HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs)

HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, Version Number: 16517v22 This formulary was updated on 10/25/2016. For more recent information or other questions, please contact HNE Medicare Advantage pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS) at 800-546-5677 or, for TTY users, 866-706-4757-24 hours a day, seven days a week, or visit www.healthnewengland.com/medicare/. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Health New England (HNE). When it refers to plan or our plan, it means HNE Medicare Advantage (HMO and HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of 10/25/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. H8578_2016_046 Accepted

What is the HNE Medicare Advantage (HMO & HMO-POS) Formulary? A formulary is a list of covered drugs selected by HNE Medicare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. HNE Medicare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a HNE Medicare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/25/2016. To get updated information about the drugs covered by HNE Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, HNE Medicare Advantage may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. 2

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 175. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? HNE Medicare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: HNE Medicare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HNE Medicare Advantage before you fill your prescriptions. If you don t get approval, HNE Medicare Advantage may not cover the drug. Quantity Limits: For certain drugs, HNE Medicare Advantage limits the amount of the drug that HNE Medicare Advantage will cover. For example, HNE Medicare Advantage provides 60 capsules per prescription for celecoxib. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, HNE Medicare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, HNE Medicare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HNE Medicare Advantage will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 3

You can ask HNE Medicare Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the HNE Medicare Advantage formulary? on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that HNE Medicare Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by HNE Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HNE Medicare Advantage. You can ask HNE Medicare Advantage to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the HNE Medicare Advantage Formulary? You can ask HNE Medicare 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 a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, HNE Medicare 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 a greater amount. Generally, HNE Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing 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, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. 4

Generally, we must make our decision within 72 hours of getting your prescriber 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 a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: 1. Beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital; 2. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary; 3. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits; 4. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. 5

All of these situations would warrant a temporary one-time fill exception irrespective of whether the beneficiary is in the first 90 days of program enrollment. For more information For more detailed information about your HNE Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about HNE Medicare Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 800-MEDICARE (800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877- 486-2048. Or, visit http://www.medicare.gov. HNE Medicare Advantage Formulary The formulary that begins on page 8 provides coverage information about the drugs covered by HNE Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 175. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., FLECTOR) and generic drugs are listed in lower-case italics (e.g., lisinopril). The second column of the formulary chart that begins on page 7 lists the tier numbers for each drug listed. The cost sharing table below lists the copayment amounts and co-insurance percentages for Tiers 1, 2, 3, or 4. For example, if a number 1 is listed in the Drug Tier column of the formulary chart, Generic copayment amounts apply. If the number 2 is listed in the Drug Tier column of the formulary chart, Brand/Preferred copayment amounts apply. A number 3 means that Brand/Non-Preferred copayment amounts apply. A number 4 means that Specialty co-insurance percentages apply. The information in the Requirements/Limits column tells you if HNE Medicare Advantage has any special requirements for coverage of your drug. 6

Cost Sharing for HNE Medicare Premium (HMO), Plus (HMO), Basic (HMO), and Plans with Prescription Drug Coverage Retail Long-Term Care Mail-Order Drug Tier 30 days 90 days 31 days 90 days 1 Generic $10.00 $30.00 $10.00 $20.00 2 Brand/ Preferred $45.00 $135.00 $45.00 $90.00 3 Brand/ Non-Preferred $90.00 $270.00 $90.00 $270.00 4 Specialty 33% 33% 33% - 1 month Cost Sharing for HNE Medicare Value (HMO) Plan with Prescription Drug Coverage Retail Long-Term Care Mail-Order Drug Tier 30 days 90 days 31 days 90 days 1 Generic $10.00 $30.00 $10.00 $20.00 2 Brand/ Preferred $45.00 $135.00 $45.00 $90.00 3 Brand/ Non-Preferred $90.00 $270.00 $90.00 $270.00 4 Specialty 29% 29% 29% - 1 month Cost Sharing for HNE Premier 1 (HMO), Premier 2 (HMO) and Premier 3 (HMO-POS) Plan with Prescription Drug Coverage Retail Long-Term Care Mail-Order Drug Tier 30 days 90 days 31 days 90 days 1 Generic $10.00 $30.00 $10.00 $20.00 2 Brand/ Preferred $45.00 $135.00 $45.00 $90.00 3 Brand/ Non-Preferred $90.00 $270.00 $90.00 $270.00 4 Specialty 33% 33% 33% - 1 month These cost sharing amounts are noted for the initial coverage phase of the benefit and are subject to Part D coverage limitations described in your Evidence of Coverage. 7

ANALGESICS Analgesics apap/codeinesol120-12/5 1 Quantity limitation 4500 per 30 days apap/codeinetab300-15mg 1 Quantity limitation 400 per 30 days apap/codeinetab300-30mg 1 Quantity limitation 400 per 30 days apap/codeinetab300-60mg 1 Quantity limitation 400 per 30 days ascomp/cod cap30mg 1 Quantity limitation 120 per 30 days but/apap/cafcap 1 Quantity limitation 120 per 30 days but/apap/cafcap 1 but/apap/cafcapcodeine 1 Quantity limitation 120 per 30 days but/apap/cafcapcodeine 1 Quantity limitation 360 per 30 days but/apap/caftab 1 Quantity limitation 120 per 30 days but/asa/caf/capcod 30mg 1 Quantity limitation 120 per 30 days but/asa/caffcap 1 Quantity limitation 180 per 30 days butal/apap tab50-325mg 1 Quantity limitation 180 per 30 days diclo/misoprtab50-0.2mg 1 diclo/misoprtab75-0.2mg 1 endocet tab10-325mg 1 Quantity limitation 120 per 30 days endocet tab5-325mg 1 Quantity limitation 120 per 30 days endocet tab7.5-325 1 Quantity limitation 120 per 30 days hycet sol7.5-325 1 Quantity limitation 3600 per 30 days hydroco/apapsol7.5-325 1 Quantity limitation 3600 per 30 days hydroco/apaptab10-300mg 1 Quantity limitation 120 per 30 days hydroco/apaptab10-325mg 1 Quantity limitation 120 per 30 days hydroco/apaptab2.5-325 1 Quantity limitation 120 per 30 days hydroco/apaptab5-300mg 1 Quantity limitation 120 per 30 days hydroco/apaptab5-325mg 1 Quantity limitation 120 per 30 days hydroco/apaptab7.5-300 1 Quantity limitation 120 per 30 days hydroco/apaptab7.5-325 1 Quantity limitation 120 per 30 days hydrocod/ibutab7.5-200 1 Quantity limitation 120 per 30 days oxycod/apap tab10-325mg 1 Quantity limitation 120 per 30 days oxycod/apap tab2.5-325 1 Quantity limitation 120 per 30 days oxycod/apap tab5-325mg 1 Quantity limitation 120 per 30 days oxycod/apap tab7.5-325 1 Quantity limitation 120 per 30 days oxycod/asa tab 1 Quantity limitation 120 per 30 days oxycod/ibu tab5-400mg 1 Quantity limitation 120 per 30 days tramadl/apaptab37.5-325 1 Quantity limitation 240 per 30 days vicodin tab5-300mg 1 Quantity limitation 120 per 30 days vicodin es tab7.5-300 1 Quantity limitation 120 per 30 days vicodin hp tab10-300mg 1 Quantity limitation 120 per 30 days xodol tab10-300mg 1 Quantity limitation 120 per 30 days xodol tab5-300mg 1 Quantity limitation 120 per 30 days xodol tab7.5-300 1 Quantity limitation 120 per 30 days 8

Nonsteroidal Anti-Inflammatory Drugs celecoxib cap100mg 1 Quantity limitation 60 per 30 days; Step therapy protocols apply celecoxib cap200mg 1 Quantity limitation 60 per 30 days; Step therapy protocols apply celecoxib cap400mg 1 Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply celecoxib cap50mg 1 diclofen pottab50mg 1 diclofenac tab100mg er 1 diclofenac tab25mg dr 1 diclofenac tab50mg dr 1 diclofenac tab75mg dr 1 diflunisal tab500mg 1 etodolac cap200mg 1 etodolac cap300mg 1 etodolac tab400mg 1 etodolac tab500mg 1 etodolac er tab400mg 1 etodolac er tab500mg 1 etodolac er tab600mg 1 fenoprofen tab600mg 1 FLECTOR DIS1.3% 3 flurbiprofentab100mg 1 flurbiprofentab50mg 1 ibuprofen sus100/5ml 1 ibuprofen tab400mg 1 ibuprofen tab600mg 1 ibuprofen tab800mg 1 indomethacincap25mg 1 indomethacincap50mg 1 indomethacincap75mg er 1 ketoprofen cap200mg er 1 This prescription drug will be provided at zero cost-sharing the first time you fill it. This prescription drug will be provided at zero cost-sharing the first time you fill it. This prescription drug will be provided at zero cost-sharing the first time you fill it. 9

ketoprofen cap50mg 1 ketoprofen cap75mg 1 meclofen sodcap100mg 1 meclofen sodcap50mg 1 Quantity limitation 30 per 30 days; This prescription drug will be provided at zero cost-sharing the first meloxicam tab15mg 1 time you fill it. Quantity limitation 30 per 30 days; This prescription drug will be provided at zero cost-sharing the first time you fill it. meloxicam tab7.5mg 1 nabumetone tab500mg 1 nabumetone tab750mg 1 naproxen sus125/5ml 1 naproxen tab250mg 1 naproxen tab375mg 1 naproxen tab500mg 1 naproxen dr tab375mg 1 naproxen dr tab500mg 1 naproxen sodtab275mg 1 naproxen sodtab550mg 1 oxaprozin tab600mg 1 piroxicam cap10mg 1 piroxicam cap20mg 1 sulindac tab150mg 1 sulindac tab200mg 1 tolmetin sodcap400mg 1 tolmetin sodtab600mg 1 Opioid Analgesics, Long-Acting fentanyl dis100mcg/h 1 Quantity limitation 30 per 30 days fentanyl dis12mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis25mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis50mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis75mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis37.5mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis62.5mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis87.5mcg/hr 1 Quantity limitation 30 per 30 days levorphanol tab2mg 1 Quantity limitation 120 per 30 days METHADONE INJ10MG/ML 3 Quantity limitation 120 per 30 days; 10

methadone sol10mg/5ml 1 Quantity limitation 600 per 30 days methadone sol5mg/5ml 1 Quantity limitation 1200 per 30 days methadone tab10mg 1 Quantity limitation 120 per 30 days methadone tab5mg 1 Quantity limitation 120 per 30 days morphine sulcap100mg er 1 Quantity limitation 60 per 30 days morphine sulcap10mg er 1 Quantity limitation 60 per 30 days morphine sulcap120mg er 1 Quantity limitation 60 per 30 days morphine sulcap20mg er 1 Quantity limitation 60 per 30 days morphine sulcap30mg er 1 Quantity limitation 60 per 30 days morphine sulcap30mg er 1 Quantity limitation 60 per 30 days morphine sulcap45mg er 1 Quantity limitation 60 per 30 days morphine sulcap50mg er 1 Quantity limitation 60 per 30 days morphine sulcap60mg er 1 Quantity limitation 60 per 30 days morphine sulcap60mg er 1 Quantity limitation 60 per 30 days morphine sulcap75mg er 1 Quantity limitation 60 per 30 days morphine sulcap80mg er 1 Quantity limitation 60 per 30 days morphine sulcap90mg er 1 Quantity limitation 60 per 30 days morphine sultab100mg er 1 Quantity limitation 120 per 30 days morphine sultab15mg er 1 Quantity limitation 120 per 30 days morphine sultab200mg er 1 Quantity limitation 120 per 30 days morphine sultab30mg er 1 Quantity limitation 120 per 30 days morphine sultab60mg er 1 Quantity limitation 120 per 30 days oxymorphone tab10mg er 1 Quantity limitation 120 per 30 days oxymorphone tab15mg er 1 Quantity limitation 120 per 30 days oxymorphone tab20mg er 1 Quantity limitation 120 per 30 days oxymorphone tab30mg er 1 Quantity limitation 120 per 30 days oxymorphone tab40mg er 1 Quantity limitation 120 per 30 days oxymorphone tab5mg er 1 Quantity limitation 120 per 30 days oxymorphone tab7.5mg er 1 Quantity limitation 120 per 30 days Opioid Analgesics, Short-Acting butorphanol sol10mg/ml 1 Quantity limitation 10 per 30 days duramorph inj0.5mg/ml 1 Quantity limitation 180 per 30 days; duramorph inj1mg/ml 1 Quantity limitation 180 per 30 days; 11

fentanyl ot loz1200mcg 1 Quantity limitation 120 per 30 days; fentanyl ot loz1600mcg 1 Quantity limitation 120 per 30 days; fentanyl ot loz200mcg 1 Quantity limitation 120 per 30 days; fentanyl ot loz400mcg 1 Quantity limitation 120 per 30 days; Quantity limitation 120 per 30 days; fentanyl ot loz600mcg 1 Quantity limitation 120 per 30 days; fentanyl ot loz800mcg 1 hydromorphontab2mg 1 Quantity limitation 120 per 30 days hydromorphontab4mg 1 Quantity limitation 120 per 30 days hydromorphontab8mg 1 Quantity limitation 120 per 30 days MORPHINE SULINJ10MG/ML 1 12

MORPHINE SULINJ2MG/ML 1 MORPHINE SULINJ4MG/ML 1 MORPHINE SULINJ8MG/ML 1 morphine sultab15mg 1 Quantity limitation 120 per 30 days morphine sultab30mg 1 Quantity limitation 120 per 30 days nalbuphine inj10mg/ml 3 Quantity limitation 120 per 30 days; Quantity limitation 120 per 30 days; nalbuphine inj20mg/ml 3 oxycodone cap5mg 1 Quantity limitation 120 per 30 days oxycodone con100/5ml 1 Quantity limitation 120 per 30 days oxycodone sol5mg/5ml 1 Quantity limitation 1800 per 30 days oxycodone tab10mg 1 Quantity limitation 120 per 30 days oxycodone tab15mg 1 Quantity limitation 120 per 30 days oxycodone tab20mg 1 Quantity limitation 120 per 30 days oxycodone tab30mg 1 Quantity limitation 120 per 30 days oxycodone tab5mg 1 Quantity limitation 120 per 30 days 13

oxymorphone tabhcl 10mg 1 Quantity limitation 120 per 30 days oxymorphone tabhcl 5mg 1 Quantity limitation 120 per 30 days tramadol hcltab50mg 1 Quantity limitation 240 per 30 days ANESTHETICS Local Anesthetics lido/prilocncre2.5-2.5% 1 lidocaine gel2% jelly 1 lidocaine gel2% jelly 1 lidocaine gel2% jelly 1 lidocaine inj0.5% 3 lidocaine oin5% 1 lidocaine pad5% 1 Quantity limitation 90 per 30 days; lidocaine sol2% visc 1 lidocaine sol4% 1 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acampro cal tab333mg 1 disulfiram tab250mg 1 disulfiram tab500mg 1 Opioid Antagonists bupren/naloxsub2-0.5mg 1 Quantity limitation 120 per 30 days bupren/naloxsub8-2mg 1 Quantity limitation 120 per 30 days buprenorphininj0.3mg/ml 2 buprenorphinsub2mg 1 Quantity limitation 120 per 30 days buprenorphinsub8mg 1 Quantity limitation 120 per 30 days BUTRANS DIS10MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS15MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS20MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS5MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS7.5MCG/HR 3 Quantity limitation 4 per 28 days SUBOXONE MIS12-3MG 3 Quantity limitation 120 per 30 days SUBOXONE MIS2-0.5MG 3 Quantity limitation 90 per 30 days 14

SUBOXONE MIS4-1MG 3 Quantity limitation 120 per 30 days SUBOXONE MIS8-2MG 3 Quantity limitation 90 per 30 days Opioid Reversal Agents naloxone inj1mg/ml 1 naltrexone tab50mg 1 Smoking Cessation Agents buproban tab150mg 1 Quantity limitation 90 per 30 days bupropion tab100mg 1 Quantity limitation 120 per 30 days bupropion tab150mg 1 Quantity limitation 90 per 30 days bupropion tab100mg sr 1 Quantity limitation 60 per 30 days bupropion tab150mg sr 1 Quantity limitation 90 per 30 days bupropion tab200mg sr 1 Quantity limitation 30 per 30 days bupropion tab75mg 1 Quantity limitation 180 per 30 days bupropn hcl tab150mg xl 1 Quantity limitation 30 per 30 days bupropn hcl tab300mg xl 1 Quantity limitation 45 per 30 days Quantity limitation 60 per 30 days; CHANTIX PAK0.5& 1MG 3 CHANTIX TAB0.5MG 3 Quantity limitation 60 per 30 days; Quantity limitation 60 per 30 days; CHANTIX TAB1MG 3 FORFIVO XL TAB450MG 3 Quantity limitation 30 per 30 days NICOTROL NS SPR10MG/ML 2 Quantity limitation 40 per 30 days ANTIBACTERIALS Aminoglycosides gentak oin0.3% op 1 gentamicin cre0.1% 2 gentamicin inj10mg/ml 3 15

gentamicin inj40mg/ml 3 GENTAMICIN OIN0.1% 2 gentamicin sol0.3% op 1 neomycin tab500mg 1 paromomycin cap250mg 1 streptomycininj1gm 3 TOBRADEX OIN0.3-0.1% 3 tobramycin inj10mg/ml 3 tobramycin inj80mg/2ml 3 tobramycin neb300/5ml 4 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY 16

tobramycin sol0.3% op 1 Antibacterials colistimeth inj150mg 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY neo/poly gu sol40/ml ir 1 SYNERCID INJ500MG 4 Antibacterials, Other acetic acid sol2% otic 1 baciim inj50000unt 3 bacitracin oinop 1 chloramphen inj1gm 1 clindamycin aer1% 1 clindamycin cap150mg 1 clindamycin cap300mg 1 clindamycin cap75mg 1 clindamycin cre2% vag 1 clindamycin gel1% 1 clindamycin inj150mg/ml 3 clindamycin lot1% 1 clindamycin pad1% 1 clindamycin sol1% 1 17

CUBICIN SOL500MG 4 linezolid inj2mg/ml 4 Quantity limitation 28 per 14 days; linezolid tab600mg 4 methenam hiptab1gm 1 metron/nacl inj500mg 1 metronidazolcre0.75% 1 metronidazolgel0.75% 1 metronidazolgel0.75%vag 1 metronidazolgel1% 1 metronidazollot0.75% 1 metronidazoltab250mg 1 metronidazoltab500mg 1 MONUROL PAKGRANULES 3 mupirocin cre2% 1 mupirocin oin2% 1 nitrofur maccap100mg 1 nitrofur maccap50mg 1 nitrofurantncap100mg 1 nitrofurantnsus25mg/5ml 1 SULFAMYLON CRE85MG/GM 3 tinidazole tab250mg 1 tinidazole tab500mg 1 trimethoprimtab100mg 1 TYGACIL INJ50MG 4 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 18

800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. vancomycin cap125mg 1 Quantity limitation 40 per 30 days; vancomycin cap250mg 1 Quantity limitation 80 per 30 days; vancomycin inj1000mg 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. vancomycin inj10gm 3 vancomycin inj500mg 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. ZYVOX SUS100MG/5M 4 19

Beta-lactam, Cephalosporins cefaclor cap250mg 1 cefaclor cap500mg 1 cefaclor er tab500mg 1 cefadroxil cap500mg 1 cefadroxil sus250/5ml 1 cefadroxil sus500/5ml 1 cefadroxil tab1gm 1 cefazolin inj10gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefazolin inj1gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefazolin inj1gm/50ml 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefazolin inj500mg 3 20

This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefdinir cap300mg 1 cefdinir sus125/5ml 1 cefdinir sus250/5ml 1 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefepime inj1gm 3 cefepime inj2gm 3 cefixime sus100/5ml 1 cefixime sus200/5ml 1 cefoxitin inj10gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 21

hours a day-seven days a week. TTY This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefoxitin inj1gm 3 cefoxitin inj2gm 3 cefpodo proxsus100/5ml 1 cefpodo proxsus50mg/5ml 1 cefpodoxime tab100mg 1 cefpodoxime tab200mg 1 cefprozil sus125/5ml 1 cefprozil sus250/5ml 1 cefprozil tab250mg 1 cefprozil tab500mg 1 ceftriaxone inj10gm 3 ceftriaxone inj250mg 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY 22

This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY ceftriaxone inj500mg 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefuroxime inj1.5gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefuroxime inj7.5gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefuroxime inj750mg 3 23

This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY cefuroxime tab250mg 1 cefuroxime tab500mg 1 cephalexin cap250mg 1 cephalexin cap500mg 1 cephalexin cap750mg 1 cephalexin sus125/5ml 1 cephalexin sus250/5ml 1 cephalexin tab250mg 1 cephalexin tab500mg 1 SUPRAX SUS500/5ML 3 TEFLARO INJ400MG 4 TEFLARO INJ600MG 4 Beta-lactam, Other AZACTAM/DEX INJ1GM 3 AZACTAM/DEX INJ2GM 4 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. 24

This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. aztreonam inj1gm 1 imipenem/cilinj250mg 1 imipenem/cilinj500mg 1 INVANZ INJ1GM 3 meropenem inj500mg 1 Beta-lactam, Penicillins amox/k clav chw200mg 1 amox/k clav chw400mg 1 amox/k clav sus200/5ml 1 amox/k clav sus250/5ml 1 amox/k clav sus400/5ml 1 amox/k clav sus600/5ml 1 amox/k clav tab250mg 1 amox/k clav tab500mg 1 amox/k clav tab875mg 1 amoxicillin cap250mg 1 amoxicillin cap500mg 1 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. 25

amoxicillin chw125mg 1 amoxicillin chw250mg 1 amoxicillin sus125/5ml 1 amoxicillin sus200/5ml 1 amoxicillin sus250/5ml 1 amoxicillin sus400/5ml 1 amoxicillin tab500mg 1 amoxicillin tab875mg 1 amox-pot clataber 1 ampicillin cap250mg 1 ampicillin cap500mg 1 ampicillin inj10gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY ampicillin inj125mg 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY ampicillin inj1gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY ampicillin sus125/5ml 1 26

ampicillin sus250/5ml 1 amp-sulbactainj1.5gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY amp-sulbactainj15gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY amp-sulbactainj3gm 3 BICILLIN C-RINJ1200000 3 BICILLIN C-RINJ900/300 3 BICILLIN L-AINJ1200000 3 BICILLIN L-AINJ2400000 3 BICILLIN L-AINJ600000 3 dicloxacill cap250mg 1 dicloxacill cap500mg 1 nafcillin inj10gm 4 27

This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY nafcillin inj1gm 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY pen g proc inj600000 3 pen g sod inj5000000 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY PENICILL GK/INJDEX 2MU 1 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY 28

PENICILL GK/INJDEX 3MU 1 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY penicilln gkinj5mu 3 penicilln vksol125/5ml 1 penicilln vksol250/5ml 1 penicilln vktab250mg 1 penicilln vktab500mg 1 piper/tazobainj3-0.375g 1 piper/tazobainj4-0.5gm 1 ZOSYN SOL2-0.25GM 3 This prescription drug may be covered 29

under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. ZOSYN SOL3-0.375G 3 This prescription drug may be covered under our medical benefit. For more information, call Member Services at 800-546-5677-24 hours a day-seven days a week. TTY users should call 866-706-4757. Macrolides azithromycininj500mg 3 azithromycininj500mg 3 azithromycinpow1gm pak 1 azithromycinsus100/5ml 1 Quantity limitation 30 per 5 days azithromycinsus200/5ml 1 Quantity limitation 90 per 5 days azithromycintab250mg 1 Quantity limitation 6 per 5 days azithromycintab500mg 1 Quantity limitation 6 per 5 days azithromycintab600mg 1 Quantity limitation 6 per 5 days clarithromycsus125/5ml 1 clarithromycsus250/5ml 1 clarithromyctab250mg 1 Quantity limitation 28 per 14 days clarithromyctab500mg 1 Quantity limitation 28 per 14 days clarithromyctab500mg er 1 Quantity limitation 28 per 14 days DIFICID TAB200MG 4 30

ery pad2% 1 ery-tab tab250mg ec 1 ery-tab tab333mg ec 1 ery-tab tab500mg ec 1 ERYTHROCIN INJ500MG 3 erythrocin tab250mg 1 ERYTHROM ETHTAB400MG 2 erythromycingel2% 1 erythromycinoinop 1 erythromycinsol2% 1 erythromycintab250mg bs 1 erythromycintab500mg bs 1 Quinolones AVELOX INJ 3 CILOXAN OIN0.3% OP 3 ciprofloxacninj200mg 1 ciprofloxacninj400mg 1 ciprofloxacnsol0.3% op 1 ciprofloxacnsus250mg/5 1 ciprofloxacnsus500mg/5 1 ciprofloxacntab1000mg 1 ciprofloxacntab100mg 1 ciprofloxacntab250mg 1 ciprofloxacntab500mg 1 31

ciprofloxacntab500mg er 1 ciprofloxacntab750mg 1 levofloxacinsol0.5% 1 levofloxacinsol25mg/ml 1 levofloxacintab250mg 1 Quantity limitation 14 per 14 days levofloxacintab500mg 1 Quantity limitation 14 per 14 days levofloxacintab750mg 1 Quantity limitation 14 per 14 days moxifloxacintab400mg 1 ofloxacin dro0.3% op 1 ofloxacin dro0.3%otic 1 ofloxacin tab400mg 1 VIGAMOX DRO0.5% 3 Sulfonamides silver sulfacre1% 1 smz/tmp ds tab800-160 1 smz-tmp inj400-80/5 3 smz-tmp sus200-40/5 1 smz-tmp tab400-80mg 1 sod sulfacetsol10% op 1 ssd cre1% 1 SULFACET SODOIN10% OP 1 sulfacetamidsus10% 1 sulfadiazinetab500mg 1 Tetracyclines demeclocycl tab150mg 1 demeclocycl tab300mg 1 doxycyc monocap100mg 1 doxycyc monotab100mg 1 doxycyc monotab150mg 1 doxycyc monotab50mg 1 doxycyc monotab75mg 1 doxycycl hyccap100mg 1 doxycycl hyccap50mg 1 doxycycl hycinj100mg 3 doxycycl hyctab100mg 1 minocycline cap100mg 1 minocycline cap50mg 1 minocycline cap75mg 1 minocycline tab100mg 1 32

minocycline tab135mg er 1 minocycline tab45mg er 1 minocycline tab50mg 1 minocycline tab75mg 1 minocycline tab90mg er 1 ANTICONVULSANTS Anticonvulsants, Other APTIOM TAB200MG 3 Quantity limitation 180 per 30 days APTIOM TAB400MG 3 Quantity limitation 90 per 30 days APTIOM TAB600MG 3 Quantity limitation 60 per 30 days APTIOM TAB800MG 3 Quantity limitation 45 per 30 days levetiracetasol100mg/ml 1 levetiracetatab1000mg 1 levetiracetatab250mg 1 levetiracetatab500mg 1 levetiracetatab500mg er 1 Quantity limitation 180 per 30 days levetiracetatab750mg 1 levetiracetatab750mg er 1 Quantity limitation 120 per 30 days levetiracetminj500/5ml 3 POTIGA TAB200MG 3 Quantity limitation 180 per 30 days POTIGA TAB300MG 3 Quantity limitation 120 per 30 days POTIGA TAB400MG 3 Quantity limitation 90 per 30 days POTIGA TAB50MG 3 Quantity limitation 720 per 30 days roweepra tab500mg 1 SPRITAM TAB1000MG 3 Quantity limitation 90 per 30 days SPRITAM TAB250MG 3 Quantity limitation 360 per 30 days SPRITAM TAB500MG 3 Quantity limitation 180 per 30 days SPRITAM TAB750MG 3 Quantity limitation 120 per 30 days Calcium Channel Modifying Agents CELONTIN CAP300MG 3 ethosuximidecap250mg 1 ethosuximidesol250/5ml 1 LYRICA CAP100MG 3 Quantity limitation 180 per 30 days LYRICA CAP150MG 3 Quantity limitation 120 per 30 days LYRICA CAP200MG 3 Quantity limitation 90 per 30 days LYRICA CAP225MG 3 Quantity limitation 60 per 30 days LYRICA CAP25MG 3 Quantity limitation 45 per 30 days LYRICA CAP300MG 3 Quantity limitation 60 per 30 days LYRICA CAP50MG 3 Quantity limitation 360 per 30 days LYRICA CAP75MG 3 Quantity limitation 240 per 30 days LYRICA SOL20MG/ML 3 Quantity limitation 900 per 30 days zonisamide cap100mg 1 zonisamide cap25mg 1 33

zonisamide cap50mg 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazep odttab0.125mg 1 Quantity limitation 4800 per 30 days clonazep odttab0.25mg 1 Quantity limitation 2400 per 30 days clonazep odttab0.5mg 1 Quantity limitation 1200 per 30 days clonazep odttab1mg 1 Quantity limitation 600 per 30 days clonazep odttab2mg 1 Quantity limitation 300 per 30 days clonazepam tab0.5mg 1 Quantity limitation 1200 per 30 days clonazepam tab1mg 1 Quantity limitation 600 per 30 days clonazepam tab2mg 1 Quantity limitation 300 per 30 days cloraz dipottab15mg 1 Quantity limitation 90 per 30 days cloraz dipottab3.75mg 1 Quantity limitation 90 per 30 days cloraz dipottab7.5mg 1 Quantity limitation 90 per 30 days DIASTAT ACDLGEL12.5-20 3 Quantity limitation 40 per 30 days DIASTAT ACDLGEL5-10MG 3 Quantity limitation 30 per 30 days DIASTAT PED GEL2.5M GEL 3 Quantity limitation 30 per 30 days diazepam con5mg/ml 1 Quantity limitation 240 per 30 days diazepam sol1mg/ml 1 Quantity limitation 1200 per 30 days diazepam tab10mg 1 Quantity limitation 180 per 30 days diazepam tab2mg 1 Quantity limitation 90 per 30 days diazepam tab5mg 1 Quantity limitation 240 per 30 days divalproex cap125mg 1 divalproex tab125mg dr 1 divalproex tab250mg dr 1 divalproex tab250mg er 1 divalproex tab500mg dr 1 divalproex tab500mg er 1 FYCOMPA SUS0.5MG/ML 3 Quantity limitation 720 per 30 days FYCOMPA TAB10MG 3 Quantity limitation 30 per 30 days FYCOMPA TAB12MG 3 Quantity limitation 30 per 30 days FYCOMPA TAB2MG 3 Quantity limitation 120 per 30 days FYCOMPA TAB4MG 3 Quantity limitation 90 per 30 days FYCOMPA TAB6MG 3 Quantity limitation 60 per 30 days FYCOMPA TAB8MG 3 Quantity limitation 30 per 30 days gabapentin cap100mg 1 Quantity limitation 360 per 30 days gabapentin cap300mg 1 Quantity limitation 360 per 30 days gabapentin cap400mg 1 Quantity limitation 270 per 30 days gabapentin sol250/5ml 1 Quantity limitation 2160 per 30 days gabapentin tab600mg 1 Quantity limitation 180 per 30 days gabapentin tab800mg 1 Quantity limitation 120 per 30 days GABITRIL TAB12MG 2 GABITRIL TAB16MG 2 lorazepam con2mg/ml 1 lorazepam tab0.5mg 1 Quantity limitation 60 per 30 days 34

lorazepam tab1mg 1 Quantity limitation 60 per 30 days lorazepam tab2mg 1 Quantity limitation 60 per 30 days ONFI SUS2.5MG/ML 3 Quantity limitation 480 per 30 days ONFI TAB10MG 3 Quantity limitation 60 per 30 days ONFI TAB20MG 3 Quantity limitation 60 per 30 days phenobarb elx20mg/5ml 1 Quantity limitation 1500 per 30 days PHENOBARB TAB100MG 1 Quantity limitation 90 per 30 days PHENOBARB TAB15MG 1 Quantity limitation 120 per 30 days phenobarb tab16.2mg 1 Quantity limitation 360 per 30 days PHENOBARB TAB30MG 1 Quantity limitation 195 per 30 days phenobarb tab32.4mg 1 Quantity limitation 180 per 30 days PHENOBARB TAB60MG 1 Quantity limitation 60 per 30 days phenobarb tab64.8mg 2 Quantity limitation 90 per 30 days phenobarb tab97.2mg 2 Quantity limitation 60 per 30 days primidone tab250mg 1 primidone tab50mg 1 Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information please call 800-546-5677-24 hours a day-seven days a week. TTY/TDD users should call 866-706- SABRIL POW500MG 3 SABRIL TAB500MG 3 tiagabine tab2mg 1 tiagabine tab4mg 1 valproate inj500/5ml 3 valproic acdcap250mg 1 valproic acdsyp250/5ml 1 Glutamate Reducing Agents felbamate sus600/5ml 1 felbamate tab400mg 1 felbamate tab600mg 1 lamotrigine chw25mg 1 lamotrigine chw5mg 1 lamotrigine tab100mg 1 lamotrigine tab100mg 1 lamotrigine tab100mg er 1 4757. Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information please call 800-546-5677-24 hours a day-seven days a week. TTY/TDD users should call 866-706- 4757. 35

lamotrigine tab150mg 1 lamotrigine tab200mg 1 lamotrigine tab200mg 1 lamotrigine tab200mg er 1 lamotrigine tab250mg er 1 lamotrigine tab25mg 1 lamotrigine tab25mg er 1 lamotrigine tab25mg odt 1 lamotrigine tab300mg er 1 lamotrigine tab50mg er 1 lamotrigine tab50mg odt 1 topiramate cap15mg 1 topiramate cap25mg 1 topiramate tab100mg 1 Quantity limitation 480 per 30 days topiramate tab200mg 1 Quantity limitation 240 per 30 days topiramate tab25mg 1 Quantity limitation 1920 per 30 days topiramate tab50mg 1 Quantity limitation 960 per 30 days TROKENDI XR CAP100MG 3 TROKENDI XR CAP200MG 4 TROKENDI XR CAP25MG 3 TROKENDI XR CAP50MG 3 Sodium Channel Agents BANZEL SUS40MG/ML 3 Quantity limitation 2400 per 30 days BANZEL TAB200MG 3 Quantity limitation 240 per 30 days BANZEL TAB400MG 3 Quantity limitation 240 per 30 days BRIVIACT INJ50MG/5ML 3 BRIVIACT SOL10MG/ML 3 Quantity limitation 600 per 30 days BRIVIACT TAB100MG 4 Quantity limitation 60 per 30 days BRIVIACT TAB10MG 4 Quantity limitation 600 per 30 days BRIVIACT TAB25MG 4 Quantity limitation 240 per 30 days BRIVIACT TAB50MG 4 Quantity limitation 120 per 30 days BRIVIACT TAB75MG 4 Quantity limitation 90 per 30 days carbamazepincap100mg er 1 carbamazepincap200mg er 1 carbamazepincap300mg er 1 carbamazepinchw100mg 1 carbamazepinsus100/5ml 1 carbamazepintab200mg 1 carbamazepintab100mg er 1 carbamazepintab200mg er 1 carbamazepintab400mg er 1 DILANTIN CAP30MG 2 epitol tab200mg 1 EQUETRO CAP100MG 3 Quantity limitation 480 per 30 days 36

EQUETRO CAP200MG 3 Quantity limitation 240 per 30 days EQUETRO CAP300MG 3 Quantity limitation 180 per 30 days fosphenytoininj100/2ml 3 oxcarbazepinsus300mg/5m 1 oxcarbazepintab150mg 1 oxcarbazepintab300mg 1 oxcarbazepintab600mg 1 OXTELLAR XR TAB150MG 3 Quantity limitation 480 per 30 days OXTELLAR XR TAB300MG 3 Quantity limitation 240 per 30 days OXTELLAR XR TAB600MG 3 Quantity limitation 120 per 30 days PEGANONE TAB250MG 3 phenytoin chw50mg 1 phenytoin inj50mg/ml 3 phenytoin sus125/5ml 1 phenytoin excap100mg 1 phenytoin excap200mg 1 phenytoin excap300mg 1 VIMPAT INJ200MG/20 3 Quantity limitation 1200 per 30 days VIMPAT SOL10MG/ML 3 Quantity limitation 1200 per 30 days VIMPAT TAB100MG 3 Quantity limitation 60 per 30 days VIMPAT TAB150MG 3 Quantity limitation 60 per 30 days VIMPAT TAB200MG 3 Quantity limitation 60 per 30 days VIMPAT TAB50MG 3 Quantity limitation 60 per 30 days ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mestab1mg oral 1 Cholinesterase Inhibitors donepezil tab10mg 1 Quantity limitation 30 per 30 days donepezil tab10mg odt 1 Quantity limitation 30 per 30 days donepezil tab5mg 1 Quantity limitation 30 per 30 days donepezil tab5mg odt 1 Quantity limitation 30 per 30 days donepezil tabhcl 23mg 1 Quantity limitation 30 per 30 days galantamine cap16mg er 1 Quantity limitation 30 per 30 days galantamine cap24mg er 1 Quantity limitation 30 per 30 days 37

galantamine cap8mg er 1 Quantity limitation 30 per 30 days galantamine sol4mg/ml 1 Quantity limitation 180 per 30 days galantamine tab12mg 1 Quantity limitation 60 per 30 days galantamine tab4mg 1 Quantity limitation 60 per 30 days galantamine tab8mg 1 Quantity limitation 60 per 30 days rivastigminecap1.5mg 1 Quantity limitation 60 per 30 days rivastigminecap3mg 1 Quantity limitation 60 per 30 days rivastigminecap4.5mg 1 Quantity limitation 60 per 30 days rivastigminecap6mg 1 Quantity limitation 60 per 30 days rivastigminedis13.3/24 1 Quantity limitation 30 per 30 days rivastigminedis4.6/24 1 Quantity limitation 30 per 30 days rivastigminedis9.5/24 1 Quantity limitation 30 per 30 days N-methyl-D-aspartate (NMDA) Receptor Antagonist memant titrapak5-10mg 1 Quantity limitation 60 per 30 days memantine tabhcl 10mg 1 Quantity limitation 60 per 30 days memantine tabhcl 5mg 1 Quantity limitation 60 per 30 days NAMENDA SOL10MG/5ML 2 Quantity limitation 360 per 30 days NAMENDA XR CAP14MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAP21MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAP28MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAP7MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAPTITRATIO 2 Quantity limitation 30 per 30 days ANTIDEPRESSANTS Antidepressants olanza/fluoxcap12-25mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap12-50mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap3-25mg 1 Quantity limitation 90 per 30 days olanza/fluoxcap6-25mg 1 Quantity limitation 90 per 30 days olanza/fluoxcap6-50mg 1 Quantity limitation 30 per 30 days perphen/amittab2-10mg 1 perphen/amittab2-25mg 1 perphen/amittab4-10mg 1 perphen/amittab4-25mg 1 perphen/amittab4-50mg 1 olanza/fluoxcap12-25mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap12-50mg 1 Quantity limitation 30 per 30 days Antidepressants, Other ABILIFY DISCTAB10MG 3 Quantity limitation 90 per 30 days ABILIFY MAININJ300MG 4 Quantity limitation 2 per 28 days ABILIFY MAININJ400MG 4 Quantity limitation 1 per 28 days aripiprazoletab10mg 1 Quantity limitation 90 per 30 days aripiprazoletab10mg odt 1 Quantity limitation 90 per 30 days aripiprazoletab15mg 1 Quantity limitation 60 per 30 days 38

aripiprazoletab15mg odt 1 Quantity limitation 60 per 30 days aripiprazoletab20mg 1 Quantity limitation 60 per 30 days aripiprazoletab2mg 1 Quantity limitation 450 per 30 days aripiprazoletab30mg 1 Quantity limitation 30 per 30 days aripiprazoletab5mg 1 Quantity limitation 180 per 30 days ARISTADA INJ441MG/1.6ML 4 Quantity limitation 1.6 per 28 days ARISTADA INJ662MG/2.4ML 4 Quantity limitation 2.4 per 28 days ARISTADA INJ882MG/3.2ML 4 Quantity limitation 3.2 per 28 days mirtazapine tab15mg 1 Quantity limitation 30 per 30 days mirtazapine tab15mg odt 1 Quantity limitation 30 per 30 days mirtazapine tab30mg 1 Quantity limitation 30 per 30 days mirtazapine tab30mg odt 1 Quantity limitation 30 per 30 days mirtazapine tab45mg 1 Quantity limitation 30 per 30 days mirtazapine tab45mg odt 1 Quantity limitation 30 per 30 days mirtazapine tab7.5mg 1 Quantity limitation 30 per 30 days quetiapine tab100mg 1 Quantity limitation 240 per 30 days quetiapine tab200mg 1 Quantity limitation 120 per 30 days quetiapine tab25mg 1 Quantity limitation 960 per 30 days quetiapine tab300mg 1 Quantity limitation 90 per 30 days quetiapine tab400mg 1 Quantity limitation 60 per 30 days quetiapine tab50mg 1 Quantity limitation 480 per 30 days REXULTI TAB0.25MG 3 Quantity limitation 480 per 30 days REXULTI TAB0.5MG 3 Quantity limitation 240 per 30 days REXULTI TAB1MG 3 Quantity limitation 120 per 30 days REXULTI TAB2MG 3 Quantity limitation 60 per 30 days REXULTI TAB3MG 3 Quantity limitation 30 per 30 days REXULTI TAB4MG 3 Quantity limitation 30 per 30 days SEROQUEL XR TAB150MG 2 Quantity limitation 30 per 30 days SEROQUEL XR TAB200MG 2 Quantity limitation 30 per 30 days SEROQUEL XR TAB300MG 2 Quantity limitation 60 per 30 days SEROQUEL XR TAB400MG 2 Quantity limitation 60 per 30 days SEROQUEL XR TAB50MG 2 Quantity limitation 60 per 30 days Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 4 Quantity limitation 30 per 30 days EMSAM DIS6MG/24HR 4 Quantity limitation 30 per 30 days EMSAM DIS9MG/24HR 4 Quantity limitation 30 per 30 days MARPLAN TAB10MG 3 phenelzine tab15mg 1 tranylcypromtab10mg 1 Serotonin/ Norepinephrine Reuptake Inhibitors BRINTELLIX TAB10MG 3 Quantity limitation 60 per 30 days BRINTELLIX TAB20MG 3 Quantity limitation 30 per 30 days BRINTELLIX TAB5MG 3 Quantity limitation 120 per 30 days citalopram sol10mg/5ml 1 Quantity limitation 600 per 30 days 39