Value 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 formulary for the full list of drugs covered under your plan.

Key:

UPPERCASE names = Brand

lowercase names = Generic

Guide to prescription drug benefits

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

Use this guide to understand how your benefits work.

Drug name(s)
abiraterone acetate (ZYTIGA)^1,³	abiraterone acetate ³	ACTEMRA ¹
ACTEMRA ACTPEN ¹	ADEMPAS ²	ALECENSA ^2,³
alosetron hcl	alyq ¹	ambrisentan ¹
ARANESP ALBUMIN FREE ¹	AUBAGIO^1,³	avita
AVONEX ¹	AVONEX PEN ¹	BELSOMRA
BERINERT ¹	BETASERON ¹	bosentan ¹
buprenorphine	capecitabine ¹	CAYSTON ¹
CHORIONIC GONADOTROPIN ¹	ciclodan	ciclopirox nail lacquer
CIMZIA ¹	CIMZIA STARTER KIT ¹	CINRYZE ²
CIPRO HC	ciprofloxacin / dexamethasone	clomipramine hcl
CORLANOR	COSENTYX ¹	COSENTYX SENSOREADY PEN ¹
COTELLIC ¹	dalfampridine er^1,³	DESVENLAFAXINE ER
dimethyl fumarate ¹	dimethyl fumarate starterpack ¹	EMSAM
ENBREL ¹	ENBREL MINI ¹	ENBREL SURECLICK ¹
EPCLUSA ¹	EPIDIOLEX ¹	ERIVEDGE^1,³
erlotinib hcl^1,³	ESBRIET ¹	FANAPT
FANAPT TITRATION PACK	fentanyl	fentanyl citrate oral transmucosal
GILENYA ¹	GILOTRIF ²	glatiramer acetate ¹
glatopa ¹	glydo	HARVONI ¹
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 ¹	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK ¹
HUMIRA PEN ¹	HUMIRA PEN-CD/UC/HS STARTER¹	HUMIRA PEN-PEDIATRIC UC STARTER PACK ¹
HUMIRA PEN-PS/UV STARTER ¹	HYCAMTIN ¹	hydromorphone hcl er
HYQVIA ¹	IBRANCE ¹	imatinib mesylate^1,³
INSULIN LISPRO	INSULIN LISPRO JUNIOR KWIKPEN	INSULIN LISPRO KWIKPEN
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN	INTRON A ¹	KALYDECO ¹
KEVZARA ¹	KOGENATE FS ¹	KOVALTRY ¹
lapatinib ditosylate ¹	LEDIPASVIR / SOFOSBUVIR ¹	LENVIMA ^2,³
LIDOCAINE GEL 2% JELLY	lidocaine hcl	lidocaine/prilocaine
lidocaine-prilocaine-cream base	LYSODREN	MAPROTILINE HCL
metaxalone	METHADONE HCL	METHITEST
METHYLTESTOSTERONE	morphine sulfate cr	morphine sulfate er
NEXAVAR^1,³	NINLARO ¹	NORDITROPIN FLEXPRO ¹
NOVAREL ¹	NOVOEIGHT ¹	NUCYNTA ER
NUPLAZID ¹	NUWIQ ¹	octreotide ¹
OTEZLA ¹	OXYCODONE HCL ER	OXYCONTIN
OXYMORPHONE HCL ER	PEGINTRON ¹	POMALYST ¹
PREGNYL W / DILUENT BENZYL ALCOHOL / NACL ¹	PROCRIT ¹	pyrimethamine
REBIF ¹	REBIF REBIDOSE ¹	REBIF REBIDOSE TITRATION PACK ¹
REBIF TITRATION PACK ¹	RESTASIS	RESTASIS MULTIDOSE
RINVOQ ¹	sildenafil citrate (REVATIO)¹	sildenafil citrate (VIAGRA)
SIMPONI ¹	sodium phenylbutyrate ¹	SOFOSBUVIR/VELPATASVIR ¹
STIMATE ¹	SYNERA	tadalafil ¹
TASIGNA^1,³	TAZAROTENE	testosterone ypionate
TESTOSTERONE ENANTHATE	TESTOSTERONE GEL 1%(25MG)	testosterone gel 1%(50mg)
testosterone gel 10mg/act	testosterone gel pump 1%	testosterone sol 30mg/ac
testosterone td gel 20.25 mg/1.25gm (1.62%)	testosterone td gel 20.25 mg/act (1.62%)	testosterone td gel 40.5 mg/2.5gm (1.62%)
THLOMID¹	tobramycin neb 300/4ml ¹	TOBRAMYCIN NEB 300/5ML¹
TRACLEER ¹	tramadol hcl er	trazodone hcl
TREMFYA ¹	tretinoin	VENCLEXTA ²
VENCLEXTA STARTING PACK ^1,²	VIIBRYD	VOSEVI ¹
VRAYLAR	WAKIX	XALKORI ^1,³
XELJANZ ¹	XELJANZ XR ¹	XIFAXAN
ZARXIO ¹	ZTLIDO GEL	ZYDELIG ²

Drug name(s)
ACCU-CHEK AVIVA PLUS	ACCU-CHEK COMPACT PLUS	ACCU-CHEK COMPACT STRIPS
ACCU-CHEK COMPACT TEST ACCU CHEK AVVA PLUS DRUM	ACCU-CHEK GUIDE	ACCU-CHEK SMARTVIEW STRIPS
ACCUTREND GLUCOSE	ADVANCE INTUITION TEST STRIPS	ADVANCE MICRO-DRAW TEST
ADVOCATE REDI CODE	ADVOCATE REDI CODE+ TEST STRIPS	ADVOCATE TEST STRIPS
AGAMATRX AMP NO CODE TEST STRIPS	AGAMATRIX JAZZ TEST STRIPS	AGAMATRX KEYNOTE TEST STRIPS
AGAMATRX PRESTO TEST STRIPS ASSURE 4 TEST STRIPS	AMCINONIDE	ASSURE 3 TEST STRIPS
ASSURE 4 TEST STRIPS	ASSURE II PLATINUM TEST STRIPS	ASSURE II CHECK STRIP
ASSURE II TEST STRIPS	ASSURE PLATNUM TEST STIRPS	ASSURE PRISM MULTI TEST STRIPS
ASSURE PRO TEST STRIPS	AT LAST TEST STRIPS	AUGMENTED BETAMETHASON DIPROPIONATE
BEPREVE	BETAMETHASONE DIPROPIONA	BOSCANNER GLUCOSE 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	CLOCORTOLONE PIVALATE	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	DEXCOM G5 MOBILE RECEIVER KIT	DEXCOM G6 RECEIVER
DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT	DEXCOM G5 RECEIVER KIT	DEXCOM G6 RECEVER
DEXCOM G6 SENSOR	DEXCOM G6 TRANSMITTER	DIATHRIVE BLOOD GLUCOSE TEST STRIPS
DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS	DIFLORASONE DIACETATE	DUO CARE TEST STRPS
EASY PLUS II BLOOD GLUCOSE TEST STRIPS	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
EASYPRO BLOOD GLUCOSE TEST STRIPS	EASYPRO PLUS	ELEMENT COMPACT TEST STRIPS
ELEMENT TEST STRIPS	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	FARXIGA
FIFTY50 GLUCOSE TEST STRIP 2.0	FLURBIPROFEN	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 LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM	FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM
FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM	FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM	FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM
FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM	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	GLYXAMBI
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
KEOPROFEN	KROGER BLOOD GLUCOSE TEST STRIPS	KROGER HEALTHPRO GLUCOSE TEST STRIPS
KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS	KROGER TEST STRIPS	lanthanum carbonate
LASTACFT	LATANOPROST	LIBERTY NEXT GENERATION XIFAXAN BLOO GLUCOSE TEST STRIPS
LIBERTY TEST STRIPS	LIVALO	LUMIGAN
MECLOFENAMATE SODIUM	MEIJER BLOOD GLUCOSE TESTSTRIPS	MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS
MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS	MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS	MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS
metformin hcl er	MICRODOT TEST STRIPS	MM EASY TOUCH GLUCOSE TEST STRIPS
MYGLUCOHEALTH BLOOD GLUCOSE TEST	MYRBETRIQ	NEUTEK 2TEK 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	pimecrolimus	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
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
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	REVEAL BLOOD GLUCOSE TEST	REXALL BLOOD GLUCOSE TEST STRIPS
RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS	RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS	RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS
RYBELSUS	SAVELLA	SAVELLA TITRATION PACK
SEVELAMER HYDROCHLORIDE	SMART SENSE PREMIUM BLOODGLUCOSE STRIPS	SMART SENSE VALUE BLOOD GLUCOSE STRIPS
SMARTEST BLOOD GLUCOSE TEST STRIPS	SOLUS V2 AUDIBLE TEST	SUMATRIPTAN SUCCINATE
SUPREME TEST STRIPS	SURE EDGE BLOOD GLUCOSE TEST STRIPS	SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS
SURECHEK BLOOD GLUCOSE TEST STRIPS	SYNJARDY	SYNJARDY XR
tacrolimus	TELCARE BLOOD GLUCOSE TEST STRIPS	TGT BLOOD GLUCOSE TEST STRIPS
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM	TOLMETIN SODIUM	TOVIAZ
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	ULTRATRAK PRO TEST STRIPS	ULTRATRAK ULTIMATE TEST STRIPS
UNISTRIP1 GENERIC	VERASENS BLOOD GLUCOSE TEST STRIPS	VICTOZA
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS	VOCAL POINT BLOOD GLUCOSE TEST STRIPS	WAVESENSE PRESTO TEST STRIPS
ZIOPTAN

Analgesics – anti-inflammatory

Drug name(s)	Quantity limits (per 30 days or as specified)
ACTEMRA injection 162/0.9¹	4 syringes / 28 days
ACTEMRA injection ACTPEN¹	4 injections / 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 carts / 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 20/0.2mL ¹	2 syringes / 28 days
HHUMIRA 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 PEDIATRIC CROHNS DISEASE STARTER	1 kit / 180 days
HUMRA pen injection 40/0.4mL¹	1 kit / 180 days
HUMIRA pen injection 40mg/0.8	2 pens / 28 days
HUMIRA pen injection 80/.8mL	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 PED UC¹	4 pens / 180 days
HUMIRA pen kit PS/UV¹	1 kit / 180 days
KEVZARA- SARILUMAB SUBCUTANEOUS Solution PREFILLED SYRINGE 150 mg/1.14mL¹	2 syringes / 28 days
KEVZARA SARILUMAB SUBCUTANEOUS Solution PREFLLED syringeE 200 mg/1.14mL¹	2 syringes / 28 days
KEVZARA- SARLUMAB SUBCUTANEOUS SOLUTION AUTO-injectionECTOR 150 mg/1.14mL¹	2 pens / 28 days
KEVZARA SARILUMAB SUBCUTANEOUS KEVZARA- SARLUMAB SUBCUTANEOUS SOLUTION AUTO-injectionECTOR 200 mg/1.14mL¹	2 pens / 28 days
OTEZLA TAB 10/20/30¹	1 kit / 180 days
OTEZLA TAB 30mg¹	60 tabs / 30 days
RINVOQ TAB 15mg ER¹	30 tabs / 30 day
SIMPNI injection 100mg/mL¹	1 syringe / 28 days
SIMPONI injection 50/0.5mL	1 syringe / 28 days
XELJANZ SOL 1mg/mL¹	240 mLs / 30 days
XELJANZ TAB 10mg¹	240 tabs / 365 days
XELJANZ TAB 5mg¹	60 tabs / 30 days
XELJANZ XR TAB 11mg¹	30 tabs / 30 days
XELJANZ XR TAB 22mg	120 tabs / 365 days

Analgesics - opioid

Drug name(s)	Adult quantity limit – 5 days	Child quantity limit – 3 days
apap/codeine solution 120-12/5	450 mL/30 days	270 mL/30 days
apap/codeine tab 300-15mg	30 tablets/30 days	18 tablets/30 days
apap/codeine tab 300-30mg	30 tablets/30 days	18 tablets/30 days
apap/codeine tab 300-60mg	25 tablets/30 days	15 tablets/30 days
buprenorphin dis 10mcg/hr	4 systems/month	N/A
buprenorphin dis 15mcg/hr	4 systems/month	N/A
buprenorphin dis 20mcg/hr	4 systems/month	N/A
buprenorphin dis 5mcg/hr	4 systems/month	N/A
buprenorphin dis 7.5/hr	4 systems/month	N/A
butorphanol solution 10mg/ml	2.5 mL (1 bottle)/30 days	0 mL/30 days
CODEINE SULF TAB 15mg	30 tablets/30 days	18 tablets/30 days
codeine sulf tab 30mg	30 tablets/30 days	18 tablets/30 days
CODEINE SULF TAB 60mg	25 tablets/30 days	15 tablets/30 days
codeine/apap tab 30-300mg	30 tablets/30 days	18 tablets/30 days
codeine/apap tab 60-300mg	25 tablets/30 days	15 tablets/30 days
endocet tab 10-325mg	15 tablets/30 days	9 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
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 50mcg/hr	0 patches/month	N/A
fentanyl dis 75mcg/hr	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
hydroco/apap solution 7.5-325	450 mL/30 days	270 mL/30 days
hydroco/apap tab 10-325mg	25 tablets/30 days	15 tablets/30 days
hydroco/apap tab 5-325mg	40 tablets/30 days	24 tablets/30 days
hydroco/apap tab 7.5-325	30 tablets/30 days	18 tablets/30 days
hydrocod/ibu tab 10-200mg	25 tablets/30 days	15 tablets/30 days
HYDROCOD/IBU TAB 5-200mg	25 tablets/30 days	15 tablets/30 days
hydrocod/ibu tab 5-200mg	25 tablets/30 days	15 tablets/30 days
hydrocod/ibu tab 7.5-200	25 tablets/30 days	15 tablets/30 days
hydromorphon liq 1mg/ml	60 mL/30 days	36 mL/30 days
hydromorphon tab 12mg er	30 tablets/month	N/A
hydromorphon tab 16mg er	0 tablets	N/A
hydromorphon tab 2mg	30 tablets/30 days
hydromorphon tab 32mg er	0 tablets	N/A
hydromorphon tab 4mg	15 tablets/30 days	9 tablets/30 days
hydromorphon tab 8mg	5 tablets/30 days	3 tablets/30 days
hydromorphon tab 8mg er	30 tablets/month	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
MEPERIDINE TAB 50mg	30 tablets/30 days	30 tablets/30 days
methadone solution 10mg/5ml	150 mL/30 days	N/A
methadone solution 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 sul solution 10/0.5ml	15 mL/30 days	15 mL/30 days
morphine sul solution 100/5ml	15 mL/30 days	15 mL/30 days
morphine sul solution 10mg/5ml	125 mL/30 days	75 mL/30 days
morphine sul solution 20mg/5ml	60 mL/30 days	36 mL/30 days
morphine sul solution 20mg/ml	15 mL/30 days	15 mL/30 days
morphine sul tab 100mg cr	0 tablets/30 days	N/A
morphine sul tab 100mg er	0 tablets/30 days	N/A
MORPHINE SUL TAB 15mg	15 tablets/30 days	9 tablets/30 days
morphine sul tab 15mg	15 tablets/30 days	9 tablets/30 days
morphine sul tab 15mg er	60 tablets/30 days	N/A
morphine sul tab 200mg er	0 tablets/30 days	N/A
MORPHINE SUL TAB 30mg	5 tablets/30 days	3 tablets/30 days
morphine sul tab 30mg	5 tablets/30 days	3 tablets/30 days
morphine sul tab 30mg er	30 tablets/30 days	N/A
morphine sul tab 60mg er	0 tablets/30 days	N/A
NUCYNTA TAB 100mg	5 tablets/30 days	3 tablets/30 days
NUCYNTA TAB 50mg	10 tablets/30 days	6 tablets/30 days
NUCYNTA TAB 75mg	5 tablets/30 days	3 tablets/30 days
NUCYNTA ER TAB 100mg	30 tablets/30 days	N/A
NUCYNTA ER TAB 150mg	0 tablets/30 days	N/A
NUCYNTA ER TAB 200mg	0 tablets/30 days	N/A
NUCYNTA ER TAB 250mg	0 tablets/30 days	N/A
NUCYNTA ER TAB 50mg	60 tablets/30 days	N/A
oxycod/apap tab 10-325mg	15 tablets/30 days	9 tablets/30 days
oxycod/apap tab 2.5-325	60 tablets/30 days	36 tablets/30 days
oxycod/apap tab 5-325mg	30 tablets/30 days	18 tablets/30 days
oxycod/apap tab 7.5-325	20 tablets/30 days	12 tablets/30 days
OXYCOD/ASA TAB	30 tablets/30 days	18 tablets/30 days
OXYCOD/IBU TAB 5-400mg	20 tablets/30 days	12 tablets/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 solution 5mg/5ml	165 mL/30 days	99 mL/30 days
oxycodone tab 10mg	15 tablets/30 days	9 tablets/30 days
OXYCODONE TAB 10mg ER	60 tablets/30 days	N/A
oxycodone tab 15mg	10 tablets/30 days	6 tablets/30 days
OXYCODONE TAB 15mg ER	60 tablets/30 days	N/A
oxycodone tab 20mg	5 tablets/30 days	3 tablets/30 days
OXYCODONE TAB 20mg ER	30 tablets/30 days	N/A
oxycodone tab 30mg	5 tablets/30 days	3 tablets/30 days
OXYCODONE TAB 30mg ER	30 tablets/30 days	N/A
OXYCODONE TAB 40mg ER	0 tablets/30 days	N/A
oxycodone tab 5mg	30 tablets/30 days	18 tablets/30 days
OXYCODONE TAB 60mg ER	0 tablets/30 days	N/A
OXYCODONE TAB 80mg ER	0 tablets/30 days	N/A
OXYCONTIN TAB 10mg CR	60 tablets/30 days	N/A
OXYCONTIN TAB 15mg CR	60 tablets/30 days	N/A
OXYCONTIN TAB 20mg CR	30 tablets/30 days	N/A
OXYCONTIN TAB 30mg CR	30 tablets/30 days	N/A
OXYCONTIN TAB 40mg CR	0 tablets/30 days	N/A
OXYCONTIN TAB 60mg CR	0 tablets/30 days	N/A
OXYCONTIN TAB 80mg CR	0 tablets/30 days	N/A
OXYMORPHONE TAB 10mg ER	30 tablets/30 days	N/A
OXYMORPHONE TAB 15mg ER	30 tablets/30 days	N/A
OXYMORPHONE TAB 20mg ER	0 tablets/30 days	N/A
OXYMORPHONE TAB 30mg ER	0 tablets/30 days	N/A
OXYMORPHONE TAB 40mg ER	0 tablets/30 days	N/A
OXYMORPHONE TAB 5mg ER	60 tablets/30 days	N/A
OXYMORPHONE TAB 7.5mg ER	60 tablets/30 days	N/A
tramadol hcl tab 100mg er	30 tablets/30 days	N/A
tramadol hcl tab 200mg er	30 tablets/30 days	N/A
tramadol hcl tab 300mg er	30 tablets/30 days	N/A
tramadol hcl tab 50mg	50 tablets/30 days	30 tablets/30 days

Androgens - anabolic

Drug name(s)	Quantity limits (per 30 days or as specified)
testost cyp inj 100mg/ml	1 vial / 28 days
testost cyp inj 200mg/ml	10 mLs / 28 days
TESTOST ENAN injection 200mg/mL	1 vial / 28 days
TESTOSTERONE GEL 1% (25mg)	60 packets / 30 days
testosterone gel 1% (25mg)	60 packets / 30 days
TESTOSTERONE GEL 1%(50mg)	60 packets / 30 days
testosterone gel 1%(50mg)	60 packets / 30 days
TESTOSTERONE GEL PUMP 1%	4 pumps / 30 days
testosterone gel pump 1%	300 grams / 30 days

Antiasthmatic and bronchodilator agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADVAIR DISKU AER 100/50	60 blisters / 30 days
ADVAIR DISKU AER 250/50	60 blisters / 30 days
ADVAIR DISKU AER 500/50	60 blisters / 30 days
ADVAIR HFA AER 115/21	1 can / 30 days
ADVAIR HFA AER 230/21	1 can / 30 days
ADVAIR HFA AER 45/21	1 can / 30 days
ALBUTEROL AER HFA	2 cans/ 30 days
albuterol aer hfa	2 cans/ 30 days
ASMANEX 120 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
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
LEVALBUTEROL AER 45/ACT	2 cans/ 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
TRELEGY AER ELLIPTA	1 inhaler / 30 days
XOpenEX HFA AER	2 cans/ 30 days

Anticonvulsants

Drug name(s)	Quantity limits (per 30 days or as specified)
pregabalin cap 25mg	90 caps / 30 days
pregabalin cap 50mg	90 caps / 30 days
pregabalin cap 75mg	90 caps / 30 days
pregabalin cap 100mg	90 caps / 30 days
pregabalin cap 150mg	90 caps / 30 days
pregabalin cap 200mg	690 caps / 30 days
pregabalin cap 225mg	60 caps / 30 days
pregabalin solutioncap 300mg	6900 CAP mLs / 30 days
pregabalin solution 20mg/ml	900 mLs / 30 days

Antidiabetics

Drug name(s)	Quantity limits (per 30 days or as specified)
FARXIGA TAB 10mg	30 tabs / 30 days
FARXIGA TAB 5mg	10mg
GLYAMBI TAB 10-5 mg	30 Tabs / 30 Days
GLYXAMBI TAB 25-5 mg	30 Tabs / 30 Days
INVOKAMET TAB 150-1000	60 Tabs / 30 Days
INVOKAMET TAB 150-500	60 tabs / 30 days
INVOKAMET TAB 50-1000	60 tabs / 30 days
INVOKAMET TAB 50-500mg	60 tabs / 30 days
INVOKAMET XR TAB 150-1000	60 tabs / 30 days
INVOKAMET XR TAB 150-500	60 tabs / 30 days
INVOKAMET XR TAB 50-1000	60 tabs / 30 days
INVOKAMET XR TAB 50-500mg	60 tabs / 30 days
INVOKANA TAB 100mg	30 tabs / 30 days
INVOKANA TAB 300mg	30 tabs / 30 days
INVOKANA TAB 300mg	30 tabs / 30 days
JANUMET TAB 50-500mg	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	30 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
metformin tab 750mg er	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
ONGLYZA TAB 2.5mg	30 tabs / 30 days
ONGLYZA TAB 5mg	30 tabs / 30 days
OZEMPIC- SEMAGLUTIDE Solution pen-injection 0.25 OR 0.5 mg/DO (2 mg/1.5mL)	1 pen / 28 days
OZEMPIC- SEMAGLUTIDE Solution pen-injection 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
SNJARDY 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
TRULICITY injection 0.75/0.5	4 pens / 28 days
TRULICITY injection 1.5/0.5	4 pens / 28 days
TRULICITY injection 3/0.5	4 pens / 28 days
TRULICITY injection 4.5/0.5	4 pens / 28 days
VICTOZA injection 18mg/3mL	3 pens / 30 days

Antiemetics

Drug name(s)	Quantity limits (per 30 days or as specified)
AKYNZEO CAP 300-0.5	2 caps / 30 days
aprepitant cap 125mg	4 caps / 30 days
aprepitant cap 40mg	8 caps / 30 days
aprepitant cap 80mg	8 caps / 30 days
granisetron tab 1mg	14 tabs / 30 days
ondansetron solution 4mg/5ml	5 bottles / 30 days
ondansetron tab 4mg odt	24 tabs / 30 days
ondansetron tab 8mg odt	24 tabs / 30 days

Antihyperlipidemics

Drug name(s)	Quantity limits (per 30 days or as specified)
atorvastatin tab 10mg	45 tabs / 30 days
atorvastatin tab 20mg	45 tabs / 30 days
atorvastatin tab 40mg	45 tabs / 30 days
atorvastatin tab 80mg	30 tabs / 30 days
LIVALO TAB 1mg	45 tabs / 30 days
LIVALO TAB 2mg	45 tabs / 30 days
LIVALO TAB 4mg	30 tabs / 30 days
lovastatin tab 10mg	60 tabs / 30 days
lovastatin tab 20mg	60 tabs / 30 days
lovastatin tab 40mg	60 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
rosuvastatin tab 5mg	45 tabs / 30 days
rosuvastatin tab 10mg	45 tabs / 30 days
rosuvastatin tab 20mg	45 tabs / 30 days
rosuvastatin tab 40mg	30 tabs / 30 days
simvastatin 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 80mg	30 tabs / 30 days

Anti-infective agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ALINIA SUS 100/5mL	300 mLs / 90 days
nitazoxanide tab 500mg	12 tabs / 90 days
XIFAXAN TAB 200mg	9 tabs / 30 days
XIFAXAN TAB 550mg	60 tabs / 30 days
ALINIA SUS 100/5mL	300 mLs / 90 days

Antineoplastics and adjunctive therapies

Drug name(s)	Quantity limits (per 30 days or as specified)
abiraterone tab 250mg^1,³	120 tabs / 30 days
abiraterone tab 500mg^1,³	60 tabs / 30 days
ALECENSA CAP 150mg ^2,³	240 caps / 30 days
COTELLIC TAB 20mg¹	63 tabs / 28 days
ERIVEDGE CAP 150mg^1,³	30 caps / 30 days
erlotinib tab 100mg^1,³	30 tabs / 30 days
erlotinib tab 150mg^1,³	30 tabs / 30 days
erlotinib tab 25mg^1,³	60 tabs / 30 days
GILOTRIF TAB 20mg³	30 tabs / 30 days
GILOTRIF TAB 30mg³	30 tabs / 30 days
GILOTRIF TAB 40mg³	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
imatinib mes tab 100mg^1,³	90 tabs / 30 days
imatinib mes tab 400mg^1,³	60 tabs / 30 days
lapatinib tab 250mg¹	180 tabs / 30 days
LENVIMA CAP 10 mg³	30 caps / 30 days
LENVIMA CAP 12mg³	90 caps / 30 days
LENVIMA CAP 14 mg³	60 caps / 30 days
LENVIMA CAP 18 mg³	90 caps / 30 days
LENVIMA CAP 20 mg³	60 caps / 30 days
LENVIMA CAP 24 mg³	90 caps / 30 days
LENVIMA CAP 4mg³	30 caps / 30 days
LENVIMA CAP 8 mg³	60 caps / 30 days
NEXAVAR TAB 200mg¹	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
POMALYST CAP 1mg¹	21 caps / 28 days
POMALYST CAP 2mg¹	21 caps / 28 days
POMALYST CAP 3mg¹	21 caps / 28 days
POMALYST CAP 4mg¹	21 caps / 28 days
TASIGNA CAP 150mg¹	120 caps / 30 days
TASIGNA CAP 200mg¹	120 caps / 30 days
TASIGNA CAP 50mg¹	120 caps / 30 days
VENCLEXTA TAB 100mg³	180 tabs / 30 days
VENCLEXTA TAB 10mg³	60 tabs / 30 days
VENCLEXTA TAB 50mg³	30 tabs / 30 days
VENCLEXTA TAB START PK³	1 pack / 180 days
XALKORI CAP 200mg¹	120 caps / 30 days
XALKORI CAP 250mg¹	120 caps / 30 days
ZYDELIG TAB 100mg³	60 tabs / 30 days
ZYDELIG TAB 150mg³	60 tabs / 30 days

Antipsychotics / anditmanic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
LATUDA TAB 120mg	30 tabs / 30 days
LATUDA TAB 20mg	30 tabs / 30 days
LATUDA TAB 40mg	30 tabs / 30 days
LATUDA TAB 60mg	30 tabs / 30 days
LATUDA TAB 80mg	60 tabs / 30 days
NUPLAZID CAP 34mg¹	30 caps / 30 days
NUPLAZID TAB 10mg¹	30 tabs / 30 days
olanzapine tab 2.5mg	30 tabs / 30 days
olanzapine tab 5mg	30 tabs / 30 days
olanzapine tab 7.5mg	30 tabs / 30 days
olanzapine tab 10mg	30 tabs / 30 days
olanzapine tab 15mg	30 tabs / 30 days
olanzapine tab 20mg	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 50mg er	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

Antivirals

Drug name(s)	Quantity limits (per 30 days or as specified)
EPCLUSA TAB 200-50mg¹	28 tabs / 28 days
EPCLUSA TAB 400-100¹	30 tabs / 30 days
HARVONI PAK¹	28 packets / 28 days
HARVONI PAK 45-200mg¹	28 packets / 28 days
HARVONI TAB 45-200mg¹	28 tabs / 28 days
HARVONI TAB 90-400mg¹	30 tabs / 30 days
LEDIP-SOFOSB TAB 90-400mg¹	30 tabs / 30 days
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
RELENZA MIS DISKHALE	40 blisters / 120 days

Cardiovascular agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADEMPAS TAB 0.5mg³	90 tabs / 30 days
ADEMPAS TAB 1mg³	90 tabs / 30 days
ADEMPAS TAB 1.5mg³	90 tabs / 30 days
ADEMPAS TAB 2.5mg³	90 tabs / 30 days
ADEMPAS TAB 2mg³	90 tabs / 30 days
alyq tab 20mg¹	60 tabs / 30 days
ambrisentan tab 5mg¹	30 tabs / 30 days
ambrisentan tab 10mg¹	30 tabs / 30 days
bosentan tab 62.5mg¹	60 tabs / 30 days
bosentan tab 125mg¹	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
sildenafil tab 20mg¹	90 tabs / 30 days
tadalafil tab 20mg¹	60 tabs / 30 days

Dermatologicals

Drug name(s)	Quantity limits (per 30 days or as specified)
ala-cort cre 2.5%	454 grams / 30 days
alclometason cre 0.05%	120 grams / 30 days
alclometason oin 0.05%	120 grams / 30 days
AMCINONIDE LOT 0.1%	120 mLs / 30 days
aug betamet cre 0.05%	200 grams / 28 days
AUG BETAMET GEL 0.05%	200 grams / 28 days
aug betamet lot 0.05%	210 mLs / 30 days
aug betamet oin 0.05%	200 grams / 28 days
BETA DIPROP GEL 0.05%	200 grams / 28 days
betameth dip cre 0.05%	135 grams / 30 days
betameth dip lot 0.05%	120 mLs / 30 days
betameth dip oin 0.05%	135 grams / 30 days
betameth val cre 0.1%	135 grams / 30 days
betameth val lot 0.1%	120 mLs / 30 days
betameth val oin 0.1%	135 grams / 30 days
ciclodan solution 8%	3.3 mLs / 30 days
ciclopirox solution 8%	3.3 mLs / 30 days
clobetasolution cre 0.05%	210 grams / 28 days
clobetasolution oin 0.05%	210 grams / 28 days
clobetasolution solution 0.05%	200 mLs / 28 days
clobetasolution e cre 0.05%	210 grams / 28 days
CLOCORTOLONE CRE 0.1%	135 grams / 30 days
COSENTYX injection 150mg/mL¹	1 syringe / 28 days
COSENTYX injection 300DOSE¹	1 pack / 28 days
COSENTYX injection 75mg/0.5¹	1 syringe / 28 days
COSENTYX pen injection 150mg/mL¹	1 injdv / 28 days
COSENTYX pen injection 300DOSE¹	1 pack / 28 days
desonide cre 0.05%	120 grams / 30 days
desonide lot 0.05%	118 mLs / 30 days
desonide oin 0.05%	120 grams / 30 days
desoximetas cre 0.05%	120 grams / 30 days
desoximetas cre 0.25%	120 grams / 30 days
desoximetas gel 0.05%	120 grams / 30 days
desoximetas oin 0.05%	120 grams / 30 days
desoximetas oin 0.25%	120 grams / 30 days
diclofenac gel 1%	10 tubes / 30 days
DIFLORASONE CRE 0.05%	120 grams / 30 days
diflorasone oin 0.05%	120 grams / 30 days
fluocin acet cre 0.01%	120 grams / 30 days
fluocin acet cre 0.025%	120 grams / 30 days
fluocin acet oil 0.01% sc	118.28 mLs / 30 days
fluocin acet oil 0.01%bdy	118.28 mLs / 30 days
fluocin acet oil body	118.28 mLs / 30 days
fluocin acet oil scalp	118.28 mLs / 30 days
fluocin acet oin 0.025%	120 grams / 30 days
fluocin acet solution 0.01%	120 mLs / 30 days
fluocinonide cre 0.05%	120 grams / 30 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 solution 0.05%	120 mLs / 30 days
flurandrenol lot 0.05%	120 mLs / 30 days
fluticasone cre 0.05%	120 grams / 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
halobetasolution cre 0.05%	200 grams / 28 days
halobetasolution oin 0.05%	200 grams / 28 days
HALOG OIN 0.1%	240 grams / 30 days
HALOG SOL 0.1%	240 mLs / 30 days
hydrocort cre 2.5%	454 grams / 30 days
hydrocort lot 2.5%	118 mLs / 30 days
hydrocort oin 2.5%	454 grams / 30 days
imiquimod cre 5%	48 packets / 60 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 gel 2% jelly	150 mLs / 30 days
lidocaine-pr cre	60 grams / 30 days
mometasone cre 0.1%	135 grams / 30 days
mometasone oin 0.1%	135 grams / 30 days
mometasone solution 0.1%	120 mLs / 30 days
nolix lot 0.05%	120 mLs / 30 days
PREDNICARBAT CRE 0.1%	120 grams / 30 days
PREDNICARBAT OIN 0.1%	120 grams / 30 days
SYNERA DIS 70-70mg	4 patches / 30 days
TREMFYA- GUSELKUMAB Solution pen-injectionECTOR 100 mg/mL¹	1 pen / 56 days
TREMFYA- GUSELKUMAB Solution PREFILLED SYRINGE 100 mg/mL¹	1 syringe / 56 days
triamcinolon cre 0.025%	454 grams / 30 days
triamcinolon cre 0.1%	454 grams / 30 days
triamcinolon cre 0.5%	454 grams / 30 days
triamcinolon lot 0.025%	120 mLs / 30 days
triamcinolon lot 0.1%	120 mLs / 30 days
triamcinolon oin 0.025%	454 grams / 30 days
triamcinolon oin 0.1%	454 grams / 30 days
triamcinolon oin 0.5%	120 grams / 30 days
triderm cre 0.1%	454 grams / 30 days
triderm cre 0.5%	454 grams / 30 days
ZTLIDO gel 2%	150 mLs / 30 days

Endocrine and metabolic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
alendronate tab 35mg	4 tabs / 28 days
alendronate tab 70mg	4 caps / 28 days
CHOR GONADOT injection 10000UNT¹	2 vials / 30 days
FOSAMAX + D TAB 70-2800	4 caps / 28 days
FOSAMAX + D TAB 70-5600	4 caps / 28 days
ibandronate tab 150mg	1 TAB / 28 days
NATPARA injection 100MCG¹	1 kit / 28 days
NATPARA injection 25MCG¹	1 kit / 28 days
NATPARA injection 50MCG¹	1 kit / 28 days
NATPARA injection 75MCG¹	1 kit / 28 days
NOVAREL injection 10000UNT¹	2 vials / 30 days
NOVAREL injection 5000unit¹	4 vials / 30 days
octreotide inj 1000/5ml¹	30 mLs / 30 days
octreotide inj 1000mcg¹	30 mLs / 30 days
OCTREOTIDE injection 100MCG¹	90 syringes / 30 days
octreotide inj 100mcg¹	90 mLs / 30 days
octreotide inj 200mcg¹	30 mLs / 30 days
octreotide inj 5000/5ml¹	30 mLs / 30 days
OCTREOTIDE injection 500MCG¹	90 syringes / 30 days
octreotide inj 500mcg¹	30 mLs / 30 days
OCTREOTIDE injection 50MCG/mL¹	90 syringes / 30 days
octreotide inj 50mcg/ml¹	90 mLs / 30 days

Gastrointestinal agents

Drug name(s)	Quantity limits (per 30 days or as specified)
alosetron tab 0.5mg	60 tabs / 30 days
alosetron tab 1mg	60 tabs / 30 days
CIMZIA PREFL kit 200mg/mL¹	2 kitS / 28 days
CIMZIA START kit 200mg/mL¹	1 kit / 180 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 VENCLEXT STARTING	30 tabs / 30 days

Hematological agents

Drug name(s)	Quantity limits (per 30 days or as specified)
BERINERT injection 500unit¹	10 vials / 30 days
CINYZE SOL 500 unit³	20 vials / 30 days
BELSOMRA TAB 10mg	10 vials / 30 days
BELSOMRA TAB 15mg	30 tabs / 30 days
BELSOMRA TAB 20mg	30 tabs / 30 days
BELSOMRA TAB 5mg	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 5mg	30 caps / 30 days
zaleplon cap 10mg	30 caps / 30 days
zolpidem tab 5mg	30 tabs / 30 days
zolpidem tab 10mg	30 tabs / 30 days

Medical devices and supplies

Drug name(s)	Quantity limits (per 30 days or as specified)
DEXCOM G5 MIS RECEIVER	1 unit / 365 days
DEXCOM G5 MIS TRANSMIT	1 unit / 84 days
DEXCOM G6 MIS RECEIVER	1 unit / 365 days
DEXCOM G6 MIS SENSOR	3 units / 30 days
DEXCOM G6 MIS TRANSMIT	1 unit / 90 days
FREESTY LIBR MIS 2 reader	1 reader / 365 days
FREESTYLE MIS reader	1 unit / 365 days
FREESTYLE LIBRE 14 day/SENSOR/FLASH MONITORING SYSTEM-¹CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR***	2 units / 28 days
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM-¹CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR***	2 sensors / 28 days
FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM-¹CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR***	3 units / 30 days
G5/G4 MIS SENSOR	4 units / 28 days
DEXCOM G5 MIS RECEIVER	1 unit / 365 days
DEXCOM G5 MIS TRANSMIT	1 unit / 84 days

Migraine products

Drug name(s)	Quantity limits (per 30 days or as specified)
almotrip mal tab 12.5mg	12 tabs / 30 days
almotrip mal tab 6.25mg	24 tabs / 30 days
almotriptan tab 12.5mg	12 tabs / 30 days
almotriptan tab 6.25mg	24 tabs / 30 days
eletriptan tab 20mg	18 tabs / 30 days
eletriptan tab 40mg	12 tabs / 30 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 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 solutionution auto-injector 4	12 syringes / 30 days
sumatriptan succinate solutionution auto-injector 6 mg/0.5ml	12 syringes / 30 days
sumatriptan succinate solutionution cartridge 4 mg/0.5ml	12 carts / 30 days
sumatriptan succinate solutionution cartridge 6 mg/0.5ml	12 carts / 30 days
SUMATRIPTAN injection 6mg/0.5	12 syringes / 30 days
zolmitriptan tab 2.5mg	18 tabs / 30 days
zolmitriptan tab 5mg	12 tabs / 30 days

Miscellaneous therapeutic classes

Drug name(s)	Quantity limits (per 30 days or as specified)
THALOMID CAP 50mg¹	30 caps / 30 days

Musculoskeletal therapy agents

Drug name(s)	Quantity limits (per 30 days or as specified)
baclofen tab 5mg	120 tabs / 30 days
baclofen tab 10mg	120 tabs / 30 days
baclofen tab 20mg	120 tabs / 30 days
carisoprodol tab 250mg	84 tabs / 90 days
carisoprodol tab 350mg	84 tabs / 90 days
chlorzoxazon tab 500mg	84 tabs / 90 days
cyclobenzaprine tab 5mg	63 tabs / 90 days
cyclobenzaprine tab 10mg	63 tabs / 90 days
dantrolene cap 25mg	90 caps / 30 days
dantrolene cap 50mg	90 caps / 30 days
dantrolene cap 100mg	90 caps / 30 days
metaxalone tab 800mg	84 tabs / 90 days
methocarbam tab 500mg	180 tabs / 90 days
methocarbam tab 750mg	132 tabs / 90 days
orphenadrine tab 100mg cr	42 tabs / 30 days
orphenadrine tab 100mg er	42 tabs / 30 days
tizanidine tab 2mg	126 tabs / 90 days
tizanidine tab 4mg	42 caps / 30 days
vanadom tab 350mg	84 tabs / 90 days

Nasal agents – systemic and topical

Drug name(s)	Quantity limits (per 30 days or as specified)
azelastine spr 0.1%	2 bottles / 30 days
FLUNISOLIDE SPR 0.025%	3 bottles / 30 days
ipratropium spr 0.03%	2 bottles / 30 days
ipratropium spr 0.06%	3 bottles / 30 days

Ophthalmic agents

Drug name(s)	Quantity limits (per 30 days or as specified)
LATANOPROST SOL 0.005%	2.5 mLs / 30 days
latanoprost solution 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 containers / 30 days

Psychotherapeutic and neurological agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ADDYI TAB 100mg	30 tabs / 30 days
AUBAGIO TAB 7mg^1,³	30 tabs / 30 days
AUBAGIO TAB 14mg^1,³	30 tabs / 30 days
AVONEX pen kit 30MCG¹	1 kit / 28 days
AVONEX PREFL kit 30MCG¹	1 kit / 28 days
BETASERON injection 0.3mg¹	1 box / 28 days
dalfampridine tab 10mg er^1,³	60 tabs / 30 days
dimethyl fumarate cap 120mg dr¹	56 caps / 180 days
dimethyl fumarate cap 240mg dr¹	60 caps / 30 days
dimethyl fumarate mis starter¹	60 caps / 180 days
GILENYA CAP 0.5mg¹	30 tabs / 30 days
glatiramer inj 20mg/ml¹	30 syringes / 30 days
glatiramer inj 40mg/ml¹	12 syringes / 28 days
glatopa inj 20mg/ml¹	30 syringes / 30 days
glatopa inj 40mg/ml¹	12 syringes / 28 days
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
SAVELLA MIS TITR PAK	1 kit / 180 days
SAVELLA TAB 12.5mg	60 tabs / 30 days
SAVELLA TAB 100mg	60 tabs / 30 days

Respiratory agents

Drug name(s)	Quantity limits (per 30 days or as specified)
ESBRIET CAP 267mg¹	180 caps / 30 days
ESBRIET TAB 267mg¹	180 tabs / 30 days
ESBRIET TAB 801mg¹	90 tabs / 30 days
KALYDECO PAK 25mg¹	60 packets / 30 days
KALYDECO PAK 50mg¹	60 packets / 30 days
KALYDECO PAK 75mg¹	60 packets / 30 days
KALYDECO TAB 150mg¹	60 tabs / 30 days

Ulcer Drugs / Antispasmodics / Anticholinergics

Drug name(s)	Quantity limits (per 30 days or as specified)
DEXILANT CAP 30mg DR	30 caps / 30 days
DEXILANT CAP 60mg DR	30 caps / 30 days
esomepra mag cap 40mg dr	30 caps / 30 days
lansoprazole cap 30mg dr	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 antispasmmodics

Drug name(s)	Quantity limits (per 30 days or as specified)
darifenacin tab 7.5mg	30 tabs / 30 days
darifenacin tab 15mg	30 tabs / 30 days
MYRBETRIQ TAB 25mg	30 tabs / 30 days
MYRBETRIQ TAB 50mg	30 tabs / 30 days
oxybutynin syp 5mg/5ml	600 mLs / 30 days
oxybutynin tab 5mg	120 tabs / 30 days
oxybutynin tab 5mg er	30 tabs / 30 days
oxybutynin tab 10mg er	60 tabs / 30 days
oxybutynin tab 15mg er	60 tabs / 30 days
solutionifenacin tab 5mg	30 tabs / 30 days
solutionifenacin tab 10mg	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
TOVIAZ TAB 4mg	30 tabs / 30 days
TOVIAZ TAB 8mg	30 tabs / 30 days
trospium chl cap 60mg er	30 caps / 30 days
trospium cl tab 20mg	60 tabs / 30 days

Specialty

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

Drug name(s)
abiraterone acetate ^1,³	ACTEMRA ¹	ACTEMRA ACTPEN ¹
alyq ¹	ambrisentan ¹	ARANESP ALBUMIN FREE ^1,⁴
AUBAGIO ^1,³	AVONEX ^1,⁴	AVONEX PEN ^1,⁴
BELSOMRA	BERINERT ¹	BETASERON ^1,⁴
bosentan ¹	capecitabine ^1,⁴	CAYSTON ¹
CHORIONIC GONADOTROPIN ¹	CIMZIA ¹	CIMZIA STARTER KIT ¹
COSENTYX ¹	COSENTYX SENSOREADY PEN ¹	COTELLIC ¹
dalfampridine er ^1,³	dimethyl fumarate ¹	dimethyl fumarate starterpack ¹
ENBREL ^1,⁴	ENBREL MINI ^1,⁴	ENBREL SURECLICK ^1,⁴
EPCLUSA ¹	EPIDIOLEX SOL 100MG/ML ¹	ERIVEDGE ^1,³
erlotinib hcl ^1,³	ESBRIET ¹	GILENYA ¹
glatiramer acetate ^1,⁴	glatopa ¹	HARVONI ^1,⁴
HUMIRA ^1,⁴	HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK ^1,⁴	HUMIRA PEN ^1,⁴
HUMIRA PEN-CD/UC/HS STARTER^1,⁴	HUMIRA PEN-PEDIATRIC UC STARTER PACK ^1,⁴	HUMIRA PEN-PS/UV STARTER ^1,⁴
HYCAMTIN ¹	HYQVIA ¹	IBRANCE ¹
imatinib mesylate ^1,³	INTRON A ¹	KALYDECO ¹
KEVZARA ¹	KOGENATE FS ¹	KOVALTRY ¹
lapatinib ditosylate ^1,⁴	LEDIPASVIR/SOFOSBUVIR ^1,⁴	NEXAVAR ^1,³
NINLARO ¹	NORDITROPIN FLEXPRO ^1,⁴	NOVAREL ^1,⁴
NOVOEIGHT ¹	NUPLAZID ¹	NUWIQ ¹
octreotide inj 500mcg ¹	octreotide inj 1000/5ml ¹	octreotide inj 100mcg ¹
octreotide inj 5000/5ml ¹	octreotide inj 50mcg/ml ¹	OCTREOTIDE INJ 100MCG ¹
OCTREOTIDE INJ 50MCG/ML ¹	octreotide inj 1000mcg ¹	octreotide inj 200mcg ¹
OCTREOTIDE INJ 500MCG ¹	OTEZLA ¹	OXYMORPHONE HYDROCHLORIDEER
PEGINTRON ^1,⁴	POMALYST ¹	PREGNYL W/DILUENT BENZYL ALCOHOL/NACL ^1,⁴
PROCRIT ^1,⁴	REBIF ^1,⁴	REBIF REBIDOSE ^1,⁴
REBIF REBIDOSE TITRATION PACK ^1,⁴	REBIF TITRATION PACK ^1,⁴	RINVOQ ¹
siLimited Distribution enafil citrate ¹	SIMPONI ¹	sodium phenylbutyrate ¹
SOFOSBUVIR/VELPATASVIR ¹	STIMATE ¹	tadalafil ¹
TASIGNA ^1,^3,⁴	THALOMID ¹	TOBRAMYCIN NEB 300/5ML ¹
tobramycin neb 300/5ml ¹	tobramycin neb 300/4ml ¹	TRACLEER ¹
TREMFYA ¹	VOSEVI ¹	XALKORI ^1,³
XELJANZ ¹	XELJANZ XR ¹	ZARXIO ¹

¹Specialty

²Limited Distribution

³Split Fill

⁴Exclusive to Accredo

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Value prescription drug benefits

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Guide to prescription drug benefits

Use this guide to understand how your benefits work.

Drug name(s)

Drug name(s)

Analgesics – anti-inflammatory

Drug name(s)

Quantity limits (per 30 days or as specified)

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

Androgens - anabolic

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiasthmatic and bronchodilator agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Anticonvulsants

Drug name(s)

Quantity limits (per 30 days or as specified)

Antidiabetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antiemetics

Drug name(s)

Quantity limits (per 30 days or as specified)

Antihyperlipidemics

Drug name(s)

Quantity limits (per 30 days or as specified)

Anti-infective agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antineoplastics and adjunctive therapies

Drug name(s)

Quantity limits (per 30 days or as specified)

Antipsychotics / anditmanic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Antivirals

Drug name(s)

Quantity limits (per 30 days or as specified)

Cardiovascular agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Dermatologicals

Drug name(s)

Quantity limits (per 30 days or as specified)

Endocrine and metabolic agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Gastrointestinal agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Hematological agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Medical devices and supplies

Drug name(s)

Quantity limits (per 30 days or as specified)

Migraine products

Drug name(s)

Quantity limits (per 30 days or as specified)

Miscellaneous therapeutic classes

Drug name(s)

Quantity limits (per 30 days or as specified)

Musculoskeletal therapy agents

Drug name(s)

Quantity limits (per 30 days or as specified)

Nasal agents – systemic and topical

Drug name(s)

Quantity limits (per 30 days or as specified)

Ophthalmic agents

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