Exclusive prescription drug benefits

Effective July 1, 2021

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 acetate1, 3

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADEMPAS 4

ADVATE1

ADYNOVATE1

AFINITOR1, 3

AFINITOR DISPERZ1, 3

AFSTYLA1

AIMOVIG1

ALECENSA3, 4

ALPHANINE SD1

ALPROLIX1

ALUNBRIG4

alyq1

ambrisentan1

ARANESP ALBUMIN FREE1

ARCALYST4

ARIKAYCE4

AUBAGIO1, 3

AUSTEDO1

avita

AVONEX1

AVONEX PEN1

AYVAKIT3, 4

BALVERSA3, 4

BELBUCA

BENEFIX1

BENLYSTA1

BERINERT1

BETASERON1

bexarotene1, 3

bosentan1

BOSULIF1, 3

BRAFTOVI4

BRUKINSA4

CABOMETYX1, 3

CALQUENCE4

capecitabine1

CAPRELSA4

CARBAGLU4

CERDELGA1

CHORIONIC GONADOTROPIN1

ciclodan

ciclopirox nail lacquer

CIMZIA1

CIMZIA STARTER KIT1

CLOZAPINE ODT

COAGADEX4

COMETRIQ3, 4

CONTRAVE

COPIKTRA3, 4

CORLANOR

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

CRESEMBA

dalfampridine er1, 3

DAURISMO1, 3

diclofenac sodium

dimethyl fumarate dr1

dimethyl fumarate starterpack1

DOPTELET4

DUPIXENT1

ELMIRON

ELOCTATE1

EMGALITY1

EMSAM

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

ENDARI4

ENDOMETRIN

ENSPRYNG1

EPCLUSA1

EPIDIOLEX1

EPOGEN1

ERIVEDGE1, 3

ERLEADA1

erlotinib1, 3

ESBRIET1

ESPEROCT1

everolimus1, 3

EVRYSDI4

FANAPT

FANAPT TITRATION PACK

FARYDAK1

FASENRA PEN

FAZACLO

fenofibrate

fenofibric acid dr

fentanyl

fentanyl citrate oral transmucosal

FETZIMA

FETZIMA TITRATION PACK

FIBRYGA

FINTEPLA4

FIRDAPSE4

fluorouracil

FLUOXETINE DR

FOLLISTIM AQ1

GALAFOLD1

ganirelix acetate1

GATTEX4

GAVRETO3, 4

GILENYA1

GILOTRIF4

glatiramer acetate1

HAEGARDA4

HARVONI1

HELIXATE FS1

HEMLIBRA1

HEMOFIL M1

HETLIOZ3, 4

HUMIRA1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1

HUMIRA PEN1

HUMIRA PEN-CD/UC/HS STARTER1

HUMIRA PEN-PEDIATRIC UC STARTER PACK1

HUMIRA PEN-PS/UV STARTER1

HYCAMTIN1

IBRANCE1

icatibant acetate1

ICLUSIG3, 4

icosapent ethyl

IDELVION1

IDHIFA1

imatinib mesylate1, 3

IMBRUVICA4

IMCIVREE4

INGREZZA4

INLYTA1, 3

INQOVI1

INREBIC1, 3

IRESSA3, 4

ISTURISA4

IXINITY1

JAKAFI1, 3

JIVI1

JUXTAPID4

JYNARQUE1

KALYDECO1

KESIMPTA1

KEVZARA1

KISQALI1

KOATE1

KOATE-DVI1

KOGENATE FS1

KORLYM4

KOSELUGO4

KOVALTRY1

lapatinib ditosylate1

LATUDA

LEDIPASVIR / SOFOSBUVIR1

LENVIMA3, 4

lidocaine

lidocaine hcl

lidocaine patch 5%

lidocaine/prilocaine

LOMAIRA

LONSURF1

LORBRENA1, 3

LUCEMYRA

LYNPARZA3, 4

LYSODREN

MATULANE1

MAVENCLAD1

MAVYRET1

MAYZENT1

MAYZENT STARTER PACK

MEKINIST1

MEKTOVI4

MENOPUR1

methadone hcl

METHITEST

METHYLTESTOSTERONE

miglustat1

MIRCERA1

MONONINE1

morphine sulfate cr

morphine sulfate er

MULPLETA1

MYALEPT4

NATPARA1

NERLYNX3, 4

NEXAVAR1, 3

NEXLETOL

NEXLIZET

NINLARO1

NOCTIVA

NORDITROPIN FLEXPRO1

NOVAREL1

NOVOEIGHT1

NOXAFIL

NUBEQA1

NUCALA

NUEDEXTA

NURTEC

NUWIQ1

OCALIVA1

ODOMZO1, 3

OFEV1, 3

ONUREG1

OPSUMIT4

ORENITRAM4

ORGOVYX4

ORIAHNN

ORILISSA

ORKAMBI1

OTEZLA1

OXBRYTA4

OXERVATE4

OXYCONTIN

OXYMORPHONE HCL ER

PALYNZIQ4

PEGINTRON1

PEMAZYRE4

phentermine hcl

PIQRAY1

PLEGRIDY1

PLEGRIDY STARTER PACK1

POMALYST1

posaconazole

posaconazole dr

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1

PRENATAL VITAMINS PLUS LOW IRON

PROCRIT1

PROCYSBI4

PROFILNINE1

PROFILNINE SD1

PROMACTA1

QINLOCK4

QSYMIA

QUDEXY XR

RAVICTI1

REBIF1

REBIF REBIDOSE1

REBIF REBIDOSE TITRATION PACK1

REBIF TITRATION PACK1

REBINYN1

RECOMBINATE1

REPATHA

REPATHA PUSHTRONEX SYSTEM

REPATHA SURECLICK

RETACRIT1

RETEVMO1, 3

REVLIMID1

REXULTI

REYVOW

RIASTAP

RINVOQ1

RISPERIDONE ODT

RIXUBIS1

ROZLYTREK1, 3

RUBRACA3, 4

RUCONEST1

RUZURGI4

RYDAPT1

SAPHRIS

sapropterin dihydrochloride1

SAXENDA

SECUADO

sildenafil citrate1

SIMPONI1

SKYRIZI INJ 150MG/ML

SKYRIZI1

SKYRIZI PEN

sodium phenylbutyrate1

SOFOSBUVIR / VELPATASVIR1

SOVALDI1

SPRYCEL1, 3

STELARA1

STIVARGA1

STRENSIQ4

SUCRAID

SUNOSI

SUTENT1, 3

SYLATRON1

SYMDEKO1

SYMPROIC

TABRECTA1

tadalafil1

TAFINLAR1

TAGRISSO3, 4

TAKHZYRO4

TALZENNA1, 3

TASIGNA1, 3

TAVALISSE4

tazarotene

TAZVERIK4

TEGSEDI4

temozolomide1

TESTOST ENAN INJ 200MG/ML

testosterone

testosterone cypionate

testosterone pump

testosterone topical solution

tetrabenazine1

THALOMID1

TIBSOVO4

tolvaptan

topiramate er

TRACLEER1

tramadol hcl er

trazodone hcle

TREMFYA1

tretinoin

TRIKAFTA1

TRINTELLIX

TROKENDI XR

TRULANCE

TUKYSA4

TURALIO4

TYMLOS1

TYVASO4

TYVASO REFILL4

TYVASO STARTER4

UBRELVY

UPTRAVI4

VASCEPA

VENCLEXTA4

VENCLEXTA STARTING PACK4

VENTAVIS3, 4

VERSACLOZ

VERZENIO3, 4

VIIBRYD

VIIBRYD STARTER PACK

VITRAKVI3, 4

VIZIMPRO1, 3

voriconazole

VOSEVI1

VOTRIENT1, 3

VRAYLAR

VYLEESI

VYNDAMAX1

VYNDAQEL1

XALKORI1, 3

XELJANZ1

XELJANZ XR1

XENICAL

XERMELO4

XHANCE

XOSPATA4

XPOVIO3, 4

XTAMPZA ER

XTANDI1, 3

XYNTHA1

XYNTHA SOLOFUSE1

XYREM4

XYWAV4

YONSA1, 3

ZEJULA3, 4

ZELBORAF1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOKINVY4

ZOLINZA1, 3

ZYDELIG4

ZYKADIA1, 3

ZYTIGA1, 3

 

Drug name(s)

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

FLURBIPROFEN

OTREXUP1

OZEMPIC

REDITREX

RYBELSUS

SOLIQUA 100/33

SUMATRIPTAN SUCCINATE

tacrolimus

TOLMETIN SODIUM

TRULICITY

VICTOZA

XULTOPHY 100/3.6

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADDERALL XR CAP 10MG

30 caps / 30 days

ADDERALL XR CAP 15MG

30 caps / 30 days

ADDERALL XR CAP 20MG

30 caps / 30 days

ADDERALL XR CAP 25MG

30 caps / 30 days

ADDERALL XR CAP 30MG

30 caps / 30 days

ADDERALL XR CAP 5MG

30 caps / 30 days

amphet/dextr tab 10mg

60 tabs / 30 days

amphet/dextr tab 12.5mg

60 tabs / 30 days

amphet/dextr tab 15mg

60 tabs / 30 days

amphet/dextr tab 20mg

90 tabs / 30 days

amphet/dextr tab 30mg

60 tabs / 30 days

amphet/dextr tab 5mg

60 tabs / 30 days

amphet/dextr tab 7.5mg

60 tabs / 30 days

Amphetamine tab 5mg

60 tabs / 30 days

Amphetamine tab 7.5mg

60 tabs / 30 days

atomoxetine cap 100mg

30 caps / 30 days

atomoxetine cap 10mg

60 caps / 30 days

atomoxetine cap 18mg

60 caps / 30 days

atomoxetine cap 25mg

60 caps / 30 days

atomoxetine cap 40mg

60 caps / 30 days

atomoxetine cap 60mg

30 caps / 30 days

atomoxetine cap 80mg

30 caps / 30 days

clonidine tab 0.1mg er

120 tabs / 30 days

CONTRAVE TAB 8-90MG

120 tabs / 30 days

dexmethylph cap 15mg er

30 caps / 30 days

dexmethylph cap 30mg er

30 caps / 30 days

dexmethylph cap 40mg er

30 caps / 30 days

dexmethylph tab 10mg

60 tabs / 30 days

dexmethylph tab 2.5mg

60 tabs / 30 days

dexmethylph tab 5mg

60 tabs / 30 days

dexmethylphe cap 10mg er

30 caps / 30 days

dexmethylphe cap 20mg er

30 caps / 30 days

dexmethylphe cap 5mg er

30 caps / 30 days

dexmethylphe cap er 25mg

30 caps / 30 days

dexmethylphe cap er 35mg

30 caps / 30 days

dextroamphet cap 10mg er

120 caps / 30 days

dextroamphet cap 15mg er

120 caps / 30 days

dextroamphet cap 5mg er

90 caps / 30 days

dextroamphet sol 5mg/5ml

1800 mLs/ 30 days

dextroamphet tab 10mg

180 tabs / 30 days

dextroamphet tab 5mg

90 tabs / 30 days

guanfacine tab 1mg er

30 tabs / 30 days

guanfacine tab 2mg er

30 tabs / 30 days

guanfacine tab 3mg er

30 tabs / 30 days

guanfacine tab 4mg er

30 tabs / 30 days

IMCIVREE injection 10MG/ML4

10 vials / 30 days

JORNAY PM CAP 100MG ER

30 caps / 30 days

JORNAY PM CAP 20MG ER

30 caps / 30 days

JORNAY PM CAP 40MG ER

30 caps / 30 days

JORNAY PM CAP 60MG ER

30 caps / 30 days

JORNAY PM CAP 80MG ER

30 caps / 30 days

LOMAIRA TAB 8MG

90 tabs / 30 days

methamphetam tab 5mg

150 tabs / 30 days

methlphenida chw 2.5mg

90 tabs / 30 days

methylphenid cap 10mg

30 caps / 30 days

methylphenid cap 20mg

30 caps / 30 days

methylphenid cap 20mg er

30 caps / 30 days

methylphenid cap 30mg

30 caps / 30 days

methylphenid cap 30mg er

30 caps / 30 days

methylphenid cap 40mg er

30 caps / 30 days

methylphenid cap 50mg

30 caps / 30 days

methylphenid cap 60mg

30 caps / 30 days

methylphenid chw 10mg

180 tabs / 30 days

methylphenid chw 5mg

90 tabs / 30 days

methylphenid sol 10mg/5ml

900 mLs/ 30 days

methylphenid sol 5mg/5ml

450 mLs/ 30 days

methylphenid tab 10mg

90 tabs / 30 days

methylphenid tab 10mg er

90 tabs / 30 days

methylphenid tab 18mg er

30 tabs / 30 days

methylphenid tab 20mg

90 tabs / 30 days

methylphenid tab 20mg er

90 tabs / 30 days

methylphenid tab 27mg er

30 tabs / 30 days

methylphenid tab 36mg er

60 tabs / 30 days

methylphenid tab 54mg er

30 tabs / 30 days

methylphenid tab 5mg

90 tabs / 30 days

phentermine cap 15mg

30 caps / 30 days

phentermine cap 30mg

30 caps / 30 days

phentermine cap 37.5mg

30 caps / 30 days

phentermine tab 37.5mg

30 tabs / 30 days

procentra sol 5mg/5ml

1800 mLs/ 30 days

QSYMIA CAP 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

QUILLICHEW CHW 20MG ER

30 tabs / 30 days

QUILLICHEW CHW 30MG ER

60 tabs / 30 days

QUILLICHEW CHW 40MG ER

30 tabs / 30 days

QUILLIVANT SUS 25MG/5ML

360 mLs/ 30 days

SAXENDA injection 18MG/3ML

15 mLs/ 30 days

SUNOSI TAB 150MG

30 tabs / 30 days

SUNOSI TAB 75MG

30 tabs / 30 days

VYVANSE CAP 10MG

30 caps / 30 days

VYVANSE CAP 20MG

30 caps / 30 days

VYVANSE CAP 30MG

30 caps / 30 days

VYVANSE CAP 40MG

30 caps / 30 days

VYVANSE CAP 50MG

30 caps / 30 days

VYVANSE CAP 60MG

30 caps / 30 days

VYVANSE CAP 70MG

30 caps / 30 days

VYVANSE CHW 10MG

30 tabs / 30 days

VYVANSE CHW 20MG

30 tabs / 30 days

VYVANSE CHW 30MG

30 tabs / 30 days

VYVANSE CHW 40MG

30 tabs / 30 days

VYVANSE CHW 50MG

30 tabs / 30 days

VYVANSE CHW 60MG

30 tabs / 30 days

XENICAL CAP 120MG

90 caps / 30 days

zenzedi tab 10mg

180 tabs / 30 days

zenzedi tab 5mg

90 tabs / 30 days

Aminoglycosides

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ARIKAYCE SUS4

28 vials / 28 days

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTEMRA injection 162/0.91

4 syringes / 28 days

ACTEMRA injection ACTpen1

4 injectionections / 28 days

ARCALYST injection 220MG4

4 vials / 28 days

ENBREL injection 25/0.5ML1

8 syringes / 28 days

ENBREL injection 25MG1

8 vials / 28 days

ENBREL injection 50MG/ML1

4 syringes / 28 days

ENBREL MINI injection 50MG/ML1

4 carts / 28 days

ENBREL SRCLK injection 50MG/ML1

4 syringes / 28 days

HUMIRA injection 10/0.1ML1

2 syringes / 28 days

HUMIRA injection 10MG/0.21

2 syringes / 28 days

HUMIRA injection 20/0.2ML1

2 syringes / 28 days

HUMIRA injection 40/0.4ML1

2 syringes / 28 days

HUMIRA kit 20MG/0.41

2 syringes / 28 days

HUMIRA kit 40MG/0.81

2 syringes / 28 days

HUMIRA PEDIA injection CROHNS1

3 kits / 180 days

HUMIRA PEDIA injection CROHNS1

1 kit / 180 days

HUMIRA pen injection 40/0.4ML1

2 pens / 28 days

HUMIRA pen injection 40MG/0.81

2 pens / 28 days

HUMIRA pen injection 80/0.8ML1

2 pens / 28 days

HUMIRA pen injection CD/UC/HS1

1 kit / 180 days

HUMIRA pen injection PS/UV1

1 kit / 180 days

HUMIRA pen kit CD/UC/HS1

1 kit / 180 days

HUMIRA pen kit PED UC1

4 pens / 180 days

HUMIRA pen kit PS/UV1

1 kit / 180 days

KETOR TROMET SPR 15.75MG

5 bottles / 5 days

ketorolac tab 10mg

20 tabs / 5 days

KEVZARA injection 150/1.141

2 syringes / 28 days

KEVZARA injection 150/1.141

2 pens / 28 days

KEVZARA injection 200/1.141

2 pens / 28 days

KEVZARA injection 200/1.141

2 syringes / 28 days

OTEZLA TAB 10/20/301

1 kit / 180 days

OTEZLA TAB 30MG1

60 tabs / 30 days

RINVOQ TAB 15MG ER1

30 tabs / 30 days

SIMPONI injection 100MG/ML1

1 syringe / 28 days

SPRIX SPR 15.75MG

5 bottles / 5 days

XELJANZ SOL 1MG/ML1

240 mLs/ 30 days

XELJANZ TAB 10MG1

224 tabs / 365 days

XELJANZ TAB 5MG1

60 tabs / 30 days

XELJANZ XR TAB 11MG1

30 tabs / 30 days

XELJANZ XR TAB 22MG1

112 tabs / 365 days

Analgesics - opioid

Drug name(s)

Adult quantity limits - 5 days

Child quantity limits - 3 days

ABSTRAL SUB 100MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 200MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 300MCG

120 tabs / 30 days

N/A

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

APADAZ TAB 4.08-325

50 tablets/30 days

30 tablets/30 days

APADAZ TAB 6.12-325

40 tablets/30 days

24 tablets/30 days

APADAZ TAB 8.16-325

30 tablets/30 days

18 tablets/30 days

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-CAFFEIN CAP DIHYDROC

50 capsules/30 days

30 capsules/30 days

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

BENZHY/ACETA TAB 4.08-325

50 tablets/30 days

30 tablets/30 days

BENZHY/ACETA TAB 6.12-325

40 tablets/30 days

24 tablets/30 days

BENZHY/ACETA TAB 8.16-325

30 tablets/30 days

18 tablets/30 days

BUNAVAIL MIS 2.1-0.3

90 films / 30 days

N/A

BUNAVAIL MIS 4.2-0.7

60 films / 30 days

N/A

BUNAVAIL MIS 6.3-1MG

60 films / 30 days

N/A

bupren/nalox mis 2-0.5mg

120 films / 30 days

N/A

bupren/nalox mis 4-1mg

60 tabs / 30 days

N/A

bupren/nalox mis 8-2mg

60 films / 30 days

N/A

bupren/nalox mis 12-3mg

60 films / 30 days

N/A

bupren/nalox sub 2-0.5mg

120 tabs / 30 days

N/A

bupren/nalox sub 8-2mg

90 tabs / 30 days

N/A

buprenorphine sub 2mg

15 tabs / 90 days

N/A

buprenorphine sub 8mg

15 tabs / 90 days

N/A

butorphanol sol 10mg/ml

2.5 ML (1 BOTTLE)/30 days

0 mL/30 days

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 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

dvorah tab

50 tablets/30 days

30 tablets/30 days

EMBEDA CAP 100-4MG

0 capsules/month

N/A

EMBEDA CAP 20-0.8MG

30 capsules/month

N/A

EMBEDA CAP 30-1.2MG

30 capsules/month

N/A

EMBEDA CAP 50-2MG

30 capsules/month

N/A

EMBEDA CAP 60-2.4MG

0 capsules/month

N/A

EMBEDA CAP 80-3.2MG

0 capsules/month

N/A

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 37.5mcg

0 patches/month

N/A

fentanyl dis 50mcg/hr

0 patches/month

N/A

fentanyl dis 62.5mcg

0 patches/month

N/A

fentanyl dis 75mcg/hr

0 patches/month

N/A

fentanyl dis 87.5mcg

0 patches/month

N/A

fentanyl dis 100mcg/h

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

hydroco/apap sol 7.5-325

450 mL/30 days

270 mL/30 days

hydroco/apap tab 10-300mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 10-325mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 5-300mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 7.5-300

30 tablets/30 days

18 tablets/30 days

hydroco/apap tab 7.5-325

30 tablets/30 days

18 tablets/30 days

hydrocod/ibu tab 10-200mg

25 tablets/30 days

15 tablets/30 days

HYDROCOD/IBU TAB 5-200MG

25 tablets/30 days

15 tablets/30 days

hydrocod/ibu 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 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 100mg er

0 tablets/30 days

N/A

hydrocodone tab 120mg er

0 tablets/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

hydromorphon liq 1mg/ml

60 mL/30 days

36 mL/30 days

hydromorphon tab 12mg er

30 tablets/month

N/A

hydromorphon tab 16mg er

0 tablets

N/A

hydromorphon tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphon tab 32mg er

0 tablets

N/A

hydromorphon tab 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphon tab 8mg

5 tablets/30 days

3 tablets/30 days

hydromorphon tab 8mg er

30 tablets/month

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 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

levorphanol tab 3mg

10 tablets/30 days

6 tablets/30 days

lorcet tab 5-325mg

40 tablets/30 days

24 tablets/30 days

lorcet plus tab 7.5-325

30 tablets/30 days

18 tablets/30 days

lorcet hd tab 10-325mg

25 tablets/30 days

15 tablets/30 days

LORTAB ELX 10-300MG

338 mL/30 days

203 mL/30 days

methadone sol 5mg/5ml

300 mL/30 days

N/A

methadone sol 10mg/5ml

150 mL/30 days

N/A

methadone tab 5mg

60 tablets/30 days

N/A

methadone tab 10mg

30 tablets/30 days

N/A

morphine sul cap 10mg er

30 capsules/30 days

N/A

morphine sul cap 100mg er

0 capsules/30 days

N/A

MORPHINE SUL CAP 120MG ER

0 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 40MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 45MG 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 75MG ER

0 capsules/30 days

N/A

morphine sul cap 80mg er

0 capsules/30 days

N/A

MORPHINE SUL CAP 90MG ER

0 capsules/30 days

N/A

morphine sul sol 10/0.5ml

15 mL/30 days

15 mL/30 days

morphine sul sol 100/5ml

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 tab 100mg cr

0 tablets/30 days

N/A

morphine sul tab 100mg er

0 tablets/30 days

N/A

MORPHINE SUL TAB 15MG

15 tablets/30 days

9 tablets/30 days

morphine sul tab 15mg er

60 tablets/30 days

N/A

morphine sul tab 200mg er

0 tablets/30 days

N/A

MORPHINE SUL TAB 30MG

5 tablets/30 days

3 tablets/30 days

morphine sul tab 30mg er

30 tablets/30 days

N/A

morphine sul tab 60mg er

0 tablets/30 days

N/A

NALOCET TAB 2.5-300

60 tablets/30 days

36 tablets/30 days

NUCYNTA TAB 100MG

5 tablets/30 days

3 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 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

NUCYNTA ER TAB 50MG

60 tablets/30 days

N/A

OXAYDO TAB 5MG

30 tablets/30 days

18 tablets/30 days

OXAYDO TAB 7.5MG

20 tablets/30 days

12 tablets/30 days

oxycodone/ACETA 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 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/apap tab 10-325mg

15 tablets/30 days

9 tablets/30 days

oxycodone/APAP TAB 5-300MG

30 tablets/30 days

18 tablets/30 days

oxycodone/apap tab 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/apap tab 7.5-325

20 tablets/30 days

12 tablets/30 days

oxycodone/ASA TAB

30 tablets/30 days

18 tablets/30 days

oxycodone/IBU TAB 5-400MG

20 tablets/30 days

12 tablets/30 days

oxycodone-APAP TAB 2.5-300

60 tablets/30 days

36 tablets/30 days

oxycodoneone cap 5mg

30 capsules/30 days

18 capsules/30 days

oxycodoneone cap hcl 5mg

30 capsules/30 days

18 capsules/30 days

oxycodoneone con 10/0.5ml

5 mL/30 days

3 mL/30 days

oxycodoneone con 100/5ml

5 mL/30 days

3 mL/30 days

oxycodoneone sol 5mg/5ml

165 mL/30 days

99 mL/30 days

oxycodoneone tab 5mg

30 tablets/30 days

18 tablets/30 days

oxycodoneone tab 10mg

15 tablets/30 days

9 tablets/30 days

oxycodoneone tab 15mg

10 tablets/30 days

6 tablets/30 days

oxycodoneone tab 20mg

5 tablets/30 days

3 tablets/30 days

oxycodoneone tab 30mg

5 tablets/30 days

3 tablets/30 days

OXYCONTIN TAB 10MG CR

60 tablets/30 days

N/A

OXYCONTIN TAB 15MG CR

60 tablets/30 days

N/A

OXYCONTIN TAB 20MG CR

30 tablets/30 days

N/A

OXYCONTIN TAB 30MG CR

30 tablets/30 days

N/A

OXYCONTIN TAB 40MG CR

0 tablets/30 days

N/A

OXYCONTIN TAB 60MG CR

0 tablets/30 days

N/A

OXYCONTIN TAB 80MG CR

0 tablets/30 days

N/A

OXYMORPHONE TAB 5MG ER

60 tablets/30 days

N/A

OXYMORPHONE TAB 7.5MG ER

60 tablets/30 days

N/A

OXYMORPHONE TAB 10MG ER

30 tablets/30 days

N/A

OXYMORPHONE TAB 15MG ER

30 tablets/30 days

N/A

OXYMORPHONE TAB 20MG ER

0 tablets/30 days

N/A

OXYMORPHONE TAB 30MG ER

0 tablets/30 days

N/A

OXYMORPHONE TAB 40MG ER

0 tablets/30 days

N/A

oxymorphone tab hcl 5mg

15 tablets/30 days

9 tablets/30 days

oxymorphone tab hcl 10mg

5 tablets/30 days

3 tablets/30 days

PRIMLEV TAB 10-300MG

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

PROLATE SOL 10/300MG

75 mL/30 days

45 mL/30 days

PROLATE TAB 10-300MG

15 tablets/30 days

9 tablets/30 days

PROLATE TAB 5-300MG

30 tablets/30 days

18 tablets/30 days

PROLATE TAB 7.5-300

20 tablets/30 days

12 tablets/30 days

QDOLO SOL 5MG/ML

400 mL/30 days

240 mL/30 days

SUBSYS SPR 100MCG

120 sprays / 30 days

N/A

SUBSYS SPR 1200MCG

240 sprays / 30 days

N/A

SUBSYS SPR 1600MCG

240 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

tramadl/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

TRAMADOL HCL TAB 100MG

120 tablets/ 30 days

120 tablets/ 30 days

tramadol hcl tab 100mg er

30 tablets/30 days

N/A

tramadol hcl tab 200mg er

30 tablets/30 days

N/A

tramadol hcl tab 300mg er

30 tablets/30 days

N/A

tramadol hcl tab 50mg

50 tablets/30 days

30 tablets/30 days

TREZIX CAP

50 capsules/30 days

30 capsules/30 days

XTAMPZA ER CAP 13.5MG

60 capsules/30 days

N/A

XTAMPZA ER CAP 18MG

30 capsules/30 days

N/A

XTAMPZA ER CAP 27MG

30 capsules/30 days

N/A

XTAMPZA ER CAP 36MG

0 capsules/30 days

N/A

XTAMPZA ER CAP 9MG

60 capsules/30 days

N/A

ZUBSOLV SUB 0.7-0.18

30 tabs / 30 days

N/A

ZUBSOLV SUB 1.4-0.36

90 tabs / 30 days

N/A

ZUBSOLV SUB 11.4-2.9

30 tabs / 30 days

N/A

ZUBSOLV SUB 2.9-0.71

30 tabs / 30 days

N/A

ZUBSOLV SUB 5.7-1.4

30 tabs / 30 days

N/A

ZUBSOLV SUB 8.6-2.1

60 tabs / 30 days

N/A

Androgens - anabolic

Drug name(s)

Quantity limits 
(per 30 days or as specified)

METHITEST TAB 10MG

600 tabs / 30 days

METHYLTESTOS CAP 10MG

600 caps / 30 days

testosterone cyp injection 100mg/ml

1 vial / 28 days

testosterone cyp injection 200mg/ml

10 mLs/ 28 days

testosterone ENAN injection 200MG/ML

1 vial / 28 days

testosteroneerone gel 1%(25mg)

60 packets / 30 days

testosteroneerone gel 1%(50mg)

60 packets / 30 days

testosteroneerone gel 1.62%

2 bottles / 30 days

testosteroneerone gel 1.62%

60 packets / 30 days

testosteroneerone gel 1.62%

30 packets / 30 days

testosteroneerone gel pump 1%

4 bottles / 30 days

testosteroneerone sol 30mg/act

2 bottles / 30 days

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADVAIR DISKU AER 100/50

60 blisters / 30 days

ADVAIR DISKU AER 250/50

60 blisters / 30 days

ADVAIR DISKU AER 500/50

60 blisters / 30 days

ADVAIR HFA AER 115/21

1 can / 30 days

ADVAIR HFA AER 230/21

1 can / 30 days

ADVAIR HFA AER 45/21

1 can / 30 days

Albuterol aer hfa

2 cans / 30 days

ANORO ELLIPT AER 62.5-25

1 inhaler / 30 days

ARCAPTA CAP 75MCG

30 caps / 30 days

ARNUITY ELPT INH 100MCG

30 blisters / 30 days

ARNUITY ELPT INH 200MCG

30 blisters / 30 days

ARNUITY ELPT INH 50MCG

30 blisters / 30 days

ASMANEX 120 AER 220MCG

1 can / 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 HFA AER 100 MCG

1 can / 30 days

ASMANEX HFA AER 200 MCG

1 can / 30 days

ASMANEX HFA AER 50MCG

1 inhaler / 30 days

ATROVENT HFA AER 17MCG

2 cans / 30 days

BREO ELLIPTA INH 100-25

60 blisters / 30 days

BREO ELLIPTA INH 200-25

60 blisters / 30 days

BREZTRI AERO AER SPHERE

1 can / 30 days

COMBIVENT AER 20-100

2 cans / 30 days

DULERA AER 100-5MCG

1 can / 30 days

DULERA AER 200-5MCG

1 can / 30 days

DULERA AER 50-5MCG

1 inhaler / 30 days

FASENRA pen injection 30MG/ML

1 pen / 56 days

FLOVENT DISK AER 100MCG

60 blisters / 30 days

FLOVENT DISK AER 250MCG

240 blisters / 30 days

FLOVENT DISK AER 50MCG

60 blisters / 30 days

FLOVENT HFA AER 110MCG

1 can / 30 days

FLOVENT HFA AER 220MCG

2 cans / 30 days

FLOVENT HFA AER 44MCG

1 can / 30 days

FLUTIC/SALME INH 113/14

1 inhaler / 30 days

FLUTIC/SALME INH 232/14

1 inhaler / 30 days

FLUTIC/SALME INH 55/14

1 inhaler / 30 days

INCRUSE ELPT INH 62.5MCG

30 blisters / 30 days

NUCALA injection 100MG/ML

3 syringes / 28 days

QVAR REDIHA AER 80MCG

2 cans / 30 days

QVAR REDIHAL AER 40MCG

1 can / 30 days

SEREVENT DIS AER 50MCG

60 blisters / 30 days

SPIRIVA AER 1.25MCG

1 cart / 30 days

SPIRIVA CAP HANDIHLR

30 caps / 30 days

SPIRIVA SPR 2.5MCG

1 cart / 30 days

STIOLTO AER 2.5-2.5

1 cart / 30 days

STRIVERDI AER 2.5MCG

1 cart / 30 days

SYMBICORT AER 160-4.5

1 can / 30 days

SYMBICORT AER 80-4.5

1 can / 30 days

TRELEGY AER ELLIPTA

1 inhaler / 30 days

VENTOLIN HFA AER

2 cans / 30 days

Anticoagulants

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BEVYXXA CAP 40MG

43 caps / 42 days

BEVYXXA CAP 80MG

43 caps / 42 days

enoxaparin injection 80/0.8ml

60 tabs / 30 days

fondaparinux injection 10/0.8ml

74 tabs / 30 days

fondaparinux injection 2.5/0.5

1 pack / 180 days

fondaparinux injection 5/0.4ml

30 syringes / 90 days

fondaparinux injection 7.5/0.6

30 syringes / 90 days

FRAGMIN injection 10000/ML

30 syringes / 90 days

FRAGMIN injection 12500UNT

30 syringes / 90 days

FRAGMIN injection 15000UNT

10 vials / 90 days

FRAGMIN injection 18000UNT

30 syringes / 90 days

FRAGMIN injection 2500/0.2

30 syringes / 90 days

FRAGMIN injection 5000/0.2

30 syringes / 90 days

FRAGMIN injection 7500/0.3

30 syringes / 90 days

FRAGMIN injection 95000UNT

10 vials / 90 days

PRADAXA CAP 110MG

71 caps / 90 days

PRADAXA CAP 150MG

60 caps / 30 days

PRADAXA CAP 75MG

60 caps / 30 days

XARELTO TAB 10MG

30 tabs / 30 days

XARELTO TAB 15MG

60 tabs / 30 days

XARELTO TAB 2.5MG

60 tabs / 30 days

XARELTO TAB 20MG

30 tabs / 30 days

XARELTO STAR TAB 15/20MG

51 tabs / 30 days

Anticonvulsants

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FINTEPLA SOL 2.2MG/ML4

360 mLs/ 30 days

NAYZILAM SPR 5MG

10 bottles / 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 25mg

90 caps / 30 days

pregabalin cap 300mg

60 caps / 30 days

pregabalin cap 50mg

90 caps / 30 days

pregabalin cap 75mg

90 caps / 30 days

pregabalin sol 20mg/ml

900 mLs/ 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

QUDEXY XR CAP 25/24HR

30 caps / 30 days

QUDEXY XR CAP 50/24HR

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

topiramate cap er 25mg

30 caps / 30 days

topiramate cap er 50mg

30 caps / 30 days

TROKENDI XR CAP 100MG

30 caps / 30 days

TROKENDI XR CAP 200MG

60 caps / 30 days

TROKENDI XR CAP 25MG

30 caps / 30 days

TROKENDI XR CAP 50MG

30 caps / 30 days

VALTOCO LIQ 15MG

5 boxes / 30 days

VALTOCO LIQ 20MG

5 boxes / 30 days

VALTOCO SPR 10MG

5 boxes / 30 days

VALTOCO SPR 5MG

5 boxes / 30 days

ANTIDIABETICS

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ANZEMET TAB 100MG

7 tabs / 30 days

ANZEMET TAB 50MG

7 tabs / 30 days

BYDUREON BC injection 2/0.85ML

4 pens / 28 days

BYDUREON pen injection 2MG

4 pens / 28 days

CESAMET CAP 1MG

42 caps / 30 days

EMEND SUS 125MG

6 packs / 30 days

FARXIGA TAB 10MG

30 tabs / 30 days

FARXIGA TAB 5MG

30 tabs / 30 days

FIASP injection 100/ML

100 mLs/ 30 days

FIASP FLEX injection TOUCH

100 mLs/ 30 days

FIASP penFIL injection U-100

100 mLs/ 30 days

GLYXAMBI TAB 10-5 MG

30 tabs / 30 days

GLYXAMBI TAB 25-5 MG

30 tabs / 30 days

HUMULIN R injection U-500

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

KORLYM TAB 300MG4

120 tabs / 30 days

LANTUS injection 100/ML

100 mLs/ 30 days

LANTUS SOLOS injection 100/ML

100 mLs/ 30 days

LEVEMIR injection

100 mLs/ 30 days

LEVEMIR injection FLEXTOUC

100 mLs/ 30 days

metformin tab 500mg er

90 tabs / 30 days

metformin tab 500mg er

120 tabs / 30 days

metformin tab 750mg er

60 tabs / 30 days

metformin tab 1000 er

60 tabs / 30 days

metformin er tab 1000mg

60 tabs / 30 days

NOVOLIN injection 70/30

100 mLs/ 30 days

NOVOLIN injection 70/30 FP

100 mLs/ 30 days

NOVOLIN N injection 100 unit

100 mLs/ 30 days

NOVOLIN N injection RELION

100 mLs/ 30 days

NOVOLIN N injection U-100

100 mLs/ 30 days

NOVOLIN R injection 100 unit

100 mLs/ 30 days

NOVOLIN R injection RELION

100 mLs/ 30 days

NOVOLIN R injection U-100

100 mLs/ 30 days

NOVOLIN70/30 injection RELION

100 mLs/ 30 days

NOVOLOG injection 100/ML

100 mLs/ 30 days

NOVOLOG injection FLEXpen

100 mLs/ 30 days

NOVOLOG injection penFILL

100 mLs/ 30 days

NOVOLOG MIX injection 70/30

100 mLs/ 30 days

NOVOLOG MIX injection FLEXpen

100 mLs/ 30 days

OZEMPIC injection 2/1.5ML

2 pens / 28 days

OZEMPIC injection 2/1.5ML

1 pen / 28 days

OZEMPIC injection 4MG/3ML

3 pens / 28 days

QTERN TAB 10-5MG

30 tabs / 30 days

QTERN TAB 5-5MG

30 tabs / 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

SOLIQUA injection 100/33

5 pens / 30 days

SYNJARDY TAB

60 tabs / 30 days

SYNJARDY TAB 12.5-500

60 tabs / 30 days

SYNJARDY TAB 5-1000MG

60 tabs / 30 days

SYNJARDY TAB 5-500MG

60 tabs / 30 days

SYNJARDY XR TAB

60 tabs / 30 days

SYNJARDY XR TAB 10-1000

60 tabs / 30 days

SYNJARDY XR TAB 25-1000

30 tabs / 30 days

SYNJARDY XR TAB 5-1000MG

60 tabs / 30 days

TOUJEO MAX injection 300IU/ML

100 mLs/ 30 days

TOUJEO SOLO injection 300IU/ML

100 mLs/ 30 days

TRESIBA injection 100unit

100 mLs/ 30 days

TRESIBA FLEX injection 100unit

100 mLs/ 30 days

TRESIBA FLEX injection 200unit

100 mLs/ 30 days

TRIJARDY XR TAB

60 tabs / 30 days

TRIJARDY XR TAB

30 tabs / 30 days

TRULICITY injection 0.75/0.5

4 pens / 28 days

TRULICITY injection 1.5/0.5

4 pens / 28 days

TRULICITY injection 3/0.5

2 pens / 28 days

TRULICITY injection 4.5/0.5

2 pens / 28 days

VICTOZA injection 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 injection 100/3.6

5 pens / 30 days

Antiemetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Aprepitant cap 40mg

8 caps / 30 days

Aprepitant cap 80mg

8 caps / 30 days

Aprepitant pak 80 & 125

4 packs / 30 days

Aprepitant cap 125mg

4 caps / 30 days

granisetron tab 1mg

14 tabs / 30 days

JUXTAPID CAP 10MG4

30 caps / 30 days

JUXTAPID CAP 20MG4

30 caps / 30 days

JUXTAPID CAP 30MG4

30 caps / 30 days

JUXTAPID CAP 40MG4

30 caps / 30 days

JUXTAPID CAP 5MG4

30 caps / 30 days

JUXTAPID CAP 60MG4

30 caps / 30 days

ondansetron sol 4mg/5ml

5 bottles / 30 days

ONDANSETRON TAB 24MG

4 tabs / 30 days

ondansetron tab 4mg

24 tabs / 30 days

ondansetron tab 4mg odt

24 tabs / 30 days

ondansetron tab 8mg

24 tabs / 30 days

ondansetron tab 8mg odt

24 tabs / 30 days

SANCUSO DIS 3.1MG

2 patches / 28 days

VARUBI TAB 90MG

4 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)

AFINITOR TAB 10MG1, 3

30 tabs / 30 days

AFINITOR DIS TAB 2MG1, 3

60 tabs / 30 days

AFINITOR DIS TAB 3MG1, 3

90 tabs / 30 days

AFINITOR DIS TAB 5MG1, 3

60 tabs / 30 days

FIRDAPSE TAB 10MG4

240 tabs / 30 days

NEXLETOL TAB 180MG

30 tabs / 30 days

NEXLIZET TAB 180/10MG

30 tabs / 30 days

RUZURGI TAB 10MG4

300 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

nitazoxanide tab 500mg

12 tabs / 90 days

Antimyasthenic / Cholinergic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALECENSA CAP 150MG3, 4

240 caps / 30 days

ALUNBRIG PAK4

30 tabs / 180 days

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Abiraterone tab 250mg1, 3

120 tabs / 30 days

Abiraterone tab 500mg1, 3

60 tabs / 30 days

ALUNBRIG TAB 180MG4

30 tabs / 30 days

ALUNBRIG TAB 30MG4

120 tabs / 30 days

ALUNBRIG TAB 90MG4

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 100MG1, 3

90 tabs / 30 days

BOSULIF TAB 400MG1, 3

30 tabs / 30 days

BOSULIF TAB 500MG1, 3

30 tabs / 30 days

BRAFTOVI CAP 75MG4

180 caps / 30 days

BRUKINSA CAP 80MG4

120 caps / 30 days

CABOMETYX TAB 20MG1, 3

30 tabs / 30 days

CABOMETYX TAB 40MG1, 3

30 tabs / 30 days

CABOMETYX TAB 60MG1, 3

30 tabs / 30 days

CALQUENCE CAP 100MG4

60 caps / 30 days

CAPLYTA CAP 42MG

30 caps / 30 days

CAPRELSA TAB 100MG4

60 tabs / 30 days

CAPRELSA TAB 300MG4

30 tabs / 30 days

COMETRIQ kit 100MG3, 4

1 carton / 28 days

COMETRIQ kit 140MG3, 4

1 carton / 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 20MG1

63 tabs / 28 days

DAURISMO TAB 100MG1, 3

30 tabs / 30 days

DAURISMO TAB 25MG1, 3

60 tabs / 30 days

ERIVEDGE CAP 150MG1, 3

30 caps / 30 days

ERLEADA TAB 60MG1

120 tabs / 30 days

erlotinib tab 100mg1, 3

30 tabs / 30 days

erlotinib tab 100mg3

30 tabs / 30 days

erlotinib tab 150mg1, 3

30 tabs / 30 days

erlotinib tab 150mg3

30 tabs / 30 days

erlotinib tab 25mg1, 3

60 tabs / 30 days

erlotinib tab 25mg3

60 tabs / 30 days

everolimus tab 2.5mg1, 3

30 tabs / 30 days

everolimus tab 5mg1, 3

30 tabs / 30 days

everolimus tab 7.5mg1, 3

30 tabs / 30 days

FARYDAK CAP 10MG1

6 caps / 21 days

FARYDAK CAP 15MG1

6 caps / 21 days

FARYDAK CAP 20MG1

6 caps / 21 days

GAVRETO CAP 100MG3, 4

120 caps / 30 days

GILOTRIF TAB 20MG4

30 tabs / 30 days

GILOTRIF TAB 30MG4

30 tabs / 30 days

GILOTRIF TAB 40MG4

30 tabs / 30 days

GOCOVRI CAP 137MG1, 3

60 caps / 30 days

GOCOVRI CAP 68.5MG1, 3

30 caps / 30 days

IBRANCE CAP 100MG1

21 caps / 28 days

IBRANCE CAP 125MG1

21 caps / 28 days

IBRANCE CAP 75MG1

21 caps / 28 days

IBRANCE TAB 100MG1

21 tabs / 28 days

IBRANCE TAB 125MG1

21 tabs / 28 days

IBRANCE TAB 75MG1

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 100MG1

30 tabs / 30 days

IDHIFA TAB 50MG1

30 tabs / 30 days

imatinib mes tab 100mg1, 3

90 tabs / 30 days

imatinib mes tab 400mg1, 3

60 tabs / 30 days

IMBRUVICA CAP 140MG4

60 caps / 30 days

IMBRUVICA CAP 70MG4

30 caps / 30 days

IMBRUVICA TAB 140MG4

30 tabs / 30 days

IMBRUVICA TAB 280MG4

30 tabs / 30 days

IMBRUVICA TAB 420MG4

30 tabs / 30 days

IMBRUVICA TAB 560MG4

30 tabs / 30 days

INLYTA TAB 1MG1, 3

180 tabs / 30 days

INLYTA TAB 5MG1, 3

120 tabs / 30 days

INQOVI TAB 35-100MG1

5 tabs / 28 days

INREBIC CAP 100MG1, 3

120 caps / 30 days

IRESSA TAB 250MG3, 4

30 tabs / 30 days

JAKAFI TAB 10MG1, 3

60 tabs / 30 days

JAKAFI TAB 15MG1, 3

60 tabs / 30 days

JAKAFI TAB 20MG1, 3

60 tabs / 30 days

JAKAFI TAB 25MG1, 3

60 tabs / 30 days

JAKAFI TAB 5MG1, 3

60 tabs / 30 days

KISQALI TAB 200DOSE1

63 tabs / 28 days

KISQALI TAB 400DOSE1

63 tabs / 28 days

KISQALI TAB 600DOSE1

63 tabs / 28 days

KISQALI 200 PAK FEMARA1

91 tabs / 28 days

KISQALI 400 PAK FEMARA1

91 tabs / 28 days

KISQALI 600 PAK FEMARA1

91 tabs / 28 days

KOSELUGO CAP 10MG4

240 caps / 30 days

KOSELUGO CAP 25MG4

120 caps / 30 days

lapatinib tab 250mg1

180 tabs / 30 days

LATUDA TAB 120MG

30 tabs / 30 days

LATUDA TAB 20MG

30 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 15-6.141

60 tabs / 28 days

LONSURF TAB 20-8.191

80 tabs / 28 days

LORBRENA TAB 100MG1, 3

30 tabs / 30 days

LORBRENA TAB 25MG1, 3

90 tabs / 30 days

LYNPARZA TAB 100MG3, 4

120 tabs / 30 days

LYNPARZA TAB 150MG3, 4

120 tabs / 30 days

MEKINIST TAB 0.5MG1

90 tabs / 30 days

MEKINIST TAB 2MG1

30 tabs / 30 days

MEKTOVI TAB 15MG4

180 tabs / 30 days

NERLYNX TAB 40MG3, 4

180 tabs / 30 days

NERLYNX TAB 40MG3

180 tabs / 30 days

NEXAVAR TAB 200MG1, 3

120 tabs / 30 days

NINLARO CAP 2.3MG1

3 caps / 28 days

NINLARO CAP 3MG1

3 caps / 28 days

NINLARO CAP 4MG1

3 caps / 28 days

NUBEQA TAB 300MG1

120 tabs / 30 days

ODOMZO CAP 200MG1, 3

30 caps / 30 days

ONUREG TAB 200MG1

14 tabs / 28 days

ONUREG TAB 300MG1

14 tabs / 28 days

ORGOVYX TAB 120MG4

30 tabs / 30 days

OSMOLEX ER TAB

60 tabs / 30 days

OSMOLEX ER TAB 129MG

30 tabs / 30 days

OSMOLEX ER TAB 193MG

30 tabs / 30 days

OSMOLEX ER TAB 258MG

30 tabs / 30 days

PEMAZYRE TAB 13.5MG4

14 tabs / 21 days

PEMAZYRE TAB 4.5MG4

14 tabs / 21 days

PEMAZYRE TAB 9MG4

14 tabs / 21 days

PIQRAY 200MG TAB DOSE1

28 tabs / 28 days

PIQRAY 250MG TAB DOSE1

56 tabs / 28 days

PIQRAY 300MG TAB DOSE1

56 tabs / 28 days

POMALYST CAP 1MG1

21 caps / 28 days

POMALYST CAP 2MG1

21 caps / 28 days

POMALYST CAP 3MG1

21 caps / 28 days

POMALYST CAP 4MG1

21 caps / 28 days

QINLOCK TAB 50MG4

90 tabs / 30 days

RETEVMO CAP 40MG1, 3

180 caps / 30 days

RETEVMO CAP 80MG1, 3

120 caps / 30 days

ROZLYTREK CAP 100MG1, 3

30 caps / 30 days

ROZLYTREK CAP 200MG1, 3

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 25MG1

240 caps / 30 days

SPRYCEL TAB 100MG1, 3

30 tabs / 30 days

SPRYCEL TAB 140MG1, 3

30 tabs / 30 days

SPRYCEL TAB 20MG1, 3

90 tabs / 30 days

SPRYCEL TAB 50MG1, 3

30 tabs / 30 days

SPRYCEL TAB 70MG1, 3

30 tabs / 30 days

SPRYCEL TAB 80MG1, 3

30 tabs / 30 days

STIVARGA TAB 40MG1

84 tabs / 28 days

SUTENT CAP 12.5MG1, 3

90 caps / 30 days

SUTENT CAP 25MG1, 3

30 caps / 30 days

SUTENT CAP 37.5MG1, 3

30 caps / 30 days

SUTENT CAP 50MG1, 3

30 caps / 30 days

TABRECTA TAB 150MG1

112 tabs / 28 days

TABRECTA TAB 200MG1

112 tabs / 28 days

TAFINLAR CAP 50MG1

120 caps / 30 days

TAFINLAR CAP 75MG1

120 caps / 30 days

TAGRISSO TAB 40MG3, 4

30 tabs / 30 days

TAGRISSO TAB 80MG3, 4

30 tabs / 30 days

TALZENNA CAP 0.25MG1, 3

90 caps / 30 days

TALZENNA CAP 1MG1, 3

30 caps / 30 days

TASIGNA CAP 150MG1, 3

120 caps / 30 days

TASIGNA CAP 200MG1, 3

120 caps / 30 days

TASIGNA CAP 50MG1, 3

120 caps / 30 days

TAZVERIK TAB 200MG4

240 tabs / 30 days

TIBSOVO TAB 250MG4

60 tabs / 30 days

TUKYSA TAB 150MG4

120 tabs / 30 days

TUKYSA TAB 50MG4

300 tabs / 30 days

TURALIO CAP 200MG4

120 caps / 30 days

VENCLEXTA TAB 100MG4

180 tabs / 30 days

VENCLEXTA TAB 10MG4

60 tabs / 30 days

VENCLEXTA TAB 50MG4

30 tabs / 30 days

VENCLEXTA TAB START PK4

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 15MG1, 3

30 tabs / 30 days

VIZIMPRO TAB 30MG1, 3

30 tabs / 30 days

VIZIMPRO TAB 45MG1, 3

30 tabs / 30 days

VOTRIENT TAB 200MG1, 3

120 tabs / 30 days

XALKORI CAP 200MG1, 3

120 caps / 30 days

XALKORI CAP 250MG1, 3

120 caps / 30 days

XOSPATA TAB 40MG4

90 tabs / 30 days

XPOVIO PAK 100MG3, 4

1 box / 28 days

XPOVIO PAK 40MG3, 4

1 box / 28 days

XPOVIO PAK 40MG3

1 box / 28 days

XPOVIO PAK 50MG3, 4

1 box / 28 days

XPOVIO PAK 60MG3, 4

1 box / 28 days

XPOVIO PAK 60MG3

1 box / 28 days

XPOVIO PAK 80MG3, 4

1 box / 28 days

XTANDI CAP 40MG1, 3

120 caps / 30 days

XTANDI TAB 40MG1, 3

90 tabs / 30 days

XTANDI TAB 80MG1, 3

60 tabs / 30 days

YONSA TAB 125MG1, 3

120 tabs / 30 days

ZEJULA CAP 100MG3, 4

90 caps / 30 days

ZELBORAF TAB 240MG1

240 tabs / 30 days

ZOLINZA CAP 100MG1, 3

120 caps / 30 days

ZYDELIG TAB 100MG4

60 tabs / 30 days

ZYDELIG TAB 150MG4

60 tabs / 30 days

ZYKADIA CAP 150MG1, 3

90 caps / 30 days

ZYKADIA TAB 150MG1, 3

90 tabs / 30 days

ZYTIGA TAB 500MG1, 3

60 tabs / 30 days

Antiparkinson and related therapy agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

LATUDA TAB 40MG

30 tabs / 30 days

LATUDA TAB 60MG

30 tabs / 30 days

LATUDA TAB 80MG

60 tabs / 30 days

NUPLAZID CAP 34MG1

30 caps / 30 days

NUPLAZID TAB 10MG1

30 tabs / 30 days

VRAYLAR CAP 1.5-3MG

1 pack / 180 days

Antipsychotics / Antimanic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EPCLUSA TAB 200-50MG1

28 tabs / 28 days

EPCLUSA TAB 400-1001

30 tabs / 30 days

HARVONI PAK1

28 packets / 28 days

HARVONI PAK 45-200MG1

28 packets / 28 days

HARVONI TAB 45-200MG1

28 tabs / 28 days

HARVONI TAB 90-400MG1

30 tabs / 30 days

MAVYRET TAB 100-40MG1

90 tabs / 30 days

olanzapine tab 10mg

30 tabs / 30 days

olanzapine tab 10mg odt

30 tabs / 30 days

olanzapine tab 15mg

30 tabs / 30 days

olanzapine tab 15mg odt

30 tabs / 30 days

olanzapine tab 2.5mg

30 tabs / 30 days

olanzapine tab 20mg

30 tabs / 30 days

olanzapine tab 20mg odt

30 tabs / 30 days

olanzapine tab 5mg

30 tabs / 30 days

olanzapine tab 5mg odt

30 tabs / 30 days

olanzapine tab 7.5mg

30 tabs / 30 days

paliperidone tab er 1.5mg

60 tabs / 30 days

paliperidone tab er 3mg

60 tabs / 30 days

paliperidone tab er 6mg

60 tabs / 30 days

paliperidone tab er 9mg

60 tabs / 30 days

PREVYMIS TAB 240MG

112 tabs / 365 days

PREVYMIS TAB 480MG

112 tabs / 365 days

quetiapine tab 150mg er

60 tabs / 30 days

quetiapine tab 200mg er

60 tabs / 30 days

quetiapine tab 300mg er

60 tabs / 30 days

quetiapine tab 400mg er

60 tabs / 30 days

quetiapine tab 50mg er

60 tabs / 30 days

VRAYLAR CAP 1.5MG

30 caps / 30 days

VRAYLAR CAP 3MG

30 caps / 30 days

VRAYLAR CAP 4.5MG

30 caps / 30 days

VRAYLAR CAP 6MG

30 caps / 30 days

Antivirals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADEMPAS TAB 0.5MG4

90 tabs / 30 days

ADEMPAS TAB 1.5MG4

90 tabs / 30 days

ADEMPAS TAB 1MG4

90 tabs / 30 days

ADEMPAS TAB 2.5MG4

90 tabs / 30 days

ADEMPAS TAB 2MG4

90 tabs / 30 days

CORLANOR SOL 5MG/5ML

600 mLs/ 30 days

CORLANOR TAB 5MG

60 tabs / 30 days

CORLANOR TAB 7.5MG

60 tabs / 30 days

OPSUMIT TAB 10MG4

30 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

RELENZA MIS DISKHALE

40 blisters / 120 days

SOVALDI PAK 150MG1

28 packets / 28 days

SOVALDI PAK 200MG1

28 packets / 28 days

SOVALDI TAB 200MG1

30 tabs / 30 days

SOVALDI TAB 400MG1

30 tabs / 30 days

VOSEVI TAB1

30 tabs / 30 days

XOFLUZA TAB 20MG

4 tabs / 120 days

XOFLUZA TAB 40MG

4 tabs / 120 days

Cardiovascular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALA-SCALP LOT 2%

118.4 ML / 30 days

Alyq tab 20mg1

60 tabs / 30 days

Ambrisentan tab 10mg1

30 tabs / 30 days

Ambrisentan tab 5mg1

30 tabs / 30 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

AUG BETAMET GEL 0.05%

200 grams / 28 days

BETA DIPROP GEL 0.05%

200 grams / 28 days

bosentan tab 62.5mg1

60 tabs / 30 days

bosentan tab 125mg1

60 tabs / 30 days

BRYHALI LOT 0.01%

200 grams / 28 days

CAPEX SHA 0.01%

840 mLs/ 28 days

EMFLAZA TAB 18MG4

30 tabs / 30 days

EMFLAZA TAB 6MG4

60 tabs / 30 days

sildenafil sus 10mg/ml1

2 bottles / 30 days

sildenafil tab 20mg1

90 tabs / 30 days

sildenafil tab 25mg

6 tabs / 30 days

sildenafil tab 50mg

6 tabs / 30 days

sildenafil tab 100mg

6 tabs / 30 days

STENDRA TAB 100MG

6 tabs / 30 days

STENDRA TAB 200MG

6 tabs / 30 days

STENDRA TAB 50MG

6 tabs / 30 days

tadalafil tab 10mg

6 tabs / 30 days

tadalafil tab 2.5mg

30 tabs / 30 days

tadalafil tab 20mg

6 tabs / 30 days

tadalafil tab 20mg1

60 tabs / 30 days

tadalafil tab 5mg

30 tabs / 30 days

TRACLEER TAB 32MG1

120 tabs / 30 days

TYVASO SOL 0.6MG/ML4

7 PKGS / 28 days

TYVASO REFIL SOL 0.6MG/ML4

1 kit / 28 days

TYVASO START SOL 0.6MG/ML4

1 kit / 180 days

UPTRAVI TAB 1000MCG4

60 tabs / 30 days

UPTRAVI TAB 1200MCG4

60 tabs / 30 days

UPTRAVI TAB 1400MCG4

60 tabs / 30 days

UPTRAVI TAB 1600MCG4

60 tabs / 30 days

UPTRAVI TAB 200/8004

1 PKG / 180 days

UPTRAVI TAB 200MCG4

140 tabs / 180 days

UPTRAVI TAB 200MCG4

60 tabs / 30 days

UPTRAVI TAB 400MCG4

60 tabs / 30 days

UPTRAVI TAB 600MCG4

60 tabs / 30 days

UPTRAVI TAB 800MCG4

60 tabs / 30 days

vardenafil tab 2.5mg

6 tabs / 30 days

vardenafil tab 5mg

6 tabs / 30 days

vardenafil tab 10mg

6 tabs / 30 days

vardenafil tab 10mg odt

6 tabs / 30 days

vardenafil tab 20mg

6 tabs / 30 days

VENTAVIS SOL 10MCG/ML3, 4

270 ampuls / 30 days

VENTAVIS SOL 20MCG/ML3, 4

270 ampuls / 30 days

VYNDAMAX CAP 61MG1

30 caps / 30 days

VYNDAQEL CAP 20MG1

120 caps / 30 days

Corticosteroids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CLOCORTOLONE CRE 0.1%

135 grams / 30 days

CLOCORTOLONE CRE PIV 0.1%

135 grams / 30 days

Dermatologicals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Ala scalp lot 2%

118.4 ML / 30 days

Ala-cort cre 1%

454 grams / 30 days

Ala-cort cre 2.5%

454 grams / 30 days

Alclometason cre 0.05%

120 grams / 30 days

Alclometason oin 0.05%

120 grams / 30 days

Aug betamet cre 0.05%

200 grams / 28 days

Aug betamet lot 0.05%

210 mLs/ 30 days

Aug betamet oin 0.05%

200 grams / 28 days

beser lot 0.05%

120 mLs/ 30 days

betameth dip cre 0.05%

135 grams / 30 days

betameth dip lot 0.05%

120 mLs/ 30 days

betameth dip oin 0.05%

135 grams / 30 days

betameth val aer 0.12%

150 grams / 30 days

betameth val cre 0.1%

135 grams / 30 days

betameth val lot 0.1%

120 mLs/ 30 days

betameth val oin 0.1%

135 grams / 30 days

CHOR GONADOT injection 10000UNT1

2 vials / 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

clobetasol e cre 0.05%

210 grams / 28 days

clodan sha 0.05%

236 mLs/ 30 days

CLODERM CRE 0.1%

135 grams / 30 days

CLODERM CRE 0.1% PMP

135 grams / 30 days

CORDRAN CRE 0.025%

120 grams / 30 days

CORDRAN 80X3 TAP 4MCG/CM

1 box / 30 days

COSENTYX injection 150MG/ML1

1 syringe / 28 days

COSENTYX injection 300DOSE1

1 pack / 28 days

COSENTYX pen injection 150MG/ML1

1 injectiondv / 28 days

COSENTYX pen injection 300DOSE1

1 pack / 28 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

desoximetasone cre 0.05%

120 grams / 30 days

desoximetasone cre 0.25%

120 grams / 30 days

desoximetasone gel 0.05%

120 grams / 30 days

desoximetasone oin 0.05%

120 grams / 30 days

desoximetasone oin 0.25%

120 grams / 30 days

desoximetasone spr 0.25%

100 mLs/ 30 days

desrx gel 0.05%

120 grams / 30 days

diclofenac gel 1%

10 tubes / 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

DOXEPIN HCL CRE 5%

45 grams / 30 days

DUPIXENT injection 200/1.141

2 syringes / 28 days

DUPIXENT injection 300/2ML1

2 syringes / 28 days

DUPIXENT injection 300/2ML1

2 pens / 28 days

fluocin acet cre 0.01%

120 grams / 30 days

fluocin acet cre 0.025%

120 grams / 30 days

fluocin acet oil 0.01% sc

118.28 mLs/ 30 days

fluocin acet oil 0.01%bdy

118.28 mLs/ 30 days

fluocin acet oil body

118.28 mLs/ 30 days

fluocin acet oil scalp

118.28 mLs/ 30 days

fluocin acet oin 0.025%

120 grams / 30 days

fluocin acet 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

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

FOLLISTIM AQ injection 300unit1

15 carts / 30 days

FOLLISTIM AQ injection 600unit1

8 carts / 30 days

FOLLISTIM AQ injection 900unit1

5 carts / 30 days

GALAFOLD CAP 123MG1

14 caps / 28 days

glydo gel 2%

150 mLs/ 30 days

halcinonide cre 0.1%

240 grams / 30 days

HALOBETASOL AER 0.05%

200 grams / 28 days

halobetasol cre 0.05%

200 grams / 28 days

halobetasol oin 0.05%

200 grams / 28 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 cre 0.1%

120 grams / 30 days

hc butyrate oin 0.1%

135 grams / 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

hydrocort cre 2.5%

454 grams / 30 days

hydrocort lot 2.5%

118 mLs/ 30 days

hydrocort oin 1%

453.6 grams / 30 days

hydrocort oin 2.5%

454 grams / 30 days

hydrocortiso lot 0.1%

118 mLs/ 30 days

hydrocortiso oin absorbas

453.6 grams / 30 days

IMPEKLO LOT 0.05%

204 grams / 28 days

ISTURISA TAB 10MG4

180 tabs / 30 days

ISTURISA TAB 1MG4

240 tabs / 30 days

ISTURISA TAB 5MG4

300 tabs / 30 days

JYNARQUE PAK 30-15MG1

56 tabs / 28 days

JYNARQUE PAK 45-15MG1

56 tabs / 28 days

JYNARQUE PAK 60-30MG1

56 tabs / 28 days

JYNARQUE PAK 90-30MG1

56 tabs / 28 days

JYNARQUE TAB 15MG1

60 tabs / 30 days

JYNARQUE TAB 15MG1

56 tabs / 28 days

JYNARQUE TAB 30MG1

30 tabs / 30 days

KEVEYIS TAB 50MG4

120 tabs / 30 days

LEXETTE AER 0.05%

200 grams / 28 days

lido/prilococaine 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 oin 5%

100 grams / 30 days

lidocaine oin pak 5%

100 grams / 30 days

lidocaine pad 5%

90 patches / 30 days

lidocaine sol 4%

150 mLs/ 30 days

MENOPUR injection 75unit1

60 vials / 30 days

MICORT-HC CRE 2.5%

120 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

ONETOUCH TES ULTRA

204 strips / 30 days

ONETOUCH TES ULTRA BL

204 strips / 30 days

ONETOUCH TES VERIO

204 strips / 30 days

PANDEL CRE 0.1%

160 grams / 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

PRUDOXIN CRE 5%

45 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

SKYRIZI injection 150DOSE1

1 box / 84 days

SKYRIZI injection 150MG/ML

1 syringe / 84 days

SKYRIZI pen injection 150MG/ML

1 injectiondv / 84 days

STELARA injection 45MG/0.51

1 syringe / 84 days

STELARA injection 90MG/ML1

1 syringe / 56 days

SUCRAID SOL 8500/ML

236 mLs/ 28 days

SYNERA DIS 70-70MG

4 patches / 30 days

TEXACORT SOL 2.5%

120 mLs/ 30 days

tovet aer 0.05%

200 grams / 28 days

TREMFYA injection 100MG/ML1

1 syringe / 56 days

TREMFYA injection 100MG/ML1

1 pen / 56 days

triamcinolon aer spray

126 grams / 30 days

triamcinolon cre 0.025%

454 grams / 30 days

triamcinolon cre 0.1%

454 grams / 30 days

triamcinolon cre 0.5%

454 grams / 30 days

triamcinolon lot 0.025%

120 mLs/ 30 days

triamcinolon lot 0.1%

120 mLs/ 30 days

triamcinolon oin 0.025%

454 grams / 30 days

triamcinolon oin 0.05%

430 grams / 30 days

triamcinolon oin 0.1%

454 grams / 30 days

triamcinolon 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

tritocin oin 0.05%

430 grams / 30 days

ULTRAVATE LOT 0.05%

240 mLs/ 30 days

VERDESO AER 0.05%

100 grams / 30 days

ZONALON CRE 5%

45 grams / 30 days

ZTLIDO PAD 1.8%

90 patches / 30 days

Diagnostic products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NATPARA injection 25MCG1

1 kit / 28 days

NATPARA injection 50MCG1

1 kit / 28 days

NATPARA injection 75MCG1

1 kit / 28 days

NATPARA injection 100MCG1

1 kit / 28 days

Digestive aids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NOCTIVA SPR 1.66/0.1

1 bottle / 30 days

Diuretics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

NOVAREL injection 10000UNT1

2 vials / 30 days

Endocrine and metabolic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALORA DIS 0.025MG

8 patches / 28 days

ALORA DIS 0.05MG

8 patches / 28 days

ALORA DIS 0.075MG

8 patches / 28 days

ALORA DIS 0.1MG

8 patches / 28 days

CLIMARA PRO DIS WEEKLY

4 patches / 28 days

COMBIPATCH DIS

8 patches / 28 days

DIVIGEL GEL 0.25MG

30 packets / 30 days

DIVIGEL GEL 0.5MG

30 packets / 30 days

DIVIGEL GEL 0.75MG

30 packets / 30 days

DIVIGEL GEL 1.25MG

37.5 grams / 30 days

DIVIGEL GEL 1MG/GM

30 packets / 30 days

dotti dis 0.025mg

8 patches / 28 days

dotti dis 0.0375mg

8 patches / 28 days

dotti dis 0.05mg

8 patches / 28 days

dotti dis 0.075mg

8 patches / 28 days

dotti dis 0.1mg

8 patches / 28 days

ELESTRIN GEL 0.06%

1 pump / 30 days

estradiol dis 0.025mg

8 patches / 28 days

ESTROGEL GEL

1 pump / 30 days

EVAMIST SPR 1.53MG

5 bottles / 93 days

ganirelix ac injection 250/0.51

5 syringes / 30 days

MENOSTAR DIS 14MCG

4 patches / 28 days

NOVAREL injection 5000unit1

4 vials / 30 days

ORIAHNN CAP

56 caps / 28 days

ORILISSA TAB 150MG

30 tabs / 30 days

ORILISSA TAB 200MG

60 tabs / 30 days

PREGNYL injection 10000UNT1

2 vials / 30 days

SAMSCA TAB 15MG1

30 tabs / 365 days

TOLVAPTAN TAB 15MG1

30 tabs / 365 days

tolvaptan tab 30mg

60 tabs / 365 days

tolvaptan tab 30mg1

60 tabs / 365 days

TYMLOS injection1

1 pen / 30 days

Estrogens

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BERINERT injection 500unit1

10 vials / 30 days

CABLIVI kit 11MG4

58 vials / 365 days

CERDELGA CAP 84MG1

60 caps / 30 days

CIMZIA PREFL kit 200MG/ML1

2 kits / 28 days

CIMZIA START kit 200MG/ML1

1 kit / 180 days

DOPTELET TAB 20MG4

60 tabs / 30 days

estradiol dis 0.025mg

4 patches / 28 days

estradiol dis 0.0375mg

8 patches / 28 days

estradiol dis 0.0375mg

4 patches / 28 days

estradiol dis 0.05mg

8 patches / 28 days

estradiol dis 0.05mg

4 patches / 28 days

estradiol dis 0.06mg

4 patches / 28 days

estradiol dis 0.075mg

8 patches / 28 days

estradiol dis 0.075mg

4 patches / 28 days

estradiol dis 0.1mg

8 patches / 28 days

estradiol dis 0.1mg

4 patches / 28 days

HAEGARDA injection 2000unit4

24 vials / 30 days

HAEGARDA injection 3000unit4

16 vials / 30 days

HEMLIBRA injection 105/0.71

4 vials / 28 days

HEMLIBRA injection 150/ML1

4 vials / 28 days

HEMLIBRA injection 30MG/ML1

4 vials / 28 days

HEMLIBRA injection 60/0.41

4 vials / 28 days

icatibant injection 30mg/3ml1

6 syringes / 30 days

lyllana dis 0.025mg

8 patches / 28 days

lyllana dis 0.0375mg

8 patches / 28 days

lyllana dis 0.05mg

8 patches / 28 days

lyllana dis 0.075mg

8 patches / 28 days

lyllana dis 0.1mg

8 patches / 28 days

MULPLETA TAB 3MG1

7 tabs / 7 days

OCALIVA TAB 10MG1

30 tabs / 30 days

OCALIVA TAB 5MG1

30 tabs / 30 days

OXBRYTA TAB 500MG4

90 tabs / 30 days

RUCONEST injection 2100unit1

8 vials / 30 days

TAKHZYRO injection 300/2ML4

4 mLs/ 28 days

TAVALISSE TAB 100MG4

60 tabs / 30 days

TAVALISSE TAB 150MG4

60 tabs / 30 days

XERMELO TAB 250MG4

90 tabs / 30 days

Gastrointestinal agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

PROMACTA PAK 25MG1

30 packs / 30 days

PROMACTA POW 12.5MG1

30 packets / 30 days

PROMACTA TAB 12.5MG1

30 tabs / 30 days

PROMACTA TAB 25MG1

30 tabs / 30 days

PROMACTA TAB 50MG1

60 tabs / 30 days

Hematological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

BELSOMRA TAB 10MG

30 tabs / 30 days

BELSOMRA TAB 15MG

30 tabs / 30 days

BELSOMRA TAB 20MG

30 tabs / 30 days

BELSOMRA TAB 5MG

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

miglustat cap 100mg1

90 caps / 30 days

PROMACTA TAB 75MG1

60 tabs / 30 days

ZOLPIMIST SPR 5MG

1 can / 30 days

Hematopoietic agents

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

zaleplon cap 10mg

30 caps / 30 days

zaleplon cap 5mg

30 caps / 30 days

zolpidem tab 10mg

30 tabs / 30 days

zolpidem tab 5mg

30 tabs / 30 days

zolpidem er tab 12.5mg

30 tabs / 30 days

zolpidem er tab 6.25mg

30 tabs / 30 days

zolpidem tar sub 1.75mg

30 tabs / 30 days

zolpidem tar sub 3.5mg

30 tabs / 30 days

Hypnotics / Sedatives / Sleep disorder agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AIMOVIG injection 140MG/ML1

1 injection / 28 days

AIMOVIG injection 70MG/ML1

1 injection / 28 days

Almotrip mal tab 12.5mg

12 tabs / 30 days

Almotrip mal tab 6.25mg

24 tabs / 30 days

Almotriptan tab 12.5mg

12 tabs / 30 days

Almotriptan tab 6.25mg

24 tabs / 30 days

DEXCOM G6 MIS SENSOR

3 units / 30 days

DEXCOM G6 MIS TRANSMIT

1 unit / 90 days

eletriptan tab 20mg

18 tabs / 30 days

EMGALITY injection 100MG/ML1

9 syringes / 180 days

EMGALITY injection 120MG/ML1

1 syringe / 28 days

G5/G4 MIS SENSOR

4 units / 28 days

NURTEC TAB 75MG ODT

45 tabs / 90 days

REYVOW TAB 100MG

8 tabs / 30 days

REYVOW TAB 50MG

8 tabs / 30 days

SUMATRIPTAN injection 6MG/0.5

12 syringes / 30 days

TOSYMRA SOL 10MG

18 sprays / 30 days

UBRELVY TAB 100MG

16 tabs / 30 days

UBRELVY TAB 50MG

16 tabs / 30 days

Medical devices and supplies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

eletriptan tab 40mg

12 tabs / 30 days

frovatriptan tab 2.5mg

27 tabs / 30 days

naratriptan tab 1mg

18 tabs / 30 days

naratriptan tab 2.5mg

18 tabs / 30 days

rizatriptan tab 5mg

36 tabs / 30 days

rizatriptan tab 10mg

18 tabs / 30 days

rizatriptan tab 10mg odt

18 tabs / 30 days

Migraine products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Azelastine/fluticasone spr 137-50

1 bottle / 30 days

Azelastine spr 0.1%

2 bottles / 30 days

BECONASE AQ SUS 0.042%

2 bottles / 30 days

BENLYSTA injection 200MG/ML1

4 syringes / 28 days

ENSPRYNG injection1

1 syringe / 28 days

FLUNISOLIDE SPR 0.025%

3 bottles / 30 days

OMNARIS SPR

1 bottle / 30 days

OZOBAX SOL 5MG/5ML

2400 mLs/ 30 days

QNASL AER 80MCG

1 inhaler / 30 days

QNASL CHILD SPR 40MCG

1 inhaler / 30 days

REVLIMID CAP 10MG1

30 caps / 30 days

REVLIMID CAP 15MG1

21 caps / 28 days

REVLIMID CAP 2.5MG1

30 caps / 30 days

REVLIMID CAP 20MG1

21 caps / 28 days

REVLIMID CAP 25MG1

21 caps / 28 days

REVLIMID CAP 5MG1

30 caps / 30 days

rizatriptan tab 5mg odt

36 tabs / 30 days

sumat-naprox tab 85-500mg

18 tabs / 30 days

sumatriptan injection 4mg/0.5

12 carts / 30 days

sumatriptan injection 4mg/0.5

12 syringes / 30 days

sumatriptan injection 6/0.5ml

12 syringes / 30 days

sumatriptan injection 6mg/0.5

12 carts / 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

THALOMID CAP 100MG1

30 caps / 30 days

THALOMID CAP 150MG1

60 caps / 30 days

THALOMID CAP 200MG1

60 caps / 30 days

THALOMID CAP 50MG1

30 caps / 30 days

XHANCE MIS 93MCG

2 bottles / 30 days

ZETONNA AER 37MCG

1 inhaler / 30 days

ZOKINVY CAP 50MG4

120 caps / 30 days

ZOKINVY CAP 75MG4

120 caps / 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

Miscellaneous therapeutic classes

Drug name(s)

Quantity limits 
(per 30 days or as specified)

Azelastine spr 0.15%

2 bottles / 30 days

EVRYSDI SOL4

240 mLs/ 30 days

fluticasone spr 50mcg

1 bottle / 30 days

ipratropium spr 0.03%

2 bottles / 30 days

ipratropium spr 0.06%

3 bottles / 30 days

LUMIGAN SOL 0.01%

2.5 mLs/ 30 days

mometasone spr 50mcg

2 bottles / 30 days

olopatadine spr 0.6%

1 bottle / 30 days

OXERVATE SOL 20MCG/ML4

56 vials / 56 days

RHOPRESSA SOL 0.02%

2.5 mLs/ 30 days

riluzole tab 50mg

60 tabs / 30 days

ROCKLATAN DROPS

2.5 mLs/ 30 days

TIGLUTIK SUS 50/10ML

600 mLs/ 30 days

VYZULTA SOL 0.024%

2.5 mLs/ 30 days

Muscoluloskeletal therapy agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

latanoprost sol 0.005%

2.5 mLs/ 30 days

Nasal agents – systemic and topical

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADDYI TAB 100MG

30 tabs / 30 days

AUBAGIO TAB 14MG1, 3

30 tabs / 30 days

AUBAGIO TAB 7MG1, 3

30 tabs / 30 days

AUSTEDO TAB 12MG1

120 tabs / 30 days

AUSTEDO TAB 6MG1

60 tabs / 30 days

AUSTEDO TAB 9MG1

120 tabs / 30 days

AVONEX pen kit 30MCG1

1 pack / 28 days

AVONEX PREFL kit 30MCG1

1 kit / 28 days

BETASERON injection 0.3MG1

1 box / 28 days

GILENYA CAP 0.5MG1

30 tabs / 30 days

GRALISE TAB 300MG

30 tabs / 30 days

GRALISE TAB 600MG

90 tabs / 30 days

HORIZANT TAB 300MG ER

60 tabs / 30 days

HORIZANT TAB 600MG ER

60 tabs / 30 days

INGREZZA CAP 40-80MG4

28 caps / 180 days

INGREZZA CAP 40MG4

30 caps / 30 days

travoprost dro 0.004%

2.5 mLs/ 30 days

Neuromuscular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

INGREZZA CAP 60MG

30 caps / 30 days

INGREZZA CAP 80MG4

30 caps / 30 days

KESIMPTA injection 20/.4ML1

1 syringe / 28 days

Ophthalmic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

LUCEMYRA TAB 0.18MG

228 tabs / 180 days

MAVENCLAD PAK 10MG (4 tablet pack)1

8 tabs / 301 days

MAVENCLAD PAK 10MG (5 tablet pack)1

10 tabs / 301 days

MAVENCLAD PAK 10MG (6 tablet pack)1

12 tabs / 301 days

MAVENCLAD PAK 10MG (7 tablet pack)1

14 tabs / 301 days

MAVENCLAD PAK 10MG (8 tablet pack)1

8 tabs / 301 days

MAVENCLAD PAK 10MG (10 tablet pack)1

20 tabs / 301 days

Psychotherapeutic and neurological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

dalfampridine tab 10mg er1, 3

60 tabs / 30 days

DEXILANT CAP 30MG DR

30 caps / 30 days

DEXILANT CAP 60MG DR

30 caps / 30 days

dimethyl fum cap 120mg dr

56 caps / 180 days

dimethyl fum cap 120mg dr1

56 caps / 180 days

dimethyl fum cap 240mg dr1

60 caps / 30 days

dimethyl fum mis starter1

60 caps / 180 days

ESBRIET CAP 267MG1

180 caps / 30 days

ESBRIET TAB 267MG1

180 tabs / 30 days

ESBRIET TAB 801MG1

90 tabs / 30 days

esomeprazole mag cap 20mg dr

30 caps / 30 days

esomeprazole mag cap 40mg dr

30 caps / 30 days

glatiramer injection 20mg/ml1

30 syringes / 30 days

glatiramer injection 40mg/ml1

12 syringes / 28 days

KALYDECO PAK 25MG1

60 packets / 30 days

KALYDECO PAK 50MG1

60 packets / 30 days

KALYDECO PAK 75MG1

60 packets / 30 days

KALYDECO TAB 150MG1

60 tabs / 30 days

lansoprazole cap 15mg dr

30 caps / 30 days

lansoprazole cap 30mg dr

30 caps / 30 days

MAVENCLAD PAK 10MG(9)1

9 tabs / 301 days

MAYZENT PAK STARTER

12 tabs / 180 days

MAYZENT TAB 0.25MG1

120 tabs / 30 days

MAYZENT TAB 2MG1

30 tabs / 30 days

OFEV CAP 100MG1, 3

60 caps / 30 days

OFEV CAP 150MG1, 3

60 caps / 30 days

omeppi cap 20-1100

30 caps / 30 days

omeppi cap 40-1100

30 caps / 30 days

omeprazole/bicarbonate cap 20-1100

30 caps / 30 days

omeprazole/bicarbonate cap 40-1100

30 caps / 30 days

ORKAMBI GRA 100-1251

60 packets / 30 days

ORKAMBI GRA 150-1881

60 packets / 30 days

ORKAMBI TAB 100-1251

120 tabs / 30 days

ORKAMBI TAB 200-1251

120 tabs / 30 days

PLEGRIDY injection1

2 syringes / 28 days

PLEGRIDY injection pen1

2 pens / 28 days

PLEGRIDY injection STARTER1

1 kit / 180 days

PLEGRIDY pen injection STARTER1

1 kit / 180 days

REBIF injection 22/0.51

12 syringes / 28 days

REBIF injection 44/0.51

1 carton / 28 days

REBIF REBIDO injection 22/0.51

1 carton / 28 days

REBIF REBIDO injection 44/0.51

1 carton / 28 days

REBIF REBIDO injection TITRATN1

1 kit / 180 days

Psychotherapeutic and neurological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

REBIF TITRTN injection pack1

1 kit / 180 days

SAVELLA MIS TITR PAK

1 pack / 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

SYMDEKO TAB 50-75MG1

56 tabs / 28 days

SYMDEKO TAB 100-1501

60 tabs / 30 days

TEGSEDI injection 284/1.54

6 mLs/ 28 days

tetrabenazin tab 12.5mg1

240 tabs / 30 days

tetrabenazin tab 25mg1

120 tabs / 30 days

TRIKAFTA TAB1

90 tabs / 30 days

VYLEESI injection 1.75/0.3

6 pens / 30 days

XYREM SOL 500MG/ML4

540 mLs/ 30 days

XYWAV SOL 0.5GM/ML4

540 mLs/ 30 days

ZEPOSIA CAP .92MG1

30 caps / 30 days

ZEPOSIA CAP STR kit1

37 caps / 180 days

ZEPOSIA 7DAY CAP STR pack1

7 caps / 180 days

Respiratory agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ENDOMETRIN SUP 100MG

84 supps / 28 days

ESTRING MIS 2MG

1 ring / 90 days

FEMRING MIS 0.05/24H

1 ring / 90 days

FEMRING MIS 0.1MG/24

1 ring / 90 days

NORTHERA CAP 100MG1

450 caps / 30 days

NORTHERA CAP 200MG1

180 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

rabeprazole tab 20mg

30 tabs / 30 days

Ulcer drugs / Antispasmodics / Anticholinergics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

droxidopa cap 100mg1

450 caps / 30 days

droxidopa cap 200mg1

180 caps / 30 days

NORTHERA CAP 300MG1

180 caps / 30 days

Vaginal and related products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ENDOMETRIN SUP 100MG

84 supps / 28 days

ESTRING MIS 2MG

1 ring / 90 days

FEMRING MIS 0.05/24H

1 ring / 90 days

FEMRING MIS 0.1MG/24

1 ring / 90 days

Vasopressors

Drug name(s)

Quantity limits 
(per 30 days or as specified)

droxidopa cap 100mg1

450 caps / 30 days

droxidopa cap 200mg1

180 caps / 30 days

droxidopa cap 300mg1

180 caps / 30 days

NORTHERA CAP 100MG1

450 caps / 30 days

NORTHERA CAP 200MG1

180 caps / 30 days

NORTHERA CAP 300MG1

180 caps / 30 days

Drug name(s)

abiraterone acetate1, 3

ACTEMRA1

ACTEMRA ACTPEN1

ACTHAR1

ADVATE1

ADYNOVATE1

AFINITOR1, 3

AFINITOR DISPERZ1, 3

AFSTYLA1

AIMOVIG1

ALPHANINE SD1

ALPROLIX1

alyq1

ambrisentan1

ARANESP ALBUMIN FREE1

AUBAGIO1, 3

AUSTEDO1

AVONEX1

AVONEX PEN1

BENEFIX1

BENLYSTA1

BERINERT1

BETASERON1

bexarotene1, 3

bosentan1

BOSULIF1, 3

CABOMETYX1, 3

capecitabine1

CERDELGA1

CHORIONIC GONADOTROPIN1

CIMZIA1

CIMZIA STARTER KIT1

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

dalfampridine er1, 3

DAURISMO1, 3

dimethyl fumarate dr1

dimethyl fumarate starter pack1

DUPIXENT1

ELOCTATE1

EMGALITY1

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

ENSPRYNG1

EPCLUSA1

EPIDIOLEX1

EPOGEN1

ERIVEDGE1, 3

ERLEADA1

erlotinib1, 3

ESBRIET1

ESPEROCT1

everolimus1, 3

FARYDAK1

FOLLISTIM AQ1

GALAFOLD1

ganirelix acetate1

GILENYA1

glatiramer acetate1

HARVONI1

HELIXATE FS1

HEMLIBRA1

HEMOFIL M1

HUMIRA1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1

HUMIRA PEN1

HUMIRA PEN-CD/UC/HS STARTER1

HUMIRA PEN-PEDIATRIC UC STARTER PACK1

HUMIRA PEN-PS/UV STARTER1

HYCAMTIN1

IBRANCE1

icatibant acetate1

IDELVION1

IDHIFA1

imatinib mesylate1, 3

INLYTA1, 3

INQOVI1

INREBIC1, 3

IXINITY1

JAKAFI1, 3

JIVI1

JYNARQUE1

KALYDECO1

KESIMPTA1

KEVZARA1

KISQALI1

KOATE1

KOATE-DVI1

KOGENATE FS1

KOVALTRY1

lapatinib ditosylate1

LEDIPASVIR / SOFOSBUVIR1

LONSURF1

LORBRENA1, 3

MATULANE1

MAVENCLAD1

MAVYRET1

MAYZENT1

MEKINIST1

MENOPUR1

miglustat1

MIRCERA1

MONONINE1

MULPLETA1

NEXAVAR1, 3

NINLARO1

NORDITROPIN FLEXPRO1

NOVAREL1

NOVOEIGHT1

NUBEQA1

NUWIQ1

OCALIVA1

ODOMZO1, 3

OFEV1, 3

ONUREG1

ORKAMBI1

OTEZLA1

PEGINTRON1

PIQRAY1

PLEGRIDY1

PLEGRIDY STARTER PACK1

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1

PROCRIT1

PROFILNINE1

PROFILNINE SD1

PROMACTA1

RAVICTI1

REBIF1

REBIF REBIDOSE1

REBIF REBIDOSE TITRATION PACK1

REBIF TITRATION PACK1

REBINYN1

RECOMBINATE1

RETACRIT1

RETEVMO1, 3

REVLIMID1

RINVOQ1

RIXUBIS1

ROZLYTREK1, 3

RUCONEST1

RYDAPT1

sapropterin dihydrochloride1

sildenafil citrate1

SIMPONI1

SKYRIZI1

sodium phenylbutyrate1

SOFOSBUVIR/VELPATASVIR1

SOVALDI1

SPRYCEL1, 3

STELARA1

STIVARGA1

SUTENT1, 3

SYLATRON1

SYMDEKO1

TABRECTA1

tadalafil1

TAFINLAR1

TALZENNA1, 3

TASIGNA1, 3

temozolomide1

tetrabenazine1

THALOMID1

TRACLEER1

TREMFYA1

TRIKAFTA1

VIZIMPRO1, 3

VOSEVI1

VOTRIENT1, 3

VYNDAMAX1

VYNDAQEL1

XALKORI1, 3

XELJANZ1

XELJANZ XR1

XTANDI1, 3

XYNTHA1

XYNTHA SOLOFUSE1

ZELBORAF1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOLINZA1, 3

ZYKADIA1, 3

ZYTIGA1, 3

 

1Specialty

2Limited distribution

3Split fill

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