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 ClearScript 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. ANALGESICS ABSTRAL (100 MCG TAB, 300 MCG TAB, 400 MCG TAB, 600 MCG TAB) ABSTRAL (200 MCG TAB, 800 MCG TAB) ACTIQ (LOZENGE HD) ARYMO ER (TAB PO ER) AVINZA (30 MG CAPSULE, 45 MG CAPSULE, 60 MG CAPSULE, 75 MG CAPSULE, 90 MG CAPSULE) AVINZA 120 MG CAPSULE BELBUCA (FILM) buprenorphine (patch tdwk) BUTRANS (PATCH TDWK) CELEBREX (CAPSULE) celecoxib (capsule) CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) DUEXIS (TABLET) DURAGESIC (12, 25, 50) DURAGESIC (75, 100) EMBEDA (CAP ER PO) EXALGO (TAB ER 24H) 4 / 28 4 / / / 30

2 fentanyl (12, 25, 50) fentanyl (37.5, 62.5) fentanyl (75, 100) fentanyl 87.5 mcg/hr patch ANALGESICS fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) FENTORA (TABLET EFF) hydromorphone er (tab er 24h) HYSINGLA ER (TAB ER 24H) KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE, ER 60 MG CAPSULE, ER 80 MG CAPSULE, ER 100 MG CAPSULE, ER 200 MG CAPSULE) ketorolac 10 mg tablet LAZANDA (300 MCG, 400 MCG) LAZANDA 100 MCG NASAL SPRAY MORPHABOND ER (TAB ER 12H) morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 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 30 mg cap, er 45 mg cap, er 60 mg cap, er 75 mg cap, er 90 mg cap) MS CONTIN (TABLET ER) NUCYNTA ER (TAB ER 12H) OPANA ER (TAB ER 12H) oxycodone hcl er (tab er 12h) OXYCONTIN (TAB ER 12H) oxymorphone hcl er (tab er 12h) SPRIX (SPRAY) SUBSYS (100 MCG, 1,200 MCG) SUBSYS (200 MCG, 400 MCG, 600 MCG, 800 MCG, 1,600 MCG) 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) 15 / / / / / 30 5 DAY SUPPLY /

3 tramadol hcl er 150 mg capsule ULTRAM ER (TAB ER 24H) VIMOVO (TAB IR DR) XTAMPZA ER (CAP SPR 12) ANALGESICS ZOHYDRO ER (ER 10 MG CAPSULE, ER 15 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE) ZOHYDRO ER 50 MG CAPSULE BUNAVAIL MG FILM BUNAVAIL MG FILM BUNAVAIL MG FILM buprenorphine 2 mg tablet sl buprenorphine 8 mg tablet sl buprenorphine-naloxone (tab subl) buproban (tab er 12h) bupropion hcl sr 150 mg tablet ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET) 1 CHANTIX STARTING MONTH BOX 1 BOX (53 TABLETS) / 28 NICOTROL (CARTRIDGE) 1 NICOTROL NS (SPRAY) 12 BOTTLES (120 ML) / 30 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 ZUBSOLV ( MG TABLET, MG TABLET) ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZYBAN (TAB ER 12H) ANTIBACTERIALS 1 1 linezolid 100 mg/5 ml susp 6 BOTTLES (900 ML) / 28

4 linezolid 600 mg tablet SIVEXTRO 200 MG TABLET SIVEXTRO 200 MG VIAL ANTIBACTERIALS 28 / 30 6 / 30 6 VIALS / 30 ZYVOX 100 MG/5 ML SUSPENSION 6 BOTTLES (900 ML) / 28 ZYVOX 600 MG TABLET 28 / 30 ANTICONVULSANTS DIASTAT (KIT) DIASTAT ACUDIAL (KIT) diazepam (2.5 mg gel sys, 10 mg gel syst, 20 mg gel syst) GRALISE 30-DAY STARTER PACK GRALISE ER 300 MG TABLET GRALISE ER 600 MG TABLET 2 PACKAGES / RX 2 PACKAGES / RX 2 PACKAGES / RX 1 PACK (78 TABLETS) / RX ANTIDEMENTIA AGENTS NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, TITRATION PACK) NAMZARIC (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE) NAMZARIC TITRATION PACK 2 PACKS (56 CAPSULES) / 365 ANTIDEPRESSANTS APLENZIN (TAB ER 24H) BRINTELLIX (TABLET) BRISDELLE (CAPSULE) bupropion hcl sr (100 mg tablet, 200 mg tablet) bupropion hcl xl 150 mg tablet bupropion hcl xl 300 mg tablet 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 desvenlafaxine suc er 100 mg desvenlafaxine succinate er (er 25 mg, er 50 mg) EMSAM (PATCH TD24)

5 ANTIDEPRESSANTS FETZIMA (ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) FETZIMA MG TITRATION PAK 1 PACK (28 CAPSULES) / 365 fluoxetine dr (capsule dr) fluvoxamine maleate er (cap er 24h) FORFIVO XL (TAB ER 24H) KHEDEZLA ER 100 MG TABLET KHEDEZLA ER 50 MG TABLET olanzapine-fluoxetine hcl (3-25 mg, 6-25 mg) olanzapine-fluoxetine hcl (6-50 mg, mg, mg) paroxetine mesylate (capsule) PEXEVA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) PEXEVA 30 MG TABLET PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET) PRISTIQ ER 100 MG TABLET PROZAC WEEKLY (CAPSULE DR) SYMBYAX (3-25 MG CAPSULE, 6-25 MG CAPSULE) SYMBYAX (6-50 MG CAPSULE, MG CAPSULE, MG CAPSULE) TRINTELLIX (TABLET) VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 4 / 28 1 / 1 4 / 28 VIIBRYD (10-20 MG PACK, MG PK) 1 PACK (30 TABLETS) / 30 WELLBUTRIN SR (TAB ER 12H) WELLBUTRIN XL 150 MG TABLET WELLBUTRIN XL 300 MG TABLET AKYNZEO (CAPSULE) ANZEMET (50 MG TABLET, 100 MG TABLET) aprepitant 125 mg capsule aprepitant mg pack aprepitant 40 mg capsule ANTIEMETICS 2 / 30 2 / 30 2 / 30 2 TRIPACKS (6 CAPSULES) / 30 1 / 30

6 aprepitant 80 mg capsule CESAMET (CAPSULE) DICLEGIS (TABLET DR) dronabinol (capsule) EMEND 125 MG CAPSULE EMEND 125 MG POWDER PACKET EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIPACK granisetron hcl 1 mg tablet MARINOL (CAPSULE) ondansetron 4 mg/5 ml solution ANTIEMETICS 4 / / RX 2 / 30 3 / 30 1 / 30 4 / 30 2 TRIPACKS (6 CAPSULES) / 30 4 / ML / 30 ondansetron 40 mg/20 ml vial 6 VIALS (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 ondansetron odt (tab rapdis) SANCUSO (PATCH TDWK) 2 / / 30 2 / 30 SUSTOL (LIQ ER SYR) 3 SYRINGES (1.2 ML) / 30 SYNDROS (SOLUTION) 4 BOTTLES (120 ML) / 30 VARUBI 90 MG TABLET 4 / 30 ZOFRAN 2 MG/ML VIAL 6 VIALS (120 ML) / 30 ZOFRAN 4 MG/5 ML ORAL SOLN ZOFRAN ODT (TAB RAPDIS) ZUPLENZ (FILM) ANTIFUNGALS 120 ML / / / 30 LAMISIL 250 MG TABLET 84 DAY SUPPLY / 180

7 ANTIFUNGALS terbinafine hcl (tablet) 84 DAY SUPPLY / 180 almotriptan malate (tablet) ALSUMA (PEN INJCTR) AMERGE (TABLET) AXERT (TABLET) ANTIMIGRAINE AGENTS 12 / 30 5 KITS / 30 9 / / 30 dihydroergotamine 4 mg/ml spry 1 BOX (8 UNITS) / 30 eletriptan hbr (tablet) FROVA (TABLET) frovatriptan succinate (tablet) IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 12 / 30 9 / 30 9 / 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 IMITREX 6 MG/0.5 ML PEN INJECT IMITREX 6 MG/0.5 ML VIAL MAXALT (TABLET) MAXALT MLT (TAB RAPDIS) 10 PENS (5 ML) / 30 5 KITS / 30 4 KITS / / / 30 MIGRANAL (SPRAY/PUMP) 1 BOX (8 UNITS) / 30 naratriptan (tablet) naratriptan hcl (tablet) 9 / 30 9 / 30 ONZETRA XSAIL (AER POW BA) 1 BOX (16 UNITS) / 30 RELPAX (TABLET) rizatriptan (5 mg tablet, 5 mg odt, 10 mg tablet, 10 mg odt) 12 / / 30 sumatriptan (spray) 2 PACKS (12 UNITS) / 30 sumatriptan 4 mg/0.5 ml inject sumatriptan 6 mg/0.5 ml inject 10 PENS (5 ML) / 30 5 KITS / 30 sumatriptan 6 mg/0.5 ml syrng 10 SYRINGES (5 ML) / 30

8 sumatriptan 6 mg/0.5 ml vial ANTIMIGRAINE AGENTS sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) 4 KITS / 30 9 / 30 sumatriptan succinate (4 ml cart, 6 ml refill) 10 CARTRIDGES (5 ML) / 30 SUMAVEL DOSEPRO (NDL FR INJ) TREXIMET (TABLET) ZECUITY (PATCH IOPH) ZEMBRACE SYMTOUCH (PEN INJCTR) zolmitriptan 2.5 mg odt zolmitriptan 2.5 mg tablet zolmitriptan 5 mg odt zolmitriptan 5 mg tablet 12 PENS (6 ML) / 30 9 / 30 4 / PENS (8 ML) / / / 30 9 / 30 9 / 30 ZOMIG (2.5 MG, 5 MG) 2 BOXES (12 UNITS) / 30 ZOMIG 2.5 MG TABLET ZOMIG 5 MG TABLET ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT 5 MG TABLET AFINITOR (TABLET) ALECENSA (CAPSULE) ALUNBRIG (TABLET) CALQUENCE (CAPSULE) CAPRELSA 100 MG TABLET COTELLIC (TABLET) FARYDAK (CAPSULE) GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET) ICLUSIG 15 MG TABLET IDHIFA (TABLET) IMBRUVICA (CAPSULE) JAKAFI 10 MG TABLET KISQALI 200 MG DAILY DOSE ANTINEOPLASTICS 12 / 30 9 / / 30 9 / 30 8 / DAY 2 CAPSULES / DAY 6 / / 28

9 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 LONSURF 15 MG-6.14 MG TABLET LONSURF 20 MG-8.19 MG TABLET NERLYNX (TABLET) NINLARO (CAPSULE) ANTINEOPLASTICS 42 / / / / / / / 84 3 / 28 PORTRAZZA (VIAL) 2 VIALS (100 ML) / 21 RUBRACA (TABLET) RYDAPT (CAPSULE) TAGRISSO (TABLET) TARCEVA (100 MG TABLET, 150 MG TABLET) TARCEVA 25 MG TABLET VERZENIO (TABLET) ZEJULA (CAPSULE) ZYKADIA (CAPSULE) ANTIPARKINSON AGENTS 8 / DAY 2 TABLETS / DAY 5 / DAY APOKYN (CARTRIDGE) 20 CARTRIDGES (60 ML) / 30 XADAGO (TABLET) ANTIPSYCHOTICS ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET) ABILIFY 1 MG/ML SOLUTION 5 BOTTLES (750 ML) / 30 ABILIFY DISCMELT (TAB RAPDIS) aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) aripiprazole 1 mg/ml solution 5 BOTTLES (750 ML) / 30 aripiprazole odt (tab rapdis)

10 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 (TABLET) ANTIPSYCHOTICS FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 9 / DAY 9 / DAY 9 / DAY FANAPT TITRATION PACK 1 PACK (8 TABLETS) / 180 FAZACLO (25 MG ODT, 100 MG ODT) FAZACLO 12.5 MG ODT FAZACLO 150 MG ODT FAZACLO 200 MG ODT GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 9 MG TABLET) INVEGA ER 6 MG TABLET LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 120 MG TABLET) LATUDA 80 MG TABLET olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet) olanzapine odt (tab rapdis) paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9 mg tablet) paliperidone er 6 mg tablet 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) REXULTI (TABLET) RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET) 9 / DAY

11 ANTIPSYCHOTICS RISPERDAL 1 MG/ML SOLUTION 8 BOTTLES (240 ML) / 30 RISPERDAL M-TAB (TAB RAPDIS) 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 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) SAPHRIS (TAB SUBL) 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 VERSACLOZ (ORAL SUSP) VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) ziprasidone hcl (capsule) ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) ZYPREXA ZYDIS (TAB RAPDIS) ANTIVIRALS 540 ML / 30 BARACLUDE 0.05 MG/ML SOLUTION 3 BOTTLES (630 ML) / 30 DAKLINZA (TABLET) EPCLUSA (TABLET) FUZEON 90 MG VIAL HARVONI (TABLET) MAVYRET (TABLET) OLYSIO (CAPSULE) 2 VIALS / DAY 3 / 1 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 RELENZA (BLST W/DEV) 2 INHALERS (40 DISKS) / 365

12 SITAVIG (MA BUC TAB) SOVALDI (TABLET) TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE) TAMIFLU 30 MG CAPSULE ANTIVIRALS 2 / / / 365 TAMIFLU 6 MG/ML SUSPENSION 6 BOTTLES (360 ML) / 365 TECHNIVIE (TABLET) valacyclovir (tablet) VALTREX (TABLET) VIEKIRA PAK (TAB DS PK) VIEKIRA XR (TAB BP 24H) VOSEVI (TABLET) ZEPATIER (TABLET) 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 ANXIOLYTICS 168 / 84 5 / DAY 5 / DAY alprazolam intensol (oral conc) 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 ATIVAN (0.5 MG TABLET, 1 MG TABLET) ATIVAN 2 MG TABLET chlordiazepoxide 10 mg capsule chlordiazepoxide 25 mg capsule chlordiazepoxide 5 mg capsule 5 / DAY 5 / DAY 5 / DAY 30 / DAY 1

13 ANXIOLYTICS 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 clorazepate 3.75 mg tablet clorazepate 7.5 mg tablet KLONOPIN (TABLET) lorazepam (0.5 mg tablet, 1 mg tablet) lorazepam 2 mg tablet 10 / DAY / DAY lorazepam 2 mg/ml oral concent 5 BOTTLES (150 ML) / 30 lorazepam intensol (oral conc) 5 BOTTLES (150 ML) / 30 oxazepam (capsule) TRANXENE T-TAB 3.75 MG TRANXENE T-TAB 7.5 MG 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 ADLYXIN MCG STARTER PACK ADLYXIN 20 MCG MAINTENANCE PK BYDUREON (VIAL) BLOOD GLUCOSE REGULATORS / DAY 5 / DAY 2 PACKS / PENS (6 ML) / 28 4 VIALS / 28 BYDUREON BCISE (AUTO INJCT) 4 AUTO-INJECTOR / 28 BYDUREON PEN (PEN INJCTR) BYETTA 10 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ SOLIQUA (INSULN PEN) TANZEUM (PEN INJCTR) TRULICITY (PEN INJCTR) 4 PENS / 28 1 PEN (2.4 ML) / 30 1 PEN (1.2 ML) / 30 6 PENS (18 ML) / 30 4 PENS / 28 4 PENS (2 ML) / 28

14 VICTOZA 2-PAK (PEN INJCTR) VICTOZA 3-PAK (PEN INJCTR) XULTOPHY (INSULN PEN) BLOOD GLUCOSE REGULATORS 3 PENS (9 ML) / 30 3 PENS (9 ML) / 30 5 PENS (15 ML) / 30 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ARIXTRA (2.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML, 10 MG/0.8 ML) 35 DAY SUPPLY / 180 BEVYXXA (CAPSULE) ELIQUIS 2.5 MG TABLET ELIQUIS 5 MG TABLET enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 mg/0.8 ml syr, 150 mg/ml syringe, 300 mg/3 ml vial) 44 / DAY SUPPLY / 180 fondaparinux sodium (syringe) 35 DAY SUPPLY / 180 FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL) LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL) 35 DAY SUPPLY / DAY SUPPLY / 180 MOZOBIL (VIAL) 8 VIALS (9.6 ML) / TRANSPLANT PRADAXA (CAPSULE) SAVAYSA (TABLET) XARELTO (10 MG TABLET, 20 MG TABLET) XARELTO 15 MG TABLET XARELTO STARTER PACK 1 PACK (51 TABLETS) / 30 YOSPRALA (TAB IR DR) CORLANOR (TABLET) ENTRESTO (TABLET) JUXTAPID (CAPSULE) KEVEYIS (TABLET) CARDIOVASCULAR AGENTS KYNAMRO (SYRINGE) 4 SYRINGES (4 ML) / 28 PRALUENT PEN (PEN INJCTR) 2 PENS (2 ML) / 28

15 CARDIOVASCULAR AGENTS PRALUENT SYRINGE (SYRINGE) 2 SYRINGES (2 ML) / 28 REPATHA PUSHTRONEX (WEAR INJCT) 1 CARTRIDGE (3.5 ML) / 28 REPATHA SURECLICK (PEN INJCTR) 3 PENS (3 ML) / 28 REPATHA SYRINGE (SYRINGE) 3 SYRINGES (3 ML) / 28 ADDERALL (TABLET) ADDERALL XR (CAP ER 24H) ADZENYS XR-ODT (TAB RAP BP) AMPYRA (TAB ER 12H) APTENSIO XR (CSBP 40-60) CENTRAL NERVOUS SYSTEM AGENTS 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) AUBAGIO (TABLET) AUSTEDO (TABLET) AVONEX 30 MCG VIAL KIT AVONEX PEN (PEN IJ KIT) AVONEX PREFILLED SYR 30 MCG KT BETASERON (KIT) CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 54 MG TABLET) CONCERTA ER 36 MG TABLET 4 KITS (4 VIALS) / 28 1 KIT / 28 1 KIT / 28 1 KIT (15 VIALS) / 30 COPAXONE 20 MG/ML SYRINGE 1 KIT (30 SYRINGES) / 30 COPAXONE 40 MG/ML SYRINGE 1 KIT (12 SYRINGES) / 28 COTEMPLA XR-ODT 17.3 MG TABLET COTEMPLA XR-ODT 25.9 MG TABLET COTEMPLA XR-ODT 8.6 MG TABLET CYMBALTA (20 MG CAPSULE, 60 MG CAPSULE) CYMBALTA 30 MG CAPSULE d-amphetamine er 10 mg capsule d-amphetamine er 15 mg capsule 3 / 1 2 / 1 6 / 1

16 d-amphetamine er 5 mg capsule DAYTRANA (PATCH TD24) DESOXYN (TABLET) DEXEDRINE 10 MG TABLET DEXEDRINE 5 MG TABLET DEXEDRINE SPANSULE 10 MG DEXEDRINE SPANSULE 15 MG DEXEDRINE SPANSULE 5 MG dexmethylphenidate er 20 mg cp dexmethylphenidate hcl (tablet) dexmethylphenidate hcl er (er 25 mg, er 35 mg) CENTRAL NERVOUS SYSTEM AGENTS dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg cp, er 30 mg cp, er 40 mg cp) dextroamphetamine 10 mg tab dextroamphetamine 5 mg tab dextroamphetamine 5 mg/5 ml dextroamphetamine-amphet er (cap er 24h) dextroamphetamine-amphetamine (tablet) duloxetine hcl (dr 20 mg cap, dr 60 mg cap) duloxetine hcl dr 30 mg cap duloxetine hcl dr 40 mg cap DYANAVEL XR (SUS BP 24H) EVEKEO (TABLET) EXTAVIA (0.3 MG VIAL, 0.3 MG KIT) FOCALIN (TABLET) 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 GILENYA (CAPSULE) 5 / DAY 1800 ML / ML / 30 1 KIT (15 VIALS) / 30 glatiramer 20 mg/ml syringe 1 KIT (30 SYRINGES) / 30 ) glatiramer 40 mg/ml syringe 1 KIT (12 SYRINGES) / 28 )

17 CENTRAL NERVOUS SYSTEM AGENTS glatopa (syringe) 1 KIT (30 SYRINGES) / 30 HORIZANT (TABLET ER) INGREZZA 40 MG CAPSULE INGREZZA 80 MG CAPSULE IRENKA (CAPSULE DR) 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 METADATE CD (CPBP 30-70) metadate er (tablet er) methamphetamine hcl (tablet) 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 tablet 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 20 mg cap, er 27 mg tab, er 30 mg cap, er 40 mg cap, er 54 mg tab) methylphenidate er 20 mg tab methylphenidate hcl (2.5 mg chew tb, 5 mg tablet, 5 mg chew tab, 20 mg tablet) methylphenidate hcl cd (cpbp 30-70) methylphenidate hcl er (cpbp 30-70) methylphenidate la (20 mg cap, 30 mg cap, 40 mg cap) methylphenidate la 60 mg cap MYDAYIS (CPTP 24HR) S 900 ML / 30 5 / DAY 900 ML / ML / 30 5 / DAY 900 ML / ML / 30 OCREVUS (VIAL) 4 VIALS (40 ML) / 365

18 CENTRAL NERVOUS SYSTEM AGENTS PLEGRIDY (SYRINGE) 2 SYRINGES (1 ML) / 28 PLEGRIDY PEN (PEN INJCTR) procentra (solution) QUILLICHEW ER (ER 20 MG TAB, ER 40 MG TAB) QUILLICHEW ER 30 MG CHEW TAB QUILLIVANT XR (SU ER RC24) REBIF (22 ML, 44 ML) REBIF REBIDOSE (22 ML, 44 ML) REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK RILUTEK (TABLET) riluzole (tablet) RITALIN (5 MG TABLET, 20 MG TABLET) RITALIN 10 MG TABLET RITALIN LA (CPBP 50-50) SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 2 PENS (1 ML) / ML / ML / 30 1 KIT (6 ML) / 28 1 KIT (6 ML) / 28 1 KIT (4.2 ML) / KIT (4.2 ML) / / DAY SAVELLA TITRATION PACK 1 PACK (55 TABLETS) / 365 STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE) STRATTERA (60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE) TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE) TECFIDERA STARTER PACK 1 PACK (60 CAPSULES) / 365 TYSABRI (VIAL) 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) 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 1 VIAL (15 ML) / 28 calcipotriene-betamethasone dp (oint. (g)) DERMATOLOGICAL AGENTS 400 G / 30

19 diclofenac sodium 1% gel DERMATOLOGICAL AGENTS 10 / 30 diclofenac sodium 3% gel 3 TUBES (300G) / 30 [] DUPIXENT (SYRINGE) ENSTILAR (FOAM) FLECTOR (PATCH TD12) QUTENZA (KIT) 4 SYRINGES / 28 7 CANS (420 G) / 30 4 / 90 SOLARAZE (GEL (GRAM)) 3 TUBES (300G) / 30 [] TACLONEX 0.005%-0.064% SUSPENS TACLONEX OINTMENT VOLTAREN (GEL (GRAM)) ACIPHEX (TABLET DR) ACIPHEX SPRINKLE (CAP DR SPR) AMITIZA (CAPSULE) DEXILANT (CAP DR BP) esomeprazole dr mg cap esomeprazole dr 49.3 mg cap esomeprazole magnesium (capsule dr) FULYZAQ (TABLET DR) lansoprazole dr 15 mg capsule lansoprazole dr 30 mg capsule LINZESS (CAPSULE) MOVANTIK (TABLET) MYTESI (TABLET DR) GASTROINTESTINAL AGENTS NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG PACKET, DR 20 MG CAPSULE, DR 20 MG PACKET, DR 40 MG PACKET, DR 40 MG CAPSULE) OCALIVA (TABLET) omeppi (capsule) omeprazole (capsule dr) omeprazole-sodium bicarbonate (20-1,100 cap, 40-1,100 cap) omeprazole-sodium bicarbonate (20-1,680, 40-1,680) 120 G / G / / 30

20 GASTROINTESTINAL AGENTS pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) PREVACID (15 MG, 30 MG) PREVACID (DR 15 MG CAPSULE, DR 30 MG CAPSULE) PRILOSEC (DR 10 MG CAPSULE, DR 20 MG CAPSULE, DR 40 MG CAPSULE) PRILOSEC (DR 2.5 MG, DR 10 MG) PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET, 40 MG SUSPENSION) rabeprazole sodium (tablet dr) RELISTOR (8 MG/0.4 ML, 12 MG/0.6 ML) RELISTOR 12 MG/0.6 ML VIAL RELISTOR 150 MG TABLET SYMPROIC (TABLET) TRULANCE (TABLET) VIBERZI (TABLET) XERMELO (TABLET) ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG CAPSULE, 40 MG PACKET) GENITOURINARY AGENTS ADDYI (TABLET) CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT, 40 MCG VIAL) CIALIS (10 MG TABLET, 20 MG TABLET) CIALIS (2.5 MG TABLET, 5 MG TABLET) EDEX (KIT) LEVITRA (TABLET) MUSE (SUPP.URETH) OXYTROL (PATCH TDSW) sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) STAXYN (TAB RAPDIS) STENDRA (TABLET) VIAGRA (TABLET) 1 SYRINGE / DAY 1 VIAL / DAY S 6 VIALS / 30 6 / 30 6 CARTRIDGES / 30 6 / 30 6 / 30 8 / 28 6 / 30 6 / 30 6 / 30 6 / 30 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) KORLYM (TABLET) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) NOVAREL 5,000 UNIT VIAL 1 VIAL / 30

21 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) CRINONE (GEL/PF APP) 60 APPLICATORS (1.125) / 30 ESTRING (VAG RING) FEMRING (VAG RING) OXANDRIN 10 MG TABLET OXANDRIN 2.5 MG TABLET oxandrolone 10 mg tablet oxandrolone 2.5 mg tablet EGRIFTA 1 MG VIAL EGRIFTA 2 MG VIAL ELIGARD 22.5 MG SYRINGE KIT ELIGARD 30 MG SYRINGE KIT ELIGARD 45 MG SYRINGE KIT ELIGARD 7.5 MG SYRINGE KIT FIRMAGON 2 X 120 MG KIT FIRMAGON 80 MG KIT HORMONAL AGENTS, SUPPRESSANT (PITUITARY) 1 / 90 1 / 84 8 / DAY 8 / DAY 2 VIALS / DAY 1 VIAL / DAY 1 SYRINGE / 84 1 SYRINGE / SYRINGE / SYRINGE / 28 2 VIALS / VIAL / 28 GANIRELIX ACETATE (SYRINGE) 14 SYRINGES (7 ML) / 30 LUPANETA PK MG 3MO KIT LUPANETA PK MG 1MO KIT SIGNIFOR (AMPUL) SIGNIFOR LAR (VIAL) SUPPRELIN LA (KIT) TRELSTAR MG SYRINGE TRELSTAR MG VIAL TRELSTAR 22.5 MG SYRINGE TRELSTAR 22.5 MG VIAL TRELSTAR 3.75 MG SYRINGE TRELSTAR 3.75 MG VIAL TRIPTODUR (VIAL) VANTAS (KIT) 1 KIT / 90 1 KIT / 30 2 AMPULES / DAY 1 VIAL / 28 1 KIT / SYRINGE / 84 1 VIAL / 84 1 SYRINGE / VIAL / SYRINGE / 28 1 VIAL / 28 1 KIT / KIT / 365

22 ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX 3.6 MG IMPLANT SYRN HORMONAL AGENTS, SUPPRESSANT (PITUITARY) 1 IMPLANT / 84 1 IMPLANT / 28 IMMUNOLOGICAL AGENTS ACTEMRA 162 MG/0.9 ML SYRINGE 4 SYRINGES (3.6 ML) / 28 ILARIS (150 MG/ML VIAL, 180 MG VIAL) 2 VIALS / 28 OTREXUP (AUTO INJCT) 4 PENS (1.6 ML) / 28 RASUVO 10 MG/0.2 ML AUTOINJ 4 PENS (0.8 ML) / 28 RASUVO 12.5 MG/0.25 ML AUTOINJ 4 PENS (1 ML) / 28 RASUVO 15 MG/0.3 ML AUTOINJ 4 PENS (1.2 ML) / 28 RASUVO 17.5 MG/0.35 ML AUTOINJ 4 PENS (1.4 ML) / 28 RASUVO 20 MG/0.4 ML AUTOINJ 4 PENS (1.6 ML) / 28 RASUVO 22.5 MG/0.45 ML AUTOINJ 4 PENS (1.8 ML) / 28 RASUVO 25 MG/0.5 ML AUTOINJ 4 PENS (2 ML) / 28 RASUVO 27.5 MG/0.55 ML AUTOINJ 4 PENS (2.2 ML) / 28 RASUVO 30 MG/0.6 ML AUTOINJ 4 PENS (2.4 ML) / 28 RASUVO 7.5 MG/0.15 ML AUTOINJ 4 PENS (0.6 ML) / 28 ACTONEL 150 MG TABLET ACTONEL 35 MG TABLET alendronate sodium (35 mg tab, 70 mg tab) ATELVIA (TABLET DR) BINOSTO (TABLET EFF) BONIVA 150 MG TABLET METABOLIC BONE DISEASE AGENTS 1 / 28 4 / 28 4 / 28 4 / 28 4 / 28 1 / 28 BONIVA 3 MG/3 ML SYRINGE 1 SYRINGE (3 ML) / 90 calcitonin-salmon (spray/pump) 1 BOTTLE (3.7 ML) / 30

23 METABOLIC BONE DISEASE AGENTS FORTICAL (SPRAY/PUMP) 1 BOTTLE (3.7 ML) / 30 FOSAMAX (TABLET) FOSAMAX PLUS D (TABLET) 4 / 28 4 / 28 ibandronate 3 mg/3 ml syringe 1 SYRINGE (3 ML) / 90 ibandronate 3 mg/3 ml vial ibandronate sodium 150 mg tab 1 VIAL / 90 1 / 28 MIACALCIN 200 UNIT NASAL SPRAY 1 BOTTLE (3.7 ML) / 30 NATPARA (CARTRIDGE) 2 CARTRIDGES / 28 PROLIA (SYRINGE) 2 SYRINGES (2 ML) / 365 risedronate sodium 150 mg tab risedronate sodium 35 mg tab risedronate sodium dr (tablet dr) bimatoprost 0.03% eye drops bromfenac sodium (drops) OPHTHALMIC AGENTS 1 / 28 4 / 28 4 / ML / 25 1 BOTTLE / RX BROMSITE (DROPS) 4 BOTTLES (20 ML) / 365 CYSTARAN (DROPS) 4 BOTTLES (60 ML) / 28 ILEVRO (DROPS SUSP) latanoprost (drops) 3.4 ML / ML / 30 LOTEMAX 0.5% EYE OINTMENT 4 TUBES (14 G) / 365 LOTEMAX 0.5% OPHTHALMIC GEL 4 BOTTLES (20 G) / 365 LUMIGAN (DROPS) 2.5 ML / 30 NEVANAC (DROPS SUSP) 2 BOTTLES (6 ML) / 30 PROLENSA (DROPS) 2 BOTTLES / 6 MONTHS RESCULA (DROPS) 1 BOTTLE (5 ML) / 25 TRAVATAN Z (DROPS) 2.5 ML / 25

24 travoprost (drops) XALATAN (DROPS) ZIOPTAN (DROPERETTE) ADCIRCA (TABLET) OPHTHALMIC AGENTS RESPIRATORY TRACT/PULMONARY AGENTS ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET, 2 MG TABLET) ADEMPAS 2.5 MG TABLET 2.5 ML / ML / / 30 ADVAIR DISKUS (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 ADVAIR HFA (HFA AER AD) 1 INHALER (12 G) / 30 AEROSPAN (HFA AER AD) 2 INHALERS (17.8 G) / 30 AIRDUO RESPICLICK (AER POW BA) albuterol 2.5 mg/0.5 ml sol albuterol 5 mg/ml solution 1 INHALER / 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 ALVESCO (HFA AER AD) 2 INHALERS (12.2 G) / 30 ANORO ELLIPTA (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 ARCAPTA NEOHALER (CAP W/DEV) ARMONAIR RESPICLICK (AER POW BA) 4 CAPSULES / DAY 1 INHALER / 30 ARNUITY ELLIPTA (BLST W/DEV) 1 INHALER (30 BLISTERS) / 30 ASMANEX (AER POW BA) 1 INHALER / 30 ASMANEX HFA (HFA AER AD) 1 INHALER (13 G) / 30 ASTEPRO (SPRAY/PUMP) 2 BOTTLES (60 ML) / 30 ATROVENT HFA (HFA AER AD) 2 INHALERS (25.8 G) / 30 azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 2 BOTTLES (60 ML) / 30

25 RESPIRATORY TRACT/PULMONARY AGENTS BECONASE AQ (SPRAY) 1 BOTTLE (25 G) / 25 BEVESPI AEROSPHERE (HFA AER AD) 1 INHALER (10.7 G) / 30 BREO ELLIPTA (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 BROVANA (VIAL-NEB) 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 (17.2 G) / 30 COMBIVENT RESPIMAT (MIST INHAL) 2 INHALERS (8 G) / 30 DULERA (HFA AER AD) 1 INHALER (13 G) / 30 DYMISTA (SPRAY/PUMP) 1 BOTTLE (23 G) / 30 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 flunisolide (spray) 1 BOTTLE (25 ML) / 30 fluticasone-salmeterol (aer pow ba) FORADIL (CAP W/DEV) GRASTEK (TAB SUBL) 1 INHALER / 30 1 INHALER (60 CAPSULES) / 30 INCRUSE ELLIPTA (BLST W/DEV) 1 INHALER (30 BLISTERS) / 30 ipratropium br 0.02% soln 125 VIALS (312.5 ML) / 30 ipratropium-albuterol (ampul-neb) 180 VIALS (540 ML) / 30 LETAIRIS (TABLET)

26 RESPIRATORY TRACT/PULMONARY AGENTS levalbuterol 1.25 mg/3 ml sol 90 VIALS (270 ML) / 30 levalbuterol concentrate (vial-neb) 90 VIALS (45 ML) / 30 levalbuterol hcl (0.31 ml, 0.63 ml) 180 VIALS (540 ML) / 30 levalbuterol tartrate hfa (hfa aer ad) 2 INHALERS (30 G) / 30 mometasone furoate 50 mcg spry 2 BOTTLES (34 G) / 30 NASONEX (SPRAY/PUMP) 2 BOTTLES (34 G) / 30 NUCALA (VIAL) OFEV (CAPSULE) 1 VIAL / 30 olopatadine 665 mcg nasal spry 1 BOTTLE (30.5 G) / 30 OMNARIS (SPRAY/PUMP) 1 BOTTLE (12.5 G) / 30 OPSUMIT (TABLET) ORALAIR (TAB SUBL) ORKAMBI (TABLET) PATANASE (SPRAY/PUMP) 1 BOTTLE (30.5 G) / 30 PERFOROMIST (VIAL-NEB) 2 VIALS (4 ML) / DAY PROAIR HFA (HFA AER AD) 2 INHALERS (17 G) / 30 PROAIR RESPICLICK (AER POW BA) 2 INHALERS / 30 PROVENTIL HFA (HFA AER AD) 2 INHALERS (13.4 G) / 30 PULMICORT (AMPUL-NEB) 60 AMPULES (120 ML) / 30 PULMICORT FLEXHALER (AER POW BA) 2 INHALERS / 30 QNASL (HFA AER AD) 1 INHALER (8.7 G) / 30 QNASL CHILDREN (HFA AER AD) 1 INHALER (4.9 G) / 30 QVAR 40 MCG ORAL INHALER 2 INHALERS (17.4 G) / 30

27 RESPIRATORY TRACT/PULMONARY AGENTS QVAR 80 MCG ORAL INHALER 3 INHALERS (26.1 G) / 30 QVAR REDIHALER (HFA AEROBA) 2 INHALERS (21.2 G) / 30 RAGWITEK (TAB SUBL) REVATIO 10 MG/ML ORAL SUSP 2 BOTTLES (224 ML) / 30 REVATIO 20 MG TABLET RHINOCORT AQUA (SPRAY/PUMP) 2 BOTTLES (17.2 G) / 30 SEEBRI NEOHALER (CAP W/DEV) 1 INHALER (60 CAPSULES) / 30 SEREVENT DISKUS (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 sildenafil (tablet) SPIRIVA (CAP W/DEV) 1 CAPSULE / DAY SPIRIVA RESPIMAT (MIST INHAL) 1 INHALER (4 G) / 30 STIOLTO RESPIMAT (MIST INHAL) 1 INHALER (4 G) / 30 STRIVERDI RESPIMAT (MIST INHAL) 1 INHALER (4 G) / 30 SYMBICORT (HFA AER AD) 1 INHALER (10.2 G) / 30 TOBI PODHALER (CAP W/DEV, CAPSULE) 1 KIT (224 CAPSULES) / 56 TRACLEER (62.5 MG TABLET, 125 MG TABLET) TRELEGY ELLIPTA (BLST W/DEV) 60 BLISTERS (1 PACK) / 30 TUDORZA PRESSAIR (AER POW BA) TYVASO (AMPUL-NEB) TYVASO INSTITUTIONAL START KIT (AMPUL-NEB) TYVASO REFILL KIT (AMPUL-NEB) TYVASO STARTER KIT (AMPUL-NEB) 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) 1 INHALER / 30 1 AMPULE / DAY 1 KIT / 28 1 KIT / 28 1 KIT / 28 UPTRAVI TITRATION PACK 2 PACKS (400 TABLETS) / 365

28 UTIBRON NEOHALER (CAP W/DEV) VENTAVIS (AMPUL-NEB) RESPIRATORY TRACT/PULMONARY AGENTS 1 INHALER (60 CAPSULES) / 30 9 AMPULES / DAY VENTOLIN HFA (HFA AER AD) 6 INHALERS (48 G) / 30 VERAMYST (SPRAY SUSP) 1 BOTTLE (10 G) / 30 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 (VIAL-NEB) 90 VIALS (45 ML) / 30 XOPENEX HFA (HFA AER AD) 2 INHALERS (30 G) / 30 ZETONNA (HFA AER AD) 1 INHALER (6.1 G) / 30 SLEEP DISORDER AGENTS AMBIEN (TABLET) AMBIEN CR (TAB MPHASE) armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) armodafinil 50 mg tablet BELSOMRA (TABLET) DORAL (TABLET) EDLUAR (TAB SUBL) estazolam (tablet) eszopiclone (tablet) flurazepam hcl (capsule) HALCION (TABLET) HETLIOZ (CAPSULE) INTERMEZZO (TAB SUBL) LUNESTA (TABLET) modafinil (tablet) NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MG TABLET) NUVIGIL 50 MG TABLET

29 PROVIGIL (TABLET) quazepam (tablet) RESTORIL (CAPSULE) ROZEREM (TABLET) SILENOR (TABLET) SONATA 10 MG CAPSULE SONATA 5 MG CAPSULE temazepam (capsule) triazolam mg tablet triazolam 0.25 mg tablet SLEEP DISORDER AGENTS XYREM (SOLUTION) 3 BOTTLES (540 ML) / 30 zaleplon 10 mg capsule zaleplon 5 mg capsule zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) zolpidem tartrate (5 mg tablet, 10 mg tablet) zolpidem tartrate er (tab mphase) ZOLPIMIST (SPRAY/PUMP) 1 BOTTLE (7.7 ML) / 30 SAMSCA (TABLET) XURIDEN (GRAN PACK) OZEMPIC MG DOSE PEN OZEMPIC 1 MG DOSE PEN TRACLEER 32 MG TABLET FOR SUSP THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES Uncategorized 30 DAY SUPPLY / 60 1 PEN (1.5 ML) / 28 2 PENS (3 ML) / 28 4 TABLETS / DAY VYZULTA (DROPS) 1 BOTTLE (5ML) / 25

30 page 1 of 2 DISCRIMINATION IS AGAINST THE LAW Final Rule Under Section 1557 for Nondiscrimination and Accessibility Requirements We comply with applicable Federal civil rights laws. We do not discriminate against, exclude or treat people differently because of race, color, national origin, age, disability or sex. We provide free aids and services to help people communicate effectively with us, such as: Qualified sign language interpreters, call TTY for hearing and language impaired, call Qualified spoken language interpreters, for people whose preferred language is not English, call Written information in other languages and formats (such as large print, audio and accessible electronic formats), call If you believe that we have 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 your facility in person or by mail, fax or . The contacts listed below will help you. For a copy of our grievance procedure, go to ClearScript SM Fairview Pharmacy Services Corporate Office, 711 Kasota Ave. S.E., Minneapolis, MN Phone: Fax: dept-pharm-compliance@fairview.org 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 LANGUAGE SERVICES Available 24 Hours ATTENTION: Language assistance services, free of charge, are available to you. Call Soomaali (Somali) FIIRO GAAR AH: Hadii aad ku hadasho Soomaali, waaxda luqadaha,qaybta kaalmada adeegyada, waxay idiin hayaan adeeg kharash la aan ah. So wac Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (Arabic) ةيبرعلا ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

31 page 2 of 2 Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните Oroomiffa (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ ខ ម រ (Cambodian) ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화해주십시오. und Karen Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます まで お電話にてご連絡ください Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer Français (French) ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (Farsi) یسراف Rev