Quantity Limit Drug List

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Allan Lawrence
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Quantity Limit Drug List Quantity limits define the maximum amount of medication covered by your drug benefit for one prescription or copayment.

1 Quantity Limit Drug List Quantity limits define the maximum amount of medication covered by your drug benefit for one prescription or copayment. This means your benefit covers a limited number of doses per prescription based on the medication s recommended dosing guidelines. If you or your physician requests an amount greater than the quantity limit of a medication, a prior authorization review may be required. The goal of the ClearScript Quantity Limit Program is to promote appropriate and cost-effective use of medications based on U.S. Food and Drug Administration (FDA) dosing guidelines, the medical literature and other factors. This list is subject to change throughout the year. The presence of a drug on this list does not guarantee coverage and not all drugs included on this list may be covered by your pharmacy benefit plan. Coverage of medications is determined your benefit plan. A abacavir-lamivudine abacavir-lamivudine-zidovudine abiraterone acetate ACANYA 50 / 30 DAYS ace aerosol cloud enhancer acetaminophen-cod #2 tablet 3 acetaminophen-cod #3 tablet 3 acetaminophen-cod #4 tablet acetaminophen-codeine (acetamin-codein mg/12.5, acetaminop-codeine mg/5) 4500 / 30 DAYS acitretin (17.5 mg capsule, 25 mg capsule) acitretin 10 mg capsule ACUVAIL 15 / 30 DAYS acyclovir 5% ointment adapalene-benzoyl peroxide 45 / 30 DAYS ADCIRCA ADDYI adefovir dipivoxil ADEMPAS 0.5 MG TABLET ADEMPAS 1 MG TABLET ADEMPAS 1.5 MG TABLET 150 / 30 DAYS ADEMPAS 2 MG TABLET

2 ADEMPAS 2.5 MG TABLET ADVAIR DISKUS ADVAIR HFA aerochamber mini aerochamber mv aerochamber plus flow-vu (, large, med, small) aerochamber plus z stat (, large, medium, small) aerochamber with flowsignal aerochamber z-stat plus (plus large, plus w-flow, plus-med, plus-small) aerotrach plus AFINITOR AFINITOR DISPERZ AGGRENOX A 210 / 30 DAYS 12 / 30 DAYS AIMOVIG AUTOINJECTOR 1 SYRINGES (1 ML) / 30 DAYS AIMOVIG AUTOINJECTOR (2 PACK) 2 SYRINGES (2 ML) / 30 DAYS AKYNZEO MG CAPSULE albuterol sulfate (0.63 ml, 1.25 ml) ALECENSA alendronate sod 70 mg/75 ml alendronate sodium (5 mg tablet, 10 mg tab, 40 mg tab) ALINIA 500 MG TABLET almotriptan malate ALORA alosetron hcl ALPHAGAN P 0.1% DROPS ALUNBRIG (90 MG-180 MG TAB PACK, 90 MG TABLET, 180 MG TABLET) ALUNBRIG 30 MG TABLET ALVESCO (80 MCG, 160 MCG) AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) AMPYRA ANDROGEL (1% GEL PUMP, 1%(5G) GEL PACKET) ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) ANDROGEL 1%(2.5G) GEL PACKET ANORO ELLIPTA 1 / 1 DAYS / 28 DAYS 6 / FILLS 12 / 30 DAYS 8 / 28 DAYS 15 / 30 DAYS 12.2 / 30 DAYS 300 / 30 DAYS 150 / 30 DAYS 75 / 30 DAYS

3 ANZEMET 100 MG TABLET ANZEMET 50 MG TABLET aprepitant 125 mg capsule aprepitant mg pack aprepitant 40 mg capsule aprepitant 80 mg capsule APRISO APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE) APTIOM (200 MG TABLET, 400 MG TABLET) APTIOM (600 MG TABLET, 800 MG TABLET) APTIVUS 250 MG CAPSULE ARCAPTA NEOHALER aripiprazole (5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) aripiprazole 1 mg/ml solution aripiprazole 2 mg tablet aripiprazole odt armodafinil ARNUITY ELLIPTA ascomp with codeine ASMANEX (TWISTHALER 110 MCG #7, TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #60, TWISTHALER 220 MCG #14, TWISTHALR 220 MCG #120) ASMANEX HFA (100 MCG, 200 MCG) aspirin-dipyridamole er atazanavir sulfate (150 mg cap, 200 mg cap) atazanavir sulfate 300 mg cap atomoxetine hcl (10 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule, 100 mg capsule) atomoxetine hcl (18 mg capsule, 25 mg capsule) atorvastatin calcium (10 mg tablet, 20 mg tablet) atovaquone ATRIPLA AUBAGIO AURYXIA AUSTEDO AVANDIA (2 MG TABLET, 4 MG TABLET) AVANDIA 8 MG TABLET A 3 / FILLS 6 / FILLS 2 / FILLS 3 / FILLS 1 / FILLS 4 / FILLS 750 / 30 DAYS 1 / 30 DAYS 13 / 30 DAYS 600 / 30 DAYS 3

4 AVONEX 30 MCG VIAL KIT AVONEX PEN AVONEX PREFILLED SYR 30 MCG KT AXERT (6.25 MG TABLET, 12.5 MG TABLET) azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) AZOPT A 1 / 30 DAYS 1.2 / 30 DAYS 12 / 30 DAYS 15 / 30 DAYS B BANZEL (200 MG TABLET, 400 MG TABLET) BARACLUDE 0.05 MG/ML SOLUTION BELBUCA belladonna-phenobarbital tab BELSOMRA (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) BEPREVE BESIVANCE BETASERON BETHKIS BEVESPI AEROSPHERE BIKTARVY bimatoprost 0.03% eye drops BOSULIF (400 MG TABLET, 500 MG TABLET) BOSULIF 100 MG TABLET BRAFTOVI 50 MG CAPSULE BRAFTOVI 75 MG CAPSULE breatherite breatherite spacer-adult mask breatherite spacer-infant mask breatherite spacer-large mask breatherite spacer-lg chld msk breatherite spacer-medium mask breatherite spacer-neonate msk breatherite spacer-sm chld msk breatherite spacer-small mask breathrite BREO ELLIPTA BRILINTA 600 / 30 DAYS 10 / 30 DAYS 5 / 7 DAYS 15 / 28 DAYS 224 / 56 DAYS (QTY OVER TIME) 10.7 / 30 DAYS 5 / 30 DAYS 270 / 30 DAYS

5 brimonidine tartrate 0.15% drp BRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) BRIVIACT (10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET) bromfenac sodium BROMSITE budesonide (0.25 ml, 0.5 ml, 1 ml inh) budesonide ec budesonide er buprenorp-nalox 8-2 mg sl film buprenorphine buprenorphine hcl (2 mg tablet, 8 mg tablet) buprenorphine-naloxone (buprenorphin-naloxon 8-2 mg, buprenorphn-naloxn mg) bupropion hcl xl 150 mg tablet bupropion hcl xl 300 mg tablet butalb-acetaminoph-caff-codein butalb-caff-acetaminoph-codein butalbital compound-codeine butalbital-acetaminophen-caffe ( , ) butalbital-acetaminophn butalbital-aspirin-caffeine butorphanol 10 mg/ml spray BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA (5 MCG, 10 MCG) BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET BYVALSON B 15 / 30 DAYS 5 / 30 DAYS 20 / 365 DAYS 9 / 23 DAYS 2.4 / 30 DAYS cabergoline CABOMETYX (20 MG TABLET, 60 MG TABLET) CABOMETYX 40 MG TABLET calcitonin-salmon C 16 / 28 DAYS 3.7 / 30 DAYS

6 C CALQUENCE CANASA candesartan cilexetil candesartan-hctz mg tb candesartan-hydrochlorothiazid ( mg tb, mg tab) CAPRELSA 100 MG TABLET CAPRELSA 300 MG TABLET CARAC carbidopa carisoprodol 250 mg tablet carisoprodol 350 mg tablet carisoprodol compound carisoprodol compound-codeine carisoprodol-aspirin carisoprodol-aspirin-codeine carvedilol er CAYSTON CELEBREX celecoxib CERDELGA CESAMET cevimeline hcl CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET) CHANTIX STARTING MONTH BOX CIALIS (10 MG TABLET, 20 MG TABLET) CIALIS (2.5 MG TABLET, 5 MG TABLET) CIMDUO CIMZIA 200 MG/ML STARTER KIT CIMZIA 200 MG/ML SYRINGE KIT CIPRO HC ciprofloxacin 0.2% otic soln CLIMARA PRO clind ph-benzoyl pero % clind ph-benzoyl perox 1.2-5% clindamycin-benzoyl peroxide 8 14 / FILLS 53 / 28 DAYS 5 / 30 DAYS 3 / 365 DAYS 1 / 28 DAYS 40 / FILLS 50 / 30 DAYS 45 / 30 DAYS 50 / 30 DAYS

7 clocortolone pivalate clomipramine hcl clonazepam (0.125 mg odt, mg dis tab, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg odt, 1 mg odt, 1 mg dis tablet) clonazepam 2 mg odt clonidine (0.2, 0.3) clonidine 0.1 mg/day patch clonidine hcl er clopidogrel 300 mg tablet clozapine clozapine odt (odt 100 mg tablet, odt 200 mg tablet) clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet) clozapine odt 150 mg tablet COARTEM colchicine COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ 140 MG DAILY-DOSE PK COMETRIQ 60 MG DAILY-DOSE PACK compact space chamber plus COMPLERA COPAXONE 20 MG/ML SYRINGE COPAXONE 40 MG/ML SYRINGE COREG CR CORLANOR COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) COSENTYX SYRINGE COTELLIC CRESTOR (5 MG TABLET, 10 MG TABLET) CRINONE CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE C 300 / 30 DAYS 8 / 28 DAYS 24 / 30 DAYS 10 / 30 DAYS 8 / 28 DAYS 8 / 30 DAYS 12 / 28 DAYS 1 / 28 DAYS 1 / 28 DAYS 1 / 28 DAYS 1 / 28 DAYS 63 / 28 DAYS / 30 DAYS 3

8 CUVPOSA cycloserine CYCLOSET C 1419 / 30 DAYS DAKLINZA dalfampridine er DALIRESP darifenacin er DAYTRANA (10 HR, 15 HR, 20 HOUR, 30 HOUR) DELZICOL DENAVIR DEPO-SUBQ PROVERA 104 desvenlafaxine er (er 50 mg tablet, er 50 mg tab) desvenlafaxine er 100 mg tab desvenlafaxine fum er 100 mg desvenlafaxine fum er 50 mg desvenlafaxine suc er 100 mg desvenlafaxine succinate er (er 25 mg, er 50 mg) DEXILANT dexmethylphenidate er 20 mg cp dexmethylphenidate hcl dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) dextroamphetamine 10 mg tab dextroamphetamine 5 mg tab dextroamphetamine 5 mg/5 ml dextroamphetamine er 10 mg cap dextroamphetamine er 15 mg cap dextroamphetamine er 5 mg cap dextroamphetamine-amphet er (er 20 mg cap, er 25 mg cap, er 30 mg cap) dextroamphetamine-amphet er (er 5 mg cap, er 10 mg cap, er 15 mg cap) diclofenac 1.5% topical soln dihydroergotamine 4 mg/ml spry donepezil hcl odt DOPTELET DUAVEE D 5 / 30 DAYS 0.65 / 84 DAYS 1800 / 30 DAYS 150 / 30 DAYS 150 / 30 DAYS 16 / 30 DAYS 15 / 5 DAYS

9 DULERA (100 MCG, 200 MCG) DUPIXENT 300 MG/2 ML SAFE SYRG DUREZOL DYANAVEL XR DYMISTA D 13 / 30 DAYS 5 / 30 DAYS 23 / 30 DAYS E e-z spacer easivent (holding chamber, mask-large, mask-medium, mask-small) EDARBI (40 MG TABLET, 80 MG TABLET) EDURANT efavirenz 200 mg capsule efavirenz 50 mg capsule efavirenz 600 mg tablet EFFIENT eletriptan hbr ELIQUIS (2.5 MG TABLET, 5 MG TABLET) ELIQUIS 5 MG STARTER PACK EMBEDA EMSAM EMTRIVA 10 MG/ML SOLUTION EMTRIVA 200 MG CAPSULE ENBREL (25 MG/0.5 ML SYRINGE, 25 MG KIT, 50 MG/ML SYRINGE) ENBREL MINI ENBREL SURECLICK ENDARI endocet enoxaparin 30 mg/0.3 ml syr enoxaparin 300 mg/3 ml vial enoxaparin 40 mg/0.4 ml syr enoxaparin 60 mg/0.6 ml syr enoxaparin sodium (100 mg/ml, 150 mg/ml) enoxaparin sodium (80 ml, 120 ml) entacapone entecavir ENTRESTO 3 12 / 30 DAYS 74 / 30 DAYS 74 / 365 DAYS 720 / 30 DAYS 8 / 28 DAYS 8 / 28 DAYS 8 / 28 DAYS 3 18 / 30 DAYS 24 / 30 DAYS 36 / 30 DAYS 48 / 30 DAYS

10 EPANED EPCLUSA EPIDUO EPIDUO FORTE EPIVIR 10 MG/ML ORAL SOLN EPIVIR HBV 25 MG/5 ML SOLN eplerenone EPOGEN eprosartan mesylate EPZICOM ERIVEDGE ERLEADA ERTACZO ERYTHROCIN STEARATE ESBRIET (267 MG TABLET, 267 MG CAPSULE) ESBRIET 801 MG TABLET esomeprazole magnesium estradiol (0.025 mg, mg, 0.05 mg, mg, 0.1 mg) estradiol (tds 0.025, patch, tds , tds 0.05, 0.06 patch, tds 0.06, patch, tds 0.075, tds 0.1) ESTRING eszopiclone EVOTAZ EXTAVIA ezetimibe ezetimibe-simvastatin FACTIVE FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) FANAPT TITRATION PACK FARXIGA (5 MG TABLET, 10 MG TABLET) FARYDAK FEMRING 0.10 MG/DAY VAG RING fenofibrate (134 mg capsule, 145 mg tablet, 160 mg tablet, 200 mg capsule) fenofibrate (48 mg tablet, 54 mg tablet) E F 1200 / 30 DAYS 45 / 30 DAYS 900 / 30 DAYS 600 / 30 DAYS 12 / 28 DAYS 270 / 30 DAYS 8 / 28 DAYS 1 / 63 DAYS 15 / 28 DAYS 8 / FILLS 6 / 21 DAYS 1 / 84 DAYS

11 fenofibric acid (35 mg tablet, dr 45 mg cap, 105 mg tablet, dr 135 mg cap) fentanyl (12, 25, 50, 75, 100) fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) FLECTOR flexichamber flexichamber mask FLOVENT 250 MCG DISKUS FLOVENT DISKUS (50 MCG, 100 MCG) FLOVENT HFA (110 MCG, 220 MCG) FLOVENT HFA 44 MCG INHALER flunisolide fluorouracil 0.5% cream fluoxetine hcl 10 mg tablet fluticasone-salmeterol fluvastatin er fluvastatin sodium fluvoxamine maleate er FORTEO FOSAMAX PLUS D fosamprenavir calcium frovatriptan succinate FUZEON FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) FYCOMPA 0.5 MG/ML ORAL SUSP F 15 / 30 DAYS 24 / 30 DAYS 21.2 / 30 DAYS 25 / 30 DAYS 45 / 30 DAYS 1 / 30 DAYS / 30 DAYS 720 / 30 DAYS galantamine er galantamine hbr gatifloxacin GELNIQUE (GEL SACHET, GEL SACHETS) GELNIQUE 3% GEL GENVOYA GILENYA GILOTRIF glatiramer 20 mg/ml syringe G 2.5 / 30 DAYS 92 / 30 DAYS

12 glatiramer 40 mg/ml syringe glatopa 20 mg/ml syringe glatopa 40 mg/ml syringe GLYXAMBI (10 MG TABLET, 25 MG TABLET) granisetron hcl 1 mg tablet GRASTEK G 12 / 28 DAYS 12 / 28 DAYS 6 / FILLS HARVONI HEPSERA HETLIOZ HUMIRA 10 MG/0.2 ML SYRINGE HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PEDIATRIC CROHN'S HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS HUMIRA PEN PSOR-UVEITS-ADOL HS HUMIRA(CF) HUMIRA(CF) PEDI CROHN MG HUMIRA(CF) PEDI CROHN 80MG/0.8 HUMIRA(CF) PEN HUMIRA(CF) PEN CROHN'S-UC-HS HUMIRA(CF) PEN PSOR-UV-ADOL HS hydrocodone-acetaminophen ( , mg, , mg) hydrocodone-acetaminophen (hydrocodone-acetamin /5, hydrocodone-acetamin 5-217/10, hydrocodone-acetamin 5-163/7.5, hydrocodone-acetamin /15, hydrocodone-acetamn /15) hydrocodone-ibuprofen ibandronate sodium 150 mg tab IBRANCE ICLUSIG 15 MG TABLET ICLUSIG 45 MG TABLET IDHIFA imatinib mesylate 100 mg tab imatinib mesylate 400 mg tab IMBRUVICA (70 MG CAPSULE, 140 MG TABLET, 280 MG TABLET, 420 MG TABLET, 560 MG TABLET) H I 2 / 28 DAYS 8 / 28 DAYS 6 / 365 DAYS 6 / 365 DAYS 4 / 365 DAYS 2 / 28 DAYS 2 / 28 DAYS 3 / 28 DAYS 2 / 28 DAYS 3 / 28 DAYS 3 / 28 DAYS / 30 DAYS 150 / 30 DAYS 1 / 28 DAYS 21 / 28 DAYS

13 IMBRUVICA 140 MG CAPSULE imiquimod 5% cream packet IMPAVIDO INCRUSE ELLIPTA INGREZZA 40 MG CAPSULE INGREZZA 80 MG CAPSULE INLYTA 1 MG TABLET INLYTA 5 MG TABLET inspirachamber (, with mask-med, with mask-small) INTELENCE (25 MG TABLET, 100 MG TABLET) INTELENCE 200 MG TABLET INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET INVOKAMET (50-1,000 MG TABLET, MG TABLET, 150-1,000 MG TABLET, MG TABLET) INVOKAMET XR (50-1,000 MG TAB, MG TABLET, MG TABLET, 150-1,000 MG TAB) INVOKANA (100 MG TABLET, 300 MG TABLET) irbesartan-hctz mg tb IRESSA ISENTRESS (100 MG POWDER PACKET, 400 MG TABLET) ISENTRESS 100 MG TABLET CHEW ISENTRESS 25 MG TABLET CHEW ISENTRESS HD itraconazole 100 mg capsule JAKAFI JANUMET ( MG TABLET, 50-1,000 MG TABLET) JANUMET XR (50-1,000 MG TABLET, MG TABLET) JANUMET XR 100-1,000 MG TABLET JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) JARDIANCE (10 MG TABLET, 25 MG TABLET) JENTADUETO (2.5 MG-500 MG TAB, 2.5 MG-850 MG TAB, 2.5 MG-1000 MG TAB) JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR 5 MG-1,000 MG TB JULUCA I J 56 / 45 DAYS 84 / 180 DAYS 270 / 30 DAYS 90 / 365 DAYS

14 JUXTAPID (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) JUXTAPID 5 MG CAPSULE JYNARQUE J KALETRA MG TABLET KALETRA MG TABLET KALETRA 80 MG-20 MG/ML SOLN KALYDECO ketorolac 10 mg tablet KEVEYIS KEVZARA KINERET KISQALI 200 MG DAILY DOSE KISQALI 400 MG DAILY DOSE KISQALI 600 MG DAILY DOSE KITABIS PAK KOMBIGLYZE XR (5-500 MG TABLET, 5-1,000 MG TAB) KOMBIGLYZE XR 2.5-1,000 MG TAB KYNAMRO K 150 / 30 DAYS 3 20 / 180 DAYS 2.28 / 28 DAYS 20.1 / 30 DAYS 21 / 28 DAYS 42 / 28 DAYS 63 / 28 DAYS 280 / 56 DAYS (QTY OVER TIME) 4 / 30 DAYS L lamivudine 10 mg/ml oral soln lamivudine 100 mg tablet lamivudine hbv lamotrigine er (er 100 mg tablet, er 200 mg tablet) lamotrigine er (er 25 mg tablet, er 50 mg tablet) lamotrigine er (er 250 mg tablet, er 300 mg tablet) lansoprazole dr 15 mg capsule lansoprazole dr 30 mg capsule lansoprazole odt 15 mg tablet lansoprazole odt 30 mg tablet LASTACAFT LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 120 MG TABLET) LATUDA 80 MG TABLET ledipasvir-sofosbuvir 900 / 30 DAYS 3 / 30 DAYS

15 LENVIMA (18 MG, 24 MG) LENVIMA (8 MG, 14 MG, 20 MG) LENVIMA 10 MG DAILY DOSE LETAIRIS levalbuterol tartrate hfa levetiracetam er 500 mg tablet levetiracetam er 750 mg tablet LEVITRA levocetirizine 2.5 mg/5 ml sol LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET LIALDA lidocaine 5% patch linezolid 600 mg tablet LINZESS (72 MCG CAPSULE, 145 MCG CAPSULE, 290 MCG CAPSULE) liteaire litetouch LIVALO (1 MG TABLET, 2 MG TABLET, 4 MG TABLET) LODOSYN LONSURF lopinavir-ritonavir lorcet lorcet hd lorcet plus lortab (5-325 mg tablet, mg tablet, mg tablet) lovastatin LUCEMYRA LUMIGAN LYNPARZA (100 MG TABLET, 150 MG TABLET) LYNPARZA 50 MG CAPSULE LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE) LYRICA 20 MG/ML ORAL SOLUTION LYRICA 300 MG CAPSULE L 5 / 30 DAYS 300 / 30 DAYS 1680 / 30 DAYS 56 / 28 DAYS 80 / 28 DAYS / 14 DAYS 5 / 30 DAYS 480 / 30 DAYS 900 / 30 DAYS MAVYRET M

16 M medroxyprogesterone 150 mg/ml mefenamic acid MEKINIST MEKTOVI meloxicam 7.5 mg/5 ml susp memantine hcl 2 mg/ml solution MENOSTAR mesalamine 800 mg dr tablet mesalamine dr 1.2 gm tablet metadate er methamphetamine hcl methylphenidate 10 mg chew tab methylphenidate er (er 10 mg tab, er 36 mg tab) methylphenidate er (er 18 mg tab, er 27 mg tab, er 54 mg tab) methylphenidate er (la) (10mg, 30mg, 40mg) methylphenidate er 20 mg tab methylphenidate er(la) 20mg cp methylphenidate hcl (2.5 mg tb, 5 mg tab) methylphenidate hcl (5 ml soln, 10 ml sol) methylphenidate hcl cd (10 mg cap, 20 mg cap, 30 mg cap) methylphenidate hcl cd (40 mg cap, 50 mg cap, 60 mg cap) methylphenidate hcl er (cd) (10mg, 20mg, 30mg) methylphenidate hcl er (cd) (40mg, 50mg, 60mg) methylphenidate la (10 mg cap, 30 mg cap, 40 mg cap) methylphenidate la (20 mg cap, 60 mg cap) microchamber microspacer miglustat MIGRANAL MIRVASO modafinil monaghan z stat (chamber, chamber-lg msk, chamber-md msk, chamber-sm msk) montelukast sod 4 mg granules morphine sulf er 200 mg tablet morphine sulfate (ir 15 mg tab, ir 30 mg tab) 1 / 90 DAYS 30 / FILLS 300 / 30 DAYS 300 / 30 DAYS 150 / 30 DAYS 900 / 30 DAYS 16 / 30 DAYS

17 morphine sulfate er (er 10 mg cap, er 20 mg cap, er 30 mg cap, er 45 mg cap, er 60 mg cap, er 75 mg cap, er 80 mg cap, er 90 mg cap) morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg tablet, er 100 mg tablet) morphine sulfate er (er 50 mg cap, er 100 mg cap, er 120 mg cap) MOVANTIK (12.5 MG TABLET, 25 MG TABLET) MOXEZA MULTAQ MYRBETRIQ nadolol (20 mg tablet, 40 mg tablet) nadolol 80 mg tablet NAMENDA 2 MG/ML SOLUTION naproxen dr 375 mg tablet naratriptan naratriptan hcl NARCAN nateglinide NEBUPENT NERLYNX NESINA (6.25 MG TABLET, 12.5 MG TABLET, 25 MG TABLET) neuac gel NEUPRO nevirapine er 100 mg tablet nevirapine er 400 mg tablet NEXAVAR niacin er (er 750 mg tablet, er 1,000 mg tablet) niacin er 500 mg tablet NINLARO nisoldipine NORTHERA (200 MG CAPSULE, 300 MG CAPSULE) NORTHERA 100 MG CAPSULE NORVIR (100 MG SOFTGEL CAP, 100 MG TABLET) NORVIR 80 MG/ML SOLUTION NUCYNTA (50 MG TABLET, 75 MG TABLET, 100 MG TABLET) NUCYNTA ER (ER 50 MG TABLET, ER 100 MG TABLET, ER 150 MG TABLET, ER 200 MG TABLET, ER 250 MG TABLET) M N 3 / 30 DAYS 300 / 30 DAYS 18 / 30 DAYS 18 / 30 DAYS 4 / FILLS 1 / 30 DAYS 45 / 30 DAYS 3 / 28 DAYS / 30 DAYS

18 NUEDEXTA NUPLAZID (10 MG TABLET, 34 MG CAPSULE) NUPLAZID 17 MG TABLET NUVARING N 1 / 21 DAYS O OCALIVA ODACTRA ODEFSEY ODOMZO OFEV olanzapine odt (odt 10 mg tablet, odt 15 mg tablet, odt 20 mg tablet) olanzapine odt 5 mg tablet olmesartan medoxomil olmesartan-hydrochlorothiazide olopatadine 665 mcg nasal spry olopatadine hcl 0.1% eye drops OLUMIANT OLYSIO omega-3 acid ethyl esters ONGLYZA (2.5 MG TABLET, 5 MG TABLET) OPSUMIT optichamber optichamber diamond (vhc, w-lrg mask, w-med mask, w-sml mask) ORALAIR ORAVIG ORENCIA (50 MG/0.4 ML, 87.5 MG/0.7 ML, 125 MG/ML) ORENCIA CLICKJECT ORENITRAM ER ORKAMBI (100 MG TABLET, 200 MG TABLET) oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75 mg capsule) OSPHENA OTEZLA 28 DAY STARTER PACK OTEZLA 30 MG TABLET OTEZLA STARTER PACK oxiconazole nitrate 30.5 / 30 DAYS 5 / 30 DAYS 14 / FILLS 42 / 180 DAYS 55 / 28 DAYS 27 / 365 DAYS

19 oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) oxybutynin cl er 5 mg tablet oxycodone hcl er oxycodone hcl-ibuprofen oxycodone-acetaminophen (oxycodon-acetaminophen , oxycodon-acetaminophen , oxycodone-acetaminophen 5-325, oxycodone-acetaminophen ) oxycodone-acetaminophn 5-325/5 OXYCONTIN oxymorphone hcl oxymorphone hcl er OXYTROL OZEMPIC MG DOSE PEN OZEMPIC 1 MG DOSE PEN paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9 mg tablet) paliperidone er 6 mg tablet paroxetine cr paroxetine er PAZEO PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS 180 MCG/ML VIAL PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PENTASA 250 MG CAPSULE PENTASA 500 MG CAPSULE phenohytro tablet PHOSLYRA PICATO 0.015% GEL PICATO 0.05% GEL pioglitazone-metformin PLEGRIDY PLEGRIDY PEN pocket chamber POMALYST POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET) O P / 30 DAYS 3 8 / 28 DAYS 1.5 / 28 DAYS 3 / 28 DAYS 2.5 / 30 DAYS 2 / 28 DAYS 2 / 28 DAYS 4 / 30 DAYS 4 / 30 DAYS 1800 / 30 DAYS 3 / 30 DAYS 2 / 30 DAYS 1 / 28 DAYS 1 / 28 DAYS 22 / 28 DAYS

20 P POTIGA 50 MG TABLET PRADAXA PRALUENT PEN PRALUENT SYRINGE PRANDIN prasugrel hcl pravastatin sodium PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, MG TABLET) PREMARIN (0.9 MG TABLET, 1.25 MG TABLET) PREMPHASE PREMPRO PREVACID 15 MG SOLUTAB PREVACID 30 MG SOLUTAB PREVYMIS (240 MG TABLET, 480 MG TABLET) PREZCOBIX PREZISTA 100 MG/ML SUSPENSION PREZISTA 150 MG TABLET PREZISTA 400 MG TABLET PREZISTA 600 MG TABLET PREZISTA 75 MG TABLET PREZISTA 800 MG TABLET PRIFTIN primeaire PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET) PRISTIQ ER 100 MG TABLET PROAIR HFA PROAIR RESPICLICK procentra prochamber PROCRIT PROMACTA (12.5 MG TABLET, 25 MG TABLET) PROMACTA (50 MG TABLET, 75 MG TABLET) PULMICORT FLEXHALER PULMOZYME pyridostigmine bromide er 2 / 28 DAYS 2 / 28 DAYS / 30 DAYS 32 / 28 DAYS 17 / 30 DAYS 2 / 30 DAYS 1800 / 30 DAYS 12 / 28 DAYS 2 / 30 DAYS 75 / 30 DAYS

21 QNASL QNASL CHILDREN QTERN quetiapine fumarate (300 mg tab, 400 mg tab) quetiapine fumarate 200 mg tab quetiapine fumarate er QUILLIVANT XR quinine sulfate QVAR 40 MCG ORAL INHALER QVAR 80 MCG ORAL INHALER QVAR REDIHALER rabeprazole sodium RAGWITEK raloxifene hcl RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) RAPAFLO RAVICTI REBIF (22 ML, 44 ML) REBIF REBIDOSE (22 ML, 44 ML) REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK RELENZA RELISTOR (12 ML VIAL, 12 ML SYRINGE) RELISTOR 8 MG/0.4 ML SYRINGE RELPAX repaglinide REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR 100 MG TABLET RESCRIPTOR 200 MG TABLET RESCULA RESTASIS RESTASIS MULTIDOSE Q R 8.7 / 30 DAYS 4.9 / 30 DAYS 3 42 / 365 DAYS 26 / 30 DAYS 26.1 / 30 DAYS 21.2 / 30 DAYS 525 / 30 DAYS 12 / 30 DAYS 12 / 30 DAYS 20 / 180 DAYS 18 / 30 DAYS 12 / 30 DAYS 12 / 30 DAYS 3.5 / 30 DAYS 3 / 30 DAYS 3 / 30 DAYS 3 5 / 25 DAYS 0.2 / 1 DAYS

22 R REVLIMID REXULTI REYATAZ (150 MG CAPSULE, 200 MG CAPSULE) REYATAZ 300 MG CAPSULE REYATAZ 50 MG POWDER PACKET RHOPRESSA rifabutin RILUTEK riluzole risedronate sodium 150 mg tab risedronate sodium 30 mg tab risedronate sodium 35 mg tab risedronate sodium 5 mg tablet risedronate sodium dr risperidone 1 mg/ml solution risperidone 4 mg odt risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mg odt, 3 mg odt) RITALIN LA 10 MG CAPSULE RITALIN LA 60 MG CAPSULE riteflo ritonavir rivastigmine (4.6 patch, 9.5 patch, 13.3 ptch) rizatriptan ropinirole er (er 2 mg tablet, er 4 mg tablet, er 6 mg tablet) ropinirole er (er 8 mg tablet, er 12 mg tablet) rosuvastatin calcium (5 mg tab, 10 mg tab) roweepra xr 500 mg tablet roweepra xr 750 mg tablet ROZEREM RUBRACA RYDAPT 150 / 30 DAYS 2.5 ML / 25 DAYS 1 / 28 DAYS 3 18 / 30 DAYS SABRIL SAIZEN (5 MG VIAL, 8.8 MG VIAL) SAMSCA S

23 S SANCUSO SAPHRIS SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) SAVELLA TITRATION PACK scopolamine SEEBRI NEOHALER SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET) SELZENTRY 300 MG TABLET SEREVENT DISKUS SEROSTIM sildenafil sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) silicone mask-infant SILIQ silodosin SIMBRINZA SIMPONI (100 MG/ML SYRINGE, 100 MG/ML PEN INJECTOR) SIMPONI (50 ML PEN INJEC, 50 ML SYRINGE) simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) SIVEXTRO 200 MG TABLET sofosbuvir-velpatasvir SOLIQUA SOLOSEC SORIATANE (17.5 MG CAPSULE, 25 MG CAPSULE) SORIATANE 10 MG CAPSULE SOVALDI space chamber plus SPIRIVA SPIRIVA RESPIMAT SPRYCEL (100 MG TABLET, 140 MG TABLET) SPRYCEL (70 MG TABLET, 80 MG TABLET) SPRYCEL 20 MG TABLET SPRYCEL 50 MG TABLET STELARA 45 MG/0.5 ML SYRINGE STELARA 45 MG/0.5 ML VIAL 2 / 15 DAYS 55 / FILLS 10 / 30 DAYS 5 / 30 DAYS 3 / 28 DAYS 8 / 30 DAYS 3 / 28 DAYS 1 / 28 DAYS 6 / FILLS 18 / 30 DAYS 1 / FILLS 4 / 30 DAYS 270 / 30 DAYS 0.5 / 84 DAYS 0.5 / 84 DAYS

24 STELARA 90 MG/ML SYRINGE STIOLTO RESPIMAT STIVARGA STRATTERA (10 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE) STRATTERA (18 MG CAPSULE, 25 MG CAPSULE) STRENSIQ 18 MG/0.45 ML VIAL STRENSIQ 28 MG/0.7 ML VIAL STRENSIQ 40 MG/ML VIAL STRENSIQ 80 MG/0.8 ML VIAL STRIBILD STRIVERDI RESPIMAT SUBOXONE (2 MG-0.5 MG, 4 MG-1 MG, 8 MG-2 MG) SUBOXONE 12 MG-3 MG SL FILM sumatriptan sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 ml inject, 4 ml cart, 6 ml refill, 6 ml syrng, 6 ml vial, 6 ml inject) SUSTIVA 200 MG CAPSULE SUSTIVA 50 MG CAPSULE SUSTIVA 600 MG TABLET SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE) SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) SYMBICORT SYMDEKO SYMFI SYMFI LO SYMLINPEN 120 SYMLINPEN 60 SYMPROIC SYNERA SYNJARDY (5-1,000 MG TABLET, MG TABLET, MG TABLET, ,000 MG TABLET) SYNJARDY XR (10-1,000 MG TABLET, 25-1,000 MG TABLET) SYNJARDY XR (5-1,000 MG TABLET, ,000 MG TAB) SYPRINE S 1 / 84 DAYS 4 / 30 DAYS / 28 DAYS 16.8 / 28 DAYS / 30 DAYS 12 / 30 DAYS 18 / 30 DAYS 4 / 30 DAYS / 30 DAYS 56 / 28 DAYS 5.4 / 30 DAYS 3 / 30 DAYS tacrolimus (0.03%, 0.1%) T 100 / 30 DAYS

25 tadalafil (2.5 mg tablet, 5 mg tablet) tadalafil 10 mg tablet tadalafil 20 mg tablet (generic for adcirca) tadalafil 20 mg tablet (generic for cialis) TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (2 PACK) TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE TALTZ SYRINGE (2 PACK) TALTZ SYRINGE (3 PACK) TANZEUM (30 MG, 50 MG) TARCEVA (100 MG TABLET, 150 MG TABLET) TARCEVA 25 MG TABLET TASIGNA TASMAR TAVALISSE TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE) TECFIDERA STARTER PACK TECHNIVIE TEKTURNA (150 MG TABLET, 300 MG TABLET) TEKTURNA HCT ( MG TAB, MG TABLET, MG TAB, MG TABLET) telmisartan temazepam 7.5 mg capsule tencon terconazole 0.4% cream terconazole 0.8% cream terconazole 80 mg suppository testosterone (1.62% gel pump, 1.62% (2.5 g) pkt, 1.62%(1.25 g) pkt) testosterone (12.5 mg/1.25, 50 mg/5 pkt) testosterone 10 mg gel pump testosterone 25 mg/2.5 gm pkt THALOMID (150 MG CAPSULE, 200 MG CAPSULE) THALOMID (50 MG CAPSULE, 100 MG CAPSULE) T 5 / 30 DAYS 5 / 30 DAYS 11 / 180 DAYS 11 / 180 DAYS 11 / 180 DAYS 11 / 180 DAYS 11 / 180 DAYS 11 / 180 DAYS 60 / 365 DAYS 56 / 28 DAYS 45 / FILLS 20 / FILLS 3 / FILLS 150 / 30 DAYS 300 / 30 DAYS 75 / 30 DAYS

26 ticlopidine hcl TIVICAY (10 MG TABLET, 25 MG TABLET) TIVICAY 50 MG TABLET TOBI PODHALER tobramycin 300 mg/5 ml ampule tobramycin pak 300 mg/5 ml tolcapone tolterodine tartrate tolterodine tartrate er TOVIAZ TRACLEER 32 MG TABLET FOR SUSP TRADJENTA tramadol hcl tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg tablet, hcl er 100 mg tablet, hcl er 200 mg tablet, hcl er 300 mg tablet) tramadol hcl-acetaminophen trandolapril-verapamil er tranexamic acid 650 mg tablet TRANSDERM-SCOP TRAVATAN Z TRELEGY ELLIPTA TREMFYA trientine hcl triklo TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) TRIUMEQ TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE) TROKENDI XR 200 MG CAPSULE trospium chloride trospium chloride er TRULANCE TRULICITY (0.75 ML, 1.5 ML) TUDORZA PRESSAIR TYBOST T 224 / 56 DAYS (QTY OVER TIME) 280 / 56 DAYS (QTY OVER TIME) 280 / 56 DAYS (QTY OVER TIME) 30 / 5 DAYS 10 / 30 DAYS 5 / 30 DAYS 1 / 56 DAYS 2 / 28 DAYS 1 / 30 DAYS

27 TYKERB TYMLOS TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT T 1.56 / 30 DAYS 89.9 / 30 DAYS 89.9 / 30 DAYS 89.9 / 30 DAYS 89.9 / 30 DAYS UCERIS 9 MG ER TABLET ULESFIA ULORIC (40 MG TABLET, 80 MG TABLET) UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) UPTRAVI TITRATION PACK UTIBRON NEOHALER VALCHLOR vardenafil hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) VARUBI 90 MG TABLET VELPHORO VELTASSA VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK VENTAVIS VENTOLIN HFA VERAMYST verdrocet VERSACLOZ VERZENIO VESICARE VIAGRA VIBERZI VICTOZA 2-PAK VICTOZA 3-PAK VIDEX VIEKIRA PAK U V 1362 / 30 DAYS 200 / 180 DAYS 5 / 30 DAYS 2 / FILLS 270 / 30 DAYS 36 / 30 DAYS 10 / 30 DAYS / 30 DAYS 5 / 30 DAYS 9 / 28 DAYS 9 / 28 DAYS 600 / 30 DAYS 112 / 28 DAYS

28 V VIEKIRA XR vigabatrin vigadrone VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) VIIBRYD MG STARTER PACK VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) VIRAMUNE XR 100 MG TABLET VIRAMUNE XR 400 MG TABLET VITEKTA voriconazole (50 mg tablet, 200 mg tablet) voriconazole 40 mg/ml susp vortex vortex holding chamber-child vortex holding chamber-toddler vortex vhc frog mask vortex vhc ladybug mask VOSEVI VOTRIENT VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) VRAYLAR 1.5 MG-3 MG PACK VYVANSE VYZULTA X XADAGO (50 MG TABLET, 100 MG TABLET) XALKORI XARELTO (10 MG TABLET, 20 MG TABLET) XARELTO (2.5 MG TABLET, 15 MG TABLET) XARELTO STARTER PACK XELJANZ XELJANZ XR XERMELO XIFAXAN 200 MG TABLET XIFAXAN 550 MG TABLET XIGDUO XR (2.5 MG TAB, 5 MG TABLET) XIGDUO XR (5 MG-500 MG TABLET, 10 MG-500 MG TABLET, 10 MG-1,000 MG TAB) / 30 DAYS 7 / 7 DAYS 5 ML / 25 DAYS 51 / 30 DAYS 9 / 3 DAYS

29 XIIDRA XOPENEX HFA XTAMPZA ER (ER 9 MG CAPSULE, ER 13.5 MG CAPSULE, ER 18 MG CAPSULE, ER 27 MG CAPSULE, ER 36 MG CAPSULE) XTANDI xulane XULTOPHY XURIDEN zafirlukast ZAVESCA zazole ZEJULA ZELBORAF ZEPATIER ZETIA zileuton er ZINBRYTA ziprasidone hcl ZOHYDRO ER (ER 10 MG CAPSULE, ER 15 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE) ZOLINZA zolmitriptan zolmitriptan 2.5 mg odt zolmitriptan 5 mg odt zolpidem tartrate er ZOMACTON 5 MG VIAL ZOMIG (2.5 MG, 5 MG) ZORBTIVE ZORTRESS ZUBSOLV ( MG TABLET, MG TABLET, MG TABLET) ZUBSOLV ( MG TABLET, MG TABLET) ZUBSOLV MG TABLET SL ZYDELIG ZYFLO CR ZYKADIA X Z 15 / 30 DAYS 20 / FILLS 1 / 30 DAYS 12 / 30 DAYS 12 / 30 DAYS 9 / 30 DAYS 12 / 30 DAYS 150 / 30 DAYS

30 ZYMAXID ZYTIGA 250 MG TABLET ZYTIGA 500 MG TABLET Z 2.5 / 30 DAYS

Aetna Better Health of Illinois Medicaid Formulary Updates

October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary