The Priority Partners Pharmacy and Therapeutics Committee may place a limit on the quantity of drug a plan participant may receive based upon cost and/or clinical reasons. Also, many drug products have a quantity limits based upon the usual dosage described in product labeling. Drugs subject to quantity limits may change.

The drugs listed below are an example of some which have quantity limits. Drugs subject to quantity limits may change. For an up-to-date list, check the formulary.

MANAGED DRUG LIMITATIONS (MDL)

Name of Drug Limit
Aranesp 4 vials or syringes/month
Combivent Respimat 2 inhalers/month
Depo-Provera (medroxyprogesterone) 150md/mL 1 mL injection/ 90 days
Diflucan (fluconazole) 150 mg 2 tabs/month

Duragesic (fentanyl) 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, and 100 mcg/hr

10 patches/month
Epogen 4 vials or syringes/month
Flovent Diskus (fluticasone) 60/25 days
Freestyle or Precision Xtra diabetic test strips (birth through age 17) 300 strips/month
Freestyle or Precision Xtra diabetic test strips (age 18 and above) 150 strips/month
Humalog/Humulin 3 vials combined/mo
Imitrex (sumatriptan) tabs 16 tabs/month
Imitrex (sumatriptan) spray 12 nasal spays/month
Imitrex (sumatriptan) injections 8 injections/month
Insulin syringes/needles 100 units/month
Kytril (granisetron) 1 mg 6 tabs/month
Kytril (granisetron) 1 mg/5 mL suspension 30 mL/month
Lantus 3 vials/month
Lovenox (enoxaparin) all strengths greater than 14 days of therapy requires a prior authorization
Lysteda (tranexamic acid) 30 tabs/month
Maxalt 16 tabs/month
Mobic 60 tabs/month
Next choice (levonorgestrel) 4 tabs/year
Novolin 3 vials combined/month
Novolog 3 vials combined/month
Omeprazole 68 tabs or capsules/month
Oxycodone (immediate-release 15mg, 20mg, 30mg) 180 tabs/month
Pantoprazole delayed-rel tabs 30 tabs/month
Plan B One-Step (levonorgestrel) 1.5 mg 2 tabs/year

Prevpac (amoxicillin 500 mg, clarithromycin 500 mg, lansoprazole 30 mg)

one pack/ 14 days
ProAir HFA 2 inhalers/month
Procrit 4 Vials or syringes/month
Relenza (zanamivir) 5 mg 5 days of therapy maximum
Tamiflu (oseltamivir) caps and suspension 5 days supply/ 180 days
Valcyte (valganciclovir) 450 mg 98 tabs/month
Valtrex (valacyclovir) all strengths 60 tabs/ 25 days
Ventolin HFA 2 inhalers/month
Vivitrol 1 vial/month
Zantac (ranitidine) 75 mg and 150 mg tabs (OTC only) 60 tabs/ 25 days
Zithromax (azithromycin) 250 mg 6 tabs/month
Zithromax (azithromycin) 500 mg 3 tabs/month
Zofran/Zofran ODT (ondansetron) 4 mg and 8 mg 12 tabs/month
Zofran (ondansetron) 4 mg/5 mL suspension 60 mL/month
Zyvox (linezolid) 600 mg 28 tabs/month