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
|
|
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 / Acular LS
|
Ophthalmic NSAID
|
2 (10 mL) bottles / month
|
|
Acuvail
|
Ophthalmic NSAID
|
64 units per 180 days
|
|
Advair Diskus/HFA
|
Asthma/COPD
|
1 device per month
|
|
Aerobid, Aerobid-M
|
Asthma/COPD
|
3 device per month
|
|
Alvesco
|
Asthma/COPD
|
2 device per month
|
|
Alora
|
Hormone Replacement Therapy
|
8 patches per 28 days
|
|
Alrex
|
Ophthalmic Steroid
|
3 (5 mL) bottles / month
|
|
Altabax
|
Antibiotics-topical
|
1 tube 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
|
|
Blood Glucose Testing Strips (all brands and generics)
|
Diabetic Testing Supplies
|
150 test strips/month
|
|
Boniva 150 mg
|
Osteoporosis
|
1 tablet per 30 days
|
|
Catapres-TTS -1
|
Blood Pressure
|
5 patches/month
|
|
Catapres-TTS -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
|
8 tablets per month
|
|
Ciloxan ophthalmic ointment
|
Ophthalmic Antibiotic
|
1 tube (3.5 gm) / 15 days
|
|
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
|
|
Diflucan (fluconazole) 150 mg
|
Antifungal
|
1 tablet per co-pay
|
|
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
|
|
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
|
Anti-TNF Agent
|
8 doses 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)
|
|
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
|
|
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)
|
|
Helidac
|
Ulcer therapy
|
1 kit per year
|
|
Humira
|
Anti-TNF Agent
|
1 package per 28 days
|
|
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
|
1 (5 mL) bottle / 15 days
|
|
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
|
|
Levitra
|
Sexual Dysfunction
|
8 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
|
|
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
|
2 (3 mL) bottles/year
|
|
Nucynta 50mg, 75mg
|
Narcotic Analgesic
|
180 tablets/month (6 per day)
|
|
Nucynta 100mg
|
Narcotic Analgesic
|
210 tablets/month (7 per day)
|
|
Ocufen (flurbiprofen)
|
Ophthalmic NSAID
|
1 (2.5 mL) bottle/15 days
|
|
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
|
|
Pegasys
|
Hepatitis C
|
4 vials / 28 days
|
|
Pegasys Kit
|
Hepatitis C
|
1 kit / 28 days
|
|
Plan B One-Step
|
Emergency Contraceptive
|
1 tablet per Rx
|
|
Prevacid NapraPAC
|
analgesic/anti-ulcer combination
|
1 box (84 units) per month
|
|
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
|
|
Quixin
|
Ophthalmic Antibiotic
|
1 (5 mL) bottle / 15 days
|
|
QVAR 40mcg
|
Asthma/COPD
|
2 devices per month
|
|
QVAR 80mcg
|
Asthma/COPD
|
3 devices per month
|
|
Regenecare Gel
|
Wound Care
|
1 copay per package
|
|
Regranex
|
Wound care
|
2 (15 gm) tubes/month
|
|
Relenza
|
Influenza Antiviral
|
20 blisters per month
|
|
Relpax
|
Acute Migraine Therapy
|
12 tablets/month
|
|
Restasis
|
Ophthalmic-other
|
60 units per 30 days
|
|
Revlimid
|
Cancer
|
28 day supply per dispensing
|
|
Rhinocort Aqua
|
Allergy (Intranasal)
|
2 (8.6 gm) devices per month
|
|
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
|
|
Soriatane Kit 10mg
|
Psoriasis
|
1 kit/month
|
|
Soriatane Kit 25mg
|
Psoriasis
|
2 kit/month
|
|
Spiriva
|
Asthma/COPD
|
30 capsules/month
|
|
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
|
|
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
|
|
Travatan and Travatan Z
|
Glaucoma
|
1 (2.5 mL) bottle/month
|
|
Treximet
|
Acute Migraine therapy
|
9 tablets/month
|
|
Ultracet (tramadol/acetaminophen)
|
Pain Medication
|
40 tablets per prescription
|
|
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
|
8 tablets per month
|
|
Vigamox
|
Ophthalmic Antibiotic
|
1 (3 mL) bottle/15 days
|
|
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 (diclofenac) Op. Sol.
|
Ophthalmic NSAID
|
1 (5 mL) bottle/15 days
|
|
Xalatan
|
Glaucoma
|
1 (2.5 mL) bottle/month
|
|
Xibrom Sol.
|
Ophthalmic NSAID
|
2 (5 mL) bottles/year
|
|
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
|
|
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
|
1 (5 mL) bottle/15 days
|
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.