Value Plus prescription drug benefits

Effective July 1, 2021

Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the 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)

ABILIFY

abiraterone acetate 1,3

ABSTRAL

ACIPHEX

ACTEMRA 1

ACTEMRA ACTPEN 1

ACTHAR 1

ACTICLATE

ACTIQ

ADCIRCA 1

ADDERALL

ADDERALL XR

ADEMPAS 2

ADHANSIA XR

ADIPEX-P

ADMELOG

ADMELOG SOLOSTAR

ADVATE 1

ADYNOVATE 1

ADZENYS ER

ADZENYS XR-ODT

AFINITOR 1,3

AFINITOR DISPERZ 1,3

AFREZZA

AFSTYLA 1

AIMOVIG 1

AJOVY 1

AKLIEF

ALDARA

ALECENSA 2,3

alosetron hcl

ALPHANINE SD 1

ALPROLIX 1

ALUNBRIG 2

alyq 1

AMBIEN

AMBIEN CR

ambrisentan 1

AMITIZA

AMPHETAMINE ER

AMPYRA 1,3

AMRIX

ANAFRANIL

ANDRODERM

ANDROGEL

ANDROGEL PUMP

APIDRA

APIDRA SOLOSTAR

APLENZIN

APTENSIO XR

ARAZLO

ARCALYST 2

ARIKAYCE 2

ARYMO ER

ATRALIN

AUBAGIO 1,3

AUSTEDO 1

AUVI-Q

avita

AVONEX 1

AVONEX PEN 1

AYVAKIT 2,3

AZESCHEW PRENATAL

AZESCO

BAFIERTAM

BALVERSA 2,3

BELBUCA

BELSOMRA

BELVIQ

BELVIQ XR

BENEFIX 1

BENLYSTA 1

benzphetamine

BENZPHETMINE

BETASERON 1

BETHKIS 1

bexarotene 1,3

bosentan 1

BOSULIF 1,3

BRAFTOVI 2

BRUKINSA 2

BUPHENYL 1

buprenorphine

BUPROPION HCL ER (XL)

BUTRANS

BYNFEZIA PEN

CABOMETYX 1,3

CALQUENCE 2

capecitabine 1

CAPLYTA

CAPRELSA 2

CARAC

CARBAGLU 2

CAYSTON 1

CELEXA

CERDELGA 1

CETROTIDE 1

CHORIONIC GONADOTROPIN 1

ciclodan

ciclopirox nail lacquer

CIMZIA 1

CIMZIA STARTER KIT 1

cinacalcet hcl 1

CIPRO HC

CIPRODEX

ciprofloxacin/ dexamethasone

clomipramine hcl

CLOZAPINE ODT

CLOZARIL

COMETRIQ 2,3

CONCERTA

CONTRAVE

CONZIP

COPAXONE 1

COPIKTRA 2,3

CORLANOR

COSENTYX 1

COSENTYX SENSOREADY PEN 1

COTELLIC 1

COTEMPLA XR-ODT

CRINONE

CUTAQUIG 2

CUVITRU 2

cyclobenzaprine hcl er

CYMBALTA

DAKLINZA 1

dalfampridine er 1,3

DANTRIUM

DARAPRIM

DAURISMO 1,3

DAYTRANA

DAYVIGO

DEPO-TESTOSTERONE

DESOXYN

DESVENLAFAXINE ER

DICLEGIS

diclofenac sodium

diethylpropion

diethylpropion hcl

DIETHYLPROPION HCL ER

dimethyl fumarate 1

dimethyl fumarate starter pack 1

DOJOLVI 2

DOLOPHINE

DORYX

DORYX MPC

DOXYCYCLINE

DOXYCYCLINE HYCLATE

doxylamine succinate/ pyridoxine hcl

droxidopa 1

DUEXIS

DUPIXENT 1

DURAGESIC

DYANAVEL XR

EDLUAR

EFFEXOR XR

EFUDEX

EGRIFTA 1

EGRIFTA SV 1

ELOCTATE 1

EMBEDA

EMFLAZA 2

EMGALITY 1

EMSAM

ENBREL 1

ENBREL MINI 1

ENBREL SURECLICK 1

ENDARI 2

ENDOMETRIN

ENSPRYNG 1

EPCLUSA 1

EPIDIOLEX 1

EPINEPHRINE

EPIPEN 2-PAK

EPIPEN-JR 2-PAK

ERIVEDGE 1,3

erlotinib 1,3

ESBRIET 1

ESPEROCT 1

EVEKEO

everolimus 1,3

EVRYSDI 2

EXTAVIA 1

EYSUVIS

FABIOR

FANAPT

FANAPT TITRATION PACK

FARYDAK 1

FAZACLO

fenofibrate

fenofibric acid dr

fentanyl

FENTANYL CITRATE

fentanyl citrate oral transmucosal

FENTORA

FETZIMA

FETZIMA TITRATION PACK

FEXMID

FINTEPLA 2

FIRAZYR 1

FIRDAPSE 2

FLUOROPLEX

FLUOROURACIL

fluorouracil

FLUOXETINE

FLUOXETINE DR

FLUOXETINE HCL

FOCALIN

FOCALIN XR

FOLLISTIM AQ 1

FORFIVO XL

FORTEO 1

FORTESTA

GALAFOLD 1

GANIRELIX AC 1

GATTEX 2

GAVRETO 2,3

GENOTROPIN 1

GENOTROPIN MINIQUICK 1

GEODON

GILENYA 1

GILOTRIF 2

glatiramer acetate 1

glatopa 1

GLEEVEC 1,3

glydo

GOCOVRI 1,3

GONAL-F 1

GONAL-F RFF 1

GONAL-F RFF REDIJECT 1

GRANIX 1

HAEGARDA 2

HARVONI 1

HELIXATE FS 1

HEMLIBRA 1

HEMOFIL M 1

HETLIOZ 2,3

HIZENTRA 1

HUMALOG

HUMALOG JUNIOR KWIKPEN

HUMALOG KWIKPEN

HUMALOG MIX

HUMALOG MIX KWIKPEN

HUMATROPE 1

HUMIRA 1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 1

HUMIRA PEN 1

HUMIRA PEN-CD/UC/HS STARTER 1

HUMIRA PEN-PEDIATRIC UC STARTER PACK 1

HUMIRA PEN-PS/UV STARTER 1

HUMULIN

HUMULIN KWIKPEN

HUMULIN N

HUMULIN N KWIKPEN

HUMULIN R

HYCAMTIN 1

hydrocodone bitartrate er

hydromorphone hcl er

HYQVIA 1

HYSINGLA ER

IBRANCE 1

icatibant acetate 1

ICLUSIG 2,3

IDELVION 1

IDHIFA 1

imatinib mesylate 1,3

IMBRUVICA 2

IMCIVREE 2

imiquimod

imiquimod pump

INGREZZA 2

INLYTA 1,3

INQOVI 1

INREBIC 1,3

INSULIN LISPRO

INSULIN LISPRO JUNIOR KWIKPEN

INSULIN LISPRO KWIKPEN

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN

INTERMEZZO

INTRON A 1

INTUNIV

INVEGA

IRESSA 2,3

ISTURISA 2

IXINITY 1

JAKAFI 1,3

JIVI 1

JORNAY PM

JUBLIA

JUXTAPID 2

JYNARQUE 1

KADIAN

KALYDECO 1

KAPVAY

KERYDIN

KESIMPTA 1

KEVEYIS 2

KEVZARA 1

KHEDEZLA

KINERET 2

KISQALI 1

KISQALI FEMARA 1

KITABIS PAK 1

KOATE 1

KOATE-DVI 1

KOGENATE FS 1

KORLYM 2

KOSELUGO

KOSELUGO 2

KOVALTRY 1

KUVAN 1

lapatinib ditosylate 1

LAZANDA

LEDIPASVIR/SOFOSBUVIR 1

LENVIMA 2,3

LETAIRIS 1

LEXAPRO

lidocaine

LIDOCAINE

LIDOCAINE AND TETRACAINE

lidocaine hcl

lidocaine pak

lidocaine patch

lidocaine/prilocaine

LIDOCAINE/TETRACAINE

LIDODERM

LINZESS

LOMAIRA

LONSURF 1

LORBRENA 1,3

LORZONE

LOTRONEX

LUBIPROSTONE

LUNESTA

LYNPARZA 2,3

LYRICA CR

LYSODREN

LYUMJEV

LYUMJEV KWIKPEN

MAPROTILINE HCL

MATULANE 1

MAVENCLAD 1

MAVYRET 1

MAYZENT 1

MAYZENT STARTER PACK

MEKINIST 1

MEKTOVI 2

MENOPUR 1

metaxall

metaxalone

METHADONE

methadone

methadone hcl

METHITEST

METHYLIN

METHYLPHENIDATE HCL ER

METHYLTESTOSTERONE

miglustat 1

MINOCIN

MINOCYCLINE HCL ER

MINOLIRA

M-NATAL PLUS

MONONINE 1

MORPHABOND ER

MORPHINE SULFATE

MORPHINE SULFATE ER

morphine sulfate cr

morphine sulfate er

MOTEGRITY

MOVANTIK

MS CONTIN

MULPLETA 1

MYALEPT 2

MYCAPSSA

MYDAYIS

MYNATAL

naproxen/esomeprazole magnesium

NATESTO

NATPARA 1

NEONATAL COMPLETE

NEONATAL PLUS

NERLYNX 2,3

NEULASTA 1

NEULASTA ONPRO KIT 1

NEXAVAR 1,3

NEXIUM

NEXLETOL

NEXLIZET

NINLARO 1

NIVA-PLUS

NOCTIVA

NORDITROPIN FLEXPRO 1

NORTHERA 1

NOVAREL 1

NOVOEIGHT 1

NUBEQA 1

NUCYNTA ER

NUPLAZID 1

NURTEC

NUTROPIN AQ NUSPIN1

NUWIQ 1

NYVEPRIA

O-CAL FA

OCALIVA 1

ODOMZO 1,3

OFEV 1,3

OLUMIANT 1

omeppi

omeprazole/sodium bicarbonate

OMNITROPE 1

ONE VITE WOMENS PRENATAL VITAMIN PLUS

ONUREG 1

OPSUMIT 2

ORACEA

ORENCIA 1

ORENCIA CLICKJECT 1

ORENITRAM 2

ORGOVYX 2

ORIAHNN

ORILISSA

ORKAMBI 1

ORLADEYO 2

OTEZLA 1

OVIDREL 1

OXBRYTA 2

OXERVATE 2

OXYCODONE HCL ER

OXYCONTIN

OXYMORPHONE HCL ER

PAXIL

PAXIL CR

PEGINTRON 1

PEMAZYRE 2

PENLAC NAIL LACQUER

PEXEVA

phendimetrazine tartrate

PHENDIMETRAZINE TARTRATE ER

phentermine hcl

PICATO

PIQRAY 1

PLEGRIDY 1

PLEGRIDY STARTER PACK 1

PLIAGLIS

PNV PRENATAL PLUS MULTIVITAMIN

PNV

POMALYST 1

POSTNATAL

PRALUENT

pregabalin er

PREGEN DHA

PREGENNA

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL 1

PRENARA

PRENATAL

PRENATAL LOW IRON

PRENATAL PLUS

PRENATAL PLUS/IRON

PRENATAL VITAMINS PLUS LOW IRON

PRENATAL/FOLIC ACID

PRENATRIX

PRENATRYL

PREPLUS

PREVACID

PRISTIQ

PROCRIT 1

PROCYSBI 2

PROFILNINE 1

PROFILNINE SD 1

PROMACTA 1

PROTONIX

PROZAC

pyrimethamine

QBREXZA

QINLOCK 2

QSYMIA

QUDEXY XR

RAVICTI 1

RAYOS

REBIF 1

REBIF REBIDOSE 1

REBIF REBIDOSE TITRATION PACK 1

REBIF TITRATION PACK 1

REBINYN 1

RECOMBINATE 1

REGRANEX

RELEXXII

RELISTOR

REMERON

REMERON SOLTAB

REPATHA

REPATHA PUSHTRONEX SYSTEM

REPATHA SURECLICK

RESTASIS

RESTASIS MULTIDOSE

RETEVMO 1,3

RETIN-A

RETIN-A MICRO

RETIN-A MICRO PUMP

REVATIO 1

REVLIMID 1

REYVOW

RINVOQ 1

RISPERDAL

RISPERIDONE ODT

RITALIN

RITALIN LA

RIXUBIS 1

ROBAXIN

ROZEREM

ROZLYTREK 1,3

RUBRACA 2,3

RUZURGI 2

RYDAPT 1

SAMSCA 1

SAPHRIS

sapropterin dihydrochloride 1

SARAFEM

SAXENDA

SENSIPAR 1

SEROQUEL

SEROQUEL XR

SEROSTIM 1

SEYSARA

SIGNIFOR 2

sildenafil citrate 1

SILENOR

SILIQ 1

SIMPONI 1

SKELAXIN

SKYRIZI 1

SKYRIZI PEN

sodium phenylbutyrate 1

SOFOSBUVIR / VELPATASVIR 1

SOMA

SOMAVERT 1

SOVALDI 1

SPRYCEL 1,3

STELARA 1

STIMATE 1

STIVARGA 1

STRATTERA

STRENSIQ 2

STRIANT

SUBSYS

SUCRAID

SUNOSI

SUTENT 1,3

SYLATRON 1

SYMDEKO 1

SYMPROIC

SYNERA

TABRECTA 1

tadalafil 1

TAFINLAR 1

TAGRISSO 2,3

TAKHZYRO 2

TALTZ 1

TALZENNA 1,3

TARCEVA 1,3

TARGADOX

TARGRETIN 1,3

TASIGNA 1,3

tavaborole

TAZAROTENE

TAZORAC

TAZVERIK 2

TECFIDERA 1

TECFIDERA STARTER PACK 1

TEGSEDI 2

TEMODAR 1

temozolomide 1

TERIPARATIDE 1

TESTIM

TESTOST ENAN

testosterone

TESTOSTERONE

testosterone cypionate

TESTOSTERONE GEL PUMP

TESTOSTERONE INJ

testosterone topical solution

tetrabenazine 1

THALOMID 1

TIBSOVO 2

TOBI 1

TOBI PODHALER 1

tobramycin 1

TOBRAMYCIN1

TOLAK

TOLVAPTAN 1

topiramate er

TRACLEER 1

TRAMADOL HCL

tramadol hcl er

tramadol hcl tab er

trazodone hcl

TREMFYA 1

tretinoin

tretinoin microsphere

tretinoin microsphere pump

TRICARE

TRIKAFTA 1

TRILIPIX

TRINAZ

TRINTELLIX

TROKENDI XR

TRULANCE

TUKYSA 2

TURALIO 2

TYKERB 1

TYMLOS 1

UBRELVY

UPTRAVI 2

VENCLEXTA 2

VENCLEXTA STARTING PACK 2

VENTAVIS 2,3

VERSACLOZ

VERZENIO 2,3

VIBERZI

VIBRAMYCIN

VIEKIRA PAK 1

VIIBRYD

VIIBRYD STARTER PACK

VIMOVO

VITATHELY/GINGER

VITRAKVI 2,3

VIZIMPRO 1,3

VOGELXO

VOGELXO PUMP

VOL-PLUS

VOSEVI 1

VOTRIENT 1,3

VRAYLAR

VUMERITY 1

VYLEESI

VYNDAMAX 1

VYNDAQEL 1

WAKIX

WELLBUTRIN SR

WELLBUTRIN XL

WESTAB PLUS

XALKORI 1,3

XELJANZ 1

XELJANZ XR 1

XELODA 1

XENAZINE 1

XENICAL

XERMELO 2

XHANCE

XIFAXAN

XIIDRA

XIMINO

XOSPATA 2

XPOVIO 2,3

XTAMPZA ER

XTANDI 1,3

XYNTHA 1

XYNTHA SOLOFUSE 1

XYOSTED

XYREM 2

XYWAV 2

ZALVIT

ZANAFLEX

ZARXIO 1

ZAVESCA 2

ZEGERID

ZEJULA 2,3

ZELBORAF 1

ZELNORM

ZEPATIER 1

ZEPOSIA 1

ZEPOSIA STARTER KIT 1

ZOHYDRO ER

ZOKINVY 2

ZOLINZA 1,3

ZOLOFT

ZOLPIMIST

ZOMACTON 1

ZORBTIVE 1

ZTLIDO

ZYCLARA

ZYCLARA PUMP

ZYDELIG 2

ZYKADIA 1,3

ZYPREXA

ZYPREXA ZYDIS

ZYTIGA 1,3

 

 

Drug name(s)

ACCU-CHEK AVIVA PLUS

ACCU-CHEK COMPACT PLUS

ACCU-CHEK COMPACT STRIPS

ACCU-CHEK COMPACT TEST DRUM

ACCU-CHEK GUIDE

ACCU-CHEK SMARTVIEW STRIPS

ACCUTREND GLUCOSE

ADLYXIN

ADLYXIN STARTER PACK

ADVANCE INTUITION TEST STRIPS

ADVANCE MICRO-DRAW TEST STRIPS

ADVOCATE REDI-CODE

ADVOCATE REDI-CODE+ TEST STRIPS

ADVOCATE TEST STRIPS

AGAMATRIX AMP NO CODE TEST STRIPS

AGAMATRIX JAZZ TEST STRIPS

AGAMATRIX KEYNOTE TEST STRIPS

AGAMATRIX PRESTO TEST STRIPS

ALA-SCALP

ALOGLIPTIN

ALOGLIPTIN/ PIOGLITAZONE

ALOGLIPTIN/METFORMIN HCL

ALTOPREV

AMCINONIDE

AMERGE

ANAPROX DS

APEXICON E

ARTHROTEC

ASSURE 3 TEST STRIPS

ASSURE 4 TEST STRIPS

ASSURE II

ASSURE II CHECK STRIP

ASSURE II TEST STRIPS

ASSURE PLATINUM TEST STRIPS

ASSURE PRISM MULTI TEST STRIPS

ASSURE PRO TEST STRIPS

AT LAST TEST STRIPS

ATACAND

ATACAND HCT

AUGMENTED BETAMETHASONE DIPROPIONATE

AVALIDE

AVAPRO

AZOR

BENICAR

BENICAR HCT

BEPREVE

BETAMETHASONE DIPROPIONATE

BIOSCANNER GLUCOSE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS PREMIUM

BYDUREON BCISE

BYDUREON PEN

BYETTA

BYVALSON

CAMBIA

CAPEX

CAREONE BLOOD GLUCOSE TEST STRIPS

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE

CARESENS N BLOOD GLUCOSE TEST STRIPS

CARETOUCH BLOOD GLUCOSE TEST STRIPS

CELEBREX

CLEVER CHEK AUTO-CODE TEST STRIPS

CLEVER CHEK AUTO-CODE VOICE TEST STRIPS

CLEVER CHEK TEST STRIPS

CLEVER CHOICE AUTO-CODE PRO TEST STRIPS

CLEVER CHOICE MICRO TEST STRIPS

CLEVER CHOICE NO CODING TEST STRIPS

CLEVER CHOICE TALK NO CODING TEST STRIPS

CLOBEX

CLOCORTOLONE PIVALATE

CLOCORTOLONE PIVALATE PUMP

CLODERM

CLODERM PUMP

CONTOUR BLOOD GLUCOSE TEST STRIPS

CONTOUR NEXT BLOOD GLUCOSE TEST

COOL BLOOD GLUCOSE TEST STRIPS

CORDRAN

COZAAR

CRESTOR

CUTIVATE

CVS ADVANCED GLUCOSE METER TEST STRIPS

DAYPRO

DERMA-SMOOTHE/FS BODY

DERMA-SMOOTHE/FS SCALP

DESONATE

DESOWEN

DETROL

DETROL LA

DEXCOM G5 MOBILE RECEIVER KIT

DEXCOM G5 MOBILE TRANSMITTER KIT

DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT

DEXCOM G5 RECEIVER KIT

DEXCOM G6 RECEIVER

DEXCOM G6 SENSOR

DEXCOM G6 TRANSMITTER

DIATHRIVE BLOOD GLUCOSE TEST STRIPS

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS

DICLOFENAC EPOLAMINE

DIFLORASONE DIACETATE

DIOVAN

DIOVAN HCT

DIPROLENE

DIPROLENE AF

DITROPAN XL

DUO-CARE TEST STRIPS

EASY PLUS II BLOOD GLUCOSE TEST

EASY STEP TEST STRIPS

EASY TALK BLOOD GLUCOSE TEST STRIPS

EASY TOUCH GLUCOSE TEST STRIPS

EASY TRAK BLOOD GLUCOSE TEST STRIPS

EASYGLUCO

EASYGLUCO PLUS

EASYMAX 15 TEST STRIPS

EASYMAX TEST STRIPS

EASYPRO BLOOD GLUCOSE TEST STRIPS

EASYPRO PLUS

EC-NAPROSYN

EDARBI

EDARBYCLOR

ELEMENT COMPACT TEST STRIPS

ELEMENT TEST STRIPS

ELESTAT

ELIDEL

ELOCON

EMBRACE BLOOD GLUCOSE TEST STRIPS

EMBRACE EVO BLOOD GLUCOSE TEST STRIPS

EMBRACE PRO BLOOD GLUCOSE TEST STRIPS

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

ENABLEX

EPROSARTAN MESYLATE

EQ BLOOD GLUCOSE TEST STRIPS

EUCRISA

EVENCARE + BLOOD GLUCOSE TEST STRIP

EVENCARE BLOOD GLUCOSE TEST STRIP

EVENCARE G2 TEST STRIPS

EVENCARE G3 TEST STRIPS

EVENCARE MINI BLOOD GLUCOSE TEST STRIPS

EVOLUTION AUTOCODE

EXACTECH R-S-G TEST STRIPS

EXACTECH TEST STRIPS

EXFORGE

EXFORGE HCT

FARXIGA

FELDENE

FENOPROFEN CALCIUM

FENORTHO

FIFTY50 GLUCOSE TEST STRIP 2.0

FLECTOR

FLOLIPID

FLURBIPROFEN

FORA BLOOD GLUCOSE TEST STRIPS

FORA D15G BLOOD GLUCOSE TEST STRIPS

FORA D20 BLOOD GLUCOSE TEST STRIPS

FORA D40/G31 BLOOD GLUCOSE TEST STRIPS

FORA G20 BLOOD GLUCOSE TEST STRIPS

FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS

FORA GD20 TEST STRIPS

FORA GD50 BLOOD GLUCOSE TEST STRIPS

FORA GTEL BLOOD GLUCOSE TEST STRIPS

FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS

FORA V10 BLOOD GLUCOSE TEST STRIPS

FORA V12 BLOOD GLUCOSE TEST STRIPS

FORA V20 BLOOD GLUCOSE TEST STRIPS

FORA V30A BLOOD GLUCOSE TEST STRIPS

FORACARE GD40

FORACARE PREMIUM V10 TEST STRIPS

FORACARE TEST N GO TEST STRIPS

FORTAMET

FORTISCARE BLOOD GLUCOSE TEST STRIP

FOSRENOL

FREESTYLE INSULINX BLOOD GLUCOSE TEST

FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS

FREESTYLE LIBRE 14 DAY /READER/FLASH MONITORING SYSTEM

FREESTYLE LIBRE 14 DAY /SENSOR/FLASH MONITORING SYSTEM

FREESTYLE LIBRE 2 / SENSOR / FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM

FREESTYLE LIBRE/READER/ FLASH MONITORING SYSTEM

FREESTYLE LIBRE/SENSOR/ FLASH MONITORING SYSTEM

FREESTYLE LITE TEST STRIPS

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS

FREESTYLE TEST STRIPS

FROVA

GE100 BLOOD GLUCOSE TEST STRIPS

GELNIQUE

GELNIQUE PUMP

GEMTESA

GENULTIMATE TEST STRIPS

GHT TEST STRIPS

GLUCO PERFECT 3 TEST STRIPS

GLUCOCARD 01 SENSOR PLUS

GLUCOCARD 01 SENSOR PLUS TEST STRIPS

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS

GLUCOCARD SHINE TEST STRIPS

GLUCOCARD VITAL TEST STRIPS

GLUCOCARD X-SENSOR

GLUCOCOM TEST STRIPS

GLUCONAVII BLOOD GLUCOSE TEST STRIPS

GLUCOSE METER TEST STRIPS ADVANCED

GLUMETZA

GLYXAMBI

GNP EASY TOUCH GLUCOSE TEST STRIPS

GOJJI BLOOD GLUCOSE TEST STRIPS

GOJJI BLOOD GLUCOSE TEST STRIPS/GOJJI STERILE LANCETS 30G

GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS

HALOG

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS

HYDROCORTISONE BUTYRATE

HYZAAR

IGLUCOSE BLOOD GLUCOSE TEST STRIPS

IMITREX

IMITREX STATDOSE REFILL

IMITREX STATDOSE SYSTEM

IMPOYZ

IN TOUCH BLOOD GLUCOSE TEST STRIPS

INDOCIN

INDOMETHACIN

INFINITY BLOOD GLUCOSE TEST STRIPS

INFINITY VOICE

INVOKAMET

INVOKAMET XR

INVOKANA

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

JENTADUETO

JENTADUETO XR

KAZANO

KENALOG

KETOPROFEN

KETOPROFEN ER

KOMBIGLYZE XR

KROGER BLOOD GLUCOSE TEST STRIPS

KROGER HEALTHPRO GLUCOSE TEST STRIPS

KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS

KROGER TEST STRIPS

lanthanum carbonate

LASTACAFT

LESCOL XL

LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS

LIBERTY TEST STRIPS

LICART

LIPITOR

LIVALO

LOCOID

LOCOID LIPOCREAM

LODINE

LUMIGAN

LUXIQ

LYRICA

MAXALT

MAXALT-MLT

MECLOFENAMATE SODIUM

MEIJER BLOOD GLUCOSE TEST STRIPS

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS

MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS

metformin hcl er

MICARDIS

MICARDIS HCT

MICORT-HC

MICRODOT TEST STRIPS

MM EASY TOUCH GLUCOSE TEST STRIPS

MYGLUCOHEALTH BLOOD GLUCOSE TEST

MYRBETRIQ

NALFON

NAPRELAN

NAPROSYN

NAPROXEN SODIUM

NESINA

NEUTEK 2TEK TEST STRIPS

NOVA MAX GLUCOSE TEST STRIPS

OLUX

OLUX-E

ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS

ON CALL PLUS BLOOD GLUCOSE TEST

ON CALL VIVID BLOOD GLUCOSE TEST

ON CALL VIVID BLOOD GLUCOSE TEST STRIPS

ONE DROP BLOOD GLUCOSE TEST STRIPS

ONGLYZA

ONZETRA XSAIL

OPTIUM TEST STRIPS

OPTIUMEZ TEST STRIPS

OPTUMRX BLOOD GLUCOSE TEST

OSENI

OTREXUP 1

OZEMPIC

PANDEL

PAZEO

PENNSAID

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS

pimecrolimus

POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS

PRAVACHOL

PRECISION PCX

PRECISION PCX PLUS TEST STRIPS

PRECISION POINT OF CARE TEST STRIPS

PRECISION QID TEST STRIPS

PRECISION SOF-TACT TEST STRIPS

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS

PREDNICARBATE

PREMIUM

PREMIUM BLOOD GLUCOSE TEST STRIPS

PRESTIGE TEST STRIPS

PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS

PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS

PROTOPIC

PSORCON

PTS PANELS GLUCOSE TEST

QTERN

QUICKTEK TEST STRIPS

QUINTET AC BLOOD GLUCOSE TEST STRIPS

QUINTET BLOOD GLUCOSE TEST STRIPS

RASUVO 1

REDITREX

REFUAH PLUS BLOOD GLUCOSETEST STRIPS

RELION ALL-IN-ONE COMPACT BLOOD GLUCOSE TESTING SYSTEM

RELION BLOOD GLUCOSE TEST STRIPS

RELION CONFIRM/MICRO TEST STRIPS

RELION PREMIER BLOOD GLUCOSE TEST STRIPS

RELION PRIME BLOOD GLUCOSE TEST STRIPS

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS

RELPAX

RENAGEL

RENVELA

REVEAL BLOOD GLUCOSE TEST

REXALL BLOOD GLUCOSE TEST STRIPS

RHOPRESSA

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS

RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS

RIOMET ER

ROCKLATAN

RYBELSUS

SAVELLA

SAVELLA TITRATION PACK

SEGLUROMET

SERNIVO

sevelamer

SIDEKICK BLOOD GLUCOSE SYSTEM

SIMVASTATIN

SMART SENSE PREMIUM BLOODGLUCOSE STRIPS

SMART SENSE VALUE BLOOD GLUCOSE STRIPS

SMARTEST BLOOD GLUCOSE TEST STRIPS

SOLIQUA

SOLUS V2 AUDIBLE TEST

STEGLATRO

STEGLUJAN

SUMATRIPTAN SUCCINATE

SUPREME TEST STRIPS

SURE EDGE BLOOD GLUCOSE TEST STRIPS

SURECHEK BLOOD GLUCOSE TEST STRIPS

SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS

SYNALAR

SYNJARDY

SYNJARDY XR

tacrolimus

TELCARE BLOOD GLUCOSE TEST STRIPS

TEMOVATE

TEXACORT

TGT BLOOD GLUCOSE TEST STRIPS

TGT BLOOD GLUCOSE TEST STRIPS PREMIUM

TIVORBEX

TOLMETIN SODIUM

TOPICORT

TOVIAZ

TRADJENTA

TRAVATAN Z

TREXIMET

TRIBENZOR

TRIDESILON

TRIJARDY XR

TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS

TRUE METRIX BLOOD GLUCOSETEST STRIPS

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS

TRUETEST STRIPS

TRUETRACK BLOOD GLUCOSE TEST

TRUETRACK TEST

TRULICITY

TWYNSTA

ULORIC

ULTRATRAK PRO TEST STRIPS

ULTRATRAK ULTIMATE TEST STRIPS

ULTRAVATE

UNISTRIP1 GENERIC

VANOS

VELPHORO

VELTIN

VERASENS BLOOD GLUCOSE TEST STRIPS

VERDESO

VESICARE

VICTOZA

VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS

VIVLODEX

VOCAL POINT BLOOD GLUCOSE TEST STRIPS

VYTORIN

VYZULTA

WAVESENSE PRESTO TEST STRIPS

WINLEVI

XALATAN

XIGDUO XR

XULTOPHY

ZEMBRACE SYMTOUCH

ZERVIATE

ZIANA

ZIOPTAN

ZIPSOR

ZOCOR

ZOLMITRIPTAN

ZOMIG

ZOMIG ZMT

   

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

benzphetamin tab 50mg

90 tabs / 30 days

diethylprop tab 25mg

90 tabs / 30 days

phendimetrazine tab 35mg

180 tabs / 30 days

phentermine cap 15mg

30 caps / 30 days

phentermine cap 30mg

30 caps / 30 days

phentermine cap 37.5mg

30 caps / 30 days

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ACTEMRA INJ 162/0.9 1

4 syringes / 28 days

ACTEMRA INJ ACTPEN 1

4 injections / 28 days

ARCALYST INJ 220MG 2

4 vials / 28 days

ENBREL INJ 25/0.5ML 1,4

8 syringes / 28 days

ENBREL INJ 25MG 1,4

8 vials / 28 days

ENBREL INJ 50MG/ml 1,4

4 syringes / 28 days

ENBREL MINI INJ 50MG/ml 1,4

4 carts / 28 days

ENBREL SRCLK INJ 50MG/ml 1,4

4 syringes / 28 days

HUMIRA INJ 10/0.1ML 1,4

2 syringes / 28 days

HUMIRA INJ 10MG/0.2 1,4

2 syringes / 28 days

HUMIRA INJ 20/0.2ML 1,4

2 syringes / 28 days

HUMIRA INJ 40/0.4ML 1,4

2 syringes / 28 days

HUMIRA kit 20MG/0.4 1,4

2 syringes / 28 days

HUMIRA kit 40MG/0.8 1,4

2 syringes / 28 days

HUMIRA PEDIA INJ CROHNS starter kit 40mg/0.4 mL and 80mg/0.8 mL syringe 1,4

1 kit / 180 days

HUMIRA PEDIA INJ CROHNS starter kit 80mg/0.8 mL syringe 1,4

3 kits / 180 days

HUMIRA pen INJ 40/0.4mL 1,4

2 pens / 28 days

HUMIRA pen INJ 40MG/0.8 1,4

2 pens / 28 days

HUMIRA pen INJ 80/0.8mL 1,4

2 pens / 28 days

HUMIRA pen INJ CD/UC/HS 1,4

1 kit / 180 days

HUMIRA pen INJ PS/UV 1,4

1 kit / 180 days

HUMIRA pen kit CD/UC/HS 1,4

1 kit / 180 days

HUMIRA pen kit PED UC 1,4

4 pens / 180 days

HUMIRA pen kit PS/UV 1,4

1 kit / 180 days

naprox-esom tab 375-20mg

60 tabs / 30 days

naprox-esom tab 500-20mg

60 tabs / 30 days

OTEZLA TAB 10/20/30 1

1 kit / 180 days

OTEZLA TAB 30MG 1

60 tabs / 30 days

RINVOQ TAB 15MG ER 1

30 tabs / 30 days

SIMPONI INJ 100MG/mL 1

1 syringe / 28 days

XELJANZ SOL 1MG/mL 1

240 mLs / 30 days

XELJANZ TAB 10MG 1

224 tabs / 365 days

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

APAP/CAFFEIN TAB DIHYDROC

50 tablets/30 days

30 tablets/30 days

apap/codeine sol 120-12/5

450 mL/30 days

270 mL/30 days

apap/codeine tab 300-15mg

30 tablets/30 days

18 tablets/30 days

apap/codeine tab 300-30mg

30 tablets/30 days

18 tablets/30 days

apap/codeine tab 300-60mg

25 tablets/30 days

15 tablets/30 days

buprenorphine dis 10mcg/hr

4 systems/month

N/A

buprenorphine dis 15mcg/hr

4 systems/month

N/A

buprenorphine dis 20mcg/hr

4 systems/month

N/A

buprenorphine dis 5mcg/hr

4 systems/month

N/A

buprenorphine dis 7.5/hr

4 systems/month

N/A

butorphanol sol 10mg/mL

2.5 mL (1 bottle)/30 days

0 mL/30 days

codeine sulf tab 30mg

30 tablets/30 days

18 tablets/30 days

codeine/apap tab 30-300mg

30 tablets/30 days

18 tablets/30 days

codeine/apap tab 60-300mg

25 tablets/30 days

15 tablets/30 days

dvorah tab

50 tablets/30 days

30 tablets/30 days

endocet tab 10-325mg

15 tablets/30 days

9 tablets/30 days

endocet tab 2.5-325

60 tablets/30 days

36 tablets/30 days

endocet tab 5-325mg

30 tablets/30 days

18 tablets/30 days

endocet tab 7.5-325

20 tablets/30 days

12 tablets/30 days

fentanyl dis 100mcg/h

0 patches/month

N/A

fentanyl dis 12mcg/hr

10 patches/month

N/A

fentanyl dis 25mcg/hr

0 patches/month

N/A

fentanyl dis 37.5mcg

0 patches/month

N/A

fentanyl dis 50mcg/hr

0 patches/month

N/A

fentanyl dis 62.5mcg

0 patches/month

N/A

fentanyl dis 75mcg/hr

0 patches/month

N/A

fentanyl dis 87.5mcg

0 patches/month

N/A

fentanyl ot loz 1200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1600mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 400mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 600mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 800mcg

120 lozenges / 30 days

N/A

hydro/aceta sol 10-325mg

375 mL/30 days

225 mL/30 days

hydroco/apap sol 7.5-325

450 mL/30 days

270 mL/30 days

hydroco/apap tab 10-300mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 10-325mg

25 tablets/30 days

15 tablets/30 days

hydroco/apap tab 5-300mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydroco/apap tab 7.5-300

30 tablets/30 days

18 tablets/30 days

hydroco/apap tab 7.5-325

30 tablets/30 days

18 tablets/30 days

hydrocod/ibu tab 10-200mg

25 tablets/30 days

15 tablets/30 days

HYDROCOD/IBU TAB 5-200MG

25 tablets/30 days

15 tablets/30 days

hydrocod/ibu tab 7.5-200

25 tablets/30 days

15 tablets/30 days

hydrocodone cap 10mg er

60 capsules/30 days

N/A

hydrocodone cap 15mg er

60 capsules/30 days

N/A

hydrocodone cap 20mg er

60 capsules/30 days

N/A

hydrocodone cap 30mg er

30 capsules/30 days

N/A

hydrocodone cap 40mg er

30 capsules/30 days

N/A

hydrocodone cap 50mg er

30 capsules/30 days

N/A

hydrocodone tab 100mg er

0 tablets/30 days

N/A

hydrocodone tab 120mg er

0 tablets/30 days

N/A

hydrocodone tab 20mg er

30 tablets/30 days

N/A

hydrocodone tab 30mg er

30 tablets/30 days

N/A

hydrocodone tab 40mg er

30 tablets/30 days

N/A

hydrocodone tab 60mg er

0 tablets/30 days

N/A

hydrocodone tab 80mg er

0 tablets/30 days

N/A

hydromorphon liq 1mg/mL

60 mL/30 days

36 mL/30 days

hydromorphon tab 12mg er

30 tablets/month

N/A

hydromorphon tab 16mg er

0 tablets

N/A

hydromorphon tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphon tab 32mg er

0 tablets

N/A

hydromorphon tab 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphon tab 8mg

5 tablets/30 days

3 tablets/30 days

hydromorphon tab 8mg er

30 tablets/month

N/A

KADIAN CAP 200MG ER

0 capsules/30 days

N/A

levorphanol tab 2mg

10 tablets/30 days

6 tablets/30 days

lorcet tab 5-325mg

40 tablets/30 days

24 tablets/30 days

lorcet hd tab 10-325mg

25 tablets/30 days

15 tablets/30 days

lorcet plus tab 7.5-325

30 tablets/30 days

18 tablets/30 days

meperidine tab 100mg

15 tablets/30 days

15 tablets/30 days

methadone sol 5mg/5mL

300 mL/30 days

N/A

methadone sol 10mg/5mL

150 mL/30 days

N/A

methadone tab 5mg

60 tablets/30 days

N/A

methadone tab 10mg

30 tablets/30 days

N/A

morphine sul cap 10mg er

30 capsules/30 days

N/A

morphine sul cap 20mg er

30 capsules/30 days

N/A

morphine sul cap 30mg er

30 capsules/30 days

N/A

morphine sul cap 100mg er

0 capsules/30 days

N/A

MORPHINE SUL CAP 40MG ER

30 capsules/30 days

N/A

morphine sul cap 50mg er

30 capsules/30 days

N/A

morphine sul cap 60mg er

0 capsules/30 days

N/A

morphine sul cap 80mg er

0 capsules/30 days

N/A

morphine sul sol 10/0.5mL

15 mL/30 days

15 mL/30 days

morphine sul sol 10mg/5mL

125 mL/30 days

75 mL/30 days

morphine sul sol 20mg/5mL

60 mL/30 days

36 mL/30 days

morphine sul sol 100/5mL

15 mL/30 days

15 mL/30 days

morphine sul sol 20mg/mL

15 mL/30 days

15 mL/30 days

morphine sul tab 15mg

15 tablets/30 days

9 tablets/30 days

morphine sul tab 15mg er

60 tablets/30 days

N/A

morphine sul tab 30mg

5 tablets/30 days

3 tablets/30 days

morphine sul tab 30mg er

30 tablets/30 days

N/A

morphine sul tab 60mg er

0 tablets/30 days

N/A

morphine sul tab 100mg cr

0 tablets/30 days

N/A

morphine sul tab 100mg er

0 tablets/30 days

N/A

morphine sul tab 200mg er

0 tablets/30 days

N/A

OXYCOD/APAP TAB 10-300MG

15 tablets/30 days

9 tablets/30 days

oxycodone/apap tab 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/apap tab 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/apap tab 7.5-325

20 tablets/30 days

12 tablets/30 days

oxycodone/apap tab 10-325mg

15 tablets/30 days

9 tablets/30 days

oxycodone/asa tab

30 tablets/30 days

18 tablets/30 days

oxycodone cap 5mg

30 capsules/30 days

18 capsules/30 days

oxycodone cap hcl 5mg

30 capsules/30 days

18 capsules/30 days

oxycodone con 10/0.5mL

5 mL/30 days

3 mL/30 days

oxycodone con 100/5mL

5 mL/30 days

3 mL/30 days

oxycodone sol 5mg/5mL

165 mL/30 days

99 mL/30 days

oxycodone tab 5mg

30 tablets/30 days

18 tablets/30 days

oxycodone tab 10mg

15 tablets/30 days

9 tablets/30 days

oxycodone tab 15mg

10 tablets/30 days

6 tablets/30 days

oxycodone tab 20mg

5 tablets/30 days

3 tablets/30 days

oxycodone tab 30mg

5 tablets/30 days

3 tablets/30 days

oxymorphone tab hcl 10mg

5 tablets/30 days

3 tablets/30 days

oxymorphone tab hcl 5mg

15 tablets/30 days

9 tablets/30 days

pentaz/nalox tab 50-0.5mg

10 tablets/30 days

6 tablets/30 days

PRImLEV TAB 10-300MG

15 tablets/30 days

9 tablets/30 days

tramadl/apap tab 37.5-325

40 tablets/30 days

24 tablets/30 days

tramadol hcl tab 50mg

50 tablets/30 days

30 tablets/30 days

tramadol hcl tab 100mg er

30 tablets/30 days

N/A

tramadol hcl tab 200mg er

30 tablets/30 days

N/A

tramadol hcl tab 300mg er

30 tablets/30 days

N/A

Androgens - anabolic

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 1.62% 75 gm pump bottle

2 pumps / 30 days

ANDROGEL GEL 1.62% 20.25 mg/1.25 gm packet

30 packets / 30 days

ANDROGEL GEL 1.62% 40.5 mg/2.5 gm packet

60 packets / 30 days

testosterone cyp inj 100mg/mL

1 vial / 28 days

testosterone cyp inj 200mg/mL

10 mLs / 28 days

testosterone enan inj 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% 75 gm pump bottle

2 bottles / 30 days

testosterone gel 1.62% 20.25 mg/1.25 gm

60 packets / 30 days

testosterone gel 1.62% 40.5 mg/2.5 gm

30 packets / 30 days

testosterone gel 10mg/act

2 bottles / 30 days

testosterone gel pump 1%

300 grams / 30 days

testosterone sol 30mg/act

2 pumps / 30 days

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADVAIR DISKU AER 100/50

60 blisters / 30 days

ADVAIR DISKU AER 250/50

60 blisters / 30 days

ADVAIR DISKU AER 500/50

60 blisters / 30 days

ADVAIR HFA AER 45/21

1 can / 30 days

ADVAIR HFA AER 115/21

1 can / 30 days

ADVAIR HFA AER 230/21

1 can / 30 days

albuterol aer hfa

2 cans / 30 days

ANORO ELLIPT AER 62.5-25

1 inhaler / 30 days

ARNUITY ELPT INH 50MCG

30 blisters / 30 days

ARNUITY ELPT INH 100MCG

30 blisters / 30 days

ARNUITY ELPT INH 200MCG

30 blisters / 30 days

ASMANEX 14 AER 220MCG

1 can / 30 days

ASMANEX 30 AER 110MCG

1 can / 30 days

ASMANEX 30 AER 220MCG

1 can / 30 days

ASMANEX 60 AER 220MCG

1 can / 30 days

ASMANEX 120 AER 220MCG

1 can / 30 days

ASMANEX HFA AER 50MCG

1 inhaler / 30 days

ASMANEX HFA AER 100 MCG

1 can / 30 days

ASMANEX HFA AER 200 MCG

1 can / 30 days

BREO ELLIPTA INH 100-25

60 blisters / 30 days

BREO ELLIPTA INH 200-25

60 blisters / 30 days

BREZTRI AERO AER SPHERE

1 can / 30 days

COMBIVENT AER 20-100

2 cans / 30 days

DULERA AER 50-5MCG

1 inhaler / 30 days

DULERA AER 100-5MCG

1 can / 30 days

DULERA AER 200-5MCG

1 can / 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 can / 30 days

FLOVENT HFA AER 110MCG

1 can / 30 days

FLOVENT HFA AER 220MCG

2 cans / 30 days

flutic/salme aer 100/50

60 blisters / 30 days

flutic/salme aer 250/50

60 blisters / 30 days

flutic/salme aer 500/50

60 blisters / 30 days

FLUTIC/SALME INH 55/14

1 inhaler / 30 days

INCRUSE ELPT INH 62.5MCG

30 blisters / 30 days

PROAIR RESPI AER

2 inhalers / 30 days

QVAR REDIHAL AER 40MCG

1 can / 30 days

QVAR REDIHA AER 80MCG

2 cans / 30 days

SEREVENT DIS AER 50MCG

60 blisters / 30 days

SPIRIVA AER 1.25MCG

1 cart / 30 days

SPIRIVA CAP HANDIHLR

30 caps / 30 days

SPIRIVA SPR 2.5MCG

1 cart / 30 days

STIOLTO AER 2.5-2.5

1 cart / 30 days

SYMBICORT AER 80-4.5

1 can / 30 days

SYMBICORT AER 160-4.5

1 can / 30 days

TRELEGY AER ELLIPTA

1 inhaler / 30 days

VENTOLIN HFA AER

2 cans / 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

Anticonvulsants

Drug name(s)

Quantity limits 
(per 30 days or as specified)

LYRICA CAP 25MG

90 caps / 30 days

LYRICA CAP 50MG

90 caps / 30 days

LYRICA CAP 75MG

90 caps / 30 days

LYRICA CAP 100MG

90 caps / 30 days

LYRICA CAP 150MG

90 caps / 30 days

LYRICA CAP 200MG

90 caps / 30 days

LYRICA CAP 225MG

60 caps / 30 days

LYRICA CAP 300MG

60 caps / 30 days

LYRICA SOL 20MG/mL

900 mLs / 30 days

pregabalin cap 25mg

90 caps / 30 days

pregabalin cap 50mg

90 caps / 30 days

pregabalin cap 75mg

90 caps / 30 days

pregabalin cap 100mg

90 caps / 30 days

pregabalin cap 150mg

90 caps / 30 days

pregabalin cap 200mg

90 caps / 30 days

pregabalin cap 225mg

60 caps / 30 days

pregabalin cap 300mg

60 caps / 30 days

pregabalin sol 20mg/mL

900 mLs / 30 days

topiramate cap er 25mg

30 caps / 30 days

topiramate cap er 50mg

30 caps / 30 days

topiramate cap er 100mg

30 caps / 30 days

topiramate cap er 150mg

30 caps / 30 days

topiramate cap er 200mg

60 caps / 30 days

Antidiabetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FARXIGA TAB 5MG

30 tabs / 30 days

FARXIGA TAB 10MG

30 tabs / 30 days

GLYXAMBI TAB 10-5 MG

30 tabs / 30 days

GLYXAMBI TAB 25-5 MG

30 tabs / 30 days

INVOKAMET TAB 50-1000

60 tabs / 30 days

INVOKAMET TAB 50-500MG

60 tabs / 30 days

INVOKAMET TAB 150-1000

60 tabs / 30 days

INVOKAMET TAB 150-500

60 tabs / 30 days

INVOKAMET XR TAB 50-1000

60 tabs / 30 days

INVOKAMET XR TAB 50-500MG

60 tabs / 30 days

INVOKAMET XR TAB 150-500

60 tabs / 30 days

INVOKAMET XR TAB 150-1000

60 tabs / 30 days

INVOKANA TAB 100MG

30 tabs / 30 days

INVOKANA TAB 300MG

30 tabs / 30 days

JANUMET TAB 50-500MG

60 tabs / 30 days

JANUMET TAB 50-1000

60 tabs / 30 days

JANUMET XR TAB 50-1000

60 tabs / 30 days

JANUMET XR TAB 50-500MG

30 tabs / 30 days

JANUMET XR TAB 100-1000

30 tabs / 30 days

JANUVIA TAB 25MG

30 tabs / 30 days

JANUVIA TAB 50MG

30 tabs / 30 days

JANUVIA TAB 100MG

30 tabs / 30 days

JARDIANCE TAB 10MG

30 tabs / 30 days

JARDIANCE TAB 25MG

30 tabs / 30 days

KORLYM TAB 300MG 2

120 tabs / 30 days

metformin osmotic tab 500mg er

90 tabs / 30 days

metformin tab 500mg er

120 tabs / 30 days

metformin tab 750mg er

60 tabs / 30 days

metformin tab 1000 er

60 tabs / 30 days

OZEMPIC INJ 2/1.5mL

1 pen / 28 days

OZEMPIC INJ 2/1.5mL

2 pens / 28 days

RYBELSUS TAB 3MG

30 tabs / 180 days

RYBELSUS TAB 7MG

30 tabs / 30 days

RYBELSUS TAB 14MG

30 tabs / 30 days

SYNJARDY TAB

60 tabs / 30 days

SYNJARDY TAB 12.5-500

60 tabs / 30 days

SYNJARDY TAB 5-1000MG

60 tabs / 30 days

SYNJARDY TAB 5-500MG

60 tabs / 30 days

SYNJARDY XR TAB

60 tabs / 30 days

SYNJARDY XR TAB 5-1000MG

60 tabs / 30 days

SYNJARDY XR TAB 10-1000

60 tabs / 30 days

SYNJARDY XR TAB 25-1000

30 tabs / 30 days

TRIJARDY XR TAB

60 tabs / 30 days

TRIJARDY XR TAB

30 tabs / 30 days

TRULICITY INJ 0.75/0.5

4 pens / 28 days

TRULICITY INJ 1.5/0.5

4 pens / 28 days

TRULICITY INJ 3/0.5

4 pens / 28 days

TRULICITY INJ 4.5/0.5

4 pens / 28 days

VICTOZA INJ 18MG/3mL

3 pens / 30 days

XIGDUO XR TAB 2.5-1000

60 tabs / 30 days

XIGDUO XR TAB 5-1000MG

60 tabs / 30 days

XIGDUO XR TAB 5-500MG

30 tabs / 30 days

XIGDUO XR TAB 10-1000

30 tabs / 30 days

XIGDUO XR TAB 10-500MG

30 tabs / 30 days

Antiemetics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

aprepitant cap 40mg

8 caps / 30 days

aprepitant cap 80mg

8 caps / 30 days

aprepitant cap 125mg

4 caps / 30 days

aprepitant pak 80 & 125

4 packs / 30 days

doxyl/pyrid tab 10-10mg

120 tabs / 30 days

EMEND SUS 125MG

6 packs / 30 days

granisetron tab 1mg

14 tabs / 30 days

ondansetron sol 4mg/5mL

5 bottles / 30 days

ondansetron tab 4mg

24 tabs / 30 days

ondansetron tab 4mg odt

24 tabs / 30 days

ondansetron tab 8mg

24 tabs / 30 days

ondansetron tab 8mg odt

24 tabs / 30 days

ondansetron tab 24mg

4 tabs / 30 days

Antihyperlidemics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

atorvastatin tab 10mg

45 tabs / 30 days

atorvastatin tab 20mg

45 tabs / 30 days

atorvastatin tab 40mg

45 tabs / 30 days

atorvastatin tab 80mg

30 tabs / 30 days

ezetim/simva tab 10-10mg

30 tabs / 30 days

ezetim/simva tab 10-20mg

30 tabs / 30 days

ezetim/simva tab 10-40mg

30 tabs / 30 days

ezetim/simva tab 10-80mg

30 tabs / 30 days

fluvastatin tab 80mg er

30 tabs / 30 days

JUXTAPID CAP 5MG 2

30 caps / 30 days

JUXTAPID CAP 10MG 2

30 caps / 30 days

JUXTAPID CAP 20MG 2

30 caps / 30 days

JUXTAPID CAP 30MG 2

30 caps / 30 days

JUXTAPID CAP 40MG 2

30 caps / 30 days

JUXTAPID CAP 60MG 2

30 caps / 30 days

lovastatin tab 10mg

60 tabs / 30 days

lovastatin tab 20mg

60 tabs / 30 days

lovastatin tab 40mg

60 tabs / 30 days

NEXLETOL TAB 180MG

30 tabs / 30 days

NEXLIZET TAB 180/10MG

30 tabs / 30 days

pravastatin tab 10mg

45 tabs / 30 days

pravastatin tab 20mg

45 tabs / 30 days

pravastatin tab 40mg

45 tabs / 30 days

pravastatin tab 80mg

30 tabs / 30 days

REPATHA INJ 140MG/mL

2 syringes / 28 days

REPATHA PUSH INJ 420/3.5

1 cart / 30 days

REPATHA SURE INJ 140MG/mL

2 pens / 28 days

rosuvastatin tab 5mg

45 tabs / 30 days

rosuvastatin tab 10mg

45 tabs / 30 days

rosuvastatin tab 20mg

45 tabs / 30 days

rosuvastatin tab 40mg

30 tabs / 30 days

simvastatin tab 5mg

45 tabs / 30 days

simvastatin tab 10mg

45 tabs / 30 days

simvastatin tab 20mg

60 tabs / 30 days

simvastatin tab 40mg

45 tabs / 30 days

simvastatin tab 80mg

30 tabs / 30 days

Ant-infective agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ALINIA SUS 100/5mL

300 mLs / 90 days

nitazoxanide tab 500mg

12 tabs / 90 days

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits 
(per 30 days or as specified)

abiraterone tab 250mg 1,3

120 tabs / 30 days

abiraterone tab 500mg 1,3

60 tabs / 30 days

AFINITOR TAB 2.5MG 1,3

30 tabs / 30 days

AFINITOR TAB 5MG 1,3

30 tabs / 30 days

AFINITOR TAB 10MG 1,3

30 tabs / 30 days

AFINITOR TAB 7.5MG 1,3

30 tabs / 30 days

AFINITOR DIS TAB 2MG 1,3

60 tabs / 30 days

AFINITOR DIS TAB 3MG 1,3

90 tabs / 30 days

AFINITOR DIS TAB 5MG 1,3

60 tabs / 30 days

ALECENSA CAP 150MG 2,3

240 caps / 30 days

ALUNBRIG PAK 2

30 tabs / 180 days

ALUNBRIG TAB 30MG 2

120 tabs / 30 days

ALUNBRIG TAB 90MG 2

30 tabs / 30 days

ALUNBRIG TAB 180MG 2

30 tabs / 30 days

AYVAkit TAB 100MG 2,3

30 tabs / 30 days

AYVAkit TAB 200MG 2,3

30 tabs / 30 days

AYVAkit TAB 300MG 2,3

30 tabs / 30 days

BALVERSA TAB 3MG 2,3

90 tabs / 30 days

BALVERSA TAB 4MG 2,3

60 tabs / 30 days

BALVERSA TAB 5MG 2,3

30 tabs / 30 days

BOSULIF TAB 100MG 1,3

90 tabs / 30 days

BOSULIF TAB 400MG 1,3

30 tabs / 30 days

BOSULIF TAB 500MG 1,3

30 tabs / 30 days

BRAFTOVI CAP 75MG 2

180 caps / 30 days

BRUKINSA CAP 80MG 2

120 caps / 30 days

CABOMETYX TAB 20MG 1,3

30 tabs / 30 days

CABOMETYX TAB 40MG 1,3

30 tabs / 30 days

CABOMETYX TAB 60MG 1,3

30 tabs / 30 days

CALQUENCE CAP 100MG 2

60 caps / 30 days

CAPRELSA TAB 100MG 2

60 tabs / 30 days

CAPRELSA TAB 300MG 2

30 tabs / 30 days

COMETRIQ kit 60MG 2,3

1 carton / 28 days

COMETRIQ kit 100MG 2,3

1 carton / 28 days

COMETRIQ kit 140MG 2,3

112 tabs / 28 days

COPIKTRA CAP 15MG 2,3

56 caps / 28 days

COPIKTRA CAP 25MG 2,3

56 caps / 28 days

COTELLIC TAB 20MG 1

63 tabs / 28 days

DAURISMO TAB 25MG 1,3

60 tabs / 30 days

DAURISMO TAB 100MG 1,3

30 tabs / 30 days

ERIVEDGE CAP 150MG 1,3

30 caps / 30 days

erlotinib tab 25mg 1,3

60 tabs / 30 days

erlotinib tab 100mg 1,3

30 tabs / 30 days

erlotinib tab 150mg 1,3

30 tabs / 30 days

everolimus tab 2.5mg 1,3

30 tabs / 30 days

everolimus tab 5mg 1,3

30 tabs / 30 days

everolimus tab 7.5mg 1,3

30 tabs / 30 days

FARYDAK CAP 10MG 1

6 caps / 21 days

FARYDAK CAP 15MG 1

6 caps / 21 days

FARYDAK CAP 20MG 1

6 caps / 21 days

GAVRETO CAP 100MG 2,3

120 caps / 30 days

GILOTRIF TAB 20MG 2

30 tabs / 30 days

GILOTRIF TAB 30MG 2

30 tabs / 30 days

GILOTRIF TAB 40MG 2

30 tabs / 30 days

GLEEVEC TAB 100MG 1,3

90 tabs / 30 days

GLEEVEC TAB 400MG 1,3

60 tabs / 30 days

IBRANCE CAP 75MG 1

21 caps / 28 days

IBRANCE CAP 100MG 1

21 caps / 28 days

IBRANCE CAP 125MG 1

21 caps / 28 days

IBRANCE TAB 75MG 1

21 tabs / 28 days

IBRANCE TAB 100MG 1

21 tabs / 28 days

IBRANCE TAB 125MG 1

21 tabs / 28 days

ICLUSIG TAB 10MG 2,3

30 tabs / 30 days

ICLUSIG TAB 15MG 2,3

30 tabs / 30 days

ICLUSIG TAB 30MG 2,3

30 tabs / 30 days

ICLUSIG TAB 45MG 2,3

30 tabs / 30 days

IDHIFA TAB 50MG 1

30 tabs / 30 days

IDHIFA TAB 100MG 1

30 tabs / 30 days

imatinib mes tab 100mg 1,3

90 tabs / 30 days

imatinib mes tab 400mg 1,3

60 tabs / 30 days

IMBRUVICA CAP 140MG 2

60 caps / 30 days

IMBRUVICA CAP 70MG 2

30 caps / 30 days

IMBRUVICA TAB 140MG 2

30 tabs / 30 days

IMBRUVICA TAB 280MG 2

30 tabs / 30 days

IMBRUVICA TAB 420MG 2

30 tabs / 30 days

IMBRUVICA TAB 560MG 2

30 tabs / 30 days

INLYTA TAB 1MG 1,3

180 tabs / 30 days

INLYTA TAB 5MG 1,3

120 tabs / 30 days

INQOVI TAB 35-100MG 1

5 tabs / 28 days

INREBIC CAP 100MG 1,3,4

120 caps / 30 days

IRESSA TAB 250MG 2,3

30 tabs / 30 days

JAKAFI TAB 5MG 1,3

60 tabs / 30 days

JAKAFI TAB 10MG 1,3

60 tabs / 30 days

JAKAFI TAB 15MG 1,3

60 tabs / 30 days

JAKAFI TAB 20MG 1,3

60 tabs / 30 days

JAKAFI TAB 25MG 1,3

60 tabs / 30 days

KISQALI TAB 200DOSE 1

63 tabs / 28 days

KISQALI TAB 400DOSE 1

63 tabs / 28 days

KISQALI TAB 600DOSE 1

63 tabs / 28 days

KISQALI 200 PAK FEMARA 1

91 tabs / 28 days

KISQALI 400 PAK FEMARA 1

91 tabs / 28 days

KISQALI 600 PAK FEMARA 1

91 tabs / 28 days

KOSELUGO CAP 10MG 2

240 caps / 30 days

KOSELUGO CAP 25MG 2

120 caps / 30 days

lapatinib tab 250mg 1,4

180 tabs / 30 days

LENVIMA CAP 4MG 2,3

30 caps / 30 days

LENVIMA CAP 8 MG 2,3

60 caps / 30 days

LENVIMA CAP 10 MG 2,3

30 caps / 30 days

LENVIMA CAP 12MG 2,3

90 caps / 30 days

LENVIMA CAP 14 MG 2,3

60 caps / 30 days

LENVIMA CAP 18 MG 2,3

90 caps / 30 days

LENVIMA CAP 20 MG 2,3

60 caps / 30 days

LENVIMA CAP 24 MG 2,3

90 caps / 30 days

LONSURF TAB 15-6.14 1

60 tabs / 28 days

LONSURF TAB 20-8.19 1

80 tabs / 28 days

LORBRENA TAB 25MG 1,3

90 tabs / 30 days

LORBRENA TAB 100MG 1,3

30 tabs / 30 days

LYNPARZA TAB 100MG 2,3

120 tabs / 30 days

LYNPARZA TAB 150MG 2,3

120 tabs / 30 days

MEKINIST TAB 0.5MG 1

90 tabs / 30 days

MEKINIST TAB 2MG 1

30 tabs / 30 days

MEKTOVI TAB 15MG 2

180 tabs / 30 days

NERLYNX TAB 40MG 2,3

180 tabs / 30 days

NEXAVAR TAB 200MG 1,3

120 tabs / 30 days

NINLARO CAP 2.3MG 1

3 caps / 28 days

NINLARO CAP 3MG 1

3 caps / 28 days

NINLARO CAP 4MG 1

3 caps / 28 days

NUBEQA TAB 300MG 1

120 tabs / 30 days

ODOMZO CAP 200MG 1,3

30 caps / 30 days

ONUREG TAB 200MG 1

14 tabs / 28 days

ONUREG TAB 300MG 1

14 tabs / 28 days

ORGOVYX TAB 120MG 2

30 tabs / 30 days

PEMAZYRE TAB 4.5MG 2

14 tabs / 21 days

PEMAZYRE TAB 9MG 2

14 tabs / 21 days

PEMAZYRE TAB 13.5MG 2

14 tabs / 21 days

PIQRAY 200MG TAB DOSE 1

28 tabs / 28 days

PIQRAY 250MG TAB DOSE 1

56 tabs / 28 days

PIQRAY 300MG TAB DOSE 1

56 tabs / 28 days

POMALYST CAP 1MG 1

21 caps / 28 days

POMALYST CAP 2MG 1

21 caps / 28 days

POMALYST CAP 3MG 1

21 caps / 28 days

POMALYST CAP 4MG 1

21 caps / 28 days

QINLOCK TAB 50MG 2

90 tabs / 30 days

RETEVMO CAP 40MG 1,3

180 caps / 30 days

RETEVMO CAP 80MG 1,3

120 caps / 30 days

ROZLYTREK CAP 100MG 1,3,4

30 caps / 30 days

ROZLYTREK CAP 200MG 1,3,4

90 caps / 30 days

RUBRACA TAB 200MG 2,3

120 tabs / 30 days

RUBRACA TAB 250MG 2,3

120 tabs / 30 days

RUBRACA TAB 300MG 2,3

120 tabs / 30 days

RYDAPT CAP 25MG 1

240 caps / 30 days

SPRYCEL TAB 20MG 1,3,4

90 tabs / 30 days

SPRYCEL TAB 50MG 1,3,4

30 tabs / 30 days

SPRYCEL TAB 70MG 1,3,4

30 tabs / 30 days

SPRYCEL TAB 80MG 1,3,4

30 tabs / 30 days

SPRYCEL TAB 100MG 1,3,4

30 tabs / 30 days

SPRYCEL TAB 140MG 1,3,4

30 tabs / 30 days

STIVARGA TAB 40MG 1

84 tabs / 28 days

SUTENT CAP 12.5MG 1,3

90 caps / 30 days

SUTENT CAP 25MG 1,3

30 caps / 30 days

SUTENT CAP 37.5MG 1,3

30 caps / 30 days

SUTENT CAP 50MG 1,3

30 caps / 30 days

TABRECTA TAB 150MG 1

120 tabs / 30 days

TABRECTA TAB 200MG 1

120 tabs / 30 days

TAFINLAR CAP 50MG 1

120 caps / 30 days

TAFINLAR CAP 75MG 1

120 caps / 30 days

TAGRISSO TAB 40MG 2,3

30 tabs / 30 days

TAGRISSO TAB 80MG 2,3

30 tabs / 30 days

TALZENNA CAP 0.25MG 1,3

90 caps / 30 days

TALZENNA CAP 1MG 1,3

30 caps / 30 days

TARCEVA TAB 25MG 1,3

60 tabs / 30 days

TARCEVA TAB 100MG 1,3

30 tabs / 30 days

TARCEVA TAB 150MG 1,3

30 tabs / 30 days

TASIGNA CAP 50MG 1,3,4

120 caps / 30 days

TASIGNA CAP 150MG 1,3,4

120 caps / 30 days

TASIGNA CAP 200MG 1,3,4

120 caps / 30 days

TAZVERIK TAB 200MG 2

240 tabs / 30 days

TIBSOVO TAB 250MG 2

60 tabs / 30 days

TUKYSA TAB 50MG 2

300 tabs / 30 days

TUKYSA TAB 150MG 2

120 tabs / 30 days

TURALIO CAP 200MG 2

120 caps / 30 days

TYKERB TAB 250MG 1,4

/p>

180 tabs / 30 days

VENCLEXTA TAB 10MG 2

60 tabs / 30 days

VENCLEXTA TAB 50MG 2

30 tabs / 30 days

VENCLEXTA TAB 100MG 2

180 tabs / 30 days

VENCLEXTA TAB START PK 2

1 pack / 180 days

VERZENIO TAB 50MG 2,3

60 tabs / 30 days

VERZENIO TAB 100MG 2,3

60 tabs / 30 days

VERZENIO TAB 150MG 2,3

60 tabs / 30 days

VERZENIO TAB 200MG 2,3

60 tabs / 30 days

VITRAKVI CAP 25MG 2,3

180 caps / 30 days

VITRAKVI CAP 100MG 2,3

60 caps / 30 days

VITRAKVI SOL 20MG/mL 2,3

300 mLs / 30 days

VIZIMPRO TAB 15MG 1,3

30 tabs / 30 days

VIZIMPRO TAB 30MG 1,3

30 tabs / 30 days

VIZIMPRO TAB 45MG 1,3

30 tabs / 30 days

VOTRIENT TAB 200MG 1,3

120 tabs / 30 days

XALKORI CAP 200MG 1,3

120 caps / 30 days

XALKORI CAP 250MG 1,3

120 caps / 30 days

XOSPATA TAB 40MG 2

90 tabs / 30 days

XPOVIO PAK 40MG 2,3

1 box / 28 days

XPOVIO PAK 50MG 2,3

1 box / 28 days

XPOVIO PAK 60MG 2,3

1 box / 28 days

XPOVIO PAK 80MG 2,3

1 box / 28 days

XPOVIO PAK 100MG 2,3

1 box / 28 days

XTANDI CAP 40MG 1,3

120 caps / 30 days

XTANDI TAB 40MG 1,3

90 tabs / 30 days

XTANDI TAB 80MG 1,3

60 tabs / 30 days

ZEJULA CAP 100MG 2,3

90 caps / 30 days

ZELBORAF TAB 240MG 1

240 tabs / 30 days

ZOLINZA CAP 100MG 1,3

120 caps / 30 days

ZYDELIG TAB 100MG 2

60 tabs / 30 days

ZYDELIG TAB 150MG 2

60 tabs / 30 days

ZYKADIA CAP 150MG 1,3

90 caps / 30 days

ZYKADIA TAB 150MG 1,3

90 tabs / 30 days

ZYTIGA TAB 250MG 1,3

120 tabs / 30 days

ZYTIGA TAB 500MG 1,3

60 tabs / 30 days

Antipsychotics / antimanic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

LATUDA TAB 20MG

30 tabs / 30 days

LATUDA TAB 40MG

30 tabs / 30 days

LATUDA TAB 60MG

30 tabs / 30 days

LATUDA TAB 80MG

60 tabs / 30 days

LATUDA TAB 120MG

30 tabs / 30 days

NUPLAZID TAB 10MG 1

30 tabs / 30 days

NUPLAZID CAP 34MG 1

30 caps / 30 days

olanzapine tab 2.5mg

30 tabs / 30 days

olanzapine tab 5mg

30 tabs / 30 days

olanzapine tab 5mg odt

30 tabs / 30 days

olanzapine tab 7.5mg

30 tabs / 30 days

olanzapine tab 10mg

30 tabs / 30 days

olanzapine tab 10mg odt

30 tabs / 30 days

olanzapine tab 15mg

30 tabs / 30 days

olanzapine tab 15mg odt

30 tabs / 30 days

olanzapine tab 20mg

30 tabs / 30 days

olanzapine tab 20mg odt

30 tabs / 30 days

paliperidone tab er 1.5mg

60 tabs / 30 days

paliperidone tab er 3mg

60 tabs / 30 days

paliperidone tab er 6mg

60 tabs / 30 days

paliperidone tab er 9mg

60 tabs / 30 days

quetiapine tab 50mg er

60 tabs / 30 days

quetiapine tab 150mg er

60 tabs / 30 days

quetiapine tab 200mg er

60 tabs / 30 days

quetiapine tab 300mg er

60 tabs / 30 days

quetiapine tab 400mg er

60 tabs / 30 days

VRAYLAR CAP 1.5-3MG

1 pack / 180 days

VRAYLAR CAP 1.5MG

30 caps / 30 days

VRAYLAR CAP 3MG

30 caps / 30 days

VRAYLAR CAP 4.5MG

30 caps / 30 days

VRAYLAR CAP 6MG

30 caps / 30 days

Antivirals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

EPCLUSA TAB 200-50MG 1

28 tabs / 28 days

EPCLUSA TAB 400-100 1

30 tabs / 30 days

HARVONI PAK 1,4

28 packets / 28 days

HARVONI PAK 45-200MG 1,4

28 packets / 28 days

HARVONI TAB 45-200MG 1,4

28 tabs / 28 days

HARVONI TAB 90-400MG 1,4

30 tabs / 30 days

LEDIP-SOFOSB TAB 90-400MG 1

30 tabs / 30 days

MAVYRET TAB 100-40MG 1,4

90 tabs / 30 days

oseltamivir cap 30mg

40 caps / 120 days

oseltamivir cap 45mg

20 caps / 120 days

oseltamivir cap 75mg

20 caps / 120 days

oseltamivir sus 6mg/mL

300 mLs / 120 days

SOFOS / VELPAT TAB 400-100 1

30 tabs / 30 days

SOVALDI PAK 150MG 1

28 packets / 28 days

SOVALDI PAK 200MG 1

28 packets / 28 days

SOVALDI TAB 200MG 1

30 tabs / 30 days

SOVALDI TAB 400MG 1

30 tabs / 30 days

VOSEVI TAB 1

30 tabs / 30 days

Cardiovascular agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ADCIRCA TAB 20MG 1

60 tabs / 30 days

ADEMPAS TAB 0.5MG 2

90 tabs / 30 days

ADEMPAS TAB 1.5MG 2

90 tabs / 30 days

ADEMPAS TAB 1MG 2

90 tabs / 30 days

ADEMPAS TAB 2MG 2

90 tabs / 30 days

ADEMPAS TAB 2.5MG 2

90 tabs / 30 days

alyq tab 20mg 1

60 tabs / 30 days

ambrisentan tab 5mg 1

30 tabs / 30 days

ambrisentan tab 10mg 1

30 tabs / 30 days

bosentan tab 125mg 1

60 tabs / 30 days

bosentan tab 62.5mg 1

60 tabs / 30 days

CORLANOR SOL 5MG/5mL

600 mLs / 30 days

CORLANOR TAB 5MG

60 tabs / 30 days

CORLANOR TAB 7.5MG

60 tabs / 30 days

REVATIO SUS 10MG/mL 1

2 bottles / 30 days

sildenafil sus 10mg/mL 1

2 bottles / 30 days

sildenafil tab 20mg 1

90 tabs / 30 days

tadalafil tab 20mg 1

60 tabs / 30 days

UPTRAVI TAB 1000MCG 2

60 tabs / 30 days

UPTRAVI TAB 1200MCG 2

60 tabs / 30 days

UPTRAVI TAB 1400MCG 2

60 tabs / 30 days

UPTRAVI TAB 1600MCG 2

60 tabs / 30 days

UPTRAVI TAB 200/800 2

1 package / 180 days

UPTRAVI TAB 200MCG 2

60 tabs / 30 days

UPTRAVI TAB 200MCG 2

140 tabs / 180 days

UPTRAVI TAB 400MCG 2

60 tabs / 30 days

UPTRAVI TAB 600MCG 2

60 tabs / 30 days

UPTRAVI TAB 800MCG 2

60 tabs / 30 days

Dermatologicals

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ala scalp lot 2%

118.4 mLs / 30 days

ala-cort cre 1%

454 grams / 30 days

ala-cort cre 2.5%

454 grams / 30 days

ALA-SCALP LOT 2%

118.4 mLs / 30 days

alclometasone cream 0.05%

120 grams / 30 days

alclometasone oinment 0.05%

120 grams / 30 days

AMCINONIDE OINMENT 0.1%

120 grams / 30 days

aug betamet cream 0.05%

200 grams / 28 days

aug betamet lot 0.05%

210 mLs / 30 days

aug betamet oinment 0.05%

200 grams / 28 days

beser lot 0.05%

120 mLs / 30 days

betameth dip cream 0.05%

135 grams / 30 days

betameth dip lot 0.05%

120 mLs / 30 days

betameth dip oinment 0.05%

135 grams / 30 days

betameth val aer 0.12%

150 grams / 30 days

betameth val cream 0.1%

135 grams / 30 days

betameth val lot 0.1%

120 mLs / 30 days

betameth val oinment 0.1%

135 grams / 30 days

CAPEX SHA 0.01%

840 mLs / 28 days

ciclodan sol 8%

3.3 mLs / 30 days

ciclopirox sol 8%

3.3 mLs / 30 days

clobetasol aer 0.05%

200 grams / 28 days

clobetasol cream 0.05%

210 grams / 28 days

clobetasol gel 0.05%

210 grams / 28 days

clobetasol lot 0.05%

177 mLs / 28 days

clobetasol oinment 0.05%

210 grams / 28 days

clobetasol sha 0.05%

236 mLs / 30 days

clobetasol sol 0.05%

200 mLs / 28 days

clobetasol spr 0.05%

236 mLs / 28 days

clobetasol e cream 0.05%

210 grams / 28 days

clodan sha 0.05%

236 mLs / 30 days

COSENTYX INJ 150MG/mL 1

1 syringe / 28 days

COSENTYX INJ 300DOSE 1

1 pack / 28 days

COSENTYX pen INJ 150MG/mL 1

1 injection / 28 days

COSENTYX pen INJ 300DOSE 1

1 pack / 28 days

desonide cream 0.05%

120 grams / 30 days

desonide gel 0.05%

120 grams / 30 days

desonide lot 0.05%

118 mLs / 30 days

desonide oinment 0.05%

120 grams / 30 days

desoximetasone cream 0.05%

120 grams / 30 days

desoximetasone cream 0.25%

120 grams / 30 days

desoximetasone gel 0.05%

120 grams / 30 days

desoximetasone oinment 0.05%

120 grams / 30 days

desoximetasone oinment 0.25%

120 grams / 30 days

desoximetaso spr 0.25%

100 mLs / 30 days

desrx gel 0.05%

120 grams / 30 days

diclofenac sol 1.5%

2 bottles / 30 days

diflorasone oinment 0.05%

120 grams / 30 days

fluocinolone acetonide cream 0.01%

120 grams / 30 days

fluocinolone acetonide cream 0.025%

120 grams / 30 days

fluocinolone acetonide oil 0.01% sc

118.28 mLs / 30 days

fluocinolone acetonide oil 0.01%bdy

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 oinment 0.025%

120 grams / 30 days

fluocinolone acetonide sol 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 oinment 0.05%

120 grams / 30 days

fluocinonide sol 0.05%

120 mLs / 30 days

fluorouracil cream 5%

240 grams / 90 days

flurandrenol cream 0.05%

120 grams / 30 days

flurandrenol lot 0.05%

120 mLs / 30 days

flurandrenol oinment 0.05%

120 grams / 30 days

fluticasone cream 0.05%

120 grams / 30 days

fluticasone lot 0.05%

120 mLs / 30 days

fluticasone oinment 0.005%

120 grams / 30 days

glydo gel 2%

150 mLs / 30 days

halcinonide cream 0.1%

240 grams / 30 days

halobetasol cream 0.05%

200 grams / 28 days

halobetasol oinment 0.05%

200 grams / 28 days

HC BUTYRATE CRE 0.1%

135 grams / 30 days

hc butyrate cream 0.1%

120 grams / 30 days

hc butyrate oinment 0.1%

135 grams / 30 days

HC BUTYRATE SOL 0.1%

120 mLs / 30 days

hc valerate cream 0.2%

120 grams / 30 days

hc valerate oinment 0.2%

120 grams / 30 days

hydrocortisone cream 1%

454 grams / 30 days

hydrocortisone cream 2.5%

454 grams / 30 days

hydrocortisone lot 2.5%

118 mLs / 30 days

hydrocortisone oinment 2.5%

454 grams / 30 days

hydrocortisone lot 0.1%

118 mLs / 30 days

imiquimod cream 5%

48 packets / 60 days

Lidocaine/prilocaine cream 2.5-2.5%

60 grams / 30 days

lidocaine gel 2%

150 mLs / 30 days

lidocaine gel 2% jelly

150 mLs / 30 days

lidocaine oinment 5%

100 grams / 30 days

lidocaine oinment pak 5%

100 grams / 30 days

lidocaine pad 5%

90 patches / 30 days

lidocaine sol 4%

150 mLs / 30 days

mometasone cream 0.1%

135 grams / 30 days

mometasone oinment 0.1%

135 grams / 30 days

mometasone sol 0.1%

120 mLs / 30 days

nolix cream 0.05%

120 grams / 30 days

nolix lot 0.05%

120 mLs / 30 days

REGRANEX GEL 0.01%

1 tube / 30 days

SKYRIZI INJ 150DOSE 1

1 box / 84 days

SKYRIZI INJ 150MG/mL

1 syringe / 84 days

SKYRIZI pen INJ 150MG/mL

1 injection / 84 days

STELARA INJ 45MG/0.5 1

1 syringe / 84 days

STELARA INJ 90MG/mL 1

1 syringe / 56 days

tavaborole sol 5%

4 mLs / 30 days

tovet aer 0.05%

200 grams / 28 days

TREMFYA INJ 100MG/mL 1

1 syringe / 56 days

TREMFYA INJ 100MG/mL 1

1 pen / 56 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 lot 0.025%

120 mLs / 30 days

triamcinolone lot 0.1%

120 mLs / 30 days

triamcinolone oinment 0.025%

454 grams / 30 days

triamcinolone oinment 0.05%

430 grams / 30 days

triamcinolone oinment 0.1%

454 grams / 30 days

triamcinolone oinment 0.5%

120 grams / 30 days

trianex oinment 0.05%

430 grams / 30 days

triderm cream 0.1%

454 grams / 30 days

triderm cream 0.5%

454 grams / 30 days

tritocin oinment 0.05%

430 grams / 30 days

Digestive aids

Drug name(s)

Quantity limits 
(per 30 days or as specified)

SUCRAID SOL 8500/mL

236 mLs / 28 days

Endocrine and metabolic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

alendronate tab 35mg

4 tabs / 28 days

alendronate tab 70mg

4 caps / 28 days

CETROTIDE kit 0.25MG 1,4

5 kits / 30 days

EGRIFTA SOL 1MG 1

60 vials / 30 days

EGRIFTA SV INJ 2MG 1

30 vials / 30 days

FOLLISTIM AQ INJ 300UNIT 1,4

15 carts / 30 days

FOLLISTIM AQ INJ 600UNIT 1,4

8 carts / 30 days

FOLLISTIM AQ INJ 900UNIT 1,4

5 carts / 30 days

FORTEO INJ 620/2.48 1,4

1 pen / 28 days

FOSAMAX + D TAB 70-2800

4 caps / 28 days

FOSAMAX + D TAB 70-5600

4 caps / 28 days

GANIRELIX AC INJ 250/0.5 1,4

5 syringes / 30 days

ibandronate tab 150mg

1 tab / 28 days

risedronate tab 35mg

4 tabs / 28 days

risedronate sodium tab 35mg dr

4 tabs / 28 days

risedronate tab 150mg

1 tab / 28 days

SIGNIFOR INJ 0.3MG/mL 2

60 mLs / 30 days

SIGNIFOR INJ 0.6MG/mL 2

60 mLs / 30 days

SIGNIFOR INJ 0.9MG/mL 2

60 mLs / 30 days

SOMAVERT INJ 10MG 1

30 vials / 30 days

SOMAVERT INJ 15MG 1

30 vials / 30 days

SOMAVERT INJ 20MG 1

30 vials / 30 days

SOMAVERT INJ 25MG 1

30 vials / 30 days

SOMAVERT INJ 30MG 1

30 vials / 30 days

tolvaptan tab 30mg 1

60 tabs / 365 days

TYmLOS INJ 1

1 pen / 30 days

Estrogens

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ORIAHNN CAP

56 caps / 28 days

Gastrointestinal agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

alosetron tab 0.5mg

60 tabs / 30 days

alosetron tab 1mg

60 tabs / 30 days

LINZESS CAP 72MCG

30 caps / 30 days

LINZESS CAP 145MCG

30 caps / 30 days

LINZESS CAP 290MCG

30 caps / 30 days

MOVANTIK TAB 12.5MG

30 tabs / 30 days

MOVANTIK TAB 25MG

30 tabs / 30 days

ZELNORM TAB 6MG

60 tabs / 30 days

Hematologial agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FIRAZYR INJ 30MG/3mL 1

6 syringes / 30 days

icatibant inj 30mg/3mL 1

6 syringes / 30 days

Hematopoietic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CERDELGA CAP 84MG 1

60 caps / 30 days

miglustat cap 100mg 1

90 caps / 30 days

PROMACTA PAK 25MG 1

30 packs / 30 days

PROMACTA POW 12.5MG 1

30 packets / 30 days

PROMACTA TAB 12.5MG 1

30 tabs / 30 days

PROMACTA TAB 25MG 1

30 tabs / 30 days

PROMACTA TAB 50MG 1

60 tabs / 30 days

PROMACTA TAB 75MG 1

60 tabs / 30 days

ZAVESCA CAP 100MG 2

90 caps / 30 days

Hypnotics/sedatives/sleep disorder agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ROZEREM TAB 8MG

30 tabs / 30 days

doxepin tab 3mg

30 tabs / 30 days

doxepin tab 6mg

30 tabs / 30 days

eszopiclone tab 1mg

30 tabs / 30 days

eszopiclone tab 2mg

30 tabs / 30 days

eszopiclone tab 3mg

30 tabs / 30 days

ramelteon tab 8mg

30 tabs / 30 days

zaleplon cap 5mg

30 caps / 30 days

zaleplon cap 10mg

30 caps / 30 days

zolpidem tab 5mg

30 tabs / 30 days

zolpidem tab 10mg

30 tabs / 30 days

zolpidem tar sub 1.75mg

30 tabs / 30 days

zolpidem tar sub 3.5mg

30 tabs / 30 days

zolpidem er tab 6.25mg

30 tabs / 30 days

zolpidem er tab 12.5mg

30 tabs / 30 days

Migraine products

Drug name(s)

Quantity limits 
(per 30 days or as specified)

almotriptan tab 6.25mg

24 tabs / 30 days

almotriptan tab 12.5mg

12 tabs / 30 days

almotriptan mal tab 6.25mg

24 tabs / 30 days

almotriptan mal tab 12.5mg

12 tabs / 30 days

eletriptan tab 20mg

18 tabs / 30 days

eletriptan tab 40mg

12 tabs / 30 days

frovatriptan tab 2.5mg

27 tabs / 30 days

naratriptan tab 1mg

18 tabs / 30 days

naratriptan tab 2.5mg

18 tabs / 30 days

rizatriptan tab 5mg

36 tabs / 30 days

rizatriptan tab 5mg odt

36 tabs / 30 days

rizatriptan tab 10mg

18 tabs / 30 days

rizatriptan tab 10mg odt

18 tabs / 30 days

sumatriptan-naproxen tab 85-500mg

18 tabs / 30 days

sumatriptan inj 4mg/0.5

12 carts / 30 days

sumatriptan inj 4mg/0.5

12 syringes / 30 days

sumatriptan inj 6mg/0.5

12 carts / 30 days

sumatriptan inj 6mg/0.5

12 syringes / 30 days

sumatriptan spr 20mg/act

12 inhalers / 30 days

sumatriptan spr 5mg/act

5 packs / 30 days

sumatriptan tab 25mg

27 tabs / 30 days

sumatriptan tab 50mg

18 tabs / 30 days

sumatriptan tab 100mg

18 tabs / 30 days

zolmitriptan tab 2.5 mg

18 tabs / 30 days

zolmitriptan tab 5mg

12 tabs / 30 days

zolmitriptan tab 5mg odt

12 tabs / 30 days

Miscellaneous therapeutic classes

Drug name(s)

Quantity limits 
(per 30 days or as specified)

REVLIMID CAP 2.5MG 1

30 caps / 30 days

REVLIMID CAP 5MG 1

30 caps / 30 days

REVLIMID CAP 10MG 1

30 caps / 30 days

REVLIMID CAP 15MG 1

21 caps / 28 days

REVLIMID CAP 20MG 1

21 caps / 28 days

REVLIMID CAP 25MG 1

21 caps / 28 days

THALOMID CAP 50MG 1

30 caps / 30 days

THALOMID CAP 100MG 1

30 caps / 30 days

THALOMID CAP 150MG 1

60 caps / 30 days

THALOMID CAP 200MG 1

60 caps / 30 days

ZOKINVY CAP 50MG 2

120 caps / 30 days

ZOKINVY CAP 75MG 2

120 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

baclofen tab 5mg

120 tabs / 30 days

baclofen tab 10mg

120 tabs / 30 days

baclofen tab 20mg

120 tabs / 30 days

carisoprodol/aspirin tab 200-325

168 tabs / 90 days

carisoprodol tab 250mg

84 tabs / 90 days

carisoprodol tab 350mg

84 tabs / 90 days

carisoprodol tab asa/cod

168 tabs / 90 days

chlorzoxazone tab 375mg

84 tabs / 90 days

chlorzoxazone tab 500mg

84 tabs / 90 days

chlorzoxazone tab 750mg

84 tabs / 90 days

cyclobenzaprine tab 5mg

63 tabs / 90 days

cyclobenzaprine tab 7.5mg

63 tabs / 90 days

cyclobenzaprine tab 10mg

63 tabs / 90 days

cyclobenzaprine cap 15mg er

21 caps / 90 days

cyclobenzaprine cap 30mg er

21 caps / 90 days

dantrolene cap 25mg

90 caps / 30 days

dantrolene cap 50mg

90 caps / 30 days

dantrolene cap 100mg

90 caps / 30 days

lorzone tab 375mg

84 tabs / 90 days

lorzone tab 750mg

84 tabs / 90 days

metaxall tab 800mg

84 tabs / 90 days

metaxalone tab 400mg

168 tabs / 90 days

metaxalone tab 800mg

84 tabs / 90 days

methocarbamol tab 500mg

180 tabs / 90 days

methocarbamol tab 750mg

132 tabs / 90 days

orphenadrine tab 100mg cr

42 tabs / 30 days

orphenadrine tab 100mg er

42 tabs / 30 days

tizanidine cap 2mg

126 caps / 90 days

tizanidine cap 4mg

126 caps / 90 days

tizanidine cap 6mg

126 caps / 90 days

tizanidine tab 2mg

126 tabs / 90 days

tizanidine tab 4mg

42 caps / 30 days

vanadom tab 350mg

84 tabs / 90 days

Nasal agents – systemic and topical

Drug name(s)

Quantity limits 
(per 30 days or as specified)

azelastine / fluticasone spr 137-50

1 bottle / 30 days

azelastine spr 0.1%

2 bottles / 30 days

azelastine spr 0.15%

2 bottles / 30 days

ipratropium spr 0.03%

2 bottles / 30 days

ipratropium spr 0.06%

3 bottles / 30 days

mometasone spr 50mcg

2 bottles / 30 days

olopatadine spr 0.6%

1 bottle / 30 days

Ophthalmic agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

bimatoprost sol 0.03%

2.5 mLs / 30 days

latanoprost sol 0.005%

2.5 mLs / 30 days

LUMIGAN SOL 0.01%

2.5 mLs / 30 days

RESTASIS EMU 0.05%

2 vials / 30 days

RESTASIS MUL EMU 0.05%

1 bottle / 30 days

TRAVATAN Z DRO 0.004%

2.5 mLs / 30 days

travoprost drops 0.004%

2.5 mLs / 30 days

ZIOPTAN DRO 0.0015%

30 cartons / 30 days

Psychotehrapeutic and neurological agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

AMPYRA TAB 10MG 1,3

60 tabs / 30 days

AUBAGIO TAB 7MG 1,3

30 tabs / 30 days

AUBAGIO TAB 14MG 1,3

30 tabs / 30 days

AVONEX pen kit 30MCG 1,4

1 kit / 28 days

AVONEX PREFL kit 30MCG 1,4

1 kit / 28 days

BETASERON INJ 0.3MG 1,4

1 box / 28 days

dalfampridine tab 10mg er 1,3

60 tabs / 30 days

dimethyl fumarate cap 120mg dr 1

56 caps / 180 days

dimethyl fumarate cap 240mg dr 1

60 caps / 30 days

dimethyl fumarate mis starter 1

60 caps / 180 days

GILENYA CAP 0.5MG 1

30 tabs / 30 days

glatiramer inj 20mg/mL 1,4

30 syringes / 30 days

glatiramer inj 40mg/mL 1,4

12 syringes / 28 days

glatopa inj 20mg/mL 1

30 syringes / 30 days

glatopa inj 40mg/mL 1

12 syringes / 28 days

INGREZZA CAP 40-80MG 2

28 caps / 180 days

INGREZZA CAP 40MG 2

30 caps / 30 days

INGREZZA CAP 60MG

30 caps / 30 days

INGREZZA CAP 80MG 2

30 caps / 30 days

KESIMPTA INJ 20/.4mL 1,4

1 syringe / 28 days

MAVENCLAD PAK 10MG(10) 1

20 tabs / 301 days

MAVENCLAD PAK 10MG(4) 1

8 tabs / 301 days

MAVENCLAD PAK 10MG(5) 1

10 tabs / 301 days

MAVENCLAD PAK 10MG(6) 1

12 tabs / 301 days

MAVENCLAD PAK 10MG(7) 1

14 tabs / 301 days

MAVENCLAD PAK 10MG(8) 1

8 tabs / 301 days

MAVENCLAD PAK 10MG(9) 1

9 tabs / 301 days

MAYZENT PAK STARTER

12 tabs / 180 days

MAYZENT TAB 0.25MG 1

120 tabs / 30 days

MAYZENT TAB 2MG 1

30 tabs / 30 days

PLEGRIDY INJ 1

2 syringes / 28 days

PLEGRIDY INJ pen 1

2 pens / 28 days

PLEGRIDY INJ STARTER 1

1 kit / 180 days

PLEGRIDY pen INJ STARTER 1

1 kit / 180 days

pregabaln er tab 82.5mg

30 tabs / 30 days

pregabaln er tab 165mg

30 tabs / 30 days

pregabaln er tab 330mg

60 tabs / 30 days

REBIF INJ 22/0.5 1,4

12 syringes / 28 days

REBIF INJ 44/0.5 1,4

1 carton / 28 days

REBIF REBIDO INJ 22/0.5 1,4

1 carton / 28 days

REBIF REBIDO INJ 44/0.5 1,4

1 carton / 28 days

REBIF REBIDO INJ TITRATN 1,4

1 kit / 180 days

REBIF TITRTN INJ pack 1,4

1 kit / 180 days

SAVELLA MIS TITR PAK

1 kit / 180 days

SAVELLA TAB 12.5MG

60 tabs / 30 days

SAVELLA TAB 25MG

60 tabs / 30 days

SAVELLA TAB 50MG

60 tabs / 30 days

SAVELLA TAB 100MG

60 tabs / 30 days

tetrabenazin tab 12.5mg 1

240 tabs / 30 days

tetrabenazin tab 25mg 1

120 tabs / 30 days

ZEPOSIA CAP .92MG 1

30 caps / 30 days

ZEPOSIA CAP STR kit 1

37 caps / 180 days

ZEPOSIA 7DAY CAP STR pack 1

7 caps / 180 days

Respiratory agents

Drug name(s)

Quantity limits 
(per 30 days or as specified)

ESBRIET CAP 267MG 1

180 caps / 30 days

ESBRIET TAB 267MG 1

180 tabs / 30 days

ESBRIET TAB 801MG 1

90 tabs / 30 days

KALYDECO PAK 25MG 1

60 packets / 30 days

KALYDECO PAK 50MG 1

60 packets / 30 days

KALYDECO PAK 75MG 1

60 packets / 30 days

KALYDECO TAB 150MG 1

60 tabs / 30 days

OFEV CAP 100MG 1,3

60 caps / 30 days

OFEV CAP 150MG 1,3

60 caps / 30 days

ORKAMBI TAB 100-125 1

120 tabs / 30 days

ORKAMBI TAB 200-125 1

120 tabs / 30 days

Ulcer drugs/antispasmodics/anticholinergics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

DEXILANT CAP 30MG DR

30 caps / 30 days

DEXILANT CAP 60MG DR

30 caps / 30 days

esomeprazole mag cap 40mg dr

30 caps / 30 days

lansoprazole cap 15mg dr

30 caps / 30 days

lansoprazole cap 30mg dr

30 caps / 30 days

omeppi cap 20-1100

30 caps / 30 days

omeppi cap 40-1100

30 caps / 30 days

omepra/bicar cap 20-1100

30 caps / 30 days

omepra/bicar cap 40-1100

30 caps / 30 days

omepra/bicar pow 20-1680

30 packets / 30 days

omepra/bicar pow 40-1680

30 packets / 30 days

omeprazole cap 10mg

30 caps / 30 days

omeprazole cap 20mg

30 caps / 30 days

omeprazole cap 40mg

30 caps / 30 days

pantoprazole tab 20mg

30 tabs / 30 days

pantoprazole tab 20mg dr

30 tabs / 30 days

pantoprazole tab 40mg

30 tabs / 30 days

pantoprazole tab 40mg dr

30 tabs / 30 days

rabeprazole tab 20mg

30 tabs / 30 days

Urinary antispasmodics

Drug name(s)

Quantity limits 
(per 30 days or as specified)

darifenacin tab 7.5mg

30 tabs / 30 days

darifenacin tab 15mg

30 tabs / 30 days

GELNIQUE GEL 10%

30 packets / 30 days

GELNIQUE GEL 10% pump

30 packets / 30 days

oxybutynin syp 5mg/5mL

600 mLs / 30 days

oxybutynin tab 5mg

120 tabs / 30 days

oxybutynin tab 5mg er

30 tabs / 30 days

oxybutynin tab 10mg er

60 tabs / 30 days

oxybutynin tab 15mg er

60 tabs / 30 days

solifenacin tab 5mg

30 tabs / 30 days

solifenacin tab 10mg

30 tabs / 30 days

tolterodine cap 2mg er

30 caps / 30 days

tolterodine cap 4mg er

30 caps / 30 days

tolterodine tab 1mg

60 tabs / 30 days

tolterodine tab 2mg

60 tabs / 30 days

trospium chl cap 60mg er

30 caps / 30 days

trospium cl tab 20mg

60 tabs / 30 days

VESICARE TAB 5MG

30 tabs / 30 days

VESICARE TAB 10MG

30 tabs / 30 days

Vasopressors

Drug name(s)

Quantity limits 
(per 30 days or as specified)

droxidopa cap 100mg 1

450 caps / 30 days

droxidopa cap 200mg 1

180 caps / 30 days

droxidopa cap 300mg 1

180 caps / 30 days

Drug name(s)

abiraterone acetate 1,3

ACTEMRA 1

ACTEMRA ACTPEN 1

ADCIRCA 1

ADEMPAS 2

ADVATE 1

AFINITOR 1,3

AFINITOR DISPERZ 1,3

AFSTYLA 1

alyq 1

ambrisentan 1

AMPYRA 1,3

AUBAGIO 1,3

AVONEX 1

AVONEX PEN 1

BETASERON 1

bexarotene 1,3

bosentan 1

capecitabine 1

CERDELGA 1

CETROTIDE 1

cinacalcet hcl 1

COSENTYX 1

COSENTYX SENSOREADY PEN 1

COTELLIC 1

dalfampridine er 1,3

dimethyl fumarate dr 1

dimethyl fumarate starter pack 1

droxidopa 1

EGRIFTA 1

EGRIFTA SV 1

ELOCTATE 1

ENBREL 1

ENBREL MINI 1

ENBREL SURECLICK 1

EPCLUSA 1

ERIVEDGE 1,3

erlotinib tab 1,3

ESBRIET 1

ESPEROCT 1

everolimus 1,3

FIRAZYR 1

FOLLISTIM AQ 1

FORTEO 1

GANIRELIX AC INJ 1

GILENYA 1

glatiramer acetate 1

glatopa 1

HARVONI 1

HUMIRA 1

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 1

HUMIRA PEN 1

HUMIRA PEN-CD/UC/HS STARTER 1

HUMIRA PEN-PEDIATRIC UC STARTER PACK 1

HUMIRA PEN-PS/UV STARTER 1

HYCAMTIN 1

IBRANCE 1

icatibant acetate 1

imatinib mesylate 1,3

INLYTA 1,3

INTRON A 1

IRESSA 2,3

JAKAFI 1,3

JIVI 1

KALYDECO 1

KESIMPTA 1

KISQALI 1

KISQALI FEMARA 1

KOGENATE FS 1

KORLYM 2

KOVALTRY 1

KUVAN 1

lapatinib ditosylate 1

LEDIPASVIR/SOFOSBUVIR 1

LONSURF 1

MATULANE 1

MAVENCLAD 1

MAVYRET 1

MAYZENT 1

MEKINIST 1

miglustat 1

NEULASTA 1

NEULASTA ONPRO KIT 1

NEXAVAR 1,3

NINLARO 1

NORDITROPIN FLEXPRO 1

NOVOEIGHT 1

NUPLAZID 1

ODOMZO 1,3

OFEV 1,3

ORKAMBI 1

OTEZLA 1

PLEGRIDY 1

PLEGRIDY STARTER PACK 1

PROMACTA 1

REBIF 1

REBIF REBIDOSE 1

REBIF REBIDOSE TITRATION PACK 1

REBIF TITRATION PACK 1

RETEVMO 1,3

REVATIO 1

REVLIMID 1

RINVOQ 1

sapropterin dihydrochloride 1

SENSIPAR 1

sildenafil citrate 1

SIMPONI 1

SKYRIZI INJ 1

sodium phenylbutyrate 1

SOFOSBUVIR/VELPATASVIR 1

SOMAVERT 1

SOVALDI 1

SPRYCEL 1,3

STELARA 1

STIMATE 1

STIVARGA 1

SUTENT 1,3

TABRECTA 1

tadalafil 1

TAFINLAR 1

TALZENNA 1,3

TARCEVA 1,3

TARGRETIN 1

TARGRETIN 1,3

TASIGNA 1,3

temozolomide 1

tetrabenazine 1

THALOMID 1

TOBRAMYCIN NEB 1

tobramycin neb 1

TOLVAPTAN 1

tolvaptan 1

TREMFYA 1

TYMLOS 1

VIZIMPRO 1,3

VOSEVI 1

VOTRIENT 1,3

XALKORI 1,3

XELJANZ 1

XELJANZ XR 1

XTANDI 1,3

ZELBORAF 1

ZEPOSIA 1

ZEPOSIA 7-DAY STARTER PACK 1

ZEPOSIA STARTER KIT 1

ZOLINZA 1,3

ZYDELIG 2

ZYKADIA 1,3

ZYTIGA 1,3

     

1Specialty

2Limited Distribution

3Split Fill

4Indicates exclusive to Alliance Rx Walgreens Prime preferred specialty