EXHIBIT_L-5_DoD_Formulary_Restrictions_and_Limitations_(April_4 _2013).xlsx

XLSX spreadsheet 125 KB Posted Aug 8, 2013

Attached to: TRICARE Pharmacy Program, Fourth Generation (TPharm4)
Solicitation number: HT9402-13-R-0001
Issued by: Defense Health Agency

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EXHIBIT_L-5 DoD Formulary Restrictions and Limitations (April 4 2013)(Excel format)

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L-5. TOC

Exhibit L-5 DoD Formulary Restrictions and Limitations

Current as of April 4, 2013
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 Table of Contents

HT9402-13-R-0001 Exhibit L-5-&P

L-5.1. QLL

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
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
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
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
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
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
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

Exhibit L-5.1 Quantity Limits

HT9402-13-R-0001 L-5.1-&P

L-5.2. PA

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
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
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
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
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
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
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	PAFC_RAAs_ST_20120201_FF.pdf
OLMESARTAN MEDOXOMIL	TABLET	40 MG	PAFC_RAAs_ST_20120201_FF.pdf
ALISKIREN/AMLODIPINE BESYLA	TABLET	300MG-10MG	PAFC_RAAs_ST_20120201_FF.pdf
IRBESARTAN/HYDROCHLOROTHIAZ	TABLET	300-12.5MG	PAFC_RAAs_ST_20120201_FF.pdf
EPROSARTAN MESYLATE	TABLET	400 MG	PAFC_RAAs_ST_20120201_FF.pdf
CANDESARTAN CILEXETIL	TABLET	16 MG	PAFC_RAAs_ST_20120201_FF.pdf
CANDESARTAN CILEXETIL	TABLET	4 MG	PAFC_RAAs_ST_20120201_FF.pdf
ALISKIREN/HYDROCHLOROTHIAZI	TABLET	300-12.5MG	PAFC_RAAs_ST_20120201_FF.pdf
IRBESARTAN	TABLET	150 MG	PAFC_RAAs_ST_20120201_FF.pdf
IRBESARTAN	TABLET	75 MG	PAFC_RAAs_ST_20120201_FF.pdf
IRBESARTAN	TABLET	300 MG	PAFC_RAAs_ST_20120201_FF.pdf

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File details come from the government source that posted it. Updated Nov 14, 2017.