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Quantity Limits/Daily Dose Limits

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Quantity Limits/Daily Dose Limits Effective 07/20/21 Alphabetical by Brand Name (when applicable) PA Medical Assistance Fee-for-Service Quantity Limits & Daily Dose Limits Maximum Therapy Class Brand Name Generic Name Daily Dose Limit Antipsychotics, Atypical ABILIFY 1 MG/ML SOLUTION ARIPIPRAZOLE 25 Antipsychotics, Atypical ABILIFY 10 MG DISCMELT ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 10 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 15 MG DISCMELT ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 15 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 2 MG TABLET ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 20 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 30 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 5 MG TABLET ARIPIPRAZOLE 1.5 Antipsychotics, Atypical ABILIFY 9.75 MG/1.3 ML INJECTION VIAL ARIPIPRAZOLE 3.9 Antipsychotics, Atypical ABILIFY MAINTENA ER 300 MG SYRINGE ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 300 MG VIAL ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 400 MG SYRINGE ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 400 MG VIAL ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MYCITE 10 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 15 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 2 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 20 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 30 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 5 MG KIT ARIPIPRAZOLE 1 Antivirals, Herpes ABREVA 10% CREAM DOCASONAL 1 Analgesics, Opioid Short-Acting ABSTRAL 100 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 200 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 300 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 400 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 600 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 800 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Leukotriene Modifiers ACCOLATE 10 MG TABLET ZAFIRLUKAST 2 Leukotriene Modifiers ACCOLATE 20 MG TABLET ZAFIRLUKAST 2 Blood Glucose Test Strips ACCU-CHECK ACTIVE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters ACCU-CHECK ACTIVE CARE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ACCU-CHECK ADVANTAGE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ACCU-CHECK AVIVA PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ACCU-CHECK AVIVA PLUS BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ACCU-CHECK COMFORT CURVE BLOOD GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ACCU-CHECK COMPACT BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Effective 07/20/21 Alphabetical by Brand Name (when applicable) Blood Glucose Meters ACCU-CHECK COMPACT PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Diabetic Supplies, Miscellaneous ACCU-CHECK FASTCLIX LANCET KIT BLOOD GLUCOSE LANCING DEVICE 1 Diabetic Supplies, Miscellaneous ACCU-CHECK MULTICLIX LANCET KIT BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ACCU-CHECK NANO SMARTVIEW BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ACCU-CHECK SMARTVIEW BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Diabetic Supplies, Miscellaneous ACCU-CHECK SOFTCLIX LANCING KIT BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ACCU-CHECK VOICEMATE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Angiotensin Modulators ACCUPRIL 10 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 20 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 40 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 5 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCURETIC 10 MG/12.5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators ACCURETIC 20 MG/12.5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators ACCURETIC 20 MG/25 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators ACEON 2 MG TABLET PERINDOPRIL 2 Angiotensin Modulators ACEON 4 MG TABLET PERINDOPRIL 2 Angiotensin Modulators ACEON 8 MG TABLET PERINDOPRIL 2 Analgesics, Opioid Short-Acting ACETAMIN/CAFF/DIHYDROCODEINE 320.5 MG/30 MG/16 MG ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 10 Analgesics, Opioid Short-Acting ACETAMIN-CODEIN 300-30 MG/12.5 ML ACETAMINOPHEN/CODEINE 90 Analgesics, Non-Salicylates ACETAMINOPHEN 120 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates ACETAMINOPHEN 160 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates ACETAMINOPHEN 160 MG/5 ML LIQUID ACETAMINOPHEN 75 Analgesics, Non-Salicylates ACETAMINOPHEN 320 MG/10 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 325 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 10 Analgesics, Non-Salicylates ACETAMINOPHEN 325 MG/10.15 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 500 MG CAP/TAB/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates ACETAMINOPHEN 500 MG/15 ML LIQUID ACETAMINOPHEN 90 Analgesics, Non-Salicylates ACETAMINOPHEN 650 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates ACETAMINOPHEN 650 MG/20.3 ML ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 80 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 30 Analgesics, Opioid Short-Acting ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 MG ACETAMINOPHEN/CAFF/DIHYDROCODONE 10 Proton Pump Inhibitors ACIPHEX 10 MG SPRINKLE DR CAPSULE RABEPRAZOLE 2 Proton Pump Inhibitors ACIPHEX 20 MG TABLET EC RABEPRAZOLE 2 Proton Pump Inhibitors ACIPHEX 5 MG SPRINKLE DR CAPSULE RABEPRAZOLE 1 Cytokine & CAM Antagonists ACTEMRA 162 MG/0.9 ML SYRINGE TOCILIZUMAB 0.13 Cytokine & CAM Antagonists ACTEMRA 200 MG/10 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA 400 MG/20 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA 80 MG/4 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA ACTPEN 162 MG/0.9 ML TOCILIZUMAB 0.13 Bile Salts ACTIGALL 300 MG CAPSULE URSODIOL 4 Analgesics, Opioid Short-Acting ACTIQ 1200 MCG LOZENGE FENTANYL CITRATE 4 Effective 07/20/21 Alphabetical by Brand Name (when applicable) Analgesics, Opioid Short-Acting ACTIQ 1600 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 200 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 400 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 600 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 800 MCG LOZENGE FENTANYL CITRATE 4 Estrogens ACTIVELLA 0.5-0.1 MG TABLET ESTRADIOL/NORETHINDRONE ACET 1 Estrogens ACTIVELLA 1MG-0.5 MG TABLET ESTRADIOL/NORETHINDRONE ACET 1 Bone Density Regulators ACTONEL 150 MG TABLET RISEDRONATE 0.04 Bone Density Regulators ACTONEL 30 MG TABLET RISEDRONATE 1 Bone Density Regulators ACTONEL 35 MG TABLET RISEDRONATE 0.15 Bone Density Regulators ACTONEL 5 MG TABLET RISEDRONATE 1 Hypoglycemics, TZDs ACTOPLUS MET 15 MG/500 MG TABLET PIOGLITAZONE/METFORMIN 3 Hypoglycemics, TZDs ACTOPLUS MET 15 MG/850 MG TABLET PIOGLITAZONE/METFORMIN 3 Hypoglycemics, TZDs ACTOS 15 MG TABLET PIOGLITAZONE 1 Hypoglycemics, TZDs ACTOS 30 MG TABLET PIOGLITAZONE 1 Hypoglycemics, TZDs ACTOS 45 MG TABLET PIOGLITAZONE 1 Vaccines ADACEL TDAP VACCINE SYRINGE DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Vaccines ADACEL TDAP VACCINE VIAL DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Calcium Channel Blockers ADALAT CC 30 MG TABLET NIFEDIPINE 1 Calcium Channel Blockers ADALAT CC 60 MG TABLET NIFEDIPINE 2 Calcium Channel Blockers ADALAT CC 90 MG TABLET NIFEDIPINE 1 Antipsychotics ADASUVE 10 MG INHALATION POWDER LOXAPINE 0.2 Oncology, Other ADCETRIS 50 MG VIAL BRENTUXIMAB VEDOTIN 0.22 PAH Agents, Oral & Inhaled ADCIRCA 20 MG TABLET TADALAFIL 2 Stimulants & Related Agents ADDERALL 10 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 12.5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 15 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 20 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 30 MG TABLET AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL 5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 7.5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL XR 10 MG CAPSULE AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents ADDERALL XR 15 MG CAPSULE AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents ADDERALL XR 20 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 25 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 30 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 5 MG CAPSULE AMPHETAMINE MIXED SALTS 1 PAH Agents, Oral & Inhaled ADEMPAS 0.5 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 1 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 1.5 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 2 MG TABLET RIOCIGUAT 3 Effective 07/20/21 Alphabetical by Brand Name (when applicable) PAH Agents, Oral & Inhaled ADEMPAS 2.5 MG TABLET RIOCIGUAT 3 Stimulants & Related Agents ADHANSIA XR 25 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 35 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 45 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 55 MG CAPSULE
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