Standard ql list (client friendly document)

Standard Quantity Limit List*
Therapeutic Category
Drug Name
Dispensing Limit
Anti-infectives
CIPRO XR (ciprofloxacin ext-release) 1000 mg CIPRO XR (ciprofloxacin ext-release) 500 mg PROQUIN XR (ciprofloxacin ext-release) 500 mg Cardiology
XARELTO (rivaroxaban) tablet 15 mg & 20 mg Central Nervous System
Standard Quantity Limit List*
Therapeutic Category
Drug Name
Dispensing Limit
Central Nervous System
HORIZANT (gabapentin enacarbil SR) 600 MG EFFEXOR XR (venlafaxine) caps 37.5 mg & 75 mg LEXAPRO (escitalopram) solution 5 mg/5 ml LEXAPRO (escitalopram) tabs 5 mg & 20 mg LUVOX (fluvoxamine) tabs 25 mg & 50 mg PAXIL CR (paroxetine) tabs 25 mg & 37.5 mg PROZAC WEEKLY (fluoxetine delayed-release) Venlafaxine SR (venlafaxine) tabs 225 mg IMITREX (sumatriptan ) Injection 6 mg/0.5 mL IMITREX (sumatriptan ) STATdose 4 mg/0.5 mL & 6 mg/0.5 mL Standard Quantity Limit List*
Therapeutic Category
Drug Name
Dispensing Limit
Central Nervous System
NUVIGIL (armodafinil) 150 mg & 250 mg Dermatology
TACLONEX (calcipotriene/betamethasone dipropionate) TACLONEX SCALP (calcipotriene/betamethasone dipropionate) 120 grams/30 days Endocrinology
Growth Hormones and Related Therapy EGRIFTA (tesamorelin) ACTONEL WITH CALCIUM (risedronate/calcium carbonate) FOSAMAX PLUS D (alendronate/cholecalciferol) Gastroenterology
EMEND (aprepitant) Combo Pack 125 mg/80 mg Standard Quantity Limit List*
Therapeutic Category
Drug Name
Dispensing Limit

Gastroenterology
Antiemetics
Immunology
Miscellaneous
Blood Glucose Monitors (blood glucose monitors) Diabetic Test Strips & Lancets (test strip & lancets) NICODERM (nicotine transdermal) Transdermal NICORETTE, COMMIT (nicotine) Gum, Lozenges SYNVISC, SYNVISC-ONE (sodium hyaluronate)
Obstetrics & Gynecology
DEPO/DEPO-SUBQ PROVERA (medroxyprogesterone) LOSEASONIQUE (ethinyl estradiol/levonorgestrel) SEASONALE (ethinyl estradiol/levonorgestrel) SEASONIQUE (ethinyl estradiol/levonorgestrel) 2 tabs (2 kits)/year (covered for females only) 2 tabs (2 kits)/year (covered for females <17 year PLAN B, NEXT CHOICE (levonorgestrel) 0.75 mg 4 tabs (2 kits)/year (covered for females <17 year Chorionic gonadotropin (chorionic gonadotropin) FOLLISTIM AQ (follitropin beta) Cartridge Standard Quantity Limit List*
Therapeutic Category
Drug Name
Dispensing Limit
Obstetrics & Gynecology
Oncology
LUPRON DEPOT (leuprolide) 11.25 mg & 22.5 mg (3-month) LUPRON DEPOT (leuprolide) 3.75 mg & 7.5 mg (1-month) LUPRON DEPOT (leuprolide) 30 mg (4-month) LUPRON DEPOT (leuprolide) 45 mg (6-month) LUPRON DEPOT-PED (leuprolide) 7.5 mg, 11.25 mg, & 15 mg TRELSTAR (triptorelin) 22.5 mg (6-month) TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) TRELSTAR LA (triptorelin) 11.25 mg (3-month) AFINITOR (everolimus) 2.5 mg & 10 mg SPRYCEL (dasatinib) 70 mg, 80mg & 100 mg
Ophthalmology
Standard Quantity Limit List*
Therapeutic Category
Drug Name
Dispensing Limit
Respiratory
BECONASE AQ (beclomethasone dipropionate) Albuterol (solution) 2.5 mg/3 mL (0.083%) ATROVENT (ipratropium) Inhalation Solution PROVENTIL (albuterol) Solution 0.083% (2.5 MG/3ML) PROVENTIL HFA, PROAIR HFA, VENTOLIN HFA (albuterol) XOPENEX (levalbuterol) 0.31 mg & 0.63 mg/3 mL 8 vials or suppositories/month (males only) CIALIS (tadalafil) 5 mg, 10 mg & 20 mg Standard Quantity Limit List*
Important note: dinical re ewfor higherquantitiesWII ONLYI:e pro ded fordrugsinthe folloWng dasses: antidepressants,L.MV\IHs,opidds,PDE-Sinhibitors andtrif:(ans. •nis drug list is sltljedto periodeupdates and may not be all inclusive.Drugs affected induded both brand and gereric 'Y'Ihere plicable Md indudes all strengths unless otterWse specifically ncted.lf a targeted dn.g has a newstrergth,it Wllautomatically be addedto thelist.

Source: http://www.botetourtva.us/insurance/documents/kroger_sql_list.pdf