2011 RxBlue Quantity Level Limits

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2011 RxBlue PDP Quantity Level LimitsABILIFY DISCMELT . 14ABILIFY . 14ACEON . 14ACIPHEX . 14ACTIQ . 14ACTONEL . 14ACTOPLUS MET XR . 15ACTOPLUS MET . 15ACTOS . 15ADCIRCA . 15ADVAIR DISKUS . 15ADVAIR HFA . 15ADVICOR . 15AEROBID-M . 15AFINITOR . 16AGGRENOX . 16alendronate . 16ALLEGRA . 16ALLEGRA-D 12 HOUR . 16ALLEGRA-D 24 HOUR . 16ALORA . 16ALTOPREV . 16ALVESCO . 17Updated: 01/20111

AMBIEN CR . 17AMBIEN . 17AMERGE . 17AMITIZA . 17AMPYRA . 17ANDRODERM . 17ANDROGEL . 17ANZEMET . 18APLENZIN . 18ARAVA . 18ARCALYST . 18ARICEPT ODT . 18ARICEPT . 18ASMANEX . 18ASTELIN . 19ATROVENT HFA . 19AVANDAMET . 19AVANDARYL . 19AVANDIA . 19AVODART . 19AVONEX ADMINISTRATION PACK . 19AVONEX . 19AXERT . 20azelastine hcl . 20BECONASE AQ . 20Updated: 01/20112

BETASERON . 20BONIVA . 20bupropion . 20butorphanol . 20BYETTA . 20cabergoline. 20CADUET . 21calcitonin . 21CARDURA XL . 21CARDURA . 21carisoprodol. 21CATAPRES-TTS 1 . 21CATAPRES-TTS 2 . 21CATAPRES-TTS 3 . 22CELEBREX . 22CELEXA . 22CESAMET . 22CIMZIA . 22citalopram. 22CLARINEX . 22CLARINEX-D 12 HOUR . 22CLARINEX-D 24 HOUR . 23CLIMARA PRO . 23CLIMARA . 23clonidine . 23Updated: 01/20113

COMBIPATCH . 23COMBIVENT . 23COPAXONE . 23COPEGUS . 23CRESTOR . 24CYMBALTA . 24DAYTRANA . 24DEPO-PROVERA . 24DEPO-SUBQ PROVERA 104 . 24DETROL LA . 24DETROL . 24DEXILANT . 24DIFLUCAN . 25DITROPAN XL . 25DIVIGEL . 25doxazosin . 25DUETACT . 25EDLUAR . 25EFFEXOR XR . 25EFFEXOR . 25EFFIENT . 26ELESTRIN . 26EMEND . 26EMSAM . 26ENABLEX . 26Updated: 01/20114

ENBREL . 26EPOGEN . 26ESTRADERM . 26estradiol. 27ESTRASORB . 27ESTROGEL . 27EVAMIST . 27EVISTA . 27EXELON . 27EXFORGE HCT . 27EXFORGE . 28EXTAVIA . 28famciclovir . 28FAMVIR . 28FANAPT . 28fentanyl citrate . 28FENTORA . 29fexofenadine . 29finasteride. 29FLECTOR . 29FLOMAX . 29FLONASE . 29FLOVENT DISKUS . 29FLOVENT HFA . 29fluconazole . 30Updated: 01/20115

flunisolide . 30fluoxetine . 30fluticasone propionate . 30fluvoxamine . 30FORADIL . 30FORTEO . 30FOSAMAX PLUS D . 30FOSAMAX . 31FROVA . 31galantamine . 31GELNIQUE . 31GEODON . 31GLEEVEC . 31glipizide . 31glipizide/metformin hcl . 32GLUCOVANCE . 32glyburide/metformin hcl . 32granisetron . 32HUMIRA . 32IMITREX . 32INFERGEN . 33INTUNIV . 33INVEGA SUSTENNA . 33INVEGA . 33itraconazole . 33Updated: 01/20116

JANUMET . 33JANUVIA . 33ketorolac. 34KYTRIL . 34LAMISIL . 34lansoprazole . 34leflunomide . 34LESCOL XL . 34LESCOL . 34LETAIRIS . 34LEXAPRO . 35LIPITOR . 35lisinopril . 35lisinopril/hctz. 35LISINOPRIL . 35LIVALO . 35lovastatin . 35LUNESTA . 36LUVOX CR . 36MAXAIR AUTOHALER . 36MAXALT MLT . 36MAXALT . 36medroxyprogesterone . 36meloxicam . 36MENOSTAR . 36Updated: 01/20117

METAGLIP . 37metformin . 37MEVACOR . 37MIACALCIN . 37MIGRANAL . 37mirtazapine . 37MOBIC . 37NASACORT AQ . 38NASONEX . 38NEUMEGA . 38NEXAVAR . 38NEXIUM . 38NUVIGIL . 38OLEPTRO ER . 38omeprazole . 38OMNARIS . 39ondansetron . 39ONGLYZA . 39ONSOLIS . 39OPANA ER . 39oxybutynin . 39OXYCONTIN . 40OXYTROL . 40pantoprazole . 40paroxetine . 40Updated: 01/20118

PATANASE . 40PAXIL CR . 40PAXIL . 40PEGASYS . 41PEGINTRON REDIPEN . 41PEGINTRON . 41perindopril erbumine. 41PEXEVA . 41PLAVIX . 41PRAVACHOL . 41pravastatin. 42prazosin . 42PREMARIN . 42PREMPHASE . 42PREMPRO . 42PREVACID . 42PRILOSEC . 42PRISTIQ . 43PROAIR HFA . 43PROCRIT . 43PROSCAR . 43PROTONIX . 43PROVENTIL HFA . 43PROZAC WEEKLY . 43PROZAC . 43Updated: 01/20119

PULMICORT FLEXHALER . 44QVAR . 44RAPAFLO . 44RAZADYNE ER . 44RAZADYNE . 44REBETOL . 44REBIF . 44REGRANEX . 45RELENZA . 45RELISTOR . 45RELPAX . 45REMERON . 45REQUIP XL .

ADVAIR HFA ADVAIR HFA 115-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA 230-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA 45-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVICOR ADVICOR 1,000 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days.

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