Advantage prescription drug benefits

Effective July 1, 2021

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 acetate1

ABSTRAL

ACIPHEX

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ACTICLATE

ACTIQ

ADCIRCA1

ADDERALL

ADDERALL XR

ADEMPAS2

ADHANSIA XR

ADIPEX-P

ADMELOG

ADMELOG SOLOSTAR

ADVATE1

ADYNOVATE1

ADZENYS ER

ADZENYS XR-ODT

AFINITOR1, 3

AFINITOR DISPERZ1, 3

AFREZZA

AFSTYLA1

AIMOVIG1

AJOVY1

AKLIEF

ALDARA

ALECENSA2, 3

alosetron hcl

ALPHANINE SD1

ALPROLIX1

ALUNBRIG2

alyq1

AMBIEN

AMBIEN CR

ambrisentan1

AMITIZA

AMPHETAMINE ER

AMPYRA1, 3

AMRIX

ANAFRANIL

ANDRODERM

ANDROGEL

ANDROGEL PUMP

APIDRA

APIDRA SOLOSTAR

APLENZIN

APTENSIO XR

ARAZLO

ARCALYST2

ARIKAYCE2

ARYMO ER

ATRALIN

AUBAGIO1, 3

AUSTEDO1

AUVI-Q

avita

AVONEX1

AVONEX PEN1

AYVAKIT2, 3

AZESCHEW PRENATAL/POSTNATAL

AZESCO

BAFIERTAM

BALVERSA2, 3

BELBUCA

BELSOMRA

BELVIQ

BELVIQ XR

BENEFIX1

BENLYSTA1

benzphetamin

BENZPHETMINE

BETASERON1

BETHKIS1

bexarotene1, 3

bosentan1

BOSULIF1, 3

BRAFTOVI2

BRUKINSA2

BUPHENYL1

buprenorphine

BUPROPION HCL ER (XL)

BUTRANS

BYNFEZIA PEN

CABOMETYX1, 3

CALQUENCE2

capecitabine1

CAPLYTA

CAPRELSA2

CARAC

CARBAGLU2

CAYSTON1

CELEXA

CERDELGA1

CETROTIDE1

CHORIONIC GONADOTROPIN*

ciclodan

ciclopirox nail lacquer

CIMZIA1

CIMZIA STARTER KIT1

cinacalcet hcl1

CIPRO HC

CIPRODEX

ciprofloxacin/ dexamethasone

clomipramine hcl

CLOZAPINE ODT

CLOZARIL

COMETRIQ2, 3

CONCERTA

CONTRAVE

CONZIP

COPAXONE1

COPIKTRA2, 3

CORLANOR

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

COTEMPLA XR-ODT

CRINONE

CUTAQUIG2

CUVITRU2

cyclobenzaprine hcl er

CYMBALTA

DAKLINZA1

dalfampridine er1, 3

DANTRIUM

DARAPRIM

DAURISMO1, 3

DAYTRANA

DAYVIGO

DEPO-TESTOSTERONE

DESOXYN

DESVENLAFAXINE ER

DICLEGIS

diclofenac sodium

diethylprop  tab

diethylpropion hcl

DIETHYLPROPION HCL ER

dimethyl fumarate dr

dimethyl fumarate starter pack1

DOJOLVI2

DOLOPHINE

DORYX

DORYX MPC

DOXYCYCLINE

DOXYCYCLINE HYCLATE

doxylamine succinate /pyridoxin hcl

droxidopa1

DUEXIS

DUPIXENT1

DURAGESIC

DYANAVEL XR

EDLUAR

EFFEXOR XR

EFUDEX

EGRIFTA1

EGRIFTA SV1

ELOCTATE1

EMBEDA

EMFLAZA2

EMGALITY1

EMSAM

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

ENDARI2

ENDOMETRIN

ENSPRYNG1

EPCLUSA1

EPIDIOLEX1

EPINEPHRINE

EPIPEN 2-PAK

EPIPEN-JR 2-PAK

ERIVEDGE1, 3

erlotinib1, 3

ESBRIET1

ESPEROCT1

EVEKEO

everolimus1, 3

EVRYSDI2

EXTAVIA1

EYSUVIS

FABIOR

FANAPT

FANAPT TITRATION PACK

FARYDAK1

FAZACLO

fenofibrate

fenofibric acid dr

fentanyl

FENTANYL CITRATE

fentanyl citrate oral transmucosal

FENTORA

FETZIMA

FETZIMA TITRATION PACK

FEXMID

FINTEPLA2

FIRAZYR1

FIRDAPSE2

FLUOROPLEX

FLUOROURACIL

FLUOXETINE

FLUOXETINE DR

FLUOXETINE HCL

FOCALIN

FOCALIN XR

FOLLISTIM AQ1

FORFIVO XL

FORTEO1

FORTESTA

GALAFOLD1

ganirelix ac1

GATTEX2

GAVRETO2, 3

GENOTROPIN1

GENOTROPIN MINIQUICK1

GEODON

GILENYA1

GILOTRIF2

glatiramer acetate1

glatopa1

GLEEVEC1, 3

glydo

GOCOVRI1, 3

GONAL-F1

GONAL-F RFF1

GONAL-F RFF REDIJECT1

GRANIX1

HAEGARDA2

HARVONI1

HELIXATE FS1

HEMLIBRA1

HEMOFIL M1

HETLIOZ2, 3

HIZENTRA1

HUMALOG

HUMALOG JUNIOR KWIKPEN

HUMALOG KWIKPEN

HUMALOG MIX

HUMALOG MIX KWIKPEN

HUMATROPE1

HUMIRA1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1

HUMIRA PEN1

HUMIRA PEN-CD/UC/HS STARTER1

HUMIRA PEN-PEDIATRIC UC STARTER PACK1

HUMIRA PEN-PS/UV STARTER1

HUMULIN

HUMULIN KWIKPEN

HUMULIN N

HUMULIN N KWIKPEN

HUMULIN R

HYCAMTIN1

hydrocodone bitartrate er

hydromorphone hcl er

HYQVIA1

HYSINGLA ER

IBRANCE1

icatibant acetate1

ICLUSIG2, 3

IDELVION1

IDHIFA1

imatinib mesylate1, 3

IMBRUVICA2

IMCIVREE2

imiquimod

imiquimod pump

INGREZZA CAP2

INLYTA1, 3

INQOVI1

INREBIC1, 3

INSULIN LISPRO

INSULIN LISPRO JUNIOR KWIKPEN

INSULIN LISPRO KWIKPEN

INSULIN LISPRO PROTAMINE / INSULIN LISPRO KWIKPEN

INTERMEZZO

INTRON A1

INTUNIV

INVEGA

IRESSA2, 3

ISTURISA2

IXINITY1

JAKAFI1, 3

JIVI1

JORNAY PM

JUBLIA

JUXTAPID2

JYNARQUE1

KADIAN

KALYDECO1

KAPVAY

KERYDIN

KESIMPTA1

KEVEYIS2

KEVZARA1

KHEDEZLA

KINERET2

KISQALI1

KISQALI FEMARA1

KITABIS PAK1

KOATE1

KOATE-DVI1

KOGENATE FS1

KORLYM2

KOSELUGO

KOSELUGO2

KOVALTRY1

KUVAN1

lapatinib ditosylate1

LAZANDA

LEDIPASVIR /SOFOSBUVIR1

LENVIMA2, 3

LETAIRIS1

LEXAPRO

lidocaine

LIDOCAINE AND TETRACAINE CREAM

lidocaine hcl

lidocaine pak

lidocaine patch

LIDOCAINE/ TETRACAINE

LIDODERM

LINZESS

LOMAIRA

LONSURF1

LORBRENA1, 3

LORZONE

LOTRONEX

LUBIPROSTONE

LUNESTA

LYNPARZA2, 3

LYRICA CR

LYSODREN

LYUMJEV

LYUMJEV KWIKPEN

MAPROTILINE HCL

MATULANE1

MAVENCLAD1

MAVYRET1

MAYZENT1

MAYZENT STARTER PACK

MEKINIST1

MEKTOVI2

MENOPUR1

metaxall

metaxalone

methadone

methadone hcl

METHADONE SOL

METHITEST

METHYLIN

METHYLPHENIDATE HCL ER

METHYLTESTOSTERONE

miglustat1

MINOCIN

MINOCYCLINE HCL ER

MINOLIRA

M-NATAL PLUS

MONONINE1

MORPHABOND ER

morphine sul er

morphine sulfate cr

MOTEGRITY

MOVANTIK

MS CONTIN

MULPLETA1

MYALEPT2

MYCAPSSA

MYDAYIS

MYNATAL

naproxen/ esomeprazole magnesium

NATESTO

NATPARA1

NEONATAL COMPLETE

NEONATAL PLUS

NERLYNX2, 3

NEULASTA1

NEULASTA ONPRO KIT1

NEXAVAR1, 3

NEXIUM

NEXLETOL

NEXLIZET

NINLARO1

NIVA-PLUS

NOCTIVA

NORDITROPIN FLEXPRO1

NORTHERA1

NOVAREL1

NOVOEIGHT1

NUBEQA1

NUCYNTA ER

NUPLAZID1

NURTEC

NUTROPIN AQ NUSPIN1

NUWIQ1

NYVEPRIA

O-CAL FA

OCALIVA1

ODOMZO1, 3

OFEV1, 3

OLUMIANT1

omeppi

omeprazole / sodium bicarbonate

OMNITROPE1

ONE VITE WOMENS PRENATAL VITAMIN PLUS

ONUREG1

OPSUMIT2

ORACEA

ORENCIA1

ORENCIA CLICKJECT1

ORENITRAM2

ORGOVYX2

ORIAHNN

ORILISSA

ORKAMBI1

ORLADEYO2

OTEZLA1

OVIDREL1

OXBRYTA2

OXERVATE2

OXYCODONE HCL ER

OXYCONTIN

OXYMORPHONE HCL ER

PAXIL

PAXIL CR

PEGINTRON1

PEMAZYRE2

PENLAC NAIL LACQUER

PEXEVA

phendimetrazine tartrate

PHENDIMETRAZINE TARTRATE ER

phentermine hcl

PICATO

PIQRAY1

PLEGRIDY1

PLEGRIDY STARTER PACK1

PLIAGLIS

PNV PRENATAL PLUS MULTIVITAMIN

PNV TABS

POMALYST1

PRALUENT

pregabalin er

PREGEN DHA

PREGENNA

PREGNYL W/DILUENT BENZYL ALCOHOL / NACL1

PRENARA

PRENATAL

PRENATAL LOW IRON

PRENATAL PLUS

PRENATAL PLUS/IRON

PRENATAL VITAMINS PLUS LOW IRON

PRENATAL/FOLIC ACID

PRENATRIX

PRENATRYL

PREPLUS

PREVACID

prilocaine

PRISTIQ

PROCRIT1

PROCYSBI2

PROFILNINE1

PROFILNINE SD1

PROMACTA1

PROTONIX

PROZAC

pyrimethamine

QBREXZA

QINLOCK2

QSYMIA

QUDEXY XR

RAVICTI1

RAYOS

REBIF1

REBIF REBIDOSE1

REBIF REBIDOSE TITRATION PACK1

REBIF TITRATION PACK1

REBINYN1

RECOMBINATE1

REGRANEX

RELEXXII

RELISTOR

REMERON

REMERON SOLTAB

REPATHA

REPATHA PUSHTRONEX SYSTEM

REPATHA SURECLICK

RESTASIS

RESTASIS MULTIDOSE

RETEVMO1, 3

RETIN-A

RETIN-A MICRO

RETIN-A MICRO PUMP

REVATIO1

REVLIMID1

REYVOW

RINVOQ1

RISPERDAL

RISPERIDONE ODT

RITALIN

RITALIN LA

RIXUBIS1

ROBAXIN

ROZEREM

ROZLYTREK1, 3

RUBRACA2, 3

RUZURGI2

RYDAPT1

SAMSCA1

SAPHRIS

sapropterin dihydrochloride1

SARAFEM

SAXENDA

SENSIPAR1

SEROQUEL

SEROQUEL XR

SEROSTIM1

SEYSARA

SIGNIFOR2

sildenafil citrate1

SILENOR

SILIQ1

SIMPONI1

SKELAXIN

SKYRIZI      INJ1

SKYRIZI PEN

sodium phenylbutyrate1

SOFOSBUVIR / VELPATASVIR1

SOMA

SOMAVERT1

SOVALDI1

SPRYCEL1, 3

STELARA1

STIMATE1

STIVARGA1

STRATTERA

STRENSIQ2

STRIANT

SUBSYS

SUCRAID

SUNOSI

SUTENT1, 3

SYLATRON1

SYMDEKO1

SYMPROIC

SYNERA

TABRECTA1

tadalafil1

TAFINLAR1

TAGRISSO2, 3

TAKHZYRO2

TALTZ1

TALZENNA1, 3

TARCEVA1, 3

TARGADOX

TARGRETIN1, 3

TASIGNA1, 3

tavaborole

TAZAROTENE  

TAZORAC

TAZVERIK2

TECFIDERA1

TECFIDERA STARTER PACK1

TEGSEDI2

TEMODAR1

temozolomide1

TERIPARATIDE1

TESTIM

TESTOST ENAN INJ

testosterone

testosterone cypionate

testosterone gel

TESTOSTERONE GEL PUMP

TESTOSTERONE INJ

testosterone sol

testosterone topical solution

tetrabenazine1

THALOMID1

TIBSOVO2

TOBI1

TOBI PODHALER1

tobramycin   neb1

TOLAK

TOLVAPTAN1

topiramate er

TRACLEER1

TRAMADOL HCL CAP ER

tramadol hcl er

trazodone hcl

TREMFYA1

tretinoin

tretinoin microsphere

tretinoin microsphere pump

TRICARE

TRIKAFTA1

TRILIPIX

TRINAZ

TRINTELLIX

TROKENDI XR

TRULANCE

TUKYSA2

TURALIO2

TYKERB1

TYMLOS1

UBRELVY

UPTRAVI2

VENCLEXTA2

VENCLEXTA STARTING PACK2

VENTAVIS2, 3

VERSACLOZ

VERZENIO2, 3

VIBERZI

VIBRAMYCIN

VIEKIRA PAK1

VIIBRYD

VIIBRYD STARTER PACK

VIMOVO

VITATHELY/GINGER

VITRAKVI2, 3

VIZIMPRO1, 3

VOGELXO

VOGELXO PUMP

VOL-PLUS

VOSEVI1

VOTRIENT1, 3

VRAYLAR

VUMERITY1

VYLEESI

VYNDAMAX1

VYNDAQEL1

WAKIX

WELLBUTRIN SR

WELLBUTRIN XL

WESTAB PLUS

XALKORI1, 3

XELJANZ1

XELJANZ XR1

XELODA1

XENAZINE1

XENICAL

XERMELO2

XHANCE

XIFAXAN

XIIDRA

XIMINO

XOSPATA2

XPOVIO2, 3

XTAMPZA ER

XTANDI1, 3

XYNTHA1

XYNTHA SOLOFUSE1

XYOSTED

XYREM2

XYWAV2

ZALVIT

ZANAFLEX

ZARXIO1

ZAVESCA2

ZEGERID

ZEJULA2, 3

ZELBORAF1

ZELNORM

ZEPATIER1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOHYDRO ER

ZOKINVY2

ZOLINZA1, 3

ZOLOFT

ZOLPIMIST

ZOMACTON1

ZORBTIVE1

ZTLIDO

ZYCLARA

ZYCLARA PUMP

ZYDELIG2

ZYKADIA1, 3

ZYPREXA

ZYPREXA ZYDIS

ZYTIGA1, 3

Drug name(s)

ACCU-CHEK AVIVA PLUS

ACCU-CHEK COMPACT PLUS

ACCU-CHEK COMPACT STRIPS

ACCU-CHEK COMPACT TEST DRUM

ACCU-CHEK GUIDE

ACCU-CHEK SMARTVIEW STRIPS

ACCUTREND GLUCOSE

ADLYXIN

ADLYXIN STARTER PACK

ADVANCE INTUITION TEST STRIPS

ADVANCE MICRO-DRAW TEST STRIPS

ADVOCATE

REDI-CODE

ADVOCATE REDI-CODE+ TEST STRIPS

ADVOCATE TEST STRIPS

AGAMATRIX AMP NO CODE TEST STRIPS

AGAMATRIX JAZZ TEST STRIPS

AGAMATRIX KEYNOTE TEST STRIPS

AGAMATRIX PRESTO TEST STRIPS

ALA-SCALP

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

BYVALSON

CAMBIA

CAPEX

CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE

CARESENS N BLOOD GLUCOSE TEST STRIPS

CARETOUCH BLOOD GLUCOSE TEST STRIPS

CELEBREX

CLEVER CHEK AUTO-CODE TEST STRIPS

CLEVER CHEK AUTO-CODE VOICE TEST STRIPS

CLEVER CHEK TEST STRIPS

CLEVER CHOICE AUTO-CODE PRO TEST STRIPS

CLEVER CHOICE MICRO TEST STRIPS

CLEVER CHOICE NO CODING TEST STRIPS

CLEVER CHOICE TALK NO CODING TEST STRIPS

CLOBEX

CLOCORTOLONE PIVALATE

CLOCORTOLONE PIVALATE PUMP

CLODERM

CLODERM PUMP

CONTOUR BLOOD GLUCOSE TEST STRIPS

CONTOUR NEXT BLOOD GLUCOSE TEST

COOL BLOOD GLUCOSE TEST STRIPS

CORDRAN

COZAAR

CRESTOR

CUTIVATE

CVS ADVANCED GLUCOSE METER TEST STRIPS

DAYPRO

DERMA-SMOOTHE / FS BODY

DERMA-SMOOTHE / FS SCALP

DESONATE

DESOWEN

DETROL

DETROL LA

DEXCOM G5 MOBILE RECEIVER KIT

DEXCOM G5 MOBILE TRANSMITTER KIT

DEXCOM G5 MOBILE / G4 PLATINUM SENSOR KIT

DEXCOM G5 RECEIVER KIT

DEXCOM G6 RECEIVER

DEXCOM G6 SENSOR

DEXCOM G6 TRANSMITTER

DIATHRIVE BLOOD GLUCOSE TEST STRIPS

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS

DICLOFENAC EPOLAMINE

DIFLORASONE DIACETATE

DIOVAN

DIOVAN HCT

DIPROLENE

DIPROLENE AF

DITROPAN XL

DUO-CARE TEST STRIPS

EASY PLUS II BLOOD GLUCOSE TEST

EASY STEP TEST STRIPS

EASY TALK BLOOD GLUCOSE TEST STRIPS

EASY TOUCH GLUCOSE TEST STRIPS

EASY TRAK BLOOD GLUCOSE TEST STRIPS

EASYGLUCO

EASYGLUCO PLUS

EASYMAX 15 TEST STRIPS

EASYMAX TEST STRIPS

EASYPRO BLOOD GLUCOSE TEST STRIPS

EASYPRO PLUS

EC-NAPROSYN

EDARBI

EDARBYCLOR

ELEMENT COMPACT TEST STRIPS

ELEMENT TEST STRIPS

ELESTAT

ELIDEL

ELOCON

EMBRACE BLOOD GLUCOSE TEST STRIPS

EMBRACE EVO BLOOD GLUCOSETEST STRIPS

EMBRACE PRO BLOOD GLUCOSE TEST STRIPS

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

ENABLEX

EPROSARTAN MESYLATE

EQ BLOOD GLUCOSE TEST STRIPS

EUCRISA

EVENCARE + BLOOD GLUCOSE TEST STRIP

EVENCARE BLOOD GLUCOSE TEST STRIP

EVENCARE G2 TEST STRIPS

EVENCARE G3 TEST STRIPS

EVENCARE MINI BLOOD GLUCOSE TEST STRIPS

EVOLUTION AUTOCODE

EXACTECH R-S-G TEST STRIPS

EXACTECH TEST STRIPS

EXFORGE

EXFORGE HCT

FARXIGA

FELDENE

FENOPROFEN CALCIUM

FENORTHO

FIFTY50 GLUCOSE TEST STRIP 2.0

FLECTOR

FLOLIPID

FLURBIPROFEN

FORA BLOOD GLUCOSE TEST STRIPS

FORA D15G BLOOD GLUCOSE TEST STRIPS

FORA D20 BLOOD GLUCOSE TEST STRIPS

FORA D40/G31 BLOOD GLUCOSE TEST STRIPS

FORA G20 BLOOD GLUCOSE TEST STRIPS

FORA G30 / PREMIUM V10 BLOOD GLUCOSE TEST STRIPS

FORA GD20 TEST STRIPS

FORA GD50 BLOOD GLUCOSE TEST STRIPS

FORA GTEL BLOOD GLUCOSE TEST STRIPS

FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS

FORA V10 BLOOD GLUCOSE TEST STRIPS

FORA V12 BLOOD GLUCOSE TEST STRIPS

FORA V20 BLOOD GLUCOSE TEST STRIPS

FORA V30A BLOOD GLUCOSE TEST STRIPS

FORACARE GD40

FORACARE PREMIUM V10 TESTSTRIPS

FORACARE TEST N GO TEST STRIPS

FORTAMET

FORTISCARE BLOOD GLUCOSE TEST STRIP

FOSRENOL

FREESTYLE INSULINX BLOOD GLUCOSE TEST

FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS

FREESTYLE LIBRE 14 DAY /READER / FLASH MONITORING SYSTEM

FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM

FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE 2

/SENSOR/

FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE/READER/

FLASH MONITORING SYSTEM

FREESTYLE LIBRE/SENSOR/

FLASH MONITORING SYSTEM

FREESTYLE LITE TEST STRIPS

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS

FREESTYLE TEST STRIPS

FROVA

GE100 BLOOD GLUCOSE TEST STRIPS

GELNIQUE

GELNIQUE PUMP

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 TEST STRIPS

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS

MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS

metformin hcl er

MICARDIS

MICARDIS HCT

MICORT-HC

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

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

OTREXUP1

OZEMPIC

PANDEL

PAZEO

PENNSAID

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS

pimecrolimus

POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS

PRAVACHOL

PRECISION PCX

PRECISION PCX PLUS TEST STRIPS

PRECISION POINT OF CARE TEST STRIPS

PRECISION QID TEST STRIPS

PRECISION SOF-TACT TEST STRIPS

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS

PREDNICARBATE

PREMIUM BLOOD GLUCOSE TEST STRIPS

PRESTIGE TEST STRIPS

PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS

PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS

PROTOPIC

PSORCON

PTS PANELS GLUCOSE TEST

QTERN

QUICKTEK TEST STRIPS

QUINTET AC BLOOD GLUCOSE TEST STRIPS

QUINTET BLOOD GLUCOSE TEST STRIPS

RASUVO1

REDITREX

REFUAH PLUS BLOOD GLUCOSETEST STRIPS

RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM

RELION BLOOD GLUCOSE TEST STRIPS

RELION CONFIRM / MICRO TEST STRIPS

RELION PREMIER BLOOD GLUCOSE TEST STRIPS

RELION PRIME BLOOD GLUCOSE TEST STRIPS

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS

RELPAX

RENAGEL

RENVELA

REVEAL BLOOD GLUCOSE TEST

REXALL BLOOD GLUCOSE TEST STRIPS

RHOPRESSA

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS

RIOMET ER

ROCKLATAN

RYBELSUS

SAVELLA

SAVELLA TITRATION PACK

SEGLUROMET

SERNIVO

SEVELAMER

sevelamer

SIDEKICK BLOOD GLUCOSE SYSTEM

SIMVASTATIN

SMART SENSE PREMIUM BLOODGLUCOSE STRIPS

SMART SENSE VALUE BLOOD GLUCOSE STRIPS

SMARTEST BLOOD GLUCOSE TEST STRIPS

SOLIQUA

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

TREXIMET

TRIBENZOR

TRIDESILON

TRIJARDY XR

TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS

TRUE METRIX BLOOD GLUCOSE TEST STRIPS

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS

TRUETEST STRIPS

TRUETRACK BLOOD GLUCOSE TEST

TRUETRACK TEST

TRULICITY

TWYNSTA

ULORIC

ULTRATRAK PRO TEST STRIPS

ULTRATRAK ULTIMATE TEST STRIPS

ULTRAVATE

UNISTRIP1 GENERIC

VANOS

VELPHORO

VELTIN

VERASENS BLOOD GLUCOSE TEST STRIPS

VERDESO

VESICARE

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

ZEMBRACE SYMTOUCH

ZERVIATE

ZIANA

ZIOPTAN

ZIPSOR

ZOCOR

ZOLMITRIPTAN

ZOMIG

ZOMIG ZMT

 

 

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADIPEX-P CAP 37.5mg

30 caps / 30 days

ADIPEX-P tab 37.5mg

30 tabs / 30 days

BELVIQ tab 10mg

60 tabs / 30 days

BELVIQ XR tab 20mg

30 tabs / 30 days

Benzphetamin 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 25mg

90 tabs / 30 days

DIETHYLPROP tab 75mg ER

30 tabs / 30 days

IMCIVREE inj 10mg/mL2

10 vials / 30 days

LOMAIRA tab 8mg

90 tabs / 30 days

PHENDIMETRAZ CAP 105mg ER

30 caps / 30 days

Phendimetraz 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 11.25-69

30 caps / 30 days

QSYMIA CAP 15-92mg

30 caps / 30 days

QSYMIA CAP 3.75-23

30 caps / 30 days

QSYMIA CAP 7.5-46mg

30 caps / 30 days

SAXENDA inj 18mg/3ML

15 mLs / 30 days

SUNOSI tab 150mg

30 tabs / 30 days

SUNOSI tab 75mg

30 tabs / 30 days

WAKIX tab 17.8mg

60 tabs / 30 days

WAKIX tab 4.45mg

60 tabs / 30 days

XENICAL CAP 120mg

90 caps / 30 days

Aminoglycosides

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ARIKAYCE SUS2

28 vials / 28 days

Analgesics – Anti-inflammatory

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTEMRA inj 162/0.91

4 syringes / 28 days

ACTEMRA inj ACTpen1

4 injs / 28 days

ARCALYST inj 220mg2

4 vials / 28 days

DUEXIS tab 800-26.6

90 tabs / 30 days

ENBREL inj 25/0.5ML1

8 syringes / 28 days

ENBREL inj 25mg1

8 vials / 28 days

ENBREL inj 50mg/mL1

4 syringes / 28 days

ENBREL MINI inj 50mg/mL1

4 carts / 28 days

ENBREL SRCLK inj 50mg/mL1

4 syringes / 28 days

HUMIRA inj 10/0.1ML1

2 syringes / 28 days

HUMIRA inj 10mg/0.21

2 syringes / 28 days

HUMIRA inj 20/0.2ML1

2 syringes / 28 days

HUMIRA inj 40/0.4ML1

2 syringes / 28 days

HUMIRA kit 20mg/0.41

2 syringes / 28 days

HUMIRA kit 40mg/0.81

2 syringes / 28 days

HUMIRA PEDIA inj CROHNS1

3 kits / 180 days

HUMIRA PEDIA inj CROHNS1

1 kit / 180 days

HUMIRA pen inj 40/0.4ML1

2 pens / 28 days

HUMIRA pen inj 40mg/0.81

2 pens / 28 days

HUMIRA pen inj 80/0.8ML1

2 pens / 28 days

HUMIRA pen inj CD/UC/HS1

1 kit / 180 days

HUMIRA pen inj PS/UV1

1 kit / 180 days

HUMIRA pen kit CD/UC/HS1

1 kit / 180 days

HUMIRA pen kit PED UC1

4 pens / 180 days

HUMIRA pen kit PS/UV1

1 kit / 180 days

KEVZARA inj 150/1.141

2 syringes / 28 days

KEVZARA inj 150/1.141

2 pens / 28 days

KEVZARA inj 200/1.141

2 syringes / 28 days

KEVZARA inj 200/1.141

2 pens / 28 days

KINERET inj2

30 syringes / 30 days

Naprox-esom tab 375-20mg

60 tabs / 30 days

Naprox-esom tab 500-20mg

60 tabs / 30 days

OLUMIANT tab 1mg1

30 tabs / 30 days

OLUMIANT tab 2mg1

30 tabs / 30 days

ORENCIA inj 125mg/mL1

4 syringes / 28 days

ORENCIA inj 50/0.4ML1

4 syringes / 28 days

ORENCIA inj 87.5/0.71

4 syringes / 28 days

ORENCIA CLCK inj 125mg/mL1

4 syringes / 28 days

OTEZLA tab 10/20/301

1 kit / 180 days

OTEZLA tab 30mg1

60 tabs / 30 days

RINVOQ tab 15mg ER1

30 tabs / 30 days

SIMPONI inj 100mg/mL1

1 syringe / 28 days

SIMPONI inj 50/0.5ML1

1 syringe / 28 days

VIMOVO tab 375-20mg

60 tabs / 30 days

VIMOVO tab 500-20mg

60 tabs / 30 days

XELJANZ SOL 1mg/mL1

240 mLs / 30 days

XELJANZ tab 10mg1

224 tabs / 365 days

XELJANZ tab 5mg1

60 tabs / 30 days

XELJANZ XR tab 11mg1

30 tabs / 30 days

XELJANZ XR tab 22mg1

112 tabs / 365 days

Analgesics - opioid

Drug name(s)

Adult quantity limits - 5 days

Child quantity limits - 3 days

ABSTRAL SUB 100MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 200MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 300MCG

120 tabs / 30 days

N/A

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 1200MCG

120 lozenges / 30 days

N/A

ACTIQ LOZ 1600MCG

120 lozenges / 30 days

N/A

ACTIQ LOZ 200MCG

120 lozenges / 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

APAP/CAFFEIN tab DIHYDROC

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 DIHYDROC

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 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 75MCG

60 films/month

N/A

BELBUCA MIS 900MCG

30 films/month

N/A

Buprenorphin dis 10mcg/hr

4 systems/month

N/A

Buprenorphin dis 15mcg/hr

4 systems/month

N/A

Buprenorphin dis 20mcg/hr

4 systems/month

N/A

Buprenorphin dis 5mcg/hr

4 systems/month

N/A

Buprenorphin dis 7.5/hr

4 systems/month

N/A

Butorphanol sol 10mg/mL

2.5 ML (1 bottle)/30 days

0 mL/30 days

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

BUTRANS DIS 5MCG/HR

4 systems/month

N/A

BUTRANS DIS 7.5/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

DOLOPHINE tab 10mg

30 tablets/30 days

N/A

DOLOPHINE tab 5mg

60 tablets/30 days

N/A

DURAGESIC DIS 100MCG/H

0 patches/month

N/A

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

Dvorah tab

50 tablets/30 days

30 tablets/30 days

EMBEDA CAP 100-4mg

0 capsules/month

N/A

EMBEDA CAP 20-0.8mg

30 capsules/month

N/A

EMBEDA CAP 30-1.2mg

30 capsules/month

N/A

EMBEDA CAP 50-2mg

30 capsules/month

N/A

EMBEDA CAP 60-2.4mg

0 capsules/month

N/A

EMBEDA CAP 80-3.2mg

0 capsules/month

N/A

Endocet tab 10-325mg

15 tablets/30 days

9 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

Fentanyl dis 100mcg/h

0 patches/month

N/A

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 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 1200mcg

120 lozenges / 30 days

N/A

Fentanyl ot loz 1600mcg

120 lozenges / 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

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

hydroco/apap sol 7.5-325

450 mL/30 days

270 mL/30 days

hydroco/apap tab 10-300mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 10-325mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 10-325mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 5-300mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 7.5-300

30 tablets/30 days

18 tablets/30 days

hydroco/apap tab 7.5-325

30 tablets/30 days

18 tablets/30 days

hydroco/apap tab 7.5-325

30 tablets/30 days

18 tablets/30 days

hydrocod/ibu tab 10-200mg

25 tablets/30 days

15 tablets/30 days

HYDROCOD/IBU tab 5-200mg

25 tablets/30 days

15 tablets/30 days

hydrocod/ibu tab 5-200mg

25 tablets/30 days

15 tablets/30 days

hydrocod/ibu tab 7.5-200

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 tab 100mg er

0 tablets/30 days

N/A

hydrocodone tab 120mg er

0 tablets/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

hydromorphon liq 1mg/mL

60 mL/30 days

36 mL/30 days

hydromorphon tab 12mg er

30 tablets/month

N/A

hydromorphon tab 12mg er

30 tablets/month

N/A

hydromorphon tab 16mg er

0 tablets

N/A

hydromorphon tab 16mg er

0 tablets

N/A

hydromorphon tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphon tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphon tab 32mg er

0 tablets

N/A

hydromorphon tab 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphon tab 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphon tab 8mg

5 tablets/30 days

3 tablets/30 days

hydromorphon tab 8mg er

30 tablets/month

N/A

hydromorphon tab 8mg er

30 tablets/month

N/A

hYSINGLA ER tab 100 mg

0 tablets/30 days

N/A

HYSINGLA ER tab 120 mg

0 tablets/30 days

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

IBUDONE tab 10-200mg

25 tablets/30 days

15 tablets/30 days

KADIAN CAP 100mg ER

0 capsules/30 days

N/A

KADIAN CAP 10mg ER

30 capsules/30 days

N/A

KADIAN CAP 200mg ER

0 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

LAZANDA SPR 100MCG

30 bottles / 30 days

N/A

LAZANDA SPR 300MCG

30 bottles / 30 days

N/A

LAZANDA SPR 400MCG

30 bottles / 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 100mg

15 tablets/30 days

15 tablets/30 days

MEPERIDINE tab 50mg

30 tablets/30 days

30 tablets/30 days

METHADONE SOL 10mg/5ML

150 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 5mg/5ml

300 mL/30 days

N/A

Methadone sol 5mg/5ml

300 mL/30 days

N/A

Methadone tab 10mg

30 tablets/30 days

N/A

Methadone tab 5mg

60 tablets/30 days

N/A

MORPHABOND tab 100mg ER

0 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

Morphine sul cap 100mg er

0 capsules/30 days

N/A

Morphine sul cap 10mg er

30 capsules/30 days

N/A

MORPHINE SUL CAP 120mg ER

0 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 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 50mg er

30 capsules/30 days

N/A

MORPHINE SUL CAP 60mg ER

0 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 80mg er

0 capsules/30 days

N/A

MORPHINE SUL CAP 90mg ER

0 capsules/30 days

N/A

Morphine sul sol 10/0.5ml

15 mL/30 days

15 mL/30 days

Morphine sul sol 100/5ml

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 tab 100mg cr

0 tablets/30 days

N/A

Morphine sul tab 100mg er

0 tablets/30 days

N/A

MORPHINE SUL tab 15mg

15 tablets/30 days

9 tablets/30 days

Morphine sul tab 15mg

15 tablets/30 days

9 tablets/30 days

Morphine sul tab 15mg er

60 tablets/30 days

N/A

Morphine sul tab 200mg er

0 tablets/30 days

N/A

MORPHINE SUL tab 30mg

5 tablets/30 days

3 tablets/30 days

Morphine sul tab 30mg

5 tablets/30 days

3 tablets/30 days

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 60mg er

0 tablets/30 days

N/A

MS CONTIN tab 100mg ER

0 tablets/30 days

N/A

MS CONTIN tab 15mg ER

60 tablets/30 days

N/A

MS CONTIN tab 200mg ER

0 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

NORCO tab 10-325mg

25 tablets/30 days

15 tablets/30 days

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

NUCYNTA tab 100mg

5 tablets/30 days

3 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 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

NUCYNTA ER tab 50mg

60 tablets/30 days

N/A

OPANA tab 10mg

5 tablets/30 days

3 tablets/30 days

OPANA tab 5mg

15 tablets/30 days

9 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

OXYCOD/ACETA SOL 10/300mg

75 mL/30 days

45 mL/30 days

OXYCOD/APAP tab 10-300mg

15 tablets/30 days

9 tablets/30 days

Oxycod/apap tab 10-325mg

15 tablets/30 days

9 tablets/30 days

Oxycod/apap tab 2.5-325

60 tablets/30 days

36 tablets/30 days

OXYCOD/APAP tab 5-300mg

30 tablets/30 days

18 tablets/30 days

Oxycod/apap tab 5-325mg

30 tablets/30 days

18 tablets/30 days

Oxycod/apap tab 7.5-325

20 tablets/30 days

12 tablets/30 days

OXYCOD/ASA tab

30 tablets/30 days

18 tablets/30 days

Oxycod/asa tab

30 tablets/30 days

18 tablets/30 days

OXYCOD/IBU tab 5-400mg

20 tablets/30 days

12 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 10mg

15 tablets/30 days

9 tablets/30 days

OXYCODONE tab 10mg ER

60 tablets/30 days

N/A

Oxycodone tab 15mg

10 tablets/30 days

6 tablets/30 days

OXYCODONE tab 15mg ER

60 tablets/30 days

N/A

Oxycodone tab 20mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE tab 20mg ER

30 tablets/30 days

N/A

Oxycodone tab 30mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE tab 30mg ER

30 tablets/30 days

N/A

OXYCODONE tab 40mg ER

0 tablets/30 days

N/A

Oxycodone tab 5mg

30 tablets/30 days

18 tablets/30 days

OXYCODONE tab 60mg ER

0 tablets/30 days

N/A

OXYCODONE tab 80mg ER

0 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 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 40mg ER

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 hcl 10mg

5 tablets/30 days

3 tablets/30 days

Oxymorphone tab hcl 5mg

15 tablets/30 days

9 tablets/30 days

pentaz/nalox tab 50-0.5mg

10 tablets/30 days

6 tablets/30 days

PERCOCET tab 10-325mg

15 tablets/30 days

9 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

PRIMLEV tab 10-300mg

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

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 15mg

10 tablets/30 days

6 tablets/30 days

ROXICODONE tab 30mg

5 tablets/30 days

3 tablets/30 days

ROXICODONE tab 5mg

30 tablets/30 days

18 tablets/30 days

SUBSYS SPR 100MCG

120 sprays / 30 days

N/A

SUBSYS SPR 1200MCG

240 sprays / 30 days

N/A

SUBSYS SPR 1600MCG

240 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

tramadl/apap tab 37.5-325

40 tablets/30 days

24 tablets/30 days

TRAMADOL HCL CAP 150mg ER

30 capsules/30 days

N/A

TRAMADOL HCL CAP ER 100mg

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

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 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

N/A

XTAMPZA ER CAP 36mg

0 capsules/30 days

N/A

XTAMPZA ER CAP 9mg

60 capsules/30 days

N/A

ZOHYDRO ER CAP 10mg

60 capsules/30 days

N/A

ZOHYDRO ER CAP 15mg

60 capsules/30 days

N/A

ZOHYDRO ER CAP 20mg

60 capsules/30 days

N/A

ZOHYDRO ER CAP 30mg

30 capsules/30 days

N/A

ZOHYDRO ER CAP 40mg

30 capsules/30 days

N/A

ZOHYDRO ER CAP 50mg

30 capsules/30 days

N/A

Androgens - anabolic

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ANDRODERM DIS 2mg/24HR

30 patches / 30 days

ANDRODERM DIS 4mg/24HR

30 patches / 30 days

ANDROGEL GEL 1%(25mg)

60 packets / 30 days

ANDROGEL GEL 1%(50mg)

60 packets / 30 days

ANDROGEL GEL 1.62%

2 pumps / 30 days

ANDROGEL GEL 1.62%

60 packets / 30 days

ANDROGEL GEL 1.62%

30 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

NATESTO GEL 5.5mg

3 pumps / 30 days

STRIANT MIS 30mg

60 systems / 30 days

TESTIM GEL 1%(50mg)

60 packets / 30 days

Testost cyp inj 100mg/mL

1 vial / 28 days

Testost cyp inj 200mg/mL

10 mLs / 28 days

TESTOST ENAN inj 200mg/mL

1 vial / 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 1.62%, 75 gm pump

2 bottles / 30 days

Testosterone gel 1.62%, 40.5 mg/2.5 gm packet

60 packets / 30 days

Testosterone gel 1.62%, 20.25 mg/1.25 gm packet

30 packets / 30 days

Testosterone gel 10mg/act

2 bottles / 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 sol 30mg/act

2 pumps / 30 days

VOGELXO GEL 1%(50mg)

60 packets / 30 days

VOGELXO GEL PUMP 1%

4 pumps / 30 days

XYOSTED inj 100/0.5

2 pens / 28 days

XYOSTED inj 50/0.5

4 pens / 28 days

XYOSTED inj 75/0.5

2 pens / 28 days

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADVAIR DISKU AER 100/50

60 blisters / 30 days

ADVAIR DISKU AER 250/50

60 blisters / 30 days

ADVAIR DISKU AER 500/50

60 blisters / 30 days

ADVAIR HFA AER 115/21

1 can / 30 days

ADVAIR HFA AER 230/21

1 can / 30 days

ADVAIR HFA AER 45/21

1 can / 30 days

AIRDUO RESPI INH 113-14

1 inhaler / 30 days

AIRDUO RESPI INH 232-14

1 inhaler / 30 days

AIRDUO RESPI INH 55-14

1 inhaler / 30 days

ALBUTEROL AER HFA

2 cans / 30 days

Albuterol aer hfa

2 cans / 30 days

ALVESCO AER 160MCG

2 cans / 30 days

ALVESCO AER 80MCG

2 cans / 30 days

ANORO ELLIPT AER 62.5-25

1 inhaler / 30 days

ARCAPTA CAP 75MCG

30 caps / 30 days

ARNUITY ELPT INH 100MCG

30 blisters / 30 days

ARNUITY ELPT INH 200MCG

30 blisters / 30 days

ARNUITY ELPT INH 50MCG

30 blisters / 30 days

ASMANEX 120 AER 220MCG

1 can / 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 HFA AER 100 MCG

1 can / 30 days

ASMANEX HFA AER 200 MCG

1 can / 30 days

ASMANEX HFA AER 50MCG

1 inhaler / 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

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

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 110MCG

1 can / 30 days

FLOVENT HFA AER 220MCG

2 cans / 30 days

FLOVENT HFA AER 44MCG

1 can / 30 days

Flutic/salme aer 100/50

60 blisters / 30 days

Flutic/salme aer 250/50

60 blisters / 30 days

Flutic/salme aer 500/50

60 blisters / 30 days

FLUTIC/SALME INH 113/14

1 inhaler / 30 days

FLUTIC/SALME INH 232/14

1 inhaler / 30 days

FLUTIC/SALME INH 55/14

1 inhaler / 30 days

INCRUSE ELPT INH 62.5MCG

30 blisters / 30 days

LEVALBUTEROL AER 45/ACT

2 cans / 30 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

Wixela inhub aer 500/50

60 blisters / 30 days

XOpenEX HFA AER

2 cans / 30 days

Anticonvulsants

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FINTEPLA SOL 2.2mg/mL2

360 mLs / 30 days

LYRICA CAP 100mg

90 caps / 30 days

LYRICA CAP 150mg

90 caps / 30 days

LYRICA CAP 200mg

90 caps / 30 days

LYRICA CAP 225mg

60 caps / 30 days

LYRICA CAP 25mg

90 caps / 30 days

LYRICA CAP 300mg

60 caps / 30 days

LYRICA CAP 50mg

90 caps / 30 days

LYRICA CAP 75mg

90 caps / 30 days

LYRICA SOL 20mg/mL

900 mLs / 30 days

Pregabalin cap 100mg

90 caps / 30 days

Pregabalin cap 150mg

90 caps / 30 days

Pregabalin cap 200mg

90 caps / 30 days

Pregabalin cap 225mg

60 caps / 30 days

Pregabalin cap 25mg

90 caps / 30 days

Pregabalin cap 300mg

60 caps / 30 days

Pregabalin cap 50mg

90 caps / 30 days

Pregabalin cap 75mg

90 caps / 30 days

Pregabalin sol 20mg/mL

900 mLs / 30 days

QUDEXY XR CAP 100/24HR

30 caps / 30 days

QUDEXY XR CAP 150/24HR

30 caps / 30 days

QUDEXY XR CAP 200/24HR

60 caps / 30 days

QUDEXY XR CAP 25/24HR

30 caps / 30 days

QUDEXY XR CAP 50/24HR

30 caps / 30 days

Topiramate cap er 100mg

30 caps / 30 days

Topiramate cap er 150mg

30 caps / 30 days

Topiramate cap er 200mg

60 caps / 30 days

Topiramate cap er 25mg

30 caps / 30 days

Topiramate cap er 50mg

30 caps / 30 days

TROKENDI XR CAP 100mg

30 caps / 30 days

TROKENDI XR CAP 200mg

60 caps / 30 days

TROKENDI XR CAP 25mg

30 caps / 30 days

TROKENDI XR CAP 50mg

30 caps / 30 days

Antidiabetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADLYXIN inj 10/20MCG

2 pens / 180 days

ADLYXIN inj 20MCG

2 pens / 28 days

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

ALOG/PIOGLIT tab 12.5-15

30 tabs / 30 days

ALOG/PIOGLIT tab 12.5-30

30 tabs / 30 days

ALOG/PIOGLIT tab 12.5-45

30 tabs / 30 days

ALOG/PIOGLIT tab 25-15mg

30 tabs / 30 days

ALOG/PIOGLIT tab 25-30mg

30 tabs / 30 days

ALOG/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

BYDUREON BC inj 2/0.85ML

4 inj dvs / 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

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

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 tab XR

60 tabs / 30 days

JENTADUETO tab XR

30 tabs / 30 days

KAZANO 12.5- tab 1000mg

60 tabs / 30 days

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 300mg2

120 tabs / 30 days

Metformin tab 1000 er

60 tabs / 30 days

Metformin tab 500mg er

90 tabs / 30 days

Metformin tab 500mg er

120 tabs / 30 days

Metformin tab 750mg er

60 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

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 2/1.5ML

1 pen / 28 days

OZEMPIC inj 2/1.5ML

2 pens / 28 days

QTERN tab 10-5mg

30 tabs / 30 days

QTERN tab 5-5mg

30 tabs / 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

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 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 10-1000

60 tabs / 30 days

SYNJARDY XR tab 25-1000

30 tabs / 30 days

SYNJARDY XR tab 5-1000mg

60 tabs / 30 days

TRADJENTA tab 5mg

30 tabs / 30 days

TRIJARDY XR tab 10mg/5mg/1000mg and 25mg/5mg/1000 mg

30 tabs / 30 days

TRIJARDY XR tab 5mg/2.5mg/1000mg and 12.5mg/2.5mg/1000mg

60 tabs / 30 days

TRULICITY inj 0.75/0.5

4 pens / 28 days

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

Antiemetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AKYNZEO CAP 300-0.5

2 caps / 30 days

ANZEMET tab 100mg

7 tabs / 30 days

ANZEMET tab 50mg

7 tabs / 30 days

Aprepitant cap 125mg

4 caps / 30 days

Aprepitant cap 40mg

8 caps / 30 days

Aprepitant cap 80mg

8 caps / 30 days

Aprepitant pak 80 & 125

4 packs / 30 days

CESAMET CAP 1mg

42 caps / 30 days

DICLEGIS tab 10-10mg

120 tabs / 30 days

Doxyl/pyrid tab 10-10mg

120 tabs / 30 days

EMEND CAP 125mg

4 caps / 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 bottles / 30 days

Ondansetron sol 4mg/5ml

5 bottles / 30 days

ONDANSETRON tab 24mg

4 tabs / 30 days

Ondansetron tab 24mg

4 tabs / 30 days

Ondansetron tab 4mg

24 tabs / 30 days

Ondansetron tab 4mg odt

24 tabs / 30 days

Ondansetron tab 8mg

24 tabs / 30 days

Ondansetron tab 8mg odt

24 tabs / 30 days

SANCUSO DIS 3.1mg

2 patches / 28 days

VARUBI tab 90mg

4 tabs / 30 days

ZOFRAN tab 4mg

24 tabs / 30 days

ZOFRAN tab 8mg

24 tabs / 30 days

ZUPLENZ MIS 4mg

24 films / 30 days

ZUPLENZ MIS 8mg

24 films / 30 days

Antihyperlidemics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALTOPREV tab 20mg ER

30 tabs / 30 days

ALTOPREV tab 40mg ER

30 tabs / 30 days

ALTOPREV tab 60mg ER

30 tabs / 30 days

Atorvastatin tab 10mg

45 tabs / 30 days

Atorvastatin tab 20mg

45 tabs / 30 days

Atorvastatin tab 40mg

45 tabs / 30 days

Atorvastatin tab 80mg

30 tabs / 30 days

CRESTOR tab 10mg

45 tabs / 30 days

CRESTOR tab 20mg

45 tabs / 30 days

CRESTOR tab 40mg

30 tabs / 30 days

CRESTOR tab 5mg

45 tabs / 30 days

Ezetim/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 10mg2

30 caps / 30 days

JUXTAPID CAP 20mg2

30 caps / 30 days

JUXTAPID CAP 30mg2

30 caps / 30 days

JUXTAPID CAP 40mg2

30 caps / 30 days

JUXTAPID CAP 5mg2

30 caps / 30 days

JUXTAPID CAP 60mg2

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

PRAVACHOL tab 80mg

30 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

1 cart / 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

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 5mg

45 tabs / 30 days

ZOCOR tab 80mg

30 tabs / 30 days

Anti-infective agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALINIA SUS 100/5ML

300 mLs / 90 days

ALINIA tab 500mg

12 tabs / 90 days

Nitazoxanide tab 500mg

12 tabs / 90 days

XIFAXAN tab 200mg

9 tabs / 30 days

XIFAXAN tab 550mg

60 tabs / 30 days

Antimyasthenic / cholinergic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FIRDAPSE tab 10mg2

240 tabs / 30 days

RUZURGI tab 10mg2

300 tabs / 30 days

Antineoplastics and adjuntive therapies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Abiraterone tab 250mg1, 3

120 tabs / 30 days

Abiraterone tab 500mg1, 3

60 tabs / 30 days

AFINITOR tab 10mg1, 3

30 tabs / 30 days

AFINITOR tab 2.5mg1, 3

30 tabs / 30 days

AFINITOR tab 5mg1, 3

30 tabs / 30 days

AFINITOR tab 7.5mg1, 3

30 tabs / 30 days

AFINITOR DIS tab 2mg1, 3

60 tabs / 30 days

AFINITOR DIS tab 3mg1, 3

90 tabs / 30 days

AFINITOR DIS tab 5mg1, 3

60 tabs / 30 days

ALECENSA CAP 150mg2, 3

240 caps / 30 days

ALUNBRIG PAK2

30 tabs / 180 days

ALUNBRIG tab 180mg2

30 tabs / 30 days

ALUNBRIG tab 30mg2

120 tabs / 30 days

ALUNBRIG tab 90mg2

30 tabs / 30 days

AYVAkit tab 100mg2, 3

30 tabs / 30 days

AYVAkit tab 200mg2, 3

30 tabs / 30 days

AYVAkit tab 300mg2, 3

30 tabs / 30 days

BALVERSA tab 3mg2, 3

90 tabs / 30 days

BALVERSA tab 4mg2, 3

60 tabs / 30 days

BALVERSA tab 5mg2, 3

30 tabs / 30 days

BOSULIF tab 100mg1, 3

90 tabs / 30 days

BOSULIF tab 400mg1, 3

30 tabs / 30 days

BOSULIF tab 500mg1, 3

30 tabs / 30 days

BRAFTOVI CAP 75mg2

180 caps / 30 days

BRUKINSA CAP 80mg2

120 caps / 30 days

CABOMETYX tab 20mg1, 3

30 tabs / 30 days

CABOMETYX tab 40mg1, 3

30 tabs / 30 days

CABOMETYX tab 60mg1, 3

30 tabs / 30 days

CALQUENCE CAP 100mg2

60 caps / 30 days

CAPRELSA tab 100mg2

60 tabs / 30 days

CAPRELSA tab 300mg2

30 tabs / 30 days

COMETRIQ kit 100mg2, 3

1 carton / 28 days

COMETRIQ kit 140mg2, 3

112 tabs / 28 days

COMETRIQ kit 60mg2, 3

1 carton / 28 days

COPIKTRA CAP 15mg2, 3

56 caps / 28 days

COPIKTRA CAP 25mg2, 3

56 caps / 28 days

COTELLIC tab 20mg1

63 tabs / 28 days

DAURISMO tab 100mg1, 3

30 tabs / 30 days

DAURISMO tab 25mg1, 3

60 tabs / 30 days

ERIVEDGE CAP 150mg1, 3

30 caps / 30 days

Erlotinib tab 100mg1, 3

30 tabs / 30 days

Erlotinib tab 100mg3

30 tabs / 30 days

Erlotinib tab 150mg1, 3

30 tabs / 30 days

Erlotinib tab 150mg3

30 tabs / 30 days

Erlotinib tab 25mg1, 3

60 tabs / 30 days

Erlotinib tab 25mg3

60 tabs / 30 days

Everolimus tab 2.5mg1, 3

30 tabs / 30 days

Everolimus tab 5mg1, 3

30 tabs / 30 days

Everolimus tab 7.5mg1, 3

30 tabs / 30 days

FARYDAK CAP 10mg1

6 caps / 21 days

FARYDAK CAP 15mg1

6 caps / 21 days

FARYDAK CAP 20mg1

6 caps / 21 days

GAVRETO CAP 100mg2, 3

120 caps / 30 days

GILOTRIF tab 20mg2

30 tabs / 30 days

GILOTRIF tab 30mg2

30 tabs / 30 days

GILOTRIF tab 40mg2

30 tabs / 30 days

GLEEVEC tab 100mg1, 3

90 tabs / 30 days

GLEEVEC tab 400mg1, 3

60 tabs / 30 days

GOCOVRI CAP 137mg1, 3

60 caps / 30 days

GOCOVRI CAP 68.5mg1, 3

30 caps / 30 days

IBRANCE CAP 100mg1

21 caps / 28 days

IBRANCE CAP 125mg1

21 caps / 28 days

IBRANCE CAP 75mg1

21 caps / 28 days

IBRANCE tab 100mg1

21 tabs / 28 days

IBRANCE tab 125mg1

21 tabs / 28 days

IBRANCE tab 75mg1

21 tabs / 28 days

ICLUSIG tab 10mg2, 3

30 tabs / 30 days

ICLUSIG tab 15mg2, 3

30 tabs / 30 days

ICLUSIG tab 30mg2, 3

30 tabs / 30 days

ICLUSIG tab 45mg2, 3

30 tabs / 30 days

IDHIFA tab 100mg1

30 tabs / 30 days

IDHIFA tab 50mg1

30 tabs / 30 days

Imatinib mes tab 100mg1, 3

90 tabs / 30 days

Imatinib mes tab 400mg1, 3

60 tabs / 30 days

IMBRUVICA CAP 140mg2

60 caps / 30 days

IMBRUVICA CAP 70mg2

30 caps / 30 days

IMBRUVICA tab 140mg2

30 tabs / 30 days

IMBRUVICA tab 280mg2

30 tabs / 30 days

IMBRUVICA tab 420mg2

30 tabs / 30 days

IMBRUVICA tab 560mg2

30 tabs / 30 days

INLYTA tab 1mg1, 3

180 tabs / 30 days

INLYTA tab 5mg1, 3

120 tabs / 30 days

INQOVI tab 35-100mg1

5 tabs / 28 days

INREBIC CAP 100mg1, 3

120 caps / 30 days

IRESSA tab 250mg2, 3

30 tabs / 30 days

JAKAFI tab 10mg1, 3

60 tabs / 30 days

JAKAFI tab 15mg1, 3

60 tabs / 30 days

JAKAFI tab 20mg1, 3

60 tabs / 30 days

JAKAFI tab 25mg1, 3

60 tabs / 30 days

JAKAFI tab 5mg1, 3

60 tabs / 30 days

KISQALI tab 200DOSE1

63 tabs / 28 days

KISQALI tab 400DOSE1

63 tabs / 28 days

KISQALI tab 600DOSE1

63 tabs / 28 days

KISQALI 200 PAK FEMARA1

91 tabs / 28 days

KISQALI 400 PAK FEMARA1

91 tabs / 28 days

KISQALI 600 PAK FEMARA1

91 tabs / 28 days

KOSELUGO CAP 10mg2

240 caps / 30 days

KOSELUGO CAP 25mg2

120 caps / 30 days

Lapatinib tab 250mg1

180 tabs / 30 days

LENVIMA CAP 10 mg2, 3

30 caps / 30 days

LENVIMA CAP 12mg2, 3

90 caps / 30 days

LENVIMA CAP 14 mg2, 3

60 caps / 30 days

LENVIMA CAP 18 mg2, 3

90 caps / 30 days

LENVIMA CAP 20 mg2, 3

60 caps / 30 days

LENVIMA CAP 24 mg2, 3

90 caps / 30 days

LENVIMA CAP 4mg2, 3

30 caps / 30 days

LENVIMA CAP 8 mg2, 3

60 caps / 30 days

LONSURF tab 15-6.141

60 tabs / 28 days

LONSURF tab 20-8.191

80 tabs / 28 days

LORBRENA tab 100mg1, 3

30 tabs / 30 days

LORBRENA tab 25mg1, 3

90 tabs / 30 days

LYNPARZA tab 100mg2, 3

120 tabs / 30 days

LYNPARZA tab 150mg2, 3

120 tabs / 30 days

MEKINIST tab 0.5mg1

90 tabs / 30 days

MEKINIST tab 2mg1

30 tabs / 30 days

MEKTOVI tab 15mg2

180 tabs / 30 days

NERLYNX tab 40mg2, 3

180 tabs / 30 days

NERLYNX tab 40mg3

180 tabs / 30 days

NEXAVAR tab 200mg1, 3

120 tabs / 30 days

NINLARO CAP 2.3mg1

3 caps / 28 days

NINLARO CAP 3mg1

3 caps / 28 days

NINLARO CAP 4mg1

3 caps / 28 days

NUBEQA tab 300mg1

120 tabs / 30 days

ODOMZO CAP 200mg1, 3

30 caps / 30 days

ONUREG tab 200mg1

14 tabs / 28 days

ONUREG tab 300mg1

14 tabs / 28 days

ORGOVYX tab 120mg2

30 tabs / 30 days

PEMAZYRE tab 13.5mg2

14 tabs / 21 days

PEMAZYRE tab 4.5mg2

14 tabs / 21 days

PEMAZYRE tab 9mg2

14 tabs / 21 days

PIQRAY 200mg tab DOSE1

28 tabs / 28 days

PIQRAY 250mg tab DOSE1

56 tabs / 28 days

PIQRAY 300mg tab DOSE1

56 tabs / 28 days

POMALYST CAP 1mg1

21 caps / 28 days

POMALYST CAP 2mg1

21 caps / 28 days

POMALYST CAP 3mg1

21 caps / 28 days

POMALYST CAP 4mg1

21 caps / 28 days

QINLOCK tab 50mg2

90 tabs / 30 days

RETEVMO CAP 40mg1, 3

180 caps / 30 days

RETEVMO CAP 80mg1, 3

120 caps / 30 days

ROZLYTREK CAP 100mg1, 3

30 caps / 30 days

ROZLYTREK CAP 200mg1, 3

90 caps / 30 days

RUBRACA tab 200mg2, 3

120 tabs / 30 days

RUBRACA tab 250mg2, 3

120 tabs / 30 days

RUBRACA tab 300mg2, 3

120 tabs / 30 days

RYDAPT CAP 25mg1

240 caps / 30 days

SPRYCEL tab 100mg1, 3

30 tabs / 30 days

SPRYCEL tab 140mg1, 3

30 tabs / 30 days

SPRYCEL tab 20mg1, 3

90 tabs / 30 days

SPRYCEL tab 50mg1, 3

30 tabs / 30 days

SPRYCEL tab 70mg1, 3

30 tabs / 30 days

SPRYCEL tab 80mg1, 3

30 tabs / 30 days

STIVARGA tab 40mg1

84 tabs / 28 days

SUTENT CAP 12.5mg1, 3

90 caps / 30 days

SUTENT CAP 25mg1, 3

30 caps / 30 days

SUTENT CAP 37.5mg1, 3

30 caps / 30 days

SUTENT CAP 50mg1, 3

30 caps / 30 days

TabRECTA tab 150mg1

120 tabs / 30 days

TabRECTA tab 200mg1

120 tabs / 30 days

TAFINLAR CAP 50mg1

120 caps / 30 days

TAFINLAR CAP 75mg1

120 caps / 30 days

TAGRISSO tab 40mg2, 3

30 tabs / 30 days

TAGRISSO tab 80mg2, 3

30 tabs / 30 days

TALZENNA CAP 0.25mg1, 3

90 caps / 30 days

TALZENNA CAP 1mg1, 3

30 caps / 30 days

TARCEVA tab 100mg1, 3

30 tabs / 30 days

TARCEVA tab 150mg1, 3

30 tabs / 30 days

TARCEVA tab 25mg1, 3

60 tabs / 30 days

TASIGNA CAP 150mg1, 3

120 caps / 30 days

TASIGNA CAP 200mg1, 3

120 caps / 30 days

TASIGNA CAP 50mg1, 3

120 caps / 30 days

TAZVERIK tab 200mg2

240 tabs / 30 days

TIBSOVO tab 250mg2

60 tabs / 30 days

TUKYSA tab 150mg2

120 tabs / 30 days

TUKYSA tab 50mg2

300 tabs / 30 days

TURALIO CAP 200mg2

120 caps / 30 days

TYKERB tab 250mg1

180 tabs / 30 days

VENCLEXTA tab 100mg2

180 tabs / 30 days

VENCLEXTA tab 10mg2

60 tabs / 30 days

VENCLEXTA tab 50mg2

30 tabs / 30 days

VENCLEXTA tab START PK2

1 pack / 180 days

VERZENIO tab 100mg2, 3

60 tabs / 30 days

VERZENIO tab 150mg2, 3

60 tabs / 30 days

VERZENIO tab 200mg2, 3

60 tabs / 30 days

VERZENIO tab 50mg2, 3

60 tabs / 30 days

VITRAKVI CAP 100mg2, 3

60 caps / 30 days

VITRAKVI CAP 25mg2, 3

180 caps / 30 days

VITRAKVI SOL 20mg/mL2, 3

300 mLs / 30 days

VIZIMPRO tab 15mg1, 3

30 tabs / 30 days

VIZIMPRO tab 30mg1, 3

30 tabs / 30 days

VIZIMPRO tab 45mg1, 3

30 tabs / 30 days

VOTRIENT tab 200mg1, 3

120 tabs / 30 days

XALKORI CAP 200mg1, 3

120 caps / 30 days

XALKORI CAP 250mg1, 3

120 caps / 30 days

XOSPATA tab 40mg2

90 tabs / 30 days

XPOVIO PAK 100mg2, 3

1 box / 28 days

XPOVIO PAK 40mg3

1 box / 28 days

XPOVIO PAK 40mg3

1 box / 28 days

XPOVIO PAK 60mg2, 3

1 box / 28 days

XPOVIO PAK 60mg3

1 box / 28 days

XPOVIO PAK 80mg2, 3

1 box / 28 days

XPOVIO PAK 80mg2, 3

1 box / 28 days

XPOVIO tab 40mg2, 3

1 box / 28 days

XPOVIO tab 50mg2, 3

1 box / 28 days

XPOVIO tab 60mg2, 3

1 box / 28 days

XTANDI CAP 40mg1, 3

120 caps / 30 days

XTANDI tab 40mg1, 3

90 tabs / 30 days

XTANDI tab 80mg1, 3

60 tabs / 30 days

ZEJULA CAP 100mg2, 3

90 caps / 30 days

ZELBORAF tab 240mg1

240 tabs / 30 days

ZOLINZA CAP 100mg1, 3

120 caps / 30 days

ZYDELIG tab 100mg2

60 tabs / 30 days

ZYDELIG tab 150mg2

60 tabs / 30 days

ZYKADIA CAP 150mg1, 3

90 caps / 30 days

ZYKADIA tab 150mg1, 3

90 tabs / 30 days

ZYTIGA tab 250mg1, 3

120 tabs / 30 days

ZYTIGA tab 500mg1, 3

60 tabs / 30 days

Antipsychotics / antimanic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CAPLYTA CAP 42mg

30 caps / 30 days

INVEGA tab 1.5mg

60 tabs / 30 days

INVEGA tab 3mg

60 tabs / 30 days

INVEGA tab 6mg

60 tabs / 30 days

INVEGA tab 9mg

60 tabs / 30 days

LATUDA tab 120mg

30 tabs / 30 days

LATUDA tab 20mg

30 tabs / 30 days

LATUDA tab 40mg

30 tabs / 30 days

LATUDA tab 60mg

30 tabs / 30 days

LATUDA tab 80mg

60 tabs / 30 days

NUPLAZID CAP 34mg1

30 caps / 30 days

NUPLAZID tab 10mg1

30 tabs / 30 days

Olanzapine tab 10mg

30 tabs / 30 days

Olanzapine tab 10mg odt

30 tabs / 30 days

Olanzapine tab 15mg

30 tabs / 30 days

Olanzapine tab 15mg odt

30 tabs / 30 days

Olanzapine tab 2.5mg

30 tabs / 30 days

Olanzapine tab 20mg

30 tabs / 30 days

Olanzapine tab 20mg odt

30 tabs / 30 days

Olanzapine tab 5mg

30 tabs / 30 days

Olanzapine tab 5mg odt

30 tabs / 30 days

Olanzapine tab 7.5mg

30 tabs / 30 days

Paliperidone tab er 1.5mg

60 tabs / 30 days

Paliperidone tab er 3mg

60 tabs / 30 days

Paliperidone tab er 6mg

60 tabs / 30 days

Paliperidone tab er 9mg

60 tabs / 30 days

Quetiapine tab 150mg er

60 tabs / 30 days

Quetiapine tab 200mg er

60 tabs / 30 days

Quetiapine tab 300mg er

60 tabs / 30 days

Quetiapine tab 400mg er

60 tabs / 30 days

Quetiapine tab 50mg er

60 tabs / 30 days

SEROQUEL XR tab 150mg

60 tabs / 30 days

SEROQUEL XR tab 200mg

60 tabs / 30 days

SEROQUEL XR tab 300mg

60 tabs / 30 days

SEROQUEL XR tab 400mg

60 tabs / 30 days

SEROQUEL XR tab 50mg

60 tabs / 30 days

VRAYLAR CAP 1.5-3mg

1 pack / 180 days

VRAYLAR CAP 1.5mg

30 caps / 30 days

VRAYLAR CAP 3mg

30 caps / 30 days

VRAYLAR CAP 4.5mg

30 caps / 30 days

VRAYLAR CAP 6mg

30 caps / 30 days

ZYPREXA tab 10mg

30 tabs / 30 days

ZYPREXA tab 15mg

30 tabs / 30 days

ZYPREXA tab 2.5mg

30 tabs / 30 days

ZYPREXA tab 20mg

30 tabs / 30 days

ZYPREXA tab 5mg

30 tabs / 30 days

ZYPREXA tab 7.5mg

30 tabs / 30 days

ZYPREXA ZYDI tab 10mg

30 tabs / 30 days

ZYPREXA ZYDI tab 15mg

30 tabs / 30 days

ZYPREXA ZYDI tab 20mg

30 tabs / 30 days

ZYPREXA ZYDI tab 5mg

30 tabs / 30 days

Antivirals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DAKLINZA tab 30mg1

30 tabs / 30 days

DAKLINZA tab 60mg1

30 tabs / 30 days

EPCLUSA tab 200-50mg1

28 tabs / 28 days

EPCLUSA tab 400-1001

30 tabs / 30 days

HARVONI PAK1

28 packets / 28 days

HARVONI PAK 45-200mg1

28 packets / 28 days

HARVONI tab 45-200mg1

28 tabs / 28 days

HARVONI tab 90-400mg1

30 tabs / 30 days

LEDIP-SOFOSB tab 90-400mg1

30 tabs / 30 days

MAVYRET tab 100-40mg1

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 400-1001

30 tabs / 30 days

SOVALDI PAK 150mg1

28 packets / 28 days

SOVALDI PAK 200mg1

28 packets / 28 days

SOVALDI tab 200mg1

30 tabs / 30 days

SOVALDI tab 400mg1

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 tab1

112 tabs / 28 days

VOSEVI tab1

30 tabs / 30 days

XOFLUZA tab 20mg

4 tabs / 120 days

XOFLUZA tab 40mg

4 tabs / 120 days

ZEPATIER tab 50-100mg1

30 tabs / 30 days

Cardiovascular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADCIRCA tab 20mg1

60 tabs / 30 days

ADEMPAS tab 0.5mg2

90 tabs / 30 days

ADEMPAS tab 1.5mg2

90 tabs / 30 days

ADEMPAS tab 1mg2

90 tabs / 30 days

ADEMPAS tab 2.5mg2

90 tabs / 30 days

ADEMPAS tab 2mg2

90 tabs / 30 days

Alyq tab 20mg1

60 tabs / 30 days

Ambrisentan tab 10mg1

30 tabs / 30 days

Ambrisentan tab 5mg1

30 tabs / 30 days

Bosentan tab 125mg1

60 tabs / 30 days

Bosentan tab 62.5mg1

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 10mg1

30 tabs / 30 days

LETAIRIS tab 5mg1

30 tabs / 30 days

OPSUMIT tab 10mg2

30 tabs / 30 days

REVATIO SUS 10mg/mL1

2 bottles / 30 days

REVATIO tab 20mg1

90 tabs / 30 days

Sildenafil sus 10mg/mL1

2 bottles / 30 days

Sildenafil tab 20mg1

90 tabs / 30 days

Tadalafil tab 20mg1

60 tabs / 30 days

TRACLEER tab 125mg1

60 tabs / 30 days

TRACLEER tab 32mg1

120 tabs / 30 days

TRACLEER tab 62.5mg1

60 tabs / 30 days

UPTRAVI tab 1000MCG2

60 tabs / 30 days

UPTRAVI tab 1200MCG2

60 tabs / 30 days

UPTRAVI tab 1400MCG2

60 tabs / 30 days

UPTRAVI tab 1600MCG2

60 tabs / 30 days

UPTRAVI tab 200/8002

1 PKG / 180 days

UPTRAVI tab 200MCG2

60 tabs / 30 days

UPTRAVI tab 200MCG2

140 tabs / 180 days

UPTRAVI tab 400MCG2

60 tabs / 30 days

UPTRAVI tab 600MCG2

60 tabs / 30 days

UPTRAVI tab 800MCG2

60 tabs / 30 days

VENTAVIS SOL 10MCG/mL2, 3

270 ampuls / 30 days

VENTAVIS SOL 20MCG/mL2, 3

270 ampuls / 30 days

VYNDAMAX CAP 61mg1

30 caps / 30 days

VYNDAQEL CAP 20mg1

120 caps / 30 days

Corticosteroids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EMFLAZA tab 18mg2

30 tabs / 30 days

EMFLAZA tab 6mg2

60 tabs / 30 days

Dermatologicals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Ala scalp lot 2%

118.4 mLs / 30 days

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

Alclometason cre 0.05%

120 grams / 30 days

Alclometason oin 0.05%

120 grams / 30 days

ALDARA CRE 5%

48 packets / 60 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 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

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

CLOCORTOLONE CRE PIV 0.1%

135 grams / 30 days

CLOCORTOLONE CRE PIV 0.1%

135 grams / 30 days

Clodan sha 0.05%

236 mLs / 30 days

CLODERM CRE 0.1%

135 grams / 30 days

CLODERM CRE 0.1% PMP

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/mL1

1 syringe / 28 days

COSENTYX inj 300DOSE1

1 pack / 28 days

COSENTYX pen inj 150mg/mL1

1 injdv / 28 days

COSENTYX pen inj 300DOSE1

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

Desoximetas cre 0.05%

120 grams / 30 days

Desoximetas cre 0.25%

120 grams / 30 days

Desoximetas gel 0.05%

120 grams / 30 days

Desoximetas oin 0.05%

120 grams / 30 days

Desoximetas oin 0.25%

120 grams / 30 days

Desoximetaso 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 bottles / 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 200/1.141

2 syringes / 28 days

DUPIXENT inj 300/2ML1

2 syringes / 28 days

DUPIXENT inj 300/2ML1

2 pens / 28 days

EFUDEX CRE 5%

240 grams / 90 days

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 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 cre 0.1%

120 grams / 30 days

Hc butyrate cre 0.1%

120 grams / 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

Hydrocort cre 1%

454 grams / 30 days

Hydrocort cre 2.5%

454 grams / 30 days

Hydrocort lot 2.5%

118 mLs / 30 days

Hydrocort oin 2.5%

454 grams / 30 days

Hydrocortiso lot 0.1%

118 mLs / 30 days

Imiquimod cre 5%

48 packets / 60 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

LIcart DIS 1.3%

30 systems / 30 days

Lido/prilocn 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 oin pak 5%

100 grams / 30 days

Lidocaine pad 5%

90 patches / 30 days

Lidocaine pad 5%

90 patches / 30 days

Lidocaine sol 4%

150 mLs / 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

MICORT-HC CRE 2.5%

120 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

QBREXZA PAD 2.4%

30 pads / 30 days

REGRANEX GEL 0.01%

1 tube / 30 days

SERNIVO SPR

120 mLs / 30 days

SERNIVO SPR 0.05%

120 mLs / 30 days

SILIQ inj 210/1.51

2 syringes / 28 days

SKYRIZI inj 150DOSE1

1 box / 84 days

SKYRIZI inj 150mg/mL

1 syringe / 84 days

SKYRIZI pen inj 150mg/mL

1 injdv / 84 days

STELARA inj 45mg/0.51

1 syringe / 84 days

STELARA inj 90mg/mL1

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/mL1

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 inj 100mg/mL1

1 syringe / 56 days

TREMFYA inj 100mg/mL1

1 pen / 56 days

Triamcinolon aer spray

126 grams / 30 days

Triamcinolon cre 0.025%

454 grams / 30 days

Triamcinolon cre 0.1%

454 grams / 30 days

Triamcinolon cre 0.5%

454 grams / 30 days

Triamcinolon lot 0.025%

120 mLs / 30 days

Triamcinolon lot 0.1%

120 mLs / 30 days

Triamcinolon oin 0.025%

454 grams / 30 days

Triamcinolon oin 0.05%

430 grams / 30 days

Triamcinolon oin 0.1%

454 grams / 30 days

Triamcinolon 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 CRE 0.05%

200 grams / 28 days

ULTRAVATE LOT 0.05%

240 mLs / 30 days

ULTRAVATE OIN 0.05%

200 grams / 28 days

VANOS CRE 0.1%

240 grams / 28 days

VERDESO AER 0.05%

100 grams / 30 days

ZTLIDO PAD 1.8%

90 patches / 30 days

Digestive aids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

SUCRAID SOL 8500/mL

236 mLs / 28 days

Diuretics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

KEVEYIS tab 50mg2

120 tabs / 30 days

Endocrine and metabolic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTONEL tab 150mg

1 tab / 28 days

ACTONEL tab 35mg

4 tabs / 28 days

Alendronate tab 35mg

4 tabs / 28 days

Alendronate tab 70mg

4 caps / 28 days

ATELVIA tab

4 tabs / 28 days

BINOSTO tab 70mg

4 tabs / 28 days

BONIVA tab 150mg

1 tab / 28 days

BYNFEZIA pen inj 2500MCG

2 pens / 30 days

CETROTIDE kit 0.25mg1

5 kits / 30 days

CHOR GONADOT inj 10000UNT*

2 vials / 30 days

EGRIFTA SOL 1mg1

60 vials / 30 days

EGRIFTA SV inj 2mg1

30 vials / 30 days

FOLLISTIM AQ inj 300unit1

15 carts / 30 days

FOLLISTIM AQ inj 600unit1

8 carts / 30 days

FOLLISTIM AQ inj 900unit1

5 carts / 30 days

FORTEO inj 620/2.481

1 pen / 28 days

FOSAMAX tab 70mg

4 caps / 28 days

FOSAMAX + D tab 70-2800

4 caps / 28 days

FOSAMAX + D tab 70-5600

4 caps / 28 days

GALAFOLD CAP 123mg1

14 caps / 28 days

GANIRELIX AC inj 250/0.51

5 syringes / 30 days

Ganirelix ac inj 250/0.51

5 syringes / 30 days

GONAL-F inj 1050unit1

4 syringes / 30 days

GONAL-F inj 450unit1

10 syringes / 30 days

GONAL-F RFF inj 300/0.51

15 pens / 30 days

GONAL-F RFF inj 450/0.751

10 pens / 30 days

GONAL-F RFF inj 75unit1

20 syringes / 30 days

GONAL-F RFF inj 900/1.51

5 pens / 30 days

Ibandronate tab 150mg

1 tab / 28 days

ISTURISA tab 10mg2

180 tabs / 30 days

ISTURISA tab 1mg2

240 tabs / 30 days

ISTURISA tab 5mg2

300 tabs / 30 days

JYNARQUE PAK 30-15mg1

56 tabs / 28 days

JYNARQUE PAK 45-15mg1

56 tabs / 28 days

JYNARQUE PAK 60-30mg1

56 tabs / 28 days

JYNARQUE PAK 90-30mg1

56 tabs / 28 days

JYNARQUE tab 15mg1

56 tabs / 28 days

JYNARQUE tab 30mg1

30 tabs / 30 days

MENOPUR inj 75unit1

60 vials / 30 days

MYcapsSA CAP 20mg

120 caps / 30 days

NATPARA inj 100MCG1

1 kit / 28 days

NATPARA inj 25MCG1

1 kit / 28 days

NATPARA inj 50MCG1

1 kit / 28 days

NATPARA inj 75MCG1

1 kit / 28 days

NOCTIVA SPR 1.66/0.1

1 bott / 30 days

NOVAREL inj 10000UNT1

2 vials / 30 days

NOVAREL inj 5000unit1

4 vials / 30 days

ORILISSA tab 150mg

30 tabs / 30 days

ORILISSA tab 200mg

60 tabs / 30 days

OVIDREL inj1

2 syringes / 30 days

PREGNYL inj 10000UNT1

2 vials / 30 days

Risedron sod tab 35mg dr

4 tabs / 28 days

Risedronate tab 150mg

1 tab / 28 days

Risedronate tab 35mg

4 tabs / 28 days

SAMSCA tab 15mg1

30 tabs / 365 days

SAMSCA tab 30mg1

60 tabs / 365 days

SIGNIFOR inj 0.3mg/mL2

60 mLs / 30 days

SIGNIFOR inj 0.6mg/mL2

60 mLs / 30 days

SIGNIFOR inj 0.9mg/mL2

60 mLs / 30 days

SOMAVERT inj 10mg1

30 vials / 30 days

SOMAVERT inj 15mg1

30 vials / 30 days

SOMAVERT inj 20mg1

30 vials / 30 days

SOMAVERT inj 25mg1

30 vials / 30 days

SOMAVERT inj 30mg1

30 vials / 30 days

TERIPARATIDE inj1

1 pen / 28 days

TOLVAPTAN tab 15mg1

30 tabs / 365 days

Tolvaptan tab 30mg1

60 tabs / 365 days

TYMLOS inj1

1 pen / 30 days

Estrogens

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ORIAHNN CAP

56 caps / 28 days

Gastrointestinal agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Alosetron tab 0.5mg

60 tabs / 30 days

Alosetron tab 1mg

60 tabs / 30 days

AMITIZA CAP 24MCG

60 caps / 30 days

AMITIZA CAP 8MCG

120 caps / 30 days

CIMZIA PREFL kit 200mg/mL1

2 kits / 28 days

CIMZIA START kit 200mg/mL1

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 24MCG

60 caps / 30 days

LUBIPROSTONE CAP 8MCG

120 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 10mg1

30 tabs / 30 days

OCALIVA tab 5mg1

30 tabs / 30 days

RELISTOR inj 12/0.6ML

60 vials / 30 days

RELISTOR inj 12/0.6ML

30 syringes / 30 days

RELISTOR inj 8/0.4ML

30 syringes / 30 days

RELISTOR tab 150mg

90 tabs / 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 250mg2

90 tabs / 30 days

ZELNORM tab 6mg

60 tabs / 30 days

Hematological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FIRAZYR inj 30mg/3ML1

6 syringes / 30 days

HAEGARDA inj 2000unit2

24 vials / 30 days

HAEGARDA inj 3000unit2

16 vials / 30 days

HEMLIBRA inj 105/0.71

4 vials / 28 days

HEMLIBRA inj 150/mL1

4 vials / 28 days

HEMLIBRA inj 30mg/mL1

4 vials / 28 days

HEMLIBRA inj 60/0.41

4 vials / 28 days

Icatibant inj 30mg/3ml1

6 syringes / 30 days

ORLADEYO CAP 110mg2

30 caps / 30 days

ORLADEYO CAP 150mg2

30 caps / 30 days

TAKHZYRO inj 300/2ML2

4 mLs / 28 days

Hematopoietic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CERDELGA CAP 84mg1

60 caps / 30 days

Miglustat cap 100mg1

90 caps / 30 days

MULPLETA tab 3mg1

7 tabs / 7 days

OXBRYTA tab 500mg2

90 tabs / 30 days

PROMACTA PAK 25mg1

30 packs / 30 days

PROMACTA POW 12.5mg1

30 packets / 30 days

PROMACTA tab 12.5mg1

30 tabs / 30 days

PROMACTA tab 25mg1

30 tabs / 30 days

PROMACTA tab 50mg1

60 tabs / 30 days

PROMACTA tab 75mg1

60 tabs / 30 days

ZAVESCA CAP 100mg2

90 caps / 30 days

Hypnotics / Sedatives / Sleep disorder agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMBIEN tab 10mg

30 tabs / 30 days

AMBIEN tab 5mg

30 tabs / 30 days

AMBIEN CR tab 12.5mg

30 tabs / 30 days

AMBIEN CR tab 6.25mg

30 tabs / 30 days

BELSOMRA tab 10mg

30 tabs / 30 days

BELSOMRA tab 15mg

30 tabs / 30 days

BELSOMRA tab 20mg

30 tabs / 30 days

BELSOMRA tab 5mg

30 tabs / 30 days

DAYVIGO tab 10mg

30 tabs / 30 days

DAYVIGO tab 5mg

30 tabs / 30 days

EDLUAR SUB 10mg

30 tabs / 30 days

EDLUAR SUB 5mg

30 tabs / 30 days

HETLIOZ CAP 20mg2, 3

30 caps / 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

ROZEREM tab 8mg

30 tabs / 30 days

SILENOR tab 3mg

30 tabs / 30 days

SILENOR tab 6mg

30 tabs / 30 days

ZOLPIMIST SPR 5mg

1 can / 30 days

Doxepin tab 3mg

30 tabs / 30 days

Doxepin tab 6mg

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

Ramelteon tab 8mg

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

Medical devices and supplies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DEXCOM G5 MIS RECEIVER

1 unit / 365 days

DEXCOM G5 MIS 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 kit 2 SENSOR

2 sensors / 28 days

FREESTY LIBR MIS 2 reader

1 reader / 365 days

FREESTYLE kit SENSOR

3 units / 30 days

FREESTYLE MIS reader

1 unit / 365 days

G5/G4 MIS SENSOR

4 units / 28 days

Migraine products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AIMOVIG inj 140mg/mL1

1 inj / 28 days

AIMOVIG inj 70mg/mL1

1 inj / 28 days

AJOVY inj 225/1.51

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

Eletriptan tab 20mg

18 tabs / 30 days

Eletriptan tab 40mg

12 tabs / 30 days

EmgALITY inj 100mg/mL1

9 syringes / 180 days

EmgALITY inj 120mg/mL1

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 inj 6mg/0.5

12 carts / 30 days

IMITREX inj 6mg/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

MAXALT tab 10mg

18 tabs / 30 days

MAXALT-MLT tab 10mg

18 tabs / 30 days

MAXALT-MLT tab 5mg

36 tabs / 30 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 4mg/0.5

12 carts / 30 days

Sumatriptan inj 4mg/0.5

12 syringes / 30 days

SUMATRIPTAN inj 6mg/0.5

12 syringes / 30 days

Sumatriptan inj 6mg/0.5

12 carts / 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

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 inj dvs / 30 days

ZOLMITRIPTAN SPR 5mg

2 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 inj dvs / 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

ZOMIG ZMT tab 5mg ODT

12 tabs / 30 days

Miscellaneous therapeutic classes

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BENLYSTA inj 200mg/mL1

4 syringes / 28 days

ENSPRYNG inj1

1 syringe / 28 days

REVLIMID CAP 10mg1

30 caps / 30 days

REVLIMID CAP 15mg1

21 caps / 28 days

REVLIMID CAP 2.5mg1

30 caps / 30 days

REVLIMID CAP 20mg1

21 caps / 28 days

REVLIMID CAP 25mg1

21 caps / 28 days

REVLIMID CAP 5mg1

30 caps / 30 days

THALOMID CAP 100mg1

30 caps / 30 days

THALOMID CAP 150mg1

60 caps / 30 days

THALOMID CAP 200mg1

60 caps / 30 days

THALOMID CAP 50mg1

30 caps / 30 days

ZOKINVY CAP 50mg2

120 caps / 30 days

ZOKINVY CAP 75mg2

120 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMRIX CAP 15mg

21 caps / 90 days

AMRIX CAP 30mg

21 caps / 90 days

Baclofen tab 10mg

120 tabs / 30 days

Baclofen tab 20mg

120 tabs / 30 days

Baclofen tab 5mg

120 tabs / 30 days

CARISOPR/ASA tab 200-325

168 tabs / 90 days

Carisopr/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

CHLORZOXAZON tab 250mg

28 tabs / 30 days

Chlorzoxazon tab 375mg

84 tabs / 90 days

Chlorzoxazon tab 500mg

84 tabs / 90 days

Chlorzoxazon tab 750mg

84 tabs / 90 days

Cyclobenzapr cap 15mg er

21 caps / 90 days

Cyclobenzapr cap 30mg er

21 caps / 90 days

Cyclobenzapr tab 10mg

63 tabs / 90 days

Cyclobenzapr tab 5mg

63 tabs / 90 days

Cyclobenzapr 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 375mg

84 tabs / 90 days

Lorzone tab 750mg

84 tabs / 90 days

Metaxall tab 800mg

84 tabs / 90 days

Metaxalone tab 400mg

168 tabs / 90 days

Metaxalone tab 800mg

84 tabs / 90 days

Methocarbam tab 500mg

180 tabs / 90 days

Methocarbam tab 750mg

132 tabs / 90 days

Orphenadrine tab 100mg cr

42 tabs / 30 days

Orphenadrine tab 100mg er

42 tabs / 30 days

ROBAXIN-750 tab 750mg

132 tabs / 90 days

SKELAXIN tab 800mg

84 tabs / 90 days

SOMA tab 250mg

84 tabs / 90 days

SOMA tab 350mg

84 tabs / 90 days

Tizanidine cap 2mg

126 caps / 90 days

Tizanidine cap 4mg

126 caps / 90 days

Tizanidine cap 6mg

126 caps / 90 days

Tizanidine tab 2mg

126 tabs / 90 days

Tizanidine tab 4mg

42 caps / 30 days

Vanadom tab 350mg

84 tabs / 90 days

ZANAFLEX CAP 2mg

126 caps / 90 days

ZANAFLEX CAP 4mg

126 caps / 90 days

ZANAFLEX CAP 6mg

126 caps / 90 days

ZANAFLEX tab 4mg

42 tabs / 30 days

Nasal agents – systemic and topical

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Azel/flutic spr 137-50

1 bott / 30 days

Azelastine spr 0.1%

2 bottles / 30 days

Azelastine spr 0.15%

2 bottles / 30 days

Azelastine spr 0.15%

2 bottles / 30 days

BECONASE AQ SUS 0.042%

2 bottles / 30 days

DYMISTA SPR 137-50

1 bott / 30 days

FLUNISOLIDE SPR 0.025%

3 bottles / 30 days

Ipratropium spr 0.03%

2 bottles / 30 days

Ipratropium spr 0.06%

3 bottles / 30 days

Mometasone spr 50mcg

2 bottles / 30 days

NASONEX SPR 50MCG/AC

2 bottles / 30 days

Olopatadine spr 0.6%

1 bott / 30 days

Olopatadine spr 0.6%

1 bott / 30 days

OMNARIS SPR

1 bott / 30 days

PATANASE SPR 0.6%

1 bott / 30 days

QNASL AER 80MCG

1 can / 30 days

QNASL CHILD SPR 40MCG

1 can / 30 days

XHANCE MIS 93MCG

2 bottles / 30 days

ZETONNA AER 37MCG

1 can / 30 days

Neuromuscular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EVRYSDI SOL2

240 mLs / 30 days

Ophthalmic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Bimatoprost sol 0.03%

2.5 mLs / 30 days

EYSUVIS DRO 0.25%

2 bottles / 90 days

Latanoprost sol 0.005%

2.5 mLs / 30 days

LUMIGAN SOL 0.01%

2.5 mLs / 30 days

OXERVATE SOL 20MCG/mL2

56 vials / 56 days

RESTASIS EMU 0.05%

2 vials / 30 days

RESTASIS MUL EMU 0.05%

1 bott / 30 days

RHOPRESSA SOL 0.02%

2.5 mLs / 30 days

ROCKLATAN DRO

2.5 mLs / 30 days

TRAVATAN Z DRO 0.004%

2.5 mLs / 30 days

Travoprost dro 0.004%

2.5 mLs / 30 days

VYZULTA SOL 0.024%

2.5 mLs / 30 days

XALATAN SOL 0.005%

2.5 mLs / 30 days

XIIDRA DRO 5%

60 vials / 30 days

ZIOPTAN DRO 0.0015%

30 cartns / 30 days

Psychotherapeutic and neurological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADDYI tab 100mg

30 tabs / 30 days

AMPYRA tab 10mg1, 3

60 tabs / 30 days

AUBAGIO tab 14mg1, 3

30 tabs / 30 days

AUBAGIO tab 7mg1, 3

30 tabs / 30 days

AUSTEDO tab 12mg1

120 tabs / 30 days

AUSTEDO tab 6mg1

60 tabs / 30 days

AUSTEDO tab 9mg1

120 tabs / 30 days

AVONEX pen kit 30MCG1

1 kit / 28 days

AVONEX PREFL kit 30MCG1

1 kit / 28 days

BAFIERTAM CAP 95mg

120 caps / 30 days

BETASERON inj 0.3mg1

1 box / 28 days

COPAXONE inj 20mg/mL1

30 syringes / 30 days

COPAXONE inj 40mg/mL1

12 syringes / 28 days

Dalfampridin tab 10mg er1, 3

60 tabs / 30 days

Dimethyl fum cap 120mg dr

56 caps / 180 days

Dimethyl fum cap 240mg dr1

60 caps / 30 days

Dimethyl fum mis starter1

60 caps / 180 days

EXTAVIA inj 0.3mg1

15 vials / 30 days

GILENYA CAP 0.5mg1

30 tabs / 30 days

Glatiramer inj 20mg/mL1

30 syringes / 30 days

Glatiramer inj 40mg/mL1

12 syringes / 28 days

Glatopa inj 20mg/mL1

30 syringes / 30 days

Glatopa inj 40mg/mL1

12 syringes / 28 days

INGREZZA CAP 40-80mg2

28 caps / 180 days

INGREZZA CAP 40mg2

30 caps / 30 days

INGREZZA CAP 60mg

30 caps / 30 days

INGREZZA CAP 80mg2

30 caps / 30 days

KESIMPTA inj 20/.4ML1

1 syringe / 28 days

LYRICA CR tab 165mg

30 tabs / 30 days

LYRICA CR tab 330mg

60 tabs / 30 days

LYRICA CR tab 82.5mg

30 tabs / 30 days

MAVENCLAD PAK 10mg(10)1

20 tabs / 301 days

MAVENCLAD PAK 10mg(4)1

8 tabs / 301 days

MAVENCLAD PAK 10mg(5)1

10 tabs / 301 days

MAVENCLAD PAK 10mg(6)1

12 tabs / 301 days

MAVENCLAD PAK 10mg(7)1

14 tabs / 301 days

MAVENCLAD PAK 10mg(8)1

8 tabs / 301 days

MAVENCLAD PAK 10mg(9)1

9 tabs / 301 days

MAYZENT PAK STARTER

12 tabs / 180 days

MAYZENT tab 0.25mg1

120 tabs / 30 days

MAYZENT tab 2mg1

30 tabs / 30 days

PLEGRIDY inj1

2 syringes / 28 days

PLEGRIDY inj pen1

2 pens / 28 days

PLEGRIDY inj STARTER1

1 kit / 180 days

PLEGRIDY pen inj STARTER1

1 kit / 180 days

Pregabaln er tab 165mg

30 tabs / 30 days

Pregabaln er tab 330mg

60 tabs / 30 days

Pregabaln er tab 82.5mg

30 tabs / 30 days

REBIF inj 22/0.51

12 syringes / 28 days

REBIF inj 44/0.51

1 carton / 28 days

REBIF REBIDO inj 22/0.51

1 carton / 28 days

REBIF REBIDO inj 44/0.51

1 carton / 28 days

REBIF REBIDO inj TITRATN1

1 kit / 180 days

REBIF TITRTN inj pack1

1 kit / 180 days

SAVELLA MIS TITR PAK

1 kit / 180 days

SAVELLA tab 100mg

60 tabs / 30 days

SAVELLA tab 12.5mg

60 tabs / 30 days

SAVELLA tab 25mg

60 tabs / 30 days

SAVELLA tab 50mg

60 tabs / 30 days

TECFIDERA CAP 120mg1

56 caps / 180 days

TECFIDERA CAP 240mg1

60 caps / 30 days

TECFIDERA MIS STARTER1

60 caps / 180 days

TEGSEDI inj 284/1.52

6 mLs / 28 days

Tetrabenazin tab 12.5mg1

240 tabs / 30 days

Tetrabenazin tab 25mg1

120 tabs / 30 days

VUMERITY CAP 231mg1

106 caps / 180 days

VYLEESI inj 1.75/0.3

6 pens / 30 days

XENAZINE tab 12.5mg1

240 tabs / 30 days

XENAZINE tab 25mg1

120 tabs / 30 days

XYREM SOL 500mg/mL2

540 mLs / 30 days

XYWAV SOL 0.5GM/mL2

540 mLs / 30 days

ZEPOSIA CAP .92mg1

30 caps / 30 days

ZEPOSIA CAP STR kit1

37 caps / 180 days

ZEPOSIA 7DAY CAP STR pack1

7 caps / 180 days

Respiratory agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ESBRIET CAP 267mg1

180 caps / 30 days

ESBRIET tab 267mg1

180 tabs / 30 days

ESBRIET tab 801mg1

90 tabs / 30 days

KALYDECO PAK 25mg1

60 packets / 30 days

KALYDECO PAK 50mg1

60 packets / 30 days

KALYDECO PAK 75mg1

60 packets / 30 days

KALYDECO tab 150mg1

60 tabs / 30 days

OFEV CAP 100mg1, 3

60 caps / 30 days

OFEV CAP 150mg1, 3

60 caps / 30 days

ORKAMBI tab 100-1251

120 tabs / 30 days

ORKAMBI tab 200-1251

120 tabs / 30 days

SYMDEKO tab 100-1501

60 tabs / 30 days

SYMDEKO tab 50-75mg1

56 tabs / 28 days

TRIKAFTA tab1

90 tabs / 30 days

Ulcer drugs / Antispasmodics / Anticholinergics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACIPHEX tab 20mg

30 tabs / 30 days

DEXILANT CAP 30mg DR

30 caps / 30 days

DEXILANT CAP 60mg DR

30 caps / 30 days

Esomepra mag 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

Omeppi cap 20-1100

30 caps / 30 days

Omeppi cap 40-1100

30 caps / 30 days

Omepra/bicar cap 20-1100

30 caps / 30 days

Omepra/bicar cap 40-1100

30 caps / 30 days

Omepra/bicar pow 20-1680

30 packets / 30 days

Omepra/bicar pow 40-1680

30 packets / 30 days

Omeprazole cap 10mg

30 caps / 30 days

Omeprazole cap 10mg

30 caps / 30 days

Omeprazole cap 20mg

30 caps / 30 days

Omeprazole cap 40mg

30 caps / 30 days

Omeprazole cap 40mg

30 caps / 30 days

Pantoprazole tab 20mg

30 tabs / 30 days

Pantoprazole tab 20mg dr

30 tabs / 30 days

Pantoprazole tab 40mg

30 tabs / 30 days

Pantoprazole tab 40mg dr

30 tabs / 30 days

PREVACID CAP 15mg DR

30 caps / 30 days

PREVACID CAP 30mg DR

30 caps / 30 days

PROTONIX tab 20mg

30 tabs / 30 days

PROTONIX tab 40mg

30 tabs / 30 days

Rabeprazole tab 20mg

30 tabs / 30 days

ZEGERID CAP 20-1100

30 caps / 30 days

ZEGERID CAP 40-1100

30 caps / 30 days

ZEGERID POW 20-1680

30 packets / 30 days

ZEGERID POW 40-1680

30 packets / 30 days

Urinary antispasmodics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Darifenacin tab 7.5mg

30 tabs / 30 days

Darifenacin tab 15mg

30 tabs / 30 days

DETROL tab 1mg

60 tabs / 30 days

DETROL tab 2mg

60 tabs / 30 days

DETROL LA CAP 2mg

30 caps / 30 days

DETROL LA CAP 4mg

30 caps / 30 days

DITROPAN XL tab 5mg

30 tabs / 30 days

DITROPAN XL tab 10mg

60 tabs / 30 days

ENABLEX tab 7.5mg

30 tabs / 30 days

ENABLEX tab 15mg

30 tabs / 30 days

GELNIQUE GEL 10%

30 packets / 30 days

GELNIQUE GEL 10% PUMP

30 packets / 30 days

GEMTESA tab 75mg

30 tabs / 30 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 5mg

30 tabs / 30 days

Solifenacin tab 10mg

30 tabs / 30 days

Tolterodine cap 2mg er

30 caps / 30 days

Tolterodine cap 4mg er

30 caps / 30 days

Tolterodine tab 1mg

60 tabs / 30 days

Tolterodine tab 2mg

60 tabs / 30 days

TOVIAZ tab 4mg

30 tabs / 30 days

TOVIAZ tab 8mg

30 tabs / 30 days

Trospium chl cap 60mg er

30 caps / 30 days

Trospium cl tab 20mg

60 tabs / 30 days

VESICARE tab 10mg

30 tabs / 30 days

VESICARE tab 5mg

30 tabs / 30 days

Vaginal and related products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CRINONE GEL 4% VAG

6 applcs / 30 days

CRINONE GEL 8% VAG

60 applcs / 30 days

ENDOMETRIN SUP 100mg

84 supps / 28 days

Vasopressors

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Droxidopa cap 100mg1

450 caps / 30 days

Droxidopa cap 200mg1

180 caps / 30 days

Droxidopa cap 300mg1

180 caps / 30 days

NORTHERA CAP 100mg1

450 caps / 30 days

NORTHERA CAP 200mg1

180 caps / 30 days

NORTHERA CAP 300mg1

180 caps / 30 days

Drug name(s)

abiraterone acetate1, 2, 3

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADCIRCA1

ADVATE1

ADYNOVATE1

AFINITOR1, 2, 3

AFINITOR DISPERZ1, 2, 3

AFSTYLA1

AIMOVIG1

AJOVY1

ALPHANINE SD1

ALPROLIX1

alyq1

ambrisentan1

AMPYRA1, 2, 3

AUBAGIO1, 2, 3

AUSTEDO1

AVONEX1

AVONEX PEN1

BENEFIX1

BENLYSTA1

BETASERON1

BETHKIS1

bexarotene1, 2, 3

bosentan1

BOSULIF1, 2, 3

BUPHENYL1

CABOMETYX1, 2, 3

capecitabine1

CAYSTON1

CERDELGA1

CETROTIDE1

CHORIONIC GONADOTROPIN1

CIMZIA1

CIMZIA STARTER KIT1

COPAXONE1

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

CUVITRU2

DAKLINZA1

dalfampridine er1, 2, 3

DAURISMO1, 2, 3

dimethyl fumarate1

dimethyl fumarate starter pack1

droxidopa1

DUPIXENT1

EGRIFTA1

EGRIFTA SV1

ELOCTATE1

EMGALITY1

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

ENSPRYNG1

EPCLUSA1

EPIDIOLEX1

ERIVEDGE1, 2, 3

erlotinib1, 2, 3

ESBRIET1

ESPEROCT1

everolimus1, 2, 3

EXTAVIA1

FARYDAK1

FIRAZYR1

FOLLISTIM AQ1

FORTEO1

GALAFOLD1

ganirelix ac1

GENOTROPIN1

GENOTROPIN MINIQUICK1

GILENYA1

glatiramer acetate1

glatopa1

GLEEVEC1, 2, 3

GOCOVRI1, 2, 3

GONAL-F1

GONAL-F RFF1

GONAL-F RFF REDIJECT1

GRANIX1

HARVONI1

HELIXATE FS1

HEMLIBRA1

HEMOFIL M1

HIZENTRA1

HUMATROPE1

HUMIRA1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1

HUMIRA PEN1

HUMIRA PEN-CD/UC/HS STARTER1

HUMIRA PEN-PEDIATRIC UC STARTER PACK1

HUMIRA PEN-PS/UV STARTER1

HYCAMTIN1

HYQVIA1

IBRANCE1

icatibant acetate1

IDELVION1

IDHIFA1

imatinib mesylate1, 2, 3

INLYTA1, 2, 3

INQOVI1

INREBIC1, 2, 3

INTRON A1

IXINITY1

JAKAFI1, 2, 3

JIVI1

JYNARQUE1

KALYDECO1

KESIMPTA1

KEVZARA1

KINERET2

KISQALI1

KISQALI FEMARA1

KITABIS PAK1

KOATE1

KOATE-DVI1

KOGENATE FS1

KOVALTRY1

KUVAN1

lapatinib ditosylate1

LEDIPASVIR/SOFOSBUVIR1

LETAIRIS1

LONSURF1

LORBRENA1, 2, 3

MATULANE1

MAVENCLAD1

MAVYRET1

MAYZENT1

MEKINIST1

MENOPUR1

miglustat1

MONONINE1

MULPLETA1

NATPARA1

NEULASTA1

NEULASTA ONPRO KIT1

NEXAVAR1, 2, 3

NINLARO1

NORDITROPIN FLEXPRO1

NORTHERA1

NOVAREL1

NOVOEIGHT1

NUBEQA1

NUPLAZID1

NUTROPIN AQ NUSPIN1

NUWIQ1

OCALIVA1

ODOMZO1, 2, 3

OFEV1, 2, 3

OLUMIANT1

OMNITROPE1

OPSUMIT2

ORENCIA1

ORENCIA CLICKJECT1

ORKAMBI1

OTEZLA1

OVIDREL1

PAXIL

PEGINTRON1

PIQRAY1

PLEGRIDY1

PLEGRIDY STARTER PACK1

POMALYST1

PROCRIT1

PROFILNINE1

PROFILNINE SD1

PROMACTA1

RAVICTI1

REBIF1

REBIF REBIDOSE1

REBIF REBIDOSE TITRATION PACK1

REBIF TITRATION PACK1

REBINYN1

RECOMBINATE1

RETEVMO1, 2, 3

REVATIO1

REVLIMID1

RINVOQ1

RIXUBIS1

ROZLYTREK1, 2, 3

RYDAPT1

SAMSCA1

sapropterin dihydrochloride1

SENSIPAR1

SEROSTIM1

SIGNIFOR2

SILIQ1

SIMPONI1

SKYRIZI1

sodium phenylbutyrate1

SOFOSBUVIR / VELPATASVIR1

SOMAVERT1

SOVALDI1

SPRYCEL1, 2, 3

STELARA1

STIMATE1

STIVARGA1

SUTENT1, 2, 3

SYLATRON1

SYMDEKO1

TABRECTA1

tadalafil1

TAFINLAR1

TALTZ1

TALZENNA1, 2, 3

TARCEVA1, 2, 3

TARGRETIN1, 2, 3

TASIGNA1, 2, 3

TECFIDERA1

TECFIDERA STARTER PACK1

TEMODAR1

temozolomide1

TERIPARATIDE1

tetrabenazine1

THALOMID1

TOBI PODHALER1

TOBRAMYCIN  1

tobramycin1

TOLVAPTAN1

TRACLEER1

TREMFYA1

TRIKAFTA1

TYKERB1

TYMLOS1

VIEKIRA PAK1

VIIBRYD STARTER PACK

VIZIMPRO1, 2, 3

VOSEVI1

VOTRIENT1, 2, 3

VUMERITY1

VYNDAMAX1

VYNDAQEL1

XALKORI1, 2, 3

XELJANZ1

XELJANZ XR1

XELODA1

XENAZINE1

XTANDI1, 2, 3

XYNTHA1

XYNTHA SOLOFUSE1

ZARXIO1

ZELBORAF1

ZEPATIER1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOLINZA1, 2, 3

ZOMACTON1

ZORBTIVE1

ZYKADIA1, 2, 3

ZYTIGA1, 2, 3

 

 

1Specialty

2Limited Distribution

3Split Fill

4Indicates exclusive to Alliance Rx Walgreens Prime preferred specialty