Alprazolam 0.25mg, 0.5mg, 1mg tablets
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1 Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service Center at (505) or , or for TTY/TDD users, call , Monday through Sunday from 8:00 a.m. to 8:00 p.m., or visit Abilify tablets Acetaminophen/codeine tablets Acyclovir ointment Alprazolam 0.25mg, 0.5mg, 1mg tablets Alprazolam 2mg tablets Amphetamine/dextroamphetamine XR 5mg, 10mg, 15mg capsules Amphetamine/dextroamphetamine XR 20mg, 25mg, 30mg capsules Amphetamine/dextroamphetamine tablets Androderm patches Androgel 50mg/5gm Androgel 1% pump Androgel 1.62% 1.25gm packet Androgel 1.62% 2.5gm packet Androgel 1.62% pump Apriso capsules Asacol tablets Bosulif 100mg tablets 30 grams Per 30 Days 135 Per 30 Days 30 patches Per 30 Days 300 grams Per 30 Days 300 grams Per 30 Days 150 grams Per 30 Days Y0055_MPC111332_NSR_ Updated 10/2014 Formulary ID Version 35 Page 1 of 8
2 Bosulif 500mg tablets Brintellix tablets Buprenorphine/naloxone tablets Bupropion XL 150mg tablets Chantix Starter Pack Chantix 0.5mg, 1mg tablets Chlordiazepoxide capsules Citalopram solution Citalopram 10mg tablets Clonazepam 0.5mg, 1mg tablets Clonazepam ODT 0.125mg, 0.25mg, 0.5mg, 1mg tablets Clorazepate tablets Codeine tablets Combivent Respimat Delzicol capsules Denavir cream Dextroamphetamine tablets Diazepam gel Diazepam solution Diazepam tablets Dificid tablets Dihydroergotamine 4mg/mL solution Donepezil 10mg tablets 106 Per 365 Days 360 Per 365 Days 600 ml Per 30 Days 45 Per 30 Days 2 inhalers Per 30 Days 1.5 grams per 30 Days 10 Per 30 Days 1200mL per 30 Days 20 Per 30 Days 8mL Per 28 Days Page 2 of 8
3 Donepezil 5mg tablets Donepezil 10mg ODT Donepezil 5mg ODT Dronabinol capsules Duloxetine capsules Emend capsules Ergomar Escitalopram 5mg, 20mg tablets Escitalopram 10mg tablets Eszopiclone tablets Fentanyl patches Fentanyl Citrate Transmucosal Lollipop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg Flurazepam capsules Fortesta gel Granisetron tablets Humalog Humalog Kwikpen Humalog Mix 50/50 Humalog Mix 50/50 Kwikpen Humalog Mix 75/25 Humalog Mix 75/25 Kwikpen Humulin 70/30 Humulin 70/30 Pen 12 Per 30 Days 20 Per 28 Days 45 Per 30 Days 10 Per 30 Days 4 Per 1 Day 120 grams Per 30 Days Page 3 of 8
4 Humulin N Humulin N U-100 Pen Humulin R Hydrocodone/acetaminophen 7.5/750mg, 10/750mg tablets Hydrocodone/acetaminophen 5/325mg, 7.5/325mg, 10/325mg, 2.5/500mg, 5/500mg, 7.5/500mg, 10/500mg, 7.5/650mg, 10/650mg, 10/660mg tablets Hydrocodone/acetaminophen solution Hydrocodone/ibuprofen 7.5/200mg tablets Hydromorphone 2mg, 4mg tablets Hydromorphone 8mg tablets Imbruvica capsules Incivek tablets Khedezla ER tablets Lantus Lantus Solostar Lazanda Levemir Levemir Flexpen Levemir Flextouch Pen Lidocaine patches Linzess capsules Lorazepam tablets Metadate CD 20mg, 30mg, 40mg capsules 150 Per 30 Days 3,600mL Per 30 Days 45mL Per 30 days Page 4 of 8
5 Methadone concentration Methadone 10mg tablets Methadone 5mg tablets Methylphenidate CD capsules Methylphenidate IR tablets Migranal solution Modafinil tablets Montelukast chewable, tablets Morphine sulfate ER 15mg, 30mg capsules Morphine sulfate ER 60mg, 100mg, 200mg capsules Morphine sulfate IR 15mg tablets Morphine sulfate IR 30mg tablets Naratriptan tablets Nicotrol inhaler Nicotrol nasal spray Novolin 70/30 Novolin N Novolin R Novolog Novolog Flexpen Novolog Mix 70/30 Novolog Mix 70/30 Prefilled Flexpen Novolog Penfill 120mL Per 30 Days 8mL Per 30 Days 18 Per 30 Days 3024 inhalers Per 365 Days 720 ml Per 365 Days Page 5 of 8
6 Nuvigil tablets Olanzapine ODT Omeprazole DR capsules Ondansetron 4mg, 8mg tablets Ondansetron ODT Onfi tablets Opana ER crush resistant tablets Oxycodone 5mg, 10mg tablets Oxycodone 15mg tablets Oxycodone 20mg tablets Oxycodone 30mg tablets Oxycodone/acetaminophen tablets Pantoprazole tablets Pen Needles Pentasa capsules Pomalyst capsules Pradaxa capsules Pristiq tablets Procrit 2000 units/ml, 3000 units/ml, 4000 units/ml injection Protopic 0.03% ointment Protopic 0.1% ointment Rabeprazole capsules Relistor injection 150 Per 30 Days 100 Per 30 Days 240 Per 30 Days 21 Per 28 Days 15 ml Per 30 Days 100 grams Per 60 Days 120 grams Per 60 Days Page 6 of 8
7 Relpax tablets Rivastigmine Tartrate capsules Rizatriptan tablets, ODT Rozerem tablets Sildenafil tablets Simbrinza ophthalmic suspension Stivarga 40mg tablets Sumatriptan 20mg/Actuation solution Sumatriptan Succinate 4mg/0.5mL injection Sumatriptan Succinate 6mg/0.5mL injection Sumatriptan Succinate tablets Tamiflu 30mg capsules Tamiflu 45mg, 75mg capsules Tamiflu 6mg/mL suspension Temazepam capsules Terbinafine tablets Tobi Podhaler Tramadol 50mg tablets Tramadol ER 100mg tablets Tramadol ER 200mg tablets Triazolam tablets Uloric tablets Vascepa capsules 18 Per 30 Days 18 Per 30 Days 8 ml Per 30 Days 6 Per 30 Days 2 ml Per 30 Days 5 ml Per 30 Days 18 Per 30 Days 56 Per 180 Days 28 Per 180 Days 360 ml Per 180 Days 224 Per 28 Days 240 Per 30 Days Page 7 of 8
8 Venlafaxine ER 37.5mg, 150mg tablets, capsules Venlafaxine ER 75mg tablets, capsules Venlafaxine ER 225mg tablets Victrelis capsules Viibryd tablets Vimpat tablets Voriconazole 200mg tablets Vyvanse capsules Xtandi capsules Zaleplon capsules Zolpidem IR tablets Zolpidem ER tablets Zortress tablets Zovirax cream Zyflo CR tablets Zykadia 150mg capsule 3 5 grams Per 30 Days #150 Per 30 Days Page 8 of 8
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