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Antiviral Drugs

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

Antiviral Drugs

Drugs

Quantity Limits

Relenza (Zanamavir) 5mg blister of powder for inhalation 

 One 4 pack of 5 (20) rotadisks (1 diskhaler) per 5 Days in 6 month period
Pegasys (Peginterferon Alfa-2A) Sub-Q 180mcg/0.5ml Kit 3 Kits per 84 Days
Synagis (Palivizumab) IM Vial 50mg/0.5ml - 0.5 Mls per 30 Days                                    100mg/ml - 1 Ml per 30 Days
Tamiflu (Oseltamivir Phosphate) Capsules and Suspension
 30mg - 10 Capsules per 5 Days in 6 month period
45mg - 20 Capsules per 5 Days in 6 month period
75mg - 10 Capsules per 5 Days in 6 month period              12mg/ml - 100 Mls per 5 Days in 6 month period

Tyzeka (Telbivudine) 600mg Tablets 

 100 Tablets per 100 Days

 

Last Modified on Nov 17, 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.