Quantity Per Dispensing Level Limits/Allowances – Drug Name

Quantity Per Dispensing Level Limits/Allowances – Drug Name

+-Quantity per Dispensing Level
Limits/Allowances
All covered prescription medications are available at a participating pharmacy for the day supply limitation stated
in your member contract/certificate (typically up to a 30-day supply at retail and up to a 90-day supply for mail
order). In addition, quantity per dispensing (QPD) limits/allowances are placed on certain medications and are
based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or
intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by Blue
Cross and Blue Shield of Louisiana.
The following is a list of the most commonly prescribed medications subject to QPD limits/allowances. Drugs
listed in this section are not meant to be a complete list of medications covered by your plan. As benefits may vary
by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage.
Drug Name
Dosage Form
Retail QLL
Mail QLL
Abilify
2 mg tablet
30
90
Abilify
5 mg tablet
30
90
Abilify
10 mg tablet
30
90
Abilify
15 mg tablet
30
90
Abilify
20 mg tablet
30
90
Abilify
30 mg tablet
30
90
Abilify Discmelt
10 mg Discmelt
60
180
Abilify Discmelt
15 mg Discmelt
60
180
Abilify Maintena ER
300 mg/vial
1 vial
3 vials
Abilify Maintena ER
400 mg/vial
1 vial
3 vials
Abstral
96*
288*
Accupril
all strengths/dosage
forms
40 mg tablet
60
180
Accupril
20 mg tablet
60
180
Accupril
10 mg tablet
60
180
Accupril
5 mg tablet
60
180
Aceon
8 mg tablet
60
180
Aceon
4 mg tablet
60
180
Aceon
2 mg tablet
60
180
Aciphex
20 mg tablet
30
90
Acthar HP
80 units/mL vial
1 vial
1 vial
Actiq
all strengths/dosage
forms
90*
270*
04HQ3923 R12/15
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Activela
35 mg tablet
4
12
Actonel
150 mg tablet
1
3
Actonel
75 mg tablet
2
6
Actonel
35 mg tablet
4
12
Actonel
30 mg tablet
30
90
Actonel
5 mg tablet
30
90
Actonel with Calcium
1 pack
3 packs
Actoplus Met
35 mg/1250 mg tablet
(28 tablets)
15 mg/500 mg tablet
90
270
Actoplus Met
15 mg/850 mg tablet
90
270
Actoplus Met XR
15 mg/1000 mg tablet
60
180
Actoplus Met XR
30 mg/1000 mg tablet
30
90
Actos
45 mg tablet
30
90
Actos
30 mg tablet
30
90
Actos
15 mg tablet
30
90
Adcirca
20 mg tablet
60
60
Adempas
0.5 mg tablet
90
90
Adempas
1 mg tablet
90
90
Adempas
1.5 mg tablet
90
90
Adempas
2 mg tablet
90
90
Adempas
2.5 mg tablet
90
90
Advair Diskus
500 mcg - 1 device of
60 blisters (powder)
250 mcg - 1 device of
60 blisters (powder)
100mcg - 1 device of
60 blisters (powder)
60 doses
(1 device)
60 doses
(1 device)
60 doses
(1 device)
180 doses
(3 devices)
180 doses
(3 devices)
180 doses
(3 devices)
Advair HFA
230/21 mcg inhaler
Advair HFA
115/21 mcg inhaler
Advair HFA
45/21 mcg inhaler
Advicor
500 mg/20 mg tablet
120 doses
(1 device)
120 doses
(1 device)
120 doses
(1 device)
60
360 doses
(3 devices)
360 doses
(3 devices)
360 doses
(3 devices)
180
Advicor
750 mg/20 mg tablet
60
180
Advicor
1000 mg/20 mg tablet
60
180
Advair Diskus
Advair Diskus
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 2 of 54
Aerobid/ Aerobid-M
7g aerosol
3 (21g)
9 (56g)
Affinitor
2.5 mg tablet
30
30
Affinitor
5 mg tablet
30
30
Afinitor
7.5 mg tablet
30
30
Affinitor
10 mg tablet
30
30
Afinitor Disperz
2 mg
30
30
Afinitor Disperz
3 mg
30
30
Afinitor Disperz
5 mg
30
30
Aggrenox
60
180
Akynzeo
each capsule contains
200mg extendedrelease dipyridamole
with 25mg aspirin
300-0.5 mg capsules
2
6
Albuterol
17 g aerosol
2 (34 g)
6 (102 g)
Albuterol HFA
17 g aerosol
2 (17 g)
6 (51 g)
alendronate
40 mg tablet
30
90
alendronate
10 mg tablet
30
90
alendronate
5 mg tablet
30
90
alendronate
4 tablets
12 tablets
4 tablets
12 tablets
Allegra
70 mg tablet (blister
pack of 4 tablets)
35 mg tablet (blister
pack of 4 tablets)
30 mg tablet
60
180
Allegra
60 mg capsule
60
180
Allegra
180 mg tablet
30
90
Allegra-D
60 mg/120 mg tablet
60
180
Allegra-D 24 Hours
180 mg/240 mg tablet
30
90
Allegra Oral Suspension
1 bottle (300 mL)
Allegra ODT
30 mg/5 mL
suspension
30 mg tablet
60
3 bottles (900
mL)
180
Alora
0.025 mg/day
8 systems
24 systems
Alora
0.05 mg/day
8 systems
24 systems
Alora
0.075 mg/day
8 systems
24 systems
Alora
0.1 mg/day
8 systems
24 systems
Alsuma inj.
6 mg syringe kit
6 syringes (3 kits) 18 syringes (9
kits)
alendronate
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 3 of 54
Altace
10 mg capsule/ tablet
60
180
Altace
5 mg capsule/ tablet
60
180
Altace
2.5 mg capsule/ tablet
60
180
Altace
1.25 mg capsule/ tablet
60
180
Altoprev
10 mg tablet
30
90
Altoprev
20 mg tablet
30
90
Altoprev
40 mg tablet
30
90
Altoprev
60 mg tablet
30
90
Alupent
14 g aerosol
2 (28 g)
6 (84 g)
Alvesco
80 mcg inhaler
1 device (6.1 g)
3 devices (18.3 g)
Alvesco
160 mcg inhaler
1 device (6.1 g)
3 devices (18.3 g)
Ambien
10 mg tablet
21
63
Ambien
5 mg tablet
21
63
Ambien CR
12.5 mg tablet
21
63
Ambien CR
6.25 mg tablet
21
63
Amerge Tablet
1 mg tablet
9
27
Amerge Tablet
2.5 mg tablet
9
27
1 pack
(91 tablets)
1 pack
(91 tablets)
1 pack
(91 tablets)
1 pack
(91 tablets)
Amitiza
0.15 mg levonorgestrel/
0.03 mg & 0.01 mg
ethinyl estradiol
0.1 mg levonorgestrel/
0.02 mg & 0.01 mg
ethinyl estradiol
8 mcg capsule
60
180
Amitiza
24 mcg capsule
60
180
Amlopidine-atorvastatin
2.5/10 mg tablet
30
90
Amlopidine-atorvastatin
2.5/20 mg tablet
30
90
Amlopidine-atorvastatin
2.5/40 mg tablet
30
90
Amlopidine-atorvastatin
5/10 mg tablet
30
90
Amlopidine-atorvastatin
5/20 mg tablet
30
90
Amlopidine-atorvastatin
5/40 mg tablet
30
90
Amlopidine-atorvastatin
5/80 mg tablet
30
90
Amlopidine-atorvastatin
10/10 mg tablet
30
90
Amlopidine-atorvastatin
10/20 mg tablet
30
90
Amethia tablet
Amethia Lo tablet
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 4 of 54
Amlopidine-atorvastatin
10/40 mg tablet
30
90
Amlopidine-atorvastatin
10/80 mg tablet
30
90
Amlodipine-valsartan
5-160 mg tablet
30
90
Amlodipine-valsartan
5-320 mg tablet
30
90
Amlodipine-valsartan
10-160 mg tablet
30
90
Amlodipine-valsartan
10-320 mg tablet
30
90
Amlodipine-valsartan-HCTZ
5-160-12.5 mg tablet
30
90
Amlodipine-valsartan-HCTZ
5-160-25 mg tablet
30
90
Amlodipine-valsartan-HCTZ
10-160-12.5 mg tablet
30
90
Amlodipine-valsartan-HCTZ
10-160-25 mg tablet
30
90
Amlodipine-valsartan-HCTZ
10-320-25 mg tablet
30
90
Ampyra ER
10 mg tablet
60
60
Amturnide
30
90
30
90
30
90
30
90
30
90
Androderm
150 mg/5 mg/12.5 mg
tablet
300 mg/10 mg/12.5 mg
tablet
300 mg/10 mg/25 mg
tablet
300 mg/5 mg/12.5 mg
tablet
300 mg/5 mg/25 mg
tablet
2 mg/day
30 systems
90 systems
Androderm
2.5 mg/day
90 systems
270 systems
Androderm
4 mg/day
30 systems
90 systems
Androderm
5 mg/day
30 systems
90 systems
AndroGel
1% (2.5 g) packet
[25 mg/2.5 g]
1% (5 g) packet
[50 mg/5 g]
1.62% (1.25 g) packet
[20.25 mg/1.25 g]
1.62% (2.5 g) packet
[40.5 mg/2.5 g]
12.5 mg (1%) per
actuation
20.25 mg (1.62%) per
actuation
62.5/25 mcg powder
capsule
75 g (30 packets)
150 g (60
packets)
150 g (2 pumps)
225 g (90
packets)
900 g (180
packets)
113 g (90
packets)
450 g (180
packets)
450 g (6 pumps)
150 g (2 pumps)
450 g (6 pumps)
1 pkg
(14 or 60)
3 pkgs
(42 or 180)
Amturnide
Amturnide
Amturnide
Amturnide
AndroGel
AndroGel
AndroGel
AndroGel Pump
Androgel Pump
Anoro Ellipta
04HQ3923 R12/15
300 g (60
packets)
38 g (30 packets)
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 5 of 54
Anzemet
50 mg tablet
4
12
Anzemet
100 mg tablet
4
12
Aplenzin
174 mg tablet
30
90
Aplenzin
348 mg tablet
30
90
Aplenzin
522 mg tablet
30
90
Aptiom
200 mg tablet
30
90
Aptiom
400 mg tablet
30
90
Aptiom
600 mg tablet
60
180
Aptiom
800 mg tablet
30
90
Aranesp
500 mcg/1 mL
1 Vial (1 pack)
1 Vial (1 pack)
Aranesp
300 mcg/1 mL
Aranesp
200 mcg/1 mL
Aranesp
150 mcg/0.75 mL
Aranesp
100 mcg/1 mL
Aranesp
60 mcg/1 mL
4 Vials
(4 Packs)
4 Vials
(4 Packs)
4 Vials
(1 Pack)
4 Vials
(1 Pack)
8 Vials
(2 Packs)
4 Vials
(4 Packs)
4 Vials
(4 Packs)
4 Vials
(1 Pack)
4 Vials
(1 Pack)
8 Vials
(2 Packs)
Aranesp
40 mcg/1 mL
Aranesp
25 mcg/1 mL
Arava
20 mg tablet
8 Vials
(2 Packs)
8 Vials
(2 Packs)
30
8 Vials
(2 Packs)
8 Vials
(2 Packs)
90
Arava
10 mg tablet
30
90
Arcalyst
Carton (4 vials)
1 carton
1 carton
Arcapta
75 mcg capsules
30
90
Aricept
10 mg tablet
30
90
Aricept
5 mg tablet
30
90
Aricept
23 mg tablet
30
90
Aricept ODT
10 mg tablet
30
90
Aricept ODT
5 mg tablet
30
90
Aripiprazole ODT
10 mg tab
60
180
Aripiprazole ODT
15 mg tab
60
180
Asmanex
110 mcg twisthaler #30
1 device
3 devices
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 6 of 54
Asmanex
1 device
3 devices
Asmanex
220 mcg twisthaler
#120
220 mcg twisthaler #60
1 device
3 devices
Asmanex
220 mcg twisthaler #30
1 device
3 devices
Asmanex
220 mcg twisthaler #14
1 device
3 devices
Astelin
137 mcg nasal spray
2 devices
6 devices
Astepro
0.15% nasal spray
2 devices
6 devices
Astepro
137 mcg nasal spray
2 devices
6 devices
Atacand
32 mg tablet
30
90
Atacand
16 mg tablet
60
180
Atacand
8 mg tablet
30
90
Atacand
4 mg tablet
30
90
Atelvia
35 mg tablet
4
12
atenolol
25 mg tablet
60
180
atenolol
50 mg tablet
60
180
atenolol
100 mg tablet
60
180
atorvastatin
10 mg tablet
30
90
atorvastatin
20 mg tablet
30
90
atorvastatin
40 mg tablet
30
90
atorvastatin
80 mg tablet
30
90
Atrovent
Aerosol
2
6
Atrovent HFA
Aerosol
2
6
Aubagio
7 mg tablet
28
84
Aubagio
14 mg tablet
28
28
Avandamet
1 mg/500 mg tablet
60
180
Avandamet
2 mg/500 mg tablet
60
180
Avandamet
4 mg/500 mg tablet
60
180
Avandamet
2 mg/1000 mg tablet
60
180
Avandamet
4 mg/1000 mg tablet
60
180
Avandaryl
8 mg/4 mg tablet
30
90
Avandaryl
8 mg/2 mg tablet
30
90
Avandaryl
4mg/4mg tablet
30
90
Avandaryl
4 mg/2 mg tablet
60
180
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 7 of 54
Avandaryl
4 mg/1 mg tablet
60
180
Avandia
8 mg tablet
30
90
Avandia
4 mg tablet
60
180
Avandia
2 mg tablet
60
180
Avapro
300 mg tablet
30
90
Avapro
150 mg tablet
30
90
Avapro
75 mg tablet
30
90
Avodart
0.5 mg capsule
30
90
Avonex
4 vials
4 vials
4 syringes
4 syringes
Avonex
Admin Pack (30 mcg
vial) as 4 vials per kit
Admin Pack (30 mcg
syringe) as 4 syringes
per kit
30 mcg pen
4 pens
4 pens
Axert
6.25 mg tablet
12
36
Axert
12.5 mg tablet
12
36
Axiron
2 pumps (180
mL)
6 pumps (540
mL)
Azelastine
90 mL metered dose
pump-(30
mg/actuation)
(1.5 mL/pump)
137 mcg nasal spray
2 devices
6 devices
Azelastine
0.15% nasal spray
60 mL(2 bottles)
180 mL(6 bottles)
Azmacort
20 g aerosol
2 (40 g)
6 (120 g)
Beconase AQ
25 g spray
2 (50 g)
6 (100 g)
Belsomra
5 mg tablet
21
63
Belsomra
10 mg tablet
21
63
Belsomra
15 mg tablet
21
63
Belsomra
20 mg tablet
21
63
benazepril
40 mg tablet
60
180
benazepril
20 mg tablet
60
180
benazepril
10 mg tablet
60
180
benazepril
5 mg tablet
60
180
Benicar
5 mg tab
60
180
Benicar
20 mg tab
30
90
Benicar
40 mg tab
30
90
Avonex
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 8 of 54
Benicar HCT
20-12.5 mg tablet
30
90
Benicar HCT
40-12.5 mg tablet
30
90
Benicar HCT
40-25 mg tablet
30
90
Betaseron
14
14
4 tablets
12 tablets
Boniva
0.25 mg vial (0.3 mg or
9.6 mu per vial)
70 mg tablet (blister
pack of 4 tablets)
2.5 mg tablet
30
90
Boniva
150 mg tablet
1
3
Boniva Injection
3 mg syringe
1
1
Bosulif
100 mg tablet
30
30
Bosulif
500 mg tablet
30
30
Breo Ellipta
200-25 mcg blisters
Brilinta
60 mg tablet
1 pkg (60
capsules)
60
3 pkg (180
capsules)
180
Brilinta
90 mg tablet
60
180
Brisdelle
7.5 mg capsule
30
90
Brovana Inhalation Solution
15 mcg/2 mL
60 respules
180 respules
budeprionSR
100 mg tablet
60
180
budeprionSR
150 mg tablet
60
180
budeprionXL
150 mg tablet
90
270
budeprionXL
300 mg tablet
30
90
budesonide
0.25 mg/2 mL respule
60 respules
180 respules
budesonide
0.5 mg/2 mL respule
60 respules
180 respules
budesonide
1 mg/2 mL respule
30 respules
90 respules
Budesonide
32 mcg nasal spray
18 g (2 bottles)
52 g (6 bottles)
Buproban
150 mg tablet
60
180
bupropionER
100 mg tablet
60
180
bupropionER
200 mg tablet
60
180
bupropionSR
100 mg tablet
60
180
bupropionSR
150 mg tablet
60
180
bupropionSR
200 mg tablet
60
180
Bupropion XL
150 mg tablet
90
270
Bupropion XL
300 mg tablet
30
90
Binosto
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 9 of 54
Butisol
50 mg tablet
21
63
Butisol
30 mg tablet
21
63
butorphanol
2 devices
6 devices
Butrans
10 mg/mL nasal spray
(2.5 mL device)
5 mcg/hr patch
4 patches
12 patches
Butrans
7.5 mcg/hr patch
4 patches
12 patches
Butrans
10 mcg/hr patch
4 patches
12 patches
Butrans
15 mcg/hr patch
4 patches
12 patches
Butrans
20 mcg/hr patch
4 patches
12 patches
Bydureon
2 mg vial
Bydureon Pen
12 single dose
trays
12 pens
Byetta
2 mg/0.65 mL pen
(4 pens per carton)
2.4 mL injection pen
4 single dose
trays
4 pens
2 pens (4.8 mL)
6 pens (14.4 mL)
Byetta
1.2 mL injection pen
2 pens (2.4 mL)
6 pens (7.2 mL)
Caduet
2.5/10 mg tablet
30
90
Caduet
2.5/20 mg tablet
30
90
Caduet
2.5/40 mg tablet
30
90
Caduet
5/10 mg tablet
30
90
Caduet
5/20 mg tablet
30
90
Caduet
5/40 mg tablet
30
90
Caduet
5/80 mg tablet
30
90
Caduet
10/10 mg tablet
30
90
Caduet
10/20 mg tablet
30
90
Caduet
10/40 mg tablet
30
90
Caduet
10/80 mg tablet
30
90
calcitonin-salmon
1 (3.7 mLs)
3 (11.1 mLs)
CaloMist
Nasal Spray 200 units
(3.7 mL bottle)
nasal spray
1 bottle (18 mL)
3 bottles (54 mL)
CaloMist
nasal spray
Cambia
50 mg powder packets
2 bottles (10.7
mL)
4 packets
6 bottles (10.7
mL)
12 packets
Candesartan
4 mg tablets
30
90
Candesartan
8 mg tablets
30
90
Candesartan
16 mg tablets
30
90
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 10 of 54
Candesartan
32 mg tablets
30
90
Camrese
1 pack (91
tablets)
1 pack (91
tablets)
Camrese Lo
0.15 mg levonorgestrel/
0.03 mg & 0.01 mg
ethinyl estradiol
0.1-0.02-0.01 mg
Capoten
100 mg tablet
1 pack (91
tablets)
90
1 pack (91
tablets)
270
Capoten
50 mg tablet
90
270
Capoten
25 mg tablet
90
270
Capoten
12.5 mg tablet
90
270
Caprelsa
100 mg
60
60
Caprelsa
300 mg
30
30
Captopril
100 mg tablet
90
270
Captopril
50 mg tablet
90
270
Captopril
25 mg tablet
90
270
Captopril
12.5 mg tablet
90
270
Cardura
8 mg tablet
60
180
Cardura
4 mg tablet
60
180
Cardura
2 mg tablet
60
180
Cardura
1 mg tablet
60
180
Cardura XL
4 mg tablet
30
90
Cardura XL
8 mg tablet
30
90
carisoprodol
250 mg
120
360
carisoprodol
350 mg
120
360
Catapres-TTS
transdermal patch
4 systems
12 systems
Caverject
10 mcg (vial or system)
8
24
Caverject
20 mcg (vial or system)
8
24
Caverject
40 mcg (vial)
8
24
Celebrex
50 mg capsule
60
180
Celebrex
100 mg capsule
60
180
Celebrex
200 mg capsule
60
180
Celebrex
400 mg capsule
60
180
Celecoxib
50 mg capsule
60
180
Celecoxib
100 mg capsule
60
180
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 11 of 54
Celecoxib
200 mg capsule
60
180
Celecoxib
400 mg capsule
60
180
Celexa
20 mg tablet
30
90
Celexa
40 mg tablet
30
90
Celexa
10 mg tablet
30
90
Cesamet
1 mg capsule
15
45
Cialis†
5 mg tablets
30
90
cilostazol
100 mg tablet
60
180
cilostazol
50 mg tablet
60
180
Cimzia
1 Kit (contains 200 mg)
1 Kit
1 Kit
Cimzia
1 Kit (contains 400 mg)
1 Kit
1 Kit
Cinryze
500 units vial
20 vials
20 vials
citalopram
20 mg tablet
30
90
citalopram
40 mg tablet
30
90
citalopram
10 mg tablet
30
90
Clarinex
5 mg tablet
30
90
Clarinex-D 24 Hours
5 mg/240 mg tablet
30
90
Clarinex-D 12 Hours
2.5 mg/120 mg tablet
60
180
Clarinex Reditabs
5 mg tablet
30
90
Climara
0.025 mg/day
4 systems
12 systems
Climara
0.0375 mg/day
4 systems
12 systems
Climara
0.05 mg/day
4 systems
12 systems
Climara
0.06 mg/day
4 systems
12 systems
Climara
0.075 mg/day
4 systems
12 systems
Climara
0.1 mg/day
4 systems
12 systems
Climara Pro
transdermal patch
4 systems
12 systems
clonidine day patch
0.1 mg/day patch
4 systems
12 systems
clonidine day patch
0.2 mg/day patch
4 systems
12 systems
clonidine day patch
0.3 mg/day patch
4 systems
12 systems
clopidogrel
75 mg tablet
34
102
clopidogrel
300 mg tablet
1
1
CombiPatch
0.05 mg estradiol/
0.14 mg norethrindone
8 systems
24 systems
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 12 of 54
(9 cm2)
CombiPatch
0.05 mg estradiol/
0.25 mg norethrindone
(16 cm2)
14.7g aerosol
8 systems
24 systems
2 (30 g)
6 (89 g)
2 inhalers
6 inhalers
Cometriq
20 mcg ipratropium/
100 mcg albuterol
60 mg daily-dose pack
1 pack
1 pack
Cometriq
100 mg daily-dose pack 1 pack
1 pack
Cometriq
140 mg daily-dose pack 1 pack
1 pack
Copaxone
20 mg vial
Copaxone
40 mg/mL
Copegus
200 mg tablet
1 Pack (30
syringes)
1 pack (12
syringes)
180
1 Pack (30
syringes)
1 pack (12
syringes)
180
Cozaar
100 mg tablet
30
90
Cozaar
50 mg tablet
60
180
Cozaar
25 mg tablet
60
180
Crestor
40 mg tablet
30
90
Crestor
20 mg tablet
30
90
Crestor
10 mg tablet
30
90
Crestor
5 mg tablet
30
90
Cymbalta
20 mg capsule
60
180
Cymbalta
30 mg capsule
60
180
Cymbalta
60 mg capsule
30
90
Cystadane
180 g bottle
1 bottle
1 bottle
Daklinza
30 mg tablet
28**
28**
Daklinza
60 mg tablet
28**
28**
Dalmane
30 mg capsule
21
63
Dalmane
15 mg capsule
21
63
Daysee
0.15-0.03-0.01 mg
Daytrana
30 mg/9 hr patch
1 pack (91
tablets)
30
1 pack (91
tablets)
90
Daytrana
20 mg/9 hr patch
30
90
Daytrana
15 mg/9 hr patch
30
90
Daytrana
10 mg/9 hr patch
30
90
Combivent
Combivent Respimat
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 13 of 54
Depo-Provera
150 mg syringe/vial
1
1
Depo-SubQ Provera
104 mg syringe
1 syringe
1 syringe
Desloratadine ODT
2.5 mg tablets
30
90
Desloratadine ODT
5 mg tablets
30
90
desloratadine
5 mg tablet
30
90
Desvenlafaxine fumarate ER
50 mg tablet
30
90
Desvenlafaxine fumarate ER
100 mg tablet
30
90
Detrol
1 mg tablet
60
180
Detrol
2 mg tablet
60
180
Detrol LA
2 mg capsule
30
90
Detrol LA
4 mg capsule
30
90
Dexilant DR
30 mg capsule
30
90
Dexilant DR
60 mg capsule
30
90
Diclofenac, transdermal
1.5% topical solution
150 mL
450 mL
Dificid
200 mg tablet
20
20
Diflucan
150 mg tablet
2
6
Diovan
320 mg tablet
30
90
Diovan
160 mg tablet/caps
60
180
Diovan
80 mg tablet/caps
60
180
Diovan
40 mg tablet
60
180
Ditropan XL
5 mg tablet
30
90
Ditropan XL
10 mg tablet
60
180
Ditropan XL
15 mg tablet
60
180
Divigel
0.25 mg packet
30
90
Divigel
0.50 mg packet
30
90
Divigel
1 mg packet
30
90
donepezil
5 mg tablet
30
90
donepezil
10 mg tablet
30
90
donepezil
23 mg tablet
30
90
donepezil ODT
10 mg tablet
30
90
donepezil ODT
5 mg tablet
30
90
Doral
7.5 mg tablet
21
63
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 14 of 54
Doral
15 mg tablet
21
63
doxazosin
8 mg tablet
60
180
doxazosin
4 mg tablet
60
180
doxazosin
2 mg tablet
60
180
doxazosin
1 mg tablet
60
180
Duetact
30 mg/4 mg tablet
30
90
Duetact
30 mg/2 mg tablet
30
90
Duexis
800-26.6 mg tablet
90
270
Dulera
100 mcg/5 mcg inhaler
Dulera
200 mcg/5 mcg inhaler
Duloxetine
20 mg capsule
1 inhaler (13
grams)
1 inhaler (13
grams)
60
3 inhalers (39
grams)
3 inhalers (39
grams)
180
Duloxetine
30 mg capsule
60
180
Duloxetine
40 mg capsule
30
90
Duloxetine
60 mg capsule
30
90
Durlaza
162.5 mg capsule
30
90
Dutasteride
0.5 mg capsule
30
90
Dutasteride-Tamsulosin
0.5/0.4mg tablet
30
90
Dutoprol
25-12.5 mg tablet
30
90
Dutoprol
50-12.5 mg tablet
30
90
Dutoprol
100-12.5 mg tablet
60
180
Dymista
Edarbi
137 mcg/50 mcg
inhaler
40 mg tablet
1 inhaler (23
grams)
30
3 inhalers (69
grams)
90
Edarbi
80 mg tablet
30
90
Edarbyclor
40-12.5 mg tablet
30
90
Edarbyclor
40-25 mg tablet
30
90
Edex
5 mcg vial
8
24
Edex
10 mcg vial
8
24
Edex
20 mcg vial
8
24
Edex
40 mcg vial
8
24
Edluar SL
5 mg tablet
21
63
Edluar SL
10 mg tablet
21
63
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 15 of 54
Effexor
25 mg
90
270
Effexor
37.5 mg
90
270
Effexor
50 mg
90
270
Effexor
75 mg
90
270
Effexor
100 mg
90
270
Effexor XR
37.5 mg
30
90
Effexor XR
75 mg
90
270
Effexor XR
150 mg
30
90
Effient
5 mg
35
105
Effient
10 mg
30
90
Elestrin
1 pump
3 pumps
Eliquis
0.06% gel
1 pump = 26 g
2.5 mg tablet
60
180
Eliquis
5 mg tablet
60
180
Ella
30 mg tablet
1 tablet
not available
Emend
125 mg capsule
2
4
Emend
80 mg capsule
4
8
Emend
40 mg capsule
1
3
Emend
2 packs
6 packs
Emsam
Tri-fold pack containing
one 125 mg capsule
and two 80 mg
capsules
12 mg/24 hours patch
30
90
Emsam
9 mg/24 hours patch
30
90
Emsam
6 mg/24 hours patch
30
90
Enablex
15 mg tablet
30
90
Enablex
7.5 mg tablet
30
90
enalapril
20 mg tablet
60
180
enalapril
10 mg tablet
60
180
enalapril
5 mg tablet
60
180
enalapril
2.5 mg tablet
60
180
Enbrel
25 mg syringe/vial
8**
8**
Enbrel
50 mg syringe
4**
4**
Epogen
2000 u/mL vial (10 vials 12 vials
per carton)
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 16 of 54
12 vials
Epogen
12 vials
12 vials
12 vials
12 vials
12 vials
12 vials
4 vials
4 vials
6 vials
6 vials
6 vials
6 vials
eprosartan mesylate
3000 u/mL vial (10 vials
per carton)
4000 u/mL vial (10 vials
per carton)
10,000 u/mL vial (10
vials per carton)
40,000 u/mL vial (10
vials per carton)
10,000 u/mL MDV
(2mL MDV-10 vials per
carton)
20,000 u/mL MDV
(1mL MDV- 10 vials per
carton)
600 mg tablet
30
90
Erivedge
150 mg capsules
30
30
escitalopram
5 mg tablet
30
90
escitalopram
10 mg tablet
30
90
escitalopram
20 mg tablet
30
90
Esclim
0.025 mg/day
8 systems
24 systems
Esclim
0.0375 mg/day
8 systems
24 systems
Esclim
0.05 mg/day
8 systems
24 systems
Esclim
0.075 mg/day
8 systems
24 systems
Esclim
0.1 mg/day
8 systems
24 systems
esomeprazole strontium
24.65 mg capsule
30
90
esomeprazole strontium
49.3 mg capsule
60
180
estazolam
2 mg tablet
21
63
estazolam
1 mg tablet
21
63
Estraderm
0.05 mg/day
8 systems
24 systems
Estraderm
0.1 mg/day
8 systems
24 systems
Estradiol TDS
0.025 mg/day
4 systems
12 systems
Estradiol TDS
0.0375 mg/day
4 systems
12 systems
Estradiol TDS
0.05 mg/day
4 systems
12 systems
Estradiol TDS
0.06 mg/day
4 systems
12 systems
Estradiol TDS
0.075 mg/day
4 systems
12 systems
Estradiol TDS
0.1 mg/day
4 systems
12 systems
Estrasorb
1.74 g/pouch
60 pouches
180 pouches
Epogen
Epogen
Epogen
Epogen
Epogen
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 17 of 54
Estring
1 ring/90 days
1 ring/90 days
1 pump
3 pumps
Eszopiclone
(estradiol vaginal ring)
2 mg vaginal ring
Metered dose pump1.25 g/dose (50 g)
1 mg tablet
21
63
Eszopiclone
2 mg tablet
21
63
Eszopiclone
3 mg tablet
21
63
Evamist
2 pumps
6 pumps
Evista
Metered dose pump 8.1 mL
60 mg tablet
30
90
Exelon
6 mg capsule
60
180
Exelon
4.5 mg capsule
60
180
Exelon
3 mg capsule
60
180
Exelon
1.5 mg capsule
60
180
Exelon
4.6 mg/24 hr patch
30
90
Exelon
9.5 mg/24 hr patch
30
90
Exelon
13.3 mg/24 hr patch
30
90
Exforge
10/320 mg tablet
30
90
Exforge
10/160 mg tablet
30
90
Exforge
5/320 mg tablet
30
90
Exforge
5/160 mg tablet
30
90
Exforge HCT
10/160/12.5 mg tablet
30
90
Exforge HCT
10/160/25 mg tablet
30
90
Exforge HCT
10/320/25 mg tablet
30
90
Exforge HCT
5/160/12.5 mg tablet
30
90
Exforge HCT
5/160/25 mg tablet
30
90
Extavia
1 Kit (contains 0.3 mg)
15 Kits
15 Kits
famciclovir
500 mg tablet
30
30
famciclovir
250 mg tablet
60
180
famciclovir
125 mg tablet
60
180
Famvir
500 mg tablet
30
30
Famvir
250 mg tablet
60
180
Famvir
125 mg tablet
60
180
Farxiga
5 mg tablet
30
90
EstroGel
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 18 of 54
Farxiga
10 mg tablet
30
90
Femring (estradiol acetate
vaginal ring)
Femring (estradiol acetate
vaginal ring)
fentanyl (oral transmucosal)
1 ring/90 days
1 ring/90 days
1 ring/90 days
1 ring/90 days
90*
270*
112*
336*
fexofenadine
0.05 mg/day vaginal
ring
0.10 mg/day vaginal
ring
all strengths/dosage
forms
all strengths/dosage
forms
30 mg tablet
60
180
fexofenadine
60 mg tablet
60
180
fexofenadine
180 mg tablet
30
90
fexofenadine/pseudoephedrine 60/120 mg tablet
60
120
fexofenadine/pseudoephedrine 180/240 mg tablet
30
90
finasteride
5 mg tablet
30
90
Firazyr
30 mg syringe
3 syringes
3 syringes
Firmagon
80 mg vial
1 vial
1 vial
Firmagon
2 x 120 mg vials
1 kit
1 kit
First-Lansoprazole Susp
3mg/mL
First-Lansoprazole Susp
3mg/mL
First-Lansoprazole Susp
3mg/mL
First-Omeprazole Susp
2mg/mL
First-Omeprazole Susp
2mg/mL
First-Omeprazole Susp
2mg/mL
Flector
90 mL bottle
4 bottles
12 bottles
150 mL bottle
2 bottles
6 bottles
300 mL bottle
1 bottle
3 bottles
90 mL bottle
7 bottles
21 bottles
150 mL bottle
4 bottles
12 bottles
300 mL bottle
2 bottle
6 bottles
Flomax
Patch (box of 30
patches)
0.4 mg capsule
1 box (30
patches)
60
1 box (30
patches)
180
Flonase
16 g nasal spray
1 (16 g)
3 (48 g)
Flovent
13 g aerosol
2 (26 g)
6 (78 g)
Flovent
50 mcg diskus
1 (60 blisters)
3 (180 blisters)
Flovent
100 mcg diskus
1 (60 blisters)
3 (180 blisters)
Flovent
250 mcg diskus
4 (240 blisters)
3 (720 blisters)
Flovent HFA
10.6 g aerosol (44 mcg) 2 (21.2 g)
Fentora
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 19 of 54
6 (63.6 g)
Flovent HFA
12 g aerosol (110 mcg)
1 (12 g)
3 (36 g)
Flovent HFA
12 g aerosol (220 mcg)
3 (36 g)
9 (108 g)
Flovent Rotadisk
Powder
fluconazole
150 mg tablet
240 doses
(16 blisters)
3
720 doses
(48 blisters)
9
flunisolide
25 mL nasal spray
3 (75 mL)
9 (225 mL)
fluoxetine
10 mg capsule, tablet
90
270
fluoxetine
20 mg capsule
120
360
fluoxetine
40 mg capsule
60
180
fluoxetine
60 mg tablet
30
90
fluoxetine DR
90 mg capsule
4
12
flurazepam
30 mg capsule
21
63
flurazepam
15 mg capsule
21
63
fluticasone
16 g nasal spray
1 (16 g)
3 (48 g)
Fluvastatin
20 mg capsule
30
90
Fluvastatin
40 mg capsule
60
180
Fluvastatin ER
80 mg
30
90
Fluvoxamine ER
100 mg capsule
60
180
Fluvoxamine ER
150 mg capsule
60
180
fluvoxamine
100 mg tablet
90
270
fluvoxamine
50 mg tablet
90
270
fluvoxamine
25 mg tablet
90
270
Foradil Aerolizer
Inhalation Powder
(1 device with 60
blisters;12 mcg/inh)
600 mcg/2.4 mL
prefilled injection pen
10 mg gel pump
1 (60 blisters)
3 (180 blisters)
1 injection pen
1 injection pen
4 pumps
4 pumps
1 (3.7 mLs)
3 (11.1 mLs)
Fosamax
Nasal Spray 200 units
(3.7 mL bottle)
40 mg tablet
30
90
Fosamax
10 mg tablet
30
90
Fosamax
5 mg tablet
30
90
Fosamax
70 mg tablet (blister
pack of 4 tablets)
35 mg tablet (blister
4 tablets
12 tablets
4 tablets
12 tablets
Forteo
Fortesta
Fortical
Fosamax
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 20 of 54
pack of 4 tablets)
Fosamax
1 box
mLs)
Fosamax Plus D
70 mg oral solution (1
box contains 4-75mL
bottles)
35 mg-2,800 IU tablet
4 tablets
12 tablets
Fosamax Plus D
70 mg-2,800 IU tablet
4 tablets
12 tablets
Fosamax Plus D
70 mg-5,600 IU tablet
4 tablets
12 tablets
fosinopril
40 mg tablet
60
180
fosinopril
20 mg tablet
60
180
fosinopril
10 mg tablet
60
180
Frova
2.5 mg tablet
9
27
furosemide
20 mg tablet
90
270
furosemide
40 mg tablet
90
270
furosemide
80 mg tablet
90
270
galantamine
4 mg tablet
60
180
galantamine
8 mg tablet
60
180
galantamine
12 mg tablet
60
180
galantamine ER
8 mg capsule
30
90
galantamine ER
16 mg capsule
30
90
galantamine ER
24 mg capsule
30
90
Gelnique
10% (1 g/sachet)
30 sachets
90 sachets
Gelnique
3% gel
1 Pump
3 Pumps
Geodon
20 mg capsule
60
180
Geodon
40 mg capsule
60
180
Geodon
60 mg capsule
60
180
Geodon
80 mg capsule
60
180
Gilenya
0.5 mg tablet
30
30
glipizide
5 mg tablet
90
270
glipizide
10 mg tablet
120
360
glipizide er
2.5 mg tablet
90
270
glipizide er
5 mg tablet
90
270
glipizide er
10 mg tablet
90
270
glipizide xl
2.5 mg tablet
90
270
04HQ3923 R12/15
(300
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 21 of 54
3 boxes (900
mLs)
glipizide xl
5 mg tablet
90
270
glipizide xl
10 mg tablet
90
270
glipizide/metformin
5 mg/500 mg tablet
120
360
glipizide/metformin
2.5 mg/500 mg tablet
120
360
glipizide/metformin
2.5 mg/250 mg tablet
60
180
Glucovance
1.25 mg/250 mg tablet
60
180
Glucovance
2.5 mg/500 mg tablet
120
360
Glucovance
5 mg/500 mg tablet
120
360
glyburide/metformin
1.25 mg/250 mg tablet
60
180
glyburide/metformin
2.5 mg/500 mg tablet
120
360
glyburide/metformin
5 mg/500 mg tablet
120
360
Glyxambi
10 mg /5 mg
30
90
Glyxambi
25 mg /5 mg
30
90
Gralise
300 mg tablets
90
270
Gralise
600 mg tablets
90
270
Gralise Starter Pack
1 starter pack
1 starter pack
granisetron
300 mg and 600 mg
tablets
1 mg tablet
8
24
Guanfacine ER
1 mg tablet
30
90
Guanfacine ER
2 mg tablet
30
90
Guanfacine ER
3 mg tablet
30
90
Guanfacine ER
4 mg tablet
30
90
Halcion
0.25 mg tablet
21
63
Halcion
0.125 mg tablet
21
63
Harvoni
90-400 mg tablet
28**
28**
Hetlioz
20 mg capsule
30
30
Horizant
600 mg
60
180
Humira
10 mg/0.2 mL syringe
2 syringes**
2 syringes**
Humira
40 mg (0.8 mL) syringe
2 syringes**
2 syringes**
Humira
40 mg (0.8 mL) pen
2 pens**
2 pens**
Humira
20 mg (0.4 mL) syringe
2 syringes**
2 syringes**
Humira
Crohn's Start Pack
1 pack
1 pack
Humira
psoriasis start pack
1 pack
1 pack
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 22 of 54
hydrochlorothiazide
12.5 mg tablet/capsule
90
270
hydrochlorothiazide
25 mg tablet/capsule
90
270
hydrochlorothiazide
50 mg tablet/capsule
90
270
Hylira
1000 g hydrating lotion
1 bottle
3 bottles
Hytrin
10 mg capsule
60
180
Hytrin
5 mg capsule
60
180
Hytrin
2 mg capsule
60
180
Hytrin
1 mg capsule
60
180
Hysingla ER
20 mg tablet
30
90
Hysingla ER
30 mg tablet
30
90
Hysingla ER
40 mg tablet
30
90
Hysingla ER
60 mg tablet
30
90
Hysingla ER
80 mg tablet
30
90
Hysingla ER
100 mg tablet
30
90
Hysingla ER
120 mg tablet
30
90
Ibandronate
150 mg tablet
1
3
Iclusig
15 mg tablet
60
60
Iclusig
45 mg tablet
30
30
Ilaris
180 mg vial
1 syringe
1 syringe
Imitrex Inj
6 mg syringe, refill kit
Imitrex Inj
Imitrex NS
4 mg syringe, vial refill
kit
5 mg NS device
6 syringes (3 kits) 18 syringes (9
kits)
6 syringes/ vials
18 syringes/ vials
(3 kits)
(9 kits)
6 devices
18 devices
Imitrex NS
20 mg NS device
6 devices
18 devices
Imitrex Tablet
25 mg tablet
9
27
Imitrex Tablet
50 mg tablet
9
27
Imitrex Tablet
100 mg tablet
9
27
Incivek
375 mg tablet
180
180
Infergen
12 vials (6 mL)
12 vials (6 mL)
Infergen
15 mcg vial (0.5 mL
vial)
9 mcg vial (0.3 mL vial)
12 vials (4mL)
12 vials (4mL)
Inlyta
1 mg tablet
60
60
Inlyta
5 mg tablet
60
60
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 23 of 54
Intal
8.1 g aerosol
2 (17 g)
6 (33 g)
Intal
14.2 g aerosol
2 (29 g)
6 (57 g)
Intermezzo
1.75 mg tablet
21
63
Intermezzo
3.5 mg tablet
21
63
Introvale
0.15-0.03 mg tablet
Intuniv ER
1 pack (91
tablets)
90
Invega
all strengths/dosage
forms
1.5 mg tablet
1 pack (91
tablets)
30
30
90
Invega
3 mg tablet
30
90
Invega
6 mg tablet
60
180
Invega
9 mg tablet
30
90
Invega Sustenna
39 mg vial
1 vial
Invega Sustenna
78 mg vial
Invega Sustenna
117 mg vial
Invega Sustenna
156 mg vial
Invega Sustenna
234 mg vial
Invokana
100 mg tablet
1 pack (contains
1 vial)
1 pack (contains
1 vial)
1 pack (contains
1 vial)
1 pack (contains
1 vial)
1 pack (contains
1 vial)
30
Invokana
300 mg tablet
30
90
Invokamet
50-500 mg tablet
60
180
Invokamet
50-1,000 mg tablet
60
180
Invokamet
150-500 mg tablet
60
180
Invokamet
150-1,000 mg tablet
60
180
Ipratropium-albuterol nebs
0.5-2.5 mg/3 mL
irbesartan
75 mg tablet
180 vials (540
mL)
30
540 vials (1,620
mL)
90
irbesartan
150 mg tablet
30
90
irbesartan
300 mg tablet
30
90
Irenka
40 mg capsule
30
90
Iressa
250 mg tablet
30
30
Itraconazole
100 mg capsule
28
84
Jakafi
5 mg tablet
60
60
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 24 of 54
1 vial
1 vial
1 vial
1 vial
90
Jakafi
10 mg tablet
60
60
Jakafi
15 mg tablet
60
60
Jakafi
20 mg tablet
60
60
Jakafi
25 mg tablet
60
60
Jalyn
0.5/0.4mg tablet
30
90
Janumet
50/500 mg tablet
60
180
Janumet
50/1000 mg tablet
60
180
Janumet XR
30
90
60
180
30
90
Januvia
50 mg sitagliptin/500
mg metformin tablet
50 mg sitagliptin/ 1000
mg metformin tablet
100 mg sitagliptin/
1000 mg metformin
tablet
25 mg tablet
30
90
Januvia
50 mg tablet
30
90
Januvia
100 mg tablet
30
90
Jardiance
10 mg tablet
30
90
Jardiance
25 mg tablet
30
90
Jentadueto
60
180
60
180
60
180
Jublia
2.5 mg linagliptin/
500 mg metformin
tablet
2.5 mg linagliptin/
850 mg metformin
tablet
2.5 mg linagliptin/
1000 mg metformin
tablet
10% topical solution
1 bottle
3 bottles
Jolessa
0.15 mg/0.03 mg tablet
Juxtapid
5 mg capsule
1 pack (91
tablets)
28
1 pack (91
tablets)
28
Juxtapid
10 mg capsule
28
28
Juxtapid
20 mg capsule
84
84
Juvisync
50 mg/10 mg
30
90
Juvisync
50 mg/20 mg
30
90
Juvisync
50 mg/40 mg
30
90
Juvisync
100 mg/10 mg
30
90
Janumet XR
Janumet XR
Jentadueto
Jentadueto
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 25 of 54
Juvisync
100 mg/20 mg
30
90
Juvisync
100 mg/40 mg
30
90
Kalydeco
150 mg tablets
60
60
Kalydeco
50 mg granule pack
60
60
Kalydeco
75 mg granule pack
60
60
Kazano
12.5-1,000 mg tablet
60
180
Kazano
12.5-500 mg tablet
60
180
Kapidex
30 mg capsule
30
90
Kapidex
60 mg capsule
30
90
Kerydin
5% topical solution
10 mL
30 mL
ketorolac
10 mg tablet
20
60
Keveyis
50 mg tablet
120
120
Kineret
100 mg syringe
30
30
Kombiglyze XR
5/500 mg tablet
30
90
Kombiglyze XR
5/1000 mg tablet
30
90
Kombiglyze XR
2.5/1000 mg tablet
60
90
Korlym
300 mg tablet
60
60
Kytril
1 mg tablet
8
24
Kytril
2 mg/mL oral solution
40 mL
120 mL
Lamisil
250 mg tablet
30
90
Lamisil
60
180
30
90
lansoprazole
125 mg granules
packet
187.5 mg granules
packet
15 mg capsule
30
90
lansoparzole
30 mg capsule
30
90
lansoprazole ODT
15 mg tablet
30
90
lansoprazole ODT
30 mg tablet
30
90
Latuda
20 mg tablet
30
90
Latuda
40 mg tablet
30
90
Latuda
60 mg tablet
30
90
Latuda
80 mg tablet
30
90
Latuda
120 mg tablet
30
90
Lazanda Nasal Spray
all strengths
23 Bottles*
69 Bottles*
Lamisil
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 26 of 54
leflunomide
10 mg tablet
30
90
leflunomide
20 mg tablet
30
90
Lescol
20 mg capsule
30
90
Lescol
40 mg capsule
60
180
Lescol
80 mg XL tablet
30
90
Letairis
10 mg tablet
30
30
Letairis
5 mg tablet
30
30
levocetirizine
5 mg tablet
30
90
levocetirizine solution
2.5 mg/5 mL
300 mL
900 mL
levonorgestrel-Eth Est
0.15-0.03 mg tablet
Lexapro
5 mg tablet
1 pack (91
tablets)
30
1 pack (91
tablets)
90
Lexapro
10 mg tablet
30
90
Lexapro
20 mg tablet
30
90
Linzess
145 mcg capsule
30
90
Linzess
290 mcg capsule
30
90
Lioresal IT
All kit strengths
1 Kit
3 Kits
Lipitor
10 mg tablet
30
90
Lipitor
20 mg tablet
30
90
Lipitor
40 mg tablet
30
90
Lipitor
80 mg tablet
30
90
Liptruzet
10/10 mg tablet
30
90
Liptruzet
10/20 mg tablet
30
90
Liptruzet
10/40 mg tablet
30
90
Liptruzet
10/80 mg tablet
30
90
lisinopril
40 mg tablet
60
180
lisinopril
30 mg tablet
60
180
lisinopril
20 mg tablet
60
180
lisinopril
10 mg tablet
60
180
lisinopril
5 mg tablet
60
180
lisinopril
2.5 mg tablet
60
180
lisinopril/hctz
10 mg/12.5 mg tablet
60
180
lisinopril/hctz
20 mg/12.5 mg tablet
120
360
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 27 of 54
lisinopril/hctz
20 mg/25 mg tablet
120
360
Livalo
1 mg tablet
30
90
Livalo
2 mg tablet
30
90
Livalo
4 mg tablet
30
90
Lorzone
375 mg tablet
120
360
Lorzone
750 mg tablet
120
360
losartan
100 mg tablet
30
90
losartan
50 mg tablet
60
180
losartan
25 mg tablet
60
180
LoSeasonique
0.1-0.02-0.01 mg
Lotensin
40 mg tablet
1 pack (91
tablets)
60
1 pack (91
tablets)
180
Lotensin
20 mg tablet
60
180
Lotensin
10 mg tablet
60
180
Lotensin
5 mg tablet
60
180
Lotronex
1 mg tablet
60
180
Lotronex
0.5 mg tablet
60
180
lovastatin
10 mg tablet
30
90
lovastatin
20 mg tablet
30
90
lovastatin
40 mg tablet
60
180
Lunesta
1 mg
21
63
Lunesta
2 mg
21
63
Lunesta
3 mg
21
63
Luvox CR
100 mg capsule
60
180
Luvox CR
150 mg capsule
60
180
Makena
250 mg/mL (5 mL vial)
1 vial
1 vial
Mavik
4 mg tablet
60
180
Mavik
2 mg tablet
60
180
Mavik
1 mg tablet
60
180
Maxair
25.6 g aerosol
2 (52 g)
6 (153 g)
Maxalt
5 mg tablet
9
27
Maxalt
10 mg tablet
9
27
Maxalt MLT
5 mg tablet
9
27
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 28 of 54
Maxalt MLT
10 mg tablet
9
27
medroxyprogesterone
150 mg injection
1
1
Mekinist
0.5 mg tablet
30
30
Mekinist
2 mg tablet
30
30
meloxicam
7.5 mg tablet
30
90
meloxicam
15 mg tablet
30
90
meloxicam
300 mL
900 mL
Menostar
7.5 mg/5 mL oral
suspension
14 mcg/day patch
4
12
Metaglip
2.5 mg/250 mg tablet
60
180
Metaglip
2.5 mg/500 mg tablet
120
360
Metaglip
5 mg/500 mg tablet
120
360
metformin
500 mg tablet
150
450
metformin
850 mg tablet
90
270
metformin
1000 mg tablet
60
180
metformin ER
500 mg tablet
120
360
metformin ER
750 mg tablet
90
270
metoprolol
25 mg tablet
90
270
metoprolol
50 mg tablet
90
270
metoprolol
100 mg tablet
120
360
Mevacor
10 mg tablet
30
90
Mevacor
20 mg tablet
30
90
Mevacor
40 mg tablet
60
180
Miacalcin
1 (3.7 mL)
3 (11.1 mL)
Micardis
Nasal Spray 220 units
(3.7 mL bottle)
80 mg tablet
30
90
Micardis
40 mg tablet
30
90
Micardis
20 mg tablet
30
90
Migranal NS
8 vials
24 vials
Minipress
1 mL vial contain 4 mg
DHE
5 mg capsule
120
360
Minipress
2 mg capsule
120
360
Minipress
1 mg capsule
90
270
Minivelle
0.025 mg patch
8 systems
24 systems
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 29 of 54
Minivelle
0.0375 mg patch
8 systems
24 systems
Minivelle
0.05 mg patch
8 systems
24 systems
Minivelle
0.075 mg patch
8 systems
24 systems
Minivelle
0.1 mg patch
8 systems
24 systems
mirtazapine
15 mg
30
90
mirtazapine
30 mg
30
90
mirtazapine
45 mg
150
450
Mobic
7.5 mg tablet
30
90
Mobic
15 mg tablet
30
90
Mobic
300 mL
900 mL
moexipril
7.5 mg/5 mL oral
suspension
15 mg tablet
60
180
moexipril
7.5 mg tablet
60
180
Monopril
40 mg tablet
60
180
Monopril
20 mg tablet
60
180
Monopril
10 mg tablet
60
180
montelukast
30
90
montelukast
4 mg chewable tablets
or oral granules
5 mg chewable tablets
30
90
montelukast
10 mg tablets
30
90
Movantik
12.5 mg tablet
30
90
Movantik
25 mg tablet
30
90
MUSE
125 mcg
8
24
MUSE
250 mcg
8
24
MUSE
500 mcg
8
24
MUSE
1000 mcg
8
24
My Way
1.5 mg tablet
1 tablet
Not available
Myrbetriq ER
25 mg tablet
30
90
Myrbetriq ER
50 mg tablet
30
90
Namenda XR
Titration pack
1 Pack
1 Pack
naratriptan
1 mg tablet
9
27
naratriptan
2.5 mg tablet
9
27
Nasacort
10 g inhaler
3 (30 g)
9 (80 g)
Nasacort AQ
16.5 g spray
1 (17 g)
3 (51 g)
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 30 of 54
Nasarel
25 mL spray
3 (75 mL)
9 (225 mL)
Nascobol
Nasal spray
1 device
1 device
Nasonex
17 g spray
2 (34 g)
6 (102 g)
Natesto pump
5.5 mg per actuation
33 g (3 pumps)
99 g (9 pumps)
Natroba
120 mL (2
bottles)
2 syringes
120 mL (2 bottles)
Neulasta
0.9% Topical
Suspension
6 mg syringe
Neumega
5 mg vial for injection
21
21
Neupogen
14 syringes
14 syringes
14 syringes
14 syringes
14 vials
14 vials
14 vials
14 vials
Neupro patch
300 mcg/0.5 mL
syringe
480 mcg/0.8 mL
syringe
300 mcg/mL – 1 mL
vial
480 mcg/mL –1.6 mL
vial
(all strengths)
30 patches
90 patches
Nexium
20 mg capsule
30
90
Nexium
40 mg capsule
30
90
Nexium
2.5 mg packet
30
90
Nexium
5 mg packet
30
90
Nexium
10 mg packet
30
90
Nexium
20 mg packet
30
90
Nexium
40 mg packet
30
90
Next Choice
1.5 mg tablet
1 tablet
not available
Nucynta ER
50 mg tablet
60
180
Nucynta ER
100 mg tablet
60
180
Nucynta ER
150 mg tablet
60
180
Nucynta ER
200 mg tablet
60
180
Nucynta ER
250 mg tablet
60
180
Nuedexta
20 mg/10 mg capsule
60
180
Nuvigil
50 mg tablet
60
180
Nuvigil
150 mg tablet
30
90
Nuvigil
200 mg tablet
30
90
Nuvigil
250 mg tablet
30
90
Neupogen
Neupogen
Neupogen
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 31 of 54
2 syringes
Odomzo
200 mg capsules
30
30
olanzapine
2.5 mg tablet
30
90
olanzapine
5 mg tablet
30
90
olanzapine
7.5 mg tablet
30
90
olanzapine
10 mg tablet
30
90
olanzapine
15 mg tablet
30
90
olanzapine
20 mg tablet
30
90
olanzapine ODT
5 mg tablet
30
90
olanzapine ODT
10 mg tablet
30
90
olanzapine ODT
15 mg tablet
30
90
olanzapine ODT
20 mg tablet
30
90
Olopatadine
665 mcg nasal spray
1 bottle (31 g)
3 bottles (92 g)
Oleptro ER
150 mg tablet
75
225
Oleptro ER
300 mg tablet
30
90
omeprazole
10 mg capsule
30
90
omeprazole
20 mg capsule
60
180
omeprazole
40 mg capsule
30
90
omeprazole/sodium
bicarbonate
omeprazole/sodium
bicarbonate
Omnaris
20/1,100 capsule
30
90
40/1,100 capsule
30
90
12.5 g nasal spray
1 (12.5 g)
3 (37.5 g)
ondansetron
4 mg tablet
60
180
ondansetron
8 mg tablet
60
180
ondansetron
24 mg tablet
4
12
ondansetron
4 mg/5 mL oral solution
120 mL
360 mL
ondansetron ODT
4 mg tablet
60
180
ondansetron ODT
8 mg tablet
60
180
Onglyza
2.5 mg tablet
30
30
Onglyza
5 mg tablet
30
30
Onmel
200 mg tablet
28
84
Onsolis
all strengths/dosage
forms
5 mg tablet
90*
270*
90*
270*
Opana ER
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 32 of 54
Opana ER
7.5 mg tablet
90*
270*
Opana ER
10 mg tablet
90*
270*
Opana ER
15 mg tablet
90*
270*
Opana ER
20 mg tablet
90*
270*
Opana ER
30 mg tablet
90*
270*
Opana ER
40 mg tablet
90*
270*
Orencia SQ
125 mg/mL Syringe
Orthro-Prefest
1 pack (4
syringes)
90
Oseni
Pink tablet: 1 mg
estradiol
White tablet: 1 mg
estradiol/0.09 mg
norgestimate (30 tablet
blister pack)
12.5-15 mg tablet
1 pack (4
syringes)
30
30
90
Oseni
12.5-30 mg tablet
30
90
Oseni
12.5-45 mg tablet
30
90
Oseni
25-15 mg tablet
30
90
Oseni
25-30 mg tablet
30
90
Oseni
25-45 mg tablet
30
90
Otezla
30 mg tablet
60
60
Otezla
Starter pack
1 Pack
1 Pack
oxybutynin cl er
5 mg tablet
30
90
oxybutynin cl er
10 mg tablet
60
180
oxybutynin cl er
15 mg tablet
60
180
Oxycodone ER
All tablet strengths
90*
270*
Oxycontin
All tablet strengths
90*
270*
oxymorphone HCL ER
5 mg tablet
90*
270*
oxymorphone HCL ER
7.5 mg
90*
270*
oxymorphone HCL ER
10 mg tablet
90*
270*
oxymorphone HCL ER
15 mg
90*
270*
oxymorphone HCL ER
20 mg tablet
90*
270*
oxymorphone HCL ER
30 mg tablet
90*
270*
oxymorphone HCL ER
40 mg tablet
90*
270*
Oxytrol
3.9 mg/24 hr patch
8
24
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 33 of 54
paliperidone ER
1.5 mg tablet
30
90
paliperidone ER
3 mg tablet
30
90
paliperidone ER
6 mg tablet
60
180
paliperidone ER
9 mg tablet
30
90
pantoprazole
20 mg tablet
30
90
pantoprazole
40 mg tablet
30
90
Parafon Forte DSC
500 mg tablet
120
360
paroxetine
10 mg tablet
30
90
paroxetine
20 mg tablet
30
90
paroxetine
30 mg tablet
60
180
paroxetine
40 mg tablet
30
90
paroxetine CR
12.5 mg tablet
30
90
paroxetine CR
25 mg tablet
60
180
paroxetine CR
37.5 mg tablet
60
180
Patanase
30.5g nasal spray
1 device (30.5 g)
3 devices (91.5 g)
Paxil
10 mg tablet
30
90
Paxil
20 mg tablet
30
90
Paxil
30 mg tablet
60
180
Paxil
40 mg tablet
30
90
Paxil CR
12.5 mg tablet
30
90
Paxil CR
25 mg tablet
60
180
Paxil CR
37.5 mg tablet
60
180
Pegasys
180 mcg single use vial
(each vial provides 1
mL containing 180 mcg
for SC injection)
Convenience Pack
4 vials
4 vials
1 pack
1 pack
All kit strengths
(contains one vial)
All package strengths
(contain one Redipen)
All four Pak strengths
(contains four Redipen
devices)
1.5% solution
4 packages
4 packages
4 packages
4 packages
1 package
1 package
1 bottle
3 bottles
Pegasys
Peg-Intron
Peg-Intron Redipen
Peg-Intron Redipen
Pennsaid
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 34 of 54
Perforomist
20 mcg/2 mL solution
60 respules
180 respules
perindopril
2 mg tablet
60
180
perindopril
4 mg tablet
60
180
perindopril
8 mg tablet
60
180
Pexeva
10 mg tablet
30
90
Pexeva
20 mg tablet
30
90
Pexeva
30 mg tablet
60
180
Pexeva
40 mg tablet
30
90
pioglitazone
15 mg tablet
30
90
pioglitazone
30 mg tablet
30
90
pioglitazone
45 mg tablet
30
90
pioglitazone-glimepiride
30 mg /2 mg tablet
30
90
pioglitazone-glimepiride
30 mg /4 mg tablet
30
90
pioglitazone-metformin
15 mg/500 mg tablet
90
270
pioglitazone-metformin
15 mg/850 mg tablet
90
270
Plan B
1 kits
Not available
1 kit
Not available
Plavix
0.75 mg levonorgestrel
tablets (2 tablets per
blister pack)
1.5 mg levonorgestrel
tablet (1 tablet per
pack)
75 mg tablet
34
102
Plavix
300 mg tablet
1
1
Plegridy Starter Pack
63-94mcg
1
1
Plegridy
125mcg/0.5mcg
2
2
Pletal
50 mg tablet
60
180
Pletal
100 mg tablet
60
180
Pomalyst
1 mg tablet
21
21
Pomalyst
2 mg tablet
21
21
Pomalyst
3 mg tablet
21
21
Pomalyst
4 mg tablet
21
21
Potiga
50 mg tablet
90
270
Potiga
200 mg tablet
90
270
Potiga
300 mg tablet
90
270
Plan B One-Step
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 35 of 54
Potiga
400 mg tablet
90
270
Pradaxa
75 mg capsule
60
180
Pradaxa
150 mg capsule
60
180
Praluent
75 mg/mL
2**
2**
Praluent
150 mg/mL
2**
2**
Pravachol
10 mg tablet
30
90
Pravachol
20 mg tablet
30
90
Pravachol
40 mg tablet
30
90
Pravachol
80 mg tablet
30
90
pravastatin
10 mg tablet
30
90
pravastatin
20 mg tablet
30
90
pravastatin
40 mg tablet
30
90
pravastatin
80 mg tablet
30
90
prazosin
5 mg capsule
120
360
prazosin
2 mg capsule
120
360
prazosin
1 mg capsule
90
270
Premarin
0.3 mg tablet
30
90
Premarin
0.625 mg tablet
90
270
Premarin
0.9 mg tablet
30
90
Premarin
1.25 mg tablet
60
180
Premarin
2.5 mg tablet
30
90
Premphase
14 x 0.625 mg
conjugated estrogen
tablets for days 1-14
and 14 x 0.625 mg
conjugated estrogen
with 5 mg
medroxyprogesterone
tablets for days 15-28
0.625 mg conjugated
estrogens/2.5 mg
medroxyprogesterone
tablet (28 tablet EZ dial
pack)
0.625 mg conjugated
estrogens/5 mg
medroxyprogesterone
tablet
30
90
28
84
28
84
Prempro
Prempro
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 36 of 54
Prempro
28
84
28
84
Prevacid
0.45 mg conjugated
estrogens/1.5 mg
medroxyprogesterone
tablet
0.3 mg conjugated
estrogens/1.5 mg
medroxyprogesterone
tablet
15 mg capsule
30
90
Prevacid
30 mg capsule
30
90
Prevacid
15 mg solutab
30
90
Prevacid
30 mg solutab
30
90
Prilosec
10 mg capsule
30
90
Prilosec
20 mg capsule
30
90
Prilosec
40 mg capsule
30
90
Prilosec Suspension Packet
2.5 mg packet
60
180
Prilosec Suspension Packet
10 mg packet
60
180
Prinivil
40 mg tablet
60
180
Prinivil
20 mg tablet
30
90
Prinivil
10 mg tablet
30
90
Prinivil
5 mg tablet
30
90
Prinivil
2.5 mg tablet
30
90
Pristiq
50 mg tablet
30
90
Pristiq
100 mg tablet
30
90
ProAir HFA
8.5 g inhaler
2 inhalers (17 g)
6 inhalers (51 g)
ProAir Respiclick
90 mcg inhaler
1 inhaler
3 inhalers
Procrit
2000 u/mL vial (6 vials
per carton)
3000 u/mL vial (6 vials
per carton)
4000 u/mL vial (6 vials
per carton)
10,000 u/mL vial (6
vials per carton)
40,000 u/mL (4 vials
per carton)
10,000 u/mL MDV (2
mL MDV-6 vials per
carton)
12 vials
12 vials
12 vials
12 vials
12 vials
12 vials
12 vials
12 vials
4 vials
4 vials
6 vials
6 vials
Prempro
Procrit
Procrit
Procrit
Procrit
Procrit
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 37 of 54
Procrit
6 vials
6 vials
1
1
Proscar
20,000 u/mL MDV (1
mL MDV- 6 vials per
carton)
60 mg/mL (1 mL)
syringe
5 mg tablet
30
90
Prosom
2 mg tablet
21
63
Prosom
1 mg tablet
21
63
Protonix
20 mg tablet
30
90
Protonix
40 mg tablet
30
90
Protonix
40 mg packet
30
90
Proventil
17 g aerosol
2 (34 g)
6 (102 g)
Proventil HFA
6.7 g aerosol
2 (14 g)
6 (41 g)
Prozac
10 mg capsule, tablet
90
270
Prozac
20 mg capsule
120
360
Prozac
40 mg capsule
60
180
Prozac Weekly
90 mg capsule
4
12
Pulmicort
0.25 mg/2 mL respule
60 respules
180 respules
Pulmicort
0.5 mg/2 mL respule
60 respules
180 respules
Pulmicort
1 mg/2 mL respule
30 respules
90 respules
Pulmicort Flexhaler
powder inhaler
2 inhalers
6 inhalers
Qnasl
8.7 g nasal spray
1 inhaler
3 inhalers
Quartette
quasense
levonorgestrel/ethinyl
estradiol
0.15 mg/0.03 mg tablet
quetiapine
25 mg tablet
1 pack (91
tablets)
1 pack (91
tablets)
90
1 pack (91
tablets)
1 pack (91
tablets)
270
quetiapine
50 mg tablet
90
270
quetiapine
100 mg tablet
90
270
quetiapine
200 mg tablet
90
270
quetiapine
300 mg tablet
60
180
quetiapine
400 mg tablet
60
180
Quillivant XR
25 mg/5 mL
360 mL
1080 mL
quinapril
40 mg tablet
60
180
quinapril
20 mg tablet
60
180
Prolia Injection
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 38 of 54
quinapril
10 mg tablet
60
180
quinapril
5 mg tablet
60
180
Qutenza
8% patch
4 patches
4 patches
Qvar
8.7 g aerosol
3
9
Rabeprazole
20 mg tablet
30
90
Raloxifene
60 mg tablet
30
90
ramipril
10 mg capsule
60
180
ramipril
5 mg capsule
60
180
ramipril
2.5 mg capsule
60
180
ramipril
1.25 mg capsule
60
180
ranitidine
150 mg tablet, gelcap
60
180
ranitidine
300 mg tablet, gelcap
60
180
Rapaflo
4 mg capsule
30
90
Rapaflo
8 mg capsule
30
90
Razadyne
4 mg tablet
60
180
Razadyne
8 mg tablet
60
180
Razadyne
12 mg tablet
60
180
Razadyne ER
8 mg capsule
30
90
Razadyne ER
16 mg capsule
30
90
Razadyne ER
24 mg capsule
30
90
Rebetol
200 mg capsule
180
180
Rebif
22 mcg syringe - single
syringe
22 mcg syringe - 12
pack
44 mcg syringe - single
syringe
44 mcg syringe - 12
pack
Titration Pack (12
syringes)
15 g gel (0.01%)
12 syringes
12 syringes
1 pack (12
syringes)
12 syringes
1 pack (12
syringes)
12 syringes
1 pack (12
syringes)
1 pack
1 pack (12
syringes)
1 pack
1 tube (15 g)
3 tubes (45 g)
5mg diskhaler (20
blisters)
12 mg/0.6 mL vial
(7 vials per kit)
20 mg tablet
1 device
1 device
14 vials (2 kits)
14 vials (2 kits)
6
18
Rebif
Rebif
Rebif
Rebif
Regranex
Relenza
Relistor
Relpax
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 39 of 54
Relpax
40 mg tablet
6
18
Remeron/ Remeron SolTab
15 mg
30
90
Remeron/ Remeron SolTab
30 mg
30
90
Remeron
45 mg
150
450
Remeron SolTab
45 mg
30
90
Reminyl
4 mg tablet
60
180
Reminyl
8 mg tablet
60
180
Reminyl
12 mg tablet
60
180
Repatha
140 mg/1 ml
2**
2**
Requip XL
2 mg tablet
90
270
Requip XL
3 mg tablet
90
270
Requip XL
4 mg tablet
90
270
Requip XL
6 mg tablet
90
270
Requip XL
8 mg tablet
90
270
Requip XL
12 mg tablet
60
180
Restasis (cyclosporine
opthalmic emulsion) 0.05%
2 trays (each tray
contains 30 vials)
6 trays (each
tray contains 30
vials)
Restoril
Single use vials
containing 0.4 mL fill in
a 0.9mL vial; 30 vials
are packaged in a
polypropylene tray.
30 mg capsule
21
63
Restoril
22.5 mg capsule
21
63
Restoril
15 mg capsule
21
63
Restoril
7.5 mg capsule
21
63
Revatio
20 mg tablet
90*
90*
Revatio
10 mg/12.5 mL
Revatio
10 mg/mL suspension
90 vials* (1,125
mL)
224 mL*
90 vials* (1,125
mL)
224 mL*
Revlimid
25 mg capsule
30
30
Revlimid
20 mg capsule
30
90
Revlimid
15 mg capsule
30
30
Revlimid
10 mg capsule
30
30
Revlimid
5 mg capsule
30
30
Revlimid
2.5 mg capsule
30
30
Rexulti
0.25 mg tablet
30
90
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 40 of 54
Rexulti
0.5 mg tablet
30
90
Rexulti
1 mg tablet
30
90
Rexulti
2 mg tablet
30
90
Rexulti
3 mg tablet
30
90
Rexulti
4 mg tablet
30
90
Rhinocort Aqua
2
6
1 pack
1 pack
1 pack
1 pack
1 pack
1 pack
180
180
ribasphere
8.6 g (120 sprays per
bottle)
400 mg-400 mg
Dosepak (56 tablets)
400 mg-600 mg
Dosepak (56 tablets)
600 mg-600 mg
Dosepak (56 tablets)
200 mg capsule and
tablet
400 mg tablet
90
90
ribasphere
600 mg tablet
60
60
Ribatab
400 mg tablet
90
90
Ribatab
600 mg tablet
60
60
Ribatab
1 pack
1 pack
1 pack
1 pack
1 pack
1 pack
180
180
risedronate
400 mg-400 mg
Dosepak (56 tablets)
400 mg-600 mg
Dosepak (56 tablets)
600 mg-600 mg
Dosepak (56 tablets)
200 mg capsule and
tablet
150 mg tablet
1
3
rivastigmine
6 mg capsule
60
180
rivastigmine
4.5 mg capsule
60
180
rivastigmine
3 mg capsule
60
180
rivastigmine
1.5 mg capsule
60
180
rivastigmine
4.6 mg/24 HR patch
30
90
rivastigmine
9.5 mg/24 HR patch
30
90
rivastigmine
13.3 mg/24 HR patch
30
90
rizatriptan
5 mg tablet
9
27
rizatriptan
10 mg tablet
9
27
rizatriptan ODT
5 mg tablet
9
27
Ribapak
Ribapak
Ribapak
ribasphere
Ribatab
Ribatab
ribavirin
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 41 of 54
rizatriptan ODT
10 mg tablet
9
27
Ropinirole ER
2 mg tablet
90
270
Ropinirole ER
4 mg tablet
90
270
Ropinirole ER
6 mg tablet
90
270
Ropinirole ER
8 mg tablet
90
270
Ropinirole ER
12 mg tablet
60
180
Rozerem
8 mg tablet
21
63
Sabril
500 mg powder packet
Sabril
500 mg tablets
150 packs (3
boxes)
180 tablets
150 packs (3
boxes)
180 tablets
Sanctura
20 mg tablet
60
180
Sanctura XR
60 mg capsule
30
90
Sancuso
Patch
2 patches
6 patches
Saphris
5 mg tablet
60
180
Saphris
10 mg tablet
60
180
Sarafem
10 mg pulvule/ tablet
28
84
Sarafem
20 mg pulvule/ tablet
28
84
Savella
100 mg tablet
60
180
Savella
50 mg tablet
60
180
Savella
25 mg tablet
60
180
Savella
12.5 mg tablet
60
180
Savella
Titration pack
containing 55 tablets
0.15 mg/0.03 mg tablet
Selfemra
0.15 mg/0.03 mg/0.01
mg tablet
10 mg capsule
1 pack (55
tablets)
1 pack (91
tablets)
1 pack (91
tablets)
28
1 pack (55
tablets)
1 pack (91
tablets)
1 pack (91
tablets)
84
Selfemra
20 mg capsule
28
84
Serevent Diskus
2 (56 blisters)
6 (168 blisters)
1 (60 blisters)
3 (180 blisters)
Seroquel
Inhalation powder
diskus with 28 blisters
Inhalation powder
diskus with 60 blisters
25 mg tablet
90
270
Seroquel
50 mg tablet
90
270
Seroquel
100 mg tablet
90
270
Seasonale
Seasonique
Serevent Diskus
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 42 of 54
Seroquel
200 mg tablet
90
270
Seroquel
300 mg tablet
60
180
Seroquel
400 mg tablet
60
180
Seroquel XR
50 mg tablet
90
270
Seroquel XR
150 mg tablet
90
270
Seroquel XR
200 mg tablet
30
90
Seroquel XR
300 mg tablet
60
180
Seroquel XR
400 mg tablet
60
180
sertraline
100 mg tablet
60
180
sertraline
50 mg tablet
45
135
sertraline
25 mg tablet
30
90
Signifor
0.3 mg/mL ampule
60
60
Signifor
0.6 mg/mL ampule
60
60
Signifor
0.9 mg/mL ampule
60
60
sildenafil
20 mg tablet
90*
90*
Silenor
3 mg tablet
42
126
Silenor
6 mg tablet
21
63
Simcor
500/20 mg tablet
60
180
Simcor
750/20 mg tablet
60
180
Simcor
1000/20 mg tablet
60
180
Simcor
1000/40 mg tablet
30
90
Simcor
500/40 mg tablet
30
90
Simponi
50 mg syringe
1 syringe**
1 syringe**
Simponi
100 mg syringe
1 syringe**
1 syringe**
simvastatin
80 mg tablet
30
90
simvastatin
40 mg tablet
30
90
simvastatin
20 mg tablet
30
90
simvastatin
10 mg tablet
30
90
simvastatin
5 mg tablet
30
90
Singulair
30
90
Singulair
4 mg chewable tablets
or oral granules
5 mg chewable tablets
30
90
Singulair
10 mg tablets
30
90
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 43 of 54
sodium hyaluronate lotion
1000 g hydrating lotion
1 bottle
3 bottles
Soma
350 mg tablet
120
360
Soma
250 mg tablet
120
360
Somavert
(pegvisomant for injection)
Somavert
(pegvisomant for injection)
Somavert
(pegvisomant for injection)
Somnote
10 mg vial
30 vials
30 vials
15 mg vial
30 vials
30 vials
20 mg vial
30 vials
30 vials
500 mg softgel
21
63
Sonata
10 mg capsule
21
63
Sonata
5 mg capsule
21
63
Spiriva
18 mcg powder caps
1 pkg (6 or 30)
3 pkgs (18 or 90)
Spiriva Respimat
1.25 mcg
1 pack
3 packs
Spiriva Respimat
2.5 mcg
1 pack
3 packs
Sporanox
100 mg capsule
28
84
Sprix
Sprycel
15.75 mg per Nasal
Spray
140 mg tablet
5 bottles per
carton
30
5 bottles per
carton
30
Sprycel
80 mg tablet
30
30
Sprycel
100 mg tablet
30
30
Sprycel
70 mg tablet
60
60
Sprycel
50 mg tablet
120
120
Sprycel
20 mg tablet
120
120
Stelara
45 mg/0.5 mL syringe
2 syringes**
2 syringes **
Stelara
90 mg/1 mL syringe
1 syringe**
1 syringe**
Stiolto respimat
1
3
Stivarga
2.5 mcg tiotropium/
2.5 mcg olodaterol
40 mg tablet
84
84
Striant Buccal System
30 mg buccal system
60
180
Subsys
All strengths
90 spray units*
180 spray units*
sumatriptan inj.
sumatriptan inj.
4 mg syringe, vial, refill
kit
6 mg syringe, refill kit
Sumatriptan NS
5 mg NS device
6 syringes/ vials
18 syringes/ vials
(3 kits)
(9 kits)
6 syringes (3 kits) 18 syringes (9
kits)
6 devices
18 devices
Sumatriptan NS
20 mg NS device
6 devices
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 44 of 54
18 devices
sumatriptan
25 mg tablet
9
27
sumatriptan
50 mg tablet
9
27
sumatriptan
100 mg tablet
9
27
Sumavel DosePro
4 mg/0.5 mL syringe
6 syringes (3 mL)
Sumavel DosePro
6 mg/0.5 mL syringe
6 syringes (3 mL)
Sutent
50 mg capsule
30
18 syringes (9
mL)
18 syringes (9
mL)
30
Sutent
25 mg capsule
30
30
Sutent
12.5 mg capsule
30
30
Sylatron
200 mcg kit
4 kits
4 kits
Sylatron
300 mcg kit
4 kits
4 kits
Sylatron
600 mcg kit
4 kits
12 kits
Symbicort Inhaler
80 mcg/4.5 mcg
1 device
3 devices
Symbicort Inhaler
160 mcg/4.5 mcg
1 device
3 devices
Symlin
0.6 mg/mL vial (5 mL)
4 vials
12 vials
SymlinPen
2 boxes (4 pens)
6 boxes (12 pens)
2 boxes (4 pens)
Synera
60 Pen Injection
(1.5 mL/pen)
120 Pen Injection
(2.7mL/pen)
Patch
2 patches
6 boxes (12
pens)
2 patches
Synjardy
5-500 mg
60
180
Synjardy
5-1000 mg
60
180
Synjardy
12.5-500 mg
60
180
Synjardy
12.5-1000 mg
60
180
Tafinlar
50 mg capsule
60 capsules
60 capsules
Tafinlar
75 mg capsule
60 capsules
60 capsules
Tamiflu
30 mg capsule
20
20
Tamiflu
45 mg capsule
10
10
Tamiflu
75 mg capsule
10
10
Tamiflu
50 mL (2 bottles)
50 mL (2 bottles)
tamsulosin
Powder for oral
suspension (25 mL
bottle)
0.4 mg capsule
60
120
Tanzeum
30 mg/0.5 mL pen
4 pens
12 pens
Tanzeum
50 mg/0.5 mL pen
4 pens
12 pens
SymlinPen
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 45 of 54
Tasigna
150 mg capsule
120
120
Tasigna
200 mg capsule
120
120
Tecfidera
Starter pack
1 pack
1 pack
Tecfidera
120 mg capsule
14
14
Tecfidera
240 mg capsule
60
60
Technivie
12.5-75 mg tablet
56**
56**
Tekamlo
150 mg-10 mg
30
90
Tekamlo
150 mg-5 mg
30
90
Tekamlo
300 mg-10 mg
30
90
Tekamlo
300 mg-5 mg
30
90
Tekturna
300 mg tablet
30
90
Tekturna
150 mg tablet
30
90
telmisartan
20 mg tablet
30
90
telmisartan
40 mg tablet
30
90
telmisartan
80 mg tablet
30
90
telmisartan-amlodipine
40-5 mg tablet
30
90
telmisartan-amlodipine
40-10 mg tablet
30
90
telmisartan-amlodipine
80-5 mg tablet
30
90
telmisartan-amlodipine
80-10 mg tablet
30
90
temazepam
30 mg capsule
21
63
temazepam
22.5 mg capsule
21
63
temazepam
15 mg capsule
21
63
temazepam
7.5 mg capsule
21
63
terazosin
10 mg capsule
60
180
terazosin
5 mg capsule
60
180
terazosin
2 mg capsule
60
180
terazosin
1 mg capsule
60
180
terbinafine
250 mg tablet
30
90
Testim Gel
1% (5 g) tube
[50 mg/5 g]
1% (2.5 g) packet
[25 mg/2.5 g]
1% (5 g) packet
[50 mg/5 g]
300 g (60 tubes)
900 g (180 tubes)
75 g (30 tubes)
225 g (90 tubes)
300 g (60 tubes)
900 g (180 tubes)
Testosterone Gel
Testosterone Gel
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 46 of 54
Testosterone Pump
150 g (2 pumps)
450 g (6 pumps)
Teveten
12.5 mg (1%) per
actuation
600 mg tablet
30
90
Teveten
400 mg tablet
60
180
Ticlid
250 mg tablet
60
180
ticlopidine
250 mg tablet
60
180
Tilade
16.2 g inhaler
3 (16.2 g)
9 (145.8 g)
Tobi
300 mg/5mL ampules
(56 per package)
1 pack
1 pack
Tobi Podhaler
28 mg capsules
224
224
Tobramycin
300 mg/5 mL ampule
tolterodine
1 mg tablet
56 ampules
(280 mL)
60
56 ampules
(280 mL)
180
tolterodine
2 mg tablet
60
180
Tolterodine ER
2 mg capsule
30
90
Tolterodine ER
4 mg capsule
30
90
Toradol
10 mg tablet
20
60
Toviaz ER
4 mg tablet
30
90
Toviaz ER
8 mg tablet
30
90
Tradjenta
5 mg tablet
30
90
trandolapril
4 mg tablet
60
180
trandolapril
2 mg tablet
60
180
trandolapril
1 mg tablet
60
180
Treximet
85 mg-500 mg tablet
9
27
triamcinolone acetonide
nasal spray
triamterene/
hydrochlorothiazide
triamterene/
hydrochlorothiazide
triamterene/
hydrochlorothiazide
triazolam
16.5 g spray
1 (17 g)
3 (51 g)
50 mg/25 mg capsule
and tablet
37.5 mg/25 mg capsule
and tablet
75 mg/50 mg capsule
and tablet
0.25 mg tablet
60
180
60
180
60
180
21
63
triazolam
0.125 mg tablet
21
63
Tribenzor
20 mg/5 mg/12.5 mg
tablet
30
90
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 47 of 54
Tribenzor
30
90
30
90
30
90
30
90
trospium
40 mg/10 mg/12.5 mg
tablet
40 mg/10 mg/25 mg
tablet
40 mg/5 mg/12.5 mg
tablet
40 mg/5 mg/25 mg
tablet
20 mg tablet
60
180
trospium ER
60 mg tablet
30
90
Trulicity
4
12
Twynsta
0.75 mg/0.5 mL
1.5mg /0.5 mL
400 mcg - 1 device of
60 blisters (powder)
40-10 mg tablet
60 doses
(1 device)
30
180 doses
(3 devices)
90
Twynsta
40-5 mg tablet
30
90
Twynsta
80-10 mg tablet
30
90
Twynsta
80-5 mg tablet
30
90
Tykerb
250 mg tablet
180
180
Tyzeka
600 mg tablet
30
30
Uloric
40 mg tablet
30
90
Uloric
80 mg tablet
30
90
Univasc
15 mg tablet
60
180
Univasc
7.5 mg tablet
60
180
valacyclovir
1000 mg tablet
30
90
valacyclovir
500 mg tablet
30
90
Valsartan
40 mg tablet
60
180
Valsartan
80 mg tablet
60
180
Valsartan
160 mg tablet
60
180
Valsartan
320 mg tablet
30
90
Valtrex
1000 mg tablet
30
90
Valtrex
500 mg tablet
30
90
Valturna
150/160 mg tablet
30
90
Valturna
300/320 mg tablet
30
90
Vanceril
16.8 g aerosol
3 (51g)
9 (152g)
Vandetanib
100 mg tablet
60
60
Tribenzor
Tribenzor
Tribenzor
Tudorza Pressair
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 48 of 54
Vandetanib
300 mg tablet
30
30
Varubi
90 mg tablet
2
6
Vascepa
1 g capsule
120
360
Vasotec
20 mg tablet
60
180
Vasotec
10 mg tablet
60
180
Vasotec
5 mg tablet
60
180
Vasotec
2.5 mg tablet
60
180
venlafaxine
100 mg tablet
90
270
venlafaxine
75 mg tablet
90
270
venlafaxine
50 mg tablet
90
270
venlafaxine
37.5 mg tablet
90
270
venlafaxine
25 mg tablet
90
270
venlafaxine ER
37.5 mg tablet
30
90
venlafaxine ER
75 mg tablet
30
90
venlafaxine ER
150 mg tablet
30
90
venlafaxine ER
225 mg tablet
30
90
venlafaxine ER
37.5 mg capsule
30
90
venlafaxine ER
75 mg capsule
90
270
venlafaxine ER
150 mg capsule
30
90
venlafaxine ER
37.5 mg tablet
30
90
venlafaxine ER
75 mg tablet
30
90
venlafaxine ER
150 mg tablet
30
90
Ventolin
17 g aerosol
2 (34 g)
6 (102 g)
Ventolin HFA
18 g aerosol
2 (36 g)
6 (108 g)
Veramyst
10g nasal spray
1 (10g)
3 (30g)
Veregen
1 tube (30 g)
3 tubes (90 g)
Vesicare
15% Ointment (30 g)
tube
10 mg tablet
30
90
Vesicare
5 mg tablet
30
90
Vfend
50 mg tablet
120
360
Vfend
200 mg tablet
60
180
Victoza
18 mg/3 mL injection
pen (6 mLs)
2 pen pack (6
mL)
6 pens (18 mL)
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 49 of 54
Victoza
3 pen pack (9
mL)
360
9 pens (27 mL)
Victrelis
18 mg/3 mL injection
pen (9 mLs)
200 mg capsule
Viibryd
10 mg tablets
30
90
Viibryd
20 mg tablets
30
90
Viibryd
40 mg tablets
30
90
Viibryd
Titration pack
1 Pack
1 Pack
Vimovo
375/20 mg
30
90
Vimovo
500/20 mg
30
90
Vivelle
0.0375 mg/day
8 systems
24 systems
Vivelle
0.05 mg/day
8 systems
24 systems
Vivelle
0.075 mg/day
8 systems
24 systems
Vivelle
0.1 mg/day
8 systems
24 systems
Vivelle-Dot
0.025 mg/day
8 systems
24 systems
Vivelle-Dot
0.0375 mg/day
8 systems
24 systems
Vivelle-Dot
0.05 mg/day
8 systems
24 systems
Vivelle-Dot
0.075 mg/day
8 systems
24 systems
Vivelle-Dot
0.1 mg/day
8 systems
24 systems
Vogelxo Pump
12.5 mg (1%)
150 g (2 pumps)
450 g (6 pumps)
Vogelxo Gel
300 g (60 tubes)
900 g (180 tubes)
voriconazole
1% (50 mg)
[50 mg/5 g]
50 mg tablet
120
360
voriconazole
200 mg tablet
60
180
Vytorin
10 mg/10 mg tablet
30
90
Vytorin
10 mg/20 mg tablet
30
90
Vytorin
10 mg/40 mg tablet
30
90
Vytorin
10 mg/80 mg tablet
30
90
Vyvanse
10 mg capsule
30
90
Vyvanse
20 mg capsule
30
90
Vyvanse
30 mg capsule
60
180
Vyvanse
40 mg capsule
30
90
Vyvanse
50 mg capsule
30
90
Vyvanse
60 mg capsule
30
90
Vyvanse
70 mg capsule
30
90
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 50 of 54
360
Wellbutrin SR
100 mg tablet
60
180
Wellbutrin SR
150 mg tablet
60
180
Wellbutrin SR
200 mg tablet
60
180
Wellbutrin XL
150 mg tablet
90
270
Wellbutrin XL
300 mg tablet
30
90
Xalkori
200 mg capsule
60
60
Xalkori
250 mg capsule
60
60
Xarelto
10 mg tablet
30
30
Xarelto
15 mg tablet
30
90
Xarelto
20 mg tablet
30
90
Xarelto
Starter pack
1 pack
1 pack
Xeljanz
5 mg tablet
60
60
Xigduo XR
5 mg/100 mg
30
90
Xigduo XR
5 mg/1000 mg
60
180
Xigduo XR
10 mg/1000 mg
30
90
Xigduo XR
10 mg/1000 mg
30
90
Xgeva Injection
120 mg/1.7 mL syringe
1
1
Xopenex HFA
45 mcg inhaler
3 inhalers
9 inhalers
Xtandi
40 mg capsule
120
120
Xyzal
5 mg tablet
30
90
Xyzal Solution
2.5 mg/5 mL
300
900
zaleplon
10 mg capsule
30
90
zaleplon
5 mg capsule
30
90
Zecuity
6.4 mg/4 hours
4
4
Zegerid
20 mg capsule
30
90
Zegerid
40 mg capsule
30
90
Zegerid
20 mg packet
30
90
Zegerid
40 mg packet
30
90
Zelboraf
240 mg tablet
240
240
Zenzedi
2.5 mg tablet
60
180
Zenzedi
5 mg tablet
90
270
Zenzedi
7.5 mg tablet
60
180
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 51 of 54
Zenzedi
10 mg tablet
90
270
Zenzedi
15 mg tablet
90
270
Zenzedi
20 mg tablet
90
270
Zenzedi
30 mg tablet
60
180
Zestril
40 mg tablet
60
180
Zestril
30 mg tablet
60
180
Zestril
20 mg tablet
30
90
Zestril
10 mg tablet
30
90
Zestril
5 mg tablet
30
90
Zestril
2.5 mg tablet
30
90
Zetia
10 mg tablet
30
90
Zetonna
37 mcg nasal spray
1 inhaler
3 inhalers
ziprasidone
20 mg capsule
60
180
ziprasidone
40 mg capsule
60
180
ziprasidone
60 mg capsule
60
180
ziprasidone
80 mg capsule
60
180
Zocor
5 mg tablet
30
90
Zocor
10 mg tablet
30
90
Zocor
20 mg tablet
30
90
Zocor
40 mg tablet
30
90
Zocor
80 mg tablet
30
90
Zofran
4 mg tablet
12
36
Zofran
8 mg tablet
12
36
Zofran
24 mg tablet
4
12
Zofran
4 mg/5 mL oral solution
120 mL
360 mL
Zofran ODT
4 mg tablet
12
36
Zofran ODT
8 mg tablet
12
36
Zohydro ER
10 mg capsule
60*
180*
Zohydro ER
15 mg capsule
60*
180*
Zohydro ER
20 mg capsule
60*
180*
Zohydro ER
30 mg capsule
60*
180*
Zohydro ER
40 mg capsule
60*
180*
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 52 of 54
Zohydro ER
50 mg capsule
60*
180*
Zolinza
100 mg capsule
60
60
zolmitriptan
2.5 mg tablet
6
18
zolmitriptan
5 mg tablet
6
18
zolmitriptan ODT
2.5 mg tablet
6
18
zolmitriptan ODT
5 mg tablet
6
18
Zoloft
25 mg tablet
30
90
Zoloft
50 mg tablet
45
135
Zoloft
100 mg tablet
60
180
zolpidem
5 mg tablet
30
90
zolpidem
10 mg tablet
30
90
zolpidem ER
12.5 mg tablet
30
90
zolpidem ER
6.25 mg tablet
30
90
Zolpimist
1 device
3 devices
Zomig Tablet
5 mg oral spray
(7.7 mL device)
2.5 mg tablet
6
18
Zomig Tablet
5 mg tablet
6
18
Zomig ZMT
2.5 mg tablet
6
18
Zomig ZMT
5 mg tablet
6
18
Zomig nasal spray
5 mg nasal spray
Zorvolex
18 mg capsule
1 package
(6 single use
units)
90
3 packages
(18 single use
units)
270
Zorvolex
35 mg capsule
90
270
Zuplenz films
4 mg film
12
36
Zuplenz films
8 mg film
12
36
Zyban
150 mg SR tablet
60
180
Zyclara
3.75% cream
1 box
3 boxes
Zyclara
1 bottle
3 bottles
Zyflo CR
3.75% cream
(7.5 g pump bottle)
600 mg tablets
120
360
Zyflo Filmtab
600 mg filmtab
120
360
Zyprexa
2.5 mg tablet
30
90
Zyprexa
5 mg tablet
30
90
Zyprexa
7.5 mg tablet
30
90
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 53 of 54
Zyprexa
10 mg tablet
30
90
Zyprexa
15 mg tablet
30
90
Zyprexa
20 mg tablet
30
90
Zyprexa Relprev
210 mg vial
2 vials
2 vials
Zyprexa Relprev
300 mg vial
2 vials
2 vials
Zyprexa Relprev
405 mg vial
1 vial
1 vial
Zyprexa Zydis
5 mg tablet
30
90
Zyprexa Zydis
10 mg tablet
30
90
Zyprexa Zydis
15 mg tablet
30
90
Zyprexa Zydis
20 mg tablet
30
90
Zyrtec
30
90
30
90
Zyrtec-D
5 mg tablet/chewable
tablet
10 mg tablet/chewable
tablet
5/120 mg
60
180
Zytiga
250 mg tablet
120
120
Zyvox
600 mg tablet
28
28
Zyvox
100 mg/ 5 mL (150 mL)
900 mL (6
bottles)
900 mL (6 bottles)
Zyrtec
04HQ3923 R12/15
*Limits are per 30 days supply at retail and per 90 days supply at mail.
**Limits are per 28 days supply at retail and/or per 84 days supply at mail.
† Limitations based on diagnosis apply.
Page 54 of 54
Notice of Language Options
04BA0365 04/15 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc.
are subsidiaries of Blue Cross and Blue Shield of Louisiana. All three companies are independent licensees of the Blue Cross and Blue Shield Association.