2014 Quantity Limits (QL) Criteria
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1 2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food and Drug Administration and manufacturer dosing recommendations. For example, Januvia 50mg is covered up to 30 tablets for a 30-day period. If your physician feels it is medically necessary for you to receive more than 30 tablets over a 30-day period, he or she must ask for an exception to the quantity limit. Doctors must secure prior approval before a higher quantity will be covered. This list includes drugs that have quantity limits. To see if your drug is on the list, refer to the index located at the end of this document for the medication you are looking for. Updated: 11/2014 Y0026_ Approved 1/12/2014 Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies, EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
2 ACTONEL Actonel TABS 150MG Actonel TABS 30MG, 5MG Actonel TABS 35MG Quantity Limit: 1 Per 30 Days Quantity Limit: 5 Per 35 Days ADCIRCA Adcirca ADVAIR DISKUS Advair Diskus Quantity Limit: 120 Per 30 Days ADVAIR HFA Advair Hfa Quantity Limit: 24 Per 30 Days ALBUTEROL SULFATE Albuterol Sulfate NEBU 0.083%, 0.63MG/3ML, 1.25MG/3ML Albuterol Sulfate NEBU 0.5% Quantity Limit: 360 Per 30 Days ALENDRONATE SODIUM Alendronate Sodium SOLN Alendronate Sodium TABS 10MG, 40MG, 5MG Alendronate Sodium TABS 35MG, 70MG Quantity Limit: 375 Per 30 Days Quantity Limit: 5 Per 30 Days ALINIA Alinia SUSR Alinia TABS Quantity Limit: 180 Per 30 Days Quantity Limit: 12 Per 30 Days AMITIZA Amitiza 1
3 ARICEPT Aricept TABS 23MG ASMANEX TWISTHALER 120 METERED DOSES Asmanex Twisthaler 120 Metered Doses Quantity Limit: 2 Per 30 Days ASMANEX TWISTHALER 30 ME TERED DOSES Asmanex Twisthaler 30 Me Tered Doses Quantity Limit: 2 Per 30 Days ASMANEX TWISTHALER 30 METERED DOSES Asmanex Twisthaler 30 Metered Doses Quantity Limit: 2 Per 30 Days ASMANEX TWISTHALER 60 METERED DOSES Asmanex Twisthaler 60 Metered Doses Quantity Limit: 2 Per 30 Days ASTEPRO Astepro ATROVENT HFA Atrovent Hfa Quantity Limit: 26 Per 30 Days AVONEX Avonex Quantity Limit: 2 Per 28 Days AZELASTINE HCL Azelastine Hcl SOLN 0.15%, 137MCG/SPRAY BENICAR Benicar 2
4 BUDESONIDE Budesonide SUSP 0.25MG/2ML, 0.5MG/2ML Quantity Limit: 120 Per 30 Days BUTORPHANOL TARTRATE Butorphanol Tartrate NASAL SOLN Quantity Limit: 5 Per 3 Days CABERGOLINE Cabergoline Quantity Limit: 20 Per 30 Days CAYSTON Cayston Quantity Limit: 84 Per 28 Days CLOPIDOGREL Clopidogrel TABS 300MG Quantity Limit: 1 Per 30 Days COPAXONE Copaxone INJ 20MG/ML CROMOLYN SODIUM Cromolyn Sodium NEBU Quantity Limit: 240 Per 30 Days DIOVAN Diovan DONEPEZIL HCL Donepezil Hcl DRONABINOL Dronabinol DULERA Dulera Quantity Limit: 13 Per 30 Days 3
5 EMEND Emend CAPS 0 Emend CAPS 125MG Emend CAPS 40MG Emend CAPS 80MG Quantity Limit: 3 Per 3 Days Quantity Limit: 2 Per 30 Days Quantity Limit: 1 Per 1 Days Quantity Limit: 4 Per 30 Days ENBREL Enbrel INJ 25MG Enbrel INJ 25MG/0.5ML, 50MG/ML Quantity Limit: 10 Per 35 Days Quantity Limit: 10 Per 35 Days ENOXAPARIN SODIUM Enoxaparin Sodium INJ 100MG/ML, 120MG/0.8ML, 150MG/ML, 30MG/0.3ML, 40MG/0.4ML, 60MG/0.6ML, 80MG/0.8ML Quantity Limit: 60 Per 180 Days EPIPEN 2-PAK Epipen 2-pak Quantity Limit: 4 Per 2 Days EPIPEN-JR 2-PAK Epipen-jr 2-pak Quantity Limit: 4 Per 2 Days EXELON Exelon PT24 EXTAVIA Extavia Quantity Limit: 14 Per 28 Days FAMCICLOVIR Famciclovir TABS 125MG Famciclovir TABS 250MG Quantity Limit: 21 Per 10 Days 4
6 Famciclovir TABS 500MG Quantity Limit: 21 Per 7 Days FENTANYL Fentanyl Quantity Limit: 10 Per 30 Days FENTANYL CITRATE ORAL TRANSMUCOSAL Fentanyl Citrate Oral Transmucosal Quantity Limit: 120 Per 30 Days FLOVENT DISKUS Flovent Diskus AEPB 100MCG/BLIST, 50MCG/BLIST Flovent Diskus AEPB 250MCG/BLIST Quantity Limit: 120 Per 30 Days Quantity Limit: 300 Per 30 Days FLOVENT HFA Flovent Hfa AERO 110MCG/ACT Flovent Hfa AERO 220MCG/ACT Flovent Hfa AERO 44MCG/ACT Quantity Limit: 12 Per 30 Days Quantity Limit: 36 Per 30 Days Quantity Limit: 21 Per 30 Days FLUCONAZOLE Fluconazole TABS 150MG Quantity Limit: 2 Per 7 Days FLUNISOLIDE Flunisolide SOLN 0.025% Quantity Limit: 50 Per 30 Days FLUTICASONE PROPIONATE Fluticasone Propionate SUSP Quantity Limit: 16 Per 30 Days FONDAPARINUX SODIUM Fondaparinux Sodium Quantity Limit: 30 Per 180 Days 5
7 FORADIL AEROLIZER Foradil Aerolizer FORTEO Forteo Quantity Limit: 3 Per 28 Days FRAGMIN Fragmin Quantity Limit: 30 Per 180 Days GALANTAMINE HYDROBROMIDE Galantamine Hydrobromide CP24 GLIPIZIDE/METFORMIN HCL Glipizide/metformin Hcl TABS 2.5MG; 250MG Glipizide/metformin Hcl TABS 2.5MG; 500MG, 5MG; 500MG Quantity Limit: 240 Per 30 Days Quantity Limit: 120 Per 30 Days GRANISETRON HCL Granisetron Hcl TABS Quantity Limit: 2 Per 1 Days HUMIRA Humira Quantity Limit: 5 Per 35 Days HUMIRA PEN-CROHNS DISEASESTARTER Humira Pen-crohns Diseasestarter Quantity Limit: 6 Per 180 Days IBANDRONATE SODIUM Ibandronate Sodium TABS Quantity Limit: 1 Per 30 Days IPRATROPIUM BROMIDE Ipratropium Bromide INHALATION SOLN 0.02% Quantity Limit: 315 Per 30 Days 6
8 Ipratropium Bromide INHALATION SOLN 0.03% Ipratropium Bromide INHALATION SOLN 0.06% IPRATROPIUM BROMIDE/ALBUTEROL SULFATE Ipratropium Bromide/albuterol Sulfate Quantity Limit: 540 Per 30 Days ITRACONAZOLE Itraconazole CAPS Quantity Limit: 120 Per 30 Days JANUMET Janumet JANUMET XR Janumet Xr JANUVIA Januvia KADIAN Kadian CP24 100MG, 10MG, 200MG, 20MG, 30MG, 40MG, 50MG, 60MG, 80MG KOMBIGLYZE XR Kombiglyze Xr TB MG; 2.5MG Kombiglyze Xr TB MG; 5MG, 500MG; 5MG LEFLUNOMIDE Leflunomide TABS LEVALBUTEROL Levalbuterol NEBU Quantity Limit: 90 Per 30 Days 7
9 LEVOCETIRIZINE DIHYDROCHLORIDE Levocetirizine Dihydrochloride TABS LUMIGAN Lumigan SOLN 0.01% Quantity Limit: 2.50 Per 30 Days LUNESTA Lunesta MEDROXYPROGESTERONE ACETATE Medroxyprogesterone Acetate INJ Quantity Limit: 1 Per 90 Days METHADONE HCL Methadone Hcl TABS Quantity Limit: 240 Per 30 Days MICONAZOLE 3 Miconazole 3 SUPP Quantity Limit: 3 Per 3 Days MORPHINE SULFATE ER Morphine Sulfate Er CP24 100MG, 10MG, 20MG, 30MG, 50MG, 80MG Morphine Sulfate Er CP24 (multiphase) 120MG, 30MG, 45MG, 60MG, 75MG, 90MG Morphine Sulfate Er TBCR 100MG, 15MG, 30MG, 60MG Morphine Sulfate Er TBCR 200MG Quantity Limit: 90 Per 30 Days Quantity Limit: 90 Per 30 Days NARATRIPTAN HCL Naratriptan Hcl Quantity Limit: 18 Per 28 Days 8
10 NASONEX Nasonex Quantity Limit: 51 Per 30 Days NEUMEGA Neumega Quantity Limit: 21 Per 21 Days NUCYNTA Nucynta Quantity Limit: 205 Per 30 Days NUCYNTA ER Nucynta Er ONDANSETRON HCL Ondansetron Hcl ORAL SOLN Ondansetron Hcl TABS 24MG Ondansetron Hcl TABS 4MG, 8MG Quantity Limit: 150 Per 5 Days Quantity Limit: 1 Per 1 Days Quantity Limit: 12 Per 5 Days ONDANSETRON ODT Ondansetron Odt Quantity Limit: 12 Per 5 Days ONGLYZA Onglyza OXYMORPHONE HYDROCHLORIDE ER Oxymorphone Hydrochloride Er TB12 15MG, 7.5MG Quantity Limit: 90 Per 30 Days PEGASYS Pegasys Quantity Limit: 4 Per 28 Days PEGASYS PROCLICK Pegasys Proclick INJ 135MCG/0.5ML Quantity Limit: 4 Per 28 Days 9
11 PEG-INTRON Peg-intron INJ 50MCG/0.5ML Quantity Limit: 5 Per 30 Days PEG-INTRON REDIPEN Peg-intron Redipen Quantity Limit: 5 Per 30 Days PERFOROMIST Perforomist Quantity Limit: 120 Per 30 Days PIOGLITAZONE HCL/METFORMIN HCL Pioglitazone Hcl/metformin Hcl Quantity Limit: 90 Per 30 Days PIOGLITAZONE HCL-GLIMEPIRIDE Pioglitazone Hcl-glimepiride PROAIR HFA Proair Hfa Quantity Limit: 18 Per 30 Days PROCRIT Procrit INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML Procrit INJ 40000UNIT/ML Quantity Limit: 24 Per 30 Days Quantity Limit: 6 Per 30 Days REBIF Rebif Quantity Limit: 6 Per 28 Days REBIF TITRATION PACK Rebif Titration Pack Quantity Limit: 6 Per 28 Days REGRANEX Regranex 10
12 RELENZA DISKHALER Relenza Diskhaler Quantity Limit: 60 Per 180 Days RESTASIS Restasis RIVASTIGMINE TARTRATE Rivastigmine Tartrate CAPS 1.5MG Rivastigmine Tartrate CAPS 3MG Rivastigmine Tartrate CAPS 4.5MG, 6MG Quantity Limit: 240 Per 30 Days Quantity Limit: 120 Per 30 Days RIZATRIPTAN BENZOATE Rizatriptan Benzoate Quantity Limit: 36 Per 30 Days RIZATRIPTAN BENZOATE ODT Rizatriptan Benzoate Odt Quantity Limit: 36 Per 30 Days ROZEREM Rozerem SANCUSO Sancuso Quantity Limit: 2 Per 15 Days SAVELLA Savella SAVELLA TITRATION PACK Savella Titration Pack SEREVENT DISKUS Serevent Diskus Quantity Limit: 120 Per 30 Days 11
13 SILDENAFIL Sildenafil Quantity Limit: 90 Per 30 Days SUBOXONE Suboxone FILM Quantity Limit: 90 Per 30 Days SUMATRIPTAN SUCCINATE Sumatriptan Succinate INJ Sumatriptan Succinate TABS Quantity Limit: 10 Per 30 Days Quantity Limit: 9 Per 30 Days SYMBICORT Symbicort Quantity Limit: 20 Per 30 Days TAMIFLU Tamiflu CAPS 30MG Tamiflu CAPS 45MG, 75MG Tamiflu SUSR 6MG/ML Quantity Limit: 84 Per 180 Days Quantity Limit: 42 Per 180 Days Quantity Limit: 600 Per 180 Days TERBINAFINE HCL Terbinafine Hcl TABS Quantity Limit: 90 Per 365 Days TERCONAZOLE Terconazole CREA 0.4% Terconazole SUPP Quantity Limit: 45 Per 7 Days Quantity Limit: 3 Per 3 Days TRAMADOL HCL Tramadol Hcl TABS Quantity Limit: 240 Per 30 Days TRAMADOL HCL ER Tramadol Hcl Er TB24 12
14 TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN Tramadol Hydrochloride/acetaminophen Quantity Limit: 240 Per 30 Days TRAVATAN Z Travatan Z Quantity Limit: 2.50 Per 30 Days TRIAMCINOLONE ACETONIDE Triamcinolone Acetonide AERO Quantity Limit: 17 Per 30 Days VALACYCLOVIR HCL Valacyclovir Hcl TABS VENTOLIN HFA Ventolin Hfa Quantity Limit: 54 Per 30 Days VERAMYST Veramyst Quantity Limit: 20 Per 30 Days VIIBRYD Viibryd KIT XOLAIR Xolair Quantity Limit: 6 Per 28 Days ZOLMITRIPTAN Zolmitriptan TABS Quantity Limit: 12 Per 30 Days ZOLMITRIPTAN ODT Zolmitriptan Odt Quantity Limit: 12 Per 30 Days 13
15 ZOLPIDEM TARTRATE Zolpidem Tartrate ZOLPIDEM TARTRATE ER Zolpidem Tartrate Er ZOSTAVAX Zostavax Quantity Limit: 1 Per 999 Days ZYKADIA Zykadia Quantity Limit: 150 Per 30 Days 14
16 INDEX A Actonel... 1 Adcirca... 1 Advair Diskus... 1 Advair Hfa... 1 Albuterol Sulfate... 1 Alendronate Sodium... 1 Alinia... 1 Amitiza... 1 Aricept... 2 Asmanex Twisthaler 120 Metered Doses... 2 Asmanex Twisthaler 30 Me Tered Doses... 2 Asmanex Twisthaler 30 Metered Doses... 2 Asmanex Twisthaler 60 Metered Doses... 2 Astepro... 2 Atrovent Hfa... 2 Avonex... 2 Azelastine Hcl... 2 B Benicar... 2 Budesonide... 2 Butorphanol Tartrate... 3 C Cabergoline... 3 Cayston... 3 Clopidogrel... 3 Copaxone... 3 Cromolyn Sodium... 3 D Diovan... 3 Donepezil Hcl... 3 Dronabinol... 3 Dulera... 3 E Emend... 4 Enbrel... 4 Enoxaparin Sodium... 4 Epipen 2-pak... 4 Epipen-jr 2-pak... 4 Exelon... 4 Extavia... 4 F Famciclovir... 4 Fentanyl... 5 Fentanyl Citrate Oral Transmucosal... 5 Flovent Diskus... 5 Flovent Hfa... 5 Fluconazole... 5 Flunisolide... 5 Fluticasone Propionate... 5 Fondaparinux Sodium... 5 Foradil Aerolizer... 5 Forteo... 6 Fragmin... 6 G Galantamine Hydrobromide... 6 Glipizide/metformin Hcl... 6 Granisetron Hcl... 6 H Humira... 6 Humira Pen-crohns Diseasestarter... 6 I Ibandronate Sodium... 6 Ipratropium Bromide... 6 Ipratropium Bromide/albuterol Sulfate... 7 Itraconazole... 7 J Janumet... 7 Janumet Xr... 7 Januvia... 7 K Kadian... 7 Kombiglyze Xr... 7 L Leflunomide... 7 Levalbuterol... 7 Levocetirizine Dihydrochloride... 7 Lumigan
17 Lunesta... 8 M Medroxyprogesterone Acetate... 8 Methadone Hcl... 8 Miconazole Morphine Sulfate Er... 8 N Naratriptan Hcl... 8 Nasonex... 8 Neumega... 9 Nucynta... 9 Nucynta Er... 9 O Ondansetron Hcl... 9 Ondansetron Odt... 9 Onglyza... 9 Oxymorphone Hydrochloride Er... 9 P Pegasys... 9 Pegasys Proclick... 9 Peg-intron... 9 Peg-intron Redipen Perforomist Pioglitazone Hcl/metformin Hcl Pioglitazone Hcl-glimepiride Proair Hfa Procrit R Rebif Rebif Titration Pack Regranex Relenza Diskhaler Restasis Rivastigmine Tartrate Rizatriptan Benzoate Rizatriptan Benzoate Odt Rozerem S Sancuso Savella Savella Titration Pack Serevent Diskus Sildenafil Suboxone Sumatriptan Succinate Symbicort T Tamiflu Terbinafine Hcl Terconazole Tramadol Hcl Tramadol Hcl Er Tramadol Hydrochloride/acetaminophen Travatan Z Triamcinolone Acetonide V Valacyclovir Hcl Ventolin Hfa Veramyst Viibryd X Xolair Z Zolmitriptan Zolmitriptan Odt Zolpidem Tartrate Zolpidem Tartrate Er Zostavax Zykadia
18 HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Group Health Incorporated (GHI) is a PPO plan and a standalone PDP with a Medicare contract. Enrollment in HIP and GHI depends on contract renewal. HIP and GHI are EmblemHealth companies. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, This document includes EmblemHealth Medicare HMO/PPO partial formulary as of November 1, For a complete, updated formulary, please visit our Web site at or call the Customer Service number below: For alternative formats or language, please call Customer Service toll free at: EmblemHealth Medicare HMO: , Monday through Sunday, 8 am to 8 pm. EmblemHealth Medicare PPO: , Monday through Sunday, 8 am to 8 pm. EmblemHealth Medicare PDP: , Monday through Sunday, 8 am to 8 pm. TTY/TDD users should call v15 17
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