Drug Quantity ManagementTo help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, 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). Based on the FDA’s guidelines and other medical information, our plan developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit. The following limits are based on a 34-day supply, but our benefit may provide a different supply. For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity. Drug Quantity Limits for MCSIGPrescription Drug BenefitName of Prescription Drug, Maximum Quantity Actonel 35 mg 5 tablets Actonel 5 and 30 mg 34 tablets Actonel 75 mg 2 tablets Actonel 150 mg 1 tablet Actonel with Calcium tablets 35 Tablets Actoplus Met 15/500mg and 15/850mg 102 tablets Actos 15, 30, 45 mg 34 tablets Advair Diskus 100/50, 250/50, and 500/50 with device 28, 120 blisters Advair HFA 2 inhalers Aerobid/Aerobid-M 7 grams 3 inhalers Aerospan 80mcg 8.9 gram 3 inhalers Aerospan 80mcg 5.1 gram 1 inhaler Albuterol generic inhaler 3 inhalers Allegra 180 mg 34 tablets Allegra 30, 60mg 68 tablets/orally disintegrating tablets Allegra-D 12 hour 68 tablets Allegra-D 24 hour 34 tablets Alora 10 patches Alupent 14 grams 3 inhalers Ambien 5, 10 mg 34 tablets Ambien CR 6.25mg and 12.5mg 34 tablets Amerge 1, 2.5 mg 9 tablets Anzemet 50, 100 mg 1 tablet Arava 10 mg, 20 mg 34 tablets Asmanex 14 inhalation units 1 inhaler Asmanex 30, 60, 120 inhalation units 2 inhalers Astelin Nasal Spray (34 ml bottle) 2 bottles Atrovent HFA 12.9 grams 2 inhalers Atrovent inhaler 14.7 grams 3 inhalers Atrovent nasal spray 0.03% (30 grams), generic 2 bottles Atrovent nasal spray 0.06% (15 grams), generic 2 bottles Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000 68 tablets Avandaryl 4mg/1mg, 4mg/2mg, 4mg/4mg, 8mg/2mg, 8mg/4mg 34 tablets Avandia 2, 4 mg 68 tablets Avandia 8 mg 34 tablets Avonex 4 syringes Axert 6.25 mg 6 tablets Axert 12.5 mg 12 tablets Azithromycin See Zithromax Azithromycin 500mg 4 tablets Azmacort 20 grams 3 inhalers Beconase AQ 25 grams 2 inhalers Betaseron 15 vials with prefilled diluent syringe Boniva 2.5 mg 34 tablets Boniva 150 mg 1 tablet Brovana Inhalation Solution (30 vial carton) 3 cartons for a 34-day supply Butorphanol tartrate Nasal Spray 2 spray bottles Byetta 1.2 ml (250 mcg/ml) 2 syringes Byetta 2.4 ml (250 mcg/ml) 2 syringes Cabergoline 0.5mg 10 tablets Catapres-TTS Patches 5 patches Caverject 12 vials, kits, or ampules Cesamet 30 capsules Chorionic gonadotropin 10000 units, generic 3 vials Cialis 5, 10, and 20 mg 6 tablets Cialis 2.5mg 34 tablets Clarinex/Clarinex Reditabs 5 mg 34 tablets Clarinex 2.5mg Reditabs 34 tablets Clarinex-D 12 hour 68 tablets Clarinex-D 24 hour 34 tablets Claritin 10 mg/Claritin Reditabs 10 mg, Claritin 5 mg chewable tablets 34 tablets Claritin-D 12 Hour 68 tablets Claritin-D 24 Hour 34 tablets Climara, Climara Pro 5 patches Combivent 14.7 grams 3 inhalers Copaxone 20 mg kit 1 kit (30 prefilled syringes) Cordran Tape 2 rolls of tape Crestor 40 mg 34 tablets Depo-Provera Contraceptive Injection 150 mg/mL 1 vial/syringe Depo-Sub Q Provera 104 1 syringe Diflucan 150 mg 2 tablets Ditropan XL 5 mg 34 tablets Divigel 0.25, 0.5, and 1 grams 34 packets Dostinex 0.5 mg 10 tablets Duetact 30/2mg and 30/4mg 34 tablets Duoneb 3 ml vial 205 vials (package size 3) Edex 12 vials or kits Elestrin gel pump 1 pump Emend 115mg vial 1 vial Emend 125 mg 1 capsule Emend 40mg capsule 1 capsule Emend 80 mg 2 capsules Emend Bifold Pack 1 pack Emend Trifold Pack (one 125 mg and two 80 mg capsules) 1 pack (package size 3) Enbrel 25mg vials 10 vials Enbrel 25 mg syringes 10 syringes Enbrel 50mg syringe/auto injectors 5 syringes/auto injectors EpiPen, EpiPen Jr. 3 units or 2 twin packs Esclim 10 patches Estraderm 10 patches Estradiol transdermal patch 5 patches Estrasorb 68 packets Estrogel .06% 50gm 2 pump bottles Evamist 1.53 mg spray 2 pumps Factive 320mg 7 tablets Famvir 125 mg 21 tablets Famvir 250 mg 68 tablets Famvir 500 mg 21 tablets Fexofenadine See Allegra Flector 1.3% patch 60 patches Flonase 16 grams 2 bottles Flovent 50mcg Diskus 2 inhalers Flovent HFA 44mcg 2 inhalers Flovent HFA 110mcg 1 inhaler Flovent HFA 220mcg 3 inhalers Fluconazole 150mg 2 tablets Flunisolide 0.025% 3 inhalers/bottles Fluticasone Nasal Spray 2 sprays Foradil Aerolizer & 12 capsules in blisters 1 package (package size 12) 12 caps Foradil Aerolizer & 60 capsules in blisters 2 packages (package size 60) 120 caps Fosamax 35 and 70 mg 5 tablets Fosamax 5, 10, and 40 mg 34 tablets Fosamax 70 mg/75 mL oral solution 5 bottles Fosamax Plus D 70 mg/2800 IU, 70mg/5600 IU 5 tablets Frova 2.5 mg 9 tablets Humira 20 mg and 40 mg syringe/pen 3 syringes/pens Humira Crohn’s Starter Pack 3 syringes IB Stat oral spray 30 mL 14 bottles Imitrex Injection (syringes/cartridges) 1 kit (2 syringes) Imitrex 4mg injection (syringes/cartridges) 1 kit (2 syringes) Imitrex Injection (vials) 2 vials Imitrex Nasal Spray 5, 20 mg 6 nasal spray devices Imitrex tablets 25, 50, and 100 mg 9 tablets Intal Inhaler 112 2 inhalers Intal Inhaler 200 2 inhalers Itraconazole 100mg 34 capsules Janumet 50/500 mg, 50/1000 mg 68 tablets Januvia 25mg, 50mg, 100mg 34 tablets Ketoralac 10 mg 20 tablets Kytril 1 mg 2 tablets Kytril solution 2 mg/10 mL 1 bottle Levitra 2.5, 5, 10, and 20 mg 6 tablets Lioresal Inthrathecal Refill Kit 1 Lunesta 1mg, 2mg, 3mg 34 tablets Maxair Autohaler 14 grams 2 inhalers Maxalt and Maxalt-MLT 5, 10 mg 12 tablets Menostar 5 patches Miconazole See Monistat Migranal 4 mg/ml 8 spray devices Mobic 7.5 mg 34 tablets Monistat 1 pre-filled 1 box Monistat 3 combination pack 200 mg & equivalent 1 box Monistat 3 suppositories 200 mg & equivalent 3 (1 box) Monistat 7 combination pack & equivalent 1 box (7 suppositories, 9 gram cream) Monistat 7 cream and equivalent 45 grams (1 tube) Monistat 7 cream pre-filled applicators 7 applicators Monistat 7 suppositories 100 mg & equivalent 7 suppositories (1 box) Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) 1 (1 box) Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) 1 (1 box) Muse 12 urethral suppositories Nasacort 10 gram 3 inhalers Nasacort AQ 16.5 gram 2 bottles Nasarel 0.025% 25 mL 3 bottles Nasonex 50 mcg nasal spray 17 gram 2 bottles NebuPent 300 mg/container 1 container (inhaler) Neumega 21 vials Newtek disposable blood glucose meter 2 meters Nexium 20 mg 34 capsules Nexium 20 mg packets 34 packets Noverel 10,000 unit 3 vials Omeprazole 10 mg 34 capsules Omnaris 50 mcg nasal spray 2 bottles Ondansetron 24 mg 1 tablet Ondansetron, Ondansetron ODT 4 and 8 mg 12 tablets Ondansetron solution 4 mg/5 mL 3 - 50 mL bottles Oxybutynin XL 5 mg 34 tablets Pantoprazole 20 mg 34 tablets Patanase 0.6% Nasal Spray 2 bottles PEG Intron Pens/Kit (containing 1 vial each) 50 mcg, 80 mcg, 120 mcg, 150 mcg 5 pens/vials Pegasys 180 mcg 5 vials (package size 1) Pegasys 180 mcg Convenience Pack ( 4 vials) 1 box (package size 1) Pegasys 180 mcg Convenience Pack (4 prefilled syringes) 1 box (package size 1) Perforomist Inhalation Solution 2 cartons (120 vials) Plan B 2 tablets Pregnyl 10,000 unit 3 vials Prevacid 15 mg, Prevacid SoluTab 34 capsules or tablets Preven Contraceptive Kit 1 kit Prevpak patient pack 14 units (1 package) Prilosec 10 mg 34 capsules Prilosec 20 mg (Brand) 34 capsules Proair HFA 3 inhalers Protonix 20 mg 34 tablets Proventil Inhaler 17 gram 3 inhalers Proventil HFA 6.7 gram 3 inhalers Pulmicort Flexhaler 90 mcg 2 inhalers Pulmicort Flexhaler 180 mcg 3 inhalers Pulmicort Respules 0.25 mg/2 mL and 0.5 mg/2 mL 70 ampules Pulmicort Respules 1 mg/2 mL 35 ampules Pulmicort Turbuhaler 2 inhalers Qvar 40, 80mcg (7.3 grams) 3 inhalers Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak 2 packages Rebif 22 mcg and 44 mcg 15 syringes Rebif Titration Pack 4.2ml 1 package Regranex 0.01%gel 2, 7.5, and 15 gm 1 tube Relenza 5 mg/blister with inhalation device 20 blisters Relpax 20 mg and 40 mg 6 tablets Restasis 0.05% 64 vials Revatio 20mg 102 tablets Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle 3 bottles Rozerem 8mg 34 tablets Serevent Diskus 28 blisters 1 package Serevent Diskus 60 blisters 2 packages Sonata 10 mg 68 capsules Sonata 5 mg 34 capsules Spiriva Handihaler 6 capsules (1 blister card) with inhaler device 1 package Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device 2 packages Spiriva Handihaler 90 capsules (6 blister cards) with inhaler device 1 package Sporanox 100 mg 34 capsules Stadol Nasal Spray 2.5 mL 2 spray bottles Suboxone 2/.0.5 mg 102 tablets Suboxone 8/2 mg 102 tablets Symbicort 80/4.5, 160/4.5 Inhaler 2 inhaler Symlin 0.6mg/ml 7 vials SymlinPen 60, 120 pen injector 8 pens Tamiflu 30 mg 20 capsules Tamiflu 45 mg 10 capsules Tamiflu 75 mg 10 capsules Tamiflu for oral suspension, 25 mL 3 bottles Terazol 3 3 (1 box) Terazol 3 Cream 0.8% 1 tube (of the 20 gram) Terazol 7 Cream 0.4% 1 tube (of the 45 gram) Terconazole See Terazol or Zazole Tilade 16.2 grams 3 inhalers TOBI 300 mg 56 ampules Toradol 10 mg 20 tablets Treximet 85 mg/500 mg 9 tablets Twinject 0.3mg or 0.15mg Auto-Injector 3 units or 2 twin packs Valtrex 1 gram 34 caplets (tablets) Valtrex 500 mg 34 caplets (tablets) Ventolin HFA 90 mcg (18 grams) 3 inhalers Veramyst Nasal Spray 2 bottles Viagra 25 mg, 50 mg, and 100 mg 6 tablets Vivelle 10 patches Vivelle-Dot 10 patches Xopenex HFA 3 canisters Xyzal 34 tablets Zazole Cream 0.4% 1 pack (45 gram) Zazole Cream 0.8% 1 pack (20 gram) Zazole 80mg Vaginal Supp 3 (1 box) Zegerid 20 mg 34 tablets Zithromax for oral suspension 100 mg/5 mL, 15 ml bottle 2 bottles Zithromax for oral suspension 200 mg/5 mL, 15 and 22.5 ml bottle 3 bottles Zithromax for oral suspension 200 mg/5 mL, 30 ml bottle 3 bottles Zithromax tablet or capsule, 250 mg 8 tablets/capsules Zithromax tablet, 500 mg 4 tablets Zmax 60 ml 1 bottle Zofran 24 mg 1 tablet Zofran, Zofran ODT 4 and 8 mg 12 tablets Zofran solution 4 mg/5 mL 3 - 50 mL bottles Zolpidem tartrate 5 and 10 mg 34 tablets Zomig/Zomig-ZMT 5 mg 6 tablets Zomig Nasal Spray 5 mg 6 nasal spray devices Zomig/Zomig-ZMT 2.5 mg 6 tablets Zyrtec, Zyrtec chewable 5 and 10 mg 34 tablets Zyrtec-D 12 Hour 68 tablets |