Quantity Limit Drug List

Transcription

1 Quantity Limit Drug List Quantity limits define the maximum amount of medication covered by your drug benefit for one prescription or copayment. This means your benefit covers a limited number of doses per prescription based on the medication s recommended dosing guidelines. If you or your physician requests an amount greater than the quantity limit of a medication, a prior authorization review may be required. The goal of the PreferredOne Quantity Limit Program is to promote appropriate and cost-effective use of medications based on U.S. Food and Drug Administration (FDA) dosing guidelines, the medical literature and other factors. This list is subject to change throughout the year. The presence of a drug on this list does not guarantee coverage and not all drugs included on this list may be covered by your pharmacy benefit plan. Coverage of medications is determined your benefit plan. A ABILIFY ABSTRAL ACIPHEX ACIPHEX SPRINKLE (DR 5 MG CAP, DR 10 MG CAP) ACTIQ ACTONEL 150 MG TABLET ACTONEL 35 MG TABLET ADCIRCA ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 12.5 MG TABLET, 15 MG TABLET, 20 MG TABLET) ADDERALL 30 MG TABLET ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE) ADDYI ADEMPAS ADLYXIN MCG STARTER PACK ADLYXIN 20 MCG MAINTENANCE PK 1 / 28 4 / 28 2 PACKS / PENS (6 ML) / 28 ADVAIR DISKUS 1 INHALER (60 BLISTERS) / 30 ADVAIR HFA 1 INHALER (12 G) / 30 ADZENYS ER ML / DAY

2 ADZENYS XR-ODT (3.1 MG TABLET, 6.3 MG TABLET, 9.4 MG TABLET, 12.5 MG TABLET, 15.7 MG TABLET, 18.8 MG TABLET) A AEROSPAN 2 INHALERS (17.8 G) / 30 AFINITOR AIMOVIG AUTOINJECTOR 2 SYRINGES (2 ML) / 30 AIMOVIG AUTOINJECTOR (2 PACK) 2 SYRINGES (2 ML) / 30 AIRDUO RESPICLICK (55-14 MCG, MCG, MCG) 1 INHALER / 30 AJOVY 1 SYRINGE (1.5 ML) / 30 AKYNZEO MG CAPSULE albuterol 2.5 mg/0.5 ml sol albuterol 5 mg/ml solution 2 / VIALS / ML / 30 albuterol sul 2.5 mg/3 ml soln 180 VIALS (540 ML) / 30 albuterol sulfate (0.63 ml, 1.25 ml) 125 VIALS (375 ML) / 30 ALECENSA alendronate sodium (35 mg tab, 70 mg tab) almotriptan malate alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) alprazolam 2 mg tablet alprazolam er (er 0.5 mg tablet, er 1 mg tablet) alprazolam er 2 mg tablet alprazolam er 3 mg tablet 8 / DAY 4 / / 30 5 / DAY 5 / DAY alprazolam intensol 10 BOTTLES (300 ML) / 30 alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1 mg tab) alprazolam odt 2 mg tab alprazolam xr (0.5 mg tablet, 1 mg tablet) alprazolam xr 2 mg tablet alprazolam xr 3 mg tablet ALUNBRIG (90 MG TABLET, 180 MG TABLET) ALUNBRIG 30 MG TABLET 5 / DAY 5 / DAY ALUNBRIG 90 MG-180 MG TAB PACK 1 PACKAGE (30 TABLETS) / 365 ALVESCO (80 MCG, 160 MCG) 2 INHALERS (12.2 G) / 30

3 AMBIEN AMBIEN CR AMERGE AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) amphetamine sulfate AMPYRA A 9 / 30 ANORO ELLIPTA 1 INHALER (60 BLISTERS) / 30 ANZEMET (50 MG TABLET, 100 MG TABLET) 2 / 30 APOKYN 20 CARTRIDGES (60 ML) / 30 aprepitant 125 mg capsule aprepitant mg pack aprepitant 40 mg capsule aprepitant 80 mg capsule APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE) ARCAPTA NEOHALER ARIKAYCE aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) 2 / 30 2 TRIPACKS (6 CAPSULES) / 30 1 / 30 4 / 30 4 CAPSULES / DAY 30 VIALS / 30 aripiprazole 1 mg/ml solution 5 BOTTLES (750 ML) / 30 aripiprazole odt ARIXTRA 35 DAY SUPPLY / 180 armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) armodafinil 50 mg tablet ARMONAIR RESPICLICK (55 MCG, 113 MCG, 232 MCG) 1 INHALER / 30 ARNUITY ELLIPTA 1 INHALER (30 BLISTERS) / 30 ARYMO ER ASMANEX (TWISTHALER 110 MCG #7, TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #60, TWISTHALER 220 MCG #14, TWISTHALR 220 MCG #120) 1 INHALER / 30 ASMANEX HFA (100 MCG, 200 MCG) 1 INHALER (13 G) / 30 ASTEPRO 2 BOTTLES (60 ML) / 30 ATIVAN (0.5 MG TABLET, 1 MG TABLET) ATIVAN 2 MG TABLET 5 / DAY

4 atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mg capsule, 40 mg capsule) atomoxetine hcl (60 mg capsule, 80 mg capsule, 100 mg capsule) A ATROVENT HFA 2 INHALERS (25.8 G) / 30 AUBAGIO (7 MG TABLET, 14 MG TABLET) AUSTEDO AVONEX 30 MCG VIAL KIT AVONEX PEN AVONEX PREFILLED SYR 30 MCG KT AXERT 4 KITS (4 VIALS) / 28 1 KIT / 28 1 KIT / / 30 azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 2 BOTTLES (60 ML) / 30 BARACLUDE 0.05 MG/ML SOLUTION 3 BOTTLES (630 ML) / 30 BECONASE AQ BELBUCA BELSOMRA (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) BETASERON B 1 BOTTLE (25 G) / 25 1 KIT (15 VIALS) / 30 BEVESPI AEROSPHERE 1 INHALER (10.7 G) / 30 BEVYXXA bimatoprost 0.03% eye drops BONIVA 150 MG TABLET 44 / ML / 25 1 / 28 BREO ELLIPTA 1 INHALER (60 BLISTERS) / 30 BRINTELLIX bromfenac sodium 1 BOTTLE / RX BROVANA 60 VIALS (120 ML) / 30 budesonide (0.25 ml, 0.5 ml, 1 ml inh) 60 AMPULES (120 ML) / 30 budesonide 32 mcg nasal spray 2 BOTTLES (16.9 G) / 30 BUNAVAIL MG FILM BUNAVAIL MG FILM BUNAVAIL MG FILM buprenorphine (5, 10, 15, 20) buprenorphine 2 mg tablet sl 4 / 28 1

5 B buprenorphine 7.5 mcg/hr patch buprenorphine 8 mg tablet sl buprenorphine-naloxone (buprenorp-nalox mg film, buprenorphin-naloxon mg) buprenorphn-naloxn mg sl buproban bupropion hcl sr (100 mg tablet, 150 mg tablet, 200 mg tablet) bupropion hcl sr 150 mg tab bupropion hcl xl 150 mg tablet bupropion hcl xl 300 mg tablet BUTRANS BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA 10 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ 4 / / 28 4 VIALS / 28 4 AUTO-INJECTOR (3.4 ML) / 28 4 PENS / 28 1 PEN (2.4 ML) / 30 1 PEN (1.2 ML) / 30 calcitonin-salmon 1 BOTTLE (3.7 ML) / 30 CALQUENCE CAPRELSA 100 MG TABLET CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT, 40 MCG VIAL) CELEBREX celecoxib CESAMET CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET) C 2 CAPSULES / DAY 6 VIALS / / RX CHANTIX STARTING MONTH BOX 1 BOX (53 TABLETS) / 28 chlordiazepoxide 10 mg capsule chlordiazepoxide 25 mg capsule chlordiazepoxide 5 mg capsule CIALIS (10 MG TABLET, 20 MG TABLET) CIALIS (2.5 MG TABLET, 5 MG TABLET) clonazepam (0.125 mg odt, mg dis tab, 0.25 mg odt, 0.5 mg tablet, 0.5 mg dis tablet, 0.5 mg odt, 1 mg tablet, 1 mg odt, 1 mg dis tablet, 2 mg tablet) clonazepam 2 mg odt clorazepate 15 mg tablet 30 / DAY 1 6 / / DAY

6 clorazepate 3.75 mg tablet clorazepate 7.5 mg tablet clozapine (25 mg tablet, 100 mg tablet) clozapine 200 mg tablet clozapine 50 mg tablet clozapine odt (odt 25 mg tablet, odt 100 mg tablet) clozapine odt 12.5 mg tablet clozapine odt 150 mg tablet clozapine odt 200 mg tablet CLOZARIL C / DAY 9 / DAY 9 / DAY COMBIVENT RESPIMAT 2 INHALERS (8 G) / 30 CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 54 MG TABLET) CONCERTA ER 36 MG TABLET CONZIP COPAXONE 20 MG/ML SYRINGE 1 KIT (30 SYRINGES) / 30 COPAXONE 40 MG/ML SYRINGE 1 KIT (12 SYRINGES) / 28 CORLANOR (5 MG TABLET, 7.5 MG TABLET) COTEMPLA XR-ODT 17.3 MG TABLET COTEMPLA XR-ODT 25.9 MG TABLET COTEMPLA XR-ODT 8.6 MG TABLET CRINONE 15 APPLICATORS (16.9 G) / 30 CYMBALTA (20 MG CAPSULE, 60 MG CAPSULE) CYMBALTA 30 MG CAPSULE CYSTARAN 4 BOTTLES (60 ML) / 28 D DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) dalfampridine er DAYTRANA (10 HR, 15 HR, 20 HOUR, 30 HOUR) DESOXYN desvenlafaxine er (er 50 mg tablet, er 50 mg tab) desvenlafaxine er 100 mg tab desvenlafaxine fum er 100 mg desvenlafaxine fum er 50 mg 5 / DAY

7 desvenlafaxine suc er 100 mg desvenlafaxine succinate er (er 25 mg, er 50 mg) DEXEDRINE 10 MG TABLET DEXEDRINE SPANSULE 10 MG DEXEDRINE SPANSULE 15 MG DEXEDRINE SPANSULE 5 MG DEXILANT dexmethylphenidate er 20 mg cp dexmethylphenidate hcl dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) dextroamp-amphetamin 30 mg tab dextroamphetamine 10 mg tab dextroamphetamine 5 mg tab dextroamphetamine 5 mg/5 ml dextroamphetamine er 10 mg cap dextroamphetamine er 15 mg cap dextroamphetamine er 5 mg cap dextroamphetamine-amphet er dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mg tab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamin 15 mg tab, dextroamp-amphetamin 20 mg tab, dextroamp-amphetamine 5 mg tab) DIASTAT DIASTAT ACUDIAL diazepam (2.5 mg gel sys, 10 mg gel syst, 20 mg gel syst) D 1800 ML / 30 2 PACKAGES / RX 2 PACKAGES / RX 2 PACKAGES / RX diclofenac sodium 1% gel 10 TUBES (1000 G) / 30 DORAL dronabinol (2.5 mg capsule, 5 mg capsule, 10 mg capsule) DULERA (100 MCG, 200 MCG) 1 INHALER (13 G) / 30 duloxetine hcl (dr 20 mg cap, dr 60 mg cap) duloxetine hcl dr 30 mg cap DUPIXENT 200 MG/1.14 ML SYRING 4 SYRINGES (4.6 ML) / 28 DUPIXENT 300 MG/2 ML SAFE SYRG 4 SYRINGES (8 ML) / 28 DURAGESIC (12, 25, 50) DURAGESIC (75, 100) 15 / / 30

8 DYANAVEL XR D 240 ML / 30 EDEX EGRIFTA 1 MG VIAL EGRIFTA 2 MG VIAL eletriptan hbr ELIGARD 22.5 MG SYRINGE KIT ELIGARD 30 MG SYRINGE KIT ELIGARD 45 MG SYRINGE KIT ELIGARD 7.5 MG SYRINGE KIT ELIQUIS 2.5 MG TABLET E 6 CARTRIDGES / 30 2 VIALS / DAY 1 VIAL / DAY 12 / 30 1 SYRINGE / 84 1 SYRINGE / SYRINGE / SYRINGE / 28 ELIQUIS 5 MG STARTER PACK 1 PACK (74 TABLETS) / 365 ELIQUIS 5 MG TABLET EMBEDA EMEND 125 MG CAPSULE EMEND 125 MG POWDER PACKET EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIPACK EMGALITY EMSAM 2 / 30 3 / 30 1 / 30 4 / 30 2 TRIPACKS (6 CAPSULES) / 30 1 SYRINGE / 30 enoxaparin sodium 35 DAY SUPPLY / 180 ENTRESTO EPCLUSA esomeprazole magnesium estazolam ESTRING eszopiclone EVEKEO (5 MG TABLET, 10 MG TABLET) EXALGO EXTAVIA (0.3 MG VIAL, 0.3 MG KIT) 1 / 90 1 KIT (15 VIALS) / 30 FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) F

9 F FANAPT TITRATION PACK 1 PACK (8 TABLETS) / 180 FARYDAK FAZACLO (25 MG ODT, 100 MG ODT) FAZACLO 12.5 MG ODT FAZACLO 150 MG ODT FAZACLO 200 MG ODT FEMRING fentanyl (12, 25, 50) fentanyl (37.5, 62.5) fentanyl (75, 100) fentanyl 87.5 mcg/hr patch fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) FENTORA FETZIMA (ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) 6 / 30 9 / DAY 1 / / / / / 30 FETZIMA MG TITRATION PAK 1 PACK (28 CAPSULES) / 365 FIRMAGON 2 X 120 MG KIT FIRMAGON 80 MG KIT FLOLIPID 20 MG/5 ML ORAL SUSP FLOLIPID 40 MG/5 ML ORAL SUSP 2 VIALS / VIAL / ML (40 MG) / DAY 5 ML (40 MG) / DAY FLOVENT 250 MCG DISKUS 4 INHALERS (240 BLISTERS) / 30 FLOVENT DISKUS (50 MCG, 100 MCG) 1 INHALER (60 BLISTERS) / 30 FLOVENT HFA (110 MCG, 220 MCG) 2 INHALERS (24 G) / 30 FLOVENT HFA 44 MCG INHALER 2 INHALERS (21.2 G) / 30 fluoxetine dr flurazepam hcl (15 mg capsule, 30 mg capsule) fluticasone-salmeterol fluvoxamine maleate er FOCALIN FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG CAPSULE) FOCALIN XR 20 MG CAPSULE 4 / 28 1 INHALER / 30 fondaparinux sodium 35 DAY SUPPLY / 180

10 FORTICAL 1 BOTTLE (3.7 ML) / 30 FOSAMAX F 4 / 28 FRAGMIN 35 DAY SUPPLY / 180 FROVA frovatriptan succinate FULYZAQ FUZEON GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) GILENYA GILOTRIF (30 MG TABLET, 40 MG TABLET) GILOTRIF 20 MG TABLET G 12 / / 30 2 VIALS / DAY glatiramer 20 mg/ml syringe 1 KIT (30 SYRINGES) / 30 glatiramer 40 mg/ml syringe 1 KIT (12 SYRINGES) / 28 glatopa 20 mg/ml syringe 1 KIT (30 SYRINGES) / 30 glatopa 40 mg/ml syringe 1 KIT (12 SYRINGES) / 28 GRALISE 30-DAY STARTER PACK GRALISE ER 300 MG TABLET GRALISE ER 600 MG TABLET granisetron hcl 1 mg tablet GRASTEK 1 PACK (78 TABLETS) / RX 4 / 30 HALCION HARVONI HETLIOZ HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) H

11 hydromorphone er HYSINGLA ER H ibandronate sodium 150 mg tab ICLUSIG 15 MG TABLET IDHIFA ILARIS ILEVRO IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) I 1 / 28 2 VIALS / ML / 30 9 / 30 IMITREX (4 ML, 6 ML) 10 CARTRIDGES (5 ML) / 30 IMITREX (5 MG, 20 MG) 2 PACKS (12 UNITS) / 30 IMITREX 4 MG/0.5 ML PEN INJECT 10 PENS (5 ML) / 30 IMITREX 6 MG/0.5 ML PEN INJECT 10 SYRINGES (5 ML) / 30 IMITREX 6 MG/0.5 ML VIAL 8 VIALS (4 ML) / 30 INCRUSE ELLIPTA 1 INHALER (30 BLISTERS) / 30 INGREZZA (40 MG CAPSULE, 80 MG CAPSULE) INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 9 MG TABLET) INVEGA ER 6 MG TABLET ipratropium br 0.02% soln 125 VIALS (312.5 ML) / 30 ipratropium-albuterol 180 VIALS (540 ML) / 30 JAKAFI 10 MG TABLET JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) JYNARQUE J 2 TABS / DAY KADIAN ketorolac 10 mg tablet KEVEYIS KHEDEZLA ER 100 MG TABLET KHEDEZLA ER 50 MG TABLET KISQALI 200 MG DAILY DOSE K 20 TABLETS / / 28

12 KISQALI 400 MG DAILY DOSE KISQALI 600 MG DAILY DOSE KISQALI FEMARA 200 MG CO-PACK KISQALI FEMARA 400 MG CO-PACK KISQALI FEMARA 600 MG CO-PACK KLONOPIN KORLYM K 42 / / / / / 28 KYNAMRO 4 SYRINGES (4 ML) / 28 LAMISIL 250 MG TABLET 84 DAY SUPPLY / 180 lansoprazole (dr 15 mg capsule, dr 30 mg capsule) lansoprazole (odt 15 mg tablet, odt 30 mg tablet) latanoprost 0.005% eye drops LATUDA (40 MG TABLET, 60 MG TABLET, 120 MG TABLET) LATUDA 80 MG TABLET LAZANDA ledipasvir-sofosbuvir LETAIRIS (5 MG TABLET, 10 MG TABLET) L 2.5 ML / 30 levalbuterol 1.25 mg/3 ml sol 90 VIALS (270 ML) / 30 levalbuterol concentrate 90 VIALS (45 ML) / 30 levalbuterol hcl (0.31 ml, 0.63 ml) 180 VIALS (540 ML) / 30 levalbuterol tartrate hfa 2 INHALERS (30 G) / 30 LEVITRA 6 / 30 linezolid 100 mg/5 ml susp 6 BOTTLES (900 ML) / 28 linezolid 600 mg tablet LINZESS (72 MCG CAPSULE, 145 MCG CAPSULE, 290 MCG CAPSULE) LONHALA MAGNAIR REFILL LONHALA MAGNAIR STARTER LONSURF 15 MG-6.14 MG TABLET LONSURF 20 MG-8.19 MG TABLET lorazepam (0.5 mg tablet, 1 mg tablet) lorazepam 2 mg tablet 28 / 30 2 ML (2 VIALS) / DAY 2 ML (2 VIALS) / DAY 100 / / 84 5 / DAY

13 lorazepam 2 mg/ml oral concent 5 BOTTLES (150 ML) / 30 lorazepam intensol 5 BOTTLES (150 ML) / 30 LOVENOX 35 DAY SUPPLY / 180 LUCEMYRA LUMIGAN LUNESTA LUPANETA PK MG 3MO KIT LUPANETA PK MG 1MO KIT LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE) LYRICA 20 MG/ML ORAL SOLUTION LYRICA 300 MG CAPSULE LYRICA CR (82.5 MG TABLET, 165 MG TABLET) LYRICA CR 330 MG TABLET L 16 TABLETS / DAY 2.5 ML / 30 1 KIT / 90 1 KIT / ML / 30 MARINOL MAVYRET MAXALT MAXALT MLT memantine hcl er METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE) metadate er methamphetamine hcl METHYLIN (2.5 MG TAB, 5 MG TABLET) METHYLIN 10 MG CHEWABLE TABLET METHYLIN 10 MG/5 ML SOLUTION METHYLIN 5 MG/5 ML SOLUTION methylphenidate 10 mg chew tab methylphenidate 10 mg/5 ml sol methylphenidate 5 mg/5 ml soln methylphenidate er (er 10 mg tab, er 36 mg tab) methylphenidate er (er 18 mg tab, er 27 mg tab, er 54 mg tab) methylphenidate er (la) (10mg, 20mg, 30mg, 40mg) methylphenidate er 20 mg tab M 18 / / 30 5 / DAY 900 ML / ML / ML / ML / 30

14 methylphenidate hcl (2.5 mg chew tb, 5 mg tablet, 5 mg chew tab, 10 mg tablet, 20 mg tablet) methylphenidate hcl cd methylphenidate hcl er (cd) methylphenidate la (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) methylphenidate la 60 mg cap M MIACALCIN 200 UNIT NASAL SPRAY 1 BOTTLE (3.7 ML) / 30 modafinil mometasone furoate 50 mcg spry 2 BOTTLES (34 G) / 30 morphine sulfate er (er 10 mg cap, er 20 mg cap, er 30 mg cap, er 40 mg cap, er 50 mg cap, er 60 mg cap, er 80 mg cap, er 100 mg cap, er 120 mg cap) morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg tablet, er 100 mg tablet, er 200 mg tablet) morphine sulfate er (er 45 mg cap, er 75 mg cap, er 90 mg cap) MOVANTIK (12.5 MG TABLET, 25 MG TABLET) MOZOBIL 8 VIALS (9.6 ML) / TRANSPLANT MS CONTIN MUSE MYDAYIS (ER 12.5 MG CAPSULE, ER 25 MG CAPSULE, ER 37.5 MG CAPSULE, ER 50 MG CAPSULE) MYTESI NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE) NAMENDA XR TITRATION PACK NAMZARIC (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE) N 6 / 30 NAMZARIC TITRATION PACK 2 PACKS (56 CAPSULES) / 365 naratriptan naratriptan hcl 9 / 30 9 / 30 NASONEX 2 BOTTLES (34 G) / 30 NATPARA NERLYNX 2 CARTRIDGES / 28 NEVANAC 2 BOTTLES (6 ML) / 30 NEXIUM NICOTROL 1

15 N NICOTROL NS 12 BOTTLES (120 ML) / 30 NINLARO NOVAREL 5,000 UNIT VIAL NUCALA NUCYNTA ER NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MG TABLET) NUVIGIL 50 MG TABLET OCALIVA (5 MG TABLET, 10 MG TABLET) ODACTRA olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet) olanzapine odt olanzapine-fluoxetine hcl (3-25 mg, 6-25 mg) olanzapine-fluoxetine hcl (6-50 mg, mg, mg) O 3 / 28 1 VIAL / 30 1 VIAL / 30 1 TABLET / DAY olopatadine 665 mcg nasal spry 1 BOTTLE (30.5 G) / 30 OLYSIO omeprazole OMNARIS 1 BOTTLE (12.5 G) / 30 ondansetron 4 mg/5 ml solution 120 ML / 30 ondansetron hcl (4 ml amp, 4 ml vial) 60 VIALS (120 ML) / 30 ondansetron hcl (4 ml isecure, hcl 4 ml syr) 60 SYRINGES (120 ML) / 30 ondansetron hcl 24 mg tablet 2 / 30 ONZETRA XSAIL 1 BOX (16 UNITS) / 30 OPANA ER OPSUMIT ORALAIR ORKAMBI (100 MG TABLET, 200 MG TABLET) ORKAMBI ( MG, MG) 2 PACKETS / DAY oseltamivir 6 mg/ml suspension 6 BOTTLES (360 ML) / 365 oseltamivir phos 30 mg capsule oseltamivir phosphate (45 mg capsule, 75 mg capsule) 40 / / 365

16 OTREXUP (7.5 ML AUTO-INJ, 10 ML AUTO-INJ, 12.5 ML AUTOINJ, 15 ML AUTO-INJ, 17.5 ML AUTOINJ, 20 ML AUTO-INJ, 22.5 ML AUTOINJ, 25 ML AUTO-INJ) OXANDRIN 10 MG TABLET OXANDRIN 2.5 MG TABLET oxandrolone 10 mg tablet oxandrolone 2.5 mg tablet oxazepam oxycodone hcl er OXYCONTIN oxymorphone hcl er OXYTROL OZEMPIC MG DOSE PEN OZEMPIC 1 MG DOSE PEN O 4 PENS (1.6 ML) / 28 8 / DAY 8 / DAY 8 / 28 1 PEN (1.5 ML) / 28 2 PENS (3 ML) / 28 paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9 mg tablet) paliperidone er 6 mg tablet PALYNZIQ 10 MG/0.5 ML SYRINGE PALYNZIQ 2.5 MG/0.5 ML SYRINGE PALYNZIQ 20 MG/ML SYRINGE pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) P 1 SYRINGE (0.5 ML) / DAY 2 SYRINGES (2ML) / DAY PATANASE 1 BOTTLE (30.5 G) / 30 PERFOROMIST PEXEVA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) PEXEVA 30 MG TABLET 2 VIALS (4 ML) / DAY PLEGRIDY 2 SYRINGES (1 ML) / 28 PLEGRIDY PEN PRADAXA PRALUENT PEN 2 PENS (1 ML) / 28 2 PENS (2 ML) / 28 PRALUENT SYRINGE 2 SYRINGES (2 ML) / 28 PREVACID (15 MG, 30 MG) PREVACID (DR 15 MG CAPSULE, DR 30 MG CAPSULE) PRILOSEC (DR 2.5 MG, DR 10 MG) PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET) PRISTIQ ER 100 MG TABLET

17 PROAIR HFA 2 INHALERS (17 G) / 30 PROAIR RESPICLICK procentra P 2 INHALERS / ML / 30 PROLIA 2 SYRINGES (2 ML) / 365 PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET, 40 MG SUSPENSION) PROVENTIL HFA 2 INHALERS (13.4 G) / 30 PROVIGIL PROZAC WEEKLY 4 / 28 PULMICORT 60 AMPULES (120 ML) / 30 PULMICORT FLEXHALER Q 2 INHALERS / 30 QNASL 1 INHALER (8.7 G) / 30 QNASL CHILDREN 1 INHALER (4.9 G) / 30 quazepam quetiapine er 200 mg tablet quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) quetiapine fumarate (300 mg tab, 400 mg tab) quetiapine fumarate er (er 50 mg tablet, er 150 mg tablet, er 300 mg tablet, er 400 mg tablet) QUILLICHEW ER (ER 20 MG TAB, ER 40 MG TAB) QUILLICHEW ER 30 MG CHEW TAB QUILLIVANT XR 360 ML / 30 QVAR 40 MCG ORAL INHALER 2 INHALERS (17.4 G) / 30 QVAR 80 MCG ORAL INHALER 3 INHALERS (26.1 G) / 30 QVAR REDIHALER 2 INHALERS (21.2 G) / 30 rabeprazole sodium RAGWITEK RASUVO 10 MG/0.2 ML AUTOINJ RASUVO 12.5 MG/0.25 ML AUTOINJ RASUVO 15 MG/0.3 ML AUTOINJ R 4 PENS (0.8 ML) / 28 4 PENS (1 ML) / 28 4 PENS (1.2 ML) / 28

18 RASUVO 17.5 MG/0.35 ML AUTOINJ RASUVO 20 MG/0.4 ML AUTOINJ RASUVO 22.5 MG/0.45 ML AUTOINJ RASUVO 25 MG/0.5 ML AUTOINJ RASUVO 27.5 MG/0.55 ML AUTOINJ RASUVO 30 MG/0.6 ML AUTOINJ RASUVO 7.5 MG/0.15 ML AUTOINJ REBIF (22 ML, 44 ML) REBIF REBIDOSE (22 ML, 44 ML) REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK R 4 PENS (1.4 ML) / 28 4 PENS (1.6 ML) / 28 4 PENS (1.8 ML) / 28 4 PENS (2 ML) / 28 4 PENS (2.2 ML) / 28 4 PENS (2.4 ML) / 28 4 PENS (0.6 ML) / 28 1 KIT (6 ML) / 28 1 KIT (6 ML) / 28 1 KIT (4.2 ML) / KIT (4.2 ML) / 365 RELENZA 2 INHALERS (40 DISKS) / 365 RELISTOR (12 ML VIAL, 12 ML SYRINGE) RELISTOR 150 MG TABLET RELISTOR 8 MG/0.4 ML SYRINGE RELPAX 1 SYRINGE (0.6 ML) / DAY 1 SYRINGE (0.4 ML) / DAY 12 / 30 REPATHA PUSHTRONEX 1 CARTRIDGE (3.5 ML) / 28 REPATHA SURECLICK 3 PENS (3 ML) / 28 REPATHA SYRINGE 3 SYRINGES (3 ML) / 28 RESCULA RESTORIL 5 ML (1 BOTTLE) / 25 REVATIO 10 MG/ML ORAL SUSP 2 BOTTLES (224 ML) / 30 REVATIO 20 MG TABLET REXULTI RHINOCORT AQUA 2 BOTTLES (17.2 G) / 30 RHOPRESSA 1 BOTTLE (2.5 ML) / 25 RILUTEK riluzole risedronate sodium 150 mg tab risedronate sodium 35 mg tab RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET) 1 / 28 4 / 28 RISPERDAL 1 MG/ML SOLUTION 8 BOTTLES (240 ML) / 30

19 RISPERDAL M-TAB risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet) risperidone 0.25 mg odt R risperidone 1 mg/ml solution 8 BOTTLES (240 ML) / 30 risperidone odt (0.5 mg odt, 1 mg odt, 2 mg odt, 3 mg odt, 4 mg odt) RITALIN RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) rizatriptan ROZEREM RUBRACA RYDAPT SAMSCA SANCUSO SAPHRIS SAVAYSA SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) S 18 / 30 8 / DAY 30 DAY SUPPLY / 60 2 / 30 SAVELLA TITRATION PACK 1 PACK (55 TABLETS) / 365 SEEBRI NEOHALER 1 INHALER (60 CAPSULES) / 30 SEREVENT DISKUS 1 INHALER (60 BLISTERS) / 30 SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) SEROQUEL (300 MG TABLET, 400 MG TABLET) SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 300 MG TABLET, 400 MG TABLET) SEROQUEL XR 200 MG TABLET SIGNIFOR SIGNIFOR LAR (10 MG KIT, 10 MG VIAL, 20 MG VIAL, 20 MG KIT, 30 MG VIAL, 30 MG KIT, 40 MG KIT, 40 MG VIAL, 60 MG KIT, 60 MG VIAL) sildenafil sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) SITAVIG SIVEXTRO 200 MG TABLET sofosbuvir-velpatasvir SOLIQUA AMPULES / DAY 1 VIAL / 28 6 / 30 2 / 30 6 / 30 6 PENS (18 ML) / 30

20 SONATA 10 MG CAPSULE SONATA 5 MG CAPSULE SOVALDI SPIRIVA SPIRIVA RESPIMAT STENDRA STIOLTO RESPIMAT STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE) STRATTERA (60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE) STRIVERDI RESPIMAT S 1 CAPSULE / DAY 1 INHALER (4 G) / 30 6 / 30 1 INHALER (4 G) / 30 1 INHALER (4 G) / 30 SUBLOCADE 100 MG/0.5 ML SYRING 3 SYRINGES (1.5 ML) / 28 SUBLOCADE 300 MG/1.5 ML SYRING 1 SYRINGE (1.5 ML) / 28 SUBOXONE 12 MG-3 MG SL FILM SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 4 MG-1 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM SUBSYS 1 1 sumatriptan 2 PACKS (12 UNITS) / 30 sumatriptan 4 mg/0.5 ml inject sumatriptan 6 mg/0.5 ml vial sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) 10 PENS (5 ML) / 30 8 VIALS (4 ML) / 30 9 / 30 sumatriptan succinate (4 ml cart, 6 ml refill) 10 CARTRIDGES (5 ML) / 30 sumatriptan succinate (6 ml syrng, 6 ml inject) 10 SYRINGES (5 ML) / 30 SUPPRELIN LA 1 KIT / 365 SUSTOL 3 SYRINGES (1.2 ML) / 30 SYMBICORT 1 INHALER (10.2 G) / 30 SYMBYAX (3-25 MG CAPSULE, 6-25 MG CAPSULE) SYMBYAX (6-50 MG CAPSULE, MG CAPSULE, MG CAPSULE) SYMDEKO SYMPROIC SYNDROS 4 BOTTLES (120 ML) / 30

21 tadalafil (2.5 mg tablet, 5 mg tablet) tadalafil 10 mg tablet tadalafil 20 mg tablet (generic for adcirca) tadalafil 20 mg tablet (generic for cialis) TAGRISSO (40 MG TABLET, 80 MG TABLET) TAKHZYRO TALZENNA TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE) TAMIFLU 30 MG CAPSULE T 6 / 30 6 / 30 2 VIALS / / / 365 TAMIFLU 6 MG/ML SUSPENSION 6 BOTTLES (360 ML) / 365 TANZEUM (30 MG, 50 MG) TARCEVA (100 MG TABLET, 150 MG TABLET) TARCEVA 25 MG TABLET TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE) 4 PENS / 28 TECFIDERA STARTER PACK 1 PACK (60 CAPSULES) / 365 TECHNIVIE temazepam 168 / 84 terbinafine hcl 84 DAY SUPPLY / 180 TIGLUTIK 2 BOTTLES (600 ML) / 30 TOBI PODHALER 1 KIT (224 CAPSULES) / 56 TRACLEER (62.5 MG TABLET, 125 MG TABLET) TRACLEER 32 MG TABLET FOR SUSP tramadol hcl tramadol hcl er (er 100 mg capsule, er 200 mg capsule, er 300 mg capsule) tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg tablet) tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg tablet) tramadol hcl er 150 mg capsule tramadol hcl-acetaminophen TRANXENE T-TAB 3.75 MG TRANXENE T-TAB 7.5 MG TRAVATAN Z 4 TABLETS / DAY 8 TABLETS / DAY 8 TABLETS / DAY ML / 25 TRELEGY ELLIPTA 60 BLISTERS (1 PACK) / 30

22 T TRELSTAR MG VIAL TRELSTAR 22.5 MG VIAL TRELSTAR 3.75 MG VIAL triazolam TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) TRIPTODUR TRULANCE TRULICITY (0.75 ML, 1.5 ML) TUDORZA PRESSAIR TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT 1 VIAL / 84 1 VIAL / VIAL / 28 1 KIT / PENS (2 ML) / 28 1 INHALER / 30 1 AMPULE (2.9 ML) / DAY 1 KIT / 28 1 KIT / 28 1 KIT / 28 ULTRACET ULTRAM ULTRAM ER UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) U 8 TABLETS / DAY 8 TABLETS / DAY UPTRAVI TITRATION PACK 2 PACKS (400 TABLETS) / 365 UTIBRON NEOHALER valacyclovir VALTREX VANTAS vardenafil hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) VARUBI 90 MG TABLET VENTAVIS (10 ML, 20 ML) V 1 INHALER (60 CAPSULES) / 30 1 KIT / / 30 4 / 30 9 AMPULES / DAY VENTOLIN HFA 6 INHALERS (48 G) / 30 VERAMYST VERSACLOZ VERZENIO VIAGRA VIBERZI 1 BOTTLE (10 G) / ML / 30 2 TABLETS / DAY 6 / 30

23 VICTOZA 2-PAK VICTOZA 3-PAK VIEKIRA PAK VIEKIRA XR VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) V 3 PENS (9 ML) / 30 3 PENS (9 ML) / 30 VIIBRYD MG STARTER PACK 1 PACK (30 TABLETS) / 30 VIZIMPRO VOSEVI VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) VYVANSE (10 MG CHEWABLE TABLET, 10 MG CAPSULE, 20 MG CHEWABLE TABLET, 20 MG CAPSULE, 30 MG CHEWABLE TABLET, 30 MG CAPSULE, 40 MG CAPSULE, 40 MG CHEWABLE TABLET, 50 MG CAPSULE, 50 MG CHEWABLE TABLET, 60 MG CHEWABLE TABLET, 60 MG CAPSULE, 70 MG CAPSULE) WELLBUTRIN SR W XADAGO XALATAN XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) XANAX 2 MG TABLET XANAX XR (0.5 MG TABLET, 1 MG TABLET) XANAX XR 2 MG TABLET XANAX XR 3 MG TABLET XARELTO (10 MG TABLET, 20 MG TABLET) XARELTO (2.5 MG TABLET, 15 MG TABLET) X 2.5 ML / 30 5 / DAY 5 / DAY XARELTO STARTER PACK 1 PACK (51 TABLETS) / 30 XELPROS XERMELO 2.5 ML / 30 XOFLUZA 1 PACK (2 TABLETS) / 365 XOPENEX (0.31 ML, 0.63 ML) 180 VIALS (540 ML) / 30 XOPENEX 1.25 MG/3 ML SOLUTION 90 VIALS (270 ML) / 30 XOPENEX CONCENTRATE 90 VIALS (45 ML) / 30 XOPENEX HFA 2 INHALERS (30 G) / 30

24 XTAMPZA ER XULTOPHY XURIDEN YUPELRI X Y 5 PENS (15 ML) / 30 1 VIAL (3ML) / DAY zaleplon 10 mg capsule zaleplon 5 mg capsule ZEJULA ZEMBRACE SYMTOUCH ZENZEDI (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MG TABLET) zenzedi 10 mg tablet ZENZEDI 30 MG TABLET ZEPATIER Z 16 PENS (8 ML) / 30 ZETONNA 1 INHALER (6.1 G) / 30 ZIOPTAN ziprasidone hcl ZOFRAN 4 MG/5 ML ORAL SOLN ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX 3.6 MG IMPLANT SYRN zolmitriptan zolmitriptan 2.5 mg odt zolmitriptan 5 mg odt zolpidem tartrate (5 mg tablet, 10 mg tablet) zolpidem tartrate er ZOMIG (2.5 MG TABLET, 5 MG TABLET) 30 / ML / 30 1 IMPLANT / 84 1 IMPLANT / / / 30 9 / / 30 ZOMIG (2.5 MG, 5 MG) 2 BOXES (12 UNITS) / 30 ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT 5 MG TABLET ZUBSOLV ( MG TABLET, MG TABLET) ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL 12 / 30 9 / 30 1

25 ZYBAN ZYKADIA ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) ZYPREXA ZYDIS Z 5 / DAY ZYVOX 100 MG/5 ML SUSPENSION 6 BOTTLES (900 ML) / 28 ZYVOX 600 MG TABLET 28 / 30

26 PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at NDR PIC LV (1/18)

27 PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at NDR PCHP LV (1/18)