Quantity Limits: Applied to certain drugs based on the approved dosing limits established during the FDA approval process. Quantity limits are applied to the number of units dispensed for each prescription. If your health plan's formulary guide reflects that there is a Quantity Limit for a specific drug, your physician must submit a prior authorization request form to the health plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense. To obtain the correct form, select the appropriate drug below and follow the instructions at the top of the form.
Quantity Limits © Prime Therapeutics LLC 06/19