CHIP prescription drug benefits

Effective January 1, 2022

Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the CHIP 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 names(s)

abiraterone acetate (ZYTIGA)1,3

abiraterone acetate3

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADEMPAS2

ALECENSA2,3

alosetron hcl

alyq1

ambrisentan1

ARANESP ALBUMIN FREE1

AUBAGIO1,3

avita

AVONEX1

AVONEX PEN1

BELSOMRA

BERINERT1

BETASERON1

bosentan1

buprenorphine

capecitabine1

CAYSTON1

ciclodan

ciclopirox nail lacquer

CIMZIA1

CIMZIA STARTER KIT1

CINRYZE2

CIPRO HC

ciprofloxacin / dexamethasone

clomipramine hcl

CORLANOR

COTELLIC1

dalfampridine er1,3

DESVENLAFAXINE ER

dimethyl fumarate1

dimethyl fumarate starterpack1

EMBEDA

EMSAM

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

EPCLUSA1

EPIDIOLEX SOL 100MG/ML

EPIDIOLEX SOL 100MG/ML1

EPINEPHRINE

ERIVEDGE1,3

erlotinib hcl1,3

ESBRIET1

FANAPT

FANAPT TITRATION PACK

fentanyl

fentanyl citrate oral transmucosal

GILENYA1

GILOTRIF2

glatiramer acetate1

glatopa1

glydo

HARVONI1

HUMALOG

HUMALOG JUNIOR KWIKPEN

HUMALOG KWIKPEN

HUMALOG MIX 50/50

HUMALOG MIX 50/50 KWIKPEN

HUMALOG MIX 75/25

HUMALOG MIX 75/25 KWIKPEN

HUMIRA1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1

HUMIRA PEN1

HUMIRA PEN-CD/UC/HS STARTER*

HUMIRA PEN-PEDIATRIC UC STARTER PACK1

HUMIRA PEN-PS/UV STARTER1

HYCAMTIN1

hydromorphone hcl er

HYQVIA1

IBRANCE1

imatinib mesylate1,3

INSULIN LISPRO

INSULIN LISPRO JUNIOR KWIKPEN

INSULIN LISPRO KWIKPEN

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN

INTRON A1

KALYDECO1

KEVZARA1

KOGENATE FS1

KOVALTRY1

lapatinib ditosylate1

LEDIPASVIR/SOFOSBUVIR1

LENVIMA 10 MG DAILY DOSE2,3

LENVIMA 12MG DAILY DOSE2,3

LENVIMA 14 MG DAILY DOSE2,3

LENVIMA 18 MG DAILY DOSE2,3

LENVIMA 20 MG DAILY DOSE2,3

LENVIMA 24 MG DAILY DOSE2,3

LENVIMA 4 MG DAILY DOSE2,3

LENVIMA 8 MG DAILY DOSE2,3

lidocaine hcl

LIDOCAINE GEL 2% JELLY

lidocaine/prilocaine

LYSODREN

MAPROTILINE HCL

metaxalone

methadone hcl

METHITEST

METHYLTESTOSTERONE

miglustat1

MORPHINE SULFATE ER

NATPARA1

NEXAVAR1,3

NINLARO1

NORDITROPIN FLEXPRO1

NOVOEIGHT1

NUCYNTA ER

NUPLAZID1

NUWIQ1

OCTREOTIDE INJ 50MCG/ML1

octreotide inj 1000mcg1

octreotide inj 500mcg1

octreotide inj 200mcg1

octreotide inj 1000/5ml1

octreotide inj 100mcg1

octreotide inj 5000/5ml1

OTEZLA1

OXYCODONE HCL ER

OXYCONTIN

OXYMORPHONE HCL ER

POMALYST1

PROCRIT1

pyrimethamine

REBIF1

REBIF REBIDOSE1

REBIF REBIDOSE TITRATION PACK1

REBIF TITRATION PACK1

RESTASIS

RESTASIS MULTIDOSE

RINVOQ1

sildenafil citrate (VIAGRA)

sildenafil citrate (REVATIO)1

SIMPONI1

SKYRIZI1

SKYRIZI PEN1

sodium phenylbutyrate1

SOFOSBUVIR / VELPATASVIR1

STELARA1

STIMATE1

SYNERA

tadalafil1

TASIGNA1,3

TAZAROTENE

TESTOSTERONE GEL 1%(50MG)

testosterone sol 30mg/act

testosterone td gel 20.25 mg/act (1.62%)

TESTOSTERONE GEL 1%(25MG)

testosterone gel 10mg/act

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

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

testosterone cypionate

TESTOST ENAN INJ 200MG/ML

TESTOSTERONE GEL PUMP 1%

tobramycin neb 300/4ml1

TOBRAMYCIN NEB 300/5ML1

TRACLEER1

TRAMADOL HCL ER

trazodone hcl

tretinoin

VENCLEXTA2

VENCLEXTA STARTING PACK2

VIIBRYD

VOSEVI1

VRAYLAR

XALKORI1,3

XELJANZ1

XELJANZ XR1

XIFAXAN

ZARXIO1

ZYDELIG2



Drug names(s)

ACCU-CHEK AVIVA PLUS

ACCU-CHEK COMPACT PLUS

ACCU-CHEK COMPACT STRIPS

ACCU-CHEK COMPACT TEST DRUM

ACCU-CHEK GUIDE

ACCU-CHEK SMARTVIEW STRIPS

ACCUTREND GLUCOSE

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

ALOGLIPTIN

ALOGLIPTIN/ METFORMIN HCL

ALOGLIPTIN/ PIOGLITAZONE

AMCINONIDE

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

AUGMENTED BETAMETHASONE DIPROPIONATE

BEPREVE

BIOSCANNER GLUCOSE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS PREMIUM

CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE

CARESENS N BLOOD GLUCOSE TEST STRIPS

CARETOUCH BLOOD GLUCOSE TEST STRIPS

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

CLOCORTOLONE PIVALATE

CLOCORTOLONE PIVALATE PUMP

CONTOUR BLOOD GLUCOSE TEST STRIPS

CONTOUR NEXT BLOOD GLUCOSE TEST

COOL BLOOD GLUCOSE TEST STRIPS

CVS ADVANCED GLUCOSE METER TEST STRIPS

D-CARE BLOOD GLUCOSE

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

DIFLORASONE DIACETATE

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

ELEMENT COMPACT TEST STRIPS

ELEMENT TEST STRIPS

EMBRACE BLOOD GLUCOSE TEST STRIPS

EMBRACE EVO BLOOD GLUCOSE TEST STRIPS

EMBRACE PRO BLOOD GLUCOSE TEST STRIPS

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

EQ BLOOD GLUCOSE TEST STRIPS

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

FARXIGA

FIFTY50 GLUCOSE TEST STRIP 2.0

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 TEST STRIPS

FORACARE TEST N GO TEST STRIPS

FORTISCARE BLOOD GLUCOSE TEST STRIP

FREESTYLE INSULINX BLOOD GLUCOSE TEST

FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS

FREESTYLE LIBRE 14 DAY/READER/ FLASH MONITORING SYSTEM

FREESTYLE LIBRE 14 DAY /SENSOR /

FLASH MONITORING SYSTEM

FREESTYLE LIBRE 2 / READER / FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE 2/ SENSOR/ FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE / READER /FLASH MONITORING SYSTEM

FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM

FREESTYLE LITE TEST STRIPS

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS

FREESTYLE TEST STRIPS

GE100 BLOOD GLUCOSE TEST STRIPS

GENULTIMATE TEST STRIPS

GHT TEST STRIPS

GLUCO PERFECT 3 TEST STRIPS

GLUCOCARD 01 SENSOR PLUS

GLUCOCARD 01 SENSOR PLUS TEST STRIPS

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS

GLUCOCARD SHINE TEST STRIPS

GLUCOCARD VITAL TEST STRIPS

GLUCOCARD X-SENSOR

GLUCOCOM TEST STRIPS

GLUCONAVII BLOOD GLUCOSE TEST STRIPS

GLUCOSE METER TEST STRIPS ADVANCED

GLYXAMBI

GNP EASY TOUCH GLUCOSE TEST STRIPS

GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS

HALOG

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

IGLUCOSE BLOOD GLUCOSE TEST STRIPS

IN TOUCH BLOOD GLUCOSE TEST STRIPS

INFINITY BLOOD GLUCOSE TEST STRIPS

INFINITY VOICE

INVOKAMET

INVOKAMET XR

INVOKANA

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

KETOPROFEN

KROGER BLOOD GLUCOSE TEST STRIPS

KROGER HEALTHPRO GLUCOSE TEST STRIPS

KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS

KROGER TEST STRIPS

lanthanum carbonate

LASTACAFT

LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS

LIBERTY TEST STRIPS

LIVALO

LUMIGAN

MECLOFENAMATE SODIUM

MEIJER BLOOD GLUCOSE TEST STRIPS

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS

MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS

MICRODOT TEST STRIPS

MM EASY TOUCH GLUCOSE TEST STRIPS

MYGLUCOHEALTH BLOOD GLUCOSE TEST

NEUTEK 2TEK TEST STRIPS

NOVA MAX GLUCOSE TEST STRIPS

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

OPTIUM TEST STRIPS

OPTIUMEZ TEST STRIPS

OPTUMRX BLOOD GLUCOSE TEST

OZEMPIC

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS

pimecrolimus

POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS

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

PTS PANELS GLUCOSE TEST

QUICKTEK TEST STRIPS

QUINTET AC BLOOD GLUCOSE TEST STRIPS

QUINTET BLOOD GLUCOSE TEST STRIPS

REFUAH PLUS BLOOD GLUCOSETEST STRIPS

RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM

RELION BLOOD GLUCOSE TEST STRIPS

RELION CONFIRM/MICRO TEST STRIPS

RELION PREMIER BLOOD GLUCOSE TEST STRIPS

RELION PRIME BLOOD GLUCOSE TEST STRIPS

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS

REVEAL BLOOD GLUCOSE TEST

REXALL BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS

RYBELSUS

SAVELLA

SAVELLA TITRATION PACK

SIDEKICK BLOOD GLUCOSE SYSTEM

SMART SENSE PREMIUM BLOOD GLUCOSE STRIPS

SMART SENSE VALUE BLOOD GLUCOSE STRIPS

SMARTEST BLOOD GLUCOSE TEST STRIPS

SOLUS V2 AUDIBLE TEST

SUMATRIPTAN SUCCINATE

SUPREME TEST STRIPS

SURE EDGE BLOOD GLUCOSE TEST STRIPS

SURECHEK BLOOD GLUCOSE TEST STRIPS

SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS

SYNJARDY

SYNJARDY XR

tacrolimus

TELCARE BLOOD GLUCOSE TEST STRIPS

TGT BLOOD GLUCOSE TEST STRIPS

TGT BLOOD GLUCOSE TEST STRIPS PREMIUM

TOLMETIN SODIUM

TRADJENTA

TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS

TRUE METRIX BLOOD GLUCOSE TEST STRIPS

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS

TRUETEST STRIPS

TRUETRACK BLOOD GLUCOSE TEST

TRUETRACK TEST

TRULICITY

ULTRATRAK PRO TEST STRIPS

ULTRATRAK ULTIMATE TEST STRIPS

UNISTRIP1 GENERIC

VERASENS BLOOD GLUCOSE TEST STRIPS

VICTOZA

VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS

VOCAL POINT BLOOD GLUCOSE TEST STRIPS

WAVESENSE PRESTO TEST STRIPS

ZIOPTAN

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits
(per 30 days or as specified)

ACTEMRA INJ 162/0.91

4 syringes / 28 days

ACTEMRA INJ ACTPEN1

4 injections / 28 days

ENBREL INJ 25/0.5ML1

4 syringes / 28 days

ENBREL INJ 25MG1

8 vials / 28 days

ENBREL INJ 50MG/ML1

4 syringes / 28 days

ENBREL MINI INJ 50MG/ML1

4 carts / 28 days

ENBREL SRCLK INJ 50MG/ML1

4 syringes / 28 days

HUMIRA INJ 10/0.1ML1

2 syringes / 28 days

HUMIRA INJ 10MG/0.21

2 syringes / 28 days

HUMIRA INJ 20/0.2ML1

2 syringes / 28 days

HUMIRA INJ 40/0.4ML1

2 syringes / 28 days

HUMIRA KIT 20MG/0.41

2 syringes / 28 days

HUMIRA KIT 40MG/0.81

2 syringes / 28 days

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

1 kit / 180 days

HUMIRA PEN INJ 40/0.4ML1

2 pens / 28 days

HUMIRA PEN INJ 40MG/0.81

2 pens / 28 days

HUMIRA PEN INJ 80/0.8ML1

2 pens / 28 days

HUMIRA PEN INJ CD/UC/HS1

1 kit / 180 days

HUMIRA PEN INJ PS/UV1

1 kit / 180 days

HUMIRA PEN KIT CD/UC/HS1

1 kit / 180 days

HUMIRA PEN KIT PED UC1

4 pens / 180 days

HUMIRA PEN KIT PS/UV1

1 kit / 180 days

KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML 1

2 syringes / 28 days

KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML 1

2 syringes / 28 days

KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML 1

2 pens / 28 days

KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML 1

2 pens / 28 days

OTEZLA TAB 10/20/301

1 kit / 180 days

OTEZLA TAB 30MG1

60 tabs / 30 days

RINVOQ TAB 15MG ER1

30 tabs / 30 days

SIMPONI INJ 100MG/ML1

1 syringe / 28 days

SIMPONI INJ 50/0.5ML1

1 syringe / 28 days

XELJANZ SOL 1MG/ML1

240 mLs / 30 days

XELJANZ TAB 5MG1

60 tabs / 30 days

XELJANZ TAB 10MG1

240 tabs / 365 days

XELJANZ XR TAB 11MG1

30 tabs / 30 days

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

apap/codeine sol 120-12/5

450 mLs / 30 days

270 mLs / 30 days

apap/codeine tab 300-15mg

30 tablets / 30 days

18 tablets / 30 days

apap/codeine tab 300-30mg

30 tablets / 30 days

18 tablets / 30 days

apap/codeine tab 300-60mg

25 tablets / 30 days

15 tablets / 30 days

buprenorphinie dis 7.5/hr

4 systems / month

N/A

buprenorphine dis 10mcg/hr

4 systems / month

N/A

buprenorphine dis 15mcg/hr

4 systems / month

N/A

buprenorphine dis 20mcg/hr

4 systems / month

N/A

buprenorphine dis 5mcg/hr

4 systems / month

N/A

butorphanol sol 10mg/ml

2.5 mL (1 bottle) / 30 days

0 mLs / 30 days

CODEINE SULF TAB 15MG

30 tablets / 30 days

18 tablets / 30 days

codeine sulf tab 30mg

30 tablets / 30 days

18 tablets / 30 days

CODEINE SULF TAB 60MG

25 tablets / 30 days

15 tablets / 30 days

EMBEDA CAP 100-4MG

0 capsules / month

N/A

EMBEDA CAP 20-0.8MG

30 capsules / month

N/A

EMBEDA CAP 30-1.2MG

30 capsules / month

N/A

EMBEDA CAP 50-2MG

30 capsules / month

N/A

EMBEDA CAP 60-2.4MG

0 capsules / month

N/A

EMBEDA CAP 80-3.2MG

0 capsules / month

N/A

endocet tab 2.5-325

60 tablets / 30 days

36 tablets / 30 days

endocet tab 5-325mg

30 tablets / 30 days

18 tablets / 30 days

endocet tab 7.5-325

20 tablets / 30 days

12 tablets / 30 days

endocet tab 10-325mg

15 tablets / 30 days

9 tablets / 30 days

fentanyl dis 12mcg/hr

10 patches / month

N/A

fentanyl dis 25mcg/hr

0 patches / month

N/A

fentanyl dis 50mcg/hr

0 patches / month

N/A

fentanyl dis 75mcg/hr

0 patches / month

N/A

fentanyl dis 100mcg/hr

0 patches / month

N/A

fentanyl ot loz 200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 400mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 600mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 800mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1600mcg

120 lozenges / 30 days

N/A

hydrocodone/apap sol 7.5-325

450 mLs / 30 days

270 mLs / 30 days

hydrocodone /apap tab 5-325mg

40 tablets / 30 days

24 tablets / 30 days

hydrocodone /apap tab 7.5-325

30 tablets / 30 days

18 tablets / 30 days

hydrocodone /apap tab 10-325mg

25 tablets / 30 days

15 tablets / 30 days

HYDROCOD/IBU TAB 5-200MG

25 tablets / 30 days

15 tablets / 30 days

hydrocodone/ibu tab 5-200mg

25 tablets / 30 days

15 tablets / 30 days

hydrocodone/ibu tab 7.5-200

25 tablets / 30 days

15 tablets / 30 days

hydrocodone /ibu tab 10-200mg

25 tablets / 30 days

15 tablets / 30 days

hydromorphone liq 1mg/ml

60 mLs / 30 days

36 mLs / 30 days

hydromorphone tab 2mg

30 tablets / 30 days

18 tablets / 30 days

hydromorphone tab 4mg

15 tablets / 30 days

9 tablets / 30 days

hydromorphone tab 8mg

5 tablets / 30 days

3 tablets / 30 days

hydromorphone tab 8mg er

30 tablets / month

N/A

hydromorphone tab 12mg er

30 tablets / month

N/A

hydromorphone tab 16mg er

0 tablets

N/A

hydromorphone tab 32mg er

0 tablets

N/A

levorphanol tab 2mg

10 tablets / 30 days

6 tablets / 30 days

lorcet tab 5-325mg

40 tablets / 30 days

24 tablets / 30 days

lorcet hd tab 10-325mg

25 tablets / 30 days

15 tablets / 30 days

lorcet plus tab 7.5-325

30 tablets / 30 days

18 tablets / 30 days

MEPERIDINE SOL 50MG/5ML

150 mLs / 30 days

150 mLs / 30 days

methadone sol 5mg/5ml

300 mLs / 30 days

N/A

methadone sol 10mg/5ml

150 mLs / 30 days

N/A

methadone tab 5mg

60 tablets / 30 days

N/A

methadone tab 10mg

30 tablets / 30 days

N/A

morphine sul sol 10mg/5ml

125 mLs / 30 days

75 mLs / 30 days

morphine sul sol 20mg/5ml

60 mLs / 30 days

36 mLs / 30 days

morphine sul sol 20mg/ml

15 mLs / 30 days

15 mLs / 30 days

morphine sul sol 100/5ml

15 mLs / 30 days

15 mLs / 30 days

morphine sul tab 100mg er

0 tablets / 30 days

N/A

MORPHINE SUL TAB 15MG

15 tablets / 30 days

9 tablets / 30 days

morphine sul tab 30mg

5 tablets / 30 days

3 tablets / 30 days

morphine sul tab 30mg er

30 tablets / 30 days

N/A

morphine sul tab 60mg er

0 tablets / 30 days

N/A

NUCYNTA TAB 100MG

5 tablets / 30 days

3 tablets / 30 days

NUCYNTA TAB 50MG

10 tablets / 30 days

6 tablets / 30 days

NUCYNTA TAB 75MG

5 tablets / 30 days

3 tablets / 30 days

NUCYNTA ER TAB 100MG

30 tablets / 30 days

N/A

NUCYNTA ER TAB 150MG

0 tablets / 30 days

N/A

NUCYNTA ER TAB 200MG

0 tablets / 30 days

N/A

NUCYNTA ER TAB 250MG

0 tablets / 30 days

N/A

NUCYNTA ER TAB 50MG

60 tablets / 30 days

N/A

oxycod/apap tab 2.5-325

60 tablets / 30 days

36 tablets / 30 days

oxycod/apap tab 5-325mg

30 tablets / 30 days

18 tablets / 30 days

oxycod/apap tab 7.5-325

20 tablets / 30 days

12 tablets / 30 days

oxycod/apap tab 10-325mg

15 tablets / 30 days

9 tablets / 30 days

OXYCOD/ASA TAB

30 tablets / 30 days

18 tablets / 30 days

OXYCOD/IBU TAB 5-400MG

20 tablets / 30 days

12 tablets / 30 days

oxycodone con 10/0.5ml

5 mLs / 30 days

3 mLs / 30 days

oxycodone con 100/5ml

5 mLs / 30 days

3 mLs / 30 days

oxycodone sol 5mg/5ml

165 mLs / 30 days

99 mLs / 30 days

oxycodone tab 5mg

30 tablets / 30 days

18 tablets / 30 days

oxycodone tab 10mg

15 tablets / 30 days

9 tablets / 30 days

oxycodone tab 15mg

10 tablets / 30 days

6 tablets / 30 days

oxycodone tab 20mg

5 tablets / 30 days

3 tablets / 30 days

oxycodone tab 30mg

5 tablets / 30 days

3 tablets / 30 days

OXYCODONE TAB 10MG ER

60 tablets / 30 days

N/A

OXYCODONE TAB 15MG ER

60 tablets / 30 days

N/A

OXYCODONE TAB 20MG ER

30 tablets / 30 days

N/A

OXYCODONE TAB 30MG ER

30 tablets / 30 days

N/A

OXYCODONE TAB 40MG ER

0 tablets / 30 days

N/A

OXYCODONE TAB 60MG ER

0 tablets / 30 days

N/A

OXYCODONE TAB 80MG ER

0 tablets / 30 days

N/A

OXYCONTIN TAB 10MG CR

60 tablets / 30 days

N/A

OXYCONTIN TAB 15MG CR

60 tablets / 30 days

N/A

OXYCONTIN TAB 20MG CR

30 tablets / 30 days

N/A

OXYCONTIN TAB 30MG CR

30 tablets / 30 days

N/A

OXYCONTIN TAB 40MG CR

0 tablets / 30 days

N/A

OXYCONTIN TAB 60MG CR

0 tablets / 30 days

N/A

OXYCONTIN TAB 80MG CR

0 tablets / 30 days

N/A

OXYMORPHONE TAB 5MG ER

60 tablets / 30 days

N/A

OXYMORPHONE TAB 7.5MG ER

60 tablets / 30 days

N/A

OXYMORPHONE TAB 10MG ER

30 tablets / 30 days

N/A

OXYMORPHONE TAB 15MG ER

30 tablets / 30 days

N/A

OXYMORPHONE TAB 20MG ER

0 tablets / 30 days

N/A

OXYMORPHONE TAB 30MG ER

0 tablets / 30 days

N/A

OXYMORPHONE TAB 40MG ER

0 tablets / 30 days

N/A

tramadol hcl tab 50mg

50 tablets / 30 days

30 tablets / 30 days

tramadol hcl tab 100mg er

30 tablets / 30 days

N/A

tramadol hcl tab 200mg er

30 tablets / 30 days

N/A

tramadol hcl tab 300mg er

30 tablets / 30 days

N/A

OXYMORPHONE TAB 5MG ER

60 tablets / 30 days

N/A

OXYMORPHONE TAB 7.5MG ER

60 tablets / 30 days

N/A

tramadol hcl tab 100mg er

30 tablets / 30 days

N/A

tramadol hcl tab 200mg er

30 tablets / 30 days

N/A

tramadol hcl tab 300mg er

30 tablets / 30 days

N/A

Androgens - anabolic

Drug name(s)

Quantity limits
(per 30 days or as specified)

testost cyp inj 100mg/ml

1 vial / 28 days

testost cyp inj 200mg/ml

10 mLs / 28 days

TESTOST ENAN INJ 200MG/ML

1 vial / 28 days

testost enan inj 200mg/ml

1 vial / 28 days

TESTOSTERONE GEL 1%(25MG)

60 packets / 30 days

testosterone gel 1%(25mg)

60 packets / 30 days

TESTOSTERONE GEL 1%(50MG)

60 packets / 30 days

testosterone gel 1%(50mg)

60 packets / 30 days

TESTOSTERONE GEL PUMP 1%

4 pumps / 30 days

testosterone gel pump 1%

300 grams / 30 days

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

ADVAIR HFA AER 45/21

1 can / 30 days

ADVAIR HFA AER 115/21

1 can / 30 days

ADVAIR HFA AER 230/21

1 can / 30 days

ALBUTEROL AER HFA

2 cans / 30 days

albuterol aer hfa

2 cans / 30 days

ASMANEX 120 AER 220MCG

1 can / 30 days

ASMANEX 30 AER 110MCG

1 can / 30 days

ASMANEX 30 AER 220MCG

1 can / 30 days

ASMANEX 60 AER 220MCG

1 can / 30 days

ASMANEX HFA AER 100 MCG

1 can / 30 days

ASMANEX HFA AER 200 MCG

1 can / 30 days

ASMANEX HFA AER 50MCG

1 inhaler / 30 days

BREO ELLIPTA INH 100-25

60 blisters / 30 days

BREO ELLIPTA INH 200-25

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 can / 30 days

FLOVENT DISK AER 50MCG

60 blisters / 30 days

FLOVENT HFA AER 110MCG

1 can / 30 days

FLOVENT HFA AER 220MCG

2 cans / 30 days

flutic/salme aer 100/50

60 blisters / 30 days

flutic/salme aer 250/50

60 blisters / 30 days

flutic/salme aer 500/50

60 blisters / 30 days

LEVALBUTEROL AER 45/ACT

2 cans / 30 days

PROAIR RESPI AER

2 inhalers / 30 days

QVAR REDIHAL AER 40MCG

1 can / 30 days

QVAR REDIHA AER 80MCG

2 cans / 30 days

SEREVENT DIS AER 50MCG

60 blisters / 30 days

SPIRIVA AER 1.25MCG

1 cart / 30 days

SPIRIVA CAP HANDIHLR

30 caps / 30 days

SPIRIVA SPR 2.5MCG

1 cart / 30 days

wixela inhub aer 100/50

60 blisters / 30 days

wixela inhub aer 250/50

60 blisters / 30 days

wixela inhub aer 500/50

60 blisters / 30 days

XOPENEX HFA AER

2 cans / 30 days

Anticonvulsants

Drug name(s)

Quantity limits
(per 30 days or as specified)

pregabalin cap 25mg

90 caps / 30 days

pregabalin cap 50mg

90 caps / 30 days

pregabalin cap 75mg

90 caps / 30 days

pregabalin cap 100mg

90 caps / 30 days

pregabalin cap 150mg

90 caps / 30 days

pregabalin cap 200mg

90 caps / 30 days

pregabalin cap 225mg

60 caps / 30 days

pregabalin cap 300mg

60 caps / 30 days

pregabalin sol 20mg/ml

900 mLs / 30 days

Antidiabetics

Drug name(s)

Quantity limits
(per 30 days or as specified)

ALOG/PIOGLIT TAB 12.5-15

30 tabs / 30 days

ALOG/PIOGLIT TAB 12.5-30

30 tabs / 30 days

ALOG/PIOGLIT TAB 12.5-45

30 tabs / 30 days

ALOG/PIOGLIT TAB 25-15MG

30 tabs / 30 days

ALOG/PIOGLIT TAB 25-30MG

30 tabs / 30 days

ALOG/PIOGLIT TAB 25-45MG

30 tabs / 30 days

ALOGLIPTIN TAB 12.5MG

30 tabs / 30 days

ALOGLIPTIN TAB 25MG

30 tabs / 30 days

ALOGLIPTIN TAB 6.25MG

30 tabs / 30 days

ALOGLIPTIN/ TAB METFORM

60 tabs / 30 days

FARXIGA TAB 10MG

30 tabs / 30 days

FARXIGA TAB 5MG

30 tabs / 30 days

GLYXAMBI TAB 10-5 MG

30 tabs / 30 days

GLYXAMBI TAB 25-5 MG

30 tabs / 30 days

INVOKAMET TAB 50-500MG

60 tabs / 30 days

INVOKAMET TAB 50-1000

60 tabs / 30 days

INVOKAMET TAB 150-500

60 tabs / 30 days

INVOKAMET TAB 150-1000

60 tabs / 30 days

INVOKAMET XR TAB 50-500MG

60 tabs / 30 days

INVOKAMET XR TAB 50-1000

60 tabs / 30 days

INVOKAMET XR TAB 150-500

60 tabs / 30 days

INVOKAMET XR TAB 150-1000

60 tabs / 30 days

INVOKANA TAB 100MG

30 tabs / 30 days

INVOKANA TAB 300MG

30 tabs / 30 days

JANUMET TAB 50-1000

60 tabs / 30 days

JANUMET TAB 50-500MG

60 tabs / 30 days

JANUMET XR TAB 100-1000

30 tabs / 30 days

JANUMET XR TAB 50-1000

60 tabs / 30 days

JANUMET XR TAB 50-500MG

30 tabs / 30 days

JANUVIA TAB 25MG

30 tabs / 30 days

JANUVIA TAB 50MG

30 tabs / 30 days

JANUVIA TAB 100MG

30 tabs / 30 days

JARDIANCE TAB 10MG

30 tabs / 30 days

JARDIANCE TAB 25MG

30 tabs / 30 days

metformin tab 750mg er

60 tabs / 30 days

metformin hcl tab er 24hr 500 mg

120 tabs / 30 days

ONGLYZA TAB 2.5MG

30 tabs / 30 days

ONGLYZA TAB 5MG

30 tabs / 30 days

OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/1.5ML)

1 pen / 28 days

OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (2 MG/1.5ML)

2 pens / 28 days

RYBELSUS TAB 3MG

30 tabs / 180 days

RYBELSUS TAB 7MG

30 tabs / 30 days

RYBELSUS TAB 14MG

30 tabs / 30 days

SYNJARDY TAB

60 tabs / 30 days

SYNJARDY TAB 12.5-500

60 tabs / 30 days

SYNJARDY TAB 5-1000MG

60 tabs / 30 days

SYNJARDY TAB 5-500MG

60 tabs / 30 days

SYNJARDY XR TAB

60 tabs / 30 days

SYNJARDY XR TAB 5-1000MG

60 tabs / 30 days

SYNJARDY XR TAB 10-1000

60 tabs / 30 days

SYNJARDY XR TAB 25-1000

30 tabs / 30 days

TRADJENTA TAB 5MG

30 tabs / 30 days

TRULICITY INJ 0.75/0.5

4 pens / 28 days

TRULICITY INJ 1.5/0.5

4 pens / 28 days

TRULICITY INJ 3/0.5

4 pens / 28 days

TRULICITY INJ 4.5/0.5

4 pens / 28 days

VICTOZA INJ 18MG/3ML

3 pens / 30 days

Antiemetics

Drug name(s)

Quantity limits
(per 30 days or as specified)

AKYNZEO CAP 300-0.5

2 caps / 30 days

aprepitant cap 40mg

8 caps / 30 days

aprepitant cap 80mg

8 caps / 30 days

aprepitant cap 125mg

4 caps / 30 days

granisetron tab 1mg

14 tabs / 30 days

ondansetron sol 4mg/5ml

5 bottles / 30 days

ondansetron tab 4mg odt

24 tabs / 30 days

ondansetron tab 8mg odt

24 tabs / 30 days

Antihyperlipidemics

Drug name(s)

Quantity limits
(per 30 days or as specified)

atorvastatin tab 10mg

45 tabs / 30 days

atorvastatin tab 20mg

45 tabs / 30 days

atorvastatin tab 40mg

45 tabs / 30 days

atorvastatin tab 80mg

30 tabs / 30 days

LIVALO TAB 1MG

45 tabs / 30 days

LIVALO TAB 2MG

45 tabs / 30 days

LIVALO TAB 4MG

30 tabs / 30 days

lovastatin tab 10mg

60 tabs / 30 days

lovastatin tab 20mg

60 tabs / 30 days

lovastatin tab 40mg

60 tabs / 30 days

pravastatin tab 10mg

45 tabs / 30 days

pravastatin tab 20mg

45 tabs / 30 days

pravastatin tab 40mg

45 tabs / 30 days

pravastatin tab 80mg

30 tabs / 30 days

rosuvastatin tab 5mg

45 tabs / 30 days

rosuvastatin tab 10mg

45 tabs / 30 days

rosuvastatin tab 20mg

45 tabs / 30 days

rosuvastatin tab 40mg

30 tabs / 30 days

simvastatin tab 5mg

45 tabs / 30 days

simvastatin tab 10mg

45 tabs / 30 days

simvastatin tab 20mg

60 tabs / 30 days

simvastatin tab 40mg

45 tabs / 30 days

simvastatin tab 80mg

30 tabs / 30 days

Anti-infective agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

nitazoxanide tab 500mg

12 tabs / 90 days

XIFAXAN TAB 200MG

9 tabs / 30 days

XIFAXAN TAB 550MG

60 tabs / 30 days

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits
(per 30 days or as specified)

abiraterone tab 250mg1,3

120 tabs / 30 days

abiraterone tab 500mg1,3

60 tabs / 30 days

ALECENSA CAP 150MG2,3

240 caps / 30 days

COTELLIC TAB 20MG1

63 tabs / 28 days

ERIVEDGE CAP 150MG1,3

30 caps / 30 days

erlotinib tab 25mg1,3

60 tabs / 30 days

erlotinib tab 100mg1,3

30 tabs / 30 days

erlotinib tab 150mg1,3

30 tabs / 30 days

GILOTRIF TAB 20MG2

30 tabs / 30 days

GILOTRIF TAB 30MG2

30 tabs / 30 days

GILOTRIF TAB 40MG2

30 tabs / 30 days

IBRANCE CAP 75MG1

21 caps / 28 days

IBRANCE CAP 100MG1

21 caps / 28 days

IBRANCE CAP 125MG1

21 caps / 28 days

IBRANCE TAB 75MG1

21 tabs / 28 days

IBRANCE TAB 100MG1

21 tabs / 28 days

IBRANCE TAB 125MG1

21 tabs / 28 days

imatinib mes tab 100mg1,3

90 tabs / 30 days

imatinib mes tab 400mg1,3

60 tabs / 30 days

lapatinib tab 250mg1

180 tabs / 30 days

LENVIMA CAP 4MG2,3

30 caps / 30 days

LENVIMA CAP 8 MG2,3

60 caps / 30 days

LENVIMA CAP 10 MG2,3

30 caps / 30 days

LENVIMA CAP 12MG2,3

90 caps / 30 days

LENVIMA CAP 14 MG2,3

60 caps / 30 days

LENVIMA CAP 18 MG2,3

90 caps / 30 days

LENVIMA CAP 20 MG2,3

60 caps / 30 days

LENVIMA CAP 24 MG2,3

90 caps / 30 days

NEXAVAR TAB 200MG1,3

120 tabs / 30 days

NINLARO CAP 2.3MG1

3 caps / 28 days

NINLARO CAP 3MG1

3 caps / 28 days

NINLARO CAP 4MG1

3 caps / 28 days

POMALYST CAP 1MG1

21 caps / 28 days

POMALYST CAP 2MG1

21 caps / 28 days

POMALYST CAP 3MG1

21 caps / 28 days

POMALYST CAP 4MG1

21 caps / 28 days

TASIGNA CAP 50MG1,3

120 caps / 30 days

TASIGNA CAP 150MG1,3

120 caps / 30 days

TASIGNA CAP 200MG1,3

120 caps / 30 days

VENCLEXTA TAB 10MG2

60 tabs / 30 days

VENCLEXTA TAB 50MG2

30 tabs / 30 days

VENCLEXTA TAB 100MG2

180 tabs / 30 days

VENCLEXTA TAB START PK2

1 pack / 180 days

XALKORI CAP 200MG1,3

120 caps / 30 days

XALKORI CAP 250MG1,3

120 caps / 30 days

ZYDELIG TAB 100MG2

60 tabs / 30 days

ZYDELIG TAB 150MG2

60 tabs / 30 days

Antipsychotics / anditmanic agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

NUPLAZID CAP 34MG1

30 caps / 30 days

NUPLAZID TAB 10MG1

30 tabs / 30 days

olanzapine tab 2.5mg

30 tabs / 30 days

olanzapine tab 5mg

30 tabs / 30 days

olanzapine tab 7.5mg

30 tabs / 30 days

olanzapine tab 10mg

30 tabs / 30 days

olanzapine tab 15mg

30 tabs / 30 days

olanzapine tab 20mg

30 tabs / 30 days

paliperidone tab er 1.5mg

60 tabs / 30 days

paliperidone tab er 3mg

60 tabs / 30 days

paliperidone tab er 6mg

60 tabs / 30 days

paliperidone tab er 9mg

60 tabs / 30 days

quetiapine tab 50mg er

60 tabs / 30 days

quetiapine tab 150mg er

60 tabs / 30 days

quetiapine tab 200mg er

60 tabs / 30 days

quetiapine tab 300mg er

60 tabs / 30 days

quetiapine tab 400mg er

60 tabs / 30 days

VRAYLAR CAP 1.5-3MG

1 pack / 180 days

VRAYLAR CAP 1.5MG

30 caps / 30 days

VRAYLAR CAP 3MG

30 caps / 30 days

VRAYLAR CAP 4.5MG

30 caps / 30 days

VRAYLAR CAP 6MG

30 caps / 30 days

Antivirals

Drug name(s)

Quantity limits
(per 30 days or as specified)

EPCLUSA TAB 200-50MG1

28 tabs / 28 days

EPCLUSA TAB 400-1001

30 tabs / 30 days

HARVONI PAK1

28 packets / 28 days

HARVONI PAK 45-200MG1

28 packets / 28 days

HARVONI TAB 45-200MG1

28 tabs / 28 days

HARVONI TAB 90-400MG1

30 tabs / 30 days

LEDIP-SOFOSB TAB 90-400MG1

30 tabs / 30 days

oseltamivir cap 30mg

40 caps / 120 days

oseltamivir cap 45mg

20 caps / 120 days

oseltamivir cap 75mg

20 caps / 120 days

oseltamivir sus 6mg/ml

300 mLs / 120 days

RELENZA MIS DISKHALE

40 blisters / 120 days

SOFOS/VELPAT TAB 400-1001

30 tabs / 30 days

VOSEVI TAB1

30 tabs / 30 days

Cardiovascular agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

ADEMPAS TAB 0.5MG2

90 tabs / 30 days

ADEMPAS TAB 1.5MG2

90 tabs / 30 days

ADEMPAS TAB 1MG2

90 tabs / 30 days

ADEMPAS TAB 2.5MG2

90 tabs / 30 days

ADEMPAS TAB 2MG2

90 tabs / 30 days

alyq tab 20mg1

60 tabs / 30 days

ambrisentan tab 5mg1

30 tabs / 30 days

ambrisentan tab 10mg1

30 tabs / 30 days

bosentan tab 62.5mg1

60 tabs / 30 days

bosentan tab 125mg1

60 tabs / 30 days

CORLANOR SOL 5MG/5ML

600 mLs / 30 days

CORLANOR TAB 5MG

60 tabs / 30 days

CORLANOR TAB 7.5MG

60 tabs / 30 days

sildenafil tab 20mg1

90 tabs / 30 days

tadalafil tab 20mg1

60 tabs / 30 days

TRACLEER TAB 32MG1

120 tabs / 30 days

Dermatologicals

Drug name(s)

Quantity limits
(per 30 days or as specified)

alclometasone cre 0.05%

120 grams / 30 days

alclometasone oin 0.05%

120 grams / 30 days

AMCINONIDE LOT 0.1%

120 mLs / 30 days

augmented betamethasone cre 0.05%

200 grams / 28 days

AUGMENTED BETAMETHASONE GEL 0.05%

200 grams / 28 days

augmented betamethasone lot 0.05%

210 mLs / 30 days

augmented betamethasone oin 0.05%

200 grams / 28 days

betamethasone diproprionate cre 0.05%

135 grams / 30 days

betamethasone diproprionate lot 0.05%

120 mLs / 30 days

betamethasone diproprionate oin 0.05%

135 grams / 30 days

betamethasone valerate cre 0.1%

135 grams / 30 days

betamethasone valerate lot 0.1%

120 mLs / 30 days

betamethasone valerate oin 0.1%

135 grams / 30 days

ciclodan sol 8%

3.3 mLs / 30 days

ciclopirox sol 8%

3.3 mLs / 30 days

clobetasol cre 0.05%

210 grams / 28 days

clobetasol oin 0.05%

210 grams / 28 days

clobetasol sol 0.05%

200 mLs / 28 days

clobetasol e cre 0.05%

210 grams / 28 days

CLOCORTOLONE CRE 0.1%

135 grams / 30 days

desonide cre 0.05%

120 grams / 30 days

desonide lot 0.05%

118 mLs / 30 days

desonide oin 0.05%

120 grams / 30 days

desoximetasone cre 0.05%

120 grams / 30 days

desoximetasone cre 0.25%

120 grams / 30 days

desoximetasone gel 0.05%

120 grams / 30 days

desoximetasone oin 0.05%

120 grams / 30 days

desoximetasone oin 0.25%

120 grams / 30 days

diclofenac gel 1%

10 tubes / 30 days

DIFLORASONE CRE 0.05%

120 grams / 30 days

diflorasone oin 0.05%

120 grams / 30 days

fluocinolone acet cre 0.01%

120 grams / 30 days

fluocinolone acet cre 0.025%

120 grams / 30 days

fluocinolone acet oil 0.01% sc

118.28 mLs / 30 days

fluocinolone acet oil 0.01%bdy

118.28 mLs / 30 days

fluocinolone acet oil body

118.28 mLs / 30 days

fluocinolone acet oil scalp

118.28 mLs / 30 days

fluocinolone acet oin 0.025%

120 grams / 30 days

fluocinolone acet sol 0.01%

120 mLs / 30 days

fluocinonide cre 0.05%

120 grams / 30 days

fluocinonide cre e 0.05%

120 grams / 30 days

fluocinonide gel 0.05%

120 grams / 30 days

fluocinonide oin 0.05%

120 grams / 30 days

fluocinonide sol 0.05%

120 mLs / 30 days

flurandrenol lot 0.05%

120 mLs / 30 days

fluticasone cre 0.05%

120 grams / 30 days

fluticasone oin 0.005%

120 grams / 30 days

glydo gel 2%

150 mLs / 30 days

halcinonide cre 0.1%

240 grams / 30 days

halobetasol cre 0.05%

200 grams / 28 days

halobetasol oin 0.05%

200 grams / 28 days

HALOG OIN 0.1%

240 grams / 30 days

HALOG SOL 0.1%

240 mLs / 30 days

hydrocortisone cre 2.5%

454 grams / 30 days

hydrocortisone lot 2.5%

118 mLs / 30 days

hydrocortisone oin 2.5%

454 grams / 30 days

imiquimod cre 5%

48 packets / 60 days

lidocaine/prilocaine cre 2.5-2.5%

60 grams / 30 days

lidocaine gel 2%

150 mLs / 30 days

LIDOCAINE GEL 2% JELLY

150 mLs / 30 days

lidocaine gel 2% jelly

150 mLs / 30 days

mometasone cre 0.1%

135 grams / 30 days

mometasone oin 0.1%

135 grams / 30 days

mometasone sol 0.1%

120 mLs / 30 days

PREDNICARBAT CRE 0.1%

120 grams / 30 days

PREDNICARBAT OIN 0.1%

120 grams / 30 days

SKYRIZI INJ 150DOSE1

1 box / 84 days

SKYRIZI INJ 150MG/ML1

1 syringe / 84 days

SKYRIZI PEN INJ 150MG/ML1

1 INJDV / 84 days

STELARA INJ 45MG/0.51

1 syringe / 84 days

STELARA INJ 90MG/ML1

1 syringe / 56 days

SYNERA DIS 70-70MG

4 patches / 30 days

triamcinolon cre 0.025%

454 grams / 30 days

triamcinolon cre 0.1%

454 grams / 30 days

triamcinolon cre 0.5%

454 grams / 30 days

triamcinolon lot 0.025%

120 mLs / 30 days

triamcinolon lot 0.1%

120 mLs / 30 days

triamcinolon oin 0.025%

454 grams / 30 days

triamcinolon oin 0.1%

454 grams / 30 days

triamcinolon oin 0.5%

120 grams / 30 days

Endocrine and metabolic agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

alendronate tab 35mg

4 tabs / 28 days

alendronate tab 70mg

4 caps / 28 days

FOSAMAX + D TAB 70-2800

4 caps / 28 days

FOSAMAX + D TAB 70-5600

4 caps / 28 days

ibandronate tab 150mg

1 tab / 28 days

NATPARA INJ 25MCG1

1 kit / 28 days

NATPARA INJ 50MCG1

1 kit / 28 days

NATPARA INJ 75MCG1

1 kit / 28 days

NATPARA INJ 100MCG1

1 kit / 28 days

octreotide inj 50mcg/ml1

90 mLs / 30 days

octreotide inj 1000/5ml1

18 vials / 30 days

octreotide inj 100mcg1

90 mLs / 30 days

octreotide inj 200mcg1

18 vials / 30 days

octreotide inj 500mcg1

30 mLs / 30 days

octreotide inj 1000mcg1

30 mLs / 30 days

octreotide inj 5000/5ml1

30 mLs / 30 days

OCTREOTIDE INJ 50MCG/ML1

90 syringes / 30 days

OCTREOTIDE INJ 100MCG1

90 syringes / 30 days

OCTREOTIDE INJ 500MCG1

90 syringes / 30 days

risedronate tab 35mg

4 tabs / 28 days

risedronate tab 150mg

1 tab / 28 days

Gastrointestinal agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

alosetron tab 0.5mg

60 tabs / 30 days

alosetron tab 1mg

60 tabs / 30 days

CIMZIA PREFL KIT 200MG/ML1

2 kits / 28 days

CIMZIA START KIT 200MG/ML1

1 kit / 180 days

LINZESS CAP 72MCG

30 caps / 30 days

LINZESS CAP 145MCG

30 caps / 30 days

LINZESS CAP 290MCG

30 caps / 30 days

MOVANTIK TAB 12.5MG

30 tabs / 30 days

MOVANTIK TAB 25MG

30 tabs / 30 days

Hematological agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

BERINERT INJ 500UNIT1

10 vials / 30 days

CINRYZE SOL 500 UNIT2

20 vials / 30 days

miglustat cap 100mg1

90 caps / 30 days

Hypnotics / sedatives / sleep disorder agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

BELSOMRA TAB 5MG

30 tabs / 30 days

BELSOMRA TAB 10MG

30 tabs / 30 days

BELSOMRA TAB 15MG

30 tabs / 30 days

BELSOMRA TAB 20MG

30 tabs / 30 days

eszopiclone tab 1mg

30 tabs / 30 days

eszopiclone tab 2mg

30 tabs / 30 days

eszopiclone tab 3mg

30 tabs / 30 days

ramelteon tab 8mg

30 tabs / 30 days

zaleplon cap 5mg

30 caps / 30 days

zaleplon cap 10mg

30 caps / 30 days

zolpidem tab 5mg

30 tabs / 30 days

zolpidem tab 10mg

30 tabs / 30 days

Medical devices and supplies

Drug name(s)

Quantity limits
(per 30 days or as specified)

DEXCOM G5 MIS RECEIVER

1 unit / 365 days

DEXCOM G5 MIS TRANSMIT

1 unit / 84 days

DEXCOM G6 MIS RECEIVER

1 unit / 365 days

DEXCOM G6 MIS SENSOR

3 units / 30 days

DEXCOM G6 MIS TRANSMIT

1 unit / 90 days

FREESTY LIBR MIS 2 READER

1 unit / 365 days

FREESTYLE MIS READER

1 unit / 365 days

FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM - CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR

2 units / 28 days

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

2 units / 28 days

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

3 units / 30 days

G5/G4 MIS SENSOR

4 units / 28 days

DEXCOM G5 MIS RECEIVER

1 unit / 365 days

DEXCOM G5 MIS TRANSMIT

1 unit / 84 days

Migraine products

Drug name(s)

Quantity limits
(per 30 days or as specified)

almotriptan mal tab 6.25mg

24 tabs / 30 days

almotriptan mal tab 12.5mg

12 tabs / 30 days

almotriptan tab 6.25mg

24 tabs / 30 days

almotriptan tab 12.5mg

12 tabs / 30 days

eletriptan tab 20mg

18 tabs / 30 days

eletriptan tab 40mg

12 tabs / 30 days

frovatriptan tab 2.5mg

27 tabs / 30 days

naratriptan tab 1mg

18 tabs / 30 days

naratriptan tab 2.5mg

18 tabs / 30 days

rizatriptan tab 5mg

36 tabs / 30 days

rizatriptan tab 5mg odt

36 tabs / 30 days

rizatriptan tab 10mg

18 tabs / 30 days

rizatriptan tab 10mg odt

18 tabs / 30 days

SUMATRIPTAN INJ 6MG/0.5

12 syringes / 30 days

sumatriptan spr 20mg/act

12 inhalers / 30 days

sumatriptan spr 5mg/act

5 packs / 30 days

sumatriptan tab 25mg

27 tabs / 30 days

sumatriptan tab 50mg

18 tabs / 30 days

sumatriptan tab 100mg

18 tabs / 30 days

sumatriptan succinate inj 6 mg/0.5ml

12 syringes / 30 days

sumatriptan succinate solution auto-injector 4 mg/0.5ml

12 syringes / 30 days

sumatriptan succinate solution auto-injector 6 mg/0.5ml

12 syringes / 30 days

sumatriptan succinate solution cartridge 4 mg/0.5ml

12 carts / 30 days

sumatriptan succinate solution cartridge 6 mg/0.5ml

12 carts / 30 days

zolmitriptan tab 2.5mg

18 tabs / 30 days

zolmitriptan tab 5mg

12 tabs / 30 days

Musculoskeletal therapy agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

baclofen tab 5mg

120 tabs / 30 days

baclofen tab 10mg

120 tabs / 30 days

baclofen tab 20mg

120 tabs / 30 days

carisoprodol tab 250mg

84 tabs / 90 days

carisoprodol tab 350mg

84 tabs / 90 days

chlorzoxazone tab 500mg

84 tabs / 90 days

cyclobenzaprine tab 5mg

63 tabs / 90 days

cyclobenzaprine tab 10mg

63 tabs / 90 days

dantrolene cap 25mg

90 caps / 30 days

dantrolene cap 50mg

90 caps / 30 days

dantrolene cap 100mg

90 caps / 30 days

metaxalone tab 800mg

84 tabs / 90 days

methocarbam tab 500mg

180 tabs / 90 days

methocarbam tab 750mg

132 tabs / 90 days

orphenadrine tab 100mg er

42 tabs / 90 days

tizanidine tab 2mg

126 tabs / 90 days

tizanidine tab 4mg

42 tabs / 30 days

baclofen tab 10mg

120 tabs / 30 days

Nasal agents – systemic and topical

Drug name(s)

Quantity limits
(per 30 days or as specified)

azelastine spr 0.1%

2 bottles / 30 days

FLUNISOLIDE SPR 0.025%

3 bottles / 30 days

ipratropium spr 0.03%

2 bottles / 30 days

ipratropium spr 0.06%

3 bottles / 30 days

Ophthalmic agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

latanoprost sol 0.005%

2.5 mLs / 30 days

LUMIGAN SOL 0.01%

2.5 mLs / 30 days

RESTASIS EMU 0.05%

60 vials / 30 days

RESTASIS MUL EMU 0.05%

1 bottle / 30 days

travoprost dro 0.004%

2.5 mLs / 30 days

ZIOPTAN DRO 0.0015%

30 cartons / 30 days

Psychotherapeutic and neurological agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

AUBAGIO TAB 7MG1,3

30 tabs / 30 days

AUBAGIO TAB 14MG1,3

30 tabs / 30 days

AVONEX PEN KIT 30MCG1

1 kit / 28 days

AVONEX PREFL KIT 30MCG1

1 kit / 28 days

BETASERON INJ 0.3MG1

1 box / 28 days

dalfampridine tab 10mg er1,3

60 tabs / 30 days

dimethyl fumarate cap 120mg dr1

56 caps / 180 days

dimethyl fumarate cap 240mg dr1

60 caps / 30 days

dimethyl fumarate mis starter1

60 caps / 180 days

GILENYA CAP 0.5MG1

30 tabs / 30 days

glatiramer inj 20mg/ml1

30 syringes / 30 days

glatiramer inj 40mg/ml1

12 syringes / 28 days

glatopa inj 20mg/ml1

30 syringes / 30 days

glatopa inj 40mg/ml1

12 syringes / 28 days

REBIF INJ 22/0.51

12 syringes / 28 days

REBIF INJ 44/0.51

1 carton / 28 days

REBIF REBIDO INJ 22/0.51

1 carton / 28 days

REBIF REBIDO INJ 44/0.51

1 carton / 28 days

REBIF REBIDO INJ TITRATN1

1 kit / 180 days

REBIF TITRTN INJ PACK1

1 kit / 180 days

SAVELLA MIS TITR PAK

1 kit / 180 days

SAVELLA TAB 12.5MG

60 tabs / 30 days

SAVELLA TAB 25MG

60 tabs / 30 days

SAVELLA TAB 50MG

60 tabs / 30 days

SAVELLA TAB 100MG

60 tabs / 30 days

Respiratory agents

Drug name(s)

Quantity limits
(per 30 days or as specified)

ESBRIET CAP 267MG1

180 caps / 30 days

ESBRIET TAB 267MG1

180 tabs / 30 days

ESBRIET TAB 801MG1

90 tabs / 30 days

KALYDECO PAK 25MG1

60 packets / 30 days

KALYDECO PAK 50MG1

60 packets / 30 days

KALYDECO PAK 75MG1

60 packets / 30 days

KALYDECO TAB 150MG1

60 tabs / 30 days

Ulcer drugs / antispasmodics / anticholinergics

Drug name(s)

Quantity limits
(per 30 days or as specified)

esomepra mag cap 40mg dr

30 caps / 30 days

lansoprazole cap 30mg dr

30 caps / 30 days

omeprazole cap 40mg

30 caps / 30 days

pantoprazole tab 20mg

30 tabs / 30 days

pantoprazole tab 20mg dr

30 tabs / 30 days

pantoprazole tab 40mg

30 tabs / 30 days

pantoprazole tab 40mg dr

30 tabs / 30 days

rabeprazole tab 20mg

30 tabs / 30 days

Urinary antispasmmodics

Drug name(s)

Quantity limits
(per 30 days or as specified)

darifenacin tab 7.5mg

30 tabs / 30 days

darifenacin tab 15mg

30 tabs / 30 days

MYRBETRIQ TAB 25MG

30 tabs / 30 days

MYRBETRIQ TAB 50MG

30 tabs / 30 days

oxybutynin syp 5mg/5ml

600 mLs / 30 days

oxybutynin tab 5mg

120 tabs / 30 days

oxybutynin tab 5mg er

30 tabs / 30 days

oxybutynin tab 10mg er

60 tabs / 30 days

oxybutynin tab 15mg er

60 tabs / 30 days

tolterodine tab 1mg

60 tabs / 30 days

tolterodine tab 2mg

60 tabs / 30 days

tolterodine cap 2mg er

30 caps / 30 days

tolterodine cap 4mg er

30 caps / 30 days

TOVIAZ TAB 4MG

30 tabs / 30 days

TOVIAZ TAB 8MG

30 tabs / 30 days

trospium chl cap 60mg er

30 caps / 30 days

trospium cl tab 20mg

60 tabs / 30 days

Specialty

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

Drug names(s)

abiraterone acetate1,3

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADEMPAS2,4

ALECENSA2,3,4

alyq1

ambrisentan1

ARANESP ALBUMIN FREE1,4

AUBAGIO1,3

AVONEX1,4

AVONEX PEN1,4

BERINERT1

BETASERON1,4

bosentan1

capecitabine1,4

CAYSTON1

CIMZIA1

CIMZIA STARTER KIT1

CINRYZE2,4

COTELLIC1

dalfampridine er1,3

dimethyl fumarate1

dimethyl fumarate starterpack 1

ENBREL1,4

ENBREL MINI1,4

ENBREL SURECLICK1,4

EPCLUSA1

EPIDIOLEX SOL 100MG/ML1

ERIVEDGE1,3

erlotinib hcl1,3

ESBRIET1

GILENYA1

GILOTRIF2,4

glatiramer acetate1,4

glatopa1

HARVONI1,4

HUMIRA1,4

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1,4

HUMIRA PEN1,4

HUMIRA PEN-CD/UC/HS STARTER1,4

HUMIRA PEN-PEDIATRIC UC STARTER PACK1,4

HUMIRA PEN-PS/UV STARTER1,4

HYCAMTIN1

HYQVIA1

IBRANCE1

imatinib mesylate1,3

INTRON A1

KALYDECO1

KEVZARA1

KOGENATE FS1

KOVALTRY1

lapatinib ditosylate1

LEDIPASVIR/SOFOSBUVIR1,4

LENVIMA 10 MG DAILY DOSE2,3,4

LENVIMA 12MG DAILY DOSE2,3,4

LENVIMA 14 MG DAILY DOSE2,3,4

LENVIMA 18 MG DAILY DOSE2,3,4

LENVIMA 20 MG DAILY DOSE2,3,4

LENVIMA 24 MG DAILY DOSE2,3,4

LENVIMA 4 MG DAILY DOSE2,3,4

LENVIMA 8 MG DAILY DOSE2,3,4

miglustat1

NATPARA1

NEXAVAR1,3

NINLARO1

NORDITROPIN FLEXPRO1,4

NOVOEIGHT1

NUPLAZID1

NUWIQ1

OCTREOTIDE INJ 50MCG/ML1

octreotide inj 1000mcg1

octreotide inj 500mcg1

octreotide inj 200mcg1

OCTREOTIDE INJ 500MCG1

octreotide inj 1000/5ml1

octreotide inj 100mcg1

octreotide inj 5000/5ml1

octreotide inj 50mcg/ml1

OCTREOTIDE INJ 100MCG1

OTEZLA1

POMALYST1

PROCRIT1,4

REBIF1,4

REBIF REBIDOSE1,4

REBIF REBIDOSE TITRATION PACK1,4

REBIF TITRATION PACK1,4

RINVOQ1

sildenafil citrate1

SIMPONI1

SKYRIZI1

SKYRIZI PEN1

sodium phenylbutyrate1

SOFOSBUVIR/VELPATASVIR1

STELARA1

STIMATE1

tadalafil1

TASIGNA1,3,4

tobramycin neb 300/4ml1

TOBRAMYCIN NEB 300/5ML1

tobramycin neb 300/5ml1

TRACLEER1

VENCLEXTA2

VENCLEXTA STARTING PACK2

VOSEVI1

XALKORI1,3

XELJANZ1

XELJANZ XR1

ZARXIO1

ZYDELIG2


1Specialty

2Limited Distribution

3Split Fill

4Indicates exclusive to Accredo Health Group Inc. preferred specialty.