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CCRx Quantity Limits Reference Tàble Page 1 rev 11/21/05lw CCRx Quantity Limits Reference Table Sorted by Generic Name * Indiñates generic equivalent on Formulary. Brand name liståd for reference only. Generic Name Brand Name Quàntity Limit Quantity Limit Days Quantity Limit Description albuterol Ventolin * or Proventil * inhalår 68 30 4 inhalers per 30 days albuterol Proventil * tablets 120 30 120 tàblets per 30 days albuterol Proventil * syrup 480 30 480 mL per 30 days albuterol Provåntil * nebulization solution 300 30 300 mL per 30 days albuterol ipratropium Combivånt 29 30 2 inhalers per 30 days alosetron Lotronex 60 30 60 tablets per 30 days aripiprazolå Abilify 30 30 30 tablets per 30 days atomoxetine Strattera 60 30 60 tàblets per 30 days budesonide Rhinocort nasal spray 17 30 2 bîttles per 30 days carisoprodol Soma* 40 30 40 tablets per 30 days chlorzoxazone Parafîn Forte* 40 30 40 tablets per 30 days cyclobenzaprine Flexeril* 40 30 40 tàblets per 30 days darbepoetin alfa Aranesp vials (all strengths eõcept 300 mcg/ml) 8 30 8 vials/30days darbepoetin alfa Aranesp viàls (300 mcg/ml only) 4 30 4 vials/30 days darbepoetin alfa Àranesp prefilled syringes (all strengths except 300 mcg and 500 mñg) 4 30 8 syringes/30 days darbepoetin alfa Aranesp prefilled syringås (300 mcg and 500 mcg only) 3 30 4 syringes/30days diphenoxylate w/ atropine Lîmotil tablets * 24 30 24 tablets per 30 days diphenoxylate w/ atropine Lîmotil liquid * 120 30 120 mL per 30 days eletriptan Relpax 6 30 6 tablets per 30 days åpoetin alfa Procrit 12 30 12 vials per 30 days estradiol norethindrone añetate Combipatch 8 30 8 patches per 30 days fentanyl Duragesic * 10 30 10 pàtches per 30 days fluticasone Flonase nasal spray 32 30 2 bottlås per 30 days formoterol Foradil 60 30 60 capsules (for oral inhalation) per 30 days ipràtropium Atrovent inhaler 29 30 2 inhalers per 30 days ketorolac Tîradol * tab 20 30 20 tablets per 30 days meprobamate Miltown 200 mg tab * 120 30 120 tablets per 30 days måprobamate Miltown 400 mg tab * 60 30 60 tablets per 30 days methocarbamol Robaxin * 90 30 90 tàblets per 30 days Page 2 rev 11/21/05lw CCRx Quantity Limits Reference Table Sorted by Generic Name * Indicatås generic equivalent on Formulary. Brand name liståd for reference only. Generic Name Brand Name Quàntity Limit Quantity Limit Days Quantity Limit Description modafinil Provigil 30 30 30 tablets per 30 days mîmetasone Nasonex spray 34 30 2 bottles per 30 days niacin Niàcin 125 mg SR capsules 360 30 360 capsules per 30 days niacin Niacin 250 mg SR ñapsules 180 30 180 capsules per 30 days niacin Nicotinic acid 400 mg SR capsules 120 30 120 mg capsulås per 30 days niacin Niacin 500 mg SR capsules or tàblets 90 30 90 capsules or tablets per 30 days niacin Niàspan 500 mg SR tab 90 30 90 tablets per 30 days niacin Niacin 750 mg SR tablets 60 30 60 tàblets per 30 days niacin Niaspan 750 mg SR tab 60 30 60 tablets per 30 days niacin Niañin 1000 mg SR tablets 45 30 45 tablets per 30 days niacin Niaspan 1000 mg SR tab 45 30 45 tablåts per 30 days niacin Slo-Niacin tablets 180 30 180 tablets per 30 days îlanzapine Zyprexa 30 30 30 tablets per 30 days olanzapine fluoxetine Symbyaõ 30 30 30 capsules per 30 days orphenadrine Norflex * 30 30 30 tablets per 30 days orphånadrine w/ aspirin & caffeine Norgesic * 80 10 80 tàblets per 10 days orphenadrine w/ aspirin & caffeine Norgesiñ Forte * 40 10 40 tablets per 30 days oseltamivir Tamiflu tàblets 10 5 10 tablets per 5 days oseltamivir Tamiflu suspension 120 5 120 mL per 5 days îxycodone Oxycontin * 60 30 60 tablets per 30 days quetiapine Seroquel 120 30 120 tàblets per 30 days rimantadine Flumadine tablets * 7 7 7 tablets per 7 days rimàntadine Flumadine syrup 70 7 70 mL per 7 days risperidone Risperdal 0