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October 2019Value Formulary TieredMedicines with Clinical Requirements: Quantity Limits (QL)Below is a list of medicines by drug class that have limits on the amounts of medicine that Value Formulary plans cover.This is to help make sure that you receive the correct amounts of medicine to effectively treat your health condition. Thelimits listed below only affect the amount of medicine covered by your plan. No further action from your doctor is requiredif your current prescription includes an amount of medicine less than these limits.Category*Drug ClassMedicines with Quantity LimitsLimit for 30-Day Limit for ZOLAM INTENSOL120 mL360 mLalprazolam 0.25 mg, 0.5 mg, 1 mg90 tablets270 tabletsalprazolam 2 mg60 tablets180 tabletschlordiazepoxide360 capsules1,080 capsulesClonazepam orally disin tegrating tablet300 tablets900 tabletsclorazepate120 tablets360 tabletsDIAZEPAM INTENSOL240 mL720 mLdiazepam oral solution1,200 mL3,600 mLdiazepam120 tablets360 tabletslorazepam concentrated solution150 mL450 mLlorazepam150 tablets450 tabletsoxazepam120 capsules360 capsulesAnti-infectives*Miscellaneousvancomycin, FIRVANQ450 mL/10 days450 mL/10 daysvancomycin capsules, VANCOCIN80 capsules/10 days80 capsules/10daysAntipuriticsPRUDOXIN, ZONALON, doxepin90 grams90 gramsAsthma*Steroid InhalantsAEROSPAN HFA†240 inhalations/2 packages720 inhalations/6 packagesALVESCO 80 mcg/actuation †180 inhalations/3 packages540 inhalations/9 packagesALVESCO 160 mcg/actuation †120 inhalations /2 packages360 inhalations/6 packagesARMONAIR RESPICLICK1 package3 packagesARNUITY ELLIPTA30 inhalations/1 package90 inhalations/3 packagesASMANEX 110 mcg/inh, 60-220 mcg/inh †2 inhalations/2 packages6 inhalations/6 packagesASMANEX 30-220 mcg/inh †4 inhalations/4 packages12 inhalations/12 packagesASMANEX 120-220 mcg/inh †1 inhalations/1 package3 inhalations/3 packagesbudesonide 0.25 mg/respule120 mL/3 packages360 mL/9 packagesbudesonide 0.50 mg/respule120 mL/2 packages360 mL/6 packagesbudesonide 1 mg/respule60 mL/1 package180 mL/3 packagesFLOVENT DISKUS 50 mcg/blister180 blisters/3 packages540 blisters/9 packages1
Category*Drug ClassAsthma* or ChronicObstructive PulmonaryDisease (COPD)*Steroid/Beta AgonistCombinationsAttention DeficitHyperactivity Disorder*Chronic ObstructivePulmonary Disease (COPD)*Anticholinergics,Long-ActingMedicines with Quantity LimitsLimit for 30-Day Limit for 90-DayPrescriptionsPrescriptionsFLOVENT DISKUS 100 mcg/blister, 250 mcg/blister240 blisters/4 packages720 blisters/12 packagesFLOVENT HFA24 grams/2 packages72 grams/6 packagesPULMICORT FLEXHALER 90 mcg/actuation †3 inhalations/3 packages9 inhalations/9 packagesPULMICORT FLEXHALER 180 mcg/actuation †2 inhalations/2 packages6 inhalations/6 packagesPULMICORT RESPULES 0.25 mg180 mL540 mLPULMICORT RESPULES 0.5 mg120 mL360 mLPULMICORT RESPULES 1 mg60 mL180 mLQVAR240 inhalations/2 packages720 inhalations/6 packagesADVAIR60 blisters/1 package180 blisters/3 packagesADVAIR HFA120 inhalations/1 package360 inhalations/3 packagesAIRDUO RESPICLICK1 package3 packagesBREO ELLIPTA†30 inhalations/1 package90 inhalations/3 packagesDULERA†120 inhalations/1 package360 inhalations/3 packagesSYMBICORT†120 inhalations/1 package360 inhalations/3 packagesatomoxetine 10 mg, 18 mg, 25 mg120 capsules360 capsulesatomoxetine 40 mg60 capsules180 capsulesatomoxetine 60 mg, 80 mg, 100 mg30 capsules90 capsulesDAYTRANA†30 patches90 patchesDESOXYN†150 tablets450 tabletsdexmethylphenid ate extended-release 30 mg, 35 mg, 40 mg30 capsules90 capsulesmethylphenidate 5 mg/5 mL solution1,800 mL3,600 mLmethylphenidate extended-release 10 mg, 20 mg, 30 mg60 capsules180 capsulesmethylphenidate extended-release 60 mgAPTENSIO XR 60 mg †30 capsules90 capsulesVYVANSE 10 mg, 20 mg, 30 mg †60 capsules180 capsulesVYVANSE 40 mg, 50 mg, 60 mg, 70 mg †30 capsules90 capsulesINCRUSE ELLIPTA, LONHALA MAGNAIR STARTER AND REFILL KIT,SEEBRI NEOHALER, SPIRIVA RESPIMAT, YUPELRI revefenacininhalation solution, glycopyrrolate1 package3 packagesATROVENT HFA, COMBIVENT RESPIMAT, CROMOLYN INHALATIONSOLUTION, ipratropium, ipratropium/albuterol2 packages6 packagesipratropium Inhalation solution 0.02%,313 mL938 mLIpratropium Bromide/albuterol sulfate inhalation solution540 mL1620 mLSPIRIVA HANDIHALER tiotropium30 capsules90 capsulesTUDORZA PRESSAIR aclidinium60 Inhalations180 Inhalations2
Category*Drug ClassMedicines with Quantity LimitsLimit for 30-Day Limit for 90-DayPrescriptionsPrescriptionsChronic ObstructivePulmonary Disease (COPD)*AnticholinergicCombinationsANORO ELLIPTA1 package3 packagesBEVESPI AEROSPHERE30 inhalations/60 blisters/1 package90 inhalations/180 blisters/3 packagesChronic ObstructivePulmonary Disease (COPD)*Beta Agonists, Long-ActingARCAPTA NEOHALER†30 capsules/1 package90 capsules/3 packagesBROVANA†120 mL360 mLPERFOROMIST120 mL360 mLSEREVENT60 blisters/1 package180 blisters/3 packagesSTRIVERDI RESPIMAT60 inhalations/1 package180 inhalations/3 packagesChronic ObstructivePulmonary Disease (COPD)*Beta Agonists, Short-Actingalbuterol (PROAIR DIGIHALER, PROAIR HFA, PROAIR RESPICKLICK,PROVENTIL HFA, VENTOLIN HFA)400 inhalations/2 packages1,200 inhalations/6 packageslevalbuterol (Xopenex)400 inhalations/2 packages1,200 inhalations/6 packagesLong-Acting oidTRELEGY ELLIPTA1 package3 packagesOpioid DependenceAgents*BUNAVAIL 2.1-0.3 mg, 4.2-0.7 mg †90 films270 filmsBUNAVAIL 6.3-1.0 mg †60 films180 filmsbuprenorphine/naloxone sublingual90 tablets270 tabletsSUBOXONE 2-0.5 mg, 4-1 mg, 8-2 mg90 films270 filmsSUBOXONE 12-3 mg60 films180 filmsnaloxone hydrochloride injection (EVZIO) 1137-H2 cartons (4 auto-injectors) per180 days2 cartons (4 auto-injectors) per180 daysnaloxone hydrochloride nasal spray (NARCAN NASAL SPRAY) 1137 -H2 cartons (4 nasal sprays) per180 days2 cartons (4 nasal sprays) per180 daysZUBSOLV 1.4-0.36 mg, 2.9-0.71 mg, 5.7-1.4 mg †90 tablets270 tabletsZUBSOLV 8.6-2.1 mg †60 tablets180 tabletsZUBSOLV 11.4-2.9 mg †30 tablets90 tabletsbutalbital/acetaminophen60 units180 unitsbutalbital/acetaminophen/caffeine60 units180 unitsbutalbital/acetaminophen/caffeine/codeine60 units180 unitsbutalbital/aspirin/caffeine60 units180 unitsbutalbital-aspirin-caffeine-codeine60 units180 unitscarisoprodol84 tablets 84 tablets carisoprodol/aspirin168 tablets 168 tablets carisoprodol/aspirin/codeine168 tablets 168 tablets fentanyl lozenges (PA)120 lozenges360 lozengesmethadone 10 mg/mL oral concentrate30 mL 30 mL NUCYNTA ER 50 mg †300 tablets900 tabletsPain and Inflammation*Butalbital ProductsPain and Inflammation*Carisoprodol ProductsPain and Inflammation*Opioid Agents, Long-Acting3
Category*Drug ClassMedicines with Quantity LimitsLimit for 30-Day Limit for 90-DayPrescriptionsPrescriptionsNUCYNTA ER 100 mg †150 tablets450 tabletsNUCYNTA ER 150 mg †90 tablets270 tabletsNUCYNTA ER 200 mg, 250 mg †60 tablets180 tabletstramadol extended-release30 capsules/30 tablets90 capsules/90 tabletsXARTEMIS XR†120 tablets 120 tablets codeine/acetaminophen oral solutioncodeine/acetaminophen suspension2,700 mL8,100 mLcodeine/acetaminophen 15-300 mg400 tablets1,200 tabletscodeine/acetaminophen 30-300 mg360 tablets1,080 tabletscodeine/acetaminophen 60-300 mg180 tablets540 tabletsdihydrocodein e/acetaminophen/caffeine 16-320.5-30 mg300 capsules900 capsulesdihydrocodein e/aspirin /caffeine 16-356.4-30 mg300 capsules900 capsuleshydrocodone/acetamin ophen 10-300 mg/15 mL solution6,000 mL18,000 mLhydrocodone/acetamin ophen 7.5-325 mg/15 mL,10-325 mg/15 mL solution5,540 mL16,620 mLhydrocodone/acetamin ophen 5-300 mg, 7.5-300 mg, 10-300 mg400 tablets1,200 tabletshydrocodone/acetamin ophen 2.5-325 mg, 5-325 mg, 7.5-325 mg,10-325 mg375 tablets1,125 tabletshydrocodone/ibuprofen50 tablets 50 tablets NUCYNTA 50 mg †360 tablets1,080 tabletsNUCYNTA 75 mg †240 tablets720 tabletsNUCYNTA 100 mg †180 tablets540 tabletsoxycodone/aspirin308 tablets924 tabletsoxycodone/acetaminophen solution1,850 mL5,550 mLoxycodone/acetaminophen 2.5-300 mg, 5-300 mg, 7.5-300 mg,10-300 mg400 tablets1,200 tabletsoxycodone/acetaminophen 2.5-325 mg, 5-325 mg, 7.5-325 mg,10-325 mg375 tablets1,125 tabletsoxycodone/ibuprofen28 tablets 28 tablets pentazocine/nalo xone180 tablets 180 tablets tramadol240 tablets720 tabletstramadol/acetaminophen40 tablets 40 tablets Skin Conditionsdoxepin, Prudoxin, Zonalon90 grams90 gramsSleep Agents*Hypnotics,Benzodiazepinesestazolam15 tablets45 tabletsflurazepam15 capsules45 capsulesquazepam15 tablets45 tabletstemazepam15 tablets45 tabletstriazolam10 tablets30 tabletsPain and Inflammation*Opioid Agents, Short-ActingPain and Inflammation*Opioid Agents, Short-Acting4
The medicines indicated above, along with their quantity limits, are subject to change .There may be additional drugs subject to prior authorization or other plan design restrictions. Though covered by your plan, some generics may not be listed in your plan’s formulary.Please consult your plan for further information.This list represents brand products in CAPS, branded generics in upper- and lowercase, and generic products in lowercase italics. This is not an all-inclusive list of available drugalternative considerations. Log in to Caremark.com to check coverage and copay information for a specific drug. Copay means the amount a plan member is required to pay for aprescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. Discussthis information with your doctor or health care provider. This information is not a substitute for medical advice or treatme nt. Talk to your doctor or health care provider about thisinformation and any health-rela ted questions you have. CVS Caremark assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result ofthis information. This list is subject to change.Subject to applicable state law restrictions.* This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. This denotes medicines that have the same quantity limit for both 30 -day and 90-day prescriptions.† This indicates a non-listed brand and is subject to very high copay or exclusion (i.e., the plan does not cover the medicine) without an authorization for medical necessity.Key abbreviations: (QL) quantity limit; (PA) prior authorization; (ST, PA) step therapy with post-step prior authorization.Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. CVSCaremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescriptiondrugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are notintended to replace the clinical judgment of the doctor. 2019 CVS Caremark. All rights reserved. 6581-32419L 100119Caremark.com5
4 Category* Drug Class Medicines with Quantity Limits Limit for 30-Day Prescriptions Limit for 90-Day Prescriptions NUCYNTA ER 100 mg† 150 tablets 450 tablets NUCYNTA ER 150 mg† 90 tablets 270 tablets NUCYNTA ER 200 mg, 250 mg† 60 tablets 180 tablets tramadol extended-release 30 capsules/30 tablets 90 capsules/90 tablets .
