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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