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 acetate2,4

ACTEMRA 2

ACTEMRA ACTPEN 2

ACTHAR 2

ADEMPAS3

ADVATE 2

ADYNOVATE 2

AFINITOR2,4

AFINITOR DISPERZ2,4

AFSTYLA 2

AKLIEF

ALECENSA 3,4

ALPHANINE SD 2

ALPROLIX 2

ALUNBRIG3

alyq 2

ambrisentan 2

ARANESP ALBUMIN FREE 2

ARCALYST3

ARIKAYCE3

AUBAGIO2,4

AUSTEDO 2

avita

AVONEX 2

AVONEX PEN 2

AYVAKIT 3,4

BALVERSA 3,4

BELBUCA

BELSOMRA

BENEFIX 2

BENLYSTA 2

BERINERT 2

BETASERON 2

bexarotene2,4

bosentan 2

BOSULIF2,4

BRAFTOVI3

BRUKINSA3

CABOMETYX2,4

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 er2,4

DAURISMO2,4

deferasirox2,4

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

ERIVEDGE2,4

ERLEADA 2

erlotinib hcl2,4

ESBRIET 2

ESPEROCT 2

everolimus tab 2.5mg1,2,4

everolimus tab 2.5mg1,4

everolimus tab 2mg1,4

everolimus tab 10mg1,4

everolimus tab 3mg1,4

everolimus tab 5mg1,2,4

everolimus tab 5mg1,4

everolimus tab 7.5mg1,2,4

everolimus tab 7.5mg1,4

EVRYSDI3

FANAPT

FANAPT TITRATION PACK

FARYDAK CAP 10MG1

FARYDAK CAP 10MG1,2

FARYDAK CAP 15MG1

FARYDAK CAP 15MG1,2

FARYDAK CAP 20MG1

FARYDAK CAP 20MG1,2

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 mesylate2,4

IMBRUVICA3

IMCIVREE3

INGREZZA3

INLYTA2,4

INQOVI 2

INREBIC2,4

IRESSA 3,4

ISTURISA3

IXINITY 2

JAKAFI2,4

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

LORBRENA2,4

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

NEXAVAR2,4

NEXLETOL

NEXLIZET

NINLARO 2

NOCTIVA

NORDITROPIN FLEXPRO 2

NOVAREL 2

NOVOEIGHT 2

NOXAFIL

NUBEQA 2

NUCALA

NUCYNTA ER

NUWIQ 2

OCALIVA 2

ODOMZO2,4

OFEV2,4

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

RETEVMO2,4

REVLIMID 2

REYVOW

RINVOQ 2

RISPERIDONE ODT

RIXUBIS 2

ROZLYTREK2,4

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

SPRYCEL2,4

STELARA 2

STIVARGA 2

STRENSIQ 3

SUCRAID

sunitinib malate2,4

SUNOSI

SUTENT2,4

SYMDEKO 2

TABRECTA 2

tadalafil 2

TAFINLAR 2

TAGRISSO 3,4

TAKHZYRO 3

TALZENNA2,4

TASIGNA2,4

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 12.5mg1,2

tetrabenazine tab 25mg+

tetrabenazine tab 25mg1,2

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

VIZIMPRO2,4

voriconazole

VOSEVI 2

VOTRIENT2,4

VRAYLAR

VYLEESI

VYNDAMAX 2

VYNDAQEL 2

WEGOVY

XALKORI2,4

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

XTANDI2,4

XYNTHA 2

XYNTHA SOLOFUSE 2

XYREM 3

XYWAV 3

YONSA2,4

ZEJULA 3,4

ZELBORAF 2

ZEPOSIA 2

ZEPOSIA 7-DAY STARTER PACK 2

ZEPOSIA STARTER KIT 2

ZOKINVY 3

ZOLINZA2,4

ZYDELIG 3

ZYKADIA2,4

 

 

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 acetate2,4

ACTEMRA 2

ACTEMRA ACTPEN 2

ACTHAR 2

ADEMPAS 3,5

ADVATE 2

ADYNOVATE 2

AFINITOR2,4

AFINITOR DISPERZ2,4

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

AUBAGIO2,4

AUSTEDO 2

AVONEX 2,5

AVONEX PEN 2,5

AYVAKIT4,5

BALVERSA4,5

BENEFIX 2

BENLYSTA 2

BERINERT 2

BETASERON 2,5

bexarotene2,4

bosentan 2

BOSULIF2,4

BRAFTOVI 3,5

BRUKINSA 3

CABOMETYX2,4

CAPRELSA 3

CARBAGLU 3,5

CERDELGA 2

CHORIONIC GONADOTROPIN 2

CIMZIA 2

CIMZIA STARTER KIT 2

COAGADEX 3

COMETRIQ 3,4,5

COPIKTRA4,5

COSENTYX 2

COSENTYX SENSOREADY PEN 2

COTELLIC 2

dalfampridine er2,4

DAURISMO2,4

deferasirox2,4

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

ERIVEDGE2,4

ERLEADA 2

erlotinib hydrochloride2,4

ESBRIET 2

ESPEROCT 2

everolimus2,4

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

ICLUSIG4,5

IDELVION 2

IDHIFA 2

imatinib mesylate2,4

IMBRUVICA 3

IMCIVREE 3

INGREZZA 3

INLYTA2,4

INQOVI 2

INREBIC 2,4,5

IRESSA 3,4,5

ISTURISA 3

IXINITY 2

JAKAFI2,4

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

LENVIMA4,5

LONSURF 2

LORBRENA2,4

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

NEXAVAR2,4

NINLARO 2

NORDITROPIN FLEXPRO 2,5

NOVAREL 2,5

NOVOEIGHT 2

NUBEQA 2

NUWIQ 2

OCALIVA 2

ODOMZO2,4

OFEV2,4

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

RETEVMO2,4

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 malate2,4

SUTENT2,4

SYMDEKO 2

TABRECTA 2

tadalafil 2

TAFINLAR 2

TAGRISSO 3,4,5

TAKHZYRO 3,5

TALZENNA2,4

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

VIZIMPRO2,4

VOSEVI 2

VOTRIENT2,4

VYNDAMAX 2

VYNDAQEL 2

XALKORI2,4

XELJANZ 2

XELJANZ XR 2

XERMELO 3

XOLAIR 2

XOSPATA 3

XPOVIO4,5

XPOVIO ONCE WEEKLY4,5

XTANDI2,4

XYNTHA 2

XYNTHA SOLOFUSE 2

XYREM 3,5

XYWAV 3,5

YONSA2,4

ZEJULA4,5

ZELBORAF 2

ZEPOSIA 2

ZEPOSIA 7-DAY STARTER PACK 2

ZEPOSIA STARTER KIT 2

ZOKINVY 3

ZOLINZA2,4

ZYDELIG 3,5

ZYKADIA2,4

1Multiple products available in both GP and GNP tiers.

2Specialty

3Limited distribution

4Split fill

5Exclusive to Accredo