2017 Formulary (List of Covered Drugs)

Transcription

1 017 Formulary (List of Covered Drugs) Liberty Health Advantage Preferred Choice (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 1791, Version Number 16 This formulary was updated on 0/3/017. For more recent information or other questions, please contact Liberty Health Advantage at or, for TTY users, , hours a day, seven days a week, or visit H3337_017 Formulary PC Accepted

2 Contents What is the Liberty Health Advantage Preferred Choice (HMO) Formulary?... 3 Can the Formulary (drug list) change?... 3 How do I use the Formulary?... What are generic drugs?... Are there any restrictions on my coverage?... How do I request an exception to the Liberty Health Advantage Formulary?... 6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception?... 6 For more information... 7 Liberty Health Advantage Formulary... 8 Drug List... 9 Index of Drugs... Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Liberty Health Advantage, INC. When it refers to plan or our plan, it means Liberty Health Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of 0/3/017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 017, and from time to time during the year. Liberty Health Advantage is an HMO plan with a Medicare Advantage contract and a contract with the New York State Medicaid program. Enrollment in Liberty Health Advantage depends on contract renewal. To request this material in an alternate format or language, call , 8am 8pm EST Sunday through Saturday. Note: After February 1, 017, Call Center hours Page of 66

3 for Saturday and Sunday are operated by alternative technology. TTY/TDD users should call What is the Liberty Health Advantage Preferred Choice (HMO) Formulary? A formulary is a list of covered drugs selected by Liberty Health Advantage 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. Liberty Health Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Liberty Health Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 0/3/017. To get updated information about the drugs covered by Liberty Health Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Liberty Health Advantage may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet. Page 3 of 66

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR. If you know what your drug is used for, look for the category name in the list that begins on page 9. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Liberty Health Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Liberty Health Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Liberty Health Advantage before you fill your prescriptions. If you don t get approval, Liberty Health Advantage may not cover the drug. Page of 66

5 Quantity Limits: For certain drugs, Liberty Health Advantage limits the amount of the drug that Liberty Health Advantage will cover. For example, Liberty Health Advantage provides 60 capsules per prescription for celecoxib. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Liberty Health Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Liberty Health Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Liberty Health Advantage will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Liberty Health Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Liberty Health Advantage Formulary? on page 6 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Liberty Health Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Liberty Health Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Liberty Health Advantage. You can ask Liberty Health Advantage to make an exception and cover your drug. See below for information about how to request an exception. Page of 66

6 How do I request an exception to the Liberty Health Advantage Formulary? You can ask Liberty Health Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. 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. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Liberty Health Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Liberty Health Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior Page 6 of 66

7 authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31- day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: i. Beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital. ii. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary iii. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits iv. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. For more information For more detailed information about your Liberty Health Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Liberty Health Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Page 7 of 66

8 If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit Liberty Health Advantage Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Liberty Health Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMIRA) and generic drugs are listed in lower-case italics (e.g., celecoxib). The information in the Requirements/Limits column tells you if Liberty Health Advantage has any special requirements for coverage of your drug. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Tier 1 Preferred Generics One month supply (30 days) Copayments for Members of Preferred Choice (HMO) 017 Retail Pharmacy or Mail Order Initial Stage Two months supply (60 days) Three months supply (90 days) $0 $0 $0 Tier Generics $10 $0 $30 Tier 3 Preferred Brand Tier Non Preferred Brands Tier Specialty Drugs $7 $9 $11 30% coinsurance 33% coinsurance 30% coinsurance 33% coinsurance 30% coinsurance 33% coinsurance Page 8 of 66

9 Drug List Updated: May 3, 017 Drug Name Tier Requirements/Limits ANALGESICS Analgesics apap/codeine sol 10-1/ ml Quantity limitation 00 per 30 days apap/codeine tab mg Quantity limitation 00 per 30 days apap/codeine tab mg Quantity limitation 00 per 30 days apap/codeine tab mg Quantity limitation 00 per 30 days ascomp/codeine cap 30 mg bupap tab mg butalbital/apap tab 0-3 mg butalbital/apap/caffeine cap butalbital/apap/caffeine 0mg/300mg/0mg cap Quantity limitation 10 per 30 days. Mail order This medication requires prior authorization. To obtain an exception please call , hours a day - 7 days a week. TTY/TDD users should call Mail order Quantity limitation 180 per 30 days. This Quantity limitation 10 per 30 days. This Page 9 of 66 your Evidence of Coverage for more information about this

10 butalbital/apap/caffeine tab butalbital/apap/caffeine w/ codeine (0/300/0/30 mg) cap butalbital/apap/caffeine w/ codeine (0/3/0/30 mg) cap butalbital/aspirin/caffeine cap butalbital/aspirin/caffeine/c odeine cap Quantity limitation 10 per 30 days. This Quantity limitation 10 per 30 days. This Quantity limitation 360 per 30 days. This Quantity limitation 180 per 30 days. This Quantity limitation 10 per 30 days. This diclofenac/misoprostol tab 0-0. mg Mail order diclofenac/misoprostol tab 7-0. mg Mail order endocet tab 10-3 mg Quantity limitation 10 per 30 days endocet tab -3 mg Quantity limitation 10 per 30 days endocet tab 7.-3 mg Quantity limitation 10 per 30 days esgic tab Quantity limitation 10 per 30 days. This hycet sol 7.-3 mg Quantity limitation 3600 per 30 days. Mail order hydrocodone/apap sol 7.-3 mg Quantity limitation 3600 per 30 days. Mail order Page 10 of 66

11 hydrocodone/apap tab mg hydrocodone/apap tab 10-3 mg hydrocodone/apap tab.-3 mg hydrocodone/apap tab mg hydrocodone/apap tab - 3 mg hydrocodone/apap tab mg hydrocodone/apap tab 7.-3 mg hydrocodone/ibuprofen tab mg lorcet plus tab 7.-3 mg lorcet tab -3 mg lorcet tab 10-3 mg lortab tab 10-3 mg lortab tab -3 mg lortab tab 7.-3 mg norco tab 10-3 mg norco tab -3 mg norco tab 7.-3 mg oxycodone/apap tab 10-3 mg oxycodone/apap tab.- 3 mg oxycodone/apap tab - 3 mg Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 360 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 360 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 360 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 360 per 30 days. Mail order Quantity limitation 10 per 30 days Quantity limitation 10 per 30 days Quantity limitation 10 per 30 days Page 11 of 66

12 oxycodone/apap tab mg Quantity limitation 10 per 30 days oxycodone/aspirin tab Quantity limitation 10 per 30 days oxycodone/ibuprofen tab -00 mg Quantity limitation 10 per 30 days tencon tab0-3mg Quantity limitation 180 per 30 days. This tramadol/apap tab mg Quantity limitation 0 per 30 days vicodin es tab mg Quantity limitation 10 per 30 days. Mail order vicodin hp tab mg Quantity limitation 10 per 30 days. Mail order vicodin tab -300 mg Quantity limitation 10 per 30 days. Mail order xodol tab -300 mg Quantity limitation 10 per 30 days. Mail order xodol tab mg Quantity limitation 10 per 30 days. Mail order xodol tab mg Quantity limitation 10 per 30 days. Mail order zebutal cap Quantity limitation 10 per 30 days. This Nonsteroidal Antiinflammatory Drugs celecoxib cap 100 mg Quantity limitation 60 per 30 days celecoxib cap 00 mg Quantity limitation 60 per 30 days celecoxib cap 00 mg Quantity limitation 60 per 30 days celecoxib cap 0 mg Quantity limitation 60 per 30 days diclofenac pot tab 0 mg Mail order diclofenac tab 100 mg er Mail order diclofenac tab mg dr Mail order diclofenac tab 0 mg dr Mail order Page 1 of 66

13 diclofenac tab 7 mg dr Mail order diflunisal tab 00 mg etodolac cap 00 mg etodolac cap 300 mg etodolac er tab 00 mg etodolac er tab 00 mg etodolac er tab 600 mg etodolac tab 00 mg etodolac tab 00 mg fenoprofen tab 600 mg FLECTOR DIS1.3% Quantity limitation 60 per 30 days flurbiprofen tab 100 mg flurbiprofen tab 0 mg ibuprofen sus 100 mg/ ml ibuprofen tab 00 mg This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. ibuprofen tab 600 mg This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. ibuprofen tab 800 mg This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. indomethacin cap mg 1* Mail order indomethacin cap 0 mg 1* Mail order indomethacin cap 7 mg er 1* Page 13 of 66

14 Mail order lodine tab00mg meclofenamate sod cap 100 mg meclofenamate sod cap 0 mg meloxicam tab 1 mg Quantity limitation 30 per 30 days. This medication is part of the free first fill program and will be provided at zero cost share when you select the medication over the brand name version of selected medications. meloxicam tab 7. mg Quantity limitation 30 per 30 days. This medication is part of the free first fill program and will be provided at zero cost share when you select the medication over the brand name version of selected medications. nabumetone tab 00 mg nabumetone tab 70 mg naproxen dr tab 37 mg Mail order naproxen dr tab 00 mg Mail order naproxen sod tab 7 mg Mail order naproxen sod tab 37 mg cr Mail order naproxen sod tab 00 mg cr Mail order naproxen sod tab 0 mg Mail order NAPROXEN SUS 1 MG/ ML Mail order naproxen tab 0 mg Mail order naproxen tab 37 mg Mail order naproxen tab 00 mg Mail order oxaprozin tab 600 mg Mail order piroxicam cap 10 mg piroxicam cap 0 mg sulindac tab 10 mg sulindac tab 00 mg tolmetin sod cap 00 mg Mail order tolmetin sod tab 600 mg Mail order Page 1 of 66

15 Opioid Analgesics, Long-acting fentanyl disc 100 mcg /hr Quantity limitation 30 per 30 days fentanyl disc 1 mcg /hr Quantity limitation 30 per 30 days fentanyl disc mcg /hr Quantity limitation 30 per 30 days fentanyl disc 0 mcg /hr Quantity limitation 30 per 30 days fentanyl disc 7 mcg /hr Quantity limitation 30 per 30 days fentanyl disc 37. mcg /hr Quantity limitation 30 per 30 days fentanyl disc 6. mcg /hr Quantity limitation 30 per 30 days fentanyl disc 87. mcg /hr Quantity limitation 30 per 30 days hydromorphontab1mg er hydromorphontab16mg er HYDROMORPHONTAB3 MG ER hydromorphontab8mg er levorphanol tab mg Quantity limitation 10 per 30 days methadone sol 10 mg/ ml Quantity limitation 600 per 30 days. Mail order methadone sol mg/ ml Quantity limitation 100 per 30 days. Mail order METHADONE INJ 10 MG/ML methadone tab 10 mg methadone tab mg morphine sul cap 10 mg er morphine sul cap 100 mg er morphine sul cap 10 mg er morphine sul cap 0 mg er Quantity limitation 10 per 30 days. Mail order This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make Quantity limitation 10 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Page 1 of 66

16 morphine sul cap 30 mg er morphine sul cap 30 mg er morphine sul cap mg er morphine sul cap 0 mg er morphine sul cap 60 mg er morphine sul cap 60 mg er morphine sul cap 7 mg er morphine sul cap 80 mg er morphine sul cap 90 mg er morphine sul tab 100 mg er Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 10 per 30 days. morphine sul tab 1 mg er Quantity limitation 10 per 30 days. morphine sul tab 00 mg er Quantity limitation 10 per 30 days. morphine sul tab 30 mg er Quantity limitation 10 per 30 days morphine sul tab 60 mg er Quantity limitation 10 per 30 days OXYCODONE TAB10MG ER OXYCODONE TAB1MG ER OXYCODONE TAB0MG ER OXYCODONE TAB30MG ER OXYCODONE TAB0MG ER OXYCODONE TAB60MG ER OXYCODONE TAB80MG ER 3 Quantity limitation 90 per 30 days 3 Quantity limitation 90 per 30 days 3 Quantity limitation 90 per 30 days 3 Quantity limitation 90 per 30 days 3 Quantity limitation 90 per 30 days 3 Quantity limitation 90 per 30 days 3 Quantity limitation 10 per 30 days Page 16 of 66

17 OXYCONTIN TAB 10 MG CR 3 Quantity limitation 90 per 30 days OXYCONTIN TAB 1 MG CR 3 Quantity limitation 90 per 30 days OXYCONTIN TAB 0 MG CR 3 Quantity limitation 90 per 30 days OXYCONTIN TAB 30 MG CR 3 Quantity limitation 90 per 30 days OXYCONTIN TAB 0 MG CR 3 Quantity limitation 90 per 30 days OXYCONTIN TAB 60 MG CR 3 Quantity limitation 90 per 30 days OXYCONTIN TAB 80 MG CR 3 Quantity limitation 10 per 30 days tramadol hcl tab 100 mg er Quantity limitation 30 per 30 days tramadol hcl tab 00 mg er Quantity limitation 30 per 30 days tramadol hcl tab 300 mg er Quantity limitation 30 per 30 days Opioid Analgesics, Short-acting butorphanol sol 10 mg/ml Quantity limitation 10 per 30 days duramorph inj 0. mg/ml Quantity limitation 180 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make duramorph inj 1 mg/ml Quantity limitation 180 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make fentanyl ot loz 100 mcg Quantity limitation 10 per 30 days. This fentanyl ot loz 1600 mcg Quantity limitation 10 per 30 days. This Page 17 of 66

18 fentanyl ot loz 00 mcg Quantity limitation 10 per 30 days. This fentanyl ot loz 00 mcg Quantity limitation 10 per 30 days. This fentanyl ot loz 600 mcg Quantity limitation 10 per 30 days. This fentanyl ot loz 800 mcg Quantity limitation 10 per 30 days. This hydromorphone tab mg Quantity limitation 10 per 30 days hydromorphone tab mg Quantity limitation 10 per 30 days hydromorphone tab 8 mg Quantity limitation 10 per 30 days HYSINGLA ER TAB 100 Quantity limitation 60 per 30 days. Mail order 3 MG HYSINGLA ER TAB 10 Quantity limitation 60 per 30 days. Mail order 3 MG HYSINGLA ER TAB 0 Quantity limitation 60 per 30 days. Mail order 3 MG HYSINGLA ER TAB 30 Quantity limitation 60 per 30 days. Mail order 3 MG HYSINGLA ER TAB 0 Quantity limitation 60 per 30 days. Mail order 3 MG HYSINGLA ER TAB 60 Quantity limitation 60 per 30 days. Mail order 3 MG HYSINGLA ER TAB 80 Quantity limitation 60 per 30 days. Mail order 3 MG MORPHINE SUL INJ 10 MG/ML Page 18 of 66

19 MORPHINE SUL INJ MG/ML MORPHINE SUL INJ MG/ML MORPHINE SUL INJ 8 MG/ML Quantity limitation 900 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make Quantity limitation 0 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make morphine sul sol 10 mg/ ml Quantity limitation 1800 per 30 days morphine sul sol 100 mg/ ml Quantity limitation 180 per 30 days MORPHINE SUL SOL 0 MG/ ML Quantity limitation 900 per 30 days morphine sul tab 1 mg Quantity limitation 10 per 30 days morphine sul tab 30 mg Quantity limitation 10 per 30 days nalbuphine inj 10 mg/ml Quantity limitation 10 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make nalbuphine inj 0 mg/ml Quantity limitation 10 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make oxycodone sol mg/ ml Quantity limitation 1800 per 30 days oxycodone cap mg Quantity limitation 10 per 30 days oxycodone con 100 mg/ ml Quantity limitation 10 per 30 days oxycodone tab 10 mg Quantity limitation 10 per 30 days Page 19 of 66

20 oxycodone tab 1 mg Quantity limitation 10 per 30 days oxycodone tab 0 mg Quantity limitation 10 per 30 days oxycodone tab 30 mg Quantity limitation 10 per 30 days oxycodone tab mg Quantity limitation 10 per 30 days tramadol hcl tab 0 mg Quantity limitation 0 per 30 days ANESTHETICS Local Anesthetics lidocaine sol % visc lidocaine sol % lidocaine gel % jelly lidocaine inj 0.% lidocaine oint % lidocaine pad % lidocaine/prilocaine cream.-.% ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anticraving acampro cal tab 333 mg disulfiram tab 0 mg disulfiram tab 00 mg VIVITROL INJ 380 MG Opioid Dependence Treatments Quantity limitation 90 per 30 days. This Page 0 of 66

21 buprenorphine inj 0.3 mg/ml 3 Quantity limitation 10 per 30 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make buprenorphine sub mg Quantity limitation 10 per 30 days buprenorphine sub 8 mg Quantity limitation 10 per 30 days. buprenorphine/naloxone sub -0. mg buprenorphine/naloxone sub 8- mg BUTRANS DISC 10 MCG /HR BUTRANS DISC 1 MCG /HR Quantity limitation 10 per 30 days. Mail order This medication requires prior authorization. To obtain an exception please call , hours a day - 7 days a week. TTY/TDD users should call Quantity limitation 10 per 30 days. Mail order This medication requires prior authorization. To obtain an exception please call , hours a day - 7 days a week. TTY/TDD users should call Quantity limitation per 8 days 3 Quantity limitation per 8 days BUTRANS DISC 0 MCG /HR 3 Quantity limitation per 8 days BUTRANS DISC MCG /HR 3 Quantity limitation per 8 days BUTRANS DISC 7. MCG/HR 3 Quantity limitation per 8 days SUBOXONE MIS 1-3 MG Quantity limitation 60 per 30 days SUBOXONE MIS -0. MG Quantity limitation 90 per 30 days SUBOXONE MIS -1 MG Quantity limitation per 30 days SUBOXONE MIS 8- MG Quantity limitation 90 per 30 days Opioid Reversal Agents naloxone inj 1 mg/ml 3 naltrexone tab 0 mg Smoking Cessation Agents Page 1 of 66

22 buproban tab 10 mg Quantity limitation 90 per 30 days bupropion hcl tab 10 mg xl Quantity limitation 30 per 30 days bupropion hcl tab 300 mg xl Quantity limitation per 30 days bupropion tab 100 mg Quantity limitation 10 per 30 days bupropion tab 10 mg Quantity limitation 90 per 30 days bupropion tab 100 mg sr Quantity limitation 60 per 30 days bupropion tab 10 mg sr Quantity limitation 90 per 30 days bupropion tab 00 mg sr Quantity limitation 30 per 30 days bupropion tab 7 mg Quantity limitation 180 per 30 days CHANTIX PAK 0. & 1 MG 3 Quantity limitation 60 per 30 days CHANTIX TAB 0. MG 3 Quantity limitation 60 per 30 days CHANTIX TAB 1 MG 3 Quantity limitation 60 per 30 days FORFIVO XL TAB 0 MG NICOTROL NS SPRAY 10 MG/ML 3 Quantity limitation 0 per 30 days ANTIBACTERIALS Aminoglycosides gentak oint 0.3% op Mail order gentamicin sol 0.3% op Mail order gentamicin cream 0.1% Mail order gentamicin inj 10 mg/ml Mail order gentamicin inj 0 mg/ml Mail order GENTAMICIN OINT 0.1% Mail order gentamicin oint 0.3% op Mail order neomycin tab 00 mg paromomycin cap 0 mg Page of 66

23 streptomycin inj 1 gm TOBRADEX OINT % tobramycin sol 0.3% op tobramycin inj 10 mg/ml tobramycin inj 80 mg/ ml tobramycin neb 300 mg/ ml Antibacterials colistimethate inj 10 mg neomycin/polymyxin gu sol 0/ml irrigation SYNERCID INJ 00 MG Antibacterials, Other acetic acid sol % otic baciim inj 0000 unit Page 3 of 66

24 bacitracin inj 0000 unit bacitracin oint op chloramphenicol inj 1 gm clindamax gel 1% clindamycin sol 1% clindamycin aer 1% clindamycin cap 10 mg clindamycin cap 300 mg clindamycin cap 7 mg clindamycin cream % vaginal clindamycin gel 1% clindamycin inj 300 mg clindamycin inj 600 mg clindamycin inj 600 mg/ ml clindamycin inj 900 mg clindamycin lotion 1% clindamycin pad1% CUBICIN SOL 00 MG daptomycin inj 00mg Mail order Page of 66

25 linezolid inj mg/ml linezolid sus 100 mg/ ml linezolid tab 600 mg Quantity limitation 8 per 1 days. This methenamine hippurate tab 1 gm metronidazole cap 37 mg metronidazole cream 0.7% metronidazole gel 0.7% metronidazole gel 0.7% vaginal metronidazole gel 1% metronidazole lotion 0.7% metronidazole tab 0 mg metronidazole tab 00 mg metronidazole/nacl inj 00 mg mupirocin cream % Mail order mupirocin oint % nitrofurantoin mac cap mg nitrofurantoin mac cap 100 mg Mail order Mail order Page of 66

26 nitrofurantoin mac cap 0 mg nitrofurantoin sus mg/ ml Mail order SULFAMYLON CREAM 8 MG/GM tinidazole tab 0 mg Mail order tinidazole tab 00 mg Mail order trimethoprim tab 100 mg TYGACIL INJ 0 MG Quantity limitation 0 per 30 days. This vancomycin cap 1 mg Quantity limitation 80 per 30 days. This vancomycin cap 0 mg vancomycin inj 10 gm vancomycin inj 1000 mg vancomycin inj 00 mg Beta-lactam, Cephalosporins Page 6 of 66

27 cefaclor cap 0 mg cefaclor cap 00 mg cefaclor er tab 00 mg cefaclor sus 1 mg/ ml cefaclor sus 0 mg ml cefaclor sus 37 mg/ ml cefadroxil cap 00 mg cefadroxil sus 0 mg/ ml cefadroxil sus 00/ ml cefadroxil tab 1 gm cefazolin inj 1 gm cefazolin inj 10 gm cefazolin inj 00 mg cefdinir cap 300 mg cefdinir sus 1 mg/ ml cefdinir sus 0 mg/ ml cefepime inj 1 gm cefepime inj gm cefixime sus 100 mg/ ml Mail order Page 7 of 66

28 cefixime sus 00 mg/ ml Mail order cefoxitin inj 1 gm cefoxitin inj 10 gm cefoxitin inj gm cefpodoxime proxetil sus 100 mg/ ml cefpodoxime proxetil sus 0 mg/ ml cefpodoxime tab 100 mg cefpodoxime tab 00 mg cefprozil sus 1 mg/ ml cefprozil sus 0 mg/ ml cefprozil tab 0 mg cefprozil tab 00 mg ceftriaxone inj 10 gm ceftriaxone inj 1 gm ceftriaxone inj gm ceftriaxone inj 0 mg ceftriaxone inj 00 mg Page 8 of 66

29 cefuroxime inj 1. gm cefuroxime inj 7. gm cefuroxime inj 70 mg cefuroxime tab 0 mg cefuroxime tab 00 mg cephalexin cap 0 mg cephalexin cap 00 mg cephalexin cap 70 mg cephalexin sus 1 mg/ ml cephalexin sus 0 mg/ ml cephalexin tab 0 mg cephalexin tab 00 mg SUPRAX CAP 00 MG Mail order TEFLARO INJ 00 MG TEFLARO INJ 600 MG Beta-lactam, Other Page 9 of 66

30 AZACTAM/DEXTROSE INJ GM aztreonam inj 1 gm imipenem/cilastatin inj 0 mg imipenem/cilastatin inj 00 mg INVANZ INJ 1 GM Mail order meropenem inj 00 mg Beta-lactam, Penicillins amoxicillin cap 0 mg 1* amoxicillin cap 00 mg 1* amoxicillin chew 1 mg 1* amoxicillin chew 0 mg 1* amoxicillin sus 1 mg/ ml 1* amoxicillin sus 00 mg/ ml 1* amoxicillin sus 0 mg/ ml 1* amoxicillin sus 00 mg/ ml 1* amoxicillin tab 00 mg 1* amoxicillin tab 87 mg 1* Page 30 of 66

31 AMOXICILLIN/K CLAV CHEW 00 MG amoxicillin/k clav chew 00 mg amoxicillin/k clav sus 00 mgmg/ ml amoxicillin/k clav sus 0 mg/ ml amoxicillin/k clav sus 00 mg/ ml amoxicillin/k clav sus 600 mg/ ml amoxicillin/k clav tab 0-1 mg amoxicillin/k clav tab 00-1 mg amoxicillin/k clav tab 87 mg amoxicillin-potassium cla tab er ampicillin cap 0 mg ampicillin cap 00 mg ampicillin inj 1 gm ampicillin inj 10 gm ampicillin inj 1 mg ampicillin sus 1 mg/ ml ampicillin sus 0 mg/ ml Page 31 of 66

32 ampicillin-sulbactam inj 1 gm ampicillin-sulbactam inj 3 gm BICILLIN C-R INJ BICILLIN C-R INJ 900/300 BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ dicloxacillin cap 0 mg dicloxacillin cap 00 mg nafcillin inj 1 gm nafcillin inj 10 gm penicillin g proc inj unit penicillin g sod inj unit penicillin gk inj mu Page 3 of 66

33 Mail order PENICILLIN GK/INJ DEX MU Mail order PENICILLIN GK/INJ DEX 3 MU Mail order penicillin vk sol 1 mg/ ml 1* Mail order penicillin vk sol 0 mg/ ml 1* Mail order penicillin vk tab 0 mg 1* Mail order penicillin vk tab 00 mg 1* Mail order piperacillin/tazobactam inj gm piperacillin/tazobactam inj -0. gm ZOSYN SOL -0. GM ZOSYN SOL GM Mail order Mail order Macrolides AZASITE SOL 1% Mail order azithromycin inj 00 mg azithromycin powder 1 gm pack Page 33 of 66

34 azithromycin sus 100 mg/ ml Quantity limitation 30 per days azithromycin sus 00 mg/ ml Quantity limitation 90 per days azithromycin tab 0 mg azithromycin tab 00 mg Quantity limitation 6 per days azithromycin tab 600 mg Quantity limitation 6 per days clarithromycin sus 1 mg/ ml clarithromycin sus 0 mg/ ml clarithromycin tab 0 mg Quantity limitation 8 per 1 days clarithromycin tab 00 mg Quantity limitation 8 per 1 days clarithromycin tab 00 mg er Quantity limitation 8 per 1 days e.e.s. tab 00 mg Mail order ery pad % ery-tab 0 mg ec ery-tab 333 mg ec ery-tab 00 mg ec ERYTHROCIN INJ 00 MG erythrocin tab 0 mg ERYTHROMYCIN ETHYL TAB 00 MG erythromycin gel % erythromycin oint op erythromycin sol % erythromycin tab 0 mg bs erythromycin tab 00 mg bs ZMAX SUS GM Quinolones Quantity limitation 60 per 30 days. Mail order Page 3 of 66

35 ciprofloxacin inj 00 mg ciprofloxacin inj 00 mg ciprofloxacin sol 0.3% op ciprofloxacin tab 100 mg ciprofloxacin tab 1000 mg ciprofloxacin tab 0 mg ciprofloxacin tab 00 mg ciprofloxacin tab 00 mg er ciprofloxacin tab 70 mg levofloxacin inj mg/ml levofloxacin sol 0.% levofloxacin sol mg/ml levofloxacin tab 0 mg Quantity limitation 1 per 1 days levofloxacin tab 00 mg Quantity limitation 1 per 1 days levofloxacin tab 70 mg Quantity limitation 1 per 1 days levofloxacin/dw inj 00 mg/100 ml MOXEZA SOL0.% 3 ofloxacin drop 0.3% op ofloxacin drop 0.3% otic ofloxacin tab 300 mg ofloxacin tab 00 mg VIGAMOX DROP 0.% 3 Sulfonamides silver sulfadiazine cream 1% 1* Page 3 of 66

36 sodium sulfacetamide sol 10% op ssd cream 1% 1* sulfamethoxazoletrimethoprim sus * mg/ ml SULFACETAMIDE SODIUM OINT 10% OP sulfacetamide sus 10% sulfadiazine tab 00 mg sulfamethoxazoletrimethoprim inj mg/ ml sulfamethoxazoletrimethoprim tab mg sulfamethoxazoletrimethoprim tab mg Tetracyclines demeclocycline tab 10 mg demeclocycline tab 300 mg 1* 1* doxy 100 inj100mg 3 doxycycline cap 10 mg doxycycline cap 7 mg doxycycline hyc cap 100 mg doxycycline hyc cap 0 mg doxycycline hyc tab 100 mg Page 36 of 66

37 doxycycline hyc tab 100 mg drr Mail order doxycycline hyc tab 10 mg dr Mail order doxycycline hyc tab 7 mg dr Mail order doxycycline hyc tab 00 mg dr Mail order doxycycline hyc tab 0 mg dr Mail order doxycycline hyclate inj 100 mg doxycycline mono cap 100 mg doxycycline mono cap 0 mg doxycycline sus mg/ ml Mail order minocycline cap 100 mg minocycline cap 0 mg minocycline cap 7 mg minocycline tab 100 mg minocycline tab 13 mg er minocycline tab mg er minocycline tab 0 mg minocycline tab 7 mg minocycline tab 90 mg er morgidox cap1x0mg ANTICONVULSANTS Anticonvulsants, Other APTIOM TAB 00 MG Quantity limitation 180 per 30 days APTIOM TAB 00 MG Quantity limitation 90 per 30 days APTIOM TAB 600 MG Quantity limitation 60 per 30 days APTIOM TAB 800 MG Quantity limitation per 30 days Page 37 of 66

38 levetiracetam sol 100 mg/ml levetiracetam tab 1000 mg levetiracetam tab 0 mg levetiracetam tab 00 mg levetiracetam tab 00 mg er Quantity limitation 180 per 30 days levetiracetam tab 70 mg levetiracetam tab 70 mg er Quantity limitation 10 per 30 days levetiracetm inj 00 mg/ ml POTIGA TAB 00 MG POTIGA TAB 300 MG POTIGA TAB 00 MG POTIGA TAB 0 MG Quantity limitation 180 per 30 days. Mail order Quantity limitation 10 per 30 days. Mail order Quantity limitation 90 per 30 days. Mail order Quantity limitation 70 per 30 days. Mail order roweepra tab 00 mg SPRITAM TAB 1000 MG Quantity limitation 90 per 30 days. Mail order SPRITAM TAB 0 MG Quantity limitation 360 per 30 days. Mail order SPRITAM TAB 00 MG Quantity limitation 180 per 30 days. Mail order SPRITAM TAB 70 MG Quantity limitation 10 per 30 days. Mail order Calcium Channel Modifying Agents CELONTIN CAP 300 MG ethosuximide cap 0 mg ethosuximide sol 0 mg ml LYRICA SOL 0 MG/ML 3 Quantity limitation 900 per 30 days Page 38 of 66

39 LYRICA CAP 100 MG 3 Quantity limitation 180 per 30 days LYRICA CAP 10 MG 3 Quantity limitation 10 per 30 days LYRICA CAP 00 MG 3 Quantity limitation 90 per 30 days LYRICA CAP MG 3 Quantity limitation 60 per 30 days LYRICA CAP MG 3 Quantity limitation 70 per 30 days LYRICA CAP 300 MG 3 Quantity limitation 60 per 30 days LYRICA CAP 0 MG 3 Quantity limitation 360 per 30 days LYRICA CAP 7 MG 3 Quantity limitation 0 per 30 days zonisamide cap 100 mg zonisamide cap mg zonisamide cap 0 mg Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tab 0.1 mg Quantity limitation 800 per 30 days clonazepam odt tab 0. mg Quantity limitation 00 per 30 days clonazepam odt tab 0. mg Quantity limitation 100 per 30 days clonazepam odt tab 1 mg Quantity limitation 600 per 30 days clonazepam odt tab mg Quantity limitation 300 per 30 days clonazepam tab 0. mg Quantity limitation 100 per 30 days clonazepam tab 1 mg Quantity limitation 600 per 30 days clonazepam tab mg Quantity limitation 300 per 30 days clorazate dipot tab 7. mg Quantity limitation 360 per 30 days clorazepate dipot tab 1 mg Quantity limitation 180 per 30 days clorazepate dipot tab 3.7 mg Quantity limitation 70 per 30 days DIASTAT ACUDIAL GEL 1.-0 MG Quantity limitation 0 per 30 days DIASTAT ACUDIAL GEL -10 MG Quantity limitation 30 per 30 days DIASTAT PED GEL. MG GEL Quantity limitation 30 per 30 days diazepam sol 1 mg/ml Quantity limitation 100 per 30 days diazepam con mg/ml Quantity limitation 0 per 30 days Page 39 of 66

40 DIAZEPAM GEL 10 MG Quantity limitation 30 per 30 days DIAZEPAM GEL. MG Quantity limitation 30 per 30 days DIAZEPAM GEL 0 MG Quantity limitation 0 per 30 days diazepam tab 10 mg Quantity limitation 180 per 30 days diazepam tab mg Quantity limitation 90 per 30 days diazepam tab mg Quantity limitation 0 per 30 days divalproex cap 1 mg divalproex tab 1 mg dr divalproex tab 0 mg dr divalproex tab 0 mg er divalproex tab 00 mg dr divalproex tab 00 mg er FYCOMPA SUS 0. MG/ML Quantity limitation 70 per 30 days FYCOMPA TAB 10 MG Quantity limitation 30 per 30 days FYCOMPA TAB 1 MG Quantity limitation 30 per 30 days FYCOMPA TAB MG Quantity limitation 10 per 30 days FYCOMPA TAB MG Quantity limitation 90 per 30 days FYCOMPA TAB 6 MG Quantity limitation 60 per 30 days FYCOMPA TAB 8 MG Quantity limitation 30 per 30 days gabapentin sol 0 mg/ ml Quantity limitation 160 per 30 days gabapentin cap 100 mg Quantity limitation 360 per 30 days gabapentin cap 300 mg Quantity limitation 360 per 30 days gabapentin cap 00 mg Quantity limitation 70 per 30 days gabapentin tab 600 mg Quantity limitation 180 per 30 days gabapentin tab 800 mg Quantity limitation 10 per 30 days GABITRIL TAB 1 MG GABITRIL TAB 16 MG lorazepam con mg/ml lorazepam tab 0. mg Quantity limitation 360 per 30 days lorazepam tab 1 mg Quantity limitation 180 per 30 days lorazepam tab mg Quantity limitation 90 per 30 days ONFI SUS. MG/ML Quantity limitation 80 per 30 days ONFI TAB 10 MG Quantity limitation 60 per 30 days ONFI TAB 0 MG Quantity limitation 60 per 30 days Page 0 of 66

41 phenobarb elx 0 mg/ ml Quantity limitation 100 per 30 days phenobarb tab 100 mg Quantity limitation 90 per 30 days phenobarb tab 1 mg Quantity limitation 10 per 30 days phenobarb tab 16. mg Quantity limitation 360 per 30 days phenobarb tab 30 mg Quantity limitation 19 per 30 days phenobarb tab 3. mg Quantity limitation 180 per 30 days phenobarb tab 60 mg Quantity limitation 60 per 30 days phenobarb tab 6.8 mg Quantity limitation 90 per 30 days phenobarb tab 97. mg Quantity limitation 60 per 30 days primidone tab 0 mg primidone tab 0 mg SABRIL POWDER 00 MG SABRIL TAB 00 MG tiagabine tab mg tiagabine tab mg valproate inj 00 mg/ ml valproic acid cap 0 mg valproic acid syp 0 mg ml Glutamate Reducing Agents felbamate sus 600 mg/ ml felbamate tab 00 mg felbamate tab 600 mg Quantity limitation 180 per 30 days. This prescription may be available only at certain pharmacies. For more information please call , hours a day - 7 days a week. TTY/TDD users should call Quantity limitation 180 per 30 days. This prescription may be available only at certain pharmacies. For more information please call , hours a day - 7 days a week. TTY/TDD users should call Page 1 of 66

42 lamotrigine chew mg Mail order lamotrigine chew mg Mail order lamotrigine odt tab 100 mg Mail order lamotrigine tab 100 mg Mail order lamotrigine tab 100 mg err Mail order lamotrigine tab 10 mg Mail order lamotrigine tab 00 mg Mail order lamotrigine odt tab 00 mg Mail order lamotrigine tab 00 mg er Mail order lamotrigine tab mg Mail order lamotrigine tab mg er Mail order lamotrigine tab mg odt Mail order lamotrigine tab 0 mg er Mail order lamotrigine tab 300 mg er Mail order lamotrigine tab 0 mg er Mail order lamotrigine tab 0 mg odt Mail order topiramate cap 1 mg topiramate cap mg topiramate tab 100 mg Quantity limitation 80 per 30 days topiramate tab 00 mg Quantity limitation 0 per 30 days topiramate tab mg Quantity limitation 190 per 30 days topiramate tab 0 mg Quantity limitation 960 per 30 days TROKENDI XR CAP 100 MG Mail order TROKENDI XR CAP 00 MG TROKENDI XR CAP MG Mail order TROKENDI XR CAP 0 MG Mail order Sodium Channel Agents BANZEL SUS 0 MG/ML Quantity limitation 00 per 30 days BANZEL TAB 00 MG Quantity limitation 0 per 30 days BANZEL TAB 00 MG Quantity limitation 0 per 30 days Page of 66

43 BRIVIACT INJ 0 MG/ ML BRIVIACT SOL 10 MG/ML Quantity limitation 600 per 30 days BRIVIACT TAB 100 MG ML Quantity limitation 60 per 30 days BRIVIACT TAB 10 MG Quantity limitation 600 per 30 days BRIVIACT TAB MG Quantity limitation 0 per 30 days BRIVIACT TAB 0 MG Quantity limitation 10 per 30 days BRIVIACT TAB 7 MG Quantity limitation 90 per 30 days carbamazepine cap 100 mg er carbamazepine cap 00 mg er carbamazepine chew 100 mg carbamazepine sus 100 mg/ ml carbamazepine tab 00 mg carbamazepine tab 100 mg er carbamazepine tab 00 mg er carbamazepine tab 00 mg er carbamazepinecap 300 mg er DILANTIN CAP 30 MG 3 epitol tab 00 mg EQUETRO CAP 100 MG Quantity limitation 80 per 30 days EQUETRO CAP 00 MG Quantity limitation 0 per 30 days EQUETRO CAP 300 MG Quantity limitation 180 per 30 days fosphenytoin inj 100 mg/ ml Mail order Page 3 of 66

44 oxcarbazepine sus 300 mg/ ml oxcarbazepine tab 10 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg OXTELLAR XR TAB 10 MG Quantity limitation 80 per 30 days OXTELLAR XR TAB 300 MG Quantity limitation 0 per 30 days OXTELLAR XR TAB 600 MG Quantity limitation 10 per 30 days PEGANONE TAB 0 MG phenytek cap 00 mg 1* Mail order phenytek cap 300 mg 1* Mail order phenytoin chew 0 mg 1* phenytoin ex cap 100 mg 1* phenytoin ex cap 00 mg 1* phenytoin ex cap 300 mg 1* phenytoin inj 0 mg/ml Mail order phenytoin sus 1 mg/ ml 1* VIMPAT SOL 10 MG/ML Quantity limitation 100 per 30 days VIMPAT INJ 00 MG/0 Quantity limitation 100 per 30 days VIMPAT TAB 100 MG Quantity limitation 60 per 30 days VIMPAT TAB 10 MG Quantity limitation 60 per 30 days VIMPAT TAB 00 MG Quantity limitation 60 per 30 days VIMPAT TAB 0 MG Quantity limitation 60 per 30 days ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mes tab 1 mg oral Page of 66

45 Cholinesterase Inhibitors donepezil tab 10 mg Quantity limitation 30 per 30 days donepezil tab 10 mg odt Quantity limitation 30 per 30 days donepezil tab mg Quantity limitation 30 per 30 days donepezil tab mg odt Quantity limitation 30 per 30 days donepezil tab hcl 3 mg galantamine sol mg/ml Quantity limitation 180 per 30 days galantamine cap 16 mg er Quantity limitation 30 per 30 days galantamine cap mg er Quantity limitation 30 per 30 days galantamine cap 8 mg er Quantity limitation 30 per 30 days galantamine tab 1 mg Quantity limitation 60 per 30 days galantamine tab mg Quantity limitation 60 per 30 days galantamine tab 8 mg Quantity limitation 60 per 30 days rivastigmine cap 1. mg Quantity limitation 60 per 30 days rivastigmine cap 3 mg Quantity limitation 60 per 30 days rivastigmine cap. mg Quantity limitation 60 per 30 days rivastigmine cap 6 mg Quantity limitation 60 per 30 days rivastigmine disc 13.3 mg/ hr Quantity limitation 30 per 30 days rivastigmine disc.6 mg/ hr Quantity limitation 30 per 30 days rivastigmine disc 9. mg/ hr Quantity limitation 30 per 30 days N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hydrochloride sol mg/ml Quantity limitation 360 per 30 days memantine tab hcl 10 mg Quantity limitation 60 per 30 days memantine tab hcl mg Quantity limitation 60 per 30 days memantine titration pak - 10 mg Quantity limitation 60 per 30 days NAMZARIC CAP 3 Mail order NAMZARIC CAP 1-10 MG 3 Mail order NAMZARIC CAP 7-10 MG 3 Mail order Page of 66

46 NAMZARIC CAP 1-10 MG 3 Mail order NAMZARIC CAP 8-10 MG 3 Mail order ANTIDEPRESSANTS Antidepressants olanzapine/fluoxetine cap 1- mg Quantity limitation 30 per 30 days olanzapine/fluoxetine cap 1-0 mg Quantity limitation 30 per 30 days olanzapine/fluoxetine cap 3- mg Quantity limitation 90 per 30 days olanzapine/fluoxetine cap 6- mg Quantity limitation 90 per 30 days olanzapine/fluoxetine cap 6-0 mg Quantity limitation 30 per 30 days perphenazine/amitriptyline tab -10 mg perphenazine/amitriptyline tab - mg perphenazine/amitriptyline tab -10 mg perphenazine/amitriptyline tab - mg perphenazine/amitriptyline tab -0 mg Antidepressants, Other ABILIFY MAIN INJ 300 MG (SYRINGE) Quantity limitation 1 per 8 days ABILIFY MAIN INJ 300 MG (VIAL) Quantity limitation per 8 days. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make ABILIFY MAIN INJ 00 MG Quantity limitation 1 per 8 days aripiprazole tab 10 mg Quantity limitation 90 per 30 days aripiprazole tab 10 mg odt Quantity limitation 90 per 30 days aripiprazole tab 1 mg Quantity limitation 60 per 30 days Page 6 of 66

47 aripiprazole tab 1 mg odt Quantity limitation 60 per 30 days aripiprazole tab mg Quantity limitation 0 per 30 days aripiprazole tab 0 mg Quantity limitation 60 per 30 days aripiprazole tab 30 mg Quantity limitation 30 per 30 days aripiprazole tab mg Quantity limitation 180 per 30 days ARISTADA INJ 1 MG/1 ML. Quantity limitation 1.6 per 8 days ARISTADA INJ 66 MG/ ML Quantity limitation. per 8 days ARISTADA INJ 88 MG/3 ML Quantity limitation 3. per 8 days mirtazapine tab 1 mg Quantity limitation 30 per 30 days mirtazapine tab 1 mg odt Quantity limitation 30 per 30 days mirtazapine tab 30 mg Quantity limitation 30 per 30 days mirtazapine tab 30 mg odt Quantity limitation 30 per 30 days mirtazapine tab mg Quantity limitation 30 per 30 days mirtazapine tab mg odt Quantity limitation 30 per 30 days mirtazapine tab 7. mg Quantity limitation 30 per 30 days quetiapine tab 100 mg Quantity limitation 0 per 30 days quetiapine tab 00 mg Quantity limitation 10 per 30 days quetiapine tab mg Quantity limitation 960 per 30 days quetiapine tab 300 mg Quantity limitation 90 per 30 days quetiapine tab 00 mg Quantity limitation 60 per 30 days quetiapine tab 0 mg Quantity limitation 80 per 30 days QUETIAPINE TAB 10MG ER QUETIAPINE TAB 00MG ER QUETIAPINE TAB 300MG ER quetiapine tab 00 mg er QUETIAPINE TAB 0MG ER Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order Quantity limitation 60 per 30 days. Mail order REXULTI TAB 0. MG Quantity limitation 80 per 30 days REXULTI TAB 0. MG Quantity limitation 0 per 30 days REXULTI TAB 1 MG Quantity limitation 10 per 30 days Page 7 of 66