Prescription Drug Quantity Limits

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

 

Drugs with a Quantity Limit as of 04/04/2020

 

Helpful Tip: Use the PDF find feature (Ctrl + F) to search for a specific drug.

Form

Drugs that appear on the quantity limits list and meet the quantity limit criteria require a quantity limit override form and approval.

High dose opioids criteria and limits may be found on the open formulary PA Drug List.

Important Notes:

  • All limits are per 30 days, except where otherwise noted (ie Zofran/ anti- emetics).
  • In addition to the limits listed, all specialty drugs are limited to a 30-day supply. If you aren't sure if your drug is a specialty drug, please call the pharmacy customer service number on the back of your card.