Allergy Medications
PHARM-13 Statement of Medical Necessity for Quantity Limits Override
| Allergy Medications - Oral and Nasal |
Drugs |
Quantity Limits |
Astelin (Azelastine HCL) 137mcg Nasal Spray/Pump |
30 mls per 30 Days |
Astepro (Azelastine HCL) 137mcg and 205.5mcg Nasal Spray/Pump |
30 mls per 30 Days |
Atrovent (Ipratropium Bromide) 21mcg and 42mcg Nasal Spray |
30 mls per 30 Days |
Beconase AQ (Beclomethasone Dipropionate) 42mcg Nasal Spray |
50 gms per 30 Days |
Flonase (Fluticasone Propionate) 50mcg Nasal Spray Suspension |
16 gms per 30 Days |
Nasacort AQ (Triamcinolone Acetonide) 55mcg Nasal Spray |
33 gms per 30 Days |
Nasalide (Flunisolide) 0.25% Nasal Spray |
75 mls per 30 Days |
Nasarel (Flunisolide) 29mcg Nasal Spray |
75 mls per 30 Days |
Nasonex (Mometasone Furoate) 50mcg Nasal Spray/Pump |
17 gms per 30 Days |
Omnaris (Ciclesonide) 50mcg Nasal Spray/Pump |
12.5 gms per 30 Days |
Patanase (Olopatadine HCL) 0.6% Nasal Spray/Pump |
30.5 gms per 30 Days |
Rhinocort Aqua (Budesonide) 32mcg Nasal Spray/Pump |
9 gms per 30 Days |
Veramyst (Fluticasone Furoate) 27.5mcg Nasal Spray Suspension |
10 gms per 30 Days |
Zyrtec (Cetirizine HCL) 5mg and 10mg Tablets and Chewable Tablets |
30 Tablets per 30 Days |
