracil (Oral Tablet)

1

Immunological Agents

Angioedema Agents

tRACK76

66


C1Berinert

C1Cinryze

C1Firazyr

C1Haegarda

C1Icatibant Acetate

C1Ruconest

B1

C1Azathioprine

C1Cimzia Prefilled

C1Cimzia

C1Cyclosporine Modified

C1Cyclosporine Modified

C1Cyclosporine

C1Enbrel Mini

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Enbrel

C1Enbrel

C1Enbrel

C1Enbrel SureClick

C1Envarsus XR

C1Everolimus

C1Gengraf

C1Gengraf

C1Humira Pediatric Crohns Start

C1Humira Pen

C1Humira Pen Crohns Disease Starter

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Berinert (Intravenous

Kit)1 PA; LA

Cinryze (Intravenous

Solution

Reconstituted)

1 PA; LA

Firazyr

(Subcutaneous

Solution)

1 PA; QL

Haegarda

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Icatibant Acetate (Subcutaneous Solution)

1 PA; QL

Ruconest


Reconstituted)

1 PA; LA

Immune Suppressants

Azathioprine (Oral Tablet)

1 B/D, PA

Cimzia Prefilled

(Subcutaneous Kit)1 PA

Cimzia

(Subcutaneous Kit)1 PA

Cyclosporine Modified (Oral Capsule)

1 B/D, PA

Cyclosporine Modified (Oral Solution)

1 B/D, PA

Cyclosporine (Oral Capsule)

1 B/D, PA

Enbrel Mini

(Subcutaneous

Solution Cartridge)

1 PA

Enbrel

(Subcutaneous

Solution)

1 PA

Enbrel

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Enbrel

(Subcutaneous

Solution

Reconstituted)

1 PA

Enbrel SureClick

(Subcutaneous

Solution Auto-

Injector)

1 PA

Envarsus XR (Oral

Tablet Extended

Release 24 Hour)

1 B/D, PA

Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet, 0.75MG Oral Tablet)

1 B/D, PA

Gengraf (Oral Capsule) 1 B/D, PA

Gengraf (Oral Solution) 1 B/D, PA

Humira Pediatric

Crohns Start

(Subcutaneous


1 PA

Humira Pen

(Subcutaneous Pen-

Injector Kit)

1 PA

Humira Pen Crohns

Disease Starter

(Subcutaneous Pen-

Injector Kit)

1 PA

tRACK 77

67


C1Humira Pen Psoriasis Starter

C1Humira

C1Kineret

C1Methotrexate

C1Methotrexate Sodium

C1Methotrexate Sodium

C1Mycophenolate Mofetil



C1Mycophenolate Sodium

C1Orencia ClickJect

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Orencia

C1Prograf

C1Rasuvo

C1Sandimmune

C1Simponi

C1Simponi

C1Sirolimus

C1Sirolimus

C1Tacrolimus

C1Trexall

C1Xatmep

C1Xeljanz

C1Xeljanz XR

C1Zortress

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Humira Pen Psoriasis

Starter

(Subcutaneous Pen-

Injector Kit)

1 PA

Humira

(Subcutaneous


1 PA

Kineret

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Methotrexate (Oral Tablet)

1

Methotrexate Sodium (50MG/2ML Injection Solution Prefilled Syringe)

1

Methotrexate Sodium (50MG/2ML Injection Solution)

1

Mycophenolate Mofetil (Oral Capsule)

1 B/D, PA

Mycophenolate Mofetil (Oral Suspension Reconstituted)

1 B/D, PA

Mycophenolate Mofetil (Oral Tablet)

1 B/D, PA

Mycophenolate Sodium (Oral Tablet Delayed Release)

1 B/D, PA

Orencia ClickJect

(Subcutaneous

Solution Auto-

Injector)

1 PA

Orencia

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Prograf (Oral Packet) 1 B/D, PA

Rasuvo

(Subcutaneous

Solution Auto-

Injector)

1 PA

Sandimmune (Oral

Solution)1 B/D, PA

Simponi

(Subcutaneous

Solution Auto-

Injector)

1 PA

Simponi

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Sirolimus (Oral Solution)

1 B/D, PA

Sirolimus (Oral Tablet) 1 B/D, PA

Tacrolimus (Oral Capsule)

1 B/D, PA

Trexall (Oral Tablet) 1

Xatmep (Oral

Solution)1 PA

Xeljanz (Oral Tablet

Immediate Release)1 PA; QL

Xeljanz XR (Oral

Tablet Extended

Release 24 Hour)

1 PA; QL

Zortress (Oral Tablet) 1 B/D, PA

Immunizing Agents, Passive

tRACK78

68


C1BIVIGAM

C1Flebogamma DIF

C1Gammagard

C1Gammagard S/D Less IgA

C1Gammaked

C1Gammaplex

C1Gamunex-C

C1Octagam

C1Panzyga

C1Privigen

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Varizig

B1

C1Actemra ACTPen

C1Actemra

C1Actimmune

C1Arcalyst

C1Benlysta

C1Benlysta

C1Leflunomide

C1Otezla

C1Otezla

C1Ridaura

C1Xolair

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

BIVIGAM (Intravenous

Solution)1 PA

Flebogamma DIF

(5GM/50ML


1 PA

Gammagard (2.5GM/

25ML Injection

Solution)

1 PA

Gammagard S/D Less

IgA (Intravenous

Solution

Reconstituted)

1 PA

Gammaked (1GM/

10ML Injection

Solution)

1 PA

Gammaplex (10GM/

100ML Intravenous

Solution, 10GM/

200ML Intravenous

Solution, 20GM/

200ML Intravenous

Solution, 5GM/50ML


1 PA

Gamunex-C (1GM/

10ML Injection

Solution)

1 PA

Octagam (1GM/20ML


2GM/20ML


1 PA

Panzyga (Intravenous

Solution)1 PA

Privigen (20GM/

200ML Intravenous

Solution)

1 PA

Varizig (Intramuscular

Solution)1

Immunomodulators

Actemra ACTPen

(Subcutaneous

Solution Auto-

Injector)

1 PA

Actemra

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Actimmune

(Subcutaneous

Solution)

1 LA

Arcalyst

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Benlysta

(Subcutaneous

Solution Auto-

Injector)

1 PA

Benlysta

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Leflunomide (Oral Tablet)

1

Otezla (Oral Tablet) 1 PA; LA

Otezla (Oral Tablet

Therapy Pack)1 PA; LA

Ridaura (Oral

Capsule)1

Xolair (Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

tRACK 79

69


C1Xolair

B1

C1ActHIB

C1Adacel

C1BCG Vaccine

C1Bexsero

C1Boostrix

C1Daptacel

C1Diphtheria-Tetanus Toxoids DT

C1Engerix-B

C1Gardasil 9

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Gardasil 9

C1Havrix

C1Hiberix

C1Imovax Rabies

C1Infanrix

C1IPOL

C1Ixiaro

C1Kinrix

C1Menactra

C1Menveo

C1M-M-R II

C1Pediarix

C1Pedvax HIB

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Xolair (Subcutaneous

Solution

Reconstituted)

1 PA; LA

Vaccines

ActHIB

(Intramuscular

Solution

Reconstituted)

1

Adacel (Intramuscular

Suspension)1

BCG Vaccine

(Injection)1

Bexsero

(Intramuscular


Syringe)

1

Boostrix (5-2.5-18.5

Intramuscular

Suspension,

5-2.5-18.5 (0.5ML

Syringe)

Intramuscular

Suspension)

1

Daptacel

(Intramuscular

Suspension)

1

Diphtheria-Tetanus

Toxoids DT

(Intramuscular

Suspension)

1

Engerix-B (Injection

Suspension)1 B/D, PA

Gardasil 9

(Intramuscular

Suspension)

1

Gardasil 9

(Intramuscular


Syringe)

1

Havrix (Intramuscular

Suspension)1 PA

Hiberix (Injection

Solution

Reconstituted)

1

Imovax Rabies

(Intramuscular

Injectable)

1 B/D, PA

Infanrix

(Intramuscular

Suspension)

1

IPOL (Injection) 1

Ixiaro (Intramuscular

Suspension)1

Kinrix (Intramuscular

Suspension)1

Menactra

(Intramuscular

Injectable)

1

Menveo

(Intramuscular

Solution

Reconstituted)

1

M-M-R II (Injection

Solution

Reconstituted)

1

Pediarix

(Intramuscular

Suspension)

1

Pedvax HIB

(Intramuscular

Suspension)

1

tRACK80

70


C1ProQuad

C1Quadracel

C1RabAvert

C1Recombivax HB

C1Rotarix

C1RotaTeq

C1Shingrix

C1TDVAX

C1Tenivac

C1Trumenba

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Twinrix

C1Typhim Vi

C1VAQTA

C1Varivax

C1YF-Vax

A1

B1

C1Apriso

C1Balsalazide Disodium

C1Canasa

C1Dipentum

C1Mesalamine ER

C1Mesalamine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

ProQuad

(Subcutaneous

Suspension

Reconstituted)

1

Quadracel

(Intramuscular

Suspension)

1

RabAvert

(Intramuscular

Suspension

Reconstituted)

1 B/D, PA

Recombivax HB

(Injection

Suspension)

1 B/D, PA

Rotarix (Oral

Suspension

Reconstituted)

1

RotaTeq (Oral

Solution)1

Shingrix

(Intramuscular

Suspension

Reconstituted)

1 PA

TDVAX

(Intramuscular

Suspension)

1

Tenivac

(Intramuscular

Injectable)

1

Trumenba

(Intramuscular


Syringe)

1

Twinrix

(Intramuscular


Syringe)

1

Typhim Vi

(Intramuscular

Solution)

1

VAQTA

(Intramuscular

Suspension)

1 PA

Varivax

(Subcutaneous

Injectable)

1

YF-Vax

(Subcutaneous

Injectable)

1

Inflammatory Bowel Disease Agents

Aminosalicylates

Apriso (Oral Capsule

Extended Release 24

Hour)

1 QL

Balsalazide Disodium (Oral Capsule)

1

Canasa (Rectal

Suppository)1

Dipentum (Oral

Capsule)1

Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)

1 QL

Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)

1 QL

tRACK 81

71


C1Mesalamine

C1Mesalamine

C1Pentasa

B1

C1Budesonide ER

C1Budesonide

C1Hydrocortisone

C1Procto-Med HC

C1Procto-Pak

C1Proctosol HC

C1Proctozone-HC

B1

C1Sulfasalazine

C1Sulfasalazine

A1

B1

C1Alendronate Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Alendronate Sodium

C1Binosto

C1Calcitonin Salmon

C1Calcitriol

C1Calcitriol

C1Cinacalcet HCl

C1Cinacalcet HCl

C1Doxercalciferol

C1Forteo

C1Ibandronate Sodium

C1Natpara

C1Paricalcitol

C1Prolia

C1Rayaldee

C1Risedronate Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Mesalamine (Rectal Enema)

1 QL

Mesalamine (Rectal Suppository)

1

Pentasa (Oral

Capsule Extended

Release)

1 QL

Glucocorticoids

Budesonide ER (Oral Tablet Extended Release 24 Hour)

1 ST

Budesonide (Oral Capsule Delayed Release Particles)

1

Hydrocortisone (Rectal Enema)

1

Procto-Med HC (External Cream)

1

Procto-Pak (External Cream)

1

Proctosol HC (External Cream)

1

Proctozone-HC (External Cream)

1

Sulfonamides

Sulfasalazine (Oral Tablet Immediate Release)

1

Sulfasalazine (Oral Tablet Delayed Release)

1

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

Alendronate Sodium (Oral Solution)

1

Alendronate Sodium (10MG Oral Tablet, 35MG Oral Tablet, 70MG Oral Tablet)

1 QL

Binosto (Oral Tablet

Effervescent)1 QL

Calcitonin Salmon (Nasal Solution)

1 QL

Calcitriol (Oral Capsule)

1 B/D, PA

Calcitriol (Oral Solution)

1 B/D, PA

Cinacalcet HCl (30MG Oral Tablet)

1 B/D, PA; QL

Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet)

1 B/D, PA; QL

Doxercalciferol (Oral Capsule)

1 B/D, PA; QL

Forteo (Subcutaneous

Solution Pen-Injector)1 PA; QL

Ibandronate Sodium (Oral Tablet)

1 QL

Natpara

(Subcutaneous

Cartridge)

1 PA; LA

Paricalcitol (Oral Capsule)

1 B/D, PA

Prolia (Subcutaneous

Solution Prefilled

Syringe)

1 QL

Rayaldee (Oral

Capsule Extended

Release)

1 QL

Risedronate Sodium (Oral Tablet Immediate Release)

1 QL

tRACK82

72


C1Teriparatide

C1Tymlos

C1Xgeva

A1

B1

C1Alcohol Prep Pads

C1Gauze

C1Insulin Syringes, Needles

A1

B1

C1Atropine Sulfate

C1Bacitracin-Polymyxin B

C1Neomycin-Polymyxin-Bacitracin-Hydrocortisone

C1Blephamide

C1Blephamide S.O.P.

C1Cystaran

C1Lacrisert

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Lastacaft

C1Neomycin-Bacitracin-Polymyxin

C1Neomycin-Polymyxin-Dexamethasone

C1Neomycin-Polymyxin-Dexamethasone

C1Neomycin-Polymyxin-Gramicidin

C1Neomycin-Polymyxin-HC

C1Polymyxin B-Trimethoprim

C1Pred-G

C1Pred-G S.O.P.

C1Proparacaine HCl

C1Restasis Single-Use Vials

C1Rhopressa

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Teriparatide

(Recombinant)

(Subcutaneous


1 PA; QL

Tymlos

(Subcutaneous


1 PA; QL

Xgeva (Subcutaneous

Solution)1 PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

Alcohol Prep Pads 1

Gauze (Non-medicated 2X2 Pad)

1

Insulin Syringes, Needles

1

Ophthalmic Agents

Ophthalmic Agents, Other

Atropine Sulfate (1%

Ophthalmic Solution)1

Bacitracin-Polymyxin B (Ophthalmic Ointment)

1

Neomycin-Polymyxin-Bacitracin-Hydrocortisone (Ophthalmic Ointment)

1

Blephamide

(Ophthalmic

Suspension)

1

Blephamide S.O.P. (Ophthalmic Ointment)

1

Cystaran (Ophthalmic

Solution)1 LA

Lacrisert (Ophthalmic

Insert)1

Lastacaft (Ophthalmic

Solution)1

Neomycin-Bacitracin-Polymyxin (5-400-10000 Ophthalmic Ointment)

1

Neomycin-Polymyxin-Dexamethasone (Ophthalmic Ointment)

1

Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 Ophthalmic Suspension)

1

Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution)

1

Neomycin-Polymyxin-HC (Ophthalmic Suspension)

1

Polymyxin B-Trimethoprim (Ophthalmic Solution)

1

Pred-G (Ophthalmic

Suspension)1

Pred-G S.O.P.

(Ophthalmic

Ointment)

1

Proparacaine HCl (Ophthalmic Solution)

1

Restasis Single-Use

Vials (Ophthalmic

Emulsion)

1 QL

Rhopressa

(Ophthalmic Solution)1 ST

tRACK 83

73


C1Sulfacetamide-Prednisolone

C1TobraDex

C1TobraDex ST

C1Tobramycin-Dexamethasone

C1Xiidra

B1

C1Alocril

C1Alomide

C1Azelastine HCl

C1Bepreve

C1Cromolyn Sodium

C1Epinastine HCl

C1Olopatadine HCl

C1Pazeo

B1

C1Alphagan P

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Apraclonidine HCl

C1Azopt

C1Betaxolol HCl

C1Betimol

C1Brimonidine Tartrate

C1Brimonidine Tartrate

C1Carteolol HCl

C1Combigan

C1Cosopt PF

C1Dorzolamide HCl

C1Dorzolamide HCl-Timolol Maleate

C1Dorzolamide HCl-Timolol Maleate Preservative Free

C1Levobunolol HCl

C1Phospholine Iodide

C1Pilocarpine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Sulfacetamide-Prednisolone (Ophthalmic Solution)

1

TobraDex

(Ophthalmic

Ointment)

1

TobraDex ST

(Ophthalmic

Suspension)

1

Tobramycin-Dexamethasone (Ophthalmic Suspension)

1

Xiidra (Ophthalmic

Solution)1 QL

Ophthalmic Anti-allergy Agents

Alocril (Ophthalmic

Solution)1

Alomide (Ophthalmic

Solution)1

Azelastine HCl (Ophthalmic Solution)

1

Bepreve (Ophthalmic

Solution)1

Cromolyn Sodium (Ophthalmic Solution)

1

Epinastine HCl (Ophthalmic Solution)

1

Olopatadine HCl (Ophthalmic Solution)

1

Pazeo (Ophthalmic

Solution)1

Ophthalmic Antiglaucoma Agents

Alphagan P (0.1%

Ophthalmic Solution)1

Apraclonidine HCl (Ophthalmic Solution)

1

Azopt (Ophthalmic

Suspension)1

Betaxolol HCl (Ophthalmic Solution)

1

Betimol (Ophthalmic

Solution)1

Brimonidine Tartrate

(0.15% Ophthalmic

Solution)

1

Brimonidine Tartrate (0.2% Ophthalmic Solution)

1

Carteolol HCl (Ophthalmic Solution)

1

Combigan

(Ophthalmic Solution)1

Cosopt PF

(Ophthalmic Solution)1

Dorzolamide HCl (Ophthalmic Solution)

1

Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution)

1

Dorzolamide HCl-Timolol Maleate Preservative Free (Ophthalmic Solution)

1

Levobunolol HCl (Ophthalmic Solution)

1

Phospholine Iodide

(Ophthalmic Solution

Reconstituted)

1

Pilocarpine HCl (Ophthalmic Solution)

1

tRACK84

74


C1Rocklatan

C1Simbrinza

C1Timolol Maleate Ophthalmic Gel Forming

C1Timolol Maleate

B1

C1Dexamethasone Sodium Phosphate

C1Diclofenac Sodium

C1Durezol

C1Flarex

C1Fluorometholone

C1Flurbiprofen Sodium

C1FML Forte

C1FML

C1Ilevro

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ketorolac Tromethamine

C1Lotemax

C1Lotemax

C1Lotemax

C1Lotemax SM

C1Loteprednol Etabonate

C1Pred Mild

C1Prednisolone Acetate

C1Prednisolone Sodium Phosphate

C1Prolensa

B1

C1Latanoprost

C1Lumigan

C1Travoprost

C1Vyzulta

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Rocklatan

(Ophthalmic Solution)1 ST

Simbrinza

(Ophthalmic

Suspension)

1

Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) (Generic Timoptic-XE)

1

Timolol Maleate (0.25% Ophthalmic Solution, 0.5% Ophthalmic Solution) (Generic Timoptic)

1

Ophthalmic Anti-inflammatories

Dexamethasone Sodium Phosphate (Ophthalmic Solution)

1

Diclofenac Sodium (Ophthalmic Solution)

1

Durezol (Ophthalmic

Emulsion)1

Flarex (Ophthalmic

Suspension)1

Fluorometholone (Ophthalmic Suspension)

1

Flurbiprofen Sodium (Ophthalmic Solution)

1

FML Forte

(Ophthalmic

Suspension)

1

FML (Ophthalmic

Ointment)1

Ilevro (Ophthalmic

Suspension)1

Ketorolac Tromethamine (Ophthalmic Solution)

1

Lotemax (Ophthalmic

Gel)1

Lotemax (Ophthalmic

Ointment)1

Lotemax (Ophthalmic

Suspension)1

Lotemax SM

(Ophthalmic Gel)1

Loteprednol Etabonate (Ophthalmic Suspension)

1

Pred Mild

(Ophthalmic

Suspension)

1

Prednisolone Acetate (Ophthalmic Suspension)

1

Prednisolone Sodium Phosphate (1% Ophthalmic Solution)

1

Prolensa (Ophthalmic

Solution)1

Ophthalmic Prostaglandin and Prostamide Analogs

Latanoprost (Ophthalmic Solution)

1

Lumigan (Ophthalmic

Solution)1

Travoprost (BAK Free) (Ophthalmic Solution)

1

Vyzulta (Ophthalmic

Solution)1

tRACK 85

75


C1Zioptan

A1

B1

C1Acetic Acid

C1Cipro HC

C1Ciprodex

C1Ciprofloxacin-Dexamethasone

C1Flac


C1Hydrocortisone-Acetic Acid



A1

B1

C1Azelastine HCl

C1Cetirizine HCl

C1Cyproheptadine HCl

C1Cyproheptadine HCl

C1Levocetirizine Dihydrochloride

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Promethazine HCl

C1Promethazine HCl

C1Promethazine HCl

C1Promethegan

B1

C1Arnuity Ellipta

C1Budesonide

C1Flovent Diskus

C1Flovent HFA

C1Flunisolide



B1

C1Montelukast Sodium



C1Zafirlukast

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Zioptan (Ophthalmic

Solution)1

Otic Agents

Otic Agents

Acetic Acid (Otic Solution)

1

Cipro HC (Otic

Suspension)1

Ciprodex (Otic

Suspension)1

Ciprofloxacin-Dexamethasone (Otic Suspension)

1

Flac (Otic Oil) 1

Fluocinolone Acetonide (Otic Oil)

1

Hydrocortisone-Acetic Acid (Otic Solution)

1

Neomycin-Polymyxin-HC (1% Otic Solution)

1

Neomycin-Polymyxin-HC (Otic Suspension)

1

Respiratory Tract/Pulmonary Agents

Antihistamines

Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal Solution)

1

Cetirizine HCl (1MG/ ML Oral Solution)

1

Cyproheptadine HCl (Oral Syrup)

1

Cyproheptadine HCl (Oral Tablet)

1

Levocetirizine Dihydrochloride (Oral Tablet)

1 QL

Promethazine HCl (Oral Syrup)

1

Promethazine HCl (Oral Tablet)

1

Promethazine HCl (Rectal Suppository)

1

Promethegan (25MG Rectal Suppository)

1

Anti-inflammatories, Inhaled Corticosteroids

Arnuity Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Budesonide (Inhalation Suspension)

1 B/D, PA

Flovent Diskus

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Flovent HFA

(Inhalation Aerosol)1 QL

Flunisolide (Nasal Solution)

1

Fluticasone Propionate (Nasal Suspension)

1

Mometasone Furoate (Nasal Suspension)

1

Antileukotrienes

Montelukast Sodium (Oral Packet)

1 QL

Montelukast Sodium (Oral Tablet)

1 QL

Montelukast Sodium (Oral Tablet Chewable)

1 QL

Zafirlukast (Oral Tablet)

1 QL

tRACK86

76


C1Zileuton ER

C1Zyflo

B1

C1Atrovent HFA

C1Incruse Ellipta

C1Ipratropium Bromide

C1Ipratropium Bromide

C1Lonhala Magnair

C1Spiriva HandiHaler

C1Spiriva Respimat

B1

C1Albuterol Sulfate HFA

C1Albuterol Sulfate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Albuterol Sulfate

C1Albuterol Sulfate

C1Epinephrine

C1EpiPen 2-Pak

C1EpiPen Jr 2-Pak

C1Levalbuterol HCl

C1Metaproterenol Sulfate

C1Perforomist

C1ProAir HFA

C1ProAir RespiClick

C1Serevent Diskus

B1

C1Bethkis

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Zileuton ER (Oral Tablet Extended Release 12 Hour)

1 ST

Zyflo (Oral Tablet

Immediate Release)1 ST

Bronchodilators, Anticholinergic

Atrovent HFA

(Inhalation Aerosol

Solution)

1

Incruse Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Ipratropium Bromide (Inhalation Solution)

1 B/D, PA

Ipratropium Bromide (Nasal Solution)

1

Lonhala Magnair

(Inhalation Solution)1 QL

Spiriva HandiHaler

(Inhalation Capsule)1 QL

Spiriva Respimat

(Inhalation Aerosol

Solution)

1 QL

Bronchodilators, Sympathomimetic

Albuterol Sulfate HFA (108 (90 Base)MCG/ ACT Inhalation Aerosol Solution (Generic Proair), 108 (90 Base)MCG/ACT Inhalation Aerosol Solution) (Generic Proventil)

1

Albuterol Sulfate (Inhalation Nebulization Solution)

1 B/D, PA

Albuterol Sulfate (Oral Syrup)

1

Albuterol Sulfate (Oral Tablet Immediate Release)

1

Epinephrine (Injection Solution Auto-Injector)

1 QL

EpiPen 2-Pak

(Injection Solution

Auto-Injector)

1 QL

EpiPen Jr 2-Pak

(Injection Solution

Auto-Injector)

1 QL

Levalbuterol HCl (Inhalation Nebulization Solution)

1 B/D, PA

Metaproterenol Sulfate (Oral Syrup)

1

Perforomist

(Inhalation

Nebulization Solution)

1 B/D, PA; QL

ProAir HFA

(Inhalation Aerosol

Solution)

1

ProAir RespiClick

(Inhalation Aerosol

Powder Breath

Activated)

1

Serevent Diskus

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Cystic Fibrosis Agents

Bethkis (Inhalation

Nebulization Solution)1 B/D, PA; QL

tRACK 87

77


C1Cayston

C1Orkambi

C1Orkambi

C1TOBI Podhaler

C1Tobramycin

B1

C1Cromolyn Sodium

B1

C1Daliresp

C1Theophylline ER

C1Theophylline ER

C1Theophylline

B1

C1Adempas

C1Alyq

C1Ambrisentan

C1Bosentan

C1Opsumit

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Orenitram

C1Orenitram

C1Sildenafil Citrate

C1Tadalafil

C1Tracleer

C1Ventavis

B1

C1Esbriet

C1Esbriet

C1Ofev

B1

C1Acetylcysteine

C1Advair Diskus

C1Advair HFA

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Cayston (Inhalation

Solution

Reconstituted)

1 PA; LA

Orkambi (Oral Packet) 1 PA; LA; QL

Orkambi (Oral Tablet) 1 PA; LA; QL

TOBI Podhaler

(Inhalation Capsule)1 PA; QL

Tobramycin (300MG/ 5ML Inhalation Nebulization Solution)

1 B/D, PA; QL

Mast Cell Stabilizers

Cromolyn Sodium (Inhalation Nebulization Solution)

1 B/D, PA

Phosphodiesterase Inhibitors, Airways Disease

Daliresp (Oral Tablet) 1 PA; QL

Theophylline ER (300MG Oral Tablet Extended Release 12 Hour)

1

Theophylline ER (Oral Tablet Extended Release 24 Hour)

1

Theophylline (Oral Solution)

1

Pulmonary Antihypertensives

Adempas (Oral

Tablet)1 PA; LA

Alyq (Oral Tablet) 1 PA; QL

Ambrisentan (Oral Tablet)

1 PA; LA; QL

Bosentan (Oral Tablet) 1 PA; LA; QL

Opsumit (Oral Tablet) 1 PA; LA

Orenitram (0.125MG

Oral Tablet Extended

Release)

1 PA; LA

Orenitram (0.25MG

Oral Tablet Extended

Release, 1MG Oral

Tablet Extended

Release, 2.5MG Oral

Tablet Extended

Release, 5MG Oral

Tablet Extended

Release)

1 PA; LA

Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)

1 PA; QL

Tadalafil (PAH) (20MG Oral Tablet)

1 PA; QL

Tracleer (Oral Tablet

Soluble)1 PA; LA; QL

Ventavis (Inhalation

Solution)1 PA; LA; QL

Pulmonary Fibrosis Agents

Esbriet (Oral Capsule) 1 PA; LA; QL

Esbriet (Oral Tablet) 1 PA; LA; QL

Ofev (Oral Capsule) 1 PA; LA; QL

Respiratory Tract Agents, Other

Acetylcysteine (Inhalation Solution)

1 B/D, PA

Advair Diskus

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Advair HFA


tRACK88

78


C1Anoro Ellipta

C1Azelastine-Fluticasone

C1Bevespi Aerosphere

C1Breo Ellipta

C1Combivent Respimat

C1Dulera

C1Dymista

C1Fasenra Pen

C1Fasenra

C1Fluticasone-Salmeterol

C1Ipratropium-Albuterol

C1Kalydeco

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Kalydeco

C1Nucala

C1Nucala

C1Nucala

C1Pulmozyme

C1Stiolto Respimat

C1Symbicort

C1Trelegy Ellipta

C1Wixela Inhub

A1

B1

C1Baclofen

C1Chlorzoxazone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Anoro Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Azelastine-Fluticasone (Nasal Suspension)

1

Bevespi Aerosphere


Breo Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Combivent Respimat

(Inhalation Aerosol

Solution)

1 QL

Dulera (Inhalation

Aerosol)1 QL

Dymista (Nasal

Suspension)1

Fasenra Pen

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA

Fasenra

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Fluticasone-Salmeterol (Inhalation Aerosol Powder Breath Activated)

1 QL

Ipratropium-Albuterol (Inhalation Solution)

1 B/D, PA

Kalydeco (Oral

Packet)1 PA; LA; QL

Kalydeco (Oral

Tablet)1 PA; LA; QL

Nucala

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA; QL

Nucala

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA; QL

Nucala

(Subcutaneous

Solution

Reconstituted)

1 PA; LA; QL

Pulmozyme

(Inhalation Solution)1 B/D, PA; QL

Stiolto Respimat

(Inhalation Aerosol

Solution)

1 QL

Symbicort (Inhalation

Aerosol)1 QL

Trelegy Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)

1 QL

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

Baclofen (Oral Tablet) 1

Chlorzoxazone (500MG Oral Tablet)

1

tRACK 89

79


C1Cyclobenzaprine HCl

C1Cyclobenzaprine HCl

C1Dantrolene Sodium

C1Tizanidine HCl

A1

B1

C1Temazepam

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Zaleplon

C1Zolpidem Tartrate

B1

C1Belsomra

C1Hetlioz

C1Modafinil

C1Ramelteon

C1Xyrem

tRACK

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Cyclobenzaprine HCl (10MG Oral Tablet, 5MG Oral Tablet)

1

Cyclobenzaprine HCl (7.5MG Oral Tablet)

1

Dantrolene Sodium (Oral Capsule)

1

Tizanidine HCl (Oral Tablet)

1

Sleep Disorder Agents

GABA Receptor Modulators

Temazepam (15MG Oral Capsule, 30MG Oral Capsule)

1 QL

Zaleplon (Oral Capsule)

1 QL

Zolpidem Tartrate (Oral Tablet Immediate Release)

1 QL

Sleep Disorders, Other

Belsomra (Oral

Tablet)1 QL

Hetlioz (Oral Capsule) 1 PA; LA; QL

Modafinil (Oral Tablet) 1 PA; QL

Ramelteon (Oral Tablet)

1 QL

Xyrem (Oral Solution) 1 PA; LA; QL

tRACK90


C2. 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 tables below.

Drug Name Quantity Limit

Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day

Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day

Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day

Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day

Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day



Acetaminophen-Codeine (120-12MG/5ML Oral Solution)

Maximum of 150 ml per day

Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)

Maximum of 13 tablets per day

Acyclovir (External Ointment) Maximum of 1 tube (30 grams) per 30 days

Advair Diskus (Inhalation Aerosol Powder

Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days

Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days

Aimovig (140MG/ML Subcutaneous Solution

Auto-Injector)Maximum of 1 pen (1 ml) per 30 days

Aimovig (70MG/ML Subcutaneous Solution

Auto-Injector)Maximum of 2 pens (2 ml) per 30 days

Albendazole (Oral Tablet) Maximum of 16 tablets per day

Alecensa (Oral Capsule) Maximum of 8 capsules per day

Alendronate Sodium (10MG Oral Tablet) Maximum of 1 tablet per day

Alendronate Sodium (35MG Oral Tablet) Maximum of 8 tablets per 28 days

Alendronate Sodium (70MG Oral Tablet) Maximum of 4 tablets per 28 days

Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day

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Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, 1MG Oral Tablet Immediate Release)


Alprazolam (2MG Oral Tablet Immediate Release)


Alunbrig (180MG Oral Tablet, 90MG Oral

Tablet)Maximum of 1 tablet per day

Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day

Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days

Alyq (Oral Tablet) Maximum of 2 tablets per day

Ambrisentan (Oral Tablet) Maximum of 1 tablet per day

Amitiza (Oral Capsule) Maximum of 2 capsules per day

Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day

Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

Maximum of 2 capsules per day

Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)


Amphetamine-Dextroamphetamine (20MG Oral Tablet)


Ampyra (Oral Tablet Extended Release 12

Hour)Maximum of 2 tablets per day

Androderm (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Anoro Ellipta (Inhalation Aerosol Powder


Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day

Apriso (Oral Capsule Extended Release 24

Hour)Maximum of 4 capsules per day

Aptiom (200MG Oral Tablet, 400MG Oral


Aptiom (600MG Oral Tablet, 800MG Oral

Tablet)Maximum of 2 tablets per day

Aptivus (Oral Capsule) Maximum of 4 capsules per day

Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days

Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day

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Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

Maximum of 1 tablet per day

Aripiprazole ODT (10MG Oral Tablet Dispersible)


Aripiprazole ODT (15MG Oral Tablet Dispersible)


Arnuity Ellipta (Inhalation Aerosol Powder


Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)


Atazanavir Sulfate (150MG Oral Capsule, 300MG Oral Capsule)

Maximum of 1 capsule per day

Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day

Atomoxetine HCl (100MG Oral Capsule, 60MG Oral Capsule, 80MG Oral Capsule)


Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Capsule)


Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day

Atripla (Oral Tablet) Maximum of 1 tablet per day

Aubagio (Oral Tablet) Maximum of 1 tablet per day

Austedo (Oral Tablet) Maximum of 4 tablets per day

Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days

Avonex Prefilled (Intramuscular Prefilled

Syringe Kit)Maximum of 1 kit per 28 days

Ayvakit (Oral Tablet) Maximum of 1 tablet per day

Balversa (3MG Oral Tablet) Maximum of 3 tablets per day

Balversa (4MG Oral Tablet) Maximum of 2 tablets per day

Balversa (5MG Oral Tablet) Maximum of 1 tablet per day

Belsomra (Oral Tablet) Maximum of 1 tablet per day

Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day

Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days

Bethkis (Inhalation Nebulization Solution) Maximum of 2 ampules (8 ml) per day

Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days

BiDil (Oral Tablet) Maximum of 6 tablets per day

Biktarvy (Oral Tablet) Maximum of 1 tablet per day

Binosto (Oral Tablet Effervescent) Maximum of 4 tablets per 28 days

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Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day

Bosentan (Oral Tablet) Maximum of 2 tablets per day

Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day

Bosulif (400MG Oral Tablet, 500MG Oral


Breo Ellipta (Inhalation Aerosol Powder


Brilinta (Oral Tablet) Maximum of 2 tablets per day

BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day

BRIVIACT (100MG Oral Tablet, 10MG Oral

Tablet, 25MG Oral Tablet, 50MG Oral Tablet,

75MG Oral Tablet)


Brukinsa (Oral Capsule) Maximum of 4 capsules per day

Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day

Buprenorphine HCl-Naloxone HCl (12-3MG Sublingual Film, 4-1MG Sublingual Film)

Maximum of 2 films per day

Buprenorphine HCl-Naloxone HCl (2-0.5MG Sublingual Film, 8-2MG Sublingual Film)

Maximum of 3 films per day

Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)


Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days

Butalbital-Acetaminophen-Caffeine (Oral Tablet)


Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day

Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days

Bydureon BCise (Subcutaneous Auto-

Injector)Maximum of 4 pens (3.4 ml) per 28 days

Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)Maximum of 1 pen (2.4 ml) per 30 days

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)Maximum of 1 pen (1.2 ml) per 30 days

Bystolic (10MG Oral Tablet, 2.5MG Oral

Tablet, 5MG Oral Tablet)Maximum of 1 tablet per day

Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day

Cablivi (Injection Kit) Maximum of 1 kit per day

Cabometyx (20MG Oral Tablet, 60MG Oral


Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day

Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days

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Calquence (Oral Capsule) Maximum of 2 capsules per day

Candesartan Cilexetil (16MG Oral Tablet, 32MG Oral Tablet, 4MG Oral Tablet)


Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day

Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Caplyta (Oral Capsule) Maximum of 1 capsule per day

Captopril (100MG Oral Tablet) Maximum of 4 tablets per day

Captopril (12.5MG Oral Tablet, 25MG Oral Tablet)


Captopril (50MG Oral Tablet) Maximum of 9 tablets per day

Captopril-Hydrochlorothiazide (25-15MG Oral Tablet, 50-15MG Oral Tablet)


Captopril-Hydrochlorothiazide (25-25MG Oral Tablet, 50-25MG Oral Tablet)


Celecoxib (Oral Capsule) Maximum of 2 capsules per day

Cimduo (Oral Tablet) Maximum of 1 tablet per day

Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Tablet)


Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day

Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day

Clobazam (10MG Oral Tablet, 20MG Oral Tablet)


Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet)


Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day

Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible)


Clonazepam ODT (2MG Oral Tablet Dispersible)


Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day

Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day

Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day

Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day

Clovique (Oral Capsule) Maximum of 8 capsules per day

Clozapine ODT (100MG Oral Tablet Dispersible)


Clozapine ODT (12.5MG Oral Tablet Dispersible)


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Clozapine ODT (25MG Oral Tablet Dispersible) Maximum of 3 tablets per day

Codeine Sulfate (15MG Oral Tablet) Maximum of 6 tablets per day

Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet)


Colchicine (0.6MG Oral Capsule) (Brand

Equivalent Mitigare)Maximum of 4 capsules per day

Colchicine (0.6MG Oral Tablet) (Generic Colcrys)


Colcrys (Oral Tablet) Maximum of 4 tablets per day

Combivent Respimat (Inhalation Aerosol

Solution)Maximum of 1 inhaler (4 grams) per 20 days

Complera (Oral Tablet) Maximum of 1 tablet per day

Copiktra (Oral Capsule) Maximum of 2 capsules per day

Corlanor (Oral Solution) Maximum of 15 ml per day

Corlanor (Oral Tablet) Maximum of 2 tablets per day

Cotellic (Oral Tablet) Maximum of 3 tablets per day

Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day

Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day

Cycloset (Oral Tablet) Maximum of 6 tablets per day

Dalfampridine ER (Oral Tablet Extended Release 12 Hour)


Daliresp (Oral Tablet) Maximum of 1 tablet per day

Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day

Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day

Delstrigo (Oral Tablet) Maximum of 1 tablet per day

Denavir (External Cream) Maximum of 1 tube (5 grams) per 30 days

Descovy (Oral Tablet) Maximum of 1 tablet per day

Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)


Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)


Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day

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Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day

Dextroamphetamine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour)






Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day

Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)


Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day

Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)


Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day

Donepezil HCl (23MG Oral Tablet, 5MG Oral Tablet)


Donepezil HCl ODT (10MG Oral Tablet Dispersible)


Donepezil HCl ODT (5MG Oral Tablet Dispersible)


Dovato (Oral Tablet) Maximum of 1 tablet per day

Doxepin HCl (External Cream) Maximum of 90 grams per 30 days

Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day

Doxercalciferol (1MCG Oral Capsule, 2.5MCG Oral Capsule)


Drizalma Sprinkle (20MG Oral Capsule

Delayed Release Sprinkle, 30MG Oral

Capsule Delayed Release Sprinkle, 60MG

Oral Capsule Delayed Release Sprinkle)


Drizalma Sprinkle (40MG Oral Capsule

Delayed Release Sprinkle)Maximum of 3 capsules per day

Dulera (120 Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days

Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)


Dutasteride (Oral Capsule) Maximum of 1 capsule per day

Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days

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Edarbi (Oral Tablet) Maximum of 1 tablet per day

Edarbyclor (Oral Tablet) Maximum of 1 tablet per day

Edurant (Oral Tablet) Maximum of 1 tablet per day

Efavirenz (Oral Capsule) Maximum of 3 capsules per day

Efavirenz (Oral Tablet) Maximum of 1 tablet per day

Eliquis DVT/PE Starter Pack (5MG Oral

Tablet)Maximum of 1 pack (74 tablets) per 30 days

Eliquis (Oral Tablet) Maximum of 2 tablets per day

Emgality (300MG Dose) (100MG/ML

Subcutaneous Solution Prefilled Syringe)

Maximum of 3 syringes or pens (3 ml) per 30 days

Emgality (Subcutaneous Solution Auto-

Injector)


Emgality (120MG/ML Subcutaneous

Solution Prefilled Syringe)


Emsam (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Emtriva (Oral Capsule) Maximum of 1 capsule per day

Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days

Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (10-25MG Oral Tablet)


Enalapril-Hydrochlorothiazide (5-12.5MG Oral Tablet)


Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML Subcutaneous Solution)

Maximum of 2 syringes (2 ml) per day

Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)

Maximum of 2 syringes (1.6 ml) per day

Enoxaparin Sodium (30MG/0.3ML Subcutaneous Solution)






Entresto (Oral Tablet) Maximum of 2 tablets per day

Epclusa (Oral Tablet) Maximum of 1 tablet per day

Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days

98



EpiPen 2-Pak (Injection Solution Auto-

Injector)Maximum of 4 pens (2 boxes) per 30 days

EpiPen Jr 2-Pak (Injection Solution Auto-

Injector)Maximum of 4 pens (2 boxes) per 30 days

Erivedge (Oral Capsule) Maximum of 1 capsule per day

Erleada (Oral Tablet) Maximum of 4 tablets per day

Erlotinib HCl (100MG Oral Tablet, 150MG Oral Tablet)


Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day

Esbriet (Oral Capsule) Maximum of 9 capsules per day

Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day

Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day

Esomeprazole Magnesium (20MG Oral Capsule Delayed Release) (Generic Nexium)


Esomeprazole Magnesium (40MG Oral Capsule Delayed Release) (Generic Nexium)


Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days

Estradiol (Vaginal Tablet) Maximum of 1 tablet per day

Evotaz (Oral Tablet) Maximum of 1 tablet per day

Ezetimibe (Oral Tablet) Maximum of 1 tablet per day

Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day

Famciclovir (125MG Oral Tablet, 250MG Oral Tablet)


Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day

Fanapt (10MG Oral Tablet, 12MG Oral

Tablet, 1MG Oral Tablet, 2MG Oral Tablet,

4MG Oral Tablet, 6MG Oral Tablet, 8MG Oral

Tablet)


Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day

Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

Maximum of 15 patches per 30 days

Fetzima (Oral Capsule Extended Release 24

Hour)Maximum of 1 capsule per day

Fintepla (Oral Solution) Maximum of 12 ml per day

Firazyr (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day

Flector (Transdermal Patch) Maximum of 2 patches per day

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Flovent Diskus (Inhalation Aerosol Powder

Breath Activated)

Maximum of 2 inhalers (120 blisters) per 30 days

Flovent HFA (110MCG/ACT Inhalation

Aerosol)Maximum of 1 inhaler (12 grams) per 30 days


Aerosol)Maximum of 2 inhalers (24 grams) per 30 days


Aerosol)Maximum of 1 inhaler (10.6 grams) 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)

Maximum of 1 inhaler (60 blisters) per 30 days

Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo)

Maximum of 1 inhaler per 30 days

Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day

Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day

Forteo (Subcutaneous Solution Pen-Injector) Maximum of 1 pen (2.4 ml) per 28 days

Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day

Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day

Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day

Fuzeon (Subcutaneous Solution

Reconstituted)Maximum of 2 vials per day

Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)


Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days

Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day

Genvoya (Oral Tablet) Maximum of 1 tablet per day

Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days

Glatiramer Acetate (20MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 1 syringe (1 ml) per day

Glatiramer Acetate (40MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 12 syringes (12 ml) per 28 days

Glatopa (20MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 1 syringe (1 ml) per day

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Glatopa (40MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 12 syringes (12 ml) per 28 days

Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day



Glipizide ER (10MG Oral Tablet Extended Release 24 Hour)


Glipizide ER (2.5MG Oral Tablet Extended Release 24 Hour)


Glipizide ER (5MG Oral Tablet Extended Release 24 Hour)


Glipizide (10MG Oral Tablet Immediate Release)


Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day

Glipizide-Metformin HCl (2.5-250MG Oral Tablet)


Glipizide-Metformin HCl (2.5-500MG Oral Tablet, 5-500MG Oral Tablet)


Glyxambi (Oral Tablet) Maximum of 1 tablet per day

Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day

Hetlioz (Oral Capsule) Maximum of 1 capsule per day

Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)


Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)


Hydromorphone HCl ER (12MG Oral Tablet ER 24 Hour Abuse-Deterrent, 16MG Oral Tablet ER 24 Hour Abuse-Deterrent, 32MG Oral Tablet ER 24 Hour Abuse-Deterrent, 8MG Oral Tablet ER 24 Hour Abuse-Deterrent)


Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day

Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release)


Hydromorphone HCl (8MG Oral Tablet Immediate Release)


Hysingla ER (Oral Tablet ER 24 Hour Abuse-

Deterrent)Maximum of 1 tablet per day

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Ibandronate Sodium (Oral Tablet) Maximum of 1 tablet per 28 days

Ibrance (Oral Capsule) Maximum of 1 capsule per day

Ibrance (Oral Tablet) Maximum of 1 tablet per day

Icatibant Acetate (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day

Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day

Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day

IDHIFA (Oral Tablet) Maximum of 1 tablet per day

Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day

Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day

Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day

Imbruvica (Oral Tablet) Maximum of 1 tablet per day

Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Incruse Ellipta (Inhalation Aerosol Powder


Ingrezza (Oral Capsule) Maximum of 1 capsule per day

Ingrezza (Oral Capsule Therapy Pack) Maximum of 1 pack (28 capsules) per 28 days

Inlyta (Oral Tablet) Maximum of 4 tablets per day

Inqovi (Oral Tablet) Maximum of 1 pack (5 tablets) per 28 days

Inrebic (Oral Capsule) Maximum of 4 capsules per day

Intelence (100MG Oral Tablet, 200MG Oral


Intelence (25MG Oral Tablet) Maximum of 4 tablets per day

Invirase (Oral Tablet) Maximum of 4 tablets per day

Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Invokamet XR (Oral Tablet Extended Release

24 Hour)Maximum of 2 tablets per day

Invokana (Oral Tablet) Maximum of 1 tablet per day

Irbesartan (150MG Oral Tablet, 300MG Oral Tablet)


Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day

Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Iressa (Oral Tablet) Maximum of 2 tablets per day

Isentress HD (Oral Tablet) Maximum of 2 tablets per day

Isentress (Oral Packet) Maximum of 2 packets per day

Isentress (Oral Tablet) Maximum of 2 tablets per day

Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day

Itraconazole (Oral Capsule) Maximum of 4 capsules per day

102



Jakafi (Oral Tablet) Maximum of 2 tablets per day

Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Janumet XR (100-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 1 tablet per day

Janumet XR (50-1000MG Oral Tablet

Extended Release 24 Hour, 50-500MG Oral

Tablet Extended Release 24 Hour)


Januvia (Oral Tablet) Maximum of 1 tablet per day

Jardiance (Oral Tablet) Maximum of 1 tablet per day

Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Jentadueto XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 2 tablets per day

Jentadueto XR (5-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 1 tablet per day

Juluca (Oral Tablet) Maximum of 1 tablet per day

Kaletra (100-25MG Oral Tablet) Maximum of 8 tablets per day

Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day

Kalydeco (Oral Packet) Maximum of 2 packets per day

Kalydeco (Oral Tablet) Maximum of 2 tablets per day

Ketoconazole (External Cream) Maximum of 90 grams per 30 days

Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day



Kisqali Femara (400MG Dose) (Oral Tablet

Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days





Korlym (Oral Tablet) Maximum of 4 tablets per day

Koselugo (10MG Oral Capsule) Maximum of 8 capsules per day

Koselugo (25MG Oral Capsule) Maximum of 4 capsules per day

Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day

Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day

Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day

Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day

Latuda (120MG Oral Tablet, 20MG Oral

Tablet, 40MG Oral Tablet, 60MG Oral Tablet)Maximum of 1 tablet per day

103



Latuda (80MG Oral Tablet) Maximum of 2 tablets per day

Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day

Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day

Lexiva (Oral Suspension) Maximum of 60 ml per day

Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days

Lidocaine (5% External Patch) Maximum of 3 patches per day

Linezolid (Oral Tablet) Maximum of 2 tablets per day

Linzess (Oral Capsule) Maximum of 1 capsule per day

Lisinopril (Oral Tablet) Maximum of 2 tablets per day

Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Tablet)


Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Tablet)


Lisinopril-Hydrochlorothiazide (20-25MG Oral Tablet)


Livalo (Oral Tablet) Maximum of 1 tablet per day

Lokelma (Oral Packet) Maximum of 90 packets per 30 days

Lonhala Magnair (Inhalation Solution) Maximum of 2 vials (2 ml) per day

Lonsurf (15-6.14MG Oral Tablet) Maximum of 10 tablets per day

Lonsurf (20-8.19MG Oral Tablet) Maximum of 8 tablets per day

Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days

Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet)


Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day

Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day

Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day

Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day

Losartan Potassium (25MG Oral Tablet, 50MG Oral Tablet)


Losartan Potassium-HCTZ (100-12.5MG Oral Tablet, 100-25MG Oral Tablet)


Losartan Potassium-HCTZ (50-12.5MG Oral Tablet)


Lovastatin (10MG Oral Tablet, 20MG Oral Tablet)


Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day

Lynparza (Oral Tablet) Maximum of 4 tablets per day

Mavyret (Oral Tablet) Maximum of 3 tablets per day

104



Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day

Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day

Memantine HCl ER (Oral Capsule Extended Release 24 Hour)


Memantine HCl (2MG/ML Oral Solution) Maximum of 10 ml per day

Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day

Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day

Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)


Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)


Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day

Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)


Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)


Metformin HCl (500MG/5ML Oral Solution) Maximum of 25.5 ml per day

Metformin HCl (1000MG Oral Tablet Immediate Release)

Maximum of 2.5 tablets per day





Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day

Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day

Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day

Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day

Methylphenidate HCl ER (10MG Oral Tablet Extended Release)


Methylphenidate HCl ER (20MG Oral Tablet Extended Release)


Methylphenidate HCl (10MG/5ML Oral Solution)


Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day

Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)


Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day


105




Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day

Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day

Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day

Montelukast Sodium (Oral Packet) Maximum of 1 packet per day

Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day

Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day

Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day

Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release) (Generic MS Contin)


Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)


Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)




Morphine Sulfate (15MG Oral Tablet

Immediate Release)Maximum of 8 tablets per day

Morphine Sulfate (30MG Oral Tablet

Immediate Release)Maximum of 6 tablets per day

Multaq (Oral Tablet) Maximum of 2 tablets per day

Namzaric (Oral Capsule ER 24 Hour Therapy

Pack)Maximum of 1 capsule per day

Namzaric (Oral Capsule Extended Release

24 Hour)Maximum of 1 capsule per day

Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days

Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day

Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day

Nebupent (Inhalation Solution Reconstituted) Maximum of 1 vial (300 mg) per 28 days

Nerlynx (Oral Tablet) Maximum of 6 tablets per day

Nevirapine ER (100MG Oral Tablet Extended Release 24 Hour)


Nevirapine ER (400MG Oral Tablet Extended Release 24 Hour)


Nevirapine (Oral Suspension) Maximum of 40 ml per day

Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day

106



Nifedipine ER (Oral Tablet Extended Release 24 Hour)


Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)


Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days

Northera (100MG Oral Capsule) Maximum of 3 capsules per day

Northera (200MG Oral Capsule, 300MG Oral

Capsule)Maximum of 6 capsules per day

Norvir (Oral Packet) Maximum of 12 packets per day

Norvir (Oral Solution) Maximum of 16 ml per day

Noxafil (Oral Suspension) Maximum of 20 ml per day

Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day

Nubeqa (Oral Tablet) Maximum of 4 tablets per day

Nucala (Subcutaneous Solution Auto-

Injector)Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution Prefilled

Syringe)Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution

Reconstituted)Maximum of 3 vials per 28 days

Nucynta ER (Oral Tablet Extended Release

12 Hour)Maximum of 2 tablets per day

Nuplazid (Oral Capsule) Maximum of 1 capsule per day

Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day

Ocaliva (Oral Tablet) Maximum of 1 tablet per day

Odefsey (Oral Tablet) Maximum of 1 tablet per day

Odomzo (Oral Capsule) Maximum of 1 capsule per day

Ofev (Oral Capsule) 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)


Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)


Olmesartan Medoxomil (20MG Oral Tablet, 40MG Oral Tablet)


Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day

Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day

107



Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)


Omeprazole (10MG Oral Capsule Delayed Release)


Orkambi (Oral Packet) Maximum of 56 packets per 28 days

Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days

Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day

Oseltamivir Phosphate (Oral Suspension Reconstituted)


Osphena (Oral Tablet) Maximum of 1 tablet per day

Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day

Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day

Oxybutynin Chloride ER (10MG Oral Tablet Extended Release 24 Hour)






Oxycodone HCl (100MG/5ML Oral Concentrate)


Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day

Oxycodone HCl (10MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)


Oxycodone HCl (15MG Oral Tablet Immediate Release)


Oxycodone HCl (20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release)


Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day

Ozempic (0.25 or 0.5MG/DOSE)

(Subcutaneous Solution Pen-Injector)Maximum of 1 pen (1.5 ml) per 28 days

Ozempic (1MG/DOSE) (Subcutaneous

Solution Pen-Injector)Maximum of 2 pens (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)


Paliperidone ER (6MG Oral Tablet Extended Release 24 Hour)


108



Pantoprazole Sodium (20MG Oral Tablet Delayed Release)


Pantoprazole Sodium (40MG Oral Tablet Delayed Release)


Pemazyre (Oral Tablet) Maximum of 1 tablet per day

Pentamidine Isethionate (Inhalation Solution Reconstituted)

Maximum of 1 vial (300 mg) per 28 days

Pentasa (250MG Oral Capsule Extended

Release)Maximum of 12 capsules per day

Pentasa (500MG Oral Capsule Extended

Release)Maximum of 8 capsules per day

Perforomist (Inhalation Nebulization

Solution)Maximum of 2 vials (4 ml) per day

Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day

Pifeltro (Oral Tablet) Maximum of 1 tablet per day

Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day

Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Tablet)


Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day

Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day

Piqray (200MG Daily Dose) (Oral Tablet

Therapy Pack)Maximum of 1 tablet per day


Therapy Pack)Maximum of 2 tablets per day


Therapy Pack)Maximum of 2 tablets per day

Pomalyst (Oral Capsule) Maximum of 1 capsule per day

Posaconazole (Oral Tablet Delayed Release) Maximum of 6 tablets per day

Praluent (Subcutaneous Solution Auto-

Injector)Maximum of 2 pens (2 ml) per 28 days

Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day

Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day

Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Capsule, 50MG Oral Capsule, 75MG Oral Capsule)


Pregabalin (225MG Oral Capsule, 300MG Oral Capsule)


Pregabalin (Oral Solution) Maximum of 30 ml per day

Premarin (Oral Tablet) Maximum of 1 tablet per day

109



Premphase (Oral Tablet) Maximum of 1 tablet per day

Prempro (Oral Tablet) Maximum of 1 tablet per day

Prezcobix (Oral Tablet) Maximum of 1 tablet per day

Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days

Prezista (150MG Oral Tablet) Maximum of 6 tablets per day

Prezista (600MG Oral Tablet, 75MG Oral


Prezista (800MG Oral Tablet) Maximum of 1 tablet per day

Prolia (Subcutaneous Solution Prefilled

Syringe)Maximum of 1 syringe per 180 days

Promacta (Oral Packet) Maximum of 6 packets per day

Promacta (12.5MG Oral Tablet, 25MG Oral


Promacta (50MG Oral Tablet, 75MG Oral


Pulmozyme (Inhalation Solution) Maximum of 2 ampules (5 ml) per day

Qinlock (Oral Tablet) Maximum of 3 tablets per day

Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 Hour)


Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour)


Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 50MG Oral Tablet Immediate Release)


Quetiapine Fumarate (25MG Oral Tablet Immediate Release)


Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate Release)


Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day

Quinapril-Hydrochlorothiazide (10-12.5MG Oral Tablet)


Quinapril-Hydrochlorothiazide (20-12.5MG Oral Tablet, 20-25MG Oral Tablet)


Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day

Ramelteon (Oral Tablet) Maximum of 1 tablet per day

110



Ramipril (Oral Capsule) Maximum of 2 capsules per day

Ranolazine ER (Oral Tablet Extended Release 12 Hour)


RAVICTI (Oral Liquid) Maximum of 17.5 ml per day

Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day

Rebif Rebidose (Subcutaneous Solution


Rebif Rebidose Titration Pack

(Subcutaneous Solution Auto-Injector)Maximum of 1 pack (4.2 ml) per 28 days

Rebif (Subcutaneous Solution Prefilled

Syringe)Maximum of 12 syringes (6 ml) per 28 days

Rebif Titration Pack (Subcutaneous Solution

Prefilled Syringe)Maximum of 1 pack (4.2 ml) per 28 days

Relenza Diskhaler (Inhalation Aerosol

Powder Breath Activated)Maximum of 3 inhalers (60 blisters) per 30 days

Relistor (Oral Tablet) Maximum of 3 tablets per day

Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day

Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day

Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day

Repatha Pushtronex System (Subcutaneous

Solution Cartridge)Maximum of 1 cartridge (3.5 ml) per 28 days

Repatha (Subcutaneous Solution Prefilled

Syringe)Maximum of 3 syringes (3 ml) per 28 days

Repatha SureClick (Subcutaneous Solution


Restasis Single-Use Vials (Ophthalmic

Emulsion)Maximum of 2 vials per day

Retevmo (40MG Oral Capsule) Maximum of 6 capsules per day

Retevmo (80MG Oral Capsule) Maximum of 4 capsules per day

Revlimid (Oral Capsule) Maximum of 1 capsule per day

Rexulti (Oral Tablet) Maximum of 1 tablet per day

Reyataz (Oral Packet) Maximum of 6 packets per day

Riomet ER (Oral Suspension Reconstituted

ER)Maximum of 20 ml per day

Riomet (Oral Solution) Maximum of 25.5 ml per day

Risedronate Sodium (150MG Oral Tablet Immediate Release)

Maximum of 1 tablet per 30 days

Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)


111



Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release)

Maximum of 4 tablets per 28 days

Ritonavir (Oral Tablet) Maximum of 12 tablets per day

Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day

Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days

Rizatriptan Benzoate ODT (Oral Tablet Dispersible)


Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day

Rozlytrek (100MG Oral Capsule) Maximum of 5 capsules per day

Rozlytrek (200MG Oral Capsule) Maximum of 3 capsules per day

Rubraca (Oral Tablet) Maximum of 4 tablets per day

Rukobia (Oral Tablet Extended Release 12

Hour)Maximum of 2 tablets per day

Rybelsus (Oral Tablet) Maximum of 1 tablet per day

Rydapt (Oral Capsule) Maximum of 8 capsules per day

Saphris (Tablet Sublingual) Maximum of 2 tablets per day

Secuado (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days

Selzentry (150MG Oral Tablet, 75MG Oral


Selzentry (25MG Oral Tablet, 300MG Oral


Serevent Diskus (Inhalation Aerosol Powder

Breath Activated)

Maximum of 1 inhaler (60 inhalations) per 30 days

Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)


Silodosin (Oral Capsule) Maximum of 1 capsule per day

Simvastatin (Oral Tablet) Maximum of 1 tablet per day

Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day

Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day

Soliqua (Subcutaneous Solution Pen-

Injector)Maximum of 6 pens (18 ml) per 30 days

Somavert (Subcutaneous Solution

Reconstituted)Maximum of 1 vial per day

Sovaldi (150MG Oral Packet) Maximum of 1 carton (28 packets) per 28 days

Sovaldi (200MG Oral Packet) Maximum of 2 cartons (56 packets) per 28 days

112



Sovaldi (400MG Oral Tablet) Maximum of 1 tablet per day

Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day

Spiriva Respimat (Inhalation Aerosol


Sprycel (100MG Oral Tablet, 140MG Oral


Sprycel (20MG Oral Tablet, 50MG Oral


Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day

Stavudine (Oral Capsule) Maximum of 2 capsules per day

Stiolto Respimat (Inhalation Aerosol


Stivarga (Oral Tablet) Maximum of 4 tablets per day

Stribild (Oral Tablet) Maximum of 1 tablet per day

Suboxone (12-3MG Sublingual Film, 4-1MG

Sublingual Film)Maximum of 2 films per day

Suboxone (2-0.5MG Sublingual Film, 8-2MG

Sublingual Film)Maximum of 3 films per day

Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days

Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)


Sumatriptan Succinate Refill (Subcutaneous

Solution Cartridge)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)

Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/0.5ML Subcutaneous Solution Auto-Injector)


Sumatriptan Succinate (6MG/0.5ML

Subcutaneous Solution Auto-Injector)

(Generic Imitrex STATdose)


Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)


Sutent (12.5MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule)Maximum of 1 capsule per day

Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day

Symbicort (120 Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days

Symfi Lo (Oral Tablet) Maximum of 1 tablet per day

Symfi (Oral Tablet) Maximum of 1 tablet per day

Sympazan (Oral Film) Maximum of 2 films per day

113



Symtuza (Oral Tablet) Maximum of 1 tablet per day

Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Synjardy XR (10-1000MG Oral Tablet




Synjardy XR (12.5-1000MG Oral Tablet




Tabrecta (Oral Tablet) Maximum of 4 tablets per day

Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day

Tagrisso (Oral Tablet) Maximum of 1 tablet per day

Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day

Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day

Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day



Tazverik (Oral Tablet) Maximum of 8 tablets per day

Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day

Telmisartan (Oral Tablet) Maximum of 1 tablet per day

Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day

Telmisartan-HCTZ (40-12.5MG Oral Tablet, 80-25MG Oral Tablet)


Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day

Temazepam (15MG Oral Capsule, 30MG Oral Capsule)


Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day

Teriparatide (Recombinant) (Subcutaneous

Solution Pen-Injector)Maximum of 1 pen (2.48 ml) per 28 days

Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day

Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day

Thalomid (100MG Oral Capsule, 50MG Oral

Capsule)Maximum of 1 capsule per day

Thalomid (150MG Oral Capsule, 200MG Oral

Capsule)Maximum of 2 capsules per day

Tibsovo (Oral Tablet) Maximum of 2 tablets per day

Tivicay (10MG Oral Tablet, 25MG Oral


Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day

Tivicay PD (Oral Tablet Soluble) Maximum of 6 tablets per day

114



TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day

Tobramycin (300MG/5ML Inhalation Nebulization Solution)

Maximum of 2 ampules (10 ml) per day

Tolcapone (Oral Tablet) Maximum of 6 tablets per day

Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day

Tradjenta (Oral Tablet) Maximum of 1 tablet per day

Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)


Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)


Tramadol HCl (50MG Oral Tablet Immediate Release)


Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day

Trandolapril (1MG Oral Tablet, 2MG Oral Tablet)


Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day

Trelegy Ellipta (Inhalation Aerosol Powder


Trezix (Oral Capsule) Maximum of 10 capsules per day

Trientine HCl (Oral Capsule) Maximum of 8 capsules per day

Trijardy XR (10-5-1000MG Oral Tablet

Extended Release 24 Hour, 25-5-1000MG

Oral Tablet Extended Release 24 Hour)


Trijardy XR (12.5-2.5-1000MG Oral Tablet

Extended Release 24 Hour, 5-2.5-1000MG

Oral Tablet Extended Release 24 Hour)


Trintellix (Oral Tablet) Maximum of 1 tablet per day

Triumeq (Oral Tablet) Maximum of 1 tablet per day

Trulicity (0.75MG/0.5ML Subcutaneous

Solution Pen-Injector, 1.5MG/0.5ML

Subcutaneous Solution Pen-Injector)

Maximum of 4 pens (2 ml) per 28 days

Truvada (Oral Tablet) Maximum of 1 tablet per day

Tukysa (150MG Oral Tablet) Maximum of 4 tablets per day

Tukysa (50MG Oral Tablet) Maximum of 12 tablets per day

Turalio (Oral Capsule) Maximum of 4 capsules per day

Tybost (Oral Tablet) Maximum of 1 tablet per day

Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days

Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day

Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day

115



Valganciclovir HCl (50MG/ML Oral Solution Reconstituted)


Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day

Valsartan (160MG Oral Tablet, 40MG Oral Tablet, 80MG Oral Tablet)


Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day

Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Valtoco 10 MG Dose (Nasal Liquid)Maximum of 10 blister packs (10 spray devices) per 30 days

Valtoco 15 MG Dose (Nasal Liquid Therapy

Pack)

Maximum of 10 blister packs (20 spray devices) per 30 days

Valtoco 20 MG Dose (Nasal Liquid Therapy

Pack)

Maximum of 10 blister packs (20 spray devices) per 30 days

Valtoco 5 MG Dose (Nasal Liquid)Maximum of 10 blister packs (10 spray devices) per 30 days

Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day

Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day

Veltassa (Oral Packet) Maximum of 1 packet per day

Vemlidy (Oral Tablet) Maximum of 1 tablet per day

Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day

Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day

Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day

Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day

Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day

Verzenio (Oral Tablet) Maximum of 2 tablets per day

Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days

Vigabatrin (Oral Packet) Maximum of 6 packets per day

Vigabatrin (Oral Tablet) Maximum of 6 tablets per day

Vigadrone (Oral Packet) Maximum of 6 packets per day

Viibryd (Oral Tablet) Maximum of 1 tablet per day

Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days

Vimpat (Oral Solution) Maximum of 40 ml per day

Vimpat (Oral Tablet) Maximum of 2 tablets per day

Viracept (250MG Oral Tablet) Maximum of 10 tablets per day

Viracept (625MG Oral Tablet) Maximum of 4 tablets per day

Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days

Viread (150MG Oral Tablet, 200MG Oral


116



Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day

Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day

Vitrakvi (Oral Solution) Maximum of 20 ml per day

Vizimpro (Oral Tablet) Maximum of 1 tablet per day

Vosevi (Oral Tablet) Maximum of 1 tablet per day

Votrient (Oral Tablet) Maximum of 4 tablets per day

Vraylar (1.5MG Oral Capsule, 3MG Oral

Capsule, 4.5MG Oral Capsule, 6MG Oral

Capsule)


Vyndamax (Oral Capsule) Maximum of 1 capsule per day

Vyndaqel (Oral Capsule) Maximum of 4 capsules per day

Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)

Maximum of 1 inhaler (60 blisters) per 30 days

Xarelto (10MG Oral Tablet, 20MG Oral


Xarelto (15MG Oral Tablet, 2.5MG Oral


Xarelto Starter Pack (Oral Tablet Therapy

Pack)Maximum of 1 pack (51 tablets) per 30 days

Xcopri (250MG Daily Dose) (Oral Tablet


Xcopri (350MG Daily Dose) (Oral Tablet


Xcopri (100MG Oral Tablet, 50MG Oral


Xcopri (150MG Oral Tablet, 200MG Oral


Xcopri (Oral Tablet Titration Therapy Pack) Maximum of 1 pack (28 tablets) per 28 days

Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Xeljanz XR (Oral Tablet Extended Release 24

Hour)Maximum of 1 tablet per day

Xiidra (Ophthalmic Solution) Maximum of 2 vials per day

Xofluza (40 MG Dose) (Oral Tablet Therapy

Pack)Maximum of 2 tablets per 30 days

Xofluza (80 MG Dose) (Oral Tablet Therapy

Pack)Maximum of 2 tablets per 30 days

Xospata (Oral Tablet) Maximum of 3 tablets per day

Xpovio (100MG Once Weekly) (Oral Tablet

Therapy Pack)Maximum of 20 tablets per 28 days

117



Xpovio (40 MG Once Weekly) (Oral Tablet


Xpovio (40 MG Twice Weekly) (Oral Tablet




Xpovio (60 MG Twice Weekly) (Oral Tablet




Xpovio (80MG Twice Weekly) (Oral Tablet


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)


Xtampza ER (27MG Oral Capsule ER 12 Hour

Abuse-Deterrent, 36MG Oral Capsule ER 12

Hour Abuse-Deterrent)


Xtandi (Oral Capsule) Maximum of 4 capsules per day

Xyrem (Oral Solution) Maximum of 18 ml per day

Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day

Zafirlukast (Oral Tablet) Maximum of 2 tablets per day

Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day

Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day

Zejula (Oral Capsule) Maximum of 3 capsules per day

Zelboraf (Oral Tablet) Maximum of 8 tablets per day

Zidovudine (Oral Capsule) Maximum of 6 capsules per day

Zidovudine (Oral Syrup) Maximum of 64 ml per day

Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day

Zolpidem Tartrate (Oral Tablet Immediate Release)


Zydelig (Oral Tablet) Maximum of 2 tablets per day

Zykadia (Oral Tablet) Maximum of 3 tablets per day

118

A1

B1

C1

C1

C1

C1

C1

C1

C1

C1

C1

C1

C1

C1

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

UnitedHealthcare Dual Complete ONE covers some prescription OTC drugs that aren’t normally covered under our Medicare Part D benefit.

You need a prescription from your doctor to have drugs on this list covered. If your prescription is for a brand name drug, you will get the generic version of the drug if it’s available, unless otherwise prescribed or directed by your doctor.

Some of these drugs may need prior authorization. Please check with your doctor and the plan. If the drug requires a prior authorization, you or your doctor will need to get approval from the plan before the drug may be covered.

The list below shows the prescription OTC drugs covered by the plan.

tRACK

OTC Drug Name OTC Drug Name C1

Analgesics ED-Apap (Liquid) C1

Analgesics Extra Strength Pain Relief (Tablet) C1

8 Hour Arthritis Pain Reliever (Tablet Feverall Adults (Suppository) C1 Extended-Release)

Feverall Childrens (Suppository) C1 8 Hour Pain Relief (Tablet Extended-

Feverall Infants (Suppository) Release) C1

Feverall Junior Strength (Suppository) 8Hr Muscle Aches & Pain (Tablet C1

GNP 8 Hour Pain Reliever (Tablet Extended-Release) Extended-Release) Acephen (120mg Suppository, 325mg

C1

GNP Acetaminophen (Tablet) Suppository, 650mg Suppository) C1

Acetaminophen (325mg Tablet, 500mg GNP Acetaminophen Extra Strength Tablet, 160mg/5ml Liquid, 160mg/5ml (Capsule)

C1

Solution, 120mg Suppository, 650mg GNP Arthritis Pain Relief (Tablet Extended-Suppository) Release)

C1

Acetaminophen ER (Tablet Extended- GNP Childrens Pain Relief (Suspension) C1 Release)

GNP Infants Pain Relief (Suspension) C1 Acetaminophen Extra Strength (Tablet)

GNP Infants Pain/Fever (Suspension) C1 Arthritis Pain Relief (Tablet Extended-

GNP Pain & Fever Childrens (Suspension) C1 Release)

GNP Pain Relief (325mg Tablet, 160mg Chewable Acetaminophen Childrens Tablet Chewable)

C1 (Tablet Chewable) GNP Pain Relief Extra Strength (167mg/ Childrens Acetaminophen (Suspension) 5ml Liquid, 500mg Tablet)

C1 Childrens Chewable Acetaminophen Goodsense Arthritis Pain (Tablet Extended-

(Tablet Chewable) Release)

Childrens Silapap (Liquid)


119


OTC Drug NameC1

Goodsense Pain & Fever Childrens (Suspension)

C1

Goodsense Pain & Fever Infants (Suspension)

C1

Goodsense Pain Relief (Tablet Extended-Release)

C1

Goodsense Pain Relief Extra Strength (Tablet)

C1

HM Acetaminophen Childrens (Tablet Chewable)

C1

HM Arthritis Pain Relief (Tablet Extended-Release)

C1

HM Pain & Fever Childrens (Suspension)C1

HM Pain & Fever Infants (Suspension)C1

HM Pain Relief (Tablet Extended-Release)C1

HM Pain Relief Extra Strength (Tablet)C1

HM Pain Reliever (Tablet)C1

HM Rapid Melts Junior (Tablet Disintegrating)

C1

Infants Pain Relief (Suspension)C1

Mapap (500mg Capsule, 325mg Tablet, 500mg Tablet, 80mg Tablet Chewable, 160mg/5ml Liquid)

C1

Mapap Acetaminophen Extra Strength (Liquid)

C1

Mapap Arthritis Pain (Tablet Extended-Release)

C1

Mapap Childrens (80mg Tablet Disintegrating, 160mg Tablet Chewable, 160mg/5ml Suspension)

C1

Mapap Extra Strength (Tablet)C1

Non-Aspirin Childrens (Suspension)C1

Pain & Fever (Tablet)C1

Pain & Fever Childrens (80mg Tablet Chewable, 160mg/5ml Solution, 160mg/5ml Suspension)

C1

Pain & Fever Childrens Dye-Free (Suspension)

OTC Drug NameC1

Pain & Fever Extra Strength (Tablet)C1

Pain & Fever Infants (Suspension)C1

Pain Relief (325mg Tablet, 500mg Tablet)C1

Pain Relief Childrens (Suspension)C1

Pain Relief Extra Strength (Tablet)C1

Pharbetol (Tablet)C1

Pharbetol Extra Strength (Tablet)C1

QC Acetaminophen 8 Hours (Tablet Extended-Release)

C1

QC Arthritis Pain Relief (Tablet Extended-Release)

C1

QC Non-Aspirin Childrens (Suspension)C1

QC Non-Aspirin Extra Strength (Tablet)C1

QC Non-Aspirin Jr Strength (Tablet Disintegrating)

C1

QC Pain Relief (Tablet)C1

QC Pain Relief Childrens (Suspension)C1

QC Pain Relief Extra Strength (Tablet)C1

QC Pain Relief Infants (Suspension)C1

SM 8 Hour Pain Relief (Tablet Extended-Release)

C1

SM Arthritis Pain Relief (Tablet Extended-Release)

C1

SM Arthritis Pain Reliever (Tablet Extended-Release)

C1

SM Pain & Fever Childrens (Suspension)C1

SM Pain & Fever Infants (Suspension)C1

SM Pain Reliever (Tablet)C1

SM Pain Reliever Extra Strength (500mg Capsule, 500mg Tablet, 650mg Tablet Extended-Release)

C1

SM Rapid Melts Junior (Tablet Disintegrating)

C1

Tactinal (Tablet)C1

Tactinal Extra Strength (Tablet)C1

Tri-Buffered Aspirin (Tablet)

120


OTC Drug NameB1

Analgesics, CombinationC1

Acetaminophen/Aspirin/Caffeine (Tablet)C1

Back & Body Extra Strength (Tablet)C1

Dologesic (Tablet)C1

Excedrin Extra Strength (Tablet)C1

Excedrin Migraine (Tablet)C1

Excedrin Tension Headache (Tablet)C1

GNP Headache Relief (Tablet)C1

GNP Headache Relief Extra Strength (Tablet)

C1

GNP Migraine Relief (Tablet)C1

Goodsense Migraine Formula (Tablet)C1

Headache Formula Added Strength (Tablet)

C1

Headache Relief (Tablet)C1

Headache Relief/Extra Strength (Tablet)C1

HM Migraine Relief (Tablet)C1

Menstrual Pain Relief Multi-Symptom Maximum Strength (Tablet)

C1

Migraine Formula (Tablet)C1

Migraine Relief (Tablet)C1

Pain Reliever Plus (Tablet)C1

QC Headache Relief (Tablet)C1

SM Migraine Relief (Tablet)C1

Tension Headache (Tablet)B1

Analgesics, TopicalC1

Arthritis Pain Relieving (Cream)C1

Blue Gel (Gel)C1

Capsaicin (Cream)C1

Cool Therapy Pain Gel (Gel)C1

GNP Capsaicin (Liquid)C1

GNP Cold & Hot Therapy Balm Extra Strength (Ointment)

C1

GNP Muscle Rub (Cream)C1

GNP Therapeutic Blue Gel (Gel)

OTC Drug NameC1

HM Muscle Rub (Cream)C1

HM Pain Relief Therapy Patch (Patch)C1

HM Salonpas Pain Relief Patch (Patch)C1

Mineral Ice (Gel)C1

Muscle Rub (Cream)C1

Muscle Rub Ultra Strength (Cream)C1

Pain Relieving Cream (Cream)C1

Pain Relieving Patch Ultra Strength (Patch)C1

SM Muscle Rub (Cream)C1

Thera-Gesic (Cream)C1

Thera-Gesic Plus (Cream)C1

Ziks Arthritis Pain Relief (Cream)B1

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

C1

Adult Aspirin Regimen (Tablet Delayed-Release)

C1

All Day Pain Relief (Tablet)C1

All Day Relief (Tablet)C1

Aspirin (325mg Tablet, 300mg Suppository, 600mg Suppository, 81mg Tablet Chewable, 81mg Tablet Delayed-Release, 325mg Tablet Delayed-Release)

C1

Aspirin 81 (Tablet Delayed-Release)C1

Aspirin Adult Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release)

C1

Aspirin Adult Low Strength (Tablet Chewable)

C1

Aspirin EC (81mg Tablet Delayed-Release, 325mg Tablet Delayed-Release)

C1

Aspirin Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release)

C1

Aspirin Low Strength (Tablet Chewable)C1

Aspir-Low (Tablet Delayed-Release)C1

Childrens Aspirin Low Strength (Tablet Chewable)

C1

Childrens Ibuprofen (Suspension)

121


OTC Drug NameC1

Ecpirin (Tablet Delayed-Release)C1

EQ Aspirin EC (Tablet Delayed-Release)C1

GNP Adult Aspirin Low Strength (Tablet Chewable)

C1

GNP All Day Pain Relief (Tablet)C1

GNP Aspirin (81mg Tablet Delayed-Release, 325mg Tablet Delayed-Release, 325mg Tablet)

C1

GNP Aspirin Low Dose (Tablet Delayed-Release)

C1

GNP Childrens Ibuprofen (Suspension)C1

GNP Ibuprofen (200mg Capsule, 200mg Tablet)

C1

GNP Ibuprofen Infants (Suspension)C1

GNP Ibuprofen Junior Strength (Tablet Chewable)

C1

GNP Naproxen Sodium (220mg Capsule, 220mg Tablet)

C1

Goodsense Aspirin (81mg Tablet Chewable, 325mg Tablet)

C1

Goodsense Aspirin Adult Low Strength (Tablet Chewable)

C1

Goodsense Ibuprofen (Tablet)C1

Goodsense Ibuprofen Childrens (Suspension)

C1

Goodsense Ibuprofen Infants (Suspension)C1

Goodsense Ibuprofen Junior Strength (Tablet Chewable)

C1

Goodsense Naproxen Sodium (Tablet)C1

HM Aspirin (81mg Tablet Chewable, 325mg Tablet)

C1

HM Aspirin EC (Tablet Delayed-Release)C1

HM Aspirin EC Low Dose (Tablet Delayed-Release)

C1

HM Ibuprofen (100mg Tablet Chewable, 200mg Tablet, 200mg Capsule)

C1

HM Ibuprofen Childrens (Suspension)C1

HM Ibuprofen IB (Tablet)

OTC Drug NameC1

HM Ibuprofen Infants (Suspension)C1

HM Naproxen Sodium (220mg Capsule, 220mg Tablet)

C1

Ibu-200 (Tablet)C1

Ibuprofen (200mg Capsule, 200mg Tablet)C1

Ibuprofen Childrens (Suspension)C1

Ibuprofen Infants (Suspension)C1

Ibuprofen Junior Strength (Tablet Chewable)

C1

Infants Ibuprofen (Suspension)C1

Naproxen Sodium (220mg Capsule, 220mg Tablet)

C1

Provil (Tablet)C1

QC Aspirin (Tablet)C1

QC Aspirin Low Dose (Tablet Delayed-Release)

C1

QC Chewable Aspirin Low Dose (Tablet Chewable)

C1

QC Childrens Ibuprofen (Suspension)C1

QC Enteric Aspirin (Tablet Delayed-Release)

C1

QC Ibuprofen (200mg Capsule, 200mg Tablet)

C1

QC Ibuprofen IB (Tablet)C1

QC Ibuprofen Infants (Suspension)C1

QC Naproxen Sodium (Tablet)C1

SB Aspirin (Tablet)C1

SB Naproxen Sodium (Tablet)C1

SM Aspirin (Tablet)C1

SM Aspirin Adult Low Strength (81mg Tablet Chewable, 81mg Tablet Delayed-Release)

C1

SM Aspirin Enteric Coated (Tablet Delayed-Release)

C1

SM Aspirin Low Dose (Tablet Chewable)C1

SM Childrens Aspirin (Tablet Chewable)

122


OTC Drug NameC1

SM Childrens Ibuprofen (Suspension)C1

SM Ibuprofen (200mg Capsule, 200mg Tablet)

C1

SM Ibuprofen IB (100mg Tablet Chewable, 200mg Tablet)

C1

SM Infants Ibuprofen (Suspension)C1

SM Naproxen Sodium (Tablet)C1

St Joseph Low Dose Aspirin (Tablet Chewable)

A1

Anti-Addiction / Substance Abuse Treatment Agents

B1

Smoking Cessation AgentsC1

GNP Nicotine Mini Lozenge (Lozenge)C1

GNP Nicotine Polacrilex (2mg Gum, 4mg Gum)

C1

GNP Nicotine Polacrilex (2mg Lozenge, 4mg Lozenge)

C1

GNP Nicotine Polacrilex Mini (Lozenge)C1

GNP Nicotine Transdermal System (Patch)C1

GNP Nicotine Transdermal System Step 2 (Patch)

C1

Goodsense Nicotine (2mg Lozenge, 4mg Lozenge)

C1

Goodsense Nicotine Gum (Gum)C1

Goodsense Nicotine Polacrilex (Lozenge)C1

HM Nicotine Polacrilex (2mg Gum, 4mg Gum)

C1

HM Nicotine Polacrilex (2mg Lozenge, 4mg Lozenge)

C1

HM Nicotine Transdermal System (14mg/24hr Patch, 21mg/24hr Patch)

C1

HM Nicotine Transdermal System Step 1 (Patch)

C1


C1


OTC Drug NameC1

Nicoderm CQ (7mg/24hr Patch, 14mg/

24hr Patch, 21mg/24hr Patch)C1

Nicorelief (2mg Gum, 4mg Gum)C1

Nicorette (2mg Gum, 4mg Gum)C1

Nicorette (2mg Lozenge, 4mg Lozenge)C1

Nicorette Mini (2mg Lozenge, 4mg

Lozenge)C1

Nicorette Starter Kit (2mg Gum, 4mg

Gum)C1

Nicotine Polacrilex (2mg Gum, 4mg Gum)C1

Nicotine Polacrilex (2mg Lozenge, 4mg Lozenge)

C1

Nicotine Polacrilex (Lozenge)C1

Nicotine Transdermal System (7mg/24hr

Patch, 14mg/24hr Patch, 21mg/24hr

Patch, 21-14-7mg/24hr Kit)C1

Nicotine Transdermal System Step 1 (Patch)

C1


C1


C1

SM Nicotine (Gum)C1

SM Nicotine (Lozenge)C1

SM Nicotine Polacrilex (2mg Gum, 4mg Gum)

C1

SM Nicotine Polacrilex (Lozenge)C1

SM Nicotine Transdermal System (7mg/24hr Patch, 14mg/24hr Patch, 21mg/24hr Patch)

C1

SM Nicotine Transdermal System/Step 1/Clear (Patch)

C1


C1


A1

Antimicrobial AgentsB1

Antimicrobials, Topical

123


OTC Drug NameC1

Advanced Hand Sanitizer (Gel)C1

Advanced Hand Sanitizer/Aloe (Liquid)C1

Alevazol (Ointment)C1

Aloe Vesta Antifungal (Ointment)C1

Aloe Vesta Clear Antifungal (Ointment)C1

Antifungal (1% Cream, 2% Cream)C1

Antifungal Powder (Powder)C1

Anti-Fungal Powder (Powder)C1

Antiseptic Skin Cleanser (Solution)C1

Athletes Foot AF Cream (Cream)C1

Athletes Foot Powder Spray (Aerosol Powder)

C1

Athletes Foot Spray (Aerosol)C1

Bacitracin (Ointment)C1

Bacitracin Zinc (Ointment)C1

Betadine (5% Solution, 10% Solution)C1

Betadine Skin Cleanser (Solution)C1

Betadine Surgical Scrub (Solution)C1

Betadine Swabsticks (Swab)C1

Betasept Surgical Scrub (Liquid)C1

Butenafine Hydrochloride (Cream)C1

Carrington Antifungal (Cream)C1

Castellani Paint Modified/Color C1

Castellani Paint Modified/Colorless C1

Clotrimazole (Solution)C1

Clotrimazole Antifungal (Cream)C1

Clotrimazole Anti-Fungal (Cream)C1

Desenex Shake Powder (Powder)C1

Desenex Spray Liquid (Aerosol)C1

Desenex Spray Powder (Aerosol Powder)C1

Ethyl Rubbing Alcohol C1

Fungoid Tincture (2% Solution)C1

Germbloc Health (Foam)C1

Germbloc Health Hand Sanitizer (Lotion)

OTC Drug NameC1

GNP Antiseptic Skin Cleanser (Solution)C1

GNP Athletes Foot (Cream)C1

GNP Athletes Foot Relief (Aerosol Powder)C1

GNP Bacitracin Zinc (Ointment)C1

GNP Hydrogen Peroxide (Solution)C1

GNP Iodides Tincture (Tincture)C1

GNP Iodine Tincture (Tincture)C1

GNP Isopropyl Alcohol C1

GNP Miconazorb AF (Powder)C1

GNP Povidone-Iodine (Solution)C1

GNP Rubbing Alcohol C1

GNP Terbinafine Hydrochloride (Cream)C1

GNP Tolnaftate (Cream)C1

GNP Triple Antibiotic (Ointment)C1

GNP Triple Antibiotic Plus (Ointment)C1

HM Antiseptic Skin Cleanser (Solution)C1

HM Bacitracin (Ointment)C1

HM Double Antibiotic (Ointment)C1

HM Hydrogen Peroxide (Solution)C1

HM Iodides Tincture (Tincture)C1

HM Iodine Tincture (Tincture)C1

HM Isopropyl Rubbing Alcohol (91% Alcohol)

C1

HM Isopropyl Rubbing Alcohol (70%

Alcohol)C1

HM Povidone-Iodine (Solution)C1

HM Triple Antibiotic (Ointment)C1

HM Triple Antibiotic Plus Maximum Strength (Ointment)

C1

Hydrogen Peroxide (Solution)C1

Iodides Tincture (Tincture)C1

Isagel (Gel)C1

Isopropyl Alcohol (70% Alcohol)C1

Jock Itch Spray (Aerosol Powder)

124


OTC Drug NameC1

Lamisil Advanced (Gel)C1

Lamisil AF Defense (Aerosol Powder)C1

Lamisil AT (Cream)C1

Lamisil AT Jock Itch (Cream)C1

Lamisil AT Spray (Solution)C1

Povidone-Iodine (10% Solution, 10% Ointment)

C1

QC Hydrogen Peroxide (Solution)C1

QC Iodides Tincture (Tincture)C1

QC Iodine Tincture (Tincture)C1

QC Isopropyl Rubbing Alcohol C1

QC Isopropyl Rubbing Alcohol Wintergreen

C1

QC Povidone Iodine (Solution)C1

QC Tolnaftate (Cream)C1

Remedy Antifungal (Cream)C1

Remedy Antimicrobial Cleanser (Liquid)C1

SM Advanced Hand Sanitizer (Liquid)C1

SM Advanced Hand Sanitizer/Aloe (Liquid)C1

SM Alcohol C1

SM Antibiotic (Ointment)C1

SM Antibiotic Plus Pain Relief Maximum Strength (Cream)

C1

SM Antifungal Clotrimazole (Cream)C1

SM Antifungal Miconazole (Cream)C1

SM Antifungal Tolnaftate (Cream)C1

SM Athletes Foot (Cream)C1

SM Double Antibiotic (Ointment)C1

SM Hydrogen Peroxide (Solution)C1

SM Iodides Tincture (Tincture)C1

SM Isopropyl Alcohol (70% Alcohol)C1

SM Isopropyl Alcohol (91% Alcohol, 99% Alcohol)

C1

SM Isopropyl Alcohol Rubbing C1

SM Povidone-Iodine (Solution)

OTC Drug NameC1

SM Triple Antibiotic (Ointment)C1

SM Triple Antibiotic Original Strength (Ointment)

C1

SM Triple Antibiotic Plus Maximum Strength (Ointment)

C1

Soothe & Cool Inzo Antifungal Cream (Cream)

C1

Terbinafine HCL (Cream)C1

Tolnaftate (Powder)C1

Tolnaftate (Cream)C1

Triple Antibiotic (Ointment)C1

Triple Antibiotic Plus (Ointment)C1

Zeasorb-AF (Powder)B1

Antimicrobials, VaginalC1

3 Day Vaginal (Cream)C1

Clotrimazole (Cream)C1

Clotrimazole 3 (Cream)C1

GNP Clotrimazole 3 (Cream)C1

GNP Miconazole 3 (Kit)C1

GNP Miconazole 3 Combination Pack (Kit)C1

GNP Miconazole 7 (Cream)C1

GNP Tioconazole 1 (Ointment)C1

Goodsense Miconazole 1 (Kit)C1

Medicated Feminine Douche (Solution)C1

Miconazole (Cream)C1

Miconazole 1 (Kit)C1

Miconazole 3 (Cream)C1

Miconazole 3 Combination Pack (Kit)C1

Miconazole 3 Combo Pack (Kit)C1

Miconazole 7 (Cream)C1

Miconazole 7 (Suppository)C1

Miconazole Nitrate (Cream)C1

Miconazole Nitrate (Suppository)C1

QC 3 Day Vaginal Cream (Cream)C1

QC Miconazole 7 (Cream)

125


OTC Drug NameC1

SM 3-Day Vaginal (Cream)C1

SM Clotrimazole Vaginal (Cream)C1

SM Miconazole 3 (Kit)C1

SM Miconazole 7 (Cream)C1

SM Miconazole 7 (Suppository)C1

SM Tioconazole-1 (Ointment)C1

Tioconazole 1 (Ointment)C1

Tioconazole-1 (Ointment)C1

Vagistat-3 (Kit)A1

AntiparasiticsB1

Pediculicides / ScabicidesC1

GNP Lice Solution Kit (Gel)C1

GNP Lice Treatment (Rinse)C1

GNP Lice Treatment (Shampoo)C1

HM Lice Killing Maximum Strength (Shampoo)

C1

HM Lice Treatment C1

Lice Killing Maximum Strength (Shampoo)C1

Lice Killing Shampoo (Shampoo)C1

Lice Treatment (Lotion)C1

Licemd Complete Kit (Gel)C1

SM Lice Killing Maximum Strength (Shampoo)

C1

SM Lice Solution Kit (Gel)C1

SM Lice Treatment (Lotion)C1

Vanalice (Gel)A1

Dermatological AgentsB1

Dermatologic Agents, TopicalC1

Abreva (Cream)C1

Acne Medication 10 (Gel)C1

Acne Medication 10 (Lotion)C1

Acne Medication 5 (Gel)C1

Acne Medication 5 (Lotion)C1

Aloe Vesta Clear Barrier Spray (Aerosol)C1

Aloe Vesta Daily Moisturizer (Lotion)

OTC Drug NameC1

Aloe Vesta Protective (Ointment)C1

Aloe Vesta Skin Conditioner (Lotion)C1

Aloe Vesta Skin Protectant (Aerosol)C1

Aluminum Acetate Astringent (Powder Packet)

C1

Ammonium Lactate (12% Cream, 12% Lotion)

C1

Anti-Dandruff Shampoo (Lotion)C1

Anti-Itch (Cream)C1

Anti-Itch Maximum Strength (Solution)C1

Anti-Itch Maximum Strength (Cream)C1

Baby Sunscreen SPF50 (Lotion)C1

Banophen (Cream)C1

Benzoin Compound Tincture (Tincture)C1

Benzoyl Peroxide (5.3% Foam, 9.8% Foam, 2.5% Gel, 5% Gel, 10% Gel))

C1

Benzoyl Peroxide Cleanser (Liquid)C1

Benzoyl Peroxide Wash (5% Liquid, 10% Liquid)

C1

BPO Foaming Cloths C1

Calamine (Lotion)C1

Calamine Medicated (Lotion)C1

Caldyphen (Lotion)C1

Caldyphen Clear (Lotion)C1

Callergy Clear (Lotion)C1

Campho-Phenique (Gel)C1

Carrington Moisture Barrier (Cream)C1

Carrington Moisture Barrier/Zinc

(Cream)C1

Clear Anti-Itch (Lotion)C1

Coats Aloe Creme (Cream)C1

Coats Aloe Gelly (Gel)C1

Coats Aloe Liniment (Lotion)C1

Coats Aloe Moisturizing Lotion (Lotion)C1

Corn And Callus Remover (Liquid)

126


OTC Drug NameC1

DHS Sal (Shampoo)C1

DHS Tar (Shampoo)C1

DHS Tar Gel (Shampoo)C1

DHS Zinc (Shampoo)C1

Diaper Rash (Ointment)C1

Differin (Gel)C1

Diphenhydramine HCL/Zinc Acetate (Cream)

C1

Dr Smiths Adult Barrier Spray (Aerosol)C1

Dr Smiths Diaper (Ointment)C1

Dr Smiths Diaper Rash Spray (Aerosol)C1

Dr Smiths Rash + Skin (Aerosol)C1

General Protection Sunscreen

Continuous Spray SPF30 (Aerosol)C1

General Protection Sunscreen

Continuous Spray SPF70 (Aerosol)C1

General Protection Sunscreen SPF30 (Lotion)

C1

General Protection Sunscreen SPF50 (Lotion)

C1

GNP Aloe Vera/Lidocaine (Gel)C1

GNP Anti-Itch (Cream)C1

GNP Anti-Itch (Lotion)C1

GNP Arthricream (Cream)C1

GNP Burn Relief Spray Aloe Extra (Aerosol)

C1

GNP Calamine (Lotion)C1

GNP Calamine Phenolated (Lotion)C1

GNP Caldyphen (Lotion)C1

GNP Caldyphen Clear (Lotion)C1

GNP Diaper Rash (Cream)C1

GNP Hydrocortisone (Cream)C1

GNP Hydrocortisone Maximum Strength (Ointment)

C1

GNP Hydrocortisone Plus (Cream)C1

GNP Hydrocortisone/Aloe (Cream)

OTC Drug NameC1

GNP Hydro-Lotion (Lotion)C1

GNP Hygienic Cleansing (Pad)C1

GNP Itch Relief Extra Strength (Liquid)C1

GNP Lidocaine Pain Relief (Patch)C1

GNP Medicated First Aid Spray (Aerosol)C1

GNP Medicated Wipes (Pad)C1

GNP Scalp Relief (Liquid)C1

GNP Vitamin A & D (Ointment)C1

GNP Wart Remover (Liquid)C1

GNP Zinc Oxide (Ointment)C1

Hair Regrowth Treatment For Men Extra Strength (Solution)

C1

HM Arthiritis Creme (Cream)C1

HM Calamine (Lotion)C1

HM Glycerin (Liquid)C1

HM Hydrocortisone Plus (Cream)C1

HM Hydrocortisone/Aloe Maximum Strength (Cream)

C1

HM Medicated Cooling Pads (Pad)C1

HM Witch Hazel (Liquid)C1

Hydrocortisone (0.5% Cream, 1% Cream, 0.5% Ointment, 1% Ointment)

C1

Hydrocortisone In Absorbase (Ointment)C1

Hydrocortisone Maximum Strength (Cream)

C1

Hydrocortisone Maximum Strength Plus 12 Moisturizers (Cream)

C1

Hydrocortisone/Aloe (0.5% Cream, 1% Cream)

C1

Hydroskin (Lotion)C1

Itch Relief Extra Strength (Cream)C1

Itch-X (Solution)C1

Itch-X (Gel)C1

Kids Sunscreen Clear Continuous Spray

SPR50 (Aerosol)C1

Lidocaine (Kit)

127


OTC Drug NameC1

Lidocaine/Transparent Dressing (Kit)C1

Medi Pads (Pad)C1

Medicated Callus Removers (Pad)C1

Medicated Corn Removers (Pad)C1

Minoxidil For Men (Solution)C1

Mobisyl (Cream)C1

Moisturel Therapeutic (Lotion)C1

Panoxyl (3% Gel, 10% Bar)C1

Panoxyl Wash (Liquid)C1

Panoxyl-4 Creamy Wash (Liquid)C1

Pedi-Boro Soak Paks (Powder Packet)C1

Petrolatum (Ointment)C1

Proshield Plus Skin Protectant (Cream)C1

QC Anti-Itch Extra Strength (Cream)C1

QC Antiseptic Pain Relief (Liquid)C1

QC Calamine (Lotion)C1

QC Witch Hazel (Liquid)C1

Remedy Cleansing Body Lotion (Lotion)C1

Remedy Dimethicone Moisture Barrier

(Cream)C1

Remedy Nutrashield (Cream)C1

Remedy Skin Repair (Cream)C1

Salactic Film (Solution)C1

Sal-Plant (Gel)C1

Sarna (Lotion)C1

Sarna Sensitive Anti-Itch (Lotion)C1

Scalpicin 2 In 1 (Liquid)C1

Scalpicin Maximum Strength (Solution)C1

Sebex (Shampoo)C1

Sensi-Care Body Cream (Cream)C1

Sensi-Care Clear Zinc Diaper Rash Skin

Protectant (Ointment)C1

Sensi-Care Moisturizing (Cream)C1

Sensi-Care Protective Barrier (Ointment)

OTC Drug NameC1

SM Alcohol Prep Pads/Benzocaine (Pad)C1

SM Anti-Dandruff Coal Tartherapeutic (Shampoo)

C1

SM Anti-Itch Extra Strength (Cream)C1

SM Arthricream Rub (Cream)C1

SM Benzoin Tincture (Tincture)C1

SM Calamine (Lotion)C1

SM Calamine Phenolated (Lotion)C1

SM Caldyphen (Lotion)C1

SM Caldyphen Clear (Lotion)C1

SM Camphor Spirit C1

SM Glycerin (Liquid)C1

SM Hydrocortisone (Cream)C1

SM Hydrocortisone Maximum Strength (Ointment)

C1

SM Hydrocortisone Plus (Cream)C1

Solbar Avo (Lotion)C1

Solbar Fifty (Cream)C1

Solbar PF Liquid/Gel SPF30 (Gel)C1

Solbar SPF40 (Cream)C1

Solbar Zinc SPF38 (Cream)C1

Soothe & Cool Body Powder (Powder)C1

Soothe & Cool Free Medseptic

(Ointment)C1

Soothe & Cool Free Moisture Barrier

(Ointment)C1

Soothe & Cool Free Skin Paste

(Ointment)C1

Soothe & Cool Inzo Barrier (Cream)C1

Soothe & Cool Protect Moisture Barrier

(Ointment)C1

Sport Sunscreen SPF50 (Lotion)C1

Therapeutic Shampoo (Shampoo)C1

Tippy Toes Diaper Rash (Ointment)C1

Trolamine Salicylate (Cream)

128


OTC Drug NameC1

Vitamin A & D (Ointment)C1

Wart Remover Maximum Strength (Liquid)C1

Wart Remover Maximum Strenth One-Step (Strip)

C1

White Petrolatum (Ointment)C1

White Petroleum Jelly (Gel)C1

Z-Bum (Cream)C1

Zinc Oxide (Ointment)A1

Gastrointestinal AgentsB1

AntacidsC1

Acid Gone (Suspension)C1

Acid Gone (Tablet Chewable)C1

Acid Reducer (Capsule Delayed-Release)C1

Acid Reducer (Tablet)C1

Acid Reducer Complete (Tablet Chewable)C1

Acid Reducer Maximum Strength (Tablet)C1

Antacid (Suspension)C1

Antacid (Tablet Chewable)C1

Antacid Anti-Gas Maximum Strength (Suspension)

C1

Antacid Calcium Extra Strength (Tablet Chewable)

C1

Antacid Calcium Regular Strength (Tablet Chewable)

C1

Antacid Extra Strength (Tablet Chewable)C1

Antacid Fast Acting (Suspension)C1

Antacid Fast Relief (Suspension)C1

Antacid Maximum Strength (Suspension)C1

Antacid Plus Anti-Gas Fast Acting (Suspension)

C1

Antacid Plus Anti-Gas Relief (Suspension)C1

Antacid Plus Anti-Gas Relief Maximum Strength (Suspension)

C1

Antacid Regular Strength (Suspension)C1

Calcium Antacid (Tablet Chewable)

OTC Drug NameC1

Calcium Antacid Extra Strength (Tablet Chewable)

C1

Calcium Antacid Ultra (Tablet Chewable)C1

Calcium Antacid Ultra Maximum Strength (Tablet Chewable)

C1

Calcium Antacid Ultra Strength (Tablet Chewable)

C1

Cal-Gest Antacid (Tablet Chewable)C1

Chewable Antacid (Tablet Chewable)C1

Dual Action Complete (Tablet Chewable)C1

Esomeprazole Magnesium (Capsule Delayed-Release)

C1

Famotidine (Tablet)C1

Fast Acting Antacid Plus Anti-Gas Maximum Strength (Suspension)

C1

GNP Acid Control 150 Maximum Strength (Tablet)

C1

GNP Acid Reducer (10mg Tablet, 75mg Tablet)

C1

GNP Acid Reducer Maximum Strength (Tablet)

C1

GNP Antacid & Anti-Gas Maximum Strength (Tablet Chewable)

C1

GNP Antacid & Anti-Gas/Regular Strength (Suspension)

C1

GNP Antacid (Tablet Chewable)C1

GNP Antacid And Anti-Gas/Maximum Strength (Suspension)

C1

GNP Antacid Anti-Gas (Suspension)C1

GNP Antacid Anti-Gas/Maximum Strength (Suspension)

C1

GNP Antacid Extra Strength (Tablet Chewable)

C1

GNP Antacid Maximum Strength (Suspension)

C1

GNP Antacid/Regular Strength (Suspension)

129


OTC Drug NameC1

GNP Esomeprazole Magnesium (Capsule Delayed-Release)

C1

GNP Heartburn Relief (Tablet)C1

GNP Lansoprazole (Capsule Delayed-Release)

C1

GNP Omeprazole (Tablet Delayed-Release)C1

Goodsense Acid Reducer (75mg Tablet, 150mg Tablet)

C1

Goodsense Esomeprazole Magnesium (Capsule Delayed-Release)

C1

Goodsense Lansoprazole (Capsule Delayed-Release)

C1

Heartburn Relief (10mg Tablet, 75mg Tablet, 200mg Tablet)

C1

Heartburn Relief 150 Maximum Strength (Tablet)

C1

Heartburn Relief Maximum Strength (Tablet)

C1

Heartburn Treatment 24 Hour (Capsule Delayed-Release)

C1

HM Acid Reducer (Tablet)C1

HM Acid Reducer Maximum Strength (Tablet)

C1

HM Advanced Antacid Maximum Strength (Suspension)

C1

HM Antacid (Suspension)C1

HM Antacid Anti-Gas Extrastrength (Suspension)

C1

HM Antacid/Antigas (Suspension)C1

HM Calcium Antacid (Tablet Chewable)C1

HM Calcium Antacid Extra Strength (Tablet Chewable)

C1

HM Calcium Antacid Smoothdissolve (Tablet Chewable)

C1

HM Calcium Antacid Smoothdissolve Extra Strength (Tablet Chewable)

C1

HM Calcium Antacid Ultra Strength (Tablet Chewable)

OTC Drug NameC1

HM Esomeprazole Magnesium Delayed Release (Capsule Delayed-Release)

C1

HM Famotidine (10mg Tablet, 20mg Tablet)

C1

HM Lansoprazole (Capsule Delayed-Release)

C1

HM Omeprazole (Tablet Delayed-Release)C1

Lansoprazole (Capsule Delayed-Release)C1

Omeprazole (20mg Capsule Delayed-Release, 20mg Tablet Delayed-Release)

C1

Omeprazole Magnesium (Capsule Delayed-Release)

C1

Prevacid 24Hr (Capsule Delayed-

Release)C1

QC Acid Controller (Tablet)C1

QC Acid Controller Maximum Strength (Tablet)

C1

QC Antacid (Suspension)C1

QC Antacid (Tablet Chewable)C1

QC Antacid/Anti-Gas (Suspension)C1

QC Heartburn 150 Maximum Strength (Tablet)

C1

QC Omeprazole Magnesium (Capsule Delayed-Release)

C1

QC Ranitidine HCL (Tablet)C1

Ranitidine 150 Maximum Strength (Tablet)C1

Ranitidine 75 (Tablet)C1

Ranitidine Maximum Strength (Tablet)C1

SM Acid Reducer (10mg Tablet, 75mg Tablet, 200mg Tablet)

C1

SM Acid Reducer Maximum Strength (Tablet)

C1

SM Antacid Advanced (Suspension)C1

SM Antacid Advanced Maxi Mum Strength (Suspension)

C1

SM Antacid/Antigas (Suspension)C1

SM Calcium Antacid (Tablet Chewable)

130


OTC Drug NameC1

SM Calcium Antacid Extra Strength (Tablet Chewable)

C1

SM Calcium Antacid Ultra Strength (Tablet Chewable)

C1

SM Esomeprazole Magnesium (Capsule Delayed-Release)

C1

SM Lansoprazole (Capsule Delayed-Release)

C1

SM Omeprazole (Tablet Delayed-Release)C1

Tums (Tablet Chewable)C1

Tums Chewy Bites (Tablet Chewable)C1

Tums Chewy Delights (Tablet Chewable)C1

Tums E-X 750 (Tablet Chewable)C1

Tums Extra Strength 750 (Tablet

Chewable)C1

Tums Freshers (Tablet Chewable)C1

Tums Gas Relief Chewy Bites (Tablet Chewable)

C1

Tums Kids (Tablet Chewable)C1

Tums Smoothies (Tablet Chewable)C1

Tums Ultra 1000 (Tablet Chewable)B1

Hemmoroidal AgentsC1

Anu-Med (Suppository)C1

Dibucaine (Ointment)C1

GNP Hemorrhoidal (Ointment)C1

GNP Hemorrhoidal Cooling (Gel)C1

Goodsense Hemorrhoidal Ointment (Ointment)

C1

Goodsense Hemorrhoidal (Suppository)C1

Hemorrhoidal (Cream)C1

Hemorrhoidal (Ointment)C1

Hemorrhoidal (Suppository)C1

Hemorrhoidal Maximum Strength/Aloe (Cream)

C1

Hemorrhoidal Suppositories (Suppository)C1

HM Hemorrhoidal (Ointment)

OTC Drug NameC1

Lidocaine 5% (Cream)C1

Major-Prep Hemorrhoidal (Ointment)C1

QC Hemorrhoidal (Ointment)C1

QC Hemorrhoidal (Suppository)B1

LaxativesC1

Adult Suppository (Suppository)C1

Bisac-Evac (Suppository)C1

Bisacodyl (Suppository)C1

Bisacodyl EC (Tablet Delayed-Release)C1

Biscolax (Suppository)C1

Citrucel (Tablet)C1

Citrucel Fiber Laxative (Powder)C1

Clearlax (Packet)C1

Clearlax (Powder)C1

Colace (Capsule)C1

Colace 2-In-1 (Tablet)C1

Colace Clear (Capsule)C1

Docu (Liquid)C1

Docusate Sodium & Senna Stimulant Laxative/Stool Softener (Tablet)

C1

Docusate Sodium (100mg Capsule)C1

Docusate Sodium (150mg/15ml Liquid, 100mg Tablet)

C1

Docusil (Capsule)C1

Docusol Kids (Enema)C1

Docusol Mini (Enema)C1

Docusol Plus Mini-Enema (Enema)C1

Dok (100mg Capsule)C1

Dok (100mg Tablet)C1

Dok (250mg Capsule)C1

Dok Plus (Tablet)C1

Ducodyl (Tablet Delayed-Release)C1

Enema (Enema)C1

Enema Mineral Oil Ready-To-Use (Enema)

131


OTC Drug NameC1

Enema Ready-To-Use (Enema)C1

Enemeez Mini (Enema)C1

Enemeez Plus (Enema)C1

Ex-Lax (15mg Tablet Chewable, 15mg

Tablet)C1

Ex-Lax Maximum Strength (Tablet)C1

Fiber Laxative (0.52gm Capsule, 625mg Tablet)

C1

Fiber Tabs (Tablet)C1

Fiber-Lax (Tablet)C1

Fleet Bisacodyl (Enema)C1

Fleet Enema (Enema)C1

Fleet Liquid Glycerin Suppositories

(Enema)C1

Fleet Oil (Enema)C1

Fleet Pediatric (Enema)C1

Gavilax (Powder)C1

Glycerin Adult (2gm Suppository, 2.1gm Suppository)

C1

Glycerin Pediatric (Suppository)C1

Glycolax (Powder)C1

GNP Bisa-Lax (Tablet Delayed-Release)C1

GNP Clearlax (Packet)C1

GNP Clearlax (Powder)C1

GNP Docusate Calcium (Capsule)C1

GNP Enema (Enema)C1

GNP Enema Mineral Oil Laxative (Enema)C1

GNP Fiber Therapy (Tablet)C1

GNP Fiber-Caps (Tablet)C1

GNP Gentle Laxative (Suppository)C1

GNP Laxative (Tablet Delayed-Release)C1

GNP Laxative Pills (Tablet)C1

GNP Milk Of Magnesia (Suspension)C1

GNP Mineral Oil Heavy (Oil)C1

GNP Natural Fiber (Powder)

OTC Drug NameC1

GNP Senna Lax (Tablet)C1

GNP Senna Plus (Tablet)C1

GNP Senna-Lax (Tablet)C1

GNP Stool Softener (100mg Capsule, 250mg Capsule, 150mg/15ml Liquid, 60mg/15ml Syrup)

C1

GNP Stool Softener Extra Strength (Capsule)

C1

GNP Stool Softener/Stimulant Laxative (Tablet)

C1

GNP Womens Gentle Laxative (Tablet Delayed-Release)

C1

GNP Womens Laxative (Tablet Delayed-Release)

C1

Goodsense Clearlax (Powder)C1

Healthylax (Packet)C1

HM Castor Oil (Oil)C1

HM Clearlax (Powder)C1

HM Enema Saline Laxative (Enema)C1

HM Enema (Enema)C1

HM Enema Mineral Oil (Enema)C1

HM Enema Ready-To-Use (Enema)C1

HM Fiber (0.52gm Capsule, 28.3% Powder, 30.9% Powder, 48.57% Powder, 58.6% Powder, 500mg Tablet)

C1

HM Laxative (Tablet Delayed-Release)C1

HM Stool Softener (100mg Capsule, 100mg Tablet)

C1

HM Stool Softener Maximum Strength (Capsule)

C1

HM Stool Softener/Stimulant Laxative (Tablet)

C1

Konsyl (Capsule)C1

Konsyl (Powder Packet)C1

Konsyl (Powder)C1

Konsyl Daily Fiber (Powder Packet)C1

Konsyl Daily Fiber (Powder)

132


OTC Drug NameC1

Konsyl Fiber (Tablet)C1

Konsyl-D (Powder)C1

Laxative (25mg Tablet)C1

Laxative (5mg Tablet Delayed-Release, 10mg Suppository)

C1

Laxative Feminine (Tablet Delayed-Release)

C1

Mineral Oil (Oil)C1

Natural Fiber Laxative (58.6% Powder, 48.57% Powder)

C1

Natural Fiber (Powder)C1

Natural Fiber Therapy (Powder)C1

Pedia-Lax (Liquid)C1

Pedia-Lax (Suppository)C1

Pedia-Lax (Tablet Chewable)C1

Peg 3350 (Packet)C1

Polyethylene Glycol 3350 (Packet)C1

Polyethylene Glycol 3350 (Powder)C1

QC Castor Oil (Oil)C1

QC Enema (Enema)C1

QC Gentle Laxative (Suppository)C1

QC Mineral Oil Heavy (Oil)C1

QC Natural Vegetable Laxative (Tablet)C1

QC Natura-Lax (Powder)C1

QC Stool Softener (Capsule)C1

QC Stool Softener Plus Laxative (Tablet)C1

QC Stool Softener Plus Stimulant Laxative (Tablet)

C1

Sani-Supp Adult (Suppository)C1

Sani-Supp Pediatric (Suppository)C1

Senexon (Tablet)C1

Senexon-S (Tablet)C1

Senna (Tablet)C1

Senna Plus (Tablet)C1

Senna Prompt (Capsule)

OTC Drug NameC1

Senna-S (Tablet)C1

Senna-Tabs (Tablet)C1

Senna-Time (Tablet)C1

Senna-Time S (Tablet)C1

Senno (Tablet)C1

Sennosides/Docusate Sodium (Tablet)C1

Senokot (Tablet)C1

Senokot Extra Strength (Tablet)C1

Senokot S (Tablet)C1

Senna Lax (Tablet)C1

Senna Laxative (Tablet)C1

Senna-Lax (Tablet)C1

Silace (150mg/15ml Liquid, 60mg/15ml Syrup)

C1

SM Castor Oil (Oil)C1

SM Clearlax (Powder)C1

SM Enema (Enema)C1

SM Fiber (Powder)C1

SM Fiber (Tablet)C1

SM Fiber Laxative (Capsule)C1

SM Fiber Laxative (Tablet)C1

SM Gentle Laxative (Tablet Delayed-Release)

C1

SM Laxative Maximum Strength (Tablet)C1

SM Senna Laxative (Tablet)C1

SM Senna-S (Tablet)C1

Soluble Fiber (Powder)C1

Stimulant Laxative (Tablet Delayed-Release)

C1

Stool Softener (Capsule)C1

Stool Softener Extra Strength (Capsule)C1

Stool Softener Plus Laxative (Tablet)C1

Vegetable Laxative+Stool Softener (Tablet)C1

Womans Laxative (Tablet Delayed-Release)B1

Gastrointestinal Agents, Other

133


OTC Drug NameC1

Actidose/Sorbitol (Liquid)C1

Actidose-Aqua (Liquid)C1

Almacone (Suspension)C1

Almacone (Tablet Chewable)C1

Almacone Double Strength (Suspension)C1

Aluminum Hydroxide (Suspension)C1

Anti-Diarrheal (2mg Capsule, 2mg Tablet)C1

Anti-Nausea (Solution)C1

Bismatrol (262mg/15ml Suspension, 262mg Tablet Chewable)

C1

Bismatrol Maximum Strength (Suspension)C1

Calcium Carbonate (1250mg/5ml Suspension, 648mg Tablet)

C1

Driminate (Tablet)C1

EZ Char (Suspension)C1

Formula EM (Solution)C1

Gas Relief (40mg/0.6ml Suspension, 60mg Tablet Chewable)

C1

Gas Relief Extra Strength (Capsule)C1

Gas Relief Maximum Strength (Tablet Chewable)

C1

Gas Relief Ultra Strength (Capsule)C1

Gas-X (Tablet Chewable)C1

Gas-X Extra Strength (Capsule)C1

Gas-X Extra Strength (Tablet Chewable)C1

Gas-X Ultra Strength (Capsule)C1

Gaviscon (Suspension)C1

Gaviscon (Tablet Chewable)C1

Gaviscon Extra Strength (Suspension)C1

Gaviscon Extra Strength (Tablet

Chewable)C1

Gaviscon Extra Strength Relief Formula

(Suspension)C1

GNP Anti-Diarrheal (2mg Capsule, 2mg Tablet)

C1

GNP Anti-Gas (Capsule)

OTC Drug NameC1

GNP Gas Relief (Tablet Chewable)C1

GNP Gas Relief Extra Strength (125mg Capsule, 125mg Tablet Chewable)

C1

GNP Infants Gas Relief (Suspension)C1

GNP Loperamide HCL (Liquid)C1

GNP Masanti Maximum Strength (Suspension)

C1

GNP Masanti Regular Strength (Suspension)

C1

GNP Motion Sickness Relief (25mg Tablet, 50mg Tablet)

C1

GNP Motion Sickness Relief (Tablet)C1

GNP Nausea Relief (Solution)C1

GNP Pink Bismuth (262mg Tablet Chewable, 262mg Tablet)

C1

GNP Stomach Relief (Suspension)C1

Goodsense Stomach Relief (Tablet Chewable)

C1

HM Anti-Diarrheal (Tablet)C1

HM Anti-Nausea (Solution)C1

HM Gas Relief (80mg Tablet Chewable, 125mg Tablet Chewable)

C1

HM Gas Relief Extra Strength (Capsule)C1

HM Gas Relief Infants (Suspension)C1

HM Loperamide HCL (2mg Capsule, 1mg/7.5ml Liquid)

C1

HM Milk Of Magnesia (Suspension)C1

HM Motion Relief (Tablet)C1

HM Motion Sickness (Tablet)C1

HM Motion Sickness Relief (Tablet)C1

HM Senna (Tablet)C1

HM Senna-S (Tablet)C1

HM Stomach Relief (262mg/15ml Suspension, 262mg Tablet Chewable)

C1

HM Stomach Relief Maximumstrength (Suspension)

134


OTC Drug NameC1

Infants Gas Relief (Suspension)C1

Infants Simethicone (Suspension)C1

Kao-Tin (240mg Capsule, 262mg/15ml Suspension)

C1

Loperamide HCL (Liquid)C1

Loperamide Hydrochloride (Tablet)C1

Mag-AL (Suspension)C1

Mag-AL Plus (Suspension)C1

Mag-AL Plus XS (Suspension)C1

Magnesium Oxide (Tablet)C1

Meclizine HCL (12.5mg Tablet, 25mg Tablet Chewable)

C1

Mi-Acid (Suspension)C1

Mi-Acid (Tablet Chewable)C1

Mi-Acid Gas Relief (Tablet Chewable)C1

Mi-Acid Maximum Strength (Suspension)C1

Milk Of Magnesia (Suspension)C1

Milk Of Magnesia Concentrate (Suspension)

C1

Mintox (Suspension)C1

Mintox Maximum Strength (Suspension)C1

Mintox Plus (Tablet Chewable)C1

Motion Sickness Relief (Tablet)C1

Motion-Time (Tablet Chewable)C1

Peptic Relief (262mg/15ml Suspension, 262mg Tablet Chewable)

C1

Perdiem Overnight Relief (Tablet)C1

Pink Bismuth (Tablet Chewable)C1

Potassium Iodide (Solution)C1

QC Anti-Diarrheal (Tablet)C1

QC Milk Of Magnesia (Suspension)C1

Reguloid (28.3% Powder, 48.57% Powder, 58.6% Powder)

C1

Rulox (Suspension)

OTC Drug NameC1

Simethicone (40mg/0.6ml Suspension, 80mg Tablet Chewable, 125mg Tablet Chewable, 180mg Capsule)

C1

SM Anti-Diarrheal (2mg Capsule, 2mg Tablet)

C1

SM Gas Relief (Tablet Chewable)C1

SM Gas Relief Antiflatuent (Capsule)C1

SM Gas Relief Drops Infants (Suspension)C1

SM Gas Relief Extra Strength (Capsule)C1

SM Loperamide HCL (Liquid)C1

SM Milk Of Magnesia (Suspension)C1

SM Motion Sickness (Tablet)C1

SM Motion Sickness Relief (Tablet)C1

SM Stomach Relief (262mg Tablet Chewable, 262mg Tablet)

C1

SM Stomach Relief Liquid (Suspension)C1

SM Stool Softener (Capsule)C1

SM Stool Softener (Tablet)C1

Sodium Bicarbonate (Tablet)C1

Stomach Relief (Suspension)C1

Stomach Relief (Tablet Chewable)C1

Stomach Relief Maximum Strength (Suspension)

C1

Travel Sickness (25mg Tablet Chewable, 50mg Tablet)

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

B1

Contraceptives, OralC1

Aftera (Tablet)C1

Econtra EZ (Tablet)C1

Econtra One-Step (Tablet)C1

Fallback Solo (Tablet)C1

Levonorgestrel (Tablet)C1

My Choice (Tablet)C1

My Way (Tablet)C1

New Day (Tablet)

135


OTC Drug NameC1

Opcicon One-Step (Tablet)C1

Option 2 (Tablet)C1

Plan B One-Step (Tablet)C1

Take Action (Tablet)A1

Miscellaneous Therapeutic AgentsB1

Devices / Other Therapeutic AgentsC1

GNP Chest Rub (Ointment)C1

GNP Epsom Salt C1

HM Chest Rub (Ointment)C1

HM Epsom Salt C1

Medicated Chest Rub (Ointment)C1

SM Epsom Salt C1

SM Medicated Chest Rub (Ointment)B1

Tear / Saliva Replacement AgentsC1

Akwa Tears (Ointment)C1

Artificial Tears (Ointment)C1

Artificial Tears (Solution)C1

Bion Tears (Solution)C1

Genteal Severe (Gel)C1

Genteal Tears Liquid Drops Moderate (Solution)

C1

Genteal Tears Mild (Solution)C1

Genteal Tears Moderate PF (Solution)C1

Genteal Tears Moderate PF (Solution)C1

GNP Artificial Tears (Solution)C1

GNP Eye Drops (Solution)C1

GNP Lubricant PM (Ointment)C1

GNP Lubricating Plus Eye Drops (Solution)C1

Goodsense Lubricant Eye Drops (Solution)C1

Goodsense Lubricating Plus Eye Drops (Solution)

C1

HM Dry Eye Relief (Solution)C1

HM Lubricating Plus (Solution)C1

HM Lubricating Tears (Solution)

OTC Drug NameC1

Isopto Tears (Solution)C1

Liquitears (Solution)C1

Lubricant Eye Drops (Solution)C1

Lubricating Plus Eye Drops (Solution)C1

Lubrifresh P.M. (Ointment)C1

Natural Balance Tears (Solution)C1

Natures Tears (Solution)C1

Puralube (Ointment)C1

Refresh (Solution)C1

Refresh Celluvisc (Gel)C1

Refresh Lacri-Lube (Ointment)C1

Refresh Liquigel (Gel)C1

Refresh Optive (Gel)C1

Refresh Optive (Solution)C1

Refresh Optive Advanced (Solution)C1

Refresh Optive Advanced Sensitive

(Solution)C1

Refresh Optive Mega-3 (Solution)C1

Refresh Optive Sensitive (Solution)C1

Refresh P.M. (Ointment)C1

Refresh Plus (Solution)C1

Refresh Tears (Solution)C1

SM Lubricant Eye Drops (Solution)C1

SM Lubricating Plus (Solution)C1

SM Lubricating Tears (Solution)C1

Systane (Solution)C1

Systane Balance Restorative Formula

(Solution)C1

Systane Complete (Solution)C1

Systane Gel (Gel)C1

Systane Nighttime (Ointment)C1

Systane Overnight Therapy Lubricant

Eye (Gel)C1

Systane Preservative Free (Solution)

136


OTC Drug NameC1

Systane Ultra (Solution)C1

Systane Ultra Preservative Free

(Solution)C1

Ultra Lubricant Eye Drops (Solution)A1

Ophthalmic AgentsB1

Allergy Agents, OphthalmicC1

Alaway (Solution)C1

Alaway Childrens Allergy Eye Itch Relief

(Solution)C1

Eye Drops (Solution)C1

Eye Itch Relief (Solution)C1

GNP Redness Relief (Solution)C1

HM Eye Drops (Solution)C1

HM Eye Drops Advanced Relief (Solution)C1

HM Eye Drops Redness Relief (Solution)C1

HM Eye Itch Relief (Solution)C1

Ketotifen Fumarate (Solution)C1

Naphcon-A (Solution)C1

Opti-Clear (Solution)C1

SM Eye Drops (Solution)C1

SM Eye Itch Relief (Solution)C1

SM Redness Relief (Solution)C1

Zaditor (Solution)B1

Ophthalmic Agents, OtherC1

Ear Drops (Solution)C1

Earwax Removal Kit (Solution)C1

Eye Irrigating Solution (Solution)C1

Eye Stream (Solution)C1

Eye Wash (Solution)C1

GNP Ear Systems (Solution)C1

HM Earwax Removal Aid (Solution)C1

HM Earwax Removal Kit (Solution)C1

Lumify (Solution)C1

Muro 128 (2% Solution, 5% Solution, 5%

Ointment)

OTC Drug NameC1

SM Ear Drops (Solution)C1

Sodium Chloride (5% Ointment, 5% Solution)

A1

Oral HealthB1

Oral Health AgentsC1

Aquafresh Cavity Protection (Paste)C1

Aquafresh Extreme Clean (Paste)C1

Aquafresh For Kids (Paste)C1

Aquafresh Sensitive (Paste)C1

Aquafresh Toothpaste C1

Aquafresh Whitening (Paste)C1

Biotene Dry Mouth (Paste)C1

Biotene Dry Mouth Gentle Formula

(Paste)C1

Biotene PBF Dry Mouth (Paste)C1

Parodontax (Paste)C1

Sensodyne Complete Protection (Paste)C1

Sensodyne Maximum Strength (Paste)C1

Sensodyne Pronamel (Paste)C1

Sensodyne Pronamel Fresh Breath

(Paste)C1

Sensodyne Rapid Relief (Paste)C1

Sensodyne Repair & Protect Whitening

(Paste)A1

Otic AgentsB1

Otic AgentsC1

Swim Ear (Liquid)A1

Personal Care ProductsB1

Personal Care ProductsC1

Overnight Ultra Thin A1

Respiratory Tract/Pulmonary AgentsB1

Antihistamines / Decongestants / Cough and Cold

C1

12 Hour Decongestant (Tablet Extended-Release)

137


OTC Drug NameC1

12 Hour Nasal Decongestant/Maximum Strength (Tablet Extended-Release)

C1

24Hr Allergy Relief (Tablet)C1

Aceta-Gesic (Tablet)C1

Ahist (Tablet)C1

Alahist CF (Tablet)C1

Alahist DM (Liquid)C1

Ala-Hist IR (Tablet)C1

Ala-Hist PE (Tablet)C1

All Day Allergy (Tablet)C1

All Day Allergy Childrens (Solution)C1

All Day Allergy D (Tablet Extended-Release)

C1

All-Day Allergy Childrens (Solution)C1

Aller-Chlor (Tablet)C1

Aller-Ease (Tablet)C1

Allergy & Congestion Relief (Tablet Extended-Release)

C1

Allergy (Tablet)C1

Allergy Childrens (Syrup)C1

Allergy Multi-Symptom (Tablet)C1

Allergy Non-Drowsy (Tablet)C1

Allergy Relief (4mg Tablet, 10mg Tablet, 25mg Capsule, 25mg Tablet, 180mg Tablet)

C1

Allergy Relief 24Hr (Tablet)C1

Allergy Relief Childrens (Liquid)C1

Allergy Relief D-24 (Tablet Extended-Release)

C1

Allergy Relief/Nasal Decongestant (Tablet Extended-Release)

C1

Allergy Relief-D (Tablet Extended-Release)C1

Allergy/Congestion Relief (Tablet Extended-Release)

C1

Allergy-Time (Tablet)C1

Allfen DM (Tablet)

OTC Drug NameC1

All-Nite Cold & Flu Nighttime Relief (Liquid)C1

Aprodine (Tablet)C1

Aquanaz (Tablet)C1

Atuss DA (Liquid)C1

Banophen (25mg Capsule, 50mg Capsule, 25mg Tablet)

C1

Banophen (Liquid)C1

Bronkaid (Tablet)C1

Brotapp (Elixir)C1

Brotapp DM (Elixir)C1

Capcof (Syrup)C1

Capmist DM (30-30-400mg Tablet)C1

Capmist DM (60-15-400mg Tablet)C1

Capron DM (Liquid)C1

Capron DMT (Tablet)C1

Cepacol Sore Throat & Cough (Lozenge)C1

Cepacol Sore Throat & Cough Extra

Strength (Lozenge)C1

Cepacol Sore Throat (Lozenge)C1

Cepacol Sore Throat Extra Strength

(Lozenge)C1

Cetirizine HCL (1mg/1ml Solution, 5mg Tablet Chewable, 10mg Tablet Chewable, 5mg Tablet, 10mg Tablet)

C1

Cetirizine HCL Allergy Childrens (Solution)C1

Cetirizine HCL Childrens (1mg/1ml Solution, 5mg Tablet Chewable, 10mg Tablet Chewable)

C1

Cetirizine HCL Childrens Allergy (Solution)C1

Cetirizine HCL/Pseudoephedrine HCL Er (Tablet Extended-Release)

C1

Cetirizine Hydrochloride (Tablet)C1

Cheratussin Ac (Solution)C1

Chest Congestion Relief (Tablet)C1

Childrens Allergy (Liquid)C1

Childrens Cold & Allergy (Elixir)

138


OTC Drug NameC1

Childrens Loratadine (Syrup)C1

Childrens Mucus Relief Cough (Liquid)C1

Childrens Mucus Relief Expectorant (Liquid)

C1

Childrens Pain Relief Plus Multi-Symptom Cold (Suspension)

C1

Childrens Pain Relief Plus Multi-Symptom Flu Relief (Suspension)

C1

Childrens Silfedrine (Liquid)C1

Chlo Hist (Solution)C1

Chlo Tuss (Liquid)C1

Chlorphen SR (Tablet Extended-Release)C1

Codeine/Guaifenesin (Solution)C1

Cold & Allergy (Tablet)C1

Cold & Allergy Childrens (Elixir)C1

Cold & Cough Childrens (Liquid)C1

Cold & Sinus Relief (Tablet)C1

Cold Head Congestion Daytime (Tablet)C1

Cold Head Congestion Nighttime (Tablet)C1

Cold Head Congestion Severe Daytime (Tablet)

C1

Cold Multi-Symptom Daytime (Tablet)C1

Cold Multi-Symptom Nighttime (Tablet)C1

Cold Multi-Symptom Severe Daytime (Tablet)

C1

Cold Relief Plus (Tablet)C1

Cold Relief/Non-Drowsy/Daytime (Tablet)C1

Cold/Cough Childrens (Elixir)C1

Complete Allergy Medicine (Capsule)C1

Conex Cold/Allergy (1-30mg/5ml

Solution, 2-60mg Tablet)C1

Congestac (Tablet)C1

Cough & Cold (Tablet)C1

Cough & Cold HBP (Tablet)C1

Cough & Sore Throat Day Time (Liquid)

OTC Drug NameC1

Cough & Sore Throat Nighttime (Liquid)C1

Cough DM (Suspension)C1

Cough DM Childrens (Suspension)C1

Cough Drops (Lozenge)C1

Cough Syrup (Syrup)C1

Cromolyn Sodium (Solution)C1

Day Time Cold/Flu Relief (Liquid)C1

Day Time Cough (Liquid)C1

Day Time Multi-Symptom Cold/Flu Relief

(Capsule)C1

Day Time/Nite Time Cold & Flu Relief (Liquid)

C1

Dayclear Allergy Relief (Tablet)C1

Dayhist Allergy 12 Hour Relief (Tablet)C1

Daytime Cold & Flu Relief (10-5-325mg Capsule, 10-5-325mg/15ml Liquid)

C1

Day-Time PE (Capsule)C1

Daytime PE Multi-Symptom Cold/Flu Relief (Capsule)

C1

Daytime Severe Cold & Flu (Liquid)C1

Deconex DMX (Tablet)C1

Deconex IR (Tablet)C1

Decongestant 12Hour Maximum Strength (Tablet Extended-Release)

C1

Delsym (Suspension)C1

Delsym Cough + Chest Congestion DM (Liquid)

C1

Delsym Cough + Chest Congestion DM Childrens (Liquid)

C1

Delsym Cough + Cold Daytime (Liquid)C1

Delsym Cough + Cold Nighttime (Liquid)C1

Delsym Cough + Cold Nighttime Childrens (Liquid)

C1

Delsym Cough Childrens (Suspension)C1

Delsym Cough + Soothing Action (Lozenge)

139


OTC Drug NameC1

Dextromethorphan Polistirex (Suspension)C1

Dextromethorphan/Guaifenesin (Liquid)C1

Dextromethorphan/Guaifenesin/Phenylephrine (Liquid)

C1

Diabetic Siltussin Das-Na (Liquid)C1

Diabetic Siltussin-DM (Liquid)C1

Diabetic Siltussin-DM Maximum Strength (Liquid)

C1

Dimaphen Childrens (Elixir)C1

Dimaphen DM Cold & Cough (Elixir)C1

Diphenhist (25mg Capsule, 12.5mg/5ml Liquid, 25mg Tablet)

C1

Diphenhydramine HCL (25mg Capsule, 50mg Capsule, 25mg Tablet)

C1

Diphenhydramine Hydrochloride (Liquid)C1

Duraflu (Tablet)C1

Dye-Free Allergy Relief Childrens (Liquid)C1

ED A-Hist (Liquid)C1

ED A-Hist (Tablet)C1

ED A-Hist DM (Liquid)C1

ED A-Hist DM (Tablet)C1

ED A-Hist PSE (Tablet)C1

ED Bron GP (Liquid)C1

ED Chlorped (Liquid)C1

ED Chlorped D (Liquid)C1

ED Chlorped Jr (Syrup)C1

Endacof-DM (Liquid)C1

Extra Action Cough (Syrup)C1

Fexofenadine HCL (60mg Tablet, 180mg Tablet)

C1

Fexofenadine HCL Childrens Allergy (Suspension)

C1

Fexofenadine HCL/Pseudoephedrine HCL ER (Tablet Extended-Release)

C1

Fexofenadine Hydrochloride (Tablet)

OTC Drug NameC1

Fexofenadine/Pseudoephedrine (Tablet Extended-Release)

C1

Flu & Severe Cold Daytime (Powder Packet)

C1

Flu & Sore Throat (Powder Packet)C1

Flu HBP (Tablet)C1

Flu/Severe Cold & Cough Daytime (Powder Packet)

C1

GNP All Day Allergy (Tablet)C1

GNP All Day Allergy Childrens (Solution)C1

GNP All Day Allergy-D (Tablet Extended-Release)

C1

GNP Allergy & Congestion Relief (Tablet Extended-Release)

C1

GNP Allergy (25mg Capsule, 4mg Tablet, 25mg Tablet)

C1

GNP Allergy Antihistamine Childrens (Liquid)

C1

GNP Allergy Multi-Symptom (Tablet)C1

GNP Allergy Plus Severe Sinus Headache Maximum Strength (Tablet)

C1

GNP Allergy Plus Sinus Headache (Tablet)C1

GNP Allergy Relief (25mg Capsule, 12.5mg Tablet Chewable, 180mg Tablet, 10mg Tablet Disintegrating)

C1

GNP Allergy Relief For Kids (Tablet)C1

GNP Childrens Allergy (Liquid)C1

GNP Childrens Pain Relief Plus Cold (Suspension)

C1

GNP Cold & Allergy Childrens (Elixir)C1

GNP Cold & Allergy Maximum Strength (Tablet)

C1

GNP Cold & Cough Childrens (Elixir)C1

GNP Cold Head Congestion Day/Night (Tablet)

C1

GNP Cold Head Congestion Night Time (Tablet)

140


OTC Drug NameC1

GNP Cold Multi-Symptom Day/Night (Tablet)

C1

GNP Cold Relief Head Congestion Severe Daytime (Tablet)

C1

GNP Cold Relief Multi-Symptom Daytime (Tablet)

C1

GNP Cold Relief Multi-Symptom Severe Daytime (Tablet)

C1

GNP Cough DM ER (Suspension)C1

GNP Cough Gels (Capsule)C1

GNP Cough Relief (Liquid)C1

GNP Day Time Cold/Flu (Capsule)C1

GNP Day Time Cold/Flu Relief (Liquid)C1

GNP Dayhist Allergy (Tablet)C1

GNP Flu & Severe Cold & Cough Nighttime (Packet)

C1

GNP Flu Relief Therapy Severe Cold Nighttime (Liquid)

C1

GNP Ibuprofen Cold/Sinus (Tablet)C1

GNP Loratadine (5mg/5ml Syrup, 10mg Tablet)

C1

GNP Loratadine Childrens (Syrup)C1

GNP Loratadine-D 12Hr (Tablet Extended-Release)

C1

GNP Loratadine-D 24 Hour (Tablet Extended-Release)

C1

GNP Mucus D 12 Hr (Tablet Extended-Release)

C1

GNP Mucus DM Maximum Strength (Tablet Extended-Release)

C1

GNP Mucus ER (Tablet Extended-Release)C1

GNP Mucus Relief Childrens (Liquid)C1

GNP Mucus Relief Cold & Sinus (Tablet)C1

GNP Mucus Relief Cold Flu & Sore Throat (Tablet)

C1

GNP Mucus Relief Cough Childrens (Liquid)

OTC Drug NameC1

GNP Mucus Relief DM (Tablet)C1

GNP Mucus Relief PE (Tablet)C1

GNP Mucus-ER (Tablet Extended-Release)C1

GNP Multi-Symptom Cold Nighttime (Liquid)

C1

GNP Nasal Decongestant (Tablet)C1

GNP Nasal Decongestant PE Maximum Strength (Tablet)

C1

GNP Nasal Decongestant/Maximum Strength (Tablet)

C1

GNP Night Time Cold & Flu (Capsule)C1

GNP Night Time Cold & Flu Multi-Symptom (Liquid)

C1

GNP Night Time Cough (Liquid)C1

GNP Pseudoephedrine HCL 12 Hour (Tablet Extended-Release)

C1

GNP Pseudoephedrine HCL ER (Tablet Extended-Release)

C1

GNP Sinus & Allergy Pe (Tablet)C1

GNP Sinus & Cold-D (Tablet Extended-Release)

C1

GNP Sinus Congestion & Pain Daytime (Tablet)

C1

GNP Sinus Relief Congestion & Pain Daytime/Nighttime (Tablet)

C1

GNP Sinus Relief Congestion & Pain Nighttime (Tablet)

C1

GNP Sinus Relief Pressure & Pain (Tablet)C1

GNP Sinus Relief Severe Congestion Relief (Tablet)

C1

GNP Sore Throat (Liquid)C1

GNP Sore Throat Spray (Liquid)C1

GNP Tab Tussin (Tablet)C1

GNP Tab Tussin DM (Tablet)C1

GNP Tussin (Syrup)C1

GNP Tussin CF Cough & Cold (Syrup)

141


OTC Drug NameC1

GNP Tussin CF Max Multi-Symptom Cold (Liquid)

C1

GNP Tussin Cough Long Acting (Syrup)C1

GNP Tussin DM (Liquid)C1

GNP Tussin DM Cough (Liquid)C1

GNP Tussin DM Max (Liquid)C1

GNP Tussin DM Max Cough & Chest Congestion (Liquid)

C1

GNP Tussin Mucus & Chest Congestion (Liquid)

C1

Goodsense All Day Allergy (Tablet)C1

Goodsense All Day Allergy Childrens (Solution)

C1

Goodsense Aller-Ease (Tablet)C1

Goodsense Cold & Flu Severe For Adults (Tablet)

C1

Goodsense Cough DM (Suspension)C1

Goodsense Cough DM Childrens (Suspension)

C1

Goodsense Day Time Cold &Flu Severe Non-Drowsy (5-10-200-325mg Capsule, 5-10-200-325mg/15ml Liquid)

C1

Goodsense Daytime Cold & Flu (10-5-325mg/15ml Liquid, 10-5-325mg Capsule)

C1

Goodsense Flu & Severe Cold & Cough Nighttime (Packet)

C1

Goodsense Flu & Severe Cold Daytime (Powder Packet)

C1

Goodsense Mucus Relief Childrens (Liquid)

C1

Goodsense Mucus-D (Tablet Extended-Release)

C1

Goodsense Nighttime Cold & Flu (Capsule)C1

Goodsense Nighttime Cold & Flu Severe (Liquid)

C1

Goodsense Nighttime Cold & Flu Severe Maximum Strength (Liquid)

OTC Drug NameC1

Goodsense Severe Sinus Congestion (Capsule)

C1

Goodsense Sinus Relief Maximum Strength (Tablet)

C1

Goodsense Tussin CF (Liquid)C1

Guaiatussin AC (Solution)C1

Guaifenesin (Liquid)C1

Guaifenesin (Tablet)C1

Guaifenesin AC (Solution)C1

Guaifenesin DCA (Solution)C1

Guaifenesin ER (Tablet Extended-Release)C1

Guaifenesin/Codeine (Solution)C1

Guaifenesin/Dextromethorphan Hydrobromide (Syrup)

C1

Guaifenesin/Pseudoephedrine Hydrochloride (Tablet Extended-Release)

C1

Guaifenesin-DM (Syrup)C1

Histex (Syrup)C1

Histex PD (Solution)C1

Histex-AC (Syrup)C1

Histex-DM (Syrup)C1

Histex-PE (Liquid)C1

HM All Day Allergy (Tablet)C1

HM All Day Allergy Childrens (Solution)C1

HM Allergy & Congestion (Tablet Extended-Release)

C1

HM Allergy Complete-D (Tablet Extended-Release)

C1

HM Allergy Relief & Nasaldecongestant (Tablet Extended-Release)

C1

HM Allergy Relief (25mg Capsule, 4mg Tablet, 25mg Tablet)

C1

HM Allergy Relief Childrens (Liquid)C1

HM Cetirizine HCL Childrens (Solution)C1

HM Cetirizine Hydrochloride (Tablet)C1

HM Chest Congestion Relief (Tablet)

142


OTC Drug NameC1

HM Chest Congestion Relief DM (Tablet)C1

HM Cold & Allergy Childrens (Elixir)C1

HM Cold & Cough Childrens (Elixir)C1

HM Cold & Sinus Relief (Tablet)C1

HM Cough DM (Suspension)C1

HM Day Time Liquid Caps (Capsule)C1

HM Daytime Cold & Flu (Liquid)C1

HM Fexofenadine HCL (Tablet)C1

HM Fexofenadine Hydrochloride (Tablet)C1

HM Loratadine (Tablet)C1

HM Loratadine Childrens (Syrup)C1

HM Mucus Relief D (Tablet Extended-Release)

C1

HM Mucus Relief DM Maximum Strength (Tablet Extended-Release)

C1

HM Nasal Decongestant (Tablet)C1

HM Nasal Decongestant 12 Hour (Tablet Extended-Release)

C1

HM Nasal Decongestant PE (Tablet)C1

HM Night Time Cold & Flu (Liquid)C1

HM Night Time Multi-Symptom Cold & Flu (Capsule)

C1

HM Severe Cold & Flu (Tablet)C1

HM Severe Cold/Cough/Flu Daytime (Powder Packet)

C1

HM Sinus & Cold-D (Tablet Extended-Release)

C1

HM Tussin Adult (Liquid)C1

HM Tussin Adult Cough & Chest Congestion DM (Liquid)

C1

HM Tussin Adult Multi-Symptom Cold (Liquid)

C1

HM Tussin Cough/Chest Congestion DM Max/Adult (Liquid)

C1

Ibuprofen Cold & Sinus (Tablet)C1

J-Max (Syrup)

OTC Drug NameC1

J-Tan D PD (Liquid)C1

J-Tan PD (Liquid)C1

Kidkare Cough/Cold (Liquid)C1

Levocetirizine Dihydrochloride (Tablet)C1

Lodrane D (Capsule)C1

Lohist-D (Liquid)C1

Lohist-DM (Syrup)C1

Loratadine (10mg Capsule, 10mg Tablet)C1

Loratadine Childrens (5mg/5ml Syrup, 5mg Tablet Chewable)

C1

Loratadine Hives Relief (Syrup)C1

Loratadine-D 12Hr (Tablet Extended-Release)

C1

Loratadine-D 24Hr (Tablet Extended-Release)

C1

Mapap Cold Formula Multi-Symptom (Tablet)

C1

Mapap Sinus Maximum Strength Congestion And Pain (Tablet)

C1

Mar-Cof CG Expectorant (Liquid)C1

Maxichlor PEH DM (Tablet)C1

Maxifed (Tablet)C1

Maxiphen (Tablet)C1

Maxiphen DM (Tablet)C1

Maxi-Tuss CD (Liquid)C1

Maxi-Tuss DM (Liquid)C1

M-Clear WC (Solution)C1

M-End DMX (Liquid)C1

M-End PE (Liquid)C1

M-Hist PD (Liquid)C1

Mucinex (Tablet Extended-Release)C1

Mucinex Allergy (Tablet)C1

Mucinex Chest Congestion Childrens (Liquid)

C1

Mucinex Childrens Cold Cough & Sore

Throat (Liquid)

143


OTC Drug NameC1

Mucinex Childrens Multi-Symptom Cold

& Fever (Liquid)C1

Mucinex Childrens Multi-Symptom Cold

(Liquid)C1

Mucinex Congestion & Cough Childrens

(Liquid)C1

Mucinex Cough Childrens (Liquid)C1

Mucinex Cough For Kids (Packet)C1

Mucinex D (Tablet Extended-Release)C1

Mucinex D Maximum Strength (Tablet

Extended-Release)C1

Mucinex DM (Tablet Extended-Release)C1

Mucinex DM Maximum Strength (Tablet

Extended-Release)C1

Mucinex Fast-Max Cold & Sinus (Liquid)C1

Mucinex Fast-Max Cold & Sinus (Tablet)C1

Mucinex Fast-Max Cold Flu& Sore Throat (Liquid)

C1

Mucinex Fast-Max Cold Flu& Sore Throat

(Tablet)C1

Mucinex Fast-Max Cold Flu& Sore Throat

Clear & Cool (Liquid)C1

Mucinex Fast-Max Cold/Flu/Sore Throat

(Capsule)C1

Mucinex Fast-Max Cold/Flu/Sore Throat

(Packet)C1

Mucinex Fast-Max Congestion & Headache (Capsule)

C1

Mucinex Fast-Max Day Time/Night Time

(Liquid)C1

Mucinex Fast-Max Day Time/Night Time

(Tablet)C1

Mucinex Fast-Max Day/Night (Capsule)C1

Mucinex Fast-Max Day/Night Maximum

Strength (Tablet)C1

Mucinex Fast-Max Day/Nite M/S (Tablet)C1

Mucinex Fast-Max DM Max (Liquid)

OTC Drug NameC1

Mucinex Fast-Max Night Time Cold & Flu (Capsule)

C1

Mucinex Fast-Max Night Time Cold & Flu (Liquid)

C1

Mucinex Fast-Max Night Time Cold & Flu (Packet)

C1

Mucinex Fast-Max Night Time Cold & Flu (Tablet)

C1

Mucinex Fast-Max Severe Cold & Sinus (Capsule)

C1

Mucinex Fast-Max Severe Cold (Liquid)C1

Mucinex Fast-Max Severe Cold (Packet)C1

Mucinex Fast-Max Severe Cold (Tablet)C1

Mucinex Fast-Max Severe Congestion & Cold (Tablet)

C1

Mucinex Fast-Max Severe Congestion &

Cough (Liquid)C1


Cough (Tablet)C1


Cough Clear & Cool (Liquid)C1

Mucinex For Kids (Packet)C1

Mucinex Maximum Strength (Tablet

Extended-Release)C1

Mucinex Multi-Symptom Cold Day/Night

Pack (Liquid)C1

Mucinex Multi-Symptom Cold Night Time Childrens (Liquid)

C1

Mucinex Sinus-Max Day/Night (Capsule)C1

Mucinex Sinus-Max Day/Night (Tablet)C1

Mucinex Sinus-Max Night Time Congestion & Cough (Liquid)

C1

Mucinex Sinus-Max Pressure & Pain

(Liquid)C1

Mucinex Sinus-Max Pressure & Pain (Tablet)

C1

Mucinex Sinus-Max Severe Congestion

Relief (Capsule)

144


OTC Drug NameC1

Mucinex Sinus-Max Severe Congestion Relief (Liquid)

C1

Mucinex Sinus-Max Severe Congestion Relief (Tablet)

C1

Mucinex Stuffy Nose & Cold Childrens

(Liquid)C1

Mucosa (Tablet)C1

Mucosa DM (Tablet)C1

Mucus & Cough Relief Childrens (Liquid)C1

Mucus D (Tablet Extended-Release)C1

Mucus Relief (Tablet)C1

Mucus Relief Chest Congestion (Tablet)C1

Mucus Relief Childrens (Liquid)C1

Mucus Relief Cold & Sinusmaximum Strength (Tablet)

C1

Mucus Relief Cold Flu & Sore Throat (Tablet)

C1

Mucus Relief Cough Childrens (Liquid)C1

Mucus Relief DM (Tablet)C1

Mucus Relief DM Cough (Tablet)C1

Mucus Relief DM Maximum Strength (Liquid)

C1

Mucus Relief Multi Symptom Cold Childrens (Liquid)

C1

Mucus Relief PE Sinus Congestion (Tablet)C1

Mucus Relief Severe Cold Maximum Strength (Tablet)

C1

Mucus-DM Maximum Strength (Tablet Extended-Release)

C1

Mucus-ER (Tablet Extended-Release)C1

Mucusrelief Sinus (Tablet)C1

Multi Symptom Flu & Severe Cold/Daytime (Powder Packet)

C1

Multi-Symptom Allergy (Capsule)C1

Nasal Decongestant (Liquid)C1

Nasal Decongestant (Syrup)

OTC Drug NameC1

Nasal Decongestant (Tablet)C1

Nasal Decongestant Maximum Strength (Tablet)

C1

Nasal Decongestant PE (Tablet)C1

Nasal Decongestant PE Maximum Strength (Tablet)

C1

Nasopen PE (Liquid)C1

Night Time Multi-Symptom Cold/Flu Relief (Capsule)

C1

Nighttime Cold/Flu Relief (Capsule)C1

Nighttime Cold/Flu Relief (Liquid)C1

Nighttime Cold/Flu Reliefmulti-Symptom (Liquid)

C1

Nighttime Cold/Flu/Maximum Strength (Liquid)

C1

Nighttime Cough (Liquid)C1

Nighttime Severe Cold & Flu/Maximum Strength (Liquid)

C1

Nighttime Sinus Congestion & Pain (Tablet)

C1

Ninjacof (Liquid)C1

Ninjacof-A (Liquid)C1

Ninjacof-XG (Liquid)C1

Nite Time Cough (Liquid)C1

Nite Time Multi-Symptom Cold/Flu Relief (Liquid)

C1

Nite Time Multi-Symptom Cold/Flu Relief (Capsule)

C1

Nite Time-D (Liquid)C1

Nite-Time Multi-Symptom Cold/Flu Relief (Liquid)

C1

Niva-Hist DM (Liquid)C1

Nivanex DMX (Tablet)C1

Nohist-DM (Liquid)C1

Nohist-LQ (Liquid)C1

Norel AD (Tablet)

145


OTC Drug NameC1

Orasep (Solution)C1

Organ-I NR (Tablet)C1

Pedia Relief Cough/Cold (Liquid)C1

Pediatric Cough/Cold (Liquid)C1

Pharbedryl (Capsule)C1

Phenaseptic (Liquid)C1

Phenylephrine HCL/Pyrilamine Maleate (Tablet)

C1

Poly Hist Forte (Tablet)C1

Poly-Hist DM (Liquid)C1

Poly-Hist PD (Liquid)C1

Poly-Tussin AC (Liquid)C1

Polytussin DM (Syrup)C1

Poly-Vent DM (Tablet)C1

Poly-Vent IR (Tablet)C1

Pro-Red AC (Syrup)C1

Pseudoephedr Tab 60mg (Tablet)C1

Pseudoephedrine HCL (Tablet)C1

Pseudoephedrine HCL ER (Tablet Extended-Release)

C1

QC All Day Allergy (Tablet)C1

QC Allergy Relief Multi-Symptom Daytime (Tablet)

C1

QC Allergy/Sinus Headache (Tablet)C1

QC Childrens Allergy (Solution)C1

QC Cold Head Congestion Nighttime (Tablet)

C1

QC Cold Multi-Symptom Nighttime (Tablet)C1

QC Cold Multi-Symptom Severe Daytime (Tablet)

C1

QC Complete Allergy Medicine (Capsule)C1

QC Cough & Cold HBP (Tablet)C1

QC Daytime Cold & Flu (Liquid)C1

QC Fexofenadine Hydrochloride (Tablet)C1

QC Ibuprofen Cold/Sinus (Tablet)

OTC Drug NameC1

QC Loratadine Allergy Relief (Tablet)C1

QC Loratadine-D (Tablet Extended-Release)

C1

QC Medifin 400 (Tablet)C1

QC Medifin DM (Tablet)C1

QC Medifin PE (Tablet)C1

QC Mucus Relief (Tablet Extended-Release)

C1

QC Mucus Relief ER 12 Hour Maximum Strength (Tablet Extended-Release)

C1

QC Severe Cold & Cough Daytime (Powder Packet)

C1

QC Severe Cold & Cough Nighttime (Packet)

C1

QC Sinus Congestion & Pain Severe Daytime (Tablet)

C1

QC Sinus Pain Relief (Tablet)C1

QC Sore Throat Spray (Liquid)C1

QC Suphedrine Maximum Strength (Tablet Extended-Release)

C1

QC Tussin CF (Liquid)C1

QC Tussin DM Cough & Chest Congestion/Adult (Liquid)

C1

Relcof IR (Tablet)C1

Relhist BP (Tablet)C1

Relhist DMX (Tablet)C1

Rescon (Tablet)C1

Rescon DM (Syrup)C1

Rescon-GG (Liquid)C1

Respaire-30 (Capsule)C1

Robafen (Syrup)C1

Robafen AC (Solution)C1

Robafen CF Multi-Symptom Cold (Liquid)C1

Robafen Cough (Capsule)C1

Robafen DM (Syrup)C1

Robafen DM Cough Clear (Syrup)

146


OTC Drug NameC1

Robafen DM Cough/Chest Congestion (Liquid)

C1

Rondec-D (Liquid)C1

Ru-Hist D (Tablet)C1

Rydex (Liquid)C1

Rymed (Tablet)C1

Rynex DM (Liquid)C1

Rynex PE (Elixir)C1

Rynex PSE (Elixir)C1

Sb Cold Multi-Symptom Day/Night (Tablet)C1

Severe Cold & Cough Nighttime (Packet)C1

Severe Cold & Flu (Tablet)C1

Siladryl Allergy (Liquid)C1

Silphen Cough (Syrup)C1

Siltussin DM Das (Liquid)C1

Siltussin SA (Syrup)C1

Siltussin-DM (Syrup)C1

Sinus & Allergy PE Maximuum Strength (Tablet)

C1

Sinus & Cold-D Non-Drowsy (Tablet Extended-Release)

C1

Sinus And Headache Daytime (Tablet)C1

Sinus Congestion & Pain Daytime (Tablet)C1

Sinus Congestion & Pain Severe Daytime (Tablet)

C1

Sinus Pressure/Pain/Adult (Tablet)C1

SM 12 Hour Sinus Decongestant (Tablet Extended-Release)

C1

SM All Day Allergy (Tablet)C1

SM All Day Allergy Childrens (Solution)C1

SM All Day Allergy-D (Tablet Extended-Release)

C1

SM Allergy 4 Hour (Tablet)C1

SM Allergy Multi-Symptom (Tablet)C1

SM Allergy Relief (25mg Capsule, 12.5mg/5ml Liquid, 1.34mg Tablet, 25mg Tablet)

OTC Drug NameC1

SM Chest Congestion Relief (Tablet)C1

SM Chest Congestion Relief DM (Tablet)C1

SM Chest Congestion Relief PE (Tablet)C1

SM Childrens Loratadine (Syrup)C1

SM Cold & Allergy Childrens (Elixir)C1

SM Cold & Cough DM Childrens (Elixir)C1

SM Cold & Flu Severe (Tablet)C1

SM Cold & Sinus Relief (Tablet)C1

SM Cough Drops (Lozenge)C1

SM Day Time Cold & Flu Relief (Liquid)C1

SM Day Time Liquid Caps (Capsule)C1

SM Daytime Liquid Caps (Capsule)C1

SM Fexofenadine HCL (Tablet)C1

SM Loratadine (5mg/5ml Syrup, 10mg Tablet)

C1

SM Lorata-Dine D (Tablet Extended-Release)

C1

SM Loratadine D 12Hr (Tablet Extended-Release)

C1

SM Mucus Relief (Tablet Extended-Release)

C1

SM Mucus Relief Cough Childrens (Liquid)C1

SM Mucus Relief D (Tablet Extended-Release)

C1

SM Mucus Relief Maximum Strength (Tablet Extended-Release)

C1

SM Mucus Relief/12 Hour (Tablet Extended-Release)

C1

SM Nasal Decongestant Maximum Strength (Tablet)

C1

SM Nasal Decongestant PE (Tablet)C1

SM Night Time Liquid Caps (Capsule)C1

SM Nite Time Cold & Flu (Liquid)C1

SM Sinus & Cold-D (Tablet Extended-Release)

C1

SM Sore Throat Spray (Liquid)

147


OTC Drug NameC1

SM Tussin CF (Liquid)C1

SM Tussin DM (Syrup)C1

SM Tussin DM Cough/Chest Congestion (Syrup)

C1

SM Tussin Mucus + Chest Congestion Adult (Liquid)

C1

Sore Throat (Lozenge)C1

Sore Throat Spray (Liquid)C1

Stahist AD (Tablet)C1

Sudogest (Tablet)C1

Sudogest 12 Hour (Tablet Extended-Release)

C1

Sudogest PE (Tablet)C1

Sudogest Sinus & Allergy (Tablet)C1

TGT Allergy Relief Non-Drowsy (Tablet)C1

Theraflu Expressmax (Liquid)C1

Theraflu Expressmax Severe Cold & Cough Daytime (Tablet)

C1

Theraflu Expressmax Severe Cold & Cough Nighttime (Tablet)

C1

Theraflu Expressmax Severe Cold & Cough/Daytime (Liquid)

C1

Theraflu Expressmax Severe Cold & Flu (Liquid)

C1

Theraflu Expressmax Severe Cold & Flu (Tablet)

C1

Theraflu Flu & Sore Throat (Powder

Packet)C1

Theraflu Powerpods Daytime Severe

Cold (Powder)C1

Theraflu Powerpods Nighttime Severe

Cold (Powder)C1

Theraflu Severe Cold & Cough Daytime/

Nighttime (Packet)C1

Theraflu Severe Cold & Cough Nighttime

(Packet)C1

Theraflu Severe Cold Multi Symptom

(Powder Packet)

OTC Drug NameC1

Theraflu Severe Cold Multi Symptom

Nighttime (Packet)C1

Triacting Day Time Cold/Cough Childrens (Solution)

C1

Triacting Nightime Cold& Cough Childrens (Liquid)

C1

Triaminic Cold & Allergy (Syrup)C1

Triaminic Cold & Cough Day Time

Childrens (Syrup)C1

Triaminic Cough & Congestion Childrens

(Syrup)C1

Triaminic Cough & Sore Throat

(Suspension)C1

Triaminic Fever & Cold Multi-Symptom Childrens (Suspension)

C1

Triaminic Night Time Cold & Cough

(Syrup)C1

Triprolidine HCL (Liquid)C1

Triprolidine Hydrochloride (Liquid)C1

Tusnel (30-15-200mg/5ml Liquid,

60-30-400mg Tablet)C1

Tusnel C (Syrup)C1

Tusnel Diabetic (Liquid)C1

Tusnel Pediatric (Liquid)C1

Tusnel-DM Pediatric (Liquid)C1

Tussin CF (Liquid)C1

Tussin CF Cough & Cold (Liquid)C1

Tussin CF Max Multi-Symptom (Liquid)C1

Tussin CF Severe Multi-Symptom Cough Cold/Flu (Liquid)

C1

Tussin Chest Congestion (Syrup)C1

Tussin Cough (Syrup)C1

Tussin DM (1-100mg/5ml Liquid, 10-100mg/5ml Syrup)

C1

Tussin DM Cough + Chest Congestion (Liquid)

C1

Tussin DM Max (Liquid)

148


OTC Drug NameC1

Tussin DM Max Adult (Liquid)C1

Tussin Mucus + Chest Congestion (100mg/5ml Liquid, 100mg/5ml Syrup)

C1

Tussin Mucus + Chest Congestion Adult (Liquid)

C1

Tussin Multi-Symptom Cold CF (Liquid)C1

Vanaclear PD (Liquid)C1

Vanacof (Liquid)C1

Vanacof AC (Liquid)C1

Vanacof DM (Liquid)C1

Vanacof-8 (Liquid)C1

Vanahist PD (Liquid)C1

Vanamine PD (Liquid)C1

Vanatab AC (Tablet)C1

Vanatab DM (Tablet)C1

Virtussin A/C (Solution)C1

Virtussin DAC (Solution)C1

Z-Tuss AC (Liquid)B1

Intranasal SpraysC1

12 Hour Nasal Spray (Solution)C1

4-Way Fast Acting (Solution)C1

Allergy Relief (Suspension)C1

Benzedrex Inhaler (Device)C1

Budesonide Nasal Spray (Suspension)C1

Flonase Allergy Relief (Suspension)C1

Flonase Allergy Relief Childrens

(Suspension)C1

Flonase Sensimist (Suspension)C1

Fluticasone Propionate (Suspension)C1

GNP 12 Hour Nasal Spray (Solution)C1

GNP 24 Hour Nasal Allergy Spray (Suspension)

C1

GNP Budesonide Nasal Spray (Suspension)

C1

GNP Fluticasone Propionate (Suspension)

OTC Drug NameC1

GNP Nasal Spray (Solution)C1

GNP Nasal Spray Extra Moisturizing (Solution)

C1

GNP Nasal Spray Fast Actiing (Solution)C1

GNP No Drip Nasal Spray (Solution)C1

GNP Nose Drops Extra Strength (Solution)C1

Goodsense Nasal Allergy Spray (Suspension)

C1

Goodsense Nasoflow (Suspension)C1

HM Allergy Relief Nasal Spray 24Hr (Suspension)

C1

HM Nasal Spray (Solution)C1

HM Nose Drops Extra Strength (Solution)C1

HM Sinus Nasal Spray (Solution)C1

Mucinex Sinus-Max Full Force (Solution)C1

Mucinex Sinus-Max Moisture Smart (Solution)

C1

Nasal Allergy 24 Hour Multi-Symptom (Suspension)

C1

Nasal Decongestant Spray (Solution)C1

Nasal Four (Solution)C1

Nasal Relief (Solution)C1

Nasal Spray 12 Hour (Solution)C1

Nasal Spray Extra Moisturizing 12 Hour (Solution)

C1

No Drip Nasal Spray (Solution)C1

Nose Drops Extra Strength (Solution)C1

QC Fluticasone Propionate (Suspension)C1

Sinus Nasal Spray (Solution)C1

Sinus Relief Extra Strength (Solution)C1

Sinus Relief Nasal Spray 12 Hour (Solution)

C1

SM Allergy Relief Nasal Spray (Suspension)

C1

SM Nasal Spray (Solution)C1

SM Nasal Spray 12 Hour (Solution)

149


OTC Drug NameC1

SM Nasal Spray Moisturizing (Solution)C1

SM Nasal Spray Sinus (Solution)C1

SM Nose Drops Nasal Decongestant Extra Strength (Solution)

C1

Triamcinolone Acetonide (Suspension)B1

Respiratory AgentsC1

Aromatic Ammonia Inhalant A1

Sleep RegulatorsB1

Sleep AidsC1

Acetaminophen PM Extra Strength (Tablet)C1

Acetaminophen/Diphenhydramine (Tablet)C1

GNP Headache PM (Tablet)C1

GNP Ibuprofen PM (Tablet)C1

GNP Nighttime Sleep Aid (Tablet)C1

GNP Pain Relief PM Extra Strength (Tablet)C1

GNP Sleep Aid (Tablet)C1

GNP Sleep Time (Liquid)C1

Goodsense Headache PM (Tablet)C1

Goodsense Ibuprofen PM (Tablet)C1

Goodsense Pain Relief PM Extra Strength (Tablet)

C1

Goodsense Sleeptime (25mg Capsule, 50mg/30ml Liquid)

C1

Headache PM (Tablet)C1

Headache PM Formula (Tablet)C1

Headache Relief PM (Tablet)C1

HM Ibuprofen PM (Tablet)C1

HM Nighttime Sleep Aid (Tablet)C1

HM Pain Reliever PM Extrastrength (Tablet)

C1

HM Sleep Aid (Tablet)C1

HM Z-Sleep (25mg Capsule, 50mg/30ml Liquid)

C1

Ibuprofen PM (Tablet)C1

Mapap PM (Tablet)

OTC Drug NameC1

Night Time Sleep Aid (Tablet)C1

Nighttime Sleep Aid (Tablet)C1

Pain Relief PM Extra Strength (Tablet)C1

Pain Reliever PM Extra Strength (Tablet)C1

Sleep Aid (25mg Capsule, 50mg Capsule, 50mg/30ml Liquid, 25mg Tablet)

C1

Sleep Tabs (Tablet)C1

SM Ibuprofen PM (Tablet)C1

SM Nighttime Sleep Aid (Tablet)C1

SM Pain Reliever PM Extra Strength (Tablet)

C1

SM Sleep Aid (Tablet)C1

SM Sleep Aid Night Time (Tablet)C1

TGT Nighttime Sleep Aid (Tablet)B1

StimulantsC1

Alertness Aid (Tablet)C1

Caffeine (Tablet)C1

GNP Stay Awake (Tablet)C1

HM Stay Awake (Tablet)C1

No Doz Maximum Strength (Tablet)C1

SM Stay Awake (Tablet)C1

SM Stay Awake Maximum Strength (Tablet)

C1

Stay Awake (Tablet)C1

Stay Awake Maximum Strength (Tablet)A1

Therapeutic Nutrients/Minerals/ElectrolytesB1

Vitamins / Nutrients / SupplementsC1

Calcium Carbonate (Tablet)C1

Calcium Gluconate (Tablet)C1

Calphron (Tablet)C1

GNP Magnesium Citrate (Solution)C1

HM Magnesium Citrate (Solution)C1

Iferex 150 (Capsule)C1

Magnebind 300 (Tablet)C1

Magnesium Citrate (Solution)

150


OTC Drug NameC1

Niacin Cap 500mg SR (Capsule Extended-Release)

C1

Niacin SR (Capsule Extended-Release)C1

QC Magnesium Citrate (Solution)C1

SM Magnesium Citrate (Solution)C1

Vitamin D3 (Capsule)C1

Wee Care (Suspension)A1

Urinary AgentsB1

Urinary AgentsC1

Oxytrol For Women (Patch)

OTC Drug NameB1

Urinary AnagelsicsC1

GNP Urinary Pain Relief (Tablet)C1

SM Urinary Pain Relief (Tablet)C1

SM Urinary Pain Relief Maximum Strength (Tablet)

C1

Urinary Pain Relief (Tablet)C1

Urinary Pain Relief Maximum Strength (Tablet)

B1

Urinary Misc AgentsC1

Sodium Citrate/Citric Acid (Solution)

151

Trackedtrack

D. Index of Covered Drugs

In this section, you can find a drug by searching for its name alphabetically. This will tell you the page number where you can find additional coverage information for your drug.

A

Abacavir Sulfate...................... 43

Abacavir Sulfate-Lamivudine............................................... 43

Abacavir-Lamivudine-Zidovudine............................ 43

Abelcet.....................................29

Abilify Maintena...................... 39

Abiraterone Acetate................33

Acamprosate Calcium............ 17

Acarbose................................. 46

Acebutolol HCl........................ 52

Acetaminophen-Codeine....... 15

Acetazolamide........................ 55

Acetazolamide ER.................. 55

Acetic Acid.............................. 86

Acetylcysteine......................... 88

Acitretin................................... 60

Actemra................................... 79

Actemra ACTPen.................... 79

ActHIB......................................80

Actimmune.............................. 79

Acyclovir.................................. 42

Acyclovir Sodium.................... 42

Adacel......................................80

Adapalene............................... 60

Adefovir Dipivoxil.................... 42

Adempas................................. 88

Advair Diskus.......................... 88

Advair HFA.............................. 88

Afinitor..................................... 35

Afinitor Disperz........................35

Aimovig.................................... 31

Ala-Cort.................................... 67

Albendazole............................ 37

Albuterol Sulfate..................... 87

Albuterol Sulfate HFA............. 87

Alclometasone Dipropionate............................................... 67

Alcohol Prep Pads.................. 83

Alecensa.................................. 35

Alendronate Sodium...............82

Alfuzosin HCl ER.....................67

Alinia........................................ 37

Aliskiren Fumarate..................54

Allopurinol............................... 31

Alocril....................................... 84

Alomide....................................84

Alosetron HCl.......................... 65

Alphagan P.............................. 84

Alprazolam.............................. 45

Altavera....................................71

Alunbrig................................... 35

Alyacen 1/35........................... 71

Alyq.......................................... 88

Amantadine HCl......................37

AmBisome............................... 29

Ambrisentan............................ 88

Amethia....................................71

Amethia Lo.............................. 71

Amikacin Sulfate..................... 18

Amiloride HCl.......................... 56

Amiloride-Hydrochlorothiazide............................................... 54

Aminosyn II.............................. 61

Aminosyn-PF........................... 61

Amiodarone HCl..................... 52

Amitiza..................................... 65

Amitriptyline HCl..................... 28

Amlodipine Besylate...............53

Amlodipine-Atorvastatin......... 54

Amlodipine-Benazepril........... 54

Amlodipine-Olmesartan..........54

Amlodipine-Valsartan............. 54

Amlodipine-Valsartan-HCTZ...54

Ammonium Lactate................ 60

Amoxapine.............................. 28

Amoxicillin............................... 21

Amoxicillin-Potassium Clavulanate........................... 21

Amoxicillin-Potassium Clavulanate ER..................... 21

Amphetamine-Dextroamphetamine.............58

Amphetamine-Dextroamphetamine ER.......58

Amphotericin B....................... 29

Ampicillin................................. 21

Ampicillin Sodium...................21

Ampicillin-Sulbactam Sodium............................................... 21

152

Tracked

Ampyra.................................... 59

Anadrol-50............................... 71

Anagrelide HCl........................ 50

Anastrozole............................. 34

Androderm.............................. 71

Anoro Ellipta............................ 89

Apokyn.....................................38

Apraclonidine HCl...................84

Aprepitant................................ 29

Apri...........................................71

Apriso.......................................81

Aptiom..................................... 26

Aptivus..................................... 44

Aralast NP................................66

Aranelle....................................71

Aranesp................................... 50

Arcalyst.................................... 79

Aripiprazole............................. 39

Aripiprazole ODT.................... 39

Aristada....................................39

Aristada Initio.......................... 39

Arnuity Ellipta.......................... 86

Ashlyna.................................... 71

Aspirin-Dipyridamole ER........ 51

Atazanavir Sulfate................... 44

Atenolol....................................52

Atenolol-Chlorthalidone..........54

Atomoxetine HCl.....................58

Atorvastatin Calcium.............. 56

Atovaquone............................. 37

Atovaquone-Proguanil HCl.....37

Atripla.......................................43

Atropine Sulfate...................... 83

Atrovent HFA........................... 87

Aubagio................................... 59

Aubra....................................... 71

Auryxia..................................... 64

Austedo................................... 58

Aviane...................................... 71

Avonex Pen............................. 59

Avonex Prefilled...................... 59

Ayvakit..................................... 35

Azasite..................................... 22

Azathioprine............................ 77

Azelaic Acid.............................60

Azelastine HCl...................84, 86

Azelastine-Fluticasone............89

Azithromycin........................... 22

Azopt........................................84

Aztreonam............................... 21

B

Bacitracin.................................18

Bacitracin-Polymyxin B...........83

Baclofen...................................89

Balsalazide Disodium............. 81

Balversa................................... 34

Balziva......................................71

Banzel...................................... 26

Baqsimi Two Pack.................. 47

Baraclude................................ 42

BCG Vaccine...........................80

Belsomra................................. 90

Benazepril HCl........................ 52

Benazepril-Hydrochlorothiazide............................................... 54

Benlysta................................... 79

Benznidazole...........................37

Benzoyl Peroxide-Erythromycin............................................... 60

Benztropine Mesylate............. 37

Bepreve................................... 84

Berinert.................................... 77

Besivance................................ 23

Betamethasone Dipropionate............................................... 68

Betamethasone Dipropionate Aug.................................. 67, 68

Betamethasone Valerate........ 68

Betaseron................................ 59

Betaxolol HCl.................... 52, 84

Bethanechol Chloride.............67

Bethkis..................................... 87

Betimol.....................................84

Bevespi Aerosphere............... 89

Bexarotene.............................. 36

Bexsero....................................80

Bicalutamide........................... 33

Bicillin C-R............................... 21

Bicillin C-R 900/300................21

Bicillin L-A................................ 21

BiDil..........................................54

Biktarvy.................................... 43

Binosto.....................................82

Bisoprolol Fumarate............... 53

Bisoprolol-Hydrochlorothiazide............................................... 54

BIVIGAM.................................. 79

Blephamide............................. 83

Blephamide S.O.P.................. 83

Blisovi 24 Fe............................ 71

Blisovi Fe 1.5/30..................... 71

Boostrix....................................80

153

Tracked

Bosentan................................. 88

Bosulif...................................... 35

Braftovi.....................................35

Breo Ellipta.............................. 89

Briellyn..................................... 71

Brilinta......................................51

Brimonidine Tartrate...............84

BRIVIACT.................................24

Bromocriptine Mesylate......... 38

Brukinsa...................................35

Budesonide.......................82, 86

Budesonide ER....................... 82

Bumetanide............................. 56

Buprenorphine........................ 14

Buprenorphine HCl.................17

Buprenorphine HCl-Naloxone HCl......................................... 17

Bupropion HCl........................ 27

Bupropion HCl SR............ 17, 27

Bupropion HCl XL...................27

Buspirone HCl.........................45

Butalbital-Acetaminophen-Caffeine................................. 14

Butalbital-Aspirin-Caffeine......14

Butorphanol Tartrate.............. 15

Bydureon................................. 46

Bydureon BCise...................... 46

Byetta 10MCG Pen................. 46

Byetta 5MCG Pen................... 46

Bystolic.................................... 53

C

Cabergoline.............................76

Cablivi...................................... 51

Cabometyx.............................. 35

Calcipotriene........................... 60

Calcitonin Salmon...................82

Calcitriol............................ 60, 82

Calcium Acetate......................64

Calquence............................... 35

Camila......................................74

Camrese Lo............................. 71

Canasa.....................................81

Candesartan Cilexetil............. 52

Candesartan Cilexetil-HCTZ............................................... 54

Caplyta.....................................39

Caprelsa.................................. 35

Captopril.................................. 52

Captopril-Hydrochlorothiazide............................................... 54

Carac........................................60

Carafate................................... 65

Carbaglu.................................. 62

Carbamazepine.......................26

Carbamazepine ER.................26

Carbidopa................................38

Carbidopa-Levodopa..............38

Carbidopa-Levodopa ER........38

Carbidopa-Levodopa ODT..... 38

Carbidopa-Levodopa-Entacapone...........................38

Carteolol HCl........................... 84

Cartia XT.................................. 53

Carvedilol.................................53

Cayston....................................88

Caziant..................................... 71

Cefaclor................................... 19

Cefadroxil................................ 19

Cefazolin Sodium....................20

Cefdinir.................................... 20

Cefepime HCl.......................... 20

Cefixime...................................20

Cefotetan Disodium................20

Cefoxitin Sodium.................... 20

Cefpodoxime Proxetil............. 20

Cefprozil.................................. 20

Ceftazidime............................. 20

Ceftriaxone Sodium................ 20

Cefuroxime Axetil....................20

Cefuroxime Sodium................20

Celecoxib.................................14

Celontin................................... 25

Cephalexin...............................20

Cetirizine HCl.......................... 86

Chantix.....................................17

Chantix Continuing Month Pak............................................... 17

Chantix Starting Month Pak... 17

Chemet.................................... 63

Chenodal................................. 64

Chlordiazepoxide HCl............ 45

Chlorhexidine Gluconate....... 60

Chloroquine Phosphate......... 37

Chlorpromazine HCl............... 38

Chlorthalidone.........................56

Chlorzoxazone........................ 89

Cholbam.................................. 66

Cholestyramine....................... 56

Cholestyramine Light............. 56

Ciclopirox.......................... 29, 30

Ciclopirox Olamine................. 30

Cilostazol................................. 51

Ciloxan..................................... 23

154

Tracked

Cimduo.................................... 43

Cimetidine............................... 65

Cimetidine HCl........................ 65

Cimzia...................................... 77

Cimzia Prefilled....................... 77

Cinacalcet HCl........................ 82

Cinryze..................................... 77

Cipro HC.................................. 86

Ciprodex.................................. 86

Ciprofloxacin HCl....................23

Ciprofloxacin in D5W..............23

Ciprofloxacin-Dexamethasone............................................... 86

Citalopram Hydrobromide..... 27

Claravis.................................... 60

Clarithromycin......................... 22

Clarithromycin ER................... 22

Clenpiq.................................... 65

Climara Pro..............................71

Clindamycin HCl..................... 18

Clindamycin Palmitate HCl.... 18

Clindamycin Phosphate... 18, 60

Clindamycin Phosphate in D5W............................................... 18

Clindamycin Phosphate-Benzoyl Peroxide..................60

Clobazam................................ 25

Clobetasol Propionate............68

Clobetasol Propionate Emollient Base...................... 68

Clomipramine HCl.................. 28

Clonazepam............................ 45

Clonazepam ODT................... 45

Clonidine................................. 51

Clonidine HCl.......................... 51

Clonidine HCl ER.................... 58

Clopidogrel Bisulfate.............. 51

Clorazepate Dipotassium....... 45

Clotrimazole............................ 30

Clotrimazole-Betamethasone............................................... 60

Clovique...................................63

Clozapine.................................41

Clozapine ODT........................41

Coartem................................... 37

Codeine Sulfate...................... 16

Colchicine................................31

Colcrys..................................... 31

Colesevelam HCl.................... 57

Colestipol HCl......................... 57

Colistimethate Sodium........... 18

Combigan................................ 84

Combivent Respimat.............. 89

Cometriq..................................35

Complera................................. 43

Compro....................................29

Constulose.............................. 65

Copiktra................................... 34

Cordran....................................68

Corlanor................................... 54

Cortisone Acetate................... 68

Cortisporin...............................60

Cosentyx..................................60

Cosentyx Sensoready.............60

Cosopt PF................................84

Cotellic..................................... 35

Creon....................................... 66

Crinone.................................... 74

Crixivan.................................... 44

Cromolyn Sodium...... 64, 84, 88

Cryselle-28...............................71

Cuvposa...................................64

Cyclafem 1/35.........................71

Cyclafem 7/7/7....................... 71

Cyclobenzaprine HCl..............90

Cyclophosphamide.................33

Cycloset................................... 46

Cyclosporine........................... 77

Cyclosporine Modified........... 77

Cyproheptadine HCl............... 86

Cyred....................................... 71

Cystadane................................66

Cystagon..................................66

Cystaran...................................83

D

Dalfampridine ER....................59

Daliresp....................................88

Dalvance.................................. 18

Danazol.................................... 71

Dantrolene Sodium.................90

Dapsone.................................. 32

Daptacel.................................. 80

Daptomycin............................. 18

DARAPRIM.............................. 37

Daurismo................................. 35

Deblitane................................. 74

Deferasirox........................ 63, 64

Deferasirox Granules.............. 63

Delstrigo.................................. 43

Demeclocycline HCl............... 24

Demser.................................... 54

Denavir.....................................42

Depen Titratabs...................... 67

155

Tracked

Depo-Estradiol.........................71

Depo-Provera.......................... 75

Descovy................................... 43

Desipramine HCl.....................28

Desmopressin Acetate........... 70

Desmopressin Acetate Spray............................................... 70

Desogestrel-Ethinyl Estradiol............................................... 72

Desonide................................. 68

Desoximetasone..................... 68

Desvenlafaxine Succinate ER............................................... 28

Dexamethasone...................... 68

Dexamethasone Sodium Phosphate............................. 85

Dexilant.................................... 66

Dexmethylphenidate HCl....... 58

Dexmethylphenidate HCl ER............................................... 58

Dextroamphetamine Sulfate............................................... 58

Dextroamphetamine Sulfate ER............................................... 58

Dextrose.................................. 62

Dextrose-NaCl......................... 62

Diastat AcuDial........................25

Diastat Pediatric...................... 25

Diazepam.......................... 25, 45

Diazepam Intensol.................. 45

Diazoxide................................. 47

Diclofenac Epolamine............ 14

Diclofenac Potassium.............14

Diclofenac Sodium.....14, 60, 85

Diclofenac Sodium ER........... 14

Dicloxacillin Sodium............... 21

Dicyclomine HCl..................... 64

Didanosine.............................. 43

Dificid....................................... 22

Diflunisal.................................. 14

Digitek......................................54

Digox........................................55

Digoxin.....................................55

Dihydroergotamine Mesylate............................................... 31

Dilantin.....................................26

Dilantin INFATABS..................26

Dilt-XR...................................... 53

Diltiazem HCl...........................53

Diltiazem HCl ER.....................53

Diltiazem HCl ER Beads.........53

Diltiazem HCl ER Coated Beads............................................... 53

Dipentum................................. 81

Diphenoxylate-Atropine.......... 64

Diphtheria-Tetanus Toxoids DT............................................... 80

Disulfiram.................................17

Diuril.........................................56

Divalproex Sodium........... 45, 46

Divalproex Sodium ER........... 45

Dofetilide................................. 52

Donepezil HCl......................... 27

Donepezil HCl ODT................ 27

Dorzolamide HCl.....................84

Dorzolamide HCl-Timolol Maleate..................................84

Dorzolamide HCl-Timolol Maleate Preservative Free... 84

Dovato......................................42

Doxazosin Mesylate................52

Doxepin HCl...................... 28, 61

Doxercalciferol........................ 82

Doxy 100..................................24

Doxycycline Hyclate............... 24

Doxycycline Monohydrate......24

Drizalma Sprinkle....................59

Dronabinol............................... 29

Drospirenone-Ethinyl Estradiol............................................... 72

Droxia.......................................33

Duavee..................................... 72

Dulera...................................... 89

Duloxetine HCl........................ 59

Durezol.....................................85

Dutasteride.............................. 67

Dymista.................................... 89

E

E.E.S. Granules....................... 22

Econazole Nitrate....................30

Edarbi.......................................52

Edarbyclor............................... 55

Edurant.................................... 43

Efavirenz.................................. 43

Egrifta SV................................. 76

Elestrin..................................... 72

Eliquis...................................... 49

Eliquis DVT/PE Starter Pack............................................... 49

Elmiron.....................................67

EluRyng................................... 72

Emcyt....................................... 33

Emgality................................... 31

Emoquette............................... 72

Emsam..................................... 27

156

Tracked

Emtriva..................................... 43

Enalapril Maleate.................... 52

Enalapril-Hydrochlorothiazide............................................... 55

Enbrel.......................................77

Enbrel Mini.............................. 77

Enbrel SureClick..................... 77

Endocet................................... 16

Engerix-B................................. 80

Enoxaparin Sodium................ 49

Enpresse-28............................ 72

Enskyce................................... 72

Entacapone............................. 38

Entecavir.................................. 42

Entresto................................... 55

Enulose.................................... 65

Envarsus XR............................ 77

Epclusa.................................... 42

Epidiolex.................................. 24

Epinastine HCl.........................84

Epinephrine............................. 87

EpiPen 2-Pak........................... 87

EpiPen Jr 2-Pak.......................87

Epitol........................................ 26

Epivir HBV............................... 42

Eplerenone.............................. 56

Eraxis....................................... 30

Ergotamine-Caffeine............... 31

Erivedge...................................35

Erleada.....................................33

Erlotinib HCl............................ 35

Errin..........................................75

Ertapenem Sodium.................21

Ery............................................ 61

Erythrocin Lactobionate......... 22

Erythromycin..................... 23, 61

Erythromycin Base..................22

Erythromycin Ethylsuccinate............................................... 23

Esbriet......................................88

Escitalopram Oxalate............. 28

Esomeprazole Magnesium.... 66

Estarylla................................... 72

Estradiol...................................72

Estradiol Valerate....................72

Estring......................................72

Ethacrynic Acid....................... 56

Ethambutol HCl.......................32

Ethosuximide...........................25

Ethynodiol Diacetate-Ethinyl Estradiol................................ 72

Etodolac...................................14

Etodolac ER.............................14

Etonogestrel-Ethinyl Estradiol............................................... 72

Euthyrox...................................75

Everolimus.........................35, 77

Evotaz...................................... 44

Exemestane.............................34

Ezetimibe................................. 57

Ezetimibe-Simvastatin............ 57

F

Falmina.................................... 72

Famciclovir.............................. 42

Famotidine...............................65

Fanapt......................................39

Fanapt Titration Pack............. 39

Farydak.................................... 35

Fasenra.................................... 89

Fasenra Pen............................ 89

Fayosim................................... 72

Febuxostat...............................31

Felbamate................................26

Felodipine ER..........................53

Femring....................................72

Femynor...................................72

Fenofibrate.............................. 56

Fenofibrate Micronized.......... 56

Fenofibric Acid........................ 56

Fentanyl................................... 15

Fentanyl Citrate....................... 16

Ferriprox.................................. 64

Fetzima.................................... 28

Fetzima Titration..................... 28

Finacea.................................... 61

Finasteride...............................67

Fintepla.................................... 24

Firazyr...................................... 77

Firmagon................................. 76

Flac...........................................86

Flarex....................................... 85

Flebogamma DIF.................... 79

Flecainide Acetate.................. 52

Flector...................................... 14

Flovent Diskus.........................86

Flovent HFA............................. 86

Fluconazole............................. 30

Fluconazole in Sodium Chloride............................................... 30

Flucytosine.............................. 30

Fludrocortisone Acetate.........68

Flunisolide............................... 86

Fluocinolone Acetonide... 68, 86

157

Tracked

Fluocinolone Acetonide Scalp............................................... 68

Fluocinonide..................... 68, 69

Fluocinonide Emulsified Base............................................... 68

Fluorometholone.....................85

Fluorouracil............................. 61

Fluoxetine HCl.........................28

Fluphenazine Decanoate....... 38

Fluphenazine HCl................... 38

Flurbiprofen............................. 14

Flurbiprofen Sodium...............85

Flutamide.................................33

Fluticasone Propionate.... 69, 86

Fluticasone-Salmeterol........... 89

Fluvastatin Sodium................. 56

Fluvoxamine Maleate..............28

FML.......................................... 85

FML Forte................................ 85

Fondaparinux Sodium............ 49

Forteo.......................................82

Fosamprenavir Calcium......... 44

Fosinopril Sodium...................52

Fosinopril Sodium-HCTZ........55

FreAmine HBC........................ 62

Furosemide............................. 56

Fuzeon..................................... 44

Fyavolv..................................... 72

Fycompa.................................. 26

G

Gabapentin..............................25

Galantamine Hydrobromide............................................... 27

Galantamine Hydrobromide ER............................................... 27

Gammagard............................ 79

Gammagard S/D Less IgA..... 79

Gammaked..............................79

Gammaplex............................. 79

Gamunex-C..............................79

Gardasil 9................................ 80

Gatifloxacin..............................23

Gattex.......................................64

Gauze.......................................83

GaviLyte-C............................... 65

GaviLyte-G............................... 65

GaviLyte-N with Flavor Pack............................................... 65

Gemfibrozil.............................. 56

Generlac.................................. 65

Gengraf....................................77

Genotropin.............................. 70

Genotropin MiniQuick............ 70

Gentak..................................... 18

Gentamicin Sulfate................. 18

Gentamicin Sulfate-0.9% Sodium Chloride...................18

Genvoya...................................42

Geodon.................................... 39

Gianvi....................................... 72

Gilenya..................................... 59

Gilotrif...................................... 35

Glassia..................................... 66

Glatiramer Acetate..................59

Glatopa.................................... 59

Gleostine................................. 33

Glimepiride.............................. 46

Glipizide................................... 46

Glipizide ER.............................46

Glipizide-Metformin HCl......... 46

GlucaGen HypoKit.................. 47

Glucagon................................. 47

Glyxambi..................................46

Granisetron HCl...................... 29

Granix.......................................50

Griseofulvin Microsize............ 30

Griseofulvin Ultramicrosize.... 30

Guanfacine HCl ER.................58

Guanidine HCl.........................32

Gvoke HypoPen 2-Pack......... 48

Gvoke PFS...............................48

H

Haegarda................................. 77

Hailey 24 Fe.............................72

Halobetasol Propionate..........69

Haloperidol.............................. 39

Haloperidol Decanoate.......... 39

Haloperidol Lactate................ 39

Havrix....................................... 80

Heparin Sodium................49, 50

HepatAmine............................ 62

Hetlioz...................................... 90

Hiberix......................................80

Humalog.................................. 48

Humalog Junior KwikPen.......48

Humalog KwikPen.................. 48

Humalog Mix 50/50................ 48

Humalog Mix 50/50 KwikPen............................................... 48

Humalog Mix 75/25................ 48

Humalog Mix 75/25 KwikPen............................................... 48

Humatrope.............................. 70

158

Tracked

Humira..................................... 78

Humira Pediatric Crohns Start............................................... 77

Humira Pen..............................77

Humira Pen Crohns Disease Starter.................................... 77

Humira Pen Psoriasis Starter............................................... 78

Humulin 70/30........................ 48

Humulin 70/30 KwikPen........ 48

Humulin N................................48

Humulin N KwikPen................48

Humulin R................................48

Humulin R U-500.....................48

Humulin R U-500 KwikPen..... 48

Hydralazine HCl...................... 57

Hydrochlorothiazide............... 56

Hydrocodone-Acetaminophen............................................... 16

Hydrocodone-Ibuprofen......... 16

Hydrocortisone................. 69, 82

Hydrocortisone Butyrate........ 69

Hydrocortisone Valerate.........69

Hydrocortisone-Acetic Acid... 86

Hydromorphone HCl.............. 16

Hydromorphone HCl ER........ 15

Hydromorphone HCl Preservative Free.................. 16

Hydroxychloroquine Sulfate............................................... 37

Hydroxyurea............................ 33

Hydroxyzine HCl..................... 45

Hydroxyzine Pamoate.............29

Hysingla ER............................. 15

I

Ibandronate Sodium............... 82

Ibrance.....................................35

Ibu............................................ 14

Ibuprofen................................. 14

Icatibant Acetate..................... 77

Iclusig.......................................35

IDHIFA......................................35

Ilevro........................................ 85

Imatinib Mesylate....................35

Imbruvica................................. 35

Imipenem-Cilastatin................ 21

Imipramine HCl....................... 29

Imipramine Pamoate.............. 29

Imiquimod............................... 61

Imiquimod Pump.................... 61

Imovax Rabies.........................80

Imvexxy Maintenance Pack... 72

Imvexxy Starter Pack.............. 72

Incassia....................................75

Increlex.................................... 70

Incruse Ellipta..........................87

Indapamide............................. 56

Indomethacin.......................... 14

Infanrix..................................... 80

Ingrezza................................... 58

Inlyta.........................................35

Inqovi....................................... 35

Inrebic...................................... 34

Insulin Lispro.....................48, 49

Insulin Lispro Junior KwikPen............................................... 49

Insulin Lispro Prot & Lispro....49

Insulin Syringes, Needles.......83

Intelence.................................. 43

Intralipid................................... 62

Intron A.................................... 42

Introvale................................... 72

Invega Sustenna..................... 40

Invega Trinza........................... 40

Invirase.....................................44

Invokamet................................ 46

Invokamet XR.......................... 46

Invokana.................................. 46

IPOL......................................... 80

Ipratropium Bromide.............. 87

Ipratropium-Albuterol..............89

Irbesartan................................ 52

Irbesartan-Hydrochlorothiazide............................................... 55

Iressa........................................35

Isentress.................................. 42

Isentress HD............................ 42

Isibloom................................... 72

Isolyte-P in D5W...................... 62

Isolyte-S................................... 62

Isoniazid...................................32

Isosorbide Dinitrate................ 57

Isosorbide Mononitrate.......... 57

Isosorbide Mononitrate ER.... 57

Isotretinoin...............................61

Itraconazole............................. 30

Ivermectin................................ 37

Ixiaro........................................ 80

J

Jadenu..................................... 64

Jadenu Sprinkle...................... 64

Jakafi........................................35

159

Tracked

Jantoven.................................. 50

Janumet................................... 46

Janumet XR............................. 46

Januvia.....................................46

Jardiance................................. 46

Jasmiel.....................................72

Jentadueto...............................46

Jentadueto XR.........................46

Jinteli........................................72

Jublia........................................30

Juleber..................................... 72

Juluca...................................... 43

Junel 1.5/30............................ 72

Junel 1/20............................... 72

Junel Fe 1.5/30....................... 72

Junel Fe 1/20.......................... 72

Junel Fe 24.............................. 72

Juxtapid................................... 57

K

Kaitlib Fe.................................. 72

Kaletra......................................44

Kalydeco.................................. 89

Kariva....................................... 72

KCl in Dextrose-NaCl.............. 62

KCl-Lactated Ringers-D5W.... 62

Kelnor 1/35............................. 72

Kelnor 1/50............................. 72

Ketoconazole.......................... 30

Ketoprofen...............................14

Ketorolac Tromethamine....... 85

Kineret......................................78

Kinrix........................................ 80

Kionex...................................... 64

Kisqali...................................... 34

Kisqali Femara........................ 34

Klor-Con...................................62

Klor-Con 10..............................62

Klor-Con 8................................62

Klor-Con M10.......................... 62

Klor-Con M15.......................... 62

Klor-Con M20.......................... 62

Korlym......................................70

Koselugo..................................35

Kurvelo.....................................72

Kuvan....................................... 66

L

Labetalol HCl...........................53

Lacrisert................................... 83

Lactulose................................. 65

Lamivudine........................42, 43

Lamivudine-Zidovudine.......... 43

Lamotrigine............................. 26

Lanoxin.................................... 55

Lansoprazole...........................66

Lanthanum Carbonate........... 64

Lantus...................................... 49

Lantus SoloStar.......................49

LARIN 1.5/30.......................... 73

LARIN 1/20............................. 73

LARIN Fe 1.5/30..................... 73

LARIN Fe 1/20........................ 73

Larissia.....................................73

Lastacaft.................................. 83

Latanoprost............................. 85

Latuda......................................40

Layolis Fe.................................73

Leena....................................... 73

Leflunomide............................ 79

Lenvima 10MG Daily Dose.....35






Lenvima 4MG Daily Dose.......36

Lenvima 8MG Daily Dose.......36

Lessina.....................................73

Letrozole.................................. 34

Leucovorin Calcium................34

Leukeran..................................33

Leukine.................................... 50

Leuprolide Acetate................. 76

Levalbuterol HCl..................... 87

Levemir.................................... 49

Levemir FlexTouch................. 49

Levetiracetam..........................24

Levetiracetam ER....................24

Levo-T...................................... 75

Levobunolol HCl..................... 84

Levocarnitine...........................62

Levocetirizine Dihydrochloride............................................... 86

Levofloxacin............................ 23

Levofloxacin in D5W............... 23

Levonest.................................. 73

Levonorgestrel-Ethinyl Estradiol............................................... 73

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol................ 73

Levonorgestrel-Ethinyl Estradiol 91-Day....................................73

Levora 0.15/30........................73

Levorphanol Tartrate.............. 15

160

Tracked

Levothyroxine Sodium............75

Levoxyl..................................... 75

Lexiva....................................... 44

Lidocaine................................. 17

Lidocaine HCl..........................17

Lidocaine Viscous...................17

Lidocaine-Prilocaine............... 17

Lindane.................................... 37

Linezolid.................................. 18

Linzess..................................... 65

Liothyronine Sodium.............. 75

Lisinopril.................................. 52

Lisinopril-Hydrochlorothiazide............................................... 55

Lithium..................................... 46

Lithium Carbonate.................. 46

Lithium Carbonate ER............ 46

Lithostat................................... 67

Livalo........................................56

Lokelma................................... 64

Lonhala Magnair..................... 87

Lonsurf.....................................34

Loperamide HCl......................64

Lopinavir-Ritonavir.................. 44

Lorazepam...............................45

Lorbrena.................................. 34

Loryna...................................... 73

Losartan Potassium................ 52

Losartan Potassium-HCTZ..... 55

Lotemax................................... 85

Lotemax SM............................ 85

Loteprednol Etabonate...........85

Lovastatin................................ 56

Low-Ogestrel........................... 73

Loxapine Succinate................ 39

Lumigan...................................85

Lupaneta Pack........................ 76

Lupron Depot.......................... 76

Lutera.......................................73

Lynparza.................................. 36

Lysodren..................................75

Lyumjev................................... 49

Lyumjev KwikPen....................49

Lyza.......................................... 75

M

M-M-R II....................................80

Magnesium Sulfate................. 62

Malathion................................. 37

Maprotiline HCl....................... 28

Marlissa................................... 73

Marplan....................................27

Matulane..................................33

Matzim LA................................53

Mavyret.................................... 42

Mayzent................................... 59

Meclizine HCl.......................... 29

Medroxyprogesterone Acetate............................................... 75

Mefloquine HCl....................... 37

Megestrol Acetate...................75

Mekinist................................... 36

Mektovi.................................... 36

Melodetta 24 Fe...................... 73

Meloxicam............................... 14

Memantine HCl....................... 27

Memantine HCl ER................. 27

Memantine HCl Titration Pak............................................... 27

Menactra..................................80

Menest..................................... 73

Mentax..................................... 30

Menveo.................................... 80

Mercaptopurine...................... 33

Meropenem............................. 21

Mesalamine.......................81, 82

Mesalamine ER....................... 81

Mesnex.................................... 36

Metaproterenol Sulfate...........87

Metformin HCl...................46, 47

Metformin HCl ER................... 46

Methadone HCl....................... 15

Methazolamide........................55

Methenamine Hippurate........ 19

Methimazole............................ 76

Methotrexate........................... 78

Methotrexate Sodium............. 78

Methoxsalen Rapid.................61

Methscopolamine Bromide....64

Methyldopa..............................51

Methyldopa-Hydrochlorothiazide............. 55

Methylphenidate HCl.............. 58

Methylphenidate HCl ER........ 58

Methylprednisolone................ 69

Metoclopramide HCl.............. 29

Metolazone.............................. 56

Metoprolol Succinate ER....... 53

Metoprolol Tartrate................. 53

Metoprolol-Hydrochlorothiazide............................................... 55

Metronidazole......................... 19

Metronidazole in NaCl 0.79%............................................... 19

161

Tracked

Mexiletine HCl......................... 52

Mibelas 24 Fe.......................... 73

Micafungin Sodium................ 30

Miconazole 3........................... 30

Microgestin 1.5/30................. 73

Microgestin 1/20.....................73

Microgestin Fe 1.5/30............ 73

Microgestin Fe 1/20............... 73

Midodrine HCl......................... 51

Migergot.................................. 31

Miglitol..................................... 47

Miglustat.................................. 66

Mili............................................73

Minitran....................................57

Minocycline HCl...................... 24

Minoxidil.................................. 57

Mirtazapine..............................27

Mirtazapine ODT..................... 27

Mirvaso.................................... 61

Misoprostol..............................66

Modafinil.................................. 90

Moexipril HCl...........................52

Molindone HCl........................ 39

Mometasone Furoate....... 69, 86

Montelukast Sodium...............86

Morphine Sulfate.................... 16

Morphine Sulfate ER.............. 15

Moxifloxacin HCl..................... 23

Moxifloxacin HCl in NaCl....... 23

Multaq...................................... 52

Mupirocin................................ 19

Mupirocin Calcium................. 19

Myalept.................................... 65

Mycamine................................ 30

Mycophenolate Mofetil...........78

Mycophenolate Sodium......... 78

Myrbetriq................................. 67

N

Nabumetone........................... 14

Nadolol.................................... 53

Nafcillin Sodium......................22

Naftifine HCl............................ 30

Naftin........................................30

Naloxone HCl.......................... 17

Naltrexone HCl........................ 17

Namzaric..................................58

Naproxen................................. 14

Naproxen DR...........................14

Naratriptan HCl....................... 32

Narcan..................................... 17

Natacyn....................................30

Nateglinide.............................. 47

Natpara.................................... 82

Nayzilam.................................. 24

Nebupent.................................37

Necon 0.5/35.......................... 73

Nefazodone HCl......................28

Neomycin Sulfate....................18

Neomycin-Bacitracin-Polymyxin............................................... 83

Neomycin-Polymyxin-Bacitracin-Hydrocortisone..................... 83

Neomycin-Polymyxin-Dexamethasone....................83

Neomycin-Polymyxin-Gramicidin.............................83

Neomycin-Polymyxin-HC....... 83, 86

NephrAmine............................ 62

Nerlynx.....................................36

Neulasta...................................51

Neupogen................................51

Neupro..................................... 38

Nevirapine............................... 43

Nevirapine ER......................... 43

Nexavar....................................36

Niacin ER................................. 57

Niacor...................................... 57

Nicardipine HCl.......................53

Nicotrol.................................... 17

Nicotrol NS.............................. 17

Nifedipine ER.......................... 53

Nifedipine ER Osmotic Release............................................... 53

Nikki......................................... 73

Nilutamide............................... 33

Nimodipine.............................. 53

Ninlaro..................................... 34

Nitisinone.................................66

Nitro-Bid...................................57

Nitrofurantoin.......................... 19

Nitrofurantoin Macrocrystal... 19

Nitrofurantoin Monohydrate...19

Nitroglycerin......................57, 58

Nitrostat................................... 58

Nora-BE....................................75

Norditropin FlexPro................ 70

Norethindrone......................... 75

Norethindrone Acetate........... 75

Norethindrone Acetate-Ethinyl Estradiol................................ 73

Norethindrone Acetate-Ethinyl Estradiol-Fe........................... 73

162

Tracked

Norgestimate-Ethinyl Estradiol............................................... 73

Norgestimate-Ethinyl Estradiol Triphasic................................73

Normosol-M in D5W............... 62

Northera...................................51

Nortrel 0.5/35.......................... 73

Nortrel 1/35............................. 74

Nortrel 7/7/7........................... 74

Nortriptyline HCl......................29

Norvir....................................... 44

Noxafil...................................... 30

Nubeqa.................................... 33

Nucala......................................89

Nucynta ER..............................15

Nuedexta................................. 58

Nuplazid...................................40

Nutrilipid.................................. 62

Nutropin AQ NuSpin 10......... 70

Nutropin AQ NuSpin 20......... 70

Nutropin AQ NuSpin 5............70

Nyamyc.................................... 30

Nymalize.................................. 54

Nystatin..............................30, 31

Nystop......................................31

O

Ocaliva..................................... 66

Ocella....................................... 74

Octagam.................................. 79

Octreotide Acetate..................76

Odefsey................................... 43

Odomzo................................... 36

Ofev..........................................88

Ofloxacin..................................23

Olanzapine.............................. 40

Olanzapine ODT......................40

Olmesartan Medoxomil.......... 52

Olmesartan Medoxomil-HCTZ............................................... 55

Olmesartan-Amlodipine-HCTZ............................................... 55

Olopatadine HCl..................... 84

Omega-3-Acid Ethyl Esters.....57

Omeprazole.............................66

Ondansetron HCl.................... 29

Ondansetron ODT.................. 29

Opsumit................................... 88

Orencia.................................... 78

Orencia ClickJect....................78

Orenitram.................................88

Orfadin..................................... 66

Orkambi................................... 88

Orsythia....................................74

Oseltamivir Phosphate..... 44, 45

Osphena.................................. 75

Otezla.......................................79

Oxacillin Sodium..................... 22

Oxacillin Sodium in Dextrose............................................... 22

Oxandrolone............................71

Oxcarbazepine........................ 26

Oxsoralen Ultra....................... 61

Oxybutynin Chloride............... 67

Oxybutynin Chloride ER......... 67

Oxycodone HCl.......................16

Oxycodone-Acetaminophen............................................... 16

Oxycodone-Aspirin................. 16

Ozempic.................................. 47

P

Pacerone................................. 52

Paliperidone ER...................... 40

Panretin................................... 36

Pantoprazole Sodium............. 66

Panzyga................................... 79

Paricalcitol............................... 82

Paromomycin Sulfate............. 18

Paroxetine HCl........................ 28

Paser........................................ 32

Paxil..........................................28

Pazeo....................................... 84

Pediarix.................................... 80

Pedvax HIB.............................. 80

PEG-3350-Electrolytes............ 65

PEG-3350-NaCl-Na Bicarbonate-KCl....................65

Peganone................................ 26

Pegasys................................... 42

Pegasys ProClick.................... 42

Pemazyre................................. 34

Penicillamine........................... 67

Penicillin G Potassium............22

Penicillin G Procaine.............. 22

Penicillin G Sodium................ 22

Penicillin V Potassium............ 22

PENTAM 300...........................37

Pentamidine Isethionate.........37

Pentasa.................................... 82

Pentoxifylline ER..................... 55

Perforomist.............................. 87

Perindopril Erbumine..............52

Permethrin...............................37

Perphenazine.......................... 29

163

Tracked

Perseris.................................... 40

Phenelzine Sulfate.................. 27

Phenobarbital.......................... 25

Phenoxybenzamine HCl......... 52

Phenytek..................................26

Phenytoin.................................26

Phenytoin Sodium Extended............................................... 26

Phoslyra................................... 64

Phospholine Iodide.................84

Picato....................................... 61

Pifeltro......................................43

Pilocarpine HCl................. 60, 84

Pimecrolimus.......................... 61

Pimozide.................................. 39

Pimtrea.....................................74

Pindolol....................................53

Pioglitazone HCl..................... 47

Pioglitazone HCl-Glimepiride............................................... 47

Pioglitazone HCl-Metformin HCl............................................... 47

Piperacillin-Tazobactam......... 22

Piqray....................................... 34

Pirmella 1/35...........................74

Piroxicam.................................14

Plasma-Lyte 148......................62

Plasma-Lyte A......................... 62

Plenamine................................62

Podofilox..................................61

Polymyxin B Sulfate................ 19

Polymyxin B-Trimethoprim.....83

Pomalyst.................................. 33

Portia-28.................................. 74

Posaconazole..........................31

Potassium Chloride................ 63

Potassium Chloride CR.......... 63

Potassium Chloride ER.......... 63

Potassium Chloride in Dextrose............................................... 63

Potassium Chloride in NaCl... 63

Potassium Citrate ER..............63

Praluent................................... 57

Pramipexole Dihydrochloride............................................... 38

Prasugrel HCl.......................... 51

Pravastatin Sodium.................56

Praziquantel............................ 37

Prazosin HCl............................52

Pred Mild................................. 85

Pred-G......................................83

Pred-G S.O.P........................... 83

Prednicarbate..........................69

Prednisolone........................... 69

Prednisolone Acetate............. 85

Prednisolone Sodium Phosphate.......................69, 85

Prednisone.............................. 69

Prednisone Intensol................69

Pregabalin............................... 59

Premarin.................................. 74

Premasol..................................63

Premphase.............................. 74

Prempro...................................74

Prevalite................................... 57

Previfem...................................74

Prezcobix................................. 44

Prezista.................................... 44

Priftin........................................32

Prilosec.................................... 66

Primaquine Phosphate........... 37

Primidone................................ 25

Privigen.................................... 79

ProAir HFA...............................87

ProAir RespiClick....................87

Probenecid.............................. 31

Probenecid-Colchicine........... 31

Procalamine............................ 63

Prochlorperazine.....................29

Prochlorperazine Maleate...... 29

Procrit...................................... 51

Procto-Med HC....................... 82

Procto-Pak............................... 82

Proctosol HC........................... 82

Proctozone-HC........................ 82

Procysbi................................... 66

Progesterone Micronized.......75

Proglycem............................... 48

Prograf..................................... 78

Prolastin-C............................... 66

Prolensa...................................85

Prolia........................................ 82

Promacta................................. 51

Promethazine HCl................... 86

Promethegan...........................86

Propafenone HCl.................... 52

Propafenone HCl ER.............. 52

Proparacaine HCl....................83

Propranolol HCl...................... 53

Propranolol HCl ER................ 53

Propranolol-HCTZ................... 55

Propylthiouracil....................... 76

ProQuad.................................. 81

Prosol....................................... 63

164

Tracked

Protriptyline HCl...................... 29

Pulmozyme..............................89

Purixan..................................... 33

Pyrazinamide...........................32

Pyridostigmine Bromide.........32

Pyridostigmine Bromide ER...32

Pyrimethamine........................ 37

Q

Qinlock.....................................34

Quadracel................................ 81

Quetiapine Fumarate.............. 40

Quetiapine Fumarate ER........ 40

Quinapril HCl........................... 52

Quinapril-Hydrochlorothiazide............................................... 55

Quinidine Gluconate ER.........52

Quinidine Sulfate.................... 52

Quinine Sulfate........................37

R

RabAvert..................................81

Rabeprazole Sodium.............. 66

Raloxifene HCl........................ 75

Ramelteon............................... 90

Ramipril................................... 52

Ranolazine ER.........................55

Rasagiline Mesylate................38

Rasuvo..................................... 78

RAVICTI................................... 66

Rayaldee..................................82

Rebif.........................................59

Rebif Rebidose....................... 59

Rebif Rebidose Titration Pack............................................... 59

Rebif Titration Pack................ 59

Reclipsen.................................74

Recombivax HB...................... 81

Rectiv....................................... 58

Regranex................................. 61

Relenza Diskhaler................... 45

Relistor.....................................65

Repaglinide............................. 47

Repatha................................... 57

Repatha Pushtronex System............................................... 57

Repatha SureClick..................57

Restasis Single-Use Vials....... 83

Retacrit.................................... 51

Retevmo.................................. 34

Revlimid................................... 33

Rexulti...................................... 40

Reyataz.................................... 44

Rhopressa............................... 83

Ribavirin...................................42

Ridaura.................................... 79

Rifabutin.................................. 32

Rifampin.................................. 32

Riluzole.................................... 58

Rimantadine HCl.....................45

Riomet..................................... 47

Riomet ER............................... 47

Risedronate Sodium...............82

Risperdal Consta.............. 40, 41

Risperidone............................. 41

Risperidone ODT.................... 41

Ritonavir...................................44

Rivastigmine............................27

Rivastigmine Tartrate............. 27

Rivelsa..................................... 74

Rizatriptan Benzoate.............. 32

Rizatriptan Benzoate ODT..... 32

Rocklatan................................ 85

Ropinirole HCl.........................38

Rosuvastatin Calcium.............56

Rotarix......................................81

RotaTeq................................... 81

Roweepra................................ 24

Roweepra XR.......................... 24

Rozlytrek..................................34

Rubraca................................... 35

Ruconest................................. 77

Rukobia................................... 44

Rybelsus.................................. 47

Rydapt..................................... 36

Rytary....................................... 38

S

Saizen...................................... 70

Saizenprep.............................. 70

Sancuso................................... 29

Sandimmune........................... 78

Santyl....................................... 61

Saphris.....................................41

Savella......................................59

Savella Titration Pack............. 59

Scopolamine........................... 29

Secuado.................................. 41

Selegiline HCl..........................38

Selenium Sulfide..................... 61

Selzentry.................................. 44

Serevent Diskus...................... 87

Serostim...................................65

Sertraline HCl.......................... 28

Setlakin.................................... 74

165

Tracked

Sevelamer Carbonate............. 64

Sharobel.................................. 75

Shingrix....................................81

Signifor.................................... 76

Sildenafil Citrate......................88

Silodosin.................................. 67

Silver Sulfadiazine...................23

Simbrinza.................................85

Simponi....................................78

Simvastatin.............................. 56

Sirolimus..................................78

Sirturo...................................... 33

Sodium Chloride..................... 63

Sodium Fluoride......................63

Sodium Phenylbutyrate....66, 67

Sodium Polystyrene Sulfonate............................................... 64

Sofosbuvir-Velpatasvir............ 42

Solifenacin Succinate............. 67

Soliqua..................................... 47

Soltamox..................................33

Somatuline Depot................... 76

Somavert................................. 76

Sotalol HCl...............................52

Sotalol HCl AF......................... 52

Sovaldi..................................... 42

Spiriva HandiHaler.................. 87

Spiriva Respimat..................... 87

Spironolactone........................56

Spironolactone-HCTZ.............55

Sprintec 28.............................. 74

Spritam ODT........................... 24

Sprycel..................................... 36

SPS.......................................... 64

Sronyx...................................... 74

SSD.......................................... 23

Stavudine.................................43

Stelara......................................61

Stiolto Respimat......................89

Stivarga....................................36

Streptomycin Sulfate.............. 18

Stribild......................................42

Suboxone................................ 17

Sucraid.....................................67

Sucralfate................................ 66

Sulfacetamide Sodium........... 23

Sulfacetamide-Prednisolone............................................... 84

Sulfadiazine............................. 23

Sulfamethoxazole-Trimethoprim......................................... 23, 24

Sulfamylon...............................19

Sulfasalazine........................... 82

Sulindac...................................14

Sumatriptan.............................32

Sumatriptan Succinate........... 32

Sumatriptan Succinate Refill............................................... 32

Suprax......................................20

Suprep Bowel Prep Kit........... 65

Sutent.......................................36

Syeda....................................... 74

Symbicort................................ 89

Symfi........................................ 43

Symfi Lo...................................43

SymlinPen 120........................ 47

SymlinPen 60.......................... 47

Sympazan................................ 25

Symtuza................................... 44

Synarel..................................... 76

Synjardy................................... 47

Synjardy XR............................. 47

Synribo.....................................34

Synthroid................................. 75

T

Tabloid..................................... 33

Tabrecta.................................. 33

Tacrolimus........................ 61, 78

Tadalafil................................... 88

Tafinlar..................................... 36

Tagrisso................................... 36

Talzenna.................................. 35

Tamoxifen Citrate................... 33

Tamsulosin HCl.......................67

Targretin.................................. 36

Tarina 24 Fe............................ 74

Tarina Fe 1/20.........................74

Tasigna.................................... 36

Tazarotene...............................61

Tazicef..................................... 21

Tazorac.................................... 61

Taztia XT.................................. 54

Tazverik....................................34

TDVAX..................................... 81

Tecfidera..................................59

Tecfidera Starter Pack............59

Tegsedi.................................... 67

Telmisartan..............................52

Telmisartan-Amlodipine......... 55

Telmisartan-HCTZ...................55

Temazepam.............................90

Tenivac.................................... 81

166

Tracked

Tenofovir Disoproxil Fumarate............................................... 43

Terazosin HCl..........................67

Terbinafine HCl....................... 31

Terconazole.............................31

Teriparatide............................. 83

Testosterone........................... 71

Testosterone Cypionate......... 71

Testosterone Enanthate......... 71

Tetrabenazine......................... 59

Tetracycline HCl......................24

Thalomid..................................33

Theophylline............................88

Theophylline ER......................88

Thioridazine HCl..................... 39

Thiothixene..............................39

Tiadylt ER................................ 54

Tiagabine HCl......................... 25

Tibsovo.................................... 36

Tigecycline.............................. 19

Timolol Maleate................ 31, 85

Timolol Maleate Ophthalmic Gel Forming.......................... 85

Tinidazole................................ 19

Tivicay................................42, 43

Tivicay PD................................ 43

Tizanidine HCl......................... 90

TOBI Podhaler.........................88

TobraDex................................. 84

TobraDex ST........................... 84

Tobramycin....................... 18, 88

Tobramycin Sulfate.................18

Tobramycin-Dexamethasone............................................... 84

Tobrex......................................18

Tolak........................................ 61

Tolcapone................................38

Topiramate.............................. 26

Toremifene Citrate.................. 33

Torsemide............................... 56

Toujeo Max SoloStar.............. 49

Toujeo SoloStar...................... 49

TPN Electrolytes..................... 63

Tracleer....................................88

Tradjenta................................. 47

Tramadol HCl.......................... 16

Tramadol HCl ER.................... 15

Tramadol-Acetaminophen..... 17

Trandolapril............................. 52

Tranexamic Acid..................... 51

Transderm-Scop..................... 29

Tranylcypromine Sulfate........ 27

Travasol................................... 63

Travoprost............................... 85

Trazodone HCl........................ 28

Trecator................................... 33

Trelegy Ellipta..........................89

Trelstar Mixject........................76

Tresiba..................................... 49

Tresiba FlexTouch.................. 49

Tretinoin............................ 36, 61

Tretinoin Microsphere............ 61

Trexall...................................... 78

Trezix....................................... 17

Tri-Estarylla.............................. 74

Tri-Legest Fe............................74

Tri-Lo-Estarylla.........................74

Tri-Lo-Sprintec.........................74

Tri-Mili...................................... 74

Tri-Previfem............................. 74

Tri-Sprintec.............................. 74

Tri-VyLibra............................... 74

Tri-VyLibra Lo.......................... 74

Triamcinolone Acetonide...... 60, 70

Triamterene............................. 56

Triamterene-HCTZ.................. 55

Triderm.................................... 70

Trientine HCl........................... 64

Trifluoperazine HCl................. 39

Trifluridine............................... 42

Trihexyphenidyl HCl............... 37

Trijardy XR............................... 47

TriLyte...................................... 65

Trimethoprim...........................19

Trimipramine Maleate............ 29

Trintellix................................... 28

Triumeq................................... 43

Trivora...................................... 74

TrophAmine.............................63

Trulicity.................................... 47

Trumenba................................ 81

Truvada....................................43

Tukysa..................................... 34

Turalio...................................... 36

Twinrix......................................81

Tybost...................................... 43

Tykerb...................................... 36

Tymlos..................................... 83

Typhim Vi.................................81

U

Udenyca...................................51

Unithroid.................................. 75

167

Tracked

Ursodiol................................... 65

V

Valacyclovir HCl...................... 42

Valchlor....................................33

Valganciclovir HCl...................41

Valproic Acid........................... 25

Valsartan.................................. 52

Valsartan-Hydrochlorothiazide............................................... 55

Valtoco 10 MG Dose...............25

Valtoco 15 MG Dose...............25

Valtoco 20 MG Dose...............25

Valtoco 5 MG Dose.................25

Vancomycin HCl..................... 19

Vandazole................................ 19

VAQTA..................................... 81

Varivax..................................... 81

Varizig...................................... 79

Vascepa................................... 57

Velivet...................................... 74

Velphoro.................................. 64

Veltassa................................... 64

Vemlidy.................................... 42

Venclexta................................. 36

Venclexta Starting Pack......... 36

Venlafaxine HCl.......................28

Venlafaxine HCl ER.................28

Ventavis................................... 88

Verapamil HCl......................... 54

Verapamil HCl ER................... 54

Versacloz................................. 41

Verzenio................................... 34

Vibramycin...............................24

Victoza..................................... 47

Vienva...................................... 74

Vigabatrin................................ 25

Vigadrone................................ 26

Viibryd......................................28

Viibryd Starter Pack................ 28

Vimpat......................................26

Viracept....................................44

Viread.......................................44

Vitrakvi..................................... 36

Vivitrol...................................... 17

Vizimpro...................................36

Voriconazole............................31

Vosevi...................................... 42

Votrient.................................... 36

VP-PNV-DHA............................64

Vraylar...................................... 41

Vyfemla.................................... 74

VyLibra.....................................74

Vyndamax................................55

Vyndaqel..................................55

Vyvanse....................................58

Vyzulta..................................... 85

W

Warfarin Sodium..................... 50

Wixela Inhub............................89

WYMZYA Fe............................ 74

X

Xalkori...................................... 36

Xarelto......................................50

Xarelto Starter Pack................50

Xatmep.....................................78

Xcopri................................ 24, 25

Xeljanz..................................... 78

Xeljanz XR............................... 78

Xgeva....................................... 83

Xifaxan..................................... 65

Xiidra........................................ 84

Xofluza..................................... 45

Xolair..................................79, 80

Xospata....................................36

Xpovio................................33, 34

Xtampza ER.............................15

Xtandi....................................... 33

Xulane...................................... 74

Xyrem....................................... 90

Y

YF-Vax...................................... 81

Yuvafem................................... 74

Z

Zafirlukast................................ 86

Zaleplon................................... 90

Zarah........................................74

Zarxio....................................... 51

Zejula....................................... 35

Zelapar ODT............................ 38

Zelboraf................................... 36

Zemaira....................................67

Zenpep.................................... 67

Zerbaxa....................................21

Zidovudine...............................44

Zileuton ER..............................87

Zioptan.....................................86

Ziprasidone HCl...................... 41

Ziprasidone Mesylate............. 41

Zirgan.......................................42

Zolinza..................................... 34

Zolpidem Tartrate................... 90

Zonisamide..............................25

168

Tracked

Zorbtive....................................65

Zortress....................................78

Zovia 1/35E............................. 74

Zyclara Pump.......................... 61

Zydelig..................................... 36

Zyflo......................................... 87

Zykadia.................................... 36

Zyprexa Relprevv.................... 41

169

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