Date

It’s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications that we cover. The Food and Drug Administration (FDA) has approved some drugs only for short-term use. And The pharmacist enters your prescription information some drugs may not work as well or can even be into the computer system. If the drug has a limit on the covered amount, the pharmacist will fill your prescription as long as it does not exceed the limit. If your prescription exceeds the quantity limit, you We base the Quantity Management program on FDA and manufacturer dosing guidelines, medical literature, safety, accepted medical practice, 1. Your pharmacist can reduce your prescription appropriate use and benefit design. Our program to the quantity your health plan covers. only affects the amount of medication your benefit plan covers. You and your doctor should 2. You can pay full price for all of your make the final decision about the amount of prescription or for the portion that exceeds 3. You or your pharmacist can ask your doctor to get a quantity override if one is available. If your plan approves the additional quantity, it will The medications and limits that apply to your plan can pay for it. If your plan does not approve it or the vary. Medication limits can also vary depending on the override is not available, you can still choose option medication strength. We post the most updated list of medications in the Quantity Management programs on our website. You can also view personal benefit If you submit your prescription to the mail-order pharmacy and do not meet the requirements for an additional quantity, the pharmacy will not fill your The medications and limits in Chart 1 apply to most prescription. It will also not fill your prescription if an plans, while the medications and limits in Chart 2 additional quantity is not available for that drug. The apply to a few plans. Check your benefits booklet or talk with your Benefits department to determine which For most medications, your plan will only cover a set amount within a set timeframe. Your plan will cover higher amounts of some medications when medically necessary. If a drug on this list has an asterisk (*) next to it, you may be able to get a medical necessity override for a larger amount. If you need more of any of these medications, please have your doctor call the Caremark Prior Authorizations department at 800-294-5979. Your doctor can also fax requests to 888-836-0730. On behalf of your health plan, Caremark administers the Quantity Management program. Caremark is an independent company that manages pharmacy benefits. hydrocodone with acetaminophen (varies by Actonel with calcium (4 tablets per month) hydrocodone with ibuprofen (varies by strength) albuterol inhalation solution (375 ml per month) albuterol nebulizer solution (120 ml per month) Intal Solution for Inhalation (120 vials per month) ipratropium nebulizer solution (120 vials per month) Tamiflu susp (1 bottle per fill, 3 fills per year) Lyrica 25mg –200 mg (90 capsules per month) Maxair Autoinhaler (1 inhaler per month) butorphanol nasal spray (2 inhalers per month)* Morphine Immediate release (180 tablets per Xopenex nebulizer solution (3 boxes per month) codeine with acetaminophen (varies by strength) Zuplenz 4 mg (9 oral patches per month)* oxycodone immediate release (180 capsules per Zuplenz 8 mg (6 oral patches per month)* oxycodone with acetaminophen (varies by strength) oxycodone with aspirin (varies by strength) oxycodone with ibuprofen (varies by strength) Flovent Diskus (1 to 4 boxes per month depending Qualaquin (42 capsules, 7 days supply per year)* Relenza (20 blisters per fill, 3 fills per year) Chart 2 Core Quantity Management Drug List albuterol inhalation solution (375 ml per month) albuterol nebulizer solution (120 ml per month) Tamiflu susp (1 bottle per fill, 3 fills per year) Xopenex nebulizer solution (3 boxes per month) butorphanol nasal spray (2 inhalers per month)* Zuplenz 4 mg (9 oral patches per month)* Zuplenz 8 mg (6 oral patches per month)* Flovent Diskus (1 to 4 boxes per month depending Intal Solution for Inhalation (120 vials per month) ipratropium nebulizer solution (120 vials per month) Maxair Autoinhaler (1 inhaler per month) PLEASE NOTE: The monthly migraine (+), sleep aid (++), ulcer (+++) and select pain (++++) drug quantity limits apply to all prescription medications within the drug class. For example, if coverage for a sleep aid is limited to one tablet per day, only one sleep aid tablet per day will be covered. The drug names listed herein may be the registered or unregistered trademarks of third-party pharmaceutical companies. These trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation. A member’s benefit document defines actual benefits available and may exclude coverage for certain drugs listed herein. This list may change Qualaquin (42 capsules, 7 days supply per year)* or expand from time to time without prior notice. When we list brand-name drugs, programs also apply Relenza (20 blisters per fill, 3 fills per year)

Source: http://www.cosbenefits.com/Quantity_Limit_Member_Handout_111610.pdf