Value Plus Prescription Drug Benefits

Effective January 1 , 2020

Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the Value Plus 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 ADCIRCA1 ADEMPAS1, 2
AFINITOR DISPERZ1 AFINITOR1 ALECENSA1, 2
alosetron hydrochloride ALUNBRIG1, 2 alyq1
ambrisentan1 AMPYRA1 ANDRODERM
ANDROGEL ANDROGEL PUMP ARCALYST1, 2
armodafinil AUBAGIO1 avita
AVONEX PEN1 AVONEX1 benzphetamine hcl
BETASERON1 bexarotene1 bosentan1
buprenorphine capecitabine1 CAPRELSA1, 2
CERDELGA1 CETROTIDE1 ciclodan
ciclopirox nail lacquer cinacalcet hydrochloride1 clomipramine hydrochloride
COMETRIQ1, 2 COPAXONE1 COSENTYX SENSOREADY PEN1
COSENTYX1 COTELLIC1 cyclobenzaprine hydrochloride er
dalfampridine er1 DARAPRIM diclofenac sodium
diethylpropion hcl diethylpropion hcl er diethylpropion hydrochloride
doxylamine succinate/pyridoxine hydrochloride EGRIFTA SV1 EGRIFTA1
ENBREL MINI1 ENBREL SURECLICK1 ENBREL1
EPCLUSA1 ERIVEDGE1 erlotinib hydrochloride1
ESBRIET1 everolimus1 fentanyl
fentanyl citrate oral transmucosal FIRAZYR1 FLUOXETINE HYDROCHLORIDE
FORTEO1 ganirelix acetate1 GANIRELIX ACETATE1
GILENYA1 GILOTRIF1, 2 glatiramer acetate1
glatopa1 HARVONI1 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1
HUMIRA PEN1 HUMIRA PEN-CD/UC/HS STARTER1 HUMIRA PEN-PS/UV STARTER1
HUMIRA1 HYCAMTIN1 hydrocodone bitartrate er
hydromorphone hydrochloride hydromorphone hydrochloride er IBRANCE1
icatibant acetate1 ICLUSIG1, 2 IMBRUVICA1, 2
INGREZZA1, 2 INLYTA1 INTRON A1
IRESSA1, 2 JAKAFI1 JUXTAPID1, 2
KADIAN KALYDECO1 KISQALI1
KISQALI FEMARA1 KOGENATE FS BIO-SET1 KOGENATE FS1
KORLYM1, 2 KUVAN1 LEDIPASVIR/SOFOSBUVIR1
LENVIMA1 lidocaine LONSURF1
LYNPARZA1, 2 MAVYRET1 MAYZENT1
MEKINIST1 metaxall metaxalone
metformin hydrochloride er methadone hydrochloride METHITEST
miglustat1 modafinil mometasone furoate
morphine sulfate cr morphine sulfate er MYALEPT1, 2
NAPROSYN NEULASTA ONPRO KIT1 NEULASTA1
NINLARO1 NORDITROPIN FLEXPRO1 NUPLAZID1
ODOMZO1 OFEV1 omeppi
omeprazole/sodium bicarbonate ORKAMBI1 OTEZLA1
oxymorphone hydrochloride phendimetrazine tartrate phentermine hydrochloride
PLEGRIDY STARTER PACK1 PLEGRIDY1 PRALUENT1
PROMACTA1 ramelteon REBIF REBIDOSE TITRATION PACK1
REBIF REBIDOSE1 REBIF TITRATION PACK1 REBIF1
REGRANEX REPATHA PUSHTRONEX SYSTEM1 REPATHA SURECLICK1
REPATHA1 RESTASIS RESTASIS MULTIDOSE
REVATIO1 REVLIMID1 RINVOQ1
ROZEREM SENSIPAR1 SIGNIFOR1, 2
sildenafil citrate1 SKYRIZI1 sodium phenylbutyrate1
SOFOSBUVIR/VELPATASVIR1 SOMAVERT1 SOVALDI1
STELARA1 STIMATE1 STIVARGA1
STRENSIQ1, 2 SUTENT1 tadalafil1
TAFINLAR1 TAGRISSO1, 2 TARCEVA1
tazarotene TAZORAC TECFIDERA STARTER PACK1
TECFIDERA1 testosterone testosterone cypionate
TESTOSTERONE ENANTHATE testosterone pump testosterone topical solution
tetrabenazine1 THALOMID1 tobramycin1
tramadol hydrochloride er TREMFYA1 tretinoin
tretinoin microsphere tretinoin microsphere pump TYMLOS1
VENCLEXTA STARTING PACK1, 2 VENCLEXTA1, 2 VIZIMPRO1
VOSEVI1 VOTRIENT1 XTANDI1
ZAVESCA1, 2 ZEJULA1, 2 ZELBORAF1
ZOLINZA1 ZYDELIG1, 2 ZYKADIA1
ZYTIGA1    

Drug Name(s)

AMCINONIDE CAPEX clindamycin phosphate/tretinoin
CLOZAPINE ODT ELIDEL EMADINE
FANAPT FANAPT TITRATION PACK GELNIQUE
GELNIQUE PUMP JENTADUETO JENTADUETO XR
lanthanum carbonate LUMIGAN LYRICA
pimecrolimus RENAGEL RYBELSUS
SAVELLA SAVELLA TITRATION PACK SEVELAMER HYDROCHLORIDE
tacrolimus TRAVATAN Z TRIANEX
ZIOPTAN    

Analgesics

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

acetaminophen/caffeine/dihydrocodeine capsules 50 Capsules/30 Days
acetaminophen/codeine solution 120-12/5 450 mLs/30 Days
acetaminophen/codeine tablet 300-15mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-30mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-60mg 25 Tablets/30 Days
buprenorphine dis 5mcg/hr 4 Systems/30 Days
buprenorphine dis 10mcg/hr 4 Systems/30 Days
buprenorphine dis 15mcg/hr 4 Systems/30 Days
buprenorphine dis 20mcg/hr 4 Systems/30 Days
butorphanol solution 10mg/mL 1 Bottle/30 Days
codeine sulfate tablet 30mg 30 Tablets/30 Days
codeine sulfate tablet 60mg 25 Tablets/30 Days
codeine/acetaminophen tablet 30-300mg 30 Tablets/30 Days
codeine sulfate tablet 60-300mg 25 Tablets/30 Days
diclofenac gel 1% 10 Tubes/30 Days
diclofenac solution 1.5% 2 Bottles/30 Days
dvorah capsules 50 Capsules/30 Days
endocet tablet 2.5-325 60 Tablets/30 Days
endocet tablet 5-325mg 30 Tablets/30 Days
endocet tablet 7.5-325 20 Tablets/30 Days
endocet tablet 10-325mg 15 Tablets/30 Days
fentanyl dis 12mcg/hr 10 Patches/30 Days
fentanyl dis 25mcg/hr 0
fentanyl dis 37.5mcg 0
fentanyl dis 50mcg/hr 0
fentanyl dis 62.5mcg 0
fentanyl dis 75mcg/hr 0
fentanyl dis 87.5mcg 0
fentanyl dis 100mcg/hr 0
fentanyl ot lozenge 200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 400mcg 120 Lozenges/30 Days
fentanyl ot lozenge 600mcg 120 Lozenges/30 Days
fentanyl ot lozenge 800mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1600mcg 120 Lozenges/30 Days
hydrocodone capsule 10mg er 60 Capsules/30 Days
hydrocodone capsule 15mg er 60 Capsules/30 Days
hydrocodone capsule 20mg er 60 Capsules/30 Days
hydrocodone capsule 30mg er 30 Capsules/30 Days
hydrocodone capsule 40mg er 30 Capsules/30 Days
hydrocodone capsule 50mg er 30 Capsules/30 Days
hydrocodone/acetaminophen solution 7.5-325 450 mLs/30 Days
hydrocodone/acetaminophen tablet 5-300mg 40 Tablets/30 Days
hydrocodone/acetaminophen tablet 7.5-300 30 Tablets/30 Days
hydrocodone/acetaminophen tablet 10-300mg 25 Tablets/30 Days
hydrocodone/acetaminophen tablet 2.5-325 60 Tablets/30 Days
hydrocodone/acetaminophen tablet 5-325mg 40 Tablets/30 Days
hydrocodone/acetaminophen tablet 7.5-325 30 Tablets/30 Days
hydrocodone/acetaminophen tablet 10-325mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 5-200mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 7.5-200 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 10-200mg 25 Tablets/30 Days
hydromorphone liquid 1mg/mL 60 mLs/30 Days
HYDROMORPHONE SUPPOSITORY 3MG 20 Suppositories/30 Days
hydromorphone tablet 2mg 30 Tablets/30 Days
hydromorphone tablet 4mg 15 Tablets/30 Days
hydromorphone tablet 8mg 5 Tablets/30 Days
hydromorphone tablet 8mg er 30 Tablets/30 Days
hydromorphone tablet 12mg er 30 Tablets/30 Days
hydromorphone tablet 16mg er 0
hydromorphone tablet 32mg er 0
ibudone tablet 5-200mg 25 Tablets/30 Days
KADIAN CAPSULE 200MG ER 0
klofensaid solution ii 2 Bottles/30 Days
levorphanol tablet 2mg 10 Tablets/30 Days
lorcet hd tablet 10-325mg 25 Tablets/30 Days
lorcet plus tablet 7.5-325 30 Tablets/30 Days
lorcet tablet 5-325mg 40 Tablets/30 Days
meperidine tablet 50mg 30 Tablets/30 Days
meperidine tablet 100mg 15 Tablets/30 Days
methadone solution 5mg/5mL 300 mLs/30 Days
methadone solution 10mg/5mL 150 mLs/30 Days
methadone tablet 5mg 60 Tablets/30 Days
methadone tablet 10mg 30 Tablets/30 Days
morphine sulfate capsule 10mg er 30 Capsules/30 Days
morphine sulfate capsule 20mg er 30 Capsules/30 Days
morphine sulfate capsule 30mg er 30 Capsules/30 Days
morphine sulfate capsule 40mg er 30 Capsules/30 Days
morphine sulfate capsule 50mg er 30 Capsules/30 Days
morphine sulfate capsule 60mg er 0
morphine sulfate capsule 80mg er 0
morphine sulfate capsule 100mg er 0
morphine sulfate solution 10mg/5mL 125 mLs/30 Days
morphine sulfate solution 20mg/mL 10 mLs/30 Days
morphine sulfate solution 20mg/5mL 60 mLs/30 Days
MORPHINE SULFATE SUPPOSITORY 30MG 5 Suppositories/30 Days
morphine sulfate tablet 15mg 15 Tablets/30 Days
morphine sulfate tablet 30mg 5 Tablets/30 Days
morphine sulfate tablet 100mg cr 0
morphine sulfate tablet 15mg er 60 Tablets/30 Days
morphine sulfate tablet 30mg er 30 Tablets/30 Days
morphine sulfate tablet 60mg er 0
morphine sulfate tablet 100mg er 0
morphine sulfate tablet 200mg er 0
oxycodone/acetaminophen tablet 2.5-325 60 Tablets/30 Days
oxycodone/acetaminophen tablet 5-325mg 30 Tablets/30 Days
oxycodone/acetaminophen tablet 7.5-325 20 Tablets/30 Days
oxycodone/acetaminophen tablet 10-325mg 15 Tablets/30 Days
oxycodone/aspirin tablet 30 Tablets/30 Days
oxycodone capsule 5mg 30 Capsules/30 Days
oxycodone concentrate 20/mL 5 mLs/30 Days
oxycodone solution 5mg/5mL 165 mLs/30 Days
oxycodone tablet 5mg 30 Tablets/30 Days
oxycodone tablet 10mg 15 Tablets/30 Days
oxycodone tablet 15mg 10 Tablets/30 Days
oxycodone tablet 20mg 5 Tablets/30 Days
oxycodone tablet 30mg 5 Tablets/30 Days
oxymorphone tablet hcl 5mg 15 Tablets/30 Days
oxymorphone tablet hcl 10mg 5 Tablets/30 Days
panlor tablet 325-30 50 Capsules/30 Days
pentazocine/naloxone tablet 50-0.5mg 10 Tablets/30 Days
tramadol/acetaminophen tablet 37.5-325 40 Tablets/30 Days
tramadol hcl tablet 50mg 50 Tablets/30 Days
tramadol hcl tablet 100mg er 30 Tablets/30 Days
tramadol hcl tablet 200mg er 30 Tablets/30 Days
tramadol hcl tablet 300mg er 30 Tablets/30 Days
vicodin es tablet 7.5-300 30 Tablets/30 Days
vicodin hp tablet 10-300mg 25 Tablets/30 Days
vicodin tablet 5-300mg 40 Tablets/30 Days
xylon tablet 10-200mg 25 Tablets/30 Days
lidocaine/prilocaine cream 2.5-2.5% 60 Grams/30 Days
lidocaine ointment 5% 600 Grams/30 Days
lidocaine ointment pack 5% 600 Grams/30 Days
lidocaine pad 5% 90 Patches/30 Days
lidocaine solution 4% 400 Grams/30 Days
lidocaine-prilocaine cream 60 Grams/30 Days

Anticonvulsants

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

LYRICA CAPSULE 25MG 90 Capsules/30 Days
LYRICA CAPSULE 50MG 90 Capsules/30 Days
LYRICA CAPSULE 75MG 90 Capsules/30 Days
LYRICA CAPSULE 100MG 90 Capsules/30 Days
LYRICA CAPSULE 150MG 90 Capsules/30 Days
LYRICA CAPSULE 200MG 90 Capsules/30 Days
LYRICA CAPSULE 225MG 60 Capsules/30 Days
LYRICA CAPSULE 300MG 60 Capsules/30 Days
LYRICA SOLUTION 20MG/mL 900 mLs/30 Days
pregabalin capsule 25mg 90 Capsules/30 Days
pregabalin capsule 50mg 90 Capsules/30 Days
pregabalin capsule 75mg 90 Capsules/30 Days
pregabalin capsule 100mg 90 Capsules/30 Days
pregabalin capsule 150mg 90 Capsules/30 Days
pregabalin capsule 200mg 90 Capsules/30 Days
pregabalin capsule 225mg 60 Capsules/30 Days
pregabalin capsule 300mg 60 Capsules/30 Days
pregabalin solution 20mg/mL 900 mLs/30 Days

Antiemetics

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

aprepitant capsule 40mg 8 Capsules/30 Days
aprepitant capsule 80mg 8 Capsules/30 Days
aprepitant capsule 125mg 4 Capsules/30 Days
aprepitant pack 80 and 125 4 Packs/30 Days
doxylamine/pyridoxine tablet 10-10mg 120 Tablets/30 Days
EMEND SUSPENSION 125MG 6 Packs/30 Days
granisetron tablet 1mg 14 Tablets/30 Days
ondansetron solution 4mg/5mL 5 Bottles/30 Days
ondansetron tablet 4mg 24 Tablets/30 Days
ondansetron tablet 8mg 24 Tablets/30 Days
ondansetron tablet 24mg 4 Tablets/30 Days
ondansetron tablet 4mg odt 24 Tablets/30 Days
ondansetron tablet 8mg odt 24 Tablets/30 Days

Antifungals

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ciclodan solution 8% 3.3 mLs/30 Days
ciclopirox solution 8% 3.3 mLs/30 Days

Antimigraine Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

almotriptan malate tablet 6.25mg 24 Tablets/30 Days
almotriptan malate tablet 12.5mg 12 Tablets/30 Days
almotriptan tablet 6.25mg 24 Tablets/30 Days
almotriptan tablet 12.5mg 12 Tablets/30 Days
eletriptan tablet 20mg 18 Tablets/30 Days
eletriptan tablet 40mg 12 Tablets/30 Days
frovatriptan tablet 2.5mg 27 Tablets/30 Days
naratriptan tablet 1mg 18 Tablets/30 Days
naratriptan tablet 2.5mg 18 Tablets/30 Days
rizatriptan tablet 5mg 36 Tablets/30 Days
rizatriptan tablet 10mg 18 Tablets/30 Days
rizatriptan tablet 5mg odt 36 Tablets/30 Days
rizatriptan tablet 10mg odt 18 Tablets/30 Days
sumatriptan-naproxen tablet 85-500mg 18 Tablets/30 Days
sumatriptan injection 4mg/0.5 12 Cartridges/30 Days
sumatriptan injection 4mg/0.5 12 Syringes/30 Days
sumatriptan injection 6mg/0.5 12 Cartridges/30 Days
sumatriptan injection 6mg/0.5 12 Syringes/30 Days
sumatriptan injection 6/0.5mL 12 Syringes/30 Days
sumatriptan spray 5mg/act 5 Packs/30 Days
sumatriptan spray 20mg/act 12 Inhalers/30 Days
sumatriptan tablet 25mg 27 Tablets/30 Days
sumatriptan tablet 50mg 18 Tablets/30 Days
sumatriptan tablet 100mg 18 Tablets/30 Days
zolmitriptan tablet 2.5mg 18 Tablets/30 Days
zolmitriptan tablet 5mg 12 Tablets/30 Days
zolmitriptan tablet 5mg odt 12 Tablets/30 Days

Antineoplastics

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

abiraterone tablet 250mg1 120 Tablets/30 Days
AFINITOR DIS TABLET 2MG1 60 Tablets/30 Days
AFINITOR DIS TABLET 3MG1 90 Tablets/30 Days
AFINITOR DIS TABLET 5MG1 60 Tablets/30 Days
AFINITOR TABLET 2.5MG1 30 Tablets/30 Days
AFINITOR TABLET 5MG1 30 Tablets/30 Days
AFINITOR TABLET 7.5MG1 30 Tablets/30 Days
AFINITOR TABLET 10MG1 30 Tablets/30 Days
ALECENSA CAPSULE 150MG1, 2 240 Capsules/30 Days
ALUNBRIG PACK1, 2 30 Tablets/180 Days
ALUNBRIG TABLET 30MG1, 2 180 Tablets/30 Days
ALUNBRIG TABLET 90MG1, 2 30 Tablets/30 Days
ALUNBRIG TABLET 180MG1, 2 30 Tablets/30 Days
CAPRELSA TABLET 100MG1, 2 60 Tablets/30 Days
CAPRELSA TABLET 300MG1, 2 30 Tablets/30 Days
COMETRIQ KIT 60MG1, 2 1 Carton/28 Days
COMETRIQ KIT 100MG1, 2 1 Carton/28 Days
COMETRIQ KIT 140MG1, 2 112 Tablets/28 Days
COTELLIC TABLET 20MG1 63 Tablets/28 Days
ERIVEDGE CAPSULE 150MG1 30 Capsules/30 Days
erlotinib tablet 25mg1 60 Tablets/30 Days
erlotinib tablet 100mg1 30 Tablets/30 Days
erlotinib tablet 150mg1 30 Tablets/30 Days
everolimus tablet 2.5mg1 30 Tablets/30 Days
everolimus tablet 5mg1 30 Tablets/30 Days
everolimus tablet 7.5mg1 30 Tablets/30 Days
GILOTRIF TABLET 20MG1, 2 30 Tablets/30 Days
GILOTRIF TABLET 30MG1, 2 30 Tablets/30 Days
GILOTRIF TABLET 40MG1, 2 30 Tablets/30 Days
IBRANCE CAPSULE 75MG1 21 Capsules/28 Days
IBRANCE CAPSULE 100MG1 21 Capsules/28 Days
IBRANCE CAPSULE 125MG1 21 Capsules/28 Days
IBRANCE TABLET 75MG 21 Tablets/28 Days
IBRANCE TABLET 100MG 21 Tablets/28 Days
IBRANCE TABLET 125MG 21 Tablets/28 Days
ICLUSIG TABLET 15MG1, 2 60 Tablets/30 Days
ICLUSIG TABLET 45MG1, 2 30 Tablets/30 Days
IMBRUVICA CAPSULE 70MG1, 2 30 Capsules/30 Days
IMBRUVICA CAPSULE 140MG1, 2 120 Capsules/30 Days
IMBRUVICA TABLET 140MG1, 2 120 Tablets/30 Days
IMBRUVICA TABLET 280MG1, 2 30 Tablets/30 Days
IMBRUVICA TABLET 420MG1, 2 30 Tablets/30 Days
IMBRUVICA TABLET 560MG1, 2 30 Tablets/30 Days
INLYTA TABLET 1MG1 180 Tablets/30 Days
INLYTA TABLET 5MG1 120 Tablets/30 Days
IRESSA TABLET 250MG1, 2 30 Tablets/30 Days
JAKAFI TABLET 5MG1 60 Tablets/30 Days
JAKAFI TABLET 10MG1 60 Tablets/30 Days
JAKAFI TABLET 15MG1 60 Tablets/30 Days
JAKAFI TABLET 20MG1 60 Tablets/30 Days
JAKAFI TABLET 25MG1 60 Tablets/30 Days
KISQALI 200 PACK FEMARA1 91 Tablets/28 Days
KISQALI 400 PACK FEMARA1 91 Tablets/28 Days
KISQALI 600 PACK FEMARA1 91 Tablets/28 Days
KISQALI TABLET 200 DOSE1 63 Tablets/28 Days
KISQALI TABLET 400 DOSE1 63 Tablets/28 Days
KISQALI TABLET 600 DOSE1 63 Tablets/28 Days
LENVIMA CAPSULE 4MG1, 2 30 Capsules/30 Days
LENVIMA CAPSULE 8 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 10 MG1, 2 30 Capsules/30 Days
LENVIMA CAPSULE 12MG1, 2 90 Capsules/30 Days
LENVIMA CAPSULE 14 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 18 MG1, 2 90 Capsules/30 Days
LENVIMA CAPSULE 20 MG1, 2 60 Capsules/30 Days
LENVIMA CAPSULE 24 MG1, 2 90 Capsules/30 Days
LONSURF TABLET 15-6.141 100 Tablets/28 Days
LONSURF TABLET 20-8.191 80 Tablets/28 Days
LYNPARZA CAPSULE 50MG1, 2 480 Capsules/30 Days
LYNPARZA TABLET 100MG1, 2 120 Tablets/30 Days
LYNPARZA TABLET 150MG1, 2 120 Tablets/30 Days
MEKINIST TABLET 0.5MG1 90 Tablets/30 Days
MEKINIST TABLET 2MG1 30 Tablets/30 Days
NINLARO CAPSULE 2.3MG1 3 Capsules/28 Days
NINLARO CAPSULE 3MG1 3 Capsules/28 Days
NINLARO CAPSULE 4MG1 3 Capsules/28 Days
ODOMZO CAPSULE 200MG1 30 Capsules/30 Days
REVLIMID CAPSULE 2.5MG1 30 Capsules/30 Days
REVLIMID CAPSULE 5MG1 30 Capsules/30 Days
REVLIMID CAPSULE 10MG1 30 Capsules/30 Days
REVLIMID CAPSULE 15MG1 21 Capsules/28 Days
REVLIMID CAPSULE 20MG1 21 Capsules/28 Days
REVLIMID CAPSULE 25MG1 21 Capsules/28 Days
STIVARGA TABLET 40MG1 84 Tablets/28 Days
SUTENT CAPSULE 12.5MG1 90 Capsules/30 Days
SUTENT CAPSULE 25MG1 30 Capsules/30 Days
SUTENT CAPSULE 37.5MG1 30 Capsules/30 Days
SUTENT CAPSULE 50MG1 30 Capsules/30 Days
TAFINLAR CAPSULE 50MG1 120 Capsules/30 Days
TAFINLAR CAPSULE 75MG1 120 Capsules/30 Days
TAGRISSO TABLET 40MG1, 2 30 Tablets/30 Days
TAGRISSO TABLET 80MG1, 2 30 Tablets/30 Days
TARCEVA TABLET 25MG1 60 Tablets/30 Days
TARCEVA TABLET 100MG1 30 Tablets/30 Days
TARCEVA TABLET 150MG1 30 Tablets/30 Days
THALOMID CAPSULE 50MG1 30 Capsules/30 Days
THALOMID CAPSULE 100MG1 30 Capsules/30 Days
THALOMID CAPSULE 150MG1 60 Capsules/30 Days
THALOMID CAPSULE 200MG1 60 Capsules/30 Days
VENCLEXTA TABLET 10MG1, 2 60 Tablets/30 Days
VENCLEXTA TABLET 50MG1, 2 30 Tablets/30 Days
VENCLEXTA TABLET 100MG1, 2 180 Tablets/30 Days
VENCLEXTA TABLET STARTER PACK1, 2 1 Pack/180 Days
VIZIMPRO TABLET 15MG1 30 Tablets/30 Days
VIZIMPRO TABLET 30MG1 30 Tablets/30 Days
VIZIMPRO TABLET 45MG1 30 Tablets/30 Days
VOTRIENT TABLET 200MG1 120 Tablets/30 Days
XTANDI CAPSULE 40MG1 120 Capsules/30 Days
ZEJULA CAPSULE 100MG1, 2 90 Capsules/30 Days
ZELBORAF TABLET 240MG1 240 Tablets/30 Days
ZOLINZA CAPSULE 100MG1 120 Capsules/30 Days
ZYDELIG TABLET 100MG1, 2 60 Tablets/30 Days
ZYDELIG TABLET 150MG1, 2 60 Tablets/30 Days
ZYKADIA CAPSULE 150MG1 90 Capsules/30 Days
ZYKADIA TABLET 150MG1 90 Tablets/30 Days
ZYTIGA TABLET 250MG1 120 Tablets/30 Days
ZYTIGA TABLET 500MG1 60 Tablets/30 Days

Antiparasitics

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ALINIA SUSPENSION 100/5mL 300 mLs/90 Days
ALINIA TABLET 500MG 12 Tablets/90 Days

Antipsychotics

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

NUPLAZID CAPSULE 34MG1 30 Capsules/30 Days
NUPLAZID TABLET 10MG1 30 Tablets/30 Days
NUPLAZID TABLET 17MG1 60 Tablets/30 Days
olanzapine tablet 2.5mg 30 Tablets/30 Days
olanzapine tablet 5mg 30 Tablets/30 Days
olanzapine tablet 7.5mg 30 Tablets/30 Days
olanzapine tablet 10mg 30 Tablets/30 Days
olanzapine tablet 15mg 30 Tablets/30 Days
olanzapine tablet 20mg 30 Tablets/30 Days
olanzapine tablet 5mg odt 30 Tablets/30 Days
olanzapine tablet 10mg odt 30 Tablets/30 Days
olanzapine tablet 15mg odt 30 Tablets/30 Days
olanzapine tablet 20mg odt 30 Tablets/30 Days
paliperidone tablet er 1.5mg 60 Tablets/30 Days
paliperidone tablet er 3mg 60 Tablets/30 Days
paliperidone tablet er 6mg 60 Tablets/30 Days
paliperidone tablet er 9mg 60 Tablets/30 Days
quetiapine tablet 50mg er 60 Tablets/30 Days
quetiapine tablet 150mg er 60 Tablets/30 Days
quetiapine tablet 200mg er 60 Tablets/30 Days
quetiapine tablet 300mg er 60 Tablets/30 Days
quetiapine tablet 400mg er 60 Tablets/30 Days

Antispasticity Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

baclofen tablet 10mg 120 Tablets/30 Days
baclofen tablet 20mg 120 Tablets/30 Days
dantrolene capsule 25mg 90 Capsules/30 Days
dantrolene capsule 50mg 90 Capsules/30 Days
dantrolene capsule 100mg 90 Capsules/30 Days
tizanidine capsule 2mg 42 Capsules/30 Days
tizanidine capsule 4mg 42 Capsules/30 Days
tizanidine capsule 6mg 42 Capsules/30 Days
tizanidine tablet 2mg 42 Capsules/30 Days
tizanidine tablet 4mg 42 Capsules/30 Days

Antivirals

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

oseltamivir capsule 30mg 40 Capsules/120 Days
oseltamivir capsule 45mg 20 Capsules/120 Days
oseltamivir capsule 75mg 20 Capsules/120 Days
oseltamivir suspension 6mg/mL 300 mLs/120 Days

Blood Products/Modifiers/ Volume Expanders

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

PROMACTA POWDER 12.5MG1 30 Packets/30 Days
PROMACTA TABLET 12.5MG1 30 Tablets/30 Days
PROMACTA TABLET 25MG1 30 Tablets/30 Days
PROMACTA TABLET 50MG1 60 Tablets/30 Days
PROMACTA TABLET 75MG1 60 Tablets/30 Days

Cardiovascular Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

atorvastatin tablet 10mg 45 Tablets/30 Days
atorvastatin tablet 20mg 45 Tablets/30 Days
atorvastatin tablet 40mg 45 Tablets/30 Days
atorvastatin tablet 80mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-10mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-20mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-40mg 30 Tablets/30 Days
ezetimibe/simvastatin tablet 10-80mg 30 Tablets/30 Days
fluvastatin tablet 80mg er 30 Tablets/30 Days
JUXTAPID CAPSULE 5MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 10MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 20MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 30MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 40MG1, 2 30 Capsules/30 Days
JUXTAPID CAPSULE 60MG1, 2 30 Capsules/30 Days
lovastatin tablet 10mg 60 Tablets/30 Days
lovastatin tablet 20mg 60 Tablets/30 Days
lovastatin tablet 40mg 60 Tablets/30 Days
PRALUENT INJECTION 75MG/mL1 2 Syringes/28 Days
PRALUENT INJECTION 150MG/mL1 2 Syringes/28 Days
pravastatin tablet 10mg 45 Tablets/30 Days
pravastatin tablet 20mg 45 Tablets/30 Days
pravastatin tablet 40mg 45 Tablets/30 Days
pravastatin tablet 80mg 30 Tablets/30 Days
REPATHA INJECTION 140MG/mL1 2 Syringes/28 Days
REPATHA PUSH INJECTION 420/3.51 1 Cartridge/30 Days
REPATHA SURE INJECTION 140MG/mL1 2 Pens/28 Days
rosuvastatin tablet 5mg 45 Tablets/30 Days
rosuvastatin tablet 10mg 45 Tablets/30 Days
rosuvastatin tablet 20mg 45 Tablets/30 Days
rosuvastatin tablet 40mg 30 Tablets/30 Days
simvastatin tablet 5mg 45 Tablets/30 Days
simvastatin tablet 10mg 45 Tablets/30 Days
simvastatin tablet 20mg 60 Tablets/30 Days
simvastatin tablet 40mg 45 Tablets/30 Days
simvastatin tablet 80mg 30 Tablets/30 Days

Central Nervous System Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

AMPYRA TABLET 10MG1 60 Tablets/30 Days
AUBAGIO TABLET 7MG1 30 Tablets/30 Days
AUBAGIO TABLET 14MG1 30 Tablets/30 Days
AVONEX KIT 30MCG1 1 Pack/28 Days
AVONEX PEN KIT 30MCG1 1 Pack/28 Days
AVONEX PREFILLED KIT 30MCG1 1 Kit/28 Days
BETASERON INJECTION 0.3MG1 1 Box/28 Days
COPAXONE INJECTION 20MG/mL1 30 Syringes/30 Days
COPAXONE INJECTION 40MG/mL1 12 Syringes/28 Days
dalfampridine tablet 10mg er1 60 Tablets/30 Days
GILENYA CAPSULE 0.5MG1 30 Tablets/30 Days
glatiramer injection 20mg/mL1 30 Syringes/30 Days
glatiramer injection 40mg/mL1 12 Syringes/28 Days
glatopa injection 20mg/mL1 30 Syringes/30 Days
glatopa injection 40mg/mL1 12 Syringes/28 Days
INGREZZA CAPSULE 40-80MG1, 2 28 Capsules/180 Days
INGREZZA CAPSULE 40MG1, 2 30 Capsules/30 Days
INGREZZA CAPSULE 80MG1, 2 30 Capsules/30 Days
MAYZENT TABLET 0.25MG1 120 Tablets/30 Days
MAYZENT TABLET 2MG1 30 Tablets/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 TITRATION2 1 Kit/180 Days
REBIF TITRATION INJECTION PACK1 1 Kit/180 Days
SAVELLA MIS TITRATION PACK 1 Kit/180 Days
SAVELLA TABLET 12.5MG 60 Tablets/30 Days
SAVELLA TABLET 25MG 60 Tablets/30 Days
SAVELLA TABLET 50MG 60 Tablets/30 Days
SAVELLA TABLET 100MG 60 Tablets/30 Days
TECFIDERA CAPSULE 120MG1 56 Capsules/180 Days
TECFIDERA CAPSULE 240MG1 60 Capsules/30 Days
TECFIDERA MIS STARTER1 1 Kit/180 Days
tetrabenazine tablet 12.5mg1 240 Tablets/30 Days
tetrabenazine tablet 25mg1 120 Tablets/30 Days

Dermatological Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ala-cort cream 1% 454 Grams/30 Days
ala-cort cream 2.5% 454 Grams/30 Days
alclometasone cream 0.05% 120 Grams/30 Days
alclometasone ointment 0.05% 120 Grams/30 Days
AMCINONIDE OINTMENT 0.1% 120 Grams/30 Days
augmented betamethasone cream 0.05% 200 Grams/28 Days
augmented betamethasone lotion 0.05% 210 mLs/30 Days
augmented betamethasone ointment 0.05% 200 Grams/28 Days
beser lotion 0.05% 120 mLs/30 Days
betamethasone dipropionate cream 0.05% 135 Grams/30 Days
betamethasone dipropionate lotion 0.05% 120 mLs/30 Days
betamethasone dipropionate ointment 0.05% 135 Grams/30 Days
betamethasone valerate aer 0.12% 150 Grams/30 Days
betamethasone valerate cream 0.1% 135 Grams/30 Days
betamethasone valerate lotion 0.1% 120 mLs/30 Days
betamethasone valerate ointment 0.1% 135 Grams/30 Days
CAPEX SHAMPOO 0.01% 840 mLs/28 Days
clobetasol aer 0.05% 200 Grams/28 Days
clobetasol cream 0.05% 210 Grams/28 Days
clobetasol e cream 0.05% 210 Grams/28 Days
clobetasol gel 0.05% 210 Grams/28 Days
clobetasol lotion 0.05% 177 mLs/28 Days
clobetasol ointment 0.05% 210 Grams/28 Days
clobetasol shampoo 0.05% 236 mLs/30 Days
clobetasol solution 0.05% 200 mLs/28 Days
clobetasol spray 0.05% 236 mLs/28 Days
clodan shampoo 0.05% 236 mLs/30 Days
desonide cream 0.05% 120 Grams/30 Days
desonide lotion 0.05% 118 mLs/30 Days
desonide ointment 0.05% 120 Grams/30 Days
desoximetasone cream 0.05% 120 Grams/30 Days
desoximetasone cream 0.25% 120 Grams/30 Days
desoximetasone gel 0.05% 120 Grams/30 Days
desoximetasone ointment 0.05% 120 Grams/30 Days
desoximetasone ointment 0.25% 120 Grams/30 Days
desoximetasone spray 0.25% 100 mLs/30 Days
diflorasone ointment 0.05% 120 Grams/30 Days
fluocinolone acetonide cream 0.01% 120 Grams/30 Days
fluocinolone acetonide cream 0.025% 120 Grams/30 Days
fluocinolone acetonide oil 0.01% scalp 118.28 mLs/30 Days
fluocinolone acetonide oil 0.01% body 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 ointment 0.025% 120 Grams/30 Days
fluocinolone acetonide solution 0.01% 120 mLs/30 Days
fluocinonide cream 0.05% 120 Grams/30 Days
fluocinonide cream 0.1% 240 Grams/28 Days
fluocinonide cream e 0.05% 120 Grams/30 Days
fluocinonide gel 0.05% 120 Grams/30 Days
fluocinonide ointment 0.05% 120 Grams/30 Days
fluocinonide solution 0.05% 120 mLs/30 Days
fluorouracil cream 5% 240 Grams/90 Days
flurandrenol cream 0.05% 120 Grams/30 Days
flurandrenol lotion 0.05% 120 mLs/30 Days
flurandrenol ointment 0.05% 120 Grams/30 Days
fluticasone cream 0.05% 120 Grams/30 Days
fluticasone lotion 0.05% 120 mLs/30 Days
fluticasone ointment 0.005% 120 Grams/30 Days
halcinonide cream 0.1% 240 Grams/30 Days
halobetasol cream 0.05% 200 Grams/28 Days
halobetasol ointment 0.05% 200 Grams/28 Days
hydrocortisone butyrate cream 0.1% 120 Grams/30 Days
hydrocortisone butyrate cream 0.1% 135 Grams/30 Days
hydrocortisone butyrate ointment 0.1% 135 Grams/30 Days
hydrocortisone butyrate solution 0.1% 120 mLs/30 Days
hydrocortisone valerate cream 0.2% 120 Grams/30 Days
hydrocortisone valerate ointment 0.2% 120 Grams/30 Days
hydrocortisone cream 1% 454 Grams/30 Days
hydrocortisone cream 2.5% 454 Grams/30 Days
hydrocortisone lotion 2.5% 118 mLs/30 Days
hydrocortisone ointment 2.5% 454 Grams/30 Days
hydrocortisone lotion 0.1% 118 mLs/30 Days
imiquimod cream 5% 48 Packets/60 Days
mometasone cream 0.1% 135 Grams/30 Days
mometasone ointment 0.1% 135 Grams/30 Days
mometasone solution 0.1% 120 mLs/30 Days
nolix cream 0.05% 120 Grams/30 Days
nolix lotion 0.05% 120 mLs/30 Days
REGRANEX GEL 0.01% 1 Tube/30 Days
tovet aer 0.05% 200 Grams/28 Days
triamcinolone aer spray 126 Grams/30 Days
triamcinolone cream 0.025% 454 Grams/30 Days
triamcinolone cream 0.1% 454 Grams/30 Days
triamcinolone cream 0.5% 454 Grams/30 Days
triamcinolone lotion 0.025% 120 mLs/30 Days
triamcinolone lotion 0.1% 120 mLs/30 Days
triamcinolone ointment 0.025% 454 Grams/30 Days
triamcinolone ointment 0.05% 430 Grams/30 Days
triamcinolone ointment 0.1% 454 Grams/30 Days
triamcinolone ointment 0.5% 120 Grams/30 Days
trianex ointment 0.05% 430 Grams/30 Days
triderm cream 0.1% 454 Grams/30 Days
triderm cream 0.5% 454 Grams/30 Days

Gastrointestinal Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

alosetron tablet 0.5mg 60 Tablets/30 Days
alosetron tablet 1mg 60 Tablets/30 Days
benzphetamine tablet 50mg 90 Tablets/30 Days
DEXILANT CAPSULE 30MG DR 30 Capsules/30 Days
DEXILANT CAPSULE 60MG DR 30 Capsules/30 Days
diethylpropion tablet 25mg 90 Tablets/30 Days
diethylpropion tablet 75mg er 30 Tablets/30 Days
esomeprazole magnesium capsule 40mg dr 30 Capsules/30 Days
lansoprazole capsule 15mg dr 30 Capsules/30 Days
lansoprazole capsule 30mg dr 30 Capsules/30 Days
LINZESS CAPSULE 72MCG 30 Capsules/30 Days
LINZESS CAPSULE 145MCG 30 Capsules/30 Days
LINZESS CAPSULE 290MCG 30 Capsules/30 Days
MOVANTIK TABLET 12.5MG 30 Tablets/30 Days
MOVANTIK TABLET 25MG 30 Tablets/30 Days
omeppi capsule 20-1100 30 Capsules/30 Days
omeppi capsule 40-1100 30 Capsules/30 Days
omeprazole/bicarbonate capsule 20-1100 30 Capsules/30 Days
omeprazole/bicarbonate capsule 40-1100 30 Capsules/30 Days
omeprazole/bicarbonate powder 20-1680 30 Packets/30 Days
omeprazole/bicarbonate powder 40-1680 30 Packets/30 Days
omeprazole capsule 10mg 30 Capsules/30 Days
omeprazole capsule 20mg 30 Capsules/30 Days
omeprazole capsule 40mg 30 Capsules/30 Days
omeprazole capsule 10mg dr 30 Capsules/30 Days
omeprazole capsule 20mg dr 30 Capsules/30 Days
pantoprazole tablet 20mg 30 Tablets/30 Days
pantoprazole tablet 40mg 30 Tablets/30 Days
pantoprazole tablet 20mg dr 30 Tablets/30 Days
pantoprazole tablet 40mg dr 30 Tablets/30 Days
phendimetrazine tablet 35mg 180 Tablets/30 Days
phentermine capsule 15mg 30 Capsules/30 Days
phentermine capsule 30mg 30 Capsules/30 Days
phentermine capsule 37.5mg 30 Capsules/30 Days
phentermine tablet 37.5mg 30 Tablets/30 Days
rabeprazole tablet 20mg 30 Tablets/30 Days

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

CERDELGA CAPSULE 84MG1 60 Capsules/30 Days
miglustat capsule 100mg1 90 Capsules/30 Days
ZAVESCA CAPSULE 100MG1, 2 90 Capsules/30 Days

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

EGRIFTA SOLUTION 1MG1 60 Vials/30 Days
EGRIFTA SV INJECTION 2MG1 30 Vials/30 Days

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ANDRODERM DIS 2MG/24HR 30 Patches/30 Days
ANDRODERM DIS 4MG/24HR 30 Patches/30 Days
ANDROGEL GEL 1.62% 2 Pumps/30 Days
ANDROGEL GEL 1.62% 30 Packets/30 Days
ANDROGEL GEL 1.62% 60 Packets/30 Days
testosterone cypionate injection 100mg/mL 1 Vial/28 Days
testosterone cypionate injection 200mg/mL 10 mLs/28 Days
TESTOSTERONE ENANTHATE INJECTION 200MG/mL 1 Vial/28 Days
testosterone gel 1%(25mg) 60 Packets/30 Days
testosterone gel 1%(50mg) 60 Packets/30 Days
testosterone gel 1.62% 2 Bottles/30 Days
testosterone gel 1.62% 30 Packets/30 Days
testosterone gel 1.62% 60 Packets/30 Days
testosterone gel 10mg/act 2 Pumps/30 Days
testosterone gel pump 1% 300 Grams/30 Days
testosterone solution 30mg/act 2 Pumps/30 Days

Hormonal Agents, Suppressant (Adrenal)

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

KORLYM TABLET 300MG1, 2 120 Tablets/30 Days

Hormonal Agents, Suppressant (Pituitary)

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

CETROTIDE KIT 0.25MG1 5 Kits/30 Days
GANIRELIX AC INJECTION 250/0.51 5 Syringes/30 Days
SIGNIFOR INJECTION 0.3MG/mL1, 2 60 mLs/30 Days
SIGNIFOR INJECTION 0.6MG/mL1, 2 60 mLs/30 Days
SIGNIFOR INJECTION 0.9MG/mL1, 2 60 mLs/30 Days
SOMAVERT INJECTION 10MG1 30 Vials/30 Days
SOMAVERT INJECTION 15MG1 30 Vials/30 Days
SOMAVERT INJECTION 20MG1 30 Vials/30 Days
SOMAVERT INJECTION 25MG1 30 Vials/30 Days
SOMAVERT INJECTION 30MG1 30 Vials/30 Days

Immunological Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ARCALYST INJECTION 220MG1, 2 4 Vials/28 Days
COSENTYX INJECTION 150MG/mL1 1 Syringe/28 Days
COSENTYX INJECTION 300 DOSE1 1 Pack/28 Days
COSENTYX PEN INJECTION 150MG/mL1 1 Injection Device/28 Days
COSENTYX PEN INJECTION 300 DOSE1 1 Pack/28 Days
ENBREL INJECTION 25MG1 8 Vials/28 Days
ENBREL INJECTION 25/0.5mL1 8 Syringes/28 Days
ENBREL INJECTION 50MG/mL1 4 Syringes/28 Days
ENBREL MINI INJECTION 50MG/mL1 4 Cartridges/28 Days
ENBREL SRCLK INJECTION 50MG/mL1 4 Syringes/28 Days
FIRAZYR INJECTION 30MG/3mL1 6 Syringes/30 Days
HUMIRA INJECTION 10MG/0.21 2 Syringes/28 Days
HUMIRA INJECTION 10/0.1mL1 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 1 Kit/180 Days
HUMIRA PEDIA INJECTION CROHNS1 3 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 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 PS/UV1 1 Kit/180 Days
icatibant injection 30mg/3mL1 6 Syringes/30 Days
OTEZLA TABLET 10/20/301 1 Kit/180 Days
OTEZLA TABLET 30MG1 60 Tablets/30 Days
RINVOQ TABLET 15MG ER1 30 Tablets/30 Days
SKYRIZI INJECTION 150 DOSE1 1 Box/84 Days
STELARA INJECTION 45MG/0.51 1 Syringe/84 Days
STELARA INJECTION 90MG/mL1 1 Syringe/56 Days
TREMFYA INJECTION 100MG/mL1 1 Pen/56 Days
TREMFYA INJECTION 100MG/mL1 1 Syringe/56 Days

Metabolic Bone Disease Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

alendronate tablet 35mg 4 Tablets/28 Days
alendronate tablet 70mg 4 Capsules/28 Days
FORTEO SOLUTION 600/2.41 1 Pen/28 Days
FOSAMAX + D TABLET 70-2800 4 Capsules/28 Days
FOSAMAX + D TABLET 70-5600 4 Capsules/28 Days
ibandronate tablet 150mg 1 Tablet/28 Days
risedronate sodium tablet 35mg dr 4 Tablets/28 Days
risedronate tablet 35mg 4 Tablets/28 Days
risedronate tablet 150mg 1 Tablet/28 Days
TYMLOS INJECTION1 1 Pen/30 Days

Ophthalmic Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

bimatoprost solution 0.03% 2.5 mLs/30 Days
latanoprost solution 0.005% 2.5 mLs/30 Days
LUMIGAN SOLUTION 0.01% 2.5 mLs/30 Days
RESTASIS EMULSION 0.05% 2 Vials/30 Days
RESTASIS MULTI DOSE EMULSION 0.05% 1 Bottle/30 Days
TRAVATAN Z DROP 0.004% 2.5 mLs/30 Days
travoprost drop 0.004% 2.5 mLs/30 Days
ZIOPTAN DROP 0.0015% 30 Containers/30 Days

Respiratory Tract/ Pulmonary Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

ADCIRCA TABLET 20MG1 60 Tablets/30 Days
ADEMPAS TABLET 0.5MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 1MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 1.5MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 2MG1, 2 90 Tablets/30 Days
ADEMPAS TABLET 2.5MG1, 2 90 Tablets/30 Days
ADVAIR DISKUS AER 100/50 60 Blisters/30 Days
ADVAIR DISKUS AER 250/50 60 Blisters/30 Days
ADVAIR DISKUS AER 500/50 60 Blisters/30 Days
ADVAIR HFA AER 45/21 1 Canister/30 Days
ADVAIR HFA AER 115/21 1 Canister/30 Days
ADVAIR HFA AER 230/21 1 Canister/30 Days
alyq tablet 20mg1 60 Tablets/30 Days
ambrisentan tablet 5mg1 30 Tablets/30 Days
ambrisentan tablet 10mg1 30 Tablets/30 Days
ARNUITY ELLIPTA INHALER 100MCG 30 Blisters/30 Days
ARNUITY ELLIPTA INHALER 200MCG 30 Blisters/30 Days
ASMANEX 14 AER 220MCG 1 Canister/30 Days
ASMANEX 30 AER 110MCG 1 Canister/30 Days
ASMANEX 30 AER 220MCG 1 Canister/30 Days
ASMANEX 60 AER 220MCG 1 Canister/30 Days
ASMANEX 120 AER 220MCG 1 Canister/30 Days
ASMANEX HFA AER 100 MCG 1 Canister/30 Days
ASMANEX HFA AER 200 MCG 1 Canister/30 Days
bosentan tablet 62.5mg1 60 Tablets/30 Days
bosentan tablet 125mg1 60 Tablets/30 Days
BREO ELLIPTA INHALER 100-25 60 Blisters/30 Days
BREO ELLIPTA INHALER 200-25 60 Blisters/30 Days
DULERA AER 100-5MCG 1 Canister/30 Days
DULERA AER 200-5MCG 1 Canister/30 Days
ESBRIET CAPSULE 267MG1 180 Capsules/30 Days
ESBRIET TABLET 267MG1 180 Tablets/30 Days
ESBRIET TABLET 801MG1 90 Tablets/30 Days
FLOVENT DISKUS AER 50MCG 60 Blisters/30 Days
FLOVENT DISKUS AER 100MCG 60 Blisters/30 Days
FLOVENT DISKUS AER 250MCG 240 Blisters/30 Days
FLOVENT HFA AER 110MCG 1 Canister/30 Days
FLOVENT HFA AER 220MCG 2 Canisters/30 Days
FLOVENT HFA AER 44MCG 1 Canister/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
KALYDECO PACK 25MG1 60 Packets/30 Days
KALYDECO PACK 50MG1 60 Packets/30 Days
KALYDECO PACK 75MG1 60 Packets/30 Days
KALYDECO TABLET 150MG1 60 Tablets/30 Days
OFEV CAPSULE 100MG1 60 Capsules/30 Days
OFEV CAPSULE 150MG1 60 Capsules/30 Days
ORKAMBI TABLET 100-1251 120 Tablets/30 Days
ORKAMBI TABLET 200-1251 120 Tablets/30 Days
QVAR AER 40MCG 1 Canister/30 Days
QVAR AER 80MCG 2 Canisters/30 Days
QVAR REDIHALER AER 40MCG 1 Canister/30 Days
QVAR REDIHALER AER 80MCG 2 Canisters/30 Days
REVATIO SUSPENSION 10MG/mL1 2 Bottles/30 Days
sildenafil suspension 10mg/mL1 224 mLs/30 Days
sildenafil tablet 20mg1 90 Tablets/30 Days
SYMBICORT AER 80-4.5 1 Canister/30 Days
SYMBICORT AER 160-4.5 1 Canister/30 Days
tadalafil tablet 20mg1 60 Tablets/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

Skeletal Muscle Relaxants

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

carisoprodol/aspirin tablet 200-325 168 Tablets/90 Days
carisoprodol tablet 250mg 28 Tablets/30 Days
carisoprodol tablet 350mg 28 Tablets/30 Days
carisoprodol tablet aspirin/codeine 168 Tablets/90 Days
CARISOPRODOL TABLET ASPIRIN/CODEINE 168 Tablets/30 Days
chlorzoxazone tablet 375mg 84 Tablets/90 Days
chlorzoxazone tablet 750mg 84 Tablets/90 Days
cyclobenzaprine capsule 15mg er 21 Capsules/30 Days
cyclobenzaprine capsule 30mg er 21 Capsules/30 Days
cyclobenzaprine tablet 5mg 21 Tablets/30 Days
cyclobenzaprine tablet 7.5mg 21 Tablets/30 Days
cyclobenzaprine tablet 10mg 90 Capsules/30 Days
lorzone tablet 375mg 84 Tablets/90 Days
lorzone tablet 750mg 84 Tablets/90 Days
metaxall tablet 800mg 28 Tablets/30 Days
metaxalone tablet 800mg 28 Tablets/30 Days
methocarbamol tablet 500mg 60 Tablets/30 Days
methocarbamol tablet 750mg 44 Tablets/30 Days
orphenadrine tablet 100mg cr 42 Tablets/30 Days
orphenadrine tablet 100mg er 42 Tablets/30 Days

Sleep Disorder Agents

Brand (generic)

Quantity Limits 
(per 30 days or as specified)

armodafinil tablet 50mg 30 Tablets/30 Days
armodafinil tablet 150mg 30 Tablets/30 Days
armodafinil tablet 200mg 30 Tablets/30 Days
armodafinil tablet 250mg 30 Tablets/30 Days
doxepin tablet 3mg 30 Tablets/30 Days
doxepin tablet 6mg 30 Tablets/30 Days
eszopiclone tablet 1mg 30 Tablets/30 Days
eszopiclone tablet 2mg 30 Tablets/30 Days
eszopiclone tablet 3mg 30 Tablets/30 Days
modafinil tablet 100mg 30 Tablets/30 Days
modafinil tablet 200mg 30 Tablets/30 Days
ramelteon tablet 8mg 30 Tablets/30 Days
ROZEREM TABLET 8MG 30 Tablets/30 Days
zaleplon capsule 5mg 30 Capsules/30 Days
zaleplon capsule 10mg 30 Capsules/30 Days
zolpidem er tablet 6.25mg 30 Tablets/30 Days
zolpidem er tablet 12.5mg 30 Tablets/30 Days
zolpidem tablet 5mg 30 Tablets/30 Days
zolpidem tablet 10mg 30 Tablets/30 Days
zolpidem tartrate sublingual 1.75mg 30 Tablets/30 Days
zolpidem tartrate sublingual 3.5mg 30 Tablets/30 Days

Drug Name(s)

abiraterone acetate1 ACTIMMUNE1 ADCIRCA1
ADEMPAS1, 2 AFINITOR DISPERZ1 AFINITOR1
ALECENSA1, 2 ALUNBRIG1, 2 alyq1
ambrisentan1 AMPYRA1 APOKYN1, 2
ARCALYST1, 2 AUBAGIO1 AVONEX PEN1
AVONEX1 BETASERON1 bexarotene1
bosentan1 BRAVELLE1 capecitabine1
CAPRELSA1, 2 CERDELGA1 CETROTIDE1
CHOLBAM1, 2 cinacalcet hydrochloride1 COMETRIQ1, 2
COPAXONE1 COSENTYX SENSOREADY PEN1 COSENTYX1
COTELLIC1 CYSTAGON1, 2 CYSTARAN1
dalfampridine er1 deferasirox1 dofetilide1
EGRIFTA SV1 EGRIFTA1 ENBREL MINI1
ENBREL SURECLICK1 ENBREL1 entecavir1
EPCLUSA1 ERIVEDGE1 erlotinib hydrochloride1
ESBRIET1 everolimus1 EXJADE1
FIRAZYR1 FOLLISTIM AQ1 FORTEO1
FUZEON1 ganirelix acetate1 GANIRELIX ACETATE1
GILENYA1 GILOTRIF1, 2 glatiramer acetate1
glatopa1 HARVONI1 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1
HUMIRA PEN1 HUMIRA PEN-CD/UC/HS STARTER1 HUMIRA PEN-PS/UV STARTER1
HUMIRA1 HYCAMTIN1 IBRANCE1
hydromorphone hydrochloride er IBRANCE1 icatibant acetate1
ICLUSIG1, 2 imatinib mesylate1 IMBRUVICA1, 2
INCRELEX1, 2 INGREZZA1, 2 INLYTA1
INTRON A1 IRESSA1, 2 JAKAFI1
JUXTAPID1, 2 KALYDECO1 KISQALI1
KISQALI FEMARA1 KOGENATE FS BIO-SET1 KOGENATE FS1
KORLYM1, 2 KUVAN1 LEDIPASVIR/SOFOSBUVIR1
LENVIMA1, 2 leuprolide acetate1 LONSURF1
LYNPARZA1, 2 MATULANE1 MAVYRET1
MAYZENT1 MEKINIST1 miglustat1
MODERIBA1 moderiba1 MYALEPT1, 2
NEULASTA ONPRO KIT1 NEULASTA1 NEXAVAR1
NINLARO1 nitisinone1, 2 NORDITROPIN FLEXPRO1
NUPLAZID1 ODOMZO1 OFEV1
ORFADIN1, 2 ORKAMBI1 OTEZLA1
PEGASYS PROCLICK1 PEGASYS1 PLEGRIDY STARTER PACK1
PLEGRIDY1 PRALUENT1 PROMACTA1
PULMOZYME1 REBETOL1 REBIF REBIDOSE TITRATION PACK1
REBIF REBIDOSE1 REBIF TITRATION PACK1 REBIF1
REPATHA PUSHTRONEX SYSTEM1 REPATHA SURECLICK1 REPATHA1
REVATIO1 REVLIMID1 RIBASPHERE RIBAPAK1
ribasphere1 ribavirin1 RINVOQ1
SENSIPAR1 SIGNIFOR1, 2 sildenafil citrate1
SKYRIZI1 sodium phenylbutyrate1 SOFOSBUVIR/VELPATASVIR1
SOMAVERT1 SOVALDI1 SPRYCEL1
STELARA1 STIMATE1 STIVARGA1
STRENSIQ1, 2 SUTENT1 SYNAREL1
tadalafil1 TAFINLAR1 TAGRISSO1, 2
TARCEVA1 TARGRETIN1 TASIGNA1
TECFIDERA STARTER PACK1 TECFIDERA1 temozolomide1
tetrabenazine1 THALOMID1 tobramycin sulfate1
tobramycin1 TREMFYA1 TYKERB1
TYMLOS1 VALCHLOR1, 2 VENCLEXTA STARTING PACK1, 2
VENCLEXTA1, 2 vigabatrin1 vigadrone1, 2
VISTOGARD1, 2 VIZIMPRO1 VOSEVI1
VOTRIENT1 XALKORI1 XTANDI1
XURIDEN1, 2 ZAVESCA1, 2 ZEJULA1, 2
ZELBORAF1 ZOLINZA1 ZYDELIG1, 2
ZYKADIA1 ZYTIGA1  

1Specialty

2Limited Distribution