Irritable Bowel System Medications

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

Irritable Bowel System Medications

Drugs	Quantity Limits
Amitiza (Lubiprostone) 8mcg and 24mcg Capsules	100 Capsules per 50 Days
Lotronex (Alosetron HCL) 0.5mg and 1mg Tablets	60 Tablets per 30 Days
Zelnorm (Tegaserod Hydrogen Maleate) 2mg and 6mg Tablets	60 Tablets 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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