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.

MANAGED DRUG LIMITATIONS (MDL)

Name of Drug Limit

Accu-Chek diabetic test strips

153/month

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
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 (OTC only) 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