CHIP Prescription Drug Benefits

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 Name(s)

abiraterone acetate tab ACTEMRA ACTPEN1 ACTEMRA1
ADEMPAS1, 2 ALECENSA1, 2 alosetron hcl tab
ambrisentan tab1 ARANESP ALBUMIN FREE1 armodafinil tab
AUBAGIO1 AVONEX PEN1 AVONEX1
BELSOMRA BERINERT1 BETASERON1
bosentan tab1 capecitabine tab1 CAYSTON1
ciclopirox solution CIMZIA STARTER KIT1 CIMZIA1
CINRYZE1, 2 clomipramine hcl cap CORLANOR
COTELLIC1 dalfampridine tab er 12hr1 DARAPRIM
DESVENLAFAXINE ER EMSAM ENBREL MINI1
ENBREL SURECLICK1 ENBREL1 EPCLUSA1
EPINEPHRINE ERIVEDGE1 erlotinib hcl tab1
ESBRIET1 fentanyl citrate lozenge on a handle fentanyl td patch 72hr
FLUNISOLIDE GILENYA1 GILOTRIF1, 2
glatiramer acetate soln prefilled syringe1 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
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1 HUMIRA PEN1 HUMIRA PEN-CD/UC/HS STARTER1
HUMIRA PEN-PS/UV STARTER1 HUMIRA1 HYCAMTIN1
hydromorphone hcl tab er 24hr deter HYQVIA1 IBRANCE1
INSULIN LISPRO INSULIN LISPRO JUNIOR KWIKPEN INSULIN LISPRO KWIKPEN
INTRON A1 KALYDECO1 KOGENATE FS1
KOVALTRY1 LEDIPASVIR/SOFOSBUVIR1 LENVIMA1, 2
metaxalone tab methadone hcl soln methadone hcl tab
METHITEST METHYLTESTOSTERONE miglustat cap1
modafinil tab morphine sulfate tab er NATPARA1
NINLARO1 NORDITROPIN FLEXPRO 1 NOVOEIGHT1
NUCYNTA ER NUPLAZID1 NUWIQ1
octreotide acetate inj1 OTEZLA1 OXYCODONE HCL ER
OXYCONTIN OXYMORPHONE HYDROCHLORIDE ER POMALYST1
PROCRIT1 pyrimethamine tab ramelteon tab
REBIF REBIDOSE TITRATION1 REBIF REBIDOSE1 REBIF TITRATION PACK1
REBIF1 REGRANEX RESTASIS
RESTASIS MULTIDOSE sildenafil citrate tab1 SIMPONI1
sodium phenylbutyrate oral powder1 SOFOSBUVIR/VELPATASVIR1 STIMATE1
tadalafil tab1 tazarotene cream TECFIDERA STARTER PACK1
TECFIDERA1 TESTOSTERONE testosterone cypionate im inj in oil
TESTOSTERONE ENANTHATE TESTOSTERONE PUMP testosterone td gel
tobramycin nebu soln1 TOBRAMYCIN1 TRACLEER1
tramadol hcl tab er 24hr tramadol hcl tab er 24hr biphasic release tretinoin cream
VENCLEXTA STARTING PACK1, 2 VENCLEXTA1, 2 VIIBRYD
VOSEVI1 XELJANZ XR1 XELJANZ1
XIFAXAN ZARXIO1 ZYDELIG1, 2
ZYTIGA1    

Drug Name(s)

LIVALO AMCINONIDE AUGMENTED BETAMETHASONE DIPROPIONATE
BEPREVE CLOCORTOLONE PIVALATE DIFLORASONE DIACETATE
FANAPT FANAPT TITRATION PACK HALOG
KETOPROFEN lanthanum carbonate chew tab LASTACAFT
MECLOFENAMATE SODIUM pimecrolimus cream PREDNICARBATE
RELION ALL-IN-ONE COMPACT BLOOD GLUCOSE TESTING SYSTEM REXULTI SAVELLA
SAVELLA TITRATION PACK SUMATRIPTAN SUCCINATE tacrolimus oint
TEST STRIPS - VARIOUS TOLMETIN SODIUM TRAVATAN Z
ZIOPTAN    

Actinic Keratosis

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

imiquimod cream 5% 48 Packets/60 Days

Acute Migraine 5HT

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

almotriptan malate tablet 6.25mg 24 Tablets/30 Days
almotriptan malate tablet 12.5mg 12 Tablets/30 Days
eletriptan tablet 20mg 18 Tablets/30 Days
eletriptan tablet 40mg 12 Tablets/30 Days
frovatriptan tablet 2.5mg 27 Tablets/30 Days
naratriptan tablet 1mg 18 Tablets/30 Days
naratriptan tablet 2.5mg 18 Tablets/30 Days
rizatriptan tablet 5mg 36 Tablets/30 Days
rizatriptan tablet 5mg odt 36 Tablets/30 Days
rizatriptan tablet 10mg 18 Tablets/30 Days
rizatriptan tablet 10mg odt 18 Tablets/30 Days
sumatriptan spray 20mg/act 12 Inhalers/30 Days
sumatriptan spray 5mg/act 5 Packs/30 Days
sumatriptan injection 4mg/0.5 12 Cartridges/30 Days
sumatriptan injection 4mg/0.5 12 Syringes/30 Days
sumatriptan injection 6/0.5mL 12 Syringes/30 Days
sumatriptan injection 6mg/0.5 12 Cartridges/30 Days
sumatriptan injection 6mg/0.5 12 Syringes/30 Days
sumatriptan tablet 25mg 27 Tablets/30 Days
sumatriptan tablet 50mg 18 Tablets/30 Days
sumatriptan tablet 100mg 18 Tablets/30 Days
zolmitriptan tablet 2.5mg 18 Tablets/30 Days
zolmitriptan tablet 5mg 12 Tablets/30 Days

Ampyra

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

dalfampridine tablet 10mg er1 60 Tablets/30 Days

Androgen/Anabolic Steroids

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

testosterone cypionate injection 100mg/mL 1 Vial/28 Days
testosterone cypionate injection 200mg/mL 10 mLs/28 Days
TESTOST ENAN INJECTION 200MG/mL 1 Vial/28 Days
TESTOSTERONE GEL PUMP 1% 4 Pumps/30 Days
testosterone gel pump 1% 300 Grams/30 Days
testosterone gel 1%(25mg) 60 Packets/30 Days
testosterone gel 1%(50mg) 60 Packets/30 Days

Antiemetic

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

AKYNZEO CAPSULE 300-0.5 2 Capsules/30 Days
aprepitant capsule 40mg 8 Capsules/30 Days
aprepitant capsule 80mg 8 Capsules/30 Days
aprepitant capsule 125mg 4 Capsules/30 Days
granisetron tablet 1mg 14 Tablets/30 Days
ondansetron solution 4mg/5mL 5 Bottles/30 Days
ondansetron tablet 4mg odt 24 Tablets/30 Days
ondansetron tablet 8mg odt 24 Tablets/30 Days

Antifungal

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ciclopirox solution 8% 3.3 mLs/30 Days

Anti-Influenza

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

oseltamivir capsule 30mg 40 Capsules/120 Days
oseltamivir capsule 45mg 20 Capsules/120 Days
oseltamivir capsule 75mg 20 Capsules/120 Days
oseltamivir suspense 6mg/mL 300 mLs/120 Days

Antiretroviral

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

RELENZA MIS DISKHALER 40 Blisters/120 Days

Atypical Antipsychotics

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

olanzapine tablet 2.5mg 30 Tablets/30 Days
olanzapine tablet 5mg 30 Tablets/30 Days
olanzapine tablet 7.5mg 30 Tablets/30 Days
olanzapine tablet 10mg 30 Tablets/30 Days
olanzapine tablet 15mg 30 Tablets/30 Days
olanzapine tablet 20mg 30 Tablets/30 Days
paliperidone tablet er 1.5mg 60 Tablets/30 Days
paliperidone tablet er 3mg 60 Tablets/30 Days
paliperidone tablet er 6mg 60 Tablets/30 Days
paliperidone tablet er 9mg 60 Tablets/30 Days
quetiapine tablet 50mg er 60 Tablets/30 Days
quetiapine tablet 150mg er 60 Tablets/30 Days
quetiapine tablet 200mg er 60 Tablets/30 Days
quetiapine tablet 300mg er 60 Tablets/30 Days
quetiapine tablet 400mg er 60 Tablets/30 Days

Biologic Immunomodulators

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ACTEMRA INJECTION 162/0.91 4 Syringes/28 Days
CIMZIA KIT STARTER1 3 Kits/180 Days
CIMZIA PREFL KIT 200MG/mL1 1 Kit/28 Days
ENBREL INJECTION 25/0.5mL1 8 Syringes/28 Days
ENBREL INJECTION 25MG1 8 Vials/28 Days
ENBREL INJECTION 50MG/mL1 4 Syringes/28 Days
ENBREL MINI INJECTION 50MG/mL 1 4 Cartridges/28 Days
ENBREL SRCLK INJECTION 50MG/mL 1 4 Syringes/28 Days
HUMIRA INJECTION 10/0.1mL1 2 Syringes/28 Days
HUMIRA INJECTION 10MG/0.21 2 Syringes/28 Days
HUMIRA INJECTION 20/0.2mL1 2 Syringes/28 Days
HUMIRA INJECTION 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 PEDIA INJECTION CROHNS 1 3 Kit/180 Days
HUMIRA PEN INJECTION 40/0.4mL 1 2 Pens/28 Days
HUMIRA PEN INJECTION 40MG/0.8 1 2 Pens/28 Days
HUMIRA PEN INJECTION CD/UC/HS 1 1 Kit/180 Days
HUMIRA PEN INJECTION PS/UV1 1 Kit/180 Days
SIMPONI INJECTION 100MG/mL1 1 Syringe/28 Days
SIMPONI INJECTION 50/0.5mL1 1 Syringe/28 Days
XELJANZ TABLET 5MG1 60 Tablets/30 Days
XELJANZ TABLET 10MG1 60 Tablets/30 Days
XELJANZ XR TABLET 11MG1 30 Tablets/30 Days
XELJANZ XR TABLET 22MG1 112 Tablets/365 Days

Bisphosphonates

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

alendronate tablet 35mg 4 Tablets/28 Days
alendronate tablet 70mg 4 Capsules/28 Days
FOSAMAX + D TABLET 70-2800 4 Capsules/28 Days
FOSAMAX + D TABLET 70-5600 4 Capsules/28 Days
ibandronate tablet 150mg 1 Tablet/28 Days
risedronate tablet 35mg 4 Tablets/28 Days
risedronate tablet 150mg 1 Tablet/28 Days

CFTR

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

KALYDECO PACK 25MG1 60 Packets/30 Days
KALYDECO PACK 50MG1 60 Packets/30 Days
KALYDECO PACK 75MG1 60 Packets/30 Days
KALYDECO TABLET 150MG1 60 Tablets/30 Days

Fibromyalgia

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

pregabalin capsule 25mg 90 Capsules/30 Days
pregabalin capsule 50mg 90 Capsules/30 Days
pregabalin capsule 75mg 90 Capsules/30 Days
pregabalin capsule 100mg 90 Capsules/30 Days
pregabalin capsule 150mg 90 Capsules/30 Days
pregabalin capsule 200mg 90 Capsules/30 Days
pregabalin capsule 225mg 90 Capsules/30 Days
pregabalin capsule 300mg 90 Capsules/30 Days
pregabalin solution 20mg/mL 900 mLs/30 Days
SAVELLA MIS TITR PACK 1 Kit/180 Days
SAVELLA TABLET 12.5MG 60 Tablets/30 Days
SAVELLA TABLET 25MG 60 Tablets/30 Days
SAVELLA TABLET 50MG 60 Tablets/30 Days

HCN Channel Blocker

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

CORLANOR TABLET 5MG 60 Tablets/30 Days
CORLANOR TABLET 7.5MG 60 Tablets/30 Days

IBS-D

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

alosetron tablet 0.5mg 60 Tablets/30 Days
alosetron tablet 1mg 60 Tablets/30 Days
XIFAXAN TABLET 200MG 9 Tablets/30 Days
XIFAXAN TABLET 550MG 60 Tablets/30 Days
ESBRIET CAPSULE 267MG1 180 Capsules/30 Days
ESBRIET TABLET 267MG1 180 Tablets/30 Days
ESBRIET TABLET 801MG1 90 Tablets/30 Days

Insomnia

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

BELSOMRA TABLET 5MG 30 Tablets/30 Days
BELSOMRA TAB 10MG 30 Tablets/30 Days
BELSOMRA TABLET 15MG 30 Tablets/30 Days
BELSOMRA TABLET 20MG 30 Tablets/30 Days
eszopiclone tablet 1mg 30 Tablets/30 Days
eszopiclone tablet 2mg 30 Tablets/30 Days
eszopiclone tablet 3mg 30 Tablets/30 Days
ramelteon tablet 8mg 30 Tablets/30 Days
zaleplon capsule 5mg 30 Capsules/30 Days
zaleplon capsule 10mg 30 Capsules/30 Days
zolpidem tablet 5mg 30 Tablets/30 Days
zolpidem tablet 10mg 30 Tablets/30 Days

Lidocaine Transdermal

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

lido/prilocaine cream 2.5-2.5% 60 Grams/30 Days
SYNERA DIS 70-70MG 4 Patches/30 Days

Multiple Sclerosis

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

AUBAGIO TABLET 7MG1 30 Tablets/30 Days
AUBAGIO TABLET 14MG1 30 Tablets/30 Days
AVONEX PEN KIT 30MCG1 1 Pack/28 Days
AVONEX PREFL KIT 30MCG1 1 Kit/28 Days
BETASERON INJECTION 0.3MG1 1 Box/28 Days
GILENYA CAPSULE 0.5MG1 30 Tablets/30 Days
glatiramer injection 20mg/mL 1 30 Syringes/30 Days
glatiramer injection 40mg/mL 1 12 Syringes/28 Days
REBIF INJECTION 22/0.51 12 Syringes/28 Days
REBIF INJECTION 44/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION 22/0.5 1 1 Carton/28 Days
REBIF REBIDO INJECTION 44/0.5 1 1 Carton/28 Days
REBIF REBIDO INJECTION TITRATN 1 1 Kit/180 Days
REBIF TITRTN INJECTION PACK1 1 Kit/180 Days
TECFIDERA CAPSULE 120MG1 56 Capsules/180 Da
TECFIDERA CAPSULE 240MG1 60 Capsules/30 Days
TECFIDERA MIS STARTER1 1 Kit/180 Days

Muscle Relaxants

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

BACLOFEN TABLET 5MG 120 Tablets/30 Days
baclofen tablet 10mg 120 Tablets/30 Days
baclofen tablet 20mg 120 Tablets/30 Days
carisoprodol tablet 250mg 28 Tablets/30 Days
carisoprodol tablet 350mg 28 Tablets/30 Days
chlorzoxazone tablet 500MG 28 Tablets/30 Days
cyclobenzaprine tablet 5mg 21 Tablets/30 Days
cyclobenzaprine tablet 10mg 90 Capsules/30 Days
dantrolene capsule 25mg 90 Capsules/30 Days
dantrolene capsule 50mg 90 Capsules/30 Days
dantrolene capsule 100mg 90 Capsules/30 Days
metaxalone tablet 800mg 28 Tablets/30 Days
methocarbamol tablet 500mg 60 Tablets/30 Days
methocarbamol tablet 750mg 44 Tablets/30 Days
orphenadrine tablet 100mg er 42 Capsules/90 Days
tizanidine capsule 2mg 42 Capsules/30 Days
tizanidine capsule 4mg 42 Capsules/30 Days

Natpara

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

NATPARA INJECTION 25MCG1 1 Kit/28 Days
NATPARA INJECTION 50MCG1 1 Kit/28 Days
NATPARA INJECTION 75MCG1 1 Kit/28 Days
NATPARA INJECTION 100MCG1 1 Kit/28 Days

Nuvigil/Provigil

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

armodafinil tablet 50mg 30 Tablets/30 Days
armodafinil tablet 150mg 30 Tablets/30 Days
armodafinil tablet 200mg 30 Tablets/30 Days
armodafinil tablet 250mg 30 Tablets/30 Days
modafinil tablet 100mg 30 Tablets/30 Days
modafinil tablet 200mg 30 Tablets/30 Days

Ophthalmic Immunomodulators

0.05%

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

RESTASIS EMULSION 2 Vials/30 Days
RESTASIS MUL EMULSION 0.05% 1 Bottle/30 Days

Ophthalmic Prostaglandins

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

latanoprost solution 0.005% 2.5 mLs/30 Days
travoprost drop 0.004% 2.5 mLs/30 Days
TRAVATAN Z DROP 0.004% 2.5 mLs/30 Days
ZIOPTAN DROP 0.0015% 30 Containers/30 Days

Opioids ER

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

fentanyl dis 12mcg/hr 10 Patches/30 Days
fentanyl dis 25mcg/hr 0
fentanyl dis 50mcg/hr 0
fentanyl dis 75mcg/hr 0
fentanyl dis 100mcg/hr 0
hydromorphone tablet 12mg er 30 Tablets/30 Days
hydromorphone tablet 16mg er 0
hydromorphone tablet 32mg er 0
hydromorphone tablet 8mg er 30 Tablets/30 Days
morphine sulfate tablet 15mg 15 Tablets/30 Days
morphine sulfate tablet 30mg 5 Tablets/30 Days
morphine sulfate tablet 15mg er 60 Tablets/30 Days
morphine sulfate tablet 30mg er 30 Tablets/30 Days
morphine sulfate tablet 60mg er 0
morphine sulfate tablet 100mg er 0
morphine sulfate tablet 200mg er 0
NUCYNTA ER TABLET 50MG 60 Tablets/30 Days
NUCYNTA ER TABLET 100MG 30 Tablets/30 Days
NUCYNTA ER TABLET 150MG 0
NUCYNTA ER TABLET 200MG 0
NUCYNTA ER TABLET 250MG 0
OXYCODONE TABLET 10MG ER 60 Tablets/30 Days
OXYCODONE TABLET 15MG ER 60 Tablets/30 Days
OXYCODONE TABLET 20MG ER 30 Tablets/30 Days
OXYCODONE TABLET 30MG ER 30 Tablets/30 Days
OXYCODONE TABLET 40MG ER 0
OXYCODONE TABLET 60MG ER 0
OXYCODONE TABLET 80MG ER 0
OXYCONTIN TABLET 10MG CR 60 Tablets/30 Days
OXYCONTIN TABLET 15MG CR 60 Tablets/30 Days
OXYCONTIN TABLET 20MG CR 30 Tablets/30 Days
OXYCONTIN TABLET 30MG CR 30 Tablets/30 Days
OXYCONTIN TABLET 40MG CR 0
OXYCONTIN TABLET 60MG CR 0
OXYCONTIN TABLET 80MG CR 0
OXYMORPHONE TABLET 5MG ER 60 Tablets/30 Days
OXYMORPHONE TABLET 7.5MG ER 60 Tablets/30 Days
OXYMORPHONE TABLET 10MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 15MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 20MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 30MG ER 0
OXYMORPHONE TABLET 40MG ER 0
tramadol hcl tablet 100mg er 30 Tablets/30 Days
tramadol hcl tablet 200mg er 30 Tablets/30 Days
tramadol hcl tablet 300mg er 30 Tablets/30 Days

Opioids IR

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

acetaminophen/codeine solution 120-12/5 450 mLs/30 Days
acetaminophen/codeine tablet 300-15mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-30mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-60mg 25 Tablets/30 Days
butorphanol solution 10mg/mL 1 Bottle/30 Days
CODEINE SULFATE TABLET 15MG 30 Tablets/30 Days
codeine sulfate tablet 30MG 30 Tablets/30 Days
CODEINE SULFATE TABLET 60MG 25 Tablets/30 Days
hydrocodone/acetaminophen tablet 5-325mg 40 Tablets/30 Days
hydrocodone/acetaminophen tablet 7.5-325mg 30 Tablets/30 Days
hydrocodone/acetaminophen tablet 10-325mg 25 Tablets/30 Days
hydrocodone/acetaminophen solution 7.5-325mg 450 mLs/30 Days
hydrocodone/ibuprofen tablet 5-200mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 7.5-200mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 10-200mg 25 Tablets/30 Days
hydromorphone liquid 1mg/mL 60 mLs/30 Days
hydromorphone tablet 2mg 30 Tablets/30 Days
hydromorphone tablet 4mg 15 Tablets/30 Days
hydromorphone tablet 8mg 5 Tablets/30 Days
levorphanol tablet 2mg 10 Tablets/30 Days
MEPERIDINE SOLUTION 50MG/5mL 150 mLs/30 Days
meperidine tablet 50mg 30 Tablets/30 Days
meperidine tablet 100mg 15 Tablets/30 Days
METHADONE SOLUTION 5MG/5mL 10 mLs/30 Days
METHADONE SOLUTION 10MG/5mL 5 mLs/30 Days
methadone tablet 5mg 60 Tablets/30 Days
methadone tablet 10mg 30 Tablets/30 Days
morphine sulfate solution 100/5mL 10 mLs/30 Days
morphine sulfate solution 10mg/5mL 125 mLs/30 Days
morphine sulfate solution 20mg/5mL 60 mLs/30 Days
MORPHINE SULFATE TABLET 15MG 15 Tablets/30 Days
MORPHINE SULFATE TABLET 30MG 5 Tablets/30 Days
NUCYNTA TABLET 50MG 10 Tablets/30 Days
NUCYNTA TABLET 75MG 5 Tablets/30 Days
NUCYNTA TABLET 100MG 5 Tablets/30 Days
oxycodone/acetaminophen tablet 2.5-325 60 Tablets/30 Days
oxycodone/acetaminophen tablet 5-325mg 30 Tablets/30 Days
oxycodone/acetaminophen tablet 7.5-325 20 Tablets/30 Days
oxycodone/acetaminophen tablet 10-325mg 15 Tablets/30 Days
oxycodone/aspirin tablet 30 Tablets/30 Days
OXYCODONE/IBUPROFEN TABLET 5-400MG 20 Tablets/30 Days
oxycodone concentrate 100/5mL 5 mLs/30 Days
oxycodone solution 5mg/5mL 165 mLs/30 Days
oxycodone tablet 5mg 30 Tablets/30 Days
oxycodone tablet 10mg 15 Tablets/30 Days
oxycodone tablet 15mg 10 Tablets/30 Days
oxycodone tablet 20mg 5 Tablets/30 Days
oxycodone tablet 30mg 5 Tablets/30 Days
tramadol hcl tablet 50mg 50 Tablets/30 Days

Oral Inhalers

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ADVAIR HFA AER 45/21 1 Canister/30 Days
ADVAIR HFA AER 115/21 1 Canister/30 Days
ADVAIR HFA AER 230/21 1 Canister/30 Days
ASMANEX 30 AER 110MCG 1 Canister/30 Days
ASMANEX 30 AER 220MCG 1 Canister/30 Days
ASMANEX 60 AER 220MCG 1 Canister/30 Days
ASMANEX 120 AER 220MCG 1 Canister/30 Days
ASMANEX HFA AER 100 MCG 1 Canister/30 Days
ASMANEX HFA AER 200 MCG 1 Canister/30 Days
BREO ELLIPTA INHALER 100-25 60 Blisters/30 Days
BREO ELLIPTA INHALER 200-25 60 Blisters/30 Days
FLOVENT DISK AER 50MCG 60 Blisters/30 Days
FLOVENT DISK AER 100MCG 60 Blisters/30 Days
FLOVENT DISK AER 250MCG 240 Blisters/30 Days
FLOVENT HFA AER 44MCG 1 Canister/30 Days
FLOVENT HFA AER 110MCG 1 Canister/30 Days
FLOVENT HFA AER 220MCG 2 Canisters/30 Days
fluticasone/salmeterol aer 100/50 60 Blisters/30 Days
fluticasone/salmeterol aer 250/50 60 Blisters/30 Days
fluticasone/salmeterol aer 500/50 60 Blisters/30 Days
QVAR AER 40MCG 1 Canister/30 Days
QVAR AER 80MCG 2 Canisters/30 Days

Oral PAH

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ADEMPAS TABLET 0.5MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 1MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 1.5MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 2MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 2.5MG1, 2 90 Tablets/30 Days
ambrisentan tablet 5mg1 30 Tablets/30 Days
ambrisentan tablet 10mg1 30 Tablets/30 Days
bosentan tablet 62.5mg1 60 Tablets/30 Days
bosentan tablet 125mg 1 60 Tablets/30 Days
sildenafil tablet 20mg1 90 Tablets/30 Days
tadalafil tablet 20mg 1 60 Tablets/30 Days
TRACLEER TABLET 32MG1 120 Tablets/30 Days

Otezla

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

OTEZLA TABLET 10/20/301 1 Kit/180 Days
OTEZLA TABLET 30MG1 60 Tablets/30 Days

Proton Pump Inhibitors (PPI)

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

lansoprazole capsule 30mg dr 30 Capsules/30 Days
omeprazole capsule 40mg dr 30 Capsules/30 Days
pantoprazole tablet 20mg 30 Tablets/30 Days
pantoprazole tablet 40mg 30 Tablets/30 Days
rabeprazole tablet 20mg 30 Tablets/30 Days

Regranex

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

REGRANEX GEL 0.01% 1 Tube/30 Days

SA Oncology

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

abiraterone tablet 250mg 1 120 Tablets/30 Days
ALECENSA CAPSULE 150MG1, 2 240 Capsules/30 Days
COTELLIC TABLET 20MG1 63 Tablets/28 Days
ERIVEDGE CAPSULE 150MG1 30 Capsules/30 Days
erlotinib tablet 25mg 1 60 Tablets/30 Days
erlotinib tablet 100mg 1 30 Tablets/30 Days
erlotinib tablet 150mg1 30 Tablets/30 Days
GILOTRIF TABLET 20MG1, 2 30 Tablets/30 Days
GILOTRIF TABLET 30MG1, 2 30 Tablets/30 Days
GILOTRIF TABLET 40MG1, 2 30 Tablets/30 Days
IBRANCE CAPSULE/TABLET 75MG1 21 Capsules/28 Days
IBRANCE CAPSULE/TABLET 100MG1 21 Capsules/28 Days
IBRANCE CAPSULE/TABLET 125MG1 21 Capsules/28 Days
LENVIMA CAPSULE 4MG1, 2 30 Capsules/30 Days
LENVIMA CAPSULE 8 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 10 MG1, 2 30 Capsules/30 Days
LENVIMA CAPSULE 12MG1, 2 90 Capsules/30 Days
LENVIMA CAPSULE 14 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 18 MG1, 2 90 Capsules/30 Days
LENVIMA CAPSULE 20 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 24 MG1, 2 90 Capsules/30 Days
NINLARO CAPSULE 2.3MG1 3 Capsules/28 Days
NINLARO CAPSULE 3MG1 3 Capsules/28 Days
NINLARO CAPSULE 4MG1 3 Capsules/28 Days
POMALYST CAPSULE 1MG1 21 Capsules/28 Days
POMALYST CAPSULE 2MG1 21 Capsules/28 Days
POMALYST CAPSULE 3MG1 21 Capsules/28 Days
POMALYST CAPSULE 4MG1 21 Capsules/28 Days
VENCLEXTA TABLET 10MG1, 2 60 Tablets/30 Days
VENCLEXTA TABLET 50MG1, 2 30 Tablets/30 Days
VENCLEXTA TABLET 100MG1, 2 180 Tablets/30 Days
VENCLEXTA TABLET START PK1, 2 1 Pack/180 Days
ZYDELIG TABLET 100MG1, 2 60 Tablets/30 Days
ZYDELIG TABLET 150MG1, 2 60 Tablets/30 Days
ZYTIGA TABLET 500MG1 60 Tablets/30 Days

SSIA

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

NUPLAZID TABLET 10MG1 30 Tablets/30 Days
NUPLAZID CAPSULE 34MG1 30 Capsules/30 Days

Statins

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

atorvastatin tablet 10mg 45 Tablets/30 Days
atorvastatin tablet 20mg 45 Tablets/30 Days
atorvastatin tablet 40mg 45 Tablets/30 Days
atorvastatin tablet 80mg 30 Tablets/30 Days
LIVALO TABLET 1MG 45 Tablets/30 Days
LIVALO TABLET 2MG 45 Tablets/30 Days
LIVALO TABLET 4MG 30 Tablets/30 Days
lovastatin tablet 10mg 60 Tablets/30 Days
lovastatin tablet 20mg 60 Tablets/30 Days
lovastatin tablet 40mg 60 Tablets/30 Days
pravastatin tablet 10mg 45 Tablets/30 Days
pravastatin tablet 20mg 45 Tablets/30 Days
pravastatin tablet 40mg 45 Tablets/30 Days
pravastatin tablet 80mg 30 Tablets/30 Days
rosuvastatin tablet 5mg 45 Tablets/30 Days
rosuvastatin tablet 10mg 45 Tablets/30 Days
rosuvastatin tablet 20mg 45 Tablets/30 Days
rosuvastatin tablet 40mg 30 Tablets/30 Days
simvastatin tablet 5mg 45 Tablets/30 Days
simvastatin tablet 10mg 45 Tablets/30 Days
simvastatin tablet 20mg 60 Tablets/30 Days
simvastatin tablet 40mg 45 Tablets/30 Days
simvastatin tablet 80mg 30 Tablets/30 Days

Substrate Reduction Therapy

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

miglustat capsule 100mg 1 90 Capsules/30 Days

Topical Corticosteroids

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

alclometasone cream 0.05% 120 Grams/30 Days
alclometasone ointment 0.05% 120 Grams/30 Days
AMCINONIDE LOTION 0.1% 120 mLs/30 Days
AUG BETAMET GEL 0.05% 200 Grams/28 Days
aug betamet cream 0.05% 200 Grams/28 Days
augmented betamethasone lotion 0.05% 210 mLs/30 Days
augmented betamethasone ointment 0.05% 200 Grams/28 Days
betamethasone dipropionate cream 0.05% 135 Grams/30 Days
betamethasone dipropionate lotion 0.05% 120 mLs/30 Days
betamethasone dipropionate ointment 0.05% 135 Grams/30 Days
betamethasone valerate cream 0.1% 135 Grams/30 Days
betamethasone valerate lotion 0.1% 120 mLs/30 Days
betamethasone valerate ointment 0.1% 135 Grams/30 Days
clobetasol cream 0.05% 210 Grams/28 Days
clobetasol e cream 0.05% 210 Grams/28 Days
clobetasol ointment 0.05% 210 Grams/28 Days
clobetasol solution 0.05% 200 mLs/28 Days
CLOCORTOLONE CREAM PIV 0.1% 135 Grams/30 Days
desonide cream 0.05% 120 Grams/30 Days
desonide lotion 0.05% 118 mLs/30 Days
desonide ointment 0.05% 120 Grams/30 Days
desoximetasone cream 0.05% 120 Grams/30 Days
desoximetasone cream 0.25% 120 Grams/30 Days
desoximetasone gel 0.05% 120 Grams/30 Days
desoximetasone ointment 0.05% 120 Grams/30 Days
desoximetasone ointment 0.25% 120 Grams/30 Days
DIFLORASONE CREAM 0.05% 120 Grams/30 Days
diflorasone ointment 0.05% 120 Grams/30 Days
fluocinolone acetonide cream 0.01% 120 Grams/30 Days
fluocinolone acetonide cream 0.025% 120 Grams/30 Days
fluocinolone acetonide oil 0.01% scalp 118.28 mLs/30 Days
fluocinolone acetonide oil 0.01% body 118.28 mLs/30 Days
fluocinolone acetonide ointment 0.025% 120 Grams/30 Days
fluocinolone acetonide solution 0.01% 120 mLs/30 Days
fluocinonide cream 0.05% 120 Grams/30 Days
fluocinonide cream e 0.05% 120 Grams/30 Days
fluocinonide gel 0.05% 120 Grams/30 Days
fluocinonide ointment 0.05% 120 Grams/30 Days
flurandrenol lotion 0.05% 120 mLs/30 Days
fluticasone cream 0.05% 120 Grams/30 Days
fluticasone ointment 0.005% 120 Grams/30 Days
halcinonide cream 0.1% 240 Grams/30 Days
halobetasol cream 0.05% 200 Grams/28 Days
halobetasol ointment 0.05% 200 Grams/28 Days
HALOG OINTMENT 0.1% 240 Grams/30 Days
hydrocortisone cream 2.5% 454 Grams/30 Days
hydrocortisone lotion 2.5% 118 mLs/30 Days
hydrocortisone ointment 2.5% 454 Grams/30 Days
mometasone cream 0.1% 135 Grams/30 Days
mometasone ointment 0.1% 135 Grams/30 Days
mometasone solution 0.1% 120 mLs/30 Days
PREDNICARBAT CREAM 0.1% 120 Grams/30 Days
PREDNICARBAT OINTMENT 0.1% 120 Grams/30 Days
triamcinolone cream 0.025% 454 Grams/30 Days
triamcinolone cream 0.1% 454 Grams/30 Days
triamcinolone cream 0.5% 454 Grams/30 Days
triamcinolone lotion 0.025% 120 mLs/30 Days
triamcinolone lotion 0.1% 120 mLs/30 Days
triamcinolone ointment 0.025% 454 Grams/30 Days
triamcinolone ointment 0.1% 454 Grams/30 Days
triamcinolone ointment 0.5% 120 Grams/30 Days

Topical NSAID

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

diclofenac gel 1% 10 Tubes/30 Days

Transmucosal Immediate Release Fentanyl

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

fentanyl ot lozenge 200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 400mcg 120 Lozenges/30 Days
fentanyl ot lozenge 600mcg 120 Lozenges/30 Days
fentanyl ot lozenge 800mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1600mcg 120 Lozenges/30 Days

Drug Name(s)

ACTEMRA ACTPEN1 ACTEMRA1 ADEMPAS1, 2
ALECENSA1, 2 ambrisentan tab1 ARANESP ALBUMIN FREE1
AUBAGIO1 AVONEX PEN1 AVONEX1
BERINERT1 BETASERON1 bosentan tab1
capecitabine tab1 CAYSTON1 CHORIONIC GONADOTROPIN 1
CIMZIA STARTER KIT1 CIMZIA1 CINRYZE1, 2
COTELLIC1 CYSTAGON1, 2 dalfampridine tab er 12hr1
dofetilide cap1 ENBREL MINI1 ENBREL SURECLICK1
ENBREL1 EPCLUSA1 ERIVEDGE1
erlotinib hcl tab1 ESBRIET1 GILENYA1
GILOTRIF1, 2 glatiramer acetate soln prefilled syringe1 HARVONI1
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1 HUMIRA PEN1 HUMIRA PEN-CD/UC/HS STARTER1
HUMIRA PEN-PS/UV STARTER1 HUMIRA1 HYCAMTIN1
HYQVIA1 IBRANCE1 imatinib mesylate tab1
INCRELEX1, 2 INTRON A1 KALYDECO1
KOGENATE FS1 KOVALTRY1 LEDIPASVIR/SOFOSBUVIR1
LENVIMA1, 2 leuprolide acetate inj kit1 miglustat cap1
NATPARA1 NEXAVAR1 NINLARO1
NORDITROPIN FLEXPRO 1 NOVAREL1 NOVOEIGHT1
NUPLAZID1 NUWIQ1 octreotide acetate inj1
OTEZLA1 PEGASYS PROCLICK1 PEGASYS1
POMALYST1 PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1 PROCRIT1
REBIF REBIDOSE TITRATION1 REBIF REBIDOSE1 REBIF TITRATION PACK1
REBIF1 ribavirin cap1 sildenafil citrate tab1
SIMPONI1 sodium phenylbutyrate oral powder1 SOFOSBUVIR/VELPATASVIR1
STIMATE1 tadalafil tab1 TASIGNA1
TECFIDERA STARTER PACK1 TECFIDERA1 tobramycin nebu-soln1
TOBRAMYCIN1 TRACLEER1 TYKERB1
VELTASSA1 VENCLEXTA STARTING PACK1, 2 VENCLEXTA1, 2
VOSEVI1 XALKORI1 XELJANZ XR1
XELJANZ1 ZARXIO1 ZYDELIG1, 2
ZYTIGA1 &nbps;  

1Specialty

2Limited Distribution