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Irritable Bowel System Medications

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

Irritable Bowel System Medications

Drugs

Quantity Limits

Amitiza (Lubiprostone) 8mcg and 24mcg Capsules

100 Capsules per 50 Days

Lotronex (Alosetron HCL) 0.5mg and 1mg Tablets 

60 Tablets per 30 Days

Zelnorm (Tegaserod Hydrogen Maleate) 2mg and 6mg Tablets 

60 Tablets per 30 Days

 

Last Modified on Nov 17, 2020
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