Quantity s Abstral (fentanyl) sl tab all strength acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg Advair Diskus Advair HFA Aero Chambers and Spacers Aerobid Aerobid M albuterol HFA 90mcg Akynzeo Aldara Alinia 500mg Alsuma (sumatriptan) 6mg/0.5ml inj Amerge 1mg, 2.5mg Amitiza Anaphylaxis Therapy Agents Anzemet Asmanex 220mcg (120) Asmanex 220mcg (14) Asmanex 220mcg (30) Asmanex 220mcg (60) Atelvia (risedronate) 35mg tab atomoxetine (Strattera) Atrovent HFA Auvi-Q Avelox Avonex 30mcg Avonex 30mcg kit 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days. No more than 180 every 30 days 180 every 30 days 4 every 365 days 1. 1 box per claim 36 every 112 days 4ml per fill 9 per fill Maximum of 90 days supply per lifetime 3 per fill 10 per fill 0. 0. 0. 4 per 30 days QL = 34 or 68 depending on strength 0.9 per day 4 units per claim Page 1 of 7
Quantity s Axert azithromycin 1g tabs (Zithromax) azithromycin 250mg tabs (Zithromax) azithromycin 500mg tabs (Zithromax) azithromycin 600mg tabs (Zithromax) azithromycin susp (Zithromax) Belbuca (all strengths) Boniva 150mg Bunavail buproprion SR (Zyban) butorphanol tartrate (Stadol NS) Butrans (buprenorphine) patch all strengths Catapres TTS Cedax cefaclor (Ceclor) cefadroxil (Duricef) cefdinir (Omnicef) cefpodoxime (Vantin) cefprozil (Cefzil) cefuroxime (Ceftin) Celebrex Celexa solution Chantix ciprofloxacin (Cipro) citalopram 10mg( Celexa) clarithromycin (Biaxin) codeine sulfate 15mg, 30mg, 60mg tabs codeine sulfate 30 mg/ml solution Combivent Condoms Copaxone 9 per fill 3 per fill 1 1 every 14 days 60 per 30days 0.04 per day 60 every 30 days 15 every 30 days 6 patches per 28 days 4 4 1 per day. No more than 30 within 30 days 1,360 per fill. No more than 168 per 366 days 4 180 per 30 days 1 per day 1. No more than 36 within 30 days Page 2 of 7
Quantity s Diaphragms Disposable Insulin syringes/supplies Duac CS Elidel Ella (ulipristal) tab Embeda (All strengths) Emend 125/80mg Emend 125mg Emend 40mg Emend 80mg Enstilar 0.005%-0.054% Foam Entresto (all strengths) Epi Pen, Epi Pen JR Eucrisa 2% Ointment fentanyl citrate (Actiq) fentanyl (Duragesic) patches Fentora Flector Flovent HFA 110mcg Flovent HFA 220 Flovent HFA 44mcg fluconazole 150mg (Diflucan) fluoxetine 10mg (Prozac) fluoxetine 10mg (Sarafem) fluoxetine 40mg (Prozac) Fosamax plus D Frova glucagon emergency kit granisetron (Kytril) Solution granisetron 1mg (Kytril) hydromorphone 2 mg, 4 mg 300 per fill 30 grams every 30 days 1 tab per day and no more then 30/30 days 3 per fill 7 tubes (60gm) every 28 days 60 per 30 days 4 per claim 100 grams per 30 days 120 every 24 days 10 per fill 120 every 24 days 2.1 per day 1. 4. 3 68 per fill 0.9 per day 18 per fill 150ml per fill 15 per fill 180 per 30 days Page 3 of 7
Quantity s hydromorphone 8 mg Insulins Intuniv itraconazole (Sporanox) Janumet Januvia ketorlac tromethamine tabs (Toradol) Kristalose 20g lactulose Lescol 40mg Levaquin 250mg & 500mg Levaquin 750mg Lexapro 10mg Lidoderm Lipitor Lyrica Marinol Maxair Maxalt meperidine 50 mg meperidine 50 mg/5ml solution midazolam injectable (for seizure control only) Migranow (sumaptriptan/camphor/menthol) kit morphine 15 and 30 mg tab morphine 20 mg/5ml and 10mg/5ml solution morphine 100 mg/5ml solution nicotine gum nicotine patches Nonoxynol 9 Noroxin Nuvaring 90 per 30 days 90 per fill Max < 12 years = 4 mg/day; 12 = 7 mg/day 8 1 per day 2 12 packets per day 180 ml per day 3 30 per rolling 30 days Not to exceed 600 mg per day 120 every 30 days 1 90 per 30 days 4 kits per fill 1 kit per 30 days 180 per 30 days 120 ml per 30 days 306 every 34 days 28 evry 28 days with 7 day refill tolerance 1. No more than 36 within 30 days 1 per 21 days Page 4 of 7
Quantity s ondansetron (Zofran) Liquid ondansetron (Zofran) 4mg and 8 mg tablets ondansetron (Zofran ODT) tablets ondansetron (Zofran) 24mg tab Oral Contraceptives oxycodone 5 mg, 10 mg,15 mg oxycodone 2mg, 20mg, 30mg oxycodone 5mg/5ml solution oxycodone 20mg/ml solution oxycodone extend release (Oxycontin) oxymorphine 5mg, 10mg paroxetine (Paxil) paroxetine CR ( Paxil CR) Peak Flow Meter Plan B polyethylene glycol (Miralax) Praluent (all strengths) pravastatin (Pravachol) PrevPac ProAir Respiclick Protopic Pulmicort Flexhaler Pulmozyme QVAR 40mcg QVAR 80mcg Rebif 44mcg Regranex Relenza Relpax Remodulin 10mg/ml Remodulin 1mg/1ml 75 per fill 15 per fill 15 per fill 10 per fill 9 90 per 30 days 120 per 30 days 120 ml per 30 days 6 per day 120 per 30 days 4 every 365 days 2 per 28 days 1 cannister per 30 days 30 grams every 30 days 75 every 30 days 1. 0.8 per day 0.25 per day 30 grams per lifetime 20 per fill 1 40 per fill 400 per fill Page 5 of 7
Quantity s Remodulin 2.5mg/ml 160 per fill Remodulin 5mg/ml 80 per fill Repatha 140mg/ml pens or syringes 2 syringes/pens per 28 days Repatha 420mg/3.5ml 3.5 ml per 28 days Restoril 7.5 1 per day. No more than 34/34 days Risperdal Consta 2 syringes every 24 days Samsca 30 day supply per fill Sancuso 1 patch every 5 days Sarafem 20mg 10 Selzentry 68 every 34 days Serevent Diskus sertraline (Zoloft) sertraline (Zoloft) Solution 340 per fill sertraline 100mg (Zoloft) 68 per fill simvastatin (Zocor) Spiriva Sporanox Liquid 840 per fill Strattera 10mg, 18mg, 40mg, 60mg, 80mg, 100mg 34 per 34 days Strattera 25mg, 68 per 25 days streptomycin sulfate 28 every 25 days Suboxone 2mg-0.5mg Suboxone 8mg-2mg Suboxone 4mg-1mg Suboxone 12mg-3mg sumatriptan 20mg nasal spray (Imitrex) Subutex 2 mg, 8 mg sumatriptan 5mg Nasal spray (Imitrex) sumatriptan succinate (Imitrex) 18 per fill sumatriptan succinate 4mg/0.5 (Imitrex) sumatriptan succinate 4mg/0.5 kit (Imitrex) sumatriptan succinate 4mg/0.5 pen (Imitrex) Page 6 of 7
Quantity s sumatriptan succinate 6mg/0.5 (Imitrex) sumatriptan succinate 6mg/0.5 kit (Imitrex) sumatriptan succinate 6mg/0.5 pen (Imitrex) Suprax Synagis (palivizumab) 50mg/0.5ml inj Synagis (palivizumab) 100mg/0.5ml inj Symbicort Taclonex oint Taclonex Scalp Taltz (ixekizumab) 80mg/ml inj Tamiflu (oseltamivir) 6mg/ml susp Tamiflu (oseltamivir) caps Tamiflu (oseltamivir) 12mg/ml susp terbinafine (Lamisil) triazolam (Halcion) Varubi 90mg Viberzi (all strengths) Vyvanse Xermelo 250mg tablets Xifaxan 200mg Xiidra(lifitegrast) 5% ophthalmic solution Xtampza ER (oxycodone) caps Zarxio (all strengths) Ziana Zinbryta (daclizumab) 150mg syringe Zomig Zyvox Zubsolv 1.4/0.36mg, 2.9/0.71mg, 5.7/1.4mg Zubsolv 11.4/2.9mg Zubsolv 8.6/2.1 5 doses per RSV season 5 doses per RSV season 20. 15 per day. No more than 28 every 365 days 15 per day. No more than 56 every 365 days 1 injection every 28 days 120ml per fill 1 50 per fill 8 10 every 30 days 2 per 7 days 60 per 30 days 80mg MAX total daily dose across strengths. 84 per 28 days 9 per fill 60 single-use containers per 30 days 60 caps per 30 days 45 ml per 30 days 84 grams per rolling 365 days 1 syringe per 30 days 1 1 per day Page 7 of 7