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

AFINITOR1,3

AFINITOR DISPERZ1,3

AFSTYLA1

ALECENSA2,3

alosetron hcl

ALUNBRIG2

alyq1

ambrisentan1

AMPYRA1,3

ANDRODERM

ARCALYST2

AUBAGIO1,3

avita

AVONEX1

AVONEX PEN1

benzphetamine hcl

BETASERON1

bexarotene1,3

bosentan1

buprenorphine

capecitabine1

CAPRELSA2

CARBAGLU2

CERDELGA1

CETROTIDE1

ciclodan

ciclopirox nail lacquer

cinacalcet (SENSIPAR) tab 30mg1,5

cinacalcet (SENSIPAR)tab 30mg5

cinacalcet (SENSIPAR) tab 90mg 5

cinacalcet (SENSIPAR) tab 90mg1,5

cinacalcet (SENSIPAR) tab 60mg5

cinacalcet (SENSIPAR) tab 60mg1,5

ciprofloxacin/dexamethasone

clomipramine hcl

COMETRIQ1,2,3

CORLANOR

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

cyclobenzaprine hcl er

dalfampridine er1,3

deferasirox1,3

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 200mg1,5

droxidopa cap 300mg 5

droxidopa cap 100mg5

droxidopa cap 300mg1,5

DUPIXENT1

DUPIXENT

EGRIFTA1

EGRIFTA SV1

ELOCTATE1

EMPAVELI

ENBREL1

ENBREL MINI1

ENBREL SURECLICK1

EPCLUSA1

ERIVEDGE1,3

erlotinib hcl1,3

ESBRIET1

ESPEROCT1

everolimus (ZORTRESS) tab 10mg3,5

everolimus (AFINITOR) tab 5mg1,3,5

everolimus tab 2mg3,5

everolimus (AFINITOR) tab 7.5mg1,3,5

everolimus tab 7.5mg3,5

everolimus tab 3mg3,5

everolimus (AFINITOR) tab 2.5mg1,3,5

everolimus tab 5mg3,5

everolimus tab 2.5mg3,5

EXJADE1,3

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 250/0.51,5

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

ICLUSIG2,3

imatinib mesylate1,3

IMBRUVICA2

imiquimod

imiquimod pump

INGREZZA2

INLYTA1,3

INTRON A1

IRESSA2,3

JAKAFI1,3

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 DOSE2,3

LENVIMA 12MG DAILY DOSE2,3

LENVIMA 14 MG DAILY DOSE2,3

LENVIMA 18 MG DAILY DOSE2,3

LENVIMA 20 MG DAILY DOSE2,3

LENVIMA 24 MG DAILY DOSE2,3

LENVIMA 4 MG DAILY DOSE2,3

LENVIMA 8 MG DAILY DOSE2,3

lidocaine

lidocaine hcl

LIDOCAINE HCL JELLY

lidocaine patch 5%

lidocaine/prilocaine

LONSURF1

LYNPARZA2,3

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

NEXAVAR1,3

NEXLETOL

NEXLIZET

NINLARO1

NORDITROPIN FLEXPRO1

NOVOEIGHT1

NUPLAZID1

NYVEPRIA

ODOMZO1,3

OFEV1,3

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

RETEVMO1,3

REVATIO1

REVLIMID1

RINVOQ1

RUBRACA2,3

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

SPRYCEL1,3

STELARA1

STIMATE1

STIVARGA1

STRENSIQ2

SUCRAID

sunitinib malate1,3

TABRECTA1

tadalafil1

TAFINLAR1

TAGRISSO2,3

TALZENNA1,3

TARCEVA1,3

TARGRETIN1

TARGRETIN1,3

TASIGNA1,3

tavaborole

TAZAROTENE

temozolomide1

TESTOSTERONE

testosterone cypionate

TESTOSTERONE PUMP

testosterone topical solution

tetrabenazine (XENAZINE) tab 12.5mg5

tetrabenazine (XENAZINE) tab 12.5mg1,5

tetrabenazine (XENAZINE) tab 25mg5

tetrabenazine (XENAZINE) tab 25mg1,5

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

VIZIMPRO1,3

voriconazole

VOSEVI1

VOTRIENT1,3

VRAYLAR

XALKORI1,3

XELJANZ1

XELJANZ XR1

XOLAIR1

XTANDI1,3

ZAVESCA2

ZEJULA2,3

ZELBORAF1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOKINVY2

ZOLINZA1,3

ZYDELIG2

ZYKADIA1,3

ZYTIGA1,3

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 150MG2,3

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 100MG2,3

1 CARTON / 28 days

COMETRIQ KIT 140MG2,3

112 tabs / 28 days

COMETRIQ KIT 60MG2,3

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 10MG2,3

30 tabs / 30 days

ICLUSIG TAB 15MG2,3

30 tabs / 30 days

ICLUSIG TAB 30MG2,3

30 tabs / 30 days

ICLUSIG TAB 45MG2,3

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 250MG2,3

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 MG2,3

30 caps / 30 days

LENVIMA CAP 12MG2,3

90 caps / 30 days

LENVIMA CAP 14 MG2,3

60 caps / 30 days

LENVIMA CAP 18 MG2,3

90 caps / 30 days

LENVIMA CAP 20 MG2,3

60 caps / 30 days

LENVIMA CAP 24 MG2,3

90 caps / 30 days

LENVIMA CAP 4MG2,3

30 caps / 30 days

LENVIMA CAP 8 MG2,3

60 caps / 30 days

LONSURF TAB 15-6.141

60 tabs / 28 days

LONSURF TAB 20-8.191

80 tabs / 28 days

LYNPARZA TAB 100MG2,3

120 tabs / 30 days

LYNPARZA TAB 150MG2,3

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 200MG2,3

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 40MG2,3

30 tabs / 30 days

TAGRISSO TAB 80MG2,3

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 100MG2,3

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 250/0.51,5

5 syringes / 30 days

ganirelix ac inj 250/0.51,5

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 12.5mg1,5

240 tabs / 30 days

tetrabenazine tab 25mg5

120 tabs / 30 days

tetrabenazine tab 25mg1,5

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 acetate1,3

ACTEMRA1

ACTEMRA ACTPEN1

ADCIRCA1

ADEMPAS2,4

ADVATE1

AFINITOR1,3

AFINITOR DISPERZ1,3

AFSTYLA1

ALECENSA2,3,4

ALUNBRIG2

alyq1

ambrisentan1

AMPYRA1,3

ARCALYST2,4

AUBAGIO1,3

AVONEX1,4

AVONEX PEN1,4

BETASERON1,4

bexarotene1,3

bosentan1

capecitabine1,4

CAPRELSA2

CARBAGLU2,4

CERDELGA1

CETROTIDE1,4

cinacalcet tab 30mg1

cinacalcet tab 60mg1

cinacalcet tab 90mg1

COMETRIQ2,3,4

COSENTYX1

COSENTYX SENSOREADY PEN1

COTELLIC1

dalfampridine er1,3

deferasirox1,3

dimethyl fumarate1

dimethyl fumarate starterpack1

droxidopa1

DUPIXENT1

EGRIFTA1

EGRIFTA SV1

ELOCTATE1

ENBREL1,4

ENBREL MINI1,4

ENBREL SURECLICK1,4

EPCLUSA1

ERIVEDGE1,3

erlotinib hcl1,3

ESBRIET1

ESPEROCT1

everolimus1,3

EXJADE1,3

FIRAZYR1

FOLLISTIM AQ1,4

FORTEO1,4

GANIRELIX AC INJ 250/0.51,4

ganirelix ac inj 250/0.51,4

GILENYA1

GILOTRIF2,4

glatiramer acetate1,4

glatopa1

HARVONI1,4

HUMIRA1,4

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1,4

HUMIRA PEN1,4

HUMIRA PEN-CD/UC/HS STARTER1,4

HUMIRA PEN-PEDIATRIC UC STARTER PACK1,4

HUMIRA PEN-PS/UV STARTER1,4

HYCAMTIN1

IBRANCE1

icatibant acetate1

ICLUSIG2,3

imatinib mesylate1,3

IMBRUVICA2

INGREZZA2

INLYTA1,3

INTRON A1

IRESSA2,3

JAKAFI1,3

JIVI1

JUXTAPID2,4

KALYDECO1

KESIMPTA1,4

KISQALI1

KISQALI FEMARA1

KOGENATE FS1

KORLYM2

KOVALTRY1

KUVAN1

lapatinib ditosylate1,4

LEDIPASVIR/SOFOSBUVIR1,4

LENVIMA2,3,4

LONSURF1

LYNPARZA2,3,4

MATULANE1

MAVYRET1,4

MAYZENT1

MEKINIST1

miglustat1

MYALEPT2,4

NEULASTA1,4

NEULASTA ONPRO KIT1,4

NEXAVAR1,3

NINLARO1

NORDITROPIN FLEXPRO1,4

NOVOEIGHT1

NUPLAZID1

ODOMZO1,3

OFEV1,3

ORKAMBI1

OTEZLA1

PLEGRIDY1

PLEGRIDY STARTER PACK1

PROMACTA1

REBIF1,4

REBIF REBIDOSE1,4

REBIF REBIDOSE TITRATION PACK1,4

REBIF TITRATION PACK1,4

RETEVMO1,3

REVATIO1

REVLIMID1

RINVOQ1

RUBRACA2,3,4

sajazir1

sapropterin dihydrochloride1

SENSIPAR1

SIGNIFOR2

sildenafil sus 10mg/ml1

sildenafil tab 20mg1

SIMPONI1

SKYRIZI1

SKYRIZI PEN1

sodium phenylbutyrate1

SOFOSBUVIR/VELPATASVIR1

SOMAVERT1

SOVALDI1

SPRYCEL1,3,4

STELARA1

STIMATE1

STIVARGA1

STRENSIQ2

sunitinib malate1,3

TABRECTA1

tadalafil1

TAFINLAR1

TAGRISSO2,3,4

TALZENNA1,3

TARCEVA1,3

TARGRETIN1

TARGRETIN1,3

TASIGNA1,3,4

temozolomide1

tetrabenazin tab1

THALOMID1

TOBRAMYCIN NEB 300/5ML1

tobramycin neb 300/4ml1

tobramycin neb 300/5ml1

TOLVAPTAN TAB 15MG1

tolvaptan tab 30mg1

TREMFYA1

TYMLOS1

UPTRAVI2,4

VENCLEXTA2

VENCLEXTA STARTING PACK2

VIZIMPRO1,3

VOSEVI1

VOTRIENT1,3

XALKORI1,3

XELJANZ1

XELJANZ XR1

XOLAIR1

XTANDI1,3

ZAVESCA2,4

ZEJULA2,3

ZELBORAF1

ZEPOSIA1

ZEPOSIA 7-DAY STARTER PACK1

ZEPOSIA STARTER KIT1

ZOKINVY2

ZOLINZA1,3

ZYDELIG2,4

ZYKADIA1,3

ZYTIGA1,3

1Specialty

2Limited Distribution

3Split Fill

4Exclusive to Accredo

5Multiple Products available in both GP and GNP tiers