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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 |
AFREZZA |
||
AFSTYLA 1 |
AKLIEF |
ALDARA |
alosetron hcl |
ALPHANINE SD 1 |
|
ALPROLIX 1 |
ALUNBRIG 2 |
alyq 1 |
AMBIEN |
AMBIEN CR |
ambrisentan 1 |
AMITIZA |
AMPHETAMINE ER |
|
AMRIX |
ANAFRANIL |
ANDRODERM |
ANDROGEL |
ANDROGEL PUMP |
APIDRA |
APIDRA SOLOSTAR |
APLENZIN |
APTENSIO XR |
ARAZLO |
ARCALYST 2 |
ARIKAYCE 2 |
ARYMO ER |
ATRALIN |
|
AUSTEDO 1 |
AUVI-Q |
avita |
AVONEX 1 |
AVONEX PEN 1 |
|
AZESCHEW PRENATAL / POSTNATAL |
AZESCO |
BAFIERTAM |
BELBUCA |
BELSOMRA |
|
BENEFIX 1 |
BENLYSTA 1 |
benzphetamin tab 50mg |
BENZPHETMINE TAB 25MG |
BETASERON 1 |
BETHKIS 1 |
bexarotene 1 - |
bosentan 1 |
|
BRAFTOVI 2 |
BRUKINSA 2 |
BUPHENYL 1 |
buprenorphine |
BUPROPION HCL ER (XL) |
BUTRANS |
BYNFEZIA PEN |
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 |
|
CONCERTA |
CONTRAVE |
CONZIP |
COPAXONE 1 |
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 |
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 |
|
ESBRIET 1 |
ESPEROCT 1 |
|
EVEKEO |
everolimus |
EVRYSDI 2 |
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 |
GENOTROPIN 1 |
GENOTROPIN MINIQUICK 1 |
|
GEODON |
GILENYA 1 |
GILOTRIF 2 |
glatiramer acetate 1 |
glatopa 1 |
|
glydo |
GONAL-F 1 |
|
GONAL-F RFF 1 |
GONAL-F RFF REDIJECT 1 |
GRANIX 1 |
HAEGARDA 2 |
HARVONI 1 |
HEMLIBRA 1 |
HEMOFIL M 1 |
||
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 |
IDELVION 1 |
IDHIFA 1 |
|
imatinib mesylate 1 |
IMBRUVICA 2 |
IMCIVREE 2 |
imiquimod |
imiquimod pump |
INGREZZA 2 |
INQOVI 1 |
||
INSULIN LISPRO |
INSULIN LISPRO JUNIOR KWIKPEN |
INSULIN LISPRO KWIKPEN |
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN |
INTERMEZZO |
INTRON A 1 |
INTUNIV |
INVEGA |
|
ISTURISA 2 |
IXINITY 1 |
|
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 |
LETAIRIS 1 |
LEXAPRO |
|
lidocaine |
lidocaine gel |
LIDOCAINE AND TETRACAINE CREAM |
lidocaine hcl |
lidocaine patch 5% |
lidocaine/prilocaine |
LIDOCAINE/TETRACAINE |
LIDODERM |
LOMAIRA |
LONSURF 1 |
LOTRONEX |
|
LUBIPROSTONE |
LUMAKRAS |
LUNESTA |
LUPKYNIS |
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 |
NEULASTA 1 |
NEULASTA ONPRO KIT 1 |
|
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 |
||
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 |
|
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 |
|
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 |
STELARA 1 |
|
STIMATE 1 |
STIVARGA 1 |
STRATTERA |
STRENSIQ 2 |
STRIANT |
SUBSYS |
SUCRAID |
SUNOSI |
|
SYMDEKO 1 |
SYNERA |
|
TABRECTA 1 |
tadalafil 1 |
TAFINLAR 1 |
TAKHZYRO 2 |
TALTZ 1 |
|
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 |
VERQUVO |
VERSACLOZ |
|
VFEND |
VIBERZI |
|
VIBRAMYCIN |
VIEKIRA PAK 1 |
VIIBRYD |
VIIBRYD STARTER PACK |
VIMOVO |
|
VOGELXO |
VOGELXO PUMP |
|
voriconazole |
VOSEVI 1 |
|
VRAYLAR |
VUMERITY 1 |
VYLEESI |
VYNDAMAX 1 |
VYNDAQEL 1 |
WAKIX |
WEGOVY |
WELLBUTRIN SR |
WELLBUTRIN XL |
WYNZORA |
XELJANZ 1 |
|
XELJANZ XR 1 |
XELODA 1 |
XENAZINE 1 |
XENICAL |
XERMELO 2 |
XHANCE |
XIFAXAN |
XIIDRA |
XIMINO |
XOLAIR 1 |
XOSPATA 2 |
|
XTAMPZA ER |
XYNTHA 1 |
|
XYNTHA SOLOFUSE 1 |
XYOSTED |
XYREM 2 |
XYWAV 2 |
ZALVIT |
ZANAFLEX |
ZARXIO 1 |
ZAVESCA 2 |
ZEGERID |
ZELBORAF 1 |
ZELNORM |
|
ZEPATIER 1 |
ZEPOSIA 1 |
ZEPOSIA 7-DAY STARTER PACK 1 |
ZEPOSIA STARTER KIT 1 |
ZOHYDRO ER |
ZOKINVY 2 |
ZOLOFT |
ZOLPIMIST |
|
ZOMACTON 1 |
ZORBTIVE 1 |
ZTLIDO |
ZYCLARA |
ZYCLARA PUMP |
ZYDELIG 2 |
ZYPREXA |
ZYPREXA ZYDIS |
|
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 |
CLOBEX |
CLOCORTOLONE PIVALATE |
CLODERM |
CONTOUR BLOOD GLUCOSE TEST STRIPS |
CONTOUR NEXT BLOOD |
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 |
DEXCOM G5 MOBILE |
DEXCOM G5 MOBILE/G4 |
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 |
FREESTYLE LIBRE/SENSOR/FLASH |
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 |
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 |
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 |
PREDNICARBATE |
PREMIUM BLOOD GLUCOSE TEST STRIPS |
PRESTIGE TEST STRIPS |
PRO VOICE V8/V9 BLOOD |
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 |
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 |
RIGHTEST GS300 BLOOD |
RIGHTEST GS550 BLOOD |
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
|
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
|
ARIKAYCE SUS 2 |
28 vials / 28 days |
Analgesics – anti-inflammatory
Drug name(s) |
Quantity limits
|
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
|
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
|
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
|
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
|
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 LINAGLIPT -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
|
30 packets / 30 days |
|
180 packets / 30 days |
|
30 packets / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
180 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
180 tabs / 30 days |
|
30 tabs / 30 days |
|
30 packets / 30 days |
|
180 packets / 30 days |
|
30 packets / 30 days |
Antiemetics
Drug name(s) |
Quantity limits
|
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
|
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
|
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
|
120 tabs / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
90 tabs / 30 days |
|
60 tabs / 30 days |
|
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 |
30 tabs / 30 days |
|
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 |
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
BRAFTOVI CAP 75MG 2 |
180 caps / 30 days |
BRUKINSA CAP 80MG 2 |
120 caps / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
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 |
30 tabs / 30 days |
|
60 tabs / 30 days |
|
30 caps / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
FARYDAK CAP 10MG4 |
6 caps / 21 days |
6 caps / 21 days |
|
FARYDAK CAP 15MG4 |
6 caps / 21 days |
6 caps / 21 days |
|
FARYDAK CAP 20MG4 |
6 caps / 21 days |
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 |
90 tabs / 30 days |
|
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 |
90 tabs / 30 days |
|
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 |
180 tabs / 30 days |
|
120 tabs / 30 days |
|
INQOVI tab 35-100MG 1 |
5 tabs / 28 days |
120 caps / 30 days |
|
IRESSA tab 250MG 2 |
30 tabs / 30 days |
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
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 |
30 tabs / 30 days |
|
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 |
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 |
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 |
180 caps / 30 days |
|
120 caps / 30 days |
|
30 caps / 30 days |
|
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 |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
STIVARGA tab 40MG 1 |
84 tabs / 28 days |
90 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
90 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
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 |
90 caps / 30 days |
|
30 caps / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
120 caps / 30 days |
|
120 caps / 30 days |
|
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 |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
120 tabs / 30 days |
|
120 caps / 30 days |
|
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 |
120 caps / 30 days |
|
120 tabs / 30 days |
|
60 tabs / 30 days |
|
ZEJULA CAP 100MG 2 |
90 caps / 30 days |
ZELBORAF tab 240MG 1 |
240 tabs / 30 days |
120 caps / 30 days |
|
ZYDELIG tab 100MG 2 |
60 tabs / 30 days |
ZYDELIG tab 150MG 2 |
60 tabs / 30 days |
90 tabs / 30 days |
|
120 tabs / 30 days |
|
60 tabs / 30 days |
Antiparkinson and related therapy agents
Drug name(s) |
Quantity limits
|
30 caps / 30 days |
|
60 caps / 30 days |
Antipsychotics / antimanic agents
Drug name(s) |
Quantity limits
|
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
|
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
|
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 |
270 AMPULS / 30 days |
|
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
|
EMFLAZA tab 6MG 2 |
60 tabs / 30 days |
EMFLAZA tab 18MG 2 |
30 tabs / 30 days |
Dermatologicals
Drug name(s) |
Quantity limits
|
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 |
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 |
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 |
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
|
SUCRAID SOL 8500/ML |
236 MLS / 28 days |
Diuretics
Drug name(s) |
Quantity limits
|
KEVEYIS tab 50MG 2 |
120 tabs / 30 days |
Endocrine and metabolic agents
Drug name(s) |
Quantity limits
|
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 |
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
|
ORIAHNN CAP |
56 caps / 28 days |
Gastrointestinal agents
Drug name(s) |
Quantity limits
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
EVRYSDI SOL 2 |
240 MLS / 30 days |
Ophthalmic agents
Drug name(s) |
Quantity limits
|
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
|
ADDYI tab 100MG |
30 tabs / 30 days |
60 tabs / 30 days |
|
30 tabs / 30 days |
|
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 |
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
|
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 |
240 tabs / 30 days |
|
tetrabenazine tab 25mg4 |
120 tabs / 30 days |
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
|
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 |
60 caps / 30 days |
|
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
|
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
|
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
|
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
|
droxidopa cap 100mg (NOTHERA)4 |
450 caps / 30 days |
450 caps / 30 days |
|
droxidopa cap 200mg (NOTHERA)4 |
180 caps / 30 days |
180 caps / 30 days |
|
droxidopa cap 300mg (NOTHERA)4 |
180 caps / 30 days |
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 |
|
ADVATE1 |
ADYNOVATE1 |
|
AFSTYLA1 |
||
ALPHANINE SD1 |
ALPROLIX1 |
ALUNBRIG2 |
alyq1 |
ambrisentan1 |
|
ARIKAYCE2 |
||
AUSTEDO1 |
||
BENEFIX1 |
||
BENLYSTA1 |
BETHKIS1 |
|
bosentan1 |
||
BRUKINSA2 |
BUPHENYL1 |
|
CALQUENCE2 |
||
CAPRELSA2 |
CAYSTON1 |
|
CERDELGA1 |
CHORIONIC GONADOTROPIN1 |
|
CIMZIA STARTER KIT1 |
cinacalcet1 |
|
COSENTYX1 |
||
COSENTYX SENSOREADY PEN1 |
COTELLIC1 |
|
dimethyl fumarate1 |
dimethyl fumarate starterpack1 |
|
droxidopa1 |
DUPIXENT1 |
|
EGRIFTA1 |
EGRIFTA SV1 |
ELOCTATE1 |
ENDARI2 |
ENSPRYNG1 |
|
EPCLUSA1 |
EPIDIOLEX1 |
|
ESBRIET1 |
ESPEROCT1 |
|
EXTAVIA1 |
||
FARYDAK* |
FINTEPLA2 |
FIRAZYR1 |
FIRDAPSE2 |
||
GALAFOLD1 |
||
GILENYA1 |
||
glatopa1 |
||
GRANIX1 |
||
HEMLIBRA1 |
HEMOFIL M1 |
|
HIZENTRA1 |
||
HYCAMTIN1 |
HYQVIA1 |
IBRANCE1 |
icatibant acetate1 |
IDELVION1 |
|
IDHIFA1 |
imatinib mesylate * |
IMBRUVICA2 |
IMCIVREE2 |
INGREZZA2 |
|
INQOVI1 |
INREBIC1,3,4 |
INTRON A1 |
ISTURISA2 |
IXINITY1 |
|
JIVI1 |
JYNARQUE1 |
|
KALYDECO1 |
KEVEYIS2 |
|
KEVZARA1 |
KINERET2 |
KISQALI1 |
KITABIS PAK1 |
KOATE1 |
KOATE-DVI1 |
KOGENATE FS1 |
KORLYM2 |
KOSELUGO2 |
KOVALTRY1 |
KUVAN1 |
|
LETAIRIS1 |
||
LONSURF1 |
||
MATULANE1 |
MAYZENT1 |
|
MEKINIST1 |
MENOPUR1 |
|
miglustat1 |
MONONINE1 |
MULPLETA1 |
NATPARA1 |
||
NINLARO1 |
NORTHERA1 |
|
NOVOEIGHT1 |
NUBEQA1 |
|
NUPLAZID1 |
NUWIQ1 |
|
OCALIVA1 |
||
OLUMIANT1 |
OMNITROPE1 |
ONUREG1 |
ORENCIA1 |
ORENCIA CLICKJECT1 |
|
ORGOVYX2 |
ORKAMBI1 |
|
ORLADEYO2 |
OTEZLA1 |
|
PEMAZYRE2 |
PIQRAY1 |
PLEGRIDY1 |
PLEGRIDY STARTER PACK1 |
POMALYST1 |
|
PROFILNINE1 |
||
PROFILNINE SD1 |
PROMACTA1 |
QINLOCK2 |
RAVICTI1 |
||
REBINYN1 |
||
RECOMBINATE1 |
REVATIO1 |
|
REVLIMID1 |
RINVOQ1 |
RIXUBIS1 |
ROZLYTREK1,3,4 |
RUZURGI2 |
|
RYDAPT1 |
sajazir1 |
SAMSCA1 |
sapropterin dihydrochloride1 |
SENSIPAR1 |
|
SIGNIFOR2 |
sildenafil sus 10mg/ml1 |
sildenafil tab 20mg1 |
SILIQ1 |
SIMPONI1 |
SKYRIZI1 |
SKYRIZI PEN1 |
sodium phenylbutyrate1 |
SOFOSBUVIR / VELPATASVIR1 |
SOMAVERT1 |
SOVALDI1 |
SPRYCEL1,3,4 |
STELARA1 |
STIMATE1 |
STIVARGA1 |
STRENSIQ2 |
||
SYMDEKO1 |
TABRECTA1 |
tadalafil1 |
TAFINLAR1 |
||
TALTZ1 |
||
TASIGNA1,3,4 |
TAZVERIK2 |
|
TECFIDERA1 |
TECFIDERA STARTER PACK1 |
|
temozolomide1 |
||
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 |
TYMLOS1 |
||
VENCLEXTA2 |
VENCLEXTA STARTING PACK2 |
|
VIEKIRA PAK1 |
||
VOSEVI1 |
||
VUMERITY1 |
VYNDAMAX1 |
VYNDAQEL1 |
XELJANZ1 |
XELJANZ XR1 |
|
XENAZINE1 |
XERMELO2 |
|
XOLAIR1 |
XOSPATA2 |
|
XYNTHA1 |
XYNTHA SOLOFUSE1 |
|
ZARXIO1 |
||
ZELBORAF1 |
||
ZEPATIER1 |
ZEPOSIA1 |
ZEPOSIA 7-DAY STARTER PACK1 |
ZEPOSIA STARTER KIT1 |
ZOKINVY2 |
|
ZORBTIVE1 |
||
|