uprehs ql may effectiveuphealth.com/pdfs/medicare-plans/cur_quantitylimits.pdfcalcipotriene-betameth...
TRANSCRIPT
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
1
7T Lido
7T LIDO EXTERNAL GEL Quantity Limit: 30 GM Per 30 Days
Abacavir Sulfate-Lamivudine
abacavir sulfate-lamivudine oral tablet Quantity Limit: 30 EA Per 30 Days
Abacavir-Lamivudine-Zidovudine
abacavir-lamivudine-zidovudine oral tablet Quantity Limit: 60 EA Per 30 Days
Abilify MyCite
ABILIFY MYCITE ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Actemra ACTPen
ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Quantity Limit: 3.6 ML Per 28 Days
Actemra
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 3.6 ML Per 28 Days
Adcirca
ADCIRCA ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Adempas
ADEMPAS ORAL TABLET Quantity Limit: 90 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
2
Advair Diskus
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 60 EA Per 30 Days
Advair HFA
ADVAIR HFA INHALATION AEROSOL Quantity Limit: 24 GM Per 30 Days
Aerospan
AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT
Quantity Limit: 17.8 GM Per 30 Days
Afinitor
AFINITOR ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Aimovig 140 Dose
AIMOVIG 140 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Quantity Limit: 2 ML Per 30 Days
Aimovig
AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML
Quantity Limit: 1 ML Per 30 Days
Akynzeo
AKYNZEO ORAL CAPSULE Quantity Limit: 2 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
3
Albuterol Sulfate
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%
Quantity Limit: 525 ML Per 30 Days
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%
Quantity Limit: 100 EA Per 30 Days
albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml
Quantity Limit: 375 ML Per 30 Days
Alecensa
ALECENSA ORAL CAPSULE Quantity Limit: 240 EA Per 30 Days
Alendronate Sodium
alendronate sodium oral tablet 70 mg Quantity Limit: 4 EA Per 28 Days
Almotriptan Malate
almotriptan malate oral tablet Quantity Limit: 12 EA Per 30 Days
Alprazolam ER
alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg
Quantity Limit: 30 EA Per 30 Days
alprazolam er oral tablet extended release 24 hour 2 mg
Quantity Limit: 150 EA Per 30 Days
alprazolam er oral tablet extended release 24 hour 3 mg
Quantity Limit: 90 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
4
Alprazolam
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg Quantity Limit: 120 EA Per 30 Days
alprazolam oral tablet 2 mg Quantity Limit: 150 EA Per 30 Days
alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg
Quantity Limit: 120 EA Per 30 Days
alprazolam oral tablet dispersible 2 mg Quantity Limit: 150 EA Per 30 Days
Alprazolam XR
alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg
Quantity Limit: 30 EA Per 30 Days
alprazolam xr oral tablet extended release 24 hour 2 mg
Quantity Limit: 150 EA Per 30 Days
alprazolam xr oral tablet extended release 24 hour 3 mg
Quantity Limit: 90 EA Per 30 Days
Alunbrig
ALUNBRIG ORAL TABLET 180 MG, 90 MG Quantity Limit: 30 EA Per 30 Days
ALUNBRIG ORAL TABLET 30 MG Quantity Limit: 120 EA Per 30 Days
ALUNBRIG ORAL TABLET THERAPY PACK Quantity Limit: 60 EA Per 365 Days
Alyq
alyq oral tablet Quantity Limit: 60 EA Per 30 Days
Amethia Lo
amethia lo oral tablet Quantity Limit: 91 EA Per 91 Days
Amethia
amethia oral tablet Quantity Limit: 91 EA Per 91 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
5
Amitiza
AMITIZA ORAL CAPSULE Quantity Limit: 60 EA Per 30 Days
Amphetamine-Dextroamphet ER
amphetamine-dextroamphet er oral capsule extended release 24 hour
Quantity Limit: 30 EA Per 30 Days
Amphetamine-Dextroamphetamine
amphetamine-dextroamphetamine oral tablet Quantity Limit: 90 EA Per 30 Days
Ampyra
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR
Quantity Limit: 60 EA Per 30 Days
Anoro Ellipta
ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 60 EA Per 30 Days
Anzemet
ANZEMET ORAL TABLET Quantity Limit: 5 EA Per 30 Days
Aplenzin
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR
Quantity Limit: 30 EA Per 30 Days
Apokyn
APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE
Quantity Limit: 90 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
6
Aprepitant
aprepitant oral capsule 125 mg Quantity Limit: 2 EA Per 30 Days
aprepitant oral capsule 40 mg Quantity Limit: 1 EA Per 30 Days
aprepitant oral capsule 80 & 125 mg Quantity Limit: 6 EA Per 30 Days
aprepitant oral capsule 80 mg Quantity Limit: 8 EA Per 30 Days
Aripiprazole
aripiprazole oral solution 1 mg/ml Quantity Limit: 750 ML Per 30 Days
aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg Quantity Limit: 30 EA Per 30 Days
aripiprazole oral tablet 2 mg, 5 mg Quantity Limit: 60 EA Per 30 Days
aripiprazole oral tablet dispersible 10 mg, 15 mg Quantity Limit: 60 EA Per 30 Days
Armodafinil
armodafinil oral tablet 150 mg, 200 mg, 250 mg Quantity Limit: 30 EA Per 30 Days
armodafinil oral tablet 50 mg Quantity Limit: 60 EA Per 30 Days
Ashlyna
ashlyna oral tablet Quantity Limit: 91 EA Per 91 Days
Asmanex 120 Metered Doses
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 1 EA Per 30 Days
Asmanex 14 Metered Doses
ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 1 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
7
Asmanex 30 Metered Doses
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 1 EA Per 30 Days
Asmanex 60 Metered Doses
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 1 EA Per 30 Days
Asmanex 7 Metered Doses
ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 1 EA Per 30 Days
Asmanex HFA
ASMANEX HFA INHALATION AEROSOL Quantity Limit: 26 GM Per 30 Days
Atomoxetine HCl
atomoxetine hcl oral capsule 10 mg Quantity Limit: 60 EA Per 30 Days
atomoxetine hcl oral capsule 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg
Quantity Limit: 30 EA Per 30 Days
Atripla
ATRIPLA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Atrovent HFA
ATROVENT HFA INHALATION AEROSOL SOLUTION
Quantity Limit: 25.8 GM Per 30 Days
Aubagio
AUBAGIO ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
8
Austedo
AUSTEDO ORAL TABLET Quantity Limit: 120 EA Per 30 Days
Avonex
AVONEX INTRAMUSCULAR KIT Quantity Limit: 4 EA Per 28 Days
Avonex Pen
AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT
Quantity Limit: 4 EA Per 28 Days
Avonex Prefilled
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT
Quantity Limit: 4 EA Per 28 Days
Azelastine HCl
azelastine hcl nasal solution 0.1 %, 0.15 % Quantity Limit: 60 ML Per 30 Days
Baraclude
BARACLUDE ORAL SOLUTION Quantity Limit: 600 ML Per 30 Days
Belsomra
BELSOMRA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Betaseron
BETASERON SUBCUTANEOUS KIT Quantity Limit: 15 EA Per 30 Days
Biktarvy
BIKTARVY ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
9
Bimatoprost
bimatoprost ophthalmic solution Quantity Limit: 5 ML Per 30 Days
Binosto
BINOSTO ORAL TABLET EFFERVESCENT Quantity Limit: 4 EA Per 28 Days
Breo Ellipta
BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 60 EA Per 30 Days
Budesonide
budesonide inhalation suspension Quantity Limit: 120 ML Per 30 Days
budesonide nasal suspension Quantity Limit: 17.2 GM Per 30 Days
Buprenorphine HCl-Naloxone HCl
buprenorphine hcl-naloxone hcl sublingual film 12-3 mg
Quantity Limit: 60 EA Per 30 Days
buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg
Quantity Limit: 360 EA Per 30 Days
buprenorphine hcl-naloxone hcl sublingual film 4-1 mg
Quantity Limit: 180 EA Per 30 Days
buprenorphine hcl-naloxone hcl sublingual film 8-2 mg
Quantity Limit: 90 EA Per 30 Days
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg
Quantity Limit: 360 EA Per 30 Days
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg
Quantity Limit: 90 EA Per 30 Days
Buprenorphine
buprenorphine transdermal patch weekly Quantity Limit: 4 EA Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
10
Bupropion HCl ER (Smoking Det)
bupropion hcl er (smoking det) oral tablet extended release 12 hour
Quantity Limit: 60 EA Per 30 Days
Bupropion HCl ER (SR)
bupropion hcl er (sr) oral tablet extended release 12 hour
Quantity Limit: 90 EA Per 30 Days
Bupropion HCl ER (XL)
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg
Quantity Limit: 90 EA Per 30 Days
bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg
Quantity Limit: 30 EA Per 30 Days
Butrans
BUTRANS TRANSDERMAL PATCH WEEKLY Quantity Limit: 4 EA Per 28 Days
Bydureon BCise
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR
Quantity Limit: 3.4 ML Per 28 Days
Bydureon
BYDUREON PEN Quantity Limit: 4 EA Per 28 Days
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG
Quantity Limit: 4 EA Per 28 Days
Cablivi
CABLIVI INJECTION KIT Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
11
Calcipotriene-Betameth Diprop
calcipotriene-betameth diprop external ointment Quantity Limit: 400 GM Per 30 Days
Calcitonin (Salmon)
calcitonin (salmon) nasal solution Quantity Limit: 3.7 ML Per 30 Days
Calquence
CALQUENCE ORAL CAPSULE Quantity Limit: 60 EA Per 30 Days
Camrese Lo
camrese lo oral tablet Quantity Limit: 91 EA Per 91 Days
Camrese
camrese oral tablet Quantity Limit: 91 EA Per 91 Days
Caprelsa
CAPRELSA ORAL TABLET 100 MG Quantity Limit: 60 EA Per 30 Days
Celecoxib
celecoxib oral capsule Quantity Limit: 60 EA Per 30 Days
Chantix Continuing Month Pak
CHANTIX CONTINUING MONTH PAK ORAL TABLET
Quantity Limit: 504 EA Per 365 Days
Chantix
CHANTIX ORAL TABLET Quantity Limit: 504 EA Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
12
Chantix Starting Month Pak
CHANTIX STARTING MONTH PAK ORAL TABLET
Quantity Limit: 504 EA Per 365 Days
Chlordiazepoxide HCl
chlordiazepoxide hcl oral capsule 10 mg Quantity Limit: 900 EA Per 30 Days
chlordiazepoxide hcl oral capsule 25 mg Quantity Limit: 360 EA Per 30 Days
chlordiazepoxide hcl oral capsule 5 mg Quantity Limit: 120 EA Per 30 Days
Cimduo
CIMDUO ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Clonazepam
clonazepam oral tablet 0.5 mg, 1 mg Quantity Limit: 90 EA Per 30 Days
clonazepam oral tablet 2 mg Quantity Limit: 300 EA Per 30 Days
clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg
Quantity Limit: 90 EA Per 30 Days
clonazepam oral tablet dispersible 2 mg Quantity Limit: 300 EA Per 30 Days
Clorazepate Dipotassium
clorazepate dipotassium oral tablet 15 mg Quantity Limit: 180 EA Per 30 Days
clorazepate dipotassium oral tablet 3.75 mg Quantity Limit: 720 EA Per 30 Days
clorazepate dipotassium oral tablet 7.5 mg Quantity Limit: 360 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
13
Clozapine
clozapine oral tablet 100 mg, 25 mg Quantity Limit: 270 EA Per 30 Days
clozapine oral tablet 200 mg Quantity Limit: 120 EA Per 30 Days
clozapine oral tablet 50 mg Quantity Limit: 180 EA Per 30 Days
clozapine oral tablet dispersible 100 mg, 25 mg Quantity Limit: 270 EA Per 30 Days
clozapine oral tablet dispersible 12.5 mg Quantity Limit: 90 EA Per 30 Days
clozapine oral tablet dispersible 150 mg Quantity Limit: 180 EA Per 30 Days
clozapine oral tablet dispersible 200 mg Quantity Limit: 120 EA Per 30 Days
Combivent Respimat
COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION
Quantity Limit: 8 GM Per 30 Days
Complera
COMPLERA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Copaxone
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML
Quantity Limit: 30 ML Per 30 Days
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML
Quantity Limit: 12 ML Per 28 Days
Corlanor
CORLANOR ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Cystaran
CYSTARAN OPHTHALMIC SOLUTION Quantity Limit: 60 ML Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
14
Daklinza
DAKLINZA ORAL TABLET Quantity Limit: 168 EA Per 365 Days
Dalfampridine ER
dalfampridine er oral tablet extended release 12 hour
Quantity Limit: 60 EA Per 30 Days
Daysee
daysee oral tablet Quantity Limit: 91 EA Per 91 Days
Delstrigo
DELSTRIGO ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Depo-Provera
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML
Quantity Limit: 10 ML Per 28 Days
Depo-SubQ Provera 104
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE
Quantity Limit: 0.65 ML Per 90 Days
Descovy
DESCOVY ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Desvenlafaxine ER
desvenlafaxine er oral tablet extended release 24 hour 100 mg
Quantity Limit: 120 EA Per 30 Days
desvenlafaxine er oral tablet extended release 24 hour 50 mg
Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
15
Desvenlafaxine Fumarate ER
DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG
Quantity Limit: 120 EA Per 30 Days
DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG
Quantity Limit: 30 EA Per 30 Days
Desvenlafaxine Succinate ER
desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg
Quantity Limit: 120 EA Per 30 Days
desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg
Quantity Limit: 30 EA Per 30 Days
Dexilant
DEXILANT ORAL CAPSULE DELAYED RELEASE Quantity Limit: 30 EA Per 30 Days
Dexmethylphenidate HCl ER
dexmethylphenidate hcl er oral capsule extended release 24 hour
Quantity Limit: 30 EA Per 30 Days
Dexmethylphenidate HCl
dexmethylphenidate hcl oral tablet Quantity Limit: 60 EA Per 30 Days
Dextroamphetamine Sulfate ER
dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg
Quantity Limit: 180 EA Per 30 Days
dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg
Quantity Limit: 120 EA Per 30 Days
dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg
Quantity Limit: 60 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
16
Dextroamphetamine Sulfate
dextroamphetamine sulfate oral solution Quantity Limit: 1800 ML Per 30 Days
dextroamphetamine sulfate oral tablet 10 mg Quantity Limit: 180 EA Per 30 Days
dextroamphetamine sulfate oral tablet 5 mg Quantity Limit: 90 EA Per 30 Days
Diazepam
diazepam oral tablet 10 mg Quantity Limit: 120 EA Per 30 Days
diazepam oral tablet 2 mg Quantity Limit: 300 EA Per 30 Days
diazepam oral tablet 5 mg Quantity Limit: 240 EA Per 30 Days
Diclofenac Sodium
diclofenac sodium transdermal gel 1 % Quantity Limit: 1000 GM Per 30 Days
Digitek
digitek oral tablet 125 mcg Quantity Limit: 30 EA Per 30 Days
Digox
digox oral tablet 125 mcg Quantity Limit: 30 EA Per 30 Days
Digoxin
digoxin oral tablet 125 mcg Quantity Limit: 30 EA Per 30 Days
Dihydroergotamine Mesylate
dihydroergotamine mesylate nasal solution Quantity Limit: 8 ML Per 30 Days
Doxepin HCl
doxepin hcl external cream Quantity Limit: 90 GM Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
17
Dronabinol
dronabinol oral capsule Quantity Limit: 60 EA Per 30 Days
Dulera
DULERA INHALATION AEROSOL Quantity Limit: 17.6 GM Per 30 Days
Duloxetine HCl
duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg
Quantity Limit: 60 EA Per 30 Days
duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg
Quantity Limit: 90 EA Per 30 Days
Dupixent
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML
Quantity Limit: 4.56 ML Per 28 Days
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML
Quantity Limit: 8 ML Per 28 Days
Dymista
DYMISTA NASAL SUSPENSION Quantity Limit: 23 GM Per 30 Days
Egrifta
EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED
Quantity Limit: 60 EA Per 30 Days
Eletriptan HBr
eletriptan hbr oral tablet Quantity Limit: 12 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
18
Eligard
ELIGARD SUBCUTANEOUS KIT 22.5 MG Quantity Limit: 1 EA Per 84 Days
ELIGARD SUBCUTANEOUS KIT 30 MG Quantity Limit: 1 EA Per 112 Days
ELIGARD SUBCUTANEOUS KIT 45 MG Quantity Limit: 1 EA Per 168 Days
ELIGARD SUBCUTANEOUS KIT 7.5 MG Quantity Limit: 1 EA Per 28 Days
Eliquis
ELIQUIS ORAL TABLET 2.5 MG Quantity Limit: 60 EA Per 30 Days
ELIQUIS ORAL TABLET 5 MG Quantity Limit: 90 EA Per 30 Days
Eliquis Starter Pack
ELIQUIS STARTER PACK ORAL TABLET Quantity Limit: 148 EA Per 365 Days
Emend
EMEND ORAL SUSPENSION RECONSTITUTED Quantity Limit: 6 EA Per 30 Days
Emsam
EMSAM TRANSDERMAL PATCH 24 HOUR Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
19
Enoxaparin Sodium
enoxaparin sodium injection solution Quantity Limit: 105 ML Per 90 Days
enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml
Quantity Limit: 35 ML Per 90 Days
enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml
Quantity Limit: 28 ML Per 90 Days
enoxaparin sodium subcutaneous solution 30 mg/0.3ml
Quantity Limit: 10.5 ML Per 90 Days
enoxaparin sodium subcutaneous solution 40 mg/0.4ml
Quantity Limit: 14 ML Per 90 Days
enoxaparin sodium subcutaneous solution 60 mg/0.6ml
Quantity Limit: 21 ML Per 90 Days
Entecavir
entecavir oral tablet Quantity Limit: 30 EA Per 30 Days
Entresto
ENTRESTO ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Epclusa
EPCLUSA ORAL TABLET Quantity Limit: 84 EA Per 365 Days
Erleada
ERLEADA ORAL TABLET Quantity Limit: 120 EA Per 30 Days
Esomeprazole Magnesium
esomeprazole magnesium oral capsule delayed release
Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
20
Estazolam
estazolam oral tablet Quantity Limit: 30 EA Per 30 Days
Estring
ESTRING VAGINAL RING Quantity Limit: 1 EA Per 90 Days
Eszopiclone
eszopiclone oral tablet Quantity Limit: 30 EA Per 30 Days
Evotaz
EVOTAZ ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Extavia
EXTAVIA SUBCUTANEOUS KIT Quantity Limit: 15 EA Per 30 Days
Fanapt
FANAPT ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Fanapt Titration Pack
FANAPT TITRATION PACK ORAL TABLET Quantity Limit: 8 EA Per 180 Days
Fayosim
fayosim oral tablet Quantity Limit: 91 EA Per 91 Days
Femring
FEMRING VAGINAL RING Quantity Limit: 1 EA Per 90 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
21
Fetzima
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR
Quantity Limit: 30 EA Per 30 Days
Fetzima Titration
FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK
Quantity Limit: 56 EA Per 365 Days
Firdapse
FIRDAPSE ORAL TABLET Quantity Limit: 240 EA Per 30 Days
Firmagon
FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG
Quantity Limit: 4 EA Per 365 Days
FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG
Quantity Limit: 1 EA Per 28 Days
Flovent Diskus
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST
Quantity Limit: 60 EA Per 30 Days
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST
Quantity Limit: 240 EA Per 30 Days
Flovent HFA
FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT
Quantity Limit: 24 GM Per 30 Days
FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT
Quantity Limit: 21.2 GM Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
22
Flunisolide
flunisolide nasal solution Quantity Limit: 50 ML Per 30 Days
Fluoxetine HCl
fluoxetine hcl oral capsule delayed release Quantity Limit: 4 EA Per 28 Days
Fluticasone-Salmeterol
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
Quantity Limit: 60 EA Per 30 Days
Fluvoxamine Maleate ER
fluvoxamine maleate er oral capsule extended release 24 hour
Quantity Limit: 60 EA Per 30 Days
Fondaparinux Sodium
fondaparinux sodium subcutaneous solution 10 mg/0.8ml
Quantity Limit: 28 ML Per 90 Days
fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml
Quantity Limit: 17.5 ML Per 90 Days
fondaparinux sodium subcutaneous solution 5 mg/0.4ml
Quantity Limit: 14 ML Per 90 Days
fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml
Quantity Limit: 21 ML Per 90 Days
Fosamax Plus D
FOSAMAX PLUS D ORAL TABLET Quantity Limit: 4 EA Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
23
Fragmin
FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML
Quantity Limit: 35 ML Per 90 Days
FRAGMIN SUBCUTANEOUS SOLUTION 12500 UNIT/0.5ML
Quantity Limit: 17.5 ML Per 90 Days
FRAGMIN SUBCUTANEOUS SOLUTION 15000 UNIT/0.6ML
Quantity Limit: 21 ML Per 90 Days
FRAGMIN SUBCUTANEOUS SOLUTION 18000 UNT/0.72ML
Quantity Limit: 25.3 ML Per 90 Days
FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML
Quantity Limit: 7 ML Per 90 Days
FRAGMIN SUBCUTANEOUS SOLUTION 7500 UNIT/0.3ML
Quantity Limit: 10.5 ML Per 90 Days
FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML
Quantity Limit: 22.8 ML Per 90 Days
Frovatriptan Succinate
frovatriptan succinate oral tablet Quantity Limit: 12 EA Per 30 Days
Fuzeon
FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED
Quantity Limit: 60 EA Per 30 Days
Gabapentin
gabapentin oral capsule 100 mg, 300 mg Quantity Limit: 360 EA Per 30 Days
gabapentin oral capsule 400 mg Quantity Limit: 270 EA Per 30 Days
gabapentin oral solution 250 mg/5ml Quantity Limit: 2160 ML Per 30 Days
gabapentin oral tablet 600 mg Quantity Limit: 180 EA Per 30 Days
gabapentin oral tablet 800 mg Quantity Limit: 150 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
24
Genvoya
GENVOYA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Geodon
GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED
Quantity Limit: 60 EA Per 30 Days
Gilenya
GILENYA ORAL CAPSULE Quantity Limit: 30 EA Per 30 Days
Gilotrif
GILOTRIF ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Glatiramer Acetate
glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml
Quantity Limit: 30 ML Per 30 Days
glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml
Quantity Limit: 12 ML Per 28 Days
Glatopa
glatopa subcutaneous solution prefilled syringe 20 mg/ml
Quantity Limit: 30 ML Per 30 Days
glatopa subcutaneous solution prefilled syringe 40 mg/ml
Quantity Limit: 12 ML Per 28 Days
Glydo
glydo external gel Quantity Limit: 30 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
25
Granisetron HCl
granisetron hcl oral tablet Quantity Limit: 30 EA Per 30 Days
Harvoni
HARVONI ORAL TABLET Quantity Limit: 168 EA Per 365 Days
Hetlioz
HETLIOZ ORAL CAPSULE Quantity Limit: 30 EA Per 30 Days
Ibandronate Sodium
ibandronate sodium oral tablet Quantity Limit: 1 EA Per 28 Days
Iclusig
ICLUSIG ORAL TABLET 15 MG Quantity Limit: 60 EA Per 30 Days
IDHIFA
IDHIFA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Ilaris (150mg Delivered)
ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 180 MG
Quantity Limit: 2 EA Per 28 Days
Ilaris
ILARIS SUBCUTANEOUS SOLUTION Quantity Limit: 2 ML Per 28 Days
Ilevro
ILEVRO OPHTHALMIC SUSPENSION Quantity Limit: 6 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
26
Incruse Ellipta
INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 30 EA Per 30 Days
Ingrezza
INGREZZA ORAL CAPSULE 40 MG Quantity Limit: 60 EA Per 30 Days
INGREZZA ORAL CAPSULE 80 MG Quantity Limit: 30 EA Per 30 Days
Insulin Syringes, Needles
insulin syringes, needles 28g x 1/2" 0.5 ml, 29g 0.3 ml, 29g x 1/2" 1 ml, 29g x 12mm
Quantity Limit: 200 EA Per 30 Days
INSULIN SYRINGES, NEEDLES 31G X 8 MM Quantity Limit: 200 EA Per 30 Days
Introvale
introvale oral tablet Quantity Limit: 91 EA Per 91 Days
Ipratropium Bromide
ipratropium bromide inhalation solution Quantity Limit: 312.5 ML Per 30 Days
Ipratropium-Albuterol
ipratropium-albuterol inhalation solution Quantity Limit: 540 ML Per 30 Days
Jakafi
JAKAFI ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Jolessa
jolessa oral tablet Quantity Limit: 91 EA Per 91 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
27
Juluca
JULUCA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Juxtapid
JUXTAPID ORAL CAPSULE Quantity Limit: 30 EA Per 30 Days
Jynarque
JYNARQUE ORAL TABLET THERAPY PACK Quantity Limit: 56 EA Per 28 Days
Ketorolac Tromethamine
ketorolac tromethamine oral tablet Quantity Limit: 20 EA Per 30 Days
Keveyis
KEVEYIS ORAL TABLET Quantity Limit: 120 EA Per 30 Days
Kisqali 200 Dose
KISQALI 200 DOSE ORAL TABLET 200 MG Quantity Limit: 63 EA Per 28 Days
Kisqali 400 Dose
KISQALI 400 DOSE ORAL TABLET 200 MG Quantity Limit: 63 EA Per 28 Days
Kisqali 600 Dose
KISQALI 600 DOSE ORAL TABLET 200 MG Quantity Limit: 63 EA Per 28 Days
Kisqali Femara 200 Dose
KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK
Quantity Limit: 91 EA Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
28
Kisqali Femara 400 Dose
KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK
Quantity Limit: 91 EA Per 28 Days
Kisqali Femara 600 Dose
KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK
Quantity Limit: 91 EA Per 28 Days
Korlym
KORLYM ORAL TABLET Quantity Limit: 120 EA Per 30 Days
Kynamro
KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 4 ML Per 28 Days
Lamivudine-Zidovudine
lamivudine-zidovudine oral tablet Quantity Limit: 60 EA Per 30 Days
Lanoxin
LANOXIN ORAL TABLET 125 MCG, 187.5 MCG Quantity Limit: 30 EA Per 30 Days
LANOXIN ORAL TABLET 62.5 MCG Quantity Limit: 60 EA Per 30 Days
Lansoprazole
lansoprazole oral capsule delayed release Quantity Limit: 30 EA Per 30 Days
lansoprazole oral tablet dispersible Quantity Limit: 30 EA Per 30 Days
Latanoprost
latanoprost ophthalmic solution Quantity Limit: 2.5 ML Per 25 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
29
Latuda
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG
Quantity Limit: 30 EA Per 30 Days
LATUDA ORAL TABLET 80 MG Quantity Limit: 60 EA Per 30 Days
Ledipasvir-Sofosbuvir
ledipasvir-sofosbuvir oral tablet Quantity Limit: 168 EA Per 365 Days
Letairis
LETAIRIS ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Levalbuterol HCl
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml
Quantity Limit: 540 ML Per 30 Days
levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml
Quantity Limit: 90 EA Per 30 Days
levalbuterol hcl inhalation nebulization solution 1.25 mg/3ml
Quantity Limit: 270 ML Per 30 Days
Levalbuterol Tartrate HFA
levalbuterol tartrate hfa inhalation aerosol 45 mcg/act
Quantity Limit: 30 GM Per 30 Days
Levonorgest-Eth Est & Eth Est
levonorgest-eth est & eth est oral tablet Quantity Limit: 91 EA Per 91 Days
Levonorgest-Eth Estrad 91-Day
levonorgest-eth estrad 91-day oral tablet Quantity Limit: 91 EA Per 91 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
30
Lidocaine
lidocaine external ointment Quantity Limit: 150 GM Per 30 Days
Lidocaine HCl
lidocaine hcl external gel 2 % Quantity Limit: 30 EA Per 30 Days
lidocaine hcl external solution Quantity Limit: 50 ML Per 30 Days
Lidocaine-Prilocaine
lidocaine-prilocaine external cream Quantity Limit: 30 GM Per 30 Days
Lidocaine-Tetracaine
LIDOCAINE-TETRACAINE EXTERNAL CREAM Quantity Limit: 30 GM Per 30 Days
Linezolid
linezolid oral suspension reconstituted Quantity Limit: 1800 ML Per 28 Days
linezolid oral tablet Quantity Limit: 56 EA Per 28 Days
Linzess
LINZESS ORAL CAPSULE Quantity Limit: 30 EA Per 30 Days
Lokelma
LOKELMA ORAL PACKET Quantity Limit: 90 EA Per 30 Days
Lonsurf
LONSURF ORAL TABLET 15-6.14 MG Quantity Limit: 100 EA Per 28 Days
LONSURF ORAL TABLET 20-8.19 MG Quantity Limit: 80 EA Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
31
Lorazepam
lorazepam oral tablet 0.5 mg, 1 mg Quantity Limit: 90 EA Per 30 Days
lorazepam oral tablet 2 mg Quantity Limit: 150 EA Per 30 Days
Lotemax
LOTEMAX OPHTHALMIC GEL Quantity Limit: 20 GM Per 365 Days
LOTEMAX OPHTHALMIC OINTMENT Quantity Limit: 14 GM Per 365 Days
Lotemax SM
LOTEMAX SM OPHTHALMIC GEL Quantity Limit: 20 GM Per 365 Days
Lucemyra
LUCEMYRA ORAL TABLET Quantity Limit: 480 EA Per 30 Days
Lumigan
LUMIGAN OPHTHALMIC SOLUTION Quantity Limit: 2.5 ML Per 25 Days
Lupaneta Pack
LUPANETA PACK COMBINATION KIT 11.25 & 5 MG
Quantity Limit: 1 EA Per 84 Days
LUPANETA PACK COMBINATION KIT 3.75 & 5 MG
Quantity Limit: 1 EA Per 28 Days
Lupron Depot (1-Month)
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT
Quantity Limit: 1 EA Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
32
Lupron Depot (3-Month)
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT
Quantity Limit: 1 EA Per 84 Days
Lupron Depot (4-Month)
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT
Quantity Limit: 1 EA Per 112 Days
Lupron Depot (6-Month)
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT
Quantity Limit: 1 EA Per 168 Days
Lupron Depot-Ped (1-Month)
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT
Quantity Limit: 1 EA Per 28 Days
Lupron Depot-Ped (3-Month)
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT
Quantity Limit: 1 EA Per 84 Days
Lyrica
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MG
Quantity Limit: 90 EA Per 30 Days
LYRICA ORAL CAPSULE 300 MG Quantity Limit: 60 EA Per 30 Days
LYRICA ORAL SOLUTION Quantity Limit: 900 ML Per 30 Days
Mavyret
MAVYRET ORAL TABLET Quantity Limit: 336 EA Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
33
Medroxyprogesterone Acetate
medroxyprogesterone acetate intramuscular suspension
Quantity Limit: 1 ML Per 90 Days
medroxyprogesterone acetate intramuscular suspension prefilled syringe
Quantity Limit: 1 ML Per 90 Days
Memantine HCl ER
memantine hcl er oral capsule extended release 24 hour
Quantity Limit: 30 EA Per 30 Days
Metadate ER
metadate er oral tablet extended release Quantity Limit: 90 EA Per 30 Days
Methylphenidate HCl ER (CD)
methylphenidate hcl er (cd) oral capsule extended release
Quantity Limit: 30 EA Per 30 Days
Methylphenidate HCl ER (LA)
methylphenidate hcl er (la) oral capsule extended release 24 hour
Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
34
Methylphenidate HCl ER
methylphenidate hcl er oral tablet extended release 10 mg
Quantity Limit: 180 EA Per 30 Days
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg, 72 mg
Quantity Limit: 30 EA Per 30 Days
methylphenidate hcl er oral tablet extended release 20 mg
Quantity Limit: 90 EA Per 30 Days
methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg
Quantity Limit: 30 EA Per 30 Days
methylphenidate hcl er oral tablet extended release 24 hour 36 mg
Quantity Limit: 60 EA Per 30 Days
methylphenidate hcl er oral tablet extended release 36 mg
Quantity Limit: 60 EA Per 30 Days
Methylphenidate HCl
methylphenidate hcl oral tablet Quantity Limit: 90 EA Per 30 Days
methylphenidate hcl oral tablet chewable 10 mg Quantity Limit: 180 EA Per 30 Days
methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg
Quantity Limit: 90 EA Per 30 Days
Modafinil
modafinil oral tablet Quantity Limit: 30 EA Per 30 Days
Mometasone Furoate
mometasone furoate nasal suspension Quantity Limit: 34 GM Per 30 Days
Mozobil
MOZOBIL SUBCUTANEOUS SOLUTION Quantity Limit: 38.4 ML Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
35
Naratriptan HCl
naratriptan hcl oral tablet Quantity Limit: 9 EA Per 30 Days
Natpara
NATPARA SUBCUTANEOUS CARTRIDGE Quantity Limit: 2 EA Per 28 Days
Nerlynx
NERLYNX ORAL TABLET Quantity Limit: 180 EA Per 30 Days
Nicotrol
NICOTROL INHALATION INHALER Quantity Limit: 2688 EA Per 365 Days
Nicotrol NS
NICOTROL NS NASAL SOLUTION Quantity Limit: 360 ML Per 365 Days
Nitrofurantoin Macrocrystal
nitrofurantoin macrocrystal oral capsule 100 mg Quantity Limit: 360 EA Per 365 Days
nitrofurantoin macrocrystal oral capsule 25 mg Quantity Limit: 1440 EA Per 365 Days
nitrofurantoin macrocrystal oral capsule 50 mg Quantity Limit: 720 EA Per 365 Days
Nitrofurantoin Monohydrate Macrocrystals
nitrofurantoin monohydrate macrocrystals oral capsule
Quantity Limit: 180 EA Per 365 Days
Nitrofurantoin
nitrofurantoin oral suspension Quantity Limit: 7200 ML Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
36
Nucala
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED
Quantity Limit: 3 EA Per 28 Days
Nuplazid
NUPLAZID ORAL CAPSULE Quantity Limit: 30 EA Per 30 Days
NUPLAZID ORAL TABLET 10 MG Quantity Limit: 30 EA Per 30 Days
NUPLAZID ORAL TABLET 17 MG Quantity Limit: 60 EA Per 30 Days
Ocaliva
OCALIVA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Ocrevus
OCREVUS INTRAVENOUS SOLUTION Quantity Limit: 40 ML Per 365 Days
Odefsey
ODEFSEY ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Olanzapine
olanzapine oral tablet Quantity Limit: 30 EA Per 30 Days
olanzapine oral tablet dispersible Quantity Limit: 30 EA Per 30 Days
Olanzapine-Fluoxetine HCl
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg
Quantity Limit: 30 EA Per 30 Days
olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg
Quantity Limit: 90 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
37
Olopatadine HCl
olopatadine hcl nasal solution Quantity Limit: 30.5 GM Per 30 Days
Olysio
OLYSIO ORAL CAPSULE 150 MG Quantity Limit: 168 EA Per 365 Days
Omeprazole
omeprazole oral capsule delayed release Quantity Limit: 30 EA Per 30 Days
Omeprazole-Sodium Bicarbonate
omeprazole-sodium bicarbonate oral capsule Quantity Limit: 30 EA Per 30 Days
omeprazole-sodium bicarbonate oral packet Quantity Limit: 60 EA Per 30 Days
OmniPod
OMNIPOD Quantity Limit: 30 EA Per 30 Days
OmniPod 5 Pack
OMNIPOD 5 PACK Quantity Limit: 30 EA Per 30 Days
OmniPod Dash 5 Pack
OMNIPOD DASH 5 PACK Quantity Limit: 30 EA Per 30 Days
OmniPod Dash System
OMNIPOD DASH SYSTEM KIT Quantity Limit: 1 EA Per 365 Days
OmniPod Starter
OMNIPOD STARTER KIT Quantity Limit: 1 EA Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
38
Ondansetron HCl
ondansetron hcl injection solution 4 mg/2ml Quantity Limit: 240 ML Per 30 Days
ondansetron hcl injection solution 40 mg/20ml Quantity Limit: 120 ML Per 30 Days
ondansetron hcl oral solution Quantity Limit: 450 ML Per 30 Days
ondansetron hcl oral tablet 24 mg Quantity Limit: 14 EA Per 28 Days
Opsumit
OPSUMIT ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Orencia ClickJect
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Quantity Limit: 4 ML Per 28 Days
Orilissa
ORILISSA ORAL TABLET 150 MG Quantity Limit: 30 EA Per 30 Days
ORILISSA ORAL TABLET 200 MG Quantity Limit: 60 EA Per 30 Days
Orkambi
ORKAMBI ORAL PACKET Quantity Limit: 56 EA Per 28 Days
ORKAMBI ORAL TABLET Quantity Limit: 112 EA Per 28 Days
Oseltamivir Phosphate
oseltamivir phosphate oral capsule 30 mg Quantity Limit: 168 EA Per 365 Days
oseltamivir phosphate oral capsule 45 mg Quantity Limit: 84 EA Per 365 Days
oseltamivir phosphate oral capsule 75 mg Quantity Limit: 110 EA Per 365 Days
oseltamivir phosphate oral suspension reconstituted
Quantity Limit: 1080 ML Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
39
Osphena
OSPHENA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Oxandrolone
oxandrolone oral tablet 10 mg Quantity Limit: 60 EA Per 30 Days
oxandrolone oral tablet 2.5 mg Quantity Limit: 240 EA Per 30 Days
Oxazepam
oxazepam oral capsule Quantity Limit: 120 EA Per 30 Days
Oxervate
OXERVATE OPHTHALMIC SOLUTION Quantity Limit: 56 ML Per 28 Days
Paliperidone ER
paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg
Quantity Limit: 30 EA Per 30 Days
paliperidone er oral tablet extended release 24 hour 6 mg
Quantity Limit: 60 EA Per 30 Days
Pantoprazole Sodium
pantoprazole sodium oral tablet delayed release Quantity Limit: 30 EA Per 30 Days
Paroxetine Mesylate
paroxetine mesylate oral capsule Quantity Limit: 30 EA Per 30 Days
Perforomist
PERFOROMIST INHALATION NEBULIZATION SOLUTION
Quantity Limit: 120 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
40
Pexeva
PEXEVA ORAL TABLET 10 MG, 20 MG, 40 MG Quantity Limit: 30 EA Per 30 Days
PEXEVA ORAL TABLET 30 MG Quantity Limit: 60 EA Per 30 Days
Plegridy Starter Pack
PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR
Quantity Limit: 2 ML Per 365 Days
PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 2 ML Per 365 Days
Plegridy
PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR
Quantity Limit: 1 ML Per 28 Days
PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 1 ML Per 28 Days
Pliaglis
PLIAGLIS EXTERNAL CREAM Quantity Limit: 30 GM Per 30 Days
Portrazza
PORTRAZZA INTRAVENOUS SOLUTION Quantity Limit: 100 ML Per 21 Days
Pradaxa
PRADAXA ORAL CAPSULE Quantity Limit: 60 EA Per 30 Days
Praluent
PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR
Quantity Limit: 2 ML Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
41
Prezcobix
PREZCOBIX ORAL TABLET Quantity Limit: 30 EA Per 30 Days
ProAir HFA
PROAIR HFA INHALATION AEROSOL SOLUTION Quantity Limit: 17 GM Per 30 Days
ProAir RespiClick
PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 2 EA Per 30 Days
Prolensa
PROLENSA OPHTHALMIC SOLUTION Quantity Limit: 12 ML Per 365 Days
Prolia
PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML Quantity Limit: 2 ML Per 365 Days
Quasense
quasense oral tablet Quantity Limit: 91 EA Per 91 Days
Quetiapine Fumarate ER
quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 300 mg, 400 mg, 50 mg
Quantity Limit: 60 EA Per 30 Days
quetiapine fumarate er oral tablet extended release 24 hour 200 mg
Quantity Limit: 90 EA Per 30 Days
Quetiapine Fumarate
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Quantity Limit: 90 EA Per 30 Days
quetiapine fumarate oral tablet 300 mg, 400 mg Quantity Limit: 60 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
42
Qvar
QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT
Quantity Limit: 17.4 GM Per 30 Days
QVAR INHALATION AEROSOL SOLUTION 80 MCG/ACT
Quantity Limit: 26.1 GM Per 30 Days
Qvar RediHaler
QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED
Quantity Limit: 21.2 GM Per 30 Days
Rabeprazole Sodium
rabeprazole sodium oral tablet delayed release Quantity Limit: 30 EA Per 30 Days
Rasuvo
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML
Quantity Limit: 0.8 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 12.5 MG/0.25ML
Quantity Limit: 1 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 15 MG/0.3ML
Quantity Limit: 1.2 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 17.5 MG/0.35ML
Quantity Limit: 1.4 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML
Quantity Limit: 1.6 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22.5 MG/0.45ML
Quantity Limit: 1.8 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 25 MG/0.5ML
Quantity Limit: 2 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 MG/0.6ML
Quantity Limit: 2.4 ML Per 28 Days
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 7.5 MG/0.15ML
Quantity Limit: 0.6 ML Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
43
Rebif Rebidose
REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Quantity Limit: 6 ML Per 28 Days
Rebif Rebidose Titration Pack
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Quantity Limit: 8.4 ML Per 365 Days
Rebif
REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 6 ML Per 28 Days
Rebif Titration Pack
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 8.4 ML Per 365 Days
Relenza Diskhaler
RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 240 EA Per 365 Days
Relexxii
relexxii oral tablet extended release Quantity Limit: 30 EA Per 30 Days
Relistor
RELISTOR ORAL TABLET Quantity Limit: 90 EA Per 30 Days
RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 12 MG/0.6ML (0.6ML SYRINGE)
Quantity Limit: 18 ML Per 30 Days
RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML
Quantity Limit: 12 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
44
Repatha Pushtronex System
REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE
Quantity Limit: 3.5 ML Per 28 Days
Repatha
REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Quantity Limit: 3 ML Per 28 Days
Repatha SureClick
REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Quantity Limit: 3 ML Per 28 Days
Rexulti
REXULTI ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Rhopressa
RHOPRESSA OPHTHALMIC SOLUTION Quantity Limit: 2.5 ML Per 25 Days
Risedronate Sodium
risedronate sodium oral tablet 150 mg Quantity Limit: 1 EA Per 28 Days
risedronate sodium oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)
Quantity Limit: 4 EA Per 28 Days
risedronate sodium oral tablet delayed release Quantity Limit: 4 EA Per 28 Days
Risperidone
risperidone oral solution 1 mg/ml Quantity Limit: 240 ML Per 30 Days
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Quantity Limit: 60 EA Per 30 Days
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Quantity Limit: 60 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
45
Rivelsa
rivelsa oral tablet Quantity Limit: 91 EA Per 91 Days
Rizatriptan Benzoate
rizatriptan benzoate oral tablet Quantity Limit: 18 EA Per 30 Days
rizatriptan benzoate oral tablet dispersible Quantity Limit: 18 EA Per 30 Days
Rozerem
ROZEREM ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Rubraca
RUBRACA ORAL TABLET Quantity Limit: 120 EA Per 30 Days
Rydapt
RYDAPT ORAL CAPSULE Quantity Limit: 240 EA Per 30 Days
Samsca
SAMSCA ORAL TABLET 15 MG Quantity Limit: 30 EA Per 60 Days
SAMSCA ORAL TABLET 30 MG Quantity Limit: 60 EA Per 30 Days
Sancuso
SANCUSO TRANSDERMAL PATCH Quantity Limit: 2 EA Per 30 Days
Saphris
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL Quantity Limit: 60 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
46
Savella
SAVELLA ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Savella Titration Pack
SAVELLA TITRATION PACK ORAL Quantity Limit: 110 EA Per 365 Days
Serevent Diskus
SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 60 EA Per 30 Days
Setlakin
setlakin oral tablet Quantity Limit: 91 EA Per 91 Days
Signifor LAR
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER
Quantity Limit: 1 EA Per 28 Days
Signifor
SIGNIFOR SUBCUTANEOUS SOLUTION Quantity Limit: 60 ML Per 30 Days
Sildenafil Citrate
sildenafil citrate oral tablet 20 mg Quantity Limit: 90 EA Per 30 Days
Silenor
SILENOR ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
47
Sivextro
SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED
Quantity Limit: 6 EA Per 30 Days
SIVEXTRO ORAL TABLET Quantity Limit: 6 EA Per 30 Days
Sofosbuvir-Velpatasvir
sofosbuvir-velpatasvir oral tablet Quantity Limit: 84 EA Per 365 Days
Sovaldi
SOVALDI ORAL TABLET Quantity Limit: 336 EA Per 365 Days
Spiriva HandiHaler
SPIRIVA HANDIHALER INHALATION CAPSULE Quantity Limit: 30 EA Per 30 Days
Spiriva Respimat
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT
Quantity Limit: 4 GM Per 30 Days
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT
Quantity Limit: 8 GM Per 28 Days
Sprix
SPRIX NASAL SOLUTION Quantity Limit: 5 EA Per 30 Days
Stiolto Respimat
STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION
Quantity Limit: 8 GM Per 28 Days
Stribild
STRIBILD ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
48
Striverdi Respimat
STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION
Quantity Limit: 4 GM Per 30 Days
Suboxone
SUBOXONE SUBLINGUAL FILM 12-3 MG Quantity Limit: 60 EA Per 30 Days
SUBOXONE SUBLINGUAL FILM 2-0.5 MG Quantity Limit: 360 EA Per 30 Days
SUBOXONE SUBLINGUAL FILM 4-1 MG Quantity Limit: 180 EA Per 30 Days
SUBOXONE SUBLINGUAL FILM 8-2 MG Quantity Limit: 90 EA Per 30 Days
Sumatriptan
sumatriptan nasal solution Quantity Limit: 12 EA Per 30 Days
Sumatriptan Succinate
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg
Quantity Limit: 9 EA Per 30 Days
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
Quantity Limit: 5 ML Per 30 Days
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml
Quantity Limit: 8 ML Per 30 Days
sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml
Quantity Limit: 5 ML Per 30 Days
sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml
Quantity Limit: 5 ML Per 30 Days
Sumatriptan Succinate Refill
SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML
Quantity Limit: 8 ML Per 30 Days
SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 6 MG/0.5ML
Quantity Limit: 5 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
49
Sumatriptan-Naproxen Sodium
sumatriptan-naproxen sodium oral tablet Quantity Limit: 9 EA Per 30 Days
Supprelin LA
SUPPRELIN LA SUBCUTANEOUS KIT Quantity Limit: 1 EA Per 365 Days
Symbicort
SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT
Quantity Limit: 12 GM Per 30 Days
SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT
Quantity Limit: 13.8 GM Per 30 Days
Symdeko
SYMDEKO ORAL TABLET THERAPY PACK Quantity Limit: 56 EA Per 28 Days
Symfi Lo
SYMFI LO ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Symfi
SYMFI ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Symtuza
SYMTUZA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Syndros
SYNDROS ORAL SOLUTION Quantity Limit: 120 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
50
Taclonex
TACLONEX EXTERNAL SUSPENSION Quantity Limit: 400 GM Per 30 Days
Tadalafil (PAH)
tadalafil (pah) oral tablet Quantity Limit: 60 EA Per 30 Days
Tadalafil
tadalafil oral tablet 2.5 mg, 5 mg Quantity Limit: 30 EA Per 30 Days
Tagrisso
TAGRISSO ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Tarceva
TARCEVA ORAL TABLET 100 MG, 150 MG Quantity Limit: 30 EA Per 30 Days
TARCEVA ORAL TABLET 25 MG Quantity Limit: 90 EA Per 30 Days
Tavalisse
TAVALISSE ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Tecfidera
TECFIDERA STARTER PACK Quantity Limit: 120 EA Per 365 Days
TECFIDERA ORAL CAPSULE DELAYED RELEASE
Quantity Limit: 60 EA Per 30 Days
Technivie
TECHNIVIE ORAL TABLET 12.5-75-50 MG Quantity Limit: 168 EA Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
51
Temazepam
temazepam oral capsule Quantity Limit: 30 EA Per 30 Days
Terbinafine HCl
terbinafine hcl oral tablet Quantity Limit: 84 EA Per 180 Days
Tibsovo
TIBSOVO ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Tobi Podhaler
TOBI PODHALER INHALATION CAPSULE Quantity Limit: 224 EA Per 56 Days
Travatan Z
TRAVATAN Z OPHTHALMIC SOLUTION Quantity Limit: 2.5 ML Per 25 Days
Trelegy Ellipta
TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 60 EA Per 30 Days
Trelstar Mixject
TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG
Quantity Limit: 1 EA Per 84 Days
TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 22.5 MG
Quantity Limit: 1 EA Per 168 Days
TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3.75 MG
Quantity Limit: 1 EA Per 28 Days
Trintellix
TRINTELLIX ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
52
Triptodur
TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER
Quantity Limit: 1 EA Per 168 Days
Triumeq
TRIUMEQ ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Trulicity
TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR
Quantity Limit: 2 ML Per 28 Days
Truvada
TRUVADA ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Tudorza Pressair
TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED
Quantity Limit: 60 EA Per 30 Days
Uptravi
UPTRAVI ORAL TABLET Quantity Limit: 60 EA Per 30 Days
UPTRAVI ORAL TABLET THERAPY PACK Quantity Limit: 400 EA Per 365 Days
Valacyclovir HCl
valacyclovir hcl oral tablet Quantity Limit: 120 EA Per 30 Days
Ventavis
VENTAVIS INHALATION SOLUTION Quantity Limit: 270 ML Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
53
Versacloz
VERSACLOZ ORAL SUSPENSION Quantity Limit: 540 ML Per 30 Days
Verzenio
VERZENIO ORAL TABLET Quantity Limit: 60 EA Per 30 Days
Victoza
VICTOZA Quantity Limit: 9 ML Per 30 Days
Viekira Pak
VIEKIRA PAK ORAL TABLET THERAPY PACK Quantity Limit: 672 EA Per 365 Days
Viekira XR
VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 200-8.33-50- 33.33 MG
Quantity Limit: 504 EA Per 365 Days
Viibryd
VIIBRYD ORAL TABLET Quantity Limit: 30 EA Per 30 Days
Viibryd Starter Pack
VIIBRYD STARTER PACK ORAL KIT Quantity Limit: 60 EA Per 365 Days
Vosevi
VOSEVI ORAL TABLET Quantity Limit: 84 EA Per 365 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
54
Vraylar
VRAYLAR ORAL CAPSULE Quantity Limit: 30 EA Per 30 Days
VRAYLAR ORAL CAPSULE THERAPY PACK Quantity Limit: 14 EA Per 365 Days
Wixela Inhub
wixela inhub inhalation aerosol powder breath activated
Quantity Limit: 60 EA Per 30 Days
Xarelto
XARELTO ORAL TABLET 10 MG, 20 MG Quantity Limit: 30 EA Per 30 Days
XARELTO ORAL TABLET 15 MG, 2.5 MG Quantity Limit: 60 EA Per 30 Days
Xarelto Starter Pack
XARELTO STARTER PACK ORAL TABLET THERAPY PACK
Quantity Limit: 102 EA Per 365 Days
Xermelo
XERMELO ORAL TABLET Quantity Limit: 90 EA Per 30 Days
Xiidra
XIIDRA OPHTHALMIC SOLUTION Quantity Limit: 60 EA Per 30 Days
Xofluza
XOFLUZA ORAL TABLET THERAPY PACK Quantity Limit: 4 EA Per 365 Days
Xuriden
XURIDEN ORAL PACKET Quantity Limit: 120 EA Per 30 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
55
Xyrem
XYREM ORAL SOLUTION Quantity Limit: 540 ML Per 30 Days
Yupelri
YUPELRI INHALATION SOLUTION Quantity Limit: 90 ML Per 30 Days
Zaleplon
zaleplon oral capsule 10 mg Quantity Limit: 60 EA Per 30 Days
zaleplon oral capsule 5 mg Quantity Limit: 30 EA Per 30 Days
Zejula
ZEJULA ORAL CAPSULE Quantity Limit: 90 EA Per 30 Days
Zenzedi
zenzedi oral tablet 10 mg Quantity Limit: 180 EA Per 30 Days
zenzedi oral tablet 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
Quantity Limit: 90 EA Per 30 Days
zenzedi oral tablet 30 mg Quantity Limit: 60 EA Per 30 Days
Zepatier
ZEPATIER ORAL TABLET Quantity Limit: 112 EA Per 365 Days
Ziprasidone HCl
ziprasidone hcl oral capsule Quantity Limit: 60 EA Per 30 Days
Zoladex
ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG Quantity Limit: 1 EA Per 84 Days
ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Quantity Limit: 1 EA Per 28 Days
Formulary ID 19062 Version 16 Effective Date: 5/1/2019
56
Zolmitriptan
zolmitriptan oral tablet 2.5 mg, 5 mg Quantity Limit: 12 EA Per 30 Days
zolmitriptan oral tablet dispersible 2.5 mg Quantity Limit: 12 EA Per 30 Days
zolmitriptan oral tablet dispersible 5 mg Quantity Limit: 9 EA Per 30 Days
Zolpidem Tartrate ER
zolpidem tartrate er oral tablet extended release Quantity Limit: 30 EA Per 30 Days
Zolpidem Tartrate
zolpidem tartrate oral tablet Quantity Limit: 30 EA Per 30 Days
zolpidem tartrate sublingual tablet sublingual Quantity Limit: 30 EA Per 30 Days
Formulary ID 19062 Effective Date: 5/1/2019
57
Index of Drugs
7 7T Lido ....................................................... 1 A Abacavir Sulfate-Lamivudine ...................... 1 Abacavir-Lamivudine-Zidovudine ............... 1 Abilify MyCite ............................................. 1 Actemra ..................................................... 1 Actemra ACTPen ....................................... 1 Adcirca ....................................................... 1 Adempas .................................................... 1 Advair Diskus ............................................. 2 Advair HFA ................................................ 2 Aerospan ................................................... 2 Afinitor ....................................................... 2 Aimovig ...................................................... 2 Aimovig 140 Dose ...................................... 2 Akynzeo ..................................................... 2 Albuterol Sulfate ......................................... 3 Alecensa .................................................... 3 Alendronate Sodium .................................. 3 Almotriptan Malate ..................................... 3 Alprazolam ................................................. 4 Alprazolam ER ........................................... 3 Alprazolam XR ........................................... 4 Alunbrig...................................................... 4 Alyq ............................................................ 4 Amethia...................................................... 4 Amethia Lo ................................................. 4 Amitiza ....................................................... 5 Amphetamine-Dextroamphet ER ............... 5 Amphetamine-Dextroamphetamine ............ 5 Ampyra ...................................................... 5 Anoro Ellipta .............................................. 5 Anzemet..................................................... 5 Aplenzin ..................................................... 5 Apokyn ....................................................... 5 Aprepitant .................................................. 6 Aripiprazole ................................................ 6 Armodafinil ................................................. 6 Ashlyna ...................................................... 6 Asmanex 120 Metered Doses .................... 6 Asmanex 14 Metered Doses ...................... 6 Asmanex 30 Metered Doses ...................... 7 Asmanex 60 Metered Doses ...................... 7 Asmanex 7 Metered Doses ........................ 7 Asmanex HFA ............................................ 7 Atomoxetine HCl ........................................ 7 Atripla ........................................................ 7
Atrovent HFA............................................. 7 Aubagio ..................................................... 7 Austedo ..................................................... 8 Avonex ...................................................... 8 Avonex Pen ............................................... 8 Avonex Prefilled ........................................ 8 Azelastine HCl ........................................... 8 B Baraclude .................................................. 8 Belsomra ................................................... 8 Betaseron .................................................. 8 Biktarvy ..................................................... 8 Bimatoprost ............................................... 9 Binosto ...................................................... 9 Breo Ellipta ................................................ 9 Budesonide ............................................... 9 Buprenorphine ........................................... 9 Buprenorphine HCl-Naloxone HCl ............. 9 Bupropion HCl ER (Smoking Det) ............10 Bupropion HCl ER (SR) ............................10 Bupropion HCl ER (XL) ............................10 Butrans.....................................................10 Bydureon ..................................................10 Bydureon BCise .......................................10 C Cablivi ......................................................10 Calcipotriene-Betameth Diprop ................11 Calcitonin (Salmon) ..................................11 Calquence ................................................11 Camrese ..................................................11 Camrese Lo .............................................11 Caprelsa ...................................................11 Celecoxib .................................................11 Chantix .....................................................11 Chantix Continuing Month Pak .................11 Chantix Starting Month Pak ......................12 Chlordiazepoxide HCl ...............................12 Cimduo.....................................................12 Clonazepam .............................................12 Clorazepate Dipotassium .........................12 Clozapine .................................................13 Combivent Respimat ................................13 Complera .................................................13 Copaxone .................................................13 Corlanor ...................................................13 Cystaran ...................................................13 D Daklinza ...................................................14
Formulary ID 19062 Effective Date: 5/1/2019
58
Dalfampridine ER ..................................... 14 Daysee .................................................... 14 Delstrigo................................................... 14 Depo-Provera .......................................... 14 Depo-SubQ Provera 104 .......................... 14 Descovy ................................................... 14 Desvenlafaxine ER .................................. 14 Desvenlafaxine Fumarate ER .................. 15 Desvenlafaxine Succinate ER .................. 15 Dexilant .................................................... 15 Dexmethylphenidate HCl ......................... 15 Dexmethylphenidate HCl ER .................... 15 Dextroamphetamine Sulfate ..................... 16 Dextroamphetamine Sulfate ER ............... 15 Diazepam ................................................. 16 Diclofenac Sodium ................................... 16 Digitek ...................................................... 16 Digox ....................................................... 16 Digoxin ..................................................... 16 Dihydroergotamine Mesylate .................... 16 Doxepin HCl ............................................. 16 Dronabinol ............................................... 17 Dulera ...................................................... 17 Duloxetine HCl ......................................... 17 Dupixent................................................... 17 Dymista .................................................... 17 E Egrifta ...................................................... 17 Eletriptan HBr .......................................... 17 Eligard ..................................................... 18 Eliquis ...................................................... 18 Eliquis Starter Pack .................................. 18 Emend ..................................................... 18 Emsam .................................................... 18 Enoxaparin Sodium .................................. 19 Entecavir .................................................. 19 Entresto ................................................... 19 Epclusa .................................................... 19 Erleada .................................................... 19 Esomeprazole Magnesium ....................... 19 Estazolam ................................................ 20 Estring ..................................................... 20 Eszopiclone ............................................. 20 Evotaz ...................................................... 20 Extavia ..................................................... 20 F Fanapt ..................................................... 20 Fanapt Titration Pack ............................... 20 Fayosim ................................................... 20 Femring.................................................... 20 Fetzima .................................................... 21
Fetzima Titration ......................................21 Firdapse ...................................................21 Firmagon ..................................................21 Flovent Diskus ..........................................21 Flovent HFA .............................................21 Flunisolide ................................................22 Fluoxetine HCl ..........................................22 Fluticasone-Salmeterol .............................22 Fluvoxamine Maleate ER .........................22 Fondaparinux Sodium ..............................22 Fosamax Plus D .......................................22 Fragmin ....................................................23 Frovatriptan Succinate .............................23 Fuzeon .....................................................23 G Gabapentin ..............................................23 Genvoya ...................................................24 Geodon ....................................................24 Gilenya .....................................................24 Gilotrif ......................................................24 Glatiramer Acetate ...................................24 Glatopa ....................................................24 Glydo .......................................................24 Granisetron HCl .......................................25 H Harvoni.....................................................25 Hetlioz ......................................................25 I Ibandronate Sodium .................................25 Iclusig .......................................................25 IDHIFA .....................................................25 Ilaris .........................................................25 Ilaris (150mg Delivered) ...........................25 Ilevro ........................................................25 Incruse Ellipta...........................................26 Ingrezza ...................................................26 Insulin Syringes, Needles .........................26 Introvale ...................................................26 Ipratropium Bromide .................................26 Ipratropium-Albuterol ................................26 J Jakafi .......................................................26 Jolessa .....................................................26 Juluca ......................................................27 Juxtapid ....................................................27 Jynarque ..................................................27 K Ketorolac Tromethamine ..........................27 Keveyis ....................................................27 Kisqali 200 Dose ......................................27 Kisqali 400 Dose ......................................27
Formulary ID 19062 Effective Date: 5/1/2019
59
Kisqali 600 Dose ...................................... 27 Kisqali Femara 200 Dose ......................... 27 Kisqali Femara 400 Dose ......................... 28 Kisqali Femara 600 Dose ......................... 28 Korlym ..................................................... 28 Kynamro .................................................. 28 L Lamivudine-Zidovudine ............................ 28 Lanoxin .................................................... 28 Lansoprazole ........................................... 28 Latanoprost .............................................. 28 Latuda ...................................................... 29 Ledipasvir-Sofosbuvir............................... 29 Letairis ..................................................... 29 Levalbuterol HCl ...................................... 29 Levalbuterol Tartrate HFA ........................ 29 Levonorgest-Eth Est & Eth Est ................. 29 Levonorgest-Eth Estrad 91-Day ............... 29 Lidocaine ................................................. 30 Lidocaine HCl .......................................... 30 Lidocaine-Prilocaine ................................. 30 Lidocaine-Tetracaine................................ 30 Linezolid................................................... 30 Linzess .................................................... 30 Lokelma ................................................... 30 Lonsurf ..................................................... 30 Lorazepam ............................................... 31 Lotemax ................................................... 31 Lotemax SM ............................................. 31 Lucemyra ................................................. 31 Lumigan ................................................... 31 Lupaneta Pack ......................................... 31 Lupron Depot (1-Month) ........................... 31 Lupron Depot (3-Month) ........................... 32 Lupron Depot (4-Month) ........................... 32 Lupron Depot (6-Month) ........................... 32 Lupron Depot-Ped (1-Month) ................... 32 Lupron Depot-Ped (3-Month) ................... 32 Lyrica ....................................................... 32 M Mavyret .................................................... 32 Medroxyprogesterone Acetate ................. 33 Memantine HCl ER .................................. 33 Metadate ER ............................................ 33 Methylphenidate HCl ................................ 34 Methylphenidate HCl ER .......................... 34 Methylphenidate HCl ER (CD) ................. 33 Methylphenidate HCl ER (LA) .................. 33 Modafinil .................................................. 34 Mometasone Furoate ............................... 34 Mozobil .................................................... 34
N Naratriptan HCl ........................................35 Natpara ....................................................35 Nerlynx .....................................................35 Nicotrol .....................................................35 Nicotrol NS ...............................................35 Nitrofurantoin............................................35 Nitrofurantoin Macrocrystal.......................35 Nitrofurantoin Monohydrate Macrocrystals
.............................................................35 Nucala ......................................................36 Nuplazid ...................................................36 O Ocaliva .....................................................36 Ocrevus ....................................................36 Odefsey ....................................................36 Olanzapine ...............................................36 Olanzapine-Fluoxetine HCl.......................36 Olopatadine HCl .......................................37 Olysio .......................................................37 Omeprazole .............................................37 Omeprazole-Sodium Bicarbonate.............37 OmniPod ..................................................37 OmniPod 5 Pack ......................................37 OmniPod Dash 5 Pack .............................37 OmniPod Dash System ............................37 OmniPod Starter ......................................37 Ondansetron HCl .....................................38 Opsumit ....................................................38 Orencia ClickJect .....................................38 Orilissa .....................................................38 Orkambi ...................................................38 Oseltamivir Phosphate .............................38 Osphena ..................................................39 Oxandrolone ............................................39 Oxazepam ................................................39 Oxervate ..................................................39 P Paliperidone ER .......................................39 Pantoprazole Sodium ...............................39 Paroxetine Mesylate .................................39 Perforomist ...............................................39 Pexeva .....................................................40 Plegridy ....................................................40 Plegridy Starter Pack ................................40 Pliaglis......................................................40 Portrazza ..................................................40 Pradaxa ....................................................40 Praluent ....................................................40 Prezcobix .................................................41 ProAir HFA ...............................................41
Formulary ID 19062 Effective Date: 5/1/2019
60
ProAir RespiClick ..................................... 41 Prolensa................................................... 41 Prolia ....................................................... 41 Q Quasense ................................................ 41 Quetiapine Fumarate ............................... 41 Quetiapine Fumarate ER ......................... 41 Qvar ......................................................... 42 Qvar RediHaler ........................................ 42 R Rabeprazole Sodium................................ 42 Rasuvo .................................................... 42 Rebif ........................................................ 43 Rebif Rebidose ........................................ 43 Rebif Rebidose Titration Pack .................. 43 Rebif Titration Pack .................................. 43 Relenza Diskhaler .................................... 43 Relexxii .................................................... 43 Relistor .................................................... 43 Repatha ................................................... 44 Repatha Pushtronex System .................... 44 Repatha SureClick ................................... 44 Rexulti ...................................................... 44 Rhopressa ............................................... 44 Risedronate Sodium ................................ 44 Risperidone .............................................. 44 Rivelsa ..................................................... 45 Rizatriptan Benzoate ................................ 45 Rozerem .................................................. 45 Rubraca ................................................... 45 Rydapt ..................................................... 45 S Samsca .................................................... 45 Sancuso ................................................... 45 Saphris .................................................... 45 Savella ..................................................... 46 Savella Titration Pack .............................. 46 Serevent Diskus ....................................... 46 Setlakin .................................................... 46 Signifor .................................................... 46 Signifor LAR ............................................. 46 Sildenafil Citrate ....................................... 46 Silenor ..................................................... 46 Sivextro .................................................... 47 Sofosbuvir-Velpatasvir ............................. 47 Sovaldi ..................................................... 47 Spiriva HandiHaler ................................... 47 Spiriva Respimat ...................................... 47 Sprix ........................................................ 47 Stiolto Respimat ....................................... 47 Stribild ...................................................... 47
Striverdi Respimat ....................................48 Suboxone .................................................48 Sumatriptan ..............................................48 Sumatriptan Succinate .............................48 Sumatriptan Succinate Refill ....................48 Sumatriptan-Naproxen Sodium ................49 Supprelin LA ............................................49 Symbicort .................................................49 Symdeko ..................................................49 Symfi ........................................................49 Symfi Lo ...................................................49 Symtuza ...................................................49 Syndros ....................................................49 T Taclonex ..................................................50 Tadalafil ...................................................50 Tadalafil (PAH) .........................................50 Tagrisso ...................................................50 Tarceva ....................................................50 Tavalisse ..................................................50 Tecfidera ..................................................50 Technivie ..................................................50 Temazepam .............................................51 Terbinafine HCl ........................................51 Tibsovo ....................................................51 Tobi Podhaler ...........................................51 Travatan Z ................................................51 Trelegy Ellipta ..........................................51 Trelstar Mixject .........................................51 Trintellix ....................................................51 Triptodur ...................................................52 Triumeq ....................................................52 Trulicity.....................................................52 Truvada ....................................................52 Tudorza Pressair ......................................52 U Uptravi......................................................52 V Valacyclovir HCl .......................................52 Ventavis ...................................................52 Versacloz .................................................53 Verzenio ...................................................53 Victoza .....................................................53 Viekira Pak ...............................................53 Viekira XR ................................................53 Viibryd ......................................................53 Viibryd Starter Pack..................................53 Vosevi ......................................................53 Vraylar......................................................54 W Wixela Inhub ............................................54
Formulary ID 19062 Effective Date: 5/1/2019
61
X Xarelto ..................................................... 54 Xarelto Starter Pack ................................. 54 Xermelo ................................................... 54 Xiidra ....................................................... 54 Xofluza ..................................................... 54 Xuriden .................................................... 54 Xyrem ...................................................... 55 Y Yupelri ..................................................... 55
Z Zaleplon ...................................................55 Zejula .......................................................55 Zenzedi ....................................................55 Zepatier ....................................................55 Ziprasidone HCl .......................................55 Zoladex ....................................................55 Zolmitriptan ..............................................56 Zolpidem Tartrate .....................................56 Zolpidem Tartrate ER ...............................56