Biologicals
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Biologicals |
Drugs | Quantity Limits |
Aranesp (Darbepoetin Alfa in Polysorbate) 25mcg/ml, 40mcg/ml, 60mcg/ml, 100mcg/ml, 200mcg/ml and 300mcg/ml Vial | 4 mls (4 doses) per 28 Days |
Aranesp (Darbepoetin Alfa in Polysorbate) 150mcg/0.75ml Vial | 3 mls (4 doses) per 28 Days |
Aranesp (Darbepoetin Alfa in Polysorbate) Disposable Syringe | 25mcg/0.42ml -- 1.68 mls (4 Syringes) per 28 Days 40mcg/0.4ml -- 1.6 mls (4 Syringes) per 28 Days 60mcg/0.3ml -- 1.2 mls (4 Syringes) per 28 Days 100mcg/0.5ml -- 2 mls (4 Syringes) per 28 Days 150mcg.0.3ml -- 1.2 mls (4 Syringes) per 28 Days 200mcg/0.4ml -- 1.6 mls (4 Syringes) per 28 Days 300mcg/0.6ml -- 2.4 mls (4 Syringes) per 28 Days 500mcg/ml -- 4 mls (4 Syringes) per 28 Days |
Arcalyst (Rilonacept) Sub-Q 220mg Vial | 4 Vials per 28 Days |
Cimzia (Certolizumab Pegol) Sub-Q 400mg Kit | 1 Kit per 28 Days |
Copaxone (Glatiramer Acetate) Sub-Q 20mg Kit | 1 Kit per 30 Days |
Flu Vaccines Vials, Disposable Syringes and Spray | 1 Dose per 1 Day |
Fragmin (Dalteparin Sodium, Porcine) 2500U/0.2ml, 5000U/0.2ml, 7500U/0.3ml, 10000U/ml, 12500U/0.5ml, 15000U/0.6ml and 18000U/0.72ml Disposable Syringes | 30 Syringes (doses) per 30 Days |
Fragmin (Dalteparin Sodium, Porcine) 10000U/ml Vial | 38 mls (30 doses) per 30 Days |
Lovenox (Enoxaparin Sodium) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml and 120mg/0.8ml Disposable Syringes | 60 Syringes (doses) per 30 Days |
Mozobil (Plerixafor) 24mg/1.2ml Vial | 4.8 mls (4 doses) per 4 Days |
Neulasta (Pegfilgrastim) 6mg/0.6ml Disposable Syringe | 0.6 mls (1 Syringe) per 21 Days |
Neupogen (Filgrastim) Disposable Syringe | 300mcg/0.5ml -- 15 mls per 30 Days 480mcg/0.8ml -- 24 mls per 30 Days |
Neupogen (Filgrastim) 480mcg/1.6ml Vial | 48 mls per 30 Days |
Pulmozyme (Dornase Alfa) 1mg/ml Inhalation Solution | 150 mls per 30 Days |
Rebif (Interferon Beta-1A - Albumin) Disposable Syringe | 22mcg/0.5ml -- 6 mls per 28 Days 44mcg/0.5ml -- 6 mls per 28 Days Titration Pack -- 4.2 mls per 30 Days |
Stelara (Ustekinumab) 45mg/0.5ml Vial | 0.5 mls (1 vial) per 84 Days10mg and 20mg Tablets |
