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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 30-day or 90-day supply.  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 Express Scripts 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 is a list of the categories that have some or all medications that are limited in quantity. The medication(s) in these categories are alphabetically listed below.

Please note that this list may not be all-inclusive and is subject to change.

Anticholinergics/Antispasmodics
Antineoplastic/Immunosuppressant Agents
Antiviral Agents
Diabetes Therapy
Diagnostics/Miscellaneous Agents
Erectile Dysfunction/Impotence Agents
Estrogens/Progestins
Migraine Therapy Drugs
Miscellaneous Gastrointestinal Agents
Miscellaneous Hormones
Miscellaneous Neurological Therapies
Multiple Sclerosis Therapy Drugs
Narcotic Analgesics
Non-Narcotic Analgesics
Ophthalmic Therapy Drugs -  Miscellaneous
Osteoporosis Therapy Drugs
Psychotherapeutic Drugs
Pulmonary Agents
Rheumatoid Arthritis Therapy Drugs
Tobacco Cessation Drugs
Topical Anesthetics

QUANTITY LIMIT MEDICATIONS
Drug Name Dosage Form Route of Admin Strength Tier Level Value Quantity Limit Amount Quantity Limit Days
ACTONEL TABLET ORAL 30MG 3 60 120
AFINITOR TABLET ORAL 10MG 4 180 90
AFINITOR TABLET ORAL 2.5MG 4 270 90
AFINITOR TABLET ORAL 5MG 4 270 90
AFINITOR TABLET ORAL 7.5MG 4 180 90
ALENDRONATE SODIUM TABLET ORAL 10MG 1 90 90
ALENDRONATE SODIUM TABLET ORAL 35MG 1 12 90
ALENDRONATE SODIUM TABLET ORAL 40MG 1 180 365
ALENDRONATE SODIUM TABLET ORAL 5MG 1 90 90
ALENDRONATE SODIUM TABLET ORAL 70MG 1 12 90
ALORA PATCH BIWEEKLY TRANSDERMAL 0.025MG/24HR 2 24 90
ALORA PATCH BIWEEKLY TRANSDERMAL 0.05MG/24HR 2 24 90
ALORA PATCH BIWEEKLY TRANSDERMAL 0.075MG/24HR 2 24 90
ALORA PATCH BIWEEKLY TRANSDERMAL 0.1MG/24HR 2 24 90
ANDROGEL GEL TRANSDERMAL 50MG/5GM 2 900 90
ANDROGEL PUMP GEL TRANSDERMAL 1.62% 2 900 90
AVONEX KIT INJECTION 30MCG/0.5ML 4 12 90
AVONEX KIT INJECTION 30MCG/VIAL 4 12 90
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" MISCELLANEOUS DOES NOT APPLY   2 600 90
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISCELLANEOUS DOES NOT APPLY   2 600 90
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISCELLANEOUS DOES NOT APPLY   2 600 90
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" MISCELLANEOUS DOES NOT APPLY   2 600 90
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM MISCELLANEOUS DOES NOT APPLY   2 600 90
BETASERON SOLUTION RECONSTITUTED INJECTION 0.3MG 4 45 90
BUPROBAN TABLET EXTENDED RELEASE 12 HOUR ORAL 150MG 5 180 90
BUTORPHANOL TARTRATE SOLUTION NASAL 10MG/ML 1 30 90
BYETTA SOLUTION INJECTION 10MCG/0.04ML 2 7.2 90
BYETTA SOLUTION INJECTION 5MCG/0.02ML 2 7.2 90
CALCITONIN-SALMON SOLUTION NASAL 200UNIT/ACT 1 12 90
CAPRELSA TABLET ORAL 100MG 4 180 90
CAPRELSA TABLET ORAL 300MG 4 90 90
CHANTIX TABLET ORAL 0.5MG 5 336 365
CHANTIX TABLET ORAL 1MG 5 336 365
CIMZIA KIT INJECTION 200MG 4 6 28
CIMZIA KIT INJECTION 200MG/ML 4 6 28
CLIMARA PRO PATCH WEEKLY TRANSDERMAL 0.045MG/DAY; 0.015MG/DAY 2 12 90
COMBIPATCH PATCH BIWEEKLY TRANSDERMAL 0.05MG/DAY; 0.14MG/DAY 2 24 90
COMBIPATCH PATCH BIWEEKLY TRANSDERMAL 0.05MG/DAY; 0.25MG/DAY 2 24 90
COPAXONE KIT INJECTION 20MG/ML 4 90 90
DIVIGEL GEL TRANSDERMAL 1MG/GM 2 90 90
EMEND CAPSULE ORAL 0 2 18 90
EMEND CAPSULE ORAL 125MG 2 6 90
EMEND CAPSULE ORAL 40MG 2 3 90
EMEND CAPSULE ORAL 80MG 2 24 90
EMSAM PATCH 24 HOUR TRANSDERMAL 12MG/24HR 3 90 90
EMSAM PATCH 24 HOUR TRANSDERMAL 6MG/24HR 3 90 90
EMSAM PATCH 24 HOUR TRANSDERMAL 9MG/24HR 3 90 90
ENBREL KIT INJECTION 25MG 4 600 90
ENBREL SOLUTION INJECTION 25MG/0.5ML 4 600 90
ENBREL SOLUTION INJECTION 50MG/ML 4 600 90
ESTRADIOL PATCH WEEKLY TRANSDERMAL 0.025MG/24HR 1 12 90
ESTRADIOL PATCH WEEKLY TRANSDERMAL 0.05MG/24HR 1 12 90
ESTRADIOL PATCH WEEKLY TRANSDERMAL 0.06MG/24HR 1 12 90
ESTRADIOL PATCH WEEKLY TRANSDERMAL 0.075MG/24HR 1 12 90
ESTRADIOL PATCH WEEKLY TRANSDERMAL 0.1MG/24HR 1 12 90
ESTRADIOL PATCH WEEKLY TRANSDERMAL 37.5MCG/24HR 1 12 90
FENTANYL PATCH 72 HOUR TRANSDERMAL 100MCG/HR 1 30 90
FENTANYL PATCH 72 HOUR TRANSDERMAL 12MCG/HR 1 30 90
FENTANYL PATCH 72 HOUR TRANSDERMAL 25MCG/HR 1 30 90
FENTANYL PATCH 72 HOUR TRANSDERMAL 50MCG/HR 1 30 90
FENTANYL PATCH 72 HOUR TRANSDERMAL 75MCG/HR 1 30 90
FENTANYL CITRATE ORAL TRANSMUCOSAL LOLLIPOP BUCCAL 1200MCG 4 360 90
FENTANYL CITRATE ORAL TRANSMUCOSAL LOLLIPOP BUCCAL 1600MCG 4 360 90
FENTANYL CITRATE ORAL TRANSMUCOSAL LOLLIPOP BUCCAL 200MCG 1 360 90
FENTANYL CITRATE ORAL TRANSMUCOSAL LOLLIPOP BUCCAL 400MCG 4 360 90
FENTANYL CITRATE ORAL TRANSMUCOSAL LOLLIPOP BUCCAL 600MCG 4 360 90
FENTANYL CITRATE ORAL TRANSMUCOSAL LOLLIPOP BUCCAL 800MCG 4 360 90
FLUNISOLIDE SOLUTION NASAL 0.025% 1 200 90
FLUTICASONE PROPIONATE SUSPENSION NASAL 50MCG/ACT 1 48 90
FORTEO SOLUTION INJECTION 600MCG/2.4ML 2 7.2 90
FORTICAL SOLUTION NASAL 200UNIT/ACT 1 12 90
GILENYA CAPSULE ORAL 0.5MG 4 28 28
HUMALOG SOLUTION INJECTION 100UNIT/ML 2 60 30
HUMALOG KWIKPEN SOLUTION INJECTION 100UNIT/ML 2 60 30
HUMALOG MIX 50/50 SUSPENSION INJECTION 50UNIT/ML; 50UNIT/ML 2 60 30
HUMALOG MIX 50/50 KWIKPEN SUSPENSION INJECTION 50UNIT/ML; 50UNIT/ML 2 60 30
HUMALOG MIX 75/25 SUSPENSION INJECTION 25UNIT/ML; 75UNIT/ML 2 60 30
HUMALOG MIX 75/25 KWIKPEN SUSPENSION INJECTION 25UNIT/ML; 75UNIT/ML 2 60 30
HUMIRA KIT INJECTION 20MG/0.4ML 4 2.4 90
HUMIRA KIT INJECTION 40MG/0.8ML 4 4.8 90
HUMULIN 70/30 SUSPENSION INJECTION 30UNIT/ML; 70UNIT/ML 2 60 30
HUMULIN 70/30 PEN SUSPENSION INJECTION 30UNIT/ML; 70UNIT/ML 2 60 30
HUMULIN N SUSPENSION INJECTION 100UNIT/ML 2 60 30
HUMULIN N U-100 PEN SUSPENSION INJECTION 100UNIT/ML 2 60 30
HUMULIN R SOLUTION INJECTION 100UNIT/ML 2 60 30
HUMULIN R U-500 (CONCENTRATED) SOLUTION INJECTION 500UNIT/ML 2 60 30
INCIVEK TABLET ORAL 375MG 4 504 84
JAKAFI TABLET ORAL 10MG 4 180 90
JAKAFI TABLET ORAL 15MG 4 180 90
JAKAFI TABLET ORAL 20MG 4 180 90
JAKAFI TABLET ORAL 25MG 4 180 90
JAKAFI TABLET ORAL 5MG 4 180 90
LANTUS SOLUTION INJECTION 100UNIT/ML 2 30 30
LANTUS SOLOSTAR SOLUTION INJECTION 100UNIT/ML 2 30 30
LEFLUNOMIDE TABLET ORAL 10MG 1 90 90
LEFLUNOMIDE TABLET ORAL 20MG 1 90 90
LETAIRIS TABLET ORAL 10MG 4 90 90
LETAIRIS TABLET ORAL 5MG 4 90 90
LEVEMIR SOLUTION INJECTION 100UNIT/ML 2 30 30
LEVEMIR FLEXPEN SOLUTION INJECTION 100UNIT/ML 2 30 30
MENOSTAR PATCH WEEKLY TRANSDERMAL 14MCG/24HR 3 12 90
MIGRANAL SOLUTION NASAL 4MG/ML 3 24 90
NARATRIPTAN HCL TABLET ORAL 1MG 1 36 90
NARATRIPTAN HCL TABLET ORAL 2.5MG 1 24 90
NEXAVAR TABLET ORAL 200MG 4 360 90
NICOTROL INHALER INHALER INHALATION 10MG 5 2688 365
NICOTROL NS SOLUTION NASAL 10MG/ML 5 7200 365
NOVOLIN 70/30 SUSPENSION INJECTION 30UNIT/ML; 70UNIT/ML 2 60 30
NOVOLIN N SUSPENSION INJECTION 100UNIT/ML 2 60 30
NOVOLIN R SOLUTION INJECTION 100UNIT/ML 2 60 30
NOVOLOG SOLUTION INJECTION 100UNIT/ML 2 60 30
NOVOLOG FLEXPEN SOLUTION INJECTION 100UNIT/ML 2 60 30
NOVOLOG MIX 70/30 SUSPENSION INJECTION 30UNIT/ML; 70UNIT/ML 2 60 30
NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUSPENSION INJECTION 30UNIT/ML; 70UNIT/ML 2 60 30
NUEDEXTA CAPSULE ORAL 20MG; 10MG 2 180 90
ONDANSETRON HCL TABLET ORAL 24MG 1 21 90
ONDANSETRON HCL TABLET ORAL 4MG 1 135 90
ONDANSETRON HCL TABLET ORAL 8MG 1 135 90
ONDANSETRON ODT TABLET DISPERSIBLE ORAL 4MG 1 135 90
ONDANSETRON ODT TABLET DISPERSIBLE ORAL 8MG 1 135 90
ONSOLIS FILM BUCCAL 1200MCG 2 360 90
ONSOLIS FILM BUCCAL 200MCG 2 720 90
ONSOLIS FILM BUCCAL 400MCG 2 360 90
ONSOLIS FILM BUCCAL 600MCG 2 360 90
ONSOLIS FILM BUCCAL 800MCG 2 360 90
OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR ORAL 10MG 2 540 90
OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR ORAL 20MG 2 540 90
OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR ORAL 30MG 2 540 90
OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR ORAL 40MG 2 540 90
OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR ORAL 5MG 2 540 90
ORENCIA SOLUTION INJECTION 125MG/1ML 4 12 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 10MG 3 540 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 15MG 3 540 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 20MG 3 540 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 30MG 3 540 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 40MG 3 540 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 60MG 3 540 90
OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR ORAL 80MG 3 540 90
OXYTROL PATCH BIWEEKLY TRANSDERMAL 3.9MG/24HR 2 32 90
PEG-INTRON KIT INJECTION 50MCG/0.5ML 4 12 90
PEG-INTRON REDIPEN KIT INJECTION 120MCG/0.5ML 4 12 90
PEG-INTRON REDIPEN KIT INJECTION 150MCG/0.5ML 4 12 90
PEG-INTRON REDIPEN KIT INJECTION 50MCG/0.5ML 4 12 90
PEG-INTRON REDIPEN KIT INJECTION 80MCG/0.5ML 4 12 90
PEGASYS KIT INJECTION 180MCG/0.5ML 4 6 90
PEGASYS SOLUTION INJECTION 180MCG/ML 4 12 90
PEGASYS PROCLICK SOLUTION INJECTION 135MCG/0.5ML 4 12 90
PROMACTA TABLET ORAL 12.5MG 4 90 90
PROMACTA TABLET ORAL 25MG 4 90 90
PROMACTA TABLET ORAL 50MG 4 90 90
PROMACTA TABLET ORAL 75MG 4 90 90
PROVIGIL TABLET ORAL 100MG 2 90 90
PROVIGIL TABLET ORAL 200MG 2 90 90
REBIF SOLUTION INJECTION 22MCG/0.5ML 4 18 90
REBIF SOLUTION INJECTION 44MCG/0.5ML 4 18 90
RELENZA DISKHALER AEROSOL POWDER BREATH ACTIVATED INHALATION 5MG/BLISTER 2 300 365
RELPAX TABLET ORAL 20MG 3 36 90
RELPAX TABLET ORAL 40MG 3 36 90
RESTASIS EMULSION OPHTHALMIC 0.05% 2 192 90
REVATIO SOLUTION INJECTION 10MG/12.5ML 4 3375 90
REVATIO TABLET ORAL 20MG 4 270 90
REVLIMID CAPSULE ORAL 10MG 4 30 30
REVLIMID CAPSULE ORAL 15MG 4 21 28
REVLIMID CAPSULE ORAL 25MG 4 21 28
REVLIMID CAPSULE ORAL 5MG 4 30 30
SANCUSO PATCH TRANSDERMAL 3.1MG/24HR 2 6 90
SILENOR TABLET ORAL 3MG 3 90 90
SILENOR TABLET ORAL 6MG 3 90 90
SIMPONI SOLUTION INJECTION 50MG/0.5ML 4 1 30
SKELID TABLET ORAL 200MG 3 180 90
SPRYCEL TABLET ORAL 100MG 4 90 90
SPRYCEL TABLET ORAL 140MG 4 90 90
SPRYCEL TABLET ORAL 20MG 4 180 90
SPRYCEL TABLET ORAL 50MG 4 90 90
SPRYCEL TABLET ORAL 70MG 4 90 90
SPRYCEL TABLET ORAL 80MG 4 90 90
SUMATRIPTAN SUCCINATE SOLUTION INJECTION 6MG/0.5ML 1 12 90
SUMATRIPTAN SUCCINATE SOLUTION INJECTION 6MG/0.5ML 1 12 90
SUMATRIPTAN SUCCINATE TABLET ORAL 100MG 1 27 90
SUMATRIPTAN SUCCINATE TABLET ORAL 25MG 1 54 90
SUMATRIPTAN SUCCINATE TABLET ORAL 50MG 1 54 90
SUTENT CAPSULE ORAL 12.5MG 4 90 90
SUTENT CAPSULE ORAL 25MG 4 90 90
SUTENT CAPSULE ORAL 50MG 4 90 90
SYLATRON KIT INJECTION 296MCG 4 12 90
SYLATRON KIT INJECTION 444MCG 4 12 90
SYLATRON KIT INJECTION 888MCG 4 8 90
SYMLINPEN 120 SOLUTION INJECTION 2700MCG/2.7ML 3 33 90
SYMLINPEN 60 SOLUTION INJECTION 1500MCG/1.5ML 3 33 90
TAMIFLU CAPSULE ORAL 30MG 2 120 365
TAMIFLU CAPSULE ORAL 45MG 2 60 365
TAMIFLU CAPSULE ORAL 75MG 2 60 365
TAMIFLU SUSPENSION RECONSTITUTED ORAL 6MG/ML 2 720 365
TARCEVA TABLET ORAL 100MG 4 90 90
TARCEVA TABLET ORAL 150MG 4 90 90
TARCEVA TABLET ORAL 25MG 4 180 90
TASIGNA CAPSULE ORAL 150MG 4 336 84
TASIGNA CAPSULE ORAL 200MG 4 336 84
TRACLEER TABLET ORAL 125MG 4 180 90
TRACLEER TABLET ORAL 62.5MG 4 180 90
TYKERB TABLET ORAL 250MG 4 540 90
VICTRELIS CAPSULE ORAL 200MG 4 1008 84
VIDAZA SUSPENSION RECONSTITUTED INJECTION 100MG 4 4200 90
VIVELLE-DOT PATCH BIWEEKLY TRANSDERMAL 0.025MG/24HR 2 24 90
VIVELLE-DOT PATCH BIWEEKLY TRANSDERMAL 0.0375MG/24HR 2 24 90
VIVELLE-DOT PATCH BIWEEKLY TRANSDERMAL 0.05MG/24HR 2 24 90
VIVELLE-DOT PATCH BIWEEKLY TRANSDERMAL 0.075MG/24HR 2 24 90
VIVELLE-DOT PATCH BIWEEKLY TRANSDERMAL 0.1MG/24HR 2 24 90
VOTRIENT TABLET ORAL 200MG 4 360 90
XALKORI CAPSULE ORAL 200MG 4 180 90
XALKORI CAPSULE ORAL 250MG 4 180 90
XGEVA SOLUTION INJECTION 120MG/1.7ML 4 5.1 90
XOLAIR SOLUTION RECONSTITUTED INJECTION 150MG 4 7.2 30
ZALEPLON CAPSULE ORAL 10MG 1 180 90
ZALEPLON CAPSULE ORAL 5MG 1 90 90
ZELBORAF TABLET ORAL 240MG 4 720 90
ZOLINZA CAPSULE ORAL 100MG 4 360 90
ZOLPIDEM TARTRATE TABLET ORAL 10MG 1 90 90
ZOLPIDEM TARTRATE TABLET ORAL 5MG 1 90 90
ZOLPIDEM TARTRATE ER TABLET EXTENDED RELEASE ORAL 12.5MG 1 90 90
ZOLPIDEM TARTRATE ER TABLET EXTENDED RELEASE ORAL 6.25MG 1 90 90
ZYTIGA TABLET ORAL 250MG 4 360 90

 

Last Modified on 05/08/2013
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