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Call the helpline at 800-987-7767, option 5, and talk to choice counselors to change your SoonerSelect health plan!

Anti-Infectives

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

Anti-Infectives

Drugs

Quantity Limits

Alinia (Nitazoxanide) 100mg/5ml Suspension

 60 mls per 3 Days

Alinia (Nitazoxanide) 500mg Tablets 

 6 Tablets per 3 Days 

Augmentin XR (Amoxicillin / Clavulanate Potassiuim) 100mg / 62.5mg Tablets 

 40 Tablets per 10 Days in 30 day period

Biaxin XL (Clarithromycin) 500mg Tablets 

 28 Tablets per 14 days in 30 day period

Cipro XR (Ciprofloxacin) Tablets 

  500mg - 28 Tablets per 28 Days in 30 day period            1000mg - 14 Tablets per 14 days in 30 day period

Diflucan (Fluconazole) 150mg Tablets 

 7 Tablets per 7 Days in 30 day period

Levaquin (Levofloxacin) 750mg Tablets 

 5 Tablets per 5 Days in 30 day period

Zmax Pediatric (Azithromycin) 2gm/60ml Suspension

  1 Unit per 1 Day in 30 day period

 

Last Modified on Dec 21, 2020
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. OHCA may share this personally identifiable data with its authorized business associates, government agencies with jurisdiction over the OHCA, or as otherwise required or permitted by applicable law.