To help make the use of prescription drugs safer and more affordable, the Plan includes a Drug Quantity Management program. For certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA).
Drug Quantity Management helps save money in two different ways:
•
If your medicine is available in different strengths, sometimes you could take one dose of a higher strength instead of two or more of a lower strength, which saves money over time because you pay for less pills.•
The program also controls the cost of “extra” supplies that could go to waste in your medicine cabinet. Here is how the program works at the pharmacy:•
When your pharmacist attempts to fill your prescription, the pharmacist will get a message about any applicable quantity limitations for the quantity prescribed. This could mean:-
You are getting your refill too soon; that is, you should still have medicine left from your last supply. In this case, ask your pharmacist when it will be time to get a refill; orrs.
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Your physician wrote you a prescription for a quantity larger than the Plan cove•
If the quantity on your prescription is more than allowed on the benefit, you can:-
Have your pharmacist fill your prescription as written, for the amount the Plan covers and pay the appropriate copayment or coinsurance amount. If you would like the additional quantity prescribed,ur physician. They can discuss changing your prescription to a higher
o ian at 1-800-417-8164, 24 hours a day, seven days a week, so a determination can be made right away.
you have the option to pay the full price.
-
Ask your pharmacist to call yostrength, if one is available.
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Ask your pharmacist to contact your physician about getting a “prior authorization.” That is, your physician can call Express Scripts to request that you receive the original quantity and strength he/she prescribed. During this call, your physician and an Express Scripts representative may discuss how your medical problem requires medicine in larger quantities than the Plan usually covers. They may consider safety issues about the quantity of medicine you receive. The Express Scripts representative will als check Plan guidelines to see if your medicine can be covered for a larger quantity. Express Scripts’ prior authorization is available to your physicFor home delivery, the Express Scripts Home Delivery Pharmacy will try to contact your physician to suggest either changing your prescription to a higher strength or a prior authorization review process. If the Express Scripts Home Delivery Pharmacy does not hear back from your physician within two days, they will fill your prescription for the quantity covered by the Plan. If a higher strength is not available, or the plan does not provide a prior authorization for a higher quantity, the Home Delivery Pharmacy can fill your prescription for the quantity that the Plan covers.
The following medications are covered under this program and the limits listed are based on a 34-day supply: Prescription Medication Maximum Quantity Prescription Medication Maximum Quantity
Actonel 150 mg 1 tablet Lansoprazole 15 mg 34 capsules
Actonel 35 mg 5 tablets Lescol 20 mg 34 capsules
Actonel 5 and 30 mg 34 tablets Lescol 40 mg 68 capsules
Actonel 75 mg 2 tablets Lescol XL 80 mg 34 tablets
Actonel with Calcium tablets 35 tablets Levitra 2.5, 5, 10 and 20 mg 6 tablets Actoplus Met 15/500 mg and
15/850 mg 102 tablets Lioresal Inthrathecal refill kit (1 ampule 10 mg/20 ml, 2 ampules 10 mg/5 ml, 1 ampule 40 mg/20 ml)
1 kit
ActoPlusMet XR 15/1000 mg 68 tablets Lipitor 10, 20, 40 and 80 mg 34 tablets ActoPlusMet XR 30/1000 mg 34 tablets Livalo 1, 2 and 4 mg tablets 34 tablets
Actos 15, 30, 45 mg 34 tablets Lovastatin 10 mg 34 tablets
Adcirca 20 mg 68 tablets Lovastatin 20 and 40 mg 68 tablets
Adrenaclick 0.15 mg, 0.3 mg
single unit carton 3 units (1 package) Lunesta 1 mg, 2 mg, 3 mg 34 tablets Adrenaclick 0.15 mg, 0.3 mg
two-pack 4 units (2 packages) Maxair Autohaler 14 grams 2 inhalers Advair Diskus 100/50, 250/50
and 500/50 with device 14, 28, 120 blisters Maxalt and Maxalt-MLT 5, 10 mg 18 tablets
Advair HFA 2 inhalers Menostar 5 patches
Advicor 500/20 34 tablets Mevacor 10 mg 34 tablets
Advicor 750/20, 1000/20 68 tablets Mevacor 20, 40 mg 68 tablets
Aerobid/Aerobid-M 7 grams 3 inhalers Miconazole See Monistat
Aerospan 80 mcg 5.1 gram 1 inhaler Migranal 4 mg/ml 8 spray devices
Aerospan 80 mcg 8.9 gram 3 inhalers Mobic 7.5 mg 34 tablets
Albuterol generic inhaler 3 inhalers Monistat 1 pre-filled 1 box Alendronate 35 and 70 mg 5 tablets Monistat 3 combination pack
200 mg and equivalent 1 box Alendronate 5, 10 and 40 mg 34 tablets Monistat 3 suppositories 200
mg and equivalent 3 (1 box)
Allegra 180 mg 34 tablets Monistat 7 combination pack
and equivalent 1 box (7 suppositories, 9 gram cream) Allegra 30, 60 mg 68 tablets/orally
disintegrating tablets Monistat 7 cream and equivalent 45 grams (1 tube) Allegra allergy 12 hour 60 mg
tablets 68 tablets Monistat 7 cream pre-filled applicators 7 applicators Allegra allergy 24 hour 180 mg
tablets 34 tablets Monistat 7 suppositories 100 mg and equivalent 7 suppositories (1 box) Allegra children’s allergy 30
mg orally disintegrating tablets
68 tablets Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream)
1 (1 box)
Prescription Medication Maximum Quantity Prescription Medication Maximum Quantity Allegra children’s allergy 30
mg tablets 68 tablets Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream)
1 (1 box)
Allegra-D 12 hour 68 tablets Muse 12 urethral suppositories
Allegra-D 12 hour allergy and
congestion 68 tablets Nasacort 10 gram 3 inhalers
Allegra-D 24 hour 34 tablets Nasacort AQ 16.5 gram 2 bottles
Allegra-D 24 hour allergy and
congestion 34 tablets Nasarel 0.025% 25 ml 3 bottles
Alora 10 patches Nasonex 50 mcg nasal spray 17
gram 2 bottles
Aloxi 0.5 mg 1 capsule NebuPent 300 mg/container 1 container (inhaler) Aloxi injection 0.25 mg/5 ml
and 0.075 mg/1.5 ml 1 vial Neulasta 6 mg/0.6 ml single-dose syringe 2 syringes
Alsuma 6 mg injection 1 kit (2 syringes) Neumega 21 vials
Altoprev 10, 20, 40, 60 mg 34 tablets Newtek disposable blood
glucose meter 2 meters
Alupent 14 grams 3 inhalers Nexium 10 and 20 mg packets 34 packets
Alvesco 160 mcg 3 inhalers Nexium 20 mg 34 capsules
Alvesco 80 mcg 2 inhalers Noverel 10,000 unit 3 vials
Ambien 5, 10 mg 34 tablets Nucynta 50 mg, 75 mg and 100
mg 205 tablets
Ambien CR 6.25 mg and 12.5
mg 34 tablets Omeprazole 10 mg 34 capsules
Amerge 1, 2.5 mg 9 tablets Omeprazole/Sodium
Bicarbonate 20 mg - 1100 mg 34 capsules Anzemet 50, 100 mg 1 tablet Omnaris 50 mcg nasal spray 2 bottles
Arava 10 mg, 20 mg 34 tablets Ondansetron 24 mg 1 tablet
Asmanex 110 inhalation units 1 inhaler Ondansetron solution 4 mg/5
ml 3 - 50 ml bottles
Asmanex 14 inhalation units 1 inhaler Ondansetron, Ondansetron
ODT 4 and 8 mg 12 tablets Asmanex 30, 60, 120
inhalation units 2 inhalers Onglyza 2.5 mg and 5 mg 34 tablets Astelin Nasal Spray (34 ml
bottle) 2 bottles Oxybutynin XL 5 mg 34 tablets
Astepro 137 mcg and 0.15%
nasal spray 2 bottles Oxytrol patch 10 patches
Atelvia 35 mg 5 tablets Pantoprazole 20 mg 34 tablets
Atrovent HFA 12.9 grams 2 inhalers Patanase 0.6% nasal spray 2 bottles Atrovent inhaler 14.7 grams 3 inhalers PEG Intron pens/kit
(containing 1 vial each) 50 mcg, 80 mcg, 120 mcg, 150 mcg
5 pens/vials
Atrovent nasal spray 0.03% (30
grams), generic 2 bottles Pegasys 180 mcg 5 vials (package size 1)
Atrovent nasal spray 0.06% (15
grams), generic 2 bottles Pegasys 180 mcg convenience pack ( 4 vials) 1 box (package size 1) Avandamet 1 mg/500 mg,
2/500, 4/500, 2/1000, 4/1000 68 tablets Pegasys 180 mcg convenience pack (4 prefilled syringes) 1 box (package size 1)
Prescription Medication Maximum Quantity Prescription Medication Maximum Quantity Avandaryl 4 mg/1 mg, 4 mg/2
mg, 4 mg/4 mg, 8 mg/2 mg, 8 mg/4 mg
34 tablets Perforomist inhalation solution 2 cartons (120 vials)
Avandia 2, 4 mg 68 tablets Plan B 2 tablets
Avandia 8 mg 34 tablets Plan B One-Step 1 tablet
Avonex 4 syringes PrandiMet 1 mg/500 mg, 2
mg/500 mg 170 tablets
Axert 12.5 mg 12 tablets Pravachol 10, 20, 40, 80 mg 34 tablets Axert 6.25 mg 6 tablets Pravastatin 10, 20, 40, 80 mg 34 tablets Azithromycin See Zithromax Pravigard PAC 81-20, 325-20,
81-40, 325-40, 81-80 and 325- 80
1 package (package size is 30)
Azithromycin 500 mg 4 tablets Pregnyl 10,000 unit 3 vials
Azmacort 20 grams 3 inhalers Prevacid 15 mg, Prevacid
SoluTab 34 capsules or tablets
Beconase AQ 25 grams 2 inhalers Prevpak patient pack 14 units (1 package) Betaseron 14 or 15 vials with prefilled
diluent syringe (depending on product packaging)
Prilosec 10 mg 34 capsules
Boniva 150 mg 1 tablet Prilosec 10 mg oral suspension
packets 34 packets
Boniva 2.5 mg 34 tablets Prilosec 2.5 mg oral
suspension packets 68 packets Brovana inhalation solution
(30 vial carton) 3 cartons for a 34-day supply Prilosec 20 mg (Brand) 34 capsules Butorphanol tartrate nasal
spray 2 spray bottles Proair HFA 3 inhalers
Byetta 1.2 ml (250 mcg/ml) 2 syringes Protonix 20 mg 34 tablets Byetta 2.4 ml (250 mcg/ml) 2 syringes Proventil HFA 6.7 gram 3 inhalers Cabergoline 0.5 mg 10 tablets Proventil inhaler 17 gram 3 inhalers Caduet 5/10,10/10, 5/20,
10/20, 5/40, 10/40, 5/80, 10/80, 2.5/10, 2.5/20, 2.5/40, 5/20, 5/40 mg
34 tablets Pulmicort Flexhaler 180 mcg 3 inhalers
Cambia 9 packets Pulmicort Flexhaler 90 mcg 2 inhalers
Cardura 1, 2, 4 mg 34 tablets Pulmicort Respules 0.25 mg/2
ml and 0.5 mg/2 ml 70 ampules Cardura 8 mg 68 tablets Pulmicort Respules 1 mg/2 ml 35 ampules Cardura XL 4, 8 mg 34 tablets Pulmicort Turbuhaler 2 inhalers Catapres-TTS patches 5 patches Qvar 40 mcg (8.7 grams) 2 inhalers Caverject 12 vials, kits or ampules Qvar 40, 80 mcg (7.3 grams) 3 inhalers
Cayston 1 kit Qvar 80 mcg (8.7 grams) 3 inhalers
Cesamet 30 capsules Rebetron Combination,
Rebetron 1200, 1000 and 600 Therapy Pak
2 packages Chorionic gonadotropin 10,000
units, generic 3 vials Rebif 22 mcg and 44 mcg 15 syringes
Cialis 2.5 mg 34 tablets Rebif Titration Pack 4.2 ml 1 package Cialis 5, 10 and 20 mg 6 tablets Regranex 0.01% gel 2, 7.5 and
15 gm 1 tube
Prescription Medication Maximum Quantity Prescription Medication Maximum Quantity Clarinex 2.5 mg Reditabs 34 tablets Relenza 5 mg/blister with
inhalation device 20 blisters Clarinex/Clarinex Reditabs 5
mg 34 tablets Relpax 20 mg and 40 mg 6 tablets
Clarinex-D 12 hour 68 tablets Restasis 0.05% 60 vials
Clarinex-D 24 hour 34 tablets Revatio 20 mg 102 tablets
Claritin 10 mg/Claritin Reditabs 10 mg/Claritin 10 mg gel caps, Claritin 5 mg chewable tablets
34 tablets Rhinocort Aqua 32 mcg (120
inhalations) 8.4 ml bottle 3 bottles
Claritin-D 12 hour 68 tablets Rozerem 8 mg 34 tablets
Claritin-D 24 hour 34 tablets Rybix ODT 272 tablets
Climara, Climara Pro 5 patches Ryzolt 100 mg, 200 mg and
300 mg 34 tablets
Combivent 14.7 grams 3 inhalers Samsca 15 mg 34 tablets
Copaxone 20 mg kit 1 kit (30 prefilled syringes) Samsca 30 mg 68 tablets
Cordran Tape 2 rolls of tape Sancuso Patch 34.3 mg 1 patch
Crestor 5, 10, 20, 40 mg 34 tablets Sandostatin LAR Depot 10
mg/5 ml and 30 mg/5 ml 1 vial Depo-Provera contraceptive
injection 150 mg/ml 1 vial/syringe Sandostatin LAR Depot 20 mg/5 ml 2 vials Depo-Sub Q Provera 104 1 syringe Serevent Diskus 28 blisters 1 package Diflucan 150 mg 2 tablets Serevent Diskus 60 blisters 2 packages
Ditropan XL 5 mg 34 tablets Silenor 3 mg and 6 mg 34 tablets
Divigel 0.25, 0.5 and 1 grams 34 packets Simcor 500/20 mg, 500/40
mg, 1000/40 mg 34 tablets
Dostinex 0.5 mg 10 tablets Simcor 750/20 mg, 1000/20
mg 68 tablets
Doxazosin 1, 2, 4 mg 34 tablets Simvastatin 5, 10, 20, 40, 80
mg 34 tablets
Doxazosin 8 mg 68 tablets Sonata 10 mg 68 capsules
Duetact 30/2 mg and 30/4 mg 34 tablets Sonata 5 mg 34 capsules
Dulera 100 mcg/5 mcg and
200 mcg/5 mcg inhalers 2 inhalers Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device
2 packages Duoneb 3 ml vial 205 vials (package size 3) Spiriva Handihaler 6 capsules
(1 blister card) with inhaler device
1 package
Edex 12 vials or kits Spiriva Handihaler 90 capsules
(6 blister cards) with inhaler device
1 package
Edluar 5 mg and 10 mg 34 tablets Sporanox 100 mg 34 capsules
Elestrin gel 26 gram 52 grams Sprix (ketorolac) nasal spray 5 bottles Elestrin gel pump 1 pump Stadol Nasal Spray 2.5 ml 2 spray bottles
Ella tablets 1 tablet Staxyn 10 mg ODT 6 tablets
Emend 115 mg vial 1 vial Suboxone 2/.0.5 mg 102 tablets or films
Emend 125 mg 1 capsule Suboxone 8/2 mg 102 tablets or films
Emend 150 mg for injection 1 vial Sumavel DosePro 8 needle-free devices (1 package)
Prescription Medication Maximum Quantity Prescription Medication Maximum Quantity Emend 40 mg capsule 1 capsule Symbicort 80/4.5, 160/4.5
inhaler 2 inhaler
Emend 80 mg 2 capsules Symlin 0.6 mg/ml 7 vials
Emend bifold pack 1 pack SymlinPen 60, 120 pen
injector 8 pens
Emend trifold pack (one 125
mg and two 80 mg capsules) 1 pack (package size 3) Tamiflu 30 mg 20 capsules
Enbrel 25 mg syringes 10 syringes Tamiflu 45 mg 10 capsules
Enbrel 25 mg vials 10 vials Tamiflu 75 mg 10 capsules
Enbrel 50 mg syringe/auto
injectors 5 syringes/auto injectors Tamiflu for oral suspension, 25ml 3 bottles Epinephrine 0.15 mg and 0.3
mg single unit pack 3 units Terazol 3 3 (1 box)
Epinephrine 0.15 mg and 0.3
mg two-pack 4 units Terazol 3 Cream 0.8% 1 tube (of the 20 gram)
EpiPen, EpiPen Jr. 3 units or 2 twin packs Terazol 7 Cream 0.4% 1 tube (of the 45 gram)
Esclim 10 patches Terazosin generic 1, 2, 5 mg 34 capsules
Estraderm 10 patches Terazosin generic 10 mg 68 capsules
Estradiol transdermal patch 5 patches Terconazole See Terazol or Zazole
Estrasorb 68 packets Tilade 16.2 grams 3 inhalers
Estrogel 0.06% 50 gm 2 pump bottles TOBI 300 mg 56 ampules
Evamist 1.53 mg spray 2 pumps Toradol 10 mg 20 tablets
Extavia 15 blister units/vials Tradjenta 5 mg tablets 34 tablets
Factive 320 mg 7 tablets Tramadol 50 mg 272 tablets
Famvir 125 mg 21 tablets Tramadol ER 100 mg, 200 mg
and 300 mg 34 tablets
Famvir 250 mg 68 tablets Tramadol/APAP 37.5 mg/325
mg 272 tablets
Famvir 500 mg 21 tablets Treximet 85 mg/500 mg 9 tablets
Fexofenadine See Allegra Twinject 0.3 mg or 0.15 mg
auto-injector 3 units or 2 twin packs Flector 1.3% patch 60 patches Ultracet/APAP 37.5 mg/325
mg 272 tablets
Flonase 16 grams 2 bottles Ultram 50 mg 272 tablets
Flovent 250 mcg diskus 5 inhalers Ultram ER 100 mg, 200 mg and
300 mg 34 tablets
Flovent 50 mcg and 100 mcg
diskus 2 inhalers Valtrex 1 gram 34 caplets (tablets)
Flovent HFA 110 mcg 1 inhaler Valtrex 500 mg 34 caplets (tablets)
Flovent HFA 220 mcg 3 inhalers Ventolin HFA 90 mcg (18
grams) 3 inhalers
Flovent HFA 44 mcg 2 inhalers Ventolin HFA 90 mcg (8 grams) 1 inhaler
Fluconazole 150 mg 2 tablets Veramyst Nasal Spray 2 bottles
Flunisolide 0.025% 3 inhalers/bottles Viagra 25 mg, 50 mg and 100
mg 6 tablets
Fluticasone nasal spray 2 sprays Victoza 6 mg/3 ml, 3 ml pen,
package of 2 pens 1 package (2 pens) Foradil Aerolizer and 12
capsules in blisters 1 package (package size 12) 12caps Victoza 6 mg/3 ml, 3 ml pen, package of 3 pens 1 package (3 pens)
Prescription Medication Maximum Quantity Prescription Medication Maximum Quantity Foradil Aerolizer and 60
capsules in blisters 2 packages (package size 60) 120 caps Vivelle 10 patches
Forteo 600 mcg/2.4 ml pen 1 pen Vivelle-Dot 10 patches
Fosamax 35 and 70 mg 5 tablets Vytorin 10/10,10/20,10/40,
10/80 mg 34 tablets
Fosamax 5, 10 and 40 mg 34 tablets Xolair 150 mg/5 ml single-use
vial 1 vial
Fosamax 70 mg/75 ml oral
solution 5 bottles Xopenex HFA 3 canisters
Fosamax Plus D 70 mg/2800
IU, 70 mg/5600 IU 5 tablets Xyzal 34 tablets
Frova 2.5 mg 9 tablets Zazole 80 mg vaginal supp 3 (1 box)
Gelnique 10% gel 34 packets Zazole Cream 0.4% 1 pack (45 gram)
Humira 20 mg and 40 mg
syringe/pen 3 syringes/pens Zazole Cream 0.8% 1 pack (20 gram)
Humira Crohn’s starter pack 3 syringes Zegerid 20 mg 34 tablets Humira Psoriasis starter pack 3 syringes Zithromax for oral suspension
100 mg/5 ml, 15 ml bottle 2 bottles Hytrin 1, 2, 5 mg 34 capsules Zithromax for oral suspension
200 mg/5 ml, 15 and 22.5 ml bottle
3 bottles
Hytrin 10 mg 68 capsules Zithromax for oral suspension
200 mg/5 ml, 30 ml bottle 3 bottles IB Stat oral spray 30 ml 14 bottles Zithromax tablet or capsule,
250 mg 8 tablets/capsules
Imitrex 4 mg injection
(syringes/cartridges) 1 kit (2 syringes) Zithromax tablet, 500 mg 4 tablets Imitrex 6 mg injection
(syringes/cartridges) 1 kit (2 syringes) Zmax 60 ml 1 bottle Imitrex injection (vials) 2 vials Zocor 5, 10, 20, 40, 80 mg 34 tablets Imitrex nasal spray 5, 20 mg 6 nasal spray devices Zofran 24 mg 1 tablet Imitrex tablets 25, 50 and 100
mg 9 tablets Zofran solution 4 mg/5 ml 3 - 50 ml bottles
Intal inhaler 112 2 inhalers Zofran, Zofran ODT 4 and 8 mg 12 tablets Intal inhaler 200 2 inhalers Zolpidem tartrate 5 and 10 mg 34 tablets Itraconazole 100 mg 34 capsules Zolpimist 5 mg/spray oral
spray 1 bottle
Janumet 50/500 mg, 50/1000
mg 68 tablets Zomig Nasal Spray 5 mg 6 nasal spray devices
Januvia 25 mg, 50 mg, 100 mg 34 tablets Zomig/Zomig-ZMT 2.5 mg 6 tablets
Kapidex 30 mg 34 capsules Zomig/Zomig-ZMT 5 mg 6 tablets
Ketoralac 10 mg 20 tablets Zuplenz 4 mg and 8 mg soluble
film 12 films
Kombiglyze XR 2.5/1000 mg
tablets 68 tablets Zyrtec, Zyrtec chewable 5 and 10 mg 34 tablets Kombiglyze XR 5/500 mg and
5/1000 mg tablets 34 tablets Zyrtec-D 12 hour 68 tablets
Kytril 1 mg 2 tablets
Kytril solution 2 mg/10 ml 1 bottle