Quantity Limits THERAPEUTIC CLASS PRODUCT NAME DRUG RESTRICTION TYPE PLAN LIMITS ACE INHIBITORS ACCUPRIL (QUINAPRIL HCL) TABS 5 MG, 10 MG DAILY DOSAGE 2 TABLETS PER DAY ACE INHIBITORS ACEON (PERINDOPRIL ERBUMINE) TABS 2MG, 8MG DAILY DOSAGE 2 TABLETS PER DAY ACE INHIBITORS CAPTOPRIL TABS 25 MG, 50 MG, 100 MG DAILY DOSAGE 3 TABLETS PER DAY ACE INHIBITORS MAVIK (TRANDOLAPRIL) TABS DAILY DOSAGE 2 TABLETS PER DAY ACE INHIBITORS UNIVASC (MOEXIPRIL HCL) TABS 7.5MG, 15MG DAILY DOSAGE 2 TABLETS PER DAY ACNE PRODUCTS ABSORICA CAPS DAILY DOSAGE 2 CAPSULES PER DAY ACNE PRODUCTS ACZONE (DAPSONE) 5% GEL TOPICAL DOSE LIMIT 1 TUBE PER FILL AMNESTEEM, CLARAVIS, MYORISAN, ZENATANE ACNE PRODUCTS (ISOTRETINOIN) CAPS DAILY DOSAGE 2 CAPSULES PER DAY ACNE PRODUCTS AZELEX 20% CREAM TOPICAL DOSE LIMIT 50 GRAMS PER 30 DAYS ACNE PRODUCTS CLEOCIN (CLINDAMYCIN PHOSPHATE) SOLN 1% TOPICAL DOSE LIMIT 60 ML PER 30 DAYS ACNE PRODUCTS DIFFERIN (ADAPALENE ) 0.1% LOTION TOPICAL DOSE LIMIT 59 ML PER 30 DAYS ACNE PRODUCTS DIFFERIN (ADAPALENE) 0.1% CREAM, 0.3% GEL TOPICAL DOSE LIMIT 45 GRAMS PER 30 DAYS ACNE PRODUCTS EPIDUO FORTE GEL TOPICAL DOSE LIMIT 45 GRAMS PER 30 DAYS ACNE PRODUCTS FABIOR 0.1% FOAM TOPICAL DOSE LIMIT 100 GRAMS PER 30 DAYS ACNE PRODUCTS KLARON (SULFACETAMIDE SODIUM 10% ) LOTION TOPICAL DOSE LIMIT 120 ML PER 10 DAYS ACNE PRODUCTS RETIN-A MICRO 0.06% MICROSPHERE GEL TOPICAL DOSE LIMIT 50 GRAMS PER FILL ACNE PRODUCTS ZIANA (CLINDAMYCIN PHOSPHATE-TRETINOIN) GEL TOPICAL DOSE LIMIT 1 TUBE PER FILL QUANTITY LIMIT 1 GRAM PER DAY AGENTS FOR EXTERNAL WARTS VEREGEN OINTMENT FILL FREQUENCY 120 GRAMS PER 365 DAYS AGENTS FOR GAUCHER DISEASE ZAVESCA (MIGLUSTAT ) CAPS DAILY DOSAGE 3 CAPSULES PER DAY ALLERGEN EXTRACTS ORALAIR DAILY DOSAGE 1 TABLET PER DAY ALPHA-2 RECEPTOR ANTAGONISTS REMERON (MIRTAZAPINE) TABS 15 MG, 7.5 MG DAILY DOSAGE 2 TABLETS PER DAY ALPHA-2 RECEPTOR ANTAGONISTS REMERON (MIRTAZAPINE) TABS 30 MG, 45 MG DAILY DOSAGE 1 TABLET PER DAY REMERON SOLTAB (MIRTAZAPINE) ORAL DISINTEGRATING 15 ALPHA-2 RECEPTOR ANTAGONISTS MG DAILY DOSAGE 2 TABLETS PER DAY REMERON SOLTAB (MIRTAZAPINE) ORAL DISINTEGRATING 30 ALPHA-2 RECEPTOR ANTAGONISTS MG, 45 MG DAILY DOSAGE 1 TABLET PER DAY COREG (CARVEDILOL) CR 24 HOUR CAPSULES 10MG, 20MG, ALPHA-BETA BLOCKERS 40MG DAILY DOSAGE 2 CAPSULES PER DAY ALPHA-BETA BLOCKERS COREG (CARVEDILOL) CR 24 HOUR CAPSULES 80 MG DAILY DOSAGE 1 CAPSULE PER DAY ALPHA-BETA BLOCKERS LABETALOL HCL TABS 300 MG DAILY DOSAGE 8 TABLETS PER DAY ALPHA-GLUCOSIDASE INHIBITORS GLYSET (MIGLITOL) TABS DAILY DOSAGE 3 TABLETS PER DAY AMINOGLYCOSIDES BETHKIS (TOBRAMYCIN) NEBULIZED SOLUTION INHALATION DOSE LIMIT 4 DOSES PER DAY AMINOGLYCOSIDES KITABIS (TOBRAMYCIN) PAK NEBULIZED SOLUTION INHALATION DOSE LIMIT 280 ML PER 56 DAYS AMINOGLYCOSIDES TOBI (TOBRAMYCIN) NEBULIZED SOLUTION INHALATION DOSE LIMIT 280 ML PER 56 DAYS AMINOGLYCOSIDES TOBI PODHALER CAPS INHALATION DOSE LIMIT 4 DOSES PER DAY ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 10 AMPHETAMINES MG DAILY DOSAGE 4 TABLETS PER DAY SHP_20173926 Quantity Limits THERAPEUTIC CLASS PRODUCT NAME DRUG RESTRICTION TYPE PLAN LIMITS ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 12.5 AMPHETAMINES MG DAILY DOSAGE 4 TABLETS PER DAY ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 15 AMPHETAMINES MG DAILY DOSAGE 4 TABLETS PER DAY ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 20 AMPHETAMINES MG DAILY DOSAGE 3 TABLETS PER DAY ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 30 AMPHETAMINES MG DAILY DOSAGE 2 TABLETS PER DAY AMPHETAMINES ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 5 MG DAILY DOSAGE 8 TABLETS PER DAY ADDERALL (AMPHETAMINE-DEXTROAMPHETAMINE) TABS 7.5 AMPHETAMINES MG DAILY DOSAGE 2 TABLETS PER DAY ADDERALL XR (AMPHETAMINE-DEXTROAMPHETAMINE) AMPHETAMINES 24 HOUR CAPS 15MG DAILY DOSAGE 4 CAPSULES PER DAY ADDERALL XR (AMPHETAMINE-DEXTROAMPHETAMINE) AMPHETAMINES 24 HOUR CAPS 20 MG DAILY DOSAGE 3 CAPSULES PER DAY ADDERALL XR (AMPHETAMINE-DEXTROAMPHETAMINE) AMPHETAMINES 24 HOUR CAPS 25 MG DAILY DOSAGE 2 CAPSULES PER DAY ADDERALL XR (AMPHETAMINE-DEXTROAMPHETAMINE) AMPHETAMINES 24 HOUR CAPS 30 MG DAILY DOSAGE 2 CAPSULES PER DAY ADDERALL XR (AMPHETAMINE-DEXTROAMPHETAMINE) AMPHETAMINES 24 HOUR CAPS 5 MG, 10 MG DAILY DOSAGE 2 CAPSULES PER DAY AMPHETAMINES DESOXYN (METHAMPHETAMINE HCL) TABS DAILY DOSAGE 5 TABLETS PER DAY DEXEDRINE (DEXTROAMPHETAMINE SULFATE) CAPS 24 HOUR AMPHETAMINES 5MG, 10MG, 15MG DAILY DOSAGE 4 CAPSULES PER DAY AMPHETAMINES PROCENTRA (DEXTROAMPHETAMINE SULFATE) SOLN 5 MG/5ML ORAL DOSE LIMIT 60 ML PER DAY AMPHETAMINES VYVANSE CAPS - ALL STRENGTHS DAILY DOSAGE 1 CAPSULE PER DAY AMPHETAMINES VYVANSE CHEW 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG DAILY DOSAGE 1 TABLET PER DAY AMPHETAMINES ZENZEDI (DEXTROAMPHETAMINE SULFATE) TABS 10 MG DAILY DOSAGE 6 TABLETS PER DAY AMPHETAMINES ZENZEDI (DEXTROAMPHETAMINE SULFATE) TABS 5 MG DAILY DOSAGE 8 TABLETS PER DAY QUANTITY LIMIT 2 FILLS PER 365 DAYS; ANALEPTICS CAFFEINE CITRATE SOLN ORAL FILL FREQUENCY 45ML PER 15 DAYS RETAIL ESGIC (BUTALBITAL-ACETAMINOPHEN-CAFFEINE) CAPS 325MG- ANALGESIC COMBINATIONS 50MG-40MG DAILY DOSAGE 4 CAPSULES PER DAY ANALGESIC COMBINATIONS FIORINAL (BUTALBITAL-ASPIRIN-CAFFEINE) CAPS DAILY DOSAGE 4 CAPSULES PER DAY EPINEPHRINE (ANAPHYLAXIS) SOLN AUTO INJECTOR QUANTITY LIMIT 2 DEVICES PER 30 DAYS ANAPHYLAXIS THERAPY AGENTS 0.15 MG/0.3ML, 0.3 MG/0.3ML FILL FREQUENCY 4 DEVICES PER 365 DAYS QUANTITY LIMIT 2 DEVICES PER 30 DAYS ANAPHYLAXIS THERAPY AGENTS EPIPEN 2-PAK SOLN AUTO INJECTOR FILL FREQUENCY 4 DEVICES PER 365 DAYS QUANTITY LIMIT 2 DEVICES PER 30 DAYS ANAPHYLAXIS THERAPY AGENTS EPIPEN-JR 2-PAK SOLN AUTO INJECTOR FILL FREQUENCY 4 DEVICES PER 365 DAYS SHP_20173926 Quantity Limits THERAPEUTIC CLASS PRODUCT NAME DRUG RESTRICTION TYPE PLAN LIMITS ANDROGENS ANDRODERM PATCH 24 HOUR, 2MG/24HR, 4MG/24HR TOPICAL DOSE LIMIT 1 PATCH PER DAY ANDROGEL (TESTOSTERONE) TRANSDERMAL TOPICAL GEL 1% ANDROGENS 2.5 GRAM PACKET TOPICAL DOSE LIMIT 150 GRAMS PER 30 DAYS ANDROGEL (TESTOSTERONE)TRANSDERMAL TOPICAL GEL ANDROGENS 1.62%, PACKETS, PUMP TOPICAL DOSE LIMIT 2 BOXES PER 30 DAYS ANDROGENS AXIRON (TESTOSTERONE) TRANSDERMAL TOPICAL SOLUTION TOPICAL DOSE LIMIT 180ML PER 30 DAYS DEPO-TESTOSTERONE (TESTOSTERONE CYPIONATE) INJ ANDROGENS 200MG/ML FILL FREQUENCY 1 FILL PER 30 DAYS TESTIM (TESTOSTERONE) TRANSDERMAL TOPICAL GEL 1% 5 ANDROGENS GRAM PACKET TOPICAL DOSE LIMIT 300 GRAMS PER 30 DAYS ANDROGENS VOGELXO (TESTOSTERONE) 1% TRANSDERMAL PUMP TOPICAL DOSE LIMIT 150 GRAMS PER 30 DAYS ANESTHETICS TOPICAL ORAL LIDOCAINE HCL (MOUTH-THROAT) SOLN ORAL DOSE LIMIT 100 ML PER 10 DAYS ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND (CANDESARTAN CILEXETIL) TABS 32 MG DAILY DOSAGE 1 TABLET PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND (CANDESARTAN CILEXETIL) TABS 4 MG, 8 MG, 16 MG DAILY DOSAGE 2 TABLETS PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR (OLMESARTAN MEDOXOMIL) 40 MG TABS DAILY DOSAGE 1 TABLET PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR (OLMESARTAN MEDOXOMIL) 5MG, 20MG TABS DAILY DOSAGE 2 TABLETS PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS DIOVAN (VALSARTAN) TABS 40 MG, 80 MG, 160 MG, 320 MG DAILY DOSAGE 1 TABLET PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS EDARBI (AZILSARTAN MEDOXOMIL) TABS 40MG, 80MG DAILY DOSAGE 1 TABLET PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS EPROSARTAN MESYLATE TABS DAILY DOSAGE 1 TABLET PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS MICARDIS (TELMISARTAN) TABS 40MG DAILY DOSAGE 2 TABLETS PER DAY ANGIOTENSIN II RECEPTOR ANTAGONISTS MICARDIS (TELMISARTAN) TABS 80MG DAILY DOSAGE 1 TABLET PER DAY QUANTITY LIMIT ANTACIDS CALCIUM CARBONATE SUSPENSION 1250ML/5ML FILL FREQUENCY 500 ML PER 30 DAYS ANTIADRENERGIC ANTIHYPERTENSIVES CATAPRES-TTS-1 PTWK (CLONIDINE HCL) TOPICAL DOSE LIMIT 4 PATCHES PER 28 DAYS ANTIADRENERGIC ANTIHYPERTENSIVES CATAPRES-TTS-2 PTWK (CLONIDINE HCL) TOPICAL DOSE LIMIT 4 PATCHES PER 28 DAYS ANTIADRENERGIC ANTIHYPERTENSIVES CATAPRES-TTS-3 PTWK (CLONIDINE HCL) TOPICAL DOSE LIMIT 4 PATCHES PER 28 DAYS ANTIADRENERGIC ANTIHYPERTENSIVES RESERPINE 0.1MG TABS DAILY DOSAGE 1 TABLET PER DAY ANTIADRENERGIC ANTIHYPERTENSIVES RESERPINE 0.25MG TABS DAILY DOSAGE 4 TABLETS PER DAY SHP_20173926 Quantity Limits THERAPEUTIC CLASS PRODUCT NAME DRUG RESTRICTION TYPE PLAN LIMITS BUSPAR (BUSPIRONE HCL) TABS 5 MG, 10 MG, 15 MG, 30 MG, 7.5 ANTIANXIETY AGENTS - MISC. MG DAILY DOSAGE 3 TABLETS PER DAY ANTICATAPLECTIC AGENTS XYREM SOLUTION ORAL DOSE LIMIT 18 ML PER DAY ANTICONVULSANTS - CLONAZEPAM-ODT ORAL DISINTEGRATING TABLETS BENZODIAZEPINES 0.125 MG, 0.25 MG, 0.5 MG, 1 MG, 2 MG DAILY DOSAGE 4 TABLETS PER DAY ANTICONVULSANTS - BENZODIAZEPINES DIASTAT (DIAZEPAM) ACUDIAL RECTAL GEL 10 MG TOPICAL DOSE LIMIT 4 DOSES PER 30 DAYS ANTICONVULSANTS - QUANTITY LIMIT BENZODIAZEPINES DIASTAT (DIAZEPAM) ACUDIAL RECTAL GEL 20 MG FILL FREQUENCY 8 DOSES PER 30 DAYS ANTICONVULSANTS - BENZODIAZEPINES DIASTAT (DIAZEPAM) PEDIATRIC RECTAL GEL 2.5MG FILL FREQUENCY 1 KIT PER FILL ANTICONVULSANTS - BENZODIAZEPINES KLONOPIN (CLONAZEPAM) TABS 0.5 MG, 1 MG, 2 MG DAILY DOSAGE 4 TABLETS PER DAY ANTICONVULSANTS - BENZODIAZEPINES NAYZILAM SPRAY TOPICAL DOSE LIMIT 10 DOSES PER 30 DAYS ANTICONVULSANTS - BENZODIAZEPINES ONFI (CLOBAZAM) SUSP 2.5MG/ML ORAL DOSE LIMIT 16ML PER DAY ANTICONVULSANTS - BENZODIAZEPINES ONFI (CLOBAZAM) TABS 10 MG DAILY DOSAGE 3 TABLETS PER DAY ANTICONVULSANTS - BENZODIAZEPINES ONFI (CLOBAZAM) TABS 20 MG DAILY DOSAGE 2 TABLETS PER DAY ANTICONVULSANTS - MISC. APTIOM TABS 200MG, 400MG DAILY DOSAGE 1 TABLET PER DAY ANTICONVULSANTS - MISC. APTIOM TABS 600MG, 800MG DAILY DOSAGE 2 TABLETS PER DAY ANTICONVULSANTS - MISC. BANZEL SUSP 40 MG/ML ORAL DOSE