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Blue Care Network Quantity Limits July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Pharmacy programs ensure safety and cost-effectiveness We monitor the use of certain medications to help ensure you receive the most appropriate and cost-effective drug therapy. Our Quantity Limits program is one of the ways we monitor medications.
This document is published monthly.
Quantity limits Our Quantity Limits program limits the amount of medicine that you can fill for certain medications. For example, a drug may have a limit of 30 pills per 30 days. We apply such limits, based on drug studies and reviews by actively practicing doctors, to certain drugs in weight loss, smoking cessation, erectile dysfunction, nausea and several other categories. If you refill a prescription too soon or if your doctor prescribes an amount that’s higher than usual, your pharmacist will tell you that the drug isn’t covered.
Only your doctor can request coverage for drugs that exceed BCN limits.
All opioids are limited to 90 morphine milligram equivalent (MME) per day.
ACE-Inhibitors and combinations Custom Custom Select
KaterziaTM 2 bottles (300mg) per 30 days Not covered
Alpha-adrenergic agents Custom Custom Select
LucemyraTM 224 tablets per 30 days
Alzheimer's Therapy Custom Custom Select
Aricept® 23mg (g)* 1 tablet per day Not covered
Namenda® titration pack 1 pack per 365 days
Namenda XR® 1 capsule per day
Namenda XR® titration pack 1 pack per 365 days
NamzaricTM* 1 capsule per day Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Angiotensin II Receptor Blockers and Combinations Custom Custom Select
Edarbi®* 1 tablet per day
Edarbyclor®* 1 tablet per day
EntrestoTM* 2 tablets per day
Tribenzor®* (g) 1 tablet per day
Anticoagulant and Hemostasis Agents Custom Custom Select
BevyxxaTM 1 tablet per day
Brilinta® 2 tablets per day
Cablivi®* <s> 1 vial (kit) per day
Effient® (g) 1 tablet per day
Eliquis® 74 tablets per 30 days 194 tablets per 90 days
Eliquis® pack 1 pack per 365 days
Pradaxa® 2 capsules per day
Savaysa® 1 tablet per day
Xarelto® 10mg, 15mg, 20mg 1 tablet per day
Xarelto® 2.5mg 2 tablets per day
Xarelto® starter kit 1 pack per 365 days
Zontivity® 1 tablet per day
Anticonvulsants Custom Custom Select
Acthar® H.P.* <s> 4 vials per 30 days Not covered
Aptiom® 200mg, 400mg* 1 tablet per day Not covered
Aptiom® 600mg, 800mg* 2 tablets per day Not covered
Briviact®* 2 tablets per day
Briviact® solution* 20 mL per day
Diacomit®* <s> 3,000mg per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Anticonvulsants (cont.) Custom Custom Select
Epidiolex®* 20 mL per day (6 bottles per 30 days)
Fycompa® tablet 1 tablet per day
Lyrica® capsules (all strengths)* 3 capsules per day
Lyrica CR 82.5mg, 165mg 1 tablet per day Not covered
Lyrica CR 330mg 2 tablets per day Not covered
Lyrica® solution* 2 bottles (946mL) per 30 days
Nayzilam® 5 boxes (10 nasal spray units) per 30 days
Onfi®* 3 tablets per day
Onfi® suspension* 16 mL (40 mg) per day
Oxtellar XR® 150mg, 300mg 1 tablet per day Not covered
Oxtellar XR 600mg 4 tablets per day Not covered
Qudexy® XR 25mg, 50mg, 100mg, 150mg* 1 capsule per day Not covered
Qudexy® XR 200mg* 2 capsules per day Not covered
Sabril tablets®* 6 tablets per day
SympazanTM* 2 films per day Not covered
TopiramateTM ER, Trokendi XR®* (25mg, 50mg, 100mg or 150mg) 1 capsule per day Not covered
TopiramateTM ER* 200mg 2 capsules per day Not covered
Valtoco® 5 boxes (10 nasal spray units) per 30 days
XcopriTM 1 tablet per day
XcopriTM Titration Pack 2 packs per 365 days
Antidepressants Custom Custom Select
Desvenlafaxine ER®* 1 tablet per day
Fetzima®* 1 capsule per day Not covered
KhedezlaTM* 1 tablet per day Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antidepressants (cont.) Custom Custom Select
Pexeva®* 1 tablet per day
Pristiq® (g) 1 tablet per day
Trintellix® * 1 tablet per day
Viibryd®* 1 tablet per day
Viibryd® Titration pack* 1 pack per 1 year
Antidiabetics Custom Custom Select
Avandia® 2 tablets per day
Cycloset®* 6 tablets per day
FarxigaTM 1 tablet per day
Glyxambi®* 1 tablet per day
Insulin syringes 200 syringes per Rx
Invokamet®, XR® 2 tablets per day
Invokana® 1 tablet per day
Janumet®, XR 50/1000mg 2 tablets per day
Janumet XR 50/500mg, 100/1000mg 1 tablet per day
Januvia® 1 tablet per day
Jardiance® 1 tablet per day
Jentadueto®* 2 tablets per day Not covered
Jentadueto® XR 2.5/1000mg* 2 tablets per day Not covered
Jentadueto XR 5mg/1000mg* 1 tablet per day Not covered
Ozempic®* 4 pens for 30 days
Qtern®* 1 tablet per day
Riomet ERTM 1 bottle (473 mL) per 30 days Not covered
Rybelsus®* 1 tablet per day
Segluromet™* 2.5mg/1,000mg, 7.5mg/500mg, 7.5mg/1,000mg 2 tablets per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antidiabetics (cont.) Custom Custom Select
Segluromet™* 2.5mg/500mg 4 tablets per day
Soliqua™* 5 pens per 30 days
Steglatro™* 5mg 2 tablets per day
Steglatro™* 15mg 1 tablet per day
Synjardy® 2 tablets per day
Synjardy® XR 5/1000 and 12.5/1000mg 2 tablets per day
Synjardy® XR 10/1000 and 25/1000mg 1 tablet per day
Tradjenta®* 1 tablet per day
Trijardy XR™ 5/2.5/1000mg, 10/5/1000mg, 12.5/2.5/1000mg 2 tablets per day
Trijardy XR™ 25/5/1000mg 1 tablet per day
Trulicity® 4 pens (2 mL) per 30 days
Victoza® 3 syringes (9 mL) per 30 days
Xigduo XR® 5mg/500mg, 10mg/500mg, or 10/1000mg 1 tablet per day
Xigduo XR® 2.5mg/1000mg, 5mg/1000mg 2 tablets per day
Xultophy® 5 pens per 30 days
Antiemetics Custom Custom Select
Akynzeo®* 4 capsules per 30 days
Bonjesta®* 2 tablets per day Not covered
Emend® (g) 80mg 4 capsules per Rx
Emend (g) 125mg 2 capsules per Rx
Emend suspension 6 packets per 30 days
Emend Trifold Pack 2 packs per Rx
Kytril® (g) 12 tablets per Rx
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antiemetics (cont.) Custom Custom Select
Sancuso®* 2 patches per Rx
Varubi™* 8 tablets per 30 days Not covered
Zuplenz®* 24 films per Rx Not covered
Antifungals Custom Custom Select
Cresemba® 70 capsules per 30 days
Noxafil® tablet 99 tablets per 30 days
Oravig® 1 tablet per day Not covered
Anti-Infectives Custom Custom Select
Aemcolo™ 12 tablets per 90 days Not covered
ArakodaTM 1 carton (16 tablets) per 30 days
Arikayce* 1 kit (28 vials) per 28 days
Coartem® 24 tablets per Rx
Dificid® 20 tablets per Rx
FirvanqTM 1 gram per day
Krintafel 2 tablets per Rx
Nuzyra™ 30 tablets per 10 days
Pretomanid* 1 tablet per day
Sirturo® * 2 tablets per day
Sivextro® 1 tablet per day/6 days per 30 days
Spectracef® (g) 14 tablets per Rx
Xenleta™ 20 tablets per 10 days
Xepi™* 1 tube per 30 days Not covered
Xifaxan® 200mg 9 tablets every 7 days
Antineoplastics and Immunosuppressants Custom Custom Select
Afinitor®, Disperz* <s> 1 tablet per day (Limited to 15 day supply per fill)
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antineoplastics and Immunosuppressants (cont.) Custom Custom Select
Alecensa®* <s> 8 capsules per day
AlunbrigTM* 30 mg <s> 2 tablets per day
AlunbrigTM* 90mg, 180mg <s> 1 tablet per day
AlunbrigTM* starter pack <s> 1 pack per 365 days
Arcalyst®* <s> 4 vials per 30 days
AyvakitTM* <s> 30 tablets per 30 days (Limited to 15 day supply per fill)
BalversaTM* <s> 3mg = 90 tablets per 30 days (Limited to 15 day supply per fill) 4mg = 60 tablets per 30 days (Limited to 15 day supply per fill) 5mg = 30 tablets per 30 days (Limited to 15 day supply per fill)
Bosulif® 100mg* <s> 90 tablets per 30 days (Limited to 15 day supply per fill)
Bosulif® 400mg, 500mg* <s> 30 tablets per 30 days (Limited to 15 day supply per fill)
Braftovi™*<s> 50mg = 1 carton (2 bottles of 60 capsules) per 30 days
75mg = 1 carton (2 bottles of 90 capsules) per 30 days
Brukinsa™*<s> 120 capsules per 30 days (Limited to 15 day supply per fill)
Cabometyx™*<s> 30 tablet per 30 days (Limited to 15 day supply per fill)
Cabometyx™ 40mg*<s> 60 tablets per 30 days (Limited to 15 day supply per fill)
Calquence®* <s> 120 capsules per 30 days (Limited to 15 day supply per fill)
Caprelsa® 100mg* <s> 60 tablets per 30 days (Limited to 15 day supply per fill)
Caprelsa® 300mg* <s> 30 tablet per 30 days (Limited to 15 day supply per fill)
Cometriq®*<s> 4 cards (1 box) per 30 days
(Limited to 15 day supply per fill)
Copiktra* 1 carton (56 capsules) per 30 days
Cotellic™*<s> 63 tablets per 28 days
Daurismo®*<s> 100mg tablets - 30 tablets per 30 days (limited to a 15 day supply per fill) 25mg tablets - 90 tablets per 30 days (limited to a 15 day supply per fill)
Erivedge®*<s> 30 capsule per 30 days (Limited to 15 day supply per fill)
Erleada®*<s> 4 tablets per day
Exjade®* <s> Limited to 15 day supply per fill
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antineoplastics and Immunosuppressants (cont.) Custom Custom Select
Farydak®*<s> 6 capsules per 21 days
Gilotrif™*<s> 1 tablet per day
Ibrance®*<s> 21 tablets/capsules per 30 days
Iclusig® 15mg<s> 60 tablets per 30 days (Limited to 15 day supply per fill)
Iclusig® 45mg<s> 30 tablets per 30 days (Limited to 15 day supply per fill)
Idhifa®*<s> 1 tablet per day
Imbruvica® capsules*<s> 120 capsules per 30 days (Limited to 15 day supply per fill)
Imbruvica® tablets*<s> 1 tablet per day
Inlyta® 1mg*<s> 180 tablets per 30 days (Limited to 15 day supply per fill)
Inlyta® 5mg*<s> 120 tablets per 30 days (Limited to 15 day supply per fill)
Inrebic®*<s> 120 capsules per 30 days (Limited to a 15 day supply)
Iressa®*<s> 1 tablet per day
Jakafi®* <s> 60 tablets per 30 days (Limited to 15 day supply per fill)
Kisqali®* <s> 63 tablets per 30 days
Kisqali Femara co-pack®*<s> 91 tablets per 30 days
Lenvima™*<s> 90 capsules per 30 days (Limited to 15 day supply per fill)
Lonsurf®* <s> 100 tablets per 30 days
Lynparza™ tablets*<s> 120 tablets per 30 days (Limited to 15 day supply per fill)
Mekinist®*<s> 0.5mg = 3 tablets per day 2mg = 1 tablet per day
Mektovi®*<s> 6 tablets per day
Mircera® * <s> 2 syringes per 30 days Not covered
NerlynxTM* <s> 180 tablets per 30 days (Limited to 15 day supply per fill)
Neulasta® <s> 2 syringes per 30 days
Nexavar®*<s> 120 tablets per 30 days (Limited to 15 day supply per fill)
Ninlaro® *<s> 3 capsules per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antineoplastics and Immunosuppressants (cont.) Custom Custom Select
Odomzo®* <s> 30 tablets per 30 days (Limited to 15 day supply per fill)
Piqray®* <s> 1 carton per 30 days
Pomalyst®* <s> 21 capsules per 30 days
Revlimid®* <s> 1 capsule per day
RozlytrekTM* <s> 90 capsules per 30 days (Limited to a 15 day supply)
Rubraca™* <s> 4 tablets per day
Rydapt®*<s> 8 capsules per day
Sprycel®*<s> Limited to 15 day supply per fill
Stivarga®*<s> 84 tablets per 30 days
Sutent®*<s> 30 capsules per 30 days (Limited to 15 day supply per fill)
SylatronTM <s> 1 kit (4 vials) per 28 days
Tafinlar®*<s> 4 capsules per day
TagrissoTM*<s> 30 tablets per 30 days (Limited to 15 day supply per fill)
Tarceva®*<s> Limited to 15 day supply per fill
Targretin®* capsules<s> Limited to 15 day supply per fill
Tasigna®*<s> 120 capsules per 30 days (Limited to 15 day supply per fill)
TazverikTM*<s> 240 tablets per 30 days (Limited to 15 day supply per fill)
Tibsovo®*<s> 60 tablets per 30 days (Limited to 15 day supply per fill)
TuralioTM* <s> 4 capsules per day
VenclextaTM*<s> 4 tablets per day
VerzenioTM* <s> 60 tablets per 30 days (Limited to 15 day supply per fill)
Vitrakvi®* 100mg - 60 capsules per 30 days (limited to a 15 day supply per fill); 25mg - 180 capsules per 30 days (limited to a 15 day supply per fill);
Solution - 10mL per day
Vizimpro®* 30 tablets per 30 days (Limited to 15 day supply per fill)
Votrient®*<s> Limited to 15 day supply per fill
Xalkori®*<s> 60 capsules per 30 days (Limited to 15 day supply per fill)
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antineoplastics and Immunosuppressants (cont.) Custom Custom Select
XpovioTM*<s> 1 carton (4 blister packs) per 30 days (Limited to a 15 day supply)
Xospata® <s> 3 tablets per day
Xtandi® <s> 120 capsules per 30 days (Limited to 15 day supply per fill)
Zejula™*<s> 90 capsules per 30 days (Limited to 15 day supply per fill)
Zelboraf®* <s> 240 tablets per 30 days (Limited to 15 day supply per fill)
Zolinza®*<s> Limited to 15 day supply per fill
Zydelig®*<s> 2 tablets per day
ZykadiaTM* <s> 90 capsules per 30 days (Limited to 15 day supply per fill)
Zytiga® 250mg* <s> 4 tablets per day
Antiparasitics/Anthelmintics Custom Custom Select
Benzidazole 12.5 mg 12 tablets/day
Benzidazole 100 mg 4 tablets/day
Emverm™ 6 tablets per 30 days Not covered
Impavido® 84 tablets per 30 days
Tindamax® (g) 20 tablets per 20 days
Antipsychotics Custom Custom Select Aristada® (441mg, 662mg and 882mg) 1 syringe per 30 days
Aristada® (1,064mg) 1 syringe per 60 days
Caplyta® 1 tablet per day
Invega® 1.5mg, 3mg, 9mg (g)* 1 tablet per day
Invega® 6mg (g)* 2 tablets per day
Invega® Trinza 4 kits per 365 days
Nuplazid™* 1 tablet/capsule per day
Perseris™ 2 syringes per 30 days
Rexulti® * 1 tablet per day Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antipsychotics (cont.) Custom Custom Select
Saphris®* 2 tablets per day
Secuado®* 1 patch per day
Seroquel XR® (g)* 2 tablets per day
VraylarTM* 1 tablet per day
Antiretrovirals Custom Custom Select
Biktarvy® 1 tablet per day
Cimduo TM 1 tablet per day
Complera® 1 tablet per day
Delstrigo TM 1 tablet per day
Descovy® 1 tablet per day
Dovato 1 tablet per day
Edurant® 1 tablet per day
EvotazTM 1 tablet per day
Genvoya® 1 tablet per day
Juluca® 1 tablet per day
Odefsey® 1 tablet per day
Pifeltro TM 1 tablet per day
Prezcobix TM 1 tablet per day
Stribild® 1 tablet per day
Symfi TM 1 tablet per day
Symfil Lo TM 1 tablet per day
Symtuza TM 1 tablet per day
Temixys TM 1 tablet per day
Triumeq® 1 tablet per day
Truvada® 1 tablet per day
Vemlidy® 1 tablet per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Antitussives Custom Custom Select
Vituz® 240 mL per Rx Not covered
Antivirals Custom Custom Select
Epclusa®* <s> 1 tablet per day
Harvoni®*<s> 1 tablet per day Not Covered
Ledipasvir-sofosbuvir <s> 1 tablet per day
MavyretTM*<s> 3 tablets per day
PrevymisTM 28 tablets (1 carton) per 30 days
Relenza® 1 inhaler per Rx, 2 Rx per 270 days
Sovaldi®*<s> 1 tablet per day
Tamiflu® 30mg 20 capsules per Rx, 2 Rx per 270 days
Tamiflu® 45mg, 75mg 10 capsules per Rx, 2 Rx per 270 days
Tamiflu suspension 180 mL per Rx, 2 Rx per 270 days
VoseviTM*<s> 1 tablet per day
XofluzaTM 2 blister packs per 180 days
Zepatier®* <s> 1 tablet per day
Beta-Blockers and Combinations Custom Custom Select
Bystolic® 2.5, 5, &10mg* 1 tablet per day
Coreg CR®* (g) 1 capsule per day Not covered
Hemangeol® 3 bottles (360 mL) per 30 days Not covered
Bowel Preparation and Cleansing Agents Custom Custom Select
OTC and prescription products - Generic only
One bowel preparation regimen per 365 days with $0 copay (for colonoscopy screening of colorectal cancer only)
BPH Treatment Custom Custom Select
Cialis 2.5mg, 5mg* 1 tablet per day Not covered
Jalyn®* (g) 1 capsule per day
Rapaflo® 1 capsule per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Calcium Channel Blockers and Combinations Custom Custom Select
Caduet® (g) 1 tablet per day
Prestalia® * 1 tablet per day Not covered
Tribenzor®* (g) 1 tablet per day
Cardiovascular treatment Custom Custom Select
Corlanor® 2 tablets per day
Corlanor® solution 4 cartons (112 pouches) per 30 days
Multaq® 2 tablets per day
Northera™*<s> 100mg, 200mg 3 tablets per day Not covered
Northera™*<s> 300mg 6 tablets per day Not covered
Vyndamax®*<s> 1 capsule per day
Vyndaqel™*<s> 4 capsules per day
Chelating Agents Custom Custom Select
Depen® 8 capsules per day
Ferriprox® oral solution* <s> 2,700 mL per 30 days
Ferriprox® tablet* <s> 540 tablets per 30 days
Jadenu™*<s> Limited to 15 day supply per fill
Syprine®* <s> 8 capsules per day
CNS Stimulants Custom Custom Select Adderall® 5mg, 7.5mg, 10mg, 12.5mg, 15mg (g) 4 tablets per day
Adderall® 20mg (g) 3 tablets per day
Adderall® 30mg (g) 2 tablets per day
Adderall XR® 2 capsules per day Not covered
Adderall XR® (g)* 2 capsules per day
Adzenys ER™ 15 mL (18.8mg per day) Not covered
Adzenys XR-ODT™* 2 tablets per day Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
CNS Stimulants (cont.) Custom Custom Select
Aptensio XR™ 1 capsule per day Not covered
Concerta® (g) 2 tablets per day
Daytrana® 1 patch per day
Desoxyn® (g) 5 tablets per day
Dexedrine® (g) 4 tablets/capsules per day
Dyanavel™ XR* 8 mL per day Not covered
Evekeo™ 4 tablets per day Not covered
Focalin® (g) 3 tablets per day
Focalin® XR (g) 2 capsules per day
Jornay PM™* 1 capsule per day Not covered
Metadate CD® (g) 10, 20, 30mg 3 capsules per day
Metadate CD® (g) 40, 50, 60mg 2 capsules per day
Methylin® chew tablet 2.5, 5, 10mg (g) 7 tablets per day Not covered
Methylin® (g); Ritalin (g) 7 tablets per day
Methylin® ER (g) 6 tablets per day
Methylin® solution (g) 80 mg per day
Methylphenidate ER 72mg 1 tablet per day
Nuvigil® (g)* 1 tablet per day
Procentra® (g)* 60 mL (60 mg) per day
Provigil® (g)* 2 tablets per day
Quillichew ER™* 60 mg per day Not covered
Quillivant XR™* 12 mL (60 mg) per day Not covered
Relexxii™ 1 tablet per day
Ritalin LA® 10mg 4 capsules per day
Ritalin LA® 20, 30mg (g) 4 capsules per day
Ritalin LA® 40mg (g) 3 capsules per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
CNS Stimulants (cont.) Custom Custom Select
Ritalin LA® 60mg 2 capsules per day
Vyvanse®* 1 capsule per day
Zenzedi® 4 tablets per day
Contraceptives and Estrogens/Combinations Custom Custom Select
Bijuva™ 1 capsule per day Not covered
Ella® 2 tablets per 30 days
Nuvaring® 1 vaginal ring per 30 days
Ortho Evra® (g) 3 patches per 28 days
Slynd® 1 blister pack per 30 days
Wide Seal® diaphragms 1 unit per 90 days
Cystic Fibrosis Agents Custom Custom Select
Bethkis®* <s> 56 ampules per 42 days Not covered
Cayston®* <s> 1 kit (84 vials) per 42 days
Kalydeco®* <s> 2 tablets or packets per day
Orkambi™* <s> 4 tablets per day
Orkambi™ granules* <s> 56 packets per 30 days
Symdeko®* <s> 1 carton (56 tablets) per 28 days
Tobi TM PodhalerTM*<s> 224 capsules per 42 days Not covered
TrikaftaTM*<s> 84 tablets (1 carton) per 28 days
Dermatology Custom Custom Select
Accutane (isotretinoin) 5 capsules per day
Aczone® 5% 90 grams per 30 days Not covered
Altreno® 1 tube (45 grams) per 30 days
Amzeeq TM* 1 can per 30 days Not covered
Doxepin Cream* 1 tube per 365 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Dermatology (cont.) Custom Custom Select
Dupixent®* 2 syringes per 30 days
EucrisaTM* 1 tube per Rx Not covered
QbrexzaTM* 1 box (30 pouches) per 30 days Not covered
Regranex® 3 tubes (45 gm) per 150 days
Vusion® 1 tube (50 gm) per Rx Not covered
Diagnostic and Other Miscellaneous Custom Custom Select
EndariTM* 6 packets per day
Firazyr®* <s> 12 syringes (36 mL) per 30 days
Haegarda® * <s> 2,000 units per day
JynarqueTM* <s> 4 tablets per day (15mg, 30mg) 2 tablets per day (45mg, 60mg, and 90mg)
KeveyisTM* <s> 4 tablets per day
Methergine® 8 tablets per day
Ruconest®* <s> 2 doses (4 vials) per 30 days
Vistogard®* <s> 20 packets per fill
Gastrointestinal Custom Custom Select
AemcoloTM 12 tablets per 90 days Not covered
Amitiza® 2 capsules per day
Gattex®* <s> 1 kit (30 vials) per 30 days
Giazo® 6 tablets per day
Lialda® 4 tablets per day
Linzess® 1 capsule per day
Lotronex® (g) 2 tablets per day
MotegrityTM 1 tablet per day Not covered
MovantikTM * 1 tablet per day Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Gastrointestinal (cont.) Custom Custom Select
Mytesi®* 2 tablets per day
OcalivaTM*<s> 1 tablet per day
Rectiv® 1 tube (30 gm) per Rx
Relistor tablet* 3 tablets per day Not covered
Sucraid®*<s> 4 bottles (472mL) per 30 days
Symproic®* 1 tablet per day Not covered
Talicia® 168 capsules per 90 days Not covered
Uceris®* 1 tablet per day Not covered
Viberzi™* 2 tablets per day Not covered
Xifaxan® 200mg 9 tablets every 7 days
Xifaxan® 550mg* 3 tablets per day
Gout Therapy Custom Custom Select
Duzallo®* 1 tablet per day Not covered
Uloric®* 1 tablet per day
Zurampic®* 1 tablet per day Not covered
Infertility Custom Custom Select
Chorionic Gonadotropin® Not applicable 2 vials per 30 days, 6 vials per 365 days
Clomid® Not applicable 30 tablets per 365 days
Follistim® AQ 150 IU/0.5mL vial Not applicable 30 vials per 30 days, 90 vials per 365 days
Follistim® AQ 300 IU/0.36mL cartridge Not applicable 15 cartridges per 30 days,
45 cartridges per 365 days Follistim® AQ 600 IU/0.72mL cartridge Not applicable 8 cartridges per 30 days,
24 cartridges per 365 days
Follistim® AQ 75 IU/0.5mL vial Not applicable 15 vials per 30 days, 45 vials per 365 days
Follistim® AQ 900 IU/1.08mL cartridge Not applicable 5 cartridges per 30 days,
15 cartridges per 365 days
Gonal-f® 1050 units/vial Not applicable 4 vials per 30 days, 12 vials per 365 days
Gonal-f® 450 units/vial Not applicable 7 vials per 30 days, 21 vials per 365 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Infertility (cont.) Custom Custom Select Gonal-f® RFF Pen 300 units/0.5mL cartridge Not applicable 15 cartridges per 30 days,
45 cartridges per 365 days Gonal-f® RFF Pen 450 units/0.75mL cartridge Not applicable 10 cartridges per 30 days,
30 cartridges per 365 days
Gonal-f® RFF 75 units/vial Not applicable 10 vials per 30 days, 30 vials per 365 days
Gonal-f® RFF Pen 900 units/1.5mL cartridge Not applicable 5 cartridges per 30 days,
15 cartridges per 365 days
Ovidrel® Not applicable 2 syringes per 30 days, 6 syringes per 365 days
Pregnyl® Not applicable 2 vials per 30 days, 6 vials per 365 days
Inhaled Anticholinergics Custom Custom Select
Atrovent HFA® 2 inhalers per 30 days
Incruse™ Ellipta® 1 inhaler per 30 days Not covered
Lonhala™ Magnair™ 2 vials per day 1 starter pack per 365 days
SeebriTM Neohaler® 60 capsules per 30 days Not covered
Spiriva HandiHaler® 1 box (30 capsules) per 30 days
Spiriva Respimat® 1 inhaler per 30 days
Tudorza Pressair® 1 inhaler per 30 days
Yupelri™ 1 vial per day
Inhaled Beta-Agonist Custom Custom Select
Arcapta Neohaler® 1 capsule per day
Brovana®* 2 vials (4 mL) per day
Perforomist®* 2 vials (4 mL) per day
Proair® HFA / Ventolin® HFA 4 inhalers per 30 days
ProAir® RespiClick 4 inhalers per 30 days
Proventil® HFA 4 inhalers per 30 days
Serevent Diskus® 1 inhaler per 30 days
Striverdi® Respimat® 1 inhaler (4 g) per 30 days Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Inhaled Beta-Agonist (cont.) Custom Custom Select
Xopenex® HFA 2 inahalers per 30 days
Inhaled Beta-Agonist and Anticholinergic Combinations Custom Custom Select
Anoro® Ellipta® 1 inhaler per 30 days
Bevespi Aerosphere™ 1 inhaler per 30 days Not covered
Combivent Respimat 2 inhalers per 30 days
Stiolto™ Respimat® 1 inhaler (4 g) per 30 days
Utibron™ Neohaler® 2 capsules per day Not covered
Inhaled Corticosteroids Custom Custom Select
Arnuity™ Ellipta® 1 inhaler per 30 days
Asmanex® HFA 1 inhaler per 30 days
Asmanex Twisthaler® 1 inhaler per 30 days
Flovent® Diskus 2 inhalers per 30 days
Flovent® HFA (all strengths) 2 inhalers per 30 days
Pulmicort Flexhaler™ 2 inhalers per 30 days
Qvar® Redihaler™ 2 inhalers per 30 days
Inhaled Steroid and Beta-Agonist Combinations Custom Custom Select
Advair Diskus® 1 inhaler (60 blisters) per 30 days
Advair HFA® 1 inhaler per 30 days
Airduo™ RespiClick® 1 inhaler per 30 days Not covered
ArmonAir™ RespiClick® 1 inhaler per 30 days Not covered
Breo® Ellipta® 1 inhaler (60 blisters) per 30 days
Dulera® 1 inhaler per 30 days
Fluticasone-salmeterol RespiClick® 1 inhaler per 30 days
Symbicort® 1 inhaler per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Inhaled Steroid, Anticholinergic, and Beta-Agonist Combinations
Custom Custom Select
TrelegyTM Ellipta® 30 inhalations (60 blisters) per 30 days
Ion Removing Agents Custom Custom Select
LokelmaTM 10 gm = 1 packet per day
5 gm = 3 packets per day
Lipid Lowering Agents Custom Custom Select
Caduet® (g) 1 tablet per day
Crestor (g) 1.5 tablets per day
Juxtapid®* <s> 1 capsule per day Not covered
Lescol, XL (g) 1 tablet per day
Lipitor (g) 1.5 tablets per day
Livalo®* 1 tablet per day
Lovaza® (g)* 4 capsules per day
Mevacor (g) 10 mg, 20 mg 1.5 tablets per day
Mevacor (g) 40 mg 2 tablets per day
NexletolTM* 1 tablet per day
NexlizetTM* 1 tablet per day
Praluent®* <s> 2 injections per 30 days
Pravachol (g) 1.5 tablets per day
Repatha®* <s> 3 injections per 30 days
Repatha® Pushtronex* <s> 1 unit per 30 days
Vascepa®* 4 capsules per day
Vytorin® (g) 1 tablet per day
Zetia® (g) 1 tablet per day
Zocor (g) 1.5 tablets per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Migraine Therapy Custom Custom Select
Aimovig 1 autoinjector/syringe (1 pack) per 30 days
Ajovy®* 1 syringe (1 pack) per 30 days
AlsumaTM (g) 2 syringes per Rx
Amerge® (g) 9 tablets per Rx
Axert® (g) 9 tablets per Rx
Cafergot® 50 tablets per Rx
D.H.E. 45® (g) 5 ampules per Rx
EmgalityTM 100mg* 1 carton (3 syringes) per 30 days; 4 cartons (12 syringes) per 365 days
EmgalityTM 120mg/mL* 1 pen/syringe per 30 days Carton of 2 syringes: 1 carton per 365 days
Ergomar® 20 tablets per Rx
Frova® (g)* 9 tablets per Rx
Imitrex® injection (g) 5 injections per Rx
Imitrex® nasal spray (g) 6 units (1 box) per Rx
Imitrex® tablet (g) 9 tablets per Rx
Maxalt®, MLT® (g) 9 tablets per Rx
Migranal® nasal spray (g) 1 kit (8 vials) per Rx
Nurtec ODTTM* 15 tablets per 30 days Not covered
OnzetraTM XsailTM* 1 dose kit per Rx Not covered
Relpax®* 9 tablets per Rx
ReyvowTM* 8 tablets per 30 days
UbrelvyTM* 16 tablets per 30 days
Treximet®* 9 tablets per Rx Not covered
ZembraceTM SymtouchTM* 2 injections per Rx Not covered
Zomig® Nasal Spray* 6 units per Rx
Zomig®, ZMT® 2.5mg (g) 9 tablets per Rx
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Migraine Therapy (cont.) Custom Custom Select
Zomig®, ZMT® 5mg (g) 9 tablets per Rx
Miscellaneous CNS Custom Custom Select
AustedoTM 9mg, 12mg* <s> 4 tablets per day
AustedoTM 6mg* <s> 7 tablets per day
Gralise®* 3 tablets per day Not covered
Gralise® starter pack * 78 tablets per 365 days Not covered
Horizant® * 2 tablets per day Not covered
IngrezzaTM* <s> 1 capsules per day
IngrezzaTM* titration pack <s> 1 pack per 365 days
Intuniv® (g) 1 tablet per day
Kapvay® (g) 4 tablets per day
Narcan® nasal spray 2 packages (4 sprays) per Rx
Nuedexta®* 2 tablets per day
Nymalize® 120 mL per day/2 Rxs per 365 days
Ozobax TM* 5 bottles (2,400 mL) per 30 days Not covered
Ruzurgi™* 10 tablets per day
Savella®* 2 tablets per day
Savella® Titration Pack* 1 pack per 180 days
Soma® (g)* N/A 4 tablets per day
Strattera® (g)* 2 capsules per day
Sunosi* 1 tablet per day
Tegsedi <s> 4 syringes per 30 days
Tiglutik 2 bottles (600 mL) per 30 days
Wakix®* <s> 2 tablets per day
Xenazine® (g)* <s> 2 tablets per day
Xyrem®* <s> 3 bottles (540 mL) per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Miscellaneous Endocrine Custom Custom Select
Baqsimi™ 8 units per 30 days; 16 units per 365 days
Cerdelga™* <s> 2 capsules per day
Egrifta®* 1 mg <s> 2 vials per day Not covered
Egrifta®* 2 mg <s> 1 vial per day Not covered
Galafold™* 1 wallet pack (14 capsules) per 28 days
Gvoke™ Syringe/Hypopen 8 units per 30 days; 16 units per 365 days
Isturisa TM*<s> 1 mg, 5 mg 4 tablets per day
Isturisa TM*<s> 10 mg 6 tablets per day
Korlym®* <s> 4 tablets per day
Myalept®* <s> 1 vial per day
Natpara® *<s> 2 pens per 30 days
Nocdurna®* 1 carton (30 tablets) per 30 days Not covered
Noctiva TM* 1 bottle per 30 days Not covered
Nubeqa® *<s> 120 tablets per 30 days (Limitied to a 15 day supply)
Palynziq TM *<s>
20mg/ml = 2 injections per day
10mg/0.5ml = 1 injection per day
2.5mg/0.5ml = 8 injections per 30 days
Ravicti®* <s> 19 gm (17.5 mL) per day
Revcovi®* <s> 48 vials per 30 days
Signifor®*<s> 2 ampules per day
Signifor® LAR* <s> 1 kit per 30 days Not covered
Somatuline® Depot* <s> 1 syringe per 30 days
Xermelo TM* <s> 3 tablets per day
Zavesca®* <s> 3 capsules per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Miscellaneous Immunology & Hematology Custom Custom Select
BenlystaTM* <s> 4 injections per 28 days
Doptelet®*<s> 2 tablets per day
Fulphila®<s> 2 syringes per 30 days
Nivestym®<s> 2 vials per day
OxbrytaTM*<s> 3 tablets per day
Takhzyro TM 2 vials per 30 days
Tavalisse TM*<s> 2 tablets per day
Udenyca®<s> 2 syringes per 30 days
Ziextenzo®<s> 2 syringes per 30 days
Miscellaneous OB-GYN Custom Custom Select
Brisdelle®* (g) 1 capsule per day Not covered
Lysteda® (g) 30 tablets per fill
Orilissa TM 150mg = 1 carton (28 tablets) per 30 days
200mg = 1 carton (56 tablets) per 30 days
Miscellaneous Respiratory Custom Custom Select
Daliresp®* 1 tablet per day
Epinephrine auto-injector 4 injectors per Rx, 8 injectors per 365 days
Esbriet® <s> 9 capsules per day
Epipen® 4 injectors per Rx, 8 injectors per 356 days
Epipen® Jr 4 injectors per Rx, 8 injectors per 365 days
Esbriet® tablets <s> 3 tablets per day (801 mg); 9 tablets per day (267 mg)
Fasenra®* pen <s> 1 pen per 30 days
Glassia ®* <s> 9 vials per 30 days
Grastek®* 1 tablet per day Not covered
Nucala®* <s> 3 auto-injectors per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Miscellaneous Respiratory (cont.) Custom Custom Select
OdactraTM* 1 tablet per day Not covered
Ofev®* <s> 2 capsules per day
Oralair®* 1 tablet per day Not covered
Ragwitek®* 1 tablet per day Not covered
SymjepiTM 4 injections per Rx 8 injections per 365 days
Zyflo CR® 4 tablets per day
Miscellaneous Urologicals Custom Custom Select
PalforziaTM*<s> 1 kit per 30 days
Thiola®* 10 tablets per day
Thiola EC®* 100mg = 10 tablets per day; 300mg = 3 tablets per day
Multiple Sclerosis Custom Custom Select
Ampyra®* <s> 2 tablets per day
Aubagio®*<s> 1 tablet per day
Avonex® 4 syringes/pens per 28 days
Betaseron® 14 syringes per 28 days
Copaxone® 20 mg 1 syringe per day
Copaxone® 40 mg 12 syringes per 30 days
Extavia® 14 vials/kits per 28 days
Gilenya® <s> 1 capsule per day
GlatopaTM 1 syringe per day
MavencladTM <s> 2 boxes per 365 days
Mayzent® <s> 0.25mg – 4 tablets per day 2mg – 1 tablet per day
Mayzent® starter pack<s> 2 packs per 365 days
Pegasys®, ProclickTM<s> 4 syringes / vials / pens per 30 days
Peg-Intron®, Redipen <s> 4 vials / redipens per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Multiple Sclerosis (cont.) Custom Custom Select
Plegridy®* <s> 1 carton (2 syringes) per 30 days
Plegridy®*starter pack <s> 1 pack per 365 days
Rebif® 12 syringes or pens per 28 days
Rebif® titration pack 1 pack per 365 days
Rebif® Rebidose® titration pack 1 pack per 365 days
Tecfidera® <s> 2 capsules per day
VumerityTM <s> 4 capsules per day
VumerityTM starter pack <s> 1 bottle per 365 days
Narcotics/Analgesic Combinations Custom Custom Select
Click here to see quantity limits for Narcotics/Analgesic Combinations
Narcotic Mixed Agonist and Antagonist Custom Custom Select
Subutex® (g)* 3 tablets per day
Non-Tumor Necrosis Factor (TNF) Blocking Agents Custom Custom Select
Actemra® subcutaneous* <s> 4 syringes per 28 days
Cosentyx™*<s> 2 pens / syringes per 30 days
Kevzara® <s> 2 syringes (1 pack) per 28 days
Kineret®* <s> 30 syringes per 30 days
Olumiant®*<s> 1 tablet per day
Orencia®* <s> 4 syringes per 30 days
Otezla®* <s> 2 tablets per day
RinvoqTM*<s> 1 tablet per day
Siliq®*<s> 1 carton (2 syringes) per 30 days
SkyriziTM*<s> 1 kit (2 syringes) per 12 weeks
Stelara®* <s> 1 syringe/vial every 56 days
Taltz®* <s> 1 injection per 30 days Not covered
Taltz® 2-pack* <s> 2 packs per 365 days Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Non-Tumor Necrosis Factor (TNF) Blocking Agents (cont.) Custom Custom Select
Taltz® 3-pack* <s> 1 pack per 365 days Not covered
Tremfya™*<s> 8 syringes per 365 days
Xeljanz®* <s> 2 tablets per day
Xeljanz® XR* <s> 1 tablet per day
NSAIDs Custom Custom Select
Fenoprofen* 200mg 16 tablets per day
Fenoprofen* 400mg 8 tablets per day
Fenoprofen* 600mg 5 tablets per day
FenorthoTM* 200mg 16 capsules per day Not covered
Flector®* 2 patches per day Not covered
Indocin® suppository 4 suppositories per day
Ketoprofen 25mg 4 capsules per day
Pennsaid® (all strengths)* 2 bottles per 30 days Not covered
Sprix® 5 bottles (630 mg) per 28 days Not covered
Toradol® tablet (g) 20 tablets every 26 days
Voltaren® gel (g) 4 tubes (400 gm) per 28 days
Ophthalmology Custom Custom Select
CequaTM 1 box (60 vials) per 30 days Not covered
CystaranTM*<s> 4 bottles (60 mL) per 30 days
InveltysTM 1 bottle per 30 days Not covered
Lotemax SM®* 1 bottle per 30 days Not covered
OxervateTM 4 cartons per 30 days (Limited to 8 cartons per 60 days)
Pazeo® Not applicable 2 bottles per 30 days
Rhopressa®* 2 (2.5ml) bottles per 30 days Not covered
RocklatanTM* 2 (2.5ml) bottles per 30 days
XelprosTM 1 bottle per Rx Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Osteoporosis Custom Custom Select
Actonel ® 5, 30mg 1 tablet per day
Actonel ® 35mg 4 tablets per 30 days
Actonel ® 150mg 1 tablet per 30 days
Atelvia® (g)* 4 tablets per 30 days
Binosto®* 4 tablets per 30 days Not covered
Boniva® 150mg 1 tablet per 30 days
Evista®* 1 tablet per day
Forteo®* <s> 1 pen per 30 days
Fosamax D® Solution 4 bottles (300mL) per 30days
Fosamax Plus D®* 4 tablets per 30 days Not covered
Fosamax® 5, 10mg 1 tablet per day
Fosamax® 35, 70mg 4 tablets per 30 days
Tymlos™*<s> 1 unit per 30 days , 3 units per 90 days
Parkinson's Disease Custom Custom Select
DuopaTM *<s> 4 cartons (2800mL) per 30 days
InbrijaTM Carton of 60 – 5 cartons per 30 days; Carton of 92 – 3 cartons per 30 days
Mirapex® ER® (g)* 1 tablet per day Not covered
Neupro®* 1 patch per day Not covered
NourianzTM* 1 tablet per day
Rytary®* 12 capsules per day Not covered
Xadago® 1 tablet per day
Zelapar® 2 tablets per day
Pulmonary Hypertension Agent Custom Custom Select
Adcirca®* <s> 2 tablets per day
Adempas®* <s> 3 tablets per day
Letairis®* <s> 1 tablet per day
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Pulmonary Hypertension Agent (cont.) Custom Custom Select
Opsumit®* <s> 1 tablet per day
Orenitram® ER* <s> 12.5 mg per day
Revatio® (g)* 3 tablets per day
Revatio® suspension* 2 bottles per 30 days
Tracleer®* <s> 2 tablets per day
Tyvaso® starter kit*<s> 1 kit per 365 days
Tyvaso® refill/replacement kit* <s> 1 kit (82 mL) per 30 days
Tyvaso® vials* <s> 28 ampules (81.2 mL) per 28 days
Uptravi®* <s> 2 tablets per day
Uptravi®* starter pack<s> 1 pack per 365 days
Ventavis®* <s> 270 ampules per 30 days
Rheumatology Custom Custom Select
OtrexupTM* <s> 4 injections per 30 days Not covered
Rasuvo®* <s> 4 injections per 30 days Not covered
Sedative/Hypnotics Custom Custom Select
Ambien® (g) 1 tablet per day
Ambien CR® (g) 1 tablet per day
Belsomra®* 1 tablet per day Not covered
Dalmane® 1 capsule per day
DayvigoTM* 1 tablet per day Not covered
Edluar®* 1 tablet per day Not covered
Halcion® 0.125 mg – 1 tablet per day
0.25mg – 2 tablets per day
HetliozTM* <s> 1 capsule per day
Intermezzo® (g)* 60 tablets per 90 days Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Sedative/Hypnotics (cont.) Custom Custom Select
Lunesta® 1 tablet per day
ProsomTM 1 tablet per day
Restoril® 1 capsule per day
Rozerem® 1 tablet per day
Silenor®* 1 tablet per day Not covered
Sonata® 10 mg – 2 capsules per day
5 mg – 1 capsule per day
Sexual Dysfunction Custom Custom Select
AddyiTM* 1 tablet per day Not covered
Caverject® 6 units per 28 days Not covered
Cialis®* 6 tablets per 28 days Not covered
Edex® 12 vials per 30 days Not covered
Levitra®* 6 units per 28 days Not covered
Muse®
Revatio® (g) 1 tablet per day Excluded for use as Sexual Dysfunction agent
Staxyn®*
6 units per 28 days Not covered Stendra®*
Viagra®* (g)
Vylessi TM* 2 cartons (8 autoinjectors per 30 days) Not covered
Smoking Cessation Custom Custom Select
Chantix® 2 tablets per day
Nicotrol®* 3 packages per 30 days
Nicotrol NS®* 40ml (4 bottles) per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Smoking Cessation (cont.) Custom Custom Select Over-the-Counter Nicotine Patch, Gum, Lozenge 1 fill/month and 6 fills/year
Testosterone Replacement Custom Custom Select
Androderm®* 30 patches per 30 days
Androgel 1% (5gm) packets® (g)* 60 packets (300 gm) per 30 days
Androgel 1% (2.5gm) packets® (g)* 90 packets (225 gm) per 30 days
Androgel 1% pump® (g)* 4 bottles (300 gm) per 30 days
Androgel 1.62% (1.25gm) packets®* 30 packets (37.5 gm) per 30 days
Androgel 1.62% (2.5gm) packets®* 60 packets (150 gm) per 30 days
Androgel 1.62% pump®* 2 bottles (150 gm) per 30 days
Android® (g)* 1 tablet per day Not covered
Axiron®* 2 bottles (180 mL) per 30 days Not covered
Fortesta®* 2 bottles (120 gm) per 30 days Not covered
Jatenzo 158mg, 198mg®* 4 capsules per day Not covered
Jatenzo 237mg®* 2 capsules per day Not covered
Methitest™* 1 tablet per day
Natesto™* 3 bottles (22 gm) per 30 days Not covered
Striant®* 2 buccal systems per day Not covered
Testim®* 60 tubes (300 gm) per 30 days Not covered
TestosteroneTM gel* 60 tubes (300 gm) per 30 days Not covered
TestosteroneTM packets* 60 packets (300 gm) per 30 days Not covered
TestosteroneTM 1% pump* 4 bottles (300 gm) per 30 days Not covered
TestosteroneTM 2% pump* 2 bottles (180 mL) per 30 days Not covered
Testred® (g)* 1 capsule per day Not covered
VogelxoTM packets* 60 packets (300 gm) per 30 days Not covered
VogelxoTM pump* 4 bottles (300 gm) per 30 days Not covered
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Testosterone Replacement (cont.) Custom Custom Select
XyostedTM 1 carton (4 injectors) per 30 days Not covered
Topical Antineoplastic Agents and Immunomodulators Custom Custom Select
Aldara® (g) 1 packet per day
Lorbrena®
25mg = 90 tablets per 30 days (Limited to a 15 day supply)
100mg = 30 tablets per 30 days (Limited to a 15 day supply)
25mg = 90 tablets per 30 days (Limited to a 15 day supply per
fill)
100mg = 30 tablets per 30 days (Limited to a 15 day
supply per fill)
Picato®* 1 carton per 30 days
Talzenna®
0.25mg = 90 tablets per 30 days (Limited to 15 day supply per fill)
1mg = 30 tablets per 30 days (Limited to 15 day supply per fill)
Valchlor®*<s> 2 tubes (120 gm) per 30 days
ZyclaraTM packet 1 packet per day
Zyclara pump 1 bottle (7.5 gm) per 30 days
Topical Antifungals Custom Custom Select
EcozaTM* 1 bottle per 30 days Not covered
LuzuTM* 1 tube per 30 days Not covered
Naftin®* 1 bottle per 30 days Not covered
Oxistat®* 1 bottle per 30 days Not covered
Xolegel®* 1 tube per 30 days Not covered
Topical Corticosteroids Custom Custom Select
Bryhali TM* 1 tube per 30 days
Duobrii TM 1 tube per 30 days
Kenalog® Spray 1 can per 365 days
Vanos® 0.1% cream 4 tubes (240gm) per 30 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Tumor Necrosis Factor Blocking Agents Custom Custom Select
Cimzia®* <s> 2 packages (4 syringes per 30 days / 2 kits in 30 days)
Cimzia® starter kit* <s> 2 starter kits per 365 days
Enbrel®* 25mg <s> 8 syringes/vials per 30 days
Enbrel®* 50mg <s> 4 syringes/vials per 30 days
Humira® <s>
10mg/0.2mL 20mg/0.4mL
1 package (2 syringes) per 30 days 40mg/0.8mL
2 packages (4 syringes) per 30 days
Humira 80mg-40mg <s> 8 kits per 365 days
Humira Crohn's kit <s> 1 kit (6 syringes) per 365 days
Humira Psoriasis kit <s> 1 kit (4 syringes) per 365 days
Simponi®* <s> 1 syringe per 30 days
Urinary Antispasmodics Custom Custom Select
Gelnique® packet 1 packet per day Not covered
Gelnique® 10% pump 1 gram per day Not covered
Myrbetriq®* 1 tablet per day
Sanctura XR® (g) 1 capsule per day
Toviaz® 1 tablet per day
Vesicare® 1 tablet per day
Urology Custom Custom Select
Procysbi® * granules <s> 2 cartons per 30 days Not covered
Procysbi® 25mg* capsules <s> 2 capsules per day Not covered
Xuriden™* <s> 4 cartons per 30 days
Vaccines Custom Custom Select
Adacel 0.5mL per fill
Afluria 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Vaccines (cont.) Custom Custom Select
Afluria Quad 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Boostrix/Boostrix TDAP 0.5 mL per fill
Chicken pox vaccine (Varivax) 0.5 mL per Rx
Fluad 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Flublok 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Flublok Quad 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Flucelvax Quad 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Flulaval 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Flumist 2 nasal spray syringes per 6 months
Fluzone High-dose 0.5 mL per fill 1 vaccine per 180 days
Fluzone Quad (all) 0.5 mL per fill
> 9 years old 1 vaccine per 180 days
Gardasil/Gardasil I-9 0.5 mL per fill
Havrix 720/0.5 ml 0.5 mL per fill
Havrix 1,440/1 ml 1 mL per fill
Measles, Mumps, Rubella vaccine (MMR II) 0.5 mL per Rx
Menactra 0.5 mL per fill
Meningococcal B vaccine (Trumenba, Bexsero) 0.5 mL per Rx
Menveo 1 kit per fill
Pneumovax 23 0.5 mL per fill
Pneumovax 23 1 fill per 2 years
Polio vaccine (Ipol) 0.5 mL per Rx
Prevnar 13 0.5 mL per fill
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Vaccines (cont.) Custom Custom Select
Prevnar 13 1 fill per 2 years
Shingrix 2 vial kits per 720 days
Tetanus/diphtheria booster (Tenivac, Tdvax) 0.5 mL per Rx
Twinrix 1 mL per fill
Vaqta 25/0.5 ml 0.5 mL per fill
Vaqta 50/1 ml 1 mL per fill
Zostavax 1 fill per 2 years
Weight Reduction Custom Custom Select
Contrave® ER* 4 tablets per day Not covered
Qsymia®* 1 capsule per day Not covered
Saxenda®* 5 pens (15 mL) per 30 days Not covered
Xenical®* 3 capsules per day Not covered
Narcotics/Analgesic Combinations Custom Custom Select
5-day limit for first fill
30-day limit
Abstral®* 4 tablets per day Not covered
Actiq® (g)* 4 lozenges per day
Avinza® (g) 1 capsule per day Not covered Yes
BelbucaTM* 2 films per day Not covered Yes
Belladonna & Opium Yes
Butrans® 4 patches per 30 days Yes
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Narcotics/Analgesic Combinations (cont.) Custom Custom Select
5-day limit for first fill
30-day limit
Capital® w-Codeine (g) Yes Yes
Codeine sulfate (g) Yes Yes
Combunox® (g) Yes Yes
DemerolTM (g) Yes Yes
Dilaudid® (g) Yes Yes
Duragesic® 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr (g)
10 patches per 30 days Yes
Duragesic® 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr (g)
10 patches per 30 days Not covered Yes
Duragesic Patch® (g) 10 patches per 30 days Yes
Esgic, Fioricet® 325mg (g) 4 grams APAP per day
Exalgo® (g)* 1 tablet per day Not covered Yes
Fentora®* 4 tablets per day Not covered
Fioricet® 300mg (g)* 4 grams APAP per day
Fioricet® w/codeine (g)* 4 grams APAP per day Yes
Fiorinal w/codeine (g) Yes
Hycet® (g) Yes Yes
Hysingla® ER* 1 tablet per day Not covered Yes
Ibudone® (g) Yes Yes
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Narcotics/Analgesic Combinations (cont.) Custom Custom Select
5-day limit for first fill
30-day limit
Ibudone 5/200mg Yes Yes
Kadian® (g) 1 capsule per day Yes
Kadian 40mg, 200mg Yes
Levorphanol tartrate Yes Yes
Long acting narcotics/combination products- brand and generic Yes
Lortab solution Yes Yes
Methadone (g) Yes
MS Contin (g) 4 tablets per day Yes
MSIR (g) Yes Yes
Norco®, Vicodin®, Xodol® (g) 4 grams APAP per day Yes Yes
Nucynta®* 6 tablets per day Yes Yes
Nucynta® ER* 2 tablets per day Yes
Opana® (g) Not covered Yes Yes
Opana ER® (g)* 4 tablets per day Yes
Oxycodone IR (g) 6 tablets per day/5,400 mg per 30 days Yes Yes
Oxycodone 5mg/5mL solution 180 mL(180 mg) per day Yes Yes
Oxycodone 20mg/mL solution 5 mL (100 mg) per day Yes Yes
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Narcotics/Analgesic Combinations (cont.) Custom Custom Select
5-day limit for first fill
30-day limit
Oxycodone HCl ER* 3 tablets per day 2 tablets per day Yes
Oxycontin®* 3 tablets per day 2 tablets per day Yes
Percocet® (g) 4 grams APAP per day Yes Yes
Percodan (g) Yes Yes
RMS® suppository (g) Yes Yes
Roxanol (g) Yes Yes
RoxicetTM (g) Yes Yes
Short acting immediate release narcotics/analgesics and combinations – brand and generic
Yes Yes
Soma Compound w/codeine (g) Yes
Stadol, NS (g) Yes Yes
Subsys®* 4 units per day Not covered
TrezixTM (g) 4 grams
APAP per day
Not covered Yes Yes
Tylenol® #3, #4 (g) 4 grams APAP per day Yes Yes
Ultracet® (g) 4 grams APAP per day Yes
Ultram (g) Yes
Ultram ER (g) Yes
Vicoprofen® (g) Yes Yes
Blue Care Network Quantity Limits
July 2020
These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070
Narcotics/Analgesic Combinations (cont.) Custom Custom Select
5-day limit for first fill
30-day limit
Zohydro® ER* 2 capsules per day Yes
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