Arthritis Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Arthritis Medications

Drugs

Quantity Limits

Arava (Leflunomide) 10mg and 20mg Tablets 

30 Tablets per 30 Days
Enbrel (Etanercept) 25mg Sub-Q Kit  8 vials per 30 Days
Enbrel (Etanercept) 25mg/0.5ml Sub-Q Disposable Syringe  4.08 mls per 28 Days
Enbrel (Etanercept) 50mg/ml Sub-Q Disposable Syringe  7.84 mls per 28 Days

Enbrel (Etanercept) 50mg/ml Sub-Q Pen Injector 

7.84 mls per 28 Days
Flector (Diclofenac Epolamine) 1.3% Topical Adhesive Patch  30 Patches per 15 Days

Humira (Adalimumab) Sub-Q Kit 

20mg/0.4ml Kit - 4 Kits per 28 Days                            40mg/0.8ml Kit - 4 Kits per 28 Days                             40mg/0.8ml Pen Kits - 6 Kits per 42 Days                      

Kineret (Anakinra) Sub-Q 100mg/0.67 ml Disposable Syringe  18.76 mls per 28 Days
Simponi (Golimumab) Sub-Q 50mg/0.5ml Syringe or Pen 1 Syringe or Injector Pen per 30 Days

Uloric (Febuxostat) 40mg and 80mg Tablets 

30 Tablets per 30 Days

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