Drugs With Quantity Limits

 Drugs

 Limits/Notes

Anti-Emetics:  Anzemet (dolasetron), Cesamet (nabilone), Emend (aprepitant), Kytril (granisetron) and Zofran (ondansetron).

15 tablets/capsules per 30-day supply

Exception:  Any prescription written by an oncologist.

Arthritis: Arava (leflunomide)

30 day supply

Antimalarial: Lariam (mefloquine)

8 pills per 30-day supply

Depression: Prozac Weekly (fluoxetine 90 mg)

8 pills per 30-day supply

Migraine: Amerge (naratriptan), Axert (almotriptan), Frova (frovatriptan), Imitrex (sumatriptan), Maxalt (rizatriptan), Relpax (eletriptan), Zomig (zolmitriptan)

Tablets: 18 per 30-day supply at retail or 54 per 90-day supply at mail order.

Nasal Spray: 8 per 30-day supply - retail ONLY.

Injectable 6 per 30-day supply - retail ONLY.

NSAID: Toradol (ketorolac)

Oral Toradol is FDA approved as a continuation of injectable Toradol.  Maximum dose per day is 40 mg. Quantity limit is 16 tablets within 5 days.       

Osteoporosis:

     Boniva (ibandronate)

     Fosamax (alendronate 35 mg and 70 mg)

     Fosamax Plus (alendronate plus D)

1 pill per 30-day supply

8 pills per 28-day supply

 4 pills per 28-day supply

Prostate: Proscar (finasteride)

Limited to men ONLY

Sexual Dysfunction: Viagra (sildenafil), Levitra (vardenafil), Cialis (tadalafil)

6 per 30-day supply.  Limited to men ONLY (when a covered benefit)

Sleep Agents (Hypnotics): Ambien (zolpidem), Dalmane (flurazepam), Lunesta (eszopiclone), Halcion (triazolam), ProSom (estazolam), Restoril (temazepam), Serax (oxazepam) and Sonata (zaleplon)

 30 per 30-day supply - retail ONLY

Tobacco Cessation: Chantix (varenicline), Zyban- generic equivalent only (bupropion)

Limited to $600 yearly maximum or the maximum amount per contract  when a covered benefit.