To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA s guidelines and other medical information, our plan developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit. The following limits are based on a 30-day supply.if your plan allows for additional days supply, your limits may be higher. For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity. Drug Target ADVAIR 100-50 DISKUS ADVAIR 250-50 DISKUS ADVAIR 500-50 DISKUS ADVAIR HFA (120) 115-21 MCG INHALER ADVAIR HFA (120) 230-21 MCG INHALER ADVAIR HFA (120) 45-21 MCG INHALER ADVAIR HFA (60) 115-21 MCG INHALER ADVAIR HFA (60) 230-21 MCG INHALER ADVAIR HFA (60) 45-21 MCG INHALER AEROBID/AEROBID-M AEROSPAN 80 MCG INHALER AKYNZEO 300/0.5MG CAPSULE ALLEGRA ALLERGY 12 HR 60 MG ALLEGRA ALLERGY 24 HR 180 MG ALLEGRA CHILDREN'S ALLERGY 30 MG TABLET ALLEGRA-D 12 HOUR ALLERGY & CONGESTION ALLEGRA-D 24 HOUR ALLERGY & CONGESTION ALORA 0.025 MG PATCH ALORA 0.05 MG PATCH ALORA 0.075 MG PATCH ALORA 0.1 MG PATCH ALOXI 0.25 MG/5 ML VIAL ALSUMA 6 MG/0.5 ML AUTO-INJECT ALVESCO 160 MCG INHALER ALVESCO 80 MCG INHALER AMBIEN 10 MG TABLET AMBIEN 5 MG TABLET AMBIEN CR 12.5 MG TABLET AMBIEN CR 6.25 MG TABLET AMERGE 1 MG TABLET AMERGE 2.5 MG TABLET ANORO ELLIPTA 62.5/25 MCG ANORO ELLIPTA 62.5/25 MCG ANZEMET 100 MG TABLET ANZEMET 50 MG TABLET ARAVA 10 MG TABLET ARAVA 20 MG TABLET ARCAPTA NEOHALER 75 MCG CAP ARNUITY ELLIPTA 100 MCG INHALER ARNUITY ELLIPTA 200 MCG INHALER Maximum Quantity 1 device (60 blisters) per prescription 1 device (60 blisters) per prescription 1 device (60 blisters) per prescription 3 inhalers per prescription 18 g (2 inhalers, 8.9 g each) per prescription 1 capsule per chemotherapy course 1 vial per prescription 1 kit/2 syringes per prescription 14 blisters (institutional pack) per prescription 60 blisters per prescription 3 tablet per prescription 3 tablet per prescription 1 package (30 capsules) per prescription 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption
ASMANEX HFA 100 MCG INHALER ASMANEX HFA 200 MCG INHALER ASMANEX TWISTHALER 110 MCG #30 ASMANEX TWISTHALER 110 MCG #7 ASMANEX TWISTHALER 220 MCG #14 ASMANEX TWISTHALER 220 MCG #30 ASMANEX TWISTHALER 220 MCG #60 ASMANEX TWISTHALR 220 MCG #120 ASTELIN 137 MCG NASAL SPRAY ATROVENT 0.03% SPRAY ATROVENT 0.06% SPRAY ATROVENT HFA INHALER ATROVENT INHALER AUVI-Q 0.15 MG AUVI-Q 0.3 MG AXERT 12.5 MG TABLET AXERT 6.25 MG TABLET BECONASE AQ 0.042% SPRAY BELSOMRA 10 MG TABLET BELSOMRA 15 MG TABLET BELSOMRA 20 MG TABLET BELSOMRA 5 MG TABLET BREO ELLIPTA 100MCG/25MCG #28 BREO ELLIPTA 100MCG/25MCG #60 BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 28 BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 60 BROVANA 15 MCG/2 ML SOLUTION BUTORPHANOL NASAL SPRAY 10 MG/ML CAMBIA 50 MG POWDER PACKET CAVERJECT 10 MCG KIT CAVERJECT 20 MCG KIT CAVERJECT 20 MCG VIAL CAVERJECT 40 MCG VIAL CAVERJECT 40 MCG/2 ML AMPUL CESAMET 1 MG PULVULE CHILDREN'S QNASAL 40 MCG (4.9 G) CHILD'S CLARITIN 5 MG TAB CHEW CHLD ALLEGRA ALLERGY 30 MG ODT CIALIS 10 MG TABLET CIALIS 2.5 MG TABLET CIALIS 20 MG TABLET CIALIS 5 MG TABLET CLARINEX 2.5 MG REDITABS CLARINEX 5 MG REDITABS CLARINEX-D 12 HOUR TABLET CLARINEX-D 24 HOUR TABLET CLARITIN 10 MG LIQUI-GEL CAP CLARITIN 10 MG REDITABS CLARITIN 10 MG TABLET CLARITIN-D 12 HOUR TABLET CLARITIN-D 24 HOUR TAB ER CLIMARA 0.025 MG/DAY PATCH CLIMARA 0.0375 MG/DAY PATCH CLIMARA 0.05 MG/DAY PATCH CLIMARA 0.06/MG DAY PATCH CLIMARA 0.075 MG/DAY PATCH CLIMARA 0.1 MG/DAY PATCH CLIMARA PRO PATCH 13 g (1 inhaler) per prescription 13 g (1 inhaler) per prescription 12 tablets per prescription 28 blisters (1 inhaler) per prescription 60 blisters per prescription 1 inhaler (28 blisters) 1 inhaler (60 blisters) 2 cartons (60 vials) per prescription 9 packets per prescription 5 grams (1 bottle) per prescription
COMBIVENT INHALER COMBIVENT RESPIMAT INHAL SPRAY DEPO-PROVERA 150 MG/ML SYRINGE DEPO-SUBQ PROVERA 104 SYRINGE DEXILANT DR 30 MG CAPSULE DEXILANT DR 60 MG CAPSULE DIFLUCAN 150 MG TABLET DIVIGEL 0.25 MG GEL PACKET DIVIGEL 0.5 MG GEL PACKET DIVIGEL 1 MG GEL PACKET DULERA 100 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER DUONEB 0.5 MG-3 MG/3 ML SOLN DYMISTA NASAL SPRAY EDEX 10 MCG KIT EDEX 20 MCG CARTRIDGE 2-PK KIT EDEX 20 MCG CARTRIDGE 6-PK KIT EDEX 40 MCG CARTRIDGE 2-PK KIT EDEX 40 MCG CARTRIDGE 6-PK KIT EDLUAR 10 MG SL TABLET EDLUAR 5 MG SL TABLET ELESTRIN 0.06% GEL ELLA 30 MG TABLET EMEND 115 MG VIAL EMEND 125 MG CAPSULE EMEND 150 MG VIAL EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIFOLD PACK EPINEPHRINE 0.15 MG AUTO-INJCT (TWO PACK) EPINEPHRINE 0.3 MG AUTO-INJECT (TWO PACK) EPIPEN 0.3 MG AUTO-INJECTOR EPIPEN JR 0.15 MG AUTO-INJCT ESOMEPRAZOLE STRONTIUM 24.65 MG CAPSULE ESTRADERM 0.05 MG PATCH ESTRADERM 0.1 MG PATCH ESTRASORB PACKET ESTROGEL 0.06% GEL EVAMIST 1.53 MG/SPRAY FAMVIR 125 MG TABLET FAMVIR 250 MG TABLET FAMVIR 500 MG TABLET 1 vial/syringe per 30 days 1 syringe per 30 days 2 tablets per prescription 180 vials (package size 3) per prescription 52 grams (2 pumps) per prescription 1 tablet (1 dose) per prescription 1 vial per prescription 1 capsule per prescription 1 vial per prescription 1 capsule per prescription 2 capsules per prescription 1 pack per prescription 3 units (package size 1), 2 units (package size 2) per prescription 3 units(package size 1), 2 units (package size 2) per prescription 56 packets (97.44 g) per prescription 1 pump bottle per prescription 2 pumps per prescription 21 tablets per prescription 21 tablets per prescription FLONASE 0.05% NASAL SPRAY FLONASE ALLERGY RELIEF 50 MCG SRAY PACKAGE SIZE FLONASE 15.8 ALLERGY RELIEF 50 MCG SRAY PACKAGE SIZE 9.9 FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS FLOVENT 50 MCG ROTADISK FLOVENT HFA 110 MCG INHALER FLOVENT HFA 220 MCG INHALER FLOVENT HFA 44 MCG INHALER FLUNISOLIDE 0.025% SPRAY FORADIL AEROLIZER 12 MCG CAP FORADIL AEROLIZER 12 MCG CAP FROVA 2.5 MG TABLET 1 unit per prescription 1 unit per prescription 4 inhalers per prescription 2 inhalers/bottles per prescription 1 package (package size 12) (12 capsules) per prescription 1 package (package size 60) (60 capsules) per prescription
GRANISOL 2 MG/10 ML SOLUTION GYNAZOLE 1 2% CREAM IMITREX 100 MG TABLET IMITREX 20 MG NASAL SPRAY IMITREX 25 MG TABLET IMITREX 4 MG/0.5 ML CARTRIDGES IMITREX 4 MG/0.5 ML PEN INJECT IMITREX 5 MG NASAL SPRAY IMITREX 50 MG TABLET IMITREX 6 MG/0.5 ML CARTRIDGE IMITREX 6 MG/0.5 ML PEN INJECT IMITREX 6 MG/0.5 ML SYRNG KIT IMITREX 6 MG/0.5 ML VIAL INCRUSE ELLIPTA 62.5 MCG INHALER INTERMEZZO 1.75 MG TAB SUBLING INTERMEZZO 3.5 MG TAB SUBLING KYTRIL 1 MG TABLET KYTRIL 2 MG/10 ML SOLUTION LEVITRA 10 MG TABLET LEVITRA 2.5 MG TABLET LEVITRA 20 MG TABLET LEVITRA 5 MG TABLET LUNESTA 1 MG TABLET LUNESTA 2 MG TABLET LUNESTA 3 MG TABLET MAXAIR AUTOHALER 0.2 MG AERO MAXALT 10 MG TABLET MAXALT 5 MG TABLET MAXALT MLT 10 MG TABLET MAXALT MLT 5 MG TABLET MENOSTAR 14 MCG/DAY PATCH MIGRANAL 4 MG/ML NASAL SPRAY MINIVELLE 0.0375 MG PATCH MINIVELLE 0.05 MG PATCH MINIVELLE 0.075 MG PATCH MINIVELLE 0.1 MG PATCH MUSE 1,000 MCG URETHRAL SUPP MUSE 125 MCG URETHRAL SUPPOS MUSE 250 MCG URETHRAL SUPPOS MUSE 500 MCG URETHRAL SUPPOS NASACORT AQ NASAL SPRAY 55 MCG NASONEX 50 MCG NASAL SPRAY NEBUPENT 300 MG INHAL POWDER NEXIUM 2.5 MG PACKET NEXIUM 20 MG CAPSULE NEXIUM 5 MG PACKET NEXIUM DR 10 MG PACKET NEXIUM DR 20 MG PACKET OMECLAMOX-PAK COMBO PACK OMNARIS 50 MCG NASAL SPRAY ONMEL 200 MG TABLET PATANASE 0.6% NASAL SPRAY PERFOROMIST 20 MCG/2 ML SOLN PLAN B 0.75 MG TABLET PLAN B ONE-STEP 1.5 MG TABLET PREVACID 15 MG CAPSULE DR PREVACID 15 MG SOLUTAB PREVPAC PATIENT PAC 5.8 g (1 pre-filled applicator) per prescription 6 devices per prescription 2 vials per prescription 1 kit per prescription 6 devices per prescription 2 vials per prescription 1 kit per prescription 1 kit per prescription 2 vials per prescription 1 inhaler (30 blisters OR 7 blisters institutional pack) per prescription 1 bottle (30 ml) per prescription 1 1 1 1 8 spray devices = 1 kit per prescription 1 container (inhaler) per 28 days 80 caps/tabs (10 cards) = 1 combo pack per prescription 15 tablets per prescription 1 carton (60 vials) per prescription 2 tablets per prescription 1 tablet per prescription 30 solutabs per prescription 112 caps/tabs (14 cards) = 1 pack per prescription
PRILOSEC 10 MG CAPSULE DR PRILOSEC 20 MG CAPSULE DR PRILOSEC DR 10 MG SUSPENSION PRILOSEC DR 2.5 MG SUSPENSION 60 packets per prescription PROAIR HFA 90 MCG INHALER PROAIR RESPICLICK 90 MCG INHALER PROTONIX DR 20 MG TABLET PROVENTIL HFA 90 MCG INHALER PULMICORT 0.25 MG/2 ML RESPUL 60 respules per prescription PULMICORT 0.5 MG/2 ML RESPULE 60 respules per prescription PULMICORT 1 MG/2 ML RESPULE 30 respules per prescription PULMICORT 180 MCG FLEXHALER PULMICORT 90 MCG FLEXHALER QNASL 80MCG NASAL SPRAY QVAR 40 MCG INHALER QVAR 80 MCG INHALER 3 inhalers per prescription RELENZA 5 MG DISKHALER 20 blisters (1 carton) per prescription RELPAX 20 MG TABLET RELPAX 40 MG TABLET RESTASIS 0.05% EYE EMULSION 60 vials per prescription RHINOCORT AQUA NASAL SPRAY ROZEREM 8 MG TABLET SANCUSO 3.1 MG/24 HR PATCH 1 patch per prescription SEREVENT DISKUS 50 MCG (28 BLISTERS) SEREVENT DISKUS 50 MCG (60 BLISTERS) SILENOR 3 MG TABLET SILENOR 6 MG TABLET SONATA 10 MG CAPSULE SONATA 5 MG CAPSULE SPIRIVA 18 MCG CP-HANDIHALER 1 package (30 doses) per prescription SPIRIVA 28 INHALATIONS PACK AND 60 INHALATIONS 1 inhaler (4 g) per prescription SPORANOX 100 MG CAPSULE STAXYN 10 MG ODT STENDRA 100 MG TABLET 6 tablets per 30 days STENDRA 150 MG TABLET 6 tablets per 30 days STENDRA 50 MG TABLET 6 tablets per 30 days STIOLTO RESPIMAT 2.5/2.5 MCG INHALATION SPRAY 1 inhaler = 4 g (60 inhalations OR 28 inhalations institutional pack) STRIVERDI RESPIMAT 28 INHALATIONS PACK, 60 INHA1 inhaler (60 inhalations OR 28 inhalations institutional pack) per prescription SUMAVEL DOSEPRO 4 MG/0.5 ML 3 ml (1 box) per prescription SUMAVEL DOSEPRO 4 MG/0.5 ML 9 ml (3 boxes) per 28 days SUMAVEL DOSEPRO 6 MG/0.5 ML 6 units per prescription SYMBICORT 160-4.5 MCG INHALER SYMBICORT 80-4.5 MCG INHALER TAMIFLU 12 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 30 MG GELCAP 20 capsules per prescription TAMIFLU 45 MG GELCAP 10 capsules per prescription TAMIFLU 6 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 75 MG GELCAP 10 capsules per prescription TREXIMET 85-500 MG TABLET TUDORZA PRESSAIR 400 MCG INH VALTREX 1 GM CAPLET 30 caplets (tablets) per prescription VALTREX 500 MG CAPLET 30 caplets (tablets) per prescription VENTOLIN HFA 90 MCG INHALER VENTOLIN HFA 90 MCG INHALER VERAMYST 27.5 MCG NASAL SPRAY VIAGRA 100 MG TABLET VIAGRA 25 MG TABLET VIAGRA 50 MG TABLET
VIVELLE-DOT 0.025 MG PATCH VIVELLE-DOT 0.0375 MG PATCH VIVELLE-DOT 0.05 MG PATCH VIVELLE-DOT 0.075 MG PATCH VIVELLE-DOT 0.1 MG PATCH XIFAXAN 200 MG TABLET XIFAXAN 550 MG TABLET XYZAL 5 MG TABLET ZEGERID 20 MG CAPSULE ZEGERID 20 MG PACKET ZETONNA 37 MCG NASAL SPRAY ZOFRAN 24 MG TABLET ZOFRAN 4 MG TABLET ZOFRAN 8 MG TABLET ZOFRAN ODT 4 MG TABLET ZOFRAN ODT 8 MG TABLET ZOFRAN SOLUTION ZOLPIMIST 5 MG ORAL SPRAY ZOMIG 2.5 MG TABLET ZOMIG 5 MG NASAL SPRAY ZOMIG 5 MG TABLET ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT 5 MG TABLET ZUPLENZ 4 MG SOLUBLE FILM ZUPLENZ 8 MG SOLUBLE FILM ZYRTEC 10 MG CHEWABLE TABLET ZYRTEC 10 MG TABLET ZYRTEC 5 MG CHEWABLE TABLET ZYRTEC 5 MG TABLET ZYRTEC-D TABLET 9 tablets 60 tablets 1 canister (60 actuations per canister) per prescription 1 tablet per prescription 6 nasal spray devices per prescription 9 films per prescription 9 films per prescription