How do I request an exception to the Liberty Health Advantage s Formulary?

QUANTITY LIMITATIONS How do I request an exception to the Liberty Health Advantage s Formulary? You can ask Liberty Health Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Liberty Health Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier. Generally, Liberty Health Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician s supporting statement. Your physician must submit a statement supporting your coverage determination or exception request. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception request. What if I have additional questions? You can call us at: 1-800-546-5677 (seven days a week, 24 hours a day) if you have any additional questions. If you have a hearing or speech impairment, please call us at TTY 1-866- 706-4757.

ABILIFY SOL1MG/ML Quantity limitation 900 per 30 days ABILIFY TAB10MG ABILIFY TAB15MG ABILIFY TAB20MG ABILIFY TAB2MG Quantity limitation 450 per 30 days ABILIFY TAB30MG ABILIFY TAB5MG ABILIFY DISCTAB10MG ABILIFY DISCTAB15MG ACTONEL TAB150MG Quantity limitation 5 per 30 days ACTONEL TAB30MG Quantity limitation 5 per 30 days ACTONEL TAB35MG Quantity limitation 5 per 30 days ACTONEL TAB5MG ACTOPLUS METTAB15-500MG ACTOPLUS METTAB15-850MG ACTOS TAB15MG ACTOS TAB30MG ACTOS TAB45MG ADCIRCA TAB20MG ADVAIR DISKUAER100/50 ADVAIR DISKUAER250/50 ADVAIR DISKUAER500/50 ADVAIR HFA AER115/21 Quantity limitation 12 per 30 days ADVAIR HFA AER230/21 Quantity limitation 12 per 30 days ADVAIR HFA AER45/21 Quantity limitation 12 per 30 days ADVICOR TAB1000-20 ADVICOR TAB1000-40 ADVICOR TAB500-20MG ADVICOR TAB750-20MG AFINITOR TAB10MG AFINITOR TAB2.5MG AFINITOR TAB5MG AFINITOR TAB7.5MG ALENDRONATE TAB10MG ALENDRONATE TAB35MG Quantity limitation 5 per 30 days ALENDRONATE TAB40MG ALENDRONATE TAB5MG ALENDRONATE TAB70MG Quantity limitation 5 per 30 days ALORA DIS0.025MG Quantity limitation 8 per 28 days ALORA DIS0.05MG Quantity limitation 8 per 28 days ALORA DIS0.075MG Quantity limitation 8 per 28 days ALORA DIS0.1MG Quantity limitation 8 per 28 days ALOXI INJ0.25MG/5 Quantity limitation 150 per 30 days AMITIZA CAP24MCG

AMITIZA CAP8MCG AMLOD/BENAZPCAP10-20MG AMLOD/BENAZPCAP10-40MG AMLOD/BENAZPCAP2.5-10MG AMLOD/BENAZPCAP5-10MG AMLOD/BENAZPCAP5-20MG AMLOD/BENAZPCAP5-40MG AMLODIPINE TAB10MG AMLODIPINE TAB2.5MG AMLODIPINE TAB5MG AMTURNIDE300TAB-5-12.5 AMTURNIDE300TAB-5-25MG ANASTROZOLE TAB1MG ANDROGEL GEL1%(50MG) Quantity limitation 300 per 30 days ANZEMET INJ20MG/ML Quantity limitation 50 per 30 days ANZEMET TAB100MG ANZEMET TAB50MG APAP/CODEINETAB300-15MG Quantity limitation 400 per 30 days APAP/CODEINETAB300-30MG Quantity limitation 400 per 30 days APAP/CODEINETAB300-60MG Quantity limitation 400 per 30 days APTIVUS SOL Quantity limitation 300 per 30 days ARANESP INJ100MCG Quantity limitation 2 per 28 days ARANESP INJ100MCG ARANESP INJ150MCG Quantity limitation 1.2 per 28 days ARANESP INJ200MCG Quantity limitation 1.6 per 28 days ARANESP INJ200MCG ARANESP INJ25MCG Quantity limitation 1.68 per 28 days ARANESP INJ25MCG ARANESP INJ300MCG Quantity limitation 2.4 per 28 days ARANESP INJ300MCG ARANESP INJ40MCG Quantity limitation 1.6 per 28 days ARANESP INJ40MCG ARANESP INJ500MCG ARANESP INJ60MCG Quantity limitation 1.2 per 28 days ARANESP INJ60MCG ARCAPTA CAP75MCG ASACOL HD TAB800MG ASCOMP/COD CAP30MG ASMANEX 120 AER220MCG Quantity limitation 2 per 30 days ASMANEX 14 AER220MCG Quantity limitation 4 per 30 days ASMANEX 30 AER110MCG Quantity limitation 2 per 30 days ASMANEX 30 AER220MCG Quantity limitation 2 per 30 days ASMANEX 60 AER220MCG Quantity limitation 2 per 30 days ASTEPRO SPR0.15% ATORVASTATINTAB10MG

ATORVASTATINTAB20MG ATORVASTATINTAB40MG ATORVASTATINTAB80MG ATROVENT HFAAER17MCG Quantity limitation 25.8 per 30 days AVINZA CAP120MG AVINZA CAP30MG AVINZA CAP45MG AVINZA CAP60MG AVINZA CAP75MG AVINZA CAP90MG AVODART CAP0.5MG AVONEX KIT30MCG AVONEX PREFLKIT30MCG AZITHROMYCINSUS100/5ML Quantity limitation 30 per 5 days AZITHROMYCINSUS200/5ML Quantity limitation 90 per 5 days AZITHROMYCINTAB250MG Quantity limitation 6 per 5 days AZITHROMYCINTAB500MG Quantity limitation 6 per 5 days AZITHROMYCINTAB600MG Quantity limitation 6 per 5 days BANZEL SUS40MG/ML Quantity limitation 2400 per 30 days BANZEL TAB200MG BANZEL TAB400MG BARACLUDE SOL.05MG/ML Quantity limitation 600 per 30 days BARACLUDE TAB0.5MG BARACLUDE TAB1MG BECONASE AQ SUS0.042% Quantity limitation 50 per 30 days BETASERON INJ0.3MG Quantity limitation 15 per 30 days BICALUTAMIDETAB50MG BONIVA INJ3MG/3ML Quantity limitation 1 per 30 days BRILINTA TAB90MG BROMDAY SOL0.09% Quantity limitation 3.4 per 30 days BUDEPRION TAB100MG SR BUDEPRION TAB150MG SR BUDEPRION XLTAB150MG BUDEPRION XLTAB300MG BUPROBAN TAB150MG BUPROPION TAB100MG BUPROPION TAB100MG SR BUPROPION TAB150MG SR BUPROPION TAB200MG SR BUPROPION TAB75MG BUTORPHANOL SOL10MG/ML Quantity limitation 10 per 30 days BYETTA INJ10MCG Quantity limitation 2.4 per 30 days BYETTA INJ5MCG Quantity limitation 2.4 per 30 days CAPRELSA TAB100MG CAPRELSA TAB300MG

CARVEDILOL TAB12.5MG CARVEDILOL TAB25MG CARVEDILOL TAB3.125MG CARVEDILOL TAB6.25MG CELEBREX CAP100MG CELEBREX CAP200MG CELEBREX CAP400MG CELEBREX CAP50MG CHANTIX PAK0.5& 1MG CHANTIX TAB0.5MG CHANTIX TAB1MG CITALOPRAM TAB10MG CITALOPRAM TAB20MG CITALOPRAM TAB40MG CLARITHROMYCTAB250MG Quantity limitation 28 per 14 days CLARITHROMYCTAB500MG Quantity limitation 28 per 14 days CLARITHROMYCTAB500MG ER Quantity limitation 28 per 14 days CLONIDINE DIS0.1/24HR CLONIDINE DIS0.2/24HR CLONIDINE DIS0.3/24HR CLOPIDOGREL TAB300MG CLOPIDOGREL TAB75MG CLORAZ DIPOTTAB15MG CLORAZ DIPOTTAB3.75MG CLORAZ DIPOTTAB7.5MG CLOZAPINE TAB100MG CLOZAPINE TAB200MG CLOZAPINE TAB25MG CLOZAPINE TAB50MG CO-GESIC TAB500-5MG COLCRYS TAB0.6MG COMBIVENT AER Quantity limitation 29.4 per 30 days COMPLERA TAB COMTAN TAB200MG COPAXONE KIT20MG/ML CRESTOR TAB10MG CRESTOR TAB20MG CRESTOR TAB40MG CRESTOR TAB5MG CYMBALTA CAP20MG CYMBALTA CAP30MG CYMBALTA CAP60MG DENAVIR CRE1% Quantity limitation 1.5 per 28 days DEXMETHYLPH TAB10MG DEXMETHYLPH TAB2.5MG

DEXMETHYLPH TAB5MG DIAZEPAM CON5MG/ML DIAZEPAM GEL10MG DIAZEPAM GEL2.5MG DIAZEPAM SOL1MG/ML Quantity limitation 1200 per 30 days DIAZEPAM TAB10MG DIAZEPAM TAB2MG DIAZEPAM TAB5MG DIOVAN HCT TAB160/12.5 DIOVAN HCT TAB160-25MG DIOVAN HCT TAB320/12.5 DIOVAN HCT TAB320-25MG DIOVAN HCT TAB80/12.5 DONEPEZIL TAB10MG DONEPEZIL TAB10MG ODT DONEPEZIL TAB5MG DONEPEZIL TAB5MG ODT DOXAZOSIN TAB1MG DOXAZOSIN TAB2MG DOXAZOSIN TAB4MG DOXAZOSIN TAB8MG EDURANT TAB25MG EFFIENT TAB10MG EFFIENT TAB5MG ELIDEL CRE1% EMEND CAP125MG EMEND CAP40MG EMEND CAP80MG Quantity limitation 2 per 30 days EMEND PAK80 & 125 Quantity limitation 3 per 3 days EMSAM DIS12MG/24H EMSAM DIS6MG/24HR EMSAM DIS9MG/24HR ENBREL INJ25/0.5ML Quantity limitation 8 per 28 days ENBREL INJ25MG Quantity limitation 16 per 28 days ENBREL INJ50MG/ML Quantity limitation 8 per 28 days ENDOCET TAB10-325MG ENDOCET TAB10-650MG ENDOCET TAB5-325MG ENDOCET TAB7.5-325M ENDOCET TAB7.5-500M ENOXAPARIN INJ100MG/ML Quantity limitation 28 per 30 days ENOXAPARIN INJ120/0.8 Quantity limitation 22.4 per 30 days ENOXAPARIN INJ150MG/ML Quantity limitation 28 per 30 days ENOXAPARIN INJ30/0.3ML Quantity limitation 8.4 per 30 days ENOXAPARIN INJ40/0.4ML Quantity limitation 11.2 per 30 days

ENOXAPARIN INJ60/0.6ML Quantity limitation 16.8 per 30 days ENOXAPARIN INJ80/0.8ML Quantity limitation 22.4 per 30 days EPIPEN 2-PAKINJ0.3MG Quantity limitation 2 per 30 days EPIPEN-JR INJ2-PAK Quantity limitation 2 per 30 days EPOGEN INJ2000/ML Quantity limitation 12 per 28 days EPOGEN INJ3000/ML Quantity limitation 12 per 28 days EPOGEN INJ4000/ML Quantity limitation 12 per 28 days ESCITALOPRAMSOL5MG/5ML Quantity limitation 620 per 30 days ESCITALOPRAMTAB10MG ESCITALOPRAMTAB20MG ESCITALOPRAMTAB5MG ESTRADIOL DIS0.025MG ESTRADIOL DIS0.0375MG ESTRADIOL DIS0.05MG ESTRADIOL DIS0.06MG ESTRADIOL DIS0.075MG ESTRADIOL DIS0.1MG ESTRING MIS2MG Quantity limitation 1 per 90 days EVISTA TAB60MG EXELON SOL2MG/ML EXFORGEH/10-TAB160-12.5 EXFORGEH/10-TAB160-25 EXFORGEH/10-TAB320-25 EXFORGEH/5- TAB160-12.5 EXFORGEH/5- TAB160-25 FAMCICLOVIR TAB125MG Quantity limitation 21 per 10 days FAMCICLOVIR TAB250MG FAMCICLOVIR TAB500MG Quantity limitation 21 per 7 days FANAPT PAK FANAPT TAB10MG FANAPT TAB12MG FANAPT TAB1MG Quantity limitation 720 per 30 days FANAPT TAB2MG FANAPT TAB4MG FANAPT TAB6MG FANAPT TAB8MG FAZACLO TAB100MG Quantity limitation 270 per 30 days FAZACLO TAB12.5MG FAZACLO TAB150MG FAZACLO TAB200MG FAZACLO TAB25MG Quantity limitation 270 per 30 days FENOFIBRATE CAP134MG FENOFIBRATE CAP200MG FENOFIBRATE CAP67MG FENOFIBRATE TAB160MG

FENOFIBRATE TAB54MG FENTANYL DIS100MCG/H FENTANYL DIS12MCG/HR FENTANYL DIS25MCG/HR FENTANYL DIS50MCG/HR FENTANYL DIS75MCG/HR FENTANYL OT LOZ1200MCG FENTANYL OT LOZ1600MCG FENTANYL OT LOZ200MCG FENTANYL OT LOZ400MCG FENTANYL OT LOZ600MCG FENTANYL OT LOZ800MCG FINASTERIDE TAB5MG FIRMAGON INJ120MG Quantity limitation 2 per 28 days FLOVENT DISKAER100MCG FLOVENT DISKAER250MCG Quantity limitation 300 per 30 days FLOVENT DISKAER50MCG FLOVENT HFA AER110MCG Quantity limitation 24 per 30 days FLOVENT HFA AER220MCG Quantity limitation 24 per 30 days FLOVENT HFA AER44MCG Quantity limitation 21.2 per 30 days FLUCONAZOLE TAB150MG Quantity limitation 2 per 7 days FLUNISOLIDE SPR0.025% Quantity limitation 50 per 30 days FLUOXETINE CAP10MG FLUOXETINE CAP40MG FLUOXETINE TAB10MG FLUTICASONE SPR50MCG Quantity limitation 16 per 30 days FLUVOXAMINE TAB100MG FLUVOXAMINE TAB25MG FLUVOXAMINE TAB50MG FORADIL CAPAEROLIZE FRAGMIN INJ10000/ML Quantity limitation 20 per 30 days FRAGMIN INJ12500UNT Quantity limitation 20 per 30 days FRAGMIN INJ15000UNT Quantity limitation 20 per 30 days FRAGMIN INJ18000UNT Quantity limitation 20 per 30 days FRAGMIN INJ2500/0.2 Quantity limitation 20 per 30 days FRAGMIN INJ25000/ML Quantity limitation 20 per 30 days FRAGMIN INJ5000/0.2 Quantity limitation 20 per 30 days FRAGMIN INJ7500/0.3 Quantity limitation 20 per 30 days GABAPENTIN CAP100MG GABAPENTIN CAP300MG GABAPENTIN CAP400MG Quantity limitation 270 per 30 days GABAPENTIN TAB600MG GABAPENTIN TAB800MG GALANTAMINE CAP16MG ER GALANTAMINE CAP24MG ER

GALANTAMINE CAP8MG ER GALANTAMINE SOL4MG/ML GLEEVEC TAB100MG GLEEVEC TAB400MG GLIMEPIRIDE TAB1MG GLIMEPIRIDE TAB2MG GLIMEPIRIDE TAB4MG GLIP/METFORMTAB2.5-250M GLIP/METFORMTAB2.5-500M GLIP/METFORMTAB5-500MG GLIPIZIDE TAB10MG GLIPIZIDE TAB5MG GLIPIZIDE ERTAB10MG GLIPIZIDE ERTAB2.5MG GLIPIZIDE ERTAB5MG GLUCAGEN INJHYPOKIT GLUCAGON KIT1MG Quantity limitation 2 per 30 days GLYB/METFORMTAB1.25-250 GLYB/METFORMTAB2.5-500 GLYB/METFORMTAB5-500MG GLYBURID MCRTAB1.5MG GLYBURID MCRTAB3MG GLYBURID MCRTAB6MG GLYBURIDE TAB1.25MG Quantity limitation 480 per 30 days GLYBURIDE TAB2.5MG GLYBURIDE TAB5MG GRANISETRON TAB1MG HUMALOG INJ100/ML HUMALOG KWIKINJ100/ML HUMALOG MIX INJ50/50 HUMALOG MIX INJ50/50KWP HUMALOG MIX INJ75/25KWP HUMALOG MIX SUS75/25 HUMIRA KIT20MG/0.4 Quantity limitation 8 per 28 days HUMIRA KIT40MG/0.8 Quantity limitation 8 per 28 days HUMIRA PEN KITCROHNS Quantity limitation 8 per 28 days HUMULIN INJ70/30 HUMULIN N INJU-100 HUMULIN N PNINJU-100 HUMULIN PEN INJ70/30 HUMULIN R INJU-100 HUMULIN R INJU-500 HYDROCO/APAPSOL7.5-500 Quantity limitation 3600 per 30 days HYDROCO/APAPTAB10-325MG HYDROCO/APAPTAB10-500MG

HYDROCO/APAPTAB10-650MG HYDROCO/APAPTAB10-660MG HYDROCO/APAPTAB10-750MG Quantity limitation 150 per 30 days HYDROCO/APAPTAB2.5-500 HYDROCO/APAPTAB5-325MG HYDROCO/APAPTAB5-500MG HYDROCO/APAPTAB7.5-325 HYDROCO/APAPTAB7.5-500 HYDROCO/APAPTAB7.5-650 HYDROCO/APAPTAB7.5-750 Quantity limitation 150 per 30 days HYDROCOD/IBUTAB7.5-200 Quantity limitation 480 per 30 days HYDROMORPHONTAB2MG HYDROMORPHONTAB4MG HYDROMORPHONTAB8MG INCIVEK TAB375MG INTELENCE TAB100MG INVEGA TAB1.5MG INVEGA TAB3MG INVEGA TAB6MG INVEGA TAB9MG IPRATROPIUM SPR0.03% IPRATROPIUM SPR0.06% JAKAFI TAB10MG JAKAFI TAB15MG JAKAFI TAB20MG JAKAFI TAB25MG JAKAFI TAB5MG JALYN CAP JANUMET TAB50-1000 JANUMET TAB50-500MG JANUMET XR TAB100-1000 JANUMET XR TAB50-1000 JANUMET XR TAB50-500MG JANUVIA TAB100MG JANUVIA TAB25MG JANUVIA TAB50MG JUVISYNC TAB100-10MG JUVISYNC TAB100-20MG JUVISYNC TAB100-40MG LANSOPRAZOLECAP15MG DR LANSOPRAZOLECAP30MG DR LANTUS INJ100/ML LANTUS INJSOLOSTAR LATANOPROST SOL0.005% Quantity limitation 5 per 30 days LATUDA TAB20MG

LATUDA TAB40MG LATUDA TAB80MG LEFLUNOMIDE TAB10MG LEFLUNOMIDE TAB20MG LETROZOLE TAB2.5MG LEVEMIR INJ LEVETIRACETATAB500MG ER LEVETIRACETATAB750MG ER LEVOFLOXACINTAB250MG Quantity limitation 14 per 14 days LEVOFLOXACINTAB500MG Quantity limitation 14 per 14 days LEVOFLOXACINTAB750MG Quantity limitation 14 per 14 days LEVORPHANOL TAB2MG LIDODERM DIS5% LOSARTAN POTTAB100MG LOSARTAN POTTAB25MG LOSARTAN POTTAB50MG LOSARTAN/HCTTAB100-12.5 LOSARTAN/HCTTAB100-25 LOSARTAN/HCTTAB50-12.5 LOTRONEX TAB0.5MG LOTRONEX TAB1MG LOVASTATIN TAB10MG LOVASTATIN TAB20MG LOVASTATIN TAB40MG LOVENOX INJ300/3ML Quantity limitation 84 per 30 days LUMIGAN SOL0.01% Quantity limitation 7.5 per 30 days LUMIGAN SOL0.03% Quantity limitation 7.5 per 30 days MEDROXYPR ACINJ150MG/ML Quantity limitation 1 per 90 days MELOXICAM TAB15MG MELOXICAM TAB7.5MG METFORMIN TAB1000MG METFORMIN TAB500MG Quantity limitation 150 per 30 days METFORMIN TAB500MG ER METFORMIN TAB750MG ER METFORMIN TAB850MG METHADONE TAB10MG METHADONE TAB5MG METHADOSE TAB10MG METOPROLOL TAB100MG ER METOPROLOL TAB200MG ER METOPROLOL TAB25MG ER METOPROLOL TAB50MG ER MICONAZOLE 3SUP200MG Quantity limitation 3 per 3 days MIRTAZAPINE TAB15MG MIRTAZAPINE TAB15MG ODT

MIRTAZAPINE TAB30MG MIRTAZAPINE TAB30MG ODT MIRTAZAPINE TAB45MG MIRTAZAPINE TAB45MG ODT MIRTAZAPINE TAB7.5MG MORPHINE SULCAP100MG ER MORPHINE SULCAP20MG ER MORPHINE SULCAP30MG ER MORPHINE SULCAP50MG ER MORPHINE SULCAP60MG ER MORPHINE SULCAP80MG ER MORPHINE SULTAB100MG ER MORPHINE SULTAB15MG MORPHINE SULTAB15MG ER MORPHINE SULTAB200MG ER MORPHINE SULTAB30MG MORPHINE SULTAB30MG ER MORPHINE SULTAB60MG ER MULTAQ TAB400MG NAMENDA SOL10MG/5ML NAMENDA TAB10MG NAMENDA TAB5-10MG NAMENDA TAB5MG NARATRIPTAN TAB1MG Quantity limitation 9 per 30 days NARATRIPTAN TAB2.5MG Quantity limitation 9 per 30 days NATEGLINIDE TAB120MG NATEGLINIDE TAB60MG NEULASTA INJ6MG/0.6M Quantity limitation 2 per 30 days NEUMEGA INJ5MG Quantity limitation 21 per 21 days NEXAVAR TAB200MG NIASPAN TAB1000 ER NIASPAN TAB500MG ER NIASPAN TAB750MG ER NICOTROL NS SPR10MG/ML Quantity limitation 40 per 30 days NOVOLIN INJ70/30 NOVOLIN N INJU-100 NOVOLIN R INJU-100 NOVOLOG INJ100/ML NOVOLOG INJFLEXPEN NOVOLOG MIX INJ70/30 NOVOLOG MIX INJFLEXPEN OLANZAPINE TAB10MG OLANZAPINE TAB10MG ODT OLANZAPINE TAB15MG OLANZAPINE TAB15MG ODT

OLANZAPINE TAB2.5MG OLANZAPINE TAB20MG OLANZAPINE TAB20MG ODT OLANZAPINE TAB5MG OLANZAPINE TAB5MG ODT OLANZAPINE TAB7.5MG OMEPRAZOLE CAP10MG OMEPRAZOLE CAP20MG OMEPRAZOLE CAP40MG ONDANSETRON SOL4MG/5ML Quantity limitation 150 per 5 days ONDANSETRON TAB24MG ONDANSETRON TAB4MG Quantity limitation 12 per 5 days ONDANSETRON TAB4MG ODT Quantity limitation 12 per 5 days ONDANSETRON TAB8MG Quantity limitation 12 per 5 days ONDANSETRON TAB8MG ODT Quantity limitation 12 per 5 days ONFI TAB10MG ONFI TAB20MG ONFI TAB5MG OXYBUTYNIN TAB10MG ER OXYBUTYNIN TAB15MG ER OXYBUTYNIN TAB5MG ER OXYCOD/APAP CAP5-500MG OXYCOD/APAP TAB10-325MG OXYCOD/APAP TAB10-650MG OXYCOD/APAP TAB2.5-325 OXYCOD/APAP TAB5-325MG OXYCOD/APAP TAB7.5-325 OXYCOD/APAP TAB7.5-500 OXYCOD/ASA TAB OXYCODONE TAB5MG OXYCONTIN TAB10MG CR OXYCONTIN TAB15MG CR OXYCONTIN TAB20MG CR OXYCONTIN TAB30MG CR OXYCONTIN TAB40MG CR OXYCONTIN TAB60MG CR OXYCONTIN TAB80MG CR OXYTROL DIS3.9MG/24 Quantity limitation 8 per 28 days PANTOPRAZOLETAB20MG PANTOPRAZOLETAB40MG PAROXETIN ERTAB12.5MG Quantity limitation 150 per 30 days PAROXETIN ERTAB37.5MG PAROXETINE TAB10MG PAROXETINE TAB20MG PAROXETINE TAB25MG ER

PAROXETINE TAB30MG PAROXETINE TAB40MG Quantity limitation 45 per 30 days PEGASYS KIT Quantity limitation 2 per 28 days PEG-INTRON KIT120 RP PEG-INTRON KIT150 RP PEG-INTRON KIT50MCG Quantity limitation 5 per 28 days PEG-INTRON KIT50MCG RP PEG-INTRON KIT80MCG RP PHENOBARB ELX20MG/5ML Quantity limitation 1500 per 30 days PHENOBARB TAB16.2MG PHENOBARB TAB30MG Quantity limitation 195 per 30 days PHENOBARB TAB32.4MG PHENOBARB TAB64.8MG PHENOBARB TAB97.2MG POTIGA TAB200MG POTIGA TAB300MG POTIGA TAB400MG POTIGA TAB50MG Quantity limitation 720 per 30 days PRADAXA CAP150MG PRADAXA CAP75MG PRAMIPEXOLE TAB0.125MG PRAMIPEXOLE TAB0.25MG PRAMIPEXOLE TAB0.5MG PRAMIPEXOLE TAB0.75MG PRAMIPEXOLE TAB1.5MG PRAMIPEXOLE TAB1MG PRAVASTATIN TAB10MG PRAVASTATIN TAB20MG PRAVASTATIN TAB40MG PRAVASTATIN TAB80MG PRISTIQ TAB100MG PRISTIQ TAB50MG PROAIR HFA AER Quantity limitation 17 per 30 days PROCRIT INJ2000/ML Quantity limitation 12 per 28 days PROCRIT INJ3000/ML Quantity limitation 12 per 28 days PROCRIT INJ4000/ML Quantity limitation 12 per 28 days PROMACTA TAB25MG PROMACTA TAB50MG PROMACTA TAB75MG PROTOPIC OIN0.03% PROTOPIC OIN0.1% PROVENTIL AERHFA Quantity limitation 13.4 per 30 days PROVIGIL TAB100MG PROVIGIL TAB200MG PULMICORT INH180MCG Quantity limitation 2 per 30 days

PULMICORT INH90MCG Quantity limitation 2 per 30 days QUETIAPINE TAB100MG QUETIAPINE TAB200MG QUETIAPINE TAB25MG Quantity limitation 960 per 30 days QUETIAPINE TAB300MG QUETIAPINE TAB400MG QUETIAPINE TAB50MG Quantity limitation 480 per 30 days QVAR AER40MCG Quantity limitation 21.9 per 30 days QVAR AER80MCG Quantity limitation 21.9 per 30 days RAMIPRIL CAP1.25MG RAMIPRIL CAP10MG RAMIPRIL CAP2.5MG RAMIPRIL CAP5MG RANEXA TAB1000MG RANEXA TAB500MG REBIF INJ22/0.5 Quantity limitation 12 per 30 days REBIF INJ44/0.5 Quantity limitation 12 per 30 days REBIF TITRTNSOLPACK Quantity limitation 6 per 30 days REGRANEX GEL0.01% Quantity limitation 15 per 30 days RELENZA MISDISKHALE Quantity limitation 60 per 180 days RELPAX TAB20MG Quantity limitation 6 per 30 days RELPAX TAB40MG Quantity limitation 6 per 30 days REQUIP XL TAB12MG REQUIP XL TAB2MG REQUIP XL TAB4MG REQUIP XL TAB8MG RESTASIS EMU0.05% RHINOCORT SUSAQUA Quantity limitation 17.2 per 30 days RISPERIDONE SOL1MG/ML Quantity limitation 480 per 30 days RISPERIDONE TAB0.25 ODT Quantity limitation 1920 per 30 days RISPERIDONE TAB0.25MG Quantity limitation 1920 per 30 days RISPERIDONE TAB0.5MG Quantity limitation 960 per 30 days RISPERIDONE TAB0.5MG OD Quantity limitation 960 per 30 days RISPERIDONE TAB1MG Quantity limitation 480 per 30 days RISPERIDONE TAB1MG ODT Quantity limitation 480 per 30 days RISPERIDONE TAB2MG RISPERIDONE TAB2MG ODT RISPERIDONE TAB3MG RISPERIDONE TAB3MG ODT RISPERIDONE TAB4MG RISPERIDONE TAB4MG ODT RIVASTIGMINECAP1.5MG RIVASTIGMINECAP3MG RIVASTIGMINECAP4.5MG RIVASTIGMINECAP6MG

ROXICET SOL5-325/5 Quantity limitation 1800 per 30 days ROXICET TAB5-500MG SABRIL POW500MG SABRIL TAB500MG SANDOSTATIN KITLAR 10MG Quantity limitation 5 per 28 days SANDOSTATIN KITLAR 20MG Quantity limitation 5 per 28 days SANDOSTATIN KITLAR 30MG Quantity limitation 5 per 28 days SANTYL OIN250/GM SAPHRIS SUB10MG SAPHRIS SUB5MG SEREVENT DISAER50MCG SEROQUEL XR TAB150MG SEROQUEL XR TAB200MG SEROQUEL XR TAB300MG SEROQUEL XR TAB400MG SEROQUEL XR TAB50MG SERTRALINE CON20MG/ML Quantity limitation 300 per 30 days SERTRALINE TAB100MG SERTRALINE TAB25MG SERTRALINE TAB50MG SIMCOR TAB1000-40 SIMCOR TAB500-20MG SIMCOR TAB500-40MG SIMCOR TAB750-20MG SIMVASTATIN TAB10MG SIMVASTATIN TAB20MG SIMVASTATIN TAB40MG SIMVASTATIN TAB5MG SIMVASTATIN TAB80MG SOLARAZE GEL3% W/W Quantity limitation 100 per 30 days SPIRIVA CAPHANDIHLR STAGESIC CAP500-5MG STRATTERA CAP100MG STRATTERA CAP10MG STRATTERA CAP18MG STRATTERA CAP25MG STRATTERA CAP40MG STRATTERA CAP60MG STRATTERA CAP80MG SUBOXONE MIS2-0.5MG SUBOXONE MIS8-2MG SUBOXONE SUB2-0.5MG SUBOXONE SUB8-2MG SUMATRIPTAN INJ6MG/0.5 Quantity limitation 6 per 30 days SUMATRIPTAN TAB100MG Quantity limitation 9 per 30 days

SUMATRIPTAN TAB25MG Quantity limitation 9 per 30 days SUMATRIPTAN TAB50MG Quantity limitation 9 per 30 days SYLATRON KIT296MCG Quantity limitation 1 per 28 days SYLATRON KIT444MCG Quantity limitation 1 per 28 days SYLATRON KIT888MCG Quantity limitation 1 per 28 days SYMBICORT AER160-4.5 Quantity limitation 10.2 per 30 days SYMBICORT AER80-4.5 Quantity limitation 6.9 per 30 days SYMBYAX CAP12-25MG SYMBYAX CAP12-50MG SYMBYAX CAP3-25MG SYMBYAX CAP6-25MG SYMBYAX CAP6-50MG SYMLINPEN 60INJ1000MCG Quantity limitation 10.8 per 30 days SYMLNPEN 120INJ1000MCG Quantity limitation 10.8 per 30 days TAMIFLU CAP30MG Quantity limitation 84 per 180 days TAMIFLU CAP45MG Quantity limitation 42 per 180 days TAMIFLU CAP75MG Quantity limitation 42 per 180 days TAMIFLU SUS6MG/ML Quantity limitation 900 per 180 days TAMSULOSIN CAP0.4MG TARGRETIN GEL1% TEKAMLO TAB150-10MG TEKAMLO TAB150-5MG TEKAMLO TAB300-10MG TEKAMLO TAB300-5MG TEKTURNA TAB150MG TEKTURNA TAB300MG TEKTURNA HCTTAB150-12.5 TEKTURNA HCTTAB150-25MG TEKTURNA HCTTAB300-12.5 TEKTURNA HCTTAB300-25MG TERAZOSIN CAP10MG TERAZOSIN CAP1MG TERAZOSIN CAP2MG TERAZOSIN CAP5MG TERCONAZOLE CRE0.4% Quantity limitation 45 per 7 days TERCONAZOLE SUP80MG Quantity limitation 3 per 3 days TOVIAZ TAB4MG TOVIAZ TAB8MG TRAMADL/APAPTAB37.5-325 TRAMADOL HCLTAB100MG ER TRAMADOL HCLTAB200MG ER TRAMADOL HCLTAB50MG TRILIPIX CAP135MG TRILIPIX CAP45MG TWINJECT INJ0.15MG Quantity limitation 4 per 30 days

VALACYCLOVIRTAB1GM VALACYCLOVIRTAB500MG VALTURNA TAB150-160 VALTURNA TAB300-320 VENLAFAXINE CAP150MG ER VENLAFAXINE CAP37.5MG VENLAFAXINE CAP75MG ER VENLAFAXINE TAB100MG VENLAFAXINE TAB150MG ER VENLAFAXINE TAB225MG ER VENLAFAXINE TAB25MG Quantity limitation 270 per 30 days VENLAFAXINE TAB37.5 ER VENLAFAXINE TAB37.5MG VENLAFAXINE TAB50MG Quantity limitation 150 per 30 days VENLAFAXINE TAB75MG Quantity limitation 150 per 30 days VENLAFAXINE TAB75MG ER VENTOLIN HFAAER Quantity limitation 36 per 30 days VERAMYST SPR27.5MCG Quantity limitation 20 per 30 days VIIBRYD TAB10MG VIIBRYD TAB20MG VIIBRYD TAB40MG VIMPAT INJ200MG/20 Quantity limitation 1200 per 30 days VIMPAT SOL10MG/ML Quantity limitation 1200 per 30 days VIMPAT TAB100MG VIMPAT TAB150MG VIMPAT TAB200MG VIMPAT TAB50MG VIVELLE-DOT DIS0.025MG Quantity limitation 8 per 28 days VIVELLE-DOT DIS0.0375MG Quantity limitation 8 per 28 days VIVELLE-DOT DIS0.05MG Quantity limitation 8 per 28 days VIVELLE-DOT DIS0.075MG Quantity limitation 8 per 28 days VIVELLE-DOT DIS0.1MG Quantity limitation 8 per 28 days VYTORIN TAB10-10MG VYTORIN TAB10-20MG VYTORIN TAB10-40MG VYTORIN TAB10-80MG XALKORI CAP200MG XALKORI CAP250MG ZAFIRLUKAST TAB10MG ZAFIRLUKAST TAB20MG ZALEPLON CAP10MG ZALEPLON CAP5MG ZAZOLE CRE0.4% Quantity limitation 45 per 7 days ZELBORAF TAB240MG ZETIA TAB10MG

ZIPRASIDONE CAP20MG ZIPRASIDONE CAP40MG ZIPRASIDONE CAP60MG ZIPRASIDONE CAP80MG ZMAX SUS2GM ZOLPIDEM TAB10MG ZOLPIDEM TAB5MG ZOLPIDEM ER TAB12.5MG ZOLPIDEM TARTAB6.25MG ZOMIG SPR5MG Quantity limitation 6 per 30 days ZOMIG TAB2.5MG Quantity limitation 6 per 30 days ZOMIG TAB5MG Quantity limitation 6 per 30 days ZOMIG ZMT TAB2.5 MG Quantity limitation 6 per 30 days ZOMIG ZMT TAB5MG Quantity limitation 6 per 30 days ZORTRESS TAB0.25MG ZORTRESS TAB0.5MG ZORTRESS TAB0.75MG ZOVIRAX CRE5% Quantity limitation 10 per 30 days ZOVIRAX OIN5% ZYFLO CR TAB600MG ZYPREXA INJ10MG ZYTIGA TAB250MG ZYVOX TAB600MG Quantity limitation 28 per 14 days