Quantity Limit Program Target Drugs Dosage/Strength...Paxil (paroxetine)a 30 mg tablet 2 tablets Paxil (paroxetine)a 40 mg tablet 1 tablet Paxil (paroxetine) 10 mg/5 mL suspension

Program Target Drugs Dosage/StrengthQuantity Limit

(Units/Day or as noted)

ADHD PS AR0320

Adderall (amphetamine/dextroamphetamine) 5 mg tableta 2 tablets

Adderall (amphetamine/dextroamphetamine) 7.5 mg tableta 2 tablets


Adderall (amphetamine/dextroamphetamine) 12.5 mg tableta 2 tablets




Adderall XR (amphetamine/dextroamphetamine extended-release) 5 mg capsulea 1 capsule






Adhansia XR (methylphenidate ER) 25 mg capsule 1 capsule






Adzenys ER (amphetamine ER) 1.25 mg/1 mL solution 15 mL

Adzenys XR-ODT (amphetamine ER) 3.1 mg oral disintegrating tablet 2 tablets

Adzenys XR-ODT (amphetamine ER) 6.3 mg oral disintegrating tablet 2 tablets

Adzenys XR-ODT (amphetamine ER) 9.4 mg oral disintegrating tablet 1 tablet




Aptensio XR, Methylphenidate ER 10 mg capsule 1 capsule





Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

BCBSMN_CS_QL_Programs_AR0320 © Copyright Prime Therapeutics LLC. 03/2020 All Rights Reserved 1

BlueCross BlueShield BluePlus of Minnesota Quantity Limit Program Summary



Concerta (methylphenidate extended-release) 18 mg tableta 1 tablet


Concerta (methylphenidate extended-release) 36 mg tableta 2 tablets


Cotempla XR ODT (methylphenidate ER orally dissolving tablet) 8.6 mg orally disintegrating tablet 1 tablet

Cotempla XR ODT (methylphenidate ER orally dissolving tablet) 17.3 mg orally disintegrating tablet 2 tablets

Cotempla XR ODT (methylphenidate ER orally dissolving tablet) 25.9 mg orally disintegrating tablet 2 tablets

Daytrana (methylphenidate transdermal patch) 10 mg/9 hr patch 1 patchDaytrana (methylphenidate transdermal patch) 15 mg/9 hr patch 1 patchDaytrana (methylphenidate transdermal patch) 20 mg/9 hr patch 1 patchDaytrana (methylphenidate transdermal patch) 30 mg/9 hr patch 1 patch

Desoxyn (methamphetamine) 5 mg tablet 5 tablets

Dexedrine (dextroamphetamine extended-release)

5 mg extended-release

capsulea

3 capsules





capsulea

4 capsules



capsulea

4 capsules

dextroamphetamine 5 mg tableta 3 tablets

dextroamphetamine 10 mg tableta 6 tablets

Dyanavel XR (amphetamine ER suspension) 2.5 mg / mL 8 mL

Evekeo (amphetamine) 5 mg tableta 3 tablets

Evekeo (amphetamine) 10 mg tableta 6 tablets

ADHD PS AR0320

Evekeo ODT (amphetamine) 5 mg orally disintegrating tablet 2 tablets




Focalin (dexmethylphenidate) 2.5 mg tableta 2 tablets

Focalin (dexmethylphenidate) 5 mg tableta 2 tablets

Focalin (dexmethylphenidate) 10 mg tableta 2 tablets

Focalin XR (dexmethylphenidate extended-release) 5 mg capsulea 1 capsule








Intuniv (guanfacine extended-release)


tableta

1 tablet



tableta

1 tablet



tableta

1 tablet



tableta

1 tablet

Jornay PM (methylphenidate extended-release) 20 mg ER capsule 1 capsule







Kapvay (clonidine extended-release)

0.1 mg extended-release

tableta

4 tabletsa

Metadate CD (methylphenidate extended-release) 10 mg capsulea 1 capsule






Metadate ER (methylphenidate extended-release) 20 mg tableta 3 tablets

Methylin (methylphenidate) 2.5 mg chewable tableta 3 tablets

Methylin (methylphenidate) 5 mg chewable tableta 3 tablets

Methylin (methylphenidate) 10 mg chewable tableta 6 tablets

Methylin (methylphenidate) 5 mg/5 mL solutiona 15 mL

Methylin (methylphenidate) 10 mg/5 mL solutiona 30 mL

Methylin ER (methylphenidate extended-release) 10 mg tableta 3 tablets

Methylin ER (methylphenidate extended-release) 20 mg tableta 3 tablets

methylphenidate ER 18 mg tablet 1 tablet

methylphenidate ER 27 mg tableta 1 tablet

methylphenidate ER 36 mg tableta 2 tablets



Mydayis 12.5 mg capsule 1 capsule

Mydayis 25 mg capsule 1 capsule

Mydayis 37.5 mg capsule 1 capsule

Mydayis 50 mg capsule 1 capsule

Procentra (dextroamphetamine) 6 mg/5 mL oral solutiona 60 mL



Quillichew (methylphenidate ER chewable) 20 mg 1 tablet

Quillichew (methylphenidate ER chewable) 30 mg 2 tablets

Quillichew (methylphenidate ER chewable) 40 mg 1 tablet

Quillivant XR (methylphenidate) 25 mg/5 ml oral

suspension

12 mL

Relexxii (methylphenidate ER) 72 mg tablet 1 tablet

Ritalin (methylphenidate) 5 mg tableta 3 tablets



Ritalin LA (methylphenidate extended–release) 10 mg capsulea 1 capsule





ADHD PS AR0320

Strattera (atomoxetine)a 10 mg capsule 2 capsules




Strattera (atomoxetine)a 60 mg capsule 1 capsule



Vyvanse (lisdexamfetamine) 10 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 20 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 30 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 40 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 50 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 60 mg capsule 1 capsuleVyvanse (lisdexamfetamine) 70 mg capsule 1 capsule

Vyvanse chewable (lisdexamfetamine) 10 mg chewable tablet 1 tablet






Zenzedi (dextroamphetamine) 2.5 mg tablet 3 tabletsZenzedi (dextroamphetamine) 7.5 mg tablet 3 tabletsZenzedi (dextroamphetamine) 15 mg tablet 3 tabletsZenzedi (dextroamphetamine) 20 mg tablet 3 tabletsZenzedi (dextroamphetamine) 30 mg tablet 2 tablets



Androgens_Anabolic Steroids

PAQL ** Androgen_Anabolic Steroid QL information is included in the individual program document

Antidepressants PS AR0420

Selective Serotonin Reuptake Inhibitors (SSRIs)

Celexa (citalopram)a 10 mg tablet 1 tablet



Celexa (citalopram)a 10 mg/5 mL oral solution 20 mL

Lexapro (escitalopram)a 5 mg tablet 1 tablet



Lexapro (escitalopram)a 5 mg/5 mL oral solution 20 mL

fluvoxamine ERa 100 mg extended-release

capsule

2 capsules

fluvoxamine ERa 150 mg extended-release

capsule

2 capsules

a - available as a generic, included in quantity limit program




fluvoxaminea 25 mg tablet 1 tablet

fluvoxaminea 50 mg tablet 1 tablet

fluvoxaminea 100 mg tablet 3 tablets

Paxil (paroxetine)a 10 mg tablet 1 tablet


Paxil (paroxetine)a 30 mg tablet 2 tablets


Paxil (paroxetine) 10 mg/5 mL suspension 30 mL

Paxil CR (paroxetine ER)a 12.5 mg controlled-

release tablet

1 tablet

Paxil CR (paroxetine ER)a 25 mg controlled-release

tablet

2 tablets

Paxil CR (paroxetine ER)a 37.5 mg controlled-

release tablet

2 tablets

Pexeva (paroxetine) 10 mg tablet 1 tablet


Pexeva (paroxetine) 30 mg tablet 2 tablets


Prozac (fluoxetine)a 10 mg capsule 1 capsule

Prozac (fluoxetine)a 20 mg capsule 4 capsules

Prozac (fluoxetine)a 40 mg capsule 2 capsules

Prozac (fluoxetine)a 10 mg tablet 1 tablet

Prozac (fluoxetine)a 20 mg tablet 4 tablets

Prozac, (fluoxetine)a 60 mg tablet 1 tablet

Prozac (fluoxetine)a 20 mg/5 mL oral solution 20 mL

Prozac Weekly (fluoxetine)a 90 mg delayed-release

capsule

4 capsules/28 days

Zoloft (sertraline)a 25 mg tablet 1 tablet

Zoloft (sertraline)a 50 mg tablet 1 tablet

Zoloft (sertraline)a 100 mg tablet 2 tablets

Zoloft (sertraline)a 20 mg/mL oral

concentrate

10 mL

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Cymbalta (duloxetine)a 20 mg delayed-release

capsule

2 capsules


capsule

2 capsules


capsule

2 capsules



Desvenlafaxine 50 mg extended-release

tablet 1 tablet

Desvenlafaxine 100 mg extended-release

tablet

1 tablet

Drizalma Sprinkle 20 mg delayed release

sprinkle capsule

2 capsules


sprinkle capsule

2 capsules


sprinkle capsule

2 capsules


sprinkle capsule

2 capsules

Effexor (venlafaxine)a 25 mg tablet 3 tablets

Effexor (venlafaxine)a 37.5 mg tablet 3 tablets




Effexor XR (venlafaxine ER)a 37.5 mg extended-

release capsule 1 capsule

Effexor XR (venlafaxine ER)a 75 mg extended-release

capsule

3 capsules

Effexor XR (venlafaxine ER)a 150 mg extended-release

capsule

1 capsule

Fetzima (levomilnacipran) 20 mg extended-release

capsule 1 capsule


capsule 1 capsule


capsule 1 capsule


capsule 1 capsule

Fetzima (levomilnacipran) Titration pack (2 x 20

mg, 26 x 40 mg) 1 kit (28 capsules)/28 days

Khedezla (desvenlafaxine) 50 mg extended-release

tablet 1 tablet

Khedezla (desvenlafaxine) 100 mg extended-release

tablet

1 tablet

duloxetinea 40 mg delayed release

capsule

3 capsules

Antidepressants PS AR0420

Venlafaxine ERa 37.5 mg extended-

release tablet 1 tablet

Venlafaxine ERa 75 mg extended-release

tablet

3 tablets




tablet

1 tablet


tablet

1 tablet

Pristiq (desvenlafaxine)a 25 mg extended-release

tablet1 tablet


tablet 1 tablet


tablet

1 tablet

Other Antidepressants

Aplenzin (bupropion) 174 mg extended-release

tablet

1 tablet


tablet

1 tablet


tablet

1 tablet

Forfivo XL (bupropion) 450 mg extended-release

tablet

1 tablet

Maprotiline 25 mg tablet 3 tablets



Remeron (mirtazapine)a

7.5 mg tabletf 1 tablet

Remeron (mirtazapine)a 15 mg tablet 1 tablet



Remeron SolTab (mirtazapine)a

15 mg orally-

disintegrating tablet

1 tablet


30 mg orally-


1 tablet


45 mg orally-


1 tablet

Trintellix (vortioxetine) 5 mg tablet 1 tablet



Viibryd (vilazodone) 10 mg tablet 1 tablet



Viibryd (vilazodone) Starter Kit (7 x 10mg, 23

x 20mg)

1 tablet (1 kit/180 days)



Wellbutrin (bupropion)a 75 mg tablet 2 tablets

Wellbutrin (bupropion)a 100 mg tablet 4 tablets

Wellbutrin SR, Budeprion SR (bupropion SR)a

100 mg sustained-

release tablet

2 tablets


150 mg sustained-

release tablet

2 tablets


200 mg sustained-

release tabletd

2 tablets

Wellbutrin XL, Budeprion XL (bupropion ER)a


tablet

1 tablet

Wellbutrin XL, Budeprion XL (bupropion ER)a


tablet

1 tablet

a - available as a generic, included in quantity limit program

Antipsychotics, Atypical PS

AR0420

Abilify (aripiprazole)a 2 mg tablet 1 tablet






aripiprazolea 1 mg/mL oral solution 30 mL

aripiprazolea 10 mg orally


2 tablets

aripiprazolea 15 mg orally


2 tablets

Abilify Maintena (aripiprazole) 300 mg vial extended-

release injection

1 vial/28 days

Abilify Maintena (aripiprazole IM ER suspension) 300 mg ER suspension

syringe

1 syringe/28 days

Abilify Maintena (aripiprazole) 400 mg vial extended-

release injection

1 vial/28 days

Abilify Maintena (aripiprazole IM ER suspension) 400 mg ER suspension

syringe

1 syringe/28 days

Abilify Mycite (aripiprazole with sensor) 2 mg tablet 1 tablet






Aristada (aripiprazole lauroxil injection) 441 mg injection 1 syringe/28 days







Aristada Initio (aripiprazole lauroxil extended-release injection) 675 mg injection 1 kit/180 days

Caplyta (lumataperone) 42 mg capsule 1 capsule

Clozaril (clozapine)a 25 mg, tablet 3 tablets

Clozaril (clozapine)a 50 mg tablet 3 tablets



Fanapt (iloperidone) 1 mg tablet 2 tablets







Fanapt (iloperidone) Titration pak 1 pak (8 tablets)/180 days

FazaClo (clozapine)a 12.5 mg orally


3 tablets

FazaClo (clozapine)a 25 mg orally


9 tablets

FazaClo (clozapine)a 100 mg orally


3 tablets

FazaClo (clozapine) 150 mg orally


6 tablets

FazaClo (clozapine) 200 mg orally


4 tablets

Geodon (ziprasidone)a 20 mg capsule 2 capsules




Geodon (ziprasidone)a 20 mg/mL injection 2 vials

Invega (paliperidone)a 1.5 mg tablet 1 tablet

Invega (paliperidone)a 3 mg tablet 1 tablet

Invega (paliperidone)a 6 mg tablet 2 tablets

Invega (paliperidone)a 9 mg tablet 1 tablet

Invega Sustenna (paliperidone)39 mg/kit extended-

release injection

1 kit/28 days


release injection

1 kit/28 days


release injection

1 kit/28 days




release injection

1 kit/28 days


release injection

1 kit/28 days

Invega Trinza (paliperidone injection) 273 mg / 0.875 mL 0.875 mL / 90 days


AR0420




Latuda (lurasidone) 20 mg tablet 1 tabletLatuda (lurasidone) 40 mg tablet 1 tabletLatuda (lurasidone) 60 mg tablet 1 tabletLatuda (lurasidone) 80 mg tablet 2 tabletLatuda (lurasidone) 120 mg tablet 1 tablet

Perseris (risperidone) 90 mg kit extended-

release injection

1 kit/30 days

Perseris (risperidone) 120 mg kit extended-

release injection

1 kit/30 days

Rexulti (brexpiprazole) 0.25 mg tablet 1 tablet

Rexulti (brexpiprazole) 0.5 mg tablet 1 tablet

Rexulti (brexpiprazole) 1 mg tablet 1 tablet




Risperdal (risperidone)a 0.25 mg tablet 2 tablets

Risperdal (risperidone)a 0.5 mg tablet 2 tablets

Risperdal (risperidone)a 1 mg tablet 2 tablets




Risperdal (risperidone)a 1 mg/mL oral solution 16 mL

risperidone0.25 mg orally


2 tablets

Risperdal M-Tab (risperidone)a

0.5 mg orally


2 tablets


1 mg orally disintegrating

tablet

2 tablets

risperidonea


tablet

2 tablets



tablet

2 tablets



tablet

4 tablets



Risperdal Consta (risperidone)12.5 mg/vial long-acting

injection

2 vials/28 days

Risperdal Consta (risperidone)25 mg/vial long-acting

injection

2 vials/28 days

Risperdal Consta (risperidone)37.5 mg/vial long-acting

injection

2 vials/28 days

Risperdal Consta (risperidone)50 mg/vial long-acting

injection

2 vials/28 days

Saphris (asenapine) 2.5 mg sublingual tablet 2 tabletsSaphris (asenapine) 5 mg sublingual tablet 2 tabletsSaphris (asenapine) 10 mg sublingual tablet 2 tablets

Secuado (asenapine) 3.8 mg/ 24hr

transdermal patch

1 patch


transdermal patch

1 patch


transdermal patch

1 patch

Seroquel (quetiapine)a 25 mg tablet 3 tablets







AR0420

Seroquel XR (quetiapine)a


tablet

2 tablets



tablet

1 tablet



tablet

1 tablet



tablet

2 tablets



tablet

2 tablets

Versacloz (clozapine)50 mg/ml oral

suspension

18 mL

Vraylar (cariprazine) 1.5 mg capsule 1 capsule

Vraylar (cariprazine) 3 mg capsule 1 capsule

Vraylar (cariprazine) 4.5 mg capsule 1 capsule

Vraylar (cariprazine) 6 mg capsule 1 capsule

Vraylar (cariprazine) Titration Therapy Pack 1 pack / 180 days



Zyprexa (olanzapine)a 2.5 mg tablet 1 tablet



Zyprexa (olanzapine)a 5 mg tablet 1 tablet

Zyprexa (olanzapine)a 7.5 mg tablet 1 tablet




Zyprexa (olanzapine)a 10 mg/vial injection 3 vials

Zyprexa Zydis (olanzapine)a


tablet

1 tablet


10 mg orally


1 tablet


15 mg orally


1 tablet


20 mg orally


1 tablet

Zyprexa Relprevv (olanzapine)210 mg vial extended-

release injection

2 vials/28 days


release injection

2 vials/28 days


release injection

1 vial/28 days

Antiretroviral PS AR0819_r0320

Aptivus (tipranavir)

100 mg/mL (95 mL

bottle) oral solution 12.6667 mL (380 mL/30 days)b

Aptivus (tipranavir) 250 mg capsule 4 capsules

Atripla (efavirenz/emtricitabine/ tenofovir)

600 mg/200 mg/300 mg

tablet 1 tablet

Biktarvy (bictegravir, emtricitabine, tenofovir) 50 mg/200 mg/25 mg

tablet 1 tablet

Cimduo, Temixys (lamivudine/tenofovir) 300 mg/300 mg tablet 1 tablet

Combivir (lamivudine/zidovudine) 150 mg/300 mg tableta

2 tablets

Complera (emtricitabine/rilpivirine/tenofovir)

200 mg/25 mg/300 mg

tablet 1 tablet

Crixivan (indinavir) 200 mg capsule 9 capsulesCrixivan (indinavir) 400 mg capsule 6 capsules

Delstrigo (doravirine/lamivudine/tenofovir) 100 mg/300 mg/300 mg 1 tablet

Descovy (emtricitabine/tenofovir) 200 mg/25 mg tablet 1 tablet

a - generic available and included in the program; b – available only as generic clozapine, no




Dovato (dolutegravir/lamivudine) 50 mg / 300 mg tablet 1 tablet

Edurant (rilpivirine) 25 mg tablet 1 tablet

Emtriva (emtracitabine) 10 mg/mL oral solution 24.2856 mL (680 mL/28 days)Emtriva (emtracitabine) 200 mg capsule 1 capsule

Epivir (lamivudine)

10 mg/mL oral solution

(240 mL bottle)a

32 mL (960 mL/30 days)b

Epivir (lamivudine) 150 mg tableta

2 tablets

Epivir (lamivudine) 300 mg tableta

1 tablet

Epzicom (lamivudine/abacavir) 600 mg/300 mg tableta

1 tablet

Evotaz (atazanavir/cobicistat) 300 mg/150 mg tablet 1 tablet

Fuzeon (enfuvirtide)108 mg/vial (to deliver

90 mg/mL dose) 2 vials (60 vials/month)

Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir) 150 mg/150 mg/200 mg/

10 mg tablet 1 tablet

Intelence (etravirine) 25 mg tablet 4 tablets

Intelence (etravirine) 100 mg tablet 2 tabletsIntelence (etravirine) 200 mg tablet 2 tablets

Invirase (saquinavir mesylate) 200 mg capsule 10 capsulesInvirase (saquinavir mesylate) 500 mg tablet 4 tablets

Isentress (raltegravir) 25 mg chewable tablets 6 tabletsIsentress (raltegravir) 100 mg chewable tablets 6 tablets

Isentress (raltegravir) 400 mg tablets 2 tablets

Isentress HD (raltegravir) 600 mg tablets 2 tablets

Isentress (raltegravir)

100 mg packet for

suspension 2 packets

Juluca (dolutegravir/rilpivirine) 50 mg/25 mg tablets 1 tablet

Kaletra (lopinavir/ritonavir)

80 mg/20 mg per mL

(160 mL bottle oral soln)a

16 mL (480 mLs/30 days)Kaletra (lopinavir/ritonavir) 100 mg/25 mg tablet 6 tabletsKaletra (lopinavir/ritonavir) 200 mg/50 mg tablet 4 tablets

Lexiva (fosamprenavir)

50 mg/mL (225 mL

bottle) oral suspension 60 mL (1800 mL/30 days)b

Lexiva (fosamprenavir) 700 mg tableta

4 tablets



Norvir (ritonavir)

80 mg/mL (240 mL

bottle) oral solution 16 mL (480 mL/30 days)b

Norvir (ritonavir) 100 mg capsule 12 capsules

Norvir (ritonavir) 100 mg tableta

12 tablets

Norvir (ritonavir) 100 mg powder packet 12 packets

Odefsey (emtricitabine/rilpivirine/tenofovir) 200 mg/25 mg/25 mg 1 tablet

Pifeltro (doravirine) 100 mg 1 tablet

Prezcobix (darunavir/cobicistat) 800 mg/150 mg tablet 1 tablet

Antiretroviral PS AR0819_r0320 Prezista (darunavir) 100 mg/mL suspension 13.3334 mL (400 mL/30 days)b

Prezista (darunavir) 75 mg tablet 10 tabletsPrezista (darunavir) 150 mg tablet 6 tabletsPrezista (darunavir) 600 mg tablet 2 tabletsPrezista (darunavir) 800 mg tablet 1 tablet

Rescriptor (delavridine) 100 mg tablet 12 tablets

Rescriptor (delavridine) 200 mg tablet 6 tablets

Reyataz (atazanavir) 150 mg capsulea

1 capsule


2 capsules


1 capsuleReyataz (atazanavir) 50 mg powder packet 8 packets

Selzentry (maraviroc) 25 mg tablet 8 tabletsSelzentry (maraviroc) 75 mg tablet 2 tabletsSelzentry (maraviroc) 150 mg tablet 2 tablets

Selzentry (maraviroc) 300 mg tablet 4 tablets

Selzentry (maraviroc) 20 mg/mL oral solution 1840 mLs/30 days

Stribild (elvitegravir/cobistat/emtricitabine/tenofovir)

150 mg/150 mg/200

mg/300mg 1 tablet

Sustiva (efavirenz) 50 mg capsulea

3 capsules

Sustiva (efavirenz) 200 mg capsulea

2 capsules

Sustiva (efavirenz) 600 mg tableta 1 tablet

Symfi (efavirenz/lamivudine/tenofovir) 600 mg/300 mg/300mg 1 tablet

Symfi Lo (efavirenz/lamivudine/tenofovir) 400 mg/300 mg/300mg1 tablet

Symtuza (darunavir/cobicistat/emtricitabine/tenofovir) 800 mg/150 mg/200

mg/10 mg

1 tablet

Tivicay (dolutegravir) 10 mg tablet 2 tablets

Tivicay (dolutegravir) 25 mg tablet 2 tabletsTivicay (dolutegravir) 50 mg tablet 2 tablets



Triumeq (abacavir/dolutegravir/lamivudine)600 mg/50 mg/300 mg

tablet 1 tablet

Trizivir (abacavir, lamivudine, zidovudine)

300 mg/150 mg/300 mg

tableta

2 tablets

Truvada (emtracitabine/tenofovir) 100/150 mg tablet 1 tablet

Truvada (emtracitabine/tenofovir) 133/200 mg tablet 1 tablet

Truvada (emtracitabine/tenofovir) 167/250 mg tablet 1 tabletTruvada (emtracitabine/tenofovir) 200 mg/300 mg tablet 1 tablet

Tybost (cobicistat) 150 mg tablet 1 tablet

Videx (didanosine)

2 g powder (10 mg/mL in

100 mL bottle) 40 mL (1200 mL/30 days)b

Videx (didanosine)

4 g powder (10 mg/mL in

200 mL bottle) 40 mL (1200 mL/30 days)Videx EC (didanosine) 125 mg capsule 1 capsule

Videx EC (didanosine) 200 mg capsulea

1 capsule


1 capsule


1 capsule

Viracept (nelfinavir) 250 mg tablet 9 tabletsViracept (nelfinavir) 625 mg tablet 4 tablets

Viramune (nevirapine)

50 mg/5 mL suspension

(240 mL bottle)a

40 mL (1200 mL/30 days)

Viramune (nevirapine) 200 mg tableta 2 tablets

Viramune XR (nevirapine)


tableta 3 tablets

Viramune XR (nevirapine)


tableta 1 tablet

Viread (tenofovir) 150 mg tablet 1 tabletViread (tenofovir) 200 mg tablet 1 tabletViread (tenofovir) 250 mg tablet 1 tablet

Viread (tenofovir) 300 mg tableta

1 tablet

Viread (tenofovir)

40 mg/1g oral powder for

reconstitution (60 g can) 8 g (240 g/30 days)b

Vitekta (elvitegravir) 85 mg tablet 1 tablet

Vitekta (elvitegravir) 150 mg tablet 1 tablet

Zerit (stavudine)


(200 mL bottle) 80 mL (2400 mL/30 days)

Zerit (stavudine) 15 mg capsulea

2 capsules




2 capsules


2 capsules


2 capsules

Antiretroviral PS AR0819_r0320

Ziagen (abacavir)


(240 mL bottle)a

32 mL (960 mL/30 days)b

Ziagen (abacavir) 300 mg tableta

2 tablets

zidovudine

50 mg/5 mL syrup (10

mg/mL in 240 mL bottle) 64 mL (1920 mL/30 days)b

zidovudine 100 mg capsulea

6 capsules

zidovudine 300 mg tableta

2 tablets

ARB/Renin Inhibitors PS AR0819_r0320 Angiotensin II Receptor Antagonists (ARBs), ARB Combinations

Atacand (candesartan)a 4 mg tablets 2 tablets



Atacand (candesartan)a 32 mg tablets 1 tablet

Atacand HCT (candesartan/hydrochlorothiazide)a

16 mg/12.5 mg tablets 1 tablet




32 mg/25 mg tablets 1 tablet

ARB/Renin Inhibitors PS

AR0819_r0320Avapro (irbesartan)

a 75 mg tablets 1 tablet

Avapro (irbesartan)a 150 mg tablets 1 tablet

Avapro (irbesartan)a 300 mg tablets 1 tablet

Avalide (irbesartan/hydrochlorothiazide)a 150 mg/12.5 mg tablets 1 tablet

Avalide (irbesartan/hydrochlorothiazide)a 300 mg/12.5 mg tablets 1 tablet

Azor (amlodipine/olmesartan medoxomil)a 5 mg/20 mg tablets 1 tablet




Benicar (olmesartan)a 5 mg tablets 2 tablets

Benicar (olmesartan)a 20 mg tablets 1 tablet

Benicar (olmesartan)a 40 mg tablets 1 tablet

Benicar HCT (olmesartan/hydrochlorothiazide)a 20 mg/12.5 mg tablets 1 tablet

Benicar HCT (olmesartan/hydrochlorothiazide)a 40 mg/12.5 mg tablets 1 tablet

Benicar HCT (olmesartan/hydrochlorothiazide)a 40 mg/25 mg tablets 1 tablet




Byvalson (nebivolol/valsartan) 5 mg/80 mg tablets 1 tablet

Cozaar (losartan)a 25 mg tablets 2 tablets

Cozaar (losartan)a 50 mg tablets 2 tablets

Cozaar (losartan)a 100 mg tablets 1 tablet

Diovan (valsartan)a 40 mg tablets 2 tablets



Diovan (valsartan)a 320 mg tablets 1 tablet

Diovan HCT (valsartan/hydrochlorothiazide)a










Edarbi (azilsartan) 40 mg tablets 1 tablet

Edarbi (azilsartan) 80 mg tablets 1 tablet

Edarbyclor (azilsartan/chlorthalidone) 40 mg/12.5 mg tablets 1 tablet

Edarbyclor (azilsartan/chlorthalidone) 40 mg/25 mg tablets 1 tablet

Exforge (amlodipine/valsartan) 5 mg/160 mg tablets 1 tablet





AR0819_r0320

Exforge HCT (amlodipine/valsartan/hydrochlorothiazide)a 5 mg/160 mg/12.5 mg

tablets 1 tablet

Exforge HCT (amlodipine/valsartan/hydrochlorothiazide)a 5 mg/160 mg/25 mg

tablets 1 tablet

Exforge HCT (amlodipine/valsartan/hydrochlorothiazide)a 10 mg/160 mg/12.5 mg

tablets 1 tablet

Exforge HCT (amlodipine/valsartan/hydrochlorothiazide)s 10 mg/160 mg/25 mg

tablets 1 tablet

Exforge HCT (amlodipine/valsartan/hydrochlorothiazide)s 10 mg/320 mg/25 mg

tablets 1 tablet

Hyzaar (losartan/hydrochlorothiazide)a 50 mg/12.5 mg tablets 1 tablet

Hyzaar (losartan/hydrochlorothiazide)a 100 mg/12.5 mg tablets 1 tablet

Hyzaar (losartan/hydrochlorothiazide)a 100 mg/25 mg tablets 1 tablet

Micardis (telmisartan)a 20 mg tablets 1 tablet





Micardis HCT (telmisartan/hydrochlorothiazide)a 40 mg/12.5 mg tablets 1 tablet

Micardis HCT (telmisartan/hydrochlorothiazide)a 80 mg/12.5 mg tablets 2 tablets

Micardis HCT (telmisartan/hydrochlorothiazide)a 80 mg/25 mg tablets 1 tablet

Teveten (eprosartan) 400 mg tablets 2 tablets

Teveten, Eprosartan 600 mg tablets 1 tablet

Teveten HCT (eprosartan/hydrochlorothiazide) 600 mg/12.5 mg tablets 1 tablet

Teveten HCT (eprosartan/hydrochlorothiazide) 600 mg/25 mg tablets 1 tablet

Tribenzor (olmesartan/amlodipine/hydrochlorothiazide)a 20 mg/5 mg/12.5 mg

tablets 1 tablet


tablets 1 tablet

Tribenzor (olmesartan/amlodipine/hydrochlorothiazide)a 40 mg/5 mg/25 mg

tablets 1 tablet


tablets 1 tablet

Tribenzor (olmesartan/amlodipine/hydrochlorothiazide)a 40 mg/10 mg/25 mg

tablets 1 tablet

Twynsta (telmisartan/amlodipine)a 40 mg/5 mg tablets 1 tablet




Renin Inhibitors, Renin Inhibitor Combinations

Tekturna (aliskiren)a 150 mg tablets 1 tablet

Tekturna (aliskiren)a 300 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 150 mg/12.5 mg tablets 1 tablet


AR0819_r0320

Tekturna HCT (aliskiren/hydrochlorothiazide) 150 mg/25 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 300 mg/12.5 mg tablets 1 tablet

Tekturna HCT (aliskiren/hydrochlorothiazide) 300 mg/25 mg tablets 1 tablet

Benign Prostatic Hypertrophy

(BPH) PS AR0819_r0320Alpha Blockers (Selective)

Flomax (tamsulosin) 0.4 mg capsulesa 2 capsules

Rapaflo (silodosin) 4 mg capsulesa 1 capsule

Rapaflo (silodosin) 8 mg capsulesa 1 capsule

Uroxatral (alfuzosin) 10 mg extended-release

tabletsa

1 tablet

Alpha Blockers (Nonselective)




Cardura (doxazosin) 1 mg tabletsa 1 tablet



Cardura (doxazosin) 8 mg tabletsa 2 tablets

Cardura XL (doxazosin) 4 mg extended-release

tablets

1 tablet

Cardura XL (doxazosin) 8 mg extended-release

tablets

1 tablet

terazosin 1 mg capsulesa 1 capsule



terazosin 10 mg capsulesa 2 capsules

Alpha Reductase Inhibitors

Avodart (dutasteride) 0.5 mg capsulesa 1 capsule

Proscar (finasteride) 5 mg tabletsa 1 tablet

Alpha Reductase Inhibitor/Alpha Blocker Combinations

Jalyn (dutasteride/tamsulosin) 0.5 mg/0.4 mg capsulesa 1 capsule

Bisphosphonates PS AR1119_r0320 Actonel (risedronate) 5 mg tablets 1 tablet

Actonel (risedronate)a 30 mg tablets 1 tablet

Actonel (risedronate)a 35 mg tablets 4 tablets (1 dose pack)/28 days

Actonel (risedronate)a 150 mg tablets 1 tablet/month

Atelvia (risedronate delayed-release)a 35 mg delayed-release

tablets

4 tablets (1 dose pack)/28 days

Binosto (alendronate) 70 mg effervescent

tablets

4 tablets /28 days

Boniva (ibandronate)a 150 mg tablets 1 tablet (blister pack)/month

Boniva (ibandronate)a 3 mg/3 mL injection 3 mL (1 kit)/90 days

Fosamax/alendronate (alendronate)a 5 mg tablets 1 tablet

Fosamax/alendronate (alendronate)a 10 mg tablets 1 tablet

Fosamax/alendronate (alendronate)a 35 mg tablets 4 tablets (1 blister pack)/28

days

Fosamax/alendronate (alendronate) 40 mg tablets 1 tablet

Fosamax/alendronate (alendronate)a 70 mg tablets 4 tablets (1 blister pack)/28

days

Fosamax/alendronate (alendronate) 70 mg/75 mLs oral

solution

75 mLs (70 mg)/week

Fosamax Plus D (alendroante/cholecalciferol) 70 mg/2800 IU 4 tablets (1 blister pack)/28




Fosamax Plus D (alendroante/cholecalciferol) 70 mg/5600 IU

(alendronate/cholecalcife

rol)

4 tablets (1 blister pack)/28

days

c -IU=International Units

Buprenorphine, buprenorphine-

naloxone PS AR0220_r0320 Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

buprenorphinea 2 mg sublingual tablet 15 tablets/90 days

buprenorphinea 8 mg sublingual tablet 15 tablets/90 days

Bunavail (buprenorphine/naloxone) 2.1 mg / 0.3 mg buccal

film

3 films

Bunavail (buprenorphine/naloxone) 4.2 mg / 0.7 mg buccal

film

2 films

Bunavail (buprenorphine/naloxone) 6.3 mg / 1 mg buccal

film

2 films

Suboxone (buprenorphine/naloxone)a 2 mg/0.5 mg sublingual

tablet

4 tablets

Suboxone (buprenorphine/naloxone)a 8 mg/2 mg sublingual

tablet

3 tablets

Suboxone (buprenorphine/naloxone)a 2 mg/0.5 mg sublingual

film

4 films


film

1 film


film

2 films


film

2 films

Zubsolv (buprenorphine/naloxone) 0.7 mg/0.18 mg

sublingual tablet

1 tablet


sublingual tablet

3 tablets

Zubsolv (buprenorphine/naloxone) 2.9 g/0.71 mg sublingual

tablet

1 tablet

Zubsolv (buprenorphine/naloxone) 5.7mg/1.4 mg sublingual

tablet

1 tablet

a - product has been discontinued by the manufacturer but may still be available




sublingual tablet

2 tablets


sublingual tablet

1 tablet

DPP-4 Inhibitors PS

AR0220_r0320

Glyxambi (empagliflozin/linagliptin) 10 mg / 5 mg 1 tablet

Glyxambi (empagliflozin/linagliptin) 25 mg / 5 mg 1 tablet

Januvia (sitagliptin) 25 mg tablet 1 tablet



Nesina (alogliptin) 6.25mg 1 tablet

Nesina (alogliptin) 12.5mg 1 tablet

Nesina (alogliptin) 25mg 1 tablet

Onglyza (saxagliptin) 2.5 mg tablet 1 tablet

Onglyza (saxagliptin) 5 mg tablet 1 tablet

Tradjenta (linagliptin) 5 mg tablet 1 tablet

Janumet (sitagliptin/metformin) 50 mg/500 mg tablet 2 tablets

Janumet (sitagliptin/metformin) 50 mg/1000 mg tablet 2 tablets

Janumet XR (sitagliptin/metformin extended-release) 50 mg/500 mg tablet 1 tablet

Janumet XR (sitagliptin/metformin extended-release) 50 mg/1000 mg tablet 2 tablets

Janumet XR (sitagliptin/metformin extended-release) 100 mg/1000 mg tablet 1 tablet

Jentadueto (linagliptin/metformin) 2.5 mg/500 mg tablet 2 tablets



Jentadueto XR (linagliptin/metformin ER) 2.5 mg/1000 mg tablet 2 tablets

Jentadueto XR (linagliptin/metformin ER) 5 mg/1000 mg tablet 1 tablet

DPP-4 Inhibitors PS

AR0220_r0320

Kazano (alogliptin/metformin) 12.5mg/500mg 2 tablets

Kazano (alogliptin/metformin) 12.5mg/100mg 2 tablets

Kombiglyze XR (saxagliptin/metformin) 2.5 mg/1000 mg tablet 2 tablets

Kombiglyze XR (saxagliptin/metformin) 5 mg/500 mg tablet 1 tablet

Kombiglyze XR (saxagliptin/metformin) 5 mg/1000 mg tablet 1 tablet

Oseni (alogliptin/pioglitazone) 12.5mg/15mg 1 tablet



Oseni (alogliptin/pioglitazone) 25mg/15mg 1 tablet






Qtern (dapagliflozin/saxagliptin) 5 mg/5 mg tablet 1 tablet

Qtern (dapagliflozin/saxagliptin) 10 mg/5 mg tablet 1 tablet

Steglujan (ertugliflozin/sitagliptin) 5 mg/100 mg tablet 1 tablet

Steglujan (ertugliflozin/sitagliptin) 15 mg/100 mg tablet 1 tablet

Trijardy XR (empagliflozin/linagliptin/metformin ER) 5 mg/2.5 mg/1000 mg

tablet

2 tablets

Trijardy XR (empagliflozin/linagliptin/metformin ER) 10 mg/5 mg/1000 mg

tablet

1 tablet

Trijardy XR (empagliflozin/linagliptin/metformin ER) 12.5 mg/2.5 mg/1000

mg tablet

2 tablets

Trijardy XR (empagliflozin/linagliptin/metformin ER) 25 mg/5 mg/1000 mg

tablet

1 tablet

Fibrates PS AR0819_r0320

Antara (fenofibrate) 30 mg micronized capsules 2 capsules

Antara (fenofibrate)a 43 mg micronized

capsules

2 capsules

Antara (fenofibrate) 90 mg micronized capsules 1 capsule

Antara (fenofibrate)a 130 mg micronized

capsules

1 capsule

Fenoglide (fenofibrate)a 40 mg tablets 2 tablets

Fenoglide (fenofibrate)a 120 mg tablets 1 tablet

Fibricor (fenofibric acid) 35 mg tablets 2 tablets

Fibricor (fenofibric acid) 105 mg tablets 1 tablet

Lipofen (fenofibrate) 50 mg capsules 2 capsules

Lipofen (fenofibrate) 150 mg capsules 1 capsule

Lofibra (fenofibrate)a 54 mg tablets 2 tablets

Lofibra (fenofibrate)a 160 mg tablets 1 tablet

Lofibra (fenofibrate)a 67 mg micronized

capsules

1 capsule


capsules

1 capsule


capsules

1 capsule

Tricor (fenofibrate)a 48 mg tablets 2 tablets

Tricor (fenofibrate)a 145 mg tablets 1 tablet

Triglide (fenofibrate) 50 mg tablets 2 tablets

Triglide (fenofibrate)a 160 mg tablets 1 tablet




Trilipix (fenofibric acid)a 45 mg delayed-release

tablets

2 tablets

Trilipix (fenofibric acid)a 135 mg delayed-release

tablets

1 tablet

Fibrates PS AR0819_r0320 Lopid (gemfibrozil)a 600 mg tablets 2 tablets

Fibromyalgia (Lyrica, Savella) PS

AR0420 Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Lyrica (pregabalin)a 25 mg capsule 3 capsules








Lyrica (pregabalin)a 20 mg/mL oral solution 30 mLs

Savella (milnacipran) 12.5 mg tablet 2 tablets

Savella (milnacipran) 25 mg tablet 2 tablets



Savella (milnacipran) Titration pack: 5 x 12.5

mg, 8 x 25 mg,

42 x 50 mg tablets

1 kit/180 days

Gabapentin ER AR0420 Quantity limits apply to FlexRx Open, GenRx Open, Health Insurance Marketplace, FocusRx and KeyRx.

Gralise (gabapentin) 300 mg extended-release

tablets1 tablet

Gralise (gabapentin) 600 mg extended-release

tablets3 tablets

Gralise (gabapentin) Starter Pack: 300 mg (9)

& 600 mg (69)1 pack/180 days

Horizant (gabapentin enacarbil) 300 mg extended-release

tablets2 tablets

Horizant (gabapentin enacarbil) 600 mg extended-release

tablets2 tablets


GLP-1 Agonists PS AR0220_r0320Adlyxin (lixisenatide)

20 mcg/injection 3 mL

pens2 pens / 28 days

Adlyxin (lixisenatide) Starter Pack (2 pens) 2 pens / 180 days

Byetta (exenatide) 5 mcg/dose prefilled pen1 prefilled pen (60 doses)/30

days



Byetta (exenatide)10 mcg/dose prefilled

pen

1 prefilled pen (60 doses)/30

days

Bydureon (exenatide ER)2 mg/vial in single dose

tray; 4 trays/carton

1 carton (4 trays/4 doses)/28

days

Bydureon (exenatide ER) 2 mg/pen; 4 trays/carton 1 carton (4 doses)/28 days

Bydureon BCise (exenatide ER) 2 mg/autoinjector; 4

autoinjector/carton

4 autoinjectors/28days

Ozempic (semaglutide) 2 mg single-patient pen

(0.25-0.5 mg per

injection)

1 pen / 28 days

Ozempic (semaglutide) 2 mg single-patient pen

(1 mg per injection)2 pens / 28 days

Rybelsus (semaglutide) 3 mg tablet 30 tablets/180 days

Rybelsus (semaglutide) 7 mg tablet 1 tablet

Rybelsus (semaglutide) 14 mg tablet 1 tablet

Tanzeum (albiglutide) 30 mg single-dose pen 4 pens/28 days

Tanzeum (albiglutide) 50 mg single-dose pen 4 pens/28 days

Trulicity (dulaglutide) 0.75 mg / 0.5 mL syringe and

pens

4 pens or syringes/28days

Trulicity (dulaglutide) 1.5 mg / 0.5 mL syringe and

pens

4 pens or syringes/28days

Victoza (liraglutide)18 mg/3 mL pen; 2 pen

package

1 pkg (2 pens; 30 doses of 1.2

mg)/30 days

Glucose Test Strips/Disks/ Quantity limits apply to FlexRx Open, Flex Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Meters PS AR0320 Glucose Test Strips Glucose test strips 204 strips or testing units/30

days

Glucose Test Disks Glucose test disks 204 strips or testing units/30

days

Glucose Test Meters Sidekick Blood Glucose

System

4 units/30 days

Insomnia PS AR0420

Ambien (zolpidem)a 5 mg tablet 1 tablet

Ambien (zolpidem)a 10 mg tablet 1 tablet

Ambien CR (zolpidem)a 6.25 mg extended-

release tablet

1 tablet

Ambien CR (zolpidem)a 12.5 mg extended-

release tablet

1 tablet

Belsomra (suvorexant) 5 mg tablet 1 tablet







Dayvigo (lemborexant) 5 mg tablet 1 tablet

Dayvigo (lemborexant) 10 mg tablet 1 tablet

Edluar (zolpidem) 5 mg orally disintegrating

tablet

1 tablet

Edluar (zolpidem) 10 mg orally


1 tablet

Intermezzo (zolpidem)a 1.75 mg sublingual tablet 1 tablet

Intermezzo (zolpidem)a 3.5 mg sublingual tablet 1 tablet

Lunesta (eszopiclone)a 1 mg tablet 1 tablet



Rozerem (ramelteon)a 8 mg tablet 1 tablet

Silenor (doxepin)a 3 mg tablet 1 tablet

Silenor (doxepin)a 6 mg tablet 1 tablet

Sonata (zaleplon)a 5 mg capsule 1 capsule

Sonata (zaleplon)a 10 mg capsule 1 capsule

ZolpiMist (zolpidem) Oral Spray 5

mg/actuation

1 canister (60 actuations)/ 30

days

Insulins PS AR0220_r0320

Fiasp (insulin aspart) 100 U/mL: 10 mL vial, 3

mL pen/cartridge

100 mL/30 days

NovoLog, Insulin Aspart (insulin aspart) 100 U/mL: 10 mL vial, 3

mL pen/cartridge

100 mL/30 days

Basaglar (insulin glargine) 3 mL pen 100 mL/30 days

Lantus (insulin glargine) 100 U/mL: 10 mL vial, 3

mL device/cartridge

100 mL/30 days

Toujeo (insulin glargine) 300 U/mL: 1.5 mL pen 100 mL/30 days

Toujeo Max (insulin glargine) 300 U/mL: 3 mL pen 100 mL/30 days

Apidra (insulin glulisine) 100 U/mL: 10 mL vial, 3

mL pen/cartridge

100 mL/30 days

Admelog (insulin lispro) 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

Humalog, Insulin Lispro (insulin lispro) 100 U/mL: 10 mL vial, 3

mL pen/cartridge

100 mL/30 days

Humalog Junior Kwikpen (insulin lispro) 100 U/mL: 3 mL pen 100 mL/30 days




Humalog Kwikpen U200 (insulin lispro) 200 U/mL: 3 mL pen 100 mL/30 days

Levemir (insulin detemir) 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

Tresiba (insulin degludec) 100 U/mL: 3 mL pen 100 mL/30 days

Tresiba (insulin degludec) 100 U/mL: 10 mL vial 100 mL/30 days

Tresiba (insulin degludec) 200 U/mL: 3 mL pen 100 mL/30 days

Humulin R, Novolin R, Relion R (insulin regular) 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

Humulin R (insulin regular) 500 U/mL: 20 mL vial 100 mL/30 days

Humulin R Kwikpen U500 (insulin regular) 500 U/mL: 3mL pen 100 mL/30 days

Novolin R 100 U/mL: 3 mL pen 100 mL/30 days

Humulin N, Novolin N 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

NovoLog 70/30 (insulin mixed) 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

Humalog 75/25; Humalog 50/50 (insulin mixed) 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

Humulin 70/30 (insulin mixed) 100 U/mL: 10 mL vial, 3

mL pen

100 mL/30 days

Afrezza 4 unit cartridges packs 2,520 cartridges / 30 days

Afrezza 8 unit cartridge packs 1260 cartridges/30 days

Afrezza 12 unit cartridge packs 900 cartridges/30 days

Afrezza 30 X 4 unit cartridges +

60 X 8 unit cartridges

mix packs

1,530 cartridges / 30 days


30 X 8 unit cartridges

mix packs


Afrezza 60 x 8 unit cartridge +

30 x 12 unit cartridge

mix packs



90 X 12 unit cartridges1,080 cartridges / 30 days


90 x 8 unit cartridge mix

packs



60 x 8 unit cartridge +

60 x 12 unit cartridge

mix packs


Insulin Combination PS

AR0220_r0320

Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, Gen Rx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Soliqua (insulin glargine/lixisenatide) 100 units/mL insulin

glargine / 33 mcg/mL

lixisenatide

5 pens / 30 days



Xultophy (insulin degludec/liraglutide) 100 units/mL insulin

degludec / 3.6 mg

liraglutide

5 pens / 30 days

Ketorolac PS AR0220_r0320 Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, Gen Rx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Ketorolaca

10 mg tablet20 tablets/prescription

Sprix, Ketorolac nasal spray 1.7 g bottle 5 bottles/prescription

Low Molelcular Weight

Heparins (LMWH) and Arixtra (fondaparinux)

Arixtra PS AR0320 Single-dose syringea 2.5 mg/ 0.5 ml 30 syringes/90 days

Single-dose syringea 5 mg/ 0.4 ml 30 syringes/90 days

Single-dose syringea 7.5 mg/0.6 ml 30 syringes/90 days

Single-dose syringea 10 mg/ 0.8 ml 30 syringes/90 days

Fragmin (dalteparin)

Single-dose syringe 2,500 IU/ 0.2 ml 30 syringes/90 days


Single-dose syringe 7,500 IU /0.3 ml 30 syringes/90 days

Single-dose graduated syringe 10,000 IU/ 1 ml 30 syringes/90 days

Single-dose syringe 12,500 IU/0.5 ml 30 syringes/90 days



Multi-dose vial95,000 IU/3.8 mL

(25,000 IU/ 1 mL)10 vials/90 days

Lovenox (enoxaparin)

Single-dose syringe 30 mg/ 0.3 mla 30 syringes/90 days

Single-dose syringe 40 mg/ 0.4 mla 30 syringes/90 days

Single-dose graduated syringe 60 mg/ 0.6 mla 30 syringes/90 days


Single-dose graduated syringe 100 mg/ 1 mla 30 syringes/90 days


Single-dose graduated syringe 150 mg/ 1 mla 30 syringes/90 days

Multiple dose vial 300 mg/ 3 mla 10 vials/90 days

Metformin ER PS AR0220_r0320 Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Fortamet (metformin osmotic ER) 500 mg 3 tablets

Fortamet (metformin osmotic ER) 1000 mg 2 tablets

Glucophage XR (metformin ER) 500 mg 4 tablets




Glucophage XR (metformin ER) 750 mg 2 tablets

Glumetza (metformin modified release ER) 500 mg 3 tablets

Glumetza (metformin modified release ER) 1000 mg 2 tablets

Riomet ER supsension (metformin ER) 500 mg/5 mL 32 mL

Multiple Sclerosis PS

AR0220_r0320

Aubagio (teriflunomide) 7 mg tablet 1 tablet

Aubagio (teriflunomide) 14 mg tablet 1 tablet

Avonex (interferon β-1a) 30 mcg vial 1 kit of 4 vials/28 days

Avonex (interferon β-1a) 30 mcg/0.5 mL

Autoinjector pen 1 kit of 4 pens/28 days

Avonex (interferon β-1a)

30 mcg/0.5 mL prefilled

syringe 1 kit of 4 syringes/28 days

Betaseron (interferon β-1b) 0.3 mg vial

14 vial/syringe units

(1 box)/28 days

Copaxone (glatiramer)a

20 mg/mL syringe 1 syringe

Copaxone (glatiramer)a 40 mg/mL syringe 12 syringes/28 days

Extavia (interferon β-1b) 0.3 mg vial 15 vials/30 days

Gilenya (fingolimod) 0.25 mg capsule 1 capsuleGilenya (fingolimod) 0.5 mg capsule 1 capsule

Glatopa (glatiramer)

20 mg/mL prefilled

syringe 1 syringe

Glatopa (glatiramer) 40 mg/mL prefilled 12 syringes/28 days

Mavenclad (cladribine) 10 mg (4 tablet pack) 8 tablets/301 days







Mayzent (siponimod) starter pack 1 kit of 12 tablets/180 daysMayzent (siponimod) 0.25 mg tablets 4 tabletsMayzent (siponimod) 2 mg tablets 1 tablet

Plegridy (peginterferon β-1a) Starter kit- syringe 1 kit/180 days

Plegridy (peginterferon β-1a) Starter kit- pen-injector 1 kit/180 days

Plegridy (peginterferon β-1a) 125 mcg/0.5 mL syringe

2 syringes/28 days (1 carton of

2 syringes/28 days)

Plegridy (peginterferon β-1a)

125 mcg/0.5mL pen-

injector

2 pens/28 days (1 carton of 2

pens/28 days)




Rebif (interferon β-1a) 22 mcg/0.5 mL

3 syringes/week

(1 carton 12 syringes/28 days)

Rebif Rebidose (interferon β-1a) 22 mcg/0.5 mL 12 syringes/28 days

Rebif (interferon β-1a) 44 mcg/0.5 mL

3 syringes/week

(1 carton 12 syringes/28 days)

Rebif Rebidose (interferon β-1a) 44 mcg/0.5 mL 12 syringes/28 days

Rebif (interferon β-1a)

Titration pack: 6 x 8.8

mcg/0.2 mL +

6 x 22 mcg/0.5 mL 1 kit/180 days

Rebif Rebidose (interferon β-1a)

Titration pack: 6 x 8.8

mcg/0.2 mL +

6 x 22 mcg/0.5 mL 1 kit/180 days

Tecfidera (dimethyl fumarate) Starter kit 1 kit/180 days

Tecfidera (dimethyl fumarate) 120 mg capsules 14 capsules/180 days

Tecfidera (dimethyl fumarate) 240 mg capsules 2 capsules

Vumerity (diroximel fumarate) Starter Bottle 231 mg 106 capsules/180 days

Vumerity (diroximel fumarate) 231 mg 4 capsules

Nasal Antiepileptics PS

AR0120_r0320Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Nayzilam (midazolam) 5 mg/ 0.1 mL nasal 10 bottles/30 days

Valtoco (diazepam) 5 mg/ 0.1 mL nasal inhaler 10 packs/30 days

Valtoco (diazepam) 10 mg/ 0.1 mL nasal inhaler 10 packs/30 days

Valtoco (diazepam) 15 mg (2 x 7.5 mg/ 0.1 mL) nasal inhaler10 packs/30 days

Valtoco (diazepam) 20 mg (2 x 10 mg/ 0.1 mL) nasal inhaler10 packs/30 days

Nasal Inhalers PS AR0220_r0320

Antihistamines

azalastine 0.1%a 137 mcg/spray (30 mL,

200 sprays) 2 bottles/30 days

Astepro (azelastine 0.15%) 205.5 mcg/spray (30

mL, 200 sprays) 2 bottles/30 days

Patanase (olopatadine)a 665 mcg/spray (30.5

gm, 240 sprays) 1 bottle/30 days

Anticholinergics

Atrovent (ipratropium 0.03%)a 21 mcg/spray (30 mL,


Atrovent (ipratropium 0.06%)a 42 mcg/spray (15 mL,


Corticosteroids

Beconase AQ (beclomethasone) 42 mcg/spray (25 gm,





Flonase (fluticasone propionate)a 50 mcg/spray (16 gm,

120 sprays) 1 bottle/30 days

Flunisolidea 25 mcg/spray (25 mL,


Nasonex (mometasone)a 50 mcg/spray (17 gm,


Omnaris (ciclesonide) 50 mcg/spray (12.5 gm,

120 sprays) 1 bottle/30 days

Qnasl (beclomethasone diproprionate) 80 mcg/spray (8.7 gm,

120 sprays) 1 canister/30 days

Qnasl Children (beclomethasone diproprionate) 40 mcg/spray (4.9 gm,

60 sprays) 1 canister/30days

Xhance (fluticasone) 93 mcg/actuation (16

mLs, 120 sprays) 2 bottles/30 days

Zetonna (ciclesonide) 37 mcg/actuation (6.1

gm, 60 actuations) 1 canister/30 days

Nasal Inhalers PS AR0220_r0320 Combinations

Dymista (azelastine/fluticasone)a 137 mcg/50 mcg/spray

(23 gm, 120 sprays) 1 bottle/30 days

Niaspan PS AR0819_r0320

Niaspan (niacin extended-release) 500 mg extended-release

tablets

1 tablet

Niaspan (niacin extended-release) 750 mg extended-release

tablets

2 tablets

Niaspan (niacin extended-release) 1000 mg extended-

release tablets

2 tablets

Ophthalmic Prostaglandins PS

AR0819_r0320

Lumigan (bimatoprost–0.01%) 2.5 mL bottle 2.5 mL/30 daysLumigan (bimatoprost–0.01%) 5 mL bottle 2.5 mL/30 daysLumigan (bimatoprost–0.01%) 7.5 mL bottle 2.5 mL/30 days

Bimatoprost-0.03%a 2.5 mL bottle 2.5 mL/30 days

Bimatoprost-0.03% 5 mL bottle 2.5 mL/30 daysBimatoprost-0.03% 7.5 mL bottle 2.5 mL/30 days

Rescula (unoprostone-0.15%) 5 mL bottle 5 mL/30 days





Travatan Z (travoprost)a 2.5 mL bottle 2.5 mL/30 days

Travatan Z (travoprost)a 5 mL bottle 2.5 mL/30 days

Travoprost 2.5 mL bottle 2.5 mL/30 daysTravoprost 5 mL bottle 2.5 mL/30 days

Vyzulta (latanoprostene bunod) 2.5 mL bottle 2.5 mL/30 days

Vyzulta (latanoprostene bunod) 5 mL bottle 2.5 mL/30 days

Xalatan (latanoprost)a 2.5 mL bottle 2.5 mL/30 days

Xelpros (latanoprost emulsion) 2.5 mL bottle 2.5 mL/30 days

Zioptan (tafluprost)0.3 mL/single-use

container

30 single-use containers/30 days

a–available as a generic and included in quantity limit program

Oral Inhalers PS AR0220_r0320 Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Atrovent HFA (ipratropium)

17 mcg/actuation (12.9

gm, 200 actuations) 2 canisters/month

Combivent Respimat (ipratropium/albuterol)

18 mcg/90

mcg/actuation (14.7gm, 2 canisters/month

Incruse Ellipta (umeclidinium) 62.5 mcg/blister 30 blisters/month

Seebri Neohaler (glycopyrrolate) 15.6 mcg/ inhalation (box of 60 capsules)60 inhalation capsule/month

Spiriva Handihaler (tiotropium) 18 mcg/inhalation

(carton of 5, 30, or 90

capsules) 30 capsules/month

Spiriva Respimat (tiotropium)

1.25 mcg/actuation (4 g

cartridge) 1 cartridge/month

Spiriva Respimat (tiotropium)

2.5 mcg/actuation (4 g

cartridge) 1 cartridge/month

Tudorza Pressair (aclidium bromide)

400 mcg/actuation (60

actuations) 1 canister/month

Short-Acting Beta Agonists

ProAir HFA (albuterol sulfate) 90 mcg/actuation (8.5


Proventil HFA (albuterol sulfate) 90 mcg/actuation (6.7


ProAir Respiclick (albuterol sulfate) 90 mcg/actuation (200

actuations) 2 inhalers/month

Anticholinergics



ProAir Digihaler (albuterol sulfate) 90 mcg/actuation (200

actuations) 2 inhalers/month

Ventolin HFA (albuterol sulfate)



Ventolin HFA (albuterol sulfate) 90 mcg/actuation (8 gm,

60 actuations) 2 canisters/month

Xopenex HFA, Levalbuterol HFA



Long-Acting Beta Agonists

Arcapta Neohaler (indacaterol)75 mcg/inhalation

(Neohaler inhaler and

box of 5 blister cards of 6

capsules each, total 30) 1 box (30 capsules)/month

Serevent (salmeterol) 50 mcg/inhalation

(disposable inhalation

device and 60 blisters) 1 package (60 blisters)/month

Striverdi Respimat (olodaterol) 2.5 mcg/actuation (4 gm,

60 actuations) 1 canister/month

Corticosteroids and Corticosteroid Combinations

Advair Diskus (fluticasone/salmeterol)a 100 mcg/50 mcg

(inhalation device, 60

blisters) 1 package (60 blisters)/month

Advair Diskus (fluticasone/salmeterol)a 250 mcg/50 mcg per

inhalation (disposable

inhalation device and 60


Advair Diskus (fluticasone/salmeterol)a 500 mcg/50 mcg per

inhalation (disposable

inhalation device and 60


Advair HFA (fluticasone/ salmeterol) 45 mcg/21 mcg (12 gm,






AirDuo Respiclick,

Fluticasone/Salmeterol

55 mcg/14 mcg (0.45

gm, 60 actuations) 1 inhaler/month

AirDuo Respiclick,


113 mcg/14 mcg (0.45




AirDuo Respiclick,


232 mcg/14 mcg (0.45


Alvesco (ciclesonide) 80 mcg/actuation (6.1

gm, 60 actuations) 1 canister/month

Oral Inhalers PS AR0220_r0320Alvesco (ciclesonide) 160 mcg/actuation (6.1


Armonair Respiclick (fluticasone) 55 mcg/actuation (0.9 g,

60 actuations) 1 inhaler/month

Armonair Respiclick (fluticasone) 113 mcg/actuation (0.9

g, 60 actuations) 1 inhaler/month

Armonair Respiclick (fluticasone) 232 mcg/actuation (0.9g,

60 actuations) 1 inhaler/month

Arnuity Ellipta (fluticasone) 50 mcg/blister 30 blisters/month

Arnuity Ellipta (umeclidinium) 100 mcg/blister 30 blisters/month

Arnuity Ellipta (umeclidinium) 200 mcg/blister 30 blisters/month

Asmanex (mometasone) 110 mcg/actuation (30


Asmanex (mometasone) 220 mcg/actuation (30,

60, 120 actuations) 1 canister/month

Asmanex HFA (mometasone)









Breo Ellipta (fluticasone/valnterol)

100 mcg/25 mcg (60

blisters, 30 actuations) 1 package (60 blisters)/month

Breo Ellipta (fluticasone/valnterol)

200 mcg/25 mcg (60


Dulera (mometasone/formoterol) 50 mcg/5 mcg (13 gm,






Flovent HFA (fluticasone) 44 mcg/actuation (10.6


Flovent HFA (fluticasone) 110 mcg/actuation (12


Flovent HFA (fluticasone) 220 mcg/actuation (12




Flovent Diskus (fluticasone) 50 mcg/inhalation (60

blisters/carton) 1 carton/month


blisters/carton) 1 carton/month


blisters/carton) 4 cartons/month

Pulmicort Flexhaler (budesonide) 90 mcg/actuation (60


Pulmicort Flexhaler (budesonide) 180 mcg/actuation (120

actuations) 2 canisters/month

Qvar Redihaler 40 mcg/actuation (10.6


Qvar Redihaler 80 mcg/actuation (10.6


Symbicort, Budesonide/ formoterol 80 mcg/4.5 mcg (10.2


Symbicort, Budesonide/ formoterol 160 mcg/4.5 mcg (10.2


Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) 100 mcg/62.5 mcg/25

mcg (30 inhalations) 1 inhaler/month

Anticholinergic/Long-Acting Beta Agonist Combination

Anoro Ellipta (umeclidinium/valnterol)

62.5 mcg/25 mcg (60


Bevespi Aerosphere (glycopyrrolate and formoterol) 9 mcg/4.8 mcg (120

inhalation canister) 1 canister/month

Duaklir Pressair (aclidinium bromide/formoterol fumarate) 400 mcg/12 mcg (60

actuations) 1 inhaler/month

Stiolto Respimat (tiotropium/olodaterol) 2.5 mcg/2.5 mcg (4

grams, 60 actuations)

1 cartridge/month

Utibron Neohaler (indacaterol/glycopyrrolate) 27.5 mcg/15.6

mg/inhalation (Box of 60

60 inhalation capsules/month

Pain Medications PS

AR0220_r0320

Quantity limits apply to FlexRx Closed, FlexRx Open, GenRx Closed, GenRx Open, Health Insurance Marketplace, FocusRx and KeyRx formularies.

Butalbital Combinations

Allzital (butalbital/acetaminophen) 25 mg/325 mg tablet 12 tablets

Butalbital/Aspirin/Caffeine 50 mg/325 mg/40 mg

tablet

6 tablets

Tencon (butalbital/acetaminophen) 50 mg/325 mg tablet 6 tablets

Vanatol LQ, Vanatol S (butalbital/acetaminophen/caffeine)a 50 mg/325 mg/40 mg/15

mL solution

90 mLs

Butalbital/Acetaminophen/Caffeinea 50 mg/325 mg/40 mg

capsule

6 capsules

b – CFC-containing inhaler mandated by FDA to be phased out by December 31, 2013



Esgic (butalbital/acetaminophen/caffeine)a 50 mg/325 mg/40 mg

tablet

6 tablets

Fioricet (butalbital/acetaminophen/caffeine)a 50 mg/325 mg/40 mg

tablet

6 tablets

Fioricet (butalbital/acetaminophen/caffeine)a 50 mg/300 mg/40 mg

capsule

6 capsules

Fiorinal (butalbital/aspirin/caffeine)a 50 mg/325 mg/40 mg

capsule

6 capsules

Orbivan (butalbital/acetaminophen/caffeine)a 50 mg/300 mg/40 mg

capsule

6 capsules

Butal/APAP (bultalbital/acetaminophen) 50 mg/300 mg capsule 6 capsules

Pain Medications PS

AR0220_r0320butalbital/acetaminophen

a 50 mg/300 mg tablets 6 tablets

PPIs PS AR0819_r0320

Aciphex (rabeprazole)

20 mg delayed-release

tabletsa 1 tablet

Aciphex (rabeprazole) 5 mg capsule sprinkle 1 capsuleAciphex (rabeprazole) 10 mg capsule sprinkle 1 capsule

Esomeprazole strontium 24.65 mg capsule 1 capsuleEsomeprazole strontium 49.3 mg capsule 1 capsule

Dexilant (dexlansoprazole) 30 mg dealyed-release

capsules 1 capsule

Dexilant (dexlansoprazole) 60 mg delayed-release

capsules 1 capsule

Nexium (esomeprazole)20 mg delayed-release

capsules

1 capsule


capsules

1 capsule


oral suspension

1 packet


oral suspension

1 packet


oral suspension

1 packet

Nexium (esomeprazole) 2.5 mg susp pack 1 packetNexium (esomeprazole) 5 mg susp pack 1 packet

Quantity limit applies to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and



Prevacid (lansoprazole)


capsulesa

1 capsule



capsulesa

1 capsule

Prevacid (lansoprazole)15 mg oral suspension

(packets)

1 packet

Prevacid (lansoprazole)30 mg oral suspension

(packets)

1 packet



orally disintegrating

tableta

1 tablet



orally disintegrating

tableta

1 tablet

Prilosec (omeprazole)


capsulesa

1 capsule



capsulesa

1 capsule



capsulesa

1 capsule

Prilosec (omeprazole)2.5 mg oral suspension

(packets)

2 packets

Prilosec (omeprazole)10 mg oral suspension

(packets)

1 packet

Protonix (pantoprazole)


oral suspension (packets)

1 packet



tabletsa

1 tablet



tabletsa

1 tablet

Zegerid (omeprazole/sodium bicarbonate)

20 mg immediate-

release capsulesa

1 capsule


40 mg immediate-

release capsulesa

1 capsule


20 mg powder for oral

suspension (packets)a

1 packet


40 mg powder for oral

suspension (packets)a

1 packet

a – available as generic and included in quantity limit program

SA Oncology PAQL **SA Oncology QL information is included in the individual program document



SGLT2 Inhibitors PS

AR0220_r0320

Farxiga (dapagliflozin) 5 mg tablet 1 tablet

Farxiga (dapagliflozin) 10 mg tablet 1 tablet

Invokana (canagliflozin) 100 mg tablet 1 tablet

Invokana (canagliflozin) 300 mg tablet 1 tablet

Invokamet (canagliflozin/metformin) 50 mg / 500 mg 2 tablets




Invokamet XR (canagliflozin/metformin ER) 50 mg/500 mg tablet 2 tablets




Jardiance (empagliflozin) 10 mg 1 tablet

Jardiance (empagliflozin) 25 mg 1 tablet

Segluromet (ertugliflozin/metformin) 2.5 mg/500 mg tablet 4 tablets




Steglatro (ertugliflozin) 5 mg tablet 2 tablets

Steglatro (ertugliflozin) 15 mg tablet 1 tablet

Synjardy (empagliflozin/metformin) 5 mg / 500 mg 2 tablets




Synjardy (empagliflozin/metformin) 5 mg / 1000 mg 2 tablets

Synjardy (empagliflozin/metformin) 12.5 mg / 500 mg 2 tablets

Synjardy (empagliflozin/metformin) 12.5 mg / 1000 mg 2 tablets

Synjardy XR (empagliflozin/metformin ER) 5 mg/1000 mg tablet 2 tablets

Synjardy XR (empagliflozin/metformin ER) 10 mg/1000 mg tablet 2 tablets

Synjardy XR (empagliflozin/metformin ER) 12.5 mg/1000 mg tablet 2 tablets

Synjardy XR (empagliflozin/metformin ER) 25 mg/1000 mg tablet 1 tablet

Xigduo XR (dapagliflozin/metformin ER) 2.5 mg/1000 mg tablet 2 tablets

Xigduo XR (dapagliflozin/metformin ER) 5 mg / 500 mg tablet 1 tablet

Xigduo XR (dapagliflozin/metformin ER) 5 mg / 1000 mg tablet 2 tablets



Statins PS AR0819_r0320

Altoprev (lovastatin extended release) 20 mg tablets 1 tablet



Crestor (rosuvastatin)a 5 mg tablets 1½ tablets



Crestor (rosuvastatin)a 40 mg tablets 1 tablet

Ezallor Sprinkle (rosuvastatin) 5 mg capsules 1 capsule




Flolipid, Simvastatin oral suspension 20 mg/5 mL solution 5 mLs

Flolipid (simvastatin oral suspension) 40 mg/5 mL solution 10 mLs

Lescol (fluvastatin)a 20 mg capsules 2 capsules

Lescol (fluvastatin)a 40 mg capsules 2 capsules

Lescol XL (fluvastatin extended release)a 80 mg tablets 1 tablet

Lipitor (atorvastatin)a 10 mg tablets 1½ tablets

Lipitor (atorvastatin)a 20 mg tablets 1½ tablets

Statins PS AR0819_r0320 Lipitor (atorvastatin)a 40 mg tablets 1½ tablets

Lipitor (atorvastatin)a 80 mg tablets 1 tablet




Livalo (pitavastatin) 1 mg tablets 1½ tablets

Livalo (pitavastatin) 2 mg tablets 1½ tablets

Livalo (pitavastatin) 4 mg tablets 1 tablet

Mevacor (lovastatin)a 10 mg tablets 2 tablets



Pravachol (pravastatin)a 10 mg tablets 1½ tablets



Pravachol (pravastatin)a 80 mg tablets 1 tablet

Vytorin (ezetimibe/simvastatin)

a 10 mg/ 10 mg tablets 1 tablet

Vytorin (ezetimibe/simvastatin)a 10 mg/ 20 mg tablets 1 tablet

Vytorin (ezetimibe/simvastatin) 10 mg/ 40 mg tablets 1 tablet

Vytorin (ezetimibe/simvastatin)a 10 mg/ 80 mg tablets 1 tablet

Zocor (simvastatin)a 5 mg tablets 1½ tablets


Zocor (simvastatin)a 20 mg tablets 2 tablets


Zocor (simvastatin)a 80 mg tablets 1 tablet

Zypitamag (pitavastatin) 1 mg 1½ tablets

Zypitamag (pitavastatin) 2 mg 1½ tablets

Zypitamag (pitavastatin) 4 mg 1 tablets

aaa

Topical Corticosteroids PS

AR1219_r0320Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, Health Insurance Marketplace, FocusRx and KeyRx.

Aclovate (alclometasone dipropionate)a 0.05% cream (15 gm, 45 gm, 60

gm)

120 grams/30 days

Aclovate (alclometasone dipropionate)a 0.05% ointment (15 gm, 45 gm,

60 gm)

120 grams/30 days

Ala Scalp (hydrocortisone) 2% lotion (29.6 mL) 118.4 mL/30 days

ApexiCon E (diflorasone diacetate) 0.05% emollient cream (30 mg,

60 gm)

120 grams/30 days

Aristocort HP (triamcinolone acetonide)a 0.5% ointment (15 gm) 120 grams/30 days

Bryhali (halobetasol propionate) 0.01% lotion (60 gm, 100 gm) 200 grams/30 days

Capex (fluocinolone acetonide) 0.01% shampoo (120 mL) 840 mL/28 days

Clobex (clobetasol propionate)a 0.05% spray (59 mL, 125 mL) 236 mL/28 days

Clobex (clobetasol propionate)a 0.05% lotion (59 mL, 118 mL) 177 mL/28 days


AR1219_r0320Clobex (clobetasol propionate)a 0.05% shampoo (118 mL)

236 mL/28 days

Cloderm (clocortolone pivalate) 0.1% cream (30 gm, 45 gm, 75

gm, 90 gm)

120 grams/30 days



Cordran (flurandrenolide) 4 mcg/cm2 (80 in x 3 in) 1 box/30 days

Cordran (flurandrenolide) 0.025% cream (120 gm) 120 grams/30 days

Cordran (flurandrenolide)a 0.05% cream (60 gm, 120 gm) 120 grams/30 days

Cordran (flurandrenolide)a 0.05% lotion (120 mL) 120 mL/30 days

Cordran (flurandrenolide)a 0.05% ointment (60 gm) 120 grams/30 days

Cutivate (fluticasone propionate)a 0.05% lotion (60 mL, 120 mL) 120 mL/30 days

Cutivate (fluticasone propionate)a 0.05% cream (15 gm, 30 gm, 60

gm)

120 grams/30 days

Cutivate (fluticasone propionate)a 0.005% ointment (15 gm, 30

gm, 60 gm)

120 grams/30 days

Cyclocort, Amcinonide 0.1% cream (15 gm, 30 gm, 60

gm)

120 grams/30 days

Cyclocort, Amcinonide 0.1% lotion (60 mLs) 120 mL/30 days

Cyclocort, Amcinonide 0.1% ointment (60 gm) 120 grams/30 days

Derma-Smoothe (fluocinolone acetonide)a 0.01% oil (body) (118.28 mL) 118.28 mL/30 days

Derma-Smoothe (fluocinolone acetonide)a 0.01% oil (scalp) (118.28 mL) 118.28 mL/30 days

Dermatop, Prednicarbatea 0.1% cream (60 gm) 120 grams/30 days

Dermatop, Prednicarbate 0.1% ointment (15 gm, 60 gm) 120 grams/30 days

Desonate (desonide) 0.05% gel (60 gm) 120 grams/30 days

DesOwen (desonide)a 0.05% lotion (59 mL, 118 mL) 118 mL/30 days

DesOwen, Tridesilon (desonide)a 0.05% cream (15 gm, 60 gm) 120 grams/30 days

DesOwen, Tridesilon (desonide)a 0.05% ointment (15 gm, 60 gm) 120 grams/30 days

Diprolene, Bethamethasone dipropionate augementeda 0.05% gel (15 gm, 50 gm) 200 grams/28 days

Diprolene (bethamethasone dipropionate augemented)a 0.05% lotion (30 mL, 60 mL) 210 mL/30 days

Diprolene (bethamethasone dipropionate augemented)a 0.05% ointment (15 gm, 45 gm,

50 gm) 200 grams/28 days

Diprolene AF (betamethasone dipropionate)a 0.05% cream (15 gm, 50 gm) 200 grams/28 days

Diprosone (betamethasone dipropionate)a 0.05% cream (15 gm, 45 gm) 135 grams/30 days

Diprosone (betamethasone dipropionate)a 0.05% lotion (60 mL) 120 mL/30 days

Diprosone (betamethasone dipropionate)a 0.05% ointment (15 gm, 45 gm,


Elocon (mometasone furoate)a 0.1% cream (15 gm, 45 gm, 50

gm) 135 grams/30 days

Elocon (mometasone furoate)a 0.1% ointment (15 gm, 45 gm) 135 grams/30 days

Elocon (mometasone furoate)a 0.1% lotion/solution (30 mL, 60

mL) 120 mL/30 days

Florone (diflorasone diacetate)a 0.05% ointment (15 gm, 30 gm,

60 gm)

120 grams/30 days

Halog (halcinonide)a 0.1% cream (30 gm, 60 gm, 216

gm, 240 gm) 240 grams/30 days

Halog (halcinonide)a 0.1% ointment (30 gm, 60 gm,


Halog (halcinonide) 0.1% solution (120 mL) 240 mL/30 days



Hytone (hydrocortisone)a 2.5% cream (3.5 gm, 20 gm, 28

gm, 28.35 gm, 30 gm, 453.6 gm,


Hytone (hydrocortisone)a 1% cream (28.35 gm, 28.4 gm,

30 gm, 85.2 gm, 453.6 gm, 454


Hytone (hydrocortisone)a 2.5% lotion (59 mL, 118 mL) 118 mL/30 days

Hytone (hydrocortisone)a 1% ointment (25 gm, 28.35 gm,

28.4 gm, 110 gm, 430 gm, 453.6

gm) 453.6 grams/30 days

Hytone (hydrocortisone)a 2.5% ointment (20 gm, 28.35

gm, 30 gm, 453.6 gm, 454 gm) 454 grams/30 days

Impoyz (clobetasol propionate) 0.025% cream (60 gm) 200 grams/30 days

Kenalog (triamcinolone acetonide)a 0.147 mg/gm aerosol spray (63


Kenalog (triamcinolone acetonide)a 0.025% lotion (60 mL) 120 mL/30 days

Kenalog (triamcinolone acetonide)a 0.1% lotion (60 mL) 120 mL/30 days

Kenalog (triamcinolone acetonide)a 0.025% ointment (15 gm, 80



AR1219_r0320Kenalog, Aristocort (triamcinolone acetonide)a 0.025% cream (15 gm, 80 gm,

453.6 gm, 454 gm) 454 grams/30 days

Kenalog, Aristocort (triamcinolone acetonide)a 0.1% cream (15 gm, 28.4 gm, 30

gm, 45 gm, 80 gm, 85.2 gm,

453.6 gm, 454 gm) 454 grams/30 days

Kenalog, Aristocort (triamcinolone acetonide)a 0.5% cream (15 gm, 454 gm) 454 grams/30 days

Kenalog, Aristocort (triamcinolone acetonide)a 0.1% ointment (15 gm, 30 gm,

80 gm, 453.6 gm, 454 gm) 454 grams/30 days

Lexette, Halobetasol propionatea 0.05% foam (50 gm, 100 gm) 200 grams/28 days

Lidex (fluocinonide)a 0.05% solution (20 mL, 60 mL) 120 mL/30 days

Lidex (fluocinonide)a 0.05% cream (15 gm, 30 gm, 60

gm, 120 gm)

120 grams/30 days

Lidex (fluocinonide)a 0.05% gel (15 gm, 30 gm, 60

gm)

120 grams/30 days

Lidex (fluocinonide)a 0.05% ointment (15 gm, 30 gm,

60 gm)

120 grams/30 days

Lidex-E (fluocinonide)a 0.05% emulsified cream (15 gm,

30 gm, 60 gm)

120 grams/30 days

Locoid (hydrocortisone butyrate)a 0.1% solution (20 mL, 60 mL) 120 mL/30 days

Locoid (hydrocortisone butyrate)a 0.1% cream (15 gm, 45 gm) 135 grams/30 days

Locoid (hydrocortisone butyrate)a 0.1% lotion (59 mL, 118 mL) 118 mL/30 days

Locoid (hydrocortisone butyrate)a 0.1% ointment (15 gm, 45 gm) 135 grams/30 days

Locoid Lipocream (hydrocortisone butyrate)a 0.1% hydrophilic lipo cream (45

gm, 60 gm)120 grams/30 days

Luxiq (betamethasone valerate)a 0.12% foam (50 gm, 100 gm) 150 grams/30 days

Micort-HC (hydrocortisone acetate) 2.5% cream (28.4 gm, 120 gm) 120 grams/30 days

Olux (clobetasol propionate)a 0.05% foam (50 gm, 100 gm) 200 grams/28 days



Olux-E (clobetasol propionate)a 0.05% emulsion foam (50 gm,


Pandel (hydrocortisone probutate) 0.1% cream (80 gm) 160 grams/30 days

Psorcon, Diflorasone diacetate 0.05% cream (15 gm, 30 gm, 60

gm)

120 grams/30 days

Sernivo (betamethasone dipropionate) 0.05% spray (120 mL) 120 mL/30 days

Synalar (fluocinolone acetonide)a 0.01% solution (60 mL, 90 mL) 120 mL/30 days

Synalar (fluocinolone acetonide)a 0.025% cream (15 gm, 60 gm,

120 gm)

120 grams/30 days

Synalar (fluocinolone acetonide)a 0.025% ointment (15 gm, 60

gm, 120 gm)

120 grams/30 days

Synalar (fluocinolone acetonide)a 0.01% cream (15 gm, 60 gm) 120 grams/30 days

Temovate (clobetasol propionate)a 0.05% solution (25 mL, 50 mL) 200 mL/28 days

Temovate (clobetasol propionate)a 0.05% cream (15 gm, 30 gm, 45


Temovate (clobetasol propionate)a 0.05% ointment (15 gm, 30 gm,

45 gm, 60 gm) 210 grams/28 days

Temovate (clobetasol propionate)a 0.05% gel (15 gm, 30 gm, 60


Temovate E (clobetasol propionate)a 0.05% emollient cream (15 gm,

30 gm, 45 gm, 60 gm) 210 grams/28 days

Texacort (hydrocortisone) 2.5 % solution (30 mL) 120 mL/30 days

Topicort (desoximetasone)a 0.05% cream (15 gm, 60 gm,

100 gm)120 grams/30 days

Topicort (desoximetasone)a 0.25% cream (15 gm, 60 gm,

100 gm)120 grams/30 days

Topicort (desoximetasone)a 0.05% gel (15 gm, 60 gm) 120 grams/30 days

Topicort (desoximetasone)a 0.05% ointment (60 gm, 100

gm)

120 grams/30 days

Topicort (desoximetasone)a 0.25% ointment (15 gm, 60 gm,

100 gm)

120 grams/30 days

Topicort (desoximetasone)a 0.25% spray (100 mL) 100 mL/30 days

Trianex (triamcinolone acetonide)a 0.05% ointment (430 gm) 430 grams/30 days

Ultravate (halobetasol propionate)a 0.05% cream (15 gm, 50 gm) 200 grams/28 days

Ultravate (halobetasol propionate) 0.05% lotion (60 mL, 120 mL) 240 mL/30 days

Ultravate (halobetasol propionate)a 0.05% ointment (15 gm, 50 gm)

200 grams/28 days

Valisone (betamethasone valerate)a 0.1% cream (15 gm, 45 gm) 135 grams/30 days

Valisone (betamethasone valerate)a 0.1% lotion (60 mL) 120 mL/30 days

Valisone (betamethasone valerate)a 0.1% ointment (15 gm, 30 gm,


Vanos (fluocinonide)a 0.1% cream (30 gm, 60 gm, 120


Verdeso (desonide) 0.05% foam (100 gm) 100 grams/30 days

Westcort (hydrocortisone valerate)a 0.2% ointment (15 gm, 45 gm,

60 gm)

120 grams/30 days



Westcort (hydrocortisone valerate)a 0.2% cream (15 gm, 45 gm, 60

gm)

120 grams/30 days

Topical NSAIDs PS AR0220_r0320

Flector, Diclofenac Epolamine Patch 180 gram topical patch

(1.3% in aqueous base)

60 patches/30 days

diclofenac sodium 1.5% topical solutiona 300 mL (2 bottles)/30 days

Pennsaid (diclofenac sodium) 2% topical solution 2 bottles/28 days

Voltaren Gel (diclofenac sodium) 1% topical gela 1000 grams (10 tubes)/30 days

Urinary Incontinence PS

AR0819_r0320 Detrol (tolterodine)a 1 mg tablet 2 tablets

Detrol (tolterodine)a 2 mg tablet 2 tablets

Detrol LA (tolterodine ER)a 2 mg extended-release

capsule 1 capsule

Detrol LA (tolterodine ER)a 4 mg extended-release

capsule 1 capsule

oxybutynin [Ditropan]a 5 mg tablets 4 tablets

oxybutynin [Ditropan]a 5 mg/5 mL syrup 20 mLs

Ditropan XL (oxybutynin ER)a 5 mg extended-release

tablet 1 tablet


tablet 2 tablets


tablet 2 tablets

Enablex (darifenacin ER)a 7.5 mg extended-release

tablet 1 tablet

Enablex (darifenacin ER)a 15 mg extended-release

tablet 1 tablet

Gelnique (oxybutynin) 1 gm (1.14 mL) gel

sachet (10% gel) 1 sachet

Gelnique (oxybutynin) 3% gel (28

mg/actuation, 90

actuations/pump) 1 metered-dose pump / 30 days

Myrbetriq (mirabegron) 25 mg extended-release

tablet 1 tablet

Myrbetriq (mirabegron) 50 mg extended-release

tablet 1 tablet





Oxytrol (oxybutynin) 36 mg patch (delivers

3.9 mg per day) 8 patches per 28 days

trospium 20 mg tablet 2 tablets

trospium ER 60 mg extended-release

capsule 1 capsule

Toviaz (fesoterodine ER) 4 mg extended-release

tablet 1 tablet

Toviaz (fesoterodine ER) 8 mg extended-release

tablet 1 tablet

VESIcare (solifenacin)a 5 mg tablet 1 tablet

VESIcare (solifenacin)a 10 mg tablet 1 tablet

Weight loss agents PAQL **Weight loss agents QL information is included in the individual program document

Xyrem PAQL **Xyrem QL information is included in the individual program document

Zetia PS AR0819_r0320

Zetia (ezetimibe)a 10 mg tablets 1 tablet

Quantity limits apply to FlexRx Open, FlexRx Closed, GenRx Open, GenRx Closed, and Health Insurance Marketplace.


Documents

Quantity Limit Program Target Drugs Dosage/Strength...Paxil (paroxetine)a 30 mg tablet 2 tablets Paxil (paroxetine)a 40 mg tablet 1 tablet Paxil (paroxetine) 10 mg/5 mL suspension