HealthChoice Medicare Supplement Plans
Medications with Quantity Limits
Due to approved therapy guidelines the following medications have set maximum quantity limits per copay. These quantity limits are less than the standard pharmacy benefit of a 34-days supply or 100 units. Quantity limits are determined by the recommended length of therapy and/or routine use of the medication and also apply when the medication form is other than a tablet or capsule.
New medications that become available in the drug categories listed below will automatically have quantity limits per copay. New drug categories may be added throughout the year. If a generic equivalent of one of these medications is available, the quantity limit will also apply.
Be aware that non-formulary medications that have been approved for coverage by a prior authorization, may also be limited in quantity.
If you have questions about medications with quantity limits, please contact Medco at the following numbers:
Members with Part D call toll-free 1-800-590-6828.
TDD users call toll-free 1-800-716-3231.
Members without Part D call toll-free 1-800-903-8113.
TDD users call toll-free 1-800-825-1230.
This list may not be all-inclusive and is subject to change.
Anticholinergics/Antispasmodics
Antineoplastic/Immunosuppressant Agents
Antiviral Agents
Diabetes Therapy
Diagnosics/Miscellaneous Agents
Erectile Dysfunction/Impotence Agents
Estrogens/Progestins
Migraine Therapy Drugs
Miscellaneous Gastroinestinal Agents
Miscellaneous Hormones
Miscellaneous Neurological Therapies
Multiple Sclerosis Therapy Drugs
Narcotic Analgesics
Non-Narcotic Analgesics
Ophthalmic Therapy Drugs - Miscellaneous
Osteoporosis Therapy Drugs
Psychotherapeutic Drugs
Pumonary Agents
Rheumatoid Arthritis Therapy Drugs
Smoking Deterrents
Topical Anesthetics
| Drug Category | Drug Name | Quantity/Days |
Anticholinergics/Antispasmodics |
||
|
Oxytrol - 3.9mg/24Hr transdermal patch |
48/90 |
|
Antineoplastic/Immunosuppressant Agents |
|
|
|
Afinitor - 10mg oral tablet |
180/90 |
|
|
Afinitor - 2.5mg oral tablet |
270/90 |
|
|
Afinitor - 5mg oral tablet |
270/90 |
|
|
Nexavar - 200mg oral tablet |
360/90 |
|
|
Revlimid - 10mg oral capsule |
30/30 |
|
|
Revlimid - 15mg oral capsule |
21/28 |
|
|
Revlimid - 25mg oral capsule |
21/28 |
|
|
Revlimid - 5mg oral capsule |
30/30 |
|
|
Sprycel - 100mg oral tablet |
90/90 |
|
|
Sprycel - 140mg oral tablet |
90/90 |
|
|
Sprycel - 20mg oral tablet |
180/90 |
|
|
Sprycel - 50mg oral tablet |
90/90 |
|
|
Sprycel - 70mg oral tablet |
90/90 |
|
|
Sprycel - 80mg oral tablet |
90/90 |
|
|
Sutent - 12.5mg oral capsule |
90/90 |
|
|
Sutent - 25mg oral capsule |
90/90 |
|
|
Sutent - 50mg oral capsule |
90/90 |
|
|
Tarceva - 100mg oral tablet |
90/90 |
|
|
Tarceva - 150mg oral tablet |
90/90 |
|
|
Tarceva - 25mg oral tablet |
180/90 |
|
|
Tasigna - 200mg oral capsule |
336/84 |
|
|
Tykerb - 250mg oral tablet |
540/90 |
|
|
Vandetanib - 100mg oral tablet |
180/90 |
|
|
Vandetanib - 300mg oral tablet |
90/90 |
|
|
Vidaza - 100mg injection suspension |
4200/90 |
|
|
Votrient - 200mg oral tablet |
360/90 |
|
|
Zolinza - 100mg oral capsule |
360/90 |
|
|
Zytiga - 250mg oral tablet |
360/90 |
|
|
|
|
|
Antiviral Agents: |
|
|
|
Relenza Diskhaler - 5mg/blister inhalation aerosol powder breath activated |
300/365 |
|
|
Tamiflu - 30mg oral capsule |
120/365 |
|
|
Tamiflu - 45mg oral capsule |
60/365 |
|
|
Tamiflu - 75mg oral capsule |
60/365 |
|
Diabetes Therapy: |
|
|
|
Apidra - 100unit/ml injection solution |
120/90 |
|
|
Apidra Solostar - 100unit/ml injection solution |
120/90 |
|
|
BD Insulin Syringe Safetyglide/1ml/29g x 1/2" |
600/90 |
|
|
BD Insulin Syringe Ultrafine/0.3ml/31g x 5/16" |
600/90 |
|
|
BD Insulin Syringe Ultrafine/0.5ml/30g x 1/2" |
600/90 |
|
|
BD Insulin Syringe Ultrafine/1ml/31g x 5/16" |
600/90 |
|
|
BD Pen Needle Ultrafine 29g x 12.7mm |
600/90 |
|
|
Byetta - 10mcg/0.04ml injection solution |
7.2/90 |
|
|
Byetta - 5mcg/0.02ml injection solution |
7.2/90 |
|
|
Humalog - 100unit/ml injection solution |
120/90 |
|
|
Humalog Kwikpen - 100unit/ml injection solution |
120/90 |
|
|
Humalog Mix 50/50 - 50%; 50% injection solution |
120/90 |
|
|
Humalog Mix 50/50 Kwikpen - 50%; 50% injection solution |
135/90 |
|
|
Humalog Mix 75/25 - 25%; 75% injection solution |
120/90 |
|
|
Humalog Mix 75/25 Kwikpen - 25%; 75% injection solution |
135/90 |
|
|
Humulin 70/30 - 30%; 70% injection suspension |
120/90 |
|
|
Humulin 70/30 Pen- 30%; 70% injection suspension |
135/90 |
|
|
Humulin N - 100unit/ml injection suspension |
120/90 |
|
|
Humulin N U-100 Pen - 100unit/ml injection suspension |
135/90 |
|
|
Humulin R - 100unit/ml injection suspension |
120/90 |
|
|
Lantus - 100unit/ml injection solution |
120/90 |
|
|
Lantus Solostar - 100unit/ml injection solution |
120/90 |
|
|
Levemir - 100unit/ml injection solution |
120/90 |
|
|
Levemir Flexpen - 100unit/ml injection solution |
135/90 |
|
|
Novolin 70/30 - 30%; 70% injection suspension |
120/90 |
|
|
Novolin N - 100unit/ml injection suspension |
120/90 |
|
|
Novolin R - 100unit/ml injection solution |
120/90 |
|
|
Novolog - 100unit/ml injection solution |
120/90 |
|
|
Novolog Flexpen- 100unit/ml injection solution |
135/90 |
|
|
Novolog Mix 70/30 - 30%; 70% injection suspension |
120/90 |
|
|
Novolog Mix 70/30 Flexpen - 30%; 70% injection suspension |
135/90 |
|
|
Symlin - 600mcg/ml injection solution |
60/90 |
|
|
Symlinpen 120 - 1000mcg/ml injection solution |
33/90 |
|
|
Symlinpen 60 - 1000mcg/ml injection solution |
33/90 |
|
Diagnosics/Miscellaneous Agents: |
|
|
|
alendronate sodium - 40mg oral tablet |
90/90 |
|
Erectile Dysfunction/Impotence Agents: |
|
|
|
Caverject - 20mcg injection solution reconstituted |
6/30 |
|
|
Caverject - 40mcg injection solution reconstituted |
6/30 |
|
|
Caverject Impulse - 10mcg kit |
6/30 |
|
|
Caverject Impulse - 20mcg kit |
6/30 |
|
|
Cialis - 2.5mg oral tablet |
6/30 |
|
|
Cialis - 5mg oral tablet |
6/30 |
|
|
Cialis - 10mg oral tablet |
6/30 |
|
|
Cialis - 20mg oral tablet |
6/30 |
|
|
Levitra - 10mg oral tablet |
6/30 |
|
|
Levitra - 2.5 mg oral tablet |
6/30 |
|
|
Levitra - 20mg oral tablet |
6/30 |
|
|
Levitra - 5mg oral tablet |
6/30 |
|
|
Muse - 1000mcg urethral pellet |
6/30 |
|
|
Muse - 125mcg urethral pellet |
6/30 |
|
|
Muse - 250mcg urethral pellet |
6/30 |
|
|
Muse - 500mgc urethral pellet |
6/30 |
|
|
Viagra - 25mg oral tablet |
6/30 |
|
|
Viagra - 50mg oral tablet |
6/30 |
|
|
Viagra - 100mg oral tablet |
6/30 |
|
Estrogens/Progestins: |
|
|
|
Alora - .025mg/24hr biweekly transdermal patch |
24/90 |
|
|
Alora - .05mg/24hr biweekly transdermal patch |
24/90 |
|
|
Alora - .075mg/24hr biweekly transdermal patch |
24/90 |
|
|
Alora - .1mg/24hr biweekly transdermal patch |
24/90 |
|
|
Climara Pro - .045mg/day; .015mg/day transdermal weekly patch |
12/90 |
|
|
Combipatch - .05mg/day; .14mg/day transdermal biweekly patch |
24/90 |
|
|
Combipatch - .05mg/day; .25mg/day transdermal biweekly patch |
24/90 |
|
|
Divigel - 1mg/gm transdermal gel |
90/90 |
|
|
Estraderm - 0.05mg/24hr transdermal biweekly patch |
24/90 |
|
|
Estraderm - 0.1mg/24hr transdermal biweekly patch |
24/90 |
|
|
Estradiol - 0.025mg/24hr transdermal weekly patch |
12/90 |
|
|
Estradiol - 0.05mg/24hr transdermal weekly patch |
12/90 |
|
|
Estradiol - 0.06mg/24hr transdermal weekly patch |
12/90 |
|
|
Estradiol - 0.075mg/24hr transdermal weekly patch |
12/90 |
|
|
Estradiol - 0.1mg/24hr transdermal weekly patch |
12/90 |
|
|
Estradiol - 37.5mcg/24hr transdermal weekly patch |
12/90 |
|
|
Menostar - 14mcg/24hr transdermal weekly patch |
12/90 |
|
|
Vivelle-Dot - 0.025mg/24hr transdermal biweekly patch |
24/90 |
|
|
Vivelle-Dot - 0.0375mg/24hr transdermal biweekly patch |
24/90 |
|
|
Vivelle-Dot - 0.05mg/24hr transdermal biweekly patch |
24/90 |
|
|
Vivelle-Dot - 0.075mg/24hr transdermal biweekly patch |
24/90 |
|
|
Vivelle-Dot - 0.1mg/24hr transdermal biweekly patch |
24/90 |
|
Migraine Therapy Drugs: |
|
|
|
butorphanol tartrate - 10mg/ml nasal solution |
30/90 |
|
|
Maxalt - 10mg oral tablet |
36/90 |
|
|
Maxalt - 5mg oral tablet |
36/90 |
|
|
Maxalt-MLT - 10mg oral dispersible tablet |
36/90 |
|
|
Maxalt-MLT - 5mg oral dispersible tablet |
36/90 |
|
|
Migranal - 4mg/ml nasal solution |
24/90 |
|
|
Naratriptan HCL - 1mg oral tablet |
36/90 |
|
|
Naratriptan HCL - 2.5mg oral tablet |
24/90 |
|
|
Relpax - 20mg oral tablet |
24/90 |
|
|
Relpax - 40mg oral tablet |
24/90 |
|
|
sumatriptan succinate - 6mg/0.5ml injection solution |
12/90 |
|
|
sumatriptan succinate - 100mg oral tablet |
27/90 |
|
|
sumatriptan succinate - 25mg oral tablet |
54/90 |
|
|
sumatriptan succinate - 50mg oral tablet |
54/90 |
|
|
Zomig - 5mg nasal solution |
24/90 |
|
|
Zomig - 2.5mg oral tablet |
36/90 |
|
|
Zomig - 5mg oral tablet |
24/90 |
|
|
Zomig ZMT - 2.5mg oral dispersible tablet |
36/90 |
|
|
Zomig ZMT - 5mg oral dispersible tablet |
24/90 |
|
Miscellaneous Gastrointestinal Agents: |
|
|
|
Cimzia - 200mg injection kit |
6/28 |
|
|
Cimzia - 200mg/ml injection kit |
6/28 |
|
|
Emend - 125mg oral capsule |
6/90 |
|
|
Emend - 40mg oral capsule |
3/90 |
|
|
Emend - 80mg oral capsule |
24/90 |
|
|
ondansetron hcl - 24mg oral tablet |
21/90 |
|
|
ondansetron hcl - 4mg oral tablet |
135/90 |
|
|
ondansetron hcl - 8mg oral tablet |
135/90 |
|
|
ondansetron odt - 4mg oral dispersible tablet |
135/90 |
|
|
ondansetron odt - 8mg oral dispersible tablet |
135/90 |
|
|
Sancuso - 3.1mg/24hr transdermal patch |
6/90 |
|
|
Zuplenz - 4mg film |
135/90 |
|
|
Zuplenz - 8mg film |
135/90 |
|
Miscellaneous Hormones: |
|
|
|
Androderm - 2.5mg/24hr transdermal patch |
180/90 |
|
|
Androderm - 5mg/24hr transdermal patch |
180/90 |
|
|
Androgel - 50mg/5gm transdermal patch gel |
900/90 |
|
|
calcitonin-salmon - 200unit/act nasal solution |
12/90 |
|
|
fortical 200unit/act nasal solution |
12/90 |
|
|
Somavert - 10mg injection solution reconstituted |
90/90 |
|
|
Somavert - 15mg injection solution reconstituted |
90/90 |
|
|
Somavert - 20mg injection solution reconstituted |
90/90 |
|
Miscellaneous Neurological Therapies: |
|
|
|
Copaxone - 20mg/ml injection kit |
90/90 |
|
|
Gilenya - .5mg oral capsule |
28/28 |
|
Multiple Sclerosis Therapy Drugs: |
|
|
|
Avonex - 30mcg/0.5ml injection kit |
12/90 |
|
|
Avonex - 30mcg/vial |
12/90 |
|
|
Betaseron - 0.3mg injection solution reconstituted |
45/90 |
|
|
Rebif - 22mcg/0.5ml injection solution |
18/90 |
|
|
Rebif - 44mcg/0.5ml injection solution |
18/90 |
|
Narcotic Analgesics: |
|
|
|
fentanyl - 100mcg/hr transdermal 72 hour patch |
45/90 |
|
|
fentanyl - 12mcg/hr transdermal 72 hour patch |
45/90 |
|
|
fentanyl - 25mcg/hr transdermal 72 hour patch |
45/90 |
|
|
fentanyl - 50mcg/hr transdermal 72 hour patch |
45/90 |
|
|
fentanyl - 75mcg/hr transdermal 72 hour patch |
45/90 |
|
Non-Narcotic Analgesics: |
|
|
|
butorphanol tartrate - 10mg/ml nasal solution |
30/90 |
|
Ophthalmic Therapy Drugs - Miscellaneous: |
|
|
|
Restasis - 0.05% ophthalmic emulsion |
192/90 |
|
Osteoporosis Therapy Drugs: |
|
|
|
alendronate sodium - 10mg oral tablet |
90/90 |
|
|
alendronate sodium - 35mg oral tablet |
12/90 |
|
|
alendronate sodium - 40mg oral tablet |
90/90 |
|
|
alendronate sodium - 5mg oral tablet |
90/90 |
|
|
alendronate sodium - 70mg oral tablet |
12/90 |
|
|
Boniva - 150mg oral tablet |
3/90 |
|
|
Forteo - 600mcg/2.4ml injection solution |
7.2/90 |
|
Psychotherapeutic Drugs: |
|
|
|
Emsam - 12mg/24hr transdermal 24 hour patch |
90/90 |
|
|
Emsam - 6mg/24hr transdermal 24 hour patch |
90/90 |
|
|
Emsam - 9mg/24hr transdermal 24 hour patch |
90/90 |
|
|
Provigil - 100mg oral tablets |
90/90 |
|
|
Provigil - 200mg oral tablets |
90/90 |
|
|
zaleplon - 10mg oral capsule |
180/365 |
|
|
zaleplon - 5mg oral capsule |
180/365 |
|
|
zolpidem tartrate - 10mg oral tablet |
180/365 |
|
|
zolpidem tartrate - 5mg oral tablet |
180/365 |
|
|
zolpidem tartrate ER - 12.5mg oral tablet |
180/365 |
|
Pulmonary Agents: |
|
|
|
flunisolide - 0.025% nasal solution |
200/90 |
|
|
fluticasone propionate - 50mcgt/act nasal suspension |
48/90 |
|
|
Xolair - 150mg injection solution |
7.2/30 |
|
Rheumatoid Arthritis Therapy Drugs: |
|
|
|
Enbrel - 25mg injection kit |
600/90 |
|
|
Enbrel - 25mg/.5ml injection solution |
600/90 |
|
|
Enbrel - 50mg/ml injection solution |
600/90 |
|
|
Humira - 20mg/0.4ml injection kit |
2.4/90 |
|
|
Humira - 40mg/0.8ml injection kit |
4.8/90 |
|
|
leflunomide - 10mg oral tablet |
90/90 |
|
|
leflunomide - 20mg oral tablet |
90/90 |
|
|
Simponi - 50mg/0.5ml injection solution |
1/30 |
|
Smoking Deterrents: |
|
|
|
buproban - 150mg oral tablet |
180/90 |
|
|
Chantix - .05mg oral tablet |
336/365 |
|
|
Chantix - 1mg oral tablet |
336/365 |
|
|
Nicotrol Inhaler - 10mg inhaler |
2688/365 |
|
|
Nicotrol NS - 10mg/ml nasal solution |
7200/365 |
|
Topical Anesthetics: |
|
|
|
Lidoderm - 5% external patch |
270/90 |
Last Modified on 01/11/2012