Antiviral Drugs
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Antiviral Drugs |
Drugs |
Quantity Limits |
Relenza (Zanamavir) 5mg blister of powder for inhalation |
One 4 pack of 5 (20) rotadisks (1 diskhaler) per 5 Days in 6 month period |
| Pegasys (Peginterferon Alfa-2A) Sub-Q 180mcg/0.5ml Kit | 3 Kits per 84 Days |
| Synagis (Palivizumab) IM Vial | 50mg/0.5ml - 0.5 Mls per 30 Days 100mg/ml - 1 Ml per 30 Days |
| Tamiflu (Oseltamivir Phosphate) Capsules and Suspension |
30mg - 10 Capsules per 5 Days in 6 month period 45mg - 20 Capsules per 5 Days in 6 month period 75mg - 10 Capsules per 5 Days in 6 month period 12mg/ml - 100 Mls per 5 Days in 6 month period |
Tyzeka (Telbivudine) 600mg Tablets |
100 Tablets per 100 Days |
Last Modified on
Nov 17, 2020
