Draft_DoD_Formulary_Restrictions_and_Limitations_(April_4 _2013).pdf

Exhibit L-5 Table of Contents

HT9402-13-R-0001 Exhibit L-5-1

Tab Description L-5.1 Quality Level Limits L-5.2 Prior Authorization L-5.3 Medical Necessity L-5.4 703B (Non-Compliant with Federal Ceiling Price) L-5.5 OTC Demo L-5.6 Gender Edits L-5.7 Age Edits L-5.8 Home Infusion Therapy L-5.9 Vaccines

Exhibit L-5 DoD Formulary Restrictions and Limitations

Current as of April 4, 2013

Exhibit L-5.1 Quantity Limits

Generic Name Dosage Form Strength Quality Limit Retail Quality Limit Mail Order

APREPITANT CAPSULE 40 MG 1 CAPSULE PER DISPENSING 1 CAPSULE PER DISPENSING

GRANISETRON PATCH TDWK 3.1MG/24HR 1 PATCH TDWK PER 1 FILLS 1 PATCH TDWK PER 1 FILLS CERTOLIZUMAB PEGOL SYRINGEKIT 400MG/2ML 2 PENS (1 KIT) PER 28 DAYS 1 SYRINGEKIT (6 SYRINGES) PER 28 DAYS

ONDANSETRON HCL TABLET 24MG 1 TABLET PER 1 FILLS 1 TABLET PER 1 FILLS

ONDANSETRON HCL TABLET 24 MG 1 TABLET PER 1 FILLS 1 TABLET PER 1 FILLS

MEDROXYPROGESTERONE ACETATE VIAL 150 MG/ML 1 VIAL/SYRINGE PER 90 DAYS 1 VIAL/SYRINGE PER 90 DAYS MEDROXYPROGESTERONE ACETATE DISP SYRIN 150 MG/ML 1 VIAL/SYRINGE PER 90 DAYS 1 VIAL/SYRINGE PER 90 DAYS MEDROXYPROGESTERONE ACET DISP SYRIN 104MG/0.65 1 VIAL/SYRINGE PER 90 DAYS 1 VIAL/SYRINGE PER 90 DAYS MEDROXYPROGESTERONE ACETATE DISP SYRIN 104MG/0.65 1 VIAL/SYRINGE PER 90 DAYS 1 VIAL/SYRINGE PER 90 DAYS PEGFILGRASTIM DISP SYRIN 6MG/0.6ML 0.6 ML (1 SYRINGE) PER 21 DAYS 1.2 ML (2 PEN) PER 45 DAYS BECLOMETHASONE DIPROPIONATE SPRAY 42MCG 50 GM (2 BOTTLES) PER 30 DAYS 100 GM (4 BOTTLES) PER 90 DAYS MOMETASONE FUROATE SPRAY/PUMP 50 MCG 34 GRAM (2 BOTTLES) PER 30 DAYS 102 GRAM (6 BOTTLES) PER 90 DAYS BECLOMETHASONE DIPROPIONATE AER W/ADAP 40 MCG 34.8 GRAM (4 INHALERS) PER 30 DAYS 104.4 GRAM (12 INHALERS) PER 90 DAYS ALBUTEROL SULFATE VIAL-NEB 1.25MG/3ML 360 ML (120 NEBS) PER 30 DAYS 1080 ML (360 NEBS) PER 90 DAYS LEVALBUTEROL HCL VIAL-NEB 0.31MG/3ML 360 ML (120 NEBS) PER 30 DAYS 1080 ML (360 NEBS) PER 90 DAYS LEVALBUTEROL HCL VIAL-NEB 0.63MG/3ML 360 ML (120 NEBS) PER 30 DAYS 1080 ML (360 NEBS) PER 90 DAYS LEVALBUTEROL HCL VIAL-NEB 1.25MG/3ML 360 ML (120 NEBS) PER 30 DAYS 1080 ML (360 NEBS) PER 90 DAYS IPRATROPIUM BROMIDE SOLUTION 0.2 MG/ML 360 ML (180 NEBS) PER 30 DAYS 1080 ML (540 NEBS) PER 90 DAYS IPRATROPIUM BROMIDE SOLUTION 0.2MG/ML 360 ML (180 NEBS) PER 30 DAYS 1080 ML (540 NEBS) PER 90 DAYS APREPITANT CAP DS PK 125MG-80MG 4 CAP DOSE PK PER 28 DAYS 12 CAP DOSE PK PER 84 DAYS FLUOXETINE HCL CAPSULE DR 90 MG 4 CAPSULE DR PER 28 DAYS 12 CAPSULE DR PER 84 DAYS

APREPITANT CAPSULE 125 MG 4 CAPSULE PER 28 DAYS 12 CAPSULE PER 84 DAYS

APREPITANT CAPSULE 125MG 4 CAPSULE PER 28 DAYS 12 CAPSULE PER 84 DAYS

BUPRENORPHINE PATCH TDWK 20 MCG/HR 4 PATCHES PER 28 DAYS 12 PATCHES PER 84 DAYS

BUPRENORPHINE PATCH TDWK 5 MCG/HR 4 PATCHES PER 28 DAYS 12 PATCHES PER 84 DAYS

BUPRENORPHINE PATCH TDWK 10 MCG/HR 4 PATCHES PER 28 DAYS 12 PATCHES PER 84 DAYS

DOLASETRON MESYLATE TABLET 100 MG 4 TABLET PER 28 DAYS 12 TABLET PER 28 DAYS

ALEFACEPT VIAL 15 MG 4 VIAL PER 28 DAYS 12 VIAL PER 84 DAYS

AZELASTINE HCL SPRAY/PUMP 137 MCG 60 GRAM (2 BOTTLES) PER 30 DAYS 120 GRAM (4 BOTTLES) PER 90 DAYS AZELASTINE HCL SPRAY/PUMP 205.5MCG 60 GRAM (2 BOTTLES) PER 30 DAYS 120 GRAM (4 BOTTLES) PER 90 DAYS CABOZANTINIB S-MALATE CAPSULE 60 MG/DAY 84 CAPSULES PER 28 DAYS FILL 126 CAPSULSE PER 42 DAYS FILL IPRATROPIUM BROMIDE SPRAY 42MCG 45 ML (3 BOTTLES) PER 30 DAYS 135 ML (9 BOTTLES) PER 90 DAYS

VANDETANIB TABLET 100 MG 90 TABLET PER 30 DAYS 135 TABLET PER 45 DAYS

PONATINIB HCL TABLET 15 MG 90 TABLETS PER 30 DAYS 135 TABLETS PER 45 DAYS

ALBUTEROL SULFATE VIAL-NEB 2.5 MG/3ML 600 ML (200 NEBS) PER 30 DAYS 1650 ML (550 NEBS) PER 90 DAYS ALBUTEROL SULFATE VIAL-NEB 2.5MG/3ML 600 ML (200 NEBS) PER 30 DAYS 1650 ML (550 NEBS) PER 90 DAYS CABOZANTINIB S-MALATE CAPSULE 140 MG/DAY 112 CAPSULES PER 28 DAY FILL 168 CAPSULES PER 42 DAY FILL

SUMATRIPTAN SPRAY 5 MG 6 DEVICES PER 30 DAYS 18 DEVICES PER 90 DAYS

SUMATRIPTAN SPRAY 20 MG 6 DEVICES PER 30 DAYS 18 DEVICES PER 90 DAYS

TADALAFIL TABLET 10 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED

SILDENAFIL CITRATE TABLET 50 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED VARDENAFIL HCL TABLET 10 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED SILDENAFIL CITRATE TABLET 100 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED

TADALAFIL TABLET 5 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED

TADALAFIL TABLET 2.5 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED

VARDENAFIL HCL TABLET 20 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED VARDENAFIL HCL TABLET 20MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED VARDENAFIL HCL TAB RAPDIS 10 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED SILDENAFIL CITRATE TABLET 25 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED

TADALAFIL TABLET 20 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED

VARDENAFIL HCL TABLET 5 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED VARDENAFIL HCL TABLET 2.5 MG 6 TABLET PER 30 DAYS FOR ED 18 TABLET PER 90 DAYS FOR ED ALPROSTADIL SUPP.URETH 250 MCG 6 URETHRAL SUPPOSITORIES PER 30 DAYS 18 URETHRAL SUPPOSITORIES PER 90 DAYS

HT9402-13-R-0001 L-5.1-1

ALPROSTADIL SUPP.URETH 1000 MCG 6 URETHRAL SUPPOSITORIES PER 30 DAYS 18 URETHRAL SUPPOSITORIES PER 90 DAYS ALPROSTADIL SUPP.URETH 500 MCG 6 URETHRAL SUPPOSITORIES PER 30 DAYS 18 URETHRAL SUPPOSITORIES PER 90 DAYS ALPROSTADIL SUPP.URETH 125 MCG 6 URETHRAL SUPPOSITORIES PER 30 DAYS 18 URETHRAL SUPPOSITORIES PER 90 DAYS

ALPROSTADIL VIAL 20 MCG 6 VIAL PER 30 DAYS 18 VIAL PER 90 DAYS

ALPROSTADIL VIAL 40 MCG 6 VIAL PER 30 DAYS 18 VIAL PER 90 DAYS

ALPROSTADIL KIT 10 MCG 6 VIAL PER 30 DAYS 18 VIAL PER 90 DAYS

ALPROSTADIL KIT 20 MCG 6 VIAL PER 30 DAYS 18 VIAL PER 90 DAYS

ALPROSTADIL KIT 40 MCG 6 VIAL PER 30 DAYS 18 VIAL PER 90 DAYS

FLUTICASONE PROPIONATE DISK W/DEV 250 MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE/SALMETEROL DISK W/DEV 250-50MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE/SALMETEROL DISK W/DEV 100-50MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE PROPIONATE DISK W/DEV 50 MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE/SALMETEROL DISK W/DEV 500-50 MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE/SALMETEROL DISK W/DEV 100-50 MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE/SALMETEROL DISK W/DEV 250-50 MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE PROPIONATE DISK W/DEV 100 MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS FLUTICASONE/SALMETEROL DISK W/DEV 500-50MCG 60 BLISTERS (1 DISKUS) PER 30 DAYS 180 BLISTERS (3 DISKUS) PER 90 DAYS SALMETEROL XINAFOATE DISK W/DEV 50 MCG 60 BLISTERS PER 30 DAYS 180 BLISTERS PER 90 DAYS

VORINOSTAT CAPSULE 100 MG 120 CAPSULE PER 30 DAYS 180 CAPSULE PER 45 DAYS

ENZALUTAMIDE CAPSULE 40 MG 120 CAPSULE PER 30 DAYS 180 CAPSULE PER 45 DAYS

FORMOTEROL FUMARATE CAP W/DEV 12 MCG 60 CAPSULE PER 30 DAYS 180 CAPSULE PER 90 DAYS

TAZAROTENE CREAM (G) 0.05 % 60 GRAM PER 30 DAYS 180 GRAM PER 90 DAYS

ALITRETINOIN GEL (GRAM) 0.1 % 60 GRAM PER 30 DAYS 180 GRAM PER 90 DAYS

ALITRETINOIN GEL (GM) 0.1% 60 GRAM PER 30 DAYS 180 GRAM PER 90 DAYS

TAZAROTENE CREAM (G) 0.1 % 60 GRAM PER 30 DAYS 180 GRAM PER 90 DAYS

LEVALBUTEROL HCL VIAL-NEB 1.25MG/0.5 60 ML (120 NEBS) PER 30 DAYS 180 ML (360 NEBS) PER 90 DAYS

SORAFENIB TOSYLATE TABLET 200 MG 120 TABLET PER 30 DAYS 180 TABLET PER 45 DAYS

PAZOPANIB HCL TABLET 200 MG 120 TABLET PER 30 DAYS 180 TABLET PER 45 DAYS

ABIRATERONE ACETATE TABLET 250 MG 120 TABLET PER 30 DAYS 180 TABLET PER 45 DAYS

ONDANSETRON TAB RAPDIS 8 MG 60 TABLET PER 30 DAYS 180 TABLET PER 90 DAYS

ONDANSETRON HCL TABLET 4 MG 60 TABLET PER 30 DAYS 180 TABLET PER 90 DAYS

ONDANSETRON HCL TABLET 8 MG 60 TABLET PER 30 DAYS 180 TABLET PER 90 DAYS

ONDANSETRON FILM 4 MG 60 TABLET PER 30 DAYS 180 TABLET PER 90 DAYS

ONDANSETRON TAB RAPDIS 4 MG 60 TABLET PER 30 DAYS 180 TABLET PER 90 DAYS

ONDANSETRON FILM 8 MG 60 TABLET PER 30 DAYS 180 TABLET PER 90 DAYS

ALBUTEROL SULFATE VIAL-NEB 2.5 MG/0.5 60 VIAL-NEB (60 ML) PER 30 DAYS 180 VIAL-NEB (180 ML) PER 90 DAYS

ENFUVIRTIDE KIT 90 MG 1 KIT PER 30 DAYS 2 KIT PER 60 DAYS

KETOROLAC TROMETHAMINE TABLET 10 MG 20 TABLET PER 30 DAYS 20 TABLET PER 30 DAYS

KETOROLAC TROMETHAMINE TABLET 10MG 20 TABLET PER 30 DAYS 20 TABLET PER 30 DAYS

FLUNISOLIDE SPRAY 25 MCG 75 ML (3 BOTTLES) PER 30 DAYS 200 ML (8 BOTTLES) PER 90 DAYS

NILOTINIB HCL CAPSULE 200 MG 112 CAPSULES PER 28 DAYS 224 CAPSULES PER 56 DAYS

NILOTINIB HCL CAPSULE 150 MG 112 CAPSULES PER 28 DAYS 224 CAPSULES PER 56 DAYS

ALBUTEROL SULFATE VIAL-NEB 0.63MG/3ML 750 ML (250 NEBS) PER 30 DAYS 2250 ML (750 NEBS) PER 90 DAYS

BUTORPHANOL TARTRATE SPRAY 10 MG/ML 8 BOTTLES PER 30 DAYS 24 BOTTLES PER 90 DAYS

APREPITANT CAPSULE 80 MG 8 CAPSULE PER 28 DAYS 24 CAPSULE PER 84 DAYS

APREPITANT CAPSULE 80MG 8 CAPSULE PER 28 DAYS 24 CAPSULE PER 84 DAYS

SUMATRIPTAN SUCCINATE CARTRIDGE 6 MG/0.5ML 8 ML (16 DEVICES) PER 30 DAYS 24 ML (48 DEVICES) PER 90 DAYS SUMATRIPTAN SUCCINATE KIT-REFILL 6MG/0.5ML 8 ML (16 DEVICES) PER 30 DAYS 24 ML (48 DEVICES) PER 90 DAYS SUMATRIPTAN SUCCINATE PEN INJCTR 6 MG/0.5ML 8 ML (16 DEVICES) PER 30 DAYS 24 ML (48 DEVICES) PER 90 DAYS SUMATRIPTAN SUCCINATE PEN INJCTR 4 MG/0.5ML 8 ML (16 DEVICES) PER 30 DAYS 24 ML (48 DEVICES) PER 90 DAYS SUMATRIPTAN SUCCINATE PEN IJ KIT 6MG/0.5ML 8 ML (16 DEVICES) PER 30 DAYS 24 ML (48 DEVICES) PER 90 DAYS SUMATRIPTAN SUCCINATE CARTRIDGE 4 MG/0.5ML 8 ML (16 DEVICES) PER 30 DAYS 24 ML (48 DEVICES) PER 90 DAYS SUMATRIPTAN SUCCINATE VIAL 6 MG/0.5ML 8ML (16 VIALS) PER 30 DAYS 24 ML (48 VIALS) PER 90 DAYS

HT9402-13-R-0001 L-5.1-2

DIHYDROERGOTAMINE MESYLATE SPRAY/PUMP 0.5MG/SPRY 8 SPRAY/PUMP PER 30 DAYS 24 SPRAY/PUMP PER 90 DAYS

GRANISETRON HCL TABLET 1 MG 8 TABLET PER 28 DAYS 24 TABLET PER 84 DAYS

DOLASETRON MESYLATE TABLET 50 MG 8 TABLET PER 28 DAYS 24 TABLET PER 84 DAYS

SUMATRIPTAN SUCCINATE TABLET 100MG 9 TABLET PER 30 DAYS 27 TABLET PER 90 DAYS

NARATRIPTAN HCL TABLET 2.5 MG 9 TABLET PER 30 DAYS 27 TABLET PER 90 DAYS

NARATRIPTAN HCL TABLET 1 MG 9 TABLET PER 30 DAYS 27 TABLET PER 90 DAYS

SUMATRIPTAN SUCCINATE TABLET 100 MG 9 TABLET PER 30 DAYS 27 TABLET PER 90 DAYS

FROVATRIPTAN SUCCINATE TABLET 2.5 MG 9 TABLET PER 30 DAYS 27 TABLET PER 90 DAYS

SUMATRIPTAN SUCC/NAPROXEN S TABLET 85MG-500MG 9 TABLET PER 30 DAYS 27 TABLET PER 90 DAYS BECLOMETHASONE DIPROPIONATE HFA AER AD 80 MCG 1 CANISTER PER 30 DAYS 3 CANISTERS PER 90 DAYS FOLLITROPIN BETA,RECOMB VIAL 150/0.5ML 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING MENOTROPINS VIAL 75 UNIT 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING UROFOLLITROPIN VIAL 75 UNIT 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING FOLLITROPIN BETA,RECOMB VIAL 75/0.5ML 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING FOLLITROPIN BETA,RECOMB CARTRIDGE 300/0.36ML 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING FOLLITROPIN BETA,RECOMB CARTRIDGE 900/1.08ML 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING FOLLITROPIN BETA,RECOMB CARTRIDGE 600/0.72ML 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING FOLLITROPIN ALFA, RECOMB AMPUL 150 UNIT 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING, NO REFILLS 30 DAYS SUPPLY (MAX 3600 UNITS) PER DISPENSING FLUTICASONE FUROATE SPRAY SUSP 27.5 MCG 10 GRAM (1 BOTTLE) PER 30 DAYS 30 GRAM (3 BOTTLES) PER 90 DAYS BUDESONIDE/FORMOTEROL FUMAR HFA AER AD 160-4.5MCG 10.2 GRAM (1 INHALER) PER 30 DAYS 30.6 GRAMS (3 INHALERS) PER 90 DAYS BUDESONIDE/FORMOTEROL FUMAR HFA AER AD 80-4.5 MCG 10.2 GRAM (1 INHALER) PER 30 DAYS 30.6 GRAMS (3 INHALERS) PER 90 DAYS

TAZAROTENE GEL (GRAM) 0.1 % 100 GRAM PER 30 DAYS 300 GRAM PER 90 DAYS

TAZAROTENE GEL (GRAM) 0.05 % 100 GRAM PER 30 DAYS 300 GRAM PER 90 DAYS

ZOLMITRIPTAN SPRAY 5MG 12 DEVICES PER 30 DAYS 36 DEVICES PER 90 DAYS

ZOLMITRIPTAN SPRAY 5 MG 12 DEVICES PER 30 DAYS 36 DEVICES PER 90 DAYS

IMIQUIMOD CREAM PACK 5 % 12 PACKETS PER 30 DAYS 36 PACKETS PER 90 DAYS

IMIQUIMOD CREAM PACK 3.75 % 12 PACKETS PER 30 DAYS 36 PACKETS PER 90 DAYS

ELETRIPTAN HBR TABLET 40 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

RIZATRIPTAN BENZOATE TAB RAPDIS 5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TAB RAPDIS 2.5MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TABLET 5MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ELETRIPTAN HBR TABLET 20 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ALMOTRIPTAN MALATE TABLET 12.5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

RIZATRIPTAN BENZOATE TAB RAPDIS 10 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

RIZATRIPTAN BENZOATE TABLET 5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TABLET 5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ALMOTRIPTAN MALATE TABLET 12.5MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

RIZATRIPTAN BENZOATE TABLET 10 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TABLET 2.5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TAB RAPDIS 5MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TAB RAPDIS 2.5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ELETRIPTAN HYDROBROMIDE TABLET 40 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TABLET 2.5MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ZOLMITRIPTAN TAB RAPDIS 5 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

ALMOTRIPTAN MALATE TABLET 6.25 MG 12 TABLET PER 30 DAYS 36 TABLET PER 90 DAYS

CICLESONIDE HFA AER AD 160 MCG 12.2 GRAM (2 INHALERS) PER 30 DAYS 36.6 GRAM (6 INHALERS) PER 90 DAYS CICLESONIDE HFA AER AD 80 MCG 12.2 GRAM (2 INHALERS) PER 30 DAYS 36.6 GRAM (6 INHALERS) PER 90 DAYS MOMETASONE FUROATE AER POW BA 220MCG(30) 120 INHALATIONS (4 INHALERS) PER 30 DAYS 360 INHALATIONS (12 INHALERS) PER 90 DAYS MOMETASONE FUROATE AER POW BA 110MCG(30) 120 INHALATIONS (4 INHALERS) PER 30 DAYS 360 INHALATIONS (12 INHALERS) PER 90 DAYS MOMETASONE FUROATE AER POW BA 220MCG 120 120 INHALATIONS (1 INHALER) PER 30 DAYS 360 INHALATIONS (3 INHALERs) PER 90 DAYS MOMETASONE FUROATE AER POW BA 220MCG(60) 120 INHALATIONS (2 INHALERS) PER 30 DAYS 360 INHALATIONS (6 INHALERS) PER 90 DAYS FENTANYL CITRATE LOZENGE HD 1600 MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FENTANYL CITRATE LOZENGE HD 800 MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS

HT9402-13-R-0001 L-5.1-3

FENTANYL CITRATE LOZENGE HD 1600MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FENTANYL CITRATE LOZENGE HD 400 MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FENTANYL CITRATE LOZENGE HD 1200 MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FENTANYL CITRATE LOZENGE HD 1200MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FENTANYL CITRATE LOZENGE HD 200 MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FENTANYL CITRATE LOZENGE HD 600 MCG 120 LOZENGE HD PER 30 DAYS 360 LOZENGES HD PER 90 DAYS FORMOTEROL FUMARATE VIAL-NEB 20 MCG/2ML 120 ML (60 NEBS) PER 30 DAYS 360 ML (180 NEBS) PER 90 DAYS BUDESONIDE AMPUL-NEB 0.5 MG/2ML 120 ML (60 NEBS) PER 30 DAYS 360 ML (180 NEBS) PER 90 DAYS ARFORMOTEROL TARTRATE VIAL-NEB 15MCG/2ML 120 ML (60 NEBS) PER 30 DAYS 360 ML (180 NEBS) PER 90 DAYS CICLESONIDE SPRAY/PUMP 50 MCG 12.5 GRAM (1 BOTTLE) PER 30 DAYS 37.5 GRAM (3 BOTTLES) PER 90 DAYS ANAKINRA DISP SYRIN 100MG/0.67 18.76 ML (28 SYRINGES) PER 28 DAYS 37.52 ML (56 SYRINGES) PER 56 DAYS MOMETASONE/FORMOTEROL HFA AER AD 200-5 MCG 13 GRAMS (1 INHALER) PER 30 DAYS 39 GRAMS (3 INHALERS) PER 90 DAYS MOMETASONE/FORMOTEROL HFA AER AD 100-5 MCG 13 GRAMS (1 INHALER) PER 30 DAYS 39 GRAMS (3 INHALERS) PER 90 DAYS

LENALIDOMIDE CAPSULE 25 MG 21 CAPSULE PER 28 DAYS 42 CAPSULE PER 56 DAYS

LENALIDOMIDE CAPSULE 15 MG 21 CAPSULE PER 28 DAYS 42 CAPSULE PER 56 DAYS

QUININE SULFATE CAPSULE 324 MG 42 CAPSULE PER DISPENSING 42 CAPSULE PER DISPENSING CAPECITABINE TABLET 150 MG 21 DAYS SUPPLY PER DISPENSING 42 DAYS SUPPLY PER DISPENSING CAPECITABINE TABLET 500 MG 21 DAYS SUPPLY PER DISPENSING 42 DAYS SUPPLY PER DISPENSING METHYLNALTREXONE BROMIDE VIAL 12MG/0.6ML 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER MAIL DISPENSING

PONATINIB HCL TABLET 45 MG 30 TABLETS PER 30 DAYS 45 TABLETS PER 45 DAYS

BOSUTINIB TABLET 500 MG 30 DAYS PER DISPENSING 45 DAYS PER DISPENSING

BOSUTINIB TABLET 100 MG 30 DAYS PER DISPENSING 45 DAYS PER DISPENSING

GEFITINIB TABLET 250 MG 30 DAYS SUPPLY (MAX 60 TABS) PER DISPENSING 45 DAYS SUPPLY (MAX 90 TABS) PER DISPENSING THALIDOMIDE CAPSULE 200 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING SUNITINIB MALATE CAPSULE 50MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING IMATINIB MESYLATE TABLET 100 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING SUNITINIB MALATE CAPSULE 50 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING SUNITINIB MALATE CAPSULE 25MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING TRETINOIN CAPSULE 10 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING THALIDOMIDE CAPSULE 100 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING IMATINIB MESYLATE TABLET 400 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING THALIDOMIDE CAPSULE 50 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING MITOTANE TABLET 500 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING SUNITINIB MALATE CAPSULE 25 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING SUNITINIB MALATE CAPSULE 12.5 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING THIOGUANINE TABLET 40 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING PROCARBAZINE HCL CAPSULE 50 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING SUNITINIB MALATE CAPSULE 12.5MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING LAPATINIB DITOSYLATE TABLET 250 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING THALIDOMIDE CAPSULE 150 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER DISPENSING VEMURAFENIB TABLET 240 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER MAIL DISPENSING ERLOTINIB HCL TABLET 25 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER MAIL DISPENSING ERLOTINIB HCL TABLET 150 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER MAIL DISPENSING ERLOTINIB HCL TABLET 100 MG 30 DAYS SUPPLY PER DISPENSING 45 DAYS SUPPLY PER MAIL DISPENSING

BECAPLERMIN GEL (GRAM) 0.01 % 15 GRAM PER 30 DAYS 45 GRAM PER 90 DAYS

DASATINIB TABLET 140 MG 30 TABLET PER 30 DAYS 45 TABLET PER 45 DAYS

VANDETANIB TABLET 300 MG 30 TABLET PER 30 DAYS 45 TABLET PER 45 DAYS

DASATINIB TABLET 100 MG 30 TABLET PER 30 DAYS 45 TABLET PER 45 DAYS

DASATINIB TABLET 80 MG 30 TABLET PER 30 DAYS 45 TABLET PER 45 DAYS

EVEROLIMUS TABLET 10 MG 30 TABLET PER 30 DAYS 45 TABLET PER 45 DAYS

FLUTICASONE PROPIONATE SPRAY SUSP 50 MCG 16 GRAM (1 BOTTLE) PER 30 DAYS 48 GRAM (3 BOTTLES) PER 90 DAYS TRIAMCINOLONE ACETONIDE SPRAY 55MCG 16.5 GRAM (1 BOTTLE) PER 30 DAYS 49.5 GRAM (3 BOTTLES) PER 90 DAYS KETOROLAC TROMETHAMINE SPRAY 15.75 MG 5 BOTTLES PER 30 DAYS 5 BOTTLES PER 30 DAYS

HT9402-13-R-0001 L-5.1-4

IPRATROPIUM/ALBUTEROL SULFA AER W/ADAP 20-100 MCG 2 AER W/ADAP (8 GM) PER 30 DAYS 5 AER W/ADAP (20 GM) PER 90 DAYS BUDESONIDE SPRAY/PUMP 32MCG 17.2 GRAM (1 BOTTLE) PER 30 DAYS 51.6 GRAM (3 BOTTLES) PER 90 DAYS BECLOMETHASONE DIPROPIONATE AER W/ADAP 80 MCG 17.4 GRAM (2 INHALERS) PER 30 DAYS 52.2 GRAM (6 INHALERS) PER 90 DAYS

SUMATRIPTAN SUCCINATE TABLET 50MG 18 TABLET PER 30 DAYS 54 TABLET PER 90 DAYS

SUMATRIPTAN SUCCINATE TABLET 50 MG 18 TABLET PER 30 DAYS 54 TABLET PER 90 DAYS

SUMATRIPTAN SUCCINATE TABLET 25 MG 18 TABLET PER 30 DAYS 54 TABLET PER 90 DAYS

IPRATROPIUM/ALBUTEROL SULFA AMPUL-NEB 0.5-3MG/3 180 AMPUL-NEB (540 ML) PER 30 DAYS 540 AMPUL-NEB (1620 ML) PER 90 DAYS ETANERCEPT PEN INJCTR 50 MG/ML 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING TEMOZOLOMIDE CAPSULE 20 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING TEMOZOLOMIDE CAPSULE 100 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING TEMOZOLOMIDE CAPSULE 140 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING TEMOZOLOMIDE CAPSULE 5 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING TEMOZOLOMIDE CAPSULE 180 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING ETANERCEPT VIAL 25 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING ETANERCEPT DISP SYRIN 25MG/0.5ML 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING TEMOZOLOMIDE CAPSULE 250 MG 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING ETANERCEPT DISP SYRIN 50 MG/ML 28 DAYS SUPPLY PER DISPENSING 56 DAYS SUPPLY PER DISPENSING IPRATROPIUM/ALBUTEROL SULFA AER W/ADAP 18-103MCG 2 AER W/ADAP (29.4 GM) PER 30 DAYS 6 AER W/ADAP (88.2 GM) PER 90 DAYS ACLIDINIUM BROMIDE AER POW BA 400 MCG 2 INHALERS PER 30 DAYS 6 INHALERS PER 90 DAYS ALBUTEROL SULFATE HFA AER AD 90 MCG 2 INHALERS PER 30 DAYS 6 INHALERS PER 90 DAYS

ALBUTEROL SULFATE HFA AER AD 90MCG 2 INHALERS PER 30 DAYS 6 INHALERS PER 90 DAYS

CERTOLIZUMAB PEGOL KIT 400 MG 2 VIALS (1 KIT) PER 28 DAYS 6 VIALS (3 KITS) PER 84 DAYS

NICOTINE POLACRILEX GUM 2MG 600 PIECES PER 60 DAYS

NICOTINE POLACRILEX GUM 4 MG 600 PIECES PER 60 DAYS

NICOTINE POLACRILEX GUM 2 MG 600 PIECES PER 60 DAYS

NICOTINE POLACRILEX LOZENGE 2 MG 600 PIECES PER 60 DAYS

NICOTINE POLACRILEX GUM 4MG 600 PIECES PER 60 DAYS

NICOTINE POLACRILEX LOZENGE 4 MG 600 PIECES PER 60 DAYS

LANCETS EACH 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 30 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 23 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 28 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

RING EACH 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 33 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 26 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 21 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 25 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 17 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

BED PAN EACH 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 32 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 18 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS & BLOOD GLUCOSE STR COMBO. PKG 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

RING EACH 2 1/2" 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

RING EACH 2" 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

LANCETS EACH 31 GAUGE 204 LANCETS PER 30 DAYS 612 LANCETS PER 90 DAYS

BLOOD SUGAR DIAGNOSTIC STRIP 204 STRIP PER 30 DAYS 612 STRIP PER 90 DAYS

BLOOD SUGAR DIAGNOSTIC KIT 204 STRIP PER 30 DAYS 612 STRIP PER 90 DAYS

BLOOD SUGAR DIAGNOSTIC, DRU STRIP 204 STRIP PER 30 DAYS 612 STRIP PER 90 DAYS

BLOOD SUGAR DIAGNOSTIC, DIS STRIP 204 STRIP PER 30 DAYS 612 STRIP PER 90 DAYS

FLUTICASONE PROPIONATE AER W/ADAP 44MCG 21.2 GRAM (2 INHALERS) PER 30 DAYS 63.6 GRAM (6 INHALERS) PER 90 DAYS AZELASTINE/FLUTICASONE SPRAY/PUMP 137-50 MCG 23 GRAMS (1 BOTTLE) PER 30 DAYS 69 GRAMS (3 BOTTLES) PER 90 DAYS

GEMIFLOXACIN MESYLATE TABLET 320 MG 7 TABLET PER 30 DAYS 7 TABLET PER 30 DAYS

FLUTICASONE PROPIONATE AER W/ADAP 220MCG 24 GRAM (2 INHALERS) PER 30 DAYS 72 GRAM (6 INHALERS) PER 90 DAYS

HT9402-13-R-0001 L-5.1-5

FLUTICASONE/SALMETEROL HFA AER AD 230-21MCG 24 GRAM (2 INHALERS) PER 30 DAYS 72 GRAM (6 INHALERS) PER 90 DAYS FLUTICASONE/SALMETEROL HFA AER AD 115-21MCG 24 GRAM (2 INHALERS) PER 30 DAYS 72 GRAM (6 INHALERS) PER 90 DAYS FLUTICASONE PROPIONATE AER W/ADAP 220 MCG 24 GRAM (2 INHALERS) PER 30 DAYS 72 GRAM (6 INHALERS) PER 90 DAYS FLUTICASONE/SALMETEROL HFA AER AD 45-21MCG 24 GRAM (2 INHALERS) PER 30 DAYS 72 GRAM (6 INHALERS) PER 90 DAYS FLUTICASONE PROPIONATE AER W/ADAP 110MCG 24 GRAM (2 INHALERS) PER 30 DAYS 72 GRAM (6 INHALERS) PER 90 DAYS BUDESONIDE AMPUL-NEB 0.25MG/2ML 240 ML (120 NEBS) PER 30 DAYS 720 ML (360 NEBS) PER 90 DAYS CROMOLYN SODIUM AMPUL-NEB 20 MG/2 ML 240 ML (120 NEBS) PER 30 DAYS 720 ML (360 NEBS) PER 90 DAYS CROMOLYN SODIUM AMPUL-NEB 20MG/2ML 240 ML (120 NEBS) PER 30 DAYS 720 ML (360 NEBS) PER 90 DAYS TRAMADOL HCL/ACETAMINOPHEN TABLET 37.5-325MG 240 TABLET PER 30 DAYS 720 TABLET PER 90 DAYS

TRAMADOL HCL TABLET 50 MG 240 TABLET PER 30 DAYS 720 TABLET PER 90 DAYS

TRAMADOL HCL TABLET 50MG 240 TABLET PER 30 DAYS 720 TABLET PER 90 DAYS

PIRBUTEROL ACETATE AER BR.ACT 200 MCG 25.6 GRAM (1 INHALER) PER 30 DAYS 76.8 GRAM (3 INHALERS) PER 90 DAYS IPRATROPIUM BROMIDE HFA AER AD 17MCG 25.8 GRAM (2 INHALERS) PER 30 DAYS 77.4 GRAM (6 INHALERS) PER 90 DAYS

ADALIMUMAB KIT 40MG/0.8ML 4 PENS (2 KIT) PER 28 DAYS 8 PENS (4 KITS) PER 56 DAYS

ADALIMUMAB KIT 20MG/0.4ML 4 PENS (2 KIT) PER 28 DAYS 8 PENS (4 KITS) PER 56 DAYS

ADALIMUMAB PEN IJ KIT 40MG/0.8ML 4 PENS (2 KIT) PER 28 DAYS 8 PENS (4 KITS) PER 56 DAYS

ABATACEPT DISP SYRIN 125 MG/ML 4 SYRINGES PER 28 DAYS 8 SYRINGES PER 56 DAYS

CABOZANTINIB S-MALATE CAPSULE 100 MG/DAY 56 CAPSULES PER 28 DAYS 84 CAPSULE PER 42 DAYS FILL

LENALIDOMIDE CAPSULE 10 MG 42 CAPSULE PER 28 DAYS 84 CAPSULE PER 56 DAYS

LENALIDOMIDE CAPSULE 5 MG 42 CAPSULE PER 28 DAYS 84 CAPSULE PER 56 DAYS

SUMATRIPTAN SUCCINATE NDL FR INJ 6 MG/0.5ML 3 ML (6 INJECTIONS) PER 30 DAYS 9 ML (18 INJECTIONS) PER 90 DAYS DIHYDROERGOTAMINE MESYLATE AMPUL 1 MG/ML 30 AMPUL PER 30 DAYS 90 AMPUL PER 90 DAYS TIOTROPIUM BROMIDE CAP W/DEV 18MCG 30 BLISTER CAPS PER 30 DAYS 90 BLISTER CAPS PER 90 DAYS TIOTROPIUM BROMIDE CAP W/DEV 18 MCG 30 BLISTER CAPS PER 30 DAYS 90 BLISTER CAPS PER 90 DAYS IPRATROPIUM BROMIDE SPRAY 21 MCG 30 ML (1 BOTTLE) PER 30 DAYS 90 ML (3 BOTTLES) PER 90 DAYS TRAMADOL HCL TAB ER 24H 100 MG 30 TAB ER 24H PER 30 DAYS 90 TAB ER 24H PER 90 DAYS TRAMADOL HCL TAB ER 24H 200 MG 30 TAB ER 24H PER 30 DAYS 90 TAB ER 24H PER 90 DAYS TRAMADOL HCL TAB ER 24H 300 MG 30 TAB ER 24H PER 30 DAYS 90 TAB ER 24H PER 90 DAYS

DASATINIB TABLET 50 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

RUXOLITINIB PHOSPHATE TABLET 10 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

EVEROLIMUS TABLET 2.5 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

DASATINIB TABLET 70 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

RUXOLITINIB PHOSPHATE TABLET 15 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

DASATINIB TABLET 20 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

RUXOLITINIB PHOSPHATE TABLET 20 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

RUXOLITINIB PHOSPHATE TABLET 25 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

EVEROLIMUS TABLET 5 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

RUXOLITINIB PHOSPHATE TABLET 5 MG 60 TABLET PER 30 DAYS 90 TABLET PER 45 DAYS

CALCIPOTRIENE CREAM(GM) 0.005% 300 GRAM PER 30 DAYS 900 GRAM PER 90 DAYS

CALCIPOTRIENE OINT.(GM) 0.005% 300 GRAM PER 30 DAYS 900 GRAM PER 90 DAYS

CALCIPOTRIENE CREAM (G) 0.005 % 300 GRAM PER 30 DAYS 900 GRAM PER 90 DAYS

CALCIPOTRIENE OINT. (G) 0.005 % 300 GRAM PER 30 DAYS 900 GRAM PER 90 DAYS

CALCIPOTRIENE SOLUTION 0.005 % 300 ML PER 30 DAYS 900 ML PER 90 DAYS

CALCIPOTRIENE SOLUTION 0.005% 300 ML PER 30 DAYS 900 ML PER 90 DAYS

NICOTINE PATCH TD24 21 MG/24HR MAXIMUM 60 DAYS PER FILL

NICOTINE SPRAY 10MG/ML MAXIMUM 60 DAYS PER FILL

VARENICLINE TARTRATE TAB DS PK 0.5(11)-1 MAXIMUM 60 DAYS PER FILL

NICOTINE PATCH TD24 7MG/24HR MAXIMUM 60 DAYS PER FILL

NICOTINE PATCH TD24 21MG/24HR MAXIMUM 60 DAYS PER FILL

NICOTINE PATCH TD24 14MG/24HR MAXIMUM 60 DAYS PER FILL

VARENICLINE TARTRATE TABLET 0.5 MG MAXIMUM 60 DAYS PER FILL

NICOTINE PATCH DYSQ 21-14-7MG MAXIMUM 60 DAYS PER FILL

NICOTINE CARTRIDGE 10 MG MAXIMUM 60 DAYS PER FILL

HT9402-13-R-0001 L-5.1-6

NICOTINE PATCH TD24 22MG/24HR MAXIMUM 60 DAYS PER FILL

NICOTINE SPRAY 10 MG/ML MAXIMUM 60 DAYS PER FILL

BUPROPION HCL TABLET ER 150 MG MAXIMUM 60 DAYS PER FILL

VARENICLINE TARTRATE TABLET 1 MG MAXIMUM 60 DAYS PER FILL

NICOTINE PATCH TD24 22 MG/24HR MAXIMUM 60 DAYS PER FILL

NICOTINE CARTRIDGE 10MG MAXIMUM 60 DAYS PER FILL

NICOTINE PATCH TD24 11MG/24HR MAXIMUM 60 DAYS PER FILL

HT9402-13-R-0001 L-5.1-7

Exhibit L-5.2 Prior Authorizations

Generic Name Dosage Form Strength Prior Authorization Form FENTANYL CITRATE LOZENGE HD 1600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf OXYCODONE HCL TAB ER 12H 80 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE TABLET ER 200 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CPMP 24HR 90 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CPMP 24HR 60 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE TABLET ER 100 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CPMP 24HR 45 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE TABLET SA 100 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TABLET EFF 300 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TABLET EFF 400 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TABLET EFF 800 MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CAP ER PEL 130 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE FILM 600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE FILM 400 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE FILM 1200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 800 MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CPMP 24HR 120 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE/NALTREXONE CAP ER PEL 100MG-4MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 1600MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CAP SR PEL 100 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TABLET EFF 100 MCG PAC_HIGHDOSEOPIOID_20110413.pdf OXYCODONE HCL TAB.SR 12H 80 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TAB SUBL 600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 1200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CAP ER PEL 150 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 400 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 1200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CAP ER PEL 200 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 1200MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE TABLET SA 200 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 100 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 400 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE FILM 800 MCG PAC_HIGHDOSEOPIOID_20110413.pdf OXYCODONE HCL TAB ER 12H 60 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CAP ER PEL 100 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TAB SUBL 300 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 800 MCG PAC_HIGHDOSEOPIOID_20110413.pdf HYDROMORPHONE HCL TAB ER 24H 12 MG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE CPMP 24HR 75 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE SPRAY/PUMP 100 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE SPRAY/PUMP 400 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TAB SUBL 100 MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE TABLET SA 100MG PAC_HIGHDOSEOPIOID_20110413.pdf

HT9402-13-R-0001 L-5.2-1

FENTANYL CITRATE FILM 200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TABLET EFF 600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TAB SUBL 200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TAB SUBL 800 MCG PAC_HIGHDOSEOPIOID_20110413.pdf OXYCODONE HCL TAB.SR 12H 80MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE LOZENGE HD 600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TABLET EFF 200 MCG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL CITRATE TAB SUBL 400 MCG PAC_HIGHDOSEOPIOID_20110413.pdf MORPHINE SULFATE TABLET SA 200MG PAC_HIGHDOSEOPIOID_20110413.pdf OXYCODONE HCL TAB.SR 12H 160 MG PAC_HIGHDOSEOPIOID_20110413.pdf FENTANYL SPRAY 1600 MCG PAC_HIGHDOSEOPIOID_20110413.pdf HYDROMORPHONE HCL TAB ER 24H 32 MG PAC_HIGHDOSEOPIOID_20110413.pdf TESTOSTERONE GEL MD PMP 10 MG (2%) PAF_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL PACKET 1.25G-1.62 PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE PATCH TD24 5 MG/24 HR PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL PACKET 2.5G-1.62% PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL MD PMP 1.25G (1%) PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL (GRAM) 50 MG (1%) PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL PACKET 25MG(1%) PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE MUC ER 12H 30 MG PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE PATCH TD24 4 MG/24 HR PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE PATCH TD24 2 MG/24 HR PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE PATCH TD24 2.5MG/24HR PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE SOL MD PMP 30MG/1.5ML PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL PACKET 50 MG (1%) PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf TESTOSTERONE GEL MD PMP 20.25/1.25 PAF_TESTOSTERONE_REPL_OTHER_THAN_FORTESTA_20130206_FF.pdf ADALIMUMAB KIT 40MG/0.8ML PAFC_ADALIMUMAB_20121018_FF.pdf ADALIMUMAB KIT 20MG/0.4ML PAFC_ADALIMUMAB_20121018_FF.pdf ADALIMUMAB PEN IJ KIT 40MG/0.8ML PAFC_ADALIMUMAB_20121018_FF.pdf SILDENAFIL CITRATE TABLET 20 MG PAFC_ADCIRCA_REVATIO20091230.pdf TADALAFIL TABLET 20 MG PAFC_ADCIRCA_REVATIO20091230.pdf ALEFACEPT VIAL 15 MG PAFC_ALEFACEPT20080201.pdf ANAKINRA DISP SYRIN 100MG/0.67 PAFC_ANAKINRA20080201.pdf ARMODAFINIL TABLET 50 MG PAFC_ARMODAFINIL_20120711_FF.pdf ARMODAFINIL TABLET 150 MG PAFC_ARMODAFINIL_20120711_FF.pdf ARMODAFINIL TABLET 250 MG PAFC_ARMODAFINIL_20120711_FF.pdf DUTASTERIDE/TAMSULOSIN HCL CPMP 24HR 0.5-0.4 MG PAFC_BPH_JALYN_20111005_FF.pdf SILODOSIN CAPSULE 4 MG PAFC_BPH_RAPAFLO_20111005_FF.pdf SILODOSIN CAPSULE 8 MG PAFC_BPH_RAPAFLO_20111005_FF.pdf BUPRENORPHINE PATCH TDWK 20 MCG/HR PAFC_BUTRANS_20120104_FF.pdf BUPRENORPHINE PATCH TDWK 5 MCG/HR PAFC_BUTRANS_20120104_FF.pdf BUPRENORPHINE PATCH TDWK 10 MCG/HR PAFC_BUTRANS_20120104_FF.pdf CERTOLIZUMAB PEGOL KIT 400 MG PAFC_CERTOLIZUMAB20091230.pdf CERTOLIZUMAB PEGOL SYRINGEKIT 400MG/2ML PAFC_CERTOLIZUMAB20091230.pdf

HT9402-13-R-0001 L-5.2-2

TADALAFIL TABLET 10 MG PAFC_CIALIS_20120418.pdf TADALAFIL TABLET 5 MG PAFC_CIALIS_20120418.pdf TADALAFIL TABLET 2.5 MG PAFC_CIALIS_20120418.pdf ROSUVASTATIN CALCIUM TABLET 10 MG PAFC_CRESTOR_20101006.pdf ROSUVASTATIN CALCIUM TABLET 40 MG PAFC_CRESTOR_20101006.pdf ROSUVASTATIN CALCIUM TABLET 20 MG PAFC_CRESTOR_20101006.pdf ROSUVASTATIN CALCIUM TABLET 5 MG PAFC_CRESTOR_20101006.pdf BROMOCRIPTINE MESYLATE TABLET 0.8 MG PAFC_CYCLOSET_ST_20120104_FF.pdf DULOXETINE HCL CAPSULE DR 30 MG PAFC_CYMBALTA__ST_20120418.pdf DULOXETINE HCL CAPSULE DR 60 MG PAFC_CYMBALTA__ST_20120418.pdf DULOXETINE HCL CAPSULE DR 30MG PAFC_CYMBALTA__ST_20120418.pdf DULOXETINE HCL CAPSULE DR 20 MG PAFC_CYMBALTA__ST_20120418.pdf DULOXETINE HCL CAPSULE DR 60MG PAFC_CYMBALTA__ST_20120418.pdf SITAGLIPTIN PHOS/METFORMIN TABLET 50MG-500MG PAFC_DPP-4_INHIBITORS_JANUMET_20120711_FF.pdf SITAGLIPTIN PHOS/METFORMIN TABLET 50-1000 MG PAFC_DPP-4_INHIBITORS_JANUMET_20120711_FF.pdf SITAGLIPTIN PHOS/METFORMIN TBMP 24HR 50-1000 MG PAFC_DPP-4_INHIBITORS_JANUMET_JANUMET_XR_20130109_FF.pdf SITAGLIPTIN PHOS/METFORMIN TBMP 24HR 100-1000MG PAFC_DPP-4_INHIBITORS_JANUMET_JANUMET_XR_20130109_FF.pdf SITAGLIPTIN PHOS/METFORMIN TBMP 24HR 50MG-500MG PAFC_DPP-4_INHIBITORS_JANUMET_JANUMET_XR_20130109_FF.pdf SITAGLIPTIN PHOSPHATE TABLET 25 MG PAFC_DPP-4_INHIBITORS_JANUVIA_ST_20120711_FF.pdf SITAGLIPTIN PHOSPHATE TABLET 100 MG PAFC_DPP-4_INHIBITORS_JANUVIA_ST_20120711_FF.pdf SITAGLIPTIN PHOSPHATE TABLET 50 MG PAFC_DPP-4_INHIBITORS_JANUVIA_ST_20120711_FF.pdf SITAGLIPTIN/SIMVASTATIN TABLET 100MG-20MG PAFC_DPP-4_INHIBITORS_JUVISYNC_20120711_FF.pdf SITAGLIPTIN/SIMVASTATIN TABLET 100MG-40MG PAFC_DPP-4_INHIBITORS_JUVISYNC_20120711_FF.pdf SITAGLIPTIN/SIMVASTATIN TABLET 100MG-10MG PAFC_DPP-4_INHIBITORS_JUVISYNC_20120711_FF.pdf SAXAGLIPTIN HCL/METFORMIN H TBMP 24HR 5 MG-500MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_MET_COMBO_AGENTS_20130109_FF.pdf SAXAGLIPTIN HCL/METFORMIN H TBMP 24HR 5MG-1000MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_MET_COMBO_AGENTS_20130109_FF.pdf SAXAGLIPTIN HCL/METFORMIN H TBMP 24HR 2.5-1000MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_MET_COMBO_AGENTS_20130109_FF.pdf LINAGLIPTIN/METFORMIN HCL TABLET 2.5-500 MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_MET_COMBO_AGENTS_20130109_FF.pdf LINAGLIPTIN/METFORMIN HCL TABLET 2.5-850 MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_MET_COMBO_AGENTS_20130109_FF.pdf LINAGLIPTIN/METFORMIN HCL TABLET 2.5-1000MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_MET_COMBO_AGENTS_20130109_FF.pdf SAXAGLIPTIN HCL TABLET 2.5 MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_SINGLE_AGENTS_20130109_FF.pdf LINAGLIPTIN TABLET 5 MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_SINGLE_AGENTS_20130109_FF.pdf SAXAGLIPTIN HCL TABLET 5 MG PAFC_DPP-4_INHIBITORS_ST__NON_PREF_SINGLE_AGENTS_20130109_FF.pdf ETANERCEPT PEN INJCTR 50 MG/ML PAFC_ETANERCEPT20080801.pdf ETANERCEPT VIAL 25 MG PAFC_ETANERCEPT20080801.pdf ETANERCEPT DISP SYRIN 25MG/0.5ML PAFC_ETANERCEPT20080801.pdf ETANERCEPT DISP SYRIN 50 MG/ML PAFC_ETANERCEPT20080801.pdf FINGOLIMOD HCL CAPSULE 0.5 MG PAFC_GILENYA_PA_20110413.pdf LIRAGLUTIDE PEN INJCTR 0.6MG/0.1 PAFC_GLP1RAs_BYDUREON_BYETTA_VICTOZA_20130320_FF.pdf EXENATIDE MICROSPHERES VIAL 2 MG PAFC_GLP1RAs_BYDUREON_BYETTA_VICTOZA_20130320_FF.pdf EXENATIDE PEN INJCTR 10MCG/0.04 PAFC_GLP1RAs_BYDUREON_BYETTA_VICTOZA_20130320_FF.pdf EXENATIDE PEN INJCTR 5MCG/0.02 PAFC_GLP1RAs_BYDUREON_BYETTA_VICTOZA_20130320_FF.pdf GOLIMUMAB PEN INJCTR 50MG/0.5ML PAFC_GOLIMUMAB20091202.pdf GOLIMUMAB DISP SYRIN 50MG/0.5ML PAFC_GOLIMUMAB20091202.pdf GABAPENTIN ENACARBIL TAB ER 24H 600 MG PAFC_GRALISE_HORIZANT_20120919.pdf

HT9402-13-R-0001 L-5.2-3

GABAPENTIN TAB ER 24H 600 MG PAFC_GRALISE_HORIZANT_20120919.pdf GABAPENTIN TAB ER 24H 300-600 MG PAFC_GRALISE_HORIZANT_20120919.pdf GABAPENTIN TAB ER 24H 300 MG PAFC_GRALISE_HORIZANT_20120919.pdf SOMATROPIN CARTRIDGE 5 MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 1MG/0.25ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 1.4MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN PEN INJCTR 15MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 10 MG/2 ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 8.8 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 5.8MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 5 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 12 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 0.6MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 2MG/0.25ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 6MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 24 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 10 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN PEN INJCTR 10MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 12MG/ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 10 MG/2 ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 10MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 6 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN PEN INJCTR 30 MG/3 ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 1.8MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 0.2MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 0.4MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 24MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 6 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 5 MG/ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 1.2MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 1.6MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN DISP SYRIN 0.8MG/0.25 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 5 MG/2 ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 20 MG/2 ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 5.8 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 12MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 12 MG/ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN PEN INJCTR 5 MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 15MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 5MG/1.5ML PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 8.8 MG/1.5 PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN VIAL 4 MG PAFC_GROWTHHORMONE20070801.pdf SOMATROPIN CARTRIDGE 8.8MG/1.5 PAFC_GROWTHHORMONE20070801.pdf FOLLITROPIN ALFA, RECOMB VIAL 75 UNIT PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN ALFA, RECOMB PEN INJCTR 900/1.5 ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf

HT9402-13-R-0001 L-5.2-4

FOLLITROPIN ALFA, RECOMB VIAL 450 UNIT PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN BETA,RECOMB VIAL 150/0.5ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf MENOTROPINS VIAL 75 UNIT PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN ALFA, RECOMB PEN INJCTR 450/0.75ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN ALFA, RECOMB PEN INJCTR 300/0.5ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN BETA,RECOMB VIAL 75/0.5ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN ALFA, RECOMB AMPUL 37.5 UNIT PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN BETA,RECOMB CARTRIDGE 300/0.36ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN BETA,RECOMB CARTRIDGE 900/1.08ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN ALFA, RECOMB VIAL 1050 UNIT PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN BETA,RECOMB CARTRIDGE 600/0.72ML PAFC_INJECTABLEGONADOTROPINS20120918.pdf FOLLITROPIN ALFA, RECOMB AMPUL 150 UNIT PAFC_INJECTABLEGONADOTROPINS20120918.pdf VARDENAFIL HCL TABLET 10 MG PAFC_LEVITRA_20120418.pdf VARDENAFIL HCL TABLET 20 MG PAFC_LEVITRA_20120418.pdf VARDENAFIL HCL TABLET 20MG PAFC_LEVITRA_20120418.pdf VARDENAFIL HCL TAB RAPDIS 10 MG PAFC_LEVITRA_20120418.pdf VARDENAFIL HCL TABLET 5 MG PAFC_LEVITRA_20120418.pdf VARDENAFIL HCL TABLET 2.5 MG PAFC_LEVITRA_20120418.pdf AMLODIPINE/ATORVASTATIN TABLET 5MG-80MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 2.5MG-10MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 2.5MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/LOVASTATIN TBMP 24HR 750MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf LOVASTATIN TAB ER 24H 40 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf PITAVASTATIN CALCIUM TABLET 2 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 10MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 10MG-80MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/LOVASTATIN TBMP 24HR 1000-40 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/SIMVASTATIN TBMP 24HR 1000-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf LOVASTATIN TAB.SR 24H 40MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 5MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf FLUVASTATIN SODIUM CAPSULE 20 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 5MG-40MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 10MG-40MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/SIMVASTATIN TBMP 24HR 500MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/SIMVASTATIN TBMP 24HR 1000-40 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 2.5MG-40MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 5 MG-10 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/LOVASTATIN TBMP 24HR 1000-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf LOVASTATIN TAB.SR 24H 20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf AMLODIPINE/ATORVASTATIN TABLET 10MG-10MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf FLUVASTATIN SODIUM TAB ER 24H 80 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/SIMVASTATIN TBMP 24HR 500MG-40MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/SIMVASTATIN TBMP 24HR 750MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf FLUVASTATIN SODIUM CAPSULE 40 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf FLUVASTATIN SODIUM TAB SR 24H 80 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf

HT9402-13-R-0001 L-5.2-5

LOVASTATIN TAB.SR 24H 60MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf LOVASTATIN TAB ER 24H 60 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf LOVASTATIN TAB ER 24H 20 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf NIACIN/LOVASTATIN TBMP 24HR 500MG-20MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf PITAVASTATIN CALCIUM TABLET 1 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf PITAVASTATIN CALCIUM TABLET 4 MG PAFC_LIP-1_LOWMODINTENSITY20101006.pdf FENOFIBRATE TABLET 160 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRIC ACID TABLET 35 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 134MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE NANOCRYSTALLIZE TABLET 50 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRIC ACID (CHOLINE) CAPSULE DR 45 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 67 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 200 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE NANOCRYSTALLIZE TABLET 160 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE CAPSULE 50 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRIC ACID TABLET 105 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 43MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 130MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE TABLET 50 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRIC ACID (CHOLINE) CAPSULE DR 135 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 43 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE,MICRONIZED CAPSULE 130 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf FENOFIBRATE CAPSULE 150 MG PAFC_LIP-2s_FIBRIC_ACID_DERIVATIVES_PA_ST_20110713_FF.pdf OMEGA-3 ACID ETHYL ESTERS CAPSULE 1 G PAFC_LOVAZA_20110811_FF.pdf PREGABALIN CAPSULE 75 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 25 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 50 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 100 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 150 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 225 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 200 MG PAFC_LYRICA_20120418.pdf PREGABALIN CAPSULE 300 MG PAFC_LYRICA_20120418.pdf MECASERMIN VIAL 10 MG/ML PAFC_MECASERMIN20070801.pdf MODAFINIL TABLET 200 MG PAFC_MODAFINIL20091230.pdf MODAFINIL TABLET 200MG PAFC_MODAFINIL20091230.pdf MODAFINIL TABLET 100 MG PAFC_MODAFINIL20091230.pdf ZOLPIDEM TARTRATE TAB MPHASE 12.5 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB MPHASE 6.25 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ESZOPICLONE TABLET 1 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf DOXEPIN HCL TABLET 6 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB MPHASE 6.25MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB SUBL 5 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB SUBL 3.5 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf RAMELTEON TABLET 8 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE SPRAY/PUMP 5 MG/SPRAY PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf

HT9402-13-R-0001 L-5.2-6

ESZOPICLONE TABLET 3 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB MPHASE 12.5MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ESZOPICLONE TABLET 2 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB SUBL 10 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ZOLPIDEM TARTRATE TAB SUBL 1.75 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf DOXEPIN HCL TABLET 3 MG PAFC_NEWER_SEDATIVE_HYPNOTICS_20130204_FF.pdf ABATACEPT DISP SYRIN 125 MG/ML PAFC_ORENCIA_SQ_201204118.pdf PANTOPRAZOLE SODIUM TABLET DR 40 MG PAFC_PPI_20110928_FF.pdf PANTOPRAZOLE SODIUM TABLET DR 20 MG PAFC_PPI_20110928_FF.pdf LANSOPRAZOLE CAPSULE DR 30 MG PAFC_PPI_20110928_FF.pdf OMEPRAZOLE/SODIUM BICARBONA CAPSULE 40MG-1.1G PAFC_PPI_20110928_FF.pdf DEXLANSOPRAZOLE CAP DR MP 60 MG PAFC_PPI_20110928_FF.pdf OMEPRAZOLE/SODIUM BICARBONA PACKET 40-1680MG PAFC_PPI_20110928_FF.pdf LANSOPRAZOLE CAPSULE DR 15 MG PAFC_PPI_20110928_FF.pdf LANSOPRAZOLE TAB RAP DR 30 MG PAFC_PPI_20110928_FF.pdf RABEPRAZOLE SODIUM TABLET DR 20 MG PAFC_PPI_20110928_FF.pdf LANSOPRAZOLE TAB RAP DR 15 MG PAFC_PPI_20110928_FF.pdf LANSOPRAZOLE CAPSULE DR 30MG PAFC_PPI_20110928_FF.pdf OMEPRAZOLE/SODIUM BICARBONA PACKET 20-1680MG PAFC_PPI_20110928_FF.pdf PANTOPRAZOLE SODIUM GRANPKT DR 40 MG PAFC_PPI_20110928_FF.pdf DEXLANSOPRAZOLE CAP DR MP 30 MG PAFC_PPI_20110928_FF.pdf PRAMLINTIDE ACETATE PEN INJCTR 1500/1.5ML PAFC_PRAMLINTIDE_20110413.pdf PRAMLINTIDE ACETATE VIAL 600MCG/ML PAFC_PRAMLINTIDE_20110413.pdf PRAMLINTIDE ACETATE PEN INJCTR 2700/2.7ML PAFC_PRAMLINTIDE_20110413.pdf DESVENLAFAXINE SUCCINATE TAB ER 24H 100 MG PAFC_PRISTIQ_ST_20120418.pdf DESVENLAFAXINE SUCCINATE TAB ER 24H 50 MG PAFC_PRISTIQ_ST_20120418.pdf QUININE SULFATE CAPSULE 324 MG PAFC_QUALAQUIN20101006.pdf ALISKIREN HEMIFUMARATE TABLET 150 MG PAFC_RAAs_ST_20120201_FF.pdf CANDESARTAN CILEXETIL TABLET 32 MG PAFC_RAAs_ST_20120201_FF.pdf CANDESARTAN/HYDROCHLOROTHIA TABLET 32MG-25MG PAFC_RAAs_ST_20120201_FF.pdf IRBESARTAN TABLET 300MG PAFC_RAAs_ST_20120201_FF.pdf AMLODIPINE BES/OLMESARTAN M TABLET 10MG-20MG PAFC_RAAs_ST_20120201_FF.pdf EPROSARTAN MESYLATE TABLET 600 MG PAFC_RAAs_ST_20120201_FF.pdf CANDESARTAN/HYDROCHLOROTHIA TABLET 32-12.5MG PAFC_RAAs_ST_20120201_FF.pdf OLMESARTAN/HYDROCHLOROTHIAZ TABLET 40 MG-25MG PAFC_RAAs_ST_20120201_FF.pdf OLMESARTAN MEDOXOMIL TABLET 20 MG…