adzenys xr-odt (amphetamine er) 3.1 mg oral …...adzenys xr-odt (amphetamine er) 6.3 mg oral...

Quantity Limit Program Summary

Program Target Drugs Dosage/StrengthQuantity Limit

(Units/Day or as noted)

5HT-1F PAQL ** 5HT-1F QL information is included in the individual program document

ADHD PS AR0320_r0520

Adderall (amphetamine/dextroamphetamine) 5 mg tableta 2 tablets

Adderall (amphetamine/dextroamphetamine) 7.5 mg tableta 2 tablets


Adderall (amphetamine/dextroamphetamine) 12.5 mg tableta 2 tablets




Adderall XR (amphetamine/dextroamphetamine extended-release)5 mg capsulea 1 capsule






Adhansia XR (methylphenidate ER) 25 mg capsule 1 capsuleAdhansia XR (methylphenidate ER) 35 mg capsule 1 capsuleAdhansia XR (methylphenidate ER) 45 mg capsule 1 capsuleAdhansia XR (methylphenidate ER) 55 mg capsule 1 capsuleAdhansia XR (methylphenidate ER) 70 mg capsule 1 capsuleAdhansia XR (methylphenidate ER) 85 mg capsule 1 capsule

Adzenys ER (amphetamine ER), Amphetamine ER suspension1.25 mg/1 mL solution 15 mL

Adzenys XR-ODT (amphetamine ER) 3.1 mg oral disintegrating tablet 2 tablets

Adzenys XR-ODT (amphetamine ER) 6.3 mg oral disintegrating tablet 2 tablets

Adzenys XR-ODT (amphetamine ER) 9.4 mg oral disintegrating tablet 1 tablet




Aptensio XR, Methylphenidate ER capsule 10 mg capsule 1 capsule


Quantity limits apply to Medicaid.

MN_Medicaid_CS_QL_Programs_AR0320 © Copyright Prime Therapeutics LLC. 03/2020 All Rights Reserved 1

Minnesota Medicaid Quantity Limit Program Criteria






Cotempla XR ODT (methylphenidate ER orally dissolving tablet)8.6 mg orally disintegrating tablet 1 tablet

Cotempla XR ODT (methylphenidate ER orally dissolving tablet)17.3 mg orally disintegrating tablet 2 tablets

Cotempla XR ODT (methylphenidate ER orally dissolving tablet)25.9 mg orally disintegrating tablet 2 tablets

Concerta (methylphenidate extended-release) 18 mg tableta 1 tablet


Concerta (methylphenidate extended-release) 36 mg tableta 2 tablets


Daytrana (methylphenidate transdermal patch)10 mg/9 hr patch 1 patch



Daytrana (methylphenidate transdermal patch)15 mg/9 hr patch 1 patchDaytrana (methylphenidate transdermal patch)20 mg/9 hr patch 1 patchDaytrana (methylphenidate transdermal patch)30 mg/9 hr patch 1 patch

Desoxyn (methamphetamine) 5 mg tablet 5 tablets

dextroamphetamine 5 mg tableta 3 tablets

dextroamphetamine 10 mg tableta 6 tablets

Dexedrine (dextroamphetamine extended-release)

5 mg extended-release

capsulea

3 capsules



capsulea

4 capsules



capsulea

4 capsules

Dyanavel XR (amphetamine ER suspension)2.5 mg / mL 8 mL

Evekeo (amphetamine) 5 mg tableta 3 tablets

Evekeo (amphetamine) 10 mg tableta 6 tablets

Evekeo ODT (amphetamine)

5 mg orally disintegrating

tablet2 tablets


10 mg orally

disintegrating tablet2 tablets


15 mg orally



20 mg orally



Focalin (dexmethylphenidate) 2.5 mg tableta 2 tablets

Focalin (dexmethylphenidate) 5 mg tableta 2 tablets

Focalin (dexmethylphenidate) 10 mg tableta 2 tablets

Focalin XR (dexmethylphenidate extended-release)5 mg capsulea 1 capsule








Intuniv (guanfacine extended-release)


tableta

1 tablet



tableta

1 tablet





tableta

1 tablet



tableta

1 tablet

Jornay PM (methylphenidate extended-release)20 mg ER capsule 1 capsuleJornay PM (methylphenidate extended-release)40 mg ER capsule 1 capsuleJornay PM (methylphenidate extended-release)60 mg ER capsule 1 capsuleJornay PM (methylphenidate extended-release)80 mg ER capsule 1 capsuleJornay PM (methylphenidate extended-release)100 mg ER capsule 1 capsule

Kapvay (clonidine extended-release)

0.1 mg extended-release

tableta

4 tabletsa

Metadate CD (methylphenidate extended-release)10 mg capsulea 1 capsule






Metadate ER (methylphenidate extended-release)20 mg tableta 3 tablets

Methylin (methylphenidate) 2.5 mg chewable tableta

3 tablets

Methylin (methylphenidate) 5 mg chewable tableta 3 tablets

Methylin (methylphenidate) 10 mg chewable tableta

6 tablets

Methylin (methylphenidate) 5 mg/5 mL solutiona 15 mL

Methylin (methylphenidate) 10 mg/5 mL solutiona 30 mL

Methylin ER (methylphenidate extended-release)10 mg tableta 3 tablets

Methylin ER (methylphenidate extended-release)20 mg tableta 3 tablets

methylphenidate ER 18 mg tablet 1 tablet


methylphenidate ER 36 mg tablet 2 tablets





Mydayis 12.5 mg capsule 1 capsule

Mydayis 25 mg capsule 1 capsule

Mydayis 37.5 mg capsule 1 capsule

Mydayis 50 mg capsule 1 capsule

Procentra (dextroamphetamine oral solution) 5 mg/5 mL oral solutiona

60 mL

Quillichew (methylphenidate ER chewable)20 mg 1 tablet

Quillichew (methylphenidate ER chewable)30 mg 2 tablets

Quillichew (methylphenidate ER chewable)40 mg 1 tablet

Quillivant XR (methylphenidate) 25 mg/5 ml oral

suspension

12 mL

Relexxii (methylphenidate ER) 72 mg tablet 1 tablet

Ritalin (methylphenidate) 5 mg tableta 3 tablets



Ritalin LA (methylphenidate extended–release) 10 mg capsulea 1 capsule






Strattera (atomoxetine) 10 mg capsulea 2 capsules




Strattera (atomoxetine) 60 mg capsulea 1 capsule



Vyvanse (lisdexamfetamine) 10 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 20 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 30 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 40 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 50 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 60 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 70 mg capsule 1 capsule



Vyvanse chewable (lisdexamfetamine) 10 mg chewable tablet 1 tablet






Zenzedi (dextroamphetamine) 2.5 mg tablet 3 tabletsZenzedi (dextroamphetamine) 7.5 mg tablet 3 tabletsZenzedi (dextroamphetamine) 15 mg tablet 3 tabletsZenzedi (dextroamphetamine) 20 mg tablet 3 tabletsZenzedi (dextroamphetamine) 30 mg tablet 2 tablets

Alinia QL ** Alinia QL information is included in the individual program document

Ampyra PAQL ** Ampyra QL information is included in the individual program document

Androgens_Anabolic

Steroids PAQL ** Androgen_Anabolic Steroid QL information is included in the individual program document

Anticoagulant QL ** Anticoagulant QL information is included in the individual program document

Antidepressants PS AR0320

Selective Serotonin Reuptake Inhibitors

(SSRIs)

Celexa (citalopram)a 10 mg tablet 1 tablet



Celexa (citalopram)a 10 mg/5 mL oral solution 20 mL

Lexapro (escitalopram)a 5 mg tablet 1 tablet



Lexapro (escitalopram)a 5 mg/5 mL oral solution 20 mL

fluvoxamine ERa 100 mg extended-release

capsule

2 capsules

fluvoxamine ERa 150 mg extended-release

capsule

2 capsules

fluvoxaminea 25 mg tablet 1 tablet

fluvoxaminea 50 mg tablet 1 tablet

a - available as a generic, included in quantity limit program




fluvoxaminea 100 mg tablet 3 tablets

Paxil (paroxetine)a 10 mg tablet 1 tablet


Paxil (paroxetine)a 30 mg tablet 2 tablets


Paxil (paroxetine) 10 mg/5 mL suspension 30 mL

Paxil CR (paroxetine ER)a 12.5 mg controlled-

release tablet

1 tablet

Paxil CR (paroxetine ER)a 25 mg controlled-release

tablet

2 tablets

Paxil CR (paroxetine ER)a 37.5 mg controlled-

release tablet

2 tablets

Pexeva (paroxetine) 10 mg tablet 1 tabletPexeva (paroxetine) 20 mg tablet 1 tabletPexeva (paroxetine) 30 mg tablet 2 tabletsPexeva (paroxetine) 40 mg tablet 1 tablet

Prozac (fluoxetine)a 10 mg capsule 1 capsule

Prozac (fluoxetine)a 20 mg capsule 4 capsules

Prozac (fluoxetine)a 40 mg capsule 2 capsules

Prozac (fluoxetine)a 10 mg tablet 1 tablet

Prozac (fluoxetine)a 20 mg tablet 4 tablets

Prozac, (fluoxetine)a 60 mg tablet 1 tablet

Prozac (fluoxetine)a 20 mg/5 mL oral solution 20 mL

Prozac Weekly (fluoxetine) 90 mg delayed-release

capsule

4 capsules/28 days

Zoloft (sertraline)a 25 mg tablet 1 tablet

Zoloft (sertraline)a 50 mg tablet 1 tablet

Zoloft (sertraline)a 100 mg tablet 2 tablets

Zoloft (sertraline)a 20 mg/mL oral

concentrate

10 mL

Serotonin Norepinephrine Reuptake

Inhibitors (SNRIs)

Cymbalta (duloxetine)a 20 mg delayed-release

capsule

2 capsules


capsule

2 capsules


capsule

2 capsules

Desvenlafaxine 50 mg extended-release

tablet 1 tablet



Desvenlafaxine 100 mg extended-release

tablet

1 tablet

Desvenlafaxine fumarate 50 mg extended-release

tablet 1 tablet

Desvenlafaxine fumarate 100 mg extended-release

tablet

1 tablet

Drizalma Sprinkle 20 mg delayed release

sprinkle capsule

2 capsules


sprinkle capsule

2 capsules


sprinkle capsule

2 capsules


sprinkle capsule

2 capsules

Effexor (venlafaxine)a 25 mg tablet 3 tablets

Effexor (venlafaxine)a 37.5 mg tablet 3 tablets




Effexor XR (venlafaxine ER)a 37.5 mg extended-

release capsule 1 capsule

Effexor XR (venlafaxine ER)a 75 mg extended-release

capsule

3 capsules

Effexor XR (venlafaxine ER)a 150 mg extended-release

capsule

1 capsule

Fetzima (levomilnacipran) 20 mg extended-release

capsule 1 capsule


capsule 1 capsule


capsule 1 capsule


capsule 1 capsule

Fetzima (levomilnacipran) Titration pack (2 x 20

mg, 26 x 40 mg) 1 kit (28 capsules)/28 days

Khedezla (desvenlafaxine) 50 mg extended-release

tablet 1 tablet

Khedezla (desvenlafaxine) 100 mg extended-release

tablet

1 tablet



duloxetinea 40 mg delayed release

capsule

3 capsules

Antidepressants PS AR0320

Venlafaxine ERa 37.5 mg extended-

release tablet 1 tablet

Venlafaxine ERa 75 mg extended-release

tablet

3 tablets


tablet

1 tablet


tablet

1 tablet

Pristiq (desvenlafaxine)a 25 mg extended-release

tablet1 tablet


tablet 1 tablet


tablet

1 tablet

Other AntidepressantsAplenzin (bupropion) 174 mg extended-release

tablet

1 tablet

Aplenzin (bupropion) 348 mg extended-release

tablet

1 tablet

Aplenzin (bupropion) 522 mg extended-release

tablet

1 tablet

Forfivo XL (bupropion)

a 450 mg extended-release

tablet

1 tablet

Maprotiline 25 mg tablet 3 tabletsMaprotiline 50 mg tablet 3 tabletsMaprotiline 75 mg tablet 3 tablets

Remeron (mirtazapine)a

7.5 mg tabletf 1 tablet

Remeron (mirtazapine)a 15 mg tablet 1 tablet



Remeron SolTab (mirtazapine)a

15 mg orally-

disintegrating tablet

1 tablet


30 mg orally-


1 tablet


45 mg orally-


1 tablet

Trintellix (vortioxetine) 5 mg tablet 1 tabletTrintellix (vortioxetine) 10 mg tablet 1 tabletTrintellix (vortioxetine) 20 mg tablet 1 tablet



Viibryd (vilazodone) 10 mg tablet 1 tabletViibryd (vilazodone) 20 mg tablet 1 tabletViibryd (vilazodone) 40 mg tablet 1 tabletViibryd (vilazodone) Starter Kit (7 x 10mg, 23

x 20mg)

1 kit/180 days

Wellbutrin (bupropion)a 75 mg tablet 2 tablets

Wellbutrin (bupropion)a 100 mg tablet 4 tablets

Wellbutrin SR, Budeprion SR (bupropion SR)a

100 mg sustained-release

tablet

2 tablets



tablet

2 tablets



tabletd

2 tablets

Wellbutrin XL, Budeprion XL (bupropion ER)a


tablet

1 tablet

Wellbutrin XL, Budeprion XL (bupropion ER)a


tablet

1 tablet


Antiemetic QL ** Antiemetic QL information is included in the individual program document

Antipsychotics, Atypical PS

AR0320Abilify (aripiprazole)

a 2 mg tablet 1 tablet

Abilify (aripiprazole)a 5 mg tablet 1 tablet





aripiprazole 1 mg/mL oral solution 30 mL

aripiprazole 10 mg orally


2 tablets

aripiprazole 15 mg orally


2 tablets

Abilify Maintena (aripiprazole) 300 mg extended-release

prefilled syringe

1 syringe/28 days

Abilify Maintena (aripiprazole) 300 mg vial extended-

release injection

1 vial/28 days

Abilify Maintena (aripiprazole) 400 mg extended-release

prefilled syringe

1 syringe/28 days

Abilify Maintena (aripiprazole) 400 mg vial extended-

release injection

1 vial/28 days



Abilify Mycite (aripiprazole with sensor) 2 mg tablet 1 tabletAbilify Mycite (aripiprazole with sensor) 5 mg tablet 1 tabletAbilify Mycite (aripiprazole with sensor) 10 mg tablet 1 tabletAbilify Mycite (aripiprazole with sensor) 15 mg tablet 1 tabletAbilify Mycite (aripiprazole with sensor) 20 mg tablet 1 tabletAbilify Mycite (aripiprazole with sensor) 30 mg tablet 1 tablet

Aristada (aripiprazole lauroxil injection) 441 mg injection 0.0534 mLAristada (aripiprazole lauroxil injection) 662 mg injection 0.08 mLAristada (aripiprazole lauroxil injection) 882 mg injection 0.1067 mLAristada (aripiprazole lauroxil injection) 1064 mg injection 0.0697 mLAristada Initio (aripiprazole lauroxil extended-

release injection)

675 mg injection 1 syringe/180 days

Caplyta (lumataperone) 42 mg capsule 1 capsule

Clozaril (clozapine)a 25 mg, tablet 3 tablets

Clozaril (clozapine)a 50 mg tablet 3 tablets



Fanapt (iloperidone) 1 mg tablet 2 tabletsFanapt (iloperidone) 2 mg tablet 2 tabletsFanapt (iloperidone) 4 mg tablet 2 tabletsFanapt (iloperidone) 6 mg tablet 2 tabletsFanapt (iloperidone) 8 mg tablet 2 tabletsFanapt (iloperidone) 10 mg tablet 2 tabletsFanapt (iloperidone) 12 mg tablet 2 tabletsFanapt (iloperidone) Titration pak 1 pak (8 tablets)/180 days

FazaClo (clozapine) 12.5 mg orally

disintegrating tableta,c

3 tablets

FazaClo (clozapine)a 25 mg orally


9 tablets

FazaClo (clozapine)a 100 mg orally


3 tablets

FazaClo (clozapine) 150 mg orally


6 tablets

FazaClo (clozapine) 200 mg orally


4 tablets

Geodon (ziprasidone)a 20 mg capsule 2 capsules




Geodon (ziprasidone)a 20 mg/mL injection 2 vials

Invega (paliperidone)a 1.5 mg tablet 1 tablet



Invega (paliperidone)a 3 mg tablet 1 tablet

Invega (paliperidone)a 6 mg tablet 2 tablets

Invega (paliperidone)a 9 mg tablet 1 tablet

Invega Sustenna (paliperidone)39 mg/kit extended-

release injection

1 kit/28 days


release injection

1 kit/28 days


release injection

1 kit/28 days


release injection

1 kit/28 days


release injection

1 kit/28 days

Invega Trinza (paliperidone) 273 mg / 0.875 mL 0.875 mL / 90 daysAntipsychotics, Atypical PS

AR0320 Invega Trinza (paliperidone)410 mg / 1.315 mL 1.315 mL / 90 days

Invega Trinza (paliperidone) 546 mg / 1.75 mL 1.75 mL / 90 daysInvega Trinza (paliperidone) 819 mg / 2.625 mL 2.625 mL / 90 days

Latuda (lurasidone) 20 mg tablet 1 tabletLatuda (lurasidone) 40 mg tablet 1 tabletLatuda (lurasidone) 60 mg tablet 1 tabletLatuda (lurasidone) 80 mg tablet 2 tabletLatuda (lurasidone) 120 mg tablet 1 tablet

Perseris (risperidone)90 mg kit extended-

release injection

1 kit/30 days

Perseris (risperidone)120 mg kit extended-

release injection

1 kit/30 days

Rexulti (brexpiprazole) 0.25 mg tablet 1 tablet

Rexulti (brexpiprazole) 0.5 mg tablet 1 tablet

Rexulti (brexpiprazole) 1 mg tablet 1 tablet




Risperdal (risperidone)a 0.25 mg tablet 2 tablets

Risperdal (risperidone)a 0.5 mg tablet 2 tablets

Risperdal (risperidone)a 1 mg tablet 2 tablets




Risperdal (risperidone)a 1 mg/mL oral solution 16 mL



risperidone0.25 mg orally


2 tablets

Risperdal M-Tab (risperidone)a

0.5 mg orally


2 tablets



tablet

2 tablets

risperidone2 mg orally disintegrating

tablet

2 tablets



tablet

2 tablets



tablet

4 tablets

Risperdal Consta (risperidone)12.5 mg/vial long-acting

injection

2 vials/28 days

Risperdal Consta (risperidone)25 mg/vial long-acting

injection

2 vials/28 days

Risperdal Consta (risperidone)37.5 mg/vial long-acting

injection

2 vials/28 days

Risperdal Consta (risperidone)50 mg/vial long-acting

injection

2 vials/28 days



Saphris (asenapine)2.5 mg sublingual tablet 2 tablets

Saphris (asenapine) 5 mg sublingual tablet 2 tablets

Saphris (asenapine)10 mg sublingual tablet 2 tablets

Secuado (asenapine)3.8 mg/ 24hr

transdermal patch

1 patch


transdermal patch

1 patch


transdermal patch

1 patch

Seroquel (quetiapine)a 25 mg tablet 3 tablets






Antipsychotics, Atypical PS

AR0320

Seroquel XR (quetiapine)a


tablet

2 tablets



tablet

1 tablet



tablet

1 tablet



tablet

2 tablets



tablet

2 tablets

Versacloz (clozapine)50 mg/ml oral

suspension

18 mL

Vraylar (cariprazine) 1.5 mg capsule 1 capsule

Vraylar (cariprazine) 3 mg capsule 1 capsule

Vraylar (cariprazine) 4.5 mg capsule 1 capsule

Vraylar (cariprazine) 6 mg capsule 1 capsule

Vraylar (cariprazine) Titration Therapy Pack 1 pack / 180 days

Zyprexa (olanzapine)a 2.5 mg tablet 1 tablet

Zyprexa (olanzapine)a 5 mg tablet 1 tablet

Zyprexa (olanzapine)a 7.5 mg tablet 1 tablet




Zyprexa (olanzapine)a 10 mg/vial injection 3 vials



Zyprexa Zydis (olanzapine)a


tablet

1 tablet


10 mg orally


1 tablet


15 mg orally


1 tablet


20 mg orally


1 tablet

Zyprexa Relprevv (olanzapine)210 mg vial extended-

release injection

2 vials/28 days


release injection

2 vials/28 days


release injection

1 vial/28 days

Antiretroviral PS

AR0819_r0420

Aptivus (tipranavir)

100 mg/mL (95 mL

bottle) oral solution 12.6667 mL (380 mL/30 days)b

Aptivus (tipranavir) 250 mg capsule 4 capsules

Atripla (efavirenz/emtricitabine/ tenofovir)

600 mg/200 mg/300 mg

tablet 1 tablet

Biktarvy (bictegravir, emtricitabine, tenofovir)

50 mg/200 mg/25 mg

tablet 1 tablet

Cimduo, Temixys (lamivudine/tenofovir) 300 mg/300 mg tablet 1 tablet

Combivir (lamivudine/zidovudine) 150 mg/300 mg tableta

2 tablets

Complera (emtricitabine/rilpivirine/tenofovir)

200 mg/25 mg/300 mg

tablet 1 tablet

Crixivan (indinavir) 200 mg capsule 9 capsulesCrixivan (indinavir) 400 mg capsule 6 capsules

Delstrigo (doravirine/lamivudine/tenofovir) 100 mg/300 mg/300 mg 1 tablet

Descovy (emtricitabine/tenofovir) 200 mg/25 mg tablet 1 tablet

Dovato (dolutegravir/lamivudine) 50 mg / 300 mg tablet 1 tablet

Edurant (rilpivirine) 25 mg tablet 1 tablet

a - generic available and included in the program; b – available only as




Emtriva (emtracitabine) 10 mg/mL oral soluion 24.2856 mL (680 mL/28 days)Emtriva (emtracitabine) 200 mg capsule 1 capsule

Epivir (lamivudine)

10 mg/mL oral soluion

(240 mL bottle)a

32 mL (960 mL/30 days)b

Epivir (lamivudine) 150 mg tableta

2 tablets

Epivir (lamivudine) 300 mg tableta

1 tablet

Epzicom (lamivudine/abacavir) 600 mg/300 mg tableta

1 tablet

Evotaz (atazanavir/cobicistat) 300 mg/150 mg tablet 1 tablet

Fuzeon (enfuvirtide)

108 mg/vial (to deliver

90 mg/mL dose) 2 vials (60 vials/month)

Genvoya

(elvitegravir/cobicistat/emtricitabine/ten

ofovir)

150 mg/150 mg/200 mg/ 10 mg tablet

1 tablet

Intelence (etravirine) 25 mg tablet 4 tabletsIntelence (etravirine) 100 mg tablet 2 tabletsIntelence (etravirine) 200 mg tablet 2 tablets

Invirase (saquinavir mesylate) 200 mg capsule 10 capsulesInvirase (saquinavir mesylate) 500 mg tablet 4 tablets

Isentress (raltegravir) 25 mg chewable tablets6 tablets

Isentress (raltegravir) 100 mg chewable tablets 6 tabletsIsentress (raltegravir) 400 mg tablets 2 tablets

Isentress (raltegravir)

100 mg packet for

suspension 2 packetsIsentress HD (raltegravir) 600 mg tablets 2 tablets

Juluca (dolutegravir/rilpivirine) 50 mg/25 mg tablets 1 tablet

Kaletra (lopinavir/ritonavir)

80 mg/20 mg per mL

(160 mL bottle oral soln)a

16 mL (480 mLs/30 days)b

Kaletra (lopinavir/ritonavir) 100 mg/25 mg tablet 6 tabletsKaletra (lopinavir/ritonavir) 200 mg/50 mg tablet 4 tablets

Lexiva (fosamprenavir)

50 mg/mL (225 mL

bottle) oral suspension 60 mL (1800 mL/30 days)b

Lexiva (fosamprenavir) 700 mg tableta

4 tablets



Norvir (ritonavir)

80 mg/mL (240 mL

bottle) oral solution 16 mL (480 mL/30 days)b

Norvir (ritonavir) 100 mg capsule 12 capsules

Norvir (ritonavir) 100 mg tableta

12 tablets

Norvir (ritonavir) 100 mg powder packet 12 packets

Odefsey (emtricitabine/rilpivirine/tenofovir)200 mg/25 mg/25 mg 1 tablet

Pifeltro (doravirine) 100 mg 1 tablet

Prezcobix (darunavir/cobicistat) 800 mg/150 mg tablet 1 tablet

Antiretroviral PS

AR0819_r0420 Prezista (darunavir) 100 mg/mL suspension 13.3334 mL (400 mL/30 days)b

Prezista (darunavir) 75 mg tablet 10 tabletsPrezista (darunavir) 150 mg tablet 6 tabletsPrezista (darunavir) 600 mg tablet 2 tabletsPrezista (darunavir) 800 mg tablet 1 tablet

Rescriptor (delavridine) 100 mg tablet 12 tabletsRescriptor (delavridine) 200 mg tablet 6 tablets

Reyataz (atazanavir) 150 mg capsulea

1 capsule


2 capsules


1 capsuleReyataz (atazanavir) 50 mg powder packet 8 packets

Selzentry (maraviroc) 25 mg tablet 8 tablets

Selzentry (maraviroc) 75 mg tablet 2 tablets

Selzentry (maraviroc) 150 mg tablet 2 tabletsSelzentry (maraviroc) 300 mg tablet 4 tablets

Selzentry (maraviroc) 20 mg/mL oral solution 61.334 mL (1840 mL/30 days)

Stribild

(elvitegravir/cobistat/emtricitabine/tenofovir)

150 mg/150 mg/200

mg/300mg 1 tablet

Sustiva (efavirenz) 50 mg capsulea

3 capsules

Sustiva (efavirenz) 200 mg capsulea

2 capsules

Sustiva (efavirenz) 600 mg tableta 1 tablet

Symfi (efavirenz/lamivudine/tenofovir) 600 mg/300 mg/300mg 1 tablet

Symfi Lo (efavirenz/lamivudine/tenofovir) 400 mg/300 mg/300mg 1 tablet



Symtuza

(darunavir/cobicistat/emtricitabine/tenofovir)

800 mg/150 mg/200

mg/10 mg 1 tablet

Tivicay (dolutegravir) 10 mg tablet 2 tablets

Tivicay (dolutegravir) 25 mg tablet 2 tabletsTivicay (dolutegravir) 50 mg tablet 2 tablets

Triumeq (abacavir/dolutegravir/lamivudine)600 mg/50 mg/300 mg

tablet 1 tablet

Trizivir (abacavir, lamivudine, zidovudine)

300 mg/150 mg/300 mg

tableta

2 tablets

Truvada (emtracitabine/tenofovir) 100/150 mg tablet 1 tablet

Truvada (emtracitabine/tenofovir) 133/200 mg tablet 1 tablet

Truvada (emtracitabine/tenofovir) 167/250 mg tablet 1 tabletTruvada (emtracitabine/tenofovir) 200 mg/300 mg tablet 1 tablet

Tybost (cobicistat) 150 mg tablet 1 tablet

Videx (didanosine)

2 g powder (10 mg/mL in

100 mL bottle) 40 mL (1200 mL/30 days)b

Videx (didanosine)

4 g powder (10 mg/mL in

200 mL bottle) 40 mL (1200 mL/30 days)Videx EC (didanosine) 125 mg capsule 1 capsuleVidex EC (didanosine) 200 mg capsule 1 capsuleVidex EC (didanosine) 250 mg capsule 1 capsule

Videx EC (didanosine) 400 mg capsulea 1 capsule

Viracept (nelfinavir) 250 mg tablet 9 tabletsViracept (nelfinavir) 625 mg tablet 4 tablets

Viramune (nevirapine)

50 mg/5 mL suspension

(240 mL bottle)a

40 mL (1200 mL/30 days)

Viramune (nevirapine) 200 mg tableta 2 tablets

Viramune XR (nevirapine)


tableta 3 tablets

Viramune XR (nevirapine)


tableta 1 tablet

Viread (tenofovir) 150 mg tablet 1 tabletViread (tenofovir) 200 mg tablet 1 tabletViread (tenofovir) 250 mg tablet 1 tablet

Viread (tenofovir) 300 mg tableta

1 tablet



Viread (tenofovir)

40 mg/1g oral powder for

reconstitution (60 g can) 8 g (240 g/30 days)b

Vitekta (elvitegravir) 85 mg tablet 1 tabletVitekta (elvitegravir) 150 mg tablet 1 tablet

Zerit (stavudine)

1 mg/mL oral solution

(200 mL bottle) 80 mL (2400 mL/30 days)

Zerit (stavudine) 15 mg capsulea

2 capsules


2 capsules


2 capsules


2 capsules

Antiretroviral PS

AR0819_r0420Ziagen (abacavir)

20 mg/mL oral solution

(240 mL bottle)a

32 mL (960 mL/30 days)b

Ziagen (abacavir) 300 mg tableta

2 tablets

zidovudine

50 mg/5 mL syrup (10

mg/mL in 240 mL bottle) 64 mL (1920 mL/30 days)b

zidovudine 100 mg capsulea

6 capsules

zidovudine 300 mg tableta

2 tablets

ARB/Renin Inhibitors PS AR0819_r0320 Angiotensin II Receptor Antagonists (ARBs), ARB Combinations

Atacand (candesartan)a 4 mg tablets 2 tablets



Atacand (candesartan)a 32 mg tablets 1 tablet

Atacand HCT

(candesartan/hydrochlorothiazide)a

16 mg/12.5 mg tablets 1 tabletAtacand HCT


32 mg/12.5 mg tablets 1 tabletAtacand HCT


32 mg/25 mg tablets 1 tablet

ARB/Renin Inhibitors PS

AR0819_r0320Avapro (irbesartan)

a 75 mg tablets 1 tablet

Avapro (irbesartan)a 150 mg tablets 1 tablet

Avapro (irbesartan)a 300 mg tablets 1 tablet

Avalide (irbesartan/hydrochlorothiazide)a 150 mg/12.5 mg tablets 1 tablet




Avalide (irbesartan/hydrochlorothiazide)a 300 mg/12.5 mg tablets 1 tablet

Azor (amlodipine/olmesartan medoxomil)a 5 mg/20 mg tablets 1 tablet




Benicar (olmesartan)a 5 mg tablets 2 tablets

Benicar (olmesartan)a 20 mg tablets 1 tablet

Benicar (olmesartan)a 40 mg tablets 1 tablet

Benicar HCT

(olmesartan/hydrochlorothiazide)a

20 mg/12.5 mg tablets 1 tablet

Benicar HCT



Benicar HCT



Byvalson (nebivolol/valsartan) 5 mg/80 mg tablets 1 tablet

Cozaar (losartan)a 25 mg tablets 2 tablets

Cozaar (losartan)a 50 mg tablets 2 tablets

Cozaar (losartan)a 100 mg tablets 1 tablet

Diovan (valsartan)a 40 mg tablets 2 tablets



Diovan (valsartan)a 320 mg tablets 1 tablet

Diovan HCT (valsartan/hydrochlorothiazide)a










Edarbi (azilsartan) 40 mg tablets 1 tabletEdarbi (azilsartan) 80 mg tablets 1 tablet



Edarbyclor (azilsartan/chlorthalidone) 40 mg/12.5 mg tablets 1 tablet

Edarbyclor (azilsartan/chlorthalidone) 40 mg/25 mg tablets 1 tablet

Exforge (amlodipine/valsartan) 5 mg/160 mg tablets 1 tabletExforge (amlodipine/valsartan) 5 mg/320 mg tablets 1 tabletExforge (amlodipine/valsartan) 10 mg/160 mg tablets 1 tabletExforge (amlodipine/valsartan) 10 mg/320 mg tablets 1 tablet

Exforge HCT

(amlodipine/valsartan/hydrochlorothiazide)a 5 mg/160 mg/12.5 mg

tablets 1 tablet

Exforge HCT

(amlodipine/valsartan/hydrochlorothiazide)a 5 mg/160 mg/25 mg

tablets 1 tablet

Exforge HCT

(amlodipine/valsartan/hydrochlorothiazide)a 10 mg/160 mg/12.5 mg

tablets 1 tablet

Exforge HCT

(amlodipine/valsartan/hydrochlorothiazide)s 10 mg/160 mg/25 mg

tablets 1 tablet

Exforge HCT

(amlodipine/valsartan/hydrochlorothiazide)s 10 mg/320 mg/25 mg

tablets 1 tablet

Hyzaar (losartan/hydrochlorothiazide)a 50 mg/12.5 mg tablets 1 tablet

Hyzaar (losartan/hydrochlorothiazide)a 100 mg/12.5 mg tablets 1 tablet

Hyzaar (losartan/hydrochlorothiazide)a 100 mg/25 mg tablets 1 tablet

Micardis (telmisartan)a 20 mg tablets 1 tablet



Micardis HCT

(telmisartan/hydrochlorothiazide)a


Micardis HCT


80 mg/12.5 mg tablets 2 tablets

Micardis HCT



Teveten (eprosartan) 400 mg tablets 2 tabletsTeveten, Eprosartan 600 mg tablets 1 tablet

Tribenzor

(olmesartan/amlodipine/hydrochlorothiazide)a 20 mg/5 mg/12.5 mg

tablets 1 tablet



Tribenzor


tablets 1 tablet

Tribenzor

(olmesartan/amlodipine/hydrochlorothiazide)a 40 mg/5 mg/25 mg

tablets 1 tablet

Tribenzor


tablets 1 tablet

Tribenzor

(olmesartan/amlodipine/hydrochlorothiazide)a 40 mg/10 mg/25 mg

tablets 1 tablet

Twynsta (telmisartan/amlodipine)a 40 mg/5 mg tablets 1 tablet




Renin Inhibitors, Renin Inhibitor Combinations

Tekturna (aliskiren)a 150 mg tablets 1 tablet

Tekturna (aliskiren)a 300 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 150 mg/12.5 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 150 mg/25 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 300 mg/12.5 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 300 mg/25 mg tablets 1 tablet

Arikayce PAQL

ATTR Amyloidosis PAQL

Baclofen PS 0120_r0320Ozobax (baclofen) 5 mg/5 mL oral solution 2400 mL/30 days

Benign Prostatic

Hypertrophy (BPH) PS

AR0819_r0320

Alpha Blockers (Selective)Flomax (tamsulosin) 0.4 mg capsules

a 2 capsules

Rapaflo (silodosin) 4 mg capsulesa 1 capsule

Rapaflo (silodosin) 8 mg capsulesa 1 capsule


**Arikayce QL information is included in the individual program document


** ATTR Amyloidosis QL information is included in the individual program document



Uroxatral (alfuzosin) 10 mg extended-release

tabletsa

1 tablet

Alpha Blockers (Nonselective)Cardura (doxazosin) 1 mg tablets

a 1 tablet

Cardura (doxazosin) 2 mg tabletsa 1 tablet

Cardura (doxazosin) 4 mg tabletsa 1 tablet

Cardura (doxazosin) 8 mg tabletsa 2 tablets

Cardura XL (doxazosin) 4 mg extended-release

tablets

1 tablet

Cardura XL (doxazosin) 8 mg extended-release

tablets

1 tablet

terazosin 1 mg capsulesa 1 capsule



terazosin 10 mg capsulesa 2 capsules

Alpha Reductase InhibitorsAvodart (dutasteride) 0.5 mg capsules

a 1 capsule

Proscar (finasteride) 5 mg tabletsa 1 tablet

Alpha Reductase Inhibitor/Alpha Blocker

CombinationsJalyn (dutasteride/tamsulosin) 0.5 mg/0.4 mg capsules

a 1 capsule

BenzodiazepinesCS AR0520 Xanax (alprazolam) 0.25 mg tablets 4 tablets

Xanax (alprazolam) 0.5 mg tablets 4 tablets

Xanax (alprazolam) 1 mg tablets 4 tablets

Xanax (alprazolam) 2 mg tablets 3 tablets

Niravam (alprazolam) 0.25 mg orally

disintegrating tablets4 tablets

Niravam (alprazolam) 0.5 mg orally


Niravam (alprazolam) 1 mg orally disintegrating

tablets4 tablets

Niravam (alprazolam) 2 mg orally disintegrating

tablets3 tablets

Xanax XR (alprazolam SR) 0.5 mg extended-release

tablets1 tablet

Xanax XR (alprazolam SR) 1 mg extended-release

tablets1 tablet


tablets2 tablets

Quantity limits apply to Medicaid only.




tablets2 tablets

Alprazolam Intensol (alprazolam) 1 mg/1mL concentrate 6 mLs

Librium (chlordiazepoxide) 5 mg capsules 4 capsules



Limbitrol (chlordiazepoxide/amitriptyline) 5mg/12.5mg tablets 4 tablets

Limbitrol (chlordiazepoxide/amitriptyline) 10mg/25mg tablets 6 tablets

Onfi (clobazam) 10 mg tablets 2 tablets

Onfi (clobazam) 20 mg tablets 2 tablets

Onfi (clobazam) 2.5 mg/mL suspension 16 mLs

Sympazan (clobazam) 5 mg oral film 8 films



Klonopin (clonazepam) 0.5 mg tablets 3 tablets

Klonopin (clonazepam) 1 mg tablets 3 tablets

Klonopin (clonazepam) 2 mg tablets 2 tablets

Klonopin (clonazepam) 0.125 mg orally






Klonopin (clonazepam) 1 mg orally disintegrating

tablets3 tablets

Klonopin (clonazepam) 2 mg orally disintegrating

tablets2 tablets

Tranxene (clorazepate) 3.75 mg tablets 3 tablets

Tranxene (clorazepate) 7.5 mg tablets 3 tablets

Tranxene (clorazepate) 15 mg tablets 4 tablets

Valium (diazepam) 2 mg tablets 4 tablets



Diazepam (diazepam) 1 mg/1mL solution 40 mLs

Diazepam Intensol (diazepam) 5 mg/1mL concentrate 8 mLs

Diastat (diazepam) 2.5 mg rectal solution 2 twin packs per 30 days

Diastat (diazepam) 10 mg rectal solution 2 twin packs per 30 days

Diastat (diazepam) 20 mg rectal solution 2 twin packs per 30 days

Valtoco (diazepam) 5 mg/ 0.1 mL nasal

inhaler10 blister packs (5 boxes) per 30 days

Valtoco (diazepam) 10 mg/ 0.1 mL nasal

inhaler10 blister packs (5 boxes) per 30 days

Valtoco (diazepam) 15 mg (2 x 7.5 mg/ 0.1

mL) nasal inhaler10 blister packs (5 boxes) per 30 days

Valtoco (diazepam) 20 mg (2 x 10 mg/ 0.1

mL) nasal inhaler10 blister packs (5 boxes) per 30 days

Prosom (estazolam) 1 mg tablets 1 tablet

Prosom (estazolam) 2 mg tablets 1 tablet

Dalmane (flurazepam) 15 mg capsules 1 capsule

Dalmane (flurazepam) 30 mg capsules 1 capsule

Ativan (lorazepam) 0.5 mg tablets 3 tablets



Ativan (lorazepam) 1 mg tablets 3 tablets

Ativan (lorazepam) 2 mg tablets 5 tablets

Ativan (lorazepam) 2 mg/1mL concentrate 5 mLs

Nayzilam (midazolam) 5mg/0.1mL nasal spray10 sprays per 30 days

Serax (oxazepam) 10 mg capsules 4 capsules



Doral (quazepam) 15 mg tablets 1 tablet

Restoril (temazepam) 7.5 mg capsules 1 capsule

Restoril (temazepam) 15 mg capsules 1 capsule

Restoril (temazepam) 22.5 mg capsules 1 capsule

Restoril (temazepam) 30 mg capsules 1 capsule

Halcion (triazolam) 0.125 mg tablets 1 tablet

Halcion (triazolam) 0.25 mg tablets 2 tablets

Biologic Immunomodulators

PAQL

Bisphosphonates PS

AR1119_r0320

Actonel (risedronate) 5 mg tablets 1 tablet

Actonel (risedronate)a 30 mg tablets 1 tablet

Actonel (risedronate)a 35 mg tablets 4 tablets (1 dose pack)/28 days

Actonel (risedronate)a 150 mg tablets 1 tablet/month

Atelvia (risedronate delayed-release)a 35 mg delayed-release

tablets

4 tablets (1 dose pack)/28 days

Binosto (alendronate) 70 mg effervescent

tablets

4 tablets /28 days

Boniva (ibandronate)a 150 mg tablets 1 tablet (blister pack)/month

Boniva (ibandronate)a 3 mg/3 mL injection 3 mL (1 kit)/90 days

Fosamax/alendronate (alendronate)a 5 mg tablets 1 tablet

Fosamax/alendronate (alendronate)a 10 mg tablets 1 tablet

Fosamax/alendronate (alendronate)a 35 mg tablets 4 tablets (1 blister pack)/28 days

Fosamax/alendronate (alendronate) 40 mg tablets 1 tablet

Fosamax/alendronate (alendronate)a 70 mg tablets 4 tablets (1 blister pack)/28 days

Fosamax/alendronate (alendronate) 70 mg/75 mLs oral

solution

75 mLs (70 mg)/week

Fosamax Plus D 70 mg/2800 IU 4 tablets (1 blister pack)/28 daysFosamax Plus D

(alendroante/cholecalciferol)

70 mg/5600 IU

(alendronate/cholecalc

iferol)

4 tablets (1 blister pack)/28 days

c -IU=International Units a - product has been discontinued by the manufacturer but may still be available


**Biologic Immunomodulators QL information is included in the individual program document



Buprenorphine, Quantity limits apply to Medicaid.

buprenorphine-naloxone PS

AR0220_r0320

buprenorphinea 2 mg sublingual tablet 15 tablets/90 days

buprenorphinea 8 mg sublingual tablet 15 tablets/90 days

Bunavail (buprenorphine/naloxone) 2.1 mg / 0.3 mg

buccal film

3 films

Bunavail (buprenorphine/naloxone) 4.2 mg / 0.7 mg

buccal film

2 films

Bunavail (buprenorphine/naloxone) 6.3 mg / 1 mg buccal

film

2 films

Suboxone (buprenorphine/naloxone)a 2 mg/0.5 mg

sublingual tablet

4 tablets

Suboxone (buprenorphine/naloxone)a 8 mg/2 mg sublingual

tablet

3 tablets

Suboxone (buprenorphine/naloxone)a 2 mg/0.5 mg

sublingual film

4 films


film

1 film


film

2 films

Suboxone (buprenorphine/naloxone)a 12 mg/3 mg

sublingual film

2 films

Zubsolv (buprenorphine/naloxone) 0.7 mg/0.18 mg

sublingual tablet

1 tablet


sublingual tablet

3 tablets

Zubsolv (buprenorphine/naloxone) 2.9 g/0.71 mg

sublingual tablet

1 tablet

Zubsolv (buprenorphine/naloxone) 5.7mg/1.4 mg

sublingual tablet

1 tablet




sublingual tablet

2 tablets


sublingual tablet

1 tablet

Cablivi QL ** Cablivi QL information is included in the individual program document

CGM QL ** CGM QL information is included in the individual program document

CGRP PAQL ** CGRP QL information is included in the individual program document

Ciclopirox_Efinaconazole_It

raconazole_Tavaborole_Ter

binafine_PAQL ** Ciclopirox_Efinaconazole_Itraconazole_Tavaborole_Terbinafine QL information is included in the individual program document

Circadian Rhythm Disorder

PAQL ** Circadian Rhythm Disorder QL information is included in the individual program document

Combination NSAID PAQL ** Combination NSAID QL information is included in the individual program document

Contraceptives PS

AR0220_r0320 Quantity limits apply to Medicaid only.

Estrogen/Progestin combinations, oral 28 tablets/21 days

Progestin combinations, oral 28 tablets/21 days

Xulane (norelgestromin /ethinyl estradiol

transdermal system)

6 mg norelgestromin,

0.75 mg ethinyl

estradiol.

3 patches/21 days

NuvaRing, Eluryng (etonogestrel/ethinyl

estradiol vaginal ring)

11.7 mg etonogestrel,

2.7 mg ethinyl

estradiol

1 vaginal ring/21 days

Annovera (segesterone acetate/ethinyl

estradiol vaginal system)

103 mg segesterone

acetate, 17.4 mg ethinyl

estradiol

1 vaginal system/365 days

DPP-4 Inhibitors PS AR0220_r0320 Glyxambi (empagliflozin/linagliptin) 10 mg / 5 mg 1 tablet

Glyxambi (empagliflozin/linagliptin) 25 mg / 5 mg 1 tablet

Januvia (sitagliptin) 25 mg tablet 1 tabletJanuvia (sitagliptin) 50 mg tablet 1 tabletJanuvia (sitagliptin) 100 mg tablet 1 tablet

Nesina (alogliptin) 6.25mg 1 tabletNesina (alogliptin) 12.5mg 1 tabletNesina (alogliptin) 25mg 1 tablet

Onglyza (saxagliptin) 2.5 mg tablet 1 tablet




Onglyza (saxagliptin) 5 mg tablet 1 tablet

Tradjenta (linagliptin) 5 mg tablet 1 tablet

Janumet (sitagliptin/metformin) 50 mg/500 mg tablet 2 tabletsJanumet (sitagliptin/metformin) 50 mg/1000 mg tablet 2 tablets

Janumet XR (sitagliptin/metformin extended- 50 mg/500 mg tablet 1 tabletJanumet XR (sitagliptin/metformin extended- 50 mg/1000 mg tablet 2 tabletsJanumet XR (sitagliptin/metformin extended- 100 mg/1000 mg tablet 1 tablet

Jentadueto (linagliptin/metformin) 2.5 mg/500 mg tablet 2 tabletsJentadueto (linagliptin/metformin) 2.5 mg/850 mg tablet 2 tabletsJentadueto (linagliptin/metformin) 2.5 mg/1000 mg tablet 2 tablets

Jentadueto XR (linagliptin/metformin ER) 2.5 mg/1000 mg 2 tablets

Jentadueto XR (linagliptin/metformin ER) 5 mg/1000 mg tablet 1 tablet

DPP-4 Inhibitors PSAR0220_r0320 Kazano (alogliptin/metformin) 12.5mg/500mg 2 tablets

Kazano (alogliptin/metformin) 12.5mg/100mg 2 tablets

Kombiglyze XR (saxagliptin/metformin) 2.5 mg/1000 mg tablet 2 tabletsKombiglyze XR (saxagliptin/metformin) 5 mg/500 mg tablet 1 tabletKombiglyze XR (saxagliptin/metformin) 5 mg/1000 mg tablet 1 tablet

Oseni (alogliptin/pioglitazone) 12.5mg/15mg 1 tabletOseni (alogliptin/pioglitazone) 12.5mg/30mg 1 tabletOseni (alogliptin/pioglitazone) 12.5mg/45mg 1 tabletOseni (alogliptin/pioglitazone) 25mg/15mg 1 tabletOseni (alogliptin/pioglitazone) 25mg/30mg 1 tabletOseni (alogliptin/pioglitazone) 25mg/45mg 1 tablet

Qtern (dapagliflozin/saxagliptin) 5 mg/5 mg tablet 1 tabletQtern (dapagliflozin/saxagliptin) 10 mg/5 mg tablet 1 tablet

Steglujan (ertugliflozin/sitagliptin) 5 mg/100 mg tablet 1 tabletSteglujan (ertugliflozin/sitagliptin) 15 mg/100 mg tablet 1 tablet

Trijardy XR

(empagliflozin/linagliptin/metformin ER)

5 mg/2.5 mg/1000 mg tablet 2 tablets

Trijardy XR


10 mg/5 mg/1000 mg tablet 1 tablet

Trijardy XR


12.5 mg/2.5 mg/1000 mg tablet 2 tablets

Trijardy XR


25 mg/5 mg/1000 mg tablet 1 tablet

Egrifta PAQL ** Egrifta QL information is included in the individual program document



Fibrates PS AR0819_r0320

Antara (fenofibrate) 30 mg micronized capsules 2 capsules

Antara (fenofibrate)a 43 mg micronized

capsules

2 capsules

Antara (fenofibrate) 90 mg micronized capsules 1 capsule

Antara (fenofibrate)a 130 mg micronized

capsules

1 capsule

Fenoglide (fenofibrate)a 40 mg tablets 2 tablets

Fenoglide (fenofibrate)a 120 mg tablets 1 tablet

Fibricor (fenofibric acid) 35 mg tablets 2 tabletsFibricor (fenofibric acid) 105 mg tablets 1 tablet

Lipofen (fenofibrate) 50 mg capsules 2 capsulesLipofen (fenofibrate) 150 mg capsules 1 capsule

Lofibra (fenofibrate)a 54 mg tablets 2 tablets

Lofibra (fenofibrate)a 160 mg tablets 1 tablet

Lofibra (fenofibrate)a 67 mg micronized

capsules

1 capsule


capsules

1 capsule


capsules

1 capsule

Tricor (fenofibrate)a 48 mg tablets 2 tablets

Tricor (fenofibrate)a 145 mg tablets 1 tablet

Triglide (fenofibrate) 50 mg tablets 2 tabletsTriglide, Fenofibrate 160 mg tablets 1 tablet

Trilipix (fenofibric acid)a 45 mg delayed-release

tablets

2 tablets

Trilipix (fenofibric acid)a 135 mg delayed-release

tablets

1 tablet

Fibrates PS AR0819_r0320 Lopid (gemfibrozil)a 600 mg tablets 2 tablets

Fibromyalgia (Lyrica,

Savella) PS AR0320 Quantity limits apply to Medicaid.

Lyrica (pregabalin)a 25 mg capsule 3 capsules











Lyrica (pregabalin)a 20 mg/mL oral

solution

30 mLs

Savella (milnacipran) 12.5 mg tablet 2 tablets

Savella (milnacipran) 25 mg tablet 2 tablets



Savella (milnacipran) Titration pack: 5 x

12.5 mg, 8 x 25 mg,

42 x 50 mg tablets

1 pack/180 days

Gabapentin ER PS AR0320Quantity limits apply to Medicaid only.

Gralise (gabapentin) 300 mg extended-release

tablets1 tablet

Gralise (gabapentin) 600 mg extended-release

tablets3 tablets

Gralise (gabapentin) Starter Pack: 300 mg (9)

& 600 mg (69)1 pack/180 days

Horizant (gabapentin enacarbil) 300 mg extended-release

tablets2 tablets

Horizant (gabapentin enacarbil) 600 mg extended-release

tablets2 tablets

Galafold PAQL

GLP-1 PS AR0220_r0320

Adlyxin (lixisenatide) 20 mcg/injection 3 mL

pens

2 pens / 28 days

Adlyxin (lixisenatide) Starter Pack (2 pens) 2 pens / 180 days

Byetta (exenatide) 5 mcg/dose prefilled

pen

1 prefilled pen (60 doses)/30 days

Byetta (exenatide) 10 mcg/dose prefilled

pen

1 prefilled pen (60 doses)/30 days

Bydureon (exenatide ER) 2 mg/vial in single

dose tray; 4

trays/carton

1 carton (4 trays/4 doses)/28 days

Bydureon (exenatide ER) 2 mg/pen; 4

trays/carton

1 carton (4 doses)/28 days

** Galafold QL information is included in the individual program




Bydureon BCise (exenatide ER) 2 mg/autoinjector; 4

autoinjector/carton

1 carton (4 doses)/28 days

Ozempic (semaglutide) 2 mg single-patient

pen (0.25-0.5 mg per

injection)

1 pen / 28 days

Ozempic (semaglutide) 2 mg single-patient

pen (1 mg per

injection)

2 pens / 28 days

Rybelsus (semaglutide) 3 mg tablet 30 tablets / 180 days

Rybelsus (semaglutide) 7 mg tablet 1 tablet

Rybelsus (semaglutide) 14 mg tablet 1 tablet

Tanzeum (albiglutide) 30 mg single-dose pen 4 pens/28 days

Tanzeum (albiglutide) 50 mg single-dose pen 4 pens/28 days

Trulicity (dulaglutide) 0.75 mg/0.5 mL

syringe and pens

4 pens or syringes/28days

Trulicity (dulaglutide) 1.5 mg/0.5 mL syringe

and pens

4 pens or syringes/28days

Victoza (liraglutide) 18 mg/3 mL pen 3 pens/30 days

Glucose Test

Strips/Disks/Meters QL

HAE PAQL

hATTR Amyloidosis

Neuropathy PAQL

HoFH PAQL

Ingrezza PAQL

Insomnia PS AR0320_r0520

Ambien (zolpidem)a 5 mg tablet 1 tablet

Ambien (zolpidem)a 10 mg tablet 1 tablet

Ambien CR (zolpidem)a 6.25 mg extended-

release tablet

1 tablet

Ambien CR (zolpidem)a 12.5 mg extended-

release tablet

1 tablet

Belsomra (suvorexant) 5 mg tablet 1 tablet

** Glucose Test Strips/Disks/Meters QL information is included in the individual program document

** hATTR Amyloidosis Neuropathy QL information is included in the individual program document

** HAE QL information is included in the individual program document


** Ingrezza QL information is included in the individual program document

** HoFH QL information is included in the individual program document



Belsomra (suvorexant) 10 mg tablet 1 tabletBelsomra (suvorexant) 15 mg tablet 1 tabletBelsomra (suvorexant) 20 mg tablet 1 tablet

Dayvigo (lemborexant) 5 mg tablet 1 tabletDayvigo (lemborexant) 10 mg tablet 1 tablet

Edluar (zolpidem) 5 mg sublingual tablet 1 tabletEdluar (zolpidem) 10 mg sublingual tablet 1 tablet

Intermezzo (zolpidem)a 1.75 mg sublingual tablet 1 tablet

Intermezzo (zolpidem)a 3.5 mg sublingual tablet 1 tablet

Lunesta (eszopiclone)a 1 mg tablet 1 tablet



Rozerem (ramelteon)a 8 mg tablet 1 tablet

Silenor, Doxepina 3 mg tablet 1 tablet

Silenor, Doxepina 6 mg tablet 1 tablet

Sonata (zaleplon)a 5 mg capsule 1 capsule

Sonata (zaleplon)a 10 mg capsule 1 capsule

ZolpiMist (zolpidem) Oral Spray 5

mg/actuation

1 canister (60 actuations)/ 30 days

Insulins CS AR0220_r0420

NovoLog, Insulin Aspart 100 U/mL: 10 mL vial 45 mL/30 days100 U/mL: 3 mL

pen/cartridge (Penfill)

45 mL/30 days

100 U/mL: 3 mL

pen/cartridge (Flexpen)

45 mL/30 days

Fiasp (insulin aspart) 100 U/mL: 10 mL vial 45 mL/30 days

100 U/mL: 3 mL

pen/cartridge (Penfill)

45 mL/30 days

100 U/mL: 3 mL

pen/cartridge

(Flextouch)

45 mL/30 days

Lantus (insulin glargine) 100 U/mL: 10 mL vial 45 mL/30 days




100 U/mL: 3 mL

device/cartridge

(Solostar)

45 mL/30 days

Toujeo (insulin glargine) 300 U/mL: 1.5 mL pen 45 mL/30 daysToujeo Max (insulin glargine) 300 U/mL: 3 mL pen 45 mL/30 daysBasaglar Kwikpen (insulin glargine) 100 U/mL: 3 mL

pen/cartridge

45 mL/30 days

Apidra (insulin glulisine) 100 U/mL: 10 mL vial 45 mL/30 days100 U/mL: 3 mL

pen/cartridge (Solostar)

45 mL/30 days

Admelog (insulin lispro) 100 U/mL: 10 mL vial 45 mL/30 daysAdmelog (insulin lispro) 100 U/mL: 3 mL pen 45 mL/30 daysHumalog, Insulin Lispro 100 U/mL: 10 mL vial 45 mL/30 days

100 U/mL: 3 mL

pen/cartridge

45 mL/30 days

Humalog Junior Kwikpen U100, Insulin Lispro

Junior Kwikpen

100 U/mL: 3 mL pen 45 mL/30 days

Humalog Kwikpen U200 (insulin lispro) 200 U/mL: 3 mL pen 45 mL/30 daysLevemir (insulin detemir) 100 U/mL: 10 mL vial 45 mL/30 days

100 U/mL: 3 mL pen

(Flexpen, Flextouch)

45 mL/30 days

Tresiba (insulin degludec) 100 U/mL: 3 mL pen 45 mL/30 daysTresiba (insulin degludec) 200 U/mL: 3 mL pen 45 mL/30 daysTresiba (insulin degludec) 100 U/mL: 10 mL vial 45 mL/30 daysHumulin R, Novolin R, Relion R (insulin

regular)

100 U/mL: 10 mL vial 45 mL/30 days

Humulin R (insulin regular) 500 U/mL: 20 mL vial 45 mL/30 daysNovolin R 100 U/mL: 3 mL pen 45 mL/30 daysHumulin R Kwikpen U500 (insulin regular) 500 U/mL: 3 mL pen 45 mL/30 days

Humulin N, Novolin N, (insulin isophane) 100 U/mL: 10 mL vial 45 mL/30 daysHumulin N, Novolin N, (insulin isophane) 100 U/mL: 3 mL pen 45 mL/30 daysNovoLog 70/30 (insulin mixed) 100 U/mL: 10 mL vial 45 mL/30 days

100 U/mL: 3 mL pen

(Flexpen)

45 mL/30 days

Humulin 70/30, Novolin 70/30, Relion 70/30 100 U/mL: 10 mL vial 45 mL/30 days

Humulin 70/30, Novolin 70/30 100 U/mL: 3 mL pen

(Kwikpen, Flexpen)

45 mL/30 days

Humalog 75/25 (insulin mixed) 100 U/mL: 10 mL vial 45 mL/30 daysHumalog Kwikpen 75/25 (insulin mixed);

Insulin Lispro Protamine/Insulin Lispro

100 U/mL: 3 mL pen 45 mL/30 days

Humalog 50/50 (insulin mixed) 100 U/mL: 10 mL vial 45 mL/30 daysHumalog Kwikpen 50/50 (insulin mixed) 100 U/mL: 3 mL pen 45 mL/30 daysAfrezza 4 unit cartridge packs 2,520 cartridges / 30 days

Afrezza 8 unit cartridge packs 1,260 cartridges / 30 days

Afrezza 12 unit cartridge

packs

900 cartridges / 30 days



Afrezza 30 X 4 unit cartridge +

60 X 8 unit cartridge mix

packs

1,530 cartridges / 30 days

Afrezza 60 X 4 unit cartridge +

30 X 8 unit cartridge mix

packs


Afrezza 60 x 8 unit cartridge +

30 x 12 unit cartridge

mix packs




mix packs




mix packs



60 x 8 unit cartridge +


mix packs


Insulin Combination PS

AR0220_r0320


Soliqua (insulin glargine/lixisenatide) 100 units/mL insulin

glargine / 33 mcg/mL

lixisenatide

15 mL (5 pens) / 30 days

Xultophy (insulin degludec/liraglutide) 100 units/mL insulin

degludec / 3.6 mg

liraglutide

15 mL (5 pens) / 30 days

Jynarque PAQL ** Jynarque QL information is included in the individual program document

Kalydeco Orkambi PAQL ** Kalydeco Orkambi QL information is included in the individual program document

Ketorolac PS AR0220_r0320 Quantity limits apply to Medicaid.

Ketorolaca

10 mg tablet 20 tablets/prescription

Sprix (ketorolac nasal spray) 1.7 g bottle 5 bottles/prescriptionSprix (ketorolac nasal spray) 1.7 g bottle (5 pack) 1 pack/prescription

Keveyis PS AR0320 Quantity limits apply to Medicaid. Keveyis 50 mg tablet 4 tablets

Low Molecular Weight Quantity limits apply to Medicaid.




Heparins (LMWH) and Arixtra (fondaparinux)

Arixtra PS AR0320 Single-dose syringea 2.5 mg/ 0.5 ml 30 syringes/90 days

Single-dose syringea 5 mg/ 0.4 ml 30 syringes/90 days

Single-dose syringea 7.5 mg/0.6 ml 30 syringes/90 days

Single-dose syringea 10 mg/ 0.8 ml 30 syringes/90 days

Fragmin (dalteparin) Single-dose syringe 2,500 IU/ 0.2 ml 30 syringes/90 days Single-dose syringe 5,000 IU/ 0.2 ml 30 syringes/90 days Single-dose syringe 7,500 IU /0.3 ml 30 syringes/90 days

Low Molecular Weight Single-dose graduated syringe 10,000 IU/ 1 ml 30 syringes/90 days

Heparins (LMWH) and Single-dose syringe 12,500 IU/0.5 ml 30 syringes/90 days

Arixtra PS AR0320 Single-dose syringe 15,000 IU/ 0.6 ml 30 syringes/90 days Single-dose syringe 18,000 IU/ 0.72 ml 30 syringes/90 days

Multi-dose vial95,000 IU/3.8 mL

(25,000 IU/ 1 mL)10 vials/90 days

Lovenox (enoxaparin)

Single-dose syringe 30 mg/ 0.3 mla 30 syringes/90 days

Single-dose syringe 40 mg/ 0.4 mla 30 syringes/90 days

Single-dose graduated syringe 60 mg/ 0.6 mla 30 syringes/90 days


Single-dose graduated syringe 100 mg/ 1 mla 30 syringes/90 days


Single-dose graduated syringe 150 mg/ 1 mla 30 syringes/90 days

Multiple dose vial 300 mg/ 3 mla 10 vials/90 days

Lucemyra PAQL

Lyrica CR PS AR0520Lyrica CR (pregabalin ER) 82.5 mg tablet 1 tabletLyrica CR (pregabalin ER) 165 mg tablet 1 tabletLyrica CR (pregabalin ER) 330 mg tablet 2 tablets

Metformin ER PS

AR0220_r0320

Fortamet (metformin osmotic ER) 500 mg 3 tablets

Fortamet (metformin osmotic ER) 1000 mg 2 tablets

Glucophage XR (metformin ER) 500 mg 4 tablets

Glucophage XR (metformin ER) 750 mg 2 tablets

Glumetza (metformin modified release

ER)

500 mg 3 tablets

Glumetza (metformin modified release

ER)

1000 mg 2 tablets

Riomet ER supsension (metformin ER) 500 mg/5 mL 960 mL/30 days

Multiple Sclerosis PAQL


**Multiple Sclerosis QL information is included in the individual program document

**Lucemyra QL information is included in the individual program document




Nasal Inhalers PS

AR0220_r0320Antihistamines

azelastine 0.1%a 137 mcg/spray (30 mL,

200 sprays) 2 bottles/30 days

Astepro (azelastine 0.15%) 205.5 mcg/spray (30

mL, 200 sprays) 2 bottles/30 days

Patanase (olopatadine)a 665 mcg/spray (30.5

gm, 240 sprays) 1 bottle/30 days

Anticholinergics

Atrovent (ipratropium 0.03%)a 21 mcg/spray (30 mL,


Atrovent (ipratropium 0.06%)a 42 mcg/spray (15 mL,


CorticosteroidsBeconase AQ (beclomethasone) 42 mcg/spray (25 gm,


Flonase (fluticasone propionate)a 50 mcg/spray (16 gm,

120 sprays) 1 bottle/30 days

Flunisolidea 25 mcg/spray (25 mL,


Nasacort AQ (triamcinolone)b 55 mcg/spray (16.5 gm,


Nasonex (mometasone)a 50 mcg/spray (17 gm,


Omnaris (ciclesonide) 50 mcg/spray (12.5 gm,


Qnasl (beclomethasone diproprionate) 80 mcg/spray (10.6 gm,

120 sprays) 1 canister/30 days

Qnasl Children (beclomethasone

diproprionate)

40 mcg/spray (6.8 gm,

60 sprays) 1 canister/30days

Rhinocort Aqua (budesonide)b 32 mcg/spray (8.6 gm,


Xhance (fluticasone) 93 mcg/actuation (16

mLs, 120 sprays) 2 bottles/30 days




Zetonna (ciclesonide) 37 mcg/actuation (6.1

gm, 60 actuations) 1 canister/30 days

Nasal Inhalers PS

AR0220_r0320

Combinations

Dymista (azelastine/fluticasone)a

137 mcg/50 mcg/spray

(23 gm, 120 sprays) 1 bottle/30 days

Neprilysin Inhibitor PAQL ** Neprilysin Inhibitor QL information is included in the individual program document

Niaspan PS AR0819_r0320Niaspan (niacin extended-release) 500 mg extended-release

tablets

1 tablet

Niaspan (niacin extended-release) 750 mg extended-release

tablets

2 tablets

Niaspan (niacin extended-release) 1000 mg extended-

release tablets

2 tablets

Noctiva PAQL ** Noctiva QL information is included in the individual program document

Northera PAQL ** Northera QL information is included in the individual program document

Ocaliva PAQL ** Ocaliva QL information is included in the individual program document

Opioids ER QL ** Opioids ER QL information is included in the individual program document

Opioids IR QL ** Opioids IR QL information is included in the individual program document

Oral Inhalers PS

AR0220_r0320Quantity limits apply to Medicaid.

Atrovent HFA (ipratropium)

17 mcg/actuation (12.9

gm, 200 actuations) 2 canisters/month

Combivent Respimat (ipratropium/albuterol)

18 mcg/90 mcg/actuation

(14.7gm, 200 actuations) 2 canisters/month

Incruse Ellipta (umeclidinium) 62.5 mcg/blister 30 blisters/month

Seebri Neohaler (glycopyrrolate) 15.6 mcg/ inhalation (box of 60 capsules)60 inhalation capsule/month


Anticholinergics

a–available as a generic and included in quantity limit program

b - product discontinued



Spiriva Handihaler (tiotropium) 18 mcg/inhalation

(carton of 5, 30, or 90

capsules) 30 capsules/month

Spiriva Respimat (tiotropium)

1.25 mcg/actuation (4 g

cartridge) 1 cartridge/month

Spiriva Respimat (tiotropium)

2.5 mcg/actuation (4 g

cartridge) 1 cartridge/month

Tudorza Pressair (aclidium bromide)

400 mcg/actuation (60

actuations) 1 canister/month

Short-Acting Beta AgonistsProAir HFA (albuterol sulfate HFA) 90 mcg/actuation (8.5


Proventil HFA (albuterol sulfate) 90 mcg/actuation (6.7


ProAir Respiclick (albuterol sulfate) 90 mcg/actuation (200

actuations) 2 inhalers/month

ProAir Digihaler (albuterol sulfate) 90 mcg/actuation (200

actuations) 2 inhalers/month

Ventolin HFA, Albuterol sulfate HFA



Ventolin HFA (albuterol sulfate) 90 mcg/actuation (8 gm,

60 actuations) 2 canisters/month

Xopenex HFA, Levalbuterol HFA



Long-Acting Beta AgonistsArcapta Neohaler (indacaterol)

75 mcg/inhalation

(Neohaler inhaler and

box of 5 blister cards of 6

capsules each, total 30) 1 box (30 capsules)/month

Foradil (formoterol)12 mcg/inhalation

(Aerolizer inhaler and

blister pack of 12 or 60) 1 blister pack of 12 or 1 blister pack of 60/month

Serevent (salmeterol)50 mcg/inhalation

(disposable inhalation

device and 60 blisters) 1 package (60 blisters)/month



Striverdi Respimat (olodaterol) 2.5 mcg/actuation (4 gm,

60 actuations) 1 canister/month

Corticosteroids and Corticosteroid

CombinationsAdvair Diskus (fluticasone/salmeterol) 100 mcg/50 mcg

(inhalation device, 60

blisters) 1 package (60 blisters)/month

Advair Diskus (fluticasone/salmeterol) 250 mcg/50 mcg per

inhalation (disposable

inhalation device and 60


Advair Diskus (fluticasone/salmeterol) 500 mcg/50 mcg per

inhalation (disposable

inhalation device and 60


Advair HFA (fluticasone/ salmeterol) 45 mcg/21 mcg (12 gm,






Aerospan (flunisolide)

80 mcg/actuation (8.9


AirDuo Respiclick,

Fluticasone/Salmeterol

55 mcg/14 mcg (0.45

gm, 60 actuations)

1 inhaler/month

AirDuo Respiclick,


113 mcg/14 mcg

(0.45 gm, 60

actuations)

1 inhaler/month

AirDuo Respiclick,


232 mcg/14 mcg

(0.45 gm, 60

actuations)

1 inhaler/month

Alvesco (ciclesonide) 80 mcg/actuation (6.1

gm, 60 actuations) 1 canister/month

Oral Inhalers PS

AR0220_r0320

Alvesco (ciclesonide)160 mcg/actuation (6.1


Armonair Respiclick (fluticasone) 55 mcg/actuation (0.9

g, 60 actuations)

1 inhaler/month

Armonair Respiclick (fluticasone) 113 mcg/actuation

(0.9 g, 60 actuations)

1 inhaler/month



Armonair Respiclick (fluticasone) 232 mcg/actuation

(0.9g, 60 actuations)

1 inhaler/month

Arnuity Ellipta (fluticasone) 50 mcg/blister 30 blisters/monthArnuity Ellipta (fluticasone) 100 mcg/blister 30 blisters/monthArnuity Ellipta (fluticasone) 200 mcg/blister 30 blisters/month

Asmanex (mometasone) 110 mcg/actuation (30


Asmanex (mometasone)220 mcg/actuation (30,

60, 120 actuations) 1 canister/month

Asmanex HFA (mometasone)









Breo Ellipta (fluticasone/valnterol)

100 mcg/25 mcg (60

blisters, 30 actuations) 1 package (60 blisters)/month

Breo Ellipta (fluticasone/valnterol)

200 mcg/25 mcg (60


Dulera (mometasone/formoterol) 50 mcg/5 mcg (13 gm,






Flovent HFA (fluticasone)44 mcg/actuation (10.6


Flovent HFA (fluticasone) 110 mcg/actuation (12


Flovent HFA (fluticasone) 220 mcg/actuation (12


Flovent Diskus (fluticasone) 50 mcg/inhalation (60

blisters/carton) 1 carton/month


blisters/carton) 1 carton/month


blisters/carton) 4 cartons/month



Pulmicort Flexhaler (budesonide) 90 mcg/actuation (60


Pulmicort Flexhaler (budesonide) 180 mcg/actuation (120

actuations) 2 canisters/month

Qvar (beclomethasone) 40 mcg/actuation (8.7


Qvar (beclomethasone) 80 mcg/actuation (8.7


Qvar Redihaler 40 mcg/actuation

(10.6 gm, 120


Qvar Redihaler 80 mcg/actuation

(10.6 gm, 120

actuations) 2 canisters/month

Symbicort, Budesonide/formoterol 80 mcg/4.5 mcg (10.2


Symbicort, Budesonide/formoterol160 mcg/4.5 mcg (10.2


Trelegy Ellipta

(fluticasone/umeclidinium/vilanterol)

100 mcg/62.5 mcg/25

mcg (30 inhalations)1 inhaler/month

Anticholinergic/Long-Acting Beta Agonist Combination

Anoro Ellipta (umeclidinium/valnterol)

62.5 mcg/25 mcg (60


Bevespi Aerosphere (glycopyrrolate and

formoterol)

9 mcg/4.8 mcg (120

inhalation canister) 1 canister/month

Duaklir Pressair (aclidinium

bromide/formoterol fumarate)

400 mcg/12 mcg (60

actuations) 1 inhaler/month

Stiolto Respimat (tiotropium/olodaterol) 2.5 mcg/2.5 mcg (4

grams, 60 actuations)

1 cartridge/month

Utibron Neohaler (indacaterol/glycopyrrolate)27.5 mcg/15.6

mg/inhalation (Box of

60 inhalation capsules/month

Ophthalmic

Immunomodulators PAQL ** Ophthalmic Immunomodulators QL information is included in the individual program document

Ophthalmic Prostaglandins

PS AR0819_r0320Lumigan (bimatoprost–0.01%) 2.5 mL bottle 2.5 mL/30 daysLumigan (bimatoprost–0.01%) 5 mL bottle 2.5 mL/30 daysLumigan (bimatoprost–0.01%) 7.5 mL bottle 2.5 mL/30 days

b – CFC-containing inhaler mandated by FDA to be phased out by December 31, 2013




Bimatoprost-0.03%a 2.5 mL bottle 2.5 mL/30 days

Bimatoprost-0.03%a 5 mL bottle 2.5 mL/30 days

Bimatoprost-0.03%a 7.5 mL bottle 2.5 mL/30 days

Rescula (unoprostone-0.15%) 5 mL bottle 5 mL/30 days

Travatan Z (travoprost)a 2.5 mL bottle 2.5 mL/30 days

Travatan Z (travoprost)a 5 mL bottle 2.5 mL/30 days

Travoprost 2.5 mL bottle 2.5 mL/30 daysTravoprost 5 mL bottle 2.5 mL/30 days

Vyzulta (latanoprostene bunod) 2.5 mL bottle 2.5 mL/30 daysVyzulta (latanoprostene bunod) 5 mL bottle 2.5 mL/30 days

Xalatan (latanoprost)a 2.5 mL bottle 2.5 mL/30 days

Xelpros (latanoprost emulsion) 2.5 mL bottle 2.5 mL/30 days

Zioptan (tafluprost)0.3 mL/single-use

container

30 single-use containers/30 days

Zioptan (tafluprost)0.3 mL/single-use

container

30 single-use containers/30 days

a–available as a generic and included in quantity limit program

Oral PAH PAQL ** Oral PAH QL information is included in the individual program document

Orilissa PAQL ** Orilissa QL information is included in the individual program document

Otezla PAQL

Oxbryta PAQL

Oxycodone ER PAQL ** Oxycodone ER QL information is included in the individual program document

Pain PS AR0220_r0320Butalbital Combinations

Allzital (butalbital/acetaminophen) 25 mg/325 mg tablet 12 tablets

Butalbital/Aspirin/Caffeine 50 mg/325 mg/40 mg

tablet

6 tablets

Tencon (butalbital/acetaminophen)a 50 mg/325 mg tablet 6 tablets

Vanatol LQ elixir, Vanatol S

(butalbital/acetaminophen/caffeine)a

50 mg/325 mg/40 mg/15

mL solution

90 mLs

Butalbital/Acetaminophen/Caffeinea 50 mg/325 mg/40 mg

capsule

6 capsules

Esgic (butalbital/acetaminophen/caffeine)a 50 mg/325 mg/40 mg

tablet

6 tablets

Fioricet (butalbital/acetaminophen/caffeine)a 50 mg/325 mg/40 mg

tablet

6 tablets

Quantity limits apply to Medicaid formularies.

** Otezla QL information is included in the individual program document

** Oxbryta QL information is included in the individual program document




tablet

6 tablets

Fiorinal (butalbital/aspirin/caffeine)a 50 mg/325 mg/40 mg

capsule

6 capsules


capsule

6 capsules

butalbital/acetaminophena 50 mg/300 mg tablets 6 tablets

Butal/APAP (bultalbital/acetaminophen)a 50 mg/300 mg capsule 6 capsules


Parathyroid Hormone

Analogs for Osteoporosis

PAQL

PCSK9 PAQL ** PCSK9 QL information is included in the individual program document

Peanut Allergy PAQL **Peanut Allergy QL information is included in the individual program document

PPIs QL

Pseudobulbar Affect PAQL **Pseudobulbar Affect QL information is included in the individual program document

SA Oncology PAQL **SA Oncology QL information is included in the individual program document

Samsca PAQL **Samsca QL information is included in the individual program document

SGLT2 Inhibitors PS

AR0220_r0320Farxiga (dapagliflozin) 5 mg tablet 1 tabletFarxiga (dapagliflozin) 10 mg tablet 1 tablet

Invokana (canagliflozin) 100 mg tablet 1 tabletInvokana (canagliflozin) 300 mg tablet 1 tablet

Invokamet (canagliflozin/metformin) 50 mg / 500 mg 2 tabletsInvokamet (canagliflozin/metformin) 50 mg / 1000 mg 2 tabletsInvokamet (canagliflozin/metformin) 150 mg / 500 mg 2 tabletsInvokamet (canagliflozin/metformin) 150 mg / 1000 mg 2 tablets

Invokamet XR (canagliflozin/metformin ER) 50 mg/500 mg tablet 2 tablets




** PPI QL information is included in the individual program document


** Parathyroid Hormone Analogs for Osteoporosis QL information is included in the individual program document



Jardiance (empagliflozin) 10 mg 1 tabletJardiance (empagliflozin) 25 mg 1 tablet

Segluromet (ertugliflozin/metformin) 2.5 mg/500 mg tablet 4 tabletsSegluromet (ertugliflozin/metformin) 2.5 mg/1000 mg tablet 2 tablets

Segluromet (ertugliflozin/metformin) 7.5 mg/500 mg tablet 2 tabletsSegluromet (ertugliflozin/metformin) 7.5 mg/1000 mg tablet 2 tablets

Steglatro (ertugliflozin) 5 mg tablet 2 tabletsSteglatro (ertugliflozin) 15 mg tablet 1 tablet

Synjardy (empagliflozin/metformin) 5 mg / 500 mg 2 tabletsSynjardy (empagliflozin/metformin) 5 mg / 1000 mg 2 tabletsSynjardy (empagliflozin/metformin) 12.5 mg / 500 mg 2 tabletsSynjardy (empagliflozin/metformin) 12.5 mg / 1000 mg 2 tablets

Synjardy XR (empagliflozin/metformin ER) 5 mg/1000 mg tablet 2 tablets

Synjardy XR (empagliflozin/metformin ER) 10 mg/1000 mg tablet 2 tablets

Synjardy XR (empagliflozin/metformin ER) 12.5 mg/1000 mg tablet 2 tablets

Synjardy XR (empagliflozin/metformin ER) 25 mg/1000 mg tablet 1 tablet

Xigduo XR (dapagliflozin/metformin ER) 2.5 mg/1000 mg tablet 2 tablets

Xigduo XR (dapagliflozin/metformin ER) 5 mg / 500 mg 1 tabletXigduo XR (dapagliflozin/metformin ER) 5 mg / 1000 mg 2 tabletsXigduo XR (dapagliflozin/metformin ER) 10 mg / 500 mg 1 tabletXigduo XR (dapagliflozin/metformin ER) 10 mg / 1000 mg 1 tablet

SSIA PS AR0520

Nuplazid (pimavanserin) 10 mg tablet 1 tabletNuplazid (pimavanserin) 17 mg tablet 2 tabletsNuplazid (pimavanserin) 34 mg capsule 1 capsule

Sunosi PAQL **Sunosi QL information is included in the individual program document

Symlin CS AR0220_r0320

Symlin (pramlintide) 60 pen-injector 4 pens (6 mL) / 30 days

Symlin (pramlintide) 120 pen-injector 4 pens (10.8 mL) / 30 days

TIRF PAQL **TIRF QL information is included in the individual program document

Topical Corticosteroids PS

AR1219_r0520






alclometasone dipropionate 0.05% cream (15 gm,

45 gm, 60 gm) 120 grams/30 days

alclometasone dipropionate 0.05% ointment (15

gm, 45 gm, 60 gm) 120 grams/30 days

Ala Scalp (hydrocortisone) 2% lotion (29.6 mL) 118.4 mLs/30 days

ApexiCon E (diflorasone diacetate) 0.05% emollient

cream (30 mg, 60 gm)120 grams/30 days

triamcinolone acetonide 0.5% ointment (15

gm) 120 grams/30 days

Bryhali (halobetasol propionate) 0.01% lotion (60 gm,

100 gm) 200 grams/28 days

Capex (fluocinolone acetonide) 0.01% shampoo (120

mL) 840 mLs/28 days

Clobex (clobetasol propionate) 0.05% spray (59 mL,

125 mL) 236 mLs/28 days

Clobex (clobetasol propionate) 0.05% lotion (59 mL,

118 mL) 177 mLs/28 days

Clobex (clobetasol propionate) 0.05% shampoo (118

mL) 236 mLs/30 days

Cloderm (clocortolone pivalate) 0.1% cream (30 gm,

45 gm, 75 gm, 90 gm)135 grams/30 days

Cordran (flurandrenolide) 4 mcg/cm2 (80 in x 3

in) 1 box/30 days

Cordran (flurandrenolide) 0.025% cream (120


Cordran (flurandrenolide) 0.05% cream (60 gm,


Cordran (flurandrenolide) 0.05% lotion (120 mL)120 mLs/30 days

Cordran (flurandrenolide) 0.05% ointment (60


Cutivate (fluticasone propionate) 0.05% lotion (60 mL,

120 mL) 120 mLs/30 days

fluticasone propionate 0.05% cream (15 gm,


fluticasone propionate 0.005% ointment (15


Amcinonide 0.1% cream (15 gm,


Amcinonide 0.1% lotion (60 mLs) 120 mLs/30 days

Amcinonide 0.1% ointment (60




Derma-Smoothe (fluocinolone acetonide) 0.01% oil (body)

(118.28 mL) 118.28 mLs/30 days

Derma-Smoothe (fluocinolone acetonide) 0.01% oil (scalp)

(118.28 mL) 118.28 mLs/30 days

Prednicarbate 0.1% cream (60 gm) 120 grams/30 days

Prednicarbate 0.1% ointment (15

gm, 60 gm) 120 grams/30 days

Desonate (desonide) 0.05% gel (60 gm) 120 grams/30 days

desonide 0.05% lotion (59 mL,

118 mL) 118 mLs/30 days

DesOwen, Tridesilon (desonide) 0.05% cream (15 gm,


desonide 0.05% ointment (15


Diprolene, Bethamethasone dipropionate

augemented

0.05% gel (15 gm, 50


bethamethasone dipropionate

augemented

0.05% lotion (30 mL,

60 mL) 210 mLs/30 days


AR1219_r0520Diprolene (bethamethasone dipropionate

augemented)

0.05% ointment (15


Diprolene AF (betamethasone

dipropionate)

0.05% cream (15 gm,


betamethasone dipropionate 0.05% cream (15 gm,


betamethasone dipropionate 0.05% lotion (60 mL) 120 mLs/30 days

betamethasone dipropionate 0.05% ointment (15


Elocon (mometasone furoate) 0.1% cream (15 gm,


mometasone furoate 0.1% ointment (15


mometasone furoate 0.1% lotion/solution

(30 mL, 60 mL) 120 mLs/30 days

diflorasone diacetate 0.05% ointment (15


Halog (halcinonide) 0.1% cream (30 gm,


Halog (halcinonide) 0.1% ointment (30


Halog (halcinonide) 0.1% solution (120

mL) 240 mLs/30 days



hydrocortisone 2.5% cream (3.5 gm,

20 gm, 28 gm, 28.35

gm, 30 gm, 453.6 gm,


hydrocortisone 1% cream (28.35 gm,

28.4 gm, 30 gm,

453.6 gm, 454 gm) 454 grams/30 days

hydrocortisone 2.5% lotion (59 mL,

118 mL) 118 mLs/30 days

hydrocortisone 1% ointment (28.35

gm) 453.6 grams/30 days

hydrocortisone 2.5% ointment (20

gm, 28.35 gm, 30 gm,

453.6 gm, 454 gm)454 grams/30 days

Impoyz (clobetasol propionate) 0.025% cream (60


Kenalog (triamcinolone acetonide) 0.147 mg/gm aerosol

spray (63 gm, 100


triamcinolone acetonide 0.025% lotion (60 mL)120 mLs/30 days

triamcinolone acetonide 0.1% lotion (60 mL) 120 mLs/30 days



triamcinolone acetonide 0.025% cream (15

gm, 80 gm, 453.6 gm,


triamcinolone acetonide 0.1% cream (15 gm,

28.4 gm, 30 gm, 45

gm, 80 gm, 453.6 gm,


triamcinolone acetonide 0.5% cream (15 gm,



gm, 30 gm, 80 gm,

453.6 gm, 454 gm) 454 grams/30 days

Lexette, Halobetasol propionate 0.05% foam (50 gm) 200 grams/28 days

fluocinonide 0.05% solution (20

mL, 60 mL) 120 mLs/30 days

fluocinonide 0.05% cream (15 gm,

30 gm, 60 gm, 120




fluocinonide 0.05% gel (15 gm, 30


fluocinonide 0.05% ointment (15


fluocinonide 0.05% emulsified

cream (15 gm, 30 gm,



AR1219_r0520Locoid (hydrocortisone butyrate) 0.1% solution (20 mL,

60 mL) 120 mLs/30 days

Locoid (hydrocortisone butyrate) 0.1% cream (15 gm,


Locoid (hydrocortisone butyrate) 0.1% lotion (59 mL,

118 mL) 118 mLs/30 days

hydrocortisone butyrate 0.1% ointment (15


Locoid Lipocream (hydrocortisone

butyrate) 0.1% hydrophilic lipo

cream (45 gm, 60 gm) 120 grams/30 days

Luxiq (betamethasone valerate) 0.12% foam (50 gm,


Micort-HC (hydrocortisone acetate)

2.5% cream (28.4


Olux (clobetasol propionate) 0.05% foam (50 gm,


Olux-E (clobetasol propionate) 0.05% emulsion foam

(50 gm, 100 gm) 200 grams/28 days

Pandel (hydrocortisone probutate) 0.1% cream (80 gm) 160 grams/30 days

Psorcon, Diflorasone diacetate 0.05% cream (15 gm,


Sernivo (betamethasone dipropionate) 0.05% spray (120 mL)120 mLs/30 days

Synalar (fluocinolone acetonide) 0.01% solution (60


Synalar (fluocinolone acetonide) 0.025% cream (15


Synalar (fluocinolone acetonide) 0.025% ointment (15


fluocinolone acetonide 0.01% cream (15 gm,


clobetasol propionate 0.05% solution (25


Temovate (clobetasol propionate) 0.05% cream (15 gm,

30 gm, 45 gm, 60 gm)210 grams/28 days



Temovate (clobetasol propionate) 0.05% ointment (15

gm, 30 gm, 45 gm, 60


clobetasol propionate 0.05% gel (15 gm, 30


Temovate E (clobetasol propionate) 0.05% emollient

cream (15 gm, 30 gm,


Texacort (hydrocortisone) 2.5 % solution (30

mL) 120 mLs/30 days

Topicort (desoximetasone) 0.05% cream (15 gm,


Topicort (desoximetasone) 0.25% cream (15 gm,


Topicort (desoximetasone) 0.05% gel (15 gm, 60


Topicort (desoximetasone) 0.05% ointment (60


Topicort (desoximetasone) 0.25% ointment (15


Topicort (desoximetasone)0.25% spray (100 mL) 100 mLs/30 days

Trianex (triamcinolone acetonide) 0.05% ointment (430


Ultravate (halobetasol propionate) 0.05% cream (15 gm,


Ultravate (halobetasol propionate) 0.05% lotion (60 mL) 240 mLs/30 days

Ultravate (halobetasol propionate) 0.05% ointment (15


betamethasone valerate 0.1% cream (15 gm,


betamethasone valerate 0.1% lotion (60 mL) 120 mLs/30 days

betamethasone valerate 0.1% ointment (15


Vanos (fluocinonide) 0.1% cream (30 gm,



AR1219_r0520Verdeso (desonide) 0.05% foam (100 gm)

100 grams/30 days

hydrocortisone valerate 0.2% ointment (15


hydrocortisone valerate 0.2% cream (15 gm,


Topical Doxepin PAQL **Topical Doxepin QL information is included in the individual program document



Topical Estrogen PS

AR1019_r0320

Alora (estradiol) 0.025 mg/day

transdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days

Climara (estradiol) 0.025 mg/day

transdermal system

4 patches/28 days


transdermal system

4 patches/28 days


transdermal system

4 patches/28 days


transdermal system

4 patches/28 days


transdermal system

4 patches/28 days


transdermal system

4 patches/28 days

Climara Pro (estradiol/levonorgestrel) 0.045 mg/0.015

mg/day transdermal

4 patches/28 days

CombiPatch (estradiol/norethindrone) 0.05 mg/0.14 mg/day

transdermal system

8 patches/28 days

CombiPatch (estradiol/norethindrone) 0.05 mg/0.25 mg/day

transdermal system

8 patches/28 days

Divigel (estradiol) 0.25 mg/packet gel 30 packets/30 days




Divigel (estradiol) 1.25 mg/packet gel 30 packets (37.5 g)/30 days

Elestrin (estradiol) 0.52 mg/pump with

gel

1 pump/30 days

Estring (estradiol) 2 mg vaginal ring (7.5

mcg/24 hour)

1 ring/90 days

Estrogel (estradiol) 50 g pump with gel

(1.25 g/dose)

1 pump/30 days

EvaMist (estradiol) 8.1 mL vial (1.53

mg/spray)

transdermal spray

5 vials/93 days

Femring (estradiol acetate) 0.05 mg/day vaginal

ring

1 ring/90 days




Femring (estradiol acetate) 0.10 mg/day vaginal

ring

1 ring/90 days

Imvexxy (estradiol) 4 mcg vaginal insert

(starter pack)

18 inserts/180 days


(maintenance pack)

8 inserts/28 days


(starter pack)

18 inserts/180 days


(maintenance pack)

8 inserts/28 days

Menostar (estradiol) 1 mg (14 mcg/24

hour) patch

4 patches/28 days

Minivelle (estradiol) 0.025 mg/day

trasdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days

Vivelle Dot (estradiol) 0.025 mg/day

transdermal system

8 patches/28 days

Topical Estrogen PS

AR1019_r0320


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days


transdermal system

8 patches/28 days

Topical Lidocaine PAQL **Topical Lidocaine QL information is included in the individual program document

Triptan QL **Triptan QL information is included in the individual program document

Urinary Incontinence PS AR0819_r0320 Detrol (tolterodine)

a 1 mg tablet 2 tablets

Detrol (tolterodine)a 2 mg tablet 2 tablets

Detrol LA (tolterodine ER)a 2 mg extended-release

capsule 1 capsule

Detrol LA (tolterodine ER)a 4 mg extended-release

capsule 1 capsule




oxybutynin [Ditropan]a 5 mg tablets 4 tablets

oxybutynin [Ditropan]a 5 mg/5 mL syrup 20 mLs

Ditropan XL (oxybutynin ER)a 5 mg extended-release

tablet 1 tablet


tablet 2 tablets


tablet 2 tablets

Enablex (darifenacin ER)a 7.5 mg extended-release

tablet 1 tablet

Enablex (darifenacin ER)a 15 mg extended-release

tablet 1 tablet

Gelnique (oxybutynin) 1 gm (1.14 mL) gel

sachet (10% gel) 1 sachet

Gelnique (oxybutynin) 3% gel (28 mg/actuation,

90 actuations/pump)1 metered-dose pump / 30 days

Myrbetriq (mirabegron) 25 mg extended-release

tablet 1 tablet

Myrbetriq (mirabegron) 50 mg extended-release

tablet 1 tablet

Oxytrol (oxybutynin) 36 mg patch (delivers 3.9

mg per day) 8 patches per 28 days

trospium 20 mg tablet 2 tablets

trospium ER 60 mg extended-release

capsule 1 capsule

Toviaz (fesoterodine ER) 4 mg extended-release

tablet 1 tablet

Toviaz (fesoterodine ER) 8 mg extended-release

tablet 1 tablet

VESIcare (solifenacin)a 5 mg tablet 1 tablet

VESIcare (solifenacin)a 10 mg tablet 1 tablet

Vascepa PAQL **Vascepa QL information is included in the individual program document

VMAT2 Inhibitors (Formerly

Xenazine) PAQL **VMAT2 Inhibitors QL information is included in the individual program document

Wakix PAQL **Wakix QL information is included in the individual program document



Zavesca (Substrate

Reduction Therapy) PAQL **Zavesca QL information is included in the individual program document


adzenys xr-odt (amphetamine er) 3.1 mg oral …...adzenys xr-odt (amphetamine er) 6.3 mg oral...

Documents