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 acetate2,4

ACTEMRA2

ACTEMRA ACTPEN2

ACTHAR2

ADEMPAS3

ADVATE2

ADYNOVATE2

AFINITOR2,4

AFINITOR DISPERZ2,4

AFSTYLA2

ALECENSA3,4

ALPHANINE SD2

ALPROLIX2

ALUNBRIG3

alyq2

ambrisentan2

ARANESP ALBUMIN FREE2

ARCALYST3

ARIKAYCE3

AUBAGIO2,4

AUSTEDO2

avita

AVONEX2

AVONEX PEN2

AYVAKIT3,4

BALVERSA3,4

BELBUCA

BENEFIX2

BENLYSTA2

BERINERT2

BETASERON2

bexarotene2,4

bosentan2

BOSULIF2,4

BRAFTOVI3

BRUKINSA3

CABOMETYX2,4

CALQUENCE3

capecitabine2

CAPRELSA3

CARBAGLU3

CERDELGA2

CHORIONIC GONADOTROPIN2

ciclodan

ciclopirox nail lacquer

CIMZIA2

CIMZIA STARTER KIT2

CLOZAPINE ODT

COAGADEX3

COMETRIQ3,4

CONTRAVE

COPIKTRA3,4

CORLANOR

COSENTYX2

COSENTYX SENSOREADY PEN2

COTELLIC2

CRESEMBA

dalfampridine er2,4

DAURISMO2,4

deferasirox2,4

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

ERIVEDGE2,4

ERLEADA2

erlotinib hcl2,4

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

GAVRETO3,4

GILENYA2

GILOTRIF3

glatiramer acetate2

HAEGARDA3

HARVONI2

HEMLIBRA2

HEMOFIL M2

HETLIOZ3,4

HETLIOZ LQ3,4

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

ICLUSIG3,4

icosapent ethyl

IDELVION2

IDHIFA2

imatinib mesylate2,4

IMBRUVICA3

IMCIVREE3

INGREZZA3

INLYTA2,4

INQOVI2

INREBIC2,4

IRESSA3,4

ISTURISA3

IXINITY2

JAKAFI2,4

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 DOSE3,4

LENVIMA 12MG DAILY DOSE3,4

LENVIMA 14 MG DAILY DOSE3,4

LENVIMA 18 MG DAILY DOSE3,4

LENVIMA 20 MG DAILY DOSE3,4

LENVIMA 24 MG DAILY DOSE3,4

LENVIMA 4 MG DAILY DOSE3,4

LENVIMA 8 MG DAILY DOSE3,4

lidocaine

lidocaine hcl

lidocaine hcl

lidocaine patch 5%

lidocaine/prilocaine

LOMAIRA

LONSURF2

LORBRENA2,4

LUCEMYRA

LUMAKRAS

LUPKYNIS

LYNPARZA3,4

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

NERLYNX3,4

NEXAVAR2,4

NEXLETOL

NEXLIZET

NINLARO2

NOCTIVA

NORDITROPIN FLEXPRO2

NOVAREL2

NOVOEIGHT2

NOXAFIL

NUBEQA2

NUCALA

NUEDEXTA

NUWIQ2

OCALIVA2

ODOMZO2,4

OFEV2,4

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

RETEVMO2,4

REVLIMID2

REYVOW

RINVOQ2

RISPERIDONE ODT

RIXUBIS2

ROZLYTREK2,4

RUBRACA3,4

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

SPRYCEL2,4

STELARA2

STIVARGA2

STRENSIQ3

SUCRAID

sunitinib malate2,4

SUNOSI

SUTENT2,4

SYMDEKO2

TABRECTA2

tadalafil2

TAFINLAR2

TAGRISSO3,4

TAKHZYRO3

TALZENNA2,4

TASIGNA2,4

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

VENTAVIS3,4

VERQUVO

VERSACLOZ

VERZENIO3,4

VIIBRYD

VIIBRYD STARTER PACK

VITRAKVI3,4

VIZIMPRO2,4

voriconazole

VOSEVI2

VOTRIENT2,4

VRAYLAR

VYLEESI

VYNDAMAX2

VYNDAQEL2

WEGOVY

XALKORI2,4

XELJANZ2

XELJANZ XR2

XENICAL

XERMELO3

XHANCE

XOLAIR2

XOSPATA3

XPOVIO3,4

XPOVIO 100 MG ONCE WEEKLY3,4

XPOVIO 40 MG ONCE WEEKLY4

XPOVIO 40 MG TWICE WEEKLY4

XPOVIO 60 MG ONCE WEEKLY3,4

XPOVIO 60 MG TWICE WEEKLY4

XPOVIO 80 MG ONCE WEEKLY3,4

XPOVIO 80 MG TWICE WEEKLY3,4

XTAMPZA ER

XTANDI2,4

XYNTHA2

XYNTHA SOLOFUSE2

XYREM3

XYWAV3

YONSA2,4

ZEJULA3,4

ZELBORAF2

ZEPOSIA2

ZEPOSIA 7-DAY STARTER PACK2

ZEPOSIA STARTER KIT2

ZOKINVY3

ZOLINZA2,4

ZYDELIG3

ZYKADIA2,4

   

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 90mg2,4

30 packets / 30 days

deferasirox gra 180mg2,4

30 packets / 30 days

deferasirox gra 360mg2,4

180 packets / 30 days

deferasirox tab 90mg2,4

30 tabs / 30 days

deferasirox tab 125mg2,4

30 tabs / 30 days

deferasirox tab 180mg2,4

30 tabs / 30 days

deferasirox tab 250mg2,4

30 tabs / 30 days

deferasirox tab 360mg2,4

180 tabs / 30 days

deferasirox tab 500mg2,4

90 tabs / 30 days

EXJADE TAB 125MG2,4

30 tabs / 30 days

EXJADE TAB 250MG2,4

30 tabs / 30 days

EXJADE TAB 500MG2,4

90 tabs / 30 days

JADENU TAB 180MG2,4

30 tabs / 30 days

JADENU TAB 360MG2,4

180 tabs / 30 days

JADENU TAB 90MG2,4

30 tabs / 30 days

JADENU SPRKL GRA 90MG2,4

30 packets / 30 days

JADENU SPRKL GRA 180MG2,4

30 packets / 30 days

JADENU SPRKL GRA 360MG2,4

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 250mg2,4

120 tabs / 30 days

abiraterone tab 500mg2,4

60 tabs / 30 days

AFINITOR TAB 10MG2,4

30 tabs / 30 days

AFINITOR TAB 2.5MG2,4

30 tabs / 30 days

AFINITOR TAB 5MG2,4

30 tabs / 30 days

AFINITOR TAB 7.5MG2,4

30 tabs / 30 days

AFINITOR DIS TAB 2MG2,4

60 tabs / 30 days

AFINITOR DIS TAB 3MG2,4

90 tabs / 30 days

AFINITOR DIS TAB 5MG2,4

60 tabs / 30 days

ALECENSA CAP 150MG3,4

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 25MG3,4

30 tabs / 30 days

AYVAKIT TAB 50MG3,4

30 tabs / 30 days

AYVAKIT TAB 100MG3,4

30 tabs / 30 days

AYVAKIT TAB 200MG3,4

30 tabs / 30 days

AYVAKIT TAB 300MG3,4

30 tabs / 30 days

BALVERSA TAB 3MG3,4

90 tabs / 30 days

BALVERSA TAB 4MG3,4

60 tabs / 30 days

BALVERSA TAB 5MG3,4

30 tabs / 30 days

BOSULIF TAB 100MG2,4

90 tabs / 30 days

BOSULIF TAB 400MG2,4

30 tabs / 30 days

BOSULIF TAB 500MG2,4

30 tabs / 30 days

BRAFTOVI CAP 75MG3

180 caps / 30 days

BRUKINSA CAP 80MG3

120 caps / 30 days

CABOMETYX TAB 20MG2,4

30 tabs / 30 days

CABOMETYX TAB 40MG2,4

30 tabs / 30 days

CABOMETYX TAB 60MG2,4

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 100MG3,4

1 carton / 28 days

COMETRIQ KIT 140MG3,4

112 tabs / 28 days

COMETRIQ KIT 60MG3,4

1 carton / 28 days

COPIKTRA CAP 15MG3,4

56 caps / 28 days

COPIKTRA CAP 25MG3,4

56 caps / 28 days

COTELLIC TAB 20MG2

63 tabs / 28 days

DAURISMO TAB 25MG2,4

60 tabs / 30 days

DAURISMO TAB 100MG2,4

30 tabs / 30 days

ERIVEDGE CAP 150MG2,4

30 caps / 30 days

erlotinib tab 25mg2,4

60 tabs / 30 days

erlotinib tab 100mg2,4

30 tabs / 30 days

erlotinib tab 150mg2,4

30 tabs / 30 days

everolimus tab 2.5mg1,2,4

30 tabs / 30 days

everolimus tab 2.5mg1, ~

30 tabs / 30 days

everolimus tab 2mg1,~

60 tabs / 30 days

everolimus tab 3mg1, ~

90 tabs / 30 days

everolimus tab 5mg1,2,4

30 tabs / 30 days

everolimus tab 5mg1, ~

60 tabs / 30 days

everolimus tab 5mg1, ~

30 tabs / 30 days

everolimus tab 7.5mg1,2,4

30 tabs / 30 days

everolimus tab 7.5mg1, ~

30 tabs / 30 days

everolimus tab 10mg1, ~

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 100MG3,4

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 100MG2,4

90 tabs / 30 days

GLEEVEC TAB 400MG2,4

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 10MG3,4

30 tabs / 30 days

ICLUSIG TAB 15MG3,4

30 tabs / 30 days

ICLUSIG TAB 30MG3,4

30 tabs / 30 days

ICLUSIG TAB 45MG3,4

30 tabs / 30 days

IDHIFA TAB 100MG2

30 tabs / 30 days

IDHIFA TAB 50MG2

30 tabs / 30 days

imatinib mes tab 100mg2,4

90 tabs / 30 days

imatinib mes tab 400mg2,4

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 1MG2,4

180 tabs / 30 days

INLYTA TAB 5MG2,4

120 tabs / 30 days

INQOVI TAB 35-100MG2

5 tabs / 28 days

INREBIC CAP 100MG2,4

120 caps / 30 days

IRESSA TAB 250MG3,4

30 tabs / 30 days

JAKAFI TAB 10MG2,4

60 tabs / 30 days

JAKAFI TAB 15MG2,4

60 tabs / 30 days

JAKAFI TAB 20MG2,4

60 tabs / 30 days

JAKAFI TAB 25MG2,4

60 tabs / 30 days

JAKAFI TAB 5MG2,4

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 MG3,4

30 caps / 30 days

LENVIMA CAP 12MG3,4

90 caps / 30 days

LENVIMA CAP 14 MG3,4

60 caps / 30 days

LENVIMA CAP 18 MG3,4

90 caps / 30 days

LENVIMA CAP 20 MG3,4

60 caps / 30 days

LENVIMA CAP 24 MG3,4

90 caps / 30 days

LENVIMA CAP 4MG3,4

30 caps / 30 days

LENVIMA CAP 8 MG3,4

60 caps / 30 days

LONSURF TAB 15-6.142

60 tabs / 28 days

LONSURF TAB 20-8.192

80 tabs / 28 days

LORBRENA TAB 100MG2,4

30 tabs / 30 days

LORBRENA TAB 25MG2,4

90 tabs / 30 days

LUMAKRAS TAB 120MG

240 tabs / 30 days

LYNPARZA TAB 100MG3,4

120 tabs / 30 days

LYNPARZA TAB 150MG3,4

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 40MG3,4

180 tabs / 30 days

NEXAVAR TAB 200MG2,4

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 200MG2,4

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 40MG2,4

180 caps / 30 days

RETEVMO CAP 80MG2,4

120 caps / 30 days

ROZLYTREK CAP 100MG2,4

30 caps / 30 days

ROZLYTREK CAP 200MG2,4

90 caps / 30 days

RUBRACA TAB 200MG3,4

120 tabs / 30 days

RUBRACA TAB 250MG3,4

120 tabs / 30 days

RUBRACA TAB 300MG3,4

120 tabs / 30 days

RYDAPT CAP 25MG2

240 caps / 30 days

SPRYCEL TAB 100MG2,4

30 tabs / 30 days

SPRYCEL TAB 140MG2,4

30 tabs / 30 days

SPRYCEL TAB 20MG2,4

90 tabs / 30 days

SPRYCEL TAB 50MG2,4

30 tabs / 30 days

SPRYCEL TAB 70MG2,4

30 tabs / 30 days

SPRYCEL TAB 80MG2,4

30 tabs / 30 days

STIVARGA TAB 40MG2

84 tabs / 28 days

sunitinib cap 12.5mg2,4

90 caps / 30 days

sunitinib cap 25mg2,4

30 caps / 30 days

sunitinib cap 37.5mg2,4

30 caps / 30 days

sunitinib cap 50mg2,4

30 caps / 30 days

SUTENT CAP 12.5MG2,4

90 caps / 30 days

SUTENT CAP 25MG2,4

30 caps / 30 days

SUTENT CAP 37.5MG2,4

30 caps / 30 days

SUTENT CAP 50MG2,4

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 40MG3,4

30 tabs / 30 days

TAGRISSO TAB 80MG3,4

30 tabs / 30 days

TALZENNA CAP 0.25MG2,4

90 caps / 30 days

TALZENNA CAP 1MG2,4

30 caps / 30 days

TARCEVA TAB 100MG2,4

30 tabs / 30 days

TARCEVA TAB 150MG2,4

30 tabs / 30 days

TARCEVA TAB 25MG2,4

60 tabs / 30 days

TASIGNA CAP 150MG2,4

120 caps / 30 days

TASIGNA CAP 200MG2,4

120 caps / 30 days

TASIGNA CAP 50MG2,4

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 100MG3,4

60 tabs / 30 days

VERZENIO TAB 150MG3,4

60 tabs / 30 days

VERZENIO TAB 200MG3,4

60 tabs / 30 days

VERZENIO TAB 50MG3,4

60 tabs / 30 days

VITRAKVI CAP 100MG3,4

60 caps / 30 days

VITRAKVI CAP 25MG3,4

180 caps / 30 days

VITRAKVI SOL 20MG/ML3,4

300 mLs / 30 days

VIZIMPRO TAB 15MG2,4

30 tabs / 30 days

VIZIMPRO TAB 30MG2,4

30 tabs / 30 days

VIZIMPRO TAB 45MG2,4

30 tabs / 30 days

VOTRIENT TAB 200MG2,4

120 tabs / 30 days

XALKORI CAP 200MG2,4

120 caps / 30 days

XALKORI CAP 250MG2,4

120 caps / 30 days

XOSPATA TAB 40MG3

90 tabs / 30 days

XPOVIO PAK 100MG3,4

1 box / 28 days

XPOVIO PAK 40MG ~

1 box / 28 days

XPOVIO PAK 60MG3,4

1 box / 28 days

XPOVIO PAK 60MG ~

1 box / 28 days

XPOVIO PAK 80MG3,4

1 box / 28 days

XPOVIO 100 MG ONCE WEEKLY3,4

1 box / 28 days

XPOVIO 40 MG ONCE WEEKLY3,4

1 box / 28 days

XPOVIO 40 MG TWICE WEEKLY3,4

1 box / 28 days

XPOVIO 60 MG ONCE WEEKLY3,4

1 box / 28 days

XPOVIO 80 MG ONCE WEEKLY3,4

1 box / 28 days

XTANDI CAP 40MG2,4

120 caps / 30 days

XTANDI TAB 40MG2,4

120 tabs / 30 days

XTANDI TAB 80MG2,4

60 tabs / 30 days

ZEJULA CAP 100MG3,4

90 caps / 30 days

ZELBORAF TAB 240MG2

240 tabs / 30 days

ZOLINZA CAP 100MG2,4

120 caps / 30 days

ZYDELIG TAB 100MG3

60 tabs / 30 days

ZYDELIG TAB 150MG3

60 tabs / 30 days

ZYKADIA TAB 150MG2,4

90 tabs / 30 days

ZYTIGA TAB 250MG2,4

120 tabs / 30 days

ZYTIGA TAB 500MG2,4

60 tabs / 30 days

Antiparkinson and related therapy agents

Drug name(s)

Quantity limits (per 30 days or as specified)

GOCOVRI CAP 68.5MG2,4

30 caps / 30 days

GOCOVRI CAP 137MG2,4

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/ml1,2

2 bottles / 30 days

sildenafil tab 20mg1,2

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/ML3,4

270 ampuls / 30 days

VENTAVIS SOL 20MCG/ML3,4

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 20MG3,4

30 caps / 30 days

HETLIOZ LQ SUS 4MG/ML3,4

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 10MG2,4

60 tabs / 30 days

AUBAGIO TAB 14MG2,4

30 tabs / 30 days

AUBAGIO TAB 7MG2,4

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 er2,4

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 100MG2,4

60 caps / 30 days

OFEV CAP 150MG2,4

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 100mg1,2

450 caps / 30 days

droxidopa cap 200mg1

180 caps / 30 days

droxidopa cap 200mg1,2

180 caps / 30 days

droxidopa cap 300mg1

180 caps / 30 days

droxidopa cap 300mg1,2

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 acetate2,4

ACTEMRA2

ACTEMRA ACTPEN2

ACTHAR2

ADEMPAS 3

ADVATE2

ADYNOVATE2

AFINITOR2,4

AFINITOR DISPERZ2,4

AFSTYLA2

ALECENSA3,4

ALPHANINE SD2

ALPROLIX2

ALUNBRIG 3

alyq2

ambrisentan2

ARANESP ALBUMIN FREE2

ARCALYST 3

ARIKAYCE 3

AUBAGIO2,4

AUSTEDO2

AVONEX2

AVONEX PEN2

AYVAKIT3,4

BALVERSA3,4

BENEFIX2

BENLYSTA2

BERINERT2

BETASERON2

bexarotene2,4

bosentan2

BOSULIF2,4

BRAFTOVI 3

BRUKINSA 3

CABOMETYX2,4

CALQUENCE 3

capecitabine2

CAPRELSA 3

CARBAGLU 3

CERDELGA2

CHORIONIC GONADOTROPIN2

CIMZIA2

CIMZIA STARTER KIT2

COAGADEX 3

COMETRIQ3,4

COPIKTRA3,4

COSENTYX2

COSENTYX SENSOREADY PEN2

COTELLIC2

dalfampridine er2,4

DAURISMO2,4

deferasirox2,4

dimethyl fumarate2

dimethyl fumarate starterpack2

DOPTELET 3

DUPIXENT2

ELOCTATE2

ENBREL2

ENBREL MINI2

ENBREL SURECLICK2

ENDARI 3

ENSPRYNG2

EPCLUSA2

EPIDIOLEX SOL 100MG/ML2

ERIVEDGE2,4

ERLEADA2

erlotinib hcl2,4

ESBRIET2

ESPEROCT2

everolimus tab 2.5mg2,4

everolimus tab 5mg2,4

everolimus tab 7.5mg2,4

EVRYSDI 3

FARYDAK CAP 10MG2

FARYDAK CAP 15MG2

FARYDAK CAP 20MG2

FINTEPLA 3

FIRDAPSE 3

FOLLISTIM AQ2

FORTEO2

GALAFOLD2

ganirelix acetate2

GATTEX 3

GAVRETO3,4

GILENYA2

GILOTRIF 3

glatiramer acetate2

HAEGARDA 3

HARVONI2

HEMLIBRA2

HEMOFIL M2

HETLIOZ3,4

HETLIOZ LQ3,4

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

ICLUSIG3,4

IDELVION2

IDHIFA2

imatinib mesylate2,4

IMBRUVICA 3

IMCIVREE 3

INGREZZA 3

INLYTA2,4

INQOVI2

INREBIC2,4

IRESSA3,4

ISTURISA 3

IXINITY2

JAKAFI2,4

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 DOSE3,4

LENVIMA 12MG DAILY DOSE3,4

LENVIMA 14 MG DAILY DOSE3,4

LENVIMA 18 MG DAILY DOSE3,4

LENVIMA 20 MG DAILY DOSE3,4

LENVIMA 24 MG DAILY DOSE3,4

LENVIMA 4 MG DAILY DOSE3,4

LENVIMA 8 MG DAILY DOSE3,4

LONSURF2

LORBRENA2,4

LYNPARZA3,4

MATULANE2

MAVYRET2

MAYZENT2

MEKINIST2

MEKTOVI 3

MENOPUR2

miglustat2

MIRCERA2

MONONINE2

MULPLETA2

NATPARA2

NERLYNX3,4

NEXAVAR2,4

NINLARO2

NORDITROPIN FLEXPRO2

NOVAREL2

NOVOEIGHT2

NUBEQA2

NUWIQ2

OCALIVA2

ODOMZO2,4

OFEV2,4

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

RETEVMO2,4

REVLIMID2

RINVOQ2

RIXUBIS2

ROZLYTREK2,4

RUBRACA3,4

RUCONEST2

RUZURGI 3

RYDAPT2

sajazir2

sapropterin dihydrochloride2

sildenafil sus 10mg/ml2

sildenafil tab 20mg2

SIMPONI2

SKYRIZI2

SKYRIZI PEN2

sodium phenylbutyrate2

SOFOSBUVIR/VELPATASVIR2

SOVALDI2

SPRYCEL2,4

STELARA2

STIVARGA2

STRENSIQ 3

sunitinib malate2,4

SUTENT2,4

SYMDEKO2

TABRECTA2

tadalafil2

TAFINLAR2

TAGRISSO3,4

TAKHZYRO 3

TALZENNA2,4

TASIGNA2,4

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

VENTAVIS3,4

VERZENIO3,4

VITRAKVI3,4

VIZIMPRO2,4

VOSEVI2

VOTRIENT2,4

VYNDAMAX2

VYNDAQEL2

XALKORI2,4

XELJANZ2

XELJANZ XR2

XERMELO 3

XOLAIR2

XOSPATA 3

XPOVIO3,4

XPOVIO 100 MG ONCE WEEKLY3,4

XPOVIO 60 MG ONCE WEEKLY3,4

XPOVIO 80 MG ONCE WEEKLY3,4

XPOVIO 80 MG TWICE WEEKLY3,4

XTANDI2,4

XYNTHA2

XYNTHA SOLOFUSE2

XYREM 3

XYWAV 3

YONSA2,4

ZEJULA3,4

ZELBORAF2

ZEPOSIA2

ZEPOSIA 7-DAY STARTER PACK2

ZEPOSIA STARTER KIT2

ZOKINVY 3

ZOLINZA2,4

ZYDELIG 3

ZYKADIA2,4

1Multiple products available in both GP and GNP tiers

2Specialty

3Limited Distribution

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