If your doctor prescribes a drug in an amount that exceeds certain criteria, we may ask for documentation.
Helpful Tip: Use the PDF find feature (Ctrl + F) to search for a specific drug.
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.
- 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.