Quantity Limit Drug List Quantity limits define the maximum amount of medication covered by your drug benefit for one prescription or copayment. This means your benefit covers a limited number of doses per prescription based on the medication s recommended dosing guidelines. If you or your physician requests an amount greater than the quantity limit of a medication, a prior authorization review may be required. The goal of the PreferredOne Quantity Limit Program is to promote appropriate and cost-effective use of medications based on U.S. Food and Drug Administration (FDA) dosing guidelines, the medical literature and other factors. This list is subject to change throughout the year. The presence of a drug on this list does not guarantee coverage and not all drugs included on this list may be covered by your pharmacy benefit plan. Coverage of medications is determined your benefit plan. ABILIFY (TABLET) ABSTRAL (TAB SUBL) ACIPHEX (TABLET DR) ACIPHEX SPRINKLE (DR 5 MG CAP, DR 10 MG CAP) ACTIQ (LOZENGE HD) ACTONEL 150 MG TABLET ACTONEL 35 MG TABLET ADCIRCA (TABLET) ADDERALL (TABLET) ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE) ADDYI (TABLET) ADEMPAS (TABLET) ADLYXIN 10-20 MCG STARTER PACK ADLYXIN 20 MCG MAINTENANCE PK A 1 / 28 4 / 28 2 PACKS / 365 2 PENS (6 ML) / 28 ADVAIR DISKUS (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 ADVAIR HFA (HFA AER AD) 1 INHALER (12 G) / 30
ADZENYS ER (SUS BP 24H) ADZENYS XR-ODT (3.1 MG TABLET, 6.3 MG TABLET, 9.4 MG TABLET, 12.5 MG TABLET, 15.7 MG TABLET, 18.8 MG TABLET) A 15.04 ML / DAY AEROSPAN (HFA AER AD) 2 INHALERS (17.8 G) / 30 AFINITOR (TABLET) AIMOVIG AUTOINJECTOR (2 PACK) (AUTO INJCT) 2 SYRINGES (2 ML) / 30 AIMOVIG AUTOINJECTOR (AUTO INJCT) 2 SYRINGES (2 ML) / 30 AIRDUO RESPICLICK (55-14 MCG, 113-14 MCG, 232-14 MCG) AKYNZEO 300-0.5 MG CAPSULE albuterol 2.5 mg/0.5 ml sol albuterol 5 mg/ml solution 1 INHALER / 30 2 / 30 150 VIALS / 30 150 ML / 30 albuterol sul 2.5 mg/3 ml soln 180 VIALS (540 ML) / 30 albuterol sulfate (0.63 ml, 1.25 ml) 125 VIALS (375 ML) / 30 ALECENSA (CAPSULE) alendronate sodium (35 mg tab, 70 mg tab) almotriptan malate (tablet) alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) alprazolam 2 mg tablet alprazolam er (er 0.5 mg tablet, er 1 mg tablet) alprazolam er 2 mg tablet alprazolam er 3 mg tablet 8 / DAY 4 / 28 12 / 30 5 / DAY 5 / DAY alprazolam intensol (oral conc) 10 BOTTLES (300 ML) / 30 alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1 mg tab) alprazolam odt 2 mg tab alprazolam xr (0.5 mg tablet, 1 mg tablet) alprazolam xr 2 mg tablet alprazolam xr 3 mg tablet ALUNBRIG (90 MG TABLET, 180 MG TABLET) ALUNBRIG 30 MG TABLET 5 / DAY 5 / DAY
ALUNBRIG 90 MG-180 MG TAB PACK A 1 PACKAGE (30 TABLETS) / 365 ALVESCO (80 MCG, 160 MCG) 2 INHALERS (12.2 G) / 30 AMBIEN (TABLET) AMBIEN CR (TAB MPHASE) AMERGE (TABLET) AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) AMPYRA (TAB ER 12H) 9 / 30 ANORO ELLIPTA (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 ANZEMET (50 MG TABLET, 100 MG TABLET) APLENZIN (ER 174 MG TABLET, ER 348 MG TABLET, ER 522 MG TABLET) 2 / 30 APOKYN (CARTRIDGE) 20 CARTRIDGES (60 ML) / 30 aprepitant 125 mg capsule aprepitant 125-80-80 mg pack aprepitant 40 mg capsule aprepitant 80 mg capsule APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE) ARCAPTA NEOHALER (CAP W/DEV) aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) 2 / 30 2 TRIPACKS (6 CAPSULES) / 30 1 / 30 4 / 30 4 CAPSULES / DAY aripiprazole 1 mg/ml solution 5 BOTTLES (750 ML) / 30 aripiprazole odt (tab rapdis) ARIXTRA (SYRINGE) 35 DAY SUPPLY / 180 armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) armodafinil 50 mg tablet ARMONAIR RESPICLICK (55 MCG, 113 MCG, 232 MCG) 1 INHALER / 30 ARNUITY ELLIPTA (BLST W/DEV) 1 INHALER (30 BLISTERS) / 30 ARYMO ER (TAB PO ER)
ASMANEX (TWISTHALER 110 MCG #7, TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #60, TWISTHALER 220 MCG #14, TWISTHALR 220 MCG #120) A 1 INHALER / 30 ASMANEX HFA (100 MCG, 200 MCG) 1 INHALER (13 G) / 30 ASTEPRO (SPRAY/PUMP) 2 BOTTLES (60 ML) / 30 ATELVIA (TABLET DR) ATIVAN (0.5 MG TABLET, 1 MG TABLET) ATIVAN 2 MG TABLET atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mg capsule, 40 mg capsule) atomoxetine hcl (60 mg capsule, 80 mg capsule, 100 mg capsule) 4 / 28 5 / DAY ATROVENT HFA (HFA AER AD) 2 INHALERS (25.8 G) / 30 AUBAGIO (7 MG TABLET, 14 MG TABLET) AUSTEDO (TABLET) AUVI-Q 0.1 MG AUTO-INJECTOR AVONEX 30 MCG VIAL KIT AVONEX PEN (PEN IJ KIT) AVONEX PREFILLED SYR 30 MCG KT AXERT (TABLET) 2 INJECTORS / 30 4 KITS (4 VIALS) / 28 1 KIT / 28 1 KIT / 28 12 / 30 azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 2 BOTTLES (60 ML) / 30 BARACLUDE 0.05 MG/ML SOLUTION 3 BOTTLES (630 ML) / 30 BECONASE AQ (SPRAY) 1 BOTTLE (25 G) / 25 BELBUCA (FILM) BELSOMRA (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) BETASERON (KIT) B 1 KIT (15 VIALS) / 30 BEVESPI AEROSPHERE (HFA AER AD) 1 INHALER (10.7 G) / 30 BEVYXXA (CAPSULE) bimatoprost 0.03% eye drops 44 / 180 2.5 ML / 25
BINOSTO (TABLET EFF) BONIVA 150 MG TABLET B 4 / 28 1 / 28 BONIVA 3 MG/3 ML SYRINGE 1 SYRINGE (3 ML) / 90 BONJESTA (TAB IR DR) BREO ELLIPTA (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 BRINTELLIX (TABLET) BRISDELLE (CAPSULE) bromfenac sodium (drops) 1 BOTTLE / RX BROMSITE (DROPS) 4 BOTTLES (20 ML) / 365 BROVANA (VIAL-NEB) 60 VIALS (120 ML) / 30 budesonide (0.25 ml, 0.5 ml, 1 ml inh) 60 AMPULES (120 ML) / 30 budesonide 32 mcg nasal spray 2 BOTTLES (16.9 G) / 30 BUNAVAIL 2.1-0.3 MG FILM BUNAVAIL 4.2-0.7 MG FILM BUNAVAIL 6.3-1 MG FILM buprenorphine (patch tdwk) buprenorphine 2 mg tablet sl buprenorphine 8 mg tablet sl buprenorphine-naloxone (buprenorp-nalox mg film, buprenorphin-naloxon mg) buprenorphn-naloxn 2-0.5 mg sl buproban (tab er 12h) bupropion hcl sr (100 mg tablet, 200 mg tablet) bupropion hcl sr 150 mg tablet bupropion hcl xl 150 mg tablet bupropion hcl xl 300 mg tablet BUTRANS (PATCH TDWK) BYDUREON (VIAL) 4 / 28 1 1 4 / 28 4 VIALS / 28 BYDUREON BCISE (AUTO INJCT) 4 AUTO-INJECTOR (3.4 ML) / 28
BYDUREON PEN (PEN INJCTR) BYETTA 10 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ calcipotriene-betamethasone dp (oint. (g)) B C 4 PENS / 28 1 PEN (2.4 ML) / 30 1 PEN (1.2 ML) / 30 400 G / 30 calcitonin-salmon (spray/pump) 1 BOTTLE (3.7 ML) / 30 CALQUENCE (CAPSULE) CAPRELSA 100 MG TABLET CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT, 40 MCG VIAL) CELEBREX (CAPSULE) celecoxib (capsule) CESAMET (CAPSULE) CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET) 2 CAPSULES / DAY 6 VIALS / 30 20 / RX CHANTIX STARTING MONTH BOX 1 BOX (53 TABLETS) / 28 chlordiazepoxide 10 mg capsule chlordiazepoxide 25 mg capsule chlordiazepoxide 5 mg capsule CIALIS (10 MG TABLET, 20 MG TABLET) CIALIS (2.5 MG TABLET, 5 MG TABLET) clonazepam (0.125 mg odt, 0.125 mg dis tab, 0.25 mg odt, 0.5 mg tablet, 0.5 mg dis tablet, 0.5 mg odt, 1 mg tablet, 1 mg odt, 1 mg dis tablet, 2 mg tablet) clonazepam 2 mg odt clorazepate 15 mg tablet clorazepate 3.75 mg tablet clorazepate 7.5 mg tablet clozapine (25 mg tablet, 100 mg tablet) clozapine 200 mg tablet clozapine 50 mg tablet clozapine odt (odt 25 mg tablet, odt 100 mg tablet) clozapine odt 12.5 mg tablet clozapine odt 150 mg tablet 30 / DAY 1 6 / 30 10 / DAY 2 1 9 / DAY 9 / DAY
clozapine odt 200 mg tablet CLOZARIL (TABLET) C 9 / DAY COMBIVENT RESPIMAT (MIST INHAL) 2 INHALERS (8 G) / 30 CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 54 MG TABLET) CONCERTA ER 36 MG TABLET CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) COPAXONE 20 MG/ML SYRINGE 1 KIT (30 SYRINGES) / 30 COPAXONE 40 MG/ML SYRINGE 1 KIT (12 SYRINGES) / 28 CORLANOR (5 MG TABLET, 7.5 MG TABLET) COTELLIC (TABLET) COTEMPLA XR-ODT 17.3 MG TABLET COTEMPLA XR-ODT 25.9 MG TABLET COTEMPLA XR-ODT 8.6 MG TABLET CRINONE (GEL/PF APP) 15 APPLICATORS (16.9 G) / 30 CYMBALTA (20 MG CAPSULE, 60 MG CAPSULE) CYMBALTA 30 MG CAPSULE CYSTARAN (DROPS) 4 BOTTLES (60 ML) / 28 D DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) DAYTRANA (10 HR, 15 HR, 20 HOUR, 30 HOUR) DESOXYN (TABLET) desvenlafaxine er (er 50 mg tablet, er 50 mg tab) desvenlafaxine er 100 mg tab desvenlafaxine fum er 100 mg desvenlafaxine fum er 50 mg desvenlafaxine suc er 100 mg desvenlafaxine succinate er (er 25 mg, er 50 mg) DEXEDRINE 10 MG TABLET DEXEDRINE 5 MG TABLET 5 / DAY
DEXEDRINE SPANSULE 10 MG DEXEDRINE SPANSULE 15 MG DEXEDRINE SPANSULE 5 MG DEXILANT (CAP DR BP) dexmethylphenidate er 20 mg cp dexmethylphenidate hcl (tablet) dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) dextroamphetamine 10 mg tab dextroamphetamine 5 mg tab dextroamphetamine 5 mg/5 ml dextroamphetamine er 10 mg cap dextroamphetamine er 15 mg cap dextroamphetamine er 5 mg cap dextroamphetamine-amphet er (cap er 24h) dextroamphetamine-amphetamine (tablet) DIASTAT (KIT) DIASTAT ACUDIAL (KIT) diazepam (2.5 mg gel sys, 10 mg gel syst, 20 mg gel syst) DICLEGIS (TABLET DR) diclofenac sodium 1% gel diclofenac sodium 3% gel D 1800 ML / 30 2 PACKAGES / RX 2 PACKAGES / RX 2 PACKAGES / RX 10 TUBES (1000 G) / DAY 3 TUBES (300G) / 30 dihydroergotamine 4 mg/ml spry 1 BOX (8 UNITS) / 30 DORAL (TABLET) dronabinol (2.5 mg capsule, 5 mg capsule, 10 mg capsule) DUEXIS (TABLET) DULERA (100 MCG, 200 MCG) 1 INHALER (13 G) / 30 duloxetine hcl (dr 20 mg cap, dr 60 mg cap) duloxetine hcl dr 30 mg cap duloxetine hcl dr 40 mg cap DUPIXENT (SYRINGE) 4 SYRINGES (8 ML) / 28
DURAGESIC (12, 25, 50) DURAGESIC (75, 100) DYANAVEL XR (SUS BP 24H) D 15 / 30 30 / 30 240 ML / 30 DYMISTA (SPRAY/PUMP) 1 BOTTLE (23 G) / 30 EDEX (KIT) EDLUAR (5 MG TABLET, 10 MG TABLET) EGRIFTA 1 MG VIAL EGRIFTA 2 MG VIAL eletriptan hbr (tablet) ELIGARD 22.5 MG SYRINGE KIT ELIGARD 30 MG SYRINGE KIT ELIGARD 45 MG SYRINGE KIT ELIGARD 7.5 MG SYRINGE KIT ELIQUIS 2.5 MG TABLET E 6 CARTRIDGES / 30 2 VIALS / DAY 1 VIAL / DAY 12 / 30 1 SYRINGE / 84 1 SYRINGE / 112 1 SYRINGE / 168 1 SYRINGE / 28 ELIQUIS 5 MG STARTER PACK 1 PACK (74 TABLETS) / 365 ELIQUIS 5 MG TABLET EMBEDA (CAP ER PO) EMEND 125 MG CAPSULE EMEND 125 MG POWDER PACKET EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIPACK EMSAM (PATCH TD24) enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 mg/0.8 ml syr, 150 mg/ml syringe, 300 mg/3 ml vial) ENSTILAR (FOAM) ENTRESTO (TABLET) EPCLUSA (TABLET) 2 / 30 3 / 30 1 / 30 4 / 30 2 TRIPACKS (6 CAPSULES) / 30 35 DAY SUPPLY / 180 7 CANS (420 G) / 30 ESOMEP-EZS (KIT CAP SP) 1 KIT (30 CAPSULES) / 30
esomeprazole dr 24.65 mg cap esomeprazole dr 49.3 mg cap esomeprazole mag dr 20 mg cap esomeprazole mag dr 40 mg cap estazolam (tablet) ESTRING (VAG RING) eszopiclone (tablet) EVEKEO (5 MG TABLET, 10 MG TABLET) EXALGO (TAB ER 24H) EXTAVIA (0.3 MG VIAL, 0.3 MG KIT) E 1 / 90 1 KIT (15 VIALS) / 30 FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) F FANAPT TITRATION PACK 1 PACK (8 TABLETS) / 180 FARYDAK (CAPSULE) FAZACLO (25 MG ODT, 100 MG ODT) FAZACLO 12.5 MG ODT FAZACLO 150 MG ODT FAZACLO 200 MG ODT FEMRING (VAG RING) fentanyl (12, 25, 50) fentanyl (37.5, 62.5) fentanyl (75, 100) fentanyl 87.5 mcg/hr patch fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) FENTORA (TABLET EFF) FETZIMA (ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) 6 / 30 9 / DAY 1 / 84 15 / 30 15 / 30 30 / 30 30 / 30 FETZIMA 20-40 MG TITRATION PAK 1 PACK (28 CAPSULES) / 365 FIRMAGON 2 X 120 MG KIT FIRMAGON 80 MG KIT 2 VIALS / 365 1 VIAL / 28
FLECTOR (PATCH TD12) F FLOVENT 250 MCG DISKUS 4 INHALERS (240 BLISTERS) / 30 FLOVENT DISKUS (50 MCG, 100 MCG) 1 INHALER (60 BLISTERS) / 30 FLOVENT HFA (110 MCG, 220 MCG) 2 INHALERS (24 G) / 30 FLOVENT HFA 44 MCG INHALER 2 INHALERS (21.2 G) / 30 flunisolide (spray) 1 BOTTLE (25 ML) / 30 fluoxetine dr (capsule dr) flurazepam hcl (15 mg capsule, 30 mg capsule) fluticasone-salmeterol (aer pow ba) fluvoxamine maleate er (cap er 24h) FOCALIN (TABLET) FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG CAPSULE) FOCALIN XR 20 MG CAPSULE 4 / 28 1 INHALER / 30 fondaparinux sodium (syringe) 35 DAY SUPPLY / 180 FORADIL (CAP W/DEV) FORFIVO XL (TAB ER 24H) 1 INHALER (60 CAPSULES) / 30 FORTICAL (SPRAY/PUMP) 1 BOTTLE (3.7 ML) / 30 FOSAMAX (TABLET) FOSAMAX PLUS D (TABLET) FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 ML VL) FROVA (TABLET) frovatriptan succinate (tablet) FULYZAQ (TABLET DR) FUZEON (VIAL) 4 / 28 4 / 28 35 DAY SUPPLY / 180 12 / 30 12 / 30 2 VIALS / DAY GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) G
GILENYA (CAPSULE) GILOTRIF (30 MG TABLET, 40 MG TABLET) GILOTRIF 20 MG TABLET G glatiramer 20 mg/ml syringe 1 KIT (30 SYRINGES) / 30 glatiramer 40 mg/ml syringe 1 KIT (12 SYRINGES) / 28 glatopa 20 mg/ml syringe 1 KIT (30 SYRINGES) / 30 glatopa 40 mg/ml syringe 1 KIT (12 SYRINGES) / 28 GRALISE 30-DAY STARTER PACK GRALISE ER 300 MG TABLET GRALISE ER 600 MG TABLET granisetron hcl 1 mg tablet GRASTEK (TAB SUBL) 1 PACK (78 TABLETS) / RX 4 / 30 HALCION (TABLET) HARVONI (TABLET) HETLIOZ (CAPSULE) HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) hydromorphone er (tab er 24h) HYSINGLA ER (TAB ER 24H) H ibandronate 3 mg/3 ml syringe 1 SYRINGE (3 ML) / 90 ibandronate 3 mg/3 ml vial ibandronate sodium 150 mg tab ICLUSIG 15 MG TABLET IDHIFA (TABLET) ILARIS 150 MG/ML VIAL ILARIS 180 MG VIAL ILEVRO (DROPS SUSP) IMBRUVICA 140 MG CAPSULE I 1 VIAL (3 ML) / 90 1 / 28 2 VIALS / 28 2 VIALS / 28 3.4 ML / 30
IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) I 9 / 30 IMITREX (4 ML, 6 ML) 10 CARTRIDGES (5 ML) / 30 IMITREX (5 MG, 20 MG) 2 PACKS (12 UNITS) / 30 IMITREX 4 MG/0.5 ML PEN INJECT 10 PENS (5 ML) / 30 IMITREX 6 MG/0.5 ML PEN INJECT 10 SYRINGES (5 ML) / 30 IMITREX 6 MG/0.5 ML VIAL 8 VIALS (4 ML) / 30 INCRUSE ELLIPTA (BLST W/DEV) 1 INHALER (30 BLISTERS) / 30 INGREZZA (CAPSULE) INTERMEZZO (TAB SUBL) INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 9 MG TABLET) INVEGA ER 6 MG TABLET ipratropium br 0.02% soln 125 VIALS (312.5 ML) / 30 ipratropium-albuterol (ampul-neb) 180 VIALS (540 ML) / 30 IRENKA (CAPSULE DR) JAKAFI 10 MG TABLET JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) JYNARQUE (TABLET SEQ) J 2 TABS / DAY KADIAN (CAP ER PEL) ketorolac 10 mg tablet KEVEYIS (TABLET) KHEDEZLA ER 100 MG TABLET KHEDEZLA ER 50 MG TABLET KISQALI 200 MG DAILY DOSE KISQALI 400 MG DAILY DOSE KISQALI 600 MG DAILY DOSE K 20 TABLETS / 30 21 / 28 42 / 28 63 / 28
KISQALI FEMARA 200 MG CO-PACK KISQALI FEMARA 400 MG CO-PACK KISQALI FEMARA 600 MG CO-PACK KLONOPIN (TABLET) KORLYM (TABLET) K 49 / 28 70 / 28 91 / 28 KYNAMRO (SYRINGE) 4 SYRINGES (4 ML) / 28 LAMISIL 250 MG TABLET 84 DAY SUPPLY / 180 lansoprazole (odt 15 mg tablet, odt 30 mg tablet) lansoprazole dr 15 mg capsule lansoprazole dr 30 mg capsule latanoprost (drops) LATUDA (40 MG TABLET, 60 MG TABLET, 120 MG TABLET) LATUDA 80 MG TABLET LAZANDA (SPRAY/PUMP) LETAIRIS (5 MG TABLET, 10 MG TABLET) L 2.5 ML / 30 levalbuterol 1.25 mg/3 ml sol 90 VIALS (270 ML) / 30 levalbuterol concentrate (vial-neb) 90 VIALS (45 ML) / 30 levalbuterol hcl (0.31 ml, 0.63 ml) 180 VIALS (540 ML) / 30 levalbuterol tartrate hfa (hfa aer ad) 2 INHALERS (30 G) / 30 LEVITRA (TABLET) 6 / 30 linezolid 100 mg/5 ml susp 6 BOTTLES (900 ML) / 28 linezolid 600 mg tablet LINZESS (72 MCG CAPSULE, 145 MCG CAPSULE, 290 MCG CAPSULE) LONHALA MAGNAIR REFILL (VIAL-NEB) LONHALA MAGNAIR STARTER (VIAL-NEB) LONSURF 15 MG-6.14 MG TABLET LONSURF 20 MG-8.19 MG TABLET 28 / 30 2 ML (2 VIALS) / DAY 2 ML (2 VIALS) / DAY 100 / 28 168 / 84
lorazepam (0.5 mg tablet, 1 mg tablet) lorazepam 2 mg tablet L 5 / DAY lorazepam 2 mg/ml oral concent 5 BOTTLES (150 ML) / 30 lorazepam intensol (oral conc) 5 BOTTLES (150 ML) / 30 LOTEMAX 0.5% EYE OINTMENT 4 TUBES (14 G) / 365 LOTEMAX 0.5% OPHTHALMIC GEL 4 BOTTLES (20 G) / 365 LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL) LUCEMYRA (TABLET) LUMIGAN (DROPS) LUNESTA (TABLET) LUPANETA PK 11.25-5 MG 3MO KIT LUPANETA PK 3.75-5 MG 1MO KIT LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE) LYRICA 20 MG/ML ORAL SOLUTION LYRICA 300 MG CAPSULE LYRICA CR (82.5 MG TABLET, 165 MG TABLET) LYRICA CR 330 MG TABLET MARINOL (CAPSULE) MAVYRET (TABLET) MAXALT (TABLET) MAXALT MLT (TAB RAPDIS) memantine hcl er (cap spr 24) METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE) metadate er (tablet er) methamphetamine hcl (tablet) METHYLIN (2.5 MG TAB, 5 MG TABLET) M 35 DAY SUPPLY / 180 16 TABLETS / DAY 2.5 ML / 30 1 KIT / 90 1 KIT / 30 900 ML / 30 18 / 30 18 / 30 5 / DAY
METHYLIN 10 MG CHEWABLE TABLET METHYLIN 10 MG/5 ML SOLUTION METHYLIN 5 MG/5 ML SOLUTION methylphenidate 10 mg chew tab methylphenidate 10 mg/5 ml sol methylphenidate 5 mg/5 ml soln methylphenidate er (er 10 mg cap, er 18 mg tab, er 20 mg cap, er 27 mg tab, er 30 mg cap, er 40 mg cap, er 54 mg tab, er 72 mg tab) methylphenidate er (er 10 mg tab, er 36 mg tab) methylphenidate er 20 mg tab methylphenidate hcl (2.5 mg chew tb, 5 mg tablet, 5 mg chew tab, 10 mg tablet, 20 mg tablet) methylphenidate hcl cd (cpbp 30-70) methylphenidate hcl er (cpbp 30-70) methylphenidate la (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) methylphenidate la 60 mg cap M 900 ML / 30 1800 ML / 30 900 ML / 30 1800 ML / 30 MIACALCIN 200 UNIT NASAL SPRAY 1 BOTTLE (3.7 ML) / 30 MIGRANAL (SPRAY/PUMP) 1 BOX (8 UNITS) / 30 modafinil (tablet) mometasone furoate 50 mcg spry 2 BOTTLES (34 G) / 30 MORPHABOND ER (TAB ER 12H) morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mg cap, er 80 mg cap, er 100 mg cap, er 120 mg cap) morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg tablet, er 100 mg tablet, er 200 mg tablet) morphine sulfate er (er 30 mg cap, er 45 mg cap, er 60 mg cap, er 75 mg cap, er 90 mg cap) MOVANTIK (12.5 MG TABLET, 25 MG TABLET) MOZOBIL (VIAL) 8 VIALS (9.6 ML) / TRANSPLANT MS CONTIN (TABLET ER) MUSE (SUPP.URETH) 6 / 30
MYDAYIS (ER 12.5 MG CAPSULE, ER 25 MG CAPSULE, ER 37.5 MG CAPSULE, ER 50 MG CAPSULE) MYTESI (TABLET DR) M NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE) NAMENDA XR TITRATION PACK NAMZARIC (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE) N NAMZARIC TITRATION PACK 2 PACKS (56 CAPSULES) / 365 naratriptan (tablet) naratriptan hcl (tablet) 9 / 30 9 / 30 NASONEX (SPRAY/PUMP) 2 BOTTLES (34 G) / 30 NATPARA (CARTRIDGE) NERLYNX (TABLET) 2 CARTRIDGES / 28 NEVANAC (DROPS SUSP) 2 BOTTLES (6 ML) / 30 NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG PACKET, DR 20 MG CAPSULE, DR 20 MG PACKET, DR 40 MG PACKET, DR 40 MG CAPSULE) NICOTROL (CARTRIDGE) 1 NICOTROL NS (SPRAY) 12 BOTTLES (120 ML) / 30 NINLARO (CAPSULE) NOVAREL 5,000 UNIT VIAL NUCALA (VIAL) NUCYNTA ER (TAB ER 12H) NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MG TABLET) NUVIGIL 50 MG TABLET OCALIVA (5 MG TABLET, 10 MG TABLET) O 3 / 28 1 VIAL / 30 1 VIAL / 30 OCREVUS (VIAL) 4 VIALS (40 ML) / 365 ODACTRA (TAB SUBL) olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet) 1 TABLET / DAY
olanzapine odt (tab rapdis) olanzapine-fluoxetine hcl (3-25 mg, 6-25 mg) olanzapine-fluoxetine hcl (6-50 mg, 12-25 mg, 12-50 mg) O olopatadine 665 mcg nasal spry 1 BOTTLE (30.5 G) / 30 OLYSIO (CAPSULE) omeppi (capsule) omeprazole (capsule dr) omeprazole-sodium bicarbonate (20-1,100 cap, 40-1,100 cap) omeprazole-sodium bicarbonate (20-1,680, 40-1,680) OMNARIS (SPRAY/PUMP) 1 BOTTLE (12.5 G) / 30 ondansetron 4 mg/5 ml solution 120 ML / 30 ondansetron 40 mg/20 ml vial 6 VIALS (120 ML) / 30 ondansetron hcl (4 ml amp, 4 ml vial) 60 VIALS (120 ML) / 30 ondansetron hcl (4 ml isecure, hcl 4 ml syr) 60 SYRINGES (120 ML) / 30 ondansetron hcl 24 mg tablet ondansetron odt (tab rapdis) 2 / 30 15 / 30 ONZETRA XSAIL (AER POW BA) 1 BOX (16 UNITS) / 30 OPANA ER (TAB ER 12H) OPSUMIT (TABLET) ORALAIR (TAB SUBL) ORKAMBI (100 MG TABLET, 200 MG TABLET) oseltamivir 6 mg/ml suspension 6 BOTTLES (360 ML) / 365 oseltamivir phos 30 mg capsule oseltamivir phosphate (45 mg capsule, 75 mg capsule) OTREXUP (7.5 ML AUTO-INJ, 10 ML AUTO-INJ, 12.5 ML AUTOINJ, 15 ML AUTO-INJ, 17.5 ML AUTOINJ, 20 ML AUTO-INJ, 22.5 ML AUTOINJ, 25 ML AUTO-INJ) OXANDRIN 10 MG TABLET OXANDRIN 2.5 MG TABLET 40 / 365 20 / 365 4 PENS (1.6 ML) / 28 8 / DAY
oxandrolone 10 mg tablet oxandrolone 2.5 mg tablet oxazepam (capsule) oxycodone hcl er (tab er 12h) OXYCONTIN (TAB ER 12H) oxymorphone hcl er (tab er 12h) OXYTROL (PATCH TDSW) OZEMPIC 0.25-0.5 MG DOSE PEN OZEMPIC 1 MG DOSE PEN O 8 / DAY 8 / 28 1 PEN (1.5 ML) / 28 2 PENS (3 ML) / 28 paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9 mg tablet) paliperidone er 6 mg tablet pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) paroxetine mesylate (capsule) P PATANASE (SPRAY/PUMP) 1 BOTTLE (30.5 G) / 30 PERFOROMIST (VIAL-NEB) PEXEVA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) PEXEVA 30 MG TABLET 2 VIALS (4 ML) / DAY PLEGRIDY (SYRINGE) 2 SYRINGES (1 ML) / 28 PLEGRIDY PEN (PEN INJCTR) 2 PENS (1 ML) / 28 PORTRAZZA (VIAL) 2 VIALS (100 ML) / 21 PRADAXA (CAPSULE) PRALUENT PEN (PEN INJCTR) 2 PENS (2 ML) / 28 PRALUENT SYRINGE (SYRINGE) 2 SYRINGES (2 ML) / 28 PREVACID (15 MG, 30 MG) PREVACID (DR 15 MG CAPSULE, DR 30 MG CAPSULE) PRILOSEC (DR 2.5 MG, DR 10 MG) PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET) PRISTIQ ER 100 MG TABLET
PROAIR HFA (HFA AER AD) 2 INHALERS (17 G) / 30 PROAIR RESPICLICK (AER POW BA) procentra (solution) P 2 INHALERS / 30 1800 ML / 30 PROLENSA (DROPS) 4 BOTTLES (12 ML) / 180 PROLIA (SYRINGE) 2 SYRINGES (2 ML) / 365 PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET, 40 MG SUSPENSION) PROVENTIL HFA (HFA AER AD) 2 INHALERS (13.4 G) / 30 PROVIGIL (TABLET) PROZAC WEEKLY (CAPSULE DR) 4 / 28 PULMICORT (AMPUL-NEB) 60 AMPULES (120 ML) / 30 PULMICORT FLEXHALER (AER POW BA) Q 2 INHALERS / 30 QNASL (HFA AER AD) 1 INHALER (8.7 G) / 30 QNASL CHILDREN (HFA AER AD) 1 INHALER (4.9 G) / 30 quazepam (tablet) quetiapine er 200 mg tablet quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) quetiapine fumarate (300 mg tab, 400 mg tab) quetiapine fumarate er (er 50 mg tablet, er 150 mg tablet, er 300 mg tablet, er 400 mg tablet) QUILLICHEW ER (ER 20 MG TAB, ER 40 MG TAB) QUILLICHEW ER 30 MG CHEW TAB QUILLIVANT XR (SU ER RC24) QUTENZA (KIT) 360 ML / 30 4 / 90 QVAR 40 MCG ORAL INHALER 2 INHALERS (17.4 G) / 30 QVAR 80 MCG ORAL INHALER 3 INHALERS (26.1 G) / 30 QVAR REDIHALER (HFA AEROBA) 2 INHALERS (21.2 G) / 30
rabeprazole sodium (tablet dr) RAGWITEK (TAB SUBL) R RASUVO 10 MG/0.2 ML AUTOINJ 4 PENS (0.8 ML) / 28 RASUVO 12.5 MG/0.25 ML AUTOINJ 4 PENS (1 ML) / 28 RASUVO 15 MG/0.3 ML AUTOINJ 4 PENS (1.2 ML) / 28 RASUVO 17.5 MG/0.35 ML AUTOINJ 4 PENS (1.4 ML) / 28 RASUVO 20 MG/0.4 ML AUTOINJ 4 PENS (1.6 ML) / 28 RASUVO 22.5 MG/0.45 ML AUTOINJ 4 PENS (1.8 ML) / 28 RASUVO 25 MG/0.5 ML AUTOINJ 4 PENS (2 ML) / 28 RASUVO 27.5 MG/0.55 ML AUTOINJ 4 PENS (2.2 ML) / 28 RASUVO 30 MG/0.6 ML AUTOINJ 4 PENS (2.4 ML) / 28 RASUVO 7.5 MG/0.15 ML AUTOINJ 4 PENS (0.6 ML) / 28 REBIF (22 ML, 44 ML) REBIF REBIDOSE (22 ML, 44 ML) REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK 1 KIT (6 ML) / 28 1 KIT (6 ML) / 28 1 KIT (4.2 ML) / 365 1 KIT (4.2 ML) / 365 RELENZA (BLST W/DEV) 2 INHALERS (40 DISKS) / 365 RELISTOR (12 ML VIAL, 12 ML SYRINGE) RELISTOR 150 MG TABLET RELISTOR 8 MG/0.4 ML SYRINGE RELPAX (TABLET) 1 SYRINGE (0.6 ML) / DAY 1 SYRINGE (0.4 ML) / DAY 12 / 30 REPATHA PUSHTRONEX (WEAR INJCT) 1 CARTRIDGE (3.5 ML) / 28 REPATHA SURECLICK (PEN INJCTR) 3 PENS (3 ML) / 28 REPATHA SYRINGE (SYRINGE) 3 SYRINGES (3 ML) / 28 RESCULA (DROPS) 5 ML (1 BOTTLE) / 25
RESTORIL (CAPSULE) R REVATIO 10 MG/ML ORAL SUSP 2 BOTTLES (224 ML) / 30 REVATIO 20 MG TABLET REXULTI (TABLET) RHINOCORT AQUA (SPRAY/PUMP) 2 BOTTLES (17.2 G) / 30 RHOPRESSA (DROPS) 1 BOTTLE (2.5 ML) / 25 RILUTEK (TABLET) riluzole (tablet) risedronate sodium 150 mg tab risedronate sodium 35 mg tab risedronate sodium dr (tablet dr) RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET) 1 / 28 4 / 28 4 / 28 RISPERDAL 1 MG/ML SOLUTION 8 BOTTLES (240 ML) / 30 RISPERDAL M-TAB (TAB RAPDIS) risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet) risperidone 0.25 mg odt risperidone 1 mg/ml solution 8 BOTTLES (240 ML) / 30 risperidone odt (0.5 mg odt, 1 mg odt, 2 mg odt, 3 mg odt, 4 mg odt) RITALIN (TABLET) RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) rizatriptan (5 mg tablet, 5 mg odt, 10 mg tablet, 10 mg odt) ROZEREM (TABLET) RUBRACA (TABLET) RYDAPT (CAPSULE) SAMSCA (TABLET) SANCUSO (PATCH TDWK) S 18 / 30 8 / DAY 30 DAY SUPPLY / 60 2 / 30
SAPHRIS (TAB SUBL) SAVAYSA (TABLET) SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) S SAVELLA TITRATION PACK 1 PACK (55 TABLETS) / 365 SEEBRI NEOHALER (CAP W/DEV) 1 INHALER (60 CAPSULES) / 30 SEREVENT DISKUS (BLST W/DEV) 1 INHALER (60 BLISTERS) / 30 SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) SEROQUEL (300 MG TABLET, 400 MG TABLET) SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 300 MG TABLET, 400 MG TABLET) SEROQUEL XR 200 MG TABLET SIGNIFOR (AMPUL) SIGNIFOR LAR (VIAL) sildenafil (tablet) sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) SILENOR (TABLET) SITAVIG (MA BUC TAB) SIVEXTRO 200 MG TABLET SIVEXTRO 200 MG VIAL SOLARAZE (GEL (GRAM)) SOLIQUA 100-33 (INSULN PEN) SONATA 10 MG CAPSULE SONATA 5 MG CAPSULE SOVALDI (TABLET) SPIRIVA (CAP W/DEV) 2 AMPULES / DAY 1 VIAL / 28 6 / 30 2 / 30 6 / 30 6 VIALS / 30 3 TUBES (300G) / 30 6 PENS (18 ML) / 30 1 CAPSULE / DAY SPIRIVA RESPIMAT (MIST INHAL) 1 INHALER (4 G) / 30 SPRIX (SPRAY) STAXYN (TAB RAPDIS) STENDRA (TABLET) 5 DAY SUPPLY / 30 6 / 30 6 / 30 STIOLTO RESPIMAT (MIST INHAL) 1 INHALER (4 G) / 30
STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE) STRATTERA (60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE) S STRIVERDI RESPIMAT (MIST INHAL) 1 INHALER (4 G) / 30 SUBLOCADE 100 MG/0.5 ML SYRING 3 SYRINGES (1.5 ML) / 28 SUBLOCADE 300 MG/1.5 ML SYRING 1 SYRINGE (1.5 ML) / 28 SUBOXONE 12 MG-3 MG SL FILM SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 4 MG-1 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM SUBSYS (SPRAY) 1 1 sumatriptan (spray) 2 PACKS (12 UNITS) / 30 sumatriptan 4 mg/0.5 ml inject sumatriptan 6 mg/0.5 ml vial sumatriptan succ-naproxen sod (tablet) sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) 10 PENS (5 ML) / 30 8 VIALS (4 ML) / 30 9 / 30 9 / 30 sumatriptan succinate (4 ml cart, 6 ml refill) 10 CARTRIDGES (5 ML) / 30 sumatriptan succinate (6 ml syrng, 6 ml inject) 10 SYRINGES (5 ML) / 30 SUMAVEL DOSEPRO (NDL FR INJ) SUPPRELIN LA (KIT) 12 PENS (6 ML) / 30 1 KIT / 365 SUSTOL (LIQ ER SYR) 3 SYRINGES (1.2 ML) / 30 SYMBICORT (HFA AER AD) 1 INHALER (10.2 G) / 30 SYMBYAX (3-25 MG CAPSULE, 6-25 MG CAPSULE) SYMBYAX (6-50 MG CAPSULE, 12-50 MG CAPSULE, 12-25 MG CAPSULE) SYMDEKO (TABLET SEQ) SYMPROIC (TABLET) SYNDROS (SOLUTION) 4 BOTTLES (120 ML) / 30
TACLONEX 0.005%-0.064% SUSPENS TACLONEX OINTMENT TAGRISSO (40 MG TABLET, 80 MG TABLET) TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE) TAMIFLU 30 MG CAPSULE T 120 G / 30 400 G / 30 20 / 365 40 / 365 TAMIFLU 6 MG/ML SUSPENSION 6 BOTTLES (360 ML) / 365 TANZEUM (30 MG, 50 MG) TARCEVA (100 MG TABLET, 150 MG TABLET) TARCEVA 25 MG TABLET TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE) 4 PENS / 28 TECFIDERA STARTER PACK 1 PACK (60 CAPSULES) / 365 TECHNIVIE (TABLET) temazepam (capsule) 168 / 84 terbinafine hcl (tablet) 84 DAY SUPPLY / 180 TOBI PODHALER (CAP W/DEV, CAPSULE) 1 KIT (224 CAPSULES) / 56 TRACLEER (62.5 MG TABLET, 125 MG TABLET) TRACLEER 32 MG TABLET FOR SUSP tramadol hcl er (er 100 mg capsule, er 200 mg capsule, er 300 mg capsule) tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg tablet) tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg tablet) tramadol hcl er 150 mg capsule TRANXENE T-TAB 3.75 MG TRANXENE T-TAB 7.5 MG TRAVATAN Z (DROPS) travoprost (drops) 4 TABLETS / DAY 2 1 2.5 ML / 25 2.5 ML / 25 TRELEGY ELLIPTA (BLST W/DEV) 60 BLISTERS (1 PACK) / 30 TRELSTAR 11.25 MG SYRINGE TRELSTAR 11.25 MG VIAL TRELSTAR 22.5 MG SYRINGE 1 SYRINGE / 84 1 VIAL / 84 1 SYRINGE / 168
TRELSTAR 22.5 MG VIAL TRELSTAR 3.75 MG SYRINGE TRELSTAR 3.75 MG VIAL TREXIMET (10-60 MG TABLET, 85-500 MG TABLET) triazolam (tablet) TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) TRIPTODUR (VIAL) TRULANCE (TABLET) TRULICITY (0.75 ML, 1.5 ML) TUDORZA PRESSAIR (AER POW BA) TYSABRI (VIAL) TYVASO (AMPUL-NEB) TYVASO INSTITUTIONAL START KIT (AMPUL-NEB) TYVASO REFILL KIT (AMPUL-NEB) TYVASO STARTER KIT (AMPUL-NEB) ULTRAM ER (TAB ER 24H) UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) T U 1 VIAL / 168 1 SYRINGE / 28 1 VIAL / 28 9 / 30 1 KIT / 168 4 PENS (2 ML) / 28 1 INHALER / 30 1 VIAL (15 ML) / 28 1 AMPULE (2.9 ML) / DAY 1 KIT / 28 1 KIT / 28 1 KIT / 28 UPTRAVI 200-800 TITRATION PACK 2 PACKS (400 TABLETS) / 365 UTIBRON NEOHALER (CAP W/DEV) valacyclovir (tablet) VALTREX (TABLET) VANTAS (KIT) VARUBI 90 MG TABLET VENTAVIS (10 ML, 20 ML) V 1 INHALER (60 CAPSULES) / 30 1 KIT / 365 4 / 30 9 AMPULES / DAY VENTOLIN HFA (HFA AER AD) 6 INHALERS (48 G) / 30 VERAMYST (SPRAY SUSP) 1 BOTTLE (10 G) / 30 VERSACLOZ (ORAL SUSP) 540 ML / 30
VERZENIO (TABLET) VIAGRA (TABLET) VIBERZI (TABLET) VICTOZA 2-PAK (PEN INJCTR) VICTOZA 3-PAK (PEN INJCTR) VIEKIRA PAK (TAB DS PK) VIEKIRA XR (TAB BP 24H) VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) V 2 TABLETS / DAY 6 / 30 3 PENS (9 ML) / 30 3 PENS (9 ML) / 30 VIIBRYD 10-20 MG STARTER PACK 1 PACK (30 TABLETS) / 30 VIMOVO (TAB IR DR) VOLTAREN (GEL (GRAM)) VOSEVI (TABLET) VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) VYVANSE (10 MG CHEWABLE TABLET, 10 MG CAPSULE, 20 MG CHEWABLE TABLET, 20 MG CAPSULE, 30 MG CHEWABLE TABLET, 30 MG CAPSULE, 40 MG CAPSULE, 40 MG CHEWABLE TABLET, 50 MG CAPSULE, 50 MG CHEWABLE TABLET, 60 MG CHEWABLE TABLET, 60 MG CAPSULE, 70 MG CAPSULE) 10 TUBES (1000 G) / DAY VYZULTA (DROPS) 1 BOTTLE (5 ML) / 25 WELLBUTRIN SR (TAB ER 12H) WELLBUTRIN XL 150 MG TABLET WELLBUTRIN XL 300 MG TABLET XADAGO (TABLET) XALATAN (DROPS) XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) XANAX 2 MG TABLET XANAX XR (0.5 MG TABLET, 1 MG TABLET) XANAX XR 2 MG TABLET XANAX XR 3 MG TABLET XARELTO (10 MG TABLET, 20 MG TABLET) W X 2.5 ML / 30 5 / DAY 5 / DAY
XARELTO 15 MG TABLET X XARELTO STARTER PACK 1 PACK (51 TABLETS) / 30 XERMELO (TABLET) XOPENEX (0.31 ML, 0.63 ML) 180 VIALS (540 ML) / 30 XOPENEX 1.25 MG/3 ML SOLUTION 90 VIALS (270 ML) / 30 XOPENEX CONCENTRATE (VIAL-NEB) 90 VIALS (45 ML) / 30 XOPENEX HFA (HFA AER AD) 2 INHALERS (30 G) / 30 XTAMPZA ER (CAP SPR 12) XULTOPHY 100-3.6 (INSULN PEN) XURIDEN (GRAN PACK) 5 PENS (15 ML) / 30 XYREM (SOLUTION) 3 BOTTLES (540 ML) / 30 YOSPRALA (TAB IR DR) zaleplon 10 mg capsule zaleplon 5 mg capsule ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG CAPSULE, 40 MG PACKET) ZEJULA (CAPSULE) ZEMBRACE SYMTOUCH (PEN INJCTR) ZENZEDI (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MG TABLET) zenzedi 10 mg tablet ZENZEDI 30 MG TABLET ZEPATIER (TABLET) Y Z 16 PENS (8 ML) / 30 ZETONNA (HFA AER AD) 1 INHALER (6.1 G) / 30 ZIOPTAN (DROPERETTE) ziprasidone hcl (capsule) 30 / 30 ZOFRAN 2 MG/ML VIAL 6 VIALS (120 ML) / 30
ZOFRAN 4 MG/5 ML ORAL SOLN ZOFRAN ODT (TAB RAPDIS) ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX 3.6 MG IMPLANT SYRN zolmitriptan (tablet) zolmitriptan 2.5 mg odt zolmitriptan 5 mg odt zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) zolpidem tartrate (5 mg tablet, 10 mg tablet) zolpidem tartrate er (tab mphase) Z 120 ML / 30 15 / 30 1 IMPLANT / 84 1 IMPLANT / 28 12 / 30 12 / 30 9 / 30 ZOLPIMIST (SPRAY/PUMP) 1 BOTTLE (7.7 ML) / 30 ZOMIG (2.5 MG TABLET, 5 MG TABLET) 12 / 30 ZOMIG (2.5 MG, 5 MG) 2 BOXES (12 UNITS) / 30 ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT 5 MG TABLET ZUBSOLV (0.7-0.18 MG TABLET, 5.7-1.4 MG TABLET) ZUBSOLV 1.4-0.36 MG TABLET SL ZUBSOLV 11.4-2.9 MG TABLET SL ZUBSOLV 2.9-0.71 MG TABLET SL ZUBSOLV 8.6-2.1 MG TABLET SL ZUPLENZ (FILM) ZYBAN (TAB ER 12H) ZYKADIA (CAPSULE) ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) ZYPREXA ZYDIS (TAB RAPDIS) 12 / 30 9 / 30 1 10 / 30 5 / DAY ZYVOX 100 MG/5 ML SUSPENSION 6 BOTTLES (900 ML) / 28 ZYVOX 600 MG TABLET 28 / 30
PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box 59212 Minneapolis, MN 55459-0212 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 Email: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDR PIC LV (1/18)
PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box 59052 Minneapolis, MN 55459-0052 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 customerservice@preferredone.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDR PCHP LV (1/18)