Prescription Drug List
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Prescription Drug Quantity Level List

Drug Name Coverage Rules
Recommended Dosing Schedule or Maximum Dose
Additional Information
Aciphex 20mg tablets. Limit to 30 tablets within a rolling 30-day period. 20 mg daily for 4-8 weeks.  
Actiq limited to 120 lozenges per rolling 30 days    
Actos 15 mg, 30 mg and 45 mg limit to 30 tablets within a rolling 30-day period or 90 tablets within a rolling 90-day period. 45 mg by mouth daily.  
Acyclovir 200mg capsules. Limit to #60 capsules within a rolling 30-day period. Dosage varies Depending on diagnosis. Maximum dose per day is 4000mg.  
Acyclovir 400mg capsules. Limit to #60 capsules within a rolling 30-day period. Dosage varies depending on diagnosis. Maximum dose is 4000mg per day.  
Acyclovir 800mg tablets. Limit to #50 tablets within a rolling 60-day period. Dosage varies depending on diagnosis. Maximum dose is 4000mg per day.  
Advair diskus 100MCG/50MCG 250MCG/50MCG 500MCG/50MCG Limit to 60 units within a rolling 30-day period or 180 units within a rolling 90-day period. 1 inhalation twice a day. Maximum dose is 500mcg/50mcg twice a day.  
Aerobid MDI (1 canister = 100 inhalations) Limit to 3 inhalers within a rolling 30-day period or 9 inhalers within a rolling 90-day period. Inhale 2 sprays (500 mcg) twice a day Adult Maximum: 4 sprays (2000 mcg) per day. Children age 6 to 15 Maximum: 1000 mcg/day Each dose delivers 250 mcg MDI = Metered Dose Inhaler
Aerobid-M MDI (1 canister = 100 inhalations) Limit to 3 inhalers within a rolling 30-day period or 9 inhalers within a rolling 90-day period. Inhale 2 sprays (500 mcg) twice a day. Adult Maximum: 4 sprays (2000 mcg) per day. Children age 6 to 15 Maximum: 1000 mcg/day Each dose delivers 250 mcg MDI = Metered Dose Inhaler
Albuterol MDI Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period. Each dose delivers 90 mcg. Not recommended for children under age 4  
Allegra 180mg tablets. Limit to 30 tablets within rolling 30-day period. 1 tablet by mouth daily.  
Allegra 60 mg capsule. Limit to 60 capsules within a rolling 30-day period. 1 tablet/capsule by mouth twice a day.  
Allegra-D tablet Limit to 60 tablets within a rolling 30-day period. 1 tablet/capsule by mouth twice a day  
Alora 0.05 mg, 0.075 mg, 0.1 mg, 24 patches Limit to 8 patches (1 box) within a rolling 30-day period or 24 patches (3 boxes) within a rolling 90-day period. Apply one patch twice a week Packaged in boxes of 8 and 24 patches
Ambien 5 mg, 10 mg tablet Limit to 30 tablets within a rolling 30-day period up to 120 tablets within a 180-day period.    
Amerge 1mg, 2.5 mg tablet 9 tablets per rolling 30 day period. Maximum of 5 mg per 24 hours  
Anzement 50 mg, 100mg Limit to 7 tablets within a rolling 30-day period. 100 mg 1 hour before chemotherapy  
Aranesp 25mcg, 40mcg, 60mcg, 100mcg & 200mcg. Limit to 100mcg weekly or 200mcg every other week.   PA will be required if patient is using more than 200mcg every other week.
Astelin Nasal Spray 125 mcg, 137 mcg. 1 canister = 100 dosages. Limit to 3 bottles within a rollng 30-day period or 9 bottles within a rolling 90-day period. Adults and children over age 12 = 2 sprays in each nostril twice a day.  
Avandamet. Limit of #60 tablets per rolling 30-day period or 180 tabs per 90 days.    
Avandia 2 mg Limit to 60 tablets within a rolling 30-day period or 180 tablets within a rolling 90-day period. 4 mg by mouth daily or twice a day up to a total of 8 mg daily  
Avandia 4mg tablets Limit to 60 tablets within a rolling 30-day period or 180 tablets within a rolling 90-day period. Maximum daily dose is 8mg.  
Avandia 8mg tablets Limit to 30 tablets within a rolling 30-day period or 90 tablets within a rolling 90-day period. Maximum daily dose is 8mg.  
Avonex 33 mcg (6.6 million IU) Limit to 4 vials (1 kit) within a rolling 30-day period or 12 vials ( 3 kits) within a rolling 90-day period. 30 mcg IM once a week  
Azmacort 20 g MDI Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period. Adults: 2 inhalations 3-4 times a day or 4 inhalations twice a day Max = 1600 mcg/day Children 6 to 12 yrs: 1 or 2 inhalations 3-4 times a day or 2- 4 twice a day Max = 1200 mcg/day 1 spray = 100 mcg
Beclovent 16.8 gm MDI 1 canister = 200 doses Limit to 3 inhalers within a rolling 30-day period or 9 inhalers within a rolling 90-day period. 840 mcg per day 1 spray = 42 mg
Beclovent 6.7gm MDI 1 cannister = 80 doses Limit to 3 inhalers within a rolling 30-day period or 9 inhalers within a rolling 90-day period. 840mcg per day 1 spray = 42mcg
Beconase 16.8 gm Nasal 1 bottle = 200 doses Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period. 336 mcg/day 1 spray = 42 mcg
Beconase AQ 0.042% Nasal 25 gm 1 bottle = 200 doses Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period. 336 mcg/day 1 spray = 42 mcg
Betaseron 0.3mg Limit to 15 vials within a rolling 30-day period or 45 vials within a rolling 90-day period. 0.25 mg SubQ every other day  
Caverject 10mcg, 20mcg, 40mcg injections Limit to 6 injections per 30 days. Maximum of 3 times per week. 1 kit contains 6 units/doses. check members policy for coverage
Celebrex Celebrex 100mg and 200mg #60 per month. Celebrex 400mg #30 per month    
Cialis Cialis is limited to 6 tabs per rolling 30 day period   Must check members policy for sexual dysfunction coverage
Clarinex 5mg tablets. limited to #30 tabs per month Maximum recommended dosing is 5mg daily.  
Climara 0.025 mg; 0.05 mg; 0.075 mg; 0.1 mg patch Limit to 4 patches ( 1 box) within a rolling 30-day period or 12 patches (3 boxex) within a rolling 90- day period. Apply one patch once a week 1 box = 4 patches
Copaxone 20 mg Limit to 1 kit within a rolling 30-day period or 3 kits within a rolling 90-day period. Inject 20 mg per day SubQ  
Diflucan 100mg tablets Limit to 30 tablets within a rolling 90-day period.    
Diflucan 150mg tablets Limit to 2 tablets within a rolling 30-day period. For vaginal candidiasis dose is a single 150 mg tablet oral dose  
Diflucan 200mg tablets Limit to 30 tablets within a rolling 90-day period.    
Edex 5 mcg, 10mcg, 20mcg, 40mcg injections Limit to 6 injections per 30 days. Maximum of 3 times per week. 1 kit contains 6 units/doses
Emend Limited to 2 tri-packs per rolling 31 days.    
Epogen 2000u/ml, 3000u/ml, 4000u/ml, 10,000u/ml & 20,000 u/ml Limit to 160,000 units in 21 days.    
Esclim patches .025mg, .0375mg, .075mg, .05mg & .1mg. Limit to 8 patches (1 box) within a rolling 30-day period or 24 patches ( 3 boxes) within a rolling 90-day period.    
Estraderm 0.05 mg; 0.1mg Limit to 8 patches (1 box) within a rolling 30-day period or 24 patches (3 boxes) within a rolling 90-day period. Apply one patch twice a week Packaged in boxes of 8 and 24 patches
Estradiol transdermal patches 0.05mg 0.1mg Limit to 4 patches (1 box) within a rolling 30-day period or 12 patches (3 boxes) within a rolling 90-day period. Apply one patch once a week.  
Famvir 125 mg tablets. Limit to 21 tablets within a rolling 30-day period. Herpes Zoster: 500 mg by mouth every 8 hours x 7 days Genital Herpes: 125 mg by mouth twice a day x 5 days  
Famvir 250mg tablets. Limited to 60 tablets within a rolling 30-day period. Herpes Zoster: 500mg every 8 hours for 7 days. Genital Herpes: 125mg twice daily for 5 days.  
Famvir 500mg tablets. Limited to 21 tablets within a rolling 30-day period. Herpes Zoster: 500mg every 8 hours for 7 days. Genital Herpes: 125mg twice daily for 5 days.  
Fempatch 0.025mg Limit to 4 patches (1 box) within a rolling 30-day period or 12 patches (3 boxes) within a rolling 90-day period. Apply one patch once a week.  
Flonase Nasal Spray Limit to 2 bottles within a rolling 30-day period or 6 bottles within a rolling 90-day period. 200 mcg/day 1 spray = 50 mcg
Flovent 44 mcg MDI Flovent 110 mcg; Flovent 220 mcg Limit to 2 bottles within a rolling 30-day period or 6 bottles within a rolling 90-day period. Maximum: Inhale up to 880 mcg twice a day Dose depends on concurrent therapies 7.9 g canister delivers 60 doses 13 g canister delivers 120 doses
Flovent Rotadisk 50 mcg; Flovent Rotadisk 100 mcg; Flovent Rotadisk 250 mcg Limit to 120 disks within a rolling 30-day period or 360 disks within a rolling 90-day period. Maximum: Inhale up to 1000 mcg twice a day Dose depends on concurrent therapies 4 blister packs containing 15 Rotadisks
Fluconazole 100mg Limited to 30 tablets within a rolling 90 days    
Fluconazole 150mg Limited to 2 tablets within a rolling 30 day period.   For Vaginal Candidiasis dose is a single 150mg tablet oral dose.
Fluconazole 200mg Limited to 30 tablets per rolling 90 days.    
Foradil Aerolizer inhaler-Inhalation powder in capsule. Each capsule is 12mcg. Limit to 60 capsules within a rolling 30-day period or 180 capsules within a rolling 90-day period. 1 capsule via inhalation every 12 hours. each dose is 12mcg.
Fragmin Limited to 30 syringes within a rolling 90 day period    
Frova 2.5mg tablets Limit to 9 tablets within a rolling 30-day period. Maximum of 7.5mg per 24 hours. All triptan tabs are limited to #9 per month new qll rule
Gabapentin 100mg Limited to 480 caps per rolling 30 days or 1440 caps within a rolling 90 day period.    
Gabapentin 300mg Limited to 240 capsules within a rolling 30 day period ro 720 capsules within a rolling 90 day period.    
Gabapentin 400mg Limited to 240 capsules withon a rolling 30 day period or 720 capaules within a rolling 90 day period.    
Imitrex 100mg tablets. Limit to 9 tablets within a rolling 30-day period. 200mg per 24 hours.  
Imitrex 20mg nasal spray. Limit to 6 sprays within a rolling 30-day period. Maximum of 40mg per 24 hours. 20mg nasal spray =100mg oral.
Imitrex 25mg tablets. Limited to 9 tablets within a rolling 30-day period. Maximum recommended dose is 200mg per 24 hours. all imitrex tablets are limited to 9 tabs per rolling 30 days
Imitrex 50mg tablets. Limited to 9 tablets within a rolling 30-day period. Maximum recommended dose is 200mg per 24 hours. all imitrex tabs are limited to 9 per rolling 30 days
Imitrex 5mg Nasal Spray. Limited to 6 sprays within a rolling 30 days. Maximum of 40mg per 24 hours. all nasal sprays are limited to 6 per rolling 30 days
Imitrex Injection 6mg/0.5ml Limit to 8 injections within a rolling 30-day period. Maximun dose of two 6mg injections per 24 hours. 1 kit (2 syringes)= 200mg oral dose
Innohep Limited to 30 syringes within a rolling 90 day period    
Intal inhaler 8.1gm & 14.2gm. Limit to 2 inhalers within a rolling 30-day period or 4 inhalers within a rolling 90-day period. 2 puffs 4 times a day. 1 cannister of 8.1gm = 112 inhalations. 1 cannister of 14.2 gm = 200 inhalations.
Kytril 1 mg tablets. Limit to 14 tablets within a rolling 30-day period. 1 mg by mouth twice a day. 1 mg tablet = 14 per 30 days.
Lamisil 250mg tablets. Limit to 30 tablets within a rolling 30-day period or 90 tablets within a rolling 180-day period. Dose for treatment of fingernail fungus is 250mg daily for 6 weeks. Dose for treatment of toenail fungus is 250mg daily for 12 weeks.  
Levitra 2.5mg, 5mg, 10mg & 20mg tablets. Limit to 6 tablets within a rolling 30-day period. Levitra should not be used more than once a day. Must check policy for coverage Sexual dysfunction coverage.
Lovenox Limited to 30 Ssyringes within a rolling 90 day period.    
Maxalt 10mg tablets. limited to 9 tabs per rolling 30 days Maximum of 30mg per 24 hours.  
Maxalt 5 mg tablets. limited to 9 tabs per rolling 30 days Maximum of 30 mg by mouth per 24 hours.  
Maxalt MLT 10mg tablets. (orally disintegrating tablets) Limit to 9 tablets within a rolling 30-day period. Maximum of 30mg per 24 hours.  
Maxalt MLT 5mg tablets. (orally disintegrating tablets) Limit to 9 tablets within a rolling 30-day period. Maximum of 30mg per 24 hours.  
Migranol nasal spray. Limit to 8 ampules in a rolling 30-day period. Maximun dose is 4 sprays = 2mg per 24 hours.  
Muse 125mcg, 250mcg, 500mcg, 1000mcg pellets Limit to 6 injections per rolling 30-day period. 1 system per 24 hours. 1 system contains 6 pellets. Must check members policy for sexual dysfunction coverage
Nasacort AQ Nasal Limit to 3 inhalers within a rolling 30-day period or 9 inhalers within a rolling 90-day period. 440mcg per day. 1 spray = 55mcg. one 6.5g canister = 60 doses. one 16.5 canister = 120 doses.
Nasonex Nasal 17g. Limit to 2 bottles within a rolling 30-day period or 6 bottles within a rolling 90-day period. 200 mcg per day. 1 spray = 50mcg.
Neurontin 100mg Limited to 480 capsules per rolling 30 days or 1440 capsules per rolling 90 days.    
Neurontin 300mg Limited to 240 capsules per rolling 30 days or 720 capsules within a rolling 90 day period    
Neurontin 400mg Limited to 240 capsules per rolling 30 days or 720 capsules within a 90 day period.    
Neurontin 600mg Limited to 180 tabs within a rolling 30 day period or 540 tabs within a rolling 90 day period.    
Neurontin 800mg Limited to120 tabs within a rolling 30 day period or 360 tabs per rolling 90 day period.    
Nexium 20 mg; 40 mg Limit to 30 capsules within a rolling 30-day period. 20 mg by mouth once a day for up to 8 weeks  
Nicotine Nasal Spray. Limit to 90 days supply in any 365-day period. 8-40 doses per day. Must check members policy for smoking cessation benefits
Nicotine inhalers. Limit to 90 day supply in any 365-day period. 6-16 cartridges per day. Must check members policy for smoking cessation coverage
Oxycontin tablets 10mg, 20mg,40mg, 80mg Limit of 120 tablets within a rolling 28-day period.    
Palladone Limited to #62 tabs every 31 days    
Peg-Intron Limit to 4 kits within a rolling 30-day period or 12 kits within a rolling 90-day period. 1 kit per week.  
Pegasys 180mcg. Limit to 4 kits per rolling 30-day period or 12 kits per rolling 90-day period. 1 kit per week.  
Penlac Penlac has a QLL of one 6.6ml bottle per 90 days will process for a 90 day day non formulary copay    
Prevacid 15 mg; 30 mg capsules Limit to 30 capsules within a rolling 30-day period. 30 mg by mouth daily for up to 8 weeks  
Prevpac Patient Pack Limit to 1 treatment (1 pack) 14 units within a rolling 30-day period. Prevacid 60 mg per day; Trimox 2,000 mg per day; Biaxin 1,000 mg per day. Compliance dosed for 1 course of therapy.
Procrit 2000u/ml, 3000u/ml, 4000u/ml, 10,000u/ml & 20,000u/ml Limit to 160,000 units in 28 days.    
Protonix Limit to 30 capsules within a rolling 30-day period. 40 mg daily up to 8 weeks  
Proventil Limit to 6 inhalers within a rolling 90-day period Inhale 2 sprays (180 mcg) q 4-6 hours Each dose delivers 90 mcg. Not recommended for children under age 4
Proventil HFA Limit to 6 inhalers within a rolling 90-day period Inhale 2 sprays (180 mcg) q 4-6 hours Each dose delivers 90 mcg. Not recommended for children under age 4
Qvar 40mcg & 80mcg. Limit to 2 units within a rolling 30-day period or 4 units within a rolling 90-day period. 320mcg twice daily.  
Relenza 5 mg Powder for inhalation. Limit to 20 units within a rolling 180-day period for patients > 12 years of age. 2 Inhalations twice a day for 5 days.  
Relpax 20mg & 40mg tablets. Limited to #9 tablets per rolling 31-day period.    
Rhinocort Aqua. Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period.    
Rhinocort Nasal 1 canister = 200 doses Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period. Maximum dose is 256 mcg per day. 1 spray = 32 mcg.
Serevent Diskus with 60 blister packs. Limit to 60 blister packs within a rolling 30-day period or 180 blister packs within a rolling 90-day period. Inhale 2 sprays twice a day. 1 spray = 25 mcg.
Sonata 5 mg & 10mg capsules. limit to 30 capsules within a rolling 30-day period up to 120 capsules within a rolling 180-day period. Maximum dose is 20 mg per day for up to 7 to 10 days.  
Sporanox 100mg capsules. Limit to 60 capsules within a rolling 30-day period or 180 capsules within a rolling 180-day period. Dose for treatment of toenail fungus is 200 mg daily for 12 weeks. Dose for treatment of fingernail fungus is 200 mg twice a day for 1 week, repeat after 3 weeks of no drug.  
Stadol Nasal Spray 10mg/ml. Limit to 9 ml (3 vials) within a rolling 30-day period. Maximum dose is 2 mg initially. May repeat 2 mg in 3 - 4 hours. 1 spray = 1 mg. 1 vial = 2.5 ml. 2.5ml = 8-15 doses.
Tamiflu 75 capsules. Limit to 10 capsules within a rolling 180-day period. 1capsule twice a day.  
Tamiflu 75 suspension. Limit to 75ml within a rolling 180-day period.    
Ultram 50mg tablets. Limit to 240 tablets within a rolling 30-day period. 50mg to 100mg by mouth every 4-6 hours. Maximum dose of 400 mg/day.  
Valtrex 1gm tablets. Limit to 30 tablets within a rolling 30-day period. Herpes Zoster: 1000mg 3 times daily for 7 days. Recurrent Genital Herpes: 500mg twice daily for 5 days.  
Valtrex 500mg tablet. Limit to 30 tablets within a rolling 30-day period. Herpes Zoster: 1,000mg three times a day for 7 days. Recurrent Genital Herpes: 500 mg twice a day for 5 days.  
Vancenase AQ Nasal Spray. Limit to 2 inhalers within a rolling 30-day period or 6 inhalers withina rolling 90-day period. 336 mcg/day. 1 spray = 42 mcg.
Vancenase Nasal Spray 16.8g. Limit to 2 inhalers within a rolling 30-day period or 6 inhalers within a rolling 90-day period. 336 mcg/day. 1 spray = 42 mcg.
Ventolin Limit to 6 inhalers within a rolling 90-day period Inhale 2 sprays (180 mcg)q 4-6 hours Each dose delivers 90 mcg. Not recommended for children under age 4
Viagra 25mg, 50mg, 100mg tablets. Limit to 6 tablets within a rolling 30 day period. Maximum recommended dosage is 100mg. Maximum recommended dosing frequency is once per day. Must check members policy for sexual dysfunction coverage
Vivelle 0.0375 mg; 0.075 mg; 0.05 mg; 0.1 mg Limit to 8 patches (1 box) within a rolling 30-day period or 24 patches (3 boxes) within a rolling 90-day period. Apply one patch twice a week Packaged in boxes of 8 and 24 patches
Vivelle-DOT 0.0375 mg; 0.075 mg; 0.05 mg; 0.1 mg Limit to 8 patches (1 box) per rolling 30-day period or 24 patches ( 3 boxes) within a rolling 90-day period. Apply one patch twice a week Packaged in boxes of 8 and 24 patches
Wellbutrin XL 150mg Wellbutrin XL is limited to 90 tabs per 30 days or 270 tabs per 90 days.   This will only apply to non-pyschiatrists.
Wellbutrin XL 300mg Wellbutrin 300mg XL is limited to 30 tabs per month. or 90 per 90 days   This will only apply to non-psychiatrists.
Yohimbine 5.4mg. Limit to 6 tablets per rolling 30-day period.    
Zetia 10mg. Limited to #30 per rolling 30-days. or 90 per 90 days    
Zithromax 100 mg/ 5 ml suspension. Limit to one 30ml bottle within a rolling 30-day period. 500 mg by mouth once a day.  
Zithromax 200mg/5ml suspension. Limit to one 15ml or 22.5ml or 30ml bottle within a rolling 30-day period. 500mg once daily.  
Zithromax 250mg Tablet. Limit to 6 tablets within a rolling 30-day period. 500 mg by mouth on day 1 then 250mg daily days 2-5.  
Zithromax 500mg tablets. Limit to 3 tablets within a rolling 30-day period. 500mg once daily for 3 days for treatment of AECB due to S. pneumoniae, H. influenza & M. catarrhalis.  
Zithromax 600 mg tablets. Limit to 10 tablets within a rolling 30-day period. 1,200 mg once a week.  
Zithromax Powder Packet. Limit to 2 packets within a rolling 30-day period. 1gm orally as a single oral dose.  
Zofran 24mg tablets. Limit to 3 tablets within a rolling 30-day period. 8mg two to three times daily for up to 3 days.  
Zofran 4 mg tablet. Limit to 21 tablets within a rolling 30-day period. 8 mg by mouth two to three times a day for up to 3 days.  
Zofran 8mg tablet. Limit to 21 tablets within a rolling 30-day period. 8mg two to three times a day for up to 3 days.  
Zofran ODT. Limit to 21 tablets within a rolling 30-day period. 8 mg by mouth two to three times a day for up to 3 days.  
Zofran oral solution 4mg/5ml. Limit to 4 bottles within a rolling 30-day period. 8mg two to three times daily for up to 3 days.  
Zomig 2.5 mg tablets. Limit to 9 tablets within a rolling 30-day period. Maximum of 10 mg by mouth in 24 hours. all triptans are limited to 9 per rolling 30 days
Zomig 5mg tablets. Limit to 9 tablets within a rolling 30-day period. Maximum of 10mg in 24 hours.  
Zomig ZMT 2.5mg tablets. Limit to 9 tablets within a rolling 30-day period. Maximum of 10 mg by mouth in 24 hours. all triptans are limited to 9 per month
Zovirax 200mg capsules. Limit to 60 capsules within a rolling 30-day period. Dosage varies depending on diagnosis. Maximum dose is 4000mg per day.  
Zovirax 400mg capsules. Limit to 60 capsules within a rolling 30-day period. Dosage varies depending on diagnosis. Maximum dose is 4000mg per day.  
Zovirax 800mg tablets. Limit to 50 tablets within a rolling 60-day period. Dosage varies depending on diagnosis. Maximum dose is 4000mg per day.  
Zyban 150mg tablets. Limit to 90 days supply within any 365-day period. Maximum recommended dose is 300mg/day. Must check members policy for smoking cessation coverage
Zyrtec 5 mg & 10 mg tablets. Limit to 30 tablets within a rolling 30-day period. Adults and children over 6 years: 5 mg to 10 mg by mouth once a day.  
Zyrtec-D tablets. Limit to 60 tablets within a rolling 30-day period. Up to 1 tablet twice a day.