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UHC PA Community and State Quantity Limit List

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UHC PA Community and State Quantity Limit List Quantity Limits Quantity Max Daily Dose Period Quantity Period Days Period Fills GPI DESCRIPTION Maximum (MDD) Edit (PQE) Edit Edit 97703040004300 *ALCOHOL SWABS*** 10 34000003101810 *AMLODIPINE BESYLATE ORAL SUSP 1 MG/ML (CMPD KIT) (BASE EQ)* 10 88501000002000 *ARTIFICIAL SALIVA - SOLUTION*** 120 Maximum quantity 86202000004200 *ARTIFICIAL TEAR OPHTH OINTMENT*** of 7 per 26 days. 33200020002065 *ATENOLOL ORAL SOLN 10 MG/ML (COMPOUND KIT)** 20 33200020002055 *ATENOLOL ORAL SOLN 2 MG/ML (COMPOUND KIT)** 50 33200020001810 *ATENOLOL ORAL SUSPENSION 1 MG/ML (CMPD KIT)** 200 78110000000100 *B-COMPLEX VITAMIN CAP** 1 Maximum quantity 78133000000920 *B-COMPLEX W/ C & FOLIC ACID LIQUID 0.9 MG/5ML*** of 237 per 26 days. 78133000000325 *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** 1 78133000000330 *B-COMPLEX W/ C & FOLIC ACID TAB 1 MG*** 1 Maximum quantity 88350010006400 *BENZOCAINE DENTAL LIQUID 20% KIT*** of 1 per 26 days. 90050010006410 *BENZOYL PEROXIDE WASH 2.5% & BENZOYL PEROXIDE LOT 10% KIT** 1 47300005100100 *BIFIDOBACTERIUM BIFIDUM CAP** 2 97202007100900 *BLOOD GLUCOSE CALIBRATION - LIQUID*** 0.04 Maximum quantity 97202011006200 *BLOOD GLUCOSE METER DISPOSABLE DEVICE WITH TEST STRIPS*** of 1 per 999 days. Maximum quantity 97202010006200 *BLOOD GLUCOSE MONITORING DEVICES*** of 1 per 365 days. Maximum quantity 97202010006410 *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** of 1 per 365 days. Maximum quantity 97202010006400 *BLOOD GLUCOSE MONITORING KIT*** of 1 per 365 days. Maximum quantity 97750010006200 *BLOOD PRESSURE MONITORING - DEVICE*** of 1 per 999 days. Maximum quantity 9025990212B120 *CALCIPOTRIENE CR 0.005% & DIMETHICONE CR 5% THERAPY PACK*** of 1 per 26 days. 79109903450340 *CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-200 UNIT*** 5 79109903450355 *CALCIUM CARB-VIT D W/ MINERALS TABS 600 MG-800 UNIT*** 2 Maximum quantity 6610990420B120 *CELECOXIB CAP 200 MG & METH SAL-MEN-CAPSAICIN LIQD THER PK* of 1 per 26 days. Maximum quantity 9097990318B120 *CHLORHEXIDINE SOL 4% & MUPIROCIN OINT 2% & DIMETH CR 5% PK* of 1 per 26 days. Maximum quantity 90150030406450 *CICLOPIROX OLAMINE SUSP 0.77% (BASE EQUIV) & CLEANSER KIT** of 1 per 26 days. 56700020002000 *CITRIC ACID-GLUCONOLACTONE-MAGNESIUM CARBONATE SOLN** 180 Maximum quantity 90059903586412 *CLINDAMYCIN 1% GEL-BENZOYL PEROX 2.5% GEL-MOISTURIZER KIT* of 1 per 26 days. Maximum quantity 90059902636420 *CLINDAMYCIN PHOSPHATE GEL 1% & MOISTURIZER KIT*** of 1 per 26 days. 97401000000000 *CONDOMS - MALE*** 2 Maximum quantity 25050010005320 *COPPER IUD** of 1 per 999 days. 75100050601810 *CYCLOBENZAPRINE HCL W/ MSM ORAL SUSP 1 MG/ML (CMPD KIT)** 30 80509903100920 *DHA-EPA-GLA LIQUID 174-558-60 MG/15ML*** 15 Maximum quantity 97402010005400 *DIAPHRAGM ARC-SPRING*** of 2 per 180 days. Maximum quantity 97402000005400 *DIAPHRAGMS*** of 2 per 180 days. Maximum quantity 66109904356430 *DICLOFENAC SOD TAB DR 75 MG & LIDO-MEN-METHYL SAL PTCH KIT* of 1 per 26 days. Maximum quantity 9037990232B120 *DICLOFENAC SODIUM GEL 3% & SILICONE TAPE THERAPY PACK*** of 1 per 26 days. Maximum quantity 66100007256430 *DICLOFENAC SODIUM TAB DR 50 MG & LINIMENT TOPICAL LIQ KIT** of 1 per 26 days. Maximum quantity 66100007256440 *DICLOFENAC SODIUM TAB DR 75 MG & LINIMENT TOPICAL LIQ KIT** of 1 per 26 days. Maximum quantity 90219904386420 *DICLOFENAC SOLN 1.5% & METHYL SAL-MENTH-CAPSAICIN LIQ KIT** of 240 per 26 days. Maximum quantity 90219904376420 *DICLOFENAC TD SOLN 1.5% & CAMP-LIDO-METHYL SAL PATCH KIT*** of 1 per 26 days. 9021990224B120 *DICLOFENAC TD SOLN 1.5% & CANNABINOIDS SUBLINGUAL LIQ PACK* 16 Maximum quantity 90972540003200 *DIETHYLTOLUAMIDE (DEET) AEROSOL*** 184 of 368 per 26 days. Maximum quantity 90972540003200 *DIETHYLTOLUAMIDE (DEET) AEROSOL*** 170 of 340 per 26 days. Maximum quantity 90972540003200 *DIETHYLTOLUAMIDE (DEET) AEROSOL*** 71 of 142 per 26 days. Maximum quantity 90972540003200 *DIETHYLTOLUAMIDE (DEET) AEROSOL*** 113 of 226 per 26 days. Maximum quantity 90972540000900 *DIETHYLTOLUAMIDE (DEET) LIQUID*** 177 of 354 per 26 days. Maximum quantity 90979904203720 *DIMETHICONE-ZINC OXIDE-VITAMIN A-VITAMIN D CREAM 1-10%*** of 480 per 67 days. Maximum quantity 4399750329C420 *DM-GG LIQD & DOXYLAMINE-DM LIQD DAY/NIGHT THER PACK** of 236 per 26 days. Maximum quantity 4399750321C520 *DM-GG SOLN & CHLORPHENIRAMINE-DM SOLN DAY/NIGHT THER PACK** of 236 per 26 days. 04000020556420 *DOXYCYCLINE HYCLATE CAP 1 X 100 MG W/ CLEANSER KIT* 0.04 04000020556410 *DOXYCYCLINE HYCLATE CAP 1 X 50 MG W/ CLEANSER KIT* 0.04 04000020556440 *DOXYCYCLINE HYCLATE CAP 2 X 100 MG W/ CLEANSER KIT* 0.04 20109902220740 *DUST MITE MIXED EXT SL TAB 12 SQ-HDM*** 1 90650000003700 *EMOLLIENT - CREAM** 15.14 90650000004100 *EMOLLIENT - LOTION** 15.14 90650000004200 *EMOLLIENT - OINTMENT** 15.14 Maximum quantity 38900040006420 *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** of 2 per 26 days. Maximum quantity 49270025106420 *ESOMEPRAZOLE MAG DR CAP 20 MG AND SWALLOWING SPRAY KIT** of 1 per 26 days. Maximum quantity 24994004303720 *ESTRADIOL-ESTRIOL-TESTOST-PROGEST MICRO CREAM (CMPD KIT)*** of 30 per 26 days. Maximum quantity 24990002053720 *ESTRIOL-ESTRADIOL CREAM (CMPD KIT)*** of 30 per 26 days. Maximum quantity 24993002753720 *ESTRIOL-PROGESTERONE MICRO CREAM 4-20 MG/GM (CMPD KIT)*** of 30 per 26 days. Maximum quantity 66100008606440 *ETODOLAC TAB 400 MG & LINIMENT TOPICAL LIQUID KIT** of 1 per 26 days. 82995006350330 *FE CARBONYL-FE GLUCONATE-FA-VIT B12-VIT C-DSS TAB 90-1 MG** 1 Maximum quantity 9055990242B120 *FLUOCINONIDE CREAM 0.1% & SILICONE TAPE THERAPY PACK*** of 1 per 26 days. Maximum quantity 6254990340B130 *GABAPENTIN CAP 300 MG & LIDO CR 4.12% &SILICONE SHEET THPK* of 1 per 26 days. Maximum quantity 6254990225B115 *GABAPENTIN CAP 300 MG & LIDOCAINE CREAM 4.12% THER PACK*** of 1 per 26 days. Maximum quantity 6254990225B120 *GABAPENTIN CAP 300 MG & LIDOCAINE PATCH 5% THERAPY PACK*** of 1 per 26 days. 72600030001810 *GABAPENTIN ORAL SUSP 25 MG/ML (CMPD KIT)** 144 Maximum quantity 20109905200720 *GRASS MIXED POLLEN EXT SL TAB 100 IR (INDEX OF REACTIVITY)* of 9 per 135 days. 20109905200730 *GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)* 1 Maximum quantity 2010990520B120 *GRASS MIXED POLLEN SL TAB THERPAK 100 (3) IR & 300 (6) IR* of 9 per 135 days. Maximum quantity 99870010000970 *HOMEOPATHIC PRODUCTS - TOPICAL LIQUID** of 10 per 26 days. Maximum quantity 97102000000000 *HUMIDIFIERS*** of 1 per 999 days. Maximum quantity 42500030002900 *HYPROMELLOSE NASAL POWDER** of 1 per 26 days. Maximum quantity 90210045003760 *IBUPROFEN CREAM 10% (COMPOUNDING KIT)** of 60 per 26 days. Maximum quantity 66100020006450 *IBUPROFEN TAB 600 MG & SWALLOWING SPRAY KIT*** of 1 per 26 days. Maximum quantity 66100020506430 *IBUPROFEN TAB 800 MG & LINIMENT TOPICAL LIQUID KIT** of 1 per 26 days. Maximum quantity 82992008350920 *IRON POLYSACCH-SENNA-C-E-B6- B12-IF-FA LIQ 165-2 MG/5ML*** of 120 per 26 days. Maximum quantity 97403000000000 *IUD'S*** of 1 per 999 days. Maximum quantity 90219903503740 *KETOPROFEN-LIDOCAINE HCL-GABAPENT CRM 20-2-10% (CMPD KIT)** of 240 per 26 days. Maximum quantity 90219903483700 *KETOPROFEN-LIDOCAINE-GABAPENTIN CREAM 20-2-10% (CMPD KIT)** of 240 per 26 days. 47300020600100 *LACTOBACILLUS RHAMNOSUS (GG) CAP** 1 Maximum quantity 97202027006300 *LANCET DEVICES*** of 1 per 365 days. Maximum quantity 97202030006400 *LANCETS KIT*** of 1 per 365 days. 97202030006300 *LANCETS MISC.*** 10 97202025006300 *LANCETS*** 10 Maximum quantity 49270040001820 *LANSOPRAZOLE SUSP 3 MG/ML (COMPOUND KIT)** of 300 per 26 days. 80309903350920 *LEVOCARNITINE-B5-TAURINE LIQD 1000-10-150 MG/15ML*** 45 25990003406420 *LEVONORGEST-ETH ESTRAD TAB 0.1 MG-20 MCG & FA TAB 1 MG KIT* 1 9085990208B120 *LIDOCAINE 5% PATCH & EMOLLIENT CREAM THERAPY PACK*** 1 Maximum quantity 90859902896430 *LIDOCAINE OINTMENT 5% & TRANSPARENT DRESSING KIT*** of 1 per 24 days. Maximum quantity 90859902096420 *LIDOCAINE PATCH 5% & ADHESIVE SHEET KIT*** of 1 per 24 days. Maximum quantity 9085990211B130 *LIDOCAINE PATCH 5% & SILICONE SHEET THERAPY PACK*** of 60 per 26 days. Maximum quantity 9085990382B120 *LIDOCAINE-PRILOCAINE CR 2.5-2.5% & BENZALK FOAM THER PACK** of 1 per 26 days. Maximum quantity 90859903796420 *LIDOCAINE-PRILOCAINE CR 2.5-2.5% &TRANSPARENT DRESSING KIT* of 1 per 26 days. 81250060000130 *L-METHYLFOLATE CAP 15 MG** 1 81259904400320 *L-METHYLFOLATE-ALGAE-B12-ACETYLCYST TAB 6-90.314-2-600MG*** 1 81259904500130 *L-METHYLFOLATE-ALGAE-VIT B12-B6 CAP 3-90.314-2-35 MG*** 2 81259904550120 *L-METHYLFOL-B12-B6-ALPHA LIPOIC AC CAP 3.75-1-25-300 MG*** 2 Maximum quantity 66100052606425 *MELOXICAM TAB 15 MG & LINIMENT TOPICAL LIQUID KIT** of 1 per 26 days. Maximum quantity 52500030206420 *MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** of 12 per 72 days. 53992005200322 *METHENAMINE-HYOS-METH BLUE-SOD PHOS-PHEN SAL TAB 81.6 MG*** 4 Maximum quantity 33200030102070 *METOPROLOL TARTRATE ORAL SOLN 10 MG/ML (COMPOUND KIT)** of 900 per 72 days. 60201025001830 *MIDAZOLAM SUSP 1 MG/ML (COMPOUND KIT)** 20 Maximum quantity 88500000009400 *MISC THROAT PRODUCTS - SWABS** of 75 per 26 days. Maximum quantity 97700000000000 *MISC. DEVICES** of 1 per 90 days. 79850050000300 *MULTIPLE MINERALS W/ VITAMINS TAB** 8 78200000003000 *MULTIPLE VITAMIN PACK** 1 Maximum quantity 78210000000300 *MULTIPLE VITAMINS W/ IRON TAB** 1 of 100 per 77 days. 78313010001230 *MULTIPLE VITAMINS W/ MINERALS & FA SYRUP 1 MG/15ML*** 1 78310000000500 *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** 2 78310000000300 *MULTIPLE VITAMINS W/ MINERALS TAB** 1 Maximum quantity 66100055606430 *NABUMETONE TAB 500 MG & LINIMENT
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