To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity ManagementManagement 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 30-day supply. If your plan allows for additional days supply, your limits may be higher. 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 Target Maximum Quantity ADVAIR 100-50 DISKUS 1 device (60 blisters) per prescription ADVAIR 250-50 DISKUS 1 device (60 blisters) per prescription ADVAIR 500-50 DISKUS 1 device (60 blisters) per prescription ADVAIR HFA (120) 115-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (120) 230-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (120) 45-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (60) 115-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (60) 230-21 MCG INHALER 1 inhaler per prescription ADVAIR HFA (60) 45-21 MCG INHALER 1 inhaler per prescription AEROBID/AEROBID-M 3 inhalers per prescription AEROSPAN 80 MCG INHALER 18 g (2 inhalers, 8.9 g each) per prescription AKYNZEO 300/0.5MG CAPSULE 1 capsule per chemotherapy course ALLEGRA ALLERGY 12 HR 60 MG 60 tablets per prescription ALLEGRA ALLERGY 24 HR 180 MG 30 tablets per prescription ALLEGRA CHILDREN'S ALLERGY 30 MG TABLET 60 tablets per prescription ALLEGRA-D 12 HOUR ALLERGY & CONGESTION 60 tablets per prescription ALLEGRA-D 24 HOUR ALLERGY & CONGESTION 30 tablets per prescription ALORA 0.025 MG PATCH 8 patches per 28 days ALORA 0.05 MG PATCH 8 patches per 28 days ALORA 0.075 MG PATCH 8 patches per 28 days ALORA 0.1 MG PATCH 8 patches per 28 days ALOXI 0.25 MG/5 ML VIAL 1 vial per prescription ALSUMA 6 MG/0.5 ML AUTO-INJECT 1 kit/2 syringes per prescription ALVESCO 160 MCG INHALER 2 inhalers per prescription ALVESCO 80 MCG INHALER 1 inhaler per prescription AMBIEN 10 MG TABLET 30 tablets per prescription AMBIEN 5 MG TABLET 30 tablets per prescription AMBIEN CR 12.5 MG TABLET 30 tablets per prescription AMBIEN CR 6.25 MG TABLET 30 tablets per prescription AMERGE 1 MG TABLET 9 tablets per prescription AMERGE 2.5 MG TABLET 9 tablets per prescription ANORO ELLIPTA 62.5/25 MCG 14 blisters (institutional pack) per prescription ANORO ELLIPTA 62.5/25 MCG 60 blisters per prescription ANZEMET 100 MG TABLET 3 tablet per prescription ANZEMET 50 MG TABLET 3 tablet per prescription ARAVA 10 MG TABLET 30 tablets per prescription ARAVA 20 MG TABLET 30 tablets per prescription ARCAPTA NEOHALER 75 MCG CAP 1 package (30 capsules) per prescription ARNUITY ELLIPTA 100 MCG INHALER 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption ARNUITY ELLIPTA 200 MCG INHALER 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption
Data Class: Internal
ASMANEX HFA 100 MCG INHALER 13 g (1 inhaler) per prescription ASMANEX HFA 200 MCG INHALER 13 g (1 inhaler) per prescription ASMANEX TWISTHALER 110 MCG #30 1 inhaler per prescription ASMANEX TWISTHALER 110 MCG #7 1 inhaler per prescription ASMANEX TWISTHALER 220 MCG #14 1 inhaler per prescription ASMANEX TWISTHALER 220 MCG #30 1 inhaler per prescription ASMANEX TWISTHALER 220 MCG #60 1 inhaler per prescription ASMANEX TWISTHALR 220 MCG #120 1 inhaler per prescription ASTELIN 137 MCG NASAL SPRAY 2 bottles per prescription ATROVENT 0.03% SPRAY 1 bottle per prescription ATROVENT 0.06% SPRAY 2 bottles per prescription ATROVENT HFA INHALER 2 inhalers per prescription ATROVENT INHALER 2 inhalers per prescription AUVI-Q 0.15 MG 2 units (1 carton) per prescription AUVI-Q 0.3 MG 2 units (1 carton) per prescription AXERT 12.5 MG TABLET 12 tablets per prescription AXERT 6.25 MG TABLET 6 tablets per prescription BECONASE AQ 0.042% SPRAY 2 inhalers per prescription BELSOMRA 10 MG TABLET 30 tablets per prescription BELSOMRA 15 MG TABLET 30 tablets per prescription BELSOMRA 20 MG TABLET 30 tablets per prescription BELSOMRA 5 MG TABLET 30 tablets per prescription BREO ELLIPTA 100MCG/25MCG #28 28 blisters (1 inhaler) per prescription BREO ELLIPTA 100MCG/25MCG #60 60 blisters per prescription BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 28 1 inhaler (28 blisters) BREO ELLIPTA 200 MCG/25 MCG, PACKAGE SIZE 60 1 inhaler (60 blisters) BROVANA 15 MCG/2 ML SOLUTION 2 cartons (60 vials) per prescription BUTORPHANOL NASAL SPRAY 10 MG/ML 2 bottles per prescription CAMBIA 50 MG POWDER PACKET 9 packets per prescription CAVERJECT 10 MCG KIT 12 units per prescription CAVERJECT 20 MCG KIT 12 units per prescription CAVERJECT 20 MCG VIAL 12 units per prescription CAVERJECT 40 MCG VIAL 12 units per prescription CAVERJECT 40 MCG/2 ML AMPUL 12 units per prescription CESAMET 1 MG PULVULE 30 capsules per prescription CHILDREN'S QNASAL 40 MCG (4.9 G) 5 grams (1 bottle) per prescription CHILD'S CLARITIN 5 MG TAB CHEW 30 tablets per prescription CHLD ALLEGRA ALLERGY 30 MG ODT 60 tablets per prescription CIALIS 10 MG TABLET 8 tablets per prescription CIALIS 2.5 MG TABLET 30 tablets per prescription CIALIS 20 MG TABLET 8 tablets per prescription CIALIS 5 MG TABLET 8 tablets per prescription CLARINEX 2.5 MG REDITABS 30 tablets per prescription CLARINEX 5 MG REDITABS 30 tablets per prescription CLARINEX-D 12 HOUR TABLET 60 tablets per prescription CLARINEX-D 24 HOUR TABLET 30 tablets per prescription CLARITIN 10 MG LIQUI-GEL CAP 30 tablets per prescription CLARITIN 10 MG REDITABS 30 tablets per prescription CLARITIN 10 MG TABLET 30 tablets per prescription CLARITIN-D 12 HOUR TABLET 60 tablets per prescription CLARITIN-D 24 HOUR TAB ER 30 tablets per prescription CLIMARA 0.025 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.0375 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.05 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.06/MG DAY PATCH 4 patches per 28 days CLIMARA 0.075 MG/DAY PATCH 4 patches per 28 days CLIMARA 0.1 MG/DAY PATCH 4 patches per 28 days CLIMARA PRO PATCH 4 patches per 28 days
Data Class: Internal
COMBIVENT INHALER 2 inhalers per prescription COMBIVENT RESPIMAT INHAL SPRAY 2 inhalers per prescription DEPO-PROVERA 150 MG/ML SYRINGE 1 vial/Syringe per 30 days DEPO-SUBQ PROVERA 104 SYRINGE 1 syringe per 30 days DEXILANT DR 30 MG CAPSULE 30 capsules per prescription DEXILANT DR 60 MG CAPSULE 30 capsules per prescription DIFLUCAN 150 MG TABLET 2 tablets per prescription DIVIGEL 0.25 MG GEL PACKET 30 packets per prescription DIVIGEL 0.5 MG GEL PACKET 30 packets per prescription DIVIGEL 1 MG GEL PACKET 30 packets per prescription DULERA 100 MCG/5 MCG INHALER 1 inhaler per prescription DULERA 200 MCG/5 MCG INHALER 1 inhaler per prescription DULERA 200 MCG/5 MCG INHALER 1 inhaler per prescription DUONEB 0.5 MG-3 MG/3 ML SOLN 180 vials (package size 3) per prescription DYMISTA NASAL SPRAY 1 bottle per prescription EDEX 10 MCG KIT 12 cartridges per prescription EDEX 20 MCG CARTRIDGE 2-PK KIT 12 cartridges per prescription EDEX 20 MCG CARTRIDGE 6-PK KIT 12 cartridges per prescription EDEX 40 MCG CARTRIDGE 2-PK KIT 12 cartridges per prescription EDEX 40 MCG CARTRIDGE 6-PK KIT 12 cartridges per prescription EDLUAR 10 MG SL TABLET 30 tablets per prescription EDLUAR 5 MG SL TABLET 30 tablets per prescription ELESTRIN 0.06% GEL 52 grams (2 pumps) per prescription ELLA 30 MG TABLET 1 tablet (1 dose) per prescription EMEND 115 MG VIAL 1 vial per prescription EMEND 125 MG CAPSULE 1 capsule per prescription EMEND 150 MG VIAL 1 vial per prescription EMEND 40 MG CAPSULE 1 capsule per prescription EMEND 80 MG CAPSULE 2 capsules per prescription EMEND TRIFOLD PACK 1 pack per prescription EPINEPHRINE 0.15 MG AUTO-INJCT (TWO PACK) 2 units (1 carton) per prescription EPINEPHRINE 0.3 MG AUTO-INJECT (TWO PACK) 2 units (1 carton) per prescription EPIPEN 0.3 MG AUTO-INJECTOR 3 units (package size 1), 2 units (package size 2) per prescription EPIPEN JR 0.15 MG AUTO-INJCT 3 units(package size 1), 2 units (package size 2) per prescription ESOMEPRAZOLE STRONTIUM 24.65 MG CAPSULE 30 capsules per prescription ESTRADERM 0.05 MG PATCH 8 patches per 28 days ESTRADERM 0.1 MG PATCH 8 patches per 28 days ESTRASORB PACKET 56 packets (97.44 g) per prescription ESTROGEL 0.06% GEL 1 pump bottle per prescription EVAMIST 1.53 MG/SPRAY 2 pumps per prescription FAMVIR 125 MG TABLET 21 tablets per prescription FAMVIR 250 MG TABLET 60 tablets per prescription
FAMVIR 500 MG TABLET 21 tablets per prescription
FLONASE 0.05% NASAL SPRAY 1 bottle per prescription FLONASE ALLERGY RELIEF 50 MCG SRAY PACKAGE 1 unit per prescription FLONASESIZE 15.8 ALLERGY RELIEF 50 MCG SRAY PACKAGE 1 unit per prescription SIZE 9.9 FLOVENT 100 MCG DISKUS 1 inhaler per prescription FLOVENT 250 MCG DISKUS 4 inhalers per prescription FLOVENT 50 MCG ROTADISK 1 inhaler per prescription FLOVENT HFA 110 MCG INHALER 1 inhaler per prescription FLOVENT HFA 220 MCG INHALER 2 inhalers per prescription FLOVENT HFA 44 MCG INHALER 1 inhaler per prescription FLUNISOLIDE 0.025% SPRAY 2 inhalers/bottles per prescription FORADIL AEROLIZER 12 MCG CAP 1 package (package size 12) (12 capsules) per prescription FORADIL AEROLIZER 12 MCG CAP 1 package (package size 60) (60 capsules) per prescription FROVA 2.5 MG TABLET 9 tablets per prescription
Data Class: Internal
GRANISOL 2 MG/10 ML SOLUTION 1 bottle per prescription GYNAZOLE 1 2% CREAM 5.8 g (1 pre-filled applicator) per prescription IMITREX 100 MG TABLET 9 tablets per prescription IMITREX 20 MG NASAL SPRAY 6 devices per prescription IMITREX 25 MG TABLET 9 tablets per prescription IMITREX 4 MG/0.5 ML CARTRIDGES 2 vials per prescription IMITREX 4 MG/0.5 ML PEN INJECT 1 kit per prescription IMITREX 5 MG NASAL SPRAY 6 devices per prescription IMITREX 50 MG TABLET 9 tablets per prescription IMITREX 6 MG/0.5 ML CARTRIDGE 2 vials per prescription IMITREX 6 MG/0.5 ML PEN INJECT 1 kit per prescription IMITREX 6 MG/0.5 ML SYRNG KIT 1 kit per prescription IMITREX 6 MG/0.5 ML VIAL 2 vials per prescription INCRUSE ELLIPTA 62.5 MCG INHALER 1 inhaler (30 blisters OR 7 blisters institutional pack) per prescription INTERMEZZO 1.75 MG TAB SUBLING 30 tablets per prescription INTERMEZZO 3.5 MG TAB SUBLING 30 tablets per prescription KYTRIL 1 MG TABLET 6 tablets per prescription KYTRIL 2 MG/10 ML SOLUTION 1 bottle (30 mL) per prescription LEVITRA 10 MG TABLET 8 tablets per prescription LEVITRA 2.5 MG TABLET 8 tablets per prescription LEVITRA 20 MG TABLET 8 tablets per prescription LEVITRA 5 MG TABLET 8 tablets per prescription LUNESTA 1 MG TABLET 30 tablets per prescription LUNESTA 2 MG TABLET 30 tablets per prescription LUNESTA 3 MG TABLET 30 tablets per prescription MAXAIR AUTOHALER 0.2 MG AERO 1 inhaler per prescription MAXALT 10 MG TABLET 18 tablets per prescription MAXALT 5 MG TABLET 18 tablets per prescription MAXALT MLT 10 MG TABLET 18 tablets per prescription MAXALT MLT 5 MG TABLET 18 tablets per prescription MENOSTAR 14 MCG/DAY PATCH 4 patches per 28 days MIGRANAL 4 MG/ML NASAL SPRAY 8 spray devices = 1 kit per prescription MINIVELLE 0.0375 MG PATCH 8 patches per 28 days MINIVELLE 0.05 MG PATCH 8 patches per 28 days MINIVELLE 0.075 MG PATCH 8 patches per 28 days MINIVELLE 0.1 MG PATCH 8 patches per 28 days MUSE 1,000 MCG URETHRAL SUPP 12 urethral suppositories per prescription MUSE 125 MCG URETHRAL SUPPOS 12 urethral suppositories per prescription MUSE 250 MCG URETHRAL SUPPOS 12 urethral suppositories per prescription MUSE 500 MCG URETHRAL SUPPOS 12 urethral suppositories per prescription NASACORT AQ NASAL SPRAY 55 MCG 1 bottle per prescription NASONEX 50 MCG NASAL SPRAY 1 bottle per prescription NEBUPENT 300 MG INHAL POWDER 1 container (inhaler) per 28 days NEXIUM 2.5 MG PACKET 30 packets per prescription NEXIUM 20 MG CAPSULE 30 capsules per prescription NEXIUM 5 MG PACKET 30 packets per prescription NEXIUM DR 10 MG PACKET 30 packets per prescription NEXIUM DR 20 MG PACKET 30 packets per prescription OMECLAMOX-PAK COMBO PACK 80 caps/tabs (10 cards) = 1 combo pack per prescription OMNARIS 50 MCG NASAL SPRAY 1 bottle per prescription ONMEL 200 MG TABLET 15 tablets per prescription PATANASE 0.6% NASAL SPRAY 1 bottle per prescription PERFOROMIST 20 MCG/2 ML SOLN 1 carton (60 vials) per prescription PLAN B 0.75 MG TABLET 2 tablets per prescription PLAN B ONE-STEP 1.5 MG TABLET 1 tablet per prescription PREVACID 15 MG CAPSULE DR 30 capsules per prescription PREVACID 15 MG SOLUTAB 30 solutabs per prescription PREVPAC PATIENT PAC 112 caps/tabs (14 cards) = 1 pack per prescription
Data Class: Internal
PRILOSEC 10 MG CAPSULE DR 30 capsules per prescription PRILOSEC 20 MG CAPSULE DR 30 capsules per prescription PRILOSEC DR 10 MG SUSPENSION 30 packets per prescription PRILOSEC DR 2.5 MG SUSPENSION 60 packets per prescription PROAIR HFA 90 MCG INHALER 2 inhalers per prescription PROAIR RESPICLICK 90 MCG INHALER 2 inhalers per prescription PROTONIX DR 20 MG TABLET 30 tablets per prescription PROVENTIL HFA 90 MCG INHALER 2 inhalers per prescription PULMICORT 0.25 MG/2 ML RESPUL 60 respules per prescription PULMICORT 0.5 MG/2 ML RESPULE 60 respules per prescription PULMICORT 1 MG/2 ML RESPULE 30 respules per prescription PULMICORT 180 MCG FLEXHALER 2 inhalers per prescription PULMICORT 90 MCG FLEXHALER 1 inhaler per prescription QNASL 80MCG NASAL SPRAY 1 bottle per prescription QVAR 40 MCG INHALER 2 inhalers per prescription QVAR 80 MCG INHALER 3 inhalers per prescription RELENZA 5 MG DISKHALER 20 blisters (1 carton) per prescription RELPAX 20 MG TABLET 6 tablets per prescription RELPAX 40 MG TABLET 6 tablets per prescription RESTASIS 0.05% EYE EMULSION 60 vials per prescription RHINOCORT AQUA NASAL SPRAY 2 bottles per prescription ROZEREM 8 MG TABLET 30 tablets per prescription SANCUSO 3.1 MG/24 HR PATCH 1 patch per prescription SEREVENT DISKUS 50 MCG (28 BLISTERS) 1 package per prescription SEREVENT DISKUS 50 MCG (60 BLISTERS) 1 package per prescription SILENOR 3 MG TABLET 30 tablets per prescription SILENOR 6 MG TABLET 30 tablets per prescription SONATA 10 MG CAPSULE 60 tablets per prescription SONATA 5 MG CAPSULE 30 tablets per prescription SPIRIVA 18 MCG CP-HANDIHALER 1 package (30 doses) per prescription SPIRIVA 28 INHALATIONS PACK AND 60 INHALATIONS 1PACK inhaler (4 g) per prescription SPORANOX 100 MG CAPSULE 30 capsules per prescription STAXYN 10 MG ODT 8 tablets per prescription STENDRA 100 MG TABLET 6 tablets per 30 days STENDRA 150 MG TABLET 6 tablets per 30 days STENDRA 50 MG TABLET 6 tablets per 30 days STIOLTO RESPIMAT 2.5/2.5 MCG INHALATION SPRAY 1 inhaler = 4 g (60 inhalations OR 28 inhalations institutional pack) STRIVERDI RESPIMAT 28 INHALATIONS PACK, 60 INHALATI1 inhalerONS (60 PACK inhalations OR 28 inhalations institutional pack) per prescription SUMAVEL DOSEPRO 4 MG/0.5 ML 3 mL (1 box) per prescription SUMAVEL DOSEPRO 4 MG/0.5 ML 9 mL (3 boxes) per 28 days SUMAVEL DOSEPRO 6 MG/0.5 ML 6 units per prescription SYMBICORT 160-4.5 MCG INHALER 1 package per prescription SYMBICORT 80-4.5 MCG INHALER 1 package per prescription TAMIFLU 12 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 30 MG GELCAP 20 capsules per prescription TAMIFLU 45 MG GELCAP 10 capsules per prescription TAMIFLU 6 MG/ML SUSPENSION 3 bottles per prescription TAMIFLU 75 MG GELCAP 10 capsules per prescription TREXIMET 85-500 MG TABLET 9 tablets per prescription TUDORZA PRESSAIR 400 MCG INH 1 inhaler per prescription VALTREX 1 GM CAPLET 30 caplets (tablets) per prescription VALTREX 500 MG CAPLET 30 caplets (tablets) per prescription VENTOLIN HFA 90 MCG INHALER 2 inhalers per prescription VENTOLIN HFA 90 MCG INHALER 1 inhaler per prescription VERAMYST 27.5 MCG NASAL SPRAY 1 bottle per prescription VIAGRA 100 MG TABLET 8 tablets per prescription VIAGRA 25 MG TABLET 8 tablets per prescription VIAGRA 50 MG TABLET 8 tablets per prescription
Data Class: Internal
VIVELLE-DOT 0.025 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.0375 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.05 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.075 MG PATCH 8 patches per 28 days VIVELLE-DOT 0.1 MG PATCH 8 patches per 28 days XIFAXAN 200 MG TABLET 9 tablets XIFAXAN 550 MG TABLET 60 tablets XYZAL 5 MG TABLET 30 tablets per prescription ZEGERID 20 MG CAPSULE 30 capsules per prescription ZEGERID 20 MG PACKET 30 packets per prescription ZETONNA 37 MCG NASAL SPRAY 1 canister (60 actuations per canister) per prescription ZOFRAN 24 MG TABLET 1 tablet per prescription ZOFRAN 4 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN 8 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN ODT 4 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN ODT 8 MG TABLET 9 tablets or orally disintegrating tablets per prescription ZOFRAN SOLUTION 2 bottles per prescription ZOLPIMIST 5 MG ORAL SPRAY 1 bottle per prescription ZOMIG 2.5 MG TABLET 6 tablets per prescription
ZOMIG 5 MG NASAL SPRAY 6 nasal spray devices per prescription
ZOMIG 5 MG TABLET 6 tablets per prescription ZOMIG ZMT 2.5 MG TABLET 6 tablets per prescription ZOMIG ZMT 5 MG TABLET 6 tablets per prescription ZUPLENZ 4 MG SOLUBLE FILM 9 films per prescription ZUPLENZ 8 MG SOLUBLE FILM 9 films per prescription ZYRTEC 10 MG CHEWABLE TABLET 30 tablets per prescription
ZYRTEC 10 MG TABLET 30 tablets per prescription
ZYRTEC 5 MG CHEWABLE TABLET 30 tablets per prescription ZYRTEC 5 MG TABLET 30 tablets per prescription ZYRTEC-D TABLET 60 tablets per prescription
Data Class: Internal