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focusing on your safetyDrug Quantity Management Program8 Quantity limits help to promote appropriate use of selected medications and enhance patient safety. If your prescription is written for more than the allowed quantity, your prescription will be filled up to the allowed quantity. You can easily identify these drugs on our formulary and Preferred Medication List as they will have a QLL symbol next to them (refer to the Preferred Medication List on pages 5 – 7).
Your physician can direct Drug Quantity Management (DQM) override requests to CVS Caremark by faxing the request with supporting clinical information to CVS Caremark at 1-866-443-1172.
Classification
Drug Name
Retail Maximum Quantity Level
ANTIDEPRESSANT THERAPY
Celexa tablets
30 tablets of 10mg, 20mg, 30mg per 30-day period
Effexor XR tablets
30 tablets of 225mg; 60 tablets of 150mg; 90 tablets of 37.5mg,
Lexapro tablets
30 tablets of 5mg, 10mg, 20mg per 30-day period
Lexapro suspension
3 bottles ( 720ml ) per 30-day period
Paxil tablets
30 tablets of 10mg, 20mg, 30mg, 40mg per 30-day period
Paxil CR tablets
30 tablets of 12.5mg, 25mg per 30-day period
Pristiq tablets
30 tablets of 50mg, 100mg per 30-day period
Prozac capsules
30 capsules of 10mg, 20mg per 30-day period
Prozac Weekly
4 capsules of 90mg per 30-day period
ANTIEMETIC THERAPY
Anzemet tablets
5 tablets of 50mg, 100mg per rx
Cesamet capsules
6 capsules of 1mg per rx
Emend capsules
8 capsules of 40mg, 80mg; 4 capsules of 125mg; 4 packs per rx
Kytril tablets
8 tablets of 1mg per rx
Kytril suspension
2 bottles (60ml) per rx
Sancuso patch
1 patch per rx
Zofran tablets
24 tablets of 4mg, 8mg; 4 tablets of 24mg per rx
Zofran suspension
5 bottles (250ml) per rx
ANTI-FLu THERAPY
Relenza inhalations
1 kit per rx; max of 2 rxs per year
Tamiflu capsules
10 capsules of 30mg, 45mg, 75mg per rx; max of 2 rxs per year
Tamiflu suspension
1 bottle (75 ml) per rx; max of 2 rxs per year
ANTI-HYPERTENSIVE THERAPY
Lotrel capsules
30 capsules of 2.5/10mg, 5/10mg per rx
Norvasc tablets
30 tablets of 2.5mg, 5mg per rx
Tarka tablets
30 tablets of 1/240mg, 2/180mg per rx
BISPHOSPHONATE THERAPY
Actonel tablets
4 tablets of 35mg; 2 tablets of 75mg per 28-day period
Actonel+Calcium tablets
4 tablets per 28-day period
Boniva tablets
1 tablet of 150mg per 28-day period
Fosamax tablets
4 tablets of 35mg, 70mg per 28-day period
Fosamax+D tablets
4 tablets per 28-day period
DISEASE MODIFYING
Cimzia
8 injectables of 200mg per 30-day period
ANTI-RHEuMATIC DRuG (DMARD) INjECTABLE
Enbrel
4 injectables of 50mg; 8 injectables of 25mg per day 30-day period
BIOLOGICALS
Humira
2 injectables of 40mg per 30-day period
Simponi
1 injectable of 50mg per 30-day period
ERECTILE DYSFuNCTION THERAPY
Caverject injection
Therapy class allows 6 units (any combination of products) per • Cialis tablets
Edex injection
Levitra tablets
Muse inserts
Viagra tablets
CHOLESTEROL-LOWERING THERAPY
Crestor tablets
30 tablets of 5mg, 10mg, 20mg, 40mg per 30-day period
Lescol XL tablets
30 tablets of 80mg per 30-day period
Lipitor tablets
30 tablets of 10mg, 20mg, 40mg per 30-day period
Livalo tablets
30 tablets of 1mg, 2mg, 4mg per 30-day period
Pravachol tablets
30 tablets of 10mg, 20mg, 40mg per 30-day period
Simcor tablets
60 tablets of 500/20mg, 750/20mg, 1,000/20mg per 30-day period
Zocor tablets
30 tablets of 5mg, 10mg, 40mg per 30-day period
LOW MOLECuLAR WEIGHT HEPARIN THERAPY
Arixtra injection
10 syringes per 30-day period
Innohep injection
10 syringes per 30-day period
Fragmin injection
20 syringes per 30-day period
Lovenox injection
20 syringes per 30-day period
Classification
Drug Name
Retail Maximum Quantity Level
MIGRAINE THERAPY
Amerge tablets
9 tablets of 2.5mg; 20 tablets of 1mg per 30-day period
Axert tablets
8 tablets of 12.5mg; 18 tablets of 6.25mg per 30-day period
Frova tablets
9 tablets of 2.5mg per 30-day period
Imitrex tablets
9 tablets of 100mg; 18 tablets of 50mg; 36 tablets of 25mg
per 30-day period
Imitrex nasal spray
8 nasal sprays of 20mg; 32 of 5mg per 30-day period
Imitrex injection
4 kits (8 syringes or vials) per 30-day period
Maxalt/-MLT tabs
12 tablets of 10mg; 24 tablets of 5mg per 30-day period
Migranal NS spray
1 kit (8 ampules) per 30-day period
Relpax tablets
6 tablets of 40mg; 12 tablets of 20mg per 30-day period
Stadol NS spray
4 spray pumps of 2.5ml per 30-day period
Sumavel injection
4 kits (8 syringes or vials) per 30-day period
Treximet tablets
9 tablets per 30-day period
Zomig tablets
9 tablets of 5mg; 18 tablets of 2.5mg per 30-day period
Zomig nasal spray
8 nasal sprays of 5mg per 30-day period
NARCOTIC PAIN RELIEVER THERAPY
Actiq lozenges
120 lozenges per 30-day period
Avinza capsules
60 capsules per 30-day period
codeine with acetaminophen
4500mls of 12/120mg per 5ml solution per 30-day period
360 tablets of 15/300mg, 30/300mg per 30-day period
180 tablets of 60/300mg per 30-day period
codeine with aspirin9
180 tablets per 30-day period
Duragesic patches
10 patches per 30-day period
Fentora lozenges
120 lozenges per 30-day period
hydrocodone with
360 tablets of 5/325mg per 30-day period
acetaminophen
240 tablets of 2.5/500mg, 5/500mg, 7.5/325mg per 30-day period
180 tablets of 7.5/500mg, 7.5/650mg, 10/325mg, 10/500mg,
10/650mg, 10/660mg per 30-day period
150 tablets of 7.5/750mg, 10/750mg per 30-day period
hydrocodone with ibuprofen
150 tablets or capsules per 30-day period
Kadian capsules
60 capsules per 30-day period
MS Contin tablets
90 tablets per 30-day period
Nucynta tablets
360 tablets of 50mg; 240 tablets of 75mg;
180 tablets of 100mg per 30-day period
Onsolis soluble films
120 films per 30-day period
Opana ER tablets
90 tablets per 30-day period
oxycodone with
360 tablets of 2.5/325mg, 5/325mg per 30-day period
acetaminophen
240 tablets of 5/500mg, 7.5/325mg, 7.5/500mg per 30-day period
180 tablets of 10/325mg, 10/650mg per 30-day period
oxycodone with aspirin
300 tablets of 4.5/325mg per 30-day period
oxycodone with ibuprofen
120 tablets per 30-day period
Oxycontin tablets
90 tablets per 30-day period
propoxyphene and
240 tablets of 50/325mg per 30-day period
acetaminophen
180 tablets of 100/325mg, 100/500mg, 65/650mg, 100/650mg per
Ryzolt ER tablets
30 tablets per 30-day period
tramadol extended release
90 tablets of 100mg per 30-day period
60 tablets of 200mg per 30-day period
30 tablets of 300mg per 30-day period
ultram/ultracet
240 tablets per 30-day period
NON-STEROIDAL
Mobic tablets
30 tablets of 7.5mg, 15mg per rx
ANTI-INFLAMMATORY THERAPY
Mobic suspension
3 bottles (300ml) per rx
PROTON PuMP INHIBITOR THERAPY
Aciphex tablets
30 tablets/capsules per 30-day period
Dexilant capsules
Nexium capsules
Prevacid
Prilosec capsules
Protonix tablets
Zegerid capsules
RESPIRATORY MEDICATIONS
Advair
1 inhaler per 30-day period
Aerobid
Alvesco
Asmanex
Azmacort
Dulera
Flovent
Pulmicort
Qvar
Symbicort
SEDATIVE/HYPNOTIC THERAPY
Ambien tablets
Therapy class allows 30 units (any combination of products) per • Ambien CR tablets
Lunesta tablets
Sonata capsules
MISCELLANEOuS MEDICATIONS
Adrenaclick
1 injectable per rx
Ampyra tablets
60 tablets per 30-day period
Epipen/Epipen jr.
1 injectable per rx
Estrogel
1 pump (93g) per rx (at mail, limit is 2 pumps per rx)
Flonase nasal spray
1 nasal spray per rx
Invega tablets
60 tablets per 30-day period
Lysteda tablets
30 tablets per 30-day period
Relistor injection
• First prescription limited to 3 doses with therapy duration no longer
than 4 months
Seroquel XR tablets
30 tablets per 30-day period
Twinject Auto-Injector
1 injectable per rx
Veramyst nasal spray
1 nasal spray per rx
Zyprexa tablets
30 tablets of all strengths per rx
Zyprexa Zydis tablets
30 tablets of 5mg, 10mg, 15mg, 20mg per rx
8 This list is not intended to be a complete list of drug classifications and is subject to change. Some classifications of drugs may not be covered under your prescription drug program. Please refer to your Certificate of Coverage for specific terms, conditions, exclusions, and limitations relating to our DQM override requests are processed as soon as possible once all information/documentation is received by CVS Caremark. For requests that meet predetermined clinical criteria, notification of approval will be communicated to the physician and to the Member in writing. If DQM override request is denied, written notification, including the reason for the denial, will be sent to the Member and the prescribing physician. Participating physicians and Members have the right to appeal a denial. Appeal instructions are provided with the written denial notification.
Drug quantity level limits apply to all applicable generic equivalents of the brand-name products listed in this document. Applicable mail service quantity levels are two to three times the retail quantity level limits, depending on the prescription drug benefit design chosen by the Member or employer group.
Current as of January 2011. 9 Effective April 1, 2011.
• Mandatory Generic Substitution Program is when a generic drug is substituted for a brand-name product. If a generic drug is available and is not substituted for a brand-name drug even if your doctor has requested Brand necessary, you will be charged the brand-name copayment or coinsurance plus the cost difference between the • Restrictive Generic Substitution Program allows your physician to specify that a brand-name drug be dispensed “No Generic Substitution Permissible” on the written prescription. In this case, you will only be charged the brand-name copayment or coinsurance. But, if you request a brand-name drug when a generic is available, you will be charged the brand-name copayment or coinsurance plus the cost difference between the generic and brand-name medication.
CuraScript®, Inc. . . . committed to providing affordable care, one patient at a timeThrough a special arrangement with CuraScript, Inc., Capital BlueCross makes it easy for you to get the patient care you deserve and the speciality medications (self-administered) you need to help manage your unique health conditions.

Source: http://lehighcounty.org/Portals/0/Intranet/PDF/HR/CVS_DrugQuantity.pdf

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