Drug Target Maximum Quantity Internal

Transcription

1 To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA s guidelines and other medical information, our plan developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit. The following limits are based on a 30-day supply. If your plan allows for additional days supply, your limits may be higher. For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity This list does not indicate coverage. Please check with your plan administrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by your plan s drug coverage and formulary plan.. Drug Target ABSTRAL 100 MCG TAB SUBLINGUAL ABSTRAL 200 MCG TAB SUBLINGUAL ABSTRAL 300 MCG TAB SUBLINGUAL ABSTRAL 400 MCG TAB SUBLINGUAL ABSTRAL 600 MCG TAB SUBLINGUAL ABSTRAL 800 MCG TAB SUBLINGUAL ACTIQ 1,200 MCG LOZENGE ACTIQ 1,600 MCG LOZENGE ACTIQ 200 MCG LOZENGE ACTIQ 400 MCG LOZENGE ACTIQ 600 MCG LOZENGE ACTIQ 800 MCG LOZENGE ACTONEL 150 MG TABLET ACTONEL 30 MG TABLET ACTONEL 35 MG TABLET ACTONEL 5 MG TABLET ACTONEL 75 MG TABLET ACTONEL WITH CALCIUM TABLETS ACTOPLUS MET 15 MG-500 MG TAB ACTOPLUS MET 15 MG-850 MG TAB ACTOPLUS MET XR 15-1,000 MG TB ACTOPLUS MET XR 30-1,000 MG TB ACTOS 15 MG TABLET ACTOS 30 MG TABLET ACTOS 45 MG TABLET ADCIRCA 20 MG TABLET ADLYXIN MAINTENANCE KIT ADLYXIN STARTER KIT ADRENACLICK 0.15 MG ADRENACLICK 0.3 MG ADVAIR DISKUS ADVAIR DISKUS ADVAIR DISKUS ADVAIR HFA (120) MCG INHALER ADVAIR HFA (120) MCG INHALER ADVAIR HFA (120) MCG INHALER ADVAIR HFA (60) MCG INHALER ADVAIR HFA (60) MCG INHALER ADVAIR HFA (60) MCG INHALER ADVICOR 1,000 MG-20 MG TABLET ADVICOR 500 MG-20 MG TABLET ADVICOR 750 MG-20 MG TABLET AEROBID/AEROBID-M AEROSPAN 80 MCG INHALER AKYNZEO 300/0.5MG CAPSULE ALLEGRA ALLERGY 12 HR 60 MG ALLEGRA ALLERGY 24 HR 180 MG ALLEGRA CHILDREN'S ALLERGY 30 MG TABLET ALLEGRA-D 12 HOUR ALLERGY & CONGESTION ALLEGRA-D 24 HOUR ALLERGY & CONGESTION ALORA MG PATCH ALORA 0.05 MG PATCH ALORA MG PATCH ALORA 0.1 MG PATCH ALOXI 0.25 MG/5 ML VIAL ALSUMA 6 MG/0.5 ML AUTO-INJECT ALTOPREV 20 MG TABLET ALTOPREV 40 MG TABLET ALTOPREV 60 MG TABLET ALVESCO 160 MCG INHALER ALVESCO 80 MCG INHALER AMBIEN 10 MG TABLET AMBIEN 5 MG TABLET AMBIEN CR 12.5 MG TABLET AMBIEN CR 6.25 MG TABLET AMERGE 1 MG TABLET Maximum Quantity 1 tablet per 30 days 2 tablet per 30 days 1 (28 day) Blister Package per prescription 90 tablets per prescription 90 tablets per prescription 1 kit per presciption 1 kit per presciption 1 device (60 blisters) per prescription 1 device (60 blisters) per prescription 1 device (60 blisters) per prescription 3 inhalers per prescription 18 g (2 inhalers, 8.9 g each) per prescription 1 capsule per chemotherapy course 1 vial per prescription 1 kit/2 syringes per prescription

2 AMERGE 2.5 MG TABLET ANORO ELLIPTA 62.5/25 MCG ANORO ELLIPTA 62.5/25 MCG ANZEMET 100 MG TABLET ANZEMET 50 MG TABLET ARAVA 10 MG TABLET ARAVA 20 MG TABLET ARCAPTA NEOHALER 75 MCG CAP ARNUITY ELLIPTA 100 MCG INHALER ARNUITY ELLIPTA 200 MCG INHALER ASMANEX HFA 100 MCG INHALER ASMANEX HFA 200 MCG INHALER ASMANEX TWISTHALER 110 MCG #30 ASMANEX TWISTHALER 110 MCG #7 ASMANEX TWISTHALER 220 MCG #14 ASMANEX TWISTHALER 220 MCG #30 ASMANEX TWISTHALER 220 MCG #60 ASMANEX TWISTHALR 220 MCG #120 ASTELIN 137 MCG NASAL SPRAY ATELVIA 35 MG TABLET ATROVENT 0.03% SPRAY ATROVENT 0.06% SPRAY ATROVENT HFA INHALER ATROVENT INHALER AUVI-Q 0.15 MG AUVI-Q 0.3 MG AVANDAMET 2 MG/500 MG TABLET AVANDAMET 2 MG-1,000 MG TAB AVANDAMET 4 MG/500 MG TABLET AVANDAMET 4 MG-1,000 MG TABLET AVANDARYL 4 MG-1 MG TABLET AVANDARYL 4 MG-2 MG TABLET AVANDARYL 4 MG-4 MG TABLET AVANDARYL 8 MG-2 MG TABLET AVANDARYL 8 MG-4 MG TABLET AVANDIA 2 MG TABLET AVANDIA 4 MG TABLET AVANDIA 8 MG TABLET AVINZA 120 MG CAPSULE AVINZA 30 MG CAPSULE AVINZA 45 MG CAPSULE AVINZA 60 MG CAPSULE AVINZA 75 MG CAPSULE AVINZA 90 MG CAPSULE AVONEX ADMIN PACK 30 MCG VL AVONEX PEN 30 MCG/0.5 ML AVONEX PREFILLED SYR 30 MCG AXERT 12.5 MG TABLET AXERT 6.25 MG TABLET BECONASE AQ 0.042% SPRAY BELBUCA 150 MCG FILM BELBUCA 300 MCG FILM BELBUCA 450 MCG FILM BELBUCA 600 MCG FILM BELBUCA 75 MCG FILM BELBUCA 750 MCG FILM BELBUCA 900 MCG FILM BELSOMRA 10 MG TABLET BELSOMRA 15 MG TABLET BELSOMRA 20 MG TABLET BELSOMRA 5 MG TABLET BETASERON 0.3 MG KIT BETHKIS 300 MG/4 ML AMPULE BEVESPI AEROSPHERE BINOSTO 70 MG TABLET EFF BONIVA 150 MG TABLET BREO ELLIPTA 100MCG/25MCG #28 BREO ELLIPTA 100MCG/25MCG #60 BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 28 BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 60 BROVANA 15 MCG/2 ML SOLUTION BUNAVAIL 2.1 MG/0.3 MG FILM BUNAVAIL 4.2 MG/0.7 MG FILM BUNAVAIL 6.3 MG/1 MG FILM BUTORPHANOL NASAL SPRAY 10 MG/ML BYDUREON 2 MG PEN BYDUREON 2 MG VIAL BYETTA 10 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ CADUET 10 MG-10 MG TABLET CADUET 10 MG-20 MG TABLET CADUET 10 MG-40 MG TABLET CADUET 10 MG-80 MG TABLET 14 blisters (institutional pack) per prescription 60 blisters per prescription 3 tablet per prescription 3 tablet per prescription 1 package (30 capsules) per prescription 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption 13 g (1 inhaler) per prescription 13 g (1 inhaler) per prescription 2 bottles per prescription 2 bottles per prescription 1 box (4 pens) per 28 days 4 syringes per 28 days 12 tablets per prescription 14 vials per 30 days 56 ampules per prescription 1 canister (120 inhalations per canister) per prescription 1 tablet per 30 days 28 blisters (1 inhaler) per prescription 60 blisters per prescription 1 inhaler (28 blisters) 1 inhaler (60 blisters) 2 cartons (60 vials) per prescription 30 films per presciption 2 bottles per prescription 4 Pens (1 package) per prescription 1 carton (4 single-dose trays) per prescription 1 syringe per prescription 1 syringe per prescription

3 CADUET 2.5 MG-10 MG TABLET CADUET 2.5 MG-20 MG TABLET CADUET 2.5 MG-40 MG TABLET CADUET 5 MG-10 MG TABLET CADUET 5 MG-20 MG TABLET CADUET 5 MG-40 MG TABLET CADUET 5 MG-80 MG TABLET CAMBIA 50 MG POWDER PACKET CARDURA 1 MG TABLET CARDURA 2 MG TABLET CARDURA 4 MG TABLET CARDURA 8 MG TABLET CARDURA XL 4 MG TABLET CARDURA XL 8 MG TABLET CATAPRES-TTS 1 PATCH CATAPRES-TTS 2 PATCH CATAPRES-TTS 3 PATCH CAVERJECT 10 MCG KIT CAVERJECT 20 MCG KIT CAVERJECT 20 MCG VIAL CAVERJECT 40 MCG VIAL CAVERJECT 40 MCG/2 ML AMPUL CAYSTON 75 MG INHAL SOLUTION CESAMET 1 MG PULVULE CHILDREN'S QNASAL 40 MCG (4.9 G) CHILD'S CLARITIN 5 MG TAB CHEW CHLD ALLEGRA ALLERGY 30 MG ODT CHOLBAM 50 MG CAPSULE CHORIONIC GONAD 10000U VIAL CIALIS 10 MG TABLET CIALIS 2.5 MG TABLET CIALIS 20 MG TABLET CIALIS 5 MG TABLET CLARINEX 2.5 MG REDITABS CLARINEX 5 MG REDITABS CLARINEX-D 12 HOUR TABLET CLARINEX-D 24 HOUR TABLET CLARITIN 10 MG LIQUI-GEL CAP CLARITIN 10 MG REDITABS CLARITIN 10 MG TABLET CLARITIN-D 12 HOUR TABLET CLARITIN-D 24 HOUR TAB ER CLIMARA MG/DAY PATCH CLIMARA MG/DAY PATCH CLIMARA 0.05 MG/DAY PATCH CLIMARA 0.06/MG DAY PATCH CLIMARA MG/DAY PATCH CLIMARA 0.1 MG/DAY PATCH CLIMARA PRO PATCH CLOBETASOL EMOLLIENT CREAM CLOBETASOL FOAM, SOLUTION, EMOLLIENT FOAM CLOBETASOL LOTION CLOBETASOL OINTMENT, CREAM AND GEL CLOBETASOL SHAMPOO CLOBETASOL SPRAY COMBIVENT INHALER COMBIVENT RESPIMAT INHAL SPRAY CONZIP ER 100 MG CAPSULE CONZIP ER 200 MG CAPSULE CONZIP ER 300 MG CAPSULE COPAXONE 20 MG COPAXONE 40 MG/ML SYRINGE CRESTOR 10 MG TABLET CRESTOR 20 MG TABLET CRESTOR 40 MG TABLET CRESTOR 5 MG TABLET DAKLINZA 30 MG TABLET DAKLINZA 60 MG TABLET DAKLINZA 90 MG TABLET DEPO-PROVERA 150 MG/ML SYRINGE DEPO-SUBQ PROVERA 104 SYRINGE DEXILANT DR 30 MG CAPSULE DEXILANT DR 60 MG CAPSULE DIFLUCAN 150 MG TABLET DIVIGEL 0.25 MG GEL PACKET DIVIGEL 0.5 MG GEL PACKET DIVIGEL 1 MG GEL PACKET DOSTINEX 0.5 MG TABLET DUETACT 30-2 MG TABLET DUETACT 30-4 MG TABLET DULERA 100 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER 9 packets per prescription 12 units per prescription 12 units per prescription 12 units per prescription 12 units per prescription 12 units per prescription 1 kit (84 vials of aztreonam and 88 vials of dliuent) per prescription 5 grams (1 bottle) per prescription 120 capsules per prescription 3 vials per prescription 120 grams per 28 days 100 grams per 28 days 118 grams per 28 days 120 grams per 28 days 236 grams per 28 days 125 grams per 28 days 1 kit (30 prefilled syringes) per 30 days 12 syringes per 30 days 1 vial/syringe per 30 days 1 syringe per 30 days 2 tablets per prescription 8 tablets per 28 days

4 DUONEB 0.5 MG-3 MG/3 ML SOLN DYMISTA NASAL SPRAY EDEX 10 MCG KIT EDEX 20 MCG CARTRIDGE 2-PK KIT EDEX 20 MCG CARTRIDGE 6-PK KIT EDEX 40 MCG CARTRIDGE 2-PK KIT EDEX 40 MCG CARTRIDGE 6-PK KIT EDLUAR 10 MG SL TABLET EDLUAR 5 MG SL TABLET ELESTRIN 0.06% GEL ELIDEL CREAM 1% ELLA 30 MG TABLET EMBEDA MG CAPSULE EMBEDA MG CAPSULE EMBEDA MG CAPSULE EMBEDA 50-2 MG CAPSULE EMBEDA MG CAPSULE EMBEDA MG CAPSULE EMEND 125 MG CAPSULE EMEND 125 MG ORAL SUSPENSION EMEND 150 MG VIAL EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIFOLD PACK ENBREL 25 MG/0.5 ML SYRINGE ENBREL 50 MG/0.5 ML SYRINGE EPCLUSA EPINEPHRINE 0.15 MG AUTO-INJCT (TWO PACK) EPINEPHRINE 0.3 MG AUTO-INJECT (TWO PACK) EPIPEN 0.3 MG AUTO-INJECTOR EPIPEN JR 0.15 MG AUTO-INJCT ESBRIET 267 MG CAPSULE: 14-DAY TITRATION BLISTER PACK ESBRIET 267 MG CAPSULE ESBRIET 267 MG CAPSULE: 4-WEEK MAINTENANCE BLISTER PACK ESOMEPRAZOLE STRONTIUM MG CAPSULE ESTRADERM 0.05 MG PATCH ESTRADERM 0.1 MG PATCH ESTRASORB PACKET ESTROGEL 0.06% GEL EVAMIST 1.53 MG/SPRAY EVZIO 0.4 MG AUTOINJECTOR EVZIO 2MG/0.4 ML AUTOINJECTOR EXALGO ER 12 MG TABLET EXALGO ER 16 MG TABLET EXALGO ER 32 MG TABLET EXALGO ER 8 MG TABLET EXTAVIA 0.3 MG KIT EXTAVIA 0.3MG VIAL FAMVIR 125 MG TABLET FAMVIR 250 MG TABLET FAMVIR 500 MG TABLET FARXIGA 10 MG TABLET FARXIGA 5 MG TABLET FENTORA 100 MCG BUCCAL TABLET FENTORA 200 MCG BUCCAL TABLET FENTORA 300 MCG BUCCAL TABLET FENTORA 400 MCG BUCCAL TABLET FENTORA 600 MCG BUCCAL TABLET FENTORA 800 MCG BUCCAL TABLET FLECTOR 1.3% PATCH FLONASE 0.05% NASAL SPRAY FLONASE ALLERGY RELIEF 50 MCG SRAY PACKAGE SIZE 15.8 FLONASE ALLERGY RELIEF 50 MCG SRAY PACKAGE SIZE 9.9 FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS FLOVENT 50 MCG ROTADISK FLOVENT HFA 110 MCG INHALER FLOVENT HFA 220 MCG INHALER FLOVENT HFA 44 MCG INHALER FLUNISOLIDE 0.025% SPRAY FLUOCINONIDE OINTMENT, GEL, SOLUTION, OR CREAM EMULSIFIED FORADIL AEROLIZER 12 MCG CAP FORADIL AEROLIZER 12 MCG CAP FORTEO 600 MCG/2.4 ML PEN INJ FOSAMAX 10 MG TABLET FOSAMAX 35 MG TABLET FOSAMAX 40 MG TABLET FOSAMAX 5 MG TABLET FOSAMAX 70 MG TABLET FOSAMAX 70 MG/75 ML SOLUTION FOSAMAX PLUS D 70 MG-2,800 IU FOSAMAX PLUS D 70 MG-5,600 IU FROVA 2.5 MG TABLET 180 vials (package size 3) per prescription 12 cartridges per prescription 12 cartridges per prescription 12 cartridges per prescription 12 cartridges per prescription 12 cartridges per prescription 52 grams (2 pumps) per prescription 100 grams per 30 days 1 tablet (1 dose) per prescription 1 capsule per prescription 3 packets per prescription 1 vial per prescription 1 capsule per prescription 2 capsules per prescription 1 pack per prescription 8 vials/syringes per 28 days 4 vials/syringes per 28 days 3 units (package size 1), 2 units (package size 2) per prescription 3 units(package size 1), 2 units (package size 2) per prescription 1 pack (63 capsules) per prescription 270 capsules per prescription 1 carton (252 capsules) per prescription 56 packets (97.44 g) per prescription 1 pump bottle per prescription 2 pumps per prescription 1 package (2 devices plus 1 trainer) per prescription 1 kit (2 auto-injectors) per prescription 15 blister units/vials per 30 days 14 or 15 vials with prefilled diluent syringe per 30 days 21 tablets per prescription 21 tablets per prescription 60 patches per prescription 1 unit per prescription 1 unit per prescription 4 inhalers per prescription 2 inhalers/bottles per prescription 120 grams per 30 days 1 package (package size 12) (12 capsules) per prescription 1 package (package size 60) (60 capsules) per prescription 1 pen per 28 days 4 bottles per 28 days

5 GELNIQUE 10% GEL SACHETS GELNIQUE 3% GEL GLYXAMBI 10 MG/5 MG TABLET GLYXAMBI 25 MG/5 MG TABLET GRANISOL 2 MG/10 ML SOLUTION HARVONI 400 MG/90 MG TABLET HUMIRA 10 MG/0.2 ML SYRINGE HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA 40 MG/0.8 ML PEN HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA CROHN'S STARTER PACK HUMIRA PSORIASIS STARTER PACK HYSINGLA ER 100 mg tablet HYSINGLA ER 120 mg tablet HYSINGLA ER 20 mg tablet HYSINGLA ER 30 mg tablet HYSINGLA ER 40 mg tablet HYSINGLA ER 60 mg tablet HYSINGLA ER 80 mg tablet HYTRIN 1 MG CAPSULE HYTRIN 10 MG CAPSULE HYTRIN 2 MG CAPSULE HYTRIN 5 MG CAPSULE IMITREX 100 MG TABLET IMITREX 20 MG NASAL SPRAY IMITREX 25 MG TABLET IMITREX 4 MG/0.5 ML CARTRIDGES IMITREX 4 MG/0.5 ML PEN INJECT IMITREX 5 MG NASAL SPRAY IMITREX 50 MG TABLET IMITREX 6 MG/0.5 ML CARTRIDGE IMITREX 6 MG/0.5 ML PEN INJECT IMITREX 6 MG/0.5 ML SYRNG KIT IMITREX 6 MG/0.5 ML VIAL INCRUSE ELLIPTA 62.5 MCG INHALER INTERMEZZO 1.75 MG TAB SUBLING INTERMEZZO 3.5 MG TAB SUBLING INVOKAMET 150 MG/1000 MG TABLET INVOKAMET 150 MG/500 MG TABLET INVOKAMET 50 MG/1000 MG TABLET INVOKAMET 50 MG/500 MG TABLET INVOKANA 100 MG TABLET INVOKANA 300 MG TABLET JANUMET 50-1,000 MG TABLET JANUMET MG TABLET JANUMET XR 100-1,000 MG TABLET JANUMET XR 50-1,000 MG TABLET JANUMET XR MG TABLET JANUVIA 100 MG TABLET JANUVIA 25 MG TABLET JANUVIA 50 MG TABLET JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET JENTADUETO 2.5 MG-1000 MG TAB JENTADUETO 2.5 MG-500 MG TAB JENTADUETO 2.5 MG-850 MG TAB JENTADUETO XR 2.5 MG TABLET JENTADUETO XR 5 MG TABLET JUVISYNC MG TABLET JUVISYNC MG TABLET JUVISYNC MG TABLET JUVISYNC MG TABLET JUVISYNC MG TABLET JUVISYNC MG TABLET KADIAN ER 10 MG CAPSULE KADIAN ER 100 MG CAPSULE KADIAN ER 130 MG CAPSULE KADIAN ER 150 MG CAPSULE KADIAN ER 20 MG CAPSULE KADIAN ER 200 MG CAPSULE KADIAN ER 30 MG CAPSULE KADIAN ER 40 MG CAPSULE KADIAN ER 50 MG CAPSULE KADIAN ER 60 MG CAPSULE KADIAN ER 70 MG CAPSULE KADIAN ER 80 MG CAPSULE KALYDECO 150 MG TABLET KALYDECO 50 MG GRANULES PACKET KALYDECO 75 MG GRANULES PACKET KAZANO ,000 MG TABLET KAZANO MG TABLET KITABIS PACK 300 MG/5 ML SOLUTION KOMBIGLYZE XR 2.5-1,000 MG TAB 30 sachets (1 carton) per prescription 1 pump per prescription 56 tablets per 365 days 2 syringes per 28 days 2 syringes per 28 days 2 pen per 28 days 2 syringes per 28 days 2 syringes per 28 days 2 syringes per 28 days 60 capsules per prescription 6 devices per prescription 2 vials per prescription 1 kit per prescription 6 devices per prescription 2 vials per prescription 1 kit per prescription 1 kit per prescription 2 vials per prescription 1 inhaler (30 blisters OR 7 blisters institutional pack) per prescription 56 packets (1 package) per prescription 56 packets (1 package) per prescription 280 ml (1 package) per prescription

6 KOMBIGLYZE XR 5-1,000 MG TAB KOMBIGLYZE XR MG TABLET KYTRIL 1 MG TABLET KYTRIL 2 MG/10 ML SOLUTION LAZANDA 100 MCG NASAL SPRAY LAZANDA 400 MCG NASAL SPRAY LESCOL 20 MG CAPSULE LESCOL 40 MG CAPSULE LESCOL XL 80 MG TABLET LEVITRA 10 MG TABLET LEVITRA 2.5 MG TABLET LEVITRA 20 MG TABLET LEVITRA 5 MG TABLET LEVONORGESTREL 0.75 MG TABLET LiDOCAINE 2.5%/PRILOCAINE 2.5% CREAM LIDOCAINE JELLY 2% LIDOCAINE OINTMENT LIPITOR 10 MG TABLET LIPITOR 20 MG TABLET LIPITOR 40 MG TABLET LIPITOR 80 MG TABLET LIPTRUZET 10 MG TABLET LIPTRUZET 20 MG TABLET LIPTRUZET 40 MG TABLET LIPTRUZET 80 MG TABLET LIVALO 1 MG TABLET LIVALO 2 MG TABLET LIVALO 4 MG TABLET LUNESTA 1 MG TABLET LUNESTA 2 MG TABLET LUNESTA 3 MG TABLET MAXAIR AUTOHALER 0.2 MG AERO MAXALT 10 MG TABLET MAXALT 5 MG TABLET MAXALT MLT 10 MG TABLET MAXALT MLT 5 MG TABLET MENOSTAR 14 MCG/DAY PATCH MEVACOR 10MG TABLET MEVACOR 20 MG TABLET MEVACOR 40 MG TABLET MIGRANAL 4 MG/ML NASAL SPRAY MINIVELLE MG PATCH MINIVELLE 0.05 MG PATCH MINIVELLE MG PATCH MINIVELLE 0.1 MG PATCH MOBIC 7.5 MG TABLET MS CONTIN 100 MG TABLET ORAMORPH SR 100 MG TABLET MS CONTIN 15 MG TABLET ORAMORPH SR 15 MG TABLET MS CONTIN 200 MG TABLET MS CONTIN 30 MG TABLET SA ORAMORPH SR 30 MG TABLET MS CONTIN 60 MG TABLET ORAMORPH SR 60 MG TABLET MUSE 1,000 MCG URETHRAL SUPP MUSE 125 MCG URETHRAL SUPPOS MUSE 250 MCG URETHRAL SUPPOS MUSE 500 MCG URETHRAL SUPPOS NARCAN 4 MG/0.1 NASAL SPRAY NASACORT AQ NASAL SPRAY 55 MCG NASONEX 50 MCG NASAL SPRAY NEBUPENT 300 MG INHAL POWDER NESINA 12.5 MG TABLET NESINA 25 MG TABLET NESINA 6.25 MG TABLET NEULASTA 6 MG/0.6 ML SYRINGE NEXIUM 2.5 MG PACKET NEXIUM 20 MG CAPSULE NEXIUM 5 MG PACKET NEXIUM DR 10 MG PACKET NEXIUM DR 20 MG PACKET NOVAREL 10,000 UNITS VIAL NUCALA 100 MG VIAL NUCYNTA 100 MG TABLET NUCYNTA 50 MG TABLET NUCYNTA 75 MG TABLET NUCYNTA ER 100 MG TABLET NUCYNTA ER 150 MG TABLET NUCYNTA ER 200 MG TABLET NUCYNTA ER 250 MG TABLET NUCYNTA ER 50 MG TABLET OCALIVA 10 MG TABLET OCALIVA 5 MG TABLET OFEV 100 MG CAPSULE 1 bottle (30 ml) per prescription 23 units (1 unit = 1 bottle with 8 sprays) per 30 days 23 units (1 unit = 1 bottle with 8 sprays) per 30 days 60 capsules per prescription 2 tablets per prescription 30 grams per 30 days 60 ml per 30 days One tube, or 50 grams per 30 days spray devices = 1 kit per prescription 12 urethral suppositories per prescription 12 urethral suppositories per prescription 12 urethral suppositories per prescription 12 urethral suppositories per prescription 1 pack (2 devices) per prescription 1 container (inhaler) per 28 days 2 syringes per 30 days 3 vials per prescription 1 vial per 28 days 181 tablets per prescription 181 tablets per prescription 181 tablets per prescription 60 capsules per prescription

7 OFEV 150 MG CAPSULE OLYSIO 150 MG CAPSULE OMECLAMOX-PAK COMBO PACK OMNARIS 50 MCG NASAL SPRAY ONGLYZA 2.5 MG TABLET ONGLYZA 5 MG TABLET ONMEL 200 MG TABLET ONSOLIS 1,200 MCG SOLUBLE FILM ONSOLIS 200 MCG SOLUBLE FILM ONSOLIS 400 MCG SOLUBLE FILM ONSOLIS 600 MCG SOLUBLE FILM ONSOLIS 800 MCG SOLUBLE FILM ONZENTRA XSAIL 11 MG NOSEPIECE OPANA ER 10 MG TABLET OPANA ER 15 MG TABLET OPANA ER 20 MG TABLET OPANA ER 30 MG TABLET OPANA ER 40 MG TABLET OPANA ER 5 MG TABLET OPANA ER 7.5 MG TABLET ORAMORPH SR 100 MG ORAMORPH SR 15 MG ORAMORPH SR 30 MG ORAMORPH SR 60 MG ORKAMBI 100 MCG/125 MG TABLET ORKAMBI 200 MCG/125 MG TABLET OSENI MG TABLET OSENI MG TABLET OSENI MG TABLET OSENI MG TABLET OSENI MG TABLET OSENI MG TABLET OXYCONTIN 10 MG TABLET OXYCONTIN 15 MG TABLET OXYCONTIN 20 MG TABLET OXYCONTIN 30 MG TABLET OXYCONTIN 40 MG TABLET OXYCONTIN 60 MG TABLET OXYCONTIN 80 MG TABLET OXYTROL 3.9 MG/24HR PATCH PATANASE 0.6% NASAL SPRAY PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS 180 MCG/ML VIAL PEGASYS PROCLICK 135 MCG/0.5 PEGASYS PROCLICK 180 MCG/0.5 PEGINTRON Redipen 150 MCG PEGINTRON 120 MCG KIT PEGINTRON 150 MCG KIT PEGINTRON 50 MCG KIT PEGINTRON 80 MCG KIT PEGINTRON Redipen 120 MCG PEGINTRON Redipen 50 MCG PEGINTRON Redipen 80 MCG PENNSAID 2% SOLUTION PENNSAID AND KLOFENSAID 1.5 DROPS PERFOROMIST 20 MCG/2 ML SOLN PLEGRIDY 125 MCG/0.5 ML PLEGRIDY 63 MCG SINGLE DOSE AND 94 MCG SINGLE DOSE PRANDIMET 1 MG-500 MG TABLET PRANDIMET 2 MG-500 MG TABLET PRAVACHOL 10 MG TABLET PRAVACHOL 20 MG TABLET PRAVACHOL 40 MG TABLET PRAVACHOL 80 MG TABLET Pregnyl 10,000 units vial PREVACID 15 MG CAPSULE DR PREVACID 15 MG SOLUTAB PREVPAC PATIENT PAC PRILOSEC 10 MG CAPSULE DR PRILOSEC 20 MG CAPSULE DR PRILOSEC DR 10 MG SUSPENSION PRILOSEC DR 2.5 MG SUSPENSION PROAIR HFA 90 MCG INHALER PROAIR RESPICLICK 90 MCG INHALER PROTONIX DR 20 MG TABLET PROTOPIC OINTMENT 0.03% PROTOPIC OINTMENT 0.10% PROVENTIL HFA 90 MCG INHALER PULMICORT 0.25 MG/2 ML RESPUL PULMICORT 0.5 MG/2 ML RESPULE PULMICORT 1 MG/2 ML RESPULE PULMICORT 180 MCG FLEXHALER 60 capsules per prescription 80 caps/tabs (10 cards) = 1 combo pack per prescription 15 tablets per prescription 90 films per 30 days 90 films per 30 days 90 films per 30 days 90 films per 30 days 90 films per 30 days 1 kit (8 doses/16 nose pieces) per prescription 112 tablets (1 box) 112 tablets (1 package) 1 box per 28 days 1 box per 28 days 1 box per 28 days 1 box per 28 days 4 pens per 28 days 4 pens per 28 days 4 pens per 28 days 4 pens per 28 days 112 grams per 28 days 150 ml per 28 days 1 carton (60 vials) per prescription 2 units (Pen and Syringe) per 28 days 1 starter pack (Pen and Syringe) per 365 days 150 tablets per prescription 150 tablets per prescription 3 vials per prescription 30 solutabs per prescription 112 caps/tabs (14 cards) = 1 pack per prescription 60 packets per prescription 100 grams per 30 days 100 grams per 30 days 60 respules per prescription 60 respules per prescription 30 respules per prescription

8 PULMICORT 90 MCG FLEXHALER QNASL 80MCG NASAL SPRAY QVAR 40 MCG INHALER QVAR 80 MCG INHALER Rebetron Combination (Rebetol capsules and Intron A injection) RebetronTherapy Pak 1000 Rebetron Combination (Rebetol capsules and Intron A injection) RebetronTherapy Pak 1200 Rebetron Combination (Rebetol capsules and Intron A injection) RebetronTherapy Pak 600 REBIF 22 MCG/0.5 ML SYRINGE REBIF 44 MCG/0.5 ML SYRINGE REBIF TITRATION PACK REGRANEX 0.01% GEL RELENZA 5 MG DISKHALER RELPAX 20 MG TABLET RELPAX 40 MG TABLET RESTASIS 0.05% EYE EMULSION RESTASIS 5.5 ML MULTIDOSE VIAL REVATIO 10 MG/ML ORAL SUSPENSION REVATIO 20 MG TABLET RHINOCORT ALLERGY SPRAY 32 MCG RHINOCORT AQUA NASAL SPRAY ROZEREM 8 MG TABLET RYBIX ODT 50 MG TABLET RYZOLT ER 100 MG TABLET RYZOLT ER 200 MG TABLET RYZOLT ER 300 MG TABLET SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET SANCUSO 3.1 MG/24 HR PATCH SECONAL 100 MG CAPSULE SEEBRI NEOHALER 15.6 MCG INHALATION POWDER SEREVENT DISKUS 50 MCG (28 BLISTERS) SEREVENT DISKUS 50 MCG (60 BLISTERS) SILENOR 3 MG TABLET SILENOR 6 MG TABLET SIMCOR 1, MG TABLET SIMCOR 1, MG TABLET SIMCOR MG TABLET SIMCOR MG TABLET SIMCOR MG TABLET SOLARAZE 3% GEL SOLIQUA 100 PACKAGE SONATA 10 MG CAPSULE SONATA 5 MG CAPSULE SOVALDI 400 MG TABLET SPIRIVA 18 MCG CP-HANDIHALER SPIRIVA 28 INHALATIONS PACK AND 60 INHALATIONS PACK SPIRIVA RESPIMAT 1.25 MCG INHALATION SPRAY SPORANOX 100 MG CAPSULE SPRIX MG NASAL SPRAY STAXYN 10 MG ODT STENDRA 100 MG TABLET STENDRA 150 MG TABLET STENDRA 200 MG TABLET STENDRA 50 MG TABLET STIOLTO RESPIMAT 2.5/2.5 MCG INHALATION SPRAY STRIVERDI RESPIMAT 28 INHALATIONS PACK, 60 INHALATIONS PACK SUBOXONE 12 MG-3 MG SL FILM SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 2 MG-0.5 MG TABLET SL SUBOXONE 4 MG-1 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM SUBOXONE 8 MG-2 MG TABLET SL SUBSYS 1,200 MCG SPRAY SUBSYS 1,600 MCG SPRAY SUBSYS 100 MCG SPRAY SUBSYS 200 MCG SPRAY SUBSYS 400 MCG SPRAY SUBSYS 600 MCG SPRAY SUBSYS 800 MCG SPRAY SUMAVEL DOSEPRO 4 MG/0.5 ML SUMAVEL DOSEPRO 4 MG/0.5 ML SUMAVEL DOSEPRO 6 MG/0.5 ML SYMBICORT MCG INHALER SYMBICORT MCG INHALER SYMLINPEN 120 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR SYNJARDY 12.5 MG/1000 MG TABLET SYNJARDY 12.5 MG/500 MG TABLET SYNJARDY 5 MG/1000 MG TABLET SYNJARDY 5 MG/500 MG TABLET 3 inhalers per prescription 2 packages per 28 days 2 packages per 28 days 2 packages per 28 days 12 syringes per 28 days 12 syringes per 28 days 1 package per 28 days 1 tube per prescription 20 blisters (1 carton) per prescription 60 vials per prescription 5.5 ml per prescription 1 (112 ml) bottle per prescription 90 tablets per prescription 9 gm (8.6 g = 1 bottle) and 5 g (1 bottle) per prescription 2 bottles per prescription 240 tablets per prescription 1 patch per prescription 60 inhalations (1 package) per prescription 1 package per prescription 1 package per prescription 100 grams per 28 days 1 package (5x3 ml syringes) per prescription 1 package (30 doses) per prescription 1 inhaler (4 g) per prescription 4 g = 1 inhaler (60 inhalations) 5 bottles per prescription 1 inhaler = 4 g (60 inhalations OR 28 inhalations institutional pack) 1 inhaler (60 inhalations OR 28 inhalations institutional pack) per prescription 60 tablets/films per prescription 90 tablets/films per prescription 90 tablets/films per prescription 90 tablets/films per prescription 90 tablets/films per prescription 90 tablets/films per prescription 3 ml (1 box) per prescription 9 ml (3 boxes) per 28 days 6 units per prescription 1 package per prescription 1 package per prescription 7 pens per prescription 7 pens per prescription

9 TAMIFLU 12 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 30 MG GELCAP 20 capsules per prescription TAMIFLU 45 MG GELCAP 10 capsules per prescription TAMIFLU 6 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 75 MG GELCAP 10 capsules per prescription TECHNIVIE DOSE PACK 3 cartons (168 tablets) per 365 days TIVORBEX 20 MG CAPSULE 90 capsules per prescription TOBI 300 MG/5 ML SOLUTION 56 ampoules per prescription TOBI PODHALER 28 MG INHALE CAP 224 capsules per prescription TORADOL 10 MG TABLET 20 tablets per prescription TRADJENTA 5 MG TABLET TRAMADOL HCL 50 MG TABLET 240 tablets per prescription TRAMADOL HCL ER 150 MG CAPSULE 60 capsules per prescription TREXIMET MG TABLET TREXIMET MG TABLET TRULICITY 0.75 MG/0.5 ML 4 units (Pen OR Syringe) per prescription TRULICITY 1.5 MG/0.5 ML 4 units (Pen OR Syringe) per prescription TUDORZA PRESSAIR 400 MCG INH ULTRACET 37.5 MG-325 MG TABLET 240 tablets per prescription ULTRAM 50 MG TABLET 240 tablets per prescription ULTRAM ER 100 MG TABLET ULTRAM ER 200 MG TABLET ULTRAM ER 300 MG TABLET UTIBRON NEOHALER 27.5/15.6 INHLATION POWDER (PACKAGE SIZE 6) UTIBRON NEOHALER 27.5/15.6 INHLATION POWDER (PACKAGE SIZE 60) VALTREX 1 GM CAPLET VALTREX 500 MG CAPLET VARUBI 90 MG TABLET VENTOLIN HFA 90 MCG INHALER VENTOLIN HFA 90 MCG INHALER VERAMYST 27.5 MCG NASAL SPRAY VIAGRA 100 MG TABLET VIAGRA 25 MG TABLET VIAGRA 50 MG TABLET VICTOZA 2-PAK 18 MG/3 ML PEN VICTOZA 3-PAK 18 MG/3 ML PEN VIEKIRA PAK VIEKIRA XR VIVELLE-DOT MG PATCH VIVELLE-DOT MG PATCH VIVELLE-DOT 0.05 MG PATCH VIVELLE-DOT MG PATCH VIVELLE-DOT 0.1 MG PATCH VIVLODEX 5 MG CAPSULE VOLTAREN 1% GEL VYTORIN MG TABLET VYTORIN MG TABLET VYTORIN MG TABLET VYTORIN MG TABLET XIFAXAN 200 MG TABLET XIFAXAN 550 MG TABLET XIGDUO ER 10 MG/1000 MG TABLET XIGDUO ER 10 MG/500 MG TABLET XIGDUO XR 5 MG/1000 MG TABLET XIGDUO XR 5 MG/500 MG TABLET XIIDRA 5% SOLUTION XOLAIR 150 MG VIAL XTAMPZA 13.5 MG TABLET XTAMPZA 18 MG TABLET XTAMPZA 27 MG TABLET XTAMPZA 36 MG TABLET XTAMPZA 9 MG TABLET XYZAL 5 MG TABLET ZECUITY TDS 6.5 MG/4 HOUR ZEGERID 20 MG CAPSULE ZEGERID 20 MG PACKET ZEMBRACE 3 MG/0.5 ML SYRINGE ZETONNA 37 MCG NASAL SPRAY ZINBRYTA 150 MG/ML SYRINGE ZOCOR 10 MG TABLET ZOCOR 20 MG TABLET ZOCOR 40 MG TABLET ZOCOR 5 MG TABLET ZOCOR 80 MG TABLET ZOFRAN 24 MG TABLET ZOFRAN 4 MG TABLET ZOFRAN 8 MG TABLET ZOFRAN ODT 4 MG TABLET ZOFRAN ODT 8 MG TABLET ZOFRAN SOLUTION 6 inhalations (1 package) per prescription 60 inhalations (1 package) per prescription 30 caplets (tablets) per prescription 30 caplets (tablets) per prescription 2 tablets (1 package) per prescription 1 package (2 pens) per prescription 1 package (3 pens) per prescription 3 paks (336 tablets) per 365 days 252 tablets per 365 days 500 grams per 28 days 60 vials per prescription 6 vials per 28 days 4 patches per prescription 4 syringes (1 kit) per prescription 1 canister (60 actuations per canister) per prescription 1 syringe per 28 days 1 tablet per prescription 9 tablets or orally disintegrating tablets per prescription 9 tablets or orally disintegrating tablets per prescription 9 tablets or orally disintegrating tablets per prescription 9 tablets or orally disintegrating tablets per prescription 2 bottles per prescription

10 ZOLPIMIST 5 MG ORAL SPRAY ZOMIG 2.5 MG TABLET ZOMIG 5 MG NASAL SPRAY ZOMIG 5 MG TABLET ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT 5 MG TABLET ZORVOLEX 18 MG CAPSULES ZOVIRAX 5% CREAM ZOVIRAX 5% OINTMENT ZUBSOLV 0.7 MG/0.18 MG TABLET ZUBSOLV 1.4 MG/0.36 MG TABLET ZUBSOLV 11.4 MG/2.9 MG TABLET ZUBSOLV 2.9 MG/0.71 MG TABLET ZUBSOLV 5.7 MG/1.4 MG TABLET ZUBSOLV 8.6 MG/2.1 MG TABLET ZUPLENZ 4 MG SOLUBLE FILM ZUPLENZ 8 MG SOLUBLE FILM ZYRTEC 10 MG CHEWABLE TABLET ZYRTEC 10 MG TABLET ZYRTEC 5 MG CHEWABLE TABLET ZYRTEC 5 MG TABLET ZYRTEC-D TABLET 6 nasal spray devices per prescription 90 capsules per prescription 1 tube/5 grams per prescription 1 tube/30 grams per prescription 9 films per prescription 9 films per prescription