Transcription
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitCapsule30 caps/30 daysCapsule30 caps/30 daysTablet30 tabs/30 daysPatch30 patches/30 daysCapsuleOralSuspension60 caps/30 daysCapsule30 caps/30 daysTablet30 tabs/30 days0.1 mg10 mg20 mg30 mg40 mg50 mg60 mgTablet60 tabs/30 daysCapsule30 caps/30 days20 mg100 mg150 mgTablet60 tabs/30 daysTablet30 tabs/30 daysTablet60 tabs/30 daysChew Tab30 tabs/30 daysOral SuspCapsule360 ml/30 days30 caps/30 daysADD/ADHD Agents5 mg10 mg15 mg20 mg25 mg30 mg10 mg15 mg20 mg30 mg40 mg50 mg60 mg18 mg27 mg36 mg54 mg10 mg15 mg20 mg30 mg5 mg10 mg15 mgAdderall XR Amphetamine/DextroamphetamineMixed salts ERAptensio XR Methylphenidate ERConcerta Methylphenidate ERDaytrana Methylphenidate PatchDexedrine Spansule Dextroamphetamine ERDyanavel XRAmphetamine ER suspensionFocalin XR Dexmethylphenidate ERIntuniv Guanfacine ERKapvay Clonidine ERMetadate CD Methylphenidate ERMetadate ER Methylphenidate ERQelbree ViloxazineQelbree ViloxazineQuillichew XR Methylphenidate ER200 mg20 mg30 mg40 mgQuillivant XR Ritalin LA Methylphenidate ERMethylphenidate ER25 mg10 mgUpdated 03/09/2022(pv06/01/2021)2.5 mg/ml5 mg10 mg15 mg20 mg25 mg30 mg35 mg40 mg1 mg2 mg3 mg4 mgPharmacy Billing Manual Appendix D240 ml/30 daysPage 1 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitTablets30 tabs/30 daysCapsule60 caps/30 daysCapsule30 caps/30 days400mg per dayRitalin SR Methylphenidate ERStrattera AtomoxetineVyvanse Lisdexamfetamine20 mg30 mg40 mg60 mg10 mg20 mg10 mg18 mg25 mg40 mg60 mg80 mg100 mg10 mg20 mg30 mg40 mg50 mg60 mg70 mgCelebrex (COX-II)CelecoxibAll StrengthsLenzapro Lidocaine-Menthol4-4%Lidoderm ToradolAcetaminophencontaining productsAnticoagulantsLidocaineKetorolac5%10 mgCapsuleTransdermalpatchTransdermalpatchTabletAll StrengthsAllLovenox Enoxaparin30 mg/0.3mlLovenox Enoxaparin40 mg/0.4mlLovenox Enoxaparin60 mg/0.6mlLovenox Enoxaparin80 mg/0.8mlLovenox EnoxaparinLovenox Enoxaparin100 mg/ml120 mg/0.8mlLovenox EnoxaparinPradaxa AntiemeticsDabigatran150 mg/ml75 mg150 mgAloxi Palonosetron HCLAnzemet AnalgesicsSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjection60 patches/30 days90 patches per rolling30 days20 tablets per 6 months3,000mgAcetaminophen per RxCapsule60 tabs/30 days0.25 mg/5 mlSolution forInjection35 mls/30 daysDolasetron50 mgTablet4 tabs/RxAnzemet Dolasetron100 mg2 tabs/RxAnzemet Dolasetron20 mg/mlTabletSolution forInjectionCesamet Nabilone1 mgCapsule180 caps/30 daysUpdated 03/09/2022(pv06/01/2021)Pharmacy Billing Manual Appendix D35 mls/30 daysPage 2 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitKytril GranisetronTablet2 tabs/RxKytril GranisetronGranisetron transdermalZofran Ondansetron4 mgZofran Ondansetron8 mgOral SolutionTransdermalpatchTablet andODTTablet andODT1 bottle/RxSancuso 1 mg1 mg/5 ml, 30ml per bottle3.1 mg/24 hr(7 day patch)Zofran OndansetronTablet1 tab/RxZofran Ondansetron24 mg4 mg/5 ml, 50ml per bottle1 bottle/RxZofran Ondansetron2 mg/mlZofran Ondansetron4 mg/2 mlZofran Ondansetron40 mg/20 mlZuplenz Ondansetron4 mgZuplenz Ondansetron8 mgOral SolutionSolution forInjectionSolution forInjectionSolution forInjectionDissolvingFilmDissolvingFilmEmend Aprepitant80 mgCapsule2 caps/RxEmend Aprepitant125 mgCapsule1 cap/RxZofran Ondansetron4 mgODT12 tabs/RxZofran Antimigraine AgentsOndansetron8 mgODT6 tabs/RxAmerge Naratriptan1 mgTablet9 tabs/monthAmerge Naratriptan2.5 mgTablet9 tabs/monthAxert Almotriptan6.25 mgTablet6 tabs/monthAxert Almotriptan12.5 mgTablet6 tabs/monthFrova Imitrex Imitrex Imitrex Imitrex Imitrex Imitrex Maxalt MaxaltMaxalt-MLTMaxalt-MLTNurtec TabletInjection KitNasal SprayNasal SprayTabletTabletODTODTODT9 tabs/month18 tabs/month9 tabs/month9 tabs/month4 injections/month12 units/month6 units/month12 tabs/month12 tabs/month12 tabs/month12 tabs/month15 tabs/monthQulipta AtogepantTablet30 tabs/30 daysUbrelvy Ubrogepant2.5 mg25 mg50 mg100 mg6 mg5 mg20 mg5 mg10 mg5 mg10 mg75 mg10 mg30 mg60 mg50 mg100 mgTablet10 tabs/monthZomig Zolmitriptan2.5 mgTablet12 tabs/monthUpdated 03/09/2022(pv06/01/2021)Pharmacy Billing Manual Appendix D1 patch/Rx12 tabs/Rx6 tabs/Rx350 mls/30 days6 mls/claim20 mls/claim12 films/Rx6 films/RxPage 3 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitZomig triptanZolmitriptan5 mg2.5 mg5 mgTabletODTNasal Spray6 tabs/month12 tabs/month12 tabs/monthBiktarvy tricitabine/tenofovirDolutegravirTenofovirTablet30 tabs/30 daysTabletTablet30 tabs/30 days30 tabs/30 daysTabletTabletTablet30 tabs/30 days30 tabs/30 days30 tabs/30 daysTabletTabletTablet30 tabs/30 days60 tabs/30 days30 tabs/30 daysDescovy Dovato Genvoya Isentress HDJuluca Stribild Tivicay Truvada Chemotherapy AgentsAvastin Bevacizumab100 mg/4 mlAvastin BevacizumabBleomycin SulfateCytarabine400 mg/16 mlAll Strengths20 mg/ml 5ml vial20 mg/ml 50ml vialHerceptin Trastuzumab440 mg vialLupron Leuprolide Acetate KitAll StrengthsNavelbine Vinorelbine TartrateTaxolPaclitaxelAll Strengths100 mg/16.7mlTaxolPaclitaxel150 mg/25 mlTaxolPaclitaxel30 mg/5 mlCytarabineTaxolPaclitaxelColony Stimulating HormonesGranix TBO-FilgrastimNeulasta PegfilgrastimNeupogen FilgrastimUpdated 03/09/2022(pv06/01/2021)300 mg/50 ml300 mcg/0.5ml480 mcg/0.8ml6 mg/0.6 ml300 mcg/0.5ml480 mcg/0.8mlSolution forInjectionSolution forInjectionVialSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionOnpro KitSolution forInjectionPharmacy Billing Manual Appendix D12 mls/claim32 mls/claim30 vials/7 days15 mls/claim250 mls/claim3 vials/claim2 kits/30 days36 mls/30 m0.8 ml/day1.2 mls/7 days8.5 ml/dayPage 4 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitFilgrastim300 mcg/0.5ml480 mcg/0.8mlSolution forInjection8.5 ml/dayAdlyxin Lixisenatide20 mcg/0.2mlPen Injector20 mcg/dayBydureon ExenatideVial or Pen2 mg/weekByetta ExenatidePen InjectorSoliqua Insulin Glargine-LixisenatidePen Injector20 mcg/day60 Units/day with20 mcg/dayTanzeum AlbiglutidePen Injector50 mg/weekTrulicity Dulaglutide2 mg5 mcg/0.02ml10 mcg/0.04ml100/33 Unitmcg/ml30 mg50 mg0.75 mg1.5 mgPen Injector1.5 mg/weekVictoza LiraglutidePen InjectorXultophy Insulin Degludec-Liraglutide18 mg/3 ml100/3.6 Unitmg/ml1.8 mg/day50 Units/day with 1.8mg/dayZarxio Diabetic MedicationsPen InjectorDiabetic SuppliesLancetsAlcohol SwabsBattery for MonitorBlood Glucose MonitorBlood Glucose Strips200 lancets/month200 swabs/month1 battery/year1 meter every 2 years200 strips/monthKeto-Stix100 strips/monthControl SolutionErythropoiesis Stimulating Agents1 solution set/monthAranesp Darbepoetin AlfaAll StrengthsEpogen /Procrit Epoetin AlfaAll StrengthsOmontys Peginesatide10mg/mlOmontys Hepatitis C AgentsPeginesatide20mg/2mlSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionDaklinza DaclatasvirTabletHarvoni Ledipasvir-SofosbuvirTabletIncivek TelaprevirOlysio SimprevirUpdated 03/09/2022(pv06/01/2021)375 mgTabletCapsulePharmacy Billing Manual Appendix D1500 mcg/30 days or3 ML per claim500,000 units/30 daysor 3 ML per claim3 ML per claim4 ML per claim14 days supply first fill,28 tabs/rolling 25 dayson subsequent fills14 days supply first fill,28 tabs/rolling 25 dayson subsequent fills168 tabs/rolling 25 days14 days supply first fill,28 caps/rolling 25 dayson subsequent fillsPage 5 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormCapsule14 days supply first fill,28 caps/rolling 25 dayson subsequent fills14 days supply first fill,2 boxes of tablets,56/28 days336 caps/rolling 25daysPack14 days supply first fill,1 pack/28 daysSovaldi SofosbuvirCapsuleTechnivie Ombitasvir / Paritaprevir /RitonavirTabletVictrelis BoceprevirViekira Pak tyx Secukinumab150 mgCosentyx Enbrel Enbrel MiniCartridgeEnbrel SureClickSecukinumab300 mgEtanercept25 mg50 mgHumira Adalimumab10 mgHumira Adalimumab20 mgHumira KitAdalimumabOlumiant BaricitinibOrencia AbataceptOtezla ApremilastRinvoq Upadacitinib30 mg15 mg30 mgStelara Ustekinumab45 mgStelara UstekinumabXeljanz TofacitinibXeljanz ER Incretin MimeticsTofacitinib90 mg5 mg10 mg11 mg22 mgRybelsus SemaglutideMultiple Sclerosis Agents200 mg1 mg2 mg50 mg87.5 mg125 mgLimitSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjectionSolution forInjection1mL/28 days2mL/28 days4mL/28 days *PlaquePsoriasis: up to anadditional 1mL/week forfirst 3 months0.2mL/28 days0.4mL/28 days1 Kit/28 daysTablet30 tabs/30 daysSolution forInjection4mL/28 daysTablets60 tabs/30 daysTabletsSolution forInjectionSolution forInjection30 tabs/30 daysTablets60 tabs/30 daysTablets30 tabs/30 days3 mg7 mg14 mgTablet30 tabs/30 days0.5mL/56 days1mL/56 daysCopaxone Glatiramer Acetate20 mgSolution forInjection30 ml/30 daysRebif Interferon Beta-1AAll StrengthsSolution forInjection6 vials/RxAmpyra dalfampridine10 mgTablet60 tabs/30 daysUpdated 03/09/2022(pv06/01/2021)Pharmacy Billing Manual Appendix DPage 6 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitActiq FentanylAll StrengthsLozenge120 lozenges per rolling30 daysAvinza Morphine SulfateAll StrengthsButrans Buprenorphine transdermal patchAll StrengthsDemerolMeperidine HydrochlorideAll StrengthsDuragesic FentanylAll StrengthsCapsuleTransdermalpatchSolution forInjectionTransdermalpatchOpioids1 capsule/day4 patches/30 days30 mls/day1 patch every 3 daysDuragesic FentanylAll StrengthsPatch1 patch every 2 days iffailure to achieve painrelief is documentedand clinical notes areprovided to the clinicalcall center.Embeda Morphine-NaltrexoneAll StrengthsCapsule2 capsules per dayExalgo Hydromorphine ERAll StrengthsTabletFentora FentanylAll StrengthsBuccal tablet1 tablet per day120 tabs per rolling 30daysHysingla ERHydrocodone ERAll StrengthsTablet1 tablet per dayKadian MS ContinMorphine SulfateMorphine SulfateAll StrengthsAll StrengthsCapsuleTablet2 caps/day3 tabs/dayNucynta ERTapentadol ERAll StrengthsTablet2 tablets/dayOpana EROxymorphone ERAll StrengthsTablet2 tablets/dayOxyContin OxycodoneAll StrengthsTablet3 tabs/dayStadol ButorphanolAll StrengthsNasal Spray2 per rolling 30 daysXartemis XROxycodone/APAP ERAll StrengthsTablet4 tabs/dayZohydro EROral ContraceptivesHydrocodone ERAll StrengthsTablet2 tabs/day100 tablets (whenprovided in aphysician's office)Oral ContraceptivesAll ProductsAll StrengthsTabletDaliresp ution30 tabs/25 daysDuoneb500 mcg0.5-2.5 mg /3 mlFlovent Fluticasone100 mcgRotadisk1 inhaler/monthFlovent Fluticasone250 mcgRotadisk1 box/monthFlovent Fluticasone50 mcgRotadiskSerevent Diskus SalmeterolXopenex erol50 mcg(AllStrengths)0.31 and 0.63mg1 box/month1 box (60 inhalationsper month)4 boxes (288ml) permonthEvery 6 hours (seemonthly max above)XopenexLevalbuterol1.25 mgRespiratoryUpdated 03/09/2022(pv06/01/2021)Pharmacy Billing Manual Appendix D360 ml/monthEvery 8 hours (seemonthly max above)Page 7 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitTablets30 tabs/30 daysTab CR30 tabs/30 daysTab30 tabs/30 daysSedative/HypnoticsAmbien ZolpidemAmbien CR Zolpidem ERBelsomra SuvorexantDalmane FlurazepamDoral QuazepamEdluar ZolpidemHalcionTriazolamHetlioz TasimelteonIntermezzo ZolpidemProsom EstazolamRestoril TemazepamRozerem RamelteonSilenor DoxepinSonata Zaleplon5 mg10 mg6, 6.25, 12,12.5 mg5, 10, 15 and20 mg15 mg and 30mgCapsule30 caps/30 days15 mg5 mg and 10mg0.125 and0.25 mgTab30 tabs/30 daysSL Tab30 tabs/30 daysTab30 tabs/30 days20 mg1 mg and 3mg1 mg and 2mg7, 7.5, 15, 22,22.5, and 30mgCapsule30 caps/30 daysSL tab30 tabs/30 daysTab30 tabs/30 daysCapsule30 caps/30 days8 mg3 mg and 6mg5 mg and 10mgTab30 tabs/30 daysTab30 tabs/30 daysCapsule30 caps/30 daysZolpimist ZolpidemBuprenorphine/ Naloxone5 mgOral Spray1 Unit/30 daysSubutex Buprenorphine2 mgSL Tab90 tabs/30 daysSubutex 8 mgSL Tab60 tabs/30 days2 mg/0.5 mgSL Tab/Film90 tabs/30 days4 mg/1 mgSL Tab/Film30 tabs/30 days8 mg/2 mgSL Tab/Film60 tabs/30 daysSuboxone eSL Tab/Film30 tabs/30 daysZubsolv Buprenorphine/ NaloxoneSL Tab90 tabs/30 daysZubsolv Buprenorphine/ Naloxone12 mg/3 mg1.4 mg/0.36mg5.7 mg/1.4mgSL Tab60 tabs/30 daysAdenocardAdenosineAll StrengthsBenadryl Diphenhydramine HCLAll StrengthsBotox OnabotulinumtoxinaAll StrengthsSolution forInjectionSolution forInjectionSolution forInjectionBrilinta ticagrelorAll StrengthsTabletSuboxone Suboxone Suboxone MiscellaneousUpdated 03/09/2022(pv06/01/2021)Pharmacy Billing Manual Appendix D255 ml/30 days5 mls/day4 vials/30 days60 tabs/25 daysPage 8 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitTablet90 tabs/30 days - FMF60 tabs/30 days Chronic GoutTablet60 tabs/30 daysColcrys ColchicineCorlanor Ivabradine0.6 mg5 mg7.5 mgCrestor Rosuvastatin10 mgTablet2 tabs/dayCrestor Rosuvastatin20 mg1 tab/dayDepo-ProveraMedroxyprogesterone150 mgTabletSolution forInjectionDuexis Ibuprofen/famotidine800/26.6 mgTablet3 tabs/dayEffient PrasugrelTabletElidel PimecrolimusTube30 tabs/30 days30 GM per rolling 30days with a 25%tolerance for refillsEntresto Tablets60 tabs/30 daysFoliteSacubitril/ValsartanFolic acid, magnesium citrate,calcium citrate, vitamin d3,n-acetyl-l-cysteine30 tabs/30 daysHaldol Haloperidol DecanoateAll StrengthsJublia EfinaconazoleKalydeco Ivacaftor10%50 mg75 mg150 mgTabletsSolution forInjectionTopicalSolution60 tabs or packs/25daysKerydin TavaboroleLamisil GranulesTerbinafine5%125 mg187.5 mgMakena Hydroxyprogesterone Caproate250 ution forInjectionMitigare ColchicineTablets60 tabs/30 daysNuvigil Armodafinil0.6 mg50 mg150 mg200 mg250 mgTablet1 tablet per dayOnmel Itraconazole200 mgTablet30 tabs/30 daysOrkambi nVC/CodeinePromethazine/CodeinePraluent Alirocumab200-125 mg6.25-10 mg/5ml6.25-10 mg/5ml75 mg150 mgProtopic TacrolimusTubeProvigil ModafinilAll Strengths100 mg200 mg112 tabs/28 days120 ml/fill, 3 fills perrolling 12 months120 ml/fill, 3 fills perrolling 12 months2 pens/syringes perrolling 28 days30 gm per rolling 30days with a 25%tolerance for refillsRegranex Becaplermin0.01%TubeUpdated 03/09/2022(pv06/01/2021)Promethazine VC/Codeine1%24-26 mg49-51 mg97-103 mgSyrupSyrupPen/SyringeTabletPharmacy Billing Manual Appendix D2 ml/3 months20 ml/30 days1 bottle/30 days1 bottle/30 days60 packs/30 days1 vial/30 days1 tablet per day15 gm tube per claim, 2tubes in lifetimePage 9 of 10
Appendix D – Quantity LimitsBrand NameGeneric NameStrengthDosage FormLimitRepatha Smoking CessationProductsEvolocumab140 mg/mlPen/Syringe3 pens/syringes perrolling 28 daysSolution forInjection180 days/yearSolu-Medrol MethylprednisoloneAll Strengths12 ml/30 daysSynagis Palivizumab100 mgVersedMidazolam HydrochlorideAll StrengthsVialSolution forInjectionTriamcinolone AcetonideBlood Factor per unit(Antihemophilic Factor, Human orRecombinant)All StrengthsSolution forInjection16 mls/30 daysUnit10,000 units/dayTablet2 tablets per day4 vials/Rx100 mls/dayViberzi EluxadolineAll Strengths75 mg100 mgXolair Omalizumab150 mgVial6 vials/28 daysXyrem Sodium oxybate500 mg/mlSolution540 ml/30 daysZonalon , Prudoxin Doxepin Topical CreamAll StrengthsCream45 gm/30 daysUpdated 03/09/2022(pv06/01/2021)Pharmacy Billing Manual Appendix DPage 10 of 10
20 mcg/0.2 ml Pen Injector 20 mcg/day Bydureon Exenatide 2 mg Vial or Pen 2 mg/week Byetta Exenatide 5 mcg/0.02 ml 10 mcg/0.04 ml Pen Injector 20 mcg/day Soliqua Insulin Glargine-Lixisenatide 100/33 Unit-mcg/ml Pen Injector 60 Units/day with 20 mcg/day Tanzeum Albiglutide 30 mg 50 mg Pen Injector 50 mg/week
