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Medical & Coding Policies
Provider Network Application
Out-of-State & Non-NetworkPrescription Drug Quantity Limits
Quantity limits are based on recommendations from the manufacturers and the U.S. Food and Drug Administration (FDA), as well as accepted medical practices for dosing. Quantity limits help ensure that your patients receive the proper dose and recommended duration of therapy for their condition, while minimizing potential for adverse events, inappropriate therapy, and excessive cost.
If a member's benefit plan includes quantity limits, the following drugs are subject to limitation(s). If these limits are not appropriate for your patient, you may submit a Prescription Drug Benefit Appeal Form.
| Drug Name | Quantity Limit |
| Abilify (aripiprazole) | 30 tablets per month |
| Acetaminophen/codeine solution | 90 mLs per day |
| 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) |
| Alsuma | 2 injections per copay |
| 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 (azelastine) | 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 |
| Avinza (morphine sulfate) | 30 tablets per month |
| Beconase | 1 bottle per month |
| Butalbital Compound (butalbital/asprin/caffeine) | 6 tablets per day |
| Capital and Codeine (acetaminophen/codeine) | 90 mLs per day |
| 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 | Coverage and quantity limits depend on benefit plan. |
| Cimzia | 1 kit per month (Prior authorization required) |
| Cocet Plus (acetaminophen/codeine) | 6 tablets per day |
| Combunox (oxycodone/ibuprofen) | 4 tablets per day |
| ConZip (tramadol) | 30 tablets per month |
| Diflucan (fluconazole) | 1 (150mg) tablet per copay |
| Dolgic Plus (butalbital/acetaminophen/caffeine) | 5 tablets per day |
| Dolgic LQ elixir (butalbital/acetaminophen/caffeine) | 90 mLs per day |
| Duragesic (fentanyl transdermal patch) | 15 patches per month |
| Embeda (morphine/naltrexone) | 60 tablets 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) |
| Esgic (butalbital/acetaminophen/caffeine) | 6 tablets per day |
| Esgic Plus (butalbital/acetaminophen/caffeine) | 6 tablets per day |
| Exalgo (hydromorphone) | 30 tablets per month |
| Fioricet (butalbital/acetaminophen/caffeine) | 6 tablets per day |
| Fioricet w/ codeine (butalbital/acetaminophen/caffeine/codeine) | 6 tablets per day |
| Fiorinal (butalbital/asprin/caffeine) | 6 tablets per day |
| Fiorinal w/ codeine (butalbital/asprin/caffeine/codeine) | 6 tablets per day |
| 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) |
| Hycet (hydrocodone/acetaminophen) | 120 mLs per day |
| Hydrocodone/acetaminophen 2.5 mg/500 mg tablet | 8 tablets per day |
| Imitrex (sumatriptan) | 9 tablets, 2 injections, or 6 bottles per copay |
| Innohep | 16 injections per month |
| Janumet (sitagliptin/metformin) | 60 tablets per month |
| Janumet XR (sitagliptin/metformin) | 30 tablets per month |
| Januvia (sitagliptin) | 30 tablets per month |
| Jentadueto (linagliptin/metformin) | 60 tablets per month |
| Juvisync (sitagliptin/simvastatin) | 30 tablets per month |
| Kadian (morphine sulfate) | 60 tablets per month |
| Kalydeco | 60 tablets per month (Prior authorization required) |
| Kapidex/Dexilant | 30 capsules per month per therapeutic class* |
| Kombiglyze XR (saxagliptin/metformin) | 30 tablets per month |
| Kytril (granisetron) | 20 tablets per month |
| Levitra | Coverage and quantity limits depend on benefit plan. |
| Lovenox (enoxaparin) |
38 injections per month |
| Lorcet, Lorcet Plus (hydrocodone/acetaminophen) | 6 tablets per day |
| Lortab (hydrocodone/acetaminophen) 5 mg/500 mg tablet | 8 tablets per day |
| Lortab (hydrocodone/acetaminophen) 7.5 mg/500 mg tablet | 6 tablets per day |
| Lortab (hydrocodone/acetaminophen) 10 mg/500 mg tablet | 6 tablets per day |
| Lortab (hydrocodone/acetaminophen) 7.5 mg/500 mg/15 mL solution | 90 mLs per day |
| Lunesta | 30 tablets per month |
| Magnacet (oxycodone/acetaminophen) 2.5 mg/400 mg tablet | 10 tablets per day |
| Magnacet (oxycodone/acetaminophen) 5 mg/400 mg tablet | 10 tablets per day |
| Magnacet (oxycodone/acetaminophen) 7.5 mg/400 mg tablet | 8 tablets per day |
| Magnacet (oxycodone/acetaminophen) 10 mg/400 mg tablet | 6 tablets per day |
| Maxalt | 12 tablets per copay |
| Maxidone (hydrocodone/acetaminophen) | 5 tablets per day |
| Migranal | 8 vials per copay |
| Mobic (meloxicam) | 30 tablets per month |
| MS Contin (morphine sulfate) | 90 tablets per month |
| Nasacort AQ | 1 bottle per month |
| Nasonex | 1 bottle per month |
| Nexium | 30 capsules per month per therapeutic class* |
| Norco (hydrocodone/acetaminophen) 5 mg/325 mg tablet | 12 tablets per day |
| Norco (hydrocodone/acetaminophen) 7.5 mg/325 mg tablet | 6 tablets per day |
| Norco (hydrocodone/acetaminophen) 10 mg/325 mg tablet | 6 tablets per day |
| Nucynta (tapentadol) | 6 tablets per day |
| Nucynta ER (tapentadol) | 60 tablets per month |
| Onglyza (saxagliptin) | 30 tablets per month |
| Onsolis | 120 films per month (Prior authorization required) |
| Opana ER (oxymorphone) | 60 tablets per month |
| Oramorph SR (morphine sulfate) | 90 tablets per month |
| Orbivan (butalbital/acetaminophen/caffeine) | 6 tablets per day |
| Oxycodone/asprin | 12 tablets per day |
| Oxycontin (oxycodone ER) 10 mg tablet | 60 tablets per month |
| Oxycontin (oxycodone ER) 15 mg tablet | 60 tablets per month |
| Oxycontin (oxycodone ER) 20 mg tablet | 60 tablets per month |
| Oxycontin (oxycodone ER) 30 mg tablet | 60 tablets per month |
| Oxycontin (oxycodone ER) 40 mg tablet | 60 tablets per month |
| Oxycontin (oxycodone ER) 60 mg tablet | 120 tablets per month |
| Oxycontin (oxycodone ER) 80 mg tablet | 120 tablets per month |
| Panlor DC, Trezix (acetaminophen/caffeine/dihydrocodeine) | 10 tablets per day |
| Panlor SS, ZerLor (acetaminophen/caffeine/dihydrocodeine) | 5 tablets per day |
| Percocet (oxycodone/acetaminophen) 2.5 mg/ 325 mg tablet | 12 tablets per day |
| Percocet (oxycodone/acetaminophen) 5 mg/ 325 mg tablet | 12 tablets per day |
| Percocet (oxycodone/acetaminophen) 7.5 mg/ 325 mg tablet | 8 tablets per day |
| Percocet (oxycodone/acetaminophen) 7.5 mg/ 500 mg tablet | 8 tablets per day |
| Percocet (oxycodone/acetaminophen) 10 mg/ 325 mg tablet | 6 tablets per day |
| Percocet (oxycodone/acetaminophen) 10 mg/ 650 mg tablet | 6 tablets per day |
| Percodan (oxycodone/asprin) | 12 tablets per day |
| Phrenilin Forte (butalbital/acetaminophen) | 6 tablets per day |
| Primalev (oxycodone/acetaminophen) 2.5 mg/ 300 mg tablet | 12 tablets per day |
| Primalev (oxycodone/acetaminophen) 5 mg/ 300 mg tablet | 12 tablets per day |
| Primalev (oxycodone/acetaminophen) 7.5 mg/ 300 mg tablet | 8 tablets per day |
| Primalev (oxycodone/acetaminophen) 10 mg/ 300 mg tablet | 6 tablets per day |
| 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 |
| Reprexain, Ibudone (hydrocodone/ibuprofen) | 5 tablets per day |
| Revatio | 90 tablets per month (Prior authorization required) |
| Rhinocort | 1 bottle per month |
| Roxicet (oxycodone/acetaminophen) 5 mg/325 mg tablet | 12 tablets per day |
| Roxicet (oxycodone/acetaminophen) 5 mg/500 mg tablet | 8 tablets per day |
| Roxicet (oxycodone/acetaminophen) 5 mg/325 mg/5 mL solution | 60 mLs per day |
| Rozerem | 30 tablets per month |
| Rybix ODT (tramadol) | 8 tablets per day |
| Ryzolt (tramadol) | 30 tablets per month |
| Seroquel XR (quetiapine) 50mg | 60 tablets per month |
| Seroquel XR (quetiapine) 150mg | 30 tablets per month |
| Seroquel XR (quetiapine) 200mg | 30 tablets per month |
| Seroquel XR (quetiapine) 300mg | 60 tablets per month |
| Seroquel XR (quetiapine) 400mg | 60 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) |
| Stragesic, Margesic-H (hydrocodone/acetaminophen) | 8 tablets per day |
| Suboxone | 60 tablets/films per month |
| Subutex (buprenorphine) | 60 tablets per month |
| Talacen (pentazocine/acetaminophen) | 6 tablets per day |
| Toradol (ketorolac) | 20 tablets per month |
| Tradjenta (linagliptin) | 30 tablets per month |
| Treximet | 9 tablets per copay |
| Tylenol w/ Codeine (acetaminophen/codeine) 300 mg/15 mg tablet | 12 tablets per day |
| Tylenol w/ Codeine (acetaminophen/codeine) 300 mg/30 mg tablet | 12 tablets per day |
| Tylenol w/ Codeine (acetaminophen/codeine) 300 mg/60 mg tablet | 6 tablets per day |
| Tylox (oxycodone/acetaminophen) | 8 tablets per day |
| Ultracet (tramadol/acetaminophen) | 8 tablets per day |
| Ultram (tramadol) | 8 tablets per day |
| Ultram ER (tramadol) | 30 tablets per month |
| Veramyst | 1 bottle per month |
| Viagra | Coverage and quantity limits depend on benefit plan. |
| Vicodin, Vicodin ES, Vicodin HP (hydrocodone/acetaminophen) 5 mg/500 mg tablet | 8 tablets per day |
| Vicodin, Vicodin ES, Vicodin HP (hydrocodone/acetaminophen) 7.5 mg/750 mg tablet | 5 tablets per day |
| Vicodin, Vicodin ES, Vicodin HP (hydrocodone/acetaminophen) 10 mg/660 mg tablet | 6 tablets per day |
| Vicoprofen (hydrocodone/ibuprofen) | 5 tablets per day |
| Xodol (hydrocodone/acetaminophen) 5 mg/300 mg tablet | 12 tablets per day |
| Xodol (hydrocodone/acetaminophen) 7.5 mg/300 mg tablet | 6 tablets per day |
| Xodol (hydrocodone/acetaminophen) 10 mg/300 mg tablet | 6 tablets per day |
| Xolox (oxycodone/acetaminophen) | 8 tablets per day |
| Zamicet (hydrocodone/acetaminophen) | 90 mLs per day |
| 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 |
| Zolvit (hydrocodone/acetaminophen) | 67.5 mLs per day |
| Zomig | 6 tablets per copay 6 bottles per copay |
| Zydone (hydrocodone/acetaminophen) 5 mg/400 mg tablet | 8 tablets per day |
| Zydone (hydrocodone/acetaminophen) 7.5 mg/400 mg tablet | 6 tablets per day |
| Zydone (hydrocodone/acetaminophen) 10 mg/400 mg tablet | 6 tablets per day |
*Therapeutic Drug Class Limit
The following Proton Pump Inhibitors (PPIs) are limited to one prescription drug per therapeutic class within a 30 day supply. For example, members may only received a total of 30 capsules, tablets or packets per 30 days.
Aciphex
Kapidex/Dexilant
Lansopraxole
Nexium
Omeprazole
Pantoprazole
Prevacid
Prilosec
Protonix
The list will be updated periodically. Members should always refer to the myBlue website for their coverage details.
