Quantity per Dispensing Level Limits/Allowances

Transcription

1 An independent licensee of the Blue Cross and Blue Shield Association. Quantity per Dispensing Level Limits/Allowances All covered prescription medications are available at a participating pharmacy for the day supply limitation stated in your member contract/certificate (typically up to a 30-day supply at retail and up to a 90-day supply for mail order). In addition, quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by Blue Cross and Blue Shield of Louisiana. The following is a list of the most commonly prescribed medications subject to QPD limits/allowances. Drugs listed in this section are not meant to be a complete list of medications covered by your plan. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. Drug Name Dosage Form Retail QLL Mail QLL Abilify 2 mg tablet Abilify 5 mg tablet Abilify 10 mg tablet Abilify 15 mg tablet Abilify 20 mg tablet Abilify 30 mg tablet Abilify Discmelt 10 mg Discmelt Abilify Discmelt 15 mg Discmelt Accupril 40 mg tablet Accupril 20 mg tablet Accupril 10 mg tablet Accupril 5 mg tablet Aceon 8 mg tablet Aceon 4 mg tablet Aceon 2 mg tablet Aciphex 20 mg tablet Acthar HP 80units/ml vial 1 vial 1 vial Actiq all strengths/dosage forms 90* 270* Actonel 150 mg tablet 1 3 Actonel 75 mg tablet 2 6 Actonel 35 mg tablet 4 12 Actonel 30 mg tablet Actonel 5 mg tablet Actonel with Calcium 35 mg/1250 mg tablet (28 tablets) 1 pack 3 packs Actoplus Met 15 mg/ 500 mg tablet Actoplus Met 15 mg/ 850 mg tablet Actos 45 mg tablet Actos 30 mg tablet Actos 15 mg tablet Adcirca 20 mg tablet HQ3923 R05/10 Page 1 of 26 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

2 Advair Diskus 500mcg - 1 device of 60 blisters (powder) 60 doses (1 device) 180 doses (3 devices) Advair Diskus 250mcg - 1 device of 60 blisters (powder) 60 doses (1 device) 180 doses (3 devices) Advair Diskus 100mcg - 1 device of 60 blisters (powder) 60 doses (1 device) 180 doses (3 devices) Advair HFA 230/21 mcg inhaler 120 doses (1 device) 360 doses (3 devices) Advair HFA 115/21 mcg inhaler 120 doses (1 device) 360 doses (3 devices) Advair HFA 45/21 mcg inhaler 120 doses (1 device) 360 doses (3 devices) Advicor 500 mg/ 20 mg tablet Advicor 750 mg/ 20 mg tablet Advicor 1000 mg/ 20 mg tablet Aerobid/ Aerobid-M 7gm aerosol 3 (21gm) 9 (56gm) Aggrenox each capsule contains 200mg extended-release dipyridamole with 25mg aspirin Affinitor 5 mg tablet Affinitor 10 mg tablet Albuterol 17gm aerosol 2 (34gm) 6 (102gm) Albuterol HFA 17gm aerosol 2 (17gm) 6 (51gm) Allegra 30 mg tablet Allegra 60mg capsule Allegra 180 mg tablet Allegra-D 60mg/120mg tablet Allegra-D 24 Hours 180mg/240mg tablet Allegra Oral Suspension 30mg/5mL suspension 1 bottle (300mL) 3 bottles (900mL) Allegra ODT 30 mg tablet alendronate 40 mg tablet alendronate 10 mg tablet alendronate 5 mg tablet alendronate 70 mg tablet (blister pack of 4 4 tablets 12 tablets tablets) alendronate 35 mg tablet (blister pack of 4 4 tablets 12 tablets tablets) Alora mg/day 8 systems 24 systems Alora 0.05 mg/day 8 systems 24 systems Alora mg/day 8 systems 24 systems Alora 0.1 mg/day 8 systems 24 systems Altace 10 mg capsule/ tablet Altace 5 mg capsule/ tablet Altace 2.5 mg capsule/ tablet Altace 1.25 mg capsule/ tablet Page 2 of 26

3 Alvesco 80 mcg inhaler 1 device 3 devices (6.1gm) (18.3gm) Alvesco 160 mcg inhaler 1 device (6.1gm) 3 devices (18.3gm) Ambien 10 mg tablet Altoprev 10 mg tablet Altoprev 20 mg tablet Altoprev 40 mg tablet Altoprev 60 mg tablet Alupent 14gm aerosol 2 (28gm) 6 (84gm) Ambien 5 mg tablet Ambien CR 12.5 mg tablet Ambein CR 6.25 mg tablet Amerge Tablet 1 mg tablet 9 27 Amerge Tablet 2.5 mg tablet 9 27 Amitiza 8 mcg capsule Amitiza 24 mcg capsule Ampyra ER 10 mg tablet Androderm 2.5 mg/day 90 systems 270 systems Androderm 5 mg/day 30 systems 90 systems AndroGel 2.5 gm/day 30 packets 90 packets AndroGel 5 gm/day 60 packets 180 packets Anzemet 50 mg tablet 4 12 Anzemet 100 mg tablet 4 12 Aplenzin 174 mg tablet Aplenzin 348 mg tablet Aplenzin 522 mg tablet Aranesp 500 mcg/1 ml 1 Vial (1 Pack) 1 Vial (1Pack) Aranesp 300 mcg/1 ml 4 Vials (4 Packs) 4 Vials (4 Packs) Aranesp 200 mcg/1 ml 4 Vials (4 Packs) 4 Vials (4 Packs) Aranesp 150 mcg/0.75 ml 4 Vials (1 Pack) 4 Vials (1 Pack) Aranesp 100 mcg/1 ml 4 Vials (1 Pack) 4 Vials (1 Pack) Aranesp 60 mcg/1 ml 8 Vials (2 Packs) 8 Vials (2 Packs) Aranesp 40 mcg/1 ml 8 Vials 8 Vials (2 Packs) Aranesp 25 mcg/1 ml 8 Vials (2 Packs) Arava 20 mg tablet Arava 10 mg tablet Page 3 of 26 (2 Packs) 8 Vials (2 Packs)

4 Arcalyst Carton (4 vials) 1 carton 1 carton Aricept 10 mg tablet Aricept 5 mg tablet Aricept ODT 10 mg tablet Aricept ODT 5 mg tablet Asmanex 110mcg twisthaler #30 1 device 3 devices Asmanex 220mcg twisthaler #120 1 device 3 devices Asmanex 220mcg twisthaler #60 1 device 3 devices Asmanex 220mcg twisthaler #30 1 device 3 devices Asmanex 220mcg twisthaler #14 1 device 3 devices Astelin 137 mcg nasal spray 2 devices 6 devices Astepro 0.15% nasal spray 2 devices 6 devices Astepro 137 mcg nasal spray 2 devices 6 devices Atacand 32 mg tablet Atacand 16 mg tablet Atacand 8 mg tablet Atacand 4 mg tablet atenolol 25 mg tablet atenolol 50 mg tablet atenolol 100 mg tablet Atrovent Aerosol 2 6 Atrovent HFA Aerosol 2 6 Avandamet 1 mg/500 mg tablet Avandamet 2 mg/500 mg tablet Avandamet 4 mg/500 mg tablet Avandamet 2mg/1000 mg tablet Avandamet 4mg/1000 mg tablet Avandaryl 8mg/4mg tablet Avandaryl 8mg/2mg tablet Avandaryl 4mg/4mg tablet Avandaryl 4mg/2mg tablet Avandaryl 4mg/1mg tablet Avandia 8 mg tablet Avandia 4 mg tablet Avandia 2 mg tablet Avapro 300 mg tablet Avapro 150 mg tablet Avapro 75 mg tablet Avodart 0.5 mg tablet Avonex Admin Pack (30 mcg vial) as 4 4 vials 4 vials vials per kit Avonex Admin Pack (30 mcg syringe) as 4 syringes 4 syringes 4 syringes per kit Axert 6.25mg tablet Axert 12.5 mg tablet Azmacort 20gm aerosol 2 (40gm) 6 (120gm) Page 4 of 26

5 Beconase AQ 25gm spray 2 (50gm) 6 (100gm) benazepril 40 mg tablet benazepril 20 mg tablet benazepril 10 mg tablet benazepril 5 mg tablet Benicar 5 mg tab Benicar 20 mg tab Benicar 40 mg tab Betaseron 0.25 mg vial (0.3mg or 9.6 mu per vial) Boniva 2.5 mg tablet Boniva 150 mg tablet 1 3 Boniva Injection 3 mg syringe 1 1 Brovana Inhalation Solution 15mcg/2mL 60 respules 180 respules budeprionsr 100 mg tablet budeprionsr 150 mg tablet budeprionxl 150mg tablet budeprionxl 300mg tablet budesonide 0.25mg/2mL respule 60 respules 180 respules budesonide 0.5mg/2mL respule 60 respules 180 respules bupropioner 100 mg tablet bupropioner 200 mg tablet bupropionsr 100 mg tablet bupropionsr 150 mg tablet bupropionsr 200 mg tablet bupropionxl 300mg tablet Butisol 50 mg tablet Butisol 30 mg tablet butorphanol 10 mg/ml nasal spray (2.5 ml 2 devices 6 devices device) Byetta 2.4 ml injection pen 2 pens 6 pens (4.8mL) Byetta 1.2 ml injection pen 2 pens (2.4mL) Caduet 5/10 mg tablet Caduet 5/20 mg tablet Caduet 5/40mg tablet Caduet 5/80 mg tablet Caduet 10/10 mg tablet Caduet 10/20 mg tablet Caduet 10/40 mg tablet Caduet 10/80 mg tablet calcitonin-salmon Nasal Spray 200 units (3.7mL bottle) CaloMist nasal spray 1 bottle (18mL) Page 5 of 26 (14.4mL) 6 pens (7.2mL) 1 (3.7mLs) 3 (11.1 mls) 3 bottles (54mL)

6 CaloMist nasal spray 2 bottles (10.7 ml) 6 bottles (10.7 ml) Capoten 100 mg tablet Capoten 50 mg tablet Capoten 25 mg tablet Capoten 12.5 mg tablet captopril 100 mg tablet captopril 50 mg tablet captopril 25 mg tablet captopril 12.5 mg tablet Cardura 8 mg tablet Cardura 4 mg tablet Cardura 2 mg tablet Cardura 1 mg tablet Cardura XL 4 mg tablet Cardura XL 8 mg tablet carisoprodol 350 mg Catapres-TTS transdermal patch 4 systems 12 systems Caverject 10mcg (vial or system) 8 24 Caverject 20mcg (vial or system) 8 24 Caverject 40mcg (vial) 8 24 Celebrex 50 mg capsule Celebrex 100 mg capsule Celebrex 200 mg capsule Celebrex 400 mg capsule Celexa 20 mg tablet Celexa 40 mg tablet Celexa 10 mg tablet Cesamet 1 mg capsule cilostazol 100 mg tablet cilostazol 50 mg tablet Cimzia 1 Kit (contains 200mg) 1 Kit 1 Kit Cimzia 1 Kit (contains 400mg) 1 Kit 1 Kit Cinryze 500 units vial 20 vials 20 vials citalopram 20 mg tablet citalopram 40 mg tablet citalopram 10 mg tablet Clarinex 5mg tablet Clarinex-D 24 Hours 5 mg/240 mg tablet Clarinex-D 12 Hours 2.5 mg/120 mg tablet Clarinex Reditabs 5mg tablet Climara mg/day 4 systems 12 systems Climara mg/day 4 systems 12 systems Climara 0.05 mg/day 4 systems 12 systems Climara 0.6 mg/day 4 systems 12 systems Climara mg/day 4 systems 12 systems Page 6 of 26

7 Climara 0.1 mg/day 4 systems 12 systems Climara Pro transdermal patch 4 systems 12 systems clonidine day patch 0.1 mg/day patch 4 systems 12 systems clonidine day patch 0.2 mg/day patch 4 systems 12 systems clonidine day patch 0.3 mg/day patch 4 systems 12 systems CombiPatch 0.05 mg estradiol/ 0.14 mg 8 systems 24 systems norethrindone (9 cm2) CombiPatch 0.05 mg estradiol/ 0.25 mg 8 systems 24 systems norethrindone (16 cm2) Combivent 14.7gm aerosol 2 (30gm) 6 (89gm) Copaxone 20 mg vial 1 Pack(30 syringes) 1 Pack (30 syringes) Copegus 200 mg tablet Cozaar 100 mg tablet Cozaar 50 mg tablet Cozaar 25 mg tablet Crestor 40 mg tablet Crestor 20 mg tablet Crestor 10 mg tablet Crestor 5 mg tablet Cymbalta 20 mg capsule Cymbalta 30 mg capsule Cymbalta 60 mg capsule Dalmane 30 mg capsule Dalmane 15 mg capsule Daytrana 30 mg/9hr patch Daytrana 20 mg/9hr patch Daytrana 15 mg/9hr patch Daytrana 10 mg/9hr patch Degarelix 80 mg vial 1 vial 1 vial Degarelix 2 x 120 mg vials 1 kit 1 kit Depo-Provera 150 mg syringe/vial 1 1 Detrol 1 mg tablet Detrol 2 mg tablet Detrol LA 2 mg capsule Detrol LA 4 mg capsule Diflucan 150mg tablet 2 6 Diovan 320 mg tablet Diovan 160 mg tablet/caps Diovan 80 mg tablet/caps Diovan 40 mg tablet Ditropan XL 5 mg tablet Ditropan XL 10 mg tablet Ditropan XL 15 mg tablet Divigel 0.25 mg packet Page 7 of 26

8 Divigel 0.50 mg packet Divigel 1 mg packet Doral 15 mg tablet Doral 7.5 mg tablet Doxazosin 8 mg tablet Doxazosin 4 mg tablet Doxazosin 2 mg tablet Doxazosin 1 mg tablet Duetact 30mg /4mg tablet Duetact 30mg /2mg tablet Edex 5mcg vial 8 24 Edex 10mcg vial 8 24 Edex 20mcg vial 8 24 Edex 40mcg vial 8 24 Edluar SL 5 mg Edluar SL 10 mg Effexor 25 mg Effexor 37.5 mg Effexor 50 mg Effexor 75 mg Effexor 100 mg Effexor XR 37.5 mg Effexor XR 75 mg Effexor XR 150 mg Effient 5 mg Effient 10 mg Elestrin 144 gm metered dose pump - 1 pump 1 pump (0.87 gm/pump) Emend 125 mg capsule 2 4 Emend 80 mg capsule 4 8 Emend 40 mg capsule 1 3 Emend Tri-fold pack containing one packs 6 packs mg capsule and two 80 mg capsules Emsam 12 mg/24 hours patch Emsam 9 mg/24 hours patch Emsam 6 mg/24 hours patch Enablex 15 mg tablet Enablex 7.5 mg tablet enalapril 20 mg tablet enalapril 10 mg tablet enalapril 5 mg tablet enalapril 2.5 mg tablet Enbrel 25 mg syringe/vial 8** 8** Enbrel 50 mg syringe 4** 4** Epogen 2000u/ml vial (10 vials per carton) 12 vials 12 vials Page 8 of 26

9 Epogen 3000u/ml vial (10 vials per carton) 12 vials 12 vials Epogen 4000u/ml vial (10 vials per carton) 12 vials 12 vials Epogen 10,000u/ml vial (10 vials per 12 vials 12 vials carton) Epogen 40,000u/ml vial (10 vials per 4 vials 4 vials carton) Epogen 10,000u/ml MDV (2ml MDV-10 6 vials 6 vials vials per carton) Epogen 20,000u/ml MDV (1ml MDV vials 6 vials vials per carton) Esclim mg/day 8 systems 24 systems Esclim mg/day 8 systems 24 systems Esclim 0.05 mg/day 8 systems 24 systems Esclim mg/day 8 systems 24 systems Esclim 0.1 mg/day 8 systems 24 systems estazolam 2 mg tablet estazolam 1 mg tablet Estraderm 0.05 mg/day 8 systems 24 systems Estraderm 0.1 mg/day 8 systems 24 systems Estradiol TDS mg/day 4 systems 12 systems Estradiol TDS 0.05 mg/day 4 systems 12 systems Estradiol TDS mg/day 4 systems 12 systems Estradiol TDS 0.1 mg/day 4 systems 12 systems Estrasorb 1.74 gm/pouch 60 pouches 180 pouches Estring (estradiol vaginal ring) 2 mg 1 ring/90 1 ring/90 days vaginal ring days EstroGel Metered dose pump pump 3 pumps gm/dose (50gm) Evamist Metered dose pump - 8.1mL 2 pumps 6 pumps Evista 60mg tablet Exelon 6 mg capsule Exelon 4.5 mg capsule Exelon 3 mg capsule Exelon 1.5 mg capsule Exelon 4.6mg/24 hr patch Exelon 9.5mg/24 hr patch Exforge 10/320 mg tablet Exforge 10/160 mg tablet Exforge 5/320 mg tablet Exforge 5/160 mg tablet Exforge HCT 10/160/12.5 tablet Exforge HCT 10/160/25 tablet Exforge HCT 10/320/25 tablet Exforge HCT 5/160/12.5 tablet Exforge HCT 5/160/25 tablet Extavia 1 Kit (contains 0.3 mg) 15 Kits 45 Kits Page 9 of 26

10 famciclovir 500 mg tablet famciclovir 250 mg tablet famciclovir 125 mg tablet Famvir 500 mg tablet Famvir 250 mg tablet Famvir 125 mg tablet Femring (estradiol acetate 0.05 mg/day vaginal ring 1 ring/90 1 ring/90 days vaginal ring) days Femring (estradiol acetate 0.10 mg/day vaginal ring 1 ring/90 1 ring/90 days vaginal ring) days fentanyl (oral transmucosal) all strengths/dosage forms 90* 270* Fentora all strengths/dosage forms 112* 336* fexofenadine 30 mg tablet fexofenadine 60 mg tablet fexofenadine 180 mg tablet fexofenadine/pseudoephedrine 60/120mg tablet finasteride 5 mg tablet Flector Patch (box of 30 patches) 1 box (30 patches) 1 box (30 patches) Flomax 0.4 mg capsule Flonase 16gm nasal spray 1 (16gm) 3 (48gm) Flovent 13gm aerosol 2 (26gm) 6 (78gm) Flovent 50mcg diskus 1 (60 blisters) 3 (180 blisters) Flovent 100mcg diskus 1 (60 blisters) 3 (180 blisters) Flovent 250mcg diskus 4 (240 blisters) 3 (720 blisters) Flovent HFA 10.6gm aerosol (44 mcg) 2 (21.2gm) 6(63.6gm) Flovent HFA 12gm aerosol (110 mcg) 1 (12gm) 3 (36gm) Flovent HFA 12gm aerosol (220 mcg) 3 (36gm) 9 (108gm) Flovent Rotadisk Powder 240 doses (16 blisters) 720 doses (48 blisters) fluconazole 150mg tablet 2 6 flunisolide 25 ml nasal spray 3 (75mL) 9 (225mL) fluoxetine 10 mg capsule, tablet fluoxetine 20 mg capsule fluoxetine 40 mg capsule fluoxetine DR 90mg capsule 4 12 flurazepam 30 mg capsule flurazepam 15 mg capsule fluticasone 16gm nasal spray 1 (16gm) 3 (48gm) fluvoxamine 100 mg tablet fluvoxamine 50 mg tablet fluvoxamine 25 mg tablet Page 10 of 26

11 Foradil Aerolizer Inhalation Powder (1 device with 60 blisters;12mcg/inh) 1 (60 blisters) 3 (180 blisters) Forteo 600 mcg/2.4 ml prefilled injection 1 injection 1 injection pen pen pen Fortical Nasal Spray 200 units (3.7mL 1 (3.7mLs) 3 (11.1 mls) bottle) Fosamax 40 mg tablet Fosamax 10 mg tablet Fosamax 5 mg tablet Fosamax 70 mg tablet (blister pack of 4 4 tablets 12 tablets tablets) Fosamax 35 mg tablet (blister pack of 4 4 tablets 12 tablets tablets) Fosamax 70 mg oral solution (1 box contains 4-75mL bottles) 1 box (300 mls) 3 boxes (900mLs) Fosamax Plus D 35 mg/2800 IU tablet (blister pack 4 tablets 12 tablets of 4 tablets) fosinopril 40 mg tablet fosinopril 20 mg tablet fosinopril 10 mg tablet Frova 2.5 mg tablet 9 27 furosemide 20 mg tablet furosemide 40 mg tablet furosemide 80 mg tablet galantamine 4 mg tablet galantamine 8 mg tablet galantamine 12 mg tablet galantamine ER 8 mg capsule galantamine ER 16 mg capsule galantamine ER 24 mg capsule Gelnique 30 sachets (1 gram/sachet) 30 sachets 90 sachets Geodon 20 mg capsule Geodon 40 mg capsule Geodon 60 mg capsule Geodon 80 mg capsule glipizide 5 mg tablet glipizide 10 mg tablet glipizide er 2.5 mg tablet glipizide er 5 mg tablet glipizide er 10 mg tablet glipizide xl 2.5 mg tablet glipizide xl 5 mg tablet glipizide xl 10 mg tablet glipizide/metformin 5mg/500mg tablet glipizide/metformin 2.5mg/500mg tablet glipizide/metformin 2.5mg/250mg tablet Page 11 of 26

12 Glucovance 1.25 mg/250 mg tablet Glucovance 2.5 mg/500 mg tablet Glucovance 5 mg/500 mg tablet glyburide/metformin 1.25 mg/250 mg tablet glyburide/metformin 2.5 mg/500 mg tablet glyburide/metformin 5 mg/500 mg tablet granisetron 1mg tablet 8 24 granisol 2mg/mL oral solution 40 ml 120 ml Halcion 0.25 mg tablet Halcion mg tablet Humira 40 mg (0.8mL) syringe 2 prefilled syringes** 2 prefilled syringes** Humira 40 mg (0.8mL) pen 2 pens** 2 pens** Humira 20 mg (0.4mL) syringe 2 prefilled syringes** 2 prefilled syringes** Humira crohn's start pack 1 pack 1 pack Humira psoriasis start pack 1 pack 1 pack hydrochlorothiazide 12.5 mg tablet and capsule hydrochlorothiazide 25 mg tablet and capsule hydrochlorothiazide 50 mg tablet and capsule Hylira 1000 gm hydrating lotion 1 bottle 3 bottles Hytrin 10 mg capsule Hytrin 5 mg capsule Hytrin 2 mg capsule Hytrin 1 mg capsule Imitrex Inj 6 mg syringe, refill kit 6 syringes (3 kits) 18 syringes (9 kits) Imitrex Inj 4 mg syringe, vial refill kit 6 syringes/ vials (3 kits) 18 syringes/ vials (9 kits) Imitrex NS 5 mg NS device 6 devices 18 devices Imitrex NS 20 mg NS device 6 devices 18 devices Imitrex Tablet 25 mg tablet 9 27 Imitrex Tablet 50 mg tablet 9 27 Imitrex Tablet 100mg tablet 9 27 Infergen 15 mcg vial (0.5ml vial) 12 vials (6ml) 12 vials (6ml) Infergen 9 mcg vial (0.3ml vial) 12 vials (4ml) 12 vials (4ml) Intal 8.1gm aerosol 2 (17gm) 6 (33gm) Intal 14.2gm aerosol 2 (29gm) 6 (57gm) Intuniv ER all strengths/dosage forms Invega 1.5mg tablet Invega 3mg tablet Invega 6mg tablet Invega 9mg tablet Page 12 of 26

13 Invega Sustenna 39mg vial 1 pack 3 vials (contains 1 vial) Invega Sustenna 78mg vial 1 pack 3 vials (contains 1 vial) Invega Sustenna 117mg vial 1 pack 3 vials (contains 1 vial) Invega Sustenna 156mg vial 1 pack 3 vials (contains 1 vial) Invega Sustenna 234mg vial 1 pack 3 vials (contains 1 vial) Iressa 250 mg tablet itraconazole 100 mg capsule Janumet 50/500mg tablet Janumet 50/1000mg tablet Januvia 25 mg tablet Januvia 50 mg tablet Januvia 100 mg tablet jolessa 0.15mg/0.03mg tablet 1 pack (91 tablets) 1 pack (91 tablets) Kapidex 30 mg capsule Kapidex 60 mg capsule ketorolac 10mg tablet Kineret 100 mg syringe Kytril 1mg tablet 8 24 Kytril 2mg/mL oral solution 40 ml 120 ml Lamisil 250 mg tablet Lamisil 125mg granules packet Lamisil 187.5mg granules packet lansoprazole 15mg capsule leflunomide 10 mg tablet leflunomide 20 mg tablet Lescol 20 mg capsule Lescol 40 mg capsule Lescol 80mg XL tablet Letairis 10 mg tablet Letairis 5 mg tablet Lexapro 5 mg tablet Lexapro 10 mg tablet Lexapro 20 mg tablet Lioresal IT All kit strengths 1 Kit 3 Kits Lipitor 10 mg tablet Page 13 of 26

14 Lipitor 20 mg tablet Lipitor 40 mg tablet Lipitor 80 mg tablet lisinopril 40 mg tablet lisinopril 30 mg tablet lisinopril 20 mg tablet lisinopril 10 mg tablet lisinopril 5 mg tablet lisinopril 2.5 mg tablet lisinopril/hctz 10 mg/ 12.5 mg tablet lisinopril/hctz 20 mg/ 12.5 mg tablet lisinopril/hctz 20 mg/ 25 mg tablet Lotensin 40 mg tablet Lotensin 20 mg tablet Lotensin 10 mg tablet Lotensin 5 mg tablet Lotronex 1 mg tablet Lotronex 0.5 mg tablet lovastatin 10 mg tablet lovastatin 20 mg tablet lovastatin 40 mg tablet Lunesta 1 mg Lunesta 2 mg Lunesta 3 mg Luvox CR 100 mg capsule Luvox CR 150 mg capsule Mavik 4 mg tablet Mavik 2 mg tablet Mavik 1 mg tablet Maxair 25.6gm aerosol 2 (52gm) 6 (153gm) Maxalt 5 mg tablet 9 27 Maxalt 10 mg tablet 9 27 Maxalt MLT 5 mg tablet 9 27 Maxalt MLT 10 mg tablet 9 27 medroxyprogesterone 150 mg injection 1 1 meloxicam 7.5 mg tablet meloxicam 15 mg tablet meloxicam 7.5mg/ 5mL oral suspension 300 mls 900 mls Menostar 14 mcg/day patch 4 12 Metaglip 2.5 mg/250 mg tablet Metaglip 2.5 mg/500 mg tablet Metaglip 5 mg/500 mg tablet metformin 500 mg tablet metformin 850 mg tablet metformin 1000 mg tablet metformin ER 500 mg tablet Page 14 of 26

15 metformin ER 750 mg tablet metoprolol 25 mg tablet metoprolol 50 mg tablet metoprolol 100 mg tablet Mevacor 10 mg tablet Mevacor 20 mg tablet Mevacor 40 mg tablet Miacalcin Nasal Spray 220 units (3.7mL 1 (3.7mLs) 3 (11.1 mls) bottle) Micardis 80 mg tablet Micardis 40 mg tablet Micardis 20 mg tablet Migranal NS 1 ml vial contain 4 mg DHE 8 vials 24 vials Minipress 5 mg capsule Minipress 2 mg capsule Minipress 1 mg capsule mirtazapine 15 mg mirtazapine 30 mg mirtazapine 45 mg Mobic 7.5 mg tablet Mobic 15 mg tablet Mobic 7.5mg/ 5mL oral suspension 300 mls 900 mls moexipril 15 mg tablet moexipril 7.5 mg tablet Monopril 40 mg tablet Monopril 20 mg tablet Monopril 10 mg tablet MUSE 125mcg 8 24 MUSE 250mcg 8 24 MUSE 500mcg 8 24 MUSE 1000mcg 8 24 Nasacort 10gm inhaler 3 (30gm) 9 (80gm) Nasacort AQ 16.5gm spray 1 (17gm) 3 (51gm) Nasarel 25ml spray 3 (75ml) 9 (225ml) Nascobol Nasal spray 1 device 1 device Nasonex 17gm spray 2 (34gm) 6 (102gm) Neulasta 6 mg syringe 2 syringes 2 syringes Neumega 5mg vial for inj Neupogen 300mcg/0.5ml syringe 14 syringes 14 syringes Neupogen 480mcg/0.8ml syringe 14 syringes 14 syringes Neupogen 300mcg/ml - 1ml vial 14 vials 14 vials Neupogen 480mcg/ml - 1.6ml vial 14 vials 14 vials Nexium 20mg capsule Nexium 40mg capsule Nexium 10mg packet Nexium 20mg packet Page 15 of 26

16 Nexium 40mg packet Next Choice 0.75 mg levonorgestrel tablets (2 1 kit not available tablets per blister pack) Nuvigil 150mg tablet Nuvigil 250mg tablet omeprazole 10mg capsule omeprazole 20mg capsule omeprazole 40mg capsule Omnaris 12.5gm nasal spray 1 (12.5gm) 3 (37.5gm) ondansetron 4mg tablet ondansetron 8 mg tablet ondansetron 24mg tablet 4 12 ondansetron 4mg/5mL oral solution 120 mls 360 mls ondansetron ODT 4mg tablet ondansetron ODT 8 mg tablet Onglyza 2.5 mg tablet Onglyza 5 mg tablet Onsolis all strengths/dosage forms 90* 270* Opana ER 5 mg tablet 90* 270* Opana ER 7.5 mg tablet 90* 270* Opana ER 10 mg tablet 90* 270* Opana ER 15 mg tablet 90* 270* Opana ER 20 mg tablet 90* 270* Opana ER 30 mg tablet 90* 270* Opana ER 40 mg tablet 90* 270* Orthro-Prefest Pink tablet: 1 mg estradiol White tablet: 1 mg estradiol/ 0.09 mg norgestimate (30 tablet blister pack) oxybutynin cl er 5 mg tablet oxybutynin cl er 10 mg tablet oxybutynin cl er 15 mg tablet Oxycodone All tablet strengths 90* 270* Oxycontin All tablet strengths 90* 270* Oxytrol 3.9 mg/24 hr patch 8 24 pantoprazole 20 mg tablet pantoprazole 40 mg tablet paroxetine 10 mg tablet paroxetine 20 mg tablet paroxetine 30 mg tablet paroxetine 40 mg tablet paroxetine CR 12.5 mg tablet paroxetine CR 25 mg tablet paroxetine CR 37.5 mg tablet Patanase 30.5gm nasal spray 1 device (30.5 gm) 3 devices (91.5 gm) Page 16 of 26

17 Paxil 10 mg tablet Paxil 20 mg tablet Paxil 30 mg tablet Paxil 40 mg tablet Paxil CR 12.5 mg tablet Paxil CR 25 mg tablet Paxil CR 37.5 mg tablet Pegasys 180 mcg single use vial (each vial 4 vials 4 vials provides 1 ml containing 180 mcg for SC injection) Pegasys Convenience Pack 1 pack 1 pack Peg-Intron All kit strenghts (contains one 4 packages 4 packages vial) Peg-Intron Redipen All package strengths (contain 4 packages 4 packages one Redipen) Peg-Intron Redipen All four Pak strengths (contains 1 package 1 package four Redipen devices) Perforomist 20mcg/2mL solution 60 respules 180 respules perindopril 2mg tablet perindopril 4mg tablet perindopril 6mg tablet Pexeva 10 mg tablet Pexeva 20 mg tablet Pexeva 30 mg tablet Pexeva 40 mg tablet Plan B 0.75 mg levonorgestrel tablets (2 1 kits not available tablets per blister pack) Plan B One-Step 1.5mg levonorgestrel tablet (1 1 kit Not available tablet per pack) Plavix 75mg tablet Plavix 300mg tablet 1 1 Pletal 50mg tablet Pletal 100mg tablet pravastatin 10 mg tablet pravastatin 20 mg tablet pravastatin 40 mg tablet Pravachol 10 mg tablet Pravachol 20 mg tablet Pravachol 40 mg tablet Pravachol 80 mg tablet prazosin 5 mg capsule prazosin 2 mg capsule prazosin 1 mg capsule Premarin 0.3 mg tablet Premarin mg tablet Premarin 0.9 mg tablet Page 17 of 26

18 Premarin 1.25 mg tablet Premarin 2.5 mg tablet Premphase 14 x mg conjugated estrogen tablets for days 1-14 and 14 x mg conjugated estrogen with 5 mg medroxyprogesterone tablets for days Prempro mg conjugated estrogens/ mg medroxyprogesterone tablet (28 tablet EZ dial pack) Prempro mg conjugated estrogens/ mg medroxyprogesterone tablet Prempro 0.45 mg conjugated estrogens/ mg medroxyprogesterone tablet Prempro 0.3 mg conjugated estrogens/ mg medroxyprogesterone tablet Prevacid 15mg capsule Prevacid 30mg capsule Prevacid 15mg solutab Prevacid 30mg solutab Prilosec 10mg capsule Prilosec 20mg capsule Prilosec 40mg capsule Prilosec Suspension Packet 2.5mg packet Prilosec Suspension Packet 10mg packet Prinivil 40 mg tablet Prinivil 20 mg tablet Prinivil 10 mg tablet Prinivil 5 mg tablet Prinivil 2.5 mg tablet Pristiq 50mg tablet Pristiq 100mg tablet Procrit 2000u/ml vial (6 vials per carton) 12 vials 12 vials Procrit 3000u/ml vial (6 vials per carton) 12 vials 12 vials Procrit 4000u/ml vial (6 vials per carton) 12 vials 12 vials Procrit 10,000u/ml vial (6 vials per 12 vials 12 vials carton) Procrit 40,000u/ml (4 vials per carton) 4 vials 4 vials Procrit 10,000u/ml MDV (2ml MDV-6 6 vials 6 vials vials per carton) Procrit 20,000u/ml MDV (1ml MDV- 6 6 vials 6 vials vials per carton) ProAir HFA 8.5gm inhaler 2 inhalers (17 grams) Page 18 of 26 6 inhalers (51 grams)

19 Proscar 5 mg tablet Prosom 2 mg tablet Prosom 1 mg tablet Protonix 20 mg tablet Protonix 40 mg tablet Protonix 40 mg packet Proventil 17gm aerosol 2 (34gm) 6 (102gm) Proventil HFA 6.7gm aerosol 2 (14gm) 6 (41gm) Prozac 10 mg capsule, tablet Prozac 20 mg capsule Prozac 40 mg capsule Prozac Weekly 90mg capsule 4 12 Pulmicort Flexhaler powder inhaler 2 inhalers 6 inhalers Pulmicort Turbuhaler powder inhaler 2 inhalers 6 inhalers Pulmicort 0.25mg/2mL respule 60 respules 180 respules Pulmicort 0.5mg/2mL respule 60 respules 180 respules Pulmicort 1mg/2mL respule 30 respules 90 respules quasense 0.15mg/0.03mg tablet 1 pack (91 tablets) 1 pack (91 tablets) quinapril 40 mg tablet quinapril 20 mg tablet quinapril 10 mg tablet quinapril 5 mg tablet Qvar 7.3gm aerosol 3 9 ramipril 10 mg capsule ramipril 5 mg capsule ramipril 2.5 mg capsule ramipril 1.25mg capsule ranitidine 150mg tablet, gelcap ranitidine 300mg tablet, gelcap Rapaflo 4 mg capsule Rapaflo 8 mg capsule Razadyne 4 mg tablet Razadyne 8 mg tablet Razadyne 12 mg tablet Razadyne ER 8 mg capsule Razadyne ER 16 mg capsule Razadyne ER 24 mg capsule Rebetol 200 mg capsule Rebif 22 mcg syringe - single syringe 12 syringes 12 syringes Rebif 22 mcg syringe - 12 pack 1 pack (12 syringes) 1 pack (12 syringes) Rebif 44 mcg syringe - single syringe 12 syringes 12 syringes Rebif 44 mcg syringe - 12 pack 1 pack (12 syringes) 1 pack (12 syringes) Rebif Titration Pack (12 syringes) 1 pack 1 pack Page 19 of 26

20 Regranex 15 gm gel (0.01%) 1 tube (15gm) 3 tubes (45gm) Relenza 5mg diskhaler (20 blisters) 1 device 1 device Relistor 12mg/0.6mL vial (7 vials per kit) 14 vials (2 kits) 14 vials (2 kits) Relpax 20 mg tablet 6 18 Relpax 40 mg tablet 6 18 Remeron/ Remeron SolTab 15 mg Remeron/ Remeron SolTab 30 mg Remeron 45 mg Remeron SolTab 45 mg Reminyl 4 mg tablet Reminyl 8 mg tablet Reminyl 12 mg tablet Requip XL 2 mg tablet Requip XL 3 mg tablet Requip XL 4 mg tablet Requip XL 6 mg tablet Requip XL 8 mg tablet Requip XL 12 mg tablet Restasis (cyclosporine opthalmic emulsion) 0.05% Single use vials containing 0.4 ml fill in a 0.9mL vial; 30 vials are packaged in a polypropylene tray. Page 20 of 26 2 trays (each tray contains 30 vials) Restoril 30 mg capsule Restoril 15 mg capsule Restoril 7.5 mg capsule Revatio 20 mg tablet 90* 90* Revatio 10 mg/12.5 ml 90 vials* (1,125mls) Revlimid 25 mg capsule Revlimid 15 mg capsule Revlimid 10 mg capsule Revlimid 5 mg capsule Rhinocort Aqua 8.6 gm (120 sprays per bottle) trays (each tray contains 30 vials) 90 vials* (1,125mls) Ribapak 400 mg-400 mg Dosepak (56 1 pack 1 pack tablets) Ribapak 400 mg-600 mg Dosepak (56 1 pack 1 pack tablets) Ribapak 600 mg-600 mg Dosepak (56 1 pack 1 pack tablets) ribasphere 200 mg capsule and tablet ribasphere 400 mg tablet ribasphere 600 mg tablet Ribatab 400 mg tablet Ribatab 600 mg tablet 60 60

21 Ribatab 400 mg-400 mg Dosepak (56 1 pack 1 pack tablets) Ribatab 400 mg-600 mg Dosepak (56 1 pack 1 pack tablets) Ribatab 600 mg-600 mg Dosepak (56 1 pack 1 pack tablets) ribavirin 200 mg capsule and tablet Rozerem 8 mg tablet Sabril 500mg powder packet 150 packs (3 boxes) 450 packs (6 boxes) Sabril 500mg tablets 180 tablets 540 tablets Sanctura 20 mg tablet Sanctura XR 60 mg capsule Sancuso Patch 2 patches 6 patches Saphris 5 mg tablet Saphris 10 mg tablet Sarafem 10 mg pulvule/ tablet Sarafem 20 mg pulvule/ tablet Savella 100 mg tablet Savella 50 mg tablet Savella 25 mg tablet Savella 12.5 mg tablet Savella Titration pack containing 55 tablets 1 pack (55 tablets) 1 pack (55 tablets) Seasonale 0.15mg/0.03mg tablet 1 pack (91 tablets) 1 pack (91 tablets) Seasonique 0.15mg/0.03mg/0.01mg tablet 1 pack (91 tablets) 1 pack (91 tablets) Selfemra 10 mg capsule Selfemra 20 mg capsule Serevent Diskus Inhalation powder diskus with 28 blisters 2 (56 blisters) 6 (168 blisters) Serevent Diskus Inhalation powder diskus with 60 blisters 1 (60 blisters) 3 (180 blisters) Seroquel 25 mg tablet Seroquel 50 mg tablet Seroquel 100 mg tablet Seroquel 200 mg tablet Seroquel 300 mg tablet Seroquel 400 mg tablet Seroquel XR 50 mg tablet Seroquel XR 150 mg tablet Seroquel XR 200 mg tablet Seroquel XR 300 mg tablet Seroquel XR 400 mg tablet sertraline 100 mg tablet Page 21 of 26

22 sertraline 50 mg tablet sertraline 25 mg tablet Simcor 500/20mg tablet Simcor 750/20mg tablet Simcor 1000/20mg tablet Simponi 50mg syringe 1 syringe** 1 syringe** simvastatin 80 mg tablet simvastatin 40 mg tablet simvastatin 20 mg tablet simvastatin 10 mg tablet simvastatin 5 mg tablet Singulair 4 mg chewable tablets or oral granules Singulair 5 mg chewable tablets Singulair 10 mg tablets sodium hyaluronate lotion 1000 gm hydrating lotion 1 bottle 3 bottles Soma 350 mg tablet Soma 250mg tablet Somavert 10 mg vial 30 vials 30 vials (pegvisomant for injection) Somavert (pegvisomant for injection) 15 mg vial 30 vials 30 vials Somavert (pegvisomant for injection) 20 mg vial 30 vials 30 vials Somnote 500 mg softgel Sonata 10 mg capsule Sonata 5 mg capsule Sprycel 100 mg tablet Sprycel 70 mg tablet Sprycel 50 mg tablet Sprycel 20 mg tablet Spiriva 18 mcg powder caps 1 pkg (6 or 30) Sporanox 100mg capsule Stelara 45mg/0.5ml syringe 90mg** 90mg** Striant Buccal System 30 mg buccal system pkgs (18 or 90) sumatriptan inj. 4 mg syringe, vial, refill kit 6 syringes/ vials (3 kits) 18 syringes/ vials (9 kits) sumatriptan inj. 6 mg syringe, refill kit 6 syringes (3 kits) 18 syringes (9 kits) Sumatriptan NS 5 mg NS device 6 devices 18 devices Sumatriptan NS 20 mg NS device 6 devices 18 devices sumatriptan 25 mg tablet 9 27 sumatriptan 50 mg tablet 9 27 sumatriptan 100 mg tablet 9 27 Page 22 of 26

23 Sumavel DosePro 6 mg/0.5 ml syringe 6 syringes** (3 mls) 18 syringes** (9 mls) Sutent 50 mg capsule Sutent 25 mg capsule Sutent 12.5 mg capsule Symlin 0.6mg/mL vial (5mL) 4 vials 12 vials SymlinPen 60 Pen Injection (1.5mL/pen) 2 boxes (4 pens) 6 boxes (12 pens) SymlinPen 120 Pen Injection (2.7mL/pen) 2 boxes (4 pens) 6 boxes (12 pens) Synera Patch 2 patches 2 patches Symbicort Inhaler 80mcg/ 4.5mcg 1 device 3 devices Symbicort Inhaler 160mcg/ 4.5mcg 1 device 3 devices Tamiflu 30 mg capsule Tamiflu 45 mg capsule Tamiflu 75 mg capsule Tamiflu Powder for oral suspension (25ml bottle) 50ml (2 bottles) tamsulosin 0.4 mg capsule Tekturna 300 mg tablet Tekturna 150 mg tablet temazepam 30 mg capsule temazepam 15 mg capsule terazosin 10 mg capsule terazosin 5 mg capsule terazosin 2 mg capsule terazosin 1 mg capsule Tasigna 200 mg capsule terbinafine 250 mg tablet ml (2 bottles) Testim gel 1% (testosterone) Each tube contains 50 mg testosterone in 5 gm of gel 2 cartons (60 tubes) 6 cartons (180 tubes) Teveten 600 mg tablet Teveten 400 mg tablet Ticlid 250mg tablet ticlopidine 250mg tablet Tilade 16.2 gm inhaler 3 (16.2 gm) 9 (145.8 gm) Tobi 300mg/5mL ampules 2 packs 2 packs (28 per package) Toradol 10mg tablet Toviaz ER 4 mg tablet Toviaz ER 8 mg tablet trandolapril 4 mg tablet trandolapril 2 mg tablet trandolapril 1 mg tablet Treximet 85mg-500mg tablet 9 27 Page 23 of 26

24 triamterene/ 50 mg/ 25 mg capsule and tablet hydrochlorothiazide triamterene/ 37.5 mg/ 25 mg capsule and hydrochlorothiazide tablet triamterene/ 75 mg/ 50 mg capsule and tablet hydrochlorothiazide triazolam 0.25 mg tablet triazolam mg tablet Twynsta mg tablet Twynsta 40-5 mg tablet Twynsta mg tablet Twynsta mg tablet Tykerb 250 mg tablet Tyzeka 600 mg tablet Uloric 40 mg tablet Uloric 80 mg tablet Univasc 15 mg tablet Univasc 7.5 mg tablet valacyclovir 1000mg tablet valacyclovir 500mg tablet Valtrex 1000 mg tablet Valtrex 500 mg tablet Valturna 150/160 mg tablet Valturna 300/320 mg tablet Vanceril 16.8gm aerosol 3 (51gm) 9 (152gm) Vasotec 20 mg tablet Vasotec 10 mg tablet Vasotec 5 mg tablet Vasotec 2.5 mg tablet venlafaxine 100 mg tablet venlafaxine 75 mg tablet venlafaxine 50 mg tablet venlafaxine 37.5 mg tablet venlafaxine 25 mg tablet Venlafaxine ER 37.5 mg tablet Venlafaxine ER 75 mg tablet Venlafaxine ER 150 mg tablet Venlafaxine ER 225 mg tablet Ventolin 17gm aerosol 2 (34gm) 6 (102gm) Ventolin HFA 18 gm aerosol 2 (36 gm) 6 (108 gm) Veramyst 10gm nasal spray 1 (10gm) 3 (30gm) Veregen 15% Ointment (15 gram) tube 1 tube (15gm) Vesicare 10 mg tablet Vesicare 5 mg tablet Page 24 of 26 3 tubes (45gm)

25 Vfend 50 mg tablet Vfend 200 mg tablet Victoza 18mg/3ml injection pen (6mls) 2 pen pack (6mL) 6 pens (18mL) Victoza 18mg/3ml injection pen (9mls) 3 pen pack (9mL) 9 pens (27mL) Vivelle mg/day 8 systems 24 systems Vivelle 0.05 mg/day 8 systems 24 systems Vivelle mg/day 8 systems 24 systems Vivelle 0.1 mg/day 8 systems 24 systems Vivelle-Dot mg/day 8 systems 24 systems Vivelle-Dot mg/day 8 systems 24 systems Vivelle-Dot 0.05 mg/day 8 systems 24 systems Vivelle-Dot mg/day 8 systems 24 systems Vivelle-Dot 0.1 mg/day 8 systems 24 systems Vytorin 10 mg/10 mg tablet Vytorin 10 mg/20 mg tablet Vytorin 10 mg/40 mg tablet Vytorin 10 mg/80 mg tablet Vyvanse 20mg capsule Vyvanse 30 mg capsule Vyvanse 40 mg capsule Vyvanse 50 mg capsule Vyvanse 60 mg capsule Vyvanse 70 mg capsule Wellbutrin SR 100 mg tablet Wellbutrin SR 150 mg tablet Wellbutrin SR 200 mg tablet Wellbutrin XL 150 mg tablet Wellbutrin XL 300 mg tablet Xyzal 5 mg tablet Xyzal Solution 2.5mg/5mL zaleplon 10 mg capsule zaleplon 5 mg capsule Zegerid 20 mg capsule Zegerid 40 mg capsule Zegerid 20 mg packet Zegerid 40 mg packet Zestril 40 mg tablet Zestril 30 mg tablet Zestril 20 mg tablet Zestril 10 mg tablet Zestril 5 mg tablet Zestril 2.5 mg tablet Zetia 10 mg tablet Zocor 5 mg tablet Page 25 of 26

26 Zocor 10 mg tablet Zocor 20 mg tablet Zocor 40 mg tablet Zocor 80 mg tablet Zofran 4mg tablet Zofran 8 mg tablet Zofran 24mg tablet 4 12 Zofran 4mg/5mL oral solution 120 mls 360 mls Zofran ODT 4mg tablet Zofran ODT 8 mg tablet Zolinza 100 mg capsule Zoloft 25 mg tablet Zoloft 50 mg tablet Zoloft 100 mg tablet zolpidem 5 mg tablet zolpidem 10 mg tablet Zomig Tablet 2.5 mg tablet 6 18 Zomig Tablet 5 mg tablet 6 18 Zomig ZMT 2.5mg tablet 6 18 Zomig ZMT 5 mg tablet 6 18 Zyban 150 mg SR tablet Zyflo 600 mg tablets Zyflo CR 600 mg tablets Zyprexa 2.5 mg tablet Zyprexa 5 mg tablet Zyprexa 7.5 mg tablet Zyprexa 10 mg tablet Zyprexa 15 mg tablet Zyprexa 20 mg tablet Zyprexa Relprev 210mg vial 4 vials 12 vials Zyprexa Zydis 5 mg tablet Zyprexa Zydis 10 mg tablet Zyprexa Zydis 15 mg tablet Zyprexa Zydis 20 mg tablet Zyrtec 5 mg tablet/chewable tablet Zyrtec 10 mg tablet/chewable tablet Zyrtec-D 5/120mg Zyvox 600 mg tablet Zyvox 100 mg/ 5 ml (150 ml) 900 mls (6 bottles) 900 mls (6 bottles) Page 26 of 26