Drug Quantity Limits List ()
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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 Express Scripts, the company chosen to manage our prescription drug benefit. The following limits are based on a 34-day supply, but our benefit may provide a different supply. For instance, you may be able to get a 90-day supply of your medication through mail order service. 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. Drug Quantity Limits Name of Prescription Drug Actonel 35 mg Actonel 5 and 30 mg Actonel with Calcium tablets Actoplus Met 15/500mg and 15/850mg Actos 15, 30, 45 mg Advair Diskus 100/50, 250/50, and 500/50 with device Advair HFA Aerobid/Aerobid-M 7 grams Aerospan 80mcg 8.9 gram Aerospan 80mcg 5.1 gram Albuterol generic inhaler/HFA Allegra 180 mg Allegra 30, 60mg Allegra-D 12 hour Allegra-D 24 hour Alora Alupent 14 grams Ambien 5, 10 mg Maximum Quantity 5 tablets 34 tablets 35 Tablets 102 tablets 34 tablets 28, 120 blisters 2 inhalers 3 inhalers 3 inhalers 1 inhaler 3 inhalers 34 tablets 68 tablets 68 tablets 34 tablets 10 patches 3 inhalers 34 tablets Name of Prescription Drug Ambien CR 6.25mg and 12.5mg Amerge 1, 2.5 mg Anzemet 50, 100 mg Arava 10 mg, 20 mg Asmanex 14 inhalation units Asmanex 30, 60, 120 inhalation units Astelin Nasal Spray (34 ml bottle) Atrovent HFA 12.9 grams Atrovent inhaler 14.7 grams Atrovent nasal spray 0.03% (30 grams) Atrovent nasal spray 0.06% (15 grams) Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000 Avandaryl 4mg/1mg Avandaryl 4mg/2mg Avandaryl 4mg/4mg Avandia 2, 4 mg Avandia 8 mg Avonex Axert 6.25 mg Axert 12.5 mg Azithromycin Azithromycin 500mg Azmacort 20 grams Beconase AQ 25 grams Betaseron Boniva 2.5 mg Boniva 150 mg Butorphanol tartrate Nasal Spray Byetta 1.2 ml (250 mcg/ml) Byetta 2.4 ml (250 mcg/ml) Cabergoline 0.5mg Catapres-TTS Patches Caverject Chorionic gonadotropin 5000,10000 units, generic Cialis 5, 10, and 20 mg Clarinex/Clarinex Reditabs 5 mg Clarinex 2.5mg Reditabs Clarinex-D 12 hour Clarinex-D 24 hour Claritin 10 mg/Claritin Reditabs 10 mg Claritin-D 12 Hour Claritin-D 24 Hour Maximum Quantity 34 tablets 9 tablets 1 tablet 34 tablets 1 inhaler 2 inhalers 2 bottles 2 inhalers 3 inhalers 2 bottles 1 bottle 68 tablets 68 tablets 68 tablets 34 tablets 68 tablets 34 tablets 4 syringes 6 tablets 12 tablets See Zithromax 4 tablets 3 inhalers 2 inhalers 15 vials with prefilled diluent syringe 34 tablets 1 tablet 2 spray bottles 2 syringes 2 syringes 10 tablets 5 patches 12 vials, kits, or ampules 3 vials 6 tablets 34 tablets 34 tablets 68 tablets 34 tablets 34 tablets 68 tablets 34 tablets Name of Prescription Drug Climara, Climara Pro Combivent 14.7 grams Copaxone 20 mg kit Cordran Tape Crestor 40 mg Depo-Provera Contraceptive Injection 150 mg/mL Depo-Sub Q Provera 104 Diflucan 150 mg Ditropan XL 5 mg Dostinex 0.5 mg Duetact 30/2mg and 30/4mg Duoneb 3 ml vial Edex Emend 125 mg Emend 40mg capsule Emend 80 mg Emend Trifold Pack (one 125 mg and two 80 mg capsules) Enbrel 25mg vials Enbrel 50mg syringe/auto injectors EpiPen, EpiPen Jr. Esclim Estraderm Estradiol transdermal patch Estrasorb Estrogel Factive 320mg Famvir 125 mg Famvir 250 mg Famvir 500 mg Fexofenadine Flonase 16 grams Flovent HFA 44mcg Flovent HFA 110mcg Flovent HFA 220mcg Fluconazole 150mg Flunisolide 0.025% Fluticasone Nasal Spray Foradil Aerolizer & 12 capsules in blisters Foradil Aerolizer & 60 capsules in blisters Fosamax 35 and 70 mg Maximum Quantity 5 patches 3 inhalers 1 kit (30 prefilled syringes) 2 rolls of tape 34 tablets 1 vial/syringe 1 syringe 2 tablets 34 tablets 10 tablets 34 tablets 205 vials (package size 3) 12 vials or kits 1 capsule 1 capsule 2 capsules 1 pack (package size 3) 10 vials 5 syringes/auto injectors 3 units or 2 twin packs 10 patches 10 patches 5 patches 68 packets 1 pump bottle 7 tablets 21 tablets 68 tablets 21 tablets See Allegra 2 bottles 2 inhalers 1 inhaler 3 inhalers 2 tablets 3 inhalers/bottles 2 sprays 1 package (package size 12) 12 caps 2 packages (package size 60) 120 caps 5 tablets Name of Prescription Drug Fosamax 5, 10, and 40 mg Fosamax 70 mg/75 mL oral solution Fosamax Plus D 70 mg/2800 IU Frova 2.5 mg Humira 40mg syringe/pen IB Stat oral spray 30 mL Imitrex Injection (syringes/cartridges) Imitrex 4mg injection (syringes/cartridges) Imitrex Injection (vials) Imitrex Nasal Spray 5, 20 mg Imitrex tablets 25, 50, and 100 mg Intal Inhaler 112 Intal Inhaler 200 Itraconazole 100mg Januvia 25mg, 50mg, 100mg Ketoralac 10 mg Kytril 1 mg Kytril solution 2 mg/10 mL Levitra 2.5, 5, 10, and 20 mg Lioresal Inthrathecal Refill Kit 1 ampule 10 mg/20 ml 2 ampules 10 mg/5 ml 1 ampule 40 mg/20 ml Lunesta 1mg, 2mg, 3mg Maxair Autohaler 14 grams Maxalt and Maxalt-MLT 5, 10 mg Menostar Miconazole Migranal 4 mg/ml Mobic 7.5 mg Monistat 1 pre-filled Monistat 3 combination pack 200 mg & equivalent Monistat 3 suppositories 200 mg & equivalent Monistat 7 combination pack & equivalent Monistat 7 cream and equivalent Monistat 7 cream pre-filled applicators Monistat 7 suppositories 100 mg & equivalent Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) Muse Maximum Quantity 34 tablets 5 bottles 5 tablets 9 tablets 3 syringes/pen 14 bottles 1 kit (2 syringes) 1 kit (2 syringes) 2 vials 6 nasal spray devices 9 tablets 2 inhalers 2 inhalers 34 capsules 34 tablets 20 tablets 2 tablets 1 bottle 6 tablets 1 kit 34 tablets 2 inhalers 9 tablets 5 patches See Monistat 8 spray devices 34 tablets 1 box 1 box 3 (1 box) 1 box (7 suppositories, 9 gram cream) 45 grams (1 tube) 7 applicators 7 suppositories (1 box) 1 (1 box) 1 (1 box) 12 urethral suppositories Name of Prescription Drug Nasacort 10 gram Nasacort AQ 16.5 gram Nasarel 0.025% 25 mL Nasonex 50 mcg nasal spray 17 gram NebuPent 300 mg/container Neumega Newtek disposable blood glucose meter Nexium 20 mg Noverel 10,000 unit Omeprazole 10 mg Ondansetron 24 mg Ondansetron, Ondansetron ODT 4 and 8 mg Ondansetron solution 4 mg/5 mL PEG Intron Pens 50 mcg, 80 mcg, 120 mcg, 150 mcg Pegasys 180 mcg Pegasys 180 mcg Convenience Pack ( 4 vials) Pegasys 180 mcg Convenience Pack (4 prefilled syringes) Plan B Pregnyl 10,000 unit Prevacid 15 mg, Prevacid SoluTab Preven Contraceptive Kit Prevpak patient pack Prilosec 10 mg Prilosec 20 mg (Brand) Protonix 20 mg Proventil Inhaler 17 gram Proventil HFA 6.7 gram Pulmicort Respules 0.25 mg/2 mL and 0.5 mg/2 mL Pulmicort Turbuhaler Qvar 40, 80mcg (7.3 grams) Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak Rebif 22 mcg and 44 mcg Rebif Titration Pack 4.2ml Regranex 0.01%gel 2, 7.5, and 15 gm Relenza 5 mg/blister with inhalation device Relpax 20 mg and 40 mg Restasis 0.05% Revatio 20mg Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle Rozerem 8mg Serevent Diskus 28 blisters Maximum Quantity 3 inhalers 2 bottles 3 bottles 2 bottles 1 container (inhaler) 21 vials 2 meters 34 capsules 3 vials 34 capsules 1 tablet 12 tablets 3 - 50 mL bottles 5 pens 5 vials (package size 1) 1 box (package size 1) 1 box (package size 1) 2 tablets 3 vials 34 capsules or tablets 1 kit 14 units (1 package) 34 capsules 34 capsules 34 tablets 3 inhalers 3 inhalers 70 ampules 2 inhalers 3 inhalers 2 packages 15 syringes 1 package 1 tube 20 blisters 6 tablets 68 vials 102 tablets 3 bottles 34 tablets 1 package Name of Prescription Drug Serevent Diskus 60 blisters Sonata 10 mg Sonata 5 mg Spiriva Handihaler 6 capsules (1 blister card) with inhaler device Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device Sporanox 100 mg Stadol Nasal Spray 2.5 mL Suboxone 2/.0.5 mg Suboxone 8/2 mg Symlin 0.6mg/ml Tamiflu 75 mg Tamiflu for oral suspension, 25 mL Terazol 3 Terazol 3 Cream 0.8% Terazol 7 Cream 0.4% Terconazole Tilade 16.2 grams TOBI 300 mg Toradol 10 mg Twinject 0.3mg or 0.15mg Auto-Injector Valtrex 1 gram Valtrex 500 mg Ventolin HFA 90 mcg (18 grams) Viagra 25 mg, 50 mg, and 100 mg Vivelle Vivelle-Dot Xopenex HFA Zazole Cream 0.4% Zazole Cream 0.8% Zazole 80mg Vaginal Supp Zegerid 20 mg Zithromax for oral suspension 100 mg/5 mL, 15 ml bottle Zithromax for oral suspension 200 mg/5 mL, 15 and 22.5 ml bottle Zithromax for oral suspension 200 mg/5 mL, 30 ml bottle Zithromax tablet or capsule, 250 mg Zithromax tablet, 500 mg Zmax 60 ml Zofran 24 mg Maximum Quantity 2 packages 68 capsules 34 capsules 1 package 2 packages 34 capsules 2 spray bottles 102 tablets 102 tablets 7 vials 10 capsules 3 bottles 3 (1 box) 1 tube (of the 20 gram) 1 tube (of the 45 gram) See Terazol or Zazole 3 inhalers 56 ampules 20 tablets 3 units or 2 twin packs 34 caplets (tablets) 34 caplets (tablets) 3 inhalers 6 tablets 10 patches 10 patches 3 canisters 1 pack (45 gram) 1 pack (20 gram) 3 (1 box) 34 tablets 2 bottles 3 bottles 3 bottles 8 tablets/capsules 4 tablets 1 bottle 1 tablet Name of Prescription Drug Zofran, Zofran ODT 4 and 8 mg Zofran solution 4 mg/5 mL Zomig/Zomig-ZMT 5 mg Zomig Nasal Spray 5 mg Zomig/Zomig-ZMT 2.5 mg Zyrtec, Zyrtec chewable 5 and 10 mg Zyrtec-D 12 Hour Maximum Quantity 12 tablets 3 - 50 mL bottles 6 tablets 6 nasal spray devices 6 tablets 34 tablets 68 tablets
