PRESCRIPTION DRUG QUANTITY LIMIT GUIDE What is a Quantity Limit?

Transcription

1 PRESCRIPTION DRUG QUANTITY LIMIT GUIDE What is a Quantity Limit? Your prescription benefit may limit the amount of a drug we will cover. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. For example, we may cover a specific number of s per day (one of atorvastatin per day). Or, we may cover a specific number of s per month (nine s of sumatriptan per month). We use medical guidelines, FDA approval and guidance from drug makers to set these quantity limits. Please consult this guide often as information is subject to change. Throughout this guide: Brand name drugs are capitalized (e.g., Cymbalta) and generic drugs are listed in lowercase italics (e.g., duloxetine) Definitions of abbreviations used: act = actuation CR = controlled release EC = enteric coated ER = extended release gm = gram HCR = Health Care Reform hr = hour mcg = microgram mg = milligrams ml = milliliter ODT = oral disintegrating PMDD = premenstrual dysphoric disorder QTY = quantity SR = sustained release UD = unit dose The Assurant Health Prescription Drug Quantity Limit Guide provides summary information. For a complete listing of benefits, exclusions, and limitations, please refer to the certificate of insurance. In the event there are discrepancies with the information in this brochure, the terms and conditions of the coverage documents will govern. Plan design, benefits, optional features, provisions, and exclusions may vary by state. Please note that not all drugs listed in this guide are covered by all pharmacy benefit programs. Check your benefit materials or contact Assurant Health by calling the customer service number on the back of your medical identification card to determine if a drug is covered. TIME INSURANCE COMPANY Assurant Health is the brand name for products underwritten and issued by Time Insurance Company. J (06/2016) 2016 Assurant, Inc. All rights reserved

2 To quickly find a specific drug, use the search feature available in Adobe Acrobat Reader (PC keyboard shortcut: Ctrl+F; Mac keyboard shortcut: Cmd+f) 2016 Prescription Drug Quantity Limit Guide Acne topical Fabior 0.1% foam Up to 100gm every 30 days Acne oral Absorica s amnesteem s claravis s myorisan s sotret s zenatane s Antianginal Ranexa 500mg Ranexa 1000mg Antibacterials macrolides Dificid 20 every 30 days Antibacterials cystic fibrosis Tobi Podhaler 8 /day Antibacterial oxazolidinone Sivextro 6 every 30 days Antibacterial tuberculosis Sirturo 68 every 30 days Anticoagulants Eliquis Pradaxa Savaysa Xarelto starter pack Xarelto 10mg Xarelto 15mg 1 pack every 30 days Up to 35 every 365 days 42 /30 days Xarelto 20mg Anticonvulsants Aptiom 200mg, 400mg, 800mg Aptiom 600mg Briviact Fycompa 2mg, 4mg, 8mg, 10mg, 12mg Fycompa 6mg Gabitril, tiagabine 2mg Gabitril, tiagabine 4mg Gabitril 12mg Gabitril 16mg Keppra XR, levetiracetam ER 500mg Keppra XR, levetiracetam ER 750mg Lamictal ODT, lamotrigine ODT 25 mg 2/ day 4/ day

3 Anticonvulsants, continued Lamictal ODT, lamotrigine ODT 50mg Lamictal ODT, lamotrigine ODT 100mg, 200mg Lamictal XR, lamotrigine ER 25mg, 50mg, 100mg Lamictal XR, lamotrigine ER 200mg Lamictal XR, lamotrigine ER 250mg, 300mg Neurontin, gabapentin 100mg Neurontin, gabapentin 300mg Neurontin, gabapentin 400mg Neurontin, gabapentin 600mg Neurontin, gabapentin 800mg Neurontin, gabapentin solution Onfi Oxtellar XR 150mg, 300mg Oxtellar XR 600mg Potiga 200mg, 300mg, 400mg Qudexy XR, topiramate ER 25mg Qudexy XR, topiramate ER 50mg Qudexy XR, topiramate ER 100mg Qudexy XR, topiramate ER 150mg Qudexy XR, topiramate ER 200mg Sabril Spritam Topamax Sprinkle, topiramate Trokendi XR 25mg, 50mg, 100mg Trokendi XR 200mg Vimpat 10mg/ml solution Vimpat 50mg /day 40ml /day 40ml /day Vimpat 100mg, 150mg, 200mg Antidepressants Aplenzin 174mg, 348mg, 522mg Brintellix 5mg, 10mg, 20mg Celexa, citalopram 10mg Celexa, citalopram 20mg Celexa, citalopram 40mg Cymbalta, duloxetine 20mg Cymbalta, duloxetine 30mg

4 Antidepressants, continued Cymbalta, duloxetine 60mg Desvenlafaxine ER 50mg, 100mg Effexor XR, venlafaxine XR 37.5mg Effexor XR, venlafaxine XR 75mg Effexor XR, venlafaxine XR 150mg Emsam TD patch Fetzima 20mg, 40mg, 80mg, 120mg Fetzima titration pack fluvoxamine 25mg, 50mg fluvoxamine 100mg Irenka, duloxetine 40mg Khedezla 50mg, 100mg Lexapro, escitalopram 5mg, 10mg Lexapro, escitalopram 20mg Lexapro, escitalopram 5mg/5ml Luvox CR, fluvoxamine ER 100mg, 150mg maprotiline 25mg maprotiline 50mg maprotiline 75mg Oleptro 150mg Oleptro 300mg Paxil, paroxetine 10mg, 20mg Paxil, paroxetine 30mg, 40mg Paxil, paroxetine 10mg/5ml suspension Pexeva 10mg, 20mg Pexeva 30mg, 40mg Paxil CR, paroxetine CR Pristiq Prozac 10mg, fluoxetine 10mg non PMDD Prozac 20mg, fluoxetine 20mg non PMDD Prozac 40mg, fluoxetine 40mg fluoxetine 10mg fluoxetine 20mg fluoxetine 60mg fluoxetine liquid 20mg/5ml Prozac weekly, fluoxetine weekly 5 /day 1 patch /day 1 pack (28 s) every 30 days 5 /day 20ml /day 1.5 /day 30ml /day 10ml /day 4 per 28 days

5 Remeron, mirtazepine 15mg Remeron, mirtazepine 7.5mg, 30mg, 45mg Remeron SLT, mirtazepine 15mg ODT Remeron SLT, mirtazepine 7.5mg, 30mg, 45mg ODT Sarafem selfemra 10mg, fluoxetine 10mg PMDD selfemra 20mg, fluoxetine 20mg PMDD Trintellix 5mg, 10mg, 20mg venlafaxine 25mg venlafaxine 37.5mg venlafaxine 50mg venlafaxine 75mg venlafaxine 100mg Venlafaxine 37.5mg ER Venlafaxine 75mg ER Venlafaxine 150mg ER Venlafaxine 225mg ER Viibryd Viibryd starter kit Wellbutrin, bupropion 75mg, 100mg Wellbutrin SR 100mg bupropion SR 100mg budeprion SR 100mg bupropion ER 100mg Wellbutrin SR 150mg bupropion SR 150mg budeprion SR 150mg bupropion ER 150mg Wellbutrin SR, bupropion SR Wellbutrin XL 150mg budeprion XL 150mg 200mg 1.5 /day 1.5 /day 14 /30 days 14 /30 days 14 /30 days 1/ day 5 /day 5 /day bupropion XL 150mg Wellbutrin XL 300mg budeprion XL 300mg bupropion XL 300mg Forfivo XL

6 Zoloft, sertraline Antidepressants, continued Zoloft, sertraline concentrate 10ml /day Antifungal Oravig 14 /30 days Antihistamines and Clarinex, desloratadine Decongestants Clarinex, desloratadine ODT Clarinex Syrup 10ml /day Clarinex D 12 hour Clarinex D 24 hour Semprex D Xyzal, levocetirizine Xyzal, levocetirizine oral solution 10ml /day Antimalarial Qualaquin, quinine sulfate 324mg 42 every 365 days Antivirals Denavir cream 5 gm /30 days Famvir, famciclovir 125mg, 250mg Famvir, famciclovir 500mg Genvoya Odefsey Relenza Tamiflu 12mg/ml Tamiflu 6mg/ml Tamiflu Tybost Valcyte, valgancyclovir 450mg Valcyte solution Zovirax cream Zovirax, acyclovir ointment 60 every 30 days 21 every 30 days 2 units (40 blisters ) /calendar year 150ml /calendar year 480ml /calendar year 20 /calendar year 102 every 30 days 1000ml every 30 days 5 gm /30 days 30 gm / 30 days Xerese cream 5 gm /30 days Asthma/COPD Advair Diskus, Advair HFA inhaler 1 /30 day supply Anoro Ellipta inhaler Arcapta powder for inhalation Arnuity Ellipta inhaler Breo Ellipta inhaler Brovana nebulizing solution Dulera inhaler Foradil for inhalation Incruse Ellipta inhaler Perforomist nebulizing solution 1 /30 day supply 1 /30 day supply 1 /30 day supply 60 vials (120ml) /30 day supply 1 /30 day supply 1 /30 day supply 60 vials (120ml) /30 day supply

7 ProAir HFA, Respiclick inhaler 2 /30 day supply Proventil HFA inhaler 2 /30 day supply Seebri Neohaler 1 /30 day supply Serevent inhaler 1 /30 day supply Singulair, montelukast 4mg granules 1 granule pack/day Singulair, montelukast 4mg chewable tab Singulair, montelukast 5mg chewable tab Singulair, montelukast 10mg Spiriva HandiHaler, Respimat inhaler 1 /30 day supply Stiolto Respimat 1 /30 day supply Striverdi Respimat inhaler 1 /30 day supply Symbicort inhaler 1 /30 day supply Utibron Neohaler 1 /30 day supply Ventolin HFA inhaler 2 /30 day supply Xopenex HFA inhaler 2 /30 day supply Benign Prostatic Hypertrophy (BPH) Cialis 2.5mg, 5mg (for BPH diagnosis) Benzodiazepine Diastat, diazepam rectal gel 1 pack per fill Blood Pressure and Heart Failure Xanax XR, alprazolam ER/XR Amturnide Atacand, candesartan Atacand HCT, candesartan HCT Avalide Avapro, irbresartan Azor Benicar Benicar HCT Corlanor Cozaar, losartan Diovan, valsartan Diovan HCT, valsartan Edarbi Edarbyclor Entresto Exforge, amlodipine/valsartan Exforge HCT, amlodipine/valsartan/hctz Hyzaar, losartan HCTZ Micardis, telmisartan

8 Micardis HCT, telmisartan/hctz Nymalize solution Tekamlo Tekturna Tekturna/HCT Teveten Tribenzor Twynsta, telmisartan/amlodipine Valturna 2520ml every 21 days Vecamyl Up to 10 /day Cataplexy Xyrem solution 18ml /day; 540ml /30 days Cholesterol Lowering/Triglycerides Advicor Altoprev 20mg Altoprev 40mg Altoprev 60mg Caduet, amlodipine atorvastatin Crestor, rosuvastatin Lescol, fluvastatin Lescol XL Lipitor, atorvastatin Liptruzet Livalo Lovaza, omega 3 acid Mevacor, lovastatin Pravachol, pravastatin Simcor mg Simcor mg Simcor mg Simcor mg Simcor mg Vytorin Zetia Zocor, simvastatin Colon/Rectal Apriso Asacol 400mg EC Asacol HD 800mg Azulfidine 500mg sulfasalazine 500mg Sulfazine 500mg 1 8 /day 8 /day

9 Azulfidine EN 500mg Sulfazine EC 500mg Canasa 1000mg suppository Colazal, balsalside Delzicol Dipentum Giazo Lialda Pentasa 250mg CR 8 /day 9 /day 1 1 Pentasa 500mg CR 8 /day Colon/Rectal, continued Uceris rectal aerosol 2 doses = (4.5g) /day Uceris Cushing Syndrome Korlym Cystic Fibrosis Kalydeco ; max 30 day supply per fill Dermatology topical Diabetes injectable Diabetes oral agents Kalydeco Pak Orkambi Picato gel 0.015% Picato gel 0.05% Bydureon injection, pen ; max 30 day supply 18 tubes (6 boxes) every 365 days 12 tubes (6 boxes) every 365 days 4 trays every 30 days Byetta Pen 5mcg/0.02ml 0.05 /day (1.4ml /30d) Byetta Pen 10mcg/0.02ml Tanzeum injection 30mg, 50mg pen Trulicity 0.75/0.5ml, 1.5/0.5ml pen Victoza injection Farxiga Fortamet 500 mg 1000 mg Glumetza 500 mg 1000 mg Glyxambi Invokana Invokamet Janumet mg, mg Janumet XR , mg Janumet XR mg 0.08 /day (2.4ml /30days) 4 pens every 28 days 4 pens /prefilled syringes every 28 days 0.3ml /day (9ml /30 days) 3/ day 2/ day 3/ day 2/ day

10 Januvia Jardiance Jentadueto Kazano Kombiglyze Nesina Onglyza Diabetes oral agents, continued Oseni Diabetes test strips Erectile Dysfunction plan specific Synjardy Tradjenta Xigduo XR 5/500, 10/500 mg Xigduo XR 10/1000 mg Xigduo XR 5/1000 mg All blood glucose test strips Caverject injection Edex injection Cialis Levitra Muse injection Viagra 1/day Up to 10 strips /day 6/30 day supply Staxyn Estrogen/combinations Alora patch 8/28 days (twice weekly) Climara, estradiol TD weekly patch Estraderm patch estradiol patch Menostar patch Vivelle DOT, Minivelle patch, estradiol disc Climara Pro Weekly Patch Combipatch 0.05 mg/0.14 mg Activella, estradiol/norethindrone Aygestin, norethindrone Angeliq Cenestin Elestrin Enjuvia Estrogel Estrasorb 4/28 days (one per week) 8/28 days (twice weekly) 4/28 days (one per week) 4/28 days (one per week) 8/28 days (twice weekly) 4/28 days (one per week) 8/28 days (twice weekly) 1.7gm /day (2 x 26gm /30 day supply) 1 pump /30 day supply 2 packets /day

11 Evamist Femhrt, norethindrone/ethinyl estradiol Femring Mimvey 2 bottles /30 day supply 1 ring/90 day supply Prefest Fibromyalgia Savella titration pak 1 /30 day supply Savella Gastrointestinal Amitiza Fulyzaq DR Linzess Movantik Ocaliva 1/ day Viberzi Gastrointestinal morning sickness Diclegis Glaucoma Lumigan, bimatoprost eye drop 3ml /30 day supply Rescula eye drop Travatan Z eye drop travaprost eye drop Xalatan, latanaprost eye drop 5ml /30 day supply 3ml /30 day supply 3ml /30 day supply 3ml /30 day supply Zioptan eye drop 1 unit /day Gout Colcrys, cholchicine Mitigare Uloric Hemostatics systemic Lysteda, tranexamic acid 30 /30 day supply Huntington s Disease chorea Xenazine, tetrabenazine 12.5mg 8 /day Hyperlipidemia Xenazine tetrabenazine 25mg Juxtapid 5mg Juxtapid 10mg Juxtapid 20mg Rx Limitations: Rx QTY max 14; days supply max 14 Rx Limitations: Rx QTY max 28; days supply max 28 Rx Limitations: Rx QTY max 84; days supply max 28 Juxtapid 3omg, 40mg, 60mg Immunomodulating Agents topical Aldara, imiquimod 5% cream 120 day supply every 365 days Immunologics Janus Kinase Inhibitor Zyclara cream packet Zyclara cream pump Xeljanz Xeljanz ER 56 packets every 365 days 2 pumps (15gm) every 365 days

12 Immunotherapy allergy Grastek Oralair Ragwitek Mania and Psychosis Abilify, aripiprazole 2mg Abilify, aripiprazole 5mg, 10mg, 15mg, 20mg, 30mg Mania and Psychosis, continued Abilify 10mg, 15mg disc Abilify, aripiprazole Solution Clozaril, clozapine 25mg, 50mg Clozaril, clozapine 100mg Fanapt Fanapt titration pak Fazaclo, clozapine ODT 12.5mg 30ml /day 9 /day 1 pack /30 day supply Fazaclo, clozapine ODT 25mg Fazaclo, clozapine ODT 100mg 9 /day Fazaclo, clozapine ODT 150mg Fazaclo, clozapine ODT 200mg Geodon, ziprasidone Invega, paliperidone 1.5mg, 3mg, 6mg Invega, paliperidone 9mg Latuda 20mg, 40mg Latuda 80mg Latuda 120mg Rexulti Risperdal, risperidone 0.25mg Risperdal, risperidone 0.5mg Risperdal, risperidone 1mg Risperdal, risperidone 2mg Risperdal, risperidone 3mg Risperdal, risperidone 4mg Risperdal M tab, risperidone ODT 0.25mg Risperdal M tab, risperidone ODT 0.5mg Risperdal M tab, risperidone ODT 1mg Risperdal M tab, risperidone ODT 2mg Risperdal M tab, risperidone ODT 3mg Risperdal M tab, risperidone ODT 4mg Saphris Seroquel, quetiapine 25mg 5 /day 5 /day

13 Seroquel, quetiapine 50mg, 100mg Seroquel, quetiapine 200mg Seroquel, quetiapine 300mg, 400mg Seroquel XR 50mg Seroquel XR 150mg, 200mg Seroquel XR 300mg, 400mg Symbyax, olanzapine fluoxetine Versacloz suspension Vraylar Vraylar 3mg Vraylar 4.5mg, 6mg 1.5mg 20ml /day 2/day Mania and Psychosis, continued Zyprexa, olanzapine 2.5mg Zyprexa, olanzapine 5mg, 7.5mg, 10mg, 15mg, 20mg Zyprexa Zydis, olanzapine ODT 5mg, 10mg, 15mg, 20mg ODT Migraine Amerge, naratriptan 9 /30 days Axert, almotriptan Cambia powder Frova, frovatriptan Imitrex, sumatriptan 5mg/act, 20mg/act nasal 6 /30 days 9 packets /30 days 9 /30 days 6 vials /30 days Imitrex, sumatriptan 9 /30 days Imitrex, sumatriptan 6mg vial sumatriptan 4mg/0.5ml vial Alsuma 6mg injection Maxalt, rizatriptan 10 vials /30 days 10 vials /30 days 10 /30 days 12 /30 days Maxalt MLT, rizatriptan MLT Migranal, dihydroergotamine nasal spray Onzetra nasal spray Relpax Sumavel 4mg/0.5ml injection Sumavel 6mg/0.5ml injection Treximet 12 /30 days 8 doses /30 days 1 kit/ 30 days 6 /30 days 6 prefilled syringes /30 days 6 prefilled syringes /30 days 9 /30 days

14 Zecuity patch Zembrace SymTouch 4 /30 days 8/30 days Zomig Nasal Spray 6 /30 days Zomig, Zomig ZMT, zolmitriptan, zolmitriptan ODT 6/30 days Miscellaneous Anti Infectives Impavido 50mg Max 28 day supply per fill Xifaxan 200mg 9 /30 days Xifaxan 550mg Multiple Sclerosis Ampyra Narcotic Partial Opioid Narcotic Partial Opioid, continued Gilenya Aubagio Tecfidera 120mg Tecfidera 240mg Tecfidera MIS starter pack Belbuca film all strengths Bunavail mg film Bunavail mg film Bunavail 6.3 1mg film Suboxone 2 0.5mg Suboxone 8 2mg buprenorphine naloxone Suboxone 2 0.5mg film Suboxone 4 1mg film Suboxone 8 2mg film Suboxone 12 3mg film Subutex, buprenorphine 2mg Subutex, buprenorphine 8mg Zubsolv mg SL Zubsolv mg SL Zubsolv mg SL Zubsolv 8.6/2.1mg SL 14 every 30 days ; 60 /30 day supply ; 60 /30 day supply ; 60/30 day supply (cumulative of all strengths) Max 24 every 30 days Max 8 every 30 days Zubsolv 11.4/2.9mg SL Nausea/Vomiting Akynzeo 5 every 30 days Anzemet Cesamet Emend 40mg, 80mg, 125mg Emend Pack granisetron Granisol solution 5 /30 days 20 /30 days 5 /30 days 2 packs (6 s) /30 days 10 /30 days 60ml /30 days

15 Zofran, ondansetron 30 every 30 days Zofran ODT, ondansetron ODT 30 every 30 days Zofran, ondansetron solution 150ml every 30 days Sancuso patch 1 patch /21 days Varubi 4/ 28 days Zuplenz soluble film 12 films /30 days Nephrotic Cystanosis Procysbi 25mg 120 every 30 days Procysbi 75mg 750 every 30 days Non 24 Disorder Hetlioz Oncology Afinitor Oncology, continued Afinitor Disperz Bosulif Cabometyx 20mg, 40mg, 60mg Cometriq Kit 60mg, 100mg, 140mg Cotellic Erivedge Farydak Gleevec Gleostine Gilotrif Ibrance Iclusig Imbruvica Inlyta Iressa Jakafi Lenvima Lonsurf 20/8.19mg Lonsurf 15/6.14mg Lynparza Mekinist Nexavar Ninlaro Odomzo Oforta Pomalyst Purixan suspension 1/ day 63 /28 days and max 30 day supply 12 every 28 days and max 30 day supply and max 30 day supply and max 30 day supply 80 /28 days 100 /28 days 1 and max 30 day supply per fill 3 s every 28 days: Max 28 day supply per fill 1/ day and max 30 day supply 100ml every 30 days; max 30 day supply per fill

16 Sprycel Sutent Stivarga Sylatron Tafinlar Tagrisso Tarceva Tasigna Temodar, temozolomide Tykerb tretinoin Caprelsa Votrient Xeloda, capecitabine Zolinza Hycamtin Venclexta 100mg 50mg 10mg Starter pack Xalkori Xtandi Zelboraf Zydelig Zykadia ; max 30 day supply per fill 4/ day 8/ day 40/ day 1 pack/ 28 days and max 30 day supply 8 /day and max 30 day supply and max 30 day supply and max 30 day supply Zytiga and max 30 day supply Ophthalmic Cystaran solution 2.15 ml /day (4 bottles of 15ml per 28 days) Osteoporosis/Paget Disease Actonel, risedronate 5mg, 30mg Osteoporosis/Paget Disease, continued Actonel, risedronate 35mg 4 / 28 days Actonel, risedronate 150mg 3 /90 days Atelvia, risedronate 35mg 4 / 28 days Binosto 70mg Boniva, ibandronate 150mg calcitonin, Fortical, Miacalcin nasal spray Fosamax, alendronate 5mg, 10mg, 40mg Fosamax, alendronate 35mg Fosamax, alendronate 70mg alendronate solution Fosamax Plus D 4 / 28 days 3 /90 days 0.12ml /day (3.7ml /30 days) 4 / 28 days 4 / 28 days 10ml /day 4 / 28 days

17 Pain (analgesics) and Inflammation Abstral 120 /30 days Actiq, fentanyl lozenge 120 lozenges (lollipop) every 30 days Avinza, morphine sulfate beads SR 24hr Up to 60 every 30 days Butrans patch butorphanol NS Celebrex ConZip, tramadol ER Dolophine, methadone, methadose Duexis Duragesic, fentanyl patch Embeda Exalgo, hydromorphine ER 8mg, 12mg Exalgo, hydromorphine ER 16mg Exalgo, hydromorphine ER 32mg Fentora Buccal Flector Patch Hysingla ER Kadian CR, morphine SR 24 hour Lazanda spray 4 patches /30 days 2 units (5ml) /30 days Up to 60 every 30 days Up to 180 every 30 days. 30 patches /30 days 120 every 30 days 2 patches /day Up to 60 every 30 days. Up to 30 bottles every 30 days methadone concentrate, solution methadone concentrate, solution MS Contin, morphine sulfate SR 12hour, Oramorph SR Nucynta Nucynta ER Onsolis film Opana ER, oxymorphone ER 10mg/ml = 180ml every 30 days 5mg/5ml = 1800ml every 30 days 10mg/5ml = 900ml every 30 days 40mg for oral suspension = Up to 120 every 30 days. 180 every 30 days 60 every 30 days 120 buccal films every 30 days Up to 120 every 30 days Pain (analgesics) and Inflammation, continued oxycodone/ibuprofen 28 every 30 days Oxycontin, oxycodone ER Pennsaid solution, diclofenac solution 1.5% 450ml /30 days Pennsaid solution 2.0% 224ml every 28 days

18 Sprix spray Subsys spray Tivorbex Toradol, ketorolac Ultram ER, tramadol ER Vimovo Vivlodex Voltaren gel Xartemis XR Xtampza ER 9 mg 13.5 mg 18 mg 27 mg 36 mg Zohydro ER 5 UD sprays /30 days 120 units every 30 days 20 every 30 days and 100% utilization Up to 60 every 30 days 16.7gm /day (5 x100gm tubes/30 days) 32 / day 21/ day 16/ day 10/ day 8/day Zorvolex Parkinson s Disease Azilect Zelapar Platelet Aggregation Inhibitors Brilinta Effient Plavix, clopidogrel 60 every 30 days Zontivity Poisoning Radiogardase 540 every 365 days Post Herpetic Neuralgia (PHN) Gralise 300mg 5 /day Gralise 600mg Gralise starter pack 1 pack (78 tabs) every 365 days Lidoderm, lidocaine patch Up to 6 patches /day Potassium Removing Veltassa powder Primary Hyperkalemic and Hypokalemic Periodic Paralysis Keveyis Proton Pump Inhibitors (PPI) AcipHex, rabeprazole AcipHex Sprinkle Dexilant Esomeprazole strontium Nexium 40mg Prevacid, lansoprazole 30mg Prevacid SoluTab, lansoprazole ODT 2 caps/day. 2/day 2/day

19 lansoprazole 3mg/ml compound kit (Cutis) First omeprazole 2mg/ml compound kit Zegerid packet Zegerid, omeprazole sodium bicarbonate 20ml /day 20ml /day Pseudobulbar Affect Nuedexta Psoriatic Arthritis Otezla 30mg 1 starter pack (27 s) every Otezla starter pack 365 days Pulmonary Arterial Adcirca Hypertension (PAH) Adempas Opsumit Revatio, sildenafil 20mg Restless Leg Syndrome Horizant 1 / day Mirapex ER, pramipexole ER Requip XL, ropinirole ER 2mg, 4mg, 6mg, 8mg Requip XL, ropinirole ER 12mg Rosacea Oracea, doxycycline Sedatives and Hypnotics Ambien, zolpidem 5mg Ambien, zolpidem 10mg Ambien CR, zolpidem ER Belsomra Edluar Intermezzo SL Lunesta, eszopiclone Rozerem Silenor Sonata 5mg Sonata 10mg Zolpimist spray 5mg Steroids glucocorticoid Entocort EC, budesonide SR Stimulant/Attention Deficit Adderall, amphetamine dexamphetamine 5mg, 7.5mg, 10mg, 12.5mg, 15mg Adderall, amphetamine dexamphetamine 20mg Adderall, amphetamine dexamphetamine 30mg Adderall XR, amphetaminedexamphetamine SR 5mg, 10mg, 15mg, 20mg, 25mg 7.7ml (1 bottle) /30 days

20 Adderall XR, amphetaminedexamphetamine SR 30mg Adenzys XR Aptensio XR Concerta, methylphenidate ER 18mg, 27mg, 36mg, 54mg Daytrana patch Desoxyn, methamphetamine Dexedrine, dextroamphetamine Dexedrine CR, dextroamphetamine CR 10mg Dexedrine CR, dextroamphetamine CR 5mg, 15mg Dyanavel XR suspension 2.5mg/ml Evekeo Focalin, dexmethylphenidate Focalin XR, dexmethylphenidate ER 5mg Focalin XR, dexmethylphenidate ER 10mg Focalin XR, dexmethylphenidate ER 15mg Focalin XR 25mg Focalin XR, dexmethylphenidate ER 20mg, 30mg Focalin XR 35mg Focalin XR, dexmethylphenidate ER 40mg Intuniv Kapvay, clonidine ER Kapvay Dose Pack Metadate CD, methylphenidate CR Metadate ER, Methylin ER, Ritalin SR, methylphenidate CR/SR/ER 20mg Methylin chew 2.5mg, 5mg chewable Methylin chew 10mg chewable Methylin, methylphenidate 5mg/5ml solution Methylin, methylphenidate 10mg/5ml solution Methylin ER 10mg 1/day 1 patch /day 8 /day 8 /day 8 /day 5 /day 8ml/day 1 pack /month (60 tabs) 1 120ml /day 60ml /day

21 Methylin, Ritalin, methylphenidate Nuvigil 50mg Nuvigil 150mg, 200mg, 250mg Procentra, dextroamphetamine 5mg/5ml solution 60ml /day Provigil 100mg, 200mg Stimulant/Attention Deficit, continued QuilliChew ER 30mg 2/day QuilliChew ER 20mg, 40mg 1/day Quillivant XR suspension Ritalin LA 10mg Ritalin LA /methylphenidate ER 20mg Ritalin LA /methylphenidate ER 30mg Ritalin LA/methylphenidate ER 40mg Ritalin LA 60mg Strattera 10mg, 18mg, 25mg, 40mg, 60mg Strattera 80mg, 100mg Vyvanse Zenzedi 2.5mg, 5mg, 7.5mg, 10mg Zenzedi 15mg Zenzedi 20mg Zenzedi 30mg 12ml /day 8 /day 5 /day Testosterone topical Androderm patch 1 patch /day AndroGel, testosterone 1% gel AndroGel 1.62% gel Axiron solution Fortesta gel Pump = 4 canisters /30 day supply 2.5gm packet = 1 packet/day 5gm packet = 2 packets/day Pump = 2 canisters /30 day supply 1.25gm packet = 1 packet/day 2.5mg packet = 2 packets/day 2 canisters /30 day supply 2 canisters /30 day supply Natesto gel 33gm /30 day supply Testosterone topical, continued Striant buccal Testim, testosterone 1% gel 2 tubes /day

22 Tobacco Cessation Vogelxo gel Vogelxo 1% gel pump Chantix Nicorette, nicotine polacrilex gum Nicorette, nicotine polacrilex lozenge Nicotrol inhaler Nicotrol nasal spray Nicoderm, transdermal nicotine patch 5gm packet = 2 packets /day 4 canisters per 30 day supply ; HCR: Up to 180 days every 365 days Up to 24 pieces /day; HCR: Up to 180 days every 365 days Up to 20 pieces /day; HCR: Up to 180 days every 365 days Up to 16 cartridges /day; HCR: Up to 180 days every 365 days Up to 12 bottles /30 day supply; HCR: Up to 180 days every 365 days 1 patch /day; HCR: Up to 180 days every 365 days Zyban, bupropion (smoking deterrent) ; HCR: Up to 180 days every 365 days Triglycerides Vascepa s Urea Cycle Disorder Ravicti liquid 17.5ml /day Viral Infections/Immune System Enhancers Daklinza Harvoni Incivek Olysio Sovaldi Technivie Victrelis Viekira Pak Zepatier 1 1/day Women s Health Brisdelle Women s Health, continued Duavee Cervical cap all brands and sizes Diaphragm all brands and sizes Nuvaring Oral combination contraceptive Oral emergency contraceptive Oral progestin only contraceptive Ortho Evra, xulane patch 1 every 365 days; also applies to HCR 1 diaphragm every 365 days ; also applies to HCR 1 ring per month; also applies to HCR 1.5 /day; also applies to HCR 1 pack (2 tabs) /fill; also applies to HCR 1.5 /day; also applies to HCR 3 patches per month; also applies to HCR

23