The following medications are subject to formulary quantity limits as shown (each entry lists the product and the explicit quantity limit).
Akynzeo — Quantity Limit: 30 EA Per 10 Days
Albuterol Sulfate HFA — Quantity Limit: 1 inhaler Per 30 Days (1 EA Max Qty Per Fill Retail)
Almotriptan Malate — Quantity Limit: 6 EA Per 30 Days
Amphetamine-Dextroamphetamine (oral tablets) — Quantity Limit: 3 EA Per 1 Day
Andembry (auto-injector) — Quantity Limit: 2.4 ML Per 30 Days
Aprepitant (125 mg, 80 mg capsules) — Quantity Limit: 3 EA Per 30 Days; aprepitant 40 mg — Quantity Limit: 1 EA Per 30 Days; aprepitant therapy pack — Quantity Limit: 1 EA Per 30 Days
Avmapki Fakzynja Co-Pack (oral therapy pack) — Quantity Limit: 66 EA Per 28 Days
Benzonatate (100 mg) — Quantity Limit: 60 EA Per 10 Days
Bethkis (inhalation nebulization solution) — Quantity Limit: 224 ML Per 28 Days
Bromfenac Sodium (ophthalmic solution 0.07%) — Quantity Limit: 2 fills Per 1 Year
Buprenorphine HCl sublingual tablet — Quantity Limit: 6 EA Per 2 Days
Caverject Impulse / Caverject intracavernosal kits/solutions — Quantity Limit: 6 EA Per 30 Days
Cayston (inhalation solution, reconstituted) — Quantity Limit: 84 ML Per 28 Days
Cladribine therapy packs (4,5,6,7,8,9,10 tab variants) — Quantity Limit: 20 EA Per 294 Days
Clindamycin HCl (capsules) — Quantity Limit: 120 EA Per 10 Days
Clomid / clomiphene citrate oral tablet — Quantity Limit: 10 EA Per 30 Days
Clotrimazole-Betamethasone external lotion — Quantity Limit: 10 EA Per 30 Days (also noted: 2 fills Per 180 Days)
Clozapine (various strengths/dispersible) — Quantity Limits vary by strength (examples: 100 mg — 270 EA Per 30 Days; 50 mg — 540 EA Per 30 Days)
Coartem (oral tablet) — Quantity Limit: 24 EA Per 30 Days
Cromolyn Sodium (nebulization solution) — Quantity Limit: 240 ML Per 30 Days
Dihydroergotamine Mesylate injection solution — Quantity Limit: 10 ML Per 30 Days; nasal solution — Quantity Limit: 8 ML Per 30 Days
Doxylamine-Pyridoxine delayed release — Quantity Limit: 3 fills Per 365 Days
Duopa enteral suspension — Quantity Limit: 3000 ML Per 30 Days
Edex (2 or 6 cartridge intracavernosal kits) — Quantity Limit: 6 EA Per 30 Days
Eletriptan Hydrobromide — Quantity Limit: 6 EA Per 30 Days
Ella (oral tablet) — Quantity Limit: 1 EA Per 30 Days
Emend oral suspension (reconstituted) — Quantity Limit: 3 days Per 30 Days
Endometrin vaginal insert — Quantity Limit: 4 fills Per 365 Days
Epinephrine auto-injector (0.15 mg/0.3 mL, 0.3 mg/0.3 mL) — Quantity Limit: 4 fills Per 365 Days
Filspari oral tablet 200 mg — Quantity Limit: 1 EA Per 1 Day
Fondaparinux Sodium subcutaneous solution — Quantity Limit: 14 days Max Qty Per Fill Retail
Fosfomycin Tromethamine oral packet — Quantity Limit: 1 EA Per 1 Fill
Fragmin subcutaneous solution (various presentations) — Quantity Limit: 14 days Max Qty Per Fill Retail
Frovatriptan Succinate — Quantity Limit: 9 EA Per 30 Days
Granisetron HCl — Quantity Limit: 2 EA Per 30 Days
HumaLOG (various formulations, pens, cartridges) — Quantity Limit: 1.5 ML Per 1 Day
HumuLIN (70/30, N, R, U-500 etc.) — Quantity Limit: 1.5 ML Per 1 Day (applies to many insulin pen/cartridge formats)
Ibandronate Sodium oral tablet — Quantity Limit: 1 EA Per 30 Days
Ingrezza oral capsule (40 mg, 60 mg) — Quantity Limit: 30 EA Per 30 Days
Insulin Glargine Max SoloStar / Solostar — Quantity Limit: 1.5 ML Per 1 Day
Ketorolac Tromethamine oral tablet — Quantity Limit: 20 EA Per 5 Days
Kitabis Pak (with nebulizer) — Quantity Limit: 280 ML Per 28 Days
Lagevrio oral capsule — Quantity Limit: 40 EA Per 5 Days
Lantus / Lantus SoloStar — Quantity Limit: 1.5 ML Per 1 Day
Levonorgestrel 1.5 mg oral tablet — Quantity Limit: 1 EA Per 30 Days
Lisdexamfetamine Dimesylate (capsule/tablet chewable) — Quantity Limit: 1 EA Per 1 Day
Lofexidine HCl oral tablet — Quantity Limit: 224 EA Per 14 Days
Lyumjev (injection and KwikPen) — Quantity Limit: 1.5 ML Per 1 Day
Methylergonovine Maleate oral tablet — Quantity Limit: 28 EA Per 7 Days
Tamiflu (capsules and suspension) — Quantity Limit: 2 fills Per 365 Days
Tetrabenazine (12.5 mg) — Quantity Limit: 3 EA Per 1 Day; (25 mg) — 4 EA Per 1 Day
Tobi Podhaler — Quantity Limit: 224 mL Per 28 Days
Tobramycin inhalation solution — Quantity Limit: 280 ML Per 28 Days
Toujeo / Toujeo Max SoloStar — Quantity Limit: 1.5 ML Per 1 Day
Tresiba / Tresiba FlexTouch — Quantity Limit: 1.5 ML Per 1 Day
Valtoco (5,10,15,20 mg dose variants) — Quantity Limit: 5 EA Per 30 Days (examples shown for multiple dose packs)
Vijoice oral packet — Quantity Limit: 30 EA Per 30 Days
Vistogard oral packet — Quantity Limit: 20 EA Per 5 Days
Xcopri (various daily dose therapy packs) — Quantity Limit: 28–56 EA Per 28–30 Days depending on pack/dose
Xifaxan (200 mg) — Quantity Limit: 9 EA Per 3 Days
Xofluza therapy packs (40 mg, 80 mg) — Quantity Limit: 2 fills Per 365 Days
Zelsuvmi external gel — Quantity Limit: 31 GM Per 30 Days
Zolmitriptan — Quantity Limit: 6 EA Per 30 Days