Quantity Limits Drug List

Transcription

1 Quantity Limits Drug List Taking too much medicine or using it too often isn t safe. And it may even drive up your health care costs. That s why this program limits the amount of medicine that s covered by your plan for a certain length of time. For example, a drug may have a limit of 30 pills per 30 days. If you refill a prescription too soon or your doctor prescribes an amount that s higher than usual, your pharmacist will tell you. The drug won t be covered at that time. Use this table to see if one of your drugs has a quantity limit. Find your type of drug in the columns on the left. Then look for the name of your drug. The amount that s covered by your plan is listed in the right-hand column. CATEGORY DRUG NAME RECOMMENDED LIMIT Analgesic, Anti-inflammatory or Abstral 100 MCG Abstral 200 MCG Abstral 300 MCG Abstral 400 MCG Abstral 600 MCG Abstral 800 MCG Chemical Dependency, Agents to acamprosate calcium 333 MG 6 tablets per day Treat Analgesic, Anti-inflammatory or acetaminophen w/codeine 300MG-30MG 1 acetaminophen w/codeine 300MG-60MG 6 tablets per day Gastrointestinal Therapy Agents Aciphex 20 MG Aciphex Sprinkle 10 MG Aciphex Sprinkle 5 MG Analgesic, Anti-inflammatory or Actemra 162 MG/0.9 4 syringes per 28 days Actiq 1200 MCG Actiq 1600 MCG Actiq 200 MCG Actiq 400 MCG Actiq 600 MCG Actiq 800 MCG Central Nervous System Agents Active-Pac 300MG-4-1% 1 per 30 days Endocrine Actonel 150 MG 1 tablet per 30 days Actonel 30 MG Actonel 35 MG 4 tablets per 28 days Actonel 5 MG Actoplus Met 15MG-500MG Actoplus Met 15MG-850MG Actoplus Met Xr MG Actoplus Met Xr MG Actos 15 MG 45231ANMENABS VPOD Effective 08/01/2016

2 Endocrine Actos 30 MG Actos 45 MG Dermatological acyclovir 5 % 30 GM in 30 days Cardiovascular Therapy Agents Adalat Cc 60 MG Adalat Cc 90 MG Adcirca 20 MG Central Nervous System Agents Addyi 100 MG Cardiovascular Therapy Agents Adempas 0.5 MG Adempas 1 MG Adempas 1.5 MG Adempas 2 MG Adempas 2.5 MG Respiratory Therapy Agents Advair Diskus MCG 1 inhaler per 30 days Advair Diskus MCG 1 inhaler per 30 days Advair Diskus MCG 1 inhaler per 30 days Advair Hfa MCG Advair Hfa MCG Advair Hfa 45-21MCG Cardiovascular Therapy Agents Advicor MG Advicor MG Advicor 750MG-20MG Respiratory Therapy Agents Aerospan 80 MCG 2 inhalers per 30 days Cardiovascular Therapy Agents afeditab cr 60 MG Biologicals Afluria 45MCG/.5ML 2 Rx per 180 days Endocrine Afrezza 4 UNIT 18 cartridges per day Afrezza 4 UNIT(30) 15 cartridges per day Afrezza 4 UNIT(60) 18 cartridges per day Afrezza 8 UNIT(60) 12 cartridges per day Hematological Agents Aggrenox 25MG-200MG Gastrointestinal Therapy Agents Akynzeo MG 5 capsules in 25 days or 15 capsules in 61 days Dermatological Aldara 5 % 12 packets per 28 days; 112 days of treatment per year Antineoplastics Alecensa 150 MG 8 per day Endocrine alendronate sodium 10 MG alendronate sodium 35 MG 4 tablets per 28 days alendronate sodium 40 MG alendronate sodium 5 MG alendronate sodium 70 MG 4 tablets per 28 days Central Nervous System Agents almotriptan malate 12.5 MG almotriptan malate 6.25 MG Ophthalmic Agents Alocril 2 % Endocrine Alogliptin 12.5 MG Alogliptin 25 MG

3 Endocrine Alogliptin 6.25 MG Alogliptin-Metformin Alogliptin-Metformin MG Alogliptin-Pioglitazone MG Alogliptin-Pioglitazone MG Alogliptin-Pioglitazone MG Alogliptin-Pioglitazone 25 MG-15MG Alogliptin-Pioglitazone 25 MG-30MG Alogliptin-Pioglitazone 25 MG-45MG Ophthalmic Agents Alomide 0.1 % Central Nervous System Agents Alsuma 6 MG/0.5ML 4 syringes per rolling 30 days Cardiovascular Therapy Agents Altoprev 60 MG Respiratory Therapy Agents Alvesco 160 MCG 2 packages per 30 days Alvesco 80 MCG Central Nervous System Agents amantadine hcl 100 MG Ambien 10 MG Ambien 5 MG Ambien Cr 12.5 MG Ambien Cr 6.25 MG Amerge 1 MG Amerge 2.5 MG Cardiovascular Therapy Agents amlodipine besylate 10 MG amlodipine-atorvastatin 10 MG-10MG amlodipine-atorvastatin 10 MG-20MG amlodipine-atorvastatin 10 MG-40MG amlodipine-atorvastatin 10 MG-80MG amlodipine-atorvastatin 5 MG-80 MG amlodipine-valsartan 10MG-160MG amlodipine-valsartan 10MG-320MG amlodipine-valsartan 5MG-320MG amlodipine-valsartan-hctz amlodipine-valsartan-hctz amlodipine-valsartan-hctz 10MG-160MG amlodipine-valsartan-hctz MG Multiple Sclerosis Agents Ampyra 10 MG Antineoplastics anastrozole 1 MG Endocrine Androderm 2 MG/24 HR Androderm 4 MG/24 HR Androgel 1.25 G(1%) 2 packets per day Androgel 1.25G packages per 30 days Androgel 2.5G-1.62% 30 packages per 30 days Androgel 20.25/1.25 Androgel 25MG(1%) 2 packets per day

4 Endocrine Androgel 50 MG (1%) 2 packets per day Respiratory Therapy Agents Anoro Ellipta MCG 1 inhaler per 30 days Gastrointestinal Therapy Agents Anzemet 100 MG 5 tablets per 30 days Anzemet 50 MG 5 tablets per 30 days Analgesic, Anti-inflammatory or apap-caffeine-dihydrocodeine MG 10 capsules per day apap-caffeine-dihydrocodeine tablets per 30 days Central Nervous System Agents Aplenzin 348MG Aplenzin 522MG Analgesic, Anti-inflammatory or Arcalyst 220 MG 4 vials per 28 days Respiratory Therapy Agents Arcapta Neohaler 75 MCG Antineoplastics Arimidex 1 MG Central Nervous System Agents armodafinil 150 MG armodafinil 250 MG armodafinil 50 MG Respiratory Therapy Agents Arnuity Ellipta 100 MCG 1 inhaler per 30 days Arnuity Ellipta 200 MCG 1 inhaler per 30 days Antineoplastics Aromasin 25 MG Respiratory Therapy Agents Asmanex 110MCG(30) Asmanex 220MCG inhaler per 30 days Asmanex 220MCG(30) 1 inhaler per 30 days Asmanex 220MCG(60) 1 inhaler per 30 days Asmanex Hfa 100 MCG 1 inhaler per 30 days Asmanex Hfa 200 MCG 1 inhaler per 30 days Hematological Agents aspirin-dipyridamole er 25MG-200MG Respiratory Therapy Agents Astelin 137 MCG 1 package per 25 days Astepro 205.5MCG 1 package per 25 days Cardiovascular Therapy Agents Atacand 16 MG Atacand 32 MG Atacand 4 MG Atacand 8 MG Atacand Hct MG Atacand Hct MG Endocrine Atelvia 35 MG 4 tablets per 28 days Cardiovascular Therapy Agents atorvastatin calcium 80 MG Respiratory Therapy Agents Atrovent 21 MCG 2 packages per 30 days Atrovent 42 MCG 2 bottles per 30 days Atrovent Hfa 17MCG 2 inhalers per 30 days Multiple Sclerosis Agents Aubagio 14 MG Aubagio 7 MG Cardiovascular Therapy Agents Avalide MG Endocrine Avandamet 2 MG-500MG 4 tablet per day Avandamet MG

5 Endocrine Avandamet MG Avandamet 4-500MG Avandaryl 4MG-1MG Avandaryl 4MG-2MG Avandaryl 4MG-4MG Avandia 2 MG Avandia 4 MG Avandia 8 MG Cardiovascular Therapy Agents Avapro 300 MG Anti-Infective Agents Avelox 400 MG 21 tablets per fill Avelox Abc Pack 400 MG 5 tablets per fill Analgesic, Anti-inflammatory or Avinza 120 MG Avinza 30 MG Avinza 45 MG Avinza 60 MG Avinza 75 MG Avinza 90 MG Central Nervous System Agents Axert 12.5 MG Axert 6.25 MG Endocrine Axiron 30MG/1.5ML Ophthalmic Agents azelastine hcl 0.05 % 1 bottle per 24 days Respiratory Therapy Agents azelastine hcl 137 MCG 1 package per 25 days azelastine hcl 205.5MCG 1 package per 25 days Anti-Infective Agents azithromycin 1 G 2 packets per fill azithromycin 100 MG/5ML 15 ml per fill azithromycin 200 MG/5ML 15 ml per fill azithromycin 250 MG 6 tablets per fill azithromycin 500 MG 3 tablets per fill azithromycin 600 MG 8 tablets per fill Cardiovascular Therapy Agents Azor 10 MG-20MG Azor 10 MG-40MG Azor 5 MG-40 MG Respiratory Therapy Agents Beconase Aq 42 MCG 2 packages per 30 days Analgesic, Anti-inflammatory or Belbuca 150 MCG 2 films per day Belbuca 300 MCG 2 films per day Belbuca 450 MCG 2 films per day Belbuca 600 MCG 2 films per day Belbuca 75 MCG 2 films per day Belbuca 750 MCG 2 films per day Belbuca 900 MCG 2 films per day Central Nervous System Agents Belsomra 10 MG Belsomra 15 MG Belsomra 20 MG

6 Central Nervous System Agents Belsomra 5 MG Cardiovascular Therapy Agents Benicar 40 MG Benicar 5 MG Benicar Hct 40 MG-25MG Benicar Hct MG Ophthalmic Agents Bepreve 1.5 % 10 ml (1 bottle) per 30 days Endocrine Binosto 70 MG 4 tablets per 28 days Medical Supplies and Durable Medical Blood Glucose meters and strips 204 per 30 days Equipment (DME) Endocrine Boniva 150 MG 1 tablet per 28 days Antineoplastics Bosulif 100 MG Bosulif 500 MG Respiratory Therapy Agents Breo Ellipta MCG 2 units per day Breo Ellipta MCG 2 units per day Hematological Agents Brilinta 60 MG Brilinta 90 MG Central Nervous System Agents Brintellix 20 MG Respiratory Therapy Agents Brovana 15MCG/2ML budesonide 0.25MG/2ML 120 ml per 30 days budesonide 0.5 MG/2ML 120 ml per 30 days budesonide 1 MG/2 ML 60 ml per 30 days budesonide 32MCG 2 packages per 30 days Chemical Dependency, Agents to Bunavail MG 8 films per day Treat Bunavail MG 4 films per day Bunavail 6.3MG-1MG 2 films per day buprenorphine hydrochloride 2 MG 12 tablets 90 days buprenorphine hydrochloride 8 MG 3 tablets per 90 days buprenorphine-naloxone 2 MG-0.5MG 1 buprenorphine-naloxone 8 MG-2 MG buproban 150 MG Central Nervous System Agents bupropion hcl 100 MG 4.5 tablets per day bupropion hcl xl 300 MG Chemical Dependency, Agents to bupropion sr 150 MG Treat Analgesic, Anti-inflammatory or butalbital/caff/apap/codeine per day butalbital/caff/apap/codeine per day butorphanol tartrate 10 MG/ML 2 bottles per 30 days Butrans 10 MCG/HR 1 package per 28 days Butrans 15 MCG/HR 1 package per 28 days Butrans 20 MCG/HR 1 package per 28 days Butrans 5 MCG/HR 1 package per 28 days Butrans 7.5 MCG/HR 1 package per 28 days Endocrine Bydureon 2 MG 4 per 28 days Byetta 10MCG/0.04

7 Endocrine Byetta 5MCG/0.02 Antineoplastics Cabometyx 20 MG 3 per day Cabometyx 40 MG Cabometyx 60 MG Cardiovascular Therapy Agents Caduet 10 MG-10MG Caduet 10 MG-20MG Caduet 10 MG-40MG Caduet 10 MG-80MG Caduet 5 MG-80 MG Calan 120 MG 4 tablet per day Calan 80 MG 4 tablet per day Calan Sr 120 MG Calan Sr 180 MG Calan Sr 240 MG Endocrine calcitonin-salmon 200/SPRAY Analgesic, Anti-inflammatory or Cambia 50 MG 9 packets per 30 days Chemical Dependency, Agents to Campral 333 MG 6 tablets per day Treat Cardiovascular Therapy Agents candesartan cilexetil 16 MG candesartan cilexetil 32 MG candesartan cilexetil 4 MG candesartan cilexetil 8 MG candesartan-hydrochlorothiazid MG candesartan-hydrochlorothiazid MG Analgesic, Anti-inflammatory or Capital W/Codeine MG/5 90 ml per day Antineoplastics Caprelsa 100 MG Caprelsa 300 MG Analgesic, Anti-inflammatory or Capxib kit per 30 days Dermatological Carac 0.5% cream 30 grams per 28 days; 28 days of treatment per year Cardiovascular Therapy Agents Cardene Sr 30 MG 4 capsules per day Cardene Sr 45 MG 4 capsules per day Cardene Sr 60 MG 4 capsules per day Cardizem 120 MG Cardizem 30 MG Cardizem 60 MG Cardizem 90 MG Cardizem Cd 240 MG Cardizem Cd 300 MG Cardizem Cd 360 MG Cardizem La 240 MG Cardizem La 300 MG

8 Cardiovascular Therapy Agents Cardizem La 360 MG Cardizem La 420 MG cartia xt 240 MG cartia xt 300 MG Analgesic, Anti-inflammatory or Celebrex 100 MG Celebrex 200 MG Celebrex 400 MG Celebrex 50 MG celecoxib 100 MG celecoxib 200 MG celecoxib 400 MG celecoxib 50 MG Central Nervous System Agents Celexa 40 MG Chemical Dependency, Agents to Chantix 0.5 (11)-1 1 package per year Treat Chantix 0.5 MG Chantix 1 MG Gastrointestinal Therapy Agents Cholbam 250 MG 4 capsules per day Cholbam 50 MG 4 capsules per day Drugs to treat Erectile Dysfunction Cialis 2.5 MG 30 tablets in 25 days or 90 tablets in 61 days Cialis 5 MG 30 tablets in 25 days or 90 tablets in 61 days Gastrointestinal Therapy Agents Cimzia 400 MG Cimzia 400MG/2ML 1 package per year Hematological Agents Cinryze 500 (5 ML) 20 vials per 30 days Anti-Infective Agents Cipro 250 MG 28 tablets per fill Cipro 250 MG/5ML 3 bottles per fill Cipro 500 MG 28 tablets per fill Cipro 500 MG/5ML 3 bottles per fill Cipro 750 MG 28 per 30 days Genitourinary Therapy Cipro Xr 1000 MG 14 tablets per fill Cipro Xr 500 MG 3 tablets per fill Anti-Infective Agents ciprofloxacin 250 MG/5ML 3 bottles per fill ciprofloxacin 500 MG/5ML 3 bottles per fill Genitourinary Therapy ciprofloxacin er 1000 MG 14 tablets per fill ciprofloxacin er 500 MG 3 tablets per fill Anti-Infective Agents ciprofloxacin hcl 100 MG 28 tablets per fill ciprofloxacin hcl 250 MG 28 tablets per fill ciprofloxacin hcl 500 MG 28 tablets per fill ciprofloxacin hcl 750 MG 28 tablets per fill Central Nervous System Agents citalopram hbr 10 MG/5 ML 20 ml day citalopram hbr 40 MG Hematological Agents clopidogrel 75 MG Mouth-Throat-Dental - Preparations clotrimazole 10 MG 5 units per day

9 Analgesic, Anti-inflammatory or co-gesic 5 MG-500MG 8 tablets per day Gout and Hyperuricemia Therapy Colchicine 0.6 MG Colcrys 0.6 MG Respiratory Therapy Agents Combivent MCG 3 packages per 30 days Combivent Respimat MCG 2 packages per 30 days Antineoplastics Cometriq 100 MG/DAY Cometriq 140 MG/DAY 4 capsules per day Cometriq 60 MG/DAY 3 capsules per day Analgesic, Anti-inflammatory or Comfort Pac-Meloxicam 15 MG Central Nervous System Agents Comtan 200 MG 8 tablets per day Analgesic, Anti-inflammatory or Conzip 100 MG Conzip 200 MG Conzip 300 MG Cardiovascular Therapy Agents Corlanor 5 MG Corlanor 7.5 MG Dermatological Cosentyx 150Mg 150 MG/ML 2 syringes per 28 days Cosentyx 300Mg 150 MG/ML 2 syringes per 28 days Antineoplastics Cotellic 20 MG Cardiovascular Therapy Agents Cozaar 100 MG Cozaar 25 MG Cozaar 50 MG Anti-Infective Agents Cresemba 186 MG Cresemba 372 MG 1 vial per day Cardiovascular Therapy Agents Crestor 40 MG Ophthalmic Agents cromolyn sodium 4 % Central Nervous System Agents Cymbalta 20 MG Cymbalta 60 MG Anti-Infective Agents Daklinza 30 MG Daklinza 60 MG Daklinza 90 MG Respiratory Therapy Agents Daliresp 500 MCG Anti-Infective Agents Daraprim 25 MG Central Nervous System Agents Daytrana 10MG/9HR Daytrana 15MG/9HR Daytrana 20 MG/9 HR Daytrana 30MG/9HR Dermatological Denavir 1 % 5 gm in 30 days DermacinRx Azenase Pak (azelastine 137mcg 1 kit per 30 days and fluticasone 50 mcg) Analgesic, Anti-inflammatory or Dermasilkrx Diclopak 75MG-.025% 1 kit per 30 days Central Nervous System Agents Desvenlafaxine Er 100 MG Gastrointestinal Therapy Agents Dexilant 30 MG

10 Gastrointestinal Therapy Agents Dexilant 60 MG Central Nervous System Agents Diastat 2.5 MG 2 syringes per fill Diastat Acudial syringes per fill Diastat Acudial MG 2 syringes per fill diazepam syringes per fill diazepam 2.5 MG 2 syringes per fill diazepam MG 2 syringes per fill Gastrointestinal Therapy Agents Diclegis 10 MG-10MG Dermatological diclofenac sodium 3 % Anti-Infective Agents Diflucan 10 MG/ML 40 ml per day Diflucan 100 MG Diflucan 150 MG Diflucan 200 MG Diflucan 40 MG/ML 10 ml per day Diflucan 50 MG 8 tablets per day Central Nervous System Agents dihydroergotamine mesylate 0.5MG/SPRY 8 each per 30 days Cardiovascular Therapy Agents Dilacor Xr 240 MG dilt-cd 240 MG dilt-cd 300 MG diltia xt 240 MG diltiazem 24hr cd 240 MG diltiazem 24hr cd 300 MG diltiazem 24hr cd 360 MG diltiazem er 120 MG diltiazem er 240 MG diltiazem er 300 MG diltiazem er 360 MG diltiazem er 420 MG diltiazem er 60 MG diltiazem er 90 MG diltiazem hcl 120 MG diltiazem hcl 240 MG diltiazem hcl 30 MG diltiazem hcl 60 MG diltiazem hcl 90 MG dilt-xr 240 MG diltzac er 240 MG diltzac er 300 MG diltzac er 360 MG Diovan 160 MG Diovan 320 MG Diovan 40 MG Diovan 80 MG

11 Cardiovascular Therapy Agents Diovan Hct MG Diovan Hct MG Diovan Hct 320MG-25MG Analgesic, Anti-inflammatory or diskets 40 MG Dolophine Hcl 10 MG 6 tablets per day Dolophine Hcl 5 MG 1 Endocrine Duetact 30 MG-2 MG Duetact 30 MG-4 MG Analgesic, Anti-inflammatory or Duexis MG Respiratory Therapy Agents Dulera MCG Dulera MCG Central Nervous System Agents duloxetine hcl 20 MG duloxetine hcl 40 MG 3 capsules per day duloxetine hcl 60 MG Analgesic, Anti-inflammatory or Duragesic 100 MCG/HR 15 patches per 30 days Duragesic 12 MCG/HR 15 patches per 30 days Duragesic 25 MCG/HR 15 patches per 30 days Duragesic 50MCG/HR 15 patches per 30 days Duragesic 75MCG/HR 15 patches per 30 days Ophthalmic Agents Durezol 0.05 % 2 bottles per 30 days Analgesic, Anti-inflammatory or Durlaza MG Respiratory Therapy Agents Dymista MCG Cardiovascular Therapy Agents Edarbyclor 40 MG-25MG Edarbyclor MG Central Nervous System Agents Edluar 10 MG Edluar 5 MG Effexor Xr 150 MG Hematological Agents Effient 10 MG Dermatological Efudex 5% cream 40 grams per 28 days; 28 days of treatment per year Endocrine Egrifta 1 MG Ophthalmic Agents Elestat 0.05 % 5 ml (1 bottle) per 30 days Antineoplastics Eligard 22.5 MG 1 per 12 weeks Eligard 30 MG 1 per 16 weeks Eligard 45 MG 1 per 24 weeks Eligard 7.5 MG 1 per 4 weeks Hematological Agents Eliquis 2.5 MG Eliquis 5 MG 74 tablets per 30 days Ophthalmic Agents Emadine 0.05 % Analgesic, Anti-inflammatory or Embeda 100MG-4MG Embeda 20MG-0.8MG Embeda 30MG-1.2MG

12 Analgesic, Anti-inflammatory or Embeda 50 MG-2 MG Embeda 60MG-2.4MG Embeda 80MG-3.2MG Gastrointestinal Therapy Agents Emend 125 MG 5 capsules per day Emend 125 mg (25 mg/ml) oral suspension 15 kits per 30 days single-dose kit Emend 125MG-80MG 5 capsules per day Emend 150 mg injection 5 vials per 30 days Emend 40 MG 1 capsule per Rx Emend 80 MG 10 capsules per day Analgesic, Anti-inflammatory or Enbrel 25 MG 8 vials 28 days Enbrel 25MG/0.5ML 8 syringes per 30 days Enbrel 50 MG/ML 4 syringes per 28 days endocet 10MG-325MG 1 endocet 10MG-650MG 6 tablets per day endocet MG 1 endocet 5 MG-325MG 1 endocet MG 1 endocet MG 8 tablets per day Central Nervous System Agents entacapone 200 MG 8 tablets per day Cardiovascular Therapy Agents Entresto 24 MG-26MG Entresto 49 MG-51MG Entresto 97MG-103MG Gastrointestinal Therapy Agents Entyvio 300 MG 1 vial per 56 days Anti-Infective Agents Epclusa MG Ophthalmic Agents epinastine hcl 0.05 % 1 bottle per 30 days Cardiovascular Therapy Agents eprosartan mesylate 600 MG Antineoplastics Erivedge 150 MG Respiratory Therapy Agents Esbriet 267 MG 9 capsules per day Central Nervous System Agents escitalopram oxalate 20 MG escitalopram oxalate 5 MG/5 ML 600 ML per 30 days Gastrointestinal Therapy Agents esomeprazole magnesium 20 MG esomeprazole magnesium 40 MG Esomeprazole Strontium MG Esomeprazole Strontium 49.3 MG Central Nervous System Agents eszopiclone 1 MG eszopiclone 2 MG eszopiclone 3 MG Antidotes and other Reversal Agents Evzio 0.4 MG/0.4 6 auto-injectors in 3 months Analgesic, Anti-inflammatory or Exalgo 12 MG Exalgo 16 MG Exalgo 32 MG Exalgo 8 MG

13 Antineoplastics exemestane 25 MG Cardiovascular Therapy Agents Exforge 10MG-160MG Exforge 10MG-320MG Exforge 5MG-320MG Exforge Hct Exforge Hct Exforge Hct 10MG-160MG Exforge Hct MG Biologicals Ez Flu (Fluvirin) 45MCG/.5ML 2 Rx per 180 days Anti-Infective Agents Factive 320 MG 7 tablets per fill Antineoplastics Fareston 60 MG Endocrine Farxiga 10 MG Farxiga 5 MG Antineoplastics Farydak 10 MG Farydak 15 MG Farydak 20 MG Cardiovascular Therapy Agents felodipine er 10 MG Antineoplastics Femara 2.5 MG Analgesic, Anti-inflammatory or fentanyl 100 MCG/HR 15 patches per 30 days fentanyl 12 MCG/HR 15 patches per 30 days fentanyl 25 MCG/HR 15 patches per 30 days Fentanyl 37.5MCG/HR 15 patches per 30 days fentanyl 50MCG/HR 15 patches per 30 days Fentanyl 62.5MCG/HR 15 patches per 30 days fentanyl 75MCG/HR 15 patches per 30 days Fentanyl 87.5MCG/HR 15 patches per 30 days Chemicals-Pharmaceutical Adjuvants fentanyl citrate 1200 MCG fentanyl citrate 1600 MCG fentanyl citrate 200 MCG fentanyl citrate 400 MCG fentanyl citrate 600 MCG fentanyl citrate 800 MCG Analgesic, Anti-inflammatory or Fentora 100 MCG 4 tablet per day Fentora 200 MCG 4 tablet per day Fentora 400 MCG 4 tablet per day Fentora 600 MCG 4 tablet per day Fentora 800 MCG 4 tablet per day Central Nervous System Agents Fetzima 120 MG Fetzima 20 MG Fetzima 20-40MG 1 pack per year Fetzima 40 MG Fetzima 80 MG

14 Analgesic, Anti-inflammatory or Fioricet With Codeine per day Fioricet With Codeine per day Antineoplastics Firmagon 120 mg 2 injections (240 mg) per 365 days Firmagon 80 mg 1 injection (80 mg) per 28 days Central Nervous System Agents flibanserin 100 % Respiratory Therapy Agents Flonase 50 MCG Flovent Diskus 100 MCG Flovent Diskus 250 MCG 4 inhalers per 30 days Flovent Diskus 50 MCG Flovent Hfa 110 MCG Flovent Hfa 220 MCG 2 packages per 30 days Flovent Hfa 44 MCG Biologicals Fluarix 45MCG/.5ML 2 Rx per 180 days Fluarix 60MCG/.5ML 2 Rx per 180 days Anti-Infective Agents Fluarix Quad MCG/.5ML 2 Rx per 180 days Biologicals Flublok MCG/0.5 2 Rx per 180 days Flublok MCG/0.5 2 Rx per 180 days Flublok MCG/0.5 2 Rx per 180 days Flucelvax 45MCG/.5ML 2 Rx per 180 days Anti-Infective Agents fluconazole 10 MG/ML 40 ml per day fluconazole 100 MG fluconazole 150 MG fluconazole 200 MG fluconazole 40 MG/ML 10 ml per day fluconazole 50 MG 8 tablets per day Biologicals Flulaval 45MCG/.5ML 2 Rx per 180 days Flulaval 60MCG/.5ML 2 Rx per 180 days Anti-Infective Agents Flulaval Quad MCG/.5ML 2 Rx per 180 days Biologicals Flumist 10E Rx per 180 days Respiratory Therapy Agents flunisolide 25 MCG Dermatological Fluoroplex 1% cream 30 grams per 28 days; 56 days of treatment per year Fluorouracil 2%, 5% solution 10 ml per 28 days; 28 days of treatment per year Central Nervous System Agents fluoxetine dr 90 MG 4 capsules per 28 days fluoxetine hcl 20 MG/5 ML 20 ml day fluoxetine hcl 40 MG Fluoxetine Hcl 60 MG Respiratory Therapy Agents fluticasone propionate 50 MCG Biologicals Fluvirin 45MCG/.5ML 2 Rx per 180 days Central Nervous System Agents fluvoxamine maleate 100 MG fluvoxamine maleate 150 MG Biologicals Fluzone 180MCG/0.5 2 Rx per 180 days Fluzone 22.5/.25ML 2 Rx per 180 days

15 Biologicals Fluzone 27MCG/.1ML 2 Rx per 180 days Fluzone 30MCG/ Rx per 180 days Fluzone 45MCG/.5ML 2 Rx per 180 days Fluzone 60MCG/.5ML 2 Rx per 180 days Fluzone High-Dose 180MCG/0.5 2 Rx per 180 days Fluzone Intraderm Quad Rx per 180 days 36MCG/.1ML Fluzone Intradermal MCG/.1ML 2 Rx per 180 days Fluzone Pedi /.25ML 2 Rx per 180 days Fluzone Quad MCG/.5ML 2 Rx per 180 days Fluzone Quad MCG/.5ML 2 Rx per 180 days Fluzone Quad Pedi MCG/ Rx per 180 days Fluzone Quad Pedi MCG/ Rx per 180 days Respiratory Therapy Agents Foradil 12 MCG Central Nervous System Agents Forfivo Xl 450 MG Endocrine Forteo 20MCG/DOSE 1 pen per 28 days Fortesta 10 MG (2%) fortical 200/SPRAY Fosamax 70 MG 4 tablets per 28 days Fosamax Plus D 70 MG tablets per 28 days Central Nervous System Agents Frova 2.5 MG frovatriptan succinate 2.5 MG Multiple Sclerosis Agents Gilenya 0.5 MG Antineoplastics Gilotrif 20 MG Gilotrif 30 MG Gilotrif 40 MG Gleevec 100 MG 8 tablets per day Gleevec 400 MG Endocrine Glyxambi 10 MG-5 MG Glyxambi 25 MG-5 MG Central Nervous System Agents Gralise 600 mg Gralise Starter Pack 1 starter pack Gastrointestinal Therapy Agents granisetron hcl 1 MG 10 tablets 30 days granisol 1 MG/5 ML 50 ml per 30 days Biologicals Grastek 2800 UNIT Anti-Infective Agents Harvoni 90MG-400MG Central Nervous System Agents Hetlioz 20 MG Horizant Gastrointestinal Therapy Agents Humira 10MG/0.2ML 2 syringes per 28 days Humira 20MG/0.4ML 2 syringes per 28 days Humira 40MG/0.8ML 2 syringes per 28 days Humira Pediatric 40MG/0.8ML 1 kit per year Analgesic, Anti-inflammatory or Hycet / ml per 30 days

16 Analgesic, Anti-inflammatory or hydrocodone bit-ibuprofen 5MG-200MG 16 tablets per day hydrocodone w/acetaminophen / ml per 30 days hydrocodone w/acetaminophen MG 6 tablets per day hydrocodone w/acetaminophen 10MG MG hydrocodone w/acetaminophen 10MG MG hydrocodone w/acetaminophen 10MG- 8 tablets per day 500MG hydrocodone w/acetaminophen 10MG- 6 tablets per day 650MG hydrocodone w/acetaminophen 10MG- 5 tablets per day 750MG hydrocodone w/acetaminophen /5 90 ml per day hydrocodone w/acetaminophen MG 8 tablets per day hydrocodone w/acetaminophen 5 MG MG hydrocodone w/acetaminophen 5 MG- 8 tablets per day 500MG hydrocodone w/acetaminophen 5-163/ ml per 30 days hydrocodone w/acetaminophen 90 ml per day 5-334MG/10 hydrocodone w/acetaminophen 5MG-300MG 1 hydrocodone w/acetaminophen MG 8 tablets per day hydrocodone w/acetaminophen / tablets per day hydrocodone w/acetaminophen MG 1 hydrocodone w/acetaminophen /15 90 ml per day hydrocodone w/acetaminophen MG 8 tablets per day hydrocodone w/acetaminophen MG 6 tablets per day hydrocodone w/acetaminophen MG 5 tablets per day hydromorphone er 12 MG hydromorphone er 16 MG hydromorphone er 32 MG hydromorphone er 8 MG Hysingla Er 100 MG Hysingla Er 120 MG Hysingla Er 20 MG Hysingla Er 30 MG Hysingla Er 40 MG Hysingla Er 60 MG Hysingla Er 80 MG Cardiovascular Therapy Agents Hyzaar MG Hyzaar 100MG-25MG Endocrine ibandronate sodium 150 MG 1 tablet per 28 days Antineoplastics Ibrance 100 MG Ibrance 125 MG

17 Antineoplastics Ibrance 75 MG Analgesic, Anti-inflammatory or Ibudone 5MG-200MG 16 tablets per day Antineoplastics Iclusig 15 MG Iclusig 45 MG Analgesic, Anti-inflammatory or Ilaris 180 MG/1.2 2 vials per 28 days Antineoplastics imatinib mesylate 100 MG 8 tablets per day imatinib mesylate 400 MG Imbruvica 140 MG 4 capsules per day Dermatological imiquimod 5 % 12 packets per 28 days Central Nervous System Agents Imitrex 100 MG Imitrex 20 MG 6 tablets rolling 30 days Imitrex 25 MG Imitrex 4 MG/0.5ML 4 syringes per rolling 30 days Imitrex 5 MG 6 tablets rolling 30 days Imitrex 50 MG Imitrex 6 MG/0.5ML 5 vials per 30 days Respiratory Therapy Agents Incruse Ellipta 62.5 MCG 1 inhaler per 30 days Analgesic, Anti-inflammatory or Inflammacin 75MG-.025% 0.04 kits per day Antineoplastics Inlyta 1 MG 8 tablets per day Inlyta 5 MG Central Nervous System Agents Intermezzo 1.75 MG Intermezzo 3.5 MG Endocrine Invokamet MG Invokamet MG Invokamet MG Invokamet 50MG-500MG Invokana 100 MG Invokana 300 MG Respiratory Therapy Agents ipratropium bromide 0.2 MG/ML 378 ml per 30 days ipratropium bromide 21 MCG 2 packages per 30 days ipratropium bromide 42 MCG 2 bottles per 30 days Cardiovascular Therapy Agents irbesartan 300 MG irbesartan-hydrochlorothiazide MG Central Nervous System Agents Irenka 40 MG 3 capsules per day Antineoplastics Iressa 250 MG Cardiovascular Therapy Agents isradipine 2.5 MG isradipine 5 MG 4 capsules per day Anti-Infective Agents itraconazole 100 MG 4. Antineoplastics Jakafi 10 MG 5 tablets per day Jakafi 15 MG Jakafi 20 MG 2.5 tablets per day

18 Antineoplastics Jakafi 25 MG Jakafi 5 MG 10 tablets per day Endocrine Janumet MG Janumet 50MG-500MG Janumet Xr MG Janumet Xr MG Janumet Xr 50MG-500MG Januvia 100 MG Januvia 25 MG Januvia 50 MG Jardiance 10 MG Jardiance 25 MG Jentadueto MG Jentadueto MG Jentadueto MG Jentadueto Xr MG Jentadueto Xr 5MG-1000MG Juvisync 100MG-10MG Juvisync 100MG-20MG Juvisync 100MG-40MG Juvisync 50 MG-10MG Juvisync 50 MG-20MG Juvisync 50 MG-40MG Cardiovascular Therapy Agents Juxtapid 40 MG Juxtapid 60 MG Analgesic, Anti-inflammatory or Kadian 10 MG Kadian 100 MG Kadian 130 MG Kadian 150 MG Kadian 20 MG Kadian 200 MG Kadian 30 MG Kadian 40 MG Kadian 50 MG Kadian 60 MG Kadian 70 MG Kadian 80 MG Respiratory Therapy Agents Kalydeco 150 MG Kalydeco 50 MG Kalydeco 75 MG Endocrine Kazano Kazano MG Anti-Infective Agents ketoconazole 200 MG

19 Analgesic, Anti-inflammatory or ketorolac tromethamine 10 MG 20 tablets 30 days ketorolac tromethamine 15 MG/ML 4 per 30 days ketorolac tromethamine 30 MG/ML 2 per 30 days ketorolac tromethamine 30MG/ML(1) 2 per 30 days ketorolac tromethamine 60 MG/2 ML 2 per 30 days Chemicals-Pharmaceutical Adjuvants ketotifen fumarate % Locomotor System Keveyis 50 MG Central Nervous System Agents Khedezla 100 MG Analgesic, Anti-inflammatory or Kineret 100MG/ syringe per day Endocrine Kombiglyze Xr MG Kombiglyze Xr 5 MG-500MG Kombiglyze Xr 5MG-1000MG Cardiovascular Therapy Agents Kynamro 200 MG/ML 4 syringes per 30 days Anti-Infective Agents Lamisil 250 MG Gastrointestinal Therapy Agents lansoprazole 15 MG lansoprazole 30 MG Ophthalmic Agents Lastacaft 0.25 % Analgesic, Anti-inflammatory or Lazanda 100MCG/SPR 30 bottles per 30 days Lazanda 300MCG/SPR Lazanda 400MCG/SPR 30 bottles per 30 days Antineoplastics Lenvima 10 MG/DAY Lenvima 14 MG/DAY Lenvima 18 MG/DAY 3 capsules per day Lenvima 20 MG/DAY Lenvima 24 MG/DAY 3 capsules per day Lenvima 8 MG/DAY Cardiovascular Therapy Agents Letairis 10 MG Letairis 5 MG Antineoplastics letrozole 2.5 MG Anti-Infective Agents Levaquin 250 MG 14 tablets per fill Levaquin 250MG/10ML 480 ml per fill; 1 fill per 30 days Levaquin 500 MG 14 tablets per fill Levaquin 750 MG 14 tablets per fill levofloxacin hemihydrate 250 MG 14 tablets per fill levofloxacin hemihydrate 250MG/10ML 280 ml per 30 days levofloxacin hemihydrate 500 MG 14 tablets per fill Levofloxacin Hemihydrate 500MG/20ML 280 ml per 30 days levofloxacin hemihydrate 750 MG 14 tablets per fill Contraceptives levonorgestrel 0.75 MG 2 tablets 30 days levonorgestrel 1.5 MG 1 tablet per 30 days Central Nervous System Agents Lexapro 20 MG Lexapro 5 MG/5 ML 600 ML per 30 days

20 Dermatological Lidovir 4 %-4 % 63 GM in 30 days Analgesic, Anti-inflammatory or Lidoxib Kit 1 kit per 30 days Anti-Infective Agents linezolid 100 MG/5ML 900 ml per fill; 1 fill per 30 days linezolid 600 MG 28 tablets per fill Cardiovascular Therapy Agents Lipitor 80 MG Liptruzet 10 MG-10MG Liptruzet 10 MG-20MG Liptruzet 10 MG-40MG Liptruzet 10 MG-80MG Livalo 4 MG Analgesic, Anti-inflammatory or Lorcet MG-650MG 6 tablets per day lorcet 5 MG-325MG 1 lorcet hd 10MG-325MG 1 lorcet plus MG 1 Lorcet Plus MG 6 tablets per day Lortab / ml per day lortab 10MG-325MG 1 Lortab 10MG-500MG 8 tablets per day lortab 5 MG-325MG 1 Lortab 5 MG-500MG 8 tablets per day lortab MG 1 Lortab /15 90 ml per day Lortab MG 8 tablets per day Cardiovascular Therapy Agents losartan potassium 100 MG losartan potassium 25 MG losartan potassium 50 MG losartan-hydrochlorothiazide MG losartan-hydrochlorothiazide 100MG-25MG lovastatin 40 MG Lovaza 1 G 4 capsules per day Central Nervous System Agents Lunesta 1 MG Lunesta 2 MG Lunesta 3 MG Endocrine Lupron Depot mg, 22.5 mg 1 kit per 12 weeks Lupron Depot 3.75 MG 1 per 4 weeks Lupron Depot 30 mg 1 per 16 weeks Lupron Depot 45 MG 1 per 24 weeks Lupron Depot 7.5 mg 1 per 4 weeks Lupron Depot-Ped 7.5 MG 1 per 4 weeks Central Nervous System Agents Luvox Cr 100 MG Luvox Cr 150 MG Antineoplastics Lynparza 50 MG 16 capsules per day

21 Central Nervous System Agents Lyrica 100 MG 3 capsules per day Lyrica 150 MG 3 capsules per day Lyrica 20 MG/ML 30 ml per day Lyrica 200 MG 3 capsules per day Lyrica 225 MG Lyrica 25 MG 3 capsules per day Lyrica 300 MG Lyrica 50 MG 3 capsules per day Lyrica 75 MG Antineoplastics Lysodren 500 MG 38 tablets per day Analgesic, Anti-inflammatory or Magnacet 10MG-400MG 10 tablets day Magnacet 5MG-400MG 10 tablets day Magnacet MG 10 tablets day Cardiovascular Therapy Agents matzim la 240 MG matzim la 300 MG matzim la 360 MG matzim la 420 MG Respiratory Therapy Agents Maxair Autohaler 200 MCG 2 packages per 30 days Central Nervous System Agents Maxalt 10 MG Maxalt 5 MG Maxalt Mlt 10 MG Maxalt Mlt 5 MG Analgesic, Anti-inflammatory or Maxidone 10MG-750MG 5 tablets per day Antineoplastics Mekinist 0.5 MG Mekinist 2 MG Analgesic, Anti-inflammatory or meloxicam 15 MG meloxicam 7.5 MG meloxicam 7.5 MG/5ML 10 ml per day methadone hcl 10 MG 6 tablets per day methadone hcl 10 MG/5 ML 30 ml per day methadone hcl 10 MG/ML 60 mg per day methadone hcl 40 MG methadone hcl 5 MG 1 methadone hcl 5 MG/5 ML 60 ml per day methadose 10 MG/ML 60 ml per day methadose 40 MG Cardiovascular Therapy Agents Mevacor 40 MG Endocrine Miacalcin 200/SPRAY Cardiovascular Therapy Agents Micardis 80 MG Micardis Hct 80 MG-25MG Micardis Hct MG Central Nervous System Agents Migranal 0.5MG/SPRY 8 bottles per 30 days

22 Central Nervous System Agents Migranow Kit 1 kit per rolling 30 days Mirapex MG Mirapex 0.25 MG Mirapex 0.5 MG Mirapex 0.75 MG Mirapex 1 MG Mirapex 1.5 MG Mirapex Er MG Mirapex Er 0.75 MG Mirapex Er 1.5 MG Mirapex Er 2.25 MG Mirapex Er 3 MG Mirapex Er 3.75 MG Mirapex Er 4.5 MG Gout and Hyperuricemia Therapy Mitigare 0.6 MG Analgesic, Anti-inflammatory or Mobic 15 MG Mobic 7.5 MG Mobic 7.5 MG/5ML 10 ml per day Central Nervous System Agents modafinil 200 MG Respiratory Therapy Agents mometasone furoate 50 MCG 2 packages per 30 days montelukast sodium 10 MG montelukast sodium 4 MG montelukast sodium 5 MG Analgesic, Anti-inflammatory or morphine sulfate 100 MG/5ML 10 ml per day morphine sulfate 15 MG morphine sulfate 20 MG/5 ML 45 ml day morphine sulfate 30 MG morphine sulfate cr 100 MG morphine sulfate cr 15 MG morphine sulfate cr 30 MG morphine sulfate cr 60 MG morphine sulfate er 10 MG morphine sulfate er 100 MG morphine sulfate er 120 MG morphine sulfate er 15 MG morphine sulfate er 20 MG morphine sulfate er 200 MG morphine sulfate er 30 MG morphine sulfate er 45 MG morphine sulfate er 50 MG morphine sulfate er 60 MG morphine sulfate er 75 MG

23 Analgesic, Anti-inflammatory or morphine sulfate er 80 MG morphine sulfate er 90 MG Ms Contin 100 MG Ms Contin 15 MG Ms Contin 200 MG Ms Contin 30 MG Ms Contin 60 MG Contraceptives my way 1.5 MG 1 tablet per 30 days Antidotes and other Reversal Agents Naloxone injection 1 mg/ml, 0.4 mg/ml 6 syringes/vials per 3 months Central Nervous System Agents naratriptan hcl 1 MG naratriptan hcl 2.5 MG Antidotes and other Reversal Agents Narcan Nasal Spray 4 mg/0.1 ml 6 nasal sprays (3 cartons) per 3 months Respiratory Therapy Agents Nasacort 55 MCG Nasacort Aq 55 MCG nasal allergy spray 55 MCG Nasonex 50 MCG 1 inhaler per 30 days Endocrine Natesto 5.5/ metered dose pumps per 30 days Natpara 100 MCG 2 cartridges per 30 days Natpara 25MCG/DOSE 2 cartridges per 30 days Natpara 50MCG/DOSE 2 cartridges per 30 days Natpara 75MCG/DOSE 2 cartridges per 30 days Nesina 12.5 MG Nesina 25 MG Nesina 6.25 MG Hematological Agents Neulasta 6MG/0.6ML 2 syringes per 28 days Central Nervous System Agents Neupro 1 MG/24 HR Neupro 2 MG/24 HR Neupro 3 MG/24 HR Neupro 4 MG/24 HR Neupro 6 MG/24 HR Neupro 8 MG/24 HR Antineoplastics Nexavar 200 MG Gastrointestinal Therapy Agents Nexium Nexium Rx 10 MG Nexium Rx 2.5 MG Nexium Rx 20 MG Nexium Rx 40 MG Nexium Rx 5 MG Contraceptives next choice 0.75 MG 2 tablets 30 days next choice one dose 1.5 MG 1 tablet per 30 days Cardiovascular Therapy Agents niacin er 1000 MG niacin er 500 MG niacin er 750 MG

24 Cardiovascular Therapy Agents Niaspan 1000 MG Niaspan 500 MG Niaspan 750 MG nicardipine hcl 20 MG 6 capsules per day nicardipine hcl 30 MG 3 capsules per day nifediac cc 90 MG nifedical xl 60 MG nifedipine 10 MG 4 capsules per day nifedipine 20 MG 4 capsules per day nifedipine er 60 MG nifedipine er 90 MG Antineoplastics Nilandron 150 MG Cardiovascular Therapy Agents nimodipine 30 MG 1 Antineoplastics Ninlaro 2.3 MG 3 capsules per day Ninlaro 3 MG 3 capsules per day Ninlaro 4 MG 3 capsules per day Cardiovascular Therapy Agents nisoldipine 25.5 MG nisoldipine 30 MG nisoldipine 34 MG nisoldipine 40 MG Analgesic, Anti-inflammatory or Norco 10MG-325MG 1 Norco 5 MG-325MG 1 Norco MG 1 Anti-Infective Agents Noroxin 400 MG 42 tablets per fill Cardiovascular Therapy Agents Norvasc 10 MG Anti-Infective Agents Noxafil 100 MG 8 tablets per day Noxafil 200 MG/5ML 20 ml day Analgesic, Anti-inflammatory or Nucynta 100 MG 181 tablets 30 days Nucynta 50 MG Nucynta 75 MG 8 tablets per day Nucynta Er 100 MG Nucynta Er 150 MG Nucynta Er 200 MG Nucynta Er 250 MG Nucynta Er 50 MG Central Nervous System Agents Nuplazid 17 MG Nuvigil 150 MG Nuvigil 250 MG Nuvigil 50 MG Hepatobiliary System Treatment Ocaliva 10 MG Agents Ocaliva 5 MG Antineoplastics Odomzo 200 MG Ofev 100 MG

25 Antineoplastics Ofev 150 MG Anti-Infective Agents ofloxacin 200 MG 56 tablets per fill ofloxacin 300 MG 56 tablets per fill ofloxacin 400 MG 56 tablets per fill Ophthalmic Agents olopatadine hcl 0.1 % 5 ml (1 bottle) per 30 days Respiratory Therapy Agents olopatadine hcl 0.6 % Anti-Infective Agents Olysio 150 MG Cardiovascular Therapy Agents omega-3 acid ethyl esters 1 G 4 capsules per day Gastrointestinal Therapy Agents omeprazole 10 MG omeprazole 20 MG omeprazole 40 MG omeprazole-sodium bicarbonate 20MG-1.1G omeprazole-sodium bicarbonate 40MG-1.1G Respiratory Therapy Agents Omnaris 50 MCG Gastrointestinal Therapy Agents ondansetron hcl 24 MG 8 tablets per 30 days ondansetron hcl 4 MG 48 tablets 30 days ondansetron hcl 4 MG/5 ML 8 ml per day ondansetron hcl 8 MG 24 tablets per 30 days ondansetron odt 4 MG 48 tablets 30 days ondansetron odt 8 MG 24 tablets per 30 days Endocrine Onglyza 5 MG Anti-Infective Agents Onmel 200 MG Analgesic, Anti-inflammatory or Onsolis 1200 MCG Onsolis 200 MCG Onsolis 400 MCG Onsolis 600 MCG Onsolis 800 MCG Central Nervous System Agents Onzetra Xsail 11 MG 1 kit per rolling 30 days Analgesic, Anti-inflammatory or Opana 10 MG 6 tablets per day Opana 5 MG Opana Er 10 MG Opana Er 15 MG Opana Er 20 MG Opana Er 30 MG Opana Er 40 MG Opana Er 5 MG Opana Er 7.5 MG Cardiovascular Therapy Agents Opsumit 10 MG Ophthalmic Agents Optivar 0.05 % 6 ml (1 bottle) per 30 days Biologicals Oralair 300 IR Analgesic, Anti-inflammatory or Orencia 125 MG/ML 4 per 28 days

26 Analgesic, Anti-inflammatory or Orencia Clickject 125 MG/ML 4 pens per 28 days Respiratory Therapy Agents Orkambi MG Endocrine Oseni MG Oseni MG Oseni MG Oseni 25 MG-15MG Oseni 25 MG-30MG Oseni 25 MG-45MG Osphena 60 MG Analgesic, Anti-inflammatory or Otezla MG 1 pack per year Otezla 30 MG Otrexup 10MG/0.4ML 4 auto-injectors per 30 days Otrexup 15MG/0.4ML 4 auto-injectors per 30 days Otrexup 17.5MG/0.4 4 auto-injectors per 30 days Otrexup 20MG/0.4ML 4 auto-injectors per 30 days Otrexup 22.5MG/0.4 4 auto-injectors per 30 days Otrexup 25MG/0.4ML 4 auto-injectors per 30 days Otrexup 7.5 MG/0.4 4 auto-injectors per 30 days Oxycodone Hcl Er 10 MG Oxycodone Hcl Er 15 MG Oxycodone Hcl Er 20 MG Oxycodone Hcl Er 30 MG Oxycodone Hcl Er 40 MG Oxycodone Hcl Er 60 MG Oxycodone Hcl Er 80 MG oxycodone hcl-ibuprofen 400MG-5MG oxycodone w/acetaminophen 10MG-325MG 12 tablet per day oxycodone w/acetaminophen 10MG-650MG 6 tablets per day oxycodone w/acetaminophen MG 1 oxycodone w/acetaminophen 5 MG-325MG 1 oxycodone w/acetaminophen 5 MG-500MG 1 oxycodone w/acetaminophen 5-325/5ML 1800 ml per 30 days oxycodone w/acetaminophen MG 1 oxycodone w/acetaminophen MG 1 Oxycontin 10 MG Oxycontin 15 MG Oxycontin 20 MG Oxycontin 30 MG Oxycontin 40 MG Oxycontin 60 MG Oxycontin 80 MG

27 Analgesic, Anti-inflammatory or oxymorphone hcl 10 MG oxymorphone hcl 15 MG oxymorphone hcl 20 MG oxymorphone hcl 30 MG oxymorphone hcl 40 MG oxymorphone hcl 5 MG oxymorphone hcl 7.5 MG oxymorphone hcl er 10 MG oxymorphone hcl er 15 MG oxymorphone hcl er 20 MG oxymorphone hcl er 30 MG oxymorphone hcl er 40 MG oxymorphone hcl er 5 MG oxymorphone hcl er 7.5 MG Gastrointestinal Therapy Agents pantoprazole sodium 20 MG pantoprazole sodium 40 MG Central Nervous System Agents paroxetine hcl 25 MG paroxetine hcl 30 MG paroxetine hcl 37.5 MG paroxetine hcl 40 MG Ophthalmic Agents Pataday 0.2 % 2.5 ml (1 bottle) per 30 days Respiratory Therapy Agents Patanase 0.6 % 1 inhaler per 30 days Ophthalmic Agents Patanol 0.1 % 5 ml (1 bottle) per 30 days Central Nervous System Agents Paxil 10 MG/5 ML 30 ml per day Paxil 30 MG Paxil 40 MG 1.5 tablets per day Paxil Cr 25 MG Paxil Cr 37.5 MG Ophthalmic Agents Pazeo 0.7 % 2.5 ml (1 bottle) per 30 days Anti-Infective Agents Pegasys 180MCG/0.5 1 kit tablets 28 days Pegasys 180MCG/ML 4 pens per 28 days Pegasys Proclick 135MCG/0.5 2 pens per 28 days Pegasys Proclick 180MCG/0.5 2 pens per 28 days Analgesic, Anti-inflammatory or Percocet 10MG-325MG 1 Percocet 10MG-650MG 6 tablets per day Percocet MG 1 Percocet 5 MG-325MG 1 Percocet MG 1 Percocet MG 8 tablets per day Respiratory Therapy Agents Perforomist 20 MCG/2ML 120 ml per 30 days Central Nervous System Agents Pexeva 30 MG Pexeva 40 MG 1.5 tablets per day Biologicals Physician Ez Use Flu MCG/.5ML 2 Rx per 180 days

28 Dermatological Picato % 1 carton (3 unit dose tubes) per fill; 1 fill per year Picato 0.05 % 1 carton (2 unit dose tubes) per fill; 1 fill per year Endocrine pioglitazone hcl 15 MG pioglitazone hcl 30 MG pioglitazone hcl 45 MG pioglitazone-glimepiride 30 MG-2 MG pioglitazone-glimepiride 30 MG-4 MG pioglitazone-metformin 15MG-500MG pioglitazone-metformin 15MG-850MG Contraceptives Plan B One-Step 1.5 MG 1 tablet per 30 days Hematological Agents Plavix 75 MG Antineoplastics Pomalyst 1 MG 4 capsules per day Pomalyst 2 MG Pomalyst 3 MG Pomalyst 4 MG Hematological Agents Pradaxa 110 MG Pradaxa 150 MG Pradaxa 75 MG Cardiovascular Therapy Agents Praluent Pen 150 MG/ML 2 injections (2 ml) per 28 days Praluent Pen 75 MG/ML 2 injections (2 ml) per 28 days Praluent Syringe 150 MG/ML 2 injections (2 ml) per 28 days Praluent Syringe 75 MG/ML 2 injections (2 ml) per 28 days Central Nervous System Agents pramipexole di-hcl MG pramipexole di-hcl 0.25 MG pramipexole di-hcl 0.5 MG pramipexole di-hcl 0.75 MG pramipexole di-hcl 1 MG pramipexole di-hcl 1.5 MG pramipexole er MG pramipexole er 0.75 MG pramipexole er 1.5 MG pramipexole er 2.25 MG pramipexole er 3 MG pramipexole er 4.5 MG Cardiovascular Therapy Agents Pravachol 80 MG pravastatin sodium 80 MG Prestalia 14MG-10MG Gastrointestinal Therapy Agents Prevacid Prevacid Rx 15 MG Prevacid Rx 30 MG Analgesic, Anti-inflammatory or Previdolrx Plus Analgesic Pak 75MG-.025% 1 kit per 30 days Gastrointestinal Therapy Agents Prilosec Rx 10 MG

29 Gastrointestinal Therapy Agents Prilosec Rx 2.5 MG Prilosec Rx 20 MG Prilosec Rx 40 MG Analgesic, Anti-inflammatory or Primlev 10MG-300MG 1 Primlev 5MG-300MG 1 Primlev MG 1 Central Nervous System Agents Pristiq Er 100 MG Respiratory Therapy Agents Proair Hfa 90 MCG 2 inhalers per 30 days Proair Respiclick 90 MCG 2 inhalers per 30 days Cardiovascular Therapy Agents Procardia 10 MG 4 capsules per day Procardia Xl 60 MG Procardia Xl 90 MG Endocrine Prolia 60 MG/ML 2 injections per year Gastrointestinal Therapy Agents Protonix 20 MG Protonix 40 MG Respiratory Therapy Agents Proventil Hfa 90 MCG 3 inhalers per 30 days Central Nervous System Agents Provigil 200 MG Prozac 40 MG Prozac Weekly 90 MG 4 pens per 28 days Respiratory Therapy Agents Pulmicort 0.25MG/2ML 120 ml per 30 days Pulmicort 0.5 MG/2ML 120 ml per 30 days Pulmicort 1 MG/2 ML Pulmicort Flexhaler 180 MCG 2 packages per 30 days Pulmicort Flexhaler 90 MCG 2 packages per 30 days Qnasl 40 MCG Qnasl 80 MCG Anti-Infective Agents Qualaquin 324 MG 60 capsules per year quinine sulfate 324 MG 42 capsules per year Respiratory Therapy Agents Qvar 40 MCG 1 inhaler per 30 days Qvar 80 MCG 2 inhalers per 30 days Gastrointestinal Therapy Agents rabeprazole sodium 20 MG Biologicals Ragwitek 12 UNIT Analgesic, Anti-inflammatory or Rasuvo 10MG/0.2ML 4 auto-injectors per 30 days Rasuvo 12.5/ auto-injectors per 30 days Rasuvo 15MG/0.3ML 4 auto-injectors per 30 days Rasuvo 17.5/ auto-injectors per 30 days Rasuvo 20MG/0.4ML 4 auto-injectors per 30 days Rasuvo 22.5/ auto-injectors per 30 days Rasuvo 25MG/0.5ML 4 auto-injectors per 30 days Rasuvo 27.5/ auto-injectors per 30 days Rasuvo 30MG/0.6ML 4 auto-injectors per 30 days Rasuvo 7.5MG/ auto-injectors per 30 days Metabolic Modifiers Ravicti 1.1GRAM/ML 17.5 ml per day

30 Anti-Infective Agents Relenza 5 MG 1 package (20 each) per fill; 1 fill per 30 days Central Nervous System Agents Relpax 20 MG Relpax 40 MG Cardiovascular Therapy Agents Repatha Sureclick 140 MG/ML 2 prefilled syringes or auto-injectors per 28 days Repatha Syringe 140 MG/ML 2 prefilled syringes or auto-injectors per 28 days Analgesic, Anti-inflammatory or reprexain 5MG-200MG 16 tablets per day Cardiovascular Therapy Agents Revatio 10 MG/ vials per day Revatio 10 MG/ML 6 ml per day Revatio 20 MG Antineoplastics Revlimid 10 MG Revlimid 15 MG Revlimid 2.5 MG Revlimid 20 MG Revlimid 25 MG Revlimid 5 MG Respiratory Therapy Agents Rhinocort Allergy 32MCG 2 packages per 30 days Rhinocort Aqua 32MCG 2 packages per 30 days Endocrine risedronate sodium 150 MG 1 tablet per 30 days risedronate sodium 30 MG risedronate sodium 35 MG 4 tablets per 28 days risedronate sodium 5 MG risedronate sodium dr 35 MG 4 tablets per 28 days Central Nervous System Agents rizatriptan 10 MG rizatriptan 5 MG Cardiovascular Therapy Agents rosuvastatin calcium 40 MG Analgesic, Anti-inflammatory or roxicet 5 MG-325MG 1 Roxicet 5-325/5ML 60 ml per day Central Nervous System Agents Rozerem 8 MG Hematological Agents Ruconest 2100 UNIT 20 vials per 30 days Analgesic, Anti-inflammatory or Rybix Odt 50 MG 8 tablets per day Gastrointestinal Therapy Agents Sancuso 3.1MG/24HR 4 per 28 days Endocrine Sandostatin LAR 10 mg, 30 mg Kit 1 kit per 28 days Sandostatin LAR 20 mg Kit 2 kits per 28 days Hematological Agents Savaysa 15 MG Savaysa 30 MG Savaysa 60 MG Central Nervous System Agents Savella 100 MG Savella 12.5 MG Savella pack per year Savella 25 MG Savella 50 MG

31 Respiratory Therapy Agents Seebri Neohaler 15.6 MCG Serevent Diskus 50 MCG 1 inhaler per 30 days Central Nervous System Agents sertraline hcl 100 MG sertraline hcl 20 MG/ML 10 ml per day Endocrine Signifor 0.3 mg/ml, 0.6 mg/ml, 0.9 mg/ml 2 ampules per day Signifor LAR 20mg, 40 mg, 60 mg Kit 1 kit per 28 days Cardiovascular Therapy Agents sildenafil citrate 10 MG/ vials per day sildenafil citrate 20 MG Central Nervous System Agents Silenor 3 MG Silenor 6 MG Cardiovascular Therapy Agents Simcor MG Simcor MG Simcor 500MG-20MG Simcor 500MG-40MG Simcor 750MG-20MG Analgesic, Anti-inflammatory or Simponi 100 MG/ML 1 syringe per 28 days Simponi 50MG/0.5ML 1 syringe per 28 days Cardiovascular Therapy Agents simvastatin 80 MG Biologicals Single Use Ez Flu MCG/.5ML 2 Rx per 180 days Single Use Ez Flu MCG/.5ML 2 Rx per 180 days Single Use Ez Flu MCG/.5ML 2 Rx per 180 days Single Use Ez Flu MCG/.5ML 2 Rx per 180 days Single Use Ez Flu MCG/.5ML 2 Rx per 180 days Respiratory Therapy Agents Singulair 10 MG Singulair 4 MG Singulair 5 MG Anti-Infective Agents Sitavig 50 MG 1 tablet in 30 days Sivextro 200 MG 6 tablets per fill; 1 fill per 30 days Central Nervous System Agents Smartrx Gabakit 300MG-4-1% 1 per 30 days Smartrx Gaba-V Kit 300MG kit per 30 days Dermatological Solaraze 3 % 100 grams per 30 days; 90 days of treatment per year Endocrine Somatuline Depot 60 mg, 90 mg, 120 mg 1 syringe/vial per 28 days Somavert 10 mg, 20 mg, 25 mg, 30 mg 1 vial per day single-use vial Somavert 15 mg single-use vial 2 vials per day Central Nervous System Agents Sonata 10 MG Sonata 5 MG Anti-Infective Agents Sovaldi 400 MG Respiratory Therapy Agents Spiriva 18 MCG Spiriva Respimat 1.25 MCG 1 inhaler per 30 days Spiriva Respimat 2.5 MCG 1 inhaler per 30 days Anti-Infective Agents Sporanox 10 MG/ML 20 ml day

32 Anti-Infective Agents Sporanox 100 MG Antineoplastics Sprycel 100 MG Sprycel 140 MG Sprycel 20 MG Sprycel 50 MG Sprycel 70 MG Sprycel 80 MG Analgesic, Anti-inflammatory or stagesic 5 MG-500MG 8 capsules per day Dermatological Stelara 45MG/0.5ML 1 syringe per 84 days Stelara 90 MG/ML 1 syringe per 84 days Respiratory Therapy Agents Stiolto Respimat MCG 1 inhaler per 30 days Antineoplastics Stivarga 40 MG Endocrine Striant 30 MG Respiratory Therapy Agents Striverdi Respimat 2.5 MCG 1 inhaler per 30 days Chemical Dependency, Agents to Suboxone 12 MG-3 MG 16 mg buprenorphine per day Treat Suboxone 2 MG-0.5MG 16 mg buprenorphine per day Suboxone 4MG-1MG 16 mg buprenorphine per day Suboxone 8 MG-2 MG 16 mg buprenorphine per day Analgesic, Anti-inflammatory or Subsys 100MCG/SPR Subsys 1200 MCG Subsys 1600 MCG Subsys 200 MCG Subsys 400MCG/SPR Subsys 600 MCG Subsys 800 MCG Cardiovascular Therapy Agents Sular 34 MG Central Nervous System Agents sumatriptan succinate 100 MG sumatriptan succinate 20 MG 6 bottles tablets 30 days sumatriptan succinate 25 MG sumatriptan succinate 4 MG/0.5ML 4 syringes per 30 days sumatriptan succinate 5 MG 6 bottles tablets 30 days sumatriptan succinate 50 MG sumatriptan succinate 6 MG/0.5ML 2 vials per 30 days Sumavel Dosepro 4 MG/0.5ML 4 unit devices per rolling 30 days Sumavel Dosepro 6 MG/0.5ML 4 unit devices per rolling 30 days Endocrine Supprelin LA 50 mg 1 implant per year Antineoplastics Sutent 12.5 MG 3 capsules per day Sutent 25 MG Sutent 37.5 MG Sutent 50 MG Respiratory Therapy Agents Symbicort MCG Symbicort MCG

33 Endocrine Synarel 2 mg/ml (60 sprays/bottle) 5 bottles per 30 days Synjardy Synjardy MG Synjardy 5 MG-500MG Synjardy 5MG-1000MG Antineoplastics Tafinlar 50 MG 4 capsules per day Tafinlar 75 MG 4 capsules per day Tagrisso 40 MG Tagrisso 80 MG Dermatological Taltz 80 mg/ml prefilled autoinjector 1 auto injector per 28 days Taltz 80 mg/ml prefilled syringe 1 syringe per 28 days Anti-Infective Agents Tamiflu 30 MG 20 per fill; 1 fill per 30 days Tamiflu 45 MG 10 per fill; 1 fill per 30 days Tamiflu 6 MG/ML 180 ml per fill; 1 fill per 30 days Tamiflu 75 MG 10 per fill; 1 fill per 30 days Endocrine Tanzeum 30MG/0.5ML 4 prefilled pens per 28 days Antineoplastics Tarceva 100 MG Tarceva 150 MG Tarceva 25 MG Cardiovascular Therapy Agents Tarka 2 MG-180MG Tarka 2-240MG Tarka 4-240MG Antineoplastics Tasigna 150 MG 4 capsules per day Tasigna 200 MG 4 capsules per day Central Nervous System Agents Tasmar 100 MG 6 tablets per day Cardiovascular Therapy Agents taztia xt 240 MG taztia xt 300 MG taztia xt 360 MG Multiple Sclerosis Agents Tecfidera 120 MG 14 capsules per year Tecfidera MG 1 package per year Tecfidera 240 MG Anti-Infective Agents Technivie MG Cardiovascular Therapy Agents Tekamlo 150MG-10MG Tekamlo 300MG-10MG Tekamlo 300MG-5MG Tekturna 300 MG Tekturna Hct 150MG-25MG Tekturna Hct MG Tekturna Hct 300MG-25MG telmisartan 80 MG telmisartan-amlodipine 40 MG-10MG telmisartan-amlodipine 80 MG-10MG telmisartan-amlodipine 80 MG-5 MG