Anti-Infectives

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

Anti-Infectives
Drugs	Quantity Limits
Alinia (Nitazoxanide) 100mg/5ml Suspension	60 mls per 3 Days
Alinia (Nitazoxanide) 500mg Tablets	6 Tablets per 3 Days
Augmentin XR (Amoxicillin / Clavulanate Potassiuim) 100mg / 62.5mg Tablets	40 Tablets per 10 Days in 30 day period
Biaxin XL (Clarithromycin) 500mg Tablets	28 Tablets per 14 days in 30 day period
Cipro XR (Ciprofloxacin) Tablets	500mg - 28 Tablets per 28 Days in 30 day period 1000mg - 14 Tablets per 14 days in 30 day period
Diflucan (Fluconazole) 150mg Tablets	7 Tablets per 7 Days in 30 day period
Levaquin (Levofloxacin) 750mg Tablets	5 Tablets per 5 Days in 30 day period
Zmax Pediatric (Azithromycin) 2gm/60ml Suspension	1 Unit per 1 Day in 30 day period

Last Modified on Dec 21, 2020

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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