Asthma and COPD Medications

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

Asthma and COPD Medications

Drugs

Quantity Limits

Accolate (Zafirlukast) 10mg and 20mg Tablets 

60 Tablets per 30 Days

AccuNeb (Albuterol Sulfate) 0.63mg/3ml and 1.25mg/3ml Inhalation Vial-Neb 

600 mls (200 nebules) per 30 Days

Advair Diskus (Fluticasone - Salmeterol) 100mcg - 50mcg, 250mcg - 50mcg and 500mcg - 50mcg Disk w/Dev 

1 Inhaler (60 doses) per 30 Days

Advair HFA (Fluticasone - Salmeterol) 45mcg - 21mcg, 115mcg - 21mcg and 230mcg - 21mcg Disk w/Dev 

1 Canister (12 gms) per 30 Days

Aerobid (Flunisolide) 250mcg Inhaler 

3 Canister (21 gms) per 30 Days

Aerobid-M (Flunisolide - Menthol) 250mcg Inhaler 

3 Canister (21 gms) per 30 Days

Airet (Albuterol Sulfate) 2.5mg/3ml Inhalation Vial-Neb 

600 mls (200 nebules) per 30 Days

Alvesco (Ciclesonide) 80mcg and 160mcg Inhalers 

1 Canister (6.1 gms) per 30 Days

Alupent (Metaproterenol Sulfate) 650mcg Inhaler

 2 Canisters (28 gms) per 30 Days

Alupent (Metaproterenol Sulfate) 4mg/ml and 6mg/ml Inhalation Solution 

500 mls per 30 Days

Asmanex (Mometasone Furoate) Inhalers 

110mcg - 1 Canister (0.14 gms) per 30 Days                   220mcg - 1 Canister (0.24 gms) per 30 Days 

Atrovent (Ipratropium Bromide) 0.2mg/ml Solution 

450 mls per 30 Days

Atrovent HFA (Ipratropium Bromide) 17mcg Inhaler 

2 Canisters (25.8gms) per 30 Days

Azmacort (Triamcinalone Acetonide) 75mcg Inhaler 

2 Canisters (40 gms) per 30 Days

Brethine (Terbutaline Sulfate) 2.5mg and 5mg Tablets 

180 Tablets per 30 Days

Brovana (Arformoterol Tartrate) 15mcg/2ml Inhalation Vial-Neb 

120 mls (60 nebules) per 30 Days

Combivent (Ipratropium - Albuterol Sulfate) 18mcg - 103mcg Inhaler 

3 Canisters (44.1gms) per 30 Days

Duoneb (Ipratropium - Albuterol Sulfate) 0.5mg - 2.5mg/3ml Inhalation Ampul-Neb 

540 mls (180 nebules) per 30 Days

Flovent Diskus (Fluticasone Propionate) 50mcg, 100mg and 250mcg Disk w/Dev  

 240 Doses per 30 Days

Flovent HFA (Fluticasone Propionate) Inhalers 

44mcg - 2 Canisters (21.2 gms) per 30 Days                         110mcg and 220mcg - 2 Canisters (24 gms) per 30 Days

Foradil (Formoterol Fumarate)12mcg Inhaler 

60 Doses (1 inhaler) per 30 Days

Intal (Cromolyn Sodium) 20mg/2ml Inhalation Vial-Neb 

360 mls (180 nebules) per 30 Days

Intal (Cromolyn Sodium) 800mcg Inhaler 

2 Canisters per 30 Days

Maxair Autohaler (Pirbuterol Acetate) 200mcg Inhaler 

1 Canister (14 gms) per 30 Days

Perforomist (Formoterol Fumarate) 20mcg/2ml Inhalation Vial-Neb 

120 mls (60 nebules) per 30 Days

Proair HFA (Albuterol Sulfate) 90mcg Inhaler 

2 Canisters per 30 Days

Proventil (Albuterol Sulfate) 5mg/ml Inhalation Solution 

80 mls per 30 Days

Proventil HFA (Albuterol Sulfate) 90mcg Inhaler 

2 Canisters per 30 Days

Pulmicort (Budesonide) 0.25mg/2ml, 0.5mg/2ml and 1mg/2ml Inhalation Ampul-Neb 

240 mls (120 nebules) per 30 Days

Pulmicort Flexhaler (Budesonide) 90mcg and 180mcg Inhaler 

2 Canisters (120 doses) per 30 Days

Qvar (Beclomethasone Dipropionate) 40mcg and 80mcg Inhaler 

4 Canisters (29.2 gms) per 30 Days

Serevent Diskus (Salmeterol Xinafoate) 50mcg Inhaler 

120 Doses per 30 Days

Singulair (Monelukast Sodium) 4mg and 5mg Chewable Tablets, 10mg Tablets and 4mg Granule Packs 

30 Tablets or Packets per 30 Days

Spiriva (Tiotropium Bromide) 18mcg Inhaler 

5, 30 or 90 Caps per 5, 30 or 90 Days

Symbicort (Budesonide - Formoterol Fumarate) 80mcg - 4.5mcg and 160mcg - 4.5mcg HFA Inhaler 

1 Canister per 30 Days

Ventolin HFA (Albuterol Sulfate) 90mcg Inhaler 

2 Canisters per 30 Days

Xopenex (Levalbuterol HCL) 0.31mg/3ml, 0.63mg/3ml,1.25mg/0.5ml and 1.25/3ml Inhalation Vial-Neb 

 288 mls per 30 Days

Xopenex HFA (Levalbuterol Tartrate) 45mcg Inhaler 

 2 Canisters (30 mgs) per 30 Days

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