Until Daily Max Pkg GENERIC DRUG NAME and STRENGTHS …

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GENERIC DRUG NAME and STRENGTHS

ACNE AGENTS (Topical)

ADAPALENE 0.1% CREAM 45UNIT PACKAGES ADAPALENE 0.1% GEL ADAPALENE 0.1% LOTION 59ML ADAPALENE 0.3% GEL PUMP 45GRAM ADAPALENE-BENZOYL PEROXIDE 0.1-2.5% GEL 45GRAM CLINDAMYCIN PHOS/BENZOYL PEROX GEL 25, 50GRAMS

ALZHEIMER'S AGENTS

DONEPEZIL HCL 5, 10 and 23MG TABLET GALANTAMINE HBR 4, 8 and 12MG TABLET GALANTAMINE HBR 8, 16 and 24MG CAPSULE GALANTAMINE HBR 4MG/ML ORAL SOLUTION 100ML MEMANTINE HCL 5MG TABLET MEMANTINE HCL 10MG TABLET MEMANTINE HCL 7, 14, 21 and 28MG CAPSULE MEMANTINE HCL 10MG/5ML SOLUTION MEMANTINE HCL TITRATION PACK MEMANTINE HCL 5-10MG TITRATION PACK 49 TABLETS RIVASTIGMINE TARTRATE 1.5MG CAPSULE RIVASTIGMINE TARTRATE 3, 4.5 and 6MG CAPSULE RIVASTIGMINE 4.6, 9.5 and 13.3MG/24HR PATCH

ANALGESICS, NARCOTIC - LONG ACTING (Non-parenteral)

BUPRENORPHINE PATCHES HYDROCODONE BITARTRATE 10-120MG HYDROMORPHONE HCL 8, 12 and 16MG TABLET MORPHINE SULFATE ER 30, 45, 60, 75, 90, 120MG MORPHINE SULFATE/NALTREXONE 20-0.8MG CAPSULE MORPHINE SULFATE/NALTREXONE 30-1.2MG CAPSULE OXYCODONE HCL 100% POWDER - All SIZES OXYCODONE HCL ACETAMINOPHEN 7.5-325MG TABLET OXYCODONE HCL ER TABLETS OXYCODONE HCL XR 60 and 80MG TABLET OXYMORPHONE HCL 5, 7.5, 10, 15, 20, 30, and 40MG TABLET OXYMORPHONE HCL ER 5, 10, 20 and 40MG TABLET TAPENTADOL HCL ER 50, 100, 150, 200 and 250MG TABLET TRAMADOL HCL 100, 200 and 300MG TABLETS or CAPSULES TRAMADOL HCL/ACETAMINOPHEN 37.5-325 TABLET

ANALGESICS, NARCOTIC - SHORT ACTING (Non-parenteral)

ACETAMINOPHEN WITH CODEINE 120-12MG/5ML SOLUTION ACETAMINOPHEN WITH CODEINE 300/12.5ML SOLUTION

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

v2015.1a

BRAND NAME

BRAND

DIFFERIN DIFFERIN DIFFERIN DIFFERIN EPIDUO BENZACLIN

BRAND

ARICEPT / ARICEPT ODT RAZADYNE RAZADYNE ER RAZADYNE NAMENDA NAMENDA NAMENDA XR NAMENDA NAMENDA XR NAMENDA EXELON EXELON / RIVASTIGMINE EXELON

BRAND

BUTRANS HYSINGLA/ZOHYDRO ER EXALGO ER AVINZA EMBEDA ER EMBEDA ER GENERIC ONLY XARTEMIS XR OXYCONTIN OXYCONTIN OPANA ER OPANA ER NUCYNTA ER CONZIP ULTRACET

BRAND

GENERIC ONLY GENERIC ONLY

Units

Units

90 90 59 45 45 50

Units

200

28 49

Units

4 60 60

56

40

Units

600 300

Until Refill

Until Refill

30 30 30 30 30 30

Until Refill

30

365

Until Refill

30 30 30

365

30

Until Refill

30 30

Daily Dose

Daily Dose

Daily Dose

1 2 1

1 2 1 10

1 2 1

Daily Dose

2 1 2 2 1 0.5

2 2 2 2 2 1

Daily Dose

Max Days

Max Days

Max Days

30 28

Max Days

Max Days

Refills

Pkg Bill

Refills Pkg Bill

Y Y Y Y Y Y

Refills Pkg Bill

0

Y

0

Y

Y

Refills Pkg Bill

Refills Pkg Bill

Age

Age

Age

Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45 Min 45

Age

Age

Gender Effective Date

Gender Gender Gender

Gender

Effective Date

07/01/2013 07/01/2013 10/01/2013 10/01/2013 10/01/2013 07/01/2013

Effective Date

07/01/2013 07/01/2013 07/01/2013 10/01/2013 03/01/2014 10/01/2013 03/01/2014 10/01/2013 10/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

10/01/2013 01/01/2015 10/01/2013 04/15/2014 03/25/2015 03/25/2015 09/01/2014 04/01/2014 09/01/2014 08/16/2013 10/01/2013 10/01/2013 10/01/2013 07/01/2013 10/01/2013

Effective Date

10/01/2013 10/01/2013

Inclusion on this list does not guarantee coverage

The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

1

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

ACETAMINOPHEN WITH CODEINE 300-15MG TABLET ACETAMINOPHEN WITH CODEINE 360-36MG/15ML SOLUTION ACETAMINOPHEN WITH CODEINE SUSPENSION ACETAMINOPHEN-COD #3 300MG-30MG & 60MG TABLET BUTALBIT/ACETAMIN/CAFF/CODEINE CAPSULES & TABLETS BUTORPHANOL TARTRATE 10 MG/ML SPRAY 2.5ML CODEINE SULFATE 15, 30 and 60MG TABLET CODEINE/BUTALBITAL/ASA/CAFFEIN 50-325-40MG CAPSULE DIHYDROCODEIN ACETAMINOPH CAFF 32-713-60MG TABLET DIHYDROCODEINE/ASPIRIN/CAFFEIN 16-356-30 CAPSULE DIHYDROCODEINE BUTALBITAL/ACETMAINPHONIE/CAFFEINE FENTANYL SPRAYS ALL STRENGTHS FENTANYL 12, 25, 50, 75 and 100MCG/HR PATCH FENTANYL CITRATE TABLETS ALL STRENGTHS FENTANYL CITRATE LOZENGES ALL STRENGTHS FENTANYL CITRATE NASAL SPRAYS ALL STRENGTHS FENTANYL CITRATE SUBLINGUAL TABLETS ALL STRENGTHS HYDROCODONE-ACETAMINOPHEN 2.5-108/5ML, 5-217/5ML HYDROCODONE/ACETAMINOPHEN SOLUTION 5ML HYDROCODONE/ACETAMINOPHEN 15ML SOLUTIONS HYDROCODONE BIT/ACETAMINOPHEN TABLETS ALL STRENGHTS HYDROCODONE/IBUPROFEN TABLETS HYDROMORPHONE HCL 1MG/ML SOLUTION HYDROMORPHONE HCL 2, 4 and 8MG TABLET IBUPROFEN/OXYCODONE HCL 5-400MG TABLET LEVORPHANOL TARTRATE 2MG TABLET MEPERIDINE 50MG/5ML SOLUTION MEPERIDINE HCL 50 and 100MG TABLET MORPHINE SULFATE 15 and 30MG TABLET OXYCODONE HCL CAPSULES or TABLETS ALL STRENGTHS OXYCODONE HCL/ACETAMINOPHEN TABLETS ALL STRENGTHS OXYCODONE HCL/ACETAMINOPHEN 5-325MG ORAL SOLUTION OXYMORPHONE HCL 5 and 10MG TABLET PENTAZOCINE HCL/ACETAMINOPHEN 25-650MG TABLET PENTAZOCINE HCL/NALOXONE HCL 2.5-500MG TABLET TAPENTADOL HCL 50, 75 and 100MG TABLET TRAMADOL HCL 50MG TABLET

ANDROGENIC AGENTS

TESTOSTERONE 1% & 1.62% GEL 2.5G PACKET TESTOSTERONE 1% GEL 5G PACKET TESTOSTERONE 1.62% GEL 1.25G PACKET TESTOSTERONE 2, 2.5, 4 and 5MG/24HR PATCH TESTOSTERONE 30MG SOLUTION 90ML TESTOSTERONE 1% GEL PUMP

GENERIC ONLY

120 30

GENERIC ONLY

360 30

CAPITAL W-CODEINE

1200 30

TYLENOL 3

120 30

FIORICET WITH CODEINE

120 30

GENERIC ONLY

2.5 30

Y

GENERIC ONLY

120 30

FIORINAL

120 30

PANLOR SS / ZERLOR

120 30

SYNALGOS-DC

120 30

TREZIX

120 30

SUBSYS

30 30

Y

DURAGESIC

10 30

FENTORA

120 30

ACTIQ

120 30

LAZANDA

1 30

ABSTRAL

120 30

GENERIC ONLY

30 2

GENERIC ONLY

600 30

30 2

HYCET/LORTAB/ZAMICET

1800 30

30 2

VICODIN / XODOL

120 30

30 2

IBUDONE / REPRAXIN

120 30

30 2

DILAUDID

1200 30

DILAUDID

120 30

GENERIC ONLY

120 30

GENERIC ONLY

120 30

MEPERIDINE

600 30

DEMEROL / MEPERITAB

120 30

GENERIC ONLY

120 30

ROXICODONE

120 30

PERCOCET / PERCODAN / ENDOCET

120 30

ROXICET

1800 30

OPANA IR / OPANA

120 30

GENERIC ONLY

120 30

GENERIC ONLY

120 30

NUCYNTA

180 30

ULTRAM / RYBIX ODT

240 30

BRAND

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

ANDROGEL

75 30

Y

ANDROGEL

150 30

Y

ANDROGEL

37.5 30

Y

ANDRODERM

1 60

AXIRON

90 30

Y

ANDROGEL

150 30

Y

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

v2015.1a

Gender

M M M M M M

08/16/2013 10/01/2013 10/01/2013 08/16/2013 08/16/2013 07/01/2013 08/16/2013 08/16/2013 08/16/2013 08/16/2013 01/01/2015 09/01/2014 07/01/2013 08/16/2013 07/01/2013 10/01/2013 08/16/2013 08/01/2014 08/01/2014 08/01/2014 08/01/2014 08/01/2014 10/01/2013 08/16/2013 08/16/2013 08/16/2013 10/01/2013 08/16/2013 08/16/2013 08/16/2013 08/16/2013 07/01/2013 07/01/2013 10/01/2013 08/16/2013 10/01/2013 10/01/2013

Effective Date

07/01/2013 07/01/2013 07/01/2013 08/01/2014 10/01/2013 07/01/2013

2

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

TESTOSTERONE 1.62% GEL PUMP 75 ML TESTOSTERONE 10MG GEL PUMP 60GRAM

ANGIOTENSIN MODULATORS

ALISKIREN/AMLODIPINE BESYLATE TABLETS ALL STRENGTHS ALISKIREN/AMLODIPINE/HCTZ TABLETS ALL STRENGTHS ALISKIREN HEMIFUMARATE 150 and 300MG TABLET ALISKIREN/HCT TABLETS ALL STRENGTHS AMLODIPINE BESYLATE /OLMESARTAN MED TABLETS ALL STRENGTHS AMLODIPINE BESYLATE/BENAZEPRIL CAPSULES ALL STRENGTHS AMLODIPINE/VALSARTAN TABLETS ALL STRENGTHS AMLODIPINE/VALSARTAN/HCTZ TABLETS ALL STRENGTHS AZILSARTAN MED/CHLORTHALIDONE TABLETS ALL STRENGTHS AZILSARTAN MEDOXOMIL 40 and 80MG TABLET BENAZEPRIL HCL 5, 10 and 20MG TABLET BENAZEPRIL HCL 40MG TABLET BENAZEPRIL/HCT TABLETS ALL STRENGTHS CANDESARTAN CILEXETIL 4, 8 and 16MG TABLET CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET CAPTOPRIL 12.5, 25 and 50MG TABLET CAPTOPRIL 100MG TABLET CAPTOPRIL/HCT TABLETS ALL STRENGTHS ENALAPRIL MALEATE 2.5, 5 and 10MG TABLET ENALAPRIL MALEATE 20MG TABLET ENALAPRIL/HCT 10-25MG TABLET ENALAPRIL/HCT 12.5MG TABLET EPROSARTAN MESYLATE 600MG TABLET EPROSARTAN/HCT 600-12.5 and 600-25MG TABLET FOSINOPRIL SODIUM 10 and 20MG TABLET FOSINOPRIL SODIUM 40MG TABLET IRBESARTAN 75, 150 and 300MG TABLET IRBESARTAN/HCT 150-12.5 and 300-12.5MG TABLET LISINOPRIL 2.5, 5, 10, 20 and 30MG TABLET LISINOPRIL 40MG TABLET LISINOPRIL/HCT 10-12.5 and 20-12.5MG TABLET LISINOPRIL/HCT 20-25MG TABLET LOSARTAN POTASSIUM 25 and 50MG TABLET LOSARTAN POTASSIUM 100MG TABLET LOSARTAN/HCT 50-12.5, 100-12.5 and 100-25MG TABLET MOEXIPRIL HCL 7.5MG TABLET MOEXIPRIL HCL 15MG TABLET MOEXIPRIL/HCT 7.5-12.5, 15-12.5 and 15-25MG TABLET OLMESARTAN MED/AMLODIPINE/HCTZ TABLETS ALL STRENGTHS OLMESARTAN MEDOXOMIL 5MG TABLET OLMESARTAN/HCT TABLETS ALL STRENGTHS

ANDROGEL FORTESTA

BRAND

TEKAMLO AMTURNIDE TEKTURNA TEKTURNA HCT AZOR LOTREL EXFORGE EXFORGE HCT EDARBYCLOR EDARBI LOTENSIN LOTENSIN LOTENSIN HCT ATACAND ATACAND HCT GENERIC ONLY GENERIC ONLY GENERIC ONLY VASOTEC VASOTEC VASERETIC GENERIC ONLY TEVETEN TEVETEN HCT GENERIC ONLY GENERIC ONLY AVAPRO AVALIDE PRINIVIL/ZESTRIL PRINIVIL/ZESTRIL PRINZIDE / ZESTORETIC ZESTORETIC COZAAR COZAAR HYZAAR UNIVASC UNIVASC UNIRETIC TRIBENZOR BENICAR BENICAR HCT

75 30

Y

60 30

Y

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

1

1

1

1

1

1

1

1

1

1

1

2

1

1

1

1

3

1

1

2

2

1

1

1

1

2

1

1

1

2

1

2

2

1

1

1

2

1

1

1

1

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

v2015.1a

M M

Gender

07/01/2013 10/01/2013

Effective Date

07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013

3

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

PERINDOPRIL ERBUMINE 2 and 4MG TABLET PERINDOPRIL ERBUMINE 8MG TABLET QUINAPRIL HCL 5, 10 and 20MG TABLET QUINAPRIL HCL 40MG TABLET QUINAPRIL HCTZ 10-12.5, 20-12.5 and 20-25MG TABLET RAMIPRIL 1.25, 2.5 and 5MG CAPSULE or TABLET RAMIPRIL 10MG TABLET or CAPSULE TELMISARTAN 80MG TABLET TELMISARTAN/AMLODIPINE TABLET ALL STRENGTHS TELMISARTAN/HYDROCHLOROTHIAZID 80-12.5MG TABLET TRANDOLAPRIL 1 and 2MG TABLET TRANDOLAPRIL 4MG TABLET TRANDOLAPRIL/VERAPAMIL HCL TABLET ALL STRENGTHS VALSARTAN 40, 80 and 160MG TABLET VALSARTAN/HCT TABLET ALL STRENGTHS

ANTI-ALLERGENS

MIXED POLLENS ALLREGAN EXTRACT STARTER PACK MIXED POLLENS ALLREGAN EXTRACT 300MG SUBLINGUAL TABLET

ANTIANGINAL & ANTI-ISCHEMIC

RANOLAZINE 500 and 1000MG TABLET

ANTIBIOTICS, GI

NITAZOXANIDE 100MG/5ML SUSPENSION NITAZOXANIDE 500MG TABLET RIFAXIMIN 200MG TABLET RIFAXIMIN 550MG TABLET TINIDAZOLE 250MG TABLET TINIDAZOLE 500MG TABLET VANCOMYCIN HCL 125 and 250MG CAPSULE

ANTIBIOTICS, INHALED

AZTREONAM LYSINE 75MG/ML INHAL SOLUTION 84ML VIAL TOBRAMYCIN IN 0.225% NACL 300MG/5ML SOLUTION

ANTICOAGULANTS

DABIGATRAN ETEXILATE MESYLATE CAPSULES ALL STRENGTHS RIVAROXABAN 10MG TABLET RIVAROXABAN 15MG TABLET RIVAROXABAN 20MG TABLET

ANTICONVULSANTS

CLOBAZAM 5, 10, 20MG TABLET DIAZEPAM 2, 5 and 10MG TABLET LAMOTRIGINE 25MG TABLET, 35 DOSE STARTER KIT LAMOTRIGINE 25 (84)-100, 98 DOSE STARTER KIT

ACEON ACEON ACCUPRIL ACCUPRIL ACCURETIC ALTACE ALTACE MICARDIS TWYNSTA MICARDIS HCT MAVIK MAVIK TARKA DIOVAN DIOVAN HCT

BRAND

ORALAIR ORALAIR

BRAND

RANEXA

BRAND

ALINIA ALINIA XIFAXAN XIFAXAN TINDAMAX TINDAMAX VANCOCIN HCL

BRAND

CAYSTON TOBI

BRAND

PRADAXA XARELTO XARELTO XARELTO

BRAND

ONFI VALIUM LAMICTAL TAB START KIT (BLUE) LAMICTAL TAB START KIT (GREEN)

1

2

1

2

1

1

2

1

1

1

1

2

1

1

1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

3 365

Y

30 1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

2

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

180 30

6 30

9 30

3

2

24 30

5

12 30

5

14 1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

3

10

Y

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

2

30 30 1

1

42 30 2

1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

2

4

35 365

0

Y

98 365

0

Y

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

v2015.1a

Gender Gender Gender

Gender Gender Gender

07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

01/01/2015 01/01/2015

Effective Date

07/01/2013

Effective Date

07/01/2013 07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

10/01/2013 10/01/2013

Effective Date

07/01/2013 10/01/2013 10/01/2013 10/01/2013

Effective Date

09/01/2014 07/01/2013 12/01/2014 12/01/2014

4

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

LAMOTRIGINE 25 (42)-100, 49 DOSE STARTER KIT LAMOTRIGINE 25-50-100, 35 DOSE STARTER KIT LAMOTRIGINE 25 (21)-50, 28 DOSE STARTER KIT LAMOTRIGINE 50-(42)-100, 56 DOSE STARTER KIT LAMOTRIGINE 25 (21)-50, 28 DOSE STARTER KIT LAMOTRIGINE 50-100-200, 35 DOSE STARTER KIT LAMOTRIGINE 25-50-100, 35 DOSE STARTER KIT

ANTIDEPRESSANTS, OTHER

BUPROPION HBR 174, 348 and 522MG TABLET BUPROPION HCL 75MG TABLET BUPROPION HCL 100MG TABLET BUPROPION HCL 450MG TABLET BUPROPION HCL SR 100 and 200MG TABLET BUPROPION HCL XL 150MG TABLET BUPROPION HCL XL 300MG TABLET DESVENLAFAXINE SUCCINATE 50 and 100MG TABLET IMIPRAMINE HCL 10MG TABLET IMIPRAMINE HCL 25MG TABLET IMIPRAMINE HCL 50MG TABLET IMIPRAMINE PAMOATE 100MG CAPSULE IMIPRAMINE PAMOATE 75, 125 and 150MG CAPSULE ISOCARBOXAZID 10MG TABLET MIRTAZAPINE 7.5, 15, 30 and 45MG TABLET & ODT TABLET NEFAZODONE HCL 50, 100, 150, 200 and 250MG TABLET PHENELZINE SULFATE 15MG TABLET SELEGILINE 6, 9 and 12MG/24HOUR PATCH TRANYLCYPROMINE SULFATE 10MG TABLET TRAZODONE HCL 50 and 100MG TABLET TRAZODONE HCL 150MG TABLET TRAZODONE HCL 150MG TABLET TRAZODONE HCL 300MG TABLET VENLAFAXINE HCL 25, 37.5, 50, 75 and 100MG TABLET VENLAFAXINE HCL ER TABLETS and XR CAPSULES ALL STRENGTHS VILAZODONE HYDROCHLORIDE 10, 20 and 40MG TABLET VILAZODONE HYDROCHLORIDE TITRATION PACK

ANTIDEPRESSANTS, SSRIs

CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION CITALOPRAM HYDROBROMIDE 10 and 20MG TABLET CITALOPRAM HYDROBROMIDE 40MG TABLET ESCITALOPRAM OXALATE 5MG/5ML SOLUTION ESCITALOPRAM OXALATE 5, 10 and 20MG TABLET FLUOXETINE HCL 20MG/5ML SOLUTION FLUOXETINE HCL 10MG CAPSULE FLUOXETINE HCL 20MG CAPSULE

LAMICTAL TB START KIT (ORANGE)

49 365

0

Y

LAMICTAL ODT START KIT (ORANGE)

35 365

0

Y

LAMICTAL ODT START KIT BLUE)

28 365

0

Y

LAMICTAL ODT START KIT GREEN)

56 365

0

Y

LAMICTAL XR START KIT BLUE)

28 365

0

Y

LAMICTAL XR START KIT (GREEN)

35 365

0

Y

LAMICTAL XR START KIT (ORANGE)

35 365

0

Y

BRAND

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

APLENZIN

1

BUDEPRION / WELLBUTRIN

6

BUDEPRION / WELLBUTRIN

3

FORFIVO XL

1

WELLBUTRIN SR

2

BUDEPRION / WELLBUTRIN

3

BUDEPRION / WELLBUTRIN

1

PRISTIQ ER

1

TOFRANIL

3

TOFRANIL

3

TOFRANIL

4

TOFRANIL-PM

2

TOFRANIL-PM

1

MARPLAN

4

REMERON

1

GENERIC ONLY

2

NARDIL

6

EMSAM

1

PARNATE

6

GENERIC ONLY

3

GENERIC ONLY

2

OLEPTRO ER

1

GENERIC ONLY

1

GENERIC ONLY

3

EFFEXOR XR

1

VIIBRYD

1

VIIBRYD

30 365

Y

BRAND

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

GENERIC ONLY

20

CELEXA

1.5

CELEXA

1

LEXAPRO

20

LEXAPRO

1

PROZAC

20

PROZAC

1

PROZAC

3

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

v2015.1a

Gender Gender

12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014

Effective Date

07/01/2013 12/01/2014 12/01/2014 07/01/2013 12/01/2014 12/01/2014 12/01/2014 07/01/2013 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014 07/01/2013 12/01/2014 12/01/2014 12/01/2014 07/01/2013 12/01/2014 12/01/2014 12/01/2014 12/01/2014 12/01/2014

Effective Date

07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 09/01/2014 07/01/2013

5

FLUOXETINE HCL 40MG CAPSULE FLUOXETINE HCL 90MG CAPSULE FLUOXETINE HCL 10, 20 and 60MG TABLET FLUVOXAMINE MALEATE 100MG TABLET FLUVOXAMINE MALEATE ER 100 and 150MG CAPSULE PAROXETINE HCL 10MG/5ML SOLUTION PAROXETINE HCL 10 20 and 40MG TABLET PAROXETINE HCL CR 12.5 and 37.5MG TABLET PAROXETINE HCL CR 25MG TABLET PAROXETINE MESYLATE 10, 20 and 40MG TABLET PAROXETINE MESYLATE 30MG TABLET SERTRALINE HCL 20MG/ML ORAL CONC SERTRALINE HCL 25 and 50MG TABLET SERTRALINE HCL 100MG TABLET

ANTIEMETICS

APREPITANT 40, 80 and 125MG CAPSULE APREPITANT TRIFOLD PACK - 3 CAPSULES PER PACK DOLASETRON MESYLATE 50 and 100MG TABLET DRONABINOL 2.5, 5 and 10MG CAPSULE GRANISETRON 3.1MG/24HR PATCH GRANISETRON HCL 1MG TABLET GRANISETRON HCL 2MG/10ML SOLUTION 30ML BOTTLE NABILONE 1MG CAPSULE ONDANSETRON 4 and 8MG SOLUBLE FILM ONDANSETRON & HCL 4, 8MG TABLETS ONDANSETRON HCL 4MG/5ML ORAL SOLUTION 50ML ONDANSETRON HCL 24MG TABLET PROMETHAZINE VC-CODEINE SYRUP 6.25-5-10 SYRUP PROMETHAZINE HCL/CODEINE 6.25-10/5ML SYRUP

ANTIFUNGALS (Oral)

FLUCONAZOLE 50, 100, 150 and 200MG TABLET GRISEOFULVIN,MICROSIZE 125MG/5ML SUSPENSION GRISEOFULVIN,MICROSIZE 500MG TABLET ITRACONAZOLE 100MG CAPSULE ITRACONAZOLE 200MG TABLET MICONAZOLE 50MG BUCCAL TABLET NYSTATIN 100K UNITS/ML SUSPENSION NYSTATIN 500K UNITS TABLET POSACONAZOLE 40MG/ML SUSPENSION 105ML BOTTLE TERBINAFINE HCL 125MG GRANULES PACKET TERBINAFINE HCL 187.5MG GRANULES PACKET TERBINAFINE HCL 250MG TABLET

ANTIFUNGALS (Topical)

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

v2015.1a

PROZAC PROZAC WEEKLY SARAFEM GENERIC ONLY LUVOX CR PAXIL PAXIL PAXIL CR PAXIL CR PEXEVA PEXEVA ZOLOFT ZOLOFT ZOLOFT

BRAND

EMEND EMEND ANZEMET MARINOL SANCUSO GENERIC ONLY GRANISOL CESAMET ZUPLENZ ZOFRAN / ZOFRAN ODT ZOFRAN GENERIC ONLY GENERIC ONLY PHENGRAN

BRAND

DIFLUCAN GENERIC ONLY GRIFULVIN V SPORANOX ONMEL ORAVIG NILSTAT MYCOSTATIN NOXAFIL LAMISIL LAMISIL LAMISIL

BRAND

2

4 30

Y

1

3

2

20

1.5

1

2

1

2

10

1.5

2

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

3 30

3 30

Y

5 30

2

1 30

10 30

30 30

2

10 30

30 30

50 30

6 30 1

240 30

240 30

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

2 30

40

2

2

1

14 30

240 30

4

105 30

2

1

1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

Age

Age

Max 6

Age

Gender Gender Gender

10/01/2013 07/01/2013 09/01/2014 10/01/2013 10/01/2013 07/01/2013 10/01/2013 10/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

10/01/2013 10/01/2013 10/01/2013 07/01/2013 10/01/2013 07/01/2013 10/01/2013 07/01/2013 10/01/2013 07/01/2013 10/01/2013 10/01/2013 07/01/2013 10/01/2013

Effective Date

10/01/2013 10/01/2013 10/01/2013 10/01/2013 10/01/2013 10/01/2013 07/14/2014 10/01/2013 10/01/2013 10/01/2013 10/01/2013 07/01/2013

Effective Date

6

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

CICLOPIROX 8% SOLUTION 6.6ML CICLOPIROX/URE/CAMPH/MENTH/EUC 8% KIT 34.6ML MICONAZOLE NITRATE KITS

ANTIHISTAMINES, MINIMALLY SEDATING

CETIRIZINE HCL 5 and 10MG CHEWABLE TABLETS, LIQUID GELS or TABLETS CETIRIZINE HCL 5MG/5ML SOLUTION CETIRIZINE HCL 1MG/ML SYRUP CETIRIZINE HCL/PSEUDOEPHEDRINE 5-120MG TABLET DESLORATADINE 2.5MG/5ML SYRUP DESLORATADINE 2.5 and 5MG ODT or TABLETS DESLORATADINE/PSEUDOEPHEDRINE 12HR TABLET FEXOFENADINE HCL 180MG TABLET LEVOCETIRIZINE DIHYDROCHLORIDE 2.5MG/5ML SOLUTION LEVOCETIRIZINE DIHYDROCHLORIDE 5MG TABLET LORATADINE 10MG ODT or TABLETS LORATADINE/PSEUDOEPHEDRINE 12HR TABLET LORATADINE/PSEUDOEPHEDRINE 24HR TABLET

ANTIHYPERTENSIVES, SYMPATHOLYTICS

CLONIDINE 0.1MG PATCH / 1 PATCH CLONIDINE 0.2MG PATCH / 2 PATCH CLONIDINE 0.3MG PATCH / 3 PATCH CLONIDINE HCL 0.1 and 0.2 MG TABLET CLONIDINE HCL 0.3 MG TABLET

ANTIHYPERURICEMICS

COLCHICINE 0.6MG TABLET FEBUXOSTAT 40 and 80MG TABLET

ANTIMIGRAINE AGENTS, OTHER

DICLOFENAC POTASSIUM 50MG POWDER PACKET

ANTIMIGRAINE AGENTS, TRIPTANS

ALMOTRIPTAN MALATE 6.25 and 12.5MG TABLET DIHYDROERGOTAMINE MESYLATE 4MG/ML SPRAY ELETRIPTAN HBR 20 and 40MG TABLET FROVATRIPTAN SUCCINATE 2.5MG TABLET NARATRIPTAN HCL 1 and 2.5MG TABLET RIZATRIPTAN BENZOATE 5 and 10MG TABLET SUMATRIPTAN 5 and 20MG NASAL SPRAY SUMATRIPTAN SUCC/NAPROXEN SOD 85-500MG TABLET SUMATRIPTAN SUCCINATE 25, 50 and 100MG TABLET SUMATRIPTAN SUCCINATE 4 and 6MG/0.5ML REFILL CARTRIDGES SUMATRIPTAN SUCCINATE 6MG/0.5ML REFILL CARTRIDGES SUMATRIPTAN SUCCINATE 4 and 6MG/0.5ML INJECTION SUMATRIPTAN SUCCINATE 6MG/0.5ML SYRINGE

CICLODAN / PENLAC CICLODAN MONISTAT 3

BRAND

ZYTREC GENERIC ONLY CHILDREN'S ZYRTEC ZYRTEC-D / CETIRI-D CLARINEX CLARINEX CLARINEX-D 12 HR ALLEGRA XYZAL XYZAL ALAVERT / CLARITIN ALAVERT / CLARITIN-D CLARITIN-D

BRAND

CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 CATAPRES CATAPRES

BRAND

COLCRYS ULORIC

BRAND

CAMBIA

BRAND

AXERT MIGRANAL RELPAX FROVA AMERGE MAXALT IMITREX TREXIMET IMITREX IMITREX IMITREX ALSUMA / IMITREX SUMAVEL DOSEPRO

6.6 30

1

Y

34.6 30

1

Y

1 30

Y

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

1

150 30

150 30

2

10

1

2

1

150 30

1

1

2

1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

4 30

4 30

Y

4 30

Y

10

8

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

20 90

1

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

9 30

Y

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

6 30

8 30

Y

6 30

9 30

9 30

9 30

6 30

9 30

9 30

2 30

2 30

2 30

Y

2 30

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

v2015.1a

Gender

Gender Gender Gender Gender

10/01/2013 10/01/2013 10/01/2013

Effective Date

07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

10/01/2013 07/01/2013

Effective Date

07/01/2013

Effective Date

07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013 07/01/2013 10/01/2013

7

SUMATRIPTAN SUCCINATE 6MG/0.5ML VIAL ZOLMITRIPTAN 2.5MG TABLET ZOLMITRIPTAN 5MG TABLET ZOLMITRIPTAN 5MG NASAL SPRAY

ANTIPARASITICS, TOPICAL

BENZYL ALCOHOL 5% LOTION LINDANE 1% LOTION or SHAMPOO MALATHION 0.5% LOTION PERMETHRIN 5% CREAM 60GRAM JAR

ANTIPARKINSON'S AGENTS (Oral)

RASAGILINE MESYLATE 0.5 and 1MG TABLET ROPINIROLE HCL 2, 4, 6 and 8MG TABLET ROPINIROLE HCL ER 12MG TABLET ROTIGOTINE 24HR PATCHS ALL STRENGTHS SELEGILINE HCL 1.25MG ODT TABLET

ANTIPSYCHOTICS, ATYPICAL

ARIPIPRAZOLE DISCMELT TABLETS ARIPIPRAZOLE TABLETS ARIPIPRAZOLE 1MG/ML SOLUTION ARIPIPRAZOLE 9.7MG/1.3ML VIAL ARIPIPRAZOLE ER VIAL ASENAPINE MALEATE 5, 10MG TAB SUBLINGUAL CHLORPROMAZINE TABLETS CLOZAPINE 12.5, 100MG ODT CLOZAPINE 25, 50, 100MG TABLET CLOZAPINE 200 MG TABLET CLOZAPINE 25, 150, 200MG ODT FLUPHENAZINE 1 MG TABLET FLUPHENAZINE 2.5, 5, 10MG TABLET FLUPHENAZINE 0.5 MG/ML CONC FLUPHENAZINE 5 MG/ML CONC ILOPERIDONE TABLETS ILOPERIDONE 1-2-6MG TAB PACK LOXAPINE CAPSULES LOXAPINE 10MG INHALATION POWDER LURASIDONE HCL 20, 40, 60, 120MG TABLETS LURASIDONE HCL 80 MG TABLET OLANZAPINE TABLETS ALL STRENGTHS OLANZAPINE ODT TABLETS ALL STRENGTHS OLANZAPINE-FLUOXETINE TABLETS ALL STRENGTHS PALIPERIDONE ER 1.5, 3, 9MG TABLETS PALIPERIDONE ER 6 MG TABLET PERPHENAZINE 2, 4, 8MG TABLET

BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID DRUG QUANTITY LIMITS

IMITREX ZOMIG / ZOMIG ZMT ZOMIG / ZOMIG ZMT ZOMIG

BRAND

ULESFIA GENERIC ONLY OVIDE ACTICIN

BRAND

AZILECT REQUIP XL REQUIP XL NEUPRO ZELAPAR

BRAND

ABILIFY ABILIFY ABILIFY ABILIFY ABILIFY MAINTENA SAPHRIS GENERIC ONLY FAZALCO GENERIC ONLY GENERIC ONLY FAZALCO GENERIC ONLY GENERIC ONLY GENERIC ONLY GENERIC ONLY FANAPT FANAPT GENERIC ONLY ADASUVE LATUDA LATUDA ZYPREXA ZYPREXA ZYDIS SYMBYAX INVEGA ER INVEGA ER GENERIC ONLY

2.5 30

6 30

3 30

6 30

Y

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

681 30

Y

60 30

Y

59 30

Y

60 14

Y

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

1

1

2

1

2

Units

Until Refill

Daily Dose

Max Days

Refills Pkg Bill

Age

1

1

150 30

1.3 30

1 30

2

3

2

2

4

4

2

1

8

2

2

1 999

2

1 30

Y

1

2

1

1

1

1

2

3

Inclusion on this list does not guarantee coverage The listing of a drug indicates both the brand and generic form - Refer to the PDL for inclusion information

Medicaid MCOs are required to follow only the limits that are specified on the PDL

v2015.1a

Gender Gender Gender

10/24/2013 07/01/2013 07/01/2013 07/01/2013

Effective Date

10/01/2013 07/01/2013 07/01/2013 04/15/2014

Effective Date

07/01/2013 07/01/2013 10/01/2013 07/01/2013 07/01/2013

Effective Date

04/01/2014 04/01/2014 04/01/2014 04/01/2014 04/01/2014 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 09/01/2014 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015 08/01/2015

8

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