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To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA’s guidelines and other medical information, our plan developed this program 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 also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity.

Drug Target Maximum Quantity ABSTRAL 100 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 200 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 300 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 400 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 600 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 800 MCG TAB SUBLINGUAL 90 units per 30 days ACTIQ 1,200 MCG LOZENGE 90 units per 30 days ACTIQ 1,600 MCG LOZENGE 90 units per 30 days ACTIQ 200 MCG LOZENGE 90 units per 30 days ACTIQ 400 MCG LOZENGE 90 units per 30 days ACTIQ 600 MCG LOZENGE 90 units per 30 days ACTIQ 800 MCG LOZENGE 90 units per 30 days ACTONEL 150 MG TABLET 1 tablet per 30 days ACTONEL 30 MG TABLET 30 tablets per prescription ACTONEL 35 MG TABLET 4 tablets per 28 days ACTONEL 5 MG TABLET 30 tablets per prescription ACTONEL 75 MG TABLET 2 tablet per 30 days ACTONEL WITH CALCIUM TABLETS 1 (28 day) Blister Package per prescription ACTOPLUS MET 15 MG-500 MG TAB 90 tablets per prescription ACTOPLUS MET 15 MG-850 MG TAB 90 tablets per prescription ACTOPLUS MET XR 15-1,000 MG TB 60 tablets per prescription ACTOPLUS MET XR 30-1,000 MG TB 30 tablets per prescription ACTOS 15 MG TABLET 30 tablets per prescription ACTOS 30 MG TABLET 30 tablets per prescription ACTOS 45 MG TABLET 30 tablets per prescription ADCIRCA 20 MG TABLET 60 tablets per prescription ADVAIR 100-50 DISKUS 1 device (60 blisters) per prescription ADVAIR 250-50 DISKUS 1 device (60 blisters) per prescription ADVAIR 500-50 DISKUS 1 device (60 blisters) per prescription ADVAIR HFA (120) 115-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (120) 230-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (120) 45-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (60) 115-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (60) 230-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (60) 45-21 MCG INHALER 1 inhaler per prescription ADVICOR 1,000 MG-20 MG TABLET 60 tablets per prescription ADVICOR 500 MG-20 MG TABLET 30 tablets per prescription ADVICOR 750 MG-20 MG TABLET 60 tablets per prescription AEROBID/AEROBID-M 3 inhalers per prescription AEROSPAN 80 MCG INHALER 18 g (2 inhalers, 8.9 g each) per prescription AKYNZEO 300/0.5MG CAPSULE 1 capsule per chemotherapy course ALLEGRA ALLERGY 12 HR 60 MG 60 tablets per prescription ALLEGRA ALLERGY 24 HR 180 MG 30 tablets per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. ALLEGRA CHILDREN'S ALLERGY 30 MG TABLET 60 tablets per prescription ALLEGRA-D 12 HOUR ALLERGY & CONGESTION 60 tablets per prescription ALLEGRA-D 24 HOUR ALLERGY & CONGESTION 30 tablets per prescription ALORA 0.025 MG PATCH 8 patches per 28 days ALORA 0.05 MG PATCH 8 patches per 28 days ALORA 0.075 MG PATCH 8 patches per 28 days ALORA 0.1 MG PATCH 8 patches per 28 days ALOXI 0.25 MG/5 ML VIAL 1 vial per prescription ALSUMA 6 MG/0.5 ML AUTO-INJECT 1 kit/2 syringes per prescription ALTOPREV 20 MG TABLET 30 tablets per prescription ALTOPREV 40 MG TABLET 30 tablets per prescription ALTOPREV 60 MG TABLET 30 tablets per prescription ALVESCO 160 MCG INHALER 2 inhalers per prescription ALVESCO 80 MCG INHALER 1 inhaler per prescription AMBIEN 10 MG TABLET 30 tablets per prescription AMBIEN 5 MG TABLET 30 tablets per prescription AMBIEN CR 12.5 MG TABLET 30 tablets per prescription AMBIEN CR 6.25 MG TABLET 30 tablets per prescription AMERGE 1 MG TABLET 9 tablets per prescription AMERGE 2.5 MG TABLET 9 tablets per prescription ANORO ELLIPTA 62.5/25 MCG 14 blisters (institutional pack) per prescription ANORO ELLIPTA 62.5/25 MCG 60 blisters per prescription ANZEMET 100 MG TABLET 3 tablet per prescription ANZEMET 50 MG TABLET 3 tablet per prescription ARAVA 10 MG TABLET 30 tablets per prescription ARAVA 20 MG TABLET 30 tablets per prescription ARCAPTA NEOHALER 75 MCG CAP 1 package (30 capsules) per prescription ARNUITY ELLIPTA 100 MCG INHALER 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption ARNUITY ELLIPTA 200 MCG INHALER 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption ASMANEX HFA 100 MCG INHALER 13 g (1 inhaler) per prescription ASMANEX HFA 200 MCG INHALER 13 g (1 inhaler) per prescription ASMANEX TWISTHALER 110 MCG #30 1 inhaler per prescription ASMANEX TWISTHALER 110 MCG #7 1 inhaler per prescription ASMANEX TWISTHALER 220 MCG #14 1 inhaler per prescription ASMANEX TWISTHALER 220 MCG #30 1 inhaler per prescription ASMANEX TWISTHALER 220 MCG #60 1 inhaler per prescription ASMANEX TWISTHALR 220 MCG #120 1 inhaler per prescription ASTELIN 137 MCG NASAL SPRAY 2 bottles per prescription ATELVIA 35 MG TABLET 4 tablets per 28 days ATROVENT 0.03% SPRAY 1 bottle per prescription ATROVENT 0.06% SPRAY 2 bottles per prescription ATROVENT HFA INHALER 2 inhalers per prescription ATROVENT INHALER 2 inhalers per prescription AVANDAMET 2 MG/500 MG TABLET 60 tablets per prescription AVANDAMET 2 MG-1,000 MG TAB 60 tablets per prescription AVANDAMET 4 MG/500 MG TABLET 60 tablets per prescription AVANDAMET 4 MG-1,000 MG TABLET 60 tablets per prescription AVANDARYL 4 MG-1 MG TABLET 30 tablets per prescription AVANDARYL 4 MG-2 MG TABLET 30 tablets per prescription AVANDARYL 4 MG-4 MG TABLET 30 tablets per prescription AVANDARYL 8 MG-2 MG TABLET 30 tablets per prescription AVANDARYL 8 MG-4 MG TABLET 30 tablets per prescription AVANDIA 2 MG TABLET 60 tablets per prescription AVANDIA 4 MG TABLET 60 tablets per prescription AVANDIA 8 MG TABLET 30 tablets per prescription AVINZA 120 MG CAPSULE 60 capsules per 30 days AVINZA 30 MG CAPSULE 60 capsules per 30 days AVINZA 45 MG CAPSULE 60 capsules per 30 days AVINZA 60 MG CAPSULE 60 capsules per 30 days AVINZA 75 MG CAPSULE 60 capsules per 30 days AVINZA 90 MG CAPSULE 60 capsules per 30 days

List is subject to change. Inclusion on this list does not guarantee coverage. AVONEX ADMIN PACK 30 MCG VL 4 vials per 28 days AVONEX PEN 30 MCG/0.5 ML 1 box (4 pens) per 28 days AVONEX PREFILLED SYR 30 MCG 4 syringes per 28 days AXERT 12.5 MG TABLET 12 tablets per prescription AXERT 6.25 MG TABLET 6 tablets per prescription BECONASE AQ 0.042% SPRAY 2 inhalers per prescription BELBUCA 150 MCG FILM 60 films per presciption BELBUCA 300 MCG FILM 60 films per presciption BELBUCA 450 MCG FILM 60 films per presciption BELBUCA 600 MCG FILM 60 films per presciption BELBUCA 75 MCG FILM 60 films per presciption BELBUCA 750 MCG FILM 60 films per presciption BELBUCA 900 MCG FILM 60 films per presciption BELSOMRA 10 MG TABLET 30 tablets per prescription BELSOMRA 15 MG TABLET 30 tablets per prescription BELSOMRA 20 MG TABLET 30 tablets per prescription BELSOMRA 5 MG TABLET 30 tablets per prescription BETASERON 0.3 MG KIT 14 vials per 30 days BETHKIS 300 MG/4 ML AMPULE 56 ampules per prescription BINOSTO 70 MG TABLET EFF 4 tablets per 28 days BONIVA 150 MG TABLET 1 tablet per 30 days BREO ELLIPTA 100MCG/25MCG #28 28 blisters (1 inhaler) per prescription BREO ELLIPTA 100MCG/25MCG #60 60 blisters per prescription BREO ELLIPTA 200 MCG/25 MCG, PKG SIZE 28 1 inhaler (28 blisters) BREO ELLIPTA 200 MCG/25 MCG, PKG SIZE 60 1 inhaler (60 blisters) BROVANA 15 MCG/2 ML SOLUTION 2 cartons (60 vials) per prescription 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 bottles per prescription BYDUREON 2 MG PEN 4 Pens (1 package) per prescription BYDUREON 2 MG VIAL 1 carton (4 single-dose trays) per prescription BYETTA 10 MCG DOSE PEN INJ 1 syringe per prescription BYETTA 5 MCG DOSE PEN INJ 1 syringe per prescription CADUET 10 MG-10 MG TABLET 30 tablets per prescription CADUET 10 MG-20 MG TABLET 30 tablets per prescription CADUET 10 MG-40 MG TABLET 30 tablets per prescription CADUET 10 MG-80 MG TABLET 30 tablets per prescription CADUET 2.5 MG-10 MG TABLET 30 tablets per prescription CADUET 2.5 MG-20 MG TABLET 30 tablets per prescription CADUET 2.5 MG-40 MG TABLET 30 tablets per prescription CADUET 5 MG-10 MG TABLET 30 tablets per prescription CADUET 5 MG-20 MG TABLET 30 tablets per prescription CADUET 5 MG-40 MG TABLET 30 tablets per prescription CADUET 5 MG-80 MG TABLET 30 tablets per prescription CAMBIA 50 MG POWDER PACKET 9 packets per prescription CARDURA 1 MG TABLET 30 tablets per prescription CARDURA 2 MG TABLET 30 tablets per prescription CARDURA 4 MG TABLET 30 tablets per prescription CARDURA 8 MG TABLET 60 tablets per prescription CARDURA XL 4 MG TABLET 30 tablets per prescription CARDURA XL 8 MG TABLET 30 tablets per prescription CATAPRES-TTS 1 PATCH 4 patches per 28 days CATAPRES-TTS 2 PATCH 4 patches per 28 days CATAPRES-TTS 3 PATCH 4 patches per 28 days CAYSTON 75 MG INHAL SOLUTION 1 kit (84 vials of aztreonam and 88 vials of dliuent) per prescription CESAMET 1 MG PULVULE 30 capsules per prescription CHILDREN'S QNASAL 40 MCG (4.9 G) 5 grams (1 bottle) per prescription CHILD'S CLARITIN 5 MG TAB CHEW 30 tablets per prescription CHLD ALLEGRA ALLERGY 30 MG ODT 60 tablets per prescription CHOLBAM 50 MG CAPSULE 120 capsules per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. CHORIONIC GONAD 10000U VIAL 3 vials per prescription CLARINEX 2.5 MG REDITABS 30 tablets per prescription CLARINEX 5 MG REDITABS 30 tablets per prescription CLARINEX-D 12 HOUR TABLET 60 tablets per prescription CLARINEX-D 24 HOUR TABLET 30 tablets per prescription CLARITIN 10 MG LIQUI-GEL CAP 30 tablets per prescription CLARITIN 10 MG REDITABS 30 tablets per prescription CLARITIN 10 MG TABLET 30 tablets per prescription CLARITIN-D 12 HOUR TABLET 60 tablets per prescription CLARITIN-D 24 HOUR TAB ER 30 tablets per prescription CLIMARA 0.025 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.0375 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.05 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.06/MG DAY PATCH 4 patches per 28 days CLIMARA 0.075 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.1 MG/DAY PATCH 4 patches per 28 days CLIMARA PRO PATCH 4 patches per 28 days COMBIVENT INHALER 2 inhalers per prescription COMBIVENT RESPIMAT INHAL SPRAY 2 inhalers per prescription CONZIP ER 100 MG CAPSULE 30 tablets per prescription CONZIP ER 200 MG CAPSULE 30 tablets per prescription CONZIP ER 300 MG CAPSULE 30 tablets per prescription COPAXONE 20 MG 1 kit (30 prefilled syringes) per 30 days COPAXONE 40 MG/ML SYRINGE 12 syringes per 30 days CRESTOR 10 MG TABLET 30 tablets per prescription CRESTOR 20 MG TABLET 30 tablets per prescription CRESTOR 40 MG TABLET 30 tablets per prescription CRESTOR 5 MG TABLET 30 tablets per prescription DAKLINZA 30 MG TABLET 84 tablets per 365 days DAKLINZA 60 MG TABLET 84 tablets per 365 days DEPO-PROVERA 150 MG/ML SYRINGE 1 vial/Syringe per 30 days DEPO-SUBQ PROVERA 104 SYRINGE 1 syringe per 30 days DEXILANT DR 30 MG CAPSULE 30 capsules per prescription DEXILANT DR 60 MG CAPSULE 30 capsules per prescription DIFLUCAN 150 MG TABLET 2 tablets per prescription DIVIGEL 0.25 MG GEL PACKET 30 packets per prescription DIVIGEL 0.5 MG GEL PACKET 30 packets per prescription DIVIGEL 1 MG GEL PACKET 30 packets per prescription DOSTINEX 0.5 MG TABLET 8 tablets per 28 days DUETACT 30-2 MG TABLET 30 tablets per prescription DUETACT 30-4 MG TABLET 30 tablets per prescription DULERA 100 MCG/5 MCG INHALER 1 inhaler per prescription DULERA 200 MCG/5 MCG INHALER 1 inhaler per prescription DULERA 200 MCG/5 MCG INHALER 1 inhaler per prescription DUONEB 0.5 MG-3 MG/3 ML SOLN 180 vials (package size 3) per prescription DYMISTA NASAL SPRAY 1 bottle per prescription EDLUAR 10 MG SL TABLET 30 tablets per prescription EDLUAR 5 MG SL TABLET 30 tablets per prescription ELESTRIN 0.06% GEL 52 grams (2 pumps) per prescription ELLA 30 MG TABLET 1 tablet (1 dose) per prescription EMBEDA 100-4 MG CAPSULE 90 capsules per 30 days EMBEDA 20-0.8 MG CAPSULE 90 capsules per 30 days EMBEDA 30-1.2 MG CAPSULE 90 capsules per 30 days EMBEDA 50-2 MG CAPSULE 90 capsules per 30 days EMBEDA 60-2.4 MG CAPSULE 90 capsules per 30 days EMBEDA 80-3.2 MG CAPSULE 90 capsules per 30 days EMEND 115 MG VIAL 1 vial per prescription EMEND 125 MG CAPSULE 1 capsule per prescription EMEND 150 MG VIAL 1 vial per prescription EMEND 40 MG CAPSULE 1 capsule per prescription EMEND 80 MG CAPSULE 2 capsules per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. EMEND TRIFOLD PACK 1 pack per prescription ENBREL 25 MG/0.5 ML SYRINGE 8 vials/syringes per 28 days ENBREL 50 MG/0.5 ML SYRINGE 4 vials/syringes per 28 days EPINEPHRINE 0.15 MG AUTO-INJCT (TWO PACK) 2 units (1 carton) per prescription EPINEPHRINE 0.3 MG AUTO-INJECT (TWO PACK) 2 units (1 carton) per prescription EPIPEN 0.3 MG AUTO-INJECTOR 3 units (package size 1), 2 units (package size 2) per prescription EPIPEN JR 0.15 MG AUTO-INJCT 3 units(package size 1), 2 units (package size 2) per prescription ESBRIET 267 MG CAP: 14-DAY TITRATION PACK 1 pack (63 capsules) per prescription ESBRIET 267 MG CAPSULE 270 capsules per prescription ESBRIET 267 MG CAP: 4-WEEK PACK 1 carton (252 capsules) per prescription ESOMEPRAZOLE STRONTIUM 24.65 MG CAPSULE 30 capsules per prescription ESTRADERM 0.05 MG PATCH 8 patches per 28 days ESTRADERM 0.1 MG PATCH 8 patches per 28 days ESTRASORB PACKET 56 packets (97.44 g) per prescription ESTROGEL 0.06% GEL 1 pump bottle per prescription EVAMIST 1.53 MG/SPRAY 2 pumps per prescription EVZIO 0.4 MG AUTOINJECTOR 1 package (2 devices plus 1 trainer) per prescription EXALGO ER 12 MG TABLET 60 tablets per 30 days EXALGO ER 16 MG TABLET 60 tablets per 30 days EXALGO ER 32 MG TABLET 60 tablets per 30 days EXALGO ER 8 MG TABLET 60 tablets per 30 days EXTAVIA 0.3 MG KIT 15 blister units/vials per 30 days EXTAVIA 0.3MG VIAL 14 or 15 vials with prefilled diluent syringe per 30 days FAMVIR 125 MG TABLET 21 tablets per prescription FAMVIR 250 MG TABLET 60 tablets per prescription FAMVIR 500 MG TABLET 21 tablets per prescription FARXIGA 10 MG TABLET 30 tablets per prescription FARXIGA 5 MG TABLET 30 tablets per prescription FENTORA 100 MCG BUCCAL TABLET 90 units per 30 days FENTORA 200 MCG BUCCAL TABLET 90 units per 30 days FENTORA 300 MCG BUCCAL TABLET 90 units per 30 days FENTORA 400 MCG BUCCAL TABLET 90 units per 30 days FENTORA 600 MCG BUCCAL TABLET 90 units per 30 days FENTORA 800 MCG BUCCAL TABLET 90 units per 30 days FLECTOR 1.3% PATCH 60 patches per prescription FLONASE 0.05% NASAL SPRAY 1 bottle per prescription FLONASE 50 MCG SRAY PACKAGE SIZE 15.8 1 unit per prescription FLONASE 50 MCG SRAY PACKAGE SIZE 9.9 1 unit per prescription FLOVENT 100 MCG DISKUS 1 inhaler per prescription FLOVENT 250 MCG DISKUS 4 inhalers per prescription FLOVENT 50 MCG ROTADISK 1 inhaler per prescription FLOVENT HFA 110 MCG INHALER 1 inhaler per prescription FLOVENT HFA 220 MCG INHALER 2 inhalers per prescription FLOVENT HFA 44 MCG INHALER 1 inhaler per prescription FLUNISOLIDE 0.025% SPRAY 2 inhalers/bottles per prescription FORADIL AEROLIZER 12 MCG CAP 1 package (package size 12) (12 capsules) per prescription FORADIL AEROLIZER 12 MCG CAP 1 package (package size 60) (60 capsules) per prescription FORTEO 600 MCG/2.4 ML PEN INJ 1 pen per 28 days FOSAMAX 10 MG TABLET 30 tablets per prescription FOSAMAX 35 MG TABLET 4 tablets per 28 days FOSAMAX 40 MG TABLET 30 tablets per prescription FOSAMAX 5 MG TABLET 30 tablets per prescription FOSAMAX 70 MG TABLET 4 tablets per 28 days FOSAMAX 70 MG/75 ML SOLUTION 4 bottles per 28 days FOSAMAX PLUS D 70 MG-2,800 IU 4 tablets per 28 days FOSAMAX PLUS D 70 MG-5,600 IU 4 tablets per 28 days FROVA 2.5 MG TABLET 9 tablets per prescription GELNIQUE 10% GEL SACHETS 30 sachets (1 carton) per prescription GELNIQUE 3% GEL 1 pump per prescription GLYXAMBI 10 MG/5 MG TABLET 30 tablets per prescription GLYXAMBI 25 MG/5 MG TABLET 30 tablets per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. GRANISOL 2 MG/10 ML SOLUTION 1 bottle per prescription HARVONI 400 MG/90 MG TABLET 56 tablets per 365 days HUMIRA 10 MG/0.2 ML SYRINGE 2 syringes per 28 days HUMIRA 20 MG/0.4 ML SYRINGE 2 syringes per 30 days HUMIRA 40 MG/0.8 ML PEN 2 pen per 28 days HUMIRA 40 MG/0.8 ML SYRINGE 2 syringes per 28 days HUMIRA CROHN'S STARTER PACK 2 syringes per 28 days HUMIRA PSORIASIS STARTER PACK 2 syringes per 28 days HYSINGLA ER 100 mg tablet 60 tablets per 30 days HYSINGLA ER 120 mg tablet 60 tablets per 30 days HYSINGLA ER 20 mg tablet 60 tablets per 30 days HYSINGLA ER 30 mg tablet 60 tablets per 30 days HYSINGLA ER 40 mg tablet 60 tablets per 30 days HYSINGLA ER 60 mg tablet 60 tablets per 30 days HYSINGLA ER 80 mg tablet 60 tablets per 30 days HYTRIN 1 MG CAPSULE 30 capsules per prescription HYTRIN 10 MG CAPSULE 60 capsules per prescription HYTRIN 2 MG CAPSULE 30 capsules per prescription HYTRIN 5 MG CAPSULE 30 capsules per prescription IMITREX 100 MG TABLET 9 tablets per prescription IMITREX 20 MG NASAL SPRAY 6 devices per prescription IMITREX 25 MG TABLET 9 tablets per prescription IMITREX 4 MG/0.5 ML CARTRIDGES 2 vials per prescription IMITREX 4 MG/0.5 ML PEN INJECT 1 kit per prescription IMITREX 5 MG NASAL SPRAY 6 devices per prescription IMITREX 50 MG TABLET 9 tablets per prescription IMITREX 6 MG/0.5 ML CARTRIDGE 2 vials per prescription IMITREX 6 MG/0.5 ML PEN INJECT 1 kit per prescription IMITREX 6 MG/0.5 ML SYRNG KIT 1 kit per prescription IMITREX 6 MG/0.5 ML VIAL 2 vials per prescription INCRUSE ELLIPTA 62.5 MCG INHALER 1 inhaler (30 blisters OR 7 blisters institutional pack) per prescription INTERMEZZO 1.75 MG TAB SUBLING 30 tablets per prescription INTERMEZZO 3.5 MG TAB SUBLING 30 tablets per prescription INVOKAMET 150 MG/1000 MG TABLET 60 tablets per prescription INVOKAMET 150 MG/500 MG TABLET 60 tablets per prescription INVOKAMET 50 MG/1000 MG TABLET 60 tablets per prescription INVOKAMET 50 MG/500 MG TABLET 60 tablets per prescription INVOKANA 100 MG TABLET 30 tablets per prescription INVOKANA 300 MG TABLET 30 tablets per prescription JANUMET 50-1,000 MG TABLET 60 tablets per prescription JANUMET 50-500 MG TABLET 60 tablets per prescription JANUMET XR 100-1,000 MG TABLET 30 tablets per prescription JANUMET XR 50-1,000 MG TABLET 60 tablets per prescription JANUMET XR 50-500 MG TABLET 60 tablets per prescription JANUVIA 100 MG TABLET 30 tablets per prescription JANUVIA 25 MG TABLET 30 tablets per prescription JANUVIA 50 MG TABLET 30 tablets per prescription JARDIANCE 10 MG TABLET 30 tablets per prescription JARDIANCE 25 MG TABLET 30 tablets per prescription JENTADUETO 2.5 MG-1000 MG TAB 60 tablets per prescription JENTADUETO 2.5 MG-500 MG TAB 60 tablets per prescription JENTADUETO 2.5 MG-850 MG TAB 60 tablets per prescription JUVISYNC 100-10 MG TABLET 30 tablets per prescription JUVISYNC 100-20 MG TABLET 30 tablets per prescription JUVISYNC 100-40 MG TABLET 30 tablets per prescription JUVISYNC 50-10 MG TABLET 30 tablets per prescription JUVISYNC 50-20 MG TABLET 30 tablets per prescription JUVISYNC 50-40 MG TABLET 30 tablets per prescription KADIAN ER 10 MG CAPSULE 90 capsules per 30 days KADIAN ER 100 MG CAPSULE 90 capsules per 30 days KADIAN ER 130 MG CAPSULE 90 capsules per 30 days

List is subject to change. Inclusion on this list does not guarantee coverage. KADIAN ER 150 MG CAPSULE 90 capsules per 30 days KADIAN ER 20 MG CAPSULE 90 capsules per 30 days KADIAN ER 200 MG CAPSULE 90 capsules per 30 days KADIAN ER 30 MG CAPSULE 90 capsules per 30 days KADIAN ER 40 MG CAPSULE 90 capsules per 30 days KADIAN ER 50 MG CAPSULE 90 capsules per 30 days KADIAN ER 60 MG CAPSULE 90 capsules per 30 days KADIAN ER 70 MG CAPSULE 90 capsules per 30 days KADIAN ER 80 MG CAPSULE 90 capsules per 30 days KALYDECO 150 MG TABLET 60 tablets per prescription KALYDECO 50 MG GRANULES PACKET 56 packets (1 package) per prescription KALYDECO 75 MG GRANULES PACKET 56 packets (1 package) per prescription KAZANO 12.5-1,000 MG TABLET 60 tablets per prescription KAZANO 12.5-500 MG TABLET 60 tablets per prescription KITABIS PACK 300 MG/5 ML SOLUTION 280 mL (1 package) per prescription KOMBIGLYZE XR 2.5-1,000 MG TAB 60 tablets per prescription KOMBIGLYZE XR 5-1,000 MG TAB 30 tablets per prescription KOMBIGLYZE XR 5-500 MG TABLET 30 tablets per prescription KYTRIL 1 MG TABLET 6 tablets per prescription KYTRIL 2 MG/10 ML SOLUTION 1 bottle (30 mL) per prescription LAZANDA 100 MCG NASAL SPRAY 23 units (1 unit = 1 bottle with 8 sprays) per 30 days LAZANDA 400 MCG NASAL SPRAY 23 units (1 unit = 1 bottle with 8 sprays) per 30 days LESCOL 20 MG CAPSULE 30 capsules per prescription LESCOL 40 MG CAPSULE 60 capsules per prescription LESCOL XL 80 MG TABLET 30 tablets per prescription LIPITOR 10 MG TABLET 30 tablets per prescription LIPITOR 20 MG TABLET 30 tablets per prescription LIPITOR 40 MG TABLET 30 tablets per prescription LIPITOR 80 MG TABLET 30 tablets per prescription LIPTRUZET 10 MG TABLET 30 tablets per prescription LIPTRUZET 20 MG TABLET 30 tablets per prescription LIPTRUZET 40 MG TABLET 30 tablets per prescription LIPTRUZET 80 MG TABLET 30 tablets per prescription LIVALO 1 MG TABLET 30 tablets per prescription LIVALO 2 MG TABLET 30 tablets per prescription LIVALO 4 MG TABLET 30 tablets per prescription LUNESTA 1 MG TABLET 30 tablets per prescription LUNESTA 2 MG TABLET 30 tablets per prescription LUNESTA 3 MG TABLET 30 tablets per prescription MAXAIR AUTOHALER 0.2 MG AERO 1 inhaler per prescription MAXALT 10 MG TABLET 18 tablets per prescription MAXALT 5 MG TABLET 18 tablets per prescription MAXALT MLT 10 MG TABLET 18 tablets per prescription MAXALT MLT 5 MG TABLET 18 tablets per prescription MENOSTAR 14 MCG/DAY PATCH 4 patches per 28 days MEVACOR 10MG TABLET 30 tablets per prescription MEVACOR 20 MG TABLET 60 tablets per prescription MEVACOR 40 MG TABLET 60 tablets per prescription MIGRANAL 4 MG/ML NASAL SPRAY 8 spray devices = 1 kit per prescription MINIVELLE 0.0375 MG PATCH 8 patches per 28 days MINIVELLE 0.05 MG PATCH 8 patches per 28 days MINIVELLE 0.075 MG PATCH 8 patches per 28 days MINIVELLE 0.1 MG PATCH 8 patches per 28 days MOBIC 7.5 MG TABLET 30 tablets per prescription MS CONTIN 100 MG / ORAMORPH SR 100 MG 120 tablets per 30 days MS CONTIN 15 MG / ORAMORPH SR 15 MG 120 tablets per 30 days MS CONTIN 200 MG TABLET 120 tablets per 30 days MS CONTIN 30 MG / ORAMORPH SR 30 MG 120 tablets per 30 days MS CONTIN 60 MG / ORAMORPH SR 60 MG 120 tablets per 30 days NASACORT AQ NASAL SPRAY 55 MCG 1 bottle per prescription NASONEX 50 MCG NASAL SPRAY 1 bottle per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. NEBUPENT 300 MG INHAL POWDER 1 container (inhaler) per 28 days NESINA 12.5 MG TABLET 30 tablets per prescription NESINA 25 MG TABLET 30 tablets per prescription NESINA 6.25 MG TABLET 30 tablets per prescription NEULASTA 6 MG/0.6 ML SYRINGE 2 syringes per 30 days NEXIUM 2.5 MG PACKET 30 packets per prescription NEXIUM 20 MG CAPSULE 30 capsules per prescription NEXIUM 5 MG PACKET 30 packets per prescription NEXIUM DR 10 MG PACKET 30 packets per prescription NEXIUM DR 20 MG PACKET 30 packets per prescription NOVAREL 10,000 UNITS VIAL 3 vials per prescription NUCALA 100 MG VIAL 1 vial per 28 days NUCYNTA 100 MG TABLET 181 tablets per prescription NUCYNTA 50 MG TABLET 181 tablets per prescription NUCYNTA 75 MG TABLET 181 tablets per prescription NUCYNTA ER 100 MG TABLET 60 tablets per 30 days NUCYNTA ER 150 MG TABLET 60 tablets per 30 days NUCYNTA ER 200 MG TABLET 60 tablets per 30 days NUCYNTA ER 250 MG TABLET 60 tablets per 30 days NUCYNTA ER 50 MG TABLET 60 tablets per 30 days OFEV 100 MG CAPSULE 60 capsules per prescription OFEV 150 MG CAPSULE 60 capsules per prescription OLYSIO 150 MG CAPSULE 84 tablets per 365 days OMECLAMOX-PAK COMBO PACK 80 caps/tabs (10 cards) = 1 combo pack per prescription OMNARIS 50 MCG NASAL SPRAY 1 bottle per prescription ONGLYZA 2.5 MG TABLET 30 tablets per prescription ONGLYZA 5 MG TABLET 30 tablets per prescription ONMEL 200 MG TABLET 15 tablets per prescription ONSOLIS 1,200 MCG SOLUBLE FILM 90 films per 30 days ONSOLIS 200 MCG SOLUBLE FILM 90 films per 30 days ONSOLIS 400 MCG SOLUBLE FILM 90 films per 30 days ONSOLIS 600 MCG SOLUBLE FILM 90 films per 30 days ONSOLIS 800 MCG SOLUBLE FILM 90 films per 30 days OPANA ER 10 MG TABLET 90 tablets per 30 days OPANA ER 15 MG TABLET 90 tablets per 30 days OPANA ER 20 MG TABLET 90 tablets per 30 days OPANA ER 30 MG TABLET 90 tablets per 30 days OPANA ER 40 MG TABLET 90 tablets per 30 days OPANA ER 5 MG TABLET 90 tablets per 30 days OPANA ER 7.5 MG TABLET 90 tablets per 30 days ORAMORPH SR 100 MG 120 tablets per 30 days ORAMORPH SR 15 MG 120 tablets per 30 days ORAMORPH SR 30 MG 120 tablets per 30 days ORAMORPH SR 60 MG 120 tablets per 30 days ORKAMBI 200 MCG/125 MG 112 tablets (1 package) OSENI 12.5-15 MG TABLET 30 tablets per prescription OSENI 12.5-30 MG TABLET 30 tablets per prescription OSENI 12.5-45 MG TABLET 30 tablets per prescription OSENI 25-15 MG TABLET 30 tablets per prescription OSENI 25-30 MG TABLET 30 tablets per prescription OSENI 25-45 MG TABLET 30 tablets per prescription OXYCONTIN 10 MG TABLET 90 tablets per 30 days OXYCONTIN 15 MG TABLET 90 tablets per 30 days OXYCONTIN 20 MG TABLET 90 tablets per 30 days OXYCONTIN 30 MG TABLET 90 tablets per 30 days OXYCONTIN 40 MG TABLET 90 tablets per 30 days OXYCONTIN 60 MG TABLET 90 tablets per 30 days OXYCONTIN 80 MG TABLET 90 tablets per 30 days OXYTROL 3.9 MG/24HR PATCH 8 patches per 28 days PATANASE 0.6% NASAL SPRAY 1 bottle per prescription PEGASYS 180 MCG/0.5 ML SYRINGE 1 box per 28 days

List is subject to change. Inclusion on this list does not guarantee coverage. PEGASYS 180 MCG/0.5 ML SYRINGE 1 box per 28 days PEGASYS 180 MCG/ML VIAL 4 vials per 28 days PEGASYS PROCLICK 135 MCG/0.5 1 box per 28 days PEGASYS PROCLICK 180 MCG/0.5 1 box per 28 days PEGINTRON Redipen 150 MCG 4 pens per 28 days PEGINTRON 120 MCG KIT 4 vials per 28 days PEGINTRON 150 MCG KIT 4 vials per 28 days PEGINTRON 50 MCG KIT 4 vials per 28 days PEGINTRON 80 MCG KIT 4 vials per 28 days PEGINTRON Redipen 120 MCG 4 pens per 28 days PEGINTRON Redipen 50 MCG 4 pens per 28 days PEGINTRON Redipen 80 MCG 4 pens per 28 days PERFOROMIST 20 MCG/2 ML SOLN 1 carton (60 vials) per prescription PLAN B 0.75 MG TABLET 2 tablets per prescription PLAN B ONE-STEP 1.5 MG TABLET 1 tablet per prescription PLEGRIDY 125 MCG/0.5 ML 2 units (Pen and Syringe) per 28 days PLEGRIDY 63 MCG AND 94 MCG SINGLE DOSE 1 starter pack (Pen and Syringe) per 365 days PRANDIMET 1 MG-500 MG TABLET 150 tablets per prescription PRANDIMET 2 MG-500 MG TABLET 150 tablets per prescription PRAVACHOL 10 MG TABLET 30 tablets per prescription PRAVACHOL 20 MG TABLET 30 tablets per prescription PRAVACHOL 40 MG TABLET 30 tablets per prescription PRAVACHOL 80 MG TABLET 30 tablets per prescription Pregnyl 10,000 units vial 3 vials per prescription PREVACID 15 MG CAPSULE DR 30 capsules per prescription PREVACID 15 MG SOLUTAB 30 solutabs per prescription PREVPAC PATIENT PAC 112 caps/tabs (14 cards) = 1 pack per prescription PRILOSEC 10 MG CAPSULE DR 30 capsules per prescription PRILOSEC 20 MG CAPSULE DR 30 capsules per prescription PRILOSEC DR 10 MG SUSPENSION 30 packets per prescription PRILOSEC DR 2.5 MG SUSPENSION 60 packets per prescription PROAIR HFA 90 MCG INHALER 2 inhalers per prescription PROAIR RESPICLICK 90 MCG INHALER 2 inhalers per prescription PROTONIX DR 20 MG TABLET 30 tablets per prescription PROVENTIL HFA 90 MCG INHALER 2 inhalers per prescription PULMICORT 0.25 MG/2 ML RESPUL 60 respules per prescription PULMICORT 0.5 MG/2 ML RESPULE 60 respules per prescription PULMICORT 1 MG/2 ML RESPULE 30 respules per prescription PULMICORT 180 MCG FLEXHALER 2 inhalers per prescription PULMICORT 90 MCG FLEXHALER 1 inhaler per prescription QNASL 80MCG NASAL SPRAY 1 bottle per prescription QVAR 40 MCG INHALER 2 inhalers per prescription QVAR 80 MCG INHALER 3 inhalers per prescription Rebetron Combination RebetronTherapy Pak 2 packages per 28 days REBIF 22 MCG/0.5 ML SYRINGE 12 syringes per 28 days REBIF 44 MCG/0.5 ML SYRINGE 12 syringes per 28 days REBIF TITRATION PACK 1 package per 28 days REGRANEX 0.01% GEL 1 tube per prescription RELENZA 5 MG DISKHALER 20 blisters (1 carton) per prescription RELPAX 20 MG TABLET 6 tablets per prescription RELPAX 40 MG TABLET 6 tablets per prescription RESTASIS 0.05% EYE EMULSION 60 vials per prescription REVATIO 10 MG/ML ORAL SUSPENSION 1 (112 ml) bottle per prescription REVATIO 20 MG TABLET 90 tablets per prescription RHINOCORT AQUA NASAL SPRAY 2 bottles per prescription ROZEREM 8 MG TABLET 30 tablets per prescription RYBIX ODT 50 MG TABLET 240 tablets per prescription RYZOLT ER 100 MG TABLET 30 tablets per prescription RYZOLT ER 200 MG TABLET 30 tablets per prescription RYZOLT ER 300 MG TABLET 30 tablets per prescription SAMSCA 15 MG TABLET 30 tablets per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. SAMSCA 30 MG TABLET 60 tablets per prescription SANCUSO 3.1 MG/24 HR PATCH 1 patch per prescription SEEBRI NEOHALER 15.6 MCG INH POWDER 60 inhalations (1 package) per prescription SEREVENT DISKUS 50 MCG (28 BLISTERS) 1 package per prescription SEREVENT DISKUS 50 MCG (60 BLISTERS) 1 package per prescription SILENOR 3 MG TABLET 30 tablets per prescription SILENOR 6 MG TABLET 30 tablets per prescription SIMCOR 1,000-20 MG TABLET 60 tablets per prescription SIMCOR 1,000-40 MG TABLET 30 tablets per prescription SIMCOR 500-20 MG TABLET 30 tablets per prescription SIMCOR 500-40 MG TABLET 30 tablets per prescription SIMCOR 750-20 MG TABLET 60 tablets per prescription SONATA 10 MG CAPSULE 60 tablets per prescription SONATA 5 MG CAPSULE 30 tablets per prescription SOVALDI 400 MG TABLET 84 tablets per 365 days SPIRIVA 18 MCG CP-HANDIHALER 1 package (30 doses) per prescription SPIRIVA 28 INHALATIONS PACK AND 60 INHALATIONS 1PACK inhaler (4 g) per prescription SPIRIVA RESPIMAT 1.25 MCG INHALATION SPRAY 4 g = 1 inhaler (60 inhalations) SPORANOX 100 MG CAPSULE 30 capsules per prescription SPRIX 15.75 MG NASAL SPRAY 5 bottles per prescription STIOLTO RESPIMAT 2.5/2.5 MCG INH SPRAY 1 inhaler = 4 g (60 inhalations OR 28 inhalations institutional pack) STRIVERDI RESPIMAT 28 INHALATIONS PACK, 60 INHALATIONS1 inhaler (60 PACK inhalations OR 28 inhalations institutional pack) per prescription SUBOXONE 12 MG-3 MG SL FILM 60 tablets/films per prescription SUBOXONE 2 MG-0.5 MG SL FILM 90 tablets/films per prescription SUBOXONE 2 MG-0.5 MG TABLET SL 90 tablets/films per prescription SUBOXONE 4 MG-1 MG SL FILM 90 tablets/films per prescription SUBOXONE 8 MG-2 MG SL FILM 90 tablets/films per prescription SUBOXONE 8 MG-2 MG TABLET SL 90 tablets/films per prescription SUBSYS 1,200 MCG SPRAY 90 single spray units per 30 days SUBSYS 1,600 MCG SPRAY 90 single spray units per 30 days SUBSYS 100 MCG SPRAY 90 single spray units per 30 days SUBSYS 200 MCG SPRAY 90 single spray units per 30 days SUBSYS 400 MCG SPRAY 90 single spray units per 30 days SUBSYS 600 MCG SPRAY 90 single spray units per 30 days SUBSYS 800 MCG SPRAY 90 single spray units per 30 days SUMAVEL DOSEPRO 4 MG/0.5 ML 3 mL (1 box) per prescription SUMAVEL DOSEPRO 4 MG/0.5 ML 9 mL (3 boxes) per 28 days SUMAVEL DOSEPRO 6 MG/0.5 ML 6 units per prescription SYMBICORT 160-4.5 MCG INHALER 1 package per prescription SYMBICORT 80-4.5 MCG INHALER 1 package per prescription SYMLINPEN 120 PEN INJECTOR 7 pens per prescription SYMLINPEN 60 PEN INJECTOR 7 pens per prescription SYNJARDY 12.5 MG/1000 MG TABLET 60 tablets per prescription SYNJARDY 12.5 MG/500 MG TABLET 60 tablets per prescription SYNJARDY 5 MG/1000 MG TABLET 60 tablets per prescription SYNJARDY 5 MG/500 MG TABLET 60 tablets per prescription TAMIFLU 12 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 30 MG GELCAP 20 capsules per prescription TAMIFLU 45 MG GELCAP 10 capsules per prescription TAMIFLU 6 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 75 MG GELCAP 10 capsules per prescription TECHNIVIE DOSE PACK 3 cartons (168 tablets) per 365 days TIVORBEX 20 MG CAPSULE 90 capsules per prescription TOBI 300 MG/5 ML SOLUTION 56 ampoules per prescription TOBI PODHALER 28 MG INHALE CAP 224 capsules per prescription TORADOL 10 MG TABLET 20 tablets per prescription TRADJENTA 5 MG TABLET 30 tablets per prescription TRAMADOL HCL 50 MG TABLET 240 tablets per prescription TRAMADOL HCL ER 150 MG CAPSULE 60 capsules per prescription TREXIMET 85-500 MG TABLET 9 tablets per prescription TRULICITY 0.75 MG/0.5 ML 4 units (Pen OR Syringe) per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. TRULICITY 1.5 MG/0.5 ML 4 units (Pen OR Syringe) per prescription TUDORZA PRESSAIR 400 MCG INH 1 inhaler per prescription ULTRACET 37.5 MG-325 MG TABLET 240 tablets per prescription ULTRAM 50 MG TABLET 240 tablets per prescription ULTRAM ER 100 MG TABLET 30 tablets per prescription ULTRAM ER 200 MG TABLET 30 tablets per prescription ULTRAM ER 300 MG TABLET 30 tablets per prescription UTIBRON NEOHALER 27.5/15.6 INH (PKG SIZE 6) 6 inhalations (1 package) per prescription UTIBRON NEOHALER 27.5/15.6 INH (PKG SZ 60) 60 inhalations (1 package) per prescription VALTREX 1 GM CAPLET 30 caplets (tablets) per prescription VALTREX 500 MG CAPLET 30 caplets (tablets) per prescription VARUBI 90 MG TABLET 2 tablets (1 package) per prescription VENTOLIN HFA 90 MCG INHALER 2 inhalers per prescription VENTOLIN HFA 90 MCG INHALER 1 inhaler per prescription VERAMYST 27.5 MCG NASAL SPRAY 1 bottle per prescription VICTOZA 2-PAK 18 MG/3 ML PEN 1 package (2 pens) per prescription VICTOZA 3-PAK 18 MG/3 ML PEN 1 package (3 pens) per prescription VIEKIRA PAK 3 paks (336 tablets) per 365 days VIVELLE-DOT 0.025 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.0375 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.05 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.075 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.1 MG PATCH 8 patches per 28 days VIVLODEX 5 MG CAPSULE 30 capsules per prescription VYTORIN 10-10 MG TABLET 30 tablets per prescription VYTORIN 10-20 MG TABLET 30 tablets per prescription VYTORIN 10-40 MG TABLET 30 tablets per prescription VYTORIN 10-80 MG TABLET 30 tablets per prescription XIFAXAN 200 MG TABLET 9 tablets XIFAXAN 550 MG TABLET 60 tablets XIGDUO ER 10 MG/1000 MG TABLET 30 tablets per prescription XIGDUO ER 10 MG/500 MG TABLET 30 tablets per prescription XIGDUO XR 5 MG/1000 MG TABLET 60 tablets per prescription XIGDUO XR 5 MG/500 MG TABLET 30 tablets per prescription XOLAIR 150 MG VIAL 6 vials per 28 days XYZAL 5 MG TABLET 30 tablets per prescription ZECUITY TDS 6.5 MG/4 HOUR 4 patches per prescription ZEGERID 20 MG CAPSULE 30 capsules per prescription ZEGERID 20 MG PACKET 30 packets per prescription ZETONNA 37 MCG NASAL SPRAY 1 canister (60 actuations per canister) per prescription ZOCOR 10 MG TABLET 30 tablets per prescription ZOCOR 20 MG TABLET 30 tablets per prescription ZOCOR 40 MG TABLET 30 tablets per prescription ZOCOR 5 MG TABLET 30 tablets per prescription ZOCOR 80 MG TABLET 30 tablets per prescription ZOFRAN 24 MG TABLET 1 tablet per prescription ZOFRAN 4 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN 8 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN ODT 4 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN ODT 8 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN SOLUTION 2 bottles per prescription ZOLPIMIST 5 MG ORAL SPRAY 1 bottle per prescription ZOMIG 2.5 MG TABLET 6 tablets per prescription ZOMIG 5 MG NASAL SPRAY 6 nasal spray devices per prescription ZOMIG 5 MG TABLET 6 tablets per prescription ZOMIG ZMT 2.5 MG TABLET 6 tablets per prescription ZOMIG ZMT 5 MG TABLET 6 tablets per prescription ZORVOLEX 18 MG CAPSULES 90 capsules per prescription ZUBSOLV 1.4 MG/0.36 MG TABLET 30 tablets per prescription ZUBSOLV 11.4 MG/2.9 MG TABLET 30 tablets per prescription ZUBSOLV 2.9 MG/0.71 MG TABLET 30 tablets per prescription

List is subject to change. Inclusion on this list does not guarantee coverage. ZUBSOLV 5.7 MG/1.4 MG TABLET 30 tablets per prescription ZUBSOLV 8.6 MG/2.1 MG TABLET 60 tablets per prescription ZUPLENZ 4 MG SOLUBLE FILM 9 films per prescription ZUPLENZ 8 MG SOLUBLE FILM 9 films per prescription ZYRTEC 10 MG CHEWABLE TABLET 30 tablets per prescription ZYRTEC 10 MG TABLET 30 tablets per prescription ZYRTEC 5 MG CHEWABLE TABLET 30 tablets per prescription ZYRTEC 5 MG TABLET 30 tablets per prescription ZYRTEC-D TABLET 60 tablets per prescription

List is subject to change. Inclusion on this list does not guarantee coverage.