Miscellaneous

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

Miscellaneous
Drugs	Quantity Limits
Aerochamber (Inhaler Assistance) Devices	2 Units per 30 Days
Arixtra (Fondaparinux Sodium) 2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml and 10mg/0.8ml Disposable Syringes	30 Syringes (doses) per 30 Days
Exforge (Amlodipine - Valsartan) 5mg - 160mg, 5mg - 320mg, 10mg - 160mg and 10mg - 320mg Tablets	30 Tablets per 30 Days
Exforge HCT (Amlodipine - Valsartan - Hydrochlorothiazide) 5mg - 160mg - 12.5mg, 5mg - 160mg - 25mg, 10mg - 160mg - 12.5mg, 10mg - 160mg - 25mg and 10mg - 320mg - 25mg Tablets	30 Tablets per 30 Days
Iressa (Gefitinib) 250mg Tablets	30 Tablets per 30 Days
Kenalog (Triamcinolone Acetonide) 10mg/ml and 40mg/ml Vial	10 mls per 7 Days
Revatio (Sildenafil Citrate) 20mg Tablets	90 Tablets per 30 Days
Savella (Milnacipran HCL) DS PK Tablets 12.5mg, 25mg, 50mg and 100mg Tablets	55 Tablets per 28 days 60 Tablets per 30 days
Somatuline Depot (Lanreotide Acetate) Sub-Q Diposable Syringe	60mg/0.2ml - 0.2 mls (1 Syringe) per 28 Days 90mg/0.3ml - 0.3 mls (1 Syringe) per 28 Days 120mg/0.5ml - 0.5 mls (1 Syringe) per 28 Days
Toviaz (Fesoterodine Fumarate) 4mg and 8mg SR Tablets	30 Tablets per 30 Days
Zelapar (Selegiline HCL) 1.25mg Rapdis Tablets	100 Tablets per 50 Days