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Fidelis drug quantity limits 2010_11_11 _2_


Drug Quantity Limits—2011

Quantity limits on medications are established to maximize the dosing regimen
and decrease cost.
Quantity limits are commonly placed on once daily drugs available in multiple
strengths. The limit allows for titration to an effective dose, but requires long-term
use with an appropriate strength of the medication. Taking medications less often
(10mg once daily versus 5mg twice daily, if appropriate) increases compliance. If
generics are added for BRAND drugs with quantity limits, the generic will have
the same quantity limit.
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Abilify Discmelt
Aerobid-M
Accolate
Aggrenox
Altoprev
Actoplus Met
Ambien CR
Advair Diskus
Advair HFA
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Beconase AQ
Benicar HCT
Betaseron
Boniva (Injection)
Boniva (Tablet)
Avandamet
Avandaryl
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Copaxone
Daytrana
Detrol LA
Cardene SR
Dexilant
Cardura XL
Chantix 0.5mg & 1mg 2 tablets per day Chantix Pak
Clarinex (Syrup)
Clarinex (Tablet) &
Reditabs
Clarinex-D

(12-Hour Tablet)
Clarinex-D
(24-Hour Tablet)
12.5mg, 160-25mg, & 2 tablets per day QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Estrogel
Exforge HCT
Fanapt Titration
Flovent HFA
Foradil Aerolizer
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Fortical
(Oral Solution)
Fosamax Plus D
Fragmin 7500U &
Gelnique
Genotropin
Miniquick
Halflytely Bowel
Invega Sustenna
Glumetza
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Maxalt-MLT
Lidoderm
Lotronex
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Nicotrol NS
Nulytely/Flavor
Micardis
Micardis HCT
Migranal
Nasacort AQ
Oxycontin (10mg 12-
Hour Tablet, 15mg
12-Hour Tablet,
20mg 12-Hour
Tablet, 30mg 12-
Nexium (Pack)
Hour Tablet, 40mg
12-Hour Tablet,
Nicotrol Inhaler
60mg 12-Hour
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Oxycontin (80mg 12-
Hour Tablet)
Rebif Titration Pack
Regranex
Patanase
Relenza Diskhaler
Prandin 0.5mg, & 1mg 4 tablets per day Prezista
Samsca 15mg Tablet
Samsca 30mg Tablet
Sanctura XR
Savella Titration
Serevent Diskus
Pulmicort Flexhaler
Singulair Chewable
QL Message—
QL Message—
Drug Name
Drug Name
Member Notes
Member Notes
Singulair (Pack)
Teveten (600mg
Singulair (Tablet)
Teveten HCT
Spiriva Handihaler
Sporanox
(Oral Solution)
Travatan Z
Suboxone
Ultram ER (100mg
24-Hour Tablet)
Uroxatral
Symbicort
Valturna
Symlin (1000mcg/ml
Injection)
Symlin (600mcg/ml
Injection)
Vesicare
Welchol (Pack)
Tamiflu (Oral
Suspension)
Tekturna
Tekturna HCT
Teveten (400mg
QL Message—
Drug Name
Member Notes
6 devices per
Zomig (Nasal Spray)
Zyprexa Zydis

Source: http://www.fidelissecurecare.net/pdfs/2011/2011-GOLD-Fidelis-Drug-Quantity-Limits.pdf

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