Responsible Quantity Program* - Florida · PDF fileAfrezza 12 unit 900 cartridges Afrezza mix pack 4 unit (30 count) + 8 unit (60 count) 1530 cartridges Afrezza mix pack 4 unit (60

*Refer to the medication guide to determine coverage status of drugs in the program. Certain drugs may be excluded from coverage for certain members.(*Consulte con la guía de medicación para determinar el estatus de cobertura de las medicinas en el programa. Algunas medicinas podrían estar excluidas de lacobertura para ciertos miembros.) Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association

Responsible Quantity Program* (Programa Responsible Quantity*)Current (Corriente) 4/1/17 Quantity Limit Authorization Form (Formulario de límite de Responsible Quantity)

Responsible Quantity program limits apply to generic versions of drugs where applicable. (Los límites del programa de cantidad responsable aplican a las versiones de medicinas genéricas).

Brand/Generic name (Marca/Nombre genérico)

Strength (Potencia) all strengths if none listed

(todas las potencias si ninguna está en la lista)

Dispensing Limit Per Month unless otherwise noted

(Límite de dispensación por mes a menos que se indique lo contrario)

Abilify (aripiprazole) 30 tabs Abilify Discmelt 60 tabs Abilify oral solution 750 mL Abstral 120 tabs acetaminophen/caffeine/dihydrocodeine 300 tabs Aciphex (rabeprazole) 20 mg tab 60 tabs Aciphex sprinkles 5 mg, 10 mg sprinkle 60 caps Actiq (fentanyl citrate) 120 units Actonel (risedronate) 5 mg, 30 mg 30 tabs Actonel (risedronate) 35 mg 4 tabs Actonel (risedronate) 150 mg 1 tab Adcirca 60 tabs Adderall (amphetamine-dextroamphetamine) 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15

mg, 30 mg 60 tabs

Adderall (amphetamine-dextroamphetamine) 20 mg 90 tabs Adderall XR 5 mg, 10 mg, 15 mg 30 caps Adderall XR 20 mg, 25 mg, 30 mg 60 caps Adempas 90 tabs Adlyxin Starter pack 1 pack / 180 days Adlyxin 20 mcg / ml pen 2 pens / 28 days Advair Diskus 60 blisters Advair HFA 1 canister Advicor 500-20, 750-20, 1000-20 60 tabs Advicor 1000-40 30 tabs Adzenys ER 450 mL Adzenys XR ODT 3.1 mg, 6.3 mg 60 tabs Adzenys XR ODT 9.4 mg, 18.8 mg, 12.5 mg, 15.7 mg 30 tabs Aerospan 2 canisters Afinitor 30 tabs Afinitor Disperz 2 mg, 5 mg 60 tabs Afinitor Disperz 3 mg 90 tabs Afrezza 4 unit 2520 cartridges

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http://www.bcbsfl.com/DocumentLibrary/Providers/Content/RxF_QuantityLimit.pdf

*Refer to the medication guide to determine coverage status of drugs in the program. Certain drugs may be excluded from coverage for certain members. (*Consulte con la guía de medicación para determinar el estatus de cobertura de las medicinas en el programa. Algunas medicinas podrían estar excluidas de la cobertura para ciertos miembros.) Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association






Afrezza 8 unit 1260 cartridges Afrezza 12 unit 900 cartridges Afrezza mix pack 4 unit (30 count) + 8 unit (60 count) 1530 cartridges Afrezza mix pack 4 unit (60 count) + 8 unit (30 count) 1890 cartridges Afrezza mix pack 8 unit (60 count) + 12 unit (30 count) 1080 cartidges Afrezza mix pack 8 unit (90 count) + 4 unit (90 count) 1800 cartridges Afrezza mix pack 4 unit (60 count) + 8 unit (60 count) +

12 unit (60 count) 1260 cartridges

AirDuo Respiclick 1 inhaler Akynzeo 2 caps Aldara 5% cream, actinic keratosis or

genital and perianal warts 12 packets / 30 days (supply limit 4

months) Aldara 5% cream, basal cell carcinoma 24 packets / 30 days (supply limit 2

months) Allzital 360 tabs Alora 8 patches / 28 days Altoprev 30 tabs Alunbrig 30 mg 180 tabs Alunbrig 90 mg, 180 mg 30 tabs Alunbrig Therapy pack 30 tabs / 180 days Alvesco 80 mcg 1 canister Alvesco 160 mcg 2 canisters Ambien (zolpidem) 30 tabs Ambien CR (zolpidem ER) 30 tabs Amerge (naratriptan) 1 mg 18 tabs Amerge (naratriptan) 2.5 mg 9 tabs Ampyra 60 tabs Amturnide 30 tabs Anlagesic LQ elixir 2700 ml Androderm patch 2 mg, 4 mg 30 patches Androderm patch 2.5 mg, 5 mg 60 patches AndroGel 1% packet 60 packets AndroGel 1% pump 4 pumps AndroGel 1.62% packet 20.25 mg / 1.25 gm 30 packets AndroGel 1.62% packet 40.5 / 2.5 gm 60 packets AndroGel 1.62% pump 2 pumps Anoro Ellipta 60 blisters Antara 30 mg 60 caps Antara 90 mg 30 caps Anzemet 50 mg 7 tabs

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Anzemet 100 mg 7 tabs Aplenzin 30 tabs Aptivus 100 mg/ml 380 ml Aptivus 250 mg 120 caps Aptensio XR 30 caps Arcalyst 4 vials / 28 days Arcapta Neohaler 30 blisters Arixtra (fondaparinux) 30 syringes / 3 months Armonair Respiclick 1 inhaler Arnuity Ellipta 30 blisters Arymo ER 90 tabs Asmanex 1 inhaler Asmanex HFA 1 inhaler Astelin (azelastine) 2 inhalers Astepro 2 bottles Atacand 4 mg, 8 mg, 16 mg 60 tabs Atacand 32 mg 30 tabs Atacand HCT (candesartan/hydrochlorothiazide) 30 tabs Atelvia (risedronate) 4 tabs / 28 days Atripla 30 tabs Atrovent (ipratropium) 0.03% 2 inhalers Atrovent (ipratropium) 0.06% 3 inhalers Atrovent HFA 2 inhalers Aubagio 30 tabs Austedo 6 mg 60 tabs Austedo 9 mg, 12 mg 120 tabs Avalide (irbesartan/hydrochlorothiazide) 30 tabs Avapro (irbesartan) 30 tabs Avinza (morphine ext release) 60 caps Avonex 4 vials/syringes / 28 days Axert (almotriptan) 6.25 mg 24 tabs Axert (almotriptan) 12.5 mg 12 tabs Axiron 2 pumps Azor 30 tabs Beconase AQ 2 inhalers Belbuca 60 films Belsomra 30 tabs Benicar 5 mg 60 tabs

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Benicar 20 mg, 40 mg 30 tabs Benicar HCT 30 tabs Benlysta 4 auto-injectors/syringes / 28 days Berinert 20 vials Betaseron 14 vials/syringes / 28 days Bevespi 1 canister Beyyxxa 43 caps/42 days Biktarvy 30 tabs Bimatoprost 2.5 mL Binosto 4 tabs / 28 days Boniva (ibandronate) 2.5 mg 30 tablets Boniva (ibandronate) 150 mg 1 tablet Bonjesta 60 tabs Bosulif 30 tabs Breo Ellipta 100 mcg/25 mcg 30 actuations Breo Ellipta 200 mcg/ 25 mcg 30 actuations Bunavail 2.1/0.3 mg 90 films Bunavail 4.2/0.7 mg, 6.3/1 mg 60 films buprenorphine 2 mg, 8 mg 15 tabs / 90 days Butalbital Compound (butalbital-acetaminophen) 180 tabs butorphanol tartrate nasal spray 1 bottle / 15 days Butrans All strengths 4 systems / 28 days Bydureon 4 syringes / 28 days Bydureon BCise 4 auto-injectors / 28 days Byetta pre-filled pen (60 doses) 1 pen Byvalson 30 tabs Cabometyx 30 tabs Calquence 60 caps Cambia 9 packets Capital and Codeine (acetaminophen/codeine solution)

2700 ml

Caprelsa 100 mg 60 tabs Caprelsa 300 mg 30 tabs Carac 0.5% cream 30 grams / 28 days (4 week supply limit) Celebrex (celecoxib) 50 mg, 100 mg, 200 mg 60 caps Celebrex (celecoxib) 400 mg 30 caps Cesamet 42 caps Cialis 2.5 mg, 5 mg 30 tabs Cimzia Starter kit 1 kit/year

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Cimzia 200mg syringe 2 syringes / 28 days Cinryze 20 vials Climara (estradiol) 4 patches Climara Pro 4 patches Clozaril (clozapine) 25 mg, 50mg 90 tabs Clozaril (clozapine) 100 mg 270 tabs Clozaril (clozapine) 200 mg 120 tabs Codeine tablets 180 tabs Combivent 2 inhalers Combivent Respimat 2 inhalers Combivent Respimat 2 bottles Combivir 60 tabs Cometriq 1 carton / 28 days Complera 30 tabs Concerta (methylphenidate ER) 18 mg, 27 mg, 54 mg 30 tabs Concerta (methylphenidate ER) 36 mg 60 tabs Conzip 30 tabs Copaxone (glatiramer) 30 syringes Copaxone 40 12 syringes / 28 days Cosentyx 150 mg / ml (injector or syringe) 1 injector or syringe / 28 days Cosentyx 300 mg (2 x 150 mg / ml injectors or

syringes per package) 1 package / 28 days

Cotempla XR ODT 8.6 mg 30 tabs Cotempla XR ODT 17.3 mg, 25.6 mg 60 tabs Cozaar (losartan) 25 mg, 50 mg 60 tabs Cozaar (losartan) 100 mg 30 tabs Crestor 5 mg, 10 mg, 20 mg 45 tabs Crestor 40 mg 30 tabs Crixivan 200 mg 270 caps Crixivan 400 mg 180 caps Daklinza 30 tabs Daliresp 30 tabs Daytrana 30 patches Delatestryl (testosterone enanthate) 200 mg/5 ml 1 vial / 28 days Demerol (meperidine) tablets 240 tabs Demerol (meperidine) liquid 2,400 ml Depo Testosterone (testosterone cypionate) 10 ml vials 1 vial / 28 days Depo Testosterone (testosterone cypionate) 1 ml vials 4 vials / 28 days Descovy 30 tabs

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Desoxyn (methamphetamine) 150 tabs Detrol 60 tabs Detrol LA 30 caps Dexedrine (dextroamphetamine) 5 mg 90 tabs Dexedrine (dextroamphetamine) 10 mg 180 tabs Dexedrine Spansule (dextroamphetamine sulfate ext-release)

5 mg 90 caps

Dexedrine Spansule (dextroamphetamine sulfate ext-release)

10 mg, 15 mg 120 caps

Dexilant 30 caps DHE 24 vials / 28 days Diabetic test strips (all brands) 204 strips/discs Dificid 40 tabs / 180 days Diclegis 120 tabs Dilaudid (hydromorphone) tablets 180 tabs Dilaudid (hydromorphone) liquid 1,440 ml Dilaudid (hydromorphone) suppository 120 suppositories Diovan (valsartan) 40 mg, 80 mg, 160 mg 60 tabs Diovan (valsartan) 320 mg 30 tabs Diovan HCT (valsartan-hydrochlorothiazide) 30 tabs Ditropan XL (oxybutynin ext-release) 5 mg 30 tabs Ditropan XL (oxybutynin ext-release) 10 mg, 15 mg 60 tabs Divigel 30 packets Dovonex cream 120 grams Dovonex (calcipotriene) solution 120 mL Doxepin 5% cream 45 grams Duexis 90 tabs Dulera 1 canister Dupixent Loading dose on Day 1 2 syringes / 14 days Dupixent Maintenance on Day 15 and beyond 2 syringes / 28 days Duragesic (fentanyl transdermal patch) 15 patches Duzallo 30 tabs Dymista 1 bottle Dynavel XR 240 ml Edarbi 30 tabs Edarbyclor 30 tabs Edluar 30 tabs Edurant 30 tabs Efudex 5% cream, multiple actinic or solar

keratosis 40 grams / 28 days (4 week supply limit)

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Efudex 5% cream, basal cell carcinoma 80 grams / 28 days (12 week supply limit) Elestrin 1 pump Eliquis 2.5 mg 60 tabs Eliquis 5 mg 120 tabs Embeda 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 60 caps Embeda 100 mg 120 caps Emend 80 mg 4 caps Emend 125 mg 2 caps Emend suspension 6 packages Emend Therapy Pack 2 Therapy Packs Emflaza 6 mg 60 tabs Emflaza 18 mg 30 tabs Emtriva 10 mg/ml 680 ml Emtriva 30 caps Enablex (darifenacin SR) 30 tabs Enbrel 25 mg 8 injections / 28 days Enbrel 50mg (months 1 - 3) 8 injections / 28 days Enbrel 50mg (months 4 and beyond) 4 injections / 28 days Endocet (oxycodone/acetaminophen) 2.5-325, 5-325 360 tabs Endocet (oxycodone/acetaminophen) 7.5-325 240 tabs Endocet (oxycodone/acetaminophen) 10-325 180 tabs Endodan (oxycodone-aspirin) 360 tabs Epclusa 30 tabs Epivir (lamivudine) 10 mg/ml 960 ml Epivir (lamivudine) 150 mg 60 tabs Epivir (lamivudine) 300 mg 30 tabs Epzicom 30 tabs Equapax/atorvastatin & CoQ10 60 caps Ergomar 20 tabs / 28 days Erivedge 30 caps Esbriet 267 mg caps 180 caps Esbriet 267 mg tabs 180 tabs Esbriet 801 mg tabs 90 tabs Esgic (butalbital-acetaminophen-caffeine) 50-325-40 180 caps or tabs Estraderm 8 patches / 28 days Estrasorb 56 pouches Estring 1 ring Estrogel 1 pump

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EvaMist 1 canister Evekeo 5 mg 90 tabs Evekeo 10 mg 180 tabs Evotaz 30 tabs Evzio 2 auto-injectors / year Exalgo all strengths 30 tablets Exforge (amlodipine-valsartan) 30 tabs Exforge HCT (amlodipine-valsartan-hydroclorothiazide)

30 tabs

Extavia 15 vials / syringes Ezvio 2 pens / year Fanapt all strengths 60 tabs Fanapt titration pack 7 kits Farxiga 30 tabs FazaClo (clozapine) 12.5 mg, 100 mg 90 tabs FazaClo (clozapine) 25 mg 270 tabs FazaClo (clozapine) 150 mg 180 tabs FazaClo (clozapine) 200 mg 120 tabs Femring 1 ring / 90 days Fenoglide 40 mg 60 tabs Fenoglide 120 mg 30 tabs fentanyl citrate transmucosal 120 units Fentora 120 tabs Fetzima 30 caps Fetzima Titration pack 1 pack/180 days Fibricor 35 mg 60 tabs Fibricor 105 mg 30 tabs Fioricet (butalbital-acetaminophen-caffeine) 180 tabs Fioricet w/codeine (butalbital-acetaminophen-caffeine-codeine)

180 caps

Fiorinal (butalbital-aspirin-caffeine) 180 caps Fiorinal w/codeine (butalbital-aspirin-caffeine-codeine)

180 caps

Firazyr 30 syringes Flector patch 60 patches Flolipid 20 mg/ 5 ml 150 ml Flolipid 40 mg/ 5 ml 300 ml Flonase (fluticasone) 1 inhaler Flovent Diskus 50 mcg, 100 mcg 1 carton Flovent Diskus 250 mcg 4 cartons

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Flovent HFA 44 mcg, 110 mcg 1 inhaler Flovent HFA 220 mcg 2 inhalers Flunisolide nasal soln 25 mcg /spray, 29 mcg /spray 3 inhalers Fluoroplex 1% cream 30 grams / month (6 week supply limit) Fluoxetine 60 mg 30 tabs flu vaccines 1 injection / 90 days fluvoxamine 25 mg, 50 mg 30 caps fluvoxamine 100 mg 90 caps Focalin (dexmethylphenidate) 60 tabs Focalin XR 30 caps Foradil Aerolizer 1 blister pack (12 or 60) Forfivo 30 tabs Fortesta 2 canisters Fosamax (alendronate) 5 mg, 10 mg, 40 mg 30 tabs Fosamax (alendronate) 35 mg, 70 mg 4 tabs Fosamax (alendronate) oral solution 300 ml/28 days Fosamax Plus D 4 tabs Fragmin syringe, all strengths 30 syringes / 3 months Fragmin vial, all strengths 10 vials / 3 months Fulzyaq 60 tabs Frova (frovatriptan) 12 tabs Fuzeon 60 vials Gattex 30 vials Gelnique 10% 30 sachets Gelnique 3% 1 pump gemfibrozil 60 tabs Genvoya 30 tabs Geodon (ziprasidone) 60 tabs Gilenya 30 caps Gilotrif All strengths 30 tabs Glatopa 1 kit Gleevec 100 mg 90 tabs Gleevec 400 mg 60 tabs Glucose Test Strips (all brands) 204 strips / discs Glucose test strips combo 200 strips Glyxambi 30 tabs Gralise 300 mg 30 tabs Gralise 600 mg 90 tabs

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Gralise Starter pack 78 tabs / 180 days granisetron 14 tabs Grastek 30 tabs Haegarda 16 vials Harvoni 30 tabs Horizant 300 mg 60 tabs Horizant 600 mg 60 tabs HP Acthar gel 7 vials/21 days Humira 10 mg, 20 mg, 40 mg 2 injections / 28 days Humira Starter pack 1 pack / year Humira pediatric Crohn’s kit 1 kit / 180 days Hycet (hydrocodone-acetaminophen) 3600 mL hydrocodone-acetaminophen 2.5 mg-325mg 360 tabs Hysingla ER 30 tabs Hyzaar (losartan/hydrochlorothiazide) 30 tabs Ibudone (hydrocodone-ibuprofen) 10-200 150 tabs Iclusig 15 mg 60 tabs Iclusig 45 mg 30 tabs Imbruvica 30 caps or tabs Imitrex nasal soln, 5 mg 6 packages (36 units) Imitrex nasal soln, 20 mg 2 packages (12 units) Imitrex (sumatriptan) 25 mg 36 tabs Imitrex (sumatriptan) 50 mg 18 tabs Imitrex (sumatriptan) 100 mg 9 tabs Imitrex (sumatriptan) vial 6 mg/0.5 mL 4 mL (8 injections) Imitrex STATdose (sumatriptan) 4 mg 6 mL (12 injections) Imitrex STATdose (sumatriptan) 6 mg 4 mL (8 injections) Incivek 168 tabs / 28 days Incruse Ellipta 30 blisters Ingrezza 40 mg 60 caps Ingrezza 80 mg 30 caps Inlyta 1 mg 180 tabs Inlyta 5 mg 120 tabs Intelence 25 mg 120 tabs Intelence 100 mg, 200 mg 60 tabs Intermezzo (zolpidem) 30 tabs Intuniv (guanfacine ER) 30 tabs Invega (paliperidone) 1.5mg, 3 mg, 9 mg 30 tabs

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Invega (paliperidone) 6 mg 60 tabs Invirase 200 mg 300 caps Invirase 500 mg 120 tabs Invokamet 60 tabs Invokamet XR 60 tabs Invokana 30 tabs Iprivask 30 vials / 3 months Irenka 90 caps Isentress 25 mg, 100 mg 180 tabs Isentress 400 mg, 600 mg 60 tabs Isentress Powder 60 packets Jakafi 60 caps Janumet 60 tabs Janumet XR 50-500, 100-1000 30 tabs Janumet XR 50-1000 60 tabs Januvia 30 tabs Jardiance 30 tabs Jentadueto 2.5/500, 2.5/850, 2.5/1000 60 tabs Jentadueto XR 2.5/1000 60 tabs Jentadueto XR 5/1000 30 tabs Juluca 30 tabs Juvisync 30 tabs Juxtapid 28 caps / 28 days Kadian (morphine once daily) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg 60 caps Kadian (morphine once daily) 60 mg, 70 mg, 80 mg, 130 mg, 150

mg 60 caps

Kadian (morphine once daily) 100 mg, 200 mg 120 caps Kaletra 80 mg/20 ml 480 ml Kaletra 100 mg/25 mg 180 tabs Kaletra 200 mg/50 mg 120 tabs Kalydeco 60 tabs Kapvay 0.1 mg 120 tabs Kapvay 0.2 mg, Dose pack 60 tabs Kazano 60 tabs ketorolac 10 mg 20 tabs / 5 days Kevzara 2 syringes / 28 days Khedzela 30 tabs Kineret 30 syringes Kisqali 200 mg 63 tabs / 28 days

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Kisqali Femera Pack 200 mg – 2.5 mg 91 tabs / 28 days Kombiglyze XR 5-500, 5-1000 30 tabs Kombiglyze XR 2.5-1000 60 tabs Korlym 120 tabs Kynamro 4 vials / 28 days Latuda 20 mg, 40 mg, 60 mg, 120 mg 30 tabs Latuda 80 mg 60 tabs Lazanda 30 bottles

Lenvima 8 mg daily dose 60 caps Lenvima 18 mg daily dose 90 caps Lescol (fluvastatin) 60 caps Lescol XL(fluvastatin) 30 tabs Letairis 30 tabs leuprolide 1 mg / 0.2 ml kit 6 vials Levodromoran (levorphanol) tablets 120 tabs Lexiva 50 mg/ml 1800 ml Lexiva 700 mg 120 tabs Lidocaine ointment 5% 20 grams / day Lidoderm (lidocaine patch) 5% 3 patches / day Lipitor 10 mg, 20 mg, 40 mg 45 tabs Lipitor 80 mg 30 tabs Lipofen 50 mg 60 caps Lipofen 150 mg 30 caps Liptruzet 30 tabs Livalo 1 mg, 2 mg 45 tabs Livalo 4 mg 30 tabs Lofibra 54 mg 60 tabs Lofibra 160 mg 30 tabs Lofibra micronized 30 caps Lonsurf 15 mg / 6.14 mg 100 tabs / 28 days Lonsurf 20 mg / 8.19 mg 80 tabs / 28 days Lopid (gemfibrozil) 60 tabs Lortab elixir (hydrocodone-acetaminophen) 7.5 mg/500 mg/15 ml 2700 ml Lortab elixir (hydrocodone-acetaminophen) 10 mg/300 mg/15 ml 2025 ml Lotronex (alosetron) 60 tabs Lovaza (omega-3-acid ethyl esters) 120 caps Lovenox (enoxaparin) syringe, all strengths 30 syringes / 3 months Lovenox (enoxaparin) vial, 300 mg/3 mL 10 vials / 3 months

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Lumigan 2.5 mL Lunesta (epszopiclone) 30 tabs Luvox CR (fluvoxamine ER) 60 caps Lynparza 50 mg 480 caps Lynparza 100 mg, 150 mg 120 tabs Lyrica 25 mg, 50 mg, 75 mg, 100 mg,

150 mg, 200 mg 90 caps

Lyrica 225 mg, 300 mg 60 caps Lyrica 20mg/ml 900 ml Maprotiline 90 tabs Mavyret 90 tabs Maxair Autohaler 1 canister Maxalt, Maxalt-MLT (rizatriptan) 5 mg 24 tabs Maxalt, Maxalt-MLT (rizatriptan) 10 mg 12 tabs Mekinist 0.5 mg 90 tabs Mekinist 2 mg 30 tabs Menostar 4 patches meperidine-promethazine 180 caps Mephyton 2 tabs Metadate CD (methylphenidate ext-release) 30 caps Metadate ER (methylphenidate ext-release) 90 caps methadone tablets all strengths 90 tabs methadone liquid 5mg / 5 ml 900 ml methadone liquid 10mg / 5 ml 450 ml methadone liquid 10mg / ml 90 ml Methergine 28 tabs / 270 days Methylin 2.5 mg, 5 mg 90 tabs Methylin 10 mg 180 tabs Methylin 5 mg/5 ml 450 ml Methylin 10 mg/5 ml 900 ml Methylin ER 90 tabs Methylphenidate ER (methylphenidate ext-release) 10 mg, 20 mg 90 tabs Methylphenidate ER 72 mg 30 tabs Mevacor (lovastatin) 60 tabs Micardis (telmisartan) 30 tabs Micardis HCT (telmisartan/hydrochlorothiazide) 40 mg/12.5 mg, 80 mg/25 mg 30 tabs Micardis HCT (telmisartan/hydrochlorothiazide) 80 mg/12.5 mg 60 tabs Migranal 8 ampules Minivelle 8 patches / 28 days

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Mirtazapine 7.5 mg, 15 mg, 30 mg, 45 mg 30 tabs Morphabond ER 60 tabs morphine tablets 15mg 240 tabs morphine tablets 30mg 180 tabs morphine liquid 10mg / 5ml 2,700 ml morphine liquid 20mg / 5ml 1,350 ml morphine liquid 20mg / ml 270 ml morphine suppository 180 suppositories MS Contin (morphine sulfate ext-release) 15 mg, 30 mg, 60 mg 120 tabs MS Contin (morphine sulfate ext-release) 100 mg, 200 mg 180 tabs Mydayis 30 caps Myrbetriq 30 tabs Narcan (naloxone) 2 bottles / year Nasacort AQ (triamcinolone) 1 inhaler Nascobal 4 bottles / 28 days Nasonex (mometasone) 2 inhalers Natesto 3 pumps Nerlynx 180 tabs Nesina 30 tabs Neulasta 2 syringes/28 days Nexavar 120 tabs Nexium (esomeprazole) 30 caps Nexium granules 30 packets Norco (hydrocodone-acetaminophen) 5 mg/325 mg 360 tabs Norco (hydrocodone-acetaminophen) 7.5 mg/325 mg, 10 mg/325 mg 180 tabs Northera 100 mg 450 caps Northera 200 mg, 300 mg 180 caps Norvir 80 mg/ml 480 ml Norvir 100 mg 360 caps or tabs Nucynta 180 tabs Nucynta ER 60 tabs Nuvigil (armodafinil) 30 tabs Odactra 30 tabs Odefsey 30 tabs Oleptro 150 mg 45 tabs Oleptro 300 mg 30 tabs Olysio 30 tabs Omnaris 1 inhaler

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ondansetron 24 mg 1 tab One Touch combo pack 1000 pouches Onglyza 30 tabs Onsolis 120 films Onzetra 32 powders Opana (oxymorphone IR) 180 tabs Opana ER (oxymorphone ER) 60 tabs Opsumit 30 tabs Oralair 30 tabs Oralair starter pack 3 tabs/180 days Oramorph SR 15 mg, 30 mg, 60 mg 120 tabs Oramorph SR 100 mg 180 tabs Orbivan 180 caps Orbivan CF 180 tabs Orencia subcutaneous or autoinjector 4 syringes / 28 days Orkambi 100-125 mg 120 tabs Oseni 30 tabs Otezla 30 mg 60 tabs Otezla Starter Pack 1 kit / 180 days Oxaydo 120 tabs oxybutynin ER 5 mg 30 tabs oxybutynin ER 10 mg, 15 mg 60 tabs oxybutynin syrup 600 mL oxybutynin tabs 5 mg 120 tabs oxycodone liquid 5mg / 5ml 5,400 ml oxycodone liquid 20mg / ml 270 ml oxycodone/aspirin 360 tabs oxycodone/ibuprofen 120 tabs oxycodone immediate release 120 caps or tabs OxyContin (oxycodone ext-release) 90 tabs Oxytrol 8 patches Ozempic 1 pen pack 1 pen / 28 days Ozempic 2 pens pack 2 pens / 28 days Panlor DC 300 caps Patanase 1 inhaler Paxil CR (paroxetine ER) 12.5 mg 30 tabs Paxil CR (paroxetine ER) 25 mg, 37.5 mg 60 tabs Pennsaid 1.5% 150 mL

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Pennsaid 2% 224 mL pentazocine-naloxone 360 tabs Percocet (oxycodone-acetaminophen) 2.5-325, 5-325 360 tabs Percocet (oxycodone-acetaminophen) 7.5-325 240 tabs Percocet (oxycodone-acetaminophen) 10-325 180 tabs Pexeva (paroxetine) 10 mg, 20 mg, 40 mg 30 tabs Pexeva (paroxetine) 30 mg 60 tabs Picato gel 0.015% gel 3 tubes / 90 days Picato gel 0.05% gel 2 tubes / 90 days Pomalyst 21 caps / 21 days Pradaxa 110 mg 71 caps / 90 days Pradaxa 75 mg, 150 mg 60 caps Pravachol (pravastatin) 10 mg, 20 mg, 40 mg 45 tabs Pravachol (pravastatin) 80 mg 30 tabs Prevacid (lansoprazole) 15 mg, 30mg 60 packets / caps Prevacid Solutab (lansoprazole) 60 tabs Prezcobix 30 tabs Prezista 75 mg 300 tabs Prezista 150 mg 180 tabs Prezista 600 mg 60 tabs Prezista 800 mg 30 tabs Prezista oral suspension 400 ml Prilosec (omeprazole delayed-release ) 10 mg, 40mg 60 caps Prilosec (omeprazole delayed-release ) 20 mg 120 caps Prilosec suspension packet 2.5 mg 120 packs Prilosec suspension packet 10 mg 60 packs Primlev 5 mg/300 mg 360 tabs Primlev 7.5 mg/300 mg 240 tabs Primlev 10 mg/300 mg 180 tabs Pristiq (desvenlafaxine ER) 30 tabs ProAir HFA 2 inhalers ProAir Respiclick 2 inhalers Procentra 1800 ml Promacta 30 tabs Protonix (pantoprazole delayed-release) 60 packets / tabs Proventil HFA 2 inhalers Provigil (modafinil) 30 tabs Prudoxin 5% cream 45 grams

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Pulmicort Flexhaler 90 mcg 1 inhaler Pulmicort Flexhaler 180 mcg 2 inhalers Quillichew ER 20 mg, 40 mg 30 tabs Quillichew ER 30 mg 60 tabs Quillivant XR 360 ml Qnasl 40 mcg 1 inhaler Qnasl 80 mcg 2 inhalers Qtern 30 tabs Qualaquin (quinine) 42 capsules / 3 months Qvar 40 mcg 1 canister / 28 days Qvar 80 mcg 2 canister / 28 days Qvar RediHaler 40 mcg 1 canister / 28 days Qvar RediHaler 80 mcg 2 canister / 28 days Ragwitek 30 tabs Rebif/Rebif Rebidose 12 syringes / 28 days Rebif Titration Pack 1 kit / 28 days Relenza 40 inhalations / 120 days Relpax (eletriptan) 20 mg 12 tabs Relpax (eletriptan) 40 mg 6 tabs Reprexain (hydrocodone-ibuprofen) 5-200 150 tabs Rescriptor 100 mg 360 tabs Rescriptor 200 mg 180 tabs Rescula 5 ml Restasis 60 doses Retrovir (zidovudine) 50 mg/5 ml 1920 ml Retrovir (zidovudine) 100 mg 180 caps Retrovir (zidovudine) 300 mg 60 caps Revatio (sildenafil) Oral suspension 224 mL Revatio (sildenafil) 20 mg 90 tabs Revlimid 2.5mg, 5 mg, 10 mg 30 caps Revlimid 15 mg, 25 mg 21 caps / 28 days Rexulti 30 tabs Reyataz 50mg 240 packets Reyataz 150 mg, 300 mg 30 caps Reyataz 200 mg 60 caps Rexulti 30 tabs Rhinocort Aqua 2 inhalers Risperdal (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 60 tabs

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Risperdal (risperidone) 4 mg 120 tabs Risperdal oral solution (risperidone) 480 mL Risperdal M-tab (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 60 tabs Risperdal M-tab (risperidone) 4 mg 120 tabs Ritalin (methylphenidate) 90 tabs Ritalin LA (methylphenidate LA) All strengths 30 caps Ritalin SR (methylphenidate ext-release) 90 tabs Roxicet (oxycodone-acetaminophen) 5-325 360 tabs Roxicet solution 1800 mL Rozerem 30 tabs Rubraca 120 tabs Ruconest 40 vials Rydapt 240 caps Ryzolt (tramadol) 30 tabs Samsca 15 mg 30 tabs / 365 days Samsca 30 mg 60 tabs / 365 days Sanctura (trospium) 60 tabs Sanctura XR (trospium ext-release) 30 tabs Sancuso 2 patches Santyl 90 grams Saphris 60 tabs Savella 60 tabs Savella Titration pack 1 pack / 180 days Savaysa 30 tabs Seebri Neohaler 60 caps Segluromet 2.5 mg/500 mg 120 tabs Segluromet 2.5 mg/ 1000 mg, 7.5 mg/500 mg,

7.5 mg/1000 mg 60 tabs

Selzentry 25 mg 240 tabs Selzentry 75 mg, 150 mg 60 tabs Selzentry 300 mg 120 tabs Selzentry 20 mg / ml 1840 ml Serevent Diskus 1 package Seroquel (quetiapine) 25 mg, 50 mg, 100 mg, 200 mg 90 tabs Seroquel (quetiapine) 300 mg, 400 mg 60 tabs Seroquel XR 50 mg, 300 mg, 400 mg 60 tabs Seroquel XR 150 mg, 200 mg 30 tabs Sidekick blood glucose system 200 strips Signifor 60 amps

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Silenor 30 tabs Simcor 500-20, 500-40, 1000-40 30 tabs Simcor 750-20, 1000-20 60 tabs Simponi 1 injection Solaraze gel (diclofenac) 100 grams / 30 days (90 day supply limit) Soliqua 5 pens / 30 days Sonata (zaleplon) 30 caps Sorilux 120 grams Sovaldi 30 tabs Spiriva Handihaler 30 caps Spiriva Respimat 1 canister Sprix 5 bottles Sprycel 20 mg 60 tabs Sprycel 50 mg, 70 mg, 80 mg, 100 mg,

140 mg 30 tabs

Steglatro 5 mg 60 tabs Steglatro 15 mg 30 tabs Steglujan 30 tabs Stelara 45 mg 1 syringe / 12 weeks Stelara 90 mg 1 syringe / 12 weeks

(Crohn’s Disease 1 syringe / 8 weeks) Strattera 10 mg, 18 mg, 25 mg, 40 mg 60 caps Strattera 60 mg, 80 mg, 100 mg 30 caps Stiolto Respimat 4 grams Stivarga 84 tabs / 28 days Striant 60 buccal systems Stribild 30 tabs Striverdi Respimat 1 canister Suboxone (buprenorphine/naloxone) 2mg / 0.5mg 120 tabs or films Suboxone (buprenorphine/naloxone) 4mg / 1mg 30 films Suboxone (buprenorphine/naloxone) 8mg / 2mg tablet 90 tablets Suboxone (buprenorphine/naloxone) 8mg / 2mg film, 12mg / 3 mg film 60 films Subsys 120 sprays Subutex (buprenorphine) 15 tabs / 3 months Sucraid 236 ml / 29 days Sumatriptan nasal soln, 5 mg 6 units Sumatriptan nasal soln, 20 mg 2 units sumatriptan 25 mg 36 tabs sumatriptan 50 mg 18 tabs

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sumatriptan 100 mg 9 tabs sumatriptan vial, 4 mg/0.5 mL 6 mL (12 injections) sumatriptan syringe, 6mg/0.5ml 6 ml (12 injections) sumatriptan auto-injector, 6mg/0.5ml 4 ml (8 injections) Sumavel DosePro 12 injections Sustiva 50 mg 90 tabs Sustiva 200 mg 60 tabs Sustiva 600 mg 30 tabs Sutent 12.5 mg 90 caps Sutent 25 mg, 50 mg 60 caps Sutent 37.5 mg 30 caps Symbicort 1 inhaler Symbyax 30 caps Synera patch 2 patches Synjardy 60 tabs Synjardy XR 5mg / 1000mg, 10 mg / 1000 mg,

12.5 mg / 1000 mg 60 tabs

Synjardy XR 25 mg / 1000mg 30 tabs Taclonex ointment 120 grams Taclonex suspension 120 mL Tafinlar 50 mg 120 tabs Tafinlar 75 mg 120 tabs Tamiflu susp, 6mg/ml 360 mL / 120 days Tamiflu susp, 12 mg/mL 150 mL / 120 days Tamiflu 30 mg, 45 mg, 75 mg 20 caps / 120 days Tanzeum 4 syringes / 28 days Tarceva 25 mg 60 tabs Tarceva 100 mg, 150 mg 30 tabs Tasigna 120 caps Tazorac cream 120 grams Tazorac gel 100 grams Tecfidera starter pack 1/6 months Tecfidera 120 mg 14 caps/6 months Tecfidera 240 mg 60 caps Technivie 60 tabs Tekamlo 30 tabs Tekturna 30 tabs Tekturna HCT 30 tabs Testim 60 tubes

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Testone CIK 4 kits / 28 days Teveten 400 mg 60 tabs Teveten (eprosartan) 600 mg 30 tabs Teveten HCT 30 tabs Thalomid 50 mg, 100 mg 30 caps Thalomid 150 mg, 200 mg 60 caps Tivicay 60 tabs Tolak 4% cream 40 grams / 28 days (supply limit 4 weeks) Toviaz 30 tabs Tracleer 32 mg 120 tabs Tracleer 62.5 mg, 125 mg 60 tabs Tradjenta 30 tabs tramadol ER 30 tabs Travatan Z 2.5 mL Travoprost 2.5 mL Trelegy Ellipta 60 blisters Tremfya 1 syringe / 56 days Treximet 85 – 500 mg 18 tabs Treximet 10 – 60 mg 9 tabs Trezix (acetaminophen/caffeine/dihydrocodeine) 300 caps Tribenzor 30 tabs Tricor 48 mg 60 tabs Tricor 145 mg 30 tabs Triglide 50 mg 60 tabs Triglide 160 mg 30 tabs Trilipix 45 mg 60 tabs Trilipix 135 mg 30 tabs Trintellix 30 tabs Triumeq 30 tabs Trizivir 60 tabs Trulicity 4 pens / 28 days Truvada 30 tabs Tudorza 1 canister Twynsta (telmisartan – amlodipine) 30 tabs Tybost 30 tabs Tykerb 180 tabs Tylenol w/Codeine (acetaminophen-codeine) 300 mg/15 mg, 300 mg/30 mg 360 tabs Tylenol w/Codeine (acetaminophen-codeine) 300 mg/60 mg 180 tabs

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Tylenol w/Codeine elixir (acetaminophen-codeine) 2700 mL Tyvaso 28 amps / 28 days Tyvaso Starter kit 1 kit / 180 days Ultracet (tramadol-acetaminophen) 240 tabs Ultram (tramadol) 240 tabs Ultram ER (tramadol ER) 30 tabs Uptravi Titration pack 1 pack / 180 days Uptravi All strengths 60 tabs Utibron Neohaler 60 caps Valturna 30 tabs Vascepa 120 caps Vectical 200 grams Venlafaxine ER 225 mg 30 tabs Ventavis 68 amps / 30 days Ventolin HFA 8 gm, 18 gm 2 canisters Veramyst 1 inhaler Varubi 4 tabs Vascepa 500 mg 240 caps Versacloz 540 ml Verzenio 60 tabs Vesicare 30 tabs Viberzi 60 tabs Vicoprofen (hydrocodone-ibuprofen) 150 tabs Victoza 1 package Victrelis 336 caps / 28 days Videx (didanosine) powders 1200 ml Videx EC capsules 30 caps Viekira 112 tabs / 28 days Viekira XR 84 tabs / 28 days Viibryd 30 tabs Viibryd 10 mg, 20 mg, 40 mg 30 tabs Viibryd Starter Kit 1 kit / 28 days Vimovo 60 tabs Viracept 250 mg 270 caps Viracept 625 mg 120 tabs Virammune 50 mg/5 ml 1200 ml Virammune 200 mg 60 tabs Virammune XR 100 mg 90 tabs

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Virammune XR 400 mg 30 tabs Viread 30 tabs Viread 40 mg/1 gm 240 grams Vitekta 30 tabs Vivelle Dot 8 patches / 28 days Voltaren gel (diclofenac) 1000 grams Votrient 120 tabs Vogelxo 300 grams Vosevi 30 tabs Vraylar 30 caps Vraylar Titration pack 1 pack / 180 days Vytorin all strengths 30 tabs Vyvanse 30 caps Vyvanse chewable 30 tabs Vyzulta 5 mL Xalatan (latanoprost) 2.5 mL Xalkori 60 caps Xarelto Starter pack 51 tabs Xarelto 15 mg 60 tabs Xarelto 10 mg, 20 mg 30 tabs Xartemis XR 120 tabs Xeljanz 60 tabs Xeloda 150 mg 240 caps Xeloda 500 mg 420 caps Xenazine 12.5 mg 240 tabs Xenazine 25 mg 120 tabs Xhance 2 bottles Xifaxan 200 mg 9 tabs / 3 days Xifaxan 550 mg Up to 90 tabs Xigduo XR 5 mg/500 mg, 10 mg/500 mg,

10 mg/1000 mg 30 tabs

Xigduo XR 2.5 mg/1000 mg, 5 mg/1000 mg 60 tabs Xiidra 60 doses Xodol (hydrocodone/acetaminophen) 5 mg/300 mg 360 tabs Xodol (hydrocodone/acetaminophen) 7.5 mg/300 mg, 10 mg/300 mg 180 tabs Xopenex HFA 2 canisters Xtampza ER 180 caps Xtandi 160 caps Xultophy 5 pens / 30 days

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Xyrem 540 ml Yosprala 30 tabs Zamicet 2700 ml Zecuity 12 patches Zegerid (omeprazole/sodium bicarbonate) 20 mg, 40 mg 30 packets / caps Zejula 90 caps Zelboraf 240 tabs Zembrace 24 pens Zenzedi 2.5 mg, 5 mg, 7.5 mg, 15 mg, 20 mg 90 tabs Zenzedi (dextroamphetamine) 10 mg 180 tabs Zenzedi 30 mg 60 tabs Zepatier 30 tabs Zerit 1 mg/1 ml 2400 ml Zerit all capsules 60 caps Zetonna 1 bottle Ziagen 20 mg/ml 960 ml Ziagen 60 tabs Zioptan 30 single-use containers Zipsor 120 caps Zocor (simvastatin) 5 mg, 10 mg, 40 mg 45 tabs Zocor (simvastatin) 20 mg 60 tabs Zocor (simvastatin) 80 mg 30 tabs Zohydro ER 60 caps Zolinza 120 caps Zolpimist 1 canister Zomig nasal soln 12 units Zomig, Zomig ZMT (zolmitriptan) 2.5 mg 18 tabs Zomig, Zomig ZMT (zolmitriptan) 5 mg 9 tabs Zonalon 5% cream 45 grams Zorvolex 90 caps Zubsolv 1.4 mg/0.36 mg, 90 tabs Zubsolv 0.7 mg / 0.18 mg, 2.9 mg/0.71 mg,

5.7mg/1.4mg, 11.4 mg/2.9mg

30 tabs

Zubsolv 8.6 mg/2.1 mg 60 tabs Zuplenz 4 mg 20 films Zuplenz 8 mg 20 films Zurampic 200 mg 30 tabs Zyclara 2.5% cream 56 packets / 6 weeks

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Zyclara 2.5% cream 15 grams / 6 weeks Zyclara 3.75% cream, for actinic keratosis 56 packets / 6 weeks Zyclara 3.75% cream, for actinic keratosis 15 grams / 6 weeks Zyclara 3.75% cream, for genital or perianal

warts 56 packets / 8 weeks

Zyclara 3.75% cream, for genital or perianal warts

15 grams / 8 weeks

Zyprexa, Zyprexa Zydis (olanzapine, olanzapine ODT)

30 tabs

Zytiga 250 mg 120 tabs Zytiga 500 mg 60 tabs

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Documents

Responsible Quantity Program* - Florida · PDF fileAfrezza 12 unit 900 cartridges Afrezza mix pack 4 unit (30 count) + 8 unit (60 count) 1530 cartridges Afrezza mix pack 4 unit (60