Quantity Limits

Quantity limits are based upon FDA guidelines, published clinical recommendations, such as the Journal of the American Medical Association (JAMA), as well as manufacturer packaging and labeling instructions. Limits are intended to encourage appropriate dosing. Exceptions are generally limited to chronic conditions that necessitate a quantity greater than "normal." These limits are not intended to restrict access to quantities of medications where limits would not be considered functional or appropriate. The P&T Committee recommends the following medications be limited to a defined quantity.

List of Products Subject to Quantity Limits

Drug Name	Therapy Class	Limit
Actiq (fentanyl oral transmucosal)	Narcotic Analgesic	6 units/day
Actonel 35 mg	Osteoporosis	4 tabs per 28 days
Actonel 75 mg	Osteoporosis	2 tablets per 30 days
Actonel 150 mg	Osteoporosis	1 tablet per 30 days
Acular / Acular LS	Ophthalmic NSAID	2 (10 mL) bottles / month
Advair Diskus/HFA	Asthma Inhaler	1 device per month
Alrex	Ophthalmic Steroid	3 (5 mL) bottles / month
Altabax	Antibiotics-topical	1 tube per month
Amerge	Acute Migraine Therapy	9 tablets per co-pay
Anzemet	Nausea and Vomiting	1 tablet per month
Aranesp	Hematopoietic Agent	28 day supply per dispensing
Asmanex	Asthma Inhaler	3 devices per month
Avonex	Multiple Sclerosis	4 injections per month
Axert	Acute Migraine Therapy	9 tablets per co-pay
Azasite	Opthalmic Antibotic	1 (2.5mL) bottle/month
Blood Glucose Testing Strips     (all brands and generics)	Diabetic Testing Supplies	150 test strips/month
Boniva 150 mg	Osteoporosis	1 tablet per 30 days
Cesamet	Nausea and Vomiting	20 capsules per co-pay
Cialis	Sexual Dysfunction	8 tablets per month
Ciloxan ophthalmic ointment	Ophthalmic Antibiotic	1 tube (3.5 gm) / 15 days
Diflucan (fluconazole) 150 mg	Antifungal	1 tablet per co-pay
Elestat	Ophthalmic Antiallergic	2 (5 mL) bottles/30 days
Emend (combo pack) 125mg-80mg	Nausea and Vomiting	1 pack per month
Emend 80 mg & 125 mg	Nausea and Vomiting	3 capsules per month
Enbrel	Anti-TNF Agent	8 doses per month
Epogen	Hematopoietic Agent	28 day supply per dispensing
Estring	Hormone Replacement Therapy	1 device per 3 months (3 co-pays)
Femring	Hormone Replacement Therapy	1 device per 3 months (3 co-pays)
Fentora	Narcotic Analgesic	6 units/day
Foradil	Asthma Medication	60 caps/month
Forteo	Osteoporosis	24 months of therapy
Fosamax (alendronate) 35 mg and 70 mg	Osteoporosis	4 tablets per 28 days
Fosamax Plus D 70/2800 and 70/5600	Osteoporosis	4 tablets per 28 days
Frova	Acute Migraine Therapy	9 tablets per co-pay
Humira	Anti-TNF Agent	1 package per 28 days
Imitrex 25mg, 50mg, 100mg	Acute Migraine Therapy	9 tablets per co-pay
Imitrex Injections	Acute Migraine Therapy	1 package per co-pay
Imitrex Nasal Spray	Acute Migraine Therapy	1 package per co-pay
Iquix	Ophthalmic Antibiotic	1 (5 mL) bottle / 15 days
Ketek	Antibotics-Other	20 dosage units per 30 days
Kytril (granisetron)	Nausea and Vomiting	2 tablets per month
Levitra	Sexual Dysfunction	8 tablets per month
Lidoderm	Anesthetic Patch	1 box per co-pay
Livostin	Ophthalmic Antiallergic	2 (5mL) bottles/month
Lumigan	Glaucoma	1 (2.5 mL) bottle/month
Lupron Depot 11.25 & 22.5	Cancer	1 unit per 90 days
Luveris	Infertility	14 vials per co-pay
Maxalt & Maxalt MLT	Acute Migraine Therapy	9 tablets per co-pay
Migranal	Acute Migraine Therapy	1 package per co-pay
Natacyn	Ophthalmic Antibiotic	1 (15 mL) bottle / 15 days
Neulasta	Hematopoietic Agent	28 day supply per dispensing
Neupogen	Hematopoietic Agent	28 day supply per dispensing
Nevanac	Ophthalmic NSAID	2 (3 mL) bottles/year
Ocufen (flurbiprofen)	Ophthalmic NSAID	1 (2.5 mL) bottle/15 days
Optivar	Ophthalmic Antiallergic	2 (5mL) bottles/30 days
Oxycontin	Narcotic Analgesic	270 tablets per month
Pataday	Ophthalmic Antiallergic	2 (2.5mL) bottles/30 days
Patanase	Allergy--Intranasal	1 (30.5mL) bottles/month
Patanol	Ophthalmic Antiallergic	2 (5mL) bottles/30 days
Pegasys	Hepatitis C	4 vials / 28 days
Pegasys Kit	Hepatitis C	1 kit / 28 days
ProAir HFA	Asthma Inhaler	2 devices per month
Procrit	Hematopoietic Agent	28 day supply per dispensing
Proventil HFA	Asthma Inhaler	2 devices/month
Prozac Weekly	SSRI Antidepressant	4 capsules per month
Quixin	Ophthalmic Antibiotic	1 (5 mL) bottle / 15 days
Regenecare Gel	Wound Care	1 copay per package
Relenza	Influenza Antiviral	1 treatment per year
Relpax	Acute Migraine Therapy	9 tablets per co-pay
Restasis	Ophthalmic-other	60 units per 30 days
Revlimid	Cancer	28 day supply per dispensing
Seasonale (Seasonique)	Contraception	1 package per 91 days (3 copays)
Serevent Diskus	Asthma Inhaler	1 device per month
Stadol NS (butorphanol)	Narcotic Analgesic Nasal Spray	4 (2.5ml) pumps per month
Symbicort	Asthma Inhaler	1 device per month
Tamiflu	Influenza Antiviral	1 treatment per year
Toradol 10mg (ketorolac)	COX-1 Inhibitor, NSAID	20 tablets per prescription
Travatan and Travatan Z	Glaucoma	1 (2.5 mL) bottle/month
Treximet	Acute Migraine therapy	9 tablets per copay
Ultracet (tramadol/acetaminophen)	Pain Medication	40 tablets per prescription
Ventolin HFA	Ashma Inhaler	2 devices/month
Veregen	External Genital Warts	16 weeks of therapy per year
Viagra	Sexual Dysfunction	8 tablets per month
Vigamox	Ophthalmic Antibiotic	1 (3 mL) bottle/15 days
Viroptic (trifluridine)	Ophthalmic Antiviral	1 (7.5 mL) bottle/15 days
Voltaren (diclofenac) Op. Sol.	Ophthalmic NSAID	1 (5 mL) bottle/15 days
Xalatan	Glaucoma	1 (2.5 mL) bottle/month
Xibrom Sol.	Ophthalmic NSAID	2 (5 mL) bottles/year
Zofran (ondansetron)     2mg, 4mg, 8mg, 24 mg	Nausea and Vomiting	18 tablets per month
Zofran (ondansetron) ODT     2mg, 4mg, 8mg	Nausea and Vomiting	18 tablets per month
Zofran (ondansetron) Oral Sol.	Nausea and Vomiting	200 mL per month
Zomig & Zomig ZMT 2.5mg, 5mg	Acute Migraine Therapy	9 tablets per co-pay
Zomig Nasal Spray	Acute Migraine Therapy	1 package per co-pay
Zymar	Ophthalmic Antibiotic	1 (5 mL) bottle/15 days

Any product listed in this information does not imply coverage. Plan booklets will provide specific benefit and coverage details. NOTE: This is only a partial listing, and not all products on this list may be covered by your prescription benefits plan. Your specific benefit plan’s guidelines regarding quantity limits will apply. If you have any questions about product status or if the product you’re considering does not appear in this listing, please call Innoviant customer service at 877-559-2995. We’re available to assist you 24-hours a day, seven days a week.