Elite 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 Elite formulary for the full list of drugs covered under your plan.


Drugs that are denoted with a “+” in the prescription drug list indicate group specific coverage. Please refer to your benefit booklet for coverage details.

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)

Tier

abiraterone acetate tab GN
ABSTRAL BN+
ACTEMRA BP
ACTEMRA ACTPEN BP
ACTHAR BN
adapalene cream GN+
adapalene gel GN+
ADDYI BN
ADEMPAS BN
ADVATE BP
ADYNOVATE BP
AFINITOR BP
AFINITOR DISPERZ BP
AFSTYLA BP
AIMOVIG BP
AKLIEF BN
ALECENSA BP
ALPHANINE SD BP
ALPROLIX BP
ALTRENO BN+
ALUNBRIG BP
ambrisentan tab GN
ANADROL-50 BN
ARANESP ALBUMIN FREE BP
ARCALYST BN
ARIKAYCE BN
AUBAGIO BP
AUSTEDO BN
AVONEX BP
AVONEX PEN BP
AYVAKIT BP
BALVERSA BN
BELBUCA BP
BENEFIX BP
BENLYSTA BN
BERINERT BN
BETASERON BP
bexarotene cap GN
bosentan tab GN
BOSULIF BP
BRAFTOVI BN
BRUKINSA BN
CABOMETYX BP
CALQUENCE BN
capecitabine tab GN
CAPRELSA BP
CARBAGLU BN
CERDELGA BN
CHORIONIC GONADOTROPIN BP
CIMZIA BN
CIMZIA STARTER KIT BN
COAGADEX BP
COMETRIQ BP
CONTRAVE BN
CONZIP BN+
COPAXONE BP
COPIKTRA BN
CORLANOR BN
COSENTYX BP
COSENTYX SENSOREADY PEN BP
COTELLIC BP
CRESEMBA BN
dalfampridine tab er GN
danazol cap GN
DAURISMO BN
DOPTELET BP
DOXEPIN HYDROCHLORIDE BN+
DUPIXENT BN
ELMIRON BN
ELOCTATE BP
EMFLAZA BN+
EMGALITY BP
ENBREL BP
ENBREL MINI BP
ENBREL SURECLICK BP
ENDARI BN
EPCLUSA BP
EPIDIOLEX BP
EPOGEN BN
ERIVEDGE BP
ERLEADA BP
erlotinib hcl tab GN
ESBRIET BN
everolimus tab GN
EVZIO BN+
FARYDAK BP
FASENRA PEN BN
FENTANYL CITRATE BN+
fentanyl citrate lozenge GN
fentanyl td patch GN
FENTORA BN+
FIBRYGA BP
FIRDAPSE BN
FOLLISTIM AQ BP
GALAFOLD BN
ganirelix acetate soln GN
GATTEX BN
GILENYA BP
GILOTRIF BP
glatiramer acetate soln GN
GOCOVRI BN+
GRASTEK BN
HAEGARDA BP
HARVONI BP
HEMLIBRA BP
HEMOFIL M BP
HETLIOZ BN
HUMIRA BP
HUMIRA PEDIATRIC CROHNS D BP
HUMIRA PEN BP
HUMIRA PEN-CD/UC/HS START BP
HUMIRA PEN-PS/UV STARTER BP
HYCAMTIN BP
hydrocodone bitartrate cap er GN
hydromorphone hcl tab er GN+
HYSINGLA ER BN+
IBRANCE BP
icatibant acetate inj GN
ICLUSIG BP
IDELVION BP
IDHIFA BN
imatinib mesylate tab GN
IMBRUVICA BP
INGREZZA BN
INLYTA BP
INREBIC BN
IRESSA BP
IXINITY BP
JAKAFI BP
JUXTAPID BN
JYNARQUE BN
KADIAN BN+
KALYDECO BP
KEVEYIS BN+
KEVZARA BN
KISQALI BP
KISQALI FEMARA BP
KOATE BP
KOATE-DVI BP
KOGENATE FS BP
KORLYM BN
KOVALTRY BP
KUVAN BN
LAZANDA BN+
LENVIMA BP
LIDOCAINE HCL JELLY GN+
lidocaine hcl soln GN
lidocaine hcl gel GN+
lidocaine oint GN+
lidocaine patch GN
lidocaine-prilocaine cream GN
LOMAIRA BN
LONSURF BP
LORBRENA BN
LUCEMYRA BN
LYNPARZA BP
LYSODREN BP
MATULANE BP
MAVENCLAD BP
MAVYRET BP
MAYZENT BP
MEKINIST BP
MEKTOVI BN
MENOPUR BP
METHITEST BN
METHYLTESTOSTERONE BN
miglustat cap GN
MIRCERA BN
MONONINE BP
morphine sulfate cap er GN
MORPHINE SULFATE ER BN+
morphine sulfate tab er GN
MULPLETA BP
MYALEPT BN
NATPARA BN
NERLYNX BN
NEXAVAR BP
NINLARO BP
NORDITROPIN FLEXPRO BP
NORTHERA BN+
NOVAREL BP
NOVOEIGHT BP
NOXAFIL BP
NUBEQA BP
NUCALA BN
NUCYNTA ER BP
NUPLAZID BN+
NUWIQ BP
OCALIVA BN
ODACTRA BN
ODOMZO BP
OFEV BN
OPSUMIT BP
ORALAIR BN
ORENITRAM BN
ORILISSA BP
ORKAMBI BN
OSMOLEX ER BN+
OTEZLA BP
oxandrolone tab GN
OXBRYTA BN
OXERVATE BN
OXYCONTIN BP
OXYMORPHONE HYDROCHLORIDE BN
OZOBAX BN+
PALYNZIQ BN
PEGASYS BP
PEGASYS PROCLICK BP
PEGINTRON BN
phentermine hcl cap GP
PIQRAY BP
PLEGRIDY BP
PLIAGLIS BN+
POMALYST BP
posaconazole tab GN
PREGNYL W/DILUENT BENZYL BP
PROCRIT BP
PROCYSBI BN
PROFILNINE BP
PROFILNINE SD BP
PROMACTA BN
PRUDOXIN BN+
QBREXZA BN+
QSYMIA BN
QUDEXY XR BN
RAGWITEK BN
RAVICTI BN
REBIF BP
REBIF REBIDOSE BP
REBIF REBIDOSE TITRATION BP
REBIF TITRATION PACK BP
REBINYN BP
RECOMBINATE BP
REPATHA BP
REPATHA PUSHTRONEX SYSTEM BP
REPATHA SURECLICK BP
RETACRIT BP
REVLIMID BP
RIASTAP BP
RINVOQ BP
RIXUBIS BP
ROZLYTREK BP
RUBRACA BP
RUCONEST BN
RUZURGI BN
RYDAPT BP
SAXENDA BN
sildenafil citrate GN
SIMPONI BP
SKYRIZI BP
sodium phenylbutyrate GN
SOVALDI BP
SPRYCEL BP
STELARA BP
STIVARGA BP
STRENSIQ BP
SUBSYS BN+
SUNOSI BP
SUTENT BP
SYLATRON BP
SYMDEKO BP
SYNERA BN+
tadalafil tab GN
TAFINLAR BP
TAGRISSO BP
TALZENNA BN
TASIGNA BP
TAVALISSE BN
tazarotene cream GN
TAZVERIK BN
TECFIDERA BP
TECFIDERA STARTER PACK BP
TEGSEDI BN
temozolomide cap GN
testosterone cypionate im inj GN
TESTOSTERONE ENANTHATE GN
testosterone td gel GN
testosterone td soln GN
tetrabenazine tab GN
THALOMID BP
TIBSOVO BN
TIGLUTIK BN+
TOPIRAMATE ER BN
TRACLEER BP
TRAMADOL HCL ER BN+
tramadol hcl tab er   GN
TREMFYA BP
tretinoin cap GN
tretinoin cream GN
tretinoin gel GN
tretinoin microsphere gel GN+
TRIKAFTA BP
TROKENDI XR BN
TURALIO BN
TYKERB BP
TYMLOS BP
TYVASO BN
TYVASO REFILL BN
TYVASO STARTER BN
UPTRAVI BP
VENCLEXTA BP
VENTAVIS BN
VERZENIO BP
VITRAKVI BP
VIZIMPRO BN
voriconazole susp GN
voriconazole tab GN
VOSEVI BP
VOTRIENT BP
VUMERITY BP
VYLEESI BN
VYNDAMAX BP
VYNDAQEL BP
XALKORI BP
XELJANZ BP
XELJANZ XR BP
XENICAL BN
XERMELO BN
XOSPATA BN
XPOVIO BN
XTAMPZA ER BN
XTANDI BP
XYNTHA BP
XYNTHA SOLOFUSE BP
XYREM BN
YONSA BP
ZEJULA BN
ZELBORAF BP
ZOHYDRO ER BN
ZOLINZA BP
ZONALON BN+
ZTLIDO BN+
ZYDELIG BP
ZYKADIA BP
ZYTIGA BP

Drug name(s)

Tier

aripiprazole tab BN+
asenapine maleate sl tab BN
asenapine td patch BN
brexpiprazole tab BN
bupropion hbr tab er BN+
bupropion hcl tab er BN+
cariprazine hcl cap BN
clozapine orally disintegrating tab BN
clozapine susp BN
continuous blood glucose BP
desvenlafaxine tab er BN+
doxepin hcl tab BN
duloxetine hcl cap delayed release sprinkle BN+
fluoxetine hcl cap delayed release BN
FORTAMET GN+
gabapentin tab BN
gabapentin enacarbil tab er BN
GLUMETZA GN+
iloperidone tab BN
insulin degludec-liraglutide sol pen-inj BP
insulin glargine-lixisenatide sol pen-inj BP
levomilnacipran hcl cap er BN
lumateperone tosylate cap BN+
lurasidone hcl tab BN
maprotiline hcl tab BN+
methotrexate soln pf auto-injector BP
paroxetine hcl oral susp BN+
paroxetine mesylate tab BN+
risperidone orally disintegrating tab BN
sumatriptan nasal spray BN+
sumatriptan succinate solution BP
suvorexant tab BP
vilazodone hcl tab BN
vortioxetine hbr tab BN
zolpidem tartrate oral spray BN+

Actinic Keratosis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALDARA CREAM 5%

38 packets/60 days

EFUDEX CREAM 5%

340 grams/90 days

fluorouracil cream 5%

340 grams/90 days

imiquimod cream 5%

38 packets/60 days

Acute Migraine 5HT

Drug name(s)

Quantity limits 
(per 30 days or as specified)

almotriptan malate tablet 6.25mg

34 tablets/30 days

almotriptan malate tablet 12.5mg

32 tablets/30 days

AMERGE TABLET 1MG

38 tablets/30 days

AMERGE TABLET 2.5MG

38 tablets/30 days

eletriptan tablet 20mg

38 tablets/30 days

eletriptan tablet 40mg

32 tablets/30 days

FROVA TABLET 2.5MG

37 tablets/30 days

frovatriptan tablet 2.5mg

37 tablets/30 days

IMITREX INJECTION 4MG/0.5

32 syringes/30 days

IMITREX INJECTION 6MG/0.5

32 syringes/30 days

IMITREX INJECTION 6MG/0.5

32 cartridges/30 days

IMITREX SPRAY 20MG/ACT

32 inhalers/30 days

IMITREX SPRAY 5MG/ACT

3 packs/30 days

IMITREX TABLET 25MG

37 tablets/30 days

IMITREX TABLET 50MG

38 tablets/30 days

IMITREX TABLET 100MG

38 tablets/30 days

MAXALT TABLET 10MG

38 tablets/30 days

MAXALT-MLT TABLET 10MG

38 tablets/30 days

MAXALT-MLT TABLET 5MG

36 tablets/30 days

naratriptan tablet 1mg

38 tablets/30 days

naratriptan tablet 2.5mg

38 tablets/30 days

NURTEC ODT 75 mg

35 tablets/90 days

ONZETRA XSAI MIS 11MG

32 inhalers/30 days

RELPAX TABLET 20MG

38 tablets/30 days

RELPAX TABLET 40MG

32 tablets/30 days

REYVOW 50 MG

3 tablets/30 days

REYVOW 100 MG

3 tablets/30 days

rizatriptan tablet 5mg

36 tablets/30 days

rizatriptan tablet 5mg odt

36 tablets/30 days

rizatriptan tablet 10mg

38 tablets/30 days

rizatriptan tablet 10mg odt

38 tablets/30 days

sumatriptan injection 4mg/0.5

32 cartridges/30 days

sumatriptan injection 4mg/0.5

32 syringes/30 days

sumatriptan injection 6/0.5ml

32 syringes/30 days

sumatriptan injection 6mg/0.5

32 cartridges/30 days

sumatriptan injection 6mg/0.5

32 syringes/30 days

sumatriptan spray 20mg/act

32 inhalers/30 days

sumatriptan spray 5mg/act

3 packs/30 days

sumatriptan tablet 25mg

37 tablets/30 days

sumatriptan tablet 50mg

38 tablets/30 days

sumatriptan tablet 100mg

38 tablets/30 days

sumatriptan-naproxen tablet 85-500mg

38 tablets/30 days

TREXIMET TABLET 10-60MG

3 tablets/30 days

TREXIMET TABLET 85-500MG

38 tablets/30 days

UBREVLY

36 tablets/30 days

ZEMBRACE SYM INJECTION 3/0.5ML

34 pens/30 days

zolmitriptan tablet 2.5 mg

38 tablets/30 days

zolmitriptan tablet 2.5mg

38 tablets/30 days

zolmitriptan tablet 5mg

32 tablets/30 days

zolmitriptan tablet 5mg odt

32 tablets/30 days

ZOMIG SPRAY 2.5MG

3 injection devices/30 days

ZOMIG SPRAY 5MG

3 sprays/30 days

ZOMIG TABLET 2.5MG

38 tablets/30 days

ZOMIG TABLET 5MG

32 tablets/30 days

ZOMIG ZMT TABLET 2.5 MG

38 tablets/30 days

ZOMIG ZMT TABLET 5MG ODT

32 tablets/30 days

Addyi

Drug name(s)

Quantity limits 
(per 30 days or as specified)

VYLEESI INJECTION 1.75/0.3

3 pens/30 days

Afrezza

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AFREZZA POWDER 4UNIT

3520 cartridges/30 days

AFREZZA POWDER 8 UNIT

3260 cartridges/30 days

AFREZZA POWDER 12 UNIT

300 cartridges/30 days

AFREZZA POWDER 4-8 UNIT

3530 cartridges/30 days

AFREZZA POWDER 4-8 UNIT

3890 cartridges/30 days

AFREZZA POWDER 4-8 UNIT

3800 cartridges/30 days

AFREZZA POWDER 8-12UNIT

3080 cartridges/30 days

AFREZZA POWDER 4-8-12

3260 cartridges/30 days

Alinia

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALINIA SUSPENSE 100/5ML

300 mLs/90 days

ALINIA TABLET 500MG

32 tablets/90 days

Amantadine ER

Drug name(s)

Quantity limits 
(per 30 days or as specified)

GOCOVRI CAPSULE 68.5MG1,3

30 capsules/30 days

GOCOVRI CAPSULE 137MG1,3

30 capsules/30 days

Amifampridine

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FIRDAPSE TABLET 10MG 1,2

340 tablets/30 days

RUZURGI TABLET 10MG 1,2

300 tablets/30 days

Ampyra

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMPYRA TABLET 10MG1,3

30 tablets/30 days

dalfampridine tablet 10mg er1

30 tablets/30 days

Androgen/Anabolic Steroids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ANDRODERM DIS 2MG/24HR

30 patches/30 days

ANDRODERM DIS 4MG/24HR

30 patches/30 days

ANDROGEL GEL 1%(25MG)

30 packets/30 days

ANDROGEL GEL 1%(50MG)

30 packets/30 days

ANDROGEL GEL 1.62%

3 pumps/30 days

ANDROGEL GEL 1.62%

30 packets/30 days

ANDROGEL GEL 1.62%

30 packets/30 days

ANDROID 10 MG CAPSULE

30 capsules/30 days

ANDROXY 10 MG TABLET

320 tablets/30 days

AVEED 250 MG/ML

3 vial/28 days

AXIRON 30 MG/1.5

3 pumps/30 days

DEPO-TESTOSTERONE INJECTION 100MG/ML

3 vial/28 days

DEPO-TESTOSTERONE INJECTION 200MG/ML

30 mLs/28 days

FORTESTA GEL 10MG/ACT

3 pumps/30 days

JATENZO 158 MG CAPSULE

320 capsules/30 days

JATENZO 198 MG CAPSULE

30 capsules/30 days

METHITEST 10 MG TABLET

300 capsules/30 days

NATESTO GEL 5.5MG

3 pumps/30 days

STRIANT MIS 30MG

30 Systems/30 days

TESTIM GEL 1%(50MG)

30 packets/30 days

TESTOPEL 75 MG

3 Pellets/90 days

testosterone cypionate injection 100mg/ml

3 vial/28 days

testosterone cypionate injection 200mg/ml

30 mLs/28 days

TESTOST ENAN INJECTION 200MG/ML

3 vial/28 days

testosterone gel 1%(25mg)

30 packets/30 days

testosterone gel 1%(50mg)

30 packets/30 days

testosterone gel 1.62%

3 bottles/30 days

testosterone gel 1.62%

30 packets/30 days

testosterone gel 1.62%

30 packets/30 days

testosterone gel 10mg/act

3 pumps/30 days

testosterone gel pump 1%

300 grams/30 days

TESTOSTERONE GEL PUMP 1%

3 pumps/30 days

TESTOSTERONE INJECTION CYPIONATE

30 mLs/28 days

testosterone solution 30mg/act

3 pumps/30 days

TESTRED 10 MG CAPSULE

300 capsules/30 days

VOGELXO GEL 1%(50MG)

30 packets/30 days

VOGELXO GEL PUMP 1%

3 pumps/30 days

XYOSTED INJECTION 100/0.5

3 pens/28 days

XYOSTED INJECTION 50/0.5

3 pens/28 days

XYOSTED IINJECTIONNJ 75/0.5

3 pens/28 days

Anticoagulant

Drug name(s)

Quantity limits (per 30 days or as specified)

BEVYXXA CAPSULE 40MG

43 capsules per 42 days

BEVYXXA  CAPSULE 80MG

43 capsules per 42 days

ELIQUIS TABLET 2.5MG

60 tablets per 30 days

ELIQUIS  TABLET 5MG

1 pack per 180 days

ELIQUIS  TABLET 5MG

74 tablets per 30 days

ELIQUIS STARTER PACK   TABLET 5MG

1 pack per 180 days

ELIQUIS STARTER PACK   TABLET 5MG

74 tablets per 30 days

PRADAXA  CAPSULE 110MG

71 capsules per 90 days

PRADAXA  CAPSULE 150MG

60 capsules per 30 days

PRADAXA  CAPSULE 75MG

60 capsules per 30 days

SAVAYSA  TABLET 15MG

30 tablets per 30 days

SAVAYSA  TABLET 30MG

30 tablets per 30 days

SAVAYSA  TABLET 60MG

30 tablets per 30 days

XARELTO  TABLET 10MG

30 tablets per 30 days

XARELTO  TABLET 15MG

60 tablets per 30 days

XARELTO  TABLET 2.5MG

60 tablets per 30 days

XARELTO  TABLET 20MG

30 tablets per 30 days

XARELTO STARTER PACK  TABLET 15MG

51 tablets per 30 days

Antidepressants

Drug name(s)

Quantity limits (per 30 days or as specified)

APLENZIN TABLET 174MG

30 tablets per 30 days

APLENZIN TABLET 348MG

30 tablets per 30 days

APLENZIN TABLET 522MG

30 tablets per 30 days

bupropion hcl tablet 100mg

120 tablets per 30 days

bupropion hcl tablet 75mg

60 tablets per 30 days

bupropion hydrochloride er (sr) tablet 100mg

60 tablets per 30 days

bupropion hydrochloride er (sr) tablet 150mg

60 tablets per 30 days

bupropion hydrochloride er (sr) tablet 200mg

60 tablets per 30 days

bupropion hydrochloride er (xl) tablet 150mg

30 tablets per 30 days

bupropion hydrochloride er (xl) tablet 300mg

30 tablets per 30 days

BUPROPION HYDROCHLORIDE ER (XL) TABLET 450MG

30 tablets per 30 days

bupropion hydrochloride tablet 100mg

120 tablets per 30 days

bupropion hydrochloride tablet 75mg

60 tablets per 30 days

CELEXA TABLET 10MG

30 tablets per 30 days

CELEXA TABLET 20MG

30 tablets per 30 days

CELEXA TABLET 40MG

30 tablets per 30 days

citalopram hydrobromide soln 10mg

600 mLs per 30 days

citalopram hydrobromide tablet 10mg

30 tablets per 30 days

citalopram hydrobromide tablet 20mg

30 tablets per 30 days

citalopram hydrobromide tablet 40mg

30 tablets per 30 days

citalopram tablet 20mg

30 tablets per 30 days

citalopram tablet 40mg

30 tablets per 30 days

CYMBALTA CAPSULE 20MG

60 capsules per 30 days

CYMBALTA CAPSULE 30MG

60 capsules per 30 days

CYMBALTA CAPSULE 60MG

60 capsules per 30 days

DESVENLAFAXINE ER TABLET 100MG

30 tablets per 30 days

desvenlafaxine er tablet 100mg

30 tablets per 30 days

desvenlafaxine er tab 25mg

30 tablets per 30 days

DESVENLAFAXINE ER TABLET 50MG

30 tablets per 30 days

desvenlafaxine er tab 50mg

30 tablets per 30 days

DRIZALMA SPRINKLE CAPSULE 20MG

60 capsules per 30 days

DRIZALMA SPRINKLE CAPSULE 30MG

60 capsules per 30 days

DRIZALMA SPRINKLE CAPSULE 40MG

60 capsules per 30 days

DRIZALMA SPRINKLE CAPSULE 60MG

60 capsules per 30 days

duloxetine hcl capsule 30mg

60 capsules per 30 days

duloxetine hcl capsule 40mg

90 capsules per 30 days

duloxetine hydrochloride capsule 20mg

60 capsules per 30 days

duloxetine hydrochloride capsule 30mg

60 capsules per 30 days

duloxetine hydrochloride capsule 40mg

90 capsules per 30 days

duloxetine hydrochloride capsule 60mg

60 capsules per 30 days

EFFEXOR XR CAPSULE 150MG

30 capsules per 30 days

EFFEXOR XR CAPSULE 37.MG

30 capsules per 30 days

EFFEXOR XR CAPSULE 75MG

90 capsules per 30 days

escitalopram oxalate soln 5mg/5ml

600 mLs per 30 days

escitalopram oxalate tablet 10mg

30 tablets per 30 days

escitalopram oxalate tablet 20mg

30 tablets per 30 days

escitalopram oxalate tablet 5mg

30 tablets per 30 days

FETZIMA CAPSULE 120MG

30 capsules per 30 days

FETZIMA CAPSULE 20MG

30 capsules per 30 days

FETZIMA CAPSULE 40MG

30 capsules per 30 days

FETZIMA CAPSULE 80MG

30 capsules per 30 days

FETZIMA TITRATION PACK CAPSULE 40MG

28 capsules per 180 days

FLUOXETINE DR CAPSULE 90MG

4 capsules per 28 days

fluoxetine hcl capsule 20mg

120 capsules per 30 days

fluoxetine hcl solution 20mg/5ml

600 mLs per 30 days

fluoxetine hcl solution 20mg/5ml

600 mLs per 30 days

fluoxetine hydrochloride capsule 10mg

30 capsules per 30 days

fluoxetine hydrochloride capsule 20mg

120 capsules per 30 days

fluoxetine hydrochloride capsule 40mg

60 capsules per 30 days

fluoxetine hydrochloride tablet 10mg

30 tablets per 30 days

fluoxetine hydrochloride tablet 20mg

120 tablets per 30 days

FLUOXETINE HYDROCHLORIDE TABLET 60MG

30 tablets per 30 days

fluoxetine hydrochloride tablet 60mg

30 tablets per 30 days

fluvoxamine maleate er capsule 100mg

60 capsules per 30 days

fluvoxamine maleate er capsule 150mg

60 capsules per 30 days

fluvoxamine maleate tablet 100mg

90 tablets per 30 days

fluvoxamine maleate tablet 25mg

30 tablets per 30 days

fluvoxamine maleate tablet 50mg

30 tablets per 30 days

FORFIVO XL TABLET 450MG

30 tablets per 30 days

KHEDEZLA TABLET 100MG

30 tablets per 30 days

KHEDEZLA TABLET 50MG

30 tablets per 30 days

LEXAPRO TABLET 10MG

30 tablets per 30 days

LEXAPRO TABLET 20MG

30 tablets per 30 days

LEXAPRO TABLET 5MG

30 tablets per 30 days

MAPROTILINE HCL TABLET 25MG

90 tablets per 30 days

MAPROTILINE HCL TABLET 50MG

90 tablets per 30 days

MAPROTILINE HCL TABLET 75MG

90 tablets per 30 days

mirtazapine odt tablet 15mg

30 tablets per 30 days

mirtazapine odt tablet 30mg

30 tablets per 30 days

mirtazapine odt tablet 45mg

30 tablets per 30 days

mirtazapine tablet 15mg

30 tablets per 30 days

mirtazapine tablet 30mg

30 tablets per 30 days

mirtazapine tablet 45mg

30 tablets per 30 days

mirtazapine tablet 7.5mg

30 tablets per 30 days

paroxetine hcl er tablet 12.mg

30 tablets per 30 days

paroxetine hcl er tablet 25mg

60 tablets per 30 days

paroxetine hcl er tablet 37.mg

60 tablets per 30 days

paroxetine hcl tablet 30mg

60 tablets per 30 days

paroxetine hcl tablet 40mg

30 tablets per 30 days

paroxetine hydrochloride er tablet 12.mg

30 tablets per 30 days

paroxetine hydrochloride er tablet 25mg

60 tablets per 30 days

paroxetine hydrochloride er tablet 37.mg

60 tablets per 30 days

paroxetine hydrochloride tablet 10mg

30 tablets per 30 days

paroxetine hydrochloride tablet 20mg

30 tablets per 30 days

PAXIL CR TABLET 12.MG

30 tablets per 30 days

PAXIL CR TABLET 25MG

60 tablets per 30 days

PAXIL CR TABLET 37.MG

60 tablets per 30 days

PAXIL SUSP 10MG/5ML

900 mLs per 30 days

PAXIL TABLET 10MG

30 tablets per 30 days

PAXIL TABLET 20MG

30 tablets per 30 days

PAXIL TABLET 30MG

60 tablets per 30 days

PAXIL TABLET 40MG

30 tablets per 30 days

PEXEVA TABLET 10MG

30 tablets per 30 days

PEXEVA TABLET 20MG

30 tablets per 30 days

PEXEVA TABLET 30MG

60 tablets per 30 days

PEXEVA TABLET 40MG

30 tablets per 30 days

PRISTIQ TABLET 100MG

30 tablets per 30 days

PRISTIQ TABLET 25MG

30 tablets per 30 days

PRISTIQ TABLET 50MG

30 tablets per 30 days

PROZAC CAPSULE 10MG

30 capsules per 30 days

PROZAC CAPSULE 20MG

120 capsules per 30 days

PROZAC CAPSULE 40MG

60 capsules per 30 days

REMERON SOLTAB TABLET 15MG

30 tablets per 30 days

REMERON SOLTAB TABLET 30MG

30 tablets per 30 days

REMERON SOLTAB TABLET 45MG

30 tablets per 30 days

REMERON TABLET 15MG

30 tablets per 30 days

REMERON TABLET 30MG

30 tablets per 30 days

sertraline hcl concentrate 20mg/ml

300 mLs per 30 days

sertraline hcl concentrate 20mg/ml

300 mLs per 30 days

sertraline hcl tablet 25mg

30 tablets per 30 days

sertraline hcl tablet 50mg

30 tablets per 30 days

sertraline hydrochloride tablet 100mg

60 tablets per 30 days

sertraline hydrochloride tablet 25mg

30 tablets per 30 days

sertraline hydrochloride tablet 50mg

30 tablets per 30 days

TRINTELLIX TABLET 10MG

30 tablets per 30 days

TRINTELLIX TABLET 20MG

30 tablets per 30 days

TRINTELLIX TABLET 5MG

30 tablets per 30 days

venlafaxine hcl er capsule 150mg

30 capsules per 30 days

venlafaxine hcl er capsule 37.mg

30 capsules per 30 days

venlafaxine hcl er tablet 37.mg

30 tablets per 30 days

venlafaxine hcl tablet 100mg

90 tablets per 30 days

venlafaxine hcl tablet 25mg

90 tablets per 30 days

venlafaxine hcl tablet 37.mg

90 tablets per 30 days

venlafaxine hcl tablet 50mg

90 tablets per 30 days

venlafaxine hcl tablet 75mg

90 tablets per 30 days

venlafaxine hydrochloride er capsule 75mg

90 capsules per 30 days

venlafaxine hydrochloride er tablet 150mg

30 tablets per 30 days

venlafaxine hydrochloride er tablet 225mg

30 tablets per 30 days

venlafaxine hydrochloride er tablet 37.mg

30 tablets per 30 days

venlafaxine hydrochloride er tablet 75mg

90 tablets per 30 days

venlafaxine hydrochloride tablet 75mg

90 tablets per 30 days

VIIBRYD STARTER PACK TABLET (23)MG

1 kit per 180 days

VIIBRYD TABLET 10MG

30 tablets per 30 days

VIIBRYD TABLET 20MG

30 tablets per 30 days

VIIBRYD TABLET 40MG

30 tablets per 30 days

WELLBUTRIN SR TABLET 100MG

60 tablets per 30 days

WELLBUTRIN SR TABLET 150MG

60 tablets per 30 days

WELLBUTRIN SR TABLET 200MG

60 tablets per 30 days

WELLBUTRIN XL TABLET 150MG

30 tablets per 30 days

WELLBUTRIN XL TABLET 300MG

30 tablets per 30 days

ZOLOFT CONCENTRATE 20MG/ML

300 mLs per 30 days

ZOLOFT TABLET 100MG

60 tablets per 30 days

ZOLOFT TABLET 25MG

30 tablets per 30 days

ZOLOFT TABLET 50MG

30 tablets per 30 days

Antiemetic

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AKYNZEO CAPSULE 300-0.5

3 capsules/30 days

ANZEMET TABLET 50MG

3 tablets/30 days

ANZEMET TABLET 100MG

3 tablets/30 days

aprepitant capsule 40mg

3 capsules/30 days

aprepitant capsule 80mg

3 capsules/30 days

aprepitant capsule 125mg

3 capsules/30 days

aprepitant pack 80 & 125

3 packs/30 days

CESAMET CAPSULE 1MG

32 capsules/30 days

DICLEGIS TABLET 10-10MG

320 tablets/30 days

doxylamine/pyridoxine tablet 10-10mg

320 tablets/30 days

EMEND CAPSULE 40MG

3 capsules/30 days

EMEND CAPSULE 80MG

3 capsules/30 days

EMEND CAPSULE 125MG

3 capsules/30 days

EMEND SUSPENSE 125MG

3 packs/30 days

EMEND TRIPAC PACK 80 & 125

3 packs/30 days

granisetron tablet 1mg

34 tablets/30 days

ondansetron solution 4mg/5ml

3 bottles/30 days

ondansetron tablet 4mg

34 tablets/30 days

ondansetron tablet 4mg odt

34 tablets/30 days

ondansetron tablet 8mg

34 tablets/30 days

ondansetron tablet 8mg odt

34 tablets/30 days

ondansetron tablet 24mg

3 tablets/30 days

ONDANSETRON TABLET 24MG

3 tablets/30 days

SANCUSO DIS 3.1MG

3 patches/28 days

VARUBI TABLET 90MG

3 tablets/30 days

ZOFRAN SOLUTION 4MG/5ML

3 bottles/30 days

ZOFRAN TABLET 4MG

34 tablets/30 days

ZOFRAN TABLET 4MG ODT

34 tablets/30 days

ZOFRAN TABLET 8MG

34 tablets/30 days

ZOFRAN TABLET 8MG ODT

34 tablets/30 days

ZUPLENZ MIS 4MG

34 films/30 days

ZUPLENZ MIS 8MG

34 films/30 days

Antifungal

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ciclodan solution 8%

3.3 mLs/30 days

ciclopirox solution 8%

3.3 mLs/30 days

JUBLIA SOLUTION 10%

3 mLs/30 days

KERYDIN SOLUTION 5%

3 mLs/30 days

PENLAC SOLUTION 8%

3.6 mLs/30 days

Anti-Influenza

Drug name(s)

Quantity limits 
(per 30 days or as specified)

oseltamivir capsule 30mg

30 capsules/120 days

oseltamivir capsule 45mg

30 capsules/120 days

oseltamivir capsule 75mg

30 capsules/120 days

oseltamivir suspense 6mg/ml

300 mLs/120 days

TAMIFLU CAPSULE 30MG

30 capsules/120 days

TAMIFLU CAPSULE 45MG

30 capsules/120 days

TAMIFLU CAPSULE 75MG

30 capsules/120 days

TAMIFLU SUSPENSE 6MG/ML

300 mLs/120 days

XOFLUZA TABLET 20MG

3 tablets/120 days

XOFLUZA TABLET 40MG

3 tablets/120 days

Anti-Migraine: Calcitonin Gene-Related Peptide (CGRP)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AIMOVIG INJECTION 70MG/ML1

3 injection/28 days

AIMOVIG INJECTION 140MG/ML1

3 injection/28 days

AJOVY INJECTION 225/1.51

3.5 syringes/84 days

EMGALITY INJECTION 100MG/ML1

3 syringes/180 days

EMGALITY INJECTION 120MG/ML1

3 syringe/28 days

Antiretroviral

Drug name(s)

Quantity limits 
(per 30 days or as specified)

RELENZA MIS DISKHALER

30 blisters/120 days

Arikayce

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ARIKAYCE SUSPENSE 1,2

18 vials/28 days

Attention Deficit Hyperactivity Disorder (ADHD)

Drug name(s)

Quantity limits (per 30 days or as specified)

ADDERALL TABLET 10MG

60 tablets per 30 days

ADDERALL TABLET 12.MG

60 tablets per 30 days

ADDERALL TABLET 15MG

60 tablets per 30 days

ADDERALL TABLET 20MG

90 tablets per 30 days

ADDERALL TABLET 30MG

60 tablets per 30 days

ADDERALL TABLET 5MG

60 tablets per 30 days

ADDERALL TABLET 7.5MG

60 tablets per 30 days

ADDERALL XR CAPSULE 10MG

30 capsules per 30 days

ADDERALL XR CAPSULE 15MG

30 capsules per 30 days

ADDERALL XR CAPSULE 20MG

30 capsules per 30 days

ADDERALL XR CAPSULE 25MG

30 capsules per 30 days

ADDERALL XR CAPSULE 30MG

30 capsules per 30 days

ADDERALL XR CAPSULE 5MG

30 capsules per 30 days

ADHANSIA XR CAPSULE 25MG

30 capsules per 30 days

ADHANSIA XR CAPSULE 35MG

30 capsules per 30 days

ADHANSIA XR CAPSULE 45MG

30 capsules per 30 days

ADHANSIA XR CAPSULE 55MG

30 capsules per 30 days

ADHANSIA XR CAPSULE 70MG

30 capsules per 30 days

ADHANSIA XR CAPSULE 85MG

30 capsules per 30 days

ADZENYS ER SUSP 1.25 MG/ML

450 mLs per 30 days

ADZENYS XR-ODT TABLET 12.MG

30 tablets per 30 days

ADZENYS XR-ODT TABLET 15.MG

30 tablets per 30 days

ADZENYS XR-ODT TABLET 18.MG

30 tablets per 30 days

ADZENYS XR-ODT TABLET 3.1MG

60 tablets per 30 days

ADZENYS XR-ODT TABLET 6.3MG

60 tablets per 30 days

ADZENYS XR-ODT TABLET 9.4MG

30 tablets per 30 days

AMPHETAMINE ER SUSP 1.25 MG/ML

450 mLs per 30 days

amphetamine sulfate tablet 10mg

180 tablets per 30 days

amphetamine sulfate tablet 5mg

90 tablets per 30 days

amphetamine/dextroamphetamine capsule 10mg

30 capsules per 30 days

amphetamine/dextroamphetamine capsule 15mg

30 capsules per 30 days

amphetamine/dextroamphetamine capsule 20mg

30 capsules per 30 days

amphetamine/dextroamphetamine capsule 25mg

30 capsules per 30 days

amphetamine/dextroamphetamine capsule 30mg

30 capsules per 30 days

amphetamine/dextroamphetamine capsule 5mg

30 capsules per 30 days

amphetamine/dextroamphetamine tablet 10mg

60 tablets per 30 days

amphetamine/dextroamphetamine tablet 12.mg

60 tablets per 30 days

amphetamine/dextroamphetamine tablet 15mg

60 tablets per 30 days

amphetamine/dextroamphetamine tablet 20mg

90 tablets per 30 days

amphetamine/dextroamphetamine tablet 30mg

60 tablets per 30 days

amphetamine/dextroamphetamine tablet 5mg

60 tablets per 30 days

amphetamine/dextroamphetamine tablet 7.5mg

60 tablets per 30 days

APTENSIO XR CAPSULE 10MG

30 capsules per 30 days

APTENSIO XR CAPSULE 15MG

30 capsules per 30 days

APTENSIO XR CAPSULE 20MG

30 capsules per 30 days

APTENSIO XR CAPSULE 30MG

30 capsules per 30 days

APTENSIO XR CAPSULE 40MG

30 capsules per 30 days

APTENSIO XR CAPSULE 50MG

30 capsules per 30 days

APTENSIO XR CAPSULE 60MG

30 capsules per 30 days

atomoxetine capsule 100mg

30 capsules per 30 days

atomoxetine capsule 10mg

60 capsules per 30 days

atomoxetine capsule 18mg

60 capsules per 30 days

atomoxetine capsule 25mg

60 capsules per 30 days

atomoxetine capsule 40mg

60 capsules per 30 days

atomoxetine capsule 60mg

30 capsules per 30 days

atomoxetine capsule 80mg

30 capsules per 30 days

atomoxetine hydrochloride capsule 100mg

30 capsules per 30 days

atomoxetine hydrochloride capsule 10mg

60 capsules per 30 days

atomoxetine hydrochloride capsule 18mg

60 capsules per 30 days

atomoxetine hydrochloride capsule 25mg

60 capsules per 30 days

atomoxetine hydrochloride capsule 40mg

60 capsules per 30 days

atomoxetine hydrochloride capsule 60mg

30 capsules per 30 days

atomoxetine hydrochloride capsule 80mg

30 capsules per 30 days

clonidine hcl er tablet 0.1mg

120 tablets per 30 days

clonidine hydrochloride er tablet 0.1mg

120 tablets per 30 days

clonidine hydrochloride tablet 0.1mg

120 tablets per 30 days

CONCERTA TABLET 18MG

30 tablets per 30 days

CONCERTA TABLET 27MG

30 tablets per 30 days

CONCERTA TABLET 36MG

60 tablets per 30 days

CONCERTA TABLET 54MG

30 tablets per 30 days

COTEMPLA XR-ODT TABLET 17.MG

60 tablets per 30 days

COTEMPLA XR-ODT TABLET 25.MG

60 tablets per 30 days

COTEMPLA XR-ODT TABLET 8.6MG

30 tablets per 30 days

DAYTRANA PATCH 10MG

30 patches per 30 days

DAYTRANA PATCH 15MG

30 patches per 30 days

DAYTRANA PATCH 20MG

30 patches per 30 days

DAYTRANA PATCH 30MG

30 patches per 30 days

DESOXYN TABLET 5 MG

150 tablets per 30 days

DEXEDRINE CAPSULE 10MG

120 capsules per 30 days

DEXEDRINE CAPSULE 15MG

120 capsules per 30 days

DEXEDRINE CAPSULE 5MG

90 capsules per 30 days

dexmethylphenidate hcl er capsule 10mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 15mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 20mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 25mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 30mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 35mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 40mg

30 capsules per 30 days

dexmethylphenidate hcl er capsule 5mg

30 capsules per 30 days

dexmethylphenidate hcl tablet 10mg

60 tablets per 30 days

dexmethylphenidate hcl tablet 2.5mg

60 tablets per 30 days

dexmethylphenidate hcl tablet 5mg

60 tablets per 30 days

dexmethylphenidate hydrochloride capsule 25mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er 5MG/ML

1800 mLs per 30 days

dexmethylphenidate hydrochloride er capsule 10mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er capsule 15mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er capsule 20mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er capsule 30mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er capsule 35mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er capsule 40mg

30 capsules per 30 days

dexmethylphenidate hydrochloride er capsule 5mg

30 capsules per 30 days

dexmethylphenidate hydrochloride tablet 10mg

60 tablets per 30 days

dexmethylphenidate hydrochloride tablet 2.5mg

60 tablets per 30 days

dexmethylphenidate hydrochloride tab 5mg

60 tablets per 30 days

dextroamphetamine sulfate er capsule 10mg

120 capsules per 30 days

dextroamphetamine sulfate er capsule 15mg

120 capsules per 30 days

dextroamphetamine sulfate er capsule 5mg

90 capsules per 30 days

dextroamphetamine sulfate tablet 10mg

180 tablets per 30 days

dextroamphetamine sulfate tablet 5mg

90 tablets per 30 days

DYANAVEL XR SUSPENSION 2.5 MG/ML

240 mLs per 30 days

EVEKEO ODT TABLET 10MG

60 tablets per 30 days

EVEKEO ODT TABLET 15MG

60 tablets per 30 days

EVEKEO ODT TABLET 20MG

60 tablets per 30 days

EVEKEO ODT TABLET 5MG

60 tablets per 30 days

EVEKEO TABLET 10MG

180 tablets per 30 days

EVEKEO TABLET 5MG

90 tablets per 30 days

FOCALIN TABLET 10MG

60 tablets per 30 days

FOCALIN TABLET 2.5MG

60 tablets per 30 days

FOCALIN TABLET 5MG

60 tablets per 30 days

FOCALIN XR CAPSULE 10MG

30 capsules per 30 days

FOCALIN XR CAPSULE 15MG

30 capsules per 30 days

FOCALIN XR CAPSULE 20MG

30 capsules per 30 days

FOCALIN XR CAPSULE 25MG

30 capsules per 30 days

FOCALIN XR CAPSULE 30MG

30 capsules per 30 days

FOCALIN XR CAPSULE 35MG

30 capsules per 30 days

FOCALIN XR CAPSULE 40MG

30 capsules per 30 days

FOCALIN XR CAPSULE 5MG

30 capsules per 30 days

guanfacine er tablet 1MG

30 tablets per 30 days

guanfacine er tablet 2MG

30 tablets per 30 days

guanfacine er tablet 3MG

30 tablets per 30 days

guanfacine er tablet 4MG

30 tablets per 30 days

guanfacine hydrochloride tablet 1MG

30 tablets per 30 days

guanfacine hydrochloride tablet 2MG

30 tablets per 30 days

guanfacine hydrochloride tablet 3MG

30 tablets per 30 days

guanfacine hydrochloride tablet 4MG

30 tablets per 30 days

INTUNIV TABLET 1MG

30 tablets per 30 days

INTUNIV TABLET 2MG

30 tablets per 30 days

INTUNIV TABLET 3MG

30 tablets per 30 days

INTUNIV TABLET 4MG

30 tablets per 30 days

JORNAY PM CAPSULE 100MG

30 capsules per 30 days

JORNAY PM CAPSULE 20MG

30 capsules per 30 days

JORNAY PM CAPSULE 40MG

30 capsules per 30 days

JORNAY PM CAPSULE 60MG

30 capsules per 30 days

JORNAY PM CAPSULE 80MG

30 capsules per 30 days

KAPVAY TABLET 0.1MG

120 tablets per 30 days

metadate er tablet 20mg

90 tablets per 30 days

methamphetamine hcl tablet 5 mg

150 tablets per 30 days

METHYLIN 10MG/5ML

900 mLs per 30 days

METHYLIN 5MG/5ML

450 mLs per 30 days

methylphenidate hydrochloride cd capsule 10mg

30 capsules per 30 days

methylphenidate hydrochloride cd capsule 20mg

30 capsules per 30 days

methylphenidate hydrochloride cd capsule 30mg

30 capsules per 30 days

methylphenidate hydrochloride cd capsule 40mg

30 capsules per 30 days

methylphenidate hydrochloride cd capsule 50mg

30 capsules per 30 days

methylphenidate hydrochloride cd capsule 60mg

30 capsules per 30 days

methylphenidate hydrochloride er (la) capsule 60mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 10mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 10mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 20mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 20mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 30mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 30mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 40mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 40mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 50mg

30 capsules per 30 days

methylphenidate hydrochloride er capsule 60mg

30 capsules per 30 days

methylphenidate hydrochloride er tablet 10mg

90 tablets per 30 days

METHYLPHENIDATE HYDROCHLORIDE ER TABLET 18MG

30 tablets per 30 days

methylphenidate hydrochloride er tablet 18mg

30 tablets per 30 days

methylphenidate hydrochloride er tablet 20mg

90 tablets per 30 days

methylphenidate hydrochloride er tablet 27mg

30 tablets per 30 days

methylphenidate hydrochloride er tablet 27mg

30 tablets per 30 days

methylphenidate hydrochloride er tablet 36mg

60 tablets per 30 days

methylphenidate hydrochloride er tablet 36mg

60 tablets per 30 days

methylphenidate hydrochloride er tablet 54mg

30 tablets per 30 days

methylphenidate hydrochloride er tablet 54mg

30 tablets per 30 days

METHYLPHENIDATE HYDROCHLORIDE ER TABLET 72MG

30 tablets per 30 days

methylphenidate hydrochloride soln 10mg/5ml

900 mLs per 30 days

methylphenidate hydrochloride soln 5mg/5ml

450 mLs per 30 days

methylphenidate hydrochloride tablet 10mg

180 tablets per 30 days

methylphenidate hydrochloride tablet 10mg

90 tablets per 30 days

methylphenidate hydrochloride tablet 2.5mg

90 tablets per 30 days

methylphenidate hydrochloride tablet 20mg

90 tablets per 30 days

methylphenidate hydrochloride tablet 5mg

90 tablets per 30 days

methylphenidate hydrochloride tablet 5mg

90 tablets per 30 days

MYDAYIS CAPSULE 12.MG

30 capsules per 30 days

MYDAYIS CAPSULE 25MG

30 capsules per 30 days

MYDAYIS CAPSULE 37.MG

30 capsules per 30 days

MYDAYIS CAPSULE 50MG

30 capsules per 30 days

procentra soln 5mg/5ml

1800 mLs per 30 days

QUILLICHEW ER TABLET 20MG

30 tablets per 30 days

QUILLICHEW ER TABLET 30MG

60 tablets per 30 days

QUILLICHEW ER TABLET 40MG

30 tablets per 30 days

QUILLIVANT XR SUSP 25 MG/5ML

360 mLs per 30 days

RELEXXII TABLET 72MG

30 tablets per 30 days

RITALIN LA CAPSULE 10MG

30 capsules per 30 days

RITALIN LA CAPSULE 20MG

30 capsules per 30 days

RITALIN LA CAPSULE 30MG

30 capsules per 30 days

RITALIN LA CAPSULE 40MG

30 capsules per 30 days

RITALIN TABLET 10MG

90 tablets per 30 days

RITALIN TABLET 20MG

90 tablets per 30 days

RITALIN TABLET 5MG

90 tablets per 30 days

STRATTERA CAPSULE 100MG

30 capsules per 30 days

STRATTERA CAPSULE 10MG

60 capsules per 30 days

STRATTERA CAPSULE 18MG

60 capsules per 30 days

STRATTERA CAPSULE 25MG

60 capsules per 30 days

STRATTERA CAPSULE 40MG

60 capsules per 30 days

STRATTERA CAPSULE 60MG

30 capsules per 30 days

STRATTERA CAPSULE 80MG

30 capsules per 30 days

VYVANSE CAPSULE 10MG

30 capsules per 30 days

VYVANSE CAPSULE 20MG

30 capsules per 30 days

VYVANSE CAPSULE 30MG

30 capsules per 30 days

VYVANSE CAPSULE 40MG

30 capsules per 30 days

VYVANSE CAPSULE 50MG

30 capsules per 30 days

VYVANSE CAPSULE 60MG

30 capsules per 30 days

VYVANSE CAPSULE 70MG

30 capsules per 30 days

VYVANSE TABLET 10MG

30 tablets per 30 days

VYVANSE TABLET 20MG

30 tablets per 30 days

VYVANSE TABLET 30MG

30 tablets per 30 days

VYVANSE TABLET 40MG

30 tablets per 30 days

VYVANSE TABLET 50MG

30 tablets per 30 days

VYVANSE TABLET 60MG

30 tablets per 30 days

zenzedi tablet 10mg

180 tablets per 30 days

ZENZEDI TABLET 15MG

90 tablets per 30 days

ZENZEDI TABLET 2.5MG

90 tablets per 30 days

ZENZEDI TABLET 20MG

90 tablets per 30 days

ZENZEDI TABLET 30MG

60 tablets per 30 days

zenzedi tablet 5mg

90 tablets per 30 days

ZENZEDI TABLET 7.5MG

90 tablets per 30 days

ATTR Amyloidosis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

TEGSEDI INJECTION 284/1.5 1,2

6 syringes/28 days

Atypical Antipsychotics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CAPLYTA 42 MG CAPSULE

30 capsules/30 days

INVEGA TABLET 1.5MG

30 tablets/30 days

INVEGA TABLET 3MG

30 tablets/30 days

INVEGA TABLET 6MG

30 tablets/30 days

INVEGA TABLET 9MG

30 tablets/30 days

olanzapine tablet 2.5mg

30 tablets/30 days

olanzapine tablet 5mg

30 tablets/30 days

olanzapine tablet 5mg odt

30 tablets/30 days

olanzapine tablet 7.5mg

30 tablets/30 days

olanzapine tablet 10mg

30 tablets/30 days

olanzapine tablet 10mg odt

30 tablets/30 days

olanzapine tablet 15mg

30 tablets/30 days

olanzapine tablet 15mg odt

30 tablets/30 days

olanzapine tablet 20mg

30 tablets/30 days

olanzapine tablet 20mg odt

30 tablets/30 days

paliperidone tablet er 1.5mg

30 tablets/30 days

paliperidone tablet er 3mg

30 tablets/30 days

paliperidone tablet er 6mg

30 tablets/30 days

paliperidone tablet er 9mg

30 tablets/30 days

quetiapine tablet 50mg er

30 tablets/30 days

quetiapine tablet 150mg er

30 tablets/30 days

quetiapine tablet 200mg er

30 tablets/30 days

quetiapine tablet 300mg er

30 tablets/30 days

quetiapine tablet 400mg er

30 tablets/30 days

SEROQUEL XR TABLET 50MG

30 tablets/30 days

SEROQUEL XR TABLET 150MG

30 tablets/30 days

SEROQUEL XR TABLET 200MG

30 tablets/30 days

SEROQUEL XR TABLET 300MG

30 tablets/30 days

SEROQUEL XR TABLET 400MG

30 tablets/30 days

ZYPREXA TABLET 2.5MG

30 tablets/30 days

ZYPREXA TABLET 5MG

30 tablets/30 days

ZYPREXA TABLET 7.5MG

30 tablets/30 days

ZYPREXA TABLET 10MG

30 tablets/30 days

ZYPREXA TABLET 15MG

30 tablets/30 days

ZYPREXA TABLET 20MG

30 tablets/30 days

ZYPREXA ZYDI TABLET 5MG

30 tablets/30 days

ZYPREXA ZYDI TABLET 10MG

30 tablets/30 days

ZYPREXA ZYDI TABLET 15MG

30 tablets/30 days

ZYPREXA ZYDI TABLET 20MG

10 tablets/30 days

Baclofen

Drug name(s)

Quantity limits (per 30 days or as specified)

OZOBAX SOLN 5MG/5ML

2400 mLs / 30 days

Bempedoic Acid

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NEXLETOL TABLET 180MG

30 tablets/30 days

Benlysta

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BENLYSTA INJECTION 200MG/ML1

3 syringes/28 days

Biologic Immunomodulators

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTEMRA INJECTION 162/0.91

3 syringes/28 days

CIMZIA PREFL KIT 200MG/ML1

3 kit/28 days

COSENTYX INJECTION 150MG/ML1

3 syringe/28 days

COSENTYX INJECTION 300DOSE1

3 pack/28 days

COSENTYX PEN INJECTION 150MG/ML1

3 injection device/28 days

COSENTYX PEN INJECTION 300DOSE1

3 pack/28 days

ENBREL INJECTION 25/0.5ML1

3 syringes/28 days

ENBREL INJECTION 25MG1

3 vials/28 days

ENBREL INJECTION 50MG/ML1

3 syringes/28 days

ENBREL MINI INJECTION 50MG/ML1

3 cartridges/28 days

ENBREL SRCLK INJECTION 50MG/ML1

3 syringes/28 days

HUMIRA INJECTION 10/0.1ML1

3 syringes/28 days

HUMIRA INJECTION 10MG/0.21

3 syringes/28 days

HUMIRA INJECTION 20/0.2ML1

3 syringes/28 days

HUMIRA INJECTION 40/0.4ML1

3 syringes/28 days

HUMIRA KIT 20MG/0.41

3 syringes/28 days

HUMIRA KIT 40MG/0.81

3 syringes/28 days

HUMIRA PEDIA INJECTION CROHNS1

3 kit/180 days

HUMIRA PEDIA INJECTION CROHNS1

3 kit/180 days

HUMIRA PEN INJECTION 40/0.4ML1

3 pens/28 days

HUMIRA PEN INJECTION 40MG/0.81

3 pens/28 days

HUMIRA PEN INJECTION CD/UC/HS1

3 kit/180 days

HUMIRA PEN INJECTION PS/UV1

3 kit/180 days

HUMIRA PEN KIT CD/UC/HS1

3 kit/180 days

HUMIRA PEN KIT PS/UV1

3 kit/180 days

KEVZARA INJECTION 150/1.141

3 pens/28 days

KEVZARA INJECTION 150/1.141

3 syringes/28 days

KEVZARA INJECTION 200/1.141

3 pens/28 days

KEVZARA INJECTION 200/1.141

3 syringes/28 days

KINERET INJECTION 1,2

30 syringes/30 days

OLUMIANT TABLET 1MG1

30 tablets/30 days

OLUMIANT TABLET 2MG1

30 tablets/30 days

ORENCIA CLCK INJECTION 125MG/ML1

3 syringes/28 days

ORENCIA IINJECTIONNJ 125MG/ML1

3 syringes/28 days

ORENCIA INJECTION 50/0.41

3 syringes/28 days

ORENCIA INJECTION 87.5/0.71

3 syringes/28 days

RINVOQ TABLET 15MG ER1

30 tablets/30 days

SILIQ ININJECTIONJ 210/1.51

3 syringes/28 days

SIMPONI INJECTION 100MG/ML1

3 syringe/28 days

SIMPONI INJECTION 50/0.5ML1

3 syringe/28 days

SKYRIZI INJECTION 150DOSE1

3 box/84 days

STELARA INJECTION 45MG/0.51

3 syringe/84 days

STELARA INJECTION 90MG/ML1

3 syringe/56 days

TALTZ INJECTION 80MG/ML1

3 mLs/28 days

TREMFYA INJECTION 100MG/ML1

3 pen/56 days

TREMFYA INJECTION 100MG/ML1

3 syringe/56 days

XELJANZ TABLET 5MG1

30 tablets/30 days

XELJANZ TABLET 10MG1

30 tablets/30 days

XELJANZ XR TABLET 11MG1

30 tablets/30 days

XELJANZ XR TABLET 22MG1

312 tablets/365 days

Bisphosphonates

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTONEL TABLET 35MG

3 tablets/28 days

ACTONEL TABLET 150MG

3 Tablet/28 days

alendronate tablet 35mg

3 tablets/28 days

alendronate tablet 70mg

3 capsules/28 days

ATELVIA 35 MG TABLET

3 tablets/28 days

BINOSTO TABLET 70MG

3 tablets/28 days

BONIVA TABLET 150MG

3 Tablet/30 days

FOSAMAX + D TABLET 70-2800

3 capsules/28 days

FOSAMAX + D TABLET 70-5600

3 capsules/28 days

FOSAMAX TABLET 70MG

3 capsules/28 days

ibandronate tablet 150mg

3 Tablet/30 days

risedronate tablet 35mg

3 tablets/28 days

risedronate tablet 35mg dr

3 tablets/28 days

risedronate tablet 150mg

1 Tablet/28 days

Bonjesta Diclegis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

doxylamine/pyridoxine  tab 10-10mg

N/A

Buprenorphine Opioid Dependence

Drug name(s)

Quantity limits (per 30 days or as specified)

BUNAVAIL MIS 2.1-0.3

90 films/30 days

BUNAVAIL MIS 4.2-0.7

60 films/30 days

BUNAVAIL MIS 6.3-1MG

60 films/30 days

buprenorphine/naloxone mis 12-3mg

60 films/30 days

buprenorphine/naloxone mis 2-0.5mg

120 films/30 days

buprenorphine/naloxone mis 4-1mg

30 films/30 days

buprenorphine/naloxone mis 8-2mg

60 films/30 days

buprenorphine/naloxone sub 2-0.5mg

120 tablets/30 days

buprenorphine/naloxone sub 8-2mg

90 tablets/30 days

buprenorphine sub 2mg

15 tablets/90 days

buprenorphine sub 8mg

15 tablets/90 days

ZUBSOLV SUB 0.7-0.18

30 tablets/30 days

ZUBSOLV SUB 1.4-0.36

90 tablets/30 days

ZUBSOLV SUB 11.4-2.9

30 tablets/30 days

ZUBSOLV SUB 2.9-0.71

30 tablets/30 days

ZUBSOLV SUB 5.7-1.4

30 tablets/30 days

ZUBSOLV SUB 8.6-2.1

60 tablets/30 days

Circadian Rhythm Disorder

Drug name(s)

Quantity limits 
(per 30 days or as specified)

HETLIOZ CAPSULE 20MG 1,2,3

30 capsules/30 days

Combination NSAID

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CONSENSI 2.5 MG / 200 MG TABLET

30 tablets/30 days

CONSENSI 5 MG / 200 MG TABLET

31 tablets/30 days

CONSENSI 10 MG / 200 MG TABLET

32 tablets/30 days

DUEXIS TABLET 800-26.6

30 tablets/30 days

VIMOVO TABLET 375-20MG

30 tablets/30 days

VIMOVO TABLET 500-20MG

30 tablets/30 days

YOSPRALA, ASPRIN/OMEPRAZOLE 81 MG/40 MG TABLET

30 tablets/30 days

YOSPRALA, ASPRIN/OMEPRAZOLE 325 MG/40 MG TABLET

30 tablets/30 days

Constipation Agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMITIZA CAPSULE 8MCG

320 capsules/30 days

AMITIZA CAPSULE 24MCG

30 capsules/30 days

LINZESS CAPSULE 72MCG

30 capsules/30 days

LINZESS CAPSULE 145MCG

30 capsules/30 days

LINZESS CAPSULE 290MCG

30 capsules/30 days

MOTEGRITY TABLET 1MG

30 tablets/30 days

MOTEGRITY TALET 2MG

30 tablets/30 days

MOVANTIK TABLET 12.5MG

30 tablets/30 days

MOVANTIK TABLET 25MG

30 tablets/30 days

RELISTOR INJECTION 8/0.4ML

30 syringes/30 days

RELISTOR INJECTION 12/0.6ML

30 vials/30 days

RELISTOR INJECTION 12/0.6ML

30 syringes/30 days

RELISTOR TABLET 150MG

30 tablets/30 days

SYMPROIC TABLET 0.2MG

30 tablets/30 days

TRULANCE TABLET 3MG

30 tablets/30 days

ZELNORM TABLET 6MG

10 tablets/30 days

Continuous Glucose Monitor (CGM)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FREESTYLE LIBRE KIT 2 SENSOR

3 Sensors/28 days

FREESTYLE LIBRE MIS 2 READER

3 Reader/365 days

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

KALYDECO PACK 25MG1

30 packets/30 days

KALYDECO PACK 50MG1

30 packets/30 days

KALYDECO PACK 75MG1

30 packets/30 days

KALYDECO TABLET 150MG1

30 tablets/30 days

ORKAMBI TABLET 100-1251

320 tablets/30 days

ORKAMBI TABLET 200-1251

320 tablets/30 days

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

Drug name(s)

Quantity limits (per 30 days or as specified)

JANUMET TABLET 50-1000

60 tablets/30 days

JANUMET TABLET 50-500MG

60 tablets/30 days

JANUMET XR TABLET 100-1000

30 tablets/30 days

JANUMET XR TABLET 50-1000

60 tablets/30 days

JANUMET XR TABLET 50-500MG

30 tablets/30 days

JANUVIA TABLET 100MG

30 tablets/30 days

JANUVIA TABLET 25MG

30 tablets/30 days

JANUVIA TABLET 50MG

30 tablets/30 days

QTERN TABLET 10MG/5MG

30 tablets/30 days

QTERN TABLET 5-5MG

30 tablets/30 days

TRIJARDY XR TABLET

60 tablets/30 days

TRIJARDY XR TABLET

30 tablets/30 days

Endocrine and Metabolic Agents: Egrifta

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EGRIFTA SOLUTION 1MG1

30 vials/30 days

EGRIFTA SV INJECTION 2MG1

30 vials/30 days

Endocrine and Metabolic Agents: Emflaza

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EMFLAZA TABLET 6MG 1,2

30 tablets/30 days

EMFLAZA TABLET 18MG 1,2

30 tablets/30 days

Endocrine and Metabolic Agents: Galafold

Drug name(s)

Quantity limits 
(per 30 days or as specified)

GALAFOLD CAPSULE 123MG1

34 capsules/28 days

Fibromyalgia

Drug name(s)

Quantity limits 
(per 30 days or as specified)

LYRICA CAPSULE 25MG

30 capsules/30 days

LYRICA CAPSULE 50MG

30 capsules/30 days

LYRICA CAPSULE 75MG

30 capsules/30 days

LYRICA CAPSULE 100MG

30 capsules/30 days

LYRICA CAPSULE 150MG

30 capsules/30 days

LYRICA CAPSULE 200MG

30 capsules/30 days

LYRICA CAPSULE 225MG

30 capsules/30 days

LYRICA CAPSULE 300MG

30 capsules/30 days

LYRICA SOLUTION 20MG/ML

300 mLs/30 days

pregabalin capsule 25mg

30 capsules/30 days

pregabalin capsule 50mg

30 capsules/30 days

pregabalin capsule 75mg

30 capsules/30 days

pregabalin capsule 100mg

30 capsules/30 days

pregabalin capsule 150mg

30 capsules/30 days

pregabalin capsule 200mg

30 capsules/30 days

pregabalin capsule 225mg

30 capsules/30 days

pregabalin capsule 300mg

30 capsules/30 days

pregabalin solution 20mg/ml

300 mLs/30 days

SAVELLA MIS TITR PACK

3 kit/180 days

SAVELLA TABLET 12.5MG

30 tablets/30 days

SAVELLA TABLET 25MG

30 tablets/30 days

SAVELLA TABLET 50MG

30 tablets/30 days

SAVELLA TABLET 100MG

30 tablets/30 days

Fintepla

Drug name(s)

Quantity limits (per 30 days or as specified)

FINTEPLA SOLUTION 2.2MG/ML

360 mLs/30 days

Gabapentin ER

Drug name(s)

Quantity limits (per 30 days or as specified)

GRALISE TABLET 300MG

30 tablets/30 days

GRALISE TABLET 600MG

90 tablets/30 days

 

GRALISE STARTER MIS 300/600

1 pack/180 days

HORIZANT TABLET 300MG ER

60 tablets/30 days

HORIZANT TABLET 600MG ER

60 tablets/30 days

Galafold

Drug name(s)

Quantity limits (per 30 days or as specified)

GALAFOLD CAPSULE 123MG

14 capsules/28 days

Glucagon-like Peptide-1 (GLP-1)

Drug name(s)

Quantity limits (per 30 days or as specified)

BYDUREON BC INJECTION 2/0.85ML

4 pens/28 days

BYDUREON PEN INJECTION 2MG

4 pens/28 days

OZEMPIC INJECTION 2/1.5ML

1 pen/28 days

OZEMPIC INJECTION 2/1.5ML

2 pens/28 days

RYBELSUS TABLET 14MG

30 tablets/30 days

RYBELSUS TABLET 3MG

30 tablets/180 days

RYBELSUS TABLET 7MG

30 tablets/30 days

TRULICITY INJECTION

2 pens/28 days

TRULICITY INJECTION 0.75/0.5

4 pens/28 days

TRULICITY INJECTION 1.5/0.5

4 pens/28 days

VICTOZA INJECTION 18MG/3ML

3 pens/30 days

Gonadotropin Hormones

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CETROTIDE KIT 0.25MG1

3 kits/30 days

chorionic gonadotropin injection 10000unt1

3 vials/30 days

GANIRELIX AC INJECTION 250/0.51

3 syringes/30 days

NOVAREL INJECTION 10000UNT1

3 vials/30 days

NOVAREL INJECTION 5000UNIT1

3 vials/30 days

PREGNYL INJECTION 10000UNT1

3 vials/30 days

Hemlibra

Drug name(s)

Quantity limits 
(per 30 days or as specified)

HEMLIBRA INJECTION 30MG/ML1

3 vials/28 days

HEMLIBRA INJECTION 60/0.41

3 vials/28 days

HEMLIBRA INJECTION 105/0.71

3 vials/28 days

HEMLIBRA INJECTION 150/ML1

3 vials/28 days

Hepatitis B Hepatitis C

Drug name(s)

Quantity limits (per 30 days or as specified)

EPCLUSA TABLET 400-100

30 tablets/30 days

HARVONI PACK

30 packets/30 days

HARVONI PACK 45-200MG

30 packets/30 days

HARVONI TABLET 45-200MG

30 tablets/30 days

HARVONI TABLET 90-400MG

30 tablets/30 days

MAVYRET TABLET 100-40MG

90 tablets/30 days

 

SOVALDI PACK 150MG

30 packets/30 days

SOVALDI PACK 200MG

30 packets/30 days

SOVALDI TABLET 200MG

30 tablets/30 days

SOVALDI TABLET 400MG

30 tablets/30 days

VOSEVI TABLET

30 tablets/30 days

Hereditary Angioedema Agents (HAE)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BERINERT 500 UNITS/10 ML

30 vials/30 days

CINRYZE 500 UNITS/10ML

30 vials/30 days

FIRAZYR INJECTION 30MG/3ML1

3 syringes/30 days

HAEGARDA INJECTION 2000UNIT 1,2

34 vials/30 days

HAEGARDA INJECTION 3000UNIT 1,2

36 vials/30 days

icatibant injection 30mg/3ml1

3 syringes/30 days

KALBITOR 3-10 MG/ML SINGLE

32 vials/30 days

RUCONEST 2100 UNIT SINGLE USE

3 vials/28 days

TAKHZYRO INJECTION 300/2ML 1,2

3 vials/28 days

Homozygous Familial Hypercholesterolemia (HoFH) Agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

JUXTAPID CAPSULE 5MG 1,2

30 capsules/30 days

JUXTAPID CAPSULE 10MG 1,2

30 capsules/30 days

JUXTAPID CAPSULE 20MG 1,2

30 capsules/30 days

JUXTAPID CAPSULE 30MG 1,2

30 capsules/30 days

JUXTAPID CAPSULE 40MG 1,2

30 capsules/30 days

JUXTAPID CAPSULE 60MG 1,2

30 capsules/30 days

KYNAMRO INJECTION 200MG/ML1

3 injections/28 days

Hyperhidrosis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

QBREXZA PAD 2.4%

30 Pads/30 days

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

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CORLANOR SOLUTION 5MG/5ML

300 mLs/30 days

CORLANOR TABLET 5MG

30 tablets/30 days

CORLANOR TABLET 7.5MG

30 tablets/30 days

Idiopathic Pulmonary Fibrosis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ESBRIET CAPSULE 267MG1

380 capsules/30 days

ESBRIET TABLET 267MG1

380 tablets/30 days

ESBRIET TABLET 801MG1

30 tablets/30 days

OFEV CAPSULE 100MG1,3

30 capsules/30 days

OFEV CAPSULE 150MG1,3

30 capsules/30 days

Insomnia

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMBIEN CR TABLET 12.5MG

30 tablets/30 days

AMBIEN CR TABLET 6.25MG

30 tablets/30 days

AMBIEN TABLET 10MG

30 tablets/30 days

AMBIEN 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

BELSOMRA TABLET 5MG

30 tablets/30 days

DAYVIGO 5 MG TABLET

30 tablets/30 days

DAYVIGO 10 MG TABLET

30 tablets/30 days

doxepin tablet 3mg

30 tablets/30 days

doxepin tablet 6mg

30 tablets/30 days

EDLUAR SUBLINGUAL 10MG

30 tablets/30 days

EDLUAR SUBLINGUAL 5MG

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

INTERMEZZO SUBLINGUAL 1.75MG

30 tablets/30 days

INTERMEZZO SUBLINGUAL 3.5MG

30 tablets/30 days

LUNESTA TABLET 1MG

30 tablets/30 days

LUNESTA TABLET 2MG

30 tablets/30 days

LUNESTA TABLET 3MG

30 tablets/30 days

ramelteon tablet 8mg

30 tablets/30 days

ROZEREM TABLET 8MG

30 tablets/30 days

SILENOR TABLET 3MG

30 tablets/30 days

SILENOR TABLET 6MG

30 tablets/30 days

SONATA CAPSULE 10MG

30 capsules/30 days

SONATA CAPSULE 5MG

30 capsules/30 days

zaleplon capsule 10mg

30 capsules/30 days

zaleplon capsule 5mg

30 capsules/30 days

zolpidem er tablet 12.5mg

30 tablets/30 days

zolpidem er tablet 6.25mg

30 tablets/30 days

zolpidem tablet 10mg

30 tablets/30 days

zolpidem tablet 5mg

30 tablets/30 days

zolpidem tartrate sublingual 1.75mg

30 tablets/30 days

zolpidem tartrate sublingual 3.5mg

30 tablets/30 days

ZOLPIMIST SPRAY 5MG

3 Canister/30 days

Insulin

Drug name(s)

Quantity limits (per 30 days or as specified)

FIASP INJECTION 100/ML

100 mLs/30 days

FIASP FLEX INJECTION TOUCH

100 mLs/30 days

FIASP PENFIL INJECTION U-100

100 mLs/30 days

HUMULIN R INJECTION U-500

100 mLs/30 days

LANTUS INJECTION 100/ML

100 mLs/30 days

LANTUS SOLOS INJECTION 100/ML

100 mLs/30 days

LEVEMIR INJECTION

100 mLs/30 days

LEVEMIR INJECTION FLEXTOUC

100 mLs/30 days

NOVOLIN INJECTION 70/30

100 mLs/30 days

NOVOLIN INJECTION 70/30 FP

100 mLs/30 days

NOVOLIN N INJECTION 100 UNIT

100 mLs/30 days

NOVOLIN N INJECTION RELION

100 mLs/30 days

NOVOLIN N NOVOLIN N INJECTION U-100

100 mLs/30 days

NOVOLIN R INJECTION 100 UNIT

100 mLs/30 days

NOVOLIN R INJECTION RELION

100 mLs/30 days

NOVOLIN R INJECTION U-100

100 mLs/30 days

NOVOLIN70/30 INJECTION RELION

100 mLs/30 days

NOVOLOG INJECTION 100/ML

100 mLs/30 days

NOVOLOG INJECTION FLEXPEN

100 mLs/30 days

NOVOLOG INJECTION PENFILL

100 mLs/30 days

NOVOLOG MIX INJECTION 70/30

100 mLs/30 days

NOVOLOG MIXINJECTION FLEXPEN

100 mLs/30 days

TOUJEO MAX INJECTION 300IU/ML

100 mLs/30 days

TOUJEO SOLO INJECTION 300IU/ML

100 mLs/30 days

TRESIBA INJECTION 100UNIT

100 mLs/30 days

TRESIBA FLEX INJECTION 100UNIT

100 mLs/30 days

TRESIBA FLEX INJECTION 200UNIT

100 mLs/30 days

SOLIQUA INJECTION 100/33

5 pens/30 days

XULTOPHY INJECTION 100/3.6

5 pens/30 days

Interleukin (IL)-1 Inhibitor

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ARCALYST INJECTION 220MG 1,2

3 vials/28 days

ILARIS 150 MG/ML

3 vials/28 days

Interleukin (IL)-4 Inhibitors

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DUPIXENT INJECTION 200/1.141

3 syringes/28 days

DUPIXENT INJECTION 300/2ML1

1 syringes/28 days

Irritable Bowel Syndrome w/Diarrhea (IBS-D)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

alosetron tablet 0.5mg

30 tablets/30 days

alosetron tablet 1mg

30 tablets/30 days

LOTRONEX TABLET 0.5MG

30 tablets/30 days

LOTRONEX TABLET 1MG

30 tablets/30 days

VIBERZI TABLET 75MG

30 tablets/30 days

VIBERZI TABLET 100MG

30 tablets/30 days

XIFAXAN TABLET 200MG

3 tablets/30 days

XIFAXAN TABLET 550MG

10 tablets/30 days

Isturisa

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ISTURISA TABLET 10MG

180 tablets/30 days

ISTURISA TABLET 1MG

240 tablets/30 days

ISTURISA TABLET 5MG

300 tablets/30 days

Jynarque

Drug name(s)

Quantity limits 
(per 30 days or as specified)

JYNARQUE PACK 30-15MG

36 tablets/28 days

JYNARQUE TABLET 15MG

36 tablets/28 days

SAMSCA TABLET 15MG1

30 tablets/365 days

SAMSCA TABLET 30MG1

30 tablets/365 days

Keveyis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

KEVEYIS TABLET 50MG 1,2

320 tablets/30 days

Korlym

Drug name(s)

Quantity limits 
(per 30 days or as specified)

KORLYM TABLET 300MG 1,2

120 tablets/30 days

Lidocaine Transdermal

Drug name(s)

Quantity limits 
(per 30 days or as specified)

lido/prilocaine cream 2.5-2.5%

30 grams/30 days

LIDOCAINE CREAM TETRACAI

320 grams/30 days

lidocaine ointment 5%

300 grams/30 days

lidocaine ointment pack 5%

300 grams/30 days

lidocaine solution 4%

300 grams/30 days

lidocaine-pr cream

30 grams/30 days

PLIAGLIS CREAM 7-7%

320 grams/30 days

SYNERA DIS 70-70MG

3 patches/30 days

Lyrica CR

Drug name(s)

Quantity limits 
(per 30 days or as specified)

LYRICA CR TABLET 82.5MG

30 tablets/30 days

LYRICA CR TABLET 165MG

30 tablets/30 days

LYRICA CR TABLET 330MG

30 tablets/30 days

Metformin ER

Drug name(s)

Quantity limits (per 30 days or as specified)

metformin tablet 500mg er

120 tablets/30 days

metformin tablet 500mg er

120 tablets/30 days

metformin tablet 750mg er

60 tablets/30 days

metformin tablet 750mg er

60 tablets/30 days

metformin tablet 500mg er

90 tablets/30 days

metformin tablet 500mg er

90 tablets/30 days

metformin er tablet 1000mg

60 tablets/30 days

metformin er tablet 1000mg

60 tablets/30 days

metformin tablet 1000 er

60 tablets/30 days

metformin tablet 1000 er

60 tablets/30 days

RIOMET ER SUS 500/5ML

960 mLs/30 days

Muscle Relaxants

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMRIX CAPSULE 15MG

31 capsules/30 days

AMRIX CAPSULE 30MG

31 capsules/30 days

BACLOFEN TABLET 5MG

320 tablets/30 days

baclofen tablet 10mg

320 tablets/30 days

baclofen tablet 20mg

320 tablets/30 days

carisoprodol/aspirin tablet 200-325

368 tablets/90 days

carisoprodol tablet 250mg

38 tablets/30 days

carisoprodol tablet 350mg

38 tablets/30 days

carisoprodol tablet aspirin/codeine

368 tablets/90 days

CARISOPRODOL TABLET ASPIRINE/CODEINE

368 tablets/30 days

chlorzoxazone tablet 250MG

38 tablets/30 days

chlorzoxazone tablet 375mg

34 tablets/90 days

chlorzoxazone tablet 500MG

38 tablets/30 days

chlorzoxazone tablet 750mg

34 tablets/90 days

cyclobenzaprine capsule 15mg er

31 capsules/30 days

cyclobenzaprine capsule 30mg er

31 capsules/30 days

cyclobenzaprine tablet 5mg

31 tablets/30 days

cyclobenzaprine tablet 7.5mg

31 tablets/30 days

cyclobenzaprine tablet 10mg

30 capsules/30 days

DANTRIUM CAPSULE 25MG

30 capsules/30 days

DANTRIUM CAPSULE 50MG

30 capsules/30 days

dantrolene capsule 25mg

30 capsules/30 days

dantrolene capsule 50mg

30 capsules/30 days

dantrolene capsule 100mg

30 capsules/30 days

FEXMID TABLET 7.5MG

31 tablets/30 days

LORZONE TABLET 375MG

38 tablets/30 days

lorzone tablet 375mg

34 tablets/90 days

lorzone tablet 750mg

34 tablets/90 days

metaxall tablet 800mg

38 tablets/30 days

METAXALONE TAB 400MG

36 tablets/30 days

metaxalone tablet 800mg

38 tablets/30 days

orphenadrine tablet 100mg cr

32 tablets/30 days

orphenadrine tablet 100mg er

32 tablets/30 days

ROBAXIN TABLET 500MG

30 tablets/30 days

ROBAXIN TABLET 750MG

34 tablets/30 days

SKELAXIN TABLET 800MG

38 tablets/30 days

SOMA TABLET 250MG

38 tablets/30 days

SOMA TABLET 350MG

38 tablets/30 days

tizanidine capsule 2mg

32 capsules/30 days

tizanidine capsule 4mg

32 capsules/30 days

tizanidine capsule 6mg

32 capsules/30 days

tizanidine tablet 2mg

32 capsules/30 days

tizanidine tablet 4mg

32 capsules/30 days

ZANAFLEX CAPSULE 2MG

32 capsules/30 days

ZANAFLEX CAPSULE 4MG

32 capsules/30 days

ZANAFLEX CAPSULE 6MG

32 capsules/30 days

ZANAFLEX TABLET 4MG

32 tablets/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 KIT 30MCG1

3 pack/28 days

AVONEX PEN KIT 30MCG1

3 pack/28 days

AVONEX PREFL KIT 30MCG1

3 kit/28 days

BETASERON INJECTION 0.3MG1

3 box/28 days

COPAXONE INJECTION 20MG/ML1

30 syringes/30 days

COPAXONE INJECTION 40MG/ML1

32 syringes/28 days

dimethyl fumarate cap 120mg dr

36 capsules/180 days

dimethyl fumarate cap 240mg dr

30 capsules/30 days

EXTAVIA INJECTION 0.3MG1

3 box/30 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

glatopa injection 20mg/ml 1

30 syringes/30 days

glatopa injection 40mg/ml 1

32 syringes/28 days

MAVENCLAD PACK 10MG(4)1

3 tablets/301 days

MAVENCLAD PACK 10MG(5)1

30 tablets/301 days

MAVENCLAD PACK 10MG(6)1

32 tablets/301 days

MAVENCLAD PACK 10MG(7)1

34 tablets/301 days

MAVENCLAD PACK 10MG(8)1

3 tablets/301 days

MAVENCLAD PACK 10MG(9)1

3 tablets/301 days

MAVENCLAD PACK 10MG(10)1

30 tablets/301 days

MAYZENT TABLET 0.25MG1

320 tablets/30 days

MAYZENT TABLET 2MG1

30 tablets/30 days

PLEGRIDY INJECTION1

3 syringes/28 days

PLEGRIDY INJECTION PEN1

3 pens/28 days

REBIF INJECTION 22/0.51

32 syringes/28 days

REBIF INJECTION 44/0.51

3 carton/28 days

REBIF REBIDO INJECTION 22/0.51

3 carton/28 days

REBIF REBIDO INJECTION 44/0.51

3 carton/28 days

REBIF REBIDO INJECTION TITRATN1

3 kit/180 days

REBIF TITRTN INJECTION PACK1

3 kit/180 days

TECFIDERA 120 MG CAPSULE3

36 capsules/28 days

TECFIDERA 240 MG CAPSULE3

30 capsules/30 days

ZEPOSIA 0.92 MG CAPSULE

30 capsules/30 days

ZEPOSIA CAPSULE STARTER KIT

37 capsules/180 days

ZEPOSIA 7 DAY CAPSULE STARTER PACK

3 capsules/180 days

Nasal Antiepileptics

Drug name(s)

Quantity limits (per 30 days or as specified)

VALTOCO SPRAY 5MG

5 boxes/30 days

VALTOCO SPRAY 10MG

5 boxes/30 days

VALTOCO LIQUID 15MG

5 boxes/30 days

VALTOCO LIQUID 20MG

5 boxes/30 days

NAYZILAM SPRAY 5MG

10 sprays/30 days

Nasal inhalers

Drug name(s)

Quantity limits (per 30 days or as specified)

azelastine/fluticasone spray 137-50

1 Bottle/30 days

azelastine spray 0.1%

2 bottles/30 days

azelastine spray 0.15%

2 bottles/30 days

BECONASE AQ SUS 0.042%

2 bottles/30 days

DYMISTA SPRAY 137-50

1 Bottle/30 days

FLUNISOLIDE SPRAY 0.025%

3 bottles/30 days

fluticasone spray 50mcg

1 Bottle/30 days

ipratropium spray 0.03%

2 bottles/30 days

ipratropium spray 0.06%

3 bottles/30 days

Mometasone spray 50mcg

2 bottles/30 days

olopatadine spray 0.6%

1 Bottle/30 days

OMNARIS SPRAY

1 Bottle/30 days

QNASL AEROSOL 80MCG

1 inhaler/30 days

QNASL CHILD SPRAY 40MCG

1 inhaler/30 days

XHANCE MIS 93MCG

2 bottles/30 days

ZETONNA AEROSOL 37MCG

1 inhaler/30 days

Natpara

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NATPARA INJECTION 25MCG1

3 kit/28 days

NATPARA INJECTION 50MCG1

3 kit/28 days

NATPARA INJECTION 75MCG1

3 kit/28 days

NATPARA INJECTION 100MCG1

3 kit/28 days

Neurotrophic Keratitis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

OXERVATE SOLUTION 20MCG/ML 1,2

36 vials/56 days

Nocturia

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NOCTIVA EMULSION 0.83/0.1

3 Bottle/30 days

NOCTIVA SPRAY 1.66/0.1

3 Bottle/30 days

NOCDURNA 27.7 MCG TABLET

30 tablets/30 days

NOCDURNA 55.3 MCG TABLET

31 tablets/30 days

Northera

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NORTHERA CAPSULE 100MG1

350 capsules/30 days

NORTHERA CAPSULE 200MG1

380 capsules/30 days

NORTHERA CAPSULE 300MG1

380 capsules/30 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

NUVIGIL TABLET 50MG

30 tablets/30 days

NUVIGIL TABLET 150MG

30 tablets/30 days

NUVIGIL TABLET 200MG

30 tablets/30 days

NUVIGIL TABLET 250MG

30 tablets/30 days

PROVIGIL TABLET 100MG

30 tablets/30 days

PROVIGIL TABLET 200MG

30 tablets/30 days

Ocaliva

Drug name(s)

Quantity limits 
(per 30 days or as specified)

OCALIVA TABLET 5MG1

30 tablets/30 days

OCALIVA TABLET 10MG1

30 tablets/30 days

Ophthalmic Immunomodulators

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CEQUA 0.9 MG/ML SOLUTION

30 vials/30 days

RESTASIS EMULSION 0.05%

3 vials/30 days

RESTASIS MUL EMULSION 0.05%

3 Bottle/30 days

XIIDRA DROP 5%

30 vials/30 days

Ophthalmic Prostaglandins

Drug name(s)

Quantity limits 
(per 30 days or as specified)

bimatoprost solution 0.03%

3.5 mLs/30 days

latanoprost solution 0.005%

3.5 mLs/30 days

LUMIGAN SOLUTION 0.01%

3.5 mLs/30 days

RESCULA SOLUTION 0.15%

3 Bottle/30 days

travoprost drop 0.004%

3.5 mLs/30 days

TRAVATAN Z DROP 0.004%

3.5 mLs/30 days

VYZULTA SOLUTION 0.024%

3 mLs/30 days

XALATAN SOLUTION 0.005%

3.5 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)

ARYMO ER TABLET 15MG

60 tablets/30 days

ARYMO ER TABLET 30MG

30 tablets/30 days

ARYMO ER TABLET 60MG

0

BELBUCA MIS 75MCG

60 films/30 days

BELBUCA MIS 150MCG

60 films/30 days

BELBUCA MIS 300MCG

60 films/30 days

BELBUCA MIS 450MCG

60 films/30 days

BELBUCA MIS 600MCG

60 films/30 days

BELBUCA MIS 750MCG

60 films/30 days

BELBUCA MIS 900MCG

30 films/30 days

buprenorphine dis 5mcg/hr

4 Systems/30 days

buprenorphine dis 10mcg/hr

4 Systems/30 days

buprenorphine dis 15mcg/hr

4 Systems/30 days

buprenorphine dis 20mcg/hr

4 Systems/30 days

buprenorphine dis 7.5/HR

4 Systems/30 days

BUTRANS DIS 5MCG/HR

4 Systems/30 days

BUTRANS DIS 7.5/HR

4 Systems/30 days

BUTRANS DIS 10MCG/HR

4 Systems/30 days

BUTRANS DIS 15MCG/HR

4 Systems/30 days

BUTRANS DIS 20MCG/HR

4 Systems/30 days

CONZIP CAPSULE 100MG

30 capsules/30 days

CONZIP CAPSULE 200MG

30 capsules/30 days

CONZIP CAPSULE 300MG

30 capsules/30 days

DURAGESIC DIS 12MCG/HR

10 patches/30 days

DURAGESIC DIS 25MCG/HR

0

DURAGESIC DIS 50MCG/HR

0

DURAGESIC DIS 75MCG/HR

0

DURAGESIC DIS 100MCG/HR

0

EMBEDA CAPSULE 20-0.8MG

30 capsules/30 days

EMBEDA CAPSULE 30-1.2MG

30 capsules/30 days

EMBEDA CAPSULE 50-2MG

30 capsules/30 days

EMBEDA CAPSULE 60-2.4MG

0

EMBEDA CAPSULE 80-3.2MG

0

EMBEDA CAPSULE 100-4MG

0

EXALGO TABLET 8MG

30 tablets/30 days

EXALGO TABLET 12MG

30 tablets/30 days

EXALGO TABLET 16MG

0

EXALGO TABLET 32MG

0

fentanyl dis 12mcg/hr

10 patches/30 days

fentanyl dis 25mcg/hr

0

fentanyl dis 37.5mcg/hr

0

fentanyl dis 50mcg/hr

0

fentanyl dis 62.5mcg/hr

0

fentanyl dis 75mcg/hr

0

fentanyl dis 87.5mcg/hr

0

fentanyl dis 100mcg/hr

0

hydrocodone capsule 10mg er

60 capsules/30 days

hydrocodone capsule 15mg er

60 capsules/30 days

hydrocodone capsule 20mg er

60 capsules/30 days

hydrocodone capsule 30mg er

30 capsules/30 days

hydrocodone capsule 40mg er

30 capsules/30 days

hydrocodone capsule 50mg er

30 capsules/30 days

hydromorphone tablet 8mg er

30 tablets/30 days

hydromorphone tablet 12mg er

30 tablets/30 days

hydromorphone tablet 16mg er

0

hydromorphone tablet 32mg er

0

HYSINGLA ER TABLET 20 MG

30 tablets/30 days

HYSINGLA ER TABLET 30 MG

30 tablets/30 days

HYSINGLA ER TABLET 40 MG

30 tablets/30 days

HYSINGLA ER TABLET 60 MG

0

HYSINGLA ER TABLET 80 MG

0

HYSINGLA ER TABLET 100 MG

0

HYSINGLA ER TABLET 120 MG

0

KADIAN CAPSULE 10MG ER

30 capsules/30 days

KADIAN CAPSULE 20MG ER

30 capsules/30 days

KADIAN CAPSULE 30MG ER

30 capsules/30 days

KADIAN CAPSULE 40MG ER

30 capsules/30 days

KADIAN CAPSULE 50MG ER

30 capsules/30 days

KADIAN CAPSULE 60MG ER

0

KADIAN CAPSULE 80MG ER

0

KADIAN CAPSULE 100MG ER

0

KADIAN CAPSULE 200MG ER

0

MORPHABOND TABLET 15MG ER

60 tablets/30 days

MORPHABOND TABLET 30MG ER

30 tablets/30 days

MORPHABOND TABLET 60MG ER

0

MORPHABOND TABLET 100MG ER

0

morphine sulfate tablet 15mg

15 tablets/30 days

morphine sulfate tablet 30mg

5 tablets/30 days

morphine sulfate capsule 10mg er

30 capsules/30 days

morphine sulfate capsule 20mg er

30 capsules/30 days

morphine sulfate capsule 30mg er

30 capsules/30 days

morphine sulfate capsule 40mg er

30 capsules/30 days

morphine sulfate capsule 50mg er

30 capsules/30 days

morphine sulfate capsule 60mg er

0

morphine sulfate capsule 80mg er

0

morphine sulfate capsule 100mg er

0

MORPHINE SULFATE CAPSULE 30MG ER

30 capsules/30 days

MORPHINESULFATE CAPSULE 45MG ER

30 capsules/30 days

MORPHINE SULFATE CAPSULE 60MG ER

0

MORPHINE SULFATE CAPSULE 75MG ER

0

MORPHINE SULFATE CAPSULE 90MG ER

0

MORPHINE SULFATE CAPSULE 120MG ER

0

morphine sulfate tablet 100mg cr

0

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

MS CONTIN TABLET 15MG ER

60 tablets/30 days

MS CONTIN TABLET 30MG ER

30 tablets/30 days

MS CONTIN TABLET 60MG ER

0

MS CONTIN TABLET 100MG ER

0

MS CONTIN 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

OPANA ER TABLET 5MG

60 tablets/30 days

OPANA ER TABLET 7.5MG

60 tablets/30 days

OPANA ER TABLET 10MG

30 tablets/30 days

OPANA ER TABLET 15MG

30 tablets/30 days

OPANA ER TABLET 20MG

0

OPANA ER TABLET 30MG

0

OPANA ER TABLET 40MG

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

0

OXYMORPHONE TABLET 30MG ER

0

OXYMORPHONE TABLET 40MG ER

0

TRAMADOL HCL CAPSULE 150MG ER

30 capsules/30 days

TRAMADOL HCL CAPSULE ER 100MG

30 capsules/30 days

TRAMADOL HCL CAPSULE ER 200MG

30 capsules/30 days

TRAMADOL HCL CAPSULE ER 300MG

30 capsules/30 days

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

XTAMPZA ER CAPSULE 9MG

60 capsules/30 days

XTAMPZA ER CAPSULE 13.5MG

60 capsules/30 days

XTAMPZA ER CAPSULE 18MG

30 capsules/30 days

XTAMPZA ER CAPSULE 27MG

30 capsules/30 days

XTAMPZA ER CAPSULE 36MG

0

ZOHYDRO ER CAPSULE 10MG

60 capsules/30 days

ZOHYDRO ER CAPSULE 15MG

60 capsules/30 days

ZOHYDRO ER CAPSULE 20MG

60 capsules/30 days

ZOHYDRO ER CAPSULE 30MG

30 capsules/30 days

ZOHYDRO ER CAPSULE 40MG

30 capsules/30 days

ZOHYDRO ER CAPSULE 50MG

30 capsules/30 days

Opioids Immediate Release (IR)

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

acetaminophen w/ codeine soln 120-12 mg/5ml

450 mLs/30 days

270 mL/30 days

acetaminophen w/ codeine tab 300-15 mg

30 tablets/30 days

N/A

acetaminophen w/ codeine tab 300-30 mg

30 tablets/30 days

N/A

acetaminophen w/ codeine tab 300-60 mg

25 tablets/30 days

N/A

acetaminophen-caffeine-dihydrocodeine tab 325-30-16 mg

50 capsules/30 days

30 capsules/30 days

butorphanol tartrate nasal soln 10 mg/ml

1 Bottle/30 days

0 mL/30 days

codeine sulfate tab 30 mg

30 tablets/30 days

18 tablets/30 days

codeine sulfate tab 60 mg

25 tablets/30 days

15 tablets/30 days

hydrocodone-acetaminophen soln 7.5-325 mg/15ml

450 mLs/30 days

270 mLs/30 days

hydrocodone-acetaminophen tab 10-300 mg

25 tablets/30 days

15 tablets/30 days

hydrocodone-acetaminophen tab 10-325 mg

25 tablets/30 days

15 tablets/30 days

hydrocodone-acetaminophen tab 5-300 mg

40 tablets/30 days

24 tablets/30 days

hydrocodone-acetaminophen tab 5-325 mg

40 tablets/30 days

24 tablets/30 days

hydrocodone-acetaminophen tab 7.5-300 mg

30 tablets/30 days

18 tablets/30 days

hydrocodone-acetaminophen tab 7.5-325 mg

30 tablets/30 days

18 tablets/30 days

hydrocodone-ibuprofen tab 10-200 mg

25 tablets/30 days

15 tablets/30 days

hydrocodone-ibuprofen tab 5-200 mg

25 tablets/30 days

15 tablets/30 days

hydrocodone-ibuprofen tab 7.5-200 mg

25 tablets/30 days

15 tablets/30 days

hydromorphone hcl liquid 1 mg/ml

60 mLs/30 days

36 mL/30 days

HYDROMORPHONE HCL SUPPOS 3 MG

20 Suppositories/30 days

N/A

hydromorphone hcl tab 2 mg

30 tablets/30 days

18 tablets/30 days

hydromorphone hcl tab 4 mg

15 tablets/30 days

9 tablets/30 days

hydromorphone hcl tab 8 mg

5 tablets/30 days

3 tablets/30 days

levorphanol tartrate tab 2 mg

10 tablets/30 days

6 tablets/30 days

meperidine hcl tab 100 mg

15 tablets/30 days

15 tablets/30 days

meperidine hcl tab 50 mg

30 tablets/30 days

30 tablets/30 days

methadone hcl soln 10 mg/5ml

125 mLs/30 days

N/A

methadone hcl soln 5 mg/5ml

10 mLs/30 days

N/A

methadone hcl tab 10 mg

30 tablets/30 days

N/A

methadone hcl tab 5 mg

60 tablets/30 days

N/A

morphine sulfate oral soln 10 mg/5ml

125 mLs/30 days

75 mLs/30 days

morphine sulfate oral soln 100 mg/5ml (20 mg/ml)

10 mLs/30 days

N/A

morphine sulfate oral soln 20 mg/5ml

60 mLs/30 days

36 mLs/30 days

MORPHINE SULFATE SUPPOS 30 MG

5 Suppositories/30 days

N/A

morphine sulfate tab 15 mg

15 tablets/30 days

9 tablets/30 days

morphine sulfate tab 30 mg

5 tablets/30 days

3 tablets/30 days

oxycodone hcl cap 5 mg

30 capsules/30 days

18 capsules/30 days

oxycodone hcl conc 100 mg/5ml (20 mg/ml)

5 mLs/30 days

3 mL/30 days

oxycodone hcl soln 5 mg/5ml

165 mLs/30 days

99 mL/30 days

oxycodone hcl tab 10 mg

15 tablets/30 days

9 tablets/30 days

oxycodone hcl tab 15 mg

10 tablets/30 days

6 tablets/30 days

oxycodone hcl tab 20 mg

5 tablets/30 days

3 tablets/30 days

oxycodone hcl tab 30 mg

5 tablets/30 days

3 tablets/30 days

oxycodone hcl tab 5 mg

30 tablets/30 days

18 capsules/30 days

oxycodone w/ acetaminophen tab 10-325 mg

15 tablets/30 days

9 tablets/30 days

oxycodone w/ acetaminophen tab 2.5-325 mg

60 tablets/30 days

36 tablets/30 days

oxycodone w/ acetaminophen tab 5-325 mg

30 tablets/30 days

18 capsules/30 days

oxycodone w/ acetaminophen tab 7.5-325 mg

20 tablets/30 days

12 tablets/30 days

oxycodone-aspirin tab 4.8355-325 mg

30 tablets/30 days

18 tablets/30 days

oxymorphone hcl tab 10 mg

5 tablets/30 days

3 tablets/30 days

oxymorphone hcl tab 5 mg

15 tablets/30 days

9 tablets/30 days

pentazocine w/ naloxone tab 50-0.5 mg

10 tablets/30 days

6 tablets/30 days

tramadol hcl tab 50 mg

50 tablets/30 days

30 tablets/30 days

tramadol-acetaminophen tab 37.5-325 mg

40 tablets/30 days

24 tablets/30 days

Oral inhalers

Drug name(s)

Quantity limits (per 30 days or as specified)

ADVAIR DISKUS AER 100/50

60 blisters/30 days

ADVAIR DISKUS AER 250/50

60 blisters/30 days

ADVAIR DISKUS AER 500/50

60 blisters/30 days

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

AEROSPAN 80 MCG

2 canisters/30 days

AIRDUO DIGIHALER 55 MCG/14 MCG

1 inhaler/30 days

AIRDUO DIGIHALER 113 MCG/14 MCG

1 inhaler/30 days

AIRDUO DIGIHALER 232 MCG/14 MCG

1 inhaler/30 days

AIRDUO RESPICLICK 55 MCG/14 MCG

1 inhaler/30 days

AIRDUO RESPICLICK 113 MCG/14 MCG

1 inhaler/30 days

AIRDUO RESPICLICK 232 MCG/14 MCG

1 inhaler/30 days

ALVESCO AER 80MCG

2 canisters/30 days

ALVESCO AER 160MCG

2 canisters/30 days

ANORO ELLIPTA 62.5 MCG/25 MCG

1 inhaler/30 days

ARCAPTA NEOHALER 75 MCG

30 capsules/30 days

ARMONAIR DIGIHALER 55 MCG

1 inhaler/30 days

ARMONAIR DIGIHALER 113 MCG

1 inhaler/30 days

ARMONAIR DIGIHALER 232 MCG

1 inhaler/30 days

ARMONAIR RESPICLICK 55 MCG

1 inhaler/30 days

ARMONAIR RESPICLICK 113 MCG

1 inhaler/30 days

ARMONAIR RESPICLICK 232 MCG

1 inhaler/30 days

ARNUITY ELLIPTA INHALER 50MCG

30 blisters/30 days

ARNUITY ELLIPTA INHALER 100MCG

30 blisters/30 days

ARNUITY ELLIPTA INHALER 200MCG

30 blisters/30 days

ASMANEX 30 AER 110MCG

1 Canister/30 days

ASMANEX 14 AER 220MCG

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

ATROVENT HFA 17 MCG

2 canisters/30 days

BEVESPI AEROSPHERE 9 MCG/4.8 MCG

1 Canister/30 days

BREO ELLIPTA INHALER 100-25

60 blisters/30 days

BREO ELLIPTA INHALER 200-25

60 blisters/30 days

BREZTRI AEROSPHERE 160 MCG/9.0 MCG/4.8 MCG

1 Canister/30 days

COMBIVENT RESPIMAT 20 MCG/100 MCG

2 canisters/30 days

DUAKLIR PRESSAIR 400 MCG/12 MCG

1 inhaler/30 days

DULERA AER 50-5MCG

1 Canister/30 days

DULERA AER 100-5MCG

1 Canister/30 days

DULERA AER 200-5MCG

1 Canister/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

FORADIL 12 MCG

60 blisters/30 days

INCRUSE ELLIPTA 62.5 MCG

30 blisters/30 days

PROAIR DIGIHALER 90 MCG

2 inhalers/30 days

PROAIR HFA 90 MCG

2 canisters/30 days

PROAIR RESPICLICK 90 MCG

2 inhalers/30 days

PROVENTIL HFA 90 MCG

2 canisters/30 days

PULMICORT INHALER 90MCG

2 canisters/30 days

PULMICORT INHALER 180MCG

2 canisters/30 days

QVAR AER 40MCG

1 Canister/30 days

QVAR AER 80MCG

2 canisters/30 days

QVAR REDIHALER AER 40MCG

1 Canister/30 days

QVAR REDIHALER AER 80MCG

2 canisters/30 days

SEEBRI NEOHALER 15.6 MCG

60 capsules/30 days

SEREVENT 50 MCG

60 blisters/30 days

SPIRIVA HANDIHALER 18 MCG

30 capsules/30 days

SPIRIVA RESPIMAT 1.25 MCG

1 cartridge/30 days

SPIRIVA RESPIMAT 2.5 MCG

1 cartridge/30 days

STIOLTO RESPIMATV 2.5 MCG/2.5 MCG

1 cartridge/30 days

STRIVERDI RESPIMAT 2.5 MCG

1 cartridge/30 days

SYMBICORT AER 80-4.5

1 Canister/30 days

SYMBICORT AER 160-4.5

1 Canister/30 days

TRELEGY ELLIPTA 100 MCG/62.5 MCG/25 MCG

1 cartridge/30 days

TUDORZA PRESSAIR 400 MCG

1 cartridge/30 days

UTIBRON NEOHALER 27.5 MCG/15.6 MG

60 capsules/30 days

VENTOLIN HFA 90 MCG

2 canisters/30 days

VENTOLIN HFA 90 MCG

2 canisters/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 45 MCG

2 canisters/30 days

Oral Pulmonary Arterial Hypertension (PAH)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADCIRCA TABLET 20MG1

30 tablets/30 days

ADEMPAS TABLET 0.5MG 1,2

30 tablets/30 days

ADEMPAS TABLET 1MG 1,2

30 tablets/30 days

ADEMPAS TABLET 1.5MG 1,2

30 tablets/30 days

ADEMPAS TABLET 2MG 1,2

30 tablets/30 days

ADEMPAS TABLET 2.5MG 1,2

30 tablets/30 days

alyq tablet 20mg1

30 tablets/30 days

ambrisentan tablet 5mg1

30 tablets/30 days

ambrisentan tablet 10mg1

30 tablets/30 days

bosentan tablet 62.5mg1

30 tablets/30 days

bosentan tablet 125mg 1

30 tablets/30 days

LETAIRIS TABLET 5MG1

30 tablets/30 days

LETAIRIS TABLET 10MG1

30 tablets/30 days

OPSUMIT TABLET 10MG 1,2

30 tablets/30 days

REVATIO SUS 10MG/ML1

3 bottles/30 days

REVATIO TABLET 20MG1

30 tablets/30 days

sildenafil suspense 10mg/ml 1

324 mLs/30 days

sildenafil tablet 20mg1

30 tablets/30 days

tadalafil tablet 20mg 1

30 tablets/30 days

TRACLEER TABLET 32MG1

320 tablets/30 days

TRACLEER TABLET 62.5MG1

30 tablets/30 days

TRACLEER TABLET 125MG1

30 tablets/30 days

TYVASO 0.6 MG/ML SYSTEM

3 kit/180 days

TYVASO 0.6 MG/ML 4 PACK

31.2 ampules/28 days

UPTRAVI TABLET 200/800 1,2

3 package/180 days

UPTRAVI TABLET 200MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 200MCG 1,2

340 tablets/180 days

UPTRAVI TABLET 400MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 600MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 800MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 1000MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 1200MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 1400MCG 1,2

30 tablets/30 days

UPTRAVI TABLET 1600MCG 1,2

30 tablets/30 days

VENTAVIS SOLUTION 10MCG/ML 1,2,3

370 ampules/30 days

VENTAVIS SOLUTION 20MCG/ML 1,2,3

370 ampules/30 days

Orilissa

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ORILISSA TABLET 150MG

30 tablets/30 days

ORILISSA TABLET 200MG

30 tablets/30 days

Otezla

Drug name(s)

Quantity limits 
(per 30 days or as specified)

OTEZLA TABLET 10/20/301

3 kit/180 days

OTEZLA TABLET 30MG1

10 tablets/30 days

Oxbryta

Drug name(s)

Quantity limits 
(per 30 days or as specified)

OXBRYTA TABLET 500MG

30 tablets/30 days

Pain Medications

Drug name(s)

Quantity limits (per 30 days or as specified)

vanatol s solution

2700 mLs/30 days

vanatol lq solution

2700 mLs/30 days

vanatol lq solution

2700 mLs/30 days

Parathyroid Hormone Analog Osteoporosis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FORTEO SOLUTION 600/2.41

3 pen/28 days

TYMLOS INJECTION1

3 pen/30 days

Phosphodiesterase Type 5 (PDE5)

Drug name(s)

Quantity limits (per 30 days or as specified)

PDE5 Inhibitors

sildenafil tablet 100mg

6 tablets/30 days

PDE5 Inhibitors

sildenafil tablet 25mg

6 tablets/30 days

PDE5 Inhibitors

sildenafil tablet 50mg

6 tablets/30 days

PDE5 Inhibitors

STENDRA TABLET 100MG

6 tablets/30 days

PDE5 Inhibitors

STENDRA TABLET 200MG

6 tablets/30 days

PDE5 Inhibitors

STENDRA TABLET 50MG

6 tablets/30 days

PDE5 Inhibitors

tadalafil tablet 10mg

6 tablets/30 days

PDE5 Inhibitors

tadalafil tablet 2.5mg

30 tablets/30 days

PDE5 Inhibitors

tadalafil tablet 20mg

6 tablets/30 days

PDE5 Inhibitors

tadalafil tablet 5mg

30 tablets/30 days

PDE5 Inhibitors

vardenafil tablet 10mg

6 tablets/30 days

PDE5 Inhibitors

vardenafil tablet 10mg odt

6 tablets/30 days

PDE5 Inhibitors

vardenafil tablet 2.5mg

6 tablets/30 days

PDE5 Inhibitors

vardenafil tablet 20mg

6 tablets/30 days

PDE5 Inhibitors

vardenafil tablet 5mg

6 tablets/30 days

PDE5 Inhibitors

Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK-9) Inhibitors

Drug name(s)

Quantity limits 
(per 30 days or as specified)

REPATHA INJECTION 140MG/ML

3 syringes/28 days

REPATHA SURE INJECTION 140MG/ML

3 pens/28 days

REPATHA PUSH INJECTION 420/3.5

3 cartridge/30 days

PRALUENT INJECTION 75MG/ML

3 syringes/28 days

PRALUENT INJECTION 150MG/ML

3 syringes/28 days

Proton pump Inhibitors (PPI)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACIPHEX TABLET 20MG

30 tablets/30 days

DEXILANT CAPSULE 30MG DR

30 capsules/30 days

DEXILANT CAPSULE 60MG DR

30 capsules/30 days

esomeprazole magnesium capsule 40mg dr

30 capsules/30 days

lansoprazole capsule 15mg dr

30 capsules/30 days

lansoprazole capsule 30mg dr

30 capsules/30 days

NEXIUM CAPSULE 40MG

30 capsules/30 days

omeppi capsule 20-1100

30 capsules/30 days

omeppi capsule 40-1100

30 capsules/30 days

omeprazole/bicarbonate capsule 20-1100

30 capsules/30 days

omeprazole/bicarbonate capsule 40-1100

30 capsules/30 days

omeprazole/bicarbonate powder 20-1680

30 packets/30 days

omeprazole/bicarbonate powder 40-1680

30 packets/30 days

omeprazole capsule 10mg

30 capsules/30 days

omeprazole capsule 10mg dr

30 capsules/30 days

omeprazole capsule 20mg

30 capsules/30 days

omeprazole capsule 20mg dr

30 capsules/30 days

omeprazole capsule 40mg

30 capsules/30 days

omeprazole capsule 40mg dr

30 capsules/30 days

pantoprazole tablet 20mg

30 tablets/30 days

pantoprazole tablet 20mg dr

30 tablets/30 days

pantoprazole tablet 40mg

30 tablets/30 days

pantoprazole tablet 40mg dr

30 tablets/30 days

PREVACID CAPSULE 15MG DR

30 capsules/30 days

PREVACID CAPSULE 30MG DR

30 capsules/30 days

PROTONIX TABLET 20MG

30 tablets/30 days

PROTONIX TABLET 40MG

30 tablets/30 days

rabeprazole tablet 20mg

30 tablets/30 days

ZEGERID CAPSULE 20-1100

30 capsules/30 days

ZEGERID CAPSULE 40-1100

30 capsules/30 days

ZEGERID POWDER 20-1680

30 packets/30 days

ZEGERID POWDER 40-1680

30 packets/30 days

Prevymis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

PREVYMIS TABLET 240MG

300 tablets/365 days

PREVYMIS TABLET 480MG

300 tablets/365 days

Progesterones 

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CRINONE GEL 4% VAG

3 applicators/30 days

CRINONE GEL 8% VAG

30 applicators/30 days

ENDOMETRIN SUPPOSITORY 100MG

3 cartons/28 days

Regranex

Drug name(s)

Quantity limits 
(per 30 days or as specified)

REGRANEX GEL 0.01%

3 tube/30 days

Rho Kinase Inhibitor

Drug name(s)

Quantity limits 
(per 30 days or as specified)

RHOPRESSA SOLUTION 0.02%

3.5 mLs/30 days

ROCKLATAN DRO

3.5 mLs/30 days

Oncology

Drug name(s)

Quantity limits 
(per 30 days or as specified)

abiraterone tablet 250mg 1

320 tablets/30 days

AFINITOR DIS TABLET 2MG1,3

30 tablets/30 days

AFINITOR DIS TABLET 3MG1,3

30 tablets/30 days

AFINITOR DIS TABLET 5MG1,3

30 tablets/30 days

AFINITOR TABLET 2.5MG1,3

30 tablets/30 days

AFINITOR TABLET 5MG1,3

30 tablets/30 days

AFINITOR TABLET 7.5MG1,3

30 tablets/30 days

AFINITOR TABLET 10MG1,3

30 tablets/30 days

ALECENSA CAPSULE 150MG 1,2,3

340 capsules/30 days

ALUNBRIG PACK 1,2

30 tablets/180 days

ALUNBRIG TABLET 30MG 1,2

380 tablets/30 days

ALUNBRIG TABLET 90MG 1,2

30 tablets/30 days

ALUNBRIG TABLET 180MG 1,2

30 tablets/30 days

BALVERSA TABLET 3MG 1,2,3

30 tablets/30 days

BALVERSA TABLET 4MG 1,2,3

30 tablets/30 days

BALVERSA TABLET 5MG 1,2,3

30 tablets/30 days

BOSULIF TABLET 100MG1,3

320 tablets/30 days

BOSULIF TABLET 400MG1,3

30 tablets/30 days

BOSULIF TABLET 500MG1,3

30 tablets/30 days

BRAFTOVI CAPSULE 50MG 1,2

380 capsules/30 days

BRAFTOVI CAPSULE 75MG 1,2

380 capsules/30 days

CABOMETYX TABLET 20MG1,3

30 tablets/30 days

CABOMETYX TABLET 40MG1,3

30 tablets/30 days

CABOMETYX TABLET 60MG1,3

30 tablets/30 days

CALQUENCE CAPSULE 100MG 1,2,3

30 capsules/30 days

CAPRELSA TABLET 100MG 1,2

30 tablets/30 days

CAPRELSA TABLET 300MG 1,2

30 tablets/30 days

COMETRIQ KIT 60MG 1,2,3

3 carton/28 days

COMETRIQ KIT 100MG 1,2,3

3 carton/28 days

COMETRIQ KIT 140MG 1,2,3

312 tablets/28 days

COPIKTRA CAPSULE 25MG 1,2,3

36 capsules/28 days

COPIKTRA CAPSULE 15MG 1,2,3

36 capsules/28 days

COTELLIC TABLET 20MG1

33 tablets/28 days

DAURISMO TABLET 25MG1,3

30 tablets/30 days

DAURISMO TABLET 100MG1,3

30 tablets/30 days

ERIVEDGE CAPSULE 150MG1,3

30 capsules/30 days

erlotinib tablet 25mg 1

30 tablets/30 days

erlotinib tablet 100mg 1

30 tablets/30 days

erlotinib tablet 150mg1

30 tablets/30 days

everolimus tablet 2.5mg1

30 tablets/30 days

everolimus tablet 5mg1

30 tablets/30 days

everolimus tablet 7.5mg 1

30 tablets/30 days

FARYDAK CAPSULE 10MG1

3 capsules/21 days

FARYDAK CAPSULE 15MG1

3 capsules/21 days

FARYDAK CAPSULE 20MG1

3 capsules/21 days

GILOTRIF TABLET 20MG 1,2

30 tablets/30 days

GILOTRIF TABLET 30MG 1,2

30 tablets/30 days

GILOTRIF TABLET 40MG 1,2

30 tablets/30 days

IBRANCE CAPSULE 75MG1

31 capsules/28 days

IBRANCE CAPSULE 100MG1

31 capsules/28 days

IBRANCE CAPSULE 125MG1

31 capsules/28 days

ICLUSIG TABLET 15MG 1,2,3

30 tablets/30 days

ICLUSIG TABLET 45MG 1,2,3

30 tablets/30 days

IDHIFA TABLET 50MG1

30 tablets/30 days

IDHIFA TABLET 100MG1

30 tablets/30 days

IMBRUVICA CAPSULE 70MG 1,2

30 capsules/30 days

IMBRUVICA CAPSULE 140MG 1,2

320 capsules/30 days

IMBRUVICA TABLET 140MG 1,2

320 tablets/30 days

IMBRUVICA TABLET 280MG 1,2

30 tablets/30 days

IMBRUVICA TABLET 420MG 1,2

30 tablets/30 days

IMBRUVICA TABLET 560MG 1,2

30 tablets/30 days

INLYTA TABLET 1MG1,3

380 tablets/30 days

INLYTA TABLET 5MG1,3

320 tablets/30 days

INREBIC CAPSULE 100MG1,3

320 capsules/30 days

IRESSA TABLET 250MG 1,2,3

30 tablets/30 days

JAKAFI TABLET 5MG1,3

30 tablets/30 days

JAKAFI TABLET 10MG1,3

30 tablets/30 days

JAKAFI TABLET 15MG1,3

30 tablets/30 days

JAKAFI TABLET 20MG1,3

30 tablets/30 days

JAKAFI TABLET 25MG1,3

30 tablets/30 days

KISQALI TABLET 200DOSE1

33 tablets/28 days

KISQALI TABLET 400DOSE1

33 tablets/28 days

KISQALI TABLET 600DOSE1

33 tablets/28 days

KISQALI 200 PACK FEMARA1

31 tablets/28 days

KISQALI 400 PACK FEMARA1

31 tablets/28 days

KISQALI 600 PACK FEMARA1

31 tablets/28 days

LENVIMA CAPSULE 4MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 8 MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 10 MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 12MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 14 MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 18 MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 20 MG 1,2,3

30 capsules/30 days

LENVIMA CAPSULE 24 MG 1,2,3

30 capsules/30 days

LONSURF TABLET 15-6.141

300 tablets/28 days

LONSURF TABLET 20-8.191

30 tablets/28 days

LORBRENA TABLET 25MG1,3

30 tablets/30 days

LORBRENA TABLET 100MG1,3

30 tablets/30 days

LYNPARZA CAPSULE 50MG 1,2,3

380 capsules/30 days

LYNPARZA TABLET 100MG 1,2,3

320 tablets/30 days

LYNPARZA TABLET 150MG 1,2,3

320 tablets/30 days

MEKINIST TABLET 0.5MG1

30 tablets/30 days

MEKINIST TABLET 2MG1

30 tablets/30 days

MEKTOVI TABLET 15MG 1,2

380 tablets/30 days

NERLYNX TABLET 40MG 1,2,3

380 tablets/30 days

NINLARO CAPSULE 2.3MG1

3 capsules/28 days

NINLARO CAPSULE 3MG1

3 capsules/28 days

NINLARO CAPSULE 4MG1

3 capsules/28 days

NUBEQA TABLET 300MG1

320 tablets/30 days

ODOMZO CAPSULE 200MG1,3

30 capsules/30 days

PIQRAY 200MG TABLET DOSE1,3

38 tablets/28 days

PIQRAY 250MG TABLET DOSE1,3

36 tablets/28 days

PIQRAY 300MG TABLET DOSE1,3

36 tablets/28 days

POMALYST CAPSULE 1MG1

31 capsules/28 days

POMALYST CAPSULE 2MG1

31 capsules/28 days

POMALYST CAPSULE 3MG1

31 capsules/28 days

POMALYST CAPSULE 4MG1

31 capsules/28 days

REVLIMID CAPSULE 2.5MG1

30 capsules/30 days

REVLIMID CAPSULE 5MG1

30 capsules/30 days

REVLIMID CAPSULE 10MG1

30 capsules/30 days

REVLIMID CAPSULE 15MG1

31 capsules/28 days

REVLIMID CAPSULE 20MG1

31 capsules/28 days

REVLIMID CAPSULE 25MG1

31 capsules/28 days

ROZLYTREK CAPSULE 100MG1,3

30 capsules/30 days

ROZLYTREK CAPSULE 200MG1,3

30 capsules/30 days

RUBRACA TABLET 200MG 1,2,3

320 tablets/30 days

RUBRACA TABLET 250MG 1,2,3

320 tablets/30 days

RUBRACA TABLET 300MG 1,2,3

320 tablets/30 days

RYDAPT CAPSULE 25MG1

340 capsules/30 days

STIVARGA TABLET 40MG1

34 tablets/28 days

SUTENT CAPSULE 12.5MG1,3

30 capsules/30 days

SUTENT CAPSULE 25MG1,3

30 capsules/30 days

SUTENT CAPSULE 37.5MG1,3

30 capsules/30 days

SUTENT CAPSULE 50MG1,3

30 capsules/30 days

TAFINLAR CAPSULE 50MG1

320 capsules/30 days

TAFINLAR CAPSULE 75MG1

320 capsules/30 days

TAGRISSO TABLET 40MG 1,2,3

30 tablets/30 days

TAGRISSO TABLET 80MG 1,2,3

30 tablets/30 days

TALZENNA CAPSULE 0.25MG1,3

30 capsules/30 days

TALZENNA CAPSULE 1MG1,3

30 capsules/30 days

TARCEVA TABLET 25MG1,3

30 tablets/30 days

TARCEVA TABLET 100MG1,3

30 tablets/30 days

TARCEVA TABLET 150MG1,3

30 tablets/30 days

THALOMID CAPSULE 50MG1

30 capsules/30 days

THALOMID CAPSULE 100MG1

30 capsules/30 days

THALOMID CAPSULE 150MG1

30 capsules/30 days

THALOMID CAPSULE 200MG1

30 capsules/30 days

TIBSOVO TABLET 250MG 1,2

30 tablets/30 days

TURALIO CAPSULE 200MG 1,2

320 capsules/30 days

VENCLEXTA TABLET 10MG 1,2

30 tablets/30 days

VENCLEXTA TABLET 50MG 1,2

30 tablets/30 days

VENCLEXTA TABLET 100MG 1,2

380 tablets/30 days

VENCLEXTA TABLET START PK 1,2

3 pack/180 days

VERZENIO TABLET 50MG 1,2,3

30 tablets/30 days

VERZENIO TABLET 100MG 1,2,3

30 tablets/30 days

VERZENIO TABLET 150MG 1,2,3

30 tablets/30 days

VERZENIO TABLET 200MG 1,2,3

30 tablets/30 days

VITRAKVI CAPSULE 25MG 1,2,3

380 capsules/30 days

VITRAKVI CAPSULE 100MG 1,2,3

30 capsules/30 days

VITRAKVI SOLUTION 20MG/ML 1,2,3

300 mLs/30 days

VIZIMPRO TABLET 15MG1,3

30 tablets/30 days

VIZIMPRO TABLET 30MG1,3

30 tablets/30 days

VIZIMPRO TABLET 45MG1,3

30 tablets/30 days

VOTRIENT TABLET 200MG1,3

320 tablets/30 days

XOSPATA TABLET 40MG 1,2

30 tablets/30 days

XPOVIO PACK 60MG 1,2,3

3 box/28 days

XPOVIO PACK 80MG 1,2,3

3 box/28 days

XPOVIO PACK 100MG 1,2,3

3 box/28 days

XTANDI CAPSULE 40MG1,3

320 capsules/30 days

ZEJULA CAPSULE 100MG 1,2,3

30 capsules/30 days

ZELBORAF TABLET 240MG1

340 tablets/30 days

ZOLINZA CAPSULE 100MG1,3

320 capsules/30 days

ZYDELIG TABLET 100MG 1,2

30 tablets/30 days

ZYDELIG TABLET 150MG 1,2

30 tablets/30 days

ZYKADIA CAPSULE 150MG1,3

30 capsules/30 days

ZYKADIA TABLET 150MG1,3

30 tablets/30 days

ZYTIGA TABLET 250MG1,3

320 tablets/30 days

ZYTIGA TABLET 500MG1,3

30 tablets/30 days

SGLT-2 Inhibitors

Drug name(s)

Quantity limits (per 30 days or as specified)

FARXIGA     TABLET 10MG

30 tablets/30 days

FARXIGA     TABLET 5MG

30 tablets/30 days

GLYXAMBI    TABLET 10-5 MG

30 tablets/30 days

GLYXAMBI    TABLET 25-5 MG

30 tablets/30 days

INVOKAMET   TABLET 150-1000

60 tablets/30 days

INVOKAMET   TABLET 150-500

60 tablets/30 days

INVOKAMET   TABLET 50-1000

60 tablets/30 days

INVOKAMET   TABLET 50-500MG

60 tablets/30 days

INVOKAMET XR TABLET 150-1000

60 tablets/30 days

INVOKAMET XR TABLET 150-500

60 tablets/30 days

INVOKAMET XR TABLET 50-1000

60 tablets/30 days

INVOKAMET XR TABLET 50-500MG

60 tablets/30 days

INVOKANA    TABLET 100MG

30 tablets/30 days

INVOKANA    TABLET 300MG

30 tablets/30 days

JARDIANCE   TABLET 10MG

30 tablets/30 days

JARDIANCE   TABLET 25MG

30 tablets/30 days

SYNJARDY    TABLET

60 tablets/30 days

SYNJARDY    TABLET 12.5-500

60 tablets/30 days

SYNJARDY    TABLET 5-1000MG

60 tablets/30 days

SYNJARDY    TA TABLET B 5-500MG

60 tablets/30 days

SYNJARDY XR TABLET

60 tablets/30 days

SYNJARDY XR TABLET 10-1000

60 tablets/30 days

SYNJARDY XR TABLET 25-1000

30 tablets/30 days

SYNJARDY XR TABLET 5-1000MG

60 tablets/30 days

XIGDUO XR TABLET 10-1000

30 tablets/30 days

XIGDUO XR TABLET 10-500MG

30 tablets/30 days

XIGDUO XR TABLET 2.5-1000

30 tablets/30 days

XIGDUO XR TABLET 5-1000MG

60 tablets/30 days

XIGDUO XR TABLET 5-500MG

30 tablets/30 days

Signifor

Drug name(s)

Quantity limits 
(per 30 days or as specified)

SIGNIFOR INJECTION 0.3MG/ML 1,2

30 mLs/30 days

SIGNIFOR INJECTION 0.6MG/ML 1,2

30 mLs/30 days

SIGNIFOR INJECTION 0.9MG/ML 1,2

30 mLs/30 days

Sodium Oxybate

Drug name(s)

Quantity limits 
(per 30 days or as specified)

XYREM SOLUTION 500MG/ML 1,2

340 mLs/30 days

Somatostatin Analogs

Drug name(s)

Quantity limits 
(per 30 days or as specified)

SOMAVERT INJECTION 10MG1

30 vials/30 days

SOMAVERT INJECTION 15MG1

30 vials/30 days

SOMAVERT INJECTION 20MG1

30 vials/30 days

SOMAVERT INJECTION 25MG1

30 vials/30 days

SOMAVERT INJECTION 30MG1

30 vials/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 TABLET 17MG1

30 tablets/30 days

NUPLAZID CAPSULE 34MG1

30 capsules/30 days

Statins

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALTOPREV TABLET 20MG ER

30 tablets/30 days

ALTOPREV TABLET 40MG ER

30 tablets/30 days

ALTOPREV TABLET 60MG ER

30 tablets/30 days

atorvastatin tablet 10mg

35 tablets/30 days

atorvastatin tablet 20mg

35 tablets/30 days

atorvastatin tablet 40mg

35 tablets/30 days

atorvastatin tablet 80mg

30 tablets/30 days

CRESTOR TABLET 5MG

35 tablets/30 days

CRESTOR TABLET 10MG

35 tablets/30 days

CRESTOR TABLET 20MG

35 tablets/30 days

CRESTOR TABLET 40MG

30 tablets/30 days

ezetimibe/simvastatin tablet 10-10mg

30 tablets/30 days

ezetimibe/simvastatin tablet 10-20mg

30 tablets/30 days

ezetimibe/simvastatin tablet 10-40mg

30 tablets/30 days

ezetimibe/simvastatin tablet 10-80mg

30 tablets/30 days

fluvastatin tablet 80mg er

30 tablets/30 days

LESCOL XL TABLET 80MG

30 tablets/30 days

LIPITOR TABLET 10MG

35 tablets/30 days

LIPITOR TABLET 20MG

35 tablets/30 days

LIPITOR TABLET 40MG

35 tablets/30 days

LIPITOR TABLET 80MG

30 tablets/30 days

LIVALO TABLET 1MG

35 tablets/30 days

LIVALO TABLET 2MG

35 tablets/30 days

LIVALO TABLET 4MG

30 tablets/30 days

lovastatin tablet 10mg

30 tablets/30 days

lovastatin tablet 20mg

30 tablets/30 days

lovastatin tablet 40mg

30 tablets/30 days

PRAVACHOL TABLET 20MG

35 tablets/30 days

PRAVACHOL TABLET 40MG

35 tablets/30 days

PRAVACHOL TABLET 80MG

30 tablets/30 days

pravastatin tablet 10mg

35 tablets/30 days

pravastatin tablet 20mg

35 tablets/30 days

pravastatin tablet 40mg

35 tablets/30 days

pravastatin tablet 80mg

30 tablets/30 days

rosuvastatin tablet 5mg

35 tablets/30 days

rosuvastatin tablet 10mg

35 tablets/30 days

rosuvastatin tablet 20mg

35 tablets/30 days

rosuvastatin tablet 40mg

30 tablets/30 days

simvastatin tablet 5mg

35 tablets/30 days

simvastatin tablet 10mg

35 tablets/30 days

simvastatin tablet 20mg

30 tablets/30 days

simvastatin tablet 40mg

35 tablets/30 days

simvastatin tablet 80mg

30 tablets/30 days

VYTORIN TABLET 10-10MG

30 tablets/30 days

VYTORIN TABLET 10-20MG

30 tablets/30 days

VYTORIN TABLET 10-40MG

30 tablets/30 days

VYTORIN TABLET 10-80MG

30 tablets/30 days

ZOCOR TABLET 5MG

35 tablets/30 days

ZOCOR TABLET 10MG

35 tablets/30 days

ZOCOR TABLET 20MG

30 tablets/30 days

ZOCOR TABLET 40MG

35 tablets/30 days

ZOCOR TABLET 80MG

30 tablets/30 days

Substrate Reduction Therapy

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CERDELGA CAPSULE 84MG1

30 capsules/30 days

miglustat capsule 100mg 1

30 capsules/30 days

ZAVESCA CAPSULE 100MG 1,2

30 capsules/30 days

Sunosi

Drug name(s)

Quantity limits 
(per 30 days or as specified)

SUNOSI TABLET 75MG

30 tablets/30 days

SUNOSI TABLET 150MG

30 tablets/30 days

Tafamidis

Drug name(s)

Quantity limits 
(per 30 days or as specified)

VYNDAMAX CAPSULE 61MG1

30 capsules/30 days

VYNDAQEL CAPSULE 20MG1

320 capsules/30 days

Thrombopoietin Receptor Agonists

Drug name(s)

Quantity limits 
(per 30 days or as specified)

MULPLETA TABLET 3MG1

3 tablets/7 days

PROMACTA POWDER 12.5MG1

30 packets/30 days

PROMACTA TABLET 12.5MG1

30 tablets/30 days

PROMACTA TABLET 25MG1

30 tablets/30 days

PROMACTA TABLET 50MG1

30 tablets/30 days

PROMACTA TABLET 75MG1

30 tablets/30 days

Topical Corticosteroids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALA SCALP LOTION 2%

318.4 mLs/30 days

ala-cort cream 1%

354 grams/30 days

ala-cort cream 2.5%

354 grams/30 days

alclometasone cream 0.05%

320 grams/30 days

alclometasone ointment 0.05%

320 grams/30 days

AMCINONIDE CREAM 0.1%

320 grams/30 days

AMCINONIDE LOTION 0.1%

320 mLs/30 days

AMCINONIDE OINTMENT 0.1%

320 grams/30 days

APEXICON E CREAM 0.05%

320 grams/30 days

aug betamet cream 0.05%

300 grams/28 days

AUG BETAMET GEL 0.05%

300 grams/28 days

augmented betamethasone lotion 0.05%

310 mLs/30 days

augmented betamethasone ointment 0.05%

300 grams/28 days

beser lotion 0.05%

320 mLs/30 days

BETA DIPROP GEL 0.05%

300 grams/28 days

betamethasone dipropionate cream 0.05%

335 grams/30 days

betamethasone dipropionate lotion 0.05%

320 mLs/30 days

betamethasone dipropionate ointment 0.05%

335 grams/30 days

betamethasone valerate aer 0.12%

350 grams/30 days

betamethasone valerate cream 0.1%

335 grams/30 days

betamethasone valerate lotion 0.1%

320 mLs/30 days

betamethasone valerate ointment 0.1%

335 grams/30 days

CAPEX SHA 0.01%

340 mLs/28 days

clobetasol aer 0.05%

300 grams/28 days

clobetasol cream 0.05%

310 grams/28 days

clobetasol e cream 0.05%

310 grams/28 days

clobetasol gel 0.05%

310 grams/28 days

clobetasol lotion 0.05%

377 mLs/28 days

clobetasol ointment 0.05%

310 grams/28 days

clobetasol shampoo 0.05%

336 mLs/30 days

clobetasol solution 0.05%

300 mLs/28 days

clobetasol spray 0.05%

336 mLs/28 days

CLOBEX LOTION 0.05%

377 mLs/28 days

CLOBEX SHA 0.05%

336 mLs/30 days

CLOBEX SPR 0.05%

336 mLs/28 days

CLOCORTOLONE CREAM 0.1%

335 grams/30 days

CLOCORTOLONE CREAM PIV 0.1%

335 grams/30 days

clodan shampoo 0.05%

336 mLs/30 days

CLODERM CREAM 0.1%

335 grams/30 days

CLODERM CREAM 0.1% PMP

335 grams/30 days

CORDRAN 80X3 TAP 4MCG/CM

3 box/30 days

CORDRAN CREAM 0.025%

320 grams/30 days

CORDRAN CREAM 0.05%

320 grams/30 days

CORDRAN LOTION 0.05%

320 mLs/30 days

CORDRAN LOTION 0.05%

320 grams/30 days

CUTIVATE LOTION 0.05%

320 mLs/30 days

DERMA-SMOOTH OIL /FS BODY

318.28 mLs/30 days

DERMA-SMOOTH OIL /FS SCLP

318.28 mLs/30 days

DESONATE GEL 0.05%

320 grams/30 days

desonide cream 0.05%

320 grams/30 days

desonide lotion 0.05%

318 mLs/30 days

desonide ointment 0.05%

320 grams/30 days

DESOWEN CREAM 0.05%

320 grams/30 days

DESOWEN LOTION 0.05%

318 mLs/30 days

desoximetasone cream 0.05%

320 grams/30 days

desoximetasone cream 0.25%

320 grams/30 days

desoximetasone gel 0.05%

320 grams/30 days

desoximetasone ointment 0.05%

320 grams/30 days

desoximetasone ointment 0.25%

320 grams/30 days

desoximetasone spray 0.25%

300 mLs/30 days

DIFLORASONE CREAM 0.05%

320 grams/30 days

diflorasone ointment 0.05%

320 grams/30 days

DIPROLENE AF CREAM 0.05%

300 grams/28 days

DIPROLENE LOTION 0.05%

300 grams/28 days

ELOCON CREAM 0.1%

335 grams/30 days

ELOCON LOTION 0.1%

335 grams/30 days

fluocinolone acetonide cream 0.01%

320 grams/30 days

fluocinolone acetonide cream 0.025%

320 grams/30 days

fluocinolone acetonide oil 0.01% scalp

318.28 mLs/30 days

fluocinolone acetonide oil 0.01%body

318.28 mLs/30 days

fluocinolone acetonide oil body

318.28 mLs/30 days

fluocinolone acetonide oil scalp

318.28 mLs/30 days

fluocinolone acetonide ointment 0.025%

320 grams/30 days

fluocinolone acetonide solution 0.01%

320 mLs/30 days

fluocinonide cream 0.05%

320 grams/30 days

fluocinonide cream 0.1%

340 grams/28 days

fluocinonide cream e 0.05%

320 grams/30 days

fluocinonide gel 0.05%

320 grams/30 days

fluocinonide ointment 0.05%

320 grams/30 days

fluocinonide solution 0.05%

320 mLs/30 days

flurandrenol cream 0.05%

320 grams/30 days

flurandrenol lotion 0.05%

320 mLs/30 days

flurandrenol ointment 0.05%

320 grams/30 days

fluticasone cream 0.05%

320 grams/30 days

fluticasone lotion 0.05%

320 mLs/30 days

fluticasone ointment 0.005%

320 grams/30 days

halcinonide cream 0.1%

340 grams/30 days

halobetasol cream 0.05%

300 grams/28 days

halobetasol ointment 0.05%

300 grams/28 days

HALOG CREAM 0.1%

340 grams/30 days

HALOG OINTMENT 0.1%

340 grams/30 days

hc butyrate cream 0.1%

320 grams/30 days

hc butyrate cream 0.1%

335 grams/30 days

hc butyrate ointment 0.1%

335 grams/30 days

hc butyrate solution 0.1%

320 mLs/30 days

hc valerate cream 0.2%

320 grams/30 days

hc valerate ointment 0.2%

320 grams/30 days

hydrocortisone cream 1%

354 grams/30 days

hydrocortisone cream 2.5%

354 grams/30 days

hydrocortisone lotion 2.5%

318 mLs/30 days

hydrocortisone ointment 2.5%

354 grams/30 days

hydrocortisone lotion 0.1%

318 mLs/30 days

IMPOYZ CREAM 0.025%

340 grams/30 days

KENALOG AER SPRAY

326 grams/30 days

LOCOID CREAM 0.1%

335 grams/30 days

LOCOID LIPO CREAM 0.1%

320 grams/30 days

LOCOID LOTION 0.1%

318 mLs/30 days

LOCOID OINTMENT 0.1%

335 grams/30 days

LOCOID SOLUTION 0.1%

320 mLs/30 days

LUXIQ AER 0.12%

350 grams/30 days

MICORT-HC CREAM 2.5%

320 grams/30 days

mometasone cream 0.1%

335 grams/30 days

mometasone ointment 0.1%

335 grams/30 days

mometasone solution 0.1%

320 mLs/30 days

nolix cream 0.05%

320 grams/30 days

nolix lotion 0.05%

320 mLs/30 days

OLUX AER 0.05%

300 grams/28 days

OLUX-E AER 0.05%

300 grams/28 days

PANDEL CREAM 0.1%

360 grams/30 days

PREDNICARBAT CREAM 0.1%

320 grams/30 days

PREDNICARBAT OINTMENT 0.1%

320 grams/30 days

PSORCON CREAM 0.05%

320 grams/30 days

SERNIVO SPRAY

320 mLs/30 days

SERNIVO SPRAY 0.05%

320 mLs/30 days

SYNALAR CREAM 0.025%

320 grams/30 days

SYNALAR OINTMENT 0.025%

320 grams/30 days

SYNALAR Solution 0.01%

320 mLs/30 days

TEMOVATE CREAM 0.05%

310 grams/28 days

TEMOVATE OINTMENT 0.05%

310 grams/28 days

TEXACORT SOLUTION 2.5%

320 mLs/30 days

TOPICORT CREAM 0.05%

320 grams/30 days

TOPICORT CREAM 0.25%

320 grams/30 days

TOPICORT GEL 0.05%

320 grams/30 days

TOPICORT OINTMENT 0.05%

320 grams/30 days

TOPICORT OINTMENT 0.25%

320 grams/30 days

TOPICORT SPRAY 0.25%

300 mLs/30 days

tovet aer 0.05%

300 grams/28 days

triamcinolone aer spray

326 grams/30 days

triamcinolone cream 0.025%

354 grams/30 days

triamcinolone cream 0.1%

354 grams/30 days

triamcinolone cream 0.5%

354 grams/30 days

triamcinolone lotion 0.025%

320 mLs/30 days

triamcinolone lotion 0.1%

320 mLs/30 days

triamcinolone ointment 0.025%

354 grams/30 days

triamcinolone ointment 0.05%

330 grams/30 days

triamcinolone ointment 0.1%

354 grams/30 days

triamcinolone ointment 0.5%

320 grams/30 days

trianex ointment 0.05%

330 grams/30 days

triderm cream 0.1%

354 grams/30 days

triderm cream 0.5%

354 grams/30 days

TRIDESILON CREAM 0.05%

320 grams/30 days

ULTRAVATE CREAM 0.05%

300 grams/28 days

ULTRAVATE LOTION 0.05%

340 mLs/30 days

ULTRAVATE OINTMENT 0.05%

300 grams/28 days

VANOS CREAM 0.1%

340 grams/28 days

VERDESO AER 0.05%

300 grams/30 days

Topical Doxepin

Drug name(s)

Quantity limits (per 30 days or as specified)

DOXEPIN HCL CREAM 5%

45 grams/30 days

ZONALON CREAM 5%

45 grams/30 days

PRUDOXIN CREAM 5%

45 grams/30 days

Topical Estrogens

Drug name(s)

Quantity limits (per 30 days or as specified)

ALORA DIS 0.025MG

8 patches/28 days

ALORA DIS 0.05MG

8 patches/28 days

ALORA DIS 0.075MG

8 patches/28 days

ALORA DIS 0.1MG

8 patches/28 days

CLIMARA PRO DIS WEEKLY

4 patches/28 days

COMBIPATCH DIS

8 patches/28 days

DIVIGEL GEL 0.25MG

30 packets/30 days

DIVIGEL GEL 0.5MG

30 packets/30 days

DIVIGEL GEL 0.75MG

30 packets/30 days

DIVIGEL GEL 1.25MG

37.5 grams/30 days

DIVIGEL GEL 1MG/GM

30 packets/30 days

dotti dis 0.025mg

8 patches/28 days

dotti dis 0.0375mg

8 patches/28 days

dotti dis 0.05mg

8 patches/28 days

dotti dis 0.075mg

8 patches/28 days

dotti dis 0.1mg

8 patches/28 days

ELESTRIN GEL 0.06%

1 pump/30 days

estradiol dis 0.025mg

8 patches/28 days

estradiol dis 0.025mg

4 patches/28 days

estradiol dis 0.0375mg

8 patches/28 days

estradiol dis 0.0375mg

4 patches/28 days

estradiol dis 0.05mg

8 patches/28 days

estradiol dis 0.05mg

4 patches/28 days

estradiol dis 0.06mg

4 patches/28 days

estradiol dis 0.075mg

8 patches/28 days

estradiol dis 0.075mg

4 patches/28 days

estradiol dis 0.1mg

8 patches/28 days

estradiol dis 0.1mg

4 patches/28 days

ESTRING MIS 2MG

1 ring/90 days

ESTROGEL GEL

1 pump/30 days

EVAMIST SPRAY 1.53MG

5 vials/93 days

FEMRING MIS 0.05/24H

1 ring/90 days

FEMRING MIS 0.1MG/24

1 ring/90 days

MENOSTAR DIS 14MCG

4 patches/28 days

Topical Lidocaine

Drug name(s)

Quantity limits 
(per 30 days or as specified)

lidocaine pad 5%

30 patches/30 days

LIDODERM DIS 5%

30 patches/30 days

ZTLIDO PAD 1.8%

30 patches/30 days

Topical NSAID

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DICLOFENAC DIS 1.3%

30 patches/30 days

diclofenac gel 1%

30 tubes/30 days

diclofenac solution 1.5%

3 bottles/30 days

FLECTOR DIS 1.3%

30 patches/30 days

klofensaid solution ii

3 bottles/30 days

PENNSAID SOLUTION 2%

3 pumps/28 days

VOLTAREN GEL 1%

30 tubes/30 days

Topiramate Extended Release

Drug name(s)

Quantity limits 
(per 30 days or as specified)

QUDEXY XR CAPSULE 25/24HR

30 capsules/30 days

QUDEXY XR CAPSULE 50/24HR

30 capsules/30 days

QUDEXY XR CAPSULE 100/24HR

30 capsules/30 days

QUDEXY XR CAPSULE 150/24HR

30 capsules/30 days

QUDEXY XR CAPSULE 200/24HR

30 capsules/30 days

TOPIRAMATE CAPSULE ER 25MG

30 capsules/30 days

TOPIRAMATE CAPSULE ER 50MG

30 capsules/30 days

TOPIRAMATE CAPSULE ER 100MG

30 capsules/30 days

TOPIRAMATE CAPSULE ER 150MG

30 capsules/30 days

TOPIRAMATE CAPSULE ER 200MG

30 capsules/30 days

TROKENDI XR CAPSULE 25MG

30 capsules/30 days

TROKENDI XR CAPSULE 50MG

30 capsules/30 days

TROKENDI XR CAPSULE 100MG

30 capsules/30 days

TROKENDI XR CAPSULE 200MG

30 capsules/30 days

Transmucosal Immediate Release Fentanyl

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ABSTRAL SUBLINGUAL 100MCG

320 tablets/30 days

ABSTRAL SUBLINGUAL 200MCG

320 tablets/30 days

ABSTRAL SUBLINGUAL 300MCG

320 tablets/30 days

ABSTRAL SUBLINGUAL 400MCG

320 tablets/30 days

ABSTRAL SUBLINGUAL 600MCG

320 tablets/30 days

ABSTRAL SUBLINGUAL 800MCG

320 tablets/30 days

ACTIQ LOZENGE 200MCG

320 lozenges/30 days

ACTIQ LOZENGE 400MCG

320 lozenges/30 days

ACTIQ LOZENGE 600MCG

320 lozenges/30 days

ACTIQ LOZENGE 800MCG

320 lozenges/30 days

ACTIQ LOZENGE 1200MCG

320 lozenges/30 days

ACTIQ LOZENGE 1600MCG

320 lozenges/30 days

FENTANYL CITRATE TABLET 100MCG

320 tablets/30 days

FENTANYL CITRATE TABLET 200MCG

320 tablets/30 days

FENTANYL CITRATE TABLET 400MCG

320 tablets/30 days

FENTANYL CITRATE TABLET 600MCG

320 tablets/30 days

FENTANYL CITRATE TABLET 800MCG

320 tablets/30 days

fentanyl ot lozenge 200mcg

320 lozenges/30 days

fentanyl ot lozenge 400mcg

320 lozenges/30 days

fentanyl ot lozenge 600mcg

320 lozenges/30 days

fentanyl ot lozenge 800mcg

320 lozenges/30 days

fentanyl ot lozenge 1200mcg

320 lozenges/30 days

fentanyl ot lozenge 1600mcg

320 lozenges/30 days

FENTORA TABLET 100MCG

320 tablets/30 days

FENTORA TABLET 200MCG

320 tablets/30 days

FENTORA TABLET 400MCG

320 tablets/30 days

FENTORA TABLET 600MCG

320 tablets/30 days

FENTORA TABLET 800MCG

320 tablets/30 days

LAZANDA SPRAY 100MCG

30 bottles/30 days

LAZANDA SPRAY 300MCG

30 bottles /30 days

LAZANDA SPRAY 400MCG

30 bottles/30 days

SUBSYS SPRAY 100MCG

320 sprays/30 days

SUBSYS SPRAY 200MCG

320 sprays/30 days

SUBSYS SPRAY 400MCG

320 sprays/30 days

SUBSYS SPRAY 600MCG

320 sprays/30 days

SUBSYS SPRAY 800MCG

320 sprays/30 days

SUBSYS SPRAY 1200MCG

340 sprays/30 days

SUBSYS SPRAY 1600MCG

340 sprays/30 days

URAT1 Inhibitor

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DUZALLO TABLET 200-200

30 tablets/30 days

DUZALLO TABLET 200-300

30 tablets/30 days

ZURAMPIC TABLET 200MG

30 tablets/30 days

Vesicular Monoamine Transporter 2 (VMAT2) Inhibitor

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AUSTEDO TABLET 6MG1

30 tablets/30 days

AUSTEDO TABLET 9MG1

320 tablets/30 days

AUSTEDO TABLET 12MG1

320 tablets/30 days

INGREZZA CAPSULE 40MG 1,2

30 capsules/30 days

INGREZZA CAPSULE 80MG 1,2

30 capsules/30 days

INGREZZA CAPSULE 40-80MG 1,2

38 capsules/180 days

tetrabenazine tablet 12.5mg1

340 tablets/30 days

tetrabenazine tablet 25mg1

320 tablets/30 days

XENAZINE TABLET 12.5MG1

340 tablets/30 days

XENAZINE TABLET 25MG1

320 tablets/30 days

Wakix

Drug name(s)

Quantity limits 
(per 30 days or as specified)

WAKIX TABLET 4.45MG

30 tablets/30 days

WAKIX TABLET 17.8MG

30 tablets/30 days

Weight Loss Agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADIPEX-P CAPSULE 37.5MG

30 capsules/30 days

ADIPEX-P TABLET 37.5MG

30 tablets/30 days

BELVIQ TABLET 10MG

30 tablets/30 days

BELVIQ XR TABLET 20MG

30 tablets/30 days

BENZPHETMINE TABLET 25MG

30 tablets/30 days

benzphetamine tablet 50mg

30 tablets/30 days

CONTRAVE TABLET 8-90MG

320 tablets/30 days

diethylpropion tablet 25mg

30 tablets/30 days

DIETHYLPROP TABLET 75MG ER

30 tablets/30 days

LOMAIRA TABLET 8MG

30 tablets/30 days

phendimetrazine tablet 35mg

380 tablets/30 days

phendimetrazine capsule 105MG SR

30 capsules/30 days

phentermine capsule 15mg

30 capsules/30 days

phentermine capsule 30mg

30 capsules/30 days

phentermine capsule 37.5mg

30 capsules/30 days

phentermine tablet 37.5mg

30 tablets/30 days

QSYMIA CAPSULE 3.75-23

30 capsules/30 days

QSYMIA CAPSULE 7.5-46MG

30 capsules/30 days

QSYMIA CAPSULE 11.25-69

30 capsules/30 days

QSYMIA CAPSULE 15-92MG

30 capsules/30 days

REGIMEX TABLET 25MG

30 tablets/30 days

SAXENDA INJECTION 18MG/3ML

35 mLs/30 days

XENICAL CAPSULE 120MG

30 capsules/30 days

Xermelo

Drug name(s)

Quantity limits 
(per 30 days or as specified)

XERMELO TABLET 250MG 1,2

30 tablets/30 days

Drug name(s)

Tier

abiraterone acetate tab GN
ACTEMRA BP
ACTHAR BN
ACTIMMUNE BP
ADEMPAS BN
ADVATE BP
ADYNOVATE BP
AFINITOR BP
AFINITOR DISPERZ BP
AFSTYLA BP
AIMOVIG BP
ALECENSA BP
ALPHANATE/VON WILLEBRAND BP
ALPHANINE SD BP
ALPROLIX BP
ALUNBRIG BP
ambrisentan tab GN
APOKYN BN
ARANESP ALBUMIN FREE4 BP
ARCALYST BN
ARIKAYCE BN
AUBAGIO BP
AUSTEDO BN
AVONEX4 BP
AYVAKIT BP
BALVERSA BN
BARACLUDE BP
BENEFIX BP
BENLYSTA BN
BERINERT BN
BETASERON4 BP
BETHKIS BN
bexarotene cap GN
bosentan tab GN
BOSULIF BP
BRAFTOVI BN
BRUKINSA BN
CABOMETYX BP
CALQUENCE BN
CAPECITABINE4 GN
CAPRELSA BP
CARBAGLU BN
CAYSTON BN
CERDELGA BN
CHENODAL BP
CHOLBAM BN
CHORIONIC GONADOTROPIN BP
CIMZIA BN
cinacalcet hcl tab GN
COAGADEX BP
COMETRIQ BP
COPAXONE4 BP
COPIKTRA BN
CORIFACT BP
COSENTYX BP
COSENTYX SENSOREADY PEN BP
COTELLIC BP
CYSTADANE BP
CYSTAGON BP
CYSTARAN BN
dalfampridine tab er GN
DAURISMO BN
deferasirox tab GN
deferasirox tab for oral susp GN
DIACOMIT BN
dofetilide cap GN
DOPTELET BP
DUPIXENT BN
ELIGARD BN
ELOCTATE BP
EMFLAZA BN+
EMGALITY BP
ENBREL4 BP
ENDARI BN
entecavir tab GN
EPCLUSA BP
EPIDIOLEX BP
EPOGEN4 BN
ERIVEDGE BP
ERLEADA BP
erlotinib hcl tab GN
ESBRIET BN
everolimus tab GN
FARYDAK BP
FEIBA BP
FERRIPROX BN
FIRDAPSE BN
FOLLISTIM AQ4 BP
FULPHILA BP
FUZEON4 BN
GALAFOLD BN
GANIRELIX ACETATE4 GN
GATTEX BN
GILENYA BP
GILOTRIF BP
GLATIRAMER ACETATE GN
GOCOVRI BN+
GRANIX BP
HAEGARDA BP
HARVONI4 BP
HEMLIBRA BP
HEMOFIL M BP
HETLIOZ BN
HUMATE-P4 BP
HUMIRA4 BP
HYCAMTIN BP
IBRANCE BP
icatibant acetate inj GN
ICLUSIG BP
IDELVION BP
IDHIFA BN
imatinib mesylate tab GN
IMBRUVICA BP
INBRIJA BP
INCRELEX BP
INGREZZA BN
INLYTA BP
INREBIC4 BN
INTRON A BP
IRESSA BP
IXINITY BP
JADENU BN
JADENU SPRINKLE BN
JAKAFI BP
JUXTAPID BN
JYNARQUE BN
KALYDECO BP
KEVEYIS BN+
KEVZARA BN
KISQALI BP
KISQALI FEMARA BP
KITABIS PAK BN
KOATE BP
KOATE-DVI BP
KOGENATE FS BP
KORLYM BN
KOVALTRY BP
KUVAN BN
LENVIMA BP
LEUKINE4 BN
LEUPROLIDE ACETATE GN
LONSURF BP
LORBRENA BN
LUPANETA PACK BN
LUPRON DEPOT4 BP
LUPRON DEPOT-PED4 BP
LYNPARZA BP
MATULANE BP
MAVENCLAD BP
MAVYRET4 BP
MAYZENT BP
MEKINIST BP
MEKTOVI BN
MENOPUR BP
miglustat cap GN
MIRCERA BN
MONONINE BP
MULPLETA BP
MYALEPT BN
NATPARA BN
NERLYNX BN
NEULASTA4 BP
NEUPOGEN4 BP
NEXAVAR BP
NINLARO BP
nitisinone cap GN
NITYR BP
NIVESTYM BP
NORDITROPIN FLEXPRO4 BP
NORTHERA BN+
NOVAREL4 BP
NOVOEIGHT BP
NOVOSEVEN RT BP
NUBEQA BP
NUPLAZID BN+
NUWIQ BP
OBIZUR BP
OCALIVA BN
octreotide acetate inj GN
ODOMZO BP
OFEV BN
OPSUMIT BP
ORENITRAM BN
ORFADIN BP
ORKAMBI BN
OTEZLA BP
OTREXUP BP
OXBRYTA BN
OXERVATE BN
PALYNZIQ BN
PEGASYS4 BP
PEGASYS PROCLICK4 BP
PEGINTRON4 BN
PIQRAY BP
PLEGRIDY BP
POMALYST BP
PREGNYL W/DILUENT BENZYL4 BP
PROCRIT4 BP
PROCYSBI BN
PROFILNINE BP
PROFILNINE SD BP
PROMACTA BN
PULMOZYME BP
RAVICTI BN
REBIF4 BP
REBIF REBIDOSE4 BP
REBIF REBIDOSE TITRATION PACK4 BP
REBIF TITRATION PACK4 BP
REBINYN BP
RECOMBINATE BP
REPATHA BP
REPATHA PUSHTRONEX SYSTEM BP
REPATHA SURECLICK BP
RETACRIT BP
REVCOVI BP
REVLIMID BP
RIBAVIRIN cap4 GN
RIBAVIRIN for inhaler solution4 GN
RIBAVIRIN tab4 GN
RINVOQ BP
RIXUBIS BP
ROZLYTREK4 BP
RUBRACA BP
RUCONEST BN
RUZURGI BN
RYDAPT BP
SAMSCA BN
SIGNIFOR BN
SIKLOS BN
sildenafil citrate suspension GN
sildenafil citrate tab GN
SIMPONI BP
SKYRIZI BP
sodium phenylbutyrate oral powder GN
sodium phenylbutyrate tab GN
SOMAVERT BN
SOVALDI BP
SPRYCEL4 BP
STELARA BP
STIMATE BP
STIVARGA BP
STRENSIQ BP
SUTENT BP
SYLATRON BP
SYMDEKO BP
SYNAREL BN
SYNRIBO BP
tadalafil tab 20 mg (pah) GN
TAFINLAR BP
TAGRISSO BP
TALZENNA BN
TASIGNA4 BP
TAVALISSE BN
TAZVERIK BN
TECFIDERA BP
TEGSEDI BN
temozolomide cap GN
tetrabenazine tab GN
THALOMID BP
THIOLA BN
THIOLA EC BN
TIBSOVO BN
TOBI PODHALER BN
TOBRAMYCIN BN
tobramycin nebu soln GN
tobramycin ophth soln GP
TRACLEER BP
TREMFYA BP
TRETTEN BP
TRIKAFTA BP
TURALIO BN
TYKERB4 BP
TYMLOS BP
TYVASO BN
UDENYCA BP
UPTRAVI BP
VALCHLOR BP
VELTASSA BP
VENCLEXTA BP
VENTAVIS BN
VERZENIO BP
vigabatrin powder pack GN
vigabatrin tab GN
VISTOGARD BN+
VITRAKVI BP
VIZIMPRO BN
VONVENDI BP
VOSEVI BP
VOTRIENT BP
VUMERITY BP
VYNDAMAX BP
VYNDAQEL BP
WILATE BP
XADAGO BN+
XALKORI BP
XELJANZ BP
XELJANZ XR BP
XEPI BN
XERMELO BN
XOSPATA BN
XPOVIO BN
XTANDI BP
XURIDEN BN+
XYNTHA BP
XYNTHA SOLOFUSE BP
XYREM BN
YONSA BP
ZARXIO BP
ZEJULA BN
ZELBORAF BP
ZOLINZA BP
ZYDELIG BP
ZYKADIA BP
ZYTIGA BP

1Specialty

2Limited distribution

3Split fill

4Indicates exclusive to Alliance Rx Walgreens Prime preferred specialty