Pequot Health Care Smart Quantity Program*
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1 Pequot Health Care 1 Annie George Drive Mashantucket, CT Phone: Fax: Pequot Health Care Smart Quantity Program* Updated January 2018 *Quantity Program limits apply to generic versions of drugs where applicable. For Group 2 Medications contact our Pharmacy Benefits Department at or Pequot_PBM@prxn.com or the number on the back of your card GROUP 1 MEDICATIONS Beta-2 Agonists & Combinations Accuneb (Albuterol) 0.63, 1.25mg Sol 1Box 3Boxes Advair Diskus Inh (60) 1 Inhaler 3 Inhalers Advair HFA Inh (12g) 120 inh 1 Inhaler 3 Inhalers Albuterol 0.083% SOL (75ml) 1Box 3Boxes Albuterol 0.5% Sol (20ml) 1Box 3Boxes Anoro Ellipta 60 inh 1 Inhaler 3 Inhalers Arnuity Ellipta 30 inh 1 Inhaler 3 Inhalers Arcapta Neohaler 30 inh 1 Inhaler 3 Inhalers Bevespi (10.7g) 120 inh 1 Inhaler 3 Inhalers Breo Ellipta 60 inh 1 Inhaler 3 Inhalers Brovana Sol (120ml ) 60 vials/box 1 Box 3 Boxes Brovana Sol (60ml) 30 vials/box 1 Box 3 Boxes Dulera 100mcg, 200mcg (13g) 1 Inhaler 3 Inhalers Foradil Aero Inh (60inh) 1 Inhaler 3 Inhalers Maxair Autohaler (14g) 400 inh 1 Inhaler 3 Inhalers Metaproterenol 0.4% 0.6% (62.5ml) 1 Box 3Boxes Perforomist Sol (120ml) 1 Box 3 Boxes Proair HFA Inh (8.5g) 200inh 1 inhaler 3 inhalers Proventil HFA Inh (7g) 200 inh 1 Inhaler 3 Inhalers Serevent Diskus Inh (60) 1 Inhaler 3 Inhalers Stiolto Respimat (4g) 1 Inhaler 3 Inhalers Striverdi Respimat (4g) 1 Inhaler 3 Inhalers Symbicort Inh (10.2g) 120 inh 1 Inhaler 3 Inhalers Trelegy Ellipta 100/62.5/25 mcg 1 Inhaler 3 Inhalers Ventolin HFA Inh(18g) 200 inh 1 Inhaler 3 Inhalers Xopenex 0.31, 0.63, 1.25mg /3 ml (72 ml) 1 Box 3 Boxes Xopenex Concentrate 1.25mg/0.5ml (15ml) 1 Box 3 Boxes Xopenex HFA (15g) 200 inh 1 Inhaler 3 Inhalers
2 Diabetes Continuous Glucose Monitoring Supplies Erectile Dysfunction (ED) *Limits represent total limit for all products combined in this class Intra-Nasal Corticosteroids/ Antihistamines Lidocaine Topicals (FDA-Approved) Dexcom G5 Receiver Kit N/A 1 unit per 365 days Dexcom G5 Transmitter Kit N/A 1 units Dexcom G5 Mobile/G4 Patinum Sensor Kit 4 pk 4 units 12 units Dexcom G4 Platinum Receiver with Share N/A 1 unit / 365 days Dexcom G4 Platinum (Ped) receiver w/ Share N/A 1 unit per 365 days Dexcom G4 Platinum Transmitter Kit N/A 1 unit per 180 days Dexcom G4 Platinum Sensors - 4 Pk 4 units 12 units Enlite Glucose Sensor 10 units 30 units Enlite N/A 1 unit per 365 days Enlite Serter N/A 1 unit per 180 days Caverject 6 Units 18 units Cialis (excluding 2.5mg & 5mg tablet) 6 Tablets 18 Tablets Edex 6 Units 18 Units Levitra 6 Tablets 18 Tablets Muse 6 Units 18 Units Viagra 6 Tablets 18 Tablets Staxyn 6 Tablets 18 Tablets Astelin (30g) 200sprays 1 Inhaler 3 Inhalers Astepro 200 sprays 1 Inhaler 3 Inhalers Beconase AQ (25g) 180 sprays 1 Inhaler 3 Inhalers Dymista (23g) 120 sprays 1 Inhaler 3 Inhalers Flonase (fluticasone) (16ml) 120 sprays 1 Inhaler 3 Inhalers Nasacort AQ (1g) 120 sprays 1 Inhaler 3 Inhalers Nasarel (flunisolide) (25g) 200 sprays 1 Inhaler 3 Inhalers Nasonex (17g) 120 sprays 1 Inhaler 3 Inhalers Omnaris (13g) 120 sprays 1 Inhaler 3 Inhalers Patanase (3g) 240 sprays 1 Inhaler 3 Inhalers Qnasl (8.7g) 120sprays 1 Inhaler 3 Inhalers Rhinocort Aqua (9ml) 120 sprays 1 Inhaler 3 Inhalers Veramyst (10g) 120 sprays 1 Inhaler 3 Inhalers Xhance 93 mcg 1 Inhaler 3 Inhalers Zetonna (6.1G) 60 sprays 1 Inhaler 3 Inhalers Emla 30gm 30gm Lidocaine 2% gel 30gm 30gm Lidocaine 4% gel 30gm 30gm Lidocaine 5% oint 50gm 50gm Lidocaine 4% soln 50ml 50ml Pliaglis 7-7% cream 30gm 30gm Synera 70-70mg patch 2 patches 2 patches
3 Mast Cell Stabilizers & Anticholinergics Oral Inhaled Corticosteroids *For dose optimization, utilize highest strength of inhaler/respules Atrovent HFA Inh (13g) 200 inh 1 inhaler 3 inhalers Atrovent (Ipratropium) Sol 63 ml/box 1Box 3 Boxes Combivent Respimat (4g) 200 inh 1 Inhaler 3 Inhalers Duoneb Sol (Ipatrop/Albut) 180 ml/box 1 box 3 boxes Incruse Ellipta (30) 1 Inhaler 3 Inhalers Intal Sol (240ml) 1 Box 3 Boxes Seebri 15.6mcg Inhaler (60) 1 Inhaler 3 Inhaler Spiriva Respimat (4g) 1 Inhaler 3 Inhalers Spiriva Handihaler (30) 1 Inhaler 3 Inhalers Tudorza 1 Inhaler 3 Inhalers Aerospan 1 Inhaler 3 Inhalers Armonair 55mcg, 113mcg, 232mcg 1 Inhaler 3 Inhalers Asmanex HFA 100mcg 1 Inhaler 3 Inhalers Asmanex HFA 200mcg 1 Inhaler 3 Inhalers Asmanex 110mcg 30 inh* 1 Inhaler 3 Inhalers Asmanex 220mcg 30, 60, 120 inh* 1 Inhaler 3 Inhalers Alvesco HFA 80mcg (6.1g) 1 Inhaler 3 Inhalers Alvesco HFA 160mcg (6.1g) 1 Inhaler 3 Inhalers Flovent HFA 44mcg, 110mcg, 220mcg 1 Inhaler 3 Inhalers Flovent Diskus 50mcg (60) 1 Inhaler 3 Inhalers Flovent Diskus 100 mcg, 250mcg 1 Inhaler 3 Inhalers Qvar 40mcg, 80mcg (8.7g) Inh* 1 Inhaler 3 Inhalers Qvar Redihaler 40mcg, 80mcg 1 Inhlaer 3 Inhalers Pulmicort Resps 0.25mg/2ml (60ml)* 1 Box 3 Boxes Pulmicort Resps 0.5mg/2ml (60ml)* 1 Box 3 Boxes Pulmicort Resps 1mg/2ml (60ml)* 1 Box 3 Boxes Pulmicort Flexhaler 90mcg* 1 Inhaler 3 Inhalers Pulmicort Flexhaler 180mcg* 1 Inhaler 3 Inhalers
4 Antiemetic Aloxi 0.25mg /5ml (5 ml) 10 ml / 21 days N/A Aloxi 0.075mg /1.5ml 5ml / 15 days N/A Akynzeo 2 caps / 21 days N/A Anzemet 50mg, 100mg Tab 6 tabs / 21 days N/A Anzemet 100mg/5ml or 12.5mg/0.625ml Inj 15ml / 180 days N/A Cesamet 1mg Cap 18 caps 54 caps Emend 40mg Cap N/A 3 caps / 180 days Emend 80mg Cap 4 caps / 21 days N/A Emend 125mg Cap 2 caps / 21 days N/A Emend 125mg/5ml Susp (single dose kit) 6 kits / 21 days N/A Emend 150mg Inj Vial 2 vial / 21 days N/A Emend Tri-Pack 2 Tripacks / 21 days N/A Emend Bi-Pack 2 Bipack / 21 days N/A Kytril (Granisitron) 1mg 12 tabs / 21 days N/A Kytril (Granisitron) 0.1mg/ml Inj. 2 ml / 21 days N/A Kytril (Granisitron) 1mg/ml Inj. 2 ml / 21 days N/A Marinol (Dronabinol) Cap 2.5mg, 5mg, 10mg 60 caps 180 Caps Sancuso Patches 2 patches / 21 days N/A Varubi 2 packs / 21 days N/A Zofran (Ondansetron) 24mg Tab 2 tabs / 21 days N/A Zofran (Ondansetron) 4mg, 8mg Tab/ODT 18 tabs / 21 days N/A Zofran (Ondansetron) Oral Sol 200 ml / 21 days N/A Zofran (Ondansetron) 2mg/ml Inj 20 ml / 21 days N/A Zuplenz 4mg, 8mg Film 18 films / 21 days N/A Proton Pump Aciphex/rabeprazole 20mg 30 tabs 90 tabs Inhibitors Dexilant 30mg, 60mg 30 caps 90 caps Reflux agents Nexium/esomeprazole 20mg, 40mg 30 caps 90 caps omeprazole 10mg, 20mg 30 caps 90 caps omeprazole 40mg 60 caps 180 caps Prevacid/lansoprazole 15mg, 30mg 30 caps/tabs 90 caps/tabs Protonix/pantoprazole 20mg, 40mg 30 tabs 90 tabs Zegerid 40mg 30 caps 90 caps Prilosec DR suspension 2.5mg 60 ml 180 ml Prilosec DR suspension 10mg 30 ml 90 ml ADHD agents Contempla 8.6mg, 17.3mg, 25.9mg 30 tabs 90 tabs
5 Sedative/Hypnotics Sleeping agents Cholesterol agents Statins Ambien/zolpidem 5mg, 10mg 30 tabs 90 tabs Ambien CR/zolpidem CR 6.25mg, 12.5mg 30 tabs 90 tabs Edluar 30 tabs 90 tabs Lunesta/eszopiclone 2mg, 3mg 30 tabs 90 tabs Placidyl 30 caps 90 caps Proscom/estazolam 1mg 30 tabs 90 tabs Restoril/temazepam 7.5mg, 15mg, 22.5mg, 30mg 30 caps 90 caps Rozerem 8mg 30 tabs 90 tabs Sonata/zaleplon 10mg 30 caps 90 caps Zolpimist 1 bottle 3 bottles Belsomra 10mg, 15mg, 20mg 30 tabs 90 tabs Altoprev 60mg 30 tabs 90 tabs Caduet 5mg/10mg, 5mg/20mg, 5mg/40mg, 30 tabs 90 tabs 10mg/10mg, 10mg/20mg, 10mg/40mg Crestor/rosuvastatin 5mg, 10mg, 20mg 40mg 30 tabs 90 tabs Lescol/fluvastatin 20mg 30 caps 90 caps Lescol XL/fluvastatin ER 80mg 30 tabs 90 tabs Lipitor/atorvastatin 10mg, 20mg, 40mg, 80mg 30 tabs 90 tabs Livalo 1mg, 2mg, 4mg 30 tabs 90 tabs Mevacor/lovastatin 10mg, 20mg 40mg 30 tabs 90 tabs Pravachol/pravastatin 10mg, 20mg, 40mg, 80mg 30 tabs 90 tabs Pravigard PAC 30 tabs 90 tabs Zocor/simvastatin 5mg, 10mg, 20mg, 40mg, 30 tabs 90 tabs 80mg Vytorin/ezetimibe-simvastatin 10mg/10mg, 30 tabs 90 tabs 10mg/20mg, 10mg/40mg, 10mg/80mg Hep-C agents Mavyret 100mg/40mg 28tabs N/A
6 GROUP 2 MEDICATIONS ** Consists of drug categories containing a Post-Limit Prior Authorization Process. With Group II medications, if you reach the MDL quantity limit for a given time period, you will be responsible for the entire cost of the medication. Your healthcare provider can request post-limit prior approval if he/she feels continuation of therapy or a quantity exceeding the MDL is warranted. DRUG CLASS DRUG CLASS DRUG CLASS DRUG CLASS Antimigraine Amerge 1mg, 2.5mg Tab 12 Tabs 36 Tabs Axert 6.25mg, 12.5mg Tab 12 Tabs 36 Tabs Frova 2.5mg Tab 12 Tabs 36 Tabs Imitrex(sumatriptan)/Alsuma Inj Kit/Refills 6 Kits (12 Inj) 18 Kits (36 Inj) Imitrex(sumatriptan) Inj 6mg/0.5ml Vial 12 Vials (6ml) 40 Vials (20ml) Imitrex (sumatriptan) 5mg Nasal Spr 4 Pkg (24 Units) 12 Pkgs (72 Units) Imitrex (sumitriptan) 20mg Nasal Spr 2 Pkg (12 Units) 6 Pkgs (36 Units) Imitrex (sumatriptan) Tabs any strength 12 Tabs 36 Tabs Maxalt / Maxalt MLT 5mg, 10mg Tabs 12 Tabs 36 Tabs Migranal NS 8ml 1 Unit 3 Units Onzetra Xsail Kit 8 Pouches/ 16 Nosepieces 24 Pouches/ 48 Nosepieces Relpax 20mg, 40mgTabs 12 Tabs 36 Tabs Sumavel Doespro 0.6mg/0.5ml 6 per Pkg 2 Pkg (6ml) 6 Pkg (18ml) Treximet Tabs (10mg-60mg, 85mg-500mg) 12 Tabs 36 Tabs Zembrace SymTouch 24 Injs 72 Injec Zomig / Zomig ZMT 2.5mg, 5mg Tab 12 Tabs 36 Tabs Zomig NS (1 pkg / 6 Units) 1 Pkgs (12 Units) 6 Pkgs ( 36 Units) Influenza * 1 Fill every 90 days unless Post-limit Approved Relenza 4 blisters/disk (5 disks pkg) N/A 2 Pkg/ 90 Days* Tamiflu 30mg Cap N/A 28 Caps/ 90 Days* Tamiflu 45mg Cap N/A 14 Caps/ 90 Days* Tamiflu 75mg Cap N/A 14 Caps/ 90 Days* Tamiflu 60mg/ 5ml Oral Liquid N/A 180ml / 90 Days* Tamiflu 30mg/ 5ml Oral Liquid N/A 180ml / 90 Days* Chemo agents Idhifa 50mg, 100mg 30 tabs N/A Lynparza 100mg, 150mg 120 caps N/A Verzenio 50mg, 100mg, 150mg, 200mg 60 tabs N/A
Data Class: Internal. 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption
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