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)

ACTEMRA ACTPEN1

ACTEMRA1

ADEMPAS1,2

ALECENSA1,2,3

alyq

ambrisentan1

ARANESP ALBUMIN FREE1

AUBAGIO1,3

avita

AVONEX PEN1

AVONEX1

BELSOMRA

BERINERT1

BETASERON1

bosentan1

capecitabine1

CAYSTON1

CHORIONIC GONADOTROPIN1

ciclodan

ciclopirox soln

CIMZIA1

CINRYZE1,2

clomipramine hcl

clomipramine hydrochloride

CORLANOR

COTELLIC1

dalfampridine er

DARAPRIM

DESVENLAFAXINE ER

dimethyl fumarate

EMBEDA

EMSAM

ENBREL SURECLICK1

ENBREL/-MINI1

EPCLUSA1

EPIDIOLEX

ERIVEDGE1,3

erlotinib hydrochloride1

ESBRIET1

fentanyl

fentanyl citrate oral transmucosal

FLUNISOLIDE

FLUOXETINE

GILENYA1

GILOTRIF1,2

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

LENVIMA 1 MG DAILY DOSE1,2,3

LENVIMA 12MG DAILY DOSE1,2,3

LENVIMA 14 MG DAILY DOSE1,2,3

LENVIMA 1 MG DAILY DOSE1,2,3

LENVIMA 2 MG DAILY DOSE1,2,3

LENVIMA 24 MG DAILY DOSE1,2,3

LENVIMA 4 MG DAILY DOSE1,2,3

LENVIMA MG DAILY DOSE1,2,3

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

TARCEVA1,3

tazarotene

TECFIDERA1,3

testosterone cypionate

TESTOSTERONE ENANTHATE

tobramycin

TRACLEER1

tramadol hcl er

tramadol hydrochloride er

tretinoin

VENCLEXTA1,2

VIIBRYD

VOSEVI1

XELJANZ XR1

XELJANZ1

XIFAXAN

ZARXIO1

ZIOPTAN1

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 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

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 
(per 30 days or as specified)

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

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 
(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/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 
(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/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 
(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/ml

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 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 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 
(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/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 
(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

Irritable Bowel Syndrome with Diarrhea (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 7MG1,3

30 tablets/30 days

AUBAGIO TABLET 14MG1,3

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

TECFIDERA CAPSULE 120MG1,3

56 capsules/180 days

TECFIDERA CAPSULE 240MG1,3

60 capsules/30 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

2 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 Extended Release (ER)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

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 
(per 30 days or as specified)

travoprost drops 0.004%

2.5 mLs/30 days

Oral inhalers

Drug name(s)

Quantity limits 
(per 30 days or as specified)

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 
(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 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 
(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 150MG1,2,3

240 capsules/30 days

COTELLIC TABLET 20MG1

63 tablets/28 days

ERIVEDGE CAPSULE 150MG1,3

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 4MG1,2,3

30 capsules/30 days

LENVIMA CAPSULE 8 MG1,2,3

60 capsules/30 days

LENVIMA CAPSULE 10 MG1,2,3

30 capsules/30 days

LENVIMA CAPSULE 12MG1,2,3

90 capsules/30 days

LENVIMA CAPSULE 14 MG1,2,3

60 capsules/30 days

LENVIMA CAPSULE 18 MG1,2,3

90 capsules/30 days

LENVIMA CAPSULE 20 MG1,2,3

60 capsules/30 days

LENVIMA CAPSULE 24 MG1,2,3

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 25MG1,3

60 tablets/30 days

TARCEVA TABLET 100MG1,3

30 tablets/30 days

TARCEVA TABLET 150MG1,3

30 tablets/30 days

VENCLEXTA TABLET START PK1,2

1 Pack/180 days

VENCLEXTA TABLET 50MG1,2

30 tablets/30 days

VENCLEXTA TABLET 100MG1,2

180 tablets/30 days

VENCLEXTA TABLET 10MG1,2

60 tablets/30 days

ZYDELIG TABLET 100MG1,2

60 tablets/30 days

LETZYDELIG TABLET 150MG1,2

60 tablets/30 days

ZYTIGA TABLET 500MG1,3

60 tablets/30 days

Somatostatin Analogs

Drug name(s)

Quantity limits 
(per 30 days or as specified)

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 
(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)

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

ADEMPAS1,2

ALECENSA1,2,3

alyq1

ambrisentan1

ARANESP ALBUMIN FREE1,4

AUBAGIO1,3

AVONEX PEN1,4

AVONEX1,4

BERINERT1

BETASERON1,4

bosentan1

capecitabine1

CAYSTON1

CHORIONIC GONADOTROPIN1

CIMZIA1

CINRYZE1,2

COTELLIC1

CYSTAGON1,2

dalfampridine er1

dofetilide1

ENBREL MINI1,4

ENBREL SURECLICK1,4

ENBREL1,4

entecavir1

EPCLUSA1

ERIVEDGE1,3

erlotinib hydrochloride1

ESBRIET1

GILENYA1

GILOTRIF1,2

GLATIRAMER ACETATE1,4

glatopa1

HARVONI1,4

HUMIRA PEN1,4

HUMIRA1,4

HYCAMTIN1

HYQVIA1

IBRANCE1

imatinib mesylate1

INCRELEX1,2

INTRON A1

KALYDECO1

KOGENATE FS BIO-SET1

KOGENATE FS1

KOVALTRY1

LEDIPASVIR/SOFOSBUVIR1,4

LENVIMA 10 MG DAILY DOSE1,2,3

LENVIMA 12MG DAILY DOSE1,2,3

LENVIMA 14 MG DAILY DOSE1,2

LENVIMA 18 MG DAILY DOSE1,2,3

LENVIMA 20 MG DAILY DOSE1,2,3

LENVIMA 24 MG DAILY DOSE1,2,3

LENVIMA 4 MG DAILY DOSE1,2,3

LENVIMA 8 MG DAILY DOSE1,2,3

LETAIRIS1

LEUPROLIDE ACETATE1,4

miglustat1

NATPARA1

NEXAVAR1,3

NINLARO1

NORDITROPIN FLEXPRO1,4

NOVAREL1,4

NOVOEIGHT1

NUPLAZID1

NUWIQ1

octreotide acetate1

OCTREOTIDE ACETATE1

OTEZLA1

PEGASYS PROCLICK1,4

PEGASYS1,4

POMALYST1

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL1,4

PROCRIT1,4

REBIF REBIDOSE TITRATION PACK1,4

REBIF REBIDOSE1,4

REBIF TITRATION PACK1,4

REBIF1,4

ribasphere1

ribavirin1

sildenafil citrate1

RINVOQ1

SIMPONI1

SKYRIZI1

sodium phenylbutyrate 1

SOFOSBUVIR/VELPATASVIR1

STIMATE1

tadalafil1

TARCEVA1,3

TASIGNA1,3,4

TECFIDERA1

tobramycin1

tobramycin sulfate1

TOBRAMYCIN1

TRACLEER1

TYKERB1,4

VELTASSA1

VENCLEXTA1,2

VOSEVI1

XALKORI1,3

XELJANZ XR1

XELJANZ1

ZARXIO1

ZYDELIG1,2

ZYTIGA1,3

 

1Specialty

2Limited Distribution

3Split Fill

4Indicates exclusive to Alliance Rx Walgreens Prime preferred specialty