mrx standard formulary utilization ......ambien cr (zolpidem cr) step therapy, quantity limit – 30...

MRX0103_0116

- 1 -

MRX STANDARD FORMULARYUTILIZATION MANAGEMENT: OVERVIEWMagellan Rx Management is committed to helping you manage your prescription drug use and costs.Prior Authorization, Quantity Limits, Step Therapy, and Age or Gender edits are recommended by theMagellan Rx Management Formulary Review Committee and may be used by your prescription drugbenefit plan to ensure you have access to safe, appropriate, and effective prescription medications.Please check your plan documents to determine your prescription drug benefit plan’s approach toutilizing these clinical edits.

The clinical edits are defined as follows:

Prior AuthorizationMedications which require pharmacy benefit manager or plan approval before you may receive benefits

Quantity Limits and Daily Dose LimitMedication whose frequency and dosage are defined by a certain quantity per day

Step TherapyMedications that require that you first use alternative medications before this medication may be triedor prescribed

Age and Gender EditsAge edits are designed to ensure that medications are used only in appropriate age groups, e.g. not foruse in infants or the elderly. Gender edits are designed to restrict access to drug therapies which arespecific to male or female populations.

Legend‡ - Preferred Specialty Product

The table below displays the clinical edits that may be associated with the use of your prescriptionmedications.

Medication Clinical Edits and GuidelinesAbilify (aripiprazole) Quantity Limit – 30 tablets per 30 days, 750ml oral solution per

30 days

Abilify Disc Tab (orallydisintegrating)

Quantity Limit – 15mg and 10mg = 60 tablets for 30 days

Abraxane Specialty, Prior Authorization

Absorica Prior Authorization, Quantity Limit – Max 30 day supply, no refills

Abstral Prior Authorization, Quantity Limit – 120 per 30 days

Acanya Gel Quantity Limit – 50G (1 jar) per 30 days

Accu-Chek testing strips Quantity Limit – 300 per 30 days

Accupril (quinipril) Quantity Limit – 30 per 30 days

Accuretic 10/12.5mg (quinapril-hctz) Quantity Limit – 30 per 30 days

Aceon 4mg (perindopril) Quantity Limit – 30 per 30 days

Aciphex (rabeprzaole sodium) Step Therapy, Quantity Limit – 60 tablets per 30 days

Aciphex SPR Quantity Limit – 30 per 30 days

MRX0103_0116

- 2 -

Medication Clinical Edits and GuidelinesActemra Specialty, Prior Authorization

Acthar HP Specialty, Prior Authorization

Acthrel Specialty, Prior Authorization

Actiq (fentanyl citrate) Prior Authorization, Quantity Limit – 120 per 30 days

Active OB Gender Edit – female only

Activella (estradiol & norethindrone) Gender Edit – female only, Quantity Limit – 30 per 30 days

Actonel Quantity Limit – 35mg = 4 tablets per 28 days, 5mg & 30mg = 30per 30 days, 150mg = 1 tablet per 30 days.

Actos (pioglitazone) Quantity Limit – 30 tablets per 30 days

ActosPlus Met (pioglitazone-metformin)

Quantity Limit – 90 tablets per 30 days

ActosPlus Met XR Quantity Limit – 15-1000 MG = 90 tablets per 30 days, 30-1000MG = 30 tablets per 30 days

Acular, Acular LS (ketorolactromethamine)

Quantity Limit – 15ml per 30 days, LS = 5ml per 23 days

Acuvail Quantity Limit – 65 vials per 180 days

Adalat CC (Nifedipine) 30mg Quantity Limit – 30 per 30 days

Adcetris Specialty, Prior Authorization

Adcirca Specialty, Quantity Limit – 60 per 30 days, Prior Authorization

Adderall(amphetamine/dextroamphetamine)

Quantity Limit – 60 per 30 days

Adderall XR(amphetamine/dextroamphetamine)

Quantity Limit – 20mg & 30 mg = 60 per 30 days, 5mg & 10mg =30 per 30 days, Therapy

Adempas Specialty, Prior Authorization, Quantity Limit – 3 tablets per day

Adoxa Step Therapy

Adrenaclick Step Therapy, Quantity Limit – 2 Pens per Rx

Advair HFA, Diskus Quantity Limit – 1 inhaler 30 days

Advicor Quantity Limit –1000-40mg = 30 per 30 days, 1000-20mg,500/20mg & & 750-20mg = 60 per 30 days

Aerospan Quantity Limit – 2 inhalers per 30 days, Step Therapy

Afinitor, Afinitor Dis Specialty, Prior Authorization, Quantity Limit – 2.5MG= 30 per 30days, 5MG, 7.5MG & 10MG = 60 per 30 days

Afrezza Prior Authorization

Akynzeo Specialty, Prior Authorization

Alagesic Liq Quantity Limit – 90ml per day ( 2700ml per 30 days)

Aldara (imiquimod) Quantity Limit – 48 packets (2 boxes) per 16 weeks

All Day Allg Tab (cetirizine) Quantity Limit – 30 per 30 days

Aldurazyme Specialty, Prior Authorization

Allegra (fexofenadine) Quantity Limit – 180mg= 30 per 30 days, 30mg & 60mg = 60 per30 days, suspension = 900ml per 30 days

Allegra ODT 30mg Quantity Limit – 60 per 30 days

Allegra-D (fexofenadine-D) Quantity Limit – 24HR = 30 per 30 days; 12HR = 60 per 30 days

Allergy D-12 Tab All Day Quantity Limit – 60 per 30 days

Allergy Relief Tab 10mg Quantity Limit – 30 per 30 days

Allergy Relief Tab 5-120mg Quantity Limit – 60 per 30 days

MRX0103_0116

- 3 -

Medication Clinical Edits and GuidelinesAller-Tec 10mg Quantity Limit – 30 per 30 days

Aller-Tec D 5-120mg Quantity Limit – 60 per 30 days

Allergy Comp D Tab 5-120mg Quantity Limit – 60 per 30 days

Alimta Specialty, Prior Authorization

Alocril Quantity Limit – 1 bottle per 30 days (5ml)

Alomide Quantity Limit – 1 bottle per 30 days (10ml)

Alora Gender Edit – females only, Quantity Limit – 8 per 28 days

Alphagan P 0.15% (brimonidine) Quantity Limit – 10ml per 30 days

Alprolix Specialty, Prior Authorization

Alsuma (sumatriptan) Quantity Limit – 5 mls per 30 days

Altace(ramipril) Quantity Limit – 1.25mg, 2.5mg, 5mg = 30 per 30 days

Atralin Quantity Limit – 1.5 grams per day, Age Edit

Altoprev ER Step Therapy, Quantity Limit – 30 per 30 days

Alvesco Quantity Limit – 2 inhalers per 30 days

Ambien (zolpidem) Step Therapy, Quantity Limit – 30 tabs per 30 days

Ambien CR (zolpidem CR) Step Therapy, Quantity Limit – 30 tabs per 30 days

Amerge (naratriptan) Quantity Limit – 9 tablets per 30 days

Amethia & Amethia Lo Quantity limit – Max day supply 91, Gender Edit – females only

Amitiza Quantity Limit – 60 per 30 days, Step Therapy

Amnesteem Prior Authorization, Quantity Limit – Max days supply 30 no refills

Ampyra ‡ Specialty, Prior Authorization, Quantity Limit – 60 per 30 days

Amturnide Step Therapy, Quantity Limit – 30 per 30 days

Anadrol-50 Gender Edit – males only

Anaprox (naproxen sodium) Quantity Limit – 275mg = 180 per 30 days, 550mg = 90 per 30days

Androderm patch Prior Authorization, Gender Edit - males only, Quantity Limit – 30patches per 30 days

AndroGel 1% Prior Authorization, Gender Edit – males only, Quantity Limit – 1%(25mg) = 75GM per 30 days; 1% (50mg), PUMP = 300G per 30days

AndroGel 1.62% Prior Authorization, Gender Edit – males only, Quantity Limit –1.62% (20.25mg) = 1.25GM per day; 1.62% (40.5mg) = 5GM perday; 1.62% (20.25mg) = 150GM per 30 days.

Android Prior Authorization, Gender Edit – males only

Angeliq Gender edit – female only, Quantity Limit – 30 per 30 days

Antara (fenofibrate micronized) Quantity Limit – 43mg & 30mg = 60 per 30 days, 130mg & 90mg= 30 per 30 days

Anzemet tablets Quantity Limit – 50mg = 6 tablets per 30 days; 100mg = 3 tabletsper 30 days

Apidra Step Therapy

Aplenzin Quantity Limit – 30 per 30 days

Apokyn Specialty, Prior Authorization

Aptensio XR Prior Authorization, Quantity Limit – 60 per day

Aralast NP Specialty, Prior Authorization

Aranesp‡ Specialty, Prior Authorization

MRX0103_0116

- 4 -

Medication Clinical Edits and GuidelinesArcalyst Specialty, Prior Authorization

Arcapta Step Therapy, Quantity Limit – 30 inhaled capsules per 30 days

Aricept & ODT (donepezil) Age edit

Aricept 23mg (donepezil) Age Edit, Step Therapy

Arnuity Ellipta Step Therapy, Quantity Limit – 100 mcg = 2 per day, 200 mcg = 1per day

Arzerra Specialty, Prior Authorization

Asmanex Quantity Limit – 1 inhaler per 30 days

Astelin Nasal (azelastine) Quantity Limit – 2 bottles(60ml) per 30 days

Astepro Quantity Limit – 2 bottles(60ml) per 30 days

Atacand (candesartan cilexetil) Quantity Limit – 30 per 30 days

Atacand HCT (candesartan cilexetil) Quantity Limit – 16/12.5mg= 60 per 30 days; 32/12.5mg & 32-25mg = 30 per 30 days

Atelvia Step Therapy, Quantity Limit – 4 tablets per 28 days

Ativan (lorazepam) Quantity Limit – 0.5mg & 1mg = 90 per 30 days, 2mg = 150 per 30days

Atrovent HFA Quantity Limit – 3 inhalers per 30 days

Atrovent (ipratropium) nasal spray Quantity Limit – 2 bottles 0.03% per 30 days; 3 bottles 0.06% per30 days

Atrovent (ipratropium) neb solution Quantity Limit – 150 unit dose vials (2.5ml) per 30 days

Atryn Specialty, Prior Authorization

Aubagio Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Augmentin sus (amoxicillin & k-clavulanate)

Quantity Limit – 125ml & 250ml = 900ml per 90 days: ES 600 =600ml per 90 days

Augmentin tab (amoxicillin & k-clavulanate)

Quantity Limit – 500mg & 875mg=120 per 90 days, XR =240 per90 days

Auvi-Q Quantity Limit – 2 pens per fill, Step Therapy

Avalide (irbesartan-HCTZ) Quantity Limit – 150-12.5 = 60 per 30 days; 300-12.5 = 30 per 30days

Avandamet Prior Authorization, Quantity Limit – 60 per 30 days

Avandaryl Prior Authorization, Quantity Limit – 30 per 30 days

Avandia Prior Authorization ,Quantity Limit – 2mg= 90 per 30 days, 4mg =60 per 30 days; 8mg = 30 per 30 days

Avapro (irbesartan) Quantity Limit – 30 per 30 days

Avastin Specialty, Prior Authorization

Aveed Specialty, Prior Authorization

Avelox (moxifloxacin hcl) Quantity Limit – 21 per fill

Avelox ABC Pak(moxifloxacin hcl) Quantity Limit – 5 per fill

Avinza (morphine sulfate) Quantity Limit – 30mg, 45mg, 60mg and 75mg = 30 per 30 days,90mg & 120mg = 60 per 30 days

Avodart Gender edit – Male only, Quantity Limit – 30 per 30 days

Avonex ‡ Specialty, Prior Authorization, Quantity Limit – 1 kit (4 syringes)per 30 days

Axert Quantity Limit – 12 per 30 days

MRX0103_0116

- 5 -

Medication Clinical Edits and GuidelinesAxiron Gender Edit – males only, Prior Authorization, Quantity Limit –

180ml per 30 days

Azopt Quantity Limit – 15ml per 30 days

Baraclude ‡ Specialty, Quantity Limit – 20ml per day, tablets: 30 per 30 days

Beconase AQ nasal Quantity Limit – 2 inhalers per 30 days

Beleodaq Specialty, Prior Authorization

Belviq Quantity Limit – 2 tablets per day

Benicar Quantity Limit – 5mg= 2 per day, 20mg & 40mg = 30 per 30 days

Benicar HCT Quantity Limit – 30 per 30 days

Benlysta Specialty, Prior Authorization

Benzaclin(clindamycin-benzoylperoxide)

Quantity Limit – 50G per 30 days

Bepreve Quantity Limit – 10ml (1 bottle) per month

Berinert Specialty, Prior Authorization

Besivance Quantity Limit – 5ml per 30 days

Betaseron ‡ Specialty, Prior Authorization, Quantity Limit – 15 vials per 28days

BiDil Quantity Limit – 180 per 30 days

Binosto Quantity Limit – 4 per 28 days

Bivigam Specialty, Prior Authorization

Blood Glucose Testing Strips, allbrands


Boniva 150mg (ibandronate) Quantity Limit – 1 tablet per 28 days

Bosulif Specialty, Prior Authorization, Quantity Limit – 100MG = 120 per30 days; 500MG = 30 per 30 days

Botox Cosmetic, Inj Specialty, Prior Authorization

BP Cleansing EMU Quantity Limit – 473ml (1 bottle) per 30 days

Bravelle ‡ Specialty, Prior Authorization

Brilinta Quantity Limit – 90 per 30days

Brintellix Quantity Limit – 30 per 30 days, Step Therapy

Brisdelle Quantity Limit – 30 per 30 days

Bromday (bromefenac sodium) Quantity Limit – 1.7ml (1 bottle) per fill

Bromfenac Sol (once daily) Quantity Limit – 5ml per 30 days

Brovana Quantity Limit – 120 doses per 30 days

Bunavail Prior Authorization, Quantity Limit – 2.1mg & .3mg: 90 per 30days, 4.2mg: 60 per 30 days

Bupap Quantity Limit – 180 per 30 days

Butrans Prior Authorization, Quantity Limit – 4 patches per 28 days

Butorphanol Quantity Limit – 3 bottles (9 mL) per month

Bydureon Quantity Limit – 4 vials per 30 days

Byetta Quantity Limit – 1 pen per 30 days

Bystolic Quantity Limit – 2.5 mg = 30 per 30 days, 5 mg &10 mg = 90 per30 days, 20 mg = 60 per 30 days

Caduet (amlodipine/atorvastatin) Quantity Limit – 30 per 30 days

Capital with Codeine Quantity Limit – 125ml per day

MRX0103_0116

- 6 -

Medication Clinical Edits and GuidelinesCaprelsa Specialty, Prior Authorization, Quantity Limit – 100 mg = 60 per

30 days, 300 mg = 30 per 30 days

Cardene SR Quantity Limit – 60 per 30 days

Cardizem CD 120mg/24hr (diltiazem) Quantity Limit – 1 per day

Cardizem LA (diltiazem hcl) Quantity Limit – 300mg, 360mg & 420mg = 30 per 30 days;120mg = 120 per 30 days; 180mg = 90 per 30 days; 240mg; 60per 30 days

Cardura XL Quantity Limit – 30 per 30 days, Step Therapy, Gender Edit –males only

Carimune NF Specialty, Prior Authorization

Cataflam (diclofenac potassium) Quantity Limit – 120 tablets per 30 days

Catapres-TTS Quantity Limit – 0.1/24HR: 4 patches per 23 days, 0.2/24HR &0.3/24HR: 8 patches per 23 days

Ceftin (cefuroxime) 500mg tablets Quantity Limit – 120 tablets per 90 days

Ceftin suspension Quantity Limit – 600mls per 90 days

Celebrex (celecoxib) 50mg & 200mg Quantity Limit – 60 tablets per 30 days

Celebrex (celecoxib) 100mg Quantity Limit – 90 tablets per 30 days

Celebrex (celecoxib) 400 mg Quantity Limit – 30 tablets per 30 days

Celexa (citalopram) Quantity Limit – 30 per 30 days

Cenestin Gender Edit – female only, Quantity Limit – 30 per 30 days

Ceredase Specialty, Prior Authorization

Cerdelga Specialty, Prior Authorization, Quantity Limit – 60 per 30 days

Cerezyme Specialty, Prior Authorization

Cesamet Prior Authorization, Quantity Limit – 20 tablets per prescriptionor up to a maximum of 3 days supply, whichever is less

Cetrotide ‡ Specialty, Prior Authorization, Gender Edit – Females only

Chantix Quantity Limit – 60 per 30 days

Chlordiazepoxide Quantity Limit – 5mg = 120 per 30 days, 10mg = 900 per 30 days,25mg = 360 per 30 days

Chloral hydrate Prior Authorization

Cholbam Specialty, Prior Authorization, Quantity limit – 4 per day

Cialis Quantity Limit – 2.5 & 5mg = 30 per 30 days, 10mg & 20mg = 6per 30 days, Gender Edit – males only, Age Edit

Ciloxan Oint & Sol (ciprofloxacin) Quantity Limit – Oint = 7GM per 30 days; Sol = 10ML per 30 days

Cimzia Specialty, Prior Authorization, Quantity Limit – Kit = 1 kit per 28days. Starter Kit = 1 kit per 365 days.

Cinryze Specialty, Prior Authorization

Cipro (ciprofloxacin) Quantity Limit – 56 per fill

Cipro XR (ciprofloxacin) Quantity Limit – 500mg ER = 3 per fill; 1000mg ER = 14 per fill

Ciprofloxaxin sol 0.3% OP Quantity Limit – 10ml per 30 days

Claravis Quantity Limit – 30 day supply, no refills

Clarinex (desloratadine) Quantity Limit – Syrup= 300ml per 30 days, 5mg = 30 per 30 days

Clarinex RDT Tab (desloratadine &pseudoephedrine)


MRX0103_0116

- 7 -

Medication Clinical Edits and Guidelines

Clarinex DQuantity Limit – 2.5/120mg = 60 per 30 days, 5/240mg = 30 per30 days

Claris Wash EMU 10-4% Quantity Limit – 437ml (1 bottle) per 30 days

Cleocin-T gel 1% (clindamycinphosphate)

Quantity Limit – 75GM per 30 days

Climara (estradiol td patch) &Climara Pro

Gender Edit – females only, Quantity Limit – 4 per 28 days

Clindagel (clindamycin phosphate) Quantity Limit – 75GM per 30 days

Clindamax (clindamycin phosphate) Quantity Limit – 75GM per 30 days

Clonazepam ODTQuantity Limit – 0.125 mg, 0.25 mg, 0.5 mg, 1 mg = 90 per 30days; 2 mg = 300 per 30 days

Co-Gesic Quantity Limit – 240 per 30 days

Colcrys Quantity Limit – 120 per 30 days

Combigan (brimonidine-timilol) Quantity Limit – 10ml (1 bottle) per 30 days

Combipatch Gender Edit – females only, Quantity Limit – 8 patches per 28days

Combivent Quantity Limit – 3 inhalers per 30 days; aer respimat - 2 inhalersper 30 days

Cometriq Specialty, Prior Authorization, Quantity Limit – 100MG = maxdaily dose 2; 140MG = max daily dose 4; 60MG = max daily dose 3

Concerta (methylphenidate) Quantity Limit – 60 per 30 days; 54mg = 30 per 30 days, StepTherapy

Conzip Prior Authorization, Quantity Limit – 30 per 30 days

Copaxone‡ Specialty, Prior Authorization, Quantity Limit – 1 kit per 30 days;inj = 12 syringes (1 kit) per 30 days

Copegus (ribavirin) Specialty, Prior Authorization

Cordran Quantity Limit – 1 Tape per 30 days; Lot – 120ML per 30 days

Cordran SP Quantity Limit – 60GM per 30 days

Coreg CR Quantity Limit – 60 per 30 days; 80mg = 30 per 30 days, StepTherapy

Corlanor Step Therapy, Quantity Limit – 2 per day

Cosentyx Specialty, Prior Authorization

Cozaar (losartan) Quantity Limit – 100mg = 30 per 30 days; 25mg & 50mg = 60 per30 days

Cresemba Specialty, Prior Authorization

Crestor Quantity Limit – 30 per 30 days

Crinone Gel Gender Edit – Females only

Cromolyn Opth Quantity Limit – 10ml per 30 days

CVS Allergy Tab Quantity Limit – 30 per 30 days

Cycloset Tab Prior Authorization, Quantity Limit – 180 per 30 days

Cymbalta (dulozetine) 30mg only Quantity Limit – 30 per 30 days

Cystaran Prior Authorization

Cyramza Specialty, Prior Authorization

Daliresp Prior Authorization, Quantity Limit – 30 per 30 days

Daklinza Specialty, Prior Authorization, Quantity Limit – 1 tablet per day

MRX0103_0116

- 8 -

Medication Clinical Edits and GuidelinesDaytrana Dis Quantity Limit – 30 patches per 30 days, Step Therapy

Delzicol Quantity Limit – 180 per 30 days

Delestrogen inj (estradiol valerate) Gender Edit – females only

Depo- Estradiol inj Gender Edit – females only

Depo-Provera injection 150mg/ml Quantity Limit – 1 vial per prescription

Depo-SQ injection Quantity Limit – Max day supply 90

Desoxyn (methamphetamine) Quantity Limit – 150 per 30 days, Step Therapy

Desvenlafax Quantity Limit – 50MG = 1 tablet per day; 100MG = 4 tablets perday

Detrol (tolterodine tartrate) Quantity Limit – 60 per 30 days

Detrol LA (tolterodine tartrate) Quantity Limit – 30 per 30 days

Dexedrine CR (dextroamphetamineSR)

Quantity Limit – 5mg = 60 per 30 days; 10mg = 150 per 30 days;15mg = 120 per 30 days

Dexilant Quantity Limit –30 per 30 days, Step Therapy

Dexrazoxane Specialty, Prior Authorization

Dextroamphetamine sulfate Quantity Limit – 5mg= 60 per 30 days; 10mg = 180 per 30 day

Dextroamphetamine sulfate ER ER 10mg – 150 per 30 days; 15mg = 120 per 30 days; 5mg = 30per 30 days; Sol: 1800ml per 30 days

Diastat Gel (diazepam) Quantity Limit – 2 boxes per fill

Differin (adapalene) Quantity Limit – cream & gel =45gm per 30 days, lot = 59ml per30 days

Diflucan (fluconazole) Quantity Limit – 150mg = 2 tabs per 30 days, females only

Dilaudid (hydromorphone) Quantity Limit – 2mg, 4mg & 8mg = 180 per 30 days

Dilt-CD Quantity Limit – 30 per 30 days

Dilt – XR Quantity Limit – 30 per 30 days

Diltzac Quantity Limit – 30 per 30 days

Diovan Quantity Limit – 30 per 30 days

Diovan HCT (valsartan/hctz) Quantity Limit – 30 per 30 days

Ditropan XL (oxybutin chloride) Quantity Limit – 10MG & 15MG = 60 per 30 days; 5MG = 30 per30 days

Dolgic Plus Quantity Limit – 150 per 30 days

Doral Quantity Limit – 30 per 30 days

Doryx Quantity Limit – Limited to 7 tablets per prescription

Duac gel (clindamycin phosph-benzoyl peroxide)

Quantity Limit – 45GM (1 tube) per 30 days

Duetact (pioglitazone) Quantity Limit – 30 per 30 days

Dulera Quantity Limit – 1 inhaler per 30 days, Step Therapy

Duopa Specialty, Prior Authorization, Quantity Limit – 1 per day

Duragesic (fentanyl patch) Quantity Limit – 100MCG/H & 75MCG/HR: 30 per 30 days,12MCG/HR, 25MCG/HR, 50MCG/HR: 15 per 30 days

Dutoprol Quantity Limit – 60 per 30 days

Dymista Spray Quantity Limit – 23G (1 bottle) per 30 days

Dysport Specialty, Prior Authorization

Edarbi Step Therapy, Quantity Limit – 30 per 30 days

Edarbyclor Step Therapy, Quantity Limit – 30 per 30 days

MRX0103_0116

- 9 -

Medication Clinical Edits and GuidelinesEdluar Sub Step Therapy, Quantity Limit – 30 per 30 days

Effexor XR (venlafaxine) Quantity Limit – 37.5MG = 30 per 30 days; 150MG = 60 per 30days; 75MG = 90 per 30 days

Effient Quantity Limit – 30 per 30 days

Egrifta Specialty, Prior Authorization, Quantity Limit – inj = max dailydose 2 vials; sol = max daily dose 1 vial

Elaprase Specialty, Prior Authorization

Elelyso Specialty, Prior Authorization

Elenzapatch Quantity Limit – max daily dose 4

Elestat (epinastine) Quantity Limit – 5ml (1 bottle) per 30 days

Elidel 1% cream Quantity Limit – 100gm (1 tube) per 30 days, Age edit, StepTherapy

Eligard Specialty, Prior Authorization

Ella Tab 30mg Quantity Limit – 1 per fill, Gender edit – females only

Eloctate Specialty, Prior Authorization

Emadine sol 5% OP Quantity Limit – 5ml (1 bottle) per 30 days

Emend Prior Authorization, Quantity Limit – 125MG & 40MG = 1 per fill,80mg = 2 per fill, PAK 80MG & 125MG = 3 per fill

Emend inj Specialty, Prior Authorization, Quantity Limit – 2 vials per fill

Enablex Quantity Limit – 30 per 30 days

Enbrel ‡ Specialty, Prior Authorization, Quantity Limit – 25mg = 8 per 28days, 50mg = 4 per 30 days

Endocet Quantity Limit – 10/325mg, 5/325mg, 7.5/325mg = max dailydose 12, 7.5/500mg = max daily dose 8, 10/650mg = max dailydose 6

Enjuvia Quantity Limit – 30 per 30 days, Gender edit – Females only

Entresto Prior Authorization, Quantity Limit – 2 tablets per day

Entyvio Specialty, Prior Authorization

Envarsus XR Specialty, Prior Authorization, Quantity Limit – 1 per day

Epiduo Quantity Limit – 45gm (1 tube) per 30 days

Epinephrine Quantity Limit – 2 pens per fill, 0.15mg, Step Therapy

Epipen Quantity Limit – 2 per fill

Epivir HBV ‡ Specialty, Safety edit for Hepatitis B duplicate therapy

Epogen Specialty, Prior Authorization

Eprosartan Quantity Limit – 30 per 30 days

EQ Allergy-D, EQL All Day Aller D,EQL All Day

Quantity Limit – Allergy D = 60 per 30 days, EQL Aller D = 60 per30 days, EQL All Day – 30 per 30 days

Erbitux Specialty, Prior Authorization

Erivedge Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Erythromycin/colchicine Erythromycin will reject if colchicine products are in theprescription profile in the last 120 days. Colchicine products willreject if erythromycin is in the prescription profile in the last 120days

Esbriet Specialty, Prior Authorization

MRX0103_0116

- 10 -

Medication Clinical Edits and GuidelinesEsgic & Esgic Plus (butalbital-APAP-caf)


Esomeprazole Quantity Limit – 30 per 30 days, Step Therapy

Estazolam Quantity Limit – 30 per 30 days

Estrace (estradiol) Gender Edit – females only, Quantity Limit – 30 per 30 days

Estrasorb Gender Edit – females only, Quantity Limit – 60 pouches per 30days

Estring Quantity Limit – one ring per 90 days, Gender Edit – females only

Estrogel Quantity Limit – 50 G per 30 days, Gender Edit – females only

Estrogen, Estrogen + Progestin Gender Edit – females only

Euflexxa‡ Specialty, Prior Authorization

Evamist Gender Edit – females only, Quantity Limit – 16.2ml per 30 days

Evekeo Quantity Limit – 6 per day

Evoclin (clindamycin phosphatefoam)

Quantity Limit – 50gm per 30 days

Evzio Prior Authorization, Quantity Limit – 4 syringes (2 boxes) per Rx

Exalgo Quantity Limit – 180 per 30 days

Exelon (rivastigmine) Age Limit – > 40 years old

Exforge (amlodipine/valsartan) Quantity Limit – 30 per 30 days, Step Therapy

Exforge HCT(amlodipine/valsartanhct)

Quantity Limit – 30 per 30 days, Step Therapy

Extavia Specialty, Prior Authorization, Quantity Limit – 15 vials per 28days.

Fabior Quantity Limit – 100 gm per 23 days, Age Edit

Fabrazyme Specialty, Prior Authorization

Factive Quantity Limit – 7 per fill

Fanapt & Fanapt PAK Quantity Limit – 60 per 30 days, 1 pak (8 tablets) per fill, StepTherapy

Farxiga Quantity Limit – 30 per 30 days, Step Therapy

Farydak Specialty, Prior Authorization

Fazaclo ODT Quantity Limit – 100mg = 270 per 30 days, 12.5mg, 150mg &200mg = 90 per 30 days

FBL Kit CRE 15-4-5% Prior Authorization

Felbatol (felbamate) Prior Authorization

Felodipine Quantity Limit – 30 per 30 days

Femara (letrozole) Prior Authorization

Femhrt Gender Edit – females only, Quantity Limit – 30 per 30 days

Femring Gender Edit – females only, Quantity Limit – 1 ring per 84 days

Fenoglide Quantity Limit – 40mg= 60 per 30 days, 120mg = 30 per 30 days

Fentora Prior Authorization, Quantity Limit – 120 per 30 days

Ferriprox Specialty, Prior Authorization

Fetzima Quantity Limit – 30 per 30 days, Step Therapy

Fibricor (fenofibric) Quantity Limit – 35mg = 60 per 30 days, 105mg = 30 per 30 days.

Finacea gel Quantity Limit – 50gm per 30 days

Finacea Kit Quantity Limit – 1 kit per 30 days, Step Therapy

MRX0103_0116

- 11 -

Medication Clinical Edits and GuidelinesFioricet w/Codeine Quantity Limit – 180 per 30 days

Fiorinal (butalbital-ASA- caffeine) Quantity Limit – 180 per 30 days

Fiorinal/Cod Cap(butalbital/ASA/caf/cod)


Firazyr Specialty, Prior Authorization

Firmagon Specialty, Prior Authorization

Flebogamma Specialty, Prior Authorization

Flector Patch Quantity Limit – 60 patches per 30 days

Flolan (epoprostenol) Specialty, Prior Authorization

Flomax (tamsulosin) Gender Edit – Males only, Quantity Limit – 60 per 30 days

Flonase (fluticasone) Nasal Inhaler Quantity Limit – 1 inhaler per 30 days

Flovent Diskus Quantity Limit – 50mcg & 100mcg= 120 blisters per 30 days.250mcg diskus = 240 blisters per 30 days

Flovent HFA Inhaler Quantity Limit – 2 inhalers per 30 days

Flunisolide Spray Quantity Limit – 1 inhaler per 30 days

Flurazepam Prior Authorization, Quantity Limit – 30 per 30 days

Focalin (dexmethylphenidate) Quantity Limit – 2.5mg & 5mg = 90 per 30 days, 10mg = 60 per 30days

Focalin XR Quantity Limit – 5mg, 10mg, 15mg, 25mg, 30mg, 35mg, & 40mg =30 per 30 days; 20mg = 60 per 30 days, Step Therapy

Follistim AQ Specialty, Prior Authorization

Folotyn Specialty, Prior Authorization

Foradil Quantity Limit – 60 capsules per 23 days, Step Therapy

Foradil /Advair Foradil will reject if Advair is in the prescription profile in the last90 days.

Forfivo XL Quantity Limit – 30 per 30 days

Fortamet (Metformin) Quantity Limit – 500mg = 150 per 30 days, 1000mg 60 per 30days

Forteo ‡ Specialty, Prior Authorization

Fortesta Prior Authorization, Gender Edit – males only, Quantity Limit –120G per 30 days

Fortical Quantity Limit – 1 bottle (3.7ml) per 30 days

Fosamax (alendronate) Quantity Limit – 70mg & 35mg = 4 per 28 days, 5mg & 10 mg = 1per 28 days

Fosinopril Quantity Limit – 30 per 30 days

Frova Quantity Limit – 9 tablets per 30 days

Fuzeon Specialty, Quantity Limit – Max daily dose 2 vials

Fycompa Quantity Limit – 30 per 30 days

Gamastan SD Specialty, Prior Authorization

Gammagard, Gammgard SD Specialty, Prior Authorization

Gammaked Specialty, Prior Authorization

Gammaplex Specialty, Prior Authorization

Gamunex C Specialty, Prior Authorization

Gattex Specialty, Prior Authorization

Gazyva Specialty, Prior Authorization

MRX0103_0116

- 12 -

Medication Clinical Edits and GuidelinesGelnique Step Therapy, Quantity Limit – 10% = max daily dose 1 sachet; 3%

= 92 G (1 bottle) per 30 days

Gel-One Specialty, Prior Authorization

Giazo Quantity Limit – 180 per 30 days, Gender Edit – Males only

Generess FE Gender Edit

Genotropin Specialty, Prior Authorization

Geodon (ziprasidone) Step Therapy, Quantity Limit – 60 per 30 days

Gilenya Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Gilotrif Prior Authorization, Quantity Limit – 30 per 30 days

Glassia Specialty, Prior Authorization

Gleevec‡ Specialty, Prior Authorization, Quantity Limit – 100mg= 240 per30 days, 400mg = 60 per 30 days

Glucophage (metformin) Quantity Limit – 500mg= 150 per 30 days, 850mg = 90 per 30days, 1000mg = 60 per 30 days

Glucophage XR (metformin XR) Quantity Limit – 500mg = 120 per 30 days, 750mg = 60 per 30days

Glucovance (metformin-glyburide) Quantity Limit – 2.5-500mg & 5-500mg = 120 per 30 days

Glumetza Quantity Limit – 500mg = 120 per 30 days, 1000mg = 60 per 30days

Glyset Quantity Limit – 90 per 30 days

Gonal- F‡ & Gonal F RFF‡ Specialty, Prior Authorization, F RFF – Gender Edit – females only

Gralise Step Therapy, Quantity Limit – 300mg = 30 per 30 days, 600mg =90 per 30 days

Granisol Quantity Limit – 30ml per 30 days

Granix Specialty, Prior Authorization

Grastek Prior Authorization, Quantity Limit – 1 tablet per day

Halaven Specialty, Prior Authorization

Halcion (triazolam) Quantity Limit – 60 per 30 days

Harvoni Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Helidac Quantity Limit – Limited to 224 tablets per 365 days

Hetlioz Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Hepsera (adefovir dipivoxil) Specialty, Safety edit for Hepatitis B duplicate therapy

Herceptin Specialty, Prior Authorization

Hizentra Specialty, Prior Authorization

Horizant Quantity Limit – 300MG = 60 per 30 days; 600MG = 30 per 30days

Humatrope Specialty, Prior Authorization

Humira‡ Specialty, Prior Authorization, Quantity Limit – 2 syringes every28 days

Hyalgan Specialty, Prior Authorization

Hycamtin Specialty, Prior Authorization

Hycet (hydrocodone-acetaminophen)

Quantity Limit – 4,200ml per 30 days

HyQvia Specialty, Prior Authorization

MRX0103_0116

- 13 -

Medication Clinical Edits and GuidelinesHyzaar (losartan hctz) Quantity Limit – 50/12.5mg = 60 per 30 days, 100/12.5mg &

100/25mg = 30 per 30 days

Ibudone 5-200mg (hydrocodone-ibuprofen)


Ibrance ‡ Specialty, Prior Authorization

Iclusig Specialty, Prior Authorization, Quantity Limit – 15MG = 60 per 30days 45MG = 30 per 30 days

Ilaris Specialty, Prior Authorization, Quantity Limit – 2 vials per 56 days

Ilevro Quantity Limit – 1.7ML per 30 days

Imbruvica Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Imitrex injection (sumatriptan) Quantity Limit – 5ML per 30 days

Imitrex tablets (sumatriptan) Quantity Limit – 9 tablets per 30 days

Imitrex Nasal Spray (sumatriptan) Quantity Limit – 6 nasal inhalers per 30 days

Incivek ‡ Specialty, Prior Authorization, Quantity Limit – 180 per 30 days

Increlex Specialty, Prior Authorization

indomethacin Quantity Limit – 75mg = 60 per 30 days

Indocin suppository Quantity Limit – 120 per 30 days

Infergen Specialty, Prior Authorization

Inlyta Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Intermezzo Sub Quantity Limit – 30 per 30 days, Step Therapy

Intron-A Specialty, Prior Authorization, Safety edit Hepatitis B duplicatetherapy

Intuniv (guanfacine hcl) Quantity Limit – 30 per 30 days, Age Edit

Invega; Invega Sust Step Therapy

Invega Trinza Prior Authorization, Quantity Limit – 0.0333 per day

Invokana Step Therapy

Iressa Specialty, Prior Authorization, Quantity Limit – 1 per day

Istodax Specialty, Prior Authorization

Ixinity Specialty, Prior Authorization

Jadenu Specialty, Prior Authorization

Jakafi Specialty, Prior Authorization, Quantity Limit- 60 per 30 days

Jalyn Quantity Limit – 30 per 30 days, Gender Edit – Males only

Janumet Quantity Limit – 60 per 30 days

Janumet XR Step Therapy, Quantity Limit – 50/1000 & 50/500 = 60 per 30days, 100/1000 = 30 per 30 days

Januvia Quantity Limit – 30 per 30 days

Jardiance Step Therapy

Jentadueto Step Therapy, Quantity Limit – 60 per 30 days

Jetrea Specialty, Prior Authorization

Jevtana Specialty, Prior Authorization

Jolessa Quantity Limit – max day supply 91, Gender Edit – females only

Jublia Quantity Limit – 4 mls per 30 days, Step Therapy

Juxtapid Specialty, Prior Authorization, Quantity Limit – 10MG & 5MG = 60per 30 days, 20MG = 90 per 30 days

Kadcyla Specialty , Prior Authorization

MRX0103_0116

- 14 -

Medication Clinical Edits and GuidelinesKadian (morphine SR) Quantity Limit – 10mg, 20mg, 30mg, 50mg, 60mg, 80mg & 100mg

= 60 per 30 days, 200mg = 120 per 30 days

Kalbitor Specialty, Prior Authorization

Kalydeco Specialty, Prior Authorization, Quantity Limit – 60 per 30 days

Kapvay (clonidine hcl) Quantity Limit – 60 per 30 days, Age Edit, Step Therapy

Kazano Quantity Limit – 60 per 30 days, Step Therapy

Keppra (levatiracetam) Quantity Limit – 250mg= 360 per 30 days, 500mg = 180 per 30days, 750mg = 120 per 30 days, 1000mg= 90 per 30 days, Solution= 946ml per 30 days

Keppra XR (levatiracetam) Quantity Limit – 500mg = 180 per 30 days, 750mg = 120 per 30days

Ketalar (ketamine) IV Prior Authorization

Keytruda Specialty, Prior Authorization

Khedezla Quantity Limit – 100MG = 120 per 30 days, 50MG = 30 per 30days

Kineret Specialty, Prior Authorization, Quantity Limit – 30 syringes per 30days

Kitabis Specialty, Prior Authorization

Klonipin (clonazepam) Quantity Limit – 0.5 mg & 1 mg = 90 per 30 days, 2 mg = 300 per30 days

Kombiglyze Step Therapy, Quantity Limit – 2.5-1000mg = 60 per 30 days, 5-500mg & 5-1000 = 30 per 30 days

Korlym Prior Authorization

Krystexxa Specialty, Prior Authorization, Quantity Limit – 4ml (2 vials) per 30days

Kuvan Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Kynamro Specialty, Prior Authorization

Kyprolis Specialty, Prior Authorization

Lamictal Kits ( IR, XR & ODT) Quantity Limit – 1 kit per fill (28, 35, 49, 56 or 89)

Lamictal XR (lamotrigine) Quantity Limit – 25mg & 50mg = 30 per 30 days, 100mg & 200mg= 90 per 30 days

Lastacaft Step Therapy, Quantity Limit – 3ml per 30 days

Latuda Step Therapy, Quantity Limit – 30 per 30 days

Lazanda Prior Authorization, Quantity Limit – 1 bottle per day

Lemtrada Specialty, Prior Authorization

Lenvima Specialty, Prior Authorization, Quantity Limit – 3 per day

Lescol (fluvastatin) Quantity Limit – 20MG = 30 per 30 days, 40MG = 60 per 30 days,Step Therapy

Lescol XL 80mg Step Therapy

Letairis ‡ Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Leukine Specialty, Prior Authorization

Leuprolide Specialty, Prior Authorization

Levaquin (levofloxacin) Quantity Limit – 21 per fill

Levitra Quantity Limit – 6 per 30 days, Gender Edit – males only, Age Edit

Levofloxacin sol 0.5% Quantity Limit – 10 mL per 23 days

MRX0103_0116

- 15 -

Medication Clinical Edits and GuidelinesLexapro (escitalopram) Quantity Limit – 5mg & 10mg = 45 per 30 days, 20mg = 30 per 30

days, oral solution = 600ml per 30 days

Lidoderm Patch (lidocaine) Quantity Limit – 90 per 30 days

Lidoprofen Prior Authorization

Linzess Quantity Limit – 30 per 30 days, Step Therapy, Age Edit

Lipitor (atorvastatin) Step Therapy, Quantity Limit – 10MG, 20MG & 40MG = 30 per 30days

Lipofen Quantity Limit – 50mg= 60 per 30 days, 150mg= 30 per 30 days

Liptruzet Quantity Limit – 30 per 30 days

Livalo Quantity Limit – 30 per 30 days

Lofibra (fenofibrate) Quantity Limit – 54mg = 60 per 30 days, 67mg, 134mg, 160mgtablets & 200mg = 30 per 30 days

Lopid (gemfibrizol) 600mg Quantity Limit – 60 per 30 days

Lorazepam Intensol (lorazepamconc)

Quantity Limit – 150ml per 30 days

Lorcet, Lorcet Plus Quantity Limit – 180 per 30 days

Lortab (hydrocodone-acetaminophen)


Lo-Seasonique (levonorgesterol- E-estradiol)

Gender Edit (females only), Max day supply 91

Lotensin (benazepril) Quantity Limit – 30 per 30 days

Lotensin HCT (benazepril/hctz) Quantity Limit – 30 per 30 days

Lotrel (amlodipine/benazepril) Quantity Limit – 30 per 30 days

Lotronex Prior Authorization, Gender Edit – Females only, Age Edit

Lovaza (omega-3-acid) Quantity Limit – 120 per 30 days

Lumigan Sol Quantity Limit – 2.5ml per 30 days

Lumizyme Specialty, Prior Authorization

Lunesta (eszopiclone) Quantity Limit – 30 per 30 days, Step Therapy, Age Edit – 3mgonly

Lupaneta Specialty, Prior Authorization

Lupron Depot Products Specialty, Prior Authorization

Lupron Dep- PED‡ Specialty, Prior Authorization

Luvox (fluvoxamine) Quantity Limit – 25mg & 50mg = 30 per 30 days,100mg = 90 per30 days; 150MG = 60 per 30 days

Luvox CR (fluvoxamine) Quantity Limit – 60 per 30 days

Luzu Quantity Limit – 60 grams per 30 days

Lynparza Specialty, Prior Authorization

Lyrica Prior Authorization, Quantity Limit – 225mg & 300mg= 60 per 30days, all other strengths = 90 per 30 days; Sol = 900ml per 30 days

Lysteda (tranexamic acid) Specialty, Gender Edit – females only, Quantity Limit – 30 per 30days

Makena ‡ Specialty, Prior Authorization, Gender Edit – females only

Malarone (atovaquone-proguanil) Prior Authorization

Marqibo Specialty, Prior Authorization

Mavik (trandolapril) Quantity Limit – 30 per 30 days

MRX0103_0116

- 16 -

Medication Clinical Edits and GuidelinesMaxair Autohaler Quantity Limit – 2 inhalers per 30 days

Maxalt; Maxalt MLT (rizatriptanbenzoate)


Maxidone (hydrocodone-acetaminophen)


Mekinist Specialty, Prior Authorization, Quantity Limit – 0.5MG = 120 per30 days, 2MG = 30 per 30 days

Menest Gender Edit – females only, Quantity Limit – 30 per 30 days

Menopur ‡ Specialty, Prior Authorization, Gender Edit – females only

Menostar Gender Edit – females only, Quantity Limit – 4 patches per 28days

Metadate CD (methylphenidate cr ) Quantity Limit – 30 per 30 days, Step Therapy

Metaglip (glipizide/metformin) Quantity Limit – 2.5-250mg = 240 per 30 days, 2.5-500mg & 5-500mg = 120 per 30 days

Methitest Gender Edit – males only, Prior Authorization

Methylin Chew Quantity Limit – 2.5mg & 5mg = 90 per 30 days; 10mg = 180 per30 days, Step Therapy

Methylin Solution(methylphenidate)

Quantity Limit – 10mg/5ml= 90ml per 30 days

Metozolv ODT Step Therapy, Quantity Limit – 12 weeks per (180 days) oftherapy

Mevacor (lovastatin) Quantity Limit – 20MG = 30 per 30 days, Step Therapy

Miacalcin (calcitonin) Quantity Limit – 1 bottle (3.7mL) per 30 days

Miacalcin inj Specialty

Micardis (telmisartan) Quantity Limit – 30 per 30 days

Micardis HCT (telmisartan HCT) Quantity Limit – 40/12.5mg & 80/25mg =30 per 30 days; 80-12.5mg = 60 per 30 days, Step Therapy

Migranal (dihydroergotaminemesylate)

Quantity Limit – 1 kit = 8 canisters per 30 days

Minivelle Quantity Limit – 8 patches per 28 days, Gender Edit – femalesonly

Mirapex ER Step Therapy, Quantity Limit – 30 per 30 days

Mircera Specialty, Prior Authorization

Mirvaso Prior Authorization, Quantity Limit – 30gm per 30 days

Mitigare Step Therapy, Quantity Limit – 3 per day

Mitoxantrone Specialty, Prior Authorization

Mobic (meloxicam) Quantity Limit – 30 per 30 days, suspension = 300ml per 30 days

Monopril (fosinopril) Quantity Limit – 10 & 20mg = 30 per 30 days

Monovisc Specialty, Prior Authorization

Mozobil Specialty, Prior Authorization

MS Contin (morphine CR) Quantity Limit – 120 per 30 days; 200MG ER – 90 per 30 days

Multaq Prior Authorization

Myalept Specialty, Prior Authorization

Myobloc Specialty, Prior Authorization

Myozyme Specialty, Prior Authorization

MRX0103_0116

- 17 -

Medication Clinical Edits and GuidelinesMyrbetriq Quantity Limit – 30 per 30 days

Naglazyme Specialty, Prior Authorization

Namenda Age Edit, Quantity Limit – 5mg= 90 per 30 days; 10mg = 60 per 30days; Solution = 360ml per 30 days

Namenda XR Quantity Limit – 30 per 30 days, Step Therapy, Age Edit

Naprelan SR Quantity Limit – 375mg = 120 per 30 days, 500mg = 90 per 30days, 750mg = 60 per 30 days

Nasacort AQ nasal (triamcinolone) Quantity Limit – 1 inhaler per 30 days

Nasonex nasal Quantity Limit – 1 inhalers per 30 days

Nesina Quantity Limit – 30 per 30 days, Step Therapy

Natesto Prior Authorization, Step Therapy, Quantity Limit – Three pumps(60 actuations each) per 30 days (21.96 grams per 30 days)

Natpara Specialty, Prior Authorization

Neulasta‡ Specialty, Prior Authorization

Neumega Specialty, Prior Authorization

Neupogen ‡ Specialty, Prior Authorization

Nevanac Quantity Limit – 6ml per 30 days

Nexavar ‡ Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Nexium Quantity Limit – 30 per 30 days, GRA = 60 per 30 days, StepTherapy

Niaspan ER (niacin) Quantity Limit – 500mg= 90 per 30 days, 750mg & 1G= 60 per 30days

Nilandron Specialty, Prior Authorization

Niravam (alprazolam odt) Quantity Limit – 0.25mg , 0.5mg & 1mg = 120 per 30 days, 2mg=150 per 30days

Norco (hydrocodone-acetaminophen)


Norditropin ‡ Specialty, Prior Authorization

Noroxin Quantity Limit – 42 per fill

Northera Specialty, Prior Authorization, Quantity Limit – 100mg & 200mg,90 per 30, 300 mg 180 per 30 days

Norvasc (amlodipine) Quantity Limit – 30 per 30 days

Novarel Specialty, Prior Authorization

Novoeight Specialty, Prior Authorization

Nplate Specialty, Prior Authorization

Nucynta Step Therapy, Quantity Limit – 50mg & 75mg= 180 per 30 days,100mg = 210 per 30 days

Nucynta ER Quantity Limit – 60 per 30 days, Step Therapy

Nuedexta Prior Authorization

Nulojix Specialty, Prior Authorization

Nutropin Specialty, Prior Authorization

Nutropin AQ Specialty, Prior Authorization

Nuvigil Prior Authorization

Octagam Specialty, Prior Authorization

Ocudox Quantity Limit – 1 kit per prescription

MRX0103_0116

- 18 -

Medication Clinical Edits and GuidelinesOcufen (flurbiprofen) Quantity Limit – 2.5ml per 23 days

Ocuflox Quantity Limit – 15ml per 23 days

Odomzo Specialty, Prior Authorization, Quantity Limit – 1 per day

Ofev Specialty, Prior Authorization, Quantity Limit – 2 per day

Ofirmev Quantity Limit – 400ml/day

Oleptro Quantity Limit – 30 per 30 days

Olysio Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Omeclamox Quantity Limit – Limited to 80 per 365 days

Omnaris Quantity Limit – 1 inhaler per 30 days

Omnitrope Specialty, Prior Authorization

Omontys Specialty, Prior Authorization

Onfi Specialty, Prior Authorization

Onglyza Quantity Limit – 30 per 30 days

Onmel Prior Authorization

Onsolis Prior Authorization, Quantity Limit – 120 films per 30 days

Opana (oxymorphone) Quantity Limit – 360 per 30 days

Opana ER (oxymorphone ER) Quantity Limit – 120 per 30 days

Opdivo Specialty, Prior Authorization

Opsumit Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Optivar (azelastine) Quantity Limit – 1 bottle per month (6ml)

Oralair Sub Prior Authorization

Oral contraceptives Gender Edit – Females only

Oramorph SR (morphine sulfate) Quantity Limit – 15mg, 30mg, 60mg = 120 per 30 days, 100mg =180 per 30 days, 200 mg 90 per 30 days

Oracea Quantity Limit – 30 per 30 days

Oravig Quantity Limit – 1 per prescription

Orencia Specialty, Prior Authorization, Quantity Limit – 4 syringes per 30days

Orenitram Specialty, Prior Authorization

Orfadin Specialty, Prior Authorization

Orkambi Specialty, Prior Authorization, Quantity Limit – 4 per day

Ortho Evra Gender Edit – Females only

Orthovisc Specialty, Prior Authorization

Oseni Quantity Limit – 30 per 30 days, Step Therapy

Otrexup Prior Authorization

Otezla Specialty, Prior Authorization, Quantity limit – Starter pack=27tablets per lifetime, 30MG = 60 per 30 days

Ovidrel ‡ Specialty, Prior Authorization

Oxandrolone & oxymetholone Gender Edit – Males only

Oxazepam Quantity Limit – 120 per 30 days

Oxecta Quantity Limit – 240 per 30 days

Oxycodone (immediate release) Quantity Limit – 240 per 30 days

Oxycontin (oxycodone time release) Step Therapy, Quantity Limit – 120 per 30 days

Oxytrol Dis Quantity Limit – 10 patches per 30 days

Pancreaze Step Therapy

MRX0103_0116

- 19 -

Medication Clinical Edits and GuidelinesPatanase Quantity Limit – 1 inhaler per 30 days (31Gm)

Patanol Quantity Limit – 1 bottle per month (5ml)

Paxil (paroxetine) Quantity Limit – 10mg = 45 per 30 days, 20mg = 30 per 30 days,30 & 40mg = 60 per 30 days, oral suspension 1260ml per 30 days

Paxil CR (paroxetine) Quantity Limit – 12.5mg = 30 per 30 days, 25mg & 37.5mg = 60per 30 days

Pazeo Quantity limit – 0.1 ml per day

Pegasys Specialty, Prior Authorization, Safety Edit – Hepatitis B duplicatetherapy

Peg-Intron ‡ Specialty, Prior Authorization

Penlac (ciclopirox) Prior Authorization, Quantity Limit – 1 bottle per prescription fill

Percocet (oxycodonew/acetaminophen)

Quantity Limit – 7.5/500 = 240 per 30 days, 10/650mg = 180 per30 days, 2.5/325, 5/325, 7.5/325 & 10/325 = 360 per 30 days

Perforomist Quantity Limit – 120mls per 30 days

Perjeta Specialty, Prior Authorization

Pertzye Step Therapy

Pexeva Quantity Limit – 30 per 30 days

Phrenilin Tab & Forte (butalbital-APAP)


Picato Step Therapy

Plan B One Step (levonorgestrel) Quantity Limit – 1.5MG = 2 per 30 days, Age Edit, Gender Edit –females only

Plavix (clopidogrel) Quantity Limit – 300mg = 3 per RX fill, 75mg = 30 per 30 days.

Plegridy ‡ Specialty, Prior Authorization, Quantity Limit – 2 (1 pak) per 30days, 1 (1 start pak) lifetime

Pomalyst Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Ponstel (mefenamic) Quantity Limit – 150 per 30 days

Potiga Prior Authorization, Quantity Limit – 90 per 30 days; 50MG = 270per 30 days

Pradaxa Prior Authorization, Quantity Limit – 60 per 30 days

Praluent ‡ Specialty, Prior Authorization, Quantity Limit – 2 pens/ syringesfor 30 days

PrandiMet Quantity Limit – 150 per 30 days

Prandin (repaglinide) Quantity Limit – 0.5mg & 1mg= 120per 30 days, 2mg = 240 per30days

Pravachol (pravastatin) Step Therapy, Quantity Limit – 20MG & 40MG = 30 per 30 days

Precose (acarbose) Step Therapy, Quantity Limit – 25mg = 360 per 30 days, 50mg =180 per 30 days, 100mg = 90 per 30 days

Prefest Gender Edit – females only, Quantity Limit – 30 per 30 days

Pregnancy Category X Claim will reject for Category X drugs when member is receivingprenatal vitamins. Warning message will be transmitted topharmacy for members receiving prenatal vitamins and CategoryC&D drugs.

Pregnyl Specialty, Prior Authorization

Premarin Gender Edit – females only, Quantity Limit – 30 per 30 days

MRX0103_0116

- 20 -

Medication Clinical Edits and GuidelinesPremphase Gender Edit – females only, Quantity Limit – 30 per 30 days

Prempro Gender Edit – females only, Quantity Limit – 30 per 30 days

Prevacid (lansoprazole) Quantity Limit – 30 per 30 days, Step Therapy

Prevpac(amoxicillin/clarithro/lansoproaz)

Quantity Limit – Limited to 112 per 365

Priftin Quantity Limit – 32 tablets per 28 days

Prilosec (omeprazole) Quantity Limit – 30 per 30 days, Step Therapy

Prinivil (lisinopril) Quantity Limit – 30 per 30 days

Prinzide (lisinopril-hctz) Quantity Limit – 30 per 30 days

Pristiq Quantity Limit – 120 tablets per 30 days

Privigen Specialty, Prior Authorization

ProAir HFA Quantity Limit – 2 inhalers per 23 days

Procardia XL (nifedipine) Quantity Limit – 30 per 30 days

Procentra (dextroamphetamine) Quantity Limit – 1800ml per 30 days, Step Therapy, Age Edit

Procrit‡ Specialty, Prior Authorization

Prolastin & Prolastin C Specialty, Prior Authorization

Prolensa Quantity Limit – Limited to 3 mL per 180 days

Proleukin Specialty, Prior Authorization

Prolia Specialty, Prior Authorization, Quantity Limit – 1 vial per 135 days

Promacta Specialty, Prior Authorization

Promethazine (all products) Age Limitation – Members under 2 years of age are not permittedto get products containing promethazine

Protonix (pantoprazole) Quantity Limit – 30 tablets per 30 days, Step Therapy

Protopic Age Edit, Step Therapy, Quantity Limit – 100g (1 tube) per 30 days

Provenge Specialty, Prior Authorization

Proventil HFA Step Therapy, Quantity Limit – 2 inhalers per 23 days

Provigil (modafinil) Prior Authorization, Quantity Limit – 30 per 30 days

Prozac (fluoxetine) Quantity Limit – 20mg = 120 per 30 days, 40mg = 60 per 30 days,90mg weekly = 4 per 28 days

Pulmicort respules Quantity Limit – 2 boxes per 30 days, 2 inhalers per 30 days

Pulmozyme Specialty, Prior Authorization, Quantity Limit – 150 ml (60ampules) per 30 days

Pylera Quantity Limit – Limited to 120 per 365 days

Qnasl Aeresol Quantity Limit – Max daily dose 0.3

Qsymia Prior Authorization, Quantity Limit – 30 per 30 days

Qualaquin (quinine sulfate) Prior Authorization, Quantity Limit – 42 per year

Quillivant Quantity Limit – 360 ml per 30 days, Step Therapy

QVAR inhaler Quantity Limit – 40mcg = 2 per 30 days, 80mcg = 3 inhalers per 30days

Ragwitek Prior Authorization, Quantity Limit – 30 per 30 days

Rapaflo Quantity Limit – 30 per 30 days, Step Therapy, Gender Edit –males only

Rasuvo Specialty, Prior Authorization, Quantity Limit – 1 injection per 7days

Ravicti Prior Authorization

MRX0103_0116

- 21 -

Medication Clinical Edits and GuidelinesRazadyne & ER (galantamine) Age Edit: > 40 years old

Rebetol Solution Specialty, Prior Authorization

Rebif Specialty, Prior Authorization, Quantity Limit – 6ml per 28 days,titration = 1 kit (4.2ml) per 365 days

Regranex Quantity Limit – 2 tubes (30 grams) per month

Relenza inhaler Quantity Limit – 40 per 365 days

Relistor Prior Authorization

Relpax Quantity Limit – 12 tablets per 30 days

Remicade ‡ Specialty, Prior Authorization

Remodulin Specialty, Prior Authorization

Repatha ‡ Specialty, Prior Authorization, Quantity Limit – 2 pens/ syringesfor 30 days

Reprexain (hydrocodone/Ibuprofen) Quantity Limit – 2.5/200MG = 150 per 30 days; 5/200MG = 180per 30 days

Repronex Specialty, Prior Authorization, Gender Edit – females only

Requip XL (ropinirole) Quantity Limit – 30 per 30 days, Step Therapy

Rescula Quantity Limit – 5ml per 30 days

Rexulti Prior Authorization, Quantity Limit – 1 per day

Risperdal Inj Quantity Limit – 2 vials per 21 days retail

Restasis Prior Authorization

Restoril (temazepam) Quantity Limit – 30 per 30 days

Retin-A-Micr Gel (tretinoin) Quantity Limit – 50 gm per 30 days

Revatio (sildenafil citrate) Specialty, Prior Authorization, Quantity Limit – 20MG = 90 per 30days, Age Edit

Revlimid Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Rhinocort Aqua nasal inhaler Quantity Limit – 17.2gm (2 bottles) per 23 days at retail

RibaPak Specialty, Prior Authorization

RibaSphere‡ Specialty, Prior Authorization

RibaTab‡ Specialty, Prior Authorization

Ribavirin 200mg caps‡ Specialty, Prior Authorization

Riomet Quantity Limit – 750ml per 30 days (oral solution)

Ritalin (methylphenidate) Quantity Limit – 5mg & 20mg = 90 per 30 days; 10mg = 150 per30 days

Ritalin LA (methylphenidate LA) Quantity Limit – 10mg, 20mg & 40mg = 30 per 30 days, 30mg = 60per 30 days, Step Therapy

Ritalin SR (methylphenidate SR) Quantity Limit – 20mg = 90 per 30 days, Age Edit

Rituxan Specialty, Prior Authorization

Roxicet 5-500 Quantity Limit – 360 per 30 days

Roxicet Solution Quantity Limit – 62ml per day

Roxicodone (oxycodone) Quantity Limit – 240 per 30 days

Rozerem Quantity Limit – 30 tablets per 30 days, Step Therapy

Ruconest Specialty, Prior Authorization

Sabril Specialty, Prior Authorization, Quantity Limit – 180 per 30 days

Safyral Gender Edit – females only

Saizen Specialty, Prior Authorization

MRX0103_0116

- 22 -

Medication Clinical Edits and GuidelinesSamsca Specialty, Prior Authorization, Quantity Limit – 15mg = 30 per 30

days, 30mg = 60 per 30 days

Sancuso Specialty, Quantity Limit – 1 per fill

Sandostatin (octreotide) Specialty, Prior Authorization

Saphris Quantity Limit – 60 per 30 days, Step Therapy

Savella Step Therapy, Quantity Limit – 60 per 30 days

Savella Mis Titr Pak Quantity Limit – 55 tablets (1 pack) per prescription

Savaysa Prior Authorization

Selzentry ‡ Specialty, Prior Authorization

Serevent Diskus Quantity Limit – 60 inhalations per 30 days

Serevent /Advair Serevent will reject if Advair is in the member’s prescriptionprofile in the last 90 days

Serostim Specialty, Prior Authorization, Quantity Limit – max daily dose 1per day

Signifor, LAR Specialty, Prior Authorization

Silenor Quantity Limit – 30 per 30 days

Simbrinza Quantity Limit – 8 ml per 30 days

Simcor Quantity Limit – 500-40 & 1000-40 = 30 per 30 days; 1000-20,500-20 & 750-20 = 60 per 30 days, Step Therapy

Simponi Specialty, Prior Authorization, Quantity Limit – 1 syringe permonth

Singulair (montelukast) Quantity Limit – 30 per 30 days

Sirturo Prior Authorization

Sivextro Tab Prior Authorization, Quantity Limit – 6 does per Rx

Solaraze gel (diclofenac sodium) Quantity Limit – 100 grams per 30 days

Somatuline Specialty, Prior Authorization

Somavert Specialty, Prior Authorization

Somnote (chloral hydrate) Prior Authorization

Sonata (zaleplon) Quantity Limit – 30 per 30 days, Step Therapy

Soriatane (acitretin) Quantity Limit – 17.5mg & 22.5mg = 60 per 30 days; 10mg = 120per 30 days

Sovaldi Specialty, Prior Authorization, Quantity Limit – 30 per 30 days

Spiriva Quantity Limit – 1 inhaler per 30 days

Sprix Quantity Limit – max day supply 5

Sprycel Specialty, Prior Authorization, Quantity Limit – 20mg = 270 per 30days; 50mg = 90 per 30 days; 70mg & 80mg = 60 per 30 days;100mg & 140mg = 30 per 30 days

Starlix (nateglinide) Quantity Limit – 90 per 30 days, Step Therapy

Staxyn Quantity Limit – 6 per 30 days, Gender Edit – Males only, Age Edit

Stelara Specialty, Prior Authorization, Quantity Limit – 45mg = 0.5ml per12 weeks, 90mg = 1ml per 12 weeks

Stendra Quantity Limit – 6 per 30 days, Age Edit, Gender Edit – Males only

Stiolto Respimat Step Therapy, Quantity Limit – 0.134 per day

Stivarga Specialty, Prior Authorization, Quantity Limit – 180 per 30 days

MRX0103_0116

- 23 -

Medication Clinical Edits and GuidelinesStrattera Quantity Limit – 40mg, 60mg, 80mg & 100 mg = 30 per 30 day;

10mg, 18mg & 25mg = 60 per 30 days, Age Edit

Striant Prior Authorization, Quantity Limit – 60 per 30 days, Gender Edit– Males only

Striverdi Respimat Quantity Limit – 1 inhaler per 30 days, Step Therapy

Suboxone, Suboxone Mis Prior Authorization, Quantity Limit – 0.5mg, 8-2mg, 2-0.5mg, &8.2mg = 90 per 30 days; 12-3mg & 4-1 = 60 per 30 days

Subsys Prior Authorization, Quantity Limit – max daily dose of 12 per day

Suclear Quantity Limit – 2480 mL (1 kit) per rx

Sumavel DosePro Quantity Limit – 4ml per 30 days

Supartz Specialty, Prior Authorization

Suprax suspension Quantity Limit – 1200ml per 3 months

Suprep Bowel Quantity Limit – 354ml per RX

Sutent Specialty, Prior Authorization, Quantity Limit – 12.5mg = 210 per30 days, 25mg = 90 per 30 days, 37.5 mg = 1 per day, 50mg = 30per 30 days

Sylatron Specialty, Prior Authorization

Sylvant Specialty, Prior Authorization

Symbicort Quantity Limit – 1 inhaler per 30 days, Duplicate Therapy Edit –Foradil and Serevent

Synribo Specialty, Prior Authorization

Synagis Specialty, Prior Authorization

Synvisc ‡ , Synvisc ONE ‡ Specialty, Prior Authorization

Taclonex Quantity Limit – 60 gm per 23 days

Tafinlar Specialty , Prior Authorization, Quantity Limit – 50mg = 6 capsulesper day; 75mg = 4 capsules per day

Tamiflu Quantity Limit – 10 capsule per fill/ 2 fills per year; 180ml per 30days

Tanzeum Quantity Limit – 4 pens/vials per 30 days, Step Therapy

Tarceva Specialty, Prior Authorization, Quantity Limit – 25mg = 180 per 30days, 100mg & 150mg = 30 per 30 days

Targretin capsules Specialty, Prior Authorization

Targretin gel Prior Authorization

Tasigna ‡ Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Tazorac Quantity Limit – 30 gm per 23 days

Tecfidera ‡ Specialty, Prior Authorization, Quantity Limit – 2 capsules per day

Technivie Specialty, Prior Authorization, Quantity Limit – 56 per 30 days

Tekamlo Quantity Limit – 30 per 30 days

Tekturna, Tekturna HCT Quantity Limit – 30 per 30 days, Step Therapy

Temodar ‡ (temozolomide) Specialty, Prior Authorization

Terazol (terconazole) Quantity Limit – 1 box per prescription, Gender Edit – femalesonly

Testim Prior Authorization, Quantity Limit – 300G per 30 days, GenderEdit – males only

Testopel Specialty, Prior Authorization, Gender Edit – males only

MRX0103_0116

- 24 -

Medication Clinical Edits and GuidelinesTestosterone Gender edit: Males only

Testred Prior Authorization, Gender Edit – males only

Teveten (eprosartan) Quantity Limit – 600mg = 30 per 30 days

Teveten HCT Quantity Limit – 30 per 30 days

Tev-tropin Specialty, Prior Authorization

Thalomid Specialty, Prior Authorization, Quantity Limit – 50mg & 100mg=120 per 30 days, 150mg & 200mg = 240 per 30 days

Tiazac (diltiazem) Quantity Limit – 30 per 30 days

Ticlid (ticlopidine) Quantity Limit – 60 per 30 days.

Tirosint Quantity Limit – 30 per 30 days

Tobi (tobramycin) Specialty, Prior Authorization

Tobradex ST Quantity Limit – 20ml per RX

Tolazamide Quantity Limit – 250mg= 120 per 30 days, 500mg = 60 per 30 days

Tolbutamide Quantity Limit – 180 per 30 days

Toradol (ketorolac)injection Quantity Limit – 15mg/ml = 40ml per 23 days, 30mg/ml = 20mlper 23 days

Toradol (ketorolac) tablets Quantity Limit – 20 tablets per 30 days

Torisel Specialty, Prior Authorization, Quantity Limit – 8ml per 28 days

Totec (dexrazoxane) Specialty, Prior Authorization

Toujeo Step Therapy

Toviaz Quantity Limit – 30 per 30 days

Tracleer ‡ Specialty, Prior Authorization, Quantity Limit – 60 per 30 days

Tradjenta Step Therapy, Quantity Limit – 30 per 30 days

Tranxene T (clorazepate) Quantity Limit – 3.75mg = 720 per 30 days, 7.5mg= 360 per 30days, 15mg = 180 per 30 days

Travatan Z Quantity Limit – 2.5ml ( 1 bottle) per 30 days

Travoprost Quantity Limit – 5ml per 23 days

Treanda Specialty, Prior Authorization

Tretinoin ‡ Specialty, Prior Authorization, Quantity Limit – 90 per 365 days

Tretten Specialty, Prior Authorization

Treximet Quantity Limit – 9 per 30 days, Step Therapy

Trezix Quantity Limit – max daily dose 11

Tribenzor Quantity Limit – 30 per 30 days, Step Therapy

Tricor (fenofibrate) Quantity Limit – 48mg = 60 per 30 days, 145mg = 30 per 30 days

Triglide Quantity Limit – 160mg = 30 per 30 days

Trilipix (choline fenofribrate) Quantity Limit – 45mg = 60 per 30 days, 135mg = 30 per 30 days

Trisenox Specialty, Prior Authorization

Triumeq Specialty, Prior Authorization

Trulicity Step Therapy

Tudorza Quantity Limit – 1 inhaler per month

Twynsta (telmisartan) Step Therapy, Quantity Limit – 30 per 30 days

Tybost ‡ Specialty, Prior Authorization

Tykerb ‡ Specialty, Prior Authorization, Quantity Limit – 180 per 30 days

Tylenol/Cod (acetaminophenw/codeine)

Quantity Limit – 300-30mg = 360 per 30 days, 300-60= 180 per 30days

MRX0103_0116

- 25 -

Medication Clinical Edits and GuidelinesTylox (oxycodonew/acetaminophen)


Tysabri Specialty, Prior Authorization

Tyvaso Specialty, Prior Authorization, Quantity Limit – 1 vial per day

Uloric Step Therapy, Quantity Limit – 30 per 30 days

Ultracet (tramadol/ acetaminophen) Quantity Limit – 240 per 30 days

Ultram (tramadol) Quantity Limit – 240 per 30 days

Ultram (tramadol) ER Quantity Limit – 30 per 30 days

Ultresa Step Therapy

Uniretic (moexipril-hctz) Quantity Limit – 30 per 30 days

Univasc (moexipril) Quantity Limit – 30 per 30 days

Uribel Quantity Limit – 120 per 30 days

Uroxatral (alfuzosin) Gender edit – Male only, Quantity Limit – 30 per 30 days

Valchlor Specialty, Prior Authorization, Quantity Limit – max daily dose 3

Valcyte Quantity Limit – 120 per 30 days

Vascepa Quantity Limit – 120 per 30 days

Vectibix Specialty, Prior Authorization

Vecamyl Prior Authorization

Velcade Specialty, Prior Authorization

Veletri Specialty, Prior Authorization

Veltin Quantity Limit – 60 G per 30 days

Ventavis Specialty, Prior Authorization, Quantity Limit – 270ml per 30 days

Ventolin HFA Quantity Limit – 2 inhalers per 30 days

Veramyst Quantity Limit – 10 grams (1 bottle) per month

Verelan PM (verapamil) Quantity Limit – 30 per 30 days

Versacloz Quantity Limit – 20ML per day

Vesicare Quantity Limit – 30 per 30 days

Vfend (voriconazole) Quantity Limit – oral solution = 20ml per day, tablets 4 per day

Viagra Quantity Limit – 6 per 30 days, Gender Edit – males only, Age Edit

Vicodin(hydrocodone\acetaminophen)


Vicodin ES Quantity Limit – 390 per 30 days

Vicodin HP Quantity Limit – 390 per 30 days

Victoza Quantity Limit – Injection = 9ml per 30 days

Victrelis Specialty, Prior Authorization, Quantity Limit – 360 per 30 days

Viekira Specialty, Prior Authorization, Quantity limit – 4 per day

Vigamox Quantity Limit – 3 ml per 30 days

Viibryd Quantity Limit – 30 per 30 days

Vimovo Quantity Limit – 60 per 30 days, Step Therapy

Viokace Step Therapy

Vitekta ‡ Specialty, Prior Authorization, Quantity Limit – 4 per day

Vivelle Dot Quantity Limit – 8 patches per 28 days, Gender Edit – femalesonly

Vivitrol Specialty, Prior Authorization

MRX0103_0116

- 26 -

Medication Clinical Edits and GuidelinesVogelxo Prior Authorization, Quantity Limit – 300gms (60 pckts) per 30

days

Voltaren gel Quantity Limit – 1000gm per 30 days

Voltaren (diclofenac) Ophth Quantity Limit – 7.5ml per 30 days

Vopac kit Prior Authorization

Votrient Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Vpriv Specialty, Prior Authorization

Vytorin Step Therapy, Quantity Limit – 30 tablets per 30 days, PriorAuthorization – 80mg only

Vyvanse Quantity Limit – 30 per 30 days

Welchol Quantity Limit – 210 per 30 days

Wellbutrin(bupropion) XL 150mg Quantity Limit – 90 per 30 days

Xalatan (latanoprost) Quantity Limit – 2.5ml per 30 days

Xalkori Specialty, Prior Authorization , Quantity Limit – 60 per 30 days

Xanax (alprazolam) Quantity Limit – 0.25 mg, 0.5 mg & 1 mg = 120 per 30 days, 2mg =150 per 30 days

Xanax XR (alprazolam SR) Quantity Limit – 0.5 mg & 1 mg = 30 per 30 days, 2mg = 150 per30 days, 3mg = 90 per 30 days

Xarelto Prior Authorization – 10MG & 15MG, Quantity Limit – 10MG &20MG = 30 per 30 days; 15MG = 60 per 30 days

Xartemis XR Quantity Limit – 360 per 30 days

Xeljanz Specialty, Prior Authorization, Quantity Limit – 60 per 30 days

Xenazine Specialty, Prior Authorization

Xenical Prior Authorization

Xeomin Specialty, Prior Authorization

Xgeva Specialty, Prior Authorization, Quantity Limit – 1.7ml per 28 days

Xigduo XR Step Therapy

Xodol(hydrocodone\acetaminophen)


Xofigo Specialty, Prior Authorization

Xolair Specialty, Prior Authorization

Xopenex HFA Quantity Limit – 30 gm (2 inhalers) per 23 days

Xtandi Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Xyrem Specialty, Prior Authorization, Quantity Limit – 3 bottles per 30days

Xyzal (levocetirizine) Quantity Limit – 30 per 30 days; 300ml per 30 days

Yervoy Specialty, Prior Authorization

Yohimbine Gender Edit – Males only

Zaltrap Specialty, Prior Authorization

Zarxio Specialty, Prior Authorization

Zavesca Specialty, Prior Authorization

Zegerid (omeprazole-sodium) Quantity Limit – 40-1680MG only = 30 per 30 days, Step Therapy

Zelboraf Specialty, Prior Authorization, Quantity Limit – 240 per 30 days

Zemaira Specialty, Prior Authorization

MRX0103_0116

- 27 -

Medication Clinical Edits and GuidelinesZenzedi Quantity Limit – 10MG=180 per 30 days; 2.5MG & 20 MG = 90

per 30 days; 5MG, 15MG & 30MG=60 per 30 days; 7.5MG = 240per 30 days, Age Edit

Zesteril (lisinopril) Quantity Limit – 30 per 30 days

Zestoretic (lisinopril-hctz) 10-12.5mg Quantity Limit – 30 per 30 days

Zetia Step Therapy, Quantity Limit – 30 tablets per 30 days

Zetonna Aeresol Quantity Limit – 1 inhaler per 30 days

Ziana Quantity Limit – 60 G per 30 days

Zinecard (dexrazoxane) Specialty, Prior Authorization

Zioptan Quantity Limit – max daily dose 1

Zipsor Quantity Limit – 120 tablets per 30 days

Zirgan Quantity Limit – 5G per 30 days

Zithromax (azithromycin) Quantity Limit – 250mg = 6 tablets per fill, 5 day therapy, 500mg= 5 tablets per fill, 600mg = 8 tablets per 30 days

Zithromax (azithromycin)Suspension

Quantity Limit – 100mg/5ml = 30ml per fill, 200mg/5ml = 60 mlper fill

Zmax Quantity Limit – 1 per fill

Zocor (simvastatin) Step Therapy, Quantity Limit – 20mg & 40mg=45 per 30 days,5mg & 80mg = 30 per 30 days; Prior Authorization – 80mg only

Zofran (ondansetron) Quantity Limit – 4mg = 18 per 30 days, 8mg = 24 per 30 days, oralsolution = 600ml per 30 days

Zohydro ER Prior Authorization, Quantity Limit – 60 per 30 days

Zolinza Specialty, Prior Authorization, Quantity Limit – 120 per 30 days

Zoloft (sertraline) Quantity Limit – 25MG & 50MG = 45 per 30 days; 100MG = 60 per30 days; 20MG/ML = 300ml per 30 days

Zolpimist spr Quantity Limit – 7.7ml per 30 days

Zomig (zolmitriptan) Quantity Limit 6 per 30 days

Zontivity Prior Authorization, Quantity Limit – 30 per 30

Zorbtive Specialty, Prior Authorization, Quantity Limit – 30 vials per 30days

Zortress Specialty, Prior Authorization

Zorvolex Quantity Limit – 90 per 30 days

Zubsolv Prior Authorization, Quantity Limit - 3 tablets per day

Zuplenz Quantity Limit – 4mg = 18 films per 30 days, 8mg = 60 films per 30days

Zyclara Quantity Limit – 56 packets per 60 days

Zydelig Specialty, Prior Authorization, Quantity Limit – 60 per 30 days

Zydone Quantity Limit – 10 per day

Zyflo Quantity Limit – 120 per 30 days

Zyflo CR Quantity Limit – 120 per 30 days

Zykadia Specialty, Prior Authorization, Quantity Limit – 150 per 30 days

Zymaxid (gatifloxacin) Quantity Limit – 2.5ml per 23 days

Zyprexa Relprew Quantity Limit – 210mg & 300mg = 2 vials per 28 days, 405mg = 1vial per 28 days

MRX0103_0116

- 28 -

Medication Clinical Edits and GuidelinesZytiga ‡ Specialty, Prior Authorization, Quantity Limit – 120 tabs per 30

days

Zyvox Quantity Limit – 900ml per fill, 28 tablets per fill

Please Note: Due to varying health benefit plans, inclusion of a drug and related items on the drug list(formulary) is not a guarantee of coverage. Please refer to your prescription drug benefit descriptionof coverage, limitations and exclusions.

mrx standard formulary utilization ......ambien cr (zolpidem cr) step therapy, quantity limit – 30...

Documents