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Quantity Limits

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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