Quantity Limits

Community Health Plan has placed quantity limits on select drugs. Drugs are considered for quantity limits if:

  1. There is significant clinical concern about potential overuse of an agent
  2. There is potential for significant use that is deemed not to be cost effective
  3. There are scientifically supported maximum use guidelines, which if exceeded, have the potential to increase the risk of harm

If medically necessary quantity limits may be overridden by having the provider call Express Scripts, Inc. at 1-888-256-6132.

Drug NamePackage SizeQuantity Limit
ABILIFY 10 MG TABLET 34
ABILIFY 15 MG TABLET 34
ABILIFY 2 MG TABLET34
ABILIFY 20 MG TABLET                 34
ABILIFY 30 MG TABLET34
ABILIFY 5 MG TABLET34
ACTOS 30 MG TABLET34
ACTOS 45 MG TABLET  34
ALENDRONATE SODIUM 35 MG TAB5
ALENDRONATE SODIUM 40 MG TAB   34
ALENDRONATE SODIUM 5 MG TABLET   34
ALENDRONATE SODIUM 70 MG TAB5
AVONEX ADMIN PACK 30 MCG VL 4
AVONEX PREFILLED SYR 30 MCG 4
AZITHROMYCIN 100 MG/5 ML SUSP1530
AZITHROMYCIN 200 MG/5 ML SUSP1545
AZITHROMYCIN 200 MG/5 ML SUSP22.567.5
AZITHROMYCIN 200 MG/5 ML SUSP3090
AZITHROMYCIN 250 MG TABLET8
AZITHROMYCIN 500 MG TABLET 4
BETASERON 0.3 MG KIT15
BUDEPRION SR 100 MG TABLET68
BUDEPRION SR 150 MG TABLET68
BUDESONIDE 0.25 MG/2 ML SUSP140
BUDESONIDE 0.5 MG/2 ML SUSP140
BUPROPION HCL 100 MG TABLET68
BUPROPION HCL SR 100 MG TABLET   68
BUPROPION HCL SR 200 MG TAB68
BUPROPION SR 150 MG TABLET68
BUTORPHANOL 10 MG/ML SPRAY2.55
CITALOPRAM HBR 10 MG TABLET34
CITALOPRAM HBR 20 MG TABLET 34
CITALOPRAM HBR 40 MG TABLET34
COPAXONE 20 MG INJECTION KIT1
CRESTOR 10 MG TABLET34
CRESTOR 20 MG TABLET34
CRESTOR 5 MG TABLET 34
CYMBALTA 20 MG CAPSULE68
CYMBALTA 30 MG CAPSULE34
CYMBALTA 60 MG CAPSULE34
DOXAZOSIN MESYLATE 1 MG TAB34
DOXAZOSIN MESYLATE 2 MG TAB34
DOXAZOSIN MESYLATE 4 MG TAB34
DOXAZOSIN MESYLATE 8 MG TAB68
ESTRADIOL 0.05 MG/DAY PATCH5
ESTRADIOL 0.1 MG/DAY PATCH 5
FLUCONAZOLE 150 MG TABLET  2
FLUOXETINE HCL 10 MG CAPSULE34
FLUOXETINE HCL 10 MG TABLET34
FLUOXETINE HCL 40 MG CAPSULE68
HELIDAC THERAPY5656
INTAL INHALER8.116.2
INTAL INHALER14.228.4
IPRATROPIUM 0.03% SPRAY3060
IPRATROPIUM 0.06% SPRAY1515
LORATADINE 10 MG ODT34
LORATADINE 10 MG TABLET34
LOVASTATIN 10 MG TABLET34
LOVASTATIN 20 MG TABLET120
LOVASTATIN 40 MG TABLET68
MICONAZOLE 100 MG VAG SUPP77
MICONAZOLE 3 200 MG VAG SUPP33
MICONAZOLE 7 100 MG VAG SUPP7
MICONAZOLE 7 CREAM4545
MICONAZOLE NITRATE 2% CREAM4545
NARATRIPTAN HCL 1 MG TABLET9
NARATRIPTAN HCL 2.5 MG TABLET9
NEUMEGA 5 MG VIAL21
NEXT CHOICE 0.75 MG TABLET2
OMEPRAZOLE 20 MG CAPSULE30
OMEPRAZOLE 20 MG TABLET30
ONDANSETRON 4 MG/5 ML SOLUTION50150
ONDANSETRON HCL 24 MG TABLET1
ONDANSETRON HCL 4 MG TABLET12
ONDANSETRON HCL 8 MG TABLET12
ONDANSETRON ODT 4 MG TABLET12
ONDANSETRON ODT 8 MG TABLET12
PAROXETINE HCL 10 MG TABLET34
PAROXETINE HCL 20 MG TABLET68
PAROXETINE HCL 30 MG TABLET68
PAROXETINE HCL 40 MG TABLET  34
PLAN B 0.75 MG TABLET2
PRAVASTATIN SODIUM 10 MG TAB34
PRAVASTATIN SODIUM 20 MG TAB34
PRAVASTATIN SODIUM 40 MG TAB60
PRAVASTATIN SODIUM 80 MG TAB34
PREVPAC PATIENT PACK1414
QVAR 40 MCG INHALER7.321.9
QVAR 40 MCG INHALER8.717.4
QVAR 80 MCG INHALER7.321.9
QVAR 80 MCG INHALER8.726.1
RELENZA 5 MG DISKHALER2020
RISPERIDONE 0.25 MG TABLET68
RISPERIDONE 0.5 MG ODT  68
RISPERIDONE 0.5 MG TABLET68
RISPERIDONE 1 MG ODT68
RISPERIDONE 1 MG TABLET68
RISPERIDONE 2 MG ODT68
RISPERIDONE 2 MG TABLET 68
RISPERIDONE 3 MG ODT68
RISPERIDONE 3 MG TABLET68
RISPERIDONE 4 MG ODT68
RISPERIDONE 4 MG TABLET 68
RISPERIDONE M-TAB 0.5 MG ODT68
RISPERIDONE M-TAB 1 MG ODT68
RISPERIDONE M-TAB 2 MG ODT68
RISPERIDONE M-TAB 3 MG ODT68
RISPERIDONE M-TAB 4 MG ODT68
SEREVENT DISKUS 50 MCG2856
SEREVENT DISKUS 50 MCG60120
SEROQUEL 100 MG TABLET102
SEROQUEL 200 MG TABLET102
SEROQUEL 25 MG TABLET102
SEROQUEL 300 MG TABLET68
SEROQUEL 400 MG TABLET68
SEROQUEL 50 MG TABLET102
SEROQUEL XR 200 MG TABLET 34
SEROQUEL XR 300 MG TABLET 68
SEROQUEL XR 400 MG TABLET68
SERTRALINE HCL 100 MG TABLET68
SERTRALINE HCL 25 MG TABLET34
SERTRALINE HCL 50 MG TABLET68
SIMVASTATIN 10 MG TABLET34
SIMVASTATIN 20 MG TABLET34
SIMVASTATIN 40 MG TABLET34
SIMVASTATIN 5 MG TABLET34
SIMVASTATIN 80 MG TABLET34
SUMATRIPTAN 20 MG NASAL SPRAY112
SUMATRIPTAN 5 MG NASAL SPRAY612
SUMATRIPTAN 6 MG/0.5 ML VIAL0.51
SUMATRIPTAN SUCC 100 MG TABLET9
SUMATRIPTAN SUCC 25 MG TABLET9
SUMATRIPTAN SUCC 50 MG TABLET9
TAMIFLU 6 MG/ML SUSPENSION60180
TAMIFLU 12 MG/ML SUSPENSION2575
TAMIFLU 30 MG GELCAP20
TAMIFLU 45 MG GELCAP   10
TAMIFLU 75 MG GELCAP10
TERAZOSIN 1 MG CAPSULE34
TERAZOSIN 10 MG CAPSULE68
TERAZOSIN 2 MG CAPSULE34
TERAZOSIN 5 MG CAPSULE  34
TERCONAZOLE 0.4% CREAM 45180
TERCONAZOLE 0.8% CREAM2080
TERCONAZOLE 80 MG SUPPOSITORY312
TOBI 300 MG/5 ML SOLUTION 5280
VALACYCLOVIR HCL 1 GRAM TABLET   34
ZYPREXA 10 MG TABLET 34
ZYPREXA 15 MG TABLET34
ZYPREXA 2.5 MG TABLET34
ZYPREXA 20 MG TABLET 34
ZYPREXA 5 MG TABLET34
ZYPREXA 7.5 MG TABLET34