Premium Quantity Limits on Medications

Premium Quantity Limits on Medications Your pharmacy benefit plan’s quantity limits program protects you and can help you get the best results from yo...
Author: Georgia Kelly
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Premium Quantity Limits on Medications Your pharmacy benefit plan’s quantity limits program protects you and can help you get the best results from your medication therapy. Along with supporting safe and appropriate dosing, quantity limits can also keep prescription drug costs lower for you and your benefit plan sponsor. Determining Quantity Limits Quantity limits are meant to minimize the risk of over-dosing and unwanted drug interactions. Quantity limit rules are based on: • Food and Drug Administration (FDA) approved indications • Manufacturer’s package labeling instructions • Well-accepted or published clinical recommendations

Establishing Guidelines for Use Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend quantity limit guidelines.

Premium Quantity Limits on Medications

Premium Non-Specialty Quantity Limit THERAPY CLASS

MEDICATION NAME

LIMIT

Antibiotics

SIVEXTRO (tedizolid) Solr SIVEXTRO (tedizolid) Tabs ZYVOX (linezolid) ZYVOX (linezolid) Suspension LAMISIL (terbinafine) 250 mg SITAVIG (acyclovir) 50 mg VALTREX (valacyclovir) RELENZA (zanamivir) TAMIFLU (oseltamivir) 30 mg TAMIFLU (oseltamivir) 45 mg, 75 mg TAMIFLU (oseltamivir) Suspension

6 vials/30 days 6 tabs/30 days 28 tabs/30 days 6 bottles (900 mL)/28 days 84 days supply/180 days 2 tabs/30 days 4 tabs/day QL is 40 inh/365 days. 40 caps/365 days 20 caps/365 days 360 mL/365 days

ELIQUIS (apixiban) ELIQUIS (apixiban) 5 mg PRADAXA (dabigatran) SAVAYSA (edoxaban) XARELTO (rivaroxaban) XARELTO (rivaroxaban) 15 mg XARELTO (rivaroxaban) Starter Pack CORLANOR (ivabradine) ENTRESTO (sacubitril/valsartan)

2 tabs/day 3 tabs/day 2 caps/day 1 tab/day 1 tab/day 2 tabs/day 1 pack/30 days 2 tabs/day 2 tabs/day

Page title interior spread Anti-infectives

Antifungals Antivirals, Herpetic Antivirals, Influenza

Cardiology Anticoagulants

Heart Failure

Central Nervous System ADHD Agents ADDERALL (amphetamine/ dextroamphetamine) ADDERALL XR (amphetamine/ dextroamphetamine mixed salts) APTENSIO XR (methylphenidate) CONCERTA (methylphenidate) 36 mg CONCERTA (methylphenidate) DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine) DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg DEXEDRINE (dextroamphetamine) 10 mg EVEKEO (amphetamine) FOCALIN (dexmethylphenidate) 2 OptumRx | optumrx.com/myCatamaranRx

3 tabs/day 1 cap/day 1 cap/day 2 tabs/day 1 tab/day 1 patch/day 5 tabs/day 3 caps/day 4 caps/day 6 caps/day 6 tabs/day 2 tabs/day

THERAPY CLASS

MEDICATION NAME

LIMIT

ADHD Agents (cont.)

FOCALIN XR (dexmethylphenidate) 20 mg FOCALIN XR (dexmethylphenidate) METADATE CD (methylphenidate) METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate) METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg METHYLPHENIDATE ER (methylphenidate) 10 mg PROCENTRA (dextroamphetamine) Sol QUILLIVANT XR (methylphenidate) RITALIN (methylphenidate) RITALIN LA (methylphenidate) RITALIN SR (methylphenidate) 20 mg STRATTERA (atomoxetine) STRATTERA (atomoxetine) 10 mg, 40 mg VYVANSE (lisdexamfetamine) ZENZEDI (dextroamphetamine) 10 mg ZENZEDI (dextroamphetamine) ZENZEDI (dextroamphetamine) 30 mg NAMENDA XR (memantine hcl) caps NAMENDA XR TITRATION PACK (memantine hcl) caps NAMZARIC (memantine hcl) caps CELEBREX (celecoxib) FLECTOR (diclofenac epolamine) Ketorolac (ketorolac) SPRIX (ketorolac) QUTENZA (capsaicin) VOLTAREN (diclofenac) Gel ACTIQ (fentanyl citrate) AVINZA (morphine ext-release) AVINZA (morphine ext-release) 120 mg BUNAVAIL (buprenorphrine/naloxone) 2.1-0.3 mg

2 caps/day 1 cap/day 1 cap/day 3 tabs/day 3 tabs/day 3 tabs/day 6 tabs/day

Alzheimers Agents

Analgesics (non-opioid)

Analgesics (opioid)

Analgesics (opioid) (cont.)

3 tabs/day 2 tabs/day 60 mL/day 12 mL/day 3 tabs/day 1 cap/day 3 tabs/day 1 cap/day 2 caps/day 1 cap/day 6 tabs/day 3 tabs/day 2 tabs/day 1 cap/day 1 cap/day 1 cap/ day 2 caps/day 2 patches/day up to 15 days 20 tabs or 5 days supply/30 days 5 bottles or 5 days supply/30 days 4 patches/3 months 10 tubes/month 4 lozenges/day 1 cap/day 2 caps/day 6 films/day

3

THERAPY CLASS

Anticonvulsants

MEDICATION NAME

LIMIT

BUNAVAIL (buprenorphrine/naloxone) 6.3-1 mg BUNAVAIL (buprenorphrine/naloxone) 4.2-0.7 mg BUTRANS (buprenorphine) CONZIP (tramadol SR) DURAGESIC (fentanyl transdermal) DURAGESIC (fentanyl transdermal) 75 mcg/hr, 100 mcg/hr EXALGO (hydromorphone) HYSINGLA ER (hydrocodone bitartrate) KADIAN (morphine ext-release) LAZANDA (fentanyl citrate) MS CONTIN (morphine ext-release) ONSOLIS (fentanyl citrate) OPANA ER (oxymorphone ext-release) OXYCONTIN (oxycodone ext-release)

2 films/day

SUBOXONE (buprenorphrine/naloxone) 8-2 mg SUBOXONE (buprenorphrine/naloxone) 12-3 mg SUBOXONE (buprenorphrine/naloxone) 4-1 mg SUBOXONE (buprenorphrine/naloxone) 2-0.5 mg SUBSYS (fentanyl) SUBUTEX (buprenorphrine) 8 mg SUBUTEX (buprenorphrine) 2 mg ULTRAM ER (tramadol ext-release) ZUBSOLV (buprenorphine/naloxone) SL Tab 5.7-1.4 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 8.6/2.1 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 11.4/2.9 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 2.9/0.71 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 1.4-0.36 MG DIAZEPAM GEL (diazepam) GRALISE (gabapentin) 300 mg

3 tabs or films/day

4 OptumRx | optumrx.com/myCatamaranRx

3 films/day 4 patches/28 days 1 cap/day 15 patches/30 days 30 patches/30 days 2 tabs/day 1 tab/day 2 caps/day 1 bottle/day 3 tabs/day 4 films/day 4 tabs/day 4 tabs/day

2 films/day 6 films/day 12 tabs or films/day 16 sprays/day 3 tabs/day 12 tabs/day 1 tab/day 3 tabs/day 2 tabs/day 1 tab/day 6 tabs/day 12 tabs/day 2 boxes/fill 6 tabs/day

THERAPY CLASS

Antidepressants

Antipsychotics

Antipsychotics (cont.)

MEDICATION NAME

LIMIT

GRALISE (gabapentin) 600 mg GRALISE (gabapentin) Pack HORIZANT (gabapentin enacarbil) LYRICA (pregabalin) 300 mg LYRICA (pregabalin) caps APLENZIN (bupropion) BRINTELLIX (vortioxetine) CYMBALTA (duloxetine) CYMBALTA (duloxetine) 30 mg desvenlafaxine fumarate (desvenlafaxine) EMSAM (selegiline) FETZIMA (levomilnacipran) FETZIMA (levomilnacipran) Pack FORFIVO XL (bupropion) 450 mg IRENKA (duloxetine) KHEDEZLA (desvenlafaxine ER) KHEDEZLA (desvenlafaxine ER) 100 mg

3 tabs/day 1 kit/fill (78 tabs per fill) 2 tabs/day 2 caps/day 3 caps/day 1 tab/day 1 tab/day 2 caps/day 3 caps/day 1 tab/day 1 patch/day 1 cap/day 1 pack (28 caps)/year 1 tab/day 2 caps/day 1 tab/day 4 tabs/day

LUVOX CR (fluvoxamine) OLEPTRO (trazodone) PEXEVA (paroxetine) PEXEVA (paroxetine) 30 mg PRISTIQ (desvenlafaxine) PRISTIQ (desvenlafaxine) 100 mg PROZAC WEEKLY (fluoxetine) VIIBRYD (vilazodone) VIIBRYD (vilazodone) Kit WELLBUTRIN SR (bupropion) WELLBUTRIN XL (bupropion) WELLBUTRIN XL (bupropion) 150 mg ABILIFY (aripiprazole) tabs ABILIFY DISCMELT (aripiprazole) ABILIFY SOLN (aripiprazole) 1 mg/mL CLOZARIL (clozapine) 100 mg CLOZARIL (clozapine) 200 mg CLOZARIL (clozapine) 25 mg CLOZARIL (clozapine) 50 mg FANAPT (iloperidone) FANAPT PAK (iloperidone) FAZACLO (clozapine) 100 mg FAZACLO (clozapine) 12.5 mg FAZACLO (clozapine) 150 mg

2 caps/day 1 tab/day 1 tab/day 2 tabs/day 1 tab/day 4 tabs/day 4 caps/28 days 1 tab/day 1 kit (30 tabs)/ fill 3 tabs/day 1 tab/day 3 tabs/day 1 tab/day 2 tabs/day 25 mL/day 9 tabs/day 4 tabs/day 9 tabs/day 6 tabs/day 2 tabs/day 1 pack/180 days 9 tabs/day 3 tabs/day 6 tabs/day 5

THERAPY CLASS

Benzodiazepines

Benzodiazepines (cont.)

MEDICATION NAME

LIMIT

FAZACLO (clozapine) 200 mg FAZACLO (clozapine) 25 mg GEODON (ziprasidone) INVEGA (paliperidone) INVEGA (paliperidone) 6 mg LATUDA (lurasidone) 20 mg, 40 mg, 60mg, 120 mg LATUDA (lurasidone) 80 mg REXULTI (brexpiprazole) RISPERDAL (risperidone) RISPERDAL M (risperidone) RISPERDAL SOLN (risperidone)

4 tabs/day 9 tabs/day 2 caps/day 1 tab/day 2 tabs/day 1 tab/day

SAPHRIS (asenapine) SEROQUEL (quetiapine) SEROQUEL (quetiapine) 25 mg, 50 mg, 100 mg, 200 mg SEROQUEL XR (quetiapine) SEROQUEL XR (quetiapine) 200 mg SYMBYAX (olanzapine/fluoxetine) SYMBYAX (olanzapine/fluoxetine) 3-25 mg SYMBYAX (olanzapine/fluoxetine) 6-25 mg VERSACLOZ (clozapine) ZYPREXA (olanzapine) ZYPREXA ZYDIS (olanzapine) CHLORDIAZEP (chlordiazepoxide) 10 mg CHLORDIAZEP (chlordiazepoxide) 25 mg

2 tabs/day 2 tabs/day 3 tabs/day

CHLORDIAZEP (chlordiazepoxide) 5 mg CLONAZEP ODT (clonazepam) CLONAZEP ODT (clonazepam) 2 mg CLORAZ DIPOT (clorazepate) 15 mg CLORAZ DIPOT (clorazepate) 3.75 mg CLORAZ DIPOT (clorazepate) 7.5 mg DORAL (quazepam) ESTAZOLAM (estazolam) FLURAZEPAM (flurazepam) HALCION (triazolam) KLONOPIN (clonazepam) LORAZEPAM (lorazepam) LORAZEPAM (lorazepam) 2 mg OXAZEPAM (oxazepam)

4 caps/day 3 tabs/day 10 tabs/day 6 tabs/day 24 tabs/day 12 tabs/day 1 tab/day 1 tab/day 1 cap/day 2 tabs/day 3 tabs/day 3 tabs/day 10 tabs/day 4 caps/day

6 OptumRx | optumrx.com/myCatamaranRx

2 tabs/day 1 tab/day 2 tabs/day 2 tabs/day 8 mL/day

2 tabs/day 3 tabs/day 1 cap/day 3 caps/day 3 caps/day 18 mL/day 1 tab/day 1 tab/day 30 caps/day 12 caps/day

THERAPY CLASS

Fibromyalgia Migraine

Miscellaneous Sedative Hypnotics

Sedative Hypnotics (cont.)

MEDICATION NAME

LIMIT

TEMAZEPAM (temazepam) XANAX (alprazolam) XANAX (alprazolam) 2 mg XANAX XR (alprazolam) XANAX XR (alprazolam) 2 mg XANAX XR (alprazolam) 3 mg SAVELLA (milnacipran) SAVELLA (milnacipran) Pack ALSUMA (sumatriptan)

1 cap/day 4 tabs/day 5 tabs/day 1 tab/day 5 tabs/day 3 tabs/day 2 tabs/day 1 pack (55 tabs)/year 5 packages (10 syringes)/30 days AMERGE (naratriptan) 9 tabs/30 days AXERT (almotriptan) 12 tabs/30 days FROVA (frovatriptan) 9 tabs/30 days IMITREX (sumatriptan) 9 tabs/30 days IMITREX (sumatriptan) AUTO-INJECTOR 4 5 kits (10 units)/30 days mg/0.5 mL & 6 mg/0 IMITREX (sumatriptan) CARTRIDGE 4 5 kits (10 units)/30 days mg/0.5 mL & 6 mg/0.5 m IMITREX (sumatriptan) Nasal 12 spray unit devices/30 days IMITREX (sumatriptan) SYRINGE 4 mg/0.5 5 kits (10 units)/30 days mL & 6 mg/0.5 mL MAXALT (rizatriptan) 18 tabs/30 days MAXALT-MLT (rizatriptan) 18 tabs/30 days MIGRANAL (dihydroergotamine) 1 package (8 vials)/30 days RELPAX (eletriptan) 12 tabs/30 days SUMAVEL DOSEPRO (sumatriptan) 12 prefilled syringes/30 days TREXIMET (sumatriptan/naproxen) 9 tabs/30 days ZOMIG (zolmitriptan) 9 tabs/30 days ZOMIG (zolmitriptan) 2.5 mg 12 tabs/30 days ZOMIG (zolmitriptan) Nasal 2 packages (12 spray units)/30 days ZOMIG ZMT (zolmitriptan) 9 tabs/30 days ZOMIG ZMT (zolmitriptan) 2.5 mg 12 tabs/30 days RILUTEK (riluzole) 2 tabs/day AMBIEN (zolpidem) 1 tab/day AMBIEN CR (zolpidem) 1 tab/day BELSOMRA (suvorexant) 1 tab/day EDLUAR (zolpidem) 1 tab/day INTERMEZZO (zolpidem) 1 tab/day LUNESTA (eszopiclone) 1 tab/day ROZEREM (ramelteon) 1 tab/day SILENOR (doxepin) 1 tab/day 7

THERAPY CLASS

Stimulants

MEDICATION NAME

LIMIT

SONATA (zaleplon) 10 mg SONATA (zaleplon) 5 mg ZOLPIMIST (zolpidem) NUVIGIL (armodafinil) NUVIGIL (armodafinil) 50 mg PROVIGIL (modafinil)

2 cap/day 1 cap/day 1 bottle (7.7 g)/30 days 1 tab/day 2 tabs/day 1 tab/day

Dermatology Miscellaneous

TACLONEX (calcipotriene/betamethasone) TACLONEX SCALP (calcipotriene/ betamethasone) Miscellaneous TAZORAC (tazarotene) FABIOR (tazarotene) Endocrinology & Metabolism Androgens, Anabolic OXANDRIN (oxandrolone) 10 mg Steroids OXANDRIN (oxandrolone) 2.5 mg Antidiabetic Agents BYDUREON (exenatide) BYETTA (exenatide) soln 10 mcg BYETTA (exenatide) soln 5 mcg TRULICITY (dulaglutide) VICTOZA (liraglutide) Osteoporosis ACTONEL (risedronate) 150 mg ACTONEL (risedronate) 35 mg ATELVIA (risedronate) BINOSTO (alendronate) BONIVA (ibandronate) BONIVA IV (ibandronate) FORTICAL (calcitonin) FOSAMAX (alendronate) 35 mg & 70 mg FOSAMAX PLUS D (alendronate/ cholecalciferol) MIACALCIN (calcitonin) Gastroenterology Antiemetics AKYNZEO (netupitant-palonosetron) ANZEMET (dolasetron) CESAMET (nabilone) DICLEGIS (doxylamine-pyridoxine) Antiemetics (cont.) EMEND (aprepitant) 125 mg EMEND (aprepitant) 125 mg/80 mg EMEND (aprepitant) 40 mg EMEND (aprepitant) 80 mg GRANISOL (granisetron) 8 OptumRx | optumrx.com/myCatamaranRx

400 g/30 days 120 g/30 days 100 g/30 days 100 g/30 days 2 tabs/day 8 tabs/day 4 vials/pen-inj/28 days. 2 syringes/30 days 2 syringes/30 days 4 pen-inj/28 days. 3 pen-inj/ 30 days 1 tab/28 days 4 tabs/28 days 4 tabs/28 days 4 tabs/28 days 1 tabs/28 days 1 syringe/90 days 1 bottle (3.7 mL)/30 days 4 tabs/28 days 4 tabs/28 days 1 bottle (3.7 mL)/30 days 2 tabs/30 days 2 tabs/30 days 20 tabs/fill or 3 max days 4 tabs/day 2 caps/30 days 2 packs (6 caps)/30 days 1 cap/30 days 4 caps/30 days 1 bottle (30 mL)/30 days

THERAPY CLASS

Constipation Diarrhea Irritable Bowel Syndrome Opioid-induced Constipation Proton Pump Inhibitors

Miscellaneous Diabetic Supplies Methotrexate Auto-Injectors Smoking Cessation Products

MEDICATION NAME

LIMIT

KYTRIL (granisetron) MARINOL (dronabinol) SANCUSO (granisetron) ZOFRAN (ondansetron) ZOFRAN (ondansetron) 24 mg ZOFRAN (ondansetron) 4 mg, 8 mg ZOFRAN ODT (ondansetron) 4 mg, 8 mg ZUPLENZ (ondansetron) AMITIZA (lubiprostone) LINZESS (linaclotide) FULYZAQ (crofelemer) VIBERZI (eluxadoline) MOVANTIK (naloxegol) RELISTOR (methylnaltrexone) RELISTOR (methylnaltrexone) Kit ACIPHEX (rabeprazole) ACIPHEX SPRINKLE (rabeprazole) SPR DEXILANT (dexlansoprazole) esomeprazole strontium (esomeprazole strontium) NEXIUM (esomeprazole) Caps NEXIUM (esomeprazole) Packs PREVACID (lansoprazole) PREVACID (lansoprazole) Solutab PRILOSEC (omeprazole) PRILOSEC PACKETS (omeprazole) PROTONIX (pantoprazole) packets PROTONIX (pantoprazole) tab ZEGERID (omeprazole) caps ZEGERID (omeprazole) packets

4 tabs/30 days 2 caps/day 2 patches/30 days 120 mL/30 days 2 tabs/30 days 15 tabs/30 days 15 tabs/30 days 10 films/30 days 2 caps/day 1 cap/day 2 tabs/day 2 tabs/day 1 tab/day 1 syringe/day 1 vial/day 1 tab/day 1 cap/day 1 cap/day 1 cap/day

Glucose Test Strips & Lancets (test strip & lancets) OTREXUP (methotrexate) RASUVO (methotrexate) CHANTIX (varenicline) COMMIT (nicotine lozenges) NICODERM (nicotine transdermal) NICORETTE (nicotine gum) NICOTROL Inhaler (nicotine)

300/30 days

1 cap/day 1 packet/day 1 cap/day 1 cap/day 1 cap/day 60 packets/30 days 1 packet/day 1 tab/day 2 caps/day 2 packets/day

4 auto-injectors/28 days 4 auto-injectors/28 days 180 days supply/year 180 days supply/year 180 days supply/year 180 days supply/year 180 days supply/year 9

THERAPY CLASS

MEDICATION NAME

LIMIT

NICOTROL NS (nicotine) ZYBAN (bupropion)

180 days supply/year 180 days supply/year

AMETHIA (levonorg-eth est) AMETHIA LO (levonorg-eth est) ASHLYNA (levonorg-eth est) CAMRESE (levonorg-eth est) CAMRESE LO (levonorg-eth est) DAYSEE (levonorg-eth est) DEPO/DEPO-SUBQ PROVERA (medroxyprogesterone) INTROVALE (levonorg-eth est) JOLESSA (levonorg-eth est) LOSEASONIQUE (ethinyl estradiol/ levonorgestrel) QUARTETTE (levonorg-eth est) QUASENSE (levonorg-eth est) SEASONIQUE (ethinyl estradiol/ levonorgestrel) ESTRING (estradiol) FEMRING (estradiol acetate) BRISDELLE (paroxetine)

1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/90 days (3 copays per fill)

BROMDAY (bromfenac) ILEVRO (nepafenac) 0.3% LOTEMAX (loteprednol) gel, oint

4 bottles/year 2 bottles/month 4 bottles/year

NEVANAC (nepafenac) 0.1% PROLENSA (bromfenac sodium) LUMIGAN (bimatoprost) TRAVATAN (travoprost) TRAVATAN Z (travoprost) XALATAN (latanoprost)

6 mL/30 days 4 bottles/year 1 bottle (2.5 mL)/25 days 1 bottle (2.5 mL)/25 days 1 bottle (2.5 mL)/25 days 1 bottle (2.5 mL)/25 days

ASTELIN (azelastine) ASTEPRO (azelastine) BECONASE AQ (beclomethasone) DYMISTA (fluticasone/azelastine) FLUNISOLIDE (flunisolide) NASONEX (mometasone) OMNARIS (ciclesonide) PATANASE (olopatadine)

2 bottles (60 mL)/30 days 2 bottles (60 mL)/30 days 1 inhaler (25 g)/25 days 1 inhaler (23 g)/30 days 1 bottle (25 mL)/30 days 2 inhalers/30 days 1 inhaler (12.5 g)/30 days 1 bottle (30.5 g)/30 days

Obstetrics & Gynecology Contraceptives

Hormone Replacement Miscellaneous Ophthalmology Anti-inflammatory

Prostaglandins

Respiratory Allergy (intranasal)

Allergy (intranasal) (cont.)

10 OptumRx | optumrx.com/myCatamaranRx

1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1/91 days (3 copays per fill) 1 package/90 days 1 package/ 90 days 1 cap/day

THERAPY CLASS

Asthma/COPD (inhaled)

Asthma/COPD (inhaled) (cont.) Asthma/COPD (nebulized)

MEDICATION NAME

LIMIT

QNASL (beclomethasone) QNASL CHILDRENS (beclomethasone) RHINOCORT AQUA (budesonide) VERAMYST (fluticasone furoate) ZETONNA (ciclesonide nasal) ADVAIR DISKUS (fluticasone/salmeterol) ADVAIR HFA (fluticasone/salmeterol) AEROSPAN (flunisolide) ANORO ELLIPTA (umeclidinium-vilanterol) ARCAPTA (indacaterol) ARNUITY ELLIPTA (fluticasone furoate) ATROVENT HFA (ipratropium) BREO ELLIPTA (fluticasone furoatevilanterol) COMBIVENT RESPIMAT (ipratropium/ albuterol) DULERA (mometasone/formoterol) FLOVENT (fluticasone) 110 mcg, 220 mcg FLOVENT (fluticasone) 44 mcg FLOVENT DISKUS (fluticasone) 250 mcg FLOVENT DISKUS (fluticasone) 50 mcg, 100 mcg FORADIL (formoterol) INCRUSE ELLIPTA (umeclidnium) MAXAIR AUTOHALER (pirbuterol) PROAIR HFA (albuterol) PROAIR RESPICLICK (albuterol) PULMICORT FLEXHALER (budesonide) QVAR (beclomethasone) 40 mcg QVAR (beclomethasone) 80 mcg SEREVENT DISKUS (salmeterol) 50 mcg SPIRIVA HANDIHALER (tiotropium) SPIRIVA RESPIMAT (tiotropium) STIOLTO RESPIMAT (tiotropium brolodaterol) STRIVERDI RESPIMAT (olodaterol) SYMBICORT (budesonide/formoterol) VENTOLIN HFA (albuterol)

1 inhaler (8.7 g)/30 days 1 inhaler (4.9 g)/30 days 2 bottles/30 days 1 bottle (10 g)/30 days 1 inhaler (6.1 g)/30 days 1 diskus (60 doses)/30 days 1 inhaler/30 days 2 inhalers (8.9 g each)/30 days 1 package (60 blisters)/30 days 4 caps/day 1 inhaler/30 days 2 inhalers (12.9 g each)/30 days 1 package (60 blisters)/30 days

ACCUNEB (albuterol)

5 packages (125 vials or 375 mL)/30 days

2 inhalers (4 g each)/30 days 1 inhaler/30 days 2 inhalers (12 g each)/30 days 2 inhalers/30 days 240 blisters/30 days 60 blisters/30 days 1 package (60 doses)/30 days 1 inhaler/30 days 1 inhaler (14 g)/30 days 2 inhalers/30 days 2 inhalers/30 days 2 packages/30 days 2 inhalers/30 days 3 inhalers/30 days 1 package (60 doses)/30 days 1 package (30 caps)/30 days 1 inhaler/30 days 1 inhaler/30 days 1 inhaler/30 days 1 inhaler/30 days 2 inhalers/30 days

11

THERAPY CLASS

MEDICATION NAME

LIMIT

Albuterol (albuterol) 2.5 mg/3 mL (0.083%) Albuterol (albuterol) 5 mg/mL (0.5%) ATROVENT (ipratropium) BROVANA (arformoterol) DUONEB (ipratropium/albuterol) Metaproterenol (inhalation solution)

180 vials (540 mL)/30 days

PERFOROMIST (formoterol) PROVENTIL (albuterol) 2.5 mg/3mL (0.083%) PULMICORT RESPULES (budesonide) XOPENEX (levalbuterol) XOPENEX (levalbuterol) 1.25 mg/0.5 mL XOPENEX (levalbuterol) 1.25 mg/3 mL Urology Erectile Dysfunction

Overactive Bladder Antispasmodics

CAVERJECT (alprostadil) CIALIS (tadalafil) 10 mg CIALIS (tadalafil) 2.5 mg CIALIS (tadalafil) 20 mg CIALIS (tadalafil) 5 mg EDEX (alprostadil) MUSE (alprostadil) STENDRA (avanafil) OXYTROL (oxybutynin)

5 packages (100 mL)/30 days 125 vials (312.5 mL)/30 days 60 vials (120 mL)/30 days 180 vials (540 mL)/30 days 5 packages (125 ampules or 312.5 mL)/30 days 60 vials (120 mL)/30 days 175 vials (525 mL)/30 days 2 packages (120 mL)/30 days 180 vials (540 mL)/30 days 90 vials (45 mL)/30 days 90 vials (270 mL)/30 days 6 units/30 days 6 tabs/30 days 1 tab/day 6 tabs/30 days 1 tab/day 6 units/30 days 6 units/30 days 6 tabs/30 days 8 patches/28 days

Premium Specialty Quantity Limit Anti-Infectives Antiretrovirals, Hepatitis B Antiretrovirals, HIV Cardiology Anticoagulants, LMWH

Antilipemic

BARACLUDE (entecavir) BARACLUDE (entecavir) Soln FUZEON (enfuvirtide)

1 tab/day 630 mL/30days 60 vials or 1 kit/30 days

ARIXTRA (fondaparinux) FRAGMIN (dalteparin) LOVENOX (enoxaparin) JUXTAPID (lomitapide) KYNAMRO (mipomersen) PRALUENT (alirocumab) REPATHA (evolocumab)

35 days supply/180 days 35 days supply/180 days 35 days supply/180 days 1 tab/day 4 syringes/28 days 2 syringes/28 days 3 syringes/28 days

12 OptumRx | optumrx.com/myCatamaranRx

THERAPY CLASS

MEDICATION NAME

LIMIT

Pulmonary Arterial Hypertension

ADCIRCA (tadalafil) ADEMPAS (riociguat) LETAIRIS (ambrisentan) OPSUMIT (macitentan) REVATIO (sildenafil) Susp REVATIO (sildenafil) Tabs TRACLEER (bosentan) TYVASO (treprostinil) UPTRAVI (selexipag) UPTRAVI (selexipag) Pack VENTAVIS (iloprost)

2 tabs/day 3 tabs/day 1 tab/day 1 tab/day 2 bottles/30 days 3 tabs/day 2 tabs/day 1 ampule/day 2 tabs/day 2 packs/year 9 ampules/day

Central Nervous System Depressant XYREM (sodium oxybate) Parkinson's APOKYN (apomorphine) Sleep Disorder HETLIOZ (tasimelteon) Electrolyte & Renal Agents Diuretics KEVEYIS (dichlorphenamide) Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) ELIGARD (leuprolide) 30 mg (4-month) ELIGARD (leuprolide) 45 mg (6-month) ELIGARD (leuprolide) 7.5 mg (1-month) FIRMAGON (degarelix) 120 mg FIRMAGON (degarelix) 80 mg LUPANETA PACK (leuprolide) 11.25 mg (3 mon) LUPANETA PACK (leuprolide) 3.75 mg (1 mon) SUPPRELIN LA (histrelin acetate) TRELSTAR (triptorelin) 22.5 mg (6-month)

Growth Hormones Hypertension Hormone Modifiers Miscellaneous

TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) TRELSTAR LA (triptorelin) 11.25 mg (3-month) VANTAS (histrelin) ZOLADEX (goserelin) 10.8 mg ZOLADEX (goserelin) 3.6 mg EGRIFTA (tesamorelin) 1 mg EGRIFTA (tesamorelin) 2 mg NATPARA (parathyroid hormone) KORLYM (mifepristone)

3 bottles (540 mL)/30 days 20 cartridges/30 days 1 cap/day 4 tabs/day 1 injection/84 days 1 injection/112 days 1 injection/168 days 1 injection/28 days 2 vials/year 1 vial/28 days 1 pack/84 days 1 pack/28 days 1 kit/365 days 1 injection/168 days 1 injection/28 days 1 injection/84 days 1 implant/year 1 injection/84 days 1 injection/28 days 2 vials (1 mg each)/day 1 vial (2 mg each)/day 2 cartridges/28 days 4 tabs/day 13

THERAPY CLASS Somatostatins Vasopressin Antagonist Enzyme-Related Cystine-depleting Agents Immunology Allergen Extracts

Hematopoietic Agents Hepatitis C Agents

Interleukins Multiple Sclerosis

Multiple Sclerosis (cont.)

MEDICATION NAME

LIMIT

PROLIA (denosumab) SIGNIFOR (pasireotide) SIGNIFOR LAR (pasireotide) SAMSCA (tolvaptan)

2 syringes/year 2 ampules/day 1 vial/28 days 30 days supply/60 days

CYSTARAN (cysteamine)

4 bottles/28 days

GRASTEK (timothy grass pollen) ORALAIR (mixed grass pollens allergen) 300 IR ORALAIR ADULT SAMPLE KIT (mixed grass pollens allergen) Kit ORALAIR ADULT STARTER PACK (mixed grass pollens allergen) ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allerg ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allerg RAGWITEK (short ragweed pollen allergen) MOZOBIL (plerixafor) DAKLINZA (daclatasvir dihydrochloride) 30 mg DAKLINZA (daclatasvir dihydrochloride) 60 mg HARVONI (ledipasvir-sofosbuvir) OLYSIO (simeprevir) SOVALDI (sofosbuvir) TECHNIVIE (ombitasvir-paritaprevirritonavir) VIEKIRA (simeprevir) ZEPATIER (elbasvir-grazoprevir) ILARIS (canakinumab) AMPYRA (dalfampridine) AUBAGIO (teriflunomide) AVONEX (interferon beta-1a) COPAXONE (glatiramer) SOSY 20 mg/ml COPAXONE (glatiramer) SOSY 40 mg/ml GILENYA (fingolimod) GLATOPA (glatiramer) SOSY 20 mg/ml PLEGRIDY (peginterferon beta)

1 tab/day 1 tab/day

14 OptumRx | optumrx.com/myCatamaranRx

1 kit/year 1 pack/year 2 kits/year 2 packs/year 1 tab/day 8 vials (9.6 mL)/transplant 3 tabs/day 1 tab/day 1 tab/day 1 cap/day 1 tab/day 2 tabs/day 4 tabs/day 1 tab/day 2 vials/4 weeks 2 tabs/day 1 tab/day 1 kit (4 syringes)/28 days 1 kit/30 days 1 kit/30 days 1 cap/day 1 kit/30 days 2 pens/syringe/28 DAYS

THERAPY CLASS

MEDICATION NAME

LIMIT

PLEGRIDY (peginterferon beta) Starter Pack TECFIDERA (dimethyl fumarate) TECFIDERA (dimethyl fumarate) Starter Pack TYSABRI (natalizumab)

1 starter pack/30 days

Obstetrics & Gynecology Hormone Replacement CRINONE (progesterone) 8% Oncology Kinase and Molecular AFINITOR (everolimus) Target Inhibitors CAPRELSA (vandetanib) 100 mg COTELLIC (cobimetnib) FARYDAK (panobinostat) GILOTRIF (afatinib) ICLUSIG (ponatinib) 15 mg JAKAFI (ruxolitinib) 10 mg NINLARO (ixazomib) PORTRAZZA (necitumumab) Soln TAGRISSO (osimertinib) TARCEVA (erlotinib) 100 mg, 150 mg TARCEVA (erlotinib) 25 mg Respiratory Asthma/COPD NUCALA (mepolizumab) Cystic Fibrosis ORKAMBI (lumacaftor-ivacaftor)

2 caps/day 1 starter pack/year 1 injection /28 days 60 applicators/30 days 1 tab/day 2 tabs/day 63 tabs/28 days 6 caps/ 21 days 1 tab/day 2 tabs/day 2 tabs/day 3 caps/28 days 2 vials/21 days 1 tab/day 1 tab/day 3 tabs/day 1 vial/28 days 112 tabs/28 days

15

Quantity Limits effective as of July 1, 2016. PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected included both brand and generic where applicable and includes all strengths unless otherwise specifically noted. If a targeted drug has a new strength, it will automatically be added to the list.

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