Asthma and COPD Medications
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Asthma and COPD Medications |
Drugs |
Quantity Limits |
Accolate (Zafirlukast) 10mg and 20mg Tablets |
60 Tablets per 30 Days |
AccuNeb (Albuterol Sulfate) 0.63mg/3ml and 1.25mg/3ml Inhalation Vial-Neb |
600 mls (200 nebules) per 30 Days |
Advair Diskus (Fluticasone - Salmeterol) 100mcg - 50mcg, 250mcg - 50mcg and 500mcg - 50mcg Disk w/Dev |
1 Inhaler (60 doses) per 30 Days |
Advair HFA (Fluticasone - Salmeterol) 45mcg - 21mcg, 115mcg - 21mcg and 230mcg - 21mcg Disk w/Dev |
1 Canister (12 gms) per 30 Days |
Aerobid (Flunisolide) 250mcg Inhaler |
3 Canister (21 gms) per 30 Days |
Aerobid-M (Flunisolide - Menthol) 250mcg Inhaler |
3 Canister (21 gms) per 30 Days |
Airet (Albuterol Sulfate) 2.5mg/3ml Inhalation Vial-Neb |
600 mls (200 nebules) per 30 Days |
Alvesco (Ciclesonide) 80mcg and 160mcg Inhalers |
1 Canister (6.1 gms) per 30 Days |
Alupent (Metaproterenol Sulfate) 650mcg Inhaler |
2 Canisters (28 gms) per 30 Days |
Alupent (Metaproterenol Sulfate) 4mg/ml and 6mg/ml Inhalation Solution |
500 mls per 30 Days |
Asmanex (Mometasone Furoate) Inhalers |
110mcg - 1 Canister (0.14 gms) per 30 Days 220mcg - 1 Canister (0.24 gms) per 30 Days |
Atrovent (Ipratropium Bromide) 0.2mg/ml Solution |
450 mls per 30 Days |
Atrovent HFA (Ipratropium Bromide) 17mcg Inhaler |
2 Canisters (25.8gms) per 30 Days |
Azmacort (Triamcinalone Acetonide) 75mcg Inhaler |
2 Canisters (40 gms) per 30 Days |
Brethine (Terbutaline Sulfate) 2.5mg and 5mg Tablets |
180 Tablets per 30 Days |
Brovana (Arformoterol Tartrate) 15mcg/2ml Inhalation Vial-Neb |
120 mls (60 nebules) per 30 Days |
Combivent (Ipratropium - Albuterol Sulfate) 18mcg - 103mcg Inhaler |
3 Canisters (44.1gms) per 30 Days |
Duoneb (Ipratropium - Albuterol Sulfate) 0.5mg - 2.5mg/3ml Inhalation Ampul-Neb |
540 mls (180 nebules) per 30 Days |
Flovent Diskus (Fluticasone Propionate) 50mcg, 100mg and 250mcg Disk w/Dev |
240 Doses per 30 Days |
Flovent HFA (Fluticasone Propionate) Inhalers |
44mcg - 2 Canisters (21.2 gms) per 30 Days 110mcg and 220mcg - 2 Canisters (24 gms) per 30 Days |
Foradil (Formoterol Fumarate)12mcg Inhaler |
60 Doses (1 inhaler) per 30 Days |
Intal (Cromolyn Sodium) 20mg/2ml Inhalation Vial-Neb |
360 mls (180 nebules) per 30 Days |
Intal (Cromolyn Sodium) 800mcg Inhaler |
2 Canisters per 30 Days |
Maxair Autohaler (Pirbuterol Acetate) 200mcg Inhaler |
1 Canister (14 gms) per 30 Days |
Perforomist (Formoterol Fumarate) 20mcg/2ml Inhalation Vial-Neb |
120 mls (60 nebules) per 30 Days |
Proair HFA (Albuterol Sulfate) 90mcg Inhaler |
2 Canisters per 30 Days |
Proventil (Albuterol Sulfate) 5mg/ml Inhalation Solution |
80 mls per 30 Days |
Proventil HFA (Albuterol Sulfate) 90mcg Inhaler |
2 Canisters per 30 Days |
Pulmicort (Budesonide) 0.25mg/2ml, 0.5mg/2ml and 1mg/2ml Inhalation Ampul-Neb |
240 mls (120 nebules) per 30 Days |
Pulmicort Flexhaler (Budesonide) 90mcg and 180mcg Inhaler |
2 Canisters (120 doses) per 30 Days |
Qvar (Beclomethasone Dipropionate) 40mcg and 80mcg Inhaler |
4 Canisters (29.2 gms) per 30 Days |
Serevent Diskus (Salmeterol Xinafoate) 50mcg Inhaler |
120 Doses per 30 Days |
Singulair (Monelukast Sodium) 4mg and 5mg Chewable Tablets, 10mg Tablets and 4mg Granule Packs |
30 Tablets or Packets per 30 Days |
Spiriva (Tiotropium Bromide) 18mcg Inhaler |
5, 30 or 90 Caps per 5, 30 or 90 Days |
Symbicort (Budesonide - Formoterol Fumarate) 80mcg - 4.5mcg and 160mcg - 4.5mcg HFA Inhaler |
1 Canister per 30 Days |
Ventolin HFA (Albuterol Sulfate) 90mcg Inhaler |
2 Canisters per 30 Days |
Xopenex (Levalbuterol HCL) 0.31mg/3ml, 0.63mg/3ml,1.25mg/0.5ml and 1.25/3ml Inhalation Vial-Neb |
288 mls per 30 Days |
Xopenex HFA (Levalbuterol Tartrate) 45mcg Inhaler |
2 Canisters (30 mgs) per 30 Days |
