Responsible Quantity Program* - Health Insurance …

1 *Refer to the medication guide to determine coverage status of drugs in the program. Certain drugs may be excluded from coverage for certain Blue is an Independent Licensee of the Blue Cross and Blue Shield AssociationResponsible Quantity Program* Current 7/1/18 Quantity Limit Authorization Form Responsible Quantity program limits apply to generic versions of drugs where applicable. Brand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Abilify (aripiprazole) 30 tabs Abilify Discmelt 60 tabs Abilify oral solution 750 mL Abstral 120 tabs acetaminophen/caffeine/dihydrocodeine 300 tabs Aciphex (rabeprazole) 20 mg tab 60 tabs Aciphex sprinkles 5 mg, 10 mg sprinkle 60 caps Actiq (fentanyl citrate) 120 units Actonel (risedronate) 5 mg, 30 mg 30 tabs Actonel (risedronate) 35 mg 4 tabs Actonel (risedronate) 150 mg 1 tab Adcirca 60 tabs Adderall (amphetamine-dextroamphetamine) 5 mg, mg, 10 mg, mg, 15 mg, 30 mg 60 tabs Adderall (amphetamine-dextroamphetamine)

2 20 mg 90 tabs Adderall XR 5 mg, 10 mg, 15 mg 30 caps Adderall XR 20 mg, 25 mg, 30 mg 60 caps Adempas 90 tabs Adlyxin Starter pack 1 pack / 180 days Adlyxin 20 mcg / ml pen 2 pens / 28 days Advair Diskus 60 blisters Advair HFA 1 canister Advicor 500-20, 750-20, 1000-2060 tabs Advicor 1000-40 30 tabs Adzenys ER 450 mL Adzenys XR ODT mg, mg 60 tabs Adzenys XR ODT mg, mg, mg, mg 30 tabs Aerospan 2 canisters Afinitor 30 tabs Afinitor Disperz 2 mg, 5 mg 60 tabs Afinitor Disperz 3 mg 90 tabs Afrezza 4 unit 2520 cartridges Afrezza 8 unit 1260 cartridges Page 1 of 24 *Refer to the medication guide to determine coverage status of drugs in the program.

3 Certain drugs may be excluded from coverage for certain members. Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Brand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Afrezza 12 unit 900 cartridges Afrezza mix pack 4 unit (30 count) + 8 unit (60 count) 1530 cartridges Afrezza mix pack 4 unit (60 count) + 8 unit (30 count) 1890 cartridges Afrezza mix pack 8 unit (60 count) + 12 unit (30 count) 1080 cartidges Afrezza mix pack 8 unit (90 count) + 4 unit (90 count) 1800 cartridges Afrezza mix pack 4 unit (60 count) + 8 unit (60 count) + 12 unit (60 count)

4 1260 cartridges Aimovig 70 mg 1 auto-injector Aimovig 140 mg 2 auto-injectors AirDuo Respiclick 1 inhaler Akynzeo 2 caps Aldara 5% cream, actinic keratosis or genital and perianal warts 12 packets / 30 days (supply limit 4 months) Aldara 5% cream, basal cell carcinoma 24 packets / 30 days (supply limit 2 months) Allzital 360 tabs Alora 8 patches / 28 days Altoprev 30 tabs Alunbrig 30 mg 180 tabs Alunbrig 90 mg, 180 mg 30 tabs Alunbrig Therapy pack 30 tabs / 180 days Alvesco 80 mcg 1 canister Alvesco 160 mcg 2 canisters Ambien (zolpidem) 30 tabs Ambien CR (zolpidem ER) 30 tabs Amerge (naratriptan) 1 mg 18 tabs Amerge (naratriptan) mg 9 tabs Ampyra 60 tabs Amturnide 30 tabs Anlagesic LQ elixir 2700 ml Androderm patch 2 mg, 4 mg 30 patches Androderm patch mg, 5 mg 60 patches AndroGel 1% packet 60 packets AndroGel 1% pump 4 pumps AndroGel packet mg / gm 30 packets AndroGel packet / gm 60 packets AndroGel pump 2 pumps Anoro Ellipta 60 blisters Antara 30 mg 60 caps Antara 90 mg 30 caps Anzemet 50 mg 7 tabs Page 2 of 24 *Refer to the medication guide to determine coverage status of drugs in the program.

5 Certain drugs may be excluded from coverage for certain members. Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Brand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Anzemet 100 mg 7 tabs Aplenzin 30 tabs Aptivus 100 mg/ml 380 ml Aptivus 250 mg 120 caps Aptensio XR 30 caps Arcalyst 4 vials / 28 days Arcapta Neohaler 30 blisters Arixtra (fondaparinux) 30 syringes / 3 months Armonair Respiclick 1 inhaler Arnuity Ellipta 30 blisters Arymo ER 90 tabs Asmanex 1 inhaler Asmanex HFA 1 inhaler Astelin (azelastine) 2 inhalers Astepro 2 bottles Atacand 4 mg, 8 mg, 16 mg 60 tabs Atacand 32 mg 30 tabs Atacand HCT (candesartan/hydrochlorothiazide) 30 tabs Atelvia (risedronate) 4 tabs / 28 days Atripla 30 tabs Atrovent (ipratropium) 2 inhalers Atrovent (ipratropium) 3 inhalers Atrovent HFA 2 inhalers Aubagio 30 tabs Austedo 6 mg 60 tabs Austedo 9 mg, 12 mg 120 tabs Avalide (irbesartan/hydrochlorothiazide) 30 tabs Avapro (irbesartan) 30 tabs Avinza (morphine ext release) 60 caps Avonex 4 vials/syringes / 28 days Axert (almotriptan) mg 24 tabs Axert (almotriptan)

6 Mg 12 tabs Axiron 2 pumps Azor 30 tabs Beconase AQ 2 inhalers Belbuca 60 films Belsomra 30 tabs Benicar 5 mg 60 tabs Benicar 20 mg, 40 mg 30 tabs Benicar HCT 30 tabs Page 3 of 24 *Refer to the medication guide to determine coverage status of drugs in the program. Certain drugs may be excluded from coverage for certain Blue is an Independent Licensee of the Blue Cross and Blue Shield AssociationBrand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Benlysta 4 auto-injectors/syringes / 28 days Berinert 20 vials Betaseron 14 vials/syringes / 28 days Bevespi 1 canister Beyyxxa 43 caps/42 days Biktarvy 30 tabs Bimatoprost mL Binosto 4 tabs / 28 days Boniva (ibandronate) mg 30 tablets Boniva (ibandronate)

7 150 mg 1 tablet Bonjesta 60 tabs Bosulif 30 tabs Breo Ellipta 100 mcg/25 mcg 30 actuations Breo Ellipta 200 mcg/ 25 mcg 30 actuations Bunavail mg 90 films Bunavail mg, mg 60 films buprenorphine 2 mg, 8 mg 15 tabs / 90 days Butalbital Compound (butalbital-acetaminophen) 180 tabs butorphanol tartrate nasal spray 2 bottles Butrans All strengths 4 systems / 28 days Bydureon 4 syringes / 28 days Bydureon BCise 4 auto-injectors / 28 days Byetta pre-filled pen (60 doses) 1 pen Byvalson 30 tabs Cabometyx 30 tabs Calquence 60 caps Cambia 9 packets Capital and Codeine (acetaminophen/codeine solution) 2700 ml Caprelsa 100 mg 60 tabs Caprelsa 300 mg 30 tabs Carac cream 30 grams / 28 days (4 week supply limit) Celebrex (celecoxib) 50 mg, 100 mg, 200 mg 60 caps Celebrex (celecoxib) 400 mg 30 caps Cesamet 42 caps Cialis mg, 5 mg 30 tabs Cimduo 30 tabs Cimzia Starter kit 1 kit/year Cimzia 200mg syringe 2 syringes / 28 days Cinryze 20 vials Page 4 of 24 *Refer to the medication guide to determine coverage status of drugs in the program.

8 Certain drugs may be excluded from coverage for certain Blue is an Independent Licensee of the Blue Cross and Blue Shield AssociationBrand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Climara (estradiol) 4 patches Climara Pro 4 patches Clozaril (clozapine) 25 mg, 50mg 90 tabs Clozaril (clozapine) 100 mg 270 tabs Clozaril (clozapine) 200 mg 120 tabs Codeine tablets 180 tabs Combivent 2 inhalers Combivent Respimat 2 inhalers Combivent Respimat 2 bottles Combivir 60 tabs Cometriq 1 carton / 28 days Complera 30 tabs Concerta (methylphenidate ER) 18 mg, 27 mg, 54 mg 30 tabs Concerta (methylphenidate ER) 36 mg 60 tabs Conzip 30 tabs Copaxone (glatiramer acetate) 20 mg 30 syringes Copaxone (glatiramer acetate) 40 mg 12 syringes / 28 days Cosentyx 150 mg / ml (injector or syringe) 1 injector or syringe / 28 days Cosentyx 300 mg (2 x 150 mg / ml injectors or syringes per package) 1 package / 28 days Cotempla XR ODT mg 30 tabs Cotempla XR ODT mg, mg 60 tabs Cozaar (losartan) 25 mg, 50 mg 60 tabs Cozaar (losartan)

9 100 mg 30 tabs Crestor 5 mg, 10 mg, 20 mg 45 tabs Crestor 40 mg 30 tabs Crixivan 200 mg 270 caps Crixivan 400 mg 180 caps Daklinza 30 tabs Daliresp 30 tabs Daytrana 30 patches Delatestryl (testosterone enanthate) 200 mg/5 ml 1 vial / 28 days Demerol (meperidine) tablets 240 tabs Demerol (meperidine) liquid 2,400 ml Depo Testosterone (testosterone cypionate) 10 ml vials 1 vial / 28 days Depo Testosterone (testosterone cypionate) 1 ml vials 4 vials / 28 days Descovy 30 tabs Desoxyn (methamphetamine) 150 tabs Detrol 60 tabs Detrol LA 30 caps Page 5 of 24 *Refer to the medication guide to determine coverage status of drugs in the program. Certain drugs may be excluded from coverage for certain members.

10 Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Brand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Dexedrine (dextroamphetamine) 5 mg 90 tabs Dexedrine (dextroamphetamine) 10 mg 180 tabs Dexedrine Spansule (dextroamphetamine sulfate ext-release) 5 mg 90 caps Dexedrine Spansule (dextroamphetamine sulfate ext-release) 10 mg, 15 mg 120 caps Dexilant 30 caps DHE 24 vials / 28 days Diabetic test strips (all brands) 204 strips/discs Dificid 40 tabs / 180 days Diclegis 120 tabs Dilaudid (hydromorphone) tablets 180 tabs Dilaudid (hydromorphone) liquid 1,440 ml Dilaudid (hydromorphone) suppository 120 suppositories Diovan (valsartan) 40 mg, 80 mg, 160 mg 60 tabs Diovan (valsartan) 320 mg 30 tabs Diovan HCT (valsartan-hydrochlorothiazide) 30 tabs Ditropan XL (oxybutynin ext-release) 5 mg 30 tabs Ditropan XL (oxybutynin ext-release) 10 mg, 15 mg 60 tabs Divigel 30 packets Dovonex cream 120 grams Dovonex (calcipotriene)