Drugs Subject to Quantity Limits

Some prescription drugs may be subject to quantity limits, based on criteria developed by the State Health Plan or its representative. Prior approval is required before excess quantities of certain drugs will be covered. If you need quantities in excess of the limit for a drug that is subject to quantity limits, it is important to make sure your provider has received prior authorization before you go to the pharmacy.

If the drug you are looking for is not listed in the chart below, please check Drugs Requiring Prior Approval and Drugs Requiring Step Therapy. Below is a list of the drugs that require prior authorization for exceeding quantity limits:

Drugs Subject to Quantity Limits	Quantity Limit Criteria	Prior Authorization Review Form
Antiemetics	Cesamet Emend All other antiemetics	Cesamet All other antiemetics
Migraine Medications	Migraine Medications	Brand Imitrex Treximet Zomig/Zomig ZMT Amerge Axert Frova Generic Sumatriptan Maxalt/Maxalt MLT Relpax Migranal NS
Proton Pump Inhibitors	Proton Pump Inhibitors	Aciphex Kapidex Prevacid Brand Prilosec Protonix Zegerid Other PPIs
Sedative Hypnotic Agents	Sedative Hypnotic Agents	Sedative Hypnotic Agents