Diabetic Medications

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

Diabetic Medications

Drugs	Quantity Limits
Byetta (Exenatide) Sub-Q Pen Injector	5mcg/0.02ml -- 3.6 mls per 90 Days 10mcg/0.04ml -- 7.2 mls per 90 Days
Insulin Assorted Vial	40 mls per 30 Days
Insulin Assorted Pen Injectors and Cartridges	45 mls per 30 Days

Last Modified on Nov 17, 2020

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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