Current Migraine Drugs and Dispensing Limits*
Formulary |
Drug Name: Brand (generic) |
Dispensing limit per 30 days |
|
| National | Select | ||
Amerge (naratriptan) 1mg & 2.5mg tablets |
18 tablets |
||
Axert (almotriptan) 6.25mg & 12.5mg tablets |
12 tablets |
||
Stadol (butorphanol) nasal spray |
3 packages (7.5mL) |
||
Frova (frovatriptan) 2.5mg tablets |
18 tablets |
||
| * | * | Imitrex (sumatriptan) 25mg & 50mg tablets |
18 tablets |
| * | * | Imitrex (sumatriptan) 100mg tablets |
9 tablets |
| * | * | Imitrex (sumatriptan) 5mg nasal spray |
4 packages (24 units) |
| * | * | Imitrex (sumatriptan) 20mg nasal spray |
2 packages (12 units) |
| * | * | Imitrex (sumatriptan) 6mg injection |
6 packages (12 syringes) |
| * | Maxalt (rizatriptan) 5mg & 10mg tablets |
18 tablets |
|
| * | Maxalt-MLT (rizatriptan) 5 mg & 10mg tablets |
18 tablets |
|
| * | * | Migranal (dihydroergotamine) nasal spray |
3 units (12ml) |
Relpax (eletriptan) 20mg & 40mg tablets |
12 tablets |
||
Treximet (sumatriptan/naproxen) 85mg/500mg tablets |
18 tablets | ||
| * | * | Zomig (zolmitriptan) 2.5mg & 5mg tablets |
12 tablets |
| * | * | Zomig –ZMT (zolmitriptan) 2.5mg & 5mg tablets |
12 tablets |
| * | * | Zomig (zolmitriptan) 5mg nasal spray |
2 packages (12 units) |
Current Erectile Dysfunction Drugs and Dispensing Limits*
Formulary |
Drug Name: Brand (generic) |
Dispensing limit per 30 days |
|
| National | Select | ||
Cialis (tadalafil) |
6 tablets |
||
| * | * | Viagra (sildenafil) |
6 tablets |
Levitra (vardenafil) |
6 tablets |
||
*Future drugs that are approved by the Food and Drug Administration in these drug classes may have dispensing limits.
OxyContin
Formulary |
Drug Name: Brand (generic) |
Dispensing limit per 30 days |
|
| National | Select | ||
| * | * | OxyContin (oxycodone HCl controlled-release) |
60 tablets* |
*For certain medical needs, exception to the OxyContin quantity limits will be considered. Call 800-432-3990 for more information.
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