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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
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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