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To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Managementprogram. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives youthe right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Foodand Drug Administration (FDA). Based on the FDA’s guidelines and other medical information, our plan developed thisprogram together with Express Scripts, the company chosen to manage our prescription drug benefit.The following limits are based on a 30-day supply. If your plan allows for additional days supply, your limits may be higher.For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could alsorequest a prior authorization. If this request is approved, a prior authorization would let you receive more than therecommended quantity.This document list is effective January 1, 2017 through December 31, 2017. This list may not be all inclusive and issubject to change. You can get more information and updates to this document at our website at Express-Scripts.com.Drug TargetMaximum QuantityABILIFY 10 MG TABLET30 tablets per prescriptionABILIFY 15 MG TABLET30 tablets per prescriptionABILIFY 2 MG TABLET30 tablets per prescriptionABILIFY 20 MG TABLET30 tablets per prescriptionABILIFY 30 MG TABLET30 tablets per prescriptionABILIFY 5 MG TABLET30 tablets per prescriptionABILIFY DISCMELT 10 MG TABLET60 tablets per prescriptionABILIFY DISCMELT 15 MG TABLET60 tablets per prescriptionABSTRAL 100 MCG TAB SUBLINGUAL90 units per 30 daysABSTRAL 200 MCG TAB SUBLINGUAL90 units per 30 daysABSTRAL 300 MCG TAB SUBLINGUAL90 units per 30 daysABSTRAL 400 MCG TAB SUBLINGUAL90 units per 30 daysABSTRAL 600 MCG TAB SUBLINGUAL90 units per 30 daysABSTRAL 800 MCG TAB SUBLINGUAL90 units per 30 daysACTIQ 1,200 MCG LOZENGE90 units per 30 daysACTIQ 1,600 MCG LOZENGE90 units per 30 daysACTIQ 200 MCG LOZENGE90 units per 30 daysACTIQ 400 MCG LOZENGE90 units per 30 daysACTIQ 600 MCG LOZENGE90 units per 30 daysACTIQ 800 MCG LOZENGE90 units per 30 daysACTONEL 150 MG TABLET1 tablet per 30 daysACTONEL 30 MG TABLET30 tablets per prescriptionACTONEL 35 MG TABLET4 tablets per 28 daysACTONEL 5 MG TABLET30 tablets per prescriptionACTONEL 75 MG TABLET2 tablet per 30 daysACTONEL WITH CALCIUM TABLETS1 (28 day) Blister Package per prescriptionACTOPLUS MET 15 MG-500 MG TAB90 tablets per prescriptionACTOPLUS MET 15 MG-850 MG TAB90 tablets per prescriptionACTOPLUS MET XR 15-1,000 MG TB60 tablets per prescriptionACTOPLUS MET XR 30-1,000 MG TB30 tablets per prescriptionACTOS 15 MG TABLET30 tablets per prescriptionACTOS 30 MG TABLET30 tablets per prescriptionACTOS 45 MG TABLET30 tablets per prescriptionADCIRCA 20 MG TABLET60 tablets per prescriptionADLYXIN MAINTENANCE KIT1 kit per presciptionADLYXIN STARTER KIT1 kit per presciptionADRENACLICK 0.15 MG2 units (1 carton) per prescriptionADRENACLICK 0.3 MG2 units (1 carton) per prescriptionADVAIR 100-50 DISKUS1 device (60 blisters) per prescriptionADVAIR 250-50 DISKUS1 device (60 blisters) per prescriptionADVAIR 500-50 DISKUS1 device (60 blisters) per prescriptionData Class: Confidential
ADVAIR HFA 115-21 MCG INHALER1 inhaler per prescriptionADVAIR HFA 115-21 MCG INHALER1 inhaler per prescriptionADVAIR HFA 230-21 MCG INHALER1 inhaler per prescriptionADVAIR HFA 230-21 MCG INHALER1 inhaler per prescriptionADVAIR HFA 45-21 MCG INHALER1 inhaler per prescriptionADVAIR HFA 45-21 MCG INHALER1 inhaler per prescriptionADVICOR 1,000 MG-20 MG TABLET60 tablets per prescriptionADVICOR 500 MG-20 MG TABLET30 tablets per prescriptionADVICOR 750 MG-20 MG TABLET60 tablets per prescriptionAEROBID/AEROBID-M3 inhalers per prescriptionsAEROSPAN 80 MCG INHALER18 g (2 inhalers, 8.9 g each) per prescriptionAKYNZEO 300/0.5MG CAPSULE1 capsule per chemotherapy courseALECENSA 150 MG CAPSULE240 capsules per prescriptionALLEGRA ALLERGY 12 HR 60 MG60 tablets per prescriptionALLEGRA ALLERGY 24 HR 180 MG30 tablets per prescriptionALLEGRA CHILDREN'S ALLERGY 30 MG TABLET60 tablets per prescriptionALLEGRA-D 12 HOUR ALLERGY & CONGESTION60 tablets per prescriptionALLEGRA-D 24 HOUR ALLERGY & CONGESTION30 tablets per prescriptionALORA 0.025 MG PATCH8 patches per 28 daysALORA 0.05 MG PATCH8 patches per 28 daysALORA 0.075 MG PATCH8 patches per 28 daysALORA 0.1 MG PATCH8 patches per 28 daysALOXI 0.25 MG/5 ML VIAL1 vial per prescriptionALSUMA 6 MG/0.5 ML AUTO-INJECT1 kit/2 syringes per prescriptionALTOPREV 20 MG TABLET30 tablets per prescriptionALTOPREV 40 MG TABLET30 tablets per prescriptionALTOPREV 60 MG TABLET30 tablets per prescriptionALVESCO 160 MCG INHALER2 inhalers per prescriptionsALVESCO 80 MCG INHALER1 inhaler per prescriptionAMBIEN 10 MG TABLET30 tablets per prescriptionAMBIEN 5 MG TABLET30 tablets per prescriptionAMBIEN CR 12.5 MG TABLET30 tablets per prescriptionAMBIEN CR 6.25 MG TABLET30 tablets per prescriptionAMERGE 1 MG TABLET9 tablets per prescriptionAMERGE 2.5 MG TABLET9 tablets per prescriptionANORO ELLIPTA 62.5/25 MCG14 blisters (institutional pack) per prescriptionANORO ELLIPTA 62.5/25 MCG60 blisters per prescriptionANZEMET 100 MG TABLET3 tablet per prescriptionANZEMET 50 MG TABLET3 tablet per prescriptionAPLENZIN ER 174 MG TABLET30 tablets per prescriptionAPLENZIN ER 348 MG TABLET30 tablets per prescriptionAPLENZIN ER 522 MG TABLET30 tablets per prescriptionARAVA 10 MG TABLET30 tablets per prescriptionARAVA 20 MG TABLET30 tablets per prescriptionARCAPTA NEOHALER 75 MCG CAP1 package (30 capsules) per prescriptionARNUITY ELLIPTA 100 MCG INHALER1 inhaler (30 blisters OR 14 blisters institutional pack) per presciptionARNUITY ELLIPTA 200 MCG INHALER1 inhaler (30 blisters OR 14 blisters institutional pack) per presciptionASMANEX HFA 100 MCG INHALER13 g (1 inhaler) per prescriptionASMANEX HFA 200 MCG INHALER13 g (1 inhaler) per prescriptionASMANEX TWISTHALER 110 MCG #301 inhaler per prescriptionASMANEX TWISTHALER 110 MCG #71 inhaler per prescriptionASMANEX TWISTHALER 220 MCG #141 inhaler per prescriptionASMANEX TWISTHALER 220 MCG #301 inhaler per prescriptionASMANEX TWISTHALER 220 MCG #601 inhaler per prescriptionASMANEX TWISTHALR 220 MCG #1201 inhaler per prescriptionASTELIN 137 MCG NASAL SPRAY2 bottles per prescriptionsATELVIA 35 MG TABLET4 tablets per 28 daysATROVENT 0.03% SPRAY1 bottle per prescriptionATROVENT 0.06% SPRAY2 bottles per prescriptionsATROVENT HFA INHALER2 inhalers per prescriptionsATROVENT INHALER2 inhalers per prescriptionsAUVI-Q 0.15 MG2 units (1 carton) per prescriptionAUVI-Q 0.3 MG2 units (1 carton) per prescriptionData Class: Confidential
AVANDAMET 2 MG/500 MG TABLET60 tablets per prescriptionAVANDAMET 2 MG-1,000 MG TAB60 tablets per prescriptionAVANDAMET 4 MG/500 MG TABLET60 tablets per prescriptionAVANDAMET 4 MG-1,000 MG TABLET60 tablets per prescriptionAVANDARYL 4 MG-1 MG TABLET30 tablets per prescriptionAVANDARYL 4 MG-2 MG TABLET30 tablets per prescriptionAVANDARYL 4 MG-4 MG TABLET30 tablets per prescriptionAVANDARYL 8 MG-2 MG TABLET30 tablets per prescriptionAVANDARYL 8 MG-4 MG TABLET30 tablets per prescriptionAVANDIA 2 MG TABLET60 tablets per prescriptionAVANDIA 4 MG TABLET60 tablets per prescriptionAVANDIA 8 MG TABLET30 tablets per prescriptionAVINZA 120 MG CAPSULE60 capsules per 30 daysAVINZA 30 MG CAPSULE60 capsules per 30 daysAVINZA 45 MG CAPSULE60 capsules per 30 daysAVINZA 60 MG CAPSULE60 capsules per 30 daysAVINZA 75 MG CAPSULE60 capsules per 30 daysAVINZA 90 MG CAPSULE60 capsules per 30 daysAVONEX ADMIN PACK 30 MCG VL4 vials per 28 daysAVONEX PEN 30 MCG/0.5 ML1 box (4 pens) per 28 daysAVONEX PREFILLED SYR 30 MCG4 syringes per 28 daysAXERT 12.5 MG TABLET12 tablets per prescriptionAXERT 6.25 MG TABLET6 tablets per prescriptionBECONASE AQ 0.042% SPRAY2 inhalers per prescriptionsBELBUCA 150 MCG FILM60 films per presciptionBELBUCA 300 MCG FILM60 films per presciptionBELBUCA 450 MCG FILM60 films per presciptionBELBUCA 600 MCG FILM60 films per presciptionBELBUCA 75 MCG FILM60 films per presciptionBELBUCA 750 MCG FILM60 films per presciptionBELBUCA 900 MCG FILM60 films per presciptionBELSOMRA 10 MG TABLET30 tablets per prescriptionBELSOMRA 15 MG TABLET30 tablets per prescriptionBELSOMRA 20 MG TABLET30 tablets per prescriptionBELSOMRA 5 MG TABLET30 tablets per prescriptionBETASERON 0.3 MG KIT14 vials per 30 daysBETHKIS 300 MG/4 ML AMPULE56 ampules per prescriptionBEVESPI AEROSPHERE1 canister (120 inhalations per canister) per prescriptionBINOSTO 70 MG TABLET EFF4 tablets per 28 daysBONIVA 150 MG TABLET1 tablet per 30 daysBOSULIF 100 MG TABLET120 tablets per prescriptionBOSULIF 500 MG TABLET30 tablets per prescriptionBREO ELLIPTA 100MCG/25MCG #2828 blisters (1 inhaler) per prescriptionBREO ELLIPTA 100MCG/25MCG #6060 blisters per prescriptionBREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 281 inhaler (28 blisters)BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 601 inhaler (60 blisters)BRISDELLE 7.5 MG CAPSULE30 capsules per prescriptionBROVANA 15 MCG/2 ML SOLUTION2 cartons (60 vials) per prescriptionBUDEPRION SR 100 MG TABLET60 tablets per prescriptionBUDEPRION SR 150 MG TABLET60 tablets per prescriptionBUDEPRION XL 300 MG TABLET30 tablets per prescriptionBUNAVAIL 2.1 MG/0.3 MG FILM30 films per presciptionBUNAVAIL 4.2 MG/0.7 MG FILM60 films per presciptionBUNAVAIL 6.3 MG/1 MG FILM60 films per presciptionBUTORPHANOL NASAL SPRAY 10 MG/ML2 bottle per prescriptionBYDUREON 2 MG PEN4 Pens (1 package) per prescriptionBYDUREON 2 MG VIAL1 carton (4 single-dose trays) per prescriptionBYETTA 10 MCG DOSE PEN INJ1 syringe per prescriptionBYETTA 5 MCG DOSE PEN INJ1 syringe per prescriptionCABOMETYX 20 MG TABLET30 tablets per prescriptionCADUET 10 MG-10 MG TABLET30 tablets per prescriptionCADUET 10 MG-20 MG TABLET30 tablets per prescriptionCADUET 10 MG-40 MG TABLET30 tablets per prescriptionData Class: Confidential
CADUET 10 MG-80 MG TABLET30 tablets per prescriptionCADUET 2.5 MG-10 MG TABLET30 tablets per prescriptionCADUET 2.5 MG-20 MG TABLET30 tablets per prescriptionCADUET 2.5 MG-40 MG TABLET30 tablets per prescriptionCADUET 5 MG-10 MG TABLET30 tablets per prescriptionCADUET 5 MG-20 MG TABLET30 tablets per prescriptionCADUET 5 MG-40 MG TABLET30 tablets per prescriptionCADUET 5 MG-80 MG TABLET30 tablets per prescriptionCAMBIA 50 MG POWDER PACKET9 packets per prescriptionCARDURA 1 MG TABLET30 tablets per prescriptionCARDURA 2 MG TABLET30 tablets per prescriptionCARDURA 4 MG TABLET30 tablets per prescriptionCARDURA 8 MG TABLET60 tablets per prescriptionCARDURA XL 4 MG TABLET30 tablets per prescriptionCARDURA XL 8 MG TABLET30 tablets per prescriptionCATAPRES-TTS 1 PATCH4 patches per 28 daysCATAPRES-TTS 2 PATCH4 patches per 28 daysCATAPRES-TTS 3 PATCH4 patches per 28 daysCAVERJECT 10 MCG KIT12 units per prescriptionCAVERJECT 20 MCG KIT12 units per prescriptionCAVERJECT 20 MCG VIAL12 units per prescriptionCAVERJECT 40 MCG VIAL12 units per prescriptionCAVERJECT 40 MCG/2 ML AMPUL12 units per prescriptionCAYSTON 75 MG INHAL SOLUTION1 kit (84 vials of aztreonam and 88 vials of dliuent) per prescriptionCELEXA 10 MG TABLET30 tablets per prescriptionCELEXA 20 MG TABLET30 tablets per prescriptionCELEXA 40 MG TABLET30 tablets per prescriptionCESAMET 1 MG PULVULE30 capsules per prescriptionCHILDREN'S QNASAL 40 MCG (4.9 G)5 grams (1 bottle) per prescriptionCHILD'S CLARITIN 5 MG TAB CHEW30 tablets per prescriptionCHLD ALLEGRA ALLERGY 30 MG ODT60 tablets per prescriptionCHOLBAM 50 MG CAPSULE120 capsules per prescriptionCHORIONIC GONAD 10000U VIAL3 vials per prescriptionCIALIS 10 MG TABLET6 tablets per prescriptionCIALIS 2.5 MG TABLET30 tablets per prescriptionCIALIS 20 MG TABLET6 tablets per prescriptionCIALIS 5 MG TABLET6 tablets per prescriptionCLARINEX 2.5 MG REDITABS30 tablets per prescriptionCLARINEX 5 MG REDITABS30 tablets per prescriptionCLARINEX-D 12 HOUR TABLET60 tablets per prescriptionCLARINEX-D 24 HOUR TABLET30 tablets per prescriptionCLARITIN 10 MG LIQUI-GEL CAP30 tablets per prescriptionCLARITIN 10 MG REDITABS30 tablets per prescriptionCLARITIN 10 MG TABLET30 tablets per prescriptionCLARITIN-D 12 HOUR TABLET60 tablets per prescriptionCLARITIN-D 24 HOUR TAB ER30 tablets per prescriptionCLIMARA 0.025 MG/DAY PATCH4 patches per 28 daysCLIMARA 0.0375 MG/DAY PATCH4 patches per 28 daysCLIMARA 0.05 MG/DAY PATCH4 patches per 28 daysCLIMARA 0.06/MG DAY PATCH4 patches per 28 daysCLIMARA 0.075 MG/DAY PATCH4 patches per 28 daysCLIMARA 0.1 MG/DAY PATCH4 patches per 28 daysCLIMARA PRO PATCH4 patches per 28 daysCLOBETASOL EMOLLIENT CREAM120 grams per 28 daysCLOBETASOL FOAM, SOLUTION, EMOLLIENT FOAM100 grams per 28 daysCLOBETASOL LOTION118 grams per 28 daysCLOBETASOL OINTMENT, CREAM AND GEL120 grams per 28 daysCLOBETASOL SHAMPOO236 grams per 28 daysCLOBETASOL SPRAY125 grams per 28 daysCOMBIVENT INHALER2 inhaler per prescriptionCOMBIVENT RESPIMAT INHAL SPRAY2 inhaler per prescriptionCONZIP ER 100 MG CAPSULE30 tablets per prescriptionCONZIP ER 200 MG CAPSULE30 tablets per prescriptionData Class: Confidential
CONZIP ER 300 MG CAPSULE30 tablets per prescriptionCOPAXONE 20 MG1 kit (30 prefilled syringes) per 30 daysCOPAXONE 40 MG/ML SYRINGE12 syringes per 30 daysCOTELLIC 20 MG TABLET63 tablets per prescriptionCRESTOR 10 MG TABLET30 tablets per prescriptionCRESTOR 20 MG TABLET30 tablets per prescriptionCRESTOR 40 MG TABLET30 tablets per prescriptionCRESTOR 5 MG TABLET30 tablets per prescriptionCYMBALTA 20 MG CAPSULE60 capsules per prescriptionCYMBALTA 30 MG CAPSULE30 capsules per prescriptionCYMBALTA 60 MG CAPSULE60 capsules per prescriptionDAKLINZA 30 MG TABLET84 tablets per 365 daysDAKLINZA 60 MG TABLET84 tablets per 365 daysDAKLINZA 90 MG TABLET84 tablets per 365 daysDEPO-PROVERA 150 MG/ML SYRINGE1 vial/syringe per 30 daysDEPO-SUBQ PROVERA 104 SYRINGE1 syringe per 30 daysDESVENLAFAXINE ER 100 MG TABLET30 tablets per prescriptionDESVENLAFAXINE ER 50 MG TABLET30 tablets per prescriptionDEXILANT DR 30 MG CAPSULE30 capsules per prescriptionDEXILANT DR 60 MG CAPSULE30 capsules per prescriptionDIFLUCAN 150 MG TABLET2 tablets per prescriptionDIVIGEL 0.25 MG GEL PACKET30 packets per prescriptionDIVIGEL 0.5 MG GEL PACKET30 packets per prescriptionDIVIGEL 1 MG GEL PACKET30 packets per prescriptionDOSTINEX 0.5 MG TABLET8 tablets per 28 daysDUETACT 30-2 MG TABLET30 tablets per prescriptionDUETACT 30-4 MG TABLET30 tablets per prescriptionDULERA 100 MCG/5 MCG INHALER1 inhaler per prescriptionDULERA 200 MCG/5 MCG INHALER1 inhaler per prescriptionDULERA 200 MCG/5 MCG INHALER1 inhaler per prescriptionDUONEB 0.5 MG-3 MG/3 ML SOLN180 vials (package size 3) per prescriptionDYMISTA NASAL SPRAY1 bottle per prescriptionEDEX 10 MCG KIT12 cartridges per prescriptionEDEX 20 MCG CARTRIDGE 2-PK KIT12 cartridges per prescriptionEDEX 20 MCG CARTRIDGE 6-PK KIT12 cartridges per prescriptionEDEX 40 MCG CARTRIDGE 2-PK KIT12 cartridges per prescriptionEDEX 40 MCG CARTRIDGE 6-PK KIT12 cartridges per prescriptionEDLUAR 10 MG SL TABLET30 tablets per prescriptionEDLUAR 5 MG SL TABLET30 tablets per prescriptionEFFEXOR 100 MG TABLET90 tablets per prescriptionEFFEXOR 25 MG TABLET90 tablets per prescriptionEFFEXOR 37.5 MG TABLET90 tablets per prescriptionEFFEXOR 50 MG TABLET90 tablets per prescriptionEFFEXOR 75 MG TABLET90 tablets per prescriptionEFFEXOR XR 150 MG CAPSULE30 tablets per prescriptionEFFEXOR XR 37.5 MG CAPSULE30 tablets per prescriptionEFFEXOR XR 75 MG CAPSULE90 tablets per prescriptionELESTRIN 0.06% GEL52 grams (2 pumps) per prescriptionELIDEL CREAM 1%100 grams per 30 daysELLA 30 MG TABLET1 tablet (1 dose) per prescriptionEMBEDA 100-4 MG CAPSULE90 capsules per 30 daysEMBEDA 20-0.8 MG CAPSULE90 capsules per 30 daysEMBEDA 30-1.2 MG CAPSULE90 capsules per 30 daysEMBEDA 50-2 MG CAPSULE90 capsules per 30 daysEMBEDA 60-2.4 MG CAPSULE90 capsules per 30 daysEMBEDA 80-3.2 MG CAPSULE90 capsules per 30 daysEMEND 125 MG CAPSULE1 capsule per prescriptionEMEND 125 MG ORAL SUSPENSION3 packets per prescriptionEMEND 150 MG VIAL1 vial per prescriptionEMEND 40 MG CAPSULE1 capsule per prescriptionEMEND 80 MG CAPSULE2 capsules per prescriptionEMEND TRIFOLD PACK1 pack per prescriptionENBREL 25 MG/0.5 ML SYRINGE8 vials/syringes per 28 daysData Class: Confidential
ENBREL 50 MG/0.5 ML SYRINGE4 vials/syringes per 28 daysENTRESTO 24 MG/26 MG TABLET60 tablets per prescriptionENTRESTO 49 MG/51 MG TABLET60 tablets per prescriptionENTRESTO 97 MG/103 MG TABLET60 tablets per prescriptionEPCLUSA84 tablets per 365 daysEPINEPHRINE 0.15 MG AUTO-INJCT (TWO PACK)2 units (1 carton) per prescriptionEPINEPHRINE 0.3 MG AUTO-INJECT (TWO PACK)2 units (1 carton) per prescriptionEPIPEN 0.3 MG AUTO-INJECTOR3 units (package size 1), 2 units (package size 2) per prescriptionEPIPEN JR 0.15 MG AUTO-INJCT3 units (package size 1), 2 units (package size 2) per prescriptionERIVEDGE 150 MG CAPSULE30 capsules per prescriptionESBRIET 267 MG CAPSULE: 14-DAY TITRATION BLISTER PACK1 pack (63 capsules) per prescriptionESBRIET 267 MG CAPSULEESBRIET 267 MG CAPSULE: 4-WEEK MAINTENANCE BLISTERPACKESOMEPRAZOLE STRONTIUM 24.65 MG CAPSULE270 capsules per prescriptionESTRADERM 0.05 MG PATCH8 patches per 28 daysESTRADERM 0.1 MG PATCH8 patches per 28 daysESTRASORB PACKET56 packets (97.44 g) per prescriptionESTROGEL 0.06% GEL1 pump bottle per prescriptionEVAMIST 1.53 MG/SPRAY2 pumps per prescriptionEVZIO 0.4 MG AUTOINJECTOR1 package (2 devices plus 1 trainer) per prescriptionEVZIO 2MG/0.4 ML AUTOINJECTOR1 kit (2 auto-injectors) per prescriptionEXALGO ER 12 MG TABLET60 tablets per 30 daysEXALGO ER 16 MG TABLET60 tablets per 30 daysEXALGO ER 32 MG TABLET60 tablets per 30 daysEXALGO ER 8 MG TABLET60 tablets per 30 daysEXTAVIA 0.3 MG KIT15 blister units/vials per 30 daysEXTAVIA 0.3MG VIAL14 or 15 vials with prefilled diluent syringe per 30 daysFAMVIR 125 MG TABLET21 tablets per prescriptionFAMVIR 250 MG TABLET60 tablets per prescriptionFAMVIR 500 MG TABLET21 tablets per prescriptionFANAPT 1 MG TABLET60 tablets per prescriptionFANAPT 10 MG TABLET60 tablets per prescriptionFANAPT 12 MG TABLET60 tablets per prescriptionFANAPT 2 MG TABLET60 tablets per prescriptionFANAPT 4 MG TABLET60 tablets per prescriptionFANAPT 6 MG TABLET60 tablets per prescriptionFANAPT 8 MG TABLET60 tablets per prescriptionFANAPT TITRATION PACK1 pack (8 tablets) per prescriptionFARXIGA 10 MG TABLET30 tablets per prescriptionFARXIGA 5 MG TABLET30 tablets per prescriptionFARYDAK 10 MG CAPSULE6 capsules per prescriptionFARYDAK 15 MG CAPSULE6 capsules per prescriptionFARYDAK 20 MG CAPSULE6 capsules per prescriptionFENTORA 100 MCG BUCCAL TABLET90 units per 30 daysFENTORA 200 MCG BUCCAL TABLET90 units per 30 daysFENTORA 300 MCG BUCCAL TABLET90 units per 30 daysFENTORA 400 MCG BUCCAL TABLET90 units per 30 daysFENTORA 600 MCG BUCCAL TABLET90 units per 30 daysFENTORA 800 MCG BUCCAL TABLET90 units per 30 daysFLECTOR 1.3% PATCH60 patches per prescriptionFLONASE 0.05% NASAL SPRAY1 bottle per prescriptionFLONASE ALLERGY RELIEF 50 MCG SRAY PACKAGE SIZE 15.81 unit per prescriptionFLONASE ALLERGY RELIEF 50 MCG SRAY PACKAGE SIZE 9.91 unit per prescriptionFLOVENT 100 MCG DISKUS1 inhaler per prescriptionFLOVENT 250 MCG DISKUS4 inhalers per prescriptionsFLOVENT 50 MCG ROTADISK1 inhaler per prescriptionFLOVENT HFA 110 MCG INHALER1 inhaler per prescriptionFLOVENT HFA 220 MCG INHALER2 inhalers per prescriptionsFLOVENT HFA 44 MCG INHALER1 inhaler per prescriptionFLUNISOLIDE 0.025% SPRAY2 inhalers/bottles per prescriptionsData Class: Confidential1 carton (252 capsules) per prescription30 capsules per prescription
FLUOCINONIDE OINTMENT, GEL, SOLUTION, OR CREAMEMULSIFIED120 grams per 30 daysFLUOXETINE 10 MG CAPSULE30 capsules, tablets per prescriptionFLUOXETINE HCL 40 MG CAPSULE60 capsules per prescriptionFLUVOXAMINE 100 MG TABLET90 capsules per prescriptionFLUVOXAMINE 25 MG TABLET30 capsules per prescriptionFLUVOXAMINE 50 MG TABLET60 capsules per prescriptionFORADIL AEROLIZER 12 MCG CAP1 package (package size 12) 12 capsules per prescriptionFORADIL AEROLIZER 12 MCG CAP1 package (package size 60) 60 capusules per prescriptionFORTEO 600 MCG/2.4 ML PEN INJ1 pen per 28 daysFORTIVO XL 450 MG TABLET30 tablets per prescriptionFOSAMAX 10 MG TABLET30 tablets per prescriptionFOSAMAX 35 MG TABLET4 tablets per 28 daysFOSAMAX 40 MG TABLET30 tablets per prescriptionFOSAMAX 5 MG TABLET30 tablets per prescriptionFOSAMAX 70 MG TABLET4 tablets per 28 daysFOSAMAX 70 MG/75 ML SOLUTION4 bottles per 28 daysFOSAMAX PLUS D 70 MG-2,800 IU4 tablets per 28 daysFOSAMAX PLUS D 70 MG-5,600 IU4 tablets per 28 daysFROVA 2.5 MG TABLET9 tablets per prescriptionGELNIQUE 10% GEL SACHETS30 sachets (1 carton) per prescriptionGELNIQUE 3% GEL1 pump per prescriptionGEODON 20 MG CAPSULE60 capsules per prescriptionGEODON 40 MG CAPSULE60 capsules per prescriptionGEODON 60 MG CAPSULE60 capsules per prescriptionGEODON 80 MG CAPSULE60 capsules per prescriptionGILOTRIF 20 MG TABLET30 tablets per prescriptionGILOTRIF 30 MG TABLET30 tablets per prescriptionGILOTRIF 40 MG TABLET30 tablets per prescriptionGLEEVEC 100 MG TABLET180 tablets per prescriptionGLEEVEC 400 MG TABLET60 capsules per prescriptionGLYXAMBI 10 MG/5 MG TABLET30 tablets per prescriptionGLYXAMBI 25 MG/5 MG TABLET30 tablets per prescriptionGRANISOL 2 MG/10 ML SOLUTION1 bottle per prescriptionHARVONI 400 MG/90 MG TABLET56 tablets per 365 daysHUMIRA 10 MG/0.2 ML SYRINGE2 syringes per 28 daysHUMIRA 20 MG/0.4 ML SYRINGE2 syringes per 28 daysHUMIRA 40 MG/0.8 ML PEN2 pen per 28 daysHUMIRA 40 MG/0.8 ML SYRINGE2 syringes per 28 daysHUMIRA CROHN'S STARTER PACK2 syringes per 28 daysHUMIRA PSORIASIS STARTER PACK2 syringes per 28 daysHYSINGLA ER 100 mg tablet60 tablets per 30 daysHYSINGLA ER 120 mg tablet60 tablets per 30 daysHYSINGLA ER 20 mg tablet60 tablets per 30 daysHYSINGLA ER 30 mg tablet60 tablets per 30 daysHYSINGLA ER 40 mg tablet60 tablets per 30 daysHYSINGLA ER 60 mg tablet60 tablets per 30 daysHYSINGLA ER 80 mg tablet60 tablets per 30 daysHYTRIN 1 MG CAPSULE30 capsules per prescriptionHYTRIN 10 MG CAPSULE60 capsules per prescriptionHYTRIN 2 MG CAPSULE30 capsules per prescriptionHYTRIN 5 MG CAPSULE30 capsules per prescriptionIBRANCE 100 MG CAPSULE21 capsules per prescriptionIBRANCE 125 MG CAPSULE21 capsules per prescriptionIBRANCE 75 MG CAPSULE21 capsules per prescriptionICLUSIG 15 MG60 tablets per prescriptionICLUSIG 45 MG30 tablets per prescriptionIMITREX 100 MG TABLET9 tablets per prescriptionIMITREX 20 MG NASAL SPRAY6 devices per prescriptionIMITREX 25 MG TABLET9 tablets per prescriptionIMITREX 4 MG/0.5 ML CARTRIDGES2 vials per prescriptionIMITREX 4 MG/0.5 ML PEN INJECT1 kit per prescriptionIMITREX 5 MG NASAL SPRAY6 devices per prescriptionData Class: Confidential
IMITREX 50 MG TABLET9 tablets per prescriptionIMITREX 6 MG/0.5 ML CARTRIDGE2 vials per prescriptionIMITREX 6 MG/0.5 ML PEN INJECT1 kit per prescriptionIMITREX 6 MG/0.5 ML SYRNG KIT1 kit per prescriptionIMITREX 6 MG/0.5 ML VIAL2 vials per prescriptionINCRUSE ELLIPTA 62.5 MCG INHALER1 inhaler (30 blisters OR 7 blisters institutional pack) per prescriptionINLYTA 1 MG TABLET180 tablets per prescriptionINLYTA 5 MG TABLET120 tablets per prescriptionINTERMEZZO 1.75 MG TAB SUBLING30 tablets per prescriptionINTERMEZZO 3.5 MG TAB SUBLING30 tablets per prescriptionINVEGA ER 1.5 MG TABLET30 tablets per prescriptionINVEGA ER 3 MG TABLET30 tablets per prescriptionINVEGA ER 6 MG TABLET60 tablets per prescriptionINVEGA ER 9 MG TABLET30 tablets per prescriptionINVOKAMET 150 MG/1000 MG TABLETINVOKAMET 150 MG/500 MG TABLETINVOKAMET 50 MG/1000 MG TABLETINVOKAMET 50 MG/500 MG TABLET60 tablets per prescriptionINVOKANA 100 MG TABLET30 tablets per prescriptionINVOKANA 300 MG TABLET30 tablets per prescriptionIRENKA (DULOXETINE) 40 MG CAPSULE30 capsules per prescriptionIRESSA 250 MG TABLET30 tablets per prescriptionJAKAFI 10 MG TABLET60 tablets per prescriptionJAKAFI 15 MG TABLET60 tablets per prescriptionJAKAFI 20 MG TABLET60 tablets per prescriptionJAKAFI 25 MG TABLET60 tablets per prescriptionJAKAFI 5 MG TABLET60 tablets per prescriptionJANUMET 50-1,000 MG TABLET60 tablets per prescriptionJANUMET 50-500 MG TABLET30 tablets per prescriptionJANUMET XR 100-1,000 MG TABLET30 tablets per prescriptionJANUMET XR 50-1,000 MG TABLET60 tablets per prescriptionJANUMET XR 50-500 MG TABLET30 tablets per prescriptionJANUVIA 100 MG TABLET30 tablets per prescriptionJANUVIA 25 MG TABLET30 tablets per prescriptionJANUVIA 50 MG TABLET30 tablets per prescriptionJARDIANCE 10 MG TABLET30 tablets per prescriptionJARDIANCE 25 MG TABLET30 tablets per prescriptionJENTADUETO 2.5 MG-1000 MG TAB60 tablets per prescriptionJENTADUETO 2.5 MG-500 MG TAB60 tablets per prescriptionJENTADUETO 2.5 MG-850 MG TAB60 tablets per prescriptionJENTADUETO XR 2.5 MG TABLET60 tablets per prescriptionJENTADUETO XR 5 MG TABLET30 tablets per prescriptionJUVISYNC 100-10 MG TABLET30 tablets per prescriptionJUVISYNC 100-20 MG TABLET30 tablets per prescriptionJUVISYNC 100-40 MG TABLET30 tablets per prescriptionJUVISYNC 50-10 MG TABLET30 tablets per prescriptionJUVISYNC 50-20 MG TABLET30 tablets per prescriptionJUVISYNC 50-40 MG TABLET30 tablets per prescriptionKADIAN ER 10 MG CAPSULE90 capsules per 30 daysKADIAN ER 100 MG CAPSULE90 capsules per 30 daysKADIAN ER 130 MG CAPSULE90 capsules per 30 daysKADIAN ER 150 MG CAPSULE90 capsules per 30 daysKADIAN ER 20 MG CAPSULE90 capsules per 30 daysKADIAN ER 200 MG CAPSULE90 capsules per 30 daysKADIAN ER 30 MG CAPSULE90 capsules per 30 daysKADIAN ER 40 MG CAPSULE90 capsules per 30 daysKADIAN ER 50 MG CAPSULE90 capsules per 30 daysKADIAN ER 60 MG CAPSULE90 capsules per 30 daysKADIAN ER 70 MG CAPSULE90 capsules per 30 daysKADIAN ER 80 MG CAPSULE90 capsules per 30 daysKALYDECO 150 MG TABLET60 tablets per prescriptionKALYDECO 50 MG GRANULES PACKET56 packets (1 package) per prescriptionKALYDECO 75 MG GRANULES PACKET56 packets (1 package) per prescriptionData Class: Confidential60 tablets per prescription60 tablets per prescription60 tablets per prescription
KAZANO 12.5-1,000 MG TABLET60 tablets per prescriptionKAZANO 12.5-500 MG TABLET60 tablets per prescriptionKHEDEZLA 100 MG TABLET30 tablets per prescriptionKHEDEZLA 50 MG TABLET30 tablets per prescriptionKITABIS PACK 300 MG/5 ML SOLUTION280 mL (1 package) per prescriptionKOMBIGLYZE XR 2.5-1,000 MG TAB60 tablets per prescriptionKOMBIGLYZE XR 5-1,000 MG TAB30 tablets per prescriptionKOMBIGLYZE XR 5-500 MG TABLET30 tablets per prescriptionKYTRIL 1 MG TABLET6 tablets per prescriptionKYTRIL 2 MG/10 ML SOLUTION1 bottle (30 mL) per prescriptionLATUDA 120 MG TABLET30 tablets per prescriptionLATUDA 20 MG TABLET30 tablets per prescriptionLATUDA 40 MG TABLET30 tablets per prescriptionLATUDA 60 MG TABLET30 tablets per prescriptionLATUDA 80 MG TABLET60 tablets per prescriptionLAZANDA 100 MCG NASAL SPRAY23 units (1 unit 1 bottle with 8 sprays) per 30 daysLAZANDA 400 MCG NASAL SPRAY23 units (1 unit 1 bottle with 8 sprays) per 30 daysLESCOL 20 MG CAPSULE30 capsules per prescriptionLESCOL 40 MG CAPSULE60 capsules per prescriptionLESCOL XL 80 MG TABLET30 tablets per prescriptionLEVITRA 10 MG TABLET6 tablets per prescriptionLEVITRA 2.5 MG TABLET6 tablets per prescriptionLEVITRA 20 MG TABLET6 tablets per prescriptionLEVITRA 5 MG TABLET6 tablets per prescriptionLEVONORGESTREL 0.75 MG TABLET2 tablets per prescriptionLEVONORGESTREL 1.5 MG TABLET (various brands and generics– for example, AFTERA, ECONTRA EZ, FALLBACK SOLO, MYWAY, NEXT CHOICE ONE DOSE, OPCICON ONE-STEP, OPTION2, PLAN B ONE-STEP, REACT, TAKE ACTION)1 tablet per prescriptionLEXAPRO 10 MG TABLET30 tablets per prescriptionLEXAPRO 20 MG TABLET30 tablets per prescriptionLEXAPRO 5 MG TABLET30 tablets per prescriptionLiDOCAINE 2.5%/PRILOCAINE 2.5% CREAM30 grams per 30 daysLIDOCAINE JELLY 2%60 mL per 30 daysLIDOCAINE OINTMENTOne tube, 35.44 or 50 grams per 30 daysLIPITOR 10 MG TABLET30 tablets per prescriptionLIPITOR 20 MG TABLET30 tablets per prescriptionLIPITOR 40 MG TABLET30 tablets per prescriptionLIPITOR 80 MG TABLET30 tablets per prescriptionLIPTRUZET 10 MG TABLET30 tablets per prescriptionLIPTRUZET 20 MG TABLET30 tablets per prescriptionLIPTRUZET 40 MG TABLET30 tablets per prescriptionLIPTRUZET 80 MG TABLET30 tablets per prescriptionLIVALO 1 MG TABLET30 tablets per prescriptionLIVALO 2 MG TABLET30 tablets per prescriptionLIVALO 4 MG TABLET30 tablets per prescriptionLUNESTA 1 MG TABLET30 tablets per prescriptionLUNESTA 2 MG TABLET30 tablets per prescriptionLUNESTA 3 MG TABLET30 tablets per prescriptionLUVOX CR 100 MG CAPSULE60 tablets per prescriptionLUVOX CR 150 MG CAPSULE60 tablets per prescriptionMAXAIR AUTOHALER 0.2 MG AERO1 inhaler per prescriptionMAXALT 10 MG TABLET18 tablets per prescriptionMAXALT 5 MG TABLET18 tablets per prescriptionMAXALT MLT 10 MG TABLET18 tablets per prescriptionMAXALT MLT 5 MG TABLET18 tablets per prescriptionMEKINIST 0.5 MG TABLET90 tablets per prescriptionMEKINIST 2MG TABLET30 tablets per prescriptionMENOSTAR 14 MCG/DAY PATCH4 patches per 28 daysMEVACOR 10MG TABLET30 tablets per prescriptionMEVACOR 20 MG TABLET60 tablets per prescriptionMEVACOR 40 MG TABLET60 tablets per prescriptionMIGRANAL 4 MG/ML NASAL SPRAY8 spray devices 1 kit per prescriptionData Class: Confidential
MINIVELLE 0.0375 MG PATCH8 patches per 28 daysMINIVELLE 0.05 MG PATCH8 patches per 28 daysMINIVELLE 0.075 MG PATCH8 patches per 28 daysMINIVELLE 0.1 MG PATCH8 patches per 28 daysMOBIC 7.5 MG TABLETMS CONTIN 100 MG TABLETORAMORPH SR 100 MG TABLETMS CONTIN 15 MG TABLETORAMORPH SR 15 MG TABLETMS CONTIN 200 MG TABLETMS CONTIN 30 MG TABLET SAORAMORPH SR 30 MG TABLETMS CONTIN 60 MG TABLETORAMORPH SR 60 MG TABLETMUSE 1,000 MCG URETHRAL SUPP30 tablets per prescriptionMUSE 125 MCG URETHRAL SUPPOS12 urethral suppositories per prescriptionMUSE 250 MCG URETHRAL SUPPOS12 urethral suppositories per prescriptionMUSE 500 MCG URETHRAL SUPPOS12 urethral suppositories per prescriptionNARCAN 4 MG/0.1 NASAL SPRAY1 pack (2 devices) per prescriptionNASACORT AQ NASAL SPRAY1 bottle per prescriptionNASONEX 50 MCG NASAL SPRAY1 bottle per prescriptionNEBUPENT 300 MG INHAL POWDER
BUNAVAIL 2.1 MG/0.3 MG FILM 30 films per presciption BUNAVAIL 4.2 MG/0.7 MG FILM 60 films per presciption BUNAVAIL 6.3 MG/1 MG FILM 60 films per presciption BUTORPHANOL NASAL SPRAY 10 MG/ML 2 bottle per prescription BYDUREON 2 MG PEN 4 Pens (1 package) per prescription BYDUREON 2 MG VIAL 1 carton (4 single-dose trays) per prescription
