Medications with Quantity Limits
Updated May 2017
A quantity limit (QL) defines how much of a particular drug patients can get during a specific time period (days supply limit) or the
maximum days supply that patients can get at once (quantity per days supply limit). The Kaiser Permanente Pharmacy and
Therapeutics Committee determines if a drug should have a quantity limit. Quantity limits are put in place for medications that are FDAapproved for short-term use, for medications that may result in adverse effects when overused, or for medications that may be
inappropriately overused. Prescriptions for quantities or durations above specified limits may be reviewed for medical necessity. Drug
specific formulary status, plan benefits, and other utilization management (e.g., prior authorization, step therapy) apply.
KEY
Dispensing unit = standard metric unit per dispense (e.g., number of tablets, volume of transdermal gel, number of pens for injection)
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ABILIFY MAIN INJ 300MG
INTRAMUSCULAR
Days supply limit is 30 days
ABILIFY MAIN INJ 400MG
INTRAMUSCULAR
Days supply limit is 30 days
8-MOP
CAP 10MG
ABACAV/LAMIV TAB /ZIDOVUD
QUANTITY PER DAYS SUPPLY LIMIT
ABSTRAL
SUB 100MCG
SUBLINGUAL
Days supply limit is 30 days
ABSTRAL
SUB 200MCG
SUBLINGUAL
Days supply limit is 30 days
ABSTRAL
SUB 300MCG
SUBLINGUAL
Days supply limit is 30 days
ABSTRAL
SUB 400MCG
SUBLINGUAL
Days supply limit is 30 days
ABSTRAL
SUB 600MCG
SUBLINGUAL
Days supply limit is 30 days
ABSTRAL
SUB 800MCG
SUBLINGUAL
Days supply limit is 30 days
ACTEMRA
INJ 162/0.9
SUBCUTANEOUS
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
ACTIMMUNE
INJ 2MU/0.5
ACTIQ
LOZ 1200MCG
BUCCAL
Days supply limit is 30 days
ACTIQ
LOZ 1600MCG
BUCCAL
Days supply limit is 30 days
ACTIQ
LOZ 200MCG
BUCCAL
Days supply limit is 30 days
1
Quantity limited to
4
dispensing units per
28
days
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
ACTIQ
LOZ 400MCG
BUCCAL
Days supply limit is 30 days
ACTIQ
LOZ 600MCG
BUCCAL
Days supply limit is 30 days
ACTIQ
LOZ 800MCG
BUCCAL
Days supply limit is 30 days
TAB 20MG
ORAL
Days supply limit is 30 days
ADCIRCA
QUANTITY PER DAYS SUPPLY LIMIT
ADDERALL XR CAP 10MG
ORAL
Quantity limited to
30
dispensing units per
30
days
ADDERALL XR CAP 15MG
ORAL
Quantity limited to
30
dispensing units per
30
days
ADDERALL XR CAP 20MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ADDERALL XR CAP 25MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ADDERALL XR CAP 30MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ADDERALL XR CAP 5MG
ORAL
Quantity limited to
30
dispensing units per
30
days
ADEFOV DIPIV TAB 10MG
ORAL
Days supply limit is 30 days
ADEMPAS
TAB 0.5MG
ORAL
Days supply limit is 30 days
ADEMPAS
TAB 1.5MG
ORAL
Days supply limit is 30 days
ADEMPAS
TAB 1MG
ORAL
Days supply limit is 30 days
ADEMPAS
TAB 2.5MG
ORAL
Days supply limit is 30 days
ADEMPAS
TAB 2MG
ORAL
Days supply limit is 30 days
AFINITOR
TAB 10MG
ORAL
Days supply limit is 30 days
AFINITOR
TAB 2.5MG
ORAL
Days supply limit is 30 days
AFINITOR
TAB 5MG
ORAL
Days supply limit is 30 days
AFINITOR
TAB 7.5MG
ORAL
Days supply limit is 30 days
AFINITOR DIS TAB 2MG
ORAL
Days supply limit is 30 days
AFINITOR DIS TAB 3MG
ORAL
Days supply limit is 30 days
AFINITOR DIS TAB 5MG
ORAL
Days supply limit is 30 days
ALECENSA
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ALKERAN
CAP 150MG
TAB 2MG
ALMOTRIP MAL TAB 12.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ALMOTRIP MAL TAB 6.25MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ALMOTRIPTAN TAB 12.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ALMOTRIPTAN TAB 6.25MG
ORAL
Quantity limited to
9
dispensing units per
30
days
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
ALSUMA
INJ 6MG/0.5
AMERGE
TAB 1MG
ORAL
Quantity limited to
9
dispensing units per
30
days
AMERGE
TAB 2.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
2
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
AMITIZA
CAP 8MCG
ORAL
Quantity limited to
120
dispensing units per
30
days
AMITIZA
CAP 24MCG
ORAL
Quantity limited to
120
dispensing units per
30
days
AMPHETAMINE CAP 10MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
AMPHETAMINE CAP 15MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
AMPHETAMINE CAP 20MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
AMPHETAMINE CAP 25MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
AMPHETAMINE CAP 30MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
AMPHETAMINE CAP 5MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
AMPYRA
ORAL
TAB 10MG
Days supply limit is 30 days
ANDRODERM
DIS 2MG/24HR
TRANSDERMAL
Quantity limited to
30
dispensing units per
30
days
ANDRODERM
DIS 4MG/24HR
TRANSDERMAL
Quantity limited to
30
dispensing units per
30
days
ANDROGEL
GEL 1%(25MG)
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
ANDROGEL
GEL 1%(50MG)
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
ANDROGEL
GEL 1.62%
TRANSDERMAL
Quantity limited to
75
dispensing units per
30
days
ANDROGEL
GEL PUMP 1%
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
APAP/CAFF/DI TAB HYDROCOD
ORAL
Quantity limited to
150
dispensing units per
30
days
APAP/CODEINE SOL 120-12/5
ORAL
Quantity limited to
5000
dispensing units per
30
days
APAP/CODEINE TAB 300-15MG
ORAL
Quantity limited to
360
dispensing units per
30
days
APAP/CODEINE TAB 300-30MG
ORAL
Quantity limited to
360
dispensing units per
30
days
APAP/CODEINE TAB 300-60MG
ORAL
Quantity limited to
180
dispensing units per
30
days
APOKYN
INJ 10MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
APTIOM
TAB 200MG
ORAL
Days supply limit is 30 days
APTIOM
TAB 400MG
ORAL
Days supply limit is 30 days
APTIOM
TAB 600MG
ORAL
Days supply limit is 30 days
APTIOM
TAB 800MG
ORAL
Days supply limit is 30 days
APTIVUS
CAP 250MG
ORAL
Days supply limit is 30 days
APTIVUS
SOL
ORAL
Days supply limit is 30 days
ARANESP
INJ 100MCG
INJECTION
Days supply limit is 30 days
ARANESP
INJ 10MCG
INJECTION
Days supply limit is 30 days
ARANESP
INJ 150MCG
INJECTION
Days supply limit is 30 days
ARANESP
INJ 200MCG
INJECTION
Days supply limit is 30 days
ARANESP
INJ 25MCG
INJECTION
Days supply limit is 30 days
3
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
ARANESP
INJ 300MCG
INJECTION
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
ARANESP
INJ 40MCG
INJECTION
Days supply limit is 30 days
ARANESP
INJ 500MCG
INJECTION
Days supply limit is 30 days
ARANESP
INJ 60MCG
INJECTION
Days supply limit is 30 days
ARCALYST
INJ 220MG
SUBCUTANEOUS
Days supply limit is 30 days
ARIXTRA
INJ 10/0.8ML
SUBCUTANEOUS
Days supply limit is 30 days
ARIXTRA
INJ 2.5/0.5
SUBCUTANEOUS
Days supply limit is 30 days
ARIXTRA
INJ 5/0.4ML
SUBCUTANEOUS
Days supply limit is 30 days
ARIXTRA
INJ 7.5/0.6
SUBCUTANEOUS
Days supply limit is 30 days
ATRIPLA
TAB
ORAL
Days supply limit is 30 days
AUBAGIO
TAB 14MG
ORAL
Days supply limit is 30 days
Quantity limited to
28
dispensing units per
28
days
AUBAGIO
TAB 7MG
ORAL
Days supply limit is 30 days
Quantity limited to
28
dispensing units per
28
days
AVINZA
CAP 120MG
ORAL
Quantity limited to
60
dispensing units per
30
days
AVINZA
CAP 30MG
ORAL
Quantity limited to
30
dispensing units per
30
days
AVINZA
CAP 45MG
ORAL
Quantity limited to
30
dispensing units per
30
days
AVINZA
CAP 60MG
ORAL
Quantity limited to
30
dispensing units per
30
days
AVINZA
CAP 75MG
ORAL
Quantity limited to
30
dispensing units per
30
days
AVINZA
CAP 90MG
ORAL
Quantity limited to
30
dispensing units per
30
days
AVONEX
KIT 30MCG
INTRAMUSCULAR
Days supply limit is 30 days
Quantity limited to
4
dispensing units per
28
days
AVONEX PEN KIT 30MCG
INTRAMUSCULAR
Days supply limit is 30 days
Quantity limited to
5
dispensing units per
30
days
AVONEX PREFL KIT 30MCG
INTRAMUSCULAR
Days supply limit is 30 days
Quantity limited to
5
dispensing units per
30
days
AXERT
TAB 12.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
AXERT
TAB 6.25MG
ORAL
Quantity limited to
9
dispensing units per
30
days
AXIRON
SOL 30MG/ACT
TRANSDERMAL
Quantity limited to
180
dispensing units per
30
days
BARACLUDE
SOL .05MG/ML
ORAL
Days supply limit is 30 days
BARACLUDE
TAB 0.5MG
ORAL
Days supply limit is 30 days
BARACLUDE
TAB 1MG
ORAL
Days supply limit is 30 days
BELBUCA
MIS 150MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
BELBUCA
MIS 300MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
BELBUCA
MIS 450MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
BELBUCA
MIS 600MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
BELBUCA
MIS 750MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
4
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
BELBUCA
MIS 75MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
BELBUCA
MIS 900MCG
BUCCAL
Quantity limited to
60
dispensing units per
30
days
BERINERT
INJ 500UNIT
INTRAVENOUS
Days supply limit is 30 days
INJ 0.3MG
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
15
dispensing units per
28
days
INHALATION
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ORAL
Quantity limited to
180
dispensing units per
30
days
BETASERON
BETHKIS
NEB 300/4ML
BEXAROTENE
CAP 75MG
BOSULIF
TAB 100MG
ORAL
Days supply limit is 30 days
BOSULIF
TAB 500MG
ORAL
Days supply limit is 30 days
BRINTELLIX TAB 10MG
ORAL
Days supply limit is 30 days
BRINTELLIX TAB 20MG
ORAL
Days supply limit is 30 days
BRINTELLIX TAB 5MG
ORAL
Days supply limit is 30 days
BUPHENYL
POW
ORAL
Days supply limit is 30 days
BUPHENYL
TAB 500MG
ORAL
Days supply limit is 30 days
BUT/APAP/CAF CAP CODEINE
BUTRANS
DIS 10MCG/HR
TRANSDERMAL
Quantity limited to
4
dispensing units per
30
days
BUTRANS
DIS 15MCG/HR
TRANSDERMAL
Quantity limited to
4
dispensing units per
30
days
BUTRANS
DIS 20MCG/HR
TRANSDERMAL
Quantity limited to
4
dispensing units per
30
days
BUTRANS
DIS 5MCG/HR
TRANSDERMAL
Quantity limited to
4
dispensing units per
30
days
BUTRANS
DIS 7.5/HR
TRANSDERMAL
Quantity limited to
4
dispensing units per
30
days
Quantity limited to
5000
dispensing units per
30
days
CAPECITABINE TAB 150MG
ORAL
Days supply limit is 30 days
CAPECITABINE TAB 500MG
ORAL
Days supply limit is 30 days
CAPITAL/COD SUS 120-12/5
ORAL
CAPRELSA
TAB 100MG
ORAL
Days supply limit is 30 days
CAPRELSA
TAB 300MG
ORAL
Days supply limit is 30 days
EXTERNAL
Days supply limit is 30 days
CARAC
CRE 0.5%
CARBAGLU
CAYSTON
TAB 200MG
INH 75MG
CERDELGA
CAP 84MG
ORAL
Days supply limit is 30 days
INHALATION
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
CIMZIA
KIT
SUBCUTANEOUS
Days supply limit is 30 days
CIMZIA
KIT STARTER
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
1
dispensing units per
28
days
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
1
dispensing units per
28
days
INTRAVENOUS
Days supply limit is 30 days
Quantity limited to
1
dispensing units per
28
days
CIMZIA PREFL KIT 200MG/ML
CINRYZE
SOL 500 UNIT
5
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
COMETRIQ
KIT 100MG
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
COMETRIQ
KIT 140MG
ORAL
Days supply limit is 30 days
COMETRIQ
KIT 60MG
ORAL
Days supply limit is 30 days
COMPLERA
TAB
ORAL
Days supply limit is 30 days
CONCERTA
TAB 18MG
ORAL
Quantity limited to
30
dispensing units per
30
days
CONCERTA
TAB 27MG
ORAL
Quantity limited to
30
dispensing units per
30
days
CONCERTA
TAB 36MG
ORAL
Quantity limited to
60
dispensing units per
30
days
CONCERTA
TAB 54MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
CONZIP
CAP 100MG
CONZIP
CAP 200MG
ORAL
Quantity limited to
30
dispensing units per
30
days
CONZIP
CAP 300MG
ORAL
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
13
dispensing units per
28
days
SUBCUTANEOUS
Quantity limited to
1
dispensing units per
28
days
SUBCUTANEOUS
Quantity limited to
1
dispensing units per
28
days
COPAXONE
INJ 20MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
COPAXONE
INJ 40MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
COPEGUS
TAB 200MG
COSENTYX
INJ 150MG/ML
COSENTYX PEN INJ 150MG/ML
COTELLIC
CRESEMBA
TAB 20MG
CAP 186 MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
CUPRIMINE
CAP 250MG
DAYTRANA
DIS 10MG/9HR
TRANSDERMAL
Quantity limited to
30
dispensing units per
30
days
DAYTRANA
DIS 15MG/9HR
TRANSDERMAL
Quantity limited to
30
dispensing units per
30
days
DAYTRANA
DIS 20MG/9HR
TRANSDERMAL
Quantity limited to
30
dispensing units per
30
days
DAYTRANA
DIS 30MG/9HR
TRANSDERMAL
Quantity limited to
30
dispensing units per
30
days
DEPEN TITRA TAB 250MG
ORAL
Days supply limit is 30 days
DEPO-PROVERA INJ 150MG/ML
INTRAMUSCULAR
Days supply limit is 30 days
DEPO-PROVERA INJ 400/ML
INTRAMUSCULAR
Quantity limited to
1
dispensing units per
84
days
DEPO-SQ PROV INJ 104
SUBCUTANEOUS
Quantity limited to
1
dispensing units per
84
days
DESCOVY
TAB 200/25
ORAL
Days supply limit is 30 days
DEXEDRINE
CAP 10MG CR
ORAL
Quantity limited to
120
dispensing units per
30
days
DEXEDRINE
CAP 15MG CR
ORAL
Quantity limited to
120
dispensing units per
30
days
DEXEDRINE
CAP 5MG CR
ORAL
Quantity limited to
60
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
DEXMETHYLPH CAP 15MG ER
6
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
DEXMETHYLPH CAP 30MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
DEXMETHYLPH CAP 40MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
DEXMETHYLPHE CAP 10MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
DEXMETHYLPHE CAP 20MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
DEXMETHYLPHE CAP 5MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
DEXTROAMPHET CAP 10MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
DEXTROAMPHET CAP 15MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
DEXTROAMPHET CAP 5MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
DOLOPHINE
TAB 10MG
ORAL
Quantity limited to
180
dispensing units per
30
days
DOLOPHINE
TAB 5MG
ORAL
Quantity limited to
180
dispensing units per
30
days
DURAGESIC
DIS 100MCG/H
TRANSDERMAL
Quantity limited to
20
dispensing units per
30
days
DURAGESIC
DIS 12MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
DURAGESIC
DIS 25MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
DURAGESIC
DIS 50MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
DURAGESIC
DIS 75MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
ECOTRIN
TAB 325MG EC
ECOTRIN LOW TAB 81MG EC
ECPIRIN
TAB 325MG EC
EFUDEX
CRE 5%
EXTERNAL
Days supply limit is 30 days
EGRIFTA
SOL 1MG
SUBCUTANEOUS
Days supply limit is 30 days
EGRIFTA
SOL 2MG
SUBCUTANEOUS
Days supply limit is 30 days
EMCYT
CAP 140MG
ORAL
Days supply limit is 30 days
ENBREL
INJ 25/0.5ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
4
dispensing units per
28
days
ENBREL
INJ 25MG
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
9
dispensing units per
28
days
ENBREL
INJ 50MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
4
dispensing units per
28
days
SUBCUTANEOUS
Days supply limit is 30 days
ENBREL SRCLK INJ 50MG/ML
Quantity limited to
4
dispensing units per
28
days
ENDOCET
TAB 10-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
ENDOCET
TAB 2.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
ENDOCET
TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
ENDOCET
TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
ENOXAPARIN
INJ 100MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
ENOXAPARIN
INJ 120/0.8
SUBCUTANEOUS
Days supply limit is 30 days
7
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
ENOXAPARIN
INJ 150MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
ENOXAPARIN
INJ 30/0.3ML
SUBCUTANEOUS
Days supply limit is 30 days
ENOXAPARIN
INJ 300/3ML
INJECTION
Days supply limit is 30 days
ENOXAPARIN
INJ 40/0.4ML
SUBCUTANEOUS
Days supply limit is 30 days
ENOXAPARIN
INJ 60/0.6ML
SUBCUTANEOUS
Days supply limit is 30 days
ENOXAPARIN
INJ 80/0.8ML
SUBCUTANEOUS
Days supply limit is 30 days
ENTECAVIR
TAB 0.5MG
ORAL
Days supply limit is 30 days
ENTECAVIR
TAB 1MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
EPCLUSA
TAB 400-100
EPIVIR HBV SOL 5MG/ML
ORAL
Days supply limit is 30 days
EPOGEN
INJ 10000/ML
INJECTION
Days supply limit is 30 days
EPOGEN
INJ 2000/ML
INJECTION
Days supply limit is 30 days
EPOGEN
INJ 20000/ML
INJECTION
Days supply limit is 30 days
EPOGEN
INJ 3000/ML
INJECTION
Days supply limit is 30 days
EPOGEN
INJ 4000/ML
INJECTION
Days supply limit is 30 days
EPZICOM
TAB 600-300
ORAL
Days supply limit is 30 days
CAP 150MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
CAP 50MG
ORAL
Days supply limit is 30 days
EVOTAZ
TAB 300-150
ORAL
Days supply limit is 30 days
EXALGO
TAB 12MG
ORAL
Quantity limited to
30
dispensing units per
30
days
EXALGO
TAB 16MG
ORAL
Quantity limited to
30
dispensing units per
30
days
EXALGO
TAB 32MG
ORAL
Quantity limited to
60
dispensing units per
30
days
EXALGO
TAB 8MG
ORAL
Quantity limited to
30
dispensing units per
30
days
EXJADE
TAB 125MG
ORAL
Days supply limit is 30 days
EXJADE
TAB 250MG
ORAL
Days supply limit is 30 days
EXJADE
TAB 500MG
ORAL
Days supply limit is 30 days
EXTAVIA
INJ 0.3MG
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
15
dispensing units per
28
days
Quantity limited to
20
dispensing units per
30
days
ERIVEDGE
ESBRIET
ETOPOSIDE
CAP 267MG
FARYDAK
CAP 10MG
ORAL
Days supply limit is 30 days
FARYDAK
CAP 15MG
ORAL
Days supply limit is 30 days
FARYDAK
CAP 20MG
ORAL
Days supply limit is 30 days
FENTANYL
DIS 100MCG/H
TRANSDERMAL
8
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
FENTANYL
DIS 12MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
FENTANYL
DIS 25MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
FENTANYL
DIS 37.5MCG
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
FENTANYL
DIS 50MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
FENTANYL
DIS 62.5MCG
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
FENTANYL
DIS 75MCG/HR
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
FENTANYL
DIS 87.5MCG
TRANSDERMAL
Quantity limited to
15
dispensing units per
30
days
Quantity limited to
180
dispensing units per
30
days
FENTANYL OT LOZ 1200MCG
BUCCAL
Days supply limit is 30 days
FENTANYL OT LOZ 1600MCG
BUCCAL
Days supply limit is 30 days
FENTANYL OT LOZ 200MCG
BUCCAL
Days supply limit is 30 days
FENTANYL OT LOZ 400MCG
BUCCAL
Days supply limit is 30 days
FENTANYL OT LOZ 600MCG
BUCCAL
Days supply limit is 30 days
FENTANYL OT LOZ 800MCG
BUCCAL
Days supply limit is 30 days
FENTORA
TAB 100MCG
BUCCAL
Days supply limit is 30 days
FENTORA
TAB 200MCG
BUCCAL
Days supply limit is 30 days
FENTORA
TAB 400MCG
BUCCAL
Days supply limit is 30 days
FENTORA
TAB 600MCG
BUCCAL
Days supply limit is 30 days
FENTORA
TAB 800MCG
BUCCAL
Days supply limit is 30 days
TAB 500MG
ORAL
Days supply limit is 30 days
FIORICET
CAP CODEINE
ORAL
FIRAZYR
INJ 30MG/3ML
SUBCUTANEOUS
Days supply limit is 30 days
FLUOROPLEX CRE 1%
EXTERNAL
Days supply limit is 30 days
FLUOROURACIL CRE 0.5%
EXTERNAL
Days supply limit is 30 days
FLUOROURACIL CRE 5%
EXTERNAL
Days supply limit is 30 days
FLUOROURACIL DRO 2%
EXTERNAL
Days supply limit is 30 days
FLUOROURACIL DRO 5%
EXTERNAL
Days supply limit is 30 days
FLUOROURACIL SOL 2%
EXTERNAL
Days supply limit is 30 days
FLUOROURACIL SOL 5%
EXTERNAL
Days supply limit is 30 days
FOCALIN XR CAP 10MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FOCALIN XR CAP 15MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FOCALIN XR CAP 20MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FOCALIN XR CAP 25MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FERRIPROX
9
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
FOCALIN XR CAP 30MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FOCALIN XR CAP 35MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FOCALIN XR CAP 40MG
ORAL
Quantity limited to
30
dispensing units per
30
days
FOCALIN XR CAP 5MG
ORAL
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
120
dispensing units per
30
days
TEST STRIP
Quantity limited to
150
dispensing units per
30
days
TAB 2.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
INJ 90MG
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
FONDAPARINUX INJ 10/0.8ML
SUBCUTANEOUS
Days supply limit is 30 days
FONDAPARINUX INJ 2.5/0.5
SUBCUTANEOUS
Days supply limit is 30 days
FONDAPARINUX INJ 5/0.4ML
SUBCUTANEOUS
Days supply limit is 30 days
FONDAPARINUX INJ 7.5/0.6
SUBCUTANEOUS
Days supply limit is 30 days
FORTEO
SUBCUTANEOUS
Days supply limit is 30 days
SOL 600/2.4
FORTESTA
GEL 10MG/ACT
TRANSDERMAL
FRAGMIN
INJ 10000/ML
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 12500UNT
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 15000UNT
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 18000UNT
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 2500/0.2
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 25000/ML
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 5000/0.2
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 7500/0.3
SUBCUTANEOUS
Days supply limit is 30 days
FRAGMIN
INJ 95000UNT
SUBCUTANEOUS
Days supply limit is 30 days
FREESTYLE
FROVA
FUZEON
TES
FYCOMPA
TAB 10MG
ORAL
Days supply limit is 30 days
FYCOMPA
TAB 12MG
ORAL
Days supply limit is 30 days
FYCOMPA
TAB 2MG
ORAL
Days supply limit is 30 days
FYCOMPA
TAB 4MG
ORAL
Days supply limit is 30 days
FYCOMPA
TAB 6MG
ORAL
Days supply limit is 30 days
FYCOMPA
TAB 8MG
ORAL
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 0.2MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 0.4MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 0.6MG
SUBCUTANEOUS
Days supply limit is 30 days
GATTEX
KIT 5MG
10
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
GENOTROPIN INJ 0.8MG
SUBCUTANEOUS
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
GENOTROPIN INJ 1.2MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 1.4MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 1.6MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 1.8MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 12MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 1MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 2MG
SUBCUTANEOUS
Days supply limit is 30 days
GENOTROPIN INJ 5MG
SUBCUTANEOUS
Days supply limit is 30 days
GILENYA
CAP 0.5MG
ORAL
Days supply limit is 30 days
GILOTRIF
TAB 20MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
GILOTRIF
TAB 30MG
ORAL
Days supply limit is 30 days
GILOTRIF
TAB 40MG
ORAL
Days supply limit is 30 days
HM ASPIRIN CHW 81MG
Quantity limited to
30
dispensing units per
30
days
HM ASPIRIN TAB 325MG
Quantity limited to
30
dispensing units per
30
days
GLATOPA
INJ 20MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
GLEEVEC
TAB 100MG
ORAL
Days supply limit is 30 days
GLEEVEC
TAB 400MG
ORAL
Days supply limit is 30 days
GLEOSTINE
CAP 5MG
H.P. ACTHAR INJ 80UNIT
ORAL
Days supply limit is 30 days
INJECTION
Days supply limit is 30 days
HARVONI
TAB 90-400MG
ORAL
Days supply limit is 30 days
HEPSERA
TAB 10MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
HETLIOZ
CAP 20MG
HEXALEN
CAP 50MG
HIZENTRA
INJ 10/50ML
SUBCUTANEOUS
Days supply limit is 30 days
HIZENTRA
INJ 1GM/5ML
SUBCUTANEOUS
Days supply limit is 30 days
HIZENTRA
INJ 2GM/10ML
SUBCUTANEOUS
Days supply limit is 30 days
HIZENTRA
INJ 4GM/20ML
SUBCUTANEOUS
Days supply limit is 30 days
HUMATROPE
INJ 12MG
INJECTION
Days supply limit is 30 days
HUMATROPE
INJ 24MG
INJECTION
Days supply limit is 30 days
HUMATROPE
INJ 5MG
INJECTION
Days supply limit is 30 days
HUMATROPE
INJ 6MG
INJECTION
Days supply limit is 30 days
11
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
HUMIRA
INJ 10MG/0.2
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
QUANTITY PER DAYS SUPPLY LIMIT
2
dispensing units per
28
days
HUMIRA
KIT 20MG/0.4
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
2
dispensing units per
28
days
HUMIRA
KIT 40MG/0.8
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
2
dispensing units per
28
days
HUMIRA PEDIA INJ CROHNS
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
2
dispensing units per
28
days
HUMIRA PEN INJ 40MG/0.8
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
2
dispensing units per
28
days
HUMIRA PEN INJ CROHNS
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
2
dispensing units per
28
days
HUMIRA PEN INJ PSORIASI
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
2
dispensing units per
28
days
HYCAMTIN
CAP 0.25MG
ORAL
Days supply limit is 30 days
HYCAMTIN
CAP 1MG
ORAL
Days supply limit is 30 days
HYCET
ORAL
Quantity limited to
2700
dispensing units per
30
days
HYDROCO/APAP SOL 7.5-325
SOL 7.5-325
ORAL
Quantity limited to
2700
dispensing units per
30
days
HYDROCO/APAP SOL 7.5-500
ORAL
Quantity limited to
2700
dispensing units per
30
days
HYDROCO/APAP TAB 10-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
HYDROCO/APAP TAB 10-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
HYDROCO/APAP TAB 10-500MG
ORAL
Quantity limited to
240
dispensing units per
30
days
HYDROCO/APAP TAB 10-650MG
ORAL
Quantity limited to
180
dispensing units per
30
days
HYDROCO/APAP TAB 10-660MG
ORAL
Quantity limited to
180
dispensing units per
30
days
HYDROCO/APAP TAB 10-750MG
ORAL
Quantity limited to
150
dispensing units per
30
days
HYDROCO/APAP TAB 2.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
HYDROCO/APAP TAB 5-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
HYDROCO/APAP TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
HYDROCO/APAP TAB 5-500MG
ORAL
Quantity limited to
240
dispensing units per
30
days
HYDROCO/APAP TAB 7.5-300
ORAL
Quantity limited to
390
dispensing units per
30
days
HYDROCO/APAP TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
HYDROCO/APAP TAB 7.5-500
ORAL
Quantity limited to
240
dispensing units per
30
days
HYDROCO/APAP TAB 7.5-650
ORAL
Quantity limited to
180
dispensing units per
30
days
HYDROGESIC CAP 5-500MG
HYDROMORPHON TAB 12MG
ER
HYDROMORPHON TAB 16MG
ER
HYDROMORPHON TAB 32MG
ER
ORAL
Quantity limited to
240
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
ORAL
Quantity limited to
60
dispensing units per
30
days
HYDROMORPHON TAB 8MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
12
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
HYQVIA
INJ 10-800
SUBCUTANEOUS
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
HYQVIA
INJ 2.5-200
SUBCUTANEOUS
Days supply limit is 30 days
HYQVIA
INJ 20-1600
SUBCUTANEOUS
Days supply limit is 30 days
HYQVIA
INJ 30-2400
SUBCUTANEOUS
Days supply limit is 30 days
HYQVIA
INJ 5-400
SUBCUTANEOUS
Days supply limit is 30 days
HYSINGLA ER TAB 100 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
HYSINGLA ER TAB 120 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
HYSINGLA ER TAB 20 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
HYSINGLA ER TAB 30 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
HYSINGLA ER TAB 40 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
HYSINGLA ER TAB 60 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
HYSINGLA ER TAB 80 MG
ORAL
Quantity limited to
30
dispensing units per
30
days
IBRANCE
CAP 100MG
ORAL
Days supply limit is 30 days
IBRANCE
CAP 125MG
ORAL
Days supply limit is 30 days
IBRANCE
CAP 75MG
ORAL
Days supply limit is 30 days
ICLUSIG
TAB 15MG
ORAL
Days supply limit is 30 days
ICLUSIG
TAB 45MG
ORAL
Days supply limit is 30 days
IMATINIB MES TAB 100MG
ORAL
Days supply limit is 30 days
IMATINIB MES TAB 400MG
ORAL
Days supply limit is 30 days
IMBRUVICA
ORAL
Days supply limit is 30 days
CAP 140MG
IMITREX
INJ 4MG/0.5
SUBCUTANEOUS
Quantity limited to
5
dispensing units per
23
days
IMITREX
INJ 4MG/0.5
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
IMITREX
INJ 6MG/0.5
SUBCUTANEOUS
Quantity limited to
5
dispensing units per
23
days
IMITREX
INJ 6MG/0.5
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
IMITREX
SPR 20MG/ACT
NASAL
Quantity limited to
8
dispensing units per
30
days
IMITREX
SPR 5MG/ACT
NASAL
Quantity limited to
8
dispensing units per
30
days
IMITREX
TAB 100MG
ORAL
Quantity limited to
9
dispensing units per
30
days
IMITREX
TAB 25MG
ORAL
Quantity limited to
9
dispensing units per
30
days
IMITREX
TAB 50MG
ORAL
Quantity limited to
9
dispensing units per
30
days
INCIVEK
TAB 375MG
ORAL
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
INCRELEX
INLYTA
INJ 40MG/4ML
TAB 1MG
13
DRUG / FORM / DOSE
INLYTA
TAB 5MG
INTELENCE TAB 25MG
ROUTE
DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
INTRON A
INJ 10MU
INJECTION
Days supply limit is 30 days
INTRON A
INJ 18MU
INJECTION
Days supply limit is 30 days
INTRON A
INJ 25MU
INJECTION
Days supply limit is 30 days
INTRON A
INJ 50MU
INJECTION
Days supply limit is 30 days
TAB 250MG
ORAL
Days supply limit is 30 days
IRESSA
JADENU
TAB 180MG
ORAL
Days supply limit is 30 days
JADENU
TAB 360MG
ORAL
Days supply limit is 30 days
TAB 90MG
JADENU
ORAL
Days supply limit is 30 days
JAKAFI
TAB 10MG
ORAL
Days supply limit is 30 days
JAKAFI
TAB 15MG
ORAL
Days supply limit is 30 days
JAKAFI
TAB 20MG
ORAL
Days supply limit is 30 days
JAKAFI
TAB 25MG
ORAL
Days supply limit is 30 days
JAKAFI
TAB 5MG
ORAL
Days supply limit is 30 days
JARDIANCE
JARDIANCE
TAB 10MG
ORAL
TAB 25MG
ORAL
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
JUXTAPID
CAP 10MG
ORAL
Days supply limit is 30 days
Quantity limited to
28
dispensing units per
28
days
JUXTAPID
CAP 20MG
ORAL
Days supply limit is 30 days
Quantity limited to
90
dispensing units per
28
days
JUXTAPID
CAP 30MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
JUXTAPID
CAP 40MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
JUXTAPID
CAP 5MG
ORAL
Days supply limit is 30 days
Quantity limited to
28
dispensing units per
28
days
JUXTAPID
CAP 60MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
KADIAN
CAP 100MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 10MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 130MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 150MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 200MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
KADIAN
CAP 20MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 30MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 40MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 50MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
14
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
KADIAN
CAP 60MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 70MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KADIAN
CAP 80MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
KALYDECO
PAK 50MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
KALYDECO
PAK 75MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
KALYDECO
TAB 150MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
ORAL
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
20
dispensing units per
28
days
INHALATION
Days supply limit is 30 days
Quantity limited to
120
dispensing units per
30
days
Quantity limited to
4
dispensing units per
28
days
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
KEVEYIS
TAB 50MG
KINERET
INJ
KITABIS PAK NEB 300/5ML
KORLYM
TAB 300MG
ORAL
Days supply limit is 30 days
KUVAN
POW 100MG
ORAL
Days supply limit is 30 days
KUVAN
TAB 100MG
ORAL
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
KYNAMRO
INJ 200MG/ML
LAZANDA
SPR 100MCG
NASAL
Days supply limit is 30 days
LAZANDA
SPR 400MCG
NASAL
Days supply limit is 30 days
LENVIMA
CAP 10MG
ORAL
Days supply limit is 30 days
LENVIMA
CAP 14MG
ORAL
Days supply limit is 30 days
LENVIMA
CAP 20MG
ORAL
Days supply limit is 30 days
LENVIMA
CAP 24MG
ORAL
Days supply limit is 30 days
LETAIRIS
TAB 10MG
ORAL
Days supply limit is 30 days
LETAIRIS
TAB 5MG
ORAL
Days supply limit is 30 days
EXTERNAL
Days supply limit is 30 days
LEVULAN KERA SOL 20%
LEXIVA
SUS 50MG/ML
ORAL
Days supply limit is 30 days
LEXIVA
TAB 700MG
ORAL
Days supply limit is 30 days
LINZESS
CAP 145MCG
ORAL
LINZESS
CAP 290MCG
ORAL
LONSURF
TAB 15-6.14
ORAL
Days supply limit is 30 days
LONSURF
TAB 20-8.19
ORAL
Days supply limit is 30 days
TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
ORAL
Quantity limited to
360
dispensing units per
30
days
LORCET PLUS TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
LORTAB
ORAL
Quantity limited to
2025
dispensing units per
30
days
LORCET
LORCET HD
TAB 10-325MG
ELX 10-300MG
15
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
LORTAB
TAB 10-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
LORTAB
TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
LORTAB
TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
LOVENOX
INJ 100MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
LOVENOX
INJ 120/0.8
SUBCUTANEOUS
Days supply limit is 30 days
LOVENOX
INJ 150MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
LOVENOX
INJ 30/0.3ML
SUBCUTANEOUS
Days supply limit is 30 days
LOVENOX
INJ 300/3ML
INJECTION
Days supply limit is 30 days
LOVENOX
INJ 40/0.4ML
SUBCUTANEOUS
Days supply limit is 30 days
LOVENOX
INJ 60/0.6ML
SUBCUTANEOUS
Days supply limit is 30 days
LOVENOX
INJ 80/0.8ML
SUBCUTANEOUS
Days supply limit is 30 days
LYNPARZA
CAP 50MG
ORAL
Days supply limit is 30 days
LYRICA
CAP 100MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 150MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 200MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 225MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 25MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 300MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 50MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
CAP 75MG
ORAL
Quantity limited to
90
dispensing units per
30
days
LYRICA
SOL 20MG/ML
ORAL
Quantity limited to
900
dispensing units per
30
days
TAB 650MG
ORAL
Quantity limited to
30
dispensing units per
30
days
CAP 50MG
ORAL
LYSTEDA
MATULANE
Days supply limit is 30 days
MAXALT
TAB 10MG
ORAL
Quantity limited to
12
dispensing units per
30
days
MAXALT
TAB 5MG
ORAL
Quantity limited to
12
dispensing units per
30
days
MAXALT-MLT
TAB 10MG
ORAL
Quantity limited to
12
dispensing units per
30
days
MAXALT-MLT
TAB 5MG
ORAL
Quantity limited to
12
dispensing units per
30
days
Quantity limited to
1
dispensing units per
68
days
ORAL
Quantity limited to
90
dispensing units per
30
days
ORAL
Quantity limited to
30
dispensing units per
30
days
MEDROXYPR AC INJ 150MG/ML
Days supply limit is 30 days
MEKINIST
TAB 0.5MG
ORAL
Days supply limit is 30 days
MEKINIST
TAB 2MG
ORAL
Days supply limit is 30 days
METADATE
TAB 20MG ER
METADATE CD CAP 10MG
16
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
METADATE CD CAP 20MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METADATE CD CAP 30MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METADATE CD CAP 40MG
ORAL
Quantity limited to
60
dispensing units per
30
days
METADATE CD CAP 50MG
ORAL
Quantity limited to
60
dispensing units per
30
days
METADATE CD CAP 60MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METHADONE
CON 10MG/ML
ORAL
Quantity limited to
900
dispensing units per
30
days
METHADONE
SOL 10MG/5ML
ORAL
Quantity limited to
900
dispensing units per
30
days
METHADONE
SOL 5MG/5ML
ORAL
Quantity limited to
900
dispensing units per
30
days
METHADONE
TAB 10MG
ORAL
Quantity limited to
180
dispensing units per
30
days
METHADONE
TAB 40MG
ORAL
Quantity limited to
90
dispensing units per
30
days
METHADONE
TAB 5MG
ORAL
Quantity limited to
180
dispensing units per
30
days
METHADOSE
CON 10MG/ML
ORAL
Quantity limited to
900
dispensing units per
30
days
METHADOSE
TAB 40MG
ORAL
Quantity limited to
90
dispensing units per
30
days
METHADOSE SF CON 10MG/ML
ORAL
Quantity limited to
900
dispensing units per
30
days
METHOXSALEN CAP 10MG
ORAL
METHYLPHENID CAP 10MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID CAP 20MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID CAP 20MG ER
ORAL
Quantity limited to
90
dispensing units per
30
days
METHYLPHENID CAP 30MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID CAP 30MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
METHYLPHENID CAP 40MG
ORAL
Quantity limited to
60
dispensing units per
30
days
METHYLPHENID CAP 40MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID CAP 50MG
ORAL
Quantity limited to
60
dispensing units per
30
days
METHYLPHENID CAP 60MG
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID TAB 10MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
METHYLPHENID TAB 18MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID TAB 20MG ER
ORAL
Quantity limited to
90
dispensing units per
30
days
METHYLPHENID TAB 20MG SR
ORAL
Quantity limited to
90
dispensing units per
30
days
METHYLPHENID TAB 27MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
METHYLPHENID TAB 36MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
METHYLPHENID TAB 54MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
METVIXIA
CRE 16.8%
EXTERNAL
Days supply limit is 30 days
Days supply limit is 30 days
17
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
MIRCERA
INJ 100MCG
INJECTION
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
MIRCERA
INJ 200MCG
INJECTION
Days supply limit is 30 days
MIRCERA
INJ 50MCG
INJECTION
Days supply limit is 30 days
MIRCERA
INJ 75MCG
INJECTION
Days supply limit is 30 days
MODERIBA
PAK 1000/DAY
ORAL
Days supply limit is 30 days
MODERIBA
PAK 1200/DAY
ORAL
Days supply limit is 30 days
MODERIBA
PAK 600/DAY
ORAL
Days supply limit is 30 days
MODERIBA
PAK 800/DAY
ORAL
Days supply limit is 30 days
MODERIBA
TAB 200MG
ORAL
Days supply limit is 30 days
MORPHINE SUL CAP 100MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 10MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 120MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 20MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 30MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
MORPHINE SUL CAP 30MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 45MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
MORPHINE SUL CAP 50MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 60MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
MORPHINE SUL CAP 60MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 75MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
MORPHINE SUL CAP 80MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
MORPHINE SUL CAP 90MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
MORPHINE SUL TAB 100MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
MORPHINE SUL TAB 15MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
MORPHINE SUL TAB 200MG ER
ORAL
Quantity limited to
180
dispensing units per
30
days
MORPHINE SUL TAB 30MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
MORPHINE SUL TAB 60MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
MOVANTIK
TAB 12.5MG
ORAL
Quantity limited to
30
dispensing units per
30
days
MOVANTIK
TAB 25MG
ORAL
Quantity limited to
30
dispensing units per
30
days
MOVANTIK
TAB 25MG
ORAL
Quantity limited to
30
dispensing units per
30
days
MS CONTIN
TAB 100MG CR
ORAL
Quantity limited to
120
dispensing units per
30
days
MS CONTIN
TAB 15MG CR
ORAL
Quantity limited to
120
dispensing units per
30
days
18
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
MS CONTIN
TAB 200MG CR
ORAL
Quantity limited to
180
dispensing units per
30
days
MS CONTIN
TAB 30MG CR
ORAL
Quantity limited to
120
dispensing units per
30
days
MS CONTIN
TAB 60MG CR
ORAL
Quantity limited to
120
dispensing units per
30
days
MYALEPT
INJ 11.3MG
MYLERAN
TAB 2MG
SUBCUTANEOUS
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
NARATRIPTAN TAB 1MG
ORAL
Quantity limited to
9
dispensing units per
30
days
NARATRIPTAN TAB 2.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
NATESTO
GEL 5.5MG
NASAL
Quantity limited to
22
dispensing units per
30
days
NATPARA
INJ 100MCG
SUBCUTANEOUS
Quantity limited to
2
dispensing units per
30
days
NATPARA
INJ 25MCG
SUBCUTANEOUS
Quantity limited to
2
dispensing units per
30
days
NATPARA
INJ 50MCG
SUBCUTANEOUS
Quantity limited to
2
dispensing units per
30
days
NATPARA
INJ 75MCG
SUBCUTANEOUS
Quantity limited to
2
dispensing units per
30
days
NEULASTA
INJ 6MG/0.6M
SUBCUTANEOUS
Days supply limit is 30 days
NEULASTA
KIT 6MG/0.6M
SUBCUTANEOUS
Days supply limit is 30 days
NEUMEGA
INJ 5MG
SUBCUTANEOUS
Days supply limit is 30 days
NEUPOGEN
INJ 300/0.5
INJECTION
Days supply limit is 30 days
NEUPOGEN
INJ 300MCG
INJECTION
Days supply limit is 30 days
NEUPOGEN
INJ 480/0.8
INJECTION
Days supply limit is 30 days
NEUPOGEN
INJ 480MCG
INJECTION
Days supply limit is 30 days
TAB 200MG
ORAL
Days supply limit is 30 days
NORCO
TAB 10-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
NORCO
TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
NORCO
TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
60
dispensing units per
30
days
NEXAVAR
NORDITROPIN INJ 10/1.5ML
SUBCUTANEOUS
Days supply limit is 30 days
NORDITROPIN INJ 15/1.5ML
SUBCUTANEOUS
Days supply limit is 30 days
NORDITROPIN INJ 30/3ML
SUBCUTANEOUS
Days supply limit is 30 days
NORDITROPIN INJ 5/1.5ML
SUBCUTANEOUS
Days supply limit is 30 days
NORTHERA
CAP 100MG
ORAL
Days supply limit is 30 days
NORTHERA
CAP 200MG
ORAL
Days supply limit is 30 days
NORTHERA
CAP 300MG
ORAL
Days supply limit is 30 days
NORWICH ASA TAB 325MG
NUCYNTA ER TAB 100MG
ORAL
19
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
NUCYNTA ER TAB 150MG
ORAL
Quantity limited to
60
dispensing units per
30
days
NUCYNTA ER TAB 200MG
ORAL
Quantity limited to
60
dispensing units per
30
days
NUCYNTA ER TAB 250MG
ORAL
Quantity limited to
60
dispensing units per
30
days
NUCYNTA ER TAB 50MG
ORAL
Quantity limited to
60
dispensing units per
30
days
NUPLAZID
ORAL
Days supply limit is 30 days
NUTROPIN AQ INJ 10MG/2ML
SUBCUTANEOUS
Days supply limit is 30 days
NUTROPIN AQ INJ 20MG/2ML
SUBCUTANEOUS
Days supply limit is 30 days
NUTROPIN AQ INJ NUSPIN 5
SUBCUTANEOUS
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
TAB 17MG
NYMALIZE
SOL 60/20ML
OCALIVA
TAB 10MG
ORAL
Days supply limit is 30 days
OCALIVA
TAB 5MG
ORAL
Days supply limit is 30 days
ODEFSEY
TAB
ORAL
Days supply limit is 30 days
ODOMZO
CAP 200MG
ORAL
Days supply limit is 30 days
OFEV
CAP 100MG
ORAL
Days supply limit is 30 days
OFEV
CAP 150MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
OLYSIO
CAP 150MG
OMNITROPE
INJ 10/1.5ML
SUBCUTANEOUS
Days supply limit is 30 days
OMNITROPE
INJ 5.8MG
SUBCUTANEOUS
Days supply limit is 30 days
OMNITROPE
INJ 5/1.5ML
SUBCUTANEOUS
Days supply limit is 30 days
OMONTYS
INJ 10MG/ML
INJECTION
Days supply limit is 30 days
OMONTYS
INJ 20MG/2ML
INJECTION
Days supply limit is 30 days
ONETOUCH
TES ULTRA
TEST STRIP
Quantity limited to
150
dispensing units per
30
days
ONETOUCH
TES ULTRA BL
TEST STRIP
Quantity limited to
150
dispensing units per
30
days
ONETOUCH
TES VERIO
TEST STRIP
Quantity limited to
150
dispensing units per
30
days
ONZETRA
MIS 11MG
NASAL
Quantity limited to
8
doses per
30
days
OPANA ER
TAB 10MG
ORAL
Quantity limited to
60
dispensing units per
30
days
OPANA ER
TAB 15MG
ORAL
Quantity limited to
60
dispensing units per
30
days
OPANA ER
TAB 20MG
ORAL
Quantity limited to
60
dispensing units per
30
days
OPANA ER
TAB 30MG
ORAL
Quantity limited to
60
dispensing units per
30
days
OPANA ER
TAB 40MG
ORAL
Quantity limited to
120
dispensing units per
30
days
OPANA ER
TAB 5MG
ORAL
Quantity limited to
60
dispensing units per
30
days
OPANA ER
TAB 7.5MG
ORAL
Quantity limited to
60
dispensing units per
30
days
20
DRUG / FORM / DOSE
OPSUMIT
TAB 10MG
ORENCIA
INJ 125MG/ML
ROUTE
DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
SUBCUTANEOUS
Days supply limit is 30 days
ORENITRAM
TAB 0.125MG
ORAL
Days supply limit is 30 days
ORENITRAM
TAB 0.25MG
ORAL
Days supply limit is 30 days
ORENITRAM
TAB 1MG
ORAL
Days supply limit is 30 days
ORENITRAM
TAB 2.5MG
ORAL
Days supply limit is 30 days
ORFADIN
CAP 10MG
ORAL
Days supply limit is 30 days
ORFADIN
CAP 2MG
ORAL
Days supply limit is 30 days
ORFADIN
CAP 5MG
ORAL
Days supply limit is 30 days
ORKAMBI
Quantity limited to
4
dispensing units per
28
days
TAB 200-125
ORAL
Days supply limit is 30 days
Quantity limited to
120
dispensing units per
30
days
OTEZLA
TAB 10/20/30
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
OTEZLA
TAB 10/20/30
ORAL
Quantity limited to
60
dispensing units per
30
days
OTEZLA
TAB 30MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
SUBCUTANEOUS
Days supply limit is 30 days
OXSORALEN-UL CAP 10MG
ORAL
Days supply limit is 30 days
OXYCOD/APAP CAP 5-500MG
ORAL
Quantity limited to
240
dispensing units per
30
days
OXYCOD/APAP TAB 10-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
OXYCOD/APAP TAB 10-650MG
ORAL
Quantity limited to
180
dispensing units per
30
days
OXYCOD/APAP TAB 2.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
OXYCOD/APAP TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
OXYCOD/APAP TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
OXYCOD/APAP TAB 7.5-500
ORAL
Quantity limited to
240
dispensing units per
30
days
OXYCODONE
TAB 10MG ER
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCODONE
TAB 20MG ER
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCODONE
TAB 40MG ER
ORAL
Quantity limited to
90
dispensing units per
30
days
TAB 80MG ER
OTREXUP
OXYCODONE
INJ 7.5/0.4
ORAL
Quantity limited to
120
dispensing units per
30
days
OXYCONTIN
TAB 10MG CR
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCONTIN
TAB 15MG CR
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCONTIN
TAB 20MG CR
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCONTIN
TAB 30MG CR
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCONTIN
TAB 40MG CR
ORAL
Quantity limited to
90
dispensing units per
30
days
OXYCONTIN
TAB 60MG CR
ORAL
Quantity limited to
90
dispensing units per
30
days
21
DRUG / FORM / DOSE
OXYCONTIN
TAB 80MG CR
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
ORAL
Quantity limited to
120
dispensing units per
30
days
OXYMORPHONE TAB 10MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
OXYMORPHONE TAB 15MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
OXYMORPHONE TAB 20MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
OXYMORPHONE TAB 30MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
OXYMORPHONE TAB 40MG ER
ORAL
Quantity limited to
120
dispensing units per
30
days
OXYMORPHONE TAB 5MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
OXYMORPHONE TAB 7.5MG ER
ORAL
Quantity limited to
60
dispensing units per
30
days
PANRETIN
GEL 0.1%
EXTERNAL
Days supply limit is 30 days
PEGASYS
INJ
SUBCUTANEOUS
Days supply limit is 30 days
PEGASYS
INJ 180MCG/M
SUBCUTANEOUS
Days supply limit is 30 days
PEGASYS
INJ PROCLICK
SUBCUTANEOUS
Days supply limit is 30 days
PEGINTRON
KIT 120MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEGINTRON
KIT 150MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEGINTRON
KIT 50MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEGINTRON
KIT 80MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 120 RP
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 120MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 150 RP
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 150MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 50MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 50MCG RP
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 80MCG
SUBCUTANEOUS
Days supply limit is 30 days
PEG-INTRON KIT 80MCG RP
SUBCUTANEOUS
Days supply limit is 30 days
PENTA/APAP
TAB 25-650MG
ORAL
Quantity limited to
180
dispensing units per
30
days
PERCOCET
TAB 10-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
PERCOCET
TAB 10-650MG
ORAL
Quantity limited to
180
dispensing units per
30
days
PERCOCET
TAB 2.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
PERCOCET
TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
PERCOCET
TAB 7.5-325
ORAL
Quantity limited to
360
dispensing units per
30
days
PERCOCET
TAB 7.5-500
ORAL
Quantity limited to
240
dispensing units per
30
days
PHENYLBUTYRA POW SODIUM
ORAL
Days supply limit is 30 days
22
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
PICATO
GEL 0.015%
EXTERNAL
Quantity limited to
1
dispensing units per
365
days
PICATO
GEL 0.05%
EXTERNAL
Quantity limited to
1
dispensing units per
365
days
PLEGRIDY
INJ
SUBCUTANEOUS
Days supply limit is 30 days
PLEGRIDY
INJ PEN
SUBCUTANEOUS
Days supply limit is 30 days
PLEGRIDY
INJ STARTER
SUBCUTANEOUS
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
PLEGRIDY PEN INJ STARTER
POMALYST
CAP 1MG
ORAL
Days supply limit is 30 days
POMALYST
CAP 2MG
ORAL
Days supply limit is 30 days
POMALYST
CAP 3MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
POMALYST
CAP 4MG
PRALUENT
INJ 150MG/ML
SUBCUTANEOUS
Quantity limited to
2
dispensing units per
30
days
PRALUENT
INJ 75MG/ML
SUBCUTANEOUS
Quantity limited to
2
dispensing units per
30
days
PREZCOBIX
TAB 800-150
ORAL
Days supply limit is 30 days
PREZISTA
SUS 100MG/ML
ORAL
Days supply limit is 30 days
PREZISTA
TAB 150MG
ORAL
Days supply limit is 30 days
PREZISTA
TAB 600MG
ORAL
Days supply limit is 30 days
PREZISTA
TAB 75MG
ORAL
Days supply limit is 30 days
PREZISTA
TAB 800MG
ORAL
Days supply limit is 30 days
PRIMLEV
TAB 10-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
PRIMLEV
TAB 5-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
PRIMLEV
TAB 7.5-300
ORAL
Quantity limited to
Quantity limited to
Quantity limited to
Quantity limited to
Quantity limited to
390
17
8.5
2
1
dispensing units per
dispensing units per
dispensing units per
dispensing units per
dispensing units per
30
30
30
30
30
days
days
days
days
days
PROAIR HFA AER
INHALATION
PROAIR RESPI AER
INHALATION
PROCRIT
INJ 10000/ML
INJECTION
Days supply limit is 30 days
PROCRIT
INJ 2000/ML
INJECTION
Days supply limit is 30 days
PROCRIT
INJ 20000/ML
INJECTION
Days supply limit is 30 days
PROCRIT
INJ 3000/ML
INJECTION
Days supply limit is 30 days
PROCRIT
INJ 4000/ML
INJECTION
Days supply limit is 30 days
PROCRIT
INJ 40000/ML
INJECTION
Days supply limit is 30 days
PROCYSBI
CAP 25MG
ORAL
Days supply limit is 30 days
PROCYSBI
CAP 75MG
ORAL
Days supply limit is 30 days
23
for age <18 years
for age >18 years
for age <18 years
for age >18 years
DRUG / FORM / DOSE
PRODIGY NO TES CODING
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
TEST STRIP
PROMACTA
TAB 12.5MG
ORAL
Days supply limit is 30 days
PROMACTA
TAB 25MG
ORAL
Days supply limit is 30 days
PROMACTA
TAB 50MG
ORAL
Days supply limit is 30 days
PROMACTA
TAB 75MG
ORAL
Days supply limit is 30 days
PROVENTIL
AER HFA
PULMOZYME
SOL 1MG/ML
INHALATION
INHALATION
Quantity limited to
150
dispensing units per
30
days
Quantity limited to
Quantity limited to
13.4
6.7
dispensing units per
dispensing units per
30
30
days
days
Quantity limited to
360
dispensing units per
30
days
Days supply limit is 30 days
QUILLIVANT SUS 25MG/5ML
ORAL
RAVICTI
LIQ 1.1GM/ML
ORAL
Days supply limit is 30 days
REBETOL
CAP 200MG
ORAL
Days supply limit is 30 days
REBETOL
SOL 40MG/ML
ORAL
Days supply limit is 30 days
REBIF
INJ 22/0.5
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
7
dispensing units per
30
days
REBIF
INJ 44/0.5
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
7
dispensing units per
30
days
REBIF REBIDO INJ 22/0.5
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
7
dispensing units per
30
days
REBIF REBIDO INJ 44/0.5
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
7
dispensing units per
30
days
REBIF REBIDO INJ TITRATN
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
5
dispensing units per
30
days
REBIF TITRTN INJ PACK
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
5
dispensing units per
30
days
RELPAX
TAB 20MG
ORAL
Quantity limited to
9
dispensing units per
30
days
RELPAX
TAB 40MG
ORAL
Quantity limited to
9
dispensing units per
30
days
REVLIMID
CAP 10MG
ORAL
Days supply limit is 30 days
REVLIMID
CAP 15MG
ORAL
Days supply limit is 30 days
REVLIMID
CAP 2.5MG
ORAL
Days supply limit is 30 days
REVLIMID
CAP 20MG
ORAL
Days supply limit is 30 days
REVLIMID
CAP 25MG
ORAL
Days supply limit is 30 days
REVLIMID
CAP 5MG
ORAL
Days supply limit is 30 days
REYATAZ
CAP 150MG
ORAL
Days supply limit is 30 days
REYATAZ
CAP 200MG
ORAL
Days supply limit is 30 days
REYATAZ
CAP 300MG
ORAL
Days supply limit is 30 days
REYATAZ
POW 50MG
ORAL
Days supply limit is 30 days
RIBAPAK
PAK 1000/DAY
ORAL
Days supply limit is 30 days
RIBAPAK
PAK 1200/DAY
ORAL
Days supply limit is 30 days
24
for age <18 years
for age >18 years
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
RIBAPAK
PAK 600/DAY
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
RIBAPAK
PAK 800/DAY
ORAL
Days supply limit is 30 days
RIBASPHERE CAP 200MG
ORAL
Days supply limit is 30 days
RIBASPHERE TAB 200MG
ORAL
Days supply limit is 30 days
RIBASPHERE TAB 400MG
ORAL
Days supply limit is 30 days
RIBASPHERE TAB 600MG
ORAL
Days supply limit is 30 days
RIBATAB
PAK 1000/DAY
ORAL
Days supply limit is 30 days
RIBATAB
TAB 1200/DAY
ORAL
Days supply limit is 30 days
RIBATAB
TAB 800/DAY
ORAL
Days supply limit is 30 days
RIBAVIRIN
CAP 200MG
ORAL
Days supply limit is 30 days
RIBAVIRIN
TAB 200MG
ORAL
Days supply limit is 30 days
RILUTEK
TAB 50MG
ORAL
Days supply limit is 30 days
TAB 50MG
ORAL
Days supply limit is 30 days
TAB 20MG SR
ORAL
Quantity limited to
90
dispensing units per
30
days
RITALIN LA CAP 10MG
ORAL
Quantity limited to
30
dispensing units per
30
days
RITALIN LA CAP 20MG
ORAL
Quantity limited to
90
dispensing units per
30
days
RITALIN LA CAP 30MG
ORAL
Quantity limited to
60
dispensing units per
30
days
RITALIN LA CAP 40MG
ORAL
Quantity limited to
30
dispensing units per
30
days
RIZATRIPTAN TAB 10MG
ORAL
Quantity limited to
12
dispensing units per
30
days
RIZATRIPTAN TAB 10MG ODT
ORAL
Quantity limited to
12
dispensing units per
30
days
RIZATRIPTAN TAB 5MG
ORAL
Quantity limited to
12
dispensing units per
30
days
RIZATRIPTAN TAB 5MG ODT
ORAL
Quantity limited to
12
dispensing units per
30
days
ROXICET
SOL 5-325/5
ORAL
Quantity limited to
1800
dispensing units per
30
days
ROXICET
TAB 5-325MG
ORAL
Quantity limited to
360
dispensing units per
30
days
RILUZOLE
RITALIN
RUCONEST
INJ 2100UNIT
INTRAVENOUS
Days supply limit is 30 days
SAIZEN
INJ 5MG
INJECTION
Days supply limit is 30 days
SAIZEN
INJ 8.8MG
INJECTION
Days supply limit is 30 days
SAMSCA
TAB 15MG
ORAL
Days supply limit is 30 days
SAMSCA
TAB 30MG
ORAL
Days supply limit is 30 days
SANDOSTATIN KIT LAR 10MG
INTRAMUSCULAR
Days supply limit is 30 days
SANDOSTATIN KIT LAR 20MG
INTRAMUSCULAR
Days supply limit is 30 days
SANDOSTATIN KIT LAR 30MG
INTRAMUSCULAR
Days supply limit is 30 days
25
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
SELZENTRY
TAB 150MG
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
SELZENTRY
TAB 300MG
ORAL
Days supply limit is 30 days
SEROSTIM
INJ 4MG
SUBCUTANEOUS
Days supply limit is 30 days
SEROSTIM
INJ 5MG
SUBCUTANEOUS
Days supply limit is 30 days
SEROSTIM
INJ 6MG
SUBCUTANEOUS
Days supply limit is 30 days
SIGNIFOR
INJ 0.3MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
SIGNIFOR
INJ 0.6MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
SIGNIFOR
INJ 0.9MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
SIMPONI
INJ 100MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
1
dispensing units per
30
days
SIMPONI
INJ 100MG/ML
SUBCUTANEOUS
Days supply limit is 30 days
SIMPONI
INJ 50/0.5ML
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
1
dispensing units per
30
days
SIRTURO
TAB 100MG
ORAL
Days supply limit is 30 days
SIVEXTRO
TAB 200MG
ORAL
Days supply limit is 30 days
SOMAVERT
INJ 10MG
SUBCUTANEOUS
Days supply limit is 30 days
SOMAVERT
INJ 15MG
SUBCUTANEOUS
Days supply limit is 30 days
SOMAVERT
INJ 20MG
SUBCUTANEOUS
Days supply limit is 30 days
SOMAVERT
INJ 25MG
SUBCUTANEOUS
Days supply limit is 30 days
SOMAVERT
INJ 30MG
SUBCUTANEOUS
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
SOVALDI
TAB 400MG
SPRYCEL
TAB 100MG
ORAL
Days supply limit is 30 days
SPRYCEL
TAB 140MG
ORAL
Days supply limit is 30 days
SPRYCEL
TAB 20MG
ORAL
Days supply limit is 30 days
SPRYCEL
TAB 50MG
ORAL
Days supply limit is 30 days
SPRYCEL
TAB 70MG
ORAL
Days supply limit is 30 days
SPRYCEL
TAB 80MG
ORAL
Days supply limit is 30 days
STAGESIC
CAP 5-500MG
ORAL
Quantity limited to
240
dispensing units per
30
days
STELARA
INJ 45MG/0.5
SUBCUTANEOUS
Quantity limited to
1
dispensing units per
84
days
STELARA
INJ 90MG/ML
SUBCUTANEOUS
Quantity limited to
1
dispensing units per
84
days
STIVARGA
TAB 40MG
Quantity limited to
60
dispensing units per
30
days
STRIANT
MIS 30MG
STRIBILD
TAB
SUBSYS
SPR 100MCG
ORAL
Days supply limit is 30 days
BUCCAL
ORAL
Days supply limit is 30 days
SUBLINGUAL
Days supply limit is 30 days
26
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
SUBSYS
SPR 1200MCG
SUBLINGUAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
SUBSYS
SPR 1600MCG
SUBLINGUAL
Days supply limit is 30 days
SUBSYS
SPR 200MCG
SUBLINGUAL
Days supply limit is 30 days
SUBSYS
SPR 400MCG
SUBLINGUAL
Days supply limit is 30 days
SUBSYS
SPR 600MCG
SUBLINGUAL
Days supply limit is 30 days
SUBSYS
SPR 800MCG
SUBLINGUAL
Days supply limit is 30 days
SUMATRIPTAN INJ 4MG/0.5
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
SUMATRIPTAN INJ 4MG/0.5
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
SUMATRIPTAN INJ 6MG/0.5
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
SUMATRIPTAN INJ 6MG/0.5
SUBCUTANEOUS
Quantity limited to
4
dispensing units per
30
days
SUMATRIPTAN SPR 20MG/ACT
NASAL
Quantity limited to
4
dispensing units per
30
days
SUMATRIPTAN SPR 5MG/ACT
NASAL
Quantity limited to
4
dispensing units per
30
days
SUMATRIPTAN TAB 100MG
ORAL
Quantity limited to
9
dispensing units per
30
days
SUMATRIPTAN TAB 25MG
ORAL
Quantity limited to
9
dispensing units per
30
days
SUMATRIPTAN TAB 50MG
ORAL
Quantity limited to
9
dispensing units per
30
days
SUMAVEL DOSE INJ 4MG/0.5
SUBCUTANEOUS
Quantity limited to
9
dispensing units per
30
days
SUMAVEL DOSE INJ 6MG/0.5
SUBCUTANEOUS
Quantity limited to
9
dispensing units per
30
days
SUTENT
CAP 12.5MG
ORAL
Days supply limit is 30 days
SUTENT
CAP 25MG
ORAL
Days supply limit is 30 days
SUTENT
CAP 37.5MG
ORAL
Days supply limit is 30 days
SUTENT
CAP 50MG
ORAL
Days supply limit is 30 days
SYLATRON
KIT 200MCG
SUBCUTANEOUS
Days supply limit is 30 days
SYLATRON
KIT 300MCG
SUBCUTANEOUS
Days supply limit is 30 days
SYLATRON
KIT 600MCG
SUBCUTANEOUS
Days supply limit is 30 days
NASAL
Days supply limit is 30 days
SYNAREL
SOL 2MG/ML
SYNJARDY
TAB
ORAL
Quantity limited to
30
dispensing units per
30
days
SYNJARDY
TAB 12.5-500
ORAL
Quantity limited to
30
dispensing units per
30
days
SYNJARDY
TAB 5-1000MG
ORAL
Quantity limited to
30
dispensing units per
30
days
SYNJARDY
TAB 5-500MG
ORAL
Quantity limited to
30
dispensing units per
30
days
SYPRINE
CAP 250MG
ORAL
Days supply limit is 30 days
TAFINLAR
CAP 50MG
ORAL
Days supply limit is 30 days
TAFINLAR
CAP 75MG
ORAL
Days supply limit is 30 days
27
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
TAGRISSO
TAB 40MG
ORAL
Days supply limit is 30 days
TAGRISSO
TAB 80MG
ORAL
Days supply limit is 30 days
SUBCUTANEOUS
Days supply limit is 30 days
TALTZ
INJ 80MG/ML
QUANTITY PER DAYS SUPPLY LIMIT
TARCEVA
TAB 100MG
ORAL
Days supply limit is 30 days
TARCEVA
TAB 150MG
ORAL
Days supply limit is 30 days
TARCEVA
TAB 25MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
TARGRETIN
CAP 75MG
TARGRETIN
GEL 1%
EXTERNAL
Days supply limit is 30 days
TASIGNA
CAP 150MG
ORAL
Days supply limit is 30 days
TASIGNA
CAP 200MG
ORAL
Days supply limit is 30 days
TECFIDERA
CAP 120MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
TECFIDERA
CAP 240MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
TECFIDERA
MIS STARTER
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
TAGRISSO
TAB 40MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
TAGRISSO
TAB 80MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
TEMODAR
CAP 100MG
ORAL
Days supply limit is 30 days
TEMODAR
CAP 140MG
ORAL
Days supply limit is 30 days
TEMODAR
CAP 180MG
ORAL
Days supply limit is 30 days
TEMODAR
CAP 20MG
ORAL
Days supply limit is 30 days
TEMODAR
CAP 250MG
ORAL
Days supply limit is 30 days
TEMODAR
CAP 5MG
ORAL
Days supply limit is 30 days
TEMOZOLOMIDE CAP 100MG
ORAL
Days supply limit is 30 days
TEMOZOLOMIDE CAP 140MG
ORAL
Days supply limit is 30 days
TEMOZOLOMIDE CAP 180MG
ORAL
Days supply limit is 30 days
TEMOZOLOMIDE CAP 20MG
ORAL
Days supply limit is 30 days
TEMOZOLOMIDE CAP 250MG
ORAL
Days supply limit is 30 days
TEMOZOLOMIDE CAP 5MG
ORAL
Days supply limit is 30 days
TESTIM
GEL 1%(50MG)
TESTOSTERONE GEL
1%(25MG)
TESTOSTERONE GEL
1%(50MG)
TESTOSTERONE GEL
10MG/ACT
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
TRANSDERMAL
Quantity limited to
120
dispensing units per
30
days
28
DRUG / FORM / DOSE
TESTOSTERONE GEL PUMP 1%
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
TRANSDERMAL
Quantity limited to
300
dispensing units per
30
days
TETRABENAZIN TAB 12.5MG
ORAL
Days supply limit is 30 days
Quantity limited to
240
dispensing units per
30
days
TETRABENAZIN TAB 25MG
ORAL
Days supply limit is 30 days
Quantity limited to
120
dispensing units per
30
days
SUBCUTANEOUS
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
TEV-TROPIN
INJ 5MG
TGT ASPIRIN CHW 81MG
TGT ASPIRIN CHW CHILD
ORAL
TGT ASPIRIN TAB 325MG
TGT ASPIRIN TAB 81MG
ORAL
TGT ASPIRIN TAB 81MG EC
TH ASPIRIN TAB 325MG
Quantity limited to
30
dispensing units per
30
days
TH ASPIRIN TAB 325MG EC
ORAL
Quantity limited to
30
dispensing units per
30
days
TH ASPIRIN TAB 81MG EC
ORAL
Quantity limited to
30
dispensing units per
30
days
THALOMID
CAP 100MG
ORAL
Days supply limit is 30 days
THALOMID
CAP 150MG
ORAL
Days supply limit is 30 days
THALOMID
CAP 200MG
ORAL
Days supply limit is 30 days
THALOMID
CAP 50MG
ORAL
Days supply limit is 30 days
THIOTEPA
INJECTION
Days supply limit is 30 days
TAB 50MG
ORAL
Days supply limit is 30 days
NEB 300/5ML
INHALATION
Days supply limit is 30 days
TOBI PODHALR CAP 28MG
INHALATION
Days supply limit is 30 days
TOBRAMYCIN
INHALATION
Days supply limit is 30 days
TIVICAY
TOBI
INJ 15MG
NEB 300/5ML
TRACLEER
TAB 125MG
ORAL
Days supply limit is 30 days
TRACLEER
TAB 62.5MG
ORAL
Days supply limit is 30 days
TRAMADL/APAP TAB 37.5-325
ORAL
Quantity limited to
240
dispensing units per
30
days
TRAMADOL HCL CAP ER 100MG
ORAL
Quantity limited to
30
dispensing units per
30
days
TRAMADOL HCL CAP ER 200MG
ORAL
Quantity limited to
30
dispensing units per
30
days
TRAMADOL HCL CAP ER 300MG
ORAL
Quantity limited to
30
dispensing units per
30
days
TRAMADOL HCL TAB 100MG ER
ORAL
Quantity limited to
90
dispensing units per
30
days
TRAMADOL HCL TAB 200MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
TRAMADOL HCL TAB 300MG ER
ORAL
Quantity limited to
30
dispensing units per
30
days
TRANEX ACID TAB 650MG
ORAL
Quantity limited to
30
dispensing units per
30
days
TRETINOIN
ORAL
CAP 10MG
Days supply limit is 30 days
29
DRUG / FORM / DOSE
TREXIMET
TREZIX
TAB 85-500MG
CAP
ROUTE
DAYS SUPPLY LIMIT
QUANTITY PER DAYS SUPPLY LIMIT
ORAL
Quantity limited to
9
dispensing units per
30
days
ORAL
Quantity limited to
300
dispensing units per
30
days
TRINTELLIX TAB 10MG
ORAL
Days supply limit is 30 days
TRINTELLIX TAB 20MG
ORAL
Days supply limit is 30 days
TRINTELLIX TAB 5MG
ORAL
Days supply limit is 30 days
TRIUMEQ
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
TRIZIVIR
TAB
TAB
TRUVADA
TYKERB
TAB 200-300
TAB 250MG
TYLENOL/COD TAB #3
ORAL
Quantity limited to
360
dispensing units per
30
days
TYLENOL/COD TAB #4
ORAL
Quantity limited to
180
dispensing units per
30
days
TYVASO
SOL 0.6MG/ML
INHALATION
Days supply limit is 30 days
TYVASO REFIL SOL 0.6MG/ML
INHALATION
Days supply limit is 30 days
TYVASO START SOL 0.6MG/ML
INHALATION
Days supply limit is 30 days
TYZEKA
TAB 600MG
ORAL
Days supply limit is 30 days
UCERIS
TAB 9MG
ORAL
Days supply limit is 30 days
ULTRACET
TAB 37.5-325
ORAL
Quantity limited to
240
dispensing units per
30
days
ULTRAM ER
TAB 100MG
ORAL
Quantity limited to
90
dispensing units per
30
days
ULTRAM ER
TAB 200MG
ORAL
Quantity limited to
30
dispensing units per
30
days
ULTRAM ER
TAB 300MG
ORAL
Quantity limited to
30
dispensing units per
30
days
UPTRAVI
TAB 1000MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 1200MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 1400MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 1600MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 200/800
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 200MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 400MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 600MCG
ORAL
Days supply limit is 30 days
UPTRAVI
TAB 800MCG
ORAL
Days supply limit is 30 days
UVADEX
INJ 20MCG/ML
INJECTION
Days supply limit is 30 days
GEL 0.016%
EXTERNAL
Days supply limit is 30 days
SOL 50MG/ML
ORAL
Days supply limit is 30 days
VALCHLOR
VALCYTE
30
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
VALGANCICLOV TAB 450MG
ORAL
Days supply limit is 30 days
VALGANCICLOV SOL 50MG/ML
ORAL
Days supply limit is 30 days
VARUBI
ORAL
Days supply limit is 30 days
VALCYTE
TAB 450MG
TAB 90MG
QUANTITY PER DAYS SUPPLY LIMIT
VELPHORO
CHW 500MG
ORAL
Days supply limit is 30 days
VENCLEXTA
TAB 10MG
ORAL
Days supply limit is 30 days
VENCLEXTA
TAB 100MG
ORAL
Days supply limit is 30 days
VENCLEXTA
TAB 50MG
ORAL
Days supply limit is 30 days
VENCLEXTA
TAB START PK
ORAL
Days supply limit is 30 days
VENTAVIS
SOL 10MCG/ML
INHALATION
Days supply limit is 30 days
VENTAVIS
SOL 20MCG/ML
INHALATION
Days supply limit is 30 days
INHALATION
Quantity limited to
Quantity limited to
16
8
dispensing units per
dispensing units per
30
30
days
days
ORAL
Quantity limited to
360
dispensing units per
30
days
TAB 5-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
VICODIN ES TAB 7.5-300
ORAL
Quantity limited to
390
dispensing units per
30
days
VICODIN HP TAB 10-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
VICTRELIS
ORAL
Days supply limit is 30 days
VIEKIRA PAK TAB
ORAL
Days supply limit is 30 days
VIEKIRA XR TAB
ORAL
Days supply limit is 30 days
VIREAD
POW 40MG/GM
ORAL
Days supply limit is 30 days
VIREAD
TAB 150MG
ORAL
Days supply limit is 30 days
VIREAD
TAB 200MG
ORAL
Days supply limit is 30 days
VIREAD
TAB 250MG
ORAL
Days supply limit is 30 days
VIREAD
TAB 300MG
ORAL
Days supply limit is 30 days
VITEKTA
TAB 150MG
ORAL
Days supply limit is 30 days
VITEKTA
TAB 85MG
ORAL
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
INTRAMUSCULAR
Days supply limit is 30 days
VENTOLIN HFA AER
VERDROCET
VICODIN
VISTOGARD
VIVITROL
TAB 2.5-325
CAP 200MG
PAK 10GM
INJ 380MG
VOTRIENT
TAB 200MG
ORAL
Days supply limit is 30 days
VRAYLAR
CAP 1.5MG
ORAL
Days supply limit is 30 days
VRAYLAR
CAP 3MG
ORAL
Days supply limit is 30 days
31
for age <18 years
for age >18 years
DRUG / FORM / DOSE
ROUTE
DAYS SUPPLY LIMIT
VRAYLAR
CAP 4.5MG
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
VRAYLAR
CAP 6MG
ORAL
Days supply limit is 30 days
VRAYLAR
CAP 1.5-3MG
ORAL
Days supply limit is 30 days
VYVANSE
CAP 10MG
ORAL
Quantity limited to
30
dispensing units per
30
days
VYVANSE
CAP 20MG
ORAL
Quantity limited to
30
dispensing units per
30
days
VYVANSE
CAP 30MG
ORAL
Quantity limited to
30
dispensing units per
30
days
VYVANSE
CAP 40MG
ORAL
Quantity limited to
30
dispensing units per
30
days
VYVANSE
CAP 50MG
ORAL
Quantity limited to
30
dispensing units per
30
days
VYVANSE
CAP 60MG
ORAL
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
30
dispensing units per
30
days
VYVANSE
CAP 70MG
ORAL
XALKORI
CAP 200MG
ORAL
Days supply limit is 30 days
XALKORI
CAP 250MG
ORAL
Days supply limit is 30 days
XELJANZ
TAB 5MG
ORAL
Days supply limit is 30 days
Quantity limited to
60
dispensing units per
30
days
XELJANZ XR TAB 11MG
ORAL
Days supply limit is 30 days
Quantity limited to
30
dispensing units per
30
days
XELODA
TAB 150MG
ORAL
Days supply limit is 30 days
XELODA
TAB 500MG
ORAL
Days supply limit is 30 days
XENAZINE
TAB 12.5MG
ORAL
Days supply limit is 30 days
Quantity limited to
240
dispensing units per
30
days
XENAZINE
TAB 25MG
ORAL
Days supply limit is 30 days
Quantity limited to
120
dispensing units per
30
days
XIFAXAN
TAB 200MG
ORAL
Days supply limit is 30 days
XIFAXAN
TAB 550MG
ORAL
Days supply limit is 30 days
XODOL
TAB 10-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
XODOL
TAB 5-300MG
ORAL
Quantity limited to
390
dispensing units per
30
days
XODOL
TAB 7.5-300
ORAL
Quantity limited to
390
dispensing units per
30
days
XOLOX
TAB 10-500MG
ORAL
Quantity limited to
240
dispensing units per
30
days
INHALATION
Quantity limited to
30
dispensing units per
30
days
Quantity limited to
2700
dispensing units per
30
days
Quantity limited to
4
dispensing units per
30
days
XOPENEX HFA AER
XTANDI
CAP 40MG
ORAL
Days supply limit is 30 days
XYREM
SOL 500MG/ML
ORAL
Days supply limit is 30 days
ZAMICET
SOL 10-325MG
ORAL
ZARXIO
INJ 300/0.5
INJECTION
Days supply limit is 30 days
ZARXIO
INJ 480/0.8
INJECTION
Days supply limit is 30 days
Days supply limit is 30 days
ZAVESCA
CAP 100MG
ORAL
ZECUITY
PAD 6.5MG/4H
TRANSDERMAL
32
DRUG / FORM / DOSE
ZELBORAF
TAB 240MG
ZEPATIER
TAB 50-100MG
ROUTE
DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
ZOHYDRO ER CAP 10MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ZOHYDRO ER CAP 15MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ZOHYDRO ER CAP 20MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ZOHYDRO ER CAP 30MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ZOHYDRO ER CAP 40MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ZOHYDRO ER CAP 50MG
ORAL
Quantity limited to
60
dispensing units per
30
days
ZOLINZA
ORAL
CAP 100MG
Days supply limit is 30 days
ZOLMITRIPTAN TAB 2.5 MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ZOLMITRIPTAN TAB 2.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ZOLMITRIPTAN TAB 5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ZOMACTON
INJ 10MG
SUBCUTANEOUS
Days supply limit is 30 days
ZOMACTON
INJ 5MG
SUBCUTANEOUS
Days supply limit is 30 days
ZOMIG
SPR 2.5MG
NASAL
Quantity limited to
8
dispensing units per
30
days
ZOMIG
TAB 2.5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ZOMIG
TAB 5MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ZOMIG NASAL SPR 5MG
NASAL
Quantity limited to
8
dispensing units per
30
days
ZOMIG ZMT
TAB 2.5 MG
ORAL
Quantity limited to
9
dispensing units per
30
days
ZOMIG ZMT
TAB 5MG
ORAL
INHALATION
Quantity limited to
Quantity limited to
Quantity limited to
9
15
30
dispensing units per
dispensing units per
dispensing units per
30
30
30
days
days
days
ORAL
Quantity limited to
120
dispensing units per
30
days
XOPENEX HFA AER
XARTEMIS XR TAB 7.5-325
ZORBTIVE
INJ 8.8MG
SUBCUTANEOUS
Days supply limit is 30 days
ZORTRESS
TAB 0.25MG
ORAL
Days supply limit is 30 days
ZORTRESS
TAB 0.5MG
ORAL
Days supply limit is 30 days
ZORTRESS
TAB 0.75MG
ORAL
Days supply limit is 30 days
ZYDELIG
TAB 100MG
ORAL
Days supply limit is 30 days
ZYDELIG
TAB 150MG
ORAL
Days supply limit is 30 days
ZYDONE
TAB 10-400MG
ORAL
Quantity limited to
300
dispensing units per
30
days
ZYDONE
TAB 5-400MG
ORAL
Quantity limited to
300
dispensing units per
30
days
ZYDONE
TAB 7.5-400
ORAL
Quantity limited to
300
dispensing units per
30
days
33
DRUG / FORM / DOSE
ZYKADIA
ZINBRYTA
ZYTIGA
CAP 150MG
INJ 150MG/ML
TAB 250MG
ROUTE
DAYS SUPPLY LIMIT
ORAL
Days supply limit is 30 days
QUANTITY PER DAYS SUPPLY LIMIT
SUBCUTANEOUS
Days supply limit is 30 days
ORAL
Days supply limit is 30 days
34