Commercial Member Quantity Limits 2008
| Anti-Migraine Agents: |
|
| Amerge |
limited to 9 tablets per month |
| Axert |
limited to 12 tablets per month |
| Frova |
limited to 9 tablets per month |
| Imitrex Nasal Spray |
limited to 6 dosage units per month |
| Imitrex Tablets |
limited to 9 tablets per month |
| Maxalt |
limited to 12 tablets per month |
| Maxalt-MLT |
limited to 12 tablets per month |
| Migranal Nasal Spray |
limited to 8 dosage units per month |
| Relpax |
limited to 6 tablets per month |
| Zomig |
limited to 6 tablets per month |
| Zomig Nasal Spray |
limited to 1 box of 6 per month |
| Zomig-ZMT |
limited to 6 tablets per month |
| Anti-Nausea Agents: |
|
| Anzemet |
limited to 5 tablets per month |
| Emend |
limited to 5 tablets per month |
| Emend |
limited to 1 combo pack per month |
| Kytril |
limited to 10 tablets per month |
| Kytril Solution |
limited to 90 ml per month |
| Zofran |
limited to 6 tablets per month |
| Zofran ODT |
limited to 5 tablets per month |
| Zofran Solution |
limited to 50ml per month |
| Erectile Dysfunction Agents: |
|
| Cialis |
limited to 4 tablets per month |
| Levitra |
limited to 4 tablets per month |
| MUSE Urethral Inserts |
limited to 6 dosage units per month |
| Viagra |
limited to 4 tablets per month |
| Proton Pump Inhibitors: |
|
| Omeprazole 10mg, 40mg |
limited to 30 capsules per month |
| Nexium |
limited to 30 capsules per month |
| Prevacid |
limited to 30 capsules per month |
| Prilosec 10mg, 40mg |
limited to 30 capsules per month |
| Protonix |
limited to 30 tablets per month |
| Sedatives: |
|
| Ambien/zolpidem |
limited to 30 tablets per month |
| Ambien CR |
limited to 30 tablets per month |
| Lunesta |
limited to 30 tablets per month |
| Rozerem |
limited to 30 tablets per month |
| Sonata |
limited to 30 capsules per month |
| Miscellaneous: |
|
| Boniva 150mg |
limited to 1 tablet per month |
| Boniva 2.5mg |
limited to 30 tablets per month |
| Butorphanol NS |
limited to 1 unit per month |
| Celebrex |
limited to 30 capsules per month |
| Combunox |
limited to 30 tablets per 180 days |
| Glucagon Emergency Kit |
limited to 1 kit per month |
| Glucometer |
limited to 1 meter every 999 days |
| Glucometer Strips |
limited to 102 per 30 days |
| Nuvaring |
limited to 1 ring per month |
| Ortho Evra |
limited to 4 patches per month |
| Relenza |
limited to 1 unit per 365 days |
| Sarafem |
limited to 28 tablets per month |
| Tamiflu |
limited to 1 blister pack (10x75mg tablets)
per 365 days |
| Tamiflu Suspension |
limited to 100ml per 365 days |
| Toradol |
limited to 20 tablets per month |
| Vagifem |
limited to 18 tablets per month |
| Valtrex |
limited to 30 tablets per month |
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