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Pharmacy Policy Bulletin

Category: Quantity Level Limits Number: J-6 Subject: Quantity Level Limits on Prescription Effective Date Begin: May 19, 2010 Effective Date End: Original Date: February 4, 2000 Review Date(s): May 19, 2010 March 3, 2010 March 4, 2009 December 3, 2008 September 3, 2008 May 21, 2008 December 5, 2007 September 5, 2007 May 16, 2007 December 6, 2006

Informational Policy

Policy Applies to: Commercial plans only

The following table contains a list of medications and the corresponding quantity level limits (number of units per prescription) that will be applied when members receive these medications through their prescription benefit. Please note that each medication has both retail and mail-order quantity level limits. Quantity level limits are applied for a variety of reasons including: (1) to prevent the stockpiling of medication; (2) to promote adherence to an appropriate course of therapy for reasons of efficacy and safety; and (3) to prevent medication misuse or abuse.

Up to 34 Days Supply 35-90 Days Supply Limit Brand Name Generic Name Limit (retail) (retail or mail) Actonel™ 35mg Risedronate 4 tablets 12 tablets Actonel™ w/calcium Risedronate 28 tablets 84 tablets Actonel™ 75 mg Risedronate 2 tablets 6 tablets Actonel™ 150 mg Risedronate 1 3 tablet Amitiza Lubiprostone 60 capsules 180 capsules AndroGel® pump Testosterone 4 pumps (2 packages) 12 pumps (6 packages) Boniva® Ibandronate 1 tablet 3 tablets Byetta™ Exenatide 1 pen 3 pens 1Caverject® Alprostadil 6 injections 18 injections 1Cialis® Tadalafil 6 tablets 18 tablets Cialis® Tadalafil 6 tablets 18 tablets 2Clomid®/Serophene® clomiphene Females only Females only CombiPatch® /norethindrone 8 patches 24 patches Cordran® Tape Flurandrenolide tape 2 tapes 6 tapes Diastat® Rectal Gel rectal gel 2 prefilled applicators 2 prefilled applicators 1Edex® Alprostadil 6 injections 18 injections Emend® (80mg, 125mg) Aprepitant 3 capsules 3 capsules Emend® (40mg) Aprepitant 1 1 capsule EpiPen® Epinephrine 2 devices 2 devices Evoclin® Clindamycin foam 1-100g or 2-50g containers 3-100g or 6-50g containers Forteo® Teriparatide 1 multi-dose pen 3 multi-dose pens Calcitonin salmon Nasal Fortical 1 bottle 3 bottles Spray Fosamax® 35 mg and 70 mg Alendronate 4 tablets 12 tablets Fosamax® plus D Alendronate 4 tablets 12 tablets Four (4) 75ml single use Twelve (12) 75ml single use Fosamax® oral Alendronate bottles bottles Gelnique™ Oxybutynin Gel 30 sachets 90 sachets GlucaGen® HypoKit™ Glucagon 1 kit 1 kit Glucagon Emergency Kit™ Glucagon 1 kit 1 kit 1Levitra® Vardenafil 6 tablets 18 tablets Levonorgestrel/ethinyl 1 extended-cycle tablet 1 extended-cycle tablet 6LoSeasonique® estradiol dispenser dispenser 3Lotronex® Alosetron 60 tablets 180 tablets Miacalcin® Nasal Spray Calcitonin Nasal Spray 1 bottle 3 bottles 1Muse® Alprostadil 6 18 suppositories Cyanocobalamin Intranasal Nascobal Intranasal Spray 1 – 5ml bottle 2 – 5ml bottles Spray Nascobal Gel Cyanocobalamin 1 bottle 2 bottles Etonogestrel / ethinyl NuvaRing® 1 vaginal ring 3 vaginal ring estradiol Norelgestromin / ethinyl Ortho Evra™ 3 patches 9 patches estradiol Oxybutynin Oxytrol™ 8 patches 24 patches System 4Plan B® Levonorgestrel 1 kit 1 kit Prozac Weekly® 90mg Delayed Release Fluoxetine 4 capsules 12 capsules Capsules 5Relenza® Zanamivir 1 Diskhaler and 5 Rotadisks 1 Diskhaler and 5 Rotadisks Granisetron transdermal Sancuso® 3 patches 3 patches system Levonorgestrel/ethinyl 1 extended-cycle tablet 1 extended-cycle tablet 6Seasonale® estradiol dispenser dispenser Seasonale® estradiol dispenser dispenser Levonorgestrel/ethinyl 1 extended-cycle tablet 1 extended-cycle tablet 6Seasonique™ estradiol dispenser dispenser Butorphanol tartrate Nasal Stadol® Nasal Spray 1 3 Spray Ten 75mg capsules (5 days Ten 75mg capsules (5 days 7Tamiflu™ Oseltamivir supply) supply) Toradol® tromethamine 20 tablets 20 tablets Twinject® Epinephrine 2 devices 2 devices 1Viagra® Sildenafil 6 tablets 18 tablets liraglutide [rDNA origin] Victoza® 3 pens 9 pens Xifaxan rifaximin 9 (200mg) tablets 9 (200mg) tablets Zolpimist Zolpidem oral spray 1 canister 1 canister Therapy Alora® Estradiol 1 box (8 patches) 3 boxes (24 patches) Climara® Estradiol 1 box (4 patches) 3 boxes (12 patches) ClimaraPro™ Estradiol/levonorgestrel 1 box (4 patches) 3 boxes (12 patches) Elestrin™ Estradiol Gel 1 metered-pump 3 metered-pumps Esclim™ Estradiol 1 box (8 patches) 3 boxes (24 patches) Estraderm® Estradiol 1 box (8 patches) 3 boxes (24 patches) EstroGel® 93 gm Estradiol 1 metered-pump 2 metered-pumps EstroGel® 50 gm Estradiol 1 metered-pump 3 metered-pumps Estrasorb® Estradiol Topical 1 carton (56 pouches) 3 cartons (168 pouches) Estring® Estradiol Vaginal Ring 1 vaginal ring 1 vaginal ring Evamist™ Estradiol 1 canister 3 canisters Femring® Estradiol Vaginal Ring 1 vaginal ring 1 vaginal ring Menostar® Estradiol 1 box (4 patches) 3 boxes (12 patches) Vivelle® Estradiol 1 box (8 patches) 3 boxes (24 patches)

1. These drugs may be excluded if the group excludes impotency coverage. When a benefit, coverage is limited to males ≥18 years of age at the limits listed above. The 6 tablets/injections per fill is coded under the QLL benefit and the 18 tablets/injections per 75 days is coded under the MRxC benefit. Related policy: MRxC J-304 2. Clomid®, Serophene® and the generic for both, clomiphene, may be excluded if the group excludes fertility coverage. 3. Lotronex® is covered for females ages 18 and over when used to treat irritable bowel syndrome. 4. Plan B® is available over-the-counter for females ≥18 years of age and is thus not covered; however Plan B® is Rx only for females <18 years and is a covered product. 5. Coverage for Relenza® is limited to a five day supply of 1 diskhaler and five rotadisks per copayment in patients 7 years or older. Additional treatment courses (1 diskhaler and five rotadisks) will require an additional copayment. 6. Coverage for LoSeasonique®, Seasonale® and Seasonique™ is limited to 1 Extended-Cycle Tablet Dispenser per 91 days. The Extended-Cycle Tablet Dispenser contains 3 blister packs containing a total of 91 tablets. Two packs contain 28 tablets each and the third pack contains 31 tablets. 7. Coverage for Tamiflu™ is limited to a five day supply of ten (10) 75mg capsules per copayment in patients 13 years or older. Additional treatment courses (ten 75mg capsules) will require an additional copayment. View Previous Versions

[Version 021 of J-6] [Version 020 of J-6] [Version 019 of J-6] [Version 018 of J-6] [Version 017 of J-6] [Version 016 of J-6] [Version 015 of J-6] [Version 014 of J-6] [Version 013 of J-6] [Version 012 of J-6] [Version 011 of J-6] [Version 010 of J-6] [Version 009 of J-6] [Version 008 of J-6] [Version 007 of J-6] [Version 006 of J-6] [Version 005 of J-6] [Version 004 of J-6] [Version 003 of J-6] [Version 002 of J-6] [Version 001 of J-6]

Pharmacy policies do not constitute medical advice, nor are they intended to govern physicians' prescribing or the practice of medicine. They are intended to reflect Highmark's coverage and reimbursement guidelines. Coverage may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its pharmacy policy at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the pharmacy policies is prohibited; however, limited copying of pharmacy policies is permitted for individual use.