Advantage prescription drug benefits

Effective January 1, 2022

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


Key:

UPPERCASE names = Brand

lowercase names = Generic

Guide to prescription drug benefits

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

Use this guide to understand how your benefits work.

Drug name(s)

ABILIFY

abiraterone acetate 1

ABSTRAL

ACIPHEX

ACTEMRA 1

ACTEMRA ACTPEN 1

ACTHAR 1

ACTICLATE

ACTIQ

ADCIRCA 1

ADDERALL

ADDERALL XR

ADEMPAS 2

ADHANSIA XR

ADIPEX-P

ADMELOG

ADMELOG SOLOSTAR

ADVATE 1

ADYNOVATE 1

ADZENYS ER

ADZENYS XR-ODT

AFINITOR 1,3

AFINITOR DISPERZ 1,3

AFREZZA

AFSTYLA 1

AKLIEF

ALDARA

ALECENSA 2,3

alosetron hcl

ALPHANINE SD 1

ALPROLIX 1

ALUNBRIG 2

alyq 1

AMBIEN

AMBIEN CR

ambrisentan 1

AMITIZA

AMPHETAMINE ER

AMPYRA 1,3

AMRIX

ANAFRANIL

ANDRODERM

ANDROGEL

ANDROGEL PUMP

APIDRA

APIDRA SOLOSTAR

APLENZIN

APTENSIO XR

ARAZLO

ARCALYST 2

ARIKAYCE 2

ARYMO ER

ATRALIN

AUBAGIO 1,3

AUSTEDO 1

AUVI-Q

avita

AVONEX 1

AVONEX PEN 1

AYVAKIT 2,3

AZESCHEW PRENATAL / POSTNATAL

AZESCO

BAFIERTAM

BALVERSA 2,3

BELBUCA

BELSOMRA

BENEFIX 1

BENLYSTA 1

benzphetamin tab 50mg

BENZPHETMINE TAB 25MG

BETASERON 1

BETHKIS 1

bexarotene 1 -

bosentan 1

BOSULIF 1,3

BRAFTOVI 2

BRUKINSA 2

BUPHENYL 1

buprenorphine

BUPROPION HCL ER (XL)

BUTRANS

BYNFEZIA PEN

CABOMETYX 1,3

CALQUENCE 2

capecitabine 1

CAPLYTA

CAPRELSA 2

CARAC

CARBAGLU 2

CAYSTON 1

CELEXA

CERDELGA 1

CETROTIDE 1

CHORIONIC GONADOTROPIN 1

ciclodan

ciclopirox nail lacquer

CIMZIA 1

CIMZIA STARTER KIT 1

cinacalcet 1

CIPRO HC

CIPRODEX

ciprofloxacin/dexamethasone

CLEMASTINE FUMARATE

clomipramine hcl

CLOZAPINE ODT

CLOZARIL

COLCHICINE

COMETRIQ 2,3

CONCERTA

CONTRAVE

CONZIP

COPAXONE 1

COPIKTRA 2,3

CORLANOR

COSENTYX 1

COSENTYX SENSOREADY PEN 1

COTELLIC 1

COTEMPLA XR-ODT

CRESEMBA

CRINONE

CUTAQUIG 2

CUVITRU 2

cyclobenzaprine hcl er

CYMBALTA

dalfampridine er 1 -

DANTRIUM

DARAPRIM

DAURISMO 1,3

DAYTRANA

DAYVIGO

deferasirox 1 -

DEPO-TESTOSTERONE

DESOXYN

DESVENLAFAXINE ER

DICLEGIS

diclofenac sodium

diethylpropion hcl

DIETHYLPROPION HCL ER

dihydroergotamine mesylate

dimethyl fumarate 1

dimethyl fumarate starterpack 1

DOJOLVI 2

DORYX

DORYX MPC

DOXYCYCLINE

DOXYCYCLINE HYCLATE DR

doxylamine succinate/pyridoxine hcl

droxidopa 1

DUEXIS

DUPIXENT 1

DURAGESIC

DYANAVEL XR

EDLUAR

EFFEXOR XR

EFUDEX

EGRIFTA 1

EGRIFTA SV 1

ELEPSIA XR

ELOCTATE 1

EMFLAZA 2

EMPAVELI

EMSAM

ENBREL 1

ENBREL MINI 1

ENBREL SURECLICK 1

ENDARI 2

ENDOMETRIN

ENSPRYNG 1

EPCLUSA 1

EPIDIOLEX 1

EPINEPHRINE

EPIPEN

EPIPEN-JR

ERIVEDGE 1,3

erlotinib hcl 1,3

ESBRIET 1

ESPEROCT 1

EVEKEO

everolimus

EVRYSDI 2

EXJADE 1,3

EXTAVIA 1

EYSUVIS

FABIOR

FANAPT

FANAPT TITRATION PACK

FARYDAK1

FASENRA PEN

fenofibrate

fenofibric acid dr

fentanyl

FENTANYL CITRATE

fentanyl citrate oral transmucosal

FENTORA

FETZIMA

FETZIMA TITRATION PACK

FEXMID

FINTEPLA 2

FIRAZYR 1

FIRDAPSE 2

FLUOROPLEX

FLUOROURACIL CRE 0.5%

fluorouracil cre 5%

FLUOXETINE DR

FLUOXETINE HCL

FOCALIN

FOCALIN XR

FOLLISTIM AQ 1

FORFIVO XL

FORTEO 1

FORTESTA

FOTIVDA

GALAFOLD 1

GANIRELIX AC

ganirelix ac 1

GATTEX 2

GAVRETO 2,3

GENOTROPIN 1

GENOTROPIN MINIQUICK 1

GEODON

GILENYA 1

GILOTRIF 2

glatiramer acetate 1

glatopa 1

GLEEVEC 1,3

glydo

GOCOVRI 1,3

GONAL-F 1

GONAL-F RFF 1

GONAL-F RFF REDIJECT 1

GRANIX 1

HAEGARDA 2

HARVONI 1

HEMLIBRA 1

HEMOFIL M 1

HETLIOZ 2,3

HETLIOZ LQ 2,3

HIZENTRA 1

HUMALOG

HUMALOG JUNIOR KWIKPEN

HUMALOG KWIKPEN

HUMALOG MIX

HUMALOG MIX KWIKPEN

HUMATROPE 1

HUMIRA 1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 1

HUMIRA PEN 1

HUMIRA PEN-CD/UC/HS STARTER 1

HUMIRA PEN-PEDIATRIC UC STARTER PACK 1

HUMIRA PEN-PS/UV STARTER 1

HUMULIN

HUMULIN WIKPEN

HUMULIN N

HUMULIN N KWIKPEN

HUMULIN R

HYCAMTIN 1

hydrocodone er

HYDROCODONE ER

hydrocodone er

hydromorphone hcl er

HYQVIA 1

HYSINGLA ER

IBRANCE 1

icatibant acetate 1

ICLUSIG 2,3

IDELVION 1

IDHIFA 1

imatinib mesylate 1

IMBRUVICA 2

IMCIVREE 2

imiquimod

imiquimod pump

INGREZZA 2

INLYTA 1,3

INQOVI 1

INREBIC 1,3

INSULIN LISPRO

INSULIN LISPRO JUNIOR KWIKPEN

INSULIN LISPRO KWIKPEN

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN

INTERMEZZO

INTRON A 1

INTUNIV

INVEGA

IRESSA 2,3

ISTURISA 2

IXINITY 1

JADENU 1,3

JADENU SPRINKLE 1,3

JAKAFI 1,3

JIVI 1

JORNAY PM

JUBLIA

JUXTAPID 2

JYNARQUE 1

KADIAN

KALYDECO 1

KAPVAY

KERENDIA

KERYDIN

KESIMPTA 1

KEVEYIS 2

KEVZARA 1

KHEDEZLA

KINERET 2

KISQALI 1

KITABIS PAK 1

KLISYRI

KOATE 1

KOATE-DVI 1

KOGENATE FS 1

KORLYM 2

KOSELUGO 2

KOVALTRY 1

KUVAN 1

lapatinib ditosylate 1

LAZANDA

LEDIPASVIR / SOFOSBUVIR 1

LENVIMA 2,3

LETAIRIS 1

LEXAPRO

lidocaine

lidocaine gel

LIDOCAINE AND TETRACAINE CREAM

lidocaine hcl

lidocaine patch 5%

lidocaine/prilocaine

LIDOCAINE/TETRACAINE

LIDODERM

LOMAIRA

LONSURF 1

LORBRENA 1,3

LOTRONEX

LUBIPROSTONE

LUMAKRAS

LUNESTA

LUPKYNIS

LYNPARZA 2,3

LYRICA CR

LYSODREN

LYUMJEV

LYUMJEV KWIKPEN

MAPROTILINE HCL

MATULANE 1

MAVYRET 1

MAYZENT 1

MAYZENT STARTER PACK

MEKINIST 1

MEKTOVI 2

MENOPUR 1

metaxalone

METHADONE

methadone hcl

METHITEST

METHYLIN

METHYLPHENIDATE HCL ER

METHYLTESTOSTERONE

miglustat 1

MIGRANAL

MINOCIN

MINOCYCLINE HCL ER

MINOLIRA

MITIGARE

MONONINE 1

MORPHABOND ER

morphine sul er

MORPHINE SUL ER

morphine sul er

morphine sulfate cr

MOTEGRITY

MS CONTIN

MULPLETA 1

MYALEPT 2

MYCAPSSA

MYDAYIS

naproxen/esomeprazole magnesium

NATESTO

NATPARA 1

NERLYNX 2,3

NEULASTA 1

NEULASTA ONPRO KIT 1

NEXAVAR 1,3

NEXIUM

NEXLETOL

NEXLIZET

NINLARO 1

NOCTIVA

NORDITROPIN FLEXPRO 1

NORTHERA 1

NOVAREL 1

NOVOEIGHT 1

NOXAFIL

NUBEQA 1

NUCALA

NUCYNTA ER

NUPLAZID 1

NUTROPIN AQ NUSPIN 10 1

NUWIQ 1

NYVEPRIA

OCALIVA 1

ODOMZO 1,3

OFEV 1,3

OLUMIANT 1

omeprazole/sodium bicarbonate

OMNITROPE 1

ONUREG 1

OPSUMIT 2

ORACEA

ORENCIA 1

ORENCIA CLICKJECT 1

ORENITRAM 2

ORGOVYX 2

ORIAHNN

ORILISSA

ORKAMBI 1

ORLADEYO 2

OTEZLA 1

OVIDREL 1

OXBRYTA 2

OXERVATE 2

OXYCODONE HCL ER

OXYCONTIN

OXYMORPHONE HCL ER

PAXIL

PAXIL CR

PEGINTRON 1

PEMAZYRE 2

PENLAC NAIL LACQUER

PEXEVA

phendimetrazine tartrate

PHENDIMETRAZINE TARTRATE ER

phentermine hcl

PICATO

PIQRAY 1

PLEGRIDY 1

PLEGRIDY STARTER PACK 1

PLIAGLIS

PNV TABS 20-1

POMALYST 1

PONVORY

PONVORY 14-DAY STARTER PACK

posaconazole

posaconazole dr

PRALUENT

pregabalin er

PREGEN DHA

PREGENNA

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL 1

PRENARA

PRENATRIX

PRENATRYL

PREVACID

PRISTIQ

PROCRIT 1

PROCYSBI 2

PROFILNINE 1

PROFILNINE SD 1

PROMACTA 1

PROTONIX

PROZAC

pyrimethamine

QBREXZA

QBREXZA

QELBREE

QINLOCK 2

QSYMIA

QUDEXY XR

RAVICTI 1

RAYOS

REBIF 1

REBIF REBIDOSE 1

REBIF REBIDOSE TITRATION PACK 1

REBIF TITRATION PACK 1

REBINYN 1

RECOMBINATE 1

RELEXXII

RELISTOR

RELTONE

REMERON

REMERON SOLTAB

REPATHA

REPATHA PUSHTRONEX SYSTEM

REPATHA SURECLICK

RESTASIS

RESTASIS MULTIDOSE

RETEVMO 1,3

RETIN-A

RETIN-A MICRO

RETIN-A MICRO PUMP

REVATIO 1

REVLIMID 1

REYVOW

RINVOQ 1

RISPERDAL

RISPERIDONE ODT

RITALIN

RITALIN LA

RIXUBIS 1

ROBAXIN-750

ROZEREM

ROZLYTREK 1,3

RUBRACA 2,3

RUZURGI 2

RYDAPT 1

sajazir 1

SAMSCA 1

SAPHRIS

sapropterin dihydrochloride 1

SARAFEM

SAXENDA

SENSIPAR 1

SEROQUEL

SEROQUEL XR

SEROSTIM 1

SEYSARA

SIGNIFOR 2

sildenafil sus 10mg/ml 1

sildenafil tab 20mg 1

SILENOR

SILIQ 1

SIMPONI 1

SKELAXIN

SKYRIZI 1

SKYRIZI PEN 1

sodium phenylbutyrate 1

SOFOSBUVIR / VELPATASVIR 1

SOMA

SOMAVERT 1

SOVALDI 1

SPRYCEL 1,3

STELARA 1

STIMATE 1

STIVARGA 1

STRATTERA

STRENSIQ 2

STRIANT

SUBSYS

SUCRAID

sunitinib malate 1,3

SUNOSI

SUTENT 1,3

SYMDEKO 1

SYNERA

TABRECTA 1

tadalafil 1

TAFINLAR 1

TAGRISSO 2,3

TAKHZYRO 2

TALTZ 1

TALZENNA 1,3

TARCEVA 1,3

TARGRETIN 1,3

TASIGNA 1,3

tavaborole

TAZAROTENE AER 0.1%

tazarotene cre 0.1%

TAZORAC

TAZVERIK 2

TECFIDERA 1

TECFIDERA STARTER PACK 1

TEGSEDI 2

TEMODAR 1

temozolomide 1

TEPMETKO 3

TERIPARATIDE 1

TESTIM

testosterone cypionate

TESTOSTERONE ENANTHATE

TESTOSTERONE GEL 1%(25MG)

testosterone gel 1%(50mg)

testosterone gel 10mg/act

testosterone gel pump 1%

testosterone sol 30mg/act

testosterone td gel 20.25 mg/1.25gm (1.62%)

testosterone td gel 20.25 mg/act (1.62%)

testosterone td gel 40.5 mg/2.5gm (1.62%)

testosterone topical solution

tetrabenazin tab 12.5mg 1

tetrabenazin tab 25mg 1

THALOMID 1

TIBSOVO 2

TOBI 1

TOBI PODHALER 1

tobramycin neb 300/4ml 1

tobramycin neb 300/5ml 1

TOLAK

TOLVAPTAN TAB 15MG 1

tolvaptan tab 30mg 1

topiramate er

TRACLEER 1

TRAMADOL HCL CAP 150MG ER

TRAMADOL HCL CAP ER 100MG

TRAMADOL HCL CAP ER 200MG

TRAMADOL HCL CAP ER 300MG

tramadol hcl tab 100mg er

tramadol hcl tab 200mg er

tramadol hcl tab 300mg er

tramadol hcl er

trazodone hcl

TREMFYA 1

tretinoin

tretinoin microsphere

tretinoin microsphere pump

TRIKAFTA 1

TRILIPIX

TRINAZ

TRINTELLIX

TROKENDI XR

TRUSELTIQ

TUKYSA 2

TURALIO 2

TYKERB 1

TYMLOS 1

UKONIQ 3

UPTRAVI 2

URSODIOL

VENCLEXTA 2

VENCLEXTA STARTING PACK 2

VENTAVIS 2,3

VERQUVO

VERSACLOZ

VERZENIO 2,3

VFEND

VIBERZI

VIBRAMYCIN

VIEKIRA PAK 1

VIIBRYD

VIIBRYD STARTER PACK

VIMOVO

VITRAKVI 2,3

VIZIMPRO 1,3

VOGELXO

VOGELXO PUMP

voriconazole

VOSEVI 1

VOTRIENT 1,3

VRAYLAR

VUMERITY 1

VYLEESI

VYNDAMAX 1

VYNDAQEL 1

WAKIX

WEGOVY

WELLBUTRIN SR

WELLBUTRIN XL

WYNZORA

XALKORI 1,3

XELJANZ 1

XELJANZ XR 1

XELODA 1

XENAZINE 1

XENICAL

XERMELO 2

XHANCE

XIFAXAN

XIIDRA

XIMINO

XOLAIR 1

XOSPATA 2

XPOVIO 2,3

XTAMPZA ER

XTANDI 1,3

XYNTHA 1

XYNTHA SOLOFUSE 1

XYOSTED

XYREM 2

XYWAV 2

ZALVIT

ZANAFLEX

ZARXIO 1

ZAVESCA 2

ZEGERID

ZEJULA 2,3

ZELBORAF 1

ZELNORM

ZEPATIER 1

ZEPOSIA 1

ZEPOSIA 7-DAY STARTER PACK 1

ZEPOSIA STARTER KIT 1

ZOHYDRO ER

ZOKINVY 2

ZOLINZA 1,3

ZOLOFT

ZOLPIMIST

ZOMACTON 1

ZORBTIVE 1

ZTLIDO

ZYCLARA

ZYCLARA PUMP

ZYDELIG 2

ZYKADIA 1,3

ZYPREXA

ZYPREXA ZYDIS

ZYTIGA 1,3

   

Drug name(s)

ACCU-CHEK AVIVA PLUS

ACCU-CHEK COMPACT PLUS

ACCU-CHEK COMPACT STRIPS

ACCU-CHEK COMPACT TEST DRUM

ACCU-CHEK GUIDE

ACCU-CHEK SMARTVIEW STRIPS

ACCUTREND GLUCOSE

ADLYXIN

ADLYXIN STARTER PACK

ADVANCE INTUITION TEST STRIPS

ADVANCE MICRO-DRAW TEST STRIPS

ADVOCATE REDI-CODE

ADVOCATE REDI-CODE+ TEST STRIPS

ADVOCATE TEST STRIPS

AGAMATRIX AMP NO CODE TEST STRIPS

AGAMATRIX JAZZ TEST STRIPS

AGAMATRIX KEYNOTE TEST STRIPS

AGAMATRIX PRESTO TEST STRIPS

AIMOVIG 1

AJOVY 1

ALA-SCALP

ALOCRIL

ALOGLIPTIN

ALOGLIPTIN/METFORMIN HCL

ALOGLIPTIN/PIOGLITAZONE

ALTOPREV

AMCINONIDE

AMERGE

ANAPROX DS

APEXICON E

ARTHROTEC 50

ARTHROTEC 75

ASSURE 3 TEST STRIPS

ASSURE 4 TEST STRIPS

ASSURE II

ASSURE II CHECK STRIP

ASSURE II TEST STRIPS

ASSURE PLATINUM TEST STRIPS

ASSURE PRISM MULTI TEST STRIPS

ASSURE PRO TEST STRIPS

AT LAST TEST STRIPS

ATACAND

ATACAND HCT

AUGMENTED BETAMETHASONE DIPROPIONATE

AVALIDE

AVAPRO

AZOR

BENICAR

BENICAR HCT

BEPREVE

BETAMETHASONE DIPROPIONATE

BIOSCANNER GLUCOSE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS PREMIUM

BYDUREON BCISE

BYDUREON PEN

BYETTA

CAMBIA

CAPEX

CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE

CARESENS N BLOOD GLUCOSE TEST STRIPS

CARETOUCH BLOOD GLUCOSE TEST STRIPS

CELEBREX

CLEVER CHEK AUTO-CODE TEST STRIPS

CLEVER CHEK AUTO-CODE VOICE TEST STRIPS

CLEVER CHEK TEST STRIPS

CLEVER CHOICE AUTO-CODE PRO TEST STRIPS

CLEVER CHOICE MICRO TEST STRIPS

CLEVER CHOICE NO CODING TEST STRIPS

CLEVER CHOICE TALK NO
CODING TEST STRIPS

CLOBEX

CLOCORTOLONE PIVALATE

CLODERM

CONTOUR BLOOD GLUCOSE TEST STRIPS

CONTOUR NEXT BLOOD
GLUCOSE TEST

COOL BLOOD GLUCOSE TEST STRIPS

CORDRAN

COZAAR

CRESTOR

CUTIVATE

CVS ADVANCED GLUCOSE METER TEST STRIPS

DAYPRO

DERMA-SMOOTHE/FS BODY

DERMA-SMOOTHE/FS SCALP

DESONATE

DESOWEN

DETROL

DETROL LA

DEXCOM G5 MOBILE
RECEIVERKIT

DEXCOM G5 MOBILE
TRANSMITTER KIT

DEXCOM G5 MOBILE/G4
PLATINUM SENSOR KIT

DEXCOM G5 RECEIVER KIT

DEXCOM G6 RECEIVER

DEXCOM G6 SENSOR

DEXCOM G6 TRANSMITTER

DIATHRIVE BLOOD GLUCOSE TEST STRIPS

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS

DICLOFENAC EPOLAMINE

DIFLORASONE DIACETATE

DIOVAN

DIOVAN HCT

DIPROLENE

DIPROLENE AF

DITROPAN XL

DUO-CARE TEST STRIPS

EASY PLUS II BLOOD GLUCOSE TEST

EASY STEP TEST STRIPS

EASY TALK BLOOD GLUCOSE TEST STRIPS

EASY TOUCH GLUCOSE TEST STRIPS

EASY TRAK BLOOD GLUCOSE TEST STRIPS

EASYGLUCO

EASYGLUCO PLUS

EASYMAX 15 TEST STRIPS

EASYMAX TEST STRIPS

EASYPRO BLOOD GLUCOSE TEST STRIPS

EASYPRO PLUS

EC-NAPROSYN

EDARBI

EDARBYCLOR

ELEMENT COMPACT TEST STRIPS

ELEMENT TEST STRIPS

ELIDEL

ELOCON

EMBRACE BLOOD GLUCOSE TEST STRIPS

EMBRACE EVO BLOOD GLUCOSETEST STRIPS

EMBRACE PRO BLOOD GLUCOSETEST STRIPS

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

EMGALITY 1

ENABLEX

EPROSARTAN MESYLATE

EQ BLOOD GLUCOSE TEST STRIPS

EUCRISA

EVENCARE + BLOOD GLUCOSE TEST STRIP

EVENCARE BLOOD GLUCOSE TEST STRIP

EVENCARE G2 TEST STRIPS

EVENCARE G3 TEST STRIPS

EVENCARE MINI BLOOD GLUCOSE TEST STRIPS

EVOLUTION AUTOCODE

EXACTECH R-S-G TEST STRIPS

EXACTECH TEST STRIPS

EXFORGE

EXFORGE HCT

EZETIMIBE/ROSUVASTATIN

FARXIGA

FELDENE

FENOPROFEN CALCIUM

FENORTHO

FIFTY50 GLUCOSE TEST STRIP 2.0

FLECTOR

FLOLIPID

FLURBIPROFEN

FORA BLOOD GLUCOSE TEST STRIPS

FORA D15G BLOOD GLUCOSE TEST STRIPS

FORA D20 BLOOD GLUCOSE TEST STRIPS

FORA D40/G31 BLOOD GLUCOSE TEST STRIPS

FORA G20 BLOOD GLUCOSE TEST STRIPS

FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS

FORA GD20 TEST STRIPS

FORA GD50 BLOOD GLUCOSE TEST STRIPS

FORA GTEL BLOOD GLUCOSE TEST STRIPS

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

FORA V10 BLOOD GLUCOSE TEST STRIPS

FORA V12 BLOOD GLUCOSE TEST STRIPS

FORA V20 BLOOD GLUCOSE TEST STRIPS

FORA V30A BLOOD GLUCOSE TEST STRIPS

FORACARE GD40

FORACARE PREMIUM V10 TESTSTRIPS

FORACARE TEST N GO TEST STRIPS

FORTAMET

FORTISCARE BLOOD GLUCOSE TEST STRIP

FOSRENOL

FREESTYLE INSULINX BLOOD GLUCOSE TEST

FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS

FREESTYLE LIBRE 14

DAY/READER/FLASH MONITORING SYSTEM

FREESTYLE LIBRE 14

DAY/SENSOR/FLASH MONITORING SYSTEM

FREESTYLE LIBRE

2/READER/FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE

2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE

LIBRE/READER/FLASH
MONITORING SYSTEM

FREESTYLE

LIBRE/SENSOR/FLASH
MONITORING SYSTEM

FREESTYLE LITE TEST STRIPS

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS

FREESTYLE TEST STRIPS

FROVA

GE100 BLOOD GLUCOSE TEST STRIPS

GELNIQUE

GEMTESA

GENULTIMATE TEST STRIPS

GHT TEST STRIPS

GLUCO PERFECT 3 TEST STRIPS

GLUCOCARD 01 SENSOR PLUS

GLUCOCARD 01 SENSOR PLUS TEST STRIPS

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS

GLUCOCARD SHINE TEST STRIPS

GLUCOCARD VITAL TEST STRIPS

GLUCOCARD X-SENSOR

GLUCOCOM TEST STRIPS

GLUCONAVII BLOOD GLUCOSE TEST STRIPS

GLUCOSE METER TEST STRIPS ADVANCED

GLUMETZA

GLYXAMBI

GNP EASY TOUCH GLUCOSE TEST STRIPS

GOJJI BLOOD GLUCOSE TEST STRIPS

GOJJI BLOOD GLUCOSE TEST STRIPS/GOJJI STERILE LANCETS 30G

GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS

HALOG

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

HYDROCORTISONE BUTYRATE

HYZAAR

IGLUCOSE BLOOD GLUCOSE TEST STRIPS

IMITREX

IMITREX STATDOSE REFILL

IMITREX STATDOSE SYSTEM

IMPOYZ

IN TOUCH BLOOD GLUCOSE TEST STRIPS

INDOCIN

INDOMETHACIN

INFINITY BLOOD GLUCOSE TEST STRIPS

INFINITY VOICE

INVOKAMET

INVOKAMET XR

INVOKANA

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

JENTADUETO

JENTADUETO XR

KAZANO

KENALOG

KETOPROFEN

KETOPROFEN ER

KOMBIGLYZE XR

KROGER BLOOD GLUCOSE TESTSTRIPS

KROGER HEALTHPRO GLUCOSE TEST STRIPS

KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS

KROGER TEST STRIPS

lanthanum carbonate

LASTACAFT

LESCOL XL

LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS

LIBERTY TEST STRIPS

LICART

LIPITOR

LIVALO

LOCOID

LOCOID LIPOCREAM

LODINE

LUMIGAN

LUXIQ

LYRICA

MAXALT

MAXALT-MLT

MECLOFENAMATE SODIUM

MEIJER BLOOD GLUCOSE TESTSTRIPS

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS

MEIJER PREMIUM BLOOD
GLUCOSE TEST STRIPS

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS

metformin hcl er

MICARDIS

MICARDIS HCT

MICRODOT TEST STRIPS

MM EASY TOUCH GLUCOSE TEST STRIPS

MYGLUCOHEALTH BLOOD GLUCOSE TEST

MYRBETRIQ

NALFON

NAPRELAN

NAPROSYN

NAPROXEN SODIUM

NESINA

NEUTEK 2TEK TEST STRIPS

NOVA MAX GLUCOSE TEST STRIPS

NURTEC

OLUX

OLUX-E

ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS

ON CALL PLUS BLOOD GLUCOSE TEST

ON CALL VIVID BLOOD GLUCOSE TEST

ON CALL VIVID BLOOD GLUCOSE TEST STRIPS

ONE DROP BLOOD GLUCOSE TEST STRIPS

ONGLYZA

ONZETRA XSAIL

OPTIUM TEST STRIPS

OPTIUMEZ TEST STRIPS

OPTUMRX BLOOD GLUCOSE TEST

OSENI

OTREXUP 1

OZEMPIC

PANDEL

PAZEO

PENNSAID

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS

pimecrolimus

POCKETCHEM EZ BLOOD
GLUCOSE TEST STRIPS

PRAVACHOL

PRECISION PCX

PRECISION PCX PLUS TEST STRIPS

PRECISION POINT OF CARE TEST STRIPS

PRECISION QID TEST STRIPS

PRECISION SOF-TACT TEST STRIPS

PRECISION XTRA BLOOD
GLUCOSE TEST STRIPS

PREDNICARBATE

PREMIUM BLOOD GLUCOSE TEST STRIPS

PRESTIGE TEST STRIPS

PRO VOICE V8/V9 BLOOD
GLUCOSE TEST STRIPS

PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS

PROTOPIC

PSORCON

PTS PANELS GLUCOSE TEST

QTERN

QUICKTEK TEST STRIPS

QUINTET AC BLOOD GLUCOSE TEST STRIPS

QUINTET BLOOD GLUCOSE TEST STRIPS

RASUVO 1

REDITREX

REFUAH PLUS BLOOD GLUCOSETEST STRIPS

RELION ALL-IN-ONE

COMPACTBLOOD GLUCOSE TESTING SYSTEM

RELION BLOOD GLUCOSE TESTSTRIPS

RELION CONFIRM/MICRO TEST STRIPS

RELION PREMIER BLOOD
GLUCOSE TEST STRIPS

RELION PRIME BLOOD GLUCOSE TEST STRIPS

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS

RELPAX

RENAGEL

RENVELA

REVEAL BLOOD GLUCOSE TEST

REXALL BLOOD GLUCOSE TEST STRIPS

RHOPRESSA

RIGHTEST GS100 BLOOD
GLUCOSE TEST STRIPS

RIGHTEST GS300 BLOOD
GLUCOSE TEST STRIPS

RIGHTEST GS550 BLOOD
GLUCOSE TEST STRIPS

RIOMET ER

ROCKLATAN

ROSZET

RYBELSUS

SAVELLA

SAVELLA TITRATION PACK

SEGLUROMET

SERNIVO

sevelamer    tab 800mg

SEVELAMER TAB 400MG

SIMVASTATIN

SMART SENSE PREMIUM BLOODGLUCOSE STRIPS

SMART SENSE VALUE BLOOD GLUCOSE STRIPS

SMARTEST BLOOD GLUCOSE TEST STRIPS

SOLIQUA 100/33

SOLUS V2 AUDIBLE TEST

STEGLATRO

STEGLUJAN

SUMATRIPTAN SUCCINATE

SUPREME TEST STRIPS

SURE EDGE BLOOD GLUCOSE TEST STRIPS

SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS

SURECHEK BLOOD GLUCOSE TEST STRIPS

SYNALAR

SYNJARDY

SYNJARDY XR

tacrolimus

TELCARE BLOOD GLUCOSE TEST STRIPS

TEMOVATE

TEXACORT

TGT BLOOD GLUCOSE TEST STRIPS

TGT BLOOD GLUCOSE TEST STRIPS PREMIUM

TIVORBEX

TOLMETIN SODIUM

TOPICORT

TOVIAZ

TRADJENTA

TRAVATAN Z

travoprost

TREXIMET

TRIBENZOR

TRIDESILON

TRIJARDY XR

TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS

TRUE METRIX BLOOD GLUCOSETEST STRIPS

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS

TRUETEST STRIPS

TRUETRACK BLOOD GLUCOSE TEST

TRUETRACK TEST

TRULICITY

TWYNSTA

UBRELVY

ULORIC

ULTRATRAK PRO TEST STRIPS

ULTRATRAK ULTIMATE TEST STRIPS

ULTRAVATE

UNISTRIP1 GENERIC

VANOS

VELPHORO

VELTIN

VERASENS BLOOD GLUCOSE TEST STRIPS

VERDESO

VESICARE

VESICARE LS

VICTOZA

VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS

VIVLODEX

VOCAL POINT BLOOD GLUCOSE TEST STRIPS

VYTORIN

VYZULTA

WAVESENSE PRESTO TEST STRIPS

WINLEVI

XALATAN

XIGDUO XR

XULTOPHY 100/3.6

ZEMBRACE SYMTOUCH

ZERVIATE

ZIANA

ZIOPTAN

ZIPSOR

ZOCOR

ZOLMITRIPTAN

ZOMIG

ZOMIG ZMT

 

 

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADIPEX-P CAP 37.5mg

30 caps / 30 days

ADIPEX-P CAP 37.5MG

30 caps / 30 days

ADIPEX-P tab 37.5MG

30 tabs / 30 days

benzphetamine tab 50mg

90 tabs / 30 days

BENZPHETMINE tab 25MG

90 tabs / 30 days

CONTRAVE tab 8-90MG

120 tabs / 30 days

diethylprop tab 25mg

90 tabs / 30 days

DIETHYLPROP tab 75MG ER

30 tabs / 30 days

IMCIVREE INJ 10MG/ML 2

10 vials / 30 days

LOMAIRA  tab 8MG

90 tabs / 30 days

PHENDIMETRAZ CAP 105MG ER

30 caps / 30 days

phendimetrazine tab 35mg

180 tabs / 30 days

phentermine cap 15mg

30 caps / 30 days

phentermine cap 30mg

30 caps / 30 days

phentermine cap 37.5mg

30 caps / 30 days

phentermine tab 37.5mg

30 tabs / 30 days

QSYMIA   CAP 3.75-23

30 caps / 30 days

QSYMIA   CAP 7.5-46MG

30 caps / 30 days

QSYMIA   CAP 11.25-69

30 caps / 30 days

QSYMIA   CAP 15-92MG

30 caps / 30 days

SAXENDA   INJ 18MG/3ML

15 MLS / 30 days

SUNOSI  tab 75MG

30 tabs / 30 days

SUNOSI  tab 150MG

30 tabs / 30 days

WAKIX    tab 4.45MG

60 tabs / 30 days

WAKIX    tab 17.8MG

60 tabs / 30 days

WEGOVY    INJ 0.25MG

4 pens / 180 days

WEGOVY    INJ 0.5MG

4 pens / 180 days

WEGOVY    INJ 1.7MG

8 pens / 180 days

WEGOVY    INJ 1MG

4 pens / 180 days

WEGOVY    INJ 2.4MG

4 pens / 28 days

XENICAL  CAP 120MG

90 caps / 30 days

Aminoglycosides

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ARIKAYCE SUS 2

28 vials / 28 days

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTEMRA INJ 162/0.9 1

4 syringes / 28 days

ACTEMRA INJ ACTpen 1

4 injections / 28 days

ARCALYST INJ 220MG 2

8 vials / 28 days

DUEXIS  tab 800-26.6

90 tabs / 30 days

ENBREL  INJ 25MG 1

8 vials / 28 days

ENBREL  INJ 25/0.5ML 1

8 syringes / 28 days

ENBREL  INJ 50MG/ML 1

4 syringes / 28 days

ENBREL MINI INJ 50MG/ML 1

4 cartS / 28 days

ENBREL SRCLK INJ 50MG/ML 1

4 syringes / 28 days

HUMIRA  INJ 10/0.1ML 1

2 syringes / 28 days

HUMIRA  INJ 10MG/0.2 1

2 syringes / 28 days

HUMIRA  INJ 20/0.2ML 1

2 syringes / 28 days

HUMIRA  INJ 40/0.4ML 1

2 syringes / 28 days

HUMIRA  KIT 20MG/0.4 1

2 syringes / 28 days

HUMIRA  KIT 40MG/0.8 1

2 syringes / 28 days

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

1 KIT / 180 days

HUMIRA pen   INJ 40/0.4ML 1

2 pens / 28 days

HUMIRA pen   INJ 40MG/0.8 1

2 pens / 28 days

HUMIRA pen   INJ 80/0.8ML 1

2 pens / 28 days

HUMIRA pen INJ CD/UC/HS 1

1 kit / 180 days

HUMIRA pen INJ PS/UV 1

1 kit / 180 days

HUMIRA pen KIT CD/UC/HS 1

1 kit / 180 days

HUMIRA pen KIT PED UC 1

4 pens / 180 days

HUMIRA pen KIT PS/UV 1

1 kit / 180 days

KEVZARA- SARILUMAB 200 mg/1.14 mL syringe SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML 1

2 syringes / 28 days

KEVZARA- SARILUMAB

SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML 1

2 syringes / 28 days

KEVZARA- SARILUMAB

SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML 1

2 pens / 28 days

KEVZARA- SARILUMAB

SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML 1

2 pens / 28 days

KINERET INJ 2

30 syringes / 30 days

naproxen-esomeprazole tab 375-20mg

60 tabs / 30 days

naproxen-esomeprazole tab 500-20mg

60 tabs / 30 days

OLUMIANT tab 1MG 1

30 tabs / 30 days

OLUMIANT tab 2MG 1

30 tabs / 30 days

ORENCIA INJ 50/0.4ML 1

4 syringes / 28 days

ORENCIA INJ 87.5/0.7 1

4 syringes / 28 days

ORENCIA INJ 125MG/ML 1

4 syringes / 28 days

ORENCIA CLCK INJ 125MG/ML 1

4 syringes / 28 days

OTEZLA   tab 10/20/30 1

1 kit / 180 days

OTEZLA   tab 30MG 1

60 tabs / 30 days

RINVOQ  tab 15MG ER 1

30 tabs / 30 days

SIMPONI INJ 50/0.5ML 1

1 syringe / 28 days

SIMPONI INJ 100MG/ML 1

1 syringe / 28 days

VIMOVO  tab 375-20MG

60 tabs / 30 days

VIMOVO  tab 500-20MG

60 tabs / 30 days

XELJANZ SOL 1MG/ML 1

240 MLS / 30 days

XELJANZ tab 5MG 1

60 tabs / 30 days

XELJANZ tab 10MG 1

240 tabs / 365 days

XELJANZ XR tab 11MG 1

30 tabs / 30 days

XELJANZ XR tab 22MG 1

120 tabs / 365 days

Analgesics - opioid

Drug name(s)

Adult quantity limits - 5 days

Child quantity limits - 3 days

ABSTRAL SUB 400MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 600MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 800MCG

120 tabs / 30 days

N/A

ACTIQ   LOZ 200MCG

120 LOZNGS / 30 days

N/A

ACTIQ   LOZ 400MCG

120 lozenges / 30 days

N/A

ACTIQ   LOZ 600MCG

120 lozenges / 30 days

N/A

ACTIQ   LOZ 800MCG

120 lozenges / 30 days

N/A

ACTIQ   LOZ 1200MCG

120 lozenges / 30 days

N/A

ACTIQ   LOZ 1600MCG

120 lozenges / 30 days

N/A

APAP/CAFFEIN tab DIHYDROCODEINE

50 tablets/30 days

30 tablets/30 days

apap/codeine sol 120-12/5

450 ML/30 days

270 ML/30 days

apap/codeine tab 300-15mg

30 tablets/30 days

18 tablets/30 days

apap/codeine tab 300-30mg

30 tablets/30 days

18 tablets/30 days

apap/codeine tab 300-60mg

25 tablets/30 days

15 tablets/30 days

APAP-CAFFEIN CAP DIHYDROCODEINE

50 capsules/30 days

30 capsules/30 days

ARYMO ER    tab 15MG

60 tablets/month

N/A

ARYMO ER    tab 30MG

30 tablets/month

N/A

ARYMO ER    tab 60MG

0 tablets/month

N/A

BELBUCA MIS 75MCG

60 films/month

N/A

BELBUCA MIS 150MCG

60 films/month

N/A

BELBUCA MIS 300MCG

60 films/month

N/A

BELBUCA MIS 450MCG

60 films/month

N/A

BELBUCA MIS 600MCG

60 films/month

N/A

BELBUCA MIS 750MCG

60 films/month

N/A

BELBUCA MIS 900MCG

30 films/month

N/A

buprenorphine dis 5mcg/hr

4 systems/month

N/A

buprenorphine dis 7.5/hr

4 systems/month

N/A

buprenorphine dis 10mcg/hr

4 systems/month

N/A

buprenorphine dis 15mcg/hr

4 systems/month

N/A

buprenorphine dis 20mcg/hr

4 systems/month

N/A

butorphanol sol 10mg/ml

2.5 ML (1 bottleLE)/30 days

0 ML/30 days

BUTRANS  DIS 5MCG/HR

4 systems/month

N/A

BUTRANS  DIS 7.5/HR

4 systems/month

N/A

BUTRANS  DIS 10MCG/HR

4 systems/month

N/A

BUTRANS  DIS 15MCG/HR

4 systems/month

N/A

BUTRANS  DIS 20MCG/HR

4 systems/month

N/A

CODEINE SULF tab 15MG

30 tablets/30 days

18 tablets/30 days

CODEINE SULF tab 30MG

30 tablets/30 days

18 tablets/30 days

codeine sulf tab 30mg

30 tablets/30 days

18 tablets/30 days

CODEINE SULF tab 60MG

25 tablets/30 days

15 tablets/30 days

codeine/apap tab 30-300mg

30 tablets/30 days

18 tablets/30 days

codeine/apap tab 60-300mg

25 tablets/30 days

15 tablets/30 days

CONZIP CAP 100MG

30 capsules/30 days

N/A

CONZIP CAP 200MG

30 capsules/30 days

N/A

CONZIP CAP 300MG

30 capsules/30 days

N/A

DILAUDID LIQ 1MG/ML

60 ML/30 days

36 ML/30 days

DILAUDID tab 2MG

30 tablets/30 days

18 tablets/30 days

DILAUDID tab 4MG

15 tablets/30 days

9 tablets/30 days

DILAUDID tab 8MG

5 tablets/30 days

3 tablets/30 days

DURAGESIC DIS 12MCG/HR

10 patches/month

N/A

DURAGESIC DIS 25MCG/HR

0 patches/month

N/A

DURAGESIC DIS 50MCG/HR

0 patches/month

N/A

DURAGESIC DIS 75MCG/HR

0 patches/month

N/A

DURAGESIC DIS 100MCG/HR

0 patches/month

N/A

dvorah tab 325mg/30mg/16mg

50 tablets/30 days

30 tablets/30 days

endocet tab 2.5-325

60 tablets/30 days

36 tablets/30 days

endocet tab 5-325mg

30 tablets/30 days

18 tablets/30 days

endocet tab 7.5-325

20 tablets/30 days

12 tablets/30 days

endocet tab 10-325mg

15 tablets/30 days

9 tablets/30 days

fentanyl dis 12mcg/hr

10 patches/month

N/A

fentanyl dis 25mcg/hr

0 patches/month

N/A

fentanyl dis 37.5mcg

0 patches/month

N/A

fentanyl dis 50mcg/hr

0 patches/month

N/A

fentanyl dis 62.5mcg

0 patches/month

N/A

fentanyl dis 75mcg/hr

0 patches/month

N/A

fentanyl dis 87.5mcg

0 patches/month

N/A

fentanyl dis 100mcg/hr

0 patches/month

N/A

FENTANYL CIT tab 100MCG

120 tabs / 30 days

N/A

FENTANYL CIT tab 200MCG

120 tabs / 30 days

N/A

FENTANYL CIT tab 400MCG

120 tabs / 30 days

N/A

FENTANYL CIT tab 600MCG

120 tabs / 30 days

N/A

FENTANYL CIT tab 800MCG

120 tabs / 30 days

N/A

fentanyl ot loz 200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 400mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 600mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 800mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1600mcg

120 lozenges / 30 days

N/A

FENTORA tab 100MCG

120 tabs / 30 days

N/A

FENTORA tab 200MCG

120 tabs / 30 days

N/A

FENTORA tab 400MCG

120 tabs / 30 days

N/A

FENTORA tab 600MCG

120 tabs / 30 days

N/A

FENTORA tab 800MCG

120 tabs / 30 days

N/A

HYDRO/ACETA SOL 10-325MG

375 ML/30 days

225 ML/30 days

hydrocodone/acetaminophen sol 10-325mg

375 ML/30 days

225 ML/30 days

hydrocodone/acetaminophen sol 7.5-325

450 ML/30 days

270 ML/30 days

hydrocodone/acetaminophen tab 5-300mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tab 7.5-300

30 tablets/30 days

18 tablets/30 days

hydrocodone/acetaminophen tab 7.5-325

30 tablets/30 days

18 tablets/30 days

hydrocodone/acetaminophen tab 10-300mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/acetaminophen tab 10-325mg

25 tablets/30 days

15 tablets/30 days

HYDROCODONE/IBUPROFEN tab 5-200MG

25 tablets/30 days

15 tablets/30 days

hydrocodone /ibuprofen tab 5-200mg

25 tablets/30 days

15 tablets/30 days

hydrocodone /ibuprofen tab 7.5-200

25 tablets/30 days

15 tablets/30 days

hydrocodone /ibuprofen tab 10-200mg

25 tablets/30 days

15 tablets/30 days

HYDROCODONE CAP 10MG ER

60 capsules/30 days

N/A

HYDROCODONE CAP 15MG ER

60 capsules/30 days

N/A

HYDROCODONE CAP 20MG ER

60 capsules/30 days

N/A

HYDROCODONE CAP 30MG ER

30 capsules/30 days

N/A

HYDROCODONE CAP 40MG ER

30 capsules/30 days

N/A

HYDROCODONE CAP 50MG ER

30 capsules/30 days

N/A

hydrocodone cap 10mg er

60 capsules/30 days

N/A

hydrocodone cap 15mg er

60 capsules/30 days

N/A

hydrocodone cap 30mg er

30 capsules/30 days

N/A

hydrocodone cap 40mg er

30 capsules/30 days

N/A

hydrocodone cap 50mg er

30 capsules/30 days

N/A

hydrocodone tab 20mg er

30 tablets/30 days

N/A

hydrocodone tab 30mg er

30 tablets/30 days

N/A

hydrocodone tab 40mg er

30 tablets/30 days

N/A

hydrocodone tab 60mg er

0 tablets/30 days

N/A

hydrocodone tab 80mg er

0 tablets/30 days

N/A

hydrocodone tab 100mg er

0 tablets/30 days

N/A

hydrocodone tab 120mg er

0 tablets/30 days

N/A

hydromorphone liq 1mg/ml

60 ML/30 days

36 ML/30 days

hydromorphone tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphone tab 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphone tab 8mg

5 tablets/30 days

3 tablets/30 days

hydromorphone tab 8mg er

30 tablets/month

N/A

hydromorphone tab 12mg er

30 tablets/month

N/A

hydromorphone tab 16mg er

0 tabLETS

N/A

hydromorphone tab 32mg er

0 tabLETS

N/A

HYSINGLA ER tab 20 MG

30 tablets/30 days

N/A

HYSINGLA ER tab 30 MG

30 tablets/30 days

N/A

HYSINGLA ER tab 40 MG

30 tablets/30 days

N/A

HYSINGLA ER tab 60 MG

0 tablets/30 days

N/A

HYSINGLA ER tab 80 MG

0 tablets/30 days

N/A

HYSINGLA ER tab 100 MG

0 tablets/30 days

N/A

HYSINGLA ER tab 120 MG

0 tablets/30 days

N/A

KADIAN CAP 10MG ER

30 capsules/30 days

N/A

KADIAN CAP 20MG ER

30 capsules/30 days

N/A

KADIAN CAP 30MG ER

30 capsules/30 days

N/A

KADIAN CAP 40MG ER

30 capsules/30 days

N/A

KADIAN CAP 50MG ER

30 capsules/30 days

N/A

KADIAN CAP 60MG ER

0 capsules/30 days

N/A

KADIAN CAP 80MG ER

0 capsules/30 days

N/A

KADIAN CAP 100MG ER

0 capsules/30 days

N/A

KADIAN CAP 200MG ER

0 capsules/30 days

N/A

LAZANDA SPR 100MCG

30 bottleles / 30 days

N/A

LAZANDA SPR 300MCG

30 bottleles / 30 days

N/A

LAZANDA SPR 400MCG

30 bottleles / 30 days

N/A

levorphanol tab 2mg

10 tablets/30 days

6 tablets/30 days

lorcet tab 5-325mg

40 tablets/30 days

24 tablets/30 days

lorcet hd tab 10-325mg

25 tablets/30 days

15 tablets/30 days

lorcet plus tab 7.5-325

30 tablets/30 days

18 tablets/30 days

LORtab ELX 10-300MG

338 ML/30 days

203 ML/30 days

MEPERIDINE SOL 50MG/5ML

150 ML/30 days

150 ML/30 days

MEPERIDINE tab 50MG

30 tablets/30 days

30 tablets/30 days

METHADONE SOL 5MG/5ML

300 ML/30 days

N/A

METHADONE SOL 10MG/5ML

150 ML/30 days

N/A

methadone sol 5mg/5ml

300 ML/30 days

N/A

methadone sol 10mg/5ml

150 ML/30 days

N/A

methadone tab 5mg

60 tablets/30 days

N/A

methadone tab 10mg

30 tablets/30 days

N/A

MORPHABOND tab 15MG ER

60 tablets/30 days

N/A

MORPHABOND tab 30MG ER

30 tablets/30 days

N/A

MORPHABOND tab 60MG ER

0 tablets/30 days

N/A

MORPHABOND tab 100MG ER

0 tablets/30 days

N/A

morphine sul cap 10mg er

30 capsules/30 days

N/A

morphine sul cap 20mg er

30 capsules/30 days

N/A

morphine sul cap 30mg er

30 capsules/30 days

N/A

morphine sul cap 50mg er

30 capsules/30 days

N/A

morphine sul cap 60mg er

0 capsules/30 days

N/A

morphine sul cap 80mg er

0 capsules/30 days

N/A

morphine sul cap 100mg er

0 capsules/30 days

N/A

MORPHINE SUL CAP 30MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 40MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 45MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 60MG ER

0 capsules/30 days

N/A

MORPHINE SUL CAP 75MG ER

0 capsules/30 days

N/A

MORPHINE SUL CAP 90MG ER

0 capsules/30 days

N/A

MORPHINE SUL CAP 120MG ER

0 capsules/30 days

N/A

morphine sul sol 10/0.5ml

15 ML/30 days

15 ML/30 days

morphine sul sol 10mg/5ml

125 ML/30 days

75 ML/30 days

morphine sul sol 20mg/5ml

60 ML/30 days

36 ML/30 days

morphine sul sol 20mg/ml

15 ML/30 days

15 ML/30 days

morphine sul sol 100/5ml

15 ML/30 days

15 ML/30 days

morphine sul tab 15mg

15 tablets/30 days

9 tablets/30 days

morphine sul tab 30mg

5 tablets/30 days

3 tablets/30 days

MORPHINE SUL tab 15MG

15 tablets/30 days

9 tablets/30 days

MORPHINE SUL tab 30MG

5 tablets/30 days

3 tablets/30 days

morphine sul tab 100mg cr

0 tablets/30 days

N/A

morphine sul tab 15mg er

60 tablets/30 days

N/A

morphine sul tab 30mg er

30 tablets/30 days

N/A

morphine sul tab 60mg er

0 tablets/30 days

N/A

morphine sul tab 100mg er

0 tablets/30 days

N/A

morphine sul tab 200mg er

0 tablets/30 days

N/A

MS CONTIN tab 15MG ER

60 tablets/30 days

N/A

MS CONTIN tab 30MG ER

30 tablets/30 days

N/A

MS CONTIN tab 60MG ER

0 tablets/30 days

N/A

MS CONTIN tab 100MG ER

0 tablets/30 days

N/A

MS CONTIN tab 200MG ER

0 tablets/30 days

N/A

NORCO tab 5-325MG

40 tablets/30 days

24 tablets/30 days

NORCO tab 7.5-325

30 tablets/30 days

18 tablets/30 days

NORCO tab 10-325MG

25 tablets/30 days

15 tablets/30 days

NUCYNTA tab 50MG

10 tablets/30 days

6 tablets/30 days

NUCYNTA tab 75MG

5 tablets/30 days

3 tablets/30 days

NUCYNTA tab 100MG

5 tablets/30 days

3 tablets/30 days

NUCYNTA ER tab 50MG

60 tablets/30 days

N/A

NUCYNTA ER tab 100MG

30 tablets/30 days

N/A

NUCYNTA ER tab 150MG

0 tablets/30 days

N/A

NUCYNTA ER tab 200MG

0 tablets/30 days

N/A

NUCYNTA ER tab 250MG

0 tablets/30 days

N/A

OPANA tab 5MG

15 tablets/30 days

9 tablets/30 days

OPANA tab 10MG

5 tablets/30 days 3 tablets/30 days

OXAYDO tab 5MG

30 tablets/30 days

18 tablets/30 days

OXAYDO tab 7.5MG

20 tablets/30 days

12 tablets/30 days

OXYCODONE/ACETAMINOPHEN SOL 10/300MG

75 ML/30 days

45 ML/30 days

OXYCODONE/ASPIRIN tab

30 tablets/30 days

18 tablets/30 days

oxycodone cap 5mg

30 capsules/30 days

18 capsules/30 days

oxycodone cap hcl 5mg

30 capsules/30 days

18 capsules/30 days

oxycodone con 10/0.5ml

5 ML/30 days 3 ML/30 days

oxycodone con 100/5ml

5 ML/30 days

3 ML/30 days

oxycodone sol 5mg/5ml

165 ML/30 days

99 ML/30 days

oxycodone tab 5mg

30 tablets/30 days

18 tablets/30 days

oxycodone tab 10mg

15 tablets/30 days

9 tablets/30 days

oxycodone tab 15mg

10 tablets/30 days

6 tablets/30 days

oxycodone tab 20mg

5 tablets/30 days

3 tablets/30 days

oxycodone tab 30mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE tab 10MG ER

60 tablets/30 days

N/A

OXYCODONE tab 15MG ER

60 tablets/30 days

N/A

OXYCODONE tab 20MG ER

30 tablets/30 days

N/A

OXYCODONE tab 40MG ER

0 tablets/30 days

N/A

OXYCODONE tab 60MG ER

0 tablets/30 days

N/A

OXYCODONE tab 80MG ER

0 tablets/30 days

N/A

oxycodone/ acetaminophen tab 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/ acetaminophen tab 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/ acetaminophen tab 7.5-325

20 tablets/30 days

12 tablets/30 days

oxycodone/ acetaminophen tab 10-325mg

15 tablets/30 days

9 tablets/30 days

OXYCODONE/ ACETAMINOPHEN tab 5-300MG

30 tablets/30 days

18 tablets/30 days

OXYCODONE/ ACETAMINOPHEN tab 10-300MG

15 tablets/30 days

9 tablets/30 days

OXYCODONE/IBUPROFEN tab 5-400MG

20 tablets/30 days

12 tablets/30 days

OXYCODONE tab 30MG ER

30 tablets/30 days

N/A

OXYCONTIN tab 10MG CR

60 tablets/30 days

N/A

OXYCONTIN tab 15MG CR

60 tablets/30 days

N/A

OXYCONTIN tab 20MG CR

30 tablets/30 days

N/A

OXYCONTIN tab 30MG CR

30 tablets/30 days

N/A

OXYCONTIN tab 40MG CR

0 tablets/30 days

N/A

OXYCONTIN tab 60MG CR

0 tablets/30 days

N/A

OXYCONTIN tab 80MG CR

0 tablets/30 days

N/A

OXYMORPHONE tab 5MG ER

60 tablets/30 days

N/A

OXYMORPHONE tab 7.5MG ER

60 tablets/30 days

N/A

OXYMORPHONE tab 10MG ER

30 tablets/30 days

N/A

OXYMORPHONE tab 15MG ER

30 tablets/30 days

N/A

OXYMORPHONE tab 20MG ER

0 tablets/30 days

N/A

OXYMORPHONE tab 30MG ER

0 tablets/30 days

N/A

OXYMORPHONE tab 40MG ER

0 tablets/30 days

N/A

oxymorphone tab hcl 5mg

15 tablets/30 days

9 tablets/30 days

oxymorphone tab hcl 10mg

5 tablets/30 days

3 tablets/30 days

pentazocine/naloxone tab 50-0.5mg

10 tablets/30 days

6 tablets/30 days

PERCOCET tab 2.5-325

60 tablets/30 days

36 tablets/30 days

PERCOCET tab 5-325MG

30 tablets/30 days

18 tablets/30 days

PERCOCET tab 7.5-325

20 tablets/30 days

12 tablets/30 days

PERCOCET tab 10-325MG

15 tablets/30 days

9 tablets/30 days

PRIMLEV tab 5-300MG

30 tablets/30 days

18 tablets/30 days

PRIMLEV tab 7.5-300

20 tablets/30 days

12 tablets/30 days

PRIMLEV tab 10-300MG

15 tablets/30 days

9 tablets/30 days

PROLATE SOL 10/300MG

75 ML/30 days

45 ML/30 days

QDOLO SOL 5MG/ML

400 ML/30 days

240 ML/30 days

ROXICODONE tab 5MG

30 tablets/30 days

18 tablets/30 days

ROXICODONE tab 15MG

10 tablets/30 days

6 tablets/30 days

ROXICODONE tab 30MG

5 tablets/30 days

3 tablets/30 days

SUBSYS SPR 100MCG

120 sprays / 30 days

N/A

SUBSYS SPR 200MCG

120 sprays / 30 days

N/A

SUBSYS SPR 400MCG

120 sprays / 30 days

N/A

SUBSYS SPR 600MCG

120 sprays / 30 days

N/A

SUBSYS SPR 800MCG

120 sprays / 30 days

N/A

SUBSYS SPR 1200MCG

240 sprays / 30 days

N/A

SUBSYS SPR 1600MCG

240 sprays / 30 days

N/A

tramadol/apap tab 37.5-325

40 tablets/30 days

24 tablets/30 days

TRAMADOL HCL CAP ER 100MG

30 capsules/30 days

N/A

TRAMADOL HCL CAP 150MG ER

30 capsules/30 days

N/A

TRAMADOL HCL CAP ER 200MG

30 capsules/30 days

N/A

TRAMADOL HCL CAP ER 300MG

30 capsules/30 days

N/A

tramadol hcl tab 100mg er

30 tablets/30 days

N/A

tramadol hcl tab 200mg er

30 tablets/30 days

N/A

tramadol hcl tab 300mg er

30 tablets/30 days

N/A

tramadol hcl tab 50mg

50 tablets/30 days

30 tablets/30 days

TREZIX CAP 320.5-30-16mg

50 capsules/30 days

30 capsules/30 days

TYLENOL/COD tab #3

30 tablets/30 days

18 tablets/30 days

TYLENOL/COD tab #4

25 tablets/30 days

15 tablets/30 days

ULTRACET tab 37.5-325

40 tablets/30 days

24 tablets/30 days

ULTRAM tab 50MG

50 tablets/30 days

30 tablets/30 days

XTAMPZA ER CAP 9MG

60 capsules/30 days

N/A

XTAMPZA ER CAP 13.5MG

60 capsules/30 days

N/A

XTAMPZA ER CAP 18MG

30 capsules/30 days

N/A

XTAMPZA ER CAP 27MG

30 capsules/30 days

XTAMPZA ER CAP 36MG

0 capsules/30 days

N/A

ZOHYDRO ER CAP 10MG

60 capsules/30 days

N/A

ZOHYDRO ER CAP 15MG

60 capsules/30 days

N/A

ZOHYDRO ER CAP 20MG

60 capsules/30 days

N/A

ZOHYDRO ER CAP 30MG

30 capsules/30 days

N/A

ZOHYDRO ER CAP 40MG

30 capsules/30 days

N/A

ZOHYDRO ER CAP 50MG

30 capsules/30 days

N/A

Androgens - anabolic

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ANDRODERM DIS 2MG/24HR

30 patches / 30 days

ANDRODERM DIS 4MG/24HR

30 patches / 30 days

ANDROGEL GEL 1%(25MG)

60 packets / 30 days

ANDROGEL GEL 1%(50MG)

60 packets / 30 days

ANDROGEL PUMP- TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)

2 pumps / 30 days

ANDROGEL- TESTOSTERONE TD GEL 20.25 MG/1.25GM (1.62%)

30 packets / 30 days

ANDROGEL- TESTOSTERONE TD GEL 40.5 MG/2.5GM (1.62%)

60 packets / 30 days

DEPO-TESTOST INJ 100MG/ML

1 vial / 28 days

DEPO-TESTOST INJ 200MG/ML

10 MLS / 28 days

FORTESTA GEL 10MG/ACT

2 pumps / 30 days

METHITEST tab 10MG

600 tabs / 30 days

METHYLTESTOS CAP 10MG

600 tabs / 30 days

NATESTO GEL 5.5MG

3 pumps / 30 days

STRIANT MIS 30MG

60 systems / 30 days

TESTIM GEL 1%(50MG)

60 packets / 30 days

testosterone cypionate inj 100mg/ml

1 vial / 28 days

testosterone cypionate inj 200mg/ml

10 MLS / 28 days

TESTOST ENAN INJ 200MG/ML

1 vial / 28 days

TESTOSTERONE GEL 1%(25MG)

60 packets / 30 days

testosterone gel 1%(25mg)

60 packets / 30 days

TESTOSTERONE GEL 1%(50MG)

60 packets / 30 days

testosterone gel 1%(50mg)

60 packets / 30 days

testosterone gel 10mg/act

2 bottleles / 30 days

TESTOSTERONE GEL PUMP 1%

4 pumps / 30 days

testosterone gel pump 1%

300 grams / 30 days

testosterone sol 30mg/act

2 pumps / 30 days

testosterone td gel 20.25 mg/1.25gm

30 packets / 30 days

(1.62%)

testosterone td gel 20.25 mg/act (1.62%)

2 bottleles / 30 days

testosterone td gel 40.5 mg/2.5gm

60 packets / 30 days

(1 62%

VOGELXO GEL 1%(50MG)

60 packets / 30 days

VOGELXO GEL PUMP 1%

4 pumps / 30 days

XYOSTED INJ 50/0.5

4 pens / 28 days

XYOSTED INJ 75/0.5

2 pens / 28 days

XYOSTED INJ 100/0.5

2 pens / 28 days

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADVAIR DISKU AER 100/50

60 blisters / 30 days

ADVAIR DISKU AER 250/50

60 blisters / 30 days

ADVAIR DISKU AER 500/50

60 blisters / 30 days

ADVAIR HFA AER 45/21

1 can / 30 days

ADVAIR HFA AER 115/21

1 can / 30 days

ADVAIR HFA AER 230/21

1 can / 30 days

AIRDUO RESPI INH 55-14

1 inhaler / 30 days

AIRDUO RESPI INH 113-14

1 inhaler / 30 days

AIRDUO RESPI INH 232-14

1 inhaler / 30 days

ALBUTEROL AER HFA

2 cans / 30 days

albuterol aer hfa

2 cans / 30 days

ALVESCO AER 80MCG

2 cans / 30 days

ALVESCO AER 160MCG

2 cans / 30 days

ANORO ELLIPT AER 62.5-25

1 inhaler / 30 days

ARCAPTA CAP 75MCG

30 caps / 30 days

ARNUITY ELPT INH 50MCG

30 blisters / 30 days

ARNUITY ELPT INH 100MCG

30 blisters / 30 days

ARNUITY ELPT INH 200MCG

30 blisters / 30 days

ASMANEX 14 AER 220MCG

1 can / 30 days

ASMANEX 30 AER 110MCG

1 can / 30 days

ASMANEX 30 AER 220MCG

1 can / 30 days

ASMANEX 60 AER 220MCG

1 can / 30 days

ASMANEX 120 AER 220MCG

1 can / 30 days

ASMANEX HFA AER 50MCG

1 inhaler / 30 days

ASMANEX HFA AER 100 MCG

1 can / 30 days

ASMANEX HFA AER 200 MCG

1 can / 30 days

ATROVENT HFA AER 17MCG

2 cans / 30 days

BEVESPI AER 9-4.8MCG

1 can / 30 days

BREO ELLIPTA INH 100-25

60 blisters / 30 days

BREO ELLIPTA INH 200-25

60 blisters / 30 days

BREZTRI AERO AER SPHERE 160-9-4.8 mcg act

1 can / 30 days

COMBIVENT AER 20-100

2 cans / 30 days

DULERA AER 100-5MCG

1 can / 30 days

DULERA AER 200-5MCG

1 can / 30 days

DULERA AER 50-5MCG

1 inhaler / 30 days

FASENRA pen INJ 30MG/ML

1 pen / 56 days

FLOVENT DISK AER 100MCG

60 blisters / 30 days

FLOVENT DISK AER 250MCG

240 blisters / 30 days

FLOVENT DISK AER 50MCG

60 blisters / 30 days

FLOVENT HFA AER 44MCG

1 can / 30 days

FLOVENT HFA AER 110MCG

1 can / 30 days

FLOVENT HFA AER 220MCG

2 cans / 30 days

fluticasone/salmeterol aer 100/50

60 blisters / 30 days

fluticasone/salmeterol aer 250/50

60 blisters / 30 days

fluticasone/salmeterol aer 500/50

60 blisters / 30 days

FLUTICASONE/SALMETEROL INH 113/14

1 inhaler / 30 days

FLUTICASONE/SALMETEROL INH 232/14

1 inhaler / 30 days

FLUTICASONE/SALMETEROL INH 55/14

1 inhaler / 30 days

INCRUSE ELPT INH 62.5MCG

30 blisters / 30 days

LEVALBUTEROL AER 45/ACT

2 cans / 30 days

NUCALA INJ 100MG/ML

3 syringes / 28 days

PROAIR HFA AER

2 cans / 30 days

PROAIR RESPI AER

2 inhalerS / 30 days

PROVENTIL AER HFA

2 cans / 30 days

PULMICORT INH 180MCG

2 cans / 30 days

PULMICORT INH 90MCG

2 cans / 30 days

QVAR REDIHA AER 80MCG

2 cans / 30 days

QVAR REDIHAL AER 40MCG

1 can / 30 days

SEEBRI NEOHA CAP 15.6MCG

60 caps / 30 days

SEREVENT DIS AER 50MCG

60 blisters / 30 days

SPIRIVA AER 1.25MCG

1 cart / 30 days

SPIRIVA CAP HANDIHLR

30 caps / 30 days

SPIRIVA SPR 2.5MCG

1 cart / 30 days

STIOLTO AER 2.5-2.5

1 cart / 30 days

STRIVERDI AER 2.5MCG

1 cart / 30 days

SYMBICORT AER 160-4.5

1 can / 30 days

SYMBICORT AER 80-4.5

1 can / 30 days

TRELEGY AER ELLIPTA

1 inhaler / 30 days

TUDORZA PRES AER 400/ACT

1 can / 30 days

UTIBRON CAP NEOHALER

60 caps / 30 days

VENTOLIN HFA AER

2 cans / 30 days

wixela inhub aer 100/50

60 blisters / 30 days

wixela inhub aer 250/50

60 blisters / 30 days

XOpenEX HFA AER

2 cans / 30 days

Anticonvulsants

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FINTEPLA SOL 2.2MG/ML 2

360 MLS / 30 days

LYRICA CAP 100MG

90 caps / 30 days

LYRICA CAP 150MG

90 caps / 30 days

LYRICA CAP 200MG

90 caps / 30 days

LYRICA CAP 225MG

60 caps / 30 days

LYRICA CAP 25MG

90 caps / 30 days

LYRICA CAP 300MG

60 caps / 30 days

LYRICA CAP 50MG

90 caps / 30 days

LYRICA CAP 75MG

90 caps / 30 days

LYRICA SOL 20MG/ML

900 MLS / 30 days

pregabalin cap 100mg

90 caps / 30 days

pregabalin cap 150mg

90 caps / 30 days

pregabalin cap 200mg

90 caps / 30 days

pregabalin cap 225mg

60 caps / 30 days

pregabalin cap 25mg

90 caps / 30 days

pregabalin cap 300mg

60 caps / 30 days

pregabalin cap 50mg

90 caps / 30 days

pregabalin cap 75mg

90 caps / 30 days

pregabalin sol 20mg/ml

900 MLS / 30 days

QUDEXY XR CAP 100/24HR

30 caps / 30 days

QUDEXY XR CAP 150/24HR

30 caps / 30 days

QUDEXY XR CAP 200/24HR

60 caps / 30 days

QUDEXY XR CAP 25/24HR

30 caps / 30 days

QUDEXY XR CAP 50/24HR

30 caps / 30 days

topiramate cap er 100mg

30 caps / 30 days

topiramate cap er 150mg

30 caps / 30 days

topiramate cap er 200mg

60 caps / 30 days

topiramate cap er 25mg

30 caps / 30 days

topiramate cap er 50mg

30 caps / 30 days

TROKENDI XR CAP 100MG

30 caps / 30 days

TROKENDI XR CAP 200MG

60 caps / 30 days

TROKENDI XR CAP 25MG

30 caps / 30 days

TROKENDI XR CAP 50MG

30 caps / 30 days

Antidiabetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADLYXIN INJ 10/20MCG

2 pens / 180 days

ADLYXIN INJ 20MCG

2 pens / 28 days

ADMELOG INJ 100U/ML

100 MLS / 30 days

ADMELOG SOLO INJ 100U/ML

100 MLS / 30 days

AFREZZA POW 12 UNIT

900 cartS / 30 days

AFREZZA POW 4-8 UNIT

1800 cartRS / 30 days

AFREZZA POW 4-8-12

1260 cartRS / 30 days

AFREZZA POW 4UNIT

2520 cartRS / 30 days

AFREZZA POW 8 UNIT

1260 cartS / 30 days

AFREZZA POW 8-12UNIT

1080 cartS / 30 days

ALOGLIPTIN/PIOGLIT tab 12.5-15

30 tabs / 30 days

ALOGLIPTIN/PIOGLIT tab 12.5-30

30 tabs / 30 days

ALOGLIPTIN/PIOGLIT tab 12.5-45

30 tabs / 30 days

ALOGLIPTIN/PIOGLIT tab 25-15MG

30 tabs / 30 days

ALOGLIPTIN/PIOGLIT tab 25-30MG

30 tabs / 30 days

ALOGLIPTIN/PIOGLIT tab 25-45MG

30 tabs / 30 days

ALOGLIPTIN tab 12.5MG

30 tabs / 30 days

ALOGLIPTIN tab 25MG

30 tabs / 30 days

ALOGLIPTIN tab 6.25MG

30 tabs / 30 days

ALOGLIPTIN tab METFORM

60 tabs / 30 days

APIDRA INJ SOLOSTAR

100 MLS / 30 days

APIDRA INJ U-100

100 MLS / 30 days

BASAGLAR INJ 100UNIT

100 MLS / 30 days

BYDUREON BC INJ 2/0.85ML

4 sprays / 28 days

BYDUREON pen INJ 2MG

4 pens / 28 days

BYETTA INJ 10MCG

1 pen / 30 days

BYETTA INJ 5MCG

1 pen / 30 days

FARXIGA tab 10MG

30 tabs / 30 days

FARXIGA tab 5MG

30 tabs / 30 days

FIASP INJ 100/ML

100 MLS / 30 days

FIASP FLEX INJ TOUCH

100 MLS / 30 days

FIASP penFIL INJ U-100

100 MLS / 30 days

FORTAMET tab 1000MG

60 tabs / 30 days

FORTAMET tab 500MG

90 tabs / 30 days

GLUMETZA tab 1000MG

60 tabs / 30 days

GLUMETZA tab 500MG

90 tabs / 30 days

GLYXAMBI tab 10-5 MG

30 tabs / 30 days

GLYXAMBI tab 25-5 MG

30 tabs / 30 days

HUMALOG INJ 100/ML

100 MLS / 30 days

HUMALOG JR INJ 100/ML

100 MLS / 30 days

HUMALOG KWIK INJ 100/ML

100 MLS / 30 days

HUMALOG KWIK INJ 200/ML

100 MLS / 30 days

HUMALOG MIX INJ 50/50

100 MLS / 30 days

HUMALOG MIX INJ 50/50KWP

100 MLS / 30 days

HUMALOG MIX INJ 75/25KWP

100 MLS / 30 days

HUMALOG MIX SUS 75/25

100 MLS / 30 days

HUMULIN INJ 70/30

100 MLS / 30 days

HUMULIN INJ 70/30KWP

100 MLS / 30 days

HUMULIN N INJ U-100

100 MLS / 30 days

HUMULIN N INJ U-100KWP

100 MLS / 30 days

HUMULIN R INJ U-100

100 MLS / 30 days

HUMULIN R INJ U-500

100 MLS / 30 days

INS ASP PROT INJ FLEXpen

100 MLS / 30 days

INSULIN ASPA INJ 100/ML

100 MLS / 30 days

INSULIN ASPA INJ 70/30

100 MLS / 30 days

INSULIN ASPA INJ FLEXpen

100 MLS / 30 days

INSULIN ASPA INJ penFILL

100 MLS / 30 days

INSULIN LISP INJ 100/ML

100 MLS / 30 days

INSULIN LISP INJ JUNIOR

100 MLS / 30 days

INSULIN LISP INJ PROTAMIN

100 MLS / 30 days

INVOKAMET tab 150-1000

60 tabs / 30 days

INVOKAMET tab 150-500

60 tabs / 30 days

INVOKAMET tab 50-1000

60 tabs / 30 days

INVOKAMET tab 50-500MG

60 tabs / 30 days

INVOKAMET XR tab 150-1000

60 tabs / 30 days

INVOKAMET XR tab 150-500

60 tabs / 30 days

INVOKAMET XR tab 50-1000

60 tabs / 30 days

INVOKAMET XR tab 50-500MG

60 tabs / 30 days

INVOKANA tab 100MG

30 tabs / 30 days

INVOKANA tab 300MG

30 tabs / 30 days

JANUMET tab 50-1000

60 tabs / 30 days

JANUMET tab 50-500MG

60 tabs / 30 days

JANUMET XR tab 100-1000

30 tabs / 30 days

JANUMET XR tab 50-1000

60 tabs / 30 days

JANUMET XR tab 50-500MG

30 tabs / 30 days

JANUVIA tab 100MG

30 tabs / 30 days

JANUVIA tab 25MG

30 tabs / 30 days

JANUVIA tab 50MG

30 tabs / 30 days

JARDIANCE tab 10MG

30 tabs / 30 days

JARDIANCE tab 25MG

30 tabs / 30 days

JENTADUETO tab 2.5-1000

60 tabs / 30 days

JENTADUETO tab 2.5-500

60 tabs / 30 days

JENTADUETO tab 2.5-850

60 tabs / 30 days

JENTADUETO XR- LINAGLIPTIN-

60 tabs / 30 days

METFORMIN HCL tab ER 24HR 2 JENTADUETO XR- LINAGLIPTIN-

30 tabs / 30 days

1000 MG

METFORMIN CL tab ER 2

KAZANO 12.5- tab 1000MG

60 tabs / 30 days

MG

KAZANO 12.5- tab 500MG

60 tabs / 30 days

KOMBIGLYZ XR tab 2.5-1000

60 tabs / 30 days

KOMBIGLYZ XR tab 5-1000MG

30 tabs / 30 days

KOMBIGLYZ XR tab 5-500MG

30 tabs / 30 days

KORLYM tab 300MG 2

120 tabs / 30 days

LANTUS INJ 100/ML

100 MLS / 30 days

LANTUS SOLOS INJ 100/ML

100 MLS / 30 days

LEVEMIR INJ

100 MLS / 30 days

LEVEMIR INJ FLEXTOUC

100 MLS / 30 days

LYUMJEV INJ 100UT/ML

100 MLS / 30 days

LYUMJEV KWPN INJ 100UT/ML

100 MLS / 30 days

LYUMJEV KWPN INJ 200UT/ML

100 MLS / 30 days

metformin tab 1000 er

60 tabs / 30 days

metformin tab 750mg er

60 tabs / 30 days

metformin er tab 1000mg

60 tabs / 30 days

metformin hcl tab er 24hr 500 mg

120 tabs / 30 days

metformin hcl tab er 24hr modified

90 tabs / 30 days

release 500 mg

metformin hcl tab er 24hr osmotic 500 mg

90 tabs / 30 days

NESINA tab 12.5MG

30 tabs / 30 days

NESINA tab 25MG

30 tabs / 30 days

NESINA tab 6.25MG

30 tabs / 30 days

NOVOLIN INJ 70/30

100 MLS / 30 days

NOVOLIN INJ 70/30 FP

100 MLS / 30 days

NOVOLIN N INJ 100 UNIT

100 MLS / 30 days

NOVOLIN N INJ RELION

100 MLS / 30 days

NOVOLIN N INJ U-100

100 MLS / 30 days

NOVOLIN R INJ 100 UNIT

100 MLS / 30 days

NOVOLIN R INJ RELION

100 MLS / 30 days

NOVOLIN R INJ U-100

100 MLS / 30 days

NOVOLIN70/30 INJ RELION

100 MLS / 30 days

NOVOLOG INJ 100/ML

100 MLS / 30 days

NOVOLOG INJ FLEXpen

100 MLS / 30 days

NOVOLOG INJ penFILL

100 MLS / 30 days

NOVOLOG INJ RELION

100 MLS / 30 days

NOVOLOG MIX INJ 70/30

100 MLS / 30 days

NOVOLOG MIX INJ FLEX REL

100 MLS / 30 days

NOVOLOG MIX INJ FLEXpen

100 MLS / 30 days

NOVOLOG RELI INJ 70/30

100 MLS / 30 days

ONGLYZA tab 2.5MG

30 tabs / 30 days

ONGLYZA tab 5MG

30 tabs / 30 days

OSENI tab 12.5-15

30 tabs / 30 days

OSENI tab 12.5-30

30 tabs / 30 days

OSENI tab 12.5-45

30 tabs / 30 days

OSENI tab 25-15MG

30 tabs / 30 days

OSENI tab 25-30MG

30 tabs / 30 days

OSENI tab 25-45MG

30 tabs / 30 days

OZEMPIC INJ 4MG/3ML

1 pen / 28 days

OZEMPIC- SEMAGLUTIDE SOLN PEN-

1 pens / 28 days

OZEMPIC- SEMAGLUTIDE SOLN PEN-

2 pens / 28 days

QTERN tab 10-5MG

30 tabs / 30 days

QTERN tab 5-5MG

30 tabs / 30 days

RELION R INJ 100/ML

100 MLS / 30 days

RIOMET ER SUS 500/5ML

960 MLS / 30 days

RYBELSUS tab 14MG

30 tabs / 30 days

RYBELSUS tab 3MG

30 tabs / 180 days

RYBELSUS tab 7MG

30 tabs / 30 days

SEGLUROMET tab 2.5-1000

60 tabs / 30 days

SEGLUROMET tab 2.5-500

120 tabs / 30 days

SEGLUROMET tab 7.5-1000

60 tabs / 30 days

SEGLUROMET tab 7.5-500

60 tabs / 30 days

SEMGLEE INJ 100U/ML

100 MLS / 30 days

SEMGLEE SOL 100U/ML

100 MLS / 30 days

SOLIQUA INJ 100/33

6 pens / 30 days

STEGLATRO tab 15MG

30 tabs / 30 days

STEGLATRO tab 5MG

60 tabs / 30 days

STEGLUJAN tab 15-100MG

30 tabs / 30 days

STEGLUJAN tab 5-100MG

30 tabs / 30 days

SYNJARDY tab

60 tabs / 30 days

SYNJARDY tab 12.5-500

60 tabs / 30 days

SYNJARDY tab 5-1000MG

60 tabs / 30 days

SYNJARDY tab 5-500MG

60 tabs / 30 days

SYNJARDY XR tab

60 tabs / 30 days

SYNJARDY XR tab 10-1000

60 tabs / 30 days

SYNJARDY XR tab 25-1000

30 tabs / 30 days

SYNJARDY XR tab 5-1000MG

60 tabs / 30 days

TOUJEO MAX INJ 300IU/ML

100 MLS / 30 days

TOUJEO SOLO INJ 300IU/ML

100 MLS / 30 days

TRADJENTA tab 5MG

30 tabs / 30 days

TRESIBA INJ 100UNIT

100 MLS / 30 days

TRESIBA FLEX INJ 100UNIT

100 MLS / 30 days

TRESIBA FLEX INJ 200UNIT

100 MLS / 30 days

TRIJARDY XR- EMPAGLIFLOZIN-

60 tabs / 30 days

LINAGLIP-METFORMIN tab ER 2 TRIJARDY XR- EMPAGLIFLOZIN-

30 tabs / 30 days

12.5-2.5-1000MG

LINAGLIPTIN-ETFORMIN tab E

TRIJARDY XR- MPAGLIFLOZIN-

30 tabs / 30 days

24HR 10-5-1000 MG

LINAGLIPTIN-METFORMIN tab E

TRIJARDY XR- MPAGLIFLOZIN-

60 tabs / 30 days

24HR 25 5 00 MG

LINAGLIPT -METFORMI

TRULICTY INJ 0.75/0.5

4 pens / 28 days

24HR 5 2.5 000MG

TRULICITY INJ 1.5/0.5

4 pens / 28 days

TRULICITY INJ 3/0.5

4 pens / 28 days

TRULICITY INJ 4.5/0.5

4 pens / 28 days

VICTOZA INJ 18MG/3ML

3 pens / 30 days

XIGDUO XR tab 10-1000

30 tabs / 30 days

XIGDUO XR tab 10-500MG

30 tabs / 30 days

XIGDUO XR tab 2.5-1000

60 tabs / 30 days

XIGDUO XR tab 5-1000MG

60 tabs / 30 days

XIGDUO XR tab 5-500MG

30 tabs / 30 days

XULTOPHY INJ 100/3.6

5 pens / 30 days

Antidotes and specific antagonists

Drug name(s)

Quantity limits 
(per 30 days or as specified)

deferasirox gra 180mg 1,3

30 packets / 30 days

deferasirox gra 360mg 1,3

180 packets / 30 days

deferasirox gra 90mg 1,3

30 packets / 30 days

deferasirox tab 125mg 1,3

30 tabs / 30 days

deferasirox tab 180mg 1,3

30 tabs / 30 days

deferasirox tab 250mg 1,3

30 tabs / 30 days

deferasirox tab 360mg 1,3

180 tabs / 30 days

deferasirox tab 500mg 1,3

90 tabs / 30 days

deferasirox tab 90mg 1,3

30 tabs / 30 days

EXJADE tab 125MG 1,3

30 tabs / 30 days

EXJADE tab 250MG 1,3

30 tabs / 30 days

EXJADE tab 500MG 1,3

90 tabs / 30 days

JADENU tab 180MG 1,3

30 tabs / 30 days

JADENU tab 360MG 1,3

180 tabs / 30 days

JADENU tab 90MG 1,3

30 tabs / 30 days

JADENU SPRKL GRA 180MG 1,3

30 packets / 30 days

JADENU SPRKL GRA 360MG 1,3

180 packets / 30 days

JADENU SPRKL GRA 90MG 1,3

30 packets / 30 days

Antiemetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AKYNZEO CAP 300-0.5

2 caps / 30 days

ANZEMET tab 100MG

7 tabs / 30 days

ANZEMET tab 50MG

7 tabs / 30 days

aprepitant cap 125mg

4 caps / 30 days

aprepitant cap 40mg

8 caps / 30 days

aprepitant cap 80mg

8 caps / 30 days

aprepitant pak 80 & 125

4 PACKS / 30 days

DICLEGIS tab 10-10MG

120 tabs / 30 days

doxylamine-pyridoxine tab 10-10mg

120 tabs / 30 days

EMEND CAP 40MG

8 caps / 30 days

EMEND CAP 80MG

8 caps / 30 days

EMEND SUS 125MG

6 PACKS / 30 days

EMEND TRIPAC PAK 80 & 125

4 PACKS / 30 days

granisetron tab 1mg

14 tabs / 30 days

ondansetron sol 4mg/5ml

5 bottleles / 30 days

ONDANSETRON tab 24MG

4 tabs / 30 days

ondansetron tab 4mg

24 tabs / 30 days

ondansetron tab 4mg odt

24 tabs / 30 days

ondansetron tab 8mg

24 tabs / 30 days

ondansetron tab 8mg odt

24 tabs / 30 days

SANCUSO DIS 3.1MG

2 patches / 28 days

VARUBI tab 90MG

4 tabs / 30 days

ZOFRAN tab 4MG

24 tabs / 30 days

ZOFRAN tab 8MG

24 tabs / 30 days

ZUPLENZ MIS 4MG

24 FILMS / 30 days

ZUPLENZ MIS 8MG

24 FILMS / 30 days

Antihyperlidemics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALTOPREV tab 20MG ER

30 tabs / 30 days

ALTOPREV tab 40MG ER

30 tabs / 30 days

ALTOPREV tab 60MG ER

30 tabs / 30 days

atorvastatin tab 10mg

45 tabs / 30 days

atorvastatin tab 20mg

45 tabs / 30 days

atorvastatin tab 40mg

45 tabs / 30 days

atorvastatin tab 80mg

30 tabs / 30 days

CRESTOR tab 10MG

45 tabs / 30 days

CRESTOR tab 20MG

45 tabs / 30 days

CRESTOR tab 40MG

30 tabs / 30 days

CRESTOR tab 5MG

45 tabs / 30 days

EZETIM/ROSUV tab 10-10MG

30 tabs / 30 days

EZETIM/ROSUV tab 10-20MG

30 tabs / 30 days

EZETIM/ROSUV tab 10-40MG

30 tabs / 30 days

EZETIM/ROSUV tab 10-5MG

30 tabs / 30 days

ezetim/simva tab 10-10mg

30 tabs / 30 days

ezetim/simva tab 10-20mg

30 tabs / 30 days

ezetim/simva tab 10-40mg

30 tabs / 30 days

ezetim/simva tab 10-80mg

30 tabs / 30 days

fluvastatin tab 80mg er

30 tabs / 30 days

JUXTAPID CAP 10MG 2

30 caps / 30 days

JUXTAPID CAP 20MG 2

30 caps / 30 days

JUXTAPID CAP 30MG 2

30 caps / 30 days

JUXTAPID CAP 40MG 2

30 caps / 30 days

JUXTAPID CAP 5MG 2

30 caps / 30 days

JUXTAPID CAP 60MG 2

30 caps / 30 days

LESCOL XL tab 80MG

30 tabs / 30 days

LIPITOR tab 10MG

45 tabs / 30 days

LIPITOR tab 20MG

45 tabs / 30 days

LIPITOR tab 40MG

45 tabs / 30 days

LIPITOR tab 80MG

30 tabs / 30 days

LIVALO tab 1MG

45 tabs / 30 days

LIVALO tab 2MG

45 tabs / 30 days

LIVALO tab 4MG

30 tabs / 30 days

lovastatin tab 10mg

60 tabs / 30 days

lovastatin tab 20mg

60 tabs / 30 days

lovastatin tab 40mg

60 tabs / 30 days

NEXLETOL tab 180MG

30 tabs / 30 days

NEXLIZET tab 180/10MG

30 tabs / 30 days

PRALUENT INJ 150MG/ML

2 syringes / 28 days

PRALUENT INJ 75MG/ML

2 syringes / 28 days

PRAVACHOL tab 20MG

45 tabs / 30 days

PRAVACHOL tab 40MG

45 tabs / 30 days

pravastatin tab 10mg

45 tabs / 30 days

pravastatin tab 20mg

45 tabs / 30 days

pravastatin tab 40mg

45 tabs / 30 days

pravastatin tab 80mg

30 tabs / 30 days

REPATHA INJ 140MG/ML

2 syringes / 28 days

REPATHA PUSH INJ 420/3.5

2 cartS / 30 days

REPATHA SURE INJ 140MG/ML

2 pens / 28 days

rosuvastatin tab 10mg

45 tabs / 30 days

rosuvastatin tab 20mg

45 tabs / 30 days

rosuvastatin tab 40mg

30 tabs / 30 days

rosuvastatin tab 5mg

45 tabs / 30 days

ROSZET tab 10-10MG

30 tabs / 30 days

ROSZET tab 20-10MG

30 tabs / 30 days

ROSZET tab 40-10MG

30 tabs / 30 days

ROSZET tab 5-10MG

30 tabs / 30 days

simvastatin tab 10mg

45 tabs / 30 days

simvastatin tab 20mg

60 tabs / 30 days

simvastatin tab 40mg

45 tabs / 30 days

simvastatin tab 5mg

45 tabs / 30 days

simvastatin tab 80mg

30 tabs / 30 days

VYTORIN tab 10-10MG

30 tabs / 30 days

VYTORIN tab 10-20MG

30 tabs / 30 days

VYTORIN tab 10-40MG

30 tabs / 30 days

VYTORIN tab 10-80MG

30 tabs / 30 days

ZOCOR tab 10MG

45 tabs / 30 days

ZOCOR tab 20MG

60 tabs / 30 days

ZOCOR tab 40MG

45 tabs / 30 days

ZOCOR tab 80MG

30 tabs / 30 days

Anti-infective agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALINIA SUS 100/5ML

300 MLS / 90 days

ALINIA tab 500MG

12 tabs / 90 days

nitazoxanide tab 500mg

12 tabs / 90 days

XIFAXAN tab 200MG

9 tabs / 30 days

XIFAXAN tab 550MG

60 tabs / 30 days

Antimyasthenic / cholinergic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FIRDAPSE tab 10MG 2

240 tabs / 30 days

RUZURGI tab 10MG 2

300 tabs / 30 days

Antineoplastics and adjuntive therapies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

abiraterone tab 250mg 1,3

120 tabs / 30 days

abiraterone tab 500mg 1,3

60 tabs / 30 days

AFINITOR tab 10MG 1,3

30 tabs / 30 days

AFINITOR tab 2.5MG 1,3

30 tabs / 30 days

AFINITOR tab 5MG 1,3

30 tabs / 30 days

AFINITOR tab 7.5MG 1,3

30 tabs / 30 days

AFINITOR DIS tab 2MG 1,3

60 tabs / 30 days

AFINITOR DIS tab 3MG 1,3

90 tabs / 30 days

AFINITOR DIS tab 5MG 1,3

60 tabs / 30 days

ALECENSA CAP 150MG 2,33

240 caps / 30 days

ALUNBRIG PAK 2

30 tabs / 180 days

ALUNBRIG tab 180MG 2

30 tabs / 30 days

ALUNBRIG tab 30MG 2

120 tabs / 30 days

ALUNBRIG tab 90MG 2

30 tabs / 30 days

AYVAKIT tab 100MG 2,33

30 tabs / 30 days

AYVAKIT tab 200MG 2,33

30 tabs / 30 days

AYVAKIT tab 25MG 2

30 tabs / 30 days

AYVAKIT tab 300MG 2

30 tabs / 30 days

AYVAKIT tab 50MG 2

30 tabs / 30 days

BALVERSA tab 3MG 2

90 tabs / 30 days

BALVERSA tab 4MG 2

60 tabs / 30 days

BALVERSA tab 5MG 2

30 tabs / 30 days

BOSULIF tab 100MG 1,3

90 tabs / 30 days

BOSULIF tab 400MG 1,3

30 tabs / 30 days

BOSULIF tab 500MG 1,3

30 tabs / 30 days

BRAFTOVI CAP 75MG 2

180 caps / 30 days

BRUKINSA CAP 80MG 2

120 caps / 30 days

CABOMETYX tab 20MG 1,3

30 tabs / 30 days

CABOMETYX tab 40MG 1,3

30 tabs / 30 days

CABOMETYX tab 60MG 1,3

30 tabs / 30 days

CALQUENCE CAP 100MG 2

60 caps / 30 days

CAPRELSA tab 100MG 2

60 tabs / 30 days

CAPRELSA tab 300MG 2

30 tabs / 30 days

COMETRIQ KIT 100MG 2

1 carton / 28 days

COMETRIQ KIT 140MG 2

112 tabs / 28 days

COMETRIQ KIT 60MG 2

1 carton / 28 days

COPIKTRA CAP 15MG 2

56 caps / 28 days

COPIKTRA CAP 25MG 2

56 caps / 28 days

COTELLIC tab 20MG 1

63 tabs / 28 days

DAURISMO tab 100MG 1,3

30 tabs / 30 days

DAURISMO tab 25MG 1,3

60 tabs / 30 days

ERIVEDGE CAP 150MG 1,3

30 caps / 30 days

erlotinib tab 25mg 1,3

60 tabs / 30 days

erlotinib tab 100mg 1,3

30 tabs / 30 days

erlotinib tab 150mg 1,3

30 tabs / 30 days

everolimus tab 2mg3,4

60 tabs / 30 days

everolimus tab 2.5mg3,1,4

30 tabs / 30 days

everolimus tab 2.5mg3,4

30 tabs / 30 days

everolimus tab 3mg3,4

90 tabs / 30 days

everolimus tab 5mg1,3,4

30 tabs / 30 days

everolimus tab 5mg3,4

60 tabs / 30 days

everolimus tab 5mg3,4

30 tabs / 30 days

everolimus tab 7.5mg1,3,4

30 tabs / 30 days

everolimus tab 7.5mg3,4

30 tabs / 30 days

everolimus tab 10mg3,4

30 tabs / 30 days

FARYDAK CAP 10MG4

6 caps / 21 days

FARYDAK CAP 10MG1,4

6 caps / 21 days

FARYDAK CAP 15MG4

6 caps / 21 days

FARYDAK CAP 15MG1,4

6 caps / 21 days

FARYDAK CAP 20MG4

6 caps / 21 days

FARYDAK CAP 20MG1,4

6 caps / 21 days

FOTIVDA CAP 0.89MG

21 caps / 28 days

FOTIVDA CAP 1.34MG

21 caps / 28 days

GAVRETO CAP 100MG 2

120 caps / 30 days

GILOTRIF tab 20MG 2

30 tabs / 30 days

GILOTRIF tab 30MG 2

30 tabs / 30 days

GILOTRIF tab 40MG 2

30 tabs / 30 days

GLEEVEC tab 100MG 1,3

90 tabs / 30 days

GLEEVEC tab 400MG 1,3

60 tabs / 30 days

IBRANCE CAP 100MG 1

21 caps / 28 days

IBRANCE CAP 125MG 1

21 caps / 28 days

IBRANCE CAP 75MG 1

21 caps / 28 days

IBRANCE tab 100MG 1

21 tabs / 28 days

IBRANCE tab 125MG 1

21 tabs / 28 days

IBRANCE tab 75MG 1

21 tabs / 28 days

ICLUSIG tab 10MG 2

30 tabs / 30 days

ICLUSIG tab 15MG 2

30 tabs / 30 days

ICLUSIG tab 30MG 2

30 tabs / 30 days

ICLUSIG tab 45MG 2

30 tabs / 30 days

IDHIFA tab 100MG 1

30 tabs / 30 days

IDHIFA tab 50MG 1

30 tabs / 30 days

imatinib mes tab 100mg 1,3

90 tabs / 30 days

imatinib mes tab 400mg 1,3

60 tabs / 30 days

IMBRUVICA CAP 140MG 2

90 caps / 30 days

IMBRUVICA CAP 70MG 2

30 caps / 30 days

IMBRUVICA tab 140MG 2

30 tabs / 30 days

IMBRUVICA tab 280MG 2

30 tabs / 30 days

IMBRUVICA tab 420MG 2

30 tabs / 30 days

IMBRUVICA tab 560MG 2

30 tabs / 30 days

INLYTA tab 1MG 1,3

180 tabs / 30 days

INLYTA tab 5MG 1,3

120 tabs / 30 days

INQOVI tab 35-100MG 1

5 tabs / 28 days

INREBIC CAP 100MG 1,3

120 caps / 30 days

IRESSA tab 250MG 2

30 tabs / 30 days

JAKAFI tab 10MG 1,3

60 tabs / 30 days

JAKAFI tab 15MG 1,3

60 tabs / 30 days

JAKAFI tab 20MG 1,3

60 tabs / 30 days

JAKAFI tab 25MG 1,3

60 tabs / 30 days

JAKAFI tab 5MG 1,3

60 tabs / 30 days

KISQALI tab 200DOSE 1

63 tabs / 28 days

KISQALI tab 400DOSE 1

63 tabs / 28 days

KISQALI tab 600DOSE 1

63 tabs / 28 days

KISQALI 200 PAK FEMARA 1

91 tabs / 28 days

KISQALI 400 PAK FEMARA 1

91 tabs / 28 days

KISQALI 600 PAK FEMARA 1

91 tabs / 28 days

KOSELUGO CAP 10MG 2

240 caps / 30 days

KOSELUGO CAP 25MG 2

120 caps / 30 days

lapatinib tab 250mg 1

180 tabs / 30 days

LENVIMA CAP 10 MG 2

30 caps / 30 days

LENVIMA CAP 12MG 2

90 caps / 30 days

LENVIMA CAP 14 MG 2

60 caps / 30 days

LENVIMA CAP 18 MG 2

90 caps / 30 days

LENVIMA CAP 20 MG 2

60 caps / 30 days

LENVIMA CAP 24 MG 2

90 caps / 30 days

LENVIMA CAP 4MG 2

30 caps / 30 days

LENVIMA CAP 8 MG 2

60 caps / 30 days

LONSURF tab 15-6.14 1

60 tabs / 28 days

LONSURF tab 20-8.19 1

80 tabs / 28 days

LORBRENA tab 100MG 1,3

30 tabs / 30 days

LORBRENA tab 25MG 1,3

90 tabs / 30 days

LUMAKRAS tab 120MG

240 tabs / 30 days

LYNPARZA tab 100MG 2

120 tabs / 30 days

LYNPARZA tab 150MG 2

120 tabs / 30 days

MEKINIST tab 0.5MG 1

90 tabs / 30 days

MEKINIST tab 2MG 1

30 tabs / 30 days

MEKTOVI tab 15MG 2

180 tabs / 30 days

NERLYNX tab 40MG 2

180 tabs / 30 days

NEXAVAR tab 200MG 1,3

120 tabs / 30 days

NINLARO CAP 2.3MG 1

3 caps / 28 days

NINLARO CAP 3MG 1

3 caps / 28 days

NINLARO CAP 4MG 1

3 caps / 28 days

NUBEQA tab 300MG 1

120 tabs / 30 days

ODOMZO CAP 200MG 1,3

30 caps / 30 days

ONUREG tab 200MG 1

14 tabs / 28 days

ONUREG tab 300MG 1

14 tabs / 28 days

ORGOVYX tab 120MG 2

30 tabs / 30 days

PEMAZYRE tab 13.5MG 2

14 tabs / 21 days

PEMAZYRE tab 4.5MG 2

14 tabs / 21 days

PEMAZYRE tab 9MG 2

14 tabs / 21 days

PIQRAY 200MG tab DOSE 1

28 tabs / 28 days

PIQRAY 250MG tab DOSE 1

56 tabs / 28 days

PIQRAY 300MG tab DOSE 1

56 tabs / 28 days

POMALYST CAP 1MG 1

21 caps / 28 days

POMALYST CAP 2MG 1

21 caps / 28 days

POMALYST CAP 3MG 1

21 caps / 28 days

POMALYST CAP 4MG 1

21 caps / 28 days

QINLOCK tab 50MG 2

90 tabs / 30 days

RETEVMO CAP 40MG 1,3

180 caps / 30 days

RETEVMO CAP 80MG 1,3

120 caps / 30 days

ROZLYTREK CAP 100MG 1,3

30 caps / 30 days

ROZLYTREK CAP 200MG 1,3

90 caps / 30 days

RUBRACA tab 200MG 2

120 tabs / 30 days

RUBRACA tab 250MG 2

120 tabs / 30 days

RUBRACA tab 300MG 2

120 tabs / 30 days

RYDAPT CAP 25MG 1

240 caps / 30 days

SPRYCEL tab 100MG 1,3_

30 tabs / 30 days

SPRYCEL tab 140MG 1,3_

30 tabs / 30 days

SPRYCEL tab 20MG 1,3_

90 tabs / 30 days

SPRYCEL tab 50MG 1,3_

30 tabs / 30 days

SPRYCEL tab 70MG 1,3_

30 tabs / 30 days

SPRYCEL tab 80MG 1,3_

30 tabs / 30 days

STIVARGA tab 40MG 1

84 tabs / 28 days

sunitinib cap 12.5mg 1,3_

90 caps / 30 days

sunitinib cap 25mg 1,3_

30 caps / 30 days

sunitinib cap 37.5mg 1,3_

30 caps / 30 days

sunitinib cap 50mg 1,3_

30 caps / 30 days

SUTENT CAP 12.5MG 1,3_

90 caps / 30 days

SUTENT CAP 25MG 1,3_

30 caps / 30 days

SUTENT CAP 37.5MG 1,3_

30 caps / 30 days

SUTENT CAP 50MG 1,3_

30 caps / 30 days

tabRECTA tab 150MG 1

120 tabs / 30 days

tabRECTA tab 200MG 1

120 tabs / 30 days

TAFINLAR CAP 50MG 1

120 caps / 30 days

TAFINLAR CAP 75MG 1

120 caps / 30 days

TAGRISSO tab 40MG 2 _

30 tabs / 30 days

TAGRISSO tab 80MG 2 _

30 tabs / 30 days

TALZENNA CAP 0.25MG 1,3_

90 caps / 30 days

TALZENNA CAP 1MG 1,3_

30 caps / 30 days

TARCEVA tab 100MG 1,3_

30 tabs / 30 days

TARCEVA tab 150MG 1,3_

30 tabs / 30 days

TARCEVA tab 25MG 1,3_

60 tabs / 30 days

TASIGNA CAP 150MG 1,3_

120 caps / 30 days

TASIGNA CAP 200MG 1,3_

120 caps / 30 days

TASIGNA CAP 50MG 1,3_

120 caps / 30 days

TAZVERIK tab 200MG 2

240 tabs / 30 days

TEPMETKO tab 225MG 3_

60 tabs / 30 days

TIBSOVO tab 250MG 2

60 tabs / 30 days

TRUSELTIQ CAP 100MG

1 PACK / 28 days

TRUSELTIQ CAP 125MG

1 PACK / 28 days

TRUSELTIQ CAP 50MG

1 PACK / 28 days

TRUSELTIQ CAP 75MG

1 PACK / 28 days

TUKYSA tab 150MG 2

120 tabs / 30 days

TUKYSA tab 50MG 2

300 tabs / 30 days

TURALIO CAP 200MG 2

120 caps / 30 days

TYKERB tab 250MG 1

180 tabs / 30 days

UKONIQ tab 200MG 3_

120 tabs / 30 days

VENCLEXTA tab 100MG 2

180 tabs / 30 days

VENCLEXTA tab 10MG 2

60 tabs / 30 days

VENCLEXTA tab 50MG 2

30 tabs / 30 days

VENCLEXTA tab START PK 2

1 PACK / 180 days

VERZENIO tab 100MG 2

60 tabs / 30 days

VERZENIO tab 150MG 2

60 tabs / 30 days

VERZENIO tab 200MG 2

60 tabs / 30 days

VERZENIO tab 50MG 2

60 tabs / 30 days

VITRAKVI CAP 100MG 2

60 caps / 30 days

VITRAKVI CAP 25MG 2

180 caps / 30 days

VITRAKVI SOL 20MG/ML 2

300 MLS / 30 days

VIZIMPRO tab 15MG 1,3

30 tabs / 30 days

VIZIMPRO tab 30MG 1,3

30 tabs / 30 days

VIZIMPRO tab 45MG 1,3

30 tabs / 30 days

VOTRIENT tab 200MG 1,3

120 tabs / 30 days

XALKORI CAP 200MG 1,3

120 caps / 30 days

XALKORI CAP 250MG 1,3

120 caps / 30 days

XOSPATA tab 40MG 2

90 tabs / 30 days

XPOVIO PAK 100MG 2

1 BOX / 28 days

XPOVIO PAK 40MG 3

1 BOX / 28 days

XPOVIO PAK 60MG 2

1 BOX / 28 days

XPOVIO 80 MG ONCE WEEKLY 2

1 BOX / 28 days

XTANDI CAP 40MG 1,3

120 caps / 30 days

XTANDI tab 40MG 1,3

120 tabs / 30 days

XTANDI tab 80MG 1,3

60 tabs / 30 days

ZEJULA CAP 100MG 2

90 caps / 30 days

ZELBORAF tab 240MG 1

240 tabs / 30 days

ZOLINZA CAP 100MG 1,3

120 caps / 30 days

ZYDELIG tab 100MG 2

60 tabs / 30 days

ZYDELIG tab 150MG 2

60 tabs / 30 days

ZYKADIA tab 150MG 1,3

90 tabs / 30 days

ZYTIGA tab 250MG 1,3

120 tabs / 30 days

ZYTIGA tab 500MG 1,3

60 tabs / 30 days

Antiparkinson and related therapy agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

GOCOVRI CAP 68.5MG 1,3

30 caps / 30 days

GOCOVRI CAP 137MG 1,3

60 caps / 30 days

Antipsychotics / antimanic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CAPLYTA CAP 42MG

30 caps / 30 days

INVEGA tab 1.5MG

60 tabs / 30 days

INVEGA tab 3MG

60 tabs / 30 days

INVEGA tab 6MG

60 tabs / 30 days

INVEGA tab 9MG

60 tabs / 30 days

LATUDA tab 120MG

30 tabs / 30 days

LATUDA tab 20MG

30 tabs / 30 days

LATUDA tab 40MG

30 tabs / 30 days

LATUDA tab 60MG

30 tabs / 30 days

LATUDA tab 80MG

60 tabs / 30 days

NUPLAZID CAP 34MG 1

30 caps / 30 days

NUPLAZID tab 10MG 1

30 tabs / 30 days

olanzapine tab 10mg

30 tabs / 30 days

olanzapine tab 10mg odt

30 tabs / 30 days

olanzapine tab 15mg

30 tabs / 30 days

olanzapine tab 15mg odt

30 tabs / 30 days

olanzapine tab 2.5mg

30 tabs / 30 days

olanzapine tab 20mg

30 tabs / 30 days

olanzapine tab 20mg odt

30 tabs / 30 days

olanzapine tab 5mg

30 tabs / 30 days

olanzapine tab 5mg odt

30 tabs / 30 days

olanzapine tab 7.5mg

30 tabs / 30 days

paliperidone tab er 1.5mg

60 tabs / 30 days

paliperidone tab er 3mg

60 tabs / 30 days

paliperidone tab er 6mg

60 tabs / 30 days

paliperidone tab er 9mg

60 tabs / 30 days

quetiapine tab 150mg er

60 tabs / 30 days

quetiapine tab 200mg er

60 tabs / 30 days

quetiapine tab 300mg er

60 tabs / 30 days

quetiapine tab 400mg er

60 tabs / 30 days

quetiapine tab 50mg er

60 tabs / 30 days

SEROQUEL XR tab 150MG

60 tabs / 30 days

SEROQUEL XR tab 200MG

60 tabs / 30 days

SEROQUEL XR tab 300MG

60 tabs / 30 days

SEROQUEL XR tab 400MG

60 tabs / 30 days

SEROQUEL XR tab 50MG

60 tabs / 30 days

VRAYLAR CAP 1.5-3MG

1 PACK / 180 days

VRAYLAR CAP 1.5MG

30 caps / 30 days

VRAYLAR CAP 3MG

30 caps / 30 days

VRAYLAR CAP 4.5MG

30 caps / 30 days

VRAYLAR CAP 6MG

30 caps / 30 days

ZYPREXA tab 10MG

30 tabs / 30 days

ZYPREXA tab 15MG

30 tabs / 30 days

ZYPREXA tab 2.5MG

30 tabs / 30 days

ZYPREXA tab 20MG

30 tabs / 30 days

ZYPREXA tab 5MG

30 tabs / 30 days

ZYPREXA tab 7.5MG

30 tabs / 30 days

ZYPREXA ZYDI tab 10MG

30 tabs / 30 days

ZYPREXA ZYDI tab 15MG

30 tabs / 30 days

ZYPREXA ZYDI tab 20MG

30 tabs / 30 days

ZYPREXA ZYDI tab 5MG

30 tabs / 30 days

Antivirals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EPCLUSA tab 200-50MG 1

28 tabs / 28 days

EPCLUSA tab 400-100 1

30 tabs / 30 days

HARVONI PAK 1

28 packets / 28 days

HARVONI PAK 45-200MG 1

28 packets / 28 days

HARVONI tab 45-200MG 1

28 tabs / 28 days

HARVONI tab 90-400MG 1

30 tabs / 30 days

LEDIP-SOFOSB tab 90-400MG 1

30 tabs / 30 days

MAVYRET tab 100-40MG 1

90 tabs / 30 days

oseltamivir cap 30mg

40 caps / 120 days

oseltamivir cap 45mg

20 caps / 120 days

oseltamivir cap 75mg

20 caps / 120 days

oseltamivir sus 6mg/ml

300 MLS / 120 days

PREVYMIS tab 240MG

112 tabs / 365 days

PREVYMIS tab 480MG

112 tabs / 365 days

RELENZA MIS DISKHALE

40 blisters / 120 days

SOFOS/VELPAT tab 400-100 1

30 tabs / 30 days

SOVALDI PAK 150MG 1

28 packets / 28 days

SOVALDI PAK 200MG 1

28 packets / 28 days

SOVALDI tab 200MG 1

30 tabs / 30 days

SOVALDI tab 400MG 1

30 tabs / 30 days

TAMIFLU CAP 30MG

40 caps / 120 days

TAMIFLU CAP 45MG

20 caps / 120 days

TAMIFLU CAP 75MG

20 caps / 120 days

TAMIFLU SUS 6MG/ML

300 MLS / 120 days

VIEKIRA PAK tab 1

112 tabs / 28 days

VOSEVI tab 1

30 tabs / 30 days

XOFLUZA tab 20MG

4 tabs / 120 days

XOFLUZA tab 80MG

2 tabs / 120 days

XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY PACK 1 X 40 MG (40 MG DOSE)

2 tabs / 120 days

XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY PACK 2 X 40 MG (80 MG DOSE)

4 tabs / 120 days

ZEPATIER tab 50-100MG 1

30 tabs / 30 days

Cardiovascular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADCIRCA tab 20MG 1

60 tabs / 30 days

ADEMPAS tab 0.5MG 2

90 tabs / 30 days

ADEMPAS tab 1.5MG 2

90 tabs / 30 days

ADEMPAS tab 1MG 2

90 tabs / 30 days

ADEMPAS tab 2.5MG 2

90 tabs / 30 days

ADEMPAS tab 2MG 2

90 tabs / 30 days

alyq tab 20mg 1

60 tabs / 30 days

ambrisentan tab 10mg 1

30 tabs / 30 days

ambrisentan tab 5mg 1

30 tabs / 30 days

bosentan tab 125mg 1

60 tabs / 30 days

bosentan tab 62.5mg 1

60 tabs / 30 days

CORLANOR SOL 5MG/5ML

600 MLS / 30 days

CORLANOR tab 5MG

60 tabs / 30 days

CORLANOR tab 7.5MG

60 tabs / 30 days

LETAIRIS tab 10MG 1

30 tabs / 30 days

LETAIRIS tab 5MG 1

30 tabs / 30 days

OPSUMIT tab 10MG 2

30 tabs / 30 days

REVATIO SUS 10MG/ML 1

2 bottleles / 30 days

REVATIO tab 20MG 1

90 tabs / 30 days

sildenafil (VIAGRA) sus 10mg/ml

2 bottleles / 30 days

sildenafil (REVATIO) sus 10mg/ml 1

2 bottleles / 30 days

sildenafil (REVATIO) tab 20mg 1

90 tabs / 30 days

tadalafil tab 20mg 1

60 tabs / 30 days

TRACLEER tab 125MG 1

60 tabs / 30 days

TRACLEER tab 32MG 1

120 tabs / 30 days

TRACLEER tab 62.5MG 1

60 tabs / 30 days

UPTRAVI tab 1000MCG 2

60 tabs / 30 days

UPTRAVI tab 1200MCG 2

60 tabs / 30 days

UPTRAVI tab 1400MCG 2

60 tabs / 30 days

UPTRAVI tab 1600MCG 2

60 tabs / 30 days

UPTRAVI tab 200/800 2

1 PKG / 180 days

UPTRAVI tab 400MCG 2

60 tabs / 30 days

UPTRAVI tab 600MCG 2

60 tabs / 30 days

UPTRAVI tab 800MCG 2

60 tabs / 30 days

UPTRAVI- SELEXIPAG tab 200 MCG 2

60 tabs / 30 days

UPTRAVI- SELEXIPAG tab 200 MCG 2

140 tabs / 180 days

VENTAVIS SOL 10MCG/ML 2,33

270 AMPULS / 30 days

VENTAVIS SOL 20MCG/ML 2,3

270 AMPULS / 30 days

VERQUVO tab 10MG

30 tabs / 30 days

VERQUVO tab 2.5MG

30 tabs / 30 days

VERQUVO tab 5MG

30 tabs / 30 days

VYNDAMAX CAP 61MG 1

30 caps / 30 days

VYNDAQEL CAP 20MG 1

120 caps / 30 days

Corticosteroids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EMFLAZA tab 6MG 2

60 tabs / 30 days

EMFLAZA tab 18MG 2

30 tabs / 30 days

Dermatologicals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ala-cort cre 1%

454 grams / 30 days

ala-cort cre 2.5%

454 grams / 30 days

ALA-SCALP LOT 2%

118.4 MLS / 30 days

alclometasone cre 0.05%

120 grams / 30 days

alclometasone oin 0.05%

120 grams / 30 days

ALDARA CRE 5%

48 packets / 112 days

AMCINONIDE CRE 0.1%

120 grams / 30 days

AMCINONIDE LOT 0.1%

120 MLS / 30 days

AMCINONIDE OIN 0.1%

120 grams / 30 days

APEXICON E CRE 0.05%

120 grams / 30 days

aug betamet cre 0.05%

200 grams / 28 days

AUG BETAMET GEL 0.05%

200 grams / 28 days

aug betamet lot 0.05%

210 MLS / 30 days

aug betamet oin 0.05%

200 grams / 28 days

beser lot 0.05%

120 MLS / 30 days

BETA DIPROP GEL 0.05%

200 grams / 28 days

betameth dip cre 0.05%

135 grams / 30 days

betameth dip lot 0.05%

120 MLS / 30 days

betameth dip oin 0.05%

135 grams / 30 days

betameth val aer 0.12%

150 grams / 30 days

betameth val cre 0.1%

135 grams / 30 days

betameth val lot 0.1%

120 MLS / 30 days

betameth val oin 0.1%

135 grams / 30 days

CAPEX SHA 0.01%

840 MLS / 28 days

ciclodan sol 8%

3.3 MLS / 30 days

ciclopirox sol 8%

3.3 MLS / 30 days

clobetasol aer 0.05%

200 grams / 28 days

clobetasol cre 0.05%

210 grams / 28 days

clobetasol gel 0.05%

210 grams / 28 days

clobetasol lot 0.05%

177 MLS / 28 days

clobetasol oin 0.05%

210 grams / 28 days

clobetasol sha 0.05%

236 MLS / 30 days

clobetasol sol 0.05%

200 MLS / 28 days

clobetasol spr 0.05%

236 MLS / 28 days

clobetasol e cre 0.05%

210 grams / 28 days

CLOBEX LOT 0.05%

177 MLS / 28 days

CLOBEX SHA 0.05%

236 MLS / 30 days

CLOBEX SPR 0.05%

236 MLS / 28 days

CLOCORTOLONE CRE 0.1%

135 grams / 30 days

clodan sha 0.05%

236 MLS / 30 days

CLODERM CRE 0.1%

135 grams / 30 days

CORDRAN CRE 0.025%

120 grams / 30 days

CORDRAN CRE 0.05%

120 grams / 30 days

CORDRAN LOT 0.05%

120 MLS / 30 days

CORDRAN OIN 0.05%

120 grams / 30 days

CORDRAN 80X3 TAP 4MCG/CM

1 BOX / 30 days

COSENTYX INJ 150MG/ML 1

1 syringe / 28 days

COSENTYX INJ 300DOSE 1

1 PACK / 28 days

COSENTYX INJ 75MG/0.5 1

1 syringe / 28 days

COSENTYX pen INJ 150MG/ML 1

1 INJDV / 28 days

COSENTYX pen INJ 300DOSE 1

1 PACK / 28 days

CUTIVATE LOT 0.05%

120 MLS / 30 days

DERMA-SMOOTH OIL /FS BODY

118.28 MLS / 30 days

DERMA-SMOOTH OIL /FS SCLP

118.28 MLS / 30 days

DESONATE GEL 0.05%

120 grams / 30 days

desonide cre 0.05%

120 grams / 30 days

desonide gel 0.05%

120 grams / 30 days

desonide lot 0.05%

118 MLS / 30 days

desonide oin 0.05%

120 grams / 30 days

DESOWEN CRE 0.05%

120 grams / 30 days

desoximetasone cre 0.05%

120 grams / 30 days

desoximetasone cre 0.25%

120 grams / 30 days

desoximetasone gel 0.05%

120 grams / 30 days

desoximetasone oin 0.05%

120 grams / 30 days

desoximetasone oin 0.25%

120 grams / 30 days

desoximetasone spr 0.25%

100 MLS / 30 days

desrx gel 0.05%

120 grams / 30 days

DICLOFENAC DIS 1.3%

60 patches / 30 days

diclofenac sol 1.5%

2 bottleles / 30 days

DIFLORASONE CRE 0.05%

120 grams / 30 days

diflorasone oin 0.05%

120 grams / 30 days

DIPROLENE OIN 0.05%

200 grams / 28 days

DIPROLENE AF CRE 0.05%

200 grams / 28 days

DUPIXENT INJ 200/1.14 1

2 syringes / 28 days

DUPIXENT INJ 200MG 1

2 pens / 28 days

DUPIXENT- DUPILUMAB

2 pens / 28 days

SBCUTANEOUS SOLN
DUPIXENT- DUPILUMAB

2 syringes / 28 days

INJECTO 00 MG/2

SUBUT EOUS SO

EFUDEX CRE 5%

240 grams / 90 days

SYRINGE 0 MG 2ML

ELOCON CRE 0.1%

135 grams / 30 days

FLECTOR DIS 1.3%

60 patches / 30 days

fluocin acet cre 0.01%

120 grams / 30 days

fluocin acet cre 0.025%

120 grams / 30 days

fluocin acet oil 0.01% sc

118.28 MLS / 30 days

fluocin acet oil 0.01%bdy

118.28 MLS / 30 days

fluocin acet oil body

118.28 MLS / 30 days

fluocin acet oil scalp

118.28 MLS / 30 days

fluocin acet oin 0.025%

120 grams / 30 days

fluocin acet sol 0.01%

120 MLS / 30 days

fluocinonide cre 0.05%

120 grams / 30 days

fluocinonide cre 0.1%

240 grams / 28 days

fluocinonide cre e 0.05%

120 grams / 30 days

fluocinonide gel 0.05%

120 grams / 30 days

fluocinonide oin 0.05%

120 grams / 30 days

fluocinonide sol 0.05%

120 MLS / 30 days

fluorouracil cre 5%

240 grams / 90 days

flurandrenol cre 0.05%

120 grams / 30 days

flurandrenol lot 0.05%

120 MLS / 30 days

flurandrenol oin 0.05%

120 grams / 30 days

fluticasone cre 0.05%

120 grams / 30 days

fluticasone lot 0.05%

120 MLS / 30 days

fluticasone oin 0.005%

120 grams / 30 days

glydo gel 2%

150 MLS / 30 days

halcinonide cre 0.1%

240 grams / 30 days

halobetasol cre 0.05%

200 grams / 28 days

halobetasol oin 0.05%

200 grams / 28 days

HALOG CRE 0.1%

240 grams / 30 days

HALOG OIN 0.1%

240 grams / 30 days

HALOG SOL 0.1%

240 MLS / 30 days

HC BUTYRATE CRE 0.1%

135 grams / 30 days

hc butyrate oin 0.1%

135 grams / 30 days

HC BUTYRATE SOL 0.1%

120 MLS / 30 days

hc butyrate sol 0.1%

120 MLS / 30 days

hc valerate cre 0.2%

120 grams / 30 days

hc valerate oin 0.2%

120 grams / 30 days

hydrocortisone cre 1%

454 grams / 30 days

hydrocortisone cre 2.5%

454 grams / 30 days

hydrocortisone lot 2.5%

118 MLS / 30 days

hydrocortisone oin 2.5%

454 grams / 30 days

hydrocortisone lot 0.1%

118 MLS / 30 days

hydrocortisone butyrate cream 0.1%

135 grams / 30 days

hydrocortisone butyrate hydrophilic lipo base cream 0.1%

120 grams / 30 days

imiquimod cre 5%

48 packets / 112 days

IMPOYZ CRE 0.025%

200 grams / 28 days

JUBLIA SOL 10%

4 MLS / 30 days

KENALOG AER SPRAY

126 grams / 30 days

KERYDIN SOL 5%

4 MLS / 30 days

KLISYRI OIN 1%

5 packets / 90 days

LIcart DIS 1.3%

30 systems / 30 days

lidocaine/prilocaine cre 2.5-2.5%

60 grams / 30 days

LIDOCA/TETRA CRE 7/7%

120 grams / 30 days

LIDOCAINE CRE TETRACAI

120 grams / 30 days

lidocaine gel 2%

150 MLS / 30 days

LIDOCAINE GEL 2% JELLY

150 MLS / 30 days

lidocaine gel 2% jelly

150 MLS / 30 days

lidocaine oin 5%

100 grams / 30 days

lidocaine pad 5%

90 patches / 30 days

lidocaine sol 4%

150 MLS / 30 days

LIDODERM DIS 5%

90 patches / 30 days

LOCOID CRE 0.1%

135 grams / 30 days

LOCOID LOT 0.1%

118 MLS / 30 days

LOCOID SOL 0.1%

120 MLS / 30 days

LOCOID LIPO CRE 0.1%

120 grams / 30 days

LUXIQ AER 0.12%

150 grams / 30 days

mometasone cre 0.1%

135 grams / 30 days

mometasone oin 0.1%

135 grams / 30 days

mometasone sol 0.1%

120 MLS / 30 days

nolix cre 0.05%

120 grams / 30 days

nolix lot 0.05%

120 MLS / 30 days

OLUX AER 0.05%

200 grams / 28 days

OLUX-E AER 0.05%

200 grams / 28 days

PANDEL CRE 0.1%

160 grams / 30 days

penLAC SOL 8%

3.3 MLS / 30 days

penNSAID SOL 2%

2 pumps / 28 days

PLIAGLIS CRE 7-7%

120 grams / 30 days

PREDNICARBAT CRE 0.1%

120 grams / 30 days

PREDNICARBAT OIN 0.1%

120 grams / 30 days

PSORCON CRE 0.05%

120 grams / 30 days

SERNIVO SPR

30 PADS / 30 days
120 MLS / 30 days

SERNIVO SPR 0.05%

N/A

120 MLS / 30 days

SILIQ INJ 210/1.5 1

2 syringes / 28 days

SKYRIZI INJ 150DOSE 1

1 BOX / 84 days

SKYRIZI INJ 150MG/ML 1

1 syringe / 84 days

SKYRIZI pen INJ 150MG/ML 1

1 INJDV / 84 days

STELARA INJ 45MG/0.5 1

1 syringe / 84 days

STELARA INJ 90MG/ML 1

1 syringe / 56 days

SYNALAR CRE 0.025%

120 grams / 30 days

SYNALAR OIN 0.025%

120 grams / 30 days

SYNALAR SOL 0.01%

120 MLS / 30 days

SYNERA DIS 70-70MG

4 patches / 30 days

TALTZ INJ 80MG/ML 1

1 MLS / 28 days

tavaborole sol 5%

4 MLS / 30 days

TEMOVATE CRE 0.05%

210 grams / 28 days

TEMOVATE OIN 0.05%

210 grams / 28 days

TEXACORT SOL 2.5%

120 MLS / 30 days

TOPICORT CRE 0.05%

120 grams / 30 days

TOPICORT CRE 0.25%

120 grams / 30 days

TOPICORT GEL 0.05%

120 grams / 30 days

TOPICORT OIN 0.05%

120 grams / 30 days

TOPICORT OIN 0.25%

120 grams / 30 days

TOPICORT SPR 0.25%

100 MLS / 30 days

tovet aer 0.05%

200 grams / 28 days

TREMFYA- GUSELKUMAB SOLN pen-

1 pen / 56 days

INJECTOR 100 MG/ML 1

TRMFYA- GUSELKUMAB SOLN

1 syringe / 56 days

PREFILLED SYRINGE 1
triamcinolone aer spray

126 grams / 30 days

triamcinolone cre 0.025%

454 grams / 30 days

triamcinolone cre 0.1%

454 grams / 30 days

triamcinolone cre 0.5%

454 grams / 30 days

triamcinolone lot 0.025%

120 MLS / 30 days

triamcinolone lot 0.1%

120 MLS / 30 days

triamcinolone oin 0.025%

454 grams / 30 days

triamcinolone oin 0.05%

430 grams / 30 days

triamcinolone oin 0.1%

454 grams / 30 days

triamcinolone oin 0.5%

120 grams / 30 days

trianex oin 0.05%

430 grams / 30 days

triderm cre 0.1%

454 grams / 30 days

triderm cre 0.5%

454 grams / 30 days

TRIDESILON CRE 0.05%

120 grams / 30 days

tritocin oin 0.05%

430 grams / 30 days

ULTRAVATE LOT 0.05%

240 MLS / 30 days

VANOS CRE 0.1%

240 grams / 28 days

VERDESO AER 0.05%

100 grams / 30 days

ZTLIDO PAD 1.8%

90 patches / 30 days

Digestive aids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

SUCRAID SOL 8500/ML

236 MLS / 28 days

Diuretics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

KEVEYIS tab 50MG 2

120 tabs / 30 days

Endocrine and metabolic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTONEL tab 150MG

1 tab / 28 days

ACTONEL tab 35MG

4 tabs / 28 days

alendronate tab 35mg

4 tabs / 28 days

alendronate tab 70mg

4 caps / 28 days

ATELVIA tab

4 tabs / 28 days

BINOSTO tab 70MG

4 tabs / 28 days

BONIVA tab 150MG

1 tab / 28 days

BYNFEZIA pen INJ 2500MCG

2 pens / 30 days

CETROTIDE KIT 0.25MG 1

5 KITS / 30 days

CHOR GONADOT INJ 10000UNT 1

2 vials / 30 days

EGRIFTA SOL 1MG 1

60 vials / 30 days

EGRIFTA SV INJ 2MG 1

30 vials / 30 days

FOLLISTIM AQ INJ 300UNIT 1

15 cartS / 30 days

FOLLISTIM AQ INJ 600UNIT 1

8 cartS / 30 days

FOLLISTIM AQ INJ 900UNIT 1

5 cartS / 30 days

FORTEO INJ 620/2.48 1

1 pen / 28 days

FOSAMAX tab 70MG

4 caps / 28 days

FOSAMAX 4 D tab 70-2800

4 caps / 28 days

FOSAMAX 4 D tab 70-5600

4 caps / 28 days

GALAFOLD CAP 123MG 1

14 caps / 28 days

GANIRELIX AC INJ 250/0.5

5 syringes / 30 days

GANIRELIX AC INJ 250/0.5 1

5 syringes / 30 days

ganirelix ac inj 250/0.5 1

5 syringes / 30 days

GONAL-F INJ 1050UNIT 1

4 syringes / 30 days

GONAL-F INJ 450UNIT 1

10 syringes / 30 days

GONAL-F RFF INJ 300/0.5 1

15 pens / 30 days

GONAL-F RFF INJ 450/0.75 1

10 pens / 30 days

GONAL-F RFF INJ 75UNIT 1

20 syringes / 30 days

GONAL-F RFF INJ 900/1.5 1

5 pens / 30 days

ibandronate tab 150mg

1 tab / 28 days

ISTURISA tab 10MG 2

180 tabs / 30 days

ISTURISA tab 1MG 2

240 tabs / 30 days

ISTURISA tab 5MG 2

300 tabs / 30 days

JYNARQUE PAK 30-15MG 1

56 tabs / 28 days

JYNARQUE PAK 45-15MG 1

56 tabs / 28 days

JYNARQUE PAK 60-30MG 1

56 tabs / 28 days

JYNARQUE PAK 90-30MG 1

56 tabs / 28 days

JYNARQUE tab 30MG 1

30 tabs / 30 days

JYNARQUE- TOLVAPTAN tab 15 MG 1

60 tabs / 30 days

JYNARQUE- TOLVAPTAN tab
THERAPY PACK 15 MG 1

56 tabs / 28 days

KERENDIA tab 10MG

30 tabs / 30 days

KERENDIA tab 20MG

30 tabs / 30 days

MENOPUR INJ 75UNIT 1

60 vials / 30 days

MYCAPSSA CAP 20MG

120 caps / 30 days

NATPARA INJ 100MCG 1

1 kit / 28 days

NATPARA INJ 25MCG 1

1 kit / 28 days

NATPARA INJ 50MCG 1

1 kit / 28 days

NATPARA INJ 75MCG 1

1 kit / 28 days

NOCTIVA SPR 1.66/0.1

1 bottle / 30 days

NOVAREL INJ 10000UNT 1

2 vials / 30 days

NOVAREL INJ 5000UNIT 1

4 vials / 30 days

ORILISSA tab 150MG

30 tabs / 30 days

ORILISSA tab 200MG

60 tabs / 30 days

OVIDREL INJ 1

2 syringes / 30 days

PREGNYL INJ 10000UNT 1

2 vials / 30 days

risedronate sod tab 35mg dr

4 tabs / 28 days

risedronate tab 150mg

1 tab / 28 days

risedronate tab 35mg

4 tabs / 28 days

SAMSCA tab 15MG 1

30 tabs / 365 days

SAMSCA tab 30MG 1

60 tabs / 365 days

SIGNIFOR INJ 0.3MG/ML 2

60 MLS / 30 days

SIGNIFOR INJ 0.6MG/ML 2

60 MLS / 30 days

SIGNIFOR INJ 0.9MG/ML 2

60 MLS / 30 days

SOMAVERT INJ 10MG 1

30 vials / 30 days

SOMAVERT INJ 15MG 1

30 vials / 30 days

SOMAVERT INJ 20MG 1

30 vials / 30 days

SOMAVERT INJ 25MG 1

30 vials / 30 days

SOMAVERT INJ 30MG 1

30 vials / 30 days

TERIPARATIDE INJ 1

1 pen / 28 days

TOLVAPTAN tab 15MG 1

30 tabs / 365 days

tolvaptan (SAMSCA) tab 30mg 1

60 tabs / 365 days

tolvaptan (JYNARQUE) tab 30mg 1

30 tabs / 30 days

TYMLOS INJ 1

1 pen / 30 days

Estrogens

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ORIAHNN CAP

56 caps / 28 days

Gastrointestinal agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

alosetron tab 0.5mg

60 tabs / 30 days

alosetron tab 1mg

60 tabs / 30 days

AMITIZA CAP 24MCG

60 caps / 30 days

AMITIZA CAP 8MCG

120 caps / 30 days

CIMZIA PREFL KIT 200MG/ML 1

2 KITS / 28 days

CIMZIA START KIT 200MG/ML 1

1 kit / 180 days

LINZESS CAP 145MCG

30 caps / 30 days

LINZESS CAP 290MCG

30 caps / 30 days

LINZESS CAP 72MCG

30 caps / 30 days

LOTRONEX tab 0.5MG

60 tabs / 30 days

LOTRONEX tab 1MG

60 tabs / 30 days

LUBIPROSTONE CAP 8MCG

120 caps / 30 days

LUBIPROSTONE CAP 24MCG

60 caps / 30 days

MOTEGRITY tab 1MG

30 tabs / 30 days

MOTEGRITY tab 2MG

30 tabs / 30 days

MOVANTIK tab 12.5MG

30 tabs / 30 days

MOVANTIK tab 25MG

30 tabs / 30 days

OCALIVA tab 10MG 1

30 tabs / 30 days

OCALIVA tab 5MG 1

30 tabs / 30 days

RELISTOR INJ 8/0.4ML

30 syringes / 30 days

RELISTOR tab 150MG

90 tabs / 30 days

RELISTOR- METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML)

60 vials / 30 days

RELISTOR- METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML)

30 syringes / 30 days

SYMPROIC tab 0.2MG

30 tabs / 30 days

TRULANCE tab 3MG

30 tabs / 30 days

VIBERZI tab 100MG

60 tabs / 30 days

VIBERZI tab 75MG

60 tabs / 30 days

XERMELO tab 250MG 2

90 tabs / 30 days

ZELNORM tab 6MG

60 tabs / 30 days

Hematological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EMPAVELI INJ 1080MG

8 vials / 28 days

FIRAZYR INJ 30MG/3ML 1

6 syringes / 30 days

HAEGARDA INJ 2000UNIT 2

24 vials / 30 days

HAEGARDA INJ 3000UNIT 2

16 vials / 30 days

HEMLIBRA INJ 105/0.7 1

4 vials / 28 days

HEMLIBRA INJ 150/ML 1

4 vials / 28 days

HEMLIBRA INJ 30MG/ML 1

4 vials / 28 days

HEMLIBRA INJ 60/0.4 1

4 vials / 28 days

icatibant inj 30mg/3ml 1

6 syringes / 30 days

ORLADEYO CAP 110MG 2

30 caps / 30 days

ORLADEYO CAP 150MG 2

30 caps / 30 days

sajazir inj 30mg/3ml 1

6 syringes / 30 days

TAKHZYRO INJ 300/2ML 2

4 MLS / 28 days

Hematopoietic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CERDELGA CAP 84MG 1

60 caps / 30 days

miglustat cap 100mg 1

90 caps / 30 days

MULPLETA tab 3MG 1

7 tabs / 7 days

OXBRYTA tab 500MG 2

90 tabs / 30 days

PROMACTA PAK 25MG 1

30 PACKS / 30 days

PROMACTA POW 12.5MG 1

30 packets / 30 days

PROMACTA tab 12.5MG 1

30 tabs / 30 days

PROMACTA tab 25MG 1

30 tabs / 30 days

PROMACTA tab 50MG 1

60 tabs / 30 days

PROMACTA tab 75MG 1

60 tabs / 30 days

ZAVESCA CAP 100MG 2

90 caps / 30 days

Hypnotics / sedatives / sleep disorder agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMBIEN tab 10MG

30 tabs / 30 days

AMBIEN tab 5MG

30 tabs / 30 days

AMBIEN CR tab 12.5MG

30 tabs / 30 days

AMBIEN CR tab 6.25MG

30 tabs / 30 days

BELSOMRA tab 10MG

30 tabs / 30 days

BELSOMRA tab 15MG

30 tabs / 30 days

BELSOMRA tab 20MG

30 tabs / 30 days

BELSOMRA tab 5MG

30 tabs / 30 days

DAYVIGO tab 10MG

30 tabs / 30 days

DAYVIGO tab 5MG

30 tabs / 30 days

doxepin tab 3mg

30 tabs / 30 days

doxepin tab 6mg

30 tabs / 30 days

EDLUAR SUB 10MG

30 tabs / 30 days

EDLUAR SUB 5MG

30 tabs / 30 days

eszopiclone tab 1mg

30 tabs / 30 days

eszopiclone tab 2mg

30 tabs / 30 days

eszopiclone tab 3mg

30 tabs / 30 days

HETLIOZ CAP 20MG 2

30 caps / 30 days

HETLIOZ LQ SUS 4MG/ML 2

158 MLS / 30 days

INTERMEZZO SUB 1.75MG

30 tabs / 30 days

LUNESTA tab 1MG

30 tabs / 30 days

LUNESTA tab 2MG

30 tabs / 30 days

LUNESTA tab 3MG

30 tabs / 30 days

ramelteon tab 8mg

30 tabs / 30 days

ROZEREM tab 8MG

30 tabs / 30 days

SILENOR tab 3MG

30 tabs / 30 days

SILENOR tab 6MG

30 tabs / 30 days

zaleplon cap 10mg

30 caps / 30 days

zaleplon cap 5mg

30 caps / 30 days

zolpidem tab 10mg

30 tabs / 30 days

zolpidem tab 5mg

30 tabs / 30 days

zolpidem er tab 12.5mg

30 tabs / 30 days

zolpidem er tab 6.25mg

30 tabs / 30 days

zolpidem tar sub 1.75mg

30 tabs / 30 days

zolpidem tar sub 3.5mg

30 tabs / 30 days

ZOLPIMIST SPR 5MG

1 can / 30 days

Medical devices and supplies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DEXCOM G5 MIS RECEIVER

1 UNIT / 365 days

DEXCOM G5 MIS TRANSMIT

1 UNIT / 84 days

DEXCOM G6 MIS RECEIVER

1 UNIT / 365 days

DEXCOM G6 MIS SENSOR

3 UNITS / 30 days

DEXCOM G6 MIS TRANSMIT

1 UNIT / 90 days

FREESTY LIBR MIS 2 READER

1 READER / 365 days

FREESTYLE MIS READER

1 UNIT / 365 days

FREESTYLE LIBRE 14

day/SENSOR/FLASH MONITORING SYSTEM-CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR

2 UNITS / 28 days

FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM-CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR

2 SENSRS / 28 days

FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM-CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR

3 UNITS / 30 days

G5/G4 MIS SENSOR

4 UNITS / 28 days

Migraine products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AIMOVIG INJ 140MG/ML 1

1 INJ / 28 days

AIMOVIG INJ 70MG/ML 1

1 INJ / 28 days

AJOVY INJ 225/1.5 1

3 syringes / 84 days

almotrip mal tab 12.5mg

12 tabs / 30 days

almotrip mal tab 6.25mg

24 tabs / 30 days

almotriptan tab 12.5mg

12 tabs / 30 days

almotriptan tab 6.25mg

24 tabs / 30 days

AMERGE tab 1MG

18 tabs / 30 days

AMERGE tab 2.5MG

18 tabs / 30 days

dihydroergot spr 4mg/ml

8 MLS / 28 days

eletriptan tab 20mg

18 tabs / 30 days

eletriptan tab 40mg

12 tabs / 30 days

EMGALITY INJ 100MG/ML 1

9 syringes / 180 days

EMGALITY INJ 120MG/ML 1

1 syringe / 28 days

FROVA tab 2.5MG

27 tabs / 30 days

frovatriptan tab 2.5mg

27 tabs / 30 days

IMITREX INJ 4MG/0.5

12 syringes / 30 days

IMITREX SPR 20MG/ACT

12 inhalerS / 30 days

IMITREX SPR 5MG/ACT

5 PACKS / 30 days

IMITREX tab 100MG

18 tabs / 30 days

IMITREX tab 25MG

27 tabs / 30 days

IMITREX tab 50MG

18 tabs / 30 days

IMITREX STATDOSE REFILL-

SUMATRIPTAN SUCCINATE SOLUTION cartRIDGE 6 MG/0.5ML

12 cartS / 30 days

IMITREX STATDOSE SYSTEM-SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML

12 syringes / 30 days

IMITREX- SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML

12 syringes / 30 days

MAXALT tab 10MG

18 tabs / 30 days

MAXALT-MLT tab 10MG

18 tabs / 30 days

MIGRANAL SPR 4MG/ML

8 MLS / 28 days

naratriptan tab 1mg

18 tabs / 30 days

naratriptan tab 2.5mg

18 tabs / 30 days

NURTEC tab 75MG ODT

45 tabs / 90 days

ONZETRA XSAI MIS 11MG

32 inhalerS / 30 days

RELPAX tab 20MG

18 tabs / 30 days

RELPAX tab 40MG

12 tabs / 30 days

REYVOW tab 100MG

8 tabs / 30 days

REYVOW tab 50MG

8 tabs / 30 days

rizatriptan tab 10mg

18 tabs / 30 days

rizatriptan tab 10mg odt

18 tabs / 30 days

rizatriptan tab 5mg

36 tabs / 30 days

rizatriptan tab 5mg odt

36 tabs / 30 days

sumat-naprox tab 85-500mg

18 tabs / 30 days

SUMATRIPTAN INJ 6MG/0.5

12 syringes / 30 days

sumatriptan spr 20mg/act

12 inhalerS / 30 days

sumatriptan spr 5mg/act

5 PACKS / 30 days

sumatriptan tab 100mg

18 tabs / 30 days

sumatriptan tab 25mg

27 tabs / 30 days

sumatriptan tab 50mg

18 tabs / 30 days

sumatriptan succinate inj 6 mg/0.5ml

12 syringes / 30 days

sumatriptan succinate solution auto-injector 4 mg/0.5ml

12 syringes / 30 days

sumatriptan succinate solution auto-injector 6 mg/0.5ml

12 syringes / 30 days

sumatriptan succinate solution cartridge 4 mg/0.5ml

12 cartS / 30 days

sumatriptan succinate solution cartridge

6 mg/0.5ml

12 cartS / 30 days

TREXIMET tab 85-500MG

18 tabs / 30 days

UBRELVY tab 100MG

16 tabs / 30 days

UBRELVY tab 50MG

16 tabs / 30 days

ZEMBRACE SYM INJ 3/0.5ML

24 pens / 30 days

ZOLMITRIPTAN SPR 2.5MG

3 sprays / 30 days

zolmitriptan tab 2.5 mg

18 tabs / 30 days

zolmitriptan tab 2.5mg

18 tabs / 30 days

zolmitriptan tab 5mg

12 tabs / 30 days

zolmitriptan tab 5mg odt

12 tabs / 30 days

ZOMIG SPR 2.5MG

3 sprays / 30 days

ZOMIG SPR 5MG

2 sprays / 30 days

ZOMIG tab 2.5MG

18 tabs / 30 days

ZOMIG tab 5MG

12 tabs / 30 days

ZOMIG ZMT tab 2.5 MG

18 tabs / 30 days

Miscellaneous therapeutic classes

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BENLYSTA INJ 200MG/ML 1

4 syringes / 28 days

ENSPRYNG INJ 1

1 syringe / 28 days

LUPKYNIS CAP 7.9MG

180 caps / 30 days

REVLIMID CAP 10MG 1

30 caps / 30 days

REVLIMID CAP 15MG 1

21 caps / 28 days

REVLIMID CAP 2.5MG 1

30 caps / 30 days

REVLIMID CAP 20MG 1

21 caps / 28 days

REVLIMID CAP 25MG 1

21 caps / 28 days

REVLIMID CAP 5MG 1

30 caps / 30 days

THALOMID CAP 100MG 1

30 caps / 30 days

THALOMID CAP 150MG 1

60 caps / 30 days

THALOMID CAP 200MG 1

60 caps / 30 days

THALOMID CAP 50MG 1

30 caps / 30 days

ZOKINVY CAP 50MG 2

120 caps / 30 days

ZOKINVY CAP 75MG 2

120 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMRIX CAP 15MG

21 caps / 90 days

AMRIX CAP 30MG

21 caps / 90 days

baclofen tab 10mg

120 tabs / 30 days

baclofen tab 20mg

120 tabs / 30 days

baclofen tab 5mg

120 tabs / 30 days

CARISOPR/ASA tab 200-325

168 tabs / 90 days

carisoprodol/asa tab 200-325

168 tabs / 90 days

carisoprodol tab 250mg

84 tabs / 90 days

carisoprodol tab 350mg

84 tabs / 90 days

CARISOPRODOL tab ASA/COD

168 tabs / 30 days

carisoprodol tab asa/cod

168 tabs / 90 days

chlorzoxazone tab 250mg

84 tabs / 90 days

chlorzoxazone tab 375mg

84 tabs / 90 days

chlorzoxazone tab 500mg

84 tabs / 90 days

chlorzoxazone tab 750mg

84 tabs / 90 days

cyclobenzaprine cap 15mg er

21 caps / 90 days

cyclobenzaprine cap 30mg er

21 caps / 90 days

cyclobenzaprine tab 10mg

63 tabs / 90 days

cyclobenzaprine tab 5mg

63 tabs / 90 days

cyclobenzaprine tab 7.5mg

63 tabs / 90 days

DANTRIUM CAP 25MG

90 caps / 30 days

DANTRIUM CAP 50MG

90 caps / 30 days

dantrolene cap 100mg

90 caps / 30 days

dantrolene cap 25mg

90 caps / 30 days

dantrolene cap 50mg

90 caps / 30 days

FEXMID tab 7.5MG

63 tabs / 90 days

lorzone tab 375mg

84 tabs / 90 days

lorzone tab 750mg

84 tabs / 90 days

metaxalone tab 400mg

168 tabs / 90 days

metaxalone tab 800mg

84 tabs / 90 days

methocarbam tab 500mg

180 tabs / 90 days

methocarbam tab 750mg

132 tabs / 90 days

orphenadrine tab 100mg cr

42 tabs / 30 days

orphenadrine tab 100mg er

42 tabs / 30 days

ROBAXIN-750 tab 750MG

132 tabs / 90 days

SKELAXIN tab 800MG

84 tabs / 90 days

SOMA tab 250MG

84 tabs / 90 days

SOMA tab 350MG

84 tabs / 90 days

tizanidine cap 2mg

126 caps / 90 days

tizanidine cap 4mg

126 caps / 90 days

tizanidine cap 6mg

126 caps / 90 days

tizanidine tab 2mg

126 tabs / 90 days

tizanidine tab 4mg

42 caps / 30 days

vanadom tab 350mg

84 tabs / 90 days

ZANAFLEX CAP 2MG

126 caps / 90 days

ZANAFLEX CAP 4MG

126 caps / 90 days

ZANAFLEX CAP 6MG

126 caps / 90 days

ZANAFLEX tab 4MG

42 tabs / 30 days

Nasal agents – systemic and topical

Drug name(s)

Quantity limits 
(per 30 days or as specified)

azelastine /fluticasone spr 137-50

1 bottle / 30 days

azelastine spr 0.1%

2 bottleles / 30 days

azelastine spr 0.15%

2 bottleles / 30 days

BECONASE AQ SUS 0.042%

2 bottleles / 30 days

DYMISTA SPR 137-50

1 bottle / 30 days

FLUNISOLIDE SPR 0.025%

3 bottleles / 30 days

ipratropium spr 0.03%

2 bottleles / 30 days

ipratropium spr 0.06%

3 bottleles / 30 days

mometasone spr 50mcg

2 bottleles / 30 days

NASONEX SPR 50MCG/AC

2 bottleles / 30 days

olopatadine spr 0.6%

1 bottle / 30 days

OMNARIS SPR

1 bottle / 30 days

PATANASE SPR 0.6%

1 bottle / 30 days

QNASL AER 80MCG

1 can / 30 days

QNASL CHILD SPR 40MCG

1 can / 30 days

XHANCE MIS 93MCG

2 bottleles / 30 days

ZETONNA AER 37MCG

1 can / 30 days

Neuromuscular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EVRYSDI SOL 2

240 MLS / 30 days

Ophthalmic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

bimatoprost sol 0.03%

2.5 MLS / 30 days

EYSUVIS DRO 0.25%

2 bottleles / 90 days

latanoprost sol 0.005%

2.5 MLS / 30 days

LUMIGAN SOL 0.01%

2.5 MLS / 30 days

OXERVATE SOL 20MCG/ML 2

56 vials / 56 days

RESTASIS EMU 0.05%

2 vials / 30 days

RESTASIS MUL EMU 0.05%

1 bottle / 30 days

RHOPRESSA SOL 0.02%

2.5 MLS / 30 days

ROCKLATAN DRO

2.5 MLS / 30 days

TRAVATAN Z DRO 0.004%

2.5 MLS / 30 days

travoprost dro 0.004%

2.5 MLS / 30 days

VYZULTA SOL 0.024%

2.5 MLS / 30 days

XALATAN SOL 0.005%

2.5 MLS / 30 days

XIIDRA DRO 5%

60 vials / 30 days

ZIOPTAN DRO 0.0015%

30 cartNS / 30 days

Psychotherapeutic and neurological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADDYI tab 100MG

30 tabs / 30 days

AMPYRA tab 10MG 1,3

60 tabs / 30 days

AUBAGIO tab 7MG 1,3

30 tabs / 30 days

AUBAGIO tab 14MG 1,3

30 tabs / 30 days

AUSTEDO tab 6MG 1

60 tabs / 30 days

AUSTEDO tab 9MG 1

120 tabs / 30 days

AUSTEDO tab 12MG 1

120 tabs / 30 days

AVONEX pen KIT 30MCG 1

1 kit / 28 days

AVONEX PREFL KIT 30MCG 1

1 kit / 28 days

BAFIERTAM CAP 95MG

120 caps / 30 days

BETASERON INJ 0.3MG 1

1 BOX / 28 days

COPAXONE INJ 20MG/ML 1

30 syringes / 30 days

COPAXONE INJ 40MG/ML 1

12 syringes / 28 days

dalfampridine tab 10mg er 1,3

60 tabs / 30 days

dimethyl fumarate cap 120mg dr 1

56 caps / 180 days

dimethyl fumarate cap 240mg dr 1

60 caps / 30 days

dimethyl fumarate mis starter 1

60 caps / 180 days

EXTAVIA INJ 0.3MG 1

15 vials / 30 days

GILENYA CAP 0.5MG 1

30 tabs / 30 days

glatiramer inj 20mg/ml 1

30 syringes / 30 days

glatiramer inj 40mg/ml 1

12 syringes / 28 days

glatopa inj 20mg/ml 1

30 syringes / 30 days

glatopa inj 40mg/ml 1

12 syringes / 28 days

INGREZZA CAP 40-80MG 2

28 caps / 180 days

INGREZZA CAP 40MG 2

30 caps / 30 days

INGREZZA CAP 60MG 2

30 caps / 30 days

INGREZZA CAP 80MG 2

30 caps / 30 days

KESIMPTA INJ 20/.4ML 1

1 syringe / 28 days

LYRICA CR tab 82.5MG

30 tabs / 30 days

LYRICA CR tab 165MG

30 tabs / 30 days

LYRICA CR tab 330MG

60 tabs / 30 days

Psychotherapeutic and neurological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

MAYZENT PAK STARTER

12 tabs / 180 days

MAYZENT tab 0.25MG 1

120 tabs / 30 days

MAYZENT tab 2MG 1

30 tabs / 30 days

PLEGRIDY INJ 1

2 syringes / 28 days

PLEGRIDY INJ pen 1

2 pens / 28 days

PLEGRIDY INJ STARTER 1

1 kit / 180 days

PLEGRIDY pen INJ STARTER 1

1 kit / 180 days

PONVORY tab 20MG

30 tabs / 30 days

PONVORY tab STARTER

14 tabs / 180 days

pregabalin er tab 82.5mg

30 tabs / 30 days

pregabalin er tab 165mg

30 tabs / 30 days

pregabalin er tab 330mg

60 tabs / 30 days

REBIF INJ 22/0.5 1

12 syringes / 28 days

REBIF INJ 44/0.5 1

1 carton / 28 days

REBIF REBIDO INJ 22/0.5 1

1 carton / 28 days

REBIF REBIDO INJ 44/0.5 1

1 carton / 28 days

REBIF REBIDO INJ TITRATN 1

1 kit / 180 days

REBIF TITRTN INJ PACK 1

1 kit / 180 days

SAVELLA MIS TITR PAK

1 kit / 180 days

SAVELLA tab 12.5MG

60 tabs / 30 days

SAVELLA tab 25MG

60 tabs / 30 days

SAVELLA tab 50MG

60 tabs / 30 days

SAVELLA tab 100MG

60 tabs / 30 days

TECFIDERA CAP 120MG 1

56 caps / 180 days

TECFIDERA CAP 240MG 1

60 caps / 30 days

TECFIDERA MIS STARTER 1

60 caps / 180 days

TEGSEDI INJ 284/1.5 2

6 MLS / 28 days

tetrabenazine tab 12.5mg4

240 tabs / 30 days

tetrabenazine tab 12.5mg1,4

240 tabs / 30 days

tetrabenazine tab 25mg4

120 tabs / 30 days

tetrabenazine tab 25mg1,4

120 tabs / 30 days

VUMERITY- DIROXIMEL FUMARATE CAPSULE DELAYED RELEASE 231 MG1

120 caps / 30 days

VUMERITY- DIROXIMEL FUMARATE CAPSULE DR STARTER bottlele 231 MG 1

106 caps / 180 days

VYLEESI INJ 1.75/0.3

6 pens / 30 days

XENAZINE tab 12.5MG 1

240 tabs / 30 days

XENAZINE tab 25MG 1

120 tabs / 30 days

Respiratory agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ESBRIET CAP 267MG 1

180 caps / 30 days

ESBRIET tab 267MG 1

180 tabs / 30 days

ESBRIET tab 801MG 1

90 tabs / 30 days

KALYDECO PAK 25MG 1

60 packets / 30 days

KALYDECO PAK 50MG 1

60 packets / 30 days

KALYDECO PAK 75MG 1

60 packets / 30 days

KALYDECO tab 150MG 1

60 tabs / 30 days

OFEV CAP 100MG 1,3_

60 caps / 30 days

OFEV CAP 150MG 1,3_

60 caps / 30 days

ORKAMBI tab 100-125 1

120 tabs / 30 days

ORKAMBI tab 200-125 1

120 tabs / 30 days

SYMDEKO tab 100-150 1

60 tabs / 30 days

SYMDEKO tab 50-75MG 1

56 tabs / 28 days

TRIKAFTA tab

100mg/50mg/75mg/150mg1

90 tabs / 30 days

Ulcer drugs / antispasmodics / anticholinergics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACIPHEX tab 20MG

30 tabs / 30 days

DEXILANT CAP 30MG DR

30 caps / 30 days

DEXILANT CAP 60MG DR

30 caps / 30 days

esomeprazole magnesium cap 40mg dr

30 caps / 30 days

lansoprazole cap 15mg dr

30 caps / 30 days

lansoprazole cap 30mg dr

30 caps / 30 days

NEXIUM CAP 40MG

30 caps / 30 days

omeprazole/bicarbinate cap 20-1100

30 caps / 30 days

omeprazole/ bicarbinate cap 40-1100

30 caps / 30 days

omeprazole/ bicarbinate pow 20-1680

30 packets / 30 days

omeprazole/ bicarbinate pow 40-1680

30 packets / 30 days

omeprazole cap 10mg

30 caps / 30 days

omeprazole cap 20mg

30 caps / 30 days

omeprazole cap 40mg

30 caps / 30 days

pantoprazole tab 20mg

30 tabs / 30 days

pantoprazole tab 20mg dr

30 tabs / 30 days

pantoprazole tab 40mg

30 tabs / 30 days

pantoprazole tab 40mg dr

30 tabs / 30 days

PREVACID CAP 15MG DR

30 caps / 30 days

PREVACID CAP 30MG DR

30 caps / 30 days

PROTONIX tab 20MG

30 tabs / 30 days

PROTONIX tab 40MG

30 tabs / 30 days

rabeprazole tab 20mg

30 tabs / 30 days

ZEGERID CAP 20-1100

30 caps / 30 days

ZEGERID CAP 40-1100

30 caps / 30 days

ZEGERID POW 20-1680

30 packets / 30 days

ZEGERID POW 40-1680

30 packets / 30 days

Urinary antispasmodics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

darifenacin tab 7.5mg

30 tabs / 30 days

darifenacin tab 15mg

30 tabs / 30 days

DETROL tab 1MG

60 tabs / 30 days

DETROL tab 2MG

60 tabs / 30 days

DETROL LA CAP 2MG

30 caps / 30 days

DETROL LA CAP 4MG

30 caps / 30 days

DITROPAN XL tab 5MG

30 tabs / 30 days

DITROPAN XL tab 10MG

60 tabs / 30 days

ENABLEX tab 7.5MG

30 tabs / 30 days

ENABLEX tab 15MG

30 tabs / 30 days

GELNIQUE GEL 10%

30 packets / 30 days

GEMTESA tab 75MG 30 tabs / 30 days

N/A

MYRBETRIQ SUS 8MG/ML

300 MLS / 28 days

MYRBETRIQ tab 25MG

30 tabs / 30 days

MYRBETRIQ tab 50MG

30 tabs / 30 days

oxybutynin syp 5mg/5ml

600 MLS / 30 days

oxybutynin tab 5mg

120 tabs / 30 days

oxybutynin tab 5mg er

30 tabs / 30 days

oxybutynin tab 10mg er

60 tabs / 30 days

oxybutynin tab 15mg er

60 tabs / 30 days

solifenacin tab 10mg

30 tabs / 30 days

solifenacin tab 5mg

30 tabs / 30 days

tolterodine cap 2mg er

30 caps / 30 days

tolterodine cap 4mg er

30 caps / 30 days

tolterodine tab 1mg

60 tabs / 30 days

tolterodine tab 2mg

60 tabs / 30 days

TOVIAZ tab 4MG

30 tabs / 30 days

TOVIAZ tab 8MG

30 tabs / 30 days

trospium chl cap 60mg er

30 caps / 30 days

trospium cl tab 20mg

60 tabs / 30 days

VESICARE tab 10MG

30 tabs / 30 days

VESICARE tab 5MG

30 tabs / 30 days

Vaginal and related products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CRINONE GEL 4% VAG

6 APPLCS / 30 days

CRINONE GEL 8% VAG

60 APPLCS / 30 days

ENDOMETRIN SUP 100MG

84 SUPPS / 28 days

Vasopressors

Drug name(s)

Quantity limits 
(per 30 days or as specified)

droxidopa cap 100mg (NOTHERA)4

450 caps / 30 days

droxidopa cap 100mg (NOTHERA)1,4

450 caps / 30 days

droxidopa cap 200mg (NOTHERA)4

180 caps / 30 days

droxidopa cap 200mg (NOTHERA)1,4

180 caps / 30 days

droxidopa cap 300mg (NOTHERA)4

180 caps / 30 days

droxidopa cap 300mg (NOTHERA)1,4

180 caps / 30 days

NORTHERA CAP 100MG 1

450 caps / 30 days

NORTHERA CAP 200MG 1

180 caps / 30 days

NORTHERA CAP 300MG 1

180 caps / 30 days

Specialty

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

Drug name(s)

abiraterone acetate1

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADCIRCA1

ADEMPAS2,4

ADVATE1

ADYNOVATE1

AFINITOR1,3

AFINITOR DISPERZ1,3

AFSTYLA1

ALECENSA2,3,4

ALPHANINE SD1

ALPROLIX1

ALUNBRIG2

alyq1

ambrisentan1

AMPYRA1,3

ARCALYST2,4

ARIKAYCE2

AUBAGIO1,3

AUSTEDO1

AVONEX1,4

AVONEX PEN1,4

AYVAKIT2,3

BALVERSA2,3

BENEFIX1

BENLYSTA1

BETASERON1,4

BETHKIS1

bexarotene1,3

bosentan1

BOSULIF1,3

BRAFTOVI2,4

BRUKINSA2

BUPHENYL1

CABOMETYX1,3

CALQUENCE2

capecitabine1,4

CAPRELSA2

CARBAGLU2,4

CAYSTON1

CERDELGA1

CETROTIDE1,4

CHORIONIC GONADOTROPIN1

CIMZIA STARTER KIT1

cinacalcet1

COMETRIQ2,3,4

COPAXONE1,4

COPIKTRA2,3

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

CUTAQUIG2,4

CUVITRU2,4

dalfampridine er1,3

DAURISMO1,3

deferasirox1,3

dimethyl fumarate1

dimethyl fumarate starterpack1

DOJOLVI2,4

droxidopa1

DUPIXENT1

EGRIFTA1

EGRIFTA SV1

ELOCTATE1

EMFLAZA2,4

ENBREL1,4

ENBREL MINI1,4

ENBREL SURECLICK1,4

ENDARI2

ENSPRYNG1

EPCLUSA1

EPIDIOLEX1

ERIVEDGE1,3

erlotinib hcl1,3

ESBRIET1

ESPEROCT1

EVRYSDI2,4

EXJADE1,3

EXTAVIA1

FARYDAK*

FINTEPLA2

FIRAZYR1

FIRDAPSE2

FOLLISTIM AQ1,4

FORTEO1,4

GALAFOLD1

ganirelix ac1,4

GATTEX2,4

GAVRETO2,3,4

GENOTROPIN1,4

GENOTROPIN MINIQUICK1,4

GILENYA1

GILOTRIF2,4

glatiramer acetate1,4

glatopa1

GLEEVEC1,3

GOCOVRI1,3

GONAL-F1,4

GONAL-F RFF1,4

GONAL-F RFF REDIJECT1,4

GRANIX1

HAEGARDA2,4

HARVONI1,4

HEMLIBRA1

HEMOFIL M1

HETLIOZ2,3,4

HETLIOZ LQ2,3,4

HIZENTRA1

HUMATROPE1,4

HUMIRA1,4

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1,4

HUMIRA PEN1,4

HUMIRA PEN-CD/UC/HS STARTER1,4

HUMIRA PEN-PEDIATRIC UC STARTER PACK1,4

HUMIRA PEN-PS/UV STARTER1,4

HYCAMTIN1

HYQVIA1

IBRANCE1

icatibant acetate1

ICLUSIG2,3

IDELVION1

IDHIFA1

imatinib mesylate *

IMBRUVICA2

IMCIVREE2

INGREZZA2

INLYTA1,3

INQOVI1

INREBIC1,3,4

INTRON A1

IRESSA2,3,4

ISTURISA2

IXINITY1

JADENU1,3

JADENU SPRINKLE1,3

JAKAFI1,3

JIVI1

JUXTAPID2,4

JYNARQUE1

KALYDECO1

KESIMPTA1,4

KEVEYIS2

KEVZARA1

KINERET2

KISQALI1

KITABIS PAK1

KOATE1

KOATE-DVI1

KOGENATE FS1

KORLYM2

KOSELUGO2

KOVALTRY1

KUVAN1

lapatinib ditosylate1,4

LEDIPASVIR / SOFOSBUVIR1,4

LENVIMA2,3,4

LETAIRIS1

LONSURF1

LORBRENA1,3

LYNPARZA2,3,4

MATULANE1

MAVYRET1,4

MAYZENT1

MEKINIST1

MEKTOVI2,4

MENOPUR1

miglustat1

MONONINE1

MULPLETA1

MYALEPT2,4

NATPARA1

NERLYNX2,3,4

NEULASTA1,4

NEULASTA ONPRO KIT1,4

NEXAVAR1,3

NINLARO1

NORDITROPIN FLEXPRO1,4

NORTHERA1

NOVAREL1,4

NOVOEIGHT1

NUBEQA1

NUPLAZID1

NUTROPIN AQ NUSPIN1,4

NUWIQ1

OCALIVA1

ODOMZO1,3

OFEV1,3

OLUMIANT1

OMNITROPE1

ONUREG1

OPSUMIT2,4

ORENCIA1

ORENCIA CLICKJECT1

ORENITRAM2,4

ORGOVYX2

ORKAMBI1

ORLADEYO2

OTEZLA1

OVIDREL1,4

OXBRYTA2,4

OXERVATE2,4

PEGINTRON1,4

PEMAZYRE2

PIQRAY1

PLEGRIDY1

PLEGRIDY STARTER PACK1

POMALYST1

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1,4

PROCRIT1,4

PROCYSBI2,4

PROFILNINE1

PROFILNINE SD1

PROMACTA1

QINLOCK2

RAVICTI1

REBIF1,4

REBIF REBIDOSE1,4

REBIF REBIDOSE TITRATION PACK1,4

REBIF TITRATION PACK1,4

REBINYN1

RECOMBINATE1

RETEVMO1,3

REVATIO1

REVLIMID1

RINVOQ1

RIXUBIS1

ROZLYTREK1,3,4

RUBRACA2,3,4

RUZURGI2

RYDAPT1

sajazir1

SAMSCA1

sapropterin dihydrochloride1

SENSIPAR1

SEROSTIM1,4

SIGNIFOR2

sildenafil sus 10mg/ml1

sildenafil tab 20mg1

SILIQ1

SIMPONI1

SKYRIZI1

SKYRIZI PEN1

sodium phenylbutyrate1

SOFOSBUVIR / VELPATASVIR1

SOMAVERT1

SOVALDI1

SPRYCEL1,3,4

STELARA1

STIMATE1

STIVARGA1

STRENSIQ2

sunitinib malate1,3

SUTENT1,3

SYMDEKO1

TABRECTA1

tadalafil1

TAFINLAR1

TAGRISSO2,3,4

TAKHZYRO2,4

TALTZ1

TALZENNA1,3

TARCEVA1,3

TARGRETIN1,3

TASIGNA1,3,4

TAZVERIK2

TECFIDERA1

TECFIDERA STARTER PACK1

TEGSEDI2,4

TEMODAR1,4

temozolomide1

TERIPARATIDE1,4

tetrabenazin tab1

 

THALOMID1

TIBSOVO2

TOBI1

TOBI PODHALER1

tobramycin neb 300/4ml1

tobramycin neb 300/5ml1

TOLVAPTAN TAB 15MG1

tolvaptan tab 30mg1

TRACLEER1

TREMFYA1

TRIKAFTA1

TUKYSA2

TURALIO2

TYKERB1,4

TYMLOS1

UPTRAVI2,4

VENCLEXTA2

VENCLEXTA STARTING PACK2

VENTAVIS2,3,4

VERZENIO2,3,4

VIEKIRA PAK1

VITRAKVI2,3,4

VIZIMPRO1,3

VOSEVI1

VOTRIENT1,3

VUMERITY1

VYNDAMAX1

VYNDAQEL1

XALKORI1,3

XELJANZ1

XELJANZ XR1

XELODA1,4

XENAZINE1

XERMELO2

XOLAIR1

XOSPATA2

XPOVIO2,3

XTANDI1,3

XYNTHA1

XYNTHA SOLOFUSE1

XYREM2,4

XYWAV2,4

ZARXIO1

ZAVESCA2,4

ZEJULA2,3

ZELBORAF1

ZEPATIER1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOKINVY2

ZOLINZA1,3

ZOMACTON1,4

ZORBTIVE1

ZYDELIG2,4

ZYKADIA1,3

ZYTIGA1,3

 

1Specialty

2Limited Distribution

3Split Fill

4Exclusive to Accredo