Medications Limited In Quantity

The following medications have specific quantity limits per copay which are less than the standard benefit of a 34-days supply or 100 units. Quantity limits are based on recommended duration of therapy and/or routine usage for each medication.

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 generic equivalents are available or become available, they will also be limited in quantity.

Some medications listed in these categories are non-formulary and will only be covered with an approved prior authorization.

This list may not be all-inclusive and is subject to change.

Cancer Therapy Drugs - Miscellaneous	Erectile Dysfunction / Impotence Agents	Inhaled Asthma Therapy Drugs (Mast Cell Stabilizers)	Intranasal Therapy Drugs
Iressa (gefitinib)	Caverject Cialis (tadalafil) Edex(alpostadil) Levitra (vardenafil) Muse (alprostadil) Viagra (sildenafil)	Intal (cromolyn) Nasalcrom (cromolyn) Tilade (nedocromil)	Beconase AQ (beclomethasone) Flonase (fluticasone) Nasacort AQ (triamcinolone) Nasarel (flunisolide) Nasonex (mometasone) Rhinocort (budesonide) Rhinocort Aqua (budesonide) Vancenase Pockethaler (beclomethasone)
Migraine Therapy Drugs	Multiple Sclerosis Therapy Drugs	Ophthalmic Therapy Drug - Miscellaneous	Osteoporosis Therapy Drugs
Amerge (naratriptan) Axert (almotriptan) Frova (frovatriptan) Imitrex (sumatriptan) Imitrex Inj (sumatriptan) Imitrex NS (sumatriptan) Maxalt (rizatriptan) Maxalt-MLT (rizatriptan) Migranal NS (dihydroergotamine mesylate) Relpax (eletriptan) Stadol NS (butorphanol nasal spray) Treximet Zomig (zolmitriptan) Zomig NS (zolmitriptan) Zomig-ZMT (zolmitriptan – orally disintegrating tablets)	Avonex (interferon beta-1a) Betaseron (interferon beta-1b) Copaxone (glatiramer) Rebif (interferon beta-1a)	Restasis (cyclosporine ophthalmic emulsion) 0.05%	Actonel (risedronate) 35mg & 75mg Boniva (ibandronate) 150mg Forteo (teriparatide) Fosamax (alendronate) 35mg & 70mg Fosamax-D (alendronate/vitamin D) 70mg/2800I.U. & 70mg/5600I.U. Fosamax Solution (alendronate) 70mg/Btl Miacalcin (calcitonin-salmon)
Rheumatoid Arthritis Therapy Drugs	Sedative and Hypnotic Drugs	Topical Estrogen Therapy Drugs	Transdermal Patches
Arava (leflunomide) Enbrel (etanercept) Humira (adalimumab) Kineret (anakinra)	Ambien (zolpidem) Butisol (butabarbital) Doral (quazepam) Halcion (triazolam) Lunesta (eszopiclone) ProSom (estazolam) Restoril (temazepam) Rozerem (ramelteon) Sonata (zaleplon) Various (chloral hydrate)	Alora (estradiol) Climara(estradiol) Climara Pro (estradiol/ levonorgestrel) CombiPatch (estradiol/ norethindrone) Esclim (estradiol) Estraderm (estradiol) Estrogel (estradiol) Estrasorb (estradiol) Menostar (estradiol) Vivelle-Dot (estradiol)	Androderm (testosterone) Androgel (testosterone) Catapres TTS (clonidine) Daytrana (methylphenidate) Duragesic (fentanyl) EmSam (selegiline) Lidoderm (lidocaine) (nitroglycerin) Ortho-Evra (norelgestromin/ethinyl estradiol) OxyTrol (oxybutynin) Striant (testosterone) Testim Gel (testosterone) Transderm-Scope (scopolamine)

HealthChoice Medicare Supplement Plans With and Without Part D Medications Limited In Quantity