Miscellaneous

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

Miscellaneous

Drugs

Quantity Limits

Aerochamber (Inhaler Assistance) Devices

2 Units per 30 Days

Arixtra (Fondaparinux Sodium) 2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml and 10mg/0.8ml Disposable Syringes 

30 Syringes (doses) per 30 Days

Exforge (Amlodipine - Valsartan) 5mg - 160mg, 5mg - 320mg, 10mg - 160mg and 10mg - 320mg Tablets 

30 Tablets per 30 Days

Exforge HCT (Amlodipine - Valsartan - Hydrochlorothiazide) 5mg - 160mg - 12.5mg, 5mg - 160mg - 25mg, 10mg - 160mg - 12.5mg, 10mg - 160mg - 25mg and 10mg - 320mg - 25mg Tablets 

30 Tablets per 30 Days

Iressa (Gefitinib) 250mg Tablets 

30 Tablets per 30 Days

Kenalog (Triamcinolone Acetonide) 10mg/ml and 40mg/ml Vial 

10 mls per 7 Days

Revatio (Sildenafil Citrate) 20mg Tablets 

90 Tablets per 30 Days

Savella (Milnacipran HCL) DS PK Tablets

12.5mg, 25mg, 50mg and 100mg Tablets

55 Tablets per 28 days

60 Tablets per 30 days

Somatuline Depot (Lanreotide Acetate) Sub-Q Diposable Syringe 

60mg/0.2ml - 0.2 mls (1 Syringe) per 28 Days                    90mg/0.3ml - 0.3 mls (1 Syringe) per 28 Days                     120mg/0.5ml - 0.5 mls (1 Syringe) per 28 Days

Toviaz (Fesoterodine Fumarate) 4mg and 8mg SR Tablets

 30 Tablets per 30 Days

Zelapar (Selegiline HCL) 1.25mg Rapdis Tablets 

100 Tablets per 50 Days

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