Know Your Limit

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April 2021Know Your Limit:Check If Your Medication Is In TheSpecialty Quantity Limit ProgramYour pharmacy benefit plan is part of the Specialty Quantity Limit Program. This programsupports safe, clinically appropriate and cost-effective use of specialty medications. Both yourplan sponsor and CVS Caremark want to make sure you receive the correct amount of medicineto effectively treat your condition.Please check the list below to see if your medications are included in the quantity limit programand note the quantity that will be covered by your prescription benefit.If you are taking more than the quantity covered by your benefit: Ask your doctor if a smalleramount will work for you. Your doctor can write or call in the new prescription to be filled at yourcurrent pharmacy or through CVS Specialty .If your current prescription includes an amount less than these limits: No further action fromyour doctor is needed.If you need more medicine than the quantity limit allows due to your medical situation: Askyour doctor to contact our Prior Authorization Department for approval of a larger amount forselect drugs on the list.Drug Label NameApproved QuantityDrug Label NameApproved QuantityACTEMRA INJ ACTPEN162 MG/0.9 ML4 autoinjectors (3.6 ml)per 28 daysADEMPAS TAB 2.5 MG90 per 30 daysADEMPAS TAB 2 MG90 per 30 daysACTEMRA INJ 162/0.9162 mg per week(3.6 ml) per 28 daysAFINITOR DIS TAB 2 MG60 per 30 daysAFINITOR DIS TAB 3 MG90 per 30 daysACTEMRA INJ 200/10 ML40 ml per 14 daysAFINITOR DIS TAB 5 MG60 per 30 daysACTEMRA INJ 400/20 ML40 ml per 14 daysAFINITOR TAB 2.5 MG30 per 30 daysACTEMRA INJ 80 MG/4 ML10 ml per 14 daysAFINITOR TAB 5 MG30 per 30 daysACTHAR INJ 80 UNIT35 ml per 21 daysAFINITOR TAB 7.5 MG30 per 30 daysADCIRCA TAB 20 MG60 per 30 daysAFINITOR TAB 10 MG30 per 30 daysADEMPAS TAB 0.5 MG90 per 30 daysALECENSA 150 MG240 per 30 daysADEMPAS TAB 1.5 MG90 per 30 daysALUNBRIG PAK30 per 30 daysADEMPAS TAB 1 MG90 per 30 daysALUNBRIG TAB 30 MG120 per 30 days1

Drug Label NameApproved QuantityDrug Label NameApproved QuantityALUNBRIG tab 90 mg30 per 30 daysBUPHENYL 500 MG TABLET1200 per 30 daysALUNBRIG tab 180 mg30 per 30 daysBUPHENYL POW750 grams per 30 daysALYQ TAB 20 MG60 per 30 daysAMPYRA TAB 10 MG60 per 30 daysBYNFEZIA PEN INJ2500 MCG7 per 30 daysAPOKYN 30 MG/3 ML20 per 30 daysCABOMETYX TAB 20 MG30 per 30 daysAPTIVUS CAP 250 MG120 per 30 daysCABOMETYX TAB 40 MG30 per 30 daysAPTIVUS SOL 100 MG/ML285 ml per 28 daysCABOMETYX TAB 60 MG30 per 30 daysARCALYST INJ 80 MG/ML8 per 28 daysCALQUENCE 100 MG CAP60 per 30 daysATRIPLA TAB30 per 30 daysCAPRELSA TAB 100 MG60 per 30 daysAUBAGIO TAB 14 MG30 per 30 daysCAPRELSA TAB 300 MG30 per 30 daysAUBAGIO TAB 7 MG30 per 30 daysCAYSTON INH 75 MG84 per 28 daysAUSTEDO TAB 6 MG60 per 30 daysCERDELGA CAP 84 MG60 per 30 daysAUSTEDO TAB 9 MG120 per 30 daysAUSTEDO TAB 12 MG120 per 30 daysCEREZYME INJ400 UNIT60 units/kg (15) per14 daysAVONEX PEN KIT 30 MCG4 inj per 28 dayscimduo tab 300 mg30 per 30 daysAVSOLA INJ 100 MG5 per 42 daysAVONEX PREFL KIT 30 MCG4 inj per 28 daysCIMZIA PREFL KIT200 MG/ML2 kits (4 syringes)per 28 daysAYVAKIT TAB 100 MG30 per 30 daysCIMZIA STARTER KIT6 syringes per 28 daysAYVAKIT TAB 200 MG30 per 30 daysCINQAIR3 vials per 28 daysAYVAKIT TAB 300 MG30 per 30 daysBAFIERTAM CAP 95 MG120 per 30 daysCINRYZE IV INJ 500 UNIT(1 VIAL)18 per 30 daysBALVERSA TAB 3 MG84 per 28 daysCINRYZE SDV 500 UNIT20 per 30 daysBALVERSA TAB 4 MG56 per 28 daysCOMBIVIR TAB 150-30060 per 30 daysBALVERSA TAB 5 MG28 per 28 daysCOMETRIQ KIT 60 MG1 box (84) per 28 daysBENLYSTA 200 MG/ML PFS4 per 28 daysCOMETRIQ KIT 100 MG1 box (56) per 28 daysBENLYSTA 200 MG/ML AIJ4 per 28 daysCOMETRIQ KIT 140 MG1 box (112) per 28 daysBERINERT IV INJ 500 UNIT(1 VIAL)60 per 90 daysCOMPLERA TAB30 per 30 daysCOPAXONE INJ 20 MG/ML30 per 30 daysBETASERON INJ 0.3 MG14 per 28 daysCOPAXONE INJ 40 MG/ML12 per 28 daysBETHKIS NEB 300/4 ML224 per 28 daysCOPIKTRA CAP 15 MG56 per 28 daysBiktarvy30 per 30 daysCOPIKTRA CAP 25 MG56 per 28 daysBOSULIF TAB 100 MG90 per 30 daysCOSENTYX INJ 150 MG/ML150 mg (1 ml) per 28 daysBOSULIF TAB 400 MG30 per 30 daysCOSENTYX INJ 300 DOSE300 mg (2 ml) per 28 daysBOSULIF TAB 500 MG30 per 30 daysBRAFTOVI 75 MG CAP180 per 30 daysCOSENTYX PEN INJ 150MG/ML150 mg (1 ml) per28 daysBRONCHITOL CAP 40MG560 per 28 daysBRONCHITOL CAP TOL TEST 20 per 7 daysCOSENTYX PEN INJ300 DOSE300 mg (2 ml) per28 daysBRUKINSA CAP 80 MGCOTELLIC TAB 20 MG63 tabs per 28 days120 per 30 days2

Drug Label NameApproved QuantityDrug Label NameApproved QuantityCRIXIVAN CAP 200 MG450 per 30 daysEMFLAZA TAB 30 MG30 per 30 daysCRIXIVAN CAP 400 MG180 per 30 daysEMFLAZA TAB 36 MG30 per 30 daysCRYSVITA 10 mg/ml10 mg per 14 daysEMTRIVA CAP 200 MG30 per 30 daysCRYSVITA 20 mg/ml80 mg per 14 daysEMTRIVA SOL 10 MG/ML680 ml per 28 daysCRYSVITA 30 mg/ml90 mg per 14 daysENBREL INJ 25/0.5 ML VIAL4 per 28 daysCYSTADROPS SOL 0.37%4 per 28 daysENBREL INJ 25 MG MDV4 per 28 daysCYSTARAN SOL 0.44%4 per 28 daysENBREL INJ 50 MG/ML SRCLK 4 per 28 daysDANYELZA INJ 40/10 ML12 per 28 daysENBREL MINI CRT 50 MG/ML4 per 28 daysDAURISMO TAB 25 MG60 per 30 daysENBREL INJ 25/0.5 ML PFS4 per 28 daysDAURISMO TAB 100 MG30 per 30 daysENBREL INJ 50 MG/ML PFS4 per 28 daysDELSTRIGO TAB30 per 30 daysENDARI POWDER 5 GM180 packets per 30 daysDESCOVY TAB 200/2530 per 30 daysENSPRYNG INJ 120 MG/ML1 per 28 daysDIACOMIT CAP 250 MG360 per 30 daysENTYVIO INJ 300 MG300 mg every 8 weeksDIACOMIT 250 MGPowder for Oral Suspension360 per 30 daysDIACOMIT CAP 500 MGDIACOMIT 500 MGPowder for Oral SuspensionEPCLUSA TAB 200 MG/50 MG 28 per 28 daysEPCLUSA TAB 400-10028 per 28 days180 per 30 daysEPIDIOLEX 100 MG/ML800 per 30 days180 per 30 daysEPIDIOLEX 100 MG/ML(100 ML)600 ml per 30 daysDIDANOSINE EC CAP 200 MG 30 per 30 daysEPIVIR SOL 10 MG/ML900 ml per 30 daysDIDANOSINE EC CAP 250 MG 30 per 30 daysEPIVIR TAB 150 MG60 per 30 daysDIDANOSINE EC CAP 400 MG 30 per 30 daysEPIVIR TAB 300 MG30 per 30 daysDOPTELET TAB 20 MGBlister card w/ 10 tabs10 tabs for 5 daysEPZICOM TAB 600-30030 per 30 daysERIVEDGE CAP 150 MG30 per 30 daysDOPTELET TAB 20 MGBlister card w/ 15 tabs15 tabs for 5 daysERLEADA120 per 30 daysESBRIET CAP 267 MG270 per 30 daysDOPTELET TAB 20 MGBlister card w/ 15 tabs x 260 tabs for 30 daysESBRIET TAB 267 MG270 per 30 daysESBRIET TAB 801 MG90 per 30 daysDOVATO TAB 50-300 MG30 per 30 daysEVENITY INJ 105 MG2 syringes per 30 daysDUPIXENT INJ 200 MG/1.14 ML400 mg (2.28 ml)per 28 daysEVOTAZ TAB 300-15030 per 30 daysEVRYSDI SOL 0.750 MG/ML120 mg per 24 daysDUPIXENT INJ 300 MG/2 ML600 mg (4 ml) per 28 daysEDURANT TAB 25 MG60 per 30 daysEXONDYS 51 VIA 100 MG/2 ML240 mL per 28 daysEGRIFTA SOL 1MG60 per 30 daysEGRIFTA SV INJ 2MG30 per 30 daysEXONDYS 51 VIA 500 MG/10 ML240 mL per 28 daysELELYSO INJ 200 UNIT30 per 14 daysEXTAVIA INJ 0.3 MG15 per 30 daysEMFLAZA SUS 22.75/ML52 ml per 30 daysFARYDAK CAP 10 MG6 per 21 daysEMFLAZA TAB 6 MG60 per 30 daysFARYDAK CAP 15 MG6 per 21 daysEMFLAZA TAB 18 MG30 per 30 daysFARYDAK CAP 20 MG6 per 21 days3

Drug Label NameApproved QuantityDrug Label NameApproved QuantityFASENRA INJ 30 MG/ML(1 PEN)1 per 56 daysHAEGARDA INJ VIAL 3000UNIT (1 VIAL)18 per 30 daysFASENRA PFS INJ 30 MG/ML 1 per 56 daysHARVONI TAB 45-200 MG28 per 28 daysFINTEPLA 2.2 MG/ML360mL per 30 daysHARVONI TAB 90-400 MG28 per 28 daysFIRAZYR INJ 30 MG/3 ML(1 SYRINGE)45 per 90 daysHETLIOZ CAP 20 MG30 per 30 daysHUMIRA INJ 10 MG/0.22 per 28 daysFIRAZYR INJ 30 MG/3 ML(3 SYRINGE)45 per 90 daysHUMIRA INJ 40 MG/0.84 per 28 daysHUMIRA INJ 10/0.1 ML2 per 28 daysFIRDAPSE TAB 10 MG240 per 30 daysHUMIRA INJ 20/0.2 ML2 per 28 daysFOLLISTIM AQ INJ 300 UNIT15 cartridges per 28 daysHUMIRA INJ 40/0.4 ML4 per 28 daysFOLLISTIM AQ INJ 600 UNIT10 cartridges per 28 daysHUMIRA KIT 20 MG/0.42 per 28 daysFOLLISTIM AQ INJ 900 UNIT7 cartridges per 28 daysHUMIRA PEDIA INJ CROHNS2 per 28 daysFORTEO SOL 600/2.42.4 ml per 28 daysHUMIRA PEDIA INJ CROHNS3 per 28 daysFULPHILA INJ2 per 28 daysFUZEON INJ 90 MG60 per 30 daysHUMIRA PEDIATRICCROHNS D6 syringes per 28 daysGALAFOLD CAP 123 MG14 per 28 daysHUMIRA PEN INJ 40/0.4 ML4 per 28 daysGATTEX KIT 5 MG30 per 30 daysHUMIRA PEN INJ CROHNS6 syringes per 28 daysGAVRETO CAP 100 MG120 per 30 daysHUMIRA PEN KIT CD/UC/HS3 per 28 daysGENVOYA TAB30 per 30 daysHUMIRA PEN KIT PS/UV3 per 28 daysGILENYA CAP 0.5 MG30 per 30 daysGILOTRIF TAB 20 MG30 per 30 daysHUMIRA PEN–PSORIASISSTAR4 syringes per 28 daysGILOTRIF TAB 30 MG30 per 30 daysGILOTRIF TAB 40 MG30 per 30 daysHYDROXYPROG 250 MG/ML(1 ML)21 per 365 daysGLATOPA30 per 30 daysGLATOPA/GLATIRAMER INJ40 MG/ML5 per 365 days)12 per 28 daysHYDROXYPROG 250 MG/ML(5 ML)GLEEVEC TAB 100 MG90 per 30 daysHARVONI PEL 45-200 MG28 per 28 daysGLEEVEC TAB 400 MG60 per 30 daysIBRANCE CAP 100 MG21 per 28 daysGONAL-F INJ 450 UNIT10 vials per 28 daysIBRANCE CAP 125 MG21 per 28 daysGONAL-F INJ 1050 UNIT6 vials per 28 daysIBRANCE CAP 75 MG21 per 28 daysGONAL-F RFF INJ 75 UNIT60 vials per 28 daysIBRANCE TAB 100 MG21 per 28 daysGONAL-F RFF INJ 300/0.515 cartridges per 28 daysIBRANCE TAB 125 MG21 per 28 daysGONAL-F RFF INJ 900/1.57 cartridges per 28 daysIBRANCE TAB 75 MG21 per 28 daysGONAL-F RFF INJ 450/0.7510 cartridges per 28 daysICLUSIG TAB 15 MG60 per 30 daysHAEGARDA VIA 2000 UNIT20 per 30 daysICLUSIG TAB 45 MG30 per 30 daysHAEGARDA VIA 3000 UNIT20 per 30 daysIDHIFA TAB 50 MG30 per 30 daysHAEGARDA INJ VIAL 2000UNIT (1 VIAL)18 per 30 daysIDHIFA TAB 100 MG30 per 30 daysILUMYA 100 MG/ML1 per 12 weeksHARVONI PEL 33.75-200 MG 28 per 28 days4

Drug Label NameApproved QuantityDrug Label NameApproved QuantityIMBRUVICA CAP 70 MG30 per 30 daysJUXTAPID CAP 60 MG28 per 28 daysIMBRUVICA CAP 140 MG90 per 30 daysJYNARQUE PAK 15-15 MG56 per 28 daysIMBRUVICA TAB 140 MG30 per 30 daysJYNARQUE PAK 30-15 MG56 per 28 daysIMBRUVICA TAB 280 MG30 per 30 daysJYNARQUE PAK 45-15 MG56 tabs per 28 daysIMBRUVICA TAB 420 MG30 per 30 daysJYNARQUE PAK 60-30 MG56 tabs per 28 daysIMBRUVICA TAB 560 MG30 per 30 daysJYNARQUE PAK 90-30 MG56 tabs per 28 daysINBRIJA CAP 42 MG300 per 30 daysJYNARQUE TAB 15 MG60 per 30 daysINFLECTRA INJ 100 MG5 vials per 42 daysJYNARQUE TAB 30 MG30 per 30 daysINGREZZA CAP 40 MG30 per 30 daysINGREZZA CAP 80 MG30 per 30 daysKALBITOR INJ VIAL 10 MG/ML (3 VIALS)30 (900 mg) per 90 daysINLYTA TAB 1 MG240 per 30 daysKALETRA SOL390 per 30 daysINLYTA TAB 5 MG120 per 30 daysKALETRA TAB 100-25 MG240 per 30 daysINQOVI 35 MG/100 MG5 per 28 daysKALETRA TAB 200-50 MG120 per 30 daysINREBIC CAP 100 MG120 per 30 daysKALYDECO PAK 25 MG56 per 28 daysINTELENCE TAB 25 MG120 per 30 daysKALYDECO PAK 50 MG56 per 28 daysINTELENCE TAB 100 MG120 per 30 daysKALYDECO PAK 75 MG56 per 28 daysINTELENCE TAB 200 MG60 per 30 daysKALYDECO PAK 150 MG56 per 28 daysINVIRASE TAB 500 MG120 per 30 daysKALYDECO TAB 150 MG60 per 30 daysIRESSA TAB 250 MG30 per 30 daysKESIMPTA INJ 20/.4 ML1 per 28 daysISENTRESS CHW 25 MG180 per 30 daysKEVEYIS TAB 50 MG120 per 30 daysISENTRESS CHW 100 MG180 per 30 daysISENTRESS HD TAB 600 MG60 per 30 daysKEVZARA 150 mg/1.14 mL2 syringes/pensper 4 weeksISENTRESS POW 100 MG60 per 30 daysISENTRESS TAB 400 MG120 per 30 daysKEVZARA 200 mg/1.14 mL2 syringes/pensper 4 weeksISTURISA TAB 10 MG180 per 30 daysKINERET INJ28 syringes per 28 daysISTURISA TAB 1 MG240 per 30 daysKISQALI 200 PAK FEMARA49 per 28 daysISTURISA TAB 5 MG360 per 30 daysKISQALI 400 PAK FEMARA70 per 28 daysJAKAFI TAB 10 MG60 per 30 daysKISQALI 600 PAK FEMARA91 per 28 daysJAKAFI TAB 15 MG60 per 30 daysKISQALI TAB 200 DAILY DOSE 21 per 28 daysJAKAFI TAB 20 MG60 per 30 daysKISQALI TAB 400 DAILY DOSE42 per 28 daysJAKAFI TAB 25 MG60 per 30 daysKISQALI TAB 600 DAILY DOSE63 per 28 daysJAKAFI TAB 5 MG60 per 30 daysKITABIS PAK NEB 300/5 ML280 per 28 daysJULUCA 50-25 MG30 per 30 daysKORLYM TAB120 per 30 daysJUXTAPID CAP 5 MG28 per 28 daysKOSELUGO CAP 10 MG240 per 30 daysJUXTAPID CAP 10 MG28 per 28 daysKOSELUGO CAP 25 MG120 per 30 daysJUXTAPID CAP 20 MG28 per 28 daysKYNMOBI 10 MG150 per 30 daysJUXTAPID CAP 30 MG28 per 28 daysKYNMOBI 15 MG151 per 30 daysJUXTAPID CAP 40 MG28 per 28 daysKYNMOBI 20 MG152 per 30 days5

Drug Label NameApproved QuantityDrug Label NameApproved QuantityKYNMOBI 25 MG153 per 30 daysMYCAPSSA 20 MG112 per 28 daysKYNMOBI 30 MG154 per 30 daysLEMTRADA INJ 12/1.2 ML5 per 12 monthsNATPARA INJ 100 MCG(2 CARTRIDGES)2 per 28 daysLENVIMA CAP 4 MG30 per 30 daysLENVIMA CAP 8 MG60 per 30 daysNATPARA INJ 25 MCG(2 CARTRIDGES)2 per 28 daysLENVIMA CAP 10 MG30 per 30 daysLENVIMA CAP 12 MG90 per 30 daysNATPARA INJ 50 MCG(2 CARTRIDGES)2 per 28 daysLENVIMA CAP 14 MG60 per 30 daysLENVIMA CAP 18 MG90 per 30 daysNATPARA INJ 75 MCG(2 CARTRIDGES)2 per 28 daysLENVIMA CAP 20 MG60 per 30 daysNERLYNX TAB 40 MG180 per 30 daysLENVIMA CAP 24 MG90 per 30 daysNEULASTA INJ 6 MG/0.6 M2 per 28 daysLETAIRIS TAB 5 MG30 per 30 daysNEXAVAR TAB 200 MG120 per 30 daysLETAIRIS TAB 10 MG30 per 30 daysNINLARO CAP 2.3 MG3 per 28 daysLEXIVA SUS 50 MG/ML1575 ml per 28 daysNINLARO CAP 3 MG3 per 28 daysLEXIVA TAB 700 MG120 per 30 daysNINLARO CAP 4 MG3 per 28 daysLONSURF TAB 15-6.14100 per 28 daysNORTHERA CAP 100 MG90 per 30 daysLONSURF TAB 20-8.1980 per 28 daysNORTHERA CAP 200 MG180 per 30 daysLORBRENA TAB 25 MG90 per 30 daysNORTHERA CAP 300 MG180 per 30 daysLORBRENA TAB 100 MG30 per 30 daysNORVIR POWD PKT 100 MG360 per 30 daysLYNPARZA TAB 100 MG120 per 30 daysNORVIR SOL 80 MG/ML480 ml per 30 daysLYNPARZA TAB 150 MG120 per 30 daysNORVIR TAB 100 MG360 per 30 daysMAKENA 250 MG/ML(1 ML VIAL)21 per 365 daysNUBEQA TAB 300 MG120 per 30 daysNUCALA POWD INJ 100 MG3 inj per 28 daysMAKENA 250 MG/ML(5 ML VIAL)5 per 365 daysNUCALA AUTO-INJECTORINJ 100 MG/ML3 inj per 28 daysMAKENA 275 mg(1 AUTO-INJECTOR)21 per 365 daysNUCALA PREFILLEDSYRINGE INJ 100 MG/ML3 inj per 28 daysMAVENCLAD PAK 10 MG20 tablets per 9 monthsNYVEPRIA INJ 6/0.6 ML2 per 28 daysMAVYRET TAB84 per 28 daysOCALIVA TAB 10 MG30 per 30 daysMAYZENT TAB 0.25 MGStarter Pack12 per 5 daysOCALIVA TAB 5 MG30 per 30 daysMAYZENT TAB 0.25 MG112 per 28 daysOCREVUS INJ 300/10 ML600 mg (20 ml) per 24weeksMAYZENT TAB 2 MG30 per 30 daysOCTREOTIDE INJ 1000 MCG 9 vials per 30 daysMEKINIST TAB 0.5 MG90 per 30 daysOCTREOTIDE INJ 200 MCG45 vials per 30 daysMEKINIST TAB 2 MG30 per 30 daysODEFSEY TAB30 per 30 daysMEKTOVI 15 MG TABS180 per 30 daysODOMZO CAP 200 MG30 per 30 daysMULPLETA TAB 3 MG7 per 14 daysOFEV CAP 100 MG60 per 30 daysMYALEPT INJ 11.3 MG (1 VIAL)30 per 30 daysOFEV CAP 150 MG60 per 30 days6

Drug Label NameApproved QuantityDrug Label NameApproved QuantityOLUMIANT TAB 1 MG30 per 30 daysPIQRAY 200 MG TAB28 per 28 daysOLUMIANT TAB 2 MG30 per 30 daysPIQRAY 250 MG TAB56 per 28 daysONPATTRO SOL 10 MG/5 ML 30 mg (3 vials) per 21 daysPIQRAY 300 MG TAB56 per 28 daysONUREG TAB 200 MG14 per 28 daysPLEGRIDY 125 MCG/0.5 ML1 per 28 daysONUREG TAB 300 MG14 per 28 daysPOMALYST CAP 1 MG21 per 28 daysOPSUMIT TAB 10 MG30 per 30 daysPOMALYST CAP 2 MG21 per 28 daysORENCIA INJ 50/0.44 per 28 daysPOMALYST CAP 3 MG21 per 28 daysORENCIA INJ 87.5/0.74 per 28 daysPOMALYST CAP 4 MG21 per 28 daysORENCIA INJ 125 MG/ML4 per 28 daysPRALUENT INJ 150 MG/ML2 per 28 daysORENCIA INJ 250 MG4 per 28 daysPRALUENT INJ 75 MG/ML2 per 28 daysORGOVYX TAB 120MG30 per 30 daysPREZCOBIX TAB 800-15030 per 30 daysORKAMBI GRA 100-12556 packets/28 daysPREZISTA SUS 100 MG/ML400 ml per 30 daysORKAMBI GRA 150-18856 packets/28 daysPREZISTA TAB 75 MG300 per 30 daysORKAMBI TAB 100-125112 per 28 daysPREZISTA TAB 150 MG180 per 30 daysORKAMBI TAB 200-125112 per 28 daysPREZISTA TAB 600 MG60 per 30 daysORLADEYO CAP 110 MG28 per 28 daysPREZISTA TAB 800 MG30 per 30 daysORLADEYO CAP 150 MG28 per 28 daysPROCYSBI GRA 300 MG180 packets per 30 daysOTEZLA TAB 10/20/3055 tabs per 28 daysPROCYSBI GRA 75 MG180 packets per 30 daysOTEZLA TAB 30 MG60 per 30 daysPROLIA SOL 60 MG/ML60 mg (1 ml) per 6 monthsOTREXUP INJ 10 MG4 inj per 28 daysPROMACTA PAK 25 MG180 per 30 daysOTREXUP INJ 15 MG4 inj per 28 daysPROMACTA POW 12.5 MG120 per 30 daysOTREXUP INJ 20 MG4 inj per 28 daysPROMACTA TAB 12.5 MG30 per 30 daysOTREXUP INJ 25 MG4 inj per 28 daysPROMACTA TAB 25 MG30 per 30 daysOTREXUP INJ 12.5/0.44 inj per 28 daysPROMACTA TAB 50 MG60 per 30 daysOTREXUP INJ 17.5/0.44 inj per 28 daysPROMACTA TAB 75 MG60 per 30 daysOTREXUP INJ 22.5/0.44 inj per 28 daysPROCYSBI 25 MG240 per 30 daysOXBRYTA TAB 500 MG90 per 30 daysPROCYSBI 75 MG750 per 30 daysOXERVATE SOL 20 MCG/ML16 cartons per 365 daysPULMOZYME SOL 1 MG/ML150 ml per 30 daysOXLUMO 94.5 MG/0.5 ML4 per 90 daysQINLOCK TAB 50 MG90 per 30 daysPADCEV INJ 20 MG21 per 28 daysRADICAVA600 mg per 28 daysPADCEV INJ 30 MG15 per 28 daysRASUVO INJ 10 MG4 inj per 28 daysPALYNZIQ 10 MG/0.5 ML30 per 30 daysRASUVO INJ 12.5 MG4 inj per 28 daysPALYNZIQ 2.5 MG/0.5 ML90 per 30 daysRASUVO INJ 15 MG4 inj per 28 daysPALYNZIQ 20 MG/ML90 per 30 daysRASUVO INJ 17.5 MG4 inj per 28 daysPEMAZYRE TAB 4.5 MG14 per 21 daysRASUVO INJ 20 MG4 inj per 28 daysPEMAZYRE TAB 9 MG14 per 21 daysRASUVO INJ 22.5 MG4 inj per 28 daysPEMAZYRE TAB 13.5 MG14 per 21 daysRASUVO INJ 25 MG4 inj per 28 daysPIFELTRO TAB60 per 30 daysRASUVO INJ 30 MG4 inj per 28 days7

Drug Label NameApproved QuantityDrug Label NameApproved QuantityRASUVO INJ 7.5 MG4 inj per 28 daysREBIF INJ 22/0.512 (6 ml) per 28 daysRUCONEST IV INJ 2100 UNIT60 per 90 days(1 VIAL)REBIF INJ 44/0.512 (6 ml) per 28 daysRUZURGI 10 MG TAB300 per 30 daysREBIF TITRTN SOL PACK12 (4.2 ml) per 28 daysRYDAPT CAP 25 MG224 per 28 daysREDITREX 20 MG/0.8 ML4 per 28 daysSABRIL POW 500 MG180 per 30 daysREDITREX 7.5 MG/0.3 ML4 per 28 daysSABRIL TAB 500 MG180 per 30 daysREDITREX 22.5 MG/0.9 ML4 per 28 daysSANDOSTATIN INJ 100 MCG 90 per 30 daysREDITREX 17.5 MG/0.7 ML4 per 28 daysSANDOSTATIN INJ 500 MCG 90 per 30 daysREDITREX 15 MG/0.6 ML4 per 28 daysREDITREX 12.5 MG/0.5 ML4 per 28 daysSANDOSTATIN INJ 50MCG/ML90 per 30 daysREDITREX 10 ML/0.4 ML4 per 28 daysREDITREX 25 MG/ML4 per 28 daysSANDOSTATIN KITLAR 10 MG10 mg (1) per 28 daysREMICADE INJ 100 MG5 vials per 42 daysRENFLEXIS INJ 100 MG5 vials per 42 daysSANDOSTATIN KITLAR 20 MG40 mg (2) per28 daysREPATHA INJ 140 MG/ML2 per 28 daysREPATHA PUSH INJ 420/3.51 per 28 daysSANDOSTATIN KIT LAR30 MG30 mg (1) per28 daysRETEVMO CAP 40 MG60 per 30 daysSCENESSE 16 MG IMPLANT1 implant per 2 monthsRETEVMO CAP 80 MG120 per 30 daysSELZENTRY SOL 20 MG/ML1840 ml per 30 daysRETROVIR CAP 100 MG180 per 30 daysSELZENTRY TAB 25 MG240 per 30 daysRETROVIR SYP 50 MG/5 ML1800 ml per 30 daysSELZENTRY TAB 75 MG60 per 30 daysREVATIO SUS 10 MG/ML224 ml per 30 daysSELZENTRY TAB 150 MG60 per 30 daysREVLIMID CAP 10 MG28 per 28 daysSELZENTRY TAB 300 MG120 per 30 daysREVLIMID CAP 15 MG28 per 28 daysSENSIPAR TAB 30 MG60 per 30 daysREVLIMID CAP 2.5 MG28 per 28 daysSENSIPAR TAB 60 MG60 per 30 daysREVLIMID CAP 20 MG21 per 28 daysSENSIPAR TAB 90 MG120 per 30 daysREVLIMID CAP 25 MG21 per 28 daysSIGNIFOR 0.3 mg/ml60 per 30 daysREVLIMID CAP 5 MG28 per 28 daysSIGNIFOR 0.6 mg/ml60 per 30 daysREYATAZ CAP 150 MG30 per 30 daysSIGNIFOR 0.9 mg/ml60 per 30 daysREYATAZ CAP 200 MG60 per 30 daysSIGNIFOR LAR 10 MG KIT1 kit per 28 daysREYATAZ CAP 300 MG30 per 30 daysSIGNIFOR LAR 20 MG KIT1 kit per 28 daysREYATAZ POW 50 MG180 packets per 30 daysSIGNIFOR LAR 30 MG KIT1 kit per 28 daysRINVOQ TAB 15 MG ER30 per 30 daysSIGNIFOR LAR 40 MG KIT1 kit per 28 daysROZLYTREK CAP 100 MG30 per 30 daysSIGNIFOR LAR 60 MG KIT1 kit per 28 daysROZLYTREK CAP 200 MG90 per 30 daysSILDENAFIL TAB 20 MG90 per 30 daysRUBRACA TAB 200 MG120 per 30 daysSILIQ 210 mg/1.5 mL2 syringes per 28 daysRUBRACA TAB 250 MG120 per 30 daysSIMPONI ARIA SOL 50 MG4 per 8 weeksRUBRACA TAB 300 MG120 per 30 daysSIMPONI INJ 100 MG/ML1 per 28 daysRUKOBIA TAB 600 MG ER60 per 30 daysSIMPONI INJ 50/0.5 ML1 per 28 days8

Drug Label NameApproved QuantityDrug Label NameApproved QuantitySKYRIZI 150 DOSE SUBQ2 syringes per 12 weeksSYMFI LO30 per 30 daysSOMATULINE INJ 120/.5 ML120 mg per 28 daysSYMTUZA TAB30 per 30 daysSOMATULINE INJ 60/0.2 ML 60 mg per 28 daysTABRECTA TAB 150 MG112 per 28 daysSOMATULINE INJ 90/0.3 ML 90 mg per 28 daysTABRECTA TAB 200 MG112 per 28 daysSOMAVERT INJ 10 MG30 per 30 daysTAFINLAR CAP 50 MG120 per 30 d

ENBREL MINI CRT 50 MG/ML 4 per 28 days ENBREL INJ 25/0.5 ML PFS 4 per 28 days ENBREL INJ 50 MG/ML PFS 4 per 28 days ENDARI POWDER 5 GM 180 packets per 30 days ENSPRYNG INJ 120 MG/ML 1 per 28 days ENTYVIO INJ 300 MG 300 mg every 8 weeks EPCLUSA TAB 200 MG/50 MG28 per 28 days EPCLUSA TAB 400-100 28 per 28 days EPIDIOLEX

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