To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug
Quantity Management program. That is, for certain medications, you can receive an amount to last you
a certain number of days. This gives you the right amount to take the daily dose considered safe and
effective, according to the recommendations of the U.S. Food and Drug Administration (FDA).
Based on the FDA’s guidelines and other medical information, our plan developed this program together
with EnvisionRxOptions, the company chosen to manage our prescription drug benefit. The following
limits are based on a 34-day supply (unless otherwise noted). Your doctor could also request a prior
authorization. If this request is approved, a prior authorization would let you receive more than the
recommended quantity.
VPHP QUANTITY LIMITS
Drug Name
Abilify 2mg, 5mg, 10mg 15mg, 20mg,
30mg
Actoplus Met 15/500mg and 15/850mg
Actoplus Met XR 15/1000mg
Actoplus Met XR 30/1000mg
Actos 15mg, 30mg, 45 mg
Adcirca 20mg
Advair Diskus 100/50, 250/50 and
500/50 with device
Advair HFA
Alendronate 35 mg and 70mg
Alendronate 5mg, 10mg and 40 mg
Aloxi Injection 0.25mg/5ml and
0.075mg/1.5ml
Alprazolam (all strengths)
Amphetamine mixtures (all strengths)
Ascensia Test Strips
Astepro 137mcg Nasal Spray
Atomexatine (all but 40 mg)
Atomexatine 40 mg
Atorvastatin 10mg, 20mg, 40mg, 80mg
Avonex
Azelastine Ready Spray Nasal Spray
Azithromycin for Oral Suspension
100mg/5ml 15 ml bottle
Azithromycin for Oral Suspension
200mg/5ml 15ml and 22.5 ml bottle
Azithromycin for Oral Suspension
200mg/5ml 30 ml bottle
Azithromycin Tab or Cap 250mg
Azithromycin Tab 500mg
Betaseron
Boniva 3mg/3ml Syringe
Budesonide Respules 0.25mg/2ml and
0.5mg/2ml
Budeprion SR 100 and 150mg
34 Day Retail Quantity
Limits†
34 Tabs
102 Tabs
68 Tabs
34 Tabs
34 Tabs
68 Tabs
14, 28, 120 Blisters
2 Inhalers
5 Tabs
34 Tabs
1 Vial
170 (4-10mg max dose)
68 Tabs (60mg max dose)
150 Strips
2 Bottles
34 Tabs (100mg max dose)
68 Tabs (100mg max dose)
34 Tabs
4 Syringes
2 Bottles
2 Bottles
3 Bottles
3 Bottles
8 Tabs/Caps
6 Tabs
14 or 15 Vials (depending on
packaging) with Prefilled
Diluents Syringe
1 Injection per 90 Days
70 Ampules
68 Tabs
Budeprion XL 300mg
Buprenorphine tabs
Buproban
Buproprion HCL
Buproprion SR/ER 100, 150, and 200 mg
Butorphanol Tartrate Nasal Spray
Byetta 1.2ml (250mc/ml)
Byetta 2.4ml (250mcg/ml)
Cabergoline 0.5mg
Cayston
Cefpodoxime Tab 100mg and 200mg
Cefpodoxime for Oral Suspension
50mg/5ml, 100mg Bottle
Cefpodoxime for Oral Suspension
50mg/5ml, 100ml Bottle
Chantix
Chlordiazepoxide
Citalopram 10mg, 20mg and 40mg
Clarithromycin for Oral Suspension
125mg/5ml, 50ml Bottle
Clarithromycin for Oral Suspension
250mg/5ml, 50ml Bottle
Clarithromycin 250mg and 500mg
Clonazepam (all strengths)
Clorazepate (all strengths)
Combivent 14.7 grams
All Contraceptives
Copaxone 20mg Kit
Crestor 5mg, 10mg, 20mg and 40 mg
Cymbalta 20mg and 60mg
Cymbalta 30mg
Diazepam (all strengths)
Doxazosin 1mg, 2mg and 4mg
Doxazosin 8mg
Duetact 30/2mg and 3-/4mg
Dulera
Duloxetine (all strengths)
Eligard
Emend 115mg Vial
Emend 125mg
Emend 40mg Cap
Emend 80mg
Emend Bifold Pack
Emend Trifold Pack (one 125mg and two
80mg caps)
Enbrel 25mg Vials
Enbrel 25mg Syringes
Enbrel 50mg Syringe/Auto Injectors
Epinephrine 0.15mg and 0.3mg Single Unit
Pack
Epinephrine 0.15mg and 0.3mg Two-Pack
EpiPen and EpiPen Jr
Estradiol Transdermal Patch
Fentanyl Patch
Fexofenadine 30mg and 60mg
Fexofenadine 180mg
Fexofenadine-PSE
Fluconazole 150mg
Flunisolide 0.025%
Fluoxetine 10mg
Fluoxetine 40mg
Flurazepam (all strengths)
Fluticasone Nasal Spray
Fluvoxamine 100mg
34 Tabs
60 Tabs
60 Tabs
60 Tabs
68 Tabs
2 Spray Bottles
2 Syringes
2 Syringes
10 Tabs
1 Kit (84 Vials of Aztreonam
and 88 Vials of Diluent)
28 Tabs
2 Bottles
2 Bottles
56 Tabs
170 Tabs (200-400mg)
34 Tabs
2 Bottles
2 Bottles
28 Tabs
170 Tabs (10-20mg max dose)
170 Tabs (60-90mg max dose)
3 Inhalers
1 Package
1 Kit
34 Tabs
68 Caps
34 Caps
136 Tabs (max dose 40mg)
34 Tabs
68 Tabs
34 Tabs
2 Inhalers
68 Tabs (max dose 60mg)
1 Package per 90 Days
1 Vial
1 Cap
1 Cap
2 Caps
1 Pack
1 Pack (package size 3)
10 Vials
10 Syringes
5 Syringes/Auto Injectors
3 Units
4Units
2 Units
5 Patches
10 Patches
68 Tabs/ODTs
34 Tabs
68 Tabs
2 Tabs
3 Inhalers/Bottles
34 Caps
68 Caps
68 Tabs (60mg max dose)
2 Sprays
102 Tabs
Fluvoxamine 25mg
Fluvoxamine 50mg
Foradil Aerolizer & 12 Caps in Blisters
Foradil Aerolizer & 60 Caps in Blisters
Forteo 600mcg/2.4ml Pen
Glucagon 1mg Emergency Kit
Granisol Solution 2mg/10ml
Granisetron 1mg
Granisetron 2mg/10ml
Humira 20mg and 40mg Syringe/Pen
Humira Crohn’s Starter Pack
Humira Psoriasis Starter Pack
Imiquimod 5% Cream, 12 grams
Insulin Pen Devices
Intal Inhaler 112
Intal Inhaler 200
Ipratropium Bromide Nasal Spray 0.03%
(30 grams)
Ipratropium Bromide Nasal Spray 0.06%
(15 grams)
Ipratropium/Albuterol
Itraconazole 100mg
Januvia 25mg, 50mg, 100mg
Janumet 50/500mg, 50/100mg
Ketorolac 10mg
Ketotifen Fumarate 0.025%
Kombiglyze XR 5/500mg and 5/1000mg
Tabs
Kombiglyze XR 2.5/1000mg Tabs
Lansoprazole 15mg
Lantus Insulin
Levemire Insulin
Lice Shampoo, 120ml Bottle
Lindane 1% Shampoo, 60ml Bottle
Lisdexamfetamine (Vyvanse) (all
strengths)
Lioresal Inthrathecal Refill Kit
1 ampule 10mg/20ml
2 ampules 10mg/5ml
1 ampule 40mg/20ml
Lorazepam (all strengths)
Lovastatin 10mg
Lovastatin 20mg and 40mg
Lupron Depot 11.25mg, 22.5mg 3-month
Kit
Medroxyprogesterone Contraceptive
Injection 150mg/ml
Meloxicam 7.5mg
Methylphenidate/Concerta (18mg, 27mg,
54mg)
Methylphenidate/Concerta (36mg)
Methylphenidate/Metadate-CD (all
strengths)
Miconazole 1 Pre-Filled
Miconazole 3 Combination Pack 200mg
and equivalent
Miconazole 3 Suppositories 200mg and
equivalent
Miconazole 7 Combination Pack and
equivalent
Miconazole 7 Cream and Equivalent
Miconazole 7 Cream Pre-Filled Applicators
34 Tabs
68 Tabs
1Package (package size 12) 12
Caps
2 Packages (package size 60)
120 Caps
1 Pen
2 Kits
1 Bottle (30ml)
2 Tabs
1 Bottle (30ml)
3 Syringes/Pens
3 Syringes
3 Syringes
2 Tubes
1 Device per 365 Days
2 Inhalers
2 Inhalers
2 Bottles
2 Bottles
2 Inhalers
34 Caps
34 Tabs
68 Tabs
20 Tabs
1 Bottle
34 Tabs
68 Tabs
34 Caps
6 Bottles
6 Bottles
1 Bottle
1 Bottle
34 Tabs (70mg max dose)
1 Kit
170 Tabs (10mg max dose)
34 Tabs
68 Tabs
1 Package Per 90 Days
1 Vial/Syringe
34 Tabs
34 Tabs (72mg max dose)
68 Tabs/2 per day (72mg max
dose)
68 Tabs (60mg max dose)
1 Box
1 Box
3 (1 box)
1Box (7 suppositories, 9 gram
cream)
45 grams (1 tube)
7 Applicators
Miconazole 7 Suppositories 100mg and
equivalent
Miconazole Dual Pak (1200mg vaginal
insert, 9 gram 2% cream)
Miconazole Dual Pak (three 200mg vaginal
suppositories, 15 gram 2% cream)
Neulasta 6mg/0.6ml Single-Dose Syringe
Neumega
Nicotine Gum
Nicotine Lozenges
Nicotine Patches
Novolin Insulin
Novolog Insulin
Ofloxacin 200mg, 300mg and 400mg
Olanzapine 2.5mg, 5mg, 7.5mg, 10mg,
15mg and 20mg
Omeprazole-Sodium Bicarbonate
Ondansetron 24mg
Ondansetron, Ondansetron ODT 4 mg
Ondansetron, Ondansetron ODT 8mg
Ondansetron Solution 4mg/5ml, 50 ml
bottle
Onglyza 2.5mg and 5mg
Opana ER
Opioid/APAP combo (all strengths)
Oxazepam (all strengths)
Oxybutynin XL 5mg
Oxycodone/Roxicodone (all strengths)
Oxycodone ER, SR 10mg, 20mg and 40mg
Oxycodone ER, SR 80mg
Oxycontin 10mg, 20mg and 40mg
Oxycontin 80mg
Pantoprazole 20mg
Paroxetine HCL 10mg and 40mg
Paroxetine HCL 20mg and 30mg
Paroxetine CR 12.5mg, 25mg, and 37.5mg
Peak Flow Meters
Peg Intron Pens/Kit (containing 1 vial
each) 50mcg, 80mcg, 120mcg, and 150mcg
Pegasys 180mcg
Pegasys 180mcg Convenience Pack (4
vials)
Pegasys 180mcg Convenience Pack (4 prefilled syringes)
Perforomist Inhalation Solution
Permethrin 1% lotion, 59mlg Bottle
Plan B
Pravastatin 10mg, 25mg, 40mg and 80mg
Proair HFA (all strengths)
Pulmicort Flexhaler 90mcg
Pulmicort Flexhaler 180mcg
Pulmicort Turbuhaler
Pulmicort Respules 1mg/2ml
Qvar 40mcg and 80mcg (7.3 grams)
Qvar 40mcg (8.7 grams)
Qvar 80mcg (8.7 grams)
Rebetron Combination (Rebetol Caps and
Intron A Injection) Rebetron 1200, 1000
and 600 Therapy Pack
Rebif 22mcg and 44mcg
Rebit Titration Pack 4.2ml
Regranex 0.01% gel 2gm, 7.5gm and 15gm
Respiratory Therapy Supplies
7 Suppositories (1 box)
1 (1 box)
1 (1 box)
2 Syringes
21 Vials
270 Units
270 Units
30 Units
6 Bottles
4 Boxes
60 Tabs
34 Tabs
34 Caps
1 Tab
18 Tabs (3 Tabs/day; 24mg max
dose)
9 Tabs (3 Tabs/day; 24mg max
dose)
3 Bottles
34 Tabs
102 Tabs
272 Tabs (4g-APAP max dose)
136 Tabs (120mg max dose)
34 Tabs
170 Tabs
102 Tabs
120 Tabs
68 Tabs
102 Tabs
34 Tabs
34 Tabs
68 Tabs
68 Tabs
2 per 365 Days
5 Pens/Vials
5 Vials (package size 1)
1 Box (package size 1)
1 box (package size 1)
2 Cartons (120 Vials)
2 Bottles
2 Tabs
34 Tabs
2 Inhalers
2 Inhalers
3 Inhalers
2 Inhalers
35 Ampules
3 Inhalers
2 Inhalers
2 Inhalers
2 Packages
15 Syringes
1 Package
1 Tube
2 per 365 Days
Relenza 5mg/Blister with Inhalation
Device
Restasis 0.05%
Risperidone 0.25mg, 0.5mg, 1mg, 2mg,
3mg, and 4mg
Risperidone M-Tab 0.5mg, 1mg, 2mg, 3mg
and 4mg
Rozerem 8mg
Samsca 15mg
Samsca 30mg
Sandostatin LAR Depot 10mg/5ml and
30mg/5ml
Sandostatin LAR Depot 20mg/5ml
Savella 12.5mg, 25mg, 50mg and 100mg
Savella Titration Pack
Selfemra 10mg
Selfemra 20mg
Seroquel 25mg, 50mg, 100mg and 200mg
Seroquel 300mg and 400mg
Seroquel XR 150mg and 200mg
Seroquel XR 50mg, 300mg and 400mg
Sertraline 50mg and 100mg
Sertraline 25mg
Simvastatin 5mg, 10mg, 20mg and 40mg
Spiriva Handihaler 6 Caps (1 blister card)
with inhaler device
Spiriva Handihaler 30 Caps (5 blister
cards) with inhaler device
Spiriva Handihaler 90 Caps (6 blister
cards) with inhaler device
Suboxone 2/0.5mg
Suboxone 8/2mg
Suboxone 12/3 mg
Sumatriptan 4mg Injection
(syringes/cartridges)
Sumatriptan Injection
(syringes/cartridges)
Sumatriptan Injection (vials)
Sumatriptan Tabs 25mg, 50mg and 100mg
Symbicort 80/4.5, 160/4.5 Inhaler
Symlin 0.6mg/ml
SymlinPen 60, 120 Pen Injector
Tamazepam (all strengths)
Tamiflu 30mg
Tamiflu 45mg
Tamiflu 75mg
Tamiflu for Oral Suspension, 25ml
Terazosin 1mg, 2mg and 5mg
Terazosin 10mg
Terbinafine 250mg
Terconazole 3
Terconazole 3 Cream 0.8%
Terconazole 7 Cream 0.4%
Tilade 16.2 grams
Tobi 300mg
Tramadol 50mg
Tramadol/APAP 37.5mg/325mg
Tramadol ER 100mg, 200mg and 300mg
Triazolam (all strengths)
Telstar LA 11.25mg Syringes
Venlafaxine 25mg, 37.5mg, 50mg and
75mg
Xolair 150mg/5ml single-use vial
Zaleplon 5mg
Zaleplon 10mg
20 Units (1 package)
64 Vials
68 Tabs
68 Tabs
34 Tabs
34 Tabs
68 Tabs
1 Vial per 28 Days
2 Vials per 28 Days
68 Tabs
55 Tabs
35 Caps
140 Caps
102 Caps
68 Tabs
34 Tabs
68 Tabs
68 Tabs
45 Tabs
34 Tabs
1 Package
2 Packages
1 Package
60 Tabs
60 Tabs
30 Tabs
1 Kit (2 Syringes)
1 Kit (2 Syringes)
2 Vials
9 Tabs
2 Inhalers
7 Vials
8 Pens
68 Tabs (60mg max dose)
20 Caps per 180 Days
10 Caps per 180 Days
10 Caps per 180 Days
2 Bottles per 180 Days
34 Caps
68 Caps
90 Tabs per 365 Days
3 (1 Box)
1 Tube (of the 20 gram)
1 Tube (of the 45 gram)
3 Inhalers
56 Ampules
272 Tabs
272 Tabs
34 Tabs
34 Tabs (0.5mg max dose)
1 Package
102 Tabs
6 vials per 28 Days
34 Tabs
68 Tabs
Zoladex 10.8mg Implant Syringe
Zolpidem Tartrate 5mg and 10mg
Zolpidem Tartrate ER 6.25mg
Zomig/Zomig-ZMT 5mg
Zomig Nasal Spray 5mg
Zomig/Zomig-ZMT 2.5mg
1 Package per 90 Days
34 Tabs
34 Tabs
6 Tabs
6 Nasal Spray Devices
6 Tabs
†Quantities as shown are per a 34-day supply and mail order quantities are triple the amount shown unless otherwise
indicated. Quantity limits work in conjunction with refill to soon edit (ex. member receives medication with the identified
enforced ratio on a per prescription basis).