Pequot Health Care Opioid Analgesic Quantity Program*

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Pequot Health Care 1 Annie George Drive Mashantucket, CT 06338 Phone: 1-888-779-6638 Fax: 1-860-396-6494 Pequot Health Care Opioid Analgesic Quantity Program* Effective January 2018 *Quantity Program limits apply to generic versions of drugs where applicable. For Group 2 Medications contact our Pharmacy Benefits Department at 888-779-6638 or Pequot_PBM@prxn.com or the number on the back of your card GROUP 1 MEDICATIONS Medications in GROUP I consist of drug categories that have stand-alone limitations based on FDA-approved drug labeling, meaning that once the maximum drug limit is reached the member is responsible for the entire cost of the medication. Prior Authorization is required for quantities exceeding limits. Immediate-Release Codeine sulfate tab 15mg 42 tablets** 42 tablets** Codeine sulfate tab 30mg 42 tablets** 42 tablets** Codeine sulfate tab 60mg 42 tablets** 42 tablets** Hydromorphone soln 1mg/ml 600 ml 1800ml Hydromorphone supp 3mg 120 supp 360 supp Hydromorphone tab 2mg 180 tablets 540 tablets Hydromorphone tab 4mg 180 tablets 540 tablets Hydromorphone tab 8mg 180 tablets 540 tablets Levorphanol tab 2mg 120 tablets 360 tablets Meperidine oral soln 50mg/5ml 90 ml** 90 ml** Meperidine tablet 50mg 18 tablets** 18 tablets** Meperidine tablet 100mg 18 tablets** 18 tablets** Morphine sulfate (conc) oral soln 20mg/ml 180ml 540ml Morphine sulfate oral soln 10mg/5ml 900ml 2700ml Morphine sulfate oral soln 20mg/5ml 900ml 2700ml Morphine sulfate sup 5mg 180 supp 540 supp Morphine sulfate sup 10mg 180 supp 540 supp Morphine sulfate sup 20mg 180 supp 540 supp Morphine sulfate sup 30mg 180 supp 540 supp Morphine sulfate tablet 15mg 180 tablets 540 tablets Morphine sulfate tablet 30mg 180 tablets 540 tablets Oxycodone (conc) soln 20mg/ml 180ml 540ml Oxycodone soln 5mg/5ml 900ml 2700ml Oxycodone capsule 5mg 180 capsules 540 capsules Oxycodone tablet 5mg 180 tablets 540 tablets Oxycodone tablet 10mg 180 tablets 540 tablets

GROUP 1 MEDICATIONS Medications in GROUP I consist of drug categories that have stand-alone limitations based on FDA-approved drug labeling, meaning that once the maximum drug limit is reached the member is responsible for the entire cost of the medication. Prior Authorization is required for quantities exceeding limits. DRUG CLASS DRUG CLASS 1 MONTH SUPPLY 3 MONTH SUPPLY Immediate-Release Extended-Release Oxycodone tablet 15mg 180 tablets 540 tablets Oxycodone tablet 20mg 180 tablets 540 tablets Oxycodone tablet 30mg 180 tablets 540 tablets Oxaydo tablet 5mg 540 tablets 1620 tablets Oxaydo tablet 7.5mg 360 tablets 1080 tablets Oxymorphone tablet 5mg 180 tablets 540 tablets Oxymorphone tablet 10mg 180 tablets 540 tablets Pentazocine/naloxone 50/0.5mg 180 tablets** 180 tablets** Tapentadol tablet 50mg 360 tablets 1080 tablets Tapentadol tablet 75mg 240 tablets 270 tablets Tapentadol tablet 100mg 180 tablets 540 tablets Tramadol tablet 50mg 180 tablets 540 tablets Arymo ER 15mg 90tablets 270 tablets Arymo ER 30mg 90 tablets 270 tablets Arymo ER 60mg 90 tablets 270 tablets Belbuca 75mcg 60 films 180 films Belbuca 150mcg 60 films 180 films Belbuca 300mcg 60 films 180 films Belbuca 450mcg 60 films 180 films Belbuca 600mcg 60 films 180 films Belbuca 750mcg 60 films 180 films Belbuca 900mcg 60 films 180 films Butrans 5mcg/hr 4 patches 12 patches Butrans 7.5mcg/hr 4 patches 12 patches Butrans 10mcg/hr 4 patches 12 patches Butrans 15 mcg/hr 4 patches 12 patches Butrans 20 mcg/hr 4 patches 12 patches Conzip 100mg 30 capsules 90 capsules Conzip 200mg 30 capsules 90 capsules Conzip 300mg 30 capsules 90 capsules Duragesic patch 12mcg 10 patches 30 patches Duragesic patch 25mcg 10 patches 30 patches Duragesic patch 37.5mcg 10 patches 30 patches Duragesic patch 50mcg 10 patches 30 patches Duragesic patch 62.5mcg 10 patches 30 patches

GROUP 1 MEDICATIONS Medications in GROUP I consist of drug categories that have stand-alone limitations based on FDA-approved drug labeling, meaning that once the maximum drug limit is reached the member is responsible for the entire cost of the medication. Prior Authorization is required for quantities exceeding limits. Extended-Release Duragesic patch 75mcg 10 patches 30 patches Duragesic patch 87.5mcg 10 patches 30 patches Duragesic patch 100mcg 10 patches 30 patches Embeda 20/0.8mg 60 capsules 180 capsules Embeda 30/1.2mg 60 capsules 180 capsules Embeda 50/2mg 60 capsules 180 capsules Embeda 60/2.4mg 60 capsules 180 capsules Embeda 80/3.2mg 60 capsules 180 capsules Embeda 100/4mg 60 capsules 180 capsules Exalgo 8mg 30 tablets 90 tablets Exalgo12mg 30 tablets 90 tablets Exalgo 16mg 30 tablets 90 tablets Exalgo 32mg 30 tablets 90 tablets Hysingla ER 20mg 30 tablets 90 tablets Hysingla ER 30mg 30 tablets 90 tablets Hysingla ER 40mg 30 tablets 90 tablets Hysingla ER 60mg 30 tablets 90 tablets Hysingla ER 80mg 30 tablets 90 tablets Hysingla ER 100mg 30 tablets 90 tablets Hysingla ER 120mg 30 tablets 90 tablets Kadian 10mg 60 capsules 180 capsules Kadian 20mg 60 capsules 180 capsules Kadian 30mg 60 capsules 180 capsules Kadian 40mg 60 capsules 180 capsules Kadian 50mg 60 capsules 180 capsules Kadian 60mg 60 capsules 180 capsules Kadian 80mg 60 capsules 180 capsules Kadian 100mg 60 capsules 180 capsules Kadian 200mg 60 capsules 180 capsules Methadone tablet 5mg 90 tablets 270 tablets Methadone tablet 10mg 90 tablets 270 tablets Methadone oral soln 5mg/5ml 450 ml 1350 ml Methadone oral soln 10mg/5ml 450 ml 1350 ml MorphaBond 15mg 60 tablets 180 tablets MorphaBond 30mg 60 tablets 180 tablets

GROUP 1 MEDICATIONS Medications in GROUP I consist of drug categories that have stand-alone limitations based on FDA-approved drug labeling, meaning that once the maximum drug limit is reached the member is responsible for the entire cost of the medication. Prior Authorization is required for quantities exceeding limits. Extended-Release MorphaBond 60mg 60 tablets 180 tablets MorphaBond 100mg 60 tablets 180 tablets MS Contin 15mg 90 tablets 270 tablets MS Contin 30mg 90 tablets 270 tablets MS Contin 60mg 90 tablets 270 tablets MS Contin 100mg 90 tablets 270 tablets MS Contin 200mg 90 tablets 270 tablets Nucynta ER 50mg 60 tablets 180 tablets Nucynta ER 100mg 60 tablets 180 tablets Nucynta ER 150mg 60 tablets 180 tablets Nucynta ER 200mg 60 tablets 180 tablets Nucynta ER 250mg 60 tablets 180 tablets Opana ER 5mg 60 tablets 180 tablets Opana ER 7.5mg 60 tablets 180 tablets Opana ER 10mg 60 tablets 180 tablets Opana ER 15mg 60 tablets 180 tablets Opana ER 20mg 60 tablets 180 tablets Opana ER 30mg 60 tablets 180 tablets Opana ER 40mg 60 tablets 180 tablets Oxycontin 10mg 60 tablets 180 tablets Oxycontin 15mg 60 tablets 180 tablets Oxycontin 20mg 60 tablets 180 tablets Oxycontin 30mg 60 tablets 180 tablets Oxycontin 40mg 60 tablets 180 tablets Oxycontin 60mg 60 tablets 180 tablets Oxycontin 80mg 120 tablets 360 tablets Tramadol ER 100mg 30 tablets 90 tablets Tramadol ER 150mg 30 capsules 90 capsules Tramadol ER 200mg 30 tablets 90 tablets Tramadol ER 300mg 30 tablets 90 tablets Troxyca ER 10mg/1.2mg 60 capsules 180 capsules Troxyca ER 20mg/2.4mg 60 capsules 180 capsules Troxyca ER 30mg/3.6mg 60 capsules 180 capsules Troxyca ER 40mg/4.8mg 60 capsules 180 capsules Troxyca ER 60mg/7.2mg 60 capsules 180 capsules

Troxyca ER 80mg/9.6mg 60 capsules 180 capsules GROUP 1 MEDICATIONS Medications in GROUP I consist of drug categories that have stand-alone limitations based on FDA-approved drug labeling, meaning that once the maximum drug limit is reached the member is responsible for the entire cost of the medication. Prior Authorization is required for quantities exceeding limits. Extended-Release Vantrela ER 15mg 60 tablets 180 tablets Vantrela ER 30mg 60 tablets 180 tablets Vantrela ER 45mg 60 tablets 180 tablets Vantrela ER 60mg 60 tablets 180 tablets Vantrela ER 90mg 60 tablets 180 tablets Xtampza ER 9mg 60 capsules 180 capsules Xtampza ER 13.5mg 60 capsules 180 capsules Xtampza ER 18mg 60 capsules 180 capsules Xtampza ER 27mg 60 capsules 180 capsules Xtampza ER 36mg 60 capsules 180 capsules Zohydro ER 10mg 60 capsules 180 capsules Zohydro ER 15mg 60 capsules 180 capsules Zohydro ER 20mg 60 capsules 180 capsules Zohydro ER 30mg 60 capsules 180 capsules Zohydro ER 40mg 60 capsules 180 capsules Zohydro ER 50mg 60 capsules 180 capsules Miscellaneous Butorphanol tartrate nasal spray 10mg/ml 2 bottles 6 bottles Methadone Intensol oral concentrate 10mg/ml 30ml 30ml Methadose oral concentrate 10mg/ml 30ml 30ml Methadose dispersible tablet 40mg 9 tablets 9 tablets Stadol NS (Butorphanol tartrate) 10mg/ ml 6ml / 25 Days 18ml/ 75 Days Xartemis XR 7.5mg-325mg 120 tablets** 120 tablets**

GROUP 2 MEDICATIONS Medications in GROUP 2 consist of drug categories that have quantity limitations based on opioid amount of 90 morphine equivalents per day; 4g acetaminophen (APAP) OR aspirin (ASA); 3200mg ibuprofen (IBU); OR the maximum FDA-approved quantity limit according to the products prescribing label. GROUP 2 medications accumulate drug limitations based on one of the following 4 categories: 1)APAP-containing solutions, suspensions, elixers accumulate together; 2)APAP-containing tablets and capsules accumulate together; 3)ASA-containing tablets and capsules accumulate together; 4) IBU-containing tablets accumulate together. Prior Authorization is required for quantities exceeding limits. Opioid Analgesic Combination Products (w/apap, ASA or IBU) APAP/codeine soln 120mg-12mg/5ml 2700 ml (max 360mg codeine/day) 8100 ml Hydrocodone/APAP soln 7.5mg-325mg/15ml Hydrocodone/APAP elixer 10mg-300mg/15ml Hydrocodone/APAP soln 10mg-325mg/15ml Oxycodone/APAP soln 5mg-325mg/5ml APAP/codeine tablet 300mg-15mg APAP/codeine tablet 300mg-30mg APAP/codeine tablet 300mg-60mg 2700 ml (max 90ml/day) 2025 ml (max 67.5ml/day) 2700 ml (max 90ml/day) 1800 ml (max 60ml/day) 400 tablets (max 360mg codeine/day) 360 tablets (max 360mg codeine/day) 180 tablets (max 360mg codeine/day) 8100 ml 6075 ml 8100 ml 5400 ml 1200 tablets 1080 tablets 540 tablets APAP/caffeine/dihydrocodeine capsule 320 mg- 30mg-16mg APAP/caffeine/dihydrocodeine tablet 712.8mg-60mg-32mg Hydrocodone/APAP tablet 2.5mg-325mg 300 capsules 900 capsules (max 10/day) 150 tablets (max 5/day) 450 tablets 360 tablets (max 1080 tablets 12/day) Hydrocodone/APAP tablet 5mg-300mg 240 tablets (max 8/day) 720 tablets Hydrocodone/APAP tablet 5mg-325mg 240 tablets (max 8/day) 720 tablets Hydrocodone/APAP tablet 7.5mg-300mg 180 tablets (max 6/day) 540 tablets Hydrocodone/APAP tablet 7.5mg-325mg 180 tablets (max 6/day) 540 tablets Hydrocodone/APAP tablet 10mg-300mg 180 tablets (max 6/day) 540 tablets Hydrocodone/APAP tablet 10mg-325mg 180 tablets (max 6/day) 540 tablets Oxycodone/APAP tablet 2.5mg-325mg 360 tablets (max 1080 tablets 12/day) Oxycodone/APAP tablet 5mg-300mg 360 tablets (max 1080 tablets

12/day) Oxycodone/APAP tablet 5mg-325mg 360 tablets (max 1080 tablets 12/day) Oxycodone/APAP tablet 7.5mg-300mg 240 tablets (max 8/day) 720 tablets Oxycodone/APAP tablet 7.5mg-325mg 240 tablets (max 8/day) 720 tablets Oxycodone/APAP tablet 10mg-300mg 180 tablets (max 6/day) 540 tablets Oxycodone/APAP tablet 10mg-325mg 180 tablets (max 6/day) 540 tablets Tramadol/APAP tablet 37.5mg-325mg (MAX 5 DAY SUPPLY) 40 tablets (max 6/day)** 40 tablets** Oxycodone/ASA tablet 4.8355mg-325mg 360 tablets (max 12/day) 1080 tablets

GROUP 2 MEDICATIONS Medications in GROUP 2 consist of drug categories that have quantity limitations based on opioid amount of 90 morphine equivalents per day; 4g acetaminophen (APAP) OR aspirin (ASA); 3200mg ibuprofen (IBU); OR the maximum FDA-approved quantity limit according to the products prescribing label. GROUP 2 medications accumulate drug limitations based on one of the following 4 categories: 1)APAP-containing solutions, suspensions, elixers accumulate together; 2)APAP-containing tablets and capsules accumulate together; 3)ASA-containing tablets and capsules accumulate together; 4) IBU-containing tablets accumulate together. Prior Authorization is required for quantities exceeding limits. Opioid Analgesic Combination Products (w/apap, ASA or IBU) Hydrocodone/IBU tablet 2.5mg-200mg (MAX 10 DAY SUPPLY) Hydrocodone/IBU tablet 5mg-200mg (MAX 10 DAY SUPPLY) Hydrocodone/IBU tablet 7.5mg-200mg (MAX 10 DAY SUPPLY) Hydrocodone/IBU tablet 10mg-200mg (MAX 10 DAY SUPPLY) Oxycodone/IBU tablet 5mg-400mg (MAX 7 DAY SUPPLY) 50 tablets (max 5/day)** 50 tablets (max 5/day)** 50 tablets (max 5/day) ** 50 tablets (max 5/day) ** 28 tablets (max 4/day) ** 50 tablets** 50 tablets** 50 tablets** 50 tablets** 28 tablets** **Product is indicated for short-term acute use only; thus, 30-day and 90-day limits are the same.

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