- You are here
- CAP
- Home
- Search plan resources
- Drugs
- Elite guide to prescription drug benefits - January
Elite prescription drug benefits
Effective January 1, 2022
Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the Elite formulary for the full list of drugs covered under your plan.
Key:
UPPERCASE names = Brand
lowercase names = Generic
Guide to prescription drug benefits
Your prescription drug coverage is one of the most important parts of your health plan.
Use this guide to understand how your benefits work.
Drug name(s) |
||
ACTEMRA 2 |
ACTEMRA ACTPEN 2 |
|
ACTHAR 2 |
ADEMPAS3 |
ADVATE 2 |
ADYNOVATE 2 |
||
AFSTYLA 2 |
AKLIEF |
|
ALPHANINE SD 2 |
ALPROLIX 2 |
ALUNBRIG3 |
alyq 2 |
ambrisentan 2 |
ARANESP ALBUMIN FREE 2 |
ARCALYST3 |
ARIKAYCE3 |
|
AUSTEDO 2 |
avita |
AVONEX 2 |
AVONEX PEN 2 |
||
BELBUCA |
BELSOMRA |
BENEFIX 2 |
BENLYSTA 2 |
BERINERT 2 |
BETASERON 2 |
bosentan 2 |
||
BRAFTOVI3 |
BRUKINSA3 |
|
CALQUENCE3 |
capecitabine 2 |
CAPRELSA3 |
CARBAGLU3 |
CERDELGA 2 |
CHORIONIC GONADOTROPIN 2 |
CIMZIA 2 |
CIMZIA STARTER KIT 2 |
CLOZAPINE ODT |
COAGADEX3 |
CONTRAVE |
|
CORLANOR |
COSENTYX 2 |
|
COSENTYX SENSOREADY PEN 2 |
COTELLIC 2 |
CRESEMBA |
dimethyl fumarate 2 |
dimethyl fumarate starterpack 2 |
DOPTELET3 |
DUPIXENT 2 |
ELMIRON |
ELOCTATE 2 |
EMPAVELI |
EMSAM |
ENBREL 2 |
ENBREL MINI 2 |
ENBREL SURECLICK 2 |
ENDARI3 |
ENDOMETRIN |
ENSPRYNG 2 |
EPCLUSA 2 |
EPIDIOLEX SOL 100MG/ML |
EPIDIOLEX SOL 100MG/ML 2 |
|
ERLEADA 2 |
ESBRIET 2 |
|
ESPEROCT 2 |
||
EVRYSDI3 |
FANAPT |
|
FANAPT TITRATION PACK |
FARYDAK CAP 10MG1 |
|
FARYDAK CAP 15MG1 |
FARYDAK CAP 20MG1 |
|
FASENRA PEN |
FAZACLO |
|
fentanyl |
fentanyl citrate oral transmucosal |
FETZIMA |
FETZIMA TITRATION PACK |
FIBRYGA |
FINTEPLA3 |
FIRDAPSE3 |
FLUOXETINE DR |
FOLLISTIM AQ 2 |
FORTEO 2 |
FOTIVDA |
GALAFOLD 2 |
ganirelix acetate 2 |
GATTEX3 |
|
GILENYA 2 |
GILOTRIF3 |
glatiramer acetate 2 |
HAEGARDA3 |
HARVONI 2 |
HEMLIBRA 2 |
HEMOFIL M 2 |
||
HUMIRA 2 |
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 2 |
HUMIRA PEN 2 |
HUMIRA PEN-CD/UC/HS STARTER 2 |
HUMIRA PEN-PEDIATRIC UC STARTER PACK 2 |
HUMIRA PEN-PS/UV STARTER 2 |
HYCAMTIN 2 |
HYDROCODONE CAP 10MG ER |
HYDROCODONE CAP 20MG ER |
HYDROCODONE CAP 15MG ER |
HYDROCODONE CAP 30MG ER |
HYDROCODONE CAP 40MG ER |
HYDROCODONE CAP 50MG ER |
IBRANCE 2 |
icatibant acetate 2 |
IDELVION 2 |
IDHIFA 2 |
|
IMBRUVICA3 |
IMCIVREE3 |
|
INGREZZA3 |
INQOVI 2 |
|
ISTURISA3 |
||
IXINITY 2 |
JIVI 2 |
|
JUXTAPID 3 |
JYNARQUE 2 |
KALYDECO 2 |
KESIMPTA 2 |
KEVZARA 2 |
KISQALI 2 |
KISQALI FEMARA 200 DOSE 2 |
KISQALI FEMARA 400 DOSE 2 |
KISQALI FEMARA 600 DOSE 2 |
KOATE 2 |
KOATE-DVI 2 |
KOGENATE FS 2 |
KORLYM 3 |
KOSELUGO 3 |
KOVALTRY 2 |
lapatinib ditosylate 2 |
||
lidocaine |
lidocaine hcl |
lidocaine patch 5% |
lidocaine/prilocaine |
LOMAIRA |
LONSURF 2 |
LUCEMYRA |
LUMAKRAS |
|
LUPKYNIS |
LYSODREN |
|
MATULANE 2 |
MAVYRET 2 |
MAYZENT 2 |
MAYZENT STARTER PACK |
MEKINIST 2 |
MEKTOVI 3 |
MENOPUR 2 |
methadone hcl |
METHITEST |
METHYLTESTOSTERONE |
miglustat 2 |
MIRCERA 2 |
MONONINE 2 |
morphine sulfate cr |
morphine sulfate er |
MULPLETA 2 |
MYALEPT 3 |
NATPARA 2 |
NEXLETOL |
||
NEXLIZET |
NINLARO 2 |
NOCTIVA |
NORDITROPIN FLEXPRO 2 |
NOVAREL 2 |
NOVOEIGHT 2 |
NOXAFIL |
NUBEQA 2 |
NUCALA |
NUCYNTA ER |
NUWIQ 2 |
OCALIVA 2 |
ONUREG 2 |
||
OPSUMIT 3 |
ORENCIA 2 |
ORENCIA CLICKJECT 2 |
ORENITRAM 3 |
ORGOVYX 3 |
ORIAHNN |
ORILISSA |
ORKAMBI 2 |
OTEZLA 2 |
OXBRYTA 3 |
OXERVATE 3 |
OXYCONTIN |
OXYMORPHONE HCL ER |
OXYMORPHONE HCL ER |
PALYNZIQ 3 |
PEGINTRON 2 |
PEMAZYRE 3 |
phentermine hcl |
PIQRAY 200MG DAILY DOSE 2 |
PIQRAY 250MG DAILY DOSE 2 |
PIQRAY 300MG DAILY DOSE 2 |
PLEGRIDY 2 |
PLEGRIDY STARTER PACK 2 |
POMALYST 2 |
posaconazole |
posaconazole dr |
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL 2 |
PROCYSBI 3 |
PROFILNINE 2 |
PROFILNINE SD 2 |
PROMACTA 2 |
QINLOCK 3 |
QSYMIA |
QUDEXY XR |
RAVICTI 2 |
REBIF 2 |
REBIF REBIDOSE 2 |
REBIF REBIDOSE TITRATION PACK 2 |
REBIF TITRATION PACK 2 |
REBINYN 2 |
RECOMBINATE 2 |
RETACRIT 2 |
REVLIMID 2 |
REYVOW |
|
RINVOQ 2 |
RISPERIDONE ODT |
RIXUBIS 2 |
RUCONEST 2 |
||
RUZURGI 3 |
RYDAPT 2 |
sajazir 2 |
sapropterin dihydrochloride 2 |
SAXENDA |
SECUADO |
sildenafil sus 10mg/ml |
sildenafil sus 10mg/ml 2 |
sildenafil tab 20mg 2 |
SIMPONI 2 |
SKYRIZI 2 |
SKYRIZI PEN 2 |
sodium phenylbutyrate 2 |
SOVALDI 2 |
|
STELARA 2 |
STIVARGA 2 |
STRENSIQ 3 |
SUCRAID |
SUNOSI |
|
SYMDEKO 2 |
TABRECTA 2 |
|
tadalafil 2 |
TAFINLAR 2 |
|
TAKHZYRO 3 |
||
TAVALISSE 3 |
tazarotene |
TAZVERIK 3 |
TEGSEDI 3 |
temozolomide 2 |
TEPMETKO4 |
testosterone |
testosterone cypionate |
TESTOST ENAN INJ 200MG/ML |
testosterone pump |
testosterone topical solution |
tetrabenazine tab 12.5mg1 |
tetrabenazine tab 25mg+ |
||
THALOMID 2 |
TIBSOVO 3 |
tolvaptan 2 |
topiramate er |
TRACLEER 2 |
tramadol hcl er |
TREMFYA 2 |
tretinoin |
TRIKAFTA 2 |
TRINTELLIX |
TROKENDI XR |
TRUSELTIQ |
TUKYSA 3 |
TURALIO 3 |
TYMLOS 2 |
TYVASO 3 |
TYVASO REFILL 3 |
TYVASO STARTER 3 |
UKONIQ4 |
UPTRAVI 3 |
VENCLEXTA 3 |
VENCLEXTA STARTING PACK 3 |
VERQUVO |
|
VERSACLOZ |
VIIBRYD |
|
VIIBRYD STARTER PACK |
||
voriconazole |
VOSEVI 2 |
|
VRAYLAR |
VYLEESI |
VYNDAMAX 2 |
VYNDAQEL 2 |
WEGOVY |
|
XELJANZ 2 |
XELJANZ XR 2 |
XENICAL |
XERMELO 3 |
XHANCE |
XOLAIR 2 |
XOSPATA 3 |
||
XPOVIO 40 MG ONCE WEEKLY4 |
XPOVIO 40 MG TWICE WEEKLY4 |
|
XPOVIO 60 MG TWICE WEEKLY4 |
||
XTAMPZA ER |
XYNTHA 2 |
|
XYNTHA SOLOFUSE 2 |
XYREM 3 |
XYWAV 3 |
ZELBORAF 2 |
||
ZEPOSIA 2 |
ZEPOSIA 7-DAY STARTER PACK 2 |
ZEPOSIA STARTER KIT 2 |
ZOKINVY 3 |
ZYDELIG 3 |
|
|
|
Drug name(s) |
||
AIMOVIG 2 |
AJOVY 2 |
BYDUREON BCISE |
BYDUREON PEN |
DEXCOM G5 MOBILE RECEIVERKIT |
DEXCOM G5 MOBILE TRANSMITTER KIT |
DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT |
DEXCOM G5 RECEIVER KIT |
DEXCOM G6 RECEIVER |
DEXCOM G6 SENSOR |
DEXCOM G6 TRANSMITTER |
EMGALITY 2 |
GRALISE |
HORIZANT |
NURTEC |
OTREXUP 2 |
OZEMPIC |
REDITREX |
RHOPRESSA |
ROCKLATAN |
RYBELSUS |
SOLIQUA 100/33 |
SUMATRIPTAN SUCCINATE |
TRULICITY |
UBRELVY |
VICTOZA |
XULTOPHY 100/3.6 |
Attention deficit hyperactivity disorder (ADHD)
Drug name(s) |
Quantity limits (per 30 days or as specified) |
amphetamine/dextroamphetamine cap 5mg er |
30 caps / 30 days |
amphetamine/dextroamphetamine cap 10mg er |
30 caps / 30 days |
amphetamine/dextroamphetamine cap 15mg er |
30 caps / 30 days |
amphetamine/dextroamphetamine cap 20mg er |
30 caps / 30 days |
amphetamine/dextroamphetamine cap 25mg er |
30 caps / 30 days |
amphetamine/dextroamphetamine cap 30mg er |
30 caps / 30 days |
amphetamine/dextroamphetamine tab 5mg |
60 tabs / 30 days |
amphetamine/dextroamphetamine tab 7.5mg |
60 tabs / 30 days |
amphetamine/dextroamphetamine tab 10mg |
60 tabs / 30 days |
amphetamine/dextroamphetamine tab 12.5mg |
60 tabs / 30 days |
amphetamine/dextroamphetamine tab 15mg |
60 tabs / 30 days |
amphetamine/dextroamphetamine tab 20mg |
90 tabs / 30 days |
amphetamine/dextroamphetamine tab 30mg |
60 tabs / 30 days |
atomoxetine cap 10mg |
60 caps / 30 days |
atomoxetine cap 18mg |
60 caps / 30 days |
atomoxetine cap 25mg |
60 caps / 30 days |
atomoxetine cap 40mg |
60 caps / 30 days |
atomoxetine cap 60mg |
30 caps / 30 days |
atomoxetine cap 80mg |
30 caps / 30 days |
atomoxetine cap 100mg |
30 caps / 30 days |
clonidine tab 0.1mg er |
120 tabs / 30 days |
CONTRAVE tab 8-90MG |
120 tabs / 30 days |
dexmethylphenidate cap 5mg er |
30 caps / 30 days |
dexmethylphenidate cap 10mg er |
30 caps / 30 days |
dexmethylphenidate cap 15mg er |
30 caps / 30 days |
dexmethylphenidate cap 20mg er |
30 caps / 30 days |
dexmethylphenidate cap er 25mg |
30 caps / 30 days |
dexmethylphenidate cap 30mg er |
30 caps / 30 days |
dexmethylphenidate cap er 35mg |
30 caps / 30 days |
dexmethylphenidate cap 40mg er |
30 caps / 30 days |
dexmethylphenidate tab 2.5mg |
60 tabs / 30 days |
dexmethylphenidate tab 5mg |
60 tabs / 30 days |
dexmethylphenidate tab 10mg |
60 tabs / 30 days |
dextroamphetamine cap 10mg er |
120 caps / 30 days |
dextroamphetamine cap 15mg er |
120 caps / 30 days |
dextroamphetamine cap 5mg er |
90 caps / 30 days |
dextroamphetamine sol 5mg/5ml |
1800 mLS / 30 days |
dextroamphetamine tab 5mg |
90 tabs / 30 days |
dextroamphetamine tab 10mg |
180 tabs / 30 days |
guanfacine tab 1mg er |
30 tabs / 30 days |
guanfacine tab 2mg er |
30 tabs / 30 days |
guanfacine tab 3mg er |
30 tabs / 30 days |
guanfacine tab 4mg er |
30 tabs / 30 days |
IMCIVREE INJ 10MG/mL 3 |
10 vials/ 30 days |
JORNAY PM CAP 20MG ER |
30 caps / 30 days |
JORNAY PM CAP 40MG ER |
30 caps / 30 days |
JORNAY PM CAP 60MG ER |
30 caps / 30 days |
JORNAY PM CAP 80MG ER |
30 caps / 30 days |
JORNAY PM CAP 100MG ER |
30 caps / 30 days |
LOMAIRA tab 8MG |
90 tabs / 30 days |
methylphenidate cap 10mg |
30 caps / 30 days |
methylphenidate cap 20mg |
30 caps / 30 days |
methylphenidate cap 30mg |
30 caps / 30 days |
methylphenidate cap 50mg |
30 caps / 30 days |
methylphenidate cap 20mg er |
30 caps / 30 days |
methylphenidate cap 30mg er |
30 caps / 30 days |
methylphenidate cap 40mg er |
30 caps / 30 days |
methylphenidate cap 60mg |
30 caps / 30 days |
methylphenidate chw 2.5mg |
90 tabs / 30 days |
methylphenidate chw 5mg |
90 tabs / 30 days |
methylphenidate chw 10mg |
180 tabs / 30 days |
methylphenidate sol 5mg/5ml |
450 mLS / 30 days |
methylphenidate sol 10mg/5ml |
900 mLS / 30 days |
methylphenidate tab 5mg |
90 tabs / 30 days |
methylphenidate tab 10mg |
90 tabs / 30 days |
methylphenidate tab 20mg |
90 tabs / 30 days |
methylphenidate tab 10mg er |
90 tabs / 30 days |
methylphenidate tab 18mg er |
30 tabs / 30 days |
methylphenidate tab 20mg er |
90 tabs / 30 days |
methylphenidate tab 27mg er |
30 tabs / 30 days |
methylphenidate tab 36mg er |
60 tabs / 30 days |
methylphenidate tab 54mg er |
30 tabs / 30 days |
phentermine cap 15mg |
30 caps / 30 days |
phentermine cap 30mg |
30 caps / 30 days |
phentermine cap 37.5mg |
30 caps / 30 days |
phentermine tab 37.5mg |
30 tabs / 30 days |
procentra sol 5mg/5ml |
1800 mLS / 30 days |
QSYMIA CAP 3.75-23 |
30 caps / 30 days |
QSYMIA CAP 7.5-46MG |
30 caps / 30 days |
QSYMIA CAP 11.25-69 |
30 caps / 30 days |
QSYMIA CAP 15-92MG |
30 caps / 30 days |
QUILLICHEW CHW 20MG ER |
30 tabs / 30 days |
QUILLICHEW CHW 30MG ER |
60 tabs / 30 days |
QUILLICHEW CHW 40MG ER |
30 tabs / 30 days |
QUILLIVANT SUS 25MG/5mL |
360 mLS / 30 days |
SAXENDA INJ 18MG/3mL |
15 mLS / 30 days |
SUNOSI tab 75MG |
30 tabs / 30 days |
SUNOSI tab 150MG |
30 tabs / 30 days |
VYVANSE CAP 10MG |
30 caps / 30 days |
VYVANSE CAP 20MG |
30 caps / 30 days |
VYVANSE CAP 30MG |
30 caps / 30 days |
VYVANSE CAP 40MG |
30 caps / 30 days |
VYVANSE CAP 50MG |
30 caps / 30 days |
VYVANSE CAP 60MG |
30 caps / 30 days |
VYVANSE CAP 70MG |
30 caps / 30 days |
VYVANSE CHW 10MG |
30 tabs / 30 days |
VYVANSE CHW 20MG |
30 tabs / 30 days |
VYVANSE CHW 30MG |
30 tabs / 30 days |
VYVANSE CHW 40MG |
30 tabs / 30 days |
VYVANSE CHW 50MG |
30 tabs / 30 days |
VYVANSE CHW 60MG |
30 tabs / 30 days |
WEGOVY INJ 0.25MG |
4 pens / 180 days |
WEGOVY INJ 0.5MG |
4 pens / 180 days |
WEGOVY INJ 1.7MG |
8 pens / 180 days |
WEGOVY INJ 1MG |
4 pens / 180 days |
WEGOVY INJ 2.4MG |
4 pens / 28 days |
XENICAL CAP 120MG |
90 caps / 30 days |
Aminoglycosides
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ARIKAYCE SUS 3 |
28 vials/ 28 days |
Analgesics – anti-inflammatory
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ACTEMRA INJ 162/0.9 2 |
4 syringes / 28 days |
ACTEMRA INJ ACTpen2 |
4 INJS / 28 days |
ARCALYST INJ 220MG 3 |
8 vials/ 28 days |
ENBREL INJ 25MG 2 |
8 vials/ 28 days |
ENBREL INJ 25/0.5mL 2 |
8 syringes / 28 days |
ENBREL INJ 50MG/mL 2 |
4 syringes / 28 days |
ENBREL MINI INJ 50MG/mL 2 |
4 cartS / 28 days |
ENBREL SRCLK INJ 50MG/mL 2 |
4 syringes / 28 days |
HUMIRA INJ 10/0.1mL 2 |
2 syringes / 28 days |
HUMIRA INJ 10MG/0.2 2 |
2 syringes / 28 days |
HUMIRA INJ 20/0.2mL 2 |
2 syringes / 28 days |
HUMIRA INJ 40/0.4mL 2 |
2 syringes / 28 days |
HUMIRA kit 20MG/0.4 2 |
2 syringes / 28 days |
HUMIRA kit 40MG/0.8 2 |
2 syringes / 28 days |
HUMIRA PEDIATRIC CROHNS DISEASE STARTER |
1 kit / 180 days |
HUMIRA pen inj 40/0.4mL 2 |
2 pens / 28 days |
HUMIRA pen inj 40MG/0.8 2 |
2 pens / 28 days |
HUMIRA pen inj 80/0.8mL 2 |
2 pens / 28 days |
HUMIRA pen inj CD/UC/HS 2 |
1 kit / 180 days |
HUMIRA pen inj PS/UV 2 |
1 kit / 180 days |
HUMIRA penkit CD/UC/HS 2 |
1 kit / 180 days |
HUMIRA penkit PED UC 2 |
4 pens / 180 days |
HUMIRA penkit PS/UV 2 |
1 kit / 180 days |
ketorolac tab 10mg |
20 tabs / 5 days |
KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14mL 2 |
2 syringes / 28 days |
KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14mL 2 |
2 syringes / 28 days |
KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14mL 2 |
2 pens / 28 days |
KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14mL 2 |
2 pens / 28 days |
ORENCIA INJ 125MG/mL 2 |
4 syringes / 28 days |
ORENCIA INJ 50/0.4mL 2 |
4 syringes / 28 days |
ORENCIA INJ 87.5/0.7 2 |
4 syringes / 28 days |
ORENCIA CLCK INJ 125MG/mL 2 |
4 syringes / 28 days |
OTEZLA tab 10/20/30 2 |
1 kit / 180 days |
OTEZLA tab 30MG 2 |
60 tabs / 30 days |
RINVOQ tab 15MG ER 2 |
30 tabs / 30 days |
SIMPONI INJ 100MG/mL 2 |
1 syringe / 28 days |
XELJANZ SOL 1MG/mL 2 |
240 mLS / 30 days |
XELJANZ tab 5MG 2 |
60 tabs / 30 days |
XELJANZ tab 10MG 2 |
240 tabs / 365 days |
XELJANZ XR tab 11MG 2 |
30 tabs / 30 days |
XELJANZ XR tab 22MG 2 |
120 tabs / 365 days |
Analgesics - opioids
Drug name(s) |
Adult quantity limit – 5 days |
Child quantity limit – 3 days |
apap/codeine sol 120-12/5 |
450 mL/30 days |
270 mL/30 days |
apap/codeine tab 300-15mg |
30 tablets/30 days |
18 tablets/30 days |
apap/codeine tab 300-30mg |
30 tablets/30 days |
18 tablets/30 days |
apap/codeine tab 300-60mg |
25 tablets/30 days |
15 tablets/30 days |
BELBUCA MIS 75MCG |
60 films/month |
N/A |
BELBUCA MIS 150MCG |
60 films/month |
N/A |
BELBUCA MIS 300MCG |
60 films/month |
N/A |
BELBUCA MIS 450MCG |
60 films/month |
N/A |
BELBUCA MIS 600MCG |
60 films/month |
N/A |
BELBUCA MIS 750MCG |
60 films/month |
N/A |
BELBUCA MIS 900MCG |
30 films/month |
N/A |
buprenorphine/naloxone mis 12-3mg |
60 FILMS / 30 days |
N/A |
buprenorphine/naloxone mis 2-0.5mg |
120 FILMS / 30 days |
N/A |
buprenorphine/naloxone mis 4-1mg |
60 tabs / 30 days |
N/A |
buprenorphine/naloxone mis 8-2mg |
60 FILMS / 30 days |
N/A |
buprenorphine/naloxone sub 2-0.5mg |
120 tabs / 30 days |
N/A |
buprenorphine/naloxone sub 8-2mg |
90 tabs / 30 days |
N/A |
buprenorphine sub 2mg |
15 tabs / 90 days |
N/A |
buprenorphine sub 8mg |
15 tabs / 90 days |
N/A |
butorphanol sol 10mg/ml |
2.5 mL (1 bottleLE)/30 days |
0 mL/30 days |
codeine sulf tab 30mg |
30 tablets/30 days |
18 tablets/30 days |
CODEINE SULF tab 15MG |
30 tablets/30 days |
18 tablets/30 days |
CODEINE SULF tab 60MG |
25 tablets/30 days |
15 tablets/30 days |
codeine/apap tab 30-300mg |
30 tablets/30 days |
18 tablets/30 days |
codeine/apap tab 60-300mg |
25 tablets/30 days |
15 tablets/30 days |
endocet tab 2.5-325 |
60 tablets/30 days |
36 tablets/30 days |
endocet tab 5-325mg |
30 tablets/30 days |
18 tablets/30 days |
endocet tab 7.5-325 |
20 tablets/30 days |
12 tablets/30 days |
endocet tab 10-325mg |
15 tablets/30 days |
|
fentanyl dis 12mcg/hr |
10 patches/month |
N/A |
fentanyl dis 25mcg/hr |
0 patches/month |
N/A |
fentanyl dis 50mcg/hr |
0 patches/month |
N/A |
fentanyl dis 75mcg/hr |
0 patches/month |
N/A |
fentanyl dis 100mcg/h |
0 patches/month |
N/A |
fentanyl ot loz 200mcg |
120 lozenges / 30 days |
N/A |
fentanyl ot loz 400mcg |
120 lozenges / 30 days |
N/A |
fentanyl ot loz 600mcg |
120 lozenges / 30 days |
N/A |
fentanyl ot loz 800mcg |
120 lozenges / 30 days |
N/A |
fentanyl ot loz 1200mcg |
120 lozenges / 30 days |
N/A |
fentanyl ot loz 1600mcg |
120 lozenges / 30 days |
N/A |
hydrocodone/apap sol 7.5-325 |
450 mL/30 days |
270 mL/30 days |
hydrocodone/apap tab 5-325mg |
40 tablets/30 days |
24 tablets/30 days |
hydrocodone/apap tab 7.5-325 |
30 tablets/30 days |
18 tablets/30 days |
hydrocodone/apap tab 10-325mg |
25 tablets/30 days |
15 tablets/30 days |
HYDROCOD/IBUPROFEN tab 5-200MG |
25 tablets/30 days |
15 tablets/30 days |
hydrocodone/ibuprofen tab 5-200mg |
25 tablets/30 days |
15 tablets/30 days |
hydrocodone/ibuprofen tab 7.5-200 |
25 tablets/30 days |
15 tablets/30 days |
hydrocodone/ibuprofen tab 10-200mg |
25 tablets/30 days |
15 tablets/30 days |
hydrocodone cap 10mg er |
60 capsules/30 days |
N/A |
hydrocodone cap 15mg er |
60 capsules/30 days |
N/A |
hydrocodone cap 30mg er |
30 capsules/30 days |
N/A |
hydrocodone cap 40mg er |
30 capsules/30 days |
N/A |
hydrocodone cap 50mg er |
30 capsules/30 days |
N/A |
HYDROCODONE CAP 10MG ER |
60 capsules/30 days |
N/A |
HYDROCODONE CAP 15MG ER |
60 capsules/30 days |
N/A |
HYDROCODONE CAP 20MG ER |
60 capsules/30 days |
N/A |
HYDROCODONE CAP 30MG ER |
30 capsules/30 days |
N/A |
HYDROCODONE CAP 40MG ER |
30 capsules/30 days |
N/A |
HYDROCODONE CAP 50MG ER |
30 capsules/30 days |
N/A |
hydromorphone liq 1mg/ml |
60 mL/30 days |
|
hydromorphone tab 2mg |
30 tablets/30 days |
18 tablets/30 days |
hydromorphone tab 4mg |
15 tablets/30 days |
9 tablets/30 days |
hydromorphone tab 8mg |
5 tablets/30 days |
3 tablets/30 days |
lorcet tab 5-325mg |
40 tablets/30 days |
24 tablets/30 days |
lorcet hd tab 10-325mg |
25 tablets/30 days |
15 tablets/30 days |
lorcet plus tab 7.5-325 |
30 tablets/30 days |
18 tablets/30 days |
methadone sol 5mg/5ml |
300 mL/30 days |
N/A |
methadone sol 10mg/5ml |
150 mL/30 days |
N/A |
methadone tab 5mg |
60 tablets/30 days |
N/A |
methadone tab 10mg |
30 tablets/30 days |
N/A |
morphine sul cap 10mg er |
30 capsules/30 days |
N/A |
morphine sul cap 20mg er |
30 capsules/30 days |
N/A |
morphine sul cap 30mg er |
30 capsules/30 days |
N/A |
morphine sul cap 50mg er |
30 capsules/30 days |
N/A |
morphine sul cap 60mg er |
0 capsules/30 days |
N/A |
morphine sul cap 80mg er |
0 capsules/30 days |
N/A |
morphine sul cap 100mg er |
0 capsules/30 days |
N/A |
morphine sul sol 10/0.5ml |
15 mL/30 days |
15 mL/30 days |
morphine sul sol 10mg/5ml |
125 mL/30 days |
75 mL/30 days |
morphine sul sol 20mg/5ml |
60 mL/30 days |
36 mL/30 days |
morphine sul sol 20mg/ml |
15 mL/30 days |
15 mL/30 days |
morphine sul sol 100/5ml |
15 mL/30 days |
|
morphine sul tab 15mg |
15 tablets/30 days |
9 tablets/30 days |
morphine sul tab 30mg |
5 tablets/30 days |
|
morphine sul tab 100mg cr |
0 tablets/30 days |
N/A |
morphine sul tab 15mg er |
60 tablets/30 days |
N/A |
morphine sul tab 30mg er |
30 tablets/30 days |
N/A |
morphine sul tab 60mg er |
0 tablets/30 days |
N/A |
morphine sul tab 200mg er |
0 tablets/30 days |
N/A |
morphine sul tab 100mg er |
0 tablets/30 days |
N/A |
MORPHINE SUL tab 15MG |
15 tablets/30 days |
|
MORPHINE SUL tab 30MG |
5 tablets/30 days |
3 tablets/30 days |
NUCYNTA ER tab 50MG |
60 tablets/30 days |
N/A |
NUCYNTA ER tab 100MG |
30 tablets/30 days |
N/A |
NUCYNTA ER tab 150MG |
0 tablets/30 days |
N/A |
NUCYNTA ER tab 200MG |
0 tablets/30 days |
N/A |
NUCYNTA ER tab 250MG |
0 tablets/30 days |
N/A |
oxycodone/apap tab 2.5-325 |
60 tablets/30 days |
36 tablets/30 days |
oxycodone/apap tab 5-325mg |
30 tablets/30 days |
18 tablets/30 days |
oxycodone/apap tab 7.5-325 |
20 tablets/30 days |
12 tablets/30 days |
oxycodone/apap tab 10-325mg |
15 tablets/30 days |
9 tablets/30 days |
OXYCOD/ASPIRIN tab |
30 tablets/30 days |
18 tablets/30 days |
OXYCOD/IBUPROFEN tab 5-400MG |
20 tablets/30 days |
12 tablets/30 days |
oxycodone cap 5mg |
30 capsules/30 days |
18 capsules/30 days |
oxycodone cap hcl 5mg |
30 capsules/30 days |
18 capsules/30 days |
oxycodone con 10/0.5ml |
5 mL/30 days |
3 mL/30 days |
oxycodone con 100/5ml |
5 mL/30 days |
3 mL/30 days |
oxycodone sol 5mg/5ml |
165 mL/30 days |
99 mL/30 days |
oxycodone tab 5mg |
30 tablets/30 days |
18 tablets/30 days |
oxycodone tab 10mg |
15 tablets/30 days |
9 tablets/30 days |
oxycodone tab 15mg |
10 tablets/30 days |
6 tablets/30 days |
oxycodone tab 20mg |
5 tablets/30 days |
3 tablets/30 days |
oxycodone tab 30mg |
5 tablets/30 days |
3 tablets/30 days |
OXYCONTIN tab 10MG CR |
60 tablets/30 days |
N/A |
OXYCONTIN tab 15MG CR |
60 tablets/30 days |
N/A |
OXYCONTIN tab 20MG CR |
30 tablets/30 days |
N/A |
OXYCONTIN tab 30MG CR |
30 tablets/30 days |
N/A |
OXYCONTIN tab 40MG CR |
0 tablets/30 days |
N/A |
OXYCONTIN tab 60MG CR |
0 tablets/30 days |
N/A |
OXYCONTIN tab 80MG CR |
0 tablets/30 days |
N/A |
OXYMORPHONE tab 5MG ER |
60 tablets/30 days |
N/A |
OXYMORPHONE tab 7.5MG ER |
60 tablets/30 days |
N/A |
OXYMORPHONE tab 10MG ER |
30 tablets/30 days |
N/A |
OXYMORPHONE tab 15MG ER |
30 tablets/30 days |
N/A |
OXYMORPHONE tab 20MG ER |
0 tablets/30 days |
N/A |
OXYMORPHONE tab 30MG ER |
0 tablets/30 days |
N/A |
OXYMORPHONE tab 40MG ER |
0 tablets/30 days |
N/A |
oxymorphone tab hcl 5mg |
15 tablets/30 days |
9 tablets/30 days |
oxymorphone tab hcl 10mg |
5 tablets/30 days |
3 tablets/30 days |
tramadol/apap tab 37.5-325 |
40 tablets/30 days |
24 tablets/30 days |
tramadol hcl tab 50mg |
50 tablets/30 days |
30 tablets/30 days |
tramadol hcl tab 100mg er |
30 tablets/30 days |
N/A |
tramadol hcl tab 200mg er |
30 tablets/30 days |
N/A |
tramadol hcl tab 300mg er |
30 tablets/30 days |
N/A |
XTAMPZA ER CAP 9MG |
60 capsules/30 days |
N/A |
XTAMPZA ER CAP 13.5MG |
60 capsules/30 days |
N/A |
XTAMPZA ER CAP 18MG |
30 capsules/30 days |
N/A |
XTAMPZA ER CAP 27MG |
30 capsules/30 days |
N/A |
XTAMPZA ER CAP 36MG |
0 capsules/30 days |
N/A |
ZUBSOLV SUB 0.7-0.18 |
30 tabs / 30 days |
N/A |
ZUBSOLV SUB 1.4-0.36 |
90 tabs / 30 days |
N/A |
ZUBSOLV SUB 2.9-0.71 |
30 tabs / 30 days |
N/A |
ZUBSOLV SUB 5.7-1.4 |
30 tabs / 30 days |
N/A |
ZUBSOLV SUB 8.6-2.1 |
60 tabs / 30 days |
N/A |
ZUBSOLV SUB 11.4-2.9 |
30 tabs / 30 days |
N/A |
Androgens - anabolic
Drug name(s) |
Quantity limits (per 30 days or as specified) |
METHITEST tab 10MG |
600 tabs / 30 days |
METHYLTESTOS CAP 10MG |
600 caps / 30 days |
testost cyp inj 100mg/ml |
1 vial / 28 days |
testost cyp inj 200mg/ml |
10 mLS / 28 days |
TESTOST ENAN INJ 200MG/mL |
1 vial / 28 days |
testost enan inj 200mg/ml |
1 vial / 28 days |
testosterone gel 1%(25mg) |
60 packets/ 30 days |
testosterone gel 1%(50mg) |
60 packets/ 30 days |
testosterone gel pump 1% |
4 bottles / 30 days |
testosterone sol 30mg/act |
2 bottles / 30 days |
testosterone td gel 20.25 mg/1.25gm (1.62%) |
30 packets/ 30 days |
testosterone td gel 20.25 mg/act (1.62%) |
2 bottles / 30 days |
testosterone td gel 40.5 mg/2.5gm (1.62%) |
60 packets/ 30 days |
Antiasthmatic and bronchodilator agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ADVAIR DISKU AER 100/50 |
60 blisters / 30 days |
ADVAIR DISKU AER 250/50 |
60 blisters / 30 days |
ADVAIR DISKU AER 500/50 |
60 blisters / 30 days |
ADVAIR HFA AER 45/21 |
1 can / 30 days |
ADVAIR HFA AER 115/21 |
1 can / 30 days |
ADVAIR HFA AER 230/21 |
1 can / 30 days |
albuterol aer hfa |
2 cans / 30 days |
ANORO ELLIPT AER 62.5-25 |
1 inhaler / 30 days |
ARCAPTA CAP 75MCG |
30 caps / 30 days |
ARNUITY ELPT INH 50MCG |
30 blisters / 30 days |
ARNUITY ELPT INH 100MCG |
30 blisters / 30 days |
ARNUITY ELPT INH 200MCG |
30 blisters / 30 days |
ASMANEX 14 AER 220MCG |
1 can / 30 days |
ASMANEX 30 AER 110MCG |
1 can / 30 days |
ASMANEX 30 AER 220MCG |
1 can / 30 days |
ASMANEX 60 AER 220MCG |
1 can / 30 days |
ASMANEX 120 AER 220MCG |
1 can / 30 days |
ASMANEX HFA AER 50MCG |
1 inhaler / 30 days |
ASMANEX HFA AER 100 MCG |
1 can / 30 days |
ASMANEX HFA AER 200 MCG |
1 can / 30 days |
ATROVENT HFA AER 17MCG |
2 cans / 30 days |
BREO ELLIPTA INH 100-25 |
60 blisters / 30 days |
BREO ELLIPTA INH 200-25 |
60 blisters / 30 days |
BREZTRI AERO AER SPHERE |
1 can / 30 days |
COMBIVENT AER 20-100 |
2 cans / 30 days |
DULERA AER 50-5MCG |
1 inhaler / 30 days |
DULERA AER 100-5MCG |
1 can / 30 days |
DULERA AER 200-5MCG |
1 can / 30 days |
FASENRA pen inj 30MG/mL |
1 pen/ 56 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 can / 30 days |
FLOVENT HFA AER 110MCG |
1 can / 30 days |
FLOVENT HFA AER 220MCG |
2 cans / 30 days |
FLUTIC/SALME INH 55/14 |
1 inhaler / 30 days |
FLUTIC/SALME INH 113/14 |
1 inhaler / 30 days |
FLUTIC/SALME INH 232/14 |
1 inhaler / 30 days |
INCRUSE ELPT INH 62.5MCG |
30 blisters / 30 days |
NUCALA INJ 100MG/mL |
3 syringes / 28 days |
QVAR REDIHA AER 80MCG |
2 cans / 30 days |
QVAR REDIHAL AER 40MCG |
1 can / 30 days |
SEREVENT DIS AER 50MCG |
60 blisters / 30 days |
SPIRIVA AER 1.25MCG |
1 cart / 30 days |
SPIRIVA CAP HANDIHLR |
30 caps / 30 days |
SPIRIVA SPR 2.5MCG |
1 cart / 30 days |
STIOLTO AER 2.5-2.5 |
1 cart / 30 days |
STRIVERDI AER 2.5MCG |
1 cart / 30 days |
SYMBICORT AER 80-4.5 |
1 can / 30 days |
SYMBICORT AER 160-4.5 |
1 can / 30 days |
TRELEGY AER ELLIPTA |
1 inhaler / 30 days |
VENTOLIN HFA AER |
2 cans / 30 days |
Anticoagulants
Drug name(s) |
Quantity limits (per 30 days or as specified) |
BEVYXXA CAP 40MG |
43 caps / 42 days |
BEVYXXA CAP 80MG |
43 caps / 42 days |
ELIQUIS tab 2.5MG |
60 tabs / 30 days |
ELIQUIS tab 5MG |
74 tabs / 30 days |
ELIQUIS ST P tab 5MG |
1 pack / 180 days |
enoxaparin inj 100mg/ml |
30 syringes / 90 days |
enoxaparin inj 120/0.8 |
30 syringes / 90 days |
enoxaparin inj 150mg/ml |
30 syringes / 90 days |
enoxaparin inj 30/0.3ml |
30 syringes / 90 days |
enoxaparin inj 300/3ml |
10 vials/ 90 days |
enoxaparin inj 40/0.4ml |
30 syringes / 90 days |
enoxaparin inj 60/0.6ml |
30 syringes / 90 days |
enoxaparin inj 80/0.8ml |
30 syringes / 90 days |
fondaparinux inj 10/0.8ml |
30 syringes / 90 days |
fondaparinux inj 5/0.4ml |
30 syringes / 90 days |
fondaparinux inj 7.5/0.6 |
30 syringes / 90 days |
FRAGMIN INJ 10000/mL |
30 syringes / 90 days |
FRAGMIN INJ 12500UNT |
30 syringes / 90 days |
FRAGMIN INJ 15000UNT |
30 syringes / 90 days |
FRAGMIN INJ 18000UNT |
30 syringes / 90 days |
FRAGMIN INJ 2500/0.2 |
30 syringes / 90 days |
FRAGMIN INJ 5000/0.2 |
30 syringes / 90 days |
FRAGMIN INJ 7500/0.3 |
30 syringes / 90 days |
FRAGMIN INJ 95000UNT |
10 vials/ 90 days |
PRADAXA CAP 75MG |
60 caps / 30 days |
PRADAXA CAP 110MG |
71 caps / 90 days |
PRADAXA CAP 150MG |
60 caps / 30 days |
XARELTO tab 2.5MG |
60 tabs / 30 days |
XARELTO tab 10MG |
30 tabs / 30 days |
XARELTO tab 15MG |
60 tabs / 30 days |
XARELTO tab 20MG |
30 tabs / 30 days |
XARELTO STAR tab 15/20MG |
51 tabs / 30 days |
Anticonvulsants
Drug name(s) |
Quantity limits (per 30 days or as specified) |
FINTEPLA SOL 2.2MG/mL 3 |
360 mLS / 30 days |
NAYZILAM SPR 5MG |
10 bottles / 30 days |
QUDEXY XR CAP 25/24HR |
30 caps / 30 days |
QUDEXY XR CAP 50/24HR |
30 caps / 30 days |
QUDEXY XR CAP 100/24HR |
30 caps / 30 days |
QUDEXY XR CAP 150/24HR |
30 caps / 30 days |
QUDEXY XR CAP 200/24HR |
60 caps / 30 days |
TROKENDI XR CAP 25MG |
30 caps / 30 days |
TROKENDI XR CAP 50MG |
30 caps / 30 days |
TROKENDI XR CAP 100MG |
30 caps / 30 days |
TROKENDI XR CAP 200MG |
60 caps / 30 days |
VALTOCO SPR 10MG |
5 boxes / 30 days |
VALTOCO SPR 15MG |
5 boxes / 30 days |
VALTOCO SPR 20MG |
5 boxes / 30 days |
VALTOCO SPR 5MG |
5 boxes / 30 days |
pregabalin cap 25mg |
90 caps / 30 days |
pregabalin cap 50mg |
90 caps / 30 days |
pregabalin cap 75mg |
90 caps / 30 days |
pregabalin cap 100mg |
90 caps / 30 days |
pregabalin cap 150mg |
90 caps / 30 days |
pregabalin cap 200mg |
90 caps / 30 days |
pregabalin cap 225mg |
60 caps / 30 days |
pregabalin cap 300mg |
60 caps / 30 days |
pregabalin sol 20mg/ml |
900 mLS / 30 days |
topiramate cap er 25mg |
30 caps / 30 days |
topiramate cap er 50mg |
30 caps / 30 days |
topiramate cap er 100mg |
30 caps / 30 days |
topiramate cap er 150mg |
30 caps / 30 days |
topiramate cap er 200mg |
60 caps / 30 days |
Antidiabetics
Drug name(s) |
Quantity limits (per 30 days or as specified) |
BYDUREON BC INJ 2/0.85mL |
4 pens / 28 days |
BYDUREON pen inj 2MG |
4 pens / 28 days |
FARXIGA tab 5MG |
30 tabs / 30 days |
FARXIGA tab 10MG |
30 tabs / 30 days |
FIASP INJ 100/mL |
100 mLS / 30 days |
FIASP FLEX INJ TOUCH |
100 mLS / 30 days |
FIASP PENFIL INJ U-100 |
100 mLS / 30 days |
GLYXAMBI tab 10-5 MG |
30 tabs / 30 days |
GLYXAMBI tab 25-5 MG |
30 tabs / 30 days |
HUMULIN R INJ U-500 |
100 mLS / 30 days |
JANUMET tab 50-1000 |
60 tabs / 30 days |
JANUMET tab 50-500MG |
60 tabs / 30 days |
JANUMET XR tab 100-1000 |
30 tabs / 30 days |
JANUMET XR tab 50-1000 |
60 tabs / 30 days |
JANUMET XR tab 50-500MG |
30 tabs / 30 days |
JANUVIA tab 100MG |
30 tabs / 30 days |
JANUVIA tab 25MG |
30 tabs / 30 days |
JANUVIA tab 50MG |
30 tabs / 30 days |
JARDIANCE tab 10MG |
30 tabs / 30 days |
JARDIANCE tab 25MG |
30 tabs / 30 days |
KORLYM tab 300MG 3 |
120 tabs / 30 days |
LEVEMIR INJ |
100 mLS / 30 days |
LEVEMIR INJ FLEXTOUC |
100 mLS / 30 days |
metformin tab 750mg er |
60 tabs / 30 days |
metformin hcl tab er 24hr 500 mg |
120 tabs / 30 days |
NOVOLIN INJ 70/30 |
100 mLS / 30 days |
NOVOLIN INJ 70/30 FP |
100 mLS / 30 days |
NOVOLIN N INJ 100 UNIT |
100 mLS / 30 days |
NOVOLIN N INJ RELION |
100 mLS / 30 days |
NOVOLIN N INJ U-100 |
100 mLS / 30 days |
NOVOLIN R INJ 100 UNIT |
100 mLS / 30 days |
NOVOLIN R INJ RELION |
100 mLS / 30 days |
NOVOLIN R INJ U-100 |
100 mLS / 30 days |
NOVOLIN70/30 INJ RELION |
100 mLS / 30 days |
NOVOLOG INJ 100/mL |
100 mLS / 30 days |
NOVOLOG INJ FLEXPEN |
100 mLS / 30 days |
NOVOLOG INJ PENFILL |
100 mLS / 30 days |
NOVOLOG INJ RELION |
100 mLS / 30 days |
NOVOLOG MIX INJ 70/30 |
100 mLS / 30 days |
NOVOLOG MIX INJ FLEX REL |
100 mLS / 30 days |
NOVOLOG MIX INJ FLEXPEN |
100 mLS / 30 days |
NOVOLOG RELI INJ 70/30 |
100 mLS / 30 days |
OZEMPIC INJ 4MG/3mL |
3 pens / 28 days |
OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 0.25 OR |
1 pen/ 28 days |
OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 1 |
2 pens / 28 days |
RYBELSUS tab 14MG |
30 tabs / 30 days |
RYBELSUS tab 3MG |
30 tabs / 180 days |
RYBELSUS tab 7MG |
30 tabs / 30 days |
SEMGLEE INJ 100U/mL |
100 mLS / 30 days |
SEMGLEE SOL 100U/mL |
100 mLS / 30 days |
SOLIQUA INJ 100/33 |
6 pens / 30 days |
SYNJARDY tab |
60 tabs / 30 days |
SYNJARDY tab 12.5-500 |
60 tabs / 30 days |
SYNJARDY tab 5-1000MG |
60 tabs / 30 days |
SYNJARDY tab 5-500MG |
60 tabs / 30 days |
SYNJARDY XR tab |
60 tabs / 30 days |
SYNJARDY XR tab 10-1000 |
60 tabs / 30 days |
SYNJARDY XR tab 25-1000 |
30 tabs / 30 days |
SYNJARDY XR tab 5-1000MG |
60 tabs / 30 days |
TOUJEO MAX INJ 300IU/mL |
100 mLS / 30 days |
TOUJEO SOLO INJ 300IU/mL |
100 mLS / 30 days |
TRESIBA INJ 100UNIT |
100 mLS / 30 days |
TRESIBA FLEX INJ 100UNIT |
100 mLS / 30 days |
TRESIBA FLEX INJ 200UNIT |
100 mLS / 30 days |
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIP4 |
60 tabs / 30 days |
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN4 |
30 tabs / 30 days |
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN4 |
30 tabs / 30 days |
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN4 |
60 tabs / 30 days |
TRULICITY INJ 0.75/0.5 |
4 pens / 28 days |
TRULICITY INJ 1.5/0.5 |
4 pens / 28 days |
TRULICITY INJ 3/0.5 |
2 pens / 28 days |
TRULICITY INJ 4.5/0.5 |
2 pens / 28 days |
VICTOZA INJ 18MG/3mL |
3 pens / 30 days |
XIGDUO XR tab 10-1000 |
30 tabs / 30 days |
XIGDUO XR tab 10-500MG |
30 tabs / 30 days |
XIGDUO XR tab 2.5-1000 |
60 tabs / 30 days |
XIGDUO XR tab 5-1000MG |
60 tabs / 30 days |
XIGDUO XR tab 5-500MG |
30 tabs / 30 days |
XULTOPHY INJ 100/3.6 |
5 pens / 30 days |
Antidotes and specific antagonists
Drug name(s) |
Quantity limits (per 30 days or as specified) |
30 packets/ 30 days |
|
30 packets/ 30 days |
|
180 packets/ 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
180 tabs / 30 days |
|
90 tabs / 30 days |
Antiemetics
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ANZEMET tab 100MG |
7 tabs / 30 days |
ANZEMET tab 50MG |
7 tabs / 30 days |
aprepitant cap 125mg |
4 caps / 30 days |
aprepitant cap 40mg |
8 caps / 30 days |
aprepitant cap 80mg |
8 caps / 30 days |
aprepitant pak 80 & 125 |
4 packS / 30 days |
EMEND SUS 125MG |
6 packS / 30 days |
granisetron tab 1mg |
14 tabs / 30 days |
ondansetron sol 4mg/5ml |
5 bottles / 30 days |
ONDANSETRON tab 24MG |
4 tabs / 30 days |
ondansetron tab 4mg |
24 tabs / 30 days |
ondansetron tab 4mg odt |
24 tabs / 30 days |
ondansetron tab 8mg |
24 tabs / 30 days |
ondansetron tab 8mg odt |
24 tabs / 30 days |
VARUBI tab 90MG |
4 tabs / 30 days |
Antihyperlipidemics
Drug name(s) |
Quantity limits (per 30 days or as specified) |
JUXTAPID CAP 5MG 3 |
30 caps / 30 days |
JUXTAPID CAP 10MG 3 |
30 caps / 30 days |
JUXTAPID CAP 20MG 3 |
30 caps / 30 days |
JUXTAPID CAP 30MG 3 |
30 caps / 30 days |
JUXTAPID CAP 40MG 3 |
30 caps / 30 days |
JUXTAPID CAP 60MG 3 |
30 caps / 30 days |
NEXLETOL tab 180MG |
30 tabs / 30 days |
NEXLIZET tab 180/10MG |
30 tabs / 30 days |
Anti-infective agents - misc
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ALINIA SUS 100/5mL |
300 mLS / 90 days |
nitazoxanide tab 500mg |
12 tabs / 90 days |
Antimyasthenic/cholinergic agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
FIRDAPSE tab 10MG 3 |
240 tabs / 30 days |
RUZURGI tab 10MG 3 |
300 tabs / 30 days |
|
Antineoplastics and adjunctive therapies
Drug name(s) |
Quantity limits (per 30 days or as specified) |
120 tabs / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
90 tabs / 30 days |
|
60 tabs / 30 days |
|
240 caps / 30 days |
|
ALUNBRIG PAK 3 |
30 tabs / 180 days |
ALUNBRIG tab 180MG 3 |
30 tabs / 30 days |
ALUNBRIG tab 30MG 3 |
120 tabs / 30 days |
ALUNBRIG tab 90MG 3 |
30 tabs / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
BRAFTOVI CAP 75MG 3 |
180 caps / 30 days |
BRUKINSA CAP 80MG 3 |
120 caps / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
CALQUENCE CAP 100MG 3 |
60 caps / 30 days |
CAPRELSA tab 100MG 3 |
60 tabs / 30 days |
CAPRELSA tab 300MG 3 |
30 tabs / 30 days |
1 carton / 28 days |
|
1 carton / 28 days |
|
1 carton / 28 days |
|
56 caps / 28 days |
|
56 caps / 28 days |
|
COTELLIC tab 20MG 2 |
63 tabs / 28 days |
30 tabs / 30 days |
|
60 tabs / 30 days |
|
30 caps / 30 days |
|
ERLEADA tab 60MG 2 |
120 tabs / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
everolimus tab 10mg 1,4 |
30 tabs / 30 days |
30 tabs / 30 days |
|
everolimus tab 2.5mg 1,4 |
30 tabs / 30 days |
everolimus tab 2mg 1,4 |
60 tabs / 30 days |
everolimus tab 3mg 1,4 |
90 tabs / 30 days |
30 tabs / 30 days |
|
everolimus tab 5mg 1,4 |
60 tabs / 30 days |
everolimus tab 5mg 1,4 |
30 tabs / 30 days |
30 tabs / 30 days |
|
everolimus tab 7.5mg 1,4 |
30 tabs / 30 days |
FARYDAK CAP 10MG |
6 caps / 21 days |
FARYDAK CAP 10MG 2 |
6 caps / 21 days |
FARYDAK CAP 15MG |
6 caps / 21 days |
FARYDAK CAP 15MG 2 |
6 caps / 21 days |
FARYDAK CAP 20MG |
6 caps / 21 days |
FARYDAK CAP 20MG 2 |
6 caps / 21 days |
FOTIVDA CAP 0.89MG |
21 caps / 28 days |
FOTIVDA CAP 1.34MG |
21 caps / 28 days |
120 caps / 30 days |
|
GILOTRIF tab 20MG 3 |
30 tabs / 30 days |
GILOTRIF tab 30MG 3 |
30 tabs / 30 days |
GILOTRIF tab 40MG 3 |
30 tabs / 30 days |
IBRANCE CAP 100MG 2 |
21 caps / 28 days |
IBRANCE CAP 125MG 2 |
21 caps / 28 days |
IBRANCE CAP 75MG 2 |
21 caps / 28 days |
IBRANCE tab 100MG 2 |
21 tabs / 28 days |
IBRANCE tab 125MG 2 |
21 tabs / 28 days |
IBRANCE tab 75MG 2 |
21 tabs / 28 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
IDHIFA tab 100MG 2 |
30 tabs / 30 days |
IDHIFA tab 50MG 2 |
30 tabs / 30 days |
90 tabs / 30 days |
|
60 tabs / 30 days |
|
IMBRUVICA CAP 140MG 3 |
90 caps / 30 days |
IMBRUVICA CAP 70MG 3 |
30 caps / 30 days |
IMBRUVICA tab 140MG 3 |
30 tabs / 30 days |
IMBRUVICA tab 280MG 3 |
30 tabs / 30 days |
IMBRUVICA tab 420MG 3 |
30 tabs / 30 days |
IMBRUVICA tab 560MG 3 |
30 tabs / 30 days |
180 tabs / 30 days |
|
120 tabs / 30 days |
|
INQOVI tab 35-100MG 2 |
5 tabs / 28 days |
120 caps / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
KISQALI tab 200DOSE 2 |
63 tabs / 28 days |
KISQALI tab 400DOSE 2 |
63 tabs / 28 days |
KISQALI tab 600DOSE 2 |
63 tabs / 28 days |
KISQALI 200 PAK FEMARA 2 |
91 tabs / 28 days |
KISQALI 400 PAK FEMARA 2 |
91 tabs / 28 days |
KISQALI 600 PAK FEMARA 2 |
91 tabs / 28 days |
KOSELUGO CAP 10MG 3 |
240 caps / 30 days |
KOSELUGO CAP 25MG 3 |
120 caps / 30 days |
lapatinib tab 250mg 2 |
180 tabs / 30 days |
30 caps / 30 days |
|
90 caps / 30 days |
|
60 caps / 30 days |
|
90 caps / 30 days |
|
60 caps / 30 days |
|
90 caps / 30 days |
|
30 caps / 30 days |
|
60 caps / 30 days |
|
LONSURF tab 15-6.14 2 |
60 tabs / 28 days |
LONSURF tab 20-8.19 2 |
80 tabs / 28 days |
30 tabs / 30 days |
|
90 tabs / 30 days |
|
LUMAKRAS tab 120MG |
240 tabs / 30 days |
120 tabs / 30 days |
|
120 tabs / 30 days |
|
MEKINIST tab 0.5MG 2 |
90 tabs / 30 days |
MEKINIST tab 2MG 2 |
30 tabs / 30 days |
MEKTOVI tab 15MG 3 |
180 tabs / 30 days |
180 tabs / 30 days |
|
120 tabs / 30 days |
|
NINLARO CAP 2.3MG 2 |
3 caps / 28 days |
NINLARO CAP 3MG 2 |
3 caps / 28 days |
NINLARO CAP 4MG 2 |
3 caps / 28 days |
NUBEQA tab 300MG 2 |
120 tabs / 30 days |
30 caps / 30 days |
|
ONUREG tab 200MG 2 |
14 tabs / 28 days |
ONUREG tab 300MG 2 |
14 tabs / 28 days |
ORGOVYX tab 120MG 3 |
30 tabs / 30 days |
PEMAZYRE tab 13.5MG 3 |
14 tabs / 21 days |
PEMAZYRE tab 4.5MG 3 |
14 tabs / 21 days |
PEMAZYRE tab 9MG 3 |
14 tabs / 21 days |
PIQRAY 200MG tab DOSE 2 |
28 tabs / 28 days |
PIQRAY 250MG tab DOSE 2 |
56 tabs / 28 days |
PIQRAY 300MG tab DOSE 2 |
56 tabs / 28 days |
POMALYST CAP 1MG 2 |
21 caps / 28 days |
POMALYST CAP 2MG 2 |
21 caps / 28 days |
POMALYST CAP 3MG 2 |
21 caps / 28 days |
POMALYST CAP 4MG 2 |
21 caps / 28 days |
QINLOCK tab 50MG 3 |
90 tabs / 30 days |
180 caps / 30 days |
|
120 caps / 30 days |
|
30 caps / 30 days |
|
90 caps / 30 days |
|
120 tabs / 30 days |
|
120 tabs / 30 days |
|
120 tabs / 30 days |
|
RYDAPT CAP 25MG 2 |
240 caps / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
STIVARGA tab 40MG 2 |
84 tabs / 28 days |
90 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
90 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
TABRECTA tab 150MG 2 |
112 tabs / 28 days |
TABRECTA tab 200MG 2 |
112 tabs / 28 days |
TAFINLAR CAP 50MG 2 |
120 caps / 30 days |
TAFINLAR CAP 75MG 2 |
120 caps / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 caps / 30 days |
|
30 caps / 30 days |
|
120 caps / 30 days |
|
120 caps / 30 days |
|
120 caps / 30 days |
|
TAZVERIK tab 200MG 3 |
240 tabs / 30 days |
TEPMETKO tab 225MG 4 |
60 tabs / 30 days |
TIBSOVO tab 250MG 3 |
60 tabs / 30 days |
TRUSELTIQ CAP 100MG |
1 pack / 28 days |
TRUSELTIQ CAP 125MG |
1 pack / 28 days |
TRUSELTIQ CAP 50MG |
1 pack / 28 days |
TRUSELTIQ CAP 75MG |
1 pack / 28 days |
TUKYSA tab 150MG 3 |
120 tabs / 30 days |
TUKYSA tab 50MG 3 |
300 tabs / 30 days |
TURALIO CAP 200MG 3 |
120 caps / 30 days |
UKONIQ tab 200MG 4 |
120 tabs / 30 days |
VENCLEXTA tab 100MG 3 |
180 tabs / 30 days |
VENCLEXTA tab 10MG 3 |
60 tabs / 30 days |
VENCLEXTA tab 50MG 3 |
30 tabs / 30 days |
VENCLEXTA tab START PK 3 |
1 pack / 180 days |
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 caps / 30 days |
|
180 caps / 30 days |
|
300 mLS / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
120 tabs / 30 days |
|
120 caps / 30 days |
|
120 caps / 30 days |
|
XOSPATA tab 40MG 3 |
90 tabs / 30 days |
1 box / 28 days |
|
XPOVIO PAK 40MG 4 |
1 box / 28 days |
1 box / 28 days |
|
XPOVIO PAK 60MG 4 |
1 box / 28 days |
1 box / 28 days |
|
1 box / 28 days |
|
1 box / 28 days |
|
1 box / 28 days |
|
1 box / 28 days |
|
1 box / 28 days |
|
120 caps / 30 days |
|
120 tabs / 30 days |
|
60 tabs / 30 days |
|
120 tabs / 30 days |
|
90 caps / 30 days |
|
ZELBORAF tab 240MG 2 |
240 tabs / 30 days |
Antineoplastics and adjunctive therapies
Drug name(s) |
Quantity limits (per 30 days or as specified) |
120 caps / 30 days |
|
ZYDELIG tab 100MG 3 |
60 tabs / 30 days |
ZYDELIG tab 150MG 3 |
60 tabs / 30 days |
90 tabs / 30 days |
Antipsychotics/antimanic agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
LATUDA tab 120MG |
30 tabs / 30 days |
LATUDA tab 20MG |
30 tabs / 30 days |
LATUDA tab 40MG |
30 tabs / 30 days |
LATUDA tab 60MG |
30 tabs / 30 days |
LATUDA tab 80MG |
60 tabs / 30 days |
olanzapine tab 10mg |
30 tabs / 30 days |
olanzapine tab 10mg odt |
30 tabs / 30 days |
olanzapine tab 15mg |
30 tabs / 30 days |
olanzapine tab 15mg odt |
30 tabs / 30 days |
olanzapine tab 2.5mg |
30 tabs / 30 days |
olanzapine tab 20mg |
30 tabs / 30 days |
olanzapine tab 20mg odt |
30 tabs / 30 days |
olanzapine tab 5mg |
30 tabs / 30 days |
olanzapine tab 5mg odt |
30 tabs / 30 days |
olanzapine tab 7.5mg |
30 tabs / 30 days |
paliperidone tab er 1.5mg |
60 tabs / 30 days |
paliperidone tab er 3mg |
60 tabs / 30 days |
paliperidone tab er 6mg |
60 tabs / 30 days |
paliperidone tab er 9mg |
60 tabs / 30 days |
quetiapine tab 150mg er |
60 tabs / 30 days |
quetiapine tab 200mg er |
60 tabs / 30 days |
quetiapine tab 300mg er |
60 tabs / 30 days |
quetiapine tab 400mg er |
60 tabs / 30 days |
quetiapine tab 50mg er |
60 tabs / 30 days |
VRAYLAR CAP 1.5-3MG |
1 pack / 180 days |
VRAYLAR CAP 1.5MG |
30 caps / 30 days |
VRAYLAR CAP 3MG |
30 caps / 30 days |
VRAYLAR CAP 4.5MG |
30 caps / 30 days |
VRAYLAR CAP 6MG |
30 caps / 30 days |
LATUDA tab 120MG |
30 tabs / 30 days |
LATUDA tab 20MG |
30 tabs / 30 days |
LATUDA tab 40MG |
30 tabs / 30 days |
LATUDA tab 60MG |
30 tabs / 30 days |
LATUDA tab 80MG |
60 tabs / 30 days |
olanzapine tab 10mg |
30 tabs / 30 days |
olanzapine tab 10mg odt |
30 tabs / 30 days |
olanzapine tab 15mg |
30 tabs / 30 days |
olanzapine tab 15mg odt |
30 tabs / 30 days |
olanzapine tab 2.5mg |
30 tabs / 30 days |
olanzapine tab 20mg |
30 tabs / 30 days |
olanzapine tab 20mg odt |
30 tabs / 30 days |
olanzapine tab 5mg |
30 tabs / 30 days |
olanzapine tab 5mg odt |
30 tabs / 30 days |
olanzapine tab 7.5mg |
30 tabs / 30 days |
paliperidone tab er 1.5mg |
60 tabs / 30 days |
paliperidone tab er 3mg |
60 tabs / 30 days |
paliperidone tab er 6mg |
60 tabs / 30 days |
paliperidone tab er 9mg |
60 tabs / 30 days |
quetiapine tab 150mg er |
60 tabs / 30 days |
quetiapine tab 200mg er |
60 tabs / 30 days |
quetiapine tab 300mg er |
60 tabs / 30 days |
Antipsychotics/antimanic agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
quetiapine tab 400mg er |
60 tabs / 30 days |
quetiapine tab 50mg er |
60 tabs / 30 days |
VRAYLAR CAP 1.5-3MG |
1 pack / 180 days |
VRAYLAR CAP 1.5MG |
30 caps / 30 days |
VRAYLAR CAP 3MG |
30 caps / 30 days |
VRAYLAR CAP 4.5MG |
30 caps / 30 days |
VRAYLAR CAP 6MG |
30 caps / 30 days |
Antivirals
Drug name(s) |
Quantity limits (per 30 days or as specified) |
EPCLUSA tab 200-50MG 2 |
28 tabs / 28 days |
EPCLUSA tab 400-100 2 |
30 tabs / 30 days |
HARVONI PAK 2 |
28 packets/ 28 days |
HARVONI PAK 45-200MG 2 |
28 packets/ 28 days |
HARVONI tab 45-200MG 2 |
28 tabs / 28 days |
HARVONI tab 90-400MG 2 |
30 tabs / 30 days |
MAVYRET tab 100-40MG 2 |
90 tabs / 30 days |
oseltamivir cap 30mg |
40 caps / 120 days |
oseltamivir cap 45mg |
20 caps / 120 days |
oseltamivir cap 75mg |
20 caps / 120 days |
oseltamivir sus 6mg/ml |
300 mLS / 120 days |
PREVYMIS tab 240MG |
112 tabs / 365 days |
PREVYMIS tab 480MG |
112 tabs / 365 days |
RELENZA MIS DISKHALE |
40 blisters / 120 days |
SOVALDI PAK 150MG 2 |
28 packets/ 28 days |
SOVALDI PAK 200MG 2 |
28 packets/ 28 days |
SOVALDI tab 200MG 2 |
30 tabs / 30 days |
SOVALDI tab 400MG 2 |
30 tabs / 30 days |
VOSEVI tab 2 |
30 tabs / 30 days |
XOFLUZA tab 20MG |
4 tabs / 120 days |
XOFLUZA tab 80MG |
2 tabs / 120 days |
XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY |
2 tabs / 120 days |
XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY |
4 tabs / 120 days |
EPCLUSA tab 200-50MG 2 |
28 tabs / 28 days |
EPCLUSA tab 400-100 2 |
30 tabs / 30 days |
HARVONI PAK 2 |
28 packets/ 28 days |
HARVONI PAK 45-200MG 2 |
28 packets/ 28 days |
HARVONI tab 45-200MG 2 |
28 tabs / 28 days |
HARVONI tab 90-400MG 2 |
30 tabs / 30 days |
MAVYRET tab 100-40MG 2 |
90 tabs / 30 days |
oseltamivir cap 30mg |
40 caps / 120 days |
oseltamivir cap 45mg |
20 caps / 120 days |
oseltamivir cap 75mg |
20 caps / 120 days |
oseltamivir sus 6mg/ml |
300 mLS / 120 days |
PREVYMIS tab 240MG |
112 tabs / 365 days |
PREVYMIS tab 480MG |
112 tabs / 365 days |
RELENZA MIS DISKHALE |
40 blisters / 120 days |
SOVALDI PAK 150MG 2 |
28 packets/ 28 days |
SOVALDI PAK 200MG 2 |
28 packets/ 28 days |
SOVALDI tab 200MG 2 |
30 tabs / 30 days |
SOVALDI tab 400MG 2 |
30 tabs / 30 days |
VOSEVI tab 2 |
30 tabs / 30 days |
XOFLUZA tab 20MG |
4 tabs / 120 days |
XOFLUZA tab 80MG |
2 tabs / 120 days |
XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY |
2 tabs / 120 days |
XOFLUZA- BALOXAVIR MARBOXIL tab THERAPY |
4 tabs / 120 days |
Cardiovascular agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ADEMPAS tab 0.5MG 3 |
90 tabs / 30 days |
ADEMPAS tab 1.5MG 3 |
90 tabs / 30 days |
ADEMPAS tab 1MG 3 |
90 tabs / 30 days |
ADEMPAS tab 2.5MG 3 |
90 tabs / 30 days |
ADEMPAS tab 2MG 3 |
90 tabs / 30 days |
alyq tab 20mg 2 |
60 tabs / 30 days |
ambrisentan tab 10mg 2 |
30 tabs / 30 days |
ambrisentan tab 5mg 2 |
30 tabs / 30 days |
bosentan tab 125mg 2 |
60 tabs / 30 days |
bosentan tab 62.5mg 2 |
60 tabs / 30 days |
CORLANOR SOL 5MG/5mL |
600 mLS / 30 days |
CORLANOR tab 5MG |
60 tabs / 30 days |
CORLANOR tab 7.5MG |
60 tabs / 30 days |
OPSUMIT tab 10MG 3 |
30 tabs / 30 days |
sildenafil sus 10mg/ml + |
2 bottles / 30 days |
sildenafil sus 10mg/ml 1,2 |
2 bottles / 30 days |
sildenafil tab 100mg + |
6 tabs / 30 days |
sildenafil tab 20mg 1,2 |
90 tabs / 30 days |
sildenafil tab 25mg + |
6 tabs / 30 days |
sildenafil tab 50mg + |
6 tabs / 30 days |
STENDRA tab 100MG |
6 tabs / 30 days |
STENDRA tab 200MG |
6 tabs / 30 days |
STENDRA tab 50MG |
6 tabs / 30 days |
tadalafil tab 10mg + |
6 tabs / 30 days |
tadalafil tab 2.5mg + |
30 tabs / 30 days |
tadalafil tab 5mg + |
30 tabs / 30 days |
tadalafil tab 20mg + |
6 tabs / 30 days |
tadalafil tab 20mg 1,2 |
60 tabs / 30 days |
TRACLEER tab 32MG 2 |
120 tabs / 30 days |
TYVASO SOL 0.6MG/mL 3 |
7 packages / 28 days |
TYVASO REFIL SOL 0.6MG/mL 3 |
1 kit / 28 days |
TYVASO START SOL 0.6MG/mL 3 |
1 kit / 180 days |
UPTRAVI tab 200/800 3 |
1 PKG / 180 days |
UPTRAVI tab 400MCG 3 |
60 tabs / 30 days |
UPTRAVI tab 600MCG 3 |
60 tabs / 30 days |
UPTRAVI tab 800MCG 3 |
60 tabs / 30 days |
UPTRAVI tab 1000MCG 3 |
60 tabs / 30 days |
UPTRAVI tab 1200MCG 3 |
60 tabs / 30 days |
UPTRAVI tab 1400MCG 3 |
60 tabs / 30 days |
UPTRAVI tab 1600MCG 3 |
60 tabs / 30 days |
UPTRAVI- SELEXIPAG tab 200 MCG 3 |
60 tabs / 30 days |
UPTRAVI- SELEXIPAG tab 200 MCG 3 |
140 tabs / 180 days |
vardenafil tab 10mg |
6 tabs / 30 days |
vardenafil tab 10mg odt |
6 tabs / 30 days |
vardenafil tab 2.5mg |
6 tabs / 30 days |
vardenafil tab 20mg |
6 tabs / 30 days |
vardenafil tab 5mg |
6 tabs / 30 days |
270 AMPULS / 30 days |
|
270 AMPULS / 30 days |
|
VERQUVO tab 10MG |
30 tabs / 30 days |
VERQUVO tab 2.5MG |
30 tabs / 30 days |
VERQUVO tab 5MG |
30 tabs / 30 days |
VYNDAMAX CAP 61MG 2 |
30 caps / 30 days |
VYNDAQEL CAP 20MG 2 |
120 caps / 30 days |
ADEMPAS tab 0.5MG 3 |
90 tabs / 30 days |
Dermatologicals
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ala-cort cre 2.5% |
454 grams / 30 days |
alclometason cre 0.05% |
120 grams / 30 days |
alclometason oin 0.05% |
120 grams / 30 days |
aug betamet cre 0.05% |
200 grams / 28 days |
AUG BETAMET GEL 0.05% |
200 grams / 28 days |
augmented betamethasone lot 0.05% |
210 mLS / 30 days |
augmented betamethasone oin 0.05% |
200 grams / 28 days |
BETA DIPROP GEL 0.05% |
200 grams / 28 days |
betamethasone dipropionate cre 0.05% |
135 grams / 30 days |
betamethasone dipropionate lot 0.05% |
120 mLS / 30 days |
betamethasone dipropionate oin 0.05% |
135 grams / 30 days |
betamethasone valerate cre 0.1% |
135 grams / 30 days |
betamethasone valerate lot 0.1% |
120 mLS / 30 days |
betamethasone valerate oin 0.1% |
135 grams / 30 days |
clobetasol cre 0.05% |
210 grams / 28 days |
clobetasol gel 0.05% |
210 grams / 28 days |
clobetasol oin 0.05% |
210 grams / 28 days |
clobetasol sol 0.05% |
200 mLS / 28 days |
clobetasol e cre 0.05% |
210 grams / 28 days |
COSENTYX INJ 150MG/mL 2 |
1 syringe / 28 days |
COSENTYX INJ 300DOSE 2 |
1 pack / 28 days |
COSENTYX INJ 75MG/0.5 2 |
1 syringe / 28 days |
COSENTYX pen inj 150MG/mL 2 |
1 injdv / 28 days |
COSENTYX pen inj 300DOSE 2 |
1 pack / 28 days |
desonide cre 0.05% |
120 grams / 30 days |
desonide oin 0.05% |
120 grams / 30 days |
desoximetasone cre 0.25% |
120 grams / 30 days |
desoximetasone oin 0.25% |
120 grams / 30 days |
diclofenac sol 1.5% |
2 bottles / 30 days |
DUPIXENT INJ 200/1.14 2 |
2 syringes / 28 days |
DUPIXENT INJ 200MG 2 |
2 pens / 28 days |
DUPIXENT- DUPILUMAB SUBCUTANEOUS SOLN |
2 pens / 28 days |
DUPIXENT- DUPILUMAB SUBCUTANEOUS SOLN |
2 syringes / 28 days |
fluocinolone acetonide cre 0.01% |
120 grams / 30 days |
fluocinolone acetonide cre 0.025% |
120 grams / 30 days |
fluocinolone acetonide oil 0.01% sc |
118.28 mLS / 30 days |
fluocinolone acetonide oil 0.01%bdy |
118.28 mLS / 30 days |
fluocinolone acetonide oil body |
118.28 mLS / 30 days |
fluocinolone acetonide oil scalp |
118.28 mLS / 30 days |
fluocinolone acetonide oin 0.025% |
120 grams / 30 days |
fluocinolone acetonide sol 0.01% |
120 mLS / 30 days |
fluocinonide cre 0.05% |
120 grams / 30 days |
fluocinonide cre 0.1% |
240 grams / 28 days |
fluocinonide gel 0.05% |
120 grams / 30 days |
fluocinonide oin 0.05% |
120 grams / 30 days |
fluocinonide sol 0.05% |
120 mLS / 30 days |
fluticasone cre 0.05% |
120 grams / 30 days |
fluticasone oin 0.005% |
120 grams / 30 days |
halobetasol cre 0.05% |
200 grams / 28 days |
hydrocort cre 2.5% |
454 grams / 30 days |
hydrocort lot 2.5% |
118 mLS / 30 days |
hydrocort oin 2.5% |
454 grams / 30 days |
lidocaine/prilocaine cre 2.5-2.5% |
60 grams / 30 days |
lidocaine pad 5% |
90 patches / 30 days |
lidocaine sol 4% |
150 mLS / 30 days |
mometasone cre 0.1% |
135 grams / 30 days |
mometasone oin 0.1% |
135 grams / 30 days |
mometasone sol 0.1% |
120 mLS / 30 days |
PENNSAID SOL 2% |
2 pumpS / 28 days |
PREDNICARBAT CRE 0.1% |
120 grams / 30 days |
PREDNICARBAT OIN 0.1% |
120 grams / 30 days |
SKYRIZI INJ 150DOSE 2 |
1 box / 84 days |
SKYRIZI INJ 150MG/mL 2 |
1 syringe / 84 days |
SKYRIZI pen INJ 150MG/mL 2 |
1 injdv / 84 days |
STELARA INJ 45MG/0.5 2 |
1 syringe / 84 days |
STELARA INJ 90MG/mL 2 |
1 syringe / 56 days |
TREMFYA- GUSELKUMAB SOLN PEN-INJECTOR |
1 pen/ 56 days |
TREMFYA- GUSELKUMAB SOLN PREFILLED |
1 syringe / 56 days |
triamcinolone cre 0.025% |
454 grams / 30 days |
triamcinolone cre 0.1% |
454 grams / 30 days |
triamcinolone cre 0.5% |
454 grams / 30 days |
triamcinolone lot 0.025% |
120 mLS / 30 days |
triamcinolone lot 0.1% |
120 mLS / 30 days |
triamcinolone oin 0.025% |
454 grams / 30 days |
triamcinolone oin 0.1% |
454 grams / 30 days |
triamcinoloen oin 0.5% |
120 grams / 30 days |
triderm cre 0.1% |
454 grams / 30 days |
triderm cre 0.5% |
454 grams / 30 days |
Diagnostic products
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ONETOUCH TES ULTRA |
204 strips / 30 days |
ONETOUCH TES ULTRA BL |
204 strips / 30 days |
ONETOUCH TES VERIO |
204 strips / 30 days |
Digestive aids
Drug name(s) |
Quantity limits (per 30 days or as specified) |
SUCRAID SOL 8500/mL |
236 mLS / 28 days |
Endocrine and metabolic agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
CHOR GONADOT INJ 10000UNT 2 |
2 vials/ 30 days |
FOLLISTIM AQ INJ 300UNIT 2 |
15 cartS / 30 days |
FOLLISTIM AQ INJ 600UNIT 2 |
8 cartS / 30 days |
FOLLISTIM AQ INJ 900UNIT 2 |
5 cartS / 30 days |
FORTEO INJ 620/2.48 2 |
1 pen/ 28 days |
GALAFOLD CAP 123MG 2 |
14 caps / 28 days |
ganirelix ac inj 250/0.5 2 |
5 syringes / 30 days |
ISTURISA tab 10MG 3 |
180 tabs / 30 days |
ISTURISA tab 1MG 3 |
240 tabs / 30 days |
ISTURISA tab 5MG 3 |
300 tabs / 30 days |
JYNARQUE PAK 30-15MG 2 |
56 tabs / 28 days |
JYNARQUE PAK 45-15MG 2 |
56 tabs / 28 days |
JYNARQUE PAK 60-30MG 2 |
56 tabs / 28 days |
JYNARQUE PAK 90-30MG 2 |
56 tabs / 28 days |
JYNARQUE tab 30MG 2 |
30 tabs / 30 days |
JYNARQUE- TOLVAPTAN tab 15 MG 2 |
60 tabs / 30 days |
JYNARQUE- TOLVAPTAN tab therapy pack 15 |
56 tabs / 28 days |
MENOPUR INJ 75UNIT 2 |
60 vials/ 30 days |
NATPARA INJ 100MCG 2 |
1 kit / 28 days |
NATPARA INJ 25MCG 2 |
1 kit / 28 days |
NATPARA INJ 50MCG 2 |
1 kit / 28 days |
NATPARA INJ 75MCG 2 |
1 kit / 28 days |
NOCTIVA SPR 1.66/0.1 |
1 bottle / 30 days |
NOVAREL INJ 10000UNT 2 |
2 vials/ 30 days |
NOVAREL INJ 5000UNIT 2 |
4 vials/ 30 days |
ORILISSA tab 150MG |
30 tabs / 30 days |
ORILISSA tab 200MG |
60 tabs / 30 days |
PREGNYL INJ 10000UNT 2 |
2 vials/ 30 days |
SAMSCA tab 15MG 2 |
30 tabs / 365 days |
TOLVAPTAN tab 15MG 2 |
30 tabs / 365 days |
tolvaptan tab 30mg + |
60 tabs / 365 days |
tolvaptan tab 30mg 1,2 |
60 tabs / 365 days |
TYmLOS INJ 2 |
1 pen/ 30 days |
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 |
ELESTRIN GEL 0.06% |
1 pump / 30 days |
estradiol dis 0.06mg |
4 patches / 28 days |
estradiol td patch twice weekly 0.025 mg/24hr |
8 patches / 28 days |
estradiol td patch twice weekly 0.0375 mg/24hr |
8 patches / 28 days |
estradiol td patch twice weekly 0.05 mg/24hr |
8 patches / 28 days |
estradiol td patch twice weekly 0.075 mg/24hr |
8 patches / 28 days |
estradiol td patch twice weekly 0.1 mg/24hr |
8 patches / 28 days |
estradiol td patch weekly 0.025 mg/24hr |
4 patches / 28 days |
estradiol td patch weekly 0.0375 mg/24hr (37.5 |
4 patches / 28 days |
estradiol td patch weekly 0.05 mg/24hr |
4 patches / 28 days |
estradiol td patch weekly 0.075 mg/24hr |
4 patches / 28 days |
estradiol td patch weekly 0.1 mg/24hr |
4 patches / 28 days |
ESTROGEL GEL |
1 pump / 30 days |
EVAMIST SPR 1.53MG |
5 bottles / 93 days |
MENOSTAR DIS 14MCG |
4 patches / 28 days |
ORIAHNN CAP |
56 caps / 28 days |
Gastrointestinal agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
CIMZIA PREFL kit 200MG/mL 2 |
2 kitS / 28 days |
CIMZIA START kit 200MG/mL 2 |
1 kit / 180 days |
OCALIVA tab 10MG 2 |
30 tabs / 30 days |
OCALIVA tab 5MG 2 |
30 tabs / 30 days |
XERMELO tab 250MG 3 |
90 tabs / 30 days |
Hematological agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
BERINERT INJ 500UNIT 2 |
10 vials/ 30 days |
CABLIVI kit 11MG 3 |
58 vials/ 365 days |
EMPAVELI INJ 1080MG |
8 vials/ 28 days |
HAEGARDA INJ 2000UNIT 3 |
24 vials/ 30 days |
HAEGARDA INJ 3000UNIT 3 |
16 vials/ 30 days |
HEmLIBRA INJ 105/0.7 2 |
4 vials/ 28 days |
HEmLIBRA INJ 150/mL 2 |
4 vials/ 28 days |
HEmLIBRA INJ 30MG/mL 2 |
4 vials/ 28 days |
HEmLIBRA INJ 60/0.4 2 |
4 vials/ 28 days |
icatibant inj 30mg/3ml 2 |
6 syringes / 30 days |
RUCONEST INJ 2100UNIT 2 |
8 vials/ 30 days |
sajazir inj 30mg/3ml 2 |
6 syringes / 30 days |
TAKHZYRO INJ 300/2mL 3 |
4 mLS / 28 days |
TAVALISSE tab 100MG 3 |
60 tabs / 30 days |
TAVALISSE tab 150MG 3 |
60 tabs / 30 days |
CERDELGA CAP 84MG 2 |
60 caps / 30 days |
DOPTELET tab 20MG 3 |
60 tabs / 30 days |
miglustat cap 100mg 2 |
90 caps / 30 days |
MULPLETA tab 3MG 2 |
7 tabs / 7 days |
OXBRYTA tab 500MG 3 |
90 tabs / 30 days |
PROMACTA PAK 25MG 2 |
30 packS / 30 days |
PROMACTA POW 12.5MG 2 |
30 packets/ 30 days |
PROMACTA tab 12.5MG 2 |
30 tabs / 30 days |
PROMACTA tab 25MG 2 |
30 tabs / 30 days |
PROMACTA tab 50MG 2 |
60 tabs / 30 days |
PROMACTA tab 75MG 2 |
60 tabs / 30 days |
Hypnotics/Sedatives/Sleep Disorder Agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
BELSOMRA tab 5MG |
30 tabs / 30 days |
Hypnotics/sedatives/sleep disorder agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
BELSOMRA tab 10MG |
30 tabs / 30 days |
BELSOMRA tab 15MG |
30 tabs / 30 days |
BELSOMRA tab 20MG |
30 tabs / 30 days |
eszopiclone tab 1mg |
30 tabs / 30 days |
eszopiclone tab 2mg |
30 tabs / 30 days |
eszopiclone tab 3mg |
30 tabs / 30 days |
30 caps / 30 days |
|
158 mLS / 30 days |
|
zaleplon cap 10mg |
30 caps / 30 days |
zaleplon cap 5mg |
30 caps / 30 days |
zolpidem tab 10mg |
30 tabs / 30 days |
zolpidem tab 5mg |
30 tabs / 30 days |
zolpidem er tab 12.5mg |
30 tabs / 30 days |
zolpidem er tab 6.25mg |
30 tabs / 30 days |
zolpidem tar sub 1.75mg |
30 tabs / 30 days |
zolpidem tar sub 3.5mg |
30 tabs / 30 days |
Medical devices and supplies
Drug name(s) |
Quantity limits (per 30 days or as specified) |
DEXCOM G5 MIS RECEIVER |
1 UNIT / 365 days |
DEXCOM G5 MIS TRANSMIT |
1 UNIT / 84 days |
DEXCOM G6 MIS RECEIVER |
1 UNIT / 365 days |
DEXCOM G6 MIS SENSOR |
3 UNITS / 30 days |
DEXCOM G6 MIS TRANSMIT |
1 UNIT / 90 days |
G5/G4 MIS SENSOR |
4 UNITS / 28 days |
MIGRAINE PRODUCTS |
|
AIMOVIG INJ 140MG/mL 2 |
1 INJ / 28 days |
AIMOVIG INJ 70MG/mL 2 |
1 INJ / 28 days |
AJOVY INJ 225/1.5 2 |
3 syringes / 84 days |
eletriptan tab 20mg |
18 tabs / 30 days |
eletriptan tab 40mg |
12 tabs / 30 days |
EMGALITY INJ 100MG/mL 2 |
9 syringes / 180 days |
EMGALITY INJ 120MG/mL 2 |
1 syringe / 28 days |
naratriptan tab 1mg |
18 tabs / 30 days |
naratriptan tab 2.5mg |
18 tabs / 30 days |
NURTEC tab 75MG ODT |
45 tabs / 90 days |
REYVOW tab 100MG |
8 tabs / 30 days |
REYVOW tab 50MG |
8 tabs / 30 days |
rizatriptan tab 10mg |
18 tabs / 30 days |
rizatriptan tab 10mg odt |
18 tabs / 30 days |
rizatriptan tab 5mg |
36 tabs / 30 days |
rizatriptan tab 5mg odt |
36 tabs / 30 days |
SUMATRIPTAN INJ 6MG/0.5 |
12 syringes / 30 days |
sumatriptan spr 20mg/act |
12 inhalers / 30 days |
sumatriptan spr 5mg/act |
5 packS / 30 days |
Migraine products
Drug name(s) |
Quantity limits (per 30 days or as specified) |
sumatriptan tab 25mg |
27 tabs / 30 days |
sumatriptan tab 50mg |
18 tabs / 30 days |
sumatriptan tab 100mg |
18 tabs / 30 days |
sumatriptan succinate inj 6 mg/0.5ml |
12 syringes / 30 days |
sumatriptan succinate solution auto-injector 4 |
12 syringes / 30 days |
sumatriptan succinate solution auto-injector 6 |
12 syringes / 30 days |
sumatriptan succinate solution cartridge 4 mg/0.5ml |
12 cartS / 30 days |
sumatriptan succinate solution cartridge 6 mg/0.5ml |
12 cartS / 30 days |
UBRELVY tab 100MG |
16 tabs / 30 days |
UBRELVY tab 50MG |
16 tabs / 30 days |
zolmitriptan tab 2.5 mg |
18 tabs / 30 days |
zolmitriptan tab 5mg |
12 tabs / 30 days |
zolmitriptan tab 5mg odt |
12 tabs / 30 days |
Miscellaneous therapeutic classes
Drug name(s) |
Quantity limits (per 30 days or as specified) |
BENLYSTA INJ 200MG/mL 2 |
4 syringes / 28 days |
ENSPRYNG INJ 2 |
1 syringe / 28 days |
LUPKYNIS CAP 7.9MG |
180 caps / 30 days |
REVLIMID CAP 10MG 2 |
30 caps / 30 days |
REVLIMID CAP 15MG 2 |
21 caps / 28 days |
REVLIMID CAP 2.5MG 2 |
30 caps / 30 days |
REVLIMID CAP 20MG 2 |
21 caps / 28 days |
REVLIMID CAP 25MG 2 |
21 caps / 28 days |
REVLIMID CAP 5MG 2 |
30 caps / 30 days |
THALOMID CAP 100MG 2 |
30 caps / 30 days |
THALOMID CAP 150MG 2 |
60 caps / 30 days |
Miscellaneous therapeutic classes
Drug name(s) |
Quantity limits (per 30 days or as specified) |
THALOMID CAP 200MG 2 |
60 caps / 30 days |
THALOMID CAP 50MG 2 |
30 caps / 30 days |
ZOKINVY CAP 50MG 3 |
120 caps / 30 days |
ZOKINVY CAP 75MG 3 |
120 caps / 30 days |
Nasal agents - systemic and topical
Drug name(s) |
Quantity limits (per 30 days or as specified) |
azelastine spr 0.1% |
2 bottles / 30 days |
fluticasone spr 50mcg |
1 bottle / 30 days |
ipratropium spr 0.03% |
2 bottles / 30 days |
ipratropium spr 0.06% |
3 bottles / 30 days |
XHANCE MIS 93MCG |
2 bottles / 30 days |
Neuromuscular agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
EVRYSDI SOL 3 |
240 mLS / 30 days |
riluzole tab 50mg |
60 tabs / 30 days |
latanoprost sol 0.005% |
2.5 mLS / 30 days |
LUMIGAN SOL 0.01% |
2.5 mLS / 30 days |
OXERVATE SOL 20MCG/mL 3 |
56 vials/ 56 days |
RHOPRESSA SOL 0.02% |
2.5 mLS / 30 days |
ROCKLATAN DRO |
2.5 mLS / 30 days |
VYZULTA SOL 0.024% |
2.5 mLS / 30 days |
|
Psychotherapeutic and neurological agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ADDYI tab 100MG |
30 tabs / 30 days |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
AUSTEDO tab 12MG 2 |
120 tabs / 30 days |
AUSTEDO tab 6MG 2 |
60 tabs / 30 days |
AUSTEDO tab 9MG 2 |
120 tabs / 30 days |
AVONEX penkit 30MCG 2 |
1 pack / 28 days |
AVONEX PREFL kit 30MCG 2 |
1 kit / 28 days |
BETASERON INJ 0.3MG 2 |
1 box / 28 days |
60 tabs / 30 days |
|
dimethyl fumarate cap 120mg dr 2 |
56 caps / 180 days |
dimethyl fumarate cap 240mg dr 2 |
60 caps / 30 days |
dimethyl fumarate mis starter 2 |
60 caps / 180 days |
GILENYA CAP 0.5MG 2 |
30 tabs / 30 days |
glatiramer inj 20mg/ml 2 |
30 syringes / 30 days |
glatiramer inj 40mg/ml 2 |
12 syringes / 28 days |
GRALISE tab 300MG |
30 tabs / 30 days |
GRALISE tab 600MG |
90 tabs / 30 days |
HORIZANT tab 300MG ER |
60 tabs / 30 days |
HORIZANT tab 600MG ER |
60 tabs / 30 days |
INGREZZA CAP 40-80MG 3 |
28 caps / 180 days |
INGREZZA CAP 40MG 3 |
30 caps / 30 days |
INGREZZA CAP 60MG 3 |
30 caps / 30 days |
INGREZZA CAP 80MG 3 |
30 caps / 30 days |
KESIMPTA INJ 20/.4mL 2 |
1 syringe / 28 days |
LUCEMYRA tab 0.18MG |
228 tabs / 180 days |
MAYZENT PAK STARTER |
12 tabs / 180 days |
MAYZENT tab 0.25MG 2 |
120 tabs / 30 days |
MAYZENT tab 2MG 2 |
30 tabs / 30 days |
PLEGRIDY INJ 2 |
2 syringes / 28 days |
PLEGRIDY INJ pen2 |
2 pens / 28 days |
PLEGRIDY INJ STARTER 2 |
1 kit / 180 days |
PLEGRIDY pen inj STARTER 2 |
1 kit / 180 days |
REBIF INJ 22/0.5 2 |
12 syringes / 28 days |
REBIF INJ 44/0.5 2 |
1 carton / 28 days |
REBIF REBIDO INJ 22/0.5 2 |
1 carton / 28 days |
REBIF REBIDO INJ 44/0.5 2 |
1 carton / 28 days |
REBIF REBIDO INJ TITRATN 2 |
1 kit / 180 days |
REBIF TITRTN INJ pack 2 |
1 kit / 180 days |
TEGSEDI INJ 284/1.5 3 |
6 mLS / 28 days |
tetrabenazine tab 12.5mg + |
240 tabs / 30 days |
tetrabenazine tab 12.5mg 1,2 |
240 tabs / 30 days |
tetrabenazine tab 25mg + |
120 tabs / 30 days |
tetrabenazine tab 25mg 1,2 |
120 tabs / 30 days |
VYLEESI INJ 1.75/0.3 |
6 pens / 30 days |
XYREM SOL 500MG/mL 3 |
540 mLS / 30 days |
XYWAV SOL 0.5GM/mL 3 |
540 mLS / 30 days |
ZEPOSIA CAP .92MG 2 |
30 caps / 30 days |
ZEPOSIA CAP STR kit 2 |
37 caps / 180 days |
ZEPOSIA 7DAY CAP STR pack 2 |
7 caps / 180 days |
Respiratory agents
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ESBRIET CAP 267MG 2 |
180 caps / 30 days |
ESBRIET tab 267MG 2 |
180 tabs / 30 days |
ESBRIET tab 801MG 2 |
90 tabs / 30 days |
KALYDECO PAK 25MG 2 |
60 packets/ 30 days |
KALYDECO PAK 50MG 2 |
60 packets/ 30 days |
KALYDECO PAK 75MG 2 |
60 packets/ 30 days |
KALYDECO tab 150MG 2 |
60 tabs / 30 days |
60 caps / 30 days |
|
60 caps / 30 days |
|
ORKAMBI GRA 100-125 2 |
60 packets/ 30 days |
ORKAMBI GRA 150-188 2 |
60 packets/ 30 days |
ORKAMBI tab 100-125 2 |
120 tabs / 30 days |
ORKAMBI tab 200-125 2 |
120 tabs / 30 days |
SYMDEKO tab 100-150 2 |
60 tabs / 30 days |
SYMDEKO tab 50-75MG 2 |
56 tabs / 28 days |
TRIKAFTA tab 100mg/50mg/75mg/150mg 2 |
90 tabs / 30 days |
Ulcer drugs/antispasmodics/anticholinergics
Drug name(s) |
Quantity limits (per 30 days or as specified) |
DEXILANT CAP 30MG DR |
30 caps / 30 days |
DEXILANT CAP 60MG DR |
30 caps / 30 days |
omeprazole cap 10mg |
30 caps / 30 days |
omeprazole cap 20mg |
30 caps / 30 days |
omeprazole cap 40mg |
30 caps / 30 days |
pantoprazole tab 20mg |
30 tabs / 30 days |
pantoprazole tab 40mg |
30 tabs / 30 days |
pantoprazole tab 20mg dr |
30 tabs / 30 days |
pantoprazole tab 40mg dr |
30 tabs / 30 days |
Vaginal and related products
Drug name(s) |
Quantity limits (per 30 days or as specified) |
ENDOMETRIN SUP 100MG |
84 supps / 28 days |
ESTRING MIS 2MG |
1 ring / 90 days |
Specialty
- Open - Members can obtain their specialty drugs at any pharmacy, even if the drug is listed as exclusive
- Open/Closed - Members obtain their specialty drugs based on the exclusivity of the drug
- Closed - Members must obtain all of their specialty drugs at our designated specialty pharmacy
Drug name(s) |
||
ACTEMRA 2 |
ACTEMRA ACTPEN 2 |
|
ACTHAR 2 |
ADVATE 2 |
|
ADYNOVATE 2 |
||
AFSTYLA 2 |
ALPHANINE SD 2 |
|
ALPROLIX 2 |
ALUNBRIG 3 |
alyq 2 |
ambrisentan 2 |
||
ARIKAYCE 3 |
AUSTEDO 2 |
|
BENEFIX 2 |
BENLYSTA 2 |
|
BERINERT 2 |
||
bosentan 2 |
||
BRUKINSA 3 |
CAPRELSA 3 |
|
CERDELGA 2 |
CHORIONIC GONADOTROPIN 2 |
|
CIMZIA 2 |
CIMZIA STARTER KIT 2 |
COAGADEX 3 |
COSENTYX 2 |
||
COSENTYX SENSOREADY PEN 2 |
COTELLIC 2 |
|
dimethyl fumarate 2 |
||
dimethyl fumarate starterpack 2 |
DUPIXENT 2 |
|
ELOCTATE 2 |
||
ENDARI 3 |
ENSPRYNG 2 |
|
EPCLUSA 2 |
EPIDIOLEX SOL 100MG/ML 2 |
|
ERLEADA 2 |
ESBRIET 2 |
|
ESPEROCT 2 |
||
FARYDAK CAP 10MG 2 |
||
GALAFOLD 2 |
||
GILENYA 2 |
||
HEMLIBRA 2 |
HEMOFIL M 2 |
|
HYCAMTIN 2 |
IBRANCE 2 |
|
icatibant acetate 2 |
IDELVION 2 |
|
IDHIFA 2 |
IMBRUVICA 3 |
|
IMCIVREE 3 |
INGREZZA 3 |
|
INQOVI 2 |
||
ISTURISA 3 |
IXINITY 2 |
|
JIVI 2 |
JYNARQUE 2 |
|
KALYDECO 2 |
KEVZARA 2 |
|
KISQALI 2 |
KISQALI FEMARA 2 |
KOATE 2 |
KOATE-DVI 2 |
KOGENATE FS 2 |
KORLYM 3 |
KOSELUGO 3 |
KOVALTRY 2 |
|
LONSURF 2 |
||
MATULANE 2 |
||
MAYZENT 2 |
MEKINIST 2 |
|
MENOPUR 2 |
miglustat 2 |
MIRCERA 2 |
MONONINE 2 |
MULPLETA 2 |
|
NATPARA 2 |
||
NINLARO 2 |
||
NOVOEIGHT 2 |
NUBEQA 2 |
NUWIQ 2 |
OCALIVA 2 |
||
ONUREG 2 |
ORENCIA 2 |
|
ORENCIA CLICKJECT 2 |
ORGOVYX 3 |
|
ORKAMBI 2 |
OTEZLA 2 |
|
PEGINTRON 2 |
||
PEMAZYRE 3 |
PIQRAY 2 |
PLEGRIDY 2 |
PLEGRIDY STARTER PACK 2 |
POMALYST 2 |
|
PROFILNINE 2 |
PROFILNINE SD 2 |
|
PROMACTA 2 |
QINLOCK 3 |
RAVICTI 2 |
REBINYN 2 |
RECOMBINATE 2 |
|
RETACRIT 2 |
REVLIMID 2 |
|
RINVOQ 2 |
RIXUBIS 2 |
|
RUCONEST 2 |
RUZURGI 3 |
|
RYDAPT 2 |
sajazir 2 |
sapropterin dihydrochloride 2 |
sildenafil sus 10mg/ml 2 |
sildenafil tab 20mg 2 |
SIMPONI 2 |
SKYRIZI 2 |
SKYRIZI PEN 2 |
sodium phenylbutyrate 2 |
SOVALDI 2 |
STELARA 2 |
|
STIVARGA 2 |
STRENSIQ 3 |
|
SYMDEKO 2 |
TABRECTA 2 |
|
tadalafil 2 |
TAFINLAR 2 |
|
TAVALISSE 3 |
TAZVERIK 3 |
|
temozolomide 2 |
tetrabenazine 2 |
THALOMID 2 |
TIBSOVO 3 |
tolvaptan 2 |
TRACLEER 2 |
TREMFYA 2 |
TRIKAFTA 2 |
TUKYSA 3 |
TURALIO 3 |
TYMLOS 2 |
|
VENCLEXTA 3 |
VENCLEXTA STARTING PACK 3 |
|
VOSEVI 2 |
VYNDAMAX 2 |
|
VYNDAQEL 2 |
XELJANZ 2 |
|
XELJANZ XR 2 |
XERMELO 3 |
XOLAIR 2 |
XOSPATA 3 |
||
XYNTHA 2 |
XYNTHA SOLOFUSE 2 |
|
ZELBORAF 2 |
ZEPOSIA 2 |
|
ZEPOSIA 7-DAY STARTER PACK 2 |
ZEPOSIA STARTER KIT 2 |
ZOKINVY 3 |