CHIP prescription drug benefits

Effective January 1, 2021

Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the 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 ACETATE1

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADEMPAS1,2

ALECENSA1,2,3

ALOSETRON HYDROCHLORIDE

ALYQ

AMBRISENTAN1

ARANESP1ALBUMIN FREE

AUBAGIO3

AVITA

AVONEX1

AVONEX PEN1

BELSOMRA

BERINERT1

BETASERON1

BOSENTAN1

BUPRENORPHINE

CAPECITABINE1

CAYSTON1

CICLODAN

CICLOPIROX NAIL LACQUER

CIMZIA1

CIMZIA1STARTER KIT

CINRYZE1,2

CIPRO HC

CIPROFLOXACIN/DEXAMETHASONE

CLOMIPRAMINE HCL

CLOMIPRAMINE HYDROCHLORIDE

CORLANOR

COTELLIC1

DALFAMPRIDINE ER1

DESVENLAFAXINE ER

DIMETHYL FUMARATE1

DIMETHYL FUMARATE1STARTERPACK

EMBEDA

EMSAM

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

EPCLUSA1

EPIDIOLEX1

EPINEPHRINE

ERIVEDGE13

ERLOTINIB HYDROCHLORIDE1

ESBRIET1

FANAPT

FANAPT TITRATION PACK

FENTANYL

FENTANYL CITRATE ORAL TRANSMUCOSAL

FLUNISOLIDE

FLUOXETINE

GILENYA1

GILOTRIF1

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

HUMIRA1PEDIATRIC CROHNS DISEASE STARTER PACK

HUMIRA PEN1

HUMIRA PEN-CD/UC/HS STARTER1

HUMIRA PEN-PS/UV STARTER1

HYCAMTIN1

HYDROMORPHONE HCL ER

HYDROMORPHONE HYDROCHLORIDE ER

HYQVIA

IBRANCE1

INSULIN LISPRO

INSULIN LISPRO JUNIOR KWIKPEN

INSULIN LISPRO KWIKPEN

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN

INTRON A1

KALYDECO

KEVZARA

KOGENATE FS1

KOVALTRY1

LEDIPASVIR/SOFOSBUVIR1

LENVIMA1,2,3 10 MG DAILY DOSE

LENVIMA1,2,3 12MG DAILY DOSE

LENVIMA1,2,3 14 MG DAILY DOSE

LENVIMA1,2,3 18 MG DAILY DOSE

LENVIMA1,2,3 20 MG DAILY DOSE

LENVIMA1,2,3  24 MG DAILY DOSE

LENVIMA1,2,3 4 MG DAILY DOSE

LENVIMA1,2,3 8 MG DAILY DOSE

LIDOCAINE HCL

LIDOCAINE HCL JELLY

LIDOCAINE HCL JELLY

LIDOCAINE/PRILOCAINE

MAPROTILINE HCL

METAXALL

METAXALONE

METHADONE HCL

METHADONE HCL

METHADONE HYDROCHLORIDE

METHITEST

METHYLTESTOSTERONE

MIGLUSTAT1

MORPHINE SULFATE ER

MORPHINE SULFATE ER

NATPARA1

NINLARO1

NORDITROPIN FLEXPRO1

NOVOEIGHT

NUCYNTA ER

NUPLAZID1

NUWIQ1

OCTREOTIDE ACETATE

OTEZLA

OXYCODONE HCL ER

OXYCODONE HYDROCHLORIDE ER

OXYCONTIN

OXYMORPHONE HYDROCHLORIDE ER

OXYMORPHONE HYDROCHLORIDEER

POMALYST1

PROCRIT1

PYRIMETHAMINE

RAMELTEON

REBIF1

REBIF REBIDOSE1

REBIF REBIDOSE TITRATION PACK1

REBIF TITRATION PACK1

REGRANEX

RESTASIS

RESTASIS MULTIDOSE

REXULTI

RINVOQ1

SILDENAFIL CITRATE1

SIMPONI1

SKYRIZI1

SODIUM PHENYLBUTYRATE1

SOFOSBUVIR/VELPATASVIR1

STELARA1

STIMATE1

SYNERA

TADALAFIL1

TAZAROTENE

TESTOSTERONE

TESTOSTERONE

TESTOSTERONE CYPIONATE

TESTOSTERONE ENANTHATE

TESTOSTERONE ENANTHATE

TESTOSTERONE PUMP

TESTOSTERONE PUMP

TOBRAMYCIN1

TRACLEER1

TRAMADOL HCL ER

TRETINOIN

VENCLEXTA1,2

VENCLEXTA1,2 STARTING PACK

VIIBRYD

VOSEVI1

VRAYLAR

XELJANZ1

XELJANZ XR1

XIFAXAN

ZARXIO1

ZYDELIG1,2

ZYTIGA1,3

Drug Name(s)

AMCINONIDE

AUGMENTED BETAMETHASONE DIPROPIONATE

BEPREVE

CLOCORTOLONE PIVALATE

DIFLORASONE DIACETATE

FANAPT

FANAPT TITRATION PACK

FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM

HALOG

KETOPROFEN

lanthanum carbonate chew tab

LASTACAFT

LIVALO

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

cream 5%

48 Packets/60 Days

Acute Migraine 5HT

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

almotriptan malate tablet 6.25mg

24 Tablets/30 Days

almotriptan malate tablet 12.5mg

12 Tablets/30 Days

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

dalfampridine tablet 10mg er 1

60 Tablets/30 Days

Androgen/Anabolic Steroids

Drug Name(s)

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

Drug Name(s)

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ciclopirox solution 8%

3.3 mLs/30 Days

Anti-Influenza

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

oseltamivir capsule 30mg

40 Capsules/120 Days

oseltamivir capsule 45mg

20 Capsules/120 Days

oseltamivir capsule 75mg

20 Capsules/120 Days

oseltamivir suspension 6mg/ml

300 mLs/120 Days

Antiretroviral

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RELENZA MIS DISKHALER

40 Blisters/120 Days

Atypical Antipsychotics

Drug Name(s)

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ACTEMRA INJECTION 162/0.91

4 Syringes/28 Days

CIMZIA STARTER  KIT1

3 Kits/180 Days

CIMZIA PREFILL 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/ML1

4 Cartridges/28 Days

ENBREL SRCLK INJECTION 50MG/ML1

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 CROHNS1

3 Kit/180 Days

HUMIRA PEN INJECTION 40/0.4ML1

2 Pens/28 Days

HUMIRA PEN INJECTION 40MG/0.81

2 Pens/28 Days

HUMIRA PEN INJECTION CD/UC/HS1

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

Drug Name(s)

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

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KALYDECO PACK 25MG1

60 Packets/30 Days

KALYDECO PACK 50MG1

60 Packets/30 Days

KALYDECO PACK 75MG1

60 Packets/30 Days

KALYDECO TABLET 150MG1

60 Tablets/30 Days

Fibromyalgia

Drug Name(s)

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 TITRATION 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

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CORLANOR TABLET 5MG

60 Tablets/30 Days

CORLANOR TABLET 7.5MG

60 Tablets/30 Days

Irritable Bowel Syndrome w/Diarrhea (IBS-D)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

alosetron tablet 0.5mg

60 Tablets/30 Days

alosetron tablet 1mg

60 Tablets/30 Days

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

Drug Name(s)

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

Drug Name(s)

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

Muscle Relaxants

Drug Name(s)

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 Tablets/90 Days

tizanidine capsule 2mg

42 Capsules/30 Days

tizanidine capsule 4mg

42 Capsules/30 Days

Multiple Sclerosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AUBAGIO TABLET 7MG1,3

30 Tablets/30 Days

AUBAGIO TABLET 14MG1,3

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/ml1

30 Syringes/30 Days

glatiramer injection 40mg/ml1

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 22/0.51

1 Carton/28 Days

REBIF REBIDO INJECTION 44/0.51

1 Carton/28 Days

REBIF REBIDO INJECTION TITRATN1

1 Kit/180 Days

REBIF TITRTN INJECTION PACK1

1 Kit/180 Days

TECFIDERA CAPSULE 120MG1,3

56 Capsules/180 Days

TECFIDERA CAPSULE 240MG1,3

60 Capsules/30 Days

TECFIDERA MIS STARTER1,3

1 Kit/180 Days

Natpara

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NATPARA INJECTION 25MCG1

1 Kit/28 Days

NATPARA INJECTION 50MCG1

1 Kit/28 Days

NATPARA INJECTION 75MCG1

1 Kit/28 Days

NATPARA INJECTION 100MCG1

1 Kit/28 Days

Nuvigil/Provigil

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

armodafinil tablet 50mg

30 Tablets/30 Days

armodafinil tablet 150mg

30 Tablets/30 Days

armodafinil tablet 200mg

30 Tablets/30 Days

armodafinil tablet 250mg

30 Tablets/30 Days

modafinil tablet 100mg

30 Tablets/30 Days

modafinil tablet 200mg

30 Tablets/30 Days

Ophthalmic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RESTASIS EMULSION 0.05%

2 Vials/30 Days

RESTASIS MUL EMULSION 0.05%

1 Bottle/30 Days

Ophthalmic Prostaglandins

Drug Name(s)

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 Extended Release (ER)

Drug Name(s)

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 Immediate Release (IR)

Drug Name(s)

Adult Quantity Limit - 5 Days

Child Quantity Limit - 3 Days

acetaminophen/codeine solution 120-12/5

450 mLs/30 Days

270 mL/30 days

acetaminophen/codeine tablet 300-15mg

30 Tablets/30 Days

N/A

acetaminophen/codeine tablet 300-30mg

30 Tablets/30 Days

N/A

acetaminophen/codeine tablet 300-60mg

25 Tablets/30 Days

N/A

butorphanol solution 10mg/ml

1 Bottle/30 Days

0 mL/30 days

CODEINE SULFATE TABLET 15MG

30 Tablets/30 Days

18 tablets/30 days

codeine sulfate tablet 30MG

30 Tablets/30 Days

18 tablets/30 days

CODEINE SULFATE TABLET 60MG

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/acetaminophen tablet 5-325mg

40 Tablets/30 Days

24 tablets/30 days

hydrocodone/acetaminophen tablet 7.5-325mg

30 Tablets/30 Days

18 tablets/30 days

hydrocodone/acetaminophen tablet 10-325mg

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/acetaminophen solution 7.5-325mg

450 mLs/30 Days

270 mL/30 days

hydrocodone/ibuprofen tablet 5-200mg

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/ibuprofen tablet 7.5-200mg

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/ibuprofen tablet 10-200mg

25 Tablets/30 Days

15 tablets/30 days

hydromorphone liquid 1mg/ml

60 mLs/30 Days

36 mL/30 days

hydromorphone tablet 2mg

30 Tablets/30 Days

18 tablets/30 days

hydromorphone tablet 4mg

15 Tablets/30 Days

9 tablets/30 days

hydromorphone tablet 8mg

5 Tablets/30 Days

3 tablets/30 days

levorphanol tablet 2mg

10 Tablets/30 Days

6 tablets/30 days

MEPERIDINE SOLUTION 50MG/5ML

150 mLs/30 Days

150 mL/30 days

meperidine tablet 50mg

30 Tablets/30 Days

30 tablets/30 days

meperidine tablet 100mg

15 Tablets/30 Days

15 tablets/30 days

METHADONE SOLUTION 5MG/5ML

10 mLs/30 Days

N/A

METHADONE SOLUTION 10MG/5ML

5 mLs/30 Days

N/A

methadone tablet 5mg

60 Tablets/30 Days

N/A

methadone tablet 10mg

30 Tablets/30 Days

N/A

morphine sulfate solution 100/5ml

10 mLs/30 Days

N/A

morphine sulfate solution 10mg/5ml

125 mLs/30 Days

75 mL/30 days

morphine sulfate solution 20mg/5ml

60 mLs/30 Days

36 mL/30 days

MORPHINE SULFATE TABLET 15MG

15 Tablets/30 Days

9 tablets/30 days

MORPHINE SULFATE TABLET 30MG

5 Tablets/30 Days

3 tablets/30 days

NUCYNTA TABLET 50MG

10 Tablets/30 Days

6 tablets/30 days

NUCYNTA TABLET 75MG

5 Tablets/30 Days

3 tablets/30 days

NUCYNTA TABLET 100MG

5 Tablets/30 Days

3 tablets/30 days

oxycodone/acetaminophen tablet 2.5-325

60 Tablets/30 Days

36 tablets/30 days

oxycodone/acetaminophen tablet 5-325mg

30 Tablets/30 Days

18 tablets/30 days

oxycodone/acetaminophen tablet 7.5-325

20 Tablets/30 Days

12 tablets/30 days

oxycodone/acetaminophen tablet 10-325mg

15 Tablets/30 Days

9 tablets/30 days

oxycodone/aspirin tablet

30 Tablets/30 Days

18 tablets/30 days

OXYCODONE/IBUPROFEN TABLET 5-400MG

20 Tablets/30 Days

12 tablets/30 days

oxycodone concentrate 100/5ml

5 mLs/30 Days

N/A

oxycodone solution 5mg/5ml

165 mLs/30 Days

99 mL/30 days

oxycodone tablet 5mg

30 Tablets/30 Days

18 capsules/30 days

oxycodone tablet 10mg

15 Tablets/30 Days

9 capsules/30 days

oxycodone tablet 15mg

10 Tablets/30 Days

6 tablets/30 days

oxycodone tablet 20mg

5 Tablets/30 Days

3 tablets/30 days

oxycodone tablet 30mg

5 Tablets/30 Days

3 tablets/30 days

tramadol hcl tablet 50mg

50 Tablets/30 Days

30 tablets/30 days

Oral Inhalers

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ADVAIR HFA AEROSOL 45/21

1 Canister/30 Days

ADVAIR HFA AEROSOL 115/21

1 Canister/30 Days

ADVAIR HFA AEROSOL 230/21

1 Canister/30 Days

ASMANEX 30 AEROSOL 110MCG

1 Canister/30 Days

ASMANEX 30 AEROSOL 220MCG

1 Canister/30 Days

ASMANEX 60 AEROSOL 220MCG

1 Canister/30 Days

ASMANEX 120 AEROSOL 220MCG

1 Canister/30 Days

ASMANEX HFA AEROSOL 100 MCG

1 Canister/30 Days

ASMANEX HFA AEROSOL 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 DISKUS AEROSOL 50MCG

60 Blisters/30 Days

FLOVENT DISKUS AEROSOL 100MCG

60 Blisters/30 Days

FLOVENT DISKUS AEROSOL 250MCG

240 Blisters/30 Days

FLOVENT HFA AEROSOL 44MCG

1 Canister/30 Days

FLOVENT HFA AEROSOL 110MCG

1 Canister/30 Days

FLOVENT HFA AEROSOL 220MCG

2 Canisters/30 Days

fluticasone/salmeterol aerosol 100/50

60 Blisters/30 Days

fluticasone/salmeterol aerosol 250/50

60 Blisters/30 Days

fluticasone/salmeterol aerosol 500/50

60 Blisters/30 Days

QVAR AEROSOL 40MCG

1 Canister/30 Days

QVAR AEROSOL 80MCG

2 Canisters/30 Days

Oral Pulmonary Arterial Hypertension (PAH)

Drug Name(s)

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 125mg1

60 Tablets/30 Days

sildenafil tablet 20mg1

90 Tablets/30 Days

tadalafil tablet 20mg1

60 Tablets/30 Days

TRACLEER TABLET 32MG1

120 Tablets/30 Days

Otezla

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

OTEZLA TABLET 10/20/301

1 Kit/180 Days

OTEZLA TABLET 30MG1

60 Tablets/30 Days

Proton Pump Inhibitors (PPI)

Drug Name(s)

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

REGRANEX GEL 0.01%

1 Tube/30 Days

Oncology

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

abiraterone tablet 250mg1

120 Tablets/30 Days

ALECENSA CAPSULE 150MG1,2,3

240 Capsules/30 Days

COTELLIC TABLET 20MG1

63 Tablets/28 Days

ERIVEDGE CAPSULE 150MG1,3

30 Capsules/30 Days

erlotinib tablet 25mg1

60 Tablets/30 Days

erlotinib tablet 100mg1

30 Tablets/30 Days

erlotinib tablet 150mg1

30 Tablets/30 Days

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 4MG1,2,3

30 Capsules/30 Days

LENVIMA CAPSULE 8 MG1,2,3

60 Capsules/30 Days

LENVIMA CAPSULE 10 MG1,2,3

30 Capsules/30 Days

LENVIMA CAPSULE 12MG1,2,3

90 Capsules/30 Days

LENVIMA CAPSULE 14 MG1,2,3

60 Capsules/30 Days

LENVIMA CAPSULE 18 MG1,2,3

90 Capsules/30 Days

LENVIMA CAPSULE 20 MG1,2,3

60 Capsules/30 Days

LENVIMA CAPSULE 24 MG1,2,3

90 Capsules/30 Days

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 500MG1,3

60 Tablets/30 Days

Selective Serotonin Inverse Agonists (SSIA)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NUPLAZID TABLET 10MG1

30 Tablets/30 Days

NUPLAZID CAPSULE 34MG1

30 Capsules/30 Days

Statins

Drug Name(s)

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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

miglustat capsule 100mg1

90 Capsules/30 Days

Topical Corticosteroids

Drug Name(s)

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

AUGMENTED BETAMETHASONE GEL 0.05%

200 Grams/28 Days

augmented betamethasone 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

PREDNICARBATE CREAM 0.1%

120 Grams/30 Days

PREDNICARBATE 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

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

diclofenac gel 1%

10 Tubes/30 Days

Transmucosal Immediate Release Fentanyl

Drug Name(s)

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)

abiraterone acetate1

ACTEMRA ACTPEN1

ACTEMRA1

ADEMPAS1,2

ALECENSA1,2,3

ambrisentan tab1

ARANESP ALBUMIN FREE1

AUBAGIO1,3

AVONEX PEN1

AVONEX1

BERINERT1

BETASERON1

bosentan tab1

capecitabine tab1

CAYSTON1

CHORIONIC GONADOTROPIN1

CIMZIA STARTER KIT1

CIMZIA1

CINRYZE1,2

COTELLIC1

CYSTAGON1,2

dalfampridine tab er 12hr1

dimethyl fumarate1

dimethyl fumarate starter pack1

dofetilide cap1

ENBREL MINI1

ENBREL SURECLICK1

ENBREL1

ENTECAVIR1

EPCLUSA1

ERIVEDGE1,3

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

lapatinib ditosylate 1

LEDIPASVIR/SOFOSBUVIR1

LENVIMA1,2,3

leuprolide acetate inj kit 1

miglustat cap1

NATPARA1

NEXAVAR1,3

NINLARO1

NORDITROPIN FLEXPRO1

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

TASIGNA1,3

TECFIDERA STARTER PACK1

TECFIDERA1,3

tobramycin nebu soln1

TOBRAMYCIN1

TRACLEER1

TYKERB1

VELTASSA1

VENCLEXTA STARTING PACK1,2

VENCLEXTA1,2

VOSEVI1

XALKORI1,3

XELJANZ XR1

XELJANZ1

ZARXIO1

ZYDELIG1,2

ZYTIGA1,3


1Specialty

2Limited Distribution

3Split Fill