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DRUG NAME
*shaded Rx rows= Maintenance Medications
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Adderall XR 20mg
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60 capsules per 30 day period
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Adderall XR 5, 10, 15, 25, 30 mg
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30 capsules per 30 day period
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Advair Diskus
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60 metered doses per 30 day period
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Advair HFA
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1 unit per 30 day period
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amlodipine 2.5, 5mg
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45 tablets per 30 day period
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amlodipine 10mg
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30 tablets per 30 day period
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Arixtra
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14 days supply per fill
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Buproban 150 mg
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90 day supply per calendar year
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Byetta 5, 10 mcg
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1 pen per 30 day period
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Caverject
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4 doses per 30 day period
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Celebrex 100, 200, 400 mg
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60 capsules per 30 day period
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Chantix
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60 tablets per 30 day period
90 days only per 12 month period
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citalopram 10, 20, 40 mg
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45 tablets per 30 day period
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clozapine 25, 100mg
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14 day supply per fill
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Crestor 5, 10, 20, 40 mg
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30 tablets per 30 day period
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Cymbalta 20mg
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60 capsules per 30 day period
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Cymbalta 30mg
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30 capsules per 30 day period
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Cymbalta 60 mg
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30 capsules per 30 day period
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doxazosin 1, 2, 4 mg
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30 tablets per 30 day period
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doxazosin 8 mg
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60 tablets per 30 day period
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Emend 125 mg
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1 capsule per 30 day period
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Emend 80 mg
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2 capsules per 30 day period
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Emend Tri-fold pack
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1 pack per 30 day period
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Enbrel 50mg
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4 vials per 30 day period
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Enbrel 25mg
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8 vials per 30 day period
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Epi-pen
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1 kit per fill
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Epi-pen Jr
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1 kit per fill
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Exforge
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30 tablets per 30 day period
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fentanyl lozenges
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120 lozenges per 30 day period
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fexofenadine 180 mg
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30 tablets per 30 day period
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fexofenadine 30, 60mg
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60 tablets or capsules per 30 day period
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fluoxetine 10mg
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90 tablets or capsules per 30 day period
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fluoxetine 20mg
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90 tablets or capsules per 30 day period
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fluoxetine 40mg
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60 tablets or capsules per 30 day period
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fluvoxamine 25 mg
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45 tablets per 30 day period
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fluvoxamine 50 mg
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60 tablets per 30 day period
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fluvoxamine 100 mg
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90 tablets per 30 day period
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Foradil Blister pack 12mcg
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60 tablets per 30 day period
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Gleevec 100mg
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60 tablets per 30 day period
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Gleevec 400mg
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30 tablets per 30 day period
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Humira 40 mg / 0.8 ml
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2 injections per 30 day period
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Humira Pen 40 mg / 0.8 ml
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2 prefilled syringes per 30 day period
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Imitrex 25, 50, 100 mg
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12 tablets per 30 day period
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Imitrex nasal spray 5, 20 mg
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6 units per 30 day period
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Januvia
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30 tablets per 30 day period
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ketorolac
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5 day supply per fill
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Levitra 2.5, 5, 10, 20 mg
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4 tablets per 30 day period
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Lotronex 0.5, 1 mg
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60 tablets per 30 day period
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lovastatin 10, 20,
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30 tablets per 30 day period
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lovastatin 40mg
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60 tablets per 30 day period
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Lovenox
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14 days supply per fill
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meloxicam 7.5, 15mg
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30 tablets per 30 day period
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MUSE
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4 doses per 30 day period
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Neulasta
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2 syringes every 30 days
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Neupogen
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10 vials/ syringes every 30 days
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Nexavar
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120 tablets per 30 day period
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Nicotine patch 7, 14, 21 mg
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30 patches in a 30 day period; 90 day supply per calendar year
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omeprazole 10 mg
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30 tablets or capsules per 30 day period
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omeprazole 20 mg
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60 tablets or capsules per 30 day period
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ondansetron hcl 4, 8mg
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12 tablets per fill
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ondansetron hcl 24mg
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1 tablet per 30 day period
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ondansetron hcl solution 4mg/5ml
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1 day supply per 30 day period
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oxycodone hcl 10, 20, 40 & 80mg
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4 tablets per day or 1
20 tablets per 30 day period
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oxycontin
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120 tablets per 30 day period
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pantoprazole 20mg, 40mg
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30 tablets per 30 day period
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paroxetine 10, 40 mg
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45 tablets per 30 day period
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paroxetine 20, 30 mg
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60 tablets per 30 day period
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pravastatin 10,20, 40mg
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30 tablets per 30 day period
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Prilosec OTC 20mg
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120 tablets per 30 day period
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Regranex
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1 tube in a 30 day period
3 tubes (90 day supply) per
12 month period
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Revlimid
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30 tablets per 30 day period
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Rozerem
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30 tablets per 30 day period
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sertraline 25, 50mg
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45 tablets per 30 day period
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sertraline 100mg
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60 tablets per 30 day period
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simvastatin 5, 10, 20, 40, 80 mg
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30 tablets per 30 day period
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Sprycel
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120 tablets per 30 day period
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Strattera 10, 18, 25, 60 mg
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30 tablets per 30 day period
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Strattera 40 mg
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60 tablets per 30 day period
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Strattera 80mg
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30 capsules per 30 day period
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Strattera 100mg
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30 capsules per 30 day period
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Suboxone 2, 8mg
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2mg= up to 270 tablets per 30 days for 90 days only
8mg=up to 90 tablets per 30 days for 90 days only
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Subutex 2, 8mg
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2mg= up to 270 tablets per 30 days for 90 days only
8mg=up to 90 tablets per 30 days for 90 days only
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Sutent
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30 tablets per 30 day period
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Symlin
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4 vials per 30 day period
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Tamiflu oral
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10 capsules per 30 day period; 20 capsules per calendar year
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Tamiflu suspension
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3 bottles per 30 day period; 6 bottles per calendar year
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terazosin 1, 5 mg
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30 capsules or tablets per 30 day period
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terazosin 2, 10 mg
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60 capsules or tablets per 30 day period
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terbinafine
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90 day supply per 12 month period
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Tykerb
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150 tablets per 30 day period
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venlafaxine hcl 25, 37.5, 50, 100mg
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60 tablets per 30 day period
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venlafaxine hcl 75mg
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90 tablets per 30 day period
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Vytorin
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30 tablets per 30 day period
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Zetia
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30 tablets per 30 day period
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Zolinza
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120 capsules per 30 day period
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zolpidem
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30 tablets per 30 day period
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Zomig 2.5, 5 mg
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12 tablets per 30 day period
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Zomig Nasal Spray 5 mg
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6 units per 30 day period
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Zomig ZMT
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12 tablets per 30 day period
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Note: This list is subject to change. For the most current list go to hne.com and click on the tab labeled Pharmacy.
