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- Value Prescription Drug Benefits - January
Value prescription drug benefits
Effective January 1, 2021
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) |
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ACTEMRA ACTPEN1 |
ACTEMRA1 |
|
|
alyq |
ambrisentan1 |
|
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ARANESP ALBUMIN FREE1 |
avita |
|
|
AVONEX PEN1 |
AVONEX1 |
BELSOMRA |
|
BERINERT1 |
BETASERON1 |
bosentan1 |
|
capecitabine1 |
CAYSTON1 |
CHORIONIC GONADOTROPIN1 |
|
ciclodan |
ciclopirox soln |
CIMZIA1 |
|
clomipramine hcl |
clomipramine hydrochloride |
|
|
CORLANOR |
COTELLIC1 |
dalfampridine er |
|
DARAPRIM |
DESVENLAFAXINE ER |
dimethyl fumarate |
|
EMBEDA |
EMSAM |
ENBREL SURECLICK1 |
|
ENBREL/-MINI1 |
EPCLUSA1 |
EPIDIOLEX |
|
erlotinib hydrochloride1 |
ESBRIET1 |
|
|
fentanyl |
fentanyl citrate oral transmucosal |
FLUNISOLIDE |
|
FLUOXETINE |
GILENYA1 |
|
|
glatiramer acetate1 |
glatopa1 |
HARVONI1 |
|
HUMALOG |
HUMALOG JUNIOR KWIKPEN |
HUMALOG KWIKPEN |
|
HUMALOG MIX / |
HUMALOG MIX / KWIKPEN |
HUMALOG MIX /2 |
|
HUMALOG MIX /2 KWIKPEN |
HUMIRA PEN1 |
HUMIRA1 |
|
HYCAMTIN1 |
hydromorphone hcl er |
hydromorphone hydrochloride |
|
hydromorphone hydrochloride er |
HYQVIA1 |
IBRANCE1 |
|
INSULIN LISPRO |
INSULIN LISPRO KWIKPEN |
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN |
|
INTRON A1 |
KALYDECO1 |
KEVZARA |
|
KOGENATE FS1 |
KOVALTRY1 |
LEDIPASVIR/SOFOSBUVIR1 |
|
MAPROTILINE HCL |
||
|
MECLOFENAMATE SODIUM |
metformin hydrochloride er (osmotic release/modified release) |
metaxall |
|
metaxalone |
methadone hcl |
METHITEST |
|
METHYLTESTOSTERONE |
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 HYDROCHLORIDEER |
pimecrolimus |
|
POMALYST1 |
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL 1 |
PROCRIT1 |
|
pyrimethamine |
ramelteon |
REBIF REBIDOSE TITRATION PACK1 |
|
REBIF REBIDOSE1 |
REBIF TITRATION PACK1 |
REBIF1 |
|
REGRANEX |
RESTASIS |
RESTASIS MULTIDOSE |
|
RINVOQ1 |
ROZEREM |
sildenafil citrate1 |
|
SIMPONI1 |
SKYRIZI1 |
sodium phenylbutyrate1 |
|
SOFOSBUVIR/VELPATASVIR1 |
STELARA1 |
STIMATE1 |
|
tacrolimus |
tadalafil 2 mg1 |
|
|
tazarotene |
testosterone cypionate |
|
|
TESTOSTERONE ENANTHATE |
tobramycin |
TRACLEER1 |
|
tramadol hcl er |
tramadol hydrochloride er |
tretinoin |
|
VIIBRYD |
VOSEVI1 |
|
|
XELJANZ XR1 |
XELJANZ1 |
XIFAXAN |
|
ZARXIO1 |
ZIOPTAN1 |
ZURAMPIC |
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ZYTIGA1 |
|
|
Drug Name(s) |
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|
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 GLUCOSETEST 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 |
|
INVOKAMET |
INVOKAMET XR |
INVOKANA |
|
JANUMET |
JANUMET XR |
JANUVIA |
|
JARDIANCE |
KETOPROFEN |
KROGER BLOOD GLUCOSE TESTSTRIPS |
|
KROGER HEALTHPRO GLUCOSE TEST STRIPS |
KROGER HEALTHPRO GLUCOSE TEST STRIPS |
KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS |
|
KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS |
KROGER TEST STRIPS |
lanthanum carbonate |
|
LASTACAFT |
LATANOPROST |
LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS |
|
LIBERTY TEST STRIPS |
LIVALO |
LUMIGAN |
|
LYRICA |
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 |
ONGLYZA |
|
OPTIUM TEST STRIPS |
OPTIUMEZ TEST STRIPS |
OPTUMRX BLOOD GLUCOSE TEST |
|
OZEMPIC |
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 |
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PRECISION XTRA BLOOD GLUCOSE TEST STRIPS |
PREDNICARBATE |
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 GLUCOSETEST STRIPS |
|
RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM |
RELION BLOOD GLUCOSE TESTSTRIPS |
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 BLOODGLUCOSE 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 |
|
SYNJARDY |
SYNJARDY XR |
TELCARE BLOOD GLUCOSE TEST STRIPS |
|
TGT BLOOD GLUCOSE TEST STRIPS |
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM |
TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS |
|
TRUE METRIX BLOOD GLUCOSETEST STRIPS |
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS |
TRUETEST STRIPS |
|
TRUETRACK BLOOD GLUCOSE TEST |
TRUETRACK TEST |
TRULICITY |
|
ULTIMA TEST STRIPS |
ULTRATRAK PRO TEST STRIPS |
ULTRATRAK ULTIMATE TEST STRIPS |
|
UNISTRIP1 GENERIC |
VERASENS BLOOD GLUCOSE TEST STRIPS |
VICTORY AGM-4000 TEST STRIPS |
|
VICTOZA |
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS |
VOCAL POINT BLOOD GLUCOSE TEST STRIPS |
|
VRAYLAR |
WAVESENSE PRESTO TEST STRIPS |
|
Actinic Keratosis
Drug Name(s) |
Quantity Limits
|
|
cream 5% |
48 Packets/60 Days |
Acute Migraine 5HT
Drug Name(s) |
Quantity Limits
|
|
almotriptan malate tablet 6.25mg |
24 Tablets/30 Days |
|
almotriptan malate tablet 12.5mg |
12 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
|
|
ALINIA SUSPENSION 100/5ML |
300 mLs/90 Days |
|
ALINIA TABLET 500MG |
12 Tablets/90 Days |
Ampyra
Drug Name(s) |
Quantity Limits
|
|
dalfampridine tablet 10mg er1 |
60 Tablets/30 Days |
Androgen/Anabolic Steroids
Drug Name(s) |
Quantity Limits
|
|
testosterone cypionate injection 100mg/ml |
1 Vial/28 Days |
|
testosterone cypionate injection 200mg/ml |
10 mLs/28 Days |
|
testosterone 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
|
|
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/5ml |
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
|
|
ciclodan solution 8% |
3.3 mLs/30 Days |
|
ciclopirox solution 8% |
3.3 mLs/30 Days |
Anti-Influenza
Drug Name(s) |
Quantity Limits
|
|
oseltamivir capsule 30mg |
40 Capsules/120 Days |
|
oseltamivir capsule 45mg |
20 Capsules/120 Days |
|
oseltamivir capsule 75mg |
20 Capsules/120 Days |
|
oseltamivir suspension 6mg/ml |
300 mLs/120 Days |
Antiretroviral
Drug Name(s) |
Quantity Limits
|
|
RELENZA MIS DISKHALER |
40 Blisters/120 Days |
Atypical Antipsychotics
Drug Name(s) |
Quantity Limits
|
|
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
|
|
ACTEMRA INJECTION 162/0.91 |
4 Syringes/28 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
|
|
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
|
|
KALYDECO PACK 25MG1 |
60 Packets/30 Days |
|
KALYDECO PACK 50MG1 |
60 Packets/30 Days |
|
KALYDECO PACK 75MG1 |
60 Packets/30 Days |
|
KALYDECO TABLET 150MG1 |
60 Tablets/30 Days |
Constipation Agents
Drug Name(s) |
Quantity Limits
|
|
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
|
|
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/ml |
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 |
90 Capsules/30 Days |
|
pregabalin capsule 300mg |
90 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
|
|
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
|
|
BERINERT INJECTION 500UNIT1 |
10 Vials/30 Days |
|
20 Vials/30 Days |
Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker
Drug Name(s) |
Quantity Limits
|
|
CORLANOR TABLET 5MG |
60 Tablets/30 Days |
|
CORLANOR TABLET 7.5MG |
60 Tablets/30 Days |
Irritable Bowel Syndrome with Diarrhea (IBS-D)
Drug Name(s) |
Quantity Limits
|
|
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
|
|
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
|
|
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
|
|
lidocaine/prilocaine cream 2.5-2.5% |
60 Grams/30 Days |
Multiple Sclerosis
Drug Name(s) |
Quantity Limits
|
|
30 Tablets/30 Days |
|
|
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/ml1 |
30 Syringes/30 Days |
|
glatiramer injection 40mg/ml1 |
12 Syringes/28 Days |
|
glatopa injection 20mg/ml1 |
30 Syringes/30 Days |
|
glatopa injection 40mg/ml1 |
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 |
|
56 Capsules/180 Days |
|
|
60 Capsules/30 Days |
Muscle Relaxants
Drug Name(s) |
Quantity Limits
|
|
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
|
|
NATPARA INJECTION 25MCG1 |
1 Kit/28 Days |
|
NATPARA INJECTION 50MCG1 |
1 Kit/28 Days |
|
NATPARA INJECTION 75MCG1 |
1 Kit/28 Days |
|
NATPARA INJECTION 100MCG1 |
2 Kit/28 Days |
Nuvigil/Provigil
Drug Name(s) |
Quantity Limits
|
|
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
|
|
RESTASIS EMULSION 0.05% |
2 Vials/30 Days |
|
RESTASIS MULTIDOSE EMULSION 0.05% |
1 Bottle/30 Days |
Ophthalmic Prostaglandins
Drug Name(s) |
Quantity Limits
|
|
latanoprost solution 0.005% |
2.5 mLs/30 Days |
|
TRAVATAN Z DROPPER 0.004% |
2.5 mLs/30 Days |
Opioids Extended Release (ER)
Drug Name(s) |
Quantity Limits
|
|
dis 12mcg/hr |
10 Patches/30 Days |
|
dis 25mcg/hr |
0 |
|
fentanyl dis 50mcg/hr |
0 |
|
fentanyl dis 75mcg/hr |
0 |
|
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 Immediate Release (IR)
Drug Name(s) |
Adult Quantity Limit – 5 Days |
Child Quantity Limit – 3 Days |
|
acetaminophen/codeine solution 120-12/5 |
450 mLs/30 Days |
270 mL/30 days |
|
acetaminophen/codeine tablet 300-15mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
acetaminophen/codeine tablet 300-30mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
acetaminophen/codeine tablet 300-60mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
butorphanol solution 10mg/ml |
1 Bottle/30 Days |
N/A |
|
CODEINE SULFATE TABLET 15MG |
30 Tablets/30 Days |
N/A |
|
codeine sulfate tablet 30mg |
30 Tablets/30 Days |
N/A |
|
CODEINE SULFATE TABLET 60MG |
25 Tablets/30 Days |
N/A |
|
codeine/acetaminophen tablet 30-300mg |
30 Tablets/30 Days |
N/A |
|
codeine/acetaminophen table 60-300mg |
25 Tablets/30 Days |
N/A |
|
codeine/acetaminophen 120 mg/12 mg/5 mL solution |
450 mLs/30 Days |
N/A |
|
endocet tablet 2.5-325 |
60 Tablets/30 Days |
N/A |
|
endocet tablet 5-325mg |
18 Tablets/30 Days |
N/A |
|
endocet tablet 7.5-325 |
20 Tablets/30 Days |
N/A |
|
endocet tablet 10-325mg |
15 Tablets/30 Days |
N/A |
|
HYDROCODONE/ACETAMINOPHEN TABLET 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
|
hydrocodone/acetaminophen tablet 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
|
hydrocodone/acetaminophen tablet 5-325mg |
40 Tablets/30 Days |
24 tablets/30 days |
|
hydrocodone/acetaminophen tablet 7.5-325 |
30 Tablets/30 Days |
18 tablets/30 days |
|
hydrocodone/acetaminophen tablet 10-325mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/ibuprofen tablet 5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/ibuprofen tablet 7.5-200 |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydrocodone/ibuprofen tablet 10-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
hydromorphone liquid 1mg/ml |
60 mLs/30 Days |
36 mL/30 days |
|
hydromorphone tablet 2mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
hydromorphone tablet 4mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
hydromorphone tablet 8mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
hydromorphone liquid 1mg/ml |
60 mLs/30 Days |
36 mL/30 days |
|
hydromorphone tablet 2mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
hydromorphone tablet 4mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
hydromorphone tablet 8mg |
5 Tablets/30 Days |
3 tablets/30 days |
| ibudone tablet 5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
|
levorphanol tablet 2mg |
10 Tablets/30 Days |
6 tablets/30 days |
|
lorcet tablet 5-325mg |
40 Tablets/30 Days |
6 tablets/30 days |
|
lorcet plus tablet 7.5-325 |
30 Tablets/30 Days |
N/A |
|
lorcet hd tablet 10-325mg |
25 Tablets/30 Days |
N/A |
|
meperidine tablet 50mg |
30 Tablets/30 Days |
30 Tablets/30 Days |
|
MEPERIDINE SOLUTION 50MG/5ML |
150 mLs/30 Days |
150 mL/30 days |
|
meperidine tablet 100mg |
15 Tablets/30 Days |
15 tablets/30 days |
|
methadone solution 5mg/5ml |
10 mLs/30 Days |
N/A |
|
methadone solution 10mg/5ml |
5 mLs/30 Days |
N/A |
|
methadone tablet 5mg |
60 Tablets/30 Days |
N/A |
|
methadone tablet 10mg |
30 Tablets/30 Days |
N/A |
|
morphine sulfate solution 10/0.5ml |
10 mLs/30 Days |
N.A |
|
morphine sulfate solution 10mg/5ml |
125 mLs/30 Days |
75 mL/30 days |
|
morphine sulfate solution 100/5ml |
10 mLs/30 Days |
N/A |
|
morphine sulfate solution 20mg/5ml |
60 mLs/30 Days |
36 mL/30 days |
|
morphine sulfate solution 20mg/ml |
10 mLs/30 Days |
6 mL/30 days |
|
MORPHINE SULFATE TABLET 15MG |
15 Tablets/30 Days |
N/A |
|
MORPHINE SULFATE TABLET 30MG |
5 Tablets/30 Days |
N/A |
|
NUCYNTA TABLET 50MG |
10 Tablets/30 Days |
6 tablets/30 days |
|
NUCYNTA TABLET 75MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
NUCYNTA TABLET 100MG |
5 Tablets/30 Days |
3 tablets/30 days |
|
oxycodone/acetaminophen tablet 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
|
oxycodone/acetaminophen tablet 5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
oxycodone/acetaminophen tablet 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
|
oxycodone/acetaminophen tablet 10-325mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
oxycodone/aspirin tablet |
30 Tablets/30 Days |
18 tablets/30 days |
|
OXYCODONE/IBUPROFEN TABLET 5-400MG |
20 Tablets/30 Days |
12 tablets/30 days |
|
oxycodone concentrate 10/0.5ml |
5 mLs/30 Days |
N/A |
|
oxycodone concentrate 100/5ml |
5 mLs/30 Days |
N/A |
|
oxycodone solution 5mg/5ml |
165 mLs/30 Days |
99 mL/30 days |
|
oxycodone concentrate 10/0.5ml |
5 mLs/30 Days |
N/A |
|
oxycodone tablet 5mg |
30 Tablets/30 Days |
18 tablets/30 days |
|
oxycodone tablet 10mg |
15 Tablets/30 Days |
9 tablets/30 days |
|
oxycodone tablet 15mg |
10 Tablets/30 Days |
6 tablets/30 days |
|
oxycodone tablet 20mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
oxycodone tablet 30mg |
5 Tablets/30 Days |
3 tablets/30 days |
|
OXYCODONE/ SOLUTION APAP |
100 mLs/30 Days |
60 mL/30 days |
|
tramadol hcl tablet 50mg |
50 Tablets/30 Days |
30 Tablets/30 Days |
|
VERDROCET TABLET 2.5-325 |
60 Tablets/30 Days |
N/A |
|
xylon tablet 10-200mg |
25 Tablets/30 Days |
N/A |
Ophthalmic Prostaglandins
Drug Name(s) |
Quantity Limits
|
|
travoprost drops 0.004% |
2.5 mLs/30 Days |
Oral Inhalers
Drug Name(s) |
Quantity Limits
|
|
ADVAIR DISKUS AEROSOL 100/50 |
60 Blisters/30 Days |
|
ADVAIR DISKUS AEROSOL 250/50 |
60 Blisters/30 Days |
|
ADVAIR DISKUS AEROSOL 500/50 |
60 Blisters/30 Days |
|
ADVAIR HFA AEROSOL 45/21 |
1 Canister/30 Days |
|
ADVAIR HFA AEROSOL 115/21 |
1 Canister/30 Days |
|
ADVAIR HFA AEROSOL 230/21 |
1 Canister/30 Days |
|
ASMANEX 30 AEROSOL 110MCG |
1 Canister/30 Days |
|
ASMANEX 30 AEROSOL 220MCG |
1 Canister/30 Days |
|
ASMANEX 60 AEROSOL 220MCG |
1 Canister/30 Days |
|
ASMANEX HFA AEROSOL 100 MCG |
1 Canister/30 Days |
|
ASMANEX HFA AEROSOL 200 MCG |
1 Canister/30 Days |
|
ASMANEX 120 AEROSOL 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 AEROSOL 50MCG |
60 Blisters/30 Days |
|
FLOVENT DISK AEROSOL 100MCG |
60 Blisters/30 Days |
|
FLOVENT DISK AEROSOL 250MCG |
240 Blisters/30 Days |
|
FLOVENT HFA AEROSOL 44MCG |
1 Canister/30 Days |
|
FLOVENT HFA AEROSOL 110MCG |
1 Canister/30 Days |
|
FLOVENT HFA AEROSOL 220MCG |
2 Canisters/30 Days |
|
fluticasone/salmeterol aerosol 100/50 |
60 Blisters/30 Days |
|
fluticasone/salmeterol aerosol 250/50 |
60 Blisters/30 Days |
|
fluticasone/salmeterol aerosol 500/50 |
60 Blisters/30 Days |
|
QVAR AEROSOL 40MCG |
1 Canister/30 Days |
|
QVAR AEROSOL 80MCG |
2 Canisters/30 Days |
|
QVAR REDIHALER AEROSOL 40MCG |
1 Canister/30 Days |
|
QVAR REDIHALER AEROSOL 80MCG |
2 Canisters/30 Days |
|
wixela inhub aerosol 100/50 |
60 Blisters/30 Days |
|
wixela inhub aerosol 250/50 |
60 Blisters/30 Days |
|
wixela inhub aerosol 500/50 |
60 Blisters/30 Days |
Oral Pulmonary Arterial Hypertension (PAH)
Drug Name(s) |
Quantity Limits
|
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
90 Tablets/30 Days |
|
|
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 TALET 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
|
|
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
|
|
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
|
|
REGRANEX GEL 0.01% |
1 Tube/30 Days |
Oncology
Drug Name(s) |
Quantity Limits
|
|
abiraterone tablet 250mg1 |
120 Tablets/30 Days |
|
240 Capsules/30 Days |
|
|
COTELLIC TABLET 20MG1 |
63 Tablets/28 Days |
|
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 |
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
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 |
|
30 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
30 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
90 Capsules/30 Days |
|
|
60 Capsules/30 Days |
|
|
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 |
|
60 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
30 Tablets/30 Days |
|
|
1 Pack/180 Days |
|
|
30 Tablets/30 Days |
|
|
180 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
|
|
60 Tablets/30 Days |
Somatostatin Analogs
Drug Name(s) |
Quantity Limits
|
|
octreotide injection 1000/5ml1 |
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/ml1 |
90 mLs/30 Days |
|
octreotide injection 5000/5ml1 |
30 mLs/30 Days |
|
octreotide injection 500mcg1 |
30 mLs/30 Days |
Selective Serotonin Inverse Agonist (SSIA)
Drug Name(s) |
Quantity Limits
|
|
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
|
|
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
|
|
miglustat capsule 100mg1 |
90 Capsules/30 Days |
Topical Corticosteroids
Drug Name(s) |
Quantity Limits
|
|
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
|
|
SYNERA DIS 70-70MG |
4 Patches/30 Days |
Topical NSAID
Drug Name(s) |
Quantity Limits
|
|
diclofenac gel 1% |
10 Tubes/30 Days |
Transmucosal Immediate Release Fentanyl
Drug Name(s) |
Quantity Limits
|
|
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
|
|
DEXCOM G5 MIS RECEIVER |
Continuous Glucose Monitors |
|
DEXCOM G5 MIS TRANSMIT |
Continuous Glucose Monitors |
|
DEXCOM G6 MIS RECEIVER |
Continuous Glucose Monitors |
|
DEXCOM G6 MIS SENSOR |
Continuous Glucose Monitors |
|
DEXCOM G6 MIS TRANSMIT |
Continuous Glucose Monitors |
|
FREESTYLE KIT SENSOR |
Continuous Glucose Monitors |
|
FREESTYLE KIT SENSOR |
Continuous Glucose Monitors |
|
FREESTYLE MIS READER |
Continuous Glucose Monitors |
|
G5/G4 MIS SENSOR |
Continuous Glucose Monitors |
|
ZURAMPIC TABLET 200MG |
30 Tablets/30 Days |
Drug Name(s) |
||
|
abiraterone acetate1 |
ACTEMRA ACTPEN1 |
ACTEMRA1 |
|
alyq1 |
||
|
ambrisentan1 |
||
|
BERINERT1 |
||
|
bosentan1 |
capecitabine1 |
|
|
CAYSTON1 |
CHORIONIC GONADOTROPIN1 |
CIMZIA1 |
|
COTELLIC1 |
||
|
dalfampridine er1 |
dofetilide1 |
|
|
entecavir1 |
||
|
EPCLUSA1 |
erlotinib hydrochloride1 |
|
|
ESBRIET1 |
GILENYA1 |
|
|
glatopa1 |
||
|
HYCAMTIN1 |
||
|
HYQVIA1 |
IBRANCE1 |
imatinib mesylate1 |
|
INTRON A1 |
KALYDECO1 |
|
|
KOGENATE FS BIO-SET1 |
KOGENATE FS1 |
KOVALTRY1 |
|
LETAIRIS1 |
miglustat1 |
|
|
NATPARA1 |
NINLARO1 |
|
|
NOVOEIGHT1 |
||
|
NUPLAZID1 |
NUWIQ1 |
octreotide acetate1 |
|
OCTREOTIDE ACETATE1 |
OTEZLA1 |
|
|
POMALYST1 |
||
|
ribasphere1 |
||
|
ribavirin1 |
sildenafil citrate1 |
RINVOQ1 |
|
SIMPONI1 |
SKYRIZI1 |
sodium phenylbutyrate 1 |
|
SOFOSBUVIR/VELPATASVIR1 |
STIMATE1 |
tadalafil1 |
|
TECFIDERA1 |
||
|
tobramycin1 |
tobramycin sulfate1 |
TOBRAMYCIN1 |
|
TRACLEER1 |
VELTASSA1 |
|
|
VOSEVI1 |
||
|
XELJANZ XR1 |
XELJANZ1 |
ZARXIO1 |
|
|
||