Advantage prescription drug benefits

Effective January 1, 2021

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

Key:

UPPERCASE names = Brand

lowercase names = Generic

Guide to Prescription Drug Benefits

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

Use this guide to understand how your benefits work.

Drug Name(s)
abiraterone acetate¹	ABSTRAL	ACIPHEX
ACTEMRA¹	ACTIQ	ADCIRCA¹
ADDERALL	ADDERALL XR	ADEMPAS^1,²
ADHANSIA XR	ADIPEX-P	ADMELOG
ADMELOG SOLOSTAR	ADZENYS ER	ADZENYS XR-ODT
AFINITOR^1, ³	AFINITOR DISPERZ^1, ³	AFREZZA
AIMOVIG¹	AJOVY¹	AKLIEF
ALDARA	ALECENSA^1,^2, ³	alosetronhydrochloride
ALUNBRIG^1,²	alyq¹	AMBIEN
AMBIEN CR	ambrisentan¹	AMITIZA
AMPHETAMINE ER	AMPYRA^1, ³	AMRIX
ANAFRANIL	ANDRODERM	ANDROGEL
ANDROGEL PUMP	ANDROID	APIDRA
APIDRA SOLOSTAR	APLENZIN	APTENSIO XR
ARCALYST^1,²	ARIKAYCE^1,²	armodafinil
ARYMO ER	ATRALIN	AUBAGIO^1, ³
AUSTEDO¹	AUVI-Q	avita
AVONEX¹	AYVAKIT	azelastine hcl/fluticasone propionate
BALVERSA^1,^2, ³	BECONASE AQ	BELBUCA
BELSOMRA	BELVIQ	BELVIQ XR
BENLYSTA¹	benzphetaminehcl	BETASERON¹
BETHKIS¹	bexarotene¹	bosentan¹
BOSULIF^1, ³	BRAFTOVI^1,²	BRUKINSA
BUPHENYL¹	buprenorphine	BUPROPION HYDROCHLORIDE ER (XL)
BUTRANS	CABOMETYX^1, ³	CALQUENCE^1,²
capecitabine¹	CAPRELSA^1,²	CARAC
CARBAGLU^1,²	CAYSTON¹	CELEXA
CERDELGA¹	CETROTIDE¹	CHORIONIC GONADOTROPIN¹
ciclodan	ciclopiroxnail lacquer	CIMZIA¹
cinacalcethydrochloride¹	ciprofloxacin/dexamethasone	clomipramine hydrochloride
COMETRIQ^1,^2, ³	CONCERTA	CONTRAVE
CONZIP	COPAXONE¹	COPIKTRA^1,^2, ³
CORLANOR	COSENTYX¹	COSENTYX SENSOREADY PEN¹
COTELLIC¹	COTEMPLA XR-ODT	CRINONE
CUTAQUIG^1,²	CUVITRU^1,²	cyclobenzaprine hydrochloride er
CYMBALTA	DAKLINZA¹	dalfampridine er¹
DARAPRIM	DAURISMO^1, ³	DAYTRANA
DEPO-TESTOSTERONE	DESOXYN	DESVENLAFAXINE ER
DICLEGIS	diclofenac sodium gel	DIETHYLPROPION HCL
diethylpropionhcl er	diethylpropionhydrochloride	DIETHYLPROPION HCL ER
dimethyl fumarate	DOLOPHINE	DORYX
DOXYCYCLINE HYCLATE	doxylaminesuccinate/pyridoxine hydrochloride	DUEXIS
DUPIXENT¹	DURAGESIC	DUZALLO
DYANAVEL XR	DYMISTA	EDLUAR
EFFEXOR XR	EFUDEX	EGRIFTA¹
EGRIFTA SV¹	EMBEDA	EMFLAZA^1,²
EMGALITY¹	EMSAM	ENBREL¹
ENBREL MINI¹	ENBREL SURECLICK¹	ENDARI^1,²
ENDOMETRIN	EPCLUSA¹	EPIDIOLEX¹
EPINEPHRINE	EPIPEN 2-PAK	EPIPEN-JR 2-PAK
ERIVEDGE^1, ³	erlotinib hydrochloride¹	ESBRIET¹
EVEKEO	everolimus¹	EVZIO
EXALGO	EXTAVIA¹	FABIOR
FARYDAK¹	fentanyl	FENTANYL CITRATE
fentanyl citrate oral transmucosal	FENTORA	FETZIMA
FETZIMA TITRATION PACK	FEXMID	FIRAZYR¹
FIRDAPSE^1,²	FLUNISOLIDE	FLUOROPLEX
FLUOROURACIL	FLUOXETINE	FLUOXETINE DR
FLUOXETINE HYDROCHLORIDE	FOCALIN	FOCALIN XR
FORFIVO XL	FORTAMET	FORTEO¹
FORTESTA	GALAFOLD¹	ganirelixacetate¹
GATTEX^1,²	GENOTROPIN¹	GENOTROPIN MINIQUICK¹
GILENYA¹	GILOTRIF^1,²	glatiramer acetate¹
glatopa¹	GLUCOPHAGE	GLUCOPHAGE XR
GLUMETZA	GOCOVRI^1, ³	GRANIX¹
HAEGARDA^1,²	HARVONI¹	HELIXATE FS¹
HEMLIBRA¹	HETLIOZ^1,^2, ³	HIZENTRA¹
HUMALOG	HUMALOG JUNIOR KWIKPEN	HUMALOG KWIKPEN
HUMALOG MIX 50/50	HUMALOG MIX 50/50 KWIKPEN	HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN	HUMATROPE	HUMIRA¹
HUMIRA PEN¹	HUMULIN 70/30	HUMULIN 70/30 KWIKPEN
HUMULIN N	HUMULIN N KWIKPEN	HUMULIN R
HYCAMTIN¹	hydrocodone bitartrate er	hydromorphone hydrochloride
hydromorphone hydrochloride er	HYQVIA¹	HYSINGLA ER
IBRANCE¹	icatibantacetate¹	ICLUSIG^1,^2, ³
IDHIFA¹	IMBRUVICA^1,²	IMIQUIMOD PUMP
INGREZZA^1,²	INLYTA^1, ³	INREBIC^1, ³
INSULIN LISPRO	INSULIN LISPRO KWIKPEN	INTERMEZZO
INTRON A¹	INTUNIV	IRESSA^1,^2, ³
JAKAFI^1, ³	JORNAY PM	JUBLIA
JUXTAPID^1,²	JYNARQUE	KADIAN
KALYDECO¹	KAPVAY	KERYDIN
KEVEYIS^1,²	KEVZARA¹	KHEDEZLA
KINERET^1,²	KISQALI¹	KISQALI FEMARA¹
KITABIS PAK¹	KOGENATE FS¹	KOGENATE FS BIO-SET¹
KORLYM^1,²	KUVAN¹	KYNAMRO¹
LAZANDA	LEDIPASVIR/SOFOSBUVIR¹	LENVIMA 10 MG DAILY DOSE^1,^2, ³
LETAIRIS¹	LEXAPRO	lidocaine pad
LIDODERM	LOMAIRA	LONSURF¹
LORBRENA^1, ³	LORZONE	LOTRONEX
LUNESTA	LYNPARZA^1,^2, ³	LYRICA CR
MAVENCLAD¹	MAVYRET¹	MAYZENT¹
MEKINIST¹	MEKTOVI^1,²	metaxall
METAXALONE	metaxalone	METFORMIN HYDROCHLORIDE soln
metformin hydrochloride er	methadone hcl	methadone hydrochloride
METHITEST	METHYLIN SOLN	METHYLPHENIDATE HYDROCHLORIDE ER
METHYLTESTOSTERONE	miglustat¹	MINOCIN
modafinil	mometasonefuroate	MORPHABOND ER
morphine sulfate er	MORPHINE SULFATE ER	MOTEGRITY
MS CONTIN ER	MULPLETA¹	MYALEPT^1,²
MYDAYIS	NAPROSYN	NASONEX
NATESTO	NATPARA¹	NERLYNX^1,^2, ³
NEULASTA¹	NEULASTA ONPRO KIT¹	NEXIUM
NINLARO¹	NOCTIVA	NORDITROPIN FLEXPRO¹
NORTHERA¹	NOVAREL¹	NUBEQA¹
NUCYNTA ER	NUPLAZID¹	NURTEC
NUTROPIN AQ NUSPIN¹	NUVIGIL	OCALIVA¹
ODOMZO^1, ³	OFEV^1, ³	OLUMIANT¹
OLYSIO¹	omeppi	omeprazole/sodium bicarbonate
OMNARIS	OMNITROPE¹	OPANA
OPANA ER (CRUSH RESISTANT)	OPSUMIT^1,²	ORENCIA¹
ORENCIA CLICKJECT¹	ORENITRAM^1,²	ORILISSA
ORKAMBI¹	OTEZLA¹	OXERVATE^1,²
OXBRYTA	OXYCODONE HYDROCHLORIDE ER	OXYCONTIN
oxymorphonehydrochloride	OXYMORPHONE HYDROCHLORIDE ER	PAXIL
PAXIL CR	PEGINTRON¹	PENLAC NAIL LACQUER
PEXEVA	phendimetrazinetartrate	PHENDIMETRAZINE TARTRATE ER
PHENDIMETRAZINE TARTRATE SR	phentermine hydrochloride	PICATO
PIQRAY^1, ³	PLEGRIDY¹	POMALYST¹
PRALUENT	PREGNYL W/DILUENT BENZYL ALCOHOL/NACL ¹	PREVACID
PRIMLEV	PRISTIQ	PROCRIT¹
PROCYSBI^1,²	PROMACTA¹	PROTONIX
PROVIGIL	PROZAC	QBREXZA
QNASL	QNASL CHILDRENS	QSYMIA
QUDEXY XR	ramelteon	RAVICTI¹
RAYOS	REBIF¹	REBIF REBIDOSE¹
REBIF REBIDOSE TITRATION PACK¹	REBIF TITRATION PACK¹	REGIMEX
REGRANEX	RELEXXII	RELISTOR
REPATHA	REPATHA PUSHTRONEX SYSTEM	REPATHA SURECLICK
RESTASIS	RESTASIS MULTIDOSE	RETIN-A
RETIN-A MICRO	RETIN-A MICRO PUMP	REVATIO¹
REVLIMID¹	REYVOW	RINVOQ¹
RIOMET	RITALIN	RITALIN LA
ROBAXIN	ROZEREM	ROZLYTREK^1, ³
RUBRACA^1,^2, ³	RUZURGI^1,²	RYDAPT¹
SAMSCA¹	SARAFEM	SAXENDA
SENSIPAR¹	SEROSTIM¹	SEYSARA
SIGNIFOR^1,²	sildenafil citrate¹	SILIQ¹
SIMPONI¹	SKELAXIN	SKYRIZI¹
sodium phenylbutyrate ¹	SOFOSBUVIR/VELPATASVIR¹	SOMA
SOMAVERT¹	SONATA	SOVALDI¹
STELARA¹	STIMATE¹	STIVARGA¹
STRATTERA	STRENSIQ^1,²	STRIANT
SUBSYS	SUNOSI	SUTENT^1, ³
SYLATRON¹	SYMPROIC	tadalafil¹
TAFINLAR¹	TAGRISSO^1,^2, ³	TAKHZYRO^1,²
TALTZ¹	TALZENNA^1, ³	TARCEVA^1, ³
TARGRETIN^1, ³	tazarotene	TAZORAC
TECHNIVIE¹	TEGSEDI^1,²	TESTIM
testosterone	TESTOSTERONE	TESTRED
tetrabenazine¹	THALOMID¹	TIBSOVO¹
TOBI¹	TOBI PODHALER¹	tobramycin¹
TOLAK	TOPIRAMATE ER	TRACLEER¹
TRAMADOL HCL ER	tramadol hydrochloride er	TREMFYA¹
tretinoin	tretinoinmicrosphere	tretinoinmicrosphere pump
TRETIN-X	TRIKAFTA	TRINTELLIX
TROKENDI XR	TRULANCE	TURALIO^1,²
TYMLOS¹	UBRELVY	UPTRAVI^1,²
VENCLEXTA^1,²	VENTAVIS^1,^2, ³	VERZENIO^1,^2, ³
VIBERZI	VIEKIRA PAK¹	VIEKIRA XR¹
VIIBRYD	VIMOVO	VITRAKVI^1,^2, ³
VIZIMPRO^1, ³	VOGELXO	VOGELXO PUMP
VOSEVI¹	VOTRIENT^1, ³	VYLEESI
VYNDAMAX¹	VYNDAQEL¹	WAKIX
WELLBUTRIN SR	WELLBUTRIN XL	XELJANZ¹
XELJANZ XR¹	XELODA¹	XENAZINE¹
XENICAL	XERMELO^1,²	XHANCE
XIFAXAN	XIIDRA	XOSPATA^1,²
XPOVIO ^1,^2, ³	XTAMPZA ER	XTANDI^1, ³
XYNTHA¹	XYNTHA SOLOFUSE¹	XYOSTED
XYREM^1,²	ZANAFLEX	ZARXIO¹
ZAVESCA^1,²	ZEGERID	ZEJULA^1,^2, ³
ZELBORAF¹	ZELNORM	ZEPATIER¹
ZEPOSIA	ZETONNA	ZOHYDRO ER
ZOLINZA^1, ³	ZOLOFT	ZOLPIMIST
ZOMACTON¹	ZORBTIVE¹	ZTLIDO
ZURAMPIC	ZYCLARA	ZYCLARA PUMP
ZYDELIG^1,²	ZYKADIA^1, ³	ZYTIGA¹

Drug Name(s)
ABILIFY	ACCU-CHEK AVIVA PLUS	ACCU-CHEK COMPACT PLUS
ACCU-CHEK COMPACT STRIPS	ACCU-CHEK COMPACT TEST DRUM	ACCU-CHEK GUIDE
ACCU-CHEK SMARTVIEW STRIPS	ACCUTREND GLUCOSE	ADLYXIN
ADVANCE INTUITION TEST STRIPS	ADVANCE MICRO-DRAW TEST STRIPS	ADVOCATE REDI-CODE
ADVOCATE REDI-CODE+ TEST STRIPS	ADVOCATE TEST STRIPS	AGAMATRIX AMP NO CODE TEST STRIPS
AGAMATRIX JAZZ TEST STRIPS	AGAMATRIX KEYNOTE TEST STRIPS	AGAMATRIX PRESTO TEST STRIPS
ALA SCALP	ALOGLIPTIN	ALOGLIPTIN/METFORMIN HCL
ALOGLIPTIN/PIOGLITAZONE	ALTOPREV	AMCINONIDE
AMERGE	ANAPROX DS	APEXICON E
ARTHROTEC	ASSURE 3 TEST STRIPS	ASSURE 4 TEST STRIPS
ASSURE II	ASSURE II CHECK STRIP	ASSURE II TEST STRIPS
ASSURE PLATINUM TEST STRIPS	ASSURE PRISM MULTI TEST STRIPS	ASSURE PRO TEST STRIPS
AT LAST TEST STRIPS	ATACAND	ATACAND HCT
ATHROTEC	AUGMENTED BETAMETHASONE DIPROPIONATE	AVALIDE
AVAPRO	AZOR	BENICAR
BENICAR HCT	BEPREVE	BETAMETHASONE DIPROPIONATE
BIOSCANNER GLUCOSE TEST STRIPS	BLOOD GLUCOSE TEST STRIPS	BLOOD GLUCOSE TEST STRIPS PREMIUM
BYDUREON BCISE	BYDUREON PEN	BYETTA
BYVALSON	CAMBIA	CAPEX
CAPLYTA	CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM	CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE
CARESENS N BLOOD GLUCOSE TEST STRIPS	CARETOUCH BLOOD GLUCOSE TEST STRIPS	CELEBREX
CLEVER CHEK AUTO-CODE TEST STRIPS	CLEVER CHEK AUTO-CODE VOICE TEST STRIPS	CLEVER CHEK TEST STRIPS
CLEVER CHOICE AUTO-CODE PRO TEST STRIPS	CLEVER CHOICE MICRO TEST STRIPS	CLEVER CHOICE NO CODING TEST STRIPS
CLEVER CHOICE TALK NO CODING TEST STRIPS	clindamycin phosphate/tretinoin	CLOBEX
CLOCORTOLONE PIVALATE	CLOCORTOLONE PIVALATE PUMP	CLODERM
CLODERM PUMP	CLOZAPINE ODT	CLOZARIL
CONTOUR BLOOD GLUCOSE TEST STRIPS	CONTOUR NEXT BLOOD GLUCOSE TEST	COOL BLOOD GLUCOSE TEST STRIPS
CORDRAN	COZAAR	CRESTOR
CUTIVATE	CVS ADVANCED GLUCOSE METER TEST STRIPS	DAYPRO
D-CARE BLOOD GLUCOSE	DERMA-SMOOTHE/FS BODY/SCALP	DESONATE
DESOWEN	DETROL	DETROL LA
DEXCOM G5 MOBILE RECEIVER KIT	DEXCOM G5 MOBILE TRANSMITTER KIT	DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT
DEXCOM G5 RECEIVER KIT	DEXCOM G6 RECEIVER	DEXCOM G6 SENSOR
DEXCOM G6 TRANSMITTER	DIATHRIVE BLOOD GLUCOSE TEST STRIPS	DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS
DICLOFENAC EPOLAMINE	DIFLORASONE DIACETATE	DIOVAN
DIOVAN HCT	DIPROLENE	DIPROLENE AF
DITROPAN XL	DUO-CARE TEST STRIPS	EASY PLUS II BLOOD GLUCOSE TEST
EASY STEP TEST STRIPS	EASY TALK BLOOD GLUCOSE TEST STRIPS	EASY TOUCH GLUCOSE TEST STRIPS
EASY TRAK BLOOD GLUCOSE TEST STRIPS	EASYGLUCO	EASYGLUCO PLUS
EASYMAX 15 TEST STRIPS	EASYMAX TEST STRIPS	EASYPRO BLOOD GLUCOSE TEST STRIPS
EASYPRO PLUS	EC-NAPROXEN	EDARBI
EDARBYCLOR	ELEMENT COMPACT TEST STRIPS	ELEMENT TEST STRIPS
ELESTAT	ELIDEL	ELOCON
EMADINE	EMBRACE BLOOD GLUCOSE TEST STRIPS	EMBRACE EVO BLOOD GLUCOSETEST STRIPS
EMBRACE PRO BLOOD GLUCOSETEST STRIPS	EMBRACE TALK BLOOD GLUCOSE TEST STRIPS	ENABLEX
EPROSARTAN MESYLATE	EQ BLOOD GLUCOSE TEST STRIPS	EUCRISA
EVENCARE + BLOOD GLUCOSE TEST STRIP	EVENCARE BLOOD GLUCOSE TEST STRIP	EVENCARE G2 TEST STRIPS
EVENCARE G3 TEST STRIPS	EVENCARE MINI BLOOD GLUCOSE TEST STRIPS	EVOLUTION AUTOCODE
EXACTECH R-S-G TEST STRIPS	EXACTECH TEST STRIPS	EXFORGE
EXFORGE HCT	EZ SMART BLOOD GLUCOSE TEST STRIPS	EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS
FANAPT	FANAPT TITRATION PACK	FARXIGA
FAZACLO	FELDENE	FENOPROFEN CALCIUM
FENORTHO	FIFTY50 GLUCOSE TEST STRIP 2.0	FLECTOR
FLOLIPID	FORA BLOOD GLUCOSE TEST STRIPS	FORA D15G BLOOD GLUCOSE TEST STRIPS
FORA D20 BLOOD GLUCOSE TEST STRIPS	FORA D40/G31 BLOOD GLUCOSE TEST STRIPS	FORA G20 BLOOD GLUCOSE TEST STRIPS
FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS	FORA GD20 TEST STRIPS	FORA GD50 BLOOD GLUCOSE TEST STRIPS
FORA GTEL BLOOD GLUCOSE TEST STRIPS	FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS	FORA V10 BLOOD GLUCOSE TEST STRIPS
FORA V12 BLOOD GLUCOSE TEST STRIPS	FORA V20 BLOOD GLUCOSE TEST STRIPS	FORA V30A BLOOD GLUCOSE TEST STRIPS
FORACARE GD40	FORACARE PREMIUM V10 TESTSTRIPS	FORACARE TEST N GO TEST STRIPS
FORTISCARE BLOOD GLUCOSE TEST STRIP	FOSRENOL	FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM
FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM	FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM	FREESTYLE INSULINX BLOOD GLUCOSE TEST
FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS	FREESTYLE LITE TEST STRIPS	FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS
FREESTYLE TEST STRIPS	FROVA	GE100 BLOOD GLUCOSE TEST STRIPS
GELNIQUE	GELNIQUE PUMP	GENULTIMATE TEST STRIPS
GEODON	GHT TEST STRIPS	GLUCO PERFECT 3 TEST STRIPS
GLUCOCARD 01 SENSOR PLUS	GLUCOCARD 01 SENSOR PLUS TEST STRIPS	GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS
GLUCOCARD SHINE TEST STRIPS	GLUCOCARD VITAL TEST STRIPS	GLUCOCARD X-SENSOR
GLUCOCOM TEST STRIPS	GLUCONAVII BLOOD GLUCOSE TEST STRIPS	GLUCOSE METER TEST STRIPS ADVANCED
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	HYZAAR
IGLUCOSE BLOOD GLUCOSE TEST STRIPS	IMITREX	IMITREX STATDOSE REFILL
IMITREX STATDOSE SYSTEM	IMPOYZ	IN TOUCH BLOOD GLUCOSE TEST STRIPS
INDOCIN	INDOMETHACIN	INFINITY BLOOD GLUCOSE TEST STRIPS
INFINITY VOICE	INVEGA	INVOKAMET /-XR
INVOKANA	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	LATANOPROST
LATUDA	LESCOL XL	LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS
LIBERTY TEST STRIPS	LIPITOR	LIVALO
LOCOID	LOCOID LIPOCREAM	LODINE
LUMIGAN	LUXIQ	LYRICA
MAXALT	MAXALT-MLT	MECLOFENAMATE SODIUM
MEIJER BLOOD GLUCOSE 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	MICARDIS
MICARDIS HCT	MICORT-HC	MICRODOT TEST STRIPS
MM EASY TOUCH GLUCOSE TEST STRIPS	MYGLUCOHEALTH BLOOD GLUCOSE TEST	NALFON
NAPRELAN	NAPROSYN	NESINA
NEUTEK 2TEK TEST STRIPS	NOVA MAX GLUCOSE TEST STRIPS	OLUX
OLUX-E	ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS	ON CALL PLUS BLOOD GLUCOSE TEST
ON CALL VIVID BLOOD GLUCOSE TEST	ON CALL VIVID BLOOD GLUCOSE TEST STRIPS	ONE DROP BLOOD GLUCOSE TEST STRIPS
ONGLYZA	ONZETRA XSAIL	OPTIUM TEST STRIPS
OPTIUMEZ TEST STRIPS	OPTUMRX BLOOD GLUCOSE TEST	OSENI
OTREXUP¹	OZEMPIC	PANDEL
PATADAY	PATANOL	PAZEO
PENNSAID	PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS	PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS
pimecrolimus<	POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS	PRAVACHOL
PRECISION PCX	PRECISION PCX PLUS TEST STRIPS	PRECISION POINT OF CARE TEST STRIPS
PRECISION QID TEST STRIPS	PRECISION SOF-TACT TEST STRIPS	PRECISION XTRA BLOOD GLUCOSE TEST STRIPS
PREDNICARBATE	PREMIUM BLOOD GLUCOSE TEST STRIPS	PRESTIGE TEST STRIPS
PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS	PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS	PROTOPIC
PSORCON	PTS PANELS GLUCOSE TEST	QTERN
QUICKTEK TEST STRIPS	QUINTET AC BLOOD GLUCOSE TEST STRIPS	QUINTET BLOOD GLUCOSE TEST STRIPS
RA TRUETEST STRIPS	RASUVO¹	REFUAH PLUS BLOOD 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
RELION ULTIMA TEST STRIPS	RELPAX	RENAGEL
RENVELA	RESCULA	REVEAL BLOOD GLUCOSE TEST
REXALL BLOOD GLUCOSE TEST STRIPS	REXULTI	RHOPRESSA
RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS	RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS	RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS
RISPERDAL	RISPERDAL M-TAB	RISPERIDONE ODT
ROCKLATAN	RYBELSUS	SAPHRIS
SAVELLA	SAVELLA TITRATION PACK	SEGLUROMET
SERNIVO	SEROQUEL	SEROQUEL XR
SEVELAMER HYDROCHLORIDE	sevelamer hydrochloride	SIDEKICK BLOOD GLUCOSE SYSTEM
SIMVASTATIN	SMART SENSE PREMIUM BLOODGLUCOSE STRIPS	SMART SENSE VALUE BLOOD GLUCOSE STRIPS
SMARTEST BLOOD GLUCOSE TEST STRIPS	SOLIQUA 100/33	SOLUS V2 AUDIBLE TEST
STEGLATRO	STEGLUJAN	SUMATRIPTAN SUCCINATE
SUPREME TEST STRIPS	SURE EDGE BLOOD GLUCOSE TEST STRIPS	SURECHEK BLOOD GLUCOSE TEST STRIPS
SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS	SYNALAR	SYNJARDY /-XR
tacrolimus	TANZEUM	TELCARE BLOOD GLUCOSE TEST STRIPS
TEMOVATE	TEXACORT	TGT BLOOD GLUCOSE TEST STRIPS
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM	TIVORBEX	TOLMETIN SODIUM
TOPICORT	TRADJENTA	TRAVATAN Z
TREXIMET	TRIANEX	TRIBENZOR
TRIDESILON	TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS	TRUE METRIX BLOOD GLUCOSETEST STRIPS
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS	TRUETEST STRIPS	TRUETRACK BLOOD GLUCOSE TEST
TRUETRACK TEST	TRUJARDY XR	TRULICITY
TWYNSTA	ULORIC	ULTIMA TEST STRIPS
ULTRATRAK PRO TEST STRIPS	ULTRATRAK ULTIMATE TEST STRIPS	ULTRAVATE
UNISTRIP1 GENERIC	VANOS	VELPHORO
VELTIN	VERASENS BLOOD GLUCOSE TEST STRIPS	VERDESO
VERSACLOZ	VICTORY AGM-4000 TEST STRIPS	VICTOZA
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS	VIVLODEX	VOCAL POINT BLOOD GLUCOSE TEST STRIPS
VOLTAREN GEL	VYTORIN	VYZULTA
WAVESENSE PRESTO TEST STRIPS	XALATAN	XIGDUO XR
XULTOPHY 100/3.6	ZEMBRACE SYMTOUCH	ZERVIATE
ZIANA	ZIOPTAN	ZIPSOR
ZOCOR	ZOMIG	ZOMIG ZMT
ZYPREXA	ZYPREXA ZYDIS

Actinic Keratosis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ALDARA CREAM 5%	48 Packets/60 Days
EFUDEX CREAM 5%	240 Grams/90 Days
fluorouracil cream 5%	240 Grams/90 Days
imiquimod cream 5%	48 Packets/60 Days

Acute Migraine 5HT

Drug Name(s)	Quantity Limits (per 30 days or as specified)
almotriptan malate tablet 6.25mg	24 Tablets/30 Days
almotriptan malate tablet 12.5mg	12 Tablets/30 Days
AMERGE TABLET 1MG	18 Tablets/30 Days
AMERGE TABLET 2.5MG	18 Tablets/30 Days
eletriptan tablet 20mg	18 Tablets/30 Days
eletriptan tablet 40mg	12 Tablets/30 Days
FROVA TABLET 2.5MG	27 Tablets/30 Days
frovatriptan tablet 2.5mg	27 Tablets/30 Days
IMITREX INJECTION 4MG/0.5	12 Syringes/30 Days
IMITREX INJECTION 6MG/0.5	12 Syringes/30 Days
IMITREX INJECTION 6MG/0.5	12 Cartridges/30 Days
IMITREX SPRAY 20MG/ACT	12 Inhalers/30 Days
IMITREX SPRAY 5MG/ACT	5 Packs/30 Days
IMITREX TABLET 25MG	27 Tablets/30 Days
IMITREX TABLET 50MG	18 Tablets/30 Days
IMITREX TABLET 100MG	18 Tablets/30 Days
MAXALT TABLET 10MG	18 Tablets/30 Days
MAXALT-MLT TABLET 10MG	18 Tablets/30 Days
MAXALT-MLT TABLET 5MG	36 Tablets/30 Days
naratriptan tablet 1mg	18 Tablets/30 Days
naratriptan tablet 2.5mg	18 Tablets/30 Days
NURTEC ODT 75 mg	45 tablets/90 Days
ONZETRA XSAI MIS 11MG	32 Inhalers/30 Days
RELPAX TABLET 20MG	18 Tablets/30 Days
RELPAX TABLET 40MG	12 Tablets/30 Days
REYVOW 50 MG	8 tablets/30 Days
REYVOW 100 MG	8 tablets/30 Days
rizatriptan tablet 5mg	36 Tablets/30 Days
rizatriptan tablet 5mg odt	36 Tablets/30 Days
rizatriptan tablet 10mg	18 Tablets/30 Days
rizatriptan tablet 10mg odt	18 Tablets/30 Days
sumatriptan injection 4mg/0.5	12 Cartridges/30 Days
sumatriptan injection 4mg/0.5	12 Syringes/30 Days
sumatriptan injection 6/0.5ml	12 Syringes/30 Days
sumatriptan injection 6mg/0.5	12 Cartridges/30 Days
sumatriptan injection 6mg/0.5	12 Syringes/30 Days
sumatriptan spray 20mg/act	12 Inhalers/30 Days
sumatriptan spray 5mg/act	5 Packs/30 Days
sumatriptan tablet 25mg	27 Tablets/30 Days
sumatriptan tablet 50mg	18 Tablets/30 Days
sumatriptan tablet 100mg	18 Tablets/30 Days
sumatriptan-naproxen tablet 85-500mg	18 Tablets/30 Days
TREXIMET TABLET 10-60MG	9 Tablets/30 Days
TREXIMET TABLET 85-500MG	18 Tablets/30 Days
UBREVLY	16 Tablets/30 days
ZEMBRACE SYM INJECTION 3/0.5ML	24 Pens/30 Days
zolmitriptan tablet 2.5 mg	18 Tablets/30 Days
zolmitriptan tablet 2.5mg	18 Tablets/30 Days
zolmitriptan tablet 5mg	12 Tablets/30 Days
zolmitriptan tablet 5mg odt	12 Tablets/30 Days
ZOMIG SPRAY 2.5MG	3 Injection Devices/30 Days
ZOMIG SPRAY 5MG	2 Sprays/30 Days
ZOMIG TABLET 2.5MG	18 Tablets/30 Days
ZOMIG TABLET 5MG	12 Tablets/30 Days
ZOMIG ZMT TABLET 2.5 MG	18 Tablets/30 Days
ZOMIG ZMT TABLET 5MG ODT	12 Tablets/30 Days

Addyi

Drug Name(s)	Quantity Limits (per 30 days or as specified)
VYLEESI INJECTION 1.75/0.3	6 Pens/30 Days

Afrezza

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AFREZZA POWDER 4UNIT	2520 Cartridges/30 Days
AFREZZA POWDER 8 UNIT	1260 Cartridges/30 Days
AFREZZA POWDER 12 UNIT	900 Cartridges/30 Days
AFREZZA POWDER 4-8 UNIT	1530 Cartridges/30 Days
AFREZZA POWDER 4-8 UNIT	1890 Cartridges/30 Days
AFREZZA POWDER 4-8 UNIT	1800 Cartridges/30 Days
AFREZZA POWDER 8-12UNIT	1080 Cartridges/30 Days
AFREZZA POWDER 4-8-12	1260 Cartridges/30 Days

Alinia

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ALINIA SUSPENSE 100/5ML	300 mLs/90 Days
ALINIA TABLET 500MG	12 Tablets/90 Days

Amantadine ER

Drug Name(s)	Quantity Limits (per 30 days or as specified)
GOCOVRI CAPSULE 68.5MG^1,³	30 Capsules/30 Days
GOCOVRI CAPSULE 137MG^1,³	60 Capsules/30 Days

Amifampridine

Drug Name(s)	Quantity Limits (per 30 days or as specified)
FIRDAPSE TABLET 10MG¹^,2	240 Tablets/30 Days
RUZURGI TABLET 10MG¹^,2	300 Tablets/30 Days

Ampyra

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AMPYRA TABLET 10MG^1,³	60 Tablets/30 Days
Dalfampridine tablet 10mg er¹	60 Tablets/30 Days

Androgen/Anabolic Steroids

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ANDRODERM DIS 2MG/24HR	30 Patches/30 Days
ANDRODERM DIS 4MG/24HR	30 Patches/30 Days
ANDROGEL GEL 1%(25MG)	60 Packets/30 Days
ANDROGEL GEL 1%(50MG)	60 Packets/30 Days
ANDROGEL GEL 1.62%	2 Pumps/30 Days
ANDROGEL GEL 1.62%	30 Packets/30 Days
ANDROGEL GEL 1.62%	60 Packets/30 Days
ANDROID 10 MG CAPSULE	20 Capsules/30 Days
ANDROXY 10 MG TABLET	120 Tablets/30 Days
AVEED 250 MG/ML	1 Vial/28 Days
AXIRON 30 MG/1.5	2 Pumps/30 Days
DEPO-TESTOSTERONE INJECTION 100MG/ML	1 Vial/28 Days
DEPO-TESTOSTERONE INJECTION 200MG/ML	10 mLs/28 Days
FORTESTA GEL 10MG/ACT	2 Pumps/30 Days
JATENZO 158 MG CAPSULE	120 Capsules/30 Days
JATENZO 198 MG CAPSULE	60 Capsules/30 Days
METHITEST 10 MG TABLET	600 Capsules/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
TESTOPEL 75 MG	6 Pellets/90 Days
testosterone cypionate injection 100mg/ml	1 Vial/28 Days
testosterone cypionate injection 200mg/ml	10 mLs/28 Days
TESTOST ENAN INJECTION 200MG/ML	1 Vial/28 Days
testosterone gel 1%(25mg)	60 Packets/30 Days
testosterone gel 1%(50mg)	60 Packets/30 Days
testosterone gel 1.62%	2 Bottles/30 Days
testosterone gel 1.62%	30 Packets/30 Days
testosterone gel 1.62%	60 Packets/30 Days
testosterone gel 10mg/act	2 Pumps/30 Days
testosterone gel pump 1%	300 Grams/30 Days
TESTOSTERONE GEL PUMP 1%	4 Pumps/30 Days
TESTOSTERONE INJECTION CYPIONATE	10 mLs/28 Days
testosterone solution 30mg/act	2 Pumps/30 Days
TESTRED 10 MG CAPSULE	600 Capsules/30 Days
VOGELXO GEL 1%(50MG)	60 Packets/30 Days
VOGELXO GEL PUMP 1%	4 Pumps/30 Days
XYOSTED INJECTION 100/0.5	2 Pens/28 Days
XYOSTED INJECTION 50/0.5	2 Pens/28 Days
XYOSTED IINJECTIONNJ 75/0.5	2 Pens/28 Days

Antiemetic

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

Antifungal

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ciclodan solution 8%	3.3 mLs/30 Days
ciclopirox solution 8%	3.3 mLs/30 Days
JUBLIA SOLUTION 10%	4 mLs/30 Days
KERYDIN SOLUTION 5%	4 mLs/30 Days
PENLAC SOLUTION 8%	6.6 mLs/30 Days

Anti-Influenza

Drug Name(s)	Quantity Limits (per 30 days or as specified)
oseltamivir capsule 30mg	40 Capsules/120 Days
oseltamivir capsule 45mg	20 Capsules/120 Days
oseltamivir capsule 75mg	20 Capsules/120 Days
oseltamivir suspense 6mg/ml	300 mLs/120 Days
TAMIFLU CAPSULE 30MG	40 Capsules/120 Days
TAMIFLU CAPSULE 45MG	20 Capsules/120 Days
TAMIFLU CAPSULE 75MG	20 Capsules/120 Days
TAMIFLU SUSPENSE 6MG/ML	300 mLs/120 Days
XOFLUZA TABLET 20MG	4 Tablets/120 Days
XOFLUZA TABLET 40MG	4 Tablets/120 Days

Antiretroviral

Drug Name(s)	Quantity Limits (per 30 days or as specified)
RELENZA MIS DISKHALER	40 Blisters/120 Days

Arikayce

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ARIKAYCE SUSPENSE¹^,2	28 Vials/28 Days

Atypical Antipsychotics

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CAPLYTA 42 MG CAPSULE	30 Capsules/30 Days
INVEGA TABLET 1.5MG	60 Tablets/30 Days
INVEGA TABLET 3MG	60 Tablets/30 Days
INVEGA TABLET 6MG	60 Tablets/30 Days
INVEGA TABLET 9MG	60 Tablets/30 Days
olanzapine tablet 2.5mg	30 Tablets/30 Days
olanzapine tablet 5mg	30 Tablets/30 Days
olanzapine tablet 5mg odt	30 Tablets/30 Days
olanzapine tablet 7.5mg	30 Tablets/30 Days
olanzapine tablet 10mg	30 Tablets/30 Days
olanzapine tablet 10mg odt	30 Tablets/30 Days
olanzapine tablet 15mg	30 Tablets/30 Days
olanzapine tablet 15mg odt	30 Tablets/30 Days
olanzapine tablet 20mg	30 Tablets/30 Days
olanzapine tablet 20mg odt	30 Tablets/30 Days
paliperidone tablet er 1.5mg	60 Tablets/30 Days
paliperidone tablet er 3mg	60 Tablets/30 Days
paliperidone tablet er 6mg	60 Tablets/30 Days
paliperidone tablet er 9mg	60 Tablets/30 Days
quetiapine tablet 50mg er	60 Tablets/30 Days
quetiapine tablet 150mg er	60 Tablets/30 Days
quetiapine tablet 200mg er	60 Tablets/30 Days
quetiapine tablet 300mg er	60 Tablets/30 Days
quetiapine tablet 400mg er	60 Tablets/30 Days
SEROQUEL XR TABLET 50MG	60 Tablets/30 Days
SEROQUEL XR TABLET 150MG	60 Tablets/30 Days
SEROQUEL XR TABLET 200MG	60 Tablets/30 Days
SEROQUEL XR TABLET 300MG	60 Tablets/30 Days
SEROQUEL XR TABLET 400MG	60 Tablets/30 Days
ZYPREXA TABLET 2.5MG	30 Tablets/30 Days
ZYPREXA TABLET 5MG	30 Tablets/30 Days
ZYPREXA TABLET 7.5MG	30 Tablets/30 Days
ZYPREXA TABLET 10MG	30 Tablets/30 Days
ZYPREXA TABLET 15MG	30 Tablets/30 Days
ZYPREXA TABLET 20MG	30 Tablets/30 Days
ZYPREXA ZYDI TABLET 5MG	30 Tablets/30 Days
ZYPREXA ZYDI TABLET 10MG	30 Tablets/30 Days
ZYPREXA ZYDI TABLET 15MG	30 Tablets/30 Days
ZYPREXA ZYDI TABLET 20MG	30 Tablets/30 Days

Bempedoic cid

Drug Name(s)	Quantity Limits (per 30 days or as specified)
NEXLETOL TABLET 180MG	30 Tablets/30 Days

Benlysta

Drug Name(s)	Quantity Limits (per 30 days or as specified)
BENLYSTA INJECTION 200MG/ML ¹	4 Syringes/28 Days

Biologic Immunomodulators

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ACTEMRA INJECTION 162/0.9 ¹	4 Syringes/28 Days
CIMZIA PREFL KIT 200MG/ML ¹	1 Kit/28 Days
COSENTYX INJECTION 150MG/ML ¹	1 Syringe/28 Days
COSENTYX INJECTION 300DOSE ¹	1 Pack/28 Days
COSENTYX PEN INJECTION 150MG/ML ¹	1 Injection Device/28 Days
COSENTYX PEN INJECTION 300DOSE ¹	1 Pack/28 Days
ENBREL INJECTION 25/0.5ML ¹	8 Syringes/28 Days
ENBREL INJECTION 25MG¹	8 Vials/28 Days
ENBREL INJECTION 50MG/ML ¹	4 Syringes/28 Days
ENBREL MINI INJECTION 50MG/ML ¹	4 Cartridges/28 Days
ENBREL SRCLK INJECTION 50MG/ML ¹	4 Syringes/28 Days
HUMIRA INJECTION 10/0.1ML ¹	2 Syringes/28 Days
HUMIRA INJECTION 10MG/0.2 ¹	2 Syringes/28 Days
HUMIRA INJECTION 20/0.2ML ¹	2 Syringes/28 Days
HUMIRA INJECTION 40/0.4ML ¹	2 Syringes/28 Days
HUMIRA KIT 20MG/0.4¹	2 Syringes/28 Days
HUMIRA KIT 40MG/0.8¹	2 Syringes/28 Days
HUMIRA PEDIA INJECTION CROHNS ¹	1 Kit/180 Days
HUMIRA PEDIA INJECTION CROHNS ¹	3 Kit/180 Days
HUMIRA PEN INJECTION 40/0.4ML ¹	2 Pens/28 Days
HUMIRA PEN INJECTION 40MG/0.8 ¹	2 Pens/28 Days
HUMIRA PEN INJECTION CD/UC/HS ¹	1 Kit/180 Days
HUMIRA PEN INJECTION PS/UV ¹	1 Kit/180 Days
HUMIRA PEN KIT CD/UC/HS¹	1 Kit/180 Days
HUMIRA PEN KIT PS/UV¹	1 Kit/180 Days
KEVZARA INJECTION 150/1.14 ¹	2 Pens/28 Days
KEVZARA INJECTION 150/1.14 ¹	2 Syringes/28 Days
KEVZARA INJECTION 200/1.14 ¹	2 Pens/28 Days
KEVZARA INJECTION 200/1.14 ¹	2 Syringes/28 Days
KINERET INJECTION¹^,2	30 Syringes/30 Days
OLUMIANT TABLET 1MG¹	30 Tablets/30 Days
OLUMIANT TABLET 2MG¹	30 Tablets/30 Days
ORENCIA CLCK INJECTION 125MG/ML ¹	4 Syringes/28 Days
ORENCIA IINJECTIONNJ 125MG/ML ¹	4 Syringes/28 Days
ORENCIA INJECTION 50/0.4 ¹	4 Syringes/28 Days
ORENCIA INJECTION 87.5/0.7 ¹	4 Syringes/28 Days
RINVOQ TABLET 15MG ER¹	30 Tablets/30 Days
SILIQ ININJECTIONJ 210/1.5 ¹	2 Syringes/28 Days
SIMPONI INJECTION 100MG/ML ¹	1 Syringe/28 Days
SIMPONI INJECTION 50/0.5ML ¹	1 Syringe/28 Days
SKYRIZI INJECTION 150DOSE ¹	1 Box/84 Days
STELARA INJECTION 45MG/0.5 ¹	1 Syringe/84 Days
STELARA INJECTION 90MG/ML ¹	1 Syringe/56 Days
TALTZ INJECTION 80MG/ML¹	1 mLs/28 Days
TREMFYA INJECTION 100MG/ML ¹	1 Pen/56 Days
TREMFYA INJECTION 100MG/ML ¹	1 Syringe/56 Days
XELJANZ TABLET 5MG¹	60 Tablets/30 Days
XELJANZ TABLET 10MG¹	60 Tablets/30 Days
XELJANZ XR TABLET 11MG¹	30 Tablets/30 Days
XELJANZ XR TABLET 22MG¹	112 Tablets/365 Days

Bisphosphonates

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ACTONEL TABLET 35MG	4 Tablets/28 Days
ACTONEL TABLET 150MG	1 Tablet/28 Days
alendronate tablet 35mg	4 Tablets/28 Days
alendronate tablet 70mg	4 Capsules/28 Days
ATELVIA 35 MG TABLET	4 Tablets/28 Days
BINOSTO TABLET 70MG	4 Tablets/28 Days
BONIVA TABLET 150MG	1 Tablet/30 Days
FOSAMAX + D TABLET 70-2800	4 Capsules/28 Days
FOSAMAX + D TABLET 70-5600	4 Capsules/28 Days
FOSAMAX TABLET 70MG	4 Capsules/28 Days
ibandronate tablet 150mg	1 Tablet/30 Days
risedronate tablet 35mg	4 Tablets/28 Days
risedronate tablet 35mg dr	4 Tablets/28 Days
risedronate tablet 150mg	1 Tablet/28 Days

Bonjesta Diclegis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
doxyl/pyrid tab 10-10mg

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Drug Name(s)	Quantity Limits (per 30 days or as specified)
KALYDECO PACK 25MG¹	60 Packets/30 Days
KALYDECO PACK 50MG¹	60 Packets/30 Days
KALYDECO PACK 75MG¹	60 Packets/30 Days
KALYDECO TABLET 150MG¹	60 Tablets/30 Days
ORKAMBI TABLET 100-125¹	120 Tablets/30 Days
ORKAMBI TABLET 200-125¹	120 Tablets/30 Days

Anti-Migraine: Calcitonin Gene-Related Peptide (CGRP)

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AIMOVIG INJECTION 70MG/ML ¹	1 Injection/28 Days
AIMOVIG INJECTION 140MG/ML ¹	1 Injection/28 Days
AJOVY INJECTION 225/1.5¹	4.5 Syringes/84 Days
EMGALITY INJECTION 100MG/ML ¹	9 Syringes/180 Days
EMGALITY INJECTION 120MG/ML ¹	1 Syringe/28 Days

Circadian Rhythm Disorder

Drug Name(s)	Quantity Limits (per 30 days or as specified)
HETLIOZ CAPSULE 20MG¹^,2^,3	30 Capsules/30 Days

Combination NSAID

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CONSENSI 2.5 MG / 200 MG TABLET	30 Tablets/30 Days
CONSENSI 5 MG / 200 MG TABLET	31 Tablets/30 Days
CONSENSI 10 MG / 200 MG TABLET	32 Tablets/30 Days
DUEXIS TABLET 800-26.6	90 Tablets/30 Days
VIMOVO TABLET 375-20MG	60 Tablets/30 Days
VIMOVO TABLET 500-20MG	60 Tablets/30 Days
YOSPRALA, ASPRIN/OMEPRAZOLE 81 MG/40 MG TABLET	30 Tablets/30 Days
YOSPRALA, ASPRIN/OMEPRAZOLE 325 MG/40 MG TABLET	30 Tablets/30 Days

Constipation Agents

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AMITIZA CAPSULE 8MCG	120 Capsules/30 Days
AMITIZA CAPSULE 24MCG	60 Capsules/30 Days
LINZESS CAPSULE 72MCG	30 Capsules/30 Days
LINZESS CAPSULE 145MCG	30 Capsules/30 Days
LINZESS CAPSULE 290MCG	30 Capsules/30 Days
MOTEGRITY TABLET 1MG	30 Tablets/30 Days
MOTEGRITY TALET 2MG	30 Tablets/30 Days
MOVANTIK TABLET 12.5MG	30 Tablets/30 Days
MOVANTIK TABLET 25MG	30 Tablets/30 Days
RELISTOR INJECTION 8/0.4ML	30 Syringes/30 Days
RELISTOR INJECTION 12/0.6ML	60 Vials/30 Days
RELISTOR INJECTION 12/0.6ML	30 Syringes/30 Days
RELISTOR TABLET 150MG	90 Tablets/30 Days
SYMPROIC TABLET 0.2MG	30 Tablets/30 Days
TRULANCE TABLET 3MG	30 Tablets/30 Days
ZELNORM TABLET 6MG	60 Tablets/30 Days

Continuous Glucose Monitor (CGM)

Drug Name(s)	Quantity Limits (per 30 days or as specified)
FREESTY LIBR KIT 2 SENSOR	2 Sensors/28 Days
FREESTY LIBR MIS 2 READER	1 Reader/365 Days

Endocrine and Metabolic Agents: Egrifta

Drug Name(s)	Quantity Limits (per 30 days or as specified)
EGRIFTA SOLUTION 1MG¹	60 Vials/30 Days
EGRIFTA SV INJECTION 2MG ¹	30 Vials/30 Days

Endocrine and Metabolic Agents: Emflaza

Drug Name(s)	Quantity Limits (per 30 days or as specified)
EMFLAZA TABLET 6MG¹^,2	60 Tablets/30 Days
EMFLAZA TABLET 18MG¹^,2	30 Tablets/30 Days

Fibromyalgia

Drug Name(s)	Quantity Limits (per 30 days or as specified)
LYRICA CAPSULE 25MG	90 Capsules/30 Days
LYRICA CAPSULE 50MG	90 Capsules/30 Days
LYRICA CAPSULE 75MG	90 Capsules/30 Days
LYRICA CAPSULE 100MG	90 Capsules/30 Days
LYRICA CAPSULE 150MG	90 Capsules/30 Days
LYRICA CAPSULE 200MG	90 Capsules/30 Days
LYRICA CAPSULE 225MG	60 Capsules/30 Days
LYRICA CAPSULE 300MG	60 Capsules/30 Days
LYRICA SOLUTION 20MG/ML	900 mLs/30 Days
pregabalin capsule 25mg	90 Capsules/30 Days
pregabalin capsule 50mg	90 Capsules/30 Days
pregabalin capsule 75mg	90 Capsules/30 Days
pregabalin capsule 100mg	90 Capsules/30 Days
pregabalin capsule 150mg	90 Capsules/30 Days
pregabalin capsule 200mg	90 Capsules/30 Days
pregabalin capsule 225mg	60 Capsules/30 Days
pregabalin capsule 300mg	60 Capsules/30 Days
pregabalin solution 20mg/ml	900 mLs/30 Days
SAVELLA MIS TITR PACK	1 Kit/180 Days
SAVELLA TABLET 12.5MG	60 Tablets/30 Days
SAVELLA TABLET 25MG	60 Tablets/30 Days
SAVELLA TABLET 50MG	60 Tablets/30 Days
SAVELLA TABLET 100MG	60 Tablets/30 Days

Endocrine and Metabolic Agents: Galafold

Drug Name(s)	Quantity Limits (per 30 days or as specified)
GALAFOLD CAPSULE 123MG¹	14 Capsules/28 Days

Gonadotropin Hormones

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CETROTIDE KIT 0.25MG¹	5 Kits/30 Days
chorionic gonadotropin injection 10000unt¹	2 Vials/30 Days
GANIRELIX AC INJECTION 250/0.5 ¹	5 Syringes/30 Days
NOVAREL INJECTION 10000UNT ¹	2 Vials/30 Days
NOVAREL INJECTION 5000UNIT ¹	4 Vials/30 Days
PREGNYL INJECTION 10000UNT ¹	2 Vials/30 Days

Hereditary Angioedema Agents (HAE)

Drug Name(s)	Quantity Limits (per 30 days or as specified)
BERINERT 500 UNITS/10 ML	10 Vials/30 Days
CINRYZE 500 UNITS/10ML	20 Vials/30 Days
FIRAZYR INJECTION 30MG/3ML ¹	6 Syringes/30 Days
HAEGARDA INJECTION 2000UNIT ¹^,2	24 Vials/30 Days
HAEGARDA INJECTION 3000UNIT ¹^,2	16 Vials/30 Days
icatibant injection 30mg/3ml¹	6 Syringes/30 Days
KALBITOR 3-10 MG/ML SINGLE	12 Vials/30 Days
RUCONEST 2100 UNIT SINGLE USE	8 Vials/28 Days
TAKHZYRO INJECTION 300/2ML ¹^,2	4 Vials/28 Days

ATTR Amyloidosis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
TEGSEDI INJECTION 284/1.5 ¹^,2	6 Syringes/28 Days

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

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CORLANOR SOLUTION 5MG/5ML	600 mLs/30 Days
CORLANOR TABLET 5MG	60 Tablets/30 Days
CORLANOR TABLET 7.5MG	60 Tablets/30 Days

Hemlibra

Drug Name(s)	Quantity Limits (per 30 days or as specified)
HEMLIBRA INJECTION 30MG/ML ¹	4 Vials/28 Days
HEMLIBRA INJECTION 60/0.4 ¹	4 Vials/28 Days
HEMLIBRA INJECTION 105/0.7 ¹	4 Vials/28 Days
HEMLIBRA INJECTION 150/ML ¹	4 Vials/28 Days

Homozygous Familail Hypercholesterolemia (HoFH) Agents

Drug Name(s)	Quantity Limits (per 30 days or as specified)
JUXTAPID CAPSULE 5MG¹^,2	30 Capsules/30 Days
JUXTAPID CAPSULE 10MG¹^,2	30 Capsules/30 Days
JUXTAPID CAPSULE 20MG¹^,2	30 Capsules/30 Days
JUXTAPID CAPSULE 30MG¹^,2	30 Capsules/30 Days
JUXTAPID CAPSULE 40MG¹^,2	30 Capsules/30 Days
JUXTAPID CAPSULE 60MG¹^,2	30 Capsules/30 Days
KYNAMRO INJECTION 200MG/ML ¹	4 Injections/28 Days

Hyperhidrosis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
QBREXZA PAD 2.4%	30 Pads/30 Days

Irritable Bowel Syndrome w/Diahrrea (IBS-D)

Drug Name(s)	Quantity Limits (per 30 days or as specified)
alosetron tablet 0.5mg	60 Tablets/30 Days
alosetron tablet 1mg	60 Tablets/30 Days
LOTRONEX TABLET 0.5MG	60 Tablets/30 Days
LOTRONEX TABLET 1MG	60 Tablets/30 Days
VIBERZI TABLET 75MG	60 Tablets/30 Days
VIBERZI TABLET 100MG	60 Tablets/30 Days
XIFAXAN TABLET 200MG	9 Tablets/30 Days
XIFAXAN TABLET 550MG	60 Tablets/30 Days

Idiopathic Pulmonary Fibrosis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ESBRIET CAPSULE 267MG¹	180 Capsules/30 Days
ESBRIET TABLET 267MG¹	180 Tablets/30 Days
ESBRIET TABLET 801MG¹	90 Tablets/30 Days
OFEV CAPSULE 100MG^1,³	60 Capsules/30 Days
OFEV CAPSULE 150MG^1,³	60 Capsules/30 Days

Insomnia

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AMBIEN CR TABLET 12.5MG	30 Tablets/30 Days
AMBIEN CR TABLET 6.25MG	30 Tablets/30 Days
AMBIEN TABLET 10MG	30 Tablets/30 Days
AMBIEN TABLET 5MG	30 Tablets/30 Days
BELSOMRA TAB 10MG	30 Tablets/30 Days
BELSOMRA TABLET 15MG	30 Tablets/30 Days
BELSOMRA TABLET 20MG	30 Tablets/30 Days
BELSOMRA TABLET 5MG	30 Tablets/30 Days
DAYVIGO 5 MG TABLET	30 Tablets/30 Days
DAYVIGO 10 MG TABLET	30 Tablets/30 Days
doxepin tablet 3mg	30 Tablets/30 Days
doxepin tablet 6mg	30 Tablets/30 Days
EDLUAR SUBLINGUAL 10MG	30 Tablets/30 Days
EDLUAR SUBLINGUAL 5MG	30 Tablets/30 Days
eszopiclone tablet 1mg	30 Tablets/30 Days
eszopiclone tablet 2mg	30 Tablets/30 Days
eszopiclone tablet 3mg	30 Tablets/30 Days
INTERMEZZO SUBLINGUAL 1.75MG	30 Tablets/30 Days
INTERMEZZO SUBLINGUAL 3.5MG	30 Tablets/30 Days
LUNESTA TABLET 1MG	30 Tablets/30 Days
LUNESTA TABLET 2MG	30 Tablets/30 Days
LUNESTA TABLET 3MG	30 Tablets/30 Days
ramelteon tablet 8mg	30 Tablets/30 Days
ROZEREM TABLET 8MG	30 Tablets/30 Days
SILENOR TABLET 3MG	30 Tablets/30 Days
SILENOR TABLET 6MG	30 Tablets/30 Days
SONATA CAPSULE 10MG	30 Capsules/30 Days
SONATA CAPSULE 5MG	30 Capsules/30 Days
zaleplon capsule 10mg	30 Capsules/30 Days
zaleplon capsule 5mg	30 Capsules/30 Days
zolpidem er tablet 12.5mg	30 Tablets/30 Days
zolpidem er tablet 6.25mg	30 Tablets/30 Days
zolpidem tablet 10mg	30 Tablets/30 Days
zolpidem tablet 5mg	30 Tablets/30 Days
zolpidem tartrate sublingual 1.75mg	30 Tablets/30 Days
zolpidem tartrate sublingual 3.5mg	30 Tablets/30 Days
ZOLPIMIST SPRAY 5MG	1 Canister/30 Days
Interleukin (IL)-1 Inhibitor
ARCALYST INJECTION 220MG ¹^,2	4 Vials/28 Days
ILARIS 150 MG/ML	2 Vials/28 Days

Interleukin (IL)-4 Inhibitors

Drug Name(s)	Quantity Limits (per 30 days or as specified)
DUPIXENT INJECTION 200/1.14 ¹	2 Syringes/28 Days
DUPIXENT INJECTION 300/2ML ¹	2 Syringes/28 Days

Isturisa

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ISTURISA TABLET 10MG	180 Tablets/30 Days
ISTURISA TABLET 1MG	240 Tablets/30 Days
ISTURISA TABLET 5MG	300 Tablets/30 Days

Jynarque

Drug Name(s)	Quantity Limits (per 30 days or as specified)
JYNARQUE PACK 30-15MG	56 Tablets/28 Days
JYNARQUE TABLET 15MG	56 Tablets/28 Days
SAMSCA TABLET 15MG¹	30 Tablets/365 Days
SAMSCA TABLET 30MG¹	60 Tablets/365 Days

Keveyis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
KEVEYIS TABLET 50MG¹^,2	120 Tablets/30 Days

Korlym

Drug Name(s)	Quantity Limits (per 30 days or as specified)
KORLYM TABLET 300MG¹^,2	120 Tablets/30 Days

Lidocaine Transdermal

Drug Name(s)	Quantity Limits (per 30 days or as specified)
lidocaine/prilocaine cream 2.5-2.5%	60 Grams/30 Days
LIDOCAINE CREAM TETRACAI	120 Grams/30 Days
lidocaine ointment 5%	600 Grams/30 Days
lidocaine ointment pack 5%	600 Grams/30 Days
lidocaine solution 4%	400 Grams/30 Days
lidocaine-pr cream	60 Grams/30 Days
PLIAGLIS CREAM 7-7%	120 Grams/30 Days
SYNERA DIS 70-70MG	4 Patches/30 Days

Lyrica CR

Drug Name(s)	Quantity Limits (per 30 days or as specified)
LYRICA CR TABLET 82.5MG	30 Tablets/30 Days
LYRICA CR TABLET 165MG	30 Tablets/30 Days
LYRICA CR TABLET 330MG	60 Tablets/30 Days

Multiple Sclerosis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AUBAGIO TABLET 7MG^1,³	30 Tablets/30 Days
AUBAGIO TABLET 14MG^1,³	30 Tablets/30 Days
AVONEX KIT 30MCG¹	1 Pack/28 Days
AVONEX PEN KIT 30MCG¹	1 Pack/28 Days
AVONEX PREFL KIT 30MCG¹	1 Kit/28 Days
BETASERON INJECTION 0.3MG ¹	1 Box/28 Days
COPAXONE INJECTION 20MG/ML ¹	30 Syringes/30 Days
COPAXONE INJECTION 40MG/ML ¹	12 Syringes/28 Days
dimethyl fumarate cap 120mg dr	56 Capsules/180 Days
dimethyl fumarate cap 240mg dr	60 Capsules/30 Days
EXTAVIA INJECTION 0.3MG¹	1 Box/30 Days
GILENYA CAPSULE 0.5MG¹	30 Tablets/30 Days
glatiramer injection 20mg/ml¹	30 Syringes/30 Days
glatiramer injection 40mg/ml¹	12 Syringes/28 Days
glatopa injection 20mg/ml¹	30 Syringes/30 Days
glatopa injection 40mg/ml¹	12 Syringes/28 Days
MAVENCLAD PACK 10MG(4)¹	8 Tablets/301 Days
MAVENCLAD PACK 10MG(5)¹	10 Tablets/301 Days
MAVENCLAD PACK 10MG(6)¹	12 Tablets/301 Days
MAVENCLAD PACK 10MG(7)¹	14 Tablets/301 Days
MAVENCLAD PACK 10MG(8)¹	8 Tablets/301 Days
MAVENCLAD PACK 10MG(9)¹	9 Tablets/301 Days
MAVENCLAD PACK 10MG(10)¹	20 Tablets/301 Days
MAYZENT TABLET 0.25MG¹	120 Tablets/30 Days
MAYZENT TABLET 2MG¹	30 Tablets/30 Days
PLEGRIDY INJECTION¹	2 Syringes/28 Days
PLEGRIDY INJECTION PEN¹	2 Pens/28 Days
REBIF INJECTION 22/0.5¹	12 Syringes/28 Days
REBIF INJECTION 44/0.5¹	1 Carton/28 Days
REBIF REBIDO INJECTION 22/0.5 ¹	1 Carton/28 Days
REBIF REBIDO INJECTION 44/0.5 ¹	1 Carton/28 Days
REBIF REBIDO INJECTION TITRATN ¹	1 Kit/180 Days
REBIF TITRTN INJECTION PACK ¹	1 Kit/180 Days
TECFIDERA 120 MG CAPSULE^,3	56 Capsules/28 Days
TECFIDERA 240 MG CAPSULE^,3	60 Capsules/30 Days
ZEPOSIA 0.92 MG CAPSULE	30 Capsules/30 Days
ZEPOSIA CAPSULE STARTER KIT	37 Capsules/180 Days
ZEPOSIA 7 DAY CAPSULE STARTER PACK	7 Capsules/180 Days

Muscle Relaxants

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AMRIX CAPSULE 15MG	21 Capsules/30 Days
AMRIX CAPSULE 30MG	21 Capsules/30 Days
BACLOFEN TABLET 5MG	120 Tablets/30 Days
baclofen tablet 10mg	120 Tablets/30 Days
baclofen tablet 20mg	120 Tablets/30 Days
carisoprodol/aspirin tablet 200-325	168 Tablets/90 Days
carisoprodol tablet 250mg	28 Tablets/30 Days
carisoprodol tablet 350mg	28 Tablets/30 Days
carisoprodol tablet aspirin/codeine	168 Tablets/90 Days
CARISOPRODOL TABLET ASPIRINE/CODEINE	168 Tablets/30 Days
Chlorzoxazone tablet 250mg	28 Tablets/30 Days
Chlorzoxazone tablet 375mg	84 Tablets/90 Days
Chlorzoxazone tablet 500mg	28 Tablets/30 Days
chlorzoxazone tablet 750mg	84 Tablets/90 Days
cyclobenzapr capsule 15mg er	21 Capsules/30 Days
cyclobenzaprine capsule 30mg er	21 Capsules/30 Days
cyclobenzaprine tablet 5mg	21 Tablets/30 Days
cyclobenzaprine tablet 7.5mg	21 Tablets/30 Days
cyclobenzaprine tablet 10mg	90 Capsules/30 Days
DANTRIUM CAPSULE 25MG	90 Capsules/30 Days
DANTRIUM CAPSULE 50MG	90 Capsules/30 Days
dantrolene capsule 25mg	90 Capsules/30 Days
dantrolene capsule 50mg	90 Capsules/30 Days
dantrolene capsule 100mg	90 Capsules/30 Days
FEXMID TABLET 7.5MG	21 Tablets/30 Days
LORZONE TABLET 375MG	28 Tablets/30 Days
lorzone tablet 375mg	84 Tablets/90 Days
lorzone tablet 750mg	84 Tablets/90 Days
metaxall tablet 800mg	28 Tablets/30 Days
METAXALONE TAB 400MG	56 Tablets/30 Days
metaxalone tablet 800mg	28 Tablets/30 Days
methocarbamol tablet 500mg	60 Tablets/30 Days
methocarbamol tablet 750mg	44 Tablets/30 Days
orphenadrine tablet 100mg cr	42 Tablets/30 Days
orphenadrine tablet 100mg er	42 Tablets/30 Days
ROBAXIN TABLET 500MG	60 Tablets/30 Days
ROBAXIN TABLET 750MG	44 Tablets/30 Days
SKELAXIN TABLET 800MG	28 Tablets/30 Days
SOMA TABLET 250MG	28 Tablets/30 Days
SOMA TABLET 350MG	28 Tablets/30 Days
tizanidine capsule 2mg	42 Capsules/30 Days
tizanidine capsule 4mg	42 Capsules/30 Days
tizanidine capsule 6mg	42 Capsules/30 Days
tizanidine tablet 2mg	42 Capsules/30 Days
tizanidine tablet 4mg	42 Capsules/30 Days
ZANAFLEX CAPSULE 2MG	42 Capsules/30 Days
ZANAFLEX CAPSULE 4MG	42 Capsules/30 Days
ZANAFLEX CAPSULE 6MG	42 Capsules/30 Days
ZANAFLEX TABLET 4MG	42 Tablets/30 Days

Natpara

Drug Name(s)	Quantity Limits (per 30 days or as specified)
NATPARA INJECTION 25MCG¹	1 Kit/28 Days
NATPARA INJECTION 50MCG¹	1 Kit/28 Days
NATPARA INJECTION 75MCG¹	1 Kit/28 Days
NATPARA INJECTION 100MCG ¹	1 Kit/28 Days

Neurotrophic Keratitis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
OXERVATE SOLUTION 20MCG/ML ¹^,2	56 Vials/56 Days

Nocturia

Drug Name(s)	Quantity Limits (per 30 days or as specified)
NOCTIVA EMULSION 0.83/0.1	1 Bottle/30 Days
NOCTIVA SPRAY 1.66/0.1	1 Bottle/30 Days
NOCDURNA 27.7 MCG TABLET	30 Tablets/30 Days
NOCDURNA 55.3 MCG TABLET	31 Tablets/30 Days

Northera

Drug Name(s)	Quantity Limits (per 30 days or as specified)
NORTHERA CAPSULE 100MG¹	450 Capsules/30 Days
NORTHERA CAPSULE 200MG¹	180 Capsules/30 Days
NORTHERA CAPSULE 300MG¹	180 Capsules/30 Days

Nuvigil/Provigil

Drug Name(s)	Quantity Limits (per 30 days or as specified)
armodafinil tablet 50mg	30 Tablets/30 Days
armodafinil tablet 150mg	30 Tablets/30 Days
armodafinil tablet 200mg	30 Tablets/30 Days
armodafinil tablet 250mg	30 Tablets/30 Days
modafinil tablet 100mg	30 Tablets/30 Days
modafinil tablet 200mg	30 Tablets/30 Days
NUVIGIL TABLET 50MG	30 Tablets/30 Days
NUVIGIL TABLET 150MG	30 Tablets/30 Days
NUVIGIL TABLET 200MG	30 Tablets/30 Days
NUVIGIL TABLET 250MG	30 Tablets/30 Days
PROVIGIL TABLET 100MG	30 Tablets/30 Days
PROVIGIL TABLET 200MG	30 Tablets/30 Days

Ocaliva

Drug Name(s)	Quantity Limits (per 30 days or as specified)
OCALIVA TABLET 5MG¹	30 Tablets/30 Days
OCALIVA TABLET 10MG¹	30 Tablets/30 Days

Ophthalmic Immunomodulators

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CEQUA 0.9 MG/ML SOLUTION	60 Vials/30 Days
RESTASIS EMULSION 0.05%	2 Vials/30 Days
RESTASIS MUL EMULSION 0.05%	1 Bottle/30 Days
XIIDRA DROP 5%	60 Vials/30 Days

Ophthalmic Prostaglandins

Drug Name(s)	Quantity Limits (per 30 days or as specified)
bimatoprost solution 0.03%	2.5 mLs/30 Days
latanoprost solution 0.005%	2.5 mLs/30 Days
LUMIGAN SOLUTION 0.01%	2.5 mLs/30 Days
RESCULA SOLUTION 0.15%	1 Bottle/30 Days
travoprost drop 0.004%	2.5 mLs/30 Days
TRAVATAN Z DROP 0.004%	2.5 mLs/30 Days
VYZULTA SOLUTION 0.024%	5 mLs/30 Days
XALATAN SOLUTION 0.005%	2.5 mLs/30 Days
ZIOPTAN DROP 0.0015%	30 Containers/30 Days

Opioids Extended Release (ER)

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

Opioids Immediate Release (IR)

Drug Name(s)	Adult Quantity Limit – 5 Days	Child Quantity Limit – 3 Days
ACETAMINOPHEN-CAFFEINE DIHYDROCODEINE CAPSULE	50 Capsules/30 Days	30 capsules/30 days
ACETAMINOPHEN/CAFFEINE DIHYDROCODEINE TABLET	50 Tablets/30 Days	30 capsules/30 days
acetaminophen/caffeine dihydrocodeine tablet	50 Capsules/30 Days	N/A
acetaminophen/codeine solution 120-12/5	450 mLs/30 Days	270 mL/30 days
acetaminophen/codeine tablet 300-15mg	30 Tablets/30 Days	N/A
acetaminophen/codeine tablet 300-30mg	30 Tablets/30 Days	N/A
acetaminophen/codeine tablet 300-60mg	25 Tablets/30 Days	N/A
butorphanol solution 10mg/ml	1 Bottle/30 Days	0 mL/30 days
CODEINE SULFATE TABLET 15MG	30 Tablets/30 Days	18 tablets/30 days
CODEINE SULFATE TABLET 30MG	30 Tablets/30 Days	18 tablets/30 days
CODEINE SULFATE TABLET 60MG	25 Tablets/30 Days	15 tablets/30 days
DEMEROL TABLET 100MG	15 Tablets/30 Days	N/A
DILAUDID LIQUID 1MG/ML	60 mLs/30 Days	36 mL/30 days
DILAUDID TABLET 2MG	30 Tablets/30 Days	18 tablets/30 days
DILAUDID TABLET 4MG	15 Tablets/30 Days	9 tablets/30 days
DILAUDID TABLET 8MG	5 Tablets/30 Days	3 tablets/30 days
DOLOPHINE TABLET 5MG	60 Tablets/30 Days	N/A
DOLOPHINE TABLET 10MG	30 Tablets/30 Days	N/A
dvorah tablet	50 Tablets/30 Days	N/A
endocet tablet 2.5-325	60 Tablets/30 Days	36 tablets/30 days
endocet tablet 5-325mg	30 Tablets/30 Days	18 tablets/30 days
endocet tablet 7.5-325	20 Tablets/30 Days	12 tablets/30 days
endocet tablet 10-325mg	15 Tablets/30 Days	9 tablets/30 days
hydrocodone/acetaminophen tablet 2.5-325mg	60 Tablets/30 Days	36 tablets/30 days
hydrocodone/acetaminophen tablet 5-325mg	40 Tablets/30 Days	24 tablets/30 days
hydrocodone/acetaminophen tablet 7.5-325mg	30 Tablets/30 Days	18 tablets/30 days
hydrocodone/acetaminophen tablet 10-325mg	25 Tablets/30 Days	15 tablets/30 days
hydrocodone/acetaminophen solution 7.5-325mg	450 mLs/30 Days	270 mL/30 days
HYDROCODONE/ACETAMINOPHEN SOLUTION 10-325MG	375 mLs/30 Days	225 mL/30 days
hydrocodone/acetaminophen tablet 5-300mg	40 Tablets/30 Days	24 tablets/30 days
hydrocodone/acetaminophen tablet 7.5-300 mg	30 Tablets/30 Days	18 tablets/30 days
hydrocodone/acetaminophen tablet 10-300mg	25 Tablets/30 Days	15 tablets/30 days
hydrocodone/ibuprofen tablet 5-200mg	25 Tablets/30 Days	15 tablets/30 days
hydrocodone/ibuprofen tablet 7.5-200mg	25 Tablets/30 Days	15 tablets/30 days
hydrocodone/ibuprofen tablet 10-200mg	25 Tablets/30 Days	15 tablets/30 days
hydromorphone liquid 1mg/ml	60 mLs/30 Days	36 mL/30 days
HYDROMORPHONE SUPPOSITORY 3MG	20 Suppositories/30 Days	N/A
hydromorphone tablet 2mg	30 Tablets/30 Days	18 tablets/30 days
hydromorphone tablet 4mg	15 Tablets/30 Days	9 tablets/30 days
hydromorphone tablet 8mg	5 Tablets/30 Days	3 tablets/30 days
ibudone tablet 5-200mg	25 Tablets/30 Days	15 tablets/30 days
IBUDONE TABLET 10-200MG	25 Tablets/30 Days	15 tablets/30 days
levorphanol tablet 2mg	10 Tablets/30 Days	6 tablets/30 days
levorphanol tablet 3mg	10 Tablets/30 Days	6 tablets/30 days
lorcet hd tablet 10-325mg	25 Tablets/30 Days	N/A
lorcet plus tablet 7.5-325	30 Tablets/30 Days	N/A
lorcet tablet 5-325mg	40 Tablets/30 Days	N/A
LORTAB ELIXER 10-300MG	338 mLs/30 Days	N/A
MEPERIDINE SOLUTION 50MG/5ML	150 mLs/30 Days	150 mL/30 days
meperidine tablet 50mg	30 Tablets/30 Days	30 tablets/30 days
meperidine tablet 100mg	15 Tablets/30 Days	15 tablets/30 days
METHADONE SOLUTION 5MG/5ML	300 mLs/30 Days	N/A
METHADONE SOLUTION 10MG/5ML	150 mLs/30 Days	N/A
methadone tablet 5mg	60 Tablets/30 Days	N/A
methadone tablet 10mg	30 Tablets/30 Days	N/A
morphine sulfate solution 10mg/5ml	125 mLs/30 Days	75 mL/30 days
morphine sulfate solution 20mg/5ml	60 mLs/30 Days	36 mL/30 days
morphine sulfate solution 20mg/ml	10 mLs/30 Days	6 mL/30 days
MORPHINE SULFATE SUPPOSITORY 5MG	50 Suppositories/30 Days	N/A
MORPHINE SULFATE SUPPOSITORY 10MG	25 Suppositories/30 Days	N/A
MORPHINE SULFATE SUPPOSITORY 20MG	10 Suppositories/30 Days	N/A
MORPHINE SULFATE SUPPOSITORY 30MG	5 Suppositories/30 Days	N/A
MORPHINE SULFATE TABLET 15MG	15 Tablets/30 Days	9 tablets/30 days
MORPHINE SULFATE TABLET 30MG	5 Tablets/30 Days	3 tablets/30 days
NORCO TABLET 5-325MG	40 Tablets/30 Days	24 tablets/30 days
NORCO TABLET 7.5-325	30 Tablets/30 Days	18 tablets/30 days
NORCO TABLET 10-325MG	25 Tablets/30 Days	15 tablets/30 days
NUCYNTA TABLET 50MG	10 Tablets/30 Days	6 tablets/30 days
NUCYNTA TABLET 75MG	5 Tablets/30 Days	3 tablets/30 days
NUCYNTA TABLET 100MG	5 Tablets/30 Days	3 tablets/30 days
OPANA TABLET 5MG	15 Tablets/30 Days	9 tablets/30 days
OPANA TABLET 10MG	5 Tablets/30 Days	3 tablets/30 days
OXAYDO TABLET 5MG	30 Tablets/30 Days	18 tablets/30 days
OXAYDO TABLET 7.5MG	20 Tablets/30 Days	12 tablets/30 days
oxycodone/acetaminophen tablet 2.5-325	60 Tablets/30 Days	36 tablets/30 days
oxycodone/acetaminophen tablet 5-325mg	30 Tablets/30 Days	18 tablets/30 days
oxycodone/acetaminophen tablet 7.5-325	20 Tablets/30 Days	12 tablets/30 days
oxycodone/acetaminophen tablet 10-325mg	15 Tablets/30 Days	9 tablets/30 days
oxycodone/aspirin tablet	30 Tablets/30 Days	18 tablets/30 days
OXYCODONE/IBUPRIOFEN TABLET 5-400MG	20 Tablets/30 Days	12 tablets/30 days
oxycodone capsule 5mg	30 Capsules/30 Days	18 capsules/30 days
oxycodone concentrate 20/ml	5 mLs/30 Days	3 mL/30 days
oxycodone solution 5mg/5ml	165 mLs/30 Days	99 mL/30 days
oxycodone tablet 5mg	30 Tablets/30 Days	18 capsules/30 days
oxycodone tablet 7.5mg	20 Tablets/30 Days	12 tablets/30 days
oxycodone tablet 10mg	15 Tablets/30 Days	9 tablets/30 days
oxycodone tablet 15mg	10 Tablets/30 Days	6 tablets/30 days
oxycodone tablet 20mg	5 Tablets/30 Days	3 tablets/30 days
oxycodone tablet 30mg	5 Tablets/30 Days	3 tablets/30 days
OXYCODONE/ SOLUTION ACETAMINOPHEN	100 mLs/30 Days	60 mL/30 days
oxymorphone tablet hcl 5mg	15 Tablets/30 Days	9 tablets/30 days
oxymorphone tablet hcl 10mg	5 Tablets/30 Days	3 tablets/30 days
panlor tablet 325-30	50 Capsules/30 Days	N/A
pentazocine/naloxone tablet 50-0.5mg	10 Tablets/30 Days	6 tablets/30 days
PERCOCET TABLET 2.5-325	60 Tablets/30 Days	36 tablets/30 days
PERCOCET TABLET 5-325MG	30 Tablets/30 Days	18 tablets/30 days
PERCOCET TABLET 7.5-325	20 Tablets/30 Days	12 tablets/30 days
PERCOCET TABLET 10-325MG	15 Tablets/30 Days	9 tablets/30 days
PRIMLEV TABLET 5-300MG	30 Tablets/30 Days	18 tablets/30 days
PRIMLEV TABLET 7.5-300	20 Tablets/30 Days	12 tablets/30 days
PRIMLEV TABLET 10-300MG	15 Tablets/30 Days	9 tablets/30 days
ROXICODONE TABLET 5MG	30 Tablets/30 Days	18 tablets/30 days
ROXICODONE TABLET 15MG	10 Tablets/30 Days	6 tablets/30 days
ROXICODONE TABLET 30MG	5 Tablets/30 Days	3 tablets/30 days
ROXYBOND TABLET 5MG	30 Tablets/30 Days	18 tablets/30 days
tramadol hcl tablet 50mg	50 Tablets/30 Days	30 tablets/30 days
tramadol/acetaminophen tablet 37.5-325	40 Tablets/30 Days	24 tablets/30 days
TREZIX CAPSULE	50 Capsules/30 Days	30 capsules/30 days
TYLENOL/CODEINE TABLET #2	30 Tablets/30 Days	18 tablets/30 days
TYLENOL/CODEINE TABLET #3	30 Tablets/30 Days	18 tablets/30 days
TYLENOL/CODEINE TABLET #4	25 Tablets/30 Days	15 tablets/30 days
ULTRACET TABLET 37.5-325	40 Tablets/30 Days	24 tablets/30 days
ULTRAM TABLET 50MG	50 Tablets/30 Days	30 tablets/30 days
VERDROCET TABLET 2.5-325	60 Tablets/30 Days	N/A
vicodin es tablet 7.5-300	30 Tablets/30 Days	N/A
vicodin hp tablet 10-300mg	25 Tablets/30 Days	N/A
vicodin tablet 5-300mg	40 Tablets/30 Days	N/A
xylon tablet 10-200mg	25 Tablets/30 Days	15 tablets/30 days

Oral Inhalers

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

Oral PAH

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ADCIRCA TABLET 20MG¹	60 Tablets/30 Days
ADEMPAS TABLET 0.5MG¹^,2	90 Tablets/30 Days
ADEMPAS TABLET 1MG¹^,2	90 Tablets/30 Days
ADEMPAS TABLET 1.5MG¹^,2	90 Tablets/30 Days
ADEMPAS TABLET 2MG¹^,2	90 Tablets/30 Days
ADEMPAS TABLET 2.5MG¹^,2	90 Tablets/30 Days
alyq tablet 20mg¹	60 Tablets/30 Days
ambrisentan tablet 5mg¹	30 Tablets/30 Days
ambrisentan tablet 10mg¹	30 Tablets/30 Days
bosentan tablet 62.5mg¹	60 Tablets/30 Days
bosentan tablet 125mg¹	60 Tablets/30 Days
LETAIRIS TABLET 5MG¹	30 Tablets/30 Days
LETAIRIS TABLET 10MG¹	30 Tablets/30 Days
OPSUMIT TABLET 10MG¹^,2	30 Tablets/30 Days
REVATIO SUS 10MG/ML¹	2 Bottles/30 Days
REVATIO TABLET 20MG¹	90 Tablets/30 Days
sildenafil suspense 10mg/ml¹	224 mLs/30 Days
sildenafil tablet 20mg¹	90 Tablets/30 Days
tadalafil tablet 20mg¹	60 Tablets/30 Days
TRACLEER TABLET 32MG¹	120 Tablets/30 Days
TRACLEER TABLET 62.5MG¹	60 Tablets/30 Days
TRACLEER TABLET 125MG¹	60 Tablets/30 Days
TYVASO 0.6 MG/ML SYSTEM	1 Kit/180 Days
TYVASO 0.6 MG/ML 4 PACK	81.2 Ampules/28 Days
UPTRAVI TABLET 200/800¹ ^,2	1 Package/180 Days
UPTRAVI TABLET 200MCG¹^,2	60 Tablets/30 Days
UPTRAVI TABLET 200MCG¹^,2	140 Tablets/180 Days
UPTRAVI TABLET 400MCG¹^,2	60 Tablets/30 Days
UPTRAVI TABLET 600MCG¹^,2	60 Tablets/30 Days
UPTRAVI TABLET 800MCG¹^,2	60 Tablets/30 Days
UPTRAVI TABLET 1000MCG¹ ^,2	60 Tablets/30 Days
UPTRAVI TABLET 1200MCG¹ ^,2	60 Tablets/30 Days
UPTRAVI TABLET 1400MCG¹ ^,2	60 Tablets/30 Days
UPTRAVI TABLET 1600MCG¹ ^,2	60 Tablets/30 Days
VENTAVIS SOLUTION 10MCG/ML ¹^,2^,3	270 Ampules/30 Days
VENTAVIS SOLUTION 20MCG/ML ¹^,2^,3	270 Ampules/30 Days

Orilissa

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ORILISSA TABLET 150MG	30 Tablets/30 Days
ORILISSA TABLET 200MG	60 Tablets/30 Days

Otezla

Drug Name(s)	Quantity Limits (per 30 days or as specified)
OTEZLA TABLET 10/20/30¹	1 Kit/180 Days
OTEZLA TABLET 30MG¹	60 Tablets/30 Days

Oxbryta

Drug Name(s)	Quantity Limits (per 30 days or as specified)
OXBRYTA TABLET 500MG	90 Tablets/30 Days

Parathyroid Hormone Analog Osteoporosis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
FORTEO SOLUTION 600/2.4¹	1 Pen/28 Days
TYMLOS INJECTION¹	1 Pen/30 Days

Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK-9) Inhibitors

Drug Name(s)	Quantity Limits (per 30 days or as specified)
REPATHA INJECTION 140MG/ML	2 Syringes/28 Days
REPATHA SURE INJECTION 140MG/ML	2 Pens/28 Days
REPATHA PUSH INJECTION 420/3.5	1 Cartridge/30 Days
PRALUENT INJECTION 75MG/ML	2 Syringes/28 Days
PRALUENT INJECTION 150MG/ML	2 Syringes/28 Days

Proton Pump Inhibitors (PPI)

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ACIPHEX TABLET 20MG	30 Tablets/30 Days
Dexilant capsule 30mg dr	30 Capsules/30 Days
Dexilant capsule 60mg dr	30 Capsules/30 Days
Esomeprazole magnesium capsule 40mg dr	30 Capsules/30 Days
lansoprazole capsule 15mg dr	30 Capsules/30 Days
lansoprazole capsule 30mg dr	30 Capsules/30 Days
NEXIUM CAPSULE 40MG	30 Capsules/30 Days
omeppi capsule 20-1100	30 Capsules/30 Days
omeppi capsule 40-1100	30 Capsules/30 Days
omeprazole/bicarbonate capsule 20-1100	30 Capsules/30 Days
omeprazole/bicarbonate capsule 40-1100	30 Capsules/30 Days
omeprazole/bicarbonate powder 20-1680	30 Packets/30 Days
omeprazole/bicarbonate powder 40-1680	30 Packets/30 Days
omeprazole capsule 10mg	30 Capsules/30 Days
omeprazole capsule 10mg dr	30 Capsules/30 Days
omeprazole capsule 20mg	30 Capsules/30 Days
omeprazole capsule 20mg dr	30 Capsules/30 Days
omeprazole capsule 40mg	30 Capsules/30 Days
omeprazole capsule 40mg dr	30 Capsules/30 Days
pantoprazole tablet 20mg	30 Tablets/30 Days
pantoprazole tablet 20mg dr	30 Tablets/30 Days
pantoprazole tablet 40mg	30 Tablets/30 Days
pantoprazole tablet 40mg dr	30 Tablets/30 Days
PREVACID CAPSULE 15MG DR	30 Capsules/30 Days
PREVACID CAPSULE 30MG DR	30 Capsules/30 Days
PROTONIX TABLET 20MG	30 Tablets/30 Days
PROTONIX TABLET 40MG	30 Tablets/30 Days
rabeprazole tablet 20mg	30 Tablets/30 Days
ZEGERID CAPSULE 20-1100	30 Capsules/30 Days
ZEGERID CAPSULE 40-1100	30 Capsules/30 Days
ZEGERID POWDER 20-1680	30 Packets/30 Days
ZEGERID POWDER 40-1680	30 Packets/30 Days

Prevymis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
PREVYMIS TABLET 240MG	100 Tablets/365 Days
PREVYMIS TABLET 480MG	100 Tablets/365 Days

Progesterones

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CRINONE GEL 4% VAG	6 Applicators/30 Days
CRINONE GEL 8% VAG	60 Applicators/30 Days
ENDOMETRIN SUPPOSITORY 100MG	4 Cartons/28 Days

Regranex

Drug Name(s)	Quantity Limits (per 30 days or as specified)
REGRANEX GEL 0.01%	1 Tube/30 Days

Rho Kinase Inhibitor

Drug Name(s)	Quantity Limits (per 30 days or as specified)
RHOPRESSA SOLUTION 0.02%	2.5 mLs/30 Days
ROCKLATAN DRO	2.5 mLs/30 Days

Oncology

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

Signifor

Drug Name(s)	Quantity Limits (per 30 days or as specified)
SIGNIFOR INJECTION 0.3MG/ML ¹^,2	60 mLs/30 Days
SIGNIFOR INJECTION 0.6MG/ML ¹^,2	60 mLs/30 Days
SIGNIFOR INJECTION 0.9MG/ML ¹^,2	60 mLs/30 Days

Sodium Oxybate

Drug Name(s)	Quantity Limits (per 30 days or as specified)
XYREM SOLUTION 500MG/ML¹ ^,2	540 mLs/30 Days

Somatostatin Analogs

Drug Name(s)	Quantity Limits (per 30 days or as specified)
SOMAVERT INJECTION 10MG¹	30 Vials/30 Days
SOMAVERT INJECTION 15MG¹	30 Vials/30 Days
SOMAVERT INJECTION 20MG¹	30 Vials/30 Days
SOMAVERT INJECTION 25MG¹	30 Vials/30 Days
SOMAVERT INJECTION 30MG¹	30 Vials/30 Days

SSIA

Drug Name(s)	Quantity Limits (per 30 days or as specified)
NUPLAZID TABLET 10MG¹	30 Tablets/30 Days
NUPLAZID TABLET 17MG¹	60 Tablets/30 Days
NUPLAZID CAPSULE 34MG¹	30 Capsules/30 Days

Statins

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ALTOPREV TABLET 20MG ER	30 Tablets/30 Days
ALTOPREV TABLET 40MG ER	30 Tablets/30 Days
ALTOPREV TABLET 60MG ER	30 Tablets/30 Days
atorvastatin tablet 10mg	45 Tablets/30 Days
atorvastatin tablet 20mg	45 Tablets/30 Days
atorvastatin tablet 40mg	45 Tablets/30 Days
atorvastatin tablet 80mg	30 Tablets/30 Days
CRESTOR TABLET 5MG	45 Tablets/30 Days
CRESTOR TABLET 10MG	45 Tablets/30 Days
CRESTOR TABLET 20MG	45 Tablets/30 Days
CRESTOR TABLET 40MG	30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-10mg	30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-20mg	30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-40mg	30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-80mg	30 Tablets/30 Days
fluvastatin tablet 80mg er	30 Tablets/30 Days
LESCOL XL TABLET 80MG	30 Tablets/30 Days
LIPITOR TABLET 10MG	45 Tablets/30 Days
LIPITOR TABLET 20MG	45 Tablets/30 Days
LIPITOR TABLET 40MG	45 Tablets/30 Days
LIPITOR TABLET 80MG	30 Tablets/30 Days
LIVALO TABLET 1MG	45 Tablets/30 Days
LIVALO TABLET 2MG	45 Tablets/30 Days
LIVALO TABLET 4MG	30 Tablets/30 Days
lovastatin tablet 10mg	60 Tablets/30 Days
lovastatin tablet 20mg	60 Tablets/30 Days
lovastatin tablet 40mg	60 Tablets/30 Days
PRAVACHOL TABLET 20MG	45 Tablets/30 Days
PRAVACHOL TABLET 40MG	45 Tablets/30 Days
PRAVACHOL TABLET 80MG	30 Tablets/30 Days
pravastatin tablet 10mg	45 Tablets/30 Days
pravastatin tablet 20mg	45 Tablets/30 Days
pravastatin tablet 40mg	45 Tablets/30 Days
pravastatin tablet 80mg	30 Tablets/30 Days
rosuvastatin tablet 5mg	45 Tablets/30 Days
rosuvastatin tablet 10mg	45 Tablets/30 Days
rosuvastatin tablet 20mg	45 Tablets/30 Days
rosuvastatin tablet 40mg	30 Tablets/30 Days
simvastatin tablet 5mg	45 Tablets/30 Days
simvastatin tablet 10mg	45 Tablets/30 Days
simvastatin tablet 20mg	60 Tablets/30 Days
simvastatin tablet 40mg	45 Tablets/30 Days
simvastatin tablet 80mg	30 Tablets/30 Days
VYTORIN TABLET 10-10MG	30 Tablets/30 Days
VYTORIN TABLET 10-20MG	30 Tablets/30 Days
VYTORIN TABLET 10-40MG	30 Tablets/30 Days
VYTORIN TABLET 10-80MG	30 Tablets/30 Days
ZOCOR TABLET 5MG	45 Tablets/30 Days
ZOCOR TABLET 10MG	45 Tablets/30 Days
ZOCOR TABLET 20MG	60 Tablets/30 Days
ZOCOR TABLET 40MG	45 Tablets/30 Days
ZOCOR TABLET 80MG	30 Tablets/30 Days

Substrate Reduction Therapy

Drug Name(s)	Quantity Limits (per 30 days or as specified)
CERDELGA CAPSULE 84MG¹	60 Capsules/30 Days
miglustat capsule 100mg¹	90 Capsules/30 Days
ZAVESCA CAPSULE 100MG¹^,2	90 Capsules/30 Days

Sunosi

Drug Name(s)	Quantity Limits (per 30 days or as specified)
SUNOSI TABLET 75MG	30 Tablets/30 Days
SUNOSI TABLET 150MG	30 Tablets/30 Days

Tafamidis

Drug Name(s)	Quantity Limits (per 30 days or as specified)
VYNDAMAX CAPSULE 61MG¹	30 Capsules/30 Days
VYNDAQEL CAPSULE 20MG¹	120 Capsules/30 Days

Thrombopoietin Receptor Agonists

Drug Name(s)	Quantity Limits (per 30 days or as specified)
MULPLETA TABLET 3MG¹	7 Tablets/7 Days
PROMACTA POWDER 12.5MG¹	30 Packets/30 Days
PROMACTA TABLET 12.5MG¹	30 Tablets/30 Days
PROMACTA TABLET 25MG¹	30 Tablets/30 Days
PROMACTA TABLET 50MG¹	60 Tablets/30 Days
PROMACTA TABLET 75MG¹	60 Tablets/30 Days

Topical Corticosteroids

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

Topical Lidocaine

Drug Name(s)	Quantity Limits (per 30 days or as specified)
lidocaine pad 5%	90 Patches/30 Days
LIDODERM DIS 5%	90 Patches/30 Days
ZTLIDO PAD 1.8%	90 Patches/30 Days

Topical NSAID

Drug Name(s)	Quantity Limits (per 30 days or as specified)
DICLOFENAC DIS 1.3%	60 Patches/30 Days
diclofenac gel 1%	10 Tubes/30 Days
diclofenac solution 1.5%	2 Bottles/30 Days
FLECTOR DIS 1.3%	60 Patches/30 Days
klofensaid solution ii	2 Bottles/30 Days
PENNSAID SOLUTION 2%	2 Pumps/28 Days
VOLTAREN GEL 1%	10 Tubes/30 Days

Topiramate ER

Drug Name(s)	Quantity Limits (per 30 days or as specified)
QUDEXY XR CAPSULE 25/24HR	30 Capsules/30 Days
QUDEXY XR CAPSULE 50/24HR	30 Capsules/30 Days
QUDEXY XR CAPSULE 100/24HR	30 Capsules/30 Days
QUDEXY XR CAPSULE 150/24HR	30 Capsules/30 Days
QUDEXY XR CAPSULE 200/24HR	60 Capsules/30 Days
TOPIRAMATE CAPSULE ER 25MG	30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 50MG	30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 100MG	30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 150MG	30 Capsules/30 Days
TOPIRAMATE CAPSULE ER 200MG	60 Capsules/30 Days
TROKENDI XR CAPSULE 25MG	30 Capsules/30 Days
TROKENDI XR CAPSULE 50MG	30 Capsules/30 Days
TROKENDI XR CAPSULE 100MG	30 Capsules/30 Days
TROKENDI XR CAPSULE 200MG	60 Capsules/30 Days

Transmucosal Immediate Release Fentanyl

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ABSTRAL SUBLINGUAL 100MCG	120 Tablets/30 Days
ABSTRAL SUBLINGUAL 200MCG	120 Tablets/30 Days
ABSTRAL SUBLINGUAL 300MCG	120 Tablets/30 Days
ABSTRAL SUBLINGUAL 400MCG	120 Tablets/30 Days
ABSTRAL SUBLINGUAL 600MCG	120 Tablets/30 Days
ABSTRAL SUBLINGUAL 800MCG	120 Tablets/30 Days
ACTIQ LOZENGE 200MCG	120 Lozenges/30 Days
ACTIQ LOZENGE 400MCG	120 Lozenges/30 Days
ACTIQ LOZENGE 600MCG	120 Lozenges/30 Days
ACTIQ LOZENGE 800MCG	120 Lozenges/30 Days
ACTIQ LOZENGE 1200MCG	120 Lozenges/30 Days
ACTIQ LOZENGE 1600MCG	120 Lozenges/30 Days
FENTANYL CITRATE TABLET 100MCG	120 Tablets/30 Days
FENTANYL CITRATE TABLET 200MCG	120 Tablets/30 Days
FENTANYL CITRATE TABLET 400MCG	120 Tablets/30 Days
FENTANYL CITRATE TABLET 600MCG	120 Tablets/30 Days
FENTANYL CITRATE TABLET 800MCG	120 Tablets/30 Days
fentanyl ot lozenge 200mcg	120 Lozenges/30 Days
fentanyl ot lozenge 400mcg	120 Lozenges/30 Days
fentanyl ot lozenge 600mcg	120 Lozenges/30 Days
fentanyl ot lozenge 800mcg	120 Lozenges/30 Days
fentanyl ot lozenge 1200mcg	120 Lozenges/30 Days
fentanyl ot lozenge 1600mcg	120 Lozenges/30 Days
FENTORA TABLET 100MCG	120 Tablets/30 Days
FENTORA TABLET 200MCG	120 Tablets/30 Days
FENTORA TABLET 400MCG	120 Tablets/30 Days
FENTORA TABLET 600MCG	120 Tablets/30 Days
FENTORA TABLET 800MCG	120 Tablets/30 Days
LAZANDA SPRAY 100MCG	30 Bottles/30 Days
LAZANDA SPRAY 300MCG	30 Bottles /30 Days
LAZANDA SPRAY 400MCG	30 Bottles/30 Days
SUBSYS SPRAY 100MCG	120 Sprays/30 Days
SUBSYS SPRAY 200MCG	120 Sprays/30 Days
SUBSYS SPRAY 400MCG	120 Sprays/30 Days
SUBSYS SPRAY 600MCG	120 Sprays/30 Days
SUBSYS SPRAY 800MCG	120 Sprays/30 Days
SUBSYS SPRAY 1200MCG	240 Sprays/30 Days
SUBSYS SPRAY 1600MCG	240 Sprays/30 Days

URAT1 Inhibitor

Drug Name(s)	Quantity Limits (per 30 days or as specified)
DUZALLO TABLET 200-200	30 Tablets/30 Days
DUZALLO TABLET 200-300	30 Tablets/30 Days
ZURAMPIC TABLET 200MG	30 Tablets/30 Days

VMAT2 Inhibitor

Drug Name(s)	Quantity Limits (per 30 days or as specified)
AUSTEDO TABLET 6MG¹	60 Tablets/30 Days
AUSTEDO TABLET 9MG¹	120 Tablets/30 Days
AUSTEDO TABLET 12MG¹	120 Tablets/30 Days
INGREZZA CAPSULE 40MG¹^,2	30 Capsules/30 Days
INGREZZA CAPSULE 80MG¹^,2	30 Capsules/30 Days
INGREZZA CAPSULE 40-80MG ¹^,2	28 Capsules/180 Days
tetrabenazine tablet 12.5mg¹	240 Tablets/30 Days
tetrabenazine tablet 25mg¹	120 Tablets/30 Days
XENAZINE TABLET 12.5MG¹	240 Tablets/30 Days
XENAZINE TABLET 25MG¹	120 Tablets/30 Days

Wakix

Drug Name(s)	Quantity Limits (per 30 days or as specified)
WAKIX TABLET 4.45MG	60 Tablets/30 Days
WAKIX TABLET 17.8MG	60 Tablets/30 Days

Weight Loss Agents

Drug Name(s)	Quantity Limits (per 30 days or as specified)
ADIPEX-P CAPSULE 37.5MG	30 Capsules/30 Days
ADIPEX-P TABLET 37.5MG	30 Tablets/30 Days
BELVIQ TABLET 10MG	60 Tablets/30 Days
BELVIQ XR TABLET 20MG	30 Tablets/30 Days
BENZPHETMINE TABLET 25MG	90 Tablets/30 Days
benzphetamine tablet 50mg	90 Tablets/30 Days
CONTRAVE TABLET 8-90MG	120 Tablets/30 Days
diethylpropion tablet 25mg	90 Tablets/30 Days
DIETHYLPROP TABLET 75MG ER	30 Tablets/30 Days
LOMAIRA TABLET 8MG	90 Tablets/30 Days
phendimetrazine tablet 35mg	180 Tablets/30 Days
phendimetrazine capsule 105mg sr	30 Capsules/30 Days
phentermine capsule 15mg	30 Capsules/30 Days
phentermine capsule 30mg	30 Capsules/30 Days
phentermine capsule 37.5mg	30 Capsules/30 Days
phentermine tablet 37.5mg	30 Tablets/30 Days
QSYMIA CAPSULE 3.75-23	30 Capsules/30 Days
QSYMIA CAPSULE 7.5-46MG	30 Capsules/30 Days
QSYMIA CAPSULE 11.25-69	30 Capsules/30 Days
QSYMIA CAPSULE 15-92MG	30 Capsules/30 Days
REGIMEX TABLET 25MG	90 Tablets/30 Days
SAXENDA INJECTION 18MG/3ML	15 mLs/30 Days
XENICAL CAPSULE 120MG	90 Capsules/30 Days

Xermelo

Drug Name(s)	Quantity Limits (per 30 days or as specified)
XERMELO TABLET 250MG¹^,2	90 Tablets/30 Days

Drug Name(s)
abiraterone acetate¹	ACTEMRA¹	ACTIMMUNE¹
ADCIRCA¹	ADEMPAS^1,²	AFINITOR^1, ³
AFINITOR DISPERZ¹	AIMOVIG¹	AJOVY¹
ALECENSA^1,^2, ³	ALUNBRIG^1,²	alyq¹
ambrisentan¹	AMPYRA^1, ³	APOKYN^1,²
ARCALYST^1,²	ARIKAYCE^1,²	AUBAGIO^1, ³
AUSTEDO¹	AVONEX¹	AVONEX PEN¹
AYVAKIT³	BALVERSA^1,^2, ³	BARACLUDE¹
BENLYSTA¹	BETASERON¹	BETHKIS¹
bexarotene¹	bosentan¹	BOSULIF^1, ³
BRAFTOVI^1,²	BRAVELLE¹	BRUKINSA
BUPHENYL¹	CABOMETYX^1, ³	CALQUENCE^1,²
capecitabine¹	CAPRELSA^1,²	CARBAGLU^1,²
CAYSTON¹	CERDELGA¹	CETROTIDE¹
CHENODAL^1,²	CHOLBAM^1,²	CHORIONIC GONADOTROPIN¹
CIMZIA¹	CIMZIA STARTER KIT¹	cinacalcet hydrochloride¹
COMETRIQ^1,^2, ³	COPAXONE¹	COPIKTRA^1,^2, ³
COSENTYX¹	COSENTYX SENSOREADY PEN¹	COTELLIC¹
CUTAQUIG^1,²	CUVITRU^1,²	CYSTADANE^1,²
CYSTAGON^1,²	CYSTARAN	DAKLINZA¹
dalfampridine er¹	DAURISMO^1, ³	deferasirox¹
DIACOMIT¹	dofetilide¹	DUPIXENT¹
EGRIFTA¹	EGRIFTA SV¹	EMFLAZA^1,²
EMGALITY¹	ENBREL¹	ENBREL MINI¹
ENBREL SURECLICK¹	ENDARI^1,²	entecavir¹
EPCLUSA¹	EPIDIOLEX¹	ERIVEDGE^1, ³
erlotinib hydrochloride¹	ESBRIET¹	everolimus¹
EXJADE^1, ³	EXTAVIA¹	FARYDAK¹
FERRIPROX^1,^2, ³	FIRAZYR¹	FIRDAPSE^1,²
FIRMAGON¹	FOLLISTIM AQ¹	FORTEO¹
FUZEON¹	GALAFOLD¹	ganirelix acetate¹
GANIRELIX ACETATE¹	GATTEX^1,²	GENOTROPIN¹
GENOTROPIN MINIQUICK¹	GILENYA¹	GILOTRIF^1,²
glatiramer acetate¹	glatopa¹	GLEEVEC^1, ³
GOCOVRI^1, ³	GONAL-F¹	GONAL-F RFF¹
GONAL-F RFF REDIJECT¹	GRANIX¹	HAEGARDA^1,²
HARVONI¹	HELIXATE FS¹	HEMLIBRA¹
HETLIOZ^1,^2, ³	HIZENTRA¹	HUMATROPE
HUMIRA¹	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK¹	HUMIRA PEN¹
HUMIRA PEN-CD/UC/HS STARTER ¹	HUMIRA PEN-PS/UV STARTER	HYCAMTIN¹
HYQVIA¹	IBRANCE¹	icatibant acetate¹
ICLUSIG^1,^2, ³	IDHIFA¹	imatinib mesylate¹
IMBRUVICA^1,²	INBRIJA¹	INCRELEX^1,²
INGREZZA^1,²	INLYTA^1, ³	INREBIC^1, ³
INTRON A¹	IRESSA^1,^2, ³	ISTURISA
JADENU^1, ³	JADENU SPRINKLE^1, ³	JAKAFI^1, ³
JUXTAPID^1,²	JYNARQUE¹	KALYDECO¹
KEVEYIS^1,²	KEVZARA¹	KINERET^1,²
KISQALI¹	KISQALI FEMARA¹	KITABIS PAK¹
KOGENATE FS¹	KOGENATE FS BIO-SET¹	KORLYM^1,²
KOSELUGO	KUVAN¹	LEDIPASVIR/SOFOSBUVIR¹
LENVIMA ^1,^2, ³	LETAIRIS¹	leuprolide acetate¹
LONSURF¹	LORBRENA^1, ³	LUPANETA PACK¹
LYNPARZA^1,^2, ³	MATULANE¹	MAVENCLAD¹
MAVYRET¹	MAYZENT¹	MEKINIST¹
MEKTOVI^1,²	MENOPUR¹	miglustat¹
moderiba¹	MODERIBA¹	MULPLETA¹
MYALEPT^1,²	NATPARA¹	NERLYNX^1,^2, ³
NEULASTA¹	NEULASTA ONPRO KIT¹	NEXAVAR^1, ³
NINLARO¹	nitisinone^1,²	NITYR^1,²
NORDITROPIN FLEXPRO¹	NORTHERA¹	NOVAREL¹
NUBEQA¹	NUPLAZID¹	NUTROPIN AQ NUSPIN¹
OCALIVA¹	ODOMZO^1, ³	OFEV^1, ³
OLUMIANT¹	OMNITROPE¹	OPSUMIT^1,²
ORENCIA¹	ORENCIA CLICKJECT¹	ORENITRAM^1,²
ORFADIN^1,²	ORKAMBI¹	OTEZLA¹
OTREXUP¹	OVIDREL¹	OXBRYTA
OXERVATE^1,²	PEGASYS¹	PEGASYS PROCLICK¹
PEGINTRON¹	PIQRAY^1, ³	PLEGRIDY¹
PLEGRIDY STARTER PACK¹	POMALYST¹	PREGNYL W/DILUENT BENZYL ALCOHOL/NACL ¹
PROCRIT¹	PROCYSBI^1,²	PROMACTA¹
PULMOZYME¹	RASUVO¹	RAVICTI¹
REBETOL¹	REBIF¹	REBIF REBIDOSE¹
REBIF REBIDOSE TITRATION PACK ¹	REBIF TITRATION PACK¹	REVATIO¹
REVCOVI¹	REVLIMID¹	ribasphere¹
RIBASPHERE¹	RIBASPHERE RIBAPAK¹	ribavirin¹
RINVOQ¹	ROZLYTREK^1, ³	RUBRACA^1,^2, ³
RUZURGI^1,²	RYDAPT¹	SABRIL¹
SAMSCA¹	SENSIPAR¹	SEROSTIM¹
SIGNIFOR^1,²	sildenafil citrate¹	SILIQ¹
SIMPONI¹	SKYRIZI¹	sodium phenylbutyrate¹
SOFOSBUVIR/VELPATASVIR¹	SOMAVERT¹	SOVALDI¹
SPRYCEL^1, ³	STELARA¹	STIMATE¹
STIVARGA¹	STRENSIQ^1,²	SUTENT^1, ³
SYLATRON¹	SYNAREL¹	tadalafil¹
TAFINLAR¹	TAGRISSO^1,^2, ³	TAKHZYRO^1,²
TALTZ¹	TALZENNA¹³	TARCEVA^1, ³
TARGRETIN^1, ³	TASIGNA¹ 3	TAZVERIK
TECFIDERA³	TECFIDERA STARTER PACK³	TEGSEDI^1,²
TEMODAR¹	temozolomide¹	TERIPARATIDE
tetrabenazine¹	THALOMID¹	THIOLA^1,²
TIBSOVO^1,²	TIKOSYN¹	TOBI¹
TOBI PODHALER¹	tobramycin¹	TOBRAMYCIN¹
tolvaptan	TRACLEER¹	TREMFYA¹
TRIKAFTA	TUKYSA	TURALIO^1,²
TYKERB¹	TYMLOS¹	UPTRAVI^1,²
VALCHLOR^1,²	VELTASSA¹	VEMLIDY¹
VENCLEXTA STARTING PACK* ^	VENCLEXTA^1,²	VENTAVIS^1,^2, ³
VERZENIO^1,^2, ³	VIEKIRA PAK¹	VIEKIRA XR¹
vigabatrin¹	vigadrone^1,²	VIRAZOLE¹
VISTOGARD^1,²	VITRAKVI^1,^2, ³	VIZIMPRO^1, ³
VOSEVI¹	VOTRIENT^1, ³	VUMERITY
VYNDAMAX¹	VYNDAQEL¹	XADAGO¹
XALKORI^1, ³	XELJANZ¹	XELJANZ XR¹
XELODA¹	XENAZINE¹	XEPI¹
XERMELO^1,²	XOSPATA^1,²	XPOVIO^1,^2, ³
XTANDI^1, ³	XURIDEN^1,²	XYNTHA¹
XYNTHA SOLOFUSE¹	XYREM^1,²	ZARXIO¹
ZAVESCA^1,²	ZEJULA^1,^2, ³	ZELBORAF¹
ZEPATIER¹	ZEPOSIA	ZOLINZA^1, ³
ZOMACTON¹	ZORBTIVE¹	ZYDELIG^1,²
ZYKADIA^1, ³	ZYTIGA^1, ³

¹Specialty

²Limited Distribution

³Split Fill

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Advantage prescription drug benefits

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Guide to Prescription Drug Benefits

Use this guide to understand how your benefits work.

Drug Name(s)

Drug Name(s)

Actinic Keratosis

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Acute Migraine 5HT

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Addyi

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Afrezza

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Alinia

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Amantadine ER

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Amifampridine

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Ampyra

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Androgen/Anabolic Steroids

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Antiemetic

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Antifungal

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Anti-Influenza

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Antiretroviral

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Arikayce

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Atypical Antipsychotics

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Bempedoic cid

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Benlysta

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Biologic Immunomodulators

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Bisphosphonates

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Bonjesta Diclegis

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Anti-Migraine: Calcitonin Gene-Related Peptide (CGRP)

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Circadian Rhythm Disorder

Drug Name(s)

Quantity Limits (per 30 days or as specified)

Combination NSAID

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