Topical Products

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

Topical Products

Drugs

Quantity Limits

Aldara (Imiquimod) 5% Packet

12 Packets per 30 days
24 Packets per 60 Days

Alora (Estradiol) 0.25mg/24hr, 0.05mg/24hr, 0.075mg/24hr and 0.1mg/24hr Transdermal Patches

8 Patches per 28 Days

Catapres-TTS (Clonidine HCL) Transdermal Patches

0.1mg/24hr - 4 Patches per 28 Days
0.2mg/24hr - 8 Patches per 28 Days
0.3mg/24hr - 8 Patches per 28 Days

Climara (Estradiol) 0.025mg/24hr, 0.0375mg/24hr, 0.05mg/24hr, 0.06mg/24hr, 0.075mg/24hr and 0.1mg/24hr Transdermal Patches

4 Patches per 28 Days

Climara Pro (Estradiol - Levonorgestrel) 0.045mg - 0.015mg Transdermal Patch

4 Patches per 28 Days

Combipatch (Estradiol - Norethindrone Acetate) 0.05mg - 0.014mg and 0.05mg-0.25mg Transdermal Patch

8 patches per 28 days

Dovonex (Calcipotriene) 0.005% cream

360 gms per 30 days

Dovonex (Calcipotriene) 0.005% solution

300 mls per 30 days

Elidel (Pimecrolimus) 1% cream

30, 60 or 100 gms per 10, 60 or 100 days

Evamist (Estradiol) 1.53mg/spray Transdermal Spray

8.1 mls per 56 days

Exelon (Rivastigmine) 4.6mg/24hr and 9.5mg/24hr Transdermal Patch

30 patches per 30 days

Menostar (Estradiol) 14mcg/24hr Transdermal Spray

4 patches per 28 days

Neupro (Rotigotine) 2mg/24hr, 4mg/24hr and 6mg/24hr Transdermal Spray

30 patches per 30 days

Panretin (Alitretinoin) 0.1% gel

60 gms per 30 days

Protopic (Tacrolimus) 0.03% Ointment

30, 60 or 100 gms per 10, 60 or 100 days

Protopic (Tacrolimus) 0.1% Ointment

30, 60 or 100 gms per 10, 60 or 100 days

Regranex (Becaplermin) 0.01% gel

15 gms per 30 days

Soriatane CK (Acitrein - Emollient) 10mg and 25mg kit

2 kits per 30 days

Tazorac (Tazarotene) 0.05% and 0.1% cream

100 gms per 30 days

Tazorac (Tazarotene) 0.05% and 0.1% gel

100 gms per 30 days

Vivelle-Dot (Estradiol) 0.0375mg/24hr Transdermal Patch

8 patches per 28 days 

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