Rx Quantity Limits
If your doctor prescribes a drug in an amount that exceeds certain criteria, we may ask for documentation.
IMPORTANT NOTE: All limits are per 30 days, except where otherwise noted.
(Updated: 08/04/10)
| anti-emetics | Quantity limits Form | quantity limits |
|---|---|---|
| Anzemet | Anzemet |
50mg - 4 tabs; 100mg - 2 tabs/copay |
| Emend | Emend |
40 & 125mg - 1 tab/dispense |
| 80 & 125mg tripack - 1 package /dispense | ||
| 80mg - 2 caps/ dispense | ||
| 115mg injection - 1 injection/dispense | ||
| Kytril/Granisetron | Kytril |
1mg - 4 tabs/copay |
| Kytril/Granisetron Oral Solution | Kytril/Granisetron Oral Solution |
20ml/copay |
| Zofran (ondansetron) | Zofran |
4mg- 15 tabs/copay; |
| 8mg - 9 tabs/copay; | ||
| 24mg - 3 tabs/copay | ||
| anti-fungals | Quantity limits Form | quantity limits |
| Diflucan | Diflucan |
150mg - 1 tab /copay |
| Fluconazole | Fluconazole |
150mg - 1 tab/dispense |
| Itraconazole | Itraconazole |
30 tabs |
| Lamisil | Lamisil |
30 tabls |
| Sporanox | Sporanox |
30 caps |
| Terbinafine | Terbinafine |
30 tabs |
| anti-Hypertensive Agents | Quantity limits Form | quantity limits |
| Atacand | Atacand |
4, 8 & 16mg - 60 tabs |
| 32mg - 30 tabs | ||
| Atacand HCT | Atacand HCT |
16/12.5mg - 60 tabs |
| 32/12.5mg & 32/25mg - 30 tabs | ||
| Avalide | Avalide |
150-12.5mg - 60 tabs |
| 300-12.5mg & 300-25mg - 30 tabs | ||
| Avapro | Avapro |
75 & 150mg - 60 tabs |
| 300mg - 30 tabs | ||
| Azor | Azor |
10-20mg, 10-40mg, 5-20mg & 5-40mg - 30 tabs |
| Benicar | Benicar |
5 & 40mg - 30 tabs |
| 20mg - 60 tab | ||
| Benicar HCT | Benicar HCT |
30 tabs |
| Bystolic | Bystolic |
2.5 & 5mg - 30 tabs |
| 10 & 20mg - 60 tabs | ||
| Cozaar/Losartan | Cozaar/Losartan |
25 & 50mg - 60 tabs |
| 100mg - 30 tabs | ||
| Diovan | Diovan |
40, 80 & 160mg - 60 tabs |
| 320mg - 30 tabs | ||
| Diovan HCT | Diovan HCT |
80/12.5mg - 60 tabs |
| 160/25, 320/25, 320/12.5 & 160/12.5mg - 30 tabs | ||
| Exforge | Exforge |
10-160, 10-320, 5-160 & 5-320mg -30 tabs |
| Exforge HCT | Exforge HCT |
30 tabs |
| Hyzaar | Hyzaar |
50-12.5mg - 60 tabs |
| 100-12.5mg & 100-25mg - 30 tabs | ||
| Micardis | Micardis |
20, 40 & 80mg - 30 tabs |
| Micardis HCT | Micardis HCT |
40-12.5, 80-12.5 & 80-25mg - 30 tabs |
| Tekturna | Tekturna |
30 tabs |
| Tevetan | Tevetan |
400mg - 60 tabs |
| 600mg - 30 tabs | ||
| Tevetan HCT | Tevetan HCT |
600-12.5 & 600-25mg - 30 tabs |
| antiHistamines | Quantity limits Form | quantity limits |
| Allegra | Allegra |
30mg & 60mg - 60 tabs/caps |
| 180mg - 30 caps | ||
| Allegra D | Allegra D |
12hr - 60 tabs |
| 24hr - 30 tabs | ||
| Clarinex | Clarinex |
2.5 & 5mg - 30 tabs |
| Clarinex D | Clarinex D |
12hr - 60 tabs |
| 24hr - 30 tabs | ||
| Xyzal | Xyzal |
30 tabs |
| Xyzal Solution | Xyzal Solution |
300mls |
| Zyrtec | Zyrtec |
5 & 10mg - 30 tabs |
| Zyrtec D | Zyrtec D |
12hr - 60 tabs |
| Zyrtec Syrup | Zyrtec Syrup |
300mls |
| anti-inflammatory Agents | Quantity limits Form | quantity limits |
| Celebrex | Celebrex |
50, 200 & 400mg - 30 caps |
| 100mg - 60 caps | ||
| biologics | Quantity limits Form | quantity limits |
| Amevive | Amevive |
7.5mg vial - 8 vials |
| 15mg vial - 4 vials | ||
| Avonex | Avonex |
4 vials |
| Betaseron | Betaseron |
15 injections |
| Byetta | Byetta |
2 packages |
| Cimzia | Cimzia |
2 kits |
| Copazone | Copazone |
1 package |
| Enbrel | Enbrel |
50mg - 4 syringes |
| 25mg kit - 8 syringes | ||
| Extavia | Extavia |
15 injections |
| Humira | Humira |
40mg pens - 2 syringes |
| Humira Crohns Starter Pack | Humira Crohns Starter Pack |
1 pack/365 days |
| Humira Psoriasis Starter Pack | Humira Psoriasis Starter Pack |
1 pack/365 days |
| Kineret | Kineret |
30 injections |
| Peg-Intron Pens & Kits | Peg-Intron Pens & Kits |
4 pens-vials |
| Pegasys | Pegasys |
180mcg convenience pack - 1 pack |
| 180mcg vials | ||
| Rebif | Rebif |
22 & 44mcg - 15 syringes |
| Rebif Titration Pack | Rebif Titration Pack |
1 package |
| Soliris | Soliris |
600mg weekly - 240mls total |
| Fertility Agents | Quantity limits Form | quantity limits |
| Antagon | Antagon |
30 injections |
| Bravelle | Bravelle |
30 vials |
| Cetrotide | Cetrotide |
0.25mg kit - 1 package |
| 3mg kit - 1 package | ||
| Fertinex | Fertinex |
150u amps - 14 injections |
| Follistim | Follistim |
5 injections |
| Gonal-F | Gonal-F |
1050u - 5 inections |
| 900u - 15 injections | ||
| 450u - 10 injections | ||
| 37.5 & 300u - 30 injections | ||
| 450u (RFF) - 30 injections | ||
| 150u - 60 injections | ||
| 75u - 90 injections | ||
| Menopur | Menopur |
10 injections |
| Novarel | Novarel |
10,000u vial - 3 vials |
| Ovidrel | Ovidrel |
1 injection |
| Pregnyl | Pregnyl |
10,000u vial - 5 vials |
| Profasi | Profasi |
3 vials |
| Repronex | Repronex |
75u vial - 10 vials |
| Synarel | Synarel |
2 packages |
| Hepatitis B Agents | Quantity limits Form | quantity limits |
| Baraclude | Baraclude |
0.5 & 1mg - 30 tabs |
| Hepera | Hepera |
10mg - 30 tabs |
| inhalers | Quantity limits Form | quantity limits |
| Advair | Advair |
1 inhaler |
| Advair Diskus | Advair Diskus |
60 puffs |
| Aerobid | Aerobid |
3 inhalers |
| Albuterol | Albuterol |
2 inhalers |
| Asmanex | Asmanex |
1 inhaler |
| Astelin | Astelin |
1 package |
| Atrovent HFA | Atrovent |
2 inhalers |
| Atrovent Nasal | Atrovant Nasal |
1 inhaler |
| Azmacort | Azmacort |
2 inhalers |
| Beconase AQ | Beconase AQ |
1 inhaler |
| Combivent | Combivent |
2 inhalers |
| Foradil | Foradil |
1 inhaler |
| 60 nebs | ||
| Flonase | Flonase |
1 inhaler |
| Flovent | Flovent |
2 inhalers |
| Intal | Intal |
2 inhalers |
| Maxair | Maxair |
2 inhalers |
| Nasonex | Nasonex |
1 inhaler |
| Nasacort | Nasacort |
1 inhaler |
| Nasarel | Nasarel |
1 inhaler |
| Omnaris | Omnaris |
1 inhaler |
| Proair HFA | Proair HFA |
2 inhalers |
| Proventil HFA | Proventil HFA |
2 inhalers |
| Pulmicort | Pulmicort |
1 inhaler |
| Pulmicort Respules | Pulmicort Respules |
60 resp |
| .25 & .5mg / 2ml respules - 60 nebs/ | ||
| 1mg/2ml respules - 30 nebs | ||
| Rhinocort AQ | Rhinocort AQ |
1 inhaler |
| Qvar | Qvar |
2 inhalers |
| Serevent | Serevent |
1 package |
| Spiriva | Spiriva |
1 box |
| Stadol Nasal | Stadal Nasal |
2 packages |
| Symbicort | Symbicort |
1 package |
| Tilade | Tilade |
2 inhalers |
| Ventolin HFA | Ventolin HFA |
2 inhalers |
| Veramyst | Veramyst |
1 inhaler |
| injections | Quantity limits Form | quantity limits |
| Epipen | Epipen |
1 kit/copay |
| Epipen Twinject | Epipen Twinject |
1 kit/copay |
| Low Molecular Weight Heparins | Quantity limits Form | quantity limits |
| Arixtra | Arixtra |
30 injections |
| Fragmin | Fragmin |
60 syringes |
| Innohep | Innohep |
60 injections |
| Lovenox | Lovenox |
60 syringes |
| Oncology | Quantity limits Form | Quantity Limit |
| Iressa | Iressa |
250mg - 30 tabs |
| Nexavar | Nexavar |
200mg - 120 tabs |
| Revlimid | Revlimid |
30 tabs |
| Sprycel | Sprycel |
30 tabs |
| 70mg - 60 tabs | ||
| Sutent | Sutent |
30 caps |
| Tarceva | Tarceva |
30mg |
| Zolinza | Zolinza |
120 caps |
| Pain Medications | Quantity limits Form | Quantity Limit |
| Actiq | Actiq |
60 cap-tabs |
| Duragesic | Duragesic |
10 patches |
| Fentora | Fentora |
60 cap-tabs |
| Narcotics containing Acetaminophen |
Narcotics containing Acetaminophen |
500mg - 240 tabs |
| 325mg - 360 tabs | ||
| Oxycontin | Oxycontin |
120 tabs |
| Toradol (Ketoralac) | Toradol |
20 tabs |
| Proton Pump Inhibitors | Quantity limits Form | Quantity Limit |
| Aciphex | Aciphex |
20mg - 60 tabs |
| Lansoprazole (Prevacid) | Lansoprazole (Prevacid) |
15mg - 60 caps |
| Nexium | Nexium |
10 & 20mg - 60 caps-packets |
| 40mg - 60 caps | ||
| Omeprazole (Prilosec) | Omeprazole (Prilosec) |
10 & 20mg - 60 caps |
| Prilosec Oral Suspension | Prilosec Oral Suspension |
60 caps |
| Prilosec OTC | Prilosec OTC |
84 tabs |
| Pantoprazole (Protonix) | Pantoprazole (Protonix) |
20mg - 60 tabs |
| Prevacid Solutabs | Prevacid Solutabs |
60 tabs |
| Zegerid | Zegerid |
20mg - 30 tabs |
| Selective Serotonin Reuptake Inhibitors | Quantity limits Form | Quantity Limit |
| Cymbalta | Cymbalta |
20 & 30mg - 60 tabs |
| 60mg - 30 tabs | ||
| Effexor XR | Effexor XR |
37.5 & 75mg - 90 caps-tabs |
| 150mg - 60 caps-tabs | ||
| Lexapro | Lexapro |
5 & 10mg - 60 tabs |
| 20mg - 30 tabs | ||
| Paroxetine CR (Paxil CR) | Paroxetine CR (Paxil CR) |
12.5, 25 & 37.5mg - 60 tabs |
| Pristiq | Pristiq |
50 & 100mg - 30 tabs |
| Prozac Weekly | Prozac Weekly |
90mg - 4 caps |
| Sleeping Agents |
Quantity limits Form | Quantity Limit |
| Ambien/ Ambien CR (zolpidem) |
Ambien/ Ambien CR |
30 tabs |
| Dalmane (flurazepem) | Dalmane |
30 tabs-caps |
| Doral | Doral |
30 tabs-caps |
| Halcion (Triazolam) | Halcion |
30 tabs-caps |
| Lunesta | Lunesta |
30 tabs-caps |
| Placidyl | Placidyl |
30 tabs-caps |
| Prosom (Estazolam) | Prosom |
30 tabs-caps |
| Restoril (Temazepam) | Restoril |
30 tabs-caps |
| Rozerem | Rozerem |
30 tabs-caps |
| Sonata (Zaleplon) | Sonata |
30 tabs-caps |
| Test Strips | Quantity limits Form | quantity limits |
| Diabetic/Glucose Test Strips | Diabetic Test Strips |
300 strips |
| triptans | Quantity limits Form | quantity limit |
| Amerge | Amerge |
12 tabs |
| Axert | Axert |
12 tabs |
| Frova | Frova |
12 tabs |
| Imitrex/Sumatriptan | Imitrex |
12 tabs |
| Imitrex NS | Imitrex NS |
6 spray devices |
| Imitrex Injection | Imitrex Injection |
8 injections |
| Imitrex refill kit | Imitrex refill kit |
2 refills |
| Maxalt | Maxalt |
12 tabs |
| Maxalt MLT | Maxalt MLT |
12 tabs |
| Relpax | Relpax |
12 tabs |
| Stadol nasal spray | Stadol nasal spray |
2 bottles |
| Treximet | Treximet |
9 tabs |
| Zomig | Zomig |
12 tabs |
| Zomig ZMT | Zomig ZMT |
12 tabs |
| Zomig NS | Zomig NS |
1 box |
| Weight Loss Agents | Quantity limits Form | quantity limits |
| Meridia | Meridia |
5, 10 & 15mg - 30 tabs |
| Xenical | Xenical |
90 tabs |
| Other | Quantity limits Form | quantity limits |
| Apokyn | Apokyn |
30 injections |
| Januvia | Januvia |
30 tabs |
| Letaris | Letaris |
5 & 10mg - 30 tabs |
| Lyrica | Lyrica |
90 tabs |
| Revatio | Revatio |
90 tabs |
| Tracleer | Tracleer |
60 tabs |
| Tysabri | Tysabri |
300mg - 1 vial |
| Ventavis | Ventavis |
540mls |
| Vyvanse | Vyvanse |
30 tabs |
