Health Plan Select follows the Federal Drug Administration’s (FDA) recommendations for allowed drug dosage. Health Plan Select’s Managed Drug Limitation (MDL) program implements drug dispensing limits in accordance with the FDA’s recommendations. The MDL program is designed to ensure that members are receiving the appropriate dosage of medications for specific conditions.
The following medications are subject to MDL. The list is subject to change without notification at the discretion of AAHPS. For an updated list please check the Health Plan Select web site regularly.
Drug |
MDL |
Ambien | 14 tablets/25 days |
Amerge 1mg, 2.5mg | 9 tablets/25 days |
Anzemet | 50 mg: 4 tablets/25days 100 mg: 2 tablets/25 days |
Axert tablets | 6 tablets/25 days |
Cipro XR | 500 mg: 3 tablets/25 days 1000 mg: 14 tablets/25 days |
Cialis | 6 tablets/25 days |
Diflucan 150mg | 2 tablets/25 days |
Frova 2.5 mg tablets | 9 tablets/25 days |
Imitrex Inj. Kits/Vials | 2 kits (4 inj.)/25 days 4 vials/25 days |
Imitrex Nasal spray 5 mg | 12 units (2 packages)/25 days |
Imitrex Nasal spray 20mg | 6 units (1 package)/25 days |
Imitrex Tabs | 9 tablets/25days |
Kytril | 4 tablets/25 days |
Levitra | 6 tablets/25 days |
Maxalt, Maxalt MLT | 6 tablets/25 days |
Migranal NS | 1 kit/25 days |
Oxycontin (all strengths) | 120 tablets/30 days |
Proton Pump Inhibitors (PPI's)Aciphex, Nexium, Prevacid, Prilosec, Protonix, and Omeprazole.Preferred PPI is Prilosec OTC - available without prior authorization; subject to Generic (tier 1) copay. | Limited to an 8 week supply - Prior Authorization required for approval of extended therapy. |
Relenza/Tamiflu | 3 treatments /calendar year (Relenza or Tamiflu or a combination for a total of 3 treatments) |
Relpax tablets | 6 tablets/25 days |
Restoril | 14 capsules/25 days |
Sonata | 14 capsules/25 days |
Viagra | 6 tablets/25 days |
Zofran | 4 mg: 16 tablets/25 days 8 mg: 8 tablets/25 days 24 mg: 6 tablets/25 days 4 mg/15 ml oral soln: one 50 ml bottle/25 days |
Zomig, Zomig ZMT 2.5mg | 6 tablets/25 days |
Zomig, Zomig ZMT 5mg | 3 tablets/25days |
Zomig Nasal | 6 nasal spray units/25 days |
Prilosec
