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 |
