Skip to main content

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


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



Quantity Limits

Aloxi (Palonosetron HCL) 0.075mg/1.5ml Vial 

4 Vials (6mls) per 28 days

Aloxi (Palonosetron HCL) 0.25mg/5ml Vial 

4 Vials (20mls) per 28 days before chemotherapy

Anzemet (Dolasetron Mesylate)  50mg and 100mg Tablets 

2 Tablets per day up to 5 days

Emend (Aprepitant) 125mg-80mg Convenience Pack Capsules

 2 packs per 30 days 

Emend (Aprepitant) 40mg, 80mg and 125mg Capsules

 1 pack per 30 days

Emend (Fosaprepitant Dimeglumine) 115mg Vial

1 Vial per 30 days

Granisol (Granisetron) 1mg/5ml Solution

30mls per 10 days

Kytril (Granisetron HCL) 1mg Tablets 

2 Tablets per day up to 10 days

Sancuso (Granisetron Transderm)  3.1mg/24hr Patch

 1 Patch per 21 days

Zofran (Ondansetron HCL) 4mg, 8mg and 24mg Tablets 

4mg and 8mg - 12 Tablets per 30 days                         24mg - 1 Tablet per 1 day in 30 day period

Zofran (Ondansetron HCL) 4mg/5ml Solution 

50 Mls per 28 days

Zofran ODT (Ondansetron HCL) 4mg and 8mg Rapdis Tablets 

12 Tablets per 30 days


Last Modified on Nov 17, 2020
Back to Top