Allergy Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override

Allergy Medications - Oral and Nasal

Drugs

Quantity Limits

Astelin (Azelastine HCL) 137mcg Nasal Spray/Pump

30 mls per 30 Days

Astepro (Azelastine HCL) 137mcg and 205.5mcg Nasal Spray/Pump 

30 mls per 30 Days

Atrovent (Ipratropium Bromide) 21mcg and 42mcg Nasal Spray

 30 mls per 30 Days

Beconase AQ (Beclomethasone Dipropionate) 42mcg Nasal Spray 

50 gms per 30 Days

Flonase (Fluticasone Propionate) 50mcg Nasal Spray Suspension 

16 gms per 30 Days

Nasacort AQ (Triamcinolone Acetonide) 55mcg Nasal Spray 

33 gms per 30 Days

Nasalide (Flunisolide) 0.25% Nasal Spray 

75 mls per 30 Days

Nasarel (Flunisolide) 29mcg Nasal Spray 

75 mls per 30 Days

Nasonex (Mometasone Furoate) 50mcg Nasal Spray/Pump 

17 gms per 30 Days

Omnaris (Ciclesonide) 50mcg Nasal Spray/Pump 

12.5 gms per 30 Days

Patanase (Olopatadine HCL) 0.6% Nasal Spray/Pump 

30.5 gms per 30 Days 

Rhinocort Aqua (Budesonide) 32mcg Nasal Spray/Pump 

9 gms per 30 Days 

Veramyst (Fluticasone Furoate) 27.5mcg Nasal Spray Suspension 

10 gms per 30 Days

Zyrtec (Cetirizine HCL) 5mg and 10mg Tablets and Chewable Tablets

 30 Tablets per 30 Days

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