Azithromycin Oral Susp. 100 2 bottles Antibiotics 200 3 bottles Factive 320 mg 7 tabs Antidepressantes- SSRIs, SNRIs, other Zmax Aplenzin Budeprion SR Budeprion XL Bupropion SR/ER Celexa Citalopram Cymbalta Effexor Effexor XR Fluoxetine Fluvoxamine Lexapro Luvox CR Paroxetine CR (and Paxil CR) Paroxetine HCl Paxil Paxil CR Prexeva Pristiq Prozac Prozac Weekly Sarafem Selfemra Wellbutrin SR Wellbutrin XL 60 ml 1 bottle 174, 348, 522 mg 100, 150 mg 60 tabs 300 mg 100, 150 mg 60 tabs 200 mg 60 tabs 10, 20, 40 mg 10, 20, 40 mg 20mg, 60 mg - 60 tabs 30 mg - 25, 37.5, 50 and 75 mg tablets 90 tabs 100 mg tablets 37.5 mg capsules 75 mg capsules - 90 tabs 150 mg capsules - 10 mg - 40 mg 60 tabs 100 mg 90 tabs 25 mg 50 mg 60 tabs 5 mg, 10 mg 20 mg 5, 10, and 20 mg 100 and 150 mg 60 tabs 12.5 mg. 25 mg, 37.5 mg 60 tabs 10 and 40 mg 20 and 30 mg 60 tabs 10 and 40 mg 20 and 30 mg 60 tabs 12.5, 25, 37.5 mg - 60 tabs 10 and 40 mg 20 and 30 mg 60 tabs 50 mg, 100 mg 10 mg 30 caps 40 mg 60 caps 90 mg 4 caps 10, 15, 20 mg 10 and 20 mg 100, 150, 200 mg 60 tabs 150 and 300 mg Zoloft (and sertraline) 25 mg - 45 tabs 50 mg and 100 mg - 60 tabs Anti-emetics Aloxi 0.25 mg/5 ml and 0.075 mg/1.5 ml 1 vial Aloxi 0.5 mg 1 tab Anzemet Cesamet Emend Granisol solution Kytril/Granisetron Kytril/Granisetron Oral Solution Sancuso Zofran/Ondansetron Zuplenz Quantity Limits Drug List Updated: February 2018 Helpful Tip: To search fo a specific drug, use the find feature (Ctrl + F) 50 and 100 mg 1 tablet 30 caps 40 and 125 mg 1 tab per dispense 80 and 125 mg tripack /dispense 80 mg 2 caps per dispense 115 mg injection 1 injection per dispense 2 mg/10 ml 1 bottle 4 tabs per copay 20ml per copay 3.1 mg/24 hour Patch 1 patch 4 mg /copay 8 mg 9 tabs/copay 24 mg 3 tabs/copay 4and 8mg soluble film 12 films Updated February 8, 2018 Page 1
Anti-fungals Itraconazole Lamisil Monistat Monistat 3 combination pack Monistat 3 suppositories Monistat 7 combination pack & equivalent 1 box 1 pre-filled box 200 mg & equivalent 1 box 200 mg & equivalent 1 box Monistat 7 cream and equivalent Monistat 7 cream pre-filled applicators 1 box 1 box Anti-Histamines Antihypertensive Agents Monistat 7 suppositories Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) Sporanox Terazol 3 Terazol 3 Cream Terazol 7 Cream Terbinafine Zazole Zazole Vaginal Suppositories Allegra Allegra D Clarinex Clarinex D Claritin Claritin D Xyzal Xyzal Solution Zyrtec Zyrtec D Zyrtec Syrup Atacand Atacand HCT Avalide Avapro Azor Benicar Benicar HCT Bystolic Cardura Cardura XL Catapres-TTS Patches 100 mg & equivalent 1 box 1 box 1 box 30 caps 1 tube 0.8% - 1 tube 0.4% - 1 tube 0.4% Cream 1 tube 0.8% Cream 1 tube 80 mg - 1 box 180 mg- 30 caps 30 and 60mg- 60 tabs/caps 12 hr 60 tabs 24 hr 2.5 and 5mg- 12 hr 60 tabs 24 hr 10 mg 12 hr 60 tabs 24 hr 300 mls 5 and 10 mg 12 hr 60 tabs 300 mls 4, 8 and 16 mg 60 tabs 32 mg- 16/12.5 mg 60 tabs 32/12.5 and 32/25 mg 150-12.5 mg 60 tabs 300-12.5 and 300-25 mg 75 and 150 mg 60 tabs 300 mg 10-20, 10-40, 5-20 and 5-40 mg 20 mg 60 tabs per 30 days 5 and 40 mg 2.5 and 5 mg 10 and 20 mg 60 tabs 1, 2, 4 mg 8 mg 60 tabs 4, 8 mg Cozaar/Losartan 25 and 50 mg 60 tabs 100 mg Diovan 40, 80 and 160 mg 60 tabs 320 mg Diovan HCT 80/12.5 mg 60 160/25, 320/25, 320/12.5 and 160/12.5 mg Doxazosin 1, 2, 4 mg 8 mg 68 tabs Exforge 10-160,10-320, 5-160 and 5-320 mg Exforge HCT Updated February 8, 2018 Page 2
Antihypertensive Agents, cont. Antivirals Hytrin Hyzaar Micardis Micardis HCT Tekturna Tevetan Tevetan Tevetan HCT 1,2, 5 mg 10 mg 60 tabs 50-12.5mg 60 tabs 100-12.5and 100-25 mg 20, 40 and 80 mg 40-12.5, 80-12.5 and 80-25 mg 400 mg 60 tabs per 30 days 600-12.5 and 600-25 mg Famvir 125 mg - 21 250 mg - 60 500 mg - 21 Relenza 5 mg/blister with inhalation device 20 caps Valtrex 1 gram - 30 500 mg 30 Atypicals Antipsychotic Abilify 2, 5, 10, 15, 20 and 30 mg Abilify DISCMELT 10 and 15mg 60 tabs Biologics Fanapt Fanapt Titration Pack Geodon Invega Invega Risperdal Risperdal M-Tab risperidone risperidone M-Tab Saphris Seroquel Seroquel Seroquel XR Zyprexa Zyprexa Zydis Amevive Avonex Betaseron Byetta Cimzia Copaxone Enbrel Extavia Humira Humira Crohns Starter Pack Humira Psoriasis Starter Pack Kineret Pegasys 180mcg Convenience pack Pegasys 180mcg vials Peg-Intron Pens and kit Rebif Rebif Titration pack Soliris 1, 2, 4, 6, 8, 10 and 12 mg 60 tabs 20, 40, 60 and 80 mg 60 tabs 1.5, 3, 9 mg 6 mg 60 tabs 0.25, 0.5, 1, 2, 3, and 4 mg 60 tabs 0.5, 1, 2, 3 and 4 mg 60 tabs 0.25, 0.5, 1, 2, 3, and 4 mg 60 tabs 0.5, 1, 2, 3 and 4 mg 60 tabs 5 and 10 mg 60 tabs 25, 50 and 100, 200 mg 90 tabs 300 and 400 mg 60 tabs 150 and 200 mg 50, 300, 400 mg 60 tabs 2.5, 5, 7.5, 10, 15 and 20 mg 5, 10, 15 and 20 mg 15 mg vial- 4 vials 7.5 mg vial- 8 vials 4 vials/syringes 15 injections 2 packages Cimzia STARTER Pack: has a QLL of "3" (3 kits = 6 syringes = 1 starter pack) Cimza vial and Cimzia maintenance kit: has a QLL of "1" (1 kit = 2 syringes and 1 vial = 1) 50 mg 4 syringes 25 mg kit 8 syringes 15 injections 40 mg pens 2 syringes 1 pack per 365 days 1 pack per 365 days 30 injections 1 pack 4 vials 4 pens/vials 22 and 44mcg 15 syringes 600 mg weekly (240 mls total) Updated February 8, 2018 Page 3
Diabetes Actos 15, 30, 45 mg 30 Actos XR 30/1000 mg 30 Actosplus Met 15/500 and 15/850mg 90 Actosplus Met XR 15/1000 mg 60 Avandamet 1mg/500, 2/500 and 4/500 mg 60 Avandaryl 4mg/1mg, 4mg/2mg 30 Avandia 2and 4mg 60 8 mg 30 Duetact 30/2mg and 30/4mg Janumet Januvia Kombiglyze Onglyza PrandiMet 50/500mg, 50/1000mg 60 tabs Symlin 0.6 mg/ml - 4 5/500 and 5/1000 2.5/500 60 tabs 2.5 and 5 mg 1mg/500mg and 2mg/500mg 150 tabs SymlinPen 60, 120 pen injector 4 Victoza 6mg/3ml, 3ml pen, package of 2 pens 1 pkg 6mg/3ml, 3ml pen, package of 3 pens 1 pkg Estrogen Alora 8 patches Climara Climara Pro Divigel Elestrin (gel) Elestrin gel pump Estraderm Estradiol transdermal Estragel Estrasorb Evamist Menostar Vivelle Vivelle-Dot 0.25, 0.5, and 1 grams 1 bottle 52gm 1 pump 8 patches 0.06% 50 gm pump 2 pumps 118.32 grams 1.53 mg spray 1 pump 10 patches per 30 days Fertility Agents Antagon 30 injections Bravelle 30 vials Cetrotide Fertinex Follistim Gonal-F Menopur Novarel Ovidrel Pregnyl Profasi Repronex Synarel 0.25mg Kit 1 pkg 3mg Kit 1 pkg 150u amps 14 inj 5 inj 1050u 5 inj 900u 15 inj 450u 10 inj 37.5u, 300u, 30 inj 450u (RFF) 30 inj 150u 60 inj 75u 90 inj 10 injections 10000u vials- 3 vials 1 injection 10,000u vials- 5 vials 3 vials 75u vials 10 vials 2 pkg Updated February 8, 2018 Page 4
Hepatitis B Agents Baraclude 0.5 and 1mg Hepera 10 mg Inhalers Advair Advair Diskus 60 puffs Aerobid Aerospan Aerospan Albuterol Alupent Inh. Alvesco Alvesco Asmanex Astelin Atrovent HFA Atrovent Nasal Azmacort Beconase AQ Brovana Inh. Sol. Combivent Dulera Duoneb Flonase Flovent Flunisolide 0.025% Spray Foradil Foradil Intal Ipratroprium Br. Nasal Spray Ipratroprium Br. Nasal Spray Maxair Nasacort Nasarel Nasonex NebuPent Omnaris Patanase 0.6% Nasal Spray Proair HFA Proventil HFA Pulmicort Pulmicort Pulmicort Respules Qvar Rhinocort AQ 3 inhalers 5.1g 8.9 3 inhalers 14 g 3 inhalers 80 mcg 160 mcg 3 inhalers 30 ml vial 90 vials 100mcg/5mcg and 200mcg/5mcg inhalers 3 ml vials 180 vials 3 inhalers 60 nebs 0.03% - 2 bottles 0.06% - 2 bottles 300 mg/container.25 and.5 mg/2ml Respules 60 nebs 1mg/2ml 30 nebs Serevent (60) Spiriva Stadol Nasal Symbicort Tilade TOBI Ventolin HFA Veramyst Xolair Xopenex HFA 1 box (9 packets) 2 packages 2 inhaleers 300 mg 45 amps 150 mg/5 ml single-use vial 6 vials Updated February 8, 2018 Page 5
Injections Adrenaclick Epipen Epipen Twinject 0.15 mg, 0.3 mg single unit carton 1 kit 0.15 mg, 0.3 mg two-pack - 1 kit 1 kit per copay 1 kit per copay Sandostatin LAR Depot 10 mg/5 ml and 30 mg/5 ml 1 vial 20 mg/5 ml 2 vials Low Molecular Weight Heparins Arixtra 30 injections Fragmin 60 syringes Innohep Lovenox 60 injections 60 syringes NSAID Anti-inflammatory Agents Meloxicam 7.5 mg 30 caps Mobic 7.5 mg 30 caps Oncology Agents Iressa 250 mg Neumega 21 vials Nexavar Revlimid Sprycel Sutent Tarceva Zolinza 200 mg 120 tabs 70 mg 60 tabs 30 caps 25 mg - 90 caps 100 and 150 mg - 30 caps 120 caps Ophthalmics Restasis 0.05% 60 tubes Actonel 35 mg - 4 5 and 30 mg - 30 Osteoporosis 75 mg - 2 150 mg - 1 Actonel with Calcium 28 tabs Alendronate 35mg and 70mg 1 5,10, and 40 mg 30 Boniva 2.5mg - 30 150 mg 1 Forteo 600mcg/2.4ml pen 1 pen Fosamax Fosamax Plus D 35 and 70 mg 4 tabs 5, 10, 40mg 70mg/75ml Oral Sol. 4 bottles 70 mg/2800 IU 4 tabs Other Adcirca 20mg tablets 60 tabs Apokyn 30 injections Arava Cabergoline Caverject Cayston Cordran Tape Dostinex Edex inj Letaris Plan B Plan B One-step 10 and 20 mg 0.5mg 8 tabs 12 vials 1 kit 2 rolls 0.5 mg 8 tabs 10 cartridges 5 and 10mg 2 packages Regranex 0.01%gel 2 7.5, and 15 gm 1 tube Revatio 90 tabs Samsca Tracleer Tysabri Ventavis Vyvanse 15 mg 30 mg 60 tabs 60 tabs 300 mg vial - 1 vial 540 mls Updated February 8, 2018 Page 6
Overactive Bladder Gelnique 10% gel 30 packets Oxybutynin XL 5 mg Oxytrol Patch XL 5 mg Pain Medications Actiq 60 lozenges /Analgesics Duragesic 10 patches /Muscle Relaxants Fentora 60 tabs /Neuropathic pain Flector patch 60 patches Lioresal Intrathecal Kit 1 kit Lyrica Narcotic analgesics containing Acetaminophen Nucynta Oxycontin Rybix ODT Ryzolt Savella Suboxone Suboxone Film Toradol (and ketoralac) Tramadol Tramadol ER Tramadol/APAP Ultracet/APAP Ultram Ultram ER 90 tabs 4000 mg per day 50, 75 and 100 mg 180 tabs all strengths 60 tabs 240 tabs 100, 200 and 300 mg 12.5, 25, 50 and 100 mg 60 tabs 8/2 and 2/0.5 mg 90 tabs or films 12/3 mg 60 films 4/1 mg 90 films 20 tabs per 365 days 50 mg 240 tabs 100, 200 and 300 mg 37.5 mg/325 mg 240 tabs 37.5 mg/325 mg 240 tabs 50 mg 240 tbs 100, 200 and 300 mg Proton Pump Inhibitors Aciphex (and rabeprazole) 20 mg 60 tabs Dexilant 30 mg Nexium Omeprazole Prevacid (and lansoprazole) Prevacid Solutabs Prilosec DR Suspension Protonix (and pantoprazole) Zegerid 10 and 20 mg 30 caps/packets 20 and 40 mg- 30 caps 10 mg or 20 mg 30 caps 15 mg 30 caps 2.5 mg - 60 packets 10 mg - 30 packets 20 mg 20 mg Smoking Cessation Chantix 180 days within rolling 365 day period Nicotine Replacement Products 180 days within rolling 365 day period Zyban Sleeping Agents Ambien/Ambien CR (and zolpidem) Edluar 5 mg and10 mg /caps Lunesta Placidyl Prosom (and estazolam) Restoril (and temazepam Rozerem Sonata (and zaleplon) Zolpimist 180 days within rolling 365 day period /caps /caps /caps /caps /caps /caps 1 bottle Statins Altoprev 10, 20, 40, 60 mg Caduet 5/10,10/10, 5/20, 10/20, 5/40, 10/40, 5/80, 10/80, 2.5/10, 2.5/20, 2.5/40, 5/20, 5/40 mg Crestor 40 mg Crestor Lescol Lescol XL Lipitor Livalo Lovastatin Mevacor 5, 10, 20 and 40 mg 20 mg 40 mg 60 tabs 80 mg 10, 20, 40 and 80 mg 1, 2 and 4 mg tablets 10 mg 20 and 40 mg 60 tabs 10 mg 20 and 40 mg 60 tabs Updated February 8, 2018 Page 7
Statins continued... Pravachol 10, 20, 40 and 80 mg Pravastatin 10, 20, 40 and 80 mg Pravigard PAC Simvastatin Vytorin Zocor Test Strips Diabetic/Glucose Test Strips 300 strips Triptans Amerge Axert Cambia Frova IB Stat oral spray Imitrex (refill kit) Imitrex injection Imitrex NS Imitrex/Sumatriptan Maxalt MLT Maxalt MLT Relpax Stadol nasal spray Sumavel DosePro Treximet Zomig Zomig (ZMT and Nasal Spray) 81-20, 325-20, 81-40, 325-40, 81-80 and 325-80 1 pkg 5, 10, 20, 40 and 80 mg 10/10,10/20,10/40 and 10/80mg 10, 20, 40 and 80 mg 1 box (9 packets) 30 ml - 12 bottles 4 kits 8 injections 6 sprac devices 2 bottles 1 kit Weight Loss Agents Xenical 90 tabs Updated February 8, 2018 Page 8