2013 Quantity Level Limits (QLL) Criteria

Transcription

1 Certain drugs covered through your EmblemHealth Medicare PDP Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food and Drug Administration and manufacturer dosing recommendations. For example, Januvia 50mg is covered up to 30 tablets for a 30-day period. If your physician feels it is medically necessary for you to receive more than 30 tablets over a 30-day period, he or she must ask for an exception to the quantity limit. Doctors must secure prior approval before a higher quantity will be covered. This list includes drugs that have quantity limits. To see if your drug is on the list, refer to the table of contents below for the quantity limit criteria you are looking for, or refer to the index located at the end of this document for the medication you are looking for. TABLE OF CONTENTS ABILIFY DISCMELT... 9 ABILIFY... 9 ABSTRAL... 9 acarbose... 9 ACTIQ... 9 ACTONEL... 9 ACTOPLUS MET XR ACTOPLUS MET ACTOS ADCIRCA ADVAIR DISKUS ADVAIR HFA ADVICOR alendronate ALORA ALOXI ALSUMA Updated: 03/2013 Y0026_ Approved 09/26/2012 Page 1 of 60 Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies, EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

2 ALTOPREV ALVESCO AMARYL AMBIEN CR AMBIEN AMERGE ANZEMET APLENZIN ARAVA ARCAPTA NEOHALER ASMANEX ASTELIN ASTEPRO ATELVIA atorvastatin calcium ATROVENT HFA ATROVENT AVANDAMET AVANDARYL AVANDIA AVINZA AVONEX ADMINISTRATION PACK AVONEX AXERT azelastine hcl BECONASE AQ BETASERON BONIVA bupropion butorphanol BYDUREON BYETTA cabergoline CADUET CAMBIA CARDURA XL CARDURA CATAPRES-TTS CATAPRES-TTS CATAPRES-TTS CAYSTON CELEXA CESAMET citalopram CLARINEX CLARINEX-D 12 HOUR Page 2 of 60

3 CLARINEX-D 24 HOUR CLIMARA PRO CLIMARA clonidine COMBIVENT RESPIMAT COMBIVENT CONZIP COPAXONE CORDRAN CRESTOR CYCLOSET CYMBALTA DEPO-PROVERA DEPO-SUBQ PROVERA desloratadine DEXILANT DIABETA DIFLUCAN DITROPAN XL DIVIGEL doxazosin DUETACT DULERA DYMISTA EDLUAR EFFEXOR XR ELESTRIN ELLA EMEND ENBREL EPIPEN 2-PAK EPIPEN JR 2-PAK escitalopram oxalate estradiol EVAMIST EXALGO EXTAVIA FACTIVE famciclovir FAMVIR FANAPT fentanyl citrate FENTORA FLECTOR FLONASE FLOVENT DISKUS Page 3 of 60

4 FLOVENT HFA fluconazole flunisolide fluoxetine fluticasone propionate fluvastatin fluvoxamine FORADIL FORFIVO XL FORTAMET FORTEO FOSAMAX PLUS D FOSAMAX FROVA GELNIQUE GEODON glimepiride glipizide glipizide/metformin hcl GLUCOPHAGE XR GLUCOPHAGE GLUCOTROL XL GLUCOTROL GLUCOVANCE GLUMETZA glyburide glyburide/metformin hcl GLYNASE GLYSET granisetron HUMIRA ibandronate IMITREX INTERMEZZO INVEGA ipratropium itraconazole JANUMET XR JANUMET JANUVIA JENTADUETO JUVISYNC KADIAN ketorolac KOMBIGLYZE XR lansoprazole Page 4 of 60

5 LATUDA LAZANDA leflunomide LESCOL XL LESCOL levocetirizine dihydrochlor levonorgestrel LEXAPRO LIPITOR LIVALO lovastatin LUNESTA LUVOX CR MAXAIR AUTOHALER MAXALT MLT MAXALT medroxyprogesterone meloxicam MENOSTAR metformin MEVACOR miconazole nitrate MIGRANAL MOBIC morphine MS CONTIN naratriptan NASACORT AQ NASONEX nateglinide NEULASTA NEUMEGA NEXIUM NUCYNTA ER NUCYNTA olanzapine omeprazole omeprazole/sodium bicarbonat OMNARIS ondansetron ONGLYZA ONSOLIS OPANA ER oxybutynin OXYCONTIN oxymorphone Page 5 of 60

6 OXYTROL pantoprazole paroxetine PATANASE PAXIL CR PAXIL PEGASYS PROCLICK PEGASYS PEGINTRON REDIPEN PEGINTRON PEXEVA pioglitazone hcl pioglitazone hcl/metformin hc PRANDIMET PRANDIN PRAVACHOL pravastatin PRECOSE PREVACID PREVPAC PRILOSEC PRISTIQ ER PROAIR HFA PROTONIX PROVENTIL HFA PROZAC WEEKLY PROZAC PULMICORT FLEXHALER QNASL quetiapine fumarate QVAR REBIF REGRANEX RELENZA RELPAX RESTASIS revatio (sildenafil citrate) REVATIO RHINOCORT AQUA RIOMET RISPERDAL M-TAB RISPERDAL risperidone ROZEREM RYZOLT SAMSCA Page 6 of 60

7 SANCUSO SANDOSTATIN LAR SAPHRIS SARAFEM SAVELLA SEREVENT DISKUS SEROQUEL XR SEROQUEL sertraline SILENOR SIMCOR simvastatin SONATA SPIRIVA SPORANOX SPRIX STARLIX SUBOXONE SUBSYS sumatriptan SUMAVEL DOSEPRO SYMBICORT SYMLINPEN SYMLINPEN TAMIFLU TERAZOL TERAZOL terazosin terconazole TOBI tolazamide tolbutamide TRADJENTA tramadol tramadol/apap TREXIMET triamcinolone acetonide TUDORZA PRESSAIR TWINJECT ULTRACET ULTRAM ER ULTRAM valacyclovir VALTREX venlafaxine VENLAFAXINE HCL ER Page 7 of 60

8 VENTOLIN HFA VERAMYST VICTOZA 3-PAK VIIBRYD VIVELLE-DOT VYTORIN WELLBUTRIN SR WELLBUTRIN XL XOLAIR XOPENEX HFA XYZAL zaleplon ZAZOLE ZEGERID ZETONNA ziprasidone ZOCOR ZOFRAN ODT ZOFRAN ZOLOFT zolpidem ZOLPIMIST ZOMIG ZMT ZOMIG ZYPREXA ZYDIS ZYPREXA Index Page 8 of 60

9 ABILIFY DISCMELT ABILIFY DISCMELT 10 MG TABLET - Limited to a quantity of 102 per 34 days. ABILIFY DISCMELT 15 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY ABILIFY 10 MG TABLET - Limited to a quantity of 102 per 34 days. ABILIFY 15 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY 2 MG TABLET - Limited to a quantity of 510 per 34 days. ABILIFY 20 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY 30 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 5 MG TABLET - Limited to a quantity of 204 per 34 days. ABSTRAL ABSTRAL 100 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days. ABSTRAL 200 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days. ABSTRAL 300 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days. ABSTRAL 400 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days. ABSTRAL 600 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days. ABSTRAL 800 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days. acarbose acarbose 100 mg tablet - Limited to a quantity of 102 per 34 days. acarbose 25 mg tablet - Limited to a quantity of 408 per 34 days. acarbose 50 mg tablet - Limited to a quantity of 204 per 34 days. ACTIQ ACTIQ 1,200 MCG LOZENGE - Limited to a quantity of 120 per 30 days. ACTIQ 1,600 MCG LOZENGE - Limited to a quantity of 120 per 30 days. ACTIQ 200 MCG LOZENGE - Limited to a quantity of 120 per 30 days. ACTIQ 400 MCG LOZENGE - Limited to a quantity of 120 per 30 days. ACTIQ 600 MCG LOZENGE - Limited to a quantity of 120 per 30 days. ACTIQ 800 MCG LOZENGE - Limited to a quantity of 120 per 30 days. ACTONEL ACTONEL 150 MG TABLET - Limited to a quantity of 1 per 34 days. ACTONEL 30 MG TABLET - Limited to a quantity of 34 per 34 days. Page 9 of 60

10 ACTONEL 35 MG TABLET - Limited to a quantity of 5 per 35 days. ACTONEL 5 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOPLUS MET XR ACTOPLUS MET XR 15-1,000 MG TB - Limited to a quantity of 68 per 34 days. ACTOPLUS MET XR 30-1,000 MG TB - Limited to a quantity of 34 per 34 days. ACTOPLUS MET ACTOPLUS MET 15 MG-500 MG TAB - Limited to a quantity of 102 per 34 days. ACTOPLUS MET 15 MG-850 MG TAB - Limited to a quantity of 102 per 34 days. ACTOS ACTOS 15 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOS 30 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOS 45 MG TABLET - Limited to a quantity of 34 per 34 days. ADCIRCA ADCIRCA 20 MG TABLET - Limited to a quantity of 68 per 34 days. ADVAIR DISKUS ADVAIR DISKUS - Limited to a quantity of 120 doses per 30 days. ADVAIR DISKUS - Limited to a quantity of 120 doses per 30 days. ADVAIR DISKUS - Limited to a quantity of 120 doses per 30 days. ADVAIR HFA ADVAIR HFA MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVICOR ADVICOR 1,000 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days. ADVICOR 1,000 MG-40 MG TABLET - Limited to a quantity of 68 per 34 days. ADVICOR 500 MG-20 MG TABLET - Limited to a quantity of 34 per 34 days. ADVICOR 750 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days. Page 10 of 60

11 alendronate alendronate sodium 10 mg tab - Limited to a quantity of 34 per 34 days. alendronate sodium 35 mg tab - Limited to a quantity of 5 per 35 days. alendronate sodium 40 mg tab - Limited to a quantity of 34 per 34 days. alendronate sodium 5 mg tablet - Limited to a quantity of 34 per 34 days. alendronate sodium 70 mg tab - Limited to a quantity of 5 per 35 days. ALORA ALORA MG PATCH - Limited to a quantity of 10 per 35 days. ALORA 0.05 MG PATCH - Limited to a quantity of 10 per 35 days. ALORA MG PATCH - Limited to a quantity of 10 per 35 days. ALORA 0.1 MG PATCH - Limited to a quantity of 10 per 35 days. ALOXI ALOXI 0.25 MG/5 ML VIAL - Limited to a quantity of 10 per 30 days. ALSUMA ALSUMA 6 MG/0.5 ML AUTO-INJECT - Limited to a quantity of 16 per 28 days. ALTOPREV ALTOPREV 20 MG TABLET - Limited to a quantity of 34 per 34 days. ALTOPREV 40 MG TABLET - Limited to a quantity of 34 per 34 days. ALTOPREV 60 MG TABLET - Limited to a quantity of 34 per 34 days. ALVESCO ALVESCO 160 MCG INHALER - Limited to a quantity of 18 gm per 34 days. ALVESCO 80 MCG INHALER - Limited to a quantity of 12 gm per 34 days. AMARYL AMARYL 1 MG TABLET - Limited to a quantity of 272 per 34 days. AMARYL 2 MG TABLET - Limited to a quantity of 136 per 34 days. AMARYL 4 MG TABLET - Limited to a quantity of 68 per 34 days. AMBIEN CR AMBIEN CR 12.5 MG TABLET - Limited to a quantity of 34 per 34 days. AMBIEN CR 6.25 MG TABLET - Limited to a quantity of 34 per 34 days. Page 11 of 60

12 AMBIEN AMBIEN 10 MG TABLET - Limited to a quantity of 34 per 34 days. AMBIEN 5 MG TABLET - Limited to a quantity of 34 per 34 days. AMERGE AMERGE 1 MG TABLET - Limited to a quantity of 18 per 28 days. AMERGE 2.5 MG TABLET - Limited to a quantity of 18 per 28 days. ANZEMET ANZEMET 100 MG TABLET - Limited to a quantity of 1 per 1 day. ANZEMET 50 MG TABLET - Limited to a quantity of 1 per 1 day. APLENZIN APLENZIN ER 174 MG TABLET - Limited to a quantity of 102 per 34 days. APLENZIN ER 348 MG TABLET - Limited to a quantity of 68 per 34 days. APLENZIN ER 522 MG TABLET - Limited to a quantity of 34 per 34 days. ARAVA ARAVA 10 MG TABLET - Limited to a quantity of 34 per 34 days. ARAVA 20 MG TABLET - Limited to a quantity of 34 per 34 days. ARCAPTA NEOHALER ARCAPTA NEOHALER 75 MCG CAP - Limited to a quantity of 60 per 34 days. ASMANEX ASMANEX TWISTHALER 110 MCG #30 - Limited to a quantity of 60 doses per 30 days. ASMANEX TWISTHALER 220 MCG #14 - Limited to a quantity of 14 doses per 14 days. ASMANEX TWISTHALER 220 MCG #30 - Limited to a quantity of 60 doses per 30 days. ASMANEX TWISTHALER 220 MCG #60 - Limited to a quantity of 120 doses per 30 days. ASMANEX TWISTHALR 220 MCG #120 - Limited to a quantity of 240 doses per 30 days. Page 12 of 60

13 ASTELIN ASTELIN 137 MCG NASAL SPRAY - Limited to a quantity of 60 ml per 34 days. ASTEPRO ASTEPRO 0.15% NASAL SPRAY - Limited to a quantity of 60 ml per 34 days. ATELVIA ATELVIA DR 35 MG TABLET - Limited to a quantity of 5 per 35 days. atorvastatin calcium atorvastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. atorvastatin 20 mg tablet - Limited to a quantity of 34 per 34 days. atorvastatin 40 mg tablet - Limited to a quantity of 34 per 34 days. atorvastatin 80 mg tablet - Limited to a quantity of 34 per 34 days. ATROVENT HFA ATROVENT HFA INHALER - Limited to a quantity of 26 gm per 34 days. ATROVENT ATROVENT 0.03% SPRAY - Limited to a quantity of 60 ml per 34 days. ATROVENT 0.06% SPRAY - Limited to a quantity of 30 ml per 34 days. AVANDAMET AVANDAMET 2 MG-1,000 MG TAB - Limited to a quantity of 68 per 34 days. AVANDAMET 2 MG-500 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDAMET 4 MG-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDAMET 4 MG-500 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDARYL AVANDARYL 4 MG-1 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 4 MG-2 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 4 MG-4 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 8 MG-2 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 8 MG-4 MG TABLET - Limited to a quantity of 34 per 34 days. Page 13 of 60

14 AVANDIA AVANDIA 2 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDIA 4 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDIA 8 MG TABLET - Limited to a quantity of 34 per 34 days. AVINZA AVINZA 120 MG CAPSULE - Limited to a quantity of 60 per 30 days. AVINZA 30 MG CAPSULE - Limited to a quantity of 60 per 30 days. AVINZA 45 MG CAPSULE - Limited to a quantity of 60 per 30 days. AVINZA 60 MG CAPSULE - Limited to a quantity of 60 per 30 days. AVINZA 75 MG CAPSULE - Limited to a quantity of 60 per 30 days. AVINZA 90 MG CAPSULE - Limited to a quantity of 60 per 30 days. AVONEX ADMINISTRATION PACK AVONEX ADMIN PACK 30 MCG VL - Limited to a quantity of 4 kits per 28 days. AVONEX AVONEX PREFILLED SYR 30 MCG - Limited to a quantity of 4 kits per 28 days. AXERT AXERT 12.5 MG TABLET - Limited to a quantity of 24 per 28 days. AXERT 6.25 MG TABLET - Limited to a quantity of 18 per 28 days. azelastine hcl azelastine 137 mcg nasal spray - Limited to a quantity of 60 ml per 34 days. BECONASE AQ BECONASE AQ 0.042% SPRAY - Limited to a quantity of 50 per 34 days. BETASERON BETASERON 0.3 MG KIT - Limited to a quantity of 15 per 30 days. BONIVA BONIVA 150 MG TABLET - Limited to a quantity of 1 per 30 days. Page 14 of 60

15 bupropion budeprion sr 100 mg tablet - Limited to a quantity of 136 per 34 days. budeprion sr 150 mg tablet - Limited to a quantity of 102 per 34 days. bupropion hcl sr 100 mg tablet - Limited to a quantity of 136 per 34 days. bupropion hcl sr 200 mg tab - Limited to a quantity of 68 per 34 days. bupropion sr 150 mg tablet - Limited to a quantity of 102 per 34 days. butorphanol butorphanol 10 mg/ml spray - Limited to a quantity of 5 ml per 3 days. BYDUREON BYDUREON 2 MG VIAL - Limited to a quantity of 4 per 28 days. BYETTA BYETTA 10 MCG DOSE PEN INJ - Limited to a quantity of 5 ml per 34 days. BYETTA 5 MCG DOSE PEN INJ - Limited to a quantity of 2 ml per 34 days. cabergoline cabergoline 0.5 mg tablet - Limited to a quantity of 20 per 34 days. CADUET CADUET 10 MG-10 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 10 MG-20 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 10 MG-40 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 10 MG-80 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 2.5 MG-10 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 2.5 MG-20 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 2.5 MG-40 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 5 MG-10 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 5 MG-20 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 5 MG-40 MG TABLET - Limited to a quantity of 34 per 34 days. CADUET 5 MG-80 MG TABLET - Limited to a quantity of 34 per 34 days. CAMBIA CAMBIA 50 MG POWDER PACKET - Limited to a quantity of 9 packets per 28 days. Page 15 of 60

16 CARDURA XL CARDURA XL 4 MG TABLET - Limited to a quantity of 34 per 34 days. CARDURA XL 8 MG TABLET - Limited to a quantity of 34 per 34 days. CARDURA CARDURA 1 MG TABLET - Limited to a quantity of 34 per 34 days. CARDURA 2 MG TABLET - Limited to a quantity of 34 per 34 days. CARDURA 4 MG TABLET - Limited to a quantity of 34 per 34 days. CARDURA 8 MG TABLET - Limited to a quantity of 68 per 34 days. CATAPRES-TTS 1 CATAPRES-TTS 1 PATCH - Limited to a quantity of 5 per 35 days. CATAPRES-TTS 2 CATAPRES-TTS 2 PATCH - Limited to a quantity of 5 per 35 days. CATAPRES-TTS 3 CATAPRES-TTS 3 PATCH - Limited to a quantity of 5 per 35 days. CAYSTON CAYSTON 75 MG INHAL SOLUTION - Limited to a quantity of 84 per 28 days. CELEXA CELEXA 10 MG TABLET - Limited to a quantity of 136 per 34 days. CELEXA 20 MG TABLET - Limited to a quantity of 68 per 34 days. CELEXA 40 MG TABLET - Limited to a quantity of 34 per 34 days. CESAMET CESAMET 1 MG CAPSULE - Limited to a quantity of 30 per 5 days. citalopram citalopram hbr 10 mg tablet - Limited to a quantity of 136 per 34 days. citalopram hbr 20 mg tablet - Limited to a quantity of 68 per 34 days. citalopram hbr 40 mg tablet - Limited to a quantity of 34 per 34 days. Page 16 of 60

17 CLARINEX CLARINEX 2.5 MG REDITABS - Limited to a quantity of 34 per 34 days. CLARINEX 5 MG REDITABS - Limited to a quantity of 34 per 34 days. CLARINEX 5 MG TABLET - Limited to a quantity of 34 per 34 days. CLARINEX-D 12 HOUR CLARINEX-D 12 HOUR TABLET - Limited to a quantity of 68 per 34 days. CLARINEX-D 24 HOUR CLARINEX-D 24 HOUR TABLET - Limited to a quantity of 34 per 34 days. CLIMARA PRO CLIMARA PRO PATCH - Limited to a quantity of 5 per 35 days. CLIMARA CLIMARA MG/DAY PATCH - Limited to a quantity of 5 per 35 days. CLIMARA MG/DAY PATCH - Limited to a quantity of 5 per 35 days. CLIMARA 0.05 MG/DAY PATCH - Limited to a quantity of 5 per 35 days. CLIMARA 0.06/MG DAY PATCH - Limited to a quantity of 5 per 35 days. CLIMARA MG/DAY PATCH - Limited to a quantity of 5 per 35 days. CLIMARA 0.1 MG/DAY PATCH - Limited to a quantity of 5 per 35 days. clonidine clonidine 0.1 mg/day patch - Limited to a quantity of 5 per 35 days. clonidine 0.2 mg/day patch - Limited to a quantity of 5 per 35 days. clonidine 0.3 mg/day patch - Limited to a quantity of 5 per 35 days. COMBIVENT RESPIMAT COMBIVENT RESPIMAT INHAL SPRAY - Limited to a quantity of 8 gm per 34 days. COMBIVENT COMBIVENT INHALER - Limited to a quantity of 44 gm per 34 days. CONZIP CONZIP 100 MG CAPSULE - Limited to a quantity of 34 per 34 days. CONZIP 200 MG CAPSULE - Limited to a quantity of 34 per 34 days. Page 17 of 60

18 CONZIP 300 MG CAPSULE - Limited to a quantity of 34 per 34 days. COPAXONE COPAXONE 20 MG INJECTION KIT - Limited to a quantity of 30 per 30 days. CORDRAN CORDRAN 4 MCG/SQ CM TAPE - Limited to a quantity of 900 square cm per 34 days. CRESTOR CRESTOR 10 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 20 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 40 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 5 MG TABLET - Limited to a quantity of 34 per 34 days. CYCLOSET CYCLOSET 0.8 MG TABLET - Limited to a quantity of 204 per 34 days. CYMBALTA CYMBALTA 20 MG CAPSULE - Limited to a quantity of 204 per 34 days. CYMBALTA 30 MG CAPSULE - Limited to a quantity of 136 per 34 days. CYMBALTA 60 MG CAPSULE - Limited to a quantity of 68 per 34 days. DEPO-PROVERA DEPO-PROVERA 150 MG/ML VIAL - Limited to a quantity of 1 per 90 days. DEPO-SUBQ PROVERA 104 DEPO-SUBQ PROVERA 104 SYRINGE - Limited to a quantity of 1 per 90 days. desloratadine desloratadine 5 mg tablet - Limited to a quantity of 34 per 34 days. DEXILANT DEXILANT DR 30 MG CAPSULE - Limited to a quantity of 34 per 34 days. Page 18 of 60

19 DIABETA DIABETA 1.25 MG TABLET - Limited to a quantity of 544 per 34 days. DIABETA 2.5 MG TABLET - Limited to a quantity of 272 per 34 days. DIABETA 5 MG TABLET - Limited to a quantity of 136 per 34 days. DIFLUCAN DIFLUCAN 150 MG TABLET - Limited to a quantity of 2 per 7 days. DITROPAN XL DITROPAN XL 5 MG TABLET - Limited to a quantity of 34 per 34 days. DIVIGEL DIVIGEL 1 MG GEL PACKET - Limited to a quantity of 34 per 34 days. doxazosin doxazosin mesylate 1 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 2 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 4 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 8 mg tab - Limited to a quantity of 68 per 34 days. DUETACT DUETACT 30-2 MG TABLET - Limited to a quantity of 34 per 34 days. DUETACT 30-4 MG TABLET - Limited to a quantity of 34 per 34 days. DULERA DULERA 100 MCG/5 MCG INHALER - Limited to a quantity of 26 gm per 34 days. DULERA 200 MCG/5 MCG INHALER - Limited to a quantity of 26 gm per 34 days. DYMISTA DYMISTA NASAL SPRAY - Limited to a quantity of 46 per 34 days. EDLUAR EDLUAR 10 MG SL TABLET - Limited to a quantity of 34 per 34 days. EDLUAR 5 MG SL TABLET - Limited to a quantity of 34 per 34 days. Page 19 of 60

20 EFFEXOR XR EFFEXOR XR 150 MG CAPSULE - Limited to a quantity of 68 per 34 days. EFFEXOR XR 37.5 MG CAPSULE - Limited to a quantity of 204 per 34 days. EFFEXOR XR 75 MG CAPSULE - Limited to a quantity of 102 per 34 days. ELESTRIN ELESTRIN 0.06% GEL - Limited to a quantity of 144 gm per 34 days. ELLA ELLA 30 MG TABLET - Limited to a quantity of 1 per 1 day. EMEND EMEND 125 MG CAPSULE - Limited to a quantity of 1 per 1 day. EMEND 40 MG CAPSULE - Limited to a quantity of 1 per 1 day. EMEND 80 MG CAPSULE - Limited to a quantity of 2 per 2 days. EMEND TRIFOLD PACK - Limited to a quantity of 3 per 3 days. ENBREL ENBREL 25 MG KIT - Limited to a quantity of 10 per 35 days. ENBREL 25 MG/0.5 ML SYRINGE - Limited to a quantity of 10 per 35 days. ENBREL 50 MG/ML SYRINGE - Limited to a quantity of 10 per 35 days. EPIPEN 2-PAK EPIPEN 2-PAK 0.3 MG AUTO-INJCT - Limited to a quantity of 4 pens per 2 days. EPIPEN JR 2-PAK EPIPEN JR 2-PAK 0.15 MG INJCTR - Limited to a quantity of 4 pens per 2 days. escitalopram oxalate escitalopram 10 mg tablet - Limited to a quantity of 68 per 34 days. escitalopram 20 mg tablet - Limited to a quantity of 34 per 34 days. escitalopram 5 mg tablet - Limited to a quantity of 136 per 34 days. estradiol estradiol tds mg/day - Limited to a quantity of 5 per 35 days. estradiol tds mg/day - Limited to a quantity of 5 per 35 days. Page 20 of 60

21 estradiol tds 0.05 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.06 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.1 mg/day - Limited to a quantity of 5 per 35 days. EVAMIST EVAMIST 1.53 MG/SPRAY - Limited to a quantity of 16 ml per 34 days. EXALGO EXALGO ER 12 MG TABLET - Limited to a quantity of 60 per 30 days. EXALGO ER 16 MG TABLET - Limited to a quantity of 60 per 30 days. EXALGO ER 8 MG TABLET - Limited to a quantity of 60 per 30 days. EXTAVIA EXTAVIA 0.3 MG KIT - Limited to a quantity of 15 trays per 30 days. FACTIVE FACTIVE 320 MG TABLET - Limited to a quantity of 7 per 7 days. famciclovir famciclovir 125 mg tablet - Limited to a quantity of 21 per 10 days. famciclovir 250 mg tablet - Limited to a quantity of 68 per 34 days. famciclovir 500 mg tablet - Limited to a quantity of 21 per 7 days. FAMVIR FAMVIR 125 MG TABLET - Limited to a quantity of 21 per 10 days. FAMVIR 250 MG TABLET - Limited to a quantity of 68 per 34 days. FAMVIR 500 MG TABLET - Limited to a quantity of 21 per 7 days. FANAPT FANAPT 1 MG TABLET - Limited to a quantity of 816 per 34 days. FANAPT 10 MG TABLET - Limited to a quantity of 102 per 34 days. FANAPT 12 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 2 MG TABLET - Limited to a quantity of 408 per 34 days. FANAPT 4 MG TABLET - Limited to a quantity of 204 per 34 days. FANAPT 6 MG TABLET - Limited to a quantity of 136 per 34 days. FANAPT 8 MG TABLET - Limited to a quantity of 102 per 34 days. FANAPT TITRATION PACK - Limited to a quantity of 1 per 34 days. Page 21 of 60

22 fentanyl citrate fentanyl cit otfc 1,200 mcg - Limited to a quantity of 120 per 30 days. fentanyl cit otfc 1,600 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 200 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 400 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 600 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 800 mcg - Limited to a quantity of 120 per 30 days. FENTORA FENTORA 100 MCG BUCCAL TABLET - Limited to a quantity of 112 per 28 days. FENTORA 200 MCG BUCCAL TABLET - Limited to a quantity of 112 per 28 days. FENTORA 400 MCG BUCCAL TABLET - Limited to a quantity of 112 per 28 days. FENTORA 600 MCG BUCCAL TABLET - Limited to a quantity of 112 per 28 days. FENTORA 800 MCG BUCCAL TABLET - Limited to a quantity of 112 per 28 days. FLECTOR FLECTOR 1.3% PATCH - Limited to a quantity of 70 per 35 days. FLONASE FLONASE 0.05% NASAL SPRAY - Limited to a quantity of 32 gm per 34 days. FLOVENT DISKUS FLOVENT 100 MCG DISKUS - Limited to a quantity of 120 doses per 30 days. FLOVENT 250 MCG DISKUS - Limited to a quantity of 300 doses per 30 days. FLOVENT 50 MCG DISKUS - Limited to a quantity of 120 doses per 30 days. FLOVENT HFA FLOVENT HFA 110 MCG INHALER - Limited to a quantity of 12 gm per 34 days. FLOVENT HFA 220 MCG INHALER - Limited to a quantity of 36 gm per 34 days. FLOVENT HFA 44 MCG INHALER - Limited to a quantity of 21 gm per 34 days. fluconazole fluconazole 150 mg tablet - Limited to a quantity of 2 per 7 days. Page 22 of 60

23 flunisolide flunisolide 0.025% spray - Limited to a quantity of 75 ml per 34 days. fluoxetine fluoxetine dr 90 mg capsule - Limited to a quantity of 5 per 34 days. fluoxetine hcl 10 mg capsule - Limited to a quantity of 272 per 34 days. fluoxetine hcl 10 mg tablet - Limited to a quantity of 272 per 34 days. fluoxetine hcl 40 mg capsule - Limited to a quantity of 68 per 34 days. fluticasone propionate fluticasone prop 50 mcg spray - Limited to a quantity of 32 gm per 34 days. fluvastatin fluvastatin sodium 20 mg cap - Limited to a quantity of 34 per 34 days. fluvastatin sodium 40 mg cap - Limited to a quantity of 68 per 34 days. fluvoxamine fluvoxamine maleate 100 mg tab - Limited to a quantity of 102 per 34 days. fluvoxamine maleate 25 mg tab - Limited to a quantity of 408 per 34 days. fluvoxamine maleate 50 mg tab - Limited to a quantity of 204 per 34 days. FORADIL FORADIL AEROLIZER 12 MCG CAP - Limited to a quantity of 120 per 34 days. FORFIVO XL FORFIVO XL 450 MG TABLET - Limited to a quantity of 34 per 34 days. FORTAMET FORTAMET ER 1,000 MG TABLET - Limited to a quantity of 85 per 34 days. FORTAMET ER 500 MG TABLET - Limited to a quantity of 170 per 34 days. FORTEO FORTEO 600 MCG/2.4 ML PEN INJ - Limited to a quantity of 3 pens per 28 days. Page 23 of 60

24 FOSAMAX PLUS D FOSAMAX PLUS D 70 MG-2,800 IU - Limited to a quantity of 5 per 35 days. FOSAMAX PLUS D 70 MG-5,600 IU - Limited to a quantity of 5 per 35 days. FOSAMAX FOSAMAX 70 MG TABLET - Limited to a quantity of 5 per 35 days. FROVA FROVA 2.5 MG TABLET - Limited to a quantity of 27 per 28 days. GELNIQUE GELNIQUE 10% GEL SACHETS - Limited to a quantity of 34 per 34 days. GEODON GEODON 20 MG CAPSULE - Limited to a quantity of 272 per 34 days. GEODON 40 MG CAPSULE - Limited to a quantity of 136 per 34 days. GEODON 60 MG CAPSULE - Limited to a quantity of 91 per 34 days. GEODON 80 MG CAPSULE - Limited to a quantity of 68 per 34 days. glimepiride glimepiride 1 mg tablet - Limited to a quantity of 272 per 34 days. glimepiride 2 mg tablet - Limited to a quantity of 136 per 34 days. glimepiride 4 mg tablet - Limited to a quantity of 68 per 34 days. glipizide glipizide 10 mg tablet - Limited to a quantity of 136 per 34 days. glipizide 5 mg tablet - Limited to a quantity of 272 per 34 days. glipizide er 10 mg tablet - Limited to a quantity of 68 per 34 days. glipizide er 2.5 mg tablet - Limited to a quantity of 272 per 34 days. glipizide er 5 mg tablet - Limited to a quantity of 136 per 34 days. glipizide/metformin hcl glipizide-metformin mg - Limited to a quantity of 272 per 34 days. glipizide-metformin mg - Limited to a quantity of 136 per 34 days. glipizide-metformin mg - Limited to a quantity of 136 per 34 days. Page 24 of 60

25 GLUCOPHAGE XR GLUCOPHAGE XR 500 MG TAB - Limited to a quantity of 136 per 34 days. GLUCOPHAGE XR 750 MG TAB - Limited to a quantity of 85 per 34 days. GLUCOPHAGE GLUCOPHAGE 1,000 MG TABLET - Limited to a quantity of 85 per 34 days. GLUCOPHAGE 500 MG TABLET - Limited to a quantity of 170 per 34 days. GLUCOPHAGE 850 MG TABLET - Limited to a quantity of 102 per 34 days. GLUCOTROL XL GLUCOTROL XL 10 MG TABLET - Limited to a quantity of 68 per 34 days. GLUCOTROL XL 2.5 MG TABLET - Limited to a quantity of 272 per 34 days. GLUCOTROL XL 5 MG TABLET - Limited to a quantity of 136 per 34 days. GLUCOTROL GLUCOTROL 10 MG TABLET - Limited to a quantity of 136 per 34 days. GLUCOTROL 5 MG TABLET - Limited to a quantity of 272 per 34 days. GLUCOVANCE GLUCOVANCE MG TABLET - Limited to a quantity of 136 per 34 days. GLUCOVANCE MG TABLET - Limited to a quantity of 136 per 34 days. GLUMETZA GLUMETZA ER 1,000 MG TABLET - Limited to a quantity of 68 per 34 days. GLUMETZA ER 500 MG TABLET - Limited to a quantity of 136 per 34 days. glyburide glyburide 1.25 mg tablet - Limited to a quantity of 544 per 34 days. glyburide 2.5 mg tablet - Limited to a quantity of 272 per 34 days. glyburide 5 mg tablet - Limited to a quantity of 136 per 34 days. glyburide micro 1.5 mg tab - Limited to a quantity of 272 per 34 days. glyburide micro 3 mg tablet - Limited to a quantity of 136 per 34 days. glyburide micro 6 mg tablet - Limited to a quantity of 68 per 34 days. glyburide/metformin hcl glyburide-metformin mg - Limited to a quantity of 136 per 34 days. glyburide-metformin mg - Limited to a quantity of 136 per 34 days. Page 25 of 60

26 glyburid-metformin mg - Limited to a quantity of 272 per 34 days. GLYNASE GLYNASE 1.5 MG PRESTAB - Limited to a quantity of 272 per 34 days. GLYNASE 3 MG PRESTAB - Limited to a quantity of 136 per 34 days. GLYNASE 6 MG PRESTAB - Limited to a quantity of 68 per 34 days. GLYSET GLYSET 100 MG TABLET - Limited to a quantity of 102 per 34 days. GLYSET 25 MG TABLET - Limited to a quantity of 408 per 34 days. GLYSET 50 MG TABLET - Limited to a quantity of 204 per 34 days. granisetron granisetron hcl 1 mg tablet - Limited to a quantity of 2 per 1 day. granisol 2 mg/10 ml solution - Limited to a quantity of 30 ml per 3 days. HUMIRA HUMIRA 20 MG/0.4 ML SYRINGE - Limited to a quantity of 5 syringes per 35 days. HUMIRA 40 MG/0.8 ML SYRINGE - Limited to a quantity of 5 syringes per 35 days. HUMIRA CROHN'S STARTER PACK - Limited to a quantity of 6 syringes per 180 days. ibandronate ibandronate sodium 150 mg tab - Limited to a quantity of 1 per 30 days. IMITREX IMITREX 100 MG TABLET - Limited to a quantity of 18 per 28 days. IMITREX 20 MG NASAL SPRAY - Limited to a quantity of 18 nasal sprayers per 28 days. IMITREX 25 MG TABLET - Limited to a quantity of 18 per 28 days. IMITREX 4 MG/0.5 ML CARTRIDGES - Limited to a quantity of 16 vials per 28 days. IMITREX 5 MG NASAL SPRAY - Limited to a quantity of 36 nasal sprayers per 28 days. IMITREX 50 MG TABLET - Limited to a quantity of 18 per 28 days. IMITREX 6 MG/0.5 ML CARTRIDGES - Limited to a quantity of 16 vials per 28 days. IMITREX 6 MG/0.5 ML VIAL - Limited to a quantity of 16 vials per 28 days. Page 26 of 60

27 INTERMEZZO INTERMEZZO 1.75 MG TAB SUBLING - Limited to a quantity of 34 per 34 days. INTERMEZZO 3.5 MG TAB SUBLING - Limited to a quantity of 34 per 34 days. INVEGA INVEGA ER 1.5 MG TABLET - Limited to a quantity of 272 per 34 days. INVEGA ER 3 MG TABLET - Limited to a quantity of 136 per 34 days. INVEGA ER 6 MG TABLET - Limited to a quantity of 68 per 34 days. INVEGA ER 9 MG TABLET - Limited to a quantity of 46 per 34 days. ipratropium ipratropium 0.03% spray - Limited to a quantity of 60 ml per 34 days. ipratropium 0.06% spray - Limited to a quantity of 30 ml per 34 days. itraconazole itraconazole 100 mg capsule - Limited to a quantity of 136 per 34 days. JANUMET XR JANUMET XR 100-1,000 MG TABLET - Limited to a quantity of 34 per 34 days. JANUMET XR 50-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. JANUMET XR MG TABLET - Limited to a quantity of 34 per 34 days. JANUMET JANUMET 50-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. JANUMET MG TABLET - Limited to a quantity of 68 per 34 days. JANUVIA JANUVIA 100 MG TABLET - Limited to a quantity of 34 per 34 days. JANUVIA 25 MG TABLET - Limited to a quantity of 34 per 34 days. JANUVIA 50 MG TABLET - Limited to a quantity of 34 per 34 days. JENTADUETO JENTADUETO 2.5 MG-1000 MG TAB - Limited to a quantity of 68 per 34 days. JENTADUETO 2.5 MG-500 MG TAB - Limited to a quantity of 68 per 34 days. JENTADUETO 2.5 MG-850 MG TAB - Limited to a quantity of 68 per 34 days. Page 27 of 60

28 JUVISYNC JUVISYNC MG TABLET - Limited to a quantity of 34 per 34 days. JUVISYNC MG TABLET - Limited to a quantity of 34 per 34 days. JUVISYNC MG TABLET - Limited to a quantity of 34 per 34 days. KADIAN KADIAN ER 10 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 100 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 20 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 200 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 30 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 50 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 60 MG CAPSULE - Limited to a quantity of 90 per 30 days. KADIAN ER 80 MG CAPSULE - Limited to a quantity of 90 per 30 days. ketorolac ketorolac 10 mg tablet - Limited to a quantity of 20 per 5 days. KOMBIGLYZE XR KOMBIGLYZE XR 2.5-1,000 MG TAB - Limited to a quantity of 68 per 34 days. KOMBIGLYZE XR 5-1,000 MG TAB - Limited to a quantity of 34 per 34 days. KOMBIGLYZE XR MG TABLET - Limited to a quantity of 34 per 34 days. lansoprazole lansoprazole dr 15 mg capsule - Limited to a quantity of 34 per 34 days. LATUDA LATUDA 20 MG TABLET - Limited to a quantity of 34 per 34 days. LATUDA 40 MG TABLET - Limited to a quantity of 68 per 34 days. LATUDA 80 MG TABLET - Limited to a quantity of 34 per 34 days. LAZANDA LAZANDA 100 MCG NASAL SPRAY - Limited to a quantity of 23 bottles per 30 days. LAZANDA 400 MCG NASAL SPRAY - Limited to a quantity of 23 bottles per 30 days. Page 28 of 60

29 leflunomide leflunomide 10 mg tablet - Limited to a quantity of 34 per 34 days. leflunomide 20 mg tablet - Limited to a quantity of 34 per 34 days. LESCOL XL LESCOL XL 80 MG TABLET - Limited to a quantity of 34 per 34 days. LESCOL LESCOL 20 MG CAPSULE - Limited to a quantity of 34 per 34 days. LESCOL 40 MG CAPSULE - Limited to a quantity of 68 per 34 days. levocetirizine dihydrochlor levocetirizine 5 mg tablet - Limited to a quantity of 34 per 34 days. levonorgestrel next choice 0.75 mg tablet - Limited to a quantity of 2 per 1 day. LEXAPRO LEXAPRO 10 MG TABLET - Limited to a quantity of 68 per 34 days. LEXAPRO 20 MG TABLET - Limited to a quantity of 34 per 34 days. LEXAPRO 5 MG TABLET - Limited to a quantity of 136 per 34 days. LIPITOR LIPITOR 10 MG TABLET - Limited to a quantity of 34 per 34 days. LIPITOR 20 MG TABLET - Limited to a quantity of 34 per 34 days. LIPITOR 40 MG TABLET - Limited to a quantity of 34 per 34 days. LIPITOR 80 MG TABLET - Limited to a quantity of 34 per 34 days. LIVALO LIVALO 1 MG TABLET - Limited to a quantity of 34 per 34 days. LIVALO 2 MG TABLET - Limited to a quantity of 34 per 34 days. LIVALO 4 MG TABLET - Limited to a quantity of 34 per 34 days. lovastatin lovastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. lovastatin 20 mg tablet - Limited to a quantity of 68 per 34 days. Page 29 of 60

30 lovastatin 40 mg tablet - Limited to a quantity of 68 per 34 days. LUNESTA LUNESTA 1 MG TABLET - Limited to a quantity of 34 per 34 days. LUNESTA 2 MG TABLET - Limited to a quantity of 34 per 34 days. LUNESTA 3 MG TABLET - Limited to a quantity of 34 per 34 days. LUVOX CR LUVOX CR 100 MG CAPSULE - Limited to a quantity of 102 per 34 days. LUVOX CR 150 MG CAPSULE - Limited to a quantity of 68 per 34 days. MAXAIR AUTOHALER MAXAIR AUTOHALER 0.2 MG AERO - Limited to a quantity of 28 per 34 days. MAXALT MLT MAXALT MLT 10 MG TABLET - Limited to a quantity of 36 per 28 days. MAXALT MLT 5 MG TABLET - Limited to a quantity of 36 per 28 days. MAXALT MAXALT 10 MG TABLET - Limited to a quantity of 36 per 28 days. MAXALT 5 MG TABLET - Limited to a quantity of 36 per 28 days. medroxyprogesterone medroxyprogesterone 150 mg/ml - Limited to a quantity of 1 per 90 days. meloxicam meloxicam 7.5 mg tablet - Limited to a quantity of 34 per 34 days. MENOSTAR MENOSTAR 14 MCG/DAY PATCH - Limited to a quantity of 5 per 35 days. metformin metformin hcl 1,000 mg tablet - Limited to a quantity of 85 per 34 days. metformin hcl 500 mg tablet - Limited to a quantity of 170 per 34 days. metformin hcl 850 mg tablet - Limited to a quantity of 102 per 34 days. Page 30 of 60

31 metformin hcl er 500 mg tablet - Limited to a quantity of 136 per 34 days. metformin hcl er 750 mg tablet - Limited to a quantity of 85 per 34 days. MEVACOR MEVACOR 20 MG TABLET - Limited to a quantity of 68 per 34 days. MEVACOR 40 MG TABLET - Limited to a quantity of 68 per 34 days. miconazole nitrate miconazole mg vag supp - Limited to a quantity of 3 per 3 days. MIGRANAL MIGRANAL NASAL SPRAY - Limited to a quantity of 8 devices per 28 days. MOBIC MOBIC 7.5 MG TABLET - Limited to a quantity of 34 per 34 days. morphine morphine sulf er 100 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 15 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 200 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 30 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 60 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulfate er 100 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 20 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 30 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 50 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 60 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 80 mg cap - Limited to a quantity of 90 per 30 days. MS CONTIN MS CONTIN 100 MG TABLET - Limited to a quantity of 120 per 30 days. MS CONTIN 15 MG TABLET - Limited to a quantity of 120 per 30 days. MS CONTIN 200 MG TABLET - Limited to a quantity of 120 per 30 days. MS CONTIN 60 MG TABLET - Limited to a quantity of 120 per 30 days. MS CONTIN CR 30 MG TABLET - Limited to a quantity of 120 per 30 days. naratriptan naratriptan hcl 1 mg tablet - Limited to a quantity of 18 per 28 days. Page 31 of 60

32 naratriptan hcl 2.5 mg tablet - Limited to a quantity of 18 per 28 days. NASACORT AQ NASACORT AQ NASAL SPRAY - Limited to a quantity of 33 per 34 days. NASONEX NASONEX 50 MCG NASAL SPRAY - Limited to a quantity of 51 gm per 34 days. nateglinide nateglinide 120 mg tablet - Limited to a quantity of 102 per 34 days. nateglinide 60 mg tablet - Limited to a quantity of 204 per 34 days. NEULASTA NEULASTA 6 MG/0.6 ML SYRINGE - Limited to a quantity of 2 syringes per 30 days. NEUMEGA NEUMEGA 5 MG VIAL - Limited to a quantity of 21 vials per 21 days. NEXIUM NEXIUM DR 10 MG PACKET - Limited to a quantity of 34 per 34 days. NEXIUM DR 20 MG CAPSULE - Limited to a quantity of 34 per 34 days. NEXIUM DR 20 MG PACKET - Limited to a quantity of 34 per 34 days. NUCYNTA ER NUCYNTA ER 100 MG TABLET - Limited to a quantity of 60 per 30 days. NUCYNTA ER 150 MG TABLET - Limited to a quantity of 60 per 30 days. NUCYNTA ER 200 MG TABLET - Limited to a quantity of 60 per 30 days. NUCYNTA ER 250 MG TABLET - Limited to a quantity of 60 per 30 days. NUCYNTA ER 50 MG TABLET - Limited to a quantity of 60 per 30 days. NUCYNTA NUCYNTA 100 MG TABLET - Limited to a quantity of 205 per 34 days. NUCYNTA 50 MG TABLET - Limited to a quantity of 205 per 34 days. NUCYNTA 75 MG TABLET - Limited to a quantity of 205 per 34 days. Page 32 of 60

33 olanzapine olanzapine 10 mg tablet - Limited to a quantity of 68 per 34 days. olanzapine 15 mg tablet - Limited to a quantity of 45 per 34 days. olanzapine 2.5 mg tablet - Limited to a quantity of 272 per 34 days. olanzapine 20 mg tablet - Limited to a quantity of 34 per 34 days. olanzapine 5 mg tablet - Limited to a quantity of 136 per 34 days. olanzapine 7.5 mg tablet - Limited to a quantity of 91 per 34 days. olanzapine odt 10 mg tablet - Limited to a quantity of 68 per 34 days. olanzapine odt 15 mg tablet - Limited to a quantity of 45 per 34 days. olanzapine odt 20 mg tablet - Limited to a quantity of 34 per 34 days. olanzapine odt 5 mg tablet - Limited to a quantity of 136 per 34 days. omeprazole omeprazole dr 10 mg capsule - Limited to a quantity of 34 per 34 days. omeprazole dr 20 mg capsule - Limited to a quantity of 34 per 34 days. omeprazole/sodium bicarbonat omeprazole-bicarb 20-1,100 cap - Limited to a quantity of 34 per 34 days. OMNARIS OMNARIS 50 MCG NASAL SPRAY - Limited to a quantity of 25 gm per 34 days. ondansetron ondansetron 4 mg/5 ml solution - Limited to a quantity of 150 ml per 5 days. ondansetron hcl 24 mg tablet - Limited to a quantity of 1 per 1 day. ondansetron hcl 4 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron hcl 8 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron odt 4 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron odt 8 mg tablet - Limited to a quantity of 12 per 5 days. ONGLYZA ONGLYZA 2.5 MG TABLET - Limited to a quantity of 34 per 34 days. ONGLYZA 5 MG TABLET - Limited to a quantity of 34 per 34 days. ONSOLIS ONSOLIS 1,200 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days. ONSOLIS 200 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days. ONSOLIS 400 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days. ONSOLIS 600 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days. Page 33 of 60

34 ONSOLIS 800 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days. OPANA ER OPANA ER 10 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 20 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 30 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 40 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 5 MG TABLET - Limited to a quantity of 90 per 30 days. oxybutynin oxybutynin cl er 5 mg tablet - Limited to a quantity of 34 per 34 days. OXYCONTIN OXYCONTIN 10 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 15 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 20 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 30 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 40 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 60 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 80 MG TABLET - Limited to a quantity of 90 per 30 days. oxymorphone oxymorphone hcl er 15 mg tab - Limited to a quantity of 90 per 30 days. oxymorphone hcl er 7.5 mg tab - Limited to a quantity of 90 per 30 days. OXYTROL OXYTROL 3.9 MG/24HR PATCH - Limited to a quantity of 10 per 35 days. pantoprazole pantoprazole sod dr 20 mg tab - Limited to a quantity of 34 per 34 days. paroxetine paroxetine cr 12.5 mg tablet - Limited to a quantity of 204 per 34 days. paroxetine cr 25 mg tablet - Limited to a quantity of 102 per 34 days. paroxetine er 37.5 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine hcl 10 mg tablet - Limited to a quantity of 204 per 34 days. paroxetine hcl 20 mg tablet - Limited to a quantity of 102 per 34 days. paroxetine hcl 30 mg tablet - Limited to a quantity of 68 per 34 days. Page 34 of 60

35 paroxetine hcl 40 mg tablet - Limited to a quantity of 51 per 34 days. PATANASE PATANASE 0.6% NASAL SPRAY - Limited to a quantity of 61 per 34 days. PAXIL CR PAXIL CR 12.5 MG TABLET - Limited to a quantity of 204 per 34 days. PAXIL CR 25 MG TABLET - Limited to a quantity of 102 per 34 days. PAXIL CR 37.5 MG TABLET - Limited to a quantity of 68 per 34 days. PAXIL PAXIL 10 MG TABLET - Limited to a quantity of 204 per 34 days. PAXIL 20 MG TABLET - Limited to a quantity of 102 per 34 days. PAXIL 30 MG TABLET - Limited to a quantity of 68 per 34 days. PAXIL 40 MG TABLET - Limited to a quantity of 51 per 34 days. PEGASYS PROCLICK PEGASYS PROCLICK 135 MCG/0.5 - Limited to a quantity of 4 per 28 days. PEGASYS PEGASYS 180 MCG/0.5 ML SYRINGE - Limited to a quantity of 4 syringes per 28 days. PEGASYS 180 MCG/ML VIAL - Limited to a quantity of 4 vials per 28 days. PEGINTRON REDIPEN PEGINTRON REDIPEN 120 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 150 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 50 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 80 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON PEGINTRON 50 MCG KIT - Limited to a quantity of 5 kits per 34 days. PEXEVA PEXEVA 10 MG TABLET - Limited to a quantity of 204 per 34 days. PEXEVA 20 MG TABLET - Limited to a quantity of 102 per 34 days. Page 35 of 60

36 PEXEVA 30 MG TABLET - Limited to a quantity of 68 per 34 days. PEXEVA 40 MG TABLET - Limited to a quantity of 51 per 34 days. pioglitazone hcl pioglitazone hcl 15 mg tablet - Limited to a quantity of 34 per 34 days. pioglitazone hcl 30 mg tablet - Limited to a quantity of 34 per 34 days. pioglitazone hcl 45 mg tablet - Limited to a quantity of 34 per 34 days. pioglitazone hcl/metformin hc pioglitazone-metformin Limited to a quantity of 102 per 34 days. pioglitazone-metformin Limited to a quantity of 102 per 34 days. PRANDIMET PRANDIMET 1 MG-500 MG TABLET - Limited to a quantity of 170 per 34 days. PRANDIMET 2 MG-500 MG TABLET - Limited to a quantity of 170 per 34 days. PRANDIN PRANDIN 0.5 MG TABLET - Limited to a quantity of 1088 per 34 days. PRANDIN 1 MG TABLET - Limited to a quantity of 544 per 34 days. PRANDIN 2 MG TABLET - Limited to a quantity of 272 per 34 days. PRAVACHOL PRAVACHOL 20 MG TABLET - Limited to a quantity of 34 per 34 days. PRAVACHOL 40 MG TABLET - Limited to a quantity of 34 per 34 days. PRAVACHOL 80 MG TABLET - Limited to a quantity of 34 per 34 days. pravastatin pravastatin sodium 10 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 20 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 40 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 80 mg tab - Limited to a quantity of 34 per 34 days. PRECOSE PRECOSE 100 MG TABLET - Limited to a quantity of 102 per 34 days. PRECOSE 25 MG TABLET - Limited to a quantity of 408 per 34 days. PRECOSE 50 MG TABLET - Limited to a quantity of 204 per 34 days. Page 36 of 60

37 PREVACID PREVACID 15 MG SOLUTAB - Limited to a quantity of 34 per 34 days. PREVACID DR 15 MG CAPSULE - Limited to a quantity of 34 per 34 days. PREVPAC PREVPAC PATIENT PACK - Limited to a quantity of 14 per 14 days. PRILOSEC PRILOSEC DR 10 MG CAPSULE - Limited to a quantity of 34 per 34 days. PRILOSEC DR 20 MG CAPSULE - Limited to a quantity of 34 per 34 days. PRISTIQ ER PRISTIQ ER 100 MG TABLET - Limited to a quantity of 136 per 34 days. PRISTIQ ER 50 MG TABLET - Limited to a quantity of 272 per 34 days. PROAIR HFA PROAIR HFA 90 MCG INHALER - Limited to a quantity of 26 gm per 34 days. PROTONIX PROTONIX DR 20 MG TABLET - Limited to a quantity of 34 per 34 days. PROVENTIL HFA PROVENTIL HFA 90 MCG INHALER - Limited to a quantity of 20 gm per 34 days. PROZAC WEEKLY PROZAC WEEKLY 90 MG CAPSULE - Limited to a quantity of 5 per 34 days. PROZAC PROZAC 10 MG PULVULE - Limited to a quantity of 272 per 34 days. PROZAC 40 MG PULVULE - Limited to a quantity of 68 per 34 days. PULMICORT FLEXHALER PULMICORT 180 MCG FLEXHALER - Limited to a quantity of 3 per 34 days. PULMICORT 90 MCG FLEXHALER - Limited to a quantity of 2 per 34 days. Page 37 of 60

38 QNASL QNASL 80 MCG NASAL SPRAY - Limited to a quantity of 18 per 34 days. quetiapine fumarate quetiapine fumarate 100 mg tab - Limited to a quantity of 272 per 34 days. quetiapine fumarate 200 mg tab - Limited to a quantity of 136 per 34 days. quetiapine fumarate 25 mg tab - Limited to a quantity of 1022 per 34 days. quetiapine fumarate 300 mg tab - Limited to a quantity of 91 per 34 days. quetiapine fumarate 400 mg tab - Limited to a quantity of 68 per 34 days. quetiapine fumarate 50 mg tab - Limited to a quantity of 544 per 34 days. QVAR QVAR 40 MCG INHALER - Limited to a quantity of 22 per 34 days. QVAR 80 MCG INHALER - Limited to a quantity of 22 per 34 days. REBIF REBIF 22 MCG/0.5 ML SYRINGE - Limited to a quantity of 8 ml per 35 days. REBIF 44 MCG/0.5 ML SYRINGE - Limited to a quantity of 8 ml per 35 days. REBIF TITRATION PACK - Limited to a quantity of 12 syringes per 28 days. REGRANEX REGRANEX 0.01% GEL - Limited to a quantity of 30 gm per 34 days. RELENZA RELENZA 5 MG DISKHALER - Limited to a quantity of 60 inhalations per 180 days. RELPAX RELPAX 20 MG TABLET - Limited to a quantity of 18 per 28 days. RELPAX 40 MG TABLET - Limited to a quantity of 18 per 28 days. RESTASIS RESTASIS 0.05% EYE EMULSION - Limited to a quantity of 60 vials per 30 days. revatio (sildenafil citrate) sildenafil 20 mg tablet - Limited to a quantity of 102 per 34 days. Page 38 of 60