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Member List 2016 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 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 ABSTRAL 100 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 200 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 300 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 400 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 600 MCG TAB SUBLINGUAL 90 units per 30 days ABSTRAL 800 MCG TAB SUBLINGUAL 90 units per 30 days ACTIQ 1,200 MCG LOZENGE 90 units per 30 days ACTIQ 1,600 MCG LOZENGE 90 units per 30 days ACTIQ 200 MCG LOZENGE 90 units per 30 days ACTIQ 400 MCG LOZENGE 90 units per 30 days ACTIQ 600 MCG LOZENGE 90 units per 30 days ACTIQ 800 MCG LOZENGE 90 units per 30 days ACTONEL 150 MG TABLET 1 tablet per 30 days ACTONEL 30 MG TABLET 30 tablets per prescription ACTONEL 35 MG TABLET 4 tablets per 28 days ACTONEL 5 MG TABLET 30 tablets per prescription ACTONEL 75 MG TABLET 2 tablet per 30 days ACTONEL WITH CALCIUM TABLETS 1 (28 day) Blister Package per prescription ACTOPLUS MET 15 MG-500 MG TAB 90 tablets per prescription ACTOPLUS MET 15 MG-850 MG TAB 90 tablets per prescription ACTOPLUS MET XR 15-1,000 MG TB 60 tablets per prescription ACTOPLUS MET XR 30-1,000 MG TB 30 tablets per prescription ACTOS 15 MG TABLET 30 tablets per prescription ACTOS 30 MG TABLET 30 tablets per prescription ACTOS 45 MG TABLET 30 tablets per prescription ADCIRCA 20 MG TABLET 60 tablets per prescription 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 ADVICOR 1,000 MG-20 MG TABLET 60 tablets per prescription ADVICOR 500 MG-20 MG TABLET 30 tablets per prescription ADVICOR 750 MG-20 MG TABLET 60 tablets 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 List is subject to change. Inclusion on this list does not guarantee coverage. 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 ALTOPREV 20 MG TABLET 30 tablets per prescription ALTOPREV 40 MG TABLET 30 tablets per prescription ALTOPREV 60 MG TABLET 30 tablets 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 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 ATELVIA 35 MG TABLET 4 tablets per 28 days 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 AVANDAMET 2 MG/500 MG TABLET 60 tablets per prescription AVANDAMET 2 MG-1,000 MG TAB 60 tablets per prescription AVANDAMET 4 MG/500 MG TABLET 60 tablets per prescription AVANDAMET 4 MG-1,000 MG TABLET 60 tablets per prescription AVANDARYL 4 MG-1 MG TABLET 30 tablets per prescription AVANDARYL 4 MG-2 MG TABLET 30 tablets per prescription AVANDARYL 4 MG-4 MG TABLET 30 tablets per prescription AVANDARYL 8 MG-2 MG TABLET 30 tablets per prescription AVANDARYL 8 MG-4 MG TABLET 30 tablets per prescription AVANDIA 2 MG TABLET 60 tablets per prescription AVANDIA 4 MG TABLET 60 tablets per prescription AVANDIA 8 MG TABLET 30 tablets per prescription AVINZA 120 MG CAPSULE 60 capsules per 30 days AVINZA 30 MG CAPSULE 60 capsules per 30 days AVINZA 45 MG CAPSULE 60 capsules per 30 days AVINZA 60 MG CAPSULE 60 capsules per 30 days AVINZA 75 MG CAPSULE 60 capsules per 30 days AVINZA 90 MG CAPSULE 60 capsules per 30 days List is subject to change. Inclusion on this list does not guarantee coverage. AVONEX ADMIN PACK 30 MCG VL 4 vials per 28 days AVONEX PEN 30 MCG/0.5 ML 1 box (4 pens) per 28 days AVONEX PREFILLED SYR 30 MCG 4 syringes per 28 days 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 BELBUCA 150 MCG FILM 60 films per presciption BELBUCA 300 MCG FILM 60 films per presciption BELBUCA 450 MCG FILM 60 films per presciption BELBUCA 600 MCG FILM 60 films per presciption BELBUCA 75 MCG FILM 60 films per presciption BELBUCA 750 MCG FILM 60 films per presciption BELBUCA 900 MCG FILM 60 films per presciption 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 BETASERON 0.3 MG KIT 14 vials per 30 days BETHKIS 300 MG/4 ML AMPULE 56 ampules per prescription BINOSTO 70 MG TABLET EFF 4 tablets per 28 days BONIVA 150 MG TABLET 1 tablet per 30 days 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, PKG SIZE 28 1 inhaler (28 blisters) BREO ELLIPTA 200 MCG/25 MCG, PKG SIZE 60 1 inhaler (60 blisters) BROVANA 15 MCG/2 ML SOLUTION 2 cartons (60 vials) per prescription BUNAVAIL 2.1 MG/0.3 MG FILM 30 films per presciption BUNAVAIL 4.2 MG/0.7 MG FILM 60 films per presciption BUNAVAIL 6.3 MG/1 MG FILM 60 films per presciption BUTORPHANOL NASAL SPRAY 10 MG/ML 2 bottles per prescription BYDUREON 2 MG PEN 4 Pens (1 package) per prescription BYDUREON 2 MG VIAL 1 carton (4 single-dose trays) per prescription BYETTA 10 MCG DOSE PEN INJ 1 syringe per prescription BYETTA 5 MCG DOSE PEN INJ 1 syringe per prescription CADUET 10 MG-10 MG TABLET 30 tablets per prescription CADUET 10 MG-20 MG TABLET 30 tablets per prescription CADUET 10 MG-40 MG TABLET 30 tablets per prescription CADUET 10 MG-80 MG TABLET 30 tablets per prescription CADUET 2.5 MG-10 MG TABLET 30 tablets per prescription CADUET 2.5 MG-20 MG TABLET 30 tablets per prescription CADUET 2.5 MG-40 MG TABLET 30 tablets per prescription CADUET 5 MG-10 MG TABLET 30 tablets per prescription CADUET 5 MG-20 MG TABLET 30 tablets per prescription CADUET 5 MG-40 MG TABLET 30 tablets per prescription CADUET 5 MG-80 MG TABLET 30 tablets per prescription CAMBIA 50 MG POWDER PACKET 9 packets per prescription CARDURA 1 MG TABLET 30 tablets per prescription CARDURA 2 MG TABLET 30 tablets per prescription CARDURA 4 MG TABLET 30 tablets per prescription CARDURA 8 MG TABLET 60 tablets per prescription CARDURA XL 4 MG TABLET 30 tablets per prescription CARDURA XL 8 MG TABLET 30 tablets per prescription CATAPRES-TTS 1 PATCH 4 patches per 28 days CATAPRES-TTS 2 PATCH 4 patches per 28 days CATAPRES-TTS 3 PATCH 4 patches per 28 days CAYSTON 75 MG INHAL SOLUTION 1 kit (84 vials of aztreonam and 88 vials of dliuent) 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 CHOLBAM 50 MG CAPSULE 120 capsules per prescription List is subject to change.
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