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
ALECENSA^2,3	alosetron hcl	alyq¹
ambrisentan¹	ARANESP ALBUMIN FREE¹	AUBAGIO^1,3
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 er^1,3
DESVENLAFAXINE ER	dimethyl fumarate¹	dimethyl fumarate starterpack¹
EMBEDA	EMSAM	ENBREL¹
ENBREL MINI¹	ENBREL SURECLICK¹	EPCLUSA¹
EPIDIOLEX SOL 100MG/ML	EPIDIOLEX SOL 100MG/ML¹	EPINEPHRINE
ERIVEDGE^1,3	erlotinib hcl^1,3	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 mesylate^1,3	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 DOSE^2,3	LENVIMA 12MG DAILY DOSE^2,3	LENVIMA 14 MG DAILY DOSE^2,3
LENVIMA 18 MG DAILY DOSE^2,3	LENVIMA 20 MG DAILY DOSE^2,3	LENVIMA 24 MG DAILY DOSE^2,3
LENVIMA 4 MG DAILY DOSE^2,3	LENVIMA 8 MG DAILY DOSE^2,3	lidocaine hcl
LIDOCAINE GEL 2% JELLY	lidocaine/prilocaine	LYSODREN
MAPROTILINE HCL	metaxalone	methadone hcl
METHITEST	METHYLTESTOSTERONE	miglustat¹
MORPHINE SULFATE ER	NATPARA¹	NEXAVAR^1,3
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	TASIGNA^1,3
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	XALKORI^1,3	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 250mg^1,3	120 tabs / 30 days
abiraterone tab 500mg^1,3	60 tabs / 30 days
ALECENSA CAP 150MG^2,3	240 caps / 30 days
COTELLIC TAB 20MG¹	63 tabs / 28 days
ERIVEDGE CAP 150MG^1,3	30 caps / 30 days
erlotinib tab 25mg^1,3	60 tabs / 30 days
erlotinib tab 100mg^1,3	30 tabs / 30 days
erlotinib tab 150mg^1,3	30 tabs / 30 days
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 100mg^1,3	90 tabs / 30 days
imatinib mes tab 400mg^1,3	60 tabs / 30 days
lapatinib tab 250mg¹	180 tabs / 30 days
LENVIMA CAP 4MG^2,3	30 caps / 30 days
LENVIMA CAP 8 MG^2,3	60 caps / 30 days
LENVIMA CAP 10 MG^2,3	30 caps / 30 days
LENVIMA CAP 12MG^2,3	90 caps / 30 days
LENVIMA CAP 14 MG^2,3	60 caps / 30 days
LENVIMA CAP 18 MG^2,3	90 caps / 30 days
LENVIMA CAP 20 MG^2,3	60 caps / 30 days
LENVIMA CAP 24 MG^2,3	90 caps / 30 days
NEXAVAR TAB 200MG^1,3	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 50MG^1,3	120 caps / 30 days
TASIGNA CAP 150MG^1,3	120 caps / 30 days
TASIGNA CAP 200MG^1,3	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 200MG^1,3	120 caps / 30 days
XALKORI CAP 250MG^1,3	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 7MG^1,3	30 tabs / 30 days
AUBAGIO TAB 14MG^1,3	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 er^1,3	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 acetate^1,3	ACTEMRA¹	ACTEMRA ACTPEN¹
ACTHAR¹	ADEMPAS^2,4	ALECENSA^2,3,4
alyq¹	ambrisentan¹	ARANESP ALBUMIN FREE^1,4
AUBAGIO^1,3	AVONEX^1,4	AVONEX PEN^1,4
BERINERT¹	BETASERON^1,4	bosentan¹
capecitabine^1,4	CAYSTON¹	CIMZIA¹
CIMZIA STARTER KIT¹	CINRYZE^2,4	COTELLIC¹
dalfampridine er^1,3	dimethyl fumarate¹	dimethyl fumarate starterpack ¹
ENBREL^1,4	ENBREL MINI^1,4	ENBREL SURECLICK^1,4
EPCLUSA¹	EPIDIOLEX SOL 100MG/ML¹	ERIVEDGE^1,3
erlotinib hcl^1,3	ESBRIET¹	GILENYA¹
GILOTRIF^2,4	glatiramer acetate^1,4	glatopa¹
HARVONI^1,4	HUMIRA^1,4	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK^1,4
HUMIRA PEN^1,4	HUMIRA PEN-CD/UC/HS STARTER^1,4	HUMIRA PEN-PEDIATRIC UC STARTER PACK^1,4
HUMIRA PEN-PS/UV STARTER^1,4	HYCAMTIN¹	HYQVIA¹
IBRANCE¹	imatinib mesylate^1,3	INTRON A¹
KALYDECO¹	KEVZARA¹	KOGENATE FS¹
KOVALTRY¹	lapatinib ditosylate¹	LEDIPASVIR/SOFOSBUVIR^1,4
LENVIMA 10 MG DAILY DOSE^2,3,4	LENVIMA 12MG DAILY DOSE^2,3,4	LENVIMA 14 MG DAILY DOSE^2,3,4
LENVIMA 18 MG DAILY DOSE^2,3,4	LENVIMA 20 MG DAILY DOSE^2,3,4	LENVIMA 24 MG DAILY DOSE^2,3,4
LENVIMA 4 MG DAILY DOSE^2,3,4	LENVIMA 8 MG DAILY DOSE^2,3,4	miglustat¹
NATPARA¹	NEXAVAR^1,3	NINLARO¹
NORDITROPIN FLEXPRO^1,4	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	PROCRIT^1,4	REBIF^1,4
REBIF REBIDOSE^1,4	REBIF REBIDOSE TITRATION PACK^1,4	REBIF TITRATION PACK^1,4
RINVOQ¹	sildenafil citrate¹	SIMPONI¹
SKYRIZI¹	SKYRIZI PEN¹	sodium phenylbutyrate¹
SOFOSBUVIR/VELPATASVIR¹	STELARA¹	STIMATE¹
tadalafil¹	TASIGNA^1,3,4	tobramycin neb 300/4ml¹
TOBRAMYCIN NEB 300/5ML¹	tobramycin neb 300/5ml¹	TRACLEER¹
VENCLEXTA²	VENCLEXTA STARTING PACK²	VOSEVI¹
XALKORI^1,3	XELJANZ¹	XELJANZ XR¹
ZARXIO¹	ZYDELIG²

¹Specialty

²Limited Distribution

³Split Fill

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

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CHIP prescription drug benefits

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Guide to prescription drug benefits

Use this guide to understand how your benefits work.

Drug names(s)

Drug names(s)

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

Androgens - anabolic

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Anticonvulsants

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidiabetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiemetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antihyperlipidemics

Drug name(s)

Quantity limits (per 30 days or as specified)

Anti-infective agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits (per 30 days or as specified)

Antipsychotics / anditmanic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antivirals

Drug name(s)

Quantity limits (per 30 days or as specified)

Cardiovascular agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Dermatologicals

Drug name(s)

Quantity limits (per 30 days or as specified)

Endocrine and metabolic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Gastrointestinal agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Hematological agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Hypnotics / sedatives / sleep disorder agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Medical devices and supplies

Drug name(s)

Quantity limits (per 30 days or as specified)

Migraine products

Drug name(s)

Quantity limits (per 30 days or as specified)

Musculoskeletal therapy agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Nasal agents – systemic and topical

Drug name(s)

Quantity limits (per 30 days or as specified)

Ophthalmic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Psychotherapeutic and neurological agents

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