1. Healthcare

Blue Medicare Rx Standard – 2014 Quantity Limit List
2014 Quantity Limits
Drug Name
abacavir 300 mg
abacavir/lamivudine/zidovudine 300-150-300 mg
ABILIFY DISCMELT - all strengths
ABILIFY injection
ABILIFY MAINTENA
ABILIFY oral solution
ABILIFY tablets - all strengths
acarbose 100 mg
acarbose 25 mg
acarbose 50 mg
acetaminophen w/codeine 300-15 mg, 300-30 mg
acetaminophen w/codeine 300-60 mg
acetaminophen w/codeine solution 120 mg/12
mg/5 mL
ACTONEL 150 mg
ACTONEL 35 mg
ACTONEL 5 mg, 30 mg
ADCIRCA 20 mg
ADVAIR DISKUS - all strengths
ADVAIR HFA - all strengths
AFINITOR 2.5 mg, 5 mg, 7.5 mg, 10 mg
AFINITOR DISPERZ 2 mg, 5 mg
AFINITOR DISPERZ 3 mg
alendronate 10 mg
alendronate 35 mg, 70 mg
alendronate 5 mg
amphetamine/dextroamphetamine ER 5 mg, 10
mg, 15 mg, 20 mg, 25 mg, 30 mg
ANDRODERM 24 hr patch 2 mg, 4 mg
ANDROGEL 1% 25 mg/2.5 gm, 50 mg/5 gm
ANDROGEL 1.62% (20.25 mg/ 1.25 gm)
ANDROGEL 1.62% (40.5 mg/ 2.5 gm)
ANDROGEL 1.62% (20.25 mg)
ANDROGEL PUMP 1%
ANORO ELLIPTA
APTIVUS 100 mg/mL
APTIVUS 250 mg
Monthly Limit
(30 days unless
otherwise noted)
60 tablets
60 tablets
60 tablets
90 vials
1 vial
750 mL
30 tablets
90 tablets
360 tablets
180 tablets
360 tablets
180 tablets
2700 mL
1 tablet per 28 days
4 tablets per 28 days
30 tablets
60 tablets
1 package of 60
1 canister
30 tablets
60 tablets
90 tablets
120 tablets
4 tablets per 28 days
30 tablets
30 capsules
30 patches
60 packets
30 packets
60 packets
2 pumps
4 pumps
1 package
4 bottles
120 capsules
2014 Quantity Limits
Drug Name
ascomp/codeine
ASMANEX TWISTHALER 14 AER 220 mcg
ASMANEX TWISTHALER 30 AER 110 mcg
ASMANEX TWISTHALER 30, 60, 120 AER 220 mcg
ASTEPRO
atorvastatin 10 mg, 20 mg, 40 mg
atorvastatin 80 mg
ATRIPLA 600-200-300 mg
ATROVENT HFA INHALER
AVODART 0.5 mg
AVONEX 30 mcg, 30 mcg/0.5 mL
AVONEX PEN KIT 30 mcg
azelastine hcl nasal spray 0.1%
azelastine hcl nasal spray 0.15%
AZOR 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg
BENICAR 20 mg, 40 mg
BENICAR 5 mg
BENICAR HCT 20-12.5 mg, 40-12.5 mg, 40-25 mg
BETASERON 0.3 mg
BOSULIF 100 mg
BOSULIF 500 mg
BREO ELLIPTA
BRINTELLIX 5 mg, 10 mg, 20 mg
budeprion SR (12 hr) 100 mg, 150 mg
buprenorphine hcl 2 mg
buprenorphine hcl 8 mg
buprenorphine hcl/naloxone 2-0.5 mg, 8-2 mg
bupropion hcl 100 mg
bupropion hcl 75 mg
bupropion hcl ER (12 hr) 100 mg, 150 mg, 200 mg
bupropion hcl XL (24 hr) 150 mg, 300 mg
butalbital/acetaminophen/caffeine w/codeine 50300-40-30 mg
butalbital/acetaminophen/caffeine w/codeine 50325-40-30 mg
butalbital/aspirin/caffeine/codeine 50-325-40-30
mg
BYDUREON 2 mg
BYDUREON pen
Monthly Limit
(30 days unless
otherwise noted)
180 capsules
1 canister
1 canister
1 canister
2 bottles
45 tablets
30 tablets
30 tablets
2 canisters
30 capsules
4 syringes (1 box/kit) per 28 days
1 kit per 28 days
2 bottles
2 bottles
30 tablets
30 tablets
60 tablets
30 tablets
15 vials/syringes
120 tablets
30 tablets
1 package
30 tablets
60 tablets
90 sublingual tablets
90 sublingual tablets
90 sublingual tablets
120 tablets
60 tablets
60 tablets
30 tablets
180 capsules
180 capsules
180 capsules
4 vials per 28 days
4 pens per 28 days
2014 Quantity Limits
Drug Name
CAPRELSA 100 mg
CAPRELSA 300 mg
CHANTIX - all strengths
CINRYZE
citalopram 10 mg, 20 mg, 40 mg
citalopram 10 mg/5 mL
clonazepam ODT 0.125 mg, 0.25 mg
clonazepam/clonazepam ODT 0.5 mg, 1 mg
clonazepam/clonazepam ODT 2 mg
clonidine ER 0.1 mg
clorazepate 15 mg
clorazepate 3.75 mg, 7.5 mg
clozapine 100 mg
clozapine 200 mg
clozapine 25 mg, 50 mg
COMETRIQ 100 mg
COMETRIQ 140 mg
COMETRIQ 60 mg
COMPLERA 200-25-300 mg
COPAXONE KIT 20 mg/mL
COPAXONE INJ 40 mg/mL
CRESTOR 40 mg
CRESTOR 5 mg, 10 mg, 20 mg
CRIXIVAN 200 mg
CRIXIVAN 400 mg
CYCLOSET 0.8 mg
CYMBALTA 20 mg, 30 mg, 60 mg
DALIRESP 500 mcg
DETROL LA - all strengths
dexmethylphenidate 2.5 mg, 5 mg, 10 mg
dextroamphetamine 10 mg
dextroamphetamine 5 mg
DIAZEPAM 1 mg/mL
diazepam 10 mg
diazepam 2 mg
diazepam 5 mg
diazepam gel 2.5 mg, 10 mg, 20 mg
didanosine 125 mg, 200 mg, 250 mg, 400 mg
Monthly Limit
(30 days unless
otherwise noted)
60 tablets
30 tablets
336 tablets or amount dispensed up to
168 days of therapy per 365 days
20 vials
30 tablets
600 mL
90 tablets
90 tablets
300 tablets
120 tablets
180 tablets
90 tablets
270 tablets
120 tablets
90 tablets
56 capsules per 28 days
112 capsules per 28 days
84 capsules per 28 days
30 tablets
30 syringes
12 syringes per 28 days
30 tablets
45 tablets
270 capsules
180 capsules
180 tablets
60 capsules
30 tablets
30 capsules
60 tablets
180 tablets
60 tablets
1200 mL
120 tablets
120 tablets
120 tablets
5 twin packs
30 capsules
2014 Quantity Limits
Drug Name
digoxin 50 mcg/mL
digoxin 0.125 mg, 0.25 mg
donepezil 5 mg, 10 mg, 23 mg
donepezil ODT 5 mg, 10 mg
doxazosin 1 mg, 2 mg, 4 mg
doxazosin 8 mg
DULERA - all strengths
duloxetine 20 mg, 30 mg, 60 mg
EDURANT 25 mg
EMTRIVA 10 mg/mL
EMTRIVA 200 mg
endocet 10-325 mg
endocet 5-325 mg
endocet 7.5-325 mg
enoxaparin syringes
enoxaparin 300 mg/3 mL vials
EPIVIR 10 mg/mL
EPZICOM 600-300 mg
ERIVEDGE 150 mg
escitalopram 5 mg, 10 mg, 20 mg
escitalopram 5 mg/5 mL
EXELON transdermal 4.6 mg/24 hr, 9.5 mg/24 hr,
13.3 mg/24 hr
EXFORGE 5-160 mg, 5-320 mg, 10-160 mg, 10-320
mg
EXFORGE HCT 5-160-12.5 mg, 5-160-25 mg, 10160-12.5 mg, 10-160-25 mg, 10-320-25 mg
FANAPT 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12
mg
FANAPT TITRATION PAK
FAZACLO 150 mg
FAZACLO 200 mg
FAZACLO ODT 12.5 mg, 100 mg
FAZACLO ODT 25 mg
fenofibrate 145 mg, 160 mg
fenofibrate 48 mg, 54 mg
fenofibrate micronized 67 mg, 134 mg, 200 mg
fentanyl citrate oral lozenges 200 mcg, 400 mcg,
600 mcg, 800 mcg, 1200 mcg, 1600 mcg
Monthly Limit
(30 days unless
otherwise noted)
75 mL
30 tablets
30 tablets
30 tablets
30 tablets
60 tablets
1 canister
60 capsules
30 tablets
5 bottles
30 capsules
180 tablets
360 tablets
240 tablets
30 syringes per 90 days
10 vials per 90 days
960 mL
30 tablets
30 capsules
30 tablets
600 mL
30 patches
30 tablets
30 tablets
60 tablets
1 pak per 4 days
180 tablets
120 tablets
90 tablets
270 tablets
30 tablets
60 tablets
30 capsules
120 lozenges
2014 Quantity Limits
Drug Name
fentanyl transdermal - all strengths
FETZIMA 20 mg, 40 mg, 80 mg, 120 mg
FETZIMA Titration Pack
finasteride 5 mg
FIRAZYR
FLOVENT DISKUS 250 mcg
FLOVENT DISKUS 50 mcg, 100 mcg
FLOVENT HFA 220 mcg
FLOVENT HFA 44 mcg, 110 mcg
fluoxetine 10 mg
fluoxetine 20 mg
fluoxetine 20 mg/5 mL
fluoxetine 40 mg
fluticasone nasal spray
fluvoxamine 100 mg
fluvoxamine 25 mg, 50 mg
fondaparinux solution 2.5 mg/0.5 mL, 5.0 mg/0.4
mL, 7.5 mg/0.6 mL, 10 mg/0.8 mL
FORADIL
FUZEON injection 90 mg
galantamine 4 mg, 8 mg, 12 mg
galantamine ER 8 mg, 16 mg, 24 mg
galantamine oral solution 4 mg/mL
gemfibrozil 600 mg
GEODON injection
GILOTRIF 20 mg, 30 mg, 40 mg
GLEEVEC 100 mg
GLEEVEC 400 mg
glimepiride 1 mg
glimepiride 2 mg
glimepiride 4 mg
glipizide 10 mg
glipizide 5 mg
glipizide ER 10 mg
glipizide ER 2.5 mg
glipizide ER 5 mg
glipizide XL 10 mg
glipizide XL 2.5 mg
glipizide XL 5 mg
Monthly Limit
(30 days unless
otherwise noted)
15 patches
30 capsules
28 capsules per 28 days
30 tablets
6 syringes
4 inhalers
1 inhaler
2 canisters
1 canister
30 capsules or tablets
120 capsules or tablets
600 mL
60 capsules
1 bottle
90 tablets
30 tablets
30 syringes per 90 days
1 package of 60
60 vials
60 tablets
30 capsules
200 mL
60 tablets
60 vials
30 tablets
90 tablets
60 tablets
240 tablets
120 tablets
60 tablets
120 tablets
240 tablets
60 tablets
240 tablets
120 tablets
60 tablets
240 tablets
120 tablets
2014 Quantity Limits
Drug Name
glyburide 1.25 mg
GLYBURIDE 1.25 mg
glyburide 2.5 mg
GLYBURIDE 2.5 mg
glyburide 5 mg
GLYBURIDE 5 mg
glyburide micronized 1.5 mg
glyburide micronized 3 mg
glyburide micronized 6 mg
GRASTEK
HETLIOZ
hydrocodone/acetaminophen 5-300 mg, 5-325 mg
hydrocodone/acetaminophen 7.5-300 mg, 7.5-325
mg, 10-300 mg, 10-325 mg
hydrocodone/acetaminophen 7.5-325 mg/15 mL
hydromorphone 2 mg, 4 mg, 8 mg
hydromorphone 1 mg/mL
ibandronate 150 mg
ICLUSIG 15 mg
ICLUSIG 45 mg
IMBRUVICA 140 mg
INLYTA 1 mg
INLYTA 5 mg
INTELENCE 100 mg, 200 mg
INTELENCE 25 mg
INTUNIV 1 mg, 2 mg, 3 mg, 4 mg
INVEGA 1.5 mg, 3 mg, 9 mg
INVEGA 6 mg
INVEGA SUSTENNA
INVIRASE 200 mg
INVIRASE 500 mg
INVOKANA 100 mg
INVOKANA 300 mg
irbesartan 75 mg, 150 mg, 300 mg
irbesartan/hydrochlorothiazide 150-12.5 mg, 30012.5 mg
ISENTRESS 400 mg
ISENTRESS CHW 25 mg, 100 mg
ISENTRESS 100 mg
Monthly Limit
(30 days unless
otherwise noted)
480 tablets
480 tablets
240 tablets
240 tablets
120 tablets
120 tablets
240 tablets
120 tablets
60 tablets
30 sublingual tablets
30 capsules
360 tablets
180 tablets
3600 mL
180 tablets
1440 mL
1 tablet per 28 days
60 tablets
30 tablets
120 capsules
180 tablets
120 tablets
60 tablets
120 tablets
30 tablets
30 tablets
60 tablets
1 kit
300 capsules
120 tablets
90 tablets
30 tablets
30 tablets
30 tablets
60 tablets
180 tablets
60 packets
2014 Quantity Limits
Drug Name
JAKAFI - all strengths
JANUMET - all strengths
JANUMET XR 100-1000 mg
JANUMET XR 50-500 mg, 50-1000 mg
JANUVIA 100 mg
JANUVIA 25 mg
JANUVIA 50 mg
JENTADUETO 2.5-500 mg, 2.5-850 mg, 2.5-1000
mg
KALETRA 100-25 mg
KALETRA 200-50 mg
KALETRA 400-100 mg/5 mL
KALYDECO 150 mg
KOMBIGLYZE XR 2.5-1000 mg
KOMBIGLYZE XR 5-500 mg, 5-1000 mg
lamivudine 150 mg
lamivudine 300 mg
lamivudine/zidovudine 150-300 mg
LATUDA 20 mg, 40 mg, 60 mg, 120 mg
LATUDA 80 mg
LAZANDA - all strengths
LETAIRIS 5 mg, 10 mg
LEXIVA 50 mg/mL
LEXIVA 700 mg
lorazepam 0.5 mg, 1 mg
lorazepam 2 mg
lorcet 5-325 mg
lorcet hd 10-325 mg
lorcet plus 7.5-325 mg
lortab 5-325 mg
lortab 7.5-325 mg, 10-325 mg
losartan 100 mg
losartan 25 mg, 50 mg
losartan/hydrochlorothiazide 50-12.5 mg, 10012.5 mg, 100-25 mg
lovastatin - all strengths
MAPROTILINE 25 mg, 50 mg, 75 mg
MEKINIST 0.5 mg
MEKINIST 2 mg
Monthly Limit
(30 days unless
otherwise noted)
60 tablets
60 tablets
30 tablets
60 tablets
30 tablets
120 tablets
60 tablets
60 tablets
300 tablets
120 tablets
2 bottles
60 tablets
60 tablets
30 tablets
60 tablets
30 tablets
60 tablets
30 tablets
60 tablets
30 bottles
30 tablets
1800 mL
120 tablets
90 tablets
150 tablets
360 tablets
180 tablets
180 tablets
360 tablets
180 tablets
30 tablets
60 tablets
30 tablets
60 tablets
90 tablets
90 tablets
30 tablets
2014 Quantity Limits
Drug Name
metadate ER 20 mg
metformin 1000 mg
metformin 500 mg
metformin 850 mg
metformin ER 500 mg
metformin ER 750 mg
methadone 5 mg, 10 mg
methadose 10 mg
methylphenidate 5 mg, 10 mg, 20 mg
methylphenidate ER 20 mg
MICARDIS 20 mg, 40 mg, 80 mg
MICARDIS HCT 40-12.5 mg, 80-25 mg
MICARDIS HCT 80-12.5 mg
mirtazapine 7.5 mg
MIRTAZAPINE 7.5 mg
mirtazapine/mirtazapine ODT 15 mg, 30 mg, 45
mg
modafinil - all strengths
MORPHINE SULFATE 15 mg
MORPHINE SULFATE 30 mg
morphine sulfate ER 15 mg, 30 mg, 60 mg, 100 mg,
200 mg
MYRBETRIQ 25 mg, 50 mg
NAMENDA 10 mg/5 mL
NAMENDA 5 mg, 10 mg
NAMENDA TITRATION PACK
NAMENDA XR 7 mg, 14 mg, 21 mg, 28 mg
NAMENDA XR Titration Pack
naratriptan - all strengths
NASONEX
nateglinide 120 mg
nateglinide 60 mg
nevirapine 200 mg
nevirapine ER 400 mg
NEXAVAR 200 mg
NEXIUM - all strengths
niacin ER 500 mg
niacin ER 750 mg, 1000 mg
NIASPAN ER 500 mg
Monthly Limit
(30 days unless
otherwise noted)
90 tablets
60 tablets
150 tablets
90 tablets
120 tablets
60 tablets
90 tablets
90 tablets
90 tablets
90 tablets
30 tablets
30 tablets
60 tablets
30 tablets
30 tablets
30 tablets
30 tablets
240 tablets
180 tablets
90 tablets
30 tablets
360 mL
60 tablets
49 tablets per 28 days
30 capsules
28 capsules per 28 days
18 tablets
2 bottles
90 tablets
180 tablets
60 tablets
30 tablets
120 tablets
30 capsules or packets
30 tablets
60 tablets
30 tablets
2014 Quantity Limits
Drug Name
NIASPAN ER 750 mg, 1000 mg
nitrofurantoin macrocrystalline 100 mg
nitrofurantoin macrocrystalline 50 mg
nitrofurantoin monohydrate 100 mg
NORVIR 100 mg
NORVIR 80 mg/mL
NUVIGIL - all strengths
olanzapine 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20
mg
olanzapine IM injection, 10 mg
olanzapine ODT 5 mg, 10 mg, 15 mg, 20 mg
omeprazole 10 mg, 20 mg, 40 mg
ONFI 10 mg, 20 mg
ONFI 2.5 mg/mL suspension
ONGLYZA 2.5 mg
ONGLYZA 5 mg
OPSUMIT 10 mg
oxybutynin 5 mg
oxybutynin syrup 5 mg/5 mL
oxycodone 10 mg, 15 mg, 20 mg, 30 mg
oxycodone 5 mg
oxycodone w/acetaminophen 10-325 mg
oxycodone w/acetaminophen 2.5-325 mg, 5-325
mg
oxycodone w/acetaminophen 7.5-325 mg
pantoprazole tabs - all strengths
paroxetine hcl 10 mg, 20 mg, 40 mg
paroxetine hcl 30 mg
paroxetine hcl ER 12.5 mg
paroxetine hcl ER 25 mg, 37.5 mg
PAXIL 10 mg/5 mL
pioglitazone 15 mg
pioglitazone 30 mg, 45 mg
POMALYST 1 mg, 2 mg, 3 mg, 4 mg
PRADAXA - all strengths
pravastatin 10 mg, 20 mg, 40 mg
Monthly Limit
(30 days unless
otherwise noted)
60 tablets
360 capsules or amount dispensed up to
90 days of therapy per 365 days
360 capsules or amount dispensed up to
90 days of therapy per 365 days
180 capsules or amount dispensed up to
90 days of therapy per 365 days
360 capsules or tablets
2 bottles
30 tablets
30 tablets
90 vials
30 tablets
30 capsules
60 tablets
480 mL
60 tablets
30 tablets
30 tablets
120 tablets
600 mL
180 tablets
360 tablets
180 tablets
360 tablets
240 tablets
30 tablets
30 tablets
60 tablets
30 tablets
60 tablets
900 mL
90 tablets
30 tablets
21 capsules per 28 days
60 capsules
45 tablets
2014 Quantity Limits
Drug Name
pravastatin 80 mg
PREZISTA 100 mg/mL suspension
PREZISTA 150 mg
PREZISTA 600 mg
PREZISTA 75 mg
PREZISTA 800 mg
PRISTIQ - all strengths
PROAIR HFA
quetiapine 25 mg, 50 mg, 100 mg, 200 mg
quetiapine 300 mg, 400 mg
QVAR 40 mcg
QVAR 80 mcg
RAGWITEK
RESCRIPTOR 100 mg
RESCRIPTOR 200 mg
REVLIMID 15 mg, 20 mg, 25 mg
REVLIMID 2.5 mg, 5 mg, 10 mg
REYATAZ 100 mg, 150 mg, 300 mg
REYATAZ 200 mg
risedronate 150 mg
RISPERDAL CONSTA injection - all strengths
risperidone 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg
risperidone 4 mg
risperidone ODT 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3
mg
risperidone ODT 4 mg
risperidone oral solution
rivastigmine 1.5 mg, 3 mg, 4.5 mg, 6 mg
rizatriptan 5 mg, 10 mg
rizatriptan ODT 5 mg, 10 mg
roxicet 5-325 mg
SAPHRIS 5 mg, 10 mg
SELZENTRY 150 mg
SELZENTRY 300 mg
SEREVENT DISKUS
SEROQUEL XR 150 mg, 200 mg
SEROQUEL XR 50 mg, 300 mg, 400 mg
sertraline 100 mg
sertraline 20 mg/mL
Monthly Limit
(30 days unless
otherwise noted)
30 tablets
400 mL
180 tablets
60 tablets
300 tablets
30 tablets
30 tablets
2 canisters
90 tablets
60 tablets
1 canister
2 canisters
30 sublingual tablets
360 tablets
180 tablets
21 capsules per 28 days
30 capsules
30 capsules
60 capsules
1 tablet per 28 days
2 vials per 28 days
60 tablets
120 tablets
60 tablets
120 tablets
480 mL
60 capsules
18 tablets
18 tablets
360 tablets
60 tablets
60 tablets
120 tablets
1 package of 60
30 tablets
60 tablets
60 tablets
300 mL
2014 Quantity Limits
Drug Name
sertraline 25 mg, 50 mg
sildenafil 20 mg
SILENOR 3 mg, 6 mg
simvastatin 20 mg
simvastatin 5 mg, 10 mg, 40 mg
simvastatin 80 mg
SPIRIVA
SPRYCEL 20 mg
SPRYCEL 50 mg, 70 mg, 80 mg, 100 mg, 140 mg
stavudine 1 mg/mL
stavudine 15 mg, 20 mg, 30 mg, 40 mg
STIVARGA 40 mg
STRATTERA 10 mg, 18 mg, 25 mg, 40 mg
STRATTERA 60 mg, 80 mg, 100 mg
STRIBILD
SUBOXONE MIS 12-3 mg, 8-2 mg
SUBOXONE MIS 2-0.5 mg
SUBOXONE MIS 4-1mg
SUMATRIPTAN NASAL - all strengths
sumatriptan tablets - all strengths
SUSTIVA 200 mg
SUSTIVA 50 mg
SUSTIVA 600 mg
SUTENT 12.5 mg
SUTENT 25 mg, 37.5 mg, 50 mg
SYMBICORT - all strengths
TAFINLAR 50 mg, 75 mg
tamsulosin 0.4 mg
TARCEVA 100 mg, 150 mg
TARCEVA 25 mg
TASIGNA 150 mg, 200 mg
TECFIDERA 120 mg, 240 mg, Starter Kit
TEKTURNA 150 mg, 300 mg
telmisartan 20 mg, 40 mg, 80 mg
telmisartan/hydrochlorothiazide 40-12.5 mg, 8025 mg
telmisartan/hydrochlorothiazide 80-12.5 mg
terazosin 1 mg, 2 mg, 5 mg
terazosin 10 mg
Monthly Limit
(30 days unless
otherwise noted)
30 tablets
90 tablets
30 tablets
60 tablets
45 tablets
30 tablets
30 capsules
60 tablets
30 tablets
2400 mL
60 capsules
84 tabs/28 days
60 capsules
30 capsules
30 tablets
60 films
90 films
30 films
12 units/2 packages
18 tablets
60 capsules
90 capsules
30 tablets
90 capsules
30 capsules
1 canister
120 capsules
60 capsules
30 tablets
60 tablets
120 capsules
60 capsules
30 tablets
30 tablets
30 tablets
60 tablets
30 capsules
60 capsules
2014 Quantity Limits
Drug Name
THALOMID 150 mg, 200 mg
THALOMID 50 mg, 100 mg
TIVICAY 50 mg
tolterodine ER 2 mg, 4 mg
TOVIAZ - all strengths
TRACLEER 62.5 mg, 125 mg
TRADJENTA
tramadol hcl 50 mg
TRIBENZOR - all strengths
TRIUMEQ 600-50-300 mg
TRIZIVIR 300-150-300 mg
TRUVADA 200-300 mg
TYKERB 250 mg
TYSABRI 300 mg/15 mL
VANDETANIB 100 mg
VANDETANIB 300 mg
venlafaxine 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg
venlafaxine ER capsules 37.5 mg, 150 mg
venlafaxine ER capsules 75 mg
VENTOLIN HFA
VERSACLOZ 50 mg/mL
VESICARE - all strengths
vicodin 5-300 mg
vicodin ES 7.5-300 mg
vicodin HP 10-300 mg
VICTOZA 18 mg/3 mL
VIDEX 2 gm, 4 gm
VIIBRYD - all strengths
VIIBRYD starter kit
VIRACEPT 250 mg
VIRACEPT 625 mg
VIRAMUNE 50 mg/5 mL
VIRAMUNE XR 100 mg
VIRAMUNE XR 400 mg
VIREAD 150 mg, 200 mg, 250 mg, 300 mg
VIREAD 40 mg/gm
VOLTAREN gel 1%
VOTRIENT 200 mg
VYTORIN 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg
Monthly Limit
(30 days unless
otherwise noted)
60 capsules
30 capsules
60 tablets
30 capsules
30 tablets
60 tablets
30 tablets
240 tablets
30 tablets
30 tablets
60 tablets
30 tablets
180 tablets
1 vial per 28 days
60 tablets
30 tablets
90 tablets
30 capsules
90 capsules
2 canisters
540 mL
30 tablets
360 tablets
180 tablets
180 tablets
1 package of 3 pens
1200 mL
30 tablets
1 kit per 30 days
270 tablets
120 tablets
1200 mL
90 tablets
30 tablets
30 tablets
240 gm
10 tubes
120 tablets
30 tablets
2014 Quantity Limits
Drug Name
Monthly Limit
(30 days unless
otherwise noted)
XALKORI - all strengths
XARELTO 10 mg
XARELTO 15 mg
XARELTO 20 mg
XENAZINE 12.5 mg
XENAZINE 25 mg
XTANDI 40 mg
XYREM 500 mg/mL
60 capsules
35 tablets per 90 days
60 tablets
30 tablets
240 tablets
120 tablets
120 capsules
540 mL
90 capsules or amount dispensed up to
90 days of therapy per 365 days
240 tablets
180 tablets
90 tablets
30 tablets
960 mL
180 capsules
60 tablets
1920 mL
60 capsules
60 capsules
120 capsules
90 tablets or amount dispensed up to 90
days of therapy per 365 days
1 vaccine per lifetime
60 tablets
150 capsules
2 vials per 28 days
1 vial per 28 days
120 tablets
zaleplon 5 mg, 10 mg
ZELBORAF
zenzedi 10 mg
zenzedi 5 mg
ZETIA 10 mg
ZIAGEN 20 mg/mL
zidovudine 100 mg
zidovudine 300 mg
zidovudine syrup 10 mg/mL
ziprasidone capsules - all strengths
ZOHYDRO ER - all strengths
ZOLINZA 100 mg
zolpidem 5 mg, 10 mg
ZOSTAVAX
ZYDELIG 100 mg, 150 mg
ZYKADIA 150 mg
ZYPREXA RELPREVV 210 mg, 300 mg
ZYPREXA RELPREVV 405 mg
ZYTIGA
Last Updated 11/01/2014