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 |
| 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/mont |
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 (20 mg tabs) | 240 tabs/month |
| Oxycodone (30 mg tabs) | 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 |
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 |
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