Responsible Quantity Program* - Health Insurance …

*Refer to the medication guide to determine coverage status of drugs in the program. Certain drugs may be excluded from coverage for certain Blue is an Independent Licensee of the Blue Cross and Blue Shield AssociationResponsible Quantity Program* Current 7/1/18 Quantity Limit Authorization Form Responsible Quantity program limits apply to generic versions of drugs where applicable. Brand/Generic name Strength all strengths if none listed Dispensing Limit Per Month unless otherwise noted Abilify (aripiprazole) 30 tabs Abilify Discmelt 60 tabs Abilify oral solution 750 mL Abstral 120 tabs acetaminophen/caffeine/dihydrocodeine 300 tabs Aciphex (rabeprazole) 20 mg tab 60 tabs Aciphex sprinkles 5 mg, 10 mg sprinkle 60 caps Actiq (fentanyl citrate) 120 units Actonel (risedronate) 5 mg, 30 mg 30 tabs Actonel (risedronate) 35 mg 4 tabs Actonel (risedronate) 150 mg 1 tab Adcirca 60 tabs Adderall (amphetamine-dextroamphetamine) 5 mg, mg, 10 mg, mg, 15 mg, 3

*Refer to the medication guide to determine coverage . status of drugs in the program. Certain drugs may be excluded from coverage for certain members.

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