Lipid Reducers

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Lipid Reducers

Drugs	Quantity Limits
Advicor (Niacin - Lovastatin) 500mg - 20mg, 750mg - 20 mg, 1000mg - 20mg and 1000mg - 40mg Tablets	30 Tablets per 30 Days
Questran (Cholestyramine - Sucrose) 4gm Packets	60 Packets per 30 Days
Questran Light (Cholestyramine - Aspartame) 4gm Packets	60 Packets per 30 Days
Simcor (Niacin - Simvastatin) 500mg - 20mg, 750mg - 20mg and 1000mg - 20mg Tablets	30 Tablets per 30 Days

Last Modified on Nov 17, 2020

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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