Quantity Limit for 30 day DRUG supply DRUG Quantity Limit ...

New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

EPINEPHRINE 0.15 MG AUTO-INJCT 4 pens / 30 daysEPINEPHRINE 0.3 MG AUTO-INJECT 4 pens / 30 daysEPIPEN JR 0.15 MG AUTO-INJECTR 4 pens / 30 daysSYMJEPI 0.15 MG/0.3 ML SYRINGE 4 syringes / 30 daysSYMJEPI 0.3 MG/0.3 ML SYRINGE 4 syringes / 30 days

APREPITANT 125 MG CAPSULE 15 capsules / 30 daysAPREPITANT 125-80-80 MG PACK 5 packs / 30 daysAPREPITANT 40 MG CAPSULE 15 capsules / 30 daysAPREPITANT 80 MG CAPSULE 15 capsules / 30 daysBONJESTA 2 tablets / dayDICLEGIS 4 tablets / dayDOXYLAMINE SUCC-PYRIDOXINE HCL 4 tablets / dayEMEND 125 MG POWDER PACKET 15 packets / 30 daysEMEND 80 MG CAPSULE 15 capsules / 30 daysEMEND TRIPACK 5 packs / 30 daysGRANISETRON HCL 1 MG TABLET 15 tablets / 30 daysONDANSETRON HCL 4 MG TABLET 15 tablets / 30 daysONDANSETRON HCL 8 MG TABLET 15 tablets / 30 daysONDANSETRON ODT 4 MG TABLET 15 tablets / 30 daysONDANSETRON ODT 8 MG TABLET 15 tablets / 30 daysZOFRAN 4 MG TABLET 15 tablets / 30 daysZUPLENZ 4 MG SOLUBLE FILM 15 films / 30 daysZUPLENZ 8 MG SOLUBLE FILM 15 films / 30 days

DIFLUCAN 150 MG TABLET 2 tablets / 30 daysFLUCONAZOLE 150 MG TABLET 2 tablets / 30 daysITRACONAZOLE 10 MG/ML SOLUTION 10 mL / dayITRACONAZOLE 100 MG CAPSULE 1 capsule / daySPORANOX 10 MG/ML SOLUTION 10 mL / daySPORANOX 100 MG CAPSULE 1 capsule / day

Anaphylaxis Agents

Anti-Emetic Agents

Antifungals

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

AIMOVIG 140 MG/ML AUTOINJECTOR 1 pen / 30 daysAIMOVIG 70 MG/ML AUTOINJECTOR 2 injections / 30 daysAJOVY 225 MG/1.5 ML AUTOINJECT 3 pens / 90 daysAJOVY 225 MG/1.5 ML SYRINGE 3 pens / 90 daysALMOTRIPTAN MALATE 12.5 MG TAB 12 tablets / 30 daysALMOTRIPTAN MALATE 6.25 MG TAB 12 tablets / 30 daysAMERGE 1 MG TABLET 18 tablets / 30 daysAMERGE 2.5 MG TABLET 18 tablets / 30 daysELETRIPTAN HBR 20 MG TABLET 6 tablets / 30 daysELETRIPTAN HBR 40 MG TABLET 6 tablets / 30 daysEMGALITY 100 MG/ML SYRINGE (1 OF 3)(300 MG DOSE = 100 MG X3) 3 syringes / 30 daysEMGALITY 120 MG/ML PEN 1 pen / 30 daysEMGALITY 120 MG/ML SYRINGE 1 syringe / 30 daysEMGALITY 120 MG/ML SYRINGE 1 syringe / 30 daysEMGALITY 300 MG DOSE (100 MG/ML X 3 SYRINGES) 3 syringes / 30 daysFROVA 2.5 MG TABLET 18 tablets / 30 daysFROVATRIPTAN SUCC 2.5 MG TAB 18 tablets / 30 daysIMITREX 100 MG TABLET 9 tablets / 30 daysIMITREX 25 MG TABLET 18 tablets / 30 daysIMITREX 50 MG TABLET 18 tablets / 30 daysMAXALT 10 MG TABLET 12 tablets / 30 daysMAXALT MLT 10 MG TABLET 12 tablets / 30 daysNARATRIPTAN HCL 1 MG TABLET 18 tablets / 30 daysNARATRIPTAN HCL 2.5 MG TABLET 18 tablets / 30 daysNURTEC ODT 75 MG TABLET 15 tablets / 30 daysRELPAX 20 MG TABLET 6 tablets / 30 daysRELPAX 40 MG TABLET 6 tablets / 30 daysREYVOW 100 MG TABLET 4 tablets / 30 daysREYVOW 50 MG TABLET 4 tablets / 30 daysRIZATRIPTAN 10 MG ODT 12 tablets / 30 daysRIZATRIPTAN 10 MG TABLET 12 tablets / 30 daysRIZATRIPTAN 5 MG ODT 12 tablets / 30 daysRIZATRIPTAN 5 MG TABLET 12 tablets / 30 daysSUMATRIPTAN SUCC 100 MG TABLET 9 tablets / 30 daysSUMATRIPTAN SUCC 25 MG TABLET 18 tablets / 30 daysSUMATRIPTAN SUCC 50 MG TABLET 18 tablets / 30 daysSUMATRIPTAN-NAPROXEN 85-500 MG 9 tablets / 30 daysTREXIMET 85-500 MG TABLET 9 tablets / 30 daysUBRELVY 100 MG TABLET 16 tablets / 30 daysUBRELVY 50 MG TABLET 16 / 30 daysVYEPTI 100 MG/ML VIAL 1 vial / 30 days

Antimigraine Agents

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

ZOLMITRIPTAN 2.5 MG ODT 6 tablets / 30 daysZOLMITRIPTAN 2.5 MG TABLET 6 tablets / 30 daysZOLMITRIPTAN 5 MG ODT 6 tablets / 30 daysZOLMITRIPTAN 5 MG TABLET 6 tablets / 30 daysZOMIG 2.5 MG NASAL SPRAY 1 kit / 30 daysZOMIG 2.5 MG TABLET 6 tablets / 30 daysZOMIG 5 MG NASAL SPRAY 1 kit / 30 daysZOMIG 5 MG TABLET 6 tablets / 30 daysZOMIG ZMT 2.5 MG TABLET 6 tablets / 30 daysZOMIG ZMT 5 MG TABLET 6 tablets / 30 days

ABILIFY MAINTENA ER 300 MG SYR 3 syringes / 90 daysABILIFY MAINTENA ER 300 MG VL 3 vials / 90 daysABILIFY MAINTENA ER 400 MG SYR 3 syringes / 90 daysABILIFY MAINTENA ER 400 MG VL 3 vials / 90 daysARISTADA ER 1,064 MG/3.9 ML SYR 2 syringes / 90 daysARISTADA ER 441 MG/1.6 ML SYRN 3 syringes / 90 daysARISTADA ER 662 MG/2.4 ML SYRN 3 syringes / 90 daysARISTADA ER 882 MG/3.2 ML SYRN 3 syringes / 90 daysINVEGA HAFYERA 1,092 MG/3.5 ML 1 syringe / 180 daysINVEGA HAFYERA 1,560 MG/5 ML 1 syringe / 180 daysINVEGA SUSTENNA 117 MG/0.75 ML 3 syringes / 90 daysINVEGA SUSTENNA 156 MG/ML SYRG 3 syringes / 90 daysINVEGA SUSTENNA 234 MG/1.5 ML 3 syringes / 90 daysINVEGA SUSTENNA 39 MG/0.25 ML 3 syringes / 90 daysINVEGA SUSTENNA 78 MG/0.5 ML 3 syringes / 90 daysINVEGA TRINZA 273 MG/0.875 ML 1 syringe / 90 daysINVEGA TRINZA 410 MG/1.315 ML 1 syringe / 90 daysINVEGA TRINZA 546 MG/1.75 ML 1 syringe / 90 daysINVEGA TRINZA 819 MG/2.625 ML 1 syringe / 90 daysPERSERIS ER 120 MG SYRINGE KIT 3 kits / 90 daysPERSERIS ER 90 MG SYRINGE KIT 3 kits / 90 daysRISPERDAL CONSTA 12.5 MG VIAL 6 vials / 90 daysRISPERDAL CONSTA 25 MG VIAL 6 vials / 90 daysRISPERDAL CONSTA 37.5 MG VIAL 6 vials / 90 daysRISPERDAL CONSTA 50 MG VIAL 6 vials / 90 daysZYPREXA RELPREVV 210 MG VL KIT 6 kits / 90 daysZYPREXA RELPREVV 300 MG VL KIT 3 kits / 90 daysZYPREXA RELPREVV 405 MG VL KIT 3 kits / 90 days

Antimigraine Agents (continued)

Antipsychotic Agents

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

FUZEON 90 MG VIAL 1 kit / 30 days

FLUMADINE 100 MG TABLET 60 tablets / 30 daysOSELTAMIVIR 6 MG/ML SUSPENSION 180 mL / 45 daysOSELTAMIVIR PHOS 30 MG CAPSULE 20 capsules / 180 daysOSELTAMIVIR PHOS 45 MG CAPSULE 10 capsules / 180 daysOSELTAMIVIR PHOS 75 MG CAPSULE 10 capsules / 180 daysRELENZA 5 MG DISKHALER 1 kit / 30 daysRIMANTADINE HCL 100 MG TABLET 60 tablets / 30 daysTAMIFLU 30 MG CAPSULE 20 capsules / 180 daysTAMIFLU 45 MG CAPSULE 10 capsules / 180 daysTAMIFLU 6 MG/ML SUSPENSION 180 mL / 45 daysTAMIFLU 75 MG CAPSULE 10 capsules / 180 daysXOFLUZA 20 MG TAB (40 MG DOSE) 1 dose / 180 daysXOFLUZA 40 MG TAB (80 MG DOSE) 1 dose / 180 daysXOFLUZA 40 MG TABLET 1 tablet / 180 daysXOFLUZA 80 MG TABLET 1 tablet / 180 days

CLENPIQ SOLUTION 1 kit / 30 daysGAVILYTE-C SOLUTION 4000 mL / 30 daysGAVILYTE-G SOLUTION 4000 mL / 30 daysGAVILYTE-N SOLUTION 4000 mL / 30 daysGOLYTELY SOLUTION 4000 mL / 30 daysMOVIPREP POWDER PACKET 1 kit / 30 daysOSMOPREP TABLET 32 tablets / 30 daysPEG 3350-ELECTROLYTE SOLUTION 4000 mL / 30 daysPEG-3350 AND ELECTROLYTES SOLN 4000 mL / 30 daysPEG3350-SOD SUL-NACL-KCL-ASCB-C 100-7.5-2.691-1.015-5.9-4.7G 1 kit / 30 daysPLENVU POWDER PACKETS 3 packets / 30 daysSUPREP BOWEL PREP KIT 1 kit / 30 daysSUTAB 1.479-0.225-0.188 GM TAB 2 tablets / 30 days

Antiretroviral Agents

Bowel Evacuants

Antiviral Agents

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

BIMATOPROST 0.03% EYE DROPS 15 mL / 90 daysLATANOPROST 0.005% EYE DROPS 15 mL / 90 daysLUMIGAN 0.01% EYE DROPS 15 mL / 90 daysRHOPRESSA 0.02% OPHTH SOLUTION 15 mL / 90 daysROCKLATAN 0.02%-0.005% EYE DRP 15 mL / 90 daysTRAVATAN Z 0.004% EYE DROP 15 mL / 90 daysTRAVOPROST 0.004% EYE DROP 15 mL / 90 daysVYZULTA 0.024% OPHTH SOLUTION 15 mL / 90 daysXALATAN 0.005% EYE DROPS 15 mL / 90 daysXELPROS 0.005% EYE DROP 15 mL / 90 daysZIOPTAN 0.0015% EYE DROPS 180 doses / 90 days

ARANESP 10 MCG/0.4 ML SYRINGE 4 syringes / 30 daysARANESP 100 MCG/0.5 ML SYRINGE 4 syringes / 30 daysARANESP 100 MCG/ML VIAL 4 vials / 30 daysARANESP 150 MCG/0.3 ML SYRINGE 4 syringes / 30 daysARANESP 200 MCG/0.4 ML SYRINGE 4 syringes / 30 daysARANESP 200 MCG/ML VIAL 4 vials / 30 daysARANESP 25 MCG/0.42 ML SYRING 4 syringes / 30 daysARANESP 25 MCG/ML VIAL 4 vials / 30 daysARANESP 300 MCG/0.6 ML SYRINGE 4 syringes / 30 daysARANESP 40 MCG/0.4 ML SYRINGE 4 syringes / 30 daysARANESP 40 MCG/ML VIAL 4 vials / 30 daysARANESP 500 MCG/1 ML SYRINGE 4 syringes / 30 daysARANESP 60 MCG/0.3 ML SYRINGE 4 syringes / 30 daysARANESP 60 MCG/ML VIAL 4 vials / 30 daysEPOGEN 10,000 UNITS/ML VIAL 8 vials / 30 daysEPOGEN 2,000 UNITS/ML VIAL 8 vials / 30 daysEPOGEN 20,000 UNITS/2 ML VIAL 8 vials / 30 daysEPOGEN 20,000 UNITS/ML VIAL 8 vials / 30 daysEPOGEN 3,000 UNITS/ML VIAL 8 vials / 30 daysEPOGEN 4,000 UNITS/ML VIAL 8 vials / 30 daysMIRCERA 100 MCG/0.3 ML SYRINGE 4 syringes / 30 daysMIRCERA 150 MCG/0.3 ML SYRINGE 4 syringes / 30 daysMIRCERA 200 MCG/0.3 ML SYRINGE 4 syringes / 30 daysMIRCERA 30 MCG/0.3 ML SYRINGE 4 syringes / 30 daysMIRCERA 50 MCG/0.3 ML SYRINGE 4 syringes / 30 daysMIRCERA 75 MCG/0.3 ML SYRINGE 4 syringes / 30 daysPROCRIT 10,000 UNITS/ML VIAL 8 vials / 30 daysPROCRIT 10,000 UNITS/ML VIAL 8 vials / 30 days

Hematopoietic Agents

Glaucoma Agents

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

PROCRIT 2,000 UNITS/ML VIAL 8 vials / 30 daysPROCRIT 20,000 UNITS/ML VIAL 8 vials / 30 daysPROCRIT 3,000 UNITS/ML VIAL 8 vials / 30 daysPROCRIT 4,000 UNITS/ML VIAL 8 vials / 30 daysPROCRIT 40,000 UNITS/ML VIAL 8 vials / 30 daysRETACRIT 10,000 UNIT/ML VIAL 8 vials / 30 daysRETACRIT 2,000 UNIT/ML VIAL 8 vials / 30 daysRETACRIT 20,000 UNIT/2 ML VIAL 8 vials / 30 daysRETACRIT 20,000 UNIT/ML VIAL 8 vials / 30 daysRETACRIT 3,000 UNIT/ML VIAL 8 vials / 30 daysRETACRIT 4,000 UNIT/ML VIAL 8 vials / 30 daysRETACRIT 40,000 UNIT/ML VIAL 8 vials / 30 days

BELBUCA 150 MCG FILM 2 films / dayBELBUCA 300 MCG FILM 2 films / dayBELBUCA 450 MCG FILM 2 films / dayBELBUCA 600 MCG FILM 2 films / dayBELBUCA 75 MCG FILM 2 films / dayBELBUCA 750 MCG FILM 2 films / dayBELBUCA 900 MCG FILM 2 films / dayBUPRENORPHINE 10 MCG/HR PATCH 1 patch / 7 daysBUPRENORPHINE 15 MCG/HR PATCH 1 patch / 7 daysBUPRENORPHINE 150 MCG FILM 2 films / dayBUPRENORPHINE 20 MCG/HR PATCH 1 patch / 7 daysBUPRENORPHINE 300 MCG FILM 2 films / dayBUPRENORPHINE 450 MCG FILM 2 films / dayBUPRENORPHINE 5 MCG/HR PATCH 1 patch / 7 daysBUPRENORPHINE 600 MCG FILM 2 films / dayBUPRENORPHINE 7.5 MCG/HR PATCH 1 patch / 7 daysBUPRENORPHINE 75 MCG FILM 2 films / dayBUPRENORPHINE 750 MCG FILM 2 films / dayBUPRENORPHINE 900 MCG FILM 2 films / dayBUTRANS 10 MCG/HR PATCH 1 patch / 7 daysBUTRANS 15 MCG/HR PATCH 1 patch / 7 daysBUTRANS 20 MCG/HR PATCH 1 patch / 7 daysBUTRANS 5 MCG/HR PATCH 1 patch / 7 daysBUTRANS 7.5 MCG/HR PATCH 1 patch / 7 daysCONZIP 100 MG CAPSULE 1 capsule / dayCONZIP 200 MG CAPSULE 1 capsule / dayCONZIP 300 MG CAPSULE 1 capsule / day

Hematopoietic Agents (continued)

Long-Acting Opioid Analgesics

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

DURAGESIC 100 MCG/HR PATCH 1 patch / 3 daysDURAGESIC 12 MCG/HR PATCH 1 patch / 3 daysDURAGESIC 25 MCG/HR PATCH 1 patch / 3 daysDURAGESIC 50 MCG/HR PATCH 1 patch / 3 daysDURAGESIC 75 MCG/HR PATCH 1 patch / 3 daysFENTANYL 100 MCG/HR PATCH 1 patch / 3 daysFENTANYL 12 MCG/HR PATCH 1 patch / 3 daysFENTANYL 25 MCG/HR PATCH 1 patch / 3 daysFENTANYL 37.5 MCG/HR PATCH 1 patch / 3 daysFENTANYL 50 MCG/HR PATCH 1 patch / 3 daysFENTANYL 62.5 MCG/HR PATCH 1 patch / 3 daysFENTANYL 75 MCG/HR PATCH 1 patch / 3 daysFENTANYL 87.5 MCG/HR PATCH 1 patch / 3 daysHYDROCODONE ER 10 MG CAPSULE 2 capsules / dayHYDROCODONE ER 100 MG TABLET 2 tablets / dayHYDROCODONE ER 120 MG TABLET 2 tablets / dayHYDROCODONE ER 15 MG CAPSULE 2 capsules / dayHYDROCODONE ER 20 MG CAPSULE 2 capsules / dayHYDROCODONE ER 20 MG TABLET 2 tablets / dayHYDROCODONE ER 30 MG CAPSULE 2 capsules / dayHYDROCODONE ER 30 MG TABLET 2 tablets / dayHYDROCODONE ER 40 MG CAPSULE 2 capsules / dayHYDROCODONE ER 40 MG TABLET 2 tablets / dayHYDROCODONE ER 50 MG CAPSULE 2 capsules / dayHYDROCODONE ER 60 MG TABLET 2 tablets / dayHYDROCODONE ER 80 MG TABLET 2 tablets / dayHYDROMORPHONE HCL ER 12 MG TAB 1 tablet / dayHYDROMORPHONE HCL ER 16 MG TAB 1 tablet / dayHYDROMORPHONE HCL ER 32 MG TAB 1 tablet / dayHYDROMORPHONE HCL ER 8 MG TAB 1 tablet / dayHYSINGLA ER 100 MG TABLET 2 tablets / dayHYSINGLA ER 120 MG TABLET 2 tablets / dayHYSINGLA ER 20 MG TABLET 2 tablets / dayHYSINGLA ER 30 MG TABLET 2 tablets / dayHYSINGLA ER 40 MG TABLET 2 tablets / dayHYSINGLA ER 60 MG TABLET 2 tablets / dayHYSINGLA ER 80 MG TABLET 2 tablets / dayKADIAN ER 10 MG CAPSULE 1 capsule / dayKADIAN ER 100 MG CAPSULE 1 capsule / dayKADIAN ER 20 MG CAPSULE 1 capsule / dayKADIAN ER 200 MG CAPSULE 1 capsule / day

Long-Acting Opioid Analgesics (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

KADIAN ER 30 MG CAPSULE 1 capsule / dayKADIAN ER 40 MG CAPSULE 1 capsule / dayKADIAN ER 50 MG CAPSULE 1 capsule / dayKADIAN ER 60 MG CAPSULE 1 capsule / dayKADIAN ER 80 MG CAPSULE 1 capsule / dayMORPHINE SULF CR 100 MG TABLET 3 tablets / dayMORPHINE SULF CR 60 MG TABLET 3 tablets / dayMORPHINE SULF ER 100 MG TABLET 3 tablets / dayMORPHINE SULF ER 15 MG TABLET 3 tablets / dayMORPHINE SULF ER 200 MG TABLET 3 tablets / dayMORPHINE SULF ER 30 MG TABLET 3 tablets / dayMORPHINE SULF ER 60 MG TABLET 3 tablets / dayMORPHINE SULFATE ER 10 MG CAP 1 capsule / dayMORPHINE SULFATE ER 100 MG CAP 1 capsule / dayMORPHINE SULFATE ER 120 MG CAP 1 capsule / dayMORPHINE SULFATE ER 20 MG CAP 1 capsule / dayMORPHINE SULFATE ER 30 MG CAP 1 capsule / dayMORPHINE SULFATE ER 30 MG CAP 1 capsule / dayMORPHINE SULFATE ER 40 MG CAP 1 capsule / dayMORPHINE SULFATE ER 45 MG CAP 1 capsule / dayMORPHINE SULFATE ER 50 MG CAP 1 capsule / dayMORPHINE SULFATE ER 60 MG CAP 1 capsule / dayMORPHINE SULFATE ER 60 MG CAP 1 capsule / dayMORPHINE SULFATE ER 75 MG CAP 1 capsule / dayMORPHINE SULFATE ER 80 MG CAP 1 capsule / dayMORPHINE SULFATE ER 90 MG CAP 1 capsule / dayMS CONTIN ER 100 MG TABLET 3 tablets / dayMS CONTIN ER 15 MG TABLET 3 tablets / dayMS CONTIN ER 200 MG TABLET 3 tablets / dayMS CONTIN ER 30 MG TABLET 3 tablets / dayMS CONTIN ER 60 MG TABLET 3 tablets / dayNUCYNTA ER 100 MG TABLET 2 tablets / dayNUCYNTA ER 150 MG TABLET 2 tablets / dayNUCYNTA ER 200 MG TABLET 2 tablets / dayNUCYNTA ER 250 MG TABLET 2 tablets / dayNUCYNTA ER 50 MG TABLET 2 tablets / dayOXYCODONE HCL ER 10 MG TABLET 2 tablets / dayOXYCODONE HCL ER 15 MG TABLET 2 tablets / dayOXYCODONE HCL ER 20 MG TABLET 2 tablets / dayOXYCODONE HCL ER 30 MG TABLET 2 tablets / dayOXYCODONE HCL ER 40 MG TABLET 2 tablets / day

Long-Acting Opioid Analgesics (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

OXYCODONE HCL ER 60 MG TABLET 2 tablets / dayOXYCODONE HCL ER 80 MG TABLET 2 tablets / dayOXYCONTIN ER 10 MG TABLET 2 tablets / dayOXYCONTIN ER 15 MG TABLET 2 tablets / dayOXYCONTIN ER 20 MG TABLET 2 tablets / dayOXYCONTIN ER 30 MG TABLET 2 tablets / dayOXYCONTIN ER 40 MG TABLET 2 tablets / dayOXYCONTIN ER 60 MG TABLET 2 tablets / dayOXYCONTIN ER 80 MG TABLET 2 tablets / dayOXYMORPHONE HCL ER 10 MG TAB 2 tablets / dayOXYMORPHONE HCL ER 15 MG TAB 2 tablets / dayOXYMORPHONE HCL ER 20 MG TAB 2 tablets / dayOXYMORPHONE HCL ER 30 MG TAB 2 tablets / dayOXYMORPHONE HCL ER 40 MG TAB 2 tablets / dayOXYMORPHONE HCL ER 5 MG TABLET 2 tablets / dayOXYMORPHONE HCL ER 7.5 MG TAB 2 tablets / dayTRAMADOL ER 100 MG TABLET 1 tablet / dayTRAMADOL ER 200 MG TABLET 1 tablet / dayTRAMADOL ER 300 MG TABLET 1 tablet / dayTRAMADOL HCL ER 100 MG CAPSULE 1 capsule / dayTRAMADOL HCL ER 100 MG TABLET 1 tablet / dayTRAMADOL HCL ER 200 MG CAPSULE 1 capsule / dayTRAMADOL HCL ER 200 MG TABLET 1 tablet / dayTRAMADOL HCL ER 300 MG CAPSULE 1 capsule / dayTRAMADOL HCL ER 300 MG TABLET 1 tablet / dayXTAMPZA ER 13.5 MG CAPSULE 2 capsules / dayXTAMPZA ER 18 MG CAPSULE 2 capsules / dayXTAMPZA ER 27 MG CAPSULE 2 capsules / dayXTAMPZA ER 36 MG CAPSULE 2 capsules / dayXTAMPZA ER 9 MG CAPSULE 2 capsules / dayZOHYDRO ER 10 MG CAPSULE 2 capsules / dayZOHYDRO ER 15 MG CAPSULE 2 capsules / dayZOHYDRO ER 20 MG CAPSULE 2 capsules / dayZOHYDRO ER 30 MG CAPSULE 2 capsules / dayZOHYDRO ER 40 MG CAPSULE 2 capsules / dayZOHYDRO ER 50 MG CAPSULE 2 capsules / day

Long-Acting Opioid Analgesics (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

AZITHROMYCIN 250 MG TABLET 6 tabs / 5 daysAZITHROMYCIN 500 MG TABLET 3 tabs / 3 daysCLARITHROMYCIN 250 MG TABLET 28 tabs / 14 daysCLARITHROMYCIN 500 MG TABLET 28 tabs / 14 daysCLARITHROMYCIN ER 500 MG TAB 14 tabs / 14 daysZITHROMAX 250 MG TABLET 6 tabs / 5 daysZITHROMAX 250 MG Z-PAK TABLET 6 tabs / 5 daysZITHROMAX 500 MG TABLET 3 tabs / 3 daysZITHROMAX TRI-PAK 500 MG TAB 3 tabs / 3 days

AUBAGIO 14 MG TABLET 1 tablet / dayAUBAGIO 7 MG TABLET 1 tablet / dayAVONEX PEN 30 MCG/0.5 ML KIT 4 kits / 30 daysAVONEX PREFILLED SYR 30 MCG KIT 4 kits / 30 daysBAFIERTAM DR 95 MG CAPSULE 4 capsules / dayBETASERON 0.3 MG KIT 15 kits / 30 daysBETASERON 0.3 MG KIT 15 kits / 30 daysCOPAXONE 20 MG/ML SYRINGE 30 syringes / 30 daysCOPAXONE 40 MG/ML SYRINGE 12 syringes / 30 daysDIMETHYL FUMARATE DR 120 MG CP 4 capsules / dayDIMETHYL FUMARATE DR 240 MG CP 2 capsules / dayEXTAVIA 0.3 MG KIT 15 kits / 30 daysEXTAVIA 0.3 MG VIAL 4 vials/ 30 daysGILENYA 0.5 MG CAPSULE 1 capsule / dayGLATIRAMER 20 MG/ML SYRINGE 30 syringes / 30 daysGLATIRAMER 40 MG/ML SYRINGE 12 syringes / 30 daysGLATOPA 20 MG/ML SYRINGE 30 syringes / 30 daysGLATOPA 40 MG/ML SYRINGE 12 syringes / 30 daysMAYZENT 2 MG TABLET 1 tablet / dayPLEGRIDY 125 MCG/0.5 ML PEN 2 pens/ 30 daysPLEGRIDY 125 MCG/0.5 ML SYRING 2 syringes / 30 daysPLEGRIDY PEN INJ STARTER PACK 2 pens / 30 daysPLEGRIDY SYRINGE STARTER PACK 2 syringes / 30 daysPONVORY 14-DAY STARTER PACK 14 tabs / 14 daysPONVORY 20 MG TABLET 1 tablet / dayREBIF 22 MCG/0.5 ML SYRINGE 6 mL / 30 daysREBIF 44 MCG/0.5 ML SYRINGE 6 mL / 30 daysREBIF REBIDOSE 22 MCG/0.5 ML 6 mL / 30 daysREBIF REBIDOSE 44 MCG/0.5 ML 6 mL / 30 daysREBIF REBIDOSE TITRATION PACK 6 mL / 30 days

Macrolides

Multiple Sclerosis Agents

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

REBIF TITRATION PACK 6 mL / 30 daysTECFIDERA DR 120 MG CAPSULE 4 capsules / dayTECFIDERA DR 240 MG CAPSULE 2 capsules / dayVUMERITY DR 231 MG CAPSULE 4 capsules / dayZEPOSIA 0.92 MG CAPSULE 1 capsule / day

BECONASE AQ 0.042% SPRAY 3 nasal inhalers / 90 daysFLUNISOLIDE 0.025% SPRAY 3 nasal inhalers / 90 daysFLUTICASONE PROP 50 MCG SPRAY 3 nasal inhalers / 90 daysMOMETASONE FUROATE 50 MCG SPRY 3 nasal inhalers / 90 daysNASONEX 50 MCG NASAL SPRAY 3 nasal inhalers / 90 daysOMNARIS 50 MCG NASAL SPRAY 3 nasal inhalers / 90 daysQNASL 80 MCG NASAL SPRAY 3 nasal inhalers / 90 daysQNASL CHILDREN'S 40 MCG SPRAY 3 nasal inhalers / 90 daysXHANCE 93 MCG EXHALATION DELIVERY NASAL SPRAY 3 nasal inhalers / 90 daysZETONNA 37 MCG NASAL SPRAY 3 nasal inhalers / 90 days

ACIPHEX DR 20 MG TABLET 90 tablets / 90 daysACIPHEX SPRINKLE DR 10 MG CAP 90 capsules / 90 daysACIPHEX SPRINKLE DR 5 MG CAP 90 capsules / 90 daysDEXILANT DR 30 MG CAPSULE 90 capsules / 90 daysDEXILANT DR 60 MG CAPSULE 90 capsules / 90 daysESOMEPRAZOLE DR 10 MG PACKET 90 packets / 90 daysESOMEPRAZOLE DR 20 MG PACKET 90 packets / 90 daysESOMEPRAZOLE DR 40 MG PACKET 90 packets / 90 daysESOMEPRAZOLE MAG DR 20 MG CAP 90 capsules / 90 daysESOMEPRAZOLE MAG DR 40 MG CAP 90 capsules / 90 daysLANSOPRAZOLE DR 15 MG CAPSULE 90 capsules / 90 daysLANSOPRAZOLE DR 30 MG CAPSULE 90 capsules / 90 daysLANSOPRAZOLE ODT 15 MG TABLET 90 tablets / 90 daysLANSOPRAZOLE ODT 30 MG TABLET 90 tablets / 90 daysNEXIUM DR 10 MG PACKET 90 packets / 90 daysNEXIUM DR 2.5 MG PACKET 90 packets / 90 daysNEXIUM DR 20 MG CAPSULE 90 capsules / 90 daysNEXIUM DR 20 MG PACKET 90 packets / 90 daysNEXIUM DR 40 MG CAPSULE 90 capsules / 90 daysNEXIUM DR 40 MG PACKET 90 packets / 90 daysNEXIUM DR 5 MG PACKET 90 packets / 90 daysOMEPRAZOLE DR 10 MG CAPSULE 90 capsules / 90 days

Proton Pump Inhibitors

Nasal Glucocorticoids

Multiple Sclerosis Agents (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

OMEPRAZOLE DR 20 MG CAPSULE 90 capsules / 90 daysOMEPRAZOLE DR 40 MG CAPSULE 90 capsules / 90 daysOMEPRAZOLE-BICARB 20-1,100 CAP 90 capsules / 90 daysOMEPRAZOLE-BICARB 20-1,680 PKT 90 packets / 90 daysOMEPRAZOLE-BICARB 40-1,100 CAP 90 capsules / 90 daysOMEPRAZOLE-BICARB 40-1,680 PKT 90 packets / 90 daysPANTOPRAZOLE 40 MG SUSPENSION 90 / 90 daysPANTOPRAZOLE SOD DR 20 MG TAB 90 tablets / 90 daysPANTOPRAZOLE SOD DR 40 MG TAB 90 tablets / 90 daysPREVACID 15 MG SOLUTAB 90 tablets / 90 daysPREVACID 30 MG SOLUTAB 90 tablets / 90 daysPREVACID DR 30 MG CAPSULE 90 capsules / 90 daysPRILOSEC DR 10 MG SUSPENSION 90 packets / 90 daysPRILOSEC DR 2.5 MG SUSPENSION 90 packets / 90 daysPROTONIX 40 MG SUSPENSION 90 packets / 90 daysPROTONIX DR 20 MG TABLET 90 tablets / 90 daysPROTONIX DR 40 MG TABLET 90 tablets / 90 daysRABEPRAZOLE SOD DR 20 MG TAB 90 tablets / 90 daysZEGERID 20 MG CAPSULE 90 capsules / 90 daysZEGERID 20 MG PACKET 90 packets / 90 daysZEGERID 40 MG CAPSULE 90 capsules / 90 daysZEGERID 40 MG PACKET 90 packets / 90 days

ADCIRCA 20 MG TABLET 2 tablets / dayALYQ 20 MG TABLET 2 tablets / dayREVATIO 20 MG TABLET 3 tablets / daySILDENAFIL 20 MG TABLET 3 tablets / dayTADALAFIL 20 MG TABLET 2 tablets / day

BAXDELA 450 MG TABLET 28 tablets / 14 daysCIPRO 250 MG TABLET 28 tablets / 14 daysCIPRO 500 MG TABLET 28 tablets / 14 daysCIPROFLOXACIN HCL 100 MG TAB 6 tablets / 3 daysCIPROFLOXACIN HCL 250 MG TAB 28 tablets / 14 daysCIPROFLOXACIN HCL 500 MG TAB 28 tablets / 14 daysCIPROFLOXACIN HCL 750 MG TAB 28 tablets / 14 daysLEVOFLOXACIN 250 MG TABLET 10 tablets / 10 daysLEVOFLOXACIN 500 MG TABLET 14 tablets / 14 daysLEVOFLOXACIN 750 MG TABLET 14 tablets / 14 days

Quinolones

Pulmonary Hypertension Agents

Proton Pump Inhibitors (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

MOXIFLOXACIN HCL 400 MG TABLET 10 tablets / 10 daysOFLOXACIN 300 MG TABLET 14 tablets / 14 daysOFLOXACIN 400 MG TABLET 28 tablets / 14 days

ARMONAIR DIGIHALER 232 MCG 3 inhalers / 90 daysARMONAIR DIGIHALER 113 MCG 3 inhalers / 90 daysARMONAIR DIGIHALER 55 MCG 3 inhalers / 90 daysASMANEX HFA 50 MCG INHALER 3 inhalers / 90 daysARNUITY ELLIPTA 50 MCG INH 3 kits / 90 daysQVAR REDIHALER 80 MCG 3 inhalers / 90 daysQVAR REDIHALER 40 MCG 3 inhalers / 90 daysASMANEX HFA 100 MCG INHALER 3 inhalers / 90 daysASMANEX HFA 200 MCG INHALER 3 inhalers / 90 daysARNUITY ELLIPTA 200 MCG INH 3 kits / 90 daysARNUITY ELLIPTA 100 MCG INH 3 kits / 90 daysASMANEX TWISTHALER 110 MCG #30 3 inhalers / 90 daysPULMICORT 180 MCG FLEXHALER 6 inhalers / 90 daysPULMICORT 90 MCG FLEXHALER 6 inhalers / 90 daysASMANEX TWISTHALER 220 MCG #60 3 inhalers / 90 daysASMANEX TWISTHALER 220 MCG #30 3 inhalers / 90 daysALVESCO 160 MCG INHALER 6 inhalers / 90 daysALVESCO 80 MCG INHALER 6 inhalers / 90 daysASMANEX TWISTHALR 220 MCG #120 3 inhalers / 90 daysBUDESONIDE 0.5 MG/2 ML SUSP 180 respules / 90 daysPULMICORT 0.5 MG/2 ML RESPULE 180 respules / 90 daysBUDESONIDE 0.25 MG/2 ML SUSP 180 respules / 90 daysPULMICORT 0.25 MG/2 ML RESPUL 180 respules / 90 daysFLOVENT HFA 220 MCG INHALER 3 inhalers / 90 daysFLOVENT HFA 44 MCG INHALER 3 inhalers / 90 daysFLOVENT HFA 110 MCG INHALER 3 inhalers / 90 daysFLOVENT 50 MCG DISKUS 3 inhalers / 90 daysFLOVENT 250 MCG DISKUS 3 inhalers / 90 daysFLOVENT 100 MCG DISKUS 3 inhalers / 90 daysBUDESONIDE 1 MG/2 ML INH SUSP 90 respules / 90 daysPULMICORT 1 MG/2 ML RESPULE 90 respules / 90 daysYUPELRI 175 MCG/3 ML SOLUTION 9 mL / 90 daysLONHALA MAGNAIR 25 MCG REFILL 3 kits / 90 daysLONHALA MAGNAIR 25 MCG STARTER 1 kit / 180 daysSPIRIVA RESPIMAT 1.25 MCG INH 3 inhalers / 90 daysINCRUSE ELLIPTA 62.5 MCG INH 3 inhalers / 90 days

Quinolones (continued)

Respiratory Agents

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Drug Quantity Limit

TUDORZA PRESSAIR 400 MCG INHAL 3 inhalers / 90 daysSPIRIVA RESPIMAT 2.5 MCG INH 3 inhalers / 90 daysSPIRIVA 18 MCG CP-HANDIHALER 90 capsules / 90 days

ADDERALL 10 MG TABLET 3 tablets / dayADDERALL 12.5 MG TABLET 3 tablets / dayADDERALL 15 MG TABLET 3 tablets / dayADDERALL 20 MG TABLET 3 tablets / dayADDERALL 30 MG TABLET 2 tablets / dayADDERALL 5 MG TABLET 3 tablets / dayADDERALL 7.5 MG TABLET 3 tablets / dayADDERALL XR 10 MG CAPSULE 1 capsule / dayADDERALL XR 15 MG CAPSULE 1 capsule / dayADDERALL XR 20 MG CAPSULE 1 capsule / dayADDERALL XR 25 MG CAPSULE 1 capsule / dayADDERALL XR 30 MG CAPSULE 1 capsule / dayADDERALL XR 5 MG CAPSULE 1 capsule / dayADHANSIA XR 25 MG CAPSULE 1 capsule / dayADHANSIA XR 35 MG CAPSULE 1 capsule / dayADHANSIA XR 45 MG CAPSULE 1 capsule / dayADHANSIA XR 55 MG CAPSULE 1 capsule / dayADHANSIA XR 70 MG CAPSULE 1 capsule / dayADHANSIA XR 85 MG CAPSULE 1 capsule / dayADZENYS XR-ODT 12.5 MG TABLET 1 tablet / dayADZENYS XR-ODT 15.7 MG TABLET 1 tablet / dayADZENYS XR-ODT 18.8 MG TABLET 1 tablet / dayADZENYS XR-ODT 3.1 MG TABLET 1 tablet / dayADZENYS XR-ODT 6.3 MG TABLET 1 tablet / dayADZENYS XR-ODT 9.4 MG TABLET 1 tablet / dayAMPHETAMINE SULFATE 10 MG TAB 6 tablets / dayAMPHETAMINE SULFATE 5 MG TAB 3 tablets / dayAPTENSIO XR 10 MG CAPSULE 1 capsule / dayAPTENSIO XR 15 MG CAPSULE 1 capsule / dayAPTENSIO XR 20 MG CAPSULE 1 capsule / dayAPTENSIO XR 30 MG CAPSULE 1 capsule / dayAPTENSIO XR 40 MG CAPSULE 1 capsule / dayAPTENSIO XR 50 MG CAPSULE 1 capsule / dayAPTENSIO XR 60 MG CAPSULE 1 capsule / dayARMODAFINIL 150 MG TABLET 1 tablet / dayARMODAFINIL 200 MG TABLET 1 tablet / day

Respiratory Agents (continued)

Stimulants and Related Agents

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

ARMODAFINIL 250 MG TABLET 1 tablet / dayARMODAFINIL 50 MG TABLET 2 tablets / dayATOMOXETINE HCL 10 MG CAPSULE 1 capsule / dayATOMOXETINE HCL 100 MG CAPSULE 1 capsule / dayATOMOXETINE HCL 18 MG CAPSULE 1 capsule / dayATOMOXETINE HCL 25 MG CAPSULE 1 capsule / dayATOMOXETINE HCL 40 MG CAPSULE 1 capsule / dayATOMOXETINE HCL 60 MG CAPSULE 1 capsule / dayATOMOXETINE HCL 80 MG CAPSULE 1 capsule / dayAZSTARYS 26.1 MG-5.2 MG CAP 1 capsule / dayAZSTARYS 39.2 MG-7.8 MG CAP 1 capsule / dayAZSTARYS 52.3 MG-10.4 MG CAP 1 capsule / dayCONCERTA ER 18 MG TABLET 1 tablet / dayCONCERTA ER 27 MG TABLET 1 capsule / dayCONCERTA ER 36 MG TABLET 2 tablets / dayCONCERTA ER 54 MG TABLET 1 tablet / dayCOTEMPLA XR-ODT 17.3 MG TABLET 2 tablets / dayCOTEMPLA XR-ODT 25.9 MG TABLET 2 tablets / dayCOTEMPLA XR-ODT 8.6 MG TABLET 2 tablets / dayDAYTRANA 10 MG/9 HR PATCH 1 patch / dayDAYTRANA 15 MG/9 HR PATCH 1 patch / dayDAYTRANA 20 MG/9 HOUR PATCH 1 patch / dayDAYTRANA 30 MG/9 HOUR PATCH 1 patch / dayDESOXYN 5 MG TABLET 5 tablets / dayDEXEDRINE SPANSULE 10 MG 1 capsule / dayDEXEDRINE SPANSULE 15 MG 4 capsules / dayDEXEDRINE SPANSULE 5 MG 1 capsule / dayDEXMETHYLPHENIDATE 10 MG TAB 2 tablets / dayDEXMETHYLPHENIDATE 2.5 MG TAB 2 tablets / dayDEXMETHYLPHENIDATE 5 MG TAB 2 tablets / dayDEXMETHYLPHENIDATE ER 10 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 15 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 20 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 25 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 30 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 35 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 40 MG CP 1 capsule / dayDEXMETHYLPHENIDATE ER 5 MG CAP 1 capsule / dayDEXTROAMP-AMPHET ER 10 MG CAP 1 capsule / dayDEXTROAMP-AMPHET ER 15 MG CAP 1 capsule / dayDEXTROAMP-AMPHET ER 20 MG CAP 1 capsule / day

Stimulants and Related Agents (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

DEXTROAMP-AMPHET ER 25 MG CAP 1 capsule / dayDEXTROAMP-AMPHET ER 30 MG CAP 1 capsule / dayDEXTROAMP-AMPHET ER 5 MG CAP 1 capsule / dayDEXTROAMP-AMPHETAM 12.5 MG TAB 3 tablets / dayDEXTROAMP-AMPHETAM 7.5 MG TAB 3 tablets / dayDEXTROAMP-AMPHETAMIN 10 MG TAB 3 tablets / dayDEXTROAMP-AMPHETAMIN 15 MG TAB 3 tablets / dayDEXTROAMP-AMPHETAMIN 20 MG TAB 3 tablets / dayDEXTROAMP-AMPHETAMIN 30 MG TAB 2 tablets / dayDEXTROAMP-AMPHETAMINE 5 MG TAB 3 tablets / dayDEXTROAMPHETAMINE 10 MG TAB 3 tablets / dayDEXTROAMPHETAMINE 15 MG TAB 3 tablets / dayDEXTROAMPHETAMINE 20 MG TAB 3 tablets / dayDEXTROAMPHETAMINE 30 MG TAB 3 tablets / dayDEXTROAMPHETAMINE 5 MG TAB 3 tablets / dayDEXTROAMPHETAMINE ER 10 MG CAP 1 capsule / dayDEXTROAMPHETAMINE ER 15 MG CAP 4 capsules / dayDEXTROAMPHETAMINE ER 5 MG CAP 1 capsule / dayEVEKEO 10 MG TABLET 6 tablets / dayEVEKEO 5 MG TABLET 3 tablets / dayEVEKEO ODT 10 MG 3 tablets / dayEVEKEO ODT 15 MG 2 tablets / dayEVEKEO ODT 20 MG 3 tablets / dayEVEKEO ODT 5 MG 2 tablets / dayFOCALIN 10 MG TABLET 2 tablets / dayFOCALIN 2.5 MG TABLET 2 tablets / dayFOCALIN 5 MG TABLET 2 tablets / dayFOCALIN XR 10 MG CAPSULE 1 capsule / dayFOCALIN XR 15 MG CAPSULE 1 capsule / dayFOCALIN XR 20 MG CAPSULE 1 capsule / dayFOCALIN XR 25 MG CAPSULE 1 capsule / dayFOCALIN XR 30 MG CAPSULE 1 capsule / dayFOCALIN XR 35 MG CAPSULE 1 capsule / dayFOCALIN XR 40 MG CAPSULE 1 capsule / dayFOCALIN XR 5 MG CAPSULE 1 capsule / dayGUANFACINE HCL ER 1 MG TABLET 1 tablet / dayGUANFACINE HCL ER 2 MG TABLET 1 tablet / dayGUANFACINE HCL ER 3 MG TABLET 1 tablet / dayGUANFACINE HCL ER 4 MG TABLET 1 tablet / dayINTUNIV ER 1 MG TABLET 1 tablet / dayINTUNIV ER 2 MG TABLET 1 tablet / day

Stimulants and Related Agents (continued)

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Drug Quantity Limit

INTUNIV ER 3 MG TABLET 1 tablet / dayINTUNIV ER 4 MG TABLET 1 tablet / dayJORNAY PM 100 MG CAPSULE 1 capsule / dayJORNAY PM 20 MG CAPSULE 1 capsule / dayJORNAY PM 40 MG CAPSULE 1 capsule / dayJORNAY PM 60 MG CAPSULE 1 capsule / dayJORNAY PM 80 MG CAPSULE 1 capsule / dayMETADATE ER 20 MG TABLET 3 tablets / dayMETHAMPHETAMINE 5 MG TABLET 5 tablets / dayMETHYLPHENIDATE 10 MG CHEW TAB 6 tablets / dayMETHYLPHENIDATE 10 MG TABLET 3 tablets / dayMETHYLPHENIDATE 2.5 MG CHEW TB 3 tablets / dayMETHYLPHENIDATE 20 MG TABLET 3 tablets / dayMETHYLPHENIDATE 5 MG CHEW TAB 3 tablets / dayMETHYLPHENIDATE 5 MG TABLET 3 tablets / dayMETHYLPHENIDATE CD 10 MG CAP 1 capsule / dayMETHYLPHENIDATE CD 20 MG CAP 1 capsule / dayMETHYLPHENIDATE CD 30 MG CAP 1 capsule / dayMETHYLPHENIDATE CD 40 MG CAP 1 capsule / dayMETHYLPHENIDATE CD 50 MG CAP 1 capsule / dayMETHYLPHENIDATE CD 60 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 10 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 10 MG TAB 3 tablets / dayMETHYLPHENIDATE ER 15 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 18 MG TAB 1 tablet / dayMETHYLPHENIDATE ER 20 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 20 MG TAB 3 tablets / dayMETHYLPHENIDATE ER 27 MG TAB 1 capsule / dayMETHYLPHENIDATE ER 30 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 36 MG TAB 2 tablets / dayMETHYLPHENIDATE ER 40 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 50 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 54 MG TAB 1 tablet / dayMETHYLPHENIDATE ER 60 MG CAP 1 capsule / dayMETHYLPHENIDATE ER 72 MG TAB 1 tablet / dayMETHYLPHENIDATE ER(CD) 10 MG CP 1 capsule / dayMETHYLPHENIDATE ER(CD) 20 MG CP 1 capsule / dayMETHYLPHENIDATE ER(CD) 30 MG CP 1 capsule / dayMETHYLPHENIDATE ER(CD) 40 MG CP 1 capsule / dayMETHYLPHENIDATE ER(CD) 50 MG CP 1 capsule / dayMETHYLPHENIDATE ER(CD) 60 MG CP 1 capsule / day

Stimulants and Related Agents (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

METHYLPHENIDATE ER(LA) 10 MG CP 1 capsule / dayMETHYLPHENIDATE ER(LA) 20 MG CP 1 capsule / dayMETHYLPHENIDATE ER(LA) 30 MG CP 2 capsules / dayMETHYLPHENIDATE ER(LA) 40 MG CP 1 capsule / dayMETHYLPHENIDATE LA 10 MG CAP 1 capsule / dayMETHYLPHENIDATE LA 20 MG CAP 1 capsule / dayMETHYLPHENIDATE LA 30 MG CAP 2 capsules / dayMETHYLPHENIDATE LA 40 MG CAP 1 capsule / dayMETHYLPHENIDATE LA 60 MG CAP 1 tablet / dayMODAFINIL 100 MG TABLET 3 tablets / dayMODAFINIL 200 MG TABLET 2 tablets / dayMYDAYIS ER 12.5 MG CAPSULE 1 capsule / dayMYDAYIS ER 25 MG CAPSULE 1 capsule / dayMYDAYIS ER 37.5 MG CAPSULE 1 capsule / dayMYDAYIS ER 50 MG CAPSULE 1 capsule / dayNUVIGIL 150 MG TABLET 1 tablet / dayNUVIGIL 200 MG TABLET 1 tablet / dayNUVIGIL 250 MG TABLET 1 tablet / dayNUVIGIL 50 MG TABLET 2 tablets / dayPROVIGIL 100 MG TABLET 3 tablets / dayPROVIGIL 200 MG TABLET 2 tablets / dayQELBREE ER 100 MG CAPSULE 1 capsule / dayQELBREE ER 150 MG CAPSULE 1 capsule / dayQELBREE ER 200 MG CAPSULE 2 capsules / dayQUILLICHEW ER 20 MG CHEW TAB 3 tablets / dayQUILLICHEW ER 30 MG CHEW TAB 2 tablets / dayQUILLICHEW ER 40 MG CHEW TAB 1 tablet / dayRELEXXII ER 72 MG TABLET 1 tablet / dayRITALIN 10 MG TABLET 3 tablets / dayRITALIN 20 MG TABLET 3 tablets / dayRITALIN 5 MG TABLET 3 tablets / dayRITALIN LA 10 MG CAPSULE 1 capsule / dayRITALIN LA 20 MG CAPSULE 1 capsule / dayRITALIN LA 30 MG CAPSULE 2 capsules / dayRITALIN LA 40 MG CAPSULE 1 capsule / daySTRATTERA 10 MG CAPSULE 1 capsule / daySTRATTERA 100 MG CAPSULE 1 capsule / daySTRATTERA 18 MG CAPSULE 1 capsule / daySTRATTERA 25 MG CAPSULE 1 capsule / daySTRATTERA 40 MG CAPSULE 1 capsule / daySTRATTERA 60 MG CAPSULE 1 capsule / day

Stimulants and Related Agents (continued)

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New Hampshire Medicaid Quantity Limit ProgramEffective 1/1/2022

Drug Quantity Limit

STRATTERA 80 MG CAPSULE 1 capsule / daySUNOSI 150 MG TABLET 1 tablet / daySUNOSI 75 MG TABLET 1 tablet / dayVYVANSE 10 MG CAPSULE 1 capsule / dayVYVANSE 10 MG CHEWABLE TABLET 1 tablet / dayVYVANSE 20 MG CAPSULE 1 capsule / dayVYVANSE 20 MG CHEWABLE TABLET 1 tablet / dayVYVANSE 30 MG CAPSULE 1 capsule / dayVYVANSE 30 MG CHEWABLE TABLET 1 tablet / dayVYVANSE 40 MG CAPSULE 1 capsule / dayVYVANSE 40 MG CHEWABLE TABLET 1 tablet / dayVYVANSE 50 MG CAPSULE 1 capsule / dayVYVANSE 50 MG CHEWABLE TABLET 1 tablet / dayVYVANSE 60 MG CAPSULE 1 capsule / dayVYVANSE 60 MG CHEWABLE TABLET 1 tablet / dayVYVANSE 70 MG CAPSULE 1 capsule / dayZENZEDI 10 MG TABLET 3 tablets / dayZENZEDI 15 MG TABLET 3 tablets / dayZENZEDI 2.5 MG TABLET 3 tablets / dayZENZEDI 2.5 MG TABLET 3 tablets / dayZENZEDI 20 MG TABLET 3 tablets / dayZENZEDI 30 MG TABLET 3 tablets / dayZENZEDI 5 MG TABLET 3 tablets / dayZENZEDI 7.5 MG TABLET 3 tablets / day

ARAVA 10 MG TABLET 1 tablet / dayARAVA 20 MG TABLET 1 tablet / dayLEFLUNOMIDE 10 MG TABLET 1 tablet / dayLEFLUNOMIDE 20 MG TABLET 1 tablet / dayOLUMIANT 1 MG TABLET 1 tablet / dayOLUMIANT 2 MG TABLET 1 tablet / dayOTEZLA 30 MG TABLET 2 tablets / dayOTEZLA STARTER PACK 2 tablets / dayRINVOQ ER 15 MG TABLET 1 tablet / dayXELJANZ 1 MG/ML SOLUTION 10 mL / dayXELJANZ 10 MG TABLET 2 tablets / dayXELJANZ 5 MG TABLET 2 tablets / dayXELJANZ XR 11 MG TABLET 1 tablet / dayXELJANZ XR 22 MG TABLET 1 tablet / day

Stimulants and Related Agents (continued)

Systemic Immunomodulators, Oral

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