Quantity Limits

  • Formulary drugs that have a quantity limit are designated “QL” following the product name.
  • In the charts below, available generics are displayed in lowercase bold text and brand drugs are listed in UPPERCASE TEXT.

Androgens and Anabolic Steroids

MEDICATION FORMULARY QUANTITY LIMIT
(per 30 days)
ANDRODERM (testosterone transdermal system) Preferred Product
2, 4, 5mg/day transdermal system
Yes 30 patches
ANDRODERM (testosterone transdermal system) Preferred Product
2.5 mg/day transdermal system
Yes 90 patches
ANDROGEL (testosterone gel) Preferred Product 1% gel, 25 mg/2.5 gm packet, 1% gel, 50 mg/5 gm packet, 1.62% gel, 40.5mg/2.5gm packet Yes 60 packets
ANDROGEL (testosterone gel) Preferred Product 1% gel, 75 gm pump, 1% gel, 2 x 75 gm pump Yes 10 gm/day (4 pumps)
ANDROGEL (testosterone gel) Preferred Product 1.62% gel, 75 gm pump Yes 5 gm/day (2 pumps)
ANDROGEL (testosterone gel) Preferred Product 1.62% gel, 20.25mg/1.25gm packet Yes 30 packets
AXIRON (testosterone solution) 30 mg/1.5 mL, 90 mL pump No 120 mg/day (2 pumps)
BIO-T-GEL (testosterone gel) 1% gel, 25 mg/2.5 gm packet, 1% gel, 50 mg/5 gm packet No 60 packets
FORTESTA (testosterone gel) 2% gel, 60 gm pump No 70 mg/day (2 pumps)
STRIANT (testosterone buccal system) 30 mg buccal system No 60 buccal dose systems
TESTIM (testosterone gel) 1% gel, 5 gm tube No 60 tubes
FIRST-TESTOSTERONE 2% ointment, 60 gm jar No 60 gm
FIRST-TESTOSTERONE MC 2% cream, 60 gm jar No 60 gm
DELATESTRYL (testosterone enanthate)
200 mg/mL, 5 mL multiple dose vial
Yes (generic);
No (brand)
1 vial/28 days
DEPO-TESTOSTERONE (testosterone cypionate) 100 mg/mL, 10 mL multiple dose vial Yes (generic);
No (brand)
1 vial/28 days
DEPO-TESTOSTERONE (testosterone cypionate) 200 mg/mL, 1 mL vial Yes (generic);
No (brand)
4 vials/28 days
DEPO-TESTOSTERONE (testosterone cypionate) 200 mg/mL, 10 mL multiple dose vial Yes (generic);
No (brand)
1 vial/28 days
TESTOPEL (testosterone pellets) 75 mg No 6 pellets/90 days

Erectile Dysfunction Medications

MEDICATION FORMULARY QUANTITY LIMIT
(per 30 days)
CIALIS (tadalafil) tabs, 2.5, 5mg Yes 30 tablets
CIALIS (tadalafil) tabs, 10, 20mg Yes 6 tablets
LEVITRA (vardenafil) No 6 tablets
STAXYN (vardenafil) No 6 tablets
STENDRA (avanafil) No 6 tablets
VIAGRA (sildenafil) No 6 tablets

Migraine Medications

MEDICATION FORMULARY QUANTITY LIMIT
(per 30 days)
ALSUMA (sumatriptan) inj. No 12 syringes (6 mL)
AMERGE (naratriptan) tabs, 1, 2.5mg Yes (generic);
No (brand)
18 tablets
AXERT (almotriptan) tabs, 6.25, 12.5mg No 12 tablets
butorphanol nasal spray No 3 packages (7.5mL)
CAMBIA (diclofenac) packets No 9 packets
FROVA (frovatriptan) tabs, 2.5mg No 18 tablets
IMITREX (sumatriptan) tabs, 25, 50mg Yes (generic);
No (brand)
18 tablets
IMITREX (sumatriptan) tabs, 100mg Yes (generic);
No (brand)
9 tablets
IMITREX (sumatriptan) nasal spray, 5mg Yes 4 packages (24 units)
IMITREX (sumatriptan) nasal spray, 20mg Yes 2 packages (12 units)
IMITREX (sumatriptan) inj, syringes Yes (generic);
No (brand)
6 packages (12 syringes)
IMITREX (sumatriptan) inj, vials Yes (generic);
No (brand)
2 vials (5mL)
MAXALT (rizatriptan) tabs, 5, 10mg Yes 24 tablets
MAXALT-MLT (rizatriptan) tabs, 5, 10mg Yes 24 tablets
MIGRANAL (dihydroergotamine) nasal spray Yes 3 units (12mL)
RELPAX (eletriptan) tabs, 20, 40mg No 12 tablets
SUMATRIPTAN nasal spray, 5 mg No 4 packages (24 units)
SUMATRIPTAN nasal spray, 20 mg No 2 packages (12 units)
SUMAVEL DOSEPRO (sumatriptan) inj. No 12 syringes (6 mL)
TREXIMET (sumatriptan/naproxen) tabs, 85mg/500mg No 18 tablets
ZOMIG (zolmitriptan) tabs, 2.5, 5mg Yes 12 tablets
ZOMIG-ZMT (zolmitriptan) tabs, 2.5, 5mg Yes 12 tablets
ZOMIG (zolmitriptan) nasal spray, 5mg Yes 2 packages (12 units)

Multiple Sclerosis Medications

MEDICATION FORMULARY QUANTITY LIMIT
(per 30 days)
AMPYRA (dalfampridine) No 60 tablets

Narcotic Analgesic Medications

MEDICATION FORMULARY QUANTITY LIMIT
(per 30 days)
OXYCONTIN (oxycodone HCl controlled release) tabs, 10, 15, 20, 30, 40, 60mg Yes 60 tablets (for certain medical needs, exceptions will be considered)
OXYCONTIN (oxycodone HCl controlled release) tabs, 80mg Yes 120 tablets (for certain medical needs, exceptions will be considered)

Miscellaneous Medications

MEDICATION FORMULARY QUANTITY LIMIT
(per 30 days)
FIRAZYR (icatibant acetate) Yes 3 syringes/Rx
KALYDECO (ivacaftor) Yes 60 tablets

 

Please call 800.432.3990 for additional information.

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