2011 Medicare National Preferred 4 Tier QLL Criteria · AMBIEN® AMBIEN 10 MG TABLET - Limited to a...

Updated: 08/2011 1

2011 Medicare National Preferred 4 Tier QLL Criteria

ABILIFY DISCMELT® ................................................................................................... 12

ABILIFY® ...................................................................................................................... 12

ABSTRAL® ................................................................................................................... 12

ACTIQ® ......................................................................................................................... 12

ACTONEL® ................................................................................................................... 12

ACTOPLUS MET XR® .................................................................................................. 13

ACTOPLUS MET® ........................................................................................................ 13

ACTOS® ....................................................................................................................... 13

ADCIRCA® ................................................................................................................... 13

ADVAIR DISKUS® ........................................................................................................ 13

ADVAIR HFA® .............................................................................................................. 13

ADVICOR® ................................................................................................................... 13

alendronate ................................................................................................................... 13

ALORA® ....................................................................................................................... 14

ALTOPREV® ................................................................................................................ 14

ALVESCO® ................................................................................................................... 14

AMBIEN CR® ................................................................................................................ 14

AMBIEN® ...................................................................................................................... 14

AMERGE® .................................................................................................................... 14

ANZEMET® .................................................................................................................. 14

APLENZIN® .................................................................................................................. 15

ARAVA® ....................................................................................................................... 15

ASMANEX® .................................................................................................................. 15

Updated: 08/2011 2

ASTELIN® ..................................................................................................................... 15

ASTEPRO® .................................................................................................................. 15

ATELVIA® ..................................................................................................................... 15

ATROVENT HFA® ........................................................................................................ 15

ATROVENT® ................................................................................................................ 16

AVANDAMET® ............................................................................................................. 16

AVANDARYL® .............................................................................................................. 16

AVANDIA® .................................................................................................................... 16

AVINZA® ....................................................................................................................... 16

AVONEX ADMINISTRATION PACK® .......................................................................... 16

AVONEX® ..................................................................................................................... 16

AXERT® ........................................................................................................................ 17

azelastine hcl ................................................................................................................ 17

azithromycin .................................................................................................................. 17

BECONASE AQ® ......................................................................................................... 17

BETASERON® ............................................................................................................. 17

BONIVA® ...................................................................................................................... 17

bupropion ...................................................................................................................... 17

butorphanol ................................................................................................................... 17

BYETTA® ...................................................................................................................... 18

cabergoline .................................................................................................................... 18

CADUET® ..................................................................................................................... 18

CARDURA XL® ............................................................................................................ 18

CARDURA® .................................................................................................................. 18

CATAPRES-TTS 1® ..................................................................................................... 18

Updated: 08/2011 3

CATAPRES-TTS 2® ..................................................................................................... 18

CATAPRES-TTS 3® ..................................................................................................... 19

CAYSTON® .................................................................................................................. 19

CELEXA® ..................................................................................................................... 19

CESAMET® .................................................................................................................. 19

citalopram ...................................................................................................................... 19

CLARINEX® .................................................................................................................. 19

CLARINEX-D 12 HOUR® ............................................................................................. 19

CLARINEX-D 24 HOUR® ............................................................................................. 19

CLIMARA PRO® ........................................................................................................... 19

CLIMARA® .................................................................................................................... 20

clonidine ........................................................................................................................ 20

COMBIVENT® .............................................................................................................. 20

COPAXONE® ............................................................................................................... 20

CORDRAN® ................................................................................................................. 20

CRESTOR® .................................................................................................................. 20

CYMBALTA® ................................................................................................................ 20

DEPO-PROVERA® ....................................................................................................... 21

DEPO-SUBQ PROVERA 104® ..................................................................................... 21

DEXILANT® .................................................................................................................. 21

DIFLUCAN® .................................................................................................................. 21

DITROPAN XL® ............................................................................................................ 21

DIVIGEL® ..................................................................................................................... 21

doxazosin ...................................................................................................................... 21

DUETACT® ................................................................................................................... 21

Updated: 08/2011 4

DULERA® ..................................................................................................................... 21

EDLUAR® ..................................................................................................................... 22

EFFEXOR XR® ............................................................................................................. 22

EFFEXOR® ................................................................................................................... 22

ELESTRIN® .................................................................................................................. 22

EMBEDA® .................................................................................................................... 22

EMEND® ....................................................................................................................... 22

EPIPEN JR® ................................................................................................................. 22

EPIPEN® ...................................................................................................................... 22

ESTRADERM® ............................................................................................................. 23

estradiol ......................................................................................................................... 23

EVAMIST® .................................................................................................................... 23

EXALGO® ..................................................................................................................... 23

EXTAVIA® .................................................................................................................... 23

FACTIVE® .................................................................................................................... 23

famciclovir ..................................................................................................................... 23

FAMVIR® ...................................................................................................................... 23

FANAPT® ..................................................................................................................... 24

fentanyl citrate ............................................................................................................... 24

FENTORA® .................................................................................................................. 24

fexofenadine .................................................................................................................. 24

FLECTOR® ................................................................................................................... 24

FLONASE® ................................................................................................................... 25

FLOVENT DISKUS® ..................................................................................................... 25

FLOVENT HFA® ........................................................................................................... 25

Updated: 08/2011 5

fluconazole .................................................................................................................... 25

flunisolide ...................................................................................................................... 25

fluoxetine ....................................................................................................................... 25

fluticasone propionate ................................................................................................... 25

fluvoxamine ................................................................................................................... 25

FORADIL® .................................................................................................................... 26

FORTEO® ..................................................................................................................... 26

FOSAMAX PLUS D® .................................................................................................... 26

FOSAMAX® .................................................................................................................. 26

FROVA® ....................................................................................................................... 26

GELNIQUE® ................................................................................................................. 26

GEODON® .................................................................................................................... 26

granisetron .................................................................................................................... 26

HUMIRA® ..................................................................................................................... 27

IMITREX® ..................................................................................................................... 27

INVEGA® ...................................................................................................................... 27

ipratropium .................................................................................................................... 27

JANUMET® ................................................................................................................... 27

JANUVIA® .................................................................................................................... 27

KADIAN® ...................................................................................................................... 28

ketorolac ........................................................................................................................ 28

KOMBIGLYZE XR® ...................................................................................................... 28

KYTRIL® ....................................................................................................................... 28

lansoprazole .................................................................................................................. 28

LATUDA® ..................................................................................................................... 28

Updated: 08/2011 6

leflunomide .................................................................................................................... 28

LESCOL XL® ................................................................................................................ 29

LESCOL® ..................................................................................................................... 29

levocetirizine dihydrochlor ............................................................................................. 29

LEXAPRO® ................................................................................................................... 29

LIPITOR® ...................................................................................................................... 29

LIVALO® ....................................................................................................................... 29

lovastatin ....................................................................................................................... 29

LUNESTA® ................................................................................................................... 29

LUVOX CR® ................................................................................................................. 30

MAXAIR AUTOHALER® ............................................................................................... 30

MAXALT MLT® ............................................................................................................. 30

MAXALT® ..................................................................................................................... 30

medroxyprogesterone ................................................................................................... 30

meloxicam ..................................................................................................................... 30

MENOSTAR® ............................................................................................................... 30

MEVACOR® ................................................................................................................. 30

miconazole nitrate ......................................................................................................... 30

MIGRANAL® ................................................................................................................. 31

MOBIC® ........................................................................................................................ 31

morphine ....................................................................................................................... 31

MS CONTIN® ............................................................................................................... 31

naratriptan ..................................................................................................................... 31

NASACORT AQ® ......................................................................................................... 31

NASONEX® .................................................................................................................. 31

Updated: 08/2011 7

NEULASTA® ................................................................................................................. 31

NEUMEGA® ................................................................................................................. 32

NEXIUM® ...................................................................................................................... 32

NUCYNTA® .................................................................................................................. 32

omeprazole ................................................................................................................... 32

omeprazole/sodium bicarbonat ..................................................................................... 32

OMNARIS® ................................................................................................................... 32

ondansetron .................................................................................................................. 32

ONGLYZA® .................................................................................................................. 32

ONSOLIS® .................................................................................................................... 33

OPANA ER® ................................................................................................................. 33

ORAMORPH SR® ........................................................................................................ 33

oxybutynin ..................................................................................................................... 33

OXYCONTIN® .............................................................................................................. 33

OXYTROL® .................................................................................................................. 34

pantoprazole ................................................................................................................. 34

paroxetine ..................................................................................................................... 34

PATANASE® ................................................................................................................ 34

PAXIL CR® ................................................................................................................... 34

PAXIL® ......................................................................................................................... 34

PEGASYS® .................................................................................................................. 34

PEGINTRON REDIPEN® ............................................................................................. 35

PEGINTRON® .............................................................................................................. 35

PEXEVA® ..................................................................................................................... 35

PRANDIMET® .............................................................................................................. 35

Updated: 08/2011 8

PRAVACHOL® ............................................................................................................. 35

pravastatin ..................................................................................................................... 35

PREVACID® ................................................................................................................. 35

PREVPAC® .................................................................................................................. 36

PRILOSEC® ................................................................................................................. 36

PRISTIQ® ..................................................................................................................... 36

PROAIR HFA® .............................................................................................................. 36

PROTONIX® ................................................................................................................. 36

PROVENTIL HFA® ....................................................................................................... 36

PROZAC WEEKLY® ..................................................................................................... 36

PROZAC® ..................................................................................................................... 36

PULMICORT FLEXHALER® ......................................................................................... 36

QVAR® ......................................................................................................................... 37

REBIF® ......................................................................................................................... 37

REGRANEX® ............................................................................................................... 37

RELENZA® ................................................................................................................... 37

RELPAX® ..................................................................................................................... 37

RESTASIS® .................................................................................................................. 37

REVATIO® .................................................................................................................... 37

RHINOCORT AQUA® ................................................................................................... 37

RISPERDAL M-TAB® ................................................................................................... 37

RISPERDAL® ............................................................................................................... 38

risperidone .................................................................................................................... 38

ROZEREM® .................................................................................................................. 38

RYZOLT® ..................................................................................................................... 38

Updated: 08/2011 9

SAMSCA® .................................................................................................................... 38

SANCUSO® .................................................................................................................. 39

SANDOSTATIN LAR® .................................................................................................. 39

SAPHRIS® .................................................................................................................... 39

SARAFEM® .................................................................................................................. 39

SAVELLA® .................................................................................................................... 39

SEREVENT DISKUS® .................................................................................................. 39

SEROQUEL XR® .......................................................................................................... 39

SEROQUEL® ................................................................................................................ 40

sertraline ....................................................................................................................... 40

SILENOR® .................................................................................................................... 40

SIMCOR® ..................................................................................................................... 40

simvastatin .................................................................................................................... 40

SONATA® ..................................................................................................................... 40

SPIRIVA® ..................................................................................................................... 41

SUBOXONE® ............................................................................................................... 41

sumatriptan ................................................................................................................... 41

SYMBICORT® .............................................................................................................. 41

SYMLIN® ...................................................................................................................... 41

SYMLINPEN 120® ........................................................................................................ 41

SYMLINPEN 60® .......................................................................................................... 41

TAMIFLU® .................................................................................................................... 41

TERAZOL 3® ................................................................................................................ 42

TERAZOL 7® ................................................................................................................ 42

terazosin ........................................................................................................................ 42

Updated: 08/2011 10

terconazole .................................................................................................................... 42

TRADJENTA® .............................................................................................................. 42

tramadol ........................................................................................................................ 42

tramadol/apap ............................................................................................................... 42

TREXIMET® ................................................................................................................. 42

TWINJECT® ................................................................................................................. 43

ULTRACET® ................................................................................................................. 43

ULTRAM ER® ............................................................................................................... 43

ULTRAM® ..................................................................................................................... 43

valacyclovir .................................................................................................................... 43

VALTREX® ................................................................................................................... 43

venlafaxine .................................................................................................................... 43

VENLAFAXINE HCL ER® ............................................................................................. 44

VENTOLIN HFA® ......................................................................................................... 44

VERAMYST® ................................................................................................................ 44

VICTOZA 3-PAK® ......................................................................................................... 44

VIIBRYD® ..................................................................................................................... 44

VIVELLE-DOT® ............................................................................................................ 44

VYTORIN® .................................................................................................................... 44

WELLBUTRIN SR® ...................................................................................................... 44

WELLBUTRIN XL® ....................................................................................................... 45

XOLAIR® ...................................................................................................................... 45

XOPENEX HFA® .......................................................................................................... 45

XYZAL® ........................................................................................................................ 45

zaleplon ......................................................................................................................... 45

Updated: 08/2011 11

ZAZOLE® ...................................................................................................................... 45

ZEGERID® .................................................................................................................... 45

ZITHROMAX TRI-PAK® ............................................................................................... 45

ZITHROMAX® .............................................................................................................. 45

ZMAX ADULT-PEDIATRIC® ......................................................................................... 46

ZOCOR® ....................................................................................................................... 46

ZOFRAN ODT® ............................................................................................................ 46

ZOFRAN® ..................................................................................................................... 46

ZOLOFT® ..................................................................................................................... 46

zolpidem ........................................................................................................................ 46

ZOLPIMIST® ................................................................................................................. 47

ZOMIG ZMT® ............................................................................................................... 47

ZOMIG® ........................................................................................................................ 47

ZUPLENZ® ................................................................................................................... 47

ZYPREXA ZYDIS® ....................................................................................................... 47

ZYPREXA® ................................................................................................................... 47

Index ............................................................................................................................. 48

Updated: 08/2011 12

ABILIFY DISCMELT®

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






ABSTRAL®

ABSTRAL 100 MCG TAB SUBLINGUAL - Limited to a quantity of 120 per 30 days.






ACTIQ®

ACTIQ 1,200 MCG LOZENGE - Limited to a quantity of 120 per 30 days.

ACTIQ 1,600 MCG LOZENGE - Limited to a quantity of 120 per 30 days.

ACTIQ 200 MCG LOZENGE - Limited to a quantity of 120 per 30 days.




ACTONEL®

ACTONEL 150 MG TABLET - Limited to a quantity of 1 per 34 days.




Updated: 08/2011 13

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®

ACTOS 15 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 34 days.



ADVAIR HFA®

ADVAIR HFA 115-21 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.

Updated: 08/2011 14



alendronate sodium 5 mg tablet - Limited to a quantity of 34 per 34 days.


ALORA®

ALORA 0.025 MG PATCH - Limited to a quantity of 10 per 35 days.




ALTOPREV®

ALTOPREV 20 MG TABLET - Limited to a quantity of 34 per 34 days.



ALVESCO®

ALVESCO 160 MCG INHALER - Limited to a quantity of 18 gm per 34 days.

ALVESCO 80 MCG INHALER - Limited to a quantity of 12 gm per 34 days.

AMBIEN CR®

AMBIEN CR 12.5 MG TABLET - Limited to a quantity of 34 per 34 days.

AMBIEN CR 6.25 MG TABLET - Limited to a quantity of 34 per 34 days.

AMBIEN®

AMBIEN 10 MG TABLET - Limited to a quantity of 34 per 34 days.

AMBIEN 5 MG TABLET - Limited to a quantity of 34 per 34 days.

AMERGE®

AMERGE 1 MG TABLET - Limited to a quantity of 18 per 28 days.

AMERGE 2.5 MG TABLET - Limited to a quantity of 18 per 28 days.

ANZEMET®

ANZEMET 100 MG TABLET - Limited to a quantity of 1 per 1 day.

ANZEMET 50 MG TABLET - Limited to a quantity of 1 per 1 day.

Updated: 08/2011 15

APLENZIN®

APLENZIN ER 174 MG TABLET - Limited to a quantity of 34 per 34 days.



ARAVA®

ARAVA 10 MG TABLET - Limited to a quantity of 34 per 34 days.

ARAVA 20 MG TABLET - Limited to a quantity of 34 per 34 days.

ASMANEX®

ASMANEX TWISTHALER 110 MCG #30 - Limited to a quantity of 60 doses per 30

days.


days.


days.


days.

ASMANEX TWISTHALR 220 MCG #120 - Limited to a quantity of 240 doses per 30

days.

ASTELIN®

ASTELIN 137 MCG NASAL SPRAY - Limited to a quantity of 60 ml per 34 days.

ASTEPRO®

ASTEPRO 0.15% NASAL SPRAY - Limited to a quantity of 60 ml per 34 days.

ATELVIA®

ATELVIA DR 35 MG TABLET - Limited to a quantity of 5 per 35 days.

ATROVENT HFA®

ATROVENT HFA INHALER - Limited to a quantity of 26 gm per 34 days.

Updated: 08/2011 16

ATROVENT®

ATROVENT 0.03% SPRAY - Limited to a quantity of 60 ml per 34 days.

ATROVENT 0.06% SPRAY - Limited to a quantity of 30 ml per 34 days.

AVANDAMET®

AVANDAMET 2 MG-1,000 MG TAB - Limited to a quantity of 68 per 34 days.

AVANDAMET 2 MG-500 MG TABLET - Limited to a quantity of 68 per 34 days.

AVANDAMET 4 MG-1,000 MG TABLET - Limited to a quantity of 68 per 34 days.

AVANDAMET 4 MG-500 MG TABLET - Limited to a quantity of 68 per 34 days.

AVANDARYL®

AVANDARYL 4 MG-1 MG TABLET - Limited to a quantity of 34 per 34 days.





AVANDIA®

AVANDIA 2 MG TABLET - Limited to a quantity of 68 per 34 days.



AVINZA®

AVINZA 120 MG CAPSULE - Limited to a quantity of 60 per 30 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.

Updated: 08/2011 17

AXERT®

AXERT 12.5 MG TABLET - Limited to a quantity of 24 per 28 days.

AXERT 6.25 MG TABLET - Limited to a quantity of 18 per 28 days.

azelastine hcl

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

azithromycin

azithromycin 100 mg/5 ml susp - Limited to a quantity of 30 ml per 5 days.

azithromycin 200 mg/5 ml susp - Limited to a quantity of 90 ml per 5 days.

azithromycin 250 mg tablet - Limited to a quantity of 8 per 7 days.

azithromycin 500 mg tablet - Limited to a quantity of 4 per 4 days.

BECONASE AQ®

BECONASE AQ 0.042% SPRAY - Limited to a quantity of 50 gm per 34 days.

BETASERON®

BETASERON 0.3 MG KIT - Limited to a quantity of 15 per 30 days.

BONIVA®

BONIVA 150 MG TABLET - Limited to a quantity of 1 per 34 days.

bupropion

budeprion sr 100 mg tablet - Limited to a quantity of 68 per 34 days.

budeprion sr 150 mg tablet - Limited to a quantity of 68 per 34 days.

budeprion xl 150 mg tablet - Limited to a quantity of 34 per 34 days.

budeprion xl 300 mg tablet - Limited to a quantity of 34 per 34 days.

bupropion hcl sr 100 mg tablet - Limited to a quantity of 68 per 34 days.

bupropion hcl sr 200 mg tab - Limited to a quantity of 68 per 34 days.

butorphanol

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

Updated: 08/2011 18

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.

CADUET®

CADUET 10 MG-10 MG TABLET - Limited to a quantity of 34 per 34 days.




CADUET 2.5 MG-10 MG TABLET - Limited to a quantity of 34 per 34 days.







CARDURA XL®

CARDURA XL 4 MG TABLET - Limited to a quantity of 34 per 34 days.

CARDURA XL 8 MG TABLET - Limited to a quantity of 34 per 34 days.

CARDURA®

CARDURA 1 MG TABLET - Limited to a quantity of 34 per 34 days.




CATAPRES-TTS 1®

CATAPRES-TTS 1 PATCH - Limited to a quantity of 5 per 35 days.

CATAPRES-TTS 2®


Updated: 08/2011 19

CATAPRES-TTS 3®


CAYSTON®

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

CELEXA®

CELEXA 10 MG TABLET - Limited to a quantity of 34 per 34 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 34 per 34 days.



CLARINEX®

CLARINEX 2.5 MG REDITABS - Limited to a quantity of 34 per 34 days.

CLARINEX 5 MG REDITABS - Limited to a quantity of 34 per 34 days.

CLARINEX 5 MG TABLET - Limited to a quantity of 34 per 34 days.

CLARINEX-D 12 HOUR®

CLARINEX-D 12 HOUR TABLET - Limited to a quantity of 68 per 34 days.

CLARINEX-D 24 HOUR®

CLARINEX-D 24 HOUR TABLET - Limited to a quantity of 34 per 34 days.

CLIMARA PRO®

CLIMARA PRO PATCH - Limited to a quantity of 5 per 35 days.

Updated: 08/2011 20

CLIMARA®

CLIMARA 0.025 MG/DAY PATCH - Limited to a quantity of 5 per 35 days.



CLIMARA 0.06/MG DAY PATCH - Limited to a quantity of 5 per 35 days.



clonidine

clonidine 0.1 mg/day patch - Limited to a quantity of 5 per 35 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 ml per 30 days.

CORDRAN®

CORDRAN 4 MCG/SQ CM TAPE - Limited to a quantity of 900 square cm per 34

days.

CRESTOR®

CRESTOR 10 MG TABLET - Limited to a quantity of 34 per 34 days.




CYMBALTA®

CYMBALTA 20 MG CAPSULE - Limited to a quantity of 68 per 34 days.



Updated: 08/2011 21

DEPO-PROVERA®

DEPO-PROVERA 150 MG/ML VIAL - Limited to a quantity of 1 ml per 90 days.

DEPO-SUBQ PROVERA 104®

DEPO-SUBQ PROVERA 104 SYRINGE - Limited to a quantity of 1 syringe per 90

days.

DEXILANT®

DEXILANT DR 30 MG CAPSULE - Limited to a quantity of 34 per 34 days.

DIFLUCAN®

DIFLUCAN 150 MG TABLET - Limited to a quantity of 2 per 7 days.

DITROPAN XL®

DITROPAN XL 5 MG TABLET - Limited to a quantity of 34 per 34 days.

DIVIGEL®

DIVIGEL 1 MG GEL PACKET - Limited to a quantity of 34 per 34 days.

doxazosin

doxazosin mesylate 1 mg tab - Limited to a quantity of 34 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.

DULERA®

DULERA 100 MCG/5 MCG INHALER - Limited to a quantity of 26 gm per 34 days.

DULERA 200 MCG/5 MCG INHALER - Limited to a quantity of 26 gm per 34 days.

Updated: 08/2011 22

EDLUAR®

EDLUAR 10 MG SL TABLET - Limited to a quantity of 34 per 34 days.

EDLUAR 5 MG SL TABLET - Limited to a quantity of 34 per 34 days.

EFFEXOR XR®

EFFEXOR XR 150 MG CAPSULE - Limited to a quantity of 34 per 34 days.

EFFEXOR XR 37.5 MG CAPSULE - Limited to a quantity of 34 per 34 days.

EFFEXOR XR 75 MG CAPSULE - Limited to a quantity of 102 per 34 days.

EFFEXOR®

EFFEXOR 50 MG TABLET - Limited to a quantity of 102 per 34 days.

ELESTRIN®

ELESTRIN 0.06% GEL - Limited to a quantity of 144 gm per 34 days.

EMBEDA®

EMBEDA 100-4 MG CAPSULE - Limited to a quantity of 90 per 30 days.

EMBEDA 20-0.8 MG CAPSULE - Limited to a quantity of 90 per 30 days.


EMBEDA 50-2 MG CAPSULE - Limited to a quantity of 90 per 30 days.



EMEND®

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.

EPIPEN JR®

EPIPEN JR 0.15 MG AUTO-INJCT - Limited to a quantity of 4 pens per 2 days.

EPIPEN®

EPIPEN 0.3 MG AUTO-INJECTOR - Limited to a quantity of 4 pens per 2 days.

Updated: 08/2011 23

ESTRADERM®

ESTRADERM 0.05 MG PATCH - Limited to a quantity of 10 per 35 days.

ESTRADERM 0.1 MG PATCH - Limited to a quantity of 10 per 35 days.

estradiol

estradiol 0.05 mg/day patch - Limited to a quantity of 5 per 35 days.

estradiol 0.1 mg/day patch - Limited to a quantity of 5 per 35 days.

estradiol tds 0.025 mg/day - Limited to a quantity of 5 per 35 days.




EVAMIST®

EVAMIST 1.53 MG/SPRAY - Limited to a quantity of 16 ml per 34 days.

EXALGO®

EXALGO ER 12 MG TABLET - Limited to a quantity of 60 per 30 days.



EXTAVIA®

EXTAVIA 0.3 MG KIT - Limited to a quantity of 15 trays per 30 days.

FACTIVE®

FACTIVE 320 MG TABLET - Limited to a quantity of 7 per 7 days.

famciclovir

famciclovir 125 mg tablet - Limited to a quantity of 21 per 10 days.



FAMVIR®

FAMVIR 125 MG TABLET - Limited to a quantity of 21 per 10 days.

Updated: 08/2011 24



FANAPT®

FANAPT 1 MG TABLET - Limited to a quantity of 68 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.




FENTORA®

FENTORA 100 MCG BUCCAL TABLET - Limited to a quantity of 112 per 28 days.






fexofenadine

fexofenadine hcl 180 mg tablet - Limited to a quantity of 34 per 34 days.



FLECTOR®

FLECTOR 1.3% PATCH - Limited to a quantity of 60 per 34 days.

Updated: 08/2011 25

FLONASE®

FLONASE 0.05% NASAL SPRAY - Limited to a quantity of 32 gm per 34 days.

FLOVENT DISKUS®

FLOVENT 100 MCG DISKUS - Limited to a quantity of 120 doses per 34 days.



FLOVENT HFA®

FLOVENT HFA 110 MCG INHALER - Limited to a quantity of 12 gm per 34 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 34 per 34 days.

fluoxetine hcl 10 mg tablet - Limited to a quantity of 34 per 34 days.

fluoxetine hcl 40 mg capsule - Limited to a quantity of 68 per 34 days.

selfemra 10 mg capsule - Limited to a quantity of 35 per 14 days.

selfemra 20 mg capsule - Limited to a quantity of 140 per 14 days.

fluticasone propionate

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

fluvoxamine

fluvoxamine maleate 100 mg tab - Limited to a quantity of 102 per 34 days.


Updated: 08/2011 26


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 1 pen per 28 days.

FOSAMAX PLUS D®

FOSAMAX PLUS D 70 MG-2,800 IU - Limited to a quantity of 5 per 35 days.

FOSAMAX PLUS D 70 MG-5,600 IU - Limited to a quantity of 5 per 35 days.

FOSAMAX®

FOSAMAX 10 MG TABLET - Limited to a quantity of 34 per 34 days.




FOSAMAX 70 MG ORAL SOLUTION - Limited to a quantity of 375 ml per 35 days.


FROVA®

FROVA 2.5 MG TABLET - Limited to a quantity of 27 per 28 days.

GELNIQUE®

GELNIQUE 10% GEL SACHETS - Limited to a quantity of 34 per 34 days.

GEODON®

GEODON 20 MG CAPSULE - Limited to a quantity of 68 per 34 days.




granisetron

granisetron hcl 1 mg tablet - Limited to a quantity of 2 per 1 day.

Updated: 08/2011 27

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

days.

IMITREX®

IMITREX 100 MG TABLET - Limited to a quantity of 18 per 28 days.

IMITREX 20 MG NASAL SPRAY - Limited to a quantity of 18 nasal sprayers per 28

days.


IMITREX 4 MG/0.5 ML KIT REFILL - Limited to a quantity of 8 vials per 28 days.

IMITREX 5 MG NASAL SPRAY - Limited to a quantity of 36 nasal sprayers per 28

days.


IMITREX 6 MG/0.5 ML KIT REFILL - Limited to a quantity of 8 vials per 28 days.

IMITREX 6 MG/0.5 ML VIAL - Limited to a quantity of 8 vials per 28 days.

INVEGA®

INVEGA ER 1.5 MG TABLET - Limited to a quantity of 34 per 34 days.

INVEGA ER 3 MG TABLET - Limited to a quantity of 34 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.

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.

Updated: 08/2011 28



KADIAN®

KADIAN ER 10 MG CAPSULE - Limited to a quantity of 90 per 30 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.

KYTRIL®

KYTRIL 1 MG TABLET - Limited to a quantity of 2 per 1 day.

lansoprazole

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

lansoprazole odt 15 mg tablet - Limited to a quantity of 34 per 34 days.

LATUDA®

LATUDA 40 MG TABLET - Limited to a quantity of 34 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.

Updated: 08/2011 29

LESCOL XL®

LESCOL XL 80 MG TABLET - Limited to a quantity of 34 per 34 days.

LESCOL®

LESCOL 20 MG CAPSULE - Limited to a quantity of 34 per 34 days.

LESCOL 40 MG CAPSULE - Limited to a quantity of 68 per 34 days.

levocetirizine dihydrochlor

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

LEXAPRO®

LEXAPRO 10 MG TABLET - Limited to a quantity of 34 per 34 days.



LIPITOR®

LIPITOR 10 MG TABLET - Limited to a quantity of 34 per 34 days.




LIVALO®

LIVALO 1 MG TABLET - Limited to a quantity of 34 per 34 days.



lovastatin

lovastatin 10 mg tablet - Limited to a quantity of 34 per 34 days.



LUNESTA®

LUNESTA 1 MG TABLET - Limited to a quantity of 34 per 34 days.

Updated: 08/2011 30



LUVOX CR®

LUVOX CR 100 MG CAPSULE - Limited to a quantity of 68 per 34 days.

LUVOX CR 150 MG CAPSULE - Limited to a quantity of 68 per 34 days.

MAXAIR AUTOHALER®

MAXAIR AUTOHALER 0.2 MG AERO - Limited to a quantity of 28 gm per 34 days.

MAXALT MLT®

MAXALT MLT 10 MG TABLET - Limited to a quantity of 36 per 28 days.

MAXALT MLT 5 MG TABLET - Limited to a quantity of 36 per 28 days.

MAXALT®

MAXALT 10 MG TABLET - Limited to a quantity of 36 per 28 days.

MAXALT 5 MG TABLET - Limited to a quantity of 36 per 28 days.

medroxyprogesterone

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

meloxicam

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

MENOSTAR®

MENOSTAR 14 MCG/DAY PATCH - Limited to a quantity of 5 per 35 days.

MEVACOR®

MEVACOR 20 MG TABLET - Limited to a quantity of 68 per 34 days.

MEVACOR 40 MG TABLET - Limited to a quantity of 68 per 34 days.

miconazole nitrate

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

Updated: 08/2011 31

MIGRANAL®

MIGRANAL NASAL SPRAY - Limited to a quantity of 16 mg per 28 days.

MOBIC®

MOBIC 7.5 MG TABLET - Limited to a quantity of 34 per 34 days.

morphine

morphine sulf er 100 mg tablet - Limited to a quantity of 120 per 30 days.





MS CONTIN®

MS CONTIN 100 MG TABLET - Limited to a quantity of 120 per 30 days.




MS CONTIN CR 30 MG TABLET - Limited to a quantity of 120 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.

NASACORT AQ®

NASACORT AQ NASAL SPRAY - Limited to a quantity of 33 gm per 34 days.

NASONEX®

NASONEX 50 MCG NASAL SPRAY - Limited to a quantity of 51 gm per 34 days.

NEULASTA®

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

days.

Updated: 08/2011 32

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.

NUCYNTA®

NUCYNTA 100 MG TABLET - Limited to a quantity of 205 per 34 days.



omeprazole

omeprazole dr 10 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.

OMNARIS®

OMNARIS 50 MCG NASAL SPRAY - Limited to a quantity of 25 gm 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.

Updated: 08/2011 33

ONSOLIS®

ONSOLIS 1,200 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days.

ONSOLIS 200 MCG SOLUBLE FILM - Limited to a quantity of 120 per 30 days.




OPANA ER®

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






OPANA ER 7.5 MG TABLET - Limited to a quantity of 90 per 30 days.

ORAMORPH SR®

ORAMORPH SR 100 MG TABLET - Limited to a quantity of 120 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.







Updated: 08/2011 34

OXYTROL®

OXYTROL 3.9 MG/24HR PATCH - Limited to a quantity of 10 per 35 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 68 per 34 days.

paroxetine cr 25 mg tablet - Limited to a quantity of 68 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 34 per 34 days.




PATANASE®

PATANASE 0.6% NASAL SPRAY - Limited to a quantity of 61 gm per 34 days.

PAXIL CR®

PAXIL CR 12.5 MG TABLET - Limited to a quantity of 68 per 34 days.

PAXIL CR 25 MG TABLET - Limited to a quantity of 68 per 34 days.

PAXIL CR 37.5 MG TABLET - Limited to a quantity of 68 per 34 days.

PAXIL®

PAXIL 10 MG TABLET - Limited to a quantity of 34 per 34 days.




PEGASYS®

PEGASYS 180 MCG/0.5 ML CONV.PK - Limited to a quantity of 4 syringes per 28

days.

PEGASYS 180 MCG/ML VIAL - Limited to a quantity of 4 vials per 28 days.

Updated: 08/2011 35

PEGINTRON REDIPEN®

PEGINTRON REDIPEN 120 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.

PEXEVA®

PEXEVA 10 MG TABLET - Limited to a quantity of 34 per 34 days.




PRANDIMET®

PRANDIMET 1 MG-500 MG TABLET - Limited to a quantity of 170 per 34 days.

PRANDIMET 2 MG-500 MG TABLET - Limited to a quantity of 170 per 34 days.

PRAVACHOL®

PRAVACHOL 10 MG TABLET - Limited to a quantity of 34 per 34 days.




pravastatin

pravastatin sodium 10 mg tab - Limited to a quantity of 34 per 34 days.




PREVACID®

PREVACID 15 MG SOLUTAB - Limited to a quantity of 34 per 34 days.

PREVACID DR 15 MG CAPSULE - Limited to a quantity of 34 per 34 days.

Updated: 08/2011 36

PREVPAC®

PREVPAC PATIENT PACK - Limited to a quantity of 14 per 14 days.

PRILOSEC®

PRILOSEC DR 10 MG CAPSULE - Limited to a quantity of 34 per 34 days.

PRILOSEC DR 20 MG CAPSULE - Limited to a quantity of 34 per 34 days.

PRISTIQ®

PRISTIQ 100 MG TABLET - Limited to a quantity of 34 per 34 days.

PRISTIQ 50 MG TABLET - Limited to a quantity of 34 per 34 days.

PROAIR HFA®

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

PROTONIX®

PROTONIX DR 20 MG TABLET - Limited to a quantity of 34 per 34 days.

PROVENTIL HFA®

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

PROZAC WEEKLY®

PROZAC WEEKLY 90 MG CAPSULE - Limited to a quantity of 5 per 34 days.

PROZAC®

PROZAC 10 MG PULVULE - Limited to a quantity of 34 per 34 days.

PROZAC 40 MG PULVULE - Limited to a quantity of 68 per 34 days.

PULMICORT FLEXHALER®

PULMICORT 180 MCG FLEXHALER - Limited to a quantity of 3 inhalers per 34

days.

PULMICORT 90 MCG FLEXHALER - Limited to a quantity of 2 inhalers per 34 days.

Updated: 08/2011 37

QVAR®

QVAR 40 MCG INHALER - Limited to a quantity of 22 gm per 34 days.

QVAR 80 MCG INHALER - Limited to a quantity of 22 gm per 34 days.

REBIF®

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.

RELPAX®

RELPAX 20 MG TABLET - Limited to a quantity of 18 per 28 days.

RELPAX 40 MG TABLET - Limited to a quantity of 18 per 28 days.

RESTASIS®

RESTASIS 0.05% EYE EMULSION - Limited to a quantity of 60 vials per 30 days.

REVATIO®

REVATIO 20 MG TABLET - Limited to a quantity of 102 per 34 days.

RHINOCORT AQUA®

RHINOCORT AQUA NASAL SPRAY - Limited to a quantity of 26 gm per 34 days.

RISPERDAL M-TAB®

RISPERDAL M-TAB 0.5 MG ODT - Limited to a quantity of 68 per 34 days.

RISPERDAL M-TAB 1 MG ODT - Limited to a quantity of 68 per 34 days.



Updated: 08/2011 38


RISPERDAL®

RISPERDAL 0.25 MG TABLET - Limited to a quantity of 68 per 34 days.

RISPERDAL 0.5 MG TABLET - Limited to a quantity of 68 per 34 days.

RISPERDAL 1 MG TABLET - Limited to a quantity of 68 per 34 days.

RISPERDAL 1 MG/ML SOLUTION - Limited to a quantity of 544 ml per 34 days.




risperidone

risperidone 0.25 mg odt - Limited to a quantity of 68 per 34 days.

risperidone 0.25 mg tablet - Limited to a quantity of 68 per 34 days.

risperidone 0.5 mg odt - Limited to a quantity of 68 per 34 days.

risperidone 0.5 mg tablet - Limited to a quantity of 68 per 34 days.

risperidone 1 mg odt - Limited to a quantity of 68 per 34 days.

risperidone 1 mg tablet - Limited to a quantity of 68 per 34 days.

risperidone 1 mg/ml solution - Limited to a quantity of 544 ml per 34 days.







ROZEREM®

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

RYZOLT®

RYZOLT ER 100 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.

Updated: 08/2011 39

SAMSCA 30 MG TABLET - Limited to a quantity of 68 per 34 days.

SANCUSO®

SANCUSO 3.1 MG/24 HR PATCH - Limited to a quantity of 1 per 7 days.

SANDOSTATIN LAR®

SANDOSTATIN LAR 10 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 68 per 34 days.

SARAFEM®

SARAFEM 10 MG TABLET - Limited to a quantity of 35 per 14 days.

SARAFEM 20 MG TABLET - Limited to a quantity of 140 per 14 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 68 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 34 per 34 days.





Updated: 08/2011 40

SEROQUEL®

SEROQUEL 100 MG TABLET - Limited to a quantity of 102 per 34 days.






sertraline

sertraline hcl 100 mg tablet - Limited to a quantity of 68 per 34 days.



SILENOR®

SILENOR 3 MG TABLET - Limited to a quantity of 34 per 34 days.

SILENOR 6 MG TABLET - Limited to a quantity of 34 per 34 days.

SIMCOR®

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

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.



simvastatin

simvastatin 10 mg tablet - Limited to a quantity of 34 per 34 days.





SONATA®

SONATA 10 MG CAPSULE - Limited to a quantity of 68 per 34 days.

SONATA 5 MG CAPSULE - Limited to a quantity of 34 per 34 days.

Updated: 08/2011 41

SPIRIVA®

SPIRIVA 18 MCG CP-HANDIHALER - Limited to a quantity of 60 capsules per 34

days.

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 4 mg/0.5 ml vial - Limited to a quantity of 8 ml per 28 days.

sumatriptan 6 mg/0.5 ml vial - Limited to a quantity of 8 ml per 28 days.

sumatriptan succ 100 mg tablet - Limited to a quantity of 18 per 28 days.



SYMBICORT®

SYMBICORT 160-4.5 MCG INHALER - Limited to a quantity of 20 gm per 34 days.

SYMBICORT 80-4.5 MCG INHALER - Limited to a quantity of 20 gm per 34 days.

SYMLIN®

SYMLIN 0.6 MG/ML VIAL - Limited to a quantity of 35 ml 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 12 MG/ML SUSPENSION - Limited to a quantity of 900 ml per 180 days.

TAMIFLU 30 MG GELCAP - Limited to a quantity of 84 per 180 days.


Updated: 08/2011 42


TERAZOL 3®

TERAZOL 3 80 MG SUPPOSITORY - Limited to a quantity of 3 per 3 days.

TERAZOL 3 CREAM - Limited to a quantity of 20 gm per 3 days.

TERAZOL 7®

TERAZOL 7 CREAM - Limited to a quantity of 45 gm per 7 days.

terazosin

terazosin 1 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.

TRADJENTA®

TRADJENTA 5 MG TABLET - Limited to a quantity of 34 per 34 days.

tramadol

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.

TREXIMET®

TREXIMET 85-500 MG TABLET - Limited to a quantity of 18 per 28 days.

Updated: 08/2011 43

TWINJECT®

TWINJECT 0.15 MG AUTO-INJECTOR - Limited to a quantity of 4 pens per 2 days.

TWINJECT 0.3 MG AUTO-INJECTOR - Limited to a quantity of 4 pens per 2 days.

ULTRACET®

ULTRACET TABLET - Limited to a quantity of 272 per 34 days.

ULTRAM ER®

ULTRAM ER 100 MG TABLET - Limited to a quantity of 34 per 34 days.



ULTRAM®

ULTRAM 50 MG TABLET - Limited to a quantity of 272 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.

VALTREX®

VALTREX 1 GM CAPLET - Limited to a quantity of 34 per 34 days.

VALTREX 500 MG CAPLET - 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 37.5 mg tablet - Limited to a quantity of 102 per 34 days.



venlafaxine hcl er 150 mg cap - Limited to a quantity of 34 per 34 days.

venlafaxine hcl er 150 mg tab - Limited to a quantity of 34 per 34 days.

venlafaxine hcl er 37.5 mg cap - Limited to a quantity of 34 per 34 days.

venlafaxine hcl er 37.5 mg tab - Limited to a quantity of 34 per 34 days.

venlafaxine hcl er 75 mg cap - Limited to a quantity of 102 per 34 days.

venlafaxine hcl er 75 mg tab - Limited to a quantity of 34 per 34 days.

Updated: 08/2011 44

VENLAFAXINE HCL ER®

VENLAFAXINE HCL ER 225 MG TAB - Limited to a quantity of 34 per 34 days.

VENTOLIN HFA®

VENTOLIN HFA 90 MCG INHALER - Limited to a quantity of 54 gm per 34 days.

VERAMYST®

VERAMYST 27.5 MCG NASAL SPRAY - Limited to a quantity of 20 gm per 34 days.

VICTOZA 3-PAK®

VICTOZA 3-PAK 18 MG/3 ML PEN - Limited to a quantity of 3 pens per 30 days.

VIIBRYD®

VIIBRYD 10 MG TABLET - Limited to a quantity of 34 per 34 days.



VIVELLE-DOT®

VIVELLE-DOT 0.025 MG PATCH - Limited to a quantity of 10 per 35 days.





VYTORIN®

VYTORIN 10-10 MG TABLET - Limited to a quantity of 34 per 34 days.




WELLBUTRIN SR®

WELLBUTRIN SR 100 MG TABLET - Limited to a quantity of 68 per 34 days.


Updated: 08/2011 45


WELLBUTRIN XL®

WELLBUTRIN XL 150 MG TABLET - Limited to a quantity of 34 per 34 days.

WELLBUTRIN XL 300 MG TABLET - Limited to a quantity of 34 per 34 days.

XOLAIR®

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

XOPENEX HFA®

XOPENEX HFA 45 MCG INHALER - Limited to a quantity of 45 gm per 34 days.

XYZAL®

XYZAL 5 MG TABLET - Limited to a quantity of 34 per 34 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.

ZAZOLE®

ZAZOLE 0.8% VAGINAL CREAM - Limited to a quantity of 20 gm per 3 days.

ZAZOLE 80 MG VAGINAL SUPP - Limited to a quantity of 3 per 3 days.

ZAZOLE VAGINAL 0.4% CREAM - Limited to a quantity of 45 gm per 7 days.

ZEGERID®

ZEGERID 20 MG CAPSULE - Limited to a quantity of 34 per 34 days.

ZEGERID 20 MG PACKET - Limited to a quantity of 34 per 34 days.

ZITHROMAX TRI-PAK®

ZITHROMAX TRI-PAK 500 MG TAB - Limited to a quantity of 4 per 4 days.

ZITHROMAX®

ZITHROMAX 100 MG/5 ML SUSP - Limited to a quantity of 30 ml per 5 days.

Updated: 08/2011 46

ZITHROMAX 200 MG/5 ML SUSP - Limited to a quantity of 90 ml per 5 days.

ZITHROMAX 250 MG TABLET - Limited to a quantity of 8 per 7 days.

ZITHROMAX 250 MG Z-PAK TABLET - Limited to a quantity of 8 per 7 days.

ZITHROMAX 500 MG TABLET - Limited to a quantity of 4 per 4 days.

ZMAX ADULT-PEDIATRIC®

ZMAX ADULT-PED 2 G/60 ML SUSP - Limited to a quantity of 60 ml per 1 day.

ZOCOR®

ZOCOR 10 MG TABLET - Limited to a quantity of 34 per 34 days.





ZOFRAN ODT®

ZOFRAN ODT 4 MG TABLET - Limited to a quantity of 12 per 5 days.

ZOFRAN ODT 8 MG TABLET - Limited to a quantity of 12 per 5 days.

ZOFRAN®

ZOFRAN 4 MG TABLET - Limited to a quantity of 12 per 5 days.

ZOFRAN 4 MG/5 ML ORAL SOLN - Limited to a quantity of 150 ml per 5 days.

ZOFRAN 8 MG TABLET - Limited to a quantity of 12 per 5 days.

ZOLOFT®

ZOLOFT 100 MG TABLET - 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.

Updated: 08/2011 47

ZOLPIMIST®

ZOLPIMIST 5 MG ORAL SPRAY - Limited to a quantity of 8 ml per 30 days.

ZOMIG ZMT®

ZOMIG ZMT 2.5 MG TABLET - Limited to a quantity of 18 per 28 days.

ZOMIG ZMT 5 MG TABLET - Limited to a quantity of 18 per 28 days.

ZOMIG®

ZOMIG 2.5 MG TABLET - Limited to a quantity of 18 per 28 days.

ZOMIG 5 MG NASAL SPRAY - Limited to a quantity of 18 nasal sprayers per 28

days.

ZOMIG 5 MG TABLET - Limited to a quantity of 18 per 28 days.

ZUPLENZ®

ZUPLENZ 4 MG SOLUBLE FILM - Limited to a quantity of 12 per 5 days.

ZUPLENZ 8 MG SOLUBLE FILM - Limited to a quantity of 12 per 5 days.

ZYPREXA ZYDIS®

ZYPREXA ZYDIS 10 MG TABLET - Limited to a quantity of 34 per 34 days.




ZYPREXA®

ZYPREXA 10 MG TABLET - Limited to a quantity of 34 per 34 days.


ZYPREXA 2.5 MG TABLET - Limited to a quantity of 34 per 34 days.



ZYPREXA 7.5 MG TABLET - Limited to a quantity of 34 per 34 days.

Updated: 08/2011 48

INDEX

ABILIFY 10 MG TABLET, 12






ABILIFY DISCMELT 10 MG TABLET,

12

ABILIFY DISCMELT 15 MG TABLET,

12

ABSTRAL 100 MCG TAB

SUBLINGUAL, 12

ABSTRAL 200 MCG TAB

SUBLINGUAL, 12

ABSTRAL 300 MCG TAB

SUBLINGUAL, 12

ABSTRAL 400 MCG TAB

SUBLINGUAL, 12

ABSTRAL 600 MCG TAB

SUBLINGUAL, 12

ABSTRAL 800 MCG TAB

SUBLINGUAL, 12

ACTIQ 1,200 MCG LOZENGE, 12

ACTIQ 1,600 MCG LOZENGE, 12

ACTIQ 200 MCG LOZENGE, 12




ACTONEL 150 MG TABLET, 12




ACTOPLUS MET 15 MG-500 MG TAB,

13

ACTOPLUS MET 15 MG-850 MG TAB,

13

ACTOPLUS MET XR 15-1,000 MG TB,

13

ACTOPLUS MET XR 30-1,000 MG TB,

13

ACTOS 15 MG TABLET, 13



ADCIRCA 20 MG TABLET, 13

ADVAIR 100-50 DISKUS, 13



ADVAIR HFA 115-21 MCG INHALER,

13

ADVAIR HFA 230-21 MCG INHALER,

13

ADVAIR HFA 45-21 MCG INHALER, 13

ADVICOR 1,000 MG-20 MG TABLET,

13

ADVICOR 1,000 MG-40 MG TABLET,

13

ADVICOR 500 MG-20 MG TABLET, 13

ADVICOR 750 MG-20 MG TABLET, 13

alendronate sodium 10 mg tab, 13



alendronate sodium 5 mg tablet, 14


ALORA 0.025 MG PATCH, 14




ALTOPREV 20 MG TABLET, 14



ALVESCO 160 MCG INHALER, 14

ALVESCO 80 MCG INHALER, 14

AMBIEN 10 MG TABLET, 14

AMBIEN 5 MG TABLET, 14

AMBIEN CR 12.5 MG TABLET, 14

AMBIEN CR 6.25 MG TABLET, 14

AMERGE 1 MG TABLET, 14

Updated: 08/2011 49

AMERGE 2.5 MG TABLET, 14

ANZEMET 100 MG TABLET, 14

ANZEMET 50 MG TABLET, 14

APLENZIN ER 174 MG TABLET, 15



ARAVA 10 MG TABLET, 15

ARAVA 20 MG TABLET, 15

ASMANEX TWISTHALER 110 MCG

#30, 15


#14, 15


#30, 15


#60, 15

ASMANEX TWISTHALR 220 MCG

#120, 15

ASTELIN 137 MCG NASAL SPRAY, 15

ASTEPRO 0.15% NASAL SPRAY, 15

ATELVIA DR 35 MG TABLET, 15

ATROVENT 0.03% SPRAY, 16

ATROVENT 0.06% SPRAY, 16

ATROVENT HFA INHALER, 15

AVANDAMET 2 MG-1,000 MG TAB, 16

AVANDAMET 2 MG-500 MG TABLET,

16

AVANDAMET 4 MG-1,000 MG

TABLET, 16

AVANDAMET 4 MG-500 MG TABLET,

16

AVANDARYL 4 MG-1 MG TABLET, 16





AVANDIA 2 MG TABLET, 16



AVINZA 120 MG CAPSULE, 16






AVONEX ADMIN PACK 30 MCG VL, 16

AVONEX PREFILLED SYR 30 MCG, 16

AXERT 12.5 MG TABLET, 17

AXERT 6.25 MG TABLET, 17

azelastine 137 mcg nasal spray, 17

azithromycin 100 mg/5 ml susp, 17

azithromycin 200 mg/5 ml susp, 17

azithromycin 250 mg tablet, 17

azithromycin 500 mg tablet, 17

BECONASE AQ 0.042% SPRAY, 17

BETASERON 0.3 MG KIT, 17

BONIVA 150 MG TABLET, 17

budeprion sr 100 mg tablet, 17

budeprion sr 150 mg tablet, 17

budeprion xl 150 mg tablet, 17

budeprion xl 300 mg tablet, 17

bupropion hcl sr 100 mg tablet, 17

bupropion hcl sr 200 mg tab, 17

butorphanol 10 mg/ml spray, 17

BYETTA 10 MCG DOSE PEN INJ, 18

BYETTA 5 MCG DOSE PEN INJ, 18

cabergoline 0.5 mg tablet, 18

CADUET 10 MG-10 MG TABLET, 18




CADUET 2.5 MG-10 MG TABLET, 18







CARDURA 1 MG TABLET, 18


Updated: 08/2011 50



CARDURA XL 4 MG TABLET, 18

CARDURA XL 8 MG TABLET, 18

CATAPRES-TTS 1 PATCH, 18



CAYSTON 75 MG INHAL SOLUTION,

19

CELEXA 10 MG TABLET, 19



CESAMET 1 MG CAPSULE, 19

citalopram hbr 10 mg tablet, 19



CLARINEX 2.5 MG REDITABS, 19

CLARINEX 5 MG REDITABS, 19

CLARINEX 5 MG TABLET, 19

CLARINEX-D 12 HOUR TABLET, 19

CLARINEX-D 24 HOUR TABLET, 19

CLIMARA 0.025 MG/DAY PATCH, 20



CLIMARA 0.06/MG DAY PATCH, 20



CLIMARA PRO PATCH, 19

clonidine 0.1 mg/day patch, 20



COMBIVENT INHALER, 20

COPAXONE 20 MG INJECTION KIT,

20

CORDRAN 4 MCG/SQ CM TAPE, 20

CRESTOR 10 MG TABLET, 20




CYMBALTA 20 MG CAPSULE, 20



DEPO-PROVERA 150 MG/ML VIAL, 21

DEPO-SUBQ PROVERA 104

SYRINGE, 21

DEXILANT DR 30 MG CAPSULE, 21

DIFLUCAN 150 MG TABLET, 21

DITROPAN XL 5 MG TABLET, 21

DIVIGEL 1 MG GEL PACKET, 21

doxazosin mesylate 1 mg tab, 21




DUETACT 30-2 MG TABLET, 21

DUETACT 30-4 MG TABLET, 21

DULERA 100 MCG/5 MCG INHALER,

21

DULERA 200 MCG/5 MCG INHALER,

21

EDLUAR 10 MG SL TABLET, 22

EDLUAR 5 MG SL TABLET, 22

EFFEXOR 50 MG TABLET, 22

EFFEXOR XR 150 MG CAPSULE, 22

EFFEXOR XR 37.5 MG CAPSULE, 22

EFFEXOR XR 75 MG CAPSULE, 22

ELESTRIN 0.06% GEL, 22

EMBEDA 100-4 MG CAPSULE, 22

EMBEDA 20-0.8 MG CAPSULE, 22


EMBEDA 50-2 MG CAPSULE, 22



EMEND 125 MG CAPSULE, 22



EMEND TRIFOLD PACK, 22

EPIPEN 0.3 MG AUTO-INJECTOR, 22

EPIPEN JR 0.15 MG AUTO-INJCT, 22

ESTRADERM 0.05 MG PATCH, 23

ESTRADERM 0.1 MG PATCH, 23

Updated: 08/2011 51

estradiol 0.05 mg/day patch, 23

estradiol 0.1 mg/day patch, 23

estradiol tds 0.025 mg/day, 23




EVAMIST 1.53 MG/SPRAY, 23

EXALGO ER 12 MG TABLET, 23



EXTAVIA 0.3 MG KIT, 23

FACTIVE 320 MG TABLET, 23

famciclovir 125 mg tablet, 23



FAMVIR 125 MG TABLET, 23



FANAPT 1 MG TABLET, 24







FANAPT TITRATION PACK, 24

fentanyl cit otfc 1,200 mcg, 24

fentanyl cit otfc 1,600 mcg, 24

fentanyl citrate otfc 200 mcg, 24




FENTORA 100 MCG BUCCAL

TABLET, 24


TABLET, 24


TABLET, 24


TABLET, 24


TABLET, 24


TABLET, 24

fexofenadine hcl 180 mg tablet, 24



FLECTOR 1.3% PATCH, 24

FLONASE 0.05% NASAL SPRAY, 25

FLOVENT 100 MCG DISKUS, 25



FLOVENT HFA 110 MCG INHALER, 25



fluconazole 150 mg tablet, 25

flunisolide 0.025% spray, 25

fluoxetine dr 90 mg capsule, 25

fluoxetine hcl 10 mg capsule, 25

fluoxetine hcl 10 mg tablet, 25

fluoxetine hcl 40 mg capsule, 25

fluticasone prop 50 mcg spray, 25

fluvoxamine maleate 100 mg tab, 25



FORADIL AEROLIZER 12 MCG CAP,

26

FORTEO 600 MCG/2.4 ML PEN INJ, 26

FOSAMAX 10 MG TABLET, 26




FOSAMAX 70 MG ORAL SOLUTION,

26


FOSAMAX PLUS D 70 MG-2,800 IU, 26

FOSAMAX PLUS D 70 MG-5,600 IU, 26

FROVA 2.5 MG TABLET, 26

GELNIQUE 10% GEL SACHETS, 26

GEODON 20 MG CAPSULE, 26

Updated: 08/2011 52




granisetron hcl 1 mg tablet, 26

granisol 2 mg/10 ml solution, 27

HUMIRA 20 MG/0.4 ML SYRINGE, 27

HUMIRA 40 MG/0.8 ML SYRINGE, 27

HUMIRA CROHN'S STARTER PACK,

27

IMITREX 100 MG TABLET, 27

IMITREX 20 MG NASAL SPRAY, 27


IMITREX 4 MG/0.5 ML KIT REFILL, 27

IMITREX 5 MG NASAL SPRAY, 27


IMITREX 6 MG/0.5 ML KIT REFILL, 27

IMITREX 6 MG/0.5 ML VIAL, 27

INVEGA ER 1.5 MG TABLET, 27

INVEGA ER 3 MG TABLET, 27



ipratropium 0.03% spray, 27

ipratropium 0.06% spray, 27

JANUMET 50-1,000 MG TABLET, 27

JANUMET 50-500 MG TABLET, 27

JANUVIA 100 MG TABLET, 27



KADIAN ER 10 MG CAPSULE, 28








ketorolac 10 mg tablet, 28

KOMBIGLYZE XR 2.5-1,000 MG TAB,

28

KOMBIGLYZE XR 5-1,000 MG TAB, 28

KOMBIGLYZE XR 5-500 MG TABLET,

28

KYTRIL 1 MG TABLET, 28

lansoprazole dr 15 mg capsule, 28

lansoprazole odt 15 mg tablet, 28

LATUDA 40 MG TABLET, 28

LATUDA 80 MG TABLET, 28

leflunomide 10 mg tablet, 28

leflunomide 20 mg tablet, 28

LESCOL 20 MG CAPSULE, 29

LESCOL 40 MG CAPSULE, 29

LESCOL XL 80 MG TABLET, 29

levocetirizine 5 mg tablet, 29

LEXAPRO 10 MG TABLET, 29



LIPITOR 10 MG TABLET, 29




LIVALO 1 MG TABLET, 29



lovastatin 10 mg tablet, 29



LUNESTA 1 MG TABLET, 29



LUVOX CR 100 MG CAPSULE, 30

LUVOX CR 150 MG CAPSULE, 30

MAXAIR AUTOHALER 0.2 MG AERO,

30

MAXALT 10 MG TABLET, 30

MAXALT 5 MG TABLET, 30

MAXALT MLT 10 MG TABLET, 30

MAXALT MLT 5 MG TABLET, 30

medroxyprogesterone 150 mg/ml, 30

meloxicam 7.5 mg tablet, 30

MENOSTAR 14 MCG/DAY PATCH, 30

Updated: 08/2011 53

MEVACOR 20 MG TABLET, 30

MEVACOR 40 MG TABLET, 30

miconazole 3 200 mg vag supp, 30

MIGRANAL NASAL SPRAY, 31

MOBIC 7.5 MG TABLET, 31

morphine sulf er 100 mg tablet, 31





MS CONTIN 100 MG TABLET, 31




MS CONTIN CR 30 MG TABLET, 31

naratriptan hcl 1 mg tablet, 31

naratriptan hcl 2.5 mg tablet, 31

NASACORT AQ NASAL SPRAY, 31

NASONEX 50 MCG NASAL SPRAY, 31

NEULASTA 6 MG/0.6 ML SYRINGE, 31

NEUMEGA 5 MG VIAL, 32

NEXIUM DR 10 MG PACKET, 32

NEXIUM DR 20 MG CAPSULE, 32

NEXIUM DR 20 MG PACKET, 32

NUCYNTA 100 MG TABLET, 32



omeprazole dr 10 mg capsule, 32

omeprazole-bicarb 20-1,100 cap, 32

OMNARIS 50 MCG NASAL SPRAY, 32

ondansetron 4 mg/5 ml solution, 32

ondansetron hcl 24 mg tablet, 32



ondansetron odt 4 mg tablet, 32

ondansetron odt 8 mg tablet, 32

ONGLYZA 2.5 MG TABLET, 32

ONGLYZA 5 MG TABLET, 32

ONSOLIS 1,200 MCG SOLUBLE FILM,

33

ONSOLIS 200 MCG SOLUBLE FILM,

33


33


33


33

OPANA ER 10 MG TABLET, 33






OPANA ER 7.5 MG TABLET, 33

ORAMORPH SR 100 MG TABLET, 33




oxybutynin cl er 5 mg tablet, 33

OXYCONTIN 10 MG TABLET, 33







OXYTROL 3.9 MG/24HR PATCH, 34

pantoprazole sod dr 20 mg tab, 34

paroxetine cr 12.5 mg tablet, 34

paroxetine cr 25 mg tablet, 34

paroxetine er 37.5 mg tablet, 34

paroxetine hcl 10 mg tablet, 34




PATANASE 0.6% NASAL SPRAY, 34

PAXIL 10 MG TABLET, 34



Updated: 08/2011 54


PAXIL CR 12.5 MG TABLET, 34

PAXIL CR 25 MG TABLET, 34

PAXIL CR 37.5 MG TABLET, 34

PEGASYS 180 MCG/0.5 ML CONV.PK,

34

PEGASYS 180 MCG/ML VIAL, 34

PEGINTRON 50 MCG KIT, 35

PEGINTRON REDIPEN 120 MCG, 35




PEXEVA 10 MG TABLET, 35




PRANDIMET 1 MG-500 MG TABLET,

35

PRANDIMET 2 MG-500 MG TABLET,

35

PRAVACHOL 10 MG TABLET, 35




pravastatin sodium 10 mg tab, 35




PREVACID 15 MG SOLUTAB, 35

PREVACID DR 15 MG CAPSULE, 35

PREVPAC PATIENT PACK, 36

PRILOSEC DR 10 MG CAPSULE, 36

PRILOSEC DR 20 MG CAPSULE, 36

PRISTIQ 100 MG TABLET, 36

PRISTIQ 50 MG TABLET, 36

PROAIR HFA 90 MCG INHALER, 36

PROTONIX DR 20 MG TABLET, 36

PROVENTIL HFA 90 MCG INHALER,

36

PROZAC 10 MG PULVULE, 36

PROZAC 40 MG PULVULE, 36

PROZAC WEEKLY 90 MG CAPSULE,

36

PULMICORT 180 MCG FLEXHALER,

36

PULMICORT 90 MCG FLEXHALER, 36

QVAR 40 MCG INHALER, 37

QVAR 80 MCG INHALER, 37

REBIF 22 MCG/0.5 ML SYRINGE, 37

REBIF 44 MCG/0.5 ML SYRINGE, 37

REBIF TITRATION PACK, 37

REGRANEX 0.01% GEL, 37

RELENZA 5 MG DISKHALER, 37

RELPAX 20 MG TABLET, 37

RELPAX 40 MG TABLET, 37

RESTASIS 0.05% EYE EMULSION, 37

REVATIO 20 MG TABLET, 37

RHINOCORT AQUA NASAL SPRAY,

37

RISPERDAL 0.25 MG TABLET, 38

RISPERDAL 0.5 MG TABLET, 38

RISPERDAL 1 MG TABLET, 38

RISPERDAL 1 MG/ML SOLUTION, 38




RISPERDAL M-TAB 0.5 MG ODT, 37

RISPERDAL M-TAB 1 MG ODT, 37




risperidone 0.25 mg odt, 38

risperidone 0.25 mg tablet, 38

risperidone 0.5 mg odt, 38

risperidone 0.5 mg tablet, 38

risperidone 1 mg odt, 38

risperidone 1 mg tablet, 38

risperidone 1 mg/ml solution, 38



Updated: 08/2011 55





ROZEREM 8 MG TABLET, 38

RYZOLT ER 100 MG TABLET, 38



SAMSCA 15 MG TABLET, 38

SAMSCA 30 MG TABLET, 39

SANCUSO 3.1 MG/24 HR PATCH, 39

SANDOSTATIN LAR 10 MG KIT, 39



SAPHRIS 10 MG TAB SUBLINGUAL,

39

SAPHRIS 5 MG TABLET

SUBLINGUAL, 39

SARAFEM 10 MG TABLET, 39

SARAFEM 20 MG TABLET, 39

SAVELLA 100 MG TABLET, 39

SAVELLA 12.5 MG TABLET, 39



SAVELLA TITRATION PACK, 39

selfemra 10 mg capsule, 25

selfemra 20 mg capsule, 25

SEREVENT DISKUS 50 MCG, 39

SEROQUEL 100 MG TABLET, 40






SEROQUEL XR 150 MG TABLET, 39





sertraline hcl 100 mg tablet, 40



SILENOR 3 MG TABLET, 40

SILENOR 6 MG TABLET, 40

SIMCOR 1,000-20 MG TABLET, 40

SIMCOR 1,000-40 MG TABLET, 40

SIMCOR 500-20 MG TABLET, 40



simvastatin 10 mg tablet, 40





SONATA 10 MG CAPSULE, 40

SONATA 5 MG CAPSULE, 40

SPIRIVA 18 MCG CP-HANDIHALER,

41

SUBOXONE 2 MG-0.5 MG SL FILM, 41

SUBOXONE 2 MG-0.5 MG TABLET SL,

41

SUBOXONE 8 MG-2 MG SL FILM, 41

SUBOXONE 8 MG-2 MG TABLET SL,

41

sumatriptan 4 mg/0.5 ml vial, 41

sumatriptan 6 mg/0.5 ml vial, 41

sumatriptan succ 100 mg tablet, 41



SYMBICORT 160-4.5 MCG INHALER,

41

SYMBICORT 80-4.5 MCG INHALER, 41

SYMLIN 0.6 MG/ML VIAL, 41

SYMLINPEN 120 PEN INJECTOR, 41

SYMLINPEN 60 PEN INJECTOR, 41

TAMIFLU 12 MG/ML SUSPENSION, 41

TAMIFLU 30 MG GELCAP, 41



TERAZOL 3 80 MG SUPPOSITORY, 42

Updated: 08/2011 56

TERAZOL 3 CREAM, 42

TERAZOL 7 CREAM, 42

terazosin 1 mg capsule, 42




terconazole 0.4% cream, 42

terconazole 0.8% cream, 42

terconazole 80 mg suppository, 42

TRADJENTA 5 MG TABLET, 42

tramadol hcl 50 mg tablet, 42

tramadol hcl er 100 mg tablet, 42

tramadol hcl er 200 mg tablet, 42

tramadol-acetaminophn 37.5-325, 42

TREXIMET 85-500 MG TABLET, 42

TWINJECT 0.15 MG AUTO-INJECTOR,

43

TWINJECT 0.3 MG AUTO-INJECTOR,

43

ULTRACET TABLET, 43

ULTRAM 50 MG TABLET, 43

ULTRAM ER 100 MG TABLET, 43



valacyclovir hcl 1 gram tablet, 43

valacyclovir hcl 500 mg tablet, 43

VALTREX 1 GM CAPLET, 43

VALTREX 500 MG CAPLET, 43

venlafaxine hcl 100 mg tablet, 43


venlafaxine hcl 37.5 mg tablet, 43



venlafaxine hcl er 150 mg cap, 43

venlafaxine hcl er 150 mg tab, 43

VENLAFAXINE HCL ER 225 MG TAB,

44

venlafaxine hcl er 37.5 mg cap, 43

venlafaxine hcl er 37.5 mg tab, 43

venlafaxine hcl er 75 mg cap, 43

venlafaxine hcl er 75 mg tab, 43

VENTOLIN HFA 90 MCG INHALER, 44

VERAMYST 27.5 MCG NASAL SPRAY,

44

VICTOZA 3-PAK 18 MG/3 ML PEN, 44

VIIBRYD 10 MG TABLET, 44



VIVELLE-DOT 0.025 MG PATCH, 44





VYTORIN 10-10 MG TABLET, 44




WELLBUTRIN SR 100 MG TABLET, 44



WELLBUTRIN XL 150 MG TABLET, 45

WELLBUTRIN XL 300 MG TABLET, 45

XOLAIR 150 MG VIAL, 45

XOPENEX HFA 45 MCG INHALER, 45

XYZAL 5 MG TABLET, 45

zaleplon 10 mg capsule, 45

zaleplon 5 mg capsule, 45

ZAZOLE 0.8% VAGINAL CREAM, 45

ZAZOLE 80 MG VAGINAL SUPP, 45

ZAZOLE VAGINAL 0.4% CREAM, 45

ZEGERID 20 MG CAPSULE, 45

ZEGERID 20 MG PACKET, 45

ZITHROMAX 100 MG/5 ML SUSP, 45

ZITHROMAX 200 MG/5 ML SUSP, 46

ZITHROMAX 250 MG TABLET, 46

ZITHROMAX 250 MG Z-PAK TABLET,

46

ZITHROMAX 500 MG TABLET, 46

ZITHROMAX TRI-PAK 500 MG TAB, 45

Updated: 08/2011 57

ZMAX ADULT-PED 2 G/60 ML SUSP,

46

ZOCOR 10 MG TABLET, 46





ZOFRAN 4 MG TABLET, 46

ZOFRAN 4 MG/5 ML ORAL SOLN, 46

ZOFRAN 8 MG TABLET, 46

ZOFRAN ODT 4 MG TABLET, 46

ZOFRAN ODT 8 MG TABLET, 46

ZOLOFT 100 MG TABLET, 46



zolpidem tart er 12.5 mg tab, 46

zolpidem tart er 6.25 mg tab, 46

zolpidem tartrate 10 mg tablet, 46

zolpidem tartrate 5 mg tablet, 46

ZOLPIMIST 5 MG ORAL SPRAY, 47

ZOMIG 2.5 MG TABLET, 47

ZOMIG 5 MG NASAL SPRAY, 47

ZOMIG 5 MG TABLET, 47

ZOMIG ZMT 2.5 MG TABLET, 47

ZOMIG ZMT 5 MG TABLET, 47

ZUPLENZ 4 MG SOLUBLE FILM, 47

ZUPLENZ 8 MG SOLUBLE FILM, 47

ZYPREXA 10 MG TABLET, 47


ZYPREXA 2.5 MG TABLET, 47



ZYPREXA 7.5 MG TABLET, 47

ZYPREXA ZYDIS 10 MG TABLET, 47




2011 Medicare National Preferred 4 Tier QLL Criteria · AMBIEN® AMBIEN 10 MG TABLET - Limited to a...

Documents

Transcript of 2011 Medicare National Preferred 4 Tier QLL Criteria · AMBIEN® AMBIEN 10 MG TABLET - Limited to a...