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



Quantity Limits

Alinia (Nitazoxanide) 100mg/5ml Suspension

60 mls per 3 Days

Alinia (Nitazoxanide) 500mg Tablets 

6 Tablets per 3 Days 

Augmentin XR (Amoxicillin / Clavulanate Potassiuim) 100mg / 62.5mg Tablets 

40 Tablets per 10 Days in 30 day period

Biaxin XL (Clarithromycin) 500mg Tablets 

28 Tablets per 14 days in 30 day period

Cipro XR (Ciprofloxacin) Tablets 

 500mg - 28 Tablets per 28 Days in 30 day period            1000mg - 14 Tablets per 14 days in 30 day period

Diflucan (Fluconazole) 150mg Tablets 

7 Tablets per 7 Days in 30 day period

Levaquin (Levofloxacin) 750mg Tablets 

5 Tablets per 5 Days in 30 day period

Zmax Pediatric (Azithromycin) 2gm/60ml Suspension

 1 Unit per 1 Day in 30 day period


Last Modified on Dec 21, 2020
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