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Quantity Limits

This list is subject to change without notice and is not applicable to all EHP groups. Consult your Summary Plan Description (SPD) to determine if your plan is subject to this list.

 

Therapy ClassMedicationRetail LimitMail Limit
Proton Pump Inhibitors (PPIs)AciphexAll products in therapy class limited to 30 units per 30 day supply and 90 units per 90 day supply.
Dexilant
Nexium
Prevacid (lansoprazole)
Priolsec (omeprazole)
Protonix (pantoprazole)
Zegerid
Sedative-Hypnotics (Sleep Agents)Ambien (zolpidem)All products in therapy class limited to 30 units per 30 day supply and 90 units per 90 day supply.
Dalmane (flurazepam)
Doral
Halcion
Lunesta
Prosom (estazolam)
Restoril (temazepam)
Rozerem
Sonata
Zolpimist
Migrane AgentsAmerge, Axert, Frova, Imitrex, Maxalt, Relpax, Sumatripan, Treximet, Zomig16 tablets48 tablets/td>
Imitrex Statdose System2 kits = 8 injections6 kits = 24 injections
Imitrex Injection8 vials24 vials
Imitrex Nasal Spray2 boxes = 12 unit dose spray devices6 boxes = 36 spray devices
Migranal1 kit = 8 unit dose sprayers3 boxes = 16 sprayers
Zomig Nasal Spray2 boxes = 12 unit dose spray devices6 boxes = 36 spray devices
Antiemetic (Nausea) AgentsAloxi capsules33
Anzemet tablets33
Anzement injection1.875 mL (3 single use vials)1.875 mL (3 single use vials)
Cesamet2424
Diclegis120 tablets/year
Emend99
Kytril (granisetron) oral solution30 mL30 mL
Kytril (granisteron) tablets66
Kytril injection6 mL (6 single use vials)6 mL (6 single use vials)
Marinol (dronabinol)6060
Zofran (ondansetron) 4 mg and 8 mg tablets1212
Zofran (ondansetron) 24 mg tablets33
Zofran (ondansetron) oral solution60 mL60 mL
Zofran injection120 mL120 mL
Agents for Erectile DysfunctionCaverjetAll products in therapy class limited to 6 units per 30 day supply and 18 units per 90 day supply.
Cialis
Edex
Levitra
Muse
Viagra
Antiviral AgentsValtrex60180
Tamiflu10 day supply after 180 days 
Miscellaneous MedicationsLysteda3030
Vivitrol1 vialn/a
Abilify30 tablets90 tablets
Seroquel XR30 tablets90 tablets
Inhalers for Asthma and COPDAccuned (albuterol) 0.83%4 boxes12 boxes
Advair Diskus, HFA1 inhaler3 inhalers
Aerobid, Aerobid-M3 inhalers9 inhalers
Albuterol 0.5% solution3 boxes9 boxes
Albuterol Inh26
Alupent 0.4% and 0.6% Solution4 boxes12 boxes
Alupent Inhalers2 inhalers6 inhalers
Alvesco2 inhalers6 inhalers
Asmanex2 inhalers6 inhalers
Atrovent Inhalers2 inhalers6 inhalers
Atrovent Solution5 boxes15 boxes
Azmacort2 inhalers6 inhalers
Brovana Solution2 boxes6 boxes
Combivent2 inhalers6 inhalers
Duoneb540 mL1620 mL
Flovent, Flovent HFA2 inhalers6 inhalers
Foradil Inhaler1 inhaler3 inhalers
Intal Inhaler2 inhalers6 inhalers
Intal Solution240 mL720 mL
Maxair Inhaler1 inhaler3 inhalers
Perforomist1 box3 boxes
ProAir HFA26
Proventil HFA26
Pulmicort 90 mcg Flexhaler4 inhalers12 inhalers
Pulmicort Respules (0.25 mg, 50 mg)2 boxes6 boxes
Pulmicort Respules (1 mg)1 box3 boxes
Pulmicort 180 mcg Flexhaler2 inhalers6 inhalers
QVar3 inhalers9 inhalers
Serevent Diskus1 inhaler3 inhalers
Spiriva1 inhaler3 inhalers
Symbicort1 inhaler3 inhalers
Tilade Inhaler3 inhalers9 inhalers
Ventolin HFA2 inhalers6 inhalers
Xopenex Solution3 boxes9 boxes
Xopenex HFA2 inhalers6 inhalers
Medications for PainOxycontin2 tablets/day
fentanyl patch10 patches/30 days
morphine ER/ MSContin3 tablets/day
Avinza1 capsule/day
Morphine ER 12 hr/Kadian2 capsules/day
Oxymorphone ER/ Opana ER2 tablets/day
Embeda2 capsules/day
Exalgo1 tablet/day
Butrans4 patches/28 days
Fentanyl lozenge4 lozenges/day

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