Blue Cross Blue Shield Vermont: Rx Quantity Limits

Prescription Drug Quantity Limits - Effective 1/1/08

For groups that were with the Plan in 2007, we will "grandfather" your use of the medication for one full year if you are taking that drug on January 1, 2008.

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

Sleeping Agents	Prior Approval (PA) Form	Quantity Limit
Ambien/Ambien CR Dalmane Doral Estazolam Flurazepam Halcion Lunesta Placidyl Prosom Restoril Rozerem Sonata Temazepam	Ambien/Ambien CR Dalmane Doral Estazolam Flurazepam Halcion Lunesta Placidyl Prosom Restoril Rozerem Sonata Temazepam	30 cap-tabs/30 days 30 caps/30 days 30 cap-tabs/30 days 30 cap-tabs/30 days 30 caps/30 days 30 tabs/30 days 30 tabs/30 days 30 tabs/30 days 30 cap-tabs/30 days 30 cap-tabs/30 days 30 caps/30 days 30 tabs/30 days 30 cap-tabs/30 days

Pain Medications	Prior Approval (PA) Form	Quantity Limits
Duragesic Oxycontin Narcotics containing Acetaminophen Toradol (Ketoralac)	Duragesic Oxycontin Narcotics containing Acetaminophen Toradol	10 patches per 30 days 120 tabs per 30 days 500mg - 240 tabs per 30 days 325mg - 360 tabs per 30 days 20 tabs per 30 days

Triptans	Prior Approval (PA) Form	Quantity Limits
Amerge Axert Frova Imitrex Imitrex NS Imitrex Injectable Imitrex refill kit Maxalt Maxalt MLT Relpax Stadol nasal spray Zomig Zomig ZMT Zomig NS	Amerge Axert Frova Imitrex Imitrex NS Imitrex Injectable Imitrex refill kit Maxalt Maxalt MLT Relpax Stadol nasal spray Zomig Zomig ZMT Zomig NS	12 tabs per 30 days 12 tabs per 30 days 12 tabs per 30 days 12 tabs per 30 days 1 box per 30 days 6mg/0.5ml - 4 vials per 30 days 2 refills per 30 days 12 tabs per 30 days 12 tabs per 30 days 12 tabs per 30 days 2 bottles per 30 days 12 tabs per 30 days 12 tabs per 30 days 1 box per 30 days

Test Strips	Prior Approval (PA) Form	Quantity Limits
Diabetic/Glucose Test Strips	Diabetic Test Strips	300 strips per 30 days

Inhalers	Prior Approval (PA) Form	Quantity Limits
Advair Aerobid Albuterol Asmanex Astelin Atrovent Azmacort Beconase AQ Combivent Foradil Flonase Flovent Intal Maxair Nasonex Nasacort Nasarel Proventil HFA Pulmicort Pulmicort Respules Rhinocort AQ Qvar Serevent Spiriva Tilade Ventolin HFA	Advair Aerobid Albuterol Asmanex Astelin Atrovent Azmacort Beconase AQ Combivent Foradil Flonase Flovent Intal Maxair Nasonex Nasacort Nasarel Proventil HFA Pulmicort Pulmicort Respules Rhinocort AQ Qvar Serevent Spiriva Tilade Ventolin HFA	1 inhaler per 30 days 3 inhalers per 30 days 2 inhalers per 30 days 1 inhaler per 30 days 1 package per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 1 inhaler per 30 days 2 inhalers per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 2 inhalers per 30 days 1 inhaler per 30 days 60 resp per 30 days 1 inhaler per 30 days 2 inhalers per 30 days 1 package per 30 days 1 box per 30 days 2 inhalers per 30 days 2 inhalers per 30 days

Anti-emetics	Prior Approval (PA) Form	Quantity Limits
Anzmet Emend Kytril Zofran	Anzmet Emend Kytril Zofran	50mg - 4 tabs; 100mg - 2 tabs/copay 80mg/125mg/Tripak - 6 tabs/copay 40mg - 1 tab per copay 1mg - 4 tabs per copay 4mg- 15 tabs/copay; 8mg - 9 tabs/copay; 24mg - 3 tabs/copay

Anti-Fungals	Prior Approval (PA) Form	Quantity Limits
Diflucan	Diflucan	150mg tabs - 1 tab per copay

Injections	Prior Approval (PA) Form	Quantity Limits
Epipen	Epipen	1 kit per copay

Other	Prior Approval (PA) Form	Quantity Limits
Januvia Lyrica	Januvia Lyrica	30/30 90/30