Blue Cross and Blue Shield of Oklahoma One Month Quantity Limit Effective Aug. 1, 2005 Drug Name Dosage Form Dispensed Units/Month Actiq 1200 MCG Lozenge/Lollipop 120 Actiq 1600 MCG Lozenge/Lollipop 120 Actiq 200 MCG Lozenge/Lollipop 120 Actiq 400 MCG Lozenge/Lollipop 120 Actiq 600 MCG Lozenge/Lollipop 120 Actiq 800 MCG Lozenge/Lollipop 120 Advair 100/50 Inhaler 1 inhaler Advair 250/50 Inhaler 1 inhaler Advair 500/50 Inhaler 1 inhaler Aerobid/Aerobid M Inhaler 3 inhalers Albuterol/Proventil/Ventolin Inhaler 2 inhalers Alupent/ metoproteranol Inhaler 2 inhalers Amerge 1mg Tablet 18 Amerge 2.5mg Tablet 18 Anzemet 50mg, 100mg Tablet 10 Astelin Spray 1 bottle Atrovent Inhaler 2 inhalers Atrovent Nasal Spray 1 bottle Avonex 2 Kits 8 injections Axert 12.5mg Tablet 12 Axert 6.25mg Tablet 12 Azmacort Inhaler 2 inhalers Bactroban Nasal Ointment 2 tubes Betaseron Injection 15 injections Combivent Inhaler 2 inhalers Copaxone Kit 1 kit Diflucan 150mg Tablet 3 Duo-neb Inhaler 3 -60pk cartons Duragesic 100 MCG/HR Patch 15 Duragesic 25 MCG/HR Patch 15 Duragesic 50 MCG/HR Patch 15 Duragesic 75 MCG/HR Patch 15 Emend 80mg, 120mg Tablet 6 Quantity Limit Drug List – Members Page 1 of 3 Esclim 0.025mg Patch 8 Esclim 0.0375mg Patch 8 Flonase Spray 1 bottle Flovent 110 HFA Inhaler 2 inhalers Flovent 220 HFA Inhaler 1 inhaler Flovent 44 HFA Inhaler 5 inhalers Flunisolide Spray 3 bottles Foradil Inhaler 1 blister pack Frova 2.5mg Tablet 12 Golytely Solution 4000ml Imitrex 100mg Tablet 18 Imitrex 20mg Nasal 1 box Imitrex 25mg Tablet 18 Imitrex 50mg Tablet 18 Imitrex 5mg Nasal 1 box Imitrex Stat dose Injection 8 injections Intal 112 Inhaler 2 inhalers Intal 200 Inhaler 2 inhalers Kytril 1mg Tablet 12 Lovenox all strengths Injection 12 Maxair Autohaler Inhaler 1 inhaler Maxalt 10mg Tablet 12 Maxalt 5mg Tablet 12 Maxalt -MLT 10mg Tablet 12 Maxalt -MLT 5mg Tablet 12 Nasacort AQ Spray 2 bottles Nasonex Spray 1 bottle Ortho Evra Patch 4 patches Oxycontin (each strength) Tablet 90 Proventil HFA\ Ventolin HFA Inhaler 2 inhalers Pulmicort Inhaler 2 inhalers Qvar Inhaler 2 inhalers Rebif 22 mcg, 44 mcg Injection 12 injections Relpax 20 mg Tablet 12 Relpax 40 mg Tablet 12 Rhinocort AQ Spray 2 inhalers Serevent Inhaler 2 inhalers Serevent Discus Inhaler 1 60pk carton Tilade Inhaler 2 inhalers Vivelle,Vivelle dot (each strength) Patch 8 Zofran 4mg, 8mg Tablet 18 Zofran ODT 4mg, 8mg Tablet 18 Zofran Oral Solution Solution 2 bottles Quantity Limit Drug List – Members Page 2 of 3 Zomig 2.5mg Tablet 12 Zomig 5 mg Tablet 12 Zomig Spray Nasal 2 boxes Zomig ZMT 2.5mg Tablet 12 Zomig ZMT 5mg Tablet 12 The Formulary is a list of preferred medications, and all plans may not provide coverage for all medications listed. Coverage of prescription drugs and supplies listed on the drug list/formulary is subject to your benefit plan's design and coverage provisions. If there are any differences between the information contained herein and a specific plan document, the plan document will govern. For additional questions about benefits or coverage, call the customer service phone number printed on your Blue Cross and Blue Shield ID card. This list is subject to change without notice. For the most current version, visit www.bcbsok.com. Effective Aug. 1, 2005. ® Registered marks Blue Cross Blue Shield Association Quantity Limit Drug List – Members Page 3 of 3 .