Some medications have specific limits for each prescription or
refill to ensure you receive the
recommended and appropriate dose and length of therapy.
The PEHP Pharmacy and Therapeutics Committee establishes
quantity levels based on criteria
that include: manufacturers; recommended maximum dosage, duration of
therapy, FDA
guidelines, PEHP Master Policy, and cost.
Pre-authorization is required for any quantity that exceeds a
PEHP quantity level limit. PEHP
may require an additional co-payment if pre-authorization is granted.
| Drug name |
Quantity Level |
|
R = Retail, M = Mail
AS = Accredo Specialty, ME = Medical |
| ACANYA GEL |
R: 50 ML PER 30 DAYS
M: 150 ML PER 90 DAYS |
| ACARBOSE 100MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| ACARBOSE 25 MG |
R: 270 UNITS PER 30 DAYS.
M: 810 UNITS PER 90 DAYS |
| ACARBOSE 50 MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| ACE AEROSOL CLOUD ENHANCER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| ACEON |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| ACIPHEX 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| ACTIQ |
R: 120 UNITS PER 30 DAYS.
M: 120 UNITS PER 30 DAYS. |
| ACTONEL 150 MG |
R: 1 UNIT PER 30 DAYS.
M: 3 UNITS PER 90 DAYS |
| ACTONEL 30 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ACTONEL 35 MG |
R: 4 UNITS PER 30 DAYS.
M: 12 UNITS PER 90 DAYS |
| ACTONEL 5 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ACTONEL 5MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ACTONEL 75 MG |
R: 2 UNITS PER 30 DAYS.
M: 6 UNITS PER 90 DAYS. |
| ACTONEL D 35MG/500 |
R: 1 PACKAGE PER 30 DAYS
M: 3 PACKAGES PER 90 DAYS |
| ACTOPLUS MET |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| ACTOS |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ACUVAIL |
R; 60 UNITS IN 180 DAYS |
| ACZONE |
R: 30 GMS PER 30 DAYS.
M: 90 GMS PER 90 DAYS |
| ADVAIR DISKUS 28 PACKAGE |
R: 56 UNITS PER 28 DAYS
M: 168 PER 84 DAYS |
| ADVAIR DISKUS 60 PACKAGE |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| ADVAIR HFA INHALER 12 GM |
R: 1 INHALER PER 30 DAYS
M: 3 INHALERS PER 90 DAYS |
| ADVICOR |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| AEROCHAMBER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| AEROTRACH PLUS |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| AFINITOR 5 MG |
SA: 90 UNITS PER 30 DAYS |
| AFINOTOR 10 MG |
SA: 60 UNITS PER 30 DAYS |
| AGGRENOX |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| ALA-HIST AC |
R: 240 ML PER SCRIPT |
| ALA-HIST D TABS |
R: 28 UNITS PER SCRIPT |
| ALA-HIST DM |
R: 240 ML PER SCRIPT |
| ALAHIST LQ LIQUID |
R: 240 ML PER 30 DAYS |
| ALA-HIST TABS |
R: 28 UNITS PER SCRIPT |
| ALCET |
R: 240 PER SCRIPT |
| ALDARA CREAM 0.25 GM PACKET |
R: 24 PACKETS PER 30 DAYS
M: 72 PACKETS PER 90 DAYS |
| ALENDRONATE 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ALENDRONATE 35 MG |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| ALENDRONATE 40 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ALENDRONATE 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ALENDRONATE 70 MG |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| ALOQUIN GEL |
R: 60 ML PER SCRIPT |
| ALTACE 1.25 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ALTACE 10MG |
R:60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| ALTACE 2.5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ALTACE 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ALTOPREV |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| AMBIEN 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| AMBIEN 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| AMBIEN CR 12.5 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| AMBIEN CR 6.25 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| AMERGE |
R: 9 TABLETS PER 30 DAYS:
M: 27 TABLETS PER 30 DAYS. |
| AMEVIVE |
SA: 60 MG PER 30 DAYS |
| AMITIZA CAPS |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| AMLODIPINE 10 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| AMLODIPINE 2.5 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS |
| AMLODIPINE 5 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS |
| ANDRODERM 2.5MG/24 |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| ANDRODERM 5MG/24H |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ANDROGEL 2.5 GM |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ANDROGEL 5 GM |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| ANDROGEL PUMP |
R: 300 GMS PER 30 DAYS.
M: 900 GMS PER 90 DAYS. |
| ANZEMET 100 MG |
R: 10 TABLETS PER 30 DAYS.
M: 30 TABLETS PER 90 DAYS |
| ANZEMET 12.5 MG/0.625ML CARTRIDGE |
R: 10 CARTRIDGES OR 6.25 ML PER 30 DAYS |
| ANZEMET 20MG/ML VIAL |
R: 1000 MG PER 30 DAYS. |
| ANZEMET 50 MG |
R: 10 TABLETS PER 30 DAYS.
M: 30 TABLETS PER 90 DAYS |
| APHTHASOL PASTE 5% |
R: 5 GRAM PER SCRIPT |
| APOKYN |
SA: 15 ML PER 30 DAYS |
| ARAVA 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ARAVA 20 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ARIXTRA 10 MG |
R: 23 ML PER 90 DAYS (7.5 MG PER 0.5ML)
SA: 23 ML PER 90 DAYS |
| ARIXTRA 2.5 MG |
R: 14 ML PER 90 DAYS (2.5 MG PER 0.5ML)
SA: 14 ML PER 90 DAYS |
| ARIXTRA 5 MG |
R: 12 ML PER 90 DAYS (5 MG PER 0.4 ML)
SA: 12 ML PER 90 DAYS |
| ARIXTRA 7.5 MG |
R: 17 ML PER 90 DAYS (7.5 MG PER 0.6ML)
SA: 17 ML PER 90 DAYS |
| ARMIDEX |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ASMANEX |
R: ONE THIRTY ACTUATION UNIT PER 30 DAYS.
M: THREE THIRTY ACTUATION UNITS PER 90 DAYS. |
| ASTHMA CONTROL |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| ATACAND |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ATACAND HCTZ |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| AURALGAN OTIC DROP |
R: 14 ML PER SCRIPT |
| AVALIDE |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| AVANDAMET 2MG/1000MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDAMET 2MG/500MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| AVANDAMET 4MG/1000MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDAMET 4MG/500MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDARYL 4MG/2MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDARYL 4MG/4MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDARYL 8MG/4MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| AVANDIA 2 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDIA 4 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| AVANDIA 8 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| AVAPRO |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| AVELOX TABLET |
R: 21 UNITS PER SCRIPT |
| AVINZA 120 MG |
R: 60 UNITS PER 30 DAYS |
| AVINZA 30 MG |
R: 30 UNITS PER 30 DAYS |
| AVINZA 45 MG |
R: 30 UNITS PER 30 DAYS |
| AVINZA 60 MG |
R: 30 UNITS PER 30 DAYS |
| AVINZA 75 MG |
R: 60 UNITS PER 30 DAYS |
| AVINZA 90 MG |
R: 60 UNITS PER 30 DAYS |
| AVONEX |
SA: 4 SYRINGES PER 30 DAYS |
| AXERT |
R: 12 TABLETS PER 30 DAYS.
M: 36 TABLETS PER 90 DAYS |
| AZOR |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| BANZEL 200 MG |
R: 480 UNITS PER 30 DAYS
M: 1440 UNITS PER 90 DAYS |
| BANZEL 400 MG |
R: 240 UNITS PER 30 DAYS
M: 720 UNITS PER 90 DAYS |
| BENICAR 20 MG, 40 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| BENICAR 5 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| BENICAR HCTZ |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| BENZAC AC 2.5% WASH |
R: 480 ML PER SCRIPT
M:1440 ML PER 90 DAYS
|
| BENZAC AC 5% LIQUID |
R: 480 ML PER SCRIPT
M:1440 ML PER 90 DAYS
|
| BENZAC W WASH 5% LIQUID |
R: 480 ML PER SCRIPT
M:1440 ML PER 90 DAYS
|
| BENZACLIN CAREKIT |
R: 1 KIT PER 30 DAYS.
M: 3 KITS PER 90 DAYS |
| BEPREVE OPTH SOL |
R: 10 ML PER 30 DAYS
M: 30 ML PER 90 DAYS |
| BETASERON |
SA: 15 SYRINGES PER 30 DAYS |
| BONIVA 150 MG |
R: 1 UNIT PER 30 DAYS
M: 3 UNITS PER 90 DAYS |
| BONIVA 2.5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| BONIVA IV |
ME: 3 UNITS (3MG) PER CLAIM |
| BP8 COUGH SUSPENSION |
R: 240 ML PER SCRIPT |
| BREATHRITE |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| BREEZE PADS KIT |
R: 62 PADS PER 30 DAYS
M: 186 PADS PER 90 DAYS |
| BROVANA |
R: 120 ML (900 MCG) PER 30 DAYS
ME: 2 UNITS (30 MCG) PER CLAIM/DAY |
| BUDEPRION XL |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| BUPROPION SR 100 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| BUPROPION SR 150 MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| BUPROPION SR 200 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| BUPROPION XL |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| BUTORPHANOL AEROSAL NASAL |
R: 10 ML PER 30 DAYS.
M: 30 ML PER 90 DAYS.
WILL CHANGE TO ON 9/1/2009:
R: 5 ML PER 30 DAYS.
M: 15 ML PER 90 DAYS
|
| B-VEX D SUSPENSION |
R: 240 ML PER SCRIPT |
| BYETTA 10 MCG |
R: ONE SYRINGE PER 30 DAYS.
M: THREE SYRINGES PER 90 DAYS |
| BYETTA 5 MCG |
R: ONE SYRINGE PER 30 DAYS.
M: THREE SYRINGES PER 90 DAYS
|
| BYSTOLIC 10MG |
R: 90 UNITS PER 30 DAYS
M: 270 PER 90 DAYS |
| BYSTOLIC 2.5 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| BYSTOLIC 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| BYSTOLIC 5 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| CADUET |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| CARAC |
60 GMS IN 180 DAYS |
| CATAPRESS TTS |
R: 4 PATCHES PER 30 DAYS
M: 12 PATCHES PER 90 DAYS |
| CELEBREX 400 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| CELEBREX 50 MG, 100 MG, 200 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| CELEXA 10 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| CELEXA 20 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS |
| CELEXA 40 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS. |
| CESAMET |
R: 30 CAPSULES PER 30 DAYS. |
| CGU WC LIQUID |
R: 240 ML PER SCRIPT |
| CHANTIX |
R: 60 UNITS PER 30 DAYS. |
| CITALOPRAM 10 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| CITALOPRAM 20 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS |
| CITALOPRAM 40 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS. |
| CLEANSE AND TREAT PADS |
R: 60 PADS PER 30 DAYS
M: 180 PADS PER 90 DAYS |
| CLIMARA |
R: 4 PATCHES PER 30 DAYS
M: 12 PATCHES PER 90 DAYS |
| CLIMARA PRO |
R: 4 PATCHES PER 30 DAYS
M: 12 PATCHES PER 90 DAYS |
| CLINDAMAX VAG 2% CRM 40 GM W/7 APL |
R: 40 GM OR 1 BOX PER SCRIPT |
| CLOMID |
R: 20 UNITS PER 30 DAYS |
| CLOMIPHENE |
R: 20 UNITS PER 30 DAYS |
| CLONIDINE PATCH |
R: 4 PATCHES PER 30 DAYS
M: 12 PATCHES PER 90 DAYS |
| COMBIGAN |
R: 10ML PER 30 DAYS
M: 30ML PER 90 DAYS |
| COPAXONE |
SA: 30 SYRINGES PER 30 DAYS |
| COPEGUS |
SA: 180 UNITS PER 30 DAYS. |
| COREG CR |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| COZAAR 100MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| COZAAR 25MG, 50MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| CRESTOR 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| CRESTOR 20 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| CRESTOR 40 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| CRESTOR 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| D.H.E. 45 1MG/ML INJECTION |
R: 12 AMPULES PER 30 DAYS |
| DALLERGY PE SYRUP |
240 ML PER SCRIPT |
| DALMANE 15 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| DALMANE 30 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| DDAVP NASAL SPRAY |
R: 20 ML PER 30 DAYS
M: 60 ML PER 90 DAYS |
| DEGARELIX |
SA: 120 MG PER 30 DAYS. |
| DELATESTRYL INJECTIBLE |
R: 10 ML PER 30 DAYS |
| DELESTROGEN INJ |
R: 5 ML PER 30 DAYS
M: 15 ML PER 90 DAYS |
| DEPO-ESTRADIOL |
R: 5 ML PER 30 DAYS.
M: 15 ML PER 90 DAYS. |
| DEPO-PROVERA INJ150MG/M |
R: 150 MG PER 90 DAYS |
| DEPO-SUBQ PROVERA INJ 104MG/0 |
R: 104 MG PER 90 DAYS |
| DEPOTESTOSTERONE INJECTIBLE |
R: 10 ML PER 30 DAYS |
| DESMOPRESSIN NASAL SPRAY |
R: 20 ML PER 30 DAYS
M: 60 ML PER 90 DAYS |
| DESQUAM X |
R: 480 ML PER SCRIPT
M:1440 ML PER 90 DAYS
|
| Dex Tuss Liquid |
R: 240 ML PER SCRIPT |
| DIASTAT |
R: 2 SYSTEMS OR 1 BOX PER SCRIPT |
| DIASTAT ACUDIAL |
R: 2 SYRINGES OR 1 PACKAGE PER SCRIPT |
| DIFFERIN GEL |
R: 45 GRAMS PER 30 DAYS
M: 135 GRAMS PER 90 DAYS. |
| DIFFERIN PAD |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| DIFFERIN SOLUTION |
R: 60 ML PER 30 DAYS.
M: 180 ML PER 90 DAYS |
| DIHYDROERGOTAMINE MESY 1MG/ML |
R: 12 VIALS PER 30 DAYS |
| DIOVAN 320MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| DIOVAN 40MG, 80MG, 160 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| DIOVAN HCT 320/12.5MG, 320/25MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| DIOVAN HCT 80/12.5MG, 160/12.5MG, 160/25MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| DONATUSSIN DM |
R: 240 ML PER SCRIPT |
| DORAL 15 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS. ALSO ONLY ALLOWS 60 DAY SUPPLY PER 90 DAYS. |
| DORAL 7.5 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS. ALSO ONLY ALLOWS 60 DAY SUPPLY PER 90 DAYS. |
| DORYX 150 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| DOXAZOSIN 4MG |
R: 270 UNITS PER 30 DAYS.
M: 810 UNITS PER 90 DAYS |
| DRONABINOL 10 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| DRONABINOL 2.5 MG |
R: 120 UNITS PER 30 DAYS.
M: 360 UNITS PER 90 DAYS. |
| DRONABINOL 5 MG |
R: 120 UNITS PER 30 DAYS.
M: 360 PER 90 DAYS |
| DUETACT |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| DUREZOL |
R: 5 ML PER SCRIPT |
| EASIVENT |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR.
|
| EFFIENT |
R: 30 UNTIS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| EFUDEX |
60 GMS IN 180 DAYS |
| ELIDEL |
R: 100 GM PER 30 DAYS.
M: 300 GMS PER 90 DAYS |
| ELLIPSE COMPACT SPACER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| EMBEDA |
R: 60 UNITS PER 30 DAYS |
| EMEND 125 MG |
R: 2 CAPSULES IN 30 DAYS.
M: 4 CAPSULES IN 90 DAYS |
| EMEND 40MG |
R: 1 CAPSULE IN 30 DAYS.
M: 2 CAPSULES IN 90 DAYS |
| EMEND 80 MG |
R: 8 CAPSULES IN 30 DAYS.
M: 16 CAPSULES IN 90 DAYS. |
| EMEND TRIFOLD PACK |
R: 2 PACKS (6 CAPS) IN 30 DAYS.
M: 4 PACKS (12 CAPS) IN 90 DAYS |
| ENBREL |
SA: 200 MG IN 23 DAYS |
| ENDOCET |
R: 240 UNITS PER SCRIPT |
| ENDACOF |
R: 240 ML PER SCRIPT |
| ENDODAN |
R: 240 UNITS PER SCRIPT |
| ENTOCORT HC |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| EPIPEN 0.3MG/0 |
R: 2 SYRINGES PER SCRIPT |
| EPIPEN JR 0.15MG |
R: 2 SYRINGES PER SCRIPT |
| EPI-PEN, JR |
R: 2 SYRINGES PER SCRIPT |
| EPLERENONE 25MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| EPLERONE 50 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| ESTAZOLAM 1 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| ESTAZOLAM 2 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| ESTRADERM |
R: 8 PATCHES PER 30 DAYS
M: 24 PATCHES PER 90 DAYS |
| ESTRADIOL VALERATE INJ |
R: 5 ML PER 30 DAYS
M: 15 ML PER 90 DAYS |
| ESTRADIOL/NORETH 1/0.5MG |
R: 28 UNITS PER 28 DAYS.
M: 84 UNITS PER 84 DAYS. |
| EUFLEXXA |
M: 2 UNITS (20 ML) PER CLAIM.
SA: 60 ML PER 30 DAYS. |
| EVISTA |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| EXECLEAR-C SYRUP |
R: 240 ML PER SCRIPT |
| EXELON CAPSULES |
R: 60 UNITS PER 30 DAYS M: 180 UNITS PER90 DAYS |
| EXELON PATCHES |
R: 30 UNITS PER 30 DAYS
M:90 UNTIS PER 90 DAYS |
| EXELON SOULTION |
R: 240 ML PER 30 DAYS
M: 600 ML PER 90 DAYS |
| EXFORGE |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| EXFORGE HCT 10/160/12.5 MG |
R: 30 UNITS PER 30 DAYS.
M: 80 UNITS PER 90 DAYS |
| EXFORGE HCT 10/160/25MG |
R: 30 UNITS PER 30 DAYS.
M: 80 UNITS PER 90 DAYS |
| EXFORGE HCT 10/320/25MG |
R: 30 UNITS PER 30 DAYS.
M: 80 UNITS PER 90 DAYS |
| EXFORGE HCT 5/160/12.5 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| EXFORGE HCT 5/160/25MG |
R: 30 UNITS PER 30 DAYS.
M: 80 UNITS PER 90 DAYS |
| EXJADE |
SA: 60 UNITS PER 30 DAYS |
| E-Z SPACER & MASK |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M:LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| FENOFIBRATE 145 MG, 160 MG, 67 MG, 134 MG, 200 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| FENOFIBRATE 54MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| FENTANYL CITRATE LOZENGE |
R: 120 UNITS PER 30 DAYS.
M: 120 UNITS PER 30 DAYS. |
| FENTORA 100 MCG |
R: 180 UNITS PER 30 DAYS. |
| FENTORA 200 MCG |
R: 180 UNITS PER 30 DAYS. |
| FENTORA 800MCG, 600 MCG, 400 MCG 300 MCG |
R: 180 UNITS PER 30 DAYS. |
| FINASTERIDE |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| FLOMAX |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| FLOUROURACIL |
R: 2 PACKAGES PER 180 DAYS.
M: 2 PACKAGES PER 180 DAYS |
| FLOVENT, HFA |
R: 2 INHALERS PER 30 DAYS.
M: 6 INHALERS PER 90 DAYS |
| FLUOROPLEX |
R: 2 PACKAGES PER 180 DAYS.
M: 2 PACKAGES PER 180 DAYS |
| FLUOROURACIL |
R: 2 PACKAGES PER 180 DAYS.
M: 2 PACKAGES PER 180 DAYS |
| FLUOXETINE 10 MG CAPSULE |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| FLURAZEPAM 15 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| FLURAZEPAM 30 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| FORTEO |
SA: 3ML OR 1 PEN PER 28 DAYS |
| FOSAMAX 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| FOSAMAX 35 MG |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| FOSAMAX 40 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| FOSAMAX 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| FOSAMAX 70MG |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| FOSAMAX 70MG/75 ML SOLUTION |
R: 4 BOTTLES PER 30 DAYS.
M: 12 BOTTLES PER 90 DAYS |
| FOSAMAX D 70MG/2800 |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| FOSAMAX D 70MG/5600 |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| FRAGMIN |
R:28 SYRINGES PER SCRIPT
SA: 28 SYRINGES PER SCRIPT |
| FROVA |
R: 9 TABLETS PER 30 DAYS:
M: 27 TABLETS PER 30 DAYS. |
| GLEEVEC 100MG |
SA: 90 UNITS PER 30 DAYS |
| GLEEVEC 400MG |
SA:60 UNITS PER 30 DAYS. |
| GLUCAGON 1MG |
R: 2 SYRINGES PER SCRIPT |
| GLUCAGON EMERGENCY KIT 1MG |
R: 2 SYRINGES PER SCRIPT |
| GLUCOPHAGE 500MG |
R: 150 UNITS PER 30 DAYS
M: 450 UNITS PER 90 DAYS |
| GLUCOPHAGE XL 750MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| GLUMETZA 1000 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| GLUMETZA 500 MG |
R: 150 UNITS PER 30 DAYS
M: 450 UNITS PER 90 DAYS |
| GRANISETRON INJECTION |
R: 14ML PER 30 DAYS. |
| GRANISETRON TABLET |
R: 14 TABLETS PER 30 DAYS.
M: 42 TABLETS PER 90 DAYS. |
| HALCION 0.125 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| HALCION 0.25 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| HEPSERA |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| HUMIRA |
SA: 2 SYRINGES PER 30 DAYS.
|
| HYLIRA GEL |
R: 680 GM PER SCRIPT.
M: 2040 GM PER SCRIPT |
| HYLIRA LOTION |
R: 1000 GM PER SCRIPT
M: 3000 GM PER SCRIPT |
| HYZAAR 100MG/12.5MG, 100MG/25MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| HYZAAR 50/12.5MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| IBUDONE |
R: 240 UNITS PER 30 DAYS |
| IMITREX 25MG, 50 MG, 100MG |
R: 9 TABLETS PER 30 DAYS:
M: 27 TABLETS PER 90 DAYS. |
| IMITREX INJECTION |
R: 2 KITS (4 SYRINGES) PER 30 DAYS.
M: 6 KITS (12 SYRINGES) PER 90 DAYS. |
| IMITREX NASAL SPRAY |
R: 12 PER 30 DAYS.
M: 36 PER 90 DAYS |
| INHALER COMPANIONS |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| INSPIREASE |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| INSPRA 25 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| INSPRA 50 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| INTELENCE |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 30 DAYS |
| INVEGA 3 MG, 9 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| INVEGA 6 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| INVEGA SUSTENNA PFL SSYR 39 MG |
R: 1 SYRINGE PER 30 DAYS |
| INVEGA SUSTENNA PFL SSYR 78 MG |
R: 1 SYRINGE PER 30 DAYS |
| INVEGA SUSTENNA PFL SSYR 117 MG |
R: 1 SYRINGE PER 30 DAYS |
| INVEGA SUSTENNA PFL SSYR 156 MG |
R: 1 SYRINGE PER 30 DAYS |
| INVEGA SUSTENNA PFL SSYR 234 MG |
R: 1 SYRINGE PER 30 DAYS |
| ISENTRESS |
R: 120 UNITS PER 30 DAYS.
M: 360 PER 90 DAYS |
| ISTALOL EYE DROP |
R: 10 ML PER 30 DAYS
M: 30 ML PER 30 DAYS |
| ITRACONAZOLE 100 MG |
R: 120 UNITS PER 30 DAYS |
| JANUMET |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| JANUVIA |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| KEPPRA XR |
R: 180 UNITS PER 30 DAYS.
M: 540 UNITS PER 90 DAYS. |
| KERAFOAM FOAM |
NO QUANTITY LIMIT |
| KERALYT SCALP COMPLETE KIT |
R: 1 KIT PER 30 DAYS
M: 3 KITS PER 90 DAYS |
| KETOROLAC 15MG, 30 MG INJECTION |
R: 20 SYRINGES PER SCRIPT |
| KETOROLAC 60 MG INJ |
R: 2 SYRINGES PER SCRIPT |
| KINERET |
SA: 30 UNITS PER 30 DAYS |
| KYTRIL INJECTION |
R: 14ML PER 30 DAYS. |
| KYTRIL SOLUTION |
R: 60 ML PER 30 DAYS. |
| KYTRIL TABLET |
R: 14 TABLETS PER 30 DAYS.
M: 42 TABLETS PER 90 DAYS. |
| LAMISIL 125 MG GRANULE |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. (HAS A MEDCO 12 WEEK MAXIMUM SUPPLY). |
| LAMISIL 187.5 GRANULE |
R: 30 UNITS PER 30 DAYS (HAS A MEDCO 12 WEEK MAXIMUM SUPPLY RULE). |
| LAMISIL 250 MG |
R: 30 UNITS PER 30 DAYS (HAS A MEDCO 12 WEEK MAXIMUM SUPPLY RULE). |
| LEFLUNOMIDE 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LEFLUNOMIDE 10MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LEFLUNOMIDE 20 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LESCOL |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| LESCOL XL |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| LETAIRIS |
SA: 30 UNITS PER 30 DAYS |
| LEVAQUIN TABLET |
R: 14 UNITS PER SCRIPT |
| LEXAPRO 10 MG |
R: 45 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| LEXAPRO 5MG, 20 MG TABLET |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LEXUSS 210 LIQUID |
R: 240 ML PER SCRIPT |
| LIDODERM |
R: 90 PATCHES PER 30 DAYS.
M: 270 PATCHES PER 90 DAYS. |
| LIPITOR 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LIPITOR 20 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LIPITOR 40 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LIPITOR 80 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| LOTRONEX |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| LOVASTATIN |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| LOVAZA |
R: 120 PER 30 DAYS.
M: 360 PER 90 DAYS |
| LUCENTIS |
SA: 2 VIALS PER 30 DAYS
ME: 10 UNITS PER CLAIM |
| LUNESTA 1 MG, 2 MG, 3 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| LUPRON DEPOT 3.75 MG, 11.25 MG |
ME: J1950 (12 UNITS PER DOSE [45 MG]).
SA: NONE |
| LUPRON DEPOT 7.5 MG, 15 MG, 22.5 MG, 30 MG |
ME: J9217 (6 UNITS PER DOSE [45 MG]).
SA: NONE |
| LUVOX CR 100MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| LUVOX CR 150MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| LYNOX |
R: 240 PER SCRIPT |
| LYRICA 225 MG, 300MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| LYRICA 25 MG, 50 MG, 75 MG, 100 MG, 150 MG, 200 MG. |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| MAGNACET |
R: 240 UNITS PER SCRIPT |
| MARINOL 10 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| MARINOL 2.5 MG |
R: 120 UNITS PER 30 DAYS.
M: 360 UNITS PER 90 DAYS. |
| MARINOL 5 MG |
R: 120 UNITS PER 30 DAYS.
M: 360 PER 90 DAYS |
| MAXALT |
R: 12 TABLETS PER 30 DAYS.
M: 36 TABLETS PER 90 DAYS |
| MEDROXYPROGESTERONE AC 150MG/M IM |
R: 150 MG PER 90 DAYS
M: 150 MG PER 90 DAYS |
| M-END WC LIQUID |
R: 240CC PER SCRIPT
M: 240 CC PER SCRIPT |
| METFORMIN 500MG |
R: 150 UNITS PER 30 DAYS
M: 450 UNITS PER 90 DAYS |
| METFORMIN ER 750 MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| MEVACOR |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| MICARDIS |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| MICARDIS HCT |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| MICROSPACER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| MIGRANAL |
R: 8 AMPULES PER 30 DAYS.
M: 24 AMPULES PER 90 DAYS |
| MIRTAZAPINE |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| MOUTHPEICE |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| NALEX AC SYRUP |
R: 240 ML PER SCRIPT |
| NAMENDA |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| NARVOX |
R:240 PER SCRIPT |
| NASONEX |
R: 17 GM PER 30 DAYS
M: 51 GM PER 90 DAYS |
| NEO DM SYRUP |
R: 240 ML PER SCRIPT |
| NEOBENZ MICRO CREAM PLUS 5.5% |
R: 480ML PER 30 DAYS
M: 1440ML PER 90 DAYS |
| NEOBENZ MICRO WASH PLUS 7%/5.5% |
R: 480ML PER 30 DAYS
M: 1440ML PER 90 DAYS |
| NEOBENZ MICRO WASH, PLUS |
R: 480 ML PER 30 DAYS
M: 1440 ML PER 90 DAYS |
| NEUMEGA |
SA: 2100 MG (42 VIALS) PER 30 DAYS
ME: 2 UNITS (10MG) PER CLAIM |
| NEXAVAR |
SA: 120 UNITS PER 30 DAYS |
| NEXIUM 10 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| NEXIUM 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| NEXIUM 40 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| NEXIUM POWDER PACKETS 10 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| NICOTROL INHALER |
R: 480 CARTRIDGES PER 30 DAYS |
| NICOTROL NASAL SPRAY |
R: 12 CANISTERS PER 30 DAYS |
| NISOLDIPINE ER 20 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| NISOLDIPINE ER 30 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| NISOLDIPINE ER 40 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| NITROLINGUAL PUMP DUOPK 16.9 GM 0. 4MG |
R: 1 PACKAGE PER SCRIPT |
| NORVASC 10 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| NORVASC 2.5 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS |
| NORVASC 5 MG |
R: 45 UNITS PER 30 DAYS.
M: 135 UNITS PER 90 DAYS |
| NOTUSS AC LIQUID |
R: 240 ML PER SCRIPT |
| NOXAFIL |
R: 460 ML PER 30 DAYS |
| NUCORT LOTION |
R: 120 ML PER 30 DAYS.
M: 360 ML PER 90 DAYS |
| NUVIGIL 150MG, 250 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| NUVIGIL 50 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| OCELLA |
R: 56 UNITS PER 28 DAYS
M: 112 UNITS PER 84 DAYS |
| OMEPRAZOLE 10 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| OMEPRAZOLE 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| OMEPRAZOLE 40 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ONDANSETRON 24 MG |
R: 2 TABLETS PER 30 DAYS. |
| ONDANSETRON 4MG, 8MG |
R: 30 TABLETS PER 30 DAYS:
M: 120 TABLETS PER 90 DAYS. |
| ONDANSETRON 4MG/2ML INJECTION |
R: 120ML PER 30 DAYS. |
| ONDANSETRON 4MG/5ML SOLUTION |
R: 300ML PER 30 DAYS
M: 900ML PER 90 DAYS |
| ONGLYZA |
R: 30 UNITS PER 30 DAYS
M:90 UNTIS PER 90 DAYS |
| ONSOLIS |
R: 120 UNITS PER 30 DAYS |
| OPANA 10 MG |
R: 540 UNITS PER 30 DAYS. |
| OPANA 5 MG |
R: 180 UNITS PER 30 DAYS. |
| OPANA ER 10 MG |
R: 60 UNITS PER 30 DAYS
|
| OPANA ER 15MG |
R: 60 UNITS PER 30 DAYS
|
| OPANA ER 20 MG |
R: 60 UNITS PER 30 DAYS
|
| OPANA ER 30 MG |
R: 60 UNITS PER 30 DAYS
|
| OPANA ER 40 MG |
R: 60 UNITS PER 30 DAYS
|
| OPANA ER 5 MG |
R: 60 UNITS PER 30 DAYS
|
| OPANA ER 7.5 MG |
R: 60 UNITS PER 30 DAYS
|
| OPTASE GEL |
R: 190 GMS PER SCRIPT |
| OPTICHAMBER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| OPTIHALER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| ORENCIA |
SA: NONE
ME: 100 UNITS (1000MG) PER CLAIM |
| OVACE PLUS WASH 10% |
R: 340 ML PER 30 DAYS
M: 1020 ML PER 90 DAYS |
| OXYCODONE 10MG |
R: 240 UNITS PER SCRIPT
M: 240 UNITS PER SCRIPT |
| OXYCODONE 20MG |
R: 240 UNITS PER SCRIPT
M: 240 UNITS PER SCRIPT |
| OXYCODONE/ASPIRIN TABLET |
R: 240 UNITS PER SCRIPT |
| OXYCONTIN 10 MG |
R: 60 UNITS PER 30 DAYS.
M: 60 UNITS PER 30 DAYS. |
| OXYCONTIN 15MG |
R: 60 UNITS PER 30 DAYS.
M: 60 UNITS PER 30 DAYS. |
| OXYCONTIN 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 60 UNITS PER 30 DAYS. |
| OXYCONTIN 30MG |
R: 60 UNITS PER 30 DAYS.
M: 60 UNITS PER 30 DAYS. |
| OXYCONTIN 40 MG |
R: 60 UNITS PER 30 DAYS.
M: 60 UNITS PER 30 DAYS. |
| OXYCONTIN 60 MG |
R: 60 UNITS PER 30 DAYS.
M: 60 UNITS PER 30 DAYS. |
| OXYCONTIN 80 MG |
R: 120 UNITS PER 30 DAYS.
M: 120 UNITS PER 30 DAYS. |
| PACINEX |
R: 480 ML PER SCRIPT
M:1440 ML PER 90 DAYS |
| PACNEX WASH |
R: 480 ML PER 30 DAYS |
| PANRETIN GEL |
R: 60 GM PER 30 DAYS
M: 180 GM PER 90 DAYS |
| PANTOPRAZOLE 20MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| PANTOPRAZOLE 40MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| PAROXETINE |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PAROXETINE CR |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PAROXETINE ER |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PAXIL |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PAXIL CR |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PBM ALLERGY SYRUP |
R: 240 ML PER SCRIPT |
| PEDIATRIC MASK |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| PERCOCET |
R: 240 UNITS PER SCRIPT |
| PERCODAN |
R: 240 UNITS PER SCRIPT |
| PERFOROMIST |
R: 60 UNITS PER 30 DAYS |
| PERLOXX |
R: 240 PER SCRIPT |
| PLAN B |
R: 2 PILLS OR 1 PACK PER SCRIPT |
| PLAVIX 300 MG |
R: 2 TABLETS PER 30 DAYS |
| PLAVIX 75 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| POCKET CHAMBER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| POCKET SPACER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| POLYTUSSIN AC LIQUID |
R: 240 ML PER SCRIPT |
| PRANDIMET |
R: 150 UNITS PER 30 DAYS
M: 450 UNITS PER 90 DAYS |
| PRAVACHOL |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| PRAVASTATIN |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| PRECOSE 100 MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| PRECOSE 25 MG |
R: 270 UNITS PER 30 DAYS.
M: 810 UNITS PER 90 DAYS |
| PRECOSE 50 MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| PREMPHASE |
R: 28 UNITS PER 28 DAYS.
M: 84 UNITS PER 84 DAYS. |
| PREMPRO |
R: 28 UNITS PER 28 DAYS.
M: 84 UNITS PER 84 DAYS. |
| PREVACID 15 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| PREVACID 30 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| PREVPAC |
R: 1 PACK PER 14 DAYS |
| PRILOSEC 10 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PRILOSEC 2.5 MG SUSPENSION |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| PRILOSEC 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| PRILOSEC 40 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| PRIMALEV 10 MG/300MG |
R: 240 PER SCRIPT |
| PRIMALEV 2.5 MG, 5 MG, 7.5 MG |
R: 240 UNITS PER SCRIPT |
| PRISTIQ |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| PROAIR |
R: 2 INHALERS PER 30 DAYS.
M: 6 INHALERS PER 90 DAYS |
| PROGESTERONE IN OIL |
30 ML PER 30 DAYS |
| PROMACTA |
SA: 30 UNITS PER 30 DAYS |
| PROSCAR 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| PROSOM 1 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| PROSOM 2 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| PROTONIX 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| PROTONIX 40 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| PROTONIX SUSP PACKET 40 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| PROTOPIC |
R: 120 GM PER 30 DAYS
M: 360 GMS PER 90 DAYS |
| PROVENTIL HFA |
R: 2 INHALERS PER 30 DAYS.
M: 6 INHALERS PER 90 DAYS |
| PROVIGIL 100 MG, 200 MG |
R: 30 PER 30 DAYS
M: 90 PER 90 DAYS |
| PROZAC 10 MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| PROZAC WEEKLY 90 MG |
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS |
| PSE BROM DM SYRUP |
R: 240 ML PER SCRIPT |
| PULMICORT INHALER |
R: 2 INHALERS PER 30 DAYS.
M: 6 INHALERS PER 90 DAYS |
| PULMICORT RESPULES 0.25MG/2ML, 0.5MG/2ML |
R: 120 ML PER 30 DAYS.
M: 360 ML PER 90 DAYS |
| PULMICORT RESPULES 1MG/2ML |
R: 60 ML PER 30 DAYS.
M: 180 ML PER 90 DAYS |
| PULMOZYME |
SA: 60 AMPULES PER 30 DAYS. |
| QVAR |
R: 2 INHALERS PER 30 DAYS.
M: 6 INHALERS PER 90 DAYS |
| RAMIPRIL 1.25 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| RAMIPRIL 10MG |
R:60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RAMIPRIL 2.5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| RAMIPRIL 5 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| RANEXA |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RAPAFLO |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| RAPTIVA |
SA: 8 SYRINGES PER 30 DAYS |
| REBETOL |
SA: 180 UNITS PER 30 DAYS. |
| REBIF |
SA: 12 SYRINGES PER 30 DAYS |
| REBIF TITRATION KIT |
SA: 1 KIT PER 30 DAYS |
| RECLAST |
ME: 5 UNITS (5MG) PER CLAIM |
| RE-DRYLEX JR TABS |
R: 100 UNITS PER SCRIPT
M: 100 UNITS PER SCRIPT |
| RELENZA |
R: 20 INHALATIONS OR 1 INHALER PER 180 DAYS |
| RELPAX |
R: 12 TABLETS PER 30 DAYS.
M: 36 TABLETS PER 90 DAYS |
| REPREXAIN |
R: 240 UNITS PER SCRIPT |
| REQUIP XL 12 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| REQUIP XL 2MG, 4 MG, 8 MG |
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS |
| REQUIP XL 6 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| RESTASIS |
R: 64 UNITS PER 30 DAYS.
M: 192 UNITS PER 90 DAYS |
| RESTORIL 15 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| RESTORIL 22.5 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| RESTORIL 30 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| RESTORIL 7.5 MG |
R: 30 UNITS PER 30 DAYS UP TO 60 UNITS PER 90 DAYS.
M: 60 UNITS PER 90 DAYS |
| RETIN-A |
R: 45 GRAMS PER 30 DAYS
M: 135 GRAMS PER 90 DAYS. |
| RETIN-A LIQUID |
R: 56 ML PER 30 DAYS.
M: 168 ML PER 90 DAYS. |
| REVATIO |
SA: 90 UNITS PER 30 DAYS |
| RIBAPAK |
SA: 180 UNITS PER 30 DAYS. |
| RIBASPHERE |
SA: 180 UNITS PER 30 DAYS. |
| RIBAVIRIN TABLET/CAPSULE |
SA: 180 UNITS PER 30 DAYS. |
| RISPERDAL 0.25MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL 0.5MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL 1MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL 2 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL 3 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| RISPERDAL 4 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| RISPERDAL M 0.25MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL M 0.5MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL M 1MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL M 2 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERDAL M 3 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| RISPERDAL M 4 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| RISPERDAL ORAL SOLUTION |
R: 480 ML PER 30 DAYS
M: 1440 ML PER 90 DAYS |
| RISPERIDONE 0.25 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERIDONE 0.5 MG ODT |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERIDONE 0.5MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERIDONE 1MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERIDONE 2 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| RISPERIDONE 3 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| RISPERIDONE 4 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| RISPERIDONE ORAL SOLUTION |
R: 480 ML PER 30 DAYS
M: 1440 ML PER 90 DAYS |
| ROSINIL CLEANSER KIT |
R: 1 KIT OR 13 OZ PER SCRIPT |
| ROXICET |
R: 240 UNITS PER SCRIPT |
| RYZOLT ER 100MG |
R: 60 UNITS PER 30 DAYS. |
| RYZOLT ER 200 MG, 300 MG |
R: 30 UNITS PER 30 DAYS |
| SABRIL PACKETS |
AS: 180 PER 30 DAYS |
| SABRIL TABLETS |
AS: 180 PER 30 DAYS |
| SANCTURA |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| SANCTURA XL |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SANCUSO PATCH |
R: 2 PATCHES PER 30 DAYS |
| SAPHRIS 5 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| SAPHRIS 10 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| SAVELLA |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SAVELLA TITRATION PACK |
R: 1 PACK PER 30 DAYS |
| SELECT-OB+DHA TB/CP PK 30DOSE |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SELZENTRY 150 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SELZENTRY 300 MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| SEROPHENE |
R: 20 UNITS PER 30 DAYS |
| SEROQUEL XR 150 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| SEROQUEL XR 200 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| SEROQUEL XR 300 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SEROQUEL XR 400 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SEROQUEL XR 50 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SERTRALINE 100 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SERTRALINE 25 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| SERTRALINE 50 MG |
R: 45 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| SIMCOR 1000 MG/ 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SIMCOR 500 MG/20 MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| SIMCOR 750 MG/20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SIMPONI |
SA: 50 MG PER 30 DAYS |
| SIMVASTATIN 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SIMVASTATIN 20 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SIMVASTATIN 40 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SIMVASTATIN 80 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SINGULAIR |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| SOLUCLENZ RX GEL |
R: 54 ML PER SCRIPT
M: 162 ML PER SCRIPT |
| SOMATULINE |
SA: 1 SYRINGE PER 30 DAYS |
| SOMAVERT 10MG, 20 MG |
SA: 30 UNITS PER 30 DAYS |
| SOMAVERT 15 MG |
SA: 60 UNITS PER 30 DAYS |
| SOMNOTE CAPS |
R: 30 UNITS PER SCRIPT |
| SONAHIST DM PED DROPS 30 ML |
R: 30 ML PER SCRIPT |
| SORIATANE 10MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| SORIATANE 25 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| SPACE CHAMBER |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| SPECTRACEF DOSE PACK |
R: 1 PACK PER SCRIPT |
| SPIRIVA |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| SPORANOX 100 MG |
R: 120 UNITS PER 30 DAYS. |
| SPORANOX SOLUTION 10 MG/ML |
R: 1200 ML PER 30 DAYS |
| SPRYCEL 100 MG |
SA: 30 UNITS PER 30 DAYS |
| SPRYCEL 20MG |
SA: 120 UNITS PER 30 DAYS |
| SPRYCEL 50 MG, 70 MG |
SA: 60 UNITS PER 30 DAYS |
| STADOL NASAL SPRAY |
R: 10 ML PER 30 DAYS.
M: 30 ML PER 90 DAYS.
WILL CHANGE TO ON 9/1/2009:
R: 5 ML PER 30 DAYS.
M: 15 ML PER 90 DAYS
|
| STALEVO |
R: 240 UNITS PER 30 DAYS.
M: 720 UNITS PER 30 DAYS. |
| STRIANT |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| SULFACETAMIDE SODIUM TOPICAL |
R: 120 ML PER 30 DAYS
M: 360 ML PER 90 DAYS |
| SUMATRIPTAN 25 MG, 50 MG, 100 MG |
R: 9 TABLETS PER 30 DAYS:
M: 27 TABLETS PER 90 DAYS. |
| SUMATRIPTAN INJECTION |
R: 2 KITS (4 SYRINGES) PER 30 DAYS.
M: 6 KITS (12 SYRINGES) PER 90 DAYS. |
| SUMATRIPTAN NASAL SPRAY |
R: 12 PER 30 DAYS.
M: 36 PER 90 DAYS |
| SUPPRELIN LA |
SA: 1 IMPLANT PER 300 DAYS |
| SUPRAX ORAL SUSP 50 ML |
R: 50 ML PER SCRIPT
M: 50 ML PER SCRIPT |
| SUPRAX ORAL SUSP 75 ML |
R: 75 ML PER SCRIPT
M: 75 ML PER SCRIPT |
| SYMBICORT |
R: 12 GRAM PER 30 DAYS
M: 36 GRAM PER 90 DAYS |
| SYNAGIS |
SA: 210 day supply dispensed in 365 days. |
| TACLONEX SCALP 60 GM |
R: 120 GM PER 30 DAYS |
| TAMIFLU 30 MG |
R: 20 UNITS PER 180 DAYS |
| TAMIFLU 75 MG, 45 MG |
R: 10 UNITS PER 180 DAYS |
| TAMIFLU SUSPENSION |
R: 75 ML PER 180 DAYS |
| TARCEVA 100MG, 150 MG |
SA: 30 UNITS PER 30 DAYS |
| TARCEVA 25 MG |
SA: 60 UNITS PER 30 DAYS |
| TASIGNA |
SA: 120 UNITS PER 30 DAYS |
| TAZORAC |
R: 100 GM PER 30 DAYS.
M: 300 GMS PER 90 DAYS |
| TEKTURNA |
R: 30 PER 30 DAYS.
M: 90 PER 90 DAYS |
| TEKTURNA HCT |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| TEMAZEPAM 15 MG |
R: 30 UNITS IN A ROLLING 23 DAYS
M: 90 UNITS IN A ROLLING 63 DAYS |
| TEMAZEPAM 30 MG |
R: 30 UNITS IN A ROLLING 23 DAYS
M: 90 UNITS IN A ROLLING 63 DAYS |
| TEMODAR 100 MG |
SA: 20 UNITS PER 30 DAYS. |
| TEMODAR 140 MG |
SA: 15 UNITS PER 30 DAYS. |
| TEMODAR 180 MG |
SA: 10 UNITS PER 30 DAYS. |
| TEMODAR 20 MG |
SA: 15 UNITS PER 30 DAYS. |
| TEMODAR 250 MG |
SA: 5 UNITS PER 30 DAYS. |
| TEMODAR 5 MG |
SA: 15 UNITS PER 30 DAYS. |
| TERBINAFINE 250 MG |
R: 30 UNITS PER 30 DAYS
(HAS A MEDCO 12 WEEK MAXIMUM SUPPLY RULE). |
| TESTIM |
R: 60 TUBES PER 30 DAYS
M: 180 TUBES PER 90 DAYS |
| TESTOPEL |
R: 10 PELLETS PER SCRIPT |
| TESTOSTERONE 50 MG |
R: 10 ML PER 30 DAYS.
M: 30 ML PER 90 DAYS. |
| TESTOSTERONE CYPIONATE INJECTIBLE |
R: 10 ML PER 30 DAYS |
| TESTOSTERONE ENANTHATE INJECTIBLE |
R: 10 ML PER 30 DAYS |
| THALOMID |
SA: 56 UNITS PER 28 DAYS |
| TOBI |
SA: 56 AMPULES PER 30 DAYS. |
| TOPISULF CREAM |
R: 56 GM PER 30 DAYS
M: 169 GM PER 90 DAYS |
| TORADOL 15MG, 30 MG INJECTION |
R: 20 SYRINGES PER SCRIPT |
| TORADOL 60 MG INJ |
R: 2 SYRINGES PER SCRIPT |
| TORISEL INJ 25MG/ML |
SA: 100 MG PER 30 DAYS.
ME: 25 MG PER WEEK. |
| TRACLEER |
SA: 60 UNITS PER 30 DAYS |
| TRETINOIN CREAM OR GEL |
R: 45 GRAMS PER 30 DAYS
M: 135 GRAMS PER 90 DAYS. |
| TREZIX |
R: 240 UNITS PER SCRIPT |
| TRIAZ FOAMING CLOTHS |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| TRIAZOLAM 0.125 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| TRIAZOLAM 0.25 MG |
R: 30 UNITS PER 23 DAYS
M: 90 UNITS PER 68 DAYS. |
| TRICOR 145 MG, 160 MG, 67 MG, 134 MG, 200 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| TRICOR 54MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| TRILIPIX 135 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| TRILIPIX 45 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| TRUZONE PEAK FLOW METER |
R: 1 METER PER 365 DAYS |
| TUSSIONEX |
R: 240 ML PER 90 DAYS |
| TYKERB 250 MG TABLET |
SA: 15O UNITS PER 30 DAYS. |
| TYLOX |
R: 240 UNITS PER SCRIPT |
| TYSABRI |
ME: 300 UNITS (300MG) PER CLAIM
SA: 300 MG (1 VIAL) PER 30 DAYS. |
| ULORIC |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 30 DAYS |
| UROXATRAL |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| VALTREX 1000 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| VALTREX 500 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| VALTURNA |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| VANTAS |
SA: 50 MG PER 300 DAYS |
| VECTIBIX |
M: 100 UNITS (1000MG PER CLAIM).
SA: 2000 MG PER 30 DAYS |
| VIADUR |
ME: 1 UNIT (65MG) PER 365 DAYS. |
| VIMPAT 100 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| VIMPAT 200 MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 30 DAYS |
| VIRAVAN-P |
R: 240 ML PER SCRIPT |
| VIVITROL IM |
SA: 380MG OR ONE VIAL PER 30 DAYS |
| VOLTAREN GEL |
R:500 GMS PER 30 DAYS
M: 1500 GMS PER 90 DAYS |
| VORTEX |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| VYTORIN (ALL STRENGTHS). |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| WELLBUTRIN SR 100MG |
R: 120 UNITS PER 30 DAYS
M: 360 UNITS PER 90 DAYS |
| WELLBUTRIN SR 150 MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| WELLBUTRIN SR 200MG |
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS |
| WELLBUTRIN XL 150 MG |
R: 90 UNITS PER 30 DAYS.
M: 270 UNITS PER 90 DAYS |
| WELLBUTRIN XL 300 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| XENAZINE 12.5 MG |
SA: 120 UNITS PER 30 DAYS |
| XENAZINE 50 MG |
SA: 60 UNITS PER 30 DAYS |
| XOLAIR |
SA: 900 MG EVERY 30 DAYS |
| XOLOX |
R: 240 UNITS PER SCRIPT |
| XOPENEX HFA |
R: 30 ML PER 30 DAYS.
M: 90 ML PER 90 DAYS. |
| XOPENEX SOLUTION |
R: 120 VIALS PER 30 DAYS
M: 360 VIALS PER 90 DAYS |
| XYREM |
SA: 270 GMS PER 30 DAYS. |
| YASMIN |
R: 56 UNITS PER 28 DAYS
M: 112 UNITS PER 84 DAYS |
| ZACARE KIT 4% |
R: 410 GM PER 30 DAYS
M: 1230 GM PER 90 DAYS |
| ZACARE KIT 8%/0.2% |
R: 1 KIT PER 30 DAYS.
M: 3 KITS PER 90 DAYS |
| ZEGERID 20 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| ZEGERID 40 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS. |
| ZETIA |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ZINOTIC ES OTIC DROPS |
R: 15 ML PER SCRIPT |
| ZOCOR 10 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ZOCOR 20 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ZOCOR 40 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ZOCOR 80 MG |
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS |
| ZODERM WASH |
R: 400 ML PER SCRIPT.
M: 1200 ML PER SCRIPT |
| ZOEY |
R: LIMITED TO ONE INHALER PER CALENDAR YEAR.
M: LIMITED TO ONE INHALER PER CALENDAR YEAR. |
| ZOFRAN 24 MG |
R: 2 TABLETS PER 30 DAYS. |
| ZOFRAN 4MG, 8 MG, |
R: 30 TABLETS PER 30 DAYS:
M: 120 TABLETS PER 90 DAYS. |
| ZOFRAN 4MG/2ML INJECTION |
R: 120ML PER 30 DAYS. |
| ZOFRAN 4MG/5ML SOLUTION |
R: 300ML PER 30 DAYS
M: 900ML PER 90 DAYS |
| ZOLADEX 10.8 MG (3-MONTH) |
SA: 10.8 MG PER 90 DAYS |
| ZOLADEX 3.6 MG |
SA: 3.6 MG PER 30 DAYS. |
| ZOLINZA |
SA: 120 UNITS PER 30 DAYS |
| ZOLOFT 100 MG |
R: 60 UNITS PER 30 DAYS.
M: 180 UNITS PER 90 DAYS |
| ZOLOFT 25 MG |
R: 30 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS. |
| ZOLOFT 50 MG |
R: 45 UNITS PER 30 DAYS.
M: 90 UNITS PER 90 DAYS |
| ZOMIG |
R: 12 TABLETS PER 30 DAYS.
M: 36 TABLETS PER 90 DAYS |
| ZOMIG NASAL SPRAY |
R: 12 PER 30 DAYS.
M: 36 PER 90 DAYS |
| ZORBTIVE |
SA: 30 VIALS PER 30 DAYS |
| ZYVOX SUSPENSION |
R: 1680 ML PER 28 DAYS |
| ZYVOX TABLET |
R: 56 TABLETS PER 28 DAYS |
