3-Tier-Quantity-Limits

Covered medications with quantity limits

Our quantity limit program encourages safe medication use. Certain medications are available in limited quantities based on FDA guidelines for appropriate and safe use.

Talk to your doctor to find the right drug therapies that your health plan covers.

This list is current as of April 1, 2017. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013. Medication Strength Limits Abstral® All strengths 4 tablets per day (fentanyl) Accolate® All strengths 2 tablets per day (zafirlukast) Aciphex® sprinkle (rabeprazole) All strengths 2 capsules per day

Actemra® 4 packages (4 syringes) All strengths (tocilizumab) per 30 days Acticlate® tablet 150 mg 40 tablets per 30 days (doxycycline hyclate) Actiq® All strengths 4 lollipops per day (fentanyl citrate) Actonel® 150 mg 1 tablet per 30 days (risedronate) Actonel® 35 mg 4 tablets per 30 days (risedronate) Actonel® 5 mg, 30 mg 1 tablet per day (risedronate) Adcirca® All strengths 2 tablets per day (tadalafil) Adderall XR® (amphetamine + All strengths 2 tablets per day dextroamphetamine) Adderall® 5 mg, 7.5 mg, 10 mg, 12.5 (amphetamine + mg, 4 tablets per day dextroamphetamine) 15 mg Adderall® (amphetamine + 20 mg 3 tablets per day dextroamphetamine)

Adderall® (amphetamine + 30 mg 2 tablets per day dextroamphetamine)

Addyi™ All strengths 1 tablet per day (fibanserin) Adempas® All strengths 3 tablets per day (riociguat) Medication Strength Limits Adlyxin® All strengths 2 pens per month (lixisenatide) Advair Diskus® 1 box (60 blisters) (fluticasone propionate + All strengths per 30 days salmeterol)

Advair HFA® (fluticasone propionate + All strengths 1 inhaler per 30 days salmeterol)

Adzenys XR-ODT™ (amphetamine extended-release) All strengths 2 tablets per day

Aerospan® inhaler (flunisolide All strengths 2 inhalers per 30 days HFA) Afinitor®, Disperz All strengths Limited to 15 day supply per fill (everolimus) Akynzeo® All strengths 4 capsules per 30 days (etupitant + palonosetron) Albenza® All strengths 4 tablets per day (albendazole) Alecensa® All strengths 8 capsules per day (alectinib) Alora® All strengths 8 patches / systems per 30 days (estradiol) Alsuma® 6 mg 6 syringes / units per Rx (sumatriptan) Altoprev® All strengths 1 tablet per day (lovastatin) Alvesco® All strengths 2 inhalers per Rx (ciclesonide) Ambien CR® All strengths 1 tablet per day (zolpidem tartrate) Ambien® All strengths 1 tablet per day (zolpidem tartrate) Amerge® All strengths 12 tablets per Rx (naratriptan) Ampyra® 10 mg 2 tablets per day (dalfampridine) Androderm® 2 mg, 4 mg 1 patch per day (testosterone) AndroGel® pump (testosterone) 4 bottles (300 gm) 1% per 30 days AndroGel® packet (testosterone) 1% 90 packets (225 gm) (2.5 gm / day) per 30 days AndroGel® packet (testosterone) 1% 60 packets (300 gm) (5 gm / day) per 30 days Medication Strength Limits AndroGel® pump (testosterone) 2 bottles (150 gm) 1.62% per 30 days AndroGel® packet (testosterone) 1.62% 30 packets (38 gm) (1.25 gm) per 30 days AndroGel® packet (testosterone) 1.62% 60 packets (150 gm) (2.5 gm) per 30 days Androxy™ All strengths 1 tablet per day (fluoxymesterone) Angeliq® All strengths 1 blister pack per 30 days (estradiol + drospirenone) Anoro® Ellipta™ All strengths 1 inhalation per day (umeclidinium + vilanterol) Anturol® topical gel (oxybutynin) All strengths 1 bottle per 30 days Aptensio™ XR (methylphenidate hydrochloride extended-release) All strengths 1 capsule per day

Aptiom® 200 mg, 400 mg 1 tablet per day (eslicarbazepine acetate) Aptiom® 600 mg, 800 mg 2 tablets per day (eslicarbazepine acetate) Arcapta™ Neohaler™ All strengths 1 capsule per day (indacaterol) Aricept® 23 mg 1 tablet per day (donepezil) Arnuity™ Ellipta® All strengths 1 inhaler per 30 days (fluticasone furoate) Asmanex® HFA All strengths 1 inhaler per 30 days (mometasone furoate) Astelin® 137 mcg / spray 2 (30 ml bottles) per 30 days (azelastine) Astepro® 205.5 mcg / spray 2 (30 ml bottles) per 30 days (azelastine) Atelvia® All strengths 4 tablets per 30 days (risedronate) Atrovent HFA® 17 mcg / puff 2 inhalers per 30 days (ipratropium bromide) Atrovent® nasal solution 21 mcg / spray 2 (30 ml bottles) per 30 days (ipratropium bromide) Atrovent® nasal solution 42 mcg / spray 3 (15 ml bottles) per 30 days (ipratropium bromide) Aubagio® All strengths 1 tablet per day (teriflunomide) Medication Strength Limits Axert® All strengths 12 tablets per Rx (almotriptan) Axiron® All strengths 2 bottles (180 ml) per 30 days (testosterone) Beconase AQ® (beclomethasone dipropionate) 42 mcg / spray 2 (25 gm bottles) per 30 days

Belbuca™ All strengths 2 films per day (buprenorphine) Belsomra® All strengths 1 tablet per day (suvorexant) Belviq® 10 mg 2 tablets per day (lorcaserin) Belviq XR® All strengths 1 tablet per day (locaserin extended release) Bethkis® 56 ampules per 300 mg / 4 ml ampule (tobramycin) 56 rolling days Bevespi Aerosphere® (glycopyrrolate + formoterol 4.8 mcg 1 cannister per 30 days fumarate)

Binosto™ All strengths 4 tablets per 30 days (alendronate) Boniva® 150 mg 1 tablet per 30 days (ibandronate) Boniva® 2.5 mg 1 tablet per day (ibandronate) Bosulif® 100 mg 4 tablets per day (bosutinib) Bosulif® 500 mg 1 tablet per day (bosutinib) Breo Ellipta® (fluticasone furoate + vilanterol) All strengths 1 inhalation per day

Bowel preparation medications (Generic polyethylene glycol 3350 products Bisacodyl Magnesium Citrate Magnesium hydroxide, All strengths 1 regimen per 365 days Phosphate laxative)

Brisdelle™ All strengths 1 capsule per day (paroxetine mesylate) Briviact® oral solution All strengths 20 ml per day (brivaracetam) Briviact® tablet (brivaracetam) All strengths 2 tablets per day Medication Strength Limits Bunavail™ All strengths 2 tablets per day (buprenorphine + naloxone) Buphenyl® 500 mg 40 tablets per day (sodium phenylbutyrate) Butrans® All strengths 4 patches per 30 days (buprenorphine) Bydureon® All strengths 4 vials / pens per 30 days (exenatide) Byetta® All strengths 1 pen per 30 days (exenatide) Byvalson™ All strengths 1 tablet per day (nebivolol + valsartan) Cabometyx™ 20 mg & 60 mg 1 tablet per day (cabozantinib) Cabometyx™ 40 mg 2 tablets per day (cabozantinib) Caduet® All strengths 1 tablet per day (amlodipine + atorvastatin) Cambia™ 50 mg 9 packets per 30 days (diclofenac) Caprelsa® 100 mg 2 tablets per day (vandetanib) Caprelsa® 300 mg 1 tablet per day (vandetanib) Carac® 0.5% 30 gm (1 tube) per 30 days (fluorouracil) Caverject® All strengths 12 vials / units per 30 days (alprostadil) Cayston® All strengths 1 kit per 28 days (aztreonam) Cerdelga™ All strengths 1 capsule per day (eliglustat) Chantix® All strengths 2 tablets per day (varenicline) Cholbam® All strengths 8 capsules per day (cholic acid) chorionic gonadotropin All strengths Not applicable Cialis® All strengths 12 tablets per 30 days (tadalafil) Cimzia® 1 package (2 syringes) All strengths (certolizumab) per 30 days Clarinex D® 12 hour (desloratadine + pseudoephedrine) 2.5 mg / 120 mg 2 tablets per day Medication Strength Limits Clarinex® / Clarinex Reditab (desloratadine) 2.5 mg, 5 mg 1 tablet per day

Climara® All strengths 4 systems / patches per 30 days (estradiol) Climara-Pro® All strengths 4 systems / patches per 30 days (estradiol + levonorgestrel) Clomid All strengths Not applicable (clomiphene) CombiPatch® All strengths 8 systems / patches per 30 days (estradiol + norethindrone) Cometriq™ All strengths 4 cards (1 box) per 30 days (cabozantinib) Complera® (emtricitabine + rilpivirine + All strengths 1 tablet per day tenofovir disoproxil fumarate) Conceptrol® 1 package (25.5 grams) All strengths (nonoxinol 9) per 30 days Contrave® (naltrexone HCl + bupropion HCl All strengths 4 tablets per day extended-release)

Corlanor® All strengths 2 tablets per day (ivabradiene) Cosentyx™ All strengths 1 package per 30 days (secukinumab) Cotellic™ All strengths 63 tablets per 30 days (cobimetinib) Cresemba® All strengths 70 capsules per 30 days (isavuconazonium sulfate) Crestor® All strengths 1 tablet per day (rosuvastatin) Cycloset® All strengths 6 tablets per day (bromocriptine mesylate) Cystaran™ 0.44 % solution 4 vials per 3 days (cysteamine) Daklinza™ All strengths 1 tablet per day (daclatasvir) Daliresp® All strengths 1 tablet per day (roflumilast) Dalmane® All strengths 1 capsule per day (flurazepam) Descovy® All strengths 1 tablet per day (emtricitabine + tenofovir) Desvenlafaxine ER All strengths 1 tablet per day Medication Strength Limits Dibenzyline® All strengths 12 capsules per day (phenoxybenzamine) Diclegis® (doxylamine succinate + pyridoxine 10 mg / 10 mg 4 tablets per day HCl)

Didronel® 200 mg 75 tablets per 30 days (etidronate) Didronel® 400 mg 150 tablets per 30 days (etidronate) Dificid® All strengths 28 tablets per Rx (fidaxomicin) Divigel® All strengths 1 packet per day (estradiol) Doral® 15 mg 1 tablet per day (quazepam) Duexis® All strengths 3 tablets per day (ibuprofen + famotidine) Dulera® (mometasone furoate + formoterol All strengths 1 inhaler per 30 days fumarate)

Dupixent® All strengths 2 syringes per 30 days (dupliumab) Durlaza™ All strengths 1 tablet per day (aspirin extended-release) Duopa™ All strengths 4 cartons (2800ml) per 30 days (carbidopa + levodopa) Dyanavel™ XR (amphetamine extended-release) All strengths 8 ml per day

Dymista® All strengths 1 bottle (23 gm) per 30 days (azelastine + fluticasone) Ecoza™ All strengths 1 bottle per 30 days (econazole) Edarbi™ All strengths 1 tablet per day (azilsartan medoxomil) Edarbyclor™ (azilsartan medoxomil + All strengths 1 tablet per day chlorthalidone)

Edex® All strengths 12 vials per 30 days (alprostadil) Edluar® All strengths 1 tablet per day (zolpidem) Edurant® All strengths 1 tablet per day (rilpivirine) Medication Strength Limits Egrifta® 1 mg 2 vials per day (tesamorelin) Egrifta® 2 mg 1 vial per day (tesamorelin) Elestrin® transdermal gel 0.06% 2 pumps per 30 days (estradiol) Eliquis® All strengths 74 capsules per 30 day (apixaban) Ella® 30 mg 1 tablet per Rx (ulipristal acetate) Embeda® (morphine sulfate + naltrexone) All strengths 2 capsules per day

Emend ® oral suspension All strengths 6 pouches per month (aprepitant) Emverm™ 100 mg 6 tablets per 30 days (mebendazole) Enablex® All strengths 1 tablet per day (darifenacin) Enbrel® 8 syringes/vials 25 mg (etanercept) per 30 days Enbrel® 4 syringes/vials 50 mg (etanercept) per 30 days Enstilar® (calcipotriene + betamethasone 0.005% / 0.064% 7 cans per 30 days dipropionate)

Entresto™ All strengths 2 tablets per day (sacubitril + valsartan) Epclusa® 400 mg / 100 mg 1 tablet per day (sofosbuvir + velpatasvir) Epiduo® Forte (adapalene + benzoyl peroxide) 0.3% / 2.5% 1 pump per 30 days epinephrine auto-injector All strengths 4 injections per Rx (Adrenaclick®) Erivedge™ All strengths 1 tablet per day (vismodegib) Esbriet® 267 mg 9 capsules / tablets per day (pirfenidone) Esbriet® 801 mg 3 tablets per day (pirfenidone) Esomeprazole strontium All strengths 2 capsules a day Estraderm® All strengths 8 systems per 30 days (estradiol) Medication Strength Limits Estrasorb® topical emulsion 4.35 mg / 1.74 gm pouch 56 pouches per 30 days (estradiol hemihydrate) Estring® 2 mg (0.075 mg / day) 1 ring per 90 days (estradiol) Estrogel® transdermal gel 0.06% 1 pump (50 gm) per 30 days (estradiol) Eucrisa™ 2% 1 tube per Rx (crisaborole) Evekeo™ All strengths 4 tablets per day (amphetamine sulfate) Evista® All strengths 1 tablet per day (raloxifene) Evotaz™ All strengths 1 tablet per day (atazanavir + cobicistat) Evzio™ All strengths 2 kits (4 auto injectors) per fill (naloxone HCl injection) Evzio™ auto-injector (naloxone All strengths 2 boxes (4 injections) per Rx HCl) Exalgo® All strengths 2 tablets per day (hydromorphone) Fabior™ All strengths 1 canister per 30 days (tazarotene) Farxiga® All strengths 1 tablet per day (dapagliflozin) Farydak® All strengths 6 capsules per 21 days (panobinostat) Female Condom All strengths 6 per 30 days Femring® All strengths 1 vaginal ring per 90 days (estradiol acetate) Fentora® All strengths 4 buccal tablets per day (fentanyl citrate) Ferriprox® tablet (deferiprone) All strengths 18 tablets per day

Ferriprox® oral solution All strengths 90 ml per day (deferiprone) Fetzima™ All strengths 1 capsule per day (levomilnacipran) Fetzima™ titration pack All strengths 1 pack per year (levomilnacipran) Finacea® Foam (azelaic acid All strengths 1 can per 30 days 0.15%) Firazyr® 30 mg / 3 ml 6 syringes per 30 days (icatibant) Flector® patch (diclofenac) All strengths 2 patches per day Medication Strength Limits Flonase® 50 mcg / spray 1 (16 gm bottle) per 30 days (fluticasone) Flovent® Diskus 100 mcg / dose, 250 mcg / 2 units (120 doses) (fluticasone propionate) dose per 30 days Flovent® Diskus 1 unit (60 doses) 50 mcg / dose (fluticasone propionate) per 30 days Flovent® HFA 110 mcg / puff, 220 mcg / 2 inhalers per 30 days (fluticasone propionate) puff Flovent® HFA 44 mcg / puff 1 inhaler per 30 days (fluticasone propionate) Flowtuss (hydrocodone bitartrate + All strengths 240 ml per Rx guaifenesin) flunisolide nasal spray All strengths 3 (25 ml bottles) per 30 days fluticasone-salmeterol All strengths 1 inhaler per 30 days inhalation power Follistim® AQ 150 IU / 0.5 ml vial Not applicable (follitropinbeta) Follistim® AQ 75 IU / 0.5 ml vial Not applicable (follitropin beta) Follistim® AQ cartridge 300 IU / 0.36 ml Not applicable (follitropin beta) Foradil® 1 box (60 blisters) 12 mcg / dose (formoterol fumarate) per 30 days Forfivo XL® All strengths 1 tablets per day (bupropion) Forteo® All strengths 1 injection pen per 30 days (teriparatide) Fortesta® 2 canisters (120 gm) All strengths (testosterone) per 30 days Fosamax Plus D® All strengths 4 tablets per 30 days (alendronate + vitamin D) Fosamax® 35 mg, 70 mg 4 tablets per 30 days (alendronate) Fosamax® 5 mg, 10 mg, 40 mg 1 tablet per day (alendronate) Fosamax® 4 bottles (300 ml) 70 mg / 75 ml (alendronate) per 30 days Frova® All strengths 12 tablets per Rx (frovatriptan) Fycompa™ oral suspension 2 bottles (680 ml) 0.5 mg/mL (perampanel) per 30 days Fycompa™ tablet (perampanel) All strengths 1 tablet per day Medication Strength Limits Gattex® 5 mg vial 1 vial per day (teduglutide) Gelnique® 10% sachet 1 gm / sachet 1 sachet per day (oxybutynin) Gelnique® pump (oxybutynin) 10% 1 gram per day

Genvoya™ (elvitegravir + cobicstat + All strengths 1 tablet per day emtricitabine + tenofovir alafenamide)

Giazo® All strengths 6 tablets per day (balsalazide) Gilenya™ 0.5 mg 1 capsule per day (fingolimod) Gilotrif™ 40 mg 1 tablet per day (afatinib) Glassia® Alpha-1 Proteinase Inhibitor 1 G / 50 ml 9 vials per 30 days (Human)

Glyxambi® All strengths 1 tablet per day (empagliflozin + linagliptin) Gonal-f® 1050 units / vial Not applicable (follitropin alfa) Gonal-f® 450 units / vial Not applicable (follitropin alfa) Gonal-f® RFF Pen 300 units / 0.5 ml Not applicable (follitropin alfa) Gonal-f® RFF 75 units / vial Not applicable (follitropin alfa) Gonal-f® RFF Pen 450 units / 0.75 ml cartridge Not applicable (follitropin alfa) Gonal-f® RFF Pen 900 units / 1.5 ml cartridge Not applicable (follitropin alfa) Gralise® All strengths 3 tablets per day (gabapentin) Gralise® starter pack (gabapentin) All strengths 78 tablets per year

Grastek® (timothy grass pollen allergen All strengths 1 tablet per day extract) Gynol II® 1 package (81 grams) All strengths (nonoxinol 9) per 30 days H.P. Acthar Gel® All strengths 4 vials per 30 days (repository corticotropin) Medication Strength Limits Halcion® 0.125 mg 1 tablet per day (triazolam) Halcion® 0.25 mg 2 tablets per day (triazolam) Harvoni® All strengths 1 tablet per day (ledipasvir + sofosbuvir) Hemangeol™ All strengths 3 bottles per 30 days (propranolol) Hetlioz™ All strengths 1 capsule per day (tasimelteon) Horizant® All strengths 2 tablets per day (gabapentin enacarbil) Humira® 10 mg / 0.2 ml 1 package (2 syringes) (adalimumab) 20 mg / 0.4 ml per 30 days Humira® 2 packages (4 syringes/pens) 40 mg / 0.8 ml (adalimumab) per 30 days Humira® Pen Starter Pack All strengths 2 packages per year (adalimumab) Hycofenix (hydrocodone bitartrate + All strengths 240 ml per Rx pseudoephendrin + guaifenesin) hydrocodone / acetaminophen, oxycodone / acetaminophen, codeine These drugs accumulate / acetaminophen 4 grams per day between all strengths (Lortab, Norco, Percocet, Tylenol with Codeine, Vicodin, Xodol)

Hysingla™ ER (hydrocodone bitartrate extended- All strengths 1 tablet per day release)

Ibrance® All strengths 21 capsules per 30 days (palbociclib) Iclusig™ 15 mg 2 tablets per day (ponatinib) Iclusig™ 45 mg 1 tablet per day (ponatinib) Imbruvica™ All strengths 4 tablets per day (ibrutinib) Imitrex® injection (sumatriptan) All strengths 6 syringes / units per Rx

Imitrex® nasal spray (sumatriptan) All strengths 6 units per Rx Medication Strength Limits Imitrex® tablets (sumatriptan) All strengths 12 tablets per Rx

Impavido® All strengths 84 capsules per 30 days (miltefosine) Incruse™ Ellipta® All strengths 1 capsule per day (umeclidinium) Inlyta® 1 mg 6 tablets per day (axitinib) Inlyta® 5 mg 4 tablets per day (axitinib) Insulin Needles and Syringes All sizes Not applicable

Intermezzo® All strengths 1 tablet per day (zolpidem) Intuniv® All strengths 1 tablet per day (guanfacine hydrochloride) Invega® 1.5 mg, 3 mg, 9 mg 1 tablet per day (paliperidone) Invega® 6 mg 2 tablets per day (paliperidone) Invega Trinza™ All strengths 4 kits per 365 days (paliperidone palmitate) Invokamet® All strengths 2 tablets per day (canagliflozin + metformin) Invokamet® XR (canagliflozin + metformin All strengths 2 tablets per day extended release)

Invokana™ All strengths 1 tablet per day (canagliflozin) Iressa® All strengths 1 tablet per day (gefitinib) Jakafi® All strengths 2 capsules per day (ruxolitinib) Jalyn™ All strengths 1 capsule per day (dutasteride + tamsulosin) Janumet XR® 50 mg / 1000 mg 2 tablets per day (sitagliptin + metformin) Janumet XR® 50 mg / 500 mg, 100 mg / 1 tablet per day (sitagliptin + metformin) 1000 mg Januvia® All strengths 1 tablet per day (sitagliptin) Jardiance® All strengths 1 tablet per day (empagliflozin) Jentadueto® All strengths 2 tablets per day (linagliptin + metformin) Medication Strength Limits Jentadueto XR® (linagliptin + metformin extended 2.5 mg / 1000 mg 2 tablets per day release)

Jentadueto XR® (linagliptin + metformin extended 5 mg / 1000 mg 1 tablet per day release)

Juvisync™ All strengths 1 tablet per day (sitagliptin + simvastatin) Juxtapid™ All strengths 1 capsule per day (lomitapide) Kalydeco™ granule (ivacaftor) All strengths 2 packets per day

Kalydeco™ tablet (ivacaftor) All strengths 2 tablets per day Kapvay® All strengths 4 tablets per day (clonidine HCl ER) Karbinal™ ER (carbinoxamine maleate extended- All strengths 1440 ml per 30 days release)

Kazano® All strengths 2 tablets per day (alogliptin + metformin) Keveyis™ All strengths 4 tablets per day (dichlorphenamide) Khedezla® ER All strengths 1 tablet per day (desvenlafaxine) Kineret® SC syringe 1 syringe per day (anakinra) Korlym™ tablet (mifepristone) All strengths 4 tablets per day Kynamro™ 200 mg / ml 4 doses per 30 days (mipomersen) Lazanda® All strengths 1 bottle per day (fentanyl citrate) Lenvima™ 10 mg 1 capsule per day (lenvatinib) Lenvima™ 8mg, 14mg, 20mg 2 capsules per day (lenvatinib) Lenvima™ 18mg, 24mg 3 capsules per day (lenvatinib) Lescol® All strengths 1 capsule per day (fluvastatin) Lescol® XL 80 mg 1 tablet per day (fluvastatin) Letairis® All strengths 1 tablet per day (ambrisentan) Levitra® All strengths 12 tablets per 30 days (vardenafil) Medication Strength Limits levonorgestrel 1.50 mg 1 tablet per Rx (Plan B) (emergency OC) Linzess™ All strengths 1 capsule per day (linaclotide) Lipitor® All strengths 1 tablet per day (atorvastatin) Liptruzet® All strengths 1 tablet per day (ezetimibe + atorvastatin) Livalo® All strengths 1 tablet per day (pitavastatin) Lonsurf® All strengths 100 tablets per 30 days (trifluridine + tipiracil) LoSeasonique® (levonorgestrel + ethinyl estradiol 84 tablets 1 mg / 0.02 mg 1 blister pack per 91 days tablets and 7 tablets 0.01 mg + ethinyl estradiol)

Lunesta® All strengths 1 tablet per day (eszopiclone) Luzu® All strengths 1 tube per 30 days (luliconazole) Lynparza™ All strengths 16 capsules per day (olaparib) Lysteda® All strengths 1 tablet per day (tranexamic acid) Maxalt® / Maxalt MLT® All strengths 12 tablets per Rx (rizatriptan) Mekinist™ 0.5 mg 3 tablets per day (trametinib) Mekinist™ 2 mg 1 tablet per day (trametinib) Menostar® 14 mcg / day 4 systems per 30 days (estradiol) Mevacor® 10 mg, 20 mg 1 tablet per day (lovastatin) Mevacor® 40 mg 2 tablets per day (lovastatin) Migranal® nasal spray 4 mg / 1 ml ampule 8 ampules per Rx (dihydroergotamine) Minivelle® All strengths 8 systems per 30 days (estradiol) Mirapex ER® (pramipexole extended release) All strengths 1 tablet per day Medication Strength Limits Mircera® (methoxy polyethylene glycol- All strengths 2 syringes per 30 days epoetin beta)

Movantik™ All strengths 1 tablet per day (naloxegol ) Multaq® 400 mg 2 tablets per day (dronedarone) MUSE® All strengths 12 pouches per 30 days (alprostadil) Myalept™ All strengths 1 vial per day (metreleptin) Myrbetriq® (mirabegron extended release) All strengths 1 tablet per day

Mytesi™ All strengths 2 tablets per day (crofelemer delayed-release) Naftin® All strengths 1 bottle per 30 days (naftifine) Namenda XR® (memantine extended release) All strengths 1 tablet per day

Namenda XR® (memantine extended release) Titration pack 2 packs per year

Namzaric™ All strengths 1 tablet per day (memantine + donepezil) Namzaric™ titration pack 1 pack (28 capsules) All strengths (memantine + donepezil) per 365 days Narcan® nasal spray (naloxone All strengths 2 cartons (4 doses) per fill hydrochloride) Nasacort AQ® 1 bottle (16.5 gm) 55 mcg / spray (triamcinolone acetonide) per 30 days Nasonex® 50 mcg / spray 2 bottle (17 gm) per 30 days (mometasone furoate) Natesto™ All strengths 3 bottles per 30 days (testosterone) Natpara® All strengths 2 cartridges per 30 days (parathyroid hormone) Nesina® All strengths 1 tablet per day (alogliptin) Neulasta® 6 mg / 0.6 ml syringe 2 syringes per 30 days (pegfilgrastim) Neupro® All strengths 1 patch per day (rotigotine) Medication Strength Limits Nexavar® All strengths Limited to 15 day supply per fill (sorafenib) Nicorette® gum / lozenges All strengths 770 pieces per 30 days (nicotine) Nicotine patch (nicotine) All strengths 1 patch per day Nicotrol® inhaler (nicotine) All strengths 3 packages per 30 days Nicotrol® NS nasal spray 10 mg / ml 40 ml (4 bottles) per 30 days (nicotine) Ninlaro® All strengths 3 tablets per 30 days (ixazomib) Northera™ 100 mg, 3 capsules per day (droxidopa) 200 mg Northera™ 300 mg 6 capsules per day (droxidopa) Novarel® All strengths Not applicable (chorionic gonadotropin) Noxafil® (posaconazole delayed-release) All strengths 93 tablets for 30 days

Nucynta® All strengths 6 tablets per day (tapentadol) Nucynta® ER All strengths 2 tablets per day (tapentadol) Nuedexta® (dextromethorphan HBr + quinidine sulfate) All strengths 2 tablets per day

Nuplazid™ All strengths 2 tablets per day (pimavanserin) Nuvaring® (etonogestrel + ethinyl estradiol) 0.12 mg / 0.015 mg 1 vaginal ring per 30 days

Nuvigil® All strengths 1 tablet per day (armodafinil) Nymalize® 2,520 ml per 21 days, 5,040 ml All strengths (nimodipine) per year Obredon® (hydrocodone bitartrate + All strengths 240 ml per Rx guaifenisin)

Ocaliva™ All strengths 1 tablet per day (obeticholic acid) Odefsey® (emtricitabine + rilpivirine + 200 mg / 25 mg / 25mg 1 tablet per day tenofovir)

Odomzo® All strengths 1 capsule per day (sonidegib) Medication Strength Limits Ofev® All strengths 2 tablets per day (nintedanib) Olysio™ All strengths 1 capsule per day (simeprevir) Omnaris® 50 mcg / spray 1 bottle (13 gm) per 30 days (ciclesonide) Onexton™ (clindamycin + benzoyl peroxide) All strengths 1 bottle per 30 days

Onfi® All strengths 3 tablets per day (clobazam) Onfi® oral suspension (clobazam) All strengths 16 ml per day

Onglyza® All strengths 1 tablet per day (saxagliptin) Onsolis® All strengths 4 films per day (fentanyl) Onzetra™ Xsail™ All strengths 1 dose pack per month (sumatriptan) Opana® All strengths 6 tablets per day (oxymorphone) Opana® ER All strengths 4 tablets per day (oxymorphone HCl) Opsumit® All strengths 1 tablet per day (macitentan) Oralair® (mixed grass pollens allergens All strengths 1 tablet per day extract)

Oralair® (mixed grass pollens allergens Starter pack 1 pack per year extract)

Oravig® All strengths 1 tablet per day (miconazole) Orencia® All strengths 4 syringes per 30 days (abatacept) Orenitram™ All strengths 9 tablets per day (treprostinil) Orkambi™ All strengths 112 tablets per 30 days (lumacaftor + ivacaftor) Ortho Evra® (ethinyl estradiol + norelgestromin) 20 mcg / 150 mcg / 24° 3 patches per 30 days

Oseni® All strengths 1 tablet per day (alogliptin + pioglitazone) Medication Strength Limits Otezla® All strengths 2 tablets per day (apremilast) Otrexup™ All strengths 4 injections per 30 days (methotrexate) Ovidrel® All strengths Not applicable (choriogonadotropin alfa i) Oxaydo® All strengths 4 tablets per day (oxycodone HCl) Oxistat® All strengths 1 bottle per 30 days (oxiconazole) Oxtellar XR™ 150 mg, 300 mg 1 tablet per day (oxcarbazepine XR) Oxtellar XR™ 600 mg 4 tablets per day (oxcarbazepine XR) Oxycodone immediate release All strengths 6 tablets per day

Oxycodone oral concentrate 20 mg / ml Not applicable Oxycodone oral solution 5 mg / 5 ml Not applicable Oxycontin® All strengths 6 tablets per day (oxycodone ER) Oxytrol® 3.9 mg / 24 hr 8 patches per 30 days (oxybutynin chloride) Patanase® 665 mcg / spray 1 bottle (30 gm) per 30 days (olopatadine) Pazeo™ (olopatadine hydrochloride 0.7%) All strengths 2 bottles per 30 days

Pegasys® 4 syringes / vials / pens per 30 All strengths (peginterferon alfa-2a) days Peg-intron® All strengths 4 vials / redipens per 30 days (peginterferon alfa-2b) Pennsaid® All strengths 2 bottles per 30 days (diclofenac sodium) Picato® All strengths 1 carton per 90 days (ingenol mebutate) Plegridy™ 1 carton ( 2 syringes) All strengths (peginterferon beta- 1a) per 30 days Pomalyst® All strengths 21 capsules per 30 days (pomalidomide) Pradaxa® All strengths 2 capsules per day (dabigatran) Praluent™ All strengths 2 doses per 30 days (alirocumab) Pravachol® All strengths 1 tablet per day (pravastatin) Medication Strength Limits Pregnyl® All strengths Not applicable (chorionic gonadotropin) Prestalia® (perindopril arginine/amlodipine) All strengths 1 tablet per day

Prevacid® All strengths Not applicable (lansoprazole) Prezcobix™ All strengths 1 tablet per day (darunavir + cobicistat) Prilosec® All strengths Not applicable (omeprazole) ProAir® HFA / Proventil® HFA / Ventolin® HFA All strengths 4 inhalers per 30 days (albuterol sulfate)

ProAir® Respiclick All strengths 4 inhalers per 30 days (albuterol sulfate) Prosom™ All strengths 1 tablet per day (estazolam) Protonix® All strengths Not applicable (pantoprazole) Provigil® All strengths 2 tablets per day (modafinil) Prozac® 60 mg 1 tablet per day (fluoxetine) Prozac® Weekly 90 mg 4 capsules per 30 days (fluoxetine) Pulmicort Flexhaler® All strengths 2 canisters per 30 days (budesonide) Qbrelis™ All strengths 40 ml per day (lisinopril) Qnasl® All strengths 1 canister per 30 days (beclomethasone) Qsymia® All strengths 1 capsule per day (phentermine + topiramate) Quartette™ (levonorgestrel + ethinyl estradiol) All strengths 1 blister pack per 91 days

Qudexy™ XR 200 mg 2 capsules per day (topiramate) Qudexy™ XR 25 mg, 50 mg, 1 capsule per day (topiramate) 100 mg, 150 mg Quillichew ER™ (methylphenidate hydrochloride extended-release) 20 mg 1.5 tablets per day Medication Strength Limits Quillichew ER™ (methylphenidate hydrochloride extended-release) 30 mg 2 tablets per day

Quillichew ER™ (methylphenidate hydrochloride extended-release) 40 mg 1 tablet per day

Quillivant XR™ 120ml /150 ml/180 ml bottle (methylphenidate hydrochloride All strengths 2 bottles per 30 days extended release)

Quillivant XR™ 60 ml bottle (methylphenidate hydrochloride All strengths 1 bottle per 30 days extended release)

QVAR® (beclomethasone dipropionate) All strengths 2 inhalers per 30 days

Ragwitek™ (short ragweed pollen allergen All strengths 1 tablet per day extract)

Rapaflo® All strengths 1 capsule per day (silodosin) Rasuvo™ All strengths 4 injections per 30 days (methotrexate) Ravicti™ 1.1 gm / ml 525 ml per 30 days (glycerol phenylbutyrate) Rayaldee® All strengths 2 capsules per day (calcifediol extended-release) Rayos® All strengths 3 tablets per day (prednisone delayed release) Rectiv™ All strengths 1 tube (30 gm) per 30 days (nitroglycerin) Relenza® 20 capsules per Rx, 40 capsules All strengths (zanamivir) per 6 months Relistor® injection All strengths 1 vial/syringe per day (methylnaltrexone) Relistor® tablet (methylnaltrexone) All strengths 3 tablets per day

Relpax® All strengths 12 tablets per Rx (eletriptan) Medication Strength Limits Repatha™ All strengths 3 ml per 30 days (evolocumab) Repatha®Pushtronex™ All strengths 1 injector per 30 days (evolocumab) Restoril™ All strengths 1 capsule per day (temazepam) Revatio® 20 mg 3 tablets per day (sildenafil citrate) Revatio® suspension (sildenafil) 150 ml bottle 2 bottles per 30 days

Revlimid® All strengths 1 tablet per day (lenalidomide) Rexulti® All strengths 1 tablet per day (brexpiprazole) Rezira™ oral solution (hydrocodone bitartrate + All strengths 240 ml per Rx pseudoephedrine) Rhinocort Aqua® 2 bottles (8.6 gm) 32 mcg / spray (budesonide) per 30 days Rozerem® All strengths 1 tablet per day (ramelteon) Ruconest™ 4 vials (8,400 units) (C1 esterase inhibitor, All strengths per 30 days [recombinant])

Rytary™ (carbidopa + levodopa extended All strengths 12 capsules per day release)

Samsca® 15 mg 1 tablet per day (tolvaptan) Samsca® 30 mg 2 tablets per day (tolvaptan) Sanctura® 20 mg 2 tablets per day (trospium) Sanctura XL® (trospium chloride extended 60 mg 1 capsule per day release)

Sancuso® (granisetron extended release) 3.1 mg 4 patches per 30 days

Saphris® All strengths 2 tablets per day (asenapine) Savaysa™ All strengths 1 tablet per day (edoxaban) Savella® All strengths 2 tablets per day (milnacipran) Medication Strength Limits Saxenda® All strengths 5 pens per 30 days (liraglutide) Seasonale® / Jolessa® / Quasense® 0.15 mg / 1 blister pack per 91 days (levonorgestrel + ethinyl estradiol) 0.03 mg

Seasonique® 84 tablets 0.15 mg / 0.03 mg (levonorgestrel + ethinyl estradiol + 1 blister pack per 91 days and 7 tablets 0.01 mg ethinyl estradiol)

Seebri™ Neohaler® All strengths 2 inhalations per day (glycopyrrolate) Serevent Diskus® 1 box (60 blisters) 50 mcg / dose (salmeterol xinafoate) per 30 days Seroquel XR® All strengths 2 tablets per day (quetiapine fumarate) Signifor® All strengths 2 ampules per day (pasireotide) Signifor® LAR All strengths 1 kit per 30 days (pasireotide) Silenor® All strengths 1 tablet per day (doxepin) Simponi® All strengths 1 syringe per 30 days (golimumab) Singulair® All strengths 1 tablet per day (montelukast) Singulair® 4 mg packet 1 packet per day (montelukast) Sitavig® All strengths 1 tablet per 30 days (acyclovir) Sivextro™ All strengths 6 tablets per Rx (tedizolid phosphate) Sklice® lotion All strengths 1 tube per 30 days (ivermectin) Solaraze® All strengths 100 gm (1 tube) per 30 days (diclofenac sodium) Soliqua™ (insulin glargine + lixisenatide All strengths 5 pens per 30 days injection)

Somatuline® Depot All strengths 1 syringe per 30 days (lanreotide) Sonata® 10 mg 2 capsules per day (zaleplon) Sonata® 5 mg 1 capsule per day (zaleplon) Medication Strength Limits Soolantra® All strengths 1 tube per 30 days (ivermectin) Sovaldi™ All strengths 1 tablet per day (sofosbuvir) Spiriva Handihaler® 1 box (30 capsules) 18 mcg / dose (tiotropium bromide) per 30 days Spiriva Respimat® All strengths 1 inhaler per 30 days (tiotropium) Spritam® 250 mg, 500 mg, 1000 mg 2 tablets per day (levetiracetam) Spritam® 750 mg 4 tablets per day (levetiracetam) Sprix® All strengths 5 bottles per 30 days (ketorolac tromethamine) Sprycel® All strengths Limited to 15 day supply per fill (dasatinib) Staxyn™ 10 mg 12 tablets per 30 days (vardenafil) Stelara® All strengths 1 syringe/vial every 56 days (ustekinumab) Stendra™ All strengths 12 tablets per 30 days (avanafil) Stiolto™ Respimat® (tiotropium bromide + olodaterol) All strengths 1 inhaler per 30 days

Stivarga® All strengths 84 tablets per 30 days (regorafenib) Strensiq™ 18 mg, 28 mg, 24 vials per 30 days (asfotase alfa) 40 mg vial Strensiq™ 80 mg vial 48 vials per 30 days (asfotase alfa) Striant® 30 mg 2 buccal systems per day (testosterone) Stribild™ (elvitegravir + cobicistat + All strengths 1 tablet per day emtricitabine +tenofovir disoproxil fumarate)

Striverdi® Respimat® (olodaterol) All strengths 1 inhaler per 30 days

Suboxone® film + tablet All strengths 3 films / tablets per day (buprenorphine + naloxone) Subutex® All strengths 3 tablets per day (buprenorphine) Subsys® All strengths 4 sprays per day (fentanyl) Medication Strength Limits Sumavel® DosePro® All strengths 6 units per 30 days (sumatriptan) Suprenza™ All strengths 1 tablet per day (phentermine HCl) Sutent® All strengths Limited to 15 day supply per fill (sunitinib) Sylatron™ All strengths 4 vials per 30 days (peginterferon alfa-2b) Symbicort® All strengths 1 inhaler per 30 days (budesonide + formoterol) Synjardy® (empagliflozin + metformin HCl) All strengths 2 tablets per day

Synjardy® XR 5mg / 1000mg (empagliflozin + metformin 2 tablets per day 12.5 mg / 1000 mg extended release)

Synjardy® XR 10 mg / 1000 mg (empagliflozin + metformin 1 tablet per day 25 mg / 1000 mg extended release)

Syprine® All strengths 8 capsules per day (trientine) Tafinlar® All strengths 4 capsules per day (dabrafenib) Tagrisso™ All strengths 1 tablet per day (osimertinib) Taltz® 3 pack (ixekizumab) All strengths 1 pack per year Taltz® 2 pack (ixekizumab) All strengths 2 packs per year Taltz® single pack (ixekizumab) All strengths 1 pack per 30 days

Tamiflu® 30 mg 40 capsules per 6 months (oseltamivir) Tamiflu® 45 mg, 75 mg 20 capsules per 6 months (oseltamivir) Tamiflu® suspension 60 ml bottle 6 bottles (360 ml) 6 mg / ml (oseltamivir) per 6 months tamoxifen citrate All strengths 2 tablets per day Tanzeum™ All strengths 4 syringes per 30 days (albiglutide) Tarceva® All strengths Limited to 15 day supply per fill (erlotinib) Targiniq™ ER All strengths 2 tablets per day (oxycodone + naloxone) Tecfidera™ (dimethyl fumarate delayed- All strengths 2 tablets per day release) Medication Strength Limits Tecfidera™ (dimethyl fumarate delayed- Starter pack 1 pack per year release)

Technivie™ (ombitasvir + paritaprevir + All strengths 56 tablets per 30 days ritonavir)

Tekamlo™ All strengths 1 tablet per day (aliskiren + amlodipine) Testim® 2 cartons (60 tubes) 1% (50 mg) (testosterone) per 30 days Tivorbex™ All strengths 3 capsules per day (indomethacin) Tobi® 300 mg / 5 ml ampule 56 ampules per 56 rolling days (tobramycin) Tobi® Podhaler™ 28 mg / capsule 224 capsules per 56 rolling days (tobramycin) Today Contraceptive Sponge® (nonoxynol-9) All strengths 6 units per 30 days

Tolak™ 40 gm (1 tube) 4% (fluorouracil) per 30 days Topiramate ER 200 mg 2 capsules per day Topiramate ER 25 mg, 50 mg, 1 capsule per day 100 mg, 150 mg Toradol® 10 mg 20 tablets per Rx (ketorolac) Toviaz® All strengths 1 tablet per day (fesoterodine) Tracleer® All strengths 2 tablets per day (bosentan) Tradjenta® All strengths 1 tablet per day (linagliptin) Treximet® 85 mg / 500 mg 9 tablets per Rx (sumatriptan + naproxen sod) Tribenzor® (olmesartan + amlodipine + All strengths 1 tablet per day hydrochlorothiazide)

Trintellix® All strengths 1 tablet per day (vortioxetine) Triumeq® (abacavir + dolutegravir + All strengths 1 tablet per day lamivudine)

Trokendi XR™ All strengths 2 tablets per day (topiramate XR) Medication Strength Limits Trulance™ All strengths 1 tablet per day (plecanatide) Trulicity™ All strengths 4 syringes per 30 days (dulaglutide) Tudorza™ Pressair™ All strengths 1 inhaler per 30 days (aclidinium bromide) TussiCaps® (hydrocodone polistirex + All strengths 14 capsules per Rx chlorpheniramine polistirex) Tuzistra™ XR (codeine polistirex + All strengths 240 ml per Rx chlorpheniramine polistirex extended-release)

Tybost® All strengths 1 tablet per day (cobicistat) Tyvaso® All strengths 4 ampules per day (treprostinil) Uceris™ (budesonide extended release) All strengths 1 tablet per day

Uloric® All strengths 1 tablet per day (febuxostat) Uptravi® All strengths 2 tablets per day (selexipag) Uptravi® Starter Pack (selexipag) All strengths 1 pack per 365 days

Utibron™ Neohaler® All strengths 2 inhalations per day (indacaterol + glycopyrrolate) Varubi™ All strengths 8 tablets per 30 days (rolapitant) Vascepa® All strengths 4 capsules per day (icosapent ethyl) VCF® contraceptive film All strengths 6 units per day (nonoxynol-9) VCF® contraceptive foam 12.5% 1 box (17 gm) per 30 days (nonoxynol-9) Vecamyl® All strengths 10 tablets per day (mecamylamine HCl) Veltassa™ 8.4 gm 2 packets per day (patiromer) Veltassa™ 16.8 gm, 25.2 gm 1 packet per day (patiromer) Vemlidy® All strengths 1 tablet per day (tenofovir alafenamide) Medication Strength Limits Venclexta™ 100 mg 4 tablets per day (venetoclax) Venclexta™ wallets (venetoclax) 10 mg, 50 mg 4 wallets per 30 days Venclexta™ unit dose 10 mg, 50 mg 28 unit packs per 30 days (venetoclax) Venclexta™ starter pack 10 mg – 50 mg – 100 mg 1 pack per year (venetoclax) Ventavis® All strengths 9 ampules per day (iloprost) Veramyst® 27.5 mcg / spray 1 bottle (10 gm) per 30 days (fluticasone) Vesicare® All Strengths 1 tablet per day (solifenacin) Viagra® All strengths 12 tablets per 30 days (sildenafil) Viberzi™ All strengths 2 tablets per day (eluxadoline) Victoza® injection All strengths 3 pens (9 ml) per 30 days (liraglutide) Victrelis® All strengths 12 tablets per day (boceprevir) Viekira Pak™ (ombitasvir + paritaprevir + All strengths 1 pack per 30 days ritonavir + dasabuvir)

Viibryd® All strengths 1 tablet per day (vilazodone) Viibryd® Titration pack 1 pack per year (vilazodone) Vimovo® (naproxen + esomeprazole All strengths 2 tablets per day magnesium)

Vitekta® All strengths 1 tablet per day (elvitegravir) Vistogard® All strengths 20 packets per fill (uridine triacetate) Vituz® (chlorpheniramine maleate + 4 mg / 5 mg / 5 ml 240 ml per Rx hydrocodone bitartrate)

Vivelle® All strengths 8 systems per 30 days (estradiol) Vivelle-Dot® All strengths 8 systems per 30 days (estradiol) Vivlodex™ All strengths 1 capsule per day (meloxicam) Medication Strength Limits Vogelxo™ All strengths 2 packets per day (testosterone) Voltaren® gel (diclofenac) All strengths 10 tubes per 30 days Votrient® All strengths Limited to 15 day supply per fill (pazopanib) Vraylar™ All strengths 1 capsule per day (cariprazine) Vraylar™ dose pack (cariprazine) 1.5 mg – 3 mg 4 packs per 30 days

Vytorin® All strengths 1 tablet per day (ezetimibe + simvastatin) Vyvanse® (lisdexamfetamine dimesylate) All strengths 1 capsule / chew tablet per day

Xalkori® All strengths 2 capsules per day (crizotinib) Xarelto® 10 mg, 20 mg 1 tablet per day (rivaroxaban) Xarelto® Starter pack 1 pack per year (rivaroxaban) Xarelto® 15 mg 2 tablets per day (rivaroxaban) Xartemis™ XR (oxycodone HCl + acetaminophen All strengths 4 tablets per day extended-release)

Xeljanz® 5 mg 2 tablets per day (tofacitinib) Xeljanz® XR 11 mg 1 tablet per day (tofacitinib extended release) Xenazine® All strengths 2 tablets per day (tetrabenazine) Xifaxan® 550 mg 84 tablets per 30 days (rifaximin) Xigduo™ XR 5/500 mg, 10/500 mg, (dapagliflozin + metformin HCl) 1 tablet per day 10/1000 mg

Xigduo™ XR (dapagliflozin + metformin HCl) 5/1000 mg 2 tablets per day

Xiidra™ 5% 2 vials per day (lifitegrast) Xolegel® All strengths 1 tube (45 g) per 30 days (ketoconazole) Medication Strength Limits Xopenex® HFA 45 mcg / puff 2 inhalers per 30 days (levalbuterol) Xtandi® All strengths 4 capsules per day (enzalutamide) Xultophy® All strengths 5 pens per month (insulin degludec + liraglutide) Xuriden™ All strengths 4 packets per day (uridine triacetate) Xyrem® 3 bottles (540 ml) 500 mg / ml (sodium oxybate) per 30 days Xyzal® oral solution (levocetirizine) 2.5 mg / 5 ml 296 ml per 30 days

Xyzal® tablet (levocetirizine) 5 mg 1 tablet per day Zavesca™ 100 mg 3 capsules per day (miglustat) Zegerid® capsule (omeprazole-sodium bicarbonate) All strengths 1 capsule per day

Zegerid® packets (omeprazole-sodium bicarbonate) All Strengths 1 packet per day

Zelboraf® All strengths 8 tablets per day (vemurafenib) Zembrace™ SymTouch™ All strengths 4 injections per 30 days (sumatriptan succinate) Zetia® 10 mg 1 tablet per day (ezetimibe) Zepatier™ 50mg / 100mg 1 tablet per day (elbasvir + grazoprevir) Zetonna® All strengths 1 canister per 30 days (ciclesonide) Zinbryta™ All strengths 1 ml per month (daclizumab) Zipsor™ All strengths 4 capsules per day (diclofenac) Zocor® All strengths 1 tablet per day (simvastatin) Zohydro ER® All strengths 2 tablets per day (hydrocodone bitartrate) Zoladex® All strengths 1 syringe per Rx (goserelin acetate) Zomig ZMT® All strengths 12 tablets per Rx (zolmitriptan) Zomig® All strengths 12 tablets per Rx (zolmitriptan) Medication Strength Limits Zomig® nasal spray (zolmitriptan) All strengths 6 units per Rx

Zontivity™ All strengths 1 tablet per day (vorapaxar) Zorvolex™ All strengths 3 capsules per day (diclofenac) Zubsolv® All strengths 3 tablets per day (buprenorphine + naloxone) Zurampic® All strengths 1 tablet per day (lesinurad) Zutripro® All strengths 240 ml per Rx (pseudoephed + hydrocod) Zyban™ 150 mg 2 tablets per day (bupropion extended release) Zyclara® 3.75% 1 sachet per day (imiquimod) Zyclara® cream pump (imiquimod) All strengths 1 bottle (8 gm) per 30 days

Zydelig™ All strengths 2 tablets per day (idelalisib) Zyflo CR® 600 mg 4 tablets per day (zileuton extended release) Zyflo® 600 mg 4 tablets per day (zileuton) Zykadia™ All strengths 5 capsules per day (ceritinib) Zytiga® 120 tablets per 30 days (Limited (abiraterone) 250 mg to 15 day supply per fill)

Zytiga® 120 tablets per 30 days (Limited (abiraterone) 500 mg to 15 day supply per fill)