Biologicals

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

Biologicals

Drugs

Quantity Limits

Aranesp (Darbepoetin Alfa in Polysorbate) 25mcg/ml, 40mcg/ml, 60mcg/ml, 100mcg/ml, 200mcg/ml and 300mcg/ml Vial  

4 mls (4 doses) per 28 Days

Aranesp (Darbepoetin Alfa in Polysorbate) 150mcg/0.75ml Vial 

3 mls (4 doses) per 28 Days

Aranesp (Darbepoetin Alfa in Polysorbate) Disposable Syringe 

25mcg/0.42ml -- 1.68 mls (4 Syringes) per 28 Days                40mcg/0.4ml -- 1.6 mls (4 Syringes) per 28 Days                   60mcg/0.3ml -- 1.2 mls (4 Syringes) per 28 Days                   100mcg/0.5ml -- 2 mls (4 Syringes) per 28 Days                     150mcg.0.3ml -- 1.2 mls (4 Syringes) per 28 Days                   200mcg/0.4ml -- 1.6 mls (4 Syringes) per 28 Days                   300mcg/0.6ml -- 2.4 mls (4 Syringes) per 28 Days                   500mcg/ml -- 4 mls (4 Syringes) per 28 Days

Arcalyst (Rilonacept) Sub-Q 220mg Vial 

4 Vials per 28 Days

Cimzia (Certolizumab Pegol) Sub-Q 400mg Kit 

1 Kit per 28 Days

Copaxone (Glatiramer Acetate) Sub-Q 20mg Kit

1 Kit per 30 Days

Flu Vaccines Vials, Disposable Syringes and Spray 

1 Dose per 1 Day

Fragmin (Dalteparin Sodium, Porcine) 2500U/0.2ml, 5000U/0.2ml, 7500U/0.3ml, 10000U/ml, 12500U/0.5ml, 15000U/0.6ml and 18000U/0.72ml Disposable Syringes

30 Syringes (doses) per 30 Days

Fragmin (Dalteparin Sodium, Porcine) 10000U/ml Vial 

38 mls (30 doses) per 30 Days

Lovenox (Enoxaparin Sodium) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml and 120mg/0.8ml Disposable Syringes 

60 Syringes (doses) per 30 Days

Mozobil (Plerixafor) 24mg/1.2ml Vial 

4.8 mls (4 doses) per 4 Days

Neulasta (Pegfilgrastim) 6mg/0.6ml Disposable Syringe 

0.6 mls (1 Syringe) per 21 Days

Neupogen (Filgrastim) Disposable Syringe

300mcg/0.5ml -- 15 mls per 30 Days                                   480mcg/0.8ml -- 24 mls per 30 Days

Neupogen (Filgrastim) 480mcg/1.6ml Vial 

48 mls per 30 Days

Pulmozyme (Dornase Alfa) 1mg/ml Inhalation Solution 

150 mls per 30 Days

Rebif  (Interferon Beta-1A - Albumin) Disposable Syringe 

22mcg/0.5ml -- 6 mls per 28 Days                                      44mcg/0.5ml -- 6 mls per 28 Days                                       Titration Pack -- 4.2 mls per 30 Days

Stelara (Ustekinumab) 45mg/0.5ml Vial 

0.5 mls (1 vial) per 84 Days10mg and 20mg Tablets

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