Health Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014) Abstral SL Actonel 35mg Limited to 4 s per month. Actonel 5,30mg adapalene cream, gel Advair Diskus Limited to 2 inhalations per day. Advair HFA Limited to 4 inhalations per day. Aerospan Afinitor Prior authorization required otherwise not covered. Not available through mail order. alendronate solution Limited to 4 bottles per month. Alinia suspension Limited to 60ml per month. Alinia Alora Alsuma Prior authorization required otherwise not covered. Limited to 4 syringes per prescription fill and up to 2 fills per month. Alvesco amethia amethia lo amlodipine amoxicillin/clarithromycin/lansoprazole Limited to 14 blister cards per fill. amphetamine/dextroamphetamine SR cap Androderm Androgel Up to 10gm per day. Androgel Pump 1.62% Anoro Ellipta Apidra Up to 2 vials or boxes per month. Aplenzin Prior authorization required otherwise not covered. Aptiom 200,400,600mg Aptiom 800mg Arcapta Neohaler Limited to one capsule per day. Asmanex Atelvia Limited to 1 per week. atorvastatin Atralin Gel Atrovent HFA Auvi-Q Axert Axiron Prior authorization required otherwise not covered. Limited to one bottle per month. azelastine HCI nasal spray 0.15% Azilect azithromycin 250mg azithromycin 500mg Limited to 3 s per fill. azithromycin 600mg Limited to 8 s per month. azithromycin suspension Baraclude solution Up to 3 bottles per month. Binosto Limited to 4 s per month. Breo Ellipta Brintellix Prior authorization required otherwise not covered. budesonide 0.25mg/2ml suspension Up to 240ml per month. budesonide 0.5mg/2ml suspension Up to 120ml per month. budesonide nasal susp 32mcg bupropion SR bupropion XL butorphanol nasal spray Limited to 1 package per month. Butrans Limited to 4 patches per 28 days. cabergoline Limited to 8 s per fill. calcipotriene cream, ointment Limited to 60gm per fill. calcipotriene-betamethasone ointment Prior authorization required otherwise not covered. Limited to 60gm per month. camrese camrese lo Cardura XL celecoxib Prior authorization required otherwise not covered. Up to 2 capsules per day. Cesamet Prior authorization required otherwise not covered. Up to 10 capsules per fill.
ciprofloxacin Limited to 28 s per fill. ciprofloxacin XR 500,1000mg citalopram 10mg Limited to 3 s per day. citalopram 20,40mg citalopram solution 10mg/5ml Limited to 600ml per month. Clarinex-D clarithromycin Limited to 28 s per fill. clarithromycin XL Climara Pro clonidine SR clopidogrel Combivent Respimat Crestor Cystaran Daliresp Daytrana Denavir Limited to 1.5gm per fill. desloratadine Dexilant dexmethylphenidate dexmethylphenidate SR 5,15,30,40mg dextroamphetamine solution Limited to 1 bottle (473ml) per month. diazepam gel Limited to 1 kit per fill. Diclegis diclofenac sodium 1.5% solution Differin Lotion Limited to 59ml per month. dihydroergotamine 1mg injection Limited to 10ml per prescription fill and 2 fills per month. dihydroergotamine nasal spray 4mg/ml Limited to 8ml per month. donepezil donepezil ODT Dovonex solution Dulera duloxetine Dymista Ecoza Edluar Prior authorization required otherwise not covered. Emend 125mg Limited to 1 capsule per fill. Emend 40mg Limited to 1 capsule per fill. Emend 80mg Limited to 2 capsules per fill. Emend pack Limited to 1 pack per fill. Emsam Emtriva solution entecavir 0.5,1mg Epaned Epiduo Gel epinephrine inj (Adrenaclick) Epipen injection Epipen JR injection eplerenone 25mg eplerenone 50mg Ertaczo Limited to 60gm per month. Esomeprazole Strontium Estraderm estradiol patch Estring Limited to 1 ring per 90 days for 3 copays. Estrogel eszopiclone Eurax cream, lotion Fabior Factive Limited to 7 s per fill. Femring Limited to 1 ring per 90 days for 3 copays. fentanyl OT lozenges Prior authorization required otherwise not covered. Up to 3 lozenges per day. fentanyl patch Limited to 1 patch every 48 hours. Fentora Finacea Limited to 50gm per fill. Flovent 100mcg Diskus Up to 10 inhalers per month. Flovent 250mcg Diskus Up to 4 inhalers per month. Flovent 50mcg Diskus Up to 20 inhalers per month. Flovent HFA 110,220mcg Flovent HFA 44mcg flunisolide nasal 0.025% solution Fluoxetine 60mg fluticasone nasal spray 2
fluvastatin fluvoxamine SR Focalin XR 10,20,25,35mg capsule Foradil Limited to 60 capsules per month. ForFivo XL Prior authorization required otherwise not covered. Fortesta Prior authorization required otherwise not covered. Limited to 2 bottles per month. Fosamax Plus D Limited to 1 per week. Frova Limited to 9 s per month. Fulyzaq Prior authorization required otherwise not covered. Giazo Prior authorization required otherwise not covered. Limited to 6 s per day. glipizide/metformin 2.5-250mg Up to 2 s per day. granisetron hcl oral solution Limited to 30ml per fill. granisetron guanfacine SR 24HR Horizant Humalog injection Humulin injection hydromorphone HCI ER 32mg hydromorphone HCI ER 8,12,16mg ibandronate 150mg Limited to 1 per month. Intermezzo Prior authorization required otherwise not covered. introvale isotretinoin Limited to 5 months treatment. Not available through mail order. jolessa Ketek Limited to 10 s per fill. ketorolac Limited to 20 s per fill. Khedezla Prior authorization required otherwise not covered. Lantus pen Up to 3 boxes per fill. Lantus vial Up to 4 vials per fill. leflunomide Lescol XL Levemir pen Up to 2 boxes per fill. Levemir vial Up to 2 vials per fill. levofloxacin levonorgestrel 1.5mg Limited to 1 per month. lidocaine patch 5% Limited to 3 patches per day. lindane Liptruzet Livalo Prior authorization required otherwise not covered. lovastatin 10,20mg Limited to 1.5 s per day. Lyrica 225,300mg Prior authorization required otherwise not covered. Up to 2 s per day. Lyrica 25,50,75,100,150,200mg Prior authorization required otherwise not covered. Up to 3 s per day. Lyrica solution Prior authorization required otherwise not covered. Limited to 30ml per day. mebendazole medroxyprogesterone acetate 150mg inj Limited to 1 injection per 90 days for 3 copays. meloxicam 15mg meloxicam 7.5mg Menostar methylphenidate hcl CD capsule methylphenidate SA OSM 18,27,54mg methylphenidate SA OSM 36mg methylphenidate SR 24 HR 20,40mg capsule methylphenidate SR 24 HR 30mg Limited to 2 capsules per day. capsule modafinil Prior authorization required otherwise not covered. montelukast 4,5,10mg montelukast granules Limited to 1 packet per day. morphine sulfate sust rel capsule morphine sulfate sust rel moxifloxacin Myrbetriq Namenda 5,10mg Prior authorization required otherwise not covered. Limited to 2 s daily. naratriptan Limited to 9 s per month. Nasonex Nexium Nexium oral suspension Prior authorization required otherwise not covered. Limited to 1 packet per day. nifedipine CR 30,90mg nifedipine CR 60mg nitrogylcerin spray Limited to 1 package per fill. norelgestromin-ethinyl estradiol patch Limited to 3 patches per fill. Novolin 3
Novolog Nucynta 100mg Nucynta 50mg Nucynta 75mg Nucynta ER NuvaRing olopatadine nasal soln ondansetron ondansetron ODT ondansetron solution Opana ER 5,10,20,30,40mg, crush resistant Oral contraceptives Oravig Oxecta OxyContin oxymorphone ER Pennsaid 2% solution Perforomist pravastatin Premarin 0.3,0.45,0.625,0.9mg Premarin 1.25mg Prempro Prevacid Solutab Proair HFA inhaler progesterone micronized propafenone SR Proventil HFA Pulmicort 180mcg Flexhaler Pulmicort 1mg/2ml suspension Pulmicort 90mcg Flexhaler Qnasl Quartette quasense Quillivant XR QVAR 40mcg inhaler QVAR 80mcg inhaler rabeprazole raloxifene ramipril ranitidine Relpax Rescula Retin-A-Micro Pump 0.08% risedronate 150mg Ritalin LA 10mg rivastigmine capsule rizatriptan rizatriptan MLT Rozerem Samsca Sancuso Savella Serevent Diskus Silenor Simcor 500-20,750-20,1000-20mg Simcor 500-40,1000-40mg simvastatin Sivextro Sorilux Spiriva Spiriva Respimat Sprix Strattera Striant Striverdi Respimat sumatriptan injection kit sumatriptan nasal spray sumatriptan Sumavel Up to 6 s per day. Maximum of 150 per 25 days. Up to 12 s per day. Maximum of 300 per 25 days. Up to 8 s per day. Maximum of 200 per 25 days. Limited to 1 ring per fill. Up to 20 s per fill. Up to 20 s per fill. Up to 100ml per fill. All oral contraceptives, with the exception of introvale, jolessa, quasense, amethia, amethia lo, camrese and camrese lo limited to 1 package per copay. Limited to 3 s per day. Limited to 4ml per day. Prior authorization required otherwise not covered for age 13 years and older. Limited to 1 per day. Up to 2 capsules per day. Up to 2 capsules per day. Up to 60ml per month. Up to 8 inhalers per month. Limited to 1 canister per month. Up to 2 bottles per month. Prior authorization required otherwise not covered. Limited to 2 s/capsules per day. Limited to 5ml per month. Prior authorization required otherwise not covered. Limited to 1 every 28 days. Limited to 2 capsules per day. Limited to 12 s per fill and 2 fills per month. Limited to 12 s per fill and 2 fills per month. Prior authorization required otherwise not covered. Limited to 1 patch per fill. Prior authorization required otherwise not covered. Limited to 60 inhalations per month. Prior authorization required otherwise not covered. Limited to 6 s per 90 days. Limited to 120gm per month. Limited to 1 bottle per day for up to a maximum of 5 days per fill. Not available through mail order. Limited to 2 units per day. Limited to 4 syringes per prescription fill and 2 fills per month. Limited to 6 units per prescription fill and 2 fills per month. Limited to 9 s per prescription fill and 2 fills per month. Prior authorization required otherwise not covered. Limited to 6 syringes per month. 4
Symbicort Taclonex suspension Tamiflu capsules, 30,45mg Tamiflu suspension Tazorac Testim testosterone gel pump tolterodine SR 24hr tranexamic acid tretinoin microsphere gel tretinoin microsphere gel pump Tretin-X Treximet triamcinolone nasal spray trospium XR Tudorza Pressair Valcyte solution Veltin Gel venlafaxine ER venlafaxine XR 37.5,75mg capsule Ventolin HFA inhaler Veramyst Versacloz Vimovo Vivelle Vivelle Dot Vogelxo Vytorin 10-10mg Vytorin 10-20mg,10-40mg Vyvanse Xifaxan 200mg Xifaxan 550mg Xopenex HFA inhaler zaleplon Zetonna Ziana gel Zioptan Zmax zolmitriptan 2.5mg zolmitriptan 5mg zolmitriptan orally disintegrating 2.5mg zolmitriptan orally disintegrating 5mg zolpidem zolpidem CR Zolpimist spray Zomig nasal spray Zorvolex Zuplenz Zyclara Zyclara Pump 2.5%, 3.75% Limited to 60gm per month. Limited to 10 capsules per 6 month period. Not available through mail order. Limited to one fill of up to 180ml per 6 month period. Not available through mail order. Limited to 30gm per fill. Prior authorization required otherwise not covered. Up to 10gm per day. Prior authorization required otherwise not covered. Limited to 10gm per day. Up to 30 s per month. Limited to 20gm per month. Limited to 35gm per month. Prior authorization required otherwise not covered. Limited to 9 s per prescription fill and 2 fills per month. Limited to 21ml per day. Limited to 30gm per month. Limited to 18ml per day. Prior authorization required otherwise not covered. Prior authorization required otherwise not covered. Limited to 10gm/day. Prior authorization required otherwise highest copay applies. Limited to 9 s per fill. Prior authorization required otherwise not covered. Limited to 30gm per month. Limited to 1 single-use container per day. Limited to 1 bottle per fill. Limited to 6 s per fill and 2 fills per month. Limited to 9 s per fill and 2 fills per month. Limited to 6 s per fill and 2 fills per month. Limited to 9 s per fill and 2 fills per month. Prior authorization required otherwise not covered. Limited to 6 units per month. Limited to 20 oral soluble films per 30 days. Limited to 28 packets per 28 days. Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. 5