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MRX STANDARD FORMULARYUTILIZATION MANAGEMENT: OVERVIEWMagellan Rx Management is committed to helping you manage your prescription drug use and costs.Prior Authorization, Quantity Limits, Step Therapy, and Age or Gender edits are recommended by theMagellan Rx Management Formulary Review Committee and may be used by your prescription drugbenefit plan to ensure you have access to safe, appropriate, and effective prescription medications.Please check your plan documents to determine your prescription drug benefit plan’s approach toutilizing these clinical edits.
The clinical edits are defined as follows:
Prior AuthorizationMedications which require pharmacy benefit manager or plan approval before you may receive benefits
Quantity Limits and Daily Dose LimitMedication whose frequency and dosage are defined by a certain quantity per day
Step TherapyMedications that require that you first use alternative medications before this medication may be triedor prescribed
Age and Gender EditsAge edits are designed to ensure that medications are used only in appropriate age groups, e.g. not foruse in infants or the elderly. Gender edits are designed to restrict access to drug therapies which arespecific to male or female populations.
Legend‡ - Preferred Specialty Product
The table below displays the clinical edits that may be associated with the use of your prescriptionmedications.
Medication Clinical Edits and GuidelinesAbilify (aripiprazole) Quantity Limit – 30 tablets per 30 days, 750ml oral solution per
30 days
Abilify Disc Tab (orallydisintegrating)
Quantity Limit – 15mg and 10mg = 60 tablets for 30 days
Abraxane Specialty, Prior Authorization
Absorica Prior Authorization, Quantity Limit – Max 30 day supply, no refills
Abstral Prior Authorization, Quantity Limit – 120 per 30 days
Acanya Gel Quantity Limit – 50G (1 jar) per 30 days
Accu-Chek testing strips Quantity Limit – 300 per 30 days
Accupril (quinipril) Quantity Limit – 30 per 30 days
Accuretic 10/12.5mg (quinapril-hctz) Quantity Limit – 30 per 30 days
Aceon 4mg (perindopril) Quantity Limit – 30 per 30 days
Aciphex (rabeprzaole sodium) Step Therapy, Quantity Limit – 60 tablets per 30 days
Aciphex SPR Quantity Limit – 30 per 30 days
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Medication Clinical Edits and GuidelinesActemra Specialty, Prior Authorization
Acthar HP Specialty, Prior Authorization
Acthrel Specialty, Prior Authorization
Actiq (fentanyl citrate) Prior Authorization, Quantity Limit – 120 per 30 days
Active OB Gender Edit – female only
Activella (estradiol & norethindrone) Gender Edit – female only, Quantity Limit – 30 per 30 days
Actonel Quantity Limit – 35mg = 4 tablets per 28 days, 5mg & 30mg = 30per 30 days, 150mg = 1 tablet per 30 days.
Actos (pioglitazone) Quantity Limit – 30 tablets per 30 days
ActosPlus Met (pioglitazone-metformin)
Quantity Limit – 90 tablets per 30 days
ActosPlus Met XR Quantity Limit – 15-1000 MG = 90 tablets per 30 days, 30-1000MG = 30 tablets per 30 days
Acular, Acular LS (ketorolactromethamine)
Quantity Limit – 15ml per 30 days, LS = 5ml per 23 days
Acuvail Quantity Limit – 65 vials per 180 days
Adalat CC (Nifedipine) 30mg Quantity Limit – 30 per 30 days
Adcetris Specialty, Prior Authorization
Adcirca Specialty, Quantity Limit – 60 per 30 days, Prior Authorization
Adderall(amphetamine/dextroamphetamine)
Quantity Limit – 60 per 30 days
Adderall XR(amphetamine/dextroamphetamine)
Quantity Limit – 20mg & 30 mg = 60 per 30 days, 5mg & 10mg =30 per 30 days, Therapy
Adempas Specialty, Prior Authorization, Quantity Limit – 3 tablets per day
Adoxa Step Therapy
Adrenaclick Step Therapy, Quantity Limit – 2 Pens per Rx
Advair HFA, Diskus Quantity Limit – 1 inhaler 30 days
Advicor Quantity Limit –1000-40mg = 30 per 30 days, 1000-20mg,500/20mg & & 750-20mg = 60 per 30 days
Aerospan Quantity Limit – 2 inhalers per 30 days, Step Therapy
Afinitor, Afinitor Dis Specialty, Prior Authorization, Quantity Limit – 2.5MG= 30 per 30days, 5MG, 7.5MG & 10MG = 60 per 30 days
Afrezza Prior Authorization
Akynzeo Specialty, Prior Authorization
Alagesic Liq Quantity Limit – 90ml per day ( 2700ml per 30 days)
Aldara (imiquimod) Quantity Limit – 48 packets (2 boxes) per 16 weeks
All Day Allg Tab (cetirizine) Quantity Limit – 30 per 30 days
Aldurazyme Specialty, Prior Authorization
Allegra (fexofenadine) Quantity Limit – 180mg= 30 per 30 days, 30mg & 60mg = 60 per30 days, suspension = 900ml per 30 days
Allegra ODT 30mg Quantity Limit – 60 per 30 days
Allegra-D (fexofenadine-D) Quantity Limit – 24HR = 30 per 30 days; 12HR = 60 per 30 days
Allergy D-12 Tab All Day Quantity Limit – 60 per 30 days
Allergy Relief Tab 10mg Quantity Limit – 30 per 30 days
Allergy Relief Tab 5-120mg Quantity Limit – 60 per 30 days
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Medication Clinical Edits and GuidelinesAller-Tec 10mg Quantity Limit – 30 per 30 days
Aller-Tec D 5-120mg Quantity Limit – 60 per 30 days
Allergy Comp D Tab 5-120mg Quantity Limit – 60 per 30 days
Alimta Specialty, Prior Authorization
Alocril Quantity Limit – 1 bottle per 30 days (5ml)
Alomide Quantity Limit – 1 bottle per 30 days (10ml)
Alora Gender Edit – females only, Quantity Limit – 8 per 28 days
Alphagan P 0.15% (brimonidine) Quantity Limit – 10ml per 30 days
Alprolix Specialty, Prior Authorization
Alsuma (sumatriptan) Quantity Limit – 5 mls per 30 days
Altace(ramipril) Quantity Limit – 1.25mg, 2.5mg, 5mg = 30 per 30 days
Atralin Quantity Limit – 1.5 grams per day, Age Edit
Altoprev ER Step Therapy, Quantity Limit – 30 per 30 days
Alvesco Quantity Limit – 2 inhalers per 30 days
Ambien (zolpidem) Step Therapy, Quantity Limit – 30 tabs per 30 days
Ambien CR (zolpidem CR) Step Therapy, Quantity Limit – 30 tabs per 30 days
Amerge (naratriptan) Quantity Limit – 9 tablets per 30 days
Amethia & Amethia Lo Quantity limit – Max day supply 91, Gender Edit – females only
Amitiza Quantity Limit – 60 per 30 days, Step Therapy
Amnesteem Prior Authorization, Quantity Limit – Max days supply 30 no refills
Ampyra ‡ Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Amturnide Step Therapy, Quantity Limit – 30 per 30 days
Anadrol-50 Gender Edit – males only
Anaprox (naproxen sodium) Quantity Limit – 275mg = 180 per 30 days, 550mg = 90 per 30days
Androderm patch Prior Authorization, Gender Edit - males only, Quantity Limit – 30patches per 30 days
AndroGel 1% Prior Authorization, Gender Edit – males only, Quantity Limit – 1%(25mg) = 75GM per 30 days; 1% (50mg), PUMP = 300G per 30days
AndroGel 1.62% Prior Authorization, Gender Edit – males only, Quantity Limit –1.62% (20.25mg) = 1.25GM per day; 1.62% (40.5mg) = 5GM perday; 1.62% (20.25mg) = 150GM per 30 days.
Android Prior Authorization, Gender Edit – males only
Angeliq Gender edit – female only, Quantity Limit – 30 per 30 days
Antara (fenofibrate micronized) Quantity Limit – 43mg & 30mg = 60 per 30 days, 130mg & 90mg= 30 per 30 days
Anzemet tablets Quantity Limit – 50mg = 6 tablets per 30 days; 100mg = 3 tabletsper 30 days
Apidra Step Therapy
Aplenzin Quantity Limit – 30 per 30 days
Apokyn Specialty, Prior Authorization
Aptensio XR Prior Authorization, Quantity Limit – 60 per day
Aralast NP Specialty, Prior Authorization
Aranesp‡ Specialty, Prior Authorization
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Medication Clinical Edits and GuidelinesArcalyst Specialty, Prior Authorization
Arcapta Step Therapy, Quantity Limit – 30 inhaled capsules per 30 days
Aricept & ODT (donepezil) Age edit
Aricept 23mg (donepezil) Age Edit, Step Therapy
Arnuity Ellipta Step Therapy, Quantity Limit – 100 mcg = 2 per day, 200 mcg = 1per day
Arzerra Specialty, Prior Authorization
Asmanex Quantity Limit – 1 inhaler per 30 days
Astelin Nasal (azelastine) Quantity Limit – 2 bottles(60ml) per 30 days
Astepro Quantity Limit – 2 bottles(60ml) per 30 days
Atacand (candesartan cilexetil) Quantity Limit – 30 per 30 days
Atacand HCT (candesartan cilexetil) Quantity Limit – 16/12.5mg= 60 per 30 days; 32/12.5mg & 32-25mg = 30 per 30 days
Atelvia Step Therapy, Quantity Limit – 4 tablets per 28 days
Ativan (lorazepam) Quantity Limit – 0.5mg & 1mg = 90 per 30 days, 2mg = 150 per 30days
Atrovent HFA Quantity Limit – 3 inhalers per 30 days
Atrovent (ipratropium) nasal spray Quantity Limit – 2 bottles 0.03% per 30 days; 3 bottles 0.06% per30 days
Atrovent (ipratropium) neb solution Quantity Limit – 150 unit dose vials (2.5ml) per 30 days
Atryn Specialty, Prior Authorization
Aubagio Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Augmentin sus (amoxicillin & k-clavulanate)
Quantity Limit – 125ml & 250ml = 900ml per 90 days: ES 600 =600ml per 90 days
Augmentin tab (amoxicillin & k-clavulanate)
Quantity Limit – 500mg & 875mg=120 per 90 days, XR =240 per90 days
Auvi-Q Quantity Limit – 2 pens per fill, Step Therapy
Avalide (irbesartan-HCTZ) Quantity Limit – 150-12.5 = 60 per 30 days; 300-12.5 = 30 per 30days
Avandamet Prior Authorization, Quantity Limit – 60 per 30 days
Avandaryl Prior Authorization, Quantity Limit – 30 per 30 days
Avandia Prior Authorization ,Quantity Limit – 2mg= 90 per 30 days, 4mg =60 per 30 days; 8mg = 30 per 30 days
Avapro (irbesartan) Quantity Limit – 30 per 30 days
Avastin Specialty, Prior Authorization
Aveed Specialty, Prior Authorization
Avelox (moxifloxacin hcl) Quantity Limit – 21 per fill
Avelox ABC Pak(moxifloxacin hcl) Quantity Limit – 5 per fill
Avinza (morphine sulfate) Quantity Limit – 30mg, 45mg, 60mg and 75mg = 30 per 30 days,90mg & 120mg = 60 per 30 days
Avodart Gender edit – Male only, Quantity Limit – 30 per 30 days
Avonex ‡ Specialty, Prior Authorization, Quantity Limit – 1 kit (4 syringes)per 30 days
Axert Quantity Limit – 12 per 30 days
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Medication Clinical Edits and GuidelinesAxiron Gender Edit – males only, Prior Authorization, Quantity Limit –
180ml per 30 days
Azopt Quantity Limit – 15ml per 30 days
Baraclude ‡ Specialty, Quantity Limit – 20ml per day, tablets: 30 per 30 days
Beconase AQ nasal Quantity Limit – 2 inhalers per 30 days
Beleodaq Specialty, Prior Authorization
Belviq Quantity Limit – 2 tablets per day
Benicar Quantity Limit – 5mg= 2 per day, 20mg & 40mg = 30 per 30 days
Benicar HCT Quantity Limit – 30 per 30 days
Benlysta Specialty, Prior Authorization
Benzaclin(clindamycin-benzoylperoxide)
Quantity Limit – 50G per 30 days
Bepreve Quantity Limit – 10ml (1 bottle) per month
Berinert Specialty, Prior Authorization
Besivance Quantity Limit – 5ml per 30 days
Betaseron ‡ Specialty, Prior Authorization, Quantity Limit – 15 vials per 28days
BiDil Quantity Limit – 180 per 30 days
Binosto Quantity Limit – 4 per 28 days
Bivigam Specialty, Prior Authorization
Blood Glucose Testing Strips, allbrands
Quantity Limit – 300 per 30 days
Boniva 150mg (ibandronate) Quantity Limit – 1 tablet per 28 days
Bosulif Specialty, Prior Authorization, Quantity Limit – 100MG = 120 per30 days; 500MG = 30 per 30 days
Botox Cosmetic, Inj Specialty, Prior Authorization
BP Cleansing EMU Quantity Limit – 473ml (1 bottle) per 30 days
Bravelle ‡ Specialty, Prior Authorization
Brilinta Quantity Limit – 90 per 30days
Brintellix Quantity Limit – 30 per 30 days, Step Therapy
Brisdelle Quantity Limit – 30 per 30 days
Bromday (bromefenac sodium) Quantity Limit – 1.7ml (1 bottle) per fill
Bromfenac Sol (once daily) Quantity Limit – 5ml per 30 days
Brovana Quantity Limit – 120 doses per 30 days
Bunavail Prior Authorization, Quantity Limit – 2.1mg & .3mg: 90 per 30days, 4.2mg: 60 per 30 days
Bupap Quantity Limit – 180 per 30 days
Butrans Prior Authorization, Quantity Limit – 4 patches per 28 days
Butorphanol Quantity Limit – 3 bottles (9 mL) per month
Bydureon Quantity Limit – 4 vials per 30 days
Byetta Quantity Limit – 1 pen per 30 days
Bystolic Quantity Limit – 2.5 mg = 30 per 30 days, 5 mg &10 mg = 90 per30 days, 20 mg = 60 per 30 days
Caduet (amlodipine/atorvastatin) Quantity Limit – 30 per 30 days
Capital with Codeine Quantity Limit – 125ml per day
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Medication Clinical Edits and GuidelinesCaprelsa Specialty, Prior Authorization, Quantity Limit – 100 mg = 60 per
30 days, 300 mg = 30 per 30 days
Cardene SR Quantity Limit – 60 per 30 days
Cardizem CD 120mg/24hr (diltiazem) Quantity Limit – 1 per day
Cardizem LA (diltiazem hcl) Quantity Limit – 300mg, 360mg & 420mg = 30 per 30 days;120mg = 120 per 30 days; 180mg = 90 per 30 days; 240mg; 60per 30 days
Cardura XL Quantity Limit – 30 per 30 days, Step Therapy, Gender Edit –males only
Carimune NF Specialty, Prior Authorization
Cataflam (diclofenac potassium) Quantity Limit – 120 tablets per 30 days
Catapres-TTS Quantity Limit – 0.1/24HR: 4 patches per 23 days, 0.2/24HR &0.3/24HR: 8 patches per 23 days
Ceftin (cefuroxime) 500mg tablets Quantity Limit – 120 tablets per 90 days
Ceftin suspension Quantity Limit – 600mls per 90 days
Celebrex (celecoxib) 50mg & 200mg Quantity Limit – 60 tablets per 30 days
Celebrex (celecoxib) 100mg Quantity Limit – 90 tablets per 30 days
Celebrex (celecoxib) 400 mg Quantity Limit – 30 tablets per 30 days
Celexa (citalopram) Quantity Limit – 30 per 30 days
Cenestin Gender Edit – female only, Quantity Limit – 30 per 30 days
Ceredase Specialty, Prior Authorization
Cerdelga Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Cerezyme Specialty, Prior Authorization
Cesamet Prior Authorization, Quantity Limit – 20 tablets per prescriptionor up to a maximum of 3 days supply, whichever is less
Cetrotide ‡ Specialty, Prior Authorization, Gender Edit – Females only
Chantix Quantity Limit – 60 per 30 days
Chlordiazepoxide Quantity Limit – 5mg = 120 per 30 days, 10mg = 900 per 30 days,25mg = 360 per 30 days
Chloral hydrate Prior Authorization
Cholbam Specialty, Prior Authorization, Quantity limit – 4 per day
Cialis Quantity Limit – 2.5 & 5mg = 30 per 30 days, 10mg & 20mg = 6per 30 days, Gender Edit – males only, Age Edit
Ciloxan Oint & Sol (ciprofloxacin) Quantity Limit – Oint = 7GM per 30 days; Sol = 10ML per 30 days
Cimzia Specialty, Prior Authorization, Quantity Limit – Kit = 1 kit per 28days. Starter Kit = 1 kit per 365 days.
Cinryze Specialty, Prior Authorization
Cipro (ciprofloxacin) Quantity Limit – 56 per fill
Cipro XR (ciprofloxacin) Quantity Limit – 500mg ER = 3 per fill; 1000mg ER = 14 per fill
Ciprofloxaxin sol 0.3% OP Quantity Limit – 10ml per 30 days
Claravis Quantity Limit – 30 day supply, no refills
Clarinex (desloratadine) Quantity Limit – Syrup= 300ml per 30 days, 5mg = 30 per 30 days
Clarinex RDT Tab (desloratadine &pseudoephedrine)
Quantity Limit – 30 per 30 days
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Medication Clinical Edits and Guidelines
Clarinex DQuantity Limit – 2.5/120mg = 60 per 30 days, 5/240mg = 30 per30 days
Claris Wash EMU 10-4% Quantity Limit – 437ml (1 bottle) per 30 days
Cleocin-T gel 1% (clindamycinphosphate)
Quantity Limit – 75GM per 30 days
Climara (estradiol td patch) &Climara Pro
Gender Edit – females only, Quantity Limit – 4 per 28 days
Clindagel (clindamycin phosphate) Quantity Limit – 75GM per 30 days
Clindamax (clindamycin phosphate) Quantity Limit – 75GM per 30 days
Clonazepam ODTQuantity Limit – 0.125 mg, 0.25 mg, 0.5 mg, 1 mg = 90 per 30days; 2 mg = 300 per 30 days
Co-Gesic Quantity Limit – 240 per 30 days
Colcrys Quantity Limit – 120 per 30 days
Combigan (brimonidine-timilol) Quantity Limit – 10ml (1 bottle) per 30 days
Combipatch Gender Edit – females only, Quantity Limit – 8 patches per 28days
Combivent Quantity Limit – 3 inhalers per 30 days; aer respimat - 2 inhalersper 30 days
Cometriq Specialty, Prior Authorization, Quantity Limit – 100MG = maxdaily dose 2; 140MG = max daily dose 4; 60MG = max daily dose 3
Concerta (methylphenidate) Quantity Limit – 60 per 30 days; 54mg = 30 per 30 days, StepTherapy
Conzip Prior Authorization, Quantity Limit – 30 per 30 days
Copaxone‡ Specialty, Prior Authorization, Quantity Limit – 1 kit per 30 days;inj = 12 syringes (1 kit) per 30 days
Copegus (ribavirin) Specialty, Prior Authorization
Cordran Quantity Limit – 1 Tape per 30 days; Lot – 120ML per 30 days
Cordran SP Quantity Limit – 60GM per 30 days
Coreg CR Quantity Limit – 60 per 30 days; 80mg = 30 per 30 days, StepTherapy
Corlanor Step Therapy, Quantity Limit – 2 per day
Cosentyx Specialty, Prior Authorization
Cozaar (losartan) Quantity Limit – 100mg = 30 per 30 days; 25mg & 50mg = 60 per30 days
Cresemba Specialty, Prior Authorization
Crestor Quantity Limit – 30 per 30 days
Crinone Gel Gender Edit – Females only
Cromolyn Opth Quantity Limit – 10ml per 30 days
CVS Allergy Tab Quantity Limit – 30 per 30 days
Cycloset Tab Prior Authorization, Quantity Limit – 180 per 30 days
Cymbalta (dulozetine) 30mg only Quantity Limit – 30 per 30 days
Cystaran Prior Authorization
Cyramza Specialty, Prior Authorization
Daliresp Prior Authorization, Quantity Limit – 30 per 30 days
Daklinza Specialty, Prior Authorization, Quantity Limit – 1 tablet per day
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Medication Clinical Edits and GuidelinesDaytrana Dis Quantity Limit – 30 patches per 30 days, Step Therapy
Delzicol Quantity Limit – 180 per 30 days
Delestrogen inj (estradiol valerate) Gender Edit – females only
Depo- Estradiol inj Gender Edit – females only
Depo-Provera injection 150mg/ml Quantity Limit – 1 vial per prescription
Depo-SQ injection Quantity Limit – Max day supply 90
Desoxyn (methamphetamine) Quantity Limit – 150 per 30 days, Step Therapy
Desvenlafax Quantity Limit – 50MG = 1 tablet per day; 100MG = 4 tablets perday
Detrol (tolterodine tartrate) Quantity Limit – 60 per 30 days
Detrol LA (tolterodine tartrate) Quantity Limit – 30 per 30 days
Dexedrine CR (dextroamphetamineSR)
Quantity Limit – 5mg = 60 per 30 days; 10mg = 150 per 30 days;15mg = 120 per 30 days
Dexilant Quantity Limit –30 per 30 days, Step Therapy
Dexrazoxane Specialty, Prior Authorization
Dextroamphetamine sulfate Quantity Limit – 5mg= 60 per 30 days; 10mg = 180 per 30 day
Dextroamphetamine sulfate ER ER 10mg – 150 per 30 days; 15mg = 120 per 30 days; 5mg = 30per 30 days; Sol: 1800ml per 30 days
Diastat Gel (diazepam) Quantity Limit – 2 boxes per fill
Differin (adapalene) Quantity Limit – cream & gel =45gm per 30 days, lot = 59ml per30 days
Diflucan (fluconazole) Quantity Limit – 150mg = 2 tabs per 30 days, females only
Dilaudid (hydromorphone) Quantity Limit – 2mg, 4mg & 8mg = 180 per 30 days
Dilt-CD Quantity Limit – 30 per 30 days
Dilt – XR Quantity Limit – 30 per 30 days
Diltzac Quantity Limit – 30 per 30 days
Diovan Quantity Limit – 30 per 30 days
Diovan HCT (valsartan/hctz) Quantity Limit – 30 per 30 days
Ditropan XL (oxybutin chloride) Quantity Limit – 10MG & 15MG = 60 per 30 days; 5MG = 30 per30 days
Dolgic Plus Quantity Limit – 150 per 30 days
Doral Quantity Limit – 30 per 30 days
Doryx Quantity Limit – Limited to 7 tablets per prescription
Duac gel (clindamycin phosph-benzoyl peroxide)
Quantity Limit – 45GM (1 tube) per 30 days
Duetact (pioglitazone) Quantity Limit – 30 per 30 days
Dulera Quantity Limit – 1 inhaler per 30 days, Step Therapy
Duopa Specialty, Prior Authorization, Quantity Limit – 1 per day
Duragesic (fentanyl patch) Quantity Limit – 100MCG/H & 75MCG/HR: 30 per 30 days,12MCG/HR, 25MCG/HR, 50MCG/HR: 15 per 30 days
Dutoprol Quantity Limit – 60 per 30 days
Dymista Spray Quantity Limit – 23G (1 bottle) per 30 days
Dysport Specialty, Prior Authorization
Edarbi Step Therapy, Quantity Limit – 30 per 30 days
Edarbyclor Step Therapy, Quantity Limit – 30 per 30 days
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Medication Clinical Edits and GuidelinesEdluar Sub Step Therapy, Quantity Limit – 30 per 30 days
Effexor XR (venlafaxine) Quantity Limit – 37.5MG = 30 per 30 days; 150MG = 60 per 30days; 75MG = 90 per 30 days
Effient Quantity Limit – 30 per 30 days
Egrifta Specialty, Prior Authorization, Quantity Limit – inj = max dailydose 2 vials; sol = max daily dose 1 vial
Elaprase Specialty, Prior Authorization
Elelyso Specialty, Prior Authorization
Elenzapatch Quantity Limit – max daily dose 4
Elestat (epinastine) Quantity Limit – 5ml (1 bottle) per 30 days
Elidel 1% cream Quantity Limit – 100gm (1 tube) per 30 days, Age edit, StepTherapy
Eligard Specialty, Prior Authorization
Ella Tab 30mg Quantity Limit – 1 per fill, Gender edit – females only
Eloctate Specialty, Prior Authorization
Emadine sol 5% OP Quantity Limit – 5ml (1 bottle) per 30 days
Emend Prior Authorization, Quantity Limit – 125MG & 40MG = 1 per fill,80mg = 2 per fill, PAK 80MG & 125MG = 3 per fill
Emend inj Specialty, Prior Authorization, Quantity Limit – 2 vials per fill
Enablex Quantity Limit – 30 per 30 days
Enbrel ‡ Specialty, Prior Authorization, Quantity Limit – 25mg = 8 per 28days, 50mg = 4 per 30 days
Endocet Quantity Limit – 10/325mg, 5/325mg, 7.5/325mg = max dailydose 12, 7.5/500mg = max daily dose 8, 10/650mg = max dailydose 6
Enjuvia Quantity Limit – 30 per 30 days, Gender edit – Females only
Entresto Prior Authorization, Quantity Limit – 2 tablets per day
Entyvio Specialty, Prior Authorization
Envarsus XR Specialty, Prior Authorization, Quantity Limit – 1 per day
Epiduo Quantity Limit – 45gm (1 tube) per 30 days
Epinephrine Quantity Limit – 2 pens per fill, 0.15mg, Step Therapy
Epipen Quantity Limit – 2 per fill
Epivir HBV ‡ Specialty, Safety edit for Hepatitis B duplicate therapy
Epogen Specialty, Prior Authorization
Eprosartan Quantity Limit – 30 per 30 days
EQ Allergy-D, EQL All Day Aller D,EQL All Day
Quantity Limit – Allergy D = 60 per 30 days, EQL Aller D = 60 per30 days, EQL All Day – 30 per 30 days
Erbitux Specialty, Prior Authorization
Erivedge Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Erythromycin/colchicine Erythromycin will reject if colchicine products are in theprescription profile in the last 120 days. Colchicine products willreject if erythromycin is in the prescription profile in the last 120days
Esbriet Specialty, Prior Authorization
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Medication Clinical Edits and GuidelinesEsgic & Esgic Plus (butalbital-APAP-caf)
Quantity Limit – 180 per 30 days
Esomeprazole Quantity Limit – 30 per 30 days, Step Therapy
Estazolam Quantity Limit – 30 per 30 days
Estrace (estradiol) Gender Edit – females only, Quantity Limit – 30 per 30 days
Estrasorb Gender Edit – females only, Quantity Limit – 60 pouches per 30days
Estring Quantity Limit – one ring per 90 days, Gender Edit – females only
Estrogel Quantity Limit – 50 G per 30 days, Gender Edit – females only
Estrogen, Estrogen + Progestin Gender Edit – females only
Euflexxa‡ Specialty, Prior Authorization
Evamist Gender Edit – females only, Quantity Limit – 16.2ml per 30 days
Evekeo Quantity Limit – 6 per day
Evoclin (clindamycin phosphatefoam)
Quantity Limit – 50gm per 30 days
Evzio Prior Authorization, Quantity Limit – 4 syringes (2 boxes) per Rx
Exalgo Quantity Limit – 180 per 30 days
Exelon (rivastigmine) Age Limit – > 40 years old
Exforge (amlodipine/valsartan) Quantity Limit – 30 per 30 days, Step Therapy
Exforge HCT(amlodipine/valsartanhct)
Quantity Limit – 30 per 30 days, Step Therapy
Extavia Specialty, Prior Authorization, Quantity Limit – 15 vials per 28days.
Fabior Quantity Limit – 100 gm per 23 days, Age Edit
Fabrazyme Specialty, Prior Authorization
Factive Quantity Limit – 7 per fill
Fanapt & Fanapt PAK Quantity Limit – 60 per 30 days, 1 pak (8 tablets) per fill, StepTherapy
Farxiga Quantity Limit – 30 per 30 days, Step Therapy
Farydak Specialty, Prior Authorization
Fazaclo ODT Quantity Limit – 100mg = 270 per 30 days, 12.5mg, 150mg &200mg = 90 per 30 days
FBL Kit CRE 15-4-5% Prior Authorization
Felbatol (felbamate) Prior Authorization
Felodipine Quantity Limit – 30 per 30 days
Femara (letrozole) Prior Authorization
Femhrt Gender Edit – females only, Quantity Limit – 30 per 30 days
Femring Gender Edit – females only, Quantity Limit – 1 ring per 84 days
Fenoglide Quantity Limit – 40mg= 60 per 30 days, 120mg = 30 per 30 days
Fentora Prior Authorization, Quantity Limit – 120 per 30 days
Ferriprox Specialty, Prior Authorization
Fetzima Quantity Limit – 30 per 30 days, Step Therapy
Fibricor (fenofibric) Quantity Limit – 35mg = 60 per 30 days, 105mg = 30 per 30 days.
Finacea gel Quantity Limit – 50gm per 30 days
Finacea Kit Quantity Limit – 1 kit per 30 days, Step Therapy
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Medication Clinical Edits and GuidelinesFioricet w/Codeine Quantity Limit – 180 per 30 days
Fiorinal (butalbital-ASA- caffeine) Quantity Limit – 180 per 30 days
Fiorinal/Cod Cap(butalbital/ASA/caf/cod)
Quantity Limit – 180 per 30 days
Firazyr Specialty, Prior Authorization
Firmagon Specialty, Prior Authorization
Flebogamma Specialty, Prior Authorization
Flector Patch Quantity Limit – 60 patches per 30 days
Flolan (epoprostenol) Specialty, Prior Authorization
Flomax (tamsulosin) Gender Edit – Males only, Quantity Limit – 60 per 30 days
Flonase (fluticasone) Nasal Inhaler Quantity Limit – 1 inhaler per 30 days
Flovent Diskus Quantity Limit – 50mcg & 100mcg= 120 blisters per 30 days.250mcg diskus = 240 blisters per 30 days
Flovent HFA Inhaler Quantity Limit – 2 inhalers per 30 days
Flunisolide Spray Quantity Limit – 1 inhaler per 30 days
Flurazepam Prior Authorization, Quantity Limit – 30 per 30 days
Focalin (dexmethylphenidate) Quantity Limit – 2.5mg & 5mg = 90 per 30 days, 10mg = 60 per 30days
Focalin XR Quantity Limit – 5mg, 10mg, 15mg, 25mg, 30mg, 35mg, & 40mg =30 per 30 days; 20mg = 60 per 30 days, Step Therapy
Follistim AQ Specialty, Prior Authorization
Folotyn Specialty, Prior Authorization
Foradil Quantity Limit – 60 capsules per 23 days, Step Therapy
Foradil /Advair Foradil will reject if Advair is in the prescription profile in the last90 days.
Forfivo XL Quantity Limit – 30 per 30 days
Fortamet (Metformin) Quantity Limit – 500mg = 150 per 30 days, 1000mg 60 per 30days
Forteo ‡ Specialty, Prior Authorization
Fortesta Prior Authorization, Gender Edit – males only, Quantity Limit –120G per 30 days
Fortical Quantity Limit – 1 bottle (3.7ml) per 30 days
Fosamax (alendronate) Quantity Limit – 70mg & 35mg = 4 per 28 days, 5mg & 10 mg = 1per 28 days
Fosinopril Quantity Limit – 30 per 30 days
Frova Quantity Limit – 9 tablets per 30 days
Fuzeon Specialty, Quantity Limit – Max daily dose 2 vials
Fycompa Quantity Limit – 30 per 30 days
Gamastan SD Specialty, Prior Authorization
Gammagard, Gammgard SD Specialty, Prior Authorization
Gammaked Specialty, Prior Authorization
Gammaplex Specialty, Prior Authorization
Gamunex C Specialty, Prior Authorization
Gattex Specialty, Prior Authorization
Gazyva Specialty, Prior Authorization
MRX0103_0116
- 12 -
Medication Clinical Edits and GuidelinesGelnique Step Therapy, Quantity Limit – 10% = max daily dose 1 sachet; 3%
= 92 G (1 bottle) per 30 days
Gel-One Specialty, Prior Authorization
Giazo Quantity Limit – 180 per 30 days, Gender Edit – Males only
Generess FE Gender Edit
Genotropin Specialty, Prior Authorization
Geodon (ziprasidone) Step Therapy, Quantity Limit – 60 per 30 days
Gilenya Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Gilotrif Prior Authorization, Quantity Limit – 30 per 30 days
Glassia Specialty, Prior Authorization
Gleevec‡ Specialty, Prior Authorization, Quantity Limit – 100mg= 240 per30 days, 400mg = 60 per 30 days
Glucophage (metformin) Quantity Limit – 500mg= 150 per 30 days, 850mg = 90 per 30days, 1000mg = 60 per 30 days
Glucophage XR (metformin XR) Quantity Limit – 500mg = 120 per 30 days, 750mg = 60 per 30days
Glucovance (metformin-glyburide) Quantity Limit – 2.5-500mg & 5-500mg = 120 per 30 days
Glumetza Quantity Limit – 500mg = 120 per 30 days, 1000mg = 60 per 30days
Glyset Quantity Limit – 90 per 30 days
Gonal- F‡ & Gonal F RFF‡ Specialty, Prior Authorization, F RFF – Gender Edit – females only
Gralise Step Therapy, Quantity Limit – 300mg = 30 per 30 days, 600mg =90 per 30 days
Granisol Quantity Limit – 30ml per 30 days
Granix Specialty, Prior Authorization
Grastek Prior Authorization, Quantity Limit – 1 tablet per day
Halaven Specialty, Prior Authorization
Halcion (triazolam) Quantity Limit – 60 per 30 days
Harvoni Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Helidac Quantity Limit – Limited to 224 tablets per 365 days
Hetlioz Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Hepsera (adefovir dipivoxil) Specialty, Safety edit for Hepatitis B duplicate therapy
Herceptin Specialty, Prior Authorization
Hizentra Specialty, Prior Authorization
Horizant Quantity Limit – 300MG = 60 per 30 days; 600MG = 30 per 30days
Humatrope Specialty, Prior Authorization
Humira‡ Specialty, Prior Authorization, Quantity Limit – 2 syringes every28 days
Hyalgan Specialty, Prior Authorization
Hycamtin Specialty, Prior Authorization
Hycet (hydrocodone-acetaminophen)
Quantity Limit – 4,200ml per 30 days
HyQvia Specialty, Prior Authorization
MRX0103_0116
- 13 -
Medication Clinical Edits and GuidelinesHyzaar (losartan hctz) Quantity Limit – 50/12.5mg = 60 per 30 days, 100/12.5mg &
100/25mg = 30 per 30 days
Ibudone 5-200mg (hydrocodone-ibuprofen)
Quantity Limit – 180 per 30 days
Ibrance ‡ Specialty, Prior Authorization
Iclusig Specialty, Prior Authorization, Quantity Limit – 15MG = 60 per 30days 45MG = 30 per 30 days
Ilaris Specialty, Prior Authorization, Quantity Limit – 2 vials per 56 days
Ilevro Quantity Limit – 1.7ML per 30 days
Imbruvica Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Imitrex injection (sumatriptan) Quantity Limit – 5ML per 30 days
Imitrex tablets (sumatriptan) Quantity Limit – 9 tablets per 30 days
Imitrex Nasal Spray (sumatriptan) Quantity Limit – 6 nasal inhalers per 30 days
Incivek ‡ Specialty, Prior Authorization, Quantity Limit – 180 per 30 days
Increlex Specialty, Prior Authorization
indomethacin Quantity Limit – 75mg = 60 per 30 days
Indocin suppository Quantity Limit – 120 per 30 days
Infergen Specialty, Prior Authorization
Inlyta Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Intermezzo Sub Quantity Limit – 30 per 30 days, Step Therapy
Intron-A Specialty, Prior Authorization, Safety edit Hepatitis B duplicatetherapy
Intuniv (guanfacine hcl) Quantity Limit – 30 per 30 days, Age Edit
Invega; Invega Sust Step Therapy
Invega Trinza Prior Authorization, Quantity Limit – 0.0333 per day
Invokana Step Therapy
Iressa Specialty, Prior Authorization, Quantity Limit – 1 per day
Istodax Specialty, Prior Authorization
Ixinity Specialty, Prior Authorization
Jadenu Specialty, Prior Authorization
Jakafi Specialty, Prior Authorization, Quantity Limit- 60 per 30 days
Jalyn Quantity Limit – 30 per 30 days, Gender Edit – Males only
Janumet Quantity Limit – 60 per 30 days
Janumet XR Step Therapy, Quantity Limit – 50/1000 & 50/500 = 60 per 30days, 100/1000 = 30 per 30 days
Januvia Quantity Limit – 30 per 30 days
Jardiance Step Therapy
Jentadueto Step Therapy, Quantity Limit – 60 per 30 days
Jetrea Specialty, Prior Authorization
Jevtana Specialty, Prior Authorization
Jolessa Quantity Limit – max day supply 91, Gender Edit – females only
Jublia Quantity Limit – 4 mls per 30 days, Step Therapy
Juxtapid Specialty, Prior Authorization, Quantity Limit – 10MG & 5MG = 60per 30 days, 20MG = 90 per 30 days
Kadcyla Specialty , Prior Authorization
MRX0103_0116
- 14 -
Medication Clinical Edits and GuidelinesKadian (morphine SR) Quantity Limit – 10mg, 20mg, 30mg, 50mg, 60mg, 80mg & 100mg
= 60 per 30 days, 200mg = 120 per 30 days
Kalbitor Specialty, Prior Authorization
Kalydeco Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Kapvay (clonidine hcl) Quantity Limit – 60 per 30 days, Age Edit, Step Therapy
Kazano Quantity Limit – 60 per 30 days, Step Therapy
Keppra (levatiracetam) Quantity Limit – 250mg= 360 per 30 days, 500mg = 180 per 30days, 750mg = 120 per 30 days, 1000mg= 90 per 30 days, Solution= 946ml per 30 days
Keppra XR (levatiracetam) Quantity Limit – 500mg = 180 per 30 days, 750mg = 120 per 30days
Ketalar (ketamine) IV Prior Authorization
Keytruda Specialty, Prior Authorization
Khedezla Quantity Limit – 100MG = 120 per 30 days, 50MG = 30 per 30days
Kineret Specialty, Prior Authorization, Quantity Limit – 30 syringes per 30days
Kitabis Specialty, Prior Authorization
Klonipin (clonazepam) Quantity Limit – 0.5 mg & 1 mg = 90 per 30 days, 2 mg = 300 per30 days
Kombiglyze Step Therapy, Quantity Limit – 2.5-1000mg = 60 per 30 days, 5-500mg & 5-1000 = 30 per 30 days
Korlym Prior Authorization
Krystexxa Specialty, Prior Authorization, Quantity Limit – 4ml (2 vials) per 30days
Kuvan Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Kynamro Specialty, Prior Authorization
Kyprolis Specialty, Prior Authorization
Lamictal Kits ( IR, XR & ODT) Quantity Limit – 1 kit per fill (28, 35, 49, 56 or 89)
Lamictal XR (lamotrigine) Quantity Limit – 25mg & 50mg = 30 per 30 days, 100mg & 200mg= 90 per 30 days
Lastacaft Step Therapy, Quantity Limit – 3ml per 30 days
Latuda Step Therapy, Quantity Limit – 30 per 30 days
Lazanda Prior Authorization, Quantity Limit – 1 bottle per day
Lemtrada Specialty, Prior Authorization
Lenvima Specialty, Prior Authorization, Quantity Limit – 3 per day
Lescol (fluvastatin) Quantity Limit – 20MG = 30 per 30 days, 40MG = 60 per 30 days,Step Therapy
Lescol XL 80mg Step Therapy
Letairis ‡ Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Leukine Specialty, Prior Authorization
Leuprolide Specialty, Prior Authorization
Levaquin (levofloxacin) Quantity Limit – 21 per fill
Levitra Quantity Limit – 6 per 30 days, Gender Edit – males only, Age Edit
Levofloxacin sol 0.5% Quantity Limit – 10 mL per 23 days
MRX0103_0116
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Medication Clinical Edits and GuidelinesLexapro (escitalopram) Quantity Limit – 5mg & 10mg = 45 per 30 days, 20mg = 30 per 30
days, oral solution = 600ml per 30 days
Lidoderm Patch (lidocaine) Quantity Limit – 90 per 30 days
Lidoprofen Prior Authorization
Linzess Quantity Limit – 30 per 30 days, Step Therapy, Age Edit
Lipitor (atorvastatin) Step Therapy, Quantity Limit – 10MG, 20MG & 40MG = 30 per 30days
Lipofen Quantity Limit – 50mg= 60 per 30 days, 150mg= 30 per 30 days
Liptruzet Quantity Limit – 30 per 30 days
Livalo Quantity Limit – 30 per 30 days
Lofibra (fenofibrate) Quantity Limit – 54mg = 60 per 30 days, 67mg, 134mg, 160mgtablets & 200mg = 30 per 30 days
Lopid (gemfibrizol) 600mg Quantity Limit – 60 per 30 days
Lorazepam Intensol (lorazepamconc)
Quantity Limit – 150ml per 30 days
Lorcet, Lorcet Plus Quantity Limit – 180 per 30 days
Lortab (hydrocodone-acetaminophen)
Quantity Limit – 240 tablets per 30 days
Lo-Seasonique (levonorgesterol- E-estradiol)
Gender Edit (females only), Max day supply 91
Lotensin (benazepril) Quantity Limit – 30 per 30 days
Lotensin HCT (benazepril/hctz) Quantity Limit – 30 per 30 days
Lotrel (amlodipine/benazepril) Quantity Limit – 30 per 30 days
Lotronex Prior Authorization, Gender Edit – Females only, Age Edit
Lovaza (omega-3-acid) Quantity Limit – 120 per 30 days
Lumigan Sol Quantity Limit – 2.5ml per 30 days
Lumizyme Specialty, Prior Authorization
Lunesta (eszopiclone) Quantity Limit – 30 per 30 days, Step Therapy, Age Edit – 3mgonly
Lupaneta Specialty, Prior Authorization
Lupron Depot Products Specialty, Prior Authorization
Lupron Dep- PED‡ Specialty, Prior Authorization
Luvox (fluvoxamine) Quantity Limit – 25mg & 50mg = 30 per 30 days,100mg = 90 per30 days; 150MG = 60 per 30 days
Luvox CR (fluvoxamine) Quantity Limit – 60 per 30 days
Luzu Quantity Limit – 60 grams per 30 days
Lynparza Specialty, Prior Authorization
Lyrica Prior Authorization, Quantity Limit – 225mg & 300mg= 60 per 30days, all other strengths = 90 per 30 days; Sol = 900ml per 30 days
Lysteda (tranexamic acid) Specialty, Gender Edit – females only, Quantity Limit – 30 per 30days
Makena ‡ Specialty, Prior Authorization, Gender Edit – females only
Malarone (atovaquone-proguanil) Prior Authorization
Marqibo Specialty, Prior Authorization
Mavik (trandolapril) Quantity Limit – 30 per 30 days
MRX0103_0116
- 16 -
Medication Clinical Edits and GuidelinesMaxair Autohaler Quantity Limit – 2 inhalers per 30 days
Maxalt; Maxalt MLT (rizatriptanbenzoate)
Quantity Limit – 18 tablets per 30 days
Maxidone (hydrocodone-acetaminophen)
Quantity Limit – 150 per 30 days
Mekinist Specialty, Prior Authorization, Quantity Limit – 0.5MG = 120 per30 days, 2MG = 30 per 30 days
Menest Gender Edit – females only, Quantity Limit – 30 per 30 days
Menopur ‡ Specialty, Prior Authorization, Gender Edit – females only
Menostar Gender Edit – females only, Quantity Limit – 4 patches per 28days
Metadate CD (methylphenidate cr ) Quantity Limit – 30 per 30 days, Step Therapy
Metaglip (glipizide/metformin) Quantity Limit – 2.5-250mg = 240 per 30 days, 2.5-500mg & 5-500mg = 120 per 30 days
Methitest Gender Edit – males only, Prior Authorization
Methylin Chew Quantity Limit – 2.5mg & 5mg = 90 per 30 days; 10mg = 180 per30 days, Step Therapy
Methylin Solution(methylphenidate)
Quantity Limit – 10mg/5ml= 90ml per 30 days
Metozolv ODT Step Therapy, Quantity Limit – 12 weeks per (180 days) oftherapy
Mevacor (lovastatin) Quantity Limit – 20MG = 30 per 30 days, Step Therapy
Miacalcin (calcitonin) Quantity Limit – 1 bottle (3.7mL) per 30 days
Miacalcin inj Specialty
Micardis (telmisartan) Quantity Limit – 30 per 30 days
Micardis HCT (telmisartan HCT) Quantity Limit – 40/12.5mg & 80/25mg =30 per 30 days; 80-12.5mg = 60 per 30 days, Step Therapy
Migranal (dihydroergotaminemesylate)
Quantity Limit – 1 kit = 8 canisters per 30 days
Minivelle Quantity Limit – 8 patches per 28 days, Gender Edit – femalesonly
Mirapex ER Step Therapy, Quantity Limit – 30 per 30 days
Mircera Specialty, Prior Authorization
Mirvaso Prior Authorization, Quantity Limit – 30gm per 30 days
Mitigare Step Therapy, Quantity Limit – 3 per day
Mitoxantrone Specialty, Prior Authorization
Mobic (meloxicam) Quantity Limit – 30 per 30 days, suspension = 300ml per 30 days
Monopril (fosinopril) Quantity Limit – 10 & 20mg = 30 per 30 days
Monovisc Specialty, Prior Authorization
Mozobil Specialty, Prior Authorization
MS Contin (morphine CR) Quantity Limit – 120 per 30 days; 200MG ER – 90 per 30 days
Multaq Prior Authorization
Myalept Specialty, Prior Authorization
Myobloc Specialty, Prior Authorization
Myozyme Specialty, Prior Authorization
MRX0103_0116
- 17 -
Medication Clinical Edits and GuidelinesMyrbetriq Quantity Limit – 30 per 30 days
Naglazyme Specialty, Prior Authorization
Namenda Age Edit, Quantity Limit – 5mg= 90 per 30 days; 10mg = 60 per 30days; Solution = 360ml per 30 days
Namenda XR Quantity Limit – 30 per 30 days, Step Therapy, Age Edit
Naprelan SR Quantity Limit – 375mg = 120 per 30 days, 500mg = 90 per 30days, 750mg = 60 per 30 days
Nasacort AQ nasal (triamcinolone) Quantity Limit – 1 inhaler per 30 days
Nasonex nasal Quantity Limit – 1 inhalers per 30 days
Nesina Quantity Limit – 30 per 30 days, Step Therapy
Natesto Prior Authorization, Step Therapy, Quantity Limit – Three pumps(60 actuations each) per 30 days (21.96 grams per 30 days)
Natpara Specialty, Prior Authorization
Neulasta‡ Specialty, Prior Authorization
Neumega Specialty, Prior Authorization
Neupogen ‡ Specialty, Prior Authorization
Nevanac Quantity Limit – 6ml per 30 days
Nexavar ‡ Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Nexium Quantity Limit – 30 per 30 days, GRA = 60 per 30 days, StepTherapy
Niaspan ER (niacin) Quantity Limit – 500mg= 90 per 30 days, 750mg & 1G= 60 per 30days
Nilandron Specialty, Prior Authorization
Niravam (alprazolam odt) Quantity Limit – 0.25mg , 0.5mg & 1mg = 120 per 30 days, 2mg=150 per 30days
Norco (hydrocodone-acetaminophen)
Quantity Limit – 360 per 30 days
Norditropin ‡ Specialty, Prior Authorization
Noroxin Quantity Limit – 42 per fill
Northera Specialty, Prior Authorization, Quantity Limit – 100mg & 200mg,90 per 30, 300 mg 180 per 30 days
Norvasc (amlodipine) Quantity Limit – 30 per 30 days
Novarel Specialty, Prior Authorization
Novoeight Specialty, Prior Authorization
Nplate Specialty, Prior Authorization
Nucynta Step Therapy, Quantity Limit – 50mg & 75mg= 180 per 30 days,100mg = 210 per 30 days
Nucynta ER Quantity Limit – 60 per 30 days, Step Therapy
Nuedexta Prior Authorization
Nulojix Specialty, Prior Authorization
Nutropin Specialty, Prior Authorization
Nutropin AQ Specialty, Prior Authorization
Nuvigil Prior Authorization
Octagam Specialty, Prior Authorization
Ocudox Quantity Limit – 1 kit per prescription
MRX0103_0116
- 18 -
Medication Clinical Edits and GuidelinesOcufen (flurbiprofen) Quantity Limit – 2.5ml per 23 days
Ocuflox Quantity Limit – 15ml per 23 days
Odomzo Specialty, Prior Authorization, Quantity Limit – 1 per day
Ofev Specialty, Prior Authorization, Quantity Limit – 2 per day
Ofirmev Quantity Limit – 400ml/day
Oleptro Quantity Limit – 30 per 30 days
Olysio Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Omeclamox Quantity Limit – Limited to 80 per 365 days
Omnaris Quantity Limit – 1 inhaler per 30 days
Omnitrope Specialty, Prior Authorization
Omontys Specialty, Prior Authorization
Onfi Specialty, Prior Authorization
Onglyza Quantity Limit – 30 per 30 days
Onmel Prior Authorization
Onsolis Prior Authorization, Quantity Limit – 120 films per 30 days
Opana (oxymorphone) Quantity Limit – 360 per 30 days
Opana ER (oxymorphone ER) Quantity Limit – 120 per 30 days
Opdivo Specialty, Prior Authorization
Opsumit Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Optivar (azelastine) Quantity Limit – 1 bottle per month (6ml)
Oralair Sub Prior Authorization
Oral contraceptives Gender Edit – Females only
Oramorph SR (morphine sulfate) Quantity Limit – 15mg, 30mg, 60mg = 120 per 30 days, 100mg =180 per 30 days, 200 mg 90 per 30 days
Oracea Quantity Limit – 30 per 30 days
Oravig Quantity Limit – 1 per prescription
Orencia Specialty, Prior Authorization, Quantity Limit – 4 syringes per 30days
Orenitram Specialty, Prior Authorization
Orfadin Specialty, Prior Authorization
Orkambi Specialty, Prior Authorization, Quantity Limit – 4 per day
Ortho Evra Gender Edit – Females only
Orthovisc Specialty, Prior Authorization
Oseni Quantity Limit – 30 per 30 days, Step Therapy
Otrexup Prior Authorization
Otezla Specialty, Prior Authorization, Quantity limit – Starter pack=27tablets per lifetime, 30MG = 60 per 30 days
Ovidrel ‡ Specialty, Prior Authorization
Oxandrolone & oxymetholone Gender Edit – Males only
Oxazepam Quantity Limit – 120 per 30 days
Oxecta Quantity Limit – 240 per 30 days
Oxycodone (immediate release) Quantity Limit – 240 per 30 days
Oxycontin (oxycodone time release) Step Therapy, Quantity Limit – 120 per 30 days
Oxytrol Dis Quantity Limit – 10 patches per 30 days
Pancreaze Step Therapy
MRX0103_0116
- 19 -
Medication Clinical Edits and GuidelinesPatanase Quantity Limit – 1 inhaler per 30 days (31Gm)
Patanol Quantity Limit – 1 bottle per month (5ml)
Paxil (paroxetine) Quantity Limit – 10mg = 45 per 30 days, 20mg = 30 per 30 days,30 & 40mg = 60 per 30 days, oral suspension 1260ml per 30 days
Paxil CR (paroxetine) Quantity Limit – 12.5mg = 30 per 30 days, 25mg & 37.5mg = 60per 30 days
Pazeo Quantity limit – 0.1 ml per day
Pegasys Specialty, Prior Authorization, Safety Edit – Hepatitis B duplicatetherapy
Peg-Intron ‡ Specialty, Prior Authorization
Penlac (ciclopirox) Prior Authorization, Quantity Limit – 1 bottle per prescription fill
Percocet (oxycodonew/acetaminophen)
Quantity Limit – 7.5/500 = 240 per 30 days, 10/650mg = 180 per30 days, 2.5/325, 5/325, 7.5/325 & 10/325 = 360 per 30 days
Perforomist Quantity Limit – 120mls per 30 days
Perjeta Specialty, Prior Authorization
Pertzye Step Therapy
Pexeva Quantity Limit – 30 per 30 days
Phrenilin Tab & Forte (butalbital-APAP)
Quantity Limit – 180 per 30 days
Picato Step Therapy
Plan B One Step (levonorgestrel) Quantity Limit – 1.5MG = 2 per 30 days, Age Edit, Gender Edit –females only
Plavix (clopidogrel) Quantity Limit – 300mg = 3 per RX fill, 75mg = 30 per 30 days.
Plegridy ‡ Specialty, Prior Authorization, Quantity Limit – 2 (1 pak) per 30days, 1 (1 start pak) lifetime
Pomalyst Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Ponstel (mefenamic) Quantity Limit – 150 per 30 days
Potiga Prior Authorization, Quantity Limit – 90 per 30 days; 50MG = 270per 30 days
Pradaxa Prior Authorization, Quantity Limit – 60 per 30 days
Praluent ‡ Specialty, Prior Authorization, Quantity Limit – 2 pens/ syringesfor 30 days
PrandiMet Quantity Limit – 150 per 30 days
Prandin (repaglinide) Quantity Limit – 0.5mg & 1mg= 120per 30 days, 2mg = 240 per30days
Pravachol (pravastatin) Step Therapy, Quantity Limit – 20MG & 40MG = 30 per 30 days
Precose (acarbose) Step Therapy, Quantity Limit – 25mg = 360 per 30 days, 50mg =180 per 30 days, 100mg = 90 per 30 days
Prefest Gender Edit – females only, Quantity Limit – 30 per 30 days
Pregnancy Category X Claim will reject for Category X drugs when member is receivingprenatal vitamins. Warning message will be transmitted topharmacy for members receiving prenatal vitamins and CategoryC&D drugs.
Pregnyl Specialty, Prior Authorization
Premarin Gender Edit – females only, Quantity Limit – 30 per 30 days
MRX0103_0116
- 20 -
Medication Clinical Edits and GuidelinesPremphase Gender Edit – females only, Quantity Limit – 30 per 30 days
Prempro Gender Edit – females only, Quantity Limit – 30 per 30 days
Prevacid (lansoprazole) Quantity Limit – 30 per 30 days, Step Therapy
Prevpac(amoxicillin/clarithro/lansoproaz)
Quantity Limit – Limited to 112 per 365
Priftin Quantity Limit – 32 tablets per 28 days
Prilosec (omeprazole) Quantity Limit – 30 per 30 days, Step Therapy
Prinivil (lisinopril) Quantity Limit – 30 per 30 days
Prinzide (lisinopril-hctz) Quantity Limit – 30 per 30 days
Pristiq Quantity Limit – 120 tablets per 30 days
Privigen Specialty, Prior Authorization
ProAir HFA Quantity Limit – 2 inhalers per 23 days
Procardia XL (nifedipine) Quantity Limit – 30 per 30 days
Procentra (dextroamphetamine) Quantity Limit – 1800ml per 30 days, Step Therapy, Age Edit
Procrit‡ Specialty, Prior Authorization
Prolastin & Prolastin C Specialty, Prior Authorization
Prolensa Quantity Limit – Limited to 3 mL per 180 days
Proleukin Specialty, Prior Authorization
Prolia Specialty, Prior Authorization, Quantity Limit – 1 vial per 135 days
Promacta Specialty, Prior Authorization
Promethazine (all products) Age Limitation – Members under 2 years of age are not permittedto get products containing promethazine
Protonix (pantoprazole) Quantity Limit – 30 tablets per 30 days, Step Therapy
Protopic Age Edit, Step Therapy, Quantity Limit – 100g (1 tube) per 30 days
Provenge Specialty, Prior Authorization
Proventil HFA Step Therapy, Quantity Limit – 2 inhalers per 23 days
Provigil (modafinil) Prior Authorization, Quantity Limit – 30 per 30 days
Prozac (fluoxetine) Quantity Limit – 20mg = 120 per 30 days, 40mg = 60 per 30 days,90mg weekly = 4 per 28 days
Pulmicort respules Quantity Limit – 2 boxes per 30 days, 2 inhalers per 30 days
Pulmozyme Specialty, Prior Authorization, Quantity Limit – 150 ml (60ampules) per 30 days
Pylera Quantity Limit – Limited to 120 per 365 days
Qnasl Aeresol Quantity Limit – Max daily dose 0.3
Qsymia Prior Authorization, Quantity Limit – 30 per 30 days
Qualaquin (quinine sulfate) Prior Authorization, Quantity Limit – 42 per year
Quillivant Quantity Limit – 360 ml per 30 days, Step Therapy
QVAR inhaler Quantity Limit – 40mcg = 2 per 30 days, 80mcg = 3 inhalers per 30days
Ragwitek Prior Authorization, Quantity Limit – 30 per 30 days
Rapaflo Quantity Limit – 30 per 30 days, Step Therapy, Gender Edit –males only
Rasuvo Specialty, Prior Authorization, Quantity Limit – 1 injection per 7days
Ravicti Prior Authorization
MRX0103_0116
- 21 -
Medication Clinical Edits and GuidelinesRazadyne & ER (galantamine) Age Edit: > 40 years old
Rebetol Solution Specialty, Prior Authorization
Rebif Specialty, Prior Authorization, Quantity Limit – 6ml per 28 days,titration = 1 kit (4.2ml) per 365 days
Regranex Quantity Limit – 2 tubes (30 grams) per month
Relenza inhaler Quantity Limit – 40 per 365 days
Relistor Prior Authorization
Relpax Quantity Limit – 12 tablets per 30 days
Remicade ‡ Specialty, Prior Authorization
Remodulin Specialty, Prior Authorization
Repatha ‡ Specialty, Prior Authorization, Quantity Limit – 2 pens/ syringesfor 30 days
Reprexain (hydrocodone/Ibuprofen) Quantity Limit – 2.5/200MG = 150 per 30 days; 5/200MG = 180per 30 days
Repronex Specialty, Prior Authorization, Gender Edit – females only
Requip XL (ropinirole) Quantity Limit – 30 per 30 days, Step Therapy
Rescula Quantity Limit – 5ml per 30 days
Rexulti Prior Authorization, Quantity Limit – 1 per day
Risperdal Inj Quantity Limit – 2 vials per 21 days retail
Restasis Prior Authorization
Restoril (temazepam) Quantity Limit – 30 per 30 days
Retin-A-Micr Gel (tretinoin) Quantity Limit – 50 gm per 30 days
Revatio (sildenafil citrate) Specialty, Prior Authorization, Quantity Limit – 20MG = 90 per 30days, Age Edit
Revlimid Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Rhinocort Aqua nasal inhaler Quantity Limit – 17.2gm (2 bottles) per 23 days at retail
RibaPak Specialty, Prior Authorization
RibaSphere‡ Specialty, Prior Authorization
RibaTab‡ Specialty, Prior Authorization
Ribavirin 200mg caps‡ Specialty, Prior Authorization
Riomet Quantity Limit – 750ml per 30 days (oral solution)
Ritalin (methylphenidate) Quantity Limit – 5mg & 20mg = 90 per 30 days; 10mg = 150 per30 days
Ritalin LA (methylphenidate LA) Quantity Limit – 10mg, 20mg & 40mg = 30 per 30 days, 30mg = 60per 30 days, Step Therapy
Ritalin SR (methylphenidate SR) Quantity Limit – 20mg = 90 per 30 days, Age Edit
Rituxan Specialty, Prior Authorization
Roxicet 5-500 Quantity Limit – 360 per 30 days
Roxicet Solution Quantity Limit – 62ml per day
Roxicodone (oxycodone) Quantity Limit – 240 per 30 days
Rozerem Quantity Limit – 30 tablets per 30 days, Step Therapy
Ruconest Specialty, Prior Authorization
Sabril Specialty, Prior Authorization, Quantity Limit – 180 per 30 days
Safyral Gender Edit – females only
Saizen Specialty, Prior Authorization
MRX0103_0116
- 22 -
Medication Clinical Edits and GuidelinesSamsca Specialty, Prior Authorization, Quantity Limit – 15mg = 30 per 30
days, 30mg = 60 per 30 days
Sancuso Specialty, Quantity Limit – 1 per fill
Sandostatin (octreotide) Specialty, Prior Authorization
Saphris Quantity Limit – 60 per 30 days, Step Therapy
Savella Step Therapy, Quantity Limit – 60 per 30 days
Savella Mis Titr Pak Quantity Limit – 55 tablets (1 pack) per prescription
Savaysa Prior Authorization
Selzentry ‡ Specialty, Prior Authorization
Serevent Diskus Quantity Limit – 60 inhalations per 30 days
Serevent /Advair Serevent will reject if Advair is in the member’s prescriptionprofile in the last 90 days
Serostim Specialty, Prior Authorization, Quantity Limit – max daily dose 1per day
Signifor, LAR Specialty, Prior Authorization
Silenor Quantity Limit – 30 per 30 days
Simbrinza Quantity Limit – 8 ml per 30 days
Simcor Quantity Limit – 500-40 & 1000-40 = 30 per 30 days; 1000-20,500-20 & 750-20 = 60 per 30 days, Step Therapy
Simponi Specialty, Prior Authorization, Quantity Limit – 1 syringe permonth
Singulair (montelukast) Quantity Limit – 30 per 30 days
Sirturo Prior Authorization
Sivextro Tab Prior Authorization, Quantity Limit – 6 does per Rx
Solaraze gel (diclofenac sodium) Quantity Limit – 100 grams per 30 days
Somatuline Specialty, Prior Authorization
Somavert Specialty, Prior Authorization
Somnote (chloral hydrate) Prior Authorization
Sonata (zaleplon) Quantity Limit – 30 per 30 days, Step Therapy
Soriatane (acitretin) Quantity Limit – 17.5mg & 22.5mg = 60 per 30 days; 10mg = 120per 30 days
Sovaldi Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Spiriva Quantity Limit – 1 inhaler per 30 days
Sprix Quantity Limit – max day supply 5
Sprycel Specialty, Prior Authorization, Quantity Limit – 20mg = 270 per 30days; 50mg = 90 per 30 days; 70mg & 80mg = 60 per 30 days;100mg & 140mg = 30 per 30 days
Starlix (nateglinide) Quantity Limit – 90 per 30 days, Step Therapy
Staxyn Quantity Limit – 6 per 30 days, Gender Edit – Males only, Age Edit
Stelara Specialty, Prior Authorization, Quantity Limit – 45mg = 0.5ml per12 weeks, 90mg = 1ml per 12 weeks
Stendra Quantity Limit – 6 per 30 days, Age Edit, Gender Edit – Males only
Stiolto Respimat Step Therapy, Quantity Limit – 0.134 per day
Stivarga Specialty, Prior Authorization, Quantity Limit – 180 per 30 days
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Medication Clinical Edits and GuidelinesStrattera Quantity Limit – 40mg, 60mg, 80mg & 100 mg = 30 per 30 day;
10mg, 18mg & 25mg = 60 per 30 days, Age Edit
Striant Prior Authorization, Quantity Limit – 60 per 30 days, Gender Edit– Males only
Striverdi Respimat Quantity Limit – 1 inhaler per 30 days, Step Therapy
Suboxone, Suboxone Mis Prior Authorization, Quantity Limit – 0.5mg, 8-2mg, 2-0.5mg, &8.2mg = 90 per 30 days; 12-3mg & 4-1 = 60 per 30 days
Subsys Prior Authorization, Quantity Limit – max daily dose of 12 per day
Suclear Quantity Limit – 2480 mL (1 kit) per rx
Sumavel DosePro Quantity Limit – 4ml per 30 days
Supartz Specialty, Prior Authorization
Suprax suspension Quantity Limit – 1200ml per 3 months
Suprep Bowel Quantity Limit – 354ml per RX
Sutent Specialty, Prior Authorization, Quantity Limit – 12.5mg = 210 per30 days, 25mg = 90 per 30 days, 37.5 mg = 1 per day, 50mg = 30per 30 days
Sylatron Specialty, Prior Authorization
Sylvant Specialty, Prior Authorization
Symbicort Quantity Limit – 1 inhaler per 30 days, Duplicate Therapy Edit –Foradil and Serevent
Synribo Specialty, Prior Authorization
Synagis Specialty, Prior Authorization
Synvisc ‡ , Synvisc ONE ‡ Specialty, Prior Authorization
Taclonex Quantity Limit – 60 gm per 23 days
Tafinlar Specialty , Prior Authorization, Quantity Limit – 50mg = 6 capsulesper day; 75mg = 4 capsules per day
Tamiflu Quantity Limit – 10 capsule per fill/ 2 fills per year; 180ml per 30days
Tanzeum Quantity Limit – 4 pens/vials per 30 days, Step Therapy
Tarceva Specialty, Prior Authorization, Quantity Limit – 25mg = 180 per 30days, 100mg & 150mg = 30 per 30 days
Targretin capsules Specialty, Prior Authorization
Targretin gel Prior Authorization
Tasigna ‡ Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Tazorac Quantity Limit – 30 gm per 23 days
Tecfidera ‡ Specialty, Prior Authorization, Quantity Limit – 2 capsules per day
Technivie Specialty, Prior Authorization, Quantity Limit – 56 per 30 days
Tekamlo Quantity Limit – 30 per 30 days
Tekturna, Tekturna HCT Quantity Limit – 30 per 30 days, Step Therapy
Temodar ‡ (temozolomide) Specialty, Prior Authorization
Terazol (terconazole) Quantity Limit – 1 box per prescription, Gender Edit – femalesonly
Testim Prior Authorization, Quantity Limit – 300G per 30 days, GenderEdit – males only
Testopel Specialty, Prior Authorization, Gender Edit – males only
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Medication Clinical Edits and GuidelinesTestosterone Gender edit: Males only
Testred Prior Authorization, Gender Edit – males only
Teveten (eprosartan) Quantity Limit – 600mg = 30 per 30 days
Teveten HCT Quantity Limit – 30 per 30 days
Tev-tropin Specialty, Prior Authorization
Thalomid Specialty, Prior Authorization, Quantity Limit – 50mg & 100mg=120 per 30 days, 150mg & 200mg = 240 per 30 days
Tiazac (diltiazem) Quantity Limit – 30 per 30 days
Ticlid (ticlopidine) Quantity Limit – 60 per 30 days.
Tirosint Quantity Limit – 30 per 30 days
Tobi (tobramycin) Specialty, Prior Authorization
Tobradex ST Quantity Limit – 20ml per RX
Tolazamide Quantity Limit – 250mg= 120 per 30 days, 500mg = 60 per 30 days
Tolbutamide Quantity Limit – 180 per 30 days
Toradol (ketorolac)injection Quantity Limit – 15mg/ml = 40ml per 23 days, 30mg/ml = 20mlper 23 days
Toradol (ketorolac) tablets Quantity Limit – 20 tablets per 30 days
Torisel Specialty, Prior Authorization, Quantity Limit – 8ml per 28 days
Totec (dexrazoxane) Specialty, Prior Authorization
Toujeo Step Therapy
Toviaz Quantity Limit – 30 per 30 days
Tracleer ‡ Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Tradjenta Step Therapy, Quantity Limit – 30 per 30 days
Tranxene T (clorazepate) Quantity Limit – 3.75mg = 720 per 30 days, 7.5mg= 360 per 30days, 15mg = 180 per 30 days
Travatan Z Quantity Limit – 2.5ml ( 1 bottle) per 30 days
Travoprost Quantity Limit – 5ml per 23 days
Treanda Specialty, Prior Authorization
Tretinoin ‡ Specialty, Prior Authorization, Quantity Limit – 90 per 365 days
Tretten Specialty, Prior Authorization
Treximet Quantity Limit – 9 per 30 days, Step Therapy
Trezix Quantity Limit – max daily dose 11
Tribenzor Quantity Limit – 30 per 30 days, Step Therapy
Tricor (fenofibrate) Quantity Limit – 48mg = 60 per 30 days, 145mg = 30 per 30 days
Triglide Quantity Limit – 160mg = 30 per 30 days
Trilipix (choline fenofribrate) Quantity Limit – 45mg = 60 per 30 days, 135mg = 30 per 30 days
Trisenox Specialty, Prior Authorization
Triumeq Specialty, Prior Authorization
Trulicity Step Therapy
Tudorza Quantity Limit – 1 inhaler per month
Twynsta (telmisartan) Step Therapy, Quantity Limit – 30 per 30 days
Tybost ‡ Specialty, Prior Authorization
Tykerb ‡ Specialty, Prior Authorization, Quantity Limit – 180 per 30 days
Tylenol/Cod (acetaminophenw/codeine)
Quantity Limit – 300-30mg = 360 per 30 days, 300-60= 180 per 30days
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Medication Clinical Edits and GuidelinesTylox (oxycodonew/acetaminophen)
Quantity Limit – 240 per 30 days
Tysabri Specialty, Prior Authorization
Tyvaso Specialty, Prior Authorization, Quantity Limit – 1 vial per day
Uloric Step Therapy, Quantity Limit – 30 per 30 days
Ultracet (tramadol/ acetaminophen) Quantity Limit – 240 per 30 days
Ultram (tramadol) Quantity Limit – 240 per 30 days
Ultram (tramadol) ER Quantity Limit – 30 per 30 days
Ultresa Step Therapy
Uniretic (moexipril-hctz) Quantity Limit – 30 per 30 days
Univasc (moexipril) Quantity Limit – 30 per 30 days
Uribel Quantity Limit – 120 per 30 days
Uroxatral (alfuzosin) Gender edit – Male only, Quantity Limit – 30 per 30 days
Valchlor Specialty, Prior Authorization, Quantity Limit – max daily dose 3
Valcyte Quantity Limit – 120 per 30 days
Vascepa Quantity Limit – 120 per 30 days
Vectibix Specialty, Prior Authorization
Vecamyl Prior Authorization
Velcade Specialty, Prior Authorization
Veletri Specialty, Prior Authorization
Veltin Quantity Limit – 60 G per 30 days
Ventavis Specialty, Prior Authorization, Quantity Limit – 270ml per 30 days
Ventolin HFA Quantity Limit – 2 inhalers per 30 days
Veramyst Quantity Limit – 10 grams (1 bottle) per month
Verelan PM (verapamil) Quantity Limit – 30 per 30 days
Versacloz Quantity Limit – 20ML per day
Vesicare Quantity Limit – 30 per 30 days
Vfend (voriconazole) Quantity Limit – oral solution = 20ml per day, tablets 4 per day
Viagra Quantity Limit – 6 per 30 days, Gender Edit – males only, Age Edit
Vicodin(hydrocodone\acetaminophen)
Quantity Limit – 240 per 30 days
Vicodin ES Quantity Limit – 390 per 30 days
Vicodin HP Quantity Limit – 390 per 30 days
Victoza Quantity Limit – Injection = 9ml per 30 days
Victrelis Specialty, Prior Authorization, Quantity Limit – 360 per 30 days
Viekira Specialty, Prior Authorization, Quantity limit – 4 per day
Vigamox Quantity Limit – 3 ml per 30 days
Viibryd Quantity Limit – 30 per 30 days
Vimovo Quantity Limit – 60 per 30 days, Step Therapy
Viokace Step Therapy
Vitekta ‡ Specialty, Prior Authorization, Quantity Limit – 4 per day
Vivelle Dot Quantity Limit – 8 patches per 28 days, Gender Edit – femalesonly
Vivitrol Specialty, Prior Authorization
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Medication Clinical Edits and GuidelinesVogelxo Prior Authorization, Quantity Limit – 300gms (60 pckts) per 30
days
Voltaren gel Quantity Limit – 1000gm per 30 days
Voltaren (diclofenac) Ophth Quantity Limit – 7.5ml per 30 days
Vopac kit Prior Authorization
Votrient Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Vpriv Specialty, Prior Authorization
Vytorin Step Therapy, Quantity Limit – 30 tablets per 30 days, PriorAuthorization – 80mg only
Vyvanse Quantity Limit – 30 per 30 days
Welchol Quantity Limit – 210 per 30 days
Wellbutrin(bupropion) XL 150mg Quantity Limit – 90 per 30 days
Xalatan (latanoprost) Quantity Limit – 2.5ml per 30 days
Xalkori Specialty, Prior Authorization , Quantity Limit – 60 per 30 days
Xanax (alprazolam) Quantity Limit – 0.25 mg, 0.5 mg & 1 mg = 120 per 30 days, 2mg =150 per 30 days
Xanax XR (alprazolam SR) Quantity Limit – 0.5 mg & 1 mg = 30 per 30 days, 2mg = 150 per30 days, 3mg = 90 per 30 days
Xarelto Prior Authorization – 10MG & 15MG, Quantity Limit – 10MG &20MG = 30 per 30 days; 15MG = 60 per 30 days
Xartemis XR Quantity Limit – 360 per 30 days
Xeljanz Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Xenazine Specialty, Prior Authorization
Xenical Prior Authorization
Xeomin Specialty, Prior Authorization
Xgeva Specialty, Prior Authorization, Quantity Limit – 1.7ml per 28 days
Xigduo XR Step Therapy
Xodol(hydrocodone\acetaminophen)
Quantity Limit – 390 tablets per 30 days
Xofigo Specialty, Prior Authorization
Xolair Specialty, Prior Authorization
Xopenex HFA Quantity Limit – 30 gm (2 inhalers) per 23 days
Xtandi Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Xyrem Specialty, Prior Authorization, Quantity Limit – 3 bottles per 30days
Xyzal (levocetirizine) Quantity Limit – 30 per 30 days; 300ml per 30 days
Yervoy Specialty, Prior Authorization
Yohimbine Gender Edit – Males only
Zaltrap Specialty, Prior Authorization
Zarxio Specialty, Prior Authorization
Zavesca Specialty, Prior Authorization
Zegerid (omeprazole-sodium) Quantity Limit – 40-1680MG only = 30 per 30 days, Step Therapy
Zelboraf Specialty, Prior Authorization, Quantity Limit – 240 per 30 days
Zemaira Specialty, Prior Authorization
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Medication Clinical Edits and GuidelinesZenzedi Quantity Limit – 10MG=180 per 30 days; 2.5MG & 20 MG = 90
per 30 days; 5MG, 15MG & 30MG=60 per 30 days; 7.5MG = 240per 30 days, Age Edit
Zesteril (lisinopril) Quantity Limit – 30 per 30 days
Zestoretic (lisinopril-hctz) 10-12.5mg Quantity Limit – 30 per 30 days
Zetia Step Therapy, Quantity Limit – 30 tablets per 30 days
Zetonna Aeresol Quantity Limit – 1 inhaler per 30 days
Ziana Quantity Limit – 60 G per 30 days
Zinecard (dexrazoxane) Specialty, Prior Authorization
Zioptan Quantity Limit – max daily dose 1
Zipsor Quantity Limit – 120 tablets per 30 days
Zirgan Quantity Limit – 5G per 30 days
Zithromax (azithromycin) Quantity Limit – 250mg = 6 tablets per fill, 5 day therapy, 500mg= 5 tablets per fill, 600mg = 8 tablets per 30 days
Zithromax (azithromycin)Suspension
Quantity Limit – 100mg/5ml = 30ml per fill, 200mg/5ml = 60 mlper fill
Zmax Quantity Limit – 1 per fill
Zocor (simvastatin) Step Therapy, Quantity Limit – 20mg & 40mg=45 per 30 days,5mg & 80mg = 30 per 30 days; Prior Authorization – 80mg only
Zofran (ondansetron) Quantity Limit – 4mg = 18 per 30 days, 8mg = 24 per 30 days, oralsolution = 600ml per 30 days
Zohydro ER Prior Authorization, Quantity Limit – 60 per 30 days
Zolinza Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Zoloft (sertraline) Quantity Limit – 25MG & 50MG = 45 per 30 days; 100MG = 60 per30 days; 20MG/ML = 300ml per 30 days
Zolpimist spr Quantity Limit – 7.7ml per 30 days
Zomig (zolmitriptan) Quantity Limit 6 per 30 days
Zontivity Prior Authorization, Quantity Limit – 30 per 30
Zorbtive Specialty, Prior Authorization, Quantity Limit – 30 vials per 30days
Zortress Specialty, Prior Authorization
Zorvolex Quantity Limit – 90 per 30 days
Zubsolv Prior Authorization, Quantity Limit - 3 tablets per day
Zuplenz Quantity Limit – 4mg = 18 films per 30 days, 8mg = 60 films per 30days
Zyclara Quantity Limit – 56 packets per 60 days
Zydelig Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Zydone Quantity Limit – 10 per day
Zyflo Quantity Limit – 120 per 30 days
Zyflo CR Quantity Limit – 120 per 30 days
Zykadia Specialty, Prior Authorization, Quantity Limit – 150 per 30 days
Zymaxid (gatifloxacin) Quantity Limit – 2.5ml per 23 days
Zyprexa Relprew Quantity Limit – 210mg & 300mg = 2 vials per 28 days, 405mg = 1vial per 28 days
MRX0103_0116
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Medication Clinical Edits and GuidelinesZytiga ‡ Specialty, Prior Authorization, Quantity Limit – 120 tabs per 30
days
Zyvox Quantity Limit – 900ml per fill, 28 tablets per fill
Please Note: Due to varying health benefit plans, inclusion of a drug and related items on the drug list(formulary) is not a guarantee of coverage. Please refer to your prescription drug benefit descriptionof coverage, limitations and exclusions.