Quantity limits are based upon FDA guidelines, published clinical recommendations, such as the Journal
of the American Medical Association (JAMA), as well as manufacturer packaging and labeling instructions.
Limits are intended to encourage appropriate dosing. Exceptions are generally limited to chronic conditions
that necessitate a quantity greater than "normal." These limits are not intended to restrict access
to quantities of medications where limits would not be considered functional or appropriate. The P&T
Committee recommends the following medications be limited to a defined quantity.
|
Drug Name
|
Therapy Class
|
Limit
|
|
Acanya
|
Dermatological - Acne
|
1 kit per month
|
|
Actiq (fentanyl oral transmucosal)
|
Narcotic Analgesic
|
120 units per month (4 per day)
|
|
Actonel 35 mg
|
Osteoporosis
|
4 tabs per 28 days
|
|
Actonel 75 mg
|
Osteoporosis
|
2 tablets per 30 days
|
|
Actonel 150 mg
|
Osteoporosis
|
1 tablet per 30 days
|
|
Acular
|
Ophthalmic NSAID
|
15 mL per month
|
|
Acular LS
|
Ophthalmic NSAID
|
5 mL per month
|
|
Acuvail
|
Ophthalmic NSAID
|
64 units per 180 days
|
|
Adoxa (doxycycline monohydrate) 100mg
|
Antibiotic
|
30 tablets/Rx
|
|
Adoxa (doxycycline monohydrate) 50mg, 75mg
|
Antibiotic
|
20 tablets/Rx
|
|
Adoxa CK kit, TT kit
|
Antibiotic
|
1 kit/Rx
|
|
Advair Diskus/HFA
|
Asthma/COPD
|
1 device per month
|
|
Aerobid, Aerobid-M
|
Asthma/COPD
|
3 device per month
|
|
Afinitor
|
Cancer
|
One month supply per dispensing
|
|
Alocril
|
Ophthalmic Antiallergic
|
3 (5 mL) bottles per month
|
|
Alomide
|
Ophthalmic Antiallergic
|
3 (10 mL) bottles per month
|
|
Alora
|
Hormone Replacement Therapy
|
8 patches per 28 days
|
|
Alphagan P
|
Ophthalmic - Miscellaneous
|
10 mL per month
|
|
Alrex
|
Ophthalmic Steroid
|
3 (5 mL) bottles / month
|
|
Altabax
|
Antibiotics-topical
|
1 tube per month
|
|
Alvesco
|
Asthma/COPD
|
2 device per month
|
|
Amerge
|
Acute Migraine Therapy
|
18 tablets/month
|
|
Anzemet
|
Nausea and Vomiting
|
1 tablet per month
|
|
Aranesp
|
Hematopoietic Agent
|
28 day supply per dispensing
|
|
Asmanex 110 mcg
|
Asthma/COPD
|
1 device per month
|
|
Asmanex 220 mcg
|
Asthma/COPD
|
3 devices per month
|
|
Astelin
|
Allergy (Intranasal)
|
2 (30 mL) devices per month
|
|
Astepro
|
Allergy (Intranasal)
|
2 (30 mL) devices per month
|
|
Avinza 120mg
|
Narcotic Analgesic
|
60 capsules/month (2 per day)
|
|
Avinza 30mg, 45mg, 60mg, 75mg, 90mg
|
Narcotic Analgesic
|
30 capsules/month (1 per day)
|
|
Avonex
|
Multiple Sclerosis
|
4 injections per month
|
|
Axert
|
Acute Migraine Therapy
|
12 tablets/month
|
|
Azasite
|
Ophthalmic Antibiotic
|
1 (2.5mL) bottle/month
|
|
Azmacort
|
Asthma/COPD
|
2 devices/month
|
|
Beconase AQ
|
Allergy (Intranasal)
|
2 (25 gm) devices per month
|
|
Bepreve
|
Ophthalmic antihistamine
|
1 (10 mL) bottle/month
|
|
Besivance
|
Ophthalmic Antibiotic
|
5 mL per month
|
|
Betaseron
|
Multiple Sclerosis
|
14 injections per month
|
|
Blood Glucose Testing Strips (all brands and generics)
|
Diabetic Testing Supplies
|
150 test strips/month
|
|
Boniva 150 mg
|
Osteoporosis
|
1 tablet per 30 days
|
|
brimonidine sol.
|
Ophthalmic - Miscellaneous
|
10 mL per month
|
|
Catapres-TTS -1 (clonidine TD patch-1)
|
Blood Pressure
|
5 patches/month
|
|
Catapres-TTS -2, -3 (clonidine TD patch -2,- 3)
|
Blood Pressure
|
10 patches/month
|
|
Cesamet
|
Nausea and Vomiting
|
20 capsules per co-pay
|
|
Cialis 2.5mg, 5mg
|
Sexual Dysfunction
|
30 tablets per month
|
|
Cialis 10mg, 20mg
|
Sexual Dysfunction
|
6 tablets per month
|
|
Ciloxan ophthalmic ointment
|
Ophthalmic Antibiotic
|
7 gm per month
|
|
Ciloxan ophthalmic sol.
|
Ophthalmic Antibiotic
|
10 mL per month
|
|
Cimzia
|
TNF Antagonists
|
2 doses per 28 days
|
|
ciprofloxacin opthalmic sol.
|
Ophthalmic Antibiotic
|
10 mL per month
|
|
Climara
|
Hormone Replacement Therapy
|
4 patches per 28 days
|
|
Climara Pro
|
Hormone Replacement Therapy
|
4 patches per 28 days
|
|
Combipatch
|
Hormone Replacement Therapy
|
8 patches per 28 days
|
|
Copaxone
|
Multiple Sclerosis
|
30 injections per month
|
|
diclofenac ophthalmic sol.
|
Ophthalmic NSAID
|
7.5 mL per month
|
|
Diflucan (fluconazole) 150 mg
|
Antifungal
|
1 tablet per co-pay
|
|
Doryx 100mg
|
Antibiotic
|
30 tablets/Rx
|
|
Doryx 75mg
|
Antibiotic
|
20 tablets/Rx
|
|
Duragesic (fentanyl TD) 12.5mcg, 25mcg, 50mcg
|
Narcotic Analgesic
|
15 patches per month
|
|
Duragesic (fentanyl TD) 75mcg, 100mcg
|
Narcotic Analgesic
|
30 patches per month
|
|
Elestat
|
Ophthalmic Antiallergic
|
2 (5 mL) bottles/30 days
|
|
Embeda
|
Narcotic Analgesic
|
60 capsules/month (2 per day)
|
|
Emend (combo pack) 125mg-80mg
|
Nausea and Vomiting
|
1 pack per month
|
|
Emend 80 mg & 125 mg
|
Nausea and Vomiting
|
3 capsules per month
|
|
Enbrel 25mg
|
TNF Antagonists
|
8 doses per 28 days
|
|
Enbrel 50mg
|
TNF Antagonists
|
4 doses per 28 days
|
|
Epiduo
|
Dermatological - Acne
|
45 gm per month
|
|
Epogen
|
Hematopoietic Agent
|
28 day supply per dispensing
|
|
Estraderm
|
Hormone Replacement Therapy
|
8 patches per 28 days
|
|
Estradiol TD patch weekly
|
Hormone Replacement Therapy
|
4 patches per 28 days
|
|
Estrasorb
|
Hormone Replacement Therapy
|
56 packets per 28 days
|
|
Estrogel
|
Hormone Replacement Therapy
|
1 bottle (93 gm) per month
|
|
Estring
|
Hormone Replacement Therapy
|
1 device per 3 months (3 co-pays)
|
|
Exalgo
|
Narcotic Analgesic
|
6 tabs/day
|
|
Extavia
|
Multiple Sclerosis
|
15 injections per month
|
|
Femring
|
Hormone Replacement Therapy
|
1 device per 3 months (3 co-pays)
|
|
Fentora
|
Narcotic Analgesic
|
120 units per month (4 per day)
|
|
Flovent Diskus 250mcg
|
Asthma/COPD
|
240 blisters/month
|
|
Flovent Diskus 50mcg, 100mcg
|
Asthma/COPD
|
120 blisters/month
|
|
Flovent HFA
|
Asthma/COPD
|
2 devices/month
|
|
flurbiprofen ophthalmic sol.
|
Ophthalmic NSAID
|
2.5 mL per month
|
|
Foradil
|
Asthma/COPD
|
60 caps/month
|
|
Forteo
|
Osteoporosis
|
24 months of therapy
|
|
Fortical (calcitonin) nasal spray
|
Osteoporosis
|
3.7 mL per month
|
|
Fosamax (alendronate) 35 mg and 70 mg
|
Osteoporosis
|
4 tablets per 28 days
|
|
Fosamax Oral Solution
|
Osteoporosis
|
375 mL per month
|
|
Fosamax Plus D 70/2800 and 70/5600
|
Osteoporosis
|
4 tablets per 28 days
|
|
Frova
|
Acute Migraine Therapy
|
18 tablets/month
|
|
Gelnique Gel
|
Genitourinary
|
30 sachets/month (1 sachet daily)
|
|
Gleevec
|
Cancer
|
One month supply per dispensing
|
|
Golytely (PEG 3350 electrolyte solution)
|
Laxatives
|
4000 mL per Rx
|
|
Helidac
|
H. pylori
|
1 kit per 6 months
|
|
Humira
|
TNF Antagonists
|
1 package (2 doses) per 28 days
|
|
Humira Crohn's Disease Starter Kit
|
TNF Antagonists
|
1 kit per year
|
|
Humira Psoriasis Starter Kit
|
TNF Antagonists
|
1 kit per year
|
|
Imitrex (sumatriptan) 25mg, 50mg, 100mg
|
Acute Migraine Therapy
|
18 tablets/month
|
|
Imitrex (sumatriptan) Injections
|
Acute Migraine Therapy
|
4 kits/month
|
|
Imitrex (sumatriptan) Nasal Spray
|
Acute Migraine Therapy
|
12 devices (2 packages) per month
|
|
Iquix
|
Ophthalmic Antibiotic
|
15 mL per month
|
|
Iressa
|
Cancer
|
One month supply per dispensing
|
|
Kadian
|
Narcotic Analgesic
|
60 capsules/month (2 per day)
|
|
Ketek
|
Antibotics-Other
|
20 dosage units per 30 days
|
|
ketorolac
|
COX-1 Inhibitor, NSAID
|
20 tablets per month
|
|
Kytril (granisetron)
|
Nausea and Vomiting
|
2 tablets per month
|
|
Lamictal XR Kit
|
Anticonvulsants
|
1 box per Rx
|
|
Levitra
|
Sexual Dysfunction
|
6 tablets per month
|
|
Lidoderm
|
Anesthetic Patch
|
3 boxes (90 patches) per month (3 patches per day)
|
|
Livostin
|
Ophthalmic Antiallergic
|
2 (5mL) bottles/month
|
|
Lumigan
|
Glaucoma
|
1 (2.5 mL) bottle/month
|
|
Lupron Depot 11.25 & 22.5
|
Cancer
|
1 unit per 90 days
|
|
Luveris
|
Infertility
|
14 vials per co-pay
|
|
Maxalt & Maxalt MLT
|
Acute Migraine Therapy
|
18 tablets/month
|
|
Menostar
|
Osteoporosis
|
4 patches per 28 days
|
|
mesalamine kit
|
Gastrointestinal Agents (miscellaneous)
|
1 kit per 7 days
|
|
metoclopramide
|
Gastrointestinal Agents (miscellaneous)
|
12 weeks of therapy per 6 months
|
|
Miacalcin (calcitonin) nasal spray
|
Osteoprosis
|
3.7 mL per month
|
|
Migranal
|
Acute Migraine Therapy
|
8 units (1 kit) per month
|
|
MS contin (morphine sulfate ER) 15mg, 30mg, 60mg, 100mg
|
Narcotic Analgesic
|
120 tablets/month (4 per day)
|
|
MS contin (morphine sulfate ER) 200mg
|
Narcotic Analgesic
|
90 tablets/month (3 per day)
|
|
Nasacort AQ
|
Allergy (Intranasal)
|
1 (16.5 gm) device per month
|
|
Nasonex
|
Allergy (Intranasal)
|
2 (17 gm) devices per month
|
|
Natacyn
|
Ophthalmic Antibiotic
|
1 (15 mL) bottle / 15 days
|
|
Neulasta
|
Hematopoietic Agent
|
28 day supply per dispensing
|
|
Neupogen
|
Hematopoietic Agent
|
28 day supply per dispensing
|
|
Nevanac
|
Ophthalmic NSAID
|
6 mL per month
|
|
Nexavar
|
Cancer
|
One month supply per dispensing
|
|
Nucynta 50mg, 75mg
|
Narcotic Analgesic
|
180 tablets/month (6 per day)
|
|
Nucynta 100mg
|
Narcotic Analgesic
|
210 tablets/month (7 per day)
|
|
Ocufen
|
Ophthalmic NSAID
|
2.5 mL per month
|
|
Ocuflox
|
Ophthalmic Antibiotic
|
10 mL per month
|
|
ofloxacin ophthalmic drops
|
Ophthalmic Antibiotic
|
10 mL per month
|
|
Omnaris
|
Allergy (Intranasal)
|
1 device (12.5 gm) per month
|
|
Onsolis
|
Narcotic Analgesic
|
120 units per month (4 per day)
|
|
Opana
|
Narcotic Analgesic
|
180 tablets/month (6 per day)
|
|
Opana ER
|
Narcotic Analgesic
|
120 units per month (4 per day)
|
|
Optivar
|
Ophthalmic Antiallergic
|
2 (5mL) bottles/30 days
|
|
Oramorph SR
|
Narcotic Analgesic
|
120 units per month (4 per day)
|
|
Oxycontin
|
Narcotic Analgesic
|
270 tablets per month
|
|
Oxytrol
|
Genitourinary
|
8 patches per 28 days
|
|
Pataday
|
Ophthalmic Antiallergic
|
2 (2.5mL) bottles/30 days
|
|
Patanase
|
Allergy (Intranasal)
|
1 (30.5mL) bottles/month
|
|
Patanol
|
Ophthalmic Antiallergic
|
2 (5mL) bottles/30 days
|
|
Plan B One-Step
|
Emergency Contraceptive
|
1 tablet per Rx
|
|
Prevacid NapraPAC
|
Analgesic/anti-ulcer combination
|
1 box (84 units) per month
|
|
Prevpac
|
H. pylori
|
14 daily dose cards per 6 months
|
|
ProAir HFA
|
Asthma/COPD
|
2 devices per month
|
|
Procrit
|
Hematopoietic Agent
|
28 day supply per dispensing
|
|
Proventil HFA
|
Asthma/COPD
|
2 devices/month
|
|
Prozac Weekly
|
SSRI Antidepressant
|
4 capsules per month
|
|
Pulmicort
|
Asthma/COPD
|
2 devices per month
|
|
Pylera
|
H. pylori
|
120 tablets per 6 months
|
|
Quixin
|
Ophthalmic Antibiotic
|
10 mL per month
|
|
QVAR 40mcg
|
Asthma/COPD
|
2 devices per month
|
|
QVAR 80mcg
|
Asthma/COPD
|
3 devices per month
|
|
Rebif
|
Multiple Sclerosis
|
12 injections per 28 days
|
|
Rebif Titration Pack
|
Multiple Sclerosis
|
one titration pack per year
|
|
Regenecare Gel
|
Wound Care
|
1 copay per package
|
|
Reglan
|
Gastrointestinal Agents (miscellaneous)
|
12 weeks of therapy per 6 months
|
|
Regranex
|
Wound care
|
2 (15 gm) tubes/month
|
|
Relenza
|
Influenza Antiviral
|
20 blisters per month
|
|
Relpax
|
Acute Migraine Therapy
|
12 tablets/month
|
|
Restasis
|
Ophthalmic - Miscellaneous
|
60 units per 30 days
|
|
Retin-A Micro
|
Dermatological - Acne
|
50 gm per month
|
|
Revlimid
|
Cancer
|
28 day supply per dispensing
|
|
Rhinocort Aqua
|
Allergy (Intranasal)
|
2 (8.6 gm) devices per month
|
|
Rowasa Kit
|
Gastrointestinal Agents (miscellaneous)
|
1 kit per 7 days
|
|
Sancuso
|
Nausea and vomiting
|
1 patch per copay
|
|
Savella Titration Pack
|
Fibromyalgia
|
1 pack per Rx
|
|
Seasonale (Seasonique)
|
Contraception
|
1 package per 91 days (3 copays)
|
|
Serevent Diskus
|
Asthma/COPD
|
1 device per month
|
|
Simponi
|
TNF Antagonists
|
1 dose/month
|
|
Soriatane Kit 10mg
|
Psoriasis
|
1 kit/month
|
|
Soriatane Kit 25mg
|
Psoriasis
|
2 kit/month
|
|
Spiriva
|
Asthma/COPD
|
30 capsules/month
|
|
Sprycel
|
Cancer
|
One month supply per dispensing
|
|
Stadol NS (butorphanol)
|
Narcotic Analgesic Nasal Spray
|
4 (2.5ml) pumps per month
|
|
Suboxone
|
Narcotic Antagonist
|
93 tablets/month (3 per day)
|
|
Subutex 2mg
|
Narcotic Antagonist
|
16 tablets per month
|
|
Subutex 8mg
|
Narcotic Antagonist
|
8 tablets per month
|
|
Sutent
|
Cancer
|
One month supply per dispensing
|
|
Symbicort
|
Asthma/COPD
|
1 device per month
|
|
Tamiflu 30mg
|
Influenza Antiviral
|
20 capsules per month
|
|
Tamiflu 45mg, 75mg
|
Influenza Antiviral
|
10 capsules per month
|
|
Tamiflu for oral supsension
|
Influenza Antiviral
|
75 mL per month
|
|
Tarceva
|
Cancer
|
One month supply per dispensing
|
|
Tasigna
|
Cancer
|
One month supply per dispensing
|
|
Thalomid
|
Cancer
|
28 day supply per dispensing
|
|
Travatan and Travatan Z
|
Glaucoma
|
1 (2.5 mL) bottle/month
|
|
Treximet
|
Acute Migraine therapy
|
9 tablets/month
|
|
Tykerb
|
Cancer
|
One month supply per dispensing
|
|
Ventolin HFA
|
Asthma/COPD
|
2 devices/month
|
|
Veramyst
|
Allergy (Intranasal)
|
1 (10 gm) device/month
|
|
Veregen
|
External Genital Warts
|
16 weeks of therapy per year
|
|
Viagra
|
Sexual Dysfunction
|
6 tablets per month
|
|
Victoza
|
Diabetic Testing Supplies
|
3 pens per month
|
|
Vigamox
|
Ophthalmic Antibiotic
|
3 mL per month
|
|
Viroptic (trifluridine)
|
Ophthalmic Antiviral
|
1 (7.5 mL) bottle/15 days
|
|
Vivelle
|
Hormone Replacement Therapy
|
8 patches per 28 days
|
|
Vivelle-Dot
|
Hormone Replacement Therapy
|
8 patches per 28 days
|
|
Voltaren Op. Sol.
|
Ophthalmic NSAID
|
7.5 mL per month
|
|
Votrient
|
Cancer
|
One month supply per dispensing
|
|
Xalatan
|
Glaucoma
|
1 (2.5 mL) bottle/month
|
|
Xibrom Sol.
|
Ophthalmic NSAID
|
5 mL per month
|
|
Xopenex HFA "D"
|
Asthma/COPD
|
2 devices/month
|
|
Xyrem
|
Narcolepsy/Cataplexy
|
540 mL per month
|
|
Zofran (ondansetron) 2mg, 4mg, 8mg, 24 mg
|
Nausea and Vomiting
|
18 tablets per month
|
|
Zofran (ondansetron) ODT 2mg, 4mg, 8mg
|
Nausea and Vomiting
|
18 tablets per month
|
|
Zofran (ondansetron) Oral Sol.
|
Nausea and Vomiting
|
200 mL per month
|
|
Zolinza
|
Cancer
|
One month supply per dispensing
|
|
Zomig & Zomig ZMT 2.5mg tablets
|
Acute Migraine Therapy
|
18 tablets/month
|
|
Zomig & Zomig ZMT 5mg tablets
|
Acute Migraine Therapy
|
9 tablets/month
|
|
Zomig Nasal Spray
|
Acute Migraine Therapy
|
12 devices (2 packages) per month
|
|
Zymar
|
Ophthalmic Antibiotic
|
5 mL per month
|
Any product listed in this information does not imply coverage. Plan booklets will provide specific
benefit and coverage details. NOTE: This is only a partial listing, and not all products on this list
may be covered by your prescription benefits plan. Your specific benefit plan's guidelines regarding
quantity limits will apply. If you have any questions about product status or if the product you're
considering does not appear in this listing, please call the number on the back of your ID card.
We're available to assist you 24-hours a day, seven days a week.