Michigan Department of Community Health Quantity Limitations
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1 Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days Advair HFA Aero chambers and Spacers Aerobid Aerobid M Albuterol HFA 90mcg Aldara Alinia 500mg, Alinia Susp Alsuma (sumatriptan) 6mg/0.5ml inj Amerge 1mg, 2.5mg Amitiza Anaphylaxis Therapy Agents Anzemet Asmanex 220mcg (120) Asmanex 220mcg (14) Asmanex 220mcg (30) Asmanex 220mcg (60) Atelvia (risedronate) 35mg tab ATOMOXETINE (Strattera) Atrovent HFA Avelox Avonex 30mcg Avonex 30mcg kit Axert Azithromycin 1g tabs (Zithromax) 180 every 30 days 4 every 365 days 0.5 per day 0.5 per day every 112 days 4ml per fill 9 per fill Maximum of 90 days supply per lifetime 3 per fill 10 per fill per day 0.3 per day 0. 4 per 30 days QL = 34 or 68 depending on strength 0.9 per day 9 per fill Page 1 of 6
2 Azithromycin 250mg tabs (Zithromax) Azithromycin 500mg tabs (Zithromax) Azithromycin 600mg tabs (Zithromax) Azithromycin susp (Zithromax) Boniva 150mg Buproprion SR (Zyban) Butorphanol Tartrate (Stadol NS) Butrans (buprenorphine) patch all strengths Catapres TTS Cedax Cefaclor (Ceclor) Cefadroxil (Duricef) Cefdinir (Omnicef) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cefuroxime (Ceftin) Celebrex Celexa solution Chantix Ciprofloxacin (Cipro) Citalopram 10mg( Celexa) Clarithromycin (Biaxin) Codeine Combivent Condoms Copaxone Diaphragms Disposable Insulin syringes/supplies Duac CS Elidel ELLA (ulipristal) tab 3 per fill 1 1 every 14 days 0.04 per day 60 every 30 days 15 every 30 days 6 patches per 28 days per day. No more than 30 within 30 days 1,360 per fill. No more than 168 per 366 days per 30 days 1 per day 1. No more than 36 within 30 days 1 per fill 300 per fill 1 per fill 30 grams every 30 days Page 2 of 6
3 Page 3 of 6 Embeda (All strengths) 1 tab per day and no more then 30/30 days Emend 125/80mg Emend 125mg Emend 40mg Emend 80mg Fentanyl Citrate (Actiq) Fentanyl patches (Duragesic) Fentora Flovent HFA 110mcg Flovent HFA 220 Flovent HFA 44mcg Fluconazole 150mg (Diflucan) Fluoxetine 10mg (Prozac) Fluoxetine 10mg (Sarafem) Fluoxetine 40mg (Prozac) Foradil Fosamax plus D Frova Glucagon emergency kit Granisetron (Kytril) Solution Granisetron 1mg (Kytril) Hydromorphone 2 mg, 4 mg Hydromorphone 8 mg Insulins Intuniv Itraconazole (Sporanox) Janumet Januvia Ketorolac Tromethamine tabs (Toradol) Kristalose 10g 3 per fill 1 per fill 1 per fill 120 every 24 days 10 per fill 120 every 24 days 2.1 per day 1.3 per day 4.3 per day 3 68 per fill 0.9 per day 18 per fill 150ml per fill 15 per fill 180 per 30 days 90 per 30 days 90 per fill 4mg MAX total daily dose across strengths. 8 1 per day 21 per fill 1
4 Kristalose 20g Lactulose Lescol 40mg Levaquin 250mg & 500mg Levaquin 750mg Lexapro Lidoderm Lipitor Lyrica (all other strengths) Lyrica 225mg & 300mg Marinol Maxair Maxalt Meperidine 50 mg Morphine 15 and 30 mg tab Morphine 20mg/5 ml and 10 mg/5 ml Morphine 100 mg/5 ml Nicotine Gum Nicotine Patches Nonoxynol 9 Noroxin Nuvaring Ondansetron (Zofran) Liquid Ondansetron tablets (Zofran) Ondansetron tablets (Zofran) Oral Contraceptives Oxycodone 5 mg, 10 mg,15 mg Oxycodone Extended release (Oxycontin) Oxymorphine 5 mg, 10 mg Paroxetine (Paxil) Paroxetine CR ( Paxil CR) Peak Flow Meter per day 3 30 per rolling 30 days 90 every 30 days 60 every 30 days 120 every 30 days 0.5 per day 1 90 per 30 days 180 per 30 days 240 ml per 30 days 120 ml per 30 days 306 every 34 days 28 every 28 days 1. No more than 36 within 30 days 1 per 21 days 75 per fill 15 per fill 10 per fill 91 per fill 90 per 30 days 6 per day 120 per 30 days 4 every 365 days Page 4 of 6
5 Pegasys 180mcg kit Plan B Polyethylene Glycol (Miralax) Pravastatin (Pravachol) PrevPac Protopic Pulmicort Flexhaler Pulmozyme QVAR 40mcg QVAR 80mcg Rebif 44mcg Regranex Relenza Relpax Remodulin 10mg/ml Remodulin 1mg/1ml Remodulin 2.5mg/ml Remodulin 5mg/ml 1 per fill. No more than 0.4 per day 30 grams every 30 days 75 every 30 days 1.3 per day 0.8 per day 0.25 per day 30 grams per lifetime 20 per fill 1 40 per fill 400 per fill 160 per fill 80 per fill Restoril per day no more then 34/34 with 10% tolerance Risperdal Consta Samsca Sancuso Sarafem 20mg Selzentry Serevent Diskus Sertraline (Zoloft) Sertraline (Zoloft) Solution Sertraline 100mg (Zoloft) Simvastatin (Zocor) Spiriva Sporanox Liquid 2 syringes every 24 days 30 day supply per fill 1 patch every 5 days every 34 days 340 per fill 68 per fill 840 per fill Page 5 of 6
6 Strattera 10mg, 18mg, 40mg, 60mg, 80mg, 100mg 34 per 34 days Strattera 25mg, 68 per 25 days Streptomycin Sulfate 28 every 25 days Page 6 of 6
7 Suboxone 2mg-0.5mg Suboxone 8mg-2mg Suboxone 4mg-1mg Suboxone 12mg-3mg Sumatriptan 20mg Nasal spray (Imitrex) Sumatriptan 5mg Nasal spray (Imitrex) Sumatriptan Succinate (Imitrex) Sumatriptan Succinate 4mg/0.5 (Imitrex) Sumatriptan Succinate 4mg/0.5 kit (Imitrex) Sumatriptan Succinate 4mg/0.5 pen (Imitrex) Sumatriptan Succinate 6mg/0.5 (Imitrex) Sumatriptan Succinate 6mg/0.5 kit (Imitrex) Sumatriptan Succinate 6mg/0.5 pen (Imitrex) Suprax Synagis (palivizumab) 50mg/0.5ml inj Synagis (palivizumab) 100mg/0.5ml inj Symbicort 4 per day 3 per day 18 per fill 5 doses per RSV season 5 doses per RSV season 20. Taclonex oint 15 per day. No more than 28 every 365 days Taclonex Scalp Tamiflu (oseltamivir) 6mg/ml susp Tamiflu (oseltamivir) caps Tamiflu (oseltamivir) 12mg/ml susp Terbinafine (Lamisil) Triazolam (Halcion) Vyvanse Xifaxan 200mg Ziana Zomig Zyvox 15 per day. No more than 56 days worth 365 days 120ml per fill 1 50 per fill 8 10 every 30 days 80mg MAX total daily dose across strengths. 9 per fill 84 grams per rolling 365 days 1 Page 7 of 6
8 Zubsolv 4 per day Page 8 of 6
Michigan Department of Health & Human Services Quantity Limitations
Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg Advair Diskus Advair HFA Aero Chambers and Spacers Aerobid Aerobid M Albuterol HFA 90mcg Akynzeo Aldara
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