National Preferred Formulary Quantity Limits Drug List Helpful Tip: To search for a specific drug, use the find feature (Ctrl + F)

Transcription

1 Page 1 of 6 Allergies Anaphylaxis Antifungal Anti-infective Anti-infective - Specialty Anti-Influenza Asthma - Specialty Asthma/COPD National Preferred Formulary Quantity Limits Drug List Helpful Tip: To search for a specific drug, use the find feature (Ctrl + F) AZELASTINE HCL 0.1% NASAL SPRY Retail-60. units, Mail-180. units BECONASE AQ 0.042% SPRAY Retail-50. units, Mail-150. units CETIRIZINE HCL 5 MG TABLET Retail-30. units, Mail-90. units CHILD CETIRIZINE 10 MG CHEW TB Retail-30. units, Mail-90. units CHILD'S CLARITIN 5 MG TAB CHEW Retail-30. units, Mail-90. units CHLD ALLEGRA ALLERGY 30 MG ODT Retail-60. units, Mail-180. units CHLD ALLEGRA ALLERGY 30 MG TAB Retail-60. units, Mail-180. units CLARINEX 2.5 MG REDITABS Retail-30. units, Mail-90. units CLARINEX 5 MG REDITABS Retail-30. units, Mail-90. units CLARINEX 5 MG TABLET Retail-30. units, Mail-90. units CLARINEX-D 12 HOUR TABLET Retail-60. units, Mail-180. units CLARINEX-D 24 HOUR TABLET Retail-30. units, Mail-90. units CLARITIN 10 MG LIQUI-GEL CAP Retail-30. units, Mail-90. units FLONASE ALLERGY RELIEF 50MCG NASAL SPRAY PS (15.8) Retail-16. units, Mail-48. units FLONASE ALLERGY RELIEF 50MCG NASAL SPRAY PS (9.9) Retail-10. units, Mail-30. units FLUNISOLIDE SPRAY Retail-50. units, Mail-150. units FLUTICASONE PROP 50 MCG SPRAY Retail-16. units, Mail-48. units IPRATROPIUM 0.03% SPRAY Retail-30. units, Mail-90. units IPRATROPIUM 0.06% SPRAY Retail-30. units, Mail-90. units LORATADINE 10 MG TABLET Retail-30. units, Mail-90. units NASACORT ALLERGY 24HR SPRAY PS (10.8) Retail-11. units, Mail-33. units NASACORT ALLERGY 24HR SPRAY PS (16.9) Retail-17. units, Mail-51. units NASONEX 50 MCG NASAL SPRAY Retail-17. units, Mail-51. units OMNARIS 50 MCG NASAL SPRAY Retail-13. units, Mail-38. units PATANASE 665 MCG NASAL SPRAY Retail-31. units, Mail-92. units RHINOCORT AQUA NASAL SPRAY Retail-18. units, Mail-52. units TRIAMCINOLONE 55 MCG NASAL SPR Retail-17. units, Mail-50. units VERAMYST 27.5 MCG NASAL SPRAY Retail-10. units, Mail-30. units XYZAL 5 MG TABLET Retail-30. units, Mail-90. units ZYRTEC 10 MG LIQUID GELS Retail-30. units, Mail-90. units ADRENACLICK, EPIPEN, TWINJECT 0.3 MG 1-PAK Retail-2. units, Mail-6. units ADRENACLICK, TWINJECT 0.15MG 1-PAK Retail-2. units, Mail-6. units ADRENACLICK, TWINJECT 0.15MG 2-PAK Retail-2. units, Mail-6. units ADRENACLICK,TWINJECT,EPIPEN 0.3 MG AUTO-INJECT PS 2 Retail-2. units, Mail-6. units EPIPEN JR 2-PAK 0.15 MG INJCTR Retail-2. units, Mail-6. units DIFLUCAN 150 MG TABLET Retail-2. units, Mail-6. units SPORANOX 100 MG CAPSULE Retail-30. units, Mail-90. units FAMCICLOVIR 125 MG TABLET Retail-21. units, Mail-63. units FAMCICLOVIR 250 MG TABLET Retail-60. units, Mail-180. units FAMCICLOVIR 500 MG TABLET Retail-21. units, Mail-63. units NEBUPENT TO BE DISP AT A MAX QTY OF 1 VIAL IN 21 DAYS OR 3 VIALS IN 63 DAYS VALACYCLOVIR HCL 1 GRAM TABLET Retail-30. units, Mail-90. units VALACYCLOVIR HCL 500 MG TABLET Retail-30. units, Mail-90. units CAYSTON 75 MG INHAL SOLUTION Retail-84. units, Mail-252. units TOBI 300 MG/5 ML SOLUTION Retail-280. units, Mail-840. units TAMIFLU 30 MG GELCAP Retail-20. units, Mail-60. units TAMIFLU 45 MG GELCAP Retail-10. units, Mail-30. units TAMIFLU 75 MG GELCAP Retail-10. units, Mail-30. units XOLAIR TO BE DISP AT A MAX QTY OF 6 VIALS IN 21 DAYS OR 18 VIALS IN 63 DAYS ADVAIR DISKUS Retail-1. units, Mail-3. units ADVAIR DISKUS Retail-1. units, Mail-3. units ADVAIR DISKUS Retail-1. units, Mail-3. units ADVAIR HFA MCG INHALER PS 12 Retail-12. units, Mail-36. units ADVAIR HFA MCG INHALER PS 8 Retail-8. units, Mail-24. units ADVAIR HFA MCG INHALER PS 12 Retail-12. units, Mail-36. units ADVAIR HFA MCG INHALER PS 8 Retail-8. units, Mail-24. units ADVAIR HFA MCG INHALER PS 12 Retail-12. units, Mail-36. units ADVAIR HFA MCG INHALER PS 8 Retail-8. units, Mail-24. units ALVESCO 160 MCG INHALER Retail-13. units, Mail-37. units ALVESCO 80 MCG INHALER Retail-7. units, Mail-19. units ASMANEX TWISTHALER 110 MCG #30 Retail-1. units, Mail-3. units ASMANEX TWISTHALER 110MCG #7 Retail-1. unit, Mail-3. units ASMANEX TWISTHALER 220 MCG #30 Retail-1. units, Mail-3. units ASMANEX TWISTHALER 220 MCG #60 Retail-1. units, Mail-3. units ASMANEX TWISTHALER 220MCG #14 Retail-1. unit, Mail-3. units ASMANEX TWISTHALR 220 MCG #120 Retail-1. units, Mail-3. units BROVANA 15 MCG/2 ML SOLUTION Retail-120. units, Mail-360. units BUDESONIDE 0.25 MG/2 ML SUSP Retail-120. units, Mail-360. units BUDESONIDE 0.5 MG/2 ML SUSP Retail-120. units, Mail-360. units COMBIVENT INHALER Retail-30. units, Mail-89. units COMBIVENT RESPIMAT INHAL SPRAY Retail-8. units, Mail-24. units DULERA 100 MCG/5 MCG INHALER Retail-1. units, Mail-3. units DULERA 200 MCG/5 MCG INHALER PS 13 Retail-13. units, Mail-39. units DULERA 200 MCG/5 MCG INHALER PS 8.8 Retail-9. units, Mail-27. units FLOVENT 100 MCG DISKUS Retail-1. units, Mail-3. units FLOVENT 250 MCG DISKUS Retail-4. units, Mail-12. units FLOVENT 50 MCG DISKUS Retail-60. units, Mail-180. units FLOVENT HFA 110 MCG INHALER Retail-12. units, Mail-36. units FLOVENT HFA 220 MCG INHALER Retail-24. units, Mail-72. units FLOVENT HFA 44 MCG INHALER Retail-11. units, Mail-32. units FORADIL AEROLIZER 12 MCG CAP PS 12 Retail-12. units, Mail-36. units FORADIL AEROLIZER 12 MCG CAP PS 60 Retail-60. units, Mail-180. units Updated:

2 Page 2 of 6 Blood Cell Deficiency Bone Conditions Contraceptives Depression IPRAT-ALBUT 0.5-3(2.5) MG/3 ML Retail-540. units, Mail units MAXAIR AUTOHALER 0.2 MG AERO Retail-14. units, Mail-42. units PERFOROMIST 20 MCG/2 ML SOLN Retail-120. units, Mail-360. units PROAIR HFA 90 MCG INHALER Retail-17. units, Mail-51. units PROVENTIL HFA 90 MCG INHALER Retail-14. units, Mail-41. units PULMICORT 1 MG/2 ML RESPULE Retail-60. units, Mail-180. units PULMICORT 180 MCG FLEXHALER Retail-2. units, Mail-6. units PULMICORT 90 MCG FLEXHALER Retail-1. units, Mail-3. units QVAR 40 MCG INHALER Retail-18. units, Mail-53. units QVAR 80 MCG INHALER Retail-27. units, Mail-79. units SEREVENT DISKUS 50 MCG Retail-28. units, Mail-84. units SEREVENT DISKUS 50 MCG Retail-60. units, Mail-180. units SYMBICORT MCG INHALER PS 10.2 Retail-11. units, Mail-31. units SYMBICORT MCG INHALER PS 6 Retail-6. units, Mail-18. units SYMBICORT MCG INHALER PS 10.2 Retail-11. units, Mail-31. units SYMBICORT MCG INHALER PS 6.9 Retail-7. units, Mail-21. units VENTOLIN HFA 90 MCG INHALER Retail-36. units, Mail-108. units VENTOLIN HFA 90 MCG INHALER Retail-8. units, Mail-24. units NEULASTA TO BE DISP AT MAX OF 2 SYRINGES IN 23 DAYS OR 6 SYRINGES IN 68 DAYS ACTONEL 150MG TO BE DISP AT MAX OF 1 TABLET IN 23 DAYS OR 3 TABLETS IN 68 DAYS ACTONEL 30 MG TABLET Retail-30. units, Mail-90. units ACTONEL 5 MG TABLET Retail-30. units, Mail-90. units ACTONEL, ATELVIA 35 MG TO BE DISPENSED AT A MAX QUANTITY OF 4 TABS IN 21 DAYS OR 12 TABS IN 63 DAYS ALENDRONATE SODIUM 10 MG TAB Retail-30. units, Mail-90. units ALENDRONATE SODIUM 40 MG TAB Retail-30. units, Mail-90. units ALENDRONATE SODIUM 5 MG TABLET Retail-30. units, Mail-90. units BONIVA 150MG TO BE DISP AT MAX QTY OF 1 TABLET IN 23 DAYS OR 3 TABLETS IN 68 DAYS FORTEO 600MCG/2.4ML TO BE DISP AT A MAX QTY OF 3ML (1 PEN) IN 21 DAYS OR 8ML (3 PENS) IN 63 DAYS FOSAMAX 35MG TO BE DISPENSED AT A MAXIMUM QUANTITY OF 4 TABS IN 21 DAYS OR 12 TABS IN 63 DAYS FOSAMAX 70MG TO BE DISP AT MAX OF 4 TABLETS IN 21 DAYS OR 12 TABLETS IN 63 DAYS FOSAMAX PLUS D 70MG-2800IU TO BE DISP AT A MAX QTY OF 4 TABS IN 21 DAYS OR 12 TABS IN 63 DAYS FOSAMAX PLUS D 70MG-5600IU TO BE DISP AT A MAX QTY OF 4 TABS IN 21 DAYS OR 12 TABS IN 63 DAYS DEPO PROVERA 150MG/ML SYRINGE/VIAL TO BE DISP AT A MAX QTY OF 1 ML IN 68 DAYS DEPO SUB-Q PROVERA 104 SYRINGE TO BE DISP AT A MAX QTY OF 1 ML (1 SYRINGE) IN 68 DAYS ELLA 30 MG TABLET Retail-1. units, Mail-3. units NEXT CHOICE ONE DOSE 1.5 MG TB Retail-1. units, Mail-3. units PLAN B 0.75 MG TABLET Retail-2. units, Mail-6. units APLENZIN ER 174 MG TABLET Retail-30. units, Mail-90. units APLENZIN ER 348 MG TABLET Retail-30. units, Mail-90. units APLENZIN ER 522 MG TABLET Retail-30. units, Mail-90. units CELEXA 10 MG TABLET Retail-30. units, Mail-90. units CELEXA 20 MG TABLET Retail-30. units, Mail-90. units CELEXA 40 MG TABLET Retail-30. units, Mail-90. units CYMBALTA 20 MG CAPSULE Retail-60. units, Mail-180. units CYMBALTA 30 MG CAPSULE Retail-30. units, Mail-90. units CYMBALTA 60 MG CAPSULE Retail-60. units, Mail-180. units EFFEXOR 100 MG TABLET Retail-90. units, Mail-270. units EFFEXOR 25 MG TABLET Retail-90. units, Mail-270. units EFFEXOR 37.5 MG TABLET Retail-90. units, Mail-270. units EFFEXOR 50 MG TABLET Retail-90. units, Mail-270. units EFFEXOR 75 MG TABLET Retail-90. units, Mail-270. units EFFEXOR XR 150 MG CAPSULE Retail-30. units, Mail-90. units EFFEXOR XR 37.5 MG CAPSULE Retail-30. units, Mail-90. units EFFEXOR XR 75 MG CAPSULE Retail-90. units, Mail-270. units FLUVOXAMINE MALEATE 100 MG TAB Retail-90. units, Mail-270. units FLUVOXAMINE MALEATE 25 MG TAB Retail-30. units, Mail-90. units FLUVOXAMINE MALEATE 50 MG TAB Retail-60. units, Mail-180. units LEXAPRO 10 MG TABLET Retail-30. units, Mail-90. units LEXAPRO 20 MG TABLET Retail-30. units, Mail-90. units LEXAPRO 5 MG TABLET Retail-30. units, Mail-90. units LUVOX CR 100 MG CAPSULE Retail-60. units, Mail-180. units LUVOX CR 150 MG CAPSULE Retail-60. units, Mail-180. units PAXIL 10 MG TABLET Retail-30. units, Mail-90. units PAXIL 20 MG TABLET Retail-60. units, Mail-180. units PAXIL 30 MG TABLET Retail-60. units, Mail-180. units PAXIL 40 MG TABLET Retail-30. units, Mail-90. units PAXIL CR 12.5 MG TABLET Retail-60. units, Mail-180. units PAXIL CR 25 MG TABLET Retail-60. units, Mail-180. units PAXIL CR 37.5 MG TABLET Retail-60. units, Mail-180. units PEXEVA 10 MG TABLET Retail-30. units, Mail-90. units PEXEVA 20 MG TABLET Retail-60. units, Mail-180. units PEXEVA 30 MG TABLET Retail-60. units, Mail-180. units PEXEVA 40 MG TABLET Retail-30. units, Mail-90. units PRISTIQ ER 100 MG TABLET Retail-30. units, Mail-90. units PRISTIQ ER 50 MG TABLET Retail-30. units, Mail-90. units PROZAC 10 MG Retail-30. units, Mail-90. units PROZAC 40 MG PULVULE Retail-60. units, Mail-180. units PROZAC WEEKLY 90 MG CAPSULE Retail-4. units, Mail-12. units SARAFEM 10 MG TABLET Retail-30. units, Mail-90. units SAVELLA 100 MG TABLET Retail-60. units, Mail-180. units SAVELLA 12.5 MG TABLET Retail-60. units, Mail-180. units SAVELLA 25 MG TABLET Retail-60. units, Mail-180. units SAVELLA 50 MG TABLET Retail-60. units, Mail-180. units SAVELLA TITRATION PACK Retail-55. units, Mail-165. units SSB DESVENLAFAXINE ER 100MG Retail-30. units, Mail-90. units SSB DESVENLAFAXINE ER 50MG Retail-30. units, Mail-90. units VENLAFAXINE HCL ER 150 MG TAB Retail-30. units, Mail-90. units VENLAFAXINE HCL ER 225 MG TAB Retail-30. units, Mail-90. units

3 Page 3 of 6 Diabetes Endocrine/Rare Eye Conditions Fertility Hepatitis C High Blood Cholesterol VENLAFAXINE HCL ER 37.5 MG TAB Retail-30. units, Mail-90. units VENLAFAXINE HCL ER 75 MG TAB Retail-30. units, Mail-90. units WELLBUTRIN SR 100 MG TABLET Retail-60. units, Mail-180. units WELLBUTRIN SR 150 MG TABLET Retail-60. units, Mail-180. units WELLBUTRIN SR 200 MG TABLET Retail-60. units, Mail-180. units WELLBUTRIN XL 150 MG TABLET Retail-30. units, Mail-90. units WELLBUTRIN XL 300 MG TABLET Retail-30. units, Mail-90. units ZOLOFT 100 MG TABLET Retail-60. units, Mail-180. units ZOLOFT 25 MG TABLET Retail-45. units, Mail-135. units ZOLOFT 50 MG TABLET Retail-60. units, Mail-180. units ACTOPLUS MET 15 MG-500 MG TAB Retail-90. units, Mail-270. units ACTOPLUS MET 15 MG-850 MG TAB Retail-90. units, Mail-270. units ACTOPLUS MET XR 15-1,000 MG TB Retail-60. units, Mail-180. units ACTOPLUS MET XR 30-1,000 MG TB Retail-30. units, Mail-90. units ACTOS 15 MG TABLET Retail-30. units, Mail-90. units AVANDAMET 2 MG-1,000 MG TAB Retail-60. units, Mail-180. units AVANDAMET 2 MG-500 MG TABLET Retail-60. units, Mail-180. units AVANDAMET 4 MG-1,000 MG TABLET Retail-60. units, Mail-180. units AVANDAMET 4 MG-500 MG TABLET Retail-60. units, Mail-180. units AVANDARYL 4 MG-1 MG TABLET Retail-30. units, Mail-90. units AVANDARYL 4 MG-2 MG TABLET Retail-30. units, Mail-90. units AVANDARYL 4 MG-4 MG TABLET Retail-30. units, Mail-90 units AVANDARYL 8 MG-2 MG TABLET Retail-30. units, Mail-90. units AVANDARYL 8 MG-4 MG TABLET Retail-30. units, Mail-90. units AVANDIA 2 MG TABLET Retail-60. units, Mail-180. units AVANDIA 4 MG TABLET Retail-60. units, Mail-180. units AVANDIA 8 MG TABLET Retail-30. units, Mail-90. units BYETTA 10 MCG DOSE PEN INJ Retail-3. units, Mail-8. units BYETTA 5 MCG DOSE PEN INJ Retail-2. units, Mail-4. units DUETACT 30-2 MG TABLET Retail-30. units, Mail-90. units DUETACT 30-4 MG TABLET Retail-30. units, Mail-90. units JANUVIA 100 MG TABLET Retail-30. units, Mail-90. units JANUVIA 25 MG TABLET Retail-30. units, Mail-90. units JANUVIA 50 MG TABLET Retail-30. units, Mail-90. units KOMBIGLYZE XR 2.5-1,000 MG TAB Retail-60. units, Mail-180. units KOMBIGLYZE XR 5-1,000 MG TAB Retail-30. units, Mail-90. units KOMBIGLYZE XR MG TABLET Retail-30. units, Mail-90. units ONGLYZA 2.5 MG TABLET Retail-30. units, Mail-90. units ONGLYZA 5 MG TABLET Retail-30. units, Mail-90. units PIOGLITAZONE HCL 30 MG TABLET Retail-30. units, Mail-90. units PIOGLITAZONE HCL 45 MG TABLET Retail-30. units, Mail-90. units PRANDIMET 1 MG-500 MG TABLET Retail-150. units, Mail-450. units PRANDIMET 2 MG-500 MG TABLET Retail-150. units, Mail-450. units SYMLINPEN 120 PEN INJECTOR Retail-19. units, Mail-57. units SYMLINPEN 60 PEN INJECTOR Retail-11. units, Mail-32. units VICTOZA 2-PAK 18 MG/3 ML PEN Retail-6. units, Mail-18. units VICTOZA 3-PAK 18 MG/3 ML PEN Retail-9. units, Mail-27. units CABERGOLINE TO BE DISP AT MAX QTY OF 8 TABLETS IN 21 DAYS OR 24 TABLETS IN 63 DAYS SAMSCA 15 MG TABLET Retail-30. units, Mail-90. units SAMSCA 30 MG TABLET Retail-60. units, Mail-180. units RESTASIS 0.05% EYE EMULSION Retail-60. units, Mail-180. units PREGNYL, NOVAREL 10,000 units PEGASYS PROCLICK 135MCG/0.5ML TO BE DISP AT A MAX QTY OF 2ML IN 21 DAYS OR 6ML IN 63 DAYS PEGASYS PROCLICK 180MCG/0.5ML TO BE DISP AT A MAX QTY OF 2ML IN 21 DAYS OR 6ML IN 63 DAYS PEGASYS SYRINGE KIT TO BE DISP AT MAX OF 1 PACKAGE IN 21 DAYS OR 3 PACKAGES IN 63 DAYS PEGASYS SYRINGE TO BE DISP AT A MAX QTY OF 2ML IN 21 DAYS OR 6ML IN 63 DAYS PEGASYS VIAL TO BE DISP AT A MAX QTY OF 4ML IN 21 DAYS OR 12ML IN 63 DAYS PEGINTRON 120MCG KIT TO BE DISP AT MAX OF 4 KITS IN 21 DAYS OR 12 KITS IN 63 DAYS PEGINTRON 150MCG KIT TO BE DISP AT MAX OF 4 KITS IN 21 DAYS OR 12 KITS IN 63 DAYS PEGINTRON 50MCG KIT TO BE DISP AT MAX OF 4 KITS IN 21 DAYS OR 12 KITS IN 63 DAYS PEGINTRON 80MCG KIT TO BE DISP AT MAX OF 4 KITS IN 21 DAYS OR 12 KITS IN 63 DAYS PEGINTRON REDIPEN 120MCG TO BE DISP AT MAX OF 4 PENS IN 21 DAYS OR 12 PENS IN 63 DAYS PEGINTRON REDIPEN 150MCG TO BE DISP AT MAX OF 4 PENS IN 21 DAYS OR 12 PENS IN 63 DAYS PEGINTRON REDIPEN 50MCG TO BE DISP AT MAX OF 4 PENS IN 21 DAYS OR 12 PENS IN 63 DAYS PEGINTRON REDIPEN 80MCG TO BE DISP AT MAX OF 4 PENS IN 21 DAYS OR 12 PENS IN 63 DAYS ADVICOR 1,000 MG-20 MG TABLET Retail-60. units, Mail-180. units ADVICOR 500 MG-20 MG TABLET Retail-30. units, Mail-90. units ADVICOR 750 MG-20 MG TABLET Retail-60. units, Mail-180. units ALTOPREV 20 MG TABLET Retail-30. units, Mail-90. units ALTOPREV 40 MG TABLET Retail-30. units, Mail-90. units ALTOPREV 60 MG TABLET Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST 5-10 MG Retail-30. units, Mail-90. units AMLODIPINE-ATORVAST 5-40 MG Retail-30. units, Mail-90. units ATORVASTATIN 80 MG TABLET Retail-30. units, Mail-90. units CADUET 10 MG-40 MG TABLET Retail-30. units, Mail-90. units CADUET 5 MG-20 MG TABLET Retail-30. units, Mail-90. units CADUET 5 MG-80 MG TABLET Retail-30. units, Mail-90. units CRESTOR 10 MG TABLET Retail-30. units, Mail-90. units CRESTOR 20 MG TABLET Retail-30. units, Mail-90. units CRESTOR 40 MG TABLET Retail-30. units, Mail-90. units CRESTOR 5 MG TABLET Retail-30. units, Mail-90. units LESCOL 20 MG CAPSULE Retail-30. units, Mail-90. units

4 Page 4 of 6 High Blood Pressure Hormone Supplementation Impotence Inflammatory Conditions Inflammatory Conditions - Specialty Mental/Neurological Disorders LESCOL 40 MG CAPSULE Retail-60. units, Mail-180. units LESCOL XL 80 MG TABLET Retail-30. units, Mail-90. units LIPITOR 10 MG TABLET Retail-30. units, Mail-90. units LIPITOR 20 MG TABLET Retail-30. units, Mail-90. units LIPITOR 40 MG TABLET Retail-30. units, Mail-90. units LIVALO 1 MG TABLET Retail-30. units, Mail-90. units LIVALO 2 MG TABLET Retail-30. units, Mail-90. units LIVALO 4 MG TABLET Retail-30. units, Mail-90. units LOVASTATIN 10 MG TABLET Retail-30. units, Mail-90. units LOVASTATIN 20 MG TABLET Retail-60. units, Mail-180. units LOVASTATIN 40 MG TABLET Retail-60. units, Mail-180. units PRAVASTATIN SODIUM 10 MG TAB Retail-30. units, Mail-90. units PRAVASTATIN SODIUM 20 MG TAB Retail-30. units, Mail-90. units PRAVASTATIN SODIUM 40 MG TAB Retail-30. units, Mail-90. units PRAVASTATIN SODIUM 80 MG TAB Retail-30. units, Mail-90. units SIMCOR 1, MG TABLET Retail-60. units, Mail-180. units SIMCOR 1, MG TABLET Retail-30. units, Mail-90. units SIMCOR MG TABLET Retail-30. units, Mail-90. units SIMCOR MG TABLET Retail-30. units, Mail-90. units SIMCOR MG TABLET Retail-60. units, Mail-180. units SIMVASTATIN 10 MG TABLET Retail-30. units, Mail-90. units SIMVASTATIN 20 MG TABLET Retail-30. units, Mail-90. units SIMVASTATIN 5 MG TABLET Retail-30. units, Mail-90. units SIMVASTATIN 80 MG TABLET Retail-30. units, Mail-90. units VYTORIN MG TABLET Retail-30. units, Mail-90. units VYTORIN MG TABLET Retail-30. units, Mail-90. units VYTORIN MG TABLET Retail-30. units, Mail-90. units VYTORIN MG TABLET Retail-30. units, Mail-90. units ZOCOR 40 MG TABLET Retail-30. units, Mail-90. units CARDURA 4 MG TABLET Retail-30. units, Mail-90. units CARDURA XL 4 MG TABLET Retail-30. units, Mail-90. units CARDURA XL 8 MG TABLET Retail-30. units, Mail-90. units CATAPRES-TTS 1 TO BE DISP AT A MAX QTY OF 4 PATCHES IN 21 DAYS OR 12 PATCHES IN 63 DAYS CATAPRES-TTS 2 TO BE DISP AT A MAX QTY OF 4 PATCHES IN 21 DAYS OR 12 PATCHES IN 63 DAYS CATAPRES-TTS 3 TO BE DISP AT A MAX QTY OF 4 PATCHES IN 21 DAYS OR 12 PATCHES IN 63 DAYS DOXAZOSIN MESYLATE 1 MG TAB Retail-30. units, Mail-90. units DOXAZOSIN MESYLATE 2 MG TAB Retail-30. units, Mail-90. units DOXAZOSIN MESYLATE 8 MG TAB Retail-60. units, Mail-180. units TERAZOSIN 1 MG CAPSULE Retail-30. units, Mail-90. units TERAZOSIN 10 MG CAPSULE Retail-60. units, Mail-180. units TERAZOSIN 2 MG CAPSULE Retail-30. units, Mail-90. units TERAZOSIN 5 MG CAPSULE Retail-30. units, Mail-90. units CLIMARA AND MENOSTAR PATCHES TO BE DISP AT MAX QTY OF 4 PATCHES IN 21 DAYS OR 12 PATCHES IN 63 DAYS CLIMARA PRO PATCH TO BE DISP AT MAX QTY OF 4 PATCHES IN 21 DAYS OR 12 PATCHES IN 63 DAYS DIVIGEL 0.25 MG GEL PACKET Retail-30. units, Mail-90. units DIVIGEL 0.5 MG GEL PACKET Retail-30. units, Mail-90. units DIVIGEL 1 MG GEL PACKET Retail-30. units, Mail-90. units ELESTRIN 0.06% GEL PS 26 Retail-52. units, Mail-156. units ESTRASORB PACKET Retail-98. units, Mail-293. units ESTROGEL 0.06% GEL Retail-50. units, Mail-150. units EVAMIST 1.53 MG/SPRAY Retail-17. units, Mail-49. units CIALIS 2.5 MG TABLET Retail-30. units, Mail-90. units CIALIS TO BE DISPENSED AT A MAXIMUM QUANTITY OF 6 units EDEX 10MCG CARTRIDGE 2-PK TO BE DISP AT A MAX QTY OF 6 units EDEX 10MCG CARTRIDGE KIT 6-PK TO BE DISP AT A MAX QTY OF 6 units EDEX 20MCG CARTRIDGE KIT 2-PK TO BE DISP AT A MAX QTY OF 6 units EDEX 20MCG CARTRIDGE KIT 6-PK TO BE DISP AT A MAX QTY OF 6 units EDEX 40MCG CARTRIDGE KIT 2-PK TO BE DISP AT A MAX QTY OF 6 units EDEX 40MCG CARTRIDGE KIT 6-PK TO BE DISP AT A MAX QTY OF 6 units SELECT ERECTILE DYSFXN DRUGS TO BE DISP AT A MAX QTY OF 6 units VIAGRA TO BE DISPENSED AT A MAXIMUM QUANTITY OF 6 units LEFLUNOMIDE 10 MG TABLET Retail-30. units, Mail-90. units LEFLUNOMIDE 20 MG TABLET Retail-30. units, Mail-90. units ENBREL 25 KITS ENBREL 25MG SYR MO/UM: SEL/DY ENBREL 25MG SYR: QUANTITY ENBREL 50MG, MO/UM: SEL/DY ENBREL 50MG: REJECT P/A HUMIRA 10MG TO BE DISPENSED AT A MAX QUANTITY OF 2 units HUMIRA 20MG TO BE DISPENSED AT A MAX QUANTITY OF 2 units ABILIFY 10 MG TABLET Retail-30. units, Mail-90. units ABILIFY 15 MG TABLET Retail-30. units, Mail-90. units ABILIFY 2 MG TABLET Retail-30. units, Mail-90. units ABILIFY 20 MG TABLET Retail-30. units, Mail-90. units ABILIFY 30 MG TABLET Retail-30. units, Mail-90. units ABILIFY 5 MG TABLET Retail-30. units, Mail-90. units ABILIFY DISCMELT 10 MG TABLET Retail-60. units, Mail-180. units ABILIFY DISCMELT 15 MG TABLET Retail-60. units, Mail-180. units FANAPT 1 MG TABLET Retail-60. units, Mail-180. units FANAPT 10 MG TABLET Retail-60. units, Mail-180. units FANAPT 12 MG TABLET Retail-60. units, Mail-180. units FANAPT 2 MG TABLET Retail-60. units, Mail-180. units FANAPT 4 MG TABLET Retail-60. units, Mail-180. units FANAPT 6 MG TABLET Retail-60. units, Mail-180. units FANAPT 8 MG TABLET Retail-60. units, Mail-180. units FANAPT TITRATION PACK Retail-8. units, Mail-24. units GENERIC RISPERIDONE 0.25MG ODT Retail-60. units, Mail-180. units GEODON 20 MG CAPSULE Retail-60. units, Mail-180. units GEODON 40 MG CAPSULE Retail-60. units, Mail-180. units GEODON 60 MG CAPSULE Retail-60. units, Mail-180. units

5 Page 5 of 6 Migraine Headaches Multiple Sclerosis Nausea/Vomiting GEODON 80 MG CAPSULE Retail-60. units, Mail-180. units INVEGA ER 1.5 MG TABLET Retail-30. units, Mail-90. units INVEGA ER 6 MG TABLET Retail-60. units, Mail-180. units INVEGA ER 9 MG TABLET Retail-30. units, Mail-90. units RISPERDAL 0.25 MG TABLET Retail-60. units, Mail-180. units RISPERDAL 0.5 MG TABLET Retail-60. units, Mail-180. units RISPERDAL 1 MG TABLET Retail-60. units, Mail-180. units RISPERDAL 2 MG TABLET Retail-60. units, Mail-180. units RISPERDAL 3 MG TABLET Retail-60. units, Mail-180. units RISPERDAL 4 MG TABLET Retail-60. units, Mail-180. units RISPERDAL M-TAB 0.5 MG Retail-60. units, Mail-180. units RISPERDAL M-TAB 1 MG Retail-60. units, Mail-180. units RISPERDAL M-TAB 2 MG Retail-60. units, Mail-180. units RISPERDAL M-TAB 3 MG Retail-60. units, Mail-180. units RISPERDAL M-TAB 4 MG Retail-60. units, Mail-180. units SAPHRIS 10 MG TAB SUBLINGUAL Retail-60. units, Mail-180. units SAPHRIS 5 MG TAB SUBLINGUAL Retail-60. units, Mail-180. units SEROQUEL 100 MG TABLET Retail-90. units, Mail-270. units SEROQUEL 200 MG TABLET Retail-90. units, Mail-270. units SEROQUEL 25 MG TABLET Retail-90. units, Mail-270. units SEROQUEL 300 MG TABLET Retail-60. units, Mail-180. units SEROQUEL 400 MG TABLET Retail-60. units, Mail-180. units SEROQUEL 50 MG TABLET Retail-90. units, Mail-270. units SEROQUEL XR 150 MG TABLET Retail-30. units, Mail-90. units SEROQUEL XR 200 MG TABLET Retail-30. units, Mail-90. units SEROQUEL XR 300 MG TABLET Retail-60. units, Mail-180. units SEROQUEL XR 400 MG TABLET Retail-60. units, Mail-180. units SEROQUEL XR 50 MG TABLET Retail-60. units, Mail-180. units ZYPREXA 10 MG TABLET Retail-30. units, Mail-90. units ZYPREXA 15 MG TABLET Retail-30. units, Mail-90. units ZYPREXA 2.5 MG TABLET Retail-30. units, Mail-90. units ZYPREXA 20MG TABLET Retail-30. units, Mail-90. units ZYPREXA 5 MG TABLET Retail-30. units, Mail-90. units ZYPREXA 7.5 MG TABLET Retail-30. units, Mail-90. units ZYPREXA ZYDIS 10MG TABLET Retail-30. units, Mail-90. units ZYPREXA ZYDIS 15MG TABLET Retail-30. units, Mail-90. units ZYPREXA ZYDIS 20MG TABLET Retail-30. units, Mail-90. units ZYPREXA ZYDIS 5MG TABLET Retail-30. units, Mail-90. units AMERGE, MO/UM: SEL/DY AMERGE: REJECT P/A AXERT 12.5, MO/UM: SEL/DY AXERT 12.5: REJECT P/A AXERT 12.5, MO/UM: SEL/DY AXERT 12.5: REJECT P/A AXERT 6.25MG, MO/UM: SEL/DY AXERT 6.25MG: QUANTITY BUTORPHANOL SPRAY TO BE DISP AT MAX QTY OF 5ML (2PKG) IN 21 DAYS OR 15ML (6 PKG) IN 63 DAYS CAMBIA, MO/UM: SEL/DY CAMBIA: QUANTITY FROVA, MO/UM: SEL/DY FROVA: QUANTITY IMITREX INJ VL, MO/UM: SEL/DY IMITREX INJ VIALS: QUANTITY IMITREX INJ VL, MO/UM: SEL/DY IMITREX INJ VIALS: REJECT P/A IMITREX NS 20MG, MO/UM: SEL/DY IMITREX NS 20MG: QUANTITY IMITREX NS 20MG, MO/UM: SEL/DY IMITREX NS 20MG: QUANTITY IMITREX NS 5MG, MO/UM: SEL/DY IMITREX NS 5MG: REJECT P/A IMITREX NS 5MG, MO/UM: SEL/DY IMITREX NS 5MG: REJECT P/A IMITREX TABS, MO/UM: SEL/DY IMITREX TABS: QUANTITY IMITREX TABS, MO/UM: SEL/DY IMITREX TABS: QUANTITY MAXALT, MO/UM: SEL/DY MAXALT: REJECT P/A MIGRANAL NS, MO/UM: SEL/DY MIGRANAL NS: REJECT P/A ONZETRA XSAIL 11MG TO BE DISP AT A MAX QTY OF 32 units RELPAX, MO/UM: SEL/DY RELPAX: REJECT P/A SUMAVEL DOSEPRO MO/UM: SEL/DY SUMAVEL DOSEPRO: QUANTITY SUMAVEL DOSEPRO MO/UM: SEL/DY SUMAVEL DOSEPRO: REJECT P/A TREXIMET, MO/UM: SEL/DY TREXIMET: REJECT P/A ZECUITY 6.5MG/4HR PATCH TO BE DISP AT A MAX QTY OF 4 PATCHES IN 21 DAYS OR 12 PATCHES IN 63 DAYS ZEMBRACE SYMTOUCH 3 MG/0.5 ML TO BE DISPENSED AT A MAX QUANTITY OF 4ML IN 21 DAYS OR 12ML IN 63 DAYS ZOMIG NS, MO/UM: SEL/DY ZOMIG NS: QUANTITY ZOMIG NS, MO/UM: SEL/DY ZOMIG NS: QUANTITY ZOMIG TABS, MO/UM: SEL/DY ZOMIG TABS: QUANTITY ZOMIG TABS, MO/UM: SEL/DY ZOMIG TABS: QUANTITY AVONEX ADMIN PACK 30MCG TO BE DISP AT A MAX QTY OF 4 KITS IN 21 DAYS OR 12 KITS IN 63 DAYS AVONEX PEN TO BE DISP AT A MAX QTY OF 4 PENS (1 BOX) IN 21 DAYS OR 12 PENS (3 BOXES) IN 63 DAYS AVONEX PREFILLED SYR 30MCG TO BE DISP AT MAX QTY OF 2ML IN 21 DAYS OR 6ML IN 63 DAYS AVONEX PREFILLED SYR KIT DISP AT A MAX QTY OF 1 KIT (4 SYR) IN 21 DAYS OR 3 KITS (12 SYR) IN 63 DAYS BETASERON KIT TO BE DISP AT A MAX QTY OF 14 KITS IN 23 DAYS OR 42 KITS IN 68 DAYS COPAXONE 20MG TO BE DISP AT MAX OF 30ML (30 SYRINGES) IN 23 DAYS OR 90ML (90 SYRINGES) IN 68 DAYS EXTAVIA 0.3MG VIAL TO BE DISP AT A MAX QTY OF 15 VIALS IN 23 DAYS OR 45 VIALS IN 68 DAYS EXTAVIA KIT TO BE DISP AT A MAX QTY OF 15 KITS IN 23 DAYS OR 45 KITS IN 68 DAYS REBIF, REBIF REBIDOSE 22MCG/0.5ML TO BE DISP AT A MAX QTY OF 6ML IN 21 DAYS OR 18ML IN 63 DAYS REBIF, REBIF REBIDOSE 44MCG/0.5ML TO BE DISP AT A MAX QTY OF 6ML IN 21 DAYS OR 18ML IN 63 DAYS REBIF, REBIF REBIDOSE TITRATION PACK TO BE DISP AT A MAX QTY OF 5ML IN 21 DAYS OR 13ML IN 63 DAYS ALOXI 0.25 MG/5 ML VIAL Retail-5. units, Mail-15. units ANZEMET 100 MG TABLET Retail-3. units, Mail-9. units ANZEMET 50 MG TABLET Retail-3. units, Mail-9. units CESAMET 1 MG CAPSULE Retail-30. units, Mail-90. units EMEND 125 MG CAPSULE Retail-1. units, Mail-3. units EMEND 150 MG VIAL Retail-1. units, Mail-3. units EMEND 40 MG CAPSULE Retail-1. units, Mail-3. units EMEND 80 MG CAPSULE Retail-2. units, Mail-6. units EMEND TRIFOLD PACK Retail-3. units, Mail-9. units GRANISETRON HCL 1 MG TABLET Retail-6. units, Mail-18. units GRANISOL 2 MG/10 ML SOLUTION Retail-30. units, Mail-90. units

6 Page 6 of 6 Oncology Agents Overactive Bladder Pain Pain - Narcotic Pulmonary Hypertension Sleep Disorder Ulcer Wound Care ONDANSETRON 4 MG/5 ML SOLUTION Retail-100. units, Mail-300. units ONDANSETRON HCL 24 MG TABLET Retail-1. units, Mail-3. units ONDANSETRON HCL 8 MG TABLET Retail-9. units, Mail-27. units ONDANSETRON ODT 8 MG TABLET Retail-9. units, Mail-27. units SANCUSO 3.1 MG/24 HR PATCH Retail-1. units, Mail-3. units ZUPLENZ 4 MG SOLUBLE FILM Retail-9. units, Mail-27. units ZUPLENZ 8 MG SOLUBLE FILM Retail-9. units, Mail-27. units IRESSA 250MG Retail-30. units, Mail-90. units NEXAVAR 200MG TABLET Retail-120. units, Mail-360. units SPRYCEL 100MG TABLET Retail-30. units, Mail-90. units SPRYCEL 20 MG TABLET Retail-60. units, Mail-180. units SPRYCEL 50 MG TABLET Retail-30. units, Mail-90. units SPRYCEL 70 MG TABLET Retail-60. units, Mail-180. units SUTENT 12.5 MG CAPSULE Retail-90. units, Mail-270. units SUTENT 25 MG CAPSULE Retail-30. units, Mail-90. units SUTENT 50 MG CAPSULE Retail-30. units, Mail-90. units TARCEVA 100 MG TABLET Retail-30. units, Mail-90. units TARCEVA 150 MG TABLET Retail-30. units, Mail-90. units TARCEVA 25 MG TABLET Retail-60. units, Mail-180. units GELNIQUE 10% GEL SACHETS Retail-30. units, Mail-90. units OXYTROL PATCH TO BE DISP AT A MAX QTY OF 8 PATCHES IN 21 DAYS OR 24 PATCHES IN 63 DAYS FLECTOR 1.3% PATCH Retail-60. units, Mail-180. units KETOROLAC 10 MG TABLET Retail-20. units, Mail-60. units MELOXICAM 7.5 MG TABLET Retail-30. units, Mail-90. units RYBIX ODT 50 MG TABLET Retail-240. units, Mail-720. units TRAMADOL HCL 50 MG TABLET Retail-240. units, Mail-720. units TRAMADOL HCL ER 100 MG TABLET Retail-30. units, Mail-90. units TRAMADOL HCL ER 150 MG CAPSULE Retail-60. units, Mail-180. units TRAMADOL HCL ER 300 MG TABLET Retail-30. units, Mail-90. units TRAMADOL-ACETAMINOPHN Retail-240. units, Mail-720. units ULTRAM ER 200 MG TABLET Retail-30. units, Mail-90. units ABSTRAL #90 per 30 days ACTIQ #90 per 30 days FENTORA #90 per 30 days LAZANDA #23 per 30 days NUCYNTA 100 MG TABLET Retail-181. units, Mail-543. units NUCYNTA 50 MG TABLET Retail-181. units, Mail-543. units NUCYNTA 75 MG TABLET Retail-181. units, Mail-543. units ONSOLIS #90 per 30 days OXYCONTIN #90 per 30 days SUBOXONE 2 MG-0.5 MG SL FILM Retail-90. units, Mail-270. units SUBOXONE 2 MG-0.5 MG TABLET Retail-90. units, Mail-270. units SUBOXONE 8 MG-2 MG SL FILM Retail-90. units, Mail-270. units SUBOXONE 8 MG-2 MG TABLET SL Retail-90. units, Mail-270. units SUBSYS #90 per 30 days ADCIRCA 20 MG TABLET Retail-60. units, Mail-180. units SILDENAFIL 20 MG TABLET Retail-90. units, Mail-270. units Ambien, Belsomra, Edluar, Halcion, Intermezzo, Lunesta, Silenor, Sonata, Restoril; (AND all generics) #15 per 30 days HETLIOZ 20MG Retail-30. units, Mail-90. units Zolimist one bottle per 30 days ACIPHEX SPRINKLE 10MG Retail-30. units, Mail-90. units ACIPHEX SPRINKLE 5MG Retail-30. units, Mail-90. units DEXILANT DR 30 MG CAPSULE Retail-30. units, Mail-90. units NEXIUM DR 10 MG PACKET Retail-30. units, Mail-90. units NEXIUM DR 2.5 MG PACKET Retail-30. units, Mail-90. units NEXIUM DR 20 MG PACKET Retail-30. units, Mail-90. units NEXIUM DR 5 MG PACKET Retail-30. units, Mail-90. units NEXIUM RX DR 20 MG CAPSULE Retail-30. units, Mail-90. units OMEPRAZOLE DR 10 MG CAPSULE Retail-30. units, Mail-90. units OMEPRAZOLE DR 20 MG CAPSULE Retail-30. units, Mail-90. units PANTOPRAZOLE SOD DR 20 MG TAB Retail-30. units, Mail-90. units PREVACID 15 MG SOLUTAB Retail-30. units, Mail-90. units PREVACID 24HR DR 15 MG CAPSULE Retail-30. units, Mail-90. units PREVPAC PATIENT PACK Retail-112. units, Mail-336. units PRILOSEC DR 10 MG SUSPENSION Retail-30. units, Mail-90. units PRILOSEC DR 2.5 MG SUSPENSION Retail-60. units, Mail-180. units ZEGERID 20 MG PACKET Retail-30. units, Mail-90. units ZEGERID RX 20-1,100 MG CAP Retail-30. units, Mail-90. units REGRANEX 0.01% GEL Retail-15. units, Mail-45. units