Topical Products

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

Topical Products
Drugs	Quantity Limits
Aldara (Imiquimod) 5% Packet	12 Packets per 30 days 24 Packets per 60 Days
Alora (Estradiol) 0.25mg/24hr, 0.05mg/24hr, 0.075mg/24hr and 0.1mg/24hr Transdermal Patches	8 Patches per 28 Days
Catapres-TTS (Clonidine HCL) Transdermal Patches	0.1mg/24hr - 4 Patches per 28 Days 0.2mg/24hr - 8 Patches per 28 Days 0.3mg/24hr - 8 Patches per 28 Days
Climara (Estradiol) 0.025mg/24hr, 0.0375mg/24hr, 0.05mg/24hr, 0.06mg/24hr, 0.075mg/24hr and 0.1mg/24hr Transdermal Patches	4 Patches per 28 Days
Climara Pro (Estradiol - Levonorgestrel) 0.045mg - 0.015mg Transdermal Patch	4 Patches per 28 Days
Combipatch (Estradiol - Norethindrone Acetate) 0.05mg - 0.014mg and 0.05mg-0.25mg Transdermal Patch	8 patches per 28 days
Dovonex (Calcipotriene) 0.005% cream	360 gms per 30 days
Dovonex (Calcipotriene) 0.005% solution	300 mls per 30 days
Elidel (Pimecrolimus) 1% cream	30, 60 or 100 gms per 10, 60 or 100 days
Evamist (Estradiol) 1.53mg/spray Transdermal Spray	8.1 mls per 56 days
Exelon (Rivastigmine) 4.6mg/24hr and 9.5mg/24hr Transdermal Patch	30 patches per 30 days
Menostar (Estradiol) 14mcg/24hr Transdermal Spray	4 patches per 28 days
Neupro (Rotigotine) 2mg/24hr, 4mg/24hr and 6mg/24hr Transdermal Spray	30 patches per 30 days
Panretin (Alitretinoin) 0.1% gel	60 gms per 30 days
Protopic (Tacrolimus) 0.03% Ointment	30, 60 or 100 gms per 10, 60 or 100 days
Protopic (Tacrolimus) 0.1% Ointment	30, 60 or 100 gms per 10, 60 or 100 days
Regranex (Becaplermin) 0.01% gel	15 gms per 30 days
Soriatane CK (Acitrein - Emollient) 10mg and 25mg kit	2 kits per 30 days
Tazorac (Tazarotene) 0.05% and 0.1% cream	100 gms per 30 days
Tazorac (Tazarotene) 0.05% and 0.1% gel	100 gms per 30 days
Vivelle-Dot (Estradiol) 0.0375mg/24hr Transdermal Patch	8 patches per 28 days

Last Modified on Nov 12, 2020