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Medication	Clinical Edits and Guidelines
Accupril ® (all strengths except 40mg)	Daily Dose 1 per day
Accuretic™ 10/12.5mg	Daily Dose 1 per day
Accutane ®	Quantity Limit - 30 day supply. No refills allowed. Not filled in mail order.
Aceon ® (all strengths except 8mg)	Daily Dose 1 per day
Aciphex ®	Step Therapy
Adalat CC ® 30mg	Daily Dose 1 per day
Aerobid ® /Aerobid M ® inhaler	Quantity Limit - 3 inhalers per 30 days Age/gender The male only edit applies to impotency, benign prostatic hypertrophy, propecia, and androgen medications. The female only edit applies to vaginal products, estrogen, progestational agents, follicle stimulating/ lutenizing hormone, contraceptive agents, Diflucan 150mg, prenatal vitamins, and Zelnorm. The age edit applies to Cognex, Aricept, Exelon, Reminyl, Namenda, Feldene, Zelnorm and the tetracycline class of antibiotics.
Alamast™	Quantity Limit - 1 bottle per month
Aldara™	Quantity Limit - 12 packets per 28 days
Alocril™	Quantity Limit - 1 bottle per month
Alomide ®	Quantity Limit - 1 bottle per month
Altace ® (all strengths except 10mg)	Daily Dose 1 per day
Altoprev (formerly Altocor) 10mg, 20mg	Daily Dose 1 per day
Alupent ® inhaler	Quantity Limit - 3 inhalers per 30 days
Amerge ®	Quantity Limit - 9 tablets per 30 days
Androderm ®	Prior Authorization
AndroGel ®	Prior Authorization
Android ®	Prior Authorization
Anzemet ® 50mg tablets	Quantity Limit - 10 tablets per 30 days
Anzemet ® 100mg tablets	Quantity Limit - 5 tablets per 30 days
Arava™	Step Therapy
Atacand ® (all strengths except 32mg)	Daily Dose 1 per day
Atrovent ® inhaler	Quantity Limit - 3 inhalers per 30 days
Atrovent ® nebulizer solution	Quantity Limit - 150 unit dose vials (2.5ml ea.) per 30 days
Atrovent ® .03% nasal spray	Quantity Limit - 2 bottles per 30 days
Atrovent ® .06% nasal spray	Quantity Limit - 3 bottles per 30 days
Augmentin ® tablets; suspension	Quantity Limit - 60 days every 3 months
Avapro ® (all strengths except 300mg)	Daily Dose 1 per day
Axert™	Quantity Limit - 6 tablets per 30 days
Azmacort ®	Quantity Limit - 2 inhalers per 30 days
Beconase AQ ® nasal inhaler	Quantity Limit - 2 inhalers per 30 days
Benicar™ 20mg	Daily Dose 1 per day
Benicar™ HCT 20/12.5mg	Daily Dose 1 per day
Bextra ®	Step Therapy
Cardizem ® CD 120mg, LA 120mg, LA 180mg	Daily Dose 1 per day
Ceftin ® tablets and suspension	Quantity Limit - 60 days every 3 months
Celebrex ® 100 mg	Step Therapy Quantity Limit - 120 tablets per 30 days
Celebrex ® 200 mg	Step Therapy Quantity Limit - 60 tablets per 30 days
Celebrex ® 400 mg	Step Therapy Quantity Limit - 30 tablets per 30 days
Celexa™ 10mg, 20mg	Quantity Limit - Daily Dose 1 per day
Cialis ® /Alpha Blockers	Cialis will reject at the point of sale if alpha blockers (except Flomax) are in the customer's prescription profile in the last 90 days.
Cialis ® /Nitrate	Cialis will reject at the point of sale if nitrates are in the customer's prescription profile in the last 90 days.
Combivent ® inhaler	Quantity Limit - 3 inhalers per 30 days
Cozaar ® 25mg, 50mg	Daily Dose 1 per day
Crestor ® 5mg, 10mg, 20mg	Quantity Limit - Daily Dose 1 per day
Crolom ®	Quantity Limit - 1 bottle per month
Delatestryl ®	Prior Authorization
Depo-Testosterone ®	Prior Authorization
Diflucan ® 150mg tablets	Quantity Limit - 2 tablets per 30 days for females
Dilacor ® XR 120mg	Daily Dose 1 per day
Diovan ® (all strength except 320mg)	Daily Dose 1 per day
Diovan ® HCT 80/12.5mg	Daily Dose 1 per day
Effexor XR 37.5mg, 75mg	Daily Dose 1 per day
Elastat	Quantity Limit - 1 bottle per month
Emadine ®	Quantity Limit - 1 bottle per month
Emend ® 80mg	Quantity Limit - 8 capsules per 30 days
Emend ® 125mg	Quantity Limit - 4 capsules per 30 days
Emend ® Therapy Pack	Quantity Limit - 4 Packs (12 capsules) per 30 days
Enbrel™	Step Therapy
Flonase ® nasal inhaler	Quantity Limit - 1 inhaler per 30 days
Flovent ® 44 inhaler, 110 inhaler	Quantity Limit - 1 inhaler (13gm) per 30 days
Flovent ® 220 inhaler	Quantity Limit - 2 inhalers (13gm) per 30 days
Flovent Rotadisk ® 50 mcg, 100mcg	Quantity Limit - 1 inhaler per 30 days
Flovent Rotadisk ® 250mcg	Quantity Limit - 4 inhalers per 30 days
Fluoxetine ® 10mg cap, tab	Daily Dose 1 per day
Foradil ®	Quantity Limit - 2 inhalers per 30 days
Foradil ® /Advair Diskus ®	Foradil will reject at the point of sale if Advair is in the customer's prescription profile in the last 90 days.
Forteo™	Prior Authorization
Frova™	Quantity Limit - 9 tablets per 30 days
Gleevec ®	Prior Authorization
Halotestin ®	Prior Authorization
Humira ®	Step Therapy
Hyzaar ® 50/12.5mg	Daily Dose 1 per day
Imitrex ® injection	Quantity Limit - 4 injections per 30 days
Imitrex ® tablets	Quantity Limit - 9 tablets per 30 days
Imitrex ® nasal inhaler	Quantity Limit - 6 nasal inhalers per 30 days
Infergen™	Prior Authorization
Intron A ®	Prior Authorization
Iressa ®	Prior Authorization
Kineret ®	Step Therapy
Kytril ® 1mg tablets	Quantity Limit - 8 tablets per 30 days
Kytril ® susp	Quantity Limit - 40ml per 30 days
Lescol ® 20mg, 40mg	Daily Dose 1 per day
Levitra ® /Alpha Blockers	Levitra will reject at the point of sale if alpha blockers (except Flomax) are in the customer's prescription profile in the last 90 days.
Levitra ® /Nitrate	Prior Authorization Levitra will reject at the point of sale if nitrates are in the customer's prescription history in the last 90 days.
Lexapro™ 5mg, 10mg	Daily Dose 1 per day
Lipitor ® 10mg, 20mg, 40mg	Daily Dose 1 per day
Livostin ®	Quantity Limit - 1 bottle per month
Lortab ® 10	Quantity Limit - 8 tablets per day
Lotensin ® (all strengths except 40mg)	Daily Dose 1 per day
Lotensin ® HCT (all strengths except 20/12.5mg)	Daily Dose 1 per day
Luvox™ 25mg	Daily Dose 1 per day
Luvox™ 50mg	Daily Dose 1 per day
Malarone ®	Prior Authorization
Mavik ® (all strengths except 4mg)	Daily Dose 1 per day
Maxair Autohaler™	Quantity Limit - 2 inhalers per 30 days
Maxalt-MLT ® tablet	Quantity Limit - 12 tablets per 30 days
Maxalt ® tablets	Quantity Limit - 12 tablets per 30 days
Mepron ®	Prior Authorization
Methitest™	Prior Authorization
Mevacor ® 10mg	Daily Dose 1 per day
Mevacor ® 20mg	Daily Dose 1 per day
Micardis ® (all strengths except 80mg)	Daily Dose 1 per day
Migranal ® nasal inhaler	Quantity Limit - 1 kit = 4 canisters per 30 days
Monopril ® (all strengths except 40mg)	Daily Dose 1 per day
Nasacort ® nasal inhaler	Quantity Limit - 3 inhalers per 30 days
Nasacort AQ ® nasal inhaler	Quantity Limit - 1 inhaler per 30 days
Nasalide ® nasal inhaler	Quantity Limit - 3 inhalers per 30 days
Nasarel ® nasal inhaler	Quantity Limit - 3 inhalers per 30 days
Nasonex ® nasal inhaler	Quantity Limit - 1 inhaler per 30 days
Nexium ®	Step Therapy
Norvasc ® 2.5mg, 5mg	Daily Dose 1 per day
Opticrom ®	Quantity Limit - 1 bottle per month
Optivar™	Quantity Limit - 1 bottle per month
Panretin ®	Prior Authorization
Patanol ®	Quantity Limit - 1 bottle per month
Paxil ® 10mg, 20mg, CR 12.5mg	Quantity Limit - Daily Dose 1 per day
Pegasys ®	Prior Authorization
Peg-Intron™	Prior Authorization
Penlac™	Step Therapy
Pexeva 10mg, 20mg	Daily Dose 1 per day
Plan B	Quantity Limit - 4 tablets per 30 days, 1 copay per 2 tablets
Plendil ® (all strengths except 10mg)	Daily Dose 1 per day
Pravachol ® 10mg, 20mg, 40mg	Daily Dose 1 per day
Pregnancy Category X	Claim will reject at point of sale for Category X drugs when customer is also receiving prenatal vitamins. Warning message will be transmitted to pharmacy for customers receiving prenatal vitamins and Category C & D drugs.
Prevacid ® Capsules	Step Therapy
Preven™ kit	Quantity Limit - 2 kits per 30 days, 1 copay per kit
Prilosec ® 40mg	Step Therapy
Primaxin ® injection	Quantity Limit - 30 days every 3 months
Prinivil ® (all strengths except 40mg)	Daily Dose 1 per day
Prinzide ® 10/12.5mg	Daily Dose 1 per day
Procardia ® XL 30mg	Daily Dose 1 per day
Proventil ® (albuterol)	Quantity Limit - 3 inhalers per 30 days
Provigil ®	Quantity Limit - 200mg per day and Prior Authorization
Prozac ® 10mg cap	Daily Dose 1 per day
Pulmicort ® inhaler	Quantity Limit - 1 inhaler per 25 days
Pulmicort ® respules	Quantity Limit - 2 boxes per 30 days
QVAR™ inhaler	Quantity Limit - 3 inhalers per 30 days
Rebetron™	Prior Authorization
Relenza ® inhaler	Quantity Limit - 1 carton (5-day supply) per member per prescription. Adults age 7 and older. No mail service for this drug.
Relpax ®	Quantity Limit - 6 tablets per 30 days
Rhinocort ® nasal inhaler	Quantity Limit - 2 inhalers per 30 days
Rhinocort Aqua™ nasal inhaler	Quantity Limit - 2 inhalers per 30 days
Rocephin ® injection	Quantity Limit - 30 days every 3 months
Roferon A ®	Prior Authorization
Serevent Diskus ® (28 & 60 each)	Quantity Limit - 3 inhalers per month on the 28 each package Quantity Limit - 2 inhalers per month on the 60 each package
Serevent Diskus ® (28 & 60 each)/Advair Diskus ®	Serevent will reject at the point of sale if Advair is in the customer's prescription profile in the last 90 days.
Spiriva ®	Quantity Limit - 1 inhaler per 30days
Stadol ® nasal spray	Quantity Limit - 1 bottle per 30 days
Sular ® 10mg, 20mg	Daily Dose 1 per day
Suprax ®	Quantity Limit - 60 days every 3 months
Tamiflu™	Quantity Limit - 1 package per member per prescription fill and 2 packages per year. Age 1 and older. No mail service for this drug.
Testim ®	Prior Authorization
Testopel ®	Prior Authorization
Testosterone Cream ® /Ointment	Prior Authorization
Testred ®	Prior Authorization
Thalomid ®	Prior Authorization
Tiazac™ 120mg, 180mg	Daily Dose 1 per day
Topamax ®	Prior Authorization
Toradol ® injections	Quantity Limit - 1 injection per 30 days
Toradol ® tablets	Quantity Limit - 20 tablets per 30 days
Uniretic ® 7.5/12.5mg	Daily Dose 1 per day
Univasc ® 7.5mg	Daily Dose 1 per day
Ventolin ® (albuterol)	Quantity Limit - 3 inhalers per 30 days
Verelan PM ® 100mg	Daily Dose 1 per day
Viagra ® /Nitrate	Viagra will reject at the point of sale if nitrates are in the customer's prescription history in the last 90 days.
Zaditor ®	Quantity Limit - 1 bottle per month
Zestoretic ® 10/12.5mg	Daily Dose 1 per day
Zestril ® (all strengths except 40mg)	Daily Dose 1 per day
Zithromax ® 250mg tablets	Quantity Limit - 6 tablets per fill, 5 day therapy
Zithromax ® 500mg tablets	Quantity Limit - 3 tablets per fill
Zithromax ® 600mg tablets	Quantity Limit - 8 tablets per 30 days
Zithromax ® Suspension 100mg/5ml	Quantity Limit - 75ml per fill
Zithromax ® Suspension 200mg/5ml	Quantity Limit - 37.5ml per fill
Zithromax ® Packets 1 gram	Quantity Limit - 2 packets per fill
Zocor ® 5mg, 10mg, 20mg, 40mg	Daily Dose 1 per day
Zofran ® /Zofran ® ODT(TM) 4mg tablets	Quantity Limit - 48 tablets per 30 days
Zofran ® /Zofran ® ODT(TM) 8mg tablets	Quantity Limit - 24 tablets per 30 days
Zofran ® 24mg tablets	Quantity Limit - 8 tablets per 30 days
Zofran ® Susp	Quantity Limit - 240ml per 30 days
Zoloft 25mg, 50mg	Daily Dose 1 per day
Zomig ® tablets	Quantity Limit - 6 tablets per 30 days
Zomig ® nasal spray	Quantity Limit - 6 inhalers per 30 days