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- Value Plus Prescription Drug Benefits - January
Value Plus prescription drug benefits
Effective January 1, 2021
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) |
||
|
ACTEMRA |
ACTEMRA ACTPEN |
|
|
alosetron hydrochloride |
alyq1 |
|
|
ambrisentan1 |
ANDRODERM |
|
|
ANDROGEL |
ANDROGEL PUMP |
|
|
armodafinil |
avita |
|
|
AVONEX PEN1 |
AVONEX1 |
benzphetamine hcl |
|
BETASERON1 |
bexarotene1 |
bosentan1 |
|
buprenorphine |
capecitabine1 |
|
|
CERDELGA1 |
CETROTIDE1 |
ciclodan |
|
ciclopirox nail lacquer |
cinacalcet hydrochloride1 |
clomipramine hydrochloride |
|
COPAXONE1 |
COSENTYX SENSOREADY PEN 1 |
|
|
COSENTYX1 |
COTELLIC1 |
cyclobenzaprine hydrochloride er |
|
dalfampridine er1 |
DARAPRIM |
diclofenac sodium |
|
diethylpropion hcl |
diethylpropion hcler |
doxylamine succinate/pyridoxine hydrochloride |
|
EGRIFTA SV1 |
EGRIFTA1 |
ENBREL MINI1 |
|
ENBREL SURECLICK1 |
ENBREL1 |
EPCLUSA1 |
|
erlotinib hydrochloride1 |
ESBRIET1 |
|
|
everolimus1 |
fentanyl |
fentanyl citrate oral transmucosal |
|
FIRAZYR1 |
FLUOXETINE HYDROCHLORIDE |
FORTEO1 |
|
ganirelix acetate1 |
GANIRELIX ACETATE1 |
GILENYA1 |
|
glatiramer acetate1 |
glatopa1 |
|
|
HARVONI1 |
HUMIRA PEN1 |
HUMIRA1 |
|
HYCAMTIN1 |
hydrocodone bitartrate er |
hydromorphone hydrochloride |
|
hydromorphone hydrochloride er |
IBRANCE1 |
icatibant acetate1 |
|
INTRON A1 |
||
|
KADIAN |
||
|
KALYDECO1 |
KISQALI1 |
KISQALI FEMARA1 |
|
KOGENATE FS BIO-SET1 |
KOGENATE FS1 |
|
|
KUVAN1 |
LEDIPASVIR/SOFOSBUVIR1 |
|
|
lidocaine |
LONSURF1 |
|
|
MAVYRET1 |
MAYZENT1 |
MEKINIST1 |
|
metaxall |
metaxalone |
metformin hydrochloride er |
|
methadone hydrochloride |
METHITEST |
miglustat1 |
|
modafinil |
mometasone furoate |
morphine sulfate CR |
|
morphine sulfate ER |
NAPROSYN |
|
|
NEULASTA ONPRO KIT1 |
NEULASTA1 |
NINLARO1 |
|
NORDITROPIN FLEXPRO1 |
NUPLAZID1 |
|
|
omeppi |
omeprazole/sodium bicarbonate |
|
|
ORKAMBI1 |
OTEZLA1 |
oxymorphone hydrochloride |
|
phendimetrazine tartrate |
phentermine hydrochloride |
PLEGRIDY1 |
|
PRALUENT |
PROMACTA1 |
ramelteon |
|
REBIF REBIDOSE TITRATION PACK1 |
REBIF REBIDOSE1 |
REBIF TITRATION PACK1 |
|
REBIF1 |
REGRANEX |
REPATHA PUSHTRONEX SYSTEM |
|
REPATHA SURECLICK |
REPATHA |
RESTASIS |
|
RESTASIS MULTIDOSE |
REVATIO1 |
REVLIMID1 |
|
RINVOQ1 |
ROZEREM |
SENSIPAR1 |
|
sildenafil citrate1 |
SKYRIZI1 |
|
|
sodium phenylbutyrate1 |
SOFOSBUVIR/VELPATASVIR1 |
SOMAVERT1 |
|
SOVALDI1 |
STELARA1 |
STIMATE1 |
|
STIVARGA1 |
||
|
tadalafil1 |
TAFINLAR1 |
|
|
tazarotene |
TAZORAC |
|
|
testosterone |
testosterone cypionate |
|
|
TESTOSTERONE ENANTHATE |
testosterone pump |
testosterone topical solution |
|
tetrabenazine1 |
THALOMID1 |
tobramycin1 |
|
tramadol hydrochloride er |
TREMFYA1 |
tretinoin |
|
tretinoin microsphere |
tretinoin microsphere pump |
TYMLOS1 |
|
VOSEVI1 |
||
|
ZELBORAF1 |
||
Drug Name(s) |
||
|
AMCINONIDE |
CAPEX |
ELIDEL |
|
EMADINE |
FANAPT |
FANAPT TITRATION PACK |
|
FARXIGA |
GELNIQUE |
GELNIQUE PUMP |
|
GLYXAMBI |
INVOKAMET |
INVOKAMET XR |
|
INVOKANA |
JANUMET |
JANUMET XR |
|
JANUVIA |
JARDIANCE |
lanthanum carbonate |
|
LATUDA |
LUMIGAN |
LYRICA |
|
OZEMPIC |
pimecrolimus |
RENAGEL |
|
RYBELSUS |
SAVELLA |
SAVELLA TITRATION PACK |
|
SEVELAMER HYDROCHLORIDE |
SOLIQUA 100/33 |
SYNJARDY |
|
SYNJARDY XR |
tacrolimus |
TRAVATAN Z |
|
TRIANEX |
TRULICITY |
VICTOZA |
|
VRAYLAR |
XULTOPHY 100/3.6 |
ZIOPTAN |
Actinic Keratosis
Drug Name(s) |
Quantity Limits
|
|
ALDARA CREAM 5% |
48 Packets/60 Days |
|
EFUDEX CREAM 5% |
240 Grams/90 Days |
|
cream 5% |
240 Grams/90 Days |
|
imiquimod cream 5% |
48 Packets/60 Days |
Acute Migraine 5HT
Drug Name(s) |
Quantity Limits
|
|
almotriptan malate tablet 6.25mg |
24 Tablets/30 Days |
|
almotriptan malate tablet 12.5mg |
12 Tablets/30 Days |
|
AMERGE TABLET 1MG |
18 Tablets/30 Days |
|
AMERGE TABLET 2.5MG |
18 Tablets/30 Days |
|
AXERT TABLET 12.5MG |
12 Tablets/30 Days |
|
AXERT TABLET 6.25MG |
24 Tablets/30 Days |
|
eletriptan tablet 20mg |
18 Tablets/30 Days |
|
eletriptan tablet 40mg |
12 Tablets/30 Days |
|
FROVA TABLET 2.5MG |
27 Tablets/30 Days |
|
frovatriptan tablet 2.5mg |
27 Tablets/30 Days |
|
IMITREX INJECTION 4MG/0.5 |
12 Syringes/30 Days |
|
IMITREX INJECTION 6MG/0.5 |
12 Syringes/30 Days |
|
IMITREX INJECTION 6MG/0.5 |
12 Cartridges/30 Days |
|
IMITREX SPRAY 20MG/ACT |
12 Inhalers/30 Days |
|
IMITREX SPRAY 5MG/ACT |
5 Packs/30 Days |
|
IMITREX TABLET 25MG |
27 Tablets/30 Days |
|
IMITREX TABLET 50MG |
18 Tablets/30 Days |
|
IMITREX TABLET 100MG |
18 Tablets/30 Days |
|
MAXALT TABLET 10MG |
18 Tablets/30 Days |
|
MAXALT-MLT TABLET 10MG |
18 Tablets/30 Days |
|
MAXALT-MLT TABLET 5MG |
36 Tablets/30 Days |
|
naratriptan tablet 1mg |
18 Tablets/30 Days |
|
naratriptan tablet 2.5mg |
18 Tablets/30 Days |
|
NURTEC ODT 75 mg |
45 tablets/90 Days |
|
ONZETRA XSAI MIS 11MG |
32 Inhalers/30 Days |
|
RELPAX TABLET 20MG |
18 Tablets/30 Days |
|
RELPAX TABLET 40MG |
12 Tablets/30 Days |
|
REYVOW 50 MG |
8 tablets/30 Days |
|
REYVOW 100 MG |
8 tablets/30 Days |
|
rizatriptan tablet 5mg |
36 Tablets/30 Days |
|
rizatriptan tablet 5mg odt |
36 Tablets/30 Days |
|
rizatriptan tablet 10mg |
18 Tablets/30 Days |
|
rizatriptan tablet 10mg odt |
18 Tablets/30 Days |
|
sumatriptan injection 4mg/0.5 |
12 Cartridges/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 Cartridges/30 Days |
|
sumatriptan injection 6mg/0.5 |
12 Syringes/30 Days |
|
sumatriptan spray 20mg/act |
12 Inhalers/30 Days |
|
sumatriptan spray 5mg/act |
5 Packs/30 Days |
|
sumatriptan tablet 25mg |
27 Tablets/30 Days |
|
sumatriptan tablet 50mg |
18 Tablets/30 Days |
|
sumatriptan tablet 100mg |
18 Tablets/30 Days |
|
sumatriptan-naproxen tablet 85-500mg |
18 Tablets/30 Days |
|
TREXIMET TABLET 10-60MG |
9 Tablets/30 Days |
|
TREXIMET TABLET 85-500MG |
18 Tablets/30 Days |
|
UBREVLY |
16 Tablets/30 days |
|
ZEMBRACE SYM INJECTION 3/0.5ML |
24 Pens/30 Days |
|
zolmitriptan tablet 2.5 mg |
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 |
|
ZOMIG SPRAY 2.5MG |
3 Injection Devices/30 Days |
|
ZOMIG SPRAY 5MG |
2 Sprays/30 Days |
|
ZOMIG TABLET 2.5MG |
18 Tablets/30 Days |
|
ZOMIG TABLET 5MG |
12 Tablets/30 Days |
|
ZOMIG ZMT TABLET 2.5 MG |
18 Tablets/30 Days |
|
ZOMIG ZMT TABLET 5MG ODT |
12 Tablets/30 Days |
Addyi
Drug Name(s) |
Quantity Limits
|
|
VYLEESI INJECTION 1.75/0.3 |
6 Pens/30 Days |
Afrezza
Drug Name(s) |
Quantity Limits
|
|
AFREZZA POWDER 4UNIT |
2520 Cartridges/30 Days |
|
AFREZZA POWDER 8 UNIT |
1260 Cartridges/30 Days |
|
AFREZZA POWDER 12 UNIT |
900 Cartridges/30 Days |
|
AFREZZA POWDER 4-8 UNIT |
1530 Cartridges/30 Days |
|
AFREZZA POWDER 4-8 UNIT |
1890 Cartridges/30 Days |
|
AFREZZA POWDER 4-8 UNIT |
1800 Cartridges/30 Days |
|
AFREZZA POWDER 8-12UNIT |
1080 Cartridges/30 Days |
|
AFREZZA POWDER 4-8-12 |
1260 Cartridges/30 Days |
Alinia
Drug Name(s) |
Quantity Limits
|
|
ALINIA SUSPENSION 100/5ML |
300 mLs/90 Days |
|
ALINIA TABLET 500MG |
12 Tablets/90 Days |
Amantadine Extended Release (ER)
Drug Name(s) |
Quantity Limits
|
|
30 Capsules/30 Days |
|
|
60 Capsules/30 Days |
Amifampridine
Drug Name(s) |
Quantity Limits
|
|
240 Tablets/30 Days |
|
|
300 Tablets/30 Days |
Ampyra
Drug Name(s) |
Quantity Limits
|
|
60 Tablets/30 Days |
|
|
dalfampridin tablet 10mg er1 |
60 Tablets/30 Days |
Androgen/Anabolic Steroids
Drug Name(s) |
Quantity Limits
|
|
ANDRODERM DIS 2MG/24HR |
30 Patches/30 Days |
|
ANDRODERM DIS 4MG/24HR |
30 Patches/30 Days |
|
ANDROGEL GEL 1%(25MG) |
60 Packets/30 Days |
|
ANDROGEL GEL 1%(50MG) |
60 Packets/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 |
|
ANDROID 10 MG CAPSULE |
20 Capsules/30 Days |
|
ANDROXY 10 MG TABLET |
120 Tablets/30 Days |
|
AVEED 250 MG/ML |
1 Vial/28 Days |
|
AXIRON 30 MG/1.5 |
2 Pumps/30 Days |
|
DEPO-TESTOSTERONE INJECTION 100MG/ML |
1 Vial/28 Days |
|
DEPO-TESTOSTERONE INJECTION 200MG/ML |
10 mLs/28 Days |
|
FORTESTA GEL 10MG/ACT |
2 Pumps/30 Days |
|
JATENZO 158 MG CAPSULE |
120 Capsules/30 Days |
|
JATENZO 198 MG CAPSULE |
60 Capsules/30 Days |
|
METHITEST 10 MG TABLET |
600 Capsules/30 Days |
|
NATESTO GEL 5.5MG |
3 Pumps/30 Days |
|
STRIANT MIS 30MG |
60 Systems/30 Days |
|
TESTIM GEL 1%(50MG) |
60 Packets/30 Days |
|
TESTOPEL 75 MG |
6 Pellets/90 Days |
|
testosterone cypionate injection 100mg/ml |
1 Vial/28 Days |
|
testosterone cypionate injection 200mg/ml |
10 mLs/28 Days |
|
TESTOST ENAN 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 GEL PUMP 1% |
4 Pumps/30 Days |
|
TESTOSTERONE INJECTION CYPIONATE |
10 mLs/28 Days |
|
testosterone solution 30mg/act |
2 Pumps/30 Days |
|
TESTRED 10 MG CAPSULE |
600 Capsules/30 Days |
|
VOGELXO GEL 1%(50MG) |
60 Packets/30 Days |
|
VOGELXO GEL PUMP 1% |
4 Pumps/30 Days |
|
XYOSTED INJECTION 100/0.5 |
2 Pens/28 Days |
|
XYOSTED INJECTION 50/0.5 |
2 Pens/28 Days |
|
XYOSTED IINJECTIONNJ 75/0.5 |
2 Pens/28 Days |
Antiemetic
Drug Name(s) |
Quantity Limits
|
|
AKYNZEO CAPSULE 300-0.5 |
2 Capsules/30 Days |
|
ANZEMET TABLET 50MG |
7 Tablets/30 Days |
|
ANZEMET TABLET 100MG |
7 Tablets/30 Days |
|
aprepitant capsule 40mg |
8 Capsules/30 Days |
|
aprepitant capsule 80mg |
8 Capsules/30 Days |
|
aprepitant capsule 125mg |
4 Capsules/30 Days |
|
aprepitant pack 80 & 125 |
4 Packs/30 Days |
|
CESAMET CAPSULE 1MG |
42 Capsules/30 Days |
|
DICLEGIS TABLET 10-10MG |
120 Tablets/30 Days |
|
doxylamine/pyridoxine tablet 10-10mg |
120 Tablets/30 Days |
|
EMEND CAPSULE 40MG |
8 Capsules/30 Days |
|
EMEND CAPSULE 80MG |
8 Capsules/30 Days |
|
EMEND CAPSULE 125MG |
4 Capsules/30 Days |
|
EMEND SUSPENSE 125MG |
6 Packs/30 Days |
|
EMEND TRIPAC PACK 80 & 125 |
4 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 4mg odt |
24 Tablets/30 Days |
|
ondansetron tablet 8mg |
24 Tablets/30 Days |
|
ondansetron tablet 8mg odt |
24 Tablets/30 Days |
|
ondansetron tablet 24mg |
4 Tablets/30 Days |
|
ONDANSETRON TABLET 24MG |
4 Tablets/30 Days |
|
SANCUSO DIS 3.1MG |
2 Patches/28 Days |
|
VARUBI TABLET 90MG |
4 Tablets/30 Days |
|
ZOFRAN SOLUTION 4MG/5ML |
5 Bottles/30 Days |
|
ZOFRAN TABLET 4MG |
24 Tablets/30 Days |
|
ZOFRAN TABLET 4MG ODT |
24 Tablets/30 Days |
|
ZOFRAN TABLET 8MG |
24 Tablets/30 Days |
|
ZOFRAN TABLET 8MG ODT |
24 Tablets/30 Days |
|
ZUPLENZ MIS 4MG |
24 Films/30 Days |
|
ZUPLENZ MIS 8MG |
24 Films/30 Days |
Antifungal
Drug Name(s) |
Quantity Limits
|
|
ciclodan solution 8% |
3.3 mLs/30 Days |
|
ciclopirox solution 8% |
3.3 mLs/30 Days |
|
JUBLIA SOLUTION 10% |
4 mLs/30 Days |
|
KERYDIN SOLUTION 5% |
4 mLs/30 Days |
|
PENLAC SOLUTION 8% |
6.6 mLs/30 Days |
Anti-Influenza
Drug Name(s) |
Quantity Limits
|
|
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 |
|
TAMIFLU CAPSULE 30MG |
40 Capsules/120 Days |
|
TAMIFLU CAPSULE 45MG |
20 Capsules/120 Days |
|
TAMIFLU CAPSULE 75MG |
20 Capsules/120 Days |
|
TAMIFLU SUSPENSE 6MG/ML |
300 mLs/120 Days |
|
XOFLUZA TABLET 20MG |
4 Tablets/120 Days |
|
XOFLUZA TABLET 40MG |
4 Tablets/120 Days |
Anti-Migraine: Calcitonin Gene-Related Peptide (CGRP)
Drug Name(s) |
Quantity Limits
|
|
AIMOVIG INJECTION 70MG/ML1 |
1 Injection/28 Days |
|
AIMOVIG INJECTION 140MG/ML1 |
1 Injection/28 Days |
|
AJOVY INJECTION 225/1.51 |
4.5 Syringes/84 Days |
|
EMGALITY INJECTION 100MG/ML1 |
9 Syringes/180 Days |
|
EMGALITY INJECTION 120MG/ML1 |
1 Syringe/28 Days |
Antiretroviral
Drug Name(s) |
Quantity Limits
|
|
RELENZA MIS DISKHALER |
40 Blisters/120 Days |
Arikayce
Drug Name(s) |
Quantity Limits
|
|
28 Vials/28 Days |
ATTR Amyloidosis
Drug Name(s) |
Quantity Limits
|
|
6 Syringes/28 Days |
Atypical Antipsychotics
Drug Name(s) |
Quantity Limits
|
|
CAPLYTA 42 MG CAPSULE |
30 Capsules/30 Days |
|
INVEGA TABLET 1.5MG |
60 Tablets/30 Days |
|
INVEGA TABLET 3MG |
60 Tablets/30 Days |
|
INVEGA TABLET 6MG |
60 Tablets/30 Days |
|
INVEGA TABLET 9MG |
60 Tablets/30 Days |
|
olanzapine tablet 2.5mg |
30 Tablets/30 Days |
|
olanzapine tablet 5mg |
30 Tablets/30 Days |
|
olanzapine tablet 5mg odt |
30 Tablets/30 Days |
|
olanzapine tablet 7.5mg |
30 Tablets/30 Days |
|
olanzapine tablet 10mg |
30 Tablets/30 Days |
|
olanzapine tablet 10mg odt |
30 Tablets/30 Days |
|
olanzapine tablet 15mg |
30 Tablets/30 Days |
|
olanzapine tablet 15mg odt |
30 Tablets/30 Days |
|
olanzapine tablet 20mg |
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 |
|
SEROQUEL XR TABLET 50MG |
60 Tablets/30 Days |
|
SEROQUEL XR TABLET 150MG |
60 Tablets/30 Days |
|
SEROQUEL XR TABLET 200MG |
60 Tablets/30 Days |
|
SEROQUEL XR TABLET 300MG |
60 Tablets/30 Days |
|
SEROQUEL XR TABLET 400MG |
60 Tablets/30 Days |
|
ZYPREXA TABLET 2.5MG |
30 Tablets/30 Days |
|
ZYPREXA TABLET 5MG |
30 Tablets/30 Days |
|
ZYPREXA TABLET 7.5MG |
30 Tablets/30 Days |
|
ZYPREXA TABLET 10MG |
30 Tablets/30 Days |
|
ZYPREXA TABLET 15MG |
30 Tablets/30 Days |
|
ZYPREXA TABLET 20MG |
30 Tablets/30 Days |
|
ZYPREXA ZYDI TABLET 5MG |
30 Tablets/30 Days |
|
ZYPREXA ZYDI TABLET 10MG |
30 Tablets/30 Days |
|
ZYPREXA ZYDI TABLET 15MG |
30 Tablets/30 Days |
|
ZYPREXA ZYDI TABLET 20MG |
30 Tablets/30 Days |
Bempedoic Acid
Drug Name(s) |
Quantity Limits
|
|
NEXLETOL TABLET 180MG |
30 Tablets/30 Days |
Benlysta
Drug Name(s) |
Quantity Limits
|
|
BENLYSTA INJECTION 200MG/ML1 |
4 Syringes/28 Days |
Biologic Immunomodulators
Drug Name(s) |
Quantity Limits
|
|
ACTEMRA INJECTION 162/0.91 |
4 Syringes/28 Days |
|
CIMZIA PREFL KIT 200MG/ML1 |
1 Kit/28 Days |
|
COSENTYX INJECTION 150MG/ML1 |
1 Syringe/28 Days |
|
COSENTYX INJECTION 300DOSE1 |
1 Pack/28 Days |
|
COSENTYX PEN INJECTION 150MG/ML1 |
1 Injection Device/28 Days |
|
COSENTYX PEN INJECTION 300DOSE1 |
1 Pack/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 Cartridges/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 |
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 |
|
KEVZARA INJECTION 150/1.141 |
2 Pens/28 Days |
|
KEVZARA INJECTION 150/1.141 |
2 Syringes/28 Days |
|
KEVZARA INJECTION 200/1.141 |
2 Pens/28 Days |
|
KEVZARA INJECTION 200/1.141 |
2 Syringes/28 Days |
|
30 Syringes/30 Days |
|
|
OLUMIANT TABLET 1MG1 |
30 Tablets/30 Days |
|
OLUMIANT TABLET 2MG1 |
30 Tablets/30 Days |
|
ORENCIA CLCK INJECTION 125MG/ML1 |
4 Syringes/28 Days |
|
ORENCIA IINJECTIONNJ 125MG/ML1 |
4 Syringes/28 Days |
|
ORENCIA INJECTION 50/0.41 |
4 Syringes/28 Days |
|
ORENCIA INJECTION 87.5/0.71 |
4 Syringes/28 Days |
|
RINVOQ TABLET 15MG ER1 |
30 Tablets/30 Days |
|
SILIQ ININJECTIONJ 210/1.51 |
2 Syringes/28 Days |
|
SIMPONI INJECTION 100MG/ML1 |
1 Syringe/28 Days |
|
SIMPONI INJECTION 50/0.5ML1 |
1 Syringe/28 Days |
|
SKYRIZI INJECTION 150DOSE1 |
1 Box/84 Days |
|
STELARA INJECTION 45MG/0.51 |
1 Syringe/84 Days |
|
STELARA INJECTION 90MG/ML1 |
1 Syringe/56 Days |
|
TALTZ INJECTION 80MG/ML1 |
1 mLs/28 Days |
|
TREMFYA INJECTION 100MG/ML1 |
1 Pen/56 Days |
|
TREMFYA INJECTION 100MG/ML1 |
1 Syringe/56 Days |
|
XELJANZ TABLET 5MG1 |
60 Tablets/30 Days |
|
XELJANZ TABLET 10MG1 |
60 Tablets/30 Days |
|
XELJANZ XR TABLET 11MG1 |
30 Tablets/30 Days |
|
XELJANZ XR TABLET 22MG1 |
112 Tablets/365 Days |
Bisphosphonates
Drug Name(s) |
Quantity Limits
|
|
ACTONEL TABLET 35MG |
4 Tablets/28 Days |
|
ACTONEL TABLET 150MG |
1 Tablet/28 Days |
|
alendronate tablet 35mg |
4 Tablets/28 Days |
|
alendronate tablet 70mg |
4 Capsules/28 Days |
|
ATELVIA 35 MG TABLET |
4 Tablets/28 Days |
|
BINOSTO TABLET 70MG |
4 Tablets/28 Days |
|
BONIVA TABLET 150MG |
1 Tablet/30 Days |
|
FOSAMAX + D TABLET 70-2800 |
4 Capsules/28 Days |
|
FOSAMAX + D TABLET 70-5600 |
4 Capsules/28 Days |
|
FOSAMAX TABLET 70MG |
4 Capsules/28 Days |
|
ibandronate tablet 150mg |
1 Tablet/30 Days |
|
risedronate tablet 35mg |
4 Tablets/28 Days |
|
risedronate tablet 35mg dr |
4 Tablets/28 Days |
|
risedronate tablet 150mg |
1 Tablet/28 Days |
Bonjesta Diclegis
Drug Name(s) |
Quantity Limits
|
|
doxylamine/pyridoxine tablet 10-10mg |
120 Tablets/30 Days |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
Drug Name(s) |
Quantity Limits
|
|
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 |
|
ORKAMBI TABLET 100-1251 |
120 Tablets/30 Days |
|
ORKAMBI TABLET 200-1251 |
120 Tablets/30 Days |
Circadian Rhythm Disorder
Drug Name(s) |
Quantity Limits
|
|
30 Capsules/30 Days |
Combination NSAID
Drug Name(s) |
Quantity Limits
|
|
CONSENSI 2.5 MG / 200 MG TABLET |
30 Tablets/30 Days |
|
CONSENSI 5 MG / 200 MG TABLET |
31 Tablets/30 Days |
|
CONSENSI 10 MG / 200 MG TABLET |
32 Tablets/30 Days |
|
DUEXIS TABLET 800-26.6 |
90 Tablets/30 Days |
|
VIMOVO TABLET 375-20MG |
60 Tablets/30 Days |
|
VIMOVO TABLET 500-20MG |
60 Tablets/30 Days |
|
YOSPRALA, ASPRIN/OMEPRAZOLE 81 MG/40 MG TABLET |
30 Tablets/30 Days |
|
YOSPRALA, ASPRIN/OMEPRAZOLE 325 MG/40 MG TABLET |
30 Tablets/30 Days |
Constipation Agents
Drug Name(s) |
Quantity Limits
|
|
AMITIZA CAPSULE 8MCG |
120 Capsules/30 Days |
|
AMITIZA CAPSULE 24MCG |
60 Capsules/30 Days |
|
LINZESS CAPSULE 72MCG |
30 Capsules/30 Days |
|
LINZESS CAPSULE 145MCG |
30 Capsules/30 Days |
|
LINZESS CAPSULE 290MCG |
30 Capsules/30 Days |
|
MOTEGRITY TABLET 1MG |
30 Tablets/30 Days |
|
MOTEGRITY TALET 2MG |
30 Tablets/30 Days |
|
MOVANTIK TABLET 12.5MG |
30 Tablets/30 Days |
|
MOVANTIK TABLET 25MG |
30 Tablets/30 Days |
|
RELISTOR INJECTION 8/0.4ML |
30 Syringes/30 Days |
|
RELISTOR INJECTION 12/0.6ML |
60 Vials/30 Days |
|
RELISTOR INJECTION 12/0.6ML |
30 Syringes/30 Days |
|
RELISTOR TABLET 150MG |
90 Tablets/30 Days |
|
SYMPROIC TABLET 0.2MG |
30 Tablets/30 Days |
|
TRULANCE TABLET 3MG |
30 Tablets/30 Days |
|
ZELNORM TABLET 6MG |
60 Tablets/30 Days |
Endocrine and Metabolic Agents: Egrifta
Drug Name(s) |
Quantity Limits
|
|
EGRIFTA SOLUTION 1MG1 |
60 Vials/30 Days |
|
EGRIFTA SV INJECTION 2MG1 |
30 Vials/30 Days |
Endocrine and Metabolic Agents: Emflaza
Drug Name(s) |
Quantity Limits
|
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
Endocrine and Metabolic Agents: Galafold
Drug Name(s) |
Quantity Limits
|
|
GALAFOLD CAPSULE 123MG1 |
14 Capsules/28 Days |
Fibromyalgia
Drug Name(s) |
Quantity Limits
|
|
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 |
|
SAVELLA MIS TITR 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 |
Gonadotropin Hormones
Drug Name(s) |
Quantity Limits
|
|
CETROTIDE KIT 0.25MG1 |
5 Kits/30 Days |
|
chorionic gonadotropin injection 10000unt1 |
2 Vials/30 Days |
|
GANIRELIX AC INJECTION 250/0.51 |
5 Syringes/30 Days |
|
NOVAREL INJECTION 10000UNT1 |
2 Vials/30 Days |
|
NOVAREL INJECTION 5000UNIT1 |
4 Vials/30 Days |
|
PREGNYL INJECTION 10000UNT1 |
2 Vials/30 Days |
Hereditary Angioedema Agents (HAE)
Drug Name(s) |
Quantity Limits
|
|
BERINERT 500 UNITS/10 ML |
10 Vials/30 Days |
|
CINRYZE 500 UNITS/10ML |
20 Vials/30 Days |
|
FIRAZYR INJECTION 30MG/3ML1 |
6 Syringes/30 Days |
|
24 Vials/30 Days |
|
|
16 Vials/30 Days |
|
|
icatibant injection 30mg/3ml1 |
6 Syringes/30 Days |
|
KALBITOR 3-10 MG/ML SINGLE |
12 Vials/30 Days |
|
RUCONEST 2100 UNIT SINGLE USE |
8 Vials/28 Days |
|
4 Vials/28 Days |
Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker
Drug Name(s) |
Quantity Limits
|
|
CORLANOR SOLUTION 5MG/5ML |
600 mLs/30 Days |
|
CORLANOR TABLET 5MG |
60 Tablets/30 Days |
|
CORLANOR TABLET 7.5MG |
60 Tablets/30 Days |
Hemlibra
Drug Name(s) |
Quantity Limits
|
|
HEMLIBRA INJECTION 30MG/ML1 |
4 Vials/28 Days |
|
HEMLIBRA INJECTION 60/0.41 |
4 Vials/28 Days |
|
HEMLIBRA INJECTION 105/0.71 |
4 Vials/28 Days |
|
HEMLIBRA INJECTION 150/ML1 |
4 Vials/28 Days |
Homozygous Familial Hypercholesterolemia (HoFH) Agents
Drug Name(s) |
Quantity Limits
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
KYNAMRO INJECTION 200MG/ML1 |
4 Injections/28 Days |
Hyperhidrosis
Drug Name(s) |
Quantity Limits
|
|
QBREXZA PAD 2.4% |
30 Pads/30 Days |
Irritable Bowel Syndrome w/Diarrhea (IBS-D)
Drug Name(s) |
Quantity Limits
|
|
alosetron tablet 0.5mg |
60 Tablets/30 Days |
|
alosetron tablet 1mg |
60 Tablets/30 Days |
|
LOTRONEX TABLET 0.5MG |
60 Tablets/30 Days |
|
LOTRONEX TABLET 1MG |
60 Tablets/30 Days |
|
VIBERZI TABLET 75MG |
60 Tablets/30 Days |
|
VIBERZI TABLET 100MG |
60 Tablets/30 Days |
|
XIFAXAN TABLET 200MG |
9 Tablets/30 Days |
|
XIFAXAN TABLET 550MG |
60 Tablets/30 Days |
Idiopathic Pulmonary Fibrosis
Drug Name(s) |
Quantity Limits
|
|
ESBRIET CAPSULE 267MG1 |
180 Capsules/30 Days |
|
ESBRIET TABLET 267MG1 |
180 Tablets/30 Days |
|
ESBRIET TABLET 801MG1 |
90 Tablets/30 Days |
|
60 Capsules/30 Days |
|
|
60 Capsules/30 Days |
Insomnia
Drug Name(s) |
Quantity Limits
|
|
AMBIEN CR TABLET 12.5MG |
30 Tablets/30 Days |
|
AMBIEN CR TABLET 6.25MG |
30 Tablets/30 Days |
|
AMBIEN TABLET 10MG |
30 Tablets/30 Days |
|
AMBIEN TABLET 5MG |
30 Tablets/30 Days |
|
BELSOMRA TAB 10MG |
30 Tablets/30 Days |
|
BELSOMRA TABLET 15MG |
30 Tablets/30 Days |
|
BELSOMRA TABLET 20MG |
30 Tablets/30 Days |
|
BELSOMRA TABLET 5MG |
30 Tablets/30 Days |
|
DAYVIGO 5 MG TABLET |
30 Tablets/30 Days |
|
DAYVIGO 10 MG TABLET |
30 Tablets/30 Days |
|
doxepin tablet 3mg |
30 Tablets/30 Days |
|
doxepin tablet 6mg |
30 Tablets/30 Days |
|
EDLUAR SUBLINGUAL 10MG |
30 Tablets/30 Days |
|
EDLUAR SUBLINGUAL 5MG |
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 |
|
INTERMEZZO SUBLINGUAL 1.75MG |
30 Tablets/30 Days |
|
INTERMEZZO SUBLINGUAL 3.5MG |
30 Tablets/30 Days |
|
LUNESTA TABLET 1MG |
30 Tablets/30 Days |
|
LUNESTA TABLET 2MG |
30 Tablets/30 Days |
|
LUNESTA TABLET 3MG |
30 Tablets/30 Days |
|
ramelteon tablet 8mg |
30 Tablets/30 Days |
|
ROZEREM TABLET 8MG |
30 Tablets/30 Days |
|
SILENOR TABLET 3MG |
30 Tablets/30 Days |
|
SILENOR TABLET 6MG |
30 Tablets/30 Days |
|
SONATA CAPSULE 10MG |
30 Capsules/30 Days |
|
SONATA CAPSULE 5MG |
30 Capsules/30 Days |
|
zaleplon capsule 10mg |
30 Capsules/30 Days |
|
zaleplon capsule 5mg |
30 Capsules/30 Days |
|
zolpidem er tablet 12.5mg |
30 Tablets/30 Days |
|
zolpidem er tablet 6.25mg |
30 Tablets/30 Days |
|
zolpidem tablet 10mg |
30 Tablets/30 Days |
|
zolpidem tablet 5mg |
30 Tablets/30 Days |
|
zolpidem tartrate sublingual 1.75mg |
30 Tablets/30 Days |
|
zolpidem tartrate sublingual 3.5mg |
30 Tablets/30 Days |
|
ZOLPIMIST SPRAY 5MG |
1 Canister/30 Days |
Interleukin (IL)-1 Inhibitor
Drug Name(s) |
Quantity Limits
|
|
4 Vials/28 Days |
|
|
ILARIS 150 MG/ML |
2 Vials/28 Days |
Interleukin (IL)-4 Inhibitors
Drug Name(s) |
Quantity Limits
|
|
DUPIXENT INJECTION 200/1.141 |
2 Syringes/28 Days |
|
DUPIXENT INJECTION 300/2ML1 |
2 Syringes/28 Days |
Jynarque
Drug Name(s) |
Quantity Limits
|
|
SAMSCA TABLET 15MG1 |
30 Tablets/365 Days |
|
SAMSCA TABLET 30MG1 |
60 Tablets/365 Days |
Keveyis
Drug Name(s) |
Quantity Limits
|
|
120 Tablets/30 Days |
Korlym
Drug Name(s) |
Quantity Limits
|
|
120 Tablets/30 Days |
Lidocaine Transdermal
Drug Name(s) |
Quantity Limits
|
|
lido/prilocn cream 2.5-2.5% |
60 Grams/30 Days |
|
LIDOCAINE CREAM TETRACAI |
120 Grams/30 Days |
|
lidocaine ointment 5% |
600 Grams/30 Days |
|
lidocaine ointment pack 5% |
600 Grams/30 Days |
|
lidocaine solution 4% |
400 Grams/30 Days |
|
lidocaine-pr cream |
60 Grams/30 Days |
|
PLIAGLIS CREAM 7-7% |
120 Grams/30 Days |
|
SYNERA DIS 70-70MG |
4 Patches/30 Days |
Lyrica CR
Drug Name(s) |
Quantity Limits
|
|
LYRICA CR TABLET 82.5MG |
30 Tablets/30 Days |
|
LYRICA CR TABLET 165MG |
30 Tablets/30 Days |
|
LYRICA CR TABLET 330MG |
60 Tablets/30 Days |
Muscle Relaxants
Drug Name(s) |
Quantity Limits
|
|
AMRIX CAPSULE 15MG |
21 Capsules/30 Days |
|
AMRIX CAPSULE 30MG |
21 Capsules/30 Days |
|
BACLOFEN TABLET 5MG |
120 Tablets/30 Days |
|
baclofen tablet 10mg |
120 Tablets/30 Days |
|
baclofen tablet 20mg |
120 Tablets/30 Days |
|
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 ASPIRINE/CODEINE |
168 Tablets/30 Days |
|
CHLORZOXAZON TABLET 250MG |
28 Tablets/30 Days |
|
chlorzoxazon tablet 375mg |
84 Tablets/90 Days |
|
CHLORZOXAZON TABLET 500MG |
28 Tablets/30 Days |
|
chlorzoxazon 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 |
|
DANTRIUM CAPSULE 25MG |
90 Capsules/30 Days |
|
DANTRIUM CAPSULE 50MG |
90 Capsules/30 Days |
|
dantrolene capsule 25mg |
90 Capsules/30 Days |
|
dantrolene capsule 50mg |
90 Capsules/30 Days |
|
dantrolene capsule 100mg |
90 Capsules/30 Days |
|
FEXMID TABLET 7.5MG |
21 Tablets/30 Days |
|
LORZONE TABLET 375MG |
28 Tablets/30 Days |
|
lorzone tablet 375mg |
84 Tablets/90 Days |
|
lorzone tablet 750mg |
84 Tablets/90 Days |
|
metaxall tablet 800mg |
28 Tablets/30 Days |
|
METAXALONE TAB 400MG |
56 Tablets/30 Days |
|
metaxalone tablet 800mg |
28 Tablets/30 Days |
|
methocarbam tablet 500mg |
60 Tablets/30 Days |
|
methocarbam tablet 750mg |
44 Tablets/30 Days |
|
orphenadrine tablet 100mg cr |
42 Tablets/30 Days |
|
orphenadrine tablet 100mg er |
42 Tablets/30 Days |
|
ROBAXIN TABLET 500MG |
60 Tablets/30 Days |
|
ROBAXIN TABLET 750MG |
44 Tablets/30 Days |
|
SKELAXIN TABLET 800MG |
28 Tablets/30 Days |
|
SOMA TABLET 250MG |
28 Tablets/30 Days |
|
SOMA TABLET 350MG |
28 Tablets/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 |
|
ZANAFLEX CAPSULE 2MG |
42 Capsules/30 Days |
|
ZANAFLEX CAPSULE 4MG |
42 Capsules/30 Days |
|
ZANAFLEX CAPSULE 6MG |
42 Capsules/30 Days |
|
ZANAFLEX TABLET 4MG |
42 Tablets/30 Days |
|
ZEPOSIA CAPSULE .92MG |
30 Capsules/30 Days |
|
Zeposia capsule starter kit |
37 Capsules/180 Days |
|
Zeposia 7 Day Capsule Starter Pack |
7 Capsules/180 Days |
Multiple Sclerosis
Drug Name(s) |
Quantity Limits
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
AVONEX KIT 30MCG1 |
1 Pack/28 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 |
|
COPAXONE INJECTION 20MG/ML1 |
30 Syringes/30 Days |
|
COPAXONE INJECTION 40MG/ML1 |
12 Syringes/28 Days |
|
dimethyl fumarate capsule 120mg dr |
56 Capsules/180 Days |
|
dimethyl fumarate capsule 240mg dr |
40 Capsules/30 Days |
|
EXTAVIA INJECTION 0.3MG1 |
1 Box/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 |
|
MAVENCLAD PACK 10MG(4)1 |
8 Tablets/301 Days |
|
MAVENCLAD PACK 10MG(5)1 |
10 Tablets/301 Days |
|
MAVENCLAD PACK 10MG(6)1 |
12 Tablets/301 Days |
|
MAVENCLAD PACK 10MG(7)1 |
14 Tablets/301 Days |
|
MAVENCLAD PACK 10MG(8)1 |
8 Tablets/301 Days |
|
MAVENCLAD PACK 10MG(9)1 |
9 Tablets/301 Days |
|
MAVENCLAD PACK 10MG(10)1 |
20 Tablets/301 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 |
|
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 |
|
REBIF TITRTN INJECTION PACK1 |
1 Kit/180 Days |
|
TECFIDERA 120 MG CAPSULE 3 |
56 Capsules/28 Days |
|
TECFIDERA 240 MG CAPSULE 3 |
60 Capsules/30 Days |
|
ZEPOSIA 0.92 MG CAPSULE |
30 Capsules/30 Days |
Natpara
Drug Name(s) |
Quantity Limits
|
|
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 |
Neurotrophic Keratitis
Drug Name(s) |
Quantity Limits
|
|
56 Vials/56 Days |
Nocturia
Drug Name(s) |
Quantity Limits
|
|
NOCTIVA EMULSION 0.83/0.1 |
1 Bottle/30 Days |
|
NOCTIVA SPRAY 1.66/0.1 |
1 Bottle/30 Days |
|
NOCDURNA 27.7 MCG TABLET |
30 Tablets/30 Days |
|
NOCDURNA 55.3 MCG TABLET |
31 Tablets/30 Days |
Northera
Drug Name(s) |
Quantity Limits
|
|
NORTHERA CAPSULE 100MG1 |
450 Capsules/30 Days |
|
NORTHERA CAPSULE 200MG1 |
180 Capsules/30 Days |
|
NORTHERA CAPSULE 300MG1 |
180 Capsules/30 Days |
Nuvigil/Provigil
Drug Name(s) |
Quantity Limits
|
|
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 |
|
modafinil tablet 100mg |
30 Tablets/30 Days |
|
modafinil tablet 200mg |
30 Tablets/30 Days |
|
NUVIGIL TABLET 50MG |
30 Tablets/30 Days |
|
NUVIGIL TABLET 150MG |
30 Tablets/30 Days |
|
NUVIGIL TABLET 200MG |
30 Tablets/30 Days |
|
NUVIGIL TABLET 250MG |
30 Tablets/30 Days |
|
PROVIGIL TABLET 100MG |
30 Tablets/30 Days |
|
PROVIGIL TABLET 200MG |
30 Tablets/30 Days |
Ocaliva
Drug Name(s) |
Quantity Limits
|
|
OCALIVA TABLET 5MG1 |
30 Tablets/30 Days |
|
OCALIVA TABLET 10MG1 |
30 Tablets/30 Days |
Ophthalmic Immunomodulators
Drug Name(s) |
Quantity Limits
|
|
CEQUA 0.9 MG/ML SOLUTION |
60 Vials/30 Days |
|
RESTASIS EMULSION 0.05% |
2 Vials/30 Days |
|
RESTASIS MUL EMULSION 0.05% |
1 Bottle/30 Days |
|
XIIDRA DROP 5% |
60 Vials/30 Days |
Ophthalmic Prostaglandins
Drug Name(s) |
Quantity Limits
|
|
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 |
|
RESCULA SOLUTION 0.15% |
1 Bottle/30 Days |
|
travoprost drop 0.004% |
2.5 mLs/30 Days |
|
TRAVATAN Z DROP 0.004% |
2.5 mLs/30 Days |
|
VYZULTA SOLUTION 0.024% |
5 mLs/30 Days |
|
XALATAN SOLUTION 0.005% |
2.5 mLs/30 Days |
|
ZIOPTAN DROP 0.0015% |
30 Containers/30 Days |
Opioids Extended Release (ER)
Drug Name(s) |
Quantity Limits
|
|
ARYMO ER TABLET 15MG |
60 Tablets/30 Days |
|
ARYMO ER TABLET 30MG |
30 Tablets/30 Days |
|
ARYMO ER TABLET 60MG |
0 |
|
BELBUCA MIS 75MCG |
60 Films/30 Days |
|
BELBUCA MIS 150MCG |
60 Films/30 Days |
|
BELBUCA MIS 300MCG |
60 Films/30 Days |
|
BELBUCA MIS 450MCG |
60 Films/30 Days |
|
BELBUCA MIS 600MCG |
60 Films/30 Days |
|
BELBUCA MIS 750MCG |
60 Films/30 Days |
|
BELBUCA MIS 900MCG |
30 Films/30 Days |
|
buprenorphin dis 5mcg/hr |
4 Systems/30 Days |
|
buprenorphin dis 10mcg/hr |
4 Systems/30 Days |
|
buprenorphin dis 15mcg/hr |
4 Systems/30 Days |
|
buprenorphin dis 20mcg/hr |
4 Systems/30 Days |
|
BUPRENORPHIN DIS 7.5/HR |
4 Systems/30 Days |
|
BUTRANS DIS 5MCG/HR |
4 Systems/30 Days |
|
BUTRANS DIS 7.5/HR |
4 Systems/30 Days |
|
BUTRANS DIS 10MCG/HR |
4 Systems/30 Days |
|
BUTRANS DIS 15MCG/HR |
4 Systems/30 Days |
|
BUTRANS DIS 20MCG/HR |
4 Systems/30 Days |
|
CONZIP CAPSULE 100MG |
30 Capsules/30 Days |
|
CONZIP CAPSULE 200MG |
30 Capsules/30 Days |
|
CONZIP CAPSULE 300MG |
30 Capsules/30 Days |
|
DURAGESIC DIS 12MCG/HR |
10 Patches/30 Days |
|
DURAGESIC DIS 25MCG/HR |
0 |
|
DURAGESIC DIS 50MCG/HR |
0 |
|
DURAGESIC DIS 75MCG/HR |
0 |
|
DURAGESIC DIS 100MCG/HR |
0 |
|
EMBEDA CAPSULE 20-0.8MG |
30 Capsules/30 Days |
|
EMBEDA CAPSULE 30-1.2MG |
30 Capsules/30 Days |
|
EMBEDA CAPSULE 50-2MG |
30 Capsules/30 Days |
|
EMBEDA CAPSULE 60-2.4MG |
0 |
|
EMBEDA CAPSULE 80-3.2MG |
0 |
|
EMBEDA CAPSULE 100-4MG |
0 |
|
EXALGO TABLET 8MG |
30 Tablets/30 Days |
|
EXALGO TABLET 12MG |
30 Tablets/30 Days |
|
EXALGO TABLET 16MG |
0 |
|
EXALGO TABLET 32MG |
0 |
|
fentanyl dis 12mcg/hr |
10 Patches/30 Days |
|
fentanyl dis 25mcg/hr |
0 |
|
fentanyl dis 37.5mcg/hr |
0 |
|
fentanyl dis 50mcg/hr |
0 |
|
fentanyl dis 62.5mcg/hr |
0 |
|
fentanyl dis 75mcg/hr |
0 |
|
fentanyl dis 87.5mcg/hr |
0 |
|
fentanyl dis 100mcg/hr |
0 |
|
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 |
|
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 |
|
HYSINGLA ER TABLET 20 MG |
30 Tablets/30 Days |
|
HYSINGLA ER TABLET 30 MG |
30 Tablets/30 Days |
|
HYSINGLA ER TABLET 40 MG |
30 Tablets/30 Days |
|
HYSINGLA ER TABLET 60 MG |
0 |
|
HYSINGLA ER TABLET 80 MG |
0 |
|
HYSINGLA ER TABLET 100 MG |
0 |
|
HYSINGLA ER TABLET 120 MG |
0 |
|
KADIAN CAPSULE 10MG ER |
30 Capsules/30 Days |
|
KADIAN CAPSULE 20MG ER |
30 Capsules/30 Days |
|
KADIAN CAPSULE 30MG ER |
30 Capsules/30 Days |
|
KADIAN CAPSULE 40MG ER |
30 Capsules/30 Days |
|
KADIAN CAPSULE 50MG ER |
30 Capsules/30 Days |
|
KADIAN CAPSULE 60MG ER |
0 |
|
KADIAN CAPSULE 80MG ER |
0 |
|
KADIAN CAPSULE 100MG ER |
0 |
|
KADIAN CAPSULE 200MG ER |
0 |
|
MORPHABOND TABLET 15MG ER |
60 Tablets/30 Days |
|
MORPHABOND TABLET 30MG ER |
30 Tablets/30 Days |
|
MORPHABOND TABLET 60MG ER |
0 |
|
MORPHABOND TABLET 100MG ER |
0 |
|
morphine sulfate tablet 15mg |
15 Tablets/30 Days |
|
morphine sulfate tablet 30mg |
5 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 CAPSULE 30MG ER |
30 Capsules/30 Days |
|
MORPHINESULFATE CAPSULE 45MG ER |
30 Capsules/30 Days |
|
MORPHINE SULFATE CAPSULE 60MG ER |
0 |
|
MORPHINE SULFATE CAPSULE 75MG ER |
0 |
|
MORPHINE SULFATE CAPSULE 90MG ER |
0 |
|
MORPHINE SULFATE CAPSULE 120MG ER |
0 |
|
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 |
|
MS CONTIN TABLET 15MG ER |
60 Tablets/30 Days |
|
MS CONTIN TABLET 30MG ER |
30 Tablets/30 Days |
|
MS CONTIN TABLET 60MG ER |
0 |
|
MS CONTIN TABLET 100MG ER |
0 |
|
MS CONTIN TABLET 200MG ER |
0 |
|
NUCYNTA ER TABLET 50MG |
60 Tablets/30 Days |
|
NUCYNTA ER TABLET 100MG |
30 Tablets/30 Days |
|
NUCYNTA ER TABLET 150MG |
0 |
|
NUCYNTA ER TABLET 200MG |
0 |
|
NUCYNTA ER TABLET 250MG |
0 |
|
OPANA ER TABLET 5MG |
60 Tablets/30 Days |
|
OPANA ER TABLET 7.5MG |
60 Tablets/30 Days |
|
OPANA ER TABLET 10MG |
30 Tablets/30 Days |
|
OPANA ER TABLET 15MG |
30 Tablets/30 Days |
|
OPANA ER TABLET 20MG |
0 |
|
OPANA ER TABLET 30MG |
0 |
|
OPANA ER TABLET 40MG |
0 |
|
OXYCODONE TABLET 10MG ER |
60 Tablets/30 Days |
|
OXYCODONE TABLET 15MG ER |
60 Tablets/30 Days |
|
OXYCODONE TABLET 20MG ER |
30 Tablets/30 Days |
|
OXYCODONE TABLET 30MG ER |
30 Tablets/30 Days |
|
OXYCODONE TABLET 40MG ER |
0 |
|
OXYCODONE TABLET 60MG ER |
0 |
|
OXYCODONE TABLET 80MG ER |
0 |
|
OXYCONTIN TABLET 10MG CR |
60 Tablets/30 Days |
|
OXYCONTIN TABLET 15MG CR |
60 Tablets/30 Days |
|
OXYCONTIN TABLET 20MG CR |
30 Tablets/30 Days |
|
OXYCONTIN TABLET 30MG CR |
30 Tablets/30 Days |
|
OXYCONTIN TABLET 40MG CR |
0 |
|
OXYCONTIN TABLET 60MG CR |
0 |
|
OXYCONTIN TABLET 80MG CR |
0 |
|
OXYMORPHONE TABLET 5MG ER |
60 Tablets/30 Days |
|
OXYMORPHONE TABLET 7.5MG ER |
60 Tablets/30 Days |
|
OXYMORPHONE TABLET 10MG ER |
30 Tablets/30 Days |
|
OXYMORPHONE TABLET 15MG ER |
30 Tablets/30 Days |
|
OXYMORPHONE TABLET 20MG ER |
0 |
|
OXYMORPHONE TABLET 30MG ER |
0 |
|
OXYMORPHONE TABLET 40MG ER |
0 |
|
TRAMADOL HCL CAPSULE 150MG ER |
30 Capsules/30 Days |
|
TRAMADOL HCL CAPSULE ER 100MG |
30 Capsules/30 Days |
|
TRAMADOL HCL CAPSULE ER 200MG |
30 Capsules/30 Days |
|
TRAMADOL HCL CAPSULE ER 300MG |
30 Capsules/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 |
|
XTAMPZA ER CAPSULE 9MG |
60 Capsules/30 Days |
|
XTAMPZA ER CAPSULE 13.5MG |
60 Capsules/30 Days |
|
XTAMPZA ER CAPSULE 18MG |
30 Capsules/30 Days |
|
XTAMPZA ER CAPSULE 27MG |
30 Capsules/30 Days |
|
XTAMPZA ER CAPSULE 36MG |
0 |
|
ZOHYDRO ER CAPSULE 10MG |
60 Capsules/30 Days |
|
ZOHYDRO ER CAPSULE 15MG |
60 Capsules/30 Days |
|
ZOHYDRO ER CAPSULE 20MG |
60 Capsules/30 Days |
|
ZOHYDRO ER CAPSULE 30MG |
30 Capsules/30 Days |
|
ZOHYDRO ER CAPSULE 40MG |
30 Capsules/30 Days |
|
ZOHYDRO ER CAPSULE 50MG |
30 Capsules/30 Days |
Opioids Immediate Release (IR)
Drug Name(s) |
Adult Quantity Limit – 5 Days |
Child Quantity Limit – 3 Days |
|
ACETAMINOPHEN-CAFFEINE DIHYDROCODEINE CAPSULE |
50 Capsules/30 Days |
30 capsules/30 days |
|
ACETAMINOPHEN/CAFFEINE DIHYDROCODEINE TABLET |
50 Tablets/30 Days |
30 capsules/30 days |
|
acetaminophen/caffeine dihydrocodeine tablet |
50 Capsules/30 Days |
N/A |
|
acetaminophen/codeine solution 120-12/5 |
450 mLs/30 Days |
270 mL/30 days |
|
acetaminophen/codeine tablet 300-15mg |
30 Tablets/30 Days |
N/A |
|
acetaminophen/codeine tablet 300-30mg |
30 Tablets/30 Days |
N/A |
|
acetaminophen/codeine tablet 300-60mg |
25 Tablets/30 Days |
N/A |
|
butorphanol solution 10mg/ml |
1 Bottle/30 Days |
0 mL/30 days |
|
CODEINE SULFATE TABLET 15MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
CODEINE SULFATE TABLET 30MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
CODEINE SULFATE TABLET 60MG |
25 Tablets/30 Days |
15 tablets/30 days |
|
DEMEROL TABLET 100MG |
15 Tablets/30 Days |
N/A |
|
DILAUDID LIQUID 1MG/ML |
60 mLs/30 Days |
36 mL/30 days |
|
DILAUDID TABLET 2MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
DILAUDID TABLET 4MG |
15 Tablets/30 Days |
9 tablets/30 days |
|
DILAUDID TABLET 8MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
DOLOPHINE TABLET 5MG |
60 Tablets/30 Days |
N/A |
|
DOLOPHINE TABLET 10MG |
30 Tablets/30 Days |
N/A |
|
dvorah tablet |
50 Tablets/30 Days |
N/A |
|
endocet tablet 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
|
endocet tablet 5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
endocet tablet 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
|
endocet tablet 10-325mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
hydrocodone/acetaminophen tablet 2.5-325mg |
60 Tablets/30 Days |
36 tablets/30 days |
|
hydrocodone/acetaminophen tablet 5-325mg |
40 Tablets/30 Days |
24 tablets/30 days |
|
hydrocodone/acetaminophen tablet 7.5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
hydrocodone/acetaminophen tablet 10-325mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/acetaminophen solution 7.5-325mg |
450 mLs/30 Days |
270 mL/30 days |
|
HYDROCODONE/ACETAMINOPHEN SOLUTION 10-325MG |
375 mLs/30 Days |
225 mL/30 days |
|
hydrocodone/acetaminophen tablet 5-300mg |
40 Tablets/30 Days |
24 tablets/30 days |
|
hydrocodone/acetaminophen tablet 7.5-300 mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
hydrocodone/acetaminophen tablet 10-300mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/ibuprofen tablet 5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/ibuprofen tablet 7.5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/ibuprofen tablet 10-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydromorphone liquid 1mg/ml |
60 mLs/30 Days |
36 mL/30 days |
|
HYDROMORPHONE SUPPOSITORY 3MG |
20 Suppositories/30 Days |
N/A |
|
hydromorphone tablet 2mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
hydromorphone tablet 4mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
hydromorphone tablet 8mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
ibudone tablet 5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
IBUDONE TABLET 10-200MG |
25 Tablets/30 Days |
15 tablets/30 days |
|
levorphanol tablet 2mg |
10 Tablets/30 Days |
6 tablets/30 days |
|
levorphanol tablet 3mg |
10 Tablets/30 Days |
6 tablets/30 days |
|
lorcet hd tablet 10-325mg |
25 Tablets/30 Days |
N/A |
|
lorcet plus tablet 7.5-325 |
30 Tablets/30 Days |
N/A |
|
lorcet tablet 5-325mg |
40 Tablets/30 Days |
N/A |
|
LORTAB ELIXER 10-300MG |
338 mLs/30 Days |
N/A |
|
MEPERIDINE SOLUTION 50MG/5ML |
150 mLs/30 Days |
150 mL/30 days |
|
meperidine tablet 50mg |
30 Tablets/30 Days |
30 tablets/30 days |
|
meperidine tablet 100mg |
15 Tablets/30 Days |
15 tablets/30 days |
|
METHADONE SOLUTION 5MG/5ML |
300 mLs/30 Days |
N/A |
|
METHADONE SOLUTION 10MG/5ML |
150 mLs/30 Days |
N/A |
|
methadone tablet 5mg |
60 Tablets/30 Days |
N/A |
|
methadone tablet 10mg |
30 Tablets/30 Days |
N/A |
|
morphine sulfate solution 10mg/5ml |
125 mLs/30 Days |
75 mL/30 days |
|
morphine sulfate solution 20mg/5ml |
60 mLs/30 Days |
36 mL/30 days |
|
morphine sulfate solution 20mg/ml |
10 mLs/30 Days |
6 mL/30 days |
|
MORPHINE SULFATE SUPPOSITORY 5MG |
50 Suppositories/30 Days |
N/A |
|
MORPHINE SULFATE SUPPOSITORY 10MG |
25 Suppositories/30 Days |
N/A |
|
MORPHINE SULFATE SUPPOSITORY 20MG |
10 Suppositories/30 Days |
N/A |
|
MORPHINE SULFATE SUPPOSITORY 30MG |
5 Suppositories/30 Days |
N/A |
|
MORPHINE SULFATE TABLET 15MG |
15 Tablets/30 Days |
9 tablets/30 days |
|
MORPHINE SULFATE TABLET 30MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
NORCO TABLET 5-325MG |
40 Tablets/30 Days |
24 tablets/30 days |
|
NORCO TABLET 7.5-325 |
30 Tablets/30 Days |
18 tablets/30 days |
|
NORCO TABLET 10-325MG |
25 Tablets/30 Days |
15 tablets/30 days |
|
NUCYNTA TABLET 50MG |
10 Tablets/30 Days |
6 tablets/30 days |
|
NUCYNTA TABLET 75MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
NUCYNTA TABLET 100MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
OPANA TABLET 5MG |
15 Tablets/30 Days |
9 tablets/30 days |
|
OPANA TABLET 10MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
OXAYDO TABLET 5MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
OXAYDO TABLET 7.5MG |
20 Tablets/30 Days |
12 tablets/30 days |
|
oxycodone/acetaminophen tablet 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
|
oxycodone/acetaminophen tablet 5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
oxycodone/acetaminophen tablet 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
|
oxycodone/acetaminophen tablet 10-325mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
oxycodone/aspirin tablet |
30 Tablets/30 Days |
18 tablets/30 days |
|
OXYCODONE/IBUPRIOFEN TABLET 5-400MG |
20 Tablets/30 Days |
12 tablets/30 days |
|
oxycodone capsule 5mg |
30 Capsules/30 Days |
18 capsules/30 days |
|
oxycodone concentrate 20/ml |
5 mLs/30 Days |
3 mL/30 days |
|
oxycodone solution 5mg/5ml |
165 mLs/30 Days |
99 mL/30 days |
|
oxycodone tablet 5mg |
30 Tablets/30 Days |
18 capsules/30 days |
|
oxycodone tablet 7.5mg |
20 Tablets/30 Days |
12 tablets/30 days |
|
oxycodone tablet 10mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
oxycodone tablet 15mg |
10 Tablets/30 Days |
6 tablets/30 days |
|
oxycodone tablet 20mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
oxycodone tablet 30mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
OXYCODONE/ SOLUTION ACETAMINOPHEN |
100 mLs/30 Days |
60 mL/30 days |
|
oxymorphone tablet hcl 5mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
oxymorphone tablet hcl 10mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
panlor tablet 325-30 |
50 Capsules/30 Days |
N/A |
|
pentazocine/naloxone tablet 50-0.5mg |
10 Tablets/30 Days |
6 tablets/30 days |
|
PERCOCET TABLET 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
|
PERCOCET TABLET 5-325MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
PERCOCET TABLET 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
|
PERCOCET TABLET 10-325MG |
15 Tablets/30 Days |
9 tablets/30 days |
|
PRIMLEV TABLET 5-300MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
PRIMLEV TABLET 7.5-300 |
20 Tablets/30 Days |
12 tablets/30 days |
|
PRIMLEV TABLET 10-300MG |
15 Tablets/30 Days |
9 tablets/30 days |
|
ROXICODONE TABLET 5MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
ROXICODONE TABLET 15MG |
10 Tablets/30 Days |
6 tablets/30 days |
|
ROXICODONE TABLET 30MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
ROXYBOND TABLET 5MG |
30 Tablets/30 Days |
18 tablets/30 days |
|
tramadol hcl tablet 50mg |
50 Tablets/30 Days |
30 tablets/30 days |
|
tramadol/acetaminophen tablet 37.5-325 |
40 Tablets/30 Days |
24 tablets/30 days |
|
TREZIX CAPSULE |
50 Capsules/30 Days |
30 capsules/30 days |
|
TYLENOL/CODEINE TABLET #2 |
30 Tablets/30 Days |
18 tablets/30 days |
|
TYLENOL/CODEINE TABLET #3 |
30 Tablets/30 Days |
18 tablets/30 days |
|
TYLENOL/CODEINE TABLET #4 |
25 Tablets/30 Days |
15 tablets/30 days |
|
ULTRACET TABLET 37.5-325 |
40 Tablets/30 Days |
24 tablets/30 days |
|
ULTRAM TABLET 50MG |
50 Tablets/30 Days |
30 tablets/30 days |
|
VERDROCET TABLET 2.5-325 |
60 Tablets/30 Days |
N/A |
|
vicodin es tablet 7.5-300 |
30 Tablets/30 Days |
N/A |
|
vicodin hp tablet 10-300mg |
25 Tablets/30 Days |
N/A |
|
vicodin tablet 5-300mg |
40 Tablets/30 Days |
N/A |
|
xylon tablet 10-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
Oral Inhalers
Drug Name(s) |
Quantity Limits
|
|
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 |
|
ALVESCO AER 80MCG |
2 Canisters/30 Days |
|
ALVESCO AER 160MCG |
2 Canisters/30 Days |
|
ARNUITY ELLIPTA INHALER 100MCG |
30 Blisters/30 Days |
|
ARNUITY ELLIPTA INHALER 200MCG |
30 Blisters/30 Days |
|
ASMANEX 30 AER 110MCG |
1 Canister/30 Days |
|
ASMANEX 14 AER 220MCG |
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 |
|
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 |
|
FLOVENT DISK AER 50MCG |
60 Blisters/30 Days |
|
FLOVENT DISK AER 100MCG |
60 Blisters/30 Days |
|
FLOVENT DISK AER 250MCG |
240 Blisters/30 Days |
|
FLOVENT HFA AER 44MCG |
1 Canister/30 Days |
|
FLOVENT HFA AER 110MCG |
1 Canister/30 Days |
|
FLOVENT HFA AER 220MCG |
2 Canisters/30 Days |
|
fluticasone/salmetrol aer 100/50 |
60 Blisters/30 Days |
|
fluticasone/salmetrol aer 250/50 |
60 Blisters/30 Days |
|
fluticasone/salmetrol aer 500/50 |
60 Blisters/30 Days |
|
PULMICORT INHALER 90MCG |
2 Canisters/30 Days |
|
PULMICORT INHALER 180MCG |
2 Canisters/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 |
|
SYMBICORT AER 80-4.5 |
1 Canister/30 Days |
|
SYMBICORT AER 160-4.5 |
1 Canister/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 |
Oral Pulmonary Arterial Hypertension (PAH)
Drug Name(s) |
Quantity Limits
|
|
ADCIRCA TABLET 20MG1 |
60 Tablets/30 Days |
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
alyq tablet 20mg1 |
60 Tablets/30 Days |
|
ambrisentan tablet 5mg1 |
30 Tablets/30 Days |
|
ambrisentan tablet 10mg1 |
30 Tablets/30 Days |
|
bosentan tablet 62.5mg1 |
60 Tablets/30 Days |
|
bosentan tablet 125mg1 |
60 Tablets/30 Days |
|
LETAIRIS TABLET 5MG1 |
30 Tablets/30 Days |
|
LETAIRIS TABLET 10MG1 |
30 Tablets/30 Days |
|
30 Tablets/30 Days |
|
|
REVATIO SUS 10MG/ML1 |
2 Bottles/30 Days |
|
REVATIO TABLET 20MG1 |
90 Tablets/30 Days |
|
sildenafil suspense 10mg/ml1 |
224 mLs/30 Days |
|
sildenafil tablet 20mg1 |
90 Tablets/30 Days |
|
tadalafil tablet 20mg1 |
60 Tablets/30 Days |
|
TRACLEER TABLET 32MG1 |
120 Tablets/30 Days |
|
TRACLEER TABLET 62.5MG1 |
60 Tablets/30 Days |
|
TRACLEER TABLET 125MG1 |
60 Tablets/30 Days |
|
TYVASO 0.6 MG/ML SYSTEM |
1 Kit/180 Days |
|
TYVASO 0.6 MG/ML 4 PACK |
81.2 Ampules/28 Days |
|
1 Package/180 Days |
|
|
60 Tablets/30 Days |
|
|
140 Tablets/180 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
270 Ampules/30 Days |
|
|
270 Ampules/30 Days |
Orilissa
Drug Name(s) |
Quantity Limits
|
|
ORILISSA TABLET 150MG |
30 Tablets/30 Days |
|
ORILISSA TABLET 200MG |
60 Tablets/30 Days |
Otezla
Drug Name(s) |
Quantity Limits
|
|
OTEZLA TABLET 10/20/301 |
1 Kit/180 Days |
|
OTEZLA TABLET 30MG1 |
60 Tablets/30 Days |
Parathyroid Hormone Analog Osteoporosis
Drug Name(s) |
Quantity Limits
|
|
FORTEO SOLUTION 600/2.41 |
1 Pen/28 Days |
|
TYMLOS INJECTION1 |
1 Pen/30 Days |
Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK-9) Inhibitors
Drug Name(s) |
Quantity Limits
|
|
REPATHA INJECTION 140MG/ML |
2 Syringes/28 Days |
|
REPATHA SURE INJECTION 140MG/ML |
2 Pens/28 Days |
|
REPATHA PUSH INJECTION 420/3.5 |
1 Cartridge/30 Days |
|
PRALUENT INJECTION 75MG/ML |
2 Syringes/28 Days |
|
PRALUENT INJECTION 150MG/ML |
2 Syringes/28 Days |
Proton Pump Inhibitors (PPI)
Drug Name(s) |
Quantity Limits
|
|
ACIPHEX TABLET 20MG |
30 Tablets/30 Days |
|
DEXILANT CAPSULE 30MG DR |
30 Capsules/30 Days |
|
DEXILANT CAPSULE 60MG DR |
30 Capsules/30 Days |
|
esomepra magnesium capsule 40mg dr |
30 Capsules/30 Days |
|
lansoprazole capsule 15mg dr |
30 Capsules/30 Days |
|
lansoprazole capsule 30mg dr |
30 Capsules/30 Days |
|
NEXIUM CAPSULE 40MG |
30 Capsules/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 10mg dr |
30 Capsules/30 Days |
|
omeprazole capsule 20mg |
30 Capsules/30 Days |
|
omeprazole capsule 20mg dr |
30 Capsules/30 Days |
|
omeprazole capsule 40mg |
30 Capsules/30 Days |
|
omeprazole capsule 40mg dr |
30 Capsules/30 Days |
|
pantoprazole tablet 20mg |
30 Tablets/30 Days |
|
pantoprazole tablet 20mg dr |
30 Tablets/30 Days |
|
pantoprazole tablet 40mg |
30 Tablets/30 Days |
|
pantoprazole tablet 40mg dr |
30 Tablets/30 Days |
|
PREVACID CAPSULE 15MG DR |
30 Capsules/30 Days |
|
PREVACID CAPSULE 30MG DR |
30 Capsules/30 Days |
|
PROTONIX TABLET 20MG |
30 Tablets/30 Days |
|
PROTONIX TABLET 40MG |
30 Tablets/30 Days |
|
rabeprazole tablet 20mg |
30 Tablets/30 Days |
|
ZEGERID CAPSULE 20-1100 |
30 Capsules/30 Days |
|
ZEGERID CAPSULE 40-1100 |
30 Capsules/30 Days |
|
ZEGERID POWDER 20-1680 |
30 Packets/30 Days |
|
ZEGERID POWDER 40-1680 |
30 Packets/30 Days |
Prevymis
Drug Name(s) |
Quantity Limits
|
|
PREVYMIS TABLET 240MG |
100 Tablets/365 Days |
|
PREVYMIS TABLET 480MG |
100 Tablets/365 Days |
Progesterone’s
Drug Name(s) |
Quantity Limits
|
|
CRINONE GEL 4% VAG |
6 Applicators/30 Days |
|
CRINONE GEL 8% VAG |
60 Applicators/30 Days |
|
ENDOMETRIN SUPPOSITORY 100MG |
4 Cartons/28 Days |
Regranex
Drug Name(s) |
Quantity Limits
|
|
REGRANEX GEL 0.01% |
1 Tube/30 Days |
Rho Kinase Inhibitor
Drug Name(s) |
Quantity Limits
|
|
RHOPRESSA SOLUTION 0.02% |
2.5 mLs/30 Days |
|
ROCKLATAN DRO |
2.5 mLs/30 Days |
SA Oncology
Drug Name(s) |
Quantity Limits
|
|
abiraterone tablet 250mg1 |
120 Tablets/30 Days |
|
60 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
240 Capsules/30 Days |
|
|
30 Tablets/180 Days |
|
|
180 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
180 Capsules/30 Days |
|
|
180 Capsules/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
60 Capsules/30 Days |
|
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
1 Carton/28 Days |
|
|
1 Carton/28 Days |
|
|
112 Tablets/28 Days |
|
|
56 Capsules/28 Days |
|
|
56 Capsules/28 Days |
|
|
COTELLIC TABLET 20MG1 |
63 Tablets/28 Days |
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
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 |
|
FARYDAK CAPSULE 10MG1 |
6 Capsules/21 Days |
|
FARYDAK CAPSULE 15MG1 |
6 Capsules/21 Days |
|
FARYDAK CAPSULE 20MG1 |
6 Capsules/21 Days |
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
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 |
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
IDHIFA TABLET 50MG1 |
30 Tablets/30 Days |
|
IDHIFA TABLET 100MG1 |
30 Tablets/30 Days |
|
30 Capsules/30 Days |
|
|
120 Capsules/30 Days |
|
|
120 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
180 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
120 Capsules/30 Days |
|
|
30 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
KISQALI TABLET 200DOSE1 |
63 Tablets/28 Days |
|
KISQALI TABLET 400DOSE1 |
63 Tablets/28 Days |
|
KISQALI TABLET 600DOSE1 |
63 Tablets/28 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 |
|
30 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
LONSURF TABLET 15-6.141 |
100 Tablets/28 Days |
|
LONSURF TABLET 20-8.191 |
80 Tablets/28 Days |
|
90 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
480 Capsules/30 Days |
|
|
120 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
MEKINIST TABLET 0.5MG1 |
90 Tablets/30 Days |
|
MEKINIST TABLET 2MG1 |
30 Tablets/30 Days |
|
180 Tablets/30 Days |
|
|
180 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 |
|
NUBEQA TABLET 300MG1 |
120 Tablets/30 Days |
|
30 Capsules/30 Days |
|
|
28 Tablets/28 Days |
|
|
56 Tablets/28 Days |
|
|
56 Tablets/28 Days |
|
|
POMALYST CAPSULE 1MG1 |
21 Capsules/28 Days |
|
POMALYST CAPSULE 2MG1 |
21 Capsules/28 Days |
|
POMALYST CAPSULE 3MG1 |
21 Capsules/28 Days |
|
POMALYST CAPSULE 4MG1 |
21 Capsules/28 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 |
|
30 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
120 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
RYDAPT CAPSULE 25MG1 |
240 Capsules/30 Days |
|
STIVARGA TABLET 40MG1 |
84 Tablets/28 Days |
|
90 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
TAFINLAR CAPSULE 50MG1 |
120 Capsules/30 Days |
|
TAFINLAR CAPSULE 75MG1 |
120 Capsules/30 Days |
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
90 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
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 |
|
60 Tablets/30 Days |
|
|
120 Capsules/30 Days |
|
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
180 Tablets/30 Days |
|
|
1 Pack/180 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
180 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
300 mLs/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
1 Box/28 Days |
|
|
1 Box/28 Days |
|
|
1 Box/28 Days |
|
|
120 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
ZELBORAF TABLET 240MG1 |
240 Tablets/30 Days |
|
120 Capsules/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
90 Capsules/30 Days |
|
|
90 Tablets/30 Days |
|
|
120 Tablets/30 Days |
|
|
60 Tablets/30 Days |
Signifor
Drug Name(s) |
Quantity Limits
|
|
60 mLs/30 Days |
|
|
60 mLs/30 Days |
|
|
60 mLs/30 Days |
Sodium Oxybate
Drug Name(s) |
Quantity Limits
|
|
540 mLs/30 Days |
Somatostatin Analogs
Drug Name(s) |
Quantity Limits
|
|
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 |
Selective Serotonin Inverse Agonists (SSIA)
Drug Name(s) |
Quantity Limits
|
|
NUPLAZID TABLET 10MG1 |
30 Tablets/30 Days |
|
NUPLAZID TABLET 17MG1 |
60 Tablets/30 Days |
|
NUPLAZID CAPSULE 34MG1 |
30 Capsules/30 Days |
Statins
Drug Name(s) |
Quantity Limits
|
|
ALTOPREV TABLET 20MG ER |
30 Tablets/30 Days |
|
ALTOPREV TABLET 40MG ER |
30 Tablets/30 Days |
|
ALTOPREV TABLET 60MG ER |
30 Tablets/30 Days |
|
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 |
|
CRESTOR TABLET 5MG |
45 Tablets/30 Days |
|
CRESTOR TABLET 10MG |
45 Tablets/30 Days |
|
CRESTOR TABLET 20MG |
45 Tablets/30 Days |
|
CRESTOR TABLET 40MG |
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 |
|
LESCOL XL TABLET 80MG |
30 Tablets/30 Days |
|
LIPITOR TABLET 10MG |
45 Tablets/30 Days |
|
LIPITOR TABLET 20MG |
45 Tablets/30 Days |
|
LIPITOR TABLET 40MG |
45 Tablets/30 Days |
|
LIPITOR TABLET 80MG |
30 Tablets/30 Days |
|
LIVALO TABLET 1MG |
45 Tablets/30 Days |
|
LIVALO TABLET 2MG |
45 Tablets/30 Days |
|
LIVALO TABLET 4MG |
30 Tablets/30 Days |
|
lovastatin tablet 10mg |
60 Tablets/30 Days |
|
lovastatin tablet 20mg |
60 Tablets/30 Days |
|
lovastatin tablet 40mg |
60 Tablets/30 Days |
|
PRAVACHOL TABLET 20MG |
45 Tablets/30 Days |
|
PRAVACHOL TABLET 40MG |
45 Tablets/30 Days |
|
PRAVACHOL TABLET 80MG |
30 Tablets/30 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 |
|
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 |
|
VYTORIN TABLET 10-10MG |
30 Tablets/30 Days |
|
VYTORIN TABLET 10-20MG |
30 Tablets/30 Days |
|
VYTORIN TABLET 10-40MG |
30 Tablets/30 Days |
|
VYTORIN TABLET 10-80MG |
30 Tablets/30 Days |
|
ZOCOR TABLET 5MG |
45 Tablets/30 Days |
|
ZOCOR TABLET 10MG |
45 Tablets/30 Days |
|
ZOCOR TABLET 20MG |
60 Tablets/30 Days |
|
ZOCOR TABLET 40MG |
45 Tablets/30 Days |
|
ZOCOR TABLET 80MG |
30 Tablets/30 Days |
Substrate Reduction Therapy
Drug Name(s) |
Quantity Limits
|
|
CERDELGA CAPSULE 84MG1 |
60 Capsules/30 Days |
|
miglustat capsule 100mg1 |
90 Capsules/30 Days |
|
90 Capsules/30 Days |
Sunosi
Drug Name(s) |
Quantity Limits
|
|
SUNOSI TABLET 75MG |
30 Tablets/30 Days |
|
SUNOSI TABLET 150MG |
30 Tablets/30 Days |
Tafamidis
Drug Name(s) |
Quantity Limits
|
|
VYNDAMAX CAPSULE 61MG1 |
30 Capsules/30 Days |
|
VYNDAQEL CAPSULE 20MG1 |
120 Capsules/30 Days |
Thrombopoietin Receptor Agonists
Drug Name(s) |
Quantity Limits
|
|
MULPLETA TABLET 3MG1 |
7 Tablets/7 Days |
|
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 |
Topical Corticosteroids
Drug Name(s) |
Quantity Limits
|
|
ALA SCALP LOTION 2% |
118.4 mLs/30 Days |
|
ala-cort cream 1% |
454 Grams/30 Days |
|
ala-cort cream 2.5% |
454 Grams/30 Days |
|
alclometason cream 0.05% |
120 Grams/30 Days |
|
alclometason ointment 0.05% |
120 Grams/30 Days |
|
AMCINONIDE CREAM 0.1% |
120 Grams/30 Days |
|
AMCINONIDE LOTION 0.1% |
120 mLs/30 Days |
|
AMCINONIDE OINTMENT 0.1% |
120 Grams/30 Days |
|
APEXICON E CREAM 0.05% |
120 Grams/30 Days |
|
aug betamet cream 0.05% |
200 Grams/28 Days |
|
AUG BETAMET GEL 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 |
|
BETA DIPROP GEL 0.05% |
200 Grams/28 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 SHA 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 |
|
CLOBEX LOTION 0.05% |
177 mLs/28 Days |
|
CLOBEX SHA 0.05% |
236 mLs/30 Days |
|
CLOBEX SPR 0.05% |
236 mLs/28 Days |
|
CLOCORTOLONE CREAM 0.1% |
135 Grams/30 Days |
|
CLOCORTOLONE CREAM PIV 0.1% |
135 Grams/30 Days |
|
clodan shampoo 0.05% |
236 mLs/30 Days |
|
CLODERM CREAM 0.1% |
135 Grams/30 Days |
|
CLODERM CREAM 0.1% PMP |
135 Grams/30 Days |
|
CORDRAN 80X3 TAP 4MCG/CM |
1 Box/30 Days |
|
CORDRAN CREAM 0.025% |
120 Grams/30 Days |
|
CORDRAN CREAM 0.05% |
120 Grams/30 Days |
|
CORDRAN LOTION 0.05% |
120 mLs/30 Days |
|
CORDRAN LOTION 0.05% |
120 Grams/30 Days |
|
CUTIVATE LOTION 0.05% |
120 mLs/30 Days |
|
DERMA-SMOOTH OIL /FS BODY |
118.28 mLs/30 Days |
|
DERMA-SMOOTH OIL /FS SCLP |
118.28 mLs/30 Days |
|
DESONATE GEL 0.05% |
120 Grams/30 Days |
|
desonide cream 0.05% |
120 Grams/30 Days |
|
desonide lotion 0.05% |
118 mLs/30 Days |
|
desonide ointment 0.05% |
120 Grams/30 Days |
|
DESOWEN CREAM 0.05% |
120 Grams/30 Days |
|
DESOWEN LOTION 0.05% |
118 mLs/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 CREAM 0.05% |
120 Grams/30 Days |
|
diflorasone ointment 0.05% |
120 Grams/30 Days |
|
DIPROLENE AF CREAM 0.05% |
200 Grams/28 Days |
|
DIPROLENE LOTION 0.05% |
200 Grams/28 Days |
|
ELOCON CREAM 0.1% |
135 Grams/30 Days |
|
ELOCON LOTION 0.1% |
135 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 |
|
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 |
|
HALOG CREAM 0.1% |
240 Grams/30 Days |
|
HALOG OINTMENT 0.1% |
240 Grams/30 Days |
|
hc butyrate cream 0.1% |
120 Grams/30 Days |
|
hc butyrate cream 0.1% |
135 Grams/30 Days |
|
hc butyrate ointment 0.1% |
135 Grams/30 Days |
|
hc butyrate solution 0.1% |
120 mLs/30 Days |
|
hc valerate cream 0.2% |
120 Grams/30 Days |
|
hc 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 |
|
IMPOYZ CREAM 0.025% |
240 Grams/30 Days |
|
KENALOG AER SPRAY |
126 Grams/30 Days |
|
LOCOID CREAM 0.1% |
135 Grams/30 Days |
|
LOCOID LIPO CREAM 0.1% |
120 Grams/30 Days |
|
LOCOID LOTION 0.1% |
118 mLs/30 Days |
|
LOCOID OINTMENT 0.1% |
135 Grams/30 Days |
|
LOCOID SOLUTION 0.1% |
120 mLs/30 Days |
|
LUXIQ AER 0.12% |
150 Grams/30 Days |
|
MICORT-HC CREAM 2.5% |
120 Grams/30 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 |
|
OLUX AER 0.05% |
200 Grams/28 Days |
|
OLUX-E AER 0.05% |
200 Grams/28 Days |
|
PANDEL CREAM 0.1% |
160 Grams/30 Days |
|
PREDNICARBAT CREAM 0.1% |
120 Grams/30 Days |
|
PREDNICARBAT OINTMENT 0.1% |
120 Grams/30 Days |
|
PSORCON CREAM 0.05% |
120 Grams/30 Days |
|
SERNIVO SPRAY |
120 mLs/30 Days |
|
SERNIVO SPRAY 0.05% |
120 mLs/30 Days |
|
SYNALAR CREAM 0.025% |
120 Grams/30 Days |
|
SYNALAR OINTMENT 0.025% |
120 Grams/30 Days |
|
SYNALAR Solution 0.01% |
120 mLs/30 Days |
|
TEMOVATE CREAM 0.05% |
210 Grams/28 Days |
|
TEMOVATE OINTMENT 0.05% |
210 Grams/28 Days |
|
TEXACORT SOLUTION 2.5% |
120 mLs/30 Days |
|
TOPICORT CREAM 0.05% |
120 Grams/30 Days |
|
TOPICORT CREAM 0.25% |
120 Grams/30 Days |
|
TOPICORT GEL 0.05% |
120 Grams/30 Days |
|
TOPICORT OINTMENT 0.05% |
120 Grams/30 Days |
|
TOPICORT OINTMENT 0.25% |
120 Grams/30 Days |
|
TOPICORT SPRAY 0.25% |
100 mLs/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 |
|
TRIDESILON CREAM 0.05% |
120 Grams/30 Days |
|
ULTRAVATE CREAM 0.05% |
200 Grams/28 Days |
|
ULTRAVATE LOTION 0.05% |
240 mLs/30 Days |
|
ULTRAVATE OINTMENT 0.05% |
200 Grams/28 Days |
|
VANOS CREAM 0.1% |
240 Grams/28 Days |
|
VERDESO AER 0.05% |
100 Grams/30 Days |
Topical Lidocaine
Drug Name(s) |
Quantity Limits
|
|
lidocaine pad 5% |
90 Patches/30 Days |
|
LIDODERM DIS 5% |
90 Patches/30 Days |
|
ZTLIDO PAD 1.8% |
90 Patches/30 Days |
Topical NSAID
Drug Name(s) |
Quantity Limits
|
|
DICLOFENAC DIS 1.3% |
60 Patches/30 Days |
|
diclofenac gel 1% |
10 Tubes/30 Days |
|
diclofenac solution 1.5% |
2 Bottles/30 Days |
|
FLECTOR DIS 1.3% |
60 Patches/30 Days |
|
klofensaid solution ii |
2 Bottles/30 Days |
|
PENNSAID SOLUTION 2% |
2 Pumps/28 Days |
|
VOLTAREN GEL 1% |
10 Tubes/30 Days |
Topiramate Extended Release (ER)
Drug Name(s) |
Quantity Limits
|
|
QUDEXY XR CAPSULE 25/24HR |
30 Capsules/30 Days |
|
QUDEXY XR CAPSULE 50/24HR |
30 Capsules/30 Days |
|
QUDEXY XR CAPSULE 100/24HR |
30 Capsules/30 Days |
|
QUDEXY XR CAPSULE 150/24HR |
30 Capsules/30 Days |
|
QUDEXY XR CAPSULE 200/24HR |
60 Capsules/30 Days |
|
TOPIRAMATE CAPSULE ER 25MG |
30 Capsules/30 Days |
|
TOPIRAMATE CAPSULE ER 50MG |
30 Capsules/30 Days |
|
TOPIRAMATE CAPSULE ER 100MG |
30 Capsules/30 Days |
|
TOPIRAMATE CAPSULE ER 150MG |
30 Capsules/30 Days |
|
TOPIRAMATE CAPSULE ER 200MG |
60 Capsules/30 Days |
|
TROKENDI XR CAPSULE 25MG |
30 Capsules/30 Days |
|
TROKENDI XR CAPSULE 50MG |
30 Capsules/30 Days |
|
TROKENDI XR CAPSULE 100MG |
30 Capsules/30 Days |
|
TROKENDI XR CAPSULE 200MG |
60 Capsules/30 Days |
Transmucosal Immediate Release Fentanyl
Drug Name(s) |
Quantity Limits
|
|
ABSTRAL SUBLINGUAL 100MCG |
120 Tablets/30 Days |
|
ABSTRAL SUBLINGUAL 200MCG |
120 Tablets/30 Days |
|
ABSTRAL SUBLINGUAL 300MCG |
120 Tablets/30 Days |
|
ABSTRAL SUBLINGUAL 400MCG |
120 Tablets/30 Days |
|
ABSTRAL SUBLINGUAL 600MCG |
120 Tablets/30 Days |
|
ABSTRAL SUBLINGUAL 800MCG |
120 Tablets/30 Days |
|
ACTIQ LOZENGE 200MCG |
120 Lozenges/30 Days |
|
ACTIQ LOZENGE 400MCG |
120 Lozenges/30 Days |
|
ACTIQ LOZENGE 600MCG |
120 Lozenges/30 Days |
|
ACTIQ LOZENGE 800MCG |
120 Lozenges/30 Days |
|
ACTIQ LOZENGE 1200MCG |
120 Lozenges/30 Days |
|
ACTIQ LOZENGE 1600MCG |
120 Lozenges/30 Days |
|
FENTANYL CITRATE TABLET 100MCG |
120 Tablets/30 Days |
|
FENTANYL CITRATE TABLET 200MCG |
120 Tablets/30 Days |
|
FENTANYL CITRATE TABLET 400MCG |
120 Tablets/30 Days |
|
FENTANYL CITRATE TABLET 600MCG |
120 Tablets/30 Days |
|
FENTANYL CITRATE TABLET 800MCG |
120 Tablets/30 Days |
|
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 |
|
FENTORA TABLET 100MCG |
120 Tablets/30 Days |
|
FENTORA TABLET 200MCG |
120 Tablets/30 Days |
|
FENTORA TABLET 400MCG |
120 Tablets/30 Days |
|
FENTORA TABLET 600MCG |
120 Tablets/30 Days |
|
FENTORA TABLET 800MCG |
120 Tablets/30 Days |
|
LAZANDA SPRAY 100MCG |
30 Bottles/30 Days |
|
LAZANDA SPRAY 300MCG |
30 Bottles /30 Days |
|
LAZANDA SPRAY 400MCG |
30 Bottles/30 Days |
|
SUBSYS SPRAY 100MCG |
120 Sprays/30 Days |
|
SUBSYS SPRAY 200MCG |
120 Sprays/30 Days |
|
SUBSYS SPRAY 400MCG |
120 Sprays/30 Days |
|
SUBSYS SPRAY 600MCG |
120 Sprays/30 Days |
|
SUBSYS SPRAY 800MCG |
120 Sprays/30 Days |
|
SUBSYS SPRAY 1200MCG |
240 Sprays/30 Days |
|
SUBSYS SPRAY 1600MCG |
240 Sprays/30 Days |
URAT1 Inhibitor
Drug Name(s) |
Quantity Limits
|
|
DUZALLO TABLET 200-200 |
30 Tablets/30 Days |
|
DUZALLO TABLET 200-300 |
30 Tablets/30 Days |
|
ZURAMPIC TABLET 200MG |
30 Tablets/30 Days |
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitor
Drug Name(s) |
Quantity Limits
|
|
AUSTEDO TABLET 6MG1 |
60 Tablets/30 Days |
|
AUSTEDO TABLET 9MG1 |
120 Tablets/30 Days |
|
AUSTEDO TABLET 12MG1 |
120 Tablets/30 Days |
|
30 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
28 Capsules/180 Days |
|
|
tetrabenazine tablet 12.5mg1 |
240 Tablets/30 Days |
|
tetrabenazine tablet 25mg1 |
120 Tablets/30 Days |
|
XENAZINE TABLET 12.5MG1 |
240 Tablets/30 Days |
|
XENAZINE TABLET 25MG1 |
120 Tablets/30 Days |
Wakix
Drug Name(s) |
Quantity Limits
|
|
WAKIX TABLET 4.45MG |
60 Tablets/30 Days |
|
WAKIX TABLET 17.8MG |
60 Tablets/30 Days |
Weight Loss Agents
Drug Name(s) |
Quantity Limits
|
|
ADIPEX-P CAPSULE 37.5MG |
30 Capsules/30 Days |
|
ADIPEX-P TABLET 37.5MG |
30 Tablets/30 Days |
|
BELVIQ TABLET 10MG |
60 Tablets/30 Days |
|
BELVIQ XR TABLET 20MG |
30 Tablets/30 Days |
|
BENZPHETMINE TABLET 25MG |
90 Tablets/30 Days |
|
benzphetamine tablet 50mg |
90 Tablets/30 Days |
|
CONTRAVE TABLET 8-90MG |
120 Tablets/30 Days |
|
diethylpropion tablet 25mg |
90 Tablets/30 Days |
|
DIETHYLPROP TABLET 75MG ER |
30 Tablets/30 Days |
|
LOMAIRA TABLET 8MG |
90 Tablets/30 Days |
|
phendimetraz tablet 35mg |
180 Tablets/30 Days |
|
PHENDIMETRAZ CAPSULE 105MG SR |
30 Capsules/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 |
|
QSYMIA CAPSULE 3.75-23 |
30 Capsules/30 Days |
|
QSYMIA CAPSULE 7.5-46MG |
30 Capsules/30 Days |
|
QSYMIA CAPSULE 11.25-69 |
30 Capsules/30 Days |
|
QSYMIA CAPSULE 15-92MG |
30 Capsules/30 Days |
|
REGIMEX TABLET 25MG |
90 Tablets/30 Days |
|
SAXENDA INJECTION 18MG/3ML |
15 mLs/30 Days |
|
XENICAL CAPSULE 120MG |
90 Capsules/30 Days |
Xermelo
Drug Name(s) |
Quantity Limits
|
|
90 Tablets/30 Days |
Drug Name(s) |
||
|
abiraterone acetate1 |
ACTIMMUNE1 |
ADCIRCA1 |
|
alyq1 |
||
|
ambrisentan1 |
||
|
AVONEX PEN1 |
||
|
AVONEX1 |
BETASERON1 |
bexarotene1 |
|
bosentan1 |
BRAVELLE1 |
capecitabine1 |
|
CERDELGA1 |
CETROTIDE1 |
|
|
cinacalcet hydrochloride1 |
||
|
COPAXONE1 |
COSENTYX SENSOREADY PEN 1 |
COSENTYX1 |
|
COTELLIC1 |
CYSTARAN1 |
|
|
dalfampridine er1 |
deferasirox1 |
dofetilide1 |
|
EGRIFTA SV1 |
EGRIFTA1 |
ENBREL MINI1 |
|
ENBREL SURECLICK1 |
ENBREL1 |
entecavir1 |
|
EPCLUSA1 |
erlotinib hydrochloride1 |
|
|
ESBRIET1 |
everolimus1 |
|
|
FIRAZYR1 |
FOLLISTIM AQ1 |
FORTEO1 |
|
FUZEON1 |
ganirelix acetate1 |
GANIRELIX ACETATE1 |
|
GILENYA1 |
glatiramer acetate1 |
|
|
glatopa1 |
HARVONI1 |
HUMIRA PEN1 |
|
HUMIRA1 |
HYCAMTIN1 |
IBRANCE1 |
|
icatibant acetate1 |
imatinib mesylate1 |
|
|
INTRON A1 |
||
|
KALYDECO1 |
||
|
KISQALI1 |
KISQALI FEMARA1 |
KOGENATE FS BIO-SET1 |
|
KOGENATE FS1 |
KUVAN1 |
|
|
LEDIPASVIR/SOFOSBUVIR1 |
leuprolide acetate1 |
|
|
LONSURF1 |
MATULANE1 |
|
|
MAVYRET1 |
MAYZENT1 |
MEKINIST1 |
|
miglustat1 |
MODERIBA1 |
moderiba1 |
|
NEULASTA ONPRO KIT1 |
NEULASTA1 |
|
|
NINLARO1 |
||
|
NORDITROPIN FLEXPRO1 |
NUPLAZID1 |
|
|
ORKAMBI1 |
||
|
OTEZLA1 |
PEGASYS PROCLICK1 |
PEGASYS1 |
|
PLEGRIDY1 |
PRALUENT |
PROMACTA1 |
|
PULMOZYME1 |
REBETOL1 |
REBIF REBIDOSE TITRATION PACK1 |
|
REBIF REBIDOSE1 |
REBIF TITRATION PACK1 |
REBIF1 |
|
REPATHA PUSHTRONEX SYSTEM |
REPATHA SURECLICK |
REPATHA |
|
REVATIO1 |
REVLIMID1 |
RIBASPHERE RIBAPAK1 |
|
ribasphere1 |
ribavirin1 |
RINVOQ1 |
|
SENSIPAR1 |
sildenafil citrate1 |
|
|
SKYRIZI1 |
sodium phenylbutyrate1 |
SOFOSBUVIR / VELPATASVIR 1 |
|
SOMAVERT1 |
SOVALDI1 |
|
|
STELARA1 |
STIMATE1 |
STIVARGA1 |
|
SYNAREL1 |
||
|
tadalafil1 |
TAFINLAR1 |
|
|
temozolomide1 |
tetrabenazine1 |
|
|
THALOMID1 |
tobramycin sulfate1 |
tobramycin1 |
|
TREMFYA1 |
TYKERB1 |
TYMLOS1 |
|
vigabatrin1 |
||
|
VOSEVI1 |
||
|
ZELBORAF1 |
||
|
|
|
|