Drug Class and Medication* | Dispensing Limit |
Birth Control |
Nuvaring ring (etonogestrel/ethinyl estradiol) | 1 ring/21 days |
Cushing’s Disease |
Signifor inj (pasireotide) | 60 mL/30 days |
Familial Hypercholesterolemia |
Juxtapid 5 mg, 10 mg caps (lomitapide) | 60 caps/30 days |
Juxtapid 15 mg, 20 mg caps (lomitapide) | 90 caps/30 days |
Kynamro inj (mipomersen) | 4 injections (4 mL)/28 days |
Mental Health Agents |
Clozaril 25 mg, 50 mg tabs (clozapine) | 90 tabs/30 days |
Clozaril 100 mg tabs (clozapine) | 270 tabs/30 days |
Clozaril 200 mg tabs (clozapine) | 120 tabs/30 days |
Fanapt tabs (iloperidone) | 60 tabs/30 days |
Fanapt Titration Pak (iloperidone) | 1 pack (8 tabs)/4 days |
Fazaclo 12.5 mg, 100 mg tabs (clozapine) | 90 tabs/30 days |
Fazaclo 25 mg tabs (clozapine) | 270 tabs/30 days |
Fazaclo 150 mg tabs (clozapine) | 180 tabs/30 days |
Fazaclo 200 mg tabs (clozapine) | 120 tabs/30 days |
Geodon caps (ziprasidone) | 60 caps/30 days |
Invega 1.5 mg, 3 mg, 9 mg tabs (paliperidone) | 30 tabs/30 days |
Invega 6 mg tabs (paliperidone) | 60 tabs/30 days |
Risperdal 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg tabs (risperidone) | 120 tabs/30 days |
Risperdal 3 mg tabs (risperidone) | 60 tabs/30 days |
Risperdal 1 mg/mL soln (risperidone) | 480 mL/30 days |
Risperdal M-Tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg tabs (risperidone ODT) | 60 tabs/30 days |
Risperdal M-Tab 4 mg tabs (risperidone ODT) | 120 tabs/30 days |
Saphris tabs (asenapine sublingual) | 60 tabs/30 days |
Seroquel 25 mg, 50 mg tabs (quetiapine) | 180 tabs/30 days |
Seroquel 100 mg tabs (quetiapine) | 120 tabs/30 days |
Seroquel 200 mg tabs (quetiapine) | 90 tabs/30 days |
Seroquel 300 mg, 400 mg tabs (quetiapine) | 60 tabs/30 days |
Seroquel XR 50 mg, 300 mg, 400 mg tabs (quetiapine ext-release) | 60 tabs/30 days |
Seroquel XR 150 mg, 200 mg tabs (quetiapine ext-release) | 30 tabs/30 days |
Zyprexa 2.5 mg, 5 mg, 7.5 mg, 10 mg tabs (olanzapine) | 60 tabs/30 days |
Zyprexa 15 mg, 20 mg tabs (olanzapine) | 30 tabs/30 days |
Zyprexa Zydis tabs (olanzapine ODT) | 30 tabs/30 days |
Nausea and Vomiting |
Emend 40 mg caps (aprepitant) | 2 caps/30 days |
Emend 80 mg caps (aprepitant) | 6 caps/30 days |
Emend 125 mg caps (aprepitant) | 3 caps/30 days |
Zofran 24 mg tabs (ondansetron) | 4 tabs/30 days |
Pain |
ConZip caps (tramadol ext-release) | 30 caps/30 days |
Embeda caps (morphine/naltrexone) | 60 caps/30 days |
Exalgo (hydromorphone ext-release) | 30 tabs/30 days |
Kadian (morphine ext-release) | 60 caps/30 days |
MS Contin tabs (morphine ext-release) | 90 tabs/30 days |
Opana ER tabs (oxymorphone ext-release) | 60 tabs/30 days |
Oramorph SR tabs (morphine ext-release) | 90 tabs/30 days |
Rybix ODT tabs (tramadol ODT) | 240 tabs/30 days |
Respiratory Agents |
Alvesco inhaler (ciclesonide) | 1 inhaler/Rx |
Flovent Diskus 50 mcg/inhalation, 100 mcg/inhalation inhaler (fluticasone) | 1 inhaler/Rx |
Flovent HFA 44 mcg/actuation, 110 mcg/actuation inhaler (fluticasone) | 1 inhaler/Rx |
Pulmicort Respules 0.25 mg/2 mL, 0.5 mg/2 mL inhal susp (budesonide) | 120 mL/Rx |
Pulmicort Respules 1 mg/2 mL inhal susp (budesonide) | 60 mL/Rx |
Xopenex 0.31 mg/3 mL, 0.63 mg/3 mL, 1.25 mg/3 mL inhal soln (levalbuterol) | 4 boxes (288 mL)/Rx |
Various Skin Conditions |
Picato 0.015% gel (ingenol) | 3 tubes/90 days |
Picato 0.05% gel (ingenol) | 2 tubes/90 days |
Zyclara 2.5%, 3.75% crm (imiquimod) | 7.5 g/Rx; 15 g/6 months |
Zyclara 3.75% packets (imiquimod) | 28 packets/Rx; 56 packets/ 6 months |