Advantage Prescription Drug Benefits

Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the Advantage formulary for the full list of drugs covered under your plan.


Key:

UPPERCASE names = Brand

lowercase names = Generic

Guide to Prescription Drug Benefits

Your prescription drug coverage is one of the most important parts of your health plan.

Use this guide to understand how your benefits work.

Drug Name(s)

abiraterone acetate1 ABSTRAL ACIPHEX
ACTEMRA1 ACTIQ ADCIRCA1
ADDERALL ADDERALL XR ADEMPAS1, 2
ADHANSIA XR ADIPEX-P ADMELOG
ADMELOG SOLOSTAR ADZENYS ER ADZENYS XR-ODT
AFINITOR1 AFINITOR DISPERZ1 AFREZZA
AIMOVIG1 AJOVY1 ALDARA
ALECENSA1, 2 alosetron hydrochloride ALUNBRIG1, 2
alyq1 AMBIEN AMBIEN CR
ambrisentan1 AMITIZA AMPHETAMINE ER
AMPYRA1 AMRIX ANAFRANIL
ANDRODERM ANDROGEL ANDROGEL PUMP
ANDROID APIDRA APIDRA SOLOSTAR
APLENZIN APTENSIO XR ARCALYST1, 2
ARIKAYCE1, 2 armodafinil ARYMO ER
ATRALIN AUBAGIO1 AUSTEDO1
AUVI-Q avita AVONEX1
BALVERSA1, 2 BECONASE AQ BELBUCA
BELSOMRA BELVIQ BELVIQ XR
BENLYSTA1 benzphetamine hcl BETASERON1
BETHKIS1 bexarotene1 bosentan1
BOSULIF1 BRAFTOVI1, 2 BUPHENYL1
buprenorphine BUPROPION HYDROCHLORIDE ER (XL) BUTRANS
CABOMETYX1 CALQUENCE1, 2 capecitabine1
CAPRELSA1, 2 CARAC CARBAGLU1, 2
CAYSTON1 CELEXA CERDELGA1
CETROTIDE1 CHORIONIC GONADOTROPIN1 ciclodan
ciclopirox nail lacquer CIMZIA1 CIMZIA STARTER KIT1
cinacalcet hydrochloride1 clomipramine hydrochloride COMETRIQ1, 2
CONCERTA CONTRAVE CONZIP
COPAXONE1 COPIKTRA1, 2 CORLANOR
COSENTYX1 COSENTYX SENSOREADY PEN1 COTELLIC1
COTEMPLA XR-ODT CRINONE CUTAQUIG1, 2
CUVITRU1, 2 cyclobenzaprine hydrochloride er CYMBALTA
DAKLINZA1 dalfampridine er1 DARAPRIM
DAURISMO1 DAYTRANA DEPO-TESTOSTERONE
DESOXYN DESVENLAFAXINE ER DICLEGIS
diclofenac sodium gel DIETHYLPROPION HCL diethylpropion hcl er
diethylpropion hydrochloride DIETHYLPROPION HCL ER DOLOPHINE
doxylamine succinate/pyridoxine hydrochloride DUEXIS DUPIXENT1
DURAGESIC DUZALLO DYANAVEL XR
DYMISTA EDLUAR EFFEXOR XR
EFUDEX EGRIFTA1 EGRIFTA SV1
EMBEDA EMFLAZA1, 2 EMGALITY1
EMSAM ENBREL1 ENBREL MINI1
ENBREL SURECLICK1 ENDARI1, 2 ENDOMETRIN
EPCLUSA1 EPIDIOLEX1 EPINEPHRINE
EPIPEN 2-PAK EPIPEN-JR 2-PAK ERIVEDGE1
erlotinib hydrochloride1 ESBRIET1 EVEKEO
everolimus1 EVZIO EXALGO
EXTAVIA1 FABIOR FARYDAK1
fentanyl FENTANYL CITRATE fentanyl citrate oral transmucosal
FENTORA FETZIMA FETZIMA TITRATION PACK
FEXMID FIRAZYR1 FIRDAPSE1, 2
FLUNISOLIDE FLUOROPLEX FLUOROURACIL
FLUOXETINE FLUOXETINE DR FLUOXETINE HYDROCHLORIDE
FOCALIN FOCALIN XR FORFIVO XL
FORTAMET FORTEO1 FORTESTA
GALAFOLD1 ganirelix acetate1 GATTEX1, 2
GENOTROPIN1 GENOTROPIN MINIQUICK1 GILENYA1
GILOTRIF1, 2 glatiramer acetate1 glatopa1
GLUCOPHAGE GLUCOPHAGE XR GLUMETZA
GOCOVRI1 GRANIX1 HAEGARDA1, 2
HARVONI1 HELIXATE FS1 HEMLIBRA1
HETLIOZ1, 2 HIZENTRA1 HUMALOG
HUMALOG JUNIOR KWIKPEN HUMALOG KWIKPEN HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN
HUMIRA1 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1 HUMIRA PEN1
HUMIRA PEN-CD/UC/HS STARTER1 HUMULIN 70/30 HUMULIN 70/30 KWIKPEN
HUMULIN N HUMULIN N KWIKPEN HUMULIN R
HYCAMTIN1 hydrocodone bitartrate er hydromorphone hydrochloride
hydromorphone hydrochloride er HYQVIA1 HYSINGLA ER
IBRANCE1 icatibant acetate1 ICLUSIG1, 2
IDHIFA1 IMBRUVICA1, 2 IMIQUIMOD PUMP
INGREZZA1, 2 INLYTA1 INREBIC1
INSULIN LISPRO INSULIN LISPRO KWIKPEN INTERMEZZO
INTRON A1 INTUNIV IRESSA1, 2
JAKAFI1 JORNAY PM JUBLIA
JUXTAPID1, 2 KADIAN KALYDECO1
KAPVAY KERYDIN KEVEYIS1, 2
KEVZARA1 KHEDEZLA KINERET1, 2
KISQALI1 KISQALI FEMARA1 KITABIS PAK1
KOGENATE FS1 KOGENATE FS BIO-SET1 KORLYM1, 2
KUVAN1 KYNAMRO1 LAZANDA
LEDIPASVIR/SOFOSBUVIR1 LENVIMA 10 MG DAILY DOSE1, 2 LETAIRIS1
LEXAPRO lidocaine pad LIDODERM
LOMAIRA LONSURF1 LORBRENA1
LORZONE LOTRONEX LUNESTA
LYNPARZA1, 2 LYRICA CR MAVENCLAD1
MAVYRET1 MAYZENT1 MEKINIST1
MEKTOVI1, 2 metaxall METAXALONE
metaxalone METFORMIN HYDROCHLORIDE soln metformin hydrochloride er
methadone hcl methadone hydrochloride METHITEST
METHYLIN SOLN METHYLPHENIDATE HYDROCHLORIDE ER METHYLTESTOSTERONE
miglustat1 MINOCIN modafinil
mometasone furoate MORPHABOND ER morphine sulfate er
MORPHINE SULFATE ER MOTEGRITY MS CONTIN ER
MULPLETA1 MYALEPT1, 2 MYDAYIS
NAPROSYN NASONEX NATESTO
NATPARA1 NERLYNX1, 2 NEULASTA1
NEULASTA ONPRO KIT1 NEXIUM NINLARO1
NOCTIVA NORDITROPIN FLEXPRO1 NORTHERA1
NOVAREL1 NUBEQA1 NUCYNTA ER
NUPLAZID1 NUTROPIN AQ NUSPIN1 NUVIGIL
OCALIVA1 ODOMZO1 OFEV1
OLUMIANT1 OLYSIO1 omeppi
omeprazole/sodium bicarbonate OMNARIS OMNITROPE1
OPANA OPANA ER (CRUSH RESISTANT) OPSUMIT1, 2
ORENCIA1 ORENCIA CLICKJECT1 ORENITRAM1, 2
ORILISSA ORKAMBI1 OTEZLA1
OXERVATE1, 2 OXYCODONE HYDROCHLORIDE ER OXYCONTIN
oxymorphone hydrochloride OXYMORPHONE HYDROCHLORIDE ER PAXIL
PAXIL CR PEGINTRON1 PENLAC NAIL LACQUER
PEXEVA phendimetrazine tartrate PHENDIMETRAZINE TARTRATE ER
PHENDIMETRAZINE TARTRATE SR phentermine hydrochloride PICATO
PIQRAY1 PLEGRIDY1 PLEGRIDY STARTER PACK1
POMALYST1 PRALUENT1 PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1
PREVACID PRIMLEV PRISTIQ
PROCRIT1 PROCYSBI1, 2 PROMACTA1
PROTONIX PROVIGIL PROZAC
QBREXZA QNASL QNASL CHILDRENS
QSYMIA QUDEXY XR ramelteon
RAVICTI1 RAYOS REBIF1
REBIF REBIDOSE1 REBIF REBIDOSE TITRATION PACK1 REBIF TITRATION PACK1
REGIMEX REGRANEX RELEXXII
RELISTOR REPATHA1 REPATHA PUSHTRONEX SYSTEM1
REPATHA SURECLICK1 RESTASIS RESTASIS MULTIDOSE
RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP
REVATIO1 REVLIMID1 RINVOQ1
RIOMET RITALIN RITALIN LA
ROBAXIN ROZEREM ROZLYTREK1
RUBRACA1, 2 RUZURGI1, 2 RYDAPT1
SAMSCA1 SARAFEM SAXENDA
SENSIPAR1 SEROSTIM1 SEYSARA
SIGNIFOR1, 2 sildenafil citrate1 SILIQ1
SIMPONI1 SKELAXIN SKYRIZI1
sodium phenylbutyrate1 SOFOSBUVIR/VELPATASVIR1 SOMA
SOMAVERT1 SONATA SOVALDI1
STELARA1 STIMATE1 STIVARGA1
STRATTERA STRENSIQ1, 2 STRIANT
SUBSYS SUNOSI SUTENT1
SYLATRON1 SYMPROIC tadalafil1
TAFINLAR1 TAGRISSO1, 2 TAKHZYRO1, 2
TALTZ1 TALZENNA1 TARCEVA1
TARGRETIN1 tazarotene TAZORAC
TECFIDERA1 TECFIDERA STARTER PACK1 TECHNIVIE1
TEGSEDI1, 2 TESTIM testosterone
TESTOSTERONE TESTRED tetrabenazine1
THALOMID1 TIBSOVO1 TOBI1
TOBI PODHALER1 tobramycin1 TOLAK
TOPIRAMATE ER TRACLEER1 TRAMADOL HCL ER
tramadol hydrochloride er TREMFYA1 tretinoin
tretinoin microsphere tretinoin microsphere pump TRETIN-X
TRINTELLIX TROKENDI XR TRULANCE
TURALIO1, 2 TYMLOS1 UPTRAVI1, 2
VENCLEXTA STARTING PACK1, 2 VENCLEXTA1, 2 VENTAVIS1, 2
VERZENIO1, 2 VIBERZI VIEKIRA PAK1
VIEKIRA XR1 VIIBRYD VIIBRYD STARTER PACK
VIMOVO VITRAKVI1, 2 VIZIMPRO1
VOGELXO VOGELXO PUMP VOSEVI1
VOTRIENT1 VYLEESI VYNDAMAX1
VYNDAQEL1 WAKIX WELLBUTRIN SR
WELLBUTRIN XL XELJANZ1 XELJANZ XR1
XELODA1 XENAZINE1 XENICAL
XERMELO1, 2 XHANCE XIFAXAN
XIIDRA XOSPATA1, 2 XPOVIO 100 MG ONCE WEEKLY1, 2
XTAMPZA ER XTANDI1 XYNTHA1
XYNTHA SOLOFUSE1 XYOSTED XYREM1, 2
ZANAFLEX ZARXIO1 ZAVESCA1, 2
ZEGERID ZEJULA1, 2 ZELBORAF1
ZELNORM ZEPATIER1 ZETONNA
ZOHYDRO ER ZOLINZA1 ZOLOFT
ZOLPIMIST ZOMACTON1 ZORBTIVE1
ZTLIDO ZURAMPIC ZYCLARA
ZYCLARA PUMP ZYDELIG1, 2 ZYKADIA1
ZYTIGA1    

Drug Name(s)

ABILIFY ACCU-CHEK AVIVA PLUS ACCU-CHEK COMPACT PLUS
ACCU-CHEK COMPACT STRIPS ACCU-CHEK COMPACT TEST DRUM ACCU-CHEK GUIDE
ACCU-CHEK SMARTVIEW STRIPS ACCUTREND GLUCOSE ADLYXIN
ADLYXIN STARTER PACK ADVANCE INTUITION TEST STRIPS ADVANCE MICRO-DRAW TEST STRIPS
ADVOCATE REDI-CODE ADVOCATE REDI-CODE+ TEST STRIPS ADVOCATE TEST STRIPS
AGAMATRIX AMP NO CODE TEST STRIPS AGAMATRIX JAZZ TEST STRIPS AGAMATRIX KEYNOTE TEST STRIPS
AGAMATRIX PRESTO TEST STRIPS ALA SCALP ALOGLIPTIN
ALOGLIPTIN/METFORMIN HCL ALOGLIPTIN/PIOGLITAZONE ALTOPREV
AMCINONIDE AMERGE ANAPROX DS
APEXICON E ARTHROTEC ASSURE 3 TEST STRIPS
ASSURE 4 TEST STRIPS ASSURE II ASSURE II CHECK STRIP
ASSURE II TEST STRIPS ASSURE PLATINUM TEST STRIPS ASSURE PRISM MULTI TEST STRIPS
ASSURE PRO TEST STRIPS AT LAST TEST STRIPS ATACAND
ATACAND HCT AUGMENTED BETAMETHASONE DIPROPIONATE AVALIDE
AVAPRO AXERT AZOR
BENICAR BENICAR HCT BEPREVE
BETAMETHASONE DIPROPIONATE BIOSCANNER GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS
BLOOD GLUCOSE TEST STRIPS PREMIUM BYDUREON BYDUREON BCISE
BYDUREON PEN BYETTA BYVALSON
CAMBIA CAPEX CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM
CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE CARESENS N BLOOD GLUCOSE TEST STRIPS CARETOUCH BLOOD GLUCOSE TEST STRIPS
CELEBREX CLEVER CHEK AUTO-CODE TEST STRIPS CLEVER CHEK AUTO-CODE VOICE TEST STRIPS
CLEVER CHEK TEST STRIPS CLEVER CHOICE AUTO-CODE PRO TEST STRIPS CLEVER CHOICE MICRO TEST STRIPS
CLEVER CHOICE NO CODING TEST STRIPS CLEVER CHOICE TALK NO CODING TEST STRIPS clindamycin phosphate/tretinoin
CLOBEX CLOCORTOLONE PIVALATE CLOCORTOLONE PIVALATE PUMP
CLODERM CLODERM PUMP CLOZAPINE ODT
CLOZARIL CONTOUR BLOOD GLUCOSE TEST STRIPS CONTOUR NEXT BLOOD GLUCOSE TEST
COOL BLOOD GLUCOSE TEST STRIPS CORDRAN COZAAR
CRESTOR CUTIVATE CVS ADVANCED GLUCOSE METER TEST STRIPS
DAYPRO D-CARE BLOOD GLUCOSE DERMA-SMOOTHE/FS BODY/SCALP
DESONATE DESOWEN DETROL
DETROL LA DIATHRIVE BLOOD GLUCOSE TEST STRIPS DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS
DICLOFENAC EPOLAMINE DIFLORASONE DIACETATE DIOVAN
DIOVAN HCT DIPROLENE DIPROLENE AF
DITROPAN XL DUO-CARE TEST STRIPS EASY PLUS BLOOD GLUCOSE TEST STRIPS
EASY PLUS II BLOOD GLUCOSE TEST EASY STEP TEST STRIPS EASY TALK BLOOD GLUCOSE TEST STRIPS
EASY TOUCH GLUCOSE TEST STRIPS EASY TRAK BLOOD GLUCOSE TEST STRIPS EASYGLUCO
EASYGLUCO PLUS EASYMAX 15 TEST STRIPS EASYMAX TEST STRIPS
EASYPLUS BLOOD GLUCOSE TEST STRIP EASYPRO BLOOD GLUCOSE TEST STRIPS EASYPRO PLUS
EC-NAPROXEN EDARBI EDARBYCLOR
ELEMENT COMPACT TEST STRIPS ELEMENT TEST STRIPS ELESTAT
ELIDEL ELOCON EMADINE
EMBRACE BLOOD GLUCOSE TEST STRIPS EMBRACE EVO BLOOD GLUCOSETEST STRIPS EMBRACE PRO BLOOD GLUCOSETEST STRIPS
EMBRACE TALK BLOOD GLUCOSE TEST STRIPS ENABLEX EPROSARTAN MESYLATE
EQ BLOOD GLUCOSE TEST STRIPS EUCRISA EVENCARE + BLOOD GLUCOSE TEST STRIP
EVENCARE BLOOD GLUCOSE TEST STRIP EVENCARE G2 TEST STRIPS EVENCARE G3 TEST STRIPS
EVENCARE MINI BLOOD GLUCOSE TEST STRIPS EVOLUTION AUTOCODE EXACTECH R-S-G TEST STRIPS
EXACTECH TEST STRIPS EXFORGE EXFORGE HCT
EZ SMART BLOOD GLUCOSE TEST STRIPS EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS FANAPT
FANAPT TITRATION PACK FAZACLO FELDENE
FENOPROFEN CALCIUM FENORTHO FIFTY50 GLUCOSE TEST STRIP 2.0
FLECTOR FLOLIPID FORA BLOOD GLUCOSE TEST STRIPS
FORA D15G BLOOD GLUCOSE TEST STRIPS FORA D20 BLOOD GLUCOSE TEST STRIPS FORA D40/G31 BLOOD GLUCOSE TEST STRIPS
FORA G20 BLOOD GLUCOSE TEST STRIPS FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS FORA GD20 TEST STRIPS
FORA GD50 BLOOD GLUCOSE TEST STRIPS FORA GTEL BLOOD GLUCOSE TEST STRIPS FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS
FORA V10 BLOOD GLUCOSE TEST STRIPS FORA V12 BLOOD GLUCOSE TEST STRIPS FORA V20 BLOOD GLUCOSE TEST STRIPS
FORA V30A BLOOD GLUCOSE TEST STRIPS FORACARE GD40 FORACARE PREMIUM V10 TESTSTRIPS
FORACARE TEST N GO TEST STRIPS FORTISCARE BLOOD GLUCOSE TEST STRIP FOSRENOL
FREESTYLE INSULINX BLOOD GLUCOSE TEST FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS FREESTYLE LITE TEST STRIPS
FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS FREESTYLE TEST STRIPS FROVA
GE100 BLOOD GLUCOSE TEST STRIPS GELNIQUE GELNIQUE PUMP
GENULTIMATE TEST STRIPS GEODON GHT TEST STRIPS
GLUCO PERFECT 3 TEST STRIPS GLUCOCARD 01 SENSOR PLUS GLUCOCARD 01 SENSOR PLUS TEST STRIPS
GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS GLUCOCARD SHINE TEST STRIPS GLUCOCARD VITAL TEST STRIPS
GLUCOCARD X-SENSOR GLUCOCOM TEST STRIPS GLUCONAVII BLOOD GLUCOSE TEST STRIPS
GLUCOSE METER TEST STRIPS ADVANCED GNP EASY TOUCH GLUCOSE TEST STRIPS GOJJI BLOOD GLUCOSE TEST STRIPS
GOJJI BLOOD GLUCOSE TEST STRIPS/GOJJI STERILE LANCETS 30G GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS HALOG
HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS HYZAAR
IGLUCOSE BLOOD GLUCOSE TEST STRIPS IMITREX IMITREX STATDOSE REFILL
IMITREX STATDOSE SYSTEM IMPOYZ IN TOUCH BLOOD GLUCOSE TEST STRIPS
INDOCIN INDOMETHACIN INFINITY BLOOD GLUCOSE TEST STRIPS
INFINITY VOICE INVEGA JENTADUETO
JENTADUETO XR KAZANO KENALOG
KETOPROFEN KETOPROFEN ER KOMBIGLYZE XR
KROGER BLOOD GLUCOSE TESTSTRIPS KROGER HEALTHPRO GLUCOSE TEST STRIPS KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS
KROGER TEST STRIPS lanthanum carbonate LASTACAFT
LATANOPROST LESCOL XL LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS
LIBERTY TEST STRIPS LIPITOR LIVALO
LOCOID LOCOID LIPOCREAM LODINE
LUMIGAN LUXIQ LYRICA
MAXALT MAXALT-MLT MECLOFENAMATE SODIUM
MEIJER BLOOD GLUCOSE TEST STRIPS MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS
MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS MICARDIS
MICARDIS HCT MICORT-HC MICRODOT TEST STRIPS
MM EASY TOUCH GLUCOSE TEST STRIPS MYGLUCOHEALTH BLOOD GLUCOSE TEST NALFON
NAPRELAN NAPROSYN NESINA
NEUTEK 2TEK TEST STRIPS NEXGEN TEST STRIPS NOVA MAX GLUCOSE TEST STRIPS
OLUX OLUX-E ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS
ON CALL PLUS BLOOD GLUCOSE TEST ON CALL VIVID BLOOD GLUCOSE TEST ON CALL VIVID BLOOD GLUCOSE TEST STRIPS
ONE DROP BLOOD GLUCOSE TEST STRIPS ONZETRA XSAIL OPTIUM TEST STRIPS
OPTIUMEZ TEST STRIPS OPTUMRX BLOOD GLUCOSE TEST OSENI
OTREXUP1 PANDEL PATADAY
PATANOL PAZEO PENNSAID
PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS pimecrolimus
POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS PRAVACHOL PRECISION PCX
PRECISION PCX PLUS TEST STRIPS PRECISION POINT OF CARE TEST STRIPS PRECISION QID TEST STRIPS
PRECISION SOF-TACT TEST STRIPS PRECISION XTRA BLOOD GLUCOSE TEST STRIPS PREDNICARBATE
PREMIUM BLOOD GLUCOSE TEST STRIPS PRESTIGE TEST STRIPS PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS
PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS PROTOPIC PSORCON
PTS PANELS GLUCOSE TEST QTERN QUICKTEK TEST STRIPS
QUINTET AC BLOOD GLUCOSE TEST STRIPS QUINTET BLOOD GLUCOSE TEST STRIPS RA TRUETEST STRIPS
RASUVO1 REFUAH PLUS BLOOD GLUCOSE TEST STRIPS RELION ALL-IN-ONE COMPACT BLOOD GLUCOSE TESTING SYSTEM
RELION BLOOD GLUCOSE TEST STRIPS RELION CONFIRM/MICRO TEST STRIPS RELION PREMIER BLOOD GLUCOSE TEST STRIPS
RELION PRIME BLOOD GLUCOSE TEST STRIPS RELION ULTIMA BLOOD GLUCOSE TEST STRIPS RELION ULTIMA TEST STRIPS
RELPAX RENAGEL RENVELA
RESCULA REVEAL BLOOD GLUCOSE TEST REXALL BLOOD GLUCOSE TEST STRIPS
REXULTI RHOPRESSA RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS
RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS RISPERDAL
RISPERDAL M-TAB RISPERIDONE ODT ROCKLATAN
RYBELSUS SAPHRIS SAVELLA
SAVELLA TITRATION PACK SEGLUROMET SERNIVO
SEROQUEL SEROQUEL XR SEVELAMER HYDROCHLORIDE
sevelamer hydrochloride SIDEKICK BLOOD GLUCOSE SYSTEM SIMVASTATIN
SMART SENSE PREMIUM BLOODGLUCOSE STRIPS SMART SENSE VALUE BLOOD GLUCOSE STRIPS SMARTEST BLOOD GLUCOSE TEST STRIPS
SOLUS V2 AUDIBLE TEST STEGLATRO STEGLUJAN
SUMATRIPTAN SUCCINATE SUPREME TEST STRIPS SURE EDGE BLOOD GLUCOSE TEST STRIPS
SURECHEK BLOOD GLUCOSE TEST STRIPS SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS SYNALAR
tacrolimus TANZEUM TELCARE BLOOD GLUCOSE TEST STRIPS
TEMOVATE TEXACORT TGT BLOOD GLUCOSE TEST STRIPS
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM TIVORBEX TOLMETIN SODIUM
TOPICORT TRADJENTA TRAVATAN Z
TREXIMET TRIANEX TRIBENZOR
TRIDESILON TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS TRUE METRIX BLOOD GLUCOSETEST STRIPS
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS TRUETEST STRIPS TRUETRACK BLOOD GLUCOSE TEST
TRUETRACK TEST TWYNSTA ULORIC
ULTIMA TEST STRIPS ULTRATRAK PRO TEST STRIPS ULTRATRAK ULTIMATE TEST STRIPS
ULTRAVATE UNISTRIP1 GENERIC VANOS
VELPHORO VELTIN VERASENS BLOOD GLUCOSE TEST STRIPS
VERDESO VERSACLOZ VICTORY AGM-4000 TEST STRIPS
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS VIVLODEX VOCAL POINT BLOOD GLUCOSE TEST STRIPS
VOLTAREN GEL VYTORIN VYZULTA
WAVESENSE PRESTO TEST STRIPS XALATAN XIGDUO XR
XULTOPHY 100/3.6 ZEMBRACE SYMTOUCH ZIANA
ZIOPTAN ZIPSOR ZOCOR
ZOMIG ZOMIG ZMT ZYPREXA
ZYPREXA ZYDIS    

Actinic Keratosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ALDARA CREAM 5% 48 Packets/60 Days
EFUDEX CREAM 5% 240 Grams/90 Days
fluorouracil cream 5% 240 Grams/90 Days
imiquimod cream 5% 48 Packets/60 Days

Acute Migraine 5HT

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

almotriptan malate tablet 6.25mg 24 Tablets/30 Days
almotriptan malate tablet 12.5mg 12 Tablets/30 Days
AMERGE TABLET 1MG 18 Tablets/30 Days
AMERGE TABLET 2.5MG 18 Tablets/30 Days
AXERT TABLET 12.5MG 12 Tablets/30 Days
AXERT TABLET 6.25MG 24 Tablets/30 Days
eletriptan tablet 20mg 18 Tablets/30 Days
eletriptan tablet 40mg 12 Tablets/30 Days
FROVA TABLET 2.5MG 27 Tablets/30 Days
frovatriptan tablet 2.5mg 27 Tablets/30 Days
IMITREX INJECTION 4MG/0.5 12 Syringes/30 Days
IMITREX INJECTION 6MG/0.5 12 Syringes/30 Days
IMITREX INJECTION 6MG/0.5 12 Cartridges/30 Days
IMITREX SPRAY 20MG/ACT 12 Inhalers/30 Days
IMITREX SPRAY 5MG/ACT 5 Packs/30 Days
IMITREX TABLET 25MG 27 Tablets/30 Days
IMITREX TABLET 50MG 18 Tablets/30 Days
IMITREX TABLET 100MG 18 Tablets/30 Days
MAXALT TABLET 10MG 18 Tablets/30 Days
MAXALT-MLT TABLET 10MG 18 Tablets/30 Days
MAXALT-MLT TABLET 5MG 36 Tablets/30 Days
naratriptan tablet 1mg 18 Tablets/30 Days
naratriptan tablet 2.5mg 18 Tablets/30 Days
ONZETRA XSAI MIS 11MG 32 Inhalers/30 Days
RELPAX TABLET 20MG/td> 18 Tablets/30 Days
RELPAX TABLET 40MG 12 Tablets/30 Days
rizatriptan tablet 5mg 36 Tablets/30 Days
rizatriptan tablet 5mg odt 36 Tablets/30 Days
rizatriptan tablet 10mg 18 Tablets/30 Days
rizatriptan tablet 10mg odt 18 Tablets/30 Days
sumatriptan injection 4mg/0.5 12 Cartridges/30 Days
sumatriptan injection 4mg/0.5 12 Syringes/30 Days
sumatriptan injection 6/0.5ml 12 Syringes/30 Days
sumatriptan injection 6mg/0.5 12 Cartridges/30 Days
sumatriptan injection 6mg/0.5 12 Syringes/30 Days
sumatriptan spray 20mg/act 12 Inhalers/30 Days
sumatriptan spray 5mg/act 5 Packs/30 Days
sumatriptan tablet 25mg 27 Tablets/30 Days
sumatriptan tablet 50mg 18 Tablets/30 Days
sumatriptan tablet 100mg 18 Tablets/30 Days
sumatriptan-naproxen tablet 85-500mg 18 Tablets/30 Days
TREXIMET TABLET 10-60MG 9 Tablets/30 Days
TREXIMET TABLET 85-500MG 18 Tablets/30 Days
ZEMBRACE SYM INJECTION 3/0.5ML 24 Pens/30 Days
zolmitriptan tablet 2.5mg 18 Tablets/30 Days
zolmitriptan tablet 5mg 12 Tablets/30 Days
zolmitriptan tablet 5mg odt 12 Tablets/30 Days
ZOMIG SPRAY 2.5MG 3 Injection Devices/30 Days
ZOMIG SPRAY 5MG 2 Sprays/30 Days
ZOMIG TABLET 2.5MG 18 Tablets/30 Days
ZOMIG TABLET 5MG 12 Tablets/30 Days
ZOMIG ZMT TABLET 2.5 MG 18 Tablets/30 Days
ZOMIG ZMT TABLET 5MG ODT 12 Tablets/30 Days

Addyi

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

VYLEESI INJECTION 1.75/0.3 6 Pens/30 Days

Afrezza

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AFREZZA POWDER 4 UNIT 2520 Cartridges/30 Days
AFREZZA POWDER 8 UNIT 1260 Cartridges/30 Days
AFREZZA POWDER 12 UNIT 900 Cartridges/30 Days
AFREZZA POWDER 4-8 UNIT 1530 Cartridges/30 Days
AFREZZA POWDER 4-8 UNIT 1890 Cartridges/30 Days
AFREZZA POWDER 4-8 UNIT 1800 Cartridges/30 Days
AFREZZA POWDER 8-12 UNIT 1080 Cartridges/30 Days
AFREZZA POWDER 4-8-12 1260 Cartridges/30 Days

Alinia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ALINIA SUSPENSION 100/5ML 300 mL/90 Days
ALINIA TABLET 500MG 12 Tablets/90 Days

Amantadine ER

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

GOCOVRI CAPSULE 68.5MG1 30 Capsules/30 Days
GOCOVRI CAPSULE 137MG1 60 Capsules/30 Days

Amifampridine

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

FIRDAPSE TABLET 10MG1, 2 240 Tablets/30 Days
RUZURGI TABLET 10MG1, 2 300 Tablets/30 Days

Ampyra

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AMPYRA TABLET 10MG1 60 Tablets/30 Days
dalfampridin tablet 10mg er1 60 Tablets/30 Days

Androgren/Anabolic Steroids

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ANDRODERM DIS 2MG/24HR 30 Patches/30 Days
ANDRODERM DIS 4MG/24HR 30 Patches/30 Days
ANDROGEL GEL 1%(25MG) 60 Packets/30 Days
ANDROGEL GEL 1%(50MG) 60 Packets/30 Days
ANDROGEL GEL 1.62% 2 Pumps/30 Days
ANDROGEL GEL 1.62% 30 Packets/30 Days
ANDROGEL GEL 1.62% 60 Packets/30 Days
DEPO-TESTOSTERONE INJECTION 100MG/ML 1 Vial/28 Days
DEPO-TESTOSTERONE INJECTION 200MG/ML 10 mL/28 Days
FORTESTA GEL 10MG/ACT 2 Pumps/30 Days
NATESTO GEL 5.5MG 3 Pumps/30 Days
STRIANT MIS 30MG 60 Systems/30 Days
TESTIM GEL 1%(50MG) 60 Packets/30 Days
testosterone cypionate injection 100MG/mL 1 Vial/28 Days
testosterone cypionate injection 200MG/mL 10 mL/28 Days
TESTOST ENAN INJECTION 200MG/ML 1 Vial/28 Days
testosterone gel 1%(25mg) 60 Packets/30 Days
testosterone gel 1%(50mg) 60 Packets/30 Days
testosterone gel 1.62% 2 Bottles/30 Days
testosterone gel 1.62% 30 Packets/30 Days
testosterone gel 1.62% 60 Packets/30 Days
testosterone gel 10mg/act 2 Pumps/30 Days
testosterone gel pump 1% 300 Grams/30 Days
TESTOSTERONE GEL PUMP 1% 4 Pumps/30 Days
TESTOSTERONE INJECTION CYPIONATE 10 mL/28 Days
testosterone solution 30mg/act 2 Pumps/30 Days
VOGELXO GEL 1%(50MG) 60 Packets/30 Days
VOGELXO GEL PUMP 1% 4 Pumps/30 Days
XYOSTED INJECTION 100/0.5 2 Pens/28 Days
XYOSTED INJECTION 50/0.5 2 Pens/28 Days
XYOSTED IINJECTIONNJ 75/0.5 2 Pens/28 Days

Antiemetic

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AKYNZEO CAPSULE 300-0.5 2 Capsules/30 Days
ANZEMET TABLET 50MG 7 Tablets/30 Days
ANZEMET TABLET 100MG 7 Tablets/30 Days
aprepitant capsule 40mg 8 Capsules/30 Days
aprepitant capsule 80mg 8 Capsules/30 Days
aprepitant capsule 125mg 4 Capsules/30 Days
aprepitant pack 80 & 125 4 Packs/30 Days
CESAMET CAPSULE 1MG 42 Capsules/30 Days
DICLEGIS TABLET 10-10MG 120 Tablets/30 Days
doxylamine/pyridoxine tablet 10-10mg 120 Tablets/30 Days
EMEND CAPSULE 40MG 8 Capsules/30 Days
EMEND CAPSULE 80MG 8 Capsules/30 Days
EMEND CAPSULE 125MG 4 Capsules/30 Days
EMEND SUSPENSE 125MG 6 Packs/30 Days
EMEND TRIPAC PACK 80 and 125 4 Packs/30 Days
granisetron tablet 1mg 14 Tablets/30 Days
ondansetron solution 4mg/5ml 5 Bottles/30 Days
ondansetron tablet 4mg 24 Tablets/30 Days
ondansetron tablet 4mg odt 24 Tablets/30 Days
ondansetron tablet 8mg 24 Tablets/30 Days
ondansetron tablet 8mg odt 24 Tablets/30 Days
ondansetron tablet 24mg 4 Tablets/30 Days
ONDANSETRON TABLET 24MG 4 Tablets/30 Days
SANCUSO DIS 3.1MG 2 Patches/28 Days
VARUBI TABLET 90MG 4 Tablets/30 Days
ZOFRAN SOLUTION 4MG/5ML 5 Bottles/30 Days
ZOFRAN TABLET 4MG 24 Tablets/30 Days
ZOFRAN TABLET 4MG ODT 24 Tablets/30 Days
ZOFRAN TABLET 8MG 24 Tablets/30 Days
ZOFRAN TABLET 8MG ODT 24 Tablets/30 Days
ZUPLENZ MIS 4MG 24 Films/30 Days
ZUPLENZ MIS 8MG 24 Films/30 Days

Antifungal

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ciclodan solution 8% 3.3 mL/30 Days
ciclopirox solution 8% 3.3 mL/30 Days
JUBLIA SOLUTION 10% 4 mL/30 Days
KERYDIN SOLUTION 5% 4 mL/30 Days
PENLAC SOLUTION 8% 3.3 mL/30 Days

Anti-Influenza

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

oseltamivir capsule 30mg 40 Capsules/120 Days
oseltamivir capsule 45mg 20 Capsules/120 Days
oseltamivir capsule 75mg 20 Capsules/120 Days
oseltamivir suspense 6MG/mL 300 mL/120 Days
TAMIFLU CAPSULE 30MG 40 Capsules/120 Days
TAMIFLU CAPSULE 45MG 20 Capsules/120 Days
TAMIFLU CAPSULE 75MG 20 Capsules/120 Days
TAMIFLU SUSPENSE 6MG/ML 300 mL/120 Days
XOFLUZA TABLET 20MG 4 Tablets/120 Days
XOFLUZA TABLET 40MG 4 Tablets/120 Days

Antiretroviral

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RELENZA MIS DISKHALER 40 Blisters/120 Days

Arikayce

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ARIKAYCE SUSPENSE1, 2 28 Vials/28 Days

Atypical Antipsychotics

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

INVEGA TABLET 1.5MG 60 Tablets/30 Days
INVEGA TABLET 3MG 60 Tablets/30 Days
INVEGA TABLET 6MG 60 Tablets/30 Days
INVEGA TABLET 9MG 60 Tablets/30 Days
olanzapine tablet 2.5mg 30 Tablets/30 Days
olanzapine tablet 5mg 30 Tablets/30 Days
olanzapine tablet 5mg odt 30 Tablets/30 Days
olanzapine tablet 7.5mg 30 Tablets/30 Days
olanzapine tablet 10mg 30 Tablets/30 Days
olanzapine tablet 10mg odt 30 Tablets/30 Days
olanzapine tablet 15mg 30 Tablets/30 Days
olanzapine tablet 15mg odt 30 Tablets/30 Days
olanzapine tablet 20mg 30 Tablets/30 Days
olanzapine tablet 20mg odt 30 Tablets/30 Days
paliperidone tablet er 1.5mg 60 Tablets/30 Days
paliperidone tablet er 3mg 60 Tablets/30 Days
paliperidone tablet er 6mg 60 Tablets/30 Days
paliperidone tablet er 9mg 60 Tablets/30 Days
quetiapine tablet 50mg er 60 Tablets/30 Days
quetiapine tablet 150mg er 60 Tablets/30 Days
quetiapine tablet 200mg er 60 Tablets/30 Days
quetiapine tablet 300mg er 60 Tablets/30 Days
quetiapine tablet 400mg er 60 Tablets/30 Days
SEROQUEL XR TABLET 50MG 60 Tablets/30 Days
SEROQUEL XR TABLET 150MG 60 Tablets/30 Days
SEROQUEL XR TABLET 200MG 60 Tablets/30 Days
SEROQUEL XR TABLET 300MG 60 Tablets/30 Days
SEROQUEL XR TABLET 400MG 60 Tablets/30 Days
ZYPREXA TABLET 2.5MG 30 Tablets/30 Days
ZYPREXA TABLET 5MG 30 Tablets/30 Days
ZYPREXA TABLET 7.5MG 30 Tablets/30 Days
ZYPREXA TABLET 10MG 30 Tablets/30 Days
ZYPREXA TABLET 15MG 30 Tablets/30 Days
ZYPREXA TABLET 20MG 30 Tablets/30 Days
ZYPREXA ZYDI TABLET 5MG 30 Tablets/30 Days
ZYPREXA ZYDI TABLET 10MG 30 Tablets/30 Days
ZYPREXA ZYDI TABLET 15MG 30 Tablets/30 Days
ZYPREXA ZYDI TABLET 20MG 30 Tablets/30 Days

Benlysta

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

BENLYSTA INJECTION 200MG/ML1 4 Syringes/28 Days

Biologic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ACTEMRA INJECTION 162/0.91 4 Syringes/28 Days
CIMZIA KIT STARTER1 3 Kits/180 Days
CIMZIA PREFL KIT 200MG/ML1 1 Kit/28 Days
COSENTYX INJECTION 150MG/ML1 1 Syringe/28 Days
COSENTYX INJECTION 300DOSE1 1 Pack/28 Days
COSENTYX PEN INJECTION 150MG/ML1 1 Injection Device/28 Days
COSENTYX PEN INJECTION 300DOSE1 1 Pack/28 Days
ENBREL INJECTION 25/0.5ML1 8 Syringes/28 Days
ENBREL INJECTION 25MG1 8 Vials/28 Days
ENBREL INJECTION 50MG/ML1 4 Syringes/28 Days
ENBREL MINI INJECTION 50MG/ML1 4 Cartridges/28 Days
ENBREL SRCLK INJECTION 50MG/ML1 4 Syringes/28 Days
HUMIRA INJECTION 10/0.1ML1 2 Syringes/28 Days
HUMIRA INJECTION 10MG/0.21 2 Syringes/28 Days
HUMIRA INJECTION 20/0.2ML1 2 Syringes/28 Days
HUMIRA INJECTION 40/0.4ML1 2 Syringes/28 Days
HUMIRA KIT 20MG/0.41 2 Syringes/28 Days
HUMIRA KIT 40MG/0.81 2 Syringes/28 Days
HUMIRA PEDIA INJECTION CROHNS1 1 Kit/180 Days
HUMIRA PEDIA INJECTION CROHNS1 3 Kit/180 Days
HUMIRA PEN INJECTION 40/0.4ML1 2 Pens/28 Days
HUMIRA PEN INJECTION 40MG/0.81 2 Pens/28 Days
HUMIRA PEN INJECTION CD/UC/HS1 1 Kit/180 Days
HUMIRA PEN INJECTION PS/UV1 1 Kit/180 Days
HUMIRA PEN KIT CD/UC/HS1 1 Kit/180 Days
HUMIRA PEN KIT PS/UV1 1 Kit/180 Days
KEVZARA INJECTION 150/1.141 2 Pens/28 Days
KEVZARA INJECTION 150/1.141 2 Syringes/28 Days
KEVZARA INJECTION 200/1.141 2 Pens/28 Days
KEVZARA INJECTION 200/1.141 2 Syringes/28 Days
KINERET INJECTION1, 2 30 Syringes/30 Days
OLUMIANT TABLET 1MG1 30 Tablets/30 Days
OLUMIANT TABLET 2MG1 30 Tablets/30 Days
ORENCIA CLCK INJECTION 125MG/ML1 4 Syringes/28 Days
ORENCIA IINJECTIONNJ 125MG/ML1 4 Syringes/28 Days
ORENCIA INJECTION 50/0.41 4 Syringes/28 Days
ORENCIA INJECTION 87.5/0.71 4 Syringes/28 Days
RINVOQ TABLET 15MG ER1 30 Tablets/30 Days
SILIQ ININJECTIONJ 210/1.51 2 Syringes/28 Days
SIMPONI INJECTION 100MG/ML1 1 Syringe/28 Days
SIMPONI INJECTION 50/0.5ML1 1 Syringe/28 Days
SKYRIZI INJECTION 150DOSE1 1 Box/84 Days
STELARA INJECTION 45MG/0.51 1 Syringe/84 Days
STELARA INJECTION 90MG/ML1 1 Syringe/56 Days
TALTZ INJECTION 80MG/ML1 1 mL/28 Days
TREMFYA INJECTION 100MG/ML1 1 Pen/56 Days
TREMFYA INJECTION 100MG/ML1 1 Syringe/56 Days
XELJANZ TABLET 5MG1 60 Tablets/30 Days
XELJANZ TABLET 10MG1 60 Tablets/30 Days
XELJANZ XR TABLET 11MG1 30 Tablets/30 Days
XELJANZ XR TABLET 22MG1 112 Tablets/365 Days

Bisphosphonates

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ACTONEL TABLET 35MG 4 Tablets/28 Days
ACTONEL TABLET 150MG 1 Tablet/28 Days
alendronate tablet 35mg 4 Tablets/28 Days
alendronate tablet 70mg 4 Tablets/28 Days
ATELVIA TABLET 4 Tablets/28 Days
BINOSTO TABLET 70MG 4 Tablets/28 Days
BONIVA TABLET 150MG 1 Tablets/28 Days
FOSAMAX + D TABLET 70-2800 4 Capsules/28 Days
FOSAMAX + D TABLET 70-5600 4 Capsules/28 Days
FOSAMAX TABLET 70MG 4 Capsules/28 Days
ibandronate tablet 150mg 1 Tablet/28 Days
risedronate tablet 35mg 4 Tablets/28 Days
risedronate tablet 35mg dr 4 Tablets/28 Days
risedronate tablet 150mg 1 Tablet/28 Days

Cystic Fibrosis Transmembrane Regulator (CFTR)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KALYDECO PAK 25MG1 60 Packets/30 Days
KALYDECO PAK 50MG1 60 Packets/30 Days
KALYDECO PAK 75MG1 60 Packets/30 Days
KALYDECO TABLET 150MG1 60 Tablets/30 Days
ORKAMBI TABLET 100-1251 120 Tablets/30 Days
ORKAMBI TABLET 200-1251 120 Tablets/30 Days

CGRP

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AIMOVIG INJECTION 70MG/ML1 1 Injection/28 Days
AIMOVIG INJECTION 140MG/ML1 1 Injection/28 Days
AJOVY INJECTION 225/1.51 4.5 Syringes/84 Days
EMGALITY INJECTION 100MG/ML1 9 Syringes/180 Days
EMGALITY INJECTION 120MG/ML1 1 Syringe/28 Days

Circadian Rhythm Disorder

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

HETLIOZ CAPSULE 20MG1, 2 30 Capsules/30 Days

Combination NSAID

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

DUEXIS TABLET 800-26.6 90 Tablets/30 Days
VIMOVO TABLET 375-20MG 60 Tablets/30 Days
VIMOVO TABLET 500-20MG 60 Tablets/30 Days

Constipation Agents

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AMITIZA CAPSULE 8MCG 120 Capsules/30 Days
AMITIZA CAPSULE 24MCG 60 Capsules/30 Days
LINZESS CAPSULE 72MCG 30 Capsules/30 Days
LINZESS CAPSULE 145MCG 30 Capsules/30 Days
LINZESS CAPSULE 290MCG 30 Capsules/30 Days
MOTEGRITY TABLET 1MG 30 Tablets/30 Days
MOTEGRITY TABLET 2MG 30 Tablets/30 Days
MOVANTIK TABLET 12.5MG 30 Tablets/30 Days
MOVANTIK TABLET 25MG 30 Tablets/30 Days
RELISTOR INJECTION 8/0.4ML 30 Syringes/30 Days
RELISTOR INJECTION 12/0.6ML 60 Vials/30 Days
RELISTOR INJECTION 12/0.6ML 30 Syringes/30 Days
RELISTOR TABLET 150MG 90 Tablets/30 Days
SYMPROIC TABLET 0.2MG 30 Tablets/30 Days
TRULANCE TABLET 3MG 30 Tablets/30 Days
ZELNORM TABLET 6MG 60 Tablets/30 Days

Egrifta

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

EGRIFTA SOLUTION 1MG1 60 Vials/30 Days
EGRIFTA SV INJECTION 2MG1 30 Vials/30 Days

Emflaza

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

EMFLAZA TABLET 6MG1, 2 60 Tablets/30 Days
EMFLAZA TABLET 18MG1, 2 30 Tablets/30 Days

Fibromyalgia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

LYRICA CAPSULE 25MG 90 Capsules/30 Days
LYRICA CAPSULE 50MG 90 Capsules/30 Days
LYRICA CAPSULE 75MG 90 Capsules/30 Days
LYRICA CAPSULE 100MG 90 Capsules/30 Days
LYRICA CAPSULE 150MG 90 Capsules/30 Days
LYRICA CAPSULE 200MG 90 Capsules/30 Days
LYRICA CAPSULE 225MG 60 Capsules/30 Days
LYRICA CAPSULE 300MG 60 Capsules/30 Days
LYRICA SOLUTION 20MG/ML 900 mL/30 Days
pregabalin capsule 25mg 90 Capsules/30 Days
pregabalin capsule 50mg 90 Capsules/30 Days
pregabalin capsule 75mg 90 Capsules/30 Days
pregabalin capsule 100mg 90 Capsules/30 Days
pregabalin capsule 150mg 90 Capsules/30 Days
pregabalin capsule 200mg 90 Capsules/30 Days
pregabalin capsule 225mg 90 Capsules/30 Days
pregabalin capsule 300mg 90 Capsules/30 Days
pregabalin solution 20MG/mL 900 mL/30 Days
SAVELLA MIS TITR PAK 1 Kit/180 Days
SAVELLA TABLET 12.5MG 60 Tablets/30 Days
SAVELLA TABLET 25MG 60 Tablets/30 Days
SAVELLA TABLET 50MG 60 Tablets/30 Days
SAVELLA TABLET 100MG 60 Tablets/30 Days

Galafold

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

GALAFOLD CAPSULE 123MG1 14 Capsules/28 Days

Gonadotropin Hormones

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CETROTIDE KIT 0.25MG1 5 Kits/30 Days
CHOR GONADOT INJECTION 10000UNT1 2 Vials/30 Days
GANIRELIX AC INJECTION 250/0.51 5 Syringes/30 Days
NOVAREL INJECTION 10000UNT1 2 Vials/30 Days
NOVAREL INJECTION 5000UNIT1 4 Vials/30 Days
PREGNYL INJECTION 10000UNT1 2 Vials/30 Days

Heredistary Angioedima (HAE)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

FIRAZYR INJECTION 30MG/3ML1 6 Syringes/30 Days
HAEGARDA INJECTION 2000UNIT1, 2 24 Vials/30 Days
HAEGARDA INJECTION 3000UNIT1, 2 16 Vials/30 Days
icatibant injection 30mg/3ml1 6 Syringes/30 Days
TAKHZYRO INJECTION 300/2ML1, 2 4 mL/28 Days

hATTR Amlyoidosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

TEGSEDI INJECTION 284/1.51, 2 6 mL/28 Days

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CORLANOR SOLUTION 5MG/5ML 600 mL/30 Days
CORLANOR TABLET 5MG 60 Tablets/30 Days
CORLANOR TABLET 7.5MG 60 Tablets/30 Days

Hemlibra

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

HEMLIBRA INJECTION 30MG/ML1 4 Vials/28 Days
HEMLIBRA INJECTION 60/0.41 4 Vials/28 Days
HEMLIBRA INJECTION 105/0.71 4 Vials/28 Days
HEMLIBRA INJECTION 150/ML1 4 Vials/28 Days

HoFH Agents

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

JUXTAPID CAPSULE 5MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 10MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 20MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 30MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 40MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 60MG1, 2 30 Capsules/30 Days
KYNAMRO INJECTION 200MG/ML1 4 Injections/28 Days

Hyperhidrosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

QBREXZA PAD 2.4% 30 Pads/30 Days

IBS-D

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

alosetron tablet 0.5mg 60 Tablets/30 Days
alosetron tablet 1mg 60 Tablets/30 Days
LOTRONEX TABLET 0.5MG 60 Tablets/30 Days
LOTRONEX TABLET 1MG 60 Tablets/30 Days
VIBERZI TABLET 75MG 60 Tablets/30 Days
VIBERZI TABLET 100MG 60 Tablets/30 Days
XIFAXAN TABLET 200MG 9 Tablets/30 Days
XIFAXAN TABLET 550MG 60 Tablets/30 Days

Idiopathic Pulmonary Fibrosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ESBRIET CAPSULE 267MG1 180 Capsules/30 Days
ESBRIET TABLET 267MG1 180 Tablets/30 Days
ESBRIET TABLET 801MG1 90 Tablets/30 Days
OFEV CAPSULE 100MG1 60 Capsules/30 Days
OFEV CAPSULE 150MG1 60 Capsules/30 Days

Insomnia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AMBIEN CR TABLET 6.25MG 30 Tablets/30 Days
AMBIEN CR TABLET 12.5MG 30 Tablets/30 days
AMBIEN TABLET 5MG 30 Tablets/30 Days
AMBIEN TABLET 10MG 30 Tablets/30 Days
BELSOMRA TABLET 5MG 30 Tablets/30 Days
BELSOMRA TABLET 10MG 30 Tablets/30 Days
BELSOMRA TABLET 15MG 30 Tablets/30 Days
BELSOMRA TABLET 20MG 30 Tablets/30 Days
EDLUAR SUBLINGUAL 5MG 30 Tablets/30 Days
EDLUAR SUBLINGUAL 10MG 30 Tablets/30 Days
eszopiclone tablet 1mg 30 Tablets/30 Days
eszopiclone tablet 2mg 30 Tablets/30 Days
eszopiclone tablet 3mg 30 Tablets/30 Days
INTERMEZZO SUBLINGUAL 1.75MG 30 Tablets/30 Days
INTERMEZZO SUBLINGUAL 3.5MG 30 Tablets/30 Days
LUNESTA TABLET 1MG 30 Tablets/30 Days
LUNESTA TABLET 2MG 30 Tablets/30 Days
LUNESTA TABLET 3MG 30 Tablets/30 Days
ramelteon tablet 8mg 30 Tablets/30 Days
ROZEREM TABLET 8MG 30 Tablets/30 Days
SILENOR TABLET 3MG 30 Tablets/30 Days
SILENOR TABLET 6MG 30 Tablets/30 Days
SONATA CAPSULE 5MG 30 Capsules/30 Days
SONATA CAPSULE 10MG 30 Capsules/30 Days
zaleplon capsule 5mg 30 Capsules/30 Days
zaleplon capsule 10mg 30 Capsules/30 Days
zolpidem er tablet 6.25mg 30 Tablets/30 Days
zolpidem er tablet 12.5mg 30 Tablets/30 Days
zolpidem tablet 5mg 30 Tablets/30 Days
zolpidem tablet 10mg 30 Tablets/30 Days
zolpidem tartrate sublingual 1.75mg 30 Tablets/30 Days
zolpidem tartrate sublingual 3.5mg 30 Tablets/30 Days
ZOLPIMIST SPRAY 5MG 1 Canister/30 Days
doxepin tablet 3mg 30 Tablets/30 Days
doxepin tablet 6mg 30 Tablets/30 Days

Interleukin (IL)-1 Inhibitor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ARCALYST INJECTION 220MG1, 2 4 Vials/28 Days

Interleukin (IL)-4 Inhibitors

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

DUPIXENT INJECTION 200/1.141 2 Syringes/28 Days
DUPIXENT INJECTION 300/2ML1 2 Syringes/28 Days

Jynarque

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SAMSCA TABLET 15MG1 30 Tablets/365 Days
SAMSCA TABLET 30MG1 60 Tablets/365 Days

Keveyis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KEVEYIS TABLET 50MG1, 2 120 Tablets/30 Days
KEVEYIS TABLET 50MG 120 Tablets/30 Days

Korlym

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KORLYM TABLET 300MG1, 2 120 Tablets/30 Days

Lidocaine Transdermal

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

lidocaine/prilocaine cream 2.5-2.5% 60 Grams/30 Days
LIDOCAINE CREAM TETRACAI 120 Grams/30 Days
lidocaine ointment 5% 600 Grams/30 Days
lidocaine ointment pack 5% 600 Grams/30 Days
lidocaine solution 4% 400 Grams/30 Days
lidocaine-pr cream 60 Grams/30 Days
PLIAGLIS CREAM 7-7% 120 Grams/30 Days
SYNERA DIS 70-70MG 4 Patches/30 Days

Lyrica CR

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

LYRICA CR TABLET 82.5MG 30 Tablets/30 Days
LYRICA CR TABLET 165MG 30 Tablets/30 Days
LYRICA CR TABLET 330MG 60 Tablets/30 Days

Multiple Sclerosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AUBAGIO TABLET 7MG1 30 Tablets/30 Days
AUBAGIO TABLET 14MG1 30 Tablets/30 Days
AVONEX KIT 30MCG1 1 Pack/28 Days
AVONEX PEN KIT 30MCG1 1 Pack/28 Days
AVONEX PREFL KIT 30MCG1 1 Kit/28 Days
BETASERON INJECTION 0.3MG1 1 Box/28 Days
COPAXONE INJECTION 20MG/ML1 30 Syringes/30 Days
COPAXONE INJECTION 40MG/ML1 12 Syringes/28 Days
EXTAVIA INJECTION 0.3MG1 1 Box/30 Days
GILENYA CAPSULE 0.5MG1 30 Tablets/30 Days
glatiramer injection 20MG/mL1 30 Syringes/30 Days
glatiramer injection 40MG/mL1 12 Syringes/28 Days
glatopa injection 20MG/mL1 30 Syringes/30 Days
glatopa injection 40MG/mL1 12 Syringes/28 Days
MAVENCLAD PACK 10MG(4)1 8 Tablets/301 Days
MAVENCLAD PACK 10MG(5)1 10 Tablets/301 Days
MAVENCLAD PACK 10MG(6)1 12 Tablets/301 Days
MAVENCLAD PACK 10MG(7)1 14 Tablets/301 Days
MAVENCLAD PACK 10MG(8)1 8 Tablets/301 Days
MAVENCLAD PACK 10MG(9)1 9 Tablets/301 Days
MAVENCLAD PACK 10MG(10)1 20 Tablets/301 Days
MAYZENT TABLET 0.25MG1 120 Tablets/30 Days
MAYZENT TABLET 2MG1 30 Tablets/30 Days
PLEGRIDY INJECTION1 2 Syringes/28 Days
PLEGRIDY INJECTION PEN1 2 Pens/28 Days
PLEGRIDY INJECTION STARTER1 1 Kit/180 Days
PLEGRIDY PEN INJECTION STARTER1 1 Kit/180 Days
REBIF INJECTION 22/0.51 12 Syringes/28 Days
REBIF INJECTION 44/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION 22/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION 44/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION TITRATN1 1 Kit/180 Days
REBIF TITRTN INJECTION PACK1 1 Kit/180 Days
TECFIDERA CAPSULE 120MG1 56 Capsules/180 Days
TECFIDERA CAPSULE 240MG1 60 Capsules/30 Days
TECFIDERA MIS STARTER1 1 Kit/180 Days

Muscle Relaxants

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AMRIX CAPSULE 15MG 21 Capsules/30 Days
AMRIX CAPSULE 30MG 21 Capsules/30 Days
BACLOFEN TABLET 5MG 120 Tablets/30 Days
baclofen tablet 10mg 120 Tablets/30 Days
baclofen tablet 20mg 120 Tablets/30 Days
carisoprodol/aspirin tablet 200-325 168 Tablets/90 Days
carisoprodol tablet 250mg 28 Tablets/30 Days
carisoprodol tablet 350mg 28 Tablets/30 Days
carisoprodol tablet aspirin/codeine 168 Tablets/90 Days
CARISOPRODOL TABLET ASPIRINE/CODEINE 168 Tablets/30 Days
CHLORZOXAZON TABLET 250MG 28 Tablets/30 Days
chlorzoxazon tablet 375mg 84 Tablets/90 Days
CHLORZOXAZON TABLET 500MG 28 Tablets/30 Days
chlorzoxazon tablet 750mg 84 Tablets/90 Days
cyclobenzapr capsule 15mg er 21 Capsules/30 Days
cyclobenzaprine capsule 30mg er 21 Capsules/30 Days
cyclobenzaprine tablet 5mg 21 Tablets/30 Days
cyclobenzaprine tablet 7.5mg 21 Tablets/30 Days
cyclobenzaprine tablet 10mg 90 Capsules/30 Days
DANTRIUM CAPSULE 25MG 90 Capsules/30 Days
DANTRIUM CAPSULE 50MG 90 Capsules/30 Days
dantrolene capsule 25mg 90 Capsules/30 Days
dantrolene capsule 50mg 90 Capsules/30 Days
dantrolene capsule 100mg 90 Capsules/30 Days
FEXMID TABLET 7.5MG 21 Tablets/30 Days
LORZONE TABLET 375MG 28 Tablets/30 Days
lorzone tablet 375mg 84 Tablets/90 Days
lorzone tablet 750mg 84 Tablets/90 Days
metaxall tablet 800mg 28 Tablets/30 Days
METAXALONE TAB 400MG 56 Tablets/30 Days
metaxalone tablet 800mg 28 Tablets/30 Days
methocarbam tablet 500mg 60 Tablets/30 Days
methocarbam tablet 750mg 44 Tablets/30 Days
orphenadrine tablet 100mg cr 42 Tablets/30 Days
orphenadrine tablet 100mg er 42 Tablets/30 Days
ROBAXIN TABLET 500MG 60 Tablets/30 Days
ROBAXIN TABLET 750MG 44 Tablets/30 Days
SKELAXIN TABLET 800MG 28 Tablets/30 Days
SOMA TABLET 250MG 28 Tablets/30 Days
SOMA TABLET 350MG 28 Tablets/30 Days
tizanidine tablet 2mg 42 Capsules/30 Days
tizanidine tablet 4mg 42 Capsules/30 Days
tizanidine capsule 6mg 42 Capsules/30 Days
tizanidine tablet 2mg 42 Capsules/30 Days
tizanidine tablet 4mg 42 Capsules/30 Days
ZANAFLEX CAPSULE 2MG 42 Capsules/30 Days
ZANAFLEX CAPSULE 4MG 42 Capsules/30 Days
ZANAFLEX CAPSULE 6MG 42 Capsules/30 Days
ZANAFLEX TABLET 4MG 42 Tablets/30 Days

Natpara

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NATPARA INJECTION 25MCG1 1 Kit/28 Days
NATPARA INJECTION 50MCG1 1 Kit/28 Days
NATPARA INJECTION 75MCG1 1 Kit/28 Days
NATPARA INJECTION 100MCG1 1 Kit/28 Days

Neurotrophic Keratitis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

OXERVATE SOLUTION 20MCG/ML1, 2 56 Vials/56 Days

Nocturia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NOCTIVA EMULSION 0.83/0.1 1 Bottle/30 Days
NOCTIVA SPRAY 1.66/0.1 1 Bottle/30 Days

Northera

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NORTHERA CAPSULE 100MG1 450 Capsules/30 Days
NORTHERA CAPSULE 200MG1 180 Capsules/30 Days
NORTHERA CAPSULE 300MG1 180 Capsules/30 Days

Nuvigil/Provigil

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

armodafinil tablet 50mg 30 Tablets/30 Days
armodafinil tablet 150mg 30 Tablets/30 Days
armodafinil tablet 200mg 30 Tablets/30 Days
armodafinil tablet 250mg 30 Tablets/30 Days
modafinil tablet 100mg 30 Tablets/30 Days
modafinil tablet 200mg 30 Tablets/30 Days
NUVIGIL TABLET 50MG 30 Tablets/30 Days
NUVIGIL TABLET 150MG 30 Tablets/30 Days
NUVIGIL TABLET 200MG 30 Tablets/30 Days
NUVIGIL TABLET 250MG 30 Tablets/30 Days
PROVIGIL TABLET 100MG 30 Tablets/30 Days
PROVIGIL TABLET 200MG 30 Tablets/30 Days

Ocaliva

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

OCALIVA TABLET 5MG1 30 Tablets/30 Days
OCALIVA TABLET 10MG1 30 Tablets/30 Days

Ophthalmic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RESTASIS EMULSION 0.05% 2 Vials/30 Days
RESTASIS MULTIDOSE EMULSION 0.05% 1 Bottle/30 Days
XIIDRA DROP 5% 60 Vials/30 Days

Ophthalmic Prostaglandins

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

bimatoprost solution 0.03% 2.5 mL/30 Days
latanoprost solution 0.005% 2.5 mL/30 Days
LUMIGAN SOLUTION 0.01% 2.5 mL/30 Days
RESCULA SOLUTION 0.15% 1 Bottle/30 Days
travoprost drop 0.004% 2.5 mL/30 Days
TRAVATAN Z DROP 0.004% 2.5 mL/30 Days
VYZULTA SOLUTION 0.024% 5 mL/30 Days
XALATAN SOLUTION 0.005% 2.5 mL/30 Days
ZIOPTAN DROP 0.0015% 30 Containers/30 Days

Opioids ER

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ARYMO ER TABLET 15MG 60 Tablets/30 Days
ARYMO ER TABLET 30MG 30 Tablets/30 Days
ARYMO ER TABLET 60MG 30 Tablets/30 Days
BELBUCA MIS 75MCG 60 Films/30 Days
BELBUCA MIS 150MCG 60 Films/30 Days
BELBUCA MIS 300MCG 60 Films/30 Days
BELBUCA MIS 450MCG 60 Films/30 Days
BELBUCA MIS 600MCG 60 Films/30 Days
BELBUCA MIS 750MCG 60 Films/30 Days
BELBUCA MIS 900MCG 30 Films/30 Days
buprenorphin dis 5mcg/hr 4 Systems/30 Days
buprenorphin dis 10mcg/hr 4 Systems/30 Days
buprenorphin dis 15mcg/hr 4 Systems/30 Days
buprenorphin dis 20mcg/hr 4 Systems/30 Days
BUPRENORPHIN DIS 7.5/HR 4 Systems/30 Days
BUTRANS DIS 5MCG/HR 4 Systems/30 Days
BUTRANS DIS 7.5/HR 4 Systems/30 Days
BUTRANS DIS 10MCG/HR 4 Systems/30 Days
BUTRANS DIS 15MCG/HR 4 Systems/30 Days
BUTRANS DIS 20MCG/HR 4 Systems/30 Days
CONZIP CAPSULE 100MG 30 Capsules/30 Days
CONZIP CAPSULE 200MG 30 Capsules/30 Days
CONZIP CAPSULE 300MG 30 Capsules/30 Days
DURAGESIC DIS 12MCG/HR 10 Patches/30 Days
DURAGESIC DIS 25MCG/HR 0
DURAGESIC DIS 50MCG/HR 0
DURAGESIC DIS 75MCG/HR 0
DURAGESIC DIS 100MCG/HR 0
EMBEDA CAPSULE 20-0.8MG 30 Capsules/30 Days
EMBEDA CAPSULE 30-1.2MG 30 Capsules/30 Days
EMBEDA CAPSULE 50-2MG 30 Capsules/30 Days
EMBEDA CAPSULE 60-2.4MG 0
EMBEDA CAPSULE 80-3.2MG 0
EMBEDA CAPSULE 100-4MG 0
EXALGO TABLET 8MG 30 Tablets/30 Days
EXALGO TABLET 12MG 30 Tablets/30 Days
EXALGO TABLET 16MG 0
EXALGO TABLET 32MG 0
fentanyl dis 12mcg/hr 10 Patches/30 Days
fentanyl dis 25mcg/hr 0
fentanyl dis 37.5mcg/hr 0
fentanyl dis 50mcg/hr 0
fentanyl dis 62.5mcg/hr 0
fentanyl dis 75mcg/hr 0
fentanyl dis 87.5mcg/hr 0
fentanyl dis 100mcg/h 0
hydrocodone capsule 10mg er 60 Capsules/30 Days
hydrocodone capsule 15mg er 60 Capsules/30 Days
hydrocodone capsule 20mg er 60 Capsules/30 Days
hydrocodone capsule 30mg er 30 Capsules/30 Days
hydrocodone capsule 40mg er 30 Capsules/30 Days
hydrocodone capsule 50mg er 30 Capsules/30 Days
hydromorphone tablet 12mg er 30 Tablets/30 Days
hydromorphone tablet 16mg er 0
hydromorphone tablet 32mg er 0
hydromorphone tablet 8mg er 30 Tablets/30 Days
HYSINGLA ER TABLET 20 MG 30 Tablets/30 Days
HYSINGLA ER TABLET 30 MG 30 Tablets/30 Days
HYSINGLA ER TABLET 40 MG 30 Tablets/30 Days
HYSINGLA ER TABLET 60 MG 0
HYSINGLA ER TABLET 80 MG 0
HYSINGLA ER TABLET 100 MG 0
HYSINGLA ER TABLET 120 MG 0
KADIAN CAPSULE 10MG ER 30 Capsules/30 Days
KADIAN CAPSULE 20MG ER 30 Capsules/30 Days
KADIAN CAPSULE 30MG ER 30 Capsules/30 Days
KADIAN CAPSULE 40MG ER 30 Capsules/30 Days
KADIAN CAPSULE 50MG ER 30 Capsules/30 Days
KADIAN CAPSULE 60MG ER 0
KADIAN CAPSULE 80MG ER 0
KADIAN CAPSULE 100MG ER 0
KADIAN CAPSULE 200MG ER 0
MORPHABOND TABLET 15MG ER 60 Tablets/30 Days
MORPHABOND TABLET 30MG ER 30 Tablets/30 Days
MORPHABOND TABLET 60MG ER 0
MORPHABOND TABLET 100MG ER 0
morphine sulfate tablet 15mg 15 Tablets/30 Days
morphine sulfate tablet 30mg 15 Tablets/30 Days
morphine sulfate capsule 10mg er 30 Capsules/30 Days
morphine sulfate capsule 20mg er 30 Capsules/30 Days
morphine sulfate capsule 30mg er 30 Capsules/30 Days
morphine sulfate capsule 40mg er 30 Capsules/30 Days
morphine sulfate capsule 50mg er 30 Capsules/30 Days
morphine sulfate capsule 60mg er 0
morphine sulfate capsule 80mg er 0
morphine sulfate capsule 100mg er 0
MORPHINE SULFATE CAPSULE 30MG ER 30 Capsules/30 Days
MORPHINESULFATE CAPSULE 45MG ER 30 Capsules/30 Days
MORPHINE SULFATE CAPSULE 60MG ER 0
MORPHINE SULFATE CAPSULE 75MG ER 0
MORPHINE SULFATE CAPSULE 90MG ER 0
MORPHINE SULFATE CAPSULE 120MG ER 0
morphine sulfate tablet 100mg cr 0
morphine sulfate tablet 15mg er 60 Tablets/30 Days
morphine sulfate tablet 30mg er 30 Tablets/30 Days
morphine sulfate tablet 60mg er 0
morphine sulfate tablet 100mg er 0
morphine sulfate tablet 200mg er 0
MS CONTIN TABLET 15MG ER 60 Tablets/30 Days
MS CONTIN TABLET 30MG ER 30 Tablets/30 Days
MS CONTIN TABLET 60MG ER 0
MS CONTIN TABLET 100MG ER 0
MS CONTIN TABLET 200MG ER 0
NUCYNTA ER TABLET 50MG 60 Tablets/30 Days
NUCYNTA ER TABLET 100MG 30 Tablets/30 Days
NUCYNTA ER TABLET 150MG 0
NUCYNTA ER TABLET 200MG 0
NUCYNTA ER TABLET 250MG 0
OPANA ER TABLET 5MG 60 Tablets/30 Days
OPANA ER TABLET 7.5MG 60 Tablets/30 Days
OPANA ER TABLET 10MG 30 Tablets/30 Days
OPANA ER TABLET 15MG 30 Tablets/30 Days
OPANA ER TABLET 20MG 0
OPANA ER TABLET 30MG 0
OPANA ER TABLET 40MG 0
OXYCODONE TABLET 10MG ER 60 Tablets/30 Days
OXYCODONE TABLET 15MG ER 60 Tablets/30 Days
OXYCODONE TABLET 20MG ER 30 Tablets/30 Days
OXYCODONE TABLET 30MG ER 30 Tablets/30 Days
OXYCODONE TABLET 40MG ER 0
OXYCODONE TABLET 60MG ER 0
OXYCODONE TABLET 80MG ER 0
OXYCONTIN TABLET 10MG CR 60 Tablets/30 Days
OXYCONTIN TABLET 15MG CR 60 Tablets/30 Days
OXYCONTIN TABLET 20MG CR 30 Tablets/30 Days
OXYCONTIN TABLET 30MG CR 30 Tablets/30 Days
OXYCONTIN TABLET 40MG CR 0
OXYCONTIN TABLET 60MG CR 0
OXYCONTIN TABLET 80MG CR 0
OXYMORPHONE TABLET 5MG ER 60 Tablets/30 Days
OXYMORPHONE TABLET 7.5MG ER 60 Tablets/30 Days
OXYMORPHONE TABLET 10MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 15MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 20MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 30MG ER 0
OXYMORPHONE TABLET 40MG ER 0
TRAMADOL HCL CAPSULE 150MG ER 30 Capsules/30 Days
TRAMADOL HCL CAPSULE ER 100MG 30 Capsules/30 Days
TRAMADOL HCL CAPSULE ER 200MG 30 Capsules/30 Days
TRAMADOL HCL CAPSULE ER 300MG 30 Capsules/30 Days
tramadol hcl tablet 100mg er 30 Tablets/30 Days
tramadol hcl tablet 200mg er 30 Tablets/30 Days
tramadol hcl tablet 300mg er 30 Tablets/30 Days
XTAMPZA ER CAPSULE 9MG 60 Capsules/30 Days
XTAMPZA ER CAPSULE 13.5MG 60 Capsules/30 Days
XTAMPZA ER CAPSULE 18MG 30 Capsules/30 Days
XTAMPZA ER CAPSULE 27MG 30 Capsules/30 Days
XTAMPZA ER CAPSULE 36MG 0
ZOHYDRO ER CAPSULE 10MG 60 Capsules/30 Days
ZOHYDRO ER CAPSULE 15MG 60 Capsules/30 Days
ZOHYDRO ER CAPSULE 20MG 60 Capsules/30 Days
ZOHYDRO ER CAPSULE 30MG 30 Capsules/30 Days
ZOHYDRO ER CAPSULE 40MG 30 Capsules/30 Days
ZOHYDRO ER CAPSULE 50MG 30 Capsules/30 Days


Opioids IR

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ACETAMINOPHEN-CAFFEINE CAPSULE DIHYDROCODEINE 50 Capsules/30 Days
ACETAMINOPHEN/CAFFEINE TABLET DIHYDROCODEINE 50 Tablets/30 Days
acetaminophen/caffeine tablet dihydrocodeine 50 Capsules/30 Days
acetaminophenp/codeine solution 120-12/5 450 mL/30 Days
acetaminophen/codeine tablet 300-15mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-30mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-60mg 25 Tablets/30 Days
butorphanol solution 10MG/mL 1 Bottle/30 Days
CODEINE SULFATE TABLET 15MG 30 Tablets/30 Days
CODEINE SULFATE TABLET 30MG 30 Tablets/30 Days
CODEINE SULFATE TABLET 60MG 25 Tablets/30 Days
codeine/acetaminophen tablet 30-300mg 30 Tablets/30 Days
codeine/acetaminophen table 60-300mg 25 Tablets/30 Days
DEMEROL TABLET 100MG 15 Tablets/30 Days
DILAUDID LIQUID 1MG/ML 60 mL/30 Days
DILAUDID TABLET 2MG 30 Tablets/30 Days
DILAUDID TABLET 4MG 15 Tablets/30 Days
DILAUDID TABLET 8MG 5 Tablets/30 Days
DOLOPHINE TABLET 5MG 60 Tablets/30 Days
DOLOPHINE TABLET 10MG 30 Tablets/30 Days
dvorah tablet 50 Capsules/30 Days
endocet tablet 2.5-325 60 Tablets/30 Days
endocet tablet 5-325mg 30 Tablets/30 Days
endocet tablet 7.5-325 20 Tablets/30 Days
endocet tablet 10-325mg 15 Tablets/30 Days
hydrocodone/acetaminophen tablet 2.5-325mg 360 Tablets/30 Days
hydrocodone/acetaminophen tablet 5-325mg 40 Tablets/30 Days
hydrocodone/acetaminophen tablet 7.5-325mg 30 Tablets/30 Days
hydrocodone/acetaminophen tablet 10-325mg 25 Tablets/30 Days
hydrocodone/acetaminophen solution 7.5-325mg 450 mL/30 Days
HYDROCODONE/ACETAMINOPHEN SOLUTION 10-325MG 375 mL/30 Days
hydrocodone/acetaminophen tablet 5-300mg 40 Tablets/30 Days
hydrocodone/acetaminophen tablet 7.5-300 mg 30 Tablets/30 Days
hydrocodone/acetaminophen tablet 10-300mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 5-200mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 7.5-200mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 10-200mg 25 Tablets/30 Days
hydromorphone liquid 1MG/mL 60 mL/30 Days
HYDROMORPHONE SUPPOSITORY 3MG 20 Suppositories/30 Days
hydromorphone tablet 2mg 30 Tablets/30 Days
hydromorphone tablet 4mg 15 Tablets/30 Days
hydromorphone tablet 8mg 5 Tablets/30 Days
ibudone tablet 5-200mg 25 Tablets/30 Days
IBUDONE TABLET 10-200MG 25 Tablets/30 Days
levorphanol tablet 2mg 10 Tablets/30 Days
lorcet hd tablet 10-325mg 25 Tablets/30 Days
lorcet plus tablet 7.5-325 30 Tablets/30 Days
lorcet tablet 5-325mg 40 Tablets/30 Days
LORTAB ELIXER 10-300MG 338 mL/30 Days
MEPERIDINE SOLUTION 50MG/5ML 150 mL/30 Days
meperidine tablet 50mg 30 Tablets/30 Days
meperidine tablet 100mg 15 Tablets/30 Days
METHADONE SOLUTION 5MG/5ML 10 mL/30 Days
METHADONE SOLUTION 10MG/5ML 5 mL/30 Days
methadone tablet 5mg 60 Tablets/30 Days
methadone tablet 10mg 30 Tablets/30 Days
morphine sulfate solution 10/0.5ml 10 mL/30 Days
morphine sulfate solution 100/5ml 10 mL/30 Days
morphine sulfate solution 10mg/5ml 125 mL/30 Days
morphine sulfate solution 20mg/5ml 60 mL/30 Days
morphine sulfate solution 20MG/mL 10 mL/30 Days
MORPHINE SULFATE SUPPOSITORY 5MG 50 Suppositories/30 Days
MORPHINE SULFATE SUPPOSITORY 10MG 25 Suppositories/30 Days
MORPHINE SULFATE SUPPOSITORY 20MG 10 mL/30 Days
MORPHINE SULFATE SUPPOSITORY 30MG 5 Suppositories/30 Days
MORPHINE SULFATE TABLET 15MG 15 Tablets/30 Days
MORPHINE SULFATE TABLET 30MG 5 Tablets/30 Days
NORCO TABLET 5-325MG 40 Tablets/30 Days
NORCO TABLET 7.5-325 30 Tablets/30 Days
NORCO TABLET 10-325MG 25 Tablets/30 Days
NUCYNTA TABLET 50MG 10 Tablets/30 Days
NUCYNTA TABLET 75MG 5 Tablets/30 Days
NUCYNTA TABLET 100MG 5 Tablets/30 Days
OPANA TABLET 5MG 15 Tablets/30 Days
OPANA TABLET 10MG 5 Tablets/30 Days
OXAYDO TABLET 5MG 30 Tablets/30 Days
OXAYDO TABLET 7.5MG 20 Tablets/30 Days
oxycodone/acetaminophen tablet 2.5-325 60 Tablets/30 Days
oxycodone/acetaminophen tablet 5-325mg 30 Tablets/30 Days
oxycodone/acetaminophen tablet 7.5-325 20 Tablets/30 Days
oxycodone/acetaminophen tablet 10-325mg 15 Tablets/30 Days
oxycodone/aspirin tablet 30 Tablets/30 Days
OXYCODONE/IBUPROFEN TABLET 5-400MG 20 Tablets/30 Days
oxycodone capsule 5mg 30 Capsules/30 Days
oxycodone concentrate 10/0.5ml 5 mL/30 Days
oxycodone concentrate 100/5ml 5 mL/30 Days
oxycodone solution 5mg/5ml 165 mL/30 Days
oxycodone tablet 5mg 30 Tablets/30 Days
oxycodone tablet 10mg 15 Tablets/30 Days
oxycodone tablet 15mg 10 Tablets/30 Days
oxycodone tablet 20mg 5 Tablets/30 Days
oxycodone tablet 30mg 5 Tablets/30 Days
OXYCODONE/ SOLUTION ACETAMINOPHEN 100 mL/30 Days
oxymorphone tablet hcl 5mg 15 Tablets/30 Days
oxymorphone tablet hcl 10mg 5 Tablets/30 Days
panlor tablet 325-30 50 Capsules/30 Days
pentaz/naloxone tablet 50-0.5mg 10 Tablets/30 Days
PERCOCET TABLET 2.5-325 60 Tablets/30 Days
PERCOCET TABLET 5-325MG 30 Tablets/30 Days
PERCOCET TABLET 7.5-325 20 Tablets/30 Days
PERCOCET TABLET 10-325MG 15 Tablets/30 Days
PRIMLEV TABLET 5-300MG 30 Tablets/30 Days
PRIMLEV TABLET 7.5-300 20 Tablets/30 Days
PRIMLEV TABLET 10-300MG 15 Tablets/30 Days
ROXICODONE TABLET 5MG 30 Tablets/30 Days
ROXICODONE TABLET 15MG 10 Tablets/30 Days
ROXICODONE TABLET 30MG 5 Tablets/30 Days
ROXYBOND TABLET 5MG 30 Tablets/30 Days
tramadol hcl tablet 50mg 50 Tablets/30 Days
tramadol/acetaminophen tablet 37.5-325 40 Tablets/30 Days
TREZIX CAPSULE 50 Capsules/30 Days
TYLENOL/CODEINE TABLET #2 30 Tablets/30 Days
TYLENOL/CODEINE TABLET #3 30 Tablets/30 Days
TYLENOL/CODEINE TABLET #4 25 Tablets/30 Days
ULTRACET TABLET 37.5-325 40 Tablets/30 Days
ULTRAM TABLET 50MG 50 Tablets/30 Days
VERDROCET TABLET 2.5-325 60 Tablets/30 Days
vicodin es tablet 7.5-300 30 Tablets/30 Days
vicodin hp tablet 10-300mg 25 Tablets/30 Days
vicodin tablet 5-300mg 40 Tablets/30 Days
xylon tablet 10-200mg 25 Tablets/30 Days

Oral Inhalers

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ADVAIR DISKUS AER 100/50 60 Blisters/30 Days
ADVAIR DISKUS AER 250/50 60 Blisters/30 Days
ADVAIR DISKUS AER 500/50 60 Blisters/30 Days
ADVAIR HFA AER 45/21 1 Canister/30 Days
ADVAIR HFA AER 115/21 1 Canister/30 Days
ADVAIR HFA AER 230/21 1 Canister/30 Days
ALVESCO AER 80MCG 2 Canisters/30 Days
ALVESCO AER 160MCG 2 Canisters/30 Days
ARNUITY ELLIPTA INHALER 100MCG 30 Blisters/30 Days
ARNUITY ELLIPTA INHALER 200MCG 30 Blisters/30 Days
ASMANEX 30 AER 110MCG 1 Canister/30 Days
ASMANEX 14 AER 220MCG 1 Canister/30 Days
ASMANEX 30 AER 220MCG 1 Canister/30 Days
ASMANEX 60 AER 220MCG 1 Canister/30 Days
ASMANEX 120 AER 220MCG 1 Canister/30 Days
ASMANEX HFA AER 100 MCG 1 Canister/30 Days
ASMANEX HFA AER 200 MCG 1 Canister/30 Days
BREO ELLIPTA INHALER 100-25 60 Blisters/30 Days
BREO ELLIPTA INHALER 200-25 60 Blisters/30 Days
DULERA AER 100-5MCG 1 Canister/30 Days
DULERA AER 200-5MCG 1 Canister/30 Days
FLOVENT DISK AER 50MCG 60 Blisters/30 Days
FLOVENT DISK AER 100MCG 60 Blisters/30 Days
FLOVENT DISK AER 250MCG 240 Blisters/30 Days
FLOVENT HFA AER 44MCG 1 Canister/30 Days
FLOVENT HFA AER 110MCG 1 Canister/30 Days
FLOVENT HFA AER 220MCG 2 Canisters/30 Days
fluticasone/salmeterol aer 100/50 60 Blisters/30 Days
fluticasone/salmeterol aer 250/50 60 Blisters/30 Days
fluticasone/salmeterol aer 500/50 60 Blisters/30 Days
PULMICORT INHALER 90MCG 2 Canisters/30 Days
PULMICORT INHALER 180MCG 2 Canisters/30 Days
QVAR AER 40MCG 1 Canister/30 Days
QVAR AER 80MCG 2 Canisters/30 Days
QVAR REDIHALER AER 40MCG 1 Canister/30 Days
QVAR REDIHALER AER 80MCG 2 Canisters/30 Days
SYMBICORT AER 80-4.5 1 Canister/30 Days
SYMBICORT AER 160-4.5 1 Canister/30 Days
wixela inhub aer 100/50 60 Blisters/30 Days
wixela inhub aer 250/50 60 Blisters/30 Days
wixela inhub aer 500/50 60 Blisters/30 Days

Oral PAH

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ADCIRCA TABLET 20MG1 60 Tablets/30 Days
ADEMPAS TABLET 0.5MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 1MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 1.5MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 2MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 2.5MG1, 2 90 Tablets/30 Days
alyq tablet 20mg1 60 Tablets/30 Days
ambrisentan tablet 5mg1 30 Tablets/30 Days
ambrisentan tablet 10mg1 30 Tablets/30 Days
bosentan tablet 62.5mg1 60 Tablets/30 Days
bosentan tablet 125mg1 60 Tablets/30 Days
LETAIRIS TABLET 5MG1 30 Tablets/30 Days
LETAIRIS TALET 10MG1 30 Tablets/30 Days
OPSUMIT TABLET 10MG1 30 Tablets/30 Days
REVATIO SUS 10MG/ML1 2 Bottles/30 Days
REVATIO TABLET 20MG1 90 Tablets/30 Days
sildenafil suspense 10MG/mL1 224 mL/30 Days
sildenafil tablet 20mg1 90 Tablets/30 Days
tadalafil tablet 20mg1 60 Tablets/30 Days
TRACLEER TABLET 32MG1 120 Tablets/30 Days
TRACLEER TABLET 62.5MG1 60 Tablets/30 Days
TRACLEER TABLET 125MG1 60 Tablets/30 Days
UPTRAVI TABLET 200/8001, 2 1 Package/180 Days
UPTRAVI TABLET 200MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 200MCG1, 2 140 Tablets/180 Days
UPTRAVI TABLET 400MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 600MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 800MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 1000MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 1200MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 1400MCG1, 2 60 Tablets/30 Days
UPTRAVI TABLET 1600MCG1, 2 60 Tablets/30 Days
VENTAVIS SOLUTION 10MCG/ML1, 2 270 Ampules/30 Days
VENTAVIS SOLUTION 20MCG/ML1, 2 270 Ampules/30 Days

Orilissa

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ORILISSA TABLET 150MG 30 Tablets/30 Days
ORILISSA TABLET 200MG 60 Tablets/30 Days

Otezla

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

OTEZLA TABLET 10/20/301 1 Kit/180 Days
OTEZLA TABLET 30MG1 60 Tablets/30 Days

Parathyroid Hormone Analog Osteoporosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

FORTEO SOLUTION 600/2.41 1 Pen/28 Days
TYMLOS INJECTION1 1 Pen/30 Days

PCSK-9 Inhibitors

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

REPATHA INJECTION 140MG/ML1 2 Syringes/28 Days
REPATHA SURE INJECTION 140MG/ML1 2 Pens/28 Days
REPATHA PUSH INJECTION 420/3.51 1 Cartridge/30 Days
PRALUENT INJECTION 75MG/ML1 2 Syringes/28 Days
PRALUENT INJECTION 150MG/ML1 2 Syringes/28 Days

Proton Pump Inibitors (PPI)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ACIPHEX TABLET 20MG 30 Tablets/30 Days
DEXILANT CAPSULE 30MG DR 30 Capsules/30 Days
DEXILANT CAPSULE 60MG DR 30 Capsules/30 Days
esomepra magnesium capsule 40mg dr 30 Capsules/30 Days
lansoprazole capsule 15mg dr 30 Capsules/30 Days
lansoprazole capsule 30mg dr 30 Capsules/30 Days
NEXIUM CAPSULE 40MG 30 Capsules/30 Days
omeppi capsule 20-1100 30 Capsules/30 Days
omeppi capsule 40-1100 30 Capsules/30 Days
omeprazole/bicarbonate capsule 20-1100 30 Capsules/30 Days
omeprazole/bicarbonate capsule 40-1100 30 Capsules/30 Days
omeprazole/bicarbonate powder 20-1680 30 Packets/30 Days
omeprazole/bicarbonate powder 40-1680 30 Packets/30 Days
omeprazole capsule 10mg 30 Capsules/30 Days
omeprazole capsule 10mg dr 30 Capsules/30 Days
omeprazole capsule 20mg 30 Capsules/30 Days
omeprazole capsule 20mg dr 30 Capsules/30 Days
omeprazole capsule 40mg 30 Capsules/30 Days
omeprazole capsule 40mg dr 30 Capsules/30 Days
pantoprazole tablet 20mg 30 Tablets/30 Days
pantoprazole tablet 20mg dr 30 Tablets/30 Days
pantoprazole tablet 40mg 30 Tablets/30 Days
pantoprazole tablet 40mg dr 30 Tablets/30 Days
PREVACID CAPSULE 15MG DR 30 Tablets/30 Days
PREVACID CAPSULE 30MG DR 30 Tablets/30 Days
PROTONIX TABLET 20MG 30 Tablets/30 Days
PROTONIX TABLET 40MG 30 Tablets/30 Days
rabeprazole tablet 20mg 30 Tablets/30 Days
ZEGERID CAPSULE 20-1100 30 Capsules/30 Days
ZEGERID CAPSULE 40-1100 30 Capsules/30 Days
ZEGERID POWDER 20-1680 30 Packets/30 Days
ZEGERID POWDER 40-1680 30 Packets/30 Days

Prevymis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

PREVYMIS TABLET 240MG 100 Tablets/365 Days
PREVYMIS TABLET 480MG 100 Tablets/365 Days

Progesterones

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CRINONE GEL 4% VAG 6 Applicators/30 Days
CRINONE GEL 8% VAG 60 Applicators/30 Days
ENDOMETRIN SUPPOSITORY 100MG 4 Cartons/28 Days

Regranex

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

REGRANEX GEL 0.01% 1 Tube/30 Days

Rho Kinase Inhibitor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RHOPRESSA SOLUTION 0.02% 2.5 mL/30 Days
ROCKLATAN DRO 2.5 mL/30 Days

SA Oncology

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

abiraterone tablet 250mg1 120 Tablets/30 Days
AFINITOR DIS TABLET 2MG1 60 Tablets/30 Days
AFINITOR DIS TABLET 3MG1 90 Tablets/30 Days
AFINITOR DIS TABLET 5MG1 60 Tablets/30 Days
AFINITOR TABLET 2.5MG1 30 Tablets/30 Days
AFINITOR TABLET 5MG1 30 Tablets/30 Days
AFINITOR TABLET 7.5MG1 30 Tablets/30 Days
AFINITOR TABLET 10MG1 30 Tablets/30 Days
ALECENSA CAPSULE 150MG1, 2 240 Capsules/30 Days
ALUNBRIG PACK1, 2 30 Tablets/180 Days
ALUNBRIG TABLET 30MG1, 2 180 Tablets/30 Days
ALUNBRIG TABLET 90MG1, 2 30 Tablets/30 Days
ALUNBRIG TABLET 180MG1, 2 30 Tablets/30 Days
BALVERSA TABLET 3MG1, 2 90 Tablets/30 Days
BALVERSA TABLET 4MG1, 2 60 Tablets/30 Days
BALVERSA TABLET 5MG1, 2 30 Tablets/30 Days
BOSULIF TABLET 100MG1 120 Tablets/30 Days
BOSULIF TABLET 400MG1 30 Tablets/30 Days
BOSULIF TABLET 500MG1 30 Tablets/30 Days
BRAFTOVI CAPSULE 50MG1, 2 180 Capsules/30 Days
BRAFTOVI CAPSULE 75MG1, 2 180 Capsules/30 Days
CABOMETYX TABLET 20MG1 30 Tablets/30 Days
CABOMETYX TABLET 40MG1 30 Tablets/30 Days
CABOMETYX TABLET 60MG1 30 Tablets/30 Days
CALQUENCE CAPSULE 100MG1, 2 60 Capsules/30 Days
CAPRELSA TABLET 100MG1, 2 60 Tablets/30 Days
CAPRELSA TABLET 300MG1, 2 30 Tablets/30 Days
COMETRIQ KIT 60MG1, 2 1 Carton/28 Days
COMETRIQ KIT 100MG1, 2 1 Carton/28 Days
COMETRIQ KIT 140MG1, 2 112 Tablets/28 Days
COPIKTRA CAPSULE 25MG1, 2 56 Capsules/28 Days
COPIKTRA CAPSULE 15MG1, 2 56 Capsules/28 Days
COTELLIC TABLET 20MG1 63 Tablets/28 Days
DAURISMO TABLET 25MG1 60 Tablets/30 Days
DAURISMO TABLET 100MG1 30 Tablets/30 Days
ERIVEDGE CAPSULE 150MG1 30 Capsules/30 Days
erlotinib tablet 25mg1 60 Tablets/30 Days
erlotinib tablet 100mg1 30 Tablets/30 Days
erlotinib tablet 150mg1 30 Tablets/30 Days
everolimus tablet 2.5mg1 30 Tablets/30 Days
everolimus tablet 5mg1 30 Tablets/30 Days
everolimus tablet 7.5mg1 30 Tablets/30 Days
FARYDAK CAPSULE 10MG1 6 Capsules/21 Days
FARYDAK CAPSULE 15MG1 6 Capsules/21 Days
FARYDAK CAPSULE 20MG1 6 Capsules/21 Days
GILOTRIF TABLET 20MG1, 2 30 Tablets/30 Days
GILOTRIF TABLET 30MG1, 2 30 Tablets/30 Days
GILOTRIF TABLET 40MG1, 2 30 Tablets/30 Days
IBRANCE CAPSULE 75MG1 21 Capsules/28 Days
IBRANCE CAPSULE 100MG1 21 Capsules/28 Days
IBRANCE CAPSULE 125MG1 21 Capsules/28 Days
ICLUSIG TABLET 15MG1, 2 60 Tablets/30 Days
ICLUSIG TABLET 45MG1, 2 30 Tablets/30 Days
IDHIFA TABLET 50MG1 30 Tablets/30 Days
IDHIFA TABLET 100MG1 30 Tablets/30 Days
IMBRUVICA CAPSULE 70MG1, 2 30 Capsules/30 Days
IMBRUVICA CAPSULE 140MG1, 2 120 Capsules/30 Days
IMBRUVICA TABLET 140MG1, 2 120 Tablets/30 Days
IMBRUVICA TABLET 280MG1, 2 30 Tablets/30 Days
IMBRUVICA TABLET 420MG1, 2 30 Tablets/30 Days
IMBRUVICA TABLET 560MG1, 2 30 Tablets/30 Days
INLYTA TABLET 1MG1 180 Tablets/30 Days
INLYTA TABLET 5MG1 120 Tablets/30 Days
INREBIC CAPSULE 100MG1 120 Capsules/30 Days
IRESSA TABLET 250MG1, 2 30 Tablets/30 Days
JAKAFI TABLET 5MG1 60 Tablets/30 Days
JAKAFI TABLET 15MG1 60 Tablets/30 Days
JAKAFI TABLET 20MG1 60 Tablets/30 Days
JAKAFI TABLET 25MG1 60 Tablets/30 Days
KISQALI TABLET 200DOSE1 63 Tablets/28 Days
KISQALI TABLET 400DOSE1 63 Tablets/28 Days
KISQALI TABLET 600DOSE1 63 Tablets/28 Days
KISQALI 200 PACK FEMARA1 91 Tablets/28 Days
KISQALI 400 PACK FEMARA1 91 Tablets/28 Days
KISQALI 600 PACK FEMARA1 91 Tablets/28 Days
LENVIMA CAPSULE 4MG1, 2 30 Capsules/30 Days
LENVIMA CAPSULE 8 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 10 MG1, 2 30 Capsules/30 Days
LENVIMA CAPSULE 12MG1, 2 90 Capsules/30 Days
LENVIMA CAPSULE 14 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 18 MG1, 2 90 Capsules/30 Days
LENVIMA CAPSULE 20 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 24 MG1, 2 90 Capsules/30 Days
LONSURF TABLET 15-6.141 100 Tablets/28 Days
LONSURF TABLET 20-8.191 80 Tablets/28 Days
LORBRENA TABLET 25MG1 90 Tablets/30 Days
LORBRENA TABLET 100MG1 30 Tablets/30 Days
LYNPARZA CAPSULE 50MG 1, 2 480 Capsules/30 Days
LYNPARZA TABLET 100MG 1, 2 120 Tablets/30 Days
LYNPARZA TABLET 150MG1, 2 120 Tablets/30 Days
MEKINIST TABLET 0.5MG1 90 Tablets/30 Days
MEKINIST TABLET 2MG1 30 Tablets/30 Days
MEKTOVI TABLET 15MG1, 2 180 Tablets/30 Days
NERLYNX TABLET 40MG1, 2 180 Tablets/30 Days
NINLARO CAPSULE 2.3MG1 3 Capsules/28 Days
NINLARO CAPSULE 3MG1 3 Capsules/28 Days
NINLARO CAPSULE 4MG1 3 Capsules/28 Days
NUBEQA TABLET 300MG1 120 Tablets/30 Days
ODOMZO CAPSULE 200MG1 30 Capsules/30 Days
PIQRAY 200MG TABLET DOSE1 28 Tablets/28 Days
PIQRAY 250MG TABLET DOSE1 56 Tablets/28 Days
PIQRAY 300MG TABLET DOSE1 56 Tablets/28 Days
POMALYST CAPSULE 1MG1 21 Capsules/28 Days
POMALYST CAPSULE 2MG1 21 Capsules/28 Days
POMALYST CAPSULE 3MG1 21 Capsules/28 Days
POMALYST CAPSULE 4MG1 21 Capsules/28 Days
REVLIMID CAPSULE 2.5MG1 30 Capsules/30 Days
REVLIMID CAPSULE 5MG1 30 Capsules/30 Days
REVLIMID CAPSULE 10MG1 30 Capsules/30 Days
REVLIMID CAPSULE 15MG1 21 Capsules/28 Days
REVLIMID CAPSULE 20MG1 21 capsules/28 Days
REVLIMID CAPSULE 25MG1 21 Capsules/28 Days
ROZLYTREK CAPSULE 100MG1 30 Capsules/30 Days
ROZLYTREK CAPSULE 200MG1 90 Capsules/30 Days
RUBRACA TABLET 200MG1, 2 120 Tablets/30 Days
RUBRACA TABLET 250MG1, 2 120 Tablets/30 Days
RUBRACA TABLET 300MG1, 2 120 Tablets/30 Days
RYDAPT CAPSULE 25MG1, 2 240 Capsules/30 Days
RSTIVARGA TABLET 40MG1, 2 84 Tablets/28 Days
SUTENT CAPSULE 12.5MG1, 2 90 Capsules/30 Days
SUTENT CAPSULE 25MG1, 2 30 Capsules/30 Days
SUTENT CAPSULE 37.5MG1, 2 30 Capsules/30 Days
SUTENT CAPSULE 50MG1, 2 30 Capsules/30 Days
TAFINLAR CAPSULE 50MG1 120 Capsules/30 Days
TAFINLAR CAPSULE 75MG1 120 Capsules/30 Days
TAGRISSO TABLET 40MG1, 2 30 Tablets/30 Days
TAGRISSO TABLET 80MG1, 2 30 Tablets/30 Days
TALZENNA CAPSULE 0.25MG1 90 Capsules/30 Days
TALZENNA CAPSULE 1MG1 30 Capsules/30 Days
TARCEVA TABLET 25MG1 60 Tablets/30 Days
TARCEVA TABLET 100MG1 30 Tablets/30 Days
TARCEVA TABLET 150MG1 30 Tablets/30 Days
THALOMID CAPSULE 50MG1 30 Capsules/30 Days
THALOMID CAPSULE 100MG1 30 Capsules/30 Days
THALOMID CAPSULE 150MG1 60 Capsules/30 Days
THALOMID CAPSULE 200MG1 60 Capsules/30 Days
TIBSOVO TABLET 250MG1, 2 60 Tablets/30 Days
TURALIO CAPSULE 200MG1, 2 120 Capsules/30 Days
VENCLEXTA TABLET 10MG1, 2 60 Tablets/30 Days
VENCLEXTA TABLET 50MG1, 2 30 Tablets/30 Days
VENCLEXTA TABLET 100MG1, 2 180 Tablets/30 Days
VENCLEXTA TABLET START PK1, 2 1 Pack/180 Days
VERZENIO TABLET 50MG1, 2 60 Tablets/30 Days
VERZENIO TABLET 100MG1, 2 60 Tablets/30 Days
VERZENIO TABLET 150MG1, 2 60 Tablets/30 Days
VERZENIO TABLET 200MG1, 2 60 Tablets/30 Days
VITRAKVI CAPSULE 25MG1, 2 180 Capsules/30 Days
VITRAKVI CAPSULE 100MG1, 2 60 Capsules/30 Days
VITRAKVI SOLUTION 20MG/ML1, 2 300 mL/30 Days
VIZIMPRO TABLET 15MG1, 2 30 Tablets/30 Days
VIZIMPRO TABLET 30MG1, 2 30 Tablets/30 Days
VIZIMPRO TABLET 45MG1, 2 30 Tablets/30 Days
VOTRIENT TABLET 200MG1, 2 120 Tablets/30 Days
XOSPATA TABLET 40MG1, 2 90 Tablets/30 Days
XPOVIO PACK 60MG1, 2 1 Box/28 Days
XPOVIO PACK 80MG1, 2 1 Box/28 Days
XPOVIO PACK 100MG1, 2 1 Box/28 Days
XTANDI CAPSULE 40MG1 120 Capsules/30 Days
ZEJULA CAPSULE 100MG1, 2 90 Capsules/30 Days
ZELBORAF TABLET 240MG1 240 Tablets/30 Days
ZOLINZA CAPSULE 100MG1 120 Capsules/30 Days
ZYDELIG TABLET 100MG1, 2 60 Tablets/30 Days
ZYDELIG TABLET 150MG1, 2 60 Tablets/30 Days
ZYKADIA CAPSULE 150MG1 90 Capsules/30 Days
ZYKADIA TABLET 150MG1 90 Tablets/30 Days
ZYTIGA TABLET 250MG1 120 Tablets/30 Days
ZYTIGA TABLET 500MG1 60 Tablets/30 Days

Signifor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SIGNIFOR INJECTION 0.3MG/ML1 60 mL/30 Days
SIGNIFOR INJECTION 0.6MG/ML1 60 mL/30 Days
SIGNIFOR INJECTION 0.9MG/ML 1 60 mL/30 Days

Sodium Oxybate

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

XYREM SOLUTION 500MG/ML1, 2 540 mL/30 Days

Somatostatin Analogs

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SOMAVERT INJECTION 10MG1 30 Vials/30 Days
SOMAVERT INJECTION 15MG1 30 Vials/30 Days
SOMAVERT INJECTION 20MG1 30 Vials/30 Days
SOMAVERT INJECTION 25MG1 30 Vials/30 Days
SOMAVERT INJECTION 30MG1 30 Vials/30 Days

Selective Serotonin Inverse Agonist (SSIA)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NUPLAZID TABLET 10MG1 30 Tablets/30 Days
NUPLAZID TABLET 17MG1 60 Tablets/30 Days
NUPLAZID CAPSULE 34MG1 30 Capsules/30 Days

Statins

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ALTOPREV TABLET 20MG ER 30 Tablets/30 Days
ALTOPREV TABLET 40MG ER 30 Tablets/30 Days
ALTOPREV TABLET 60MG ER 30 Tablets/30 Days
atorvastatin tablet 10mg 45 Tablets/30 Days
atorvastatin tablet 20mg 45 Tablets/30 Days
atorvastatin tablet 40mg 45 Tablets/30 Days
atorvastatin tablet 80mg 30 Tablets/30 Days
CRESTOR TABLET 5MG 45 Tablets/30 Days
CRESTOR TABLET 10MG 45 Tablets/30 Days
CRESTOR TABLET 20MG 45 Tablets/30 Days
CRESTOR TABLET 40MG 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-10mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-20mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-40mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-80mg 30 Tablets/30 Days
fluvastatin tablet 80mg er 30 Tablets/30 Days
LESCOL XL TABLET 80MG 30 Tablets/30 Days
LIPITOR TABLET 10MG 45 Tablets/30 Days
LIPITOR TABLET 20MG 45 Tablets/30 Days
LIPITOR TABLET 40MG 45 Tablets/30 Days
LIPITOR TABLET 80MG 30 Tablets/30 Days
LIVALO TABLET 1MG 45 Tablets/30 Days
LIVALO TABLET 2MG 45 Tablets/30 Days
LIVALO TABLET 4MG 30 Tablets/30 Days
lovastatin tablet 10mg 60 Tablets/30 Days
lovastatin tablet 20mg 60 Tablets/30 Days
lovastatin tablet 40mg 60 Tablets/30 Days
PRAVACHOL TABLET 20MG 45 Tablets/30 Days
PRAVACHOL TABLET 40MG 45 Tablets/30 Days
PRAVACHOL TABLET 80MG 30 Tablets/30 Days
pravastatin tablet 10mg 45 Tablets/30 Days
pravastatin tablet 20mg 45 Tablets/30 Days
pravastatin tablet 40mg 45 Tablets/30 Days
pravastatin tablet 80mg 30 Tablets/30 Days
rosuvastatin tablet 5mg 45 Tablets/30 Days
rosuvastatin tablet 10mg 45 Tablets/30 Days
rosuvastatin tablet 20mg 45 Tablets/30 Days
rosuvastatin tablet 40mg 30 Tablets/30 Days
simvastatin tablet 5mg 45 Tablets/30 Days
simvastatin tablet 10mg 45 Tablets/30 Days
simvastatin tablet 20mg 60 Tablets/30 Days
simvastatin tablet 40mg 45 Tablets/30 Days
simvastatin tablet 80mg 30 Tablets/30 Days
VYTORIN TABLET 10-10MG 30 Tablets/30 Days
VYTORIN TABLET 10-20MG 30 Tablets/30 Days
VYTORIN TABLET 10-40MG 30 Tablets/30 Days
VYTORIN TABLET 10-80MG 30 Tablets/30 Days
ZOCOR TABLET 5MG 45 Tablets/30 Days
ZOCOR TABLET 10MG 45 Tablets/30 Days
ZOCOR TABLET 20MG 60 Tablets/30 Days
ZOCOR TABLET 40MG 45 Tablets/30 Days
ZOCOR TABLET 80MG 30 Tablets/30 Days

Substrate Reduction Therapy

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CERDELGA CAPSULE 84MG1 60 Capsules/30 Days

Sunosi

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SUNOSI TABLET 75MG 30 Tablets/30 Days
SUNOSI TABLET 150MG 30 Tablets/30 Days
miglustat capsule 100mg1 90 Capsules/30 Days
ZAVESCA CAPSULE 100MG1, 2 90 Capsules/30 Days

Tafamidis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

VYNDAMAX CAPSULE 61MG1 30 Capsules/30 Days
VYNDAQEL CAPSULE 20MG1 120 Capsules/30 Days

Thrombopoietin Receptor Agonists

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

MULPLETA TABLET 3MG1 7 Tablets/7 Days
PROMACTA POWDER 12.5MG1 30 Packets/30 Days
PROMACTA TABLET 12.5MG1 30 Tablets/30 Days
PROMACTA TABLET 25MG1 30 Tablets/30 Days
PROMACTA TABLET 50MG1 60 Tablets/30 Days
PROMACTA TABLET 75MG1 60 Tablets/30 Days

Topical Corticosteroids

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ALA SCALP LOTION 2% 118.4 mL/30 Days
ala-cort cream 1% 454 Grams/30 Days
ala-cort cream 2.5% 454 Grams/30 Days
alclometason cream 0.05% 120 Grams/30 Days
alclometason ointment 0.05% 120 Grams/30 Days
AMCINONIDE CREAM 0.1% 120 Grams/30 Days
AMCINONIDE LOTION 0.1% 120 mL/30 Days
AMCINONIDE OINTMENT 0.1% 120 Grams/30 Days
APEXICON E CREAM 0.05% 120 Grams/30 Days
aug betamet cream 0.05% 200 Grams/28 Days
AUG BETAMET GEL 0.05% 200 Grams/28 Days
augmented betamethasone lotion 0.05% 210 mL/30 Days
augmented betamethasone ointment 0.05% 200 Grams/28 Days
beser lotion 0.05% 120 mL/30 Days
BETA DIPROP GEL 0.05% 200 Grams/28 Days
betamethasone dipropionate cream 0.05% 135 Grams/30 Days
betamethasone dipropionate lotion 0.05% 120 mL/30 Days
betamethasone dipropionate ointment 0.05% 135 Grams/30 Days
betamethasone valerate aer 0.12% 150 Grams/30 Days
betamethasone valerate cream 0.1% 135 Grams/30 Days
betamethasone valerate lotion 0.1% 120 mL/30 Days
betamethasone valerate ointment 0.1% 135 Grams/30 Days
CAPEX SHA 0.01% 840 mL/28 Days
clobetasol aer 0.05% 200 Grams/28 Days
clobetasol cream 0.05% 210 Grams/28 Days
clobetasol e cream 0.05% 210 Grams/28 Days
clobetasol gel 0.05% 210 Grams/28 Days
clobetasol lotion 0.05% 177 mL/28 Days
clobetasol ointment 0.05% 210 Grams/28 Days
clobetasol shampoo 0.05% 236 mL/30 Days
clobetasol solution 0.05% 200 mL/28 Days
clobetasol spray 0.05% 236 mL/28 Days
CLOBEX LOTION 0.05% 177 mL/28 Days
CLOBEX SHA 0.05% 236 mL/30 Days
CLOBEX SPR 0.05% 236 mL/28 Days
CLOCORTOLONE CREAM 0.1% 135 Grams/30 Days
CLOCORTOLONE CREAM PIV 0.1% 135 Grams/30 Days
clodan shampoo 0.05% 236 mL/30 Days
CLODERM CREAM 0.1% 135 Grams/30 Days
CLODERM CREAM 0.1% PMP 135 Grams/30 Days
CORDRAN 80X3 TAP 4MCG/CM 1 Box/30 Days
CORDRAN CREAM 0.025% 120 Grams/30 Days
CORDRAN CREAM 0.05% 120 Grams/30 Days
CORDRAN LOTION 0.05% 120 mL/30 Days
CORDRAN LOTION 0.05% 120 Grams/30 Days
CUTIVATE LOTION 0.05% 120 mL/30 Days
DERMA-SMOOTH OIL/FS BODY 118.28 mL/30 Days
DERMA-SMOOTH OIL/FS SCLP 118.28 mL/30 Days
DESONATE GEL 0.05% 120 Grams/30 Days
desonide cream 0.05% 120 Grams/30 Days
desonide lotion 0.05% 118 mL/30 Days
desonide ointment 0.05% 120 Grams/30 Days
DESOWEN CREAM 0.05% 120 Grams/30 Days
DESOWEN LOTION 0.05% 118 mL/30 Days
desoximetas cream 0.05% 120 Grams/30 Days
desoximetas cream 0.25% 120 Grams/30 Days
desoximetas gel 0.05% 120 Grams/30 Days
desoximetas ointment 0.05% 120 Grams/30 Days
desoximetas ointment 0.25% 120 Grams/30 Days
desoximetasone spray 0.25% 100 mL/30 Days
DIFLORASONE CREAM 0.05% 120 Grams/30 Days
diflorasone ointment 0.05% 120 Grams/30 Days
DIPROLENE AF CREAM 0.05% 200 Grams/28 Days
DIPROLENE LOTION 0.05% 200 Grams/28 Days
ELOCON CREAM 0.1% 135 Grams/30 Days
ELOCON LOTION 0.1% 135 Grams/30 Days
fluocinoline acetonide cream 0.01% 120 Grams/30 Days
fluocinoline acetonide cream 0.025% 120 Grams/30 Days
fluocinoline acetonide oil 0.01% scalp 118.28 mL/30 Days
fluocinoline acetonide oil 0.01% body 118.28 mL/30 Days
fluocinoline acetonide oil body 118.28 mL/30 Days
fluocinoline acetonide oil scalp 118.28 mL/30 Days
fluocinoline acetonide ointment 0.025% 120 Grams/30 Days
fluocinoline acetonide solution 0.01% 120 mL/30 Days
fluocinonide cream 0.05% 120 Grams/30 Days
fluocinonide cream 0.1% 240 Grams/28 Days
fluocinonide cream e 0.05% 120 Grams/30 Days
fluocinonide gel 0.05% 120 Grams/30 Days
fluocinonide ointment 0.05% 120 Grams/30 Days
fluocinonide solution 0.05% 120 mL/30 Days
flurandrenol cream 0.05% 120 Grams/30 Days
flurandrenol lotion 0.05% 120 mL/30 Days
flurandrenol ointment 0.05% 120 Grams/30 Days
fluticasone cream 0.05% 120 Grams/30 Days
fluticasone lotion 0.05% 120 mL/30 Days
fluticasone ointment 0.005% 120 Grams/30 Days
halcinonide cream 0.1% 240 Grams/30 Days
halobetasol cream 0.05% 200 Grams/28 Days
halobetasol ointment 0.05% 200 Grams/28 Days
HALOG CREAM 0.1% 240 Grams/30 Days
HALOG OINTMENT 0.1% 240 Grams/30 Days
hc butyrate cream 0.1% 120 Grams/30 Days
hc butyrate cream 0.1% 135 Grams/30 Days
hc butyrate ointment 0.1% 135 Grams/30 Days
hc butyrate solution 0.1% 120 mL/30 Days
hc valerate cream 0.2% 120 Grams/30 Days
hc valerate ointment 0.2% 120 Grams/30 Days
hydrocortisone cream 1% 454 Grams/30 Days
hydrocortisone cream 2.5% 454 Grams/30 Days
hydrocortisone lotion 2.5% 118 mL/30 Days
hydrocortisone ointment 2.5% 454 Grams/30 Days
hydrocortisone lotion 0.1% 118 mL/30 Days
IMPOYZ CREAM 0.025% 240 Grams/30 Days
KENALOG AER SPRAY 126 Grams/30 Days
LOCOID CREAM 0.1% 135 Grams/30 Days
LOCOID LIPO CREAM 0.1% 120 Grams/30 Days
LOCOID LOTION 0.1% 118 mL/30 Days
LOCOID OINTMENT 0.1% 135 Grams/30 Days
LOCOID SOLUTION 0.1% 120 mL/30 Days
LUXIQ AER 0.12% 150 Grams/30 Days
MICORT-HC CREAM 2.5% 120 Grams/30 Days
mometasone cream 0.1% 135 Grams/30 Days
mometasone ointment 0.1% 135 Grams/30 Days
mometasone solution 0.1% 120 mL/30 Days
nolix cream 0.05% 120 Grams/30 Days
nolix lotion 0.05% 120 mL/30 Days
OLUX AER 0.05% 200 Grams/28 Days
OLUX-E AER 0.05% 200 Grams/28 Days
PANDEL CREAM 0.1% 160 Grams/30 Days
PREDNICARBATE CREAM 0.1% 120 Grams/30 Days
PREDNICARBATE OINTMENT 0.1% 120 Grams/30 Days
PSORCON CREAM 0.05% 120 Grams/30 Days
SERNIVO SPRAY 120 mL/30 Days
SERNIVO SPRAY 0.05% 120 mL/30 Days
SYNALAR CREAM 0.025% 120 Grams/30 Days
SYNALAR OINTMENT 0.025% 120 Grams/30 Days
SYNALAR Solution 0.01% 120 mL/30 Days
TEMOVATE CREAM 0.05% 210 Grams/28 Days
TEMOVATE OINTMENT 0.05% 210 Grams/28 Days
TEXACORT SOLUTION 2.5% 120 mL/30 Days
TOPICORT CREAM 0.05% 120 Grams/30 Days
TOPICORT CREAM 0.25% 120 Grams/30 Days
TOPICORT GEL 0.05% 120 Grams/30 Days
TOPICORT OINTMENT 0.05% 120 Grams/30 Days
TOPICORT OINTMENT 0.25% 120 Grams/30 Days
TOPICORT SPRAY 0.25% 100 mL/30 Days
tovet aer 0.05% 200 Grams/28 Days
triamcinolone aer spray 126 Grams/30 Days
triamcinolone cream 0.025% 454 Grams/30 Days
triamcinolone cream 0.1% 454 Grams/30 Days
triamcinolone cream 0.5% 454 Grams/30 Days
triamcinolone lotion 0.025% 120 mL/30 Days
triamcinolone lotion 0.1% 120 mL/30 Days
triamcinolone ointment 0.025% 454 Grams/30 Days
triamcinolone ointment 0.05% 430 Grams/30 Days
triamcinolone ointment 0.1% 454 Grams/30 Days
triamcinolone ointment 0.5% 120 Grams/30 Days
trianex ointment 0.05% 430 Grams/30 Days
triderm cream 0.1% 454 Grams/30 Days
triderm cream 0.5% 454 Grams/30 Days
TRIDESILON CREAM 0.05% 120 Grams/30 Days
ULTRAVATE CREAM 0.05% 200 Grams/28 Days
ULTRAVATE LOTION 0.05% 240 mL/30 Days
ULTRAVATE OINTMENT 0.05% 200 Grams/28 Days
VANOS CREAM 0.1% 240 Grams/28 Days
VERDESO AER 0.05% 100 Grams/30 Days

Topical Lidocaine

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

lidocaine pad 5% 90 Patches/30 Days
LIDODERM DIS 5% 90 Patches/30 Days
ZTLIDO PAD 1.8% 90 Patches/30 Days

Topical NSAID

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

DICLOFENAC DIS 1.3% 60 Patches/30 Days
diclofenac gel 1% 10 Tubes/30 Days
diclofenac solution 1.5% 2 Bottles/30 Days
FLECTOR DIS 1.3% 60 Patches/30 Days
klofensaid solution ii 2 Bottles/30 Days
PENNSAID SOLUTION 2% 2 Pumps/28 Days
VOLTAREN GEL 1% 10 Tubes/30 Days

Topiramate ER

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

QUDEXY XR CAPSULE 25/24HR 30 Capsules/30 Days
QUDEXY XR CAPSULE 50/24HR 30 Capsules/30 Days
QUDEXY XR CAPSULE 100/24HR 30 Capsules/30 Days
QUDEXY XR CAPSULE 150/24HR 30 Capsules/30 Days
QUDEXY XR CAPSULE 200/24HR 60 Capsules/30 Days
TOPIRAMATE CAPSULE ER 25MG 30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 50MG 30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 100MG 30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 150MG 30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 200MG 60 Capsules/30 Days
TROKENDI XR CAPSULE 25MG 30 Capsules/30 Days
TROKENDI XR CAPSULE 50MG 30 Capsules/30 Days
TROKENDI XR CAPSULE 100MG 30 Capsules/30 Days
TROKENDI XR CAPSULE 200MG 60 Capsules/30 Days

Transmucosal Immediate Release Fentanyl

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ABSTRAL SUBLINGUAL 100MCG 120 Tablets/30 Days
ABSTRAL SUBLINGUAL 200MCG 120 Tablets/30 Days
ABSTRAL SUBLINGUAL 300MCG 120 Tablets/30 Days
ABSTRAL SUBLINGUAL 400MCG 120 Tablets/30 Days
ABSTRAL SUBLINGUAL 600MCG 120 Tablets/30 Days
ABSTRAL SUBLINGUAL 800MCG 120 Tablets/30 Days
ACTIQ LOZENGE 200MCG 120 Lozenges/30 Days
ACTIQ LOZENGE 400MCG 120 Lozenges/30 Days
ACTIQ LOZENGE 600MCG 120 Lozenges/30 Days
ACTIQ LOZENGE 800MCG 120 Lozenges/30 Days
ACTIQ LOZENGE 1200MCG 120 Lozenges/30 Days
ACTIQ LOZENGE 1600MCG 120 Lozenges/30 Days
FENTANYL CITRATE TABLET 100MCG 120 Tablets/30 Days
FENTANYL CITRATE TABLET 200MCG 120 Tablets/30 Days
FENTANYL CITRATE TABLET 400MCG 120 Tablets/30 Days
FENTANYL CITRATE TABLET 600MCG 120 Tablets/30 Days
FENTANYL CITRATE TABLET 800MCG 120 Tablets/30 Days
fentanyl ot lozenge 200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 400mcg 120 Lozenges/30 Days
fentanyl ot lozenge 600mcg 120 Lozenges/30 Days
fentanyl ot lozenge 800mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1600mcg 120 Lozenges/30 Days
FENTORA TABLET 100MCG 120 Tablets/30 Days
FENTORA TABLET 200MCG 120 Tablets/30 Days
FENTORA TABLET 400MCG 120 Tablets/30 Days
FENTORA TABLET 600MCG 120 Tablets/30 Days
FENTORA TABLET 800MCG 120 Tablets/30 Days
LAZANDA SPRAY 100MCG 1 Bottle/30 Days
LAZANDA SPRAY 300MCG 1 Bottle/30 Days
LAZANDA SPRAY 400MCG 1 Bottle/30 Days
SUBSYS SPRAY 100MCG 120 Sprays/30 Days
SUBSYS SPRAY 200MCG 120 Sprays/30 Days
SUBSYS SPRAY 400MCG 120 Sprays/30 Days
SUBSYS SPRAY 600MCG 120 Sprays/30 Days
SUBSYS SPRAY 800MCG 120 Sprays/30 Days
SUBSYS SPRAY 1200MCG 240 Sprays/30 Days
SUBSYS SPRAY 1600MCG 240 Sprays/30 Days

URAT1 Inhibitor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

DUZALLO TABLET 200-200 30 Tablets/30 Days
DUZALLO TABLET 200-300 30 Tablets/30 Days
ZURAMPIC TABLET 200MG 30 Tablets/30 Days

VMAT2 Inhibitor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AUSTEDO TABLET 6MG1 60 Tablets/30 Days
AUSTEDO TABLET 9MG1 120 Tablets/30 Days
AUSTEDO TABLET 12MG1 120 Tablets/30 Days
INGREZZA CAPSULE 40MG1, 2 30 Capsules/30 Days
INGREZZA CAPSULE 80MG1, 2 30 Capsules/30 Days
INGREZZA CAPSULE 40-80MG1, 2 28 Capsules/180 Days
tetrabenazine tablet 12.5mg1 240 Tablets/30 Days
tetrabenazine tablet 25mg1 120 Tablets/30 Days
XENAZINE TABLET 12.5MG1 240 Tablets/30 Days
XENAZINE TABLET 25MG1 120 Tablets/30 Days

Wakix

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

WAKIX TABLET 4.45MG 60 Tablets/30 Days
WAKIX TABLET 17.8MG 60 Tablets/30 Days

Weight Loss Agents

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ADIPEX-P CAPSULE 37.5MG 30 Capsules/30 Days
ADIPEX-P TABLET 37.5MG 30 Tablets/30 Days
BELVIQ TABLET 10MG 60 Tablets/30 Days
BELVIQ XR TABLET 20MG 30 Tablets/30 Days
BENZPHETMINE TABLET 25MG 90 Tablets/30 Days
benzphetamine tablet 50mg 90 Tablets/30 Days
CONTRAVE TABLET 8-90MG 120 Tablets/30 Days
diethylpropion tablet 25mg 90 Tablets/30 Days
DIETHYLPROP TABLET 75MG ER 30 Tablets/30 Days
LOMAIRA TABLET 8MG 90 Tablets/30 Days
phendimetraz tablet 35mg 180 Tablets/30 Days
PHENDIMETRAZ CAPSULE 105MG SR 30 Capsules/30 Days
phentermine capsule 15mg 30 Capsules/30 Days
phentermine capsule 30mg 30 Capsules/30 Days
phentermine capsule 37.5mg 30 Capsules/30 Days
phentermine tablet 37.5mg 30 Tablets/30 Days
QSYMIA CAPSULE 3.75-23 30 Capsules/30 Days
QSYMIA CAPSULE 7.5-46MG 30 Capsules/30 Days
QSYMIA CAPSULE 11.25-69 30 Capsules/30 Days
QSYMIA CAPSULE 15-92MG 30 Capsules/30 Days
REGIMEX TABLET 25MG 90 Tablets/30 Days
SAXENDA INJECTION 18MG/3ML 15 mL/30 Days
XENICAL CAPSULE 120MG 90 Capsules/30 Days

Xermelo

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

XERMELO TABLET 250MG1, 2 90 Tablets/30 Days

Drug Name(s)

abiraterone acetate1 ACTEMRA1 ACTIMMUNE1
ADCIRCA1 ADEMPAS1, 2 AFINITOR1
AFINITOR DISPERZ1 AIMOVIG1 AJOVY1
ALECENSA1, 2 ALUNBRIG1, 2 alyq1
ambrisentan1 AMPYRA1 APOKYN1, 2
ARCALYST1, 2 ARIKAYCE1, 2 AUBAGIO1
AUSTEDO1 AVONEX1 AVONEX PEN1
BALVERSA1, 2 BARACLUDE1 BENLYSTA1
BETASERON1 BETHKIS1 bexarotene1
bosentan1 BOSULIF1 BRAFTOVI1, 2
BRAVELLE1 BUPHENYL1 CABOMETYX1
CALQUENCE1, 2 capecitabine1 CAPRELSA1, 2
CARBAGLU1, 2 CAYSTON1 CERDELGA1
CETROTIDE1 CHENODAL1, 2 CHOLBAM1, 2
CHORIONIC GONADOTROPIN1 CIMZIA1 CIMZIA STARTER KIT1
cinacalcet hydrochloride1 COMETRIQ1, 2 COPAXONE1
COPIKTRA1, 2 COSENTYX1 COSENTYX SENSOREADY PEN1
COTELLIC1 CUTAQUIG1, 2 CUVITRU1, 2
CYSTADANE1, 2 CYSTAGON1, 2 DAKLINZA1
dalfampridine er1 DAURISMO1 deferasirox1
DIACOMIT1 dofetilide1 DUPIXENT1
EGRIFTA1 EGRIFTA SV1 EMFLAZA1, 2
EMGALITY1 ENBREL1 ENBREL MINI1
ENBREL SURECLICK1 ENDARI1, 2 entecavir1
EPCLUSA1 EPIDIOLEX1 ERIVEDGE1
erlotinib hydrochloride1 ESBRIET1 everolimus1
EXJADE1 EXTAVIA1 FARYDAK1
FERRIPROX1, 2 FIRAZYR1 FIRDAPSE1, 2
FIRMAGON1 FOLLISTIM AQ1 FORTEO1
FUZEON1 GALAFOLD1 ganirelix acetate1
GANIRELIX ACETATE1 GATTEX1, 2 GENOTROPIN1
GENOTROPIN MINIQUICK 1 GILENYA1 GILOTRIF1, 2
glatiramer acetate1 glatopa1 GLEEVEC1
GOCOVRI1 GONAL-F1 GONAL-F RFF1
GONAL-F RFF REDIJECT1 GRANIX1 HAEGARDA1, 2
HARVONI1 HELIXATE FS1 HEMLIBRA1
HETLIOZ1, 2 HIZENTRA1 HUMIRA1
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1 HUMIRA PEN1 HUMIRA PEN-CD/UC/HS STARTER1
HYCAMTIN1 HYQVIA1 IBRANCE1
icatibant acetate1 ICLUSIG1, 2 IDHIFA1
imatinib mesylate1 IMBRUVICA1, 2 INBRIJA1
INCRELEX1, 2 INGREZZA1, 2 INLYTA1
INREBIC1 INTRON A1 IRESSA1, 2
JADENU1 JADENU SPRINKLE1 JAKAFI1
JUXTAPID1, 2 JYNARQUE1 KALYDECO1
KEVEYIS1, 2 KEVZARA1 KINERET1, 2
KISQALI1 KISQALI FEMARA1 KITABIS PAK1
KOGENATE FS1 KOGENATE FS BIO-SET1 KORLYM1, 2
KUVAN1 KYNAMRO1 LEDIPASVIR/SOFOSBUVIR1
LENVIMAE1, 2 LETAIRIS1 leuprolide acetate1
LONSURF1 LORBRENA1 LUPANETA PACK1
LYNPARZA1, 2 MATULANE1 MAVENCLAD1
MAVYRET1 MAYZENT1 MEKINIST1
MEKTOVI1, 2 MENOPUR1 miglustat1
moderiba1 MODERIBA1 MULPLETA1
MYALEPT1, 2 NATPARA1 NERLYNX1, 2
NEULASTA1 NEULASTA ONPRO KIT1 NEXAVAR1
NINLARO1 nitisinone1, 2 NITYR1, 2
NORDITROPIN FLEXPRO1 NORTHERA1 NOVAREL1
NUBEQA1 NUPLAZID1 NUTROPIN AQ NUSPIN1
OCALIVA 1 ODOMZO1 OFEV1
OLUMIANT1 OLYSIO1 OMNITROPE1
OPSUMIT1, 2 ORENCIA1 ORENCIA CLICKJECT1
ORENITRAM1, 2 ORFADIN1, 2 ORKAMBI1
OTEZLA1 OTREXUP1 OVIDREL1
OXERVATE1, 2 PEGASYS1 PEGASYS PROCLICK1
PEGINTRON1 PIQRAY1 PLEGRIDY1
PLEGRIDY STARTER PACK1 POMALYST1 PRALUENT1
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1 PROCRIT1 PROCYSBI1, 2
PROMACTA1 PULMOZYME1 RASUVO1
RAVICTI1 REBETOL1 REBIF1
REBIF REBIDOSE1 REBIF REBIDOSE TITRATION PACK1 REBIF TITRATION PACK1
REPATHA 1 REPATHA PUSHTRONEX SYSTEM1 REPATHA SURECLICK1
REVATIO1 REVCOVI1 REVLIMID1
ribasphere1 RIBASPHERE1 RIBASPHERE RIBAPAK1
ribavirin1 RINVOQ1 ROZLYTREK1
RUBRACA1, 2 RUZURGI1, 2 RYDAPT1
SABRIL1 SAMSCA1 SENSIPAR1
SEROSTIM1 SIGNIFOR1, 2 sildenafil citrate1
SILIQ1 SIMPONI1 SKYRIZI1
sodium phenylbutyrate1 SOFOSBUVIR/VELPATASVIR1 SOMAVERT1
SOVALDI1 SPRYCEL1 STELARA1
STIMATE1 STIVARGA1 STRENSIQ1, 2
SUTENT1 SYLATRON1 SYNAREL1
tadalafil1 TAFINLAR1 TAGRISSO1, 2
TAKHZYRO1, 2 TALTZ1 TALZENNA1
TARCEVA1 TARGRETIN1 TASIGNA1
TECFIDERA1 TECFIDERA STARTER PACK1 TECHNIVIE1
TEGSEDI1, 2 TEMODAR1 temozolomide1
tetrabenazine1 THALOMID1 THIOLA1, 2
TIBSOVO1, 2 TIKOSYN1 TOBI1
TOBI PODHALER1 tobramycin1 TOBRAMYCIN1
TRACLEER1 TREMFYA1 TURALIO1, 2
TYKERB1 TYMLOS1 UPTRAVI1, 2
VALCHLOR1, 2 VELTASSA1 VEMLIDY1
VENCLEXTA STARTING PACK1, 2 VENCLEXTA1, 2 VENTAVIS1, 2
VERZENIO1, 2 VIEKIRA PAK1 VIEKIRA XR1
vigabatrin1 vigadrone1, 2 VIRAZOLE1
VISTOGARD1, 2 VITRAKVI1, 2 VIZIMPRO1
VOSEVI1 VOTRIENT1 VYNDAMAX1
VYNDAQEL1 XADAGO1 XALKORI1
XELJANZ1 XELJANZ XR1 XELODA1
XENAZINE1 XEPI1 XERMELO1, 2
XOSPATA1, 2 XPOVIO1, 2 XTANDI1
XURIDEN1, 2 XYNTHA1 XYNTHA SOLOFUSE1
XYREM1, 2 ZARXIO1 ZAVESCA1, 2
ZEJULA1, 2 ZELBORAF1 ZEPATIER1
ZINBRYTA1 ZOLINZA1 ZOMACTON1
ZORBTIVE1 ZYDELIG1, 2 ZYKADIA1
ZYTIGA1    

1Specialty

2Limited Distribution