Managed Drug Limitations (MDLs)
Managed Drug Limitations (MDLs) are specific limits applied to the medications
listed below which help assure an appropriate quantity is dispensed as it relates
to the days supply or length of therapy.
| Notes Legend: |
| F |
Formulary copay applies |
| NF |
Nonformulary copay applies |
| * |
Not available through mail-order |
| Drug |
MDL |
Notes |
| Abilify |
30/23 days |
NF |
| Aldara |
12 (1 box)/21 days for 16 weeks |
F* |
| Ambien
|
30/23 days |
NF |
| Amerge
1mg, 2.5mg |
9/23 days |
NF |
| Axert 6.25mg, 12.5mg |
12/23 days |
NF |
| Bextra |
30/30 days |
NF |
| Celebrex |
60/30 days |
NF |
| Cipro XR 500mg |
3/23 days |
NF* |
| Crestor |
30/23 days |
F |
| Diflucan
150mg |
2/23 days |
F |
| DHE-45
150mg |
10/23 days |
NF |
| Duragesic |
10/23 days |
NF |
| Emend |
12/23 days |
NF* |
| EMLA
|
30gm tube/59 days |
F |
| Fragmin |
30/90 days |
NF* |
| Frova |
18/23 days |
NF |
| Imitrex
Inj Kits |
3/23 days |
NF |
| Imitrex Inj Vials |
6/23 days |
NF |
| Imitrex
Nasal 5mg |
1 x 1 pack of 6/23 days |
NF |
| Imitrex
Nasal 20mg |
1 x 1 pack of 6/23 days |
NF |
| Imitrex
Tabs |
18/23 days |
NF |
| Kytril |
15/23 days |
F |
| Lovenox |
30/90 days |
F* |
| Maxalt,
Maxalt MLT |
12/23 days |
F |
| Migranal
NS |
2 x 1 pack of 4/23 days |
NF |
| Plan
B |
4/year |
NF |
| Preven
|
2 kits/year |
NF* |
| Preven/Plan
B |
3 fills/365 days |
NF* |
| Provigil |
30/23 days |
NF |
| Regranex |
15/23 days |
F* |
| Relenza
|
2 treatments (40 disks)/year |
NF* |
| Relpax |
12/23 days |
NF |
| Revia |
180/360 days |
F |
| Sonata
|
30/23 days |
NF |
| Stadol
NS |
6ml (2 bottles)/23 days |
F |
| Tamiflu
|
2 treatments (20 caps)/year |
NF* |
| Toradol
10mg Tabs |
20/23 days |
NF |
| Vioxx |
30/30 days |
F |
| Xanax XR |
60/23 days |
NF |
| Zithromax
250mg |
12/23 days |
F |
| Zofran |
15/23 days |
F |
| Zomig,
Zomig ZMT 2.5mg |
12/23 days |
F |
| Zomig,
Zomig ZMT 5mg |
6/23 days |
F |
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Drugs page
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