MEDICAID QUANTITY LIMIT DRUG LIST PH51-R-02162018
Brand Name Generic Name Dosage Form Tier Quantity Limit Details Cambia Diclofenac Potassium PACK Tier 2 QL: 9 per 30 days Fentanyl (12 Mcg/Hr, 25 Mcg/ Hr, 50 Mcg/Hr, 75 Mcg/Hr, 100 Mcg/Hr) Fentanyl PATCH TD72 Tier 1 QL: 15 per 30 days; Cumulative Opioid Nucynta ER Tapentadol TB12 Tier 2 QL: 120 per 30 days; Cumulative Opioid Nucynta Er Tapentadol TB12 Tier 2 QL: 60 per 30 days; Cumulative Opioid Nucynta Tapentadol TABLET Tier 2 QL: 60 per 30 days; Cumulative Opioid Buprenorphine Buprenorphine PATCH TDWK Tier 2 QL: 4 per 28 days; Cumulative Opioid Butrans Buprenorphine PATCH TDWK Tier 2 QL: 4 per 28 days; Cumulative Opioid Buprenorphine Buprenorphine TAB SUBL Tier 1 QL: 90 per 30 days; Cumulative Opioid Suboxone (12 Mg - 3 Mg) Buprenorphine / FILM Tier 2 QL: 60 per 30 days; Cumulative Opioid Naloxone Suboxone (2 Mg - 0.5 Mg, 4 Mg Buprenorphine / FILM Tier 2 QL: 90 per 30 days; Cumulative Opioid - 1 Mg, 8 Mg - 2 Mg) Naloxone Buprenorphine-Naloxone Buprenorphine / TAB SUBL Tier 1 QL: 90 per 30 days; Cumulative Opioid Naloxone Narcan Naloxone SPRAY Tier 2 QL: 2 per 365 days Azasite Azithromycin SOLN Tier 2 QL: 5 per 30 days Almotriptan Malate Almotriptan Malate TABLET Tier 1
Eletriptan HBR Eletriptan HBR TABLET Tier 1 Frovatriptan Succinate Frovatriptan Succinate TABLET Tier 1 Naratriptan Naratriptan TABLET Tier 1 Rizatriptan Rizatriptan Benzoate TABLET Tier 1 Rizatriptan Rizatriptan Benzoate TBDP Tier 1 Sumatriptan Sumatriptan SPRAY Tier 1 Onzetra Xsail Sumatriptan Succinate AER POW BA Tier 2 Sumatriptan Succinate Sumatriptan Succinate CARTRIDGE Tier 1 Imitrex (6 Mg) Sumatriptan Succinate PEN INJCTR Tier 2 Sumatriptan Succinate Sumatriptan Succinate PEN INJCTR Tier 1 Sumatriptan Succinate Sumatriptan Succinate SOCT Tier 1 Sumatriptan Succinate Sumatriptan Succinate SOLN Tier 1 Sumatriptan Succinate Sumatriptan Succinate SYRINGE Tier 1 Sumatriptan Succinate Sumatriptan Succinate TABLET Tier 1 Zomig Zolmitriptan SOLN Tier 2 Zomig Zolmitriptan SPRAY Tier 2 QL: 16 per 30 days, ST (total for all triptans
Zolmitriptan ODT Zolmitriptan TAB RAPDIS Tier 1 Zolmitriptan Zolmitriptan TABLET Tier 1 Tagrisso Osimertinib Mesylate TABLET Tier 2 QL: 30 per 30 days Neupro Rotigotine PATCH TD24 Tier 2 QL: 30 per 30 days Neupro Rotigotine PT24 Tier 2 QL: 30 per 30 days Vraylar Cariprazine CAPSULE Tier 2 QL: 30 per 30 days, ST Invokamet Canagliflozin/Metformin TABLET Tier 2 QL: 60 per 30 days Xigduo Xr (5 Mg- 1000 Mg) Dapagliflozin/Metformin TAB BP 24H Tier 2 QL: 60 per 30 days Xigduo Xr (5 Mg - 500 Mg, 10 Dapagliflozin/Metformin Mg - 500 Mg, 10 Mg - 1000 Mg) TAB BP 24H Tier 2 QL: 30 per 30 days Synjardy XR Empagliflozin/Metformin TAB BP 24H Tier 2 QL: 30 per 30 days Synjardy Empagliflozin/Metformin TABLET Tier 2 QL: 60 per 30 days Bydureon Pen Exenatide Microspheres PEN INJCTR Tier 2 QL: 4 per 28 days Bydureon Exenatide Microspheres SRER Tier 2 QL: 4 per 28 days Xarelto (10 Mg) Rivaroxaban TABLET Tier 2 QL: 94 per 365 days Clonidine Clonidine PATCH TDWK Tier 1 QL: 4 per 28 days Nitro-Dur (0.3 Mg/Hr, 0.8 Mg/ Hr) Nitroglycerin PATCH TD24 Tier 2 QL: 30 per 30 days Nitroglycerin Patch Nitroglycerin PATCH TD24 Tier 1 QL: 30 per 30 days Minitran Nitroglycerin PT24 Tier 1 QL: 30 per 30 days Wide Seal Diaphragm Diaphragms, Wide Seal DIAPHRAGM $0 Copay Durable Medical Equipment; QL: 3 per 365 days Oxytrol Oxybutynin PATCH TDSW Tier 2 QL: 8 per 28 days Cialis (2.5 Mg, 5 Mg) Tadalafil TABLET Tier 2 QL: 30 per 30 days Caverject Alprostadil KIT Tier 2 QL: 6 per 30 days
Edex Alprostadil KIT Tier 2 QL: 6 per 30 days Caverject Alprostadil VIAL Tier 2 QL: 6 per 30 days Stendra Avanafil TABLET Tier 2 QL: 8 per 30 days Cialis (10 Mg, 20 Mg) Tadalafil TABLET Tier 2 QL: 8 per 30 days Staxyn Vardenafil HCl TAB RAPDIS Tier 2 QL: 8 per 30 days Levitra Vardenafil TABLET Tier 2 QL: 8 per 30 days Androderm Testosterone PATCH TD24 Tier 2 QL: 30 per 30 days Testosterone Testosterone SOL MD PMP Tier 1 QL: 180 per 30 days Alora Estradiol PATCH TDSW Tier 2 QL: 8 per 28 days Estradiol Estradiol PATCH TDSW Tier 1 QL: 8 per 28 days Minivelle Estradiol PATCH TDSW Tier 2 QL: 8 per 28 days Climara Estradiol PATCH TDWK Tier 2 QL: 4 per 28 days Estradiol Estradiol PATCH TDWK Tier 1 QL: 4 per 28 days Menostar Estradiol PATCH TDWK Tier 2 QL: 4 per 28 days Estring Estradiol VAG RING Tier 2 QL: 1 per 90 days Femring Estradiol Acetate VAG RING Tier 2 QL: 1 per 90 days Climara Pro Estradiol/Levonorgestrel PATCH TDWK Tier 2 QL: 4 per 28 days Combipatch Estradiol/Norethindrone Acet PTTW Tier 2 QL: 8 per 28 days Nuvaring Etonogestrel/Ethinyl Estradiol VAG RING $0 Copay QL: 1 per 28 days Ortho Evra Norelgestromin/Ethin. Estradiol PATCH TDWK Tier 2 QL: 3 per 28 days Xulane Norelgestromin/Ethin. Estradiol PATCH TDWK $0 Copay QL: 3 per 28 days Kyleena Levonorgestrel IUD $0 Copay Liletta Levonorgestrel IUD $0 Copay Mirena Levonorgestrel IUD $0 Copay
Skyla Levonorgestrel IUD $0 Copay Paragard T 380-A Copper IUD $0 Copay Alendronate Sodium Alendronate Sodium SOLUTION Tier 1 QL: 300 per 28 days Alendronate Sodium (35 Mg, 70 Mg) Alendronate Sodium TABLET Tier 1 QL: 4 per 28 days Fosamax Plus D Alendronate Sodium/ Vitamin D3 TABLET Tier 2 QL: 4 per 28 days Boniva Ibandronate Sodium SOLN Tier 3 Medical Injectable QL: 3 per 90 days Ibandronate Sodium Ibandronate Sodium SYRINGE Tier 3 Medical Injectable QL: 3 per 90 days Ibandronate Sodium Ibandronate Sodium TABLET Tier 1 QL: 1 per 28 days Risedronate Sodium (150 Mg) Risedronate Sodium TABLET Tier 1 QL: 1 per 28 days Risedronate Sodium (35 Mg) Risedronate Sodium TABLET Tier 1 QL: 4 per 28 days Restasis Cyclosporine EMUL Tier 2 QL: 60 per 30 days Lacrisert Hydroxypropyl Cellulose INSERT Tier 2 Specialty QL: 60 per 30 days Tobramycin-Dexamethasone Tobramycin/ Dexamethasone DROPS SUSP Tier 1 QL: 20 per 30 days Olopatadine Olopatadine DROPS Tier 1 QL: 5 per 30 days Olopatadine Olopatadine DROPS Tier 1 QL: 5 per 31 days Betaxolol Betaxolol DROPS Tier 1 QL: 5 per 30 days Betoptic-S Betaxolol SUSP Tier 2 QL: 10 per 30 days Alphagan P (0.1%) Brimonidine Tartrate DROPS Tier 2 QL: 10 per 30 days Brimonidine Tartrate Brimonidine Tartrate DROPS Tier 1 QL: 10 per 30 days Combigan Brimonidine Tartrate/ Timolol DROPS Tier 2 QL: 10 per 30 days Azopt Brinzolamide DROPS SUSP Tier 2 QL: 10 per 30 days Carteolol Carteolol DROPS Tier 1 QL: 5 per 30 days Dorzolamide-Timolol Dorzolamide Hcl/Timolol Maleat SOLN Tier 1 QL: 10 per 30 days Cosopt PF Dorzolamide/Timolol/PF SOLN Tier 2 QL: 60 per 30 days
Levobunolol Levobunolol SOLN Tier 1 QL: 5 per 30 days Pilocarpine Pilocarpine DROPS Tier 1 QL: 15 per 30 days Pilocarpine Pilocarpine SOLN Tier 1 QL: 15 per 30 days Betimol Timolol SOLN Tier 2 QL: 10 per 30 days Timolol Maleate (0.5%) Timolol Maleate DROPS Tier 1 QL: 5 per 30 days Timolol Maleate Timolol Maleate SOL-GEL Tier 1 QL: 5 per 30 days Timolol Male Sol 0.5% Timolol Maleate SOLN Tier 1 QL: 5 per 30 days Diclofenac Sodium (0.1%) Diclofenac Sodium DROPS Tier 1 QL: 5 per 30 days Lumigan Bimatoprost DROPS Tier 2 QL: 5 per 60 days Latanoprost Latanoprost DROPS Tier 1 QL: 2.5 per 30 days Zioptan Tafluprost/PF SOLN Tier 2 QL: 30 per 30 days Travatan Z Travoprost DROPS Tier 2 QL: 5 per 60 days Azelastine Azelastine SPRAY/PUMP Tier 1 QL: 60 per 30 days Qvar Beclomethasone Dipropionate AER W/ADAP Tier 2 QL: 17.4 per 30 days Qvar Beclomethasone Dipropionate AERS Tier 2 QL: 17.4 per 30 days Beconase AQ Beclomethasone Dipropionate SPRAY Tier 2 QL: 50 per 30 days Pulmicort Flexhaler Budesonide AER POW BA Tier 2 QL: 2 per 30 days Alvesco Ciclesonide HFA AER AD Tier 2 QL: 12.2 per 30 days Flunisolide Flunisolide SPRAY Tier 1 QL: 50 per 30 days Arnuity Ellipta Fluticasone Furoate BLST W/DEV Tier 2 QL: 30 per 30 days Flovent HFA (44 Mcg) Fluticasone Propionate AER W/ADAP Tier 2 QL: 21.2 per 30 days Flovent Diskus Fluticasone Propionate BLST W/DEV Tier 2 QL: 120 per 30 days Asmanex Twisthaler 14 Metered Doses Mometasone Furoate AEPB Tier 2 QL: 1 per 30 days Asmanex (7, 14, 30, 60) Mometasone Furoate AER POW BA Tier 2 QL: 1 per 30 days Asmanex (120) Mometasone Furoate AER POW BA Tier 2 QL: 1 per 60 days Asmanex HFA Mometasone Furoate HFA AER AD Tier 2 QL: 13 per 30 days Mometasone Furoate Mometasone Furoate SPRAY/PUMP Tier 1 QL: 34 per 30 days Triamcinolone Acetonide Triamcinolone Acetonide SPRAY Tier 1 QL: 33 per 30 days Seebri Neohaler Glycopyrrolate CAP W/DEV Tier 2 QL: 60 per 30 days
Atrovent HFA Ipratropium Bromide HFA AER AD Tier 2 QL: 25.8 per 30 days Incruse Ellipta Umeclidinium Bromide BLST W/DEV Tier 2 QL: 30 per 30 days Proair Respiclick Albuterol Sulfate AER POW BA Tier 2 QL: 2 per 30 days Proair HFA Albuterol Sulfate AERS Tier 2 QL: 17 per 30 days Ventolin HFA Albuterol Sulfate AERS Tier 2 QL: 36 per 30 days Proventil HFA Albuterol Sulfate HFA AER AD Tier 2 QL: 13.4 per 30 days Ventolin HFA Albuterol Sulfate HFA AER AD Tier 2 QL: 36 per 30 days Arcapta Neohaler Indacaterol Maleate CAP W/DEV Tier 2 QL: 30 per 30 days Xopenex HFA Levalbuterol Tartrate HFA AER AD Tier 2 QL: 30 per 30 days Striverdi Respimat Olodaterol MIST INHAL Tier 2 QL: 4 per 30 days Serevent Diskus Salmeterol Xinafoate AEPB Tier 2 QL: 60 per 30 days Serevent Diskus Salmeterol Xinafoate BLST W/DEV Tier 2 QL: 60 per 30 days Symbicort Budesonide/Formoterol Fumarate HFA AER AD Tier 2 QL: 10.2 per 30 days Advair Diskus Fluticasone/Salmeterol AEPB Tier 2 QL: 60 per 30 days, ST Advair Diskus Fluticasone/Salmeterol BLST W/DEV Tier 2 QL: 60 per 30 days, ST Advair HFA Fluticasone/Salmeterol HFA AER AD Tier 2 QL: 12 per 30 days, ST Breo Ellipta Fluticasone/Vilanterol BLST W/DEV Tier 2 QL: 60 per 30 days Utibron Neohaler Indacaterol/Glycopyrrolate CAP W/DEV Tier 2 QL: 60 per 30 days Dulera Mometasone/Formoterol HFA AER AD Tier 2 QL: 13 per 30 days Combivent Respimat Ipratropium/Albuterol Sulfate MIST INHAL Tier 2 QL: 8 per 30 days Stiolto Respimat Tiotropium Br/Olodaterol MIST INHAL Tier 2 QL: 4 per 30 days