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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