Value Prescription Drug Benefits

Effective January 1, 2020

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


Key:

UPPERCASE names = Brand

lowercase names = Generic


Guide to Prescription Drug Benefits

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

Use this guide to understand how your benefits work.

Drug Name(s)

ACTEMRA ACTPEN1 ACTEMRA1 ADEMPAS1, 2
ALECENSA1, 2 ambrisentan1 ARANESP ALBUMIN FREE1
armodafinil AUBAGIO1 AVONEX PEN1
AVONEX1 BELSOMRA BERINERT1
BETASERON1 bosentan1 capecitabine1
CAYSTON1 CHORIONIC GONADOTROPIN1 CIMZIA1
CINRYZE1, 2 clomipramine hcl clomipramine hydrochloride
CORLANOR COTELLIC1 DARAPRIM
EMSAM ENBREL SURECLICK1 ENBREL1
EPCLUSA1 ERIVEDGE1 erlotinib hydrochloride1
ESBRIET1 fentanyl fentanyl citrate oral transmucosal
FLUNISOLIDE GILENYA1 GILOTRIF1, 2
glatiramer acetate1 glatopa1 HARVONI1
HUMALOG HUMALOG JUNIOR KWIKPEN HUMALOG KWIKPEN
HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1 HUMIRA PEN1
HUMIRA PEN-CD/UC/HS STARTER1 HUMIRA PEN-PS/UV STARTER1 HUMIRA1
HYCAMTIN1 hydromorphone hcl er hydromorphone hydrochloride
hydromorphone hydrochloride er HYQVIA1 IBRANCE
IBRANCE1 INSULIN LISPRO INSULIN LISPRO KWIKPEN
INTRON A1 KALYDECO1 KOGENATE FS1
KOVALTRY1 LEDIPASVIR/SOFOSBUVIR1 LENVIMA 10 MG DAILY DOSE1, 2
LENVIMA 12MG DAILY DOSE1, 2 LENVIMA 14 MG DAILY DOSE1, 2 LENVIMA 18 MG DAILY DOSE1, 2
LENVIMA 20 MG DAILY DOSE1, 2 LENVIMA 24 MG DAILY DOSE1, 2 LENVIMA 4 MG DAILY DOSE1, 2
LENVIMA 8 MG DAILY DOSE1, 2 LETAIRIS1 metaxall
metaxalone methadone hcl methadone hydrochloride
METHITEST METHYLTESTOSTERONE miglustat1
modafinil morphine sulfate cr morphine sulfate er
NINLARO1 NORDITROPIN FLEXPRO1 NOVAREL1
NOVOEIGHT1 NUCYNTA ER NUPLAZID1
NUWIQ1 octreotide acetate1 OTEZLA1
OXYCODONE HCL ER OXYCODONE HYDROCHLORIDE ER OXYCONTIN
OXYMORPHONE HYDROCHLORIDE ER OXYMORPHONE HYDROCHLORIDE ER POMALYST1
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1 PROCRIT1 ramelteon
REBIF REBIDOSE TITRATION PACK1 REBIF REBIDOSE1 REBIF TITRATION PACK1
REBIF1 REGRANEX RESTASIS
RESTASIS MULTIDOSE ROZEREM sildenafil citrate1
SIMPONI1 sodium phenylbutyrate1 SOFOSBUVIR/VELPATASVIR1
STIMATE1 TARCEVA1 TECFIDERA STARTER PACK1
TECFIDERA1 testosterone cypionate TESTOSTERONE ENANTHATE
tobramycin TRACLEER1 tramadol hcl er
tramadol hydrochloride er VENCLEXTA STARTING PACK1, 2 VENCLEXTA1, 2
VIIBRYD VOSEVI1 XELJANZ XR1
XELJANZ1 XIFAXAN ZARXIO1
ZURAMPIC ZYDELIG1, 2 ZYTIGA1

Drug Name(s)

ACCU-CHEK AVIVA PLUS ACCU-CHEK COMPACT PLUS ACCU-CHEK COMPACT STRIPS
ACCU-CHEK COMPACT TEST DRUM ACCU-CHEK GUIDE ACCU-CHEK SMARTVIEW STRIPS
ACCUTREND GLUCOSE ADVANCE INTUITION TEST STRIPS ADVANCE MICRO-DRAW TEST STRIPS
ADVOCATE REDI-CODE ADVOCATE REDI-CODE+ TEST STRIPS ADVOCATE TEST STRIPS
AGAMATRIX AMP NO CODE TEST STRIPS AGAMATRIX JAZZ TEST STRIPS AGAMATRIX KEYNOTE TEST STRIPS
AGAMATRIX PRESTO TEST STRIPS ASSURE 3 TEST STRIPS ASSURE 4 TEST STRIPS
ASSURE II ASSURE II CHECK STRIP ASSURE II TEST STRIPS
ASSURE PLATINUM TEST STRIPS ASSURE PRISM MULTI TEST STRIPS ASSURE PRO TEST STRIPS
AT LAST TEST STRIPS BEPREVE BIOSCANNER GLUCOSE TEST STRIPS
BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS PREMIUM CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM
CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE CARESENS N BLOOD GLUCOSE TEST STRIPS CARETOUCH BLOOD GLUCOSE TEST STRIPS
CLEVER CHEK AUTO-CODE TEST STRIPS CLEVER CHEK AUTO-CODE VOICE TEST STRIPS CLEVER CHEK TEST STRIPS
CLEVER CHOICE AUTO-CODE PRO TEST STRIPS CLEVER CHOICE MICRO TEST STRIPS CLEVER CHOICE NO CODING TEST STRIPS
CLEVER CHOICE TALK NO CODING TEST STRIPS CONTOUR BLOOD GLUCOSE TEST STRIPS CONTOUR NEXT BLOOD GLUCOSE TEST
COOL BLOOD GLUCOSE TEST STRIPS CVS ADVANCED GLUCOSE METER TEST STRIPS D-CARE BLOOD GLUCOSE
DIATHRIVE BLOOD GLUCOSE TEST STRIPS DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS DUO-CARE TEST STRIPS
EASY PLUS BLOOD GLUCOSE TEST STRIPS EASY PLUS II BLOOD GLUCOSE TEST EASY STEP TEST STRIPS
EASY TALK BLOOD GLUCOSE TEST STRIPS EASY TOUCH GLUCOSE TEST STRIPS EASY TRAK BLOOD GLUCOSE TEST STRIPS
EASYGLUCO EASYGLUCO PLUS EASYMAX 15 TEST STRIPS
EASYMAX TEST STRIPS EASYPLUS BLOOD GLUCOSE TEST STRIP EASYPRO BLOOD GLUCOSE TEST STRIPS
EASYPRO PLUS ELEMENT COMPACT TEST STRIPS ELEMENT TEST STRIPS
EMADINE EMBRACE BLOOD GLUCOSE TEST STRIPS EMBRACE EVO BLOOD GLUCOSETEST STRIPS
EMBRACE PRO BLOOD GLUCOSE TEST STRIPS EMBRACE TALK BLOOD GLUCOSE TEST STRIPS EQ BLOOD GLUCOSE TEST STRIPS
EVENCARE + BLOOD GLUCOSE TEST STRIP EVENCARE BLOOD GLUCOSE TEST STRIP EVENCARE G2 TEST STRIPS
EVENCARE G3 TEST STRIPS EVENCARE MINI BLOOD GLUCOSE TEST STRIPS EVOLUTION AUTOCODE
EXACTECH R-S-G TEST STRIPS EXACTECH TEST STRIPS EZ SMART BLOOD GLUCOSE TEST STRIPS
EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS FANAPT FANAPT TITRATION PACK
FIFTY50 GLUCOSE TEST STRIP 2.0 FORA BLOOD GLUCOSE TEST STRIPS FORA D15G BLOOD GLUCOSE TEST STRIPS
FORA D20 BLOOD GLUCOSE TEST STRIPS FORA D40/G31 BLOOD GLUCOSE TEST STRIPS FORA G20 BLOOD GLUCOSE TEST STRIPS
FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS FORA GD20 TEST STRIPS FORA GD50 BLOOD GLUCOSE TEST STRIPS
FORA GTEL BLOOD GLUCOSE TEST STRIPS FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS FORA V10 BLOOD GLUCOSE TEST STRIPS
FORA V12 BLOOD GLUCOSE TEST STRIPS FORA V20 BLOOD GLUCOSE TEST STRIPS FORA V30A BLOOD GLUCOSE TEST STRIPS
FORACARE GD40 FORACARE PREMIUM V10 TESTSTRIPS FORACARE TEST N GO TEST STRIPS
FORTISCARE BLOOD GLUCOSE TEST STRIP FREESTYLE INSULINX BLOOD GLUCOSE TEST FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS
FREESTYLE LITE TEST STRIPS FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS FREESTYLE TEST STRIPS
GE100 BLOOD GLUCOSE TEST STRIPS GENULTIMATE TEST STRIPS GHT TEST STRIPS
GLUCO PERFECT 3 TEST STRIPS GLUCOCARD 01 SENSOR PLUS GLUCOCARD 01 SENSOR PLUS TEST STRIPS
GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS GLUCOCARD SHINE TEST STRIPS GLUCOCARD VITAL TEST STRIPS
GLUCOCARD X-SENSOR GLUCOCOM TEST STRIPS GLUCONAVII BLOOD GLUCOSE TEST STRIPS
GLUCOSE METER TEST STRIPS ADVANCED GNP EASY TOUCH GLUCOSE TEST STRIPS GOJJI BLOOD GLUCOSE TEST STRIPS
GOJJI BLOOD GLUCOSE TEST STRIPS/GOJJI STERILE LANCETS 30G GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS HALOG
HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS IGLUCOSE BLOOD GLUCOSE TEST STRIPS
IN TOUCH BLOOD GLUCOSE TEST STRIPS INFINITY BLOOD GLUCOSE TEST STRIPS INFINITY VOICE
KETOPROFEN KROGER BLOOD GLUCOSE TESTSTRIPS KROGER HEALTHPRO GLUCOSE TEST STRIPS
KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS KROGER TEST STRIPS LASTACAFT
LATANOPROST LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS LIBERTY TEST STRIPS
LIVALO LYRICA MEIJER BLOOD GLUCOSE TEST STRIPS
MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS
MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS MICRODOT TEST STRIPS MM EASY TOUCH GLUCOSE TEST STRIPS
MYGLUCOHEALTH BLOOD GLUCOSE TEST MYRBETRIQ NEUTEK 2TEK TEST STRIPS
NEXGEN TEST STRIPS NOVA MAX GLUCOSE TEST STRIPS ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS
ON CALL PLUS BLOOD GLUCOSE TEST ON CALL VIVID BLOOD GLUCOSE TEST ON CALL VIVID BLOOD GLUCOSE TEST STRIPS
ONE DROP BLOOD GLUCOSE TEST STRIPS OPTIUM TEST STRIPS OPTIUMEZ TEST STRIPS
OPTUMRX BLOOD GLUCOSE TEST
PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS
PRECISION PCX PRECISION PCX PLUS TEST STRIPS PRECISION POINT OF CARE TEST STRIPS
PRECISION QID TEST STRIPS PRECISION SOF-TACT TEST STRIPS PRECISION XTRA BLOOD GLUCOSE TEST STRIPS
PREMIUM BLOOD GLUCOSE TEST STRIPS PRESTIGE TEST STRIPS PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS
PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS PTS PANELS GLUCOSE TEST QUICKTEK TEST STRIPS
QUINTET AC BLOOD GLUCOSE TEST STRIPS QUINTET BLOOD GLUCOSE TEST STRIPS RA TRUETEST STRIPS
REFUAH PLUS BLOOD GLUCOSE TEST STRIPS RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM RELION BLOOD GLUCOSE TEST STRIPS
RELION CONFIRM/MICRO TEST STRIPS RELION PREMIER BLOOD GLUCOSE TEST STRIPS RELION PRIME BLOOD GLUCOSE TEST STRIPS
RELION ULTIMA BLOOD GLUCOSE TEST STRIPS RELION ULTIMA TEST STRIPS REVEAL BLOOD GLUCOSE TEST
REXALL BLOOD GLUCOSE TEST STRIPS REXULTI RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS
RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS SAVELLA
SAVELLA TITRATION PACK SIDEKICK BLOOD GLUCOSE SYSTEM SMART SENSE PREMIUM BLOOD GLUCOSE STRIPS
SMART SENSE VALUE BLOOD GLUCOSE STRIPS SMARTEST BLOOD GLUCOSE TEST STRIPS SOLUS V2 AUDIBLE TEST
SUPREME TEST STRIPS SURE EDGE BLOOD GLUCOSE TEST STRIPS SURECHEK BLOOD GLUCOSE TEST STRIPS
SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS TELCARE BLOOD GLUCOSE TEST STRIPS TGT BLOOD GLUCOSE TEST STRIPS
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM TOVIAZ TRAVATAN Z
TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS TRUE METRIX BLOOD GLUCOSE TEST STRIPS TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS
TRUETEST STRIPS TRUETRACK BLOOD GLUCOSE TEST TRUETRACK TEST
ULTIMA TEST STRIPS ULTRATRAK PRO TEST STRIPS ULTRATRAK ULTIMATE TEST STRIPS
UNISTRIP1 GENERIC VERASENS BLOOD GLUCOSE TEST STRIPS VICTORY AGM-4000 TEST STRIPS
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS VOCAL POINT BLOOD GLUCOSE TEST STRIPS WAVESENSE PRESTO TEST STRIPS

Actinic Keratosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

imiquimod cream 5% 48 Packets/60 Days

Acute Migraine 5HT

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

almotriptan malate tablet 6.25mg 24 Tablets/30 Days
almotriptan malate tablet 12.5mg 14 Tablets/30 Days
eletriptan tablet 20mg 18 Tablets/30 Days
eletriptan tablet 40mg 12 Tablets/30 Days
frovatriptan tablet 2.5mg 27 Tablets/30 Days
naratriptan tablet 1mg 18 Tablets/30 Days
naratriptan tablet 2.5mg 18 Tablets/30 Days
rizatriptan tablet 5mg 36 Tablets/30 Days
rizatriptan tablet 5mg odt 36 Tablets/30 Days
rizatriptan tablet 10mg 18 Tablets/30 Days
rizatriptan tablet 10mg odt 18 Tablets/30 Days
sumatriptan spray 5mg/act 5 Packs/30 Days
sumatriptan injection 4mg/0.5 12 Cartridges/30 Days
sumatriptan injection 4mg/0.5 12 Syringes/30 Days
sumatriptan injection 6mg/0.5 12 Syringes/30 Days
sumatriptan injection 6mg/0.5 12 Cartridges/30 Days
sumatriptan spray 20mg/act 12 Inhalers/30 Days
sumatriptan tablet 25mg 27 Tablets/30 Days
sumatriptan tablet 50mg 18 Tablets/30 Days
sumatriptan tablet 100mg 18 Tablets/30 Days
zolmitriptan tablet 2.5mg 18 Tablets/30 Days
zolmitriptan tablet 5mg 12 Tablets/30 Days

Alinia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ALINIA SUSPENSION 100/5ML 300 mLs/90 Days
ALINIA TABLET 500MG 12 Tablets/90 Days

Ampyra

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

dalfampridine tablet 10mg er1 60 Tablets/30 Days

Androgen/Anabolic Steroids

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

testosterone cypionate injection 100mg/m 1 Vial/28 Days
testosterone cypionate injection 200mg/m 10 mLs/28 Days
TESTOST ENAN INJECTION 200MG/ML 1 Vial/28 Days
testosterone gel 1%(25mg) 60 Packets/30 Days
testosterone gel 1%(50mg) 60 Packets/30 Days
testosterone gel pump 1% 300 Grams/30 Days
TESTOSTERONE GEL PUMP 1% 4 Pumps/30 Days
TESTOSTERONE INJECTION CYPIONATE 10 mLs/28 Days

Antiemetic

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AKYNZEO CAPSULE 300-0.5 2 Capsules/30 Days
aprepitant capsule 80mg 8 Capsules/30 Days
aprepitant capsule 40mg 8 Capsules/30 Days
aprepitant capsule 125mg 4 Capsules/30 Days
CESAMET CAPSULE 1MG 42 Capsules/30 Days
granisetron tablet 1mg 14 Tablets/30 Days
ondansetron solution 4mg/5m 5 Bottles/30 Days
ondansetron tablet 4mg odt 24 Tablets/30 Days
ondansetron tablet 8mg odt 24 Tablets/30 Days

Antifungal

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ciclodan solution 8% 3.3 mLs/30 Days
ciclopirox solution 8% 3.3 mLs/30 Days

Anti-Influenza

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

oseltamivir capsule 30mg 40 Capsules/120 Days
oseltamivir capsule 45mg 20 Capsules/120 Days
oseltamivir capsule 75mg 20 Capsules/120 Days
oseltamivir suspension 6mg/m 300 mLs/120 Days

Antiretroviral

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RELENZA MIS DISKHALER 40 Blisters/120 Days

Atypical Antipsychotics

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

olanzapine tablet 2.5mg 30 Tablets/30 Days
olanzapine tablet 5mg 30 Tablets/30 Days
olanzapine tablet 7.5mg 30 Tablets/30 Days
olanzapine tablet 10mg 30 Tablets/30 Days
olanzapine tablet 15mg 30 Tablets/30 Days
olanzapine tablet 20mg 30 Tablets/30 Days
paliperidone tablet er 1.5mg 60 Tablets/30 Days
paliperidone tablet er 3mg 60 Tablets/30 Days
paliperidone tablet er 6mg 60 Tablets/30 Days
paliperidone tablet er 9mg 60 Tablets/30 Days
quetiapine tablet 50mg er 60 Tablets/30 Days
quetiapine tablet 150mg er 60 Tablets/30 Days
quetiapine tablet 200mg er 60 Tablets/30 Days
quetiapine tablet 300mg er 60 Tablets/30 Days
quetiapine tablet 400mg er 60 Tablets/30 Days

Biologic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ACTEMRA INJECTION 162/0.91 4 Syringes/28 Days
CIMZIA KIT STARTER1 3 Kits/180 Days
CIMZIA PREFL KIT 200MG/ML1 1 Kit/28 Days
ENBREL INJECTION 25/0.5ML1 8 Syringes/28 Days
ENBREL INJECTION 25MG1 8 Vials/28 Days
ENBREL INJECTION 50MG/ML1 4 Syringes/28 Days
ENBREL MINI INJECTION 50MG/ML1 4 Cartridges/28 Days
ENBREL SRCLK INJECTION 50MG/ML1 4 Syringes/28 Days
HUMIRA INJECTION 10/0.1ML1 2 Syringes/28 Days
HUMIRA INJECTION 10MG/0.21 2 Syringes/28 Days
HUMIRA INJECTION 20/0.2ML1 2 Syringes/28 Days
HUMIRA INJECTION 40/0.4ML1 2 Syringes/28 Days
HUMIRA KIT 20MG/0.41 2 Syringes/28 Days
HUMIRA KIT 40MG/0.81 2 Syringes/28 Days
HUMIRA PEDIA INJECTION CROHNS1 1 Kit/180 Days
HUMIRA PEDIA INJECTION CROHNS1 3 Kit/180 Days
HUMIRA PEN INJECTION 40/0.4ML1 2 Pens/28 Days
HUMIRA PEN INJECTION 40MG/0.81 2 Pens/28 Days
HUMIRA PEN INJECTION CD/UC/HS1 1 Kit/180 Days
HUMIRA PEN INJECTION PS/UV1 1 Kit/180 Days
HUMIRA PEN KIT CD/UC/HS1 1 Kit/180 Days
HUMIRA PEN KIT PS/UV1 1 Kit/180 Days
SIMPONI INJECTION 100MG/ML1 1 Syringe/28 Days
SIMPONI INJECTION 50/0.5ML1 1 Syringe/28 Days
XELJANZ TABLET 5MG1 60 Tablets/30 Days
XELJANZ TABLET 10MG1 60 Tablets/30 Days
XELJANZ XR TABLET 11MG1 30 Tablets/30 Days
XELJANZ XR TABLET 22MG1 112 Tablets/365 Days

Bisphosphonates

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

alendronate tablet 35mg 4 Tablets/28 Days
alendronate tablet 70mg 4 Capsules/28 Days
FOSAMAX + D TABLET 70-2800 4 Capsules/28 Days
FOSAMAX + D TABLET 70-5600 4 Capsules/28 Days
ibandronate tablet 150mg 1 Tablet/28 Days
risedronate tablet 35mg 4 Tablets/28 Days
risedronate tablet 150mg 1 Tablet/28 Days

Cystic Fibrosis Transmembrane Regulator (CFTR)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

KALYDECO PAK 25MG1 60 Packets/30 Days
KALYDECO PAK 50MG1 60 Packets/30 Days
KALYDECO PAK 75MG1 60 Packets/30 Days
KALYDECO TABLET 150MG1 60 Tablets/30 Days

Constipation Agents

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

LINZESS CAPSULE 72MCG 30 Capsules/30 Days
LINZESS CAPSULE 145MCG 30 Capsules/30 Days
LINZESS CAPSULE 290MCG 30 Capsules/30 Days
MOVANTIK TABLET 12.5MG 30 Tablets/30 Days
MOVANTIK TABLET 25MG 30 Tablets/30 Days

Fibromyalgia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

LYRICA CAPSULE 25MG 90 Capsules/30 Days
LYRICA CAPSULE 50MG 90 Capsules/30 Days
LYRICA CAPSULE 75MG 90 Capsules/30 Days
LYRICA CAPSULE 100MG 93 Capsules/30 Days
LYRICA CAPSULE 150MG 90 Capsules/30 Days
LYRICA CAPSULE 200MG 90 Capsules/30 Days
LYRICA CAPSULE 225MG 60 Capsules/30 Days
LYRICA CAPSULE 300MG 60 Capsules/30 Days
LYRICA SOLUTION 20MG/ML 900 mLs/30 Days
pregabalin solution 20mg/m 900 mLs/30 Days
pregabalin capsule 50mg 90 Capsules/30 Days
pregabalin capsule 75mg 90 Capsules/30 Days
pregabalin capsule 100mg 90 Capsules/30 Days
pregabalin capsule 150mg 90 Capsules/30 Days
pregabalin capsule 200mg 90 Capsules/30 Days
pregabalin capsule 225mg 60 Capsules/30 Days
pregabalin capsule 300mg 60 Capsules/30 Days
SAVELLA MIS TITR PAK 1 Kit/180 Days
SAVELLA TABLET 12.5MG 60 Tablets/30 Days
SAVELLA TABLET 25MG 60 Tablets/30 Days
SAVELLA TABLET 50MG 60 Tablets/30 Days
SAVELLA TABLET 100MG 60 Tablets/30 Days

Gonadotropin Hormones

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CHOR GONADOT INJECTION 10000UNT1 2 Vials/30 Days
NOVAREL INJECTION 10000UNT1 2 Vials/30 Days
NOVAREL INJECTION 5000UNIT1 4 Vials/30 Days
PREGNYL INJECTION 10000UNT1 2 Vials/30 Days

Hereditary Angioedema (HAE)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

BERINERT INJECTION 500UNIT1 10 Vials/30 Days
CINRYZE SOLUTION 500 UNIT1,2 20 Vials/30 Days

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

CORLANOR TABLET 5MG 60 Tablets/30 Days
CORLANOR TABLET 7.5MG 60 Tablets/30 Days

IBS-D

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

alosetron tablet 0.5mg 60 Tablets/30 Days
alosetron tablet 1mg 60 Tablets/30 Days
XIFAXAN TABLET 200MG 9 Tablets/30 Days
XIFAXAN TABLET 550MG 60 Tablets/30 Days

Idiopathic Pulmonary Fibrosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ESBRIET CAPSULE 267MG1 180 Capsules/30 Days
ESBRIET TABLET 267MG1 180 Tablets/30 Days
ESBRIET TABLET 801MG1 90 Tablets/30 Days

Insomnia

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

BELSOMRA TABLET 5MG 30 Tablets/30 Days
BELSOMRA TABLET 10MG 32 Tablets/30 Days
BELSOMRA TABLET 15MG 30 Tablets/30 Days
BELSOMRA TABLET 20MG 30 Tablets/30 Days
eszopiclone tablet 1mg 30 Tablets/30 Days
eszopiclone tablet 2mg 30 Tablets/30 Days
eszopiclone tablet 3mg 30 Tablets/30 Days
ramelteon tablet 8mg 30 Tablets/30 Days
ROZEREM TABLET 8MG 30 Tablets/30 Days
zaleplon capsule 5mg 30 Capsules/30 Days
zaleplon capsule 10mg 30 Capsules/30 Days
zolpidem tablet 5mg 30 Tablets/30 Days
zolpidem tablet 10mg 30 Tablets/30 Days

Lidocaine Transdermal

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

lidocaine/prilocaine cream 2.5-2.5% 60 Grams/30 Days

Multiple Sclerosis

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

AUBAGIO TABLET 7MG1 30 Tablets/30 Days
AUBAGIO TABLET 14MG1 30 Tablets/30 Days
AVONEX KIT 30MCG1 1 Pack/28 Days
AVONEX PEN KIT 30MCG1 1 Pack/28 Days
AVONEX PREFL KIT 30MCG1 1 Kit/28 Days
BETASERON INJECTION 0.3MG1 1 Box/28 Days
GILENYA CAPSULE 0.5MG1 30 Tablets/30 Days
glatiramer injection 20mg/m1 30 Syringes/30 Days
glatiramer injection 40mg/m1 12 Syringes/28 Days
glatopa injection 20mg/m1 30 Syringes/30 Days
glatopa injection 40mg/m1 12 Syringes/28 Days
REBIF INJECTION 22/0.51 12 Syringes/28 Days
REBIF INJECTION 44/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION 22/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION 44/0.51 1 Carton/28 Days
REBIF REBIDO INJECTION TITRATN1 1 Kit/180 Days
REBIF TITRTN INJECTION PACK1 1 Kit/180 Days
TECFIDERA CAPSULE 120MG1 56 Capsules/180 Days
TECFIDERA CAPSULE 240MG1 60 Capsules/30 Days
TECFIDERA MIS STARTER1 1 Kit/180 Days

Muscle Relaxants

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

BACLOFEN TABLET 5MG 120 Tablets/30 Days
baclofen tablet 10mg 120 Tablets/30 Days
baclofen tablet 20mg 120 Tablets/30 Days
carisoprodol tablet 250mg 28 Tablets/30 Days
carisoprodol tablet 350mg 28 Tablets/30 Days
CHLORZOXAZON TABLET 500MG 28 Tablets/30 Days
cyclobenzaprine tablet 5mg 21 Tablets/30 Days
cyclobenzaprine tablet 10mg 90 Capsules/30 Days
dantrolene capsule 25mg 90 Capsules/30 Days
dantrolene capsule 50mg 90 Capsules/30 Days
dantrolene capsule 100mg 90 Capsules/30 Days
metaxall tablet 800mg 28 Tablets/30 Days
metaxalone tablet 800mg 28 Tablets/30 Days
methocarbamol tablet 500mg 60 Tablets/30 Days
methocarbamol tablet 750mg 44 Tablets/30 Days
orphenadrine tablet 100mg cr 42 Tablets/30 Days
orphenadrine tablet 100mg er 42 Tablets/30 Days
tizanidine tablet 2mg 42 Capsules/30 Days
tizanidine tablet 4mg 42 Capsules/30 Days

Natpara

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NATPARA INJECTION 25MCG1 1 Kit/28 Days
NATPARA INJECTION 50MCG1 1 Kit/28 Days
NATPARA INJECTION 75MCG1 1 Kit/28 Days
NATPARA INJECTION 100MCG1 1 Kit/28 Days

Nuvigil/Provigil

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

armodafinil tablet 50mg 30 Tablets/30 Days
armodafinil tablet 150mg 30 Tablets/30 Days
armodafinil tablet 200mg 30 Tablets/30 Days
armodafinil tablet 250mg 30 Tablets/30 Days
modafinil tablet 100mg 30 Tablets/30 Days
modafinil tablet 200mg 30 Tablets/30 Days

Ophthalmic Immunomodulators

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

RESTASIS EMULSION 0.05% 2 Vials/30 Days
RESTASIS MULTIDOSE EMULSION 0.05% 1 Bottle/30 Days

Ophthalmic Prostaglandins

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

latanoprost solution 0.005% 2.5 mLs/30 Days
TRAVATAN Z DROPPER 0.004% 2.5 mLs/30 Days

Opioids ER

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

fentanyl dis 12mcg/hr 10 Patches/30 Days
fentanyl dis 25mcg/hr 0
fentanyl dis 50mcg/hr 0
fentanyl dis 75mcg/hr 0
fentanyl dis 100mcg/h 0
hydromorphone tablet 8mg er 30 Tablets/30 Days
hydromorphone tablet 12mg er 30 Tablets/30 Days
hydromorphone tablet 16mg er 0
hydromorphone tablet 32mg er 0
morphine sulfate tablet 15mg er 60 Tablets/30 Days
morphine sulfate tablet 30mg er 30 Tablets/30 Days
morphine sulfate tablet 60mg er 0
morphine sulfate tablet 100mg cr 0
morphine sulfate tablet 100mg er 0
morphine sulfate tablet 200mg er 0
NUCYNTA ER TABLET 50MG 60 Tablets/30 Days
NUCYNTA ER TABLET 100MG 0
NUCYNTA ER TABLET 150MG 0
NUCYNTA ER TABLET 200MG 0
NUCYNTA ER TABLET 250MG 0
OXYCODONE TABLET 10MG ER 60 Tablets/30 Days
OXYCODONE TABLET 15MG ER 60 Tablets/30 Days
OXYCODONE TABLET 20MG ER 30 Tablets/30 Days
OXYCODONE TABLET 30MG ER 30 Tablets/30 Days
OXYCODONE TABLET 40MG ER 0
OXYCODONE TABLET 60MG ER 0
OXYCODONE TABLET 80MG ER 0
OXYCONTIN TABLET 10MG CR 60 Tablets/30 Days
OXYCONTIN TABLET 15MG CR 60 Tablets/30 Days
OXYCONTIN TABLET 20MG CR 30 Tablets/30 Days
OXYCONTIN TABLET 30MG CR 30 Tablets/30 Days
OXYCONTIN TABLET 40MG CR 0
OXYCONTIN TABLET 60MG CR 0
OXYCONTIN TABLET 80MG CR 0
OXYMORPHONE TABLET 5MG ER 60 Tablets/30 Days
OXYMORPHONE TABLET 7.5MG ER 60 Tablets/30 Days
OXYMORPHONE TABLET 10MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 15MG ER 30 Tablets/30 Days
OXYMORPHONE TABLET 20MG ER 0 Tablets/30 Days
OXYMORPHONE TABLET 30MG ER 0
OXYMORPHONE TABLET 40MG ER 0
tramadol hcl tablet 100mg er 30 Tablets/30 Days
tramadol hcl tablet 200mg er 30 Tablets/30 Days
tramadol hcl tablet 300mg er 30 Tablets/30 Days
morphine sulfate tablet 15mg 15 Tablets/30 Days
morphine sulfate tablet 30mg 15 Tablets/30 Days

Opioids IR

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

acetaminophen/codeine solution 120-12/5 450 mLs/30 Days
acetaminophen/codeine tablet 300-15mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-30mg 30 Tablets/30 Days
acetaminophen/codeine tablet 300-60mg 25 Tablets/30 Days
butorphanol solution 10mg/m 1 Bottle/30 Days
CODEINE SULFATE TABLET 15MG 30 Tablets/30 Days
codeine sulfate tablet 30mg 30 Tablets/30 Days
CODEINE SULFATE TABLET 60MG 25 Tablets/30 Days
codeine/acetaminophen tablet 30-300mg 30 Tablets/30 Days
codeine/acetaminophen table 60-300mg 25 Tablets/30 Days
codeine/acetaminophen 120 mg/12 mg/5 mL solution 450 mLs/30 Days
endocet tablet 2.5-325 60 Tablets/30 Days
endocet tablet 5-325mg 18 Tablets/30 Days
endocet tablet 7.5-325 20 Tablets/30 Days
endocet tablet 10-325mg 15 Tablets/30 Days
HYDROCODONE/ACETAMINOPHEN TABLET 2.5-325 60 Tablets/30 Days
hydrocodone/acetaminophen tablet 2.5-325 60 Tablets/30 Days
hydrocodone/acetaminophen tablet 5-325mg 40 Tablets/30 Days
hydrocodone/acetaminophen tablet 7.5-325 30 Tablets/30 Days
hydrocodone/acetaminophen tablet 10-325mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 5-200mg 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 7.5-200 25 Tablets/30 Days
hydrocodone/ibuprofen tablet 10-200mg 25 Tablets/30 Days
hydromorphone liquid 1mg/m 60 mLs/30 Days
hydromorphone tablet 2mg 30 Tablets/30 Days
hydromorphone tablet 4mg 15 Tablets/30 Days
hydromorphone tablet 8mg 5 Tablets/30 Days
hydromorphone liquid 1mg/m 60 mLs/30 Days
hydromorphone tablet 2mg 30 Tablets/30 Days
hydromorphone tablet 4mg 15 Tablets/30 Days
hydromorphone tablet 8mg 5 Tablets/30 Days
ibudone tablet 5-200mg 25 Tablets/30 Days
levorphanol tablet 2mg 10 Tablets/30 Days
lorcet tablet 5-325mg 40 Tablets/30 Days
lorcet plus tablet 7.5-325 30 Tablets/30 Days
lorcet hd tablet 10-325mg 25 Tablets/30 Days
meperidine tablet 50mg 30 Tablets/30 Days
MEPERIDINE SOLUTION 50MG/5ML 150 mLs/30 Days
meperidine tablet 100mg 15 Tablets/30 Days
methadone solution 5mg/5m 10 mLs/30 Days
methadone solution 10mg/5m 5 mLs/30 Days
methadone tablet 5mg 60 Tablets/30 Days
methadone tablet 10mg 30 Tablets/30 Days
morphine sulfate solution 10/0.5m 10 mLs/30 Days
morphine sulfate solution 10mg/5m 125 mLs/30 Days
morphine sulfate solution 100/5m 10 mLs/30 Days
morphine sulfate solution 20mg/5m 60 mLs/30 Days
morphine sulfate solution 20mg/m 10 mLs/30 Days
MORPHINE SULFATE TABLET 15MG 15 Tablets/30 Days
MORPHINE SULFATE TABLET 30MG 5 Tablets/30 Days
NUCYNTA TABLET 50MG 10 Tablets/30 Days
NUCYNTA TABLET 75MG 5 Tablets/30 Days
NUCYNTA TABLET 100MG 5 Tablets/30 Days
oxycodone/acetaminophen tablet 2.5-325 60 Tablets/30 Days
oxycodone/acetaminophen tablet 5-325mg 30 Tablets/30 Days
oxycodone/acetaminophen tablet 7.5-325 20 Tablets/30 Days
oxycodone/acetaminophen tablet 10-325mg 15 Tablets/30 Days
oxycodone/aspirin tablet 30 Tablets/30 Days
OXYCODONE/IBUPROFEN TABLET 5-400MG 20 Tablets/30 Days
oxycodone concentrate 10/0.5m 5 mLs/30 Days
oxycodone concentrate 100/5m 5 mLs/30 Days
oxycodone solution 5mg/5m 165 mLs/30 Days
oxycodone concentrate 10/0.5m 5 mLs/30 Days
oxycodone tablet 5mg 30 Tablets/30 Days
oxycodone tablet 10mg 15 Tablets/30 Days
oxycodone tablet 15mg 10 Tablets/30 Days
oxycodone tablet 20mg 5 Tablets/30 Days
oxycodone tablet 30mg 5 Tablets/30 Days
OXYCODONE/ SOLUTION APAP 100 mLs/30 Days
tramadol hcl tablet 50mg 50 Tablets/30 Days
VERDROCET TABLET 2.5-325 60 Tablets/30 Days
xylon tablet 10-200mg 25 Tablets/30 Days

Ophthalmic Prostaglandins

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

travoprost dro 0.004% 2.5 mLs/30 Days

Oral Inhalers

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ADVAIR DISKUS AER 100/50 60 Blisters/30 Days
ADVAIR DISKUS AER 250/50 60 Blisters/30 Days
ADVAIR DISKUS AER 500/50 60 Blisters/30 Days
ADVAIR HFA AER 45/21 1 Canister/30 Days
ADVAIR HFA AER 115/21 1 Canister/30 Days
ADVAIR HFA AER 230/21 1 Canister/30 Days
ASMANEX 30 AER 110MCG 1 Canister/30 Days
ASMANEX 30 AER 220MCG 1 Canister/30 Days
ASMANEX 60 AER 220MCG 1 Canister/30 Days
ASMANEX HFA AER 100 MCG 1 Canister/30 Days
ASMANEX HFA AER 200 MCG 1 Canister/30 Days
ASMANEX 120 AER 220MCG 1 Canister/30 Days
BREO ELLIPTA INHALER 100-25 60 Blisters/30 Days
BREO ELLIPTA INHALER 200-25 60 Blisters/30 Days
FLOVENT DISK AER 50MCG 60 Blisters/30 Days
FLOVENT DISK AER 100MCG 60 Blisters/30 Days
FLOVENT DISK AER 250MCG 240 Blisters/30 Days
FLOVENT HFA AER 44MCG 1 Canister/30 Days
FLOVENT HFA AER 110MCG 1 Canister/30 Days
FLOVENT HFA AER 220MCG 2 Canisters/30 Days
fluticasone/salmeterol aer 100/50 60 Blisters/30 Days
fluticasone/salmeterol aer 250/50 60 Blisters/30 Days
fluticasone/salmeterol aer 500/50 60 Blisters/30 Days
QVAR AER 40MCG 1 Canister/30 Days
QVAR AER 80MCG 2 Canisters/30 Days
QVAR REDIHALER AER 40MCG 1 Canister/30 Days
QVAR REDIHALER AER 80MCG 2 Canisters/30 Days
wixela inhub aer 100/50 60 Blisters/30 Days
wixela inhub aer 250/50 60 Blisters/30 Days
wixela inhub aer 500/50 60 Blisters/30 Days

Oral PAH

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ADEMPAS TABLET 0.5MG1,2 90 Tablets/30 Days
ADEMPAS TABLET 1MG1,2 90 Tablets/30 Days
ADEMPAS TABLET 1.5MG1,2 90 Tablets/30 Days
ADEMPAS TABLET 2MG1,2 90 Tablets/30 Days
ADEMPAS TABLET 2.5MG1,2 90 Tablets/30 Days
alyq tablet 20mg1 60 Tablets/30 Days
ambrisentan tablet 5mg1 30 Tablets/30 Days
ambrisentan tablet 10mg1 30 Tablets/30 Days
bosentan tablet 62.5mg1 60 Tablets/30 Days
bosentan tablet 125mg1 60 Tablets/30 Days
LETAIRIS TABLET 5MG1 30 Tablets/30 Days
LETAIRIS TABLET 10MG1 30 Tablets/30 Days
sildenafil tablet 20mg1 90 Tablets/30 Days
tadalafil tablet 20mg1 60 Tablets/30 Days
TRACLEER TABLET 32MG1 120 Tablets/30 Days
TRACLEER TABLET 62.5MG1 60 Tablets/30 Days
TRACLEER TABLET 125MG1 60 Tablets/30 Days

Otezla

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

OTEZLA TABLET 10/20/301 1 Kit/180 Days
OTEZLA TABLET 30MG1 60 Tablets/30 Days

Proton Pump Inhibitor (PPI)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

DEXILANT CAPSULE 30MG DR 30 Capsules/30 Days
DEXILANT CAPSULE 60MG DR 30 Capsules/30 Days
lansoprazole capsule 30mg dr 30 Capsules/30 Days
omeprazole capsule 40mg 30 Capsules/30 Days
pantoprazole tablet 20mg 30 Tablets/30 Days
pantoprazole tablet 20mg dr 30 Tablets/30 Days
pantoprazole tablet 40mg 30 Tablets/30 Days
pantoprazole tablet 40mg dr 30 Tablets/30 Days
rabeprazole tablet 20mg 30 Tablets/30 Days

Regranex

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

REGRANEX GEL 0.01% 1 Tube/30 Days

Oncology

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

abiraterone tablet 250mg1 120 Tablets/30 Days
ALECENSA CAPSULE 150MG1,2 240 Capsules/30 Days
COTELLIC TABLET 20MG1 63 Tablets/28 Days
ERIVEDGE CAPSULE 150MG1 30 Capsules/30 Days
erlotinib tablet 100mg1 30 Tablets/30 Days
erlotinib tablet 150mg1 30 Tablets/30 Days
erlotinib tablet 25mg1 60 Tablets/30 Days
GILOTRIF TABLET 20MG1,2 30 Tablets/30 Days
GILOTRIF TABLET 30MG1,2 30 Tablets/30 Days
GILOTRIF TABLET 40MG1,2 30 Tablets/30 Days
IBRANCE CAPSULE 75MG1 21 Capsules/28 Days
IBRANCE CAPSULE 100MG1 21 Capsules/28 Days
IBRANCE CAPSULE 125MG1 21 Capsules/28 Days
LENVIMA CAPSULE 4MG1,2 30 Capsules/30 Days
LENVIMA CAPSULE 8 MG1,2 60 Capsules/30 Days
LENVIMA CAPSULE 10 MG1,2 30 Capsules/30 Days
LENVIMA CAPSULE 12MG1,2 90 Capsules/30 Days
LENVIMA CAPSULE 14 MG1,2 60 Capsules/30 Days
LENVIMA CAPSULE 18 MG1,2 90 Capsules/30 Days
LENVIMA CAPSULE 20 MG1,2 60 Capsules/30 Days
LENVIMA CAPSULE 24 MG1,2 90 Capsules/30 Days
NINLARO CAPSULE 2.3MG1 3 Capsules/28 Days
NINLARO CAPSULE 3MG1 3 Capsules/28 Days
NINLARO CAPSULE 4MG1 3 Capsules/28 Days
POMALYST CAPSULE 1MG1 21 Capsules/28 Days
POMALYST CAPSULE 2MG1 21 Capsules/28 Days
POMALYST CAPSULE 3MG1 21 Capsules/28 Days
POMALYST CAPSULE 4MG1 21 Capsules/28 Days
TARCEVA TABLET 25MG1 60 Tablets/30 Days
TARCEVA TABLET 100MG1 30 Tablets/30 Days
TARCEVA TABLET 150MG1 30 Tablets/30 Days
VENCLEXTA TABLET START PK1,2 1 Pack/180 Days
VENCLEXTA TABLET 10MG1,2 60 Tablets/30 Days
VENCLEXTA TABLET 50MG1,2 30 Tablets/30 Days
VENCLEXTA TABLET 100MG1,2 180 Tablets/30 Days
ZYDELIG TABLET 100MG1,2 60 Tablets/30 Days
LETZYDELIG TABLET 150MG1,2 60 Tablets/30 Days
ZYTIGA TABLET 500MG1 60 Tablets/30 Days

Somatostatin Analogs

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

octreotide injection 1000/5m1 30 mLs/30 Days
octreotide injection 1000mcg1 30 mLs/30 Days
octreotide injection 100mcg1 90 mLs/30 Days
octreotide injection 200mcg1 30 mLs/30 Days
OCTREOTIDE INJECTION 200MCG1 90 mLs/30 Days
octreotide injection 50mcg/m1 90 mLs/30 Days
octreotide injection 5000/5m1 30 mLs/30 Days
octreotide injection 500mcg1 30 mLs/30 Days

Selective Serotonin Inverse Agonist (SSIA)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NUPLAZID TABLET 10MG1 30 Tablets/30 Days
NUPLAZID TABLET 17MG1 60 Tablets/30 Days
NUPLAZID CAPSULE 34MG1 30 Capsules/30 Days

Statin

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

atorvastatin tablet 10mg 45 Tablets/30 Days
atorvastatin tablet 20mg 45 Tablets/30 Days
atorvastatin tablet 40mg 45 Tablets/30 Days
atorvastatin tablet 80mg 30 Tablets/30 Days
LIVALO TABLET 1MG 45 Tablets/30 Days
LIVALO TABLET 2MG 45 Tablets/30 Days
LIVALO TABLET 4MG 30 Tablets/30 Days
lovastatin tablet 10mg 60 Tablets/30 Days
lovastatin tablet 20mg 60 Tablets/30 Days
lovastatin tablet 40mg 60 Tablets/30 Days
pravastatin tablet 10mg 45 Tablets/30 Days
pravastatin tablet 20mg 45 Tablets/30 Days
pravastatin tablet 40mg 45 Tablets/30 Days
pravastatin tablet 80mg 30 Tablets/30 Days
rosuvastatin tablet 10mg 45 Tablets/30 Days
rosuvastatin tablet 20mg 45 Tablets/30 Days
rosuvastatin tablet 40mg 30 Tablets/30 Days
rosuvastatin tablet 5mg 45 Tablets/30 Days
simvastatin tablet 10mg 45 Tablets/30 Days
simvastatin tablet 20mg 60 Tablets/30 Days
simvastatin tablet 40mg 45 Tablets/30 Days
simvastatin tablet 5mg 45 Tablets/30 Days
simvastatin tablet 80mg 30 Tablets/30 Days

Substrate Reduction Therapy

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

miglustat capsule 100mg1 90 Capsules/30 Days

Topical Corticosteroids

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ala-cort cream 2.5% 454 Grams/30 Days
alclometasone cream 0.05% 120 Grams/30 Days
alclometasone ointment 0.05% 120 Grams/30 Days
AMCINONIDE LOTION 0.1% 120 mLs/30 Days
augmented betamethasone cream 0.05% 200 Grams/28 Days
AUGMENTED BETAMET GEL 0.05% 200 Grams/28 Days
augmented betamethasone lotion 0.05% 210 mLs/30 Days
augmented betamethasone ointment 0.05% 200 Grams/28 Days
BETAMETHASONE DIPROPIONATE GEL 0.05% 200 Grams/28 Days
betamethasone dipropionate cream 0.05% 135 Grams/30 Days
betamethasone dipropionate lotion 0.05% 120 mLs/30 Days
betamethasone dipropionate ointment 0.05% 135 Grams/30 Days
betamethasone valerate cream 0.1% 135 Grams/30 Days
betamethasone valerate lotion 0.1% 120 mLs/30 Days
betamethasone valerate ointment 0.1% 135 Grams/30 Days
clobetasol cream 0.05% 210 Grams/28 Days
clobetasol e cream 0.05% 210 Grams/28 Days
clobetasol ointment 0.05% 210 Grams/28 Days
clobetasol solution 0.05% 200 mLs/28 Days
CLOCORTOLONE CREAM 0.1% 135 Grams/30 Days
CLOCORTOLONE CREAM PIV 0.1% 135 Grams/30 Days
desonide cream 0.05% 120 Grams/30 Days
desonide lotion 0.05% 118 mLs/30 Days
desonide ointment 0.05% 120 Grams/30 Days
desoximetasone cream 0.05% 120 Grams/30 Days
desoximetasone cream 0.25% 120 Grams/30 Days
desoximetasone gel 0.05% 120 Grams/30 Days
desoximetasone ointment 0.05% 120 Grams/30 Days
desoximetasone ointment 0.25% 120 Grams/30 Days
DIFLORASONE CREAM 0.05% 120 Grams/30 Days
diflorasone ointment 0.05% 120 Grams/30 Days
fluocinolone acetonide cream 0.01% 120 Grams/30 Days
fluocinolone acetonide cream 0.025% 120 Grams/30 Days
fluocinolone acetonide oil 0.01% scalp 118.28 mLs/30 Days
fluocinolone acetonide oil 0.01% body 118.28 mLs/30 Days
fluocinolone acetonide oil body 118.28 mLs/30 Days
fluocinolone acetonide oil scalp 118.28 mLs/30 Days
fluocinolone acetonide ointment 0.025% 120 Grams/30 Days
fluocinolone acetonide solution 0.01% 120 mLs/30 Days
fluocinonide cream 0.05% 120 Grams/30 Days
fluocinonide cream e 0.05% 120 Grams/30 Days
fluocinonide gel 0.05% 120 Grams/30 Days
fluocinonide ointment 0.05% 120 Grams/30 Days
fluocinonide solution 0.05% 120 mLs/30 Days
flurandrenol lotion 0.05% 120 mLs/30 Days
fluticasone cream 0.05% 120 Grams/30 Days
fluticasone ointment 0.005% 120 Grams/30 Days
halcinonide cream 0.1% 240 Grams/30 Days
halobetasol cream 0.05% 200 Grams/28 Days
halobetasol ointment 0.05% 200 Grams/28 Days
HALOG CREAM 0.1% 240 Grams/30 Days
HALOG OINTMENT 0.1% 240 Grams/30 Days
hydrocortisone cream 2.5% 454 Grams/30 Days
hydrocortisone lotion 2.5% 118 mLs/30 Days
hydrocortisone ointment 2.5% 454 Grams/30 Days
mometasone cream 0.1% 135 Grams/30 Days
mometasone ointment 0.1% 135 Grams/30 Days
mometasone solution 0.1% 120 mLs/30 Days
nolix lotion 0.05% 120 mLs/30 Days
PREDNICARBATE CREAM 0.1% 120 Grams/30 Days
PREDNICARBATE OINTMENT 0.1% 120 Grams/30 Days
triamcinolone cream 0.025% 454 Grams/30 Days
triamcinolone cream 0.1% 454 Grams/30 Days
triamcinolone cream 0.5% 454 Grams/30 Days
triamcinolone lotion 0.025% 120 mLs/30 Days
triamcinolone lotion 0.1% 120 mLs/30 Days
triamcinolone ointment 0.025% 454 Grams/30 Days
triamcinolone ointment 0.1% 454 Grams/30 Days
triamcinolone ointment 0.5% 120 Grams/30 Days
triderm cream 0.1% 454 Grams/30 Days
triderm cream 0.5% 454 Grams/30 Days

Topical Lidocaine

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

SYNERA DIS 70-70MG 4 Patches/30 Days

Topical NSAID

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

diclofenac gel 1% 10 Tubes/30 Days

Transmucosal Immediate Release Fentanyl

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

fentanyl ot lozenge 200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 400mcg 120 Lozenges/30 Days
fentanyl ot lozenge 600mcg 120 Lozenges/30 Days
fentanyl ot lozenge 800mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1200mcg 120 Lozenges/30 Days
fentanyl ot lozenge 1600mcg 120 Lozenges/30 Days

URAT1 Inhibitor

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ZURAMPIC TABLET 200MG 30 Tablets/30 Days

Drug Name(s)

abiraterone acetate1 ACTEMRA ACTPEN1 ACTEMRA1
ADEMPAS1, 2 ALECENSA1, 2 alyq1
ambrisentan1 ARANESP ALBUMIN FREE1 AUBAGIO1
AVONEX PEN1 AVONEX1 BERINERT1
BETASERON1 bosentan1 capecitabine1
CAYSTON1 CHORIONIC GONADOTROPIN1 CIMZIA STARTER KIT1
CIMZIA1 CINRYZE1, 2 COTELLIC1
CYSTAGON1, 2 dalfampridine er1 dofetilide1
ENBREL MINI1 ENBREL SURECLICK1 ENBREL1
entecavir1 EPCLUSA1 ERIVEDGE1
erlotinib hydrochloride1 ESBRIET1 GILENYA1
GILOTRIF1, 2 glatiramer acetate1 glatopa1
HARVONI1 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK1 HUMIRA PEN1
HUMIRA PEN-CD/UC/HS STARTER1 HUMIRA PEN-PS/UV STARTER1 HUMIRA1
HYCAMTIN1 HYQVIA1 IBRANCE1
imatinib mesylate1 INCRELEX1, 2 INTRON A1
KALYDECO1 KOGENATE FS KOGENATE FS BIO-SET1 KOVALTRY1
LEDIPASVIR/SOFOSBUVIR1 LENVIMA 10 MG DAILY DOSE1, 2 LENVIMA 12MG DAILY DOSE1, 2
LENVIMA 14 MG DAILY DOSE1, 2 LENVIMA 18 MG DAILY DOSE1, 2 LENVIMA 20 MG DAILY DOSE1, 2
LENVIMA 24 MG DAILY DOSE1, 2 LENVIMA 4 MG DAILY DOSE1, 2 LENVIMA 8 MG DAILY DOSE1, 2
LETAIRIS1 leuprolide acetate1 miglustat1
NATPARA1 NEXAVAR1 NINLARO1
NORDITROPIN FLEXPRO1 NOVAREL1 NOVOEIGHT1
NUPLAZID1 NUWIQ1 octreotide acetate1
OCTREOTIDE ACETATE1 OTEZLA1 PEGASYS PROCLICK1
PEGASYS1 POMALYST1 PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1
PROCRIT1 REBIF REBIDOSE TITRATION PACK1 REBIF REBIDOSE1
REBIF TITRATION PACK1 REBIF1 ribasphere1
ribavirin1 sildenafil citrate SIMPONI1
sodium phenylbutyrate1 SOFOSBUVIR/VELPATASVIR1 STIMATE1
tadalafil1 TARCEVA1 TASIGNA1
TECFIDERA STARTER PACK1 TECFIDERA1 tobramycin sulfate1
TOBRAMYCIN1 tobramycin1 TRACLEER1
TYKERB1 VELTASSA1 VENCLEXTA STARTING PACK1, 2
VENCLEXTA1, 2 VOSEVI1 XALKORI1
XELJANZ XR1 XELJANZ1 ZARXIO1
ZYDELIG1, 2 ZYTIGA1  

1Specialty

2Limited Distribution