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HNE Formulary: Limitations
Introduction How To Use The List Tier 1 Tier 2 Limitations Brand/Non-Formulary Search

The formulary list was last updated on 09/01/07, please be advised the information listed may not reflect the most current data and may be updated at any time without notice.

Please call HNE Member Services at (413) 787-4000 or
(800) 310-2835 for assistance.

Quantity Limitations / Quantity-based Co-payments
The following medications have quantity limitations or have quantity-based co-payments (that is, one co-payment is charged for the quantity shown below).

PHARMACY BENEFIT HEALTH NEW ENGLAND QUANTIITY LIMITED DRUGS
*shaded Rx rows= Maintenance Medications

DRUG NAME
 Copayment Tier Coverage Limitations
Aciphex Tier 3 30 tablets per 30 day period;
Actiq Tier 3 120 lozenges per 30 day period
Adderall XR Tier 2 20mg = 60 capsules per 30 day period, 5mg, 10mg, 15mg, 25mg & 30mg = 30 capsules per 30 day period.
Advair Diskus Tier 2 1 diskus = 60 metered dose per 30 day period
Advair HFA Tier 2 1 inhaler  (120 actuations) for 30 day period
Advicor Tier 3  60 tablets per 30 day period. 
Allegra Tier 3 30mg & 60mg = 60 tablets per 30 day period.;  180mg = 30 tablets per 30 day period
Allegra-D-12 hour Tier 3 60 tablets per 30 day period
Allegra-D-24 hour Tier 3 30 tablets per 30 day period
Altoprev Tier 3 30 tablets per 30 day period.
Ambien Tier 3  30 tablets per 30 day period
Ambien CR Tier 3 30 tablets per 30 day period
Amerge Tier 3 12 tablets per 30 day period
Amitiza Tier 3 60 capsules per 30 day period
amlodipine (eq=Norvasc) Tier 1 2.5mg & 5mg = 45 tablets per 30 day period; 10mg = 30 tablets per 30 day period
Anzemet Tier 3 2 tablets per 30 day period
Arixtra Tier 3 14 days supply of medication per fill
Axert Tier 3 12 tablets per fill
Buproban Tier 1 90 day supply per 12 month period
Byetta Tier 2 1 pen per 30 day period for 5mcg strength and 1 pen per 30 days for 10mcg strength
Caduet Tier 3 30 talets per 30 day period. 
Cardura Tier 3 1mg, 2mg & 4mg = 30 tablets per 30 day period; 8mg = 60 tablets per 30 day period
Cardura XL Tier 3 4mg & 8mg = 30 tablets per 30 day period.
Catapres TTS-1 Tier 2  4 patches in a 30 day period
Catapres TTS-2 Tier 2 4 patches in a 30 day period
Catapres TTS-3 Tier 2 4 patches in a 30 day period
Caverject Tier 2 4 doses per 30 day period
Caverject Tier 2 4 doses per 30 day period
Celebrex Tier 2 60 capsules per 30 day period
Celexa Tier 3 45 tablets per 30 day period.
Chantix Tier 3 60 tabs per 30 day period, AND  90 days only per 12 month period
Cialis Tier 3 4 tablets per 30 day period
citalopram (eq=Celexa) Tier 1 45 tablets per 30 day period.
Clarinex Tier 3 30 tablets per 30 day period
Clarinex D 12 hour Tier 3  60 tablets per 30 day period
Clarinex D 24hr Tier 3  30 tablets per 30 day period
Clarinex Reditabs Tier 3  30 tablets per 30 day period
clozapine (eq=Clozaril) Tier 1 14 day supply for fill the first year, copay applies each fill.  After 1 year then 30 day supply per fill.
Clozaril Tier 3 14 day supply for fill the first year, copay applies each fill.  After 1 year then 30 day supply per fill.
Concerta Tier 2 18mg, 27mg, 54mg= 30 tablets per 30 day period; 36mg = 60 tablets per 30 day period
Crestor Tier 3  30 tablets per 30 day period. 
Cymbalta Tier 3 20mg = 60 capsules per 30 day period; 30mg & 60mg = 30 capsules per 30 day perod.
Daytrana patch Tier 3 30 patches per 30 day period
doxazosin (eq=Cardura) Tier 1 1mg, 2mg & 4mg = 30 tablets per 30 day period; 8mg = 60 tablets 30 day period
Edex Tier 2 4 doses per 30 day period
Effexor Tier 3  60 tablets per 30 day period.
Effexor XR Tier 2 37.5mg = 30 capsules per 30 day period, 75mg = 90 capsules per 30 day period; 150mg = 60 capsules per 30 day period.  
Emend Tier 3 125mg = 1 tablet per 30 day period; 40mg & 80mg = 2 tablets per 30 day period; trifold = 1 pack per 30 day period
Enbrel Tier 2 25mg= 8 syringes per 30 day period; 50mg = 4 syringes per 30 day period.

Exforge

Tier 3

30 tablets per 30 day period

fentanyl lozenge (eq=actiq) Tier 1 120  lozenges per 30 day period

Fentora

Tier 3

120 tablets per 30 day period

fexofenadine (eq= Allegra) Tier 1 30mg & 60mg = 60 tablets per 30 day period.;  180mg = 30 tablets per 30 day period
fluoxetine (eq=Prozac) Tier 1 10mg & 20mg= 90 capsules per 30 day period; 40mg = 60 capsules per 30 day period.
fluvoxamine (eq=Luvox) Tier 1 25mg =45 tablets per  30 day period; 50mg = 60 tablets per 30 day period, 100mg = 90 tablets per 30 day period.
Focalin XR Tier 3 30 tablets  per 30 day period
Foradil Aerolizer Tier 2 1 package (60 blisters) per 30 day period
Fragmin Tier 3 14 days supply of medication per fill
Frova Tier 3 12 tablets per 30 day period
Gleevec Tier 3

100mg= 60 tablets per 30 day period
400mg= 30 tablets per 30 day period

Humira Tier 2 2 injections per 30 day period
Hytrin Tier 3  1mg & 5mg = 30 capsules per 30 day period; 2mg & 10mg = 60 capsules per 30 day period
Imitrex, injection Tier 2 1Kit (2 syringes) per 30 day period
Imitrex, intranasal Tier 2  6 units per 30 day period
Imitrex, oral Tier 2 12 tablets per 30 day period
Innohep Tier 3 14 days supply of medication per fill
itraconazole (eq=Sporanox) Tier 1 90 day supply per 12 month period
Janumet Tier 3 30 tablets per 30 day period
Januvia Tier 2 30 tablets per 30 day period
Ketorolac Tier 1 5 days supply per fill
Kytril Tier 3 6 tablets per 30 day period;  solution-1 bottle (30ml) per 30 day period
Lamisil Tier 3 90 daysupply per 12 month period, per member
Lescol, Lescol XL Tier 3 25mg =45 tablets per 30 day period; 50mg = 60 tablets per 30 day period, 100mg = 90 tablets per 30 day period. 
Levitra Tier 3  4 tablets per 30 day period
Lexapro Tier 2 45 tablets per 30 day period. 
Lipitor Tier 3 30 tablets per 30 day period.
Lotronex Tier 3 60 tablets per 30 day period
lovastatin (eq=Mevacor) Tier 1  30 tablets per 30 day period.
Lovenox Tier 2 14 days supply of medication per fill
Lunesta Tier 3 30 tablets per 30 day period.
Luvox Tier 3 25mg =45 tablets per  30 day period; 50mg = 60 tablets per 30 day period, 100mg = 90 tablets per 30 day period. 
Maxalt Tier 3 12 tablets per 30 day period
Maxalt MLT Tier 3 12 tablets per 30 day period
meloxicam (eq-Mobic) Tier 1  30 tablets per 30 day period
Mevacor Tier 3 30 tablets per 30 day period. 
Mobic Tier 3 30 tablets per 30 day period
MUSE Tier 2 4 doses per 30 day period
Neulasta Tier 3 2 syringes per 30 day period
Neupogen Tier 3 10 vials/syringes per 30 day period
Nexavar Tier 3 120 tablets per 30 day period,
Nexium Tier 3 30 tablets per 30 day period; 
Nexium packet Tier 3 30 packets per 30 day period; 
Nicotrol Inhaler Tier 3 168 units per rx, 90 day supply per 12 month period
Nicotrol Nasal Spray Tier 3 4 bottles per rx, 90 day supply per 12 month period.
Norvasc Tier 3 2.5mg & 5mg = 45 tablets per 30 day period; 10mg = 30 tablets per 30 day period
omeprazole (eq=Prilosec) Tier 1 10mg = 30 capsules per 30 day period, 20mg = 60 capsules per 30 day period;
ondansetron HCI (injectable) (eq=Zofran) Tier 1 solution - 1 day supply per 30 day period
Ondansetron HCL (eq=Zofran) Tier 1 4mg, 8mg-12 tablets per fill;  24mg - 1 tablet per 30 day period; solution - 1 day supply per 30 day period
Ortho-Evra Tier 3 3 patches per 30 day period
Oxycontin Tier 3 120 tablets per 30 day period
Palladone Tier 3  
paroxetine (eq=Paxil) Tier 1 10mg & 40mg = 45 tablets per 30 day period; 20mg  & 30mg = 60 tablets per 30 dayp eriod.
Paxil Tier 3 10mg & 40mg = 45 tablets per 30 day period; 20mg & 30mg = 60 tablets per 30 day period. 
Paxil CR Tier 3 12.mg = 30 tablets per 30 day period; 25mg & 37.5mg = 60 tablets per 30 day period. 
Pexeva Tier 3 10mg& 40mg = 45 tablets per 30 day period; 20mg & 30mg = 60 tablets per 30 day period. 
Pravachol Tier 3 30 tablets per 30 day period.  
pravastatin (eq=Pravachol) Tier 1 30 tablets per 30 day period.
Pravigard PAC Tier 3 30 tablets per 30 day period.   
Prevacid Tier 3 30 tablets per 30 day period;
Prilosec Tier 3 10mg = 30 capsules per 30 day period,  20mg = 60 capsules per 30 day period; Must try and fail at least one of the following w/in the previous 180 days omeprazole, Prilosec OTC
Prilosec OTC Tier 1 42 tablets per 42 days.
Protonix Tier 2 30 tablets per 30 day period; Must try and fail at least one of the following w/in the previous 180 days omeprazole, Prilosec OTC
Prozac Tier 3 10mg & 20mg= 90 capsule per 30 day period; 40mg = 60 capsules per 30 day period.  Must try and fail at least one of the following within the past 180 days: fluoxetine HCL, citalopram HBR, paroxetine HCL, fluvoxamine maleate, bupropion, bupropion SR, mirta
Prozac Weekly Tier 3 4 capsules per 30 day period;  must try and fail at least one of the following in the past 180 days: fluoxetine HCL, citalopram HBR, paroxetine HCL, fluvoxamine maleate, bupropion, bupropion SR, mirtazapine, sertraline, venlafaxine
Regranex Tier 3 1 tube in a 30 day period; 3 tubes  (90 day supply) per 12 month period
Relenza Tier 3 1 kit per 30 day period; 2 kits per 12 month period
Relpax Tier 3 12 tablets per 30 days
Revlimid Tier 3 30 tablets per 30 day period
Rozerem Tier 3 30 tablets per 30 day period.
Sarafem Tier 3 30 capsules per 30 day period
Serevent Diskus Tier 2 60 metered doses per 30 day period
sertraline (eq-Zoloft) Tier1 25mg & 50mg = 45 tablets per 30 day period; 100mg = 60 tablets per 30 day period.
simvastatin (eq-Zocor) Tier 1  30 tablets per 30 day period.  Must try and fail at least one of the following w/in the previous 180 days lovastatin, pravastatin, simvastatin
Sonata Tier 3 14 capsules per 30 day period
Sporanox Tier 3 90 day supply per 12 month period
Sprycel Tier 3 120 tablets per 30 day period.
Strattera Tier 3 10mg, 18mg, 25mg, 60mg, 80mg & 100mg = 30 tablets per 30 day  period; 40mg = 60 tabs per 30 day period
Sutent Tier 3 30 tablets per 30 day period.
Symlin Tier 2 4 vials per 30 day period
Tamiflu Tier 3 10 capsules per 30 day period, 20 capsules per 12 month period; liquid=3 bottles per 30 day period or 6 bottles per 12 month period
terazosin (eq=Hytrin) Tier 1  1mg & 5mg = 30 capsules 30 day period; 2 mg & 10mg = 60 capsules per 30 day period
terbinafine Tier 1

90 day supply per 12 month period

Toradol Tier 3 5 day supply per fill
Transderm Scop Tier 2 1 box (4 patches) per copay
Tykerb Tier 3 150 tablets per 30 day period
venlafaxine (eq-effexor) Tier 1 60 tablets per 30 day period.
Viagra Tier 2 4 tablets per 30 day period
Vytorin Tier 2 30 tablets per 30 day period. 
Xifaxan Tier 3 9 tablets per 30 day period
Zegerid Tier 3 30 units per 30 day period;
Zelnorm Tier 3 60 tablets per 30 day period
Zetia Tier 2 30 tablets per 30 day period.
Zocor Tier 3  30 tablets per 30 day period. 
Zofran Tier 3 4mg, 8mg-12 tablets per fill;  24mg - 1 tablet per 30 day period; solution - 1 day supply per 30 day period
Zofran (injectable) Tier 3 solution - 1 day supply per 30 day period
Zolinza Tier 3 120 capsules per 30 day period
Zoloft Tier3 25mg & 50mg = 45 tablets per 30 day period; 100mg = 60 tablets per 30 day period. 
zolpidem (eq=Ambien) Tier 1  30 tablets per 30 day period
Zomig Tier 2 12 tablets per 30 day period
Zomig Nasal Spray Tier 2 6 units per 30 day period
Zomig ZMT Tier 2 12 tablets per 30 day period
Zyban Tier 3 90 day supply per 12 month period
Zyrtec Tier 3 30 tablets per 30 day period
Zyrtec-D Tier 3 60 tablets per 30 day period

Note: This list is subject to change.

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