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Diabetic Medications

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

Diabetic Medications

Drugs

Quantity Limits

Byetta (Exenatide)  Sub-Q Pen Injector                   

5mcg/0.02ml -- 3.6 mls per 90 Days                                    10mcg/0.04ml -- 7.2 mls per 90 Days

Insulin Assorted Vial 

40 mls per 30 Days 

Insulin Assorted Pen Injectors and Cartridges

45 mls per 30 Days

 

Last Modified on Nov 17, 2020
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