Irritable Bowel System Medications
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Irritable Bowel System Medications |
Drugs | Quantity Limits |
Amitiza (Lubiprostone) 8mcg and 24mcg Capsules | 100 Capsules per 50 Days |
Lotronex (Alosetron HCL) 0.5mg and 1mg Tablets | 60 Tablets per 30 Days |
Zelnorm (Tegaserod Hydrogen Maleate) 2mg and 6mg Tablets | 60 Tablets per 30 Days |
Last Modified on
Nov 17, 2020
