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2017 Abridged
FORMULARY
(Partial list of covered prescription drugs)
UnitedHealthcare® Group Medicare Advantage (PPO)
Offered by State Health Benefit Plan
Please read: This document contains information about some of the drugs
we cover in this plan.
This Abridged Formulary (drug list) is not a complete list of drugs covered by our
plan. For a complete list of covered drugs or if you have other questions, please
call UnitedHealthcare Group Medicare Advantage (PPO) Customer Service at:
Toll-Free 877-246-4190, TTY 711
8 a.m. - 8 p.m. local time, Monday - Friday
www.UHCRetiree.com/shbp
Formulary ID Number 00017015, Version 10
Y0066_160708_113639
Last updated August 1, 2016
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This Abridged Formulary is a partial list of the prescription drugs covered by our plan. It is current
as of August 1, 2016.
For an up-to-date formulary (drug list), please call us. Our contact information, along with the date
we last updated the formulary, is on the cover.
When this formulary (drug list) refers to “we,” “us,” or “our,” it means UnitedHealthcare. When it
refers to “plan” or “our plan,” it means UnitedHealthcare Group Medicare Advantage (PPO).
Our list of covered prescription drugs is called a Formulary. We call it a “drug list” for short.
Note to existing members: This partial drug list has changed since last year. Please review this
document to make sure your prescription drugs are still covered. In most cases, you must use
network pharmacies to have your prescriptions covered by the plan.
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The UnitedHealthcare Group Medicare Advantage (PPO)
ABRIDGED FORMULARY
(drug list)
A formulary (drug list) is a list of covered drugs selected by your plan in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of
a quality treatment program.
Your plan will generally cover the drugs listed in our drug list as long as the drug is:
· Medically necessary
· The prescription is filled at a plan network pharmacy
· Other plan rules are followed
For more information on how to fill your prescriptions, please review your Evidence of Coverage.
This document is a partial drug list and includes only some of the drugs covered by your plan. For a
complete listing of all prescription drugs covered by your plan, please call us toll-free at
877-246-4190, TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday. Or visit us online at
www.UHCRetiree.com/shbp. The date we last updated the drug list is on the cover.
For your prescription drug to be covered by your plan, it must be included in the Comprehensive
Formulary (list of covered prescription drugs).
In addition to the Comprehensive Formulary (list of covered prescription drugs), your plan includes
extra coverage for certain drugs through your medical plan coverage and Additional Drug Coverage.
These drugs are either not generally covered under Medicare Part D or are covered at a different tier
or cost level than the ones shown in your plan’s formulary (drug list).
To find out if your drug is covered:
1. See if your drug is included in this partial drug list.
2. If you cannot find your drug in this partial list, you can check the complete drug list by visiting us
online at www.UHCRetiree.com/shbp. Use the online tools to look up your drugs. The
information is updated on a regular basis.
3. Or call Customer Service toll-free at 877-246-4190, TTY 711, 8 a.m. - 8 p.m. local time, Monday Friday.
In most cases, your prescription must also be filled at one of our network pharmacies.
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The drug list may change
We try to make as few changes to the drug list as possible during the plan year.
· If there are changes to the drug list, such as regular or necessary updates, members may see
information in their Explanation of Benefits (EOB) statements.
· If there are changes to the drug list outside of regular or necessary updates, members may
receive a special mailing.
The drug list may change during the year if your plan:
· Adds new drugs, including generic drugs, as they become available.
· Removes a drug that has been found to be ineffective or unsafe.
· Changes the requirements or limits for a drug.
· Moves a drug into a different tier.
Generally, if you are taking a drug on the 2017 drug list that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2017 plan year except when
a new, less expensive generic drug becomes available or when new information about the safety or
effectiveness of a drug is released.
Other types of drug list changes, such as removing a drug from the list, will not affect members who
are currently taking the drug. For those members it will remain available at the same cost for the
remainder of the plan year. We feel it is important for you to have access for the entire plan year to
the list of drugs that were available when you chose your plan, except when you can save additional
money or your safety is a concern.
If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, during the plan year we must
notify affected members at least 60 days before the change becomes effective, or when the
member requests a refill of the drug. At this time the member will receive a 60-day supply of the
drug.
If the Food and Drug Administration (FDA) declares a drug on our drug list to be unsafe, or if the
drug’s manufacturer removes the drug from the market, your plan will immediately remove the drug
from the drug list and notify members who take the drug. The enclosed drug list is current as of the
date printed on the cover. To get updated information about the drugs covered by your plan, please
call Customer Service toll-free at 877-246-4190, TTY 711, 8 a.m. - 8 p.m. local time, Monday Friday. Or visit us online at www.UHCRetiree.com/shbp.
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Drug payment stages and drug tiers
The amount you pay for a covered drug will depend on:
· Your drug payment stage. Your plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the coverage stage you’re in.
· The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier has a copay and/or co-insurance amount. The chart below shows the differences between the tiers.
For more information about drug coverage and co-pay or co-insurance amounts for each tier,
please review your Evidence of Coverage.
Drug Tier
Includes
Tier 1:
Preferred generic
All covered generic drugs.
Tier 2:
Preferred brand
Many common brand name drugs, called preferred
brands.
Tier 3:
Non-preferred drug
Non-preferred brand name drugs. In addition, Part D
eligible compound medications are covered in Tier 3.
Tier 4:
Specialty tier
Unique and/or very high-cost brand drugs.
If you qualify for Extra Help
If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be
lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People
Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your
costs. You can also call Customer Service toll-free at 877-246-4190, TTY 711, 8 a.m. - 8 p.m. local
time, Monday - Friday.
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How to use the drug list
There are two ways to find your prescription drugs in this partial drug list:
1. Medical condition: Turn to the “Covered drugs by medical condition” section, which
begins on page 12, to look for drugs based on your medical conditions. For example,
if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Agents”
category and look under “Dyslipidemics, HMG CoA Reductase Inhibitors.”
2. Alphabetical list (index): If you are not sure what category to look under, turn to the
“Index of covered drugs” section, which begins on page 45. Find the name of your
drug. The page number where you can find the drug will be next to it.
Generic drugs
Your plan covers both brand name drugs and generic drugs.
Generic drugs:
· Are approved by the Food and Drug Administration (FDA) as having the same active ingredients
as brand name drugs.
· Usually cost less than brand name drugs.
Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then
review the drug list to make sure you are getting the drug you need for the least amount of money.
The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in
plain type (for example, Simvastatin).
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Dummy
Required actions, restrictions or limits
Some covered drugs may have additional requirements or limits on coverage. If your drug has any
requirements or limits, there will be a code(s) in the “Required actions, restrictions or limits”
column of the drug list. The codes and what they mean are shown below.
Utilization Management Restrictions
PA - Prior authorization
The plan requires you or your doctor to get prior authorization for certain drugs. This means the
plan needs more information from your doctor to make sure the drug is being used correctly for a
medical condition covered by Medicare. If you don’t get approval, the plan may not cover the
drug.
QL - Quantity limits
The plan will cover only a certain amount of this drug for one co-pay/co-insurance or over a
certain number of days. These limits may be in place to ensure safe and effective use of the drug.
If your doctor prescribes more than this amount or thinks the limit is not right for your situation,
you or your doctor can ask the plan to cover the additional quantity.
ST - Step therapy
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You
may be required to try one or more of these other drugs before the plan will cover your drug. If
you have already tried other drugs or your doctor thinks they are not right for you, you or your
doctor can ask the plan to cover this drug.
Other Special Requirements for Coverage
B/D - Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and
outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide
the plan with more information about how this drug will be used to make sure it’s correctly
covered by Medicare.
HRM - High Risk Medication
This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This
drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to
see if an alternative drug is available to treat your condition.
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.
MED - Morphine Equivalent Dose
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is
calculated based on the number of opioid drugs prescribed for you over a period of time. This
cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids
for those individuals who may be taking more than one 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.
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You can find out if your drug has any additional requirements, restrictions or limits by looking it up
in the “Covered drugs by medical condition” section that begins on page 12. You can also get
more information about the restrictions applied to specific covered drugs by visiting our website.
We have posted online documents that explain our prior authorization and step therapy
restrictions. You may ask us to send you a copy. Please call Customer Service toll-free at
877-246-4190, TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday. Or visit us online at
www.UHCRetiree.com/shbp. The date we last updated the drug list is on the cover.
You and your doctor may ask the plan for an exception to these requirements, restrictions or limits,
or for a list of other, similar drugs that may treat your health condition. See the, “How to request an
exception to the UnitedHealthcare Group Medicare Advantage (PPO) drug list” section on the next
page or review your Evidence of Coverage to learn more. If you do not get prior approval from the
plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug.
If your drug is not on the drug list
If your drug is not included in this formulary (list of covered prescription drugs), you should call
Customer Service and ask if your drug is covered. Call us toll-free at 877-246-4190, TTY
711, 8 a.m. - 8 p.m. local time, Monday - Friday. Or visit us online at
www.UHCRetiree.com/shbp. The date we last updated the drug list is on the cover.
If you learn that your plan does not cover your drug, you have two options:
1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him
or her to prescribe one of the appropriate drugs from the list.
2. Ask your plan to make an exception and cover your drug. See next page for information about
how to request an exception.
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How to request an exception to the
UnitedHealthcare Group Medicare Advantage (PPO) drug list
At times you may need to ask for drug coverage that’s not normally provided by your plan. When
you do, your plan will consider your request and respond with a coverage decision (coverage
determination).
You can ask your plan to make an exception to the coverage rules. There are several types of
exceptions that you can ask us to make.
· Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list.
If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not
be able to ask us to provide the drug at a lower cost-sharing level.
· Tiering exception: You can ask your plan to cover a formulary drug at a lower cost-sharing level
if this drug is not on the specialty tier.
· Utilization exception: You can ask your plan to waive coverage restrictions or limits on your
drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a
quantity limit, you can ask your plan to waive the limit and cover more.
Generally, your plan will approve your request for an exception only if the alternative drugs included
in your plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be
as effective in treating your condition and/or would cause adverse medical effects.
Who can ask for a coverage decision
You, your authorized representative or your doctor can ask for an initial coverage decision for a
formulary exception, tiering exception or utilization restriction exception.
When you are requesting a formulary exception, tiering exception or utilization restriction
exception, your prescriber or physician should submit a statement supporting your request.
Receiving a coverage decision
Generally, your plan will make a coverage decision within 72 hours after receiving your prescribing
physician’s statement. You can request an expedited, or fast, decision if you or your doctor
believes your health requires it. If your plan agrees to a fast decision, you will receive a decision
within 24 hours after your plan receives your doctor’s or prescribing physician’s supporting
statement.
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What to do while you talk to your doctor about changing your drugs
or requesting an exception
New or continuing members
As a new or continuing member in your plan, you may be taking drugs that are not on the drug list.
Or you may be taking a drug that is on the drug list but your ability to get it is limited. For example,
you may need prior authorization before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that your plan covers, or request a
formulary exception so your plan will cover the prescription drug you are currently taking.
In certain cases, while you talk to your doctor to decide what to do, your plan may cover up to at
least a 30-day supply of prescription drugs (unless you have a prescription written for fewer days)
from a network pharmacy during the first 90 days you are a member of your plan. This would apply
to each of your prescription drugs not on the list, or if your ability to get your drugs is limited. After
you receive at least a 30-day supply, your plan will not pay for these drugs, even if you have been a
member of your plan less than 90 days.
Long-term care facility residents
If you’re a resident of a long-term care facility, your plan may allow you to refill your prescription
until you have been provided with at least a 98-day transition supply of the drug consistent with
dispensing increment (unless your prescription is written for fewer days). Your plan will also cover
more than one refill of these drugs for the first 90 days you are a member of your plan. If you need
a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the
first 90 days of membership in the plan, your plan will cover at least a 31-day emergency supply of
the drug (unless your prescription is written for fewer days) while you request a formulary
exception.
Other transitions
You may have an unplanned transition, like a hospital discharge or a change in your level of care. If
this happens and your doctor prescribes a drug that is not on the drug list, or a drug that is on the
drug list but your ability to get it is limited, your plan may cover a one-time supply of at least 30days. You may ask for a one-time emergency supply of at least 30-days to give you time to talk to
your doctor about other treatment options or to try to get a formulary exception.
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Drugs with dosages other than a one-month supply
Drugs packaged in an extended day supply
Some drugs are packaged from the manufacturer to provide more than a one-month supply. When
you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single
prescription. For more information, please call Customer Service toll-free at 877-246-4190, TTY
711, 8 a.m. - 8 p.m. local time, Monday - Friday.
Daily cost sharing rate
A “daily cost sharing rate” may apply when your doctor prescribes less than a full month’s supply of
certain drugs for you and you are required to pay a co-payment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days,
then your “daily cost-sharing rate” is $1 per day. This means you pay $1 for each day’s supply when
you fill your prescription.
Daily cost share for oral medications filled for less than a one-month supply
Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule)
when dispensed for a supply of less than one month under applicable law.
The daily cost share requirements do not apply to either of the following:
1. Solid oral doses of antibiotics.
2. Solid oral doses that are dispensed in their original container or are usually dispensed in their
original packaging to help patients comply with usage and dosage directions.
For more information
For more information about your plan’s prescription drug coverage, please review your Evidence of
Coverage and other plan materials. If you have questions about your plan, please call us toll-free at
877-246-4190, TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday. Or visit us online at
www.UHCRetiree.com/shbp.
If you have general questions about Medicare prescription drug coverage, visit www.medicare.gov
or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.
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Covered drugs by medical condition
The Abridged Formulary (drug list) below provides coverage information about some of the drugs
covered by your plan. If you have trouble finding your drug in the list, turn to the “Index of covered
drugs,” which begins on page 45.
Remember: This is only a partial list of drugs covered by your plan. If your drug is not in this partial
drug list, please call Customer Service toll-free at 877-246-4190, TTY 711, 8 a.m. - 8 p.m. local
time, Monday - Friday. The date we last updated the drug list is on the cover.
The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for
example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin).
The second column of the chart lists which coverage level (Tier) your drug is in.
The “Required Actions, Restrictions or Limits” column shows you if your plan has any special
coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts
are shown in the chart on pages 34-44.
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Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Analgesics
Nonsteroidal Anti-inflammatory Drugs
Celecoxib (Capsule)
1
QL
Diclofenac Potassium
(Tablet Immediate1
Release)
Diclofenac Sodium DR
(Tablet Delayed1
Release)
Diclofenac Sodium ER
(Tablet Extended1
Release 24 Hour)
Ibuprofen (100mg/5ml
Suspension, 400mg
1
Tablet, 600mg Tablet,
800mg Tablet)
Meloxicam (Tablet)
1
Celecoxib
Diclofenac Potassium
Diclofenac Sodium DR
Diclofenac Sodium ER
Ibuprofen
Meloxicam
Bold type = Brand name drug
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Naproxen (Tablet
1
Immediate-Release)
Voltaren (Gel)
3
Opioid Analgesics, Long-acting
Embeda (Capsule
2
Extended-Release)
Fentanyl (Patch 72
1
Hour)
Methadone HCl (Oral
1
Solution, Tablet)
Morphine Sulfate ER
(Tablet Extended1
Release) (Generic MS
Contin)
Nucynta ER (Tablet
Extended-Release 12
2
Hour)
Naproxen
Voltaren
PA
Embeda
QL, MED
Fentanyl
QL, MED
Methadone HCl
QL, MED
Morphine Sulfate ER
QL, MED
Nucynta ER
Plain type = Generic drug
12
QL, MED
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Last updated August 1, 2016
Drug Name
Drug
Tier
13
Required
Actions,
Restrictions
or Limits
Opana ER (Tablet
Extended-Release 12
2
Hour AbuseDeterrent)
OxyContin (Tablet
Extended-Release 12
2
Hour AbuseDeterrent)
Opioid Analgesics, Short-acting
Acetaminophen/
1
Codeine (Tablet)
Hydrocodone/
Acetaminophen
(10mg-325mg Tablet,
1
2.5mg-325mg Tablet,
5mg-325mg Tablet,
7.5mg-325mg Tablet)
Hydromorphone HCl
(Tablet Immediate1
Release)
Oxycodone HCl (Tablet
1
Immediate-Release)
Oxycodone/
Acetaminophen
(10mg-325mg Tablet,
1
2.5mg-325mg Tablet,
5mg-325mg Tablet,
7.5mg-325mg Tablet)
Tramadol HCl (Tablet
1
Immediate-Release)
Tramadol HCl/
Acetaminophen
1
(Tablet)
Anesthetics
Opana ER
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Local Anesthetics
Lidocaine (Ointment)
1
Lidocaine HCl (Gel)
1
Lidocaine Viscous
1
(Solution)
Lidocaine/Prilocaine
1
(Cream)
Anti-Addiction/Substance Abuse Treatment
Agents
Alcohol Deterrents/Anti-craving
Acamprosate Calcium
DR (Tablet Delayed1
Release)
Disulfiram (Tablet)
1
Naltrexone HCl
1
(Tablet)
Opioid Dependence Treatments
Buprenorphine HCl
1
PA, QL
(Tablet Sublingual)
Butrans (Patch
2
QL, MED
Weekly)
Suboxone (Film)
3
PA, QL
Smoking Cessation Agents
Chantix (Tablet)
2
Nicotrol Inhaler
3
Antibacterials
Aminoglycosides
Lidocaine
QL, MED
Lidocaine HCl
Lidocaine Viscous
OxyContin
QL, MED
Acetaminophen/Codeine
QL, MED
Lidocaine/Prilocaine
Acamprosate Calcium DR
Hydrocodone/Acetaminophen
QL, MED
Disulfiram
Naltrexone HCl
Hydromorphone HCl
QL, MED
Oxycodone HCl
Buprenorphine HCl
Butrans
QL, MED
Oxycodone/Acetaminophen
Suboxone
QL, MED
Chantix
Nicotrol Inhaler
Tramadol HCl
QL, MED
Tramadol HCl/Acetaminophen
QL, MED
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
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Drug Name
Last updated August 1, 2016
Drug
Tier
Gentamicin Sulfate
(0.1% Cream, 0.1%
Ointment, 0.3%
1
Ophthalmic Ointment,
0.3% Ophthalmic
Solution)
Tobramycin Sulfate
1
(Ophthalmic Solution)
Antibacterials, Other
Metronidazole (Tablet
1
Immediate-Release)
Nitrofurantoin
Macrocrystals (25mg
Capsule, 50mg
1
Capsule) (Generic
Macrodantin)
Nitrofurantoin
Monohydrate (100mg
1
Capsule) (Generic
Macrobid)
Beta-lactam, Cephalosporins
Cefuroxime Axetil
1
(Tablet)
Cephalexin (Capsule,
1
Oral Suspension)
Suprax (100mg Tablet
Chewable, 200mg
2
Tablet Chewable)
Suprax (100mg/5ml
3
Suspension)
Suprax (200mg/5ml
4
Suspension)
Required
Actions,
Restrictions
or Limits
Gentamicin Sulfate
Meropenem
Suprax
Bold type = Brand name drug
3
1
1
Penicillin V Potassium
1
Azithromycin
Clarithromycin
Nitrofurantoin Monohydrate
Suprax
2
Amoxicillin
Nitrofurantoin Macrocrystals
Suprax
Suprax (400mg
Capsule, 500mg/5ml
Suspension)
Beta-lactam, Other
Invanz (Injection)
Meropenem (Injection)
Beta-lactam, Penicillins
Amoxicillin (Capsule,
Tablet)
Penicillin V Potassium
(Tablet)
Macrolides
Azithromycin (Oral
Suspension, Tablet
Immediate-Release)
Clarithromycin (Tablet)
Quinolones
Ciprofloxacin HCl
(Tablet ImmediateRelease)
Levofloxacin (Tablet)
Sulfonamides
Silver Sulfadiazine
(Cream)
Sulfamethoxazole/
Trimethoprim DS
(Tablet)
Tetracyclines
Doxycycline Hyclate
(Capsule ImmediateRelease)
Invanz
Metronidazole
Cephalexin
Drug
Tier
Suprax
Tobramycin Sulfate
Cefuroxime Axetil
Drug Name
QL, HRM
1
1
Ciprofloxacin HCl
Levofloxacin
1
1
Silver Sulfadiazine
1
Sulfamethoxazole/Trimethoprim DS
1
Doxycycline Hyclate
Plain type = Generic drug
14
1
Required
Actions,
Restrictions
or Limits
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4
Last updated August 1, 2016
Drug Name
Drug
Tier
15
Required
Actions,
Restrictions
or Limits
Minocycline HCl
(Capsule Immediate1
Release)
Anticonvulsants
Anticonvulsants, Other
Fycompa (Tablet)
3
Levetiracetam (Tablet
1
Immediate-Release)
Calcium Channel Modifying Agents
Ethosuximide (250mg
Capsule, 250mg/5ml
1
Oral Solution)
Zonisamide (Capsule)
1
Gamma-aminobutyric Acid (GABA)
Augmenting Agents
Gabapentin (Capsule,
1
Tablet)
Valproic Acid (250mg
Capsule, 250mg/5ml
1
Syrup)
Glutamate Reducing Agents
Lamotrigine (Tablet
1
Immediate-Release)
Topiramate (Tablet
1
Immediate-Release)
Sodium Channel Agents
Carbamazepine
(100mg Tablet
Chewable, 100mg/5ml
1
Suspension, 200mg
Tablet ImmediateRelease)
Oxcarbazepine (Tablet) 1
Minocycline HCl
Fycompa
Levetiracetam
Ethosuximide
Zonisamide
Gabapentin
Valproic Acid
Lamotrigine
Topiramate
Carbamazepine
Oxcarbazepine
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Phenytoin Sodium
1
Extended (Capsule)
Antidementia Agents
Cholinesterase Inhibitors
Donepezil HCl,
Donepezil HCl ODT
1
QL
(Tablet)
Rivastigmine Tartrate
(Capsule Immediate1
QL
Release)
N-methyl-D-aspartate (NMDA) Receptor
Antagonist
Memantine HCl
1
PA, QL
(Tablet)
Namenda (Oral
Solution, Tablet
3
PA, QL
Immediate-Release)
Namenda XR
(Capsule Extended2
PA, QL
Release 24 Hour)
Antidepressants
Antidepressants, Other
Bupropion HCl,
Bupropion HCl SR,
1
Bupropion HCl XL
(Tablet)
Mirtazapine,
Mirtazapine ODT
1
(Tablet)
SSRI/SNRI (Selective Serotonin Reuptake
Inhibitors/Serotonin and Norepinephrine
Reuptake Inhibitors)
Trintellix (Tablet)
3
QL
Phenytoin Sodium Extended
Donepezil HCl, Donepezil HCl ODT
Rivastigmine Tartrate
Memantine HCl
Namenda
Namenda XR
Bupropion HCl, Bupropion HCl SR, Bupropion HCl XL
Mirtazapine, Mirtazapine ODT
Trintellix
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
15
tRACK
5
5
16
Drug Name
Last updated August 1, 2016
Drug
Tier
Citalopram HBr
1
(Tablet)
Escitalopram Oxalate
1
(Tablet)
Pristiq (Tablet
Extended-Release 24
3
Hour)
Sertraline HCl (Tablet)
1
Trazodone HCl (Tablet) 1
Tricyclics
Amitriptyline HCl
1
(Tablet)
Nortriptyline HCl
(Capsule, Oral
1
Solution)
Antiemetics
Antiemetics, Other
Meclizine HCl (12.5mg
1
Tablet)
Metoclopramide HCl
1
(Tablet)
Transderm-Scop
3
(Patch 72 Hour)
Emetogenic Therapy Adjuncts
Dronabinol (Capsule)
1
Ondansetron HCl,
Ondansetron ODT
1
(Tablet)
Antifungals
Antifungals
Fluconazole (Tablet)
1
Required
Actions,
Restrictions
or Limits
Citalopram HBr
Nystatin
Pristiq
QL
Sertraline HCl
Allopurinol
Trazodone HCl
Colchicine
Amitriptyline HCl
PA, HRM
Uloric
Nortriptyline HCl
PA, HRM
Dihydroergotamine Mesylate
Meclizine HCl
Migergot
PA, HRM
Metoclopramide HCl
Rizatriptan Benzoate, Rizatriptan ODT
Transderm-Scop
Sumatriptan Succinate
PA, QL
Ondansetron HCl, Ondansetron ODT
Fluconazole
Bold type = Brand name drug
B/D, PA
Drug
Tier
Ketoconazole (2%
Cream, 2% Shampoo,
1
200mg Tablet)
Nystatin (Cream,
Ointment, Powder,
1
Suspension, Tablet)
Antigout Agents
Antigout Agents
Allopurinol (Tablet)
1
Colchicine (0.6mg
Tablet) (Generic
2
QL
Colcrys)
Uloric (Tablet)
2
ST
Antimigraine Agents
Ergot Alkaloids
Dihydroergotamine
1
Mesylate (Injection)
Migergot (Suppository) 4
Serotonin (5-HT) 1b/1d Receptor Agonists
Rizatriptan Benzoate,
Rizatriptan ODT
1
QL
(Tablet)
Sumatriptan Succinate
1
QL
(Tablet)
Antimyasthenic Agents
Parasympathomimetics
Guanidine HCl
2
(Tablet)
Pyridostigmine
1
Bromide (Tablet)
Antimycobacterials
Antimycobacterials, Other
Ketoconazole
Escitalopram Oxalate
Dronabinol
Drug Name
Required
Actions,
Restrictions
or Limits
Guanidine HCl
Pyridostigmine Bromide
Plain type = Generic drug
16
tRACK
6
6
Last updated August 1, 2016
Drug Name
Dapsone (Tablet)
Dapsone
Drug
Tier
17
Required
Actions,
Restrictions
or Limits
1
Rifabutin (Capsule)
1
Antituberculars
Isoniazid (Tablet)
1
Rifampin (Capsule)
1
Antineoplastics
Alkylating Agents
Cyclophosphamide
3
B/D, PA
(Capsule)
Leukeran (Tablet)
2
Antiandrogens
Bicalutamide (Tablet)
1
Zytiga (Tablet)
4
PA, QL
Antiangiogenic Agents
Pomalyst (Capsule)
4
PA, QL
Revlimid (Capsule)
4
PA, QL, LA
Antiestrogens/Modifiers
Fareston (Tablet)
4
Tamoxifen Citrate
1
(Tablet)
Antimetabolites
Hydroxyurea (Capsule) 1
Mercaptopurine
1
(Tablet)
Antineoplastics, Other
Carboplatin (Injection)
1
Leucovorin Calcium
1
(Tablet)
Aromatase Inhibitors, 3rd Generation
Anastrozole (Tablet)
1
Rifabutin
Isoniazid
Rifampin
Cyclophosphamide
Leukeran
Bicalutamide
Zytiga
Pomalyst
Revlimid
Fareston
Tamoxifen Citrate
Hydroxyurea
Mercaptopurine
Carboplatin
Leucovorin Calcium
Anastrozole
Drug Name
Drug
Tier
Letrozole (Tablet)
1
Enzyme Inhibitors
Etoposide (Injection)
1
Topotecan HCl
1
(Injection)
Molecular Target Inhibitors
Gleevec (Tablet)
4
Required
Actions,
Restrictions
or Limits
Letrozole
Etoposide
Topotecan HCl
Gleevec
Sprycel (Tablet)
4
Tasigna (Capsule)
4
Monoclonal Antibodies
Avastin (Injection)
4
Rituxan (Injection)
4
Retinoids
Targretin (75mg
4
Capsule, 1% Gel)
Tretinoin (Capsule)
1
Antiparasitics
Anthelmintics
Albenza (Tablet)
4
Ivermectin (Tablet)
1
Antiprotozoals
Atovaquone/Proguanil
HCl (Tablet) (Generic
1
Malarone)
Hydroxychloroquine
1
Sulfate (Tablet)
Pediculicides/Scabicides
Lindane (1% Lotion,
1
1% Shampoo)
Permethrin (Cream)
1
Antiparkinson Agents
Sprycel
Tasigna
Avastin
Rituxan
PA, QL
PA, QL
PA, QL
PA
PA
Targretin
PA
Tretinoin
Albenza
QL
Ivermectin
Atovaquone/Proguanil HCl
Hydroxychloroquine Sulfate
Lindane
Permethrin
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
17
tRACK
7
7
18
Drug Name
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Anticholinergics
Benztropine Mesylate
1
PA, HRM
(Tablet)
Trihexyphenidyl HCl
1
PA, HRM
(Elixir)
Antiparkinson Agents, Other
Amantadine HCl
(100mg Capsule,
1
100mg Tablet, 50mg/
5ml Syrup)
Comtan (Tablet)
3
Entacapone (Tablet)
1
Dopamine Agonists
Pramipexole
Dihydrochloride
1
(Tablet ImmediateRelease)
Ropinirole HCl (Tablet
1
Immediate-Release)
Dopamine Precursors/L-Amino Acid
Decarboxylase Inhibitors
Carbidopa/Levodopa
(Tablet Immediate1
Release)
Carbidopa/Levodopa
ER (Tablet Extended1
Release)
Carbidopa/Levodopa
ODT (Tablet
1
Dispersible)
Monoamine Oxidase B (MAO-B) Inhibitors
Azilect (Tablet)
2
Benztropine Mesylate
Trihexyphenidyl HCl
Amantadine HCl
Comtan
Entacapone
Pramipexole Dihydrochloride
Ropinirole HCl
Carbidopa/Levodopa
Carbidopa/Levodopa ER
Carbidopa/Levodopa ODT
Drug Name
Selegiline HCl (5mg
1
Capsule, 5mg Tablet)
Antipsychotics
1st Generation/Typical
Fluphenazine HCl
1
(Tablet)
Haloperidol (Tablet)
1
2nd Generation/Atypical
Latuda (Tablet)
4
Olanzapine (Tablet
1
Immediate-Release)
Quetiapine Fumarate
(Tablet Immediate1
Release)
Risperidone (Tablet
1
Immediate-Release)
Saphris (Tablet
3
Sublingual)
Seroquel XR (Tablet
Extended-Release 24
2
Hour)
Treatment-Resistant
Clozapine (Tablet
1
Immediate-Release)
Clozapine ODT
(100mg Tablet
1
Dispersible, 25mg
Tablet Dispersible)
Selegiline HCl
Fluphenazine HCl
Haloperidol
Latuda
QL
Olanzapine
QL
Quetiapine Fumarate
QL
Risperidone
Saphris
QL
Seroquel XR
QL
Clozapine
Clozapine ODT
Azilect
Bold type = Brand name drug
Drug
Tier
Required
Actions,
Restrictions
or Limits
Plain type = Generic drug
18
QL
tRACK
8
8
Last updated August 1, 2016
Drug Name
Drug
Tier
19
Required
Actions,
Restrictions
or Limits
Clozapine ODT
(12.5mg Tablet
Dispersible, 150mg
1
QL
Tablet Dispersible,
200mg Tablet
Dispersible)
Versacloz
4
(Suspension)
Antivirals
Anti-cytomegalovirus (CMV) Agents
Valganciclovir (Tablet)
1
QL
Zirgan (Gel)
3
Anti-hepatitis B (HBV) Agents
Entecavir (Tablet)
1
Lamivudine (Tablet)
1
Anti-hepatitis C (HCV) Agents
Daklinza (Tablet)
4
PA, QL
Harvoni (Tablet)
4
PA, QL
Pegasys (Injection)
4
PA
Sovaldi (Tablet)
4
PA, QL
Zepatier (Tablet)
4
PA, QL
Antiherpetic Agents
Acyclovir (Tablet)
1
Valacyclovir HCl
1
QL
(Tablet)
Anti-HIV Agents, Integrase Inhibitors
(INSTI)
Isentress (Tablet)
4
QL
Tivicay (Tablet)
4
QL
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTI)
Clozapine ODT
Versacloz
Valganciclovir
Zirgan
Entecavir
Lamivudine
Daklinza
Harvoni
Pegasys
Sovaldi
Zepatier
Acyclovir
Valacyclovir HCl
Isentress
Drug Name
Atripla (Tablet)
Atripla
Drug
Tier
Required
Actions,
Restrictions
or Limits
4
QL
Intelence (Tablet)
4
QL
Anti-HIV Agents, Nucleoside and
Nucleotide Reverse Transcriptase
Inhibitors (NRTI)
Epzicom (Tablet)
4
QL
Truvada (Tablet)
4
QL
Viread (Powder,
4
QL
Tablet)
Anti-HIV Agents, Other
Fuzeon (Injection)
4
QL
Selzentry (Tablet)
4
QL
Anti-HIV Agents, Protease Inhibitors
Norvir (100mg
Capsule, 100mg
3
QL
Tablet, 80mg/ml Oral
Solution)
Prezista (100mg/ml
Suspension, 150mg
4
QL
Tablet, 600mg Tablet,
800mg Tablet)
Reyataz (150mg
Capsule, 200mg
Capsule, 300mg
4
QL
Capsule, 50mg
Packet)
Anti-influenza Agents
Rimantadine HCl
1
(Tablet)
Intelence
Epzicom
Truvada
Viread
Fuzeon
Selzentry
Norvir
Prezista
Reyataz
Rimantadine HCl
Tivicay
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
19
tRACK
9
9
20
Drug Name
Tamiflu (30mg
Capsule, 45mg
Capsule, 75mg
Capsule, 6mg/ml
Suspension)
Anxiolytics
Anxiolytics, Other
Buspirone HCl (Tablet)
Hydroxyzine HCl
(10mg/5ml Syrup)
Benzodiazepines
Alprazolam (Tablet
Immediate-Release)
Clonazepam (Tablet
Immediate-Release)
Clonazepam ODT
(Tablet Dispersible)
Diazepam (Tablet)
Diazepam (1mg/ml
Oral Solution)
Diazepam Intensol
(5mg/ml Concentrate)
Lorazepam (Tablet)
Lorazepam Intensol
(2mg/ml Concentrate)
Bipolar Agents
Mood Stabilizers
Divalproex Sodium
(Capsule Sprinkle),
Divalproex Sodium DR
(Tablet), Divalproex
Sodium ER (Tablet)
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Tamiflu
Buspirone HCl
3
QL
Equetro (Capsule
Extended-Release 12
3
Hour)
Lithium Carbonate
(Capsule Immediate1
Release, Tablet
Immediate-Release)
Lithium Carbonate ER
(Tablet Extended1
Release)
Blood Glucose Regulators
Antidiabetic Agents
Bydureon (Injection)
2
Byetta (Injection)
3
Farxiga (Tablet)
3
Glimepiride (Tablet)
1
Glipizide, Glipizide ER
1
(Tablet)
Invokamet (Tablet)
2
Invokana (Tablet)
2
Janumet (Tablet
2
Immediate-Release)
Janumet XR (Tablet
Extended-Release 24
2
Hour)
Januvia (Tablet)
2
Jardiance (Tablet)
2
Jentadueto (Tablet)
3
Kazano (Tablet)
3
Kombiglyze XR
(Tablet Extended2
Release 24 Hour)
Lithium Carbonate
Lithium Carbonate ER
1
1
PA, HRM
1
QL
Alprazolam
Bydureon
Byetta
Clonazepam
1
QL
1
QL
Clonazepam ODT
Farxiga
Glimepiride
QL
QL
QL, ST
QL
Glipizide, Glipizide ER
1
QL
Diazepam
Invokamet
1
Invokana
Diazepam Intensol
Lorazepam
Drug
Tier
Equetro
Hydroxyzine HCl
Diazepam
Drug Name
Required
Actions,
Restrictions
or Limits
1
QL
1
QL
1
QL
Lorazepam Intensol
Jentadueto
Kazano
Bold type = Brand name drug
QL
Janumet XR
Jardiance
1
QL
QL
Janumet
Januvia
Divalproex Sodium
QL
QL
QL
QL
QL
QL, ST
Kombiglyze XR
Plain type = Generic drug
20
QL
tRACK
10
10
Last updated August 1, 2016
Drug Name
Metformin HCl (Tablet
Immediate-Release)
Metformin HCl ER
(1000mg Tablet
Extended-Release 24
Hour) (Generic
Fortamet)
Metformin HCl ER
(500mg Tablet
Extended-Release 24
Hour, 750mg Tablet
Extended-Release 24
Hour) (Generic
Glucophage XR)
Nesina (Tablet)
Onglyza (Tablet)
Oseni (Tablet)
Pioglitazone HCl
(Tablet)
SymlinPen 120,
SymlinPen 60
(Injection)
Synjardy (Tablet)
Tradjenta (Tablet)
Trulicity (Injection)
Victoza (Injection)
Xigduo XR (Tablet
Extended-Release 24
Hour)
Glycemic Agents
GlucaGen HypoKit
(Injection)
Drug
Tier
21
Required
Actions,
Restrictions
or Limits
Metformin HCl
1
QL
Oseni
1
PA, QL
Humulin Injection
Lantus Injection
Levemir Injection
1
QL
Toujeo SoloStar
3
2
3
QL, ST
QL
QL, ST
1
QL
4
PA
2
3
2
2
QL
QL
QL
QL
3
QL, ST
Pioglitazone HCl
SymlinPen 120, SymlinPen 60
Synjardy
Tradjenta
Trulicity
Victoza
Glucagon Emergency
2
Kit (Injection)
Insulins
Humalog Injection
2
(Cartridge, Pen, Vial)
Humulin Injection
2
(Pen, Vial)
Lantus Injection
2
(SoloStar, Vial)
Levemir Injection
2
(FlexTouch, Vial)
Toujeo SoloStar
2
(Injection)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
Eliquis (Tablet)
2
PA, QL
Pradaxa (Capsule)
3
PA, QL
Warfarin Sodium
1
(Tablet)
Xarelto (Tablet)
2
PA, QL
Blood Formation Modifiers
Anagrelide HCl
1
(Capsule)
Humalog Injection
Metformin HCl ER
Onglyza
Drug
Tier
Glucagon Emergency Kit
Metformin HCl ER
Nesina
Drug Name
Required
Actions,
Restrictions
or Limits
Eliquis
Pradaxa
Warfarin Sodium
Xarelto
Anagrelide HCl
Xigduo XR
GlucaGen HypoKit
3
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
21
tRACK
11
11
22
Drug Name
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Aranesp Albumin
Free (100mcg/0.5ml
Injection, 100mcg/ml
Injection, 150mcg/
0.3ml Injection,
200mcg/0.4ml
Injection, 200mcg/ml
4
Injection, 300mcg/
0.6ml Injection,
300mcg/ml Injection,
500mcg/ml Injection,
60mcg/0.3ml
Injection, 60mcg/ml
Injection)
Aranesp Albumin
Free (10mcg/0.4ml
Injection, 25mcg/
0.42ml Injection,
3
25mcg/ml Injection,
40mcg/0.4ml
Injection, 40mcg/ml
Injection)
Procrit (10000unit/ml
Injection, 2000unit/
ml Injection,
3
3000unit/ml
Injection, 4000unit/
ml Injection)
Procrit (20000unit/ml
Injection, 40000unit/
4
ml Injection)
Blood Products/Modifiers/Volume
Expanders
Aranesp Albumin Free
Drug Name
Argatroban (125mg/
1
B/D, PA
125ml-0.9% Injection)
Argatroban (250mg/
1
B/D, PA
2.5ml Injection)
Coagulants
Tranexamic Acid
(1000mg/10ml
1
Injection, 650mg
Tablet)
Platelet Modifying Agents
Aggrenox (Capsule
Extended-Release 12
3
PA, QL
Hour)
Cilostazol (Tablet)
1
Clopidogrel (Tablet)
1
QL
Cardiovascular Agents
Alpha-adrenergic Agonists
Clonidine HCl (Tablet
1
Immediate-Release)
Methyldopa (Tablet)
1
PA, HRM
Alpha-adrenergic Blocking Agents
Doxazosin Mesylate
1
(Tablet)
Prazosin HCl (Capsule) 1
Angiotensin II Receptor Antagonists
Benicar (Tablet)
2
QL
Edarbi (Tablet)
3
QL
Irbesartan (Tablet)
1
QL
Losartan Potassium
1
QL
(Tablet)
Telmisartan (Tablet)
1
QL
Argatroban
Argatroban
Tranexamic Acid
PA
Aggrenox
Cilostazol
Aranesp Albumin Free
Clopidogrel
PA
Clonidine HCl
Methyldopa
Procrit
Doxazosin Mesylate
PA
Prazosin HCl
Benicar
Procrit
Edarbi
PA
Irbesartan
Losartan Potassium
Telmisartan
Bold type = Brand name drug
Drug
Tier
Required
Actions,
Restrictions
or Limits
Plain type = Generic drug
22
tRACK
12
12
Last updated August 1, 2016
Drug Name
Drug
Tier
23
Required
Actions,
Restrictions
or Limits
Valsartan (Tablet)
1
QL
Angiotensin-converting Enzyme (ACE)
Inhibitors
Benazepril HCl (Tablet) 1
QL
Valsartan
Benazepril HCl
Captopril (Tablet)
1
Enalapril Maleate
1
(Tablet)
Lisinopril (Tablet)
1
Quinapril HCl (Tablet)
1
Ramipril (Capsule)
1
Antiarrhythmics
Amiodarone HCl
1
(Tablet)
Multaq (Tablet)
2
Sotalol HCl, Sotalol
1
HCl AF (Tablet)
Beta-adrenergic Blocking Agents
Atenolol (Tablet)
1
Bisoprolol Fumarate
1
(Tablet)
Bystolic (Tablet)
2
Carvedilol (Tablet
1
Immediate-Release)
Metoprolol Succinate
ER (Tablet Extended1
Release 24 Hour)
Metoprolol Tartrate
(Tablet Immediate1
Release)
Nadolol (Tablet)
1
Captopril
QL
Enalapril Maleate
Lisinopril
Quinapril HCl
Ramipril
QL
QL
QL
QL
QL
Atenolol
Bisoprolol Fumarate
Carvedilol
Metoprolol Succinate ER
Metoprolol Tartrate
Nadolol
Propranolol HCl
(Tablet Immediate1
Release)
Propranolol HCl ER
(Capsule Extended1
Release 24 Hour)
Calcium Channel Blocking Agents
Amlodipine Besylate
1
(Tablet)
Diltiazem CD (240mg
Capsule Extended1
Release 24 Hour)
(Generic Cardizem CD)
Diltiazem HCl (Tablet
1
Immediate-Release)
Diltiazem HCl ER
(120mg Capsule
Extended-Release,
300mg Capsule
Extended-Release)
(Generic Cardizem
1
CD), (180mg Capsule
Extended-Release,
360mg Capsule
Extended-Release,
420mg Capsule
Extended-Release 24
Hour) (Generic Tiazac)
Verapamil HCl (Tablet
1
Immediate-Release)
Verapamil HCl ER
(Tablet Extended1
Release)
Cardiovascular Agents, Other
Propranolol HCl
Propranolol HCl ER
Diltiazem CD
Diltiazem HCl
Sotalol HCl, Sotalol HCl AF
Bystolic
Drug
Tier
Amlodipine Besylate
Amiodarone HCl
Multaq
Drug Name
Required
Actions,
Restrictions
or Limits
QL
Diltiazem HCl ER
Verapamil HCl
Verapamil HCl ER
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
23
tRACK
13
13
24
Drug Name
Amlodipine Besylate/
Benazepril HCl
(Capsule)
Benazepril HCl/
Hydrochlorothiazide
(Tablet)
Benicar HCT (Tablet)
Bisoprolol Fumarate/
Hydrochlorothiazide
(Tablet)
Digoxin (125mcg
Tablet)
Digoxin (250mcg
Tablet)
Edarbyclor (Tablet)
Enalapril Maleate/
Hydrochlorothiazide
(Tablet)
Irbesartan/
Hydrochlorothiazide
(Tablet)
Lisinopril/
Hydrochlorothiazide
(Tablet)
Losartan Potassium/
Hydrochlorothiazide
(Tablet)
Quinapril/
Hydrochlorothiazide
(Tablet)
Ranexa (Tablet
Extended-Release 12
Hour)
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Amlodipine Besylate/Benazepril HCl
1
QL
Triamterene/Hydrochlorothiazide
1
QL
2
QL
Tribenzor
Bisoprolol Fumarate/Hydrochlorothiazide
Valsartan/Hydrochlorothiazide
1
QL
1
QL, HRM
1
PA, HRM
3
QL
1
QL
1
QL
Digoxin
Digoxin
Edarbyclor
Enalapril Maleate/Hydrochlorothiazide
Irbesartan/Hydrochlorothiazide
Acetazolamide
Acetazolamide ER
Methazolamide
Bumetanide
Furosemide
Lisinopril/Hydrochlorothiazide
1
QL
Eplerenone
Spironolactone
Losartan Potassium/Hydrochlorothiazide
1
QL
Chlorthalidone
Quinapril/Hydrochlorothiazide
1
QL
2
QL
Ranexa
Bold type = Brand name drug
Drug
Tier
Telmisartan/
Hydrochlorothiazide
1
QL
(Tablet)
Triamterene/
Hydrochlorothiazide
1
(Capsule, Tablet)
Tribenzor (Tablet)
2
QL
Valsartan/
Hydrochlorothiazide
1
QL
(Tablet)
Diuretics, Carbonic Anhydrase Inhibitors
Acetazolamide (Tablet
1
Immediate-Release)
Acetazolamide ER
(Capsule Extended1
Release 12 Hour)
Methazolamide
1
(Tablet)
Diuretics, Loop
Bumetanide (Tablet)
1
Furosemide (Tablet)
1
Diuretics, Potassium-sparing
Eplerenone (Tablet)
1
Spironolactone
1
(Tablet)
Diuretics, Thiazide
Chlorthalidone (Tablet) 1
Hydrochlorothiazide
(12.5mg Capsule,
1
12.5mg Tablet, 25mg
Tablet, 50mg Tablet)
Dyslipidemics, Fibric Acid Derivatives
Telmisartan/Hydrochlorothiazide
Benazepril HCl/Hydrochlorothiazide
Benicar HCT
Drug Name
Required
Actions,
Restrictions
or Limits
Hydrochlorothiazide
Plain type = Generic drug
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Drug Name
Drug
Tier
25
Required
Actions,
Restrictions
or Limits
Fenofibrate (145mg
Tablet, 48mg Tablet)
(Generic Tricor),
1
Fenofibrate (160mg
Tablet, 54mg Tablet)
(Generic Lofibra)
Gemfibrozil (Tablet)
1
Dyslipidemics, HMG CoA Reductase
Inhibitors
Atorvastatin Calcium
1
QL
(Tablet)
Crestor (Tablet)
2
QL
Lovastatin (Tablet
1
QL
Immediate-Release)
Pravastatin Sodium
1
QL
(Tablet)
Rosuvastatin Calcium
1
QL
(Tablet)
Simvastatin (Tablet)
1
QL
Dyslipidemics, Other
Niacin ER (Tablet
1
Extended-Release)
Omega-3-Acid Ethyl
Esters (Capsule)
1
QL
(Generic Lovaza)
Vytorin (Tablet)
3
QL
Welchol (3.75gm
Packet, 625mg
2
Tablet)
Zetia (Tablet)
2
QL
Vasodilators, Direct-acting Arterial
Fenofibrate
Gemfibrozil
Atorvastatin Calcium
Crestor
Lovastatin
Pravastatin Sodium
Rosuvastatin Calcium
Simvastatin
Niacin ER
Omega-3-Acid Ethyl Esters
Vytorin
Welchol
Zetia
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Hydralazine HCl
1
(Tablet)
Minoxidil (Tablet)
1
Vasodilators, Direct-acting Arterial/Venous
Isosorbide Dinitrate,
Isosorbide Dinitrate ER 1
(Tablet)
Isosorbide
Mononitrate,
1
Isosorbide Mononitrate
ER (Tablet)
Nitrostat (Tablet
2
Sublingual)
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines
Amphetamine/
Dextroamphetamine
(Capsule Extended1
QL
Release 24 Hour,
Tablet ImmediateRelease)
Vyvanse (Capsule)
3
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetamines
Methylphenidate HCl
(Tablet Immediate1
QL
Release) (Generic
Ritalin)
Strattera (Capsule)
3
QL, ST
Central Nervous System, Other
Nuedexta (Capsule)
3
PA
Hydralazine HCl
Minoxidil
Isosorbide Dinitrate, Isosorbide Dinitrate ER
Isosorbide Mononitrate, Isosorbide Mononitrate ER
Nitrostat
Amphetamine/Dextroamphetamine
Vyvanse
Methylphenidate HCl
Strattera
Nuedexta
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
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Drug Name
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Riluzole (Tablet)
1
Fibromyalgia Agents
Duloxetine HCl (20mg
Capsule DelayedRelease, 30mg
Capsule Delayed1
Release, 60mg
Capsule DelayedRelease)
Lyrica (Capsule)
2
Savella (Tablet)
2
Multiple Sclerosis Agents
Aubagio (Tablet)
4
Avonex (Injection)
4
Betaseron (Injection)
4
Copaxone (Injection)
4
PA, QL
PA
PA
PA
4
4
PA, QL
PA
4
PA, QL
Duloxetine HCl
Imiquimod
Santyl
QL
Creon
QL
Zenpep
Savella
Aubagio
Avonex
Betaseron
Copaxone
Gilenya (Capsule)
Rebif (Injection)
Tecfidera (Capsule
Delayed-Release)
Dental and Oral Agents
Dental and Oral Agents
Chlorhexidine
Gluconate Oral Rinse
(Solution)
Pilocarpine HCl
(Tablet)
Dermatological Agents
Dermatological Agents
Gilenya
Rebif
Tecfidera
Dicyclomine HCl
Methscopolamine Bromide
Diphenoxylate/Atropine
Loperamide HCl
Chlorhexidine Gluconate Oral Rinse
Ursodiol
1
Pilocarpine HCl
Cimetidine
1
Cimetidine HCl
Famotidine
Ranitidine HCl
Bold type = Brand name drug
Drug
Tier
Ammonium Lactate
(12% Cream, 12%
1
Lotion)
Imiquimod (Cream)
1
Santyl (Ointment)
3
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
Creon (Capsule
2
Delayed-Release)
Zenpep (Capsule
2
Delayed-Release)
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
Dicyclomine HCl
(10mg Capsule, 20mg
1
Tablet)
Methscopolamine
1
Bromide (Tablet)
Gastrointestinal Agents, Other
Diphenoxylate/
1
Atropine (Tablet)
Loperamide HCl
1
(Capsule)
Ursodiol (Capsule,
1
Tablet)
Histamine2 (H2) Receptor Antagonists
Cimetidine (Tablet)
1
Cimetidine HCl (Oral
1
Solution)
Famotidine (Tablet)
1
Ranitidine HCl (Tablet)
1
Irritable Bowel Syndrome Agents
Ammonium Lactate
Riluzole
Lyrica
Drug Name
Required
Actions,
Restrictions
or Limits
Plain type = Generic drug
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27
Drug
Tier
Required
Actions,
Restrictions
or Limits
2
QL
Linzess (Capsule)
2
Laxatives
Lactulose (Oral
1
Solution)
Polyethylene Glycol
3350 Powder (Generic
1
MiraLAX)
Protectants
Carafate
3
(Suspension)
Misoprostol (Tablet)
1
Sucralfate (Tablet)
1
Proton Pump Inhibitors
Dexilant (Capsule
3
Delayed-Release)
Omeprazole (10mg
Capsule DelayedRelease, 40mg
1
Capsule DelayedRelease)
Omeprazole (20mg
Capsule Delayed1
Release)
Pantoprazole Sodium
(Tablet Delayed1
Release)
Genitourinary Agents
Antispasmodics, Urinary
Myrbetriq (Tablet
Extended-Release 24
2
Hour)
QL
Drug Name
Amitiza (Capsule)
Amitiza
Linzess
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Oxybutynin Chloride
ER (Tablet Extended1
QL
Release 24 Hour)
Vesicare (Tablet)
2
QL
Benign Prostatic Hypertrophy Agents
Alfuzosin HCl ER
(Tablet Extended1
Release 24 Hour)
Finasteride (5mg
Tablet) (Generic
1
Proscar)
Rapaflo (Capsule)
2
QL
Tamsulosin HCl
1
(Capsule)
Terazosin HCl
1
(Capsule)
Genitourinary Agents, Other
Bethanechol Chloride
1
(Tablet)
Elmiron (Capsule)
3
Phosphate Binders
Calcium Acetate
1
(Capsule)
Renagel (Tablet)
2
ST
Oxybutynin Chloride ER
Vesicare
Lactulose
Alfuzosin HCl ER
Polyethylene Glycol 3350 Powder
Finasteride
Carafate
Rapaflo
Misoprostol
Tamsulosin HCl
Sucralfate
Terazosin HCl
Dexilant
QL
Omeprazole
Bethanechol Chloride
QL
Elmiron
Calcium Acetate
Omeprazole
Renagel
Pantoprazole Sodium
Myrbetriq
Renvela (Tablet)
2
Hormonal Agents, Stimulant/Replacement/
Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/
Modifying (Adrenal)
Prednisone (5mg/5ml
1
Oral Solution, Tablet)
Renvela
QL
Prednisone
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
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28
Drug Name
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Triamcinolone
Acetonide (Cream,
1
Ointment)
Hormonal Agents, Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/
Modifying (Pituitary)
Desmopressin Acetate
1
(Tablet)
Genotropin (12mg
Injection, 5mg
4
PA
Injection)
Genotropin Miniquick
3
PA
(0.2mg Injection)
Genotropin Miniquick
(0.4mg Injection,
0.6mg Injection,
0.8mg Injection,
1.2mg Injection,
4
PA
1.4mg Injection,
1.6mg Injection,
1.8mg Injection, 1mg
Injection, 2mg
Injection)
Nutropin AQ
4
PA
(Injection)
Hormonal Agents, Stimulant/Replacement/
Modifying (Prostaglandins)
Hormonal Agents, Stimulant/Replacement/
Modifying (Prostaglandins)
Korlym (Tablet)
4
PA, QL
Hormonal Agents, Stimulant/Replacement/
Modifying (Sex Hormones/Modifiers)
Triamcinolone Acetonide
Desmopressin Acetate
Genotropin
Genotropin Miniquick
Genotropin Miniquick
Nutropin AQ
Korlym
Bold type = Brand name drug
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Androgens
Androderm (Patch 24
2
PA, QL
Hour)
AndroGel (1.62%
2
PA
Packet, 1.62% Pump)
Testosterone
1
Cypionate (Injection)
Estrogens
Estradiol Tablet
1
PA, HRM
(Generic Estrace)
Premarin (Vaginal
2
Cream)
Progestins
Medroxyprogesterone
1
Acetate (Tablet)
Norethindrone Acetate
1
(Tablet)
Progesterone
1
PA
(Capsule)
Selective Estrogen Receptor Modifying
Agents
Raloxifene HCl (Tablet) 1
QL
Hormonal Agents, Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/
Modifying (Thyroid)
Levothyroxine Sodium
1
(Tablet)
Liothyronine Sodium
1
(Tablet)
Synthroid (Tablet)
2
Hormonal Agents, Suppressant (Adrenal)
Androderm
AndroGel
Testosterone Cypionate
Estradiol Tablet
Premarin
Medroxyprogesterone Acetate
Norethindrone Acetate
Progesterone
Raloxifene HCl
Levothyroxine Sodium
Liothyronine Sodium
Synthroid
Plain type = Generic drug
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Drug Name
Drug
Tier
29
Required
Actions,
Restrictions
or Limits
Hormonal Agents, Suppressant (Adrenal)
Lysodren (Tablet)
2
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant
(Parathyroid)
Sensipar (30mg
2
QL
Tablet)
Sensipar (60mg
4
QL
Tablet, 90mg Tablet)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
Cabergoline (Tablet)
1
Lupron Depot
4
PA
(Injection)
Lupron Depot-PED
4
PA
(Injection)
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
Methimazole (Tablet)
1
Propylthiouracil
1
(Tablet)
Immunological Agents
Angioedema (HAE) Agents
Cinryze (Injection)
4
PA, LA
Lysodren
Sensipar
Sensipar
Cabergoline
Lupron Depot
Lupron Depot-PED
Methimazole
Propylthiouracil
Cinryze
Firazyr (Injection)
4
Immune Suppressants
Azathioprine (Tablet)
1
Enbrel (Injection)
4
Humira (Injection)
4
Methotrexate (Tablet)
1
Immunizing Agents, Passive
Firazyr
Azathioprine
Enbrel
Humira
Methotrexate
PA, QL
B/D, PA
PA
PA
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Gammagard Liquid
4
(Injection)
Thymoglobulin
4
(Injection)
Immunomodulators
Benlysta (Injection)
4
Leflunomide (Tablet)
1
Vaccines
Adacel (Injection)
2
Zostavax (Injection)
3
Inflammatory Bowel Disease Agents
Aminosalicylates
Apriso (Capsule
Extended-Release 24
2
Hour)
Balsalazide Disodium
1
(Capsule)
Lialda (Tablet
2
Delayed-Release)
Glucocorticoids
Budesonide (Capsule
1
Delayed-Release)
Proctosol HC (Cream)
1
Sulfonamides
Sulfasalazine (500mg
Tablet Delayed1
Release, 500mg Tablet
Immediate-Release)
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
Alendronate Sodium
1
(Tablet)
Gammagard Liquid
PA
Thymoglobulin
Benlysta
PA
Leflunomide
Adacel
Zostavax
PA
Apriso
QL
Balsalazide Disodium
Lialda
QL
Budesonide
Proctosol HC
Sulfasalazine
Alendronate Sodium
QL
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
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30
Drug Name
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Calcitriol (Capsule)
1
B/D, PA
Ibandronate Sodium
1
QL
(Tablet)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Alcohol Prep Pads
2
Insulin Syringes,
2
Needles
Ophthalmic Agents
Ophthalmic Agents, Other
Lastacaft (Ophthalmic
2
Solution)
Restasis (Emulsion)
2
QL
Tobramycin/
Dexamethasone
1
(Ophthalmic
Suspension)
Ophthalmic Anti-allergy Agents
Azelastine HCl (0.05%
1
Ophthalmic Solution)
Pataday (Ophthalmic
2
Solution)
Pazeo (Ophthalmic
2
Solution)
Ophthalmic Antiglaucoma Agents
Azopt (Suspension)
2
Brimonidine Tartrate
(0.15% Ophthalmic
1
Solution)
Brimonidine Tartrate
(0.2% Ophthalmic
1
Solution)
Calcitriol
Ibandronate Sodium
Alcohol Prep Pads
Insulin Syringes, Needles
Lastacaft
Restasis
Tobramycin/Dexamethasone
Azelastine HCl
Pataday
Pazeo
Azopt
Brimonidine Tartrate
Brimonidine Tartrate
Bold type = Brand name drug
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Combigan
2
(Ophthalmic Solution)
Dorzolamide HCl/
Timolol Maleate
1
(Ophthalmic Solution)
Simbrinza
2
(Suspension)
Timolol Maleate
Ophthalmic Gel
1
Forming (Solution)
Ophthalmic Anti-inflammatories
Durezol (Emulsion)
2
Ilevro (Suspension)
2
Ketorolac
Tromethamine
1
(Ophthalmic Solution)
Lotemax (0.5% Gel,
0.5% Ointment, 0.5%
3
Suspension)
Nevanac
2
(Suspension)
Prednisolone Acetate
(Ophthalmic
1
Suspension)
Prolensa (Ophthalmic
3
Solution)
Ophthalmic Prostaglandin and Prostamide
Analogs
Latanoprost
1
(Ophthalmic Solution)
Lumigan (Ophthalmic
2
Solution)
Combigan
Dorzolamide HCl/Timolol Maleate
Simbrinza
Timolol Maleate Ophthalmic Gel Forming
Durezol
Ilevro
Ketorolac Tromethamine
Lotemax
Nevanac
Prednisolone Acetate
Prolensa
Latanoprost
Lumigan
Plain type = Generic drug
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Drug Name
Drug
Tier
31
Required
Actions,
Restrictions
or Limits
Travatan Z
2
(Ophthalmic Solution)
Otic Agents
Otic Agents
Ciprodex (Otic
2
Suspension)
Fluocinolone
1
Acetonide (Otic Oil)
Respiratory Tract/Pulmonary Agents
Antihistamines
Azelastine HCl (0.1%
1
QL
Nasal Solution)
Azelastine HCl (0.15%
1
Nasal Solution)
Levocetirizine
Dihydrochloride
1
QL
(Tablet)
Promethazine HCl
1
PA, HRM
(Tablet)
Anti-inflammatories, Inhaled
Corticosteroids
Arnuity Ellipta
2
QL
(Aerosol Powder)
Flovent Diskus,
2
QL
Flovent HFA (Aerosol)
Fluticasone Propionate
1
(Suspension)
Nasonex
3
PA
(Suspension)
Pulmicort Flexhaler
3
QL, ST
(Aerosol Powder)
Antileukotrienes
Travatan Z
Ciprodex
Fluocinolone Acetonide
Azelastine HCl
Azelastine HCl
Levocetirizine Dihydrochloride
Promethazine HCl
Arnuity Ellipta
Flovent Diskus, Flovent HFA
Fluticasone Propionate
Nasonex
Pulmicort Flexhaler
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Montelukast Sodium
(Packet, Tablet, Tablet
1
QL
Chewable)
Zafirlukast (Tablet)
1
QL
Bronchodilators, Anticholinergic
Atrovent HFA
3
(Aerosol Solution)
Incruse Ellipta
2
QL
(Aerosol Powder)
Ipratropium Bromide
(0.02% Inhalation
1
B/D, PA
Solution)
Ipratropium Bromide
(0.03% Nasal Solution,
1
0.06% Nasal Solution)
Spiriva HandiHaler
2
QL
(Capsule)
Spiriva Respimat
2
QL
(Aerosol Solution)
Bronchodilators, Sympathomimetic
EpiPen (Injection)
2
Perforomist
3
B/D, PA, QL
(Nebulized Solution)
ProAir HFA (Aerosol
2
Solution)
ProAir RespiClick
2
(Aerosol Powder)
Serevent Diskus
2
QL
(Aerosol Powder)
Cystic Fibrosis Agents
Cayston (Inhalation
4
PA, LA
Solution)
Montelukast Sodium
Zafirlukast
Atrovent HFA
Incruse Ellipta
Ipratropium Bromide
Ipratropium Bromide
Spiriva HandiHaler
Spiriva Respimat
EpiPen
Perforomist
ProAir HFA
ProAir RespiClick
Serevent Diskus
Cayston
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
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Drug Name
Last updated August 1, 2016
Drug
Tier
Required
Actions,
Restrictions
or Limits
Kalydeco (Packet)
4
PA, QL
Phosphodiesterase Inhibitors, Airways
Disease
Daliresp (Tablet)
3
PA, QL
Theophylline (Oral
Solution), Theophylline
CR (Tablet),
1
Theophylline ER
(Tablet)
Pulmonary Antihypertensives
Adcirca (Tablet)
4
PA, QL
Opsumit (Tablet)
4
PA, LA
Orenitram (0.125mg
Tablet Extended3
PA, QL
Release)
Orenitram (0.25mg
Tablet Extended4
PA, QL
Release, 1mg Tablet
Extended-Release)
Orenitram (2.5mg
Tablet Extended4
PA
Release)
Sildenafil (20mg
Tablet) (Generic
1
PA, QL
Revatio)
Respiratory Tract Agents, Other
Advair Diskus, Advair
2
QL
HFA (Aerosol)
Anoro Ellipta (Aerosol
2
QL
Powder)
Breo Ellipta (Aerosol
2
QL
Powder)
Kalydeco
Daliresp
Theophylline
Adcirca
Opsumit
Orenitram
Orenitram
Orenitram
Sildenafil
Advair Diskus, Advair HFA
Anoro Ellipta
Breo Ellipta
Bold type = Brand name drug
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Stiolto Respimat
2
QL
(Aerosol Solution)
Symbicort (Aerosol)
2
QL
Respiratory Tract/Pulmonary Agents
Combivent Respimat
2
(Aerosol Solution)
Dymista (Suspension) 3
Ipratropium Bromide/
Albuterol Sulfate
1
B/D, PA
(Inhalation Solution)
Xolair (Injection)
4
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
Baclofen (Tablet)
1
Tizanidine HCl (Tablet) 1
Sleep Disorder Agents
GABA Receptor Modulators
Zolpidem Tartrate
PA, QL,
(Tablet Immediate1
HRM
Release)
Sleep Disorders, Other
Belsomra (Tablet)
2
QL
Modafinil (Tablet)
1
PA, QL
Stiolto Respimat
Symbicort
Combivent Respimat
Dymista
Ipratropium Bromide/Albuterol Sulfate
Xolair
Baclofen
Tizanidine HCl
Zolpidem Tartrate
Belsomra
Modafinil
Nuvigil (Tablet)
3
PA, QL
Rozerem (Tablet)
3
QL
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
Exjade (Tablet
4
PA
Soluble)
Sodium Polystyrene
1
Sulfonate (Suspension)
Nuvigil
Rozerem
Exjade
Sodium Polystyrene Sulfonate
Plain type = Generic drug
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Drug Name
Drug
Tier
33
Required
Actions,
Restrictions
or Limits
Electrolyte/Mineral Replacement
Carbaglu (Tablet)
4
Klor-Con 10 (Tablet
1
Extended-Release)
Klor-Con 8 (Tablet
1
Extended-Release)
Klor-Con M20 (Tablet
1
Extended-Release)
Carbaglu
Klor-Con 10
Klor-Con 8
Klor-Con M20
Drug Name
Drug
Tier
Required
Actions,
Restrictions
or Limits
Potassium Chloride ER
(Capsule Extended1
Release, Tablet
Extended-Release)
Potassium Citrate ER
(Tablet Extended1
Release)
Therapeutic Nutrients/Minerals/
Electrolytes
Dextrose 5%/NaCl
1
(Injection)
Levocarnitine (Tablet)
1
B/D, PA
Potassium Chloride ER
LA
Potassium Citrate ER
Dextrose 5%/NaCl
Levocarnitine
You can find information on what the symbols and abbreviations in this table mean by going to
page 7.
33
track
34
Drugs with a quantity limit (QL)
This list shows drugs that have a quantity limit. Your plan will cover only a certain amount of these
drugs for one co-pay/co-insurance or will only cover these drugs for a certain number of days.
These limits may be in place to ensure your safety.
Drugs are listed in alphabetical order in the chart below. Some drugs come in many strengths.
Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the
different strengths are listed on separate lines.
For more information about quantity limits, talk to your doctor or pharmacist. You can also contact
us by calling Customer Service toll-free at 877-246-4190, TTY 711, 8 a.m. - 8 p.m. local time,
Monday - Friday. The date we last updated the drug list is on the cover.
Drug Name
Quantity Limit
Acetaminophen/Codeine (Tablet)
Adcirca (Tablet)
Advair Diskus (Aerosol Powder)
Advair HFA (Aerosol)
Aggrenox (Capsule Extended-Release 12
Hour)
Albenza (Tablet)
Alendronate Sodium (10mg Tablet, 40mg
Tablet, 5mg Tablet)
Alendronate Sodium (35mg Tablet)
Alendronate Sodium (70mg Tablet)
Alprazolam (0.25mg Tablet Immediate-Release,
0.5mg Tablet Immediate-Release, 1mg Tablet
Immediate-Release)
Alprazolam (2mg Tablet Immediate-Release)
Amitiza (Capsule)
Amlodipine Besylate/Benazepril HCl (Capsule)
Amphetamine/Dextroamphetamine ER
(Capsule Extended-Release 24 Hour)
Amphetamine/Dextroamphetamine (10mg
Tablet Immediate-Release, 12.5mg Tablet
Immediate-Release, 15mg Tablet ImmediateRelease, 30mg Tablet Immediate-Release, 5mg
Tablet Immediate-Release, 7.5mg Tablet
Immediate-Release)
Amphetamine/Dextroamphetamine (20mg
Tablet Immediate-Release)
Maximum of 13 tablets per day
Maximum of 2 tablets per day
Maximum of 1 inhaler (60 blisters) per 30 days
Maximum of 1 inhaler (12 grams) per 30 days
Bold type = Brand name drug
Maximum of 2 capsules per day
Maximum of 16 tablets per day
Maximum of 1 tablet per day
Maximum of 8 tablets per 28 days
Maximum of 4 tablets per 28 days
Maximum of 4 tablets per day
Maximum of 5 tablets per day
Maximum of 2 capsules per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Plain type = Generic drug
34
35
Drug Name
Quantity Limit
Androderm (Patch 24 Hour)
Anoro Ellipta (Aerosol Powder)
Apriso (Capsule Extended-Release 24 Hour)
Arnuity Ellipta (Aerosol Powder)
Atorvastatin Calcium (Tablet)
Atripla (Tablet)
Aubagio (Tablet)
Azelastine HCl (0.1% Nasal Solution)
Belsomra (Tablet)
Benazepril HCl (Tablet)
Benazepril HCl/Hydrochlorothiazide (Tablet)
Benicar (20mg Tablet, 40mg Tablet)
Benicar (5mg Tablet)
Benicar HCT (Tablet)
Bisoprolol Fumarate/Hydrochlorothiazide
(Tablet)
Breo Ellipta (Aerosol Powder)
Buprenorphine HCl (2mg Tablet Sublingual,
8mg Tablet Sublingual)
Butrans (Patch Weekly)
Bydureon (Injection)
Byetta (10mcg/0.04ml Solution Pen injector)
Byetta (5mcg/0.02ml Solution Pen injector)
Bystolic (10mg Tablet, 2.5mg Tablet, 5mg
Tablet)
Bystolic (20mg Tablet)
Captopril (100mg Tablet)
Captopril (12.5mg Tablet, 25mg Tablet)
Captopril (50mg Tablet)
Celecoxib (Capsule)
Clonazepam (0.5mg Tablet Immediate-Release,
1mg Tablet Immediate-Release)
Clonazepam (2mg Tablet Immediate-Release)
Clonazepam ODT (0.125mg Tablet Dispersible,
0.25mg Tablet Dispersible, 0.5mg Tablet
Dispersible, 1mg Tablet Dispersible)
Clonazepam ODT (2mg Tablet Dispersible)
Maximum of 1 patch per day
Maximum of 1 inhaler (60 blisters) per 30 days
Maximum of 4 capsules per day
Maximum of 1 inhaler (30 blisters) per 30 days
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 bottles (60 ml) per 30 days
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Bold type = Brand name drug
Maximum of 2 tablets per day
Maximum of 1 inhaler (60 blisters) per 30 days
Maximum of 3 tablets per day
Maximum of 4 patches per 28 days
Maximum of 4 vials per 28 days
Maximum of 1 pen (2.4 ml) per 30 days
Maximum of 1 pen (1.2 ml) per 30 days
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 3 tablets per day
Maximum of 9 tablets per day
Maximum of 2 capsules per day
Maximum of 4 tablets per day
Maximum of 10 tablets per day
Maximum of 4 tablets per day
Maximum of 10 tablets per day
Plain type = Generic drug
35
36
Drug Name
Quantity Limit
Clopidogrel (300mg Tablet)
Clopidogrel (75mg Tablet)
Clozapine ODT (100mg Tablet Dispersible)
Clozapine ODT (12.5mg Tablet Dispersible)
Clozapine ODT (25mg Tablet Dispersible)
Colchicine (0.6mg Tablet) (Generic Colcrys)
Crestor (Tablet)
Daklinza (Tablet)
Daliresp (Tablet)
Dexilant (Capsule Delayed-Release)
Diazepam (Tablet Immediate-Release)
Diazepam Intensol (5mg/ml Concentrate)
Digoxin (125mcg Tablet)
Donepezil HCl (10mg Tablet ImmediateRelease)
Donepezil HCl (23mg Tablet ImmediateRelease, 5mg Tablet Immediate-Release)
Donepezil HCl ODT (10mg Tablet Dispersible)
Donepezil HCl ODT (5mg Tablet Dispersible)
Dronabinol (Capsule)
Duloxetine HCl (20mg Capsule DelayedRelease, 30mg Capsule Delayed-Release, 60mg
Capsule Delayed-Release)
Edarbi (Tablet)
Edarbyclor (Tablet)
Eliquis (Tablet)
Embeda (100mg-4mg Capsule ExtendedRelease)
Embeda (20mg-0.8mg Capsule ExtendedRelease, 80mg-3.2mg Capsule ExtendedRelease)
Embeda (30mg-1.2mg Capsule ExtendedRelease, 50mg-2mg Capsule ExtendedRelease)
Embeda (60mg-2.4mg Capsule ExtendedRelease)
Enalapril Maleate (Tablet)
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 9 tablets per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 4 tablets per day
Maximum of 8 ml per day
Maximum of 1 tablet per day
Bold type = Brand name drug
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 capsules per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 3 capsules per day
Maximum of 4 capsules per day
Maximum of 2 capsules per day
Maximum of 6 capsules per day
Maximum of 2 tablets per day
Plain type = Generic drug
36
37
Drug Name
Quantity Limit
Enalapril Maleate/Hydrochlorothiazide
(10mg-25mg Tablet)
Enalapril Maleate/Hydrochlorothiazide
(5mg-12.5mg Tablet)
Epzicom (Tablet)
Farxiga (Tablet)
Fentanyl (Patch 72 Hour)
Firazyr (Injection)
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Flovent Diskus (Aerosol Powder)
Flovent HFA (110mcg/ACT Aerosol)
Flovent HFA (220mcg/ACT Aerosol)
Flovent HFA (44mcg/ACT Aerosol)
Fuzeon (Injection)
Gilenya (Capsule)
Gleevec (Tablet)
Glimepiride (1mg Tablet)
Glimepiride (2mg Tablet)
Glimepiride (4mg Tablet)
Glipizide (10mg Tablet Immediate-Release)
Glipizide (5mg Tablet Immediate-Release)
Glipizide ER (10mg Tablet Extended-Release 24
Hour)
Glipizide ER (2.5mg Tablet Extended-Release
24 Hour)
Glipizide ER (5mg Tablet Extended-Release 24
Hour)
Harvoni (Tablet)
Hydrocodone/Acetaminophen (10mg-325mg
Tablet, 2.5mg-325mg Tablet, 5mg-325mg
Tablet, 7.5mg-325mg Tablet)
Hydromorphone HCl (2mg Tablet ImmediateRelease, 4mg Tablet Immediate-Release)
Hydromorphone HCl (8mg Tablet ImmediateRelease)
Ibandronate Sodium (150mg Tablet)
Incruse Ellipta (Aerosol Powder)
Intelence (100mg Tablet)
Bold type = Brand name drug
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 15 patches per 30 days
Maximum of 9 ml per day
Maximum of 2 inhalers (120 blisters) per 30
days
Maximum of 1 inhaler (12 grams) per 30 days
Maximum of 2 inhalers (24 grams) per 30 days
Maximum of 1 inhaler (10.6 grams) per 30 days
Maximum of 3 vials per day
Maximum of 1 pack (30 capsules) per 30 days
Maximum of 3 tablets per day
Maximum of 8 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 8 tablets per day
Maximum of 2 tablets per day
Maximum of 8 tablets per day
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 12 tablets per day
Maximum of 8 tablets per day
Maximum of 11 tablets per day
Maximum of 1 tablet per 28 days
Maximum of 1 inhaler (30 blisters) per 30 days
Maximum of 2 tablets per day
Plain type = Generic drug
37
38
Drug Name
Quantity Limit
Intelence (200mg Tablet)
Invokamet (Tablet)
Invokana (Tablet)
Irbesartan (150mg Tablet, 300mg Tablet)
Irbesartan (75mg Tablet)
Irbesartan/Hydrochlorothiazide (Tablet)
Isentress (Tablet)
Janumet (Tablet Immediate-Release)
Janumet XR (Tablet Extended-Release 24
Hour)
Januvia (Tablet)
Jardiance (Tablet)
Jentadueto (Tablet)
Kalydeco (Packet)
Kazano (Tablet)
Kombiglyze XR (2.5mg-1000mg Tablet
Extended-Release 24 Hour)
Kombiglyze XR (5mg-1000mg Tablet
Extended-Release 24 Hour, 5mg-500mg
Tablet Extended-Release 24 Hour)
Korlym (Tablet)
Latuda (120mg Tablet, 20mg Tablet, 40mg
Tablet, 60mg Tablet)
Latuda (80mg Tablet)
Levocetirizine Dihydrochloride (5mg Tablet)
Lialda (Tablet Delayed-Release)
Linzess (Capsule)
Lisinopril (Tablet)
Lisinopril/Hydrochlorothiazide (10mg-12.5mg
Tablet)
Lisinopril/Hydrochlorothiazide (20mg-12.5mg
Tablet)
Lisinopril/Hydrochlorothiazide (20mg-25mg
Tablet)
Lorazepam (0.5mg Tablet, 1mg Tablet)
Lorazepam (2mg Tablet)
Lorazepam Intensol (2mg/ml Concentrate)
Losartan Potassium (100mg Tablet)
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Bold type = Brand name drug
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 packets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 1 capsule per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 5 tablets per day
Maximum of 5 ml per day
Maximum of 1 tablet per day
Plain type = Generic drug
38
39
Drug Name
Quantity Limit
Losartan Potassium (25mg Tablet, 50mg
Tablet)
Losartan Potassium/Hydrochlorothiazide
(100mg-12.5mg Tablet, 100mg-25mg Tablet)
Losartan Potassium/Hydrochlorothiazide
(50mg-12.5mg Tablet)
Lovastatin (10mg Tablet Immediate-Release,
20mg Tablet Immediate-Release)
Lovastatin (40mg Tablet Immediate-Release)
Lyrica (100mg Capsule, 150mg Capsule,
200mg Capsule, 25mg Capsule, 50mg
Capsule, 75mg Capsule)
Lyrica (225mg Capsule, 300mg Capsule)
Memantine HCl (10mg Tablet)
Memantine HCl (5mg Tablet)
Metformin HCl (1000mg Tablet ImmediateRelease)
Metformin HCl (500mg Tablet ImmediateRelease)
Metformin HCl (850mg Tablet ImmediateRelease)
Metformin HCl ER (1000mg Tablet ExtendedRelease 24 Hour) (Generic Fortamet)
Metformin HCl ER (500mg Tablet ExtendedRelease 24 Hour) (Generic Glucophage XR)
Metformin HCl ER (750mg Tablet ExtendedRelease 24 Hour) (Generic Glucophage XR)
Methadone HCl (10mg Tablet)
Methadone HCl (10mg/5ml Oral Solution)
Methadone HCl (5mg Tablet)
Methadone HCl (5mg/5ml Oral Solution)
Methylphenidate HCl (Tablet ImmediateRelease) (Generic Ritalin)
Modafinil (100mg Tablet)
Modafinil (200mg Tablet)
Montelukast Sodium (10mg Tablet)
Montelukast Sodium (4mg Packet)
Montelukast Sodium (4mg Tablet Chewable,
5mg Tablet Chewable)
Bold type = Brand name drug
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 3 capsules per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 2.5 tablets per day
Maximum of 5 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 12 tablets per day
Maximum of 60 ml per day
Maximum of 8 tablets per day
Maximum of 120 ml per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 packet per day
Maximum of 1 tablet per day
Plain type = Generic drug
39
40
Drug Name
Quantity Limit
Morphine Sulfate ER (100mg Tablet ExtendedRelease, 15mg Tablet Extended-Release)
(Generic MS Contin)
Morphine Sulfate ER (200mg Tablet ExtendedRelease) (Generic MS Contin)
Morphine Sulfate ER (30mg Tablet ExtendedRelease, 60mg Tablet Extended-Release)
(Generic MS Contin)
Multaq (Tablet)
Namenda (10mg Tablet Immediate-Release)
Namenda (10mg/5ml Oral Solution)
Namenda (5mg Tablet Immediate-Release)
Namenda XR (Capsule Extended-Release 24
Hour)
Nesina (Tablet)
Nitrofurantoin Monohydrate (100mg Capsule)
(Generic Macrobid)
Norvir (100mg Capsule)
Norvir (100mg Tablet)
Norvir (80mg/ml Oral Solution)
Nucynta ER (Tablet Extended-Release 12
Hour)
Nuvigil (150mg Tablet, 200mg Tablet, 250mg
Tablet)
Nuvigil (50mg Tablet)
Olanzapine (Tablet Immediate-Release)
Omega-3-Acid Ethyl Esters (Capsule) (Generic
Lovaza)
Omeprazole (10mg Capsule Delayed-Release)
Omeprazole (40mg Capsule Delayed-Release)
Onglyza (Tablet)
Opana ER (10mg Tablet Extended-Release 12
Hour Abuse-Deterrent, 15mg Tablet
Extended-Release 12 Hour Abuse-Deterrent,
20mg Tablet Extended-Release 12 Hour
Abuse-Deterrent, 5mg Tablet ExtendedRelease 12 Hour Abuse-Deterrent, 7.5mg
Tablet Extended-Release 12 Hour AbuseDeterrent)
Bold type = Brand name drug
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 10 ml per day
Maximum of 3 tablets per day
Maximum of 1 capsule per day
Maximum of 1 tablet per day
Maximum of 90 days of use per year
Maximum of 18 capsules per day
Maximum of 18 tablets per day
Maximum of 24 ml per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 4 capsules per day
Maximum of 3 capsules per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Plain type = Generic drug
40
41
Drug Name
Quantity Limit
Opana ER (30mg Tablet Extended-Release 12
Hour Abuse-Deterrent)
Opana ER (40mg Tablet Extended-Release 12
Hour Abuse-Deterrent)
Orenitram (0.125mg Tablet ExtendedRelease, 0.25mg Tablet Extended-Release,
1mg Tablet Extended-Release)
Oseni (Tablet)
Oxybutynin Chloride ER (10mg Tablet
Extended-Release 24 Hour, 15mg Tablet
Extended-Release 24 Hour)
Oxybutynin Chloride ER (5mg Tablet ExtendedRelease 24 Hour)
Oxycodone HCl (10mg Tablet ImmediateRelease, 20mg Tablet Immediate-Release, 5mg
Tablet Immediate-Release)
Oxycodone HCl (15mg Tablet ImmediateRelease)
Oxycodone HCl (30mg Tablet ImmediateRelease)
Oxycodone/Acetaminophen (10mg-325mg
Tablet, 2.5mg-325mg Tablet, 5mg-325mg
Tablet, 7.5mg-325mg Tablet)
OxyContin (Tablet Extended-Release 12 Hour
Abuse-Deterrent)
Pantoprazole Sodium (20mg Tablet DelayedRelease)
Pantoprazole Sodium (40mg Tablet DelayedRelease)
Perforomist (Nebulized Solution)
Pioglitazone HCl (15mg Tablet)
Pioglitazone HCl (30mg Tablet, 45mg Tablet)
Pomalyst (Capsule)
Pradaxa (Capsule)
Pravastatin Sodium (Tablet)
Prezista (100mg/ml Suspension)
Prezista (150mg Tablet)
Prezista (600mg Tablet, 800mg Tablet)
Bold type = Brand name drug
Maximum of 4 tablets per day
Maximum of 3 tablets per day
Maximum of 6 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 12 tablets per day
Maximum of 16 tablets per day
Maximum of 8 tablets per day
Maximum of 12 tablets per day
Maximum of 3 tablets per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 2 vials (4 ml) per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 60 ml per day
Maximum of 6 tablets per day
Maximum of 3 tablets per day
Plain type = Generic drug
41
42
Drug Name
Quantity Limit
Pristiq (100mg Tablet Extended-Release 24
Hour)
Pristiq (25mg Tablet Extended-Release 24
Hour, 50mg Tablet Extended-Release 24
Hour)
Pulmicort Flexhaler (Aerosol Powder)
Quetiapine Fumarate (100mg Tablet ImmediateRelease, 200mg Tablet Immediate-Release,
50mg Tablet Immediate-Release)
Quetiapine Fumarate (25mg Tablet ImmediateRelease)
Quetiapine Fumarate (300mg Tablet ImmediateRelease, 400mg Tablet Immediate-Release)
Quinapril HCl (Tablet)
Quinapril/Hydrochlorothiazide (10mg-12.5mg
Tablet)
Quinapril/Hydrochlorothiazide (20mg-12.5mg
Tablet, 20mg-25mg Tablet)
Raloxifene HCl (Tablet)
Ramipril (Capsule)
Ranexa (Tablet Extended-Release 12 Hour)
Rapaflo (Capsule)
Restasis (Emulsion)
Revlimid (Capsule)
Reyataz (150mg Capsule, 300mg Capsule)
Reyataz (200mg Capsule)
Reyataz (50mg Packet)
Rivastigmine Tartrate (Capsule ImmediateRelease)
Rizatriptan Benzoate (Tablet ImmediateRelease)
Rizatriptan Benzoate ODT (Tablet Dispersible)
Rosuvastatin Calcium (Tablet)
Rozerem (Tablet)
Saphris (Tablet Sublingual)
Selzentry (150mg Tablet)
Selzentry (300mg Tablet)
Sensipar (30mg Tablet, 60mg Tablet)
Bold type = Brand name drug
Maximum of 4 tablets per day
Maximum of 1 tablet per day
Maximum of 2 inhalers per 30 days
Maximum of 3 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 capsules per day
Maximum of 2 tablets per day
Maximum of 1 capsule per day
Maximum of 2 vials per day
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 3 capsules per day
Maximum of 8 packets per day
Maximum of 2 capsules per day
Maximum of 12 tablets per 30 days
Maximum of 12 tablets per 30 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 6 tablets per day
Maximum of 2 tablets per day
Plain type = Generic drug
42
43
Drug Name
Quantity Limit
Sensipar (90mg Tablet)
Maximum of 4 tablets per day
Maximum of 1 inhaler (60 inhalations) per 30
days
Serevent Diskus (Aerosol Powder)
Seroquel XR (150mg Tablet ExtendedRelease 24 Hour, 200mg Tablet ExtendedRelease 24 Hour)
Seroquel XR (300mg Tablet ExtendedRelease 24 Hour, 400mg Tablet ExtendedRelease 24 Hour, 50mg Tablet ExtendedRelease 24 Hour)
Sildenafil (20mg Tablet) (Generic Revatio)
Simvastatin (Tablet)
Sovaldi (Tablet)
Spiriva HandiHaler (Capsule)
Spiriva Respimat (Aerosol Solution)
Sprycel (100mg Tablet, 140mg Tablet, 70mg
Tablet)
Sprycel (20mg Tablet, 50mg Tablet)
Sprycel (80mg Tablet)
Stiolto Respimat (Aerosol Solution)
Strattera (100mg Capsule, 60mg Capsule,
80mg Capsule)
Strattera (10mg Capsule, 18mg Capsule,
25mg Capsule, 40mg Capsule)
Suboxone (12mg-3mg Film, 4mg-1mg Film)
Suboxone (2mg-0.5mg Film, 8mg-2mg Film)
Sumatriptan Succinate (Tablet)
Symbicort (Aerosol)
Synjardy (Tablet)
Tamiflu (30mg Capsule, 45mg Capsule,
75mg Capsule)
Tamiflu (6mg/ml Suspension)
Tasigna (150mg Capsule)
Tasigna (200mg Capsule)
Tecfidera (Capsule Delayed-Release)
Telmisartan (Tablet)
Telmisartan/Hydrochlorothiazide (Tablet)
Tivicay (Tablet)
Bold type = Brand name drug
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 3 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 capsule per day
Maximum of 1 inhaler (4 grams) per 30 days
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Maximum of 2 tablets per day
Maximum of 1 inhaler (4 grams) per 30 days
Maximum of 1 capsule per day
Maximum of 2 capsules per day
Maximum of 2 sublingual films per day
Maximum of 3 sublingual films per day
Maximum of 9 tablets per 30 days
Maximum of 1 inhaler (10.2 grams) per 30 days
Maximum of 2 tablets per day
Maximum of 2 capsules per day
Maximum of 26 ml per day
Maximum of 5 capsules per day
Maximum of 4 capsules per day
Maximum of 2 capsules per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 tablets per day
Plain type = Generic drug
43
44
Drug Name
Quantity Limit
Tradjenta (Tablet)
Tramadol HCl (Tablet Immediate-Release)
Tramadol HCl/Acetaminophen (Tablet)
Tribenzor (Tablet)
Trintellix (Tablet)
Trulicity (Injection)
Truvada (Tablet)
Valacyclovir HCl (1000mg Tablet)
Valacyclovir HCl (500mg Tablet)
Valganciclovir (Tablet)
Valsartan (160mg Tablet, 40mg Tablet, 80mg
Tablet)
Valsartan (320mg Tablet)
Valsartan/Hydrochlorothiazide (Tablet)
Vesicare (Tablet)
Victoza (Injection)
Viread (150mg Tablet)
Viread (200mg Tablet, 250mg Tablet, 300mg
Tablet)
Viread (40mg/gm Powder)
Vytorin (Tablet)
Xarelto (10mg Tablet, 20mg Tablet)
Xarelto (15mg Tablet)
Xigduo XR (10mg-1000mg Tablet ExtendedRelease 24 Hour, 10mg-500mg Tablet
Extended-Release 24 Hour, 5mg-500mg
Tablet Extended-Release 24 Hour)
Xigduo XR (5mg-1000mg Tablet ExtendedRelease 24 Hour)
Zafirlukast (Tablet)
Zepatier (Tablet)
Zetia (Tablet)
Zolpidem Tartrate (Tablet Immediate-Release)
Zytiga (Tablet)
Maximum of 1 tablet per day
Maximum of 8 tablets per day
Maximum of 12 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 4 pens (2 ml) per 28 days
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 4 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 3 pens (9 ml) per 30 days
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 6 bottles (360 grams) per 30 days
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 2 tablets per day
Maximum of 2 tablets per day
Maximum of 1 tablet per day
Maximum of 1 tablet per day
Maximum of 90 days of use per year
Maximum of 4 tablets per day
track
Bold type = Brand name drug
Plain type = Generic drug
44
Tracked
45
track
Index of covered drugs
A
Aranesp Albumin Free.........22
Breo Ellipta........................... 32
Acamprosate Calcium DR...13
Argatroban........................... 22
Brimonidine Tartrate............30
Acetaminophen/Codeine....13
Arnuity Ellipta....................... 31
Budesonide.......................... 29
Acetazolamide..................... 24
Atenolol.................................23
Bumetanide.......................... 24
Acetazolamide ER............... 24
Atorvastatin Calcium........... 25
Buprenorphine HCl..............13
Acyclovir............................... 19
Adacel...................................29
Atovaquone/Proguanil HCl
............................................ 17
Adcirca..................................32
Atripla....................................19
Bupropion HCl, Bupropion
HCl SR, Bupropion HCl XL
............................................ 15
Advair Diskus, Advair HFA
............................................ 32
Atrovent HFA........................ 31
Buspirone HCl......................20
Aubagio................................ 26
Butrans................................. 13
Aggrenox.............................. 22
Avastin.................................. 17
Bydureon.............................. 20
Albenza................................. 17
Avonex.................................. 26
Byetta....................................20
Alcohol Prep Pads............... 30
Azathioprine......................... 29
Bystolic................................. 23
Alendronate Sodium............29
Azelastine HCl................30, 31
C
Alfuzosin HCl ER..................27
Azilect................................... 18
Cabergoline..........................29
Allopurinol............................ 16
Azithromycin........................ 14
Calcitriol................................30
Alprazolam........................... 20
Azopt.....................................30
Calcium Acetate...................27
Amantadine HCl...................18
B
Captopril............................... 23
Amiodarone HCl.................. 23
Baclofen................................32
Carafate................................ 27
Amitiza.................................. 27
Balsalazide Disodium.......... 29
Carbaglu............................... 33
Amitriptyline HCl.................. 16
Belsomra.............................. 32
Carbamazepine....................15
Amlodipine Besylate............23
Benazepril HCl..................... 23
Carbidopa/Levodopa.......... 18
Amlodipine Besylate/
Benazepril HCl...................24
Benazepril HCl/
Hydrochlorothiazide.......... 24
Carbidopa/Levodopa ER.... 18
Ammonium Lactate............. 26
Benicar..................................22
Carbidopa/Levodopa ODT
............................................ 18
Amoxicillin............................ 14
Benicar HCT.........................24
Carboplatin...........................17
Amphetamine/
Dextroamphetamine..........25
Benlysta................................ 29
Carvedilol..............................23
Benztropine Mesylate..........18
Cayston.................................31
Anagrelide HCl.....................21
Betaseron............................. 26
Cefuroxime Axetil.................14
Anastrozole...........................17
Bethanechol Chloride..........27
Celecoxib..............................12
Androderm........................... 28
Bicalutamide........................ 17
Cephalexin............................14
AndroGel.............................. 28
Bisoprolol Fumarate............ 23
Chantix..................................13
Anoro Ellipta.........................32
Bisoprolol Fumarate/
Hydrochlorothiazide.......... 24
Chlorhexidine Gluconate Oral
Rinse...................................26
Apriso....................................29
45
Tracked
46
Chlorthalidone...................... 24
Diclofenac Sodium ER.........12
Epzicom................................ 19
Cilostazol...............................22
Dicyclomine HCl................... 26
Equetro..................................20
Cimetidine.............................26
Digoxin.................................. 24
Escitalopram Oxalate........... 16
Cimetidine HCl......................26
Estradiol Tablet.....................28
Cinryze.................................. 29
Dihydroergotamine Mesylate
.............................................16
Ciprodex................................31
Diltiazem CD......................... 23
Etoposide.............................. 17
Ciprofloxacin HCl................. 14
Diltiazem HCl........................ 23
Exjade....................................32
Citalopram HBr.....................16
Diltiazem HCl ER.................. 23
F
Clarithromycin...................... 14
Diphenoxylate/Atropine.......26
Famotidine............................ 26
Clonazepam..........................20
Disulfiram.............................. 13
Fareston................................ 17
Clonazepam ODT................. 20
Divalproex Sodium............... 20
Farxiga...................................20
Clonidine HCl........................22
Donepezil HCl, Donepezil HCl
ODT..................................... 15
Fenofibrate............................25
Dorzolamide HCl/Timolol
Maleate............................... 30
Finasteride............................ 27
Clopidogrel........................... 22
Clozapine.............................. 18
Clozapine ODT............... 18, 19
Colchicine............................. 16
Combigan............................. 30
Combivent Respimat............32
Comtan..................................18
Copaxone..............................26
Creon.....................................26
Crestor...................................25
Cyclophosphamide.............. 17
D
Daklinza.................................19
Daliresp................................. 32
Dapsone................................ 17
Desmopressin Acetate.........28
Doxazosin Mesylate............. 22
Doxycycline Hyclate............. 14
Dronabinol............................ 16
Duloxetine HCl......................26
Durezol.................................. 30
Dymista..................................32
E
Edarbi.................................... 22
Edarbyclor.............................24
Eliquis.................................... 21
Elmiron.................................. 27
Embeda................................. 12
Enalapril Maleate..................23
Dexilant................................. 27
Enalapril Maleate/
Hydrochlorothiazide...........24
Dextrose 5%/NaCl................33
Enbrel.................................... 29
Diazepam.............................. 20
Entacapone...........................18
Diazepam Intensol................20
Entecavir............................... 19
Diclofenac Potassium.......... 12
EpiPen................................... 31
Diclofenac Sodium DR.........12
Eplerenone............................24
46
Ethosuximide........................ 15
Fentanyl.................................12
Firazyr.................................... 29
Flovent Diskus, Flovent HFA
.............................................31
Fluconazole...........................16
Fluocinolone Acetonide.......31
Fluphenazine HCl................. 18
Fluticasone Propionate........ 31
Furosemide........................... 24
Fuzeon...................................19
Fycompa............................... 15
G
Gabapentin........................... 15
Gammagard Liquid.............. 29
Gemfibrozil............................25
Genotropin............................ 28
Genotropin Miniquick.......... 28
Gentamicin Sulfate...............14
Gilenya.................................. 26
Gleevec................................. 17
Glimepiride............................20
Tracked
47
Glipizide, Glipizide ER..........20
Letrozole............................... 17
GlucaGen HypoKit................21
Irbesartan/
Hydrochlorothiazide...........24
Glucagon Emergency Kit.....21
Isentress................................ 19
Leukeran............................... 17
Guanidine HCl...................... 16
Isoniazid................................ 17
Levemir Injection.................. 21
H
Isosorbide Dinitrate,
Isosorbide Dinitrate ER......25
Levetiracetam....................... 15
Humalog Injection................ 21
Isosorbide Mononitrate,
Isosorbide Mononitrate ER
.............................................25
Levocetirizine Dihydrochloride
.............................................31
Humira...................................29
Ivermectin..............................17
Humulin Injection................. 21
J
Hydralazine HCl.................... 25
Janumet................................ 20
Hydrochlorothiazide............. 24
Janumet XR.......................... 20
Hydrocodone/Acetaminophen
.............................................13
Januvia.................................. 20
Haloperidol............................18
Harvoni.................................. 19
Hydromorphone HCl............ 13
Hydroxychloroquine Sulfate
.............................................17
Hydroxyurea..........................17
Hydroxyzine HCl................... 20
I
Ibandronate Sodium............ 30
Ibuprofen...............................12
Ilevro...................................... 30
Imiquimod............................. 26
Incruse Ellipta....................... 31
Insulin Syringes, Needles.... 30
Intelence................................19
Invanz.................................... 14
Invokamet..............................20
Invokana................................20
Ipratropium Bromide............31
Ipratropium Bromide/
Albuterol Sulfate.................32
Irbesartan.............................. 22
Jardiance...............................20
Jentadueto............................ 20
K
Kalydeco............................... 32
Kazano...................................20
Ketoconazole........................ 16
Ketorolac Tromethamine..... 30
Klor-Con 10........................... 33
Klor-Con 8............................. 33
Klor-Con M20........................33
Kombiglyze XR..................... 20
Korlym................................... 28
L
Lactulose...............................27
Leucovorin Calcium............. 17
Levocarnitine........................ 33
Levofloxacin..........................14
Levothyroxine Sodium......... 28
Lialda..................................... 29
Lidocaine...............................13
Lidocaine HCl....................... 13
Lidocaine Viscous................ 13
Lidocaine/Prilocaine............ 13
Lindane................................. 17
Linzess.................................. 27
Liothyronine Sodium............28
Lisinopril................................23
Lisinopril/Hydrochlorothiazide
.............................................24
Lithium Carbonate................20
Lithium Carbonate ER..........20
Loperamide HCl................... 26
Lorazepam............................ 20
Lorazepam Intensol..............20
Losartan Potassium..............22
Lamivudine............................19
Losartan Potassium/
Hydrochlorothiazide...........24
Lamotrigine...........................15
Lotemax................................ 30
Lantus Injection.................... 21
Lovastatin..............................25
Lastacaft................................30
Lumigan................................ 30
Latanoprost...........................30
Lupron Depot........................29
Latuda................................... 18
Lupron Depot-PED............... 29
Leflunomide.......................... 29
Lyrica..................................... 26
47
Tracked
48
Lysodren............................... 29
N
Oseni..................................... 21
M
Nadolol.................................. 23
Oxcarbazepine......................15
Meclizine HCl........................16
Naltrexone HCl..................... 13
Oxybutynin Chloride ER.......27
Medroxyprogesterone Acetate
.............................................28
Namenda...............................15
Oxycodone HCl.................... 13
Namenda XR.........................15
Meloxicam.............................12
Naproxen...............................12
Oxycodone/Acetaminophen
.............................................13
Memantine HCl.....................15
Nasonex................................ 31
OxyContin............................. 13
Mercaptopurine.................... 17
Nesina................................... 21
P
Meropenem.......................... 14
Nevanac................................ 30
Pantoprazole Sodium...........27
Metformin HCl...................... 21
Niacin ER.............................. 25
Pataday................................. 30
Metformin HCl ER................ 21
Nicotrol Inhaler..................... 13
Pazeo.....................................30
Methadone HCl.................... 12
Nitrofurantoin Macrocrystals
.............................................14
Pegasys................................. 19
Nitrofurantoin Monohydrate
.............................................14
Perforomist........................... 31
Methscopolamine Bromide
.............................................26
Nitrostat.................................25
Norethindrone Acetate........ 28
Phenytoin Sodium Extended
.............................................15
Methyldopa........................... 22
Nortriptyline HCl................... 16
Pilocarpine HCl.....................26
Methylphenidate HCl........... 25
Norvir..................................... 19
Pioglitazone HCl................... 21
Metoclopramide HCl............ 16
Nucynta ER........................... 12
Metoprolol Succinate ER.....23
Nuedexta...............................25
Polyethylene Glycol 3350
Powder................................27
Metoprolol Tartrate...............23
Nutropin AQ.......................... 28
Pomalyst................................17
Metronidazole....................... 14
Nuvigil....................................32
Potassium Chloride ER........33
Migergot................................16
Nystatin................................. 16
Potassium Citrate ER........... 33
Methazolamide..................... 24
Methimazole......................... 29
Methotrexate.........................29
Minocycline HCl................... 15
O
Penicillin V Potassium..........14
Permethrin............................ 17
Pradaxa................................. 21
Pramipexole Dihydrochloride
.............................................18
Minoxidil................................ 25
Olanzapine............................ 18
Mirtazapine, Mirtazapine ODT
.............................................15
Omega-3-Acid Ethyl Esters
.............................................25
Misoprostol........................... 27
Omeprazole.......................... 27
Prazosin HCl......................... 22
Modafinil............................... 32
Prednisolone Acetate...........30
Montelukast Sodium............ 31
Ondansetron HCl,
Ondansetron ODT..............16
Morphine Sulfate ER............ 12
Onglyza................................. 21
Premarin................................28
Multaq................................... 23
Opana ER..............................13
Prezista..................................19
Myrbetriq...............................27
Opsumit.................................32
Pristiq.................................... 16
Orenitram.............................. 32
ProAir HFA............................ 31
48
Pravastatin Sodium.............. 25
Prednisone............................27
Tracked
49
ProAir RespiClick................. 31
Rivastigmine Tartrate........... 15
Sulfasalazine.........................29
Procrit.................................... 22
Sumatriptan Succinate........ 16
Proctosol HC.........................29
Rizatriptan Benzoate,
Rizatriptan ODT..................16
Progesterone........................ 28
Ropinirole HCl...................... 18
Symbicort.............................. 32
Prolensa................................ 30
Rosuvastatin Calcium.......... 25
Promethazine HCl................ 31
Rozerem................................32
SymlinPen 120, SymlinPen 60
.............................................21
Propranolol HCl.................... 23
S
Suprax................................... 14
Synjardy.................................21
Synthroid...............................28
Propranolol HCl ER.............. 23
Santyl.....................................26
Propylthiouracil.....................29
Saphris.................................. 18
Pulmicort Flexhaler.............. 31
Savella................................... 26
Tamiflu...................................20
Pyridostigmine Bromide...... 16
Selegiline HCl....................... 18
Tamoxifen Citrate................. 17
Q
Selzentry................................19
Tamsulosin HCl.................... 27
Quetiapine Fumarate........... 18
Sensipar................................ 29
Targretin................................17
Quinapril HCl........................ 23
Serevent Diskus....................31
Tasigna..................................17
Quinapril/Hydrochlorothiazide
.............................................24
Seroquel XR..........................18
Tecfidera............................... 26
Sertraline HCl........................16
Telmisartan........................... 22
Sildenafil................................32
T
Raloxifene HCl...................... 28
Silver Sulfadiazine................ 14
Telmisartan/
Hydrochlorothiazide...........24
Ramipril................................. 23
Simbrinza.............................. 30
Terazosin HCl....................... 27
Ranexa.................................. 24
Simvastatin............................25
Testosterone Cypionate.......28
Ranitidine HCl.......................26
Sodium Polystyrene Sulfonate
.............................................32
Theophylline......................... 32
Sotalol HCl, Sotalol HCl AF
.............................................23
Timolol Maleate Ophthalmic
Gel Forming........................30
Sovaldi...................................19
Tivicay....................................19
Spiriva HandiHaler................31
Tizanidine HCl...................... 32
Spiriva Respimat.................. 31
Tobramycin Sulfate.............. 14
Spironolactone..................... 24
Sprycel.................................. 17
Tobramycin/Dexamethasone
.............................................30
Stiolto Respimat................... 32
Topiramate............................15
Strattera.................................25
Topotecan HCl......................17
Suboxone..............................13
Toujeo SoloStar....................21
Sucralfate.............................. 27
Tradjenta............................... 21
Sulfamethoxazole/
Trimethoprim DS................14
Tramadol HCl........................13
R
Rapaflo.................................. 27
Rebif...................................... 26
Renagel................................. 27
Renvela..................................27
Restasis.................................30
Revlimid................................ 17
Reyataz..................................19
Rifabutin................................17
Rifampin................................ 17
Riluzole..................................26
Rimantadine HCl.................. 19
Risperidone...........................18
Rituxan.................................. 17
49
Thymoglobulin......................29
Tracked
50
Tramadol HCl/
Acetaminophen..................13
Ursodiol................................. 26
Tranexamic Acid...................22
Valacyclovir HCl....................19
Transderm-Scop...................16
Valganciclovir........................19
Travatan Z............................. 31
Valproic Acid.........................15
Xarelto................................... 21
Trazodone HCl......................16
Valsartan............................... 23
Xigduo XR............................. 21
Tretinoin................................ 17
Valsartan/Hydrochlorothiazide
.............................................24
Xolair......................................32
Triamterene/
Hydrochlorothiazide...........24
Verapamil HCl.......................23
Zafirlukast............................. 31
Verapamil HCl ER.................23
Tribenzor............................... 24
Zenpep.................................. 26
Versacloz...............................19
Trihexyphenidyl HCl............. 18
Zepatier................................. 19
Vesicare.................................27
Trintellix.................................15
Zetia.......................................25
Victoza...................................21
Trulicity..................................21
Zirgan.................................... 19
Viread.................................... 19
Truvada................................. 19
Zolpidem Tartrate.................32
Voltaren................................. 12
U
Zonisamide........................... 15
Vytorin................................... 25
Uloric..................................... 16
Zostavax................................ 29
Vyvanse................................. 25
Zytiga.....................................17
Triamcinolone Acetonide.... 28
V
50
W
Warfarin Sodium...................21
Welchol..................................25
X
Z
This Abridged Formulary (drug list) is not a complete list of
drugs covered by our plan. For a complete list of covered drugs
or if you have other questions, please call
UnitedHealthcare Group Medicare Advantage (PPO) Customer
Service at:
Toll-Free 877-246-4190, TTY 711
8 a.m. - 8 p.m. local time, Monday - Friday
www.UHCRetiree.com/shbp
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, and/or co-payments/co-insurance may change from time to time
during each plan year. You will receive notice when necessary.
This information is available for free in other languages. Please call our Customer Service number
listed above.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on
the plan’s contract renewal with Medicare.
UHEX17PP3838282_000
Last updated August 1, 2016