Drug Quantity Limits

Tier 1 Formulary Drug Quantity Limits 2016 Updated: 06/21/2016 Effective: 07/01/2016 What are Quantity Limits? For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. How do I request an exception to the coverage rules? You can ask us to make an exception to our coverage rules. For specific types of exceptions that you can ask us to make, please refer to your Comprehensive Formulary. When you are requesting a utilization restriction or limit exception, including Quantity Limits, you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination* form. Generally, we must make our decision within 72 hours of getting your prescriber s or prescribing doctor s supporting statement. You can request expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing doctor s supporting statement. *Please note You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride Formulary ID: 00016288; Version 14 Y0020_QLCriteria16_11172015 Page 1 of 72

preparations). Please call our Member Services number at 1(844) 867-1156 for a complete drug list or if you have questions. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day. Benefits may change on January 1 of each year. The Formulary may change at any time. You will receive notice when necessary. Trillium Community Health Plan is an HMO and a PPO plan with a Medicare contract. Enrollment in Trillium Community Health Plan depends on contract renewal. This information is available for free in other languages. Please call our Member Services number at 1(844) 867-1156. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day. Member Services also has free language interpreter services available for non-english speakers. Page 2 of 72

Drug Category Page # ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE... 11 ABILIFY... 11 ABILIFY DISCMELT... 11 ABSTRAL... 11 ACETAMINOPHEN/CODEINE... 11 ACETAMINOPHEN/CODEINE #3... 11 ACTEMRA... 11 ADCIRCA... 12 ADEFOVIR DIPIVOXIL... 12 ADEMPAS... 12 ADVAIR DISKUS... 12 ADVAIR HFA... 12 ALBUTEROL SULFATE... 12 ALECENSA... 13 ALENDRONATE SODIUM... 13 ALMOTRIPTAN MALATE... 13 ALVESCO... 13 AMETHIA... 13 AMETHIA LO... 13 AMITIZA... 13 AMPHETAMINE/DEXTROAMPHETAMINE... 13 AMPYRA... 14 ANORO ELLIPTA... 14 APLENZIN... 14 APTIVUS... 14 ARCAPTA NEOHALER... 14 ARIPIPRAZOLE... 14 ARIPIPRAZOLE ODT... 15 ARMODAFINIL... 15 ASHLYNA... 15 ASMANEX HFA... 15 ASMANEX TWISTHALER 120 METERED DOSES... 15 ASMANEX TWISTHALER 14 METERED DOSES... 15 ASMANEX TWISTHALER 30 METERED DOSES... 15 ASMANEX TWISTHALER 60 METERED DOSES... 16 ASMANEX TWISTHALER 7 METERED DOSES... 16 ATRIPLA... 16 ATROVENT HFA... 16 AUBAGIO... 16 AVANDIA... 16 AVONEX... 16 AVONEX PEN... 17 AXERT... 17 AZELASTINE HCL... 17 BARACLUDE... 17 BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"... 17 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"... 17 Page 3 of 72

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"... 17 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"... 17 BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM... 18 BETASERON... 18 BIMATOPROST... 18 BREO ELLIPTA... 18 BRINTELLIX... 18 BROVANA... 18 BUDESONIDE... 18 BUPRENORPHINE HCL... 19 BUPRENORPHINE HCL/NALOXONE HCL... 19 BUPROBAN... 19 BUPROPION HCL SR... 19 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE... 19 BUTORPHANOL TARTRATE... 19 BUTRANS... 19 CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE... 20 CALCITONIN-SALMON... 20 CAMRESE... 20 CAMRESE LO... 20 CAPRELSA... 20 CELECOXIB... 20 CHANTIX... 20 CHANTIX CONTINUING MONTH PAK... 20 CHANTIX STARTING MONTH PAK... 21 CLOZAPINE... 21 CLOZAPINE ODT... 21 COMBIVENT RESPIMAT... 21 COMPLERA... 21 COPAXONE... 22 COTELLIC... 22 CYSTARAN... 22 DAKLINZA... 22 DAYSEE... 22 DAYTRANA... 22 DEPO-SUBQ PROVERA 104... 22 DESCOVY... 22 DESVENLAFAXINE ER... 23 DEXILANT... 23 DEXMETHYLPHENIDATE HCL... 23 DEXMETHYLPHENIDATE HCL ER... 23 DEXTROAMPHETAMINE SULFATE... 23 DEXTROAMPHETAMINE SULFATE ER... 23 DIFICID... 24 DIGITEK... 24 DIGOX... 24 DIGOXIN... 24 DIHYDROERGOTAMINE MESYLATE... 24 DRONABINOL... 24 Page 4 of 72

DROPLET PEN NEEDLES 29GX10MM... 24 DULERA... 25 DULOXETINE HCL... 25 DYMISTA... 25 ELIGARD... 25 ELIQUIS... 25 ELLA... 25 EMEND... 26 EMSAM... 26 ENDOCET... 26 ENDODAN... 26 ENOXAPARIN SODIUM... 26 ENTECAVIR... 27 ENTRESTO... 27 ESOMEPRAZOLE MAGNESIUM... 27 ESTRING... 27 EVOTAZ... 27 EXTAVIA... 27 FANAPT... 27 FANAPT TITRATION PACK... 28 FARYDAK... 28 FEMRING... 28 FENTANYL... 28 FENTANYL CITRATE ORAL TRANSMUCOSAL... 28 FENTORA... 28 FETZIMA... 28 FETZIMA TITRATION PACK... 28 FIRMAGON... 29 FLECTOR... 29 FLOVENT DISKUS... 29 FLOVENT HFA... 29 FLUNISOLIDE... 29 FLUOXETINE DR... 29 FLUTICASONE PROPIONATE... 30 FLUVOXAMINE MALEATE ER... 30 FONDAPARINUX SODIUM... 30 FORADIL AEROLIZER... 30 FORFIVO XL... 30 FORTEO... 30 FORTICAL... 31 FOSAMAX PLUS D... 31 FRAGMIN... 31 FROVA... 31 FROVATRIPTAN SUCCINATE... 31 FUZEON... 32 GENVOYA... 32 GILENYA... 32 GLATOPA... 32 GLIMEPIRIDE... 32 Page 5 of 72

GLIPIZIDE... 32 GLIPIZIDE ER... 33 GLIPIZIDE XL... 33 GLIPIZIDE/METFORMIN HCL... 33 GLYBURIDE... 33 GLYBURIDE MICRONIZED... 34 GLYBURIDE/METFORMIN HCL... 34 GRANISETRON HCL... 34 HARVONI... 34 HETLIOZ... 34 HYDROCODONE BITARTRATE/ACETAMINOPHEN... 34 HYDROCODONE/ACETAMINOPHEN... 35 HYDROMORPHONE HCL ER... 35 ICLUSIG... 35 INSUPEN 33GX4MM... 35 INTELENCE... 35 INTROVALE... 36 INVEGA... 36 IPRATROPIUM BROMIDE... 36 IPRATROPIUM BROMIDE/ALBUTEROL SULFATE... 36 IRENKA... 36 ISENTRESS... 36 JANUMET... 37 JANUMET XR... 37 JENTADUETO... 37 JOLESSA... 37 JUXTAPID... 37 KETOROLAC TROMETHAMINE... 37 KEVEYIS... 38 KOMBIGLYZE XR... 38 KORLYM... 38 KYNAMRO... 38 LANOXIN... 38 LANSOPRAZOLE... 38 LATANOPROST... 38 LATUDA... 39 LAZANDA... 39 LETAIRIS... 39 LEVALBUTEROL... 39 LEVALBUTEROL HCL... 39 LEVONORGESTREL AND ETHINYL ESTRADIOL... 39 LEVONORGESTREL/ETHINYL ESTRADIOL... 39 LINEZOLID... 40 LINZESS... 40 LORCET... 40 LORCET HD... 40 LORCET PLUS... 40 LORTAB... 40 LUMIGAN... 40 Page 6 of 72

LUPANETA PACK... 41 LUPRON DEPOT... 41 LUPRON DEPOT-PED... 41 METADATE ER... 41 METFORMIN HCL... 41 METFORMIN HCL ER... 42 METHAMPHETAMINE HCL... 42 METHYLPHENIDATE HCL... 42 METHYLPHENIDATE HCL CD... 42 METHYLPHENIDATE HCL ER... 42 MODAFINIL... 43 MOMETASONE FUROATE... 43 MORPHINE SULFATE ER... 43 MOZOBIL... 43 NAMENDA XR... 44 NAMENDA XR TITRATION PACK... 44 NARATRIPTAN HCL... 44 NASONEX... 44 NATPARA... 44 NICOTROL NS... 44 NITROFURANTOIN... 44 NITROFURANTOIN MACROCRYSTALS... 44 NITROFURANTOIN MONOHYDRATE... 45 NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS... 45 NUCYNTA... 45 NUCYNTA ER... 45 NUPLAZID... 45 NUVIGIL... 45 ODEFSEY... 45 OLANZAPINE... 46 OLANZAPINE ODT... 46 OLANZAPINE/FLUOXETINE... 46 OLOPATADINE HCL... 46 OMEPRAZOLE... 46 ONDANSETRON HCL... 46 OPSUMIT... 47 ORKAMBI... 47 OTEZLA... 47 OXANDROLONE... 47 OXYCODONE HCL ER... 47 OXYCODONE/ACETAMINOPHEN... 47 OXYCODONE/ASPIRIN... 47 OXYMORPHONE HYDROCHLORIDE ER... 48 OXYTROL... 48 PALIPERIDONE ER... 48 PANTOPRAZOLE SODIUM... 48 PERFOROMIST... 48 PEXEVA... 48 PIOGLITAZONE HCL... 48 Page 7 of 72

PIOGLITAZONE HCL/METFORMIN HCL... 49 PIOGLITAZONE HCL-GLIMEPIRIDE... 49 PLEGRIDY... 49 PLEGRIDY STARTER PACK... 49 PRADAXA... 49 PRALUENT... 49 PRANDIMET... 49 PREZCOBIX... 50 PRISTIQ... 50 PROAIR HFA... 50 PROAIR RESPICLICK... 50 PROLIA... 50 PROVENTIL HFA... 50 PULMICORT... 50 PULMICORT FLEXHALER... 51 QUASENSE... 51 QUETIAPINE FUMARATE... 51 QVAR... 51 RABEPRAZOLE SODIUM... 51 REBIF... 51 REBIF REBIDOSE... 51 REBIF REBIDOSE TITRATION PACK... 52 REBIF TITRATION PACK... 52 RELENZA DISKHALER... 52 RELPAX... 52 REPAGLINIDE/METFORMIN HYDROCHLORIDE... 52 REPATHA... 52 REPATHA SURECLICK... 52 RESERPINE... 52 RESTASIS... 53 REXULTI... 53 RILUZOLE... 53 RISEDRONATE SODIUM... 53 RISEDRONATE SODIUM DR... 53 RISPERIDONE... 53 RISPERIDONE M-TAB... 53 RISPERIDONE ODT... 54 RIZATRIPTAN BENZOATE... 54 RIZATRIPTAN BENZOATE ODT... 54 ROXICET... 54 ROZEREM... 54 SANCUSO... 54 SAPHRIS... 54 SAVAYSA... 55 SAVELLA... 55 SAVELLA TITRATION PACK... 55 SELZENTRY... 55 SEREVENT DISKUS... 55 SEROQUEL XR... 55 Page 8 of 72

SETLAKIN... 55 SIGNIFOR... 56 SIGNIFOR LAR... 56 SILDENAFIL... 56 SILENOR... 56 SIVEXTRO... 56 SPIRIVA HANDIHALER... 56 SPIRIVA RESPIMAT... 56 STRATTERA... 57 STRIBILD... 57 SUBOXONE... 57 SUMATRIPTAN... 57 SUMATRIPTAN SUCCINATE... 57 SUMATRIPTAN SUCCINATE REFILL... 57 SYMBICORT... 58 SYNJARDY... 58 TACLONEX... 58 TAGRISSO... 58 TAMIFLU... 58 TAZORAC... 59 TECFIDERA... 59 TECFIDERA STARTER PACK... 59 TECHNIVIE... 59 TERBINAFINE HCL... 59 TOBI PODHALER... 59 TOLAZAMIDE... 59 TOLBUTAMIDE... 60 TRACLEER... 60 TRAMADOL HCL... 60 TRAMADOL HCL ER... 60 TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN... 60 TRAVATAN Z... 60 TRAVOPROST... 60 TRELSTAR MIXJECT... 60 TRIAMCINOLONE ACETONIDE... 61 TRINTELLIX... 61 TRIUMEQ... 61 TRUVADA... 61 TUDORZA PRESSAIR... 61 TYSABRI... 61 TYVASO... 61 TYZEKA... 62 UPTRAVI... 62 VALACYCLOVIR HCL... 62 VENTAVIS... 62 VENTOLIN HFA... 62 VERAMYST... 62 VERDROCET... 63 VERSACLOZ... 63 Page 9 of 72

VIBERZI... 63 VICODIN... 63 VICODIN ES... 63 VICODIN HP... 63 VICTOZA... 63 VIEKIRA PAK... 63 VIIBRYD... 64 VIIBRYD STARTER PACK... 64 VITEKTA... 64 VRAYLAR... 64 XARELTO... 64 XARELTO STARTER PACK... 64 XELJANZ XR... 64 XOPENEX HFA... 65 XURIDEN... 65 XYREM... 65 ZALEPLON... 65 ZAMICET... 65 ZENZEDI...65 ZEPATIER... 66 ZIPRASIDONE HCL... 66 ZOLMITRIPTAN... 66 ZOLMITRIPTAN ODT... 66 ZOLPIDEM TARTRATE... 66 ZOLPIDEM TARTRATE ER... 66 ZOMIG... 66 ZOMIG NASAL SPRAY... 66 ZOSTAVAX... 67 ZYVOX... 67 Page 10 of 72

ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE Abacavir Sulfate/lamivudine/zidovudine ABILIFY Abilify INJ Quantity Limit: 900 ML Per 30 Days Abilify ORAL SOLN Quantity Limit: 900 ML Per 30 Days ABILIFY DISCMELT Abilify Discmelt ABSTRAL Abstral Quantity Limit: 120 EA Per 30 Days ACETAMINOPHEN/CODEINE Acetaminophen/codeine SOLN Quantity Limit: 5000 ML Per 30 Days Acetaminophen/codeine TABS 300MG; 15MG, 300MG; 60MG Quantity Limit: 390 EA Per 30 Days ACETAMINOPHEN/CODEINE #3 Acetaminophen/codeine #3 Quantity Limit: 390 EA Per 30 Days ACTEMRA Actemra INJ 162MG/0.9ML Quantity Limit: 4 ML Per 28 Days Page 11 of 72

ADCIRCA Adcirca ADEFOVIR DIPIVOXIL Adefovir Dipivoxil ADEMPAS Adempas Quantity Limit: 90 EA Per 30 Days ADVAIR DISKUS Advair Diskus ADVAIR HFA Advair Hfa Quantity Limit: 16 GM Per 30 Days ALBUTEROL SULFATE Albuterol Sulfate NEBU 0.083% Quantity Limit: 525 ML Per 30 Days Albuterol Sulfate NEBU 0.5% Quantity Limit: 100 ML Per 30 Days Albuterol Sulfate NEBU 0.63MG/3ML, 1.25MG/3ML Quantity Limit: 375 ML Per 30 Days Page 12 of 72

ALECENSA Alecensa Quantity Limit: 240 EA Per 30 Days ALENDRONATE SODIUM Alendronate Sodium TABS 35MG, 70MG Quantity Limit: 4 EA Per 28 Days ALMOTRIPTAN MALATE Almotriptan Malate Quantity Limit: 12 EA Per 30 Days ALVESCO Alvesco Quantity Limit: 12.20 GM Per 30 Days AMETHIA Amethia Quantity Limit: 91 EA Per 91 Days AMETHIA LO Amethia Lo Quantity Limit: 91 EA Per 91 Days AMITIZA Amitiza AMPHETAMINE/DEXTROAMPHETAMINE Amphetamine/dextroamphetamine CP24 Page 13 of 72

Amphetamine/dextroamphetamine TABS AMPYRA Ampyra ANORO ELLIPTA Anoro Ellipta APLENZIN Aplenzin APTIVUS Aptivus CAPS Quantity Limit: 120 EA Per 30 Days ARCAPTA NEOHALER Arcapta Neohaler ARIPIPRAZOLE Aripiprazole SOLN Quantity Limit: 900 ML Per 30 Days Aripiprazole TABS 10MG, 15MG, 20MG, 30MG Aripiprazole TABS 2MG, 5MG Page 14 of 72

ARIPIPRAZOLE ODT Aripiprazole Odt ARMODAFINIL Armodafinil TABS 150MG, 200MG, 250MG Armodafinil TABS 50MG ASHLYNA Ashlyna Quantity Limit: 91 EA Per 91 Days ASMANEX HFA Asmanex Hfa Quantity Limit: 26 GM Per 30 Days ASMANEX TWISTHALER 120 METERED DOSES Asmanex Twisthaler 120 Metered Doses Quantity Limit: 2 EA Per 30 Days ASMANEX TWISTHALER 14 METERED DOSES Asmanex Twisthaler 14 Metered Doses Quantity Limit: 2 EA Per 30 Days ASMANEX TWISTHALER 30 METERED DOSES Asmanex Twisthaler 30 Metered Doses Quantity Limit: 2 EA Per 30 Days Page 15 of 72

ASMANEX TWISTHALER 60 METERED DOSES Asmanex Twisthaler 60 Metered Doses Quantity Limit: 2 EA Per 30 Days ASMANEX TWISTHALER 7 METERED DOSES Asmanex Twisthaler 7 Metered Doses Quantity Limit: 2 EA Per 30 Days ATRIPLA Atripla ATROVENT HFA Atrovent Hfa Quantity Limit: 25.80 GM Per 30 Days AUBAGIO Aubagio AVANDIA Avandia TABS 2MG Quantity Limit: 120 EA Per 30 Days Avandia TABS 4MG Avandia TABS 8MG AVONEX Avonex Quantity Limit: 2 EA Per 28 Days Page 16 of 72

AVONEX PEN Avonex Pen Quantity Limit: 2 EA Per 28 Days AXERT Axert Quantity Limit: 12 EA Per 30 Days AZELASTINE HCL Azelastine Hcl SOLN 0.1%, 0.15% Quantity Limit: 60 ML Per 30 Days BARACLUDE Baraclude SOLN Quantity Limit: 630 ML Per 30 Days BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" Bd Insulin Syringe Safetyglide/1ml/29g X 1/2" Quantity Limit: 200 EA Per 30 Days BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" Bd Insulin Syringe Ultrafine/0.3ml/31g X 5/16" Quantity Limit: 200 EA Per 30 Days BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" Bd Insulin Syringe Ultrafine/0.5ml/30g X 1/2" Quantity Limit: 200 EA Per 30 Days BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" Bd Insulin Syringe Ultrafine/1ml/31g X 5/16" Quantity Limit: 200 EA Per 30 Days Page 17 of 72

BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM Bd Pen Needle/ultrafine/29g X 12.7mm Quantity Limit: 200 EA Per 30 Days BETASERON Betaseron Quantity Limit: 15 EA Per 30 Days BIMATOPROST Bimatoprost SOLN Quantity Limit: 5 ML Per 30 Days BREO ELLIPTA Breo Ellipta BRINTELLIX Brintellix BROVANA Brovana Quantity Limit: 120 ML Per 30 Days BUDESONIDE Budesonide NASAL SUSP 0.25MG/2ML, 0.5MG/2ML, 1MG/2ML Quantity Limit: 120 ML Per 30 Days Budesonide NASAL SUSP 32MCG/ACT Quantity Limit: 17.20 GM Per 30 Days Page 18 of 72

BUPRENORPHINE HCL Buprenorphine Hcl SUBL 2MG Quantity Limit: 240 EA Per 30 Days Buprenorphine Hcl SUBL 8MG Quantity Limit: 90 EA Per 30 Days BUPRENORPHINE HCL/NALOXONE HCL Buprenorphine Hcl/naloxone Hcl SUBL 2MG; 0.5MG Quantity Limit: 360 EA Per 30 Days Buprenorphine Hcl/naloxone Hcl SUBL 8MG; 2MG Quantity Limit: 90 EA Per 30 Days BUPROBAN Buproban Quantity Limit: 540 EA Per 365 Days BUPROPION HCL SR Bupropion Hcl Sr TB12 150MG Quantity Limit: 540 EA Per 365 Days BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE Butalbital/acetaminophen/caffeine/codeine Quantity Limit: 180 EA Per 30 Days BUTORPHANOL TARTRATE Butorphanol Tartrate NASAL SOLN Quantity Limit: 10 ML Per 30 Days BUTRANS Butrans Quantity Limit: 4 EA Per 28 Days Page 19 of 72

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE Calcipotriene/betamethasone Dipropionate Quantity Limit: 400 GM Per 28 Days CALCITONIN-SALMON Calcitonin-salmon Quantity Limit: 3.70 ML Per 30 Days CAMRESE Camrese Quantity Limit: 91 EA Per 91 Days CAMRESE LO Camrese Lo Quantity Limit: 91 EA Per 91 Days CAPRELSA Caprelsa TABS 100MG CELECOXIB Celecoxib CAPS CHANTIX Chantix TABS 0.5MG, 1MG Quantity Limit: 504 EA Per 365 Days CHANTIX CONTINUING MONTH PAK Chantix Continuing Month Pak Quantity Limit: 504 EA Per 365 Days Page 20 of 72

CHANTIX STARTING MONTH PAK Chantix Starting Month Pak Quantity Limit: 159 EA Per 365 Days CLOZAPINE Clozapine TABS 100MG, 25MG Quantity Limit: 270 EA Per 30 Days Clozapine TABS 200MG Quantity Limit: 120 EA Per 30 Days Clozapine TABS 50MG Quantity Limit: 180 EA Per 30 Days CLOZAPINE ODT Clozapine Odt TBDP 100MG, 25MG Quantity Limit: 270 EA Per 30 Days Clozapine Odt TBDP 12.5MG Quantity Limit: 90 EA Per 30 Days Clozapine Odt TBDP 150MG Quantity Limit: 180 EA Per 30 Days Clozapine Odt TBDP 200MG Quantity Limit: 120 EA Per 30 Days COMBIVENT RESPIMAT Combivent Respimat Quantity Limit: 8 GM Per 30 Days COMPLERA Complera Page 21 of 72

COPAXONE Copaxone INJ 40MG/ML Quantity Limit: 12 ML Per 28 Days COTELLIC Cotellic Quantity Limit: 90 EA Per 30 Days CYSTARAN Cystaran Quantity Limit: 60 ML Per 28 Days DAKLINZA Daklinza Quantity Limit: 168 EA Per 365 Days DAYSEE Daysee Quantity Limit: 91 EA Per 91 Days DAYTRANA Daytrana DEPO-SUBQ PROVERA 104 Depo-subq Provera 104 Quantity Limit: 0.65 ML Per 84 Days DESCOVY Descovy Page 22 of 72

DESVENLAFAXINE ER Desvenlafaxine Er DEXILANT Dexilant DEXMETHYLPHENIDATE HCL Dexmethylphenidate Hcl DEXMETHYLPHENIDATE HCL ER Dexmethylphenidate Hcl Er CP24 10MG, 15MG, 30MG, 40MG, 5MG Dexmethylphenidate Hcl Er CP24 20MG DEXTROAMPHETAMINE SULFATE Dextroamphetamine Sulfate SOLN Quantity Limit: 1800 ML Per 30 Days Dextroamphetamine Sulfate TABS 10MG Quantity Limit: 180 EA Per 30 Days Dextroamphetamine Sulfate TABS 5MG Quantity Limit: 90 EA Per 30 Days DEXTROAMPHETAMINE SULFATE ER Dextroamphetamine Sulfate Er CP24 10MG Quantity Limit: 180 EA Per 30 Days Page 23 of 72

Dextroamphetamine Sulfate Er CP24 15MG Quantity Limit: 120 EA Per 30 Days Dextroamphetamine Sulfate Er CP24 5MG Quantity Limit: 90 EA Per 30 Days DIFICID Dificid Quantity Limit: 20 EA Per 10 Days DIGITEK Digitek TABS 0.125MG DIGOX Digox TABS 125MCG DIGOXIN Digoxin TABS 125MCG DIHYDROERGOTAMINE MESYLATE Dihydroergotamine Mesylate NASAL SOLN Quantity Limit: 8 ML Per 28 Days DRONABINOL Dronabinol DROPLET PEN NEEDLES 29GX10MM Droplet Pen Needles 29gx10mm Quantity Limit: 200 EA Per 30 Days Page 24 of 72

DULERA Dulera Quantity Limit: 17.60 GM Per 30 Days DULOXETINE HCL Duloxetine Hcl CPEP 20MG, 40MG, 60MG Duloxetine Hcl CPEP 30MG Quantity Limit: 90 EA Per 30 Days DYMISTA Dymista Quantity Limit: 23 GM Per 30 Days ELIGARD Eligard INJ 22.5MG Quantity Limit: 1 EA Per 84 Days Eligard INJ 30MG Quantity Limit: 1 EA Per 112 Days Eligard INJ 45MG Quantity Limit: 1 EA Per 168 Days Eligard INJ 7.5MG Quantity Limit: 1 EA Per 28 Days ELIQUIS Eliquis ELLA Ella Quantity Limit: 4 EA Per 365 Days Page 25 of 72

EMEND Emend CAPS 0 Quantity Limit: 6 EA Per 30 Days Emend CAPS 125MG Quantity Limit: 2 EA Per 30 Days Emend CAPS 40MG Quantity Limit: 1 EA Per 30 Days Emend CAPS 80MG Quantity Limit: 8 EA Per 30 Days EMSAM Emsam ENDOCET Endocet Quantity Limit: 360 EA Per 30 Days ENDODAN Endodan Quantity Limit: 360 EA Per 30 Days ENOXAPARIN SODIUM Enoxaparin Sodium INJ 100MG/ML, 150MG/ML Quantity Limit: 35 ML Per 90 Days Enoxaparin Sodium INJ 120MG/0.8ML, 80MG/0.8ML Quantity Limit: 28 ML Per 90 Days Enoxaparin Sodium INJ 300MG/3ML Quantity Limit: 105 ML Per 90 Days Enoxaparin Sodium INJ 30MG/0.3ML Quantity Limit: 10.50 ML Per 90 Days Page 26 of 72

Enoxaparin Sodium INJ 40MG/0.4ML Quantity Limit: 14 ML Per 90 Days Enoxaparin Sodium INJ 60MG/0.6ML Quantity Limit: 21 ML Per 90 Days ENTECAVIR Entecavir ENTRESTO Entresto ESOMEPRAZOLE MAGNESIUM Esomeprazole Magnesium ESTRING Estring Quantity Limit: 1 EA Per 90 Days EVOTAZ Evotaz EXTAVIA Extavia Quantity Limit: 15 EA Per 30 Days FANAPT Fanapt Page 27 of 72

FANAPT TITRATION PACK Fanapt Titration Pack Quantity Limit: 8 EA Per 180 Days FARYDAK Farydak Quantity Limit: 6 EA Per 21 Days FEMRING Femring Quantity Limit: 1 EA Per 90 Days FENTANYL Fentanyl Quantity Limit: 10 EA Per 30 Days FENTANYL CITRATE ORAL TRANSMUCOSAL Fentanyl Citrate Oral Transmucosal Quantity Limit: 120 EA Per 30 Days FENTORA Fentora Quantity Limit: 112 EA Per 28 Days FETZIMA Fetzima FETZIMA TITRATION PACK Fetzima Titration Pack Quantity Limit: 56 EA Per 365 Days Page 28 of 72

FIRMAGON Firmagon INJ 120MG Quantity Limit: 6 EA Per 365 Days Firmagon INJ 80MG Quantity Limit: 4 EA Per 28 Days FLECTOR Flector Quantity Limit: 30 EA Per 15 Days FLOVENT DISKUS Flovent Diskus AEPB 100MCG/BLIST, 50MCG/BLIST Flovent Diskus AEPB 250MCG/BLIST Quantity Limit: 240 EA Per 30 Days FLOVENT HFA Flovent Hfa AERO 110MCG/ACT, 220MCG/ACT Quantity Limit: 24 GM Per 30 Days Flovent Hfa AERO 44MCG/ACT Quantity Limit: 21.20 GM Per 30 Days FLUNISOLIDE Flunisolide Quantity Limit: 50 ML Per 30 Days FLUOXETINE DR Fluoxetine Dr Quantity Limit: 4 EA Per 28 Days Page 29 of 72

FLUTICASONE PROPIONATE Fluticasone Propionate SUSP Quantity Limit: 16 GM Per 30 Days FLUVOXAMINE MALEATE ER Fluvoxamine Maleate Er FONDAPARINUX SODIUM Fondaparinux Sodium INJ 10MG/0.8ML Quantity Limit: 28 ML Per 90 Days Fondaparinux Sodium INJ 2.5MG/0.5ML Quantity Limit: 17.50 ML Per 90 Days Fondaparinux Sodium INJ 5MG/0.4ML Quantity Limit: 14 ML Per 90 Days Fondaparinux Sodium INJ 7.5MG/0.6ML Quantity Limit: 21 ML Per 90 Days FORADIL AEROLIZER Foradil Aerolizer FORFIVO XL Forfivo XL FORTEO Forteo Quantity Limit: 2.40 ML Per 28 Days Page 30 of 72

FORTICAL Fortical Quantity Limit: 3.70 ML Per 30 Days FOSAMAX PLUS D Fosamax Plus D Quantity Limit: 4 EA Per 28 Days FRAGMIN Fragmin INJ 10000UNIT/ML Quantity Limit: 35 ML Per 90 Days Fragmin INJ 12500UNIT/0.5ML Quantity Limit: 17.50 ML Per 90 Days Fragmin INJ 15000UNIT/0.6ML Quantity Limit: 21 ML Per 90 Days Fragmin INJ 18000UNT/0.72ML Quantity Limit: 25.30 ML Per 90 Days Fragmin INJ 25000UNIT/ML, 95000UNIT/3.8ML Quantity Limit: 22.80 ML Per 90 Days Fragmin INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML Quantity Limit: 7 ML Per 90 Days Fragmin INJ 7500UNIT/0.3ML Quantity Limit: 10.50 ML Per 90 Days FROVA Frova Quantity Limit: 9 EA Per 30 Days FROVATRIPTAN SUCCINATE Frovatriptan Succinate Quantity Limit: 9 EA Per 30 Days Page 31 of 72

FUZEON Fuzeon GENVOYA Genvoya GILENYA Gilenya Quantity Limit: 28 EA Per 28 Days GLATOPA Glatopa Quantity Limit: 30 ML Per 30 Days GLIMEPIRIDE Glimepiride TABS 1MG Quantity Limit: 240 EA Per 30 Days Glimepiride TABS 2MG Quantity Limit: 120 EA Per 30 Days Glimepiride TABS 4MG GLIPIZIDE Glipizide TABS 10MG Quantity Limit: 120 EA Per 30 Days Glipizide TABS 5MG Quantity Limit: 240 EA Per 30 Days Page 32 of 72

GLIPIZIDE ER Glipizide Er TB24 10MG Glipizide Er TB24 2.5MG Quantity Limit: 240 EA Per 30 Days Glipizide Er TB24 5MG Quantity Limit: 120 EA Per 30 Days GLIPIZIDE XL Glipizide XL TB24 10MG Glipizide XL TB24 2.5MG Quantity Limit: 240 EA Per 30 Days Glipizide XL TB24 5MG Quantity Limit: 120 EA Per 30 Days GLIPIZIDE/METFORMIN HCL Glipizide/metformin Hcl TABS 2.5MG; 250MG Quantity Limit: 240 EA Per 30 Days Glipizide/metformin Hcl TABS 2.5MG; 500MG, 5MG; 500MG Quantity Limit: 120 EA Per 30 Days GLYBURIDE Glyburide TABS 1.25MG Quantity Limit: 480 EA Per 30 Days Glyburide TABS 2.5MG Quantity Limit: 240 EA Per 30 Days Glyburide TABS 5MG Quantity Limit: 120 EA Per 30 Days Page 33 of 72

GLYBURIDE MICRONIZED Glyburide Micronized TABS 1.5MG Quantity Limit: 240 EA Per 30 Days Glyburide Micronized TABS 3MG Quantity Limit: 120 EA Per 30 Days Glyburide Micronized TABS 6MG GLYBURIDE/METFORMIN HCL Glyburide/metformin Hcl TABS 1.25MG; 250MG Quantity Limit: 240 EA Per 30 Days Glyburide/metformin Hcl TABS 2.5MG; 500MG, 5MG; 500MG Quantity Limit: 120 EA Per 30 Days GRANISETRON HCL Granisetron Hcl TABS HARVONI Harvoni Quantity Limit: 168 EA Per 365 Days HETLIOZ Hetlioz HYDROCODONE BITARTRATE/ACETAMINOPHEN Hydrocodone Bitartrate/acetaminophen SOLN 325MG/15ML; 7.5MG/15ML Quantity Limit: 5550 ML Per 30 Days Page 34 of 72

Hydrocodone Bitartrate/acetaminophen TABS 300MG; 10MG, 300MG; 5MG, 300MG; 7.5MG Quantity Limit: 390 EA Per 30 Days Hydrocodone Bitartrate/acetaminophen TABS 325MG; 2.5MG Quantity Limit: 360 EA Per 30 Days HYDROCODONE/ACETAMINOPHEN Hydrocodone/acetaminophen TABS 325MG; 10MG, 325MG; 5MG, 325MG; 7.5MG Quantity Limit: 360 EA Per 30 Days HYDROMORPHONE HCL ER Hydromorphone Hcl Er T24A 12MG Quantity Limit: 150 EA Per 30 Days Hydromorphone Hcl Er T24A 16MG Quantity Limit: 120 EA Per 30 Days Hydromorphone Hcl Er T24A 32MG Hydromorphone Hcl Er T24A 8MG Quantity Limit: 240 EA Per 30 Days ICLUSIG Iclusig TABS 15MG INSUPEN 33GX4MM Insupen 33gx4mm Quantity Limit: 200 EA Per 30 Days INTELENCE Intelence TABS 100MG Quantity Limit: 120 EA Per 30 Days Page 35 of 72

Intelence TABS 200MG INTROVALE Introvale Quantity Limit: 91 EA Per 91 Days INVEGA Invega TB24 1.5MG, 3MG, 9MG Invega TB24 6MG IPRATROPIUM BROMIDE Ipratropium Bromide INHALATION SOLN 0.02% Quantity Limit: 312.50 ML Per 30 Days Ipratropium Bromide INHALATION SOLN 0.03% Quantity Limit: 60 ML Per 30 Days Ipratropium Bromide INHALATION SOLN 0.06% Quantity Limit: 30 ML Per 30 Days IPRATROPIUM BROMIDE/ALBUTEROL SULFATE Ipratropium Bromide/albuterol Sulfate Quantity Limit: 540 ML Per 30 Days IRENKA Irenka ISENTRESS Isentress TABS Page 36 of 72

JANUMET Janumet TABS 1000MG; 50MG Janumet TABS 500MG; 50MG Quantity Limit: 120 EA Per 30 Days JANUMET XR Janumet Xr TB24 1000MG; 100MG Janumet Xr TB24 1000MG; 50MG, 500MG; 50MG JENTADUETO Jentadueto JOLESSA Jolessa Quantity Limit: 91 EA Per 91 Days JUXTAPID Juxtapid KETOROLAC TROMETHAMINE Ketorolac Tromethamine TABS Quantity Limit: 20 EA Per 5 Days Page 37 of 72

KEVEYIS Keveyis Quantity Limit: 120 EA Per 30 Days KOMBIGLYZE XR Kombiglyze Xr TB24 1000MG; 2.5MG, 1000MG; 5MG Kombiglyze Xr TB24 500MG; 5MG Quantity Limit: 120 EA Per 30 Days KORLYM Korlym Quantity Limit: 120 EA Per 30 Days KYNAMRO Kynamro Quantity Limit: 4 ML Per 28 Days LANOXIN Lanoxin TABS 125MCG LANSOPRAZOLE Lansoprazole CPDR LATANOPROST Latanoprost SOLN Quantity Limit: 2.50 ML Per 25 Days Page 38 of 72

LATUDA Latuda TABS 120MG, 20MG, 40MG, 60MG Latuda TABS 80MG LAZANDA Lazanda LETAIRIS Letairis LEVALBUTEROL Levalbuterol NEBU Quantity Limit: 45 EA Per 30 Days LEVALBUTEROL HCL Levalbuterol Hcl NEBU 0.31MG/3ML, 0.63MG/3ML Quantity Limit: 540 ML Per 30 Days Levalbuterol Hcl NEBU 1.25MG/3ML Quantity Limit: 270 ML Per 30 Days LEVONORGESTREL AND ETHINYL ESTRADIOL Levonorgestrel And Ethinyl Estradiol TABS 0; 0 Quantity Limit: 91 EA Per 91 Days LEVONORGESTREL/ETHINYL ESTRADIOL Levonorgestrel/ethinyl Estradiol TABS 0.03MG; 0.15MG, 0; 0 Quantity Limit: 91 EA Per 91 Days Page 39 of 72

LINEZOLID Linezolid SUSR Quantity Limit: 2400 ML Per 30 Days Linezolid TABS LINZESS Linzess LORCET Lorcet Quantity Limit: 360 EA Per 30 Days LORCET HD Lorcet Hd Quantity Limit: 360 EA Per 30 Days LORCET PLUS Lorcet Plus TABS 325MG; 7.5MG Quantity Limit: 360 EA Per 30 Days LORTAB Lortab TABS Quantity Limit: 360 EA Per 30 Days LUMIGAN Lumigan Quantity Limit: 2.50 ML Per 25 Days Page 40 of 72

LUPANETA PACK Lupaneta Pack KIT 11.25MG; 5MG Quantity Limit: 1 EA Per 84 Days Lupaneta Pack KIT 3.75MG; 5MG Quantity Limit: 1 EA Per 28 Days LUPRON DEPOT Lupron Depot INJ 11.25MG, 22.5MG Quantity Limit: 1 EA Per 84 Days Lupron Depot INJ 3.75MG, 7.5MG Quantity Limit: 1 EA Per 28 Days Lupron Depot INJ 30MG Quantity Limit: 1 EA Per 112 Days Lupron Depot INJ 45MG Quantity Limit: 1 EA Per 168 Days LUPRON DEPOT-PED Lupron Depot-ped INJ 11.25MG, 15MG, 7.5MG Quantity Limit: 1 EA Per 28 Days Lupron Depot-ped INJ 11.25MG, 30MG Quantity Limit: 1 EA Per 84 Days METADATE ER Metadate Er Quantity Limit: 90 EA Per 30 Days METFORMIN HCL Metformin Hcl TABS 1000MG Metformin Hcl TABS 500MG Quantity Limit: 150 EA Per 30 Days Metformin Hcl TABS 850MG Quantity Limit: 90 EA Per 30 Days Page 41 of 72

METFORMIN HCL ER Metformin Hcl Er TB24 1000MG, 750MG Metformin Hcl Er TB24 500MG Quantity Limit: 120 EA Per 30 Days METHAMPHETAMINE HCL Methamphetamine Hcl Quantity Limit: 150 EA Per 30 Days METHYLPHENIDATE HCL Methylphenidate Hcl CHEW 10MG Quantity Limit: 180 EA Per 30 Days Methylphenidate Hcl CHEW 2.5MG, 5MG Quantity Limit: 90 EA Per 30 Days Methylphenidate Hcl TABS Quantity Limit: 90 EA Per 30 Days METHYLPHENIDATE HCL CD Methylphenidate Hcl CD CPCR 10MG, 20MG, 30MG Methylphenidate Hcl CD CPCR 40MG, 50MG, 60MG METHYLPHENIDATE HCL ER Methylphenidate Hcl Er CP24 20MG, 30MG Methylphenidate Hcl Er CP24 40MG Page 42 of 72

Methylphenidate Hcl Er TB24 18MG Quantity Limit: 120 EA Per 30 Days Methylphenidate Hcl Er TB24 27MG, 54MG Methylphenidate Hcl Er TB24 36MG Methylphenidate Hcl Er TBCR 10MG Quantity Limit: 180 EA Per 30 Days Methylphenidate Hcl Er TBCR 18MG Quantity Limit: 120 EA Per 30 Days Methylphenidate Hcl Er TBCR 20MG Quantity Limit: 90 EA Per 30 Days MODAFINIL Modafinil MOMETASONE FUROATE Mometasone Furoate SUSP Quantity Limit: 34 GM Per 30 Days MORPHINE SULFATE ER Morphine Sulfate Er CP24 100MG, 10MG, 20MG, 30MG, 50MG, 60MG, 80MG Morphine Sulfate Er CP24 120MG, 30MG, 45MG, 60MG, 75MG, 90MG Morphine Sulfate Er TBCR Quantity Limit: 90 EA Per 30 Days MOZOBIL Mozobil Quantity Limit: 9.60 ML Per 30 Days Page 43 of 72

NAMENDA XR Namenda Xr NAMENDA XR TITRATION PACK Namenda Xr Titration Pack Quantity Limit: 56 EA Per 365 Days NARATRIPTAN HCL Naratriptan Hcl Quantity Limit: 9 EA Per 30 Days NASONEX Nasonex Quantity Limit: 34 GM Per 30 Days NATPARA Natpara Quantity Limit: 2 EA Per 28 Days NICOTROL NS Nicotrol Ns Quantity Limit: 360 ML Per 365 Days NITROFURANTOIN Nitrofurantoin SUSP Quantity Limit: 7200 ML Per 365 Days NITROFURANTOIN MACROCRYSTALS Nitrofurantoin Macrocrystals CAPS 100MG Quantity Limit: 360 EA Per 365 Days Page 44 of 72

Nitrofurantoin Macrocrystals CAPS 50MG Quantity Limit: 720 EA Per 365 Days NITROFURANTOIN MONOHYDRATE Nitrofurantoin Monohydrate Quantity Limit: 180 EA Per 365 Days NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS Nitrofurantoin Monohydrate/macrocrystals Quantity Limit: 180 EA Per 365 Days NUCYNTA Nucynta Quantity Limit: 180 EA Per 30 Days NUCYNTA ER Nucynta Er NUPLAZID Nuplazid NUVIGIL Nuvigil TABS 150MG, 200MG, 250MG Nuvigil TABS 50MG ODEFSEY Odefsey Page 45 of 72

OLANZAPINE Olanzapine TABS OLANZAPINE ODT Olanzapine Odt OLANZAPINE/FLUOXETINE Olanzapine/fluoxetine CAPS 25MG; 12MG, 25MG; 3MG, 50MG; 12MG, 50MG; 6MG Olanzapine/fluoxetine CAPS 25MG; 6MG Quantity Limit: 90 EA Per 30 Days OLOPATADINE HCL Olopatadine Hcl NASAL SOLN 0.6% Quantity Limit: 30.50 GM Per 30 Days OMEPRAZOLE Omeprazole CPDR ONDANSETRON HCL Ondansetron Hcl INJ 4MG/2ML Quantity Limit: 144 ML Per 28 Days Ondansetron Hcl ORAL SOLN Quantity Limit: 450 ML Per 30 Days Ondansetron Hcl TABS 24MG Quantity Limit: 14 EA Per 28 Days Page 46 of 72

OPSUMIT Opsumit ORKAMBI Orkambi Quantity Limit: 112 EA Per 28 Days OTEZLA Otezla TBPK Quantity Limit: 110 EA Per 365 Days OXANDROLONE Oxandrolone TABS 10MG Oxandrolone TABS 2.5MG Quantity Limit: 120 EA Per 30 Days OXYCODONE HCL ER Oxycodone Hcl Er Quantity Limit: 120 EA Per 30 Days OXYCODONE/ACETAMINOPHEN Oxycodone/acetaminophen TABS 325MG; 10MG, 325MG; 2.5MG, 325MG; 5MG, 325MG; 7.5MG Quantity Limit: 360 EA Per 30 Days OXYCODONE/ASPIRIN Oxycodone/aspirin Quantity Limit: 360 EA Per 30 Days Page 47 of 72

OXYMORPHONE HYDROCHLORIDE ER Oxymorphone Hydrochloride Er OXYTROL Oxytrol Quantity Limit: 8 EA Per 28 Days PALIPERIDONE ER Paliperidone Er TB24 1.5MG, 3MG, 9MG Paliperidone Er TB24 6MG PANTOPRAZOLE SODIUM Pantoprazole Sodium TBEC PERFOROMIST Perforomist Quantity Limit: 120 ML Per 30 Days PEXEVA Pexeva TABS 10MG, 20MG, 40MG Pexeva TABS 30MG PIOGLITAZONE HCL Pioglitazone Hcl TABS 15MG Page 48 of 72

Pioglitazone Hcl TABS 30MG Quantity Limit: 45 EA Per 30 Days Pioglitazone Hcl TABS 45MG PIOGLITAZONE HCL/METFORMIN HCL Pioglitazone Hcl/metformin Hcl Quantity Limit: 90 EA Per 30 Days PIOGLITAZONE HCL-GLIMEPIRIDE Pioglitazone Hcl-glimepiride Quantity Limit: 45 EA Per 30 Days PLEGRIDY Plegridy Quantity Limit: 2 ML Per 28 Days PLEGRIDY STARTER PACK Plegridy Starter Pack Quantity Limit: 2 ML Per 365 Days PRADAXA Pradaxa PRALUENT Praluent Quantity Limit: 2 ML Per 28 Days PRANDIMET Prandimet Quantity Limit: 150 EA Per 30 Days Page 49 of 72

PREZCOBIX Prezcobix PRISTIQ Pristiq TB24 100MG, 50MG Quantity Limit: 120 EA Per 30 Days Pristiq TB24 25MG PROAIR HFA Proair Hfa Quantity Limit: 17 GM Per 30 Days PROAIR RESPICLICK Proair Respiclick Quantity Limit: 2 EA Per 30 Days PROLIA Prolia Quantity Limit: 2 ML Per 365 Days PROVENTIL HFA Proventil Hfa Quantity Limit: 13.40 GM Per 30 Days PULMICORT Pulmicort SUSP 1MG/2ML Quantity Limit: 120 ML Per 30 Days Page 50 of 72

PULMICORT FLEXHALER Pulmicort Flexhaler Quantity Limit: 1 EA Per 30 Days QUASENSE Quasense Quantity Limit: 91 EA Per 91 Days QUETIAPINE FUMARATE Quetiapine Fumarate TABS 100MG, 200MG, 300MG, 400MG Quetiapine Fumarate TABS 25MG, 50MG Quantity Limit: 90 EA Per 30 Days QVAR Qvar Quantity Limit: 17.40 GM Per 30 Days RABEPRAZOLE SODIUM Rabeprazole Sodium REBIF Rebif Quantity Limit: 6 ML Per 28 Days REBIF REBIDOSE Rebif Rebidose Quantity Limit: 6 ML Per 28 Days Page 51 of 72

REBIF REBIDOSE TITRATION PACK Rebif Rebidose Titration Pack Quantity Limit: 4.20 ML Per 28 Days REBIF TITRATION PACK Rebif Titration Pack Quantity Limit: 4.20 ML Per 28 Days RELENZA DISKHALER Relenza Diskhaler Quantity Limit: 112 EA Per 365 Days RELPAX Relpax Quantity Limit: 9 EA Per 30 Days REPAGLINIDE/METFORMIN HYDROCHLORIDE Repaglinide/metformin Hydrochloride Quantity Limit: 150 EA Per 30 Days REPATHA Repatha Quantity Limit: 3 ML Per 28 Days REPATHA SURECLICK Repatha Sureclick Quantity Limit: 3 ML Per 28 Days RESERPINE Reserpine TABS 0.1MG Page 52 of 72

RESTASIS Restasis REXULTI Rexulti RILUZOLE Riluzole RISEDRONATE SODIUM Risedronate Sodium TABS 150MG Quantity Limit: 1 EA Per 28 Days Risedronate Sodium TABS 35MG Quantity Limit: 4 EA Per 28 Days RISEDRONATE SODIUM DR Risedronate Sodium Dr Quantity Limit: 4 EA Per 28 Days RISPERIDONE Risperidone SOLN Quantity Limit: 240 ML Per 30 Days Risperidone TABS RISPERIDONE M-TAB Risperidone M-tab Page 53 of 72

RISPERIDONE ODT Risperidone Odt RIZATRIPTAN BENZOATE Rizatriptan Benzoate Quantity Limit: 18 EA Per 30 Days RIZATRIPTAN BENZOATE ODT Rizatriptan Benzoate Odt Quantity Limit: 18 EA Per 30 Days ROXICET Roxicet SOLN Quantity Limit: 1800 ML Per 30 Days Roxicet TABS Quantity Limit: 360 EA Per 30 Days ROZEREM Rozerem SANCUSO Sancuso Quantity Limit: 4 EA Per 28 Days SAPHRIS Saphris Page 54 of 72

SAVAYSA Savaysa SAVELLA Savella SAVELLA TITRATION PACK Savella Titration Pack Quantity Limit: 55 EA Per 28 Days SELZENTRY Selzentry TABS 150MG Selzentry TABS 300MG Quantity Limit: 120 EA Per 30 Days SEREVENT DISKUS Serevent Diskus SEROQUEL XR Seroquel Xr TB24 150MG, 200MG Seroquel Xr TB24 300MG, 400MG, 50MG SETLAKIN Setlakin Quantity Limit: 91 EA Per 91 Days Page 55 of 72

SIGNIFOR Signifor Quantity Limit: 60 ML Per 30 Days SIGNIFOR LAR Signifor Lar Quantity Limit: 1 EA Per 28 Days SILDENAFIL Sildenafil INJ Quantity Limit: 1125 ML Per 30 Days Sildenafil TABS Quantity Limit: 90 EA Per 30 Days SILENOR Silenor SIVEXTRO Sivextro Quantity Limit: 6 EA Per 30 Days SPIRIVA HANDIHALER Spiriva Handihaler SPIRIVA RESPIMAT Spiriva Respimat AERS 1.25MCG/ACT Quantity Limit: 4 GM Per 28 Days Spiriva Respimat AERS 2.5MCG/ACT Quantity Limit: 4 GM Per 30 Days Page 56 of 72

STRATTERA Strattera STRIBILD Stribild SUBOXONE Suboxone FILM 12MG; 3MG Suboxone FILM 2MG; 0.5MG Quantity Limit: 360 EA Per 30 Days Suboxone FILM 4MG; 1MG Quantity Limit: 180 EA Per 30 Days Suboxone FILM 8MG; 2MG Quantity Limit: 90 EA Per 30 Days SUMATRIPTAN Sumatriptan SOLN Quantity Limit: 18 EA Per 30 Days SUMATRIPTAN SUCCINATE Sumatriptan Succinate INJ Quantity Limit: 8 ML Per 30 Days Sumatriptan Succinate INJ 6MG/0.5ML Quantity Limit: 10 ML Per 30 Days Sumatriptan Succinate TABS Quantity Limit: 18 EA Per 30 Days SUMATRIPTAN SUCCINATE REFILL Sumatriptan Succinate Refill Quantity Limit: 8 ML Per 30 Days Page 57 of 72

SYMBICORT Symbicort AERO 160MCG/ACT; 4.5MCG/ACT Quantity Limit: 12 GM Per 30 Days Symbicort AERO 80MCG/ACT; 4.5MCG/ACT Quantity Limit: 13.80 GM Per 30 Days SYNJARDY Synjardy TABS 12.5MG; 1000MG, 5MG; 1000MG Synjardy TABS 12.5MG; 500MG, 5MG; 500MG Quantity Limit: 120 EA Per 30 Days TACLONEX Taclonex SUSP Quantity Limit: 420 GM Per 28 Days TAGRISSO Tagrisso TAMIFLU Tamiflu CAPS 30MG Quantity Limit: 112 EA Per 365 Days Tamiflu CAPS 45MG Quantity Limit: 60 EA Per 365 Days Tamiflu CAPS 75MG Quantity Limit: 110 EA Per 365 Days Tamiflu SUSR Quantity Limit: 720 ML Per 365 Days Page 58 of 72

TAZORAC Tazorac Quantity Limit: 100 GM Per 30 Days TECFIDERA Tecfidera TECFIDERA STARTER PACK Tecfidera Starter Pack TECHNIVIE Technivie Quantity Limit: 168 EA Per 365 Days TERBINAFINE HCL Terbinafine Hcl TABS Quantity Limit: 84 EA Per 168 Days TOBI PODHALER Tobi Podhaler Quantity Limit: 224 EA Per 56 Days TOLAZAMIDE Tolazamide TABS 250MG Quantity Limit: 120 EA Per 30 Days Tolazamide TABS 500MG Page 59 of 72

TOLBUTAMIDE Tolbutamide Quantity Limit: 180 EA Per 30 Days TRACLEER Tracleer TRAMADOL HCL Tramadol Hcl TABS Quantity Limit: 240 EA Per 30 Days TRAMADOL HCL ER Tramadol Hcl Er TB24 TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN Tramadol Hydrochloride/acetaminophen Quantity Limit: 240 EA Per 30 Days TRAVATAN Z Travatan Z Quantity Limit: 2.50 ML Per 25 Days TRAVOPROST Travoprost Quantity Limit: 2.50 ML Per 25 Days TRELSTAR MIXJECT Trelstar Mixject INJ 11.25MG Quantity Limit: 1 EA Per 84 Days Page 60 of 72

Trelstar Mixject INJ 22.5MG Quantity Limit: 1 EA Per 168 Days Trelstar Mixject INJ 3.75MG Quantity Limit: 1 EA Per 28 Days TRIAMCINOLONE ACETONIDE Triamcinolone Acetonide AERO Quantity Limit: 16.50 GM Per 30 Days TRINTELLIX Trintellix TRIUMEQ Triumeq TRUVADA Truvada TUDORZA PRESSAIR Tudorza Pressair TYSABRI Tysabri Quantity Limit: 15 ML Per 28 Days TYVASO Tyvaso Quantity Limit: 87 ML Per 30 Days Page 61 of 72

TYZEKA Tyzeka UPTRAVI Uptravi TABS 1000MCG, 1200MCG, 1400MCG, 1600MCG, 400MCG, 600MCG, 800MCG Uptravi TABS 200MCG Quantity Limit: 150 EA Per 30 Days Uptravi TBPK Quantity Limit: 400 EA Per 365 Days VALACYCLOVIR HCL Valacyclovir Hcl TABS 1000MG Quantity Limit: 90 EA Per 30 Days Valacyclovir Hcl TABS 500MG VENTAVIS Ventavis Quantity Limit: 270 ML Per 30 Days VENTOLIN HFA Ventolin Hfa Quantity Limit: 48 GM Per 30 Days VERAMYST Veramyst Quantity Limit: 10 GM Per 30 Days Page 62 of 72

VERDROCET Verdrocet Quantity Limit: 360 EA Per 30 Days VERSACLOZ Versacloz Quantity Limit: 540 ML Per 30 Days VIBERZI Viberzi VICODIN Vicodin TABS 300MG; 5MG Quantity Limit: 390 EA Per 30 Days VICODIN ES Vicodin Es TABS 300MG; 7.5MG Quantity Limit: 390 EA Per 30 Days VICODIN HP Vicodin Hp TABS 300MG; 10MG Quantity Limit: 390 EA Per 30 Days VICTOZA Victoza Quantity Limit: 9 ML Per 30 Days VIEKIRA PAK Viekira Pak Quantity Limit: 672 EA Per 365 Days Page 63 of 72

VIIBRYD Viibryd VIIBRYD STARTER PACK Viibryd Starter Pack VITEKTA Vitekta VRAYLAR Vraylar CAPS Vraylar CPPK Quantity Limit: 14 EA Per 365 Days XARELTO Xarelto TABS 10MG, 20MG Xarelto TABS 15MG XARELTO STARTER PACK Xarelto Starter Pack Quantity Limit: 102 EA Per 365 Days XELJANZ XR Xeljanz Xr Page 64 of 72

XOPENEX HFA Xopenex Hfa Quantity Limit: 30 GM Per 30 Days XURIDEN Xuriden Quantity Limit: 120 EA Per 30 Days XYREM Xyrem Quantity Limit: 540 ML Per 30 Days ZALEPLON Zaleplon CAPS 10MG Zaleplon CAPS 5MG ZAMICET Zamicet Quantity Limit: 5550 ML Per 30 Days ZENZEDI Zenzedi TABS 10MG Quantity Limit: 180 EA Per 30 Days Zenzedi TABS 15MG, 2.5MG, 20MG, 5MG, 7.5MG Quantity Limit: 90 EA Per 30 Days Zenzedi TABS 30MG Page 65 of 72

ZEPATIER Zepatier Quantity Limit: 112 EA Per 365 Days ZIPRASIDONE HCL Ziprasidone Hcl ZOLMITRIPTAN Zolmitriptan TABS Quantity Limit: 12 EA Per 30 Days ZOLMITRIPTAN ODT Zolmitriptan Odt Quantity Limit: 12 EA Per 30 Days ZOLPIDEM TARTRATE Zolpidem Tartrate TABS ZOLPIDEM TARTRATE ER Zolpidem Tartrate Er ZOMIG Zomig SOLN 2.5MG Quantity Limit: 18 EA Per 30 Days ZOMIG NASAL SPRAY Zomig Nasal Spray Quantity Limit: 18 EA Per 30 Days Page 66 of 72

ZOSTAVAX Zostavax Quantity Limit: 1 EA Per 365 Days ZYVOX Zyvox SUSR Quantity Limit: 2400 ML Per 30 Days Page 67 of 72

INDEX A Abacavir Sulfate/lamivudine/zidovudine.. 11 Abilify... 11 Abilify Discmelt... 11 Abstral... 11 Acetaminophen/codeine... 11 Acetaminophen/codeine #3... 11 Actemra... 11 Adcirca... 12 Adefovir Dipivoxil... 12 Adempas... 12 Advair Diskus... 12 Advair Hfa... 12 Albuterol Sulfate... 12 Alecensa... 13 Alendronate Sodium... 13 Almotriptan Malate... 13 Alvesco... 13 Amethia... 13 Amethia Lo... 13 Amitiza... 13 Amphetamine/dextroamphetamine... 13, 14 Ampyra... 14 Anoro Ellipta... 14 Aplenzin... 14 Aptivus... 14 Arcapta Neohaler... 14 Aripiprazole... 14 Aripiprazole Odt... 15 Armodafinil... 15 Ashlyna... 15 Asmanex Hfa... 15 Asmanex Twisthaler 120 Metered Doses. 15 Asmanex Twisthaler 14 Metered Doses... 15 Asmanex Twisthaler 30 Metered Doses... 15 Asmanex Twisthaler 60 Metered Doses... 16 Asmanex Twisthaler 7 Metered Doses... 16 Atripla... 16 Atrovent Hfa... 16 Aubagio... 16 Avandia... 16 Avonex... 16 Avonex Pen... 17 Axert... 17 Azelastine Hcl... 17 B Baraclude... 17 Bd Insulin Syringe Safetyglide/1ml/29g X 1/2... 17 Bd Insulin Syringe Ultrafine/0.3ml/31g X 5/16... 17 Bd Insulin Syringe Ultrafine/0.5ml/30g X 1/2... 17 Bd Insulin Syringe Ultrafine/1ml/31g X 5/16... 17 Bd Pen Needle/ultrafine/29g X 12.7mm... 18 Betaseron... 18 Bimatoprost... 18 Breo Ellipta... 18 Brintellix... 18 Brovana... 18 Budesonide... 18 Buprenorphine Hcl... 19 Buprenorphine Hcl/naloxone Hcl... 19 Buproban... 19 Bupropion Hcl Sr... 19 Butalbital/acetaminophen/caffeine/codeine... 19 Butorphanol Tartrate... 19 Butrans... 19 C Calcipotriene/betamethasone Dipropionate... 20 Calcitonin-salmon... 20 Camrese... 20 Camrese Lo... 20 Caprelsa... 20 Celecoxib... 20 Chantix... 20 Chantix Continuing Month Pak... 20 Chantix Starting Month Pak... 21 Clozapine... 21 Clozapine Odt... 21 Page 68 of 72

Combivent Respimat... 21 Complera... 21 Copaxone... 22 Cotellic... 22 Cystaran... 22 D Daklinza... 22 Daysee... 22 Daytrana... 22 Depo-subq Provera 104... 22 Descovy... 22 Desvenlafaxine Er... 23 Dexilant... 23 Dexmethylphenidate Hcl... 23 Dexmethylphenidate Hcl Er... 23 Dextroamphetamine Sulfate... 23 Dextroamphetamine Sulfate Er... 23, 24 Dificid... 24 Digitek... 24 Digox... 24 Digoxin... 24 Dihydroergotamine Mesylate... 24 Dronabinol... 24 Droplet Pen Needles 29gx10mm... 24 Dulera... 25 Duloxetine Hcl... 25 Dymista... 25 E Eligard... 25 Eliquis... 25 Ella... 25 Emend... 26 Emsam... 26 Endocet... 26 Endodan... 26 Enoxaparin Sodium... 26, 27 Entecavir... 27 Entresto... 27 Esomeprazole Magnesium... 27 Estring... 27 Evotaz... 27 Extavia... 27 F Fanapt... 27 Fanapt Titration Pack... 28 Farydak... 28 Femring... 28 Fentanyl... 28 Fentanyl Citrate Oral Transmucosal... 28 Fentora... 28 Fetzima... 28 Fetzima Titration Pack... 28 Firmagon... 29 Flector... 29 Flovent Diskus... 29 Flovent Hfa... 29 Flunisolide... 29 Fluoxetine Dr... 29 Fluticasone Propionate... 30 Fluvoxamine Maleate Er... 30 Fondaparinux Sodium... 30 Foradil Aerolizer... 30 Forfivo XL... 30 Forteo... 30 Fortical... 31 Fosamax Plus D... 31 Fragmin... 31 Frova... 31 Frovatriptan Succinate... 31 Fuzeon... 32 G Genvoya... 32 Gilenya... 32 Glatopa... 32 Glimepiride... 32 Glipizide... 32 Glipizide Er... 33 Glipizide XL... 33 Glipizide/metformin Hcl... 33 Glyburide... 33 Glyburide Micronized... 34 Glyburide/metformin Hcl... 34 Granisetron Hcl... 34 H Harvoni... 34 Hetlioz... 34 Hydrocodone Bitartrate/acetaminophen.. 34, 35 Hydrocodone/acetaminophen... 35 Hydromorphone Hcl Er... 35 Page 69 of 72

I Iclusig... 35 Insupen 33gx4mm... 35 Intelence... 35, 36 Introvale... 36 Invega... 36 Ipratropium Bromide... 36 Ipratropium Bromide/albuterol Sulfate... 36 Irenka... 36 Isentress... 36 J Janumet... 37 Janumet Xr... 37 Jentadueto... 37 Jolessa... 37 Juxtapid... 37 K Ketorolac Tromethamine... 37 Keveyis... 38 Kombiglyze Xr... 38 Korlym... 38 Kynamro... 38 L Lanoxin... 38 Lansoprazole... 38 Latanoprost... 38 Latuda... 39 Lazanda... 39 Letairis... 39 Levalbuterol... 39 Levalbuterol Hcl... 39 Levonorgestrel And Ethinyl Estradiol... 39 Levonorgestrel/ethinyl Estradiol... 39 Linezolid... 40 Linzess... 40 Lorcet... 40 Lorcet Hd... 40 Lorcet Plus... 40 Lortab... 40 Lumigan... 40 Lupaneta Pack... 41 Lupron Depot... 41 Lupron Depot-ped... 41 M Metadate Er... 41 Metformin Hcl... 41 Metformin Hcl Er... 42 Methamphetamine Hcl... 42 Methylphenidate Hcl... 42 Methylphenidate Hcl CD... 42 Methylphenidate Hcl Er... 42, 43 Modafinil... 43 Mometasone Furoate... 43 Morphine Sulfate Er... 43 Mozobil... 43 N Namenda Xr... 44 Namenda Xr Titration Pack... 44 Naratriptan Hcl... 44 Nasonex... 44 Natpara... 44 Nicotrol Ns... 44 Nitrofurantoin... 44 Nitrofurantoin Macrocrystals... 44, 45 Nitrofurantoin Monohydrate... 45 Nitrofurantoin Monohydrate/macrocrystals... 45 Nucynta... 45 Nucynta Er... 45 Nuplazid... 45 Nuvigil... 45 O Odefsey... 45 Olanzapine... 46 Olanzapine Odt... 46 Olanzapine/fluoxetine... 46 Olopatadine Hcl... 46 Omeprazole... 46 Ondansetron Hcl... 46 Opsumit... 47 Orkambi... 47 Otezla... 47 Oxandrolone... 47 Oxycodone Hcl Er... 47 Oxycodone/acetaminophen... 47 Oxycodone/aspirin... 47 Oxymorphone Hydrochloride Er... 48 Oxytrol... 48 Page 70 of 72

P Paliperidone Er... 48 Pantoprazole Sodium... 48 Perforomist... 48 Pexeva... 48 Pioglitazone Hcl... 48, 49 Pioglitazone Hcl/metformin Hcl... 49 Pioglitazone Hcl-glimepiride... 49 Plegridy... 49 Plegridy Starter Pack... 49 Pradaxa... 49 Praluent... 49 Prandimet... 49 Prezcobix... 50 Pristiq... 50 Proair Hfa... 50 Proair Respiclick... 50 Prolia... 50 Proventil Hfa... 50 Pulmicort... 50 Pulmicort Flexhaler... 51 Q Quasense... 51 Quetiapine Fumarate... 51 Qvar... 51 R Rabeprazole Sodium... 51 Rebif... 51 Rebif Rebidose... 51 Rebif Rebidose Titration Pack... 52 Rebif Titration Pack... 52 Relenza Diskhaler... 52 Relpax... 52 Repaglinide/metformin Hydrochloride... 52 Repatha... 52 Repatha Sureclick... 52 Reserpine... 52 Restasis... 53 Rexulti... 53 Riluzole... 53 Risedronate Sodium... 53 Risedronate Sodium Dr... 53 Risperidone... 53 Risperidone M-tab... 53 Risperidone Odt... 54 Rizatriptan Benzoate... 54 Rizatriptan Benzoate Odt... 54 Roxicet... 54 Rozerem... 54 S Sancuso... 54 Saphris... 54 Savaysa... 55 Savella... 55 Savella Titration Pack... 55 Selzentry... 55 Serevent Diskus... 55 Seroquel Xr... 55 Setlakin... 55 Signifor... 56 Signifor Lar... 56 Sildenafil... 56 Silenor... 56 Sivextro... 56 Spiriva Handihaler... 56 Spiriva Respimat... 56 Strattera... 57 Stribild... 57 Suboxone... 57 Sumatriptan... 57 Sumatriptan Succinate... 57 Sumatriptan Succinate Refill... 57 Symbicort... 58 Synjardy... 58 T Taclonex... 58 Tagrisso... 58 Tamiflu... 58 Tazorac... 59 Tecfidera... 59 Tecfidera Starter Pack... 59 Technivie... 59 Terbinafine Hcl... 59 Tobi Podhaler... 59 Tolazamide... 59 Tolbutamide... 60 Tracleer... 60 Tramadol Hcl... 60 Tramadol Hcl Er... 60 Tramadol Hydrochloride/acetaminophen. 60 Travatan Z... 60 Travoprost... 60 Page 71 of 72

Trelstar Mixject... 60, 61 Triamcinolone Acetonide... 61 Trintellix... 61 Triumeq... 61 Truvada... 61 Tudorza Pressair... 61 Tysabri... 61 Tyvaso... 61 Tyzeka... 62 U Uptravi... 62 V Valacyclovir Hcl... 62 Ventavis... 62 Ventolin Hfa... 62 Veramyst... 62 Verdrocet... 63 Versacloz... 63 Viberzi... 63 Vicodin... 63 Vicodin Es... 63 Vicodin Hp... 63 Victoza... 63 Viekira Pak... 63 Viibryd... 64 Viibryd Starter Pack... 64 Vitekta... 64 Vraylar... 64 X Xarelto... 64 Xarelto Starter Pack... 64 Xeljanz Xr... 64 Xopenex Hfa... 65 Xuriden... 65 Xyrem... 65 Z Zaleplon... 65 Zamicet... 65 Zenzedi... 65 Zepatier... 66 Ziprasidone Hcl... 66 Zolmitriptan... 66 Zolmitriptan Odt... 66 Zolpidem Tartrate... 66 Zolpidem Tartrate Er... 66 Zomig... 66 Zomig Nasal Spray... 66 Zostavax... 67 Zyvox... 67 Page 72 of 72