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2011 Medicare Prime Closed QLL Criteria


ABILIFY DISCMELT®
ABILIFY DISCMELT 10 MG TABLET - Limited to a quantity of 68 per 34 days. ABILIFY DISCMELT 15 MG TABLET - Limited to a quantity of 68 per 34 days.
ABILIFY®
ABILIFY 10 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 15 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 2 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 20 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 30 MG TABLET - Limited to a quantity of 34 per 34 days. ABILIFY 5 MG TABLET - Limited to a quantity of 34 per 34 days.
ACTONEL®
ACTONEL 150 MG TABLET - Limited to a quantity of 1 per 34 days. ACTONEL 30 MG TABLET - Limited to a quantity of 34 per 34 days. ACTONEL 35 MG TABLET - Limited to a quantity of 5 per 35 days. ACTONEL 5 MG TABLET - Limited to a quantity of 34 per 34 days.
ACTOPLUS MET XR®
ACTOPLUS MET XR 15-1,000 MG TB - Limited to a quantity of 68 per 34 days. ACTOPLUS MET XR 30-1,000 MG TB - Limited to a quantity of 34 per 34 days.
ACTOPLUS MET®
ACTOPLUS MET 15 MG-500 MG TAB - Limited to a quantity of 102 per 34 days. ACTOPLUS MET 15 MG-850 MG TAB - Limited to a quantity of 102 per 34 days. ACTOS 15 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOS 30 MG TABLET - Limited to a quantity of 34 per 34 days. ACTOS 45 MG TABLET - Limited to a quantity of 34 per 34 days. ADCIRCA®
ADCIRCA 20 MG TABLET - Limited to a quantity of 68 per 34 days.
ADVAIR DISKUS®
ADVAIR 100-50 DISKUS - Limited to a quantity of 120 doses per 34 days. ADVAIR 250-50 DISKUS - Limited to a quantity of 120 doses per 34 days. ADVAIR 500-50 DISKUS - Limited to a quantity of 120 doses per 34 days.
ADVAIR HFA®
ADVAIR HFA 115-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA 230-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days. ADVAIR HFA 45-21 MCG INHALER - Limited to a quantity of 24 gm per 34 days.
ADVICOR®
ADVICOR 1,000 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days. ADVICOR 1,000 MG-40 MG TABLET - Limited to a quantity of 68 per 34 days. ADVICOR 500 MG-20 MG TABLET - Limited to a quantity of 34 per 34 days. ADVICOR 750 MG-20 MG TABLET - Limited to a quantity of 68 per 34 days.
alendronate
alendronate sodium 10 mg tab - Limited to a quantity of 34 per 34 days. alendronate sodium 35 mg tab - Limited to a quantity of 5 per 35 days. alendronate sodium 40 mg tab - Limited to a quantity of 34 per 34 days. alendronate sodium 5 mg tablet - Limited to a quantity of 34 per 34 days. alendronate sodium 70 mg tab - Limited to a quantity of 5 per 35 days.
ASMANEX®
ASMANEX TWISTHALER 110 MCG #30 - Limited to a quantity of 60 doses per 30 ASMANEX TWISTHALER 220 MCG #14 - Limited to a quantity of 14 doses per 14 ASMANEX TWISTHALER 220 MCG #30 - Limited to a quantity of 60 doses per 30 ASMANEX TWISTHALER 220 MCG #60 - Limited to a quantity of 120 doses per 30 ASMANEX TWISTHALR 220 MCG #120 - Limited to a quantity of 240 doses per 30 days.
ASTEPRO®
ASTEPRO 0.15% NASAL SPRAY - Limited to a quantity of 60 ml per 34 days.
ATELVIA®
ATELVIA DR 35 MG TABLET - Limited to a quantity of 5 per 35 days.
ATROVENT HFA®
ATROVENT HFA INHALER - Limited to a quantity of 26 gm per 34 days.
AVANDAMET®
AVANDAMET 2 MG-1,000 MG TAB - Limited to a quantity of 68 per 34 days. AVANDAMET 2 MG-500 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDAMET 4 MG-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDAMET 4 MG-500 MG TABLET - Limited to a quantity of 68 per 34 days.
AVANDARYL®
AVANDARYL 4 MG-1 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 4 MG-2 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 4 MG-4 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 8 MG-2 MG TABLET - Limited to a quantity of 34 per 34 days. AVANDARYL 8 MG-4 MG TABLET - Limited to a quantity of 34 per 34 days.
AVANDIA®
AVANDIA 2 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDIA 4 MG TABLET - Limited to a quantity of 68 per 34 days. AVANDIA 8 MG TABLET - Limited to a quantity of 34 per 34 days.
AVONEX ADMINISTRATION PACK®
AVONEX ADMIN PACK 30 MCG VL - Limited to a quantity of 4 kits per 28 days. AVONEX®
AVONEX PREFILLED SYR 30 MCG - Limited to a quantity of 4 kits per 28 days.
azelastine hcl
azelastine 137 mcg nasal spray - Limited to a quantity of 60 ml per 34 days.
azithromycin
azithromycin 100 mg/5 ml susp - Limited to a quantity of 30 ml per 5 days. azithromycin 200 mg/5 ml susp - Limited to a quantity of 90 ml per 5 days. azithromycin 250 mg tablet - Limited to a quantity of 8 per 7 days. azithromycin 500 mg tablet - Limited to a quantity of 4 per 4 days.
BETASERON®
BETASERON 0.3 MG KIT - Limited to a quantity of 15 per 30 days.
BONIVA®
BONIVA 150 MG TABLET - Limited to a quantity of 1 per 34 days.
bupropion
budeprion sr 100 mg tablet - Limited to a quantity of 68 per 34 days. budeprion sr 150 mg tablet - Limited to a quantity of 68 per 34 days. budeprion xl 150 mg tablet - Limited to a quantity of 34 per 34 days. budeprion xl 300 mg tablet - Limited to a quantity of 34 per 34 days. bupropion hcl sr 100 mg tablet - Limited to a quantity of 68 per 34 days. bupropion hcl sr 200 mg tab - Limited to a quantity of 68 per 34 days.
butorphanol
butorphanol 10 mg/ml spray - Limited to a quantity of 5 ml per 3 days.
BYETTA®
BYETTA 10 MCG DOSE PEN INJ - Limited to a quantity of 5 ml per 34 days. BYETTA 5 MCG DOSE PEN INJ - Limited to a quantity of 2 ml per 34 days. cabergoline
cabergoline 0.5 mg tablet - Limited to a quantity of 20 per 34 days.
CAYSTON®
CAYSTON 75 MG INHAL SOLUTION - Limited to a quantity of 84 vials per 28 days.
CESAMET®
CESAMET 1 MG CAPSULE - Limited to a quantity of 30 per 5 days.
citalopram
citalopram hbr 10 mg tablet - Limited to a quantity of 34 per 34 days. citalopram hbr 20 mg tablet - Limited to a quantity of 34 per 34 days. citalopram hbr 40 mg tablet - Limited to a quantity of 34 per 34 days.
CLIMARA PRO®
CLIMARA PRO PATCH - Limited to a quantity of 5 per 35 days.
clonidine
clonidine 0.1 mg/day patch - Limited to a quantity of 5 per 35 days. clonidine 0.2 mg/day patch - Limited to a quantity of 5 per 35 days. clonidine 0.3 mg/day patch - Limited to a quantity of 5 per 35 days.
COMBIVENT®
COMBIVENT INHALER - Limited to a quantity of 44 gm per 34 days.
COPAXONE®
COPAXONE 20 MG INJECTION KIT - Limited to a quantity of 30 ml per 30 days.
CRESTOR®
CRESTOR 10 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 20 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 40 MG TABLET - Limited to a quantity of 34 per 34 days. CRESTOR 5 MG TABLET - Limited to a quantity of 34 per 34 days.
CYMBALTA®
CYMBALTA 20 MG CAPSULE - Limited to a quantity of 68 per 34 days. CYMBALTA 30 MG CAPSULE - Limited to a quantity of 34 per 34 days. CYMBALTA 60 MG CAPSULE - Limited to a quantity of 68 per 34 days.
doxazosin
doxazosin mesylate 1 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 2 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 4 mg tab - Limited to a quantity of 34 per 34 days. doxazosin mesylate 8 mg tab - Limited to a quantity of 68 per 34 days.
DUETACT®
DUETACT 30-2 MG TABLET - Limited to a quantity of 34 per 34 days. DUETACT 30-4 MG TABLET - Limited to a quantity of 34 per 34 days. EMEND 125 MG CAPSULE - Limited to a quantity of 1 per 1 day. EMEND 40 MG CAPSULE - Limited to a quantity of 1 per 1 day. EMEND 80 MG CAPSULE - Limited to a quantity of 2 per 2 days. EMEND TRIFOLD PACK - Limited to a quantity of 3 per 3 days.
EPIPEN JR®
EPIPEN JR 0.15 MG AUTO-INJCT - Limited to a quantity of 4 pens per 2 days.
EPIPEN®
EPIPEN 0.3 MG AUTO-INJECTOR - Limited to a quantity of 4 pens per 2 days.
ESTRADERM®
ESTRADERM 0.05 MG PATCH - Limited to a quantity of 10 per 35 days. ESTRADERM 0.1 MG PATCH - Limited to a quantity of 10 per 35 days.
estradiol
estradiol 0.05 mg/day patch - Limited to a quantity of 5 per 35 days. estradiol 0.1 mg/day patch - Limited to a quantity of 5 per 35 days. estradiol tds 0.025 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.0375 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.06 mg/day - Limited to a quantity of 5 per 35 days. estradiol tds 0.075 mg/day - Limited to a quantity of 5 per 35 days.
famciclovir
famciclovir 125 mg tablet - Limited to a quantity of 21 per 10 days. famciclovir 250 mg tablet - Limited to a quantity of 68 per 34 days. famciclovir 500 mg tablet - Limited to a quantity of 21 per 7 days.
FANAPT®
FANAPT 1 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 10 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 12 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 2 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 4 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 6 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT 8 MG TABLET - Limited to a quantity of 68 per 34 days. FANAPT TITRATION PACK - Limited to a quantity of 1 per 34 days.
fentanyl citrate
fentanyl cit otfc 1,200 mcg - Limited to a quantity of 120 per 30 days. fentanyl cit otfc 1,600 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 200 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 400 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 600 mcg - Limited to a quantity of 120 per 30 days. fentanyl citrate otfc 800 mcg - Limited to a quantity of 120 per 30 days.
fexofenadine
fexofenadine hcl 180 mg tablet - Limited to a quantity of 34 per 34 days. fexofenadine hcl 30 mg tablet - Limited to a quantity of 68 per 34 days. fexofenadine hcl 60 mg tablet - Limited to a quantity of 68 per 34 days.
fluconazole
fluconazole 150 mg tablet - Limited to a quantity of 2 per 7 days.
flunisolide
flunisolide 0.025% spray - Limited to a quantity of 75 ml per 34 days.
fluoxetine
fluoxetine dr 90 mg capsule - Limited to a quantity of 5 per 34 days. fluoxetine hcl 10 mg capsule - Limited to a quantity of 34 per 34 days. fluoxetine hcl 10 mg tablet - Limited to a quantity of 34 per 34 days. fluoxetine hcl 40 mg capsule - Limited to a quantity of 68 per 34 days. selfemra 10 mg capsule - Limited to a quantity of 35 per 14 days. selfemra 20 mg capsule - Limited to a quantity of 140 per 14 days.
fluticasone propionate
fluticasone prop 50 mcg spray - Limited to a quantity of 32 gm per 34 days.
fluvoxamine
fluvoxamine maleate 100 mg tab - Limited to a quantity of 102 per 34 days. fluvoxamine maleate 25 mg tab - Limited to a quantity of 34 per 34 days. fluvoxamine maleate 50 mg tab - Limited to a quantity of 68 per 34 days.
FORADIL®
FORADIL AEROLIZER 12 MCG CAP - Limited to a quantity of 120 per 34 days.
FORTEO®
FORTEO 600 MCG/2.4 ML PEN INJ - Limited to a quantity of 1 pen per 28 days. FROVA 2.5 MG TABLET - Limited to a quantity of 27 per 28 days.
GEODON®
GEODON 20 MG CAPSULE - Limited to a quantity of 68 per 34 days. GEODON 40 MG CAPSULE - Limited to a quantity of 68 per 34 days. GEODON 60 MG CAPSULE - Limited to a quantity of 68 per 34 days. GEODON 80 MG CAPSULE - Limited to a quantity of 68 per 34 days.
granisetron
granisetron hcl 1 mg tablet - Limited to a quantity of 2 per 1 day. granisol 2 mg/10 ml solution - Limited to a quantity of 30 ml per 3 days.
HUMIRA®
HUMIRA 20 MG/0.4 ML SYRINGE - Limited to a quantity of 5 syringes per 35 days. HUMIRA 40 MG/0.8 ML SYRINGE - Limited to a quantity of 5 syringes per 35 days. HUMIRA CROHN|S STARTER PACK - Limited to a quantity of 6 syringes per 180 days.
INVEGA®
INVEGA ER 1.5 MG TABLET - Limited to a quantity of 34 per 34 days. INVEGA ER 3 MG TABLET - Limited to a quantity of 34 per 34 days. INVEGA ER 6 MG TABLET - Limited to a quantity of 68 per 34 days. INVEGA ER 9 MG TABLET - Limited to a quantity of 34 per 34 days.
ipratropium
ipratropium 0.03% spray - Limited to a quantity of 60 ml per 34 days. ipratropium 0.06% spray - Limited to a quantity of 30 ml per 34 days.
JANUMET®
JANUMET 50-1,000 MG TABLET - Limited to a quantity of 68 per 34 days. JANUMET 50-500 MG TABLET - Limited to a quantity of 68 per 34 days.
JANUVIA®
JANUVIA 100 MG TABLET - Limited to a quantity of 34 per 34 days. JANUVIA 25 MG TABLET - Limited to a quantity of 34 per 34 days. JANUVIA 50 MG TABLET - Limited to a quantity of 34 per 34 days.
ketorolac
ketorolac 10 mg tablet - Limited to a quantity of 20 per 5 days. KOMBIGLYZE XR®
KOMBIGLYZE XR 2.5-1,000 MG TAB - Limited to a quantity of 68 per 34 days. KOMBIGLYZE XR 5-1,000 MG TAB - Limited to a quantity of 34 per 34 days. KOMBIGLYZE XR 5-500 MG TABLET - Limited to a quantity of 34 per 34 days.
lansoprazole
lansoprazole dr 15 mg capsule - Limited to a quantity of 34 per 34 days. lansoprazole odt 15 mg tablet - Limited to a quantity of 34 per 34 days.
LATUDA®
LATUDA 40 MG TABLET - Limited to a quantity of 34 per 34 days. LATUDA 80 MG TABLET - Limited to a quantity of 34 per 34 days.
leflunomide
leflunomide 10 mg tablet - Limited to a quantity of 34 per 34 days. leflunomide 20 mg tablet - Limited to a quantity of 34 per 34 days.
levocetirizine dihydrochlor
levocetirizine 5 mg tablet - Limited to a quantity of 34 per 34 days.
LEXAPRO®
LEXAPRO 10 MG TABLET - Limited to a quantity of 34 per 34 days. LEXAPRO 20 MG TABLET - Limited to a quantity of 34 per 34 days. LEXAPRO 5 MG TABLET - Limited to a quantity of 34 per 34 days.
lovastatin
lovastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. lovastatin 20 mg tablet - Limited to a quantity of 68 per 34 days. lovastatin 40 mg tablet - Limited to a quantity of 68 per 34 days.
LUNESTA®
LUNESTA 1 MG TABLET - Limited to a quantity of 34 per 34 days. LUNESTA 2 MG TABLET - Limited to a quantity of 34 per 34 days. LUNESTA 3 MG TABLET - Limited to a quantity of 34 per 34 days.
MAXALT MLT®
MAXALT MLT 10 MG TABLET - Limited to a quantity of 36 per 28 days. MAXALT MLT 5 MG TABLET - Limited to a quantity of 36 per 28 days.
MAXALT®
MAXALT 10 MG TABLET - Limited to a quantity of 36 per 28 days. MAXALT 5 MG TABLET - Limited to a quantity of 36 per 28 days.
medroxyprogesterone
medroxyprogesterone 150 mg/ml - Limited to a quantity of 1 ml per 90 days.
meloxicam
meloxicam 7.5 mg tablet - Limited to a quantity of 34 per 34 days.
miconazole nitrate
miconazole 3 200 mg vag supp - Limited to a quantity of 3 per 3 days.
morphine
morphine sulf er 100 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 15 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 200 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 30 mg tablet - Limited to a quantity of 120 per 30 days. morphine sulf er 60 mg tablet - Limited to a quantity of 120 per 30 days.
naratriptan
naratriptan hcl 1 mg tablet - Limited to a quantity of 18 per 28 days. naratriptan hcl 2.5 mg tablet - Limited to a quantity of 18 per 28 days.
NASACORT AQ®
NASACORT AQ NASAL SPRAY - Limited to a quantity of 33 gm per 34 days. NEULASTA®
NEULASTA 6 MG/0.6 ML SYRINGE - Limited to a quantity of 2 syringes per 30 days.
NEUMEGA®
NEUMEGA 5 MG VIAL - Limited to a quantity of 21 vials per 21 days.
NEXIUM®
NEXIUM DR 10 MG PACKET - Limited to a quantity of 34 per 34 days. NEXIUM DR 20 MG CAPSULE - Limited to a quantity of 34 per 34 days. NEXIUM DR 20 MG PACKET - Limited to a quantity of 34 per 34 days.
omeprazole
omeprazole dr 10 mg capsule - Limited to a quantity of 34 per 34 days.
omeprazole/sodium bicarbonat
omeprazole-bicarb 20-1,100 cap - Limited to a quantity of 34 per 34 days.
ondansetron
ondansetron 4 mg/5 ml solution - Limited to a quantity of 150 ml per 5 days. ondansetron hcl 24 mg tablet - Limited to a quantity of 1 per 1 day. ondansetron hcl 4 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron hcl 8 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron odt 4 mg tablet - Limited to a quantity of 12 per 5 days. ondansetron odt 8 mg tablet - Limited to a quantity of 12 per 5 days.
ONGLYZA®
ONGLYZA 2.5 MG TABLET - Limited to a quantity of 34 per 34 days. ONGLYZA 5 MG TABLET - Limited to a quantity of 34 per 34 days.
OPANA ER®
OPANA ER 10 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 15 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 20 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 30 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 40 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 5 MG TABLET - Limited to a quantity of 90 per 30 days. OPANA ER 7.5 MG TABLET - Limited to a quantity of 90 per 30 days.
oxybutynin
oxybutynin cl er 5 mg tablet - Limited to a quantity of 34 per 34 days.
OXYCONTIN®
OXYCONTIN 10 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 15 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 20 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 30 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 40 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 60 MG TABLET - Limited to a quantity of 90 per 30 days. OXYCONTIN 80 MG TABLET - Limited to a quantity of 90 per 30 days.
pantoprazole
pantoprazole sod dr 20 mg tab - Limited to a quantity of 34 per 34 days.
paroxetine
paroxetine cr 12.5 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine cr 25 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine er 37.5 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine hcl 10 mg tablet - Limited to a quantity of 34 per 34 days. paroxetine hcl 20 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine hcl 30 mg tablet - Limited to a quantity of 68 per 34 days. paroxetine hcl 40 mg tablet - Limited to a quantity of 34 per 34 days.
PEGASYS®
PEGASYS 180 MCG/0.5 ML CONV.PK - Limited to a quantity of 4 syringes per 28 PEGASYS 180 MCG/ML VIAL - Limited to a quantity of 4 vials per 28 days.
PEGINTRON REDIPEN®
PEGINTRON REDIPEN 120 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 150 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 50 MCG - Limited to a quantity of 5 pens per 34 days. PEGINTRON REDIPEN 80 MCG - Limited to a quantity of 5 pens per 34 days.
PEGINTRON®
PEGINTRON 50 MCG KIT - Limited to a quantity of 5 kits per 34 days.
PRANDIMET®
PRANDIMET 1 MG-500 MG TABLET - Limited to a quantity of 170 per 34 days. PRANDIMET 2 MG-500 MG TABLET - Limited to a quantity of 170 per 34 days.
pravastatin
pravastatin sodium 10 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 20 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 40 mg tab - Limited to a quantity of 34 per 34 days. pravastatin sodium 80 mg tab - Limited to a quantity of 34 per 34 days.
PRISTIQ®
PRISTIQ 100 MG TABLET - Limited to a quantity of 34 per 34 days. PRISTIQ 50 MG TABLET - Limited to a quantity of 34 per 34 days.
PROAIR HFA®
PROAIR HFA 90 MCG INHALER - Limited to a quantity of 26 gm per 34 days.
PROVENTIL HFA®
PROVENTIL HFA 90 MCG INHALER - Limited to a quantity of 20 gm per 34 days. QVAR 40 MCG INHALER - Limited to a quantity of 22 gm per 34 days. QVAR 80 MCG INHALER - Limited to a quantity of 22 gm per 34 days. REBIF 22 MCG/0.5 ML SYRINGE - Limited to a quantity of 8 ml per 35 days. REBIF 44 MCG/0.5 ML SYRINGE - Limited to a quantity of 8 ml per 35 days. REBIF TITRATION PACK - Limited to a quantity of 12 syringes per 28 days.
REGRANEX®
REGRANEX 0.01% GEL - Limited to a quantity of 30 gm per 34 days.
RELENZA®
RELENZA 5 MG DISKHALER - Limited to a quantity of 60 inhalations per 180 days.
RESTASIS®
RESTASIS 0.05% EYE EMULSION - Limited to a quantity of 60 vials per 30 days.
REVATIO®
REVATIO 20 MG TABLET - Limited to a quantity of 102 per 34 days.
risperidone
risperidone 0.25 mg odt - Limited to a quantity of 68 per 34 days. risperidone 0.25 mg tablet - Limited to a quantity of 68 per 34 days. risperidone 0.5 mg odt - Limited to a quantity of 68 per 34 days. risperidone 0.5 mg tablet - Limited to a quantity of 68 per 34 days. risperidone 1 mg odt - Limited to a quantity of 68 per 34 days. risperidone 1 mg tablet - Limited to a quantity of 68 per 34 days. risperidone 1 mg/ml solution - Limited to a quantity of 544 ml per 34 days. risperidone 2 mg odt - Limited to a quantity of 68 per 34 days. risperidone 2 mg tablet - Limited to a quantity of 68 per 34 days. risperidone 3 mg odt - Limited to a quantity of 68 per 34 days. risperidone 3 mg tablet - Limited to a quantity of 68 per 34 days. risperidone 4 mg odt - Limited to a quantity of 68 per 34 days. risperidone 4 mg tablet - Limited to a quantity of 68 per 34 days.
ROZEREM®
ROZEREM 8 MG TABLET - Limited to a quantity of 34 per 34 days.
SAMSCA®
SAMSCA 15 MG TABLET - Limited to a quantity of 68 per 34 days. SAMSCA 30 MG TABLET - Limited to a quantity of 68 per 34 days.
SANDOSTATIN LAR®
SANDOSTATIN LAR 10 MG KIT - Limited to a quantity of 1 per 28 days. SANDOSTATIN LAR 20 MG KIT - Limited to a quantity of 2 per 28 days. SANDOSTATIN LAR 30 MG KIT - Limited to a quantity of 1 per 28 days.
SAPHRIS®
SAPHRIS 10 MG TAB SUBLINGUAL - Limited to a quantity of 68 per 34 days. SAPHRIS 5 MG TABLET SUBLINGUAL - Limited to a quantity of 68 per 34 days.
SAVELLA®
SAVELLA 100 MG TABLET - Limited to a quantity of 68 per 34 days. SAVELLA 12.5 MG TABLET - Limited to a quantity of 68 per 34 days. SAVELLA 25 MG TABLET - Limited to a quantity of 68 per 34 days. SAVELLA 50 MG TABLET - Limited to a quantity of 68 per 34 days. SAVELLA TITRATION PACK - Limited to a quantity of 1 per 34 days.
SEROQUEL XR®
SEROQUEL XR 150 MG TABLET - Limited to a quantity of 34 per 34 days. SEROQUEL XR 200 MG TABLET - Limited to a quantity of 34 per 34 days. SEROQUEL XR 300 MG TABLET - Limited to a quantity of 68 per 34 days. SEROQUEL XR 400 MG TABLET - Limited to a quantity of 68 per 34 days. SEROQUEL XR 50 MG TABLET - Limited to a quantity of 68 per 34 days.
SEROQUEL®
SEROQUEL 100 MG TABLET - Limited to a quantity of 102 per 34 days. SEROQUEL 200 MG TABLET - Limited to a quantity of 102 per 34 days. SEROQUEL 25 MG TABLET - Limited to a quantity of 102 per 34 days. SEROQUEL 300 MG TABLET - Limited to a quantity of 68 per 34 days. SEROQUEL 400 MG TABLET - Limited to a quantity of 68 per 34 days. SEROQUEL 50 MG TABLET - Limited to a quantity of 102 per 34 days.
sertraline
sertraline hcl 100 mg tablet - Limited to a quantity of 68 per 34 days. sertraline hcl 25 mg tablet - Limited to a quantity of 34 per 34 days. sertraline hcl 50 mg tablet - Limited to a quantity of 68 per 34 days.
SIMCOR®
SIMCOR 1,000-20 MG TABLET - Limited to a quantity of 68 per 34 days. SIMCOR 1,000-40 MG TABLET - Limited to a quantity of 34 per 34 days. SIMCOR 500-20 MG TABLET - Limited to a quantity of 34 per 34 days. SIMCOR 500-40 MG TABLET - Limited to a quantity of 34 per 34 days. SIMCOR 750-20 MG TABLET - Limited to a quantity of 68 per 34 days.
simvastatin
simvastatin 10 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 20 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 40 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 5 mg tablet - Limited to a quantity of 34 per 34 days. simvastatin 80 mg tablet - Limited to a quantity of 34 per 34 days.
SPIRIVA®
SPIRIVA 18 MCG CP-HANDIHALER - Limited to a quantity of 60 capsules per 34 days.
SUBOXONE®
SUBOXONE 2 MG-0.5 MG TABLET SL - Limited to a quantity of 102 per 34 days. SUBOXONE 8 MG-2 MG TABLET SL - Limited to a quantity of 102 per 34 days.
sumatriptan
sumatriptan 4 mg/0.5 ml vial - Limited to a quantity of 8 vials per 28 days. sumatriptan 6 mg/0.5 ml inject - Limited to a quantity of 8 vials per 28 days. sumatriptan 6 mg/0.5 ml vial - Limited to a quantity of 8 vials per 28 days. sumatriptan succ 100 mg tablet - Limited to a quantity of 18 per 28 days. sumatriptan succ 25 mg tablet - Limited to a quantity of 18 per 28 days. sumatriptan succ 50 mg tablet - Limited to a quantity of 18 per 28 days.
SYMBICORT®
SYMBICORT 160-4.5 MCG INHALER - Limited to a quantity of 20 gm per 34 days. SYMBICORT 80-4.5 MCG INHALER - Limited to a quantity of 20 gm per 34 days. SYMLIN®
SYMLIN 0.6 MG/ML VIAL - Limited to a quantity of 35 ml per 34 days.
SYMLINPEN 120®
SYMLINPEN 120 PEN INJECTOR - Limited to a quantity of 22 ml per 34 days.
SYMLINPEN 60®
SYMLINPEN 60 PEN INJECTOR - Limited to a quantity of 12 pens per 34 days.
TAMIFLU®
TAMIFLU 12 MG/ML SUSPENSION - Limited to a quantity of 900 ml per 180 days. TAMIFLU 30 MG GELCAP - Limited to a quantity of 84 per 180 days. TAMIFLU 45 MG GELCAP - Limited to a quantity of 42 per 180 days. TAMIFLU 75 MG GELCAP - Limited to a quantity of 42 per 180 days.
terazosin
terazosin 1 mg capsule - Limited to a quantity of 34 per 34 days. terazosin 10 mg capsule - Limited to a quantity of 68 per 34 days. terazosin 2 mg capsule - Limited to a quantity of 34 per 34 days. terazosin 5 mg capsule - Limited to a quantity of 34 per 34 days.
terconazole
terconazole 0.4% cream - Limited to a quantity of 45 gm per 7 days. terconazole 0.8% cream - Limited to a quantity of 20 gm per 3 days. terconazole 80 mg suppository - Limited to a quantity of 3 per 3 days.
tramadol
tramadol hcl 50 mg tablet - Limited to a quantity of 272 per 34 days. tramadol hcl er 100 mg tablet - Limited to a quantity of 34 per 34 days. tramadol hcl er 200 mg tablet - Limited to a quantity of 34 per 34 days.
tramadol/apap
tramadol-acetaminophn 37.5-325 - Limited to a quantity of 272 per 34 days. triamcinolone acetonide
triamcinolone 55 mcg nasal spy - Limited to a quantity of 33 gm per 34 days.
valacyclovir
valacyclovir hcl 1 gram tablet - Limited to a quantity of 34 per 34 days. valacyclovir hcl 500 mg tablet - Limited to a quantity of 34 per 34 days.
venlafaxine
venlafaxine hcl 100 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl 25 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl 37.5 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl 50 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl 75 mg tablet - Limited to a quantity of 102 per 34 days. venlafaxine hcl er 150 mg cap - Limited to a quantity of 34 per 34 days. venlafaxine hcl er 37.5 mg cap - Limited to a quantity of 34 per 34 days. venlafaxine hcl er 75 mg cap - Limited to a quantity of 102 per 34 days.
VIIBRYD®
VIIBRYD 10 MG TABLET - Limited to a quantity of 34 per 34 days. VIIBRYD 20 MG TABLET - Limited to a quantity of 34 per 34 days. VIIBRYD 40 MG TABLET - Limited to a quantity of 34 per 34 days.
VIVELLE-DOT®
VIVELLE-DOT 0.025 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.0375 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.05 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.075 MG PATCH - Limited to a quantity of 10 per 35 days. VIVELLE-DOT 0.1 MG PATCH - Limited to a quantity of 10 per 35 days.
VYTORIN®
VYTORIN 10-10 MG TABLET - Limited to a quantity of 34 per 34 days. VYTORIN 10-20 MG TABLET - Limited to a quantity of 34 per 34 days. VYTORIN 10-40 MG TABLET - Limited to a quantity of 34 per 34 days. VYTORIN 10-80 MG TABLET - Limited to a quantity of 34 per 34 days. XOLAIR®
XOLAIR 150 MG VIAL - Limited to a quantity of 6 vials per 28 days.
zaleplon
zaleplon 10 mg capsule - Limited to a quantity of 68 per 34 days. zaleplon 5 mg capsule - Limited to a quantity of 34 per 34 days.
zolpidem
zolpidem tart er 12.5 mg tab - Limited to a quantity of 34 per 34 days. zolpidem tart er 6.25 mg tab - Limited to a quantity of 34 per 34 days. zolpidem tartrate 10 mg tablet - Limited to a quantity of 34 per 34 days. zolpidem tartrate 5 mg tablet - Limited to a quantity of 34 per 34 days. ZOMIG 5 MG NASAL SPRAY - Limited to a quantity of 18 nasal sprayers per 28 days.
ZYPREXA ZYDIS®
ZYPREXA ZYDIS 10 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA ZYDIS 15 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA ZYDIS 20 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA ZYDIS 5 MG TABLET - Limited to a quantity of 34 per 34 days.
ZYPREXA®
ZYPREXA 10 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA 15 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA 2.5 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA 20 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA 5 MG TABLET - Limited to a quantity of 34 per 34 days. ZYPREXA 7.5 MG TABLET - Limited to a quantity of 34 per 34 days. azelastine 137 mcg nasal spray, 10 azithromycin 100 mg/5 ml susp, 10 azithromycin 200 mg/5 ml susp, 10 azithromycin 250 mg tablet, 10 alendronate sodium 10 mg tab, 8 azithromycin 500 mg tablet, 10 alendronate sodium 35 mg tab, 8 alendronate sodium 40 mg tab, 8 alendronate sodium 5 mg tablet, 8 budeprion sr 100 mg tablet, 10 alendronate sodium 70 mg tab, 8 budeprion sr 150 mg tablet, 10 budeprion xl 150 mg tablet, 10 budeprion xl 300 mg tablet, 10 bupropion hcl sr 100 mg tablet, 10 estradiol 0.05 mg/day patch, 12 bupropion hcl sr 200 mg tab, 10 estradiol 0.1 mg/day patch, 13 butorphanol 10 mg/ml spray, 10 estradiol tds 0.025 mg/day, 13 estradiol tds 0.0375 mg/day, 13 estradiol tds 0.06 mg/day, 13 cabergoline 0.5 mg tablet, 11 estradiol tds 0.075 mg/day, 13 famciclovir 125 mg tablet, 13 famciclovir 250 mg tablet, 13 famciclovir 500 mg tablet, 13 citalopram hbr 10 mg tablet, 11 citalopram hbr 20 mg tablet, 11 citalopram hbr 40 mg tablet, 11 clonidine 0.1 mg/day patch, 11 clonidine 0.2 mg/day patch, 11 clonidine 0.3 mg/day patch, 11 fentanyl cit otfc 1,200 mcg, 13 fentanyl cit otfc 1,600 mcg, 13 fentanyl citrate otfc 200 mcg, 13 fentanyl citrate otfc 400 mcg, 13 fentanyl citrate otfc 600 mcg, 13 fentanyl citrate otfc 800 mcg, 13 fexofenadine hcl 180 mg tablet, 13 fexofenadine hcl 30 mg tablet, 13 fexofenadine hcl 60 mg tablet, 13 doxazosin mesylate 1 mg tab, 12 fluconazole 150 mg tablet, 13 doxazosin mesylate 2 mg tab, 12 flunisolide 0.025% spray, 14 doxazosin mesylate 4 mg tab, 12 fluoxetine dr 90 mg capsule, 14 doxazosin mesylate 8 mg tab, 12 fluoxetine hcl 10 mg capsule, 14 fluoxetine hcl 10 mg tablet, 14 fluoxetine hcl 40 mg capsule, 14 fluticasone prop 50 mcg spray, 14 fluvoxamine maleate 100 mg tab, 14 fluvoxamine maleate 25 mg tab, 14 fluvoxamine maleate 50 mg tab, 14 lovastatin 20 mg tablet, 16 lovastatin 40 mg tablet, 16 granisetron hcl 1 mg tablet, 15 granisol 2 mg/10 ml solution, 15 medroxyprogesterone 150 mg/ml, 17 meloxicam 7.5 mg tablet, 17 miconazole 3 200 mg vag supp, 17 morphine sulf er 100 mg tablet, 17 morphine sulf er 15 mg tablet, 17 morphine sulf er 200 mg tablet, 17 morphine sulf er 30 mg tablet, 17 ipratropium 0.03% spray, 15 morphine sulf er 60 mg tablet, 17 ipratropium 0.06% spray, 15 naratriptan hcl 1 mg tablet, 17 naratriptan hcl 2.5 mg tablet, 17 ketorolac 10 mg tablet, 15 omeprazole dr 10 mg capsule, 18 omeprazole-bicarb 20-1,100 cap, 18 ondansetron 4 mg/5 ml solution, 18 ondansetron hcl 24 mg tablet, 18 lansoprazole dr 15 mg capsule, 16 ondansetron hcl 4 mg tablet, 18 lansoprazole odt 15 mg tablet, 16 ondansetron hcl 8 mg tablet, 18 ondansetron odt 4 mg tablet, 18 ondansetron odt 8 mg tablet, 18 leflunomide 10 mg tablet, 16 leflunomide 20 mg tablet, 16 levocetirizine 5 mg tablet, 16 lovastatin 10 mg tablet, 16 oxybutynin cl er 5 mg tablet, 19 risperidone 0.25 mg odt, 21 risperidone 0.25 mg tablet, 21 pantoprazole sod dr 20 mg tab, 19 risperidone 0.5 mg odt, 21 paroxetine cr 12.5 mg tablet, 19 risperidone 0.5 mg tablet, 21 paroxetine cr 25 mg tablet, 19 paroxetine er 37.5 mg tablet, 19 risperidone 1 mg tablet, 21 paroxetine hcl 10 mg tablet, 19 risperidone 1 mg/ml solution, 21 paroxetine hcl 20 mg tablet, 19 paroxetine hcl 30 mg tablet, 19 risperidone 2 mg tablet, 21 paroxetine hcl 40 mg tablet, 19 risperidone 3 mg tablet, 21 risperidone 4 mg tablet, 21 pravastatin sodium 10 mg tab, 20 pravastatin sodium 20 mg tab, 20 pravastatin sodium 40 mg tab, 20 pravastatin sodium 80 mg tab, 20 selfemra 10 mg capsule, 14 selfemra 20 mg capsule, 14 terazosin 1 mg capsule, 24 terazosin 10 mg capsule, 24 terazosin 2 mg capsule, 24 terazosin 5 mg capsule, 24 terconazole 0.4% cream, 24 sertraline hcl 100 mg tablet, 22 terconazole 0.8% cream, 24 sertraline hcl 25 mg tablet, 22 terconazole 80 mg suppository, 24 sertraline hcl 50 mg tablet, 22 tramadol hcl 50 mg tablet, 24 tramadol hcl er 100 mg tablet, 24 tramadol hcl er 200 mg tablet, 24 tramadol-acetaminophn 37.5-325, 24 triamcinolone 55 mcg nasal spy, 25 valacyclovir hcl 1 gram tablet, 25 simvastatin 10 mg tablet, 23 valacyclovir hcl 500 mg tablet, 25 simvastatin 20 mg tablet, 23 venlafaxine hcl 100 mg tablet, 25 simvastatin 40 mg tablet, 23 venlafaxine hcl 25 mg tablet, 25 simvastatin 5 mg tablet, 23 venlafaxine hcl 37.5 mg tablet, 25 simvastatin 80 mg tablet, 23 venlafaxine hcl 50 mg tablet, 25 venlafaxine hcl 75 mg tablet, 25 venlafaxine hcl er 150 mg cap, 25 venlafaxine hcl er 37.5 mg cap, 25 venlafaxine hcl er 75 mg cap, 25 sumatriptan 4 mg/0.5 ml vial, 23 sumatriptan 6 mg/0.5 ml inject, 23 sumatriptan 6 mg/0.5 ml vial, 23 sumatriptan succ 100 mg tablet, 23 sumatriptan succ 25 mg tablet, 23 sumatriptan succ 50 mg tablet, 23 zaleplon 10 mg capsule, 26 zolpidem tart er 12.5 mg tab, 26 zolpidem tart er 6.25 mg tab, 26 zolpidem tartrate 10 mg tablet, 26 zolpidem tartrate 5 mg tablet, 26

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