Quantity Limits

 

The medication listed below are subject to specific quantity limits. These quantity limits may be in addition to step therapy or prior authorization requirements. Quantity limits apply to both brand and generic versions of the medication unless otherwise specified. Exceptions to the quantity limits may be approved by the Pharmacy Help Desk when clinical circumstance warrant. Please call 1-800-522-0114, option 4.

PHARM-13 Statement of Medical Necessity for Quantity Limits Override

ADHD and Narcolepsy Drugs
Allergy Medications 
Analgesics - Opioids
Analgesics, NSAIDs, and Antipyretics
Antidepressants
Antiemetics
Anti-Infectives
Antimigraine Drugs
Anticonvulsants
Antipsychotic Drugs
Anti-Ulcer Medications
Antiviral Drugs
Arthritis Medications
Asthma and COPD Medications
Benzodiazepine
Biologicals
Diabetic Medications
Insomnia Medications
Irritable Bowel System Medications
Lipid Reducers
Miscellaneous
Muscle Relaxants
Ophthalmic Allergy Products
Ophthalmic Preparations
Osteoporosis Medications
Pediculicide Products
Smoking Cessation
Topical Products 

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