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

ADEMPAS1,2

AFINITOR DISPERZ1,3

AFINITOR1,3

ALECENSA1,2,3

alosetron hydrochloride

ALUNBRIG1,2

alyq1

ambrisentan1

AMPYRA1,3

ANDRODERM

ANDROGEL

ANDROGEL PUMP

ARCALYST1,2

armodafinil

AUBAGIO1,3

avita

AVONEX PEN1

AVONEX1

benzphetamine hcl

BETASERON1

bexarotene1

bosentan1

buprenorphine

capecitabine1

CAPRELSA1,2

CERDELGA1

CETROTIDE1

ciclodan

ciclopirox nail lacquer

cinacalcet hydrochloride1

clomipramine hydrochloride

COMETRIQ1,2,3

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

ERIVEDGE1,3

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 PEN1

HUMIRA1

HYCAMTIN1

hydrocodone bitartrate er

hydromorphone hydrochloride

hydromorphone hydrochloride er

IBRANCE1

icatibant acetate1

ICLUSIG1,2,3

IMBRUVICA1,2

INGREZZA1,2,3

INLYTA1,3

INTRON A1

IRESSA1,2,3

JAKAFI1,3

JUXTAPID1,2

KADIAN

KALYDECO1

KISQALI1

KISQALI FEMARA1

KOGENATE FS BIO-SET1

KOGENATE FS1

KORLYM1,2

KUVAN1

LEDIPASVIR/SOFOSBUVIR1

LENVIMA1,2,3

lidocaine

LONSURF1

LYNPARZA1,2,3

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

ODOMZO1,3

OFEV1,3

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

SIGNIFOR1,2

sildenafil citrate1

SKYRIZI1

sodium phenylbutyrate1

SOFOSBUVIR/VELPATASVIR1

SOMAVERT1

SOVALDI1

STELARA1

STIMATE1

STIVARGA1

STRENSIQ1,2

SUTENT1,3

tadalafil1

TAFINLAR1

TAGRISSO1,2,3

TARCEVA1,3

tazarotene

TAZORAC

TECFIDERA1,3

testosterone

testosterone cypionate

TESTOSTERONE ENANTHATE

testosterone pump

testosterone topical solution

tetrabenazine1

THALOMID1

tobramycin1

tramadol hydrochloride er

TREMFYA1

tretinoin

tretinoin microsphere

tretinoin microsphere pump

TYMLOS1

VENCLEXTA1,2

VIZIMPRO1,3

VOSEVI1

VOTRIENT1,3

XTANDI1,3

ZAVESCA1,2

ZEJULA1,2,3

ZELBORAF1

ZOLINZA1,3

ZYDELIG1,2

ZYKADIA1,3

ZYTIGA1,3

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

VYLEESI INJECTION 1.75/0.3

6 Pens/30 Days

Afrezza

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

ALINIA SUSPENSION 100/5ML

300 mLs/90 Days

ALINIA TABLET 500MG

12 Tablets/90 Days

Amantadine Extended Release (ER)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

GOCOVRI CAPSULE 68.5MG1,3

30 Capsules/30 Days

GOCOVRI CAPSULE 137MG1,3

60 Capsules/30 Days

Amifampridine

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

FIRDAPSE TABLET 10MG1,2

240 Tablets/30 Days

RUZURGI TABLET 10MG1,2

300 Tablets/30 Days

Ampyra

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AMPYRA TABLET 10MG1,3

60 Tablets/30 Days

dalfampridine tablet 10mg er1

60 Tablets/30 Days

Androgen/Anabolic Steroids

Drug Name(s)

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%(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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(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

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

RELENZA MIS DISKHALER

40 Blisters/120 Days

Arikayce

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ARIKAYCE SUSPENSION1,2

28 Vials/28 Days

ATTR Amyloidosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

TEGSEDI INJECTION 284/1.51,2

6 Syringes/28 Days

Atypical Antipsychotics

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

NEXLETOL TABLET 180MG

30 Tablets/30 Days

Benlysta

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

BENLYSTA INJECTION 200MG/ML1

4 Syringes/28 Days

Biologic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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

KINERET INJECTION1,2

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

doxylamine/pyridoxine tablet 10-10mg

120 Tablets/30 Days

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

HETLIOZ CAPSULE 20MG1,2,3

30 Capsules/30 Days

Combination NSAID

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

EMFLAZA TABLET 6MG1,2

60 Tablets/30 Days

EMFLAZA TABLET 18MG1,2

30 Tablets/30 Days

Endocrine and Metabolic Agents: Galafold

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

GALAFOLD CAPSULE 123MG1

14 Capsules/28 Days

Fibromyalgia

Drug Name(s)

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

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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

HAEGARDA INJECTION 2000UNIT1,2

24 Vials/30 Days

HAEGARDA INJECTION 3000UNIT1,2

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

TAKHZYRO INJECTION 300/2ML1,2

4 Vials/28 Days

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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

KYNAMRO INJECTION 200MG/ML1

4 Injections/28 Days

Hyperhidrosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

QBREXZA PAD 2.4%

30 Pads/30 Days

Irritable Bowel Syndrome w/Diarrhea (IBS-D)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

ESBRIET CAPSULE 267MG1

180 Capsules/30 Days

ESBRIET TABLET 267MG1

180 Tablets/30 Days

ESBRIET TABLET 801MG1

90 Tablets/30 Days

OFEV CAPSULE 100MG1,3

60 Capsules/30 Days

OFEV CAPSULE 150MG1,3

60 Capsules/30 Days

Insomnia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

ARCALYST INJECTION 220MG1,2

4 Vials/28 Days

ILARIS 150 MG/ML

2 Vials/28 Days

Interleukin (IL)-4 Inhibitors

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

DUPIXENT INJECTION 200/1.141

2 Syringes/28 Days

DUPIXENT INJECTION 300/2ML1

2 Syringes/28 Days

Jynarque

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SAMSCA TABLET 15MG1

30 Tablets/365 Days

SAMSCA TABLET 30MG1

60 Tablets/365 Days

Keveyis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KEVEYIS TABLET 50MG1,2

120 Tablets/30 Days

Korlym

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KORLYM TABLET 300MG1,2

120 Tablets/30 Days

Lidocaine Transdermal

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

lidocaine/prilocaine 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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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

chlorzoxazone tablet 250MG

28 Tablets/30 Days

chlorzoxazone tablet 375mg

84 Tablets/90 Days

chlorzoxazone tablet 500MG

28 Tablets/30 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

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

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

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 
(per 30 days or as specified)

AUBAGIO TABLET 7MG1,3

30 Tablets/30 Days

AUBAGIO TABLET 14MG1,3

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 
(per 30 days or as specified)

NATPARA INJECTION 25MCG1

1 Kit/28 Days

NATPARA INJECTION 50MCG1

1 Kit/28 Days

NATPARA INJECTION 75MCG1

1 Kit/28 Days

NATPARA INJECTION 100MCG1

1 Kit/28 Days

Neurotrophic Keratitis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

OXERVATE SOLUTION 20MCG/ML1,2

56 Vials/56 Days

Nocturia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(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

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 
(per 30 days or as specified)

OCALIVA TABLET 5MG1

30 Tablets/30 Days

OCALIVA TABLET 10MG1

30 Tablets/30 Days

Ophthalmic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(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

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 
(per 30 days or as specified)

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

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

buprenorphine 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 
(per 30 days or as specified)

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/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

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 
(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

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

OPSUMIT TABLET 10MG1,2

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

UPTRAVI TABLET 200/8001,2

1 Package/180 Days

UPTRAVI TABLET 200MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 200MCG1,2

140 Tablets/180 Days

UPTRAVI TABLET 400MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 600MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 800MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 1000MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 1200MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 1400MCG1,2

60 Tablets/30 Days

UPTRAVI TABLET 1600MCG1,2

60 Tablets/30 Days

VENTAVIS SOLUTION 10MCG/ML1,2,3

270 Ampules/30 Days

VENTAVIS SOLUTION 20MCG/ML1,2,3

270 Ampules/30 Days

Orilissa

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ORILISSA TABLET 150MG

30 Tablets/30 Days

ORILISSA TABLET 200MG

60 Tablets/30 Days

Otezla

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

ACIPHEX TABLET 20MG

30 Tablets/30 Days

DEXILANT CAPSULE 30MG DR

30 Capsules/30 Days

DEXILANT CAPSULE 60MG DR

30 Capsules/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

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 
(per 30 days or as specified)

PREVYMIS TABLET 240MG

100 Tablets/365 Days

PREVYMIS TABLET 480MG

100 Tablets/365 Days

Progesterone’s

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

REGRANEX GEL 0.01%

1 Tube/30 Days

Rho Kinase Inhibitor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RHOPRESSA SOLUTION 0.02%

2.5 mLs/30 Days

ROCKLATAN DRO

2.5 mLs/30 Days

SA Oncology

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

abiraterone tablet 250mg1

120 Tablets/30 Days

AFINITOR DIS TABLET 2MG1,3

60 Tablets/30 Days

AFINITOR DIS TABLET 3MG1,3

90 Tablets/30 Days

AFINITOR DIS TABLET 5MG1,3

60 Tablets/30 Days

AFINITOR TABLET 2.5MG1,3

30 Tablets/30 Days

AFINITOR TABLET 5MG1,3

30 Tablets/30 Days

AFINITOR TABLET 7.5MG1,3

30 Tablets/30 Days

AFINITOR TABLET 10MG1,3

30 Tablets/30 Days

ALECENSA CAPSULE 150MG1,2,3

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

BALVERSA TABLET 3MG1,2,3

90 Tablets/30 Days

BALVERSA TABLET 4MG1,2,3

60 Tablets/30 Days

BALVERSA  TABLET 5MG1,2,3

30 Tablets/30 Days

BOSULIF TABLET 100MG1,3

120 Tablets/30 Days

BOSULIF TABLET 400MG1,3

30 Tablets/30 Days

BOSULIF TABLET 500MG1,3

30 Tablets/30 Days

BRAFTOVI  CAPSULE 50MG1,2

180 Capsules/30 Days

BRAFTOVI CAPSULE 75MG1,2

180 Capsules/30 Days

CABOMETYX TABLET 20MG1,3

30 Tablets/30 Days

CABOMETYX TABLET 40MG1,3

30 Tablets/30 Days

CABOMETYX TABLET 60MG1,3

30 Tablets/30 Days

CALQUENCE CAPSULE 100MG1,2,3

60 Capsules/30 Days

CAPRELSA TABLET 100MG1,2

60 Tablets/30 Days

CAPRELSA TABLET 300MG1,2

30 Tablets/30 Days

COMETRIQ KIT 60MG1,2,3

1 Carton/28 Days

COMETRIQ KIT 100MG1,2,3

1 Carton/28 Days

COMETRIQ KIT 140MG1,2,3

112 Tablets/28 Days

COPIKTRA CAPSULE 25MG1,2,3

56 Capsules/28 Days

COPIKTRA  CAPSULE 15MG1,2,3

56 Capsules/28 Days

COTELLIC TABLET 20MG1

63 Tablets/28 Days

DAURISMO TABLET 25MG1,3

60 Tablets/30 Days

DAURISMO TABLET 100MG1,3

30 Tablets/30 Days

ERIVEDGE CAPSULE 150MG1,3

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

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

ICLUSIG  TABLET 15MG1,2,3

60 Tablets/30 Days

ICLUSIG TABLET 45MG1,2,3

30 Tablets/30 Days

IDHIFA TABLET 50MG1

30 Tablets/30 Days

IDHIFA TABLET 100MG1

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 1MG1,3

180 Tablets/30 Days

INLYTA TABLET 5MG1,3

120 Tablets/30 Days

INREBIC CAPSULE 100MG1,3

120 Capsules/30 Days

IRESSA TABLET 250MG1,2,3

30 Tablets/30 Days

JAKAFI TABLET 5MG1,3

60 Tablets/30 Days

JAKAFI TABLET 10MG1,3

60 Tablets/30 Days

JAKAFI TABLET 15MG1,3

60 Tablets/30 Days

JAKAFI TABLET 20MG1,3

60 Tablets/30 Days

JAKAFI TABLET 25MG1,3

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

LENVIMA  CAPSULE 4MG1,2,3

30 Capsules/30 Days

LENVIMA CAPSULE 8 MG1,2,3

60 Capsules/30 Days

LENVIMA CAPSULE 10 MG1,2,3

30 Capsules/30 Days

LENVIMA CAPSULE 12MG1,2,3

90 Capsules/30 Days

LENVIMA CAPSULE 14 MG1,2,3

60 Capsules/30 Days

LENVIMA CAPSULE 18 MG1,2,3

90 Capsules/30 Days

LENVIMA CAPSULE 20 MG1,2,3

60 Capsules/30 Days

LENVIMA CAPSULE 24 MG1,2,3

90 Capsules/30 Days

LONSURF TABLET 15-6.141

100 Tablets/28 Days

LONSURF TABLET 20-8.191

80 Tablets/28 Days

LORBRENA TABLET 25MG1,3

90 Tablets/30 Days

LORBRENA TABLET 100MG1,3

30 Tablets/30 Days

LYNPARZA CAPSULE 50MG1,2,3

480 Capsules/30 Days

LYNPARZA TABLET 100MG1,2,3

120 Tablets/30 Days

LYNPARZA TABLET 150MG1,2,3

120 Tablets/30 Days

MEKINIST TABLET 0.5MG1

90 Tablets/30 Days

MEKINIST TABLET 2MG1

30 Tablets/30 Days

MEKTOVI TABLET 15MG1,2

180 Tablets/30 Days

NERLYNX TABLET 40MG1,2,3

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

ODOMZO CAPSULE 200MG1,3

30 Capsules/30 Days

PIQRAY 200MG TABLET DOSE1,3

28 Tablets/28 Days

PIQRAY 250MG TABLET DOSE1,3

56 Tablets/28 Days

PIQRAY 300MG TABLET DOSE1,3

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

ROZLYTREK CAPSULE 100MG1,3

30 Capsules/30 Days

ROZLYTREK CAPSULE 200MG1,3

90 Capsules/30 Days

RUBRACA TABLET 200MG1,2,3

120 Tablets/30 Days

RUBRACA TABLET 250MG1,2,3

120 Tablets/30 Days

RUBRACA TABLET 300MG1,2,3

120 Tablets/30 Days

RYDAPT CAPSULE 25MG1

240 Capsules/30 Days

STIVARGA TABLET 40MG1

84 Tablets/28 Days

SUTENT CAPSULE 12.5MG1,3

90 Capsules/30 Days

SUTENT CAPSULE 25MG1,3

30 Capsules/30 Days

SUTENT CAPSULE 37.5MG1,3

30 Capsules/30 Days

SUTENT CAPSULE 50MG1,3

30 Capsules/30 Days

TAFINLAR CAPSULE 50MG1

120 Capsules/30 Days

TAFINLAR CAPSULE 75MG1

120 Capsules/30 Days

TAGRISSO TABLET 40MG1,2,3

30 Tablets/30 Days

TAGRISSO TABLET 80MG1,2,3

30 Tablets/30 Days

TALZENNA CAPSULE 0.25MG1,3

90 Capsules/30 Days

TALZENNA CAPSULE 1MG1,3

30 Capsules/30 Days

TARCEVA TABLET 25MG1,3

60 Tablets/30 Days

TARCEVA TABLET 100MG1,3

30 Tablets/30 Days

TARCEVA TABLET 150MG1,3

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

TIBSOVO TABLET 250MG1,2

60 Tablets/30 Days

TURALIO CAPSULE 200MG1,2

120 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 START PK1,2

1 Pack/180 Days

VERZENIO TABLET 50MG1,2,3

60 Tablets/30 Days

VERZENIO TABLET 100MG1,2,3

60 Tablets/30 Days

VERZENIO TABLET 150MG1,2,3

60 Tablets/30 Days

VERZENIO TABLET 200MG1,2,3

60 Tablets/30 Days

VITRAKVI CAPSULE 25MG1,2,3

180 Capsules/30 Days

VITRAKVI CAPSULE 100MG1,2,3

60 Capsules/30 Days

VITRAKVI SOLUTION 20MG/ML1,2,3

300 mLs/30 Days

VIZIMPRO TABLET 15MG1,3

30 Tablets/30 Days

VIZIMPRO TABLET 30MG1,3

30 Tablets/30 Days

VIZIMPRO TABLET 45MG1,3

30 Tablets/30 Days

VOTRIENT TABLET 200MG1,3

120 Tablets/30 Days

XOSPATA TABLET 40MG1,2

90 Tablets/30 Days

XPOVIO PACK 60MG1,2,3

1 Box/28 Days

XPOVIO PACK 80MG1,2,3

1 Box/28 Days

XPOVIO PACK 100MG1,2,3

1 Box/28 Days

XTANDI CAPSULE 40MG1,3

120 Capsules/30 Days

ZEJULA CAPSULE 100MG1,2,3

90 Capsules/30 Days

ZELBORAF TABLET 240MG1

240 Tablets/30 Days

ZOLINZA CAPSULE 100MG1,3

120 Capsules/30 Days

ZYDELIG TABLET 100MG1,2

60 Tablets/30 Days

ZYDELIG TABLET 150MG1,2

60 Tablets/30 Days

ZYKADIA CAPSULE 150MG1,3

90 Capsules/30 Days

ZYKADIA TABLET 150MG1,3

90 Tablets/30 Days

ZYTIGA TABLET 250MG1,3

120 Tablets/30 Days

ZYTIGA TABLET 500MG1,3

60 Tablets/30 Days

Signifor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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

Sodium Oxybate

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

XYREM SOLUTION 500MG/ML1,2

540 mLs/30 Days

Somatostatin Analogs

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(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

Sunosi

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SUNOSI TABLET 75MG

30 Tablets/30 Days

SUNOSI TABLET 150MG

30 Tablets/30 Days

Tafamidis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

VYNDAMAX CAPSULE 61MG1

30 Capsules/30 Days

VYNDAQEL CAPSULE 20MG1

120 Capsules/30 Days

Thrombopoietin Receptor Agonists

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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

alclometasone cream 0.05%

120 Grams/30 Days

alclometasone 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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

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 
(per 30 days or as specified)

AUSTEDO TABLET 6MG1

60 Tablets/30 Days

AUSTEDO TABLET 9MG1

120 Tablets/30 Days

AUSTEDO TABLET 12MG1

120 Tablets/30 Days

INGREZZA CAPSULE 40MG1,2

30 Capsules/30 Days

INGREZZA CAPSULE 80MG1,2

30 Capsules/30 Days

INGREZZA CAPSULE 40-80MG1,2

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 
(per 30 days or as specified)

WAKIX TABLET 4.45MG

60 Tablets/30 Days

WAKIX TABLET 17.8MG

60 Tablets/30 Days

Weight Loss Agents

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

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

Phendimetrazine tablet 35mg

180 Tablets/30 Days

Phendimetrazine 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 
(per 30 days or as specified)

XERMELO TABLET 250MG1,2

90 Tablets/30 Days

Drug Name(s)

abiraterone acetate1

ACTIMMUNE1

ADCIRCA1

ADEMPAS1,2

AFINITOR DISPERZ1,3

AFINITOR1,3

ALECENSA1,2,3

ALUNBRIG1,2

alyq1

ambrisentan1

AMPYRA1,3

APOKYN1,2

ARCALYST1,2

AUBAGIO1,3

AVONEX PEN1

AVONEX1

BETASERON1

bexarotene1

bosentan1

BRAVELLE1

capecitabine1

CAPRELSA1,2

CERDELGA1

CETROTIDE1

CHOLBAM1,2

cinacalcet hydrochloride1

COMETRIQ1,2,3

COPAXONE1

COSENTYX SENSOREADY PEN 1

COSENTYX1

COTELLIC1

CYSTAGON1,2

CYSTARAN1

dalfampridine er1

deferasirox1

dofetilide1

EGRIFTA SV1

EGRIFTA1

ENBREL MINI1

ENBREL SURECLICK1

ENBREL1

entecavir1

EPCLUSA1

ERIVEDGE1,3

erlotinib hydrochloride1

ESBRIET1

everolimus1

EXJADE1,3

FIRAZYR1

FOLLISTIM AQ1

FORTEO1

FUZEON1

ganirelix acetate1

GANIRELIX ACETATE1

GILENYA1

GILOTRIF1,2

glatiramer acetate1

glatopa1

HARVONI1

HUMIRA PEN1

HUMIRA1

HYCAMTIN1

IBRANCE1

icatibant acetate1

ICLUSIG1,2,3

imatinib mesylate1

IMBRUVICA1,2

INCRELEX1,2

INGREZZA1,2,3

INLYTA1,3

INTRON A1

IRESSA1,2,3

JAKAFI1,3

JUXTAPID1,2

KALYDECO1

KISQALI1

KISQALI FEMARA1

KOGENATE FS BIO-SET1

KOGENATE FS1

KORLYM1,2

KUVAN1

LEDIPASVIR/SOFOSBUVIR1

LENVIMA1,2,3

leuprolide acetate1

LONSURF1

LYNPARZA1,2,3

MATULANE1

MAVYRET1

MAYZENT1

MEKINIST1

miglustat1

MODERIBA1

moderiba1

MYALEPT1,2

NEULASTA ONPRO KIT1

NEULASTA1

NEXAVAR1,3

NINLARO1

nitisinone1,2

NORDITROPIN FLEXPRO1

NUPLAZID1

ODOMZO1,3

OFEV1,3

ORFADIN1,2

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

SIGNIFOR1,2

sildenafil citrate1

SKYRIZI1

sodium phenylbutyrate1

SOFOSBUVIR / VELPATASVIR 1

SOMAVERT1

SOVALDI1

SPRYCEL1,3

STELARA1

STIMATE1

STIVARGA1

STRENSIQ1,2

SUTENT1,3

SYNAREL1

tadalafil1

TAFINLAR1

TAGRISSO1,2,3

TARCEVA1,3

TARGRETIN1,3

TASIGNA1,3

TECFIDERA1,3

temozolomide1

tetrabenazine1

THALOMID1

tobramycin sulfate1

tobramycin1

TREMFYA1

TYKERB1

TYMLOS1

VALCHLOR1,2

VENCLEXTA STARTING PACK 1,2

VENCLEXTA1,2

vigabatrin1

vigadrone1,2

VISTOGARD1,2

VIZIMPRO1,3

VOSEVI1

VOTRIENT1,3

XALKORI1,3

XTANDI1,3

XURIDEN1,2

ZAVESCA1,2

ZEJULA1,2,3

ZELBORAF1

ZOLINZA1,3

ZYDELIG1,2

ZYKADIA1,3

ZYTIGA1,3

 

 

1Specialty

2Limited Distribution

3Split Fill