Value Plus prescription drug benefits

Effective January 1, 2022

Learn how to use your Rx benefits, including lists of drugs with certain requirements for coverage. See the Value Plus formulary for the full list of drugs covered under your plan.

Key:

UPPERCASE names = Brand

lowercase names = Generic

Guide to prescription drug benefits

Your prescription drug coverage is one of the most important parts of your health plan.

Use this guide to understand how your benefits work.

Drug name(s)
abiraterone acetate (ZYTIGA)^3,⁵	abiraterone acetate (ZYTIGA)^1,^3,⁵	ACTEMRA¹
ACTEMRA ACTPEN¹	ADCIRCA¹	ADEMPAS²
ADVATE¹	AFINITOR^1,³	AFINITOR DISPERZ^1,³
AFSTYLA¹	ALECENSA^2,³	alosetron hcl
ALUNBRIG²	alyq¹	ambrisentan¹
AMPYRA^1,³	ANDRODERM	ARCALYST²
AUBAGIO^1,³	avita	AVONEX¹
AVONEX PEN¹	benzphetamine hcl	BETASERON¹
bexarotene^1,³	bosentan¹	buprenorphine
capecitabine¹	CAPRELSA²	CARBAGLU²
CERDELGA¹	CETROTIDE¹	ciclodan
ciclopirox nail lacquer	cinacalcet (SENSIPAR) tab 30mg^1,⁵	cinacalcet (SENSIPAR)tab 30mg⁵
cinacalcet (SENSIPAR) tab 90mg ⁵	cinacalcet (SENSIPAR) tab 90mg^1,⁵	cinacalcet (SENSIPAR) tab 60mg⁵
cinacalcet (SENSIPAR) tab 60mg^1,⁵	ciprofloxacin/dexamethasone	clomipramine hcl
COMETRIQ^1,^2,³	CORLANOR	COSENTYX¹
COSENTYX SENSOREADY PEN¹	COTELLIC¹	cyclobenzaprine hcl er
dalfampridine er^1,³	deferasirox^1,³	diclofenac sodium
diethylpropion hcl	dihydroergotamine mesylate	dimethyl fumarate¹
dimethyl fumarate starterpack¹	doxylamine succinate/pyridoxine hcl	droxidopa cap 200mg ⁵
droxidopa cap 100mg ^1,⁵	droxidopa cap 200mg^1,⁵	droxidopa cap 300mg ⁵
droxidopa cap 100mg⁵	droxidopa cap 300mg^1,⁵	DUPIXENT¹
DUPIXENT	EGRIFTA¹	EGRIFTA SV¹
ELOCTATE¹	EMPAVELI	ENBREL¹
ENBREL MINI¹	ENBREL SURECLICK¹	EPCLUSA¹
ERIVEDGE^1,³	erlotinib hcl^1,³	ESBRIET¹
ESPEROCT¹	everolimus (ZORTRESS) tab 10mg^3,⁵	everolimus (AFINITOR) tab 5mg^1,^3,⁵
everolimus tab 2mg^3,⁵	everolimus (AFINITOR) tab 7.5mg^1,^3,⁵	everolimus tab 7.5mg^3,⁵
everolimus tab 3mg^3,⁵	everolimus (AFINITOR) tab 2.5mg^1,^3,⁵	everolimus tab 5mg^3,⁵
everolimus tab 2.5mg^3,⁵	EXJADE^1,³	FANAPT
FANAPT TITRATION PACK	fenofibrate	fenofibric acid dr
fentanyl	fentanyl citrate oral transmucosal	FIRAZYR¹
FLUOROURACIL	FOLLISTIM AQ¹	FORTEO¹
GANIRELIX AC INJ 250/0.5⁵	GANIRELIX AC INJ 250/0.5^1,⁵	GILENYA¹
GILOTRIF²	glatiramer acetate¹	glatopa¹
glydo	HARVONI¹	HUMIRA¹
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK¹	HUMIRA PEN¹	HUMIRA PEN-CD/UC/HS STARTER¹
HUMIRA PEN-PEDIATRIC UC STARTER PACK¹	HUMIRA PEN-PS/UV STARTER¹	HYCAMTIN¹
hydrocodone tab 30mg er	hydrocodone cap 40mg er	HYDROCODONE CAP 30MG ER
hydrocodone cap 50mg er	hydrocodone tab 80mg er	hydrocodone tab 60mg er
hydrocodone cap 15mg er	HYDROCODONE CAP 10MG ER	hydrocodone tab 120mg er
hydrocodone tab 100mg er	hydrocodone tab 40mg er	HYDROCODONE CAP 20MG ER
hydrocodone tab 20mg er	hydromorphone hcl er	IBRANCE¹
icatibant acetate¹	ICLUSIG^2,³	imatinib mesylate^1,³
IMBRUVICA²	imiquimod	imiquimod pump
INGREZZA²	INLYTA^1,³	INTRON A¹
IRESSA^2,³	JAKAFI^1,³	JIVI¹
JUXTAPID²	KADIAN	KALYDECO¹
KESIMPTA¹	KISQALI¹	KISQALI FEMARA 200 DOSE¹
KISQALI FEMARA 400 DOSE¹	KISQALI FEMARA 600 DOSE¹	KOGENATE FS¹
KORLYM²	KOVALTRY¹	KUVAN¹
lapatinib ditosylate¹	LEDIPASVIR/SOFOSBUVIR¹	LENVIMA 10 MG DAILY DOSE^2,³
LENVIMA 12MG DAILY DOSE^2,³	LENVIMA 14 MG DAILY DOSE^2,³	LENVIMA 18 MG DAILY DOSE^2,³
LENVIMA 20 MG DAILY DOSE^2,³	LENVIMA 24 MG DAILY DOSE^2,³	LENVIMA 4 MG DAILY DOSE^2,³
LENVIMA 8 MG DAILY DOSE^2,³	lidocaine	lidocaine hcl
LIDOCAINE HCL JELLY	lidocaine patch 5%	lidocaine/prilocaine
LONSURF¹	LYNPARZA^2,³	LYSODREN
MATULANE¹	MAVYRET¹	MAYZENT¹
MAYZENT STARTER PACK	MEKINIST¹	metaxalone
METHADONE HCL	METHITEST	miglustat¹
morphine sulfate cr	MORPHINE SULFATE ER	MYALEPT²
naproxen/esomeprazole magnesium	NEULASTA¹	NEULASTA ONPRO KIT¹
NEXAVAR^1,³	NEXLETOL	NEXLIZET
NINLARO¹	NORDITROPIN FLEXPRO¹	NOVOEIGHT¹
NUPLAZID¹	NYVEPRIA	ODOMZO^1,³
OFEV^1,³	omeprazole/sodium bicarbonate	ORIAHNN
ORKAMBI¹	OTEZLA¹	phendimetrazine tartrate
phentermine hcl	PLEGRIDY¹	PLEGRIDY STARTER PACK¹
posaconazole	posaconazole dr	pregabalin er
PROMACTA¹	pyrimethamine	REBIF¹
REBIF REBIDOSE¹	REBIF REBIDOSE TITRATION PACK¹	REBIF TITRATION PACK¹
REPATHA	REPATHA PUSHTRONEX SYSTEM	REPATHA SURECLICK
RESTASIS	RESTASIS MULTIDOSE	RETEVMO^1,³
REVATIO¹	REVLIMID¹	RINVOQ¹
RUBRACA^2,³	sajazir¹	sapropterin dihydrochloride¹
SENSIPAR¹	SIGNIFOR²	sildenafil tab 20mg¹
sildenafil sus 10mg/ml	sildenafil sus 10mg/ml¹	SIMPONI¹
SKYRIZI¹	SKYRIZI PEN¹	sodium phenylbutyrate¹
SOFOSBUVIR/VELPATASVIR¹	SOMAVERT¹	SOVALDI¹
SPRYCEL^1,³	STELARA¹	STIMATE¹
STIVARGA¹	STRENSIQ²	SUCRAID
sunitinib malate^1,³	TABRECTA¹	tadalafil¹
TAFINLAR¹	TAGRISSO^2,³	TALZENNA^1,³
TARCEVA^1,³	TARGRETIN¹	TARGRETIN^1,³
TASIGNA^1,³	tavaborole	TAZAROTENE
temozolomide¹	TESTOSTERONE	testosterone cypionate
TESTOSTERONE PUMP	testosterone topical solution	tetrabenazine (XENAZINE) tab 12.5mg⁵
tetrabenazine (XENAZINE) tab 12.5mg^1,⁵	tetrabenazine (XENAZINE) tab 25mg⁵	tetrabenazine (XENAZINE) tab 25mg^1,⁵
THALOMID¹	TOBRAMYCIN NEB 300/5ML¹	tobramycin neb 300/4ml¹
TOLVAPTAN TAB 15MG¹	tolvaptan tab 30mg	tolvaptan tab 30mg¹
topiramate er	TRAMADOL HCL ER	trazodone hcl
TREMFYA¹	tretinoin	tretinoin microsphere
tretinoin microsphere pump	TYMLOS¹	UPTRAVI²
VENCLEXTA²	VENCLEXTA STARTING PACK²	VERQUVO
VIZIMPRO^1,³	voriconazole	VOSEVI¹
VOTRIENT^1,³	VRAYLAR	XALKORI^1,³
XELJANZ¹	XELJANZ XR¹	XOLAIR¹
XTANDI^1,³	ZAVESCA²	ZEJULA^2,³
ZELBORAF¹	ZEPOSIA¹	ZEPOSIA 7-DAY STARTER PACK¹
ZEPOSIA STARTER KIT¹	ZOKINVY²	ZOLINZA^1,³
ZYDELIG²	ZYKADIA^1,³	ZYTIGA^1,³

Drug name(s)
AIMOVIG¹	AJOVY¹	AMCINONIDE
CAPEX	EMGALITY¹	FARXIGA
GELNIQUE	GLYXAMBI	HYDROCORTISONE BUTYRATE
JANUMET	JANUMET XR	JANUVIA
JARDIANCE	lanthanum carbonate	LUMIGAN
metformin hcl er	OZEMPIC	pimecrolimus
REDITREX	RYBELSUS	SAVELLA
SAVELLA TITRATION PACK	sevelamer tab 800mg	SEVELAMER TAB 400MG
SOLIQUA 100/33	SYNJARDY	SYNJARDY XR
tacrolimus	travoprost	TRIJARDY XR
TRULICITY	UBRELVY	VICTOZA
XIGDUO XR	XULTOPHY 100/3.6	ZIOPTAN

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)	Quantity limits (per 30 days or as specified)
benzphetamine tab 50mg	90 tabs / 30 days
diethylpropion 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
phentermine tab 37.5mg	30 tabs / 30 days

Analgesics – anti-inflammatory

Drug name(s)	Quantity limits (per 30 days or as specified)
ACTEMRA INJ 162/0.9¹	4 syringes / 28 days
ACTEMRA INJ ACTPEN¹	4 injections / 28 days
ARCALYST INJ 220MG²	8 vials / 28 days
ENBREL INJ 25/0.5ML¹	8 syringes / 28 days
ENBREL INJ 25MG¹	8 vials / 28 days
ENBREL INJ 50MG/ML¹	4 syringes / 28 days
ENBREL MINI INJ 50MG/ML¹	4 carts / 28 days
ENBREL SRCLK INJ 50MG/ML¹	4 syringes / 28 days
HUMIRA INJ 10/0.1ML¹	2 syringes / 28 days
HUMIRA INJ 10MG/0.2¹	2 syringes / 28 days
HUMIRA INJ 20/0.2ML¹	2 syringes / 28 days
HUMIRA INJ 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 PEDIATRIC CROHNS DISEASE STARTER pack	1 kit / 180 days
HUMIRA PEN INJ 40/0.4ML¹	2 pens / 28 days
HUMIRA PEN INJ 40MG/0.8¹	2 pens / 28 days
HUMIRA PEN INJ 80/0.8ML¹	2 pens / 28 days
HUMIRA PEN INJ CD/UC/HS¹	1 kit / 180 days
HUMIRA PEN INJ PS/UV¹	1 kit / 180 days
HUMIRA PEN KIT CD/UC/HS¹	1 kit / 180 days
HUMIRA PEN KIT PED UC¹	4 pens / 180 days
HUMIRA PEN KIT PS/UV¹	1 kit / 180 days
naproxen-esomeprazole tab 375-20mg	60 tabs / 30 days
naproxen-esomeprazole tab 500-20mg	60 tabs / 30 days
OTEZLA TAB 10/20/30¹	1 kit / 180 days
OTEZLA TAB 30MG¹	60 tabs / 30 days
RINVOQ TAB 15MG ER¹	30 tabs / 30 days
SIMPONI INJ 100MG/ML¹	1 syringe / 28 days
XELJANZ SOL 1MG/ML¹	240 mLs / 30 days
XELJANZ TAB 5MG¹	60 tabs / 30 days
XELJANZ TAB 10MG¹	240 tabs / 365 days
XELJANZ XR TAB 11MG¹	30 tabs / 30 days
XELJANZ XR TAB 22MG¹	120 tabs / 365 days

Drug name(s)	Adult quantity limit – 5 days	Child quantity limit – 3 days
acetaminophen /codeine sol 120-12/5	450 mL/30 days	270 mL/30 days
acetaminophen /codeine tab 300-15mg	30 tablets/30 days	18 tablets/30 days
acetaminophen /codeine tab 300-30mg	30 tablets/30 days	18 tablets/30 days
acetaminophen /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 sulfate tab 30mg	30 tablets/30 days	18 tablets/30 days
codeine/acetaminophen tab 30-300mg	30 tablets/30 days	18 tablets/30 days
codeine/acetaminophen tab 60-300mg	25 tablets/30 days	15 tablets/30 days
dvorah tab	50 tablets/30 days	30 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
endocet tab 10-325mg	15 tablets/30 days	9 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
HYDROCODONE/ACETAMINOPHEN SOL 10-325MG	375 mL/30 days	225 mL/30 days
hydrocodone/acetaminophen sol 10-325mg	375 mL/30 days	225 mL/30 days
hydrocodone/acetaminophen sol 7.5-325	450 mL/30 days	270 mL/30 days
hydrocodone/acetaminophen tab 10-300mg	25 tablets/30 days	15 tablets/30 days
hydrocodone/acetaminophen tab 10-325mg	25 tablets/30 days	15 tablets/30 days
hydrocodone/acetaminophen tab 5-300mg	40 tablets/30 days	24 tablets/30 days
hydrocodone/acetaminophen tab 5-325mg	40 tablets/30 days	24 tablets/30 days
hydrocodone/acetaminophen tab 7.5-300	30 tablets/30 days	18 tablets/30 days
hydrocodone/acetaminophen tab 7.5-325	30 tablets/30 days	18 tablets/30 days
hydrocodone/ibuprofen tab 10-200mg	25 tablets/30 days	15 tablets/30 days
HYDROCODONE/IBUPROFEN TAB 5-200MG	25 tablets/30 days	15 tablets/30 days
hydrocodone/ibuprofen tab 5-200mg	25 tablets/30 days	15 tablets/30 days
hydrocodone/ibuprofen tab 7.5-200	25 tablets/30 days	15 tablets/30 days
HYDROCODONE CAP 10MG ER	60 capsules/30 days	N/A
hydrocodone cap 10mg er	60 capsules/30 days	N/A
HYDROCODONE CAP 15MG 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 30mg er	30 capsules/30 days	N/A
HYDROCODONE CAP 40MG 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 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
hydromorphone liq 1mg/ml	60 mL/30 days	36 mL/30 days
hydromorphone tab 12mg er	30 tablets/month	N/A
hydromorphone tab 16mg er	0 tablets	N/A
hydromorphone tab 2mg	30 tablets/30 days	18 tablets/30 days
hydromorphone tab 32mg er	0 tablets	N/A
hydromorphone tab 4mg	15 tablets/30 days	9 tablets/30 days
hydromorphone tab 8mg	5 tablets/30 days	3 tablets/30 days
hydromorphone 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
methadone sol 10mg/5ml	150 mL/30 days	N/A
methadone sol 5mg/5ml	300 mL/30 days	N/A
methadone tab 10mg	30 tablets/30 days	N/A
methadone tab 5mg	60 tablets/30 days	N/A
morphine sulfate cap 100mg er	0 capsules/30 days	N/A
morphine sulfate cap 10mg er	30 capsules/30 days	N/A
morphine sulfate cap 20mg er	30 capsules/30 days	N/A
morphine sulfate cap 30mg er	30 capsules/30 days	N/A
morphine sulfate cap 50mg er	30 capsules/30 days	N/A
morphine sulfate cap 60mg er	0 capsules/30 days	N/A
morphine sulfate cap 80mg er	0 capsules/30 days	N/A
morphine sulfate sol 10/0.5ml	15 mL/30 days	15 mL/30 days
morphine sulfate sol 100/5ml	15 mL/30 days	15 mL/30 days
morphine sulfate sol 10mg/5ml	125 mL/30 days	75 mL/30 days
morphine sulfate sol 20mg/5ml	60 mL/30 days	36 mL/30 days
morphine sulfate sol 20mg/ml	15 mL/30 days	15 mL/30 days
morphine sulfate tab 100mg cr	0 tablets/30 days	N/A
morphine sulfate tab 100mg er	0 tablets/30 days	N/A
morphine sulfate tab 15mg	15 tablets/30 days	9 tablets/30 days
morphine sulfate tab 15mg er	60 tablets/30 days	N/A
morphine sulfate tab 200mg er	0 tablets/30 days	N/A
morphine sulfate tab 30mg	5 tablets/30 days	3 tablets/30 days
morphine sulfate tab 30mg er	30 tablets/30 days	N/A
morphine sulfate tab 60mg er	0 tablets/30 days	N/A
oxycodone/ acetaminophen tab 10-325mg	15 tablets/30 days	9 tablets/30 days
oxycodone/ acetaminophen tab 2.5-325	60 tablets/30 days	36 tablets/30 days
oxycodone/ acetaminophen tab 5-325mg	30 tablets/30 days	18 tablets/30 days
oxycodone/ acetaminophen tab 7.5-325	20 tablets/30 days	12 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 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
oxycodone tab 5mg	30 tablets/30 days	18 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
pentazocine/naloxone tab 50-0.5mg	10 tablets/30 days	6 tablets/30 days
tramadol/acetaminophen tab 37.5-325	40 tablets/30 days	24 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
tramadol hcl tab 50mg	50 tablets/30 days	30 tablets/30 days

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
METHITEST TAB 10MG	600 tabs / 30 days
testost cyp inj 100mg/ml	1 VIAL / 28 days
testost cyp inj 200mg/ml	10 mLs / 28 days
testosterone gel 1%(25mg)	60 packets / 30 days
testosterone gel 1%(50mg)	60 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
testosterone td gel 20.25 mg/1.25gm (1.62%)	30 packets / 30 days
testosterone td gel 20.25 mg/act (1.62%)	2 bottles / 30 days
testosterone td gel 40.5 mg/2.5gm (1.62%)	60 packets / 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 115/21	1 can / 30 days
ADVAIR HFA AER 230/21	1 can / 30 days
ADVAIR HFA AER 45/21	1 can / 30 days
albuterol aer hfa	2 cans / 30 days
ANORO ELLIPT AER 62.5-25	1 inhaler / 30 days
ARNUITY ELPT INH 100MCG	30 blisters / 30 days
ARNUITY ELPT INH 200MCG	30 blisters / 30 days
ARNUITY ELPT INH 50MCG	30 blisters / 30 days
ASMANEX 120 AER 220MCG	1 can / 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 HFA AER 100 MCG	1 can / 30 days
ASMANEX HFA AER 200 MCG	1 can / 30 days
ASMANEX HFA AER 50MCG	1 inhaler / 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 100-5MCG	1 can / 30 days
DULERA AER 200-5MCG	1 can / 30 days
DULERA AER 50-5MCG	1 inhaler / 30 days
FLOVENT DISK AER 100MCG	60 blisters / 30 days
FLOVENT DISK AER 250MCG	240 blisters / 30 days
FLOVENT DISK AER 50MCG	60 blisters / 30 days
FLOVENT HFA AER 110MCG	1 can / 30 days
FLOVENT HFA AER 220MCG	2 cans / 30 days
FLOVENT HFA AER 44MCG	1 can / 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
FLUTICASONE/SALMETEROL INH 55/14	1 inhaler / 30 days
INCRUSE ELPT INH 62.5MCG	30 blisters / 30 days
PROAIR RESPI AER	2 inhalers / 30 days
QVAR REDIHA AER 80MCG	2 cans / 30 days
QVAR REDIHAL AER 40MCG	1 can / 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 160-4.5	1 can / 30 days
SYMBICORT AER 80-4.5	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)
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 25mg	90 caps / 30 days
pregabalin cap 300mg	60 caps / 30 days
pregabalin cap 50mg	90 caps / 30 days
pregabalin cap 75mg	90 caps / 30 days
pregabalin sol 20mg/ml	900 mLs / 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
topiramate cap er 25mg	30 caps / 30 days
topiramate cap er 50mg	30 caps / 30 days

Antidiabetics

Drug name(s)	Quantity limits (per 30 days or as specified)
FARXIGA TAB 10MG	30 tabs / 30 days
FARXIGA TAB 5MG	30 tabs / 30 days
FIASP INJ 100/ML	100 mLs / 30 days
FIASP FLEX INJ TOUCH	100 mLs / 30 days
FIASP PENFIL INJ U-100	100 mLs / 30 days
GLYXAMBI TAB 10-5 MG	30 tabs / 30 days
GLYXAMBI TAB 25-5 MG	30 tabs / 30 days
HUMULIN R INJ U-500	100 mLs / 30 days
INS ASP PROT INJ FLEXPEN	100 mLs / 30 days
INSULIN ASPA INJ 100/ML	100 mLs / 30 days
INSULIN ASPA INJ 70/30	100 mLs / 30 days
INSULIN ASPA INJ FLEXPEN	100 mLs / 30 days
INSULIN ASPA INJ PENFILL	100 mLs / 30 days
JANUMET TAB 50-1000	60 tabs / 30 days
JANUMET TAB 50-500MG	60 tabs / 30 days
JANUMET XR TAB 100-1000	30 tabs / 30 days
JANUMET XR TAB 50-1000	60 tabs / 30 days
JANUMET XR TAB 50-500MG	30 tabs / 30 days
JANUVIA TAB 100MG	30 tabs / 30 days
JANUVIA TAB 25MG	30 tabs / 30 days
JANUVIA TAB 50MG	30 tabs / 30 days
JARDIANCE TAB 10MG	30 tabs / 30 days
JARDIANCE TAB 25MG	30 tabs / 30 days
KORLYM TAB 300MG²	120 tabs / 30 days
LANTUS INJ 100/ML	100 mLs / 30 days
LANTUS SOLOS INJ 100/ML	100 mLs / 30 days
LEVEMIR INJ	100 mLs / 30 days
LEVEMIR INJ FLEXTOUC	100 mLs / 30 days
metformin tab 1000 er	60 tabs / 30 days
metformin tab 750mg er	60 tabs / 30 days
metformin er tab 1000mg	60 tabs / 30 days
metformin hcl tab er 24hr 500 mg	120 tabs / 30 days
metformin hcl tab er 24hr modified release 500 mg	90 tabs / 30 days
metformin hcl tab er 24hr osmotic 500 mg	90 tabs / 30 days
NOVOLIN INJ 70/30	100 mLs / 30 days
NOVOLIN INJ 70/30 FP	100 mLs / 30 days
NOVOLIN N INJ 100 UNIT	100 mLs / 30 days
NOVOLIN N INJ RELION	100 mLs / 30 days
NOVOLIN N INJ U-100	100 mLs / 30 days
NOVOLIN R INJ 100 UNIT	100 mLs / 30 days
NOVOLIN R INJ RELION	100 mLs / 30 days
NOVOLIN R INJ U-100	100 mLs / 30 days
NOVOLIN70/30 INJ RELION	100 mLs / 30 days
NOVOLOG INJ 100/ML	100 mLs / 30 days
NOVOLOG INJ FLEXPEN	100 mLs / 30 days
NOVOLOG INJ PENFILL	100 mLs / 30 days
NOVOLOG INJ RELION	100 mLs / 30 days
NOVOLOG MIX INJ 70/30	100 mLs / 30 days
NOVOLOG MIX INJ FLEX REL	100 mLs / 30 days
NOVOLOG MIX INJ FLEXPEN	100 mLs / 30 days
NOVOLOG RELI INJ 70/30	100 mLs / 30 days
OZEMPIC INJ 4MG/3ML	1 pen / 28 days
OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/1.5ML)	1 pen / 28 days
OZEMPIC- SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (2 MG/1.5ML)	2 pens / 28 days
RYBELSUS TAB 14MG	30 tabs / 30 days
RYBELSUS TAB 3MG	30 tabs / 180 days
RYBELSUS TAB 7MG	30 tabs / 30 days
SOLIQUA INJ 100/33	6 pens / 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 10-1000	60 tabs / 30 days
SYNJARDY XR TAB 25-1000	30 tabs / 30 days
SYNJARDY XR TAB 5-1000MG	60 tabs / 30 days
TOUJEO MAX INJ 300IU/ML	100 mLs / 30 days
TOUJEO SOLO INJ 300IU/ML	100 mLs / 30 days
TRESIBA INJ 100UNIT	100 mLs / 30 days
TRESIBA FLEX INJ 100UNIT	100 mLs / 30 days
TRESIBA FLEX INJ 200UNIT	100 mLs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIP-METFORMIN TAB ER 24HR 12.5-2.5-1000MG	60 tabs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 10-5-1000 MG	30 tabs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 25-5-1000 MG	30 tabs / 30 days
TRIJARDY XR- EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 5-2.5-1000MG	60 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 10-1000	30 tabs / 30 days
XIGDUO XR TAB 10-500MG	30 tabs / 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
XULTOPHY INJ 100/3.6	5 pens / 30 days

Antidotes and specific antagonists

Drug name(s)	Quantity limits (per 30 days or as specified)
deferasirox gra 180mg ^1,³	30 packets / 30 days
deferasirox gra 360mg ^1,³	180 packets / 30 days
deferasirox gra 90mg ^1,³	30 packets / 30 days
deferasirox tab 125mg ^1,³	30 tabs / 30 days
deferasirox tab 180mg ^1,³	30 tabs / 30 days
deferasirox tab 250mg ^1,³	30 tabs / 30 days
deferasirox tab 360mg ^1,³	180 tabs / 30 days
deferasirox tab 500mg ^1,³	90 tabs / 30 days
deferasirox tab 90mg ^1,³	30 tabs / 30 days
EXJADE TAB 125MG ^1,³	30 tabs / 30 days
EXJADE TAB 250MG ^1,³	30 tabs / 30 days
EXJADE TAB 500MG ^1,³	90 tabs / 30 days

Antiemetics

Drug name(s)	Quantity limits (per 30 days or as specified)
aprepitant cap 125mg	4 caps / 30 days
aprepitant cap 40mg	8 caps / 30 days
aprepitant cap 80mg	8 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

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
ezetimibe/simvastatin tab 10-10mg	30 tabs / 30 days
ezetimibe/simvastatin tab 10-20mg	30 tabs / 30 days
ezetimibe/simvastatin tab 10-40mg	30 tabs / 30 days
ezetimibe/simvastatin tab 10-80mg	30 tabs / 30 days
fluvastatin tab 80mg er	30 tabs / 30 days
JUXTAPID CAP 10MG²	30 caps / 30 days
JUXTAPID CAP 20MG²	30 caps / 30 days
JUXTAPID CAP 30MG²	30 caps / 30 days
JUXTAPID CAP 40MG²	30 caps / 30 days
JUXTAPID CAP 5MG²	30 caps / 30 days
JUXTAPID CAP 60MG²	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	2 carts / 30 days
REPATHA SURE INJ 140MG/ML	2 pens / 28 days
rosuvastatin tab 10mg	45 tabs / 30 days
rosuvastatin tab 20mg	45 tabs / 30 days
rosuvastatin tab 40mg	30 tabs / 30 days
rosuvastatin 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 5mg	45 tabs / 30 days
simvastatin tab 80mg	30 tabs / 30 days

Anti-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 10MG ^1,³	30 tabs / 30 days
AFINITOR TAB 2.5MG ^1,³	30 tabs / 30 days
AFINITOR TAB 5MG ^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 PAK²	30 tabs / 180 days
ALUNBRIG TAB 180MG²	30 tabs / 30 days
ALUNBRIG TAB 30MG²	120 tabs / 30 days
ALUNBRIG TAB 90MG²	30 tabs / 30 days
CAPRELSA TAB 100MG²	60 tabs / 30 days
CAPRELSA TAB 300MG²	30 tabs / 30 days
COMETRIQ KIT 100MG^2,³	1 CARTON / 28 days
COMETRIQ KIT 140MG^2,³	112 tabs / 28 days
COMETRIQ KIT 60MG^2,³	1 CARTON / 28 days
COTELLIC TAB 20MG¹	63 tabs / 28 days
ERIVEDGE CAP 150MG ^1,³	30 caps / 30 days
erlotinib tab 100mg ^1,³	30 tabs / 30 days
erlotinib tab 150mg ^1,³	30 tabs / 30 days
erlotinib tab 25mg ^1,³	60 tabs / 30 days
everolimus tab 10mg³	30 tabs / 30 days
everolimus tab 2.5mg ^1,³	30 tabs / 30 days
everolimus tab 2.5mg³	30 tabs / 30 days
everolimus tab 2mg³	60 tabs / 30 days
everolimus tab 3mg³	90 tabs / 30 days
everolimus tab 5mg ^1,³	30 tabs / 30 days
everolimus tab 5mg³	60 tabs / 30 days
everolimus tab 5mg³	30 tabs / 30 days
everolimus tab 7.5mg ^1,³	30 tabs / 30 days
everolimus tab 7.5mg³	30 tabs / 30 days
GILOTRIF TAB 20MG²	30 tabs / 30 days
GILOTRIF TAB 30MG²	30 tabs / 30 days
GILOTRIF TAB 40MG²	30 tabs / 30 days
IBRANCE CAP 100MG¹	21 caps / 28 days
IBRANCE CAP 125MG¹	21 caps / 28 days
IBRANCE CAP 75MG¹	21 caps / 28 days
IBRANCE TAB 100MG¹	21 tabs / 28 days
IBRANCE TAB 125MG¹	21 tabs / 28 days
IBRANCE TAB 75MG¹	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
imatinib mesylate tab 100mg ^1,³	90 tabs / 30 days
imatinib mesylate tab 400mg ^1,³	60 tabs / 30 days
IMBRUVICA CAP 140MG²	90 caps / 30 days
IMBRUVICA CAP 70MG²	30 caps / 30 days
IMBRUVICA TAB 140MG²	30 tabs / 30 days
IMBRUVICA TAB 280MG²	30 tabs / 30 days
IMBRUVICA TAB 420MG²	30 tabs / 30 days
IMBRUVICA TAB 560MG²	30 tabs / 30 days
INLYTA TAB 1MG ^1,³	180 tabs / 30 days
INLYTA TAB 5MG ^1,³	120 tabs / 30 days
IRESSA TAB 250MG^2,³	30 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
JAKAFI TAB 5MG ^1,³	60 tabs / 30 days
KISQALI TAB 200DOSE¹	63 tabs / 28 days
KISQALI TAB 400DOSE¹	63 tabs / 28 days
KISQALI TAB 600DOSE¹	63 tabs / 28 days
KISQALI 200 PAK FEMARA¹	91 tabs / 28 days
KISQALI 400 PAK FEMARA¹	91 tabs / 28 days
KISQALI 600 PAK FEMARA¹	91 tabs / 28 days
lapatinib tab 250mg¹	180 tabs / 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
LENVIMA CAP 4MG^2,³	30 caps / 30 days
LENVIMA CAP 8 MG^2,³	60 caps / 30 days
LONSURF TAB 15-6.14¹	60 tabs / 28 days
LONSURF TAB 20-8.19¹	80 tabs / 28 days
LYNPARZA TAB 100MG^2,³	120 tabs / 30 days
LYNPARZA TAB 150MG^2,³	120 tabs / 30 days
MEKINIST TAB 0.5MG¹	90 tabs / 30 days
MEKINIST TAB 2MG¹	30 tabs / 30 days
NEXAVAR TAB 200MG ^1,³	120 tabs / 30 days
NINLARO CAP 2.3MG¹	3 caps / 28 days
NINLARO CAP 3MG¹	3 caps / 28 days
NINLARO CAP 4MG¹	3 caps / 28 days
ODOMZO CAP 200MG ^1,³	30 caps / 30 days
RETEVMO CAP 40MG ^1,³	180 caps / 30 days
RETEVMO CAP 80MG ^1,³	120 caps / 30 days
RUBRACA TAB 200MG^2,³	120 tabs / 30 days
SPRYCEL TAB 100MG ^1,³	30 tabs / 30 days
SPRYCEL TAB 140MG ^1,³	30 tabs / 30 days
SPRYCEL TAB 20MG ^1,³	90 tabs / 30 days
SPRYCEL TAB 50MG ^1,³	30 tabs / 30 days
SPRYCEL TAB 70MG ^1,³	30 tabs / 30 days
SPRYCEL TAB 80MG ^1,³	30 tabs / 30 days
STIVARGA TAB 40MG¹	84 tabs / 28 days
sunitinib cap 12.5mg ^1,³	90 caps / 30 days
sunitinib cap 25mg ^1,³	30 caps / 30 days
sunitinib cap 37.5mg ^1,³	30 caps / 30 days
sunitinib cap 50mg ^1,³	30 caps / 30 days
TABRECTA TAB 150MG¹	120 tabs / 30 days
TABRECTA TAB 200MG¹	120 tabs / 30 days
TAFINLAR CAP 50MG¹	120 caps / 30 days
TAFINLAR CAP 75MG¹	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 100MG ^1,³	30 tabs / 30 days
TARCEVA TAB 150MG ^1,³	30 tabs / 30 days
TARCEVA TAB 25MG ^1,³	60 tabs / 30 days
TASIGNA CAP 150MG ^1,³	120 caps / 30 days
TASIGNA CAP 200MG ^1,³	120 caps / 30 days
VENCLEXTA TAB 100MG²	180 tabs / 30 days
VENCLEXTA TAB 10MG²	60 tabs / 30 days
VENCLEXTA TAB 50MG²	30 tabs / 30 days
VENCLEXTA TAB START PK²	1 pack / 180 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
XTANDI CAP 40MG ^1,³	120 caps / 30 days
XTANDI TAB 40MG ^1,³	120 tabs / 30 days
XTANDI TAB 80MG ^1,³	60 tabs / 30 days
ZEJULA CAP 100MG^2,³	90 caps / 30 days
ZELBORAF TAB 240MG¹	240 tabs / 30 days
ZOLINZA CAP 100MG ^1,³	120 caps / 30 days
ZYDELIG TAB 100MG²	60 tabs / 30 days
ZYDELIG TAB 150MG²	60 tabs / 30 days
ZYKADIA TAB 150MG ^1,³	90 tabs / 30 days
ZYTIGA TAB 250MG ^1,³	120 tabs / 30 days

Antipsychotics / antimanic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
LATUDA TAB 120MG	30 tabs / 30 days
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
NUPLAZID CAP 34MG¹	30 caps / 30 days
NUPLAZID TAB 10MG¹	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 2.5mg	30 tabs / 30 days
olanzapine tab 20mg	30 tabs / 30 days
olanzapine tab 20mg odt	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
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 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
quetiapine tab 50mg 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 200-50MG¹	28 tabs / 28 days
EPCLUSA TAB 400-100¹	30 tabs / 30 days
HARVONI PAK¹	28 packets / 28 days
HARVONI PAK 45-200MG¹	28 packets / 28 days
HARVONI TAB 45-200MG¹	28 tabs / 28 days
HARVONI TAB 90-400MG¹	30 tabs / 30 days
LEDIP-SOFOSB TAB 90-400MG¹	30 tabs / 30 days
MAVYRET TAB 100-40MG¹	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 400-100¹	30 tabs / 30 days
SOVALDI PAK 150MG¹	28 packets / 28 days
SOVALDI PAK 200MG¹	28 packets / 28 days
SOVALDI TAB 200MG¹	30 tabs / 30 days
SOVALDI TAB 400MG¹	30 tabs / 30 days
VOSEVI TAB¹	30 tabs / 30 days

Cardiovascular agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADCIRCA TAB 20MG¹	60 tabs / 30 days
ADEMPAS TAB 0.5MG²	90 tabs / 30 days
ADEMPAS TAB 1.5MG²	90 tabs / 30 days
ADEMPAS TAB 1MG²	90 tabs / 30 days
ADEMPAS TAB 2.5MG²	90 tabs / 30 days
ADEMPAS TAB 2MG²	90 tabs / 30 days
alyq tab 20mg¹	60 tabs / 30 days
ambrisentan tab 10mg¹	30 tabs / 30 days
ambrisentan tab 5mg¹	30 tabs / 30 days
bosentan tab 125mg¹	60 tabs / 30 days
bosentan tab 62.5mg¹	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/ML¹	2 bottles / 30 days
sildenafil sus 10mg/ml	2 bottles / 30 days
sildenafil sus 10mg/ml¹	2 bottles / 30 days
sildenafil tab 20mg¹	90 tabs / 30 days
tadalafil tab 20mg¹	60 tabs / 30 days
UPTRAVI TAB 1000MCG²	60 tabs / 30 days
UPTRAVI TAB 1200MCG²	60 tabs / 30 days
UPTRAVI TAB 1400MCG²	60 tabs / 30 days
UPTRAVI TAB 1600MCG²	60 tabs / 30 days
UPTRAVI TAB 200/800²	1 PKG / 180 days
UPTRAVI TAB 400MCG²	60 tabs / 30 days
UPTRAVI TAB 600MCG²	60 tabs / 30 days
UPTRAVI TAB 800MCG²	60 tabs / 30 days
UPTRAVI- SELEXIPAG TAB 200 MCG²	60 tabs / 30 days
UPTRAVI- SELEXIPAG TAB 200 MCG²	140 tabs / 180 days
VERQUVO TAB 10MG	30 tabs / 30 days
VERQUVO TAB 2.5MG	30 tabs / 30 days
VERQUVO TAB 5MG	30 tabs / 30 days

Dermatologicals

Drug name(s)	Quantity limits (per 30 days or as specified)
ala-cort cre 1%	454 grams / 30 days
ala-cort cre 2.5%	454 grams / 30 days
alclometasone cre 0.05%	120 grams / 30 days
alclometasone oin 0.05%	120 grams / 30 days
AMCINONIDE OIN 0.1%	120 grams / 30 days
augmented betamethasone cre 0.05%	200 grams / 28 days
augmented betamethasone lot 0.05%	210 mLs / 30 days
augmented betamethasone oin 0.05%	200 grams / 28 days
beser lot 0.05%	120 mLs / 30 days
betamethasone dipropionate cre 0.05%	135 grams / 30 days
betamethasone dipropionate lot 0.05%	120 mLs / 30 days
betamethasone dipropionate oin 0.05%	135 grams / 30 days
betamethasone valerate aer 0.12%	150 grams / 30 days
betamethasone valerate cre 0.1%	135 grams / 30 days
betamethasone valerate lot 0.1%	120 mLs / 30 days
betamethasone valerate oin 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 cre 0.05%	210 grams / 28 days
clobetasol gel 0.05%	210 grams / 28 days
clobetasol lot 0.05%	177 mLs / 28 days
clobetasol oin 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 cre 0.05%	210 grams / 28 days
clodan sha 0.05%	236 mLs / 30 days
COSENTYX INJ 150MG/ML¹	1 syringe / 28 days
COSENTYX INJ 300DOSE¹	1 pack / 28 days
COSENTYX INJ 75MG/0.5¹	1 syringe / 28 days
COSENTYX PEN INJ 150MG/ML¹	1 injdv / 28 days
COSENTYX PEN INJ 300DOSE¹	1 pack / 28 days
desonide cre 0.05%	120 grams / 30 days
desonide gel 0.05%	120 grams / 30 days
desonide lot 0.05%	118 mLs / 30 days
desonide oin 0.05%	120 grams / 30 days
desoximetasone cre 0.05%	120 grams / 30 days
desoximetasone cre 0.25%	120 grams / 30 days
desoximetasone gel 0.05%	120 grams / 30 days
desoximetasone oin 0.05%	120 grams / 30 days
desoximetasone oin 0.25%	120 grams / 30 days
desoximetasone spr 0.25%	100 mLs / 30 days
desrx gel 0.05%	120 grams / 30 days
diclofenac sol 1.5%	2 bottles / 30 days
diflorasone oin 0.05%	120 grams / 30 days
DUPIXENT INJ 200/1.14¹	2 syringes / 28 days
DUPIXENT INJ 200MG¹	2 pens / 28 days
DUPIXENT- DUPILUMAB SUBCUTANEOUS SOLN PEN-INJECTOR 300 MG/2ML¹	2 pens / 28 days
DUPIXENT- DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 300 MG/2ML¹	2 syringes / 28 days
fluocinolone acetonide cre 0.01%	120 grams / 30 days
fluocinolone acetonide cre 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	118.28 mLs / 30 days
fluocinolone acetonide	118.28 mLs / 30 days
fluocinolone acetonide oin 0.025%	120 grams / 30 days
fluocinolone acetonide 0.01%	120 mLs / 30 days
fluocinonide cre 0.05%	120 grams / 30 days
fluocinonide cre 0.1%	240 grams / 28 days
fluocinonide cre e 0.05%	120 grams / 30 days
fluocinonide gel 0.05%	120 grams / 30 days
fluocinonide oin 0.05%	120 grams / 30 days
fluocinonide sol 0.05%	120 mLs / 30 days
fluorouracil cre 5%	240 grams / 90 days
flurandrenolide cre 0.05%	120 grams / 30 days
flurandrenolide lot 0.05%	120 mLs / 30 days
flurandrenolide	120 grams / 30 days
fluticasone cre 0.05%	120 grams / 30 days
fluticasone lot 0.05%	120 mLs / 30 days
fluticasone oin 0.005%	120 grams / 30 days
glydo gel 2%	150 mLs / 30 days
halcinonide cre 0.1%	240 grams / 30 days
halobetasol cre 0.05%	200 grams / 28 days
halobetasol oin 0.05%	200 grams / 28 days
HC BUTYRATE CRE 0.1%	135 grams / 30 days
hc butyrate oin 0.1%	135 grams / 30 days
hc butyrate sol 0.1%	120 mLs / 30 days
hc valerate cre 0.2%	120 grams / 30 days
hc valerate oin 0.2%	120 grams / 30 days
hydrocortisone cre 1%	454 grams / 30 days
hydrocortisone cre 2.5%	454 grams / 30 days
hydrocortisone lot 2.5%	118 mLs / 30 days
hydrocortisone oin 2.5%	454 grams / 30 days
hydrocortisone lot 0.1%	118 mLs / 30 days
hydrocortisonebutyrate cream 0.1%	135 grams / 30 days
hydrocortisone butyrate hydrophilic lipo base cream 0.1%	120 grams / 30 days
imiquimod cre 5%	48 packets / 112 days
lido/prilocn cre 2.5-2.5%	60 grams / 30 days
lidocaine gel 2%	150 mLs / 30 days
lidocaine gel 2% jelly	150 mLs / 30 days
lidocaine oin 5%	100 grams / 30 days
lidocaine pad 5%	90 patches / 30 days
lidocaine sol 4%	150 mLs / 30 days
mometasone cre 0.1%	135 grams / 30 days
mometasone oin 0.1%	135 grams / 30 days
mometasone sol 0.1%	120 mLs / 30 days
nolix cre 0.05%	120 grams / 30 days
nolix lot 0.05%	120 mLs / 30 days
SKYRIZI INJ 150DOSE¹	1 box / 84 days
SKYRIZI INJ 150MG/ML¹	1 syringe / 84 days
SKYRIZI PEN INJ 150MG/ML¹	1 injdv / 84 days
STELARA INJ 45MG/0.5¹	1 syringe / 84 days
STELARA INJ 90MG/ML¹	1 syringe / 56 days
tavaborole sol 5%	4 mLs / 30 days
tovet aer 0.05%	200 grams / 28 days
TREMFYA- GUSELKUMAB SOLN PEN-INJECTOR 100 MG/ML¹	1 pen / 56 days
TREMFYA- GUSELKUMAB SOLN PREFILLED SYRINGE 100 MG/ML¹	1 syringe / 56 days
triamcinolone aer spray	126 grams / 30 days
triamcinolone cre 0.025%	454 grams / 30 days
triamcinolone cre 0.1%	454 grams / 30 days
triamcinolone cre 0.5%	454 grams / 30 days
triamcinolone lot 0.025%	120 mLs / 30 days
triamcinolone lot 0.1%	120 mLs / 30 days
triamcinolone oin 0.025%	454 grams / 30 days
triamcinolone oin 0.05%	430 grams / 30 days
triamcinolone oin 0.1%	454 grams / 30 days
triamcinolone oin 0.5%	120 grams / 30 days
trianex oin 0.05%	430 grams / 30 days
triderm cre 0.1%	454 grams / 30 days
triderm cre 0.5%	454 grams / 30 days
tritocin oin 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 0.25MG¹	5 KITS / 30 days
EGRIFTA SOL 1MG¹	60 vials / 30 days
EGRIFTA SV INJ 2MG¹	30 vials / 30 days
FOLLISTIM AQ INJ 300UNIT¹	15 carts / 30 days
FOLLISTIM AQ INJ 600UNIT¹	8 carts / 30 days
FOLLISTIM AQ INJ 900UNIT¹	5 carts / 30 days
FORTEO INJ 620/2.48¹	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 250/0.5⁵	5 syringes / 30 days
GANIRELIX AC INJ 250/0.5^1,⁵	5 syringes / 30 days
ganirelix ac inj 250/0.5^1,⁵	5 syringes / 30 days
ibandronate tab 150mg	1 TAB / 28 days
risedronatesod tab 35mg dr	4 tabs / 28 days
risedronate tab 150mg	1 TAB / 28 days
risedronate tab 35mg	4 tabs / 28 days
SIGNIFOR INJ 0.3MG/ML²	60 mLs / 30 days
SIGNIFOR INJ 0.6MG/ML²	60 mLs / 30 days
SIGNIFOR INJ 0.9MG/ML²	60 mLs / 30 days
SOMAVERT INJ 10MG¹	30 vials / 30 days
SOMAVERT INJ 15MG¹	30 vials / 30 days
SOMAVERT INJ 20MG¹	30 vials / 30 days
SOMAVERT INJ 25MG¹	30 vials / 30 days
SOMAVERT INJ 30MG¹	30 vials / 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 145MCG	30 caps / 30 days
LINZESS CAP 290MCG	30 caps / 30 days
LINZESS CAP 72MCG	30 caps / 30 days
MOVANTIK TAB 12.5MG	30 tabs / 30 days
MOVANTIK TAB 25MG	30 tabs / 30 days

Hematologial agents

Drug name(s)	Quantity limits (per 30 days or as specified)
EMPAVELI INJ 1080MG	8 vials / 28 days
FIRAZYR INJ 30MG/3ML¹	6 syringes / 30 days
icatibant inj 30mg/3ml¹	6 syringes / 30 days
sajazir inj 30mg/3ml¹	6 syringes / 30 days

Hematopoietic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
CERDELGA CAP 84MG¹	60 caps / 30 days
miglustat cap 100mg¹	90 caps / 30 days
PROMACTA PAK 25MG¹	30 packs / 30 days
PROMACTA POW 12.5MG¹	30 packets / 30 days
PROMACTA TAB 12.5MG¹	30 tabs / 30 days
PROMACTA TAB 25MG¹	30 tabs / 30 days
PROMACTA TAB 50MG¹	60 tabs / 30 days
PROMACTA TAB 75MG¹	60 tabs / 30 days
ZAVESCA CAP 100MG²	90 caps / 30 days

Hypnotics / Sedatives / Sleep Disorder Agents

Drug name(s)	Quantity limits (per 30 days or as specified)
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 10mg	30 caps / 30 days
zaleplon cap 5mg	30 caps / 30 days
zolpidem tab 10mg	30 tabs / 30 days
zolpidem tab 5mg	30 tabs / 30 days
zolpidem er tab 12.5mg	30 tabs / 30 days
zolpidem er tab 6.25mg	30 tabs / 30 days
zolpidem tartrate sub 1.75mg	30 tabs / 30 days
zolpidem tartrate sub 3.5mg	30 tabs / 30 days

Migraine products

Drug name(s)	Quantity limits (per 30 days or as specified)
AIMOVIG INJ 140MG/ML¹	1 injection / 28 days
AIMOVIG INJ 70MG/ML¹	1 injection / 28 days
AJOVY INJ 225/1.5¹	3 syringes / 84 days
almotriptan malate tab 12.5mg	12 tabs / 30 days
almotriptan malate tab 6.25mg	24 tabs / 30 days
almotriptan tab 12.5mg	12 tabs / 30 days
almotriptan tab 6.25mg	24 tabs / 30 days
dihydroergotamine spr 4mg/ml	8 mLs / 28 days
eletriptan tab 20mg	18 tabs / 30 days
eletriptan tab 40mg	12 tabs / 30 days
EMGALITY INJ 100MG/ML¹	9 syringes / 180 days
EMGALITY INJ 120MG/ML¹	1 syringe / 28 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 10mg	18 tabs / 30 days
rizatriptan tab 10mg odt	18 tabs / 30 days
rizatriptan tab 5mg	36 tabs / 30 days
rizatriptan tab 5mg odt	36 tabs / 30 days
sumatriptan-naproxen tab 85-500mg	18 tabs / 30 days
sumatriptan spr 20mg/act	12 inhalers / 30 days
sumatriptan spr 5mg/act	5 packs / 30 days
sumatriptan tab 100mg	18 tabs / 30 days
sumatriptan tab 25mg	27 tabs / 30 days
sumatriptan tab 50mg	18 tabs / 30 days
sumatriptan succinate inj 6 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution auto-injector 4 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution auto-injector 6 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solution cartridge 4 mg/0.5ml	12 carts / 30 days
sumatriptan succinate solution cartridge 6 mg/0.5ml	12 carts / 30 days
UBRELVY TAB 100MG	16 tabs / 30 days
UBRELVY TAB 50MG	16 tabs / 30 days
zolmitriptan tab 2.5mg	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 10MG¹	30 caps / 30 days
REVLIMID CAP 15MG¹	21 caps / 28 days
REVLIMID CAP 2.5MG¹	30 caps / 30 days
REVLIMID CAP 20MG¹	21 caps / 28 days
REVLIMID CAP 25MG¹	21 caps / 28 days
REVLIMID CAP 5MG¹	30 caps / 30 days
THALOMID CAP 100MG¹	30 caps / 30 days
THALOMID CAP 150MG¹	60 caps / 30 days
THALOMID CAP 200MG¹	60 caps / 30 days
THALOMID CAP 50MG¹	30 caps / 30 days
ZOKINVY CAP 50MG²	120 caps / 30 days
ZOKINVY CAP 75MG²	120 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)	Quantity limits (per 30 days or as specified)
baclofen tab 10mg	120 tabs / 30 days
baclofen tab 20mg	120 tabs / 30 days
baclofen tab 5mg	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 250mg	84 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 cap 15mg er	21 caps / 90 days
cyclobenzaprine cap 30mg er	21 caps / 90 days
cyclobenzaprine tab 10mg	63 tabs / 90 days
cyclobenzaprine tab 5mg	63 tabs / 90 days
cyclobenzaprine tab 7.5mg	63 tabs / 90 days
dantrolene cap 100mg	90 caps / 30 days
dantrolene cap 25mg	90 caps / 30 days
dantrolene cap 50mg	90 caps / 30 days
lorzone tab 375mg	84 tabs / 90 days
lorzone tab 750mg	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
travoprost dro 0.004%	2.5 mLs / 30 days
ZIOPTAN DRO 0.0015%	30 cartons / 30 days
bimatoprost sol 0.03%	2.5 mLs / 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 14MG ^1,³	30 tabs / 30 days
AUBAGIO TAB 7MG ^1,³	30 tabs / 30 days
AVONEX PEN KIT 30MCG¹	1 kit / 28 days
AVONEX PREFL KIT 30MCG¹	1 kit / 28 days
BETASERON INJ 0.3MG¹	1 box / 28 days
dalfampridine tab 10mg er ^1,³	60 tabs / 30 days
dimethyl fumarate cap 120mg dr¹	56 caps / 180 days
dimethyl fumarate cap 240mg dr¹	60 caps / 30 days
dimethyl fumarate mis starter¹	60 caps / 180 days
GILENYA CAP 0.5MG¹	30 tabs / 30 days
glatiramer inj 20mg/ml¹	30 syringes / 30 days
glatiramer inj 40mg/ml¹	12 syringes / 28 days
glatopa inj 20mg/ml¹	30 syringes / 30 days
glatopa inj 40mg/ml¹	12 syringes / 28 days
INGREZZA CAP 40-80MG²	28 caps / 180 days
INGREZZA CAP 40MG²	30 caps / 30 days
INGREZZA CAP 60MG²	30 caps / 30 days
INGREZZA CAP 80MG²	30 caps / 30 days
KESIMPTA INJ 20/.4ML¹	1 syringe / 28 days
MAYZENT PAK STARTER	12 tabs / 180 days
MAYZENT TAB 0.25MG¹	120 tabs / 30 days
MAYZENT TAB 2MG¹	30 tabs / 30 days
PLEGRIDY INJ¹	2 syringes / 28 days
PLEGRIDY INJ PEN¹	2 pens / 28 days
PLEGRIDY INJ STARTER¹	1 kit / 180 days
PLEGRIDY PEN INJ STARTER¹	1 kit / 180 days
pregabalin er tab 165mg	30 tabs / 30 days
pregabalin er tab 330mg	60 tabs / 30 days
pregabalin er tab 82.5mg	30 tabs / 30 days
REBIF INJ 22/0.5¹	12 syringes / 28 days
REBIF INJ 44/0.5¹	1 CARTON / 28 days
REBIF REBIDO INJ 22/0.5¹	1 CARTON / 28 days
REBIF REBIDO INJ 44/0.5¹	1 CARTON / 28 days
REBIF REBIDO INJ TITRATN¹	1 kit / 180 days
REBIF TITRTN INJ pack¹	1 kit / 180 days
SAVELLA MIS TITR PAK	1 kit / 180 days
SAVELLA TAB 100MG	60 tabs / 30 days
SAVELLA TAB 12.5MG	60 tabs / 30 days
SAVELLA TAB 25MG	60 tabs / 30 days
SAVELLA TAB 50MG	60 tabs / 30 days
tetrabenazine tab 12.5mg⁵	240 tabs / 30 days
tetrabenazine tab 12.5mg^1,⁵	240 tabs / 30 days
tetrabenazine tab 25mg⁵	120 tabs / 30 days
tetrabenazine tab 25mg^1,⁵	120 tabs / 30 days
ZEPOSIA CAP .92MG¹	30 caps / 30 days
ZEPOSIA CAP STR KIT¹	37 caps / 180 days
ZEPOSIA 7DAY CAP STR pack¹	7 caps / 180 days

Respiratory agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ESBRIET CAP 267MG¹	180 caps / 30 days
ESBRIET TAB 267MG¹	180 tabs / 30 days
ESBRIET TAB 801MG¹	90 tabs / 30 days
KALYDECO PAK 25MG¹	60 packets / 30 days
KALYDECO PAK 50MG¹	60 packets / 30 days
KALYDECO PAK 75MG¹	60 packets / 30 days
KALYDECO TAB 150MG¹	60 tabs / 30 days
OFEV CAP 100MG ^1,³	60 caps / 30 days
OFEV CAP 150MG ^1,³	60 caps / 30 days
ORKAMBI TAB 100-125¹	120 tabs / 30 days
ORKAMBI TAB 200-125¹	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
omeprazole/bicarbonate cap 20-1100	30 caps / 30 days
omeprazole/bicarbonate cap 40-1100	30 caps / 30 days
omeprazole/bicarbonate pow 20-1680	30 packets / 30 days
omeprazole/bicarbonate 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 15mg	30 tabs / 30 days
darifenacin tab 7.5mg	30 tabs / 30 days
GELNIQUE GEL 10%	30 packets / 30 days
oxybutynin syp 5mg/5ml	600 mLs / 30 days
oxybutynin tab 10mg er	60 tabs / 30 days
oxybutynin tab 15mg er	60 tabs / 30 days
oxybutynin tab 5mg	120 tabs / 30 days
oxybutynin tab 5mg er	30 tabs / 30 days
solifenacin tab 10mg	30 tabs / 30 days
solifenacin tab 5mg	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

Vasopressors

Drug name(s)	Quantity limits (per 30 days or as specified)
droxidopa cap 100mg ⁵	450 caps / 30 days
droxidopa cap 100mg ^1,⁵	450 caps / 30 days
droxidopa cap 200mg ⁵	180 caps / 30 days
droxidopa cap 200mg ^1,⁵	180 caps / 30 days
droxidopa cap 300mg ⁵	180 caps / 30 days
droxidopa cap 300mg ^1,⁵	180 caps / 30 days

Specialty

Open - Members can obtain their specialty drugs at any pharmacy, even if the drug is listed as exclusive
Open/Closed - Members obtain their specialty drugs based on the exclusivity of the drug
Closed - Members must obtain all of their specialty drugs at our designated specialty pharmacy

Drug name(s)
abiraterone acetate^1,³	ACTEMRA¹	ACTEMRA ACTPEN¹
ADCIRCA¹	ADEMPAS^2,⁴	ADVATE¹
AFINITOR^1,³	AFINITOR DISPERZ^1,³	AFSTYLA¹
ALECENSA^2,^3,⁴	ALUNBRIG²	alyq¹
ambrisentan¹	AMPYRA^1,³	ARCALYST^2,⁴
AUBAGIO^1,³	AVONEX^1,⁴	AVONEX PEN^1,⁴
BETASERON^1,⁴	bexarotene^1,³	bosentan¹
capecitabine^1,⁴	CAPRELSA²	CARBAGLU^2,⁴
CERDELGA¹	CETROTIDE^1,⁴	cinacalcet tab 30mg¹
cinacalcet tab 60mg¹	cinacalcet tab 90mg¹	COMETRIQ^2,^3,⁴
COSENTYX¹	COSENTYX SENSOREADY PEN¹	COTELLIC¹
dalfampridine er^1,³	deferasirox^1,³	dimethyl fumarate¹
dimethyl fumarate starterpack¹	droxidopa¹	DUPIXENT¹
EGRIFTA¹	EGRIFTA SV¹	ELOCTATE¹
ENBREL^1,⁴	ENBREL MINI^1,⁴	ENBREL SURECLICK^1,⁴
EPCLUSA¹	ERIVEDGE^1,³	erlotinib hcl^1,³
ESBRIET¹	ESPEROCT¹	everolimus^1,³
EXJADE^1,³	FIRAZYR¹	FOLLISTIM AQ^1,⁴
FORTEO^1,⁴	GANIRELIX AC INJ 250/0.5^1,⁴	ganirelix ac inj 250/0.5^1,⁴
GILENYA¹	GILOTRIF^2,⁴	glatiramer acetate^1,⁴
glatopa¹	HARVONI^1,⁴	HUMIRA^1,⁴
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK^1,⁴	HUMIRA PEN^1,⁴	HUMIRA PEN-CD/UC/HS STARTER^1,⁴
HUMIRA PEN-PEDIATRIC UC STARTER PACK^1,⁴	HUMIRA PEN-PS/UV STARTER^1,⁴	HYCAMTIN¹
IBRANCE¹	icatibant acetate¹	ICLUSIG^2,³
imatinib mesylate^1,³	IMBRUVICA²	INGREZZA²
INLYTA^1,³	INTRON A¹	IRESSA^2,³
JAKAFI^1,³	JIVI¹	JUXTAPID^2,⁴
KALYDECO¹	KESIMPTA^1,⁴	KISQALI¹
KISQALI FEMARA¹	KOGENATE FS¹	KORLYM²
KOVALTRY¹	KUVAN¹	lapatinib ditosylate^1,⁴
LEDIPASVIR/SOFOSBUVIR^1,⁴	LENVIMA^2,^3,⁴	LONSURF¹
LYNPARZA^2,^3,⁴	MATULANE¹	MAVYRET^1,⁴
MAYZENT¹	MEKINIST¹	miglustat¹
MYALEPT^2,⁴	NEULASTA^1,⁴	NEULASTA ONPRO KIT^1,⁴
NEXAVAR^1,³	NINLARO¹	NORDITROPIN FLEXPRO^1,⁴
NOVOEIGHT¹	NUPLAZID¹	ODOMZO^1,³
OFEV^1,³	ORKAMBI¹	OTEZLA¹
PLEGRIDY¹	PLEGRIDY STARTER PACK¹	PROMACTA¹
REBIF^1,⁴	REBIF REBIDOSE^1,⁴	REBIF REBIDOSE TITRATION PACK^1,⁴
REBIF TITRATION PACK^1,⁴	RETEVMO^1,³	REVATIO¹
REVLIMID¹	RINVOQ¹	RUBRACA^2,^3,⁴
sajazir¹	sapropterin dihydrochloride¹	SENSIPAR¹
SIGNIFOR²	sildenafil sus 10mg/ml¹	sildenafil tab 20mg¹
SIMPONI¹	SKYRIZI¹	SKYRIZI PEN¹
sodium phenylbutyrate¹	SOFOSBUVIR/VELPATASVIR¹	SOMAVERT¹
SOVALDI¹	SPRYCEL^1,^3,⁴	STELARA¹
STIMATE¹	STIVARGA¹	STRENSIQ²
sunitinib malate^1,³	TABRECTA¹	tadalafil¹
TAFINLAR¹	TAGRISSO^2,^3,⁴	TALZENNA^1,³
TARCEVA^1,³	TARGRETIN¹	TARGRETIN^1,³
TASIGNA^1,^3,⁴	temozolomide¹	tetrabenazin tab¹
THALOMID¹	TOBRAMYCIN NEB 300/5ML¹	tobramycin neb 300/4ml¹
tobramycin neb 300/5ml¹	TOLVAPTAN TAB 15MG¹	tolvaptan tab 30mg¹
TREMFYA¹	TYMLOS¹	UPTRAVI^2,⁴
VENCLEXTA²	VENCLEXTA STARTING PACK²	VIZIMPRO^1,³
VOSEVI¹	VOTRIENT^1,³	XALKORI^1,³
XELJANZ¹	XELJANZ XR¹	XOLAIR¹
XTANDI^1,³	ZAVESCA^2,⁴	ZEJULA^2,³
ZELBORAF¹	ZEPOSIA¹	ZEPOSIA 7-DAY STARTER PACK¹
ZEPOSIA STARTER KIT¹	ZOKINVY²	ZOLINZA^1,³
ZYDELIG^2,⁴	ZYKADIA^1,³	ZYTIGA^1,³

¹Specialty

²Limited Distribution

³Split Fill

⁴Exclusive to Accredo

⁵Multiple Products available in both GP and GNP tiers

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Value Plus prescription drug benefits

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Guide to prescription drug benefits

Use this guide to understand how your benefits work.

Drug name(s)

Drug name(s)

Attention deficit hyperactivity disorder (ADHD)

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits (per 30 days or as specified)

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

Androgens - anabolic

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Anticonvulsants

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidiabetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidotes and specific antagonists

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiemetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antihyperlidemics

Drug name(s)

Quantity limits (per 30 days or as specified)

Anti-infective agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits (per 30 days or as specified)

Antipsychotics / antimanic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antivirals

Drug name(s)

Quantity limits (per 30 days or as specified)

Cardiovascular agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Dermatologicals

Drug name(s)

Quantity limits (per 30 days or as specified)

Digestive aids

Drug name(s)

Quantity limits (per 30 days or as specified)

Endocrine and metabolic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Estrogens

Drug name(s)

Quantity limits (per 30 days or as specified)

Gastrointestinal agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Hematologial agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Hematopoietic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Hypnotics / Sedatives / Sleep Disorder Agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Migraine products

Drug name(s)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)

Quantity limits
(per 30 days or as specified)