What You Should Know about Dispensing Limits

• Your prescription drug coverage includes limits on certain medications.
• Limits may include quantity of covered medication per prescription or quantity of covered medication in a given time period.
• These limits reflect generally accepted pharmaceutical manufacturers' guidelines.
• They also help encourage medication use as intended by the U.S. Food and Drug Administration (FDA).
• For more information, view the Dispensing Limits for your Drug List:

• Metallic Drug List Dispensing Limits 
• Basic Drug List Dispensing Limits 
• Enhanced Drug List Dispensing Limits 
• Balanced Drug List Dispensing Limits 
• Performance Drug List Dispensing Limits 
• Performance Select Drug List Dispensing Limits 

Request Override for Dispensing Limit

If your drug request is not shown in the drug categories of the dispensing limits drug list, please use the standard dispensing limit override form below. This form should be completed by the prescribing physician and faxed to the Prime Therapeutics Clinical Review Department at 877-243-6930. If you have questions or need additional information, call 888-723-7443.

• Dispensing Limit Override Physician Fax Form