Exclusive 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 Exclusive 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	ACTEMRA²	ACTEMRA ACTPEN²
ACTHAR²	ADEMPAS³	ADVATE²
ADYNOVATE²	AFINITOR^2,⁴	AFINITOR DISPERZ^2,⁴
AFSTYLA²	ALECENSA^3,⁴	ALPHANINE SD²
ALPROLIX²	ALUNBRIG³	alyq²
ambrisentan²	ARANESP ALBUMIN FREE²	ARCALYST³
ARIKAYCE³	AUBAGIO^2,⁴	AUSTEDO²
avita	AVONEX²	AVONEX PEN²
AYVAKIT^3,⁴	BALVERSA^3,⁴	BELBUCA
BENEFIX²	BENLYSTA²	BERINERT²
BETASERON²	bexarotene^2,⁴	bosentan²
BOSULIF^2,⁴	BRAFTOVI³	BRUKINSA³
CABOMETYX^2,⁴	CALQUENCE³	capecitabine²
CAPRELSA³	CARBAGLU³	CERDELGA²
CHORIONIC GONADOTROPIN²	ciclodan	ciclopirox nail lacquer
CIMZIA²	CIMZIA STARTER KIT²	CLOZAPINE ODT
COAGADEX³	COMETRIQ^3,⁴	CONTRAVE
COPIKTRA^3,⁴	CORLANOR	COSENTYX²
COSENTYX SENSOREADY PEN²	COTELLIC²	CRESEMBA
dalfampridine er^2,⁴	DAURISMO^2,⁴	deferasirox^2,⁴
diclofenac sodium	dimethyl fumarate²	dimethyl fumarate starterpack²
DOPTELET³	DUPIXENT²	ELMIRON
ELOCTATE²	EMPAVELI	EMSAM
ENBREL²	ENBREL MINI²	ENBREL SURECLICK²
ENDARI³	ENDOMETRIN	ENSPRYNG²
EPCLUSA²	EPIDIOLEX SOL 100MG/ML⁺	EPIDIOLEX SOL 100MG/ML⁺²
ERIVEDGE^2,⁴	ERLEADA²	erlotinib hcl^2,⁴
ESBRIET²	ESPEROCT²	everolimus tab 10mg⁺⁴
everolimus tab 2.5mg⁺^2,⁴	everolimus tab 2.5mg⁺⁴	everolimus tab 2mg⁺⁴
everolimus tab 3mg⁺⁴	everolimus tab 5mg⁺^2,⁴	everolimus tab 5mg⁺⁴
everolimus tab 7.5mg⁺^2,⁴	everolimus tab 7.5mg⁺⁴	EVRYSDI³
FANAPT	FANAPT TITRATION PACK	FARYDAK CAP 10MG
FARYDAK CAP 10MG²	FARYDAK CAP 15MG	FARYDAK CAP 15MG²
FARYDAK CAP 20MG	FARYDAK CAP 20MG²	FASENRA PEN
FAZACLO	fentanyl	fentanyl citrate oral transmucosal
FETZIMA	FETZIMA TITRATION PACK	FIBRYGA
FINTEPLA³	FIRDAPSE³	fluorouracil
FLUOXETINE DR	FOLLISTIM AQ²	FORTEO²
FOTIVDA	GALAFOLD²	ganirelix acetate²
GATTEX³	GAVRETO^3,⁴	GILENYA²
GILOTRIF³	glatiramer acetate²	HAEGARDA³
HARVONI²	HEMLIBRA²	HEMOFIL M²
HETLIOZ^3,⁴	HETLIOZ LQ^3,⁴	HUMIRA²
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK²	HUMIRA PEN²	HUMIRA PEN-CD/UC/HS STARTER²
HUMIRA PEN-PEDIATRIC UC STARTER PACK²	HUMIRA PEN-PS/UV STARTER²	HYCAMTIN²
IBRANCE²	icatibant acetate²	ICLUSIG^3,⁴
icosapent ethyl	IDELVION²	IDHIFA²
imatinib mesylate^2,⁴	IMBRUVICA³	IMCIVREE³
INGREZZA³	INLYTA^2,⁴	INQOVI²
INREBIC^2,⁴	IRESSA^3,⁴	ISTURISA³
IXINITY²	JAKAFI^2,⁴	JIVI²
JUXTAPID³	JYNARQUE²	KALYDECO²
KESIMPTA²	KEVZARA²	KISQALI²
KISQALI FEMARA 200 DOSE²	KISQALI FEMARA 400 DOSE²	KISQALI FEMARA 600 DOSE²
KOATE²	KOATE-DVI²	KOGENATE FS²
KORLYM³	KOSELUGO³	KOVALTRY²
lapatinib ditosylate²	LEDIPASVIR/SOFOSBUVIR²	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 hcl	lidocaine patch 5%	lidocaine/prilocaine
LOMAIRA	LONSURF²	LORBRENA^2,⁴
LUCEMYRA	LUMAKRAS	LUPKYNIS
LYNPARZA^3,⁴	LYSODREN	MATULANE²
MAVENCLAD²	MAVYRET²	MAYZENT²
MAYZENT STARTER PACK	MEKINIST²	MEKTOVI³
MENOPUR²	methadone hcl	methadone hcl
METHITEST	METHYLTESTOSTERONE	miglustat²
MIRCERA²	MONONINE²	morphine sulfate cr
morphine sulfate er	MULPLETA²	MYALEPT³
NATPARA²	NERLYNX^3,⁴	NEXAVAR^2,⁴
NEXLETOL	NEXLIZET	NINLARO²
NOCTIVA	NORDITROPIN FLEXPRO²	NOVAREL²
NOVOEIGHT²	NOXAFIL	NUBEQA²
NUCALA	NUEDEXTA	NUWIQ²
OCALIVA²	ODOMZO^2,⁴	OFEV^2,⁴
ONUREG²	OPSUMIT³	ORENCIA²
ORENCIA CLICKJECT²	ORENITRAM³	ORGOVYX³
ORIAHNN	ORILISSA	ORKAMBI²
OTEZLA²	OXBRYTA³	OXERVATE³
OXYCONTIN	OXYMORPHONE HCL ER	OXYMORPHONE HCL ER
PALYNZIQ³	PEGINTRON²	PEMAZYRE³
phentermine hcl	phentermine hcl	PIQRAY 200MG DAILY DOSE²
PIQRAY 250MG DAILY DOSE²	PIQRAY 300MG DAILY DOSE²	PLEGRIDY²
PLEGRIDY STARTER PACK²	POMALYST²	posaconazole
posaconazole dr	PREGNYL W/DILUENT BENZYL ALCOHOL/NACL²	PROCYSBI³
PROFILNINE²	PROFILNINE SD²	PROMACTA²
QINLOCK³	QSYMIA	QUDEXY XR
RAVICTI²	REBIF²	REBIF REBIDOSE²
REBIF REBIDOSE TITRATION PACK²	REBIF TITRATION PACK²	REBINYN²
RECOMBINATE²	REPATHA	REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK	RETACRIT²	RETEVMO^2,⁴
REVLIMID²	REYVOW	RINVOQ²
RISPERIDONE ODT	RIXUBIS²	ROZLYTREK^2,⁴
RUBRACA^3,⁴	RUCONEST²	RUZURGI³
RYDAPT²	sajazir²	sapropterin dihydrochloride²
SAXENDA	SECUADO	sildenafil sus 10mg/ml
sildenafil sus 10mg/ml²	sildenafil tab 20mg²	SIMPONI²
SKYRIZI²	SKYRIZI PEN²	sodium phenylbutyrate²
SOFOSBUVIR/VELPATASVIR²	SOVALDI²	SPRYCEL^2,⁴
STELARA²	STIVARGA²	STRENSIQ³
SUCRAID	sunitinib malate^2,⁴	SUNOSI
SUTENT^2,⁴	SYMDEKO²	TABRECTA²
tadalafil²	TAFINLAR²	TAGRISSO^3,⁴
TAKHZYRO³	TALZENNA^2,⁴	TASIGNA^2,⁴
TAVALISSE³	tazarotene	TAZVERIK³
TEGSEDI³	temozolomide²	TEPMETKO⁴
testosterone	testosterone cypionate	TESTOST ENAN INJ 200MG/ML
testost enan inj 200mg/ml	testosterone pump	testosterone topical solution
tetrabenazine tab 12.5mg	tetrabenazine tab 12.5mg²	tetrabenazine tab 25mg
tetrabenazine tab 25mg²	THALOMID²	TIBSOVO³
tolvaptan²	topiramate er	TRACLEER²
tramadol hcl er	tramadol hcl er	TREMFYA²
tretinoin	TRIKAFTA²	TRINTELLIX
TROKENDI XR	TRUSELTIQ	TUKYSA³
TURALIO³	TYMLOS²	TYVASO³
TYVASO REFILL³	TYVASO STARTER³	UKONIQ⁴
UPTRAVI³	VASCEPA	VENCLEXTA³
VENCLEXTA STARTING PACK³	VENTAVIS^3,⁴	VERQUVO
VERSACLOZ	VERZENIO^3,⁴	VIIBRYD
VIIBRYD STARTER PACK	VITRAKVI^3,⁴	VIZIMPRO^2,⁴
voriconazole	VOSEVI²	VOTRIENT^2,⁴
VRAYLAR	VYLEESI	VYNDAMAX²
VYNDAQEL²	WEGOVY	XALKORI^2,⁴
XELJANZ²	XELJANZ XR²	XENICAL
XERMELO³	XHANCE	XOLAIR²
XOSPATA³	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	XYNTHA²
XYNTHA SOLOFUSE²	XYREM³	XYWAV³
YONSA^2,⁴	ZEJULA^3,⁴	ZELBORAF²
ZEPOSIA²	ZEPOSIA 7-DAY STARTER PACK²	ZEPOSIA STARTER KIT²
ZOKINVY³	ZOLINZA^2,⁴	ZYDELIG³
ZYKADIA^2,⁴

Drug name(s)
AIMOVIG²	AJOVY²	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	EMGALITY²
FLURBIPROFEN	NURTEC	OTREXUP²
OZEMPIC	REDITREX	RYBELSUS
SOLIQUA 100/33	SUMATRIPTAN SUCCINATE	tacrolimus
TOLMETIN SODIUM	TRULICITY	UBRELVY
VICTOZA	XULTOPHY 100/3.6

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)	Quantity limits (per 30 days or as specified)
ADIPEX-P CAP 37.5MG	30 caps / 30 days
ADIPEX-P TAB 37.5MG	30 tabs / 30 days
benzphetamin tab 50mg	90 tabs / 30 days
BENZPHETMINE TAB 25MG	90 tabs / 30 days
CONTRAVE TAB 8-90MG	120 tabs / 30 days
diethylpropion tab 25mg	90 tabs / 30 days
DIETHYLPROPION TAB 75MG ER	30 tabs / 30 days
IMCIVREE INJ 10MG/ML³	10 vials / 30 days
LOMAIRA TAB 8MG	90 tabs / 30 days
PHENDIMETRAZ CAP 105MG ER	30 caps / 30 days
phendimetrazine tab 35mg	180 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
QSYMIA CAP 11.25-69	30 caps / 30 days
QSYMIA CAP 15-92MG	30 caps / 30 days
QSYMIA CAP 3.75-23	30 caps / 30 days
QSYMIA CAP 7.5-46MG	30 caps / 30 days
SAXENDA INJ 18MG/3ML	15 mLs / 30 days
SUNOSI TAB 150MG	30 tabs / 30 days
SUNOSI TAB 75MG	30 tabs / 30 days
WAKIX TAB 17.8MG	60 tabs / 30 days
WAKIX TAB 4.45MG	60 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 SUS³	28 vials / 28 days

Analgesics – anti-inflammatory

Drug name(s)	Quantity limits (per 30 days or as specified)
ACTEMRA INJ 162/0.9²	4 syringes / 28 days
ACTEMRA INJ ACTPEN²	4 injections / 28 days
ARCALYST INJ 220MG³	8 vials / 28 days
DUEXIS TAB 800-26.6	90 tabs / 30 days
ENBREL INJ 25/0.5ML²	8 syringes / 28 days
ENBREL INJ 25MG²	8 vials / 28 days
ENBREL INJ 50MG/ML²	4 syringes / 28 days
ENBREL MINI INJ 50MG/ML²	4 carts / 28 days
ENBREL SRCLK INJ 50MG/ML²	4 syringes / 28 days
HUMIRA INJ 10/0.1ML²	2 syringes / 28 days
HUMIRA INJ 10MG/0.2²	2 syringes / 28 days
HUMIRA INJ 20/0.2ML²	2 syringes / 28 days
HUMIRA INJ 40/0.4ML²	2 syringes / 28 days
HUMIRA KIT 20MG/0.4²	2 syringes / 28 days
HUMIRA KIT 40MG/0.8²	2 syringes / 28 days
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK	1 kit /180 days
HUMIRA PEN INJ 40/0.4ML²	2 pens / 28 days
HUMIRA PEN INJ 40MG/0.8²	2 pens / 28 days
HUMIRA PEN INJ 80/0.8ML²	2 pens / 28 days
HUMIRA PEN INJ CD/UC/HS²	1 kit /180 days
HUMIRA PEN INJ PS/UV²	1 kit /180 days
HUMIRA PEN KIT CD/UC/HS²	1 kit /180 days
HUMIRA PEN KIT PED UC²	4 pens / 180 days
HUMIRA PEN KIT PS/UV²	1 kit /180 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML²	2 syringes / 28 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML²	2 syringes / 28 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML²	2 pens / 28 days
KEVZARA- SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML²	2 pens / 28 days
KINERET INJ³	30 syringes / 30 days
naproxen-esomeprazole tab 375-20mg	60 tabs / 30 days
naproxen-esomeprazole tab 500-20mg	60 tabs / 30 days
OLUMIANT TAB 1MG²	30 tabs / 30 days
OLUMIANT TAB 2MG²	30 tabs / 30 days
ORENCIA INJ 125MG/ML²	4 syringes / 28 days
ORENCIA INJ 50/0.4ML²	4 syringes / 28 days
ORENCIA INJ 87.5/0.7²	4 syringes / 28 days
ORENCIA CLCK INJ 125MG/ML²	4 syringes / 28 days
OTEZLA TAB 10/20/30²	1 kit /180 days
OTEZLA TAB 30MG²	60 tabs / 30 days
RINVOQ TAB 15MG ER²	30 tabs / 30 days
SIMPONI INJ 100MG/ML²	1 syringe / 28 days
SIMPONI INJ 50/0.5ML²	1 syringe / 28 days
VIMOVO TAB 375-20MG	60 tabs / 30 days
VIMOVO TAB 500-20MG	60 tabs / 30 days
XELJANZ SOL 1MG/ML²	240 mLs / 30 days
XELJANZ TAB 10MG²	240 tabs / 365 days
XELJANZ TAB 5MG²	60 tabs / 30 days
XELJANZ XR TAB 11MG²	30 tabs / 30 days
XELJANZ XR TAB 22MG²	120 tabs / 365 days

Analgesics - opioid

Drug name(s)	Adult quantity limit – 5 days	Child quantity limit – 3 days
ABSTRAL SUB 400MCG	120 tabs / 30 days	N/A
ABSTRAL SUB 600MCG	120 tabs / 30 days	N/A
ABSTRAL SUB 800MCG	120 tabs / 30 days	N/A
ACTIQ LOZ 1200MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 1600MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 200MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 400MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 600MCG	120 lozenges / 30 days	N/A
ACTIQ LOZ 800MCG	120 lozenges / 30 days	N/A
APAP/CAFFEIN TAB DIHYDROC	50 tablets /30 days	30 tablets /30 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
APAP-CAFFEINE CAP DIHYDROCODONE	50 capsules /30 days	30 capsules /30 days
ARYMO ER TAB 15MG	60 tablets /month	N/A
ARYMO ER TAB 30MG	30 tablets /month	N/A
ARYMO ER TAB 60MG	0 tablets /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 75MCG	60 films/month	N/A
BELBUCA MIS 900MCG	30 films/month	N/A
buprenorphine dis 10mcg/hr	4 systems /month	N/A
buprenorphine dis 15mcg/hr	4 systems /month	N/A
buprenorphine dis 20mcg/hr	4 systems /month	N/A
buprenorphine dis 5mcg/hr	4 systems /month	N/A
buprenorphine dis 7.5/hr	4 systems /month	N/A
butorphanol sol 10mg/ml	2.5 ML (1 bottle)/30 days	0 mL/30 days
BUTRANS DIS 10MCG/HR	4 systems /month	N/A
BUTRANS DIS 15MCG/HR	4 systems /month	N/A
BUTRANS DIS 20MCG/HR	4 systems /month	N/A
BUTRANS DIS 5MCG/HR	4 systems /month	N/A
BUTRANS DIS 7.5/HR	4 systems /month	N/A
CODEINE SULF TAB 15MG	30 tablets /30 days	18 tablets /30 days
CODEINE SULF TAB 30MG	30 tablets /30 days	18 tablets /30 days
codeine sulf tab 30mg	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
CONZIP CAP 100MG	30 capsules /30 days	N/A
CONZIP CAP 200MG	30 capsules /30 days	N/A
CONZIP CAP 300MG	30 capsules /30 days	N/A
DILAUDID LIQ 1MG/ML	60 mL/30 days	36 mL/30 days
DILAUDID TAB 2MG	30 tablets /30 days	18 tablets /30 days
DILAUDID TAB 4MG	15 tablets /30 days	9 tablets /30 days
DILAUDID TAB 8MG	5 tablets /30 days	3 tablets /30 days
DURAGESIC DIS 100MCG/H	0 patches/month	N/A
DURAGESIC DIS 12MCG/HR	10 patches/month	N/A
DURAGESIC DIS 25MCG/HR	0 patches/month	N/A
DURAGESIC DIS 50MCG/HR	0 patches/month	N/A
DURAGESIC DIS 75MCG/HR	0 patches/month	N/A
dvorah tab	50 tablets /30 days	30 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	9 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/hr	0 patches/month	N/A
fentanyl dis 37.5mcg	0 patches/month	N/A
fentanyl dis 62.5mcg	0 patches/month	N/A
fentanyl dis 87.5mcg	0 patches/month	N/A
FENTANYL CIT TAB 100MCG	120 tabs / 30 days	N/A
FENTANYL CIT TAB 200MCG	120 tabs / 30 days	N/A
FENTANYL CIT TAB 400MCG	120 tabs / 30 days	N/A
FENTANYL CIT TAB 600MCG	120 tabs / 30 days	N/A
FENTANYL CIT TAB 800MCG	120 tabs / 30 days	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
FENTORA TAB 100MCG	120 tabs / 30 days	N/A
FENTORA TAB 200MCG	120 tabs / 30 days	N/A
FENTORA TAB 400MCG	120 tabs / 30 days	N/A
FENTORA TAB 600MCG	120 tabs / 30 days	N/A
FENTORA TAB 800MCG	120 tabs / 30 days	N/A
HYDRO/ACETA SOL 10-325MG	375 mL/30 days	225 mL/30 days
hydrocodone/acetaminophen sol 10-325mg	375 mL/30 days	225 mL/30 days
hydrocodone/apap sol 7.5-325	450 mL/30 days	270 mL/30 days
hydrocodone/apap tab 5-300mg	40 tablets /30 days	24 tablets /30 days
hydrocdone/apap tab 5-325mg	40 tablets /30 days	24 tablets /30 days
hydrocdone/apap tab 7.5-300	30 tablets /30 days	18 tablets /30 days
hydrocodone/apap tab 7.5-325	30 tablets /30 days	18 tablets /30 days
hydrocodone/apap tab 10-300mg	25 tablets /30 days	15 tablets /30 days
hydrocodone/apap tab 10-325mg	25 tablets /30 days	15 tablets /30 days
hydrocodone/ibuprofen tab 10-200mg	25 tablets /30 days	15 tablets /30 days
HYDROCODONE/IBUPROFEN TAB 5-200MG	25 tablets /30 days	15 tablets /30 days
hydrocodone/ibuprofen tab 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 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
hydrocodone tab 20mg er	30 tablets /30 days	N/A
hydrocodone tab 30mg er	30 tablets /30 days	N/A
hydrocodone tab 40mg er	30 tablets /30 days	N/A
hydrocodone tab 60mg er	0 tablets /30 days	N/A
hydrocodone tab 80mg er	0 tablets /30 days	N/A
hydrocodone tab 100mg er	0 tablets /30 days	N/A
hydrocodone tab 120mg er	0 tablets /30 days	N/A
hydromorphone liq 1mg/ml	60 mL/30 days	36 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
hydromorphone tab 8mg er	30 tablets /month	N/A
hydromorphone tab 12mg er	30 tablets /month	N/A
hydromorphone tab 16mg er	0 tablets	N/A
hydromorphone tab 32mg er	0 tablets	N/A
HYSINGLA ER TAB 100 MG	0 tablets /30 days	N/A
HYSINGLA ER TAB 120 MG	0 tablets /30 days	N/A
HYSINGLA ER TAB 20 MG	30 tablets /30 days	N/A
HYSINGLA ER TAB 30 MG	30 tablets /30 days	N/A
HYSINGLA ER TAB 40 MG	30 tablets /30 days	N/A
HYSINGLA ER TAB 60 MG	0 tablets /30 days	N/A
HYSINGLA ER TAB 80 MG	0 tablets /30 days	N/A
KADIAN CAP 10MG ER	30 capsules /30 days	N/A
KADIAN CAP 20MG ER	30 capsules /30 days	N/A
KADIAN CAP 30MG ER	30 capsules /30 days	N/A
KADIAN CAP 40MG ER	30 capsules /30 days	N/A
KADIAN CAP 50MG ER	30 capsules /30 days	N/A
KADIAN CAP 60MG ER	0 capsules /30 days	N/A
KADIAN CAP 80MG ER	0 capsules /30 days	N/A
KADIAN CAP 100MG ER	0 capsules /30 days	N/A
KADIAN CAP 200MG ER	0 capsules /30 days	N/A
LAZANDA SPR 100MCG	30 bottles / 30 days	N/A
LAZANDA SPR 300MCG	30 bottles / 30 days	N/A
LAZANDA SPR 400MCG	30 bottles / 30 days	N/A
levorphanol tab 2mg	10 tablets /30 days	6 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
LORTAB ELX 10-300MG	338 mL/30 days	203 mL/30 days
MEPERIDINE SOL 50MG/5ML	150 mL/30 days	150 mL/30 days
MEPERIDINE TAB 50MG	30 tablets /30 days	30 tablets /30 days
METHADONE SOL 5MG/5ML	300 mL/30 days	N/A
METHADONE SOL 10MG/5ML	150 mL/30 days	N/A
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
MORPHABOND TAB 15MG ER	60 tablets /30 days	N/A
MORPHABOND TAB 30MG ER	30 tablets /30 days	N/A
MORPHABOND TAB 60MG ER	0 tablets /30 days	N/A
MORPHABOND TAB 100MG ER	0 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 CAP 30MG ER	30 capsules /30 days	N/A
MORPHINE SUL CAP 40MG ER	30 capsules /30 days	N/A
MORPHINE SUL CAP 45MG ER	30 capsules /30 days	N/A
MORPHINE SUL CAP 60MG ER	0 capsules /30 days	N/A
MORPHINE SUL CAP 75MG ER	0 capsules /30 days	N/A
MORPHINE SUL CAP 90MG ER	0 capsules /30 days	N/A
MORPHINE SUL CAP 120MG 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	15 mL/30 days
morphine sul tab 15mg	15 tablets /30 days	9 tablets /30 days
morphine sul tab 30mg	5 tablets /30 days	3 tablets /30 days
MORPHINE SUL TAB 15MG	15 tablets /30 days	9 tablets /30 days
MORPHINE SUL TAB 30MG	5 tablets /30 days	3 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 100mg er	0 tablets /30 days	N/A
morphine sul tab 200mg er	0 tablets /30 days	N/A
MS CONTIN TAB 15MG ER	60 tablets /30 days	N/A
MS CONTIN TAB 30MG ER	30 tablets /30 days	N/A
MS CONTIN TAB 60MG ER	0 tablets /30 days	N/A
MS CONTIN TAB 100MG ER	0 tablets /30 days	N/A
MS CONTIN TAB 200MG ER	0 tablets /30 days	N/A
NORCO TAB 5-325MG	40 tablets /30 days	24 tablets /30 days
NORCO TAB 7.5-325	30 tablets /30 days	18 tablets /30 days
NORCO TAB 10-325MG	25 tablets /30 days	15 tablets /30 days
NUCYNTA TAB 50MG	10 tablets /30 days	6 tablets /30 days
NUCYNTA TAB 75MG	5 tablets /30 days	3 tablets /30 days
NUCYNTA TAB 100MG	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
OPANA TAB 5MG	15 tablets /30 days	9 tablets /30 days
OPANA TAB 10MG	5 tablets /30 days	3 tablets /30 days
OXAYDO TAB 5MG	30 tablets /30 days	18 tablets /30 days
OXAYDO TAB 7.5MG	20 tablets /30 days	12 tablets /30 days
OXYCODONE/ACETAMINOPHEN SOL 10/300MG	75 mL/30 days	45 mL/30 days
OXYCODONE/APAP TAB 10-300MG	15 tablets /30 days	9 tablets /30 days
oxycodone/apap tab 5-325mg	30 tablets /30 days	18 tablets /30 days
oxycodone/apap tab 10-325mg	15 tablets /30 days	9 tablets /30 days
oxycodone/apap tab 2.5-325	60 tablets /30 days	36 tablets /30 days
oxycodone/apap tab 7.5-325	20 tablets /30 days	12 tablets /30 days
OXYCODONE/APAP TAB 5-300MG	30 tablets /30 days	18 tablets /30 days
OXYCODONE/IBUPROFEN TAB 5-400MG	20 tablets /30 days	12 tablets /30 days
OXYCODONE/ASA TAB	30 tablets /30 days	18 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
OXYCODONE TAB 10MG ER	60 tablets /30 days	N/A
OXYCODONE TAB 15MG ER	60 tablets /30 days	N/A
OXYCODONE TAB 20MG ER	30 tablets /30 days	N/A
OXYCODONE TAB 30MG ER	30 tablets /30 days	N/A
OXYCODONE TAB 40MG ER	0 tablets /30 days	N/A
OXYCODONE TAB 60MG ER	0 tablets /30 days	N/A
OXYCODONE TAB 80MG ER	0 tablets /30 days	N/A
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
pentazocine/naloxone tab 50-0.5mg	10 tablets /30 days	6 tablets /30 days
PERCOCET TAB 2.5-325	60 tablets /30 days	36 tablets /30 days
PERCOCET TAB 5-325MG	30 tablets /30 days	18 tablets /30 days
PERCOCET TAB 7.5-325	20 tablets /30 days	12 tablets /30 days
PERCOCET TAB 10-325MG	15 tablets /30 days	9 tablets /30 days
PRIMLEV TAB 5-300MG	30 tablets /30 days	18 tablets /30 days
PRIMLEV TAB 7.5-300	20 tablets /30 days	12 tablets /30 days
PRIMLEV TAB 10-300MG	15 tablets /30 days	9 tablets /30 days
PROLATE SOL 10/300MG	75 mL/30 days	45 mL/30 days
QDOLO SOL 5MG/ML	400 mL/30 days	240 mL/30 days
ROXICODONE TAB 5MG	30 tablets /30 days	18 tablets /30 days
ROXICODONE TAB 15MG	10 tablets /30 days	6 tablets /30 days
ROXICODONE TAB 30MG	5 tablets /30 days	3 tablets /30 days
SUBSYS SPR 100MCG	120 SPRAYS / 30 days	N/A
SUBSYS SPR 200MCG	120 SPRAYS / 30 days	N/A
SUBSYS SPR 400MCG	120 SPRAYS / 30 days	N/A
SUBSYS SPR 600MCG	120 SPRAYS / 30 days	N/A
SUBSYS SPR 800MCG	120 SPRAYS / 30 days	N/A
SUBSYS SPR 1200MCG	240 SPRAYS / 30 days	N/A
SUBSYS SPR 1600MCG	240 SPRAYS / 30 days	N/A
tramadol/apap tab 37.5-325	40 tablets /30 days	24 tablets /30 days
TRAMADOL HCL CAP 150MG ER	30 capsules /30 days	N/A
TRAMADOL HCL CAP ER 100MG	30 capsules /30 days	N/A
TRAMADOL HCL CAP ER 200MG	30 capsules /30 days	N/A
TRAMADOL HCL CAP ER 300MG	30 capsules /30 days	N/A
tramadolhcl tab 100mg er	30 tablets /30 days	N/A
tramadolhcl tab 200mg er	30 tablets /30 days	N/A
tramadolhcl tab 300mg er	30 tablets /30 days	N/A
tramadolhcl tab 50mg	50 tablets /30 days	30 tablets /30 days
TREZIX CAP	50 capsules /30 days	30 capsules /30 days
TYLENOL/COD TAB #3	30 tablets /30 days	18 tablets /30 days
TYLENOL/COD TAB #4	25 tablets /30 days	15 tablets /30 days
ULTRACET TAB 37.5-325	40 tablets /30 days	24 tablets /30 days
ULTRAM TAB 50MG	50 tablets /30 days	30 tablets /30 days
XTAMPZA ER CAP 13.5MG	60 capsules /30 days	N/A
XTAMPZA ER CAP 9MG	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
ZOHYDRO ER CAP 10MG	60 capsules /30 days	N/A
ZOHYDRO ER CAP 15MG	60 capsules /30 days	N/A
ZOHYDRO ER CAP 20MG	60 capsules /30 days	N/A
ZOHYDRO ER CAP 30MG	30 capsules /30 days	N/A
ZOHYDRO ER CAP 40MG	30 capsules /30 days	N/A
ZOHYDRO ER CAP 50MG	30 capsules /30 days	N/A
ANDRODERM DIS 2MG/24HR	30 patches / 30 days	N/A
ANDRODERM DIS 4MG/24HR	30 patches / 30 days	N/A
ANDROGEL GEL 1%(25MG)	60 packets / 30 days	N/A
ANDROGEL GEL 1%(50MG)	60 packets / 30 days	N/A
ANDROGEL PUMP- TESTOSTERONE TD GEL 20.25 MG/ACT (1.62%)	2 pumps / 30 days	N/A
ANDROGEL- TESTOSTERONE TD GEL 20.25 MG/1.25GM (1.62%)	30 packets / 30 days	N/A
ANDROGEL- TESTOSTERONE TD GEL 40.5 MG/2.5GM (1.62%)	60 packets / 30 days	N/A
DEPO-TESTOST INJ 100MG/ML	1 vial / 28 days	N/A
DEPO-TESTOST INJ 200MG/ML	10 mLs / 28 days	N/A
FORTESTA GEL 10MG/ACT	2 pumps / 30 days	N/A
METHITEST TAB 10MG	600 tabs / 30 days	N/A
METHYLTESTOS CAP 10MG	600 tabs / 30 days	N/A
NATESTO GEL 5.5MG	3 pumps / 30 days	N/A
STRIANT MIS 30MG	60 systems / 30 days	N/A
TESTIM GEL 1%(50MG)	60 packets / 30 days	N/A
testosterone cypionate inj 100mg/ml	1 vial / 28 days	N/A
testosterone cypionate inj 200mg/ml	10 mLs / 28 days	N/A
TESTOST ENAN INJ 200MG/ML	1 vial / 28 days	N/A
testosterone gel 1%(50mg)	60 packets / 30 days	N/A
testosterone gel 1%(25mg)	60 packets / 30 days	N/A
TESTOSTERONE GEL 1%(25MG)	60 packets / 30 days	N/A
TESTOSTERONE GEL 1%(50MG)	60 packets / 30 days	N/A
testosterone gel 10mg/act	2 bottles / 30 days	N/A
TESTOSTERONE GEL PUMP 1%	4 pumps / 30 days	N/A
testosterone gel pump 1%	300 grams / 30 days	N/A
testosterone sol 30mg/act	2 pumps / 30 days	N/A
testosterone td gel 20.25 mg/1.25gm (1.62%)	30 packets / 30 days	N/A
testosterone td gel 20.25 mg/act (1.62%)	2 bottles / 30 days	N/A
testosterone td gel 40.5 mg/2.5gm (1.62%)	60 packets / 30 days	N/A
VOGELXO GEL 1%(50MG)	60 packets / 30 days	N/A
VOGELXO GEL PUMP 1%	4 pumps / 30 days	N/A

Androgens - anabolic

Drug name(s)	Quantity limits (per 30 days or as specified)
XYOSTED INJ 50/0.5	4 pens / 28 days
XYOSTED INJ 75/0.5	2 pens / 28 days
XYOSTED INJ 100/0.5	2 pens / 28 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
AIRDUO RESPI INH 55-14	1 inhaler / 30 days
AIRDUO RESPI INH 113-14	1 inhaler / 30 days
AIRDUO RESPI INH 232-14	1 inhaler / 30 days
ALBUTEROL AER HFA	2 cans / 30 days
albuterol aer hfa	2 cans / 30 days
ALVESCO AER 80MCG	2 cans / 30 days
ALVESCO AER 160MCG	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
BEVESPI AER 9-4.8MCG	1 can / 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 100-5MCG	1 can / 30 days
DULERA AER 200-5MCG	1 can / 30 days
DULERA AER 50-5MCG	1 inhaler / 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
fluticasone/salmeterol aer 100/50	60 blisters / 30 days
fluticasone/salmeterol aer 250/50	60 blisters / 30 days
fluticasone/salmeterol aer 500/50	60 blisters / 30 days
FLUTICASONE/SALMETEROL INH 55/14	1 inhaler / 30 days
FLUTICASONE/SALMETEROL INH 113/14	1 inhaler / 30 days
FLUTICASONE/SALMETEROL INH 232/14	1 inhaler / 30 days
INCRUSE ELPT INH 62.5MCG	30 blisters / 30 days
LEVALBUTEROL AER 45/ACT	2 cans / 30 days
NUCALA INJ 100MG/ML	3 syringes / 28 days
PROAIR HFA AER	2 cans / 30 days
PROAIR RESPI AER	2 inhalers / 30 days
PROVENTIL AER HFA	2 cans / 30 days
PULMICORT INH 90MCG	2 cans / 30 days
PULMICORT INH 180MCG	2 cans / 30 days
QVAR REDIHAL AER 40MCG	1 can / 30 days
QVAR REDIHA AER 80MCG	2 cans / 30 days
SEEBRI NEOHA CAP 15.6MCG	60 caps / 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
TUDORZA PRES AER 400/ACT	1 can / 30 days
UTIBRON CAP NEOHALER	60 caps / 30 days
VENTOLIN HFA AER	2 cans / 30 days
wixela inhub aer 100/50	60 blisters / 30 days
wixela inhub aer 250/50	60 blisters / 30 days
wixela inhub aer 500/50	60 blisters / 30 days
XOPENEX HFA AER	2 cans / 30 days

Anticonvulsants

Drug name(s)	Quantity limits (per 30 days or as specified)
FINTEPLA SOL 2.2MG/ML³	360 mLs / 30 days
LYRICA CAP 25MG	90 caps / 30 days
LYRICA CAP 50MG	90 caps / 30 days
LYRICA CAP 75MG	90 caps / 30 days
LYRICA CAP 100MG	90 caps / 30 days
LYRICA CAP 150MG	90 caps / 30 days
LYRICA CAP 200MG	90 caps / 30 days
LYRICA CAP 225MG	60 caps / 30 days
LYRICA CAP 300MG	60 caps / 30 days
LYRICA SOL 20MG/ML	900 mLs / 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
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)
ADLYXIN INJ 10/20MCG	2 pens / 180 days
ADLYXIN INJ 20MCG	2 pens / 28 days
ADMELOG INJ 100U/ML	100 mLs / 30 days
ADMELOG SOLO INJ 100U/ML	100 mLs / 30 days
AFREZZA POW 12 unit	900 carts / 30 days
AFREZZA POW 4-8 unit	1800 cartrs / 30 days
AFREZZA POW 4-8-12	1260 cartrs / 30 days
AFREZZA POW 4unit	2520 cartrs / 30 days
AFREZZA POW 8 unit	1260 carts / 30 days
AFREZZA POW 8-12unit	1080 carts / 30 days
ALOGlIPTIN/PIOGLITAZONE TAB 12.5-15	30 tabs / 30 days
ALOGlIPTIN/PIOGLITAZONE TAB 12.5-30	30 tabs / 30 days
ALOGlIPTIN/PIOGLITAZONE TAB 12.5-45	30 tabs / 30 days
ALOGlIPTIN/PIOGLITAZONE TAB 25-15MG	30 tabs / 30 days
ALOGlIPTIN/PIOGLITAZONE TAB 25-30MG	30 tabs / 30 days
ALOGlIPTIN/PIOGLITAZONE TAB 25-45MG	30 tabs / 30 days
ALOGLIPTIN TAB 12.5MG	30 tabs / 30 days
ALOGLIPTIN TAB 25MG	30 tabs / 30 days
ALOGLIPTIN TAB 6.25MG	30 tabs / 30 days
ALOGLIPTIN/ TAB METFORM	60 tabs / 30 days
APIDRA INJ SOLOSTAR	100 mLs / 30 days
APIDRA INJ U-100	100 mLs / 30 days
BASAGLAR INJ 100unit	100 mLs / 30 days
BYDUREON BC INJ 2/0.85ML	4 injdvs / 28 days
BYDUREON PEN INJ 2MG	4 pens / 28 days
BYETTA INJ 5MCG	1 pen / 30 days
BYETTA INJ 10MCG	1 pen / 30 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
FORTAMET TAB 1000MG	60 tabs / 30 days
FORTAMET TAB 500MG	90 tabs / 30 days
GLUMETZA TAB 500MG	90 tabs / 30 days
GLUMETZA TAB 1000MG	60 tabs / 30 days
GLYXAMBI TAB 10-5 MG	30 tabs / 30 days
GLYXAMBI TAB 25-5 MG	30 tabs / 30 days
HUMALOG INJ 100/ML	100 mLs / 30 days
HUMALOG JR INJ 100/ML	100 mLs / 30 days
HUMALOG KWIK INJ 100/ML	100 mLs / 30 days
HUMALOG KWIK INJ 200/ML	100 mLs / 30 days
HUMALOG MIX INJ 50/50	100 mLs / 30 days
HUMALOG MIX INJ 50/50KWP	100 mLs / 30 days
HUMALOG MIX INJ 75/25KWP	100 mLs / 30 days
HUMALOG MIX SUS 75/25	100 mLs / 30 days
HUMULIN INJ 70/30	100 mLs / 30 days
HUMULIN INJ 70/30KWP	100 mLs / 30 days
HUMULIN N INJ U-100	100 mLs / 30 days
HUMULIN N INJ U-100KWP	100 mLs / 30 days
HUMULIN R INJ U-100	100 mLs / 30 days
HUMULIN R INJ U-500	100 mLs / 30 days
INS ASP PROT INJ FLEXPEN	100 mLs / 30 days
INSULIN ASPA INJ 100/ML	100 mLs / 30 days
INSULIN ASPA INJ 70/30	100 mLs / 30 days
INSULIN ASPA INJ FLEXPEN	100 mLs / 30 days
INSULIN ASPA INJ PENFILL	100 mLs / 30 days
INSULIN LISP INJ 100/ML	100 mLs / 30 days
INSULIN LISP INJ JUNIOR	100 mLs / 30 days
INSULIN LISP INJ PROTAMIN	100 mLs / 30 days
INVOKAMET TAB 150-1000	60 tabs / 30 days
INVOKAMET TAB 150-500	60 tabs / 30 days
INVOKAMET TAB 50-1000	60 tabs / 30 days
INVOKAMET TAB 50-500MG	60 tabs / 30 days
INVOKAMET XR TAB 150-1000	60 tabs / 30 days
INVOKAMET XR TAB 150-500	60 tabs / 30 days
INVOKAMET XR TAB 50-1000	60 tabs / 30 days
INVOKAMET XR TAB 50-500MG	60 tabs / 30 days
INVOKANA TAB 100MG	30 tabs / 30 days
INVOKANA TAB 300MG	30 tabs / 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
JENTADUETO TAB 2.5-1000	60 tabs / 30 days
JENTADUETO TAB 2.5-500	60 tabs / 30 days
JENTADUETO TAB 2.5-850	60 tabs / 30 days
JENTADUETO XR- LINAGLIPTIN-METFORMIN HCL TAB ER 24HR 2.5-1000 MG	60 tabs / 30 days
JENTADUETO XR- LINAGLIPTIN-METFORMIN HCL TAB ER 24HR 5-1000 MG	30 tabs / 30 days
KAZANO 12.5- TAB 1000MG	60 tabs / 30 days
KAZANO 12.5- TAB 500MG	60 tabs / 30 days
KOMBIGLYZ XR TAB 2.5-1000	60 tabs / 30 days
KOMBIGLYZ XR TAB 5-1000MG	30 tabs / 30 days
KOMBIGLYZ XR TAB 5-500MG	30 tabs / 30 days
KORLYM TAB 300MG³	120 tabs / 30 days
LANTUS INJ 100/ML	100 mLs / 30 days
LANTUS SOLOS INJ 100/ML	100 mLs / 30 days
LEVEMIR INJ	100 mLs / 30 days
LEVEMIR INJ FLEXTOUC	100 mLs / 30 days
LYUMJEV INJ 100UT/ML	100 mLs / 30 days
LYUMJEV KWPN INJ 100UT/ML	100 mLs / 30 days
LYUMJEV KWPN INJ 200UT/ML	100 mLs / 30 days
metformin tab 1000 er	60 tabs / 30 days
metformin tab 750mg er	60 tabs / 30 days
metforminer tab 1000mg	60 tabs / 30 days
metforminhcl tab er 24hr 500 mg	120 tabs / 30 days
metforminhcl tab er 24hr modified release 500 mg	90 tabs / 30 days
metforminhcl tab er 24hr osmotic 500 mg	90 tabs / 30 days
NESINA TAB 12.5MG	30 tabs / 30 days
NESINA TAB 25MG	30 tabs / 30 days
NESINA TAB 6.25MG	30 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
ONGLYZA TAB 2.5MG	30 tabs / 30 days
ONGLYZA TAB 5MG	30 tabs / 30 days
OSENI TAB 12.5-15	30 tabs / 30 days
OSENI TAB 12.5-30	30 tabs / 30 days
OSENI TAB 12.5-45	30 tabs / 30 days
OSENI TAB 25-15MG	30 tabs / 30 days
OSENI TAB 25-30MG	30 tabs / 30 days
OSENI TAB 25-45MG	30 tabs / 30 days
OZEMPIC INJ 4MG/3ML	1 pen / 28 days
OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/1.5ML)	1 pen / 28 days
OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (2 MG/1.5ML)	2 pens / 28 days
QTERN TAB 10-5MG	30 tabs / 30 days
QTERN TAB 5-5MG	30 tabs / 30 days
RELION R INJ 100/ML	100 mLs / 30 days
RIOMET ER SUS 500/5ML	960 mLs / 30 days
RYBELSUS TAB 14MG	30 tabs / 30 days
RYBELSUS TAB 3MG	30 tabs / 180 days
RYBELSUS TAB 7MG	30 tabs / 30 days
SEGLUROMET TAB 2.5-1000	60 tabs / 30 days
SEGLUROMET TAB 2.5-500	120 tabs / 30 days
SEGLUROMET TAB 7.5-1000	60 tabs / 30 days
SEGLUROMET TAB 7.5-500	60 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
STEGLATRO TAB 15MG	30 tabs / 30 days
STEGLATRO TAB 5MG	60 tabs / 30 days
STEGLUJAN TAB 15-100MG	30 tabs / 30 days
STEGLUJAN TAB 5-100MG	30 tabs / 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
TRADJENTA TAB 5MG	30 tabs / 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-LINAGLIP-METFORMIN TAB ER 24HR 12.5-2.5-1000MG	60 tabs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 10-5-1000 MG	30 tabs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 25-5-1000 MG	30 tabs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 5-2.5-1000MG	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	4 pens / 28 days
TRULICITY INJ 4.5/0.5	4 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
EXJADE TAB 125MG^2,⁴	30 tabs / 30 days
EXJADE TAB 250MG^2,⁴	30 tabs / 30 days
EXJADE TAB 500MG^2,⁴	90 tabs / 30 days
JADENU TAB 180MG^2,⁴	30 tabs / 30 days
JADENU TAB 360MG^2,⁴	180 tabs / 30 days
JADENU TAB 90MG^2,⁴	30 tabs / 30 days
JADENU SPRKL GRA 90MG^2,⁴	30 packets / 30 days
JADENU SPRKL GRA 180MG^2,⁴	30 packets / 30 days
JADENU SPRKL GRA 360MG^2,⁴	180 packets / 30 days

Antiemetics

Drug name(s)	Quantity limits (per 30 days or as specified)
AKYNZEO CAP 300-0.5	2 caps / 30 days
ANZEMET TAB 50MG	7 tabs / 30 days
ANZEMET TAB 100MG	7 tabs / 30 days
aprepitant cap 40mg	8 caps / 30 days
aprepitant cap 80mg	8 caps / 30 days
aprepitant cap 125mg	4 caps / 30 days
aprepitant pak 80 & 125	4 packs / 30 days
DICLEGIS TAB 10-10MG	120 tabs / 30 days
doxylamine/pyridoxine tab 10-10mg	120 tabs / 30 days
EMEND CAP 40MG	8 caps / 30 days
EMEND CAP 80MG	8 caps / 30 days
EMEND SUS 125MG	6 packs / 30 days
EMEND TRIPAC PAK 80 & 125	4 packs / 30 days
granisetron tab 1mg	14 tabs / 30 days
ondansetron sol 4mg/5ml	5 bottles / 30 days
ondansetron tab 4mg	24 tabs / 30 days
ondansetron tab 8mg	24 tabs / 30 days
ondansetron tab 4mg odt	24 tabs / 30 days
ondansetron tab 8mg odt	24 tabs / 30 days
ONDANSETRON TAB 24MG	4 tabs / 30 days
SANCUSO DIS 3.1MG	2 patches / 28 days
VARUBI TAB 90MG	4 tabs / 30 days
ZOFRAN TAB 4MG	24 tabs / 30 days
ZOFRAN TAB 8MG	24 tabs / 30 days
ZUPLENZ MIS 4MG	24 films / 30 days
ZUPLENZ MIS 8MG	24 films / 30 days

Antihyperlipidemics

Drug name(s)	Quantity limits (per 30 days or as specified)
ALTOPREV TAB 20MG ER	30 tabs / 30 days
ALTOPREV TAB 40MG ER	30 tabs / 30 days
ALTOPREV TAB 60MG ER	30 tabs / 30 days
atorvastatin tab 10mg	45 tabs / 30 days
atorvastatin tab 20mg	45 tabs / 30 days
atorvastatin tab 40mg	45 tabs / 30 days
atorvastatin tab 80mg	30 tabs / 30 days
CRESTOR TAB 5MG	45 tabs / 30 days
CRESTOR TAB 10MG	45 tabs / 30 days
CRESTOR TAB 20MG	45 tabs / 30 days
CRESTOR TAB 40MG	30 tabs / 30 days
EZETIMIBE/ROSUVASTATIN TAB 10-5MG	30 tabs / 30 days
EZETIMIBE/ROSUVASTATIN TAB 10-10MG	30 tabs / 30 days
EZETIMIBE/ROSUVASTATIN TAB 10-20MG	30 tabs / 30 days
EZETIMIBE/ROSUVASTATIN TAB 10-40MG	30 tabs / 30 days
ezetimibe/simvastatin tab 10-10mg	30 tabs / 30 days
ezetimibe/simvastatin tab 10-20mg	30 tabs / 30 days
ezetimibe/simvastatin tab 10-40mg	30 tabs / 30 days
ezetimibe/simvastatin tab 10-80mg	30 tabs / 30 days
fluvastatin tab 80mg er	30 tabs / 30 days
JUXTAPID CAP 5MG³	30 caps / 30 days
JUXTAPID CAP 10MG³	30 caps / 30 days
JUXTAPID CAP 20MG³	30 caps / 30 days
JUXTAPID CAP 30MG³	30 caps / 30 days
JUXTAPID CAP 40MG³	30 caps / 30 days
JUXTAPID CAP 60MG³	30 caps / 30 days
LESCOL XL TAB 80MG	30 tabs / 30 days
LIPITOR TAB 10MG	45 tabs / 30 days
LIPITOR TAB 20MG	45 tabs / 30 days
LIPITOR TAB 40MG	45 tabs / 30 days
LIPITOR TAB 80MG	30 tabs / 30 days
LIVALO TAB 1MG	45 tabs / 30 days
LIVALO TAB 2MG	45 tabs / 30 days
LIVALO TAB 4MG	30 tabs / 30 days
lovastatin tab 10mg	60 tabs / 30 days
lovastatin tab 20mg	60 tabs / 30 days
lovastatin tab 40mg	60 tabs / 30 days
NEXLETOL TAB 180MG	30 tabs / 30 days
NEXLIZET TAB 180/10MG	30 tabs / 30 days
PRALUENT INJ 150MG/ML	2 syringes / 28 days
PRALUENT INJ 75MG/ML	2 syringes / 28 days
PRAVACHOL TAB 20MG	45 tabs / 30 days
PRAVACHOL TAB 40MG	45 tabs / 30 days
pravastatin tab 10mg	45 tabs / 30 days
pravastatin tab 20mg	45 tabs / 30 days
pravastatin tab 40mg	45 tabs / 30 days
pravastatin tab 80mg	30 tabs / 30 days
REPATHA INJ 140MG/ML	2 syringes / 28 days
REPATHA PUSH INJ 420/3.5	2 carts / 30 days
REPATHA SURE INJ 140MG/ML	2 pens / 28 days
rosuvastatin tab 5mg	45 tabs / 30 days
rosuvastatin tab 10mg	45 tabs / 30 days
rosuvastatin tab 20mg	45 tabs / 30 days
rosuvastatin tab 40mg	30 tabs / 30 days
ROSZET TAB 5-10MG	30 tabs / 30 days
ROSZET TAB 10-10MG	30 tabs / 30 days
ROSZET TAB 20-10MG	30 tabs / 30 days
ROSZET TAB 40-10MG	30 tabs / 30 days
simvastatin tab 5mg	45 tabs / 30 days
simvastatin tab 10mg	45 tabs / 30 days
simvastatin tab 20mg	60 tabs / 30 days
simvastatin tab 40mg	45 tabs / 30 days
simvastatin tab 80mg	30 tabs / 30 days
VYTORIN TAB 10-10MG	30 tabs / 30 days
VYTORIN TAB 10-20MG	30 tabs / 30 days
VYTORIN TAB 10-40MG	30 tabs / 30 days
VYTORIN TAB 10-80MG	30 tabs / 30 days
ZOCOR TAB 10MG	45 tabs / 30 days
ZOCOR TAB 20MG	60 tabs / 30 days
ZOCOR TAB 40MG	45 tabs / 30 days
ZOCOR TAB 80MG	30 tabs / 30 days

Anti-infective agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ALINIA SUS 100/5ML	300 mLs / 90 days
ALINIA TAB 500MG	12 tabs / 90 days
nitazoxanide tab 500mg	12 tabs / 90 days
XIFAXAN TAB 200MG	9 tabs / 30 days
XIFAXAN TAB 550MG	60 tabs / 30 days

Antimyasthenic/Cholinergic Agents

Drug name(s)	Quantity limits (per 30 days or as specified)
FIRDAPSE TAB 10MG³	240 tabs / 30 days
RUZURGI TAB 10MG³	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 TAB 2.5MG^2,⁴	30 tabs / 30 days
AFINITOR TAB 5MG^2,⁴	30 tabs / 30 days
AFINITOR TAB 7.5MG^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 PAK³	30 tabs / 180 days
ALUNBRIG TAB 180MG³	30 tabs / 30 days
ALUNBRIG TAB 30MG³	120 tabs / 30 days
ALUNBRIG TAB 90MG³	30 tabs / 30 days
AYVAKIT TAB 25MG^3,⁴	30 tabs / 30 days
AYVAKIT TAB 50MG^3,⁴	30 tabs / 30 days
AYVAKIT TAB 100MG^3,⁴	30 tabs / 30 days
AYVAKIT TAB 200MG^3,⁴	30 tabs / 30 days
AYVAKIT TAB 300MG^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 75MG³	180 caps / 30 days
BRUKINSA CAP 80MG³	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 100MG³	60 caps / 30 days
CAPRELSA TAB 100MG³	60 tabs / 30 days
CAPRELSA TAB 300MG³	30 tabs / 30 days
COMETRIQ KIT 100MG^3,⁴	1 carton / 28 days
COMETRIQ KIT 140MG^3,⁴	112 tabs / 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 20MG²	63 tabs / 28 days
DAURISMO TAB 25MG^2,⁴	60 tabs / 30 days
DAURISMO TAB 100MG^2,⁴	30 tabs / 30 days
ERIVEDGE CAP 150MG^2,⁴	30 caps / 30 days
erlotinib tab 25mg^2,⁴	60 tabs / 30 days
erlotinib tab 100mg^2,⁴	30 tabs / 30 days
erlotinib tab 150mg^2,⁴	30 tabs / 30 days
everolimus tab 2.5mg^1,^2,⁴	30 tabs / 30 days
everolimus tab 2.5mg^1, ~	30 tabs / 30 days
everolimus tab 2mg^1,~	60 tabs / 30 days
everolimus tab 3mg^1, ~	90 tabs / 30 days
everolimus tab 5mg^1,^2,⁴	30 tabs / 30 days
everolimus tab 5mg^1, ~	60 tabs / 30 days
everolimus tab 5mg^1, ~	30 tabs / 30 days
everolimus tab 7.5mg^1,^2,⁴	30 tabs / 30 days
everolimus tab 7.5mg^1, ~	30 tabs / 30 days
everolimus tab 10mg^1, ~	30 tabs / 30 days
FARYDAK CAP 10MG	6 caps / 21 days
FARYDAK CAP 10MG²	6 caps / 21 days
FARYDAK CAP 15MG	6 caps / 21 days
FARYDAK CAP 15MG²	6 caps / 21 days
FARYDAK CAP 20MG	6 caps / 21 days
FARYDAK CAP 20MG²	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 20MG³	30 tabs / 30 days
GILOTRIF TAB 30MG³	30 tabs / 30 days
GILOTRIF TAB 40MG³	30 tabs / 30 days
GLEEVEC TAB 100MG^2,⁴	90 tabs / 30 days
GLEEVEC TAB 400MG^2,⁴	60 tabs / 30 days
IBRANCE CAP 100MG²	21 caps / 28 days
IBRANCE CAP 125MG²	21 caps / 28 days
IBRANCE CAP 75MG²	21 caps / 28 days
IBRANCE TAB 100MG²	21 tabs / 28 days
IBRANCE TAB 125MG²	21 tabs / 28 days
IBRANCE TAB 75MG²	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 100MG²	30 tabs / 30 days
IDHIFA TAB 50MG²	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 140MG³	90 caps / 30 days
IMBRUVICA CAP 70MG³	30 caps / 30 days
IMBRUVICA TAB 140MG³	30 tabs / 30 days
IMBRUVICA TAB 280MG³	30 tabs / 30 days
IMBRUVICA TAB 420MG³	30 tabs / 30 days
IMBRUVICA TAB 560MG³	30 tabs / 30 days
INLYTA TAB 1MG^2,⁴	180 tabs / 30 days
INLYTA TAB 5MG^2,⁴	120 tabs / 30 days
INQOVI TAB 35-100MG²	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 200DOSE²	63 tabs / 28 days
KISQALI TAB 400DOSE²	63 tabs / 28 days
KISQALI TAB 600DOSE²	63 tabs / 28 days
KISQALI 200 PAK FEMARA²	91 tabs / 28 days
KISQALI 400 PAK FEMARA²	91 tabs / 28 days
KISQALI 600 PAK FEMARA²	91 tabs / 28 days
KOSELUGO CAP 10MG³	240 caps / 30 days
KOSELUGO CAP 25MG³	120 caps / 30 days
lapatinib tab 250mg²	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 15-6.14²	60 tabs / 28 days
LONSURF TAB 20-8.19²	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 0.5MG²	90 tabs / 30 days
MEKINIST TAB 2MG²	30 tabs / 30 days
MEKTOVI TAB 15MG³	180 tabs / 30 days
NERLYNX TAB 40MG^3,⁴	180 tabs / 30 days
NEXAVAR TAB 200MG^2,⁴	120 tabs / 30 days
NINLARO CAP 2.3MG²	3 caps / 28 days
NINLARO CAP 3MG²	3 caps / 28 days
NINLARO CAP 4MG²	3 caps / 28 days
NUBEQA TAB 300MG²	120 tabs / 30 days
ODOMZO CAP 200MG^2,⁴	30 caps / 30 days
ONUREG TAB 200MG²	14 tabs / 28 days
ONUREG TAB 300MG²	14 tabs / 28 days
ORGOVYX TAB 120MG³	30 tabs / 30 days
PEMAZYRE TAB 13.5MG³	14 tabs / 21 days
PEMAZYRE TAB 4.5MG³	14 tabs / 21 days
PEMAZYRE TAB 9MG³	14 tabs / 21 days
PIQRAY 200MG TAB DOSE²	28 tabs / 28 days
PIQRAY 250MG TAB DOSE²	56 tabs / 28 days
PIQRAY 300MG TAB DOSE²	56 tabs / 28 days
POMALYST CAP 1MG²	21 caps / 28 days
POMALYST CAP 2MG²	21 caps / 28 days
POMALYST CAP 3MG²	21 caps / 28 days
POMALYST CAP 4MG²	21 caps / 28 days
QINLOCK TAB 50MG³	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 25MG²	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 40MG²	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 150MG²	120 tabs / 30 days
TABRECTA TAB 200MG²	120 tabs / 30 days
TAFINLAR CAP 50MG²	120 caps / 30 days
TAFINLAR CAP 75MG²	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
TARCEVA TAB 100MG^2,⁴	30 tabs / 30 days
TARCEVA TAB 150MG^2,⁴	30 tabs / 30 days
TARCEVA TAB 25MG^2,⁴	60 tabs / 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 200MG³	240 tabs / 30 days
TEPMETKO TAB 225MG ~	60 tabs / 30 days
TIBSOVO TAB 250MG³	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 150MG³	120 tabs / 30 days
TUKYSA TAB 50MG³	300 tabs / 30 days
TURALIO CAP 200MG³	120 caps / 30 days
TYKERB TAB 250MG²	180 tabs / 30 days
UKONIQ TAB 200MG ~	120 tabs / 30 days
VENCLEXTA TAB 10MG³	60 tabs / 30 days
VENCLEXTA TAB 50MG³	30 tabs / 30 days
VENCLEXTA TAB 100MG³	180 tabs / 30 days
VENCLEXTA TAB START PK³	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 40MG³	90 tabs / 30 days
XPOVIO PAK 100MG^3,⁴	1 box / 28 days
XPOVIO PAK 40MG ~	1 box / 28 days
XPOVIO PAK 60MG^3,⁴	1 box / 28 days
XPOVIO PAK 60MG ~	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
ZEJULA CAP 100MG^3,⁴	90 caps / 30 days
ZELBORAF TAB 240MG²	240 tabs / 30 days
ZOLINZA CAP 100MG^2,⁴	120 caps / 30 days
ZYDELIG TAB 100MG³	60 tabs / 30 days
ZYDELIG TAB 150MG³	60 tabs / 30 days
ZYKADIA TAB 150MG^2,⁴	90 tabs / 30 days
ZYTIGA TAB 250MG^2,⁴	120 tabs / 30 days
ZYTIGA TAB 500MG^2,⁴	60 tabs / 30 days

Antiparkinson and related therapy agents

Drug name(s)	Quantity limits (per 30 days or as specified)
GOCOVRI CAP 68.5MG^2,⁴	30 caps / 30 days
GOCOVRI CAP 137MG^2,⁴	60 caps / 30 days

Antipsychotics/Antimanic Agents

Drug name(s)	Quantity limits (per 30 days or as specified)
CAPLYTA CAP 42MG	30 caps / 30 days
INVEGA TAB 1.5MG	60 tabs / 30 days
INVEGA TAB 3MG	60 tabs / 30 days
INVEGA TAB 6MG	60 tabs / 30 days
INVEGA TAB 9MG	60 tabs / 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
NUPLAZID CAP 34MG²	30 caps / 30 days
NUPLAZID TAB 10MG²	30 tabs / 30 days
olanzapine tab 2.5mg	30 tabs / 30 days
olanzapine tab 5mg	30 tabs / 30 days
olanzapine tab 7.5mg	30 tabs / 30 days
olanzapine tab 10mg	30 tabs / 30 days
olanzapine tab 15mg	30 tabs / 30 days
olanzapine tab 20mg	30 tabs / 30 days
olanzapine tab 5mg odt	30 tabs / 30 days
olanzapine tab 10mg odt	30 tabs / 30 days
olanzapine tab 15mg odt	30 tabs / 30 days
olanzapine tab 20mg odt	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 50mg er	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
SEROQUEL XR TAB 50MG	60 tabs / 30 days
SEROQUEL XR TAB 150MG	60 tabs / 30 days
SEROQUEL XR TAB 200MG	60 tabs / 30 days
SEROQUEL XR TAB 300MG	60 tabs / 30 days
SEROQUEL XR TAB 400MG	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
ZYPREXA TAB 10MG	30 tabs / 30 days
ZYPREXA TAB 15MG	30 tabs / 30 days
ZYPREXA TAB 2.5MG	30 tabs / 30 days
ZYPREXA TAB 20MG	30 tabs / 30 days
ZYPREXA TAB 5MG	30 tabs / 30 days
ZYPREXA TAB 7.5MG	30 tabs / 30 days
ZYPREXA ZYDI TAB 5MG	30 tabs / 30 days
ZYPREXA ZYDI TAB 10MG	30 tabs / 30 days
ZYPREXA ZYDI TAB 15MG	30 tabs / 30 days
ZYPREXA ZYDI TAB 20MG	30 tabs / 30 days

Antivirals

Drug name(s)	Quantity limits (per 30 days or as specified)
EPCLUSA TAB 200-50MG²	28 tabs / 28 days
EPCLUSA TAB 400-100²	30 tabs / 30 days
HARVONI PAK²	28 packets / 28 days
HARVONI PAK 45-200MG²	28 packets / 28 days
HARVONI TAB 45-200MG²	28 tabs / 28 days
HARVONI TAB 90-400MG²	30 tabs / 30 days
LEDIP-SOFOSB TAB 90-400MG²	30 tabs / 30 days
MAVYRET TAB 100-40MG²	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
SOFOS/VELPAT TAB 400-100²	30 tabs / 30 days
SOVALDI PAK 150MG²	28 packets / 28 days
SOVALDI PAK 200MG²	28 packets / 28 days
SOVALDI TAB 200MG²	30 tabs / 30 days
SOVALDI TAB 400MG²	30 tabs / 30 days
TAMIFLU CAP 30MG	40 caps / 120 days
TAMIFLU CAP 45MG	20 caps / 120 days
TAMIFLU CAP 75MG	20 caps / 120 days
TAMIFLU SUS 6MG/ML	300 mLs / 120 days
VIEKIRA PAK TAB²	112 tabs / 28 days
VOSEVI TAB²	30 tabs / 30 days
XOFLUZA TAB 20MG	4 tabs / 120 days
XOFLUZA TAB 80MG	2 tabs / 120 days
XOFLUZA- BALOXAVIR MARboxIL TAB THERAPY PACK 1 X 40 MG (40 MG DOSE)	2 tabs / 120 days
XOFLUZA- BALOXAVIR MARboxIL TAB THERAPY PACK 2 X 40 MG (80 MG DOSE)	4 tabs / 120 days
ZEPATIER TAB 50-100MG²	30 tabs / 30 days

Cardiovascular agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADCIRCA TAB 20MG²	60 tabs / 30 days
ADEMPAS TAB 0.5MG³	90 tabs / 30 days
ADEMPAS TAB 1.5MG³	90 tabs / 30 days
ADEMPAS TAB 1MG³	90 tabs / 30 days
ADEMPAS TAB 2.5MG³	90 tabs / 30 days
ADEMPAS TAB 2MG³	90 tabs / 30 days
alyq tab 20mg²	60 tabs / 30 days
ambrisentan tab 5mg²	30 tabs / 30 days
ambrisentan tab 10mg²	30 tabs / 30 days
bosentan tab 62.5mg²	60 tabs / 30 days
bosentan tab 125mg²	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
LETAIRIS TAB 5MG²	30 tabs / 30 days
LETAIRIS TAB 10MG²	30 tabs / 30 days
OPSUMIT TAB 10MG³	30 tabs / 30 days
REVATIO SUS 10MG/ML²	2 bottles / 30 days
REVATIO TAB 20MG²	90 tabs / 30 days
sildenafil sus 10mg/ml	2 bottles / 30 days
sildenafil sus 10mg/ml^1,²	2 bottles / 30 days
sildenafil tab 20mg^1,²	90 tabs / 30 days
tadalafil tab 20mg²	60 tabs / 30 days
TRACLEER TAB 125MG²	60 tabs / 30 days
TRACLEER TAB 32MG²	120 tabs / 30 days
TRACLEER TAB 62.5MG²	60 tabs / 30 days
UPTRAVI TAB 1000MCG³	60 tabs / 30 days
UPTRAVI TAB 1200MCG³	60 tabs / 30 days
UPTRAVI TAB 1400MCG³	60 tabs / 30 days
UPTRAVI TAB 1600MCG³	60 tabs / 30 days
UPTRAVI TAB 200/800³	1 package / 180 days
UPTRAVI TAB 400MCG³	60 tabs / 30 days
UPTRAVI TAB 600MCG³	60 tabs / 30 days
UPTRAVI TAB 800MCG³	60 tabs / 30 days
UPTRAVI- SELEXIPAG TAB 200 MCG³	60 tabs / 30 days
UPTRAVI- SELEXIPAG TAB 200 MCG³	140 tabs / 180 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 61MG²	30 caps / 30 days
VYNDAQEL CAP 20MG²	120 caps / 30 days

Corticosteroids

Drug name(s)	Quantity limits (per 30 days or as specified)
EMFLAZA TAB 6MG³	60 tabs / 30 days
EMFLAZA TAB 18MG³	30 tabs / 30 days

Dermatologicals

Drug name(s)	Quantity limits (per 30 days or as specified)
ala-cort cre 1%	454 grams / 30 days
ala-cort cre 2.5%	454 grams / 30 days
ALA-SCALP LOT 2%	118.4 mLs / 30 days
alclometason cre 0.05%	120 grams / 30 days
alclometason oin 0.05%	120 grams / 30 days
ALDARA CRE 5%	48 packets / 112 days
AMCINONIDE CRE 0.1%	120 grams / 30 days
AMCINONIDE LOT 0.1%	120 mLs / 30 days
AMCINONIDE OIN 0.1%	120 grams / 30 days
APEXICON E CRE 0.05%	120 grams / 30 days
augmented betamethasone 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
beser lot 0.05%	120 mLs / 30 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 aer 0.12%	150 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
CAPEX SHA 0.01%	840 mLs / 28 days
ciclodan sol 8%	3.3 mLs / 30 days
ciclopirox sol 8%	3.3 mLs / 30 days
clobetasol aer 0.05%	200 grams / 28 days
clobetasol cre 0.05%	210 grams / 28 days
clobetasol gel 0.05%	210 grams / 28 days
clobetasol lot 0.05%	177 mLs / 28 days
clobetasol oin 0.05%	210 grams / 28 days
clobetasol sha 0.05%	236 mLs / 30 days
clobetasol sol 0.05%	200 mLs / 28 days
clobetasol spr 0.05%	236 mLs / 28 days
clobetasole cre 0.05%	210 grams / 28 days
CLOBEX LOT 0.05%	177 mLs / 28 days
CLOBEX SHA 0.05%	236 mLs / 30 days
CLOBEX SPR 0.05%	236 mLs / 28 days
CLOCORTOLONE CRE 0.1%	135 grams / 30 days
clodan sha 0.05%	236 mLs / 30 days
CLODERM CRE 0.1%	135 grams / 30 days
CORDRAN CRE 0.025%	120 grams / 30 days
CORDRAN CRE 0.05%	120 grams / 30 days
CORDRAN LOT 0.05%	120 mLs / 30 days
CORDRAN OIN 0.05%	120 grams / 30 days
CORDRAN 80X3 TAP 4MCG/CM	1 box / 30 days
COSENTYX INJ 150MG/ML²	1 syringe / 28 days
COSENTYX INJ 300DOSE²	1 PACK / 28 days
COSENTYX INJ 75MG/0.5²	1 syringe / 28 days
COSENTYX PEN INJ 150MG/ML²	1 INJDV / 28 days
COSENTYX PEN INJ 300DOSE²	1 PACK / 28 days
CUTIVATE LOT 0.05%	120 mLs / 30 days
DERMA-SMOOTH OIL /FS BODY	118.28 mLs / 30 days
DERMA-SMOOTH OIL /FS SCLP	118.28 mLs / 30 days
DESONATE GEL 0.05%	120 grams / 30 days
desonide cre 0.05%	120 grams / 30 days
desonide gel 0.05%	120 grams / 30 days
desonide lot 0.05%	118 mLs / 30 days
desonide oin 0.05%	120 grams / 30 days
DESOWEN CRE 0.05%	120 grams / 30 days
desoximetas cre 0.05%	120 grams / 30 days
desoximetas cre 0.25%	120 grams / 30 days
desoximetas gel 0.05%	120 grams / 30 days
desoximetas oin 0.05%	120 grams / 30 days
desoximetas oin 0.25%	120 grams / 30 days
desoximetaso spr 0.25%	100 mLs / 30 days
desrx gel 0.05%	120 grams / 30 days
DICLOFENAC DIS 1.3%	60 patches / 30 days
diclofenac sol 1.5%	2 bottles / 30 days
DIFLORASONE CRE 0.05%	120 grams / 30 days
diflorasone oin 0.05%	120 grams / 30 days
DIPROLENE OIN 0.05%	200 grams / 28 days
DIPROLENE AF CRE 0.05%	200 grams / 28 days
DUPIXENT INJ 200/1.14²	2 syringes / 28 days
DUPIXENT INJ 200MG²	2 pens / 28 days
DUPIXENT- DUPILUMAB SUBCUTANEOUS SOLN PEN-INJECTOR 300 MG/2ML²	2 pens / 28 days
DUPIXENT- DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 300 MG/2ML²	2 syringes / 28 days
EFUDEX CRE 5%	240 grams / 90 days
ELOCON CRE 0.1%	135 grams / 30 days
FLECTOR DIS 1.3%	60 patches / 30 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 cre e 0.05%	120 grams / 30 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
fluorouracil cre 5%	240 grams / 90 days
flurandrenol cre 0.05%	120 grams / 30 days
flurandrenol lot 0.05%	120 mLs / 30 days
flurandrenol oin 0.05%	120 grams / 30 days
fluticasone cre 0.05%	120 grams / 30 days
fluticasone lot 0.05%	120 mLs / 30 days
fluticasone oin 0.005%	120 grams / 30 days
glydo gel 2%	150 mLs / 30 days
halcinonide cre 0.1%	240 grams / 30 days
halobetasol cre 0.05%	200 grams / 28 days
halobetasol oin 0.05%	200 grams / 28 days
HALOG CRE 0.1%	240 grams / 30 days
HALOG OIN 0.1%	240 grams / 30 days
HALOG SOL 0.1%	240 mLs / 30 days
HC BUTYRATE CRE 0.1%	135 grams / 30 days
hc butyrate oin 0.1%	135 grams / 30 days
HC BUTYRATE SOL 0.1%	120 mLs / 30 days
hc butyrate sol 0.1%	120 mLs / 30 days
hc valerate cre 0.2%	120 grams / 30 days
hc valerate oin 0.2%	120 grams / 30 days
hydrocort cre 1%	454 grams / 30 days
hydrocortisone cre 2.5%	454 grams / 30 days
hydrocortisone lot 2.5%	118 mLs / 30 days
hydrocortisone oin 2.5%	454 grams / 30 days
hydrocortisone lot 0.1%	118 mLs / 30 days
hydrocortisonebutyrate cream 0.1%	135 grams / 30 days
hydrocortisone butyrate hydrophilic lipo base cream 0.1%	120 grams / 30 days
imiquimod cre 5%	48 packets / 112 days
IMPOYZ CRE 0.025%	200 grams / 28 days
JUBLIA SOL 10%	4 mLs / 30 days
KENALOG AER SPRAY	126 grams / 30 days
KERYDIN SOL 5%	4 mLs / 30 days
KLISYRI OIN 1%	5 packets / 90 days
LICART DIS 1.3%	30 systems / 30 days
lidocaine/prilocaine cre 2.5-2.5%	60 grams / 30 days
LIDOCA/TETRA CRE 7/7%	120 grams / 30 days
LIDOCAINE CRE TETRACAI	120 grams / 30 days
lidocaine gel 2%	150 mLs / 30 days
LIDOCAINE GEL 2% JELLY	150 mLs / 30 days
lidocaine gel 2% jelly	150 mLs / 30 days
lidocaine oin 5%	100 grams / 30 days
lidocaine pad 5%	90 patches / 30 days
lidocaine sol 4%	150 mLs / 30 days
LIDODERM DIS 5%	90 patches / 30 days
LOCOID CRE 0.1%	135 grams / 30 days
LOCOID LOT 0.1%	118 mLs / 30 days
LOCOID SOL 0.1%	120 mLs / 30 days
LOCOID LIPO CRE 0.1%	120 grams / 30 days
LUXIQ AER 0.12%	150 grams / 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
nolix cre 0.05%	120 grams / 30 days
nolix lot 0.05%	120 mLs / 30 days
OLUX AER 0.05%	200 grams / 28 days
OLUX-E AER 0.05%	200 grams / 28 days
PANDEL CRE 0.1%	160 grams / 30 days
PENLAC SOL 8%	3.3 mLs / 30 days
PENNSAID SOL 2%	2 pumps / 28 days
PLIAGLIS CRE 7-7%	120 grams / 30 days
PREDNICARBAT CRE 0.1%	120 grams / 30 days
PREDNICARBAT OIN 0.1%	120 grams / 30 days
PSORCON CRE 0.05%	120 grams / 30 days
QBREXZA PAD 2.4%	30 PADS / 30 days
SERNIVO SPR	120 mLs / 30 days
SERNIVO SPR 0.05%	120 mLs / 30 days
SILIQ INJ 210/1.5²	2 syringes / 28 days
SKYRIZI INJ 150DOSE²	1 box / 84 days
SKYRIZI INJ 150MG/ML²	1 syringe / 84 days
SKYRIZI PEN INJ 150MG/ML²	1 INJDV / 84 days
STELARA INJ 45MG/0.5²	1 syringe / 84 days
STELARA INJ 90MG/ML²	1 syringe / 56 days
SYNALAR CRE 0.025%	120 grams / 30 days
SYNALAR OIN 0.025%	120 grams / 30 days
SYNALAR SOL 0.01%	120 mLs / 30 days
SYNERA DIS 70-70MG	4 patches / 30 days
TALTZ INJ 80MG/ML²	1 mLs / 28 days
tavaborole sol 5%	4 mLs / 30 days
TEMOVATE CRE 0.05%	210 grams / 28 days
TEMOVATE OIN 0.05%	210 grams / 28 days
TEXACORT SOL 2.5%	120 mLs / 30 days
TOPICORT CRE 0.05%	120 grams / 30 days
TOPICORT CRE 0.25%	120 grams / 30 days
TOPICORT GEL 0.05%	120 grams / 30 days
TOPICORT OIN 0.05%	120 grams / 30 days
TOPICORT OIN 0.25%	120 grams / 30 days
TOPICORT SPR 0.25%	100 mLs / 30 days
tovet aer 0.05%	200 grams / 28 days
TREMFYA- GUSELKUMAB SOLN PEN-INJECTOR 100 MG/ML²	1 pen / 56 days
TREMFYA- GUSELKUMAB SOLN PREFILLED SYRINGE 100 MG/ML²	1 syringe / 56 days
triamcinolone aer spray	126 grams / 30 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 0.05%	430 grams / 30 days
triamcinolone oin 0.1%	454 grams / 30 days
triamcinolone oin 0.5%	120 grams / 30 days
trianex oin 0.05%	430 grams / 30 days
triderm cre 0.1%	454 grams / 30 days
triderm cre 0.5%	454 grams / 30 days
TRIDESILON CRE 0.05%	120 grams / 30 days
tritocin oin 0.05%	430 grams / 30 days
ULTRAVATE LOT 0.05%	240 mLs / 30 days
VANOS CRE 0.1%	240 grams / 28 days
VERDESO AER 0.05%	100 grams / 30 days
ZTLIDO PAD 1.8%	90 patches / 30 days

Digestive aids

Drug name(s)	Quantity limits (per 30 days or as specified)
SUCRAID SOL 8500/ML	236 mLs / 28 days

Diuretics

Drug name(s)	Quantity limits (per 30 days or as specified)
KEVEYIS TAB 50MG³	120 tabs / 30 days

Endocrine and metabolic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ACTONEL TAB 150MG	1 TAB / 28 days
ACTONEL TAB 35MG	4 tabs / 28 days
alendronate tab 35mg	4 tabs / 28 days
alendronate tab 70mg	4 caps / 28 days
ATELVIA TAB	4 tabs / 28 days
BINOSTO TAB 70MG	4 tabs / 28 days
BONIVA TAB 150MG	1 TAB / 28 days
BYNFEZIA PEN INJ 2500MCG	2 pens / 30 days
CETROTIDE KIT 0.25MG²	5 KITS / 30 days
CHOR GONADOT INJ 10000UNT²	2 vials / 30 days
EGRIFTA SOL 1MG²	60 vials / 30 days
EGRIFTA SV INJ 2MG²	30 vials / 30 days
FOLLISTIM AQ INJ 300unit²	15 carts / 30 days
FOLLISTIM AQ INJ 600unit²	8 carts / 30 days
FOLLISTIM AQ INJ 900unit²	5 carts / 30 days
FORTEO INJ 620/2.48²	1 pen / 28 days
FOSAMAX TAB 70MG	4 caps / 28 days
FOSAMAX + D TAB 70-2800	4 caps / 28 days
FOSAMAX + D TAB 70-5600	4 caps / 28 days
GALAFOLD CAP 123MG²	14 caps / 28 days
GANIRELIX AC INJ 250/0.5	5 syringes / 30 days
GANIRELIX AC INJ 250/0.5²	5 syringes / 30 days
ganirelix ac inj 250/0.5²	5 syringes / 30 days
GONAL-F INJ 1050unit²	4 syringes / 30 days
GONAL-F INJ 450unit²	10 syringes / 30 days
GONAL-F RFF INJ 300/0.5²	15 pens / 30 days
GONAL-F RFF INJ 450/0.75²	10 pens / 30 days
GONAL-F RFF INJ 75unit²	20 syringes / 30 days
GONAL-F RFF INJ 900/1.5²	5 pens / 30 days
ibandronate tab 150mg	1 TAB / 28 days
ISTURISA TAB 10MG³	180 tabs / 30 days
ISTURISA TAB 1MG³	240 tabs / 30 days
ISTURISA TAB 5MG³	300 tabs / 30 days
JYNARQUE PAK 30-15MG²	56 tabs / 28 days
JYNARQUE PAK 45-15MG²	56 tabs / 28 days
JYNARQUE PAK 60-30MG²	56 tabs / 28 days
JYNARQUE PAK 90-30MG²	56 tabs / 28 days
JYNARQUE TAB 30MG²	30 tabs / 30 days
JYNARQUE- TOLVAPTAN TAB 15 MG²	60 tabs / 30 days
JYNARQUE- TOLVAPTAN TAB THERAPY PACK 15 MG²	56 tabs / 28 days
KERENDIA TAB 10MG	30 tabs / 30 days
KERENDIA TAB 20MG	30 tabs / 30 days
MENOPUR INJ 75unit²	60 vials / 30 days
MYCAPSSA CAP 20MG	120 caps / 30 days
NATPARA INJ 100MCG²	1 kit /28 days
NATPARA INJ 25MCG²	1 kit /28 days
NATPARA INJ 50MCG²	1 kit /28 days
NATPARA INJ 75MCG²	1 kit /28 days
NOCTIVA SPR 1.66/0.1	1 bottle / 30 days
NOVAREL INJ 10000UNT²	2 vials / 30 days
NOVAREL INJ 5000unit²	4 vials / 30 days
ORILISSA TAB 150MG	30 tabs / 30 days
ORILISSA TAB 200MG	60 tabs / 30 days
OVIDREL INJ²	2 syringes / 30 days
PREGNYL INJ 10000UNT²	2 vials / 30 days
risedronate sod tab 35mg dr	4 tabs / 28 days
risedronate tab 150mg	1 TAB / 28 days
risedronate tab 35mg	4 tabs / 28 days
SAMSCA TAB 15MG²	30 tabs / 365 days
SAMSCA TAB 30MG²	60 tabs / 365 days
SIGNIFOR INJ 0.3MG/ML³	60 mLs / 30 days
SIGNIFOR INJ 0.6MG/ML³	60 mLs / 30 days
SIGNIFOR INJ 0.9MG/ML³	60 mLs / 30 days
SOMAVERT INJ 10MG²	30 vials / 30 days
SOMAVERT INJ 15MG²	30 vials / 30 days
SOMAVERT INJ 20MG²	30 vials / 30 days
SOMAVERT INJ 25MG²	30 vials / 30 days
SOMAVERT INJ 30MG²	30 vials / 30 days
TERIPARATIDE INJ²	1 pen / 28 days
TOLVAPTAN TAB 15MG²	30 tabs / 365 days
tolvaptan tab 30mg	60 tabs / 365 days
tolvaptan tab 30mg²	60 tabs / 365 days
TYMLOS INJ²	1 pen / 30 days

Estrogens

Drug name(s)	Quantity limits (per 30 days or as specified)
ORIAHNN CAP	56 caps / 28 days

Gastrointestinal agents

Drug name(s)	Quantity limits (per 30 days or as specified)
alosetron tab 0.5mg	60 tabs / 30 days
alosetron tab 1mg	60 tabs / 30 days
AMITIZA CAP 24MCG	60 caps / 30 days
AMITIZA CAP 8MCG	120 caps / 30 days
CIMZIA PREFL KIT 200MG/ML²	2 KITS / 28 days
CIMZIA START KIT 200MG/ML²	1 kit /180 days
LINZESS CAP 145MCG	30 caps / 30 days
LINZESS CAP 290MCG	30 caps / 30 days
LINZESS CAP 72MCG	30 caps / 30 days
LOTRONEX TAB 0.5MG	60 tabs / 30 days
LOTRONEX TAB 1MG	60 tabs / 30 days
LUBIPROSTONE CAP 24MCG	60 caps / 30 days
LUBIPROSTONE CAP 8MCG	120 caps / 30 days
MOTEGRITY TAB 1MG	30 tabs / 30 days
MOTEGRITY TAB 2MG	30 tabs / 30 days
MOVANTIK TAB 12.5MG	30 tabs / 30 days
MOVANTIK TAB 25MG	30 tabs / 30 days
OCALIVA TAB 10MG²	30 tabs / 30 days
OCALIVA TAB 5MG²	30 tabs / 30 days
RELISTOR INJ 8/0.4ML	30 syringes / 30 days
RELISTOR TAB 150MG	90 tabs / 30 days
RELISTOR- METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML)	60 vials / 30 days
RELISTOR- METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML)	30 syringes / 30 days
SYMPROIC TAB 0.2MG	30 tabs / 30 days
TRULANCE TAB 3MG	30 tabs / 30 days
VIBERZI TAB 100MG	60 tabs / 30 days
VIBERZI TAB 75MG	60 tabs / 30 days
XERMELO TAB 250MG³	90 tabs / 30 days
ZELNORM TAB 6MG	60 tabs / 30 days

Hematological agent

Drug name(s)	Quantity limits (per 30 days or as specified)
EMPAVELI INJ 1080MG	8 vials / 28 days
FIRAZYR INJ 30MG/3ML²	6 syringes / 30 days
HAEGARDA INJ 2000unit³	24 vials / 30 days
HAEGARDA INJ 3000unit³	16 vials / 30 days
HEMLIBRA INJ 105/0.7²	4 vials / 28 days
HEMLIBRA INJ 150/ML²	4 vials / 28 days
HEMLIBRA INJ 30MG/ML²	4 vials / 28 days
HEMLIBRA INJ 60/0.4²	4 vials / 28 days
icatibant inj 30mg/3ml²	6 syringes / 30 days
ORLADEYO CAP 110MG³	30 caps / 30 days
ORLADEYO CAP 150MG³	30 caps / 30 days
sajazir inj 30mg/3ml²	6 syringes / 30 days
TAKHZYRO INJ 300/2ML³	4 mLs / 28 days

Hematopoietic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
CERDELGA CAP 84MG²	60 caps / 30 days
miglustat cap 100mg²	90 caps / 30 days
MULPLETA TAB 3MG²	7 tabs / 7 days
OXBRYTA TAB 500MG³	90 tabs / 30 days
PROMACTA PAK 25MG²	30 packs / 30 days
PROMACTA POW 12.5MG²	30 packets / 30 days
PROMACTA TAB 12.5MG²	30 tabs / 30 days
PROMACTA TAB 25MG²	30 tabs / 30 days
PROMACTA TAB 50MG²	60 tabs / 30 days
PROMACTA TAB 75MG²	60 tabs / 30 days
ZAVESCA CAP 100MG³	90 caps / 30 days

Hypnotics/sedatives/sleep disorder agents

Drug name(s)	Quantity limits (per 30 days or as specified)
AMBIEN TAB 10MG	30 tabs / 30 days
AMBIEN TAB 5MG	30 tabs / 30 days
AMBIEN CR TAB 12.5MG	30 tabs / 30 days
AMBIEN CR TAB 6.25MG	30 tabs / 30 days
BELSOMRA TAB 10MG	30 tabs / 30 days
BELSOMRA TAB 15MG	30 tabs / 30 days
BELSOMRA TAB 20MG	30 tabs / 30 days
BELSOMRA TAB 5MG	30 tabs / 30 days
DAYVIGO TAB 10MG	30 tabs / 30 days
DAYVIGO TAB 5MG	30 tabs / 30 days
doxepin tab 3mg	30 tabs / 30 days
doxepin tab 6mg	30 tabs / 30 days
EDLUAR SUB 10MG	30 tabs / 30 days
EDLUAR SUB 5MG	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
INTERMEZZO SUB 1.75MG	30 tabs / 30 days
LUNESTA TAB 1MG	30 tabs / 30 days
LUNESTA TAB 2MG	30 tabs / 30 days
LUNESTA TAB 3MG	30 tabs / 30 days
ramelteon tab 8mg	30 tabs / 30 days
ROZEREM TAB 8MG	30 tabs / 30 days
SILENOR TAB 3MG	30 tabs / 30 days
SILENOR TAB 6MG	30 tabs / 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
zolpidemer tab 12.5mg	30 tabs / 30 days
zolpidemer tab 6.25mg	30 tabs / 30 days
zolpidemtar sub 1.75mg	30 tabs / 30 days
zolpidem tar sub 3.5mg	30 tabs / 30 days
ZOLPIMIST SPR 5MG	1 can / 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
FREESTY LIBR MIS 2 READER	1 READER / 365 days
FREESTYLE MIS READER	1 unit / 365 days
FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM- CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR**	2 unitS / 28 days
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM- CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR**	2 SENSRS / 28 days
FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM- CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR**	3 unitS / 30 days
G5/G4 MIS SENSOR	4 unitS / 28 days

Migraine products

Drug name(s)	Quantity limits (per 30 days or as specified)
AIMOVIG INJ 140MG/ML²	1 INJ / 28 days
AIMOVIG INJ 70MG/ML²	1 INJ / 28 days
AJOVY INJ 225/1.5²	3 syringes / 84 days
almotriptanmalate tab 12.5mg	12 tabs / 30 days
almotriptanmalate tab 6.25mg	24 tabs / 30 days
almotriptan tab 12.5mg	12 tabs / 30 days
almotriptan tab 6.25mg	24 tabs / 30 days
AMERGE TAB 1MG	18 tabs / 30 days
AMERGE TAB 2.5MG	18 tabs / 30 days
dihydroergotamine spr 4mg/ml	8 mLs / 28 days
eletriptan tab 20mg	18 tabs / 30 days
eletriptan tab 40mg	12 tabs / 30 days
EMGALITY INJ 100MG/ML²	9 syringes / 180 days
EMGALITY INJ 120MG/ML²	1 syringe / 28 days
FROVA TAB 2.5MG	27 tabs / 30 days
frovatriptan tab 2.5mg	27 tabs / 30 days
IMITREX INJ 4MG/0.5	12 syringes / 30 days
IMITREX SPR 20MG/ACT	12 inhalers / 30 days
IMITREX SPR 5MG/ACT	5 packs / 30 days
IMITREX TAB 100MG	18 tabs / 30 days
IMITREX TAB 25MG	27 tabs / 30 days
IMITREX TAB 50MG	18 tabs / 30 days
IMITREX STATDOSE REFILL- SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML	12 carts / 30 days
IMITREX STATDOSE SYSTEM- SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML	12 syringes / 30 days
IMITREX- SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML	12 syringes / 30 days
MAXALT TAB 10MG	18 tabs / 30 days
MAXALT-MLT TAB 10MG	18 tabs / 30 days
MIGRANAL SPR 4MG/ML	8 mLs / 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
ONZETRA XSAI MIS 11MG	32 inhalers / 30 days
RELPAX TAB 20MG	18 tabs / 30 days
RELPAX TAB 40MG	12 tabs / 30 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-naproxen tab 85-500mg	18 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
sumatriptan tab 100mg	18 tabs / 30 days
sumatriptan tab 25mg	27 tabs / 30 days
sumatriptan tab 50mg	18 tabs / 30 days
sumatriptan succinate inj 6 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution auto-injector 4 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution auto-injector 6 mg/0.5ml	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
TREXIMET TAB 85-500MG	18 tabs / 30 days
UBRELVY TAB 100MG	16 tabs / 30 days
UBRELVY TAB 50MG	16 tabs / 30 days
ZEMBRACE SYM INJ 3/0.5ML	24 pens / 30 days
ZOLMITRIPTAN SPR 2.5MG	3 injdvs / 30 days
zolmitriptan tab 2.5 mg	18 tabs / 30 days
zolmitriptan tab 2.5mg	18 tabs / 30 days
zolmitriptan tab 5mg	12 tabs / 30 days
zolmitriptan tab 5mg odt	12 tabs / 30 days
ZOMIG SPR 2.5MG	3 injdvs / 30 days
ZOMIG SPR 5MG	2 SPRAYS / 30 days
ZOMIG TAB 2.5MG	18 tabs / 30 days
ZOMIG TAB 5MG	12 tabs / 30 days

Miscellaneous therapeutic classes

Drug name(s)	Quantity limits (per 30 days or as specified)
BENLYSTA INJ 200MG/ML²	4 syringes / 28 days
ENSPRYNG INJ²	1 syringe / 28 days
LUPKYNIS CAP 7.9MG	180 caps / 30 days
REVLIMID CAP 10MG²	30 caps / 30 days
REVLIMID CAP 15MG²	21 caps / 28 days
REVLIMID CAP 2.5MG²	30 caps / 30 days
REVLIMID CAP 20MG²	21 caps / 28 days
REVLIMID CAP 25MG²	21 caps / 28 days
REVLIMID CAP 5MG²	30 caps / 30 days
THALOMID CAP 100MG²	30 caps / 30 days
THALOMID CAP 150MG²	60 caps / 30 days
THALOMID CAP 200MG²	60 caps / 30 days
THALOMID CAP 50MG²	30 caps / 30 days
ZOKINVY CAP 50MG³	120 caps / 30 days
ZOKINVY CAP 75MG³	120 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)	Quantity limits (per 30 days or as specified)
AMRIX CAP 15MG	21 caps / 90 days
AMRIX CAP 30MG	21 caps / 90 days
baclofen tab 10mg	120 tabs / 30 days
baclofen tab 20mg	120 tabs / 30 days
baclofen tab 5mg	120 tabs / 30 days
CARISOPR/ASA TAB 200-325	168 tabs / 90 days
carisoprodol /asa tab 200-325	168 tabs / 90 days
carisoprodol tab 250mg	84 tabs / 90 days
carisoprodol tab 350mg	84 tabs / 90 days
CARISOPRODOL TAB ASA/COD	168 tabs / 30 days
carisoprodol tab asa/cod	168 tabs / 90 days
chlorzoxazon tab 250mg	84 tabs / 90 days
chlorzoxazon tab 375mg	84 tabs / 90 days
chlorzoxazon tab 500mg	84 tabs / 90 days
chlorzoxazon tab 750mg	84 tabs / 90 days
cyclobenzapr cap 15mg er	21 caps / 90 days
cyclobenzapr cap 30mg er	21 caps / 90 days
cyclobenzapr tab 10mg	63 tabs / 90 days
cyclobenzapr tab 5mg	63 tabs / 90 days
cyclobenzapr tab 7.5mg	63 tabs / 90 days
DANTRIUM CAP 25MG	90 caps / 30 days
DANTRIUM CAP 50MG	90 caps / 30 days
dantrolene cap 100mg	90 caps / 30 days
dantrolene cap 25mg	90 caps / 30 days
dantrolene cap 50mg	90 caps / 30 days
FEXMID TAB 7.5MG	63 tabs / 90 days
lorzone tab 375mg	84 tabs / 90 days
lorzone tab 750mg	84 tabs / 90 days
metaxalone tab 400mg	168 tabs / 90 days
metaxalone tab 800mg	84 tabs / 90 days
methocarbam tab 500mg	180 tabs / 90 days
methocarbam tab 750mg	132 tabs / 90 days
orphenadrine tab 100mg cr	42 tabs / 30 days
orphenadrine tab 100mg er	42 tabs / 30 days
ROBAXIN-750 TAB 750MG	132 tabs / 90 days
SKELAXIN TAB 800MG	84 tabs / 90 days
SOMA TAB 250MG	84 tabs / 90 days
SOMA TAB 350MG	84 tabs / 90 days
tizanidine cap 2mg	126 caps / 90 days
tizanidine cap 4mg	126 caps / 90 days
tizanidine cap 6mg	126 caps / 90 days
tizanidine tab 2mg	126 tabs / 90 days
tizanidine tab 4mg	42 caps / 30 days
vanadom tab 350mg	84 tabs / 90 days
ZANAFLEX CAP 2MG	126 caps / 90 days
ZANAFLEX CAP 4MG	126 caps / 90 days
ZANAFLEX CAP 6MG	126 caps / 90 days
ZANAFLEX TAB 4MG	42 tabs / 30 days

Nasal agents - systemic and topical

Drug name(s)	Quantity limits (per 30 days or as specified)
azel/flutic spr 137-50	1 bottle / 30 days
azelastine spr 0.1%	2 bottles / 30 days
azelastine spr 0.15%	2 bottles / 30 days
BECONASE AQ SUS 0.042%	2 bottles / 30 days
DYMISTA SPR 137-50	1 bottle / 30 days
FLUNISOLIDE SPR 0.025%	3 bottles / 30 days
ipratropium spr 0.03%	2 bottles / 30 days
ipratropium spr 0.06%	3 bottles / 30 days
mometasone spr 50mcg	2 bottles / 30 days
NASONEX SPR 50MCG/AC	2 bottles / 30 days
olopatadine spr 0.6%	1 bottle / 30 days
OMNARIS SPR	1 bottle / 30 days
PATANASE SPR 0.6%	1 bottle / 30 days
QNASL AER 80MCG	1 can / 30 days
QNASL CHILD SPR 40MCG	1 can / 30 days
XHANCE MIS 93MCG	2 bottles / 30 days
ZETONNA AER 37MCG	1 can / 30 days

Neuromuscular agents

Drug name(s)	Quantity limits (per 30 days or as specified)
EVRYSDI SOL³	240 mLs / 30 days

Ophthalmic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
bimatoprost sol 0.03%	2.5 mLs / 30 days
bimatoprost sol 0.03%	2.5 mLs / 30 days
EYSUVIS DRO 0.25%	2 bottles / 90 days
EYSUVIS DRO 0.25%	2 bottles / 90 days
latanoprost sol 0.005%	2.5 mLs / 30 days
latanoprost sol 0.005%	2.5 mLs / 30 days
LUMIGAN SOL 0.01%	2.5 mLs / 30 days
LUMIGAN SOL 0.01%	2.5 mLs / 30 days
OXERVATE SOL 20MCG/ML³	56 vials / 56 days
OXERVATE SOL 20MCG/ML³	56 vials / 56 days
RESTASIS EMU 0.05%	2 vials / 30 days
RESTASIS EMU 0.05%	2 vials / 30 days
RESTASIS MUL EMU 0.05%	1 bottle / 30 days
RESTASIS MUL EMU 0.05%	1 bottle / 30 days
RHOPRESSA SOL 0.02%	2.5 mLs / 30 days
RHOPRESSA SOL 0.02%	2.5 mLs / 30 days
ROCKLATAN DRO	2.5 mLs / 30 days
ROCKLATAN DRO	2.5 mLs / 30 days
TRAVATAN Z DRO 0.004%	2.5 mLs / 30 days
TRAVATAN Z DRO 0.004%	2.5 mLs / 30 days
travoprost dro 0.004%	2.5 mLs / 30 days
travoprost dro 0.004%	2.5 mLs / 30 days
VYZULTA SOL 0.024%	2.5 mLs / 30 days
VYZULTA SOL 0.024%	2.5 mLs / 30 days
XALATAN SOL 0.005%	2.5 mLs / 30 days
XALATAN SOL 0.005%	2.5 mLs / 30 days
XIIDRA DRO 5%	60 vials / 30 days
XIIDRA DRO 5%	60 vials / 30 days
ZIOPTAN DRO 0.0015%	30 cartons / 30 days
ZIOPTAN DRO 0.0015%	30 cartons / 30 days

Psychotherapeutic and neurological agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADDYI TAB 100MG	30 tabs / 30 days
AMPYRA TAB 10MG^2,⁴	60 tabs / 30 days
AUBAGIO TAB 14MG^2,⁴	30 tabs / 30 days
AUBAGIO TAB 7MG^2,⁴	30 tabs / 30 days
AUSTEDO TAB 12MG²	120 tabs / 30 days
AUSTEDO TAB 6MG²	60 tabs / 30 days
AUSTEDO TAB 9MG²	120 tabs / 30 days
AVONEX PEN KIT 30MCG²	1 kit /28 days
AVONEX PREFL KIT 30MCG²	1 kit /28 days
BAFIERTAM CAP 95MG	120 caps / 30 days
BETASERON INJ 0.3MG²	1 box / 28 days
COPAXONE INJ 20MG/ML²	30 syringes / 30 days
COPAXONE INJ 40MG/ML²	12 syringes / 28 days
dalfampridin tab 10mg er^2,⁴	60 tabs / 30 days
dimethyl fum cap 120mg dr²	56 caps / 180 days
dimethyl fum cap 240mg dr²	60 caps / 30 days
dimethyl fum mis starter²	60 caps / 180 days
EXTAVIA INJ 0.3MG²	15 vials / 30 days
GILENYA CAP 0.5MG²	30 tabs / 30 days
glatiramer inj 20mg/ml²	30 syringes / 30 days
glatiramer inj 40mg/ml²	12 syringes / 28 days
glatopa inj 20mg/ml²	30 syringes / 30 days
glatopa inj 40mg/ml²	12 syringes / 28 days
INGREZZA CAP 40-80MG³	28 caps / 180 days
INGREZZA CAP 40MG³	30 caps / 30 days
INGREZZA CAP 60MG³	30 caps / 30 days
INGREZZA CAP 80MG³	30 caps / 30 days
KESIMPTA INJ 20/.4ML²	1 syringe / 28 days
LYRICA CR TAB 165MG	30 tabs / 30 days
LYRICA CR TAB 330MG	60 tabs / 30 days
LYRICA CR TAB 82.5MG	30 tabs / 30 days
MAYZENT PAK STARTER	12 tabs / 180 days
MAYZENT TAB 0.25MG²	120 tabs / 30 days
MAYZENT TAB 2MG²	30 tabs / 30 days
PLEGRIDY INJ²	2 syringes / 28 days
PLEGRIDY INJ PEN²	2 pens / 28 days
PLEGRIDY INJ STARTER²	1 kit /180 days
PLEGRIDY PEN INJ STARTER²	1 kit /180 days
PONVORY TAB 20MG	30 tabs / 30 days
PONVORY TAB STARTER	14 tabs / 180 days
pregabalner tab 165mg	30 tabs / 30 days
pregabalner tab 330mg	60 tabs / 30 days
pregabaln er tab 82.5mg	30 tabs / 30 days
REBIF INJ 22/0.5²	12 syringes / 28 days
REBIF INJ 44/0.5²	1 carton / 28 days
REBIF REBIDO INJ 22/0.5²	1 carton / 28 days
REBIF REBIDO INJ 44/0.5²	1 carton / 28 days
REBIF REBIDO INJ TITRATN²	1 kit /180 days
REBIF TITRTN INJ PACK²	1 kit /180 days
SAVELLA MIS TITR PAK	1 kit /180 days
SAVELLA TAB 100MG	60 tabs / 30 days
SAVELLA TAB 12.5MG	60 tabs / 30 days
SAVELLA TAB 25MG	60 tabs / 30 days
SAVELLA TAB 50MG	60 tabs / 30 days
TECFIDERA CAP 120MG²	56 caps / 180 days
TECFIDERA CAP 240MG²	60 caps / 30 days
TECFIDERA MIS STARTER²	60 caps / 180 days
TEGSEDI INJ 284/1.5³	6 mLs / 28 days
tetrabenazin tab 12.5mg	240 tabs / 30 days
tetrabenazin tab 12.5mg²	240 tabs / 30 days
tetrabenazin tab 25mg	120 tabs / 30 days
tetrabenazin tab 25mg²	120 tabs / 30 days
VUMERITY- DIROXIMEL FUMARATE CAPSULE DELAYED RELEASE 231 MG²	120 caps / 30 days
VUMERITY- DIROXIMEL FUMARATE CAPSULE DR STARTER bottle 231 MG²	106 caps / 180 days
VYLEESI INJ 1.75/0.3	6 pens / 30 days
XENAZINE TAB 12.5MG²	240 tabs / 30 days
XENAZINE TAB 25MG²	120 tabs / 30 days
XYREM SOL 500MG/ML³	540 mLs / 30 days
XYWAV SOL 0.5GM/ML³	540 mLs / 30 days
ZEPOSIA CAP .92MG²	30 caps / 30 days
ZEPOSIA CAP STR KIT²	37 caps / 180 days
ZEPOSIA 7DAY CAP STR PACK²	7 caps / 180 days

Respiratory agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ESBRIET CAP 267MG²	180 caps / 30 days
ESBRIET TAB 267MG²	180 tabs / 30 days
ESBRIET TAB 801MG²	90 tabs / 30 days
KALYDECO PAK 25MG²	60 packets / 30 days
KALYDECO PAK 50MG²	60 packets / 30 days
KALYDECO PAK 75MG²	60 packets / 30 days
KALYDECO TAB 150MG²	60 tabs / 30 days
OFEV CAP 100MG^2,⁴	60 caps / 30 days
OFEV CAP 150MG^2,⁴	60 caps / 30 days
ORKAMBI TAB 100-125²	120 tabs / 30 days
ORKAMBI TAB 200-125²	120 tabs / 30 days
SYMDEKO TAB 100-150²	60 tabs / 30 days
SYMDEKO TAB 50-75MG²	56 tabs / 28 days
TRIKAFTA TAB 100mg/50mg/75mg/150mg²	90 tabs / 30 days

Ulcer Drugs / Antispasmodics / Anticholinergics

Urinary antispasmodics

Drug name(s)	Quantity limits (per 30 days or as specified)
ACIPHEX TAB 20MG	30 tabs / 30 days
DEXILANT CAP 30MG DR	30 caps / 30 days
DEXILANT CAP 60MG DR	30 caps / 30 days
esomepra mag cap 40mg dr	30 caps / 30 days
lansoprazole cap 15mg dr	30 caps / 30 days
lansoprazole cap 30mg dr	30 caps / 30 days
NEXIUM CAP 40MG	30 caps / 30 days
omepra/bicar cap 20-1100	30 caps / 30 days
omepra/bicar cap 40-1100	30 caps / 30 days
omepra/bicar pow 20-1680	30 packets / 30 days
omepra/bicar pow 40-1680	30 packets / 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 20mg dr	30 tabs / 30 days
pantoprazole tab 40mg	30 tabs / 30 days
pantoprazole tab 40mg dr	30 tabs / 30 days
PREVACID CAP 15MG DR	30 caps / 30 days
PREVACID CAP 30MG DR	30 caps / 30 days
PROTONIX TAB 20MG	30 tabs / 30 days
PROTONIX TAB 40MG	30 tabs / 30 days
rabeprazole tab 20mg	30 tabs / 30 days
ZEGERID CAP 20-1100	30 caps / 30 days
ZEGERID CAP 40-1100	30 caps / 30 days
ZEGERID POW 20-1680	30 packets / 30 days
ZEGERID POW 40-1680	30 packets / 30 days

Urinary antispasmodics

Drug name(s)	Quantity limits (per 30 days or as specified)
darifenacin tab 15mg	30 tabs / 30 days
darifenacin tab 7.5mg	30 tabs / 30 days
DETROL TAB 1MG	60 tabs / 30 days
DETROL TAB 2MG	60 tabs / 30 days
DETROL LA CAP 2MG	30 caps / 30 days
DETROL LA CAP 4MG	30 caps / 30 days
DITROPAN XL TAB 10MG	60 tabs / 30 days
DITROPAN XL TAB 5MG	30 tabs / 30 days
ENABLEX TAB 15MG	30 tabs / 30 days
ENABLEX TAB 7.5MG	30 tabs / 30 days
GELNIQUE GEL 10%	30 packets / 30 days
GEMTESA TAB 75MG	30 tabs / 30 days
MYRBETRIQ SUS 8MG/ML	300 mLs / 28 days
MYRBETRIQ TAB 25MG	30 tabs / 30 days
MYRBETRIQ TAB 50MG	30 tabs / 30 days
oxybutynin syp 5mg/5ml	600 mLs / 30 days
oxybutynin tab 10mg er	60 tabs / 30 days
oxybutynin tab 15mg er	60 tabs / 30 days
oxybutynin tab 5mg	120 tabs / 30 days
oxybutynin tab 5mg er	30 tabs / 30 days
solifenacin tab 10mg	30 tabs / 30 days
solifenacin tab 5mg	30 tabs / 30 days
tolterodine cap 2mg er	30 caps / 30 days
tolterodine cap 4mg er	30 caps / 30 days
tolterodine tab 1mg	60 tabs / 30 days
tolterodine tab 2mg	60 tabs / 30 days
TOVIAZ TAB 4MG	30 tabs / 30 days
TOVIAZ TAB 8MG	30 tabs / 30 days
trospium chl cap 60mg er	30 caps / 30 days
trospium cl tab 20mg	60 tabs / 30 days
VESICARE TAB 10MG	30 tabs / 30 days
VESICARE TAB 5MG	30 tabs / 30 days
VESICARE LS SUS 5MG/5ML	300 mLs / 30 days

Vaginal and related products

Drug name(s)	Quantity limits (per 30 days or as specified)
CRINONE GEL 4% VAG	6 applcs / 30 days
CRINONE GEL 8% VAG	60 applcs / 30 days
ENDOMETRIN SUP 100MG	84 SUPPS / 28 days

Vasopressors

Drug name(s)	Quantity limits (per 30 days or as specified)
droxidopa cap 100mg¹	450 caps / 30 days
droxidopa cap 100mg^1,²	450 caps / 30 days
droxidopa cap 200mg¹	180 caps / 30 days
droxidopa cap 200mg^1,²	180 caps / 30 days
droxidopa cap 300mg¹	180 caps / 30 days
droxidopa cap 300mg^1,²	180 caps / 30 days
NORTHERA CAP 100MG²	450 caps / 30 days
NORTHERA CAP 200MG²	180 caps / 30 days
NORTHERA CAP 300MG²	180 caps / 30 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	ACTEMRA²	ACTEMRA ACTPEN²
ACTHAR²	ADEMPAS ³	ADVATE²
ADYNOVATE²	AFINITOR^2,⁴	AFINITOR DISPERZ^2,⁴
AFSTYLA²	ALECENSA^3,⁴	ALPHANINE SD²
ALPROLIX²	ALUNBRIG ³	alyq²
ambrisentan²	ARANESP ALBUMIN FREE²	ARCALYST ³
ARIKAYCE ³	AUBAGIO^2,⁴	AUSTEDO²
AVONEX²	AVONEX PEN²	AYVAKIT^3,⁴
BALVERSA^3,⁴	BENEFIX²	BENLYSTA²
BERINERT²	BETASERON²	bexarotene^2,⁴
bosentan²	BOSULIF^2,⁴	BRAFTOVI ³
BRUKINSA ³	CABOMETYX^2,⁴	CALQUENCE ³
capecitabine²	CAPRELSA ³	CARBAGLU ³
CERDELGA²	CHORIONIC GONADOTROPIN²	CIMZIA²
CIMZIA STARTER KIT²	COAGADEX ³	COMETRIQ^3,⁴
COPIKTRA^3,⁴	COSENTYX²	COSENTYX SENSOREADY PEN²
COTELLIC²	dalfampridine er^2,⁴	DAURISMO^2,⁴
deferasirox^2,⁴	dimethyl fumarate²	dimethyl fumarate starterpack²
DOPTELET ³	DUPIXENT²	ELOCTATE²
ENBREL²	ENBREL MINI²	ENBREL SURECLICK²
ENDARI ³	ENSPRYNG²	EPCLUSA²
EPIDIOLEX SOL 100MG/ML²	ERIVEDGE^2,⁴	ERLEADA²
erlotinib hcl^2,⁴	ESBRIET²	ESPEROCT²
everolimus tab 2.5mg^2,⁴	everolimus tab 5mg^2,⁴	everolimus tab 7.5mg^2,⁴
EVRYSDI ³	FARYDAK CAP 10MG²	FARYDAK CAP 15MG²
FARYDAK CAP 20MG²	FINTEPLA ³	FIRDAPSE ³
FOLLISTIM AQ²	FORTEO²	GALAFOLD²
ganirelix acetate²	GATTEX ³	GAVRETO^3,⁴
GILENYA²	GILOTRIF ³	glatiramer acetate²
HAEGARDA ³	HARVONI²	HEMLIBRA²
HEMOFIL M²	HETLIOZ^3,⁴	HETLIOZ LQ^3,⁴
HUMIRA²	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK²	HUMIRA PEN²
HUMIRA PEN-CD/UC/HS STARTER²	HUMIRA PEN-PEDIATRIC UC STARTER PACK²	HUMIRA PEN-PS/UV STARTER²
HYCAMTIN²	IBRANCE²	icatibant acetate²
ICLUSIG^3,⁴	IDELVION²	IDHIFA²
imatinib mesylate^2,⁴	IMBRUVICA ³	IMCIVREE ³
INGREZZA ³	INLYTA^2,⁴	INQOVI²
INREBIC^2,⁴	IRESSA^3,⁴	ISTURISA ³
IXINITY²	JAKAFI^2,⁴	JIVI²
JUXTAPID ³	JYNARQUE²	KALYDECO²
KESIMPTA²	KEVZARA²	KISQALI²
KISQALI FEMARA 200 DOSE²	KISQALI FEMARA 400 DOSE²	KISQALI FEMARA 600 DOSE²
KOATE²	KOATE-DVI²	KOGENATE FS²
KORLYM ³	KOSELUGO ³	KOVALTRY²
lapatinib ditosylate²	LEDIPASVIR/SOFOSBUVIR²	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	LONSURF²	LORBRENA^2,⁴
LYNPARZA^3,⁴	MATULANE²	MAVYRET²
MAYZENT²	MEKINIST²	MEKTOVI ³
MENOPUR²	miglustat²	MIRCERA²
MONONINE²	MULPLETA²	NATPARA²
NERLYNX^3,⁴	NEXAVAR^2,⁴	NINLARO²
NORDITROPIN FLEXPRO²	NOVAREL²	NOVOEIGHT²
NUBEQA²	NUWIQ²	OCALIVA²
ODOMZO^2,⁴	OFEV^2,⁴	ONUREG²
OPSUMIT ³	ORENCIA²	ORENCIA CLICKJECT²
ORENITRAM ³	ORGOVYX ³	ORKAMBI²
OTEZLA²	OXBRYTA ³	OXERVATE ³
PALYNZIQ ³	PEGINTRON²	PEMAZYRE ³
PIQRAY 200MG DAILY DOSE²	PIQRAY 250MG DAILY DOSE²	PIQRAY 300MG DAILY DOSE²
PLEGRIDY²	PLEGRIDY STARTER PACK²	POMALYST²
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL²	PROCYSBI ³	PROFILNINE²
PROFILNINE SD²	PROMACTA²	QINLOCK ³
RAVICTI²	REBIF²	REBIF REBIDOSE²
REBIF REBIDOSE TITRATION PACK²	REBIF TITRATION PACK²	REBINYN²
RECOMBINATE²	RETACRIT²	RETEVMO^2,⁴
REVLIMID²	RINVOQ²	RIXUBIS²
ROZLYTREK^2,⁴	RUBRACA^3,⁴	RUCONEST²
RUZURGI ³	RYDAPT²	sajazir²
sapropterin dihydrochloride²	sildenafil sus 10mg/ml²	sildenafil tab 20mg²
SIMPONI²	SKYRIZI²	SKYRIZI PEN²
sodium phenylbutyrate²	SOFOSBUVIR/VELPATASVIR²	SOVALDI²
SPRYCEL^2,⁴	STELARA²	STIVARGA²
STRENSIQ ³	sunitinib malate^2,⁴	SUTENT^2,⁴
SYMDEKO²	TABRECTA²	tadalafil²
TAFINLAR²	TAGRISSO^3,⁴	TAKHZYRO ³
TALZENNA^2,⁴	TASIGNA^2,⁴	TAVALISSE ³
TAZVERIK ³	TEGSEDI ³	temozolomide²
tetrabenazine tab 12.5mg²	tetrabenazine tab 25mg²	THALOMID²
TIBSOVO ³	tolvaptan²	TRACLEER²
TREMFYA²	TRIKAFTA²	TUKYSA ³
TURALIO ³	TYMLOS²	TYVASO ³
TYVASO REFILL ³	TYVASO STARTER ³	UPTRAVI ³
VENCLEXTA ³	VENCLEXTA STARTING PACK ³	VENTAVIS^3,⁴
VERZENIO^3,⁴	VITRAKVI^3,⁴	VIZIMPRO^2,⁴
VOSEVI²	VOTRIENT^2,⁴	VYNDAMAX²
VYNDAQEL²	XALKORI^2,⁴	XELJANZ²
XELJANZ XR²	XERMELO ³	XOLAIR²
XOSPATA ³	XPOVIO^3,⁴	XPOVIO 100 MG ONCE WEEKLY^3,⁴
XPOVIO 60 MG ONCE WEEKLY^3,⁴	XPOVIO 80 MG ONCE WEEKLY^3,⁴	XPOVIO 80 MG TWICE WEEKLY^3,⁴
XTANDI^2,⁴	XYNTHA²	XYNTHA SOLOFUSE²
XYREM ³	XYWAV ³	YONSA^2,⁴
ZEJULA^3,⁴	ZELBORAF²	ZEPOSIA²
ZEPOSIA 7-DAY STARTER PACK²	ZEPOSIA STARTER KIT²	ZOKINVY ³
ZOLINZA^2,⁴	ZYDELIG ³	ZYKADIA^2,⁴

Drug name(s)

abiraterone acetate^2,⁴

ACTEMRA²

ACTEMRA ACTPEN²

ACTHAR²

ADEMPAS ³

ADVATE²

ADYNOVATE²

AFINITOR^2,⁴

AFINITOR DISPERZ^2,⁴

AFSTYLA²

ALECENSA^3,⁴

ALPHANINE SD²

ALPROLIX²

ALUNBRIG ³

alyq²

ambrisentan²

ARANESP ALBUMIN FREE²

ARCALYST ³

ARIKAYCE ³

AUBAGIO^2,⁴

AUSTEDO²

AVONEX²

AVONEX PEN²

AYVAKIT^3,⁴

BALVERSA^3,⁴

BENEFIX²

BENLYSTA²

BERINERT²

BETASERON²

bexarotene^2,⁴

bosentan²

BOSULIF^2,⁴

BRAFTOVI ³

BRUKINSA ³

CABOMETYX^2,⁴

CALQUENCE ³

capecitabine²

CAPRELSA ³

CARBAGLU ³

CERDELGA²

CHORIONIC GONADOTROPIN²

CIMZIA²

CIMZIA STARTER KIT²

COAGADEX ³

COMETRIQ^3,⁴

COPIKTRA^3,⁴

COSENTYX²

COSENTYX SENSOREADY PEN²

COTELLIC²

dalfampridine er^2,⁴

DAURISMO^2,⁴

deferasirox^2,⁴

dimethyl fumarate²

dimethyl fumarate starterpack²

DOPTELET ³

DUPIXENT²

ELOCTATE²

ENBREL²

ENBREL MINI²

ENBREL SURECLICK²

ENDARI ³

ENSPRYNG²

EPCLUSA²

EPIDIOLEX SOL 100MG/ML²

ERIVEDGE^2,⁴

ERLEADA²

erlotinib hcl^2,⁴

ESBRIET²

ESPEROCT²

everolimus tab 2.5mg^2,⁴

everolimus tab 5mg^2,⁴

everolimus tab 7.5mg^2,⁴

EVRYSDI ³

FARYDAK CAP 10MG²

FARYDAK CAP 15MG²

FARYDAK CAP 20MG²

FINTEPLA ³

FIRDAPSE ³

FOLLISTIM AQ²

FORTEO²

GALAFOLD²

ganirelix acetate²

GATTEX ³

GAVRETO^3,⁴

GILENYA²

GILOTRIF ³

glatiramer acetate²

HAEGARDA ³

HARVONI²

HEMLIBRA²

HEMOFIL M²

HETLIOZ^3,⁴

HETLIOZ LQ^3,⁴

HUMIRA²

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK²

HUMIRA PEN²

HUMIRA PEN-CD/UC/HS STARTER²

HUMIRA PEN-PEDIATRIC UC STARTER PACK²

HUMIRA PEN-PS/UV STARTER²

HYCAMTIN²

IBRANCE²

icatibant acetate²

ICLUSIG^3,⁴

IDELVION²

IDHIFA²

imatinib mesylate^2,⁴

IMBRUVICA ³

IMCIVREE ³

INGREZZA ³

INLYTA^2,⁴

INQOVI²

INREBIC^2,⁴

IRESSA^3,⁴

ISTURISA ³

IXINITY²

JAKAFI^2,⁴

JIVI²

JUXTAPID ³

JYNARQUE²

KALYDECO²

KESIMPTA²

KEVZARA²

KISQALI²

KISQALI FEMARA 200 DOSE²

KISQALI FEMARA 400 DOSE²

KISQALI FEMARA 600 DOSE²

KOATE²

KOATE-DVI²

KOGENATE FS²

KORLYM ³

KOSELUGO ³

KOVALTRY²

lapatinib ditosylate²

LEDIPASVIR/SOFOSBUVIR²

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

LONSURF²

LORBRENA^2,⁴

LYNPARZA^3,⁴

MATULANE²

MAVYRET²

MAYZENT²

MEKINIST²

MEKTOVI ³

MENOPUR²

miglustat²

MIRCERA²

MONONINE²

MULPLETA²

NATPARA²

NERLYNX^3,⁴

NEXAVAR^2,⁴

NINLARO²

NORDITROPIN FLEXPRO²

NOVAREL²

NOVOEIGHT²

NUBEQA²

NUWIQ²

OCALIVA²

ODOMZO^2,⁴

OFEV^2,⁴

ONUREG²

OPSUMIT ³

ORENCIA²

ORENCIA CLICKJECT²

ORENITRAM ³

ORGOVYX ³

ORKAMBI²

OTEZLA²

OXBRYTA ³

OXERVATE ³

PALYNZIQ ³

PEGINTRON²

PEMAZYRE ³

PIQRAY 200MG DAILY DOSE²

PIQRAY 250MG DAILY DOSE²

PIQRAY 300MG DAILY DOSE²

PLEGRIDY²

PLEGRIDY STARTER PACK²

POMALYST²

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL²

PROCYSBI ³

PROFILNINE²

PROFILNINE SD²

PROMACTA²

QINLOCK ³

RAVICTI²

REBIF²

REBIF REBIDOSE²

REBIF REBIDOSE TITRATION PACK²

REBIF TITRATION PACK²

REBINYN²

RECOMBINATE²

RETACRIT²

RETEVMO^2,⁴

REVLIMID²

RINVOQ²

RIXUBIS²

ROZLYTREK^2,⁴

RUBRACA^3,⁴

RUCONEST²

RUZURGI ³

RYDAPT²

sajazir²

sapropterin dihydrochloride²

sildenafil sus 10mg/ml²

sildenafil tab 20mg²

SIMPONI²

SKYRIZI²

SKYRIZI PEN²

sodium phenylbutyrate²

SOFOSBUVIR/VELPATASVIR²

SOVALDI²

SPRYCEL^2,⁴

STELARA²

STIVARGA²

STRENSIQ ³

sunitinib malate^2,⁴

SUTENT^2,⁴

SYMDEKO²

TABRECTA²

tadalafil²

TAFINLAR²

TAGRISSO^3,⁴

TAKHZYRO ³

TALZENNA^2,⁴

TASIGNA^2,⁴

TAVALISSE ³

TAZVERIK ³

TEGSEDI ³

temozolomide²

tetrabenazine tab 12.5mg²

tetrabenazine tab 25mg²

THALOMID²

TIBSOVO ³

tolvaptan²

TRACLEER²

TREMFYA²

TRIKAFTA²

TUKYSA ³

TURALIO ³

TYMLOS²

TYVASO ³

TYVASO REFILL ³

TYVASO STARTER ³

UPTRAVI ³

VENCLEXTA ³

VENCLEXTA STARTING PACK ³

VENTAVIS^3,⁴

VERZENIO^3,⁴

VITRAKVI^3,⁴

VIZIMPRO^2,⁴

VOSEVI²

VOTRIENT^2,⁴

VYNDAMAX²

VYNDAQEL²

XALKORI^2,⁴

XELJANZ²

XELJANZ XR²

XERMELO ³

XOLAIR²

XOSPATA ³

XPOVIO^3,⁴

XPOVIO 100 MG ONCE WEEKLY^3,⁴

XPOVIO 60 MG ONCE WEEKLY^3,⁴

XPOVIO 80 MG ONCE WEEKLY^3,⁴

XPOVIO 80 MG TWICE WEEKLY^3,⁴

XTANDI^2,⁴

XYNTHA²

XYNTHA SOLOFUSE²

XYREM ³

XYWAV ³

YONSA^2,⁴

ZEJULA^3,⁴

ZELBORAF²

ZEPOSIA²

ZEPOSIA 7-DAY STARTER PACK²

ZEPOSIA STARTER KIT²

ZOKINVY ³

ZOLINZA^2,⁴

ZYDELIG ³

ZYKADIA^2,⁴

¹Multiple products available in both GP and GNP tiers

²Specialty

³Limited Distribution

⁴Indicates exclusive to Accredo Health Group Inc. preferred specialty.

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Exclusive 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 - opioid

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)

Anticonvulsants

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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

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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)

Antiparkinson and related therapy agents

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Quantity limits (per 30 days or as specified)

Drug name(s)

Quantity limits (per 30 days or as specified)

Antivirals

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Quantity limits (per 30 days or as specified)

Cardiovascular agents

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Quantity limits (per 30 days or as specified)

Corticosteroids

Drug name(s)

Quantity limits (per 30 days or as specified)

Dermatologicals

Drug name(s)

Quantity limits (per 30 days or as specified)

Digestive aids

Drug name(s)

Quantity limits (per 30 days or as specified)

Diuretics

Drug name(s)

Quantity limits (per 30 days or as specified)

Endocrine and metabolic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Estrogens

Drug name(s)

Quantity limits (per 30 days or as specified)