Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List
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- Agatha Fleming
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1 Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List Drug Name Monthly Limit (30 days unless otherwise noted) abacavir 300 mg abacavir/lamivudine/zidovudine mg ABILIFY 10 mg ABILIFY 15 mg ABILIFY 2 mg ABILIFY 20 mg ABILIFY 30 mg ABILIFY 5 mg ABILIFY MAINTENA 300 mg 1 syringe or 1 vial ABILIFY MAINTENA 400 mg 1 vial acarbose 100 mg acarbose 25 mg 3 acarbose 50 mg acetaminophen/codeine mg/5 ml soln 2700 ml acetaminophen/codeine mg 3 acetaminophen/codeine mg 3 acetaminophen/codeine mg ADCIRCA 20 mg ADVAIR DISKUS 100/50 1 package of 60 ADVAIR DISKUS 250/50 1 package of 60 ADVAIR DISKUS 500/50 1 package of 60 ADVAIR HFA 115/21 ADVAIR HFA 230/21 ADVAIR HFA 45/21 AFINITOR 10 mg AFINITOR 2.5 mg AFINITOR 5 mg AFINITOR 7.5 mg AFINITOR DISPERZ 2 mg AFINITOR DISPERZ 3 mg AFINITOR DISPERZ 5 mg alendronate 10 mg alendronate 35 mg 4 tablets per 28 days alendronate 5 mg alendronate 70 mg 4 tablets per 28 days amlodipine besylate/valsartan mg amlodipine besylate/valsartan mg
2 amlodipine besylate/valsartan mg amlodipine besylate/valsartan mg amlodipine/valsartan/hydrochlorothiazide mg amlodipine/valsartan/hydrochlorothiazide mg amlodipine/valsartan/hydrochlorothiazide mg amlodipine/valsartan/hydrochlorothiazide mg amlodipine/valsartan/hydrochlorothiazide mg amphetamine/dextroamphetamine ER 10 mg amphetamine/dextroamphetamine ER 15 mg amphetamine/dextroamphetamine ER 20 mg amphetamine/dextroamphetamine ER 25 mg amphetamine/dextroamphetamine ER 30 mg amphetamine/dextroamphetamine ER 5 mg ANDRODERM 2 mg/24 hour 30 patches ANDRODERM 4 mg/24 hour 30 patches ANDROGEL 1% (25 mg/ 2.5 gm) 60 packets ANDROGEL 1% (50 mg/ 5 gm) 60 packets ANDROGEL 1.62% (20.25 mg/ 1.25 gm) 30 packets ANDROGEL 1.62% (40.5 mg/ 2.5 gm) 60 packets ANDROGEL PUMP 1% 4 pump bottles ANDROGEL PUMP 1.62% 2 pump bottles ANORO ELLIPTA 1 package APTIVUS 100 mg/ml soln 380 ml APTIVUS 250 mg 120 capsules aripiprazole 2 mg aripiprazole 5 mg aripiprazole 10 mg aripiprazole 15 mg aripiprazole 20 mg aripiprazole 30 mg aripiprazole 1 mg/ml oral soln 750 ml ARIPIPRAZOLE ODT 10 mg ARIPIPRAZOLE ODT 15 mg ARNUITY ELLIPTA inh 100 mcg 30 blisters ARNUITY ELLIPTA inh 200 mcg 30 blisters ascomp/codeine 30 mg 180 capsules ASMANEX HFA 100 mcg/act
3 ASMANEX HFA 200 mcg/act ASMANEX TWISTHALER 120 (220 mcg) ASMANEX TWISTHALER 14 (220 mcg) ASMANEX TWISTHALER 30 (110 mcg) ASMANEX TWISTHALER 30 (220 mcg) ASMANEX TWISTHALER 60 (220 mcg) ASMANEX TWISTHALER 7 (110 mcg) ASTEPRO 0.15% atorvastatin 10 mg atorvastatin 20 mg atorvastatin 40 mg atorvastatin 80 mg ATRIPLA mg ATROVENT HFA 17 mcg AVODART 0.5 mg AVONEX KIT 30 mcg AVONEX PEN KIT 30 mcg azelastine 0.1% nasal spray azelastine 0.15% nasal spray AZOR mg AZOR mg AZOR 5-20 mg AZOR 5-40 mg BENICAR 20 mg BENICAR 40 mg BENICAR 5 mg BENICAR HCT mg BENICAR HCT mg BENICAR HCT mg BETASERON 0.3 mg BOSULIF 100 mg BOSULIF 500 mg BREO ELLIPTA mcg/inh BREO ELLIPTA mcg/inh BRINTELLIX 10 mg BRINTELLIX 20 mg BRINTELLIX 5 mg budeprion SR 150 mg bupropion 100 mg bupropion 75 mg bupropion ER 100 mg bupropion ER 150 mg 2 bottles 2 canisters 1 kit per 28 days 1 kit per 28 days 2 bottles 2 bottles 15 vials/syringes 1 package 1 package
4 bupropion ER 200 mg bupropion SR 100 mg bupropion SR 150 mg bupropion SR 200 mg bupropion XL 150 mg bupropion XL 300 mg butalbital/acetaminophen/caffeine w/ codeine mg 180 capsules butalbital/acetaminophen/caffeine w/ codeine mg 180 capsules butalbital/aspirin/caffeine w/ codeine mg 180 capsules BYDUREON 2 mg 4 vials per 28 days BYDUREON PEN 2 mg 4 vials per 28 days CAPRELSA 100 mg CAPRELSA 300 mg CHANTIX 0.5 mg 336 tablets or amount dispensed up to 168 days of therapy per 365 days CHANTIX 1 mg 336 tablets or amount dispensed up to 168 days of therapy per 365 days CHANTIX PAK 0.5 mg & 1 mg 336 tablets or amount dispensed up to 168 days of therapy per 365 days CHANTIX PAK 1 mg 336 tablets or amount dispensed up to 168 days of therapy per 365 days CINRYZE 20 vials or 100 ml citalopram 10 mg citalopram 10 mg/5 ml soln 600 ml citalopram 20 mg citalopram 40 mg clonazepam 0.5 mg clonazepam 1 mg clonazepam 2 mg 300 tablets clonazepam ODT mg clonazepam ODT 0.25 mg clonazepam ODT 0.5 mg clonazepam ODT 1 mg clonazepam ODT 2 mg 300 tablets clonidine ER 0.1 mg clorazepate dipotassium 15 mg clorazepate dipotassium 3.75 mg clorazepate dipotassium 7.5 mg clozapine 100 mg 270 tablets
5 clozapine 200 mg clozapine 25 mg clozapine 50 mg COMETRIQ KIT 100 mg COMETRIQ KIT 140 mg COMETRIQ KIT 60 mg COMPLERA mg COPAXONE soln prefilled syringe 40 mg/ml COPAXONE soln prefilled syringe 20 mg/ml CORLANOR 5 mg CORLANOR 7.5 mg CRESTOR 10 mg CRESTOR 20 mg CRESTOR 40 mg CRESTOR 5 mg CRIXIVAN 200 mg CRIXIVAN 400 mg CYCLOSET 0.8 mg DALIRESP 500 mcg dexedrine 5 mg dexedrine 10 mg dexmethylphenidate 10 mg dexmethylphenidate 2.5 mg dexmethylphenidate 5 mg dextroamphetamine 10 mg dextroamphetamine 5 mg DIAZEPAM 1 mg/ml soln diazepam 10 mg DIAZEPAM 10 mg gel diazepam 2 mg DIAZEPAM 2.5 mg gel DIAZEPAM 20 mg gel diazepam 5 mg didanosine 125 mg didanosine 200 mg didanosine 250 mg didanosine 400 mg digox mg digox 0.25 mg digoxin mg digoxin 0.25 mg DIGOXIN 50 mcg/ml soln 56 capsules per 28 days 112 capsules per 28 days 84 capsules per 28 days 12 syringes per 28 days 30 syringes 270 capsules 180 capsules 1200 ml 5 twin packs 5 twin packs 5 twin packs 75 ml
6 doxazosin 1 mg doxazosin 2 mg doxazosin 4 mg doxazosin 8 mg DULERA mcg DULERA mcg duloxetine 20 mg duloxetine 30 mg duloxetine 60 mg EDURANT 25 mg EMTRIVA 10 mg/ml soln EMTRIVA 200 mg endocet mg endocet mg endocet mg endocet mg enoxaparin 100 mg/ml enoxaparin 120 mg/0.8 ml enoxaparin 150 mg/ml enoxaparin 30 mg/0.3 ml enoxaparin 300 mg/3 ml enoxaparin 40 mg/0.4 ml enoxaparin 60 mg/0.6 ml enoxaparin 80 mg/0.8 ml EPIVIR 10 mg/ml soln EPZICOM mg ERIVEDGE 150 mg ESBRIET 267 mg escitalopram 10 mg escitalopram 20 mg escitalopram 5 mg escitalopram 5 mg/5 ml soln EVOTAZ mg EXFORGE mg EXFORGE mg EXFORGE mg EXFORGE mg EXFORGE HCT mg EXFORGE HCT mg EXFORGE HCT mg EXFORGE HCT mg EXFORGE HCT mg 850 ml syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 10 vials per 90 days 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 960 ml 270 capsules 600 ml
7 FANAPT 1 mg FANAPT 10 mg FANAPT 12 mg FANAPT 2 mg FANAPT 4 mg FANAPT 6 mg FANAPT 8 mg FANAPT PAK FARYDAK 10 mg FARYDAK 15 mg FARYDAK 20 mg FAZACLO ODT 100 mg FAZACLO ODT 12.5 mg FAZACLO ODT 150 mg FAZACLO ODT 200 mg FAZACLO ODT 25 mg fenofibrate 134 mg fenofibrate 145 mg fenofibrate 160 mg fenofibrate 200 mg fenofibrate 48 mg fenofibrate 54 mg fenofibrate 67 mg fentanyl 100 mcg/hr transdermal patch fentanyl 12 mcg/hr transdermal patch fentanyl 25 mcg/hr transdermal patch fentanyl 50 mcg/hr transdermal patch fentanyl 75 mcg/hr transdermal patch fentanyl 1200 mcg lozenge on a handle fentanyl 1600 mcg lozenge on a handle fentanyl 200 mcg lozenge on a handle fentanyl 400 mcg lozenge on a handle fentanyl 600 mcg lozenge on a handle fentanyl 800 mcg lozenge on a handle FETZIMA 120 mg FETZIMA 20 mg FETZIMA 40 mg FETZIMA 80 mg FETZIMA TITRATION PACK finasteride 5 mg FIRAZYR 30 mg/3 ml FLOVENT DISKUS 100 mcg 7 packs (56 tablets) per 28 days 6 capsules per 21 days 6 capsules per 21 days 6 capsules per 21 days 270 tablets 15 patches 15 patches 15 patches 15 patches 15 patches 120 lozenges 120 lozenges 120 lozenges 120 lozenges 120 lozenges 120 lozenges 28 capsules per 28 days 6 syringes 1 inhaler
8 FLOVENT DISKUS 250 mcg 4 inhalers FLOVENT DISKUS 50 mcg 1 inhaler FLOVENT HFA 110 mcg FLOVENT HFA 220 mcg 2 canisters FLOVENT HFA 44 mcg fluoxetine 10 mg capsule fluoxetine 10 mg tablet fluoxetine 20 mg capsule 120 capsules fluoxetine 20 mg tablet fluoxetine 20 mg/5 ml soln 600 ml fluoxetine 40 mg capsule fluticasone 50 mcg nasal spray 1 bottle fluvoxamine 100 mg fluvoxamine 25 mg fluvoxamine 50 mg fondaparinux sodium subcutaneous inj 10 mg/0.8 ml 30 syringes per 90 days fondaparinux sodium subcutaneous inj 2.5 mg/0.5 ml 30 syringes per 90 days fondaparinux sodium subcutaneous inj 5 mg/0.4 ml 30 syringes per 90 days fondaparinux sodium subcutaneous inj 7.5 mg/0.6 ml 30 syringes per 90 days FORADIL 1 package of 60 FUZEON 90 mg inj 60 vials gemfibrozil 600 mg GEODON 20 mg inj 60 vials GILOTRIF 20 mg GILOTRIF 30 mg GILOTRIF 40 mg glatopa 20 mg/ml inj 30 syringes GLEEVEC 100 mg GLEEVEC 400 mg glimepiride 1 mg glimepiride 2 mg glimepiride 4 mg glipizide 10 mg glipizide 5 mg glipizide ER 10 mg glipizide ER 2.5 mg glipizide ER 5 mg glipizide XL 10 mg glipizide XL 2.5 mg glipizide XL 5 mg
9 GLYBURIDE 2.5 mg GLYBURIDE 5 mg glyburide 1.25 mg GLYBURIDE 1.25 mg glyburide 2.5 mg glyburide 5 mg glyburide micronized 1.5 mg glyburide micronized 3 mg glyburide micronized 6 mg GRASTEK HETLIOZ 20 mg hydrocodone/acetaminophen mg hydrocodone/acetaminophen mg hydrocodone/acetaminophen mg hydrocodone/acetaminophen mg hydrocodone/acetaminophen mg hydrocodone/acetaminophen mg hydrocodone/acetaminophen mg soln hydromorphone 1 mg/ml liquid hydromorphone 2 mg hydromorphone 4 mg hydromorphone 8 mg ibandronate 150 mg IBRANCE 75 mg IBRANCE 100 mg IBRANCE 125 mg ICLUSIG 15 mg ICLUSIG 45 mg IMBRUVICA 140 mg INLYTA 1 mg INLYTA 5 mg INTELENCE 100 mg INTELENCE 200 mg INTELENCE 25 mg INVEGA 1.5 mg INVEGA 3 mg INVEGA 6 mg INVEGA 9 mg INVEGA SUSTENNA 117 mg/0.75 ml INVEGA SUSTENNA 156 mg/ml INVEGA SUSTENNA 234 mg/1.5 ml INVEGA SUSTENNA 39 mg/0.25 ml 480 tablets 480 tablets ml 1440 ml 1 tablet per 28 days 21 capsules per 28 days 21 capsules per 28 days 21 capsules per 28 days 120 capsules 1 kit 1 kit 1 kit 1 kit
10 INVEGA SUSTENNA 78 mg/0.5 ml INVEGA TRINZA 273 mg INVEGA TRINZA 410 mg INVEGA TRINZA 546 mg INVEGA TRINZA 819 mg INVIRASE 200 mg INVIRASE 500 mg INVOKANA 100 mg INVOKANA 300 mg ipratropium 0.03% nasal spray ipratropium 0.06% nasal spray irbesartan 150 mg irbesartan 300 mg irbesartan 75 mg irbesartan/hydrochlorothiazide mg irbesartan/hydrochlorothiazide mg IRESSA 250 mg ISENTRESS 100 mg chewable tablet ISENTRESS 100 mg packet ISENTRESS 25 mg chewable tablet ISENTRESS 400 mg tablet JAKAFI 10 mg JAKAFI 15 mg JAKAFI 20 mg JAKAFI 25 mg JAKAFI 5 mg JANUMET mg JANUMET mg JANUMET XR mg JANUMET XR mg JANUMET XR mg JANUVIA 100 mg JANUVIA 25 mg JANUVIA 50 mg JENTADUETO mg JENTADUETO mg JENTADUETO mg KALETRA mg KALETRA mg KALETRA soln KALYDECO 150 mg KALYDECO packet 50 mg 1 kit 1 kit per 90 days 1 kit per 90 days 1 kit per 90 days 1 kit per 90 days 300 capsules 2 bottles 3 bottles 60 packets 300 tablets 320 ml 60 packets
11 KALYDECO packet 75 mg KOMBIGLYZE XR mg KOMBIGLYZE XR mg KOMBIGLYZE XR mg lamivudine 150 mg lamivudine 10 mg/ml oral solution lamivudine 300 mg lamivudine/zidovudine mg LATUDA 120 mg LATUDA 20 mg LATUDA 40 mg LATUDA 60 mg LATUDA 80 mg LAZANDA 100 mcg nasal spray LAZANDA 400 mcg nasal spray LENVIMA 10 mg DAILY DOSE LENVIMA 14 mg DAILY DOSE LENVIMA 20 mg DAILY DOSE LENVIMA 24 mg DAILY DOSE LETAIRIS 10 mg LETAIRIS 5 mg LEXIVA 50 mg/ml susp LEXIVA 700 mg LONSURF mg LONSURF mg lorazepam 0.5 mg lorazepam 1 mg lorazepam 2 mg lorcet mg lorcet hd mg lorcet plus mg lortab mg lortab mg lortab mg losartan 100 mg losartan 25 mg losartan 50 mg losartan/hydrochlorothiazide mg losartan/hydrochlorothiazide mg losartan/hydrochlorothiazide mg lovastatin 10 mg lovastatin 20 mg 60 packets 960 ml 30 bottles 30 bottles 90 capsules 1800 ml 40 tablets per 28 days 80 tablets per 28 days 150 tablets 3 3
12 lovastatin 40 mg LYNPARZA 50 mg MAPROTILINE 25 mg MAPROTILINE 50 mg MAPROTILINE 75 mg MEKINIST 0.5 mg MEKINIST 2 mg metadate ER 20 mg metformin 1000 mg metformin 500 mg metformin 850 mg metformin ER 500 mg metformin ER 750 mg methadone 10 mg methadone 5 mg methadose 10 mg methylphenidate 10 mg methylphenidate 20 mg methylphenidate 5 mg methylphenidate ER 20 mg methylphenidate SR 20 mg mirtazapine 15 mg mirtazapine 30 mg mirtazapine 45 mg mirtazapine 7.5 mg mirtazapine ODT 15 mg mirtazapine ODT 30 mg mirtazapine ODT 45 mg modafinil 100 mg modafinil 200 mg MORPHINE SULFATE 15 mg tablet MORPHINE SULFATE 30 mg tablet morphine sulfate ER 100 mg tablet morphine sulfate ER 15 mg tablet morphine sulfate ER 200 mg tablet morphine sulfate ER 30 mg tablet morphine sulfate ER 60 mg tablet MYRBETRIQ 25 mg MYRBETRIQ 50 mg naratriptan 1 mg naratriptan 2.5 mg NASONEX 480 capsules 75 tablets 150 tablets tablets 18 tablets 2 bottles
13 nateglinide 120 mg nateglinide 60 mg nevirapine 200 mg nevirapine 50 mg/5 ml susp 1200 ml nevirapine ER 400 mg NEXAVAR 200 mg NEXIUM 10 mg susp packet 30 packets NEXIUM 2.5 mg susp packet 30 packets NEXIUM 20 mg NEXIUM 20 mg susp packet 30 packets NEXIUM 40 mg NEXIUM 40 mg susp packet 30 packets NEXIUM 5 mg susp packet 30 packets niacin ER 1000 mg niacin ER 500 mg niacin ER 750 mg nitrofurantoin macrocrystalline 100 mg< 3 or amount dispensed up to 90 days of therapy per 365 days nitrofurantoin macrocrystalline 50 mg< 3 or amount dispensed up to 90 days of therapy per 365 days nitrofurantoin monohydrate 100 mg< 180 capsules or amount dispensed up to 90 days of therapy per 365 days NORVIR 100 mg capsule 3 NORVIR 100 mg tablet 3 NORVIR 80 mg/ml soln 480 ml NUVIGIL 150 mg NUVIGIL 200 mg NUVIGIL 250 mg NUVIGIL 50 mg ODOMZO 200 mg OFEV 100 mg OFEV 150 mg olanzapine 10 mg olanzapine 10 mg inj 90 vials olanzapine 15 mg olanzapine 2.5 mg olanzapine 20 mg olanzapine 5 mg olanzapine 7.5 mg olanzapine ODT 10 mg olanzapine ODT 15 mg olanzapine ODT 20 mg
14 olanzapine ODT 5 mg omeprazole 10 mg omeprazole 20 mg omeprazole 40 mg ONFI 10 mg ONFI 2.5 mg/ml susp ONFI 20 mg ONFI 5 mg ONGLYZA 2.5 mg ONGLYZA 5 mg OPSUMIT 10 mg ORKAMBI mg oxybutynin 5 mg oxybutynin 5 mg/5 ml syrup oxycodone 10 mg oxycodone 15 mg oxycodone 20 mg oxycodone 30 mg oxycodone 5 mg oxycodone/acetaminophen mg oxycodone/acetaminophen mg oxycodone/acetaminophen mg oxycodone/acetaminophen mg paliperidone sr 24hr 1.5 mg paliperidone sr 24hr 3 mg paliperidone sr 24hr 6 mg paliperidone sr 24hr 9 mg pantoprazole 20 mg pantoprazole 40 mg paroxetine 10 mg paroxetine 20 mg paroxetine 30 mg paroxetine 40 mg paroxetine ER 12.5 mg paroxetine ER 25 mg paroxetine ER 37.5 mg PAXIL 10 mg/5 ml susp pioglitazone 15 mg pioglitazone 30 mg pioglitazone 45 mg PLEGRIDY PEN PLEGRIDY PEN STARTER PACK 480 ml 600 ml ml 2 syringes per 28 days 2 syringes per 28 days
15 PLEGRIDY inj PLEGRIDY inj STARTER PACK POMALYST 1 mg POMALYST 2 mg POMALYST 3 mg POMALYST 4 mg PRADAXA 150 mg PRADAXA 75 mg pravastatin 10 mg pravastatin 20 mg pravastatin 40 mg pravastatin 80 mg PREZCOBIX mg PREZISTA 100 mg/ml susp PREZISTA 150 mg PREZISTA 600 mg PREZISTA 75 mg PREZISTA 800 mg PRISTIQ 100 mg PRISTIQ 50 mg PRISTIQ 25 mg PROAIR HFA PROAIR RESPICLICK quetiapine 100 mg quetiapine 200 mg quetiapine 25 mg quetiapine 300 mg quetiapine 400 mg quetiapine 50 mg QVAR 40 mcg QVAR 80 mcg RAGWITEK RESCRIPTOR 100 mg RESCRIPTOR 200 mg REVLIMID 10 mg REVLIMID 15 mg REVLIMID 2.5 mg REVLIMID 20 mg REVLIMID 25 mg REVLIMID 5 mg REXULTI 0.25 mg REXULTI 0.5 mg 2 syringes per 28 days 2 syringes per 28 days 21 capsules per 28 days 21 capsules per 28 days 21 capsules per 28 days 21 capsules per 28 days 400 ml 300 tablets 2 canisters 2 canisters 2 canisters 3 21 capsules per 28 days 21 capsules per 28 days 21 capsules per 28 days
16 REXULTI 1 mg REXULTI 2 mg REXULTI 3 mg REXULTI 4 mg REYATAZ 50 mg powder 150 packets REYATAZ 100 mg REYATAZ 150 mg REYATAZ 200 mg REYATAZ 300 mg RISPERDAL 12.5 mg inj 2 vials per 28 days RISPERDAL 25 mg inj 2 vials per 28 days RISPERDAL 37.5 mg inj 2 vials per 28 days RISPERDAL 50 mg inj 2 vials per 28 days risperidone 0.25 mg risperidone 0.5 mg risperidone 1 mg risperidone 1 mg/ml soln 480 ml risperidone 2 mg risperidone 3 mg risperidone 4 mg risperidone ODT 0.25 mg risperidone ODT 0.5 mg risperidone ODT 1 mg risperidone ODT 2 mg risperidone ODT 3 mg risperidone ODT 4 mg rizatriptan 10 mg 18 tablets rizatriptan 5 mg 18 tablets rizatriptan ODT 10 mg 18 tablets rizatriptan ODT 5 mg 18 tablets roxicet mg 3 SAPHRIS 2.5 mg SAPHRIS 10 mg SAPHRIS 5 mg SELZENTRY 150 mg SELZENTRY 300 mg SEREVENT DISKUS 50 mcg 1 package of 60 SEROQUEL XR 150 mg SEROQUEL XR 200 mg SEROQUEL XR 300 mg SEROQUEL XR 400 mg SEROQUEL XR 50 mg
17 sertraline 100 mg sertraline 20 mg/ml conc sertraline 25 mg sertraline 50 mg sildenafil 20 mg SILENOR 3 mg SILENOR 6 mg simvastatin 10 mg simvastatin 20 mg simvastatin 40 mg simvastatin 5 mg simvastatin 80 mg SPIRIVA HANDIHALER SPIRIVA RESPIMAT 2.5 mcg/act SPRYCEL 100 mg SPRYCEL 140 mg SPRYCEL 20 mg SPRYCEL 50 mg SPRYCEL 70 mg SPRYCEL 80 mg stavudine 1 mg/ml soln stavudine 15 mg stavudine 20 mg stavudine 30 mg stavudine 40 mg STIVARGA 40 mg STRATTERA 10 mg STRATTERA 100 mg STRATTERA 18 mg STRATTERA 25 mg STRATTERA 40 mg STRATTERA 60 mg STRATTERA 80 mg STRIBILD mg sumatriptan 100 mg SUMATRIPTAN 20 mg/act nasal spray sumatriptan 25 mg SUMATRIPTAN 5 mg/act nasal spray sumatriptan 50 mg SUSTIVA 200 mg capsule SUSTIVA 50 mg capsule SUSTIVA 600 mg tablet 300 ml 2400 ml 84 tablets per 28 days 18 tablets 12 units/2 packages 18 tablets 12 units/2 packages 18 tablets 90 capsules
18 SUTENT 12.5 mg SUTENT 25 mg SUTENT 37.5 mg SUTENT 50 mg SYMBICORT mcg/act SYMBICORT mcg/act TAFINLAR 50 mg TAFINLAR 75 mg tamsulosin 0.4 mg TARCEVA 100 mg TARCEVA 150 mg TARCEVA 25 mg TASIGNA 150 mg TASIGNA 200 mg TECFIDERA 120 mg TECFIDERA 240 mg TECFIDERA STARTER KIT TEKTURNA 150 mg TEKTURNA 300 mg telmisartan 20 mg telmisartan 40 mg telmisartan 80 mg telmisartan/hydrochlorothiazide mg telmisartan/hydrochlorothiazide mg telmisartan/hydrochlorothiazide mg terazosin 1 mg terazosin 10 mg terazosin 2 mg terazosin 5 mg tetrabenazine 12.5 mg tetrabenazine 25 mg THALOMID 100 mg THALOMID 150 mg THALOMID 200 mg THALOMID 50 mg TIVICAY 50 mg tolterodine ER 2 mg tolterodine ER 4 mg TOVIAZ 4 mg TOVIAZ 8 mg TRACLEER 125 mg TRACLEER 62.5 mg 90 capsules 120 capsules 120 capsules 120 capsules 120 capsules
19 TRADJENTA 5 mg tramadol 50 mg TRIBENZOR mg TRIBENZOR mg TRIBENZOR mg TRIBENZOR mg TRIBENZOR mg TRIUMEQ mg TRUVADA mg TYBOST 150 mg TYKERB 250 mg venlafaxine 100 mg tablet venlafaxine 25 mg tablet venlafaxine 37.5 mg tablet venlafaxine 50 mg tablet venlafaxine 75 mg tablet venlafaxine ER 150 mg capsule venlafaxine ER 37.5 mg capsule venlafaxine ER 75 mg capsule VENTOLIN HFA (18 grams) VENTOLIN HFA (8 grams) VERSACLOZ 50 mg/ml susp VESICARE 10 mg VESICARE 5 mg vicodin mg vicodin ES mg vicodin HP mg VICTOZA 18 mg/3 ml inj VIDEX 2 gm soln VIDEX 4 gm soln VIIBRYD 10 mg VIIBRYD 20 mg VIIBRYD 40 mg VIIBRYD KIT VIIBRYD STARTER PACK VIRACEPT 250 mg VIRACEPT 625 mg VIRAMUNE 50 mg/5 ml susp VIRAMUNE XR 100 mg VIREAD 150 mg VIREAD 200 mg VIREAD 250 mg 90 capsules 2 canisters 2 canisters 540 ml 3 1 package of 3 pens 1200 ml 1200 ml 1 kit per 30 days 1 kit per 30 days 270 tablets 1200 ml
20 VIREAD 300 mg VIREAD 40 mg/gm oral powder 240 grams VITEKTA 85 mg VITEKTA 150 mg VOTRIENT 200 mg VYTORIN mg VYTORIN mg VYTORIN mg VYTORIN mg XALKORI 200 mg XALKORI 250 mg XARELTO 10 mg 35 tablets per 90 days XARELTO 15 mg XARELTO 20 mg XARELTO STARTER PACK 51 tablets XENAZINE 12.5 mg XENAZINE 25 mg XTANDI 40 mg 120 capsules XYREM 500 mg/ml soln 540 ml zaleplon 10 mg< 90 capsules or amount dispensed up to 90 days of therapy per 365 days zaleplon 5 mg< 90 capsules or amount dispensed up to 90 days of therapy per 365 days ZELBORAF 240 mg zenzedi 10 mg zenzedi 5 mg ZETIA 10 mg ZIAGEN 20 mg/ml soln 960 ml zidovudine 100 mg capsule 180 capsules zidovudine 300 mg tablet zidovudine 50 mg/ml syrup 1920 ml ziprasidone 20 mg ziprasidone 40 mg ziprasidone 60 mg ziprasidone 80 mg ZOHYDRO ER 10 mg ZOHYDRO ER abuse-deterrent 10 mg ZOHYDRO ER 15 mg ZOHYDRO ER abuse-deterrent 15 mg ZOHYDRO ER 20 mg ZOHYDRO ER abuse-deterrent 20 mg ZOHYDRO ER 30 mg
21 ZOHYDRO ER abuse-deterrent 30 mg ZOHYDRO ER 40 mg ZOHYDRO ER abuse-deterrent 40 mg ZOHYDRO ER 50 mg ZOHYDRO ER abuse-deterrent 50 mg ZOLINZA 100 mg zolpidem 10 mg< zolpidem 5 mg< ZOSTAVAX inj ZYDELIG 100 mg ZYDELIG 150 mg ZYKADIA 150 mg ZYPREXA RELPREVV 210 mg ZYPREXA RELPREVV 300 mg ZYPREXA RELPREVV 405 mg ZYTIGA 250 mg 120 capsules or amount dispensed up to 90 days of therapy per 365 days or amount dispensed up to 90 days of therapy per 365 days 1 vaccine per lifetime 150 capsules 2 vials per 28 days 2 vials per 28 days 1 vial per 28 days Effective: 12/01/2015 Last Updated: 11/04/2015
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016
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Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
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ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR
ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if
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ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG FETZIMA CAPSULE
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