Qll drug list.xlsx

Quantity Level Limit Program: Limit per Refill
Quantity
Quantity
Acanya 1.2 - 2.5%
Emend® 40 and 125 mg
Acular LS® ophthalmic
Emend® 80 mg
Acuvail®
Emend® Unit of Use Pack
Aczone® 5%
Epiduo™
Adrenaclick® 0.15 and 0.3 mg
EpiPen® 0.15 and 0.3 mg
Afinitor® 2.5 and 5 mg
Evoclin®
Afinitor® 10 mg
Extina® Foam
Aldara cream
Famvir® 125 and 250 mg
Alinia® 100 mg/mL suspension
Famvir® 500 mg
Alinia® 500 mg tablets
Firazyr® 10 mg/ml
Alphagan® P 0.1 and 0.15%
Fragmin®
Alrex® ophthalmic
Frova® 2.5 mg
Alsuma™ 6 mg
Gleevec® 100mg
Altabax®
Gleevec® 400 mg
Amerge® 1 and 2.5 mg
Glucagon/Glucagen®
Analapram E kit™ with 1 oz tube and 30
Granisol™ 2 mg/10 mL
single use kit
Anzemet® 50 and 100 mg
Hycamtin® 0.25 mg
Arixtra® 2.5, 5, 7.5, and 10 mg
Hycamtin® 1 mg
Astelin® Nasal Spray
Imiquimod
Astepro 0.1 and 0.15%
Imitrex® 4 mg Syringe/injection
Avita® 0.025% gel
Imitrex® 6 mg Syringe/Injection
Axert® 6.25 and 12.5 mg
Imitrex® 6 mg vials
Azasite 1%
Imitre® Nasal Spray 20 mg
Azopt® ophthalmic
Imitrex® Nasal Spray 5 mg
Bactroban® Cream
Imitrex® Tablets 25, 50, and 100 mg
Bactroban® Ointment
Innohep®
Beconase AQ®
Iressa® 250 mg
BenzaClin® kit
Kytril® 1 mg
BenzEfoam™
Lastacaft™ 0.25%
Bepreve®
Lindane Lotion and Shampoo
Betimol®
Locoid lipocream®
Bromday™ 0.09%
Locoid lotion®
Lovenox® 30, 40, 60, 80, 100, 120, and 150
Butorphanol NS
Cambia® 50 mg packets
Lovenox® 300 mg
Caprelsa® 100 mg
Lumigan®
Caprelsa® 300 mg
Luxiq® 50 and 100 gram
Clobex® lotion and spray
Maxair Autohaler®
Clobex® shampoo
Maxalt®/Maxalt MLT® 5 and 10 mg
Cloderm® 30 and 75 gram pump
Momexin combo pack™
Cloderm® 45 and 90 gram tube
Nasacort® AQ
Combigan® 0.2% / 0.5% ophthalmic
Nasonex®
Desonate™
Nevanac® Ophthalmic
Diastat® 2.5 mg/ Diastat® AcuDial™ 10 and
Nexavar® 200 mg
Dovonex®
Nitrolingual Pump/spray
Dovonex® Scalp Solution
Nitromist® 0.4mg/spray
Elestat® ophthalmic
Nitromist lingual aerosol
Elidel®
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Quantity
Quantity
Omnaris® 50 mcg nasal spray
Treximet® 85/500 mg
Optivar® Ophthalmic
Trianex™
Oravig™ 50 mg
Triaz foaming cloths®
Pataday™ Ophthalmic
Tussionex®
Twinject® 0.15 and 0.3 mg inj. Single
Patanase 0.60% grams
cartridge
Patanol® Ophthalmic
Tykerb® 250 mg
Prevpac®
Ultracet®
Proair HFA
Valtrex® 1 gram
Protopic®
Valtrex® 500 mg
Proventil® HFA
Relpax® 20 and 40 mg
Vectical ®
Restasis® 0.05%
Ventolin® HFA
Revlimid® 15 and 25 mg
Verdeso™
Revlimid® 5 mg
Vfend® 200 mg
Revlimid® 10 mg
Vfend® 50 mg
Rhinocort Aqua® Nasal Spray (32 mcg/spray) 2 bottles (18 g)
Voltaren Ophthalmic®
Sancuso®
Votrient™ 200 mg
Sprycel® 20
Xalatan®
Sprycel® 50, 70, 100, and 140 mg
Xeloda® 150 mg
Sprycel® 80
Xeloda® 500 mg
Sumavel™ DosePro™
Xibrom®
Sutent® 12.5 mg
Xifaxan® 200 mg
Sutent® 25 and 50 mg
Xopenex HFA®
Xopenex® 0.31 mg/3mL, 0.63 mg/3 mL, and
Taclonex®
1.25 mg/3 mL Solution
Taclonex Scalp®
Xopenex® 1.25 mg/0.5 mL Solution
Tarceva® 100 and 150 mg
Zelboraf® 240 mg
Tarceva® 25 mg
Zirgan® 0.15%
Tasigna 150 and 200 mg
Zolinza® 100 mg
Tazorac® 0.5 and 0.1% cream
Zomig® 2.5 and 5 mg
Tazorac® 0.5 and 0.1% gel
Zomig® Nasal Spray 5 mg
Thalomid® 50 mg
Zomig ZMT® 2.5 and 5 mg
Thalomid® 100 mg
Zovirax 5% cream
Thalomid® 150 mg
Zuplenz® 4 and 8 mg
Thalomid® 200 mg
Zutripro™ 5mg/4mg/60mg per 5ml
Tobradex ST 0.3%/0.05% solution
Zyclara 3.75%®
Travatan Z®
Tretinoin 10mg
Zytiga™ 250 mg
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.

Source: http://schneider.welcometouhc.com/files/schneider/content/schneider_qll_drug_list.pdf