Essential Health Benefits Non-Specialty Quantity Limit List
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1 Anti-infectives Antibiotics ZYVOX (linezolid) 28 tabs/30 days ZYVOX (linezolid) Suspension 4 bottles (600 ml)/28 days Antifungals LAMISIL (terbinafine) 250 mg 84 days supply/180 days Antimalarial QUALAQUIN (quinine) QL varies* Antivirals, Herpetic FAMVIR (famciclovir) 125 mg FAMVIR (famciclovir) 250 mg FAMVIR (famciclovir) 500 mg 21 tabs/30 days VALTREX (valacyclovir) 1000 mg VALTREX (valacyclovir) 500 mg Antivirals, Influenza RELENZA (zanamivir) QL is 40 inh per 365 days. TAMIFLU (oseltamivir) 30 mg 40 caps per 365 days TAMIFLU (oseltamivir) 45 mg, 75 mg 20 caps per 365 days TAMIFLU (oseltamivir) Suspension 360 ml/365 days Cardiology Anticoagulants ELIQUIS (apixiban) ELIQUIS (apixiban) 5 mg PRADAXA (dabigatran) XARELTO (rivaroxaban) 10 mg 35 days supply/180 days XARELTO (rivaroxaban) 15 mg XARELTO (rivaroxaban) 20 mg XARELTO (rivaroxaban) Starter Pack 2 starter packs/year ADHD Agents ADDERALL (amphetamine/dextroamphetamine) ADDERALL XR (amphetamine/dextroamphetamine mixed salts) CONCERTA (methylphenidate) CONCERTA (methylphenidate) 36 mg DAYTRANA (methylphenidate transdermal) 1 patch/day DESOXYN (methamphetamine) 5 tabs/day DEXEDRINE (dextroamphetamine) 10 mg 6 caps/day DEXEDRINE (dextroamphetamine) 15 mg 4 caps/day DEXEDRINE (dextroamphetamine) 5 mg 3 caps/day FOCALIN (dexmethylphenidate) FOCALIN XR (dexmethylphenidate) FOCALIN XR (dexmethylphenidate) 20 mg METADATE CD (methylphenidate) 10 mg METADATE CD (methylphenidate) 20 mg METADATE CD (methylphenidate) 30 mg METADATE CD (methylphenidate) 40 mg METADATE CD (methylphenidate) 50 mg METADATE CD (methylphenidate) 60 mg METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate) METHYLIN ER (methylphenidate) 20 mg PROCENTRA (dextroamphetamine) Sol 60 mls/day QUILLIVANT XR (methylphenidate) 12 ml/day RITALIN (methylphenidate) RITALIN LA (methylphenidate ) RITALIN LA (methylphenidate ) 40 mg RITALIN SR (methylphenidate) 20 mg STRATTERA (atomoxetine) VYVANSE (lisdexamfetamine) Updated 9/29/2015 Page 1 of 7
2 ADHD Agents ZENZEDI (dextroamphetamine) ZENZEDI (dextroamphetamine) 10 mg 6 tabs/day ZENZEDI (dextroamphetamine) 30 mg Alzheimers Agents NAMENDA XR (memantine hcl) caps NAMENDA XR TITRATION PACK (memantine hcl) caps 56 caps/ year NAMZARIC (memantine hcl) caps 1 cap/ day Analgesics (non-opioid) CELEBREX (celecoxib) DUEXIS (naproxen/esomeprazole) FLECTOR (diclofenac epolamine) 2 patches/day up to 15 days Ketorolac (ketorolac) 20 tabs or 5 days supply per 30 days PENNSAID (diclofenac) 1.5% 2 bottles/28 days PENNSAID (diclofenac) 2% 2 bottles/28 days SPRIX (ketorolac) 5 bottles or 5 days supply per 30 days VIMOVO (naproxen/esomeprazole) VOLTAREN (diclofenac) Gel 10 tubes/month Analgesics (opioid) ABSTRAL (fentanyl citrate) ACTIQ (fentanyl citrate) 4 lozenges/day AVINZA (morphine ext-release) BUTRANS (buprenorphine) 4 patches/28 days CONZIP (tramadol SR) DURAGESIC (fentanyl transdermal) 10 patches/30 days EXALGO (hydromorphone) FENTORA (fentanyl citrate) KADIAN (morphine ext-release) LAZANDA (fentanyl citrate) 1 bottle/day MS CONTIN (morphine ext-release) NUCYNTA ER (tapentadol) ONSOLIS (fentanyl citrate) 4 films/day OPANA ER (oxymorphone ext-release) OXYCONTIN (oxycodone ext-release) SUBOXONE (buprenorphrine/naloxone) 12-3 mg 2 films/day SUBOXONE (buprenorphrine/naloxone) mg 12 tabs or films/day SUBOXONE (buprenorphrine/naloxone) 4-1 mg 6 films/day SUBOXONE (buprenorphrine/naloxone) 8-2 mg 3 tabs or films/day SUBSYS (fentanyl) 4 sprays/day SUBUTEX (buprenorphrine) 2 mg 1 SUBUTEX (buprenorphrine) 8 mg ULTRAM ER (tramadol ext-release) Anticonvulsants GRALISE (gabapentin) 300 mg 6 tabs/day GRALISE (gabapentin) 600 mg GRALISE (gabapentin) Pack 2 kits per year (156 tabs per year) HORIZANT (gabapentin enacarbil) LYRICA (pregabalin) 225 mg LYRICA (pregabalin) 300 mg LYRICA (pregabalin) caps 3 caps/day LYRICA (pregabalin) Soln 900 mls/30 days Antidepressants APLENZIN (bupropion) CYMBALTA (duloxetine) CYMBALTA (duloxetine) 30 mg 3 caps/day EMSAM (selegiline) 1 patch/day FORFIVO XL (bupropion) 450 mg Updated 9/29/2015 Page 2 of 7
3 Antidepressants IRENKA (duloxetine) KHEDEZLA (desvenlafaxine ER) PRISTIQ (desvenlafaxine) PROZAC WEEKLY (fluoxetine) 4 caps/28 days VIIBRYD (vilazodone) WELLBUTRIN SR (bupropion) WELLBUTRIN XL (bupropion) Antipsychotics ABILIFY (aripiprazole) 10 mg ABILIFY (aripiprazole) 15 mg ABILIFY (aripiprazole) 2 mg ABILIFY (aripiprazole) 20 mg ABILIFY (aripiprazole) 30 mg ABILIFY (aripiprazole) 5 mg ABILIFY DISCMELT (aripiprazole) ABILIFY SOLN (aripiprazole) 1 mg/ml 30 mls/day CLOZARIL (clozapine) 100 mg CLOZARIL (clozapine) 200 mg CLOZARIL (clozapine) 25 mg CLOZARIL (clozapine) 50 mg 6 tabs/day FANAPT (iloperidone) FAZACLO (clozapine) 100 mg FAZACLO (clozapine) 12.5 mg FAZACLO (clozapine) 150 mg 6 tabs/day FAZACLO (clozapine) 200 mg FAZACLO (clozapine) 25 mg INVEGA (paliperidone) 1.5 mg INVEGA (paliperidone) 3 mg INVEGA (paliperidone) 6 mg INVEGA (paliperidone) 9 mg LATUDA (lurasidone) 20 mg, 40 mg, 60mg, 120 mg LATUDA (lurasidone) 80 mg RISPERDAL (risperidone) RISPERDAL M (risperidone) RISPERDAL SOLN (risperidone) 8 mls/day SAPHRIS (asenapine) SEROQUEL (quetiapine) SEROQUEL (quetiapine) 25 mg SEROQUEL (quetiapine) 50 mg SEROQUEL XR (quetiapine) SEROQUEL XR (quetiapine) 300 mg SEROQUEL XR (quetiapine) 400 mg SEROQUEL XR (quetiapine) 50 mg ZYPREXA (olanzapine) ZYPREXA ZYDIS (olanzapine) Fibromyalgia SAVELLA (milnacipran) SAVELLA (milnacipran) Pack 1 pack (55 tabs)/year Migraine ALSUMA (sumatriptan) 5 packages (10 syringes)/30 days AMERGE (naratriptan) AXERT (almotriptan) FROVA (frovatriptan) IMITREX (sumatriptan) Updated 9/29/2015 Page 3 of 7
4 Migraine IMITREX (sumatriptan) AUTO-INJECTOR 4 mg/0.5 ml & 6 mg/0. 5 kits (10 units)/30 days IMITREX (sumatriptan) CARTRIDGE 4 mg/0.5 ml & 6 mg/0.5 ml 5 kits (10 units)/30 days IMITREX (sumatriptan) Nasal 12 spray unit devices/30 days IMITREX (sumatriptan) SYRINGE 4 mg/0.5 ml & 6 mg/0.5 ml 5 kits (10 units)/30 days MAXALT (rizatriptan) 18 tabs/30 days MAXALT-MLT (rizatriptan) 18 tabs/30 days RELPAX (eletriptan) SUMAVEL DOSEPRO (sumatriptan) 12 prefilled syringes/30 days TREXIMET (sumatriptan/naproxen) ZECUITY (sumatriptan) 4 systems (1 carton)/30 days. ZOMIG (zolmitriptan) ZOMIG (zolmitriptan) 2.5 mg ZOMIG (zolmitriptan) Nasal 2 packages (12 spray units)/30 days ZOMIG ZMT (zolmitriptan) ZOMIG ZMT (zolmitriptan) 2.5 mg Miscellaneous RILUTEK (riluzole) Sedative Hypnotics AMBIEN (zolpidem) AMBIEN CR (zolpidem) INTERMEZZO (zolpidem) LUNESTA (eszopiclone) ROZEREM (ramelteon) SILENOR (doxepin) SONATA (zaleplon) 10 mg 2 cap/day SONATA (zaleplon) 5 mg Stimulants NUVIGIL (armodafinil) NUVIGIL (armodafinil) 50 mg PROVIGIL (modafinil) Dermatology Miscellaneous TACLONEX (calcipotriene/betamethasone) 400 g/30 days TACLONEX SCALP (calcipotriene/betamethasone) 120 g/30 days TAZORAC (tazarotene) 100 g/30 days Endocrinology & Metabolism Androgens, Anabolic Steroids OXANDRIN (oxandrolone) 10 mg OXANDRIN (oxandrolone) 2.5 mg 8 tabs/day Osteoporosis ACTONEL (risedronate) 150 mg 1 tab/28 days ACTONEL (risedronate) 35 mg ATELVIA (risedronate) BINOSTO (alendronate) BONIVA (ibandronate) 1 tabs/28 days BONIVA IV (ibandronate) 1 syringe/90 days FORTICAL (calcitonin) 1 bottle (3.7 ml)/30 days FOSAMAX (alendronate) 35 mg & 70 mg FOSAMAX PLUS D (alendronate/cholecalciferol) MIACALCIN (calcitonin) 1 bottle (3.7 ml)/30 days Gastroenterology Antiemetics ANZEMET (dolasetron) 2 tabs/30 days CESAMET (nabilone) 60 caps/30 days EMEND (aprepitant) 1 cap/30 days EMEND (aprepitant) 125 mg 2 caps/30 days EMEND (aprepitant) 125 mg/80 mg 2 packs (6 caps)/30 days EMEND (aprepitant) 40 mg 1 cap/30 days Updated 9/29/2015 Page 4 of 7
5 Gastroenterology Antiemetics EMEND (aprepitant) 80 mg 4 caps/30 days GRANISOL (granisetron) 1 bottle (30 ml)/30 days KYTRIL (granisetron) 4 tabs/30 days MARINOL (dronabinol) 60 caps/30 days SANCUSO (granisetron) 2 patches/30 days ZOFRAN (ondansetron) 120 ml/30 days ZOFRAN (ondansetron) 24 mg 2 tabs/30 days ZOFRAN (ondansetron) 4 mg, 8 mg 15 tabs/30 days ZOFRAN IV (ondansetron) 48 mg/ day ZOFRAN ODT (ondansetron) 4 mg, 8 mg 15 tabs/30 days ZUPLENZ (ondansetron) 10 films/30 days Constipation AMITIZA (lubiprostone) LINZESS (linaclotide) Opioid-induced Constipation RELISTOR (methylnaltrexone) QL is 1 syringe/day. RELISTOR (methylnaltrexone) Kit 1 vial/day Proton Pump Inhibitors ACIPHEX (rabeprazole) ACIPHEX SPRINKLE (rabeprazole) SPR DEXILANT (dexlansoprazole) NEXIUM (esomeprazole) 1 cap or packet/day PREVACID (lansoprazole) PREVACID (lansoprazole) Solutab PRILOSEC (omeprazole) PROTONIX (pantoprazole) tab ZEGERID (omeprazole) caps ZEGERID (omeprazole) packets 1 packet/day Miscellaneous Diabetic Supplies Blood Glucose Monitors (blood glucose monitors) 1 monitor/year Glucose Test Strips & Lancets (test strip & lancets) 300/30 days Insulin Syringes and Pen Needles (all) 200 units/30 days Smoking Cessation Products CHANTIX (varenicline) COMMIT (nicotine lozenges) NICODERM (nicotine transdermal) NICORETTE (nicotine gum) NICOTROL Inhaler (nicotine) NICOTROL NS (nicotine) ZYBAN (bupropion) Obstetrics & Gynecology Contraceptives AMETHIA (levonorg-eth est) AMETHIA LO (levonorg-eth est) ASHLYNA (levonorg-eth est) CAMRESE (levonorg-eth est) CAMRESE LO (levonorg-eth est) DAYSEE (levonorg-eth est) DEPO/DEPO-SUBQ PROVERA (medroxyprogesterone) 1/90 days (3 copays per fill) INTROVALE (levonorg-eth est) JOLESSA (levonorg-eth est) LOSEASONIQUE (ethinyl estradiol/levonorgestrel) NUVARING (ethinyl estradiol/etonogestrel) 1/28 days QUARTETTE (levonorg-eth est) QUASENSE (levonorg-eth est) SEASONIQUE (ethinyl estradiol/levonorgestrel) Updated 9/29/2015 Page 5 of 7
6 Obstetrics & Gynecology Hormone Replacement ESTRING (estradiol) 1 package/90 days Ophthalmology Anti-inflammatory BROMDAY (bromfenac) ILEVRO (nepafenac) 0.3% LOTEMAX (loteprednol) gel, oint NEVANAC (nepafenac) 0.1% PROLENSA (bromfenac sodium) Miscellaneous RESTASIS (cyclosporine) 2 vials/day Prostaglandins LUMIGAN (bimatoprost) 1 bottle (2.5 ml)/25 days TRAVATAN (travoprost) 1 bottle (2.5 ml)/25 days TRAVATAN Z (travoprost) 1 bottle (2.5 ml)/25 days XALATAN (latanoprost) 1 bottle (2.5 ml)/25 days ZIOPTAN (tafluprost) 1 container/day Respiratory Allergy (intranasal) ASTELIN (azelastine) 2 bottles (60 ml)/30 days ASTEPRO (azelastine) 2 bottles (60 ml)/30 days ATROVENT (ipratropium) 2 bottles/30 days BECONASE AQ (beclomethasone) 1 inhaler (25 g)/30 days DYMISTA (fluticasone/azelastine) 1 inhaler (23 g)/30 days FLONASE (fluticasone) 1 bottle (16 g)/30 days FLUNISOLIDE (flunisolide) 1 bottle (25 ml)/30 days NASACORT AQ (triamcinolone) 1 inhaler (16.5 g)/30 days NASONEX (mometasone) 1 inhaler (17 g)/30 days OMNARIS (ciclesonide) 1 inhaler (12.5 g)/30 days PATANASE (olopatadine) 1 bottle (30.5 g)/30 days QNASL (beclomethasone) 1 inhaler (8.7 g)/30 days QNASL CHILDRENS (beclomethasone) 1 inhaler (4.9 g)/30 days RHINOCORT AQUA (budesonide) 1 bottle (8.6 g)/30 days VERAMYST (fluticasone furoate) 1 bottle (10 g)/30 days ZETONNA (ciclesonide nasal) 1 inhaler (6.1 g)/30 days Asthma/COPD (inhaled) ADVAIR DISKUS (fluticasone/salmeterol) 1 diskus (60 doses)/30 days ADVAIR HFA (fluticasone/salmeterol) ALVESCO (ciclesonide) 2 inhalers (6.1 g each)/30 days ARCAPTA (indacaterol) 4 caps/day ASMANEX HFA (mometasone) ASMANEX TWISTHALER (mometasone) ATROVENT HFA (ipratropium) 2 inhalers (12.9 g each)/30 days BREO ELLIPTA (fluticasone furoate-vilanterol) 1 package (60 blisters)/30 days COMBIVENT RESPIMAT (ipratropium/albuterol) 2 inhalers (4 g each)/30 days DULERA (mometasone/formoterol) FLOVENT (fluticasone) 110 mcg, 220 mcg 2 inhalers (12 g each)/30 days FLOVENT (fluticasone) 44 mcg FLOVENT DISKUS (fluticasone) 50 mcg, 100 mcg 60 blisters/30 days FORADIL (formoterol) 1 package (60 doses)/30 days MAXAIR AUTOHALER (pirbuterol) 1 inhaler (14 g)/30 days PROAIR HFA (albuterol) PROAIR RESPICLICK (albuterol) PROVENTIL HFA (albuterol) PULMICORT FLEXHALER (budesonide) 2 packages/30 days QVAR (beclomethasone) SEREVENT DISKUS (salmeterol) 50 mcg 1 package (60 doses)/30 days Updated 9/29/2015 Page 6 of 7
7 Respiratory Asthma/COPD (inhaled) SPIRIVA HANDIHALER (tiotropium) 1 package (30 caps)/30 days SYMBICORT (budesonide/formoterol) TUDORZA (aclidinium bromide) 1 pouch (60 doses)/30 days VENTOLIN HFA (albuterol) XOPENEX HFA (levalbuterol) 2 inhalers (15 g)/30 days Asthma/COPD (nebulized) ACCUNEB (albuterol) 5 packages (125 vials or 375 ml)/30 days Albuterol (albuterol) 2.5 mg/3 ml (0.083%) 180 vials (540 ml)/30 days Albuterol (albuterol) 5 mg/ml (0.5%) 5 packages (100 ml)/30 days ATROVENT (ipratropium) 125 vials (312.5 ml)/30 days BROVANA (arformoterol) 60 vials (120 ml)/30 days DUONEB (ipratropium/albuterol) 180 vials (540 ml)/30 days PERFOROMIST (formoterol) 60 vials (120 ml)/30 days PROVENTIL (albuterol) 2.5 mg/3ml (0.083%) 175 vials (525 ml)/30 days PULMICORT RESPULES (budesonide) 2 packages (120 ml)/30 days XOPENEX (levalbuterol) 180 vials (540 ml)/30 days XOPENEX (levalbuterol) 1.25 mg/0.5 ml 90 vials (45 ml)/30 days XOPENEX (levalbuterol) 1.25 mg/3 ml 90 vials (270 ml)/30 days Supplies AEROCHAMBER (spacer) 1 spacer/year INSPIREASE (spacer) 1 spacer/year Urology Erectile Dysfunction CAVERJECT (alprostadil) 8 vials or suppositories/30 days (males only) CIALIS (tadalafil) 10 mg CIALIS (tadalafil) 2.5 mg (males only) CIALIS (tadalafil) 20 mg CIALIS (tadalafil) 5 mg EDEX (alprostadil) 8 vials or suppositories/30 days (males only) MUSE (alprostadil) 8 vials or suppositories/30 days (males only) VIAGRA (sildenafil) Overactive Bladder Antispasmodics OXYTROL (oxybutynin) 8 patches/28 days PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected included both brand and generic where applicable and includes all strengths unless otherwise specifically noted. If a targeted drug has a new strength, it will automatically be added to the list. Updated 9/29/2015 Page 7 of 7
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With the safety of our members in mind, we regularly review recommendations from the Food and Drug Administration (FDA) and evidence-based treatment guidelines from the medical literature with our Pharmacy
90 dosage units per 90 days OR. Extended-release Formulations Ultram ER 90 dosage units per 90 days OR
Pre - PA Allowance 12 years of age or older Quantity Immediate-release Formulation Ultracet 720 dosage units per 90 days OR Ultram 720 dosage units per 90 days Extended-release Formulations Ultram ER 90
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HYSINGLA ER (hydrocodone bitartrate) Prior authorization is not required if prescribed by an oncologist.
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Medication Tier 2 options Tier 1 options Nexium- Tier 3 Aciphex Lansoprazole Omeprazole Pantoprazole Crestor- Tier 3 Lipitor Simvastatin Vytorin- Tier 3 Atacand- Tier 3 Avapro Benicar Cozaar Micardis Tevetan
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MORPHINE IR DRUG CLASS Morphine IR, Dilaudid IR (hydromorphone), Opana IR (oxymorphone)
Pre - PA Allowance Tablets & Suppositories Morphine sulfate tablets Morphine sulfate suppositories Oxymorphone tablets Hydromorphone tablets Hydromorphone suppositories 360 tablets per 90 days OR 360 suppositories
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Duragesic patch. Duragesic patch (fentanyl patch) Description. Section: Prescription Drugs Effective Date: January 1, 2019
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Duragesic patch Page: 1 of 9 Last Review Date: November 30, 2018 Duragesic patch Description Duragesic patch (fentanyl
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Belbuca Page: 1 of 9 Last Review Date: September 15, 2016 Belbuca (buprenorphine buccal film)
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If you have questions about quantity limits for your medication contact ClearScript Member Services at the number on the back of your ID Card.
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1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.31 Section: Prescription Drugs Effective Date: April1, 2017 Subject: Duragesic patch Page: 1 of 10 Last Review Date: March
Drug Quantity Limits
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Maryland Medicaid Pharmacy Program Quantity Limits Maryland Medicaid limits the coverage of quantities for certain drugs. Quantity Limits are in place to promote safe and appropriate use of medication
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
Duragesic Patch (fentanyl patch) Prior authorization is not required if prescribed by an oncologist
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.39 Subject: Embeda Page: 1 of 8 Last Review Date: September 15, 2017 Embeda Description Embeda (morphine
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