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2013 Medicare High Performance 1 Tier QLL Criteria

ABILIFY DISCMELT®

ABILIFY DISCMELT 10 MG TABLET - Limited to a quantity of 102 per 34 days. ABILIFY DISCMELT 15 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY®

ABILIFY 10 MG TABLET - Limited to a quantity of 102 per 34 days. ABILIFY 15 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY 2 MG TABLET - Limited to a quantity of 510 per 34 days. ABILIFY 20 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY 30 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 5 MG TABLET - Limited to a quantity of 204 per 34 days. acarbose

acarbose 100 mg tablet - Limited to a quantity of 102 per 34 days. acarbose 25 mg tablet - Limited to a quantity of 408 per 34 days. acarbose 50 mg tablet - Limited to a quantity of 204 per 34 days. ACTOPLUS MET XR®

ACTOPLUS MET XR 15-1,000 MG TB - Limited to a quantity of 68 per 34 days. ACTOPLUS MET XR 30-1,000 MG TB - Limited to a quantity of 34 per 34 days. ACTOPLUS MET®

ACTOPLUS MET 15 MG-500 MG TAB - Limited to a quantity of 102 per 34 days. ACTOPLUS MET 15 MG-850 MG TAB - Limited to a quantity of 102 per 34 days. ACTOS 15 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOS 30 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOS 45 MG TABLET - Limited to a quantity of 34 per 34 days. ADCIRCA®

ADCIRCA 20 MG TABLET - Limited to a quantity of 68 per 34 days. ADVAIR DISKUS®

ADVAIR 100-50 DISKUS - Limited to a quantity of 120 doses per 30 days. ADVAIR 250-50 DISKUS - Limited to a quantity of 120 doses per 30 days. ADVAIR 500-50 DISKUS - Limited to a quantity of 120 doses per 30 days. ADVAIR HFA®

ADVAIR HFA 115-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA 230-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA 45-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVICOR®

ADVICOR 1,000 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days. ADVICOR 1,000 MG-40 MG TABLET - Limited to a quantity of 68 per 34 days. ADVICOR 500 MG-20 MG TABLET - Limited to a quantity of 34 per 34 days. ADVICOR 750 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days. alendronate

alendronate sodium 10 mg tab - Limited to a quantity of 34 per 34 days. alendronate sodium 35 mg tab - Limited to a quantity of 5 per 35 days. alendronate sodium 40 mg tab - Limited to a quantity of 34 per 34 days. alendronate sodium 5 mg tablet - Limited to a quantity of 34 per 34 days. alendronate sodium 70 mg tab - Limited to a quantity of 5 per 35 days. ALOXI 0.25 MG/5 ML VIAL - Limited to a quantity of 10 per 30 days. ASMANEX®

ASMANEX TWISTHALER 110 MCG #30 - Limited to a quantity of 60 doses per 30 ASMANEX TWISTHALER 220 MCG #14 - Limited to a quantity of 14 doses per 14 ASMANEX TWISTHALER 220 MCG #30 - Limited to a quantity of 60 doses per 30 ASMANEX TWISTHALER 220 MCG #60 - Limited to a quantity of 120 doses per 30 ASMANEX TWISTHALR 220 MCG #120 - Limited to a quantity of 240 doses per 30 atorvastatin calcium

atorvastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. atorvastatin 20 mg tablet - Limited to a quantity of 34 per 34 days. atorvastatin 40 mg tablet - Limited to a quantity of 34 per 34 days. atorvastatin 80 mg tablet - Limited to a quantity of 34 per 34 days. ATROVENT HFA®

ATROVENT HFA INHALER - Limited to a quantity of 26 gm per 34 days. AVONEX ADMINISTRATION PACK®

AVONEX ADMIN PACK 30 MCG VL - Limited to a quantity of 4 kits per 28 days. AVONEX®

AVONEX PREFILLED SYR 30 MCG - Limited to a quantity of 4 kits per 28 days. azelastine hcl

azelastine 137 mcg nasal spray - Limited to a quantity of 60 ml per 34 days. BONIVA®

BONIVA 150 MG TABLET - Limited to a quantity of 1 per 30 days. bupropion

budeprion sr 100 mg tablet - Limited to a quantity of 136 per 34 days. budeprion sr 150 mg tablet - Limited to a quantity of 102 per 34 days. bupropion hcl sr 100 mg tablet - Limited to a quantity of 136 per 34 days. bupropion hcl sr 200 mg tab - Limited to a quantity of 68 per 34 days. bupropion sr 150 mg tablet - Limited to a quantity of 102 per 34 days. butorphanol

butorphanol 10 mg/ml spray - Limited to a quantity of 5 ml per 3 days. BYETTA®

BYETTA 10 MCG DOSE PEN INJ - Limited to a quantity of 5 ml per 34 days. BYETTA 5 MCG DOSE PEN INJ - Limited to a quantity of 2 ml per 34 days. cabergoline

cabergoline 0.5 mg tablet - Limited to a quantity of 20 per 34 days. CAYSTON®

CAYSTON 75 MG INHAL SOLUTION - Limited to a quantity of 84 per 28 days. CESAMET®

CESAMET 1 MG CAPSULE - Limited to a quantity of 30 per 5 days. citalopram

citalopram hbr 10 mg tablet - Limited to a quantity of 136 per 34 days. citalopram hbr 20 mg tablet - Limited to a quantity of 68 per 34 days. citalopram hbr 40 mg tablet - Limited to a quantity of 34 per 34 days. clonidine

clonidine 0.1 mg/day patch - Limited to a quantity of 5 per 35 days. clonidine 0.2 mg/day patch - Limited to a quantity of 5 per 35 days. clonidine 0.3 mg/day patch - Limited to a quantity of 5 per 35 days. COMBIVENT RESPIMAT®

COMBIVENT RESPIMAT INHAL SPRAY - Limited to a quantity of 8 gm per 34 days. COMBIVENT®

COMBIVENT INHALER - Limited to a quantity of 44 gm per 34 days. COPAXONE®

COPAXONE 20 MG INJECTION KIT - Limited to a quantity of 30 per 30 days. CRESTOR®

CRESTOR 10 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 20 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 40 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 5 MG TABLET - Limited to a quantity of 34 per 34 days. CYMBALTA®

CYMBALTA 20 MG CAPSULE - Limited to a quantity of 204 per 34 days. CYMBALTA 30 MG CAPSULE - Limited to a quantity of 136 per 34 days. CYMBALTA 60 MG CAPSULE - Limited to a quantity of 68 per 34 days. desloratadine

desloratadine 5 mg tablet - Limited to a quantity of 34 per 34 days. doxazosin

doxazosin mesylate 1 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 2 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 4 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 8 mg tab - Limited to a quantity of 68 per 34 days. DUETACT®

DUETACT 30-2 MG TABLET - Limited to a quantity of 34 per 34 days. DUETACT 30-4 MG TABLET - Limited to a quantity of 34 per 34 days. EMEND 125 MG CAPSULE - Limited to a quantity of 1 per 1 day. EMEND 40 MG CAPSULE - Limited to a quantity of 1 per 1 day. EMEND 80 MG CAPSULE - Limited to a quantity of 2 per 2 days. EMEND TRIFOLD PACK - Limited to a quantity of 3 per 3 days. ENBREL®

ENBREL 25 MG KIT - Limited to a quantity of 10 per 35 days. ENBREL 25 MG/0.5 ML SYRINGE - Limited to a quantity of 10 per 35 days. ENBREL 50 MG/ML SYRINGE - Limited to a quantity of 10 per 35 days. EPIPEN 2-PAK®

EPIPEN 2-PAK 0.3 MG AUTO-INJCT - Limited to a quantity of 4 pens per 2 days. EPIPEN JR 2-PAK®

EPIPEN JR 2-PAK 0.15 MG INJCTR - Limited to a quantity of 4 pens per 2 days. escitalopram oxalate

escitalopram 10 mg tablet - Limited to a quantity of 68 per 34 days. escitalopram 20 mg tablet - Limited to a quantity of 34 per 34 days. escitalopram 5 mg tablet - Limited to a quantity of 136 per 34 days. estradiol

estradiol tds 0.025 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.0375 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.05 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.06 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.075 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.1 mg/day - Limited to a quantity of 5 per 35 days. famciclovir

famciclovir 125 mg tablet - Limited to a quantity of 21 per 10 days. famciclovir 250 mg tablet - Limited to a quantity of 68 per 34 days. famciclovir 500 mg tablet - Limited to a quantity of 21 per 7 days. FANAPT®

FANAPT 1 MG TABLET - Limited to a quantity of 816 per 34 days. FANAPT 10 MG TABLET - Limited to a quantity of 102 per 34 days. FANAPT 12 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 2 MG TABLET - Limited to a quantity of 408 per 34 days. FANAPT 4 MG TABLET - Limited to a quantity of 204 per 34 days. FANAPT 6 MG TABLET - Limited to a quantity of 136 per 34 days. FANAPT 8 MG TABLET - Limited to a quantity of 102 per 34 days. FANAPT TITRATION PACK - Limited to a quantity of 1 per 34 days. fentanyl citrate

fentanyl cit otfc 1,200 mcg - Limited to a quantity of 120 per 30 days. fentanyl cit otfc 1,600 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 200 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 400 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 600 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 800 mcg - Limited to a quantity of 120 per 30 days. fluconazole

fluconazole 150 mg tablet - Limited to a quantity of 2 per 7 days. flunisolide

flunisolide 0.025% spray - Limited to a quantity of 75 ml per 34 days. fluoxetine

fluoxetine dr 90 mg capsule - Limited to a quantity of 5 per 34 days. fluoxetine hcl 10 mg capsule - Limited to a quantity of 272 per 34 days. fluoxetine hcl 10 mg tablet - Limited to a quantity of 272 per 34 days. fluoxetine hcl 40 mg capsule - Limited to a quantity of 68 per 34 days. fluticasone propionate

fluticasone prop 50 mcg spray - Limited to a quantity of 32 gm per 34 days. fluvastatin

fluvastatin sodium 20 mg cap - Limited to a quantity of 34 per 34 days. fluvastatin sodium 40 mg cap - Limited to a quantity of 68 per 34 days. fluvoxamine

fluvoxamine maleate 100 mg tab - Limited to a quantity of 102 per 34 days. fluvoxamine maleate 25 mg tab - Limited to a quantity of 408 per 34 days. fluvoxamine maleate 50 mg tab - Limited to a quantity of 204 per 34 days. FORADIL®

FORADIL AEROLIZER 12 MCG CAP - Limited to a quantity of 120 per 34 days. FORTEO®

FORTEO 600 MCG/2.4 ML PEN INJ - Limited to a quantity of 3 pens per 28 days. glimepiride

glimepiride 1 mg tablet - Limited to a quantity of 272 per 34 days. glimepiride 2 mg tablet - Limited to a quantity of 136 per 34 days. glimepiride 4 mg tablet - Limited to a quantity of 68 per 34 days. glipizide

glipizide 10 mg tablet - Limited to a quantity of 136 per 34 days. glipizide 5 mg tablet - Limited to a quantity of 272 per 34 days. glipizide er 10 mg tablet - Limited to a quantity of 68 per 34 days. glipizide er 2.5 mg tablet - Limited to a quantity of 272 per 34 days. glipizide er 5 mg tablet - Limited to a quantity of 136 per 34 days. glipizide/metformin hcl

glipizide-metformin 2.5-250 mg - Limited to a quantity of 272 per 34 days. glipizide-metformin 2.5-500 mg - Limited to a quantity of 136 per 34 days. glipizide-metformin 5-500 mg - Limited to a quantity of 136 per 34 days. glyburide

glyburide 1.25 mg tablet - Limited to a quantity of 544 per 34 days. glyburide 2.5 mg tablet - Limited to a quantity of 272 per 34 days. glyburide 5 mg tablet - Limited to a quantity of 136 per 34 days. glyburide micro 1.5 mg tab - Limited to a quantity of 272 per 34 days. glyburide micro 3 mg tablet - Limited to a quantity of 136 per 34 days. glyburide micro 6 mg tablet - Limited to a quantity of 68 per 34 days. glyburide/metformin hcl

glyburide-metformin 2.5-500 mg - Limited to a quantity of 136 per 34 days. glyburide-metformin 5-500 mg - Limited to a quantity of 136 per 34 days. glyburid-metformin 1.25-250 mg - Limited to a quantity of 272 per 34 days. granisetron

granisetron hcl 1 mg tablet - Limited to a quantity of 2 per 1 day. granisol 2 mg/10 ml solution - Limited to a quantity of 30 ml per 3 days. HUMIRA®

HUMIRA 20 MG/0.4 ML SYRINGE - Limited to a quantity of 5 syringes per 35 days. HUMIRA 40 MG/0.8 ML SYRINGE - Limited to a quantity of 5 syringes per 35 days. HUMIRA CROHN'S STARTER PACK - Limited to a quantity of 6 syringes per 180 ibandronate

ibandronate sodium 150 mg tab - Limited to a quantity of 1 per 30 days. INVEGA®

INVEGA ER 1.5 MG TABLET - Limited to a quantity of 272 per 34 days. INVEGA ER 3 MG TABLET - Limited to a quantity of 136 per 34 days. INVEGA ER 6 MG TABLET - Limited to a quantity of 68 per 34 days. INVEGA ER 9 MG TABLET - Limited to a quantity of 46 per 34 days. ipratropium

ipratropium 0.03% spray - Limited to a quantity of 60 ml per 34 days. ipratropium 0.06% spray - Limited to a quantity of 30 ml per 34 days. itraconazole

itraconazole 100 mg capsule - Limited to a quantity of 136 per 34 days. JANUMET XR®

JANUMET XR 100-1,000 MG TABLET - Limited to a quantity of 34 per 34 days. JANUMET XR 50-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. JANUMET XR 50-500 MG TABLET - Limited to a quantity of 34 per 34 days. JANUMET®

JANUMET 50-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. JANUMET 50-500 MG TABLET - Limited to a quantity of 68 per 34 days. JANUVIA®

JANUVIA 100 MG TABLET - Limited to a quantity of 34 per 34 days. JANUVIA 25 MG TABLET - Limited to a quantity of 34 per 34 days. JANUVIA 50 MG TABLET - Limited to a quantity of 34 per 34 days. JUVISYNC®

JUVISYNC 100-10 MG TABLET - Limited to a quantity of 34 per 34 days. JUVISYNC 100-20 MG TABLET - Limited to a quantity of 34 per 34 days. JUVISYNC 100-40 MG TABLET - Limited to a quantity of 34 per 34 days. ketorolac

ketorolac 10 mg tablet - Limited to a quantity of 20 per 5 days. KOMBIGLYZE XR®

KOMBIGLYZE XR 2.5-1,000 MG TAB - Limited to a quantity of 68 per 34 days. KOMBIGLYZE XR 5-1,000 MG TAB - Limited to a quantity of 34 per 34 days. KOMBIGLYZE XR 5-500 MG TABLET - Limited to a quantity of 34 per 34 days. lansoprazole

lansoprazole dr 15 mg capsule - Limited to a quantity of 34 per 34 days. LATUDA®

LATUDA 20 MG TABLET - Limited to a quantity of 34 per 34 days. LATUDA 40 MG TABLET - Limited to a quantity of 68 per 34 days. LATUDA 80 MG TABLET - Limited to a quantity of 34 per 34 days. leflunomide

leflunomide 10 mg tablet - Limited to a quantity of 34 per 34 days. leflunomide 20 mg tablet - Limited to a quantity of 34 per 34 days. levocetirizine dihydrochlor

levocetirizine 5 mg tablet - Limited to a quantity of 34 per 34 days. levonorgestrel

next choice 0.75 mg tablet - Limited to a quantity of 2 per 1 day. lovastatin

lovastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. lovastatin 20 mg tablet - Limited to a quantity of 68 per 34 days. lovastatin 40 mg tablet - Limited to a quantity of 68 per 34 days. medroxyprogesterone

medroxyprogesterone 150 mg/ml - Limited to a quantity of 1 per 90 days. meloxicam

meloxicam 7.5 mg tablet - Limited to a quantity of 34 per 34 days. metformin

metformin hcl 1,000 mg tablet - Limited to a quantity of 85 per 34 days. metformin hcl 500 mg tablet - Limited to a quantity of 170 per 34 days. metformin hcl 850 mg tablet - Limited to a quantity of 102 per 34 days. metformin hcl er 500 mg tablet - Limited to a quantity of 136 per 34 days. metformin hcl er 750 mg tablet - Limited to a quantity of 85 per 34 days. miconazole nitrate

miconazole 3 200 mg vag supp - Limited to a quantity of 3 per 3 days. morphine

morphine sulf er 100 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 15 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 200 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 30 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 60 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulfate er 100 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 20 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 30 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 50 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 60 mg cap - Limited to a quantity of 90 per 30 days. morphine sulfate er 80 mg cap - Limited to a quantity of 90 per 30 days. naratriptan

naratriptan hcl 1 mg tablet - Limited to a quantity of 18 per 28 days. naratriptan hcl 2.5 mg tablet - Limited to a quantity of 18 per 28 days. nateglinide

nateglinide 120 mg tablet - Limited to a quantity of 102 per 34 days. nateglinide 60 mg tablet - Limited to a quantity of 204 per 34 days. NEULASTA®

NEULASTA 6 MG/0.6 ML SYRINGE - Limited to a quantity of 2 syringes per 30 NEUMEGA®

NEUMEGA 5 MG VIAL - Limited to a quantity of 21 vials per 21 days. NEXIUM®

NEXIUM DR 10 MG PACKET - Limited to a quantity of 34 per 34 days. NEXIUM DR 20 MG CAPSULE - Limited to a quantity of 34 per 34 days. NEXIUM DR 20 MG PACKET - Limited to a quantity of 34 per 34 days. olanzapine

olanzapine 10 mg tablet - Limited to a quantity of 68 per 34 days. olanzapine 15 mg tablet - Limited to a quantity of 45 per 34 days. olanzapine 2.5 mg tablet - Limited to a quantity of 272 per 34 days. olanzapine 20 mg tablet - Limited to a quantity of 34 per 34 days. olanzapine 5 mg tablet - Limited to a quantity of 136 per 34 days. olanzapine 7.5 mg tablet - Limited to a quantity of 91 per 34 days. olanzapine odt 10 mg tablet - Limited to a quantity of 68 per 34 days. olanzapine odt 15 mg tablet - Limited to a quantity of 45 per 34 days. olanzapine odt 20 mg tablet - Limited to a quantity of 34 per 34 days. olanzapine odt 5 mg tablet - Limited to a quantity of 136 per 34 days. omeprazole

omeprazole dr 10 mg capsule - Limited to a quantity of 34 per 34 days. omeprazole dr 20 mg capsule - Limited to a quantity of 34 per 34 days. omeprazole/sodium bicarbonat

omeprazole-bicarb 20-1,100 cap - Limited to a quantity of 34 per 34 days. ondansetron

ondansetron 4 mg/5 ml solution - Limited to a quantity of 150 ml per 5 days. ondansetron hcl 24 mg tablet - Limited to a quantity of 1 per 1 day. ondansetron hcl 4 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron hcl 8 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron odt 4 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron odt 8 mg tablet - Limited to a quantity of 12 per 5 days. ONGLYZA®

ONGLYZA 2.5 MG TABLET - Limited to a quantity of 34 per 34 days. ONGLYZA 5 MG TABLET - Limited to a quantity of 34 per 34 days. OPANA ER®

OPANA ER 10 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 20 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 30 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 40 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 5 MG TABLET - Limited to a quantity of 90 per 30 days. oxybutynin

oxybutynin cl er 5 mg tablet - Limited to a quantity of 34 per 34 days. OXYCONTIN®

OXYCONTIN 10 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 15 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 20 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 30 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 40 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 60 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 80 MG TABLET - Limited to a quantity of 90 per 30 days. oxymorphone

oxymorphone hcl er 15 mg tab - Limited to a quantity of 90 per 30 days. oxymorphone hcl er 7.5 mg tab - Limited to a quantity of 90 per 30 days. pantoprazole

pantoprazole sod dr 20 mg tab - Limited to a quantity of 34 per 34 days. paroxetine

paroxetine cr 12.5 mg tablet - Limited to a quantity of 204 per 34 days. paroxetine cr 25 mg tablet - Limited to a quantity of 102 per 34 days. paroxetine er 37.5 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine hcl 10 mg tablet - Limited to a quantity of 204 per 34 days. paroxetine hcl 20 mg tablet - Limited to a quantity of 102 per 34 days. paroxetine hcl 30 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine hcl 40 mg tablet - Limited to a quantity of 51 per 34 days. PEGASYS PROCLICK®

PEGASYS PROCLICK 135 MCG/0.5 - Limited to a quantity of 4 per 28 days. PEGASYS®

PEGASYS 180 MCG/0.5 ML SYRINGE - Limited to a quantity of 4 syringes per 28 PEGASYS 180 MCG/ML VIAL - Limited to a quantity of 4 vials per 28 days. PEGINTRON REDIPEN®

PEGINTRON REDIPEN 120 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 150 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 50 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 80 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON®

PEGINTRON 50 MCG KIT - Limited to a quantity of 5 kits per 34 days. pioglitazone hcl

pioglitazone hcl 15 mg tablet - Limited to a quantity of 34 per 34 days. pioglitazone hcl 30 mg tablet - Limited to a quantity of 34 per 34 days. pioglitazone hcl 45 mg tablet - Limited to a quantity of 34 per 34 days. pioglitazone hcl/metformin hc

pioglitazone-metformin 15-500 - Limited to a quantity of 102 per 34 days. pioglitazone-metformin 15-850 - Limited to a quantity of 102 per 34 days. pravastatin

pravastatin sodium 10 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 20 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 40 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 80 mg tab - Limited to a quantity of 34 per 34 days. PRISTIQ ER®

PRISTIQ ER 100 MG TABLET - Limited to a quantity of 136 per 34 days. PRISTIQ ER 50 MG TABLET - Limited to a quantity of 272 per 34 days. PROAIR HFA®

PROAIR HFA 90 MCG INHALER - Limited to a quantity of 26 gm per 34 days. PROVENTIL HFA®

PROVENTIL HFA 90 MCG INHALER - Limited to a quantity of 20 gm per 34 days. quetiapine fumarate

quetiapine fumarate 100 mg tab - Limited to a quantity of 272 per 34 days. quetiapine fumarate 200 mg tab - Limited to a quantity of 136 per 34 days. quetiapine fumarate 25 mg tab - Limited to a quantity of 1022 per 34 days. quetiapine fumarate 300 mg tab - Limited to a quantity of 91 per 34 days. quetiapine fumarate 400 mg tab - Limited to a quantity of 68 per 34 days. quetiapine fumarate 50 mg tab - Limited to a quantity of 544 per 34 days. QVAR 40 MCG INHALER - Limited to a quantity of 22 per 34 days. QVAR 80 MCG INHALER - Limited to a quantity of 22 per 34 days. REBIF 22 MCG/0.5 ML SYRINGE - Limited to a quantity of 8 ml per 35 days. REBIF 44 MCG/0.5 ML SYRINGE - Limited to a quantity of 8 ml per 35 days. REBIF TITRATION PACK - Limited to a quantity of 12 syringes per 28 days. REGRANEX®

REGRANEX 0.01% GEL - Limited to a quantity of 30 gm per 34 days. RELENZA®

RELENZA 5 MG DISKHALER - Limited to a quantity of 60 inhalations per 180 days. RESTASIS®

RESTASIS 0.05% EYE EMULSION - Limited to a quantity of 60 vials per 30 days. revatio (sildenafil citrate)

sildenafil 20 mg tablet - Limited to a quantity of 102 per 34 days. RIOMET®

RIOMET 500 MG/5 ML SOLUTION - Limited to a quantity of 867 per 34 days. risperidone

risperidone 0.25 mg odt - Limited to a quantity of 2176 per 34 days. risperidone 0.25 mg tablet - Limited to a quantity of 2176 per 34 days. risperidone 0.5 mg odt - Limited to a quantity of 1088 per 34 days. risperidone 0.5 mg tablet - Limited to a quantity of 1088 per 34 days. risperidone 1 mg odt - Limited to a quantity of 544 per 34 days. risperidone 1 mg tablet - Limited to a quantity of 544 per 34 days. risperidone 1 mg/ml solution - Limited to a quantity of 544 ml per 34 days. risperidone 2 mg odt - Limited to a quantity of 272 per 34 days. risperidone 2 mg tablet - Limited to a quantity of 272 per 34 days. risperidone 3 mg odt - Limited to a quantity of 182 per 34 days. risperidone 3 mg tablet - Limited to a quantity of 182 per 34 days. risperidone 4 mg odt - Limited to a quantity of 136 per 34 days. risperidone 4 mg tablet - Limited to a quantity of 136 per 34 days. ROZEREM®

ROZEREM 8 MG TABLET - Limited to a quantity of 34 per 34 days. SAMSCA®

SAMSCA 15 MG TABLET - Limited to a quantity of 68 per 34 days. SAMSCA 30 MG TABLET - Limited to a quantity of 68 per 34 days. SANDOSTATIN LAR®

SANDOSTATIN LAR 10 MG KIT - Limited to a quantity of 1 per 28 days. SANDOSTATIN LAR 20 MG KIT - Limited to a quantity of 2 per 28 days. SANDOSTATIN LAR 30 MG KIT - Limited to a quantity of 1 per 28 days. SAPHRIS®

SAPHRIS 10 MG TAB SUBLINGUAL - Limited to a quantity of 68 per 34 days. SAPHRIS 5 MG TABLET SUBLINGUAL - Limited to a quantity of 136 per 34 days. SAVELLA®

SAVELLA 100 MG TABLET - Limited to a quantity of 68 per 34 days. SAVELLA 12.5 MG TABLET - Limited to a quantity of 544 per 34 days. SAVELLA 25 MG TABLET - Limited to a quantity of 272 per 34 days. SAVELLA 50 MG TABLET - Limited to a quantity of 136 per 34 days. SAVELLA TITRATION PACK - Limited to a quantity of 1 per 34 days. SEREVENT DISKUS®

SEREVENT DISKUS 50 MCG - Limited to a quantity of 120 doses per 34 days. SEROQUEL XR®

SEROQUEL XR 150 MG TABLET - Limited to a quantity of 182 per 34 days. SEROQUEL XR 200 MG TABLET - Limited to a quantity of 136 per 34 days. SEROQUEL XR 300 MG TABLET - Limited to a quantity of 91 per 34 days. SEROQUEL XR 400 MG TABLET - Limited to a quantity of 68 per 34 days. SEROQUEL XR 50 MG TABLET - Limited to a quantity of 544 per 34 days. sertraline

sertraline hcl 100 mg tablet - Limited to a quantity of 68 per 34 days. sertraline hcl 25 mg tablet - Limited to a quantity of 272 per 34 days. sertraline hcl 50 mg tablet - Limited to a quantity of 136 per 34 days. SIMCOR®

SIMCOR 1,000-40 MG TABLET - Limited to a quantity of 34 per 34 days. SIMCOR 500-20 MG TABLET - Limited to a quantity of 34 per 34 days. SIMCOR 500-40 MG TABLET - Limited to a quantity of 34 per 34 days. SIMCOR 750-20 MG TABLET - Limited to a quantity of 68 per 34 days. simvastatin

simvastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 20 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 40 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 5 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 80 mg tablet - Limited to a quantity of 34 per 34 days. SPIRIVA®

SPIRIVA 18 MCG CP-HANDIHALER - Limited to a quantity of 60 capsules per 30 SUBOXONE®

SUBOXONE 2 MG-0.5 MG SL FILM - Limited to a quantity of 102 per 34 days. SUBOXONE 2 MG-0.5 MG TABLET SL - Limited to a quantity of 102 per 34 days. SUBOXONE 8 MG-2 MG SL FILM - Limited to a quantity of 102 per 34 days. SUBOXONE 8 MG-2 MG TABLET SL - Limited to a quantity of 102 per 34 days. sumatriptan

sumatriptan 6 mg/0.5 ml inject - Limited to a quantity of 16 vials per 28 days. sumatriptan 6 mg/0.5 ml vial - Limited to a quantity of 16 vials per 28 days. sumatriptan succ 100 mg tablet - Limited to a quantity of 18 per 28 days. sumatriptan succ 25 mg tablet - Limited to a quantity of 18 per 28 days. sumatriptan succ 50 mg tablet - Limited to a quantity of 18 per 28 days. SYMBICORT®

SYMBICORT 160-4.5 MCG INHALER - Limited to a quantity of 20 per 34 days. SYMBICORT 80-4.5 MCG INHALER - Limited to a quantity of 20 per 34 days. SYMLINPEN 120®

SYMLINPEN 120 PEN INJECTOR - Limited to a quantity of 22 ml per 34 days. SYMLINPEN 60®

SYMLINPEN 60 PEN INJECTOR - Limited to a quantity of 12 pens per 34 days. TAMIFLU®

TAMIFLU 30 MG GELCAP - Limited to a quantity of 84 per 180 days. TAMIFLU 45 MG GELCAP - Limited to a quantity of 42 per 180 days. TAMIFLU 6 MG/ML SUSPENSION - Limited to a quantity of 600 ml per 180 days. TAMIFLU 75 MG GELCAP - Limited to a quantity of 42 per 180 days. terazosin

terazosin 1 mg capsule - Limited to a quantity of 34 per 34 days. terazosin 10 mg capsule - Limited to a quantity of 68 per 34 days. terazosin 2 mg capsule - Limited to a quantity of 34 per 34 days. terazosin 5 mg capsule - Limited to a quantity of 34 per 34 days. terconazole

terconazole 0.4% cream - Limited to a quantity of 45 gm per 7 days. terconazole 0.8% cream - Limited to a quantity of 20 gm per 3 days. terconazole 80 mg suppository - Limited to a quantity of 3 per 3 days. zazole vaginal 0.4% cream - Limited to a quantity of 45 gm per 7 days. TOBI 300 MG/5 ML SOLUTION - Limited to a quantity of 56 ampules per 28 days. tolazamide

tolazamide 250 mg tablet - Limited to a quantity of 136 per 34 days. tolazamide 500 mg tablet - Limited to a quantity of 68 per 34 days. tolbutamide

tolbutamide 500 mg tablet - Limited to a quantity of 204 per 34 days. tramadol

tramadol er 300 mg tablet - Limited to a quantity of 34 per 34 days. tramadol hcl 50 mg tablet - Limited to a quantity of 272 per 34 days. tramadol hcl er 100 mg tablet - Limited to a quantity of 34 per 34 days. tramadol hcl er 200 mg tablet - Limited to a quantity of 34 per 34 days. tramadol/apap

tramadol-acetaminophn 37.5-325 - Limited to a quantity of 272 per 34 days. triamcinolone acetonide

triamcinolone 55 mcg nasal spr - Limited to a quantity of 33 gm per 34 days. TUDORZA PRESSAIR®

TUDORZA PRESSAIR 400 MCG INH - Limited to a quantity of 2 per 34 days. valacyclovir

valacyclovir hcl 1 gram tablet - Limited to a quantity of 34 per 34 days. valacyclovir hcl 500 mg tablet - Limited to a quantity of 34 per 34 days. venlafaxine

venlafaxine hcl 100 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl 25 mg tablet - Limited to a quantity of 306 per 34 days. venlafaxine hcl 37.5 mg tablet - Limited to a quantity of 204 per 34 days. venlafaxine hcl 50 mg tablet - Limited to a quantity of 170 per 34 days. venlafaxine hcl 75 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl er 150 mg cap - Limited to a quantity of 68 per 34 days. venlafaxine hcl er 37.5 mg cap - Limited to a quantity of 204 per 34 days. venlafaxine hcl er 75 mg cap - Limited to a quantity of 102 per 34 days. VIIBRYD®

VIIBRYD 10 MG TABLET - Limited to a quantity of 136 per 34 days. VIIBRYD 20 MG TABLET - Limited to a quantity of 68 per 34 days. VIIBRYD 40 MG TABLET - Limited to a quantity of 34 per 34 days. VIIBRYD TITRATION PACK - Limited to a quantity of 30 per 30 days. VIVELLE-DOT®

VIVELLE-DOT 0.025 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.0375 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.05 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.075 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.1 MG PATCH - Limited to a quantity of 10 per 35 days. XOLAIR®

XOLAIR 150 MG VIAL - Limited to a quantity of 6 vials per 28 days. zaleplon

zaleplon 10 mg capsule - Limited to a quantity of 68 per 34 days. zaleplon 5 mg capsule - Limited to a quantity of 34 per 34 days. ziprasidone

ziprasidone hcl 20 mg capsule - Limited to a quantity of 272 per 34 days. ziprasidone hcl 40 mg capsule - Limited to a quantity of 136 per 34 days. ziprasidone hcl 60 mg capsule - Limited to a quantity of 91 per 34 days. ziprasidone hcl 80 mg capsule - Limited to a quantity of 68 per 34 days. zolpidem

zolpidem tart er 12.5 mg tab - Limited to a quantity of 34 per 34 days. zolpidem tart er 6.25 mg tab - Limited to a quantity of 34 per 34 days. zolpidem tartrate 10 mg tablet - Limited to a quantity of 34 per 34 days. zolpidem tartrate 5 mg tablet - Limited to a quantity of 34 per 34 days. ZOMIG 5 MG NASAL SPRAY - Limited to a quantity of 18 nasal sprayers per 28 atorvastatin 10 mg tablet, 7 atorvastatin 20 mg tablet, 7 atorvastatin 40 mg tablet, 7 atorvastatin 80 mg tablet, 7 azelastine 137 mcg nasal spray, 7 budeprion sr 100 mg tablet, 7 budeprion sr 150 mg tablet, 7 bupropion hcl sr 100 mg tablet, 7 bupropion hcl sr 200 mg tab, 7 bupropion sr 150 mg tablet, 7 butorphanol 10 mg/ml spray, 7 cabergoline 0.5 mg tablet, 8 citalopram hbr 10 mg tablet, 8 citalopram hbr 20 mg tablet, 8 citalopram hbr 40 mg tablet, 8 clonidine 0.1 mg/day patch, 8 clonidine 0.2 mg/day patch, 8 clonidine 0.3 mg/day patch, 8 alendronate sodium 10 mg tab, 6 alendronate sodium 35 mg tab, 6 alendronate sodium 40 mg tab, 6 alendronate sodium 5 mg tablet, 6 alendronate sodium 70 mg tab, 6 CYMBALTA 60 MG CAPSULE, 9 desloratadine 5 mg tablet, 9 doxazosin mesylate 1 mg tab, 9 fluoxetine hcl 40 mg capsule, 11 doxazosin mesylate 2 mg tab, 9 fluticasone prop 50 mcg spray, 11 doxazosin mesylate 4 mg tab, 9 fluvastatin sodium 20 mg cap, 11 doxazosin mesylate 8 mg tab, 9 fluvastatin sodium 40 mg cap, 11 fluvoxamine maleate 100 mg tab, 11 fluvoxamine maleate 25 mg tab, 11 fluvoxamine maleate 50 mg tab, 11 glimepiride 1 mg tablet, 11 glimepiride 2 mg tablet, 11 glimepiride 4 mg tablet, 11 glipizide 10 mg tablet, 11 escitalopram 10 mg tablet, 10 glipizide er 10 mg tablet, 11 escitalopram 20 mg tablet, 10 glipizide er 2.5 mg tablet, 12 escitalopram 5 mg tablet, 10 glipizide er 5 mg tablet, 12 estradiol tds 0.025 mg/day, 10 glipizide-metformin 2.5-250 mg, 12 estradiol tds 0.0375 mg/day, 10 glipizide-metformin 2.5-500 mg, 12 estradiol tds 0.05 mg/day, 10 glipizide-metformin 5-500 mg, 12 estradiol tds 0.06 mg/day, 10 glyburide 1.25 mg tablet, 12 estradiol tds 0.075 mg/day, 10 glyburide 2.5 mg tablet, 12 estradiol tds 0.1 mg/day, 10 famciclovir 125 mg tablet, 10 glyburide micro 1.5 mg tab, 12 famciclovir 250 mg tablet, 10 glyburide micro 3 mg tablet, 12 famciclovir 500 mg tablet, 10 glyburide micro 6 mg tablet, 12 glyburide-metformin 2.5-500 mg, 12 glyburide-metformin 5-500 mg, 12 glyburid-metformin 1.25-250 mg, 12 granisetron hcl 1 mg tablet, 12 granisol 2 mg/10 ml solution, 12 fentanyl cit otfc 1,200 mcg, 10 fentanyl cit otfc 1,600 mcg, 10 ibandronate sodium 150 mg tab, 12 fentanyl citrate otfc 200 mcg, 10 fentanyl citrate otfc 400 mcg, 10 fentanyl citrate otfc 600 mcg, 10 fentanyl citrate otfc 800 mcg, 10 fluconazole 150 mg tablet, 10 ipratropium 0.03% spray, 13 flunisolide 0.025% spray, 11 ipratropium 0.06% spray, 13 fluoxetine dr 90 mg capsule, 11 itraconazole 100 mg capsule, 13 fluoxetine hcl 10 mg capsule, 11 fluoxetine hcl 10 mg tablet, 11 naratriptan hcl 1 mg tablet, 15 naratriptan hcl 2.5 mg tablet, 15 nateglinide 120 mg tablet, 15 nateglinide 60 mg tablet, 15 next choice 0.75 mg tablet, 14 olanzapine 10 mg tablet, 16 ketorolac 10 mg tablet, 13 olanzapine 15 mg tablet, 16 olanzapine 2.5 mg tablet, 16 olanzapine 20 mg tablet, 16 olanzapine 5 mg tablet, 16 olanzapine 7.5 mg tablet, 16 olanzapine odt 10 mg tablet, 16 lansoprazole dr 15 mg capsule, 14 olanzapine odt 15 mg tablet, 16 olanzapine odt 20 mg tablet, 16 olanzapine odt 5 mg tablet, 16 omeprazole dr 10 mg capsule, 16 leflunomide 10 mg tablet, 14 omeprazole dr 20 mg capsule, 16 leflunomide 20 mg tablet, 14 omeprazole-bicarb 20-1,100 cap, 16 levocetirizine 5 mg tablet, 14 ondansetron 4 mg/5 ml solution, 16 lovastatin 10 mg tablet, 14 ondansetron hcl 24 mg tablet, 16 lovastatin 20 mg tablet, 14 ondansetron hcl 4 mg tablet, 16 lovastatin 40 mg tablet, 14 ondansetron hcl 8 mg tablet, 16 medroxyprogesterone 150 mg/ml, 14 ondansetron odt 4 mg tablet, 16 meloxicam 7.5 mg tablet, 14 ondansetron odt 8 mg tablet, 16 metformin hcl 1,000 mg tablet, 14 metformin hcl 500 mg tablet, 14 metformin hcl 850 mg tablet, 14 metformin hcl er 500 mg tablet, 14 metformin hcl er 750 mg tablet, 14 miconazole 3 200 mg vag supp, 15 morphine sulf er 100 mg tablet, 15 morphine sulf er 15 mg tablet, 15 oxybutynin cl er 5 mg tablet, 17 morphine sulf er 200 mg tablet, 15 morphine sulf er 30 mg tablet, 15 morphine sulf er 60 mg tablet, 15 morphine sulfate er 100 mg cap, 15 morphine sulfate er 20 mg cap, 15 morphine sulfate er 30 mg cap, 15 morphine sulfate er 50 mg cap, 15 morphine sulfate er 60 mg cap, 15 oxymorphone hcl er 15 mg tab, 17 morphine sulfate er 80 mg cap, 15 oxymorphone hcl er 7.5 mg tab, 17 pantoprazole sod dr 20 mg tab, 17 paroxetine cr 12.5 mg tablet, 17 risperidone 0.25 mg odt, 19 paroxetine cr 25 mg tablet, 17 risperidone 0.25 mg tablet, 19 paroxetine er 37.5 mg tablet, 17 risperidone 0.5 mg odt, 19 paroxetine hcl 10 mg tablet, 17 risperidone 0.5 mg tablet, 19 paroxetine hcl 20 mg tablet, 17 paroxetine hcl 30 mg tablet, 17 risperidone 1 mg tablet, 20 paroxetine hcl 40 mg tablet, 17 risperidone 1 mg/ml solution, 20 risperidone 2 mg tablet, 20 risperidone 3 mg tablet, 20 risperidone 4 mg tablet, 20 pioglitazone hcl 15 mg tablet, 18 pioglitazone hcl 30 mg tablet, 18 pioglitazone hcl 45 mg tablet, 18 pioglitazone-metformin 15-500, 18 pioglitazone-metformin 15-850, 18 pravastatin sodium 10 mg tab, 18 pravastatin sodium 20 mg tab, 18 pravastatin sodium 40 mg tab, 18 pravastatin sodium 80 mg tab, 18 quetiapine fumarate 100 mg tab, 18 quetiapine fumarate 200 mg tab, 19 quetiapine fumarate 25 mg tab, 19 quetiapine fumarate 300 mg tab, 19 sertraline hcl 100 mg tablet, 21 quetiapine fumarate 400 mg tab, 19 sertraline hcl 25 mg tablet, 21 quetiapine fumarate 50 mg tab, 19 sertraline hcl 50 mg tablet, 21 sildenafil 20 mg tablet, 19 simvastatin 10 mg tablet, 21 simvastatin 20 mg tablet, 21 simvastatin 40 mg tablet, 21 simvastatin 5 mg tablet, 21 tramadol hcl er 200 mg tablet, 23 simvastatin 80 mg tablet, 21 tramadol-acetaminophn 37.5-325, 23 triamcinolone 55 mcg nasal spr, 23 valacyclovir hcl 1 gram tablet, 23 valacyclovir hcl 500 mg tablet, 23 venlafaxine hcl 100 mg tablet, 23 venlafaxine hcl 25 mg tablet, 23 venlafaxine hcl 37.5 mg tablet, 23 sumatriptan 6 mg/0.5 ml inject, 21 venlafaxine hcl 50 mg tablet, 23 sumatriptan 6 mg/0.5 ml vial, 21 venlafaxine hcl 75 mg tablet, 23 sumatriptan succ 100 mg tablet, 21 venlafaxine hcl er 150 mg cap, 23 sumatriptan succ 25 mg tablet, 21 venlafaxine hcl er 37.5 mg cap, 23 sumatriptan succ 50 mg tablet, 21 venlafaxine hcl er 75 mg cap, 23 terazosin 1 mg capsule, 22 terazosin 10 mg capsule, 22 zaleplon 10 mg capsule, 24 terazosin 2 mg capsule, 22 terazosin 5 mg capsule, 22 zazole vaginal 0.4% cream, 22 terconazole 0.4% cream, 22 ziprasidone hcl 20 mg capsule, 24 terconazole 0.8% cream, 22 ziprasidone hcl 40 mg capsule, 24 terconazole 80 mg suppository, 22 ziprasidone hcl 60 mg capsule, 24 ziprasidone hcl 80 mg capsule, 24 tolazamide 250 mg tablet, 22 zolpidem tart er 12.5 mg tab, 24 tolazamide 500 mg tablet, 22 zolpidem tart er 6.25 mg tab, 24 tolbutamide 500 mg tablet, 23 zolpidem tartrate 10 mg tablet, 24 tramadol er 300 mg tablet, 23 zolpidem tartrate 5 mg tablet, 24 tramadol hcl 50 mg tablet, 23 tramadol hcl er 100 mg tablet, 23

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