Quantity Limits

Quantity limitations are in place for the drugs listed below. When a drug has a quantity limit, the amount of medication per prescription is limited to a specified amount per 30 days. These limitations may be in place due to safety issues or because the use of a dose higher than what is recommended has been shown to result in minimal additional benefit to the patient.  Requests for increased quantities are only approved when the guidelines below are met.  Quantity limit guidelines are developed and approved by a panel of practicing physicians and pharmacists. 

Click on the drug name below to view the specific quantity limit guideline.

Commercial Guidelines: 

ACIPHEX (rabeprazole sodium)
ACIPHEX SPRINKLE (rabeprazole sodium)
Actiq Fentora 
AKYNZEO (netupitant/palonosetron hcl)
Amerge (Nartriptan HCL)
AMPYRA (dalfampridine) 
Antiemetics QL
ANZEMET (dolasetron mesylate)
Atypical Antipsychotics ST and QLAVINZA (morphine sulfate)
Axert (Almotriptan Malate)
BELBUCA (buprenorphine) 
Cabometyx (Cabozantinib) 
CELEBREX (celecoxib) 
Conzip ST and QL 
DEXILANT (dexlansoprazole)
ED Agents 
EMBEDA (morphine/naltrexone)
EXALGO (hydromorphone)
Fentora Onsolis 
Frova (Frovatriptan Succinate)
GRANISOL (granisetron)
Imitrex, Alsuma, Sumavel Dosepro, Imitrex Nasal Spray, Zecuity, Zembrace Symtouch Orizetra Xsail (Sumatriptan Succinate)
Imitrex Nasal Spray (Sumatriptan) 
Iressa PA and QLKADIAN (morphine sulfate)
KYTRIL (granisetron)
NEXIUM (esomprazole magnesium)
Neupro ST and QL 
NUCYNTA (tapentadol) 
Nuplazid (Pimavanserin) 
Onzetra Xsail (Sumatriptan)
OPANA ER (oxymorphone)
OXYCONTIN (oxycodone)
PREVACID (lansoprazole)
PRILOSEC (omeprazole)
PRILOSEC (omeprazole magnesium)
Pristiq ST and QL 
PROTONIX (pantoprazole sodium)  
Relpax (Eletriptan HCL)
Rexulti ST and QL 
SANCUSO (granisetron)
SAVELLA (milnacipran) 
Uloric ST and QL 
VIMOVO (naproxen-esomeprazole) 
VIVLODEX (meloxicam) 
Vyvanse PA and QL 
XARELTO (rivaroxaban) 
Xenazine PA and QL
ZEGERID (omeprazole/sodium bicarbonate)
ZIPSOR (diclofenac)
ZOFRAN (ondansetron hcl)
Zomig, Zomig Spray, Zomig ZMT (Zolmitriptan) 

Last Updated: 04/2018