Quantity Limits Drug List
Drug Name
BRAND NAME DRUG
generic drug
AMITIZA
BYETTA 10 MCG PEN
BYETTA 5 MCG PEN
fentanyl 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr patch(es)
fentanyl citrate 1200 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg lollipop(s)
fentanyl citrate 200 mcg lollipop(s)
FENTORA 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG TAB(S)
FENTORA 300 MCG TAB(S)
ketorolac tromethamine 10 mg tab(s), 15 mg/ml , 30 mg/ml
LUNESTA 1 MG TAB(S)
LUNESTA 2 MG, 3 MG TAB(S)
MAXALT
MAXALT-MLT
OXYCONTIN 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG TAB(S)
RELENZA DISKHALER
RELPAX
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
TAMIFLU 12 MG/ML
TAMIFLU 30 MG CAP(S)
TAMIFLU 45 MG CAP(S)
TAMIFLU 75 MG CAP(S)
zaleplon
zolpidem tartrate 10 mg, 12.5 mg tab(s)
zolpidem tartrate 5 mg, 6.25 mg tab(s)
ZYVOX 100 MG/5ML
ZYVOX 600 MG TAB(S)
Quantity Limits
60 per 30 days
2.4 per 25 days
2.4 per 25 days
20 per 30 days
120 per 30 days
120 per 30 days
120 per 30 days
120 per 30 days
20 per 25 days
90 per 30 days
30 per 30 days
12 per 30 days
12 per 30 days
120 per 30 days
56 per 180 days
6 per 30 days
20 per 30 days
5.4 per 30 days
4.5 per 30 days
270 per 365 days
50 per 25 days
25 per 25 days
28 per 180 days
60 per 30 days
30 per 30 days
60 per 30 days
1800 per 28 days
56 per 28 days
Please note: limits on the amount of a given drug that First+Plus will cover may be in addition to a standard
one-month or three-month supply.
Updated October, 2011
1 | First+Plus – 2012 – Quantity Limits Drug List
Y0031_FP_12_1009_09_I F&U 11/28/2011