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What is Quantity Management? It’s a quality and safety program that promotes the safe use of medications. The program limits the amounts of some medications that we cover. The Food and Drug Administration (FDA) has approved some drugs only for short-term use. And The pharmacist enters your prescription information some drugs may not work as well or can even be into the computer system. If the drug has a limit on the covered amount, the pharmacist will fill your prescription as long as it does not exceed the limit. If your prescription exceeds the quantity limit, you We base the Quantity Management program on FDA and manufacturer dosing guidelines, medical literature, safety, accepted medical practice, 1. Your pharmacist can reduce your prescription appropriate use and benefit design. Our program to the quantity your health plan covers. only affects the amount of medication your benefit plan covers. You and your doctor should 2. You can pay full price for all of your make the final decision about the amount of prescription or for the portion that exceeds 3. You or your pharmacist can ask your doctor to get a quantity override if one is available. If your plan approves the additional quantity, it will The medications and limits that apply to your plan can pay for it. If your plan does not approve it or the vary. Medication limits can also vary depending on the override is not available, you can still choose option medication strength. We post the most updated list of medications in the Quantity Management programs on our Web site. You can also view personal benefit If you submit your prescription to the mail-order pharmacy and do not meet the requirements for an additional quantity, the pharmacy will not fill your The medications and limits in Chart 1 apply to some prescription. It will also not fill your prescription if an plans, while the medications and limits in Chart 2 or additional quantity is not available for that drug. The Chart 3 apply to other plans. Check your benefits booklet or talk with your Benefits department to determine which quantity limits apply to you. For most medications, your plan will only cover a set amount within a set timeframe. Your plan will cover higher amounts of some medications when medically necessary. If a drug on this list has an asterisk (*) next to it, you may be able to get a medical necessity override for a larger amount. If you need more of any of these medications, please have your doctor call the Caremark Prior Authorizations department at 800-294-5979. Your doctor can also fax requests to 888-836-0730. On behalf of your health plan, Caremark administers the Quantity Management program. Caremark is an independent company that manages pharmacy benefits. Intal Solution for Inhalation (1 box per month) ipratropium nebulizer solution (120 vials per albuterol inhalation solution (5 boxes per albuterol nebulizer solution (120 ml per month) Morphine immediate release (180 tablets per oxycodone immediate release (180 tablets per oxycodone with acetaminophen (limit varies by oxycodone with aspirin (limit varies by strength) oxycodone with ibuprofen (limit varies by codeine with acetaminophen (limit varies by codeine with aspirin (limit varies by strength) PLEASE NOTE: The monthly migraine (+), sleep aid (++), prescription ulcer (+++) and select pain (++++) drug quantity limits apply to all prescription medications within the drug class. For example, if coverage for a sleep aid is limited to one tablet per day, only one sleep aid registered or unregistered trademarks of third- trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation. A member’s hydrocodone with acetaminophen (limit varies Sporanox solution (600 ml per month, 1,800 benefit document defines actual benefits available and may exclude coverage for certain hydrocodone with aspirin (limit varies by drugs listed herein. This list may change or expand from time to time without prior notice. When we list brand-name drugs, programs also apply to any available generic equivalents. Imitrex Injection (12 vials per month)*+ hydrocodone with acetaminophen (varies by hydrocodone with aspirin (varies by strength) Sporanox solution (600 ml per month, 1,800 Intal Solution for Inhalation (120 vials per albuterol inhalation solution (5 boxes per ipratropium nebulizer solution (120 vials per albuterol nebulizer solution (120 ml per month) Lyrica 25mg –200 mg (90 capsules per month) Maxair Autoinhaler (1 inhaler per month) Morphine Immediate release (180 tablets per codeine with aspirin (varies by strength) oxycodone immediate release (180 tablets per PLEASE NOTE: The monthly migraine (+), sleep oxycodone with aspirin (varies by strength) aid (++), prescription ulcer (+++) and select oxycodone with ibuprofen (varies by strength) pain (++++) drug quantity limits apply to all prescription medications within the drug class. For example, if coverage for a sleep aid is limited to one tablet per day, only one sleep aid registered or unregistered trademarks of third- trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation. A member’s benefit document defines actual benefits available and may exclude coverage for certain drugs listed herein. This list may change or expand from time to time without prior notice. When we list brand-name drugs, programs also apply to any available generic equivalents. Protonix (90 days supply every 365 days)*+++ AcipHex (90 days supply every 365 days)*+++ Pulmicort Respules (3 packages per month) Pulmicort Turbuhaler (2 inhalers per month) Albuterol Solution .5% (3 packages per month) Alupent Solution .4% (4 packages per month) Alupent Solution .6% (4 packages per month) Alupent Solution 5% (3 packages per month) Tamiflu 30 mg (20 capsules every 6 months)* Tamiflu 45 mg (10 capsules every 6 months)* Tamiflu 75 mg (10 capsules every 6 months)* Atrovent Solution (4 packages per month) Zegerid (90 days supply every 365 days)*+++ Dexilant (90 days supply every 365 days)*+++ Zomig Nasal Spray (1 package per month)*+ Imitrex injection kits (2 kits per month)*+ Imitrex injection vials (4 vials per month)*+ Imitrex NS 20 mg (1 package per month)*+ Imitrex NS 5 mg (2 packages per month)*+ Imitrex Oral Tablets (9 tablets per month)*+ PLEASE NOTE: The monthly migraine (+), sleep Kapidex (90 days supply every 365 days)*+++ aid (++), ulcer (+++) and select pain (++++) drug quantity limits apply to all prescription Kytril 2 mg/10 ml oral solution (30 ml per example, if coverage for a sleep aid is limited to one tablet per day, only one sleep aid tablet registered or unregistered trademarks of third- trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation. A member’s benefit document defines actual benefits Nexium (90 days supply every 365 days)*+++ available and may exclude coverage for certain drugs listed herein. This list may change or expand from time to time without prior notice. When we list brand-name drugs, programs also Prevacid (90 days supply every 365 days)*+++ apply to any available generic equivalents. Prilosec (90 days supply every 365 days)*+++ What is Prior Authorization? It’s a quality and safety program that promotes the proper use of certain medications. If your doctor prescribes a medication that is included in our Prior Authorization (PA) program, you must get prior approval before your plan will cover your medication. We base our prior authorization guidelines on FDA and manufacturer guidelines, medical literature, safety, accepted medical practice, appropriate use and benefit design. Our program only affects the medication that your benefit plan covers. You and your doctor should make the final decision about the medication that is right The pharmacist enters your prescription information into the computer system. If your medication needs prior authorization and you already have it, the pharmacist will fill your prescription. If you do not have prior authorization, you have three choices. We post the most updated list on our Web site, 1. You or your pharmacist can call your doctor though the requirements for your plan can vary. Most members need prior authorization for the medications in Chart 1. Members with some plans need prior authorization for the medications in Chart 1 and in Chart 2. Check your benefits booklet or talk 2. You can pay full price for your medication. with your Benefits department to determine which chart applies to you. You can also view personal 3. You or your pharmacist can ask your doctor benefit information through our Web site. If you do not meet the requirements for prior If your doctor prescribes a medication that needs authorization, you can still choose option 1 or 2. prior authorization, please have your doctor call the Caremark Prior Authorizations department at 800- If you submit your prescription to your plan’s mail- 294-5979. Your doctor can also fax requests to 888- order pharmacy and do not get prior authorization, 836-0730. On behalf of your health plan, Caremark the pharmacy will not fill your prescription. You will administers the Prior Authorization program. Caremark is an independent company that manages

Source: http://www.seapinesbenefits.com/Quantity_Limit_and_Prior_authorization.pdf