CBC Quantity Limit Drug List (Effective 1/1/02)

CAPITAL BLUE CROSS Quantity Limit Drug List (Effective 1/1/02)

Therapeutic Category

Anti-Flu Therapy

Erectile Dysfunction

Migraine Therapy

Brand Name Generic Name

Relenza

Tamiflu Tamiflu

Zanamivir

Oseltamivir Oseltamivir

Caverject

Alprostadil injection

Edex

Alprostadil injection

Muse Viagra

Alprostadil urethral inserts

Sildenafil tablets

Dosage Form

Retail Quantity Level Limit

Blisters of 1 kit (20 of the 5 mg blisters + a

powder

Diskhaler device) per Rx; max of 2

Rxs per year

Capsules (75 10 of the 75 mg capsules per Rx; max

mg)

of 2 Rxs per year

Bottle (oral 1 bottle (75 ml) per Rx; max of 2 Rxs

suspension) per year

Injection

Injection

Urethral inserts Tablets

6 units in any combination of injections or urethral inserts or oral formulation per 30 day period 6 units in any combination of injections or urethral inserts or oral formulation per 30 day period 6 units in any combination of injections or urethral inserts or oral formulation per 30 day period 6 units in any combination of injections or urethral inserts or oral formulation per 30 day period

Imitrex

Sumatriptan

Tablets

9 of 100 mg; 18 of 50 mg; 36 of the 25 mg per 30 day period

Nasal spray 8 of 20 mg; 32 of 5 mg per 30 day

period

Injection: 4 injection kits (8 syringes); 8 injection

prefilled

vials per 30 day period

syringes &

vials

Zomig/ Zomig Zolmitriptan

Tablets (all 9 of 5 mg; 18 of 2.5 mg per 30 day

ZMT

forms)

period

Maxalt/Maxalt Rizatriptan

Tablets (all 12 of 10 mg; 24 of 5 mg per 30 day

MLT

forms)

period

Amerge

Naratriptan

Tablets

9 of 2.5 mg; 20 of 1 mg per 30 day

period

Axert

Almotriptan

Tablets

8 of 12.5 mg; 18 of 6.25 mg per 30 day

period

Migranal NS Dihydroergotamine Nasal spray 2 kits (8 ampules) per 30 day period

Stadol NS

Butorphanol

Nasal spray 4 of 2.5 ml spray pump per 30 day

period

*** Ample supply rules apply to QLL drugs ***

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