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Brand name

Washington
Drugs with a quantity limit
Effective July 1, 2012
(Published June 15, 2012)

Brand Name
Comments
Limited to 1 package of 28 tablets per month. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Not available through mail order. Prior authorization required otherwise not covered. Limited to 4 syringes per prescription fill and up to 2 fills per month. Limited to 1 package per 91 days for 3 copays. Limited to 1 package per 91 days for 3 copays. amphetamine/dextroamphetamine SR Limited to 1 capsule per day. cap Androderm Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 4 injections per month. Not available through mail order. Limited to 1 package per 91 days for 3 copays. Limited to 1 package per 91 days for 3 copays. Prior authorization required otherwise not covered. Up to 2 capsules per day. Prior authorization required otherwise not covered. Up to 10 capsules per fill. Brand Name
Comments
Prior authorization required otherwise not covered. Limited to 1 kit per month. Not available through mail order. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 1 capsule per day. Prior authorization required otherwise not covered. Limited to 1 capsule per day. Limited to 10ml per prescription fill and 2 fills per month. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. The first fill of up to 20 syringes per year will process without prior authorization. Not available through mail order. Limited to 2 kits per fill. Not available through mail order. Limited to 2 kits per fill. Not available through mail order. Limited to 2 kits per fill. Not available through mail order. Limited to 1 ring per 90 days for 3 copays. Limited to 1 ring per 90 days for 3 copays. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. The first fill of up to 20 syringes per year will process without prior authorization. Not available through mail order. Brand Name
Comments
Prior authorization required otherwise not covered. Limited to 1 tablet per month. Prior authorization required otherwise not covered. Limited to 20 tablets per fill. Limited to 1 package per 91 days for 3 copays. Prior authorization required otherwise not covered. The first fill of up to 20 vials per year will process without prior authorization. Not available through mail order. Limited to 5 months treatment. Not available through mail order. Limited to 1 package per 91 days for 3 copays. Prior authorization required otherwise not covered. Limited to 10 tablets per fill. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Up to 2 tablets per day. Prior authorization required otherwise not covered. Up to 3 tablets per day. Limited to 12 tablets per fill and 2 fills per month. Limited to 12 tablets per fill and 2 fills per month. medroxyprogesterone acetate 150mg inj Limited to 1 injection per 90 days for 3 copays. meloxicam tablet methylphenidate SA OSM 18,27,54mg Limited to 1 tablet per day. tablet methylphenidate SA OSM 36mg tablet Limited to 2 tablets per day. methylphenidate SR 24 HR 20,40mg Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 2 tablets daily. Prior authorization required otherwise not covered. Limited to 1 capsule per day. Prior authorization required otherwise not covered. Limited to 1 packet per day. Up to 6 tablets per day. Maximum of 150 per 25 days. Up to 12 tablets per day. Maximum of 300 per 25 days. Up to 8 tablets per day. Maximum of 200 per 25 days. Brand Name
Comments
All oral contraceptives, with the exception of introvale, jolessa, quasense, amethia, amethia lo, camrese and camrese lo limited to 1 package per copay.* Limited to 1 tablet per month. Coverage authorized for members under 17 years of age.
Limited to 1 package per 91 days for 3 copays. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 2 tablets per day. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Limited to 1 bottle per day for up to a maximum of 5 days per fill. Not available through mail order. Limited to 4 syringes per prescription fill and 2 fills per month. Limited to 6 units per prescription fill and 2 fills per month. Limited to 9 tablets per prescription fill and 2 fills per month. Prior authorization required otherwise not covered. Limited to 4 syringes per prescription fill and 2 fills per month. Limited to 10 capsules per 6 month period. Not available through mail order. Limited to one fill of up to 180ml per 6 month period. Not available through mail order. Limited to 5 tablets per month. Not available through mail order. Prior authorization required otherwise not covered. Limited to 9 tablets per prescription fill and 2 fills per month. Brand Name
Comments
Limited to 2 syringes per fill. Not available through mail order. Prior authorization required otherwise not covered. Limited to 2 tablets per day. Prior authorization required otherwise highest copay applies. Limited to 1 tablet per day.
Prior authorization required otherwise not covered. Limited to 2 tablets per day. Prior authorization required otherwise not covered. Limited to 1 tablet per day. Prior authorization required otherwise not covered. Limited to 1 bottle per month. Limited to 6 tablets per fill and 2 fills per month. Limited to 6 units per fill, and 2 fills per month. Limited to 9 tablets per fill and 2 fills per month. Limited to 6 tablets per fill and 2 fills per month. Limited to 9 tablets per fill and 2 fills per month. Limited to 20 oral soluble films per 30 days. Health Net Health Plan of Oregon, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.

Source: http://www.pacifichealthtrust.com/2012-2013/7-2012%20WA%20QL.pdf

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