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- CHIP prescription drug benefits - January 2022
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 acetate3 |
ACTEMRA1 |
|
ACTEMRA ACTPEN1 |
ACTHAR1 |
ADEMPAS2 |
alosetron hcl |
alyq1 |
|
ambrisentan1 |
ARANESP ALBUMIN FREE1 |
|
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 |
|
DESVENLAFAXINE ER |
dimethyl fumarate1 |
dimethyl fumarate starterpack1 |
EMBEDA |
EMSAM |
ENBREL1 |
ENBREL MINI1 |
ENBREL SURECLICK1 |
EPCLUSA1 |
EPIDIOLEX SOL 100MG/ML |
EPIDIOLEX SOL 100MG/ML1 |
EPINEPHRINE |
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 |
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 |
lidocaine hcl |
||
LIDOCAINE GEL 2% JELLY |
lidocaine/prilocaine |
LYSODREN |
MAPROTILINE HCL |
metaxalone |
methadone hcl |
METHITEST |
METHYLTESTOSTERONE |
miglustat1 |
MORPHINE SULFATE ER |
NATPARA1 |
|
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 |
|
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 |
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
120 tabs / 30 days |
|
60 tabs / 30 days |
|
240 caps / 30 days |
|
COTELLIC TAB 20MG1 |
63 tabs / 28 days |
30 caps / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
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 |
90 tabs / 30 days |
|
60 tabs / 30 days |
|
lapatinib tab 250mg1 |
180 tabs / 30 days |
30 caps / 30 days |
|
60 caps / 30 days |
|
30 caps / 30 days |
|
90 caps / 30 days |
|
60 caps / 30 days |
|
90 caps / 30 days |
|
60 caps / 30 days |
|
90 caps / 30 days |
|
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 |
120 caps / 30 days |
|
120 caps / 30 days |
|
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 |
120 caps / 30 days |
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
30 tabs / 30 days |
|
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 |
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
|
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
|
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
|
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) |
||||
ACTEMRA1 |
ACTEMRA ACTPEN1 |
|||
ACTHAR1 |
||||
alyq1 |
ambrisentan1 |
|||
BERINERT1 |
bosentan1 |
|||
CAYSTON1 |
CIMZIA1 |
|||
CIMZIA STARTER KIT1 |
COTELLIC1 |
|||
dimethyl fumarate1 |
dimethyl fumarate starterpack 1 |
|||
EPCLUSA1 |
EPIDIOLEX SOL 100MG/ML1 |
|||
ESBRIET1 |
GILENYA1 |
|||
glatopa1 |
||||
HYCAMTIN1 |
HYQVIA1 |
|||
IBRANCE1 |
INTRON A1 |
|||
KALYDECO1 |
KEVZARA1 |
KOGENATE FS1 |
||
KOVALTRY1 |
lapatinib ditosylate1 |
|||
miglustat1 |
||||
NATPARA1 |
NINLARO1 |
|||
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 |
||||
RINVOQ1 |
sildenafil citrate1 |
SIMPONI1 |
||
SKYRIZI1 |
SKYRIZI PEN1 |
sodium phenylbutyrate1 |
||
SOFOSBUVIR/VELPATASVIR1 |
STELARA1 |
STIMATE1 |
||
tadalafil1 |
tobramycin neb 300/4ml1 |
|||
TOBRAMYCIN NEB 300/5ML1 |
tobramycin neb 300/5ml1 |
TRACLEER1 |
||
VENCLEXTA2 |
VENCLEXTA STARTING PACK2 |
VOSEVI1 |
||
XELJANZ1 |
XELJANZ XR1 |
|||
ZARXIO1 |
ZYDELIG2 |