Flexrx Standard Prior Authorization, Quantity Limit, and Step Therapy Drug List

FlexRx Standard Prior Authorization, Quantity Limit, and Step Therapy Drug List

How to use this drug list This drug list includes drugs that have a prior authorization (PA) requirement, a quantity limitation (QL), or a step therapy (ST) requirement. For additional information about the various drug programs, you can refer to Bluecrossmn.com. This information is subject to change.

Generic drugs are listed in lowercase boldface (e.g., rabeprazole) Brand name drugs are capitalized (e.g., ACIPHEX)

Acronyms PA = Prior Authorization, QL = Quantity Limit per 30 days, ST = Step Therapy Program *Unless otherwise noted, prior authorization program and quantity limits applies to both brand and generic.

These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details. BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± ABILIFY MAINTENA QL 1 vial/4 weeks ABILIFY tabs (aripiprazole) QL ST* 30 tabs ABSTRAL PA QL 120 tabs ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE QL 300 caps or tabs acetaminophen/codeine solution, 120-12 mg/5 mL QL 2700 mL ACIPHEX (rabeprazole) 20 mg tab QL ST* 30 tabs ACIPHEX sprinkle QL ST 30 caps ACTEMRA QL ST 4 syringes/28 days ACTICLATE (doxycycline hyclate) PA ACTIQ (fentanyl citrate lozenge on a handle) PA QL 120 lozenges ACTONEL (risedronate) 150 mg QL 1 tab ACTONEL (risedronate) 35 mg QL 4 tabs/28 days ACTONEL (risedronate) 5 mg, 30 mg QL 30 tabs ADCIRCA PA** QL 60 tabs ADDERALL (amphetamine/dextroamphetamine) 20 mg QL 90 tabs ADDERALL (amphetamine/dextroamphetamine) 5 mg, 7.5 mg, 10 mg, 12.5 mg, QL 60 tabs 15 mg, 30 mg ADDERALL XR (amphetamine/dextroamphetamine ext-release) QL 30 caps ADDYI PA QL 30 tabs ADEMPAS PA QL 90 tabs ADIPEX-P (phentermine) PA QL 30 caps or tabs ADLYXIN ST ADOXA (doxycycline monohydrate) PA ADVAIR DISKUS QL 1 canister ADVAIR HFA QL 1 canister ADZENYS XR-ODT 3.1 mg, 6.3 mg QL 60 tabs ADZENYS XR-ODT 9.4 mg, 12.5 mg, 15.7 mg, 18.8 mg QL 30 tabs AEROSPAN QL 2 canisters AFINITOR PA QL 30 tabs AFINITOR DISPERZ 2 mg, 5 mg PA QL 60 tabs AFINITOR DISPERZ 3 mg PA QL 90 tabs AFREZZA 12 units/cartridge PA QL 900 cartridges AFREZZA 4 units/cartridge PA QL 2,520 cartridges AFREZZA 4 units/cartridge & 8 units/cartridge PA QL 1,890 cartridges AFREZZA 8 units/cartridge PA QL 1,260 cartridges AFREZZA 8 units/cartridge & 12 units/cartridge PA QL 1,260 cartridges AFREZZA TITRATION PACK: 4 units/cartridge & 8 units/cartridge PA QL 1,800 cartridges AFREZZA TITRATION PACK: 4 units/cartridge, 8 units/cartridge & 12 units/cartridge PA QL 7 boxes (10,080 units) AIRDUO RESPICLICK QL 1 inhaler AKYNZEO QL 2 caps External genital and perianal warts or ALDARA (imiquimod 5% cream) PA QL actinic keratosis: 12 packets/month for up to 4 months Superficial basal cell carcinoma: 24 ALDARA (imiquimod 5% cream) PA QL packets/month for up to 2 months ALECENSA PA QL 240 caps alendronate 35 mg, 70 mg QL 4 tabs ALENDRONATE 40 mg QL 30 tabs alendronate 5 mg, 10 mg QL 30 tabs ALENDRONATE solution QL 300 mL/28 days BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± ALLZITAL QL 360 tabs ALOGLIPTIN QL 30 tabs ALOGLIPTIN/METFORMIN QL 60 tabs ALOGLIPTIN/PIOGLITAZONE QL 30 tabs ALTOPREV QL ST 30 tabs ALUNBRIG PA QL 180 tabs ALVESCO 160 mcg QL 2 canisters ALVESCO 80 mcg QL 1 canister AMBIEN (zolpidem) QL ST* 30 tabs AMBIEN CR (zolpidem ext-release) QL ST* 30 tabs AMERGE (naratriptan) QL 18 tabs AMITIZA PA AMPYRA PA ANDRODERM 2 mg/day, 4 mg/day PA QL 30 patches ANDROGEL (testosterone) 1% GEL packet PA QL 60 packets ANDROGEL 1.62% GEL pump PA QL 300 g ANDROGEL 1.62% GEL, 20.25 mg/1.25 g packet PA QL 30 packets ANDROGEL 1.62% GEL, 40.5 mg/2.5 g packet PA QL 60 packets ANORO ELLIPTA QL 60 blisters ANTARA 30 mg QL 60 caps ANTARA 90 mg QL 30 caps ANZEMET QL 7 tabs APIDRA QL 100 mL APLENZIN QL ST 30 tabs APTENSIO XR QL 30 caps APTIVUS caps QL 120 caps APTIVUS oral solution QL 380 mL ARANESP PA ARCAPTA NEOHALER QL 30 caps ARICEPT (donepezil) QL 30 tabs aripiprazole ODT QL 60 tabs aripiprazole solution QL 25 mL ARISTADA QL ST 1 syringe/56 days ARIXTRA (fondaparinux) QL 30 syringes/90 days ARNUITY ELLIPTA QL 30 blisters ARYMO ER QL 90 tabs Ascomp/codeine 50-325-40-30 mg QL 180 caps ASMANEX HFA QL 1 inhaler ASMANEX TWISTHALER 30, 60, 120 metered doses QL 1 canister ASPIRIN/CAFFEINE/DIHYDROCODEINE caps QL 360 caps ASTEPRO (azelastine 0.15%) QL 2 bottles ATACAND (candesartan) 32 mg QL ST* 30 tabs ATACAND (candesartan) 4 mg, 8 mg, 16 mg QL ST* 60 tabs ATACAND HCT (candesartan/hydrochlorothiazide) QL ST* 30 tabs ATELVIA (risedronate delayed-release) QL 4 tabs/28 days ATRIPLA QL 30 tabs ATROVENT HFA QL 2 canisters AUBAGIO QL 30 tabs AUSTEDO 6 mg PA QL 60 tabs AUSTEDO 9 mg, 12 mg PA QL 120 tabs AVALIDE (irbesartan/hydrochlorothiazide) QL ST* 30 tabs AVAPRO (irbesartan) QL ST* 30 tabs AVIDOXY DK PA AVODART (dutasteride) QL 30 caps AVONEX 30 mcg vial QL 4 vials or one kit of 4 vials/28 days AVONEX 30 mcg/0.5 mL auto-injector pen QL One kit of 4 pens/28 days AVONEX 30 mcg/0.5 mL prefilled syringe QL One kit of 4 syringes/28 days AXERT (almotriptan) QL 12 tabs AXIRON (testosterone) transdermal solution, 30 mg/act PA QL 3600 mg azelastine 0.1% QL 2 bottles AZENASE QL 1 inhaler AZOR (amlodipine/olmesartan) QL ST* 30 tabs BASAGLAR KWIKPEN QL 100 mL BECONASE AQ QL 2 bottles BELBUCA QL 60 films BELSOMRA QL ST 30 tabs BELVIQ PA QL 60 tabs BELVIQ XR PA QL 60 tabs BENICAR (olmesartan) 20 mg, 40 mg QL ST* 30 tabs

© Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 2 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± BENICAR (olmesartan) 5 mg QL ST* 60 tabs BENICAR HCT (olmesartan/hydrochlorothiazide) QL ST* 30 tabs benzphetamine PA QL 90 tabs BERINERT PA QL 10 vials (5,000 IU) BETASERON QL 14 vial/syringe units (1 box)/28 days BEVESPI AEROSPHERE QL 1 inhaler (10.7 gm) BIMATOPROST QL 2.5 mL BINOSTO QL 4 tabs/28 days BIO-T-GEL PA QL 60 packets BONIVA (ibandronate) tabs QL 1 blister pack BOSULIF 100 mg PA QL 120 tabs BOSULIF 500 mg PA QL 30 tabs BREO ELLIPTA QL 1 package (60 blisters) BRIVIACT ST budesonide nasal susp QL 2 bottles BUNAVAIL 2.1-0.3 mg QL 90 films BUNAVAIL 4.2-0.7 mg, 6.3-1 mg QL 60 films Bupap 50-300 mg QL 180 tabs BUPHENYL (sodium phenylbutyrate) PA buprenorphine QL 15 tabs/90 days BUPRENORPHINE transdermal patch weekly QL 4 patch/28 days buprenorphine/naloxone QL 90 tabs bupropion 100 mg QL 120 tabs bupropion 75 mg tab QL 60 tabs butalbital/acetaminophen 50-300 mg, 50-325 mg QL 180 tabs butalbital/acetaminophen/caffeine 50-325-40 mg QL 180 tabs/caps butalbital/acetaminophen/caffeine/codeine 50-325-40-30 mg QL 180 caps butorphanol 10 mg/mL nasal spray QL 87.5 mL butorphanol nasal spray QL 3 x 2.5 mL BUTRANS QL 4 patch/28 days BYDUREON ST BYETTA ST BYVALSON QL ST 30 tabs CABOMETYX PA QL 30 tabs Capacet QL 180 caps CAPRELSA 100 mg PA QL 60 tabs CAPRELSA 300 mg PA QL 30 tabs CARAC PA QL one 30 g tube/month for up to 4 weeks CARDURA (doxazosin) 1 mg, 2 mg, 4 mg QL 30 tabs CARDURA (doxazosin) 8 mg QL 60 tabs CARDURA XL QL 30 tabs CATENA PA CELEXA (citalopram) QL ST* 30 tabs CERDELGA PA QL 60 caps CESAMET QL 42 caps CIALIS 10 mg, 20 mg QL 6 tabs CIALIS 2.5 mg, 5 mg QL 30 tabs CIMZIA 2x200 mg vial, kit QL ST 2 vials (1 kit)/28 days CIMZIA 2x200 mg/mL syringe, kit QL ST 2 syringes (1 kit)/28 days CIMZIA 6x200 mg/mL syringe starter kit QL ST 1 kit/180 days CINRYZE PA QL 20 vials (10,000 IU) citalopram solution QL 600 mL clozapine 200 mg QL 120 tabs clozapine 50 mg QL 90 tabs CLOZAPINE ODT 12.5 mg QL ST 90 tabs CLOZAPINE ODT 150 mg QL ST 180 tabs CLOZAPINE ODT 200 mg QL ST 120 tabs CLOZARIL (clozapine) 25 mg QL ST* 90 tabs CLOZARIL (clozapine) 100 mg QL ST* 270 tabs CODEINE SULFATE (codeine sulfate) 15 mg, 30 mg, 60 mg QL 180 tabs COMBIVENT RESPIMAT QL 2 canisters COMBIVIR (lamivudine/zidovudine) QL 60 tabs COMETRIQ PA QL 1 carton/28 days COMMIT (nicotine) QL 680 lozenges COMPLERA QL 30 tabs CONCERTA (methylphenidate ext-release OSM) 18 mg, 27 mg, 54 mg QL 30 tabs CONCERTA (methylphenidate ext-release OSM) 36 mg QL 60 tabs CONTRAVE PA QL 120 tabs CONZIP QL 30 caps COPAXONE (glatiramer) 20 mg/mL syringe QL 1 box of 30 syringes © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 3 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± COPAXONE 40 mg/mL syringe QL 12 mLs/28 days CORLANOR PA QL 60 tabs COSENTYX 150 mg/mL pre-filled syringe QL ST 1 syringe/28 days COSENTYX SENSOREADY PEN 150 mg/mL auto-injector QL ST 1 injector/28 days COTELLIC PA QL 63 tabs/28 days COZAAR (losartan) 100 mg tabs QL ST* 30 tabs COZAAR (losartan) 25 mg, 50 mg QL ST* 60 tabs CRESTOR (rosuvastatin) 40 mg QL ST* 30 tabs CRESTOR (rosuvastatin) 5 mg, 10 mg, 20 mg QL ST* 45 tabs CRIXIVAN 200 mg QL 270 caps CRIXIVAN 400 mg QL 180 caps CYMBALTA (duloxetine) QL ST* 60 caps DAKLINZA PA DAYTRANA QL 30 patches DEMEROL (meperidine) 100 mg QL 240 tabs DESCOVY QL 30 tabs DESOXYN (methamphetamine) QL 150 tabs DESVENLAFAXINE FUMARATE EXT-RELEASE 24 hr QL ST 30 tabs DETROL (tolterodine) QL 60 tabs DETROL LA (tolterodine ext-release) QL 30 caps DEXEDRINE SPANSULES (dextroamphetamine ext-release) 10 mg, 15 mg QL 120 caps DEXEDRINE SPANSULES (dextroamphetamine ext-release) 5 mg QL 90 caps DEXILANT QL ST 30 caps dextroamphetamine 10 mg QL 180 tabs dextroamphetamine 5 mg QL 90 tabs diclofenac sodium 1.5% solution QL ST¥ 2 bottles (300 mL) DIETHYLPROPION PA QL 90 tabs diethylpropion PA QL 90 tabs diethylpropion ext-release PA QL 30 tabs DILAUDID (hydromorphone) 2 mg, 4 mg, 8 mg QL 180 tabs DILAUDID (hydromorphone) liquid, 1 mg/mL QL 1440 mL DIOVAN (valsartan) 320 mg tabs QL ST* 30 tabs DIOVAN (valsartan) 40 mg, 80 mg, 160 mg tabs QL ST* 60 tabs DIOVAN HCT (valsartan/hydrocholorothiazide) QL ST* 30 tabs DITROPAN XL (oxybutynin ext-release) 10 mg, 15 mg QL 60 tabs DITROPAN XL (oxybutynin ext-release) 5 mg QL 30 tabs DOLOPHINE (methadone) 5 mg, 10 mg QL 90 tabs donepezil orally disintegrating tab QL 30 tabs DORYX (doxycycline hyclate delayed-release) PA DORYX MPC PA DOXYCYCLINE (rosacea) delayed-release cap, 40 mg PA doxycycline hyclate delayed release tab PA drisapersen (brand name not known) PA DUEXIS ST DULERA QL 1 canister DULOXETINE 40 mg QL ST 90 caps DUPIXENT PA DURAGESIC (fentanyl transdermal patch) 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 QL 15 patches mcg/hr, 100 mcg/hr DYANAVEL XR QL 240 mL DYMISTA QL 1 bottle EDARBI QL ST 30 tabs EDARBYCLOR QL ST 30 tabs EDLUAR QL ST 30 tabs EDURANT QL 30 tabs EFFEXOR XR (venlafaxine ext-release) 37.5 mg, 150 mg cap QL ST* 30 caps EFFEXOR XR (venlafaxine ext-release) 75 mg cap QL ST* 90 caps Multiple actinic or solar keratosis: one 40 EFUDEX (fluoruracil cream 5%) PA* QL g tube/month for up to 4 weeks Superficial basal cell carcinomas- two 40 EFUDEX (fluoruracil cream 5%) PA* QL g tubes/month for up to 12 weeks ELIDEL ST ELIQUIS QL 120 tabs EMEND (aprepitant) THERAPY PACK QL 2 therapy packs EMEND (aprepitant) 125 mg cap QL 2 caps EMEND (aprepitant) 80 mg cap QL 4 caps EMEND solution 125 mg QL 6 kits/30 days EMFLAZA PA EMTRIVA caps QL 30 caps © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 4 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± EMTRIVA oral solution QL 728 mL ENABLEX (darifenacin ext-release) QL 30 tabs ENBREL 25 mg/0.5mL QL ST 8 syringes/28 days ENBREL 25 mg/vial, kit QL ST 8 vials/28 days ENBREL 50 mg/mL SureClick autoinjector QL ST 4 autoinjections/28 days ENBREL 50 mg/mL syringe QL ST 4 syringes/28 days ENDARI PA Endocet 10-325 mg QL 180 tabs Endocet 2.5-325 mg, 5-325 mg QL 360 tabs Endocet 7.5-325 mg QL 240 tabs ENTRESTO PA QL 60 tabs EPCLUSA PA EPIVIR (lamivudine) 150 mg tabs QL 60 tabs EPIVIR (lamivudine) 300 mg tabs QL 30 tabs EPIVIR (lamivudine) oral solution QL 960 mL EPOGEN PA EPROSARTAN 600 mg tabs QL ST 30 tabs EPZICOM (abacavir/lamivudine) QL 30 tabs ERIVEDGE PA QL 30 caps ESBRIET 267 mg PA QL 180 caps or tabs ESBRIET 801 mg PA QL 90 tabs escitalopram solution QL 600 mL ESGIC (butalbital/acetaminophen/caffeine) 50-325-40 mg tabs QL 180 tabs Esgic caps QL 180 caps ESOMEPRAZOLE STRONTIUM QL ST 30 caps EUCRISA ST EVEKEO tabs, 10 mg QL 180 tabs EVEKEO tabs, 5 mg QL 90 tabs EVOTAZ QL 30 tabs EXALGO (hydromorphone ext-release 24 hr) 8 mg, 12 mg, 16 mg, 32 mg QL 30 tabs EXELON patch (rivastigmine) QL 30 patches EXFORGE (amlodipine/valsartan) QL ST* 30 tabs EXFORGE HCT (amlodipine/valsartan/hydrochlorothiazide) QL ST* 30 tabs EXTAVIA QL ST 15 vial/syringe units (1 box) FANAPT QL ST 60 tabs FANAPT TITRATION PACK QL 1 pack (8 tablets)/4 days FARXIGA QL 30 tabs FARYDAK PA QL 6 caps (per 21 days) FAZACLO (clozapine orally disintegrating) 100 mg QL ST* 90 tabs FAZACLO (clozapine orally disintegrating) 25 mg QL ST* 270 tabs FAZACLO 12.5 mg QL ST 90 tabs FAZACLO 150 mg QL ST 180 tabs FAZACLO 200 mg QL ST 120 tabs fenofibrate 130 mg QL 30 caps FENOFIBRATE 150 caps QL 30 caps fenofibrate 160 mg tabs QL 30 tabs fenofibrate 43 mg QL 60 caps FENOFIBRATE 50 mg caps QL 60 caps FENOFIBRIC ACID 105 mg tabs QL 30 tabs FENOFIBRIC ACID 35 mg tabs QL 60 tabs FENOGLIDE (fenofibrate) 120 mg tabs QL 30 tabs FENOGLIDE (fenofibrate) 40 mg tabs QL 60 tabs FENTANYL TRANSDERMAL PATCH 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr QL 15 patches FENTORA PA QL 120 tabs FETZIMA caps QL ST 30 caps FETZIMA titration kit QL ST 1 kit (28 capsules)/28 days FIBRICOR 105 mg tabs QL 30 tabs FIBRICOR 35 mg tabs QL 60 tabs FIORICET (butalbital/acetaminophen/caffeine) 50-300-40 mg QL 180 caps FIORICET W/ CODEINE (butalbital/acetaminophen/caffeine/codeine) 50-300-40- QL 180 caps 30 mg FIORINAL 50-325-40 mg (butalbital/aspirin/caffeine) QL 180 caps FIORINAL W/ CODEINE (butalbital/aspirin/caffeine/codeine) 50-325-40-30 mg QL 180 caps FIRAZYR PA QL 6 syringes FLECTOR QL ST 60 patches FLOMAX (tamsulosin) QL 60 caps FLOVENT DISKUS 250 mcg/inhalation QL 4 cartons/month FLOVENT DISKUS 50 mcg/inhalation, 100 mcg/inhalation QL 1 carton/month FLOVENT HFA 220 mcg QL 2 canisters FLOVENT HFA 44 mcg, 110 mcg QL 1 canister © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 5 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± FLUNISOLIDE nasal QL 3 bottles FLUOROPLEX PA QL one 30 g tube/month for up to 6 weeks FLUOROURACIL cream 0.5% PA QL one 30 g tube/month for up to 4 weeks FLUOXETINE 60 mg QL ST 30 tabs FLUOXETINE delayed-release caps, 90 mg QL ST 4 caps/28 days fluoxetine solution QL 600 mL fluoxetine tabs, 10 mg QL 30 tabs fluoxetine tabs, 20 mg QL 120 tabs fluticasone propionate nasal spray QL 1 bottle FLUTICASONE PROPIONATE/SALMETEROL QL 1 inhaler fluvastatin QL 60 caps fluvoxamine 100 mg QL 90 tabs fluvoxamine 25 mg, 50 mg QL 30 tabs fluvoxamine ext-release QL 60 caps FOCALIN (dexmethylphenidate) QL 60 tabs FOCALIN XR (dexmethylphenidate ext-release) QL 30 caps FORFIVO XL QL ST 30 tabs FORTEO PA FORTESTA PA QL 2400 mg FOSAMAX (alendronate) 70 mg QL 4 tabs/28 days FOSAMAX PLUS D QL 4 tabs/28 days FRAGMIN multi-dose vial QL 10 vials/90 days FRAGMIN single-dose syringe QL 30 syringes/90 days FROVA (frovatriptan) QL 18 tabs FUZEON QL 60 vials GALANTAMINE solution QL 200 mL GATTEX PA GELNIQUE 10% gel QL 30 sachets GELNIQUE 3% pump QL 92 grams (one pump) GENOTROPIN PA ST GENVOYA QL 30 tabs GEODON (ziprasidone) caps QL ST* 60 caps GEODON inj QL ST 60 vials GILENYA QL 30 tabs GILOTRIF PA QL 30 tabs Glatopa QL 1 box of 30 syringes glecaprevir/pibrentasvir (brand name not yet known) PA GLEEVEC (imatinib) 100 mg PA QL 90 tabs GLEEVEC (imatinib) 400 mg PA QL 60 tabs glucose test strips, all manufacturers QL 204 strips glucose test strips, all manufacturers except Bayer/Ascensia QL ST 204 strips GLYXAMBI QL 30 tabs GRALISE 300 mg QL ST 30 tabs GRALISE 600 mg QL ST 90 tabs GRALISE starter pack QL ST 1 pack granisetron 1 mg tabs QL 14 tabs GRASTEK PA QL 30 tabs H.P. ACTHAR PA HARVONI PA HETLIOZ PA QL 30 caps HEXALEN PA HORIZANT QL ST 60 tabs HUMALOG, HUMALOG KWIKPEN, HUMALOG MIX 75/25, HUMALOG MIX 75/25 QL 100 mL KWIKPEN, HUMALOG MIX 50/50, HUMALOG 50/50 KWIKPEN HUMATROPE PA ST HUMIRA 10 mg/0.2 mL syringe QL ST 2 syringes/28 days HUMIRA 20 mg/0.4 mL, 40 mg/0.8 mL syringe, kit QL ST 2 syringes/28 days HUMIRA 40 mg/0.8 mL pen, Crohn’s Starter kit QL ST 1 kit/180 days HUMIRA 40 mg/0.8 mL pen, kit QL ST 2 pens (kits)/28 days HUMIRA 40 mg/0.8 mL pen, Psoriasis Starter kit QL ST 1 kit/180 days HUMIRA 40mg/0.8 mL syringe, Pediatric Crohn's Starter kit (3 syringes) QL ST 1 kit/180 days HUMIRA 40mg/0.8 mL syringe, Pediatric Crohn's Starter kit (6 syringes) QL ST 1 kit/180 days HUMULIN N, HUMULIN N KWIKPEN, HUMULIN R, HUMULIN 70/30, HUMULIN QL 100 mL 70/30 KWIKPEN, HUMULIN R U-500, HUMULIN R U-500 KWIKPEN HYCAMTIN PA HYCET (hydrocodone/acetaminophen) solution, 7.5-325 mg/15 mL QL 3600 mL hydrocodone/acetaminophen tabs, 2.5-325 mg QL 360 tabs hydrocodone/ibuprofen 5-200 mg, 7.5-200 mg QL 150 tabs HYQVIA PA © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 6 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± HYSINGLA ER QL 30 tabs HYZAAR (losartan/hydrochlorothiazide) QL ST* 30 tabs IBRANCE PA QL 21 caps (per 28 days) IBUDONE (hydrocodone/ibuprofen) 10-200 mg QL 150 tabs Ibudone 5-200 mg QL 150 tabs ICLUSIG 15 mg PA QL 60 tabs ICLUSIG 45 mg PA QL 30 tabs IMBRUVICA PA QL 120 caps IMITREX (sumatriptan) single dose vial, 6 mg/0.5 mL QL 10 vials IMITREX (sumatriptan) tabs QL 18 tabs IMITREX NASAL SPRAY (sumatriptan) QL 12 spray unit devices IMITREX STATdose (sumatriptan) QL 12 syringe cartridges INCRUSE ELLIPTA QL INGREZZA PA QL INLYTA 1 mg PA QL 180 tabs INLYTA 5 mg PA QL 120 tabs INTELENCE 100 mg, 200 mg tabs QL 60 tabs INTELENCE 25 mg tabs QL 120 tabs INTERMEZZO (zolpidem SL) QL ST* 30 tabs INTUNIV (guanfacine ext-release) QL 30 tabs INVEGA (paliperidone ext-release 24 hr) 1.5 mg, 3 mg, 9 mg QL ST* 30 tabs INVEGA (paliperidone ext-release 24 hr) 6 mg QL ST* 60 tabs INVEGA SUSTENNA QL ST 1 kit INVEGA TRINZA QL ST 1 injection/90 days INVIRASE 200 mg caps QL 300 caps INVIRASE 500 mg tabs QL 120 tabs INVOKAMET QL 60 tabs INVOKAMET XR QL 60 tabs INVOKANA QL 30 tabs ipratropium 0.03%, ipratropium 0.06% QL 2 bottles IRENKA QL ST 90 caps IRESSA PA QL 30 tabs ISENTRESS chewable tabs, 25 mg, 100 mg QL 180 tabs ISENTRESS HD QL 60 tabs ISENTRESS oral suspension QL 60 packets ISENTRESS tabs, 400 mg QL 60 tabs JAKAFI PA QL 60 tabs JALYN (dutasteride/tamsulosin) QL 30 caps JANUMET QL 60 tabs JANUMET XR tabs, 100-1000 mg, 50-500 mg QL 30 tabs JANUMET XR tabs, 50-1000 mg QL 60 tabs JANUVIA QL 30 tabs JARDIANCE QL 30 tabs JENTADUETO QL 60 tabs JENTADUETO XR 2.5-1000 mg QL 60 tabs JENTADUETO XR 5-1000 mg QL 30 tabs JUBLIA PA QL 4 mL JUXTAPID PA QL 30 caps KADIAN (morphine sulfate ext-release) 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 QL 60 caps mg, 100 mg KADIAN 40 mg, 200 mg QL 60 caps KALBITOR PA QL 4 kits KALETRA (lopinavir/ritonavir) oral solution QL 480 mL KALETRA 100-25 mg tabs QL 180 tabs KALETRA 200-50 mg tabs QL 120 tabs KALYDECO packets PA QL 60 packets KALYDECO tabs PA QL 2 tabs KAPVAY (clonidine ext-release 12 hr) QL 120 tabs KAZANO QL 60 tabs KERYDIN PA QL 4 mL ketorolac tabs QL 20 tabs/prescription KEVZARA QL ST 2 syringes per 28 days. KHEDEZLA QL ST 30 tabs KINERET 100 mg syringe QL ST 30 syringes/30 days KISQALI PA QL 63 tablets/28 days KISQALI FEMARA CO-PACK PA QL 91 tabs/ 28 days Klofensaid II solution QL ST¥ 2 bottles (300 mL) KOMBIGLYZE XR 2.5-1000 mg QL 60 tabs KOMBIGLYZE XR 5-500 mg, 5-1000 mg QL 30 tabs KORLYM PA QL 120 tabs © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 7 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± KUVAN PA KYNAMRO PA QL One injection/week LAMISIL (terbinafine) tab PA* QL 30 tabs LAMISIL granules packet PA QL 30 packets LANTUS QL 100 mL LANTUS SOLOSTAR QL 100 mL LATUDA 20 mg, 40 mg, 60 mg, 120 mg QL ST 30 tabs LATUDA 80 mg QL ST 60 tabs LAZANDA PA QL 30 bottles LENVIMA 10 mg PA QL 30 caps LENVIMA 18 mg, 24 mg PA QL 90 caps LENVIMA 8 mg, 14 mg, 20 mg PA QL 60 caps LESCOL XL (fluvastatin ext-release) QL ST* 30 tabs LETAIRIS PA QL 30 tabs LEVALBUTEROL TARTRATE HFA QL 2 canisters LEVEMIR QL 100 mL LEVEMIR FLEXTOUCH QL 100 mL LEVITRA QL 6 tabs LEVORPHANOL 2 mg QL 120 tabs LEXAPRO (escitalopram) tabs QL ST* 30 tabs LEXIVA oral suspension QL 1800 mL (8 bottles) LEXIVA tabs QL 120 tabs lidocaine ointment 5% PA QL 600 g LIDODERM (lidocaine) 5% patch PA QL 90 patches LINZESS PA LIPITOR (atorvastatin) 10 mg, 20 mg, 40 mg QL ST* 45 tabs LIPITOR (atorvastatin) 80 mg QL ST* 30 tabs LIPOFEN 150 mg caps QL 30 caps LIPOFEN 50 mg caps QL 60 caps LIVALO 1 mg, 2 mg QL ST 45 tabs LIVALO 4 mg QL ST 30 tabs LOFIBRA (fenofibrate) 54 mg tabs QL 60 tabs LOFIBRA (fenofibrate) 67 mg, 134 mg, 200 mg caps QL 30 caps LOMAIRA PA QL 90 tabs LONSURF 15 mg-6.14 mg PA QL 100 per 28 days LONSURF 20 mg-8.19 mg PA QL 80 per 28 days LOPID (gemfibrozil) QL 60 tabs Lorcet 5-325 mg QL 360 tabs Lorcet HD, Lorcet Plus 7.5-325 mg, 10-325 mg QL 180 tabs LORTAB elixir 10-300 mg/15 mL QL 2025 mL lovastatin 10 mg, 20 mg, 40 mg QL 60 tabs LOVENOX (enoxaparin) mult-dose vial QL 10 vials/90 days LOVENOX (enoxaparin) single-dose syringes QL 30 syringes/90 days LUMIGAN QL 2.5 mL LUNESTA (eszopiclone) QL ST* 30 tabs LYNPARZA PA QL 16 caps (per 28 days) LYRICA 20 mg/mL oral solution QL 900 mL LYRICA 225 mg, 300 mg QL 60 caps LYRICA 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg QL 90 caps LYSODREN PA MAPROTILINE QL ST 90 tabs Marten-Tab QL 180 tabs MATULANE PA MAVYRET PA MAXALT, MAXALT MLT (rizatriptan) QL 18 tabs MEKINIST 0.5 mg PA QL 90 tabs MEKINIST 2 mg PA QL 30 tabs meperidine 50 mg QL 240 tabs MEPERIDINE 50 mg/5 mL QL 2400 mL Metadate ER tabs, 20 mg QL 90 tabs METHADONE (methadone) 10 mg/5 mL QL 450 mL METHADONE (methadone) 5 mg/5 mL QL 900 mL methadone 40 mg soluble tablet QL 90 tabs METHADOSE (methadone) concentrate 10 mg/mL QL 90 mL Methadose 40 mg soluble tablet QL 90 tabs METHYLIN (methylphenidate) solution, 10 mg/5 mL QL 900 mL METHYLIN (methylphenidate) solution, 5 mg/5 mL QL 450 mL METHYLPHENIDATE chew tabs, 10 mg QL 180 tabs METHYLPHENIDATE chew tabs, 2.5 mg, 5 mg QL 90 tabs © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 8 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± METHYLPHENIDATE ext-release 24 hr 18 mg, 27 mg, 54 mg QL 30 tabs METHYLPHENIDATE ext-release 24 hr 36 mg QL 60 tabs METHYLPHENIDATE ext-release 24 hr 60 mg QL 60 caps methylphenidate ext-release CD caps QL 30 caps methylphenidate ext-release tab 10 mg, 20 mg QL 90 tabs MICARDIS (telmisartan) QL ST* 30 tabs MICARDIS HCT (telmisartan/hydrochlorothiazide) QL ST* 30 tabs MINOCIN (minocycline) PA MINOCYCLINE ext-release 24 hr tabs 45 mg PA minocycline ext-release 24 hr tabs 90 mg, 135 mg PA MIRCERA PA MONODOX (doxycycline monohydrate) PA MORGIDOX Kit PA MORPHABOND ER QL 60 tabs MORPHINE SULFATE 15 mg QL 240 tabs MORPHINE SULFATE 30 mg QL 180 tabs MORPHINE SULFATE BEADS EXT-RELEASE QL 30 caps morphine sulfate solution 10 mg/5 mL QL 2700 mL morphine sulfate solution 20 mg/5 mL QL 1350 mL morphine sulfate solution 20 mg/mL QL 270 mL MS CONTIN (morphine sulfate ext-release) QL 90 tabs MYALEPT PA MYDAYIS QL 30 caps MYRBETRIQ QL 30 tabs NAMENDA (memantine) solution QL 360 mL/30 days NAMENDA (memantine) tabs QL 60 tabs NAMENDA (memantine) titration pack QL 1 pak (28 tablets)/28 days NAMENDA XR QL 30 caps NAMENDA XR titration kit QL 1 kit (28 capsules)/28 days NAMZARIC QL 30 caps NASONEX (mometasone) QL 2 bottles NATESTO PA QL 180 pumps NATPARA PA QL 1 package (2 cartridges) per 28 days NERLYNX PA QL 180 tabs NESINA QL 30 tabs NEVIRAPINE oral suspension QL 5 bottles NEXAVAR PA QL 120 tabs NEXIUM (esomeprazole) QL ST* 30 caps NEXIUM DR granules, 10 mg, 20 mg, 40 mg QL ST 30 packets NEXIUM DR granules, 2.5 mg, 5 mg QL ST 30 packets NIASPAN (niacin ext-release) 500 mg tabs QL 30 tabs NIASPAN (niacin ext-release) 750 mg, 1000 mg tabs QL 60 tabs NICORETTE (nicotine) QL 816 pieces NICOTROL NASAL SPRAY QL 12 bottles NICOTROL ORAL INHALER QL 3 inhalers NINLARO PA QL 3 capsules/28 days NORCO (hydrocodone/acetaminophen) 5-325 mg QL 360 tabs NORCO (hydrocodone/acetaminophen) 7.5-325 mg, 10-325 mg QL 180 tabs NORDITROPIN PA ST NORTHERA 100 mg PA QL 450 caps NORTHERA 200 mg & 300 mg PA QL 180 caps NORVIR caps QL 360 caps NORVIR oral solution QL 480 mL NORVIR tabs QL 360 tabs NOVOLIN products QL 100 mL NOVOLOG QL 100 mL NUCYNTA QL 180 tabs NUCYNTA ER QL 60 tabs NUTRIDOX PA NUTROPIN AQ PA ST OCALIVA PA QL 30 tabs ODEFSEY QL 30 tabs ODOMZO PA QL 30 tabs OFEV PA QL 60 caps OLYSIO PA OMEPPI (omeprazole/sodium bicarbonate) caps QL ST¥ 30 caps omeprazole 10 mg, 20 mg, 40 mg QL 30 caps OMNARIS QL 1 bottle OMNITROPE PA ondansetron 24 mg tabs QL 1 tab © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 9 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± ONGLYZA QL 30 tabs ONMEL PA QL 30 tabs ONZETRA QL 32 nosepieces (2 kits) per 30 days. OPANA (oxymorphone) 5 mg, 10 mg QL 180 tabs OPANA ER (CRUSH RESISTANT) QL 60 tabs OPSUMIT PA QL 30 tabs ORACEA PA ORALAIR starter pack PA QL 1 pack/180 days ORALAIR tabs PA QL 30 tabs ORENCIA 125 mg/mL (subcutaneous) QL ST 4 syringes/28 days ORENCIA 50 mg/0.4 mL, 87.5 mg/0.7 mL QL ST 4 syringes/28 days ORENCIA ClickJect QL ST 4 per 28 days ORENITRAM PA ORKAMBI PA QL 120 tabs OSENI QL 30 tabs OTEZLA 10 mg, 20 mg & 30 mg tablet starter pack (four week) QL ST 1 starter kit of 55 tablets/180 days OTEZLA 30 mg tabs QL ST 60 tabs OXAYDO 5 mg QL 270 tabs OXAYDO 7.5 mg QL 180 tabs oxybutynin syrup QL 600 mL oxybutynin tabs QL 120 tabs oxycodone 10 mg, 20 mg QL 180 tabs oxycodone 5 mg QL 360 caps oxycodone concentrate 20 mg/mL QL 270 mL OXYCODONE ER 10 mg, 15 mg, 20 mg, 30 mg, 40 mg QL 60 tabs OXYCODONE ER 60 mg, 80 mg QL 120 tabs oxycodone solution 5 mg/5 mL QL 5400 mL OXYCODONE/ACETAMINOPHEN solution QL 1800 mL oxycodone/aspirin QL 360 tabs OXYCODONE/IBUPROFEN QL 120 tabs OXYCONTIN 10 mg, 15 mg, 20 mg, 30 mg, 40 mg QL 60 tabs OXYCONTIN 60 mg, 80 mg QL 120 tabs OXYMORPHONE ER QL 60 tabs OXYTROL (prescription) QL 8 patches/28 days PATANASE (olopatadine) QL 1 bottle PAXIL (paroxetine) 10 mg, 20 mg, 40 mg tabs QL ST* 30 tabs PAXIL (paroxetine) 30 mg tabs QL ST* 60 tabs PAXIL CR (paroxetine ext-release) 12.5 mg tabs QL ST* 30 tabs PAXIL CR (paroxetine ext-release) 25 mg, 37.5 mg QL ST* 60 tabs PAXIL oral suspension QL ST 900 mL PENLAC (ciclopirox) PA* QL 6.6 mL PENNSAID 2% solution QL ST 2 pumps/28 days PERCOCET (oxycodone/acetaminophen) 10-325 mg QL 180 tabs PERCOCET (oxycodone/acetaminophen) 2.5-325 mg, 5-325 mg QL 360 tabs PERCOCET (oxycodone/acetaminophen) 7.5-325 mg QL 240 tabs PEXEVA 10 mg, 20 mg, 40 mg QL ST 30 tabs PEXEVA 30 mg QL ST 60 tabs phendimetrazine PA QL 180 tabs PHENDIMETRAZINE ER PA QL 30 tabs phentermine PA QL 30 caps Actinic keratosis (face or scalp): 3 tubes PICATO PA QL for up to 90 days Actinic keratosis (trunk or extremities): 2 PICATO PA QL tubes for up to 90 days 2 syringes or pens per 28 days (1 carton PLEGRIDY 125 mcg/0.5 mL syringe or pen-jector QL of 2 syringes/28 days) PLEGRIDY starter kit- pen-injector QL 1 kit/180 days PLEGRIDY starter kit- syringe QL 1 kit/180 days POMALYST PA QL 21 caps/28 days PRADAXA 110 mg QL 71 caps/91 days PRADAXA 75, 150 mg QL 60 caps 1 package of 2 pens or syringes per 28 PRALUENT pre-filled pen or syringe, 75 mg/mL, 150 mg/mL PA QL days PRAVACHOL (pravastatin) 20 mg, 40 mg QL ST* 45 tabs PRAVACHOL (pravastatin) 80 mg QL ST* 30 tabs pravastatin 10 mg QL 45 tabs PREVACID (lansoprazole) QL ST* 30 caps PREVACID SOLUTAB QL ST 30 tabs PREZCOBIX tabs QL 30 tabs PREZISTA 150 mg tabs QL 180 tabs

© Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 10 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± PREZISTA 600 mg tabs QL 60 tabs PREZISTA 75 mg tabs QL 300 tabs PREZISTA 800 mg tabs QL 30 tabs PREZISTA oral suspension QL 400 mL PRILOSEC packets, 10 mg QL ST 30 packets PRILOSEC packets, 2.5 mg QL ST 60 packets PRIMLEV 10-300 mg QL 180 tabs PRIMLEV 5-300 mg QL 360 tabs PRIMLEV 7.5-300 mg QL 240 tabs PRISTIQ (desvenlafaxine succinate ext-release 24 hr) QL ST 30 tabs PROAIR HFA QL 2 canisters PROAIR RESPICLICK QL 2 inhalers PROCENTRA (dextroamphetamine) oral solution QL 1800 mL PROCRIT PA PROMACTA 12.5 mg, 25 mg PA QL 30 tabs PROMACTA 50 mg, 75 mg PA QL 60 tabs PROSCAR (finasteride) 5 mg QL 30 tabs PROTONIX (pantoprazole) QL ST* 30 tabs PROTONIX packets QL ST 30 packets PROTOPIC (tacrolimus) ST¥ PROVENTIL HFA QL 2 canisters PROZAC (fluoxetine) 10 mg caps QL ST* 30 caps PROZAC (fluoxetine) 20 mg caps QL ST* 120 caps PROZAC (fluoxetine) 40 mg caps QL ST* 60 caps PULMICORT FLEXHALER 180 mcg QL 2 canisters PULMICORT FLEXHALER 90 mcg QL 1 canister QNASL QL 1 canister QNASL CHILDREN QL 1 canister QSYMIA PA QL 30 caps QUILLICHEW ER 20 mg, 40 mg QL 30 tabs QUILLICHEW ER 30 mg QL 60 tabs QUILLIVANT XR QL 360 mL QVAR 40 mcg QL 1 canister QVAR 80 mcg QL 2 canisters RAGWITEK PA QL 30 tabs RAPAFLO QL 30 caps RAVICTI PA RAYOS PA RAZADYNE ER (galantamine ext-release 24 hr) QL 30 caps RAZADYNE tabs (galantamine) QL 60 tabs REBIF 22 mcg/0.5 mL QL 1 carton 12 syringes/28 days REBIF 44 mcg/0.5 mL QL 1 carton 12 syringes/28 days REBIF Titration pack QL 1 kit/180 days REGIMEX (benzphetamine) PA QL 90 tabs RELION products QL 100 mL RELPAX (elitriptan) QL 12 tabs REMERON, REMERON SOLTAB (mirtazapine) QL ST* 30 tabs REPATHA 140 mg/mL pre-filled syringe or auto-injector PA QL 2 syringes or pens per 28 days REPATHA 420 mg/3.5 mL pre-filled syringe or auto-injector PA QL 1 Pushtronex system RESCRIPTOR 100 mg tabs QL 360 tabs RESCRIPTOR 200 mg tabs QL 180 tabs RESCULA QL 5 mL RESTASIS PA QL 60 single use vials RESTASIS PA QL 1 bottle RETROVIR (zidovudine) 100 mg caps QL 180 caps RETROVIR (zidovudine) syrup QL 1920 mL (8 bottles) REVATIO (sildenafil) PA QL 90 tabs REVATIO susp PA QL 2 bottles (224 mL) REVLIMID 15 mg, 20 mg, 25 mg PA QL 21 caps/28 days REVLIMID 2.5 mg, 5 mg, 10 mg PA QL 30 caps REXULTI QL ST 30 tabs REYATAZ 150 mg caps QL 30 caps REYATAZ 200 mg caps QL 60 caps REYATAZ 300 mg caps QL 30 caps REYATAZ 50 mg powder packet QL 240 packets RISPERDAL (risperidone) solution QL ST* 480 mL RISPERDAL (risperidone) tabs, 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg QL ST* 60 tabs RISPERDAL (risperidone) tabs, 4 mg QL ST* 120 tabs RISPERDAL CONSTA QL ST 2 vials/28 days RISPERDAL M-TAB (risperidone) 0.5 mg, 1 mg, 2 mg, 3 mg QL ST* 60 tabs © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 11 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± RISPERDAL M-TAB (risperidone), 4 mg QL ST* 120 tabs risperidone ODT 0.25 mg QL 60 tabs RITALIN (methylphenidate) QL 90 tabs RITALIN LA (methylphenidate ext-release) 20 mg, 30 mg, 40 mg QL 30 caps RITALIN LA 10 mg QL 30 caps rivastigmine caps QL 60 caps ROXICODONE (oxycodone) 15 mg, 30 mg QL 180 tabs ROXICODONE (oxycodone) 5 mg QL 360 tabs ROZEREM QL ST 30 tabs RUBRACA PA QL 120 tabs RUCONEST PA QL 8 vials RYDAPT PA QL 240 caps SAIZEN PA ST SANCUSO QL 1 patch SAPHRIS QL ST 60 tabs SAVAYSA QL 30 tabs SAVELLA tabs QL 60 tabs SAVELLA titration pack QL 1 kit per 180 days SAXENDA PA QL 5 pens SELZENTRY 25 mg QL 240 tabs SELZENTRY 300 mg QL 120 tabs SELZENTRY 75 mg, 150 mg QL 60 tabs SELZENTRY solution QL 1840 mL per 30 days SENSIPAR PA SEREVENT DISKUS QL 1 canister SEROQUEL (quetiapine) 25 mg, 50 mg, 100 mg, 200 mg QL ST* 90 tabs SEROQUEL (quetiapine) 300 mg, 400 mg QL ST* 60 tabs SEROQUEL XR (quetiapine ext-release) 150 mg, 200 mg QL ST* 30 tabs SEROQUEL XR (quetiapine ext-release) 50 mg, 300 mg, 400 mg QL ST* 60 tabs SEROSTIM PA ST SILENOR ST 30 tabs SILIQ QL ST 2 syringes/28 days SIMPONI QL ST 1 syringe/28 days SOLARAZE (diclofenac) gel 3% PA QL one 100 g tube/month for up to 90 days SOLIQUA QL ST 5 pens (15 mL)/30 days SOLODYN PA SONATA (zaleplon) QL ST* 30 caps SOVALDI PA SPIRIVA HANDIHALER QL 30 caps SPIRIVA RESPIMAT QL 1 cartridge/month SPORANOX (itraconazole) cap PA* QL 120 caps SPORANOX 10 mg/mL oral solution PA QL 1200 mL SPRIX QL 5 bottles/prescription SPRYCEL 20 mg PA QL 60 tabs SPRYCEL 50 mg, 70 mg, 80 mg, 100 mg, 140 mg PA QL 30 tabs STAXYN QL 6 tabs STELARA 45 mg/0.5 mL QL ST 1 syringe or vial/84 days STELARA 90 mg/1 mL syringe QL ST 1 syringe/56 days STENDRA QL 6 tabs STIOLTO RESPIMAT QL 1 inhaler STIVARGA PA QL 90 tabs STRATTERA (atomoxetine) 10 mg, 18 mg, 25 mg, 40 mg QL 60 caps STRATTERA (atomoxetine) 60 mg, 80 mg, 100 mg QL 30 caps STRIANT PA QL 60 systems STRIBILD QL 30 tabs STRIVERDI RESPIMAT QL 1 canister SUBOXONE 2 mg-0.5 mg QL 120 films SUBOXONE 4 mg-1 mg QL 30 films SUBOXONE 8 mg-2 mg, 12 mg-3 mg QL 60 films SUBSYS 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg PA QL 120 sprays SUBSYS 1200 mcg, 1600 mcg PA QL 240 sprays SUMATRIPTAN PREFILLED SYRINGE, 6 mg/0.5 mL QL 12 doses SUMAVEL DOSEPRO QL 12 injection devices SUSTIVA 200 mg caps QL 60 caps SUSTIVA 50 mg caps QL 90 caps SUSTIVA 600 mg tabs QL 30 tabs SUTENT 12.5 mg PA QL 90 caps

© Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 12 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± SUTENT 25 mg, 37.5 mg, 50 mg PA QL 30 caps SYLATRON PA SYMBICORT QL 1 canister SYNALGOS DC QL 360 caps SYNJARDY QL 60 tabs SYNJARDY XR 25-1000 mg QL 30 tabs SYNJARDY XR 5-1000 mg, 10-1000 mg, 12.5-1000 mg QL 60 tabs TAFINLAR PA QL 120 caps TAGRISSO PA QL 30 tabs TALTZ QL ST 1 syringe/ 28 days TANZEUM ST TARCEVA 100 mg, 150 mg PA QL 30 tabs TARCEVA 25 mg PA QL 60 tabs TARGRETIN (bexarotene) caps PA TASIGNA PA QL 120 caps TECFIDERA 120 mg caps QL 14 capsules/180 days TECFIDERA 240 mg caps QL 60 caps TECFIDERA Starter kit QL 1 kit/180 days TECHNIVIE PA TEKTURNA QL ST 30 tabs TEKTURNA HCT QL ST 30 tabs TEMODAR (temozolomide) caps PA TENCON QL 180 tabs terazosin 1 mg, 2 mg, 5 mg caps QL 30 caps terazosin 10 mg QL 60 caps TESTIM PA QL 60 tubes testosterone 1% gel packet PA QL 60 packets testosterone 1% gel pump PA QL 300 g TESTOSTERONE TD gel PA QL 300 mg THALOMID 150 mg, 200 mg PA QL 60 caps THALOMID 50 mg, 100 mg PA QL 30 caps TIVICAY QL 60 tabs TOLAK PA QL one 40 g tube/month for up to 4 weeks TOUJEO SOLOSTAR QL 100 mL TOVIAZ QL 30 tabs TRACLEER PA QL 60 tabs TRADJENTA QL 30 tabs TRAMADOL BIPHASIC RELEASE caps QL 30 caps tramadol biphasic release tabs QL 30 tabs tramadol ext-release QL 30 tabs TRANSLARNA PA TRAVATAN Z QL 2.5 mL TRESIBA FLEXTOUCH QL 100 mL tretinoin oral PA TREXIMET 10-60 mg QL 9 tabs TREXIMET 85-500 mg QL 18 tabs TREZIX QL 300 caps triamcinolone nasal QL 1 bottle TRIBENZOR (olmesartan/amlodipine/hydrochlorothiazide) QL ST* 30 tabs TRICOR (fenofibrate) 145 mg QL 30 tabs TRICOR (fenofibrate) 48 mg QL 60 tabs TRIGLIDE 160 mg QL 30 tabs TRILIPIX (fenofibric acid delayed-release) 135 mg QL 30 tabs TRILIPIX (fenofibric acid delayed-release) 45 mg QL 60 tabs TRINTELLIX (formerly BRINTELLIX) QL ST 30 tabs TRIUMEQ QL 30 tabs TRIZIVIR (abacavir/lamivudine/zidovudine) QL 60 tabs trospium QL 60 tabs trospium ext-release QL 30 caps TRULANCE PA TRULICITY ST TRUVADA PRESSAIR QL 30 tabs TUDORZA QL 1 canister TWYNSTA (telmisartan/amlodipine) QL ST* 30 tabs © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 13 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± TYBOST QL 30 tabs TYKERB PA QL 180 tabs TYLENOL W/CODEINE (acetaminophen/codeine) 300-15 mg, 300-30 mg QL 360 tabs TYLENOL W/CODEINE (acetaminophen/codeine) 300-60 mg QL 180 tabs TYVASO 0.6 mg/mL 4 pack Carton PA QL 7 packages of 4 ampules/28 days TYVASO 0.6 mg/mL System Refill kit PA QL 1 package of 28 ampules/28 days TYVASO starter kit PA QL 1 kit/180 days ULTRACET (tramadol/acetaminophen) QL 240 tabs ULTRAM (tramadol) QL 240 tabs UPTRAVI PA QL 60 tabs UPTRAVI titration pack PA QL 1 pack/180 days UROXATRAL (alfuzosin) QL 30 tabs UTIBRON NEOHALER QL 60 inhalation capsules/month VANATOL LQ, VANATOL S QL 2700 mL VARUBI QL 4 tablets VENCLEXTA 10 mg PA QL 60 tabs VENCLEXTA 100 mg PA QL 120 tabs VENCLEXTA 50 mg PA QL 30 tabs VENCLEXTA starter pack PA QL 1 pack (42 tablets) per 180 days VENLAFAXINE ER (venlafaxine ext-release 24 hr) 37.5 mg, 150 mg tabs QL ST* 30 tabs VENLAFAXINE ER (venlafaxine ext-release 24 hr) 75 mg tabs QL ST* 90 tabs venlafaxine ext-release 24 hr 225 mg tabs QL ST 30 tabs venlafaxine immediate release QL 90 tabs VENTAVIS PA QL 9 packages of 30 ampules VENTOLIN HFA QL 2 canisters VERAMYST QL 1 bottle Verdrocet, 2.5-325 mg QL 360 tabs VERSACLOZ QL ST 540 mL VESICARE QL 30 tabs VIAGRA QL 6 tabs VIBRAMYCIN (doxycycline hyclate) caps PA* VIBRAMYCIN (doxycycline monohydrate) susp PA* VIBRAMYCIN syrup PA Vicodin 5-300 mg QL 360 tabs Vicodin ES 7.5-300 mg QL 180 tabs Vicodin HP 10-300 mg QL 180 tabs VICTOZA ST VIDEX EC (didanosine) QL 30 caps VIDEX oral solution QL 1200 mL VIEKIRA PAK PA VIEKIRA XR PA VIIBRYD starter kit QL ST 1 kit per 180 days VIIBRYD tabs QL ST 30 tabs VIMOVO QL ST 60 tabs VIRACEPT 250 mg tabs QL 270 tabs VIRACEPT 625 mg tabs QL 120 tabs VIRAMUNE oral suspension QL 5 bottles VIRAMUNE tabs (nevirapine) QL 60 tabs VIRAMUNE XR (nevirapine ext-release) 100 mg tabs QL 90 tabs VIRAMUNE XR (nevirapine ext-release) 400 mg tabs QL 30 tabs VIREAD oral powder QL 240 g VIREAD tabs QL 30 tabs VOGELXO PA QL 300 g VOLTAREN (diclofenac sodium) 1% gel QL ST¥ 10 tubes (1000 g) VOSEVI PA VOTRIENT PA QL 120 tabs VRAYLAR caps QL ST 30 caps VRAYLAR therapy pack QL ST 1 pack/180 days ¥ VYTORIN (ezetimibe/simvastatin) QL ST 30 tabs VYVANSE caps QL 30 caps © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 14 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± VYVANSE chew tabs QL 30 tabs WELLBUTRIN SR (bupropion ext-release) QL ST* 60 tabs WELLBUTRIN XL (bupropion ext-release) QL ST* 30 tabs XALATAN (latanoprost) QL 2.5 mL XALKORI PA QL 60 caps XARELTO 10 mg QL 35 tabs/90 days XARELTO 15 mg QL 60 tabs XARELTO 20 mg QL 30 tabs XARELTO starter pack QL one pack XELJANZ QL ST 60 tabs XELJANZ XR QL ST 30 tabs XELODA (capecitabine) PA XENAZINE (tetrabenazine) 12.5 mg PA QL 240 tabs XENAZINE (tetrabenazine) 25 mg PA QL 120 tabs XENICAL PA QL 90 caps XIGDUO XR 5-1000 mg QL 60 tabs XIGDUO XR 5-500 mg, 10-500 mg, 10-1000 mg QL 30 tabs XIIDRA PA QL 60 containers XODOL (hydrocodone/acetaminophen) 5-300 mg QL 360 tabs XODOL (hydrocodone/acetaminophen) 7.5-300 mg, 10-300 mg QL 180 tabs XOLAIR PA XOPENEX HFA QL 2 canisters XTAMPZA ER QL 60 caps XTANDI PA QL 120 caps XULTOPHY QL ST 5 pens (15 mL)/30 days Xylon 10-200 mg QL 150 tabs XYREM PA QL 540 mL YOSPRALA ST ZAMICET solution, 10-325 mg/15 mL QL 2700 mL ZAVESCA PA QL 90 caps Zebutal QL 180 caps ZEGERID (omeprazole/sodium bicarbonate) caps QL ST¥ 30 caps ZEGERID (omeprazole/sodium bicarbonate) packets QL ST¥ 30 packets ZEJULA PA QL 90 caps ZELBORAF PA QL 240 tabs ZEMBRACE QL 24 syringes/30 days Zenzedi 10 mg QL 180 tabs ZENZEDI 2.5 mg, 7.5 mg, 15 mg, 20 mg QL 90 tabs ZENZEDI 30 mg QL 60 tabs Zenzedi 5 mg QL 90 tabs ZEPATIER PA ZERIT (stavudine) caps QL 60 caps ZERIT oral solution QL 12 bottles ZETIA (ezetimibe) QL ST¥ 30 tabs ZETONNA QL 1 canister ZIAGEN (abacavir) QL 60 tabs ZIAGEN oral solution QL 960 mL (4 bottles) zidovudine 300 mg tabs QL 60 tabs ZINBRYTA QL ST 1 syringe/30 days ZIOPTAN QL 30 single-use containers ZOCOR (simvastatin) 20 mg QL ST* 60 tabs ZOCOR (simvastatin) 5 mg, 10 mg, 40 mg QL ST* 45 tabs ZOCOR (simvastatin) 80 mg QL ST* 30 tabs ZOFRAN (ondansetron) 4 mg, 8 mg tabs QL 21 tabs ZOFRAN (ondansetron) 4 mg/5 mL solution QL 100 mL (2 bottles) ZOFRAN ODT (ondansetron orally disintegrating tabs) QL 21 tabs ZOLINZA PA QL 120 caps ZOLOFT (sertraline) 100 mg tabs QL ST* 60 tabs ZOLOFT (sertraline) 25 mg, 50 mg tabs QL ST* 30 tabs ZOLOFT (sertraline) oral concentrate QL ST* 300 mL © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 15 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± ZOLPIMIST QL ST 1 canister (60 actuations) ZOMACTON PA ST ZOMIG nasal spray QL 12 units (2 packages of 6) ZOMIG, ZOMIG ZMT (zolmitriptan) QL 12 tabs ZORBTIVE PA ST ZUBSOLV 0.7-0.18 mg, 2.9-0.71 mg, 11.4-2.9 mg QL 30 tabs ZUBSOLV 1.4-0.36 mg, 5.7-1.4 mg QL 90 tabs ZUBSOLV 8.6-2.1 mg QL 60 tabs ZUPLENZ QL 20 films (2 boxes of 10) 56 packets for up to 6 weeks ZYCLARA 2.5% cream PA QL two 7.5 g pumps for up to 6 weeks one 15 g pump for up to 6 weeks 56 packets for up to 6 weeks (actinic ZYCLARA 3.75% cream PA QL keratosis) or 8 weeks (external genital or perianal warts) one 15 g pump for up to 6 weeks (actinic ZYCLARA 3.75% cream PA QL keratosis) or 8 weeks (external genital or perianal warts) ZYDELIG PA QL 60 tabs ZYKADIA PA QL 150 caps ZYPREXA (olanzapine) tabs QL ST* 30 tabs ZYPREXA RELPREVV 210 mg, 300 mg QL ST 2 vials/28 days ZYPREXA RELPREVV 405 mg QL ST 1 vial/28 days ZYPREXA ZYDIS (olanzapine orally disintegrating tabs) QL ST* 30 tabs ZYTIGA 250 mg PA QL 120 tabs ZYTIGA 500 mg PA QL 60 tabs

*Generic available- the generic is not subject to prior authorization or step therapy ¥Generic available- the generic is also subject to step therapy ± Quantity Limit apply to brand and generic **Reviewed for use in pulmonary arterial hypertension, not approved for erectile dysfunction

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