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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