USFHP: Providers

The retail pharmacy network is comprised of 5,170 Rite Aid Pharmacies and Eckerd Pharmacies, nationwide. Retail prescriptions may be filled for up to a 30-day supply, and mail order up to a 90-day supply. However, beneficiaries may fill up to a 90-day supply at an of the network retail pharmacies for the same co-pay as mail order. To locate a Rite Aid pharmacy near you, you may log onto www.riteaid.com

Beneficiaries may also obtain up to 90 day supply of eligible medications by mail. To use the Mail Order option, send the original copy of your prescription and a check or credit card payment for your co-pay to the Rite Aid pharmacy, at Wyman Park

Generic Drugs:                          $3 – for up to 90 days supply
Preferred Brand Drugs:               $9 – for up to 90 days supply
Non-preferred Brand Drugs:         $22 – for up to 90 days supply

For a complete listing of 3 tiers of drug co-payments CLICK HERE.

The Department of Defense Pharmacy and Therapeutics Committee has established quantity limits, or days supply on certain medications. If your medical condition warrants use of quantities greater than listed quantities for each drug, your provider may submit a Prior-authorization request form on your behalf. Medical justification for such a request must be provided by your physician.

Antiemetics
Drug	Quantity Limits
Aprepitant (Emend) convenience packs	6 packs per 90 days OR 2 packs per 30 days
Aprepitant (Emend) 80 mg capsules	12 capsules per 90 days OR 4 capsules per 30 days
Aprepitant (Emend) 125 mg capsules	6 capsules per 90 days OR 2 capsules per 30 days
Granisetron (Kytril) 1mg tablets	24 tablets per 90 days OR 8 tablets per 30 days
Ondansetron (Zofran) (Zofran; Zofran ODT) 4 and 8 mg tablets and orally disintegrating tablets	45 tablets per 90 days OR 15 tablets per 30 days
Dolasetron (Anzemet) 50 and 100 mg tablets	15 tablets per 90 days OR 5 tablets per 30 days
Antimigraine Drugs
Drug	Quantity Limits
Almotriptan (Axert) 6.25 and 12.5 mg tablets	36 tablets per 90 days OR 12 tablets per 30 days
Dihydroergotamine (Migranal) 1 mL ampules for nasal spray	48 amps per 90 days OR 16 amps per 30 days
Dihydroergotamine 1 mg/ml injection	90 ampules per 90 days OR 30 ampules per 30 days
Eletriptan (Relpax)	36 tablets per 90 days OR 12 tablets per 30 days
Frovatriptan (Frova) 2.5 mg tablets	27 tablets per 90 days OR 9 tablets per 30 days
Naratriptan (Amerge) 1 and 2.5 mg tablets	27 tablets per 90 days OR 9 tablets per 30 days
Rizatriptan (Maxalt; Maxalt MLT) 5 and 10 mg tablets and orally-disintegrating tablets	12 tablets per 30 days OR 36 tablets per 90 days
Sumatriptan (Imitrex) 25, 50 mg tablets	54 tablets per 90 days OR 18 tablets per 30 days
Sumatriptan (Imitrex) 100 mg tablets	27 tablets per 90 days OR 9 tablets per 30 days
Sumatriptan (Imitrex) injection 6mg/0.5mL autoinjector (syringes)	24 syringes per 90 days OR 8 syringes per 30 days
Sumatriptan (Imitrex) injection 6mg/0.5mL vials	24 vials per 90 days OR 8 vials per 30 days
Sumatriptan (Imitrex) 5mg/100 µL and 20 mg/100 µL nasal spray	18 unit dose nasal sprays per 90 days OR 6 unit dose nasal sprays per 30 days
Zolmitriptan nasal spray 5 mg/100 µL nasal spray	36 unit dose nasal sprays per 90 days OR 12 unit dose nasal sprays per 30 days
Zolmitriptan (Zomig; Zomig-ZMT) 2.5 and 5 mg tablets and orally-disintegrating tablets	36 tablets per 90 days OR12 tablets per 30 days
Erectile Dysfunction Agents
Drug	Quantity Limits
Alprostadil injection (Caverject, Edex) 5, 10, 20, and 40 mcg syringes (kits) and vials	18 syringes or vials per 90 days OR 6 syringes or vials per 30 days
Alprostadil intraurethral pellet (Muse) 125, 250, 500, and 1000 mcg pellets	18 pellets per 90 days OR 6 pellets per 30 days
Oral phosphodiesterase-5 (PDE-5) inhibitors Sildenafil (Viagra) 25-, 50-, and 100-mg tablets Tadalafil (Cialis) 5-, 10-, and 20-mg tablets Vardenafil (Levitra) 2.5-, 5-, 10-, and 20-mg tablets	18 tablets per 90 days OR 6 tablets per 30 days Quantity limit applies collectively to all strengths of sildenafil, tadalafil, and vardenafil. No more than 18 tablets of any combination of these medications per 90-day supply.
Miscellaneous
Drug	Quantity Limits
All syringes & needles	600 syringes and/or needles per 90 days OR 200 syringes and/or needles per 30 days
Adalimumab (Humira) 40 mg prefilled pens/syringes	6 syringes per 42 days (6 weeks) OR 4 syringes per 28 days (4 weeks)
Adalimumab (Humira) 40 mg prefilled pens - Crohn's Disease starter pack (contains 6 pens)	1 pack (6 pens) - no refills
Anakinra (Kineret) 100 mg/0.67 mL single use prefilled syringes	56 syringes per 56 days (8 weeks) OR28 syringes per 28 days (4 weeks)
Erlotinib (Tarceva) tablets	45 day supply per prescription
Glucose test strips (includes blood and urine test strips)	612 strips per 90 days OR204 strips per 30 days
Butorphanol (Stadol) metered dose nasal spray 2.5 mL bottles	15mL per 45 days OR10mL per 30 days
Dasatinib (Sprycel) 20 mg tablets	180 tablets per 45 days OR 120 tablets per 30 days
Dasatinib (Sprycel) 50 mg tablets	180 tablets per 45 days OR120 tablets per 30 days
Dasatinib (Sprycel) 70 mg tablets	90 tablets per 45 days OR 60 tablets per 30 days
Enfuvirtide (Fuzeon) injection kit	2 kits (60-days supply) OR 1 kit (30-days supply)
Etanercept (Enbrel) injection	8 weeks supply based on instructions for use on the prescription
Fluoxetine 90 mg capsule (Prozac Weekly)	12 capsules per 90 days OR 4 capsules per 30 days
Gefitinib tablets (Iressa)	45 tablets per 45 days OR 30 tablets per 30 days
Gemifloxacin (Factive) tablets	21 tablets per 90 days OR 7 tablets per 30 days
Imitinab capsules (Gleevec)	45 days supply based on instructions for use on the prescription
Ketorolac (Toradol) 10mg tablets	20 tablets (5 day supply) per 30 days
PEG-filgrastim (Neulasta) 6 mg/0.6 mL injection	1.2 mL per 45 days OR 0.6 mL per 21 days
Sunitinib (Sutent) 12.5 mg capsules	180 capsules per 84 days OR 120 capsules per 30 days
Sunitinib (Sutent) 25 mg capsules	120 capsules per 84 days OR 60 capsules per 30 days
Sunitinib (Sutent) 50 mg capsules	60 capsules per 84 days OR 30 capsules per 30 days
Sorafenib tosylate (Nexavar) 200mg tablets	120 tablets per 30 days; no more than 30 days supply will be dispensed in the retail network at any one time
Tramadol (Ultram) 50 mg tablets; tramadol / acetaminophen (Ultracet) 37.5/325 mg tablets	720 tablets per 90 days OR 240 tablets per 30 days
Tramadol extended release (Ultram ER) 100mg tablets	90 tablets per 90 days OR 30 tablets per 30 days
Tramadol extended release (Ultram ER) 200 and 300mg tablets	90 tablets per 90 days OR 30 tablets per 30 days
Tykerb (lapatinib)	150 tablets per 30 days OR 225 tablets per 45 days
Veramyst (fluticasone furoate)	1 inh 30 days and 3 inh 90 days
Zolinza (vorinostat)	120 tablets per 30 days OR 180 tablets per 45 days
Drug	Quantity Limits
Azelastine nasal spray (Astelin)	4 bottles per 90 days OR 2 bottles per 30 days
Budesonide AQ (Rhinocort Aqua) 32mcg nasal spray	54 gm per 90 days (8.6 gm: 6 inhalers) OR 18 gm per 30 days (8.6 gm: 2 inhalers)
Flunisolide (Nasalide) nasal solution 0.025%	225 mL per 90 days (25 mL: 9 inhalers) OR 75 mL per 30 days ( 25 mL: 3 inhalers)
Fluticasone (Flonase) 0.05% nasal spray	48 gm per 90 days (16 gm: 3 inhalers) OR 16 gm per 30 days (16 gm: 1 inhaler)
Ipratropium bromide (Atrovent) 0.03% and 0.06% nasal spray	0.03% - 2 inhalers per 30 days OR 6 inhalers per 90 days / 0.06% - 3 inhalers per 30 days OR 9 inhalers per 90 days
Mometasone (Nasonex) nasal inhaler 50mcg	2 inhalers per 30 days OR 6 inhalers per 90 days
Triamcinolone AQ (Nasacort AQ) 55mcg nasal spray	99 gm per 90 days (16.5 gm: 6 inhalers) OR 33 gm per 30 days (16.5 gm: 2 inhalers)
Triamcinolone (Nasacort) 55mcg nasal spray	90 gm per 90 days (10 gm: 9 inhalers) OR 30 gm per 30 days (10 gm: 3 inhalers)
Triamcinolone (Tri-nasal) 50 mcg nasal spray	90 mL per 90 days (15 mL: 6 inhalers) OR 30 mL per 30 days (15 mL: 2 inhalers)
Oral Inhalers and Inhalant Solutions
Drug	Quantity Limits
Albuterol (AccuNeb) inhalant solution 0.63mg/3mL and 1.25mg/3mL	1650 mL per 90 days (550 unit-dose vials) OR 600 mL per 30 days (200 unit-dose vials)
Albuterol (Proventil) 0.083% inhalant solution 3 mL	1650 mL per 90 days (500 unit-dose vials) OR 600 mL per 30 days (200 unit-dose vials)
Albuterol (Proventil) 0.5% inhalant solution 20 mL	180 mL per 90 days (9 bottles) OR 60 mL per 30 days (3 bottles)
Albuterol (Proventil) 90mcg metered dose inhaler	102 gm per 90 days OR 34 gm per 30 days (17 gm: 6 inhalers)
Albuterol HFA (Proventil HFA, Ventolin HFA) 90 mcg	108 gm per 90 days (18 gm: 6 inhalers) OR 36 gm per 30 days (18 gm: 2 inhalers)
Albuterol sulfate 3 mg / ipratropium bromide 0.5 mg per 3 mL inhalent solution (DuoNeb)	1620 mL per 90 days (540 unit-dose vials) OR 540 mL per 30 days (180 unit-dose vials)
Beclomethasone 42 mcg (Beclovent) oral inhaler	160.8 gm per 90 days (16.8 gm: 9 inhalers) OR 53.6 gm per 30 days (16.8 gm: 3 inhalers)
Beclomethasone 84 mcg (Vanceril DS) oral inhaler	129.6 gm per 90 days (12.2 gm: 9 inhalers) OR 43.2 gm per 30 days (12.2 gm: 3 inhalers)
Beclomethasone dipropionate HFA 40 mcg inhalation aerosol (QVar)	87.6 gm per 90 days (7.3 gm: 12 inhalers) OR 29.2 gm per 30 days (7.3 gm: 4 inhalers)
Beclomethasone dipropionate HFA 80 mcg inhalation aerosol (QVar)	43.8 gm per 90 days (7.3 gm: 6 inhalers) OR 33.6 gm per 30 days (7.3 gm: 2 inhalers)
Bitolterol (Tornalate) 0.8% oral inhaler	90 mL per 90 days (6 inhalers) OR 30 mL per 30 days (2 inhalers)
Bitolterol (Tornalate) inhalant solution 0.2%	720 mL per 90 days (30 mL: 24 bottles ) OR 240 mL per 30 days (30 mL: 8 bottles )
Brovana (arfomoterol)	60 unit dose per 30 days and 180 unit dose per 90 days
Budesonide (Pulmicort) oral inhaler	6 inhalers per 90 days OR 2 inhalers per 30 days
Budesonide 0.25 mg Inhalation Suspension 2 mL (Pulmicort Respules)	720 mL per 90 days (360 single-dose Respules) OR 240 mL per 30 days (120 single-dose Respules)
Budesonide 0.5 mg Inhalation Suspension 2 mL (Pulmicort Respules)	360 mL per 90 days (180 single-dose Respules) OR 120 mL per 30 days (60 single-dose Respules)
Cromolyn sodium (Intal) oral inhaler 800mcg	85.2 gm per 90 days (14.2 gm: 6 inhalers) OR 28.4 gm per 30 days ( 2 inhalers)
Cromolyn sodium (Intal) nebulizing solution 20 mg/ 2 mL unit dose ampules	1080 mL per 90 days (540 unit-dose ampules) OR 360 mL per 30 days (180 unit-dose ampules)
Flunisolide (Aerobid; Aerobid-M) oral inhaler 250 mcg	63 gm per 90 days (7 gm: 9 inhalers) OR 21 gm per 30 days (7 gm: 3 inhalers)
Fluticasone (Flovent or Flovent HFA) 44-, 110-, and 200-mcg oral inhalers	72 gm per 90 days (6 inhalers) OR 24 gm per 30 days (2 inhalers)
Fluticasone (Flovent) 50-, 100-, and 250 -mcg Rotadisks®	720 doses per 90 days OR 240 doses per 30 days
Fluticasone / salmeterol (Advair) powder for inhalation 100 mcg/50 mcg; 250 mcg/50 mcg; and 500 mcg/50 mcg	180 doses per 90 days (3 inhalers) OR 60 doses per 30 days (1 inhaler)
Formoterol fumarate (Foradil) powder for inhalation 12 mcg	180 doses per 90 days (3 inhalers) OR 60 doses per 30 days (1 inhaler)
Ipratropium (Atrovent) 0.02% inhalant solution (2.5mL unit dose ampules)	1350 mL per 90 days (540 unit-dose ampules) OR 450 mL per 30 days (180 unit-dose ampules)
Ipratropium (Atrovent) oral inhaler 18 mcg	89 gm per 90 days (14.7 gm: 6 inhalers) OR 30 gm per 30 days (14.7 gm: 2 inhalers)
Levalbuterol (Xopenex) inhalant solution 0.63/3 mL or 1.25 mg/3mL ampules	1080 mL per 90 days (360 unit-dose vials) OR 360 mL per 30 days (120 unit-dose vials)
Metaproterenol (Alupent) inhalant solution 0.4% or 0.6% 2.5mL unit dose ampules	1250 mL per 90 days (500 unit-dose ampules) OR 500 mL per 30 days (200 unit-dose ampules)
Metaproterenol (Alupent) inhalant solution 5% 10mL	180 mL per 90 days OR 60 mL per 30 days
Metaproterenol (Alupent) oral inhaler 650mcg	84 gm per 90 days (14 gm: 6 inhalers) OR 28 gm per 30 days (14 gm: 2 inhalers)
Mometasone furoate (Asmanex) oral inhaler	120 inhalations per 30 days OR 360 inhalations per 90 days
Nedocromil (Tilade) oral inhaler	145.8 gm per 90 days (16.2 gm: 9 inhalers) OR 48.6 gm per 30 days (16.2 gm: 3 inhalers)
Pirbuterol (Maxair) oral Autohaler®	42 gm per 90 days (14 gm: 3 inhalers) OR 14 gm per 30 days (14 gm: 1 inhaler)
Pirbuterol (Maxair) oral inhaler	153.6 gm per 90 days (25.6 gm: 6 inhalers) OR 51.2 gm per 30 days (25.6 gm: 2 inhalers)
Salmeterol (Serevent DISKUS®) 50mcg oral inhalation powder	180 doses per 90 days OR 60 doses per 30 days
Symbicort (budesonide/formoterol)	1 inhaler 30 days and 3 inhalers 90 days
Tiotropium bromide (Spiriva HandiHaler) inhalation powder	90 capsules for inhalation per 90 days OR 30 capsules for inhalation per 30 days
Triamcinolone (Azmacort) oral inhaler 20gm	120 gm per 90 days (20 gm: 6 inhalers) OR 40 gm per 30 days (20 gm: 2 inhalers)
Topicals
Drug	Quantity Limits
Calcipotriene (Dovonex) 0.005% cream or ointment (30-, 60-, or 100-gm Tubes)	900 gm per 90 days OR 300 gm per 30 days
Calcipotriene (Dovonex) 0.005% solution, 60 mL bottles	900 mL per 90 days OR 300 mL per 30 days
Alitretinoin (Panretin) 0.1% gel, 60 gm tubes	180 gm per 90 days OR 60 gm per 30 days
Becaplermin (Regranex) 0.01% gel (2-, 7.5- or 15-gm tubes)	45 gm per 90 days OR 15 gm per 30 days
Tazarotene (Tazorac) 0.05% or 0.1% gel (30- or 100-gm tubes)	300 gm per 90 days OR 100 gm per 30 days
Tazarotene (Tazorac) 0.05% or 0.1% Cream (30- or 60-gm tubes)	180 gm per 90 days OR 60 gm per 30 days

If a brand name medication has a generic equivalent, network pharmacists are required to dispense the generic equivalent instead of the brand name medication. If clinically warranted, your provider may submit a clinical request on your behalf, to obtain a brand name medication instead of the generic equivalent.

Generic drugs are chemically identical to their branded counterparts. They are made with the same active ingredients, and produce the same effects as their brand name equivalents. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand name drugs. Also, the FDA requires that all drugs, including generic drugs be safe and effective. Although generic drugs are chemically identical to their branded counterparts, and are held to the same FDA standards for safety and performance as brand name drugs, they sell for 30-75 percent less. Not all drugs have a commercially available generic alternative, however, 7,602 of the 10,375 drugs listed in the FDA’s Orange Book have generic equivalents. You can safe money on your co-payment by choosing generic drugs when applicable. Additional information on generic drugs is available on the FDA website at, www.fda.gov/cder/ogd/

Some medications require prior-authorization before they can be dispensed. To initiate a prior-authorization: your provider must complete and fax the appropriate form to the Johns Hopkins Healthcare Pharmacy department at 410-424-4607. The following list of drugs require prior-authorization

In the event that you fill a prescription at a non-network pharmacy due to an emergent situation, you may seek reimbursement for incurred cost. To obtain reimbursement, complete the Prescription Drug Claim Form, and mail to the address indicated on the form. You will be reimbursed for the cost of the prescription less applicable co-payment.