Rx Quantity Limits

If your doctor prescribes a drug in an amount that exceeds certain criteria, we may ask for documentation.

Sleeping Agents	PA Form	Quantity Limit
Ambien/ Ambien CR	Ambien/ Ambien CR	30 cap-tabs/30 days
Dalmane	Dalmane	30 caps/30 days
Doral	Doral	30 cap-tabs/30 days
Estazolam	Estazolam	30 cap-tabs/30 days
Flurazepam	Flurazepam	30 caps/30 days
Halcion	Halcion	30 tabs/30 days
Lunesta	Lunesta	30 tabs/30 days
Placidyl	Placidyl	30 tabs/30 days
Prosom	Prosom	30 cap-tabs/30 days
Restoril	Restoril	30 cap-tabs/30 days
Rozerem	Rozerem	30 caps/30 days
Sonata	Sonata	30 tabs/30 days
Temazepam	Temazepam	30 cap-tabs/30 days
Pain Medications	PA Form	Quantity Limit
Duragesic	Duragesic	10 patches per 30 days
Oxycontin	Oxycontin	120 tabs per 30 days
Narcotics containing Acetaminophen	Narcotics containing Acetaminophen	500mg - 240 tabs per 30 days
		325mg - 360 tabs per 30 days
Toradol (Ketoralac)	Toradol	20 tabs per 30 days
triptans	pa form	quantity limit
Amerge	Amerge	12 tabs per 30 days
Axert	Axert	12 tabs per 30 days
Frova	Frova	12 tabs per 30 days
Imitrex	Imitrex	12 tabs per 30 days
Imitrex NS	Imitrex NS	1 box per 30 days
Imitrex Injectable	Imitrex Injectable	6mg/0.5ml - 4 vials per 30 days
Imitrex refill kit	Imitrex refill kit	2 refills per 30 days
Maxalt	Maxalt	12 tabs per 30 days
Maxalt MLT	Maxalt MLT	12 tabs per 30 days
Relpax	Relpax	12 tabs per 30 days
Stadol nasal spray	Stadol nasal spray	2 bottles per 30 days
Zomig	Zomig	12 tabs per 30 days
Zomig ZMT	Zomig ZMT	12 tabs per 30 days
Zomig NS	Zomig NS	1 box per 30 days
Test Strips	pa form	quantity limits
Diabetic/Glucose Test Strips	Diabetic Test Strips	300 strips per 30 days
inhalers	pa form	quantity limits
Advair	Advair	1 inhaler per 30 days
Aerobid	Aerobid	3 inhalers per 30 days
Albuterol	Albuterol	2 inhalers per 30 days
Asmanex	Asmanex	1 inhaler per 30 days
Atrovent	Atrovent	2 inhalers per 30 days
Azmacort	Azmacort	2 inhalers per 30 days
Beconase AQ	Beconase AQ	1 inhaler per 30 days
Combivent	Combivent	2 inhalers per 30 days
Foradil	Foradil	1 inhaler per 30 days
Flonase	Flonase	1 inhaler per 30 days
Flovent	Flovent	2 inhalers per 30 days
Intal	Intal	2 inhalers per 30 days
Maxair	Maxair	2 inhalers per 30 days
Nasonex	Nasonex	1 inhaler per 30 days
Nasacort	Nasacort	1 inhaler per 30 days
Nasarel	Nasarel	1 inhaler per 30 days
Proventil HFA	Proventil HFA	2 inhalers per 30 days
Pulmicort	Pulmicort	1 inhaler per 30 days
Pulmicort Respules	Pulmicort Respules	60 resp per 30 days
Rhinocort AQ	Rhinocort AQ	1 inhaler per 30 days
Qvar	Qvar	2 inhalers per 30 days
Serevent	Serevent	1 package per 30 days
Spiriva	Spiriva	1 box per 30 days
Tilade	Tilade	2 inhalers per 30 days
Ventolin HFA	Ventolin HFA	2 inhalers per 30 days
anti-emetics	pa form	quantity limits
Anzmet	Anzmet	50mg - 4 tabs; 100mg - 2 tabs/copay
Emend	Emend	80mg/125mg/Tripak - 6 tabs/copay
		40mg - 1 tab per copay
Kytril	Kytril	1mg - 4 tabs per copay
Zofran	Zofran	4mg- 15 tabs/copay;
		8mg - 9 tabs/copay;
		24mg - 3 tabs/copay
anti-fungals	pa form	quantity limits
Diflucan	Diflucan	150mg tabs - 1 tab per copay
injections	pa form	quantity limits
Epipen	Epipen	1 kit per copay
Other	pa form	quantity limits
Januvia	Januvia	30/30
Lyrica	Lyrica	90/30