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Quantity Limits – NC Standard
Commercial Policy
Version Date: March 2025
Quantity Limitations:
Quantity limitations apply to brand and associated generic products.
| Medication | Quantity per Day (unless specified) |
|---|---|
| ADLARITY – donepezil transdermal system 5 mg/day | 4 patches per 28 days |
| ADLARITY – donepezil transdermal system 10 mg/day | 4 patches per 28 days |
| ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 100-50 mcg/dose | 60 blisters per 30 days |
| ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 250-50 mcg/dose | 60 blisters per 30 days |
| ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 500-50 mcg/dose | 60 blisters per 30 days |
| ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/ act | 1 canister per 30 days |
| ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/ act | 1 canister per 30 days |
| ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/ act | 1 canister per 30 days |
| AIRDUO DIGIHALER 113/14 – fluticasone-salmeterol aer powder ba 113-14 mcg/act w/sensor | 1 inhaler per 30 days |
| AIRDUO DIGIHALER 232/14 – fluticasone-salmeterol aer powder ba 232-14 mcg/act w/sensor | 1 inhaler per 30 days |
| AIRDUO DIGIHALER 55/14 – fluticasone-salmeterol aer powder ba 55-14 mcg/act w/ sensor | 1 inhaler per 30 days |
| AIRDUO RESPICLICK 113/14 – fluticasone-salmeterol aer powder ba 113-14 mcg/act | 1 inhaler per 30 days |
| AIRDUO RESPICLICK 232/14 – fluticasone-salmeterol aer powder ba 232-14 mcg/act | 1 inhaler per 30 days |
| AIRDUO RESPICLICK 55/14 – fluticasone-salmeterol aer powder ba 55-14 mcg/act | 1 inhaler per 30 days |
| AIRSUPRA – albuterol-budesonide 90-80 mcg/act | 3 inhalers per 30 days |
| ALA-SCALP – hydrocortisone 2% lotion | 118.4 mL per 30 days |
| ALVESCO – ciclesonide inhal aerosol 160 mcg/act | 2 canisters per 30 days |
| ALVESCO – ciclesonide inhal aerosol 80 mcg/ac | 1 canister per 30 days |
| ANNOVERA -segesterone-ethinlyl estradiol vaginal ring | 1 ring per 365 days (1 year) |
| ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh | 60 blisters per 30 days |
| APEXICON E – diflorasone 0.05% cream | 120 grams per 30 days |
| ARICEPT – donepezil hydrochloride tab 5 mg | 1 tablet |
| ARICEPT – donepezil hydrochloride tab 10 mg | 1 tablet |
| ARICEPT – donepezil hydrochloride tab 23 mg | 1 tablet |
| ARMONAIR DIGIHALER – fluticasone propionate aer pow ba 113 mcg/act with sensor | 1 inhaler per 30 days |
| ARMONAIR DIGIHALER – fluticasone propionate aer pow ba 232 mcg/act with sensor | 1 inhaler per 30 days |
| ARMONAIR DIGIHALER – fluticasone propionate aer pow ba 55 mcg/act with sensor | 1 inhaler per 30 days |
| ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 100 mcg/act | 30 blisters per 30 days |
| ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 200 mcg/act | 30 blisters per 30 days |
| ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 50 mcg/act | 30 blisters per 30 days |
| ASMANEX HFA – mometasone furoate inhal aerosol suspension 100 mcg/act | 1 canister per 30 days |
| ASMANEX HFA – mometasone furoate inhal aerosol suspension 200 mcg/act | 1 canister per 30 days |
| ASMANEX HFA – mometasone furoate inhal aerosol suspension 50 mcg/act | 1 canister per 30 days |
| ASMANEX TWISTHALER 120 METERED DOSES – mometasone furoate inhal powd 220 mcg/inh | 1 canister per 30 days |
| ASMANEX TWISTHALER 30 METERED DOSES – mometasone furoate inhal powd 110 mcg/inh | 1 canister per 30 days |
| ASMANEX TWISTHALER 30 METERED DOSES – mometasone furoate inhal powd 220 mcg/inh | 1 canister per 30 days |
| ASMANEX TWISTHALER 60 METERED DOSES – mometasone furoate inhal powd 220 mcg/inh | 1 canister per 30 days |
| ATROVENT HFA – ipratropium bromide hfa inhal aerosol 17 mcg/act | 2 canisters per 30 days |
| AUVI-Q – epinephrine 0.1 mg/0.1 mL auto-injector | 4 pens per 30 days |
| AUVI-Q – epinephrine 0.15 mg/0.15 mL auto-injector | 4 pens per 30 days |
| AUVI-Q – epinephrine 0.3 mg/0.3 mL auto-injector | 4 pens per 30 days |
| BASAGLAR KWIKPEN – insulin glargine soln pen-injector 100 unit/ml | 100 mL per 30 days |
| BASAGLAR TEMPO PEN – insulin glargine pen-injector with transmitter port 100 unit/ml | 100 mL per 30 days |
| BETHKIS – tobramycin nebu soln 300 mg/4ml | 224 mL per 56 days |
| BEVESPI AEROSPHERE – glycopyrrolate-formoterol fumarate aerosol 9-4.8 mcg/act | 1 canister per 30 days |
| BRENZAVVY – bexagliflozin tab 20 mg | 1 tablet |
| BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 50-25 mcg/inh | 60 blisters per 30 days |
| BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh | 60 blisters per 30 days |
| BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh | 60 blisters per 30 days |
| BREZTRI AEROSPHERE – budesonide-glycopyrrolateformoterol aers 160-9-4.8 mcg/act | 1 canister per 30 days |
| BRYHALI – halobetasol 0.01% lotion | 200 grams per 28 days |
| CAPEX – fluocinolone 0.01% shampoo | 180 mL per 28 days |
| CAYSTON – aztreonam lysine for inhal soln 75 mg (base equivalent) | 84 mL per 56 days |
| CIALIS – tadalafil tab 2.5 mg | 1 tablet |
| CIALIS – tadalafil tab 5 mg | 1 tablet |
| ciclopirox 0.77% gel | 6 grams |
| clindamycin 1% solution | 6 mL |
| CLOBEX – clobetasol 0.05% lotion | 177 mL per 28 days |
| CLOBEX – clobetasol 0.05% spray | 236 mL per 28 days |
| CLOBEX – clobetasol, clodan 0.05% shampoo | 236 mL per 30 days |
| CLODERM – clocortolone 0.1% cream | 135 grams per 30 days |
| COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act | 2 canisters per 30 days |
| CORDRAN – flurandrenolide 0.025% cream | 120 grams per 30 days |
| CORDRAN – flurandrenolide 0.05% lotion, cream, ointment | 120 grams or 120 mL per 30 days |
| CORDRAN – flurandrenolide tape | 1 box per 30 days |
| cromolyn sodium soln nebu 20 mg/2ml | 8 mL |
| CUTIVATE – fluticasone 0.05% lotion | 120 mL per 30 days |
| DALIRESP – roflumilast tab 250 mcg | 1 tablet |
| DALIRESP – roflumilast tab 500 mcg | 1 tablet |
| DESONATE – desonide 0.05% gel | 120 grams per 30 days |
| DESOWEN – desonide 0.05% lotion | 118 mL per 30 days |
| desoximetasone cream, ointment 0.05% | 120 grams per 30 days |
| DETROL – tolterodine tartrate tab 1 mg | 2 tablets |
| DETROL – tolterodine tartrate tab 2 mg | 2 tablets |
| DETROL LA – tolterodine tartrate cap er 24hr 2 mg | 1 tablet |
| DETROL LA – tolterodine tartrate cap er 24hr 4 mg | 1 tablet |
| DITROPAN XL – oxybutynin chloride tab er 24hr 5 mg | 1 tablet |
| DITROPAN XL – oxybutynin chloride tab er 24hr 10 mg | 2 tablets |
| donepezil hydrochloride orally disintegrating tab 5 mg | 1 tablet |
| donepezil hydrochloride orally disintegrating tab 10 mg | 1 tablet |
| DUAKLIR PRESSAIR – aclidinium br-formoterol fum aero pow br act 400-12 mcg/act | 1 inhaler per 30 days |
| DULERA – mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act | 3 canisters per 30 days |
| DULERA – mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act | 3 canisters per 30 days |
| DULERA – mometasone furoate-formoterol fumarate aerosol 50-5 mcg/act | 3 canisters per 30 days |
| econazole 1% cream | 170 grams per 30 days |
| ELIQUIS – apixaban tab 2.5 mg | 2 tablets |
| ELIQUIS – apixaban tab 5 mg | 74 tablets/30 days |
| ELIQUIS STARTER PACK – apixaban tab starter pack 5 mg | 1 pack per 180 days |
| ENABLEX – darifenacin ER 7.5 mg tablet | 1 tablet |
| ENABLEX – darifenacin ER 15 mg tablet | 1 tablet |
| ENTADFI – finasteride-tadalafil 5-5 mg capsule | 1 capsule |
| EPINEPHRINE (AMNEAL/AVKARE BRAND) – epinephrine 0.3 mg/0.3 mL auto-injector | 4 pens per 30 days |
| EPIPEN – epinephrine 0.3 mg/0.3 mL auto-injector | 4 pens per 30 days |
| EPIPEN JR. – epinephrine 0.15 mg/0.3 mL auto-injector | 4 pens per 30 days |
| ERYGEL – erythromycin 2% gel | 6 grams |
| erythromycin 2% solution | 6 mL |
| EXELON – rivastigmine 1.5 mg capsule | 2 capsules |
| EXELON – rivastigmine 3 mg capsule | 2 capsules |
| EXELON – rivastigmine 4.5 mg capsule | 2 capsules |
| EXELON – rivastigmine 6 mg capsule | 2 capsules |
| EXELON – rivastigmine td patch 24hr 4.6 mg/24hr | 1 patch |
| EXELON – rivastigmine td patch 24hr 9.5 mg/24hr | 1 patch |
| EXELON – rivastigmine td patch 24hr 13.3 mg/24hr | 1 patch |
| FARXIGA – dapagliflozin propanediol tab 10 mg | 1 tablet |
| FARXIGA – dapagliflozin propanediol tab 5 mg | 1 tablet |
| FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/blister | 60 blisters per 30 days |
| FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/blister | 240 blisters per 30 days |
| FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/ blister | 60 blisters per 30 days |
| FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/ act (125/valve) | 1 canister per 30 days |
| FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/ act (250/valve) | 2 canisters per 30 days |
| FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/ act (50/valve) | 1 canister per 30 days |
| GALANTAMINE HYDROBROMIDE – galantamine hydrobromide oral soln 4 mg/ml | 200 mL per 30 days |
| GELNIQUE – oxybutynin chloride td gel 10% sachet | 1 sachet |
| GEMTESA – vibegron tab 75 mg | 1 tablet |
| gentamicin 0.1% cream | 120 grams per 90 days |
| gentamicin 0.1% ointment | 120 grams per 90 days |
| GLIPIZIDE – glipizide tab 2.5 mg | 1 tablet |
| GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg | 1 tablet |
| GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg | 1 tablet |
| HALOG – halcinonide 0.1% cream, ointment | 240 grams per 30 days |
| HALOG – halcinonide 0.1% solution | 240 mL per 30 days |
| HYDROCORT – hydrocortisone 2.5% lotion | 118 mL per 30 days |
| IMPEKLO – clobetasol propionate 0.05% lotion | 4 bottles (165.6 grams) per 28 days |
| IMPOYZ – clobetasol propionate 0.025% | 200 grams per 28 days |
| INCRUSE ELLIPTA – umeclidinium br aero powd breath act 62.5 mcg/inh | 30 blisters per 30 days |
| INPEFA – sotagliflozin tab 200 mg | 1 tablet |
| INPEFA – sotagliflozin tab 400 mg | 1 tablet |
| INSULIN DEGLUDEC – insulin degludec inj 100 unit/ml | 100 mL per 30 days |
| INSULIN DEGLUDEC – insulin degludec soln pen-injector 100 unit/ml | 100 mL per 30 days |
| INSULIN DEGLUDEC – insulin degludec soln pen-injector 200 unit/ml | 100 mL per 30 days |
| INSULIN GLARGINE – insulin glargine inj 100 unit/ml | 100 mL per 30 days |
| INSULIN GLARGINE – insulin glargine soln pen-injector 100 unit/ml | 100 mL per 30 days |
| INSULIN GLARGINE – insulin glargine-yfgn inj 100 unit/ml | 100 mL per 30 days |
| INSULIN GLARGINE – insulin glargine-yfgn soln pen-injector 100 unit/ml | 100 mL per 30 days |
| INSULIN GLARGINE – insulin glargine soln pen-injector 300 unit/ml (2 unit dial) | 100 mL per 30 days |
| INSULIN GLARGINE – insulin glargine soln pen-injector 300 unit/ml (1 unit dial) | 100 mL per 30 days |
| INTUNIV – guanfacine extended release 1 mg | 1 tablet |
| INTUNIV – guanfacine extended release 2 mg | 1 tablet |
| INTUNIV – guanfacine extended release 3 mg | 1 tablet |
| INTUNIV – guanfacine extended release 4 mg | 1 tablet |
| INVOKAMET – canagliflozin-metformin hcl tab 150-1000 mg | 2 tablets |
| INVOKAMET – canagliflozin-metformin hcl tab 150-500 mg | 2 tablets |
| INVOKAMET – canagliflozin-metformin hcl tab 50-1000 mg | 2 tablets |
| INVOKAMET – canagliflozin-metformin hcl tab 50-500 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 150-1000 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 150-500 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 50-1000 mg | 2 tablets |
| INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 50-500 mg | 2 tablets |
| INVOKANA – canagliflozin tab 100 mg | 1 tablet |
| INVOKANA – canagliflozin tab 300 mg | 1 tablet |
| JANUMET – sitagliptin-metformin hcl tab 50-1000 mg | 2 tablets |
| JANUMET – sitagliptin-metformin hcl tab 50-500 mg | 2 tablets |
| JANUMET XR – sitagliptin-metformin hcl tab er 24hr 100-1000 mg | 1 tablet |
| JANUMET XR – sitagliptin-metformin hcl tab er 24hr 50-1000 mg | 2 tablets |
| JANUMET XR – sitagliptin-metformin hcl tab er 24hr 50-500 mg | 1 tablet |
| JANUVIA – sitagliptin phosphate tab 100 mg | 1 tablet |
| JANUVIA – sitagliptin phosphate tab 25 mg | 1 tablet |
| JANUVIA – sitagliptin phosphate tab 50 mg | 1 tablet |
| JARDIANCE – empagliflozin tab 10 mg | 1 tablet |
| JARDIANCE – empagliflozin tab 25 mg | 1 tablet |
| JENTADUETO – linagliptin-metformin hcl tab 2.5-1000 mg | 2 tablets |
| JENTADUETO – linagliptin-metformin hcl tab 2.5-500 mg | 2 tablets |
| JENTADUETO – linagliptin-metformin hcl tab 2.5-850 mg | 2 tablets |
| JENTADUETO XR – linagliptin-metformin hcl tab er 24hr 2.5-1000 mg | 2 tablets |
| JENTADUETO XR – linagliptin-metformin hcl tab er 24hr 5-1000 mg | 1 tablet |
| JOURNAVX – suzetrigine tab 50 mg | 30 tablets per 30 days |
| KAPVAY – clonidine extended release 0.1 mg | 4 tablets |
| KAZANO – alogliptin-metformin hcl tab 12.5-1000 mg | 2 tablets |
| KAZANO – alogliptin-metformin hcl tab 12.5-500 mg | 2 tablets |
| KENALOG – triamcinolone spray | 126 grams per 30 days |
| ketoconazole 2% cream | 6 grams |
| ketorolac tromethamine tab 10 mg | 21 tablets per 30 days |
| KITABIS PAK – tobramycin nebu soln 300 mg/5ml | 280 mL per 56 days |
| KLOXXADO – naloxone hcl nasal spray 8 mg/0.1ml | 12 (6 boxes) per 365 days |
| KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 2.5-1000 mg | 2 tablets |
| KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 5-1000 mg | 1 tablet |
| KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 5-500 mg | 1 tablet |
| LAGEVRIO – molnupiravir capsule 200 mg | 40 capsules per 30 days |
| LANTUS – insulin glargine inj 100 unit/ml | 100 mL per 30 days |
| LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml | 100 mL per 30 days |
| LEVEMIR – insulin detemir inj 100 unit/ml | 100 mL per 30 days |
| LEVEMIR FLEXTOUCH/FLEXPEN – insulin detemir soln pen-injector 100 unit/ml | 100 mL per 30 days |
| LEXETTE – halobetasol 0.05% aerosol | 200 grams per 28 days |
| LIKMEZ – metronidazole susp 500mg/5Ml | 400 mL per 10 days |
| LOCOID LIPOCREAM – hydrocortisone butyrate lipid 0.1% | 120 grams per 30 days |
| LOCOID – hydrocortisone 0.1% lotion | 118 mL per 30 days |
| LODOCO – colchicine (cardiovascular) tab 0.5 mg | 1 tablet |
| LOPROX – ciclopirox olamine 0.77% cream | 6 grams |
| LOPROX – ciclopirox olamine 0.77% susp | 6 mL |
| MYRBETRIQ – mirabegron tab er 24 hr 25 mg | 1 tablet |
| MYRBETRIQ – mirabegron tab er 24 hr 50 mg | 1 tablet |
| MYRBETRIQ – mirabegron granules for oral extended release susp 8 mg/ml | 10 mL |
| NAMENDA – memantine hcl tab 5 mg | 2 tablets |
| NAMENDA – memantine hcl tab 10 mg | 2 tablets |
| NAMENDA TITRATION PAK – memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack | 1 pack (49 tablets) per 28 days |
| NAMENDA XR – memantine hcl cap er 24hr 7 mg | 1 capsule |
| NAMENDA XR – memantine hcl cap er 24hr 14 mg | 1 capsule |
| NAMENDA XR – memantine hcl cap er 24hr 21 mg | 1 capsule |
| NAMENDA XR – memantine hcl cap er 24hr 28 mg | 1 capsule |
| NAMZARIC – memantine-donepezil cap er 24hr 7 & 14 & 21 & 28-10 mg pack | 28 capsules per 180 days |
| NAMZARIC – memantine hcl-donepezil hcl cap er 24hr 7-10 mg | 1 capsule |
| NAMZARIC – memantine hcl-donepezil hcl cap er 24hr 14-10 mg | 1 capsule |
| NAMZARIC – memantine hcl-donepezil hcl cap er 24hr 21-10 mg | 1 capsule |
| NAMZARIC – memantine hcl-donepezil hcl cap er 24hr 28-10 mg | 1 capsule |
| NARCAN – naloxone hcl nasal spray 4 mg/0.1 ml | 12 (6 boxes) per 365 days |
| NAYZILAM – midazolam nasal spray soln 5 mg/0.1 ml | 10 sprays per 30 days |
| NEFFY - epinephrine nasal spray 2 mg/0.1 mL | 4 devices per 30 days |
| NESINA – alogliptin benzoate tab 12.5 mg | 1 tablet |
| NESINA – alogliptin benzoate tab 25 mg | 1 tablet |
| NESINA – alogliptin benzoate tab 6.25 mg | 1 tablet |
| OLUX/OLUX-E – clobetasol 0.05% foam | 200 grams per 28 days |
| ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv) | 1 tablet |
| ONGLYZA – saxagliptin hcl tab 5 mg | 1 tablet |
| OPVEE – nalmefene hcl nasal spray 2.7 mg/0.1 Ml | 12 devices per 365 days |
| OSENI – alogliptin-pioglitazone tab 12.5-15 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 12.5-30 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 12.5-45 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 25-15 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 25-30 mg | 1 tablet |
| OSENI – alogliptin-pioglitazone tab 25-45 mg | 1 tablet |
| Oxybutynin chloride tab 2.5 mg | 3 tablets |
| oxybutynin chloride tab 5 mg | 4 tablets |
| oxybutynin chloride syrup 5 mg/5ml | 20 mL |
| oxybutynin chloride solution 5 mg/5ml | 20 mL |
| OXYTROL – oxybutynin td patch twice weekly 3.9 mg/24hr | 8 patches per 28 days |
| PANDEL – hydrocortisone probutate 0.1% cream | 160 grams per 30 days |
| PAXLOVID – nirmatrelvir & ritonavir tablet pack 150 mg, 100 mg | 20 tablets per 30 days |
| PAXLOVID – nirmatrelvir & ritonavir tablet pack 300 mg, 100 mg | 30 tablets per 30 days |
| PRADAXA – dabigatran etexilate mesylate cap 110 mg | 71 capsules per 90 days |
| PRADAXA – dabigatran etexilate mesylate cap 150 mg | 2 capsules |
| PRADAXA – dabigatran etexilate mesylate cap 75 mg | 2 capsules |
| PRADAXA PAK – dabigatran etexilate mesylate pellet pack 20 mg | 60 packets per 30 days |
| PRADAXA PAK – dabigatran etexilate mesylate pellet pack 30 mg | 120 packets per 30 days |
| PRADAXA PAK – dabigatran etexilate mesylate pellet pack 40 mg | 120 packets per 30 days |
| PRADAXA PAK – dabigatran etexilate mesylate pellet pack 50 mg | 120 packets per 30 days |
| PRADAXA PAK – dabigatran etexilate mesylate pellet pack 110 mg | 120 packets per 30 days |
| PRADAXA PAK – dabigatran etexilate mesylate pellet pack 150 mg | 60 packets per 30 days |
| PROAIR DIGIHALER – albuterol sulfate aer pow ba 108 mcg/act with sensor | 2 inhalers per 30 days |
| PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) | 2 canisters per 30 days |
| PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 mcg/ act (90 mcg base equiv) | 2 inhalers per 30 days |
| PROVENTIL HFA – albuterol sulfate inhal aero 108 mcg/act | 2 canisters per 30 days |
| PSORCON – diflorasone 0.05% cream | 120 grams per 30 days |
| PULMICORT FLEXHALER – budesonide inhal aero powd 180 mcg/act (breath activated) | 2 canisters per 30 days |
| PULMICORT FLEXHALER – budesonide inhal aero powd 90 mcg/act (breath activated) | 1 canister per 30 days |
| QBREXZA – glycopyrronium 2.4% cloths | 1 cloth |
| QELBREE ER – viloxazine extended release 100 mg | 1 capsule |
| QELBREE ER – viloxazine extended release 150 mg | 2 capsules |
| QELBREE ER – viloxazine extended release 200 mg | 3 capsules |
| QTERN – dapagliflozin-saxagliptin tab 10-5 mg | 1 tablet |
| QTERN – dapagliflozin-saxagliptin tab 5-5 mg | 1 tablet |
| QVAR REDIHALER – beclomethasone diprop hfa breath act inh aer 40 mcg/act | 1 canister per 30 days |
| QVAR REDIHALER – beclomethasone diprop hfa breath act inh aer 80 mcg/act | 2 canisters per 30 days |
| RAZADYNE – galantamine hydrobromide tab 4 mg | 2 tablets |
| RAZADYNE – galantamine hydrobromide tab 8 mg | 2 tablets |
| RAZADYNE – galantamine hydrobromide tab 12 mg | 2 tablets |
| RAZADYNE ER – galantamine hydrobromide cap er 24hr 8 mg | 1 capsule |
| RAZADYNE ER – galantamine hydrobromide cap er 24hr 16 mg | 1 capsule |
| RAZADYNE ER – galantamine hydrobromide cap er 24hr 24 mg | 1 capsule |
| RESTASIS – cyclosporine ophthalmic emulsion 0.05% multidose bottle | 1 bottle (5.5 mL) per 28 days |
| RESTASIS – cyclosporine ophthalmic emulsion 0.05% single use vial | 2 vials |
| REXTOVY – naloxone hcl nasal spray 4mg/0.25ml | 12 (6 boxes) per 365 days |
| REZVOGLAR KWIKPEN – insulin glargine-aglr soln pen-injector 100 unit/ml | 100 mL per 30 days |
| SAVAYSA – edoxaban tosylate tab 15 mg | 1 tablet |
| SAVAYSA – edoxaban tosylate tab 30 mg | 1 tablet |
| SAVAYSA – edoxaban tosylate tab 60 mg | 1 tablet |
| SAVELLA – milnacipran 12.5 mg tablet | 2 tablets |
| SAVELLA – milnacipran 25 mg tablet | 2 tablets |
| SAVELLA – milnacipran 50 mg tablet | 2 tablets |
| SAVELLA – milnacipran 100 mg tablet | 2 tablets |
| SAVELLA – milnacipran 5 x 12.5 mg, 8 x 25 mg, 42 x 50 mg titration pack | 1 pack (55 tablets) per 180 days |
| SEGLUROMET – ertugliflozin-metformin hcl tab 2.5-1000 mg | 2 tablets |
| SEGLUROMET – ertugliflozin-metformin hcl tab 2.5-500 mg | 4 tablets |
| SEGLUROMET – ertugliflozin-metformin hcl tab 7.5-1000 mg | 2 tablets |
| SEGLUROMET – ertugliflozin-metformin hcl tab 7.5-500 mg | 2 tablets |
| SEMGLEE – insulin glargine-yfgn inj 100 unit/ml | 100 mL per 30 days |
| SEMGLEE – insulin glargine-yfgn soln pen-injector 100 unit/m | 100 mL per 30 days |
| SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/ dose | 60 blisters per 30 days |
| SERNIVO – betamethasone spray | 120 mL per 30 days |
SOLIQUA – insulin glargine-lixisenatide sol pen-inj 100-33 unit-mcg/mL | 6 pens per 30 days |
| SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg | 30 capsules per 30 days |
| SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act | 1 cartridge per 30 days |
| SPRIX – ketorolac tromethamine nasal spray 15.75 mg/spray | 5 bottles/prescription per 30 days |
| STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg | 1 tablet |
| STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg | 2 tablets |
| STEGLUJAN – ertugliflozin-sitagliptin tab 15-100 mg | 1 tablet |
| STEGLUJAN – ertugliflozin-sitagliptin tab 5-100 mg | 1 tablet |
| STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act | 1 cartridge per 30 days |
| STRATTERA – atomoxetine 10 mg | 2 capsules |
| STRATTERA – atomoxetine 18 mg | 2 capsules |
| STRATTERA – atomoxetine 25 mg | 2 capsules |
| STRATTERA – atomoxetine 40 mg | 2 capsules |
| STRATTERA – atomoxetine 60 mg | 2 capsules |
| STRATTERA – atomoxetine 80 mg | 1 capsule |
| STRATTERA – atomoxetine 100 mg | 1 capsule |
| STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv) | 1 cartridge per 30 days |
| SYMBICORT – Breyna, budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act | 3 canisters per 30 days |
| SYMBICORT – Breyna, budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act | 3 canisters per 30 days |
| SYMJEPI – epinephrine 0.15 mg/0.3 mL prefilled syringe | 4 syringes per 30 days |
| SYMJEPI – epinephrine 0.3 mg/0.3 mL prefilled syringe | 4 syringes per 30 days |
| SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000 mg | 2 tablets |
| SYNJARDY – empagliflozin-metformin hcl tab 12.5-500 mg | 2 tablets |
| SYNJARDY – empagliflozin-metformin hcl tab 5-1000 mg | 2 tablets |
| SYNJARDY – empagliflozin-metformin hcl tab 5-500 mg | 2 tablets |
| SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr 10-1000 mg | 2 tablets |
| SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr 12.5-1000 mg | 2 tablets |
| SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr 25-1000 mg | 1 tablet |
| SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr 5-1000 mg | 2 tablets |
| TEMOVATE – clobetasol 0.05% cream, gel | 210 grams per 28 days |
| TOBI PODHALER – tobramycin inhal cap 28 mg | 224 capsules per 56 days |
| tobramycin ophthalmic soln 0.3% | 3 bottles (15 mL) per 30 days |
| TOPICORT 0.05% – desoximetasone 0.05% cream, ointment | 120 grams per 30 days |
| TOPICORT 0.25% – desoximetasone 0.25% spray, ointment | 120 grams or 120 Ml per 30 days |
| TOUJEO MAX SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml (2 unit dial) | 100 mL per 30 days |
| TOUJEO SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml (1 unit dial) | 100 mL per 30 days |
| TOVIAZ – fesoterodine fumarate tab er 24hr 4 mg | 1 tablet |
| TOVIAZ – fesoterodine fumarate tab er 24hr 8 mg | 1 tablet |
| TRADJENTA – linagliptin tab 5 mg | 1 tablet |
| TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol aepb 100-62.5-25 mcg/inh | 1 inhaler per 30 days |
| TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol aepb 200-62.5-25 mcg/inh | 1 inhaler per 30 days |
| TRESIBA – insulin degludec inj 100 unit/ml | 100 mL per 30 days |
| TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 100 unit/ml | 100 mL per 30 days |
| TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 200 unit/m | 100 mL per 30 days |
| TRIANEX – triamcinolone 0.05% ointment | 430 grams per 30 days |
| TRIJARDY XR – empagliflozin-linagliptin-metformin tab er 24hr 12.5-2.5-1000 mg | 2 tablets |
| TRIJARDY XR – empagliflozin-linagliptin-metformin tab er 24hr 10-5-1000 mg | 1 tablet |
| TRIJARDY XR – empagliflozin-linagliptin-metformin tab er 24hr 25-5-1000 mg | 1 tablet |
| TRIJARDY XR – empagliflozin-linagliptin-metformin tab er 24hr 5-2.5-1000 mg | 2 tablets |
| trospium chloride cap er 24hr 60 mg | 1 capsule |
| trospium chloride tab 20 mg | 2 tablets |
| TUDORZA PRESSAIR – aclidinium bromide aerosol powd breath activated 400 mcg/act | 1 canister per 30 days |
| TYRVAYA – varenicline tartrate nasal spray 0.03 mg/act | 2 bottles (8.4mL) per 28 days |
| ULTRAVATE – halobetasol 0.05% lotion | 240 mL per 30 days |
| VALTOCO – diazepam nasal spray 10 mg/0.1 ml | 10 blister packs per 30 days |
| VALTOCO – diazepam nasal spray 5 mg/0.1 ml | 10 blister packs per 30 days |
| VALTOCO – diazepam nasal spray ther pack 2 x 10 mg/0.1ml (20 mg dose) | 10 blister packs per 30 days |
| VALTOCO – diazepam nasal spray ther pack 2 x 7.5 mg/0.1ml (15 mg dose) | 10 blister packs per 30 days |
| VANCOCIN – vancomycin cap 125 mg | 4 capsules |
| VANCOCIN – vancomycin cap 250 mg | 8 capsules |
| VANOS – fluocinonide 0.1% cream | 240 grams per 28 days |
| VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) | 2 canisters per 30 days |
| VERDESO – desonide 0.05% foam | 100 grams per 30 days |
| VESICARE – solifenacin succinate tab 5 mg | 1 tablet |
| VESICARE – solifenacin succinate tab 10 mg | 1 tablet |
| VESICARE LS – solifenacin succinate susp 5 mg/5ml (1 mg/ml) | 10 mL |
| XARELTO – rivaroxaban tab 10 mg | 1 tablet |
| XARELTO – rivaroxaban tab 15 mg | 2 tablets |
| XARELTO – rivaroxaban tab 2.5 mg | 2 tablets |
| XARELTO – rivaroxaban tab 20 mg | 1 tablet |
| XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg & 20 mg | 1 pack per 180 days |
| XIGDUO XR – dapagliflozin-metformin hcl tab er 24hr 10-1000 mg | 1 tablet |
| XIGDUO XR – dapagliflozin-metformin hcl tab er 24hr 10-500 mg | 1 tablet |
| XIGDUO XR – dapagliflozin-metformin hcl tab er 24hr 2.5-1000 mg | 2 tablets |
| XIGDUO XR – dapagliflozin-metformin hcl tab er 24hr 5-1000 mg | 2 tablets |
| XIGDUO XR – dapagliflozin-metformin hcl tab er 24hr 5-500 mg | 1 tablet |
| XOFLUZA – baloxavir marboxil tab therapy pack 1 x 40 mg (40 mg dose) | (2 boxes) 2 tablets per 120 days |
| XOFLUZA – baloxavir marboxil tab therapy pack 1 x 80 mg (80 mg dose) | (2 boxes) 2 tablets per 120 days |
| XOFLUZA – baloxavir marboxil tab therapy pack 2 x 20 mg (40 mg dose) | (2 boxes) 4 tablets per 120 days |
| XOFLUZA – baloxavir marboxil tab therapy pack 2 x 40 mg (80 mg dose) | (2 boxes) 4 tablets per 120 days |
| XOPENEX HFA – levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) | 2 canisters per 30 days |
XULTOPHY – insulin degludec-liraglutide sol pen-inj 100-3.6 unit-mg/mL | 5 pens per 30 days |
| ZITUVIMET – sitagliptin-metformin hcl tab 50-500mg | 2 tablets |
| ZITUVIMET – sitagliptin-metformin hcl tab 50-1000mg | 2 tablets |
| ZITUVIMET XR – sitagliptin-metformin hcl er tab 50-500mg | 1 tablet |
| ZITUVIMET XR – sitagliptin-metformin hcl er tab 50-1000mg | 2 tablets |
| ZITUVIMET XR – sitagliptin-metformin hcl er tab 100-1000mg | 1 tablet |
| ZITUVIO – sitagliptin 25 mg | 1 tablet |
| ZITUVIO – sitagliptin 50 mg | 1 tablet |
| ZITUVIO – sitagliptin 100 mg | 1 tablet |
| ZUNVEYL – benzgalantamine gluconate tab delayed release 5 mg | 2 tablets |
| ZUNVEYL – benzgalantamine gluconate tab delayed release 10 mg | 2 tablets |
| ZUNVEYL – benzgalantamine gluconate tab delayed release 15 mg | 2 tablets |
| ZYFLO – zileuton tab 600 mg | 4 tablets |
Quantity Limit Exception Criteria:
- The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND
- The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND
- The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR
- If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).
Duration of Approval: 365 days (1 year)
References:
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information:
Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.
March 2025: Criteria update: Added new to market Zunveyl to policy.
March 2025: Criteria update: Added Soliqua and Xultophy to policy.
February 2025: Criteria update: Added new to market Journavx to policy.
January 2025: Criteria update: removed Latuda from policy.
December 2024: Criteria change (Restasis multidose): Updated QL for Restasis multidose to 1 bottle per 28 days.
October 2024: Criteria update: Added new to market Zituvimet and Zituvimet XR to policy.
October 2024: Criteria update: Added Auvi-Q, Epipen, Epipen Jr., Savella, and Symjepi to the policy. Increased Vancocin QL to 8 capsules/day.
August 2024: Criteria update: Added neffy to the policy.
July 2024: Criteria update: Added new to market sitagliptin-metformin to policy.
July 2024: Criteria update: Removed Xiidra from the policy and added Tyrvaya to the policy. Added foot bath and soak products and Qbrexza to the policy.
June 2024: Criteria update: Added Hydrocort 2.5% lotion to policy.
May 2024: Criteria update: Added new to market Rextovy nasal spray to policy.
April 2024: Criteria update: Added Exelon (rivastigmine) capsules to policy.
March 2024: Criteria change: removed QL from stimulant ADHD products
January 2024: Criteria update: Added new to market Insulin Glargine (unbranded Toujeo biosimilar) to policy.
January 2024: Criteria update: Added new to market Zituvio to policy.
November 2023: Criteria update: Added new to market Inpefa 400mg and Relexxii 18mg, 27mg, 36mg, and 54mg strengths to policy.
November 2023: Criteria update: Added new to market Likmez and Glipizide 2.5mg immediate-release tablets to policy.
October 2023: Criteria update: Added new to market Breo Ellipta 50-25mcg/act inhaler to policy.
September 2023: Criteria update: Added new to market Lodoco to policy.
September 2023: Criteria update: Added new to market Airsupra to policy.
September 2023: Criteria update: Added new to market Opvee to policy.
August 2023: Criteria update: Added new to market Breyna (generic Symbicort) to policy.
August 2023: Criteria update: Added new to market Brenzavvy to policy.
August 2023: Criteria update: Added Cordran 0.025% cream to policy. Removed Triderm 0.1% cream from policy.
July 2023: Criteria update: Added topical steroids to policy.
June 2023: Criteria update: Added new to market Inpefa to policy.
May 2023: Criteria update: Removed quantity limits on all HIV medications.
March 2023: Criteria update: Criteria update: Added new to market Rezvoglar, an interchangeable biosimilar to Lantus, to policy.
March 2023: Criteria update: Added new to market Oxybutynin 2.5mg tablets to policy.
March 2023: Criteria update: Added new to market Pradaxa packets to policy.
February 2023: Criteria update: Added Latuda to policy.
January 2023: Criteria update: Added new to market Oxybutynin solution to policy.
January 2023: Criteria update: Added new to market Sunlenca to policy.
January 2023: Criteria update: Added new to market Levemir Flexpen to policy.
December 2022: Criteria update: Added new to market Basaglar Tempo Pen and Methylphenidate ER Osmotic Release (AG Relexxii) 45mg and 63mg to policy.
December 2022: Criteria change: Increased Dulera and Symbicort QL to 3 canisters per 30 days.
November 2022: Criteria update: Added new to market Xelstrym to policy.
October 2022: Criteria update: Corrected Qelbree ER 200mg tablets QL to 3 tablets per day.
September 2022: Criteria update: Added new to market Insulin Degludec (unbranded Tresiba biosimilar) to policy.
September 2022: Criteria update: Added Biktarvy 50-200-25mg to policy. Removed Seebri Neohaler from policy (obsolete). Added ADHD products to policy.
August 2022: Criteria update: Added Annovera and Entadfi to policy.
July 2022: Criteria update: Added Restasis and Xiidra to policy.
June 2022: Criteria update: Added new to market Adlarity to policy.
June 2022: Criteria update: Molnupiravir brand name changed to Lagevrio.
April 2022: Criteria update: Added new to market Triumeq PD to policy.
April 2022: Criteria update: Added Antiretroviral, DPP4, SGLT2, DOAC, OAB products to policy. Removed Arcapta Neohaler, Utibron Neohaler, Zyflo CR (obsolete).
March 2022: Criteria update: Added Descovy 120-15mg tablet to policy.
January 2022: Criteria update: Added molnupiravir and Paxlovid to policy. Clarified Ketorolac tablets QL is 21 tablets per 30 days.
Historical policy changes prior to 2022 can be obtained from BCBSNC Corporate Pharmacy
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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