Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016

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1 Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016 ANALGESICS acetaminophen w/ codeine ( mg, mg, mg) acetaminophen w/ codeine soln mg/5ml buprenorphine hcl-naloxone hcl dihydrate butorphanol tartrate nasal soln 10 mg/ml celecoxib (100 mg, 200 mg, 400 mg, 50 mg) fentanyl (37.5, 62.5, 87.5, td 100, td 12, td 25, td 50, td 75) fentanyl citrate (lollipop 1200 mcg, lollipop 1600 mcg, lollipop 200 mcg, lollipop 400 mcg, lollipop 600 mcg, lollipop 800 mcg, lozenge on a handle 1200 mcg, lozenge on a handle 1600 mcg, lozenge on a handle 200 mcg, lozenge on a handle 400 mcg, lozenge on a handle 600 mcg, lozenge on a handle 800 mcg) FENTORA (100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG) FLECTOR hydrocodone-acetaminophen ( mg, mg, mg) hydrocodone-acetaminophen soln mg/15ml hydrocodone-ibuprofen tab mg hydromorphone hcl (2 mg, 4 mg, 8 mg) ketorolac tromethamine tab 10 mg methadone hcl (10 mg, 5 mg) methadone hcl (soln 10, soln 5, solution 10, solution 5) morphine sulfate (100 mg, 15 mg, 30 mg, 60 mg) MORPHINE SULFATE (15 MG, 30 MG) morphine sulfate (cap sr 24hr 10 mg, cap sr 24hr 100 mg, cap sr 24hr 20 mg, cap sr 24hr 30 mg, cap sr 24hr 50 mg, cap sr 24hr 60 mg, cap sr 24hr 80 mg, tab cr 200 mg) MORPHINE SULFATE ER BEADS NUCYNTA oxycodone hcl (cap 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg, tab 5 mg) Quantity Limit: 400 per 30 Days Quantity Limit: 5000 per 30 Days Quantity Limit: 5 per 3 Days Quantity Limit: 10 per 30 Days Quantity Limit: 360 per 30 Days Quantity Limit: 5400 per 30 Days Quantity Limit: 150 per 30 Days Quantity Limit: 270 per 30 Days Quantity Limit: 20 per 5 Days Quantity Limit: 600 per 30 Days Quantity Limit: 181 per 30 Days 1

2 ANALGESICS oxycodone w/ acetaminophen ( mg, mg, mg, mg) oxymorphone hcl (10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg) ROXICET SOLUTION MG/5ML tramadol hcl (100 mg, 200 mg, 300 mg, biphasic release 100 mg, biphasic release 200 mg, biphasic release 300 mg) tramadol hcl tab 50 mg tramadol-acetaminophen ANESTHETICS lidocaine patch 5% ANTI-INFECTIVES TRUVADA TAB MG ANTINEOPLASTIC AGENTS CARDIOVASCULAR DRUGS ADVICOR (ER MG, ER MG) ADVICOR (ER MG, ER MG) atorvastatin calcium (10 mg, 20 mg, 40 mg, 80 mg) CRESTOR digoxin tab 125 mcg (0.125 mg) doxazosin mesylate (1 mg, 4 mg) fluvastatin sodium cap 20 mg fluvastatin sodium cap 40 mg fluvastatin sodium tab sr 24 hr 80 mg LANOXIN TAB 125 MCG lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg niacin tab cr 500 mg (antihyperlipidemic) pravastatin sodium SIMCOR (ER MG, ER MG, ER MG) SIMCOR TAB ER 24H MG simvastatin (10 mg, 20 mg, 40 mg, 5 mg, 80 mg) Quantity Limit: 360 per 30 Days Quantity Limit: 1800 per 30 Days Quantity Limit: 3 per 1 Days Quantity Limit: 30 per 30 DAYS 2

3 CARDIOVASCULAR DRUGS VYTORIN CENTRAL NERVOUS SYSTEM ABILIFY DISCMELT TAB DISP 10 MG ABILIFY MAINTENA amphetamine-dextroamphetamine (15 mg, 20 mg, 25 mg, 30 mg) amphetamine-dextroamphetamine (cap sr 24hr 10 mg, cap sr 24hr 5 mg, tab 20 mg) amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg APLENZIN TAB ER 24H 174 MG APLENZIN TAB ER 24H 348 MG APLENZIN TAB ER 24H 522 MG APTIOM TAB 200 MG APTIOM TAB 400 MG APTIOM TAB 600 MG APTIOM TAB 800 MG aripiprazole (10 mg, 15 mg) aripiprazole (10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg) ARISTADA PRSYR 441 MG/1.6ML ARISTADA PRSYR 662 MG/2.4ML ARISTADA PRSYR 882 MG/3.2ML BRINTELLIX TAB 10 MG BRINTELLIX TAB 20 MG BRINTELLIX TAB 5 MG BRISDELLE bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg citalopram hydrobromide (10 mg, 20 mg) citalopram hydrobromide tab 40 mg (base equiv) clonazepam (0.5 mg, orally disintegrating 0.5 mg) Quantity Limit: 1 per 28 Days Quantity Limit: 144 per 30 Days Quantity Limit: 360 per 30 Days Quantity Limit: 60 per 30 DAYS Quantity Limit: 1.6 per 28 DAYS Quantity Limit: 2.4 per 28 DAYS Quantity Limit: 3.2 per 28 DAYS 3

4 CENTRAL NERVOUS SYSTEM clonazepam (1 mg, orally disintegrating 1 mg) clonazepam (2 mg, orally disintegrating 2 mg) clonazepam orally disintegrating tab mg clonazepam orally disintegrating tab 0.25 mg clorazepate dipotassium (3.75 mg, 7.5 mg) clorazepate dipotassium tab 15 mg clozapine (200 mg, disp 200 mg) clozapine tab 100 mg CLOZAPINE TAB DISP 150 MG diazepam (10 mg, 2 mg, 5 mg) diazepam conc 5 mg/ml DIAZEPAM SOLUTION 1 MG/ML donepezil hydrochloride (5 mg, orally disintegrating 5 mg) duloxetine hcl (20 mg, 30 mg, 60 mg) EMSAM escitalopram oxalate (10 mg, 5 mg) escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 20 mg (base equiv) FANAPT FAZACLO TAB DISP 150 MG FAZACLO TAB DISP 200 MG FETZIMA (ER 120 MG, ER 80 MG) FETZIMA CAP ER 24H 20 MG FETZIMA CAP ER 24H 40 MG fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap delayed release 90 mg fluoxetine hcl tab 10 mg fluvoxamine maleate (25 mg, 50 mg) fluvoxamine maleate cap sr 24hr 100 mg fluvoxamine maleate cap sr 24hr 150 mg FORFIVO XL FYCOMPA (10 MG, 12 MG, 8 MG) FYCOMPA TAB 2 MG Quantity Limit: 300 per 30 Days Quantity Limit: 960 per 30 Days Quantity Limit: 480 per 30 Days Quantity Limit: 135 per 30 Days Quantity Limit: 270 per 30 Days Quantity Limit: 1200 per 30 Days Quantity Limit: 600 per 30 Days Quantity Limit: 135 per 30 Days 4

5 CENTRAL NERVOUS SYSTEM FYCOMPA TAB 4 MG FYCOMPA TAB 6 MG gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg galantamine hydrobromide (16 mg, 8 mg) galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg GEODON RECON SOLN 20 MG INVEGA (ER 1.5 MG, ER 3 MG, ER 9 MG) INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML INVEGA SUSTENNA SUSPENSION 156 MG/ML INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML INVEGA TAB ER 24H 6 MG LATUDA (120 MG, 40 MG) LATUDA (60 MG, 80 MG) LATUDA TAB 20 MG lorazepam (conc 2 mg/ml, tab 0.5 mg, tab 1 mg, tab 2 mg) LYRICA (100 MG, 150 MG, 25 MG, 50 MG, 75 MG) LYRICA (225 MG, 300 MG) LYRICA CAP 200 MG LYRICA SOLUTION 20 MG/ML MARPLAN methylphenidate hcl (10 mg, 5 mg) methylphenidate hcl (20 mg, cr 10 mg, cr 20 mg) Quantity Limit: 1080 per 30 Days Quantity Limit: 360 per 30 Days Quantity Limit: 270 per 30 Days Quantity Limit: 2160 per 30 Days Quantity Limit: 6 per 3 Days Quantity Limit: 0.75 per 28 Days Quantity Limit: 1 per 28 Days Quantity Limit: 1.5 per 28 Days Quantity Limit: 0.25 per 28 Days Quantity Limit: 0.5 per 28 Days Quantity Limit: 150 per 30 Days Quantity Limit: 946 per 30 Days 5

6 CENTRAL NERVOUS SYSTEM methylphenidate hcl soln 10 mg/5ml methylphenidate hcl soln 5 mg/5ml MIGRANAL mirtazapine (15 mg, 7.5 mg) mirtazapine orally disintegrating tab 15 mg naratriptan hcl olanzapine (10 mg, 15 mg, 20 mg, orally disintegrating 10 mg, orally disintegrating 15 mg, orally disintegrating 20 mg) olanzapine (2.5 mg, 5 mg, 7.5 mg, orally disintegrating 5 mg) olanzapine for im inj 10 mg paliperidone (1.5 mg, 3 mg, 9 mg) paliperidone tab sr 24hr 6 mg paroxetine hcl (10 mg, 20 mg, 40 mg) paroxetine hcl tab 30 mg paroxetine hcl tab sr 24hr 12.5 mg paroxetine hcl tab sr 24hr 25 mg paroxetine hcl tab sr 24hr 37.5 mg PAXIL SUSPENSION 10 MG/5ML POTIGA (300 MG, 400 MG) POTIGA TAB 200 MG PRISTIQ (ER 100 MG, ER 50 MG) quetiapine fumarate RELPAX REXULTI (3 MG, 4 MG) REXULTI TAB 0.25 MG REXULTI TAB 0.5 MG REXULTI TAB 1 MG REXULTI TAB 2 MG risperidone (0.25 mg, 0.5 mg, orally disintegrating 0.25 mg, orally disintegrating 0.5 mg) risperidone (1 mg, 2 mg, 3 mg, orally disintegrating 1 mg, orally disintegrating 2 mg, orally disintegrating 3 mg) risperidone (4 mg, orally disintegrating 4 mg) risperidone soln 1 mg/ml rivastigmine Quantity Limit: 900 per 30 Days Quantity Limit: 1800 per 30 Days Quantity Limit: 8 per 28 Days Quantity Limit: 9 per 30 Days Quantity Limit: 3 per 1 Days Quantity Limit: 30 per 30 DAYS Quantity Limit: 60 per 30 DAYS Quantity Limit: 900 per 30 Days Quantity Limit: 12 per 30 Days Quantity Limit: 30 per 30 DAYS Quantity Limit: 360 per 30 DAYS Quantity Limit: 180 per 30 DAYS Quantity Limit: 90 per 30 DAYS Quantity Limit: 60 per 30 DAYS Quantity Limit: 30 per 30 DAYS 6

7 CENTRAL NERVOUS SYSTEM rizatriptan benzoate ROZEREM SABRIL SAPHRIS SL TAB 10 MG SAPHRIS SL TAB 2.5 MG SAPHRIS SL TAB 5 MG SARAFEM TAB 10 MG SARAFEM TAB 20 MG SAVELLA TAB 100 MG SAVELLA TAB 12.5 MG SAVELLA TAB 25 MG SAVELLA TAB 50 MG SEROQUEL XR (ER 150 MG, ER 200 MG) SEROQUEL XR (ER 300 MG, ER 400 MG) SEROQUEL XR TAB ER 24H 50 MG sertraline hcl (25 mg, 50 mg) STRATTERA (10 MG, 18 MG, 25 MG) STRATTERA (100 MG, 60 MG, 80 MG) STRATTERA CAP 40 MG sumatriptan nasal spray 20 mg/act sumatriptan nasal spray 5 mg/act sumatriptan succinate (100 mg, 25 mg, 50 mg) sumatriptan succinate (auto-injector 4, auto-injector 6, cartridge 4, cartridge 6) sumatriptan succinate inj 6 mg/0.5ml sumatriptan succinate solution prefilled syringe 6 mg/0.5ml SURMONTIL CAP 100 MG SURMONTIL CAP 25 MG SURMONTIL CAP 50 MG tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg trimipramine maleate cap 100 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg Quantity Limit: 18 per 30 Days Quantity Limit: 272 per 14 Days Quantity Limit: 140 per 14 Days Quantity Limit: 480 per 30 Days Quantity Limit: 12 per 30 Days Quantity Limit: 24 per 30 Days Quantity Limit: 9 per 30 Days Quantity Limit: 6 per 30 OVER TIME Quantity Limit: 6 per 30 Days Quantity Limit: 6 per 30 Days Quantity Limit: 240 per 30 DAYS Quantity Limit: 120 per 30 DAYS Quantity Limit: 60 per 30 DAYS Quantity Limit: 240 per 30 DAYS Quantity Limit: 120 per 30 DAYS 7

8 CENTRAL NERVOUS SYSTEM venlafaxine hcl (37.5 mg, 75 mg) venlafaxine hcl cap sr 24hr 150 mg (base equivalent) VENLAFAXINE HCL ER TAB ER 24H 150 MG VENLAFAXINE HCL ER TAB ER 24H 225 MG VENLAFAXINE HCL ER TAB ER 24H 37.5 MG VENLAFAXINE HCL ER TAB ER 24H 75 MG venlafaxine hcl tab sr 24hr 150 mg (base equivalent) venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) venlafaxine hcl tab sr 24hr 75 mg (base equivalent) VERSACLOZ VIIBRYD (10 MG, 20 MG, 40 MG) VIMPAT (100 MG, 150 MG, 200 MG) VIMPAT SOLUTION 10 MG/ML VIMPAT TAB 50 MG XENAZINE TAB 12.5 MG XENAZINE TAB 25 MG XYREM ziprasidone hcl (20 mg, 40 mg) ziprasidone hcl (60 mg, 80 mg) zolmitriptan (2.5 mg, 5 mg, orally disintegrating 2.5 mg, orally disintegrating 5 mg) zolpidem tartrate (10 mg, 5 mg, cr 12.5 mg, cr 6.25 mg) DERMATOLOGICAL DRUGS EAR, NOSE, AND THROAT fluticasone propionate (nasal) triamcinolone acetonide (nasal) ENDOCRINE AND METABOLIC DISORDERS ACTOPLUS MET XR TAB ER 24H MG ACTOPLUS MET XR TAB ER 24H MG alendronate sodium (35 mg, 70 mg) AXIRON BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN Quantity Limit: 600 per 30 Days Quantity Limit: 1200 per 30 Days Quantity Limit: 540 per 30 Days Quantity Limit: 12 per 30 Days Quantity Limit: 16 per 30 Days Quantity Limit: 16.5 per 30 Days Quantity Limit: 440 per 30 Days Quantity Limit: 2.4 per 30 Days Quantity Limit: 1.2 per 30 Days 8

9 ENDOCRINE AND METABOLIC DISORDERS CYCLOSET FARXIGA TAB 10 MG FARXIGA TAB 5 MG FORTEO glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide (10 mg, sr 24hr 5 mg) glipizide (5 mg, sr 24hr 2.5 mg) glipizide tab sr 24hr 10 mg glipizide-metformin hcl ( mg, mg) glipizide-metformin hcl tab mg ibandronate sodium tab 150 mg (base equivalent) INVOKAMET ( MG, MG, MG) INVOKAMET TAB MG INVOKANA TAB 100 MG INVOKANA TAB 300 MG JANUMET JANUMET XR (ER MG, ER MG) JANUMET XR TAB ER 24H MG JANUVIA JENTADUETO KOMBIGLYZE XR (ER MG, ER MG) KOMBIGLYZE XR TAB ER 24H MG metformin hcl (1000 mg, sr 24hr osmotic 1000 mg) metformin hcl (500 mg, osmotic 500 mg) metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab sr 24hr 750 mg nateglinide ONGLYZA pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl Quantity Limit: 2.4 per 28 Days Quantity Limit: 1 per 30 Days Quantity Limit: 75 per 30 Days Quantity Limit: 150 per 30 Days 9

10 ENDOCRINE AND METABOLIC DISORDERS PRANDIMET PROLIA repaglinide (0.5 mg, 1 mg) repaglinide tab 2 mg REPAGLINIDE-METFORMIN HCL RIOMET SAMSCA SENSIPAR (30 MG, 90 MG) SENSIPAR TAB 60 MG SYMLINPEN 120 SYMLINPEN 60 TRADJENTA VICTOZA GASTROINTESTINAL DRUGS ALOXI AMITIZA amoxicillin-clarithromycin w/ lansoprazole CESAMET dronabinol LINZESS CAP 145 MCG LINZESS CAP 290 MCG TRANSDERM-SCOP (1.5 MG) GENITOURINARY AGENTS alfuzosin hcl AVODART dutasteride dutasteride-tamsulosin hcl JALYN MYRBETRIQ TAB ER 24H 25 MG MYRBETRIQ TAB ER 24H 50 MG oxybutynin chloride (10 mg, 15 mg) oxybutynin chloride tab sr 24hr 5 mg tolterodine tartrate (2 mg, 4 mg) TOVIAZ Quantity Limit: 150 per 30 Days Quantity Limit: 1 per 180 Days Quantity Limit: 150 per 30 DAYS Quantity Limit: 946 per 30 Days Quantity Limit: 10.8 per 30 Days Quantity Limit: 12 per 30 Days Quantity Limit: 9 per 30 Days Quantity Limit: 10 per 30 Days Quantity Limit: 112 per 30 Days Quantity Limit: 30 per 5 Days Quantity Limit: 10 per 30 Days Quantity Limit: 30 per 30 DAYS Quantity Limit: 30 per 30 DAYS 10

11 GENITOURINARY AGENTS trospium chloride tab 20 mg VESICARE HEMATOLOGIC DRUGS NEULASTA NEULASTA ONPRO PROMACTA TAB 12.5 MG PROMACTA TAB 25 MG PROMACTA TAB 50 MG PROMACTA TAB 75 MG IMMUNOLOGICAL AGENTS AVONEX AVONEX PEN AVONEX PREFILLED BETASERON COPAXONE SOLN PRSYR 20 MG/ML COPAXONE SOLN PRSYR 40 MG/ML GILENYA PEG-INTRON (120, 150, 80) PEG-INTRON KIT 50 MCG/0.5ML PEG-INTRON REDIPEN PEG-INTRON REDIPEN PAK 4 PEGASYS (KIT 180 MCG/0.5ML, SOLUTION 180 MCG/0.5ML, SOLUTION 180 MCG/ML) PEGASYS PROCLICK SOLUTION 135 MCG/0.5ML PEGINTRON (120, 150, 80) PEGINTRON KIT 50 MCG/0.5ML PLEGRIDY SOLN PEN 125 MCG/0.5ML PLEGRIDY SOLN PRSYR 125 MCG/0.5ML PLEGRIDY STARTER PACK REBIF REBIF REBIDOSE REBIF TITRATION PACK ZOSTAVAX Quantity Limit: 2 per 30 Days Quantity Limit: 2 per 30 Days Quantity Limit: 360 per 30 Days Quantity Limit: 14 per 28 Days Quantity Limit: 12 per 28 Days Quantity Limit: 28 per 28 Days Quantity Limit: 5 per 34 Days Quantity Limit: 5 per 34 Days Quantity Limit: 1 per 28 DAYS Quantity Limit: 1 per 28 Days Quantity Limit: 1 per 28 Days Quantity Limit: 6 per 28 Days Quantity Limit: 6 per 28 Days Quantity Limit: 12 per 28 Days Quantity Limit: 1 per 999 Days 11

12 MEDICAL (MISCELLANEOUS) SUPPLIES MISCELLANEOUS DRUGS MISCELLANEOUS PRODUCTS NUTRITIONAL PRODUCTS/SUPPLEMENTS OBSTETRICS AND GYNECOLOGY CLIMARA PRO DEPO-SUBQ PROVERA 104 DIVIGEL (0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM) MICONAZOLE 3 VIVELLE-DOT OPHTHALMICS RESTASIS RESPIRATORY TRACT/PULMONARY AGENTS ADCIRCA ADEMPAS ANORO ELLIPTA ATROVENT HFA COMBIVENT RESPIMAT DULERA FLOVENT DISKUS (100, 50) FLOVENT DISKUS AER POW BA 250 MCG/BLIST FLOVENT HFA (110, 220) FLOVENT HFA AEROSOL 44 MCG/ACT FORADIL AEROLIZER INCRUSE ELLIPTA LETAIRIS OPSUMIT PROAIR HFA PROVENTIL HFA PULMICORT FLEXHALER QVAR AERO SOLN 80 MCG/ACT REVATIO RECON SUSP 10 MG/ML SEREVENT DISKUS sildenafil citrate tab 20 mg SPIRIVA HANDIHALER Quantity Limit: 1 per 90 Days Quantity Limit: 3 per 3 Days Quantity Limit: 8 per 28 Days Quantity Limit: 64 per 30 Days Quantity Limit: 25.8 per 30 Days Quantity Limit: 8 per 30 Days Quantity Limit: 13 per 30 Days Quantity Limit: 24 per 30 Days Quantity Limit: 21.2 per 30 Days Quantity Limit: 17 per 30 Days Quantity Limit: 13.4 per 30 Days Quantity Limit: 2 per 30 Days Quantity Limit: 17.4 per 30 Days Quantity Limit: 224 per 30 Days 12

13 RESPIRATORY TRACT/PULMONARY AGENTS SPIRIVA RESPIMAT AERO SOLN 1.25 MCG/ACT SPIRIVA RESPIMAT AERO SOLN 2.5 MCG/ACT STRIVERDI RESPIMAT SYMBICORT TRACLEER TAB 125 MG TRACLEER TAB 62.5 MG VENTOLIN HFA XOPENEX HFA RHEUMATIC AND MUSCULOSKELETAL DRUGS ENBREL RECON SOLN 25 MG Quantity Limit: 4 per 30 DAYS Quantity Limit: 4 per 30 Days Quantity Limit: 4 per 30 Days Quantity Limit: 10.2 per 30 Days Quantity Limit: 36 per 30 Days Quantity Limit: 16 per 28 Days TOXICOLOGIC AGENTS 13

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