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	ADEMPAS^1,²
AFINITOR DISPERZ^1,³	AFINITOR^1,³	ALECENSA^1,^2,³
alosetron hydrochloride	ALUNBRIG^1,²	alyq¹
ambrisentan¹	AMPYRA^1,³	ANDRODERM
ANDROGEL	ANDROGEL PUMP	ARCALYST^1,²
armodafinil	AUBAGIO^1,³	avita
AVONEX PEN¹	AVONEX¹	benzphetamine hcl
BETASERON¹	bexarotene¹	bosentan¹
buprenorphine	capecitabine¹	CAPRELSA^1,²
CERDELGA¹	CETROTIDE¹	ciclodan
ciclopirox nail lacquer	cinacalcet hydrochloride¹	clomipramine hydrochloride
COMETRIQ^1,^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
ERIVEDGE^1,³	erlotinib hydrochloride¹	ESBRIET¹
everolimus¹	fentanyl	fentanyl citrate oral transmucosal
FIRAZYR¹	FLUOXETINE HYDROCHLORIDE	FORTEO¹
ganirelix acetate¹	GANIRELIX ACETATE¹	GILENYA¹
GILOTRIF^1,²	glatiramer acetate¹	glatopa¹
HARVONI¹	HUMIRA PEN¹	HUMIRA¹
HYCAMTIN¹	hydrocodone bitartrate er	hydromorphone hydrochloride
hydromorphone hydrochloride er	IBRANCE¹	icatibant acetate¹
ICLUSIG^1,^2,³	IMBRUVICA^1,²	INGREZZA^1,^2,³
INLYTA^1,³	INTRON A¹	IRESSA^1,^2,³
JAKAFI^1,³	JUXTAPID^1,²	KADIAN
KALYDECO¹	KISQALI¹	KISQALI FEMARA¹
KOGENATE FS BIO-SET¹	KOGENATE FS¹	KORLYM^1,²
KUVAN¹	LEDIPASVIR/SOFOSBUVIR¹	LENVIMA^1,^2,³
lidocaine	LONSURF¹	LYNPARZA^1,^2,³
MAVYRET¹	MAYZENT¹	MEKINIST¹
metaxall	metaxalone	metformin hydrochloride er
methadone hydrochloride	METHITEST	miglustat¹
modafinil	mometasone furoate	morphine sulfate CR
morphine sulfate ER	MYALEPT^1,²	NAPROSYN
NEULASTA ONPRO KIT¹	NEULASTA¹	NINLARO¹
NORDITROPIN FLEXPRO¹	NUPLAZID¹	ODOMZO^1,³
OFEV^1,³	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
SIGNIFOR^1,²	sildenafil citrate¹	SKYRIZI¹
sodium phenylbutyrate¹	SOFOSBUVIR/VELPATASVIR¹	SOMAVERT¹
SOVALDI¹	STELARA¹	STIMATE¹
STIVARGA¹	STRENSIQ^1,²	SUTENT^1,³
tadalafil¹	TAFINLAR¹	TAGRISSO^1,^2,³
TARCEVA^1,³	tazarotene	TAZORAC
TECFIDERA^1,³	testosterone	testosterone cypionate
TESTOSTERONE ENANTHATE	testosterone pump	testosterone topical solution
tetrabenazine¹	THALOMID¹	tobramycin¹
tramadol hydrochloride er	TREMFYA¹	tretinoin
tretinoin microsphere	tretinoin microsphere pump	TYMLOS¹
VENCLEXTA^1,²	VIZIMPRO^1,³	VOSEVI¹
VOTRIENT^1,³	XTANDI^1,³	ZAVESCA^1,²
ZEJULA^1,^2,³	ZELBORAF¹	ZOLINZA^1,³
ZYDELIG^1,²	ZYKADIA^1,³	ZYTIGA^1,³

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 68.5MG^1,³	30 capsules/30 days
GOCOVRI CAPSULE 137MG^1,³	60 capsules/30 days

Amifampridine

Drug name(s)	Quantity limits (per 30 days or as specified)
FIRDAPSE TABLET 10MG^1,²	240 tablets/30 days
RUZURGI TABLET 10MG^1,²	300 tablets/30 days

Ampyra

Drug name(s)	Quantity limits (per 30 days or as specified)
AMPYRA TABLET 10MG^1,³	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 SUSPENSION^1,²	28 vials/28 days

ATTR Amyloidosis

Drug name(s)	Quantity limits (per 30 days or as specified)
TEGSEDI INJECTION 284/1.5^1,²	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 INJECTION^1,²	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 20MG^1,^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 6MG^1,²	60 tablets/30 days
EMFLAZA TABLET 18MG^1,²	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 2000UNIT^1,²	24 vials/30 days
HAEGARDA INJECTION 3000UNIT^1,²	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 300/2ML^1,²	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 5MG^1,²	30 capsules/30 days
JUXTAPID CAPSULE 10MG^1,²	30 capsules/30 days
JUXTAPID CAPSULE 20MG^1,²	30 capsules/30 days
JUXTAPID CAPSULE 30MG^1,²	30 capsules/30 days
JUXTAPID CAPSULE 40MG^1,²	30 capsules/30 days
JUXTAPID CAPSULE 60MG^1,²	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 100MG^1,³	60 capsules/30 days
OFEV CAPSULE 150MG^1,³	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 220MG^1,²	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 50MG^1,²	120 tablets/30 days

Korlym

Drug name(s)	Quantity limits (per 30 days or as specified)
KORLYM TABLET 300MG^1,²	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 7MG^1,³	30 tablets/30 days
AUBAGIO TABLET 14MG^1,³	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/ML^1,²	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 0.5MG^1,²	90 tablets/30 days
ADEMPAS TABLET 1MG^1,²	90 tablets/30 days
ADEMPAS TABLET 1.5MG^1,²	90 tablets/30 days
ADEMPAS TABLET 2MG^1,²	90 tablets/30 days
ADEMPAS TABLET 2.5MG^1,²	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 10MG^1,²	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 200/800^1,²	1 package/180 days
UPTRAVI TABLET 200MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 200MCG^1,²	140 tablets/180 days
UPTRAVI TABLET 400MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 600MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 800MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 1000MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 1200MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 1400MCG^1,²	60 tablets/30 days
UPTRAVI TABLET 1600MCG^1,²	60 tablets/30 days
VENTAVIS SOLUTION 10MCG/ML^1,^2,³	270 ampules/30 days
VENTAVIS SOLUTION 20MCG/ML^1,^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 2MG^1,³	60 tablets/30 days
AFINITOR DIS TABLET 3MG^1,³	90 tablets/30 days
AFINITOR DIS TABLET 5MG^1,³	60 tablets/30 days
AFINITOR TABLET 2.5MG^1,³	30 tablets/30 days
AFINITOR TABLET 5MG^1,³	30 tablets/30 days
AFINITOR TABLET 7.5MG^1,³	30 tablets/30 days
AFINITOR TABLET 10MG^1,³	30 tablets/30 days
ALECENSA CAPSULE 150MG^1,^2,³	240 capsules/30 days
ALUNBRIG PACK^1,²	30 tablets/180 days
ALUNBRIG TABLET 30MG^1,²	180 tablets/30 days
ALUNBRIG TABLET 90MG^1,²	30 tablets/30 days
ALUNBRIG TABLET 180MG^1,²	30 tablets/30 days
BALVERSA TABLET 3MG^1,^2,³	90 tablets/30 days
BALVERSA TABLET 4MG^1,^2,³	60 tablets/30 days
BALVERSA TABLET 5MG^1,^2,³	30 tablets/30 days
BOSULIF TABLET 100MG^1,³	120 tablets/30 days
BOSULIF TABLET 400MG^1,³	30 tablets/30 days
BOSULIF TABLET 500MG^1,³	30 tablets/30 days
BRAFTOVI CAPSULE 50MG^1,²	180 capsules/30 days
BRAFTOVI CAPSULE 75MG^1,²	180 capsules/30 days
CABOMETYX TABLET 20MG^1,³	30 tablets/30 days
CABOMETYX TABLET 40MG^1,³	30 tablets/30 days
CABOMETYX TABLET 60MG^1,³	30 tablets/30 days
CALQUENCE CAPSULE 100MG^1,^2,³	60 capsules/30 days
CAPRELSA TABLET 100MG^1,²	60 tablets/30 days
CAPRELSA TABLET 300MG^1,²	30 tablets/30 days
COMETRIQ KIT 60MG^1,^2,³	1 carton/28 days
COMETRIQ KIT 100MG^1,^2,³	1 carton/28 days
COMETRIQ KIT 140MG^1,^2,³	112 tablets/28 days
COPIKTRA CAPSULE 25MG^1,^2,³	56 capsules/28 days
COPIKTRA CAPSULE 15MG^1,^2,³	56 capsules/28 days
COTELLIC TABLET 20MG¹	63 tablets/28 days
DAURISMO TABLET 25MG^1,³	60 tablets/30 days
DAURISMO TABLET 100MG^1,³	30 tablets/30 days
ERIVEDGE CAPSULE 150MG^1,³	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 20MG^1,²	30 tablets/30 days
GILOTRIF TABLET 30MG^1,²	30 tablets/30 days
GILOTRIF TABLET 40MG^1,²	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 15MG^1,^2,³	60 tablets/30 days
ICLUSIG TABLET 45MG^1,^2,³	30 tablets/30 days
IDHIFA TABLET 50MG¹	30 tablets/30 days
IDHIFA TABLET 100MG¹	30 tablets/30 days
IMBRUVICA CAPSULE 70MG^1,²	30 capsules/30 days
IMBRUVICA CAPSULE 140MG^1,²	120 capsules/30 days
IMBRUVICA TABLET 140MG^1,²	120 tablets/30 days
IMBRUVICA TABLET 280MG^1,²	30 tablets/30 days
IMBRUVICA TABLET 420MG^1,²	30 tablets/30 days
IMBRUVICA TABLET 560MG^1,²	30 tablets/30 days
INLYTA TABLET 1MG^1,³	180 tablets/30 days
INLYTA TABLET 5MG^1,³	120 tablets/30 days
INREBIC CAPSULE 100MG^1,³	120 capsules/30 days
IRESSA TABLET 250MG^1,^2,³	30 tablets/30 days
JAKAFI TABLET 5MG^1,³	60 tablets/30 days
JAKAFI TABLET 10MG^1,³	60 tablets/30 days
JAKAFI TABLET 15MG^1,³	60 tablets/30 days
JAKAFI TABLET 20MG^1,³	60 tablets/30 days
JAKAFI TABLET 25MG^1,³	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 4MG^1,^2,³	30 capsules/30 days
LENVIMA CAPSULE 8 MG^1,^2,³	60 capsules/30 days
LENVIMA CAPSULE 10 MG^1,^2,³	30 capsules/30 days
LENVIMA CAPSULE 12MG^1,^2,³	90 capsules/30 days
LENVIMA CAPSULE 14 MG^1,^2,³	60 capsules/30 days
LENVIMA CAPSULE 18 MG^1,^2,³	90 capsules/30 days
LENVIMA CAPSULE 20 MG^1,^2,³	60 capsules/30 days
LENVIMA CAPSULE 24 MG^1,^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 25MG^1,³	90 tablets/30 days
LORBRENA TABLET 100MG^1,³	30 tablets/30 days
LYNPARZA CAPSULE 50MG^1,^2,³	480 capsules/30 days
LYNPARZA TABLET 100MG^1,^2,³	120 tablets/30 days
LYNPARZA TABLET 150MG^1,^2,³	120 tablets/30 days
MEKINIST TABLET 0.5MG¹	90 tablets/30 days
MEKINIST TABLET 2MG¹	30 tablets/30 days
MEKTOVI TABLET 15MG^1,²	180 tablets/30 days
NERLYNX TABLET 40MG^1,^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 200MG^1,³	30 capsules/30 days
PIQRAY 200MG TABLET DOSE^1,³	28 tablets/28 days
PIQRAY 250MG TABLET DOSE^1,³	56 tablets/28 days
PIQRAY 300MG TABLET DOSE^1,³	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 100MG^1,³	30 capsules/30 days
ROZLYTREK CAPSULE 200MG^1,³	90 capsules/30 days
RUBRACA TABLET 200MG^1,^2,³	120 tablets/30 days
RUBRACA TABLET 250MG^1,^2,³	120 tablets/30 days
RUBRACA TABLET 300MG^1,^2,³	120 tablets/30 days
RYDAPT CAPSULE 25MG¹	240 capsules/30 days
STIVARGA TABLET 40MG¹	84 tablets/28 days
SUTENT CAPSULE 12.5MG^1,³	90 capsules/30 days
SUTENT CAPSULE 25MG^1,³	30 capsules/30 days
SUTENT CAPSULE 37.5MG^1,³	30 capsules/30 days
SUTENT CAPSULE 50MG^1,³	30 capsules/30 days
TAFINLAR CAPSULE 50MG¹	120 capsules/30 days
TAFINLAR CAPSULE 75MG¹	120 capsules/30 days
TAGRISSO TABLET 40MG^1,^2,³	30 tablets/30 days
TAGRISSO TABLET 80MG^1,^2,³	30 tablets/30 days
TALZENNA CAPSULE 0.25MG^1,³	90 capsules/30 days
TALZENNA CAPSULE 1MG^1,³	30 capsules/30 days
TARCEVA TABLET 25MG^1,³	60 tablets/30 days
TARCEVA TABLET 100MG^1,³	30 tablets/30 days
TARCEVA TABLET 150MG^1,³	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 250MG^1,²	60 tablets/30 days
TURALIO CAPSULE 200MG^1,²	120 capsules/30 days
VENCLEXTA TABLET 10MG^1,²	60 tablets/30 days
VENCLEXTA TABLET 50MG^1,²	30 tablets/30 days
VENCLEXTA TABLET 100MG^1,²	180 tablets/30 days
VENCLEXTA TABLET START PK^1,²	1 pack/180 days
VERZENIO TABLET 50MG^1,^2,³	60 tablets/30 days
VERZENIO TABLET 100MG^1,^2,³	60 tablets/30 days
VERZENIO TABLET 150MG^1,^2,³	60 tablets/30 days
VERZENIO TABLET 200MG^1,^2,³	60 tablets/30 days
VITRAKVI CAPSULE 25MG^1,^2,³	180 capsules/30 days
VITRAKVI CAPSULE 100MG^1,^2,³	60 capsules/30 days
VITRAKVI SOLUTION 20MG/ML^1,^2,³	300 mLs/30 days
VIZIMPRO TABLET 15MG^1,³	30 tablets/30 days
VIZIMPRO TABLET 30MG^1,³	30 tablets/30 days
VIZIMPRO TABLET 45MG^1,³	30 tablets/30 days
VOTRIENT TABLET 200MG^1,³	120 tablets/30 days
XOSPATA TABLET 40MG^1,²	90 tablets/30 days
XPOVIO PACK 60MG^1,^2,³	1 box/28 days
XPOVIO PACK 80MG^1,^2,³	1 box/28 days
XPOVIO PACK 100MG^1,^2,³	1 box/28 days
XTANDI CAPSULE 40MG^1,³	120 capsules/30 days
ZEJULA CAPSULE 100MG^1,^2,³	90 capsules/30 days
ZELBORAF TABLET 240MG¹	240 tablets/30 days
ZOLINZA CAPSULE 100MG^1,³	120 capsules/30 days
ZYDELIG TABLET 100MG^1,²	60 tablets/30 days
ZYDELIG TABLET 150MG^1,²	60 tablets/30 days
ZYKADIA CAPSULE 150MG^1,³	90 capsules/30 days
ZYKADIA TABLET 150MG^1,³	90 tablets/30 days
ZYTIGA TABLET 250MG^1,³	120 tablets/30 days
ZYTIGA TABLET 500MG^1,³	60 tablets/30 days

Signifor

Drug name(s)	Quantity limits (per 30 days or as specified)
SIGNIFOR INJECTION 0.3MG/ML^1,²	60 mLs/30 days
SIGNIFOR INJECTION 0.6MG/ML^1,²	60 mLs/30 days
SIGNIFOR INJECTION 0.9MG/ML^1,²	60 mLs/30 days

Sodium Oxybate

Drug name(s)	Quantity limits (per 30 days or as specified)
XYREM SOLUTION 500MG/ML^1,²	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 100MG^1,²	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 40MG^1,²	30 capsules/30 days
INGREZZA CAPSULE 80MG^1,²	30 capsules/30 days
INGREZZA CAPSULE 40-80MG^1,²	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 250MG^1,²	90 tablets/30 days

Drug name(s)
abiraterone acetate¹	ACTIMMUNE¹	ADCIRCA¹
ADEMPAS^1,²	AFINITOR DISPERZ^1,³	AFINITOR^1,³
ALECENSA^1,^2,³	ALUNBRIG^1,²	alyq¹
ambrisentan¹	AMPYRA^1,³	APOKYN^1,²
ARCALYST^1,²	AUBAGIO^1,³	AVONEX PEN¹^,4
AVONEX¹^,4	BETASERON¹^,4	bexarotene¹
bosentan¹	BRAVELLE¹	capecitabine¹
CAPRELSA^1,²	CERDELGA¹	CETROTIDE¹^,4
CHOLBAM^1,²	cinacalcet hydrochloride¹	COMETRIQ^1,^2,³
COPAXONE¹^,4	COSENTYX SENSOREADY PEN ¹	COSENTYX¹
COTELLIC¹	CYSTAGON^1,²	CYSTARAN¹
dalfampridine er¹	deferasirox¹	dofetilide¹
EGRIFTA SV¹	EGRIFTA¹	ENBREL MINI¹^,4
ENBREL SURECLICK¹^,4	ENBREL¹^,4	entecavir¹
EPCLUSA¹	ERIVEDGE^1,³	erlotinib hydrochloride¹
ESBRIET¹	everolimus¹	EXJADE^1,³
FIRAZYR¹	FOLLISTIM AQ¹^,4	FORTEO¹^,4
FUZEON¹^,4	ganirelix acetate¹	GANIRELIX ACETATE¹^,4
GILENYA¹	GILOTRIF^1,²	GLATIRAMER ACETATE¹^,4
glatopa¹	HARVONI¹^,4	HUMIRA PEN¹^,4
HUMIRA¹^,4	HYCAMTIN¹	IBRANCE¹
icatibant acetate¹	ICLUSIG^1,^2,³	imatinib mesylate¹
IMBRUVICA^1,²	INCRELEX^1,²	INGREZZA^1,^2,³
INLYTA^1,³	INTRON A¹	IRESSA^1,^2,³
JAKAFI^1,³	JUXTAPID^1,²	KALYDECO¹
KISQALI¹	KISQALI FEMARA¹	KOGENATE FS BIO-SET¹
KOGENATE FS¹	KORLYM^1,²	KUVAN¹
LEDIPASVIR/SOFOSBUVIR¹^,4	LENVIMA^1,^2,³	LEUPROLIDE ACETATE¹^,4
LONSURF¹	LYNPARZA^1,^2,³	MATULANE¹
MAVYRET¹^,4	MAYZENT¹	MEKINIST¹
miglustat¹	MODERIBA¹	moderiba¹
MYALEPT^1,²	NEULASTA ONPRO KIT¹^,4	NEULASTA¹^,4
NEXAVAR^1,³	NINLARO¹	nitisinone^1,²
NORDITROPIN FLEXPRO¹	NUPLAZID¹	ODOMZO^1,³
OFEV^1,³	ORFADIN^1,²	ORKAMBI¹
OTEZLA¹	PEGASYS PROCLICK¹^,4	PEGASYS¹^,4
PLEGRIDY¹	PRALUENT	PROMACTA¹
PULMOZYME¹	REBETOL¹^,4	REBIF REBIDOSE TITRATION PACK¹^,4
REBIF REBIDOSE¹^,4	REBIF TITRATION PACK¹^,4	REBIF¹^,4
REPATHA PUSHTRONEX SYSTEM	REPATHA SURECLICK	REPATHA
REVATIO¹	REVLIMID¹	RIBASPHERE RIBAPAK¹
ribasphere¹	ribavirin¹	RINVOQ¹
SENSIPAR¹	SIGNIFOR^1,²	sildenafil citrate¹
SKYRIZI¹	sodium phenylbutyrate¹	SOFOSBUVIR / VELPATASVIR ¹
SOMAVERT¹	SOVALDI¹	SPRYCEL^1,³^,4
STELARA¹	STIMATE¹	STIVARGA¹
STRENSIQ^1,²	SUTENT^1,³	SYNAREL¹
tadalafil¹	TAFINLAR¹	TAGRISSO^1,^2,³
TARCEVA^1,³	TARGRETIN^1,³	TASIGNA^1,³^,4
TECFIDERA^1,³	temozolomide¹	tetrabenazine¹
THALOMID¹	tobramycin sulfate¹	tobramycin¹
TREMFYA¹	TYKERB¹^,4	TYMLOS¹
VALCHLOR^1,²	VENCLEXTA STARTING PACK ^1,²	VENCLEXTA^1,²
vigabatrin¹	vigadrone^1,²	VISTOGARD^1,²
VIZIMPRO^1,³	VOSEVI¹	VOTRIENT^1,³
XALKORI^1,³	XTANDI^1,³	XURIDEN^1,²
ZAVESCA^1,²	ZEJULA^1,^2,³	ZELBORAF¹
ZOLINZA^1,³	ZYDELIG^1,²	ZYKADIA^1,³
ZYTIGA^1,³

¹Specialty

²Limited Distribution

³Split Fill

⁴Indicates exclusive to Alliance Rx Walgreens Prime preferred specialty

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Value Plus prescription drug benefits

Web Content Viewer - Fixed Context

Guide to prescription drug benefits

Use this guide to understand how your benefits work.

Drug name(s)

Drug name(s)

Actinic Keratosis

Drug name(s)

Quantity limits (per 30 days or as specified)

Acute Migraine 5HT

Drug name(s)

Quantity limits (per 30 days or as specified)

Addyi

Drug name(s)

Quantity limits (per 30 days or as specified)

Afrezza

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Quantity limits (per 30 days or as specified)

Alinia

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Quantity limits (per 30 days or as specified)

Amantadine Extended Release (ER)

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Amifampridine

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Ampyra

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Androgen/Anabolic Steroids

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Antiemetic

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Antifungal

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Quantity limits (per 30 days or as specified)

Anti-Influenza

Drug name(s)

Quantity limits (per 30 days or as specified)

Anti-Migraine: Calcitonin Gene-Related Peptide (CGRP)

Drug name(s)

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Antiretroviral

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Arikayce

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Quantity limits (per 30 days or as specified)

ATTR Amyloidosis

Drug name(s)

Quantity limits (per 30 days or as specified)

Atypical Antipsychotics

Drug name(s)

Quantity limits (per 30 days or as specified)

Bempedoic Acid

Drug name(s)

Quantity limits (per 30 days or as specified)

Benlysta

Drug name(s)

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Biologic Immunomodulators

Drug name(s)

Quantity limits (per 30 days or as specified)

Bisphosphonates

Drug name(s)

Quantity limits (per 30 days or as specified)

Bonjesta Diclegis

Drug name(s)

Quantity limits (per 30 days or as specified)

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Drug name(s)

Quantity limits (per 30 days or as specified)

Circadian Rhythm Disorder

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