UHC PA Community and State Quantity Limit List

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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