Advantage prescription drug benefits

Effective January 1, 2022

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)
ABILIFY	abiraterone acetate ¹	ABSTRAL
ACIPHEX	ACTEMRA ¹	ACTEMRA ACTPEN ¹
ACTHAR ¹	ACTICLATE	ACTIQ
ADCIRCA ¹	ADDERALL	ADDERALL XR
ADEMPAS ²	ADHANSIA XR	ADIPEX-P
ADMELOG	ADMELOG SOLOSTAR	ADVATE ¹
ADYNOVATE ¹	ADZENYS ER	ADZENYS XR-ODT
AFINITOR ^1,³	AFINITOR DISPERZ ^1,³	AFREZZA
AFSTYLA ¹	AKLIEF	ALDARA
ALECENSA ^2,³	alosetron hcl	ALPHANINE SD ¹
ALPROLIX ¹	ALUNBRIG ²	alyq ¹
AMBIEN	AMBIEN CR	ambrisentan ¹
AMITIZA	AMPHETAMINE ER	AMPYRA ^1,³
AMRIX	ANAFRANIL	ANDRODERM
ANDROGEL	ANDROGEL PUMP	APIDRA
APIDRA SOLOSTAR	APLENZIN	APTENSIO XR
ARAZLO	ARCALYST ²	ARIKAYCE ²
ARYMO ER	ATRALIN	AUBAGIO ^1,³
AUSTEDO ¹	AUVI-Q	avita
AVONEX ¹	AVONEX PEN ¹	AYVAKIT ^2,³
AZESCHEW PRENATAL / POSTNATAL	AZESCO	BAFIERTAM
BALVERSA ^2,³	BELBUCA	BELSOMRA
BENEFIX ¹	BENLYSTA ¹	benzphetamin tab 50mg
BENZPHETMINE TAB 25MG	BETASERON ¹	BETHKIS ¹
bexarotene ¹ -	bosentan ¹	BOSULIF ^1,³
BRAFTOVI ²	BRUKINSA ²	BUPHENYL ¹
buprenorphine	BUPROPION HCL ER (XL)	BUTRANS
BYNFEZIA PEN	CABOMETYX ^1,³	CALQUENCE ²
capecitabine ¹	CAPLYTA	CAPRELSA ²
CARAC	CARBAGLU ²	CAYSTON ¹
CELEXA	CERDELGA ¹	CETROTIDE ¹
CHORIONIC GONADOTROPIN ¹	ciclodan	ciclopirox nail lacquer
CIMZIA ¹	CIMZIA STARTER KIT ¹	cinacalcet ¹
CIPRO HC	CIPRODEX	ciprofloxacin/dexamethasone
CLEMASTINE FUMARATE	clomipramine hcl	CLOZAPINE ODT
CLOZARIL	COLCHICINE	COMETRIQ ^2,³
CONCERTA	CONTRAVE	CONZIP
COPAXONE ¹	COPIKTRA ^2,³	CORLANOR
COSENTYX ¹	COSENTYX SENSOREADY PEN ¹	COTELLIC ¹
COTEMPLA XR-ODT	CRESEMBA	CRINONE
CUTAQUIG ²	CUVITRU ²	cyclobenzaprine hcl er
CYMBALTA	dalfampridine er ¹ -	DANTRIUM
DARAPRIM	DAURISMO ^1,³	DAYTRANA
DAYVIGO	deferasirox ¹ -	DEPO-TESTOSTERONE
DESOXYN	DESVENLAFAXINE ER	DICLEGIS
diclofenac sodium	diethylpropion hcl	DIETHYLPROPION HCL ER
dihydroergotamine mesylate	dimethyl fumarate ¹	dimethyl fumarate starterpack ¹
DOJOLVI ²	DORYX	DORYX MPC
DOXYCYCLINE	DOXYCYCLINE HYCLATE DR	doxylamine succinate/pyridoxine hcl
droxidopa ¹	DUEXIS	DUPIXENT ¹
DURAGESIC	DYANAVEL XR	EDLUAR
EFFEXOR XR	EFUDEX	EGRIFTA ¹
EGRIFTA SV ¹	ELEPSIA XR	ELOCTATE ¹
EMFLAZA ²	EMPAVELI	EMSAM
ENBREL ¹	ENBREL MINI ¹	ENBREL SURECLICK ¹
ENDARI ²	ENDOMETRIN	ENSPRYNG ¹
EPCLUSA ¹	EPIDIOLEX ¹	EPINEPHRINE
EPIPEN	EPIPEN-JR	ERIVEDGE ^1,³
erlotinib hcl ^1,³	ESBRIET ¹	ESPEROCT ¹
EVEKEO	everolimus	EVRYSDI ²
EXJADE ^1,³	EXTAVIA ¹	EYSUVIS
FABIOR	FANAPT	FANAPT TITRATION PACK
FARYDAK¹	FASENRA PEN	fenofibrate
fenofibric acid dr	fentanyl	FENTANYL CITRATE
fentanyl citrate oral transmucosal	FENTORA	FETZIMA
FETZIMA TITRATION PACK	FEXMID	FINTEPLA ²
FIRAZYR ¹	FIRDAPSE ²	FLUOROPLEX
FLUOROURACIL CRE 0.5%	fluorouracil cre 5%	FLUOXETINE DR
FLUOXETINE HCL	FOCALIN	FOCALIN XR
FOLLISTIM AQ ¹	FORFIVO XL	FORTEO ¹
FORTESTA	FOTIVDA	GALAFOLD ¹
GANIRELIX AC	ganirelix ac ¹	GATTEX ²
GAVRETO ^2,³	GENOTROPIN ¹	GENOTROPIN MINIQUICK ¹
GEODON	GILENYA ¹	GILOTRIF ²
glatiramer acetate ¹	glatopa ¹	GLEEVEC ^1,³
glydo	GOCOVRI ^1,³	GONAL-F ¹
GONAL-F RFF ¹	GONAL-F RFF REDIJECT ¹	GRANIX ¹
HAEGARDA ²	HARVONI ¹	HEMLIBRA ¹
HEMOFIL M ¹	HETLIOZ ^2,³	HETLIOZ LQ ^2,³
HIZENTRA ¹	HUMALOG	HUMALOG JUNIOR KWIKPEN
HUMALOG KWIKPEN	HUMALOG MIX	HUMALOG MIX KWIKPEN
HUMATROPE ¹	HUMIRA ¹	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK ¹
HUMIRA PEN ¹	HUMIRA PEN-CD/UC/HS STARTER ¹	HUMIRA PEN-PEDIATRIC UC STARTER PACK ¹
HUMIRA PEN-PS/UV STARTER ¹	HUMULIN	HUMULIN WIKPEN
HUMULIN N	HUMULIN N KWIKPEN	HUMULIN R
HYCAMTIN ¹	hydrocodone er	HYDROCODONE ER
hydrocodone er	hydromorphone hcl er	HYQVIA ¹
HYSINGLA ER	IBRANCE ¹	icatibant acetate ¹
ICLUSIG ^2,³	IDELVION ¹	IDHIFA ¹
imatinib mesylate ¹	IMBRUVICA ²	IMCIVREE ²
imiquimod	imiquimod pump	INGREZZA ²
INLYTA ^1,³	INQOVI ¹	INREBIC ^1,³
INSULIN LISPRO	INSULIN LISPRO JUNIOR KWIKPEN	INSULIN LISPRO KWIKPEN
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN	INTERMEZZO	INTRON A ¹
INTUNIV	INVEGA	IRESSA ^2,³
ISTURISA ²	IXINITY ¹	JADENU ^1,³
JADENU SPRINKLE ^1,³	JAKAFI ^1,³	JIVI ¹
JORNAY PM	JUBLIA	JUXTAPID ²
JYNARQUE ¹	KADIAN	KALYDECO ¹
KAPVAY	KERENDIA	KERYDIN
KESIMPTA ¹	KEVEYIS ²	KEVZARA ¹
KHEDEZLA	KINERET ²	KISQALI ¹
KITABIS PAK ¹	KLISYRI	KOATE ¹
KOATE-DVI ¹	KOGENATE FS ¹	KORLYM ²
KOSELUGO ²	KOVALTRY ¹	KUVAN ¹
lapatinib ditosylate ¹	LAZANDA	LEDIPASVIR / SOFOSBUVIR ¹
LENVIMA ^2,³	LETAIRIS ¹	LEXAPRO
lidocaine	lidocaine gel	LIDOCAINE AND TETRACAINE CREAM
lidocaine hcl	lidocaine patch 5%	lidocaine/prilocaine
LIDOCAINE/TETRACAINE	LIDODERM	LOMAIRA
LONSURF ¹	LORBRENA ^1,³	LOTRONEX
LUBIPROSTONE	LUMAKRAS	LUNESTA
LUPKYNIS	LYNPARZA ^2,³	LYRICA CR
LYSODREN	LYUMJEV	LYUMJEV KWIKPEN
MAPROTILINE HCL	MATULANE ¹	MAVYRET ¹
MAYZENT ¹	MAYZENT STARTER PACK	MEKINIST ¹
MEKTOVI ²	MENOPUR ¹	metaxalone
METHADONE	methadone hcl	METHITEST
METHYLIN	METHYLPHENIDATE HCL ER	METHYLTESTOSTERONE
miglustat ¹	MIGRANAL	MINOCIN
MINOCYCLINE HCL ER	MINOLIRA	MITIGARE
MONONINE ¹	MORPHABOND ER	morphine sul er
MORPHINE SUL ER	morphine sul er	morphine sulfate cr
MOTEGRITY	MS CONTIN	MULPLETA ¹
MYALEPT ²	MYCAPSSA	MYDAYIS
naproxen/esomeprazole magnesium	NATESTO	NATPARA ¹
NERLYNX ^2,³	NEULASTA ¹	NEULASTA ONPRO KIT ¹
NEXAVAR ^1,³	NEXIUM	NEXLETOL
NEXLIZET	NINLARO ¹	NOCTIVA
NORDITROPIN FLEXPRO ¹	NORTHERA ¹	NOVAREL ¹
NOVOEIGHT ¹	NOXAFIL	NUBEQA ¹
NUCALA	NUCYNTA ER	NUPLAZID ¹
NUTROPIN AQ NUSPIN 10 ¹	NUWIQ ¹	NYVEPRIA
OCALIVA ¹	ODOMZO ^1,³	OFEV ^1,³
OLUMIANT ¹	omeprazole/sodium bicarbonate	OMNITROPE ¹
ONUREG ¹	OPSUMIT ²	ORACEA
ORENCIA ¹	ORENCIA CLICKJECT ¹	ORENITRAM ²
ORGOVYX ²	ORIAHNN	ORILISSA
ORKAMBI ¹	ORLADEYO ²	OTEZLA ¹
OVIDREL ¹	OXBRYTA ²	OXERVATE ²
OXYCODONE HCL ER	OXYCONTIN	OXYMORPHONE HCL ER
PAXIL	PAXIL CR	PEGINTRON ¹
PEMAZYRE ²	PENLAC NAIL LACQUER	PEXEVA
phendimetrazine tartrate	PHENDIMETRAZINE TARTRATE ER	phentermine hcl
PICATO	PIQRAY ¹	PLEGRIDY ¹
PLEGRIDY STARTER PACK ¹	PLIAGLIS	PNV TABS 20-1
POMALYST ¹	PONVORY	PONVORY 14-DAY STARTER PACK
posaconazole	posaconazole dr	PRALUENT
pregabalin er	PREGEN DHA	PREGENNA
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL ¹	PRENARA	PRENATRIX
PRENATRYL	PREVACID	PRISTIQ
PROCRIT ¹	PROCYSBI ²	PROFILNINE ¹
PROFILNINE SD ¹	PROMACTA ¹	PROTONIX
PROZAC	pyrimethamine	QBREXZA
QBREXZA	QELBREE	QINLOCK ²
QSYMIA	QUDEXY XR	RAVICTI ¹
RAYOS	REBIF ¹	REBIF REBIDOSE ¹
REBIF REBIDOSE TITRATION PACK ¹	REBIF TITRATION PACK ¹	REBINYN ¹
RECOMBINATE ¹	RELEXXII	RELISTOR
RELTONE	REMERON	REMERON SOLTAB
REPATHA	REPATHA PUSHTRONEX SYSTEM	REPATHA SURECLICK
RESTASIS	RESTASIS MULTIDOSE	RETEVMO ^1,³
RETIN-A	RETIN-A MICRO	RETIN-A MICRO PUMP
REVATIO ¹	REVLIMID ¹	REYVOW
RINVOQ ¹	RISPERDAL	RISPERIDONE ODT
RITALIN	RITALIN LA	RIXUBIS ¹
ROBAXIN-750	ROZEREM	ROZLYTREK ^1,³
RUBRACA ^2,³	RUZURGI ²	RYDAPT ¹
sajazir ¹	SAMSCA ¹	SAPHRIS
sapropterin dihydrochloride ¹	SARAFEM	SAXENDA
SENSIPAR ¹	SEROQUEL	SEROQUEL XR
SEROSTIM ¹	SEYSARA	SIGNIFOR ²
sildenafil sus 10mg/ml ¹	sildenafil tab 20mg ¹	SILENOR
SILIQ ¹	SIMPONI ¹	SKELAXIN
SKYRIZI ¹	SKYRIZI PEN ¹	sodium phenylbutyrate ¹
SOFOSBUVIR / VELPATASVIR ¹	SOMA	SOMAVERT ¹
SOVALDI ¹	SPRYCEL ^1,³	STELARA ¹
STIMATE ¹	STIVARGA ¹	STRATTERA
STRENSIQ ²	STRIANT	SUBSYS
SUCRAID	sunitinib malate ^1,³	SUNOSI
SUTENT ^1,³	SYMDEKO ¹	SYNERA
TABRECTA ¹	tadalafil ¹	TAFINLAR ¹
TAGRISSO ^2,³	TAKHZYRO ²	TALTZ ¹
TALZENNA ^1,³	TARCEVA ^1,³	TARGRETIN ^1,³
TASIGNA ^1,³	tavaborole	TAZAROTENE AER 0.1%
tazarotene cre 0.1%	TAZORAC	TAZVERIK ²
TECFIDERA ¹	TECFIDERA STARTER PACK ¹	TEGSEDI ²
TEMODAR ¹	temozolomide ¹	TEPMETKO ³
TERIPARATIDE ¹	TESTIM	testosterone cypionate
TESTOSTERONE ENANTHATE	TESTOSTERONE GEL 1%(25MG)	testosterone gel 1%(50mg)
testosterone gel 10mg/act	testosterone gel pump 1%	testosterone sol 30mg/act
testosterone td gel 20.25 mg/1.25gm (1.62%)	testosterone td gel 20.25 mg/act (1.62%)	testosterone td gel 40.5 mg/2.5gm (1.62%)
testosterone topical solution	tetrabenazin tab 12.5mg ¹	tetrabenazin tab 25mg ¹
THALOMID ¹	TIBSOVO ²	TOBI ¹
TOBI PODHALER ¹	tobramycin neb 300/4ml ¹	tobramycin neb 300/5ml ¹
TOLAK	TOLVAPTAN TAB 15MG ¹	tolvaptan tab 30mg ¹
topiramate er	TRACLEER ¹	TRAMADOL HCL CAP 150MG ER
TRAMADOL HCL CAP ER 100MG	TRAMADOL HCL CAP ER 200MG	TRAMADOL HCL CAP ER 300MG
tramadol hcl tab 100mg er	tramadol hcl tab 200mg er	tramadol hcl tab 300mg er
tramadol hcl er	trazodone hcl	TREMFYA ¹
tretinoin	tretinoin microsphere	tretinoin microsphere pump
TRIKAFTA ¹	TRILIPIX	TRINAZ
TRINTELLIX	TROKENDI XR	TRUSELTIQ
TUKYSA ²	TURALIO ²	TYKERB ¹
TYMLOS ¹	UKONIQ ³	UPTRAVI ²
URSODIOL	VENCLEXTA ²	VENCLEXTA STARTING PACK ²
VENTAVIS ^2,³	VERQUVO	VERSACLOZ
VERZENIO ^2,³	VFEND	VIBERZI
VIBRAMYCIN	VIEKIRA PAK ¹	VIIBRYD
VIIBRYD STARTER PACK	VIMOVO	VITRAKVI ^2,³
VIZIMPRO ^1,³	VOGELXO	VOGELXO PUMP
voriconazole	VOSEVI ¹	VOTRIENT ^1,³
VRAYLAR	VUMERITY ¹	VYLEESI
VYNDAMAX ¹	VYNDAQEL ¹	WAKIX
WEGOVY	WELLBUTRIN SR	WELLBUTRIN XL
WYNZORA	XALKORI ^1,³	XELJANZ ¹
XELJANZ XR ¹	XELODA ¹	XENAZINE ¹
XENICAL	XERMELO ²	XHANCE
XIFAXAN	XIIDRA	XIMINO
XOLAIR ¹	XOSPATA ²	XPOVIO ^2,³
XTAMPZA ER	XTANDI ^1,³	XYNTHA ¹
XYNTHA SOLOFUSE ¹	XYOSTED	XYREM ²
XYWAV ²	ZALVIT	ZANAFLEX
ZARXIO ¹	ZAVESCA ²	ZEGERID
ZEJULA ^2,³	ZELBORAF ¹	ZELNORM
ZEPATIER ¹	ZEPOSIA ¹	ZEPOSIA 7-DAY STARTER PACK ¹
ZEPOSIA STARTER KIT ¹	ZOHYDRO ER	ZOKINVY ²
ZOLINZA ^1,³	ZOLOFT	ZOLPIMIST
ZOMACTON ¹	ZORBTIVE ¹	ZTLIDO
ZYCLARA	ZYCLARA PUMP	ZYDELIG ²
ZYKADIA ^1,³	ZYPREXA	ZYPREXA ZYDIS
ZYTIGA ^1,³

Drug name(s)
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
AIMOVIG ¹	AJOVY ¹	ALA-SCALP
ALOCRIL	ALOGLIPTIN	ALOGLIPTIN/METFORMIN HCL
ALOGLIPTIN/PIOGLITAZONE	ALTOPREV	AMCINONIDE
AMERGE	ANAPROX DS	APEXICON E
ARTHROTEC 50	ARTHROTEC 75	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	AZOR	BENICAR
BENICAR HCT	BEPREVE	BETAMETHASONE DIPROPIONATE
BIOSCANNER GLUCOSE TEST STRIPS	BLOOD GLUCOSE TEST STRIPS	BLOOD GLUCOSE TEST STRIPS PREMIUM
BYDUREON BCISE	BYDUREON PEN	BYETTA
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	CLOBEX
CLOCORTOLONE PIVALATE	CLODERM	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	DERMA-SMOOTHE/FS BODY
DERMA-SMOOTHE/FS SCALP	DESONATE	DESOWEN
DETROL	DETROL LA	DEXCOM G5 MOBILE RECEIVERKIT
DEXCOM G5 MOBILE TRANSMITTER KIT	DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT	DEXCOM G5 RECEIVER KIT
DEXCOM G6 RECEIVER	DEXCOM G6 SENSOR	DEXCOM G6 TRANSMITTER
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 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	EASYPRO BLOOD GLUCOSE TEST STRIPS	EASYPRO PLUS
EC-NAPROSYN	EDARBI	EDARBYCLOR
ELEMENT COMPACT TEST STRIPS	ELEMENT TEST STRIPS	ELIDEL
ELOCON	EMBRACE BLOOD GLUCOSE TEST STRIPS	EMBRACE EVO BLOOD GLUCOSETEST STRIPS
EMBRACE PRO BLOOD GLUCOSETEST STRIPS	EMBRACE TALK BLOOD GLUCOSE TEST STRIPS	EMGALITY ¹
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	EZETIMIBE/ROSUVASTATIN
FARXIGA	FELDENE	FENOPROFEN CALCIUM
FENORTHO	FIFTY50 GLUCOSE TEST STRIP 2.0	FLECTOR
FLOLIPID	FLURBIPROFEN	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	FORTAMET	FORTISCARE BLOOD GLUCOSE TEST STRIP
FOSRENOL	FREESTYLE INSULINX BLOOD GLUCOSE TEST	FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS
FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM	FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM	FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM	FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM	FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM
FREESTYLE LITE TEST STRIPS	FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS	FREESTYLE TEST STRIPS
FROVA	GE100 BLOOD GLUCOSE TEST STRIPS	GELNIQUE
GEMTESA	GENULTIMATE TEST STRIPS	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	GLUMETZA	GLYXAMBI
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	HYDROCORTISONE BUTYRATE	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	INVOKAMET	INVOKAMET XR
INVOKANA	JANUMET	JANUMET XR
JANUVIA	JARDIANCE	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
LESCOL XL	LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS	LIBERTY TEST STRIPS
LICART	LIPITOR	LIVALO
LOCOID	LOCOID LIPOCREAM	LODINE
LUMIGAN	LUXIQ	LYRICA
MAXALT	MAXALT-MLT	MECLOFENAMATE SODIUM
MEIJER BLOOD GLUCOSE TESTSTRIPS	MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS	MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS
MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS	MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS	metformin hcl er
MICARDIS	MICARDIS HCT	MICRODOT TEST STRIPS
MM EASY TOUCH GLUCOSE TEST STRIPS	MYGLUCOHEALTH BLOOD GLUCOSE TEST	MYRBETRIQ
NALFON	NAPRELAN	NAPROSYN
NAPROXEN SODIUM	NESINA	NEUTEK 2TEK TEST STRIPS
NOVA MAX GLUCOSE TEST STRIPS	NURTEC	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
ONGLYZA	ONZETRA XSAIL	OPTIUM TEST STRIPS
OPTIUMEZ TEST STRIPS	OPTUMRX BLOOD GLUCOSE TEST	OSENI
OTREXUP ¹	OZEMPIC	PANDEL
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	RASUVO ¹	REDITREX
REFUAH PLUS BLOOD GLUCOSETEST STRIPS	RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM	RELION BLOOD GLUCOSE TESTSTRIPS
RELION CONFIRM/MICRO TEST STRIPS	RELION PREMIER BLOOD GLUCOSE TEST STRIPS	RELION PRIME BLOOD GLUCOSE TEST STRIPS
RELION ULTIMA BLOOD GLUCOSE TEST STRIPS	RELPAX	RENAGEL
RENVELA	REVEAL BLOOD GLUCOSE TEST	REXALL BLOOD GLUCOSE TEST STRIPS
RHOPRESSA	RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS	RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS
RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS	RIOMET ER	ROCKLATAN
ROSZET	RYBELSUS	SAVELLA
SAVELLA TITRATION PACK	SEGLUROMET	SERNIVO
sevelamer tab 800mg	SEVELAMER TAB 400MG	SIMVASTATIN
SMART SENSE PREMIUM BLOODGLUCOSE STRIPS	SMART SENSE VALUE BLOOD GLUCOSE STRIPS	SMARTEST BLOOD GLUCOSE TEST STRIPS
SOLIQUA 100/33	SOLUS V2 AUDIBLE TEST	STEGLATRO
STEGLUJAN	SUMATRIPTAN SUCCINATE	SUPREME TEST STRIPS
SURE EDGE BLOOD GLUCOSE TEST STRIPS	SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS	SURECHEK BLOOD GLUCOSE TEST STRIPS
SYNALAR	SYNJARDY	SYNJARDY XR
tacrolimus	TELCARE BLOOD GLUCOSE TEST STRIPS	TEMOVATE
TEXACORT	TGT BLOOD GLUCOSE TEST STRIPS	TGT BLOOD GLUCOSE TEST STRIPS PREMIUM
TIVORBEX	TOLMETIN SODIUM	TOPICORT
TOVIAZ	TRADJENTA	TRAVATAN Z
travoprost	TREXIMET	TRIBENZOR
TRIDESILON	TRIJARDY XR	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	TRULICITY
TWYNSTA	UBRELVY	ULORIC
ULTRATRAK PRO TEST STRIPS	ULTRATRAK ULTIMATE TEST STRIPS	ULTRAVATE
UNISTRIP1 GENERIC	VANOS	VELPHORO
VELTIN	VERASENS BLOOD GLUCOSE TEST STRIPS	VERDESO
VESICARE	VESICARE LS	VICTOZA
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS	VIVLODEX	VOCAL POINT BLOOD GLUCOSE TEST STRIPS
VYTORIN	VYZULTA	WAVESENSE PRESTO TEST STRIPS
WINLEVI	XALATAN	XIGDUO XR
XULTOPHY 100/3.6	ZEMBRACE SYMTOUCH	ZERVIATE
ZIANA	ZIOPTAN	ZIPSOR
ZOCOR	ZOLMITRIPTAN	ZOMIG
ZOMIG ZMT

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)	Quantity limits (per 30 days or as specified)
ADIPEX-P CAP 37.5mg	30 caps / 30 days
ADIPEX-P CAP 37.5MG	30 caps / 30 days
ADIPEX-P tab 37.5MG	30 tabs / 30 days
benzphetamine tab 50mg	90 tabs / 30 days
BENZPHETMINE tab 25MG	90 tabs / 30 days
CONTRAVE tab 8-90MG	120 tabs / 30 days
diethylprop tab 25mg	90 tabs / 30 days
DIETHYLPROP tab 75MG ER	30 tabs / 30 days
IMCIVREE INJ 10MG/ML ²	10 vials / 30 days
LOMAIRA tab 8MG	90 tabs / 30 days
PHENDIMETRAZ CAP 105MG ER	30 caps / 30 days
phendimetrazine tab 35mg	180 tabs / 30 days
phentermine cap 15mg	30 caps / 30 days
phentermine cap 30mg	30 caps / 30 days
phentermine cap 37.5mg	30 caps / 30 days
phentermine tab 37.5mg	30 tabs / 30 days
QSYMIA CAP 3.75-23	30 caps / 30 days
QSYMIA CAP 7.5-46MG	30 caps / 30 days
QSYMIA CAP 11.25-69	30 caps / 30 days
QSYMIA CAP 15-92MG	30 caps / 30 days
SAXENDA INJ 18MG/3ML	15 MLS / 30 days
SUNOSI tab 75MG	30 tabs / 30 days
SUNOSI tab 150MG	30 tabs / 30 days
WAKIX tab 4.45MG	60 tabs / 30 days
WAKIX tab 17.8MG	60 tabs / 30 days
WEGOVY INJ 0.25MG	4 pens / 180 days
WEGOVY INJ 0.5MG	4 pens / 180 days
WEGOVY INJ 1.7MG	8 pens / 180 days
WEGOVY INJ 1MG	4 pens / 180 days
WEGOVY INJ 2.4MG	4 pens / 28 days
XENICAL CAP 120MG	90 caps / 30 days

Aminoglycosides

Drug name(s)	Quantity limits (per 30 days or as specified)
ARIKAYCE SUS ²	28 vials / 28 days

Analgesics – anti-inflammatory

Drug name(s)	Quantity limits (per 30 days or as specified)
ACTEMRA INJ 162/0.9 ¹	4 syringes / 28 days
ACTEMRA INJ ACTpen ¹	4 injections / 28 days
ARCALYST INJ 220MG ²	8 vials / 28 days
DUEXIS tab 800-26.6	90 tabs / 30 days
ENBREL INJ 25MG ¹	8 vials / 28 days
ENBREL INJ 25/0.5ML ¹	8 syringes / 28 days
ENBREL INJ 50MG/ML ¹	4 syringes / 28 days
ENBREL MINI INJ 50MG/ML ¹	4 cartS / 28 days
ENBREL SRCLK INJ 50MG/ML ¹	4 syringes / 28 days
HUMIRA INJ 10/0.1ML ¹	2 syringes / 28 days
HUMIRA INJ 10MG/0.2 ¹	2 syringes / 28 days
HUMIRA INJ 20/0.2ML ¹	2 syringes / 28 days
HUMIRA INJ 40/0.4ML ¹	2 syringes / 28 days
HUMIRA KIT 20MG/0.4 ¹	2 syringes / 28 days
HUMIRA KIT 40MG/0.8 ¹	2 syringes / 28 days
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK	1 KIT / 180 days
HUMIRA pen INJ 40/0.4ML ¹	2 pens / 28 days
HUMIRA pen INJ 40MG/0.8 ¹	2 pens / 28 days
HUMIRA pen INJ 80/0.8ML ¹	2 pens / 28 days
HUMIRA pen INJ CD/UC/HS ¹	1 kit / 180 days
HUMIRA pen INJ PS/UV ¹	1 kit / 180 days
HUMIRA pen KIT CD/UC/HS ¹	1 kit / 180 days
HUMIRA pen KIT PED UC ¹	4 pens / 180 days
HUMIRA pen KIT PS/UV ¹	1 kit / 180 days
KEVZARA- SARILUMAB 200 mg/1.14 mL syringe SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML ¹	2 syringes / 28 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML ¹	2 syringes / 28 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML ¹	2 pens / 28 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML ¹	2 pens / 28 days
KINERET INJ ²	30 syringes / 30 days
naproxen-esomeprazole tab 375-20mg	60 tabs / 30 days
naproxen-esomeprazole tab 500-20mg	60 tabs / 30 days
OLUMIANT tab 1MG ¹	30 tabs / 30 days
OLUMIANT tab 2MG ¹	30 tabs / 30 days
ORENCIA INJ 50/0.4ML ¹	4 syringes / 28 days
ORENCIA INJ 87.5/0.7 ¹	4 syringes / 28 days
ORENCIA INJ 125MG/ML ¹	4 syringes / 28 days
ORENCIA CLCK INJ 125MG/ML ¹	4 syringes / 28 days
OTEZLA tab 10/20/30 ¹	1 kit / 180 days
OTEZLA tab 30MG ¹	60 tabs / 30 days
RINVOQ tab 15MG ER ¹	30 tabs / 30 days
SIMPONI INJ 50/0.5ML ¹	1 syringe / 28 days
SIMPONI INJ 100MG/ML ¹	1 syringe / 28 days
VIMOVO tab 375-20MG	60 tabs / 30 days
VIMOVO tab 500-20MG	60 tabs / 30 days
XELJANZ SOL 1MG/ML ¹	240 MLS / 30 days
XELJANZ tab 5MG ¹	60 tabs / 30 days
XELJANZ tab 10MG ¹	240 tabs / 365 days
XELJANZ XR tab 11MG ¹	30 tabs / 30 days
XELJANZ XR tab 22MG ¹	120 tabs / 365 days

Analgesics - opioid

Drug name(s)	Adult quantity limits - 5 days	Child quantity limits - 3 days
ABSTRAL SUB 400MCG	120 tabs / 30 days	N/A
ABSTRAL SUB 600MCG	120 tabs / 30 days	N/A
ABSTRAL SUB 800MCG	120 tabs / 30 days	N/A
ACTIQ LOZ 200MCG	120 LOZNGS / 30 days	N/A
ACTIQ LOZ 400MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 600MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 800MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 1200MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 1600MCG	120 lozenges / 30 days	N/A
APAP/CAFFEIN tab DIHYDROCODEINE	50 tablets/30 days	30 tablets/30 days
apap/codeine sol 120-12/5	450 ML/30 days	270 ML/30 days
apap/codeine tab 300-15mg	30 tablets/30 days	18 tablets/30 days
apap/codeine tab 300-30mg	30 tablets/30 days	18 tablets/30 days
apap/codeine tab 300-60mg	25 tablets/30 days	15 tablets/30 days
APAP-CAFFEIN CAP DIHYDROCODEINE	50 capsules/30 days	30 capsules/30 days
ARYMO ER tab 15MG	60 tablets/month	N/A
ARYMO ER tab 30MG	30 tablets/month	N/A
ARYMO ER tab 60MG	0 tablets/month	N/A
BELBUCA MIS 75MCG	60 films/month	N/A
BELBUCA MIS 150MCG	60 films/month	N/A
BELBUCA MIS 300MCG	60 films/month	N/A
BELBUCA MIS 450MCG	60 films/month	N/A
BELBUCA MIS 600MCG	60 films/month	N/A
BELBUCA MIS 750MCG	60 films/month	N/A
BELBUCA MIS 900MCG	30 films/month	N/A
buprenorphine dis 5mcg/hr	4 systems/month	N/A
buprenorphine dis 7.5/hr	4 systems/month	N/A
buprenorphine dis 10mcg/hr	4 systems/month	N/A
buprenorphine dis 15mcg/hr	4 systems/month	N/A
buprenorphine dis 20mcg/hr	4 systems/month	N/A
butorphanol sol 10mg/ml	2.5 ML (1 bottleLE)/30 days	0 ML/30 days
BUTRANS DIS 5MCG/HR	4 systems/month	N/A
BUTRANS DIS 7.5/HR	4 systems/month	N/A
BUTRANS DIS 10MCG/HR	4 systems/month	N/A
BUTRANS DIS 15MCG/HR	4 systems/month	N/A
BUTRANS DIS 20MCG/HR	4 systems/month	N/A
CODEINE SULF tab 15MG	30 tablets/30 days	18 tablets/30 days
CODEINE SULF tab 30MG	30 tablets/30 days	18 tablets/30 days
codeine sulf tab 30mg	30 tablets/30 days	18 tablets/30 days
CODEINE SULF tab 60MG	25 tablets/30 days	15 tablets/30 days
codeine/apap tab 30-300mg	30 tablets/30 days	18 tablets/30 days
codeine/apap tab 60-300mg	25 tablets/30 days	15 tablets/30 days
CONZIP CAP 100MG	30 capsules/30 days	N/A
CONZIP CAP 200MG	30 capsules/30 days	N/A
CONZIP CAP 300MG	30 capsules/30 days	N/A
DILAUDID LIQ 1MG/ML	60 ML/30 days	36 ML/30 days
DILAUDID tab 2MG	30 tablets/30 days	18 tablets/30 days
DILAUDID tab 4MG	15 tablets/30 days	9 tablets/30 days
DILAUDID tab 8MG	5 tablets/30 days	3 tablets/30 days
DURAGESIC DIS 12MCG/HR	10 patches/month	N/A
DURAGESIC DIS 25MCG/HR	0 patches/month	N/A
DURAGESIC DIS 50MCG/HR	0 patches/month	N/A
DURAGESIC DIS 75MCG/HR	0 patches/month	N/A
DURAGESIC DIS 100MCG/HR	0 patches/month	N/A
dvorah tab 325mg/30mg/16mg	50 tablets/30 days	30 tablets/30 days
endocet tab 2.5-325	60 tablets/30 days	36 tablets/30 days
endocet tab 5-325mg	30 tablets/30 days	18 tablets/30 days
endocet tab 7.5-325	20 tablets/30 days	12 tablets/30 days
endocet tab 10-325mg	15 tablets/30 days	9 tablets/30 days
fentanyl dis 12mcg/hr	10 patches/month	N/A
fentanyl dis 25mcg/hr	0 patches/month	N/A
fentanyl dis 37.5mcg	0 patches/month	N/A
fentanyl dis 50mcg/hr	0 patches/month	N/A
fentanyl dis 62.5mcg	0 patches/month	N/A
fentanyl dis 75mcg/hr	0 patches/month	N/A
fentanyl dis 87.5mcg	0 patches/month	N/A
fentanyl dis 100mcg/hr	0 patches/month	N/A
FENTANYL CIT tab 100MCG	120 tabs / 30 days	N/A
FENTANYL CIT tab 200MCG	120 tabs / 30 days	N/A
FENTANYL CIT tab 400MCG	120 tabs / 30 days	N/A
FENTANYL CIT tab 600MCG	120 tabs / 30 days	N/A
FENTANYL CIT tab 800MCG	120 tabs / 30 days	N/A
fentanyl ot loz 200mcg	120 lozenges / 30 days	N/A
fentanyl ot loz 400mcg	120 lozenges / 30 days	N/A
fentanyl ot loz 600mcg	120 lozenges / 30 days	N/A
fentanyl ot loz 800mcg	120 lozenges / 30 days	N/A
fentanyl ot loz 1200mcg	120 lozenges / 30 days	N/A
fentanyl ot loz 1600mcg	120 lozenges / 30 days	N/A
FENTORA tab 100MCG	120 tabs / 30 days	N/A
FENTORA tab 200MCG	120 tabs / 30 days	N/A
FENTORA tab 400MCG	120 tabs / 30 days	N/A
FENTORA tab 600MCG	120 tabs / 30 days	N/A
FENTORA tab 800MCG	120 tabs / 30 days	N/A
HYDRO/ACETA SOL 10-325MG	375 ML/30 days	225 ML/30 days
hydrocodone/acetaminophen sol 10-325mg	375 ML/30 days	225 ML/30 days
hydrocodone/acetaminophen sol 7.5-325	450 ML/30 days	270 ML/30 days
hydrocodone/acetaminophen tab 5-300mg	40 tablets/30 days	24 tablets/30 days
hydrocodone/acetaminophen tab 5-325mg	40 tablets/30 days	24 tablets/30 days
hydrocodone/acetaminophen tab 7.5-300	30 tablets/30 days	18 tablets/30 days
hydrocodone/acetaminophen tab 7.5-325	30 tablets/30 days	18 tablets/30 days
hydrocodone/acetaminophen tab 10-300mg	25 tablets/30 days	15 tablets/30 days
hydrocodone/acetaminophen tab 10-325mg	25 tablets/30 days	15 tablets/30 days
HYDROCODONE/IBUPROFEN tab 5-200MG	25 tablets/30 days	15 tablets/30 days
hydrocodone /ibuprofen tab 5-200mg	25 tablets/30 days	15 tablets/30 days
hydrocodone /ibuprofen tab 7.5-200	25 tablets/30 days	15 tablets/30 days
hydrocodone /ibuprofen tab 10-200mg	25 tablets/30 days	15 tablets/30 days
HYDROCODONE CAP 10MG ER	60 capsules/30 days	N/A
HYDROCODONE CAP 15MG ER	60 capsules/30 days	N/A
HYDROCODONE CAP 20MG ER	60 capsules/30 days	N/A
HYDROCODONE CAP 30MG ER	30 capsules/30 days	N/A
HYDROCODONE CAP 40MG ER	30 capsules/30 days	N/A
HYDROCODONE CAP 50MG ER	30 capsules/30 days	N/A
hydrocodone cap 10mg er	60 capsules/30 days	N/A
hydrocodone cap 15mg er	60 capsules/30 days	N/A
hydrocodone cap 30mg er	30 capsules/30 days	N/A
hydrocodone cap 40mg er	30 capsules/30 days	N/A
hydrocodone cap 50mg er	30 capsules/30 days	N/A
hydrocodone tab 20mg er	30 tablets/30 days	N/A
hydrocodone tab 30mg er	30 tablets/30 days	N/A
hydrocodone tab 40mg er	30 tablets/30 days	N/A
hydrocodone tab 60mg er	0 tablets/30 days	N/A
hydrocodone tab 80mg er	0 tablets/30 days	N/A
hydrocodone tab 100mg er	0 tablets/30 days	N/A
hydrocodone tab 120mg er	0 tablets/30 days	N/A
hydromorphone liq 1mg/ml	60 ML/30 days	36 ML/30 days
hydromorphone tab 2mg	30 tablets/30 days	18 tablets/30 days
hydromorphone tab 4mg	15 tablets/30 days	9 tablets/30 days
hydromorphone tab 8mg	5 tablets/30 days	3 tablets/30 days
hydromorphone tab 8mg er	30 tablets/month	N/A
hydromorphone tab 12mg er	30 tablets/month	N/A
hydromorphone tab 16mg er	0 tabLETS	N/A
hydromorphone tab 32mg er	0 tabLETS	N/A
HYSINGLA ER tab 20 MG	30 tablets/30 days	N/A
HYSINGLA ER tab 30 MG	30 tablets/30 days	N/A
HYSINGLA ER tab 40 MG	30 tablets/30 days	N/A
HYSINGLA ER tab 60 MG	0 tablets/30 days	N/A
HYSINGLA ER tab 80 MG	0 tablets/30 days	N/A
HYSINGLA ER tab 100 MG	0 tablets/30 days	N/A
HYSINGLA ER tab 120 MG	0 tablets/30 days	N/A
KADIAN CAP 10MG ER	30 capsules/30 days	N/A
KADIAN CAP 20MG ER	30 capsules/30 days	N/A
KADIAN CAP 30MG ER	30 capsules/30 days	N/A
KADIAN CAP 40MG ER	30 capsules/30 days	N/A
KADIAN CAP 50MG ER	30 capsules/30 days	N/A
KADIAN CAP 60MG ER	0 capsules/30 days	N/A
KADIAN CAP 80MG ER	0 capsules/30 days	N/A
KADIAN CAP 100MG ER	0 capsules/30 days	N/A
KADIAN CAP 200MG ER	0 capsules/30 days	N/A
LAZANDA SPR 100MCG	30 bottleles / 30 days	N/A
LAZANDA SPR 300MCG	30 bottleles / 30 days	N/A
LAZANDA SPR 400MCG	30 bottleles / 30 days	N/A
levorphanol tab 2mg	10 tablets/30 days	6 tablets/30 days
lorcet tab 5-325mg	40 tablets/30 days	24 tablets/30 days
lorcet hd tab 10-325mg	25 tablets/30 days	15 tablets/30 days
lorcet plus tab 7.5-325	30 tablets/30 days	18 tablets/30 days
LORtab ELX 10-300MG	338 ML/30 days	203 ML/30 days
MEPERIDINE SOL 50MG/5ML	150 ML/30 days	150 ML/30 days
MEPERIDINE tab 50MG	30 tablets/30 days	30 tablets/30 days
METHADONE SOL 5MG/5ML	300 ML/30 days	N/A
METHADONE SOL 10MG/5ML	150 ML/30 days	N/A
methadone sol 5mg/5ml	300 ML/30 days	N/A
methadone sol 10mg/5ml	150 ML/30 days	N/A
methadone tab 5mg	60 tablets/30 days	N/A
methadone tab 10mg	30 tablets/30 days	N/A
MORPHABOND tab 15MG ER	60 tablets/30 days	N/A
MORPHABOND tab 30MG ER	30 tablets/30 days	N/A
MORPHABOND tab 60MG ER	0 tablets/30 days	N/A
MORPHABOND tab 100MG ER	0 tablets/30 days	N/A
morphine sul cap 10mg er	30 capsules/30 days	N/A
morphine sul cap 20mg er	30 capsules/30 days	N/A
morphine sul cap 30mg er	30 capsules/30 days	N/A
morphine sul cap 50mg er	30 capsules/30 days	N/A
morphine sul cap 60mg er	0 capsules/30 days	N/A
morphine sul cap 80mg er	0 capsules/30 days	N/A
morphine sul cap 100mg er	0 capsules/30 days	N/A
MORPHINE SUL CAP 30MG ER	30 capsules/30 days	N/A
MORPHINE SUL CAP 40MG ER	30 capsules/30 days	N/A
MORPHINE SUL CAP 45MG ER	30 capsules/30 days	N/A
MORPHINE SUL CAP 60MG ER	0 capsules/30 days	N/A
MORPHINE SUL CAP 75MG ER	0 capsules/30 days	N/A
MORPHINE SUL CAP 90MG ER	0 capsules/30 days	N/A
MORPHINE SUL CAP 120MG ER	0 capsules/30 days	N/A
morphine sul sol 10/0.5ml	15 ML/30 days	15 ML/30 days
morphine sul sol 10mg/5ml	125 ML/30 days	75 ML/30 days
morphine sul sol 20mg/5ml	60 ML/30 days	36 ML/30 days
morphine sul sol 20mg/ml	15 ML/30 days	15 ML/30 days
morphine sul sol 100/5ml	15 ML/30 days	15 ML/30 days
morphine sul tab 15mg	15 tablets/30 days	9 tablets/30 days
morphine sul tab 30mg	5 tablets/30 days	3 tablets/30 days
MORPHINE SUL tab 15MG	15 tablets/30 days	9 tablets/30 days
MORPHINE SUL tab 30MG	5 tablets/30 days	3 tablets/30 days
morphine sul tab 100mg cr	0 tablets/30 days	N/A
morphine sul tab 15mg er	60 tablets/30 days	N/A
morphine sul tab 30mg er	30 tablets/30 days	N/A
morphine sul tab 60mg er	0 tablets/30 days	N/A
morphine sul tab 100mg er	0 tablets/30 days	N/A
morphine sul tab 200mg er	0 tablets/30 days	N/A
MS CONTIN tab 15MG ER	60 tablets/30 days	N/A
MS CONTIN tab 30MG ER	30 tablets/30 days	N/A
MS CONTIN tab 60MG ER	0 tablets/30 days	N/A
MS CONTIN tab 100MG ER	0 tablets/30 days	N/A
MS CONTIN tab 200MG ER	0 tablets/30 days	N/A
NORCO tab 5-325MG	40 tablets/30 days	24 tablets/30 days
NORCO tab 7.5-325	30 tablets/30 days	18 tablets/30 days
NORCO tab 10-325MG	25 tablets/30 days	15 tablets/30 days
NUCYNTA tab 50MG	10 tablets/30 days	6 tablets/30 days
NUCYNTA tab 75MG	5 tablets/30 days	3 tablets/30 days
NUCYNTA tab 100MG	5 tablets/30 days	3 tablets/30 days
NUCYNTA ER tab 50MG	60 tablets/30 days	N/A
NUCYNTA ER tab 100MG	30 tablets/30 days	N/A
NUCYNTA ER tab 150MG	0 tablets/30 days	N/A
NUCYNTA ER tab 200MG	0 tablets/30 days	N/A
NUCYNTA ER tab 250MG	0 tablets/30 days	N/A
OPANA tab 5MG	15 tablets/30 days	9 tablets/30 days
OPANA tab 10MG	5 tablets/30 days 3 tablets/30 days
OXAYDO tab 5MG	30 tablets/30 days	18 tablets/30 days
OXAYDO tab 7.5MG	20 tablets/30 days	12 tablets/30 days
OXYCODONE/ACETAMINOPHEN SOL 10/300MG	75 ML/30 days	45 ML/30 days
OXYCODONE/ASPIRIN tab	30 tablets/30 days	18 tablets/30 days
oxycodone cap 5mg	30 capsules/30 days	18 capsules/30 days
oxycodone cap hcl 5mg	30 capsules/30 days	18 capsules/30 days
oxycodone con 10/0.5ml	5 ML/30 days 3 ML/30 days
oxycodone con 100/5ml	5 ML/30 days	3 ML/30 days
oxycodone sol 5mg/5ml	165 ML/30 days	99 ML/30 days
oxycodone tab 5mg	30 tablets/30 days	18 tablets/30 days
oxycodone tab 10mg	15 tablets/30 days	9 tablets/30 days
oxycodone tab 15mg	10 tablets/30 days	6 tablets/30 days
oxycodone tab 20mg	5 tablets/30 days	3 tablets/30 days
oxycodone tab 30mg	5 tablets/30 days	3 tablets/30 days
OXYCODONE tab 10MG ER	60 tablets/30 days	N/A
OXYCODONE tab 15MG ER	60 tablets/30 days	N/A
OXYCODONE tab 20MG ER	30 tablets/30 days	N/A
OXYCODONE tab 40MG ER	0 tablets/30 days	N/A
OXYCODONE tab 60MG ER	0 tablets/30 days	N/A
OXYCODONE tab 80MG ER	0 tablets/30 days	N/A
oxycodone/ acetaminophen tab 2.5-325	60 tablets/30 days	36 tablets/30 days
oxycodone/ acetaminophen tab 5-325mg	30 tablets/30 days	18 tablets/30 days
oxycodone/ acetaminophen tab 7.5-325	20 tablets/30 days	12 tablets/30 days
oxycodone/ acetaminophen tab 10-325mg	15 tablets/30 days	9 tablets/30 days
OXYCODONE/ ACETAMINOPHEN tab 5-300MG	30 tablets/30 days	18 tablets/30 days
OXYCODONE/ ACETAMINOPHEN tab 10-300MG	15 tablets/30 days	9 tablets/30 days
OXYCODONE/IBUPROFEN tab 5-400MG	20 tablets/30 days	12 tablets/30 days
OXYCODONE tab 30MG ER	30 tablets/30 days	N/A
OXYCONTIN tab 10MG CR	60 tablets/30 days	N/A
OXYCONTIN tab 15MG CR	60 tablets/30 days	N/A
OXYCONTIN tab 20MG CR	30 tablets/30 days	N/A
OXYCONTIN tab 30MG CR	30 tablets/30 days	N/A
OXYCONTIN tab 40MG CR	0 tablets/30 days	N/A
OXYCONTIN tab 60MG CR	0 tablets/30 days	N/A
OXYCONTIN tab 80MG CR	0 tablets/30 days	N/A
OXYMORPHONE tab 5MG ER	60 tablets/30 days	N/A
OXYMORPHONE tab 7.5MG ER	60 tablets/30 days	N/A
OXYMORPHONE tab 10MG ER	30 tablets/30 days	N/A
OXYMORPHONE tab 15MG ER	30 tablets/30 days	N/A
OXYMORPHONE tab 20MG ER	0 tablets/30 days	N/A
OXYMORPHONE tab 30MG ER	0 tablets/30 days	N/A
OXYMORPHONE tab 40MG ER	0 tablets/30 days	N/A
oxymorphone tab hcl 5mg	15 tablets/30 days	9 tablets/30 days
oxymorphone tab hcl 10mg	5 tablets/30 days	3 tablets/30 days
pentazocine/naloxone tab 50-0.5mg	10 tablets/30 days	6 tablets/30 days
PERCOCET tab 2.5-325	60 tablets/30 days	36 tablets/30 days
PERCOCET tab 5-325MG	30 tablets/30 days	18 tablets/30 days
PERCOCET tab 7.5-325	20 tablets/30 days	12 tablets/30 days
PERCOCET tab 10-325MG	15 tablets/30 days	9 tablets/30 days
PRIMLEV tab 5-300MG	30 tablets/30 days	18 tablets/30 days
PRIMLEV tab 7.5-300	20 tablets/30 days	12 tablets/30 days
PRIMLEV tab 10-300MG	15 tablets/30 days	9 tablets/30 days
PROLATE SOL 10/300MG	75 ML/30 days	45 ML/30 days
QDOLO SOL 5MG/ML	400 ML/30 days	240 ML/30 days
ROXICODONE tab 5MG	30 tablets/30 days	18 tablets/30 days
ROXICODONE tab 15MG	10 tablets/30 days	6 tablets/30 days
ROXICODONE tab 30MG	5 tablets/30 days	3 tablets/30 days
SUBSYS SPR 100MCG	120 sprays / 30 days	N/A
SUBSYS SPR 200MCG	120 sprays / 30 days	N/A
SUBSYS SPR 400MCG	120 sprays / 30 days	N/A
SUBSYS SPR 600MCG	120 sprays / 30 days	N/A
SUBSYS SPR 800MCG	120 sprays / 30 days	N/A
SUBSYS SPR 1200MCG	240 sprays / 30 days	N/A
SUBSYS SPR 1600MCG	240 sprays / 30 days	N/A
tramadol/apap tab 37.5-325	40 tablets/30 days	24 tablets/30 days
TRAMADOL HCL CAP ER 100MG	30 capsules/30 days	N/A
TRAMADOL HCL CAP 150MG ER	30 capsules/30 days	N/A
TRAMADOL HCL CAP ER 200MG	30 capsules/30 days	N/A
TRAMADOL HCL CAP ER 300MG	30 capsules/30 days	N/A
tramadol hcl tab 100mg er	30 tablets/30 days	N/A
tramadol hcl tab 200mg er	30 tablets/30 days	N/A
tramadol hcl tab 300mg er	30 tablets/30 days	N/A
tramadol hcl tab 50mg	50 tablets/30 days	30 tablets/30 days
TREZIX CAP 320.5-30-16mg	50 capsules/30 days	30 capsules/30 days
TYLENOL/COD tab #3	30 tablets/30 days	18 tablets/30 days
TYLENOL/COD tab #4	25 tablets/30 days	15 tablets/30 days
ULTRACET tab 37.5-325	40 tablets/30 days	24 tablets/30 days
ULTRAM tab 50MG	50 tablets/30 days	30 tablets/30 days
XTAMPZA ER CAP 9MG	60 capsules/30 days	N/A
XTAMPZA ER CAP 13.5MG	60 capsules/30 days	N/A
XTAMPZA ER CAP 18MG	30 capsules/30 days	N/A
XTAMPZA ER CAP 27MG	30 capsules/30 days
XTAMPZA ER CAP 36MG	0 capsules/30 days	N/A
ZOHYDRO ER CAP 10MG	60 capsules/30 days	N/A
ZOHYDRO ER CAP 15MG	60 capsules/30 days	N/A
ZOHYDRO ER CAP 20MG	60 capsules/30 days	N/A
ZOHYDRO ER CAP 30MG	30 capsules/30 days	N/A
ZOHYDRO ER CAP 40MG	30 capsules/30 days	N/A
ZOHYDRO ER CAP 50MG	30 capsules/30 days	N/A

Androgens - anabolic

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 PUMP- TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)	2 pumps / 30 days
ANDROGEL- TESTOSTERONE TD GEL 20.25 MG/1.25GM (1.62%)	30 packets / 30 days
ANDROGEL- TESTOSTERONE TD GEL 40.5 MG/2.5GM (1.62%)	60 packets / 30 days
DEPO-TESTOST INJ 100MG/ML	1 vial / 28 days
DEPO-TESTOST INJ 200MG/ML	10 MLS / 28 days
FORTESTA GEL 10MG/ACT	2 pumps / 30 days
METHITEST tab 10MG	600 tabs / 30 days
METHYLTESTOS CAP 10MG	600 tabs / 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 inj 100mg/ml	1 vial / 28 days
testosterone cypionate inj 200mg/ml	10 MLS / 28 days
TESTOST ENAN INJ 200MG/ML	1 vial / 28 days
TESTOSTERONE GEL 1%(25MG)	60 packets / 30 days
testosterone gel 1%(25mg)	60 packets / 30 days
TESTOSTERONE GEL 1%(50MG)	60 packets / 30 days
testosterone gel 1%(50mg)	60 packets / 30 days
testosterone gel 10mg/act	2 bottleles / 30 days
TESTOSTERONE GEL PUMP 1%	4 pumps / 30 days
testosterone gel pump 1%	300 grams / 30 days
testosterone sol 30mg/act	2 pumps / 30 days
testosterone td gel 20.25 mg/1.25gm	30 packets / 30 days
(1.62%) testosterone td gel 20.25 mg/act (1.62%)	2 bottleles / 30 days
testosterone td gel 40.5 mg/2.5gm	60 packets / 30 days
(1 62% VOGELXO GEL 1%(50MG)	60 packets / 30 days
VOGELXO GEL PUMP 1%	4 pumps / 30 days
XYOSTED INJ 50/0.5	4 pens / 28 days
XYOSTED INJ 75/0.5	2 pens / 28 days
XYOSTED INJ 100/0.5	2 pens / 28 days

Antiasthmatic and bronchodilator agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADVAIR DISKU AER 100/50	60 blisters / 30 days
ADVAIR DISKU AER 250/50	60 blisters / 30 days
ADVAIR DISKU AER 500/50	60 blisters / 30 days
ADVAIR HFA AER 45/21	1 can / 30 days
ADVAIR HFA AER 115/21	1 can / 30 days
ADVAIR HFA AER 230/21	1 can / 30 days
AIRDUO RESPI INH 55-14	1 inhaler / 30 days
AIRDUO RESPI INH 113-14	1 inhaler / 30 days
AIRDUO RESPI INH 232-14	1 inhaler / 30 days
ALBUTEROL AER HFA	2 cans / 30 days
albuterol aer hfa	2 cans / 30 days
ALVESCO AER 80MCG	2 cans / 30 days
ALVESCO AER 160MCG	2 cans / 30 days
ANORO ELLIPT AER 62.5-25	1 inhaler / 30 days
ARCAPTA CAP 75MCG	30 caps / 30 days
ARNUITY ELPT INH 50MCG	30 blisters / 30 days
ARNUITY ELPT INH 100MCG	30 blisters / 30 days
ARNUITY ELPT INH 200MCG	30 blisters / 30 days
ASMANEX 14 AER 220MCG	1 can / 30 days
ASMANEX 30 AER 110MCG	1 can / 30 days
ASMANEX 30 AER 220MCG	1 can / 30 days
ASMANEX 60 AER 220MCG	1 can / 30 days
ASMANEX 120 AER 220MCG	1 can / 30 days
ASMANEX HFA AER 50MCG	1 inhaler / 30 days
ASMANEX HFA AER 100 MCG	1 can / 30 days
ASMANEX HFA AER 200 MCG	1 can / 30 days
ATROVENT HFA AER 17MCG	2 cans / 30 days
BEVESPI AER 9-4.8MCG	1 can / 30 days
BREO ELLIPTA INH 100-25	60 blisters / 30 days
BREO ELLIPTA INH 200-25	60 blisters / 30 days
BREZTRI AERO AER SPHERE 160-9-4.8 mcg act	1 can / 30 days
COMBIVENT AER 20-100	2 cans / 30 days
DULERA AER 100-5MCG	1 can / 30 days
DULERA AER 200-5MCG	1 can / 30 days
DULERA AER 50-5MCG	1 inhaler / 30 days
FASENRA pen INJ 30MG/ML	1 pen / 56 days
FLOVENT DISK AER 100MCG	60 blisters / 30 days
FLOVENT DISK AER 250MCG	240 blisters / 30 days
FLOVENT DISK AER 50MCG	60 blisters / 30 days
FLOVENT HFA AER 44MCG	1 can / 30 days
FLOVENT HFA AER 110MCG	1 can / 30 days
FLOVENT HFA AER 220MCG	2 cans / 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
FLUTICASONE/SALMETEROL INH 113/14	1 inhaler / 30 days
FLUTICASONE/SALMETEROL INH 232/14	1 inhaler / 30 days
FLUTICASONE/SALMETEROL INH 55/14	1 inhaler / 30 days
INCRUSE ELPT INH 62.5MCG	30 blisters / 30 days
LEVALBUTEROL AER 45/ACT	2 cans / 30 days
NUCALA INJ 100MG/ML	3 syringes / 28 days
PROAIR HFA AER	2 cans / 30 days
PROAIR RESPI AER	2 inhalerS / 30 days
PROVENTIL AER HFA	2 cans / 30 days
PULMICORT INH 180MCG	2 cans / 30 days
PULMICORT INH 90MCG	2 cans / 30 days
QVAR REDIHA AER 80MCG	2 cans / 30 days
QVAR REDIHAL AER 40MCG	1 can / 30 days
SEEBRI NEOHA CAP 15.6MCG	60 caps / 30 days
SEREVENT DIS AER 50MCG	60 blisters / 30 days
SPIRIVA AER 1.25MCG	1 cart / 30 days
SPIRIVA CAP HANDIHLR	30 caps / 30 days
SPIRIVA SPR 2.5MCG	1 cart / 30 days
STIOLTO AER 2.5-2.5	1 cart / 30 days
STRIVERDI AER 2.5MCG	1 cart / 30 days
SYMBICORT AER 160-4.5	1 can / 30 days
SYMBICORT AER 80-4.5	1 can / 30 days
TRELEGY AER ELLIPTA	1 inhaler / 30 days
TUDORZA PRES AER 400/ACT	1 can / 30 days
UTIBRON CAP NEOHALER	60 caps / 30 days
VENTOLIN HFA AER	2 cans / 30 days
wixela inhub aer 100/50	60 blisters / 30 days
wixela inhub aer 250/50	60 blisters / 30 days
XOpenEX HFA AER	2 cans / 30 days

Anticonvulsants

Drug name(s)	Quantity limits (per 30 days or as specified)
FINTEPLA SOL 2.2MG/ML ²	360 MLS / 30 days
LYRICA CAP 100MG	90 caps / 30 days
LYRICA CAP 150MG	90 caps / 30 days
LYRICA CAP 200MG	90 caps / 30 days
LYRICA CAP 225MG	60 caps / 30 days
LYRICA CAP 25MG	90 caps / 30 days
LYRICA CAP 300MG	60 caps / 30 days
LYRICA CAP 50MG	90 caps / 30 days
LYRICA CAP 75MG	90 caps / 30 days
LYRICA SOL 20MG/ML	900 MLS / 30 days
pregabalin cap 100mg	90 caps / 30 days
pregabalin cap 150mg	90 caps / 30 days
pregabalin cap 200mg	90 caps / 30 days
pregabalin cap 225mg	60 caps / 30 days
pregabalin cap 25mg	90 caps / 30 days
pregabalin cap 300mg	60 caps / 30 days
pregabalin cap 50mg	90 caps / 30 days
pregabalin cap 75mg	90 caps / 30 days
pregabalin sol 20mg/ml	900 MLS / 30 days
QUDEXY XR CAP 100/24HR	30 caps / 30 days
QUDEXY XR CAP 150/24HR	30 caps / 30 days
QUDEXY XR CAP 200/24HR	60 caps / 30 days
QUDEXY XR CAP 25/24HR	30 caps / 30 days
QUDEXY XR CAP 50/24HR	30 caps / 30 days
topiramate cap er 100mg	30 caps / 30 days
topiramate cap er 150mg	30 caps / 30 days
topiramate cap er 200mg	60 caps / 30 days
topiramate cap er 25mg	30 caps / 30 days
topiramate cap er 50mg	30 caps / 30 days
TROKENDI XR CAP 100MG	30 caps / 30 days
TROKENDI XR CAP 200MG	60 caps / 30 days
TROKENDI XR CAP 25MG	30 caps / 30 days
TROKENDI XR CAP 50MG	30 caps / 30 days

Antidiabetics

Drug name(s)	Quantity limits (per 30 days or as specified)
ADLYXIN INJ 10/20MCG	2 pens / 180 days
ADLYXIN INJ 20MCG	2 pens / 28 days
ADMELOG INJ 100U/ML	100 MLS / 30 days
ADMELOG SOLO INJ 100U/ML	100 MLS / 30 days
AFREZZA POW 12 UNIT	900 cartS / 30 days
AFREZZA POW 4-8 UNIT	1800 cartRS / 30 days
AFREZZA POW 4-8-12	1260 cartRS / 30 days
AFREZZA POW 4UNIT	2520 cartRS / 30 days
AFREZZA POW 8 UNIT	1260 cartS / 30 days
AFREZZA POW 8-12UNIT	1080 cartS / 30 days
ALOGLIPTIN/PIOGLIT tab 12.5-15	30 tabs / 30 days
ALOGLIPTIN/PIOGLIT tab 12.5-30	30 tabs / 30 days
ALOGLIPTIN/PIOGLIT tab 12.5-45	30 tabs / 30 days
ALOGLIPTIN/PIOGLIT tab 25-15MG	30 tabs / 30 days
ALOGLIPTIN/PIOGLIT tab 25-30MG	30 tabs / 30 days
ALOGLIPTIN/PIOGLIT tab 25-45MG	30 tabs / 30 days
ALOGLIPTIN tab 12.5MG	30 tabs / 30 days
ALOGLIPTIN tab 25MG	30 tabs / 30 days
ALOGLIPTIN tab 6.25MG	30 tabs / 30 days
ALOGLIPTIN tab METFORM	60 tabs / 30 days
APIDRA INJ SOLOSTAR	100 MLS / 30 days
APIDRA INJ U-100	100 MLS / 30 days
BASAGLAR INJ 100UNIT	100 MLS / 30 days
BYDUREON BC INJ 2/0.85ML	4 sprays / 28 days
BYDUREON pen INJ 2MG	4 pens / 28 days
BYETTA INJ 10MCG	1 pen / 30 days
BYETTA INJ 5MCG	1 pen / 30 days
FARXIGA tab 10MG	30 tabs / 30 days
FARXIGA tab 5MG	30 tabs / 30 days
FIASP INJ 100/ML	100 MLS / 30 days
FIASP FLEX INJ TOUCH	100 MLS / 30 days
FIASP penFIL INJ U-100	100 MLS / 30 days
FORTAMET tab 1000MG	60 tabs / 30 days
FORTAMET tab 500MG	90 tabs / 30 days
GLUMETZA tab 1000MG	60 tabs / 30 days
GLUMETZA tab 500MG	90 tabs / 30 days
GLYXAMBI tab 10-5 MG	30 tabs / 30 days
GLYXAMBI tab 25-5 MG	30 tabs / 30 days
HUMALOG INJ 100/ML	100 MLS / 30 days
HUMALOG JR INJ 100/ML	100 MLS / 30 days
HUMALOG KWIK INJ 100/ML	100 MLS / 30 days
HUMALOG KWIK INJ 200/ML	100 MLS / 30 days
HUMALOG MIX INJ 50/50	100 MLS / 30 days
HUMALOG MIX INJ 50/50KWP	100 MLS / 30 days
HUMALOG MIX INJ 75/25KWP	100 MLS / 30 days
HUMALOG MIX SUS 75/25	100 MLS / 30 days
HUMULIN INJ 70/30	100 MLS / 30 days
HUMULIN INJ 70/30KWP	100 MLS / 30 days
HUMULIN N INJ U-100	100 MLS / 30 days
HUMULIN N INJ U-100KWP	100 MLS / 30 days
HUMULIN R INJ U-100	100 MLS / 30 days
HUMULIN R INJ U-500	100 MLS / 30 days
INS ASP PROT INJ FLEXpen	100 MLS / 30 days
INSULIN ASPA INJ 100/ML	100 MLS / 30 days
INSULIN ASPA INJ 70/30	100 MLS / 30 days
INSULIN ASPA INJ FLEXpen	100 MLS / 30 days
INSULIN ASPA INJ penFILL	100 MLS / 30 days
INSULIN LISP INJ 100/ML	100 MLS / 30 days
INSULIN LISP INJ JUNIOR	100 MLS / 30 days
INSULIN LISP INJ PROTAMIN	100 MLS / 30 days
INVOKAMET tab 150-1000	60 tabs / 30 days
INVOKAMET tab 150-500	60 tabs / 30 days
INVOKAMET tab 50-1000	60 tabs / 30 days
INVOKAMET tab 50-500MG	60 tabs / 30 days
INVOKAMET XR tab 150-1000	60 tabs / 30 days
INVOKAMET XR tab 150-500	60 tabs / 30 days
INVOKAMET XR tab 50-1000	60 tabs / 30 days
INVOKAMET XR tab 50-500MG	60 tabs / 30 days
INVOKANA tab 100MG	30 tabs / 30 days
INVOKANA tab 300MG	30 tabs / 30 days
JANUMET tab 50-1000	60 tabs / 30 days
JANUMET tab 50-500MG	60 tabs / 30 days
JANUMET XR tab 100-1000	30 tabs / 30 days
JANUMET XR tab 50-1000	60 tabs / 30 days
JANUMET XR tab 50-500MG	30 tabs / 30 days
JANUVIA tab 100MG	30 tabs / 30 days
JANUVIA tab 25MG	30 tabs / 30 days
JANUVIA tab 50MG	30 tabs / 30 days
JARDIANCE tab 10MG	30 tabs / 30 days
JARDIANCE tab 25MG	30 tabs / 30 days
JENTADUETO tab 2.5-1000	60 tabs / 30 days
JENTADUETO tab 2.5-500	60 tabs / 30 days
JENTADUETO tab 2.5-850	60 tabs / 30 days
JENTADUETO XR- LINAGLIPTIN-	60 tabs / 30 days
METFORMIN HCL tab ER 24HR 2 JENTADUETO XR- LINAGLIPTIN-	30 tabs / 30 days
1000 MG METFORMIN CL tab ER 2 KAZANO 12.5- tab 1000MG	60 tabs / 30 days
MG KAZANO 12.5- tab 500MG	60 tabs / 30 days
KOMBIGLYZ XR tab 2.5-1000	60 tabs / 30 days
KOMBIGLYZ XR tab 5-1000MG	30 tabs / 30 days
KOMBIGLYZ XR tab 5-500MG	30 tabs / 30 days
KORLYM tab 300MG ²	120 tabs / 30 days
LANTUS INJ 100/ML	100 MLS / 30 days
LANTUS SOLOS INJ 100/ML	100 MLS / 30 days
LEVEMIR INJ	100 MLS / 30 days
LEVEMIR INJ FLEXTOUC	100 MLS / 30 days
LYUMJEV INJ 100UT/ML	100 MLS / 30 days
LYUMJEV KWPN INJ 100UT/ML	100 MLS / 30 days
LYUMJEV KWPN INJ 200UT/ML	100 MLS / 30 days
metformin tab 1000 er	60 tabs / 30 days
metformin tab 750mg er	60 tabs / 30 days
metformin er tab 1000mg	60 tabs / 30 days
metformin hcl tab er 24hr 500 mg	120 tabs / 30 days
metformin hcl tab er 24hr modified	90 tabs / 30 days
release 500 mg metformin hcl tab er 24hr osmotic 500 mg	90 tabs / 30 days
NESINA tab 12.5MG	30 tabs / 30 days
NESINA tab 25MG	30 tabs / 30 days
NESINA tab 6.25MG	30 tabs / 30 days
NOVOLIN INJ 70/30	100 MLS / 30 days
NOVOLIN INJ 70/30 FP	100 MLS / 30 days
NOVOLIN N INJ 100 UNIT	100 MLS / 30 days
NOVOLIN N INJ RELION	100 MLS / 30 days
NOVOLIN N INJ U-100	100 MLS / 30 days
NOVOLIN R INJ 100 UNIT	100 MLS / 30 days
NOVOLIN R INJ RELION	100 MLS / 30 days
NOVOLIN R INJ U-100	100 MLS / 30 days
NOVOLIN70/30 INJ RELION	100 MLS / 30 days
NOVOLOG INJ 100/ML	100 MLS / 30 days
NOVOLOG INJ FLEXpen	100 MLS / 30 days
NOVOLOG INJ penFILL	100 MLS / 30 days
NOVOLOG INJ RELION	100 MLS / 30 days
NOVOLOG MIX INJ 70/30	100 MLS / 30 days
NOVOLOG MIX INJ FLEX REL	100 MLS / 30 days
NOVOLOG MIX INJ FLEXpen	100 MLS / 30 days
NOVOLOG RELI INJ 70/30	100 MLS / 30 days
ONGLYZA tab 2.5MG	30 tabs / 30 days
ONGLYZA tab 5MG	30 tabs / 30 days
OSENI tab 12.5-15	30 tabs / 30 days
OSENI tab 12.5-30	30 tabs / 30 days
OSENI tab 12.5-45	30 tabs / 30 days
OSENI tab 25-15MG	30 tabs / 30 days
OSENI tab 25-30MG	30 tabs / 30 days
OSENI tab 25-45MG	30 tabs / 30 days
OZEMPIC INJ 4MG/3ML	1 pen / 28 days
OZEMPIC- SEMAGLUTIDE SOLN PEN-	1 pens / 28 days
OZEMPIC- SEMAGLUTIDE SOLN PEN-	2 pens / 28 days
QTERN tab 10-5MG	30 tabs / 30 days
QTERN tab 5-5MG	30 tabs / 30 days
RELION R INJ 100/ML	100 MLS / 30 days
RIOMET ER SUS 500/5ML	960 MLS / 30 days
RYBELSUS tab 14MG	30 tabs / 30 days
RYBELSUS tab 3MG	30 tabs / 180 days
RYBELSUS tab 7MG	30 tabs / 30 days
SEGLUROMET tab 2.5-1000	60 tabs / 30 days
SEGLUROMET tab 2.5-500	120 tabs / 30 days
SEGLUROMET tab 7.5-1000	60 tabs / 30 days
SEGLUROMET tab 7.5-500	60 tabs / 30 days
SEMGLEE INJ 100U/ML	100 MLS / 30 days
SEMGLEE SOL 100U/ML	100 MLS / 30 days
SOLIQUA INJ 100/33	6 pens / 30 days
STEGLATRO tab 15MG	30 tabs / 30 days
STEGLATRO tab 5MG	60 tabs / 30 days
STEGLUJAN tab 15-100MG	30 tabs / 30 days
STEGLUJAN tab 5-100MG	30 tabs / 30 days
SYNJARDY tab	60 tabs / 30 days
SYNJARDY tab 12.5-500	60 tabs / 30 days
SYNJARDY tab 5-1000MG	60 tabs / 30 days
SYNJARDY tab 5-500MG	60 tabs / 30 days
SYNJARDY XR tab	60 tabs / 30 days
SYNJARDY XR tab 10-1000	60 tabs / 30 days
SYNJARDY XR tab 25-1000	30 tabs / 30 days
SYNJARDY XR tab 5-1000MG	60 tabs / 30 days
TOUJEO MAX INJ 300IU/ML	100 MLS / 30 days
TOUJEO SOLO INJ 300IU/ML	100 MLS / 30 days
TRADJENTA tab 5MG	30 tabs / 30 days
TRESIBA INJ 100UNIT	100 MLS / 30 days
TRESIBA FLEX INJ 100UNIT	100 MLS / 30 days
TRESIBA FLEX INJ 200UNIT	100 MLS / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-	60 tabs / 30 days
LINAGLIP-METFORMIN tab ER 2 TRIJARDY XR- EMPAGLIFLOZIN-	30 tabs / 30 days
12.5-2.5-1000MG LINAGLIPTIN-ETFORMIN tab E TRIJARDY XR- MPAGLIFLOZIN-	30 tabs / 30 days
24HR 10-5-1000 MG LINAGLIPTIN-METFORMIN tab E TRIJARDY XR- MPAGLIFLOZIN-	60 tabs / 30 days
24HR 25 5 00 MG LINAGL_IPT -METFORMI TRULICTY INJ 0.75/0.5	4 pens / 28 days
24HR 5 2.5 000MG TRULICITY INJ 1.5/0.5	4 pens / 28 days
TRULICITY INJ 3/0.5	4 pens / 28 days
TRULICITY INJ 4.5/0.5	4 pens / 28 days
VICTOZA INJ 18MG/3ML	3 pens / 30 days
XIGDUO XR tab 10-1000	30 tabs / 30 days
XIGDUO XR tab 10-500MG	30 tabs / 30 days
XIGDUO XR tab 2.5-1000	60 tabs / 30 days
XIGDUO XR tab 5-1000MG	60 tabs / 30 days
XIGDUO XR tab 5-500MG	30 tabs / 30 days
XULTOPHY INJ 100/3.6	5 pens / 30 days

Antidotes and specific antagonists

Drug name(s)	Quantity limits (per 30 days or as specified)
deferasirox gra 180mg ^1,³	30 packets / 30 days
deferasirox gra 360mg ^1,³	180 packets / 30 days
deferasirox gra 90mg ^1,³	30 packets / 30 days
deferasirox tab 125mg ^1,³	30 tabs / 30 days
deferasirox tab 180mg ^1,³	30 tabs / 30 days
deferasirox tab 250mg ^1,³	30 tabs / 30 days
deferasirox tab 360mg ^1,³	180 tabs / 30 days
deferasirox tab 500mg ^1,³	90 tabs / 30 days
deferasirox tab 90mg ^1,³	30 tabs / 30 days
EXJADE tab 125MG ^1,³	30 tabs / 30 days
EXJADE tab 250MG ^1,³	30 tabs / 30 days
EXJADE tab 500MG ^1,³	90 tabs / 30 days
JADENU tab 180MG ^1,³	30 tabs / 30 days
JADENU tab 360MG ^1,³	180 tabs / 30 days
JADENU tab 90MG ^1,³	30 tabs / 30 days
JADENU SPRKL GRA 180MG ^1,³	30 packets / 30 days
JADENU SPRKL GRA 360MG ^1,³	180 packets / 30 days
JADENU SPRKL GRA 90MG ^1,³	30 packets / 30 days

Antiemetics

Drug name(s)	Quantity limits (per 30 days or as specified)
AKYNZEO CAP 300-0.5	2 caps / 30 days
ANZEMET tab 100MG	7 tabs / 30 days
ANZEMET tab 50MG	7 tabs / 30 days
aprepitant cap 125mg	4 caps / 30 days
aprepitant cap 40mg	8 caps / 30 days
aprepitant cap 80mg	8 caps / 30 days
aprepitant pak 80 & 125	4 PACKS / 30 days
DICLEGIS tab 10-10MG	120 tabs / 30 days
doxylamine-pyridoxine tab 10-10mg	120 tabs / 30 days
EMEND CAP 40MG	8 caps / 30 days
EMEND CAP 80MG	8 caps / 30 days
EMEND SUS 125MG	6 PACKS / 30 days
EMEND TRIPAC PAK 80 & 125	4 PACKS / 30 days
granisetron tab 1mg	14 tabs / 30 days
ondansetron sol 4mg/5ml	5 bottleles / 30 days
ONDANSETRON tab 24MG	4 tabs / 30 days
ondansetron tab 4mg	24 tabs / 30 days
ondansetron tab 4mg odt	24 tabs / 30 days
ondansetron tab 8mg	24 tabs / 30 days
ondansetron tab 8mg odt	24 tabs / 30 days
SANCUSO DIS 3.1MG	2 patches / 28 days
VARUBI tab 90MG	4 tabs / 30 days
ZOFRAN tab 4MG	24 tabs / 30 days
ZOFRAN tab 8MG	24 tabs / 30 days
ZUPLENZ MIS 4MG	24 FILMS / 30 days
ZUPLENZ MIS 8MG	24 FILMS / 30 days

Antihyperlidemics

Drug name(s)	Quantity limits (per 30 days or as specified)
ALTOPREV tab 20MG ER	30 tabs / 30 days
ALTOPREV tab 40MG ER	30 tabs / 30 days
ALTOPREV tab 60MG ER	30 tabs / 30 days
atorvastatin tab 10mg	45 tabs / 30 days
atorvastatin tab 20mg	45 tabs / 30 days
atorvastatin tab 40mg	45 tabs / 30 days
atorvastatin tab 80mg	30 tabs / 30 days
CRESTOR tab 10MG	45 tabs / 30 days
CRESTOR tab 20MG	45 tabs / 30 days
CRESTOR tab 40MG	30 tabs / 30 days
CRESTOR tab 5MG	45 tabs / 30 days
EZETIM/ROSUV tab 10-10MG	30 tabs / 30 days
EZETIM/ROSUV tab 10-20MG	30 tabs / 30 days
EZETIM/ROSUV tab 10-40MG	30 tabs / 30 days
EZETIM/ROSUV tab 10-5MG	30 tabs / 30 days
ezetim/simva tab 10-10mg	30 tabs / 30 days
ezetim/simva tab 10-20mg	30 tabs / 30 days
ezetim/simva tab 10-40mg	30 tabs / 30 days
ezetim/simva tab 10-80mg	30 tabs / 30 days
fluvastatin tab 80mg er	30 tabs / 30 days
JUXTAPID CAP 10MG ²	30 caps / 30 days
JUXTAPID CAP 20MG ²	30 caps / 30 days
JUXTAPID CAP 30MG ²	30 caps / 30 days
JUXTAPID CAP 40MG ²	30 caps / 30 days
JUXTAPID CAP 5MG ²	30 caps / 30 days
JUXTAPID CAP 60MG ²	30 caps / 30 days
LESCOL XL tab 80MG	30 tabs / 30 days
LIPITOR tab 10MG	45 tabs / 30 days
LIPITOR tab 20MG	45 tabs / 30 days
LIPITOR tab 40MG	45 tabs / 30 days
LIPITOR tab 80MG	30 tabs / 30 days
LIVALO tab 1MG	45 tabs / 30 days
LIVALO tab 2MG	45 tabs / 30 days
LIVALO tab 4MG	30 tabs / 30 days
lovastatin tab 10mg	60 tabs / 30 days
lovastatin tab 20mg	60 tabs / 30 days
lovastatin tab 40mg	60 tabs / 30 days
NEXLETOL tab 180MG	30 tabs / 30 days
NEXLIZET tab 180/10MG	30 tabs / 30 days
PRALUENT INJ 150MG/ML	2 syringes / 28 days
PRALUENT INJ 75MG/ML	2 syringes / 28 days
PRAVACHOL tab 20MG	45 tabs / 30 days
PRAVACHOL tab 40MG	45 tabs / 30 days
pravastatin tab 10mg	45 tabs / 30 days
pravastatin tab 20mg	45 tabs / 30 days
pravastatin tab 40mg	45 tabs / 30 days
pravastatin tab 80mg	30 tabs / 30 days
REPATHA INJ 140MG/ML	2 syringes / 28 days
REPATHA PUSH INJ 420/3.5	2 cartS / 30 days
REPATHA SURE INJ 140MG/ML	2 pens / 28 days
rosuvastatin tab 10mg	45 tabs / 30 days
rosuvastatin tab 20mg	45 tabs / 30 days
rosuvastatin tab 40mg	30 tabs / 30 days
rosuvastatin tab 5mg	45 tabs / 30 days
ROSZET tab 10-10MG	30 tabs / 30 days
ROSZET tab 20-10MG	30 tabs / 30 days
ROSZET tab 40-10MG	30 tabs / 30 days
ROSZET tab 5-10MG	30 tabs / 30 days
simvastatin tab 10mg	45 tabs / 30 days
simvastatin tab 20mg	60 tabs / 30 days
simvastatin tab 40mg	45 tabs / 30 days
simvastatin tab 5mg	45 tabs / 30 days
simvastatin tab 80mg	30 tabs / 30 days
VYTORIN tab 10-10MG	30 tabs / 30 days
VYTORIN tab 10-20MG	30 tabs / 30 days
VYTORIN tab 10-40MG	30 tabs / 30 days
VYTORIN tab 10-80MG	30 tabs / 30 days
ZOCOR tab 10MG	45 tabs / 30 days
ZOCOR tab 20MG	60 tabs / 30 days
ZOCOR tab 40MG	45 tabs / 30 days
ZOCOR tab 80MG	30 tabs / 30 days

Anti-infective agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ALINIA SUS 100/5ML	300 MLS / 90 days
ALINIA tab 500MG	12 tabs / 90 days
nitazoxanide tab 500mg	12 tabs / 90 days
XIFAXAN tab 200MG	9 tabs / 30 days
XIFAXAN tab 550MG	60 tabs / 30 days

Antimyasthenic / cholinergic agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

FIRDAPSE tab 10MG ²

240 tabs / 30 days

RUZURGI tab 10MG ²

300 tabs / 30 days

Antineoplastics and adjuntive therapies

Drug name(s)	Quantity limits (per 30 days or as specified)
abiraterone tab 250mg ^1,³	120 tabs / 30 days
abiraterone tab 500mg ^1,³	60 tabs / 30 days
AFINITOR tab 10MG ^1,³	30 tabs / 30 days
AFINITOR tab 2.5MG ^1,³	30 tabs / 30 days
AFINITOR tab 5MG ^1,³	30 tabs / 30 days
AFINITOR tab 7.5MG ^1,³	30 tabs / 30 days
AFINITOR DIS tab 2MG ^1,³	60 tabs / 30 days
AFINITOR DIS tab 3MG ^1,³	90 tabs / 30 days
AFINITOR DIS tab 5MG ^1,³	60 tabs / 30 days
ALECENSA CAP 150MG ^2,³³	240 caps / 30 days
ALUNBRIG PAK ²	30 tabs / 180 days
ALUNBRIG tab 180MG ²	30 tabs / 30 days
ALUNBRIG tab 30MG ²	120 tabs / 30 days
ALUNBRIG tab 90MG ²	30 tabs / 30 days
AYVAKIT tab 100MG ^2,³³	30 tabs / 30 days
AYVAKIT tab 200MG ^2,³³	30 tabs / 30 days
AYVAKIT tab 25MG ²	30 tabs / 30 days
AYVAKIT tab 300MG ²	30 tabs / 30 days
AYVAKIT tab 50MG ²	30 tabs / 30 days
BALVERSA tab 3MG ²	90 tabs / 30 days
BALVERSA tab 4MG ²	60 tabs / 30 days
BALVERSA tab 5MG ²	30 tabs / 30 days
BOSULIF tab 100MG ^1,³	90 tabs / 30 days
BOSULIF tab 400MG ^1,³	30 tabs / 30 days
BOSULIF tab 500MG ^1,³	30 tabs / 30 days
BRAFTOVI CAP 75MG ²	180 caps / 30 days
BRUKINSA CAP 80MG ²	120 caps / 30 days
CABOMETYX tab 20MG ^1,³	30 tabs / 30 days
CABOMETYX tab 40MG ^1,³	30 tabs / 30 days
CABOMETYX tab 60MG ^1,³	30 tabs / 30 days
CALQUENCE CAP 100MG ²	60 caps / 30 days
CAPRELSA tab 100MG ²	60 tabs / 30 days
CAPRELSA tab 300MG ²	30 tabs / 30 days
COMETRIQ KIT 100MG ²	1 carton / 28 days
COMETRIQ KIT 140MG ²	112 tabs / 28 days
COMETRIQ KIT 60MG ²	1 carton / 28 days
COPIKTRA CAP 15MG ²	56 caps / 28 days
COPIKTRA CAP 25MG ²	56 caps / 28 days
COTELLIC tab 20MG ¹	63 tabs / 28 days
DAURISMO tab 100MG ^1,³	30 tabs / 30 days
DAURISMO tab 25MG ^1,³	60 tabs / 30 days
ERIVEDGE CAP 150MG ^1,³	30 caps / 30 days
erlotinib tab 25mg ^1,³	60 tabs / 30 days
erlotinib tab 100mg ^1,³	30 tabs / 30 days
erlotinib tab 150mg ^1,³	30 tabs / 30 days
everolimus tab 2mg^3,⁴	60 tabs / 30 days
everolimus tab 2.5mg^3,^1,⁴	30 tabs / 30 days
everolimus tab 2.5mg^3,⁴	30 tabs / 30 days
everolimus tab 3mg^3,⁴	90 tabs / 30 days
everolimus tab 5mg^1,^3,⁴	30 tabs / 30 days
everolimus tab 5mg^3,⁴	60 tabs / 30 days
everolimus tab 5mg^3,⁴	30 tabs / 30 days
everolimus tab 7.5mg^1,^3,⁴	30 tabs / 30 days
everolimus tab 7.5mg^3,⁴	30 tabs / 30 days
everolimus tab 10mg^3,⁴	30 tabs / 30 days
FARYDAK CAP 10MG⁴	6 caps / 21 days
FARYDAK CAP 10MG^1,⁴	6 caps / 21 days
FARYDAK CAP 15MG⁴	6 caps / 21 days
FARYDAK CAP 15MG^1,⁴	6 caps / 21 days
FARYDAK CAP 20MG⁴	6 caps / 21 days
FARYDAK CAP 20MG^1,⁴	6 caps / 21 days
FOTIVDA CAP 0.89MG	21 caps / 28 days
FOTIVDA CAP 1.34MG	21 caps / 28 days
GAVRETO CAP 100MG ²	120 caps / 30 days
GILOTRIF tab 20MG ²	30 tabs / 30 days
GILOTRIF tab 30MG ²	30 tabs / 30 days
GILOTRIF tab 40MG ²	30 tabs / 30 days
GLEEVEC tab 100MG ^1,³	90 tabs / 30 days
GLEEVEC tab 400MG ^1,³	60 tabs / 30 days
IBRANCE CAP 100MG ¹	21 caps / 28 days
IBRANCE CAP 125MG ¹	21 caps / 28 days
IBRANCE CAP 75MG ¹	21 caps / 28 days
IBRANCE tab 100MG ¹	21 tabs / 28 days
IBRANCE tab 125MG ¹	21 tabs / 28 days
IBRANCE tab 75MG ¹	21 tabs / 28 days
ICLUSIG tab 10MG ²	30 tabs / 30 days
ICLUSIG tab 15MG ²	30 tabs / 30 days
ICLUSIG tab 30MG ²	30 tabs / 30 days
ICLUSIG tab 45MG ²	30 tabs / 30 days
IDHIFA tab 100MG ¹	30 tabs / 30 days
IDHIFA tab 50MG ¹	30 tabs / 30 days
imatinib mes tab 100mg ^1,³	90 tabs / 30 days
imatinib mes tab 400mg ^1,³	60 tabs / 30 days
IMBRUVICA CAP 140MG ²	90 caps / 30 days
IMBRUVICA CAP 70MG ²	30 caps / 30 days
IMBRUVICA tab 140MG ²	30 tabs / 30 days
IMBRUVICA tab 280MG ²	30 tabs / 30 days
IMBRUVICA tab 420MG ²	30 tabs / 30 days
IMBRUVICA tab 560MG ²	30 tabs / 30 days
INLYTA tab 1MG ^1,³	180 tabs / 30 days
INLYTA tab 5MG ^1,³	120 tabs / 30 days
INQOVI tab 35-100MG ¹	5 tabs / 28 days
INREBIC CAP 100MG ^1,³	120 caps / 30 days
IRESSA tab 250MG ²	30 tabs / 30 days
JAKAFI tab 10MG ^1,³	60 tabs / 30 days
JAKAFI tab 15MG ^1,³	60 tabs / 30 days
JAKAFI tab 20MG ^1,³	60 tabs / 30 days
JAKAFI tab 25MG ^1,³	60 tabs / 30 days
JAKAFI tab 5MG ^1,³	60 tabs / 30 days
KISQALI tab 200DOSE ¹	63 tabs / 28 days
KISQALI tab 400DOSE ¹	63 tabs / 28 days
KISQALI tab 600DOSE ¹	63 tabs / 28 days
KISQALI 200 PAK FEMARA ¹	91 tabs / 28 days
KISQALI 400 PAK FEMARA ¹	91 tabs / 28 days
KISQALI 600 PAK FEMARA ¹	91 tabs / 28 days
KOSELUGO CAP 10MG ²	240 caps / 30 days
KOSELUGO CAP 25MG ²	120 caps / 30 days
lapatinib tab 250mg ¹	180 tabs / 30 days
LENVIMA CAP 10 MG ²	30 caps / 30 days
LENVIMA CAP 12MG ²	90 caps / 30 days
LENVIMA CAP 14 MG ²	60 caps / 30 days
LENVIMA CAP 18 MG ²	90 caps / 30 days
LENVIMA CAP 20 MG ²	60 caps / 30 days
LENVIMA CAP 24 MG ²	90 caps / 30 days
LENVIMA CAP 4MG ²	30 caps / 30 days
LENVIMA CAP 8 MG ²	60 caps / 30 days
LONSURF tab 15-6.14 ¹	60 tabs / 28 days
LONSURF tab 20-8.19 ¹	80 tabs / 28 days
LORBRENA tab 100MG ^1,³	30 tabs / 30 days
LORBRENA tab 25MG ^1,³	90 tabs / 30 days
LUMAKRAS tab 120MG	240 tabs / 30 days
LYNPARZA tab 100MG ²	120 tabs / 30 days
LYNPARZA tab 150MG ²	120 tabs / 30 days
MEKINIST tab 0.5MG ¹	90 tabs / 30 days
MEKINIST tab 2MG ¹	30 tabs / 30 days
MEKTOVI tab 15MG ²	180 tabs / 30 days
NERLYNX tab 40MG ²	180 tabs / 30 days
NEXAVAR tab 200MG ^1,³	120 tabs / 30 days
NINLARO CAP 2.3MG ¹	3 caps / 28 days
NINLARO CAP 3MG ¹	3 caps / 28 days
NINLARO CAP 4MG ¹	3 caps / 28 days
NUBEQA tab 300MG ¹	120 tabs / 30 days
ODOMZO CAP 200MG ^1,³	30 caps / 30 days
ONUREG tab 200MG ¹	14 tabs / 28 days
ONUREG tab 300MG ¹	14 tabs / 28 days
ORGOVYX tab 120MG ²	30 tabs / 30 days
PEMAZYRE tab 13.5MG ²	14 tabs / 21 days
PEMAZYRE tab 4.5MG ²	14 tabs / 21 days
PEMAZYRE tab 9MG ²	14 tabs / 21 days
PIQRAY 200MG tab DOSE ¹	28 tabs / 28 days
PIQRAY 250MG tab DOSE ¹	56 tabs / 28 days
PIQRAY 300MG tab DOSE ¹	56 tabs / 28 days
POMALYST CAP 1MG ¹	21 caps / 28 days
POMALYST CAP 2MG ¹	21 caps / 28 days
POMALYST CAP 3MG ¹	21 caps / 28 days
POMALYST CAP 4MG ¹	21 caps / 28 days
QINLOCK tab 50MG ²	90 tabs / 30 days
RETEVMO CAP 40MG ^1,³	180 caps / 30 days
RETEVMO CAP 80MG ^1,³	120 caps / 30 days
ROZLYTREK CAP 100MG ^1,³	30 caps / 30 days
ROZLYTREK CAP 200MG ^1,³	90 caps / 30 days
RUBRACA tab 200MG ²	120 tabs / 30 days
RUBRACA tab 250MG ²	120 tabs / 30 days
RUBRACA tab 300MG ²	120 tabs / 30 days
RYDAPT CAP 25MG ¹	240 caps / 30 days
SPRYCEL tab 100MG ^1,³_	30 tabs / 30 days
SPRYCEL tab 140MG ^1,³_	30 tabs / 30 days
SPRYCEL tab 20MG ^1,³_	90 tabs / 30 days
SPRYCEL tab 50MG ^1,³_	30 tabs / 30 days
SPRYCEL tab 70MG ^1,³_	30 tabs / 30 days
SPRYCEL tab 80MG ^1,³_	30 tabs / 30 days
STIVARGA tab 40MG ¹	84 tabs / 28 days
sunitinib cap 12.5mg ^1,³_	90 caps / 30 days
sunitinib cap 25mg ^1,³_	30 caps / 30 days
sunitinib cap 37.5mg ^1,³_	30 caps / 30 days
sunitinib cap 50mg ^1,³_	30 caps / 30 days
SUTENT CAP 12.5MG ^1,³_	90 caps / 30 days
SUTENT CAP 25MG ^1,³_	30 caps / 30 days
SUTENT CAP 37.5MG ^1,³_	30 caps / 30 days
SUTENT CAP 50MG ^1,³_	30 caps / 30 days
tabRECTA tab 150MG ¹	120 tabs / 30 days
tabRECTA tab 200MG ¹	120 tabs / 30 days
TAFINLAR CAP 50MG ¹	120 caps / 30 days
TAFINLAR CAP 75MG ¹	120 caps / 30 days
TAGRISSO tab 40MG ² _	30 tabs / 30 days
TAGRISSO tab 80MG ² _	30 tabs / 30 days
TALZENNA CAP 0.25MG ^1,³_	90 caps / 30 days
TALZENNA CAP 1MG ^1,³_	30 caps / 30 days
TARCEVA tab 100MG ^1,³_	30 tabs / 30 days
TARCEVA tab 150MG ^1,³_	30 tabs / 30 days
TARCEVA tab 25MG ^1,³_	60 tabs / 30 days
TASIGNA CAP 150MG ^1,³_	120 caps / 30 days
TASIGNA CAP 200MG ^1,³_	120 caps / 30 days
TASIGNA CAP 50MG ^1,³_	120 caps / 30 days
TAZVERIK tab 200MG ²	240 tabs / 30 days
TEPMETKO tab 225MG ³_	60 tabs / 30 days
TIBSOVO tab 250MG ²	60 tabs / 30 days
TRUSELTIQ CAP 100MG	1 PACK / 28 days
TRUSELTIQ CAP 125MG	1 PACK / 28 days
TRUSELTIQ CAP 50MG	1 PACK / 28 days
TRUSELTIQ CAP 75MG	1 PACK / 28 days
TUKYSA tab 150MG ²	120 tabs / 30 days
TUKYSA tab 50MG ²	300 tabs / 30 days
TURALIO CAP 200MG ²	120 caps / 30 days
TYKERB tab 250MG ¹	180 tabs / 30 days
UKONIQ tab 200MG ³_	120 tabs / 30 days
VENCLEXTA tab 100MG ²	180 tabs / 30 days
VENCLEXTA tab 10MG ²	60 tabs / 30 days
VENCLEXTA tab 50MG ²	30 tabs / 30 days
VENCLEXTA tab START PK ²	1 PACK / 180 days
VERZENIO tab 100MG ²	60 tabs / 30 days
VERZENIO tab 150MG ²	60 tabs / 30 days
VERZENIO tab 200MG ²	60 tabs / 30 days
VERZENIO tab 50MG ²	60 tabs / 30 days
VITRAKVI CAP 100MG ²	60 caps / 30 days
VITRAKVI CAP 25MG ²	180 caps / 30 days
VITRAKVI SOL 20MG/ML ²	300 MLS / 30 days
VIZIMPRO tab 15MG ^1,³	30 tabs / 30 days
VIZIMPRO tab 30MG ^1,³	30 tabs / 30 days
VIZIMPRO tab 45MG ^1,³	30 tabs / 30 days
VOTRIENT tab 200MG ^1,³	120 tabs / 30 days
XALKORI CAP 200MG ^1,³	120 caps / 30 days
XALKORI CAP 250MG ^1,³	120 caps / 30 days
XOSPATA tab 40MG ²	90 tabs / 30 days
XPOVIO PAK 100MG ²	1 BOX / 28 days
XPOVIO PAK 40MG ³	1 BOX / 28 days
XPOVIO PAK 60MG ²	1 BOX / 28 days
XPOVIO 80 MG ONCE WEEKLY ²	1 BOX / 28 days
XTANDI CAP 40MG ^1,³	120 caps / 30 days
XTANDI tab 40MG ^1,³	120 tabs / 30 days
XTANDI tab 80MG ^1,³	60 tabs / 30 days
ZEJULA CAP 100MG ²	90 caps / 30 days
ZELBORAF tab 240MG ¹	240 tabs / 30 days
ZOLINZA CAP 100MG ^1,³	120 caps / 30 days
ZYDELIG tab 100MG ²	60 tabs / 30 days
ZYDELIG tab 150MG ²	60 tabs / 30 days
ZYKADIA tab 150MG ^1,³	90 tabs / 30 days
ZYTIGA tab 250MG ^1,³	120 tabs / 30 days
ZYTIGA tab 500MG ^1,³	60 tabs / 30 days

Antiparkinson and related therapy agents

Drug name(s)	Quantity limits (per 30 days or as specified)
GOCOVRI CAP 68.5MG ^1,³	30 caps / 30 days
GOCOVRI CAP 137MG ^1,³	60 caps / 30 days

Antipsychotics / antimanic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
CAPLYTA CAP 42MG	30 caps / 30 days
INVEGA tab 1.5MG	60 tabs / 30 days
INVEGA tab 3MG	60 tabs / 30 days
INVEGA tab 6MG	60 tabs / 30 days
INVEGA tab 9MG	60 tabs / 30 days
LATUDA tab 120MG	30 tabs / 30 days
LATUDA tab 20MG	30 tabs / 30 days
LATUDA tab 40MG	30 tabs / 30 days
LATUDA tab 60MG	30 tabs / 30 days
LATUDA tab 80MG	60 tabs / 30 days
NUPLAZID CAP 34MG ¹	30 caps / 30 days
NUPLAZID tab 10MG ¹	30 tabs / 30 days
olanzapine tab 10mg	30 tabs / 30 days
olanzapine tab 10mg odt	30 tabs / 30 days
olanzapine tab 15mg	30 tabs / 30 days
olanzapine tab 15mg odt	30 tabs / 30 days
olanzapine tab 2.5mg	30 tabs / 30 days
olanzapine tab 20mg	30 tabs / 30 days
olanzapine tab 20mg odt	30 tabs / 30 days
olanzapine tab 5mg	30 tabs / 30 days
olanzapine tab 5mg odt	30 tabs / 30 days
olanzapine tab 7.5mg	30 tabs / 30 days
paliperidone tab er 1.5mg	60 tabs / 30 days
paliperidone tab er 3mg	60 tabs / 30 days
paliperidone tab er 6mg	60 tabs / 30 days
paliperidone tab er 9mg	60 tabs / 30 days
quetiapine tab 150mg er	60 tabs / 30 days
quetiapine tab 200mg er	60 tabs / 30 days
quetiapine tab 300mg er	60 tabs / 30 days
quetiapine tab 400mg er	60 tabs / 30 days
quetiapine tab 50mg er	60 tabs / 30 days
SEROQUEL XR tab 150MG	60 tabs / 30 days
SEROQUEL XR tab 200MG	60 tabs / 30 days
SEROQUEL XR tab 300MG	60 tabs / 30 days
SEROQUEL XR tab 400MG	60 tabs / 30 days
SEROQUEL XR tab 50MG	60 tabs / 30 days
VRAYLAR CAP 1.5-3MG	1 PACK / 180 days
VRAYLAR CAP 1.5MG	30 caps / 30 days
VRAYLAR CAP 3MG	30 caps / 30 days
VRAYLAR CAP 4.5MG	30 caps / 30 days
VRAYLAR CAP 6MG	30 caps / 30 days
ZYPREXA tab 10MG	30 tabs / 30 days
ZYPREXA tab 15MG	30 tabs / 30 days
ZYPREXA tab 2.5MG	30 tabs / 30 days
ZYPREXA tab 20MG	30 tabs / 30 days
ZYPREXA tab 5MG	30 tabs / 30 days
ZYPREXA tab 7.5MG	30 tabs / 30 days
ZYPREXA ZYDI tab 10MG	30 tabs / 30 days
ZYPREXA ZYDI tab 15MG	30 tabs / 30 days
ZYPREXA ZYDI tab 20MG	30 tabs / 30 days
ZYPREXA ZYDI tab 5MG	30 tabs / 30 days

Antivirals

Drug name(s)	Quantity limits (per 30 days or as specified)
EPCLUSA tab 200-50MG ¹	28 tabs / 28 days
EPCLUSA tab 400-100 ¹	30 tabs / 30 days
HARVONI PAK ¹	28 packets / 28 days
HARVONI PAK 45-200MG ¹	28 packets / 28 days
HARVONI tab 45-200MG ¹	28 tabs / 28 days
HARVONI tab 90-400MG ¹	30 tabs / 30 days
LEDIP-SOFOSB tab 90-400MG ¹	30 tabs / 30 days
MAVYRET tab 100-40MG ¹	90 tabs / 30 days
oseltamivir cap 30mg	40 caps / 120 days
oseltamivir cap 45mg	20 caps / 120 days
oseltamivir cap 75mg	20 caps / 120 days
oseltamivir sus 6mg/ml	300 MLS / 120 days
PREVYMIS tab 240MG	112 tabs / 365 days
PREVYMIS tab 480MG	112 tabs / 365 days
RELENZA MIS DISKHALE	40 blisters / 120 days
SOFOS/VELPAT tab 400-100 ¹	30 tabs / 30 days
SOVALDI PAK 150MG ¹	28 packets / 28 days
SOVALDI PAK 200MG ¹	28 packets / 28 days
SOVALDI tab 200MG ¹	30 tabs / 30 days
SOVALDI tab 400MG ¹	30 tabs / 30 days
TAMIFLU CAP 30MG	40 caps / 120 days
TAMIFLU CAP 45MG	20 caps / 120 days
TAMIFLU CAP 75MG	20 caps / 120 days
TAMIFLU SUS 6MG/ML	300 MLS / 120 days
VIEKIRA PAK tab ¹	112 tabs / 28 days
VOSEVI tab ¹	30 tabs / 30 days
XOFLUZA tab 20MG	4 tabs / 120 days
XOFLUZA tab 80MG	2 tabs / 120 days
XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY PACK 1 X 40 MG (40 MG DOSE)	2 tabs / 120 days
XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY PACK 2 X 40 MG (80 MG DOSE)	4 tabs / 120 days
ZEPATIER tab 50-100MG ¹	30 tabs / 30 days

Cardiovascular agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADCIRCA tab 20MG ¹	60 tabs / 30 days
ADEMPAS tab 0.5MG ²	90 tabs / 30 days
ADEMPAS tab 1.5MG ²	90 tabs / 30 days
ADEMPAS tab 1MG ²	90 tabs / 30 days
ADEMPAS tab 2.5MG ²	90 tabs / 30 days
ADEMPAS tab 2MG ²	90 tabs / 30 days
alyq tab 20mg ¹	60 tabs / 30 days
ambrisentan tab 10mg ¹	30 tabs / 30 days
ambrisentan tab 5mg ¹	30 tabs / 30 days
bosentan tab 125mg ¹	60 tabs / 30 days
bosentan tab 62.5mg ¹	60 tabs / 30 days
CORLANOR SOL 5MG/5ML	600 MLS / 30 days
CORLANOR tab 5MG	60 tabs / 30 days
CORLANOR tab 7.5MG	60 tabs / 30 days
LETAIRIS tab 10MG ¹	30 tabs / 30 days
LETAIRIS tab 5MG ¹	30 tabs / 30 days
OPSUMIT tab 10MG ²	30 tabs / 30 days
REVATIO SUS 10MG/ML ¹	2 bottleles / 30 days
REVATIO tab 20MG ¹	90 tabs / 30 days
sildenafil (VIAGRA) sus 10mg/ml	2 bottleles / 30 days
sildenafil (REVATIO) sus 10mg/ml ¹	2 bottleles / 30 days
sildenafil (REVATIO) tab 20mg ¹	90 tabs / 30 days
tadalafil tab 20mg ¹	60 tabs / 30 days
TRACLEER tab 125MG ¹	60 tabs / 30 days
TRACLEER tab 32MG ¹	120 tabs / 30 days
TRACLEER tab 62.5MG ¹	60 tabs / 30 days
UPTRAVI tab 1000MCG ²	60 tabs / 30 days
UPTRAVI tab 1200MCG ²	60 tabs / 30 days
UPTRAVI tab 1400MCG ²	60 tabs / 30 days
UPTRAVI tab 1600MCG ²	60 tabs / 30 days
UPTRAVI tab 200/800 ²	1 PKG / 180 days
UPTRAVI tab 400MCG ²	60 tabs / 30 days
UPTRAVI tab 600MCG ²	60 tabs / 30 days
UPTRAVI tab 800MCG ²	60 tabs / 30 days
UPTRAVI- SELEXIPAG tab 200 MCG ²	60 tabs / 30 days
UPTRAVI- SELEXIPAG tab 200 MCG ²	140 tabs / 180 days
VENTAVIS SOL 10MCG/ML ^2,³³	270 AMPULS / 30 days
VENTAVIS SOL 20MCG/ML ^2,³	270 AMPULS / 30 days
VERQUVO tab 10MG	30 tabs / 30 days
VERQUVO tab 2.5MG	30 tabs / 30 days
VERQUVO tab 5MG	30 tabs / 30 days
VYNDAMAX CAP 61MG ¹	30 caps / 30 days
VYNDAQEL CAP 20MG ¹	120 caps / 30 days

Corticosteroids

Drug name(s)	Quantity limits (per 30 days or as specified)
EMFLAZA tab 6MG ²	60 tabs / 30 days
EMFLAZA tab 18MG ²	30 tabs / 30 days

Dermatologicals

Drug name(s)	Quantity limits (per 30 days or as specified)
ala-cort cre 1%	454 grams / 30 days
ala-cort cre 2.5%	454 grams / 30 days
ALA-SCALP LOT 2%	118.4 MLS / 30 days
alclometasone cre 0.05%	120 grams / 30 days
alclometasone oin 0.05%	120 grams / 30 days
ALDARA CRE 5%	48 packets / 112 days
AMCINONIDE CRE 0.1%	120 grams / 30 days
AMCINONIDE LOT 0.1%	120 MLS / 30 days
AMCINONIDE OIN 0.1%	120 grams / 30 days
APEXICON E CRE 0.05%	120 grams / 30 days
aug betamet cre 0.05%	200 grams / 28 days
AUG BETAMET GEL 0.05%	200 grams / 28 days
aug betamet lot 0.05%	210 MLS / 30 days
aug betamet oin 0.05%	200 grams / 28 days
beser lot 0.05%	120 MLS / 30 days
BETA DIPROP GEL 0.05%	200 grams / 28 days
betameth dip cre 0.05%	135 grams / 30 days
betameth dip lot 0.05%	120 MLS / 30 days
betameth dip oin 0.05%	135 grams / 30 days
betameth val aer 0.12%	150 grams / 30 days
betameth val cre 0.1%	135 grams / 30 days
betameth val lot 0.1%	120 MLS / 30 days
betameth val oin 0.1%	135 grams / 30 days
CAPEX SHA 0.01%	840 MLS / 28 days
ciclodan sol 8%	3.3 MLS / 30 days
ciclopirox sol 8%	3.3 MLS / 30 days
clobetasol aer 0.05%	200 grams / 28 days
clobetasol cre 0.05%	210 grams / 28 days
clobetasol gel 0.05%	210 grams / 28 days
clobetasol lot 0.05%	177 MLS / 28 days
clobetasol oin 0.05%	210 grams / 28 days
clobetasol sha 0.05%	236 MLS / 30 days
clobetasol sol 0.05%	200 MLS / 28 days
clobetasol spr 0.05%	236 MLS / 28 days
clobetasol e cre 0.05%	210 grams / 28 days
CLOBEX LOT 0.05%	177 MLS / 28 days
CLOBEX SHA 0.05%	236 MLS / 30 days
CLOBEX SPR 0.05%	236 MLS / 28 days
CLOCORTOLONE CRE 0.1%	135 grams / 30 days
clodan sha 0.05%	236 MLS / 30 days
CLODERM CRE 0.1%	135 grams / 30 days
CORDRAN CRE 0.025%	120 grams / 30 days
CORDRAN CRE 0.05%	120 grams / 30 days
CORDRAN LOT 0.05%	120 MLS / 30 days
CORDRAN OIN 0.05%	120 grams / 30 days
CORDRAN 80X3 TAP 4MCG/CM	1 BOX / 30 days
COSENTYX INJ 150MG/ML ¹	1 syringe / 28 days
COSENTYX INJ 300DOSE ¹	1 PACK / 28 days
COSENTYX INJ 75MG/0.5 ¹	1 syringe / 28 days
COSENTYX pen INJ 150MG/ML ¹	1 INJDV / 28 days
COSENTYX pen INJ 300DOSE ¹	1 PACK / 28 days
CUTIVATE LOT 0.05%	120 MLS / 30 days
DERMA-SMOOTH OIL /FS BODY	118.28 MLS / 30 days
DERMA-SMOOTH OIL /FS SCLP	118.28 MLS / 30 days
DESONATE GEL 0.05%	120 grams / 30 days
desonide cre 0.05%	120 grams / 30 days
desonide gel 0.05%	120 grams / 30 days
desonide lot 0.05%	118 MLS / 30 days
desonide oin 0.05%	120 grams / 30 days
DESOWEN CRE 0.05%	120 grams / 30 days
desoximetasone cre 0.05%	120 grams / 30 days
desoximetasone cre 0.25%	120 grams / 30 days
desoximetasone gel 0.05%	120 grams / 30 days
desoximetasone oin 0.05%	120 grams / 30 days
desoximetasone oin 0.25%	120 grams / 30 days
desoximetasone spr 0.25%	100 MLS / 30 days
desrx gel 0.05%	120 grams / 30 days
DICLOFENAC DIS 1.3%	60 patches / 30 days
diclofenac sol 1.5%	2 bottleles / 30 days
DIFLORASONE CRE 0.05%	120 grams / 30 days
diflorasone oin 0.05%	120 grams / 30 days
DIPROLENE OIN 0.05%	200 grams / 28 days
DIPROLENE AF CRE 0.05%	200 grams / 28 days
DUPIXENT INJ 200/1.14 ¹	2 syringes / 28 days
DUPIXENT INJ 200MG ¹	2 pens / 28 days
DUPIXENT- DUPILUMAB	2 pens / 28 days
SBCUTANEOUS SOLN DUPIXENT- DUPILUMAB	2 syringes / 28 days
INJECTO 00 MG/2 SUBUT EOUS SO EFUDEX CRE 5%	240 grams / 90 days
SYRINGE 0 MG 2ML ELOCON CRE 0.1%	135 grams / 30 days
FLECTOR DIS 1.3%	60 patches / 30 days
fluocin acet cre 0.01%	120 grams / 30 days
fluocin acet cre 0.025%	120 grams / 30 days
fluocin acet oil 0.01% sc	118.28 MLS / 30 days
fluocin acet oil 0.01%bdy	118.28 MLS / 30 days
fluocin acet oil body	118.28 MLS / 30 days
fluocin acet oil scalp	118.28 MLS / 30 days
fluocin acet oin 0.025%	120 grams / 30 days
fluocin acet sol 0.01%	120 MLS / 30 days
fluocinonide cre 0.05%	120 grams / 30 days
fluocinonide cre 0.1%	240 grams / 28 days
fluocinonide cre e 0.05%	120 grams / 30 days
fluocinonide gel 0.05%	120 grams / 30 days
fluocinonide oin 0.05%	120 grams / 30 days
fluocinonide sol 0.05%	120 MLS / 30 days
fluorouracil cre 5%	240 grams / 90 days
flurandrenol cre 0.05%	120 grams / 30 days
flurandrenol lot 0.05%	120 MLS / 30 days
flurandrenol oin 0.05%	120 grams / 30 days
fluticasone cre 0.05%	120 grams / 30 days
fluticasone lot 0.05%	120 MLS / 30 days
fluticasone oin 0.005%	120 grams / 30 days
glydo gel 2%	150 MLS / 30 days
halcinonide cre 0.1%	240 grams / 30 days
halobetasol cre 0.05%	200 grams / 28 days
halobetasol oin 0.05%	200 grams / 28 days
HALOG CRE 0.1%	240 grams / 30 days
HALOG OIN 0.1%	240 grams / 30 days
HALOG SOL 0.1%	240 MLS / 30 days
HC BUTYRATE CRE 0.1%	135 grams / 30 days
hc butyrate oin 0.1%	135 grams / 30 days
HC BUTYRATE SOL 0.1%	120 MLS / 30 days
hc butyrate sol 0.1%	120 MLS / 30 days
hc valerate cre 0.2%	120 grams / 30 days
hc valerate oin 0.2%	120 grams / 30 days
hydrocortisone cre 1%	454 grams / 30 days
hydrocortisone cre 2.5%	454 grams / 30 days
hydrocortisone lot 2.5%	118 MLS / 30 days
hydrocortisone oin 2.5%	454 grams / 30 days
hydrocortisone lot 0.1%	118 MLS / 30 days
hydrocortisone butyrate cream 0.1%	135 grams / 30 days
hydrocortisone butyrate hydrophilic lipo base cream 0.1%	120 grams / 30 days
imiquimod cre 5%	48 packets / 112 days
IMPOYZ CRE 0.025%	200 grams / 28 days
JUBLIA SOL 10%	4 MLS / 30 days
KENALOG AER SPRAY	126 grams / 30 days
KERYDIN SOL 5%	4 MLS / 30 days
KLISYRI OIN 1%	5 packets / 90 days
LIcart DIS 1.3%	30 systems / 30 days
lidocaine/prilocaine cre 2.5-2.5%	60 grams / 30 days
LIDOCA/TETRA CRE 7/7%	120 grams / 30 days
LIDOCAINE CRE TETRACAI	120 grams / 30 days
lidocaine gel 2%	150 MLS / 30 days
LIDOCAINE GEL 2% JELLY	150 MLS / 30 days
lidocaine gel 2% jelly	150 MLS / 30 days
lidocaine oin 5%	100 grams / 30 days
lidocaine pad 5%	90 patches / 30 days
lidocaine sol 4%	150 MLS / 30 days
LIDODERM DIS 5%	90 patches / 30 days
LOCOID CRE 0.1%	135 grams / 30 days
LOCOID LOT 0.1%	118 MLS / 30 days
LOCOID SOL 0.1%	120 MLS / 30 days
LOCOID LIPO CRE 0.1%	120 grams / 30 days
LUXIQ AER 0.12%	150 grams / 30 days
mometasone cre 0.1%	135 grams / 30 days
mometasone oin 0.1%	135 grams / 30 days
mometasone sol 0.1%	120 MLS / 30 days
nolix cre 0.05%	120 grams / 30 days
nolix lot 0.05%	120 MLS / 30 days
OLUX AER 0.05%	200 grams / 28 days
OLUX-E AER 0.05%	200 grams / 28 days
PANDEL CRE 0.1%	160 grams / 30 days
penLAC SOL 8%	3.3 MLS / 30 days
penNSAID SOL 2%	2 pumps / 28 days
PLIAGLIS CRE 7-7%	120 grams / 30 days
PREDNICARBAT CRE 0.1%	120 grams / 30 days
PREDNICARBAT OIN 0.1%	120 grams / 30 days
PSORCON CRE 0.05%	120 grams / 30 days
SERNIVO SPR	30 PADS / 30 days 120 MLS / 30 days
SERNIVO SPR 0.05%	N/A 120 MLS / 30 days
SILIQ INJ 210/1.5 ¹	2 syringes / 28 days
SKYRIZI INJ 150DOSE ¹	1 BOX / 84 days
SKYRIZI INJ 150MG/ML ¹	1 syringe / 84 days
SKYRIZI pen INJ 150MG/ML ¹	1 INJDV / 84 days
STELARA INJ 45MG/0.5 ¹	1 syringe / 84 days
STELARA INJ 90MG/ML ¹	1 syringe / 56 days
SYNALAR CRE 0.025%	120 grams / 30 days
SYNALAR OIN 0.025%	120 grams / 30 days
SYNALAR SOL 0.01%	120 MLS / 30 days
SYNERA DIS 70-70MG	4 patches / 30 days
TALTZ INJ 80MG/ML ¹	1 MLS / 28 days
tavaborole sol 5%	4 MLS / 30 days
TEMOVATE CRE 0.05%	210 grams / 28 days
TEMOVATE OIN 0.05%	210 grams / 28 days
TEXACORT SOL 2.5%	120 MLS / 30 days
TOPICORT CRE 0.05%	120 grams / 30 days
TOPICORT CRE 0.25%	120 grams / 30 days
TOPICORT GEL 0.05%	120 grams / 30 days
TOPICORT OIN 0.05%	120 grams / 30 days
TOPICORT OIN 0.25%	120 grams / 30 days
TOPICORT SPR 0.25%	100 MLS / 30 days
tovet aer 0.05%	200 grams / 28 days
TREMFYA- GUSELKUMAB SOLN pen-	1 pen / 56 days
INJECTOR 100 MG/ML ¹ TRMFYA- GUSELKUMAB SOLN	1 syringe / 56 days
PREFILLED SYRINGE 1 triamcinolone aer spray	126 grams / 30 days
triamcinolone cre 0.025%	454 grams / 30 days
triamcinolone cre 0.1%	454 grams / 30 days
triamcinolone cre 0.5%	454 grams / 30 days
triamcinolone lot 0.025%	120 MLS / 30 days
triamcinolone lot 0.1%	120 MLS / 30 days
triamcinolone oin 0.025%	454 grams / 30 days
triamcinolone oin 0.05%	430 grams / 30 days
triamcinolone oin 0.1%	454 grams / 30 days
triamcinolone oin 0.5%	120 grams / 30 days
trianex oin 0.05%	430 grams / 30 days
triderm cre 0.1%	454 grams / 30 days
triderm cre 0.5%	454 grams / 30 days
TRIDESILON CRE 0.05%	120 grams / 30 days
tritocin oin 0.05%	430 grams / 30 days
ULTRAVATE LOT 0.05%	240 MLS / 30 days
VANOS CRE 0.1%	240 grams / 28 days
VERDESO AER 0.05%	100 grams / 30 days
ZTLIDO PAD 1.8%	90 patches / 30 days

Digestive aids

Drug name(s)	Quantity limits (per 30 days or as specified)
SUCRAID SOL 8500/ML	236 MLS / 28 days

Diuretics

Drug name(s)	Quantity limits (per 30 days or as specified)
KEVEYIS tab 50MG ²	120 tabs / 30 days

Endocrine and metabolic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ACTONEL tab 150MG	1 tab / 28 days
ACTONEL tab 35MG	4 tabs / 28 days
alendronate tab 35mg	4 tabs / 28 days
alendronate tab 70mg	4 caps / 28 days
ATELVIA tab	4 tabs / 28 days
BINOSTO tab 70MG	4 tabs / 28 days
BONIVA tab 150MG	1 tab / 28 days
BYNFEZIA pen INJ 2500MCG	2 pens / 30 days
CETROTIDE KIT 0.25MG ¹	5 KITS / 30 days
CHOR GONADOT INJ 10000UNT ¹	2 vials / 30 days
EGRIFTA SOL 1MG ¹	60 vials / 30 days
EGRIFTA SV INJ 2MG ¹	30 vials / 30 days
FOLLISTIM AQ INJ 300UNIT ¹	15 cartS / 30 days
FOLLISTIM AQ INJ 600UNIT ¹	8 cartS / 30 days
FOLLISTIM AQ INJ 900UNIT ¹	5 cartS / 30 days
FORTEO INJ 620/2.48 ¹	1 pen / 28 days
FOSAMAX tab 70MG	4 caps / 28 days
FOSAMAX ⁴ D tab 70-2800	4 caps / 28 days
FOSAMAX ⁴ D tab 70-5600	4 caps / 28 days
GALAFOLD CAP 123MG ¹	14 caps / 28 days
GANIRELIX AC INJ 250/0.5	5 syringes / 30 days
GANIRELIX AC INJ 250/0.5 ¹	5 syringes / 30 days
ganirelix ac inj 250/0.5 ¹	5 syringes / 30 days
GONAL-F INJ 1050UNIT ¹	4 syringes / 30 days
GONAL-F INJ 450UNIT ¹	10 syringes / 30 days
GONAL-F RFF INJ 300/0.5 ¹	15 pens / 30 days
GONAL-F RFF INJ 450/0.75 ¹	10 pens / 30 days
GONAL-F RFF INJ 75UNIT ¹	20 syringes / 30 days
GONAL-F RFF INJ 900/1.5 ¹	5 pens / 30 days
ibandronate tab 150mg	1 tab / 28 days
ISTURISA tab 10MG ²	180 tabs / 30 days
ISTURISA tab 1MG ²	240 tabs / 30 days
ISTURISA tab 5MG ²	300 tabs / 30 days
JYNARQUE PAK 30-15MG ¹	56 tabs / 28 days
JYNARQUE PAK 45-15MG ¹	56 tabs / 28 days
JYNARQUE PAK 60-30MG ¹	56 tabs / 28 days
JYNARQUE PAK 90-30MG ¹	56 tabs / 28 days
JYNARQUE tab 30MG ¹	30 tabs / 30 days
JYNARQUE- TOLVAPTAN tab 15 MG ¹	60 tabs / 30 days
JYNARQUE- TOLVAPTAN tab THERAPY PACK 15 MG ¹	56 tabs / 28 days
KERENDIA tab 10MG	30 tabs / 30 days
KERENDIA tab 20MG	30 tabs / 30 days
MENOPUR INJ 75UNIT ¹	60 vials / 30 days
MYCAPSSA CAP 20MG	120 caps / 30 days
NATPARA INJ 100MCG ¹	1 kit / 28 days
NATPARA INJ 25MCG ¹	1 kit / 28 days
NATPARA INJ 50MCG ¹	1 kit / 28 days
NATPARA INJ 75MCG ¹	1 kit / 28 days
NOCTIVA SPR 1.66/0.1	1 bottle / 30 days
NOVAREL INJ 10000UNT ¹	2 vials / 30 days
NOVAREL INJ 5000UNIT ¹	4 vials / 30 days
ORILISSA tab 150MG	30 tabs / 30 days
ORILISSA tab 200MG	60 tabs / 30 days
OVIDREL INJ ¹	2 syringes / 30 days
PREGNYL INJ 10000UNT ¹	2 vials / 30 days
risedronate sod tab 35mg dr	4 tabs / 28 days
risedronate tab 150mg	1 tab / 28 days
risedronate tab 35mg	4 tabs / 28 days
SAMSCA tab 15MG ¹	30 tabs / 365 days
SAMSCA tab 30MG ¹	60 tabs / 365 days
SIGNIFOR INJ 0.3MG/ML ²	60 MLS / 30 days
SIGNIFOR INJ 0.6MG/ML ²	60 MLS / 30 days
SIGNIFOR INJ 0.9MG/ML ²	60 MLS / 30 days
SOMAVERT INJ 10MG ¹	30 vials / 30 days
SOMAVERT INJ 15MG ¹	30 vials / 30 days
SOMAVERT INJ 20MG ¹	30 vials / 30 days
SOMAVERT INJ 25MG ¹	30 vials / 30 days
SOMAVERT INJ 30MG ¹	30 vials / 30 days
TERIPARATIDE INJ ¹	1 pen / 28 days
TOLVAPTAN tab 15MG ¹	30 tabs / 365 days
tolvaptan (SAMSCA) tab 30mg ¹	60 tabs / 365 days
tolvaptan (JYNARQUE) tab 30mg ¹	30 tabs / 30 days
TYMLOS INJ ¹	1 pen / 30 days

Estrogens

Drug name(s)	Quantity limits (per 30 days or as specified)
ORIAHNN CAP	56 caps / 28 days

Gastrointestinal agents

Drug name(s)	Quantity limits (per 30 days or as specified)
alosetron tab 0.5mg	60 tabs / 30 days
alosetron tab 1mg	60 tabs / 30 days
AMITIZA CAP 24MCG	60 caps / 30 days
AMITIZA CAP 8MCG	120 caps / 30 days
CIMZIA PREFL KIT 200MG/ML ¹	2 KITS / 28 days
CIMZIA START KIT 200MG/ML ¹	1 kit / 180 days
LINZESS CAP 145MCG	30 caps / 30 days
LINZESS CAP 290MCG	30 caps / 30 days
LINZESS CAP 72MCG	30 caps / 30 days
LOTRONEX tab 0.5MG	60 tabs / 30 days
LOTRONEX tab 1MG	60 tabs / 30 days
LUBIPROSTONE CAP 8MCG	120 caps / 30 days
LUBIPROSTONE CAP 24MCG	60 caps / 30 days
MOTEGRITY tab 1MG	30 tabs / 30 days
MOTEGRITY tab 2MG	30 tabs / 30 days
MOVANTIK tab 12.5MG	30 tabs / 30 days
MOVANTIK tab 25MG	30 tabs / 30 days
OCALIVA tab 10MG ¹	30 tabs / 30 days
OCALIVA tab 5MG ¹	30 tabs / 30 days
RELISTOR INJ 8/0.4ML	30 syringes / 30 days
RELISTOR tab 150MG	90 tabs / 30 days
RELISTOR- METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML)	60 vials / 30 days
RELISTOR- METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML)	30 syringes / 30 days
SYMPROIC tab 0.2MG	30 tabs / 30 days
TRULANCE tab 3MG	30 tabs / 30 days
VIBERZI tab 100MG	60 tabs / 30 days
VIBERZI tab 75MG	60 tabs / 30 days
XERMELO tab 250MG ²	90 tabs / 30 days
ZELNORM tab 6MG	60 tabs / 30 days

Hematological agents

Drug name(s)	Quantity limits (per 30 days or as specified)
EMPAVELI INJ 1080MG	8 vials / 28 days
FIRAZYR INJ 30MG/3ML ¹	6 syringes / 30 days
HAEGARDA INJ 2000UNIT ²	24 vials / 30 days
HAEGARDA INJ 3000UNIT ²	16 vials / 30 days
HEMLIBRA INJ 105/0.7 ¹	4 vials / 28 days
HEMLIBRA INJ 150/ML ¹	4 vials / 28 days
HEMLIBRA INJ 30MG/ML ¹	4 vials / 28 days
HEMLIBRA INJ 60/0.4 ¹	4 vials / 28 days
icatibant inj 30mg/3ml ¹	6 syringes / 30 days
ORLADEYO CAP 110MG ²	30 caps / 30 days
ORLADEYO CAP 150MG ²	30 caps / 30 days
sajazir inj 30mg/3ml ¹	6 syringes / 30 days
TAKHZYRO INJ 300/2ML ²	4 MLS / 28 days

Hematopoietic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
CERDELGA CAP 84MG ¹	60 caps / 30 days
miglustat cap 100mg ¹	90 caps / 30 days
MULPLETA tab 3MG ¹	7 tabs / 7 days
OXBRYTA tab 500MG ²	90 tabs / 30 days
PROMACTA PAK 25MG ¹	30 PACKS / 30 days
PROMACTA POW 12.5MG ¹	30 packets / 30 days
PROMACTA tab 12.5MG ¹	30 tabs / 30 days
PROMACTA tab 25MG ¹	30 tabs / 30 days
PROMACTA tab 50MG ¹	60 tabs / 30 days
PROMACTA tab 75MG ¹	60 tabs / 30 days
ZAVESCA CAP 100MG ²	90 caps / 30 days

Hypnotics / sedatives / sleep disorder agents

Drug name(s)	Quantity limits (per 30 days or as specified)
AMBIEN tab 10MG	30 tabs / 30 days
AMBIEN tab 5MG	30 tabs / 30 days
AMBIEN CR tab 12.5MG	30 tabs / 30 days
AMBIEN CR tab 6.25MG	30 tabs / 30 days
BELSOMRA tab 10MG	30 tabs / 30 days
BELSOMRA tab 15MG	30 tabs / 30 days
BELSOMRA tab 20MG	30 tabs / 30 days
BELSOMRA tab 5MG	30 tabs / 30 days
DAYVIGO tab 10MG	30 tabs / 30 days
DAYVIGO tab 5MG	30 tabs / 30 days
doxepin tab 3mg	30 tabs / 30 days
doxepin tab 6mg	30 tabs / 30 days
EDLUAR SUB 10MG	30 tabs / 30 days
EDLUAR SUB 5MG	30 tabs / 30 days
eszopiclone tab 1mg	30 tabs / 30 days
eszopiclone tab 2mg	30 tabs / 30 days
eszopiclone tab 3mg	30 tabs / 30 days
HETLIOZ CAP 20MG ²	30 caps / 30 days
HETLIOZ LQ SUS 4MG/ML ²	158 MLS / 30 days
INTERMEZZO SUB 1.75MG	30 tabs / 30 days
LUNESTA tab 1MG	30 tabs / 30 days
LUNESTA tab 2MG	30 tabs / 30 days
LUNESTA tab 3MG	30 tabs / 30 days
ramelteon tab 8mg	30 tabs / 30 days
ROZEREM tab 8MG	30 tabs / 30 days
SILENOR tab 3MG	30 tabs / 30 days
SILENOR tab 6MG	30 tabs / 30 days
zaleplon cap 10mg	30 caps / 30 days
zaleplon cap 5mg	30 caps / 30 days
zolpidem tab 10mg	30 tabs / 30 days
zolpidem tab 5mg	30 tabs / 30 days
zolpidem er tab 12.5mg	30 tabs / 30 days
zolpidem er tab 6.25mg	30 tabs / 30 days
zolpidem tar sub 1.75mg	30 tabs / 30 days
zolpidem tar sub 3.5mg	30 tabs / 30 days
ZOLPIMIST SPR 5MG	1 can / 30 days

Medical devices and supplies

Drug name(s)	Quantity limits (per 30 days or as specified)
DEXCOM G5 MIS RECEIVER	1 UNIT / 365 days
DEXCOM G5 MIS TRANSMIT	1 UNIT / 84 days
DEXCOM G6 MIS RECEIVER	1 UNIT / 365 days
DEXCOM G6 MIS SENSOR	3 UNITS / 30 days
DEXCOM G6 MIS TRANSMIT	1 UNIT / 90 days
FREESTY LIBR MIS 2 READER	1 READER / 365 days
FREESTYLE MIS READER	1 UNIT / 365 days
FREESTYLE LIBRE 14 day/SENSOR/FLASH MONITORING SYSTEM-CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR	2 UNITS / 28 days
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM-CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR	2 SENSRS / 28 days
FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM-CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR	3 UNITS / 30 days
G5/G4 MIS SENSOR	4 UNITS / 28 days

Migraine products

Drug name(s)	Quantity limits (per 30 days or as specified)
AIMOVIG INJ 140MG/ML ¹	1 INJ / 28 days
AIMOVIG INJ 70MG/ML ¹	1 INJ / 28 days
AJOVY INJ 225/1.5 ¹	3 syringes / 84 days
almotrip mal tab 12.5mg	12 tabs / 30 days
almotrip mal tab 6.25mg	24 tabs / 30 days
almotriptan tab 12.5mg	12 tabs / 30 days
almotriptan tab 6.25mg	24 tabs / 30 days
AMERGE tab 1MG	18 tabs / 30 days
AMERGE tab 2.5MG	18 tabs / 30 days
dihydroergot spr 4mg/ml	8 MLS / 28 days
eletriptan tab 20mg	18 tabs / 30 days
eletriptan tab 40mg	12 tabs / 30 days
EMGALITY INJ 100MG/ML ¹	9 syringes / 180 days
EMGALITY INJ 120MG/ML ¹	1 syringe / 28 days
FROVA tab 2.5MG	27 tabs / 30 days
frovatriptan tab 2.5mg	27 tabs / 30 days
IMITREX INJ 4MG/0.5	12 syringes / 30 days
IMITREX SPR 20MG/ACT	12 inhalerS / 30 days
IMITREX SPR 5MG/ACT	5 PACKS / 30 days
IMITREX tab 100MG	18 tabs / 30 days
IMITREX tab 25MG	27 tabs / 30 days
IMITREX tab 50MG	18 tabs / 30 days
IMITREX STATDOSE REFILL- SUMATRIPTAN SUCCINATE SOLUTION cartRIDGE 6 MG/0.5ML	12 cartS / 30 days
IMITREX STATDOSE SYSTEM-SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML	12 syringes / 30 days
IMITREX- SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML	12 syringes / 30 days
MAXALT tab 10MG	18 tabs / 30 days
MAXALT-MLT tab 10MG	18 tabs / 30 days
MIGRANAL SPR 4MG/ML	8 MLS / 28 days
naratriptan tab 1mg	18 tabs / 30 days
naratriptan tab 2.5mg	18 tabs / 30 days
NURTEC tab 75MG ODT	45 tabs / 90 days
ONZETRA XSAI MIS 11MG	32 inhalerS / 30 days
RELPAX tab 20MG	18 tabs / 30 days
RELPAX tab 40MG	12 tabs / 30 days
REYVOW tab 100MG	8 tabs / 30 days
REYVOW tab 50MG	8 tabs / 30 days
rizatriptan tab 10mg	18 tabs / 30 days
rizatriptan tab 10mg odt	18 tabs / 30 days
rizatriptan tab 5mg	36 tabs / 30 days
rizatriptan tab 5mg odt	36 tabs / 30 days
sumat-naprox tab 85-500mg	18 tabs / 30 days
SUMATRIPTAN INJ 6MG/0.5	12 syringes / 30 days
sumatriptan spr 20mg/act	12 inhalerS / 30 days
sumatriptan spr 5mg/act	5 PACKS / 30 days
sumatriptan tab 100mg	18 tabs / 30 days
sumatriptan tab 25mg	27 tabs / 30 days
sumatriptan tab 50mg	18 tabs / 30 days
sumatriptan succinate inj 6 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution auto-injector 4 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution auto-injector 6 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution cartridge 4 mg/0.5ml	12 cartS / 30 days
sumatriptan succinate solution cartridge 6 mg/0.5ml	12 cartS / 30 days
TREXIMET tab 85-500MG	18 tabs / 30 days
UBRELVY tab 100MG	16 tabs / 30 days
UBRELVY tab 50MG	16 tabs / 30 days
ZEMBRACE SYM INJ 3/0.5ML	24 pens / 30 days
ZOLMITRIPTAN SPR 2.5MG	3 sprays / 30 days
zolmitriptan tab 2.5 mg	18 tabs / 30 days
zolmitriptan tab 2.5mg	18 tabs / 30 days
zolmitriptan tab 5mg	12 tabs / 30 days
zolmitriptan tab 5mg odt	12 tabs / 30 days
ZOMIG SPR 2.5MG	3 sprays / 30 days
ZOMIG SPR 5MG	2 sprays / 30 days
ZOMIG tab 2.5MG	18 tabs / 30 days
ZOMIG tab 5MG	12 tabs / 30 days
ZOMIG ZMT tab 2.5 MG	18 tabs / 30 days

Miscellaneous therapeutic classes

Drug name(s)	Quantity limits (per 30 days or as specified)
BENLYSTA INJ 200MG/ML ¹	4 syringes / 28 days
ENSPRYNG INJ ¹	1 syringe / 28 days
LUPKYNIS CAP 7.9MG	180 caps / 30 days
REVLIMID CAP 10MG ¹	30 caps / 30 days
REVLIMID CAP 15MG ¹	21 caps / 28 days
REVLIMID CAP 2.5MG ¹	30 caps / 30 days
REVLIMID CAP 20MG ¹	21 caps / 28 days
REVLIMID CAP 25MG ¹	21 caps / 28 days
REVLIMID CAP 5MG ¹	30 caps / 30 days
THALOMID CAP 100MG ¹	30 caps / 30 days
THALOMID CAP 150MG ¹	60 caps / 30 days
THALOMID CAP 200MG ¹	60 caps / 30 days
THALOMID CAP 50MG ¹	30 caps / 30 days
ZOKINVY CAP 50MG ²	120 caps / 30 days
ZOKINVY CAP 75MG ²	120 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)	Quantity limits (per 30 days or as specified)
AMRIX CAP 15MG	21 caps / 90 days
AMRIX CAP 30MG	21 caps / 90 days
baclofen tab 10mg	120 tabs / 30 days
baclofen tab 20mg	120 tabs / 30 days
baclofen tab 5mg	120 tabs / 30 days
CARISOPR/ASA tab 200-325	168 tabs / 90 days
carisoprodol/asa tab 200-325	168 tabs / 90 days
carisoprodol tab 250mg	84 tabs / 90 days
carisoprodol tab 350mg	84 tabs / 90 days
CARISOPRODOL tab ASA/COD	168 tabs / 30 days
carisoprodol tab asa/cod	168 tabs / 90 days
chlorzoxazone tab 250mg	84 tabs / 90 days
chlorzoxazone tab 375mg	84 tabs / 90 days
chlorzoxazone tab 500mg	84 tabs / 90 days
chlorzoxazone tab 750mg	84 tabs / 90 days
cyclobenzaprine cap 15mg er	21 caps / 90 days
cyclobenzaprine cap 30mg er	21 caps / 90 days
cyclobenzaprine tab 10mg	63 tabs / 90 days
cyclobenzaprine tab 5mg	63 tabs / 90 days
cyclobenzaprine tab 7.5mg	63 tabs / 90 days
DANTRIUM CAP 25MG	90 caps / 30 days
DANTRIUM CAP 50MG	90 caps / 30 days
dantrolene cap 100mg	90 caps / 30 days
dantrolene cap 25mg	90 caps / 30 days
dantrolene cap 50mg	90 caps / 30 days
FEXMID tab 7.5MG	63 tabs / 90 days
lorzone tab 375mg	84 tabs / 90 days
lorzone tab 750mg	84 tabs / 90 days
metaxalone tab 400mg	168 tabs / 90 days
metaxalone tab 800mg	84 tabs / 90 days
methocarbam tab 500mg	180 tabs / 90 days
methocarbam tab 750mg	132 tabs / 90 days
orphenadrine tab 100mg cr	42 tabs / 30 days
orphenadrine tab 100mg er	42 tabs / 30 days
ROBAXIN-750 tab 750MG	132 tabs / 90 days
SKELAXIN tab 800MG	84 tabs / 90 days
SOMA tab 250MG	84 tabs / 90 days
SOMA tab 350MG	84 tabs / 90 days
tizanidine cap 2mg	126 caps / 90 days
tizanidine cap 4mg	126 caps / 90 days
tizanidine cap 6mg	126 caps / 90 days
tizanidine tab 2mg	126 tabs / 90 days
tizanidine tab 4mg	42 caps / 30 days
vanadom tab 350mg	84 tabs / 90 days
ZANAFLEX CAP 2MG	126 caps / 90 days
ZANAFLEX CAP 4MG	126 caps / 90 days
ZANAFLEX CAP 6MG	126 caps / 90 days
ZANAFLEX tab 4MG	42 tabs / 30 days

Nasal agents – systemic and topical

Drug name(s)	Quantity limits (per 30 days or as specified)
azelastine /fluticasone spr 137-50	1 bottle / 30 days
azelastine spr 0.1%	2 bottleles / 30 days
azelastine spr 0.15%	2 bottleles / 30 days
BECONASE AQ SUS 0.042%	2 bottleles / 30 days
DYMISTA SPR 137-50	1 bottle / 30 days
FLUNISOLIDE SPR 0.025%	3 bottleles / 30 days
ipratropium spr 0.03%	2 bottleles / 30 days
ipratropium spr 0.06%	3 bottleles / 30 days
mometasone spr 50mcg	2 bottleles / 30 days
NASONEX SPR 50MCG/AC	2 bottleles / 30 days
olopatadine spr 0.6%	1 bottle / 30 days
OMNARIS SPR	1 bottle / 30 days
PATANASE SPR 0.6%	1 bottle / 30 days
QNASL AER 80MCG	1 can / 30 days
QNASL CHILD SPR 40MCG	1 can / 30 days
XHANCE MIS 93MCG	2 bottleles / 30 days
ZETONNA AER 37MCG	1 can / 30 days

Neuromuscular agents

Drug name(s)	Quantity limits (per 30 days or as specified)
EVRYSDI SOL ²	240 MLS / 30 days

Ophthalmic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
bimatoprost sol 0.03%	2.5 MLS / 30 days
EYSUVIS DRO 0.25%	2 bottleles / 90 days
latanoprost sol 0.005%	2.5 MLS / 30 days
LUMIGAN SOL 0.01%	2.5 MLS / 30 days
OXERVATE SOL 20MCG/ML ²	56 vials / 56 days
RESTASIS EMU 0.05%	2 vials / 30 days
RESTASIS MUL EMU 0.05%	1 bottle / 30 days
RHOPRESSA SOL 0.02%	2.5 MLS / 30 days
ROCKLATAN DRO	2.5 MLS / 30 days
TRAVATAN Z DRO 0.004%	2.5 MLS / 30 days
travoprost dro 0.004%	2.5 MLS / 30 days
VYZULTA SOL 0.024%	2.5 MLS / 30 days
XALATAN SOL 0.005%	2.5 MLS / 30 days
XIIDRA DRO 5%	60 vials / 30 days
ZIOPTAN DRO 0.0015%	30 cartNS / 30 days

Psychotherapeutic and neurological agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADDYI tab 100MG	30 tabs / 30 days
AMPYRA tab 10MG ^1,³	60 tabs / 30 days
AUBAGIO tab 7MG ^1,³	30 tabs / 30 days
AUBAGIO tab 14MG ^1,³	30 tabs / 30 days
AUSTEDO tab 6MG ¹	60 tabs / 30 days
AUSTEDO tab 9MG ¹	120 tabs / 30 days
AUSTEDO tab 12MG ¹	120 tabs / 30 days
AVONEX pen KIT 30MCG ¹	1 kit / 28 days
AVONEX PREFL KIT 30MCG ¹	1 kit / 28 days
BAFIERTAM CAP 95MG	120 caps / 30 days
BETASERON INJ 0.3MG ¹	1 BOX / 28 days
COPAXONE INJ 20MG/ML ¹	30 syringes / 30 days
COPAXONE INJ 40MG/ML ¹	12 syringes / 28 days
dalfampridine tab 10mg er ^1,³	60 tabs / 30 days
dimethyl fumarate cap 120mg dr ¹	56 caps / 180 days
dimethyl fumarate cap 240mg dr ¹	60 caps / 30 days
dimethyl fumarate mis starter ¹	60 caps / 180 days
EXTAVIA INJ 0.3MG ¹	15 vials / 30 days
GILENYA CAP 0.5MG ¹	30 tabs / 30 days
glatiramer inj 20mg/ml ¹	30 syringes / 30 days
glatiramer inj 40mg/ml ¹	12 syringes / 28 days
glatopa inj 20mg/ml ¹	30 syringes / 30 days
glatopa inj 40mg/ml ¹	12 syringes / 28 days
INGREZZA CAP 40-80MG ²	28 caps / 180 days
INGREZZA CAP 40MG ²	30 caps / 30 days
INGREZZA CAP 60MG ²	30 caps / 30 days
INGREZZA CAP 80MG ²	30 caps / 30 days
KESIMPTA INJ 20/.4ML ¹	1 syringe / 28 days
LYRICA CR tab 82.5MG	30 tabs / 30 days
LYRICA CR tab 165MG	30 tabs / 30 days
LYRICA CR tab 330MG	60 tabs / 30 days

Psychotherapeutic and neurological agents

Drug name(s)	Quantity limits (per 30 days or as specified)
MAYZENT PAK STARTER	12 tabs / 180 days
MAYZENT tab 0.25MG ¹	120 tabs / 30 days
MAYZENT tab 2MG ¹	30 tabs / 30 days
PLEGRIDY INJ ¹	2 syringes / 28 days
PLEGRIDY INJ pen ¹	2 pens / 28 days
PLEGRIDY INJ STARTER ¹	1 kit / 180 days
PLEGRIDY pen INJ STARTER ¹	1 kit / 180 days
PONVORY tab 20MG	30 tabs / 30 days
PONVORY tab STARTER	14 tabs / 180 days
pregabalin er tab 82.5mg	30 tabs / 30 days
pregabalin er tab 165mg	30 tabs / 30 days
pregabalin er tab 330mg	60 tabs / 30 days
REBIF INJ 22/0.5 ¹	12 syringes / 28 days
REBIF INJ 44/0.5 ¹	1 carton / 28 days
REBIF REBIDO INJ 22/0.5 ¹	1 carton / 28 days
REBIF REBIDO INJ 44/0.5 ¹	1 carton / 28 days
REBIF REBIDO INJ TITRATN ¹	1 kit / 180 days
REBIF TITRTN INJ PACK ¹	1 kit / 180 days
SAVELLA MIS TITR PAK	1 kit / 180 days
SAVELLA tab 12.5MG	60 tabs / 30 days
SAVELLA tab 25MG	60 tabs / 30 days
SAVELLA tab 50MG	60 tabs / 30 days
SAVELLA tab 100MG	60 tabs / 30 days
TECFIDERA CAP 120MG ¹	56 caps / 180 days
TECFIDERA CAP 240MG ¹	60 caps / 30 days
TECFIDERA MIS STARTER ¹	60 caps / 180 days
TEGSEDI INJ 284/1.5 ²	6 MLS / 28 days
tetrabenazine tab 12.5mg⁴	240 tabs / 30 days
tetrabenazine tab 12.5mg^1,⁴	240 tabs / 30 days
tetrabenazine tab 25mg⁴	120 tabs / 30 days
tetrabenazine tab 25mg^1,⁴	120 tabs / 30 days
VUMERITY- DIROXIMEL FUMARATE CAPSULE DELAYED RELEASE 231 MG¹	120 caps / 30 days
VUMERITY- DIROXIMEL FUMARATE CAPSULE DR STARTER bottlele 231 MG ¹	106 caps / 180 days
VYLEESI INJ 1.75/0.3	6 pens / 30 days
XENAZINE tab 12.5MG ¹	240 tabs / 30 days
XENAZINE tab 25MG ¹	120 tabs / 30 days

Respiratory agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ESBRIET CAP 267MG ¹	180 caps / 30 days
ESBRIET tab 267MG ¹	180 tabs / 30 days
ESBRIET tab 801MG ¹	90 tabs / 30 days
KALYDECO PAK 25MG ¹	60 packets / 30 days
KALYDECO PAK 50MG ¹	60 packets / 30 days
KALYDECO PAK 75MG ¹	60 packets / 30 days
KALYDECO tab 150MG ¹	60 tabs / 30 days
OFEV CAP 100MG ^1,³_	60 caps / 30 days
OFEV CAP 150MG ^1,³_	60 caps / 30 days
ORKAMBI tab 100-125 ¹	120 tabs / 30 days
ORKAMBI tab 200-125 ¹	120 tabs / 30 days
SYMDEKO tab 100-150 ¹	60 tabs / 30 days
SYMDEKO tab 50-75MG ¹	56 tabs / 28 days
TRIKAFTA tab 100mg/50mg/75mg/150mg¹	90 tabs / 30 days

Ulcer drugs / antispasmodics / anticholinergics

Drug name(s)	Quantity limits (per 30 days or as specified)
ACIPHEX tab 20MG	30 tabs / 30 days
DEXILANT CAP 30MG DR	30 caps / 30 days
DEXILANT CAP 60MG DR	30 caps / 30 days
esomeprazole magnesium cap 40mg dr	30 caps / 30 days
lansoprazole cap 15mg dr	30 caps / 30 days
lansoprazole cap 30mg dr	30 caps / 30 days
NEXIUM CAP 40MG	30 caps / 30 days
omeprazole/bicarbinate cap 20-1100	30 caps / 30 days
omeprazole/ bicarbinate cap 40-1100	30 caps / 30 days
omeprazole/ bicarbinate pow 20-1680	30 packets / 30 days
omeprazole/ bicarbinate pow 40-1680	30 packets / 30 days
omeprazole cap 10mg	30 caps / 30 days
omeprazole cap 20mg	30 caps / 30 days
omeprazole cap 40mg	30 caps / 30 days
pantoprazole tab 20mg	30 tabs / 30 days
pantoprazole tab 20mg dr	30 tabs / 30 days
pantoprazole tab 40mg	30 tabs / 30 days
pantoprazole tab 40mg dr	30 tabs / 30 days
PREVACID CAP 15MG DR	30 caps / 30 days
PREVACID CAP 30MG DR	30 caps / 30 days
PROTONIX tab 20MG	30 tabs / 30 days
PROTONIX tab 40MG	30 tabs / 30 days
rabeprazole tab 20mg	30 tabs / 30 days
ZEGERID CAP 20-1100	30 caps / 30 days
ZEGERID CAP 40-1100	30 caps / 30 days
ZEGERID POW 20-1680	30 packets / 30 days
ZEGERID POW 40-1680	30 packets / 30 days

Urinary antispasmodics

Drug name(s)	Quantity limits (per 30 days or as specified)
darifenacin tab 7.5mg	30 tabs / 30 days
darifenacin tab 15mg	30 tabs / 30 days
DETROL tab 1MG	60 tabs / 30 days
DETROL tab 2MG	60 tabs / 30 days
DETROL LA CAP 2MG	30 caps / 30 days
DETROL LA CAP 4MG	30 caps / 30 days
DITROPAN XL tab 5MG	30 tabs / 30 days
DITROPAN XL tab 10MG	60 tabs / 30 days
ENABLEX tab 7.5MG	30 tabs / 30 days
ENABLEX tab 15MG	30 tabs / 30 days
GELNIQUE GEL 10%	30 packets / 30 days
GEMTESA tab 75MG 30 tabs / 30 days	N/A
MYRBETRIQ SUS 8MG/ML	300 MLS / 28 days
MYRBETRIQ tab 25MG	30 tabs / 30 days
MYRBETRIQ tab 50MG	30 tabs / 30 days
oxybutynin syp 5mg/5ml	600 MLS / 30 days
oxybutynin tab 5mg	120 tabs / 30 days
oxybutynin tab 5mg er	30 tabs / 30 days
oxybutynin tab 10mg er	60 tabs / 30 days
oxybutynin tab 15mg er	60 tabs / 30 days
solifenacin tab 10mg	30 tabs / 30 days
solifenacin tab 5mg	30 tabs / 30 days
tolterodine cap 2mg er	30 caps / 30 days
tolterodine cap 4mg er	30 caps / 30 days
tolterodine tab 1mg	60 tabs / 30 days
tolterodine tab 2mg	60 tabs / 30 days
TOVIAZ tab 4MG	30 tabs / 30 days
TOVIAZ tab 8MG	30 tabs / 30 days
trospium chl cap 60mg er	30 caps / 30 days
trospium cl tab 20mg	60 tabs / 30 days
VESICARE tab 10MG	30 tabs / 30 days
VESICARE tab 5MG	30 tabs / 30 days

Vaginal and related products

Drug name(s)	Quantity limits (per 30 days or as specified)
CRINONE GEL 4% VAG	6 APPLCS / 30 days
CRINONE GEL 8% VAG	60 APPLCS / 30 days
ENDOMETRIN SUP 100MG	84 SUPPS / 28 days

Vasopressors

Drug name(s)	Quantity limits (per 30 days or as specified)
droxidopa cap 100mg (NOTHERA)⁴	450 caps / 30 days
droxidopa cap 100mg (NOTHERA)^1,⁴	450 caps / 30 days
droxidopa cap 200mg (NOTHERA)⁴	180 caps / 30 days
droxidopa cap 200mg (NOTHERA)^1,⁴	180 caps / 30 days
droxidopa cap 300mg (NOTHERA)⁴	180 caps / 30 days
droxidopa cap 300mg (NOTHERA)^1,⁴	180 caps / 30 days
NORTHERA CAP 100MG ¹	450 caps / 30 days
NORTHERA CAP 200MG ¹	180 caps / 30 days
NORTHERA CAP 300MG ¹	180 caps / 30 days

Specialty

Open - Members can obtain their specialty drugs at any pharmacy, even if the drug is listed as exclusive
Open/Closed - Members obtain their specialty drugs based on the exclusivity of the drug
Closed - Members must obtain all of their specialty drugs at our designated specialty pharmacy

Drug name(s)
abiraterone acetate¹	ACTEMRA¹	ACTEMRA ACTPEN¹
ACTHAR¹	ADCIRCA¹	ADEMPAS^2,⁴
ADVATE¹	ADYNOVATE¹	AFINITOR^1,³
AFINITOR DISPERZ^1,³	AFSTYLA¹	ALECENSA^2,^3,⁴
ALPHANINE SD¹	ALPROLIX¹	ALUNBRIG²
alyq¹	ambrisentan¹	AMPYRA^1,³
ARCALYST^2,⁴	ARIKAYCE²	AUBAGIO^1,³
AUSTEDO¹	AVONEX^1,⁴	AVONEX PEN^1,⁴
AYVAKIT^2,³	BALVERSA^2,³	BENEFIX¹
BENLYSTA¹	BETASERON^1,⁴	BETHKIS¹
bexarotene^1,³	bosentan¹	BOSULIF^1,³
BRAFTOVI^2,⁴	BRUKINSA²	BUPHENYL¹
CABOMETYX^1,³	CALQUENCE²	capecitabine^1,⁴
CAPRELSA²	CARBAGLU^2,⁴	CAYSTON¹
CERDELGA¹	CETROTIDE^1,⁴	CHORIONIC GONADOTROPIN¹
CIMZIA STARTER KIT¹	cinacalcet¹	COMETRIQ^2,^3,⁴
COPAXONE^1,⁴	COPIKTRA^2,³	COSENTYX¹
COSENTYX SENSOREADY PEN¹	COTELLIC¹	CUTAQUIG^2,⁴
CUVITRU^2,⁴	dalfampridine er^1,³	DAURISMO^1,³
deferasirox^1,³	dimethyl fumarate¹	dimethyl fumarate starterpack¹
DOJOLVI^2,⁴	droxidopa¹	DUPIXENT¹
EGRIFTA¹	EGRIFTA SV¹	ELOCTATE¹
EMFLAZA^2,⁴	ENBREL^1,⁴	ENBREL MINI^1,⁴
ENBREL SURECLICK^1,⁴	ENDARI²	ENSPRYNG¹
EPCLUSA¹	EPIDIOLEX¹	ERIVEDGE^1,³
erlotinib hcl^1,³	ESBRIET¹	ESPEROCT¹
EVRYSDI^2,⁴	EXJADE^1,³	EXTAVIA¹
FARYDAK*	FINTEPLA²	FIRAZYR¹
FIRDAPSE²	FOLLISTIM AQ^1,⁴	FORTEO^1,⁴
GALAFOLD¹	ganirelix ac^1,⁴	GATTEX^2,⁴
GAVRETO^2,^3,⁴	GENOTROPIN^1,⁴	GENOTROPIN MINIQUICK^1,⁴
GILENYA¹	GILOTRIF^2,⁴	glatiramer acetate^1,⁴
glatopa¹	GLEEVEC^1,³	GOCOVRI^1,³
GONAL-F^1,⁴	GONAL-F RFF^1,⁴	GONAL-F RFF REDIJECT^1,⁴
GRANIX¹	HAEGARDA^2,⁴	HARVONI^1,⁴
HEMLIBRA¹	HEMOFIL M¹	HETLIOZ^2,^3,⁴
HETLIOZ LQ^2,^3,⁴	HIZENTRA¹	HUMATROPE^1,⁴
HUMIRA^1,⁴	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK^1,⁴	HUMIRA PEN^1,⁴
HUMIRA PEN-CD/UC/HS STARTER^1,⁴	HUMIRA PEN-PEDIATRIC UC STARTER PACK^1,⁴	HUMIRA PEN-PS/UV STARTER^1,⁴
HYCAMTIN¹	HYQVIA¹	IBRANCE¹
icatibant acetate¹	ICLUSIG^2,³	IDELVION¹
IDHIFA¹	imatinib mesylate *	IMBRUVICA²
IMCIVREE²	INGREZZA²	INLYTA^1,³
INQOVI¹	INREBIC^1,^3,⁴	INTRON A¹
IRESSA^2,^3,⁴	ISTURISA²	IXINITY¹
JADENU^1,³	JADENU SPRINKLE^1,³	JAKAFI^1,³
JIVI¹	JUXTAPID^2,⁴	JYNARQUE¹
KALYDECO¹	KESIMPTA^1,⁴	KEVEYIS²
KEVZARA¹	KINERET²	KISQALI¹
KITABIS PAK¹	KOATE¹	KOATE-DVI¹
KOGENATE FS¹	KORLYM²	KOSELUGO²
KOVALTRY¹	KUVAN¹	lapatinib ditosylate^1,⁴
LEDIPASVIR / SOFOSBUVIR^1,⁴	LENVIMA^2,^3,⁴	LETAIRIS¹
LONSURF¹	LORBRENA^1,³	LYNPARZA^2,^3,⁴
MATULANE¹	MAVYRET^1,⁴	MAYZENT¹
MEKINIST¹	MEKTOVI^2,⁴	MENOPUR¹
miglustat¹	MONONINE¹	MULPLETA¹
MYALEPT^2,⁴	NATPARA¹	NERLYNX^2,^3,⁴
NEULASTA^1,⁴	NEULASTA ONPRO KIT^1,⁴	NEXAVAR^1,³
NINLARO¹	NORDITROPIN FLEXPRO^1,⁴	NORTHERA¹
NOVAREL^1,⁴	NOVOEIGHT¹	NUBEQA¹
NUPLAZID¹	NUTROPIN AQ NUSPIN^1,⁴	NUWIQ¹
OCALIVA¹	ODOMZO^1,³	OFEV^1,³
OLUMIANT¹	OMNITROPE¹	ONUREG¹
OPSUMIT^2,⁴	ORENCIA¹	ORENCIA CLICKJECT¹
ORENITRAM^2,⁴	ORGOVYX²	ORKAMBI¹
ORLADEYO²	OTEZLA¹	OVIDREL^1,⁴
OXBRYTA^2,⁴	OXERVATE^2,⁴	PEGINTRON^1,⁴
PEMAZYRE²	PIQRAY¹	PLEGRIDY¹
PLEGRIDY STARTER PACK¹	POMALYST¹	PREGNYL W/DILUENT BENZYL ALCOHOL/NACL^1,⁴
PROCRIT^1,⁴	PROCYSBI^2,⁴	PROFILNINE¹
PROFILNINE SD¹	PROMACTA¹	QINLOCK²
RAVICTI¹	REBIF^1,⁴	REBIF REBIDOSE^1,⁴
REBIF REBIDOSE TITRATION PACK^1,⁴	REBIF TITRATION PACK^1,⁴	REBINYN¹
RECOMBINATE¹	RETEVMO^1,³	REVATIO¹
REVLIMID¹	RINVOQ¹	RIXUBIS¹
ROZLYTREK^1,^3,⁴	RUBRACA^2,^3,⁴	RUZURGI²
RYDAPT¹	sajazir¹	SAMSCA¹
sapropterin dihydrochloride¹	SENSIPAR¹	SEROSTIM^1,⁴
SIGNIFOR²	sildenafil sus 10mg/ml¹	sildenafil tab 20mg¹
SILIQ¹	SIMPONI¹	SKYRIZI¹
SKYRIZI PEN¹	sodium phenylbutyrate¹	SOFOSBUVIR / VELPATASVIR¹
SOMAVERT¹	SOVALDI¹	SPRYCEL^1,^3,⁴
STELARA¹	STIMATE¹	STIVARGA¹
STRENSIQ²	sunitinib malate^1,³	SUTENT^1,³
SYMDEKO¹	TABRECTA¹	tadalafil¹
TAFINLAR¹	TAGRISSO^2,^3,⁴	TAKHZYRO^2,⁴
TALTZ¹	TALZENNA^1,³	TARCEVA^1,³
TARGRETIN^1,³	TASIGNA^1,^3,⁴	TAZVERIK²
TECFIDERA¹	TECFIDERA STARTER PACK¹	TEGSEDI^2,⁴
TEMODAR^1,⁴	temozolomide¹	TERIPARATIDE^1,⁴
tetrabenazin tab¹		THALOMID¹
TIBSOVO²	TOBI¹	TOBI PODHALER¹
tobramycin neb 300/4ml¹	tobramycin neb 300/5ml¹	TOLVAPTAN TAB 15MG¹
tolvaptan tab 30mg¹	TRACLEER¹	TREMFYA¹
TRIKAFTA¹	TUKYSA²	TURALIO²
TYKERB^1,⁴	TYMLOS¹	UPTRAVI^2,⁴
VENCLEXTA²	VENCLEXTA STARTING PACK²	VENTAVIS^2,^3,⁴
VERZENIO^2,^3,⁴	VIEKIRA PAK¹	VITRAKVI^2,^3,⁴
VIZIMPRO^1,³	VOSEVI¹	VOTRIENT^1,³
VUMERITY¹	VYNDAMAX¹	VYNDAQEL¹
XALKORI^1,³	XELJANZ¹	XELJANZ XR¹
XELODA^1,⁴	XENAZINE¹	XERMELO²
XOLAIR¹	XOSPATA²	XPOVIO^2,³
XTANDI^1,³	XYNTHA¹	XYNTHA SOLOFUSE¹
XYREM^2,⁴	XYWAV^2,⁴	ZARXIO¹
ZAVESCA^2,⁴	ZEJULA^2,³	ZELBORAF¹
ZEPATIER¹	ZEPOSIA¹	ZEPOSIA 7-DAY STARTER PACK¹
ZEPOSIA STARTER KIT¹	ZOKINVY²	ZOLINZA^1,³
ZOMACTON^1,⁴	ZORBTIVE¹	ZYDELIG^2,⁴
ZYKADIA^1,³	ZYTIGA^1,³

¹Specialty

²Limited Distribution

³Split Fill

⁴Exclusive to Accredo

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Advantage prescription drug benefits

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Guide to prescription drug benefits

Use this guide to understand how your benefits work.

Drug name(s)

Drug name(s)

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits (per 30 days or as specified)

Aminoglycosides

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics - opioid

Drug name(s)

Adult quantity limits - 5 days

Child quantity limits - 3 days

Androgens - anabolic

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Anticonvulsants

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidiabetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidotes and specific antagonists

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiemetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antihyperlidemics

Drug name(s)

Quantity limits (per 30 days or as specified)

Anti-infective agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antimyasthenic / cholinergic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antineoplastics and adjuntive therapies

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiparkinson and related therapy agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antipsychotics / antimanic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antivirals

Drug name(s)

Quantity limits (per 30 days or as specified)

Cardiovascular agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Corticosteroids

Drug name(s)

Quantity limits (per 30 days or as specified)

Dermatologicals

Drug name(s)

Quantity limits (per 30 days or as specified)

Digestive aids

Drug name(s)

Quantity limits (per 30 days or as specified)

Diuretics

Drug name(s)

Quantity limits (per 30 days or as specified)

Endocrine and metabolic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Estrogens

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)