Medicare Advantage Members
New Quantity Limits for 2024 |
|---|
| Drug | Amount/Frequency |
|---|
| ACETAMIN-CODEIN 300-30 MG/12.5 | 4500 ML/23 DAYS |
| ACETAMINOP-CODEINE 120-12 MG/5 | 4500 ML/23 DAYS |
| ARFORMOTEROL 15 MCG/2 ML SOLN | 60 VIALS/MONTH |
| ARIPIPRAZOLE 2 MG, 5 MG, 10 MG or 15 MG TABLET | 30/MONTH |
| ATORVASTATIN 10 MG, 20 MG, 40 MG or 80 MG TABLET | 30/MONTH |
| BUPRENORPHINE-NALOX 12-3MG FLM | 60/23 DAYS |
| BUPRENORPHINE-NALOX 2-0.5MG TB | 360/23 DAYS |
| BUPRENORPHINE-NALOX 8-2 MG TAB | 90/23 DAYS |
| BUPROPION HCL SR 150 MG TABLET | 60/MONTH |
| BUPROPION HCL XL 150 MG TABLET | 90/MONTH |
| BUPROPION HCL XL 300 MG TABLET | 30/MONTH |
| CICLOPIROX 8% SOLUTION | 6.6 ML/28 DAYS |
| CIPROFLOX-DEXAMETH OTIC SUSP | 1 BOTTLE/WEEK |
| CITALOPRAM HBR 40 MG TABLET | 30/MONTH |
| CLINDAMYCIN PH 1% SOLUTION | 120 ML/23 DAYS |
| CLOBETASOL 0.05% GEL | 120 GM/21 DAYS |
| CLONAZEPAM 0.5 MG TABLET | 90/MONTH |
| CLOPIDOGREL 75 MG TABLET | 30/MONTH |
| CLORAZEPATE 15 MG TABLET | 180/MONTH |
| CLORAZEPATE 3.75 MG TABLET | 90/MONTH |
| CLORAZEPATE 7.5 MG TABLET | 360/MONTH |
| DESVENLAFAXINE SUCCNT ER 25 MG or 50 MG | 30/MONTH |
| DIAZEPAM 5 MG TABLET | 120/MONTH |
| DULOXETINE HCL DR 20 MG, 30 MG or 60 MG CAP | 60/MONTH |
| ECONAZOLE NITRATE 1% CREAM | 85 GM/21 DAYS |
| ENOXAPARIN 120 MG/0.8 ML SYR | 1 SYR/MONTH |
| ERTAPENEM 1 GRAM VIAL | 14/14 DAYS |
| ESCITALOPRAM 10 MG TABLET | 30/MONTH |
| ESOMEPRAZOLE MAG DR 40 MG CAP | 60/MONTH |
| FLUOXETINE HCL 20 MG CAPSULE | 90/MONTH |
| FLUOXETINE HCL 40 MG CAPSULE | 60/MONTH |
| FORMOTEROL 20 MCG/2 ML NEB VL | 60 VIALS/MONTH |
| GABAPENTIN 600 MG TABLET | 180/MONTH |
| GABAPENTIN 800 MG TABLET | 120/MONTH |
| GLIMEPIRIDE 1 MG TABLET | 240/MONTH |
| GLIMEPIRIDE 2 MG TABLET | 120/MONTH |
| GLIMEPIRIDE 4 MG TABLET | 60/MONTH |
| GLIPIZIDE-METFORMIN 2.5-250 MG | 240/MONTH |
| GLIPIZIDE-METFORMIN 2.5-500 MG or 5-500 MG | 120/MONTH |
| HUMIRA(CF) PEN 80 MG/0.8 ML | 2 UNITS/FILL |
| HUMIRA(CF) PEN CRHN-UC-HS 80MG | 1 UNIT/MONTH |
| HYDROCODONE-ACETAMIN 7.5-325 or 10-325 MG | 360/23 DAYS |
| JENTADUETO 2.5 MG-500 MG TAB or 2.5 MG-1,000 MG TAB | 60/MONTH |
| JENTADUETO XR 2.5 MG-1,000 MG | 60/MONTH |
| JENTADUETO XR 5 MG-1,000 MG TB | 30/MONTH |
| KALYDECO 150 MG TABLET | 60/MONTH |
| LACOSAMIDE 10 MG/ML SOLUTION | 1,200 ML/30 DAYS |
| LACOSAMIDE 150 MG/15 ML CUP | 1,200 ML/MONTH |
| LACOSAMIDE 200 MG/20 ML CUP | 1,200 ML/MONTH |
| LANSOPRAZOLE DR 30 MG CAPSULE | 60/MONTH |
| LENALIDOMIDE 2.5 MG, 5 MG or 10 MG CAPSULE | 30/MONTH |
| LENVIMA 10 MG DAILY DOSE | 30/MONTH |
| LENVIMA 12 MG DAILY DOSE | 90/MONTH |
| LENVIMA 14 MG DAILY DOSE | 60/MONTH |
| LENVIMA 18 MG DAILY DOSE | 90/MONTH |
| LENVIMA 20 MG DAILY DOSE | 60/MONTH |
| LENVIMA 24 MG DAILY DOSE | 90/MONTH |
| LENVIMA 4 MG CAPSULE | 30/MONTH |
| LENVIMA 8 MG DAILY DOSE | 60/MONTH |
| LIDOCAINE 5% OINTMENT | 1 TUBE/23 DAYS |
| LIDOCAINE-PRILOCAINE CREAM | 30 GM TUBE/23 DAYS |
| LORAZEPAM 1 MG TABLET | 90/MONTH |
| LOVASTATIN 20 MG TABLET | 60/MONTH |
| MELOXICAM 7.5 MG or 15 MG TABLET | 30/MONTH |
| METFORMIN HCL 1,000 MG TABLET | 75/MONTH |
| METFORMIN HCL 500 MG TABLET | 150/MONTH |
| METFORMIN HCL 850 MG TABLET | 90/MONTH |
| METFORMIN HCL ER 500 MG TABLET | 120/MONTH |
| METFORMIN HCL ER 750 MG TABLET | 60/MONTH |
| MORPHINE SULF 10 MG/5 ML CUP | 900 ML/23 DAYS |
| MOVANTIK 12.5 MG or 25 MG TABLET | 30/MONTH |
| OLANZAPINE 20 MG TABLET | 30/MONTH |
| OMEPRAZOLE DR 40 MG CAPSULE | 60/MONTH |
| OXYCODONE HCL (IR) 10 MG TAB | 180/23 DAYS |
| PALIPERIDONE ER 1.5 MG, 3 MG or 9 MG TABLET | 30/MONTH |
| PALIPERIDONE ER 6 MG TABLET | 60/MONTH |
| PANTOPRAZOLE SOD DR 40 MG TAB | 60/MONTH |
| PERMETHRIN 5% CREAM | 60 GM TUBE/MONTH |
| PREGABALIN 150 MG CAPSULE | 90/MONTH |
| QUETIAPINE FUMARATE 25 MG, 50 MG, 100 MG or 200 MG TAB | 90/MONTH |
| QULIPTA 10 MG, 30 MG or 60 MG TABLET | 30/MONTH |
| REGRANEX 0.01% GEL | 15 GM TUBE/MONTH |
| REZUROCK 200 MG TABLET | 30/MONTH |
| ROFLUMILAST 250 MCG TABLET | 30/MONTH |
| ROSUVASTATIN CALCIUM 5 MG, 10 MG, 20 MG or 40 MG TAB | 30/MONTH |
| RYDAPT 25 MG CAPSULE | 240/MONTH |
| SERTRALINE HCL 100 MG TABLET | 60/MONTH |
| SERTRALINE HCL 25 MG TABLET | 30/MONTH |
| SEVELAMER CARBONATE 800 MG TAB | 270/MONTH |
| SHINGRIX VIAL KIT | 2 VACCINES/2 YEARS |
| SILDENAFIL 20 MG TABLET | 90/MONTH |
| SYNJARDY XR 10-1,000 MG TABLET | 30/MONTH |
| TACROLIMUS 0.03% OINTMENT | 100 GM/23 DAYS |
| TADALAFIL 20 MG TABLET | 60/MONTH |
| TALZENNA 0.25 MG CAPSULE | 30/MONTH |
| TERIFLUNOMIDE 7 MG or 14 MG TABLET | 30/MONTH |
| TRADJENTA 5 MG TABLET | 30/MONTH |
| TRULANCE 3 MG TABLET | 30/MONTH |
| VALACYCLOVIR HCL 1 GRAM TABLET | 120/MONTH |
| VALACYCLOVIR HCL 500 MG TABLET | 60/MONTH |
| VANCOMYCIN 1 GM VIAL | 20/10 DAYS |
| VANCOMYCIN 500 MG VIAL | 10/10 DAYS |
| VANCOMYCIN HCL 10 GM VIAL | 2/10 DAYS |
| VANCOMYCIN HCL 125 MG CAPSULE | 40/10 DAYS |
| VANCOMYCIN HCL 250 MG CAPSULE | 80/10 DAYS |
| XERMELO 250 MG TABLET | 90/MONTH |
| XOSPATA 40 MG TABLET | 90/MONTH |
| ZIPRASIDONE HCL 80 MG CAPSULE | 60/MONTH |
| ZOLINZA 100 MG CAPSULE | 120/MONTH |
| ZOLPIDEM TARTRATE 5 MG TABLET | 30/MONTH |
