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)
abiraterone acetate^2,⁴	ACTEMRA ²	ACTEMRA ACTPEN ²
ACTHAR ²	ADEMPAS³	ADVATE ²
ADYNOVATE ²	AFINITOR^2,⁴	AFINITOR DISPERZ^2,⁴
AFSTYLA ²	AKLIEF	ALECENSA ^3,⁴
ALPHANINE SD ²	ALPROLIX ²	ALUNBRIG³
alyq ²	ambrisentan ²	ARANESP ALBUMIN FREE ²
ARCALYST³	ARIKAYCE³	AUBAGIO^2,⁴
AUSTEDO ²	avita	AVONEX ²
AVONEX PEN ²	AYVAKIT ^3,⁴	BALVERSA ^3,⁴
BELBUCA	BELSOMRA	BENEFIX ²
BENLYSTA ²	BERINERT ²	BETASERON ²
bexarotene^2,⁴	bosentan ²	BOSULIF^2,⁴
BRAFTOVI³	BRUKINSA³	CABOMETYX^2,⁴
CALQUENCE³	capecitabine ²	CAPRELSA³
CARBAGLU³	CERDELGA ²	CHORIONIC GONADOTROPIN ²
CIMZIA ²	CIMZIA STARTER KIT ²	CLOZAPINE ODT
COAGADEX³	COMETRIQ ^3,⁴	CONTRAVE
COPIKTRA ^3,⁴	CORLANOR	COSENTYX ²
COSENTYX SENSOREADY PEN ²	COTELLIC ²	CRESEMBA
dalfampridine er^2,⁴	DAURISMO^2,⁴	deferasirox^2,⁴
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	ERIVEDGE^2,⁴
ERLEADA ²	erlotinib hcl^2,⁴	ESBRIET ²
ESPEROCT ²	everolimus tab 2.5mg^1,^2,⁴	everolimus tab 2.5mg^1,⁴
everolimus tab 2mg^1,⁴	everolimus tab 10mg^1,⁴	everolimus tab 3mg^1,⁴
everolimus tab 5mg^1,^2,⁴	everolimus tab 5mg^1,⁴	everolimus tab 7.5mg^1,^2,⁴
everolimus tab 7.5mg^1,⁴	EVRYSDI³	FANAPT
FANAPT TITRATION PACK	FARYDAK CAP 10MG¹	FARYDAK CAP 10MG^1,²
FARYDAK CAP 15MG¹	FARYDAK CAP 15MG^1,²	FARYDAK CAP 20MG¹
FARYDAK CAP 20MG^1,²	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	GAVRETO ^3,⁴
GILENYA ²	GILOTRIF³	glatiramer acetate ²
HAEGARDA³	HARVONI ²	HEMLIBRA ²
HEMOFIL M ²	HETLIOZ ^3,⁴	HETLIOZ LQ ^3,⁴
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
ICLUSIG ^3,⁴	IDELVION ²	IDHIFA ²
imatinib mesylate^2,⁴	IMBRUVICA³	IMCIVREE³
INGREZZA³	INLYTA^2,⁴	INQOVI ²
INREBIC^2,⁴	IRESSA ^3,⁴	ISTURISA³
IXINITY ²	JAKAFI^2,⁴	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	LENVIMA 10 MG DAILY DOSE ^3,⁴	LENVIMA 12MG DAILY DOSE ^3,⁴
LENVIMA 14 MG DAILY DOSE ^3,⁴	LENVIMA 18 MG DAILY DOSE ^3,⁴	LENVIMA 20 MG DAILY DOSE ^3,⁴
LENVIMA 24 MG DAILY DOSE ^3,⁴	LENVIMA 4 MG DAILY DOSE ^3,⁴	LENVIMA 8 MG DAILY DOSE ^3,⁴
lidocaine	lidocaine hcl	lidocaine patch 5%
lidocaine/prilocaine	LOMAIRA	LONSURF ²
LORBRENA^2,⁴	LUCEMYRA	LUMAKRAS
LUPKYNIS	LYNPARZA ^3,⁴	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
NERLYNX ^3,⁴	NEXAVAR^2,⁴	NEXLETOL
NEXLIZET	NINLARO ²	NOCTIVA
NORDITROPIN FLEXPRO ²	NOVAREL ²	NOVOEIGHT ²
NOXAFIL	NUBEQA ²	NUCALA
NUCYNTA ER	NUWIQ ²	OCALIVA ²
ODOMZO^2,⁴	OFEV^2,⁴	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
RETEVMO^2,⁴	REVLIMID ²	REYVOW
RINVOQ ²	RISPERIDONE ODT	RIXUBIS ²
ROZLYTREK^2,⁴	RUBRACA ^3,⁴	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	SPRYCEL^2,⁴
STELARA ²	STIVARGA ²	STRENSIQ ³
SUCRAID	sunitinib malate^2,⁴	SUNOSI
SUTENT^2,⁴	SYMDEKO ²	TABRECTA ²
tadalafil ²	TAFINLAR ²	TAGRISSO ^3,⁴
TAKHZYRO ³	TALZENNA^2,⁴	TASIGNA^2,⁴
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 12.5mg^1,²	tetrabenazine tab 25mg+	tetrabenazine tab 25mg^1,²
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	VENTAVIS ^3,⁴	VERQUVO
VERSACLOZ	VERZENIO ^3,⁴	VIIBRYD
VIIBRYD STARTER PACK	VITRAKVI ^3,⁴	VIZIMPRO^2,⁴
voriconazole	VOSEVI ²	VOTRIENT^2,⁴
VRAYLAR	VYLEESI	VYNDAMAX ²
VYNDAQEL ²	WEGOVY	XALKORI^2,⁴
XELJANZ ²	XELJANZ XR ²	XENICAL
XERMELO ³	XHANCE	XOLAIR ²
XOSPATA ³	XPOVIO ^3,⁴	XPOVIO 100 MG ONCE WEEKLY ^3,⁴
XPOVIO 40 MG ONCE WEEKLY⁴	XPOVIO 40 MG TWICE WEEKLY⁴	XPOVIO 60 MG ONCE WEEKLY ^3,⁴
XPOVIO 60 MG TWICE WEEKLY⁴	XPOVIO 80 MG ONCE WEEKLY ^3,⁴	XPOVIO 80 MG TWICE WEEKLY ^3,⁴
XTAMPZA ER	XTANDI^2,⁴	XYNTHA ²
XYNTHA SOLOFUSE ²	XYREM ³	XYWAV ³
YONSA^2,⁴	ZEJULA ^3,⁴	ZELBORAF ²
ZEPOSIA ²	ZEPOSIA 7-DAY STARTER PACK ²	ZEPOSIA STARTER KIT ²
ZOKINVY ³	ZOLINZA^2,⁴	ZYDELIG ³
ZYKADIA^2,⁴

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)
deferasirox gra 90mg ^2,⁴	30 packets/ 30 days
deferasirox gra 180mg ^2,⁴	30 packets/ 30 days
deferasirox gra 360mg ^2,⁴	180 packets/ 30 days
deferasirox tab 90mg ^2,⁴	30 tabs / 30 days
deferasirox tab 125mg ^2,⁴	30 tabs / 30 days
deferasirox tab 180mg ^2,⁴	30 tabs / 30 days
deferasirox tab 250mg ^2,⁴	30 tabs / 30 days
deferasirox tab 360mg ^2,⁴	180 tabs / 30 days
deferasirox tab 500mg ^2,⁴	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)
abiraterone tab 250mg ^2,⁴	120 tabs / 30 days
abiraterone tab 500mg ^2,⁴	60 tabs / 30 days
AFINITOR tab 10MG ^2,⁴	30 tabs / 30 days
AFINITOR DIS tab 2MG ^2,⁴	60 tabs / 30 days
AFINITOR DIS tab 3MG ^2,⁴	90 tabs / 30 days
AFINITOR DIS tab 5MG ^2,⁴	60 tabs / 30 days
ALECENSA CAP 150MG ^3,⁴	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
AYVAKIT tab 100MG ^3,⁴	30 tabs / 30 days
AYVAKIT tab 200MG ^3,⁴	30 tabs / 30 days
AYVAKIT tab 25MG ^3,⁴	30 tabs / 30 days
AYVAKIT tab 300MG ^3,⁴	30 tabs / 30 days
AYVAKIT tab 50MG ^3,⁴	30 tabs / 30 days
BALVERSA tab 3MG ^3,⁴	90 tabs / 30 days
BALVERSA tab 4MG ^3,⁴	60 tabs / 30 days
BALVERSA tab 5MG ^3,⁴	30 tabs / 30 days
BOSULIF tab 100MG ^2,⁴	90 tabs / 30 days
BOSULIF tab 400MG ^2,⁴	30 tabs / 30 days
BOSULIF tab 500MG ^2,⁴	30 tabs / 30 days
BRAFTOVI CAP 75MG ³	180 caps / 30 days
BRUKINSA CAP 80MG ³	120 caps / 30 days
CABOMETYX tab 20MG ^2,⁴	30 tabs / 30 days
CABOMETYX tab 40MG ^2,⁴	30 tabs / 30 days
CABOMETYX tab 60MG ^2,⁴	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
COMETRIQ kit 100MG ^3,⁴	1 carton / 28 days
COMETRIQ kit 140MG ^3,⁴	1 carton / 28 days
COMETRIQ kit 60MG ^3,⁴	1 carton / 28 days
COPIKTRA CAP 15MG ^3,⁴	56 caps / 28 days
COPIKTRA CAP 25MG ^3,⁴	56 caps / 28 days
COTELLIC tab 20MG ²	63 tabs / 28 days
DAURISMO tab 100MG ^2,⁴	30 tabs / 30 days
DAURISMO tab 25MG ^2,⁴	60 tabs / 30 days
ERIVEDGE CAP 150MG ^2,⁴	30 caps / 30 days
ERLEADA tab 60MG ²	120 tabs / 30 days
erlotinib tab 100mg ^1,^2,⁴	30 tabs / 30 days
erlotinib tab 150mg ^1,^2,⁴	30 tabs / 30 days
erlotinib tab 25mg ^1,^2,⁴	60 tabs / 30 days
everolimus tab 10mg ^1,⁴	30 tabs / 30 days
everolimus tab 2.5mg ^1,^2,⁴	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
everolimus tab 5mg ^1,^2,⁴	30 tabs / 30 days
everolimus tab 5mg ^1,⁴	60 tabs / 30 days
everolimus tab 5mg ^1,⁴	30 tabs / 30 days
everolimus tab 7.5mg ^1,^2,⁴	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
GAVRETO CAP 100MG ^3,⁴	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
ICLUSIG tab 10MG ^3,⁴	30 tabs / 30 days
ICLUSIG tab 15MG ^3,⁴	30 tabs / 30 days
ICLUSIG tab 30MG ^3,⁴	30 tabs / 30 days
ICLUSIG tab 45MG ^3,⁴	30 tabs / 30 days
IDHIFA tab 100MG ²	30 tabs / 30 days
IDHIFA tab 50MG ²	30 tabs / 30 days
imatinib mes tab 100mg ^2,⁴	90 tabs / 30 days
imatinib mes tab 400mg ^2,⁴	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
INLYTA tab 1MG ^2,⁴	180 tabs / 30 days
INLYTA tab 5MG ^2,⁴	120 tabs / 30 days
INQOVI tab 35-100MG ²	5 tabs / 28 days
INREBIC CAP 100MG ^2,⁴	120 caps / 30 days
IRESSA tab 250MG ^3,⁴	30 tabs / 30 days
JAKAFI tab 10MG ^2,⁴	60 tabs / 30 days
JAKAFI tab 15MG ^2,⁴	60 tabs / 30 days
JAKAFI tab 20MG ^2,⁴	60 tabs / 30 days
JAKAFI tab 25MG ^2,⁴	60 tabs / 30 days
JAKAFI tab 5MG ^2,⁴	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
LENVIMA CAP 10 MG ^3,⁴	30 caps / 30 days
LENVIMA CAP 12MG ^3,⁴	90 caps / 30 days
LENVIMA CAP 14 MG ^3,⁴	60 caps / 30 days
LENVIMA CAP 18 MG ^3,⁴	90 caps / 30 days
LENVIMA CAP 20 MG ^3,⁴	60 caps / 30 days
LENVIMA CAP 24 MG ^3,⁴	90 caps / 30 days
LENVIMA CAP 4MG ^3,⁴	30 caps / 30 days
LENVIMA CAP 8 MG ^3,⁴	60 caps / 30 days
LONSURF tab 15-6.14 ²	60 tabs / 28 days
LONSURF tab 20-8.19 ²	80 tabs / 28 days
LORBRENA tab 100MG ^2,⁴	30 tabs / 30 days
LORBRENA tab 25MG ^2,⁴	90 tabs / 30 days
LUMAKRAS tab 120MG	240 tabs / 30 days
LYNPARZA tab 100MG ^3,⁴	120 tabs / 30 days
LYNPARZA tab 150MG ^3,⁴	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
NERLYNX tab 40MG ^3,⁴	180 tabs / 30 days
NEXAVAR tab 200MG ^2,⁴	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
ODOMZO CAP 200MG ^2,⁴	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
RETEVMO CAP 40MG ^2,⁴	180 caps / 30 days
RETEVMO CAP 80MG ^2,⁴	120 caps / 30 days
ROZLYTREK CAP 100MG ^2,⁴	30 caps / 30 days
ROZLYTREK CAP 200MG ^2,⁴	90 caps / 30 days
RUBRACA tab 200MG ^3,⁴	120 tabs / 30 days
RUBRACA tab 250MG ^3,⁴	120 tabs / 30 days
RUBRACA tab 300MG ^3,⁴	120 tabs / 30 days
RYDAPT CAP 25MG ²	240 caps / 30 days
SPRYCEL tab 100MG ^2,⁴	30 tabs / 30 days
SPRYCEL tab 140MG ^2,⁴	30 tabs / 30 days
SPRYCEL tab 20MG ^2,⁴	90 tabs / 30 days
SPRYCEL tab 50MG ^2,⁴	30 tabs / 30 days
SPRYCEL tab 70MG ^2,⁴	30 tabs / 30 days
SPRYCEL tab 80MG ^2,⁴	30 tabs / 30 days
STIVARGA tab 40MG ²	84 tabs / 28 days
sunitinib cap 12.5mg ^2,⁴	90 caps / 30 days
sunitinib cap 25mg ^2,⁴	30 caps / 30 days
sunitinib cap 37.5mg ^2,⁴	30 caps / 30 days
sunitinib cap 50mg ^2,⁴	30 caps / 30 days
SUTENT CAP 12.5MG ^2,⁴	90 caps / 30 days
SUTENT CAP 25MG ^2,⁴	30 caps / 30 days
SUTENT CAP 37.5MG ^2,⁴	30 caps / 30 days
SUTENT CAP 50MG ^2,⁴	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
TAGRISSO tab 40MG ^3,⁴	30 tabs / 30 days
TAGRISSO tab 80MG ^3,⁴	30 tabs / 30 days
TALZENNA CAP 0.25MG ^2,⁴	90 caps / 30 days
TALZENNA CAP 1MG ^2,⁴	30 caps / 30 days
TASIGNA CAP 150MG ^2,⁴	120 caps / 30 days
TASIGNA CAP 200MG ^2,⁴	120 caps / 30 days
TASIGNA CAP 50MG ^2,⁴	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
VERZENIO tab 100MG ^3,⁴	60 tabs / 30 days
VERZENIO tab 150MG ^3,⁴	60 tabs / 30 days
VERZENIO tab 200MG ^3,⁴	60 tabs / 30 days
VERZENIO tab 50MG ^3,⁴	60 tabs / 30 days
VITRAKVI CAP 100MG ^3,⁴	60 caps / 30 days
VITRAKVI CAP 25MG ^3,⁴	180 caps / 30 days
VITRAKVI SOL 20MG/mL ^3,⁴	300 mLS / 30 days
VIZIMPRO tab 15MG ^2,⁴	30 tabs / 30 days
VIZIMPRO tab 30MG ^2,⁴	30 tabs / 30 days
VIZIMPRO tab 45MG ^2,⁴	30 tabs / 30 days
VOTRIENT tab 200MG ^2,⁴	120 tabs / 30 days
XALKORI CAP 200MG ^2,⁴	120 caps / 30 days
XALKORI CAP 250MG ^2,⁴	120 caps / 30 days
XOSPATA tab 40MG ³	90 tabs / 30 days
XPOVIO PAK 100MG ^3,⁴	1 box / 28 days
XPOVIO PAK 40MG ⁴	1 box / 28 days
XPOVIO PAK 60MG ^3,⁴	1 box / 28 days
XPOVIO PAK 60MG ⁴	1 box / 28 days
XPOVIO PAK 80MG ^3,⁴	1 box / 28 days
XPOVIO 100 MG ONCE WEEKLY ^3,⁴	1 box / 28 days
XPOVIO 40 MG ONCE WEEKLY ^3,⁴	1 box / 28 days
XPOVIO 40 MG TWICE WEEKLY ^3,⁴	1 box / 28 days
XPOVIO 60 MG ONCE WEEKLY ^3,⁴	1 box / 28 days
XPOVIO 80 MG ONCE WEEKLY ^3,⁴	1 box / 28 days
XTANDI CAP 40MG ^2,⁴	120 caps / 30 days
XTANDI tab 40MG ^2,⁴	120 tabs / 30 days
XTANDI tab 80MG ^2,⁴	60 tabs / 30 days
YONSA tab 125MG ^2,⁴	120 tabs / 30 days
ZEJULA CAP 100MG ^3,⁴	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)
ZOLINZA CAP 100MG ^2,⁴	120 caps / 30 days
ZYDELIG tab 100MG ³	60 tabs / 30 days
ZYDELIG tab 150MG ³	60 tabs / 30 days
ZYKADIA tab 150MG ^2,⁴	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
VENTAVIS SOL 10MCG/mL ^3,⁴	270 AMPULS / 30 days
VENTAVIS SOL 20MCG/mL ^3,⁴	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
HETLIOZ CAP 20MG ^3,⁴	30 caps / 30 days
HETLIOZ LQ SUS 4MG/mL ^3,⁴	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
AUBAGIO tab 14MG ^2,⁴	30 tabs / 30 days
AUBAGIO tab 7MG ^2,⁴	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
dalfampridin tab 10mg er ^2,⁴	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
OFEV CAP 100MG ^2,⁴	60 caps / 30 days
OFEV CAP 150MG ^2,⁴	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)
abiraterone acetate^2,⁴	ACTEMRA ²	ACTEMRA ACTPEN ²
ACTHAR ²	ADEMPAS ^3,⁵	ADVATE ²
ADYNOVATE ²	AFINITOR^2,⁴	AFINITOR DISPERZ^2,⁴
AFSTYLA ²	ALECENSA ^3,^4,⁵	ALPHANINE SD ²
ALPROLIX ²	ALUNBRIG ³	alyq ²
ambrisentan ²	ARANESP ALBUMIN FREE ^2,⁵	ARCALYST ^3,⁵
ARIKAYCE ³	AUBAGIO^2,⁴	AUSTEDO ²
AVONEX ^2,⁵	AVONEX PEN ^2,⁵	AYVAKIT^4,⁵
BALVERSA^4,⁵	BENEFIX ²	BENLYSTA ²
BERINERT ²	BETASERON ^2,⁵	bexarotene^2,⁴
bosentan ²	BOSULIF^2,⁴	BRAFTOVI ^3,⁵
BRUKINSA ³	CABOMETYX^2,⁴	CAPRELSA ³
CARBAGLU ^3,⁵	CERDELGA ²	CHORIONIC GONADOTROPIN ²
CIMZIA ²	CIMZIA STARTER KIT ²	COAGADEX ³
COMETRIQ ^3,^4,⁵	COPIKTRA^4,⁵	COSENTYX ²
COSENTYX SENSOREADY PEN ²	COTELLIC ²	dalfampridine er^2,⁴
DAURISMO^2,⁴	deferasirox^2,⁴	dimethyl fumarate ²
dimethyl fumarate starterpack ²	DOPTELET ^3,⁵	DUPIXENT ²
ELOCTATE ²	ENBREL ^2,⁵	ENBREL MINI ^2,⁵
ENBREL SURECLICK ^2,⁵	ENDARI ³	ENSPRYNG ²
EPCLUSA ²	EPIDIOLEX SOL 100MG/ML ²	ERIVEDGE^2,⁴
ERLEADA ²	erlotinib hydrochloride^2,⁴	ESBRIET ²
ESPEROCT ²	everolimus^2,⁴	EVRYSDI ^3,⁵
FARYDAK CAP 10MG ²	FOLLISTIM AQ ^2,⁵	FORTEO ^2,⁵
GALAFOLD ²	ganirelix acetate ^2,⁵	GATTEX ^3,⁵
GAVRETO ^3,^4,⁵	GILENYA ²	GILOTRIF ^3,⁵
glatiramer acetate ^2,⁵	HAEGARDA ^3,⁵	HARVONI ^2,⁵
HEMLIBRA ²	HEMOFIL M ²	HETLIOZ ^3,^4,⁵
HETLIOZ LQ ^3,^4,⁵	HUMIRA ^2,⁵	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK ^2,⁵
HUMIRA PEN ^2,⁵	HUMIRA PEN-CD/UC/HS STARTER ^2,⁵	HUMIRA PEN-PEDIATRIC UC STARTER PACK ^2,⁵
HUMIRA PEN-PS/UV STARTER ^2,⁵	HYCAMTIN ²	IBRANCE ²
icatibant acetate ²	ICLUSIG^4,⁵	IDELVION ²
IDHIFA ²	imatinib mesylate^2,⁴	IMBRUVICA ³
IMCIVREE ³	INGREZZA ³	INLYTA^2,⁴
INQOVI ²	INREBIC ^2,^4,⁵	IRESSA ^3,^4,⁵
ISTURISA ³	IXINITY ²	JAKAFI^2,⁴
JIVI ²	JUXTAPID ^3,⁵	JYNARQUE ²
KALYDECO ²	KESIMPTA ^2,⁵	KEVZARA ²
KISQALI ²	KISQALI FEMARA ²	KOATE ²
KOATE-DVI ²	KOGENATE FS ²	KORLYM ³
KOSELUGO ³	KOVALTRY ²	lapatinib ditosylate ^2,⁵
LENVIMA^4,⁵	LONSURF ²	LORBRENA^2,⁴
LYNPARZA ^3,^4,⁵	MATULANE ²	MAVYRET ^2,⁵
MAYZENT ²	MEKINIST ²	MEKTOVI ^3,⁵
MENOPUR ²	miglustat ²	MIRCERA ²
MONONINE ²	MULPLETA ²	MYALEPT ^3,⁵
NATPARA ²	NERLYNX ^3,^4,⁵	NEXAVAR^2,⁴
NINLARO ²	NORDITROPIN FLEXPRO ^2,⁵	NOVAREL ^2,⁵
NOVOEIGHT ²	NUBEQA ²	NUWIQ ²
OCALIVA ²	ODOMZO^2,⁴	OFEV^2,⁴
ONUREG ²	OPSUMIT ^3,⁵	ORENCIA ²
ORENCIA CLICKJECT ²	ORENITRAM ^3,⁵	ORGOVYX ³
ORKAMBI ²	OTEZLA ²	OXBRYTA ^3,⁵
OXERVATE ^3,⁵	PALYNZIQ ^3,⁵	PEGINTRON ²
PEMAZYRE ³	PIQRAY ²	PLEGRIDY ²
PLEGRIDY STARTER PACK ²	POMALYST ²	PREGNYL W/DILUENT BENZYL ALCOHOL/NACL ^2,⁵
PROCYSBI ^3,⁵	PROFILNINE ²	PROFILNINE SD ²
PROMACTA ²	QINLOCK ³	RAVICTI ²
REBIF ^2,⁵	REBIF REBIDOSE ^2,⁵	REBIF REBIDOSE TITRATION PACK ^2,⁵
REBIF TITRATION PACK ^2,⁵	REBINYN ²	RECOMBINATE ²
RETACRIT ²	RETEVMO^2,⁴	REVLIMID ²
RINVOQ ²	RIXUBIS ²	ROZLYTREK ^2,^4,⁵
RUBRACA ^3,^4,⁵	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	SPRYCEL ^2,^4,⁵	STELARA ²
STIVARGA ²	STRENSIQ ³	sunitinib malate^2,⁴
SUTENT^2,⁴	SYMDEKO ²	TABRECTA ²
tadalafil ²	TAFINLAR ²	TAGRISSO ^3,^4,⁵
TAKHZYRO ^3,⁵	TALZENNA^2,⁴	TASIGNA ^2,^4,⁵
TAVALISSE ³	TAZVERIK ³	TEGSEDI ^3,⁵
temozolomide ²	tetrabenazine ²	THALOMID ²
TIBSOVO ³	tolvaptan ²	TRACLEER ²
TREMFYA ²	TRIKAFTA ²	TUKYSA ³
TURALIO ³	TYMLOS ²	TYVASO ^3,⁵
TYVASO REFILL ^3,⁵	TYVASO STARTER ^3,⁵	UPTRAVI ^3,⁵
VENCLEXTA ³	VENCLEXTA STARTING PACK ³	VENTAVIS ^3,^4,⁵
VERZENIO ^3,^4,⁵	VITRAKVI ^3,^4,⁵	VIZIMPRO^2,⁴
VOSEVI ²	VOTRIENT^2,⁴	VYNDAMAX ²
VYNDAQEL ²	XALKORI^2,⁴	XELJANZ ²
XELJANZ XR ²	XERMELO ³	XOLAIR ²
XOSPATA ³	XPOVIO^4,⁵	XPOVIO ONCE WEEKLY^4,⁵
XTANDI^2,⁴	XYNTHA ²	XYNTHA SOLOFUSE ²
XYREM ^3,⁵	XYWAV ^3,⁵	YONSA^2,⁴
ZEJULA^4,⁵	ZELBORAF ²	ZEPOSIA ²
ZEPOSIA 7-DAY STARTER PACK ²	ZEPOSIA STARTER KIT ²	ZOKINVY ³
ZOLINZA^2,⁴	ZYDELIG ^3,⁵	ZYKADIA^2,⁴

¹Multiple products available in both GP and GNP tiers.

²Specialty

³Limited distribution

⁴Split fill

⁵Exclusive to Accredo

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Elite prescription drug benefits

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Guide to prescription drug benefits

Use this guide to understand how your benefits work.

Drug name(s)

Drug name(s)

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits (per 30 days or as specified)

Aminoglycosides

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics - opioids

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

Androgens - anabolic

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Anticoagulants

Drug name(s)

Quantity limits (per 30 days or as specified)

Anticonvulsants

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidiabetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidotes and specific antagonists

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiemetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antihyperlipidemics

Drug name(s)

Quantity limits (per 30 days or as specified)

Anti-infective agents - misc

Drug name(s)

Quantity limits (per 30 days or as specified)

Antimyasthenic/cholinergic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits (per 30 days or as specified)

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits (per 30 days or as specified)

Antipsychotics/antimanic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antipsychotics/antimanic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antivirals

Drug name(s)

Quantity limits (per 30 days or as specified)

Cardiovascular agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Dermatologicals

Drug name(s)

Quantity limits (per 30 days or as specified)

Diagnostic products

Drug name(s)

Quantity limits (per 30 days or as specified)

Digestive aids

Drug name(s)

Quantity limits (per 30 days or as specified)