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- Value Plus prescription drug benefits - July
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) |
||
ACTEMRA1 |
||
ACTEMRA ACTPEN1 |
ADCIRCA1 |
ADEMPAS2 |
ADVATE1 |
||
AFSTYLA1 |
alosetron hcl |
|
ALUNBRIG2 |
alyq1 |
ambrisentan1 |
ANDRODERM |
ARCALYST2 |
|
avita |
AVONEX1 |
|
AVONEX PEN1 |
benzphetamine hcl |
BETASERON1 |
bosentan1 |
buprenorphine |
|
capecitabine1 |
CAPRELSA2 |
CARBAGLU2 |
CERDELGA1 |
CETROTIDE1 |
ciclodan |
ciclopirox nail lacquer |
cinacalcet (SENSIPAR)tab 30mg5 |
|
cinacalcet (SENSIPAR) tab 90mg 5 |
cinacalcet (SENSIPAR) tab 60mg5 |
|
ciprofloxacin/dexamethasone |
clomipramine hcl |
|
CORLANOR |
COSENTYX1 |
|
COSENTYX SENSOREADY PEN1 |
COTELLIC1 |
cyclobenzaprine hcl er |
diclofenac sodium |
||
diethylpropion hcl |
dihydroergotamine mesylate |
dimethyl fumarate1 |
dimethyl fumarate starterpack1 |
doxylamine succinate/pyridoxine hcl |
droxidopa cap 200mg 5 |
droxidopa cap 300mg 5 |
||
droxidopa cap 100mg5 |
DUPIXENT1 |
|
DUPIXENT |
EGRIFTA1 |
EGRIFTA SV1 |
ELOCTATE1 |
EMPAVELI |
ENBREL1 |
ENBREL MINI1 |
ENBREL SURECLICK1 |
EPCLUSA1 |
ESBRIET1 |
||
ESPEROCT1 |
||
FANAPT |
||
FANAPT TITRATION PACK |
fenofibrate |
fenofibric acid dr |
fentanyl |
fentanyl citrate oral transmucosal |
FIRAZYR1 |
FLUOROURACIL |
FOLLISTIM AQ1 |
FORTEO1 |
GANIRELIX AC INJ 250/0.55 |
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 |
||
IMBRUVICA2 |
imiquimod |
imiquimod pump |
INGREZZA2 |
INTRON A1 |
|
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 |
|
lidocaine |
lidocaine hcl |
|
LIDOCAINE HCL JELLY |
lidocaine patch 5% |
lidocaine/prilocaine |
LONSURF1 |
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 |
NEXLETOL |
NEXLIZET |
|
NINLARO1 |
NORDITROPIN FLEXPRO1 |
NOVOEIGHT1 |
NUPLAZID1 |
NYVEPRIA |
|
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 |
|
REVATIO1 |
REVLIMID1 |
RINVOQ1 |
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 |
STELARA1 |
STIMATE1 |
|
STIVARGA1 |
STRENSIQ2 |
SUCRAID |
TABRECTA1 |
tadalafil1 |
|
TAFINLAR1 |
||
TARGRETIN1 |
||
tavaborole |
TAZAROTENE |
|
temozolomide1 |
TESTOSTERONE |
testosterone cypionate |
TESTOSTERONE PUMP |
testosterone topical solution |
tetrabenazine (XENAZINE) tab 12.5mg5 |
tetrabenazine (XENAZINE) tab 25mg5 |
||
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 |
voriconazole |
VOSEVI1 |
|
VRAYLAR |
||
XELJANZ1 |
XELJANZ XR1 |
XOLAIR1 |
ZAVESCA2 |
||
ZELBORAF1 |
ZEPOSIA1 |
ZEPOSIA 7-DAY STARTER PACK1 |
ZEPOSIA STARTER KIT1 |
ZOKINVY2 |
|
ZYDELIG2 |
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
|
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
|
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
|
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
|
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
|
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
|
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
|
30 packets / 30 days |
|
180 packets / 30 days |
|
30 packets / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
180 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
Antiemetics
Drug name(s) |
Quantity limits
|
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
|
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
|
ALINIA SUS 100/5ML |
300 mLs / 90 days |
nitazoxanide tab 500mg |
12 tabs / 90 days |
Antineoplastics and adjunctive therapies
Drug name(s) |
Quantity limits
|
120 tabs / 30 days |
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
90 tabs / 30 days |
|
60 tabs / 30 days |
|
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 |
1 CARTON / 28 days |
|
112 tabs / 28 days |
|
1 CARTON / 28 days |
|
COTELLIC TAB 20MG1 |
63 tabs / 28 days |
30 caps / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
everolimus tab 10mg3 |
30 tabs / 30 days |
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 |
30 tabs / 30 days |
|
everolimus tab 5mg3 |
60 tabs / 30 days |
everolimus tab 5mg3 |
30 tabs / 30 days |
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 |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
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 |
180 tabs / 30 days |
|
120 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
60 tabs / 30 days |
|
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 |
30 caps / 30 days |
|
90 caps / 30 days |
|
60 caps / 30 days |
|
90 caps / 30 days |
|
60 caps / 30 days |
|
90 caps / 30 days |
|
30 caps / 30 days |
|
60 caps / 30 days |
|
LONSURF TAB 15-6.141 |
60 tabs / 28 days |
LONSURF TAB 20-8.191 |
80 tabs / 28 days |
120 tabs / 30 days |
|
120 tabs / 30 days |
|
MEKINIST TAB 0.5MG1 |
90 tabs / 30 days |
MEKINIST TAB 2MG1 |
30 tabs / 30 days |
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 |
30 caps / 30 days |
|
180 caps / 30 days |
|
120 caps / 30 days |
|
120 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
STIVARGA TAB 40MG1 |
84 tabs / 28 days |
90 caps / 30 days |
|
30 caps / 30 days |
|
30 caps / 30 days |
|
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 |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
90 caps / 30 days |
|
30 caps / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
60 tabs / 30 days |
|
120 caps / 30 days |
|
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 |
30 tabs / 30 days |
|
30 tabs / 30 days |
|
30 tabs / 30 days |
|
120 tabs / 30 days |
|
120 caps / 30 days |
|
120 caps / 30 days |
|
120 caps / 30 days |
|
120 tabs / 30 days |
|
60 tabs / 30 days |
|
90 caps / 30 days |
|
ZELBORAF TAB 240MG1 |
240 tabs / 30 days |
120 caps / 30 days |
|
ZYDELIG TAB 100MG2 |
60 tabs / 30 days |
ZYDELIG TAB 150MG2 |
60 tabs / 30 days |
90 tabs / 30 days |
|
120 tabs / 30 days |
Antipsychotics / antimanic agents
Drug name(s) |
Quantity limits
|
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
|
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
|
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
|
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
|
SUCRAID SOL 8500/ML |
236 mLs / 28 days |
Endocrine and metabolic agents
Drug name(s) |
Quantity limits
|
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 |
5 syringes / 30 days |
|
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
|
ORIAHNN CAP |
56 caps / 28 days |
Gastrointestinal agents
Drug name(s) |
Quantity limits
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
60 tabs / 30 days |
|
30 tabs / 30 days |
|
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 |
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 |
240 tabs / 30 days |
|
tetrabenazine tab 25mg5 |
120 tabs / 30 days |
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
|
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 |
60 caps / 30 days |
|
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
|
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
|
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
|
droxidopa cap 100mg 5 |
450 caps / 30 days |
450 caps / 30 days |
|
droxidopa cap 200mg 5 |
180 caps / 30 days |
180 caps / 30 days |
|
droxidopa cap 300mg 5 |
180 caps / 30 days |
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) |
||
ACTEMRA1 |
ACTEMRA ACTPEN1 |
|
ADCIRCA1 |
ADVATE1 |
|
AFSTYLA1 |
||
ALUNBRIG2 |
alyq1 |
|
ambrisentan1 |
||
bosentan1 |
||
CAPRELSA2 |
||
CERDELGA1 |
cinacalcet tab 30mg1 |
|
cinacalcet tab 60mg1 |
cinacalcet tab 90mg1 |
|
COSENTYX1 |
COSENTYX SENSOREADY PEN1 |
COTELLIC1 |
dimethyl fumarate1 |
||
dimethyl fumarate starterpack1 |
droxidopa1 |
DUPIXENT1 |
EGRIFTA1 |
EGRIFTA SV1 |
ELOCTATE1 |
EPCLUSA1 |
||
ESBRIET1 |
ESPEROCT1 |
|
FIRAZYR1 |
||
GILENYA1 |
||
glatopa1 |
||
HYCAMTIN1 |
||
IBRANCE1 |
icatibant acetate1 |
|
IMBRUVICA2 |
INGREZZA2 |
|
INTRON A1 |
||
JIVI1 |
||
KALYDECO1 |
KISQALI1 |
|
KISQALI FEMARA1 |
KOGENATE FS1 |
KORLYM2 |
KOVALTRY1 |
KUVAN1 |
|
LONSURF1 |
||
MATULANE1 |
||
MAYZENT1 |
MEKINIST1 |
miglustat1 |
NINLARO1 |
||
NOVOEIGHT1 |
NUPLAZID1 |
|
ORKAMBI1 |
OTEZLA1 |
|
PLEGRIDY1 |
PLEGRIDY STARTER PACK1 |
PROMACTA1 |
REVATIO1 |
||
REVLIMID1 |
RINVOQ1 |
|
sajazir1 |
sapropterin dihydrochloride1 |
SENSIPAR1 |
SIGNIFOR2 |
sildenafil sus 10mg/ml1 |
sildenafil tab 20mg1 |
SIMPONI1 |
SKYRIZI1 |
SKYRIZI PEN1 |
sodium phenylbutyrate1 |
SOFOSBUVIR/VELPATASVIR1 |
SOMAVERT1 |
SOVALDI1 |
STELARA1 |
|
STIMATE1 |
STIVARGA1 |
STRENSIQ2 |
TABRECTA1 |
tadalafil1 |
|
TAFINLAR1 |
||
TARGRETIN1 |
||
temozolomide1 |
tetrabenazin tab1 |
|
THALOMID1 |
TOBRAMYCIN NEB 300/5ML1 |
tobramycin neb 300/4ml1 |
tobramycin neb 300/5ml1 |
TOLVAPTAN TAB 15MG1 |
tolvaptan tab 30mg1 |
TREMFYA1 |
TYMLOS1 |
|
VENCLEXTA2 |
VENCLEXTA STARTING PACK2 |
|
VOSEVI1 |
||
XELJANZ1 |
XELJANZ XR1 |
XOLAIR1 |
ZELBORAF1 |
ZEPOSIA1 |
ZEPOSIA 7-DAY STARTER PACK1 |
ZEPOSIA STARTER KIT1 |
ZOKINVY2 |
|