Blue Care Network Quantity Limits
January 2017
Pharmacy programs ensure safety and cost-effectiveness
We monitor the use of certain medications to help ensure you receive the most appropriate and
cost‑effective drug therapy. Our Quantity Limits program is one of the ways we monitor medications.
This document is published biannually (January and July). The BCN Drug List Update provides current
coverage requirements. Or visit bcbsm.com/pharmacy.
Quantity limits
Our Quantity Limits program limits the amount of medicine that you can fill for certain medications.
For example, a drug may have a limit of 30 pills per 30 days. We apply such limits, based on drug studies
and reviews by actively practicing doctors, to certain drugs in weight loss, smoking cessation, erectile
dysfunction, nausea and several other categories. If you refill a prescription too soon or if your doctor
prescribes an amount that’s higher than usual, your pharmacist will tell you that the drug isn’t covered. Dose optimization
Dose optimization means taking more of a medication once a day instead of taking a lower dose two or
more times a day. It’s easier to remember to take a medication once a day, and it will probably cost you
less. In some cases, your out-of-pocket costs can be reduced by as much as 50 percent. Included in this
program are drugs for depression, cholesterol, heart disease and several other drug categories. Talk to
your doctor about dose optimization.
Only your doctor can request coverage for drugs that exceed BCN limits.
Alzheimer's Therapy
Aricept® 23mg (g)*
Namenda XR® (Nonpreferred)*
Namenda XR® titration pack (Nonpreferred)*
NamzaricTM (Nonpreferred)*
Anticonvulsants
Acthar® H.P. (Nonpreferred)* <s>
Aptiom® 200mg, 400mg (Nonpreferred)*
Aptiom® 600mg, 800mg (Nonpreferred)*
Briviact® (Nonpreferred)*
Briviact® solution (Nonpreferred)*
Fycompa® tablet (Nonpreferred)
Lyrica® 25mg, 50mg, 75mg, 100mg, 150mg
(Nonpreferred)*
Lyrica 200mg, 225mg, 300mg (Nonpreferred)*
Onfi® (Nonpreferred)*
Custom
Comprehensive
1 tablet per day
1 capsule per day
1 pack per 2 years
1 capsule per day
Custom
Comprehensive
4 vials per month
1 tablet per day
2 tablets per day
2 tablets per day
20mL per day
1 tablet per day
Custom Select
Excluded
Excluded
Excluded
Excluded
Custom Select
Excluded
Excluded
Excluded
3 capsules per day
600mg per day
2 tablets per day
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available
on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Anticonvulsants (cont.)
Onfi® suspension (Nonpreferred)*
Oxtellar XR® 150mg, 300mg (Nonpreferred)
Oxtellar XR 600mg (Nonpreferred)
Qudexy® XR 25mg, 50mg, 100mg, 150mg
(Nonpreferred)*
Qudexy® XR 200mg (Nonpreferred)*
Trokendi XR®; TopiramateTM ER (Nonpreferred)*
(25mg, 50mg, 100mg or 150mg)
Antidepressants
Desvenlafaxine ER® (Nonpreferred)*
Desvenlafaxine Fumarate® (Nonpreferred)*
Fetzima® (Nonpreferred)*
KhedezlaTM (Nonpreferred)*
Oleptro ERTM (Nonpreferred)*
Pexeva® (Nonpreferred)*
Pristiq® (Nonpreferred)*
Trintellix® (Nonpreferred)*
Viibryd® (Nonpreferred)*
Viibryd® Titration pack (Nonpreferred)*
Antidiabetics
Adlyxin® (Nonpreferred)*
Alogliptin® (Nonpreferred)*
Alogliptin-metformin® (Nonpreferred)*
Alogliptin-pioglitazone® (Nonpreferred)*
Avandamet® (Nonpreferred)*
Avandia® (Nonpreferred)*
Bydureon®, Pen*
Byetta® (Nonpreferred)*
Cycloset® (Nonpreferred)*
FarxigaTM*
Glyxambi® (Nonpreferred)*
Insulin syringes
Invokamet®*, XR®*
Invokana®*
Janumet®, XR 50/1000mg
Janumet XR 50/500mg, 100/1000mg
Januvia®
Jardiance® (Nonpreferred)*
Jentadueto®, XR 2.5/1000mg (Nonpreferred)*
Jentadueto XR 5mg/1000mg (Nonpreferred)*
Custom
Comprehensive
16mL (40mg) per day
1 tablet per day
4 tablets per day
Custom Select
Excluded
Excluded
1 capsule per day
Excluded
2 capsules per day
Excluded
1 capsule per day
Excluded
Custom
Comprehensive
Custom Select
1 tablet per day
Excluded
1 tablet per day
1 capsule per day
Excluded
1 tablet per day
Excluded
1 tablet per day
Excluded
1 tablet per day
1 tablet per day
Excluded
1 tablet per day
1 tablet per day
1 pack per 1 year
Custom
Comprehensive
Custom Select
2 pens (6mL) per month
Excluded
1 tablet per day
Excluded
2 tablets per day
Excluded
1 tablet per day
Excluded
2 tablets per day
2 tablets per day
4 vials/pens per 28 days
1 cartridge (1.2mL or 2.4mL) per month
6 tablets per day
1 tablet per day
1 tablet per day
Excluded
200 syringes per Rx
2 tablets per day
1 tablet per day
2 tablets per day
1 tablet per day
1 tablet per day
1 tablet per day
Excluded
2 tablets per day
Excluded
1 tablets per day
Excluded
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Antidiabetics (cont.)
Kazano® (Nonpreferred)*
Kombiglyze® XR 2.5/1000mg
Kombiglyze® XR 5/500mg, 5/1000mg
Nesina® (Nonpreferred)*
Onglyza®
Oseni® (Nonpreferred)*
Synjardy® (Nonpreferred)*
Tanzeum® (Nonpreferred)*
Tradjenta® (Nonpreferred)*
Trulicity® (Nonpreferred)*
Victoza®*
Xigduo XR® 5mg/500mg, 10mg/500mg, or 10/1000mg*
Xigduo XR® 5mg/1000mg*
Antiemetics
Akynzeo® (Nonpreferred)*
Anzemet® (Nonpreferred)
Emend® 80mg
Emend 125mg
Emend suspension
Emend Trifold Pack
Kytril® (g)
Sancuso® (Nonpreferred)*
Varubi™ (Nonpreferred)*
Zuplenz® (Nonpreferred)*
Antihistamines/Combinations
Vituz® (Nonpreferred)
Anti-Infectives
Coartem®
Cresemba®
Dificid® (Nonpreferred)
Emverm™ (Nonpreferred)
Impavido®
Noxafil® tablet
Oravig® (Nonpreferred)
Sirturo® *
Sivextro®
Spectracef® (g)
Tindamax® (g)
Tobi TM PodhalerTM (Nonpreferred)*<s>
Xifaxan® 200mg (Nonpreferred)
Custom
Comprehensive
Custom Select
2 tablets per day
Excluded
2 tablets per day
1 tablet per day
1 tablet per day
Excluded
1 tablet per day
1 tablet per day
Excluded
2 tablets per day
Excluded
4 pens per month
Excluded
1 tablet per day
4 pens (2mL) per month
Excluded
3 syringes (9mL) per month
1 tablet per day
2 tablets per day
Custom
Comprehensive
Custom Select
2 capsules per Rx
6 tablets per Rx
4 capsules per Rx
2 capsules per Rx
6 packets per Rx
2 packs per Rx
12 tablets per Rx
2 patches per Rx
8 tablets per month
Excluded
24 films per Rx
Excluded
Custom
Comprehensive
Custom Select
240mL per Rx
Excluded
Custom
Comprehensive
Custom Select
24 tablets per Rx
68 capsules per month
20 tablets per Rx
6 tablets per month
Excluded
84 tablets per month
99 tablets per month
1 tablet per day
Excluded
2 tablets per day
1 tablet per day/6 days per month
14 tablets per Rx
20 tablets per 20 days
224 capsules per 42 days
Excluded
9 tablets every 7 days
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Antineoplastics and Immunosuppressants
Afinitor®, Disperz* <s>
Alecensa® <s>*
Arcalyst®* <s>
Bosulif® 100mg* <s>
Bosulif® 500mg* <s>
Cabometyx™*<s>
Caprelsa® 100mg* <s>
Caprelsa® 300mg* <s>
Cometriq®*<s>
Cotellic™*<s>
Erivedge®*<s>
Exjade® (Nonpreferred)* <s>
Farydak®*<s>
Gleevec® (brand) <s>
Gilotrif™*<s>
Ibrance®*<s>
Iclusig®*<s>
Imbruvica®*<s>
Inlyta® 1mg*<s>
Inlyta® 5mg*<s>
Iressa®*<s>
Jadenu™*<s>
Jakafi®* <s>
Lenvima™*<s>
Lonsurf®* <s>
Lynparza™*<s>
Mekinist®*<s>
Mircera® (Nonpreferred)* <s>
Neulasta® (Nonpreferred) <s>
Nexavar®*<s>
Ninlaro® *<s>
Odomzo®* <s>
Pomalyst® (Nonpreferred)* <s>
Revlimid® (Nonpreferred)* <s>
Stivarga®*<s>
Sutent®*<s>
Sprycel®*<s>
SylatronTM (Nonpreferred)<s>
Tafinlar®*<s>
TagrissoTM*<s>
Custom
Comprehensive
Custom Select
1 tablet per day (Limited to 15 day supply per fill)
8 capsules per day
4 vials per month
2 tablets per day (Limited to 15 day supply per fill)
1 tablet per day (Limited to 15 day supply per fill)
1 tablet per day (Limited to 15 day supply per fill)
2 tablets per day (Limited to 15 day supply per fill)
1 tablet per day (Limited to 15 day supply per fill)
4 cards (1 box) per 28 days
(Limited to 15 day supply per fill)
63 tablets per 28 days
1 capsule per day (Limited to 15 day supply per fill)
Limited to 15 day supply per fill
6 capsules per 21 days
Limited to 15 day supply per fill
1 tablet per day (Limited to 15 day supply per fill)
21 capsules per 28 days
1 tablet per day (Limited to 15 day supply per fill)
4 tablets per day (Limited to 15 day supply per fill)
6 tablets per day (Limited to 15 day supply per fill)
4 tablets per day (Limited to 15 day supply per fill)
1 tablet per day
Limited to 15 day supply per fill
2 tablets per day (Limited to 15 day supply per fill)
3 capsules per day (Limited to 15 day supply per fill)
80 tablets per 28 days
16 capsules per day (Limited to 15 day supply per fill)
1 tablet per day
2 syringes per month
Excluded
2 syringes per month
4 tablets per day (Limited to 15 day supply per fill)
3 capsules per 28 days
1 tablet per day (Limited to 15 day supply per fill)
1 capsule per day
1 capsule per day
4 tablets per day
1 capsule per day (Limited to 15 day supply per fill)
Limited to 15 day supply per fill
1 kit (4 vials) per 28 days
4 capsules per day
1 tablet per day (Limited to 15 day supply per fill)
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Antineoplastics and Immunosuppressants (cont.)
Tarceva®*<s>
Targretin®*<s>
Tasigna®*<s>
Valchlor® (Nonpreferred)*<s>
VenclextaTM*<s>
Votrient®*<s>
Xalkori®*<s>
Xtandi®* <s>
Zelboraf®* <s>
Zolinza®*<s>
Zydelig®*<s>
ZykadiaTM* <s>
Zytiga® (Nonpreferred)* <s>
Antipsychotics
Invega® 1.5mg, 3mg, 9mg (g)*
Invega® 6mg (g)*
Nuplazid™ (Nonpreferred)*
Rexulti® (Nonpreferred)*
Saphris® (Nonpreferred)*
Seroquel XR® (g)*
VraylarTM (Nonpreferred)*
Antiretrovirals
Complera®
Descovy®
Edurant®
EvotazTM
Genvoya®
Odefsey®
Prezcobix TM
Stribild®
Triumeq®
Antivirals
DaklinzaTM (Nonpreferred)*<s>
Epclusa®* <s>
Harvoni® (Nonpreferred)*<s>
Olysio® (Nonpreferred)* <s>
Relenza®
Sovaldi® (Nonpreferred)*<s>
Tamiflu®
Tamiflu suspension
TechnivieTM (Nonpreferred)*<s>
Zepatier®* <s>
Comprehensive
Custom Select
Limited to 15 day supply per fill
Limited to 15 day supply per fill
4 capsules per day (Limited to 15 day supply per fill)
2 tubes (120gm) per month
4 tablets per day
Limited to 15 day supply per fill
2 capsules per day (Limited to 15 day supply per fill)
4 tablets per day (Limited to 15 day supply per fill)
8 tablets per day (Limited to 15 day supply per fill)
Limited to 15 day supply per fill
2 tablets per day (Limited to 15 day supply per fill)
5 capsules per day (Limited to 15 day supply per fill)
4 tablets per day (Limited to 15 day supply per fill)
Custom
Comprehensive
Custom Select
1 tablet per day
2 tablets per day
2 tablets per day
1 tablet per day
Excluded
2 tablets per day
2 tablets per day
1 tablet per day
Custom
Comprehensive
Custom Select
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
Custom
Comprehensive
Custom Select
1 tablet per day
1 tablet per day
1 tablet per day
1 capsule per day
1 inhaler per Rx, 2 Rx per 270 days
1 tablet per day
10 capsules per Rx, 2 Rx per 270 days
180mL per Rx
2 tablets per day
1 tablet per day
Custom
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Bowel Preparation and Cleansing Agents
OTC and prescription products - Generic only
Cardiovascular
Azor®* (g)
Benicar, HCT®* (g)
Brilinta®
Bystolic® 2.5, 5, &10mg (Nonpreferred)*
ByvalsonTM (Nonpreferred)*
Caduet® (g)
Coreg CR® (Nonpreferred)*
Corlanor®*
Edarbi® (Nonpreferred)*
Edarbyclor® (Nonpreferred)*
Effient®
Eliquis®
EntrestoTM (Nonpreferred)*
Hemangeol® (Nonpreferred)
Multaq®
Northera™ (Nonpreferred)*<s> 100mg, 200mg
Northera™ (Nonpreferred)*<s> 300mg
Plavix® (g)
Pradaxa®
Prestalia® (Nonpreferred)*
Savaysa® (Nonpreferred)
Tekamlo® (Nonpreferred)*
Tribenzor®* (g)
Xarelto®
Xarelto® 15mg
Xarelto® starter kit
Zontivity® (Nonpreferred)
Chelating Agents
Depen®
Ferriprox® tablet (Nonpreferred)* <s>
Ferriprox® oral solution (Nonpreferred)* <s>
Syprine® (Nonpreferred)* <s>
Dermatology
Aczone® (Nonpreferred)
Aldara® (g)
Cosentyx™*<s>
Enbrel®* <s>
Custom
Comprehensive
Custom Select
One bowel preparation regimen per year with $0 copay (for
colonoscopy screening of colorectal cancer only)
Custom
Comprehensive
Custom Select
1 tablet per day
1 tablet per day
2 tablets per day
1 tablet per day
1 tablet per day
1 tablet per day
1 capsule per day
Excluded
2 tablets per day
1 tablet per day
1 tablet per day
1 tablet per day
74 tablets per month
2 tablets per day
3 bottles (360mL) per month
Excluded
2 tablets per day
3 tablets per day
Excluded
6 tablets per day
Excluded
1.2 tablets per day
2 capsules per day
1 tablet per day
Excluded
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
51 tablets per month
1 starter kit per 2 years
1 tablet per day
Custom
Comprehensive
Custom Select
8 capsules per day
540 tablets per month
2,700mL per month
8 capsules per day
Custom
Comprehensive
Custom Select
1 tube (60gm) per Rx
Excluded
1 packet per day
Initial dosing limited to 8 pens for the first month, 2 pens per
month thereafter
4 syringes per 28 days
Psoriasis only: 1 injection twice weekly (8 injections per
month) for the first 3 months.
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Dermatology (cont.)
Humira® <s>
Humira Crohn's kit <s>
Humira Psoriasis kit <s>
Picato® (Nonpreferred)*
Regranex® (Nonpreferred)
Stelara®* <s>
Taltz® (Nonpreferred)* <s>
Taltz® 2-pack (Nonpreferred)* <s>
Taltz® 3-pack (Nonpreferred)* <s>
Vusion® (Nonpreferred)
ZyclaraTM packet (Nonpreferred)
Zyclara pump (Nonpreferred)
Diagnostic and Other Miscellaneous
Firazyr® (Nonpreferred)* <s>
KeveyisTM (Nonpreferred)* <s>
Lysteda® (g)
Ruconest® (Nonpreferred)* <s>
Vistogard®* <s>
Contraceptives and Estrogens/Combinations
Alora®
Climara® (g), Pro® (Nonpreferred)
Combipatch® (Nonpreferred)
Ella® (Nonpreferred)
Estring®
Evamist® (Nonpreferred)
Femring® (Nonpreferred)
Menostar® (Nonpreferred)
Minivelle® (Nonpreferred)
Nuvaring® (Nonpreferred)
Ortho Evra® (g)
Vivelle-Dot® (g)
Wide Seal® diaphragms
Gastrointestinal
Aciphex® Sprinkle™(Nonpreferred)*
Amitiza® (Nonpreferred)*
Cimzia® (Nonpreferred)* <s>
Cimzia® starter kit (Nonpreferred)* <s>
DexilantTM (Nonpreferred)*
Gattex®* <s>
Giazo® (Nonpreferred)
HalfLytely-Bisacodyl® (g)
Custom
Comprehensive
Custom Select
1 kit (2 syringes of 0.8mL) per 28 days
1 kit (6 syringes) per year
1 kit (4 syringes) per year
1 carton per month
3 tubes (45gm) per 150 days
Initial dosing limited to 2 syringes for the first month, 1
injection per 90 days thereafter
1 injection per month
Excluded
2 packs per year
Excluded
1 pack per year
Excluded
1 tube (50gm) per Rx
Excluded
1 packet per day
1 bottle (7.5gm) per month
Custom
Comprehensive
Custom Select
6 syringes (18mL) per month
4 tablets per day
30 tablets per fill
2 doses (4 vials) per month
20 packets per fill
Custom
Comprehensive
Custom Select
8 patches per 28 days
4 patches per 28 days
8 patches per 28 days
2 tablets per month
1 ring per 90 days
1 bottle (8.1mL) per month
1 ring per 90 days
4 patches per 28 days
8 patches per 28 days
1 ring per 28 days
3 patches per 28 days
8 patches per 28 days
1 unit per 90 days
Custom
Comprehensive
Custom Select
Excluded
2 capsules per day
Excluded
2 capsules per day
1 kit (2 syringes) per 28 days
1 starter kit per 2 years
Excluded
2 capsules per day
Excluded
1 kit (30 vials) per month
6 tablets per day
1 kit per Rx
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Gastrointestinal (cont.)
Humira® <s>
Humira Crohn's kit <s>
Humira Psoriasis kit <s>
Lialda® (Nonpreferred)
Linzess® (Nonpreferred)*
Lotronex® (g)
MovantikTM (Nonpreferred)*
Mytesi®*
Nexium® (Rx Only) (g)*
OcalivaTM*<s>
Rectiv® (Nonpreferred)
Relistor® syringe, vial*
Relistor tablet (Nonpreferred)*
Simponi® (Nonpreferred)* <s>
Stelara®* <s>
Uceris® (Nonpreferred)*
Viberzi™ (Nonpreferred)*
Xifaxan® 550mg (Nonpreferred)*
Zegerid® packet (g)*
Zegerid® capsule (g)*
Lipotropics
Altoprev® (Nonpreferred)*
Juxtapid® (Nonpreferred)* <s>
Kynamro®* <s>
Livalo® (Nonpreferred)*
Lovaza® (g)*
Praluent® (Nonpreferred)* <s>
Repatha® (Nonpreferred)* <s>
Vascepa® (Nonpreferred)*
Vytorin® (Nonpreferred)
Zetia® (g)
Migraine Therapy
AlsumaTM (g)
Amerge® (g)
Axert® (g)
Cafergot®
D.H.E. 45® (g)
Frova® (g)*
Imitrex® injection (g)
Imitrex® nasal spray (g)
Custom
Comprehensive
Custom Select
1 kit (2 syringes of 0.8mL) per 28 days
1 kit (6 syringes) per year
1 kit (4 syringes) per year
4 tablets per day
1 capsule per day
2 tablets per day
1 tablet per day
Excluded
2 tablets per day
Excluded
2 capsules per day
Excluded
1 tablet per day
1 tube (30gm) per Rx
30 vials per month
Excluded
3 tablets per day
Excluded
Initial dosing limited to 3 syringes for the first month, 1 syringe
per month thereafter
Initial dosing limited to 2 syringes for the first month, 1
injection per 90 days thereafter
1 tablet per day
Excluded
2 tablets per day
Excluded
2 tablets per day
Excluded
1 packet per day
Excluded
Excluded
1 capsule per day
Excluded
Custom
Comprehensive
Custom Select
1 tablet per day
Excluded
1 capsule per day
Excluded
4 syringes/vials per month
1 tablet per day
4 capsules per day
2 injections per month
3 injections per month
4 capsules per day
Excluded
1 tablet per day
1 tablet per day
Custom
Comprehensive
Custom Select
2 syringes per Rx
9 tablets per Rx
6 tablets per Rx
50 tablets per Rx
5 ampules per Rx
9 tablets per Rx
5 injections per Rx
6 units (1 box) per Rx
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Migraine Therapy
Imitrex® tablet (g)
Maxalt®, MLT® (g)
Migranal® nasal spray (g)
OnzetraTM XsailTM (Nonpreferred)*
Relpax® (Nonpreferred)*
Sumavel® Dosepro® (Nonpreferred)*
Treximet® (Nonpreferred)*
ZembraceTM SymtouchTM (Nonpreferred)*
Zomig® Nasal Spray (Nonpreferred)*
Zomig®, ZMT® 2.5mg (g)
Zomig®, ZMT® 5mg (g)
Miscellaneous CNS
Amrix® (Nonpreferred)
Conzip® (Nonpreferred)
Evzio®
Gralise® (Nonpreferred)*
Horizant® (Nonpreferred)*
Intuniv® (g)
Kapvay® (g)
Narcan® nasal spray
Nuedexta®*
Nymalize® (Nonpreferred)
Ryzolt® (g)
Savella® (Nonpreferred)*
Savella® Titration Pack (Nonpreferred)*
Soma® (g)*
Strattera® (Nonpreferred)*
Subutex® (g)*
Tramadol ER capsule (Nonpreferred)
Xenazine® (g)* <s>
Xyrem® (Nonpreferred)* <s>
Miscellaneous Endocrine
Cerdelga™ (Nonpreferred)* <s>
Egrifta® (Nonpreferred)* <s>
Korlym®* <s>
Myalept® (Nonpreferred)* <s>
Natpara® *<s>
Ravicti® (Nonpreferred)* <s>
Signifor®*<s>
Signifor® LAR (Nonpreferred)* <s>
Zavesca® (Nonpreferred)* <s>
Comprehensive
Custom Select
9 tablets per Rx
9 tablets per Rx
1 kit (8 vials) per Rx
1 dose kit per Rx
Excluded
6 tablets per Rx
2 injections per Rx
Excluded
9 tablets per Rx
Excluded
2 injections per Rx
Excluded
6 units per Rx
6 tablets per Rx
3 tablets per Rx
Custom
Comprehensive
Custom Select
30 capsules per 180 days
Excluded
1 capsule per day
Excluded
2 packages (4 auto-injectors) per Rx
3 tablets per day
Excluded
1 tablet per day
Excluded
1 tablet per day
Excluded
4 tablets per day
2 packages (4 sprays) per Rx
2 tablets per day
120mL per day/2 Rxs per year
1 tablet per day
2 tablets per day
1 pack per 180 days
N/A
4 tablets per day
2 capsules per day
3 tablets per day
1 capsule per day
Excluded
1 tablet per day
18mL (9gm) per day
Custom
Comprehensive
Custom Select
2 capsules per day
1 vial per day
Excluded
4 tablets per day
1 vial per day
2 pens per month
19gm (17.5mL) per day
2mL per day
1 kit per month
Excluded
3 capsules per day
Custom
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Miscellaneous OB-GYN
Custom
Comprehensive
Custom Select
Brisdelle® (Nonpreferred)*
1 capsule per day
Excluded
Multiple Sclerosis
Custom
Comprehensive
Custom Select
Ampyra® (Nonpreferred)* <s>
2 tablets per day
Aubagio® (Nonpreferred)*<s>
1 tablet per day
®
Gilenya <s>
1 capsule per day
®
TM
Pegasys , Proclick <s>
4 injections per 28 days
Peg-Intron®, Redipen <s>
4 injections per 28 days
®
Plegridy (Nonpreferred)* <s>
1 carton per month
Excluded
®
Tecfidera <s>
2 capsules per day
Zinbryta (Nonpreferred)* <s>
1 injection per month
Excluded
Narcotics/Analgelsic Combinations
Custom
Comprehensive
Custom Select
Click here to see quantity limits for Narcotics/Analgesic Combinations
NSAIDs
Custom
Comprehensive
Custom Select
®
Flector (Nonpreferred)*
30 patches per month
Excluded
Sprix® (Nonpreferred)
5 bottles (630mg) per 28 days
Excluded
®
Toradol tablet (g)
20 tablets every 26 days
®
Voltaren gel (g)
4 tubes (400gm) per 28 days
Opthalmology
Custom
Comprehensive
Custom Select
TM
Cystaran *<s>
3 bottles (45mL) per month
Osteoporosis
Custom
Comprehensive
Custom Select
®
Atelvia (g)*
4 tablets per 28 days
®
Binosto (Nonpreferred)*
4 tablets per 28 days
Excluded
Forteo® (Nonpreferred)* <s>
1 pen per 28 days
Fosamax Plus D® (Nonpreferred)*
4 tablets per 28 days
Excluded
Parkinson's Disease
Custom
Comprehensive
Custom Select
DuopaTM *<s>
1 vial per day
®
®
Mirapex ER (g)*
1 tablet per day
Excluded
Neupro® (Nonpreferred)*
1 patch per day
Excluded
®
Rytary (Nonpreferred)*
12 capsules per day
Excluded
®
Zelapar (Nonpreferred)
2 tablets per day
Respiratory
Custom
Comprehensive
Custom Select
®
Adcirca * <s>
2 tablets per day
Adempas®* <s>
3 tablets per day
®
®
Anoro Ellipta (Nonpreferred)
1 inhaler per month
®
Arcapta Neohaler (Nonpreferred)
1 capsule per day
Bethkis® (Nonpreferred)* <s>
56 ampules per 42 days
Excluded
Bevespi Aerosphere™(Nonpreferred)
1 inhaler (10.7g) per month
Excluded
®
®
Breo Ellipta (Nonpreferred)
2 inhalations per day
Excluded
Brovana® (Nonpreferred)*
2 vials (4mL) per day
Cayston® (Nonpreferred)* <s>
1 kit (84 vials) per 42 days
Dulera®
1 inhaler (13g) per month
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Respiratory (cont.)
Daliresp® (Nonpreferred)*
Epinephrine auto-injector
Esbriet® (Nonpreferred)* <s>
Grastek® (Nonpreferred)*
Kalydeco®* <s>
Letairis®* <s>
Ofev® (Nonpreferred)* <s>
Opsumit®* <s>
Oralair® (Nonpreferred)*
Orenitram® ER* <s>
Orkambi™* <s>
Perforomist® (Nonpreferred)*
Ragwitek® (Nonpreferred)*
Revatio® (g)*
Stiolto™ Respimat®
Striverdi® Respimat® (Nonpreferred)
Tracleer®* <s>
Tudorza Pressair® (Nonpreferred)
Tyvaso® starter kit*<s>
Tyvaso® refill/replacement kit* <s>
Tyvaso® vials* <s>
Uptravi®* <s>
Ventavis®* <s>
Zyflo CR® (Nonpreferred)
Rheumatology
Actemra® subcutaneous* <s>
Cimzia® (Nonpreferred)* <s>
Cimzia® starter kit (Nonpreferred)* <s>
Cosentyx™*<s>
Enbrel®* <s>
Humira® <s>
Humira Crohn's kit <s>
Humira Psoriasis kit <s>
Kineret®(Nonpreferred)* <s>
Orencia® (Nonpreferred)* <s>
Otezla®* <s>
OtrexupTM (Nonpreferred)* <s>
Rasuvo® (Nonpreferred)* <s>
Taltz® (Nonpreferred)* <s>
Comprehensive
Custom Select
1 tablet per day
4 pens per fill, max 16 pens per year
9 capsules per day
1 tablet per day
Excluded
2 tablets or packets per day
1 tablet per day
2 capsules per day
1 tablet per day
1 tablet per day
Excluded
12.5mg per day
4 tablets per day
2 vials (4mL) per day
1 tablet per day
Excluded
3 tablets per day
1 inhaler (4g) per month
1 inhaler (4g) per month
Excluded
2 tablets per day
1 inhaler per month
1 kit per year
1 kit (82mL) per month
4 ampules (12mL) per month
2 tablets per day
270 ampules per month
4 tablets per day
Custom
Comprehensive
Custom Select
4 syringes per 28 days
1 kit (2 syringes) per 28 days
1 starter kit per 2 years
Initial dosing limited to 8 pens for the first month, 2 pens per
month thereafter
4 syringes per 28 days
1 kit (2 syringes of 0.8mL) per 28 days
1 kit (6 syringes) per year
1 kit (4 syringes) per year
30 syringes per month
4 syringes (4mL) per 28 days
2 tablets per day
4 syringes per 28 days
Excluded
4 syringes per 28 days
Excluded
1 injection per month
Excluded
Custom
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Rheumatology (cont.)
Taltz® 2-pack (Nonpreferred)* <s>
Taltz® 3-pack (Nonpreferred)* <s>
Uloric®*
Xeljanz®* <s>
Xeljanz® XR* <s>
Zurampic® (Nonpreferred)*
Sedative/Hypnotics
Ambien CR® (g)
Belsomra® (Nonpreferred)*
Edluar® (Nonpreferred)*
HetliozTM (Nonpreferred)* <s>
Intermezzo® (g)*
Silenor® (Nonpreferred)*
Zolpimist® (Nonpreferred)*
Sexual Dysfunction
AddyiTM (Nonpreferred)*
Caverject®
Cialis®*
Edex® (Nonpreferred)
Levitra® (Nonpreferred)*
Muse®
Revatio® (g)
Staxyn® (Nonpreferred)*
Stendra® (Nonpreferred)*
Viagra®*
Smoking Cessation
Chantix®
Nicotrol, NS®*
Over-the-Counter Nicotine Patch, Gum, Lozenge
Stimulants
Adderall® (g)
Adderall XR®
Adderall XR® (g)*
Adzenys XR-ODT™ (Nonpreferred)*
Aptensio XR™ (Nonpreferred)
Concerta® (g)
Daytrana® (Nonpreferred)
Desoxyn® (g)
Dexedrine® (g)
Custom
Custom Select
Excluded
Excluded
Comprehensive
2 packs per year
1 pack per year
1 tablet per day
2 tablets per day
1 tablet per day
1 tablet per day
Custom
Comprehensive
1 tablet per day
1 tablet per day
1 tablet per day
1 capsule per day
25 tablets per month,
57 tablets per 90 days
1 tablet per day
1 bottle (7.7mL) per month
Custom
Comprehensive
1 tablet per day
Excluded
Custom Select
Excluded
Excluded
Excluded
Excluded
Excluded
Custom Select
Excluded
6 units per 28 days
Excluded
1 tablet per day
Excluded for use as
Sexual Dysfunction
agent
6 units per 28 days
Excluded
Custom
Comprehensive
Custom Select
1 fill/month and 6 fills/year
Comprehensive
Custom Select
4 tablets per day
2 capsules per day
Excluded
2 capsules per day
2 tablets per day
Excluded
1 capsule per day
Excluded
2 tablets per day
1 patch per day
5 tablets per day
4 tablets/capsules per day
Custom
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Stimulants
Dyanavel™ XR (Nonpreferred)*
Evekeo™ (Nonpreferred)
Focalin® (g)
Focalin® XR 25, 35mg (Nonpreferred)
Focalin® XR (g)
Metadate CD® (g) 10, 20, 30mg
Metadate CD® (g) 40, 50, 60mg
Methylin® chew (g)
Methylin® (g); Ritalin (g)
Methylin® ER (g); Ritalin-SR (g)
Methylin® solution (g)
Nuvigil® (g)*
Procentra® (g)*
Provigil® (g)*
Quillichew ER™ (Nonpreferred)*
Quillivant XR™ (Nonpreferred)*
Ritalin LA® 10mg (Nonpreferred)
Ritalin LA® 20, 30mg (g)
Ritalin LA® 40mg (g)
Ritalin LA® 60mg (Nonpreferred)
Vyvanse® (Nonpreferred)*
Zenzedi®
Testosterone Replacement
Androderm®*
Androgel 1% gel packets® (g)*
Androgel 1% pump® (g)*
Androgel 1.62% pump®*
Android® (g)*
Androxy™ (g)*
Axiron® (Nonpreferred)*
Fortesta® (Nonpreferred)*
Methitest™ (Nonpreferred)*
Natesto™ (Nonpreferred)*
Striant® (Nonpreferred)*
Testim® (Nonpreferred)*
TestosteroneTM gel (Nonpreferred)*
TestosteroneTM pump (Nonpreferred)*
TestosteroneTM packets (Nonpreferred)*
Testred® (g)*
VogelxoTM pump (Nonpreferred)*
VogelxoTM packets (Nonpreferred)*
Custom
Comprehensive
8mL per day
4 tablets per day
3 tablets per day
2 capsules per day
Custom Select
Excluded
Excluded
Excluded
Excluded
3 capsules per day
2 capsules per day
10 tablets per day
Excluded
7 tablets per day
6 tablets per day
80mg per day
1 tablet per day
60mL (60mg) per day
2 tablets per day
60mg per day
Excluded
12mL (60mg) per day
Excluded
4 capsules per day
4 capsules per day
3 capsules per day
2 capsules per day
1 capsule per day
4 tablets per day
Custom
Comprehensive
Custom Select
30 patches per month
30 packets (150gm) per month
2 bottles (150gm) per month
1 bottle (75gm) per month
1 tablet per day
Excluded
1 tablet per day
1 bottle (90mL) per month
Excluded
1 bottle (60gm) per month
Excluded
1 tablet per day
3 bottles (22gm) per month
Excluded
2 buccal systems per day
Excluded
30 tubes (150gm) per month
Excluded
30 tubes (150gm) per month
Excluded
2 bottles (150gm) per month
Excluded
30 packets (150gm) per month
Excluded
1 capsule per day
Excluded
2 bottles (150gm) per month
Excluded
30 packets (150gm) per month
Excluded
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Urology
Cialis 2.5mg, 5mg*
Gelnique® packet (Nonpreferred)
Jalyn®* (g)
Myrbetriq®(Nonpreferred)*
Oxytrol® (Nonpreferred)
Procysbi® 25mg (Nonpreferred)* <s>
Rapaflo® (Nonpreferred)
Sanctura XR® (g)
Toviaz® (Nonpreferred for Custom Select)
Xuriden™* <s>
Weight Reduction
Adipex-P® (g)
Belviq® (Nonpreferred)*
Belviq XR (Nonpreferred)*
Bontril® (g)
Contrave® ER (Nonpreferred)*
Didrex® (g)
Lomaira™ (Nonpreferred)
Qsymia® (Nonpreferred)*
Regimex® (g)
Regimex tablet (Nonpreferred)
Saxenda® (Nonpreferred)*
Tenuate® (g)
Xenical® (Nonpreferred)*
Custom
Comprehensive
1 tablet per day
1 packet per day
1 capsule per day
1 tablet per day
8 patches per 28 days
2 capsules per day
1 capsule per day
1 capsule per day
1 tablet per day
4 cartons per month
Custom
Comprehensive
Max 12 month supply
2 tablets per day, max 12 month supply
1 tablet per day, max 12 month supply
Max 12 month per lifetime
4 tablets per day, max 12 month supply
Max 12 month supply
Custom Select
Excluded
Excluded
Excluded
Excluded
Custom Select
Excluded
5 pens (15mL) per month, max 12 month
supply
Max 12 month supply
Max 24 month supply
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Narcotics/Analgelsic Combinations
Abstral® (Nonpreferred)*
Actiq® (g)*
Avinza® (g)
BelbucaTM (Nonpreferred)*
Butrans® (Nonpreferred)*
Capital® w-Codeine (g)
Codeine sulfate (g)
Combunox® (g)
DemerolTM (g)
Dilaudid® (g)
Duragesic Patch® (g)
Embeda® (Nonpreferred)*
Esgic, Fioricet® 325mg (g)
Exalgo® (g)*
Fentanyl 37.5 62.5, 87.5mg
(Nonpreferred)
Fentora® (Nonpreferred)*
Fioricet® 300mg (g)*
Fioricet® w/codeine (g)*
Hycet® (g)
Hysingla® ER (Nonpreferred)*
Ibudone® (g)
Ibudone 5/200mg
Kadian® (g)
Kadian 40mg, 200mg (Nonpreferred)
Lazanda® (Nonpreferred)*
Levorphanol tartrate
Lortab solution (Nonpreferred)
Methadone (g)
MS Contin (g)
MSIR (g)
Norco®, Vicodin®, Xodol® (g)
Nucynta® (Nonpreferred)*
Nucynta® ER (Nonpreferred)*
Opana® (g)
Opana ER® (g)*
OxaydoTM (Nonpreferred)
Oxycodone IR (g)
Oxycodone 5mg/5mL solution
Oxycodone 20mg/mL solution
Oxycodone hcl ER (Nonpreferred)*
Oxycontin® (Nonpreferred)*
Custom
Comprehensive
Custom Select
4 tablets per day
Excluded
4 lozenges per day
1 capsule per day
Excluded
2 tablets per day
Excluded
4 patches per 28 days
15-day 30-day
limit
limit
Yes
Yes
Yes
Yes
Yes
10 patches per month
2 capsules per day
Excluded
4 grams APAP per day
4 tablets per day
10 patches per month
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Excluded
Yes
4 tablets per day
Excluded
4 grams APAP per day
4 grams APAP per day
Yes
1 tablet per day
Excluded
Yes
Yes
1 bottle (5mL) per day
Yes
Yes
Yes
Yes
Yes
Yes
Excluded
Yes
Yes
4 grams APAP per day
6 tablets per day
2 tablets per day
Yes
Yes
Yes
Yes
4 tablets per day
Excluded
6 tablets per day/5,400mg per
Excluded
month
6 tablets per day/5,400mg per month
180mL(180mg) per day
5mL (100mg) per day
4 tablets per day
4 tablets per day
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
R001070
Blue Care Network Quantity Limits
January 2017
Narcotics/Analgelsic Combinations
(cont.)
Percocet® (g)
Percodan (g)
PrimlevTM (Nonpreferred)
RMS® suppository (g)
Roxanol (g)
RoxicetTM (g)
Stadol, NS (g)
Subsys® (Nonpreferred)*
Synalogos-DC® (g)
Talwin NX (g)
TrezixTM (g)
Tylenol® #3, #4 (g)
Ultracet® (g)
Vicoprofen® (g)
XartemisTM XR (Nonpreferred)*
Zamicet (g)
Zohydro® ER (Nonpreferred)*
Custom
Comprehensive
Custom Select
4 grams APAP per day
4 grams APAP per day
Excluded
4 units per day
Excluded
15-day 30-day
limit
limit
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
4 grams APAP per day
Excluded
4 grams APAP per day
4 grams APAP per day
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
4 tablets per day
Yes
2 capsules per day
These limits do not apply to BCN Advantage members.
* Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines
available on the web at: bcbsm.com/rxinfo.
<s> Specialty drug (g) generic drug
Dec. 16 r3
R001070