Diabetic Medications
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Diabetic Medications |
Drugs | Quantity Limits |
Byetta (Exenatide) Sub-Q Pen Injector | 5mcg/0.02ml -- 3.6 mls per 90 Days 10mcg/0.04ml -- 7.2 mls per 90 Days |
Insulin Assorted Vial | 40 mls per 30 Days |
Insulin Assorted Pen Injectors and Cartridges | 45 mls per 30 Days |
Last Modified on
Nov 17, 2020
