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Quantity Limit Summary
Policy Number: PH-1086
| Program | Target Drug | Dosage/Strength | Quantity Limit (Units/Day or as noted) |
| NOTE: a = generic available and included in quantity limit program | |||
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Antiretroviral Agents_PS_ AR0722_r0123 | Aptivus (tipranavir) | 100 mg/mL (95 mL bottle) oral solution | 12.6667 mL (380 mL/30 days)b |
| Aptivus (tipranavir) | 250 mg capsule | 4 capsules | |
| Atripla (efavirenz, emtricitabine, tenofovir) | 600 mg/200 mg/300 mg tableta | 1 tablet | |
| Biktarvy (bictegravir/emtricitabine/tenofovir) | 30 mg/120 mg/15 mg tablet | 1 tablet | |
| Biktarvy (bictegravir/emtricitabine/tenofovir) | 50 mg/200 mg/25 mg tablet | 1 tablet | |
| Cimduo, Temixys (lamivudine/tenofovir) | 300 mg/300 mg tablet | 1 tablet | |
| Combivir (lamivudine/zidovudine) | 150 mg/300 mg tableta | 2 tablets | |
| Complera (emtricitabine/rilpivirine/tenofovir) | 200 mg/25 mg/300 mg tablet | 1 tablet | |
| Crixivan (indinavir) | 200 mg capsule | 9 capsules | |
| Crixivan (indinavir) | 400 mg capsule | 6 capsules | |
| Delstrigo (doravirine/lamivudine/tenofovir) | 100 mg/300 mg/300 mg | 1 tablet | |
| Descovy (emtricitabine/tenofovir) | 120 mg/15 mg | 1 tablet | |
| Descovy (emtricitabine/tenofovir) | 200 mg/25 mg | 1 tablet | |
| Dovato (dolutegravir/lamivudine) | 50 mg / 300 mg tablet | 1 tablet | |
| Edurant (rilpivirine) | 25 mg tablet | 1 tablet | |
| Emtriva (emtracitabine) | 10 mg/mL oral soluion | 24.2856 mL (680 mL/28 days) | |
| Emtriva (emtracitabine) | 200 mg capsulea | 1 capsule | |
| Epivir (lamivudine) | 10 mg/mL oral soluion (240 mL bottle)a | 32 mL (960 mL/30 days) | |
| Epivir (lamivudine) | 150 mg tableta | 2 tablets | |
| Epivir (lamivudine) | 300 mg tableta | 1 tablet | |
| Epzicom (lamivudine/abacavir) | 600 mg/300 mg tableta | 1 tablet | |
| Evotaz (atazanavir/cobicistat) | 300 mg/150 mg tablet | 1 tablet | |
| Fuzeon (enfuvirtide) | 108 mg/vial (to deliver 90 mg/mL dose) | 2 vials (60 vials/month) | |
| Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir) | 150 mg/150 mg/200 mg/ 10 mg tablet | 1 tablet | |
| Intelence (etravirine) | 25 mg tablet | 4 tablets | |
| Intelence (etravirine) | 100 mg tableta | 2 tablets | |
| Intelence (etravirine) | 200 mg tablet a | 2 tablets | |
| Invirase (saquinavir mesylate) | 500 mg tablet | 4 tablets | |
| Isentress (raltegravir) | 25 mg chewable tablets | 6 tablets | |
| Isentress (raltegravir) | 100 mg chewable tablets | 6 tablets | |
| Isentress (raltegravir) | 400 mg tablets | 2 tablets | |
| Isentress HD (raltegravir) | 600 mg tablets | 2 tablets | |
| Isentress (raltegravir) | 100 mg packet for suspension | 2 packets | |
| Juluca (dolutegravir/rilpivirine) | 50 mg/25 mg tablets | 1 tablet | |
| Antiretroviral Agents_PS_ AR0722_r0123 | |||
| Kaletra (lopinavir/ritonavir) | 80 mg/20 mg per mL (160 mL bottle oral soln)a | 16 mL (480 mL/30 days) | |
| Kaletra (lopinavir/ritonavir) | 100 mg/25 mg tableta | 6 tablets | |
| Kaletra (lopinavir/ritonavir) | 200 mg/50 mg tableta | 4 tablets | |
| Lexiva (fosamprenavir) | 50 mg/mL (225 mL bottle) oral suspension | 60 mL (1800 mL/30 days) | |
| Lexiva (fosamprenavir) | 700 mg tableta | 4 tablets | |
| Norvir (ritonavir) | 80 mg/mL (240 mL bottle) oral solution | 16 mL (480 mL/30 days) | |
| Norvir (ritonavir) | 100 mg tableta | 12 tablets | |
| Norvir (ritonavir) | 100 mg powder packet | 12 packets | |
| Odefsey (emtricitabine/rilpivirine/tenofovir) | 200 mg/25 mg/25 mg | 1 tablet | |
| Pifeltro (doravirine) | 100 mg | 1 tablet | |
| Prezcobix (darunavir/cobicistat) | 800 mg/150 mg tablet | 1 tablet | |
| Prezista (darunavir) | 100 mg/mL suspension | 13.3334 mL (400 mL/30 days) | |
| Prezista (darunavir) | 75 mg tablet | 10 tablets | |
| Prezista (darunavir) | 150 mg tablet | 6 tablets | |
| Prezista (darunavir) | 600 mg tablet | 2 tablets | |
| Prezista (darunavir) | 800 mg tablet | 1 tablet | |
| Retrovir (zidovudine) | 50 mg/5 mL syrup (10 mg/mL in 240 mL bottle)a | 64 mL (1920 mL/30 days) | |
| Retrovir (zidovudine) | 100 mg capsulea | 6 capsules | |
| zidovudine | 300 mg tableta | 2 tablets | |
| Reyataz (atazanavir) | 150 mg capsulea | 1 capsule | |
| Reyataz (atazanavir) | 200 mg capsulea | 2 capsules | |
| Reyataz (atazanavir) | 300 mg capsulea | 1 capsule | |
| Reyataz (atazanavir) | 50 mg powder packet | 8 packets | |
| Rukobia (fostemsavir) | 600 mg extended-release tablet | 2 tablets | |
| Selzentry (maraviroc) | 25 mg tablet | 8 tablets | |
| Selzentry (maraviroc) | 75 mg tablet | 2 tablets | |
| Selzentry (maraviroc) | 150 mg tableta | 2 tablets | |
| Selzentry (maraviroc) | 300 mg tableta | 4 tablets | |
| Selzentry (maraviroc) | 20 mg/mL oral solution | 1840 mLs/30 days | |
| Stribild (elvitegravir/cobistat/emtricitabine/tenofovir) | 150 mg/150 mg/200 mg/300mg tablet | 1 tablet | |
| Sunlenca (Lenacapavir Sodium Tab Therapy Pack) | 300mg Tablet | 4 tablets/365 days | |
| Sunlenca (Lenacapavir Sodium Tab Therapy Pack) | 300mg Tablet | 5 tablets/365 days | |
| Sustiva (efavirenz) | 50 mg capsulea | 3 tablets | |
| Sustiva (efavirenz) | 200 mg capsulea | 2 tablets | |
| Sustiva (efavirenz) | 600 mg tableta | 1 tablet | |
| Antiretroviral Agents_PS_ AR0722_r0123 | |||
| Symfi (efavirenz/lamivudine/tenofovir)a | 600 mg/300 mg/300mg | 1 tablet | |
| Symfi Lo (efavirenz/lamivudine/tenofovir)a | 400 mg/300 mg/300mg | 1 tablet | |
| Symtuza (darunavir/cobicistat/emtricitabine/tenofovir) | 800 mg/150 mg/200 mg/10 mg tablet | 1 tablet | |
| Tivicay PD (dolutegravir) | 5 mg tablet | 12 tablets | |
| Tivicay (dolutegravir) | 10 mg tablet | 8 tablets | |
| Tivicay (dolutegravir) | 25 mg tablet | 2 tablets | |
| Tivicay (dolutegravir) | 50 mg tablet | 2 tablets | |
| Triumeq (abacavir, dolutegravir, and lamivudine) | 600 mg/50 mg/300 mg tablet | 1 tablet | |
| Triumeq PD (abacavir, dolutegravir, and lamivudine) | 60 mg/5 mg/30 mg tablet | 6 tablets | |
| Trizivir (abacavir+lamivudine+zidovudine) | 300 mg/150 mg/300 mg tablet | 2 tablets | |
| Truvada (emtracitabine/tenofovir)a | 100/150 mg tablet | 1 tablet | |
| Truvada (emtracitabine/tenofovir)a | 133/200 mg tablet | 1 tablet | |
| Truvada (emtracitabine/tenofovir)a | 167/250 mg tablet | 1 tablet | |
| Truvada (emtracitabine/tenofovir)a | 200 mg/300 mg tablet | 1 tablet | |
| Tybost (cobicistat) | 150 mg tablet | 1 tablet | |
| Videx EC, Didanosine | 200 mg capsule | 1 capsule | |
| Videx EC, Didanosine | 250 mg capsule | 1 capsule | |
| Videx EC, Didanosine | 400 mg capsule | 1 capsule | |
| Viracept (nelfinavir) | 250 mg tablet | 9 tablets | |
| Viracept (nelfinavir) | 625 mg tablet | 4 tablets | |
| Viramune, Nevirapine | 50 mg/5 mL suspension (240 mL bottle) | 40 mL (1200 mL/30 days) | |
| Viramune (nevirapine) | 200 mg tableta | 2 tablets | |
| Nevirapine | 100 mg extended-release tableta | 3 tablets | |
| Viramune XR (nevirapine) | 400 mg extended-release tableta | 1 tablet | |
| Viread (tenofovir) | 150 mg tablet | 1 tablet | |
| Viread (tenofovir) | 200 mg tablet | 1 tablet | |
| Viread (tenofovir) | 250 mg tablet | 1 tablet | |
| Viread (tenofovir) | 300 mg tableta | 1 tablet | |
| Viread (tenofovir) | 40 mg/1g oral powder for reconstitution (60 g can) | 8 g (240 g/30 days) | |
| Stavudine | 15 mg capsule | 2 capsules | |
| Stavudine | 20 mg capsule | 2 capsules | |
| Stavudine | 30 mg capsule | 2 capsules | |
| Stavudine | 40 mg capsule | 2 capsules | |
| Antiretroviral Agents_PS_ AR0722_r0123 | |||
| Ziagen (abacavir) | 20 mg/mL oral solution (240 mL bottle)a | 32 mL (960 mL/30 days) | |
| Ziagen (abacavir) | 300 mg tableta | 2 tablets | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Antitussive Combination Products_CS_AR0122 | TussiCaps (hydrocodone/chlorpheniramine) | 10 mg/8 mg capsule | 2 capsules per day 20 capsules per 30 days |
| hydrocodone/chlorpheniraminea | 10 mg/8 mg/5 mL suspension | 10 mLs per day 100 mLs per 30 days |
|
| Tuzistra XR (codeine/chlorpheniramine) | 20 mg/4 mg/5 mL suspension | 20 mLs per day 200 mLs per 30 days |
|
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Atypical Antipsychotics - Extended Maintenance Agents_PS_AR0422 | Abilify Maintena (aripiprazole) | 300 mg ER reconstituted suspension vial | 1 vial/28 days |
| Abilify Maintena (aripiprazole) | 300 mg ER suspension syringe | 1 syringe/28 days | |
| Abilify Maintena (aripiprazole) | 400 mg ER reconstituted suspension vial | 1 vial/28 days | |
| Abilify Maintena (aripiprazole) | 400 mg ER suspension syringe | 1 syringe/28 days | |
| Aristada (aripiprazole lauroxil injection) | 441 mg injection | 1 syringe/28 days | |
| Aristada (aripiprazole lauroxil injection) | 662 mg injection | 1 syringe/28 days | |
| Aristada (aripiprazole lauroxil injection) | 882 mg injection | 1 syringe/28 days | |
| Aristada (aripiprazole lauroxil injection) | 1064 mg injection | 1 syringe/56 days | |
| Aristada Initio (aripiprazole lauroxil extended-release injection) | 675 mg injection | 1 kit/180 days | |
| Invega Hafyera (paliperidone injection) | 1092 mg/3.5 mL extended-release suspension prefilled syringe | 1 syringe/180 days | |
| Invega Hafyera (paliperidone injection) | 1560 mg/5 mL extended-release suspension prefilled syringe | 1 syringe/180 days | |
| Invega Trinza (paliperidone injection) | 273 mg / 0.88 mL | 1 syringe/84 days | |
| Invega Trinza (paliperidone injection) | 410 mg / 1.32 mL | 1 syringe/84 days | |
| Invega Trinza (paliperidone injection) | 546 mg / 1.75 mL | 1 syringe/84 days | |
| Invega Trinza (paliperidone injection) | 819 mg / 2.63 mL | 1 syringe/84 days | |
| Invega Sustenna (paliperidone) | 39 mg/kit extended-release injection | 1 kit/28 days | |
| Invega Sustenna (paliperidone) | 78 mg/kit extended-release injection | 1 kit/28 days | |
| Invega Sustenna (paliperidone) | 117 mg/kit extended-release injection | 1 kit/28 days | |
| Invega Sustenna (paliperidone) | 156 mg/kit extended-release injection | 1 kit/28 days | |
| Invega Sustenna (paliperidone) | 234 mg/kit extended-release injection | 1 kit/28 days | |
| Perseris (risperidone) | 90 mg kit extended-release injection | 1 kit/28 days | |
| Perseris (risperidone) | 120 mg kit extended-release injection | 1 kit/28 days | |
| Risperdal Consta (risperidone) | 12.5 mg/vial long-acting injection | 2 vials/28 days | |
| Risperdal Consta (risperidone) | 25 mg/vial long-acting injection | 2 vials/28 days | |
| Risperdal Consta (risperidone) | 37.5 mg/vial long-acting injection | 2 vials/28 days | |
| Risperdal Consta (risperidone) | 50 mg/vial long-acting injection | 2 vials/28 days | |
| Zyprexa Relprevv (olanzapine) | 210 mg vial extended-release injection | 2 vials/28 days | |
| Zyprexa Relprevv (olanzapine) | 300 mg vial extended-release injection | 2 vials/28 days | |
| Atypical Antipsychotics - Extended Maintenance Agents_PS_AR0422 | Zyprexa Relprevv (olanzapine) | 405 mg vial extended-release injection | 1 vial/28 days |
| CMV_PS_AR0722 | This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | ||
| Livtencity (maribavir) | 200 mg tablet | 4 tablets | |
| Prevymis (letermovir) | 240 mg tablet | 100 tablets/365 days | |
| Prevymis (letermovir) | 480 mg tablet | 100 tablets/365 days | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Fibromyalgia (Lyrica and Savella)_PS_AR0422 | Lyrica (pregabalin) | 25 mg capsulea | 3 capsules |
| Lyrica (pregabalin) | 50 mg capsulea | 3 capsules | |
| Lyrica (pregabalin) | 75 mg capsulea | 3 capsules | |
| Lyrica (pregabalin) | 100 mg capsulea | 3 capsules | |
| Lyrica (pregabalin) | 150 mg capsulea | 3 capsules | |
| Lyrica (pregabalin) | 200 mg capsulea | 3 capsules | |
| Lyrica (pregabalin) | 225 mg capsulea | 2 capsules | |
| Lyrica (pregabalin) | 300 mg capsulea | 2 capsules | |
| Lyrica (pregabalin) | 20 mg/mL oral solutiona | 30 mL | |
| Savella (milnacipran) | 12.5 mg tablet | 2 tablets | |
| Savella (milnacipran) | 25 mg tablet | 2 tablets | |
| Savella (milnacipran) | 50 mg tablet | 2 tablets | |
| Savella (milnacipran) | 100 mg tablet | 2 tablets | |
| Savella (milnacipran) | Titration pack: 5 x 12.5 mg, 8 x 25 mg, 42 x 50 mg tablets | 1 kit (55 tablets)/180 days | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Gabapentin ER_PS_ AR0422 | Gralise (gabapentin) | 300 mg extended-release tablets | 1 tablet |
| Gralise (gabapentin) | 600 mg extended-release tablets | 3 tablets | |
| Horizant (gabapentin enacarbil) | 300 mg extended-release tablets | 2 tablets | |
| Horizant (gabapentin enacarbil) | 600 mg extended-release tablets | 2 tablets | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Insomnia_PS_ AR0422 | Ambien (zolpidem) | 5 mg tableta | 1 tablet |
| Ambien (zolpidem) | 10 mg tableta | 1 tablet | |
| Ambien CR (zolpidem) | 6.25 mg extended-release tableta | 1 tablet | |
| Ambien CR (zolpidem) | 12.5 mg extended-release tableta | 1 tablet | |
| Belsomra (suvorexant) | 5 mg tablet | 1 tablet | |
| Belsomra (suvorexant) | 10 mg tablet | 1 tablet | |
| Belsomra (suvorexant) | 15 mg tablet | 1 tablet | |
| Belsomra (suvorexant) | 20 mg tablet | 1 tablet | |
| Dayvigo (lemborexant) | 5 mg tablet | 1 tablet | |
| Dayvigo (lemborexant) | 10 mg tablet | 1 tablet | |
| Edluar (zolpidem) | 5 mg orally disintegrating tablet | 1 tablet | |
| Edluar (zolpidem) | 10 mg orally disintegrating tablet | 1 tablet | |
| Intermezzo (zolpidem) | 1.75 mg sublingual tablet | 1 tablet | |
| zolpidem | 3.5 mg sublingual tablet | 1 tablet | |
| Lunesta (eszopiclone) | 1 mg tableta | 1 tablet | |
| Lunesta (eszopiclone) | 2 mg tableta | 1 tablet | |
| Lunesta (eszopiclone) | 3 mg tableta | 1 tablet | |
| Quviviq (daridorexant) | 25 mg tablet | 1 tablet | |
| Quviviq (daridorexant) | 50 mg tablet | 1 tablet | |
| Roserem (ramelteon) | 8 mg tableta | 1 tablet | |
| Silenor (doxepin) | 3 mg tableta | 1 tablet | |
| Silenor (doxepin) | 6 mg tableta | 1 tablet | |
| zaleplon | 5 mg capsulea | 1 capsule | |
| zaleplon | 10 mg capsulea | 1 capsule | |
| Zopimist (zolpidem) | Oral Spray 5 mg/actuation | 1 canister (60 actuations)/ 30 days | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Ophthalmic Prostaglandins_PS_AR0722_r1222 | |||
| Lumigan (bimatoprost 0.01%) | 2.5 mL, 5 mL, 7.5 mL bottle | 2.5 mL/30 days | |
| bimatoprost 0.03%a | 2.5 mL, 5 mL, 7.5 mL bottle | 2.5 mL/30 days | |
| Travatan Z (travoprost)a | 2.5 mL, 5 mL bottle | 2.5 mL/30 days | |
| Vyzulta (latanoprostene bunod) | 2.5 mL, 5 mL bottle | 2.5 mL/30 days | |
| Xalatan (latanoprost)a | 2.5 mL, 7.5 mL bottle | 2.5 mL/30 days | |
| Zioptan (tafluprost)a | 0.3 mL/single-use container | 30 single-use containers/30 days | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Pain Medications (Combination Products) PS_AR0122 | Butalbital Combinations | ||
| Allzital, Butalbital/acetaminophen | 25 mg/325 mg tablet | 12 tablets | |
| Butalbital/Aspirin/Caffeine | 50 mg/325 mg/40 mg tablet | 6 tablets | |
| Fiorinal(butalbital/aspirin/caffeine) | 50 mg/325 mg/40 mg capsulea | 6 capsules | |
| Tencon (butalbital/ |
50 mg/325 mg tableta | 6 tablets | |
| butalbital/acetaminophen/caffeine | 50 mg/325 mg/40 mg/15 mLa solution | 90 mLs | |
| Butalbital/Acetaminophen/Caffeine | 50 mg/325 mg/40 mg capsulea | 6 capsules | |
| Esgic (butalbital/acetaminophen/caffeine) | 50 mg/325 mg/40 mg tableta | 6 tablets | |
| Fioricet (butalbital/acetaminophen/caffeine) | 50 mg/300 mg/40 mg capsulea | 6 capsules | |
| butalbital/acetaminophen | 50 mg/300 mg tableta | 6 tablets | |
| Bultalbital/Acetaminophen | 50 mg/300 mg capsule | 6 capsules | |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| Qualaquin_CS_AR0722 | Qualaquin (quinine sulfate) | 324 mg capsulesa | 42 capsules/90 days |
| This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace | |||
| SGLT2 Inhibitors_ PS_AR0122 | Farxiga (dapagliflozin) | 5 mg tablet | 1 tablet |
| Farxiga (dapagliflozin) | 10 mg tablet | 1 tablet | |
| Glyxambi (empagliflozin/linagliptin) | 10 mg / 5 mg | 1 tablet | |
| Glyxambi (empagliflozin/linagliptin) | 25 mg / 5 mg | 1 tablet | |
| Invokana (canagliflozin) | 100 mg tablet | 1 tablet | |
| Invokana (canagliflozin) | 300 mg tablet | 1 tablet | |
| Invokamet (canagliflozin/metformin) | 50 mg / 500 mg | 2 tablets | |
| Invokamet (canagliflozin/metformin) | 50 mg / 1000 mg | 2 tablets | |
| Invokamet (canagliflozin/metformin) | 150 mg / 500 mg | 2 tablets | |
| Invokamet (canagliflozin/metformin) | 150 mg / 1000 mg | 2 tablets | |
| Invokamet XR (canagliflozin/metformin ER) | 50 mg/500 mg tablet | 2 tablets | |
| Invokamet XR (canagliflozin/metformin ER) | 50 mg/1000 mg tablet | 2 tablets | |
| Invokamet XR (canagliflozin/metformin ER) | 150 mg/500 mg tablet | 2 tablets | |
| Invokamet XR (canagliflozin/metformin ER) | 150 mg/1000 mg tablet | 2 tablets | |
| Jardiance (empagliflozin) | 10 mg | 1 tablet | |
| Jardiance (empagliflozin) | 25 mg | 1 tablet | |
| Qtern (dapagliflozin/saxagliptin) | 5 mg/5 mg tablet | 1 tablet | |
| Qtern (dapagliflozin/saxagliptin) | 10 mg/5 mg tablet | 1 tablet | |
| Segluromet (ertugliflozin/metformin) | 2.5 mg/500 mg tablet | 4 tablets | |
| Segluromet (ertugliflozin/metformin) | 2.5 mg/1000 mg tablet | 2 tablets | |
| Segluromet (ertugliflozin/metformin) | 7.5 mg/500 mg tablet | 2 tablets | |
| Segluromet (ertugliflozin/metformin) | 7.5 mg/1000 mg tablet | 2 tablets | |
| Steglatro (ertugliflozin) | 5 mg tablet | 2 tablets | |
| Steglatro (ertugliflozin) | 15 mg tablet | 1 tablet | |
| Steglujan (ertugliflozin/sitagliptin) | 5 mg/100 mg tablet | 1 tablet | |
| Steglujan (ertugliflozin/sitagliptin) | 15 mg/100 mg tablet | 1 tablet | |
| Synjardy (empagliflozin/metformin) | 5 mg / 500 mg | 2 tablets | |
| Synjardy (empagliflozin/metformin) | 5 mg / 1000 mg | 2 tablets | |
| Synjardy (empagliflozin/metformin) | 12.5 mg / 500 mg | 2 tablets | |
| Synjardy (empagliflozin/metformin) | 12.5 mg / 1000 mg | 2 tablets | |
| Synjardy XR (empagliflozin/metformin ER) | 5 mg/1000 mg tablet | 2 tablets | |
| Synjardy XR (empagliflozin/metformin ER) | 10 mg/1000 mg tablet | 2 tablets | |
| Synjardy XR (empagliflozin/metformin ER) | 12.5 mg/1000 mg tablet | 2 tablets | |
| Synjardy XR (empagliflozin/metformin ER) | 25 mg/1000 mg tablet | 1 tablet | |
| SGLT2 Inhibitors_ PS_AR0122 | Trijardy XR (empagliflozin/linagliptin/metformin ER) | 5 mg/2.5 mg/1000 mg tablet | 2 tablets |
| Trijardy XR (empagliflozin/linagliptin/metformin ER) | 10 mg/5 mg/1000 mg tablet | 1 tablet | |
| Trijardy XR (empagliflozin/linagliptin/metformin ER) | 12.5 mg/2.5 mg/1000 mg tablet | 2 tablets | |
| Trijardy XR (empagliflozin/linagliptin/metformin ER) | 25 mg/5 mg/1000 mg tablet | 1 tablet | |
| Xigduo XR (dapagliflozin/metformin ER) | 2.5 mg / 1000 mg | 2 tablets | |
| Xigduo XR (dapagliflozin/metformin ER) | 5 mg / 500 mg | 1 tablet | |
| Xigduo XR (dapagliflozin/metformin ER) | 5 mg / 1000 mg | 2 tablets | |
| Xigduo XR (dapagliflozin/metformin ER) | 10 mg / 500 mg | 1 tablet | |
| Xigduo XR (dapagliflozin/metformin ER) | 10 mg / 1000 mg | 1 tablet | |