| Drug Name |
Quantity Limit |
| Aciphex |
30 tablets per month per therapeutic class |
| Actiq (fentanyl) |
120 lozenges per month
(Prior authorization required) |
| Adcirca |
60 tablets per month
(Prior authorization required) |
Ambien (zolpidem)
Edluar |
30 tablets per month |
Amerge (naratriptan)
|
9 tablets per copay |
| Ampyra |
60 tablets per month
(Prior authorization required) |
| Anzemet |
10 tablets per month
|
| Astelin |
1 bottle per 25 days |
| Atrovent |
1 (0.03%) bottle per month
2 (0.06%) bottles per month |
| Axert |
6 (6.25mg) tablets per copay
12 (12.5mg) tablets per copay |
| Beconase |
1 bottle per month |
| Celebrex |
60 (50mg) capsules per month
60 (100mg) capsules per month
30 (200mg) capsules per month
(Only members with rheumatoid arthritis or
ankylosing spondylitis will be allowed 60
capsules of Celebrex 200 mg per month) |
| Cialis |
30 (2.5mg or 5mg) tablets per month
8 (10mg or 20mg) tablets per month
(This drug may not be covered by your
benefit plan) |
| Cimzia |
1 kit per month
(Prior authorization required) |
| Diflucan (fluconazole) |
1 (150mg) tablet per copay |
| Duragesic (fentanyl) |
10 patches per month |
| Emend |
5 tablets per copay
1 dosepack per copay |
| Enbrel |
8 (25mg) injections per month
4 (50mg) injections per month
(Prior authorization required) |
| Flonase (fluticasone) |
1 bottle per month |
| Flunisolide |
2 bottles per month |
| Fragmin |
16 injections per month |
| Frova |
9 tablets per copay |
| Humira |
2 injections per month
(Prior authorization required) |
| Imitrex (sumatriptan) |
9 tablets, 2 injections, or 6 bottles per
copay |
| Innohep |
16 injections per month |
| Kapidex/Dexilant |
30 capsules per month per therapeutic class |
| Kytril (granisetron) |
20 tablets per month |
| Levitra |
8 tablets per month
(This drug may not be covered by your
benefit plan) |
Lovenox (enoxaparin)
|
38 injections per month |
| Lunesta |
30 tablets per month |
| Maxalt |
12 tablets per copay |
| Migranal |
8 vials per copay |
| Mobic (meloxicam) |
30 tablets per month |
| Nasacort AQ |
1 bottle per month |
| Nasarel |
2 bottles per month |
| Nasonex |
1 bottle per month |
| Nexium |
30 capsules per month per therapeutic class |
| Onsolis |
120 films per month
(Prior authorization required) |
| Palladone |
30 capsules per month |
Prevacid (lansoprazole)
|
30 capsules, 30 tablets, or
30 packets per month per therapeutic class |
| Prilosec (omeprazole) |
30 capsules per month per therapeutic class |
| Protonix (pantoprazole) |
30 tablets or packets per month per therapeutic class |
| Pulmicort |
60 bottles (120mLs) per month
2 inhalers per month |
| Relpax |
6 tablets per copay |
| Revatio |
90 tablets per month
(Prior authorization required) |
| Rhinocort |
1 bottle per month |
| Rozerem |
30 tablets per month |
| Simponi |
1 injection per month
(Prior authorization required) |
| Sonata (zaleplon) |
30 capsules per month |
| Stadol (butorphanol) |
1 bottle per copay |
| Stelara |
2 (45mg) injections per twelve weeks
1 (90mg) injection per twelve weeks
(Prior authorization required) |
| Toradol (ketorolac) |
20 tablets per month |
| Treximet |
9 tablets per copay |
| Tri-Nasal |
1 bottle per month |
| Vancenase |
2 bottles per month |
| Veramyst |
1 bottle per month |
| Viagra |
8 tablets per month
(This drug may not be covered by your benefit plan.) |
Zegerid (omeprazole/sodium bicarbonate)
|
30 capsules or packets per month |
| Zofran (ondansetron) |
30 (4mg or 8mg) tablets per month
10 (24mg) tablets per month
150 mLs per month |
| Zomig |
6 tablets per copay
6 bottles per copay |
