Quantity limits This program helps keep you safe by making sure you get the amount of medicine that s right for you.

Member education Quantity limits This program helps keep you safe by making sure you get the amount of medicine that s right for you.

Member education What are quantity limits? Taking too much medicine or using it too often isn t safe. And it may even drive up your health care costs. That s why this program limits the amount of medicine that s covered by your plan for a certain length of time. For example, a drug may have a limit of 30 pills per 30 days. If you refill a prescription too soon or your doctor prescribes an amount that s higher than usual, your pharmacist will tell you. The drug won t be covered at that time. Your doctor can request we cover the amount of medicine prescribed. If your doctor thinks you have a medical reason to get the larger amount, he or she can request that we cover the drug. Requesting approval is called prior authorization. Here s how it works: First, we ll need to know a little more about your health. Your doctor calls or faxes the information to us. If the information meets your plan s guidelines, the request is approved. Your doctor or pharmacist lets you know the prescription can be filled. If we need more information, we may contact your doctor directly. If the request is denied, you and your doctor will receive a letter explaining how to appeal it. For more information about our Drug List, please visit anthem.com/pharmacyinformation and click on the Drug Selection tab. 2 Quantity limits

Use this table to see if one of your drugs has a quantity limit. Find your type of drug in the columns on the left. Then look for the name of your drug. The amount that s covered by your plan is listed in the right-hand column. Category Type Medication Quantity limit Allergy Antihistamine Allegra 180mg 30 tablets per 30 days Allergy Antihistamine Allegra 30mg, 60mg 60 tablets per 30 days Allergy Antihistamine Allegra 900mL 30 days per 30 days Allergy Antihistamine Clarinex 30 per 30 days 300mL per 30 days Allergy Antihistamine Xyzal 2.5mg /5mL 300mL per 30 days Allergy Antihistamine Xyzal 5mg 30 per 30 days Allergy Antihistamine Zyrtec 5mg, 10mg (including chewables) 30 tablets per 30 days Allergy Antihistamine/Decongestant Allegra D 180mg/240mg 30 tablets per 30 days Allergy Antihistamine/Decongestant Allegra D 60mg/120mg 60 tablets per 30 days Allergy Antihistamine/Decongestant Clarinex D (12 hour tablet) 60 per 30 days Allergy Antihistamine/Decongestant Clarinex D (24 hour tablet) 30 per 30 days Allergy Antihistamine/Decongestant Zyrtec-D 60 tablets per 30 days Allergy Nasal Antihistamine Astelin Nasal Spray 1 nasal inhaler per 25 days Allergy Nasal Antihistamine Astepro Nasal Spray 137, 205.5 mcg 1 nasal inhaler per 25 days Allergy Nasal Antihistamine Atrovent Nasal Spray.03% 2 bottles per 30 days Allergy Nasal Antihistamine Atrovent Nasal Spray.06% 3 bottles per 30 days Allergy Nasal Antihistamine Patanase Nasal Spray 30.5g 1 nasal inhaler per 30 days Allergy Nasal Steroid Beconase AQ nasal inhaler 2 inhalers per 30 days Allergy Nasal Steroid Flonase Nasal Spray 1 inhaler per 30 days Allergy Nasal Steroid Nasacort AQ Nasal Spray 1 inhaler per 30 days Allergy Nasal Steroid Nasarel Nasal Spray 3 inhalers per 30 days Allergy Nasal Steroid Nasonex Nasal Spray 2 inhalers per 30 days Allergy Nasal Steroid Omnaris Nasal Spray 1 inhaler per 30 days Allergy Nasal Steroid Rhinocort Aqua Nasal Spray 2 inhalers per 30 days Allergy Nasal Steroid Veramyst Nasal Spray 1 inhaler per 30 days Allergy Lastacaft 0.25% Eye Drops 2 per 30 days Allergy/Asthma Anti-Inflammatory Singulair 30 units per 30 days Anti-acne treatment Isotretinoin 30 days per fill Antibiotic Xifaxan 200mg 9 tablets per 30 Antibiotic Xifaxan 550mg 60 tablets per 30 days Arthritis Orencia (125mg) 4 vials per 28 days Arthritis/Crohn's Disease Cimzia 1 pack or kit= 2 x 200mg vials per 28 days 1 syringe kit = 2 x 200mg/ml syringes per 28 days Arthritis/Crohn's Disease/Psoriasis Humira 2 vials every 28 days Arthritis/Psoriasis Enbrel 2mg 8 vials every 28 days Arthritis/Psoriasis Enbrel 50mg 4 vials every 28 days Arthritis/Psoriasis Simponi 1 injection per 28 days Quantity limits 3

Asthma Anti-Inflammatory (Inhaled) Aerobid/Aerobid M inhaler 3 inhalers per 30 days Asthma Anti-Inflammatory (Inhaled) Alvesco 160mcg 2 inhalers/30 days Asthma Anti-Inflammatory (Inhaled) Alvesco 80mcg 1 inhaler/30 days Asthma Anti-Inflammatory (Inhaled) Asmanex 1 inhaler per 30 days Asthma Anti-Inflammatory (Inhaled) Flovent Diskus 4 inhalers per 30 days Asthma Anti-Inflammatory (Inhaled) Flovent HFA 110 inhaler, 44 inhaler 1 inhaler (13gm) per 30 days Asthma Anti-Inflammatory (Inhaled) Flovent HFA 220 inhaler 2 inhalers (13gm) per 30 days Asthma Anti-Inflammatory (Inhaled) Pulmicort Flexhaler 2 inhaler per 30 days Asthma Anti-Inflammatory (Inhaled) Pulmicort respules 2 boxes per 30 days Asthma Anti-Inflammatory (Inhaled) QVAR inhaler 3 inhalers per 30 days Asthma Bronchodilator Maxair Autohaler 2 inhalers per 30 days Asthma Bronchodilator ProAIR inhaler (27gm) 3 inhalers per 30 days Asthma Bronchodilator Proventil HFA (21gm) 3 inhaler per 30 days Asthma Bronchodilator Serevent Diskus 2 inhalers per month 28 each 1 inhalers per month 60 each Asthma Bronchodilator Ventolin HFA inhaler 3 inhalers per 30 days Asthma Bronchodilator Xopenex HFA 3 inhalers per 30 days Asthma Dulera Inhaler 100 and 200mcg 1 per 30 days Asthma/COPD Asthma/COPD Asthma/COPD Asthma/COPD Anti-Inflammatory (Inhaled)/Bronchodilator Combination Anti-Inflammatory (Inhaled)/Bronchodilator Combination Anti-Inflammatory (Inhaled)/Bronchodilator Combination Anti-Inflammatory (Inhaled)/Bronchodilator Combination Advair Diskus (28ml) Advair Diskus (60ml) Advair HFA (12gm) Symbicort 10.2gm 2 inhalers/30 days 1 inhaler/30 days 1 inhaler/30 days 1 inhaler per 30 days Asthma/COPD Bronchodilator Foradil 60 caps per 30 days Asthma/COPD Bronchodilator Perforomist 60 vials per 30 days Birth Control Plan B 2 kits per 30 days, 1 copay per kit Birth Control Plan B One-Step 1 per 30 days Blood Builder Neulasta 2 vials per 28 days Bone Fracture/Pain Due to Cancer Xgeva 120 mg 1 vial per 28 days COPD Daliresp 500mcg 30 per 30 days COPD Anti-Inflammatory (Inhaled)/Bronchodilator Combination Combivent inhaler 3 inhalers per 30 days COPD Bronchodilator Arcapta 75mcg 30 per 30 days COPD Bronchodilator Atrovent inhaler 3 inhalers per 30 days COPD Bronchodilator Atrovent nebulizer solution 2.5ml 150 unit dose vials per 30 days COPD Bronchodilator Brovana 60 per 30 days COPD Bronchodilator Spiriva 1 inhaler per 30 days Diabetes Blood Glucose Meters/Strips Blood Glucose Testing Strips, all brands 200 per 30 days Diabetes ActoPlus Met 15/500mg, 15/850mg 90 tablets per 30 days Diabetes ActoPlus Met 30/1000mg 30 tablets per 30 days Diabetes ActoPlus Met XR 15/1000mg 60 tablets per 30 days Diabetes ActoPlus Met XR 30/1000mg 30 tablets per 30 days Diabetes Actos 30 tablets per 30 days Diabetes Avandamet 2/500mg 120 tablets 4 Quantity limits

Diabetes Avandamet 2/1000mg, 4/500mg,4/1000mg 60 tablets Diabetes Avandaryl 4-1mg, 4-2mg 60 per 30 days Diabetes Avandaryl 4-4mg 30 per 30 days Diabetes Avandia 2mg, 4mg 60 tablets Diabetes Avandia 8mg 30 tablets Diabetes Bydureon 4 vials per 28 days Diabetes Byetta 1 prefilled pen per 30 days Diabetes Duetact 30 per 30 days Diabetes Janumet 60 per 30 days Diabetes Janumet XR 50mg-500mg 30 tablets per 30 days Diabetes Janumet XR 50mg-1,000mg 60 tablets per 30 days Diabetes Janumet XR 100mg-1,000mg 30 tablets per 30 days Diabetes Januvia 30 per 30 days Diabetes Jentadueto 60 tablets per 30 days Diabetes Kombiglyze 1000 MG-2.5 MG 2 tablets per day Diabetes Kombiglyze 1000 MG-5 MG 1 tablet per day Diabetes Kombiglyze 500 MG-5 MG 1 tablet per day Diabetes Onglyza 2.5mg, 5mg 30 tablets per 30 days Diabetes Tradjenta 5mg 1 tablet per day Diabetes Victoza 1 box per 30 days Excessive Sleepiness Nuvigil 150mg, 250mg 30 tablets per 30 days Excessive Sleepiness Nuvigil 50mg 60 tablets per 30 days Excessive Sleepiness Provigil 30 per 30 days Eye Drops Allergy eye drops Alamast 1 bottle per month Eye Drops Allergy eye drops Alocril 1 bottle per month Eye Drops Allergy eye drops Alomide 1 bottle per month Eye Drops Allergy eye drops Bepreve 1 bottle per month Eye Drops Allergy eye drops Elestat 1 bottle per month Eye Drops Allergy eye drops Emadine 1 bottle per month Eye Drops Allergy eye drops Optivar 1 bottle per month Eye Drops Allergy eye drops Pataday 1 bottle per month Eye Drops Allergy eye drops Patanol 1 bottle per month Eye Drops Allergy eye drops Zaditor 1 bottle per month Eye Drops Anti-inflammation eye drops Crolom 1 bottle per month Eye Drops Anti-inflammation eye drops Cromolyn sodium 1 bottle per month Eye Drops Anti-inflammation eye drops Durezol 10mL per 30 days (2 x 5mL bottles or 4 x 2.5mL bottles) Gastrointestinal Health Indigestion,GERD, peptic ulcers Aciphex 30 tablets per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Dexilant 30 capsules per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Nexium 30 capsules per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Prevacid Capsules 30 capsules per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Prilosec (omeprazole) 20mg, 40mg 30 capsules per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Prilosec Powder packets for suspension 30 doses per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Protonix (pantoprazole) 30 per 30 days Gastrointestinal Health Indigestion,GERD, peptic ulcers Zegerid 30 packets per 30 days Gastrointestinal Health Nausea/ Vomiting Anzemet 100mg 5 tablets per 30 days Quantity limits 5

Gastrointestinal Health Nausea/ Vomiting Anzemet 50mg 5 tablets per 30 days Gastrointestinal Health Nausea/ Vomiting Emend 4 Packs (12 capsules) per 30 days therapy pack Gastrointestinal Health Nausea/ Vomiting Emend 125mg 4 capsules per 30 days Gastrointestinal Health Nausea/ Vomiting Emend 40mg 1 dose per fill Gastrointestinal Health Nausea/ Vomiting Emend 80mg 8 capsules per 30 days Gastrointestinal Health Nausea/ Vomiting Kytril 10 tablets per 30 days Gastrointestinal Health Nausea/ Vomiting Kytril suspension 50ml per 30 days Gastrointestinal Health Nausea/ Vomiting Sancuso 4 patches per 28 days Gastrointestinal Health Nausea/ Vomiting Zofran Suspension 240ml per 30 days Gastrointestinal Health Nausea/ Vomiting Zofran, ODT tablets 4mg 48 tablets per 30 days Gastrointestinal Health Nausea/ Vomiting Zofran, ODT tablets 8mg 24 tablets per 30 days Gout Colcrys 69 tablets per 30 days Heart Attack and Stroke Prevention Brilinta 90mg 30 per 30 days Heart Attack and Stroke Prevention Plavix 75mg 30 tablets per 30 days Heart Attack Prevention Effient 10mg 30 tablets per 30 days Heart Health and Blood Pressure Heart Failure Treatment/High Blood Pressure Atacand 16mg 2 doses per day Heart Health and Blood Pressure Heart Failure Treatment/High Blood Pressure Atacand 32mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Atacand HCT 32/12.5mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Avalide 300/12.5mg, 300/25mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Avapro 300mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Azor 5/40mg, 10/40mg, 10/20mg 30 tablets per 30 days Heart Health and Blood Pressure High Blood Pressure Benicar 40mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Benicar HCT 40/12.5mg, 40/25mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Cozaar 100mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Cozaar 50mg 2 dose per day Heart Health and Blood Pressure High Blood Pressure Diovan 160mg 2 doses per day Heart Health and Blood Pressure High Blood Pressure Diovan 320mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Diovan HCT 160/25mg, 320/12.5mg and 320/25mg 1 dose per day Heart Health and Blood Pressure HIgh Blood Pressure Exforge 5/320mg, 10/160mg, 10/320mg 30 tablets per 30 days Heart Health and Blood Pressure High Blood Pressure Exforge HCT 5/160/25mg, 10/160/12.5mg, 10/160/25mg, 10/320/25mg 30 tablets per 30 days Heart Health and Blood Pressure High Blood Pressure Hyzaar 100/12.5mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Hyzaar 100/25mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Micardis 80mg 2 doses per day Heart Health and Blood Pressure High Blood Pressure Micardis HCT 80/12.5mg 2 doses per day Heart Health and Blood Pressure High Blood Pressure Micardis HCT 80/25mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Tekturna 30mg 30 tablets per 30 days Heart Health and Blood Pressure High Blood Pressure Tekturna HCT 150/25mg, 300/12.5mg, 300/25mg 30 tablets per 30 days Heart Health and Blood Pressure High Blood Pressure Teveten 400mg 60 per 30 days Heart Health and Blood Pressure High Blood Pressure Teveten 600mg 30 per 30 days Heart Health and Blood Pressure High Blood Pressure Teveten HCT 600/12.5mg, 600/25mg 1 dose per day Heart Health and Blood Pressure High Blood Pressure Twynsta 40/10mg, 80/5mg, 80/10mg 30 tablets per 30 days Heart Health and Blood Pressure High Blood Pressure Valturna 300/320mg 30 tablets per 30 days Heart Health and Blood Pressure Edarbi 80mg 1 per day (30 tabs per 30 days) 6 Quantity limits

Heart Health and Blood Pressure Edarbyclor 30 per 30 days Heart Health and Blood Pressure Tekamlo 150-10mg, 300-10mg, and 300-5mg 30 per 30 days Hepatitis Pegasys 4 vials per 28 days; 1 kit per 28 days Hepatitis PEGASYS PROCLICK 135 MCG/0.5 4 injections per 28 days High Blood Pressure Sular 40mg 1 per day High Cholesterol Advicor 1000-20mg, 750-20mg 60 tablets per 30 days High Cholesterol Advicor 1000-40mg 30 tablets per 30 days High Cholesterol Altoprev 60mg 30 tablets per 30 days High Cholesterol Caduet 5-80mg, 10-10mg, 10-20mg, 10-40mg, 10-80mg 30 tablets per 30 days High Cholesterol Crestor 40mg 30 per 30 days High Cholesterol Lipitor 80mg 30 per 30 days High Cholesterol Livalo 4mg only 30 tabs per 30 days High Cholesterol Mevacor 40mg 60 per 30 days High Cholesterol Pravachol 80mg 30 per 30 days High Cholesterol Simcor 60 per 30 days High Cholesterol Vytorin 30 tablets per 30 days High Cholesterol Zetia 30 tablets per 30 days High Cholesterol Zocor 80mg 30 per 30 days Hormone Therapy Androderm 2 MG/24HR Patch 30 patches per 30 days Hormone Therapy Androderm 2.5mg 60 patches per 30 days Hormone Therapy Androderm 4 MG/24HR Patch 30 patches per 30 days Hormone Therapy Androderm 5mg 30 patches per 30 days Hormone Therapy AndroGel 2.5gm 60 packets per 30 days 2 units of the pumps per 30 days Hormone Therapy AndroGel 5gm 30 packets per 30 days 2 units of the pumps per 30 days Hormone Therapy Axiron 1 bottle per 30 days Hormone Therapy Fortesta 1 bottle per 30 days Hormone Therapy Testim 30 tubes per 30 days Human Growth Hormone Egrifta (tesamorelin) (60 x 1 mg vials) 1 box per 30 days Immune System Multiple Myeloma Revlimid 1 dose per day Infection prevention and treatment Antibiotic Avelox 21 per fill Infection prevention and treatment Antibiotic Avelox ABC Pak 5 per fill Infection prevention and treatment Antibiotic Cipro 56 per fill Infection prevention and treatment Antibiotic Cipro XR 1000mg 14 per fill Infection prevention and treatment Antibiotic Cipro XR 500mg 3 per fill Infection prevention and treatment Antibiotic Factive 7 per fill Infection prevention and treatment Antibiotic Floxin 56 per fill Infection prevention and treatment Antibiotic Levaquin 21 per fill Infection prevention and treatment Antibiotic Levaquin Leva-Pak 5 per fill Infection prevention and treatment Antibiotic Noroxin 42 per fill Infection prevention and treatment Antibiotic Zithromax 250mg 6 tablets per fill, 5 day therapy Infection prevention and treatment Antibiotic Zithromax 500mg 3 tablets per fill Infection prevention and treatment Antibiotic Zithromax 600mg 8 tablets per 30 days Quantity limits 7

Infection prevention and treatment Antibiotic Zithromax Susp 15ml per fill 100mg/5ml suspension 15ml per fill (15ml size), 46ml per fill (23ml size), 60ml per fill (30ml size) 200mg/5ml suspension 2 packets per fill 1 gram powder Infection prevention and treatment Antibiotic Zmax 1 packet per fill Infection prevention and treatment Antibiotic Zyvox 28 tablets per fill Infection prevention and treatment Antibiotic Zyvox Suspension 900 ml per fill Infection prevention and treatment Flu Influenza virus vaccine 2 fills per 180 days Infection prevention and treatment Flu Relenza Diskhaler 1 pkg (20 ea) per dispensing. Age 7 and older. No mail service for this drug. Infection prevention and treatment Flu Tamiflu Treatment: 10 per fill / 20 per year Prophylaxis: 10 per fill / 42 per year Infection prevention and treatment Flu Tamiflu Suspension 600ml per calendar year Infection prevention and treatment Malaria Qualaquin 42 capsules per 365 days Mental Health Antidepressant Aplenzin 30 tablets per 30 days Mental Health Antidepressant Celexa (citalopram) 10mg/5mL 600mL/30 days Mental Health Antidepressant Celexa (citalopram) 40mg tabs 30 tabs per 30 days Mental Health Antidepressant Celexa Suspension 600mL per 30 days Mental Health Antidepressant Cymbalta 20mg,60mg 60 capsules per 30 days Mental Health Antidepressant Effexor XR 150mg 30 capsules per 30 days Mental Health Antidepressant Fluoxetine (Prozac) 20mg/5mL 600 ml per 30 days Mental Health Antidepressant Fluoxetine (Prozac) 40mg 60 per 30 days Mental Health Antidepressant Fluoxetine HCL 60mg tablet Mental Health Antidepressant Paxil 40mg 60 per 30 days Mental Health Antidepressant Paxil CR 25mg, 37.5mg 60 per 30 days Mental Health Antidepressant Paxil Suspension 1250mL per 30 days Mental Health Antidepressant Pexeva 40mg 2 per day or 60 per 30 days Mental Health Antidepressant Pristiq 100mg 30 per 30 days Mental Health Antidepressant Prozac weekly 90mg 4 per 28 days Mental Health Antidepressant Sarafem 15mg 30 tablets per 30 days Mental Health Antidepressant Venlafaxine Extended Release Tablets 150mg, 225 mg 30 tablets per 30 days Mental Health Antidepressant Zoloft 100mg 60 per 30 days Mental Health Antidepressant Zoloft 20mg/ml 300ml per 30 days Mental Health Anti-depressant Lexapro 20mg 30 per 30 days Mental Health Anti-depressant Lexapro 5mg/5ml Soln 600ml per 30 days Mental Health Attention Deficit Hyperactivity Disorder Treatment Daytrana 30 patches per 30 days Multiple Sclerosis Ampyra 60 tabs per 30 days Multiple Sclerosis Gilenya 30 tabs per 30 days Nausea Zuplenz 4 mg Soluble Film 48 per 30 days. Nausea Zuplenz 8mg Soluble Film 24 per 30 days. Opiod Dependence Suboxone 24 mg per day Osteoporosis Actonel 150mg 1 tablet per 30 days Osteoporosis Actonel 35mg 4 tablets per 28 days Osteoporosis Actonel 5mg, 30mg 30 tablets Osteoporosis Actonel with Calcium 30 tablets per 30 days Osteoporosis Atelvia 4 tablets per 28 days 8 Quantity limits

Osteoporosis Boniva 2.5mg 1 per day Osteoporosis Boniva 150mg 1 per 28 days Osteoporosis Forteo 1 pen per 28 days Osteoporosis Fosamax 300mL per 30 days 70mg/75mL Osteoporosis Fosamax 35mg, 70mg 4 tablets per 28 days Osteoporosis Fosamax 5mg, 10mg, 40mg 30 tablets Osteoporosis Fosamax Plus D 4 per 28 days Osteoporosis Miacalcin Nasal Spray 3.7mL 1 bottle per 30 days Osteoporosis Prolia (16mg) 2 injections per year Pain Relief Anti-inflammatory (Nonsteroidal) Celebrex 100mg, 200mg 60 capsules per 30 days Pain Relief Anti-inflammatory (Nonsteroidal) Celebrex 400mg 30 capsules per 30 days Pain Relief Anti-inflammatory (Nonsteroidal) Celebrex 400mg 30 capsules per 30 days Pain Relief Anti-inflammatory (Nonsteroidal) Duexis 90 tablets per 30 days Pain Relief Anti-inflammatory (Nonsteroidal) Mobic 30 per 30 days Pain Relief Anti-inflammatory (Nonsteroidal) Toradol 20 tablets per 30 days Pain Relief Anti-inflammatory (Nonsteroidal) Toradol injections 60mg/30 days Pain Relief Anti-inflammatory (Nonsteroidal) Vimovo 60 tablets per 30 days Pain Relief Fibromyalgia Savella 60 tablets per 30 days 1 titration pack per year Pain Relief Migraine Amerge * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Axert * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Cambia 4 packets per 30 days Pain Relief Migraine Relpax * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Sumavel Dosepro 4 syringes per 30 days Pain Relief Migraine Frova * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Imitrex * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Imitrex injection 4 injections per 30 days Pain Relief Migraine Imitrex nasal inhaler 6 nasal inhalers per 30 days Pain Relief Migraine Maxalt * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Maxalt-MLT * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Migranal nasal inhaler 1 kit = 8 canisters per 30 days Pain Relief Migraine Treximet * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Zomig * This includes all drugs in this class 9 tablets per 30 days Pain Relief Migraine Zomig nasal spray 6 inhaler per 30 days Pain Relief Narcotic Analgesic Actiq 120 units per 30 days Pain Relief Narcotic Analgesic APAP/Caf/Dihydrocodeine (Panlor SS, Zerlor) 150 per 30 days Pain Relief Narcotic Analgesic APAP/Caf/Dihydrocodeine (Panlor DC) 330 per 30 days Pain Relief Narcotic Analgesic APAP/codeine (Tylenol with Codeine) 390 per 30 days Pain Relief Narcotic Analgesic APAP/codeine (Vopac 650-300) 180 per 30 days Pain Relief Narcotic Analgesic APAP/codeine Susp or Elixir (Capital with Codeine) 1200ml per 30 days Pain Relief Narcotic Analgesic Avinza 30mg, 60mg, 90mg 120 capsules per 30 days Pain Relief Narcotic Analgesic Avinza 120mg 180 capsules per 30 days Pain Relief Narcotic Analgesic Butalbital/APAP/Caffeine/Codeine (Fioricet with Codeine) 180 per 30 days Quantity limits 9

Pain Relief Narcotic Analgesic Combunox 4 tablets/day AND 28 tablets/fill Pain Relief Narcotic Analgesic Duragesic 75mg,100mg 30 units per 30 days Pain Relief Narcotic Analgesic Duragesic 12.5mg, 25mg,50mg 15 units per 30 days Pain Relief Narcotic Analgesic Embeda 60 capsules per 30 days Pain Relief Narcotic Analgesic Fentany (Actiq) 120 per 30 days Pain Relief Narcotic Analgesic Fentanyl (Duragesic 12mcg/hr, 25mcg/hr, 50mcg/hr) Pain Relief Narcotic Analgesic Fentanyl (Duragesic 75mcg/hr, 100mcg/hr) 15 per 30 days 30 per 30 days Pain Relief Narcotic Analgesic Fentanyl (Fentora) 120 per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Hycet) 3,600ml per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Lorcet HD, Lortab, Vicodin) Pain Relief Narcotic Analgesic Hydrocodone/APAP (Lorcet, Lorcet Plus, Vicodin HP) 240 per 30 days 180 per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Lortab) 1200 ml per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Maxidone, Vicodin ES) 150 per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Norco) 360 per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Xodol 10-300, 5-300, 7.5-300) 390 tablets per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Zamicet) 2,700ml per 30 days Pain Relief Narcotic Analgesic Hydrocodone/APAP (Zydone 10-400, 7.5-400, 5-400) Pain Relief Narcotic Analgesic Hydrocodone/Ibuprofen (Reprexain, Vicoprofen) 300 per 30 days 480 per 30 days Pain Relief Narcotic Analgesic Kadian 100mg, 200mg 180 capsules per 30 days Pain Relief Narcotic Analgesic Kadian 10mg, 20mg, 30mg, 50mg, 60mg, 80mg Pain Relief Narcotic Analgesic Morphine sulfate (Avinza 120mg, Kadian 100mg & 200mg, Oramorph SR 100mg, MS Contin 100mg & 200mg) Pain Relief Narcotic Analgesic Morphine sulfate (Avinza <120mg, Kadian <100mg, Oramorph SR <100mg, MS Contin <100mg) 120 capsules per 30 days 180 per 30 days 120 per 30 days Pain Relief Narcotic Analgesic Morphine sulfate (Roxanol) 300ml per 30 days Pain Relief Narcotic Analgesic Nucynta 50mg, 75mg, 100mg 181 tablets per 30 days Pain Relief Narcotic Analgesic Onsolis 120 tablets per 30 days Pain Relief Narcotic Analgesic Opana ER 7.5mg, 10mg, 15mg, 20mg, 30mg 120 per 30 days Pain Relief Narcotic Analgesic Opana ER 40mg 180 per 30 days Pain Relief Narcotic Analgesic Oxycodone <80mg 120 per 30 days Pain Relief Narcotic Analgesic Oxycodone 80mg 180 per 30 days Pain Relief Narcotic Analgesic Oxycodone/APAP 180 per 30 days Pain Relief Narcotic Analgesic Percocet 10/325 360 per 30 days Pain Relief Narcotic Analgesic Percocet 10/600mg 180 per 30 days Pain Relief Narcotic Analgesic Percocet 2.5/325 360 per 30 days Pain Relief Narcotic Analgesic Percocet 5/325 360 per 30 days Pain Relief Narcotic Analgesic Percocet 7.5/325 360 per 30 days Pain Relief Narcotic Analgesic Percocet 7.5/500 240 per 30 days Pain Relief Narcotic Analgesic Roxicet 5/325 tablets 360 per 30 days 10 Quantity limits

Pain Relief Narcotic Analgesic Roxicet 5/500 240 per 30 days Pain Relief Narcotic Analgesic Tylox 240 per 30 days Pain Relief Narcotic Analgesic Oxycodone/APAP (Roxicet Solution) 600ml per 30 days Pain Relief Narcotic Analgesic Oxycodone/IBU (Combunox) 4 tablets/day AND 28 tablets/fill Pain Relief Narcotic Analgesic Oxymorphone (Opana ER <40mg) 180 per 30 days Pain Relief Narcotic Analgesic Oxymorphone (Opana ER 40mg) 120 per 30 days Pain Relief Narcotic Analgesic Stadol nasal spray 1 bottle per 30 days Pain Relief Narcotic Analgesic Subutex 2mg 12 tablets per 90 days Pain Relief Narcotic Analgesic Subutex 8mg 11 tablets per 90 days Pain Relief Narcotic Analgesic Tramadol (Ultram) 240 per 30 days Pain Relief Narcotic Analgesic Tramadol ER (Ryzolt, Ultram ER) 30 per 30 days Pain Relief Narcotic Analgesic Tramadol/APAP (Ultracet) 300 per 30 days Pain Relief Abstral 120 sublingual tablets per 30 days Pain Relief Lazanda 30 bottles per 30 days Pain Relief Rybix ODT 50mg Tablet 240 per 30 days. Skin Condition Psoriasis Treatment Stelara 1 vial/syringe (45mg/0.5mL or 90mg/1mL) per 84 days (12 weeks). 1 additional vial/syringe (45mg/0.5mL or 90mg/1mL) one time only for the first 84 days (12 weeks) for initial dosing Skin Condition Aldara 12 packets per 28 days Skin Condition Zyclara 14 packets per 28 days Sleep Aid Ambien 30 tablets per 30 days Sleep Aid Ambien CR 30 tablets per 30 days Sleep Aid Edluar 30 tablets per 30 days Sleep Aid Intermezzo 30 tablets per 30 days Sleep Aid Lunesta 30 tablets per 30 days Sleep Aid Rozerem 30 tablets per 30 days Sleep Aid Silenor 30 tablets per 30 days Sleep Aid Sonata 1 dose per day Sleep Aid Zolpimist 1 bottle (60 sprays) per 30 days Smoking Cessation Chantix 60 tablets per 30 days & one starter pak per year Stroke Prevention Aggrenox 60 capsules per 30 days Stroke Prevention Pradaxa 60 capsules per 30 days Due to varying health benefit plans, inclusion of a drug and related items on the drug list/formulary is not a guarantee of coverage. Please refer to the prescription drug benefit description of coverage, limitations and exclusions. What if my drug isn t on the list? This list may change throughout the year. Visit empireblue.com to view a current list or call customer service to check a specific drug. Quantity limits 11

Services provided by Empire HealthChoice Assurance, Inc., licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 11161NYMENEBS Rev. 8/12