Quantity Management-Limited

To help make the use of prescription 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 ADRENACLICK 0.15 MG 2 units (1 carton) per prescription ADRENACLICK 0.3 MG 2 units (1 carton) 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 AEROBID/AEROBID-M 3 inhalers per prescription AEROSPAN 80 MCG INHALER 18 g (2 inhalers, 8.9 g each) per prescription Aimovig 140 mg/mL 1 auto-injector/syringe Aimovig 70 mg/ml 1 auto-injector AirDuo 113-14 mcg inhaler 1 inhaler per prescription AirDuo 232-14 mcg inhaler 1 inhaler per prescription AirDuo 55-14 mcg inhaler 1 inhaler per prescription Ajovy 225 mg/1.5 mL 3 pre-filled syringes Ajovy 225 mg/1.5 mL 3 autoinjectors per 90 days AKYNZEO 300/0.5MG 1 capsule per chemotherapy course Albenza 200 mg 120 tablets per 30 days Alinia 100 mg/5 ml 360 ml per 30 days Alinia 500 mg 14 tablets per 30 days ALLEGRA ALLERGY 12 HR 60 MG 60 tablets per prescription ALLEGRA ALLERGY 24 HR 180 MG 30 tablets per prescription ALLEGRA CHILDREN'S ALLERGY 30 MG 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 ALVESCO 160 MCG INHALER 2 inhalers per prescription ALVESCO 80 MCG INHALER 1 inhaler per prescription

Data Class: Internal Last updated 08/03/21 Drug Quantity Management-Limited

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 Androderm 2 mg/24 hr 30 patches per prescription Androderm 4 mg/24 hr 30 patches per prescription AndroGel 1% 2.5 gm gel 30 packets per prescription AndroGel 1% 5 gm gel 60 packets per prescription AndroGel 1% 75 gm pump 300 grams per prescription AndroGel 1.62% 1.25 gm gel 30 packets per prescription AndroGel 1.62% 2.5 gm gel 60 packets per prescription AndroGel 1.62% 75 gm pump 150 grams 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 Armonair Respiclick 113 mcg 1 inhaler per prescription Armonair Respiclick 232 mcg 2 inhaler per prescription Armonair Respiclick 55 mcg 3 inhaler 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 Arnuity Ellipta 50 mcg 1 inhaler (30 blisters) ASMANEX HFA 100 MCG INHALER 13 g (1 inhaler) per prescription ASMANEX HFA 200 MCG INHALER 13 g (1 inhaler) per prescription Asmanex HFA 50 mcg 13 grams (1 inhaler) 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 2 per prescription ATROVENT 0.03% SPRAY 1 per prescription ATROVENT 0.06% SPRAY 2 bottles per prescription ATROVENT HFA INHALER 2 inhalers per prescription ATROVENT INHALER 2 inhalers per prescription AUVI-Q 0.15 MG 2 units (1 carton) per prescription AUVI-Q 0.3 MG 2 units (1 carton) per prescription AXERT 12.5 MG TABLET 12 tablets per prescription AXERT 6.25 MG TABLET 6 tablets per prescription Axiron topical 90 mL pump 180 mL per prescription Baxdela 450 mg 28 tablets per prescription BECONASE AQ 0.042% SPRAY 2 inhalers per prescription 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 Benlysta 200 mg auto-injector 4 auto-injectors per 28 days Benlysta 200 mg pre-filled syringe 4 pre-filled syringes per 28 days Benznidazole 100 mg 720 tablets per 365 days

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

Benznidazole 12.5 mg 720 tablets per 365 days BEVESPI AEROSPHERE 1 canister (120 inhalations per canister) per prescription Bonjesta 360 tablets per 365 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, PACKAGE SIZE 28 1 inhaler (28 blisters) BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 60 1 inhaler (60 blisters) Breztri Aerosphere 10.7 gm 1 inhaler Breztri Aerosphere 5.9 gm 1 inhaler BROVANA 15 MCG/2 ML SOLUTION 2 cartons (60 vials) per prescription BUTORPHANOL NASAL SPRAY 10 MG/ML 2 bottles per prescription Calcipotriene 120 grams per 30 days Calcitrene 120 grams per 30 days CAMBIA 50 MG PACKET 9 packets per prescription CAVERJECT 10 MCG KIT 12 units per prescription CAVERJECT 20 MCG KIT 12 units per prescription CAVERJECT 20 MCG VIAL 12 units per prescription CAVERJECT 40 MCG VIAL 12 units per prescription CAVERJECT 40 MCG/2 ML AMPUL 12 units 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 CIALIS 10 MG TABLET 8 tablets per prescription CIALIS 2.5 MG TABLET 30 tablets per prescription CIALIS 20 MG TABLET 8 tablets per prescription CIALIS 5 MG TABLET 8 tablets per prescription Ciclopirox 0.77% gel 45 grams per 28 days 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 Clindagel 1% 150 ml topical gel CLOBETASOL EMOLLIENT 120 grams per 28 days CLOBETASOL FOAM, SOLUTION, EMOLLIENT FOAM 100 grams per 28 days CLOBETASOL 118 grams per 28 days CLOBETASOL OINTMENT, CREAM AND GEL 120 grams per 28 days CLOBETASOL 236 grams per 28 days CLOBETASOL SPRAY 125 grams per 28 days

Clotrimazole 1% cream 45 grams per 28 days

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

Clotrimazole 1% solution 30 ml per 28 days

Clotrimazole-betamethasone lotion 60 ml per 28 days Coartem 20/120 mg 24 tablets per 30 days COMBIVENT INHALER 2 inhalers per prescription COMBIVENT RESPIMAT INHAL SPRAY 2 inhalers per prescription Daliresp 250 mcg 30 tablets 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 Diclegis 720 tablets per 365 days Dificid 200 mg 20 tablets DIFLUCAN 150 MG TABLET 2 tablets per prescription Divigel 0.25 mg 30 packets DIVIGEL 0.25 MG GEL PACKET 30 packets per prescription Divigel 0.5 mg 30 packets DIVIGEL 0.5 MG GEL PACKET 30 packets per prescription Divigel 0.75 mg 30 packets DIVIGEL 1 MG GEL PACKET 30 packets per prescription Divigel 1.25 gram 30 packets per 30 days Dovonex Cream 120 grams per 30 days Duaklir Pressair 400 mcg/12 mcg 60 inhalations 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 Dulera 50 mcg/5 mcg 13 grams (1 inhaler) DUONEB 0.5 MG-3 MG/3 ML SOLN 180 vials (package size 3) per prescription DYMISTA NASAL SPRAY 1 bottle per prescription Econazole 1% cream 85 grams per 28 days Ecoza 1% foam 70 grams per 28 days EDEX 10 MCG KIT 12 cartridges per prescription EDEX 20 MCG CARTRIDGE 2-PK KIT 12 cartridges per prescription EDEX 20 MCG CARTRIDGE 6-PK KIT 12 cartridges per prescription EDEX 40 MCG CARTRIDGE 2-PK KIT 12 cartridges per prescription EDEX 40 MCG CARTRIDGE 6-PK KIT 12 cartridges 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

ELIDEL CREAM 1% 100 grams per 30 days

ELLA 30 MG TABLET 1 tablet (1 dose) per prescription EMEND 125 MG CAPSULE 1 capsule per prescription EMEND 125 MG ORAL SUSPENSION 3 packets 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 Emend IV 1 unit EMEND TRIFOLD PACK 1 pack per prescription Emgality 100 mg/mL 1 pre-filled syringe Emgality 120 mg/mL 1 pre-filled syringe

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

Emverm 100 mg chewable tablets 6 tablets per 30 days Enstilar Foam 60 grams per 30 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 Ertaczo 2% cream 60 grams per 28 days 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 Eucrisa 2% Ointment 120 grams per 28 days EVAMIST 1.53 MG/SPRAY 2 pumps per prescription Evoclin 1% 100 grams topical foam Exelderm 1% cream & solution 60 grams per 28 days Extina 2% foam 100 grams per 28 days Eysuvis 0.25% ophthalmic suspension 8.3 mL per 14 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 Firvanq 25 mg/mL oral solution 300 mL Firvanq 50 mg/mL oral solution 450 mL FLONASE 0.05% NASAL SPRAY 1 bottle per prescription Flonase Allergy Relief 50 mcg nasal spray (15.8 g) 1 bottle per prescription Flonase Allergy Relief 50 mcg nasal spray (9.9 g) 1 bottle per prescription FLONASE ALLERGY RELIEF 50 MCG SRAY 1 unit per prescription FLONASEPACKAGE ALLERGYSIZE 15 8 RELIEF 50 MCG SRAY 1 unit per prescription PACKAGE SIZE 9 9 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 FLUOCINONIDE OINTMENT, GEL, SOLUTION, OR 120 grams per 30 days CREAM EMULSIFIED 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 Fortesta 60 gm gel pump 120 grams per prescription FROVA 2.5 MG TABLET 9 tablets per prescription GRANISOL 2 MG/10 ML SOLUTION 1 bottle 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 Impavido 50 mg 84 capsules per 30 days Impeklo 0.05% lotion 136 gm per 21 days

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

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 Jatenzo 158 mg 60 capsules Jatenzo 198 mg 60 capsules Jatenzo 237 mg 60 capsules Ketoconazole 2% cream 60 grams per 28 days KYTRIL 1 MG TABLET 6 tablets per prescription KYTRIL 2 MG/10 ML SOLUTION 1 bottle (30 mL) per prescription

Lampit 120 mg 540 tablets per 180 days

Lampit 30 mg 720 tablets per 180 days LEVITRA 10 MG TABLET 8 tablets per prescription LEVITRA 2.5 MG TABLET 8 tablets per prescription LEVITRA 20 MG TABLET 8 tablets per prescription LEVITRA 5 MG TABLET 8 tablets per prescription LEVONORGESTREL 0.75 MG TABLET 2 tablets per prescription LEVONORGESTREL 1.5 MG TABLET (various brands 1 tablet per prescription and generics – for example AFTERA ECONTRA EZ LiDOCAINE 2.5%/PRILOCAINE 2.5% CREAM 30 grams per 30 days LIDOCAINE JELLY 2% 60 mL per 30 days LIDOCAINE OINTMENT One tube, 35.44 or 50 grams per 30 days Locoid 0.1% cream 120 grams Locoid 0.1% lotion 118 mL Locoid 0.1% solution 120 mL

Locoid Lipocream 0.1% cream 120 grams

Lonhala Magnair 25 mcg/1 mL 60 vials

Loprox 0.77% cream 90 grams per 28 days Loprox 0.77% suspension 60 ml per 28 days Loprox 1% shampoo 120 ml per 28 days Lotrisone cream 45 grams per 28 days LUNESTA 1 MG TABLET 30 tablets per prescription LUNESTA 2 MG TABLET 30 tablets per prescription LUNESTA 3 MG TABLET 30 tablets per prescription Luzu 1% cream 60 grams per 28 days Malarone 250/100 mg 60 tablets per 180 days Malarone 62.5/25 mg 180 tablets per 180 days 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 Mefloquine 250 mg 13 tablets MENOSTAR 14 MCG/DAY PATCH 4 patches per 28 days Mentax 1% cream 30 grams per 28 days Methergine 0.2 mg 240 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

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

MUSE 1,000 MCG URETHRAL SUPP 12 urethral per prescription

MUSE 125 MCG URETHRAL SUPPOS 12 urethral suppositories per prescription MUSE 250 MCG URETHRAL SUPPOS 12 urethral suppositories per prescription MUSE 500 MCG URETHRAL SUPPOS 12 urethral suppositories per prescription Naftin 1 % & 2% cream 60 grams per 28 days NASACORT AQ NASAL SPRAY 55 MCG 1 bottle per prescription

Nasonex 50 mcg 1 bottle

NASONEX 50 MCG NASAL SPRAY 1 bottle per prescription

Natesto 60 metered actuations gel pump 3 metered dose pumps per prescription NEBUPENT 300 MG INHAL POWDER 1 container (inhaler) per 28 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 Nizoral 2% shampoo 120 ml per 28 days Nurtec ODT 75 mg 16 tablets Nuvigil 150 mg 30 tablets per 30 days Nuvigil 200 mg 30 tablets per 30 days Nuvigil 250 mg 30 tablets per 30 days Nuvigil 50 mg 30 tablets per 30 days Nuzyra 150 mg 30 tablets Nystatin cream & ointment 30 grams per 28 days Nystatin Powder 180 grams Nystatin-triamcinolone cream & ointment 60 grams per 28 days OMECLAMOX-PAK COMBO PACK 80 caps/tabs (10 cards) = 1 combo pack per prescription OMNARIS 50 MCG NASAL SPRAY 1 bottle per prescription ONMEL 200 MG TABLET 15 tablets per prescription ONZENTRA XSAIL 11 MG NOSEPIECE 1 kit (8 doses/16 nose pieces) per prescription Orilissa 150 mg 30 tablets Orilissa 200 mg 60 tablets Otiprio 6% 1 vial Oxistat 1% cream 60 grams per 28 days Palforzia 12 mg Level 3 45 capsules Palforzia 120 mg Level 7 30 capsules Palforzia 160 mg Level 8 60 capsules Palforzia 20 mg Level 4 15 capsules Palforzia 200 mg Level 9 30 capsules Palforzia 240 mg Level 10 60 capsules Palforzia 3 mg Level 1 45 capsules Palforzia 300 mg Level 11 15 packets Palforzia 300 mg Maintenance 30 packets Palforzia 40 mg Level 5 30 capsules Palforzia 6 mg Level 2 90 capsules Palforzia 80 mg Level 6 60 capsules Palforzia Initial Dose Pack 13 capsules PATANASE 0.6% NASAL SPRAY 1 bottle per prescription PENNSAID 2% SOLUTION 112 grams per 28 days PENNSAID AND KLOFENSAID 1.5 DROPS 150 mL per 28 days PERFOROMIST 20 MCG/2 ML SOLN 1 carton (60 vials) per prescription Phexxi 1.8%-1%-0.4% 12 applicators

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

Pliaglis Cream 30 grams 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 Prevymis 240 mg 100 tablets (30 tablets per fill) Prevymis 480 mg 100 tablets (30 tablets per fill) 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 Primaquine 26.3 mg 120 capsules per 180 days ProAir Digihaler 117 mcg 2 inhalers 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 PROTOPIC OINTMENT 0.03% 100 grams per 30 days PROTOPIC OINTMENT 0.10% 100 grams per 30 days PROVENTIL HFA 90 MCG INHALER 2 inhalers per prescription Provigil 100 mg 30 tablets per 30 days Provigil 200 mg 60 tablets per 30 days 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 Qualaquin 324 mg 40 tablets per 30 days QVAR 40 MCG INHALER 2 inhalers per prescription QVAR 80 MCG INHALER 3 inhalers per prescription Qvar Redihaler 40 mcg 1 inhaler Qvar Redihaler 80 mcg 2 inhalers 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 60 vials per prescription RESTASIS 5.5 ML MULTIDOSE VIAL 5.5 ml per prescription Reyvow 100 mg 8 tablets Reyvow 100 mg 16 tablets Reyvow 50 mg 8 tablets Reyvow 50 mg 8 tablets RHINOCORT ALLERGY SPRAY 32 MCG 9 gm (8.6 g = 1 bottle) and 5 g (1 bottle) per prescription RHINOCORT AQUA NASAL SPRAY 2 bottles per prescription ROZEREM 8 MG TABLET 30 tablets per prescription SANCUSO 3.1 MG/24 HR PATCH 1 patch per prescription SECONAL 100 MG CAPSULE 30 capsules per prescription SEEBRI NEOHALER 15.6 MCG INHALATION 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 SOLARAZE 3% GEL 100 grams per 28 days Solosec 2 g granules 1 packet SONATA 10 MG CAPSULE 60 tablets per prescription

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

SONATA 5 MG CAPSULE 30 tablets per prescription Soolantra 1% cream 60 grams Sorilux Foam 120 grams per 30 days SPIRIVA 18 MCG CP-HANDIHALER 1 package (30 doses) per prescription SPIRIVA 28 INHALATIONS PACK AND 60 INHALATIONS1 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 STAXYN 10 MG ODT 8 tablets per prescription STENDRA 100 MG TABLET 8 tablets per prescription STENDRA 150 MG TABLET 8 tablets per prescription STENDRA 200 MG TABLET 8 tablets per prescription STENDRA 50 MG TABLET 8 tablets per prescription STIOLTO RESPIMAT 2.5/2.5 MCG INHALATION 1 inhaler = 4 g (60 inhalations OR 28 inhalations institutional pack) SPRAY Striant Buccal System 60 buccal systems per prescription STRIVERDI RESPIMAT 28 INHALATIONS PACK, 60 INH1 inhaler (60 inhalations OR 28 inhalations institutional pack) per prescription Stromectol 3 mg tablets 20 tablets 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 Sunosi 150 mg 30 tablets per 30 days Sunosi 75 mg 30 tablets per 30 days SYMBICORT 160-4.5 MCG INHALER 1 package per prescription SYMBICORT 80-4.5 MCG INHALER 1 package per prescription Symjepi 0.15 mg 2 syringes Symjepi 0.3 mg 2 syringes Taclonex Ointment & Suspension 60 grams per 30 days Talicia 10-250-12.5 mg 168 capsules 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 Testim 5 gm gel 60 tubes per prescription Tindamax 250 mg 40 tablets per 30 days Tindamax 500 mg tablets 20 tablets per 30 days Tolsura 65 mg 60 capsules Tosymra 10 mg 1 carton/6 nasal spray units Tosymra 10 mg 4 cartons/24 nasal spray units Trelegy Ellipta 28 blisters per prescription Trelegy Ellipta 60 blisters per prescription Trelegy Ellipta 200/62.5/25 mcg 60 blisters per 60 days Trelegy Ellipta 200/62.5/25 mcg 28 blisters per 28 days TREXIMET 10-60 MG TABLET 9 tablets per prescription TREXIMET 85-500 MG TABLET 9 tablets per prescription TUDORZA PRESSAIR 400 MCG INH 1 inhaler per prescription Ubrelvy 100 mg 10 tablets Ubrelvy 100 mg 20 tablets Ubrelvy 50 mg 10 tablets Ubrelvy 50 mg 20 tablets UTIBRON NEOHALER 27.5/15.6 INHLATION POWDER 6 inhalations (1 package) per prescription (PACKAGE SIZE 6) UTIBRON NEOHALER 27.5/15.6 INHLATION POWDER 60 inhalations (1 package) per prescription (PACKAGE SIZE 60) VALTREX 1 GM CAPLET 30 caplets (tablets) per prescription

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

VALTREX 500 MG CAPLET 30 caplets (tablets) per prescription Vancocin 125 mg 40 capsules Vancocin 250 mg 80 capsules Vancomycin 250 mg/5 mL oral solution 450 mL 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 Veregen 15% ointment 30 grams VIAGRA 100 MG TABLET 8 tablets per prescription VIAGRA 25 MG TABLET 8 tablets per prescription VIAGRA 50 MG TABLET 8 tablets per prescription 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 Vogelxo 5 gm gel 60 packets per prescription Vogelxo 5 gm gel 60 tubes per prescription Vogelxo 75 gm gel pump 300 grams per prescription VOLTAREN 1% GEL 500 grams per 28 days Vusion ointment 50 grams per 28 days Wakix 17.8 mg 60 tablets Wakix 4.45 mg 30 tablets Xhance Nasal Spray 2 bottles (32 mL) per prescription XIFAXAN 200 MG TABLET 9 tablets per prescription XIFAXAN 550 MG TABLET 60 tablets per prescription XIIDRA 5% SOLUTION 60 vials per prescription Xofluza 20 mg 2 tablets Xofluza 40 mg 2 tablets Xolegel 2% gel 45 grams per 28 days Xopenex HFA 45 mcg 2 inhalers XYZAL 5 MG TABLET 30 tablets per prescription Yupelri 175 mcg/3 mL 30 vials 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 ZEMBRACE 3 MG/0.5 ML SYRINGE 4 syringes (1 kit) per prescription ZETONNA 37 MCG NASAL SPRAY 1 canister (60 actuations per canister) 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 Zonalon 5%, Prudoxin 5% Cream 45 grams per 28 days ZOVIRAX 5% CREAM 1 tube/5 grams per prescription ZOVIRAX 5% OINTMENT 1 tube/30 grams per prescription ZUPLENZ 4 MG SOLUBLE FILM 10 films per prescription

Data Class: Internal Last updated 08/03/21

Drug Quantity Management-Limited

ZUPLENZ 8 MG SOLUBLE FILM 10films 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 Gentamicin 0.1% cream 60 grams Gentamicin 0.1% ointment 60 grams Condylox 0.5% gel 7 grams Xyosted 100 mg/0.5 mL 4 autoinjectors Xyosted 50 mg/0.5 mL 4 autoinjectors Xyosted 75 mg/0.5 mL 4 autoinjectors Hetlioz LQ 4 mg/mL 158 mL oral suspension

Data Class: Internal Last updated 08/03/21