Transcription of Inhaled Meds Oral Inhalers Quantity Limits list
1 Inhaled meds oral Inhalers Quantity Limits list Original Effective 08/16/2019 Implemented 11/3/2020 Brand Name Generic Name Drug Strength Max Billable Units per 30 Days Dose Form (ea) (ml) (gm) Advair Diskus Fluticasone/Salmeterol 100-50mcg; 250-50mcg; 500-50mcg 60 = 1 inhaler ea Advair HFA Fluticasone/Salmeterol 45-21mcg; 115-21mcg; 230-21mcg 8 or 12 = 1 inhaler gm Airduo Digihaler Fluticasone/Salmeterol 55-14mcg; 113-14mcg; 232-14mcg 1 = 1 inhaler ea Airduo Respiclick Fluticasone/Salmeterol 55-14mcg; 113-14mcg; 232-14mcg 1 = 1 inhaler ea Albuterol HFA Albuterol 90mcg Refer to Proair HFA, Proventil HFA, and Ventolin HFA = 2 Inhalers gm Alvesco Ciclesonide 80mcg = 1 inhaler gm Alvesco Ciclesonide 160mcg = 2 Inhalers gm Anoro Ellipta Umeclidinium bromide/vilanterol trifenatate 60 = 1 inhaler ea Arcapta Neohaler Indacaterol 75mcg 30 =1 inhaler ea Armonair Digihaler Fluticasone 55mcg; 113mcg; 232mcg 1 = 1 inhaler ea Arnuity Ellipta Fluticasone 50mcg; 100mcg; 200mcg 30 = 1 inhaler ea Asmanex HFA Mometasone 50mcg; 100mcg.
2 200mcg 13 = 1 inhaler gm Asmanex Twisthaler Mometasone 110mcg 1 = 1 inhaler ea Asmanex Twisthaler Mometasone 220mcg 1 = 1 inhaler ea Atrovent HFA Ipratropium 17mcg = 2 Inhalers gm Bevespi Aerosphere Glycopyrrolate/formoterol fumarate = 1 inhaler gm Breo Ellipta fluticasone furoate/vilanterol trifenatate 100-25mcg; 200-25mcg 60 = 1 inhaler ea Breztri Aerosphere Budesonide/glycopyrrolate/ formoterol fumarate = 1 inhaler gm Combivent Respimat ipratropium bromide/albuterol 20-100mcg 4 = 1 inhaler gm Duaklir Pressair aclidinium bromide/formoterol fumarate 400-12mcg 1 = 1 inhaler ea Dulera mometasone furoate/formoterol fumarate dihydrate 50-5mcg; 100-5mcg; 200-5mcg 13 = 1 inhaler gm Flovent Diskus Fluticasone 50mcg.
3 100mcg 60 = 1 diskus ea Flovent Diskus Fluticasone 250mcg 120 = 2 diskus ea Flovent HFA Fluticasone 44mcg = 1 inhaler gm Inhaled meds oral Inhalers Quantity Limits list Original Effective 08/16/2019 Implemented 11/3/2020 Brand Name Generic Name Drug Strength Max Billable Units per 30 Days Dose Form (ea) (ml) (gm) Flovent HFA Fluticasone 110mcg 12 = 1 inhaler gm Flovent HFA Fluticasone 220mcg 24 = 2 Inhalers gm Incruse Ellipta Umeclidinium 30 = 1 inhaler ea Levalbuterol HFA Levalbuterol 45mcg 30 = 2 Inhalers gm Proair Digihaler Albuterol 90mcg 2 = 2 Inhalers ea ProAir HFA Albuterol 90mcg 17 = 2 Inhalers gm ProAir Respiclick Albuterol 97mcg 2 = 2 Inhalers ea Proventil HFA Albuterol 90mcg =2 Inhalers gm Pulmicort Flexhaler Budesonide 90mcg 1 = 1 inhaler ea Pulmicort Flexhaler Budesonide 180mcg 1 = 1 inhaler ea Qvar oral inhaler Beclomethasone dipropionate 40mcg = 2 Inhalers gm Qvar Redihaler beclomethasone dipropionate 40mcg = 1 inhaler gm Qvar
4 Redihaler Beclomethasone dipropionate 80mcg = 2 Inhalers gm Seebri Neohaler Glycopyrrolate 60 = 1 inhaler ea Serevent Diskus Salmeterol 50mcg 60 = 1 inhaler ea Spiriva Handihaler Tiotropium 18mcg 30 = 1 kit ea Spiriva Respimat Tiotropium ; 4 = 1 inhaler gm Stiolto Respimat tiotropium bromide/olodaterol 4 = 1 inhaler gm Striverdi Respimat olodaterol 4 = 1 inhaler gm Symbicort Budesonide/formoterol fumarate dihydrate ; = 1 inhaler gm Trelegy Ellipta fluticasone furoate/umeclidinium bromide/ vilanterol trifenatate 60 = 1 inhaler ea Tudorza Pressair aclidinium bromide 400mcg 1 = 1 inhaler ea Utibron Neohaler Indacaterol/glycopyrrolate 60 = 1 inhaler ea Ventolin HFA Albuterol 90mcg 16 or 36 =2 Inhalers gm Wixela Fluticasone/Salmeterol 100-50mcg; 250-50mcg.
5 500-50mcg 60 = 1 inhaler ea Xopenex HFA Levalbuterol 45mcg 30 = 2 Inhalers gm Inhaled meds Nebulizer Solutions Quantity Limits list Original Effective 08/16/2019 Implemented 11/3/2020 Brand Name Generic Name Drug Strength Max Billable Units per 30 Days Dose Form (ea) (ml) (gm) Albuterol Albuterol sulfate vial Neb = 375ml ml Albuterol Albuterol sulfate inhalation solution 60ml ml Albuterol Albuterol sulfate vial Neb 60ml = 4 boxes ml AccuNeb Albuterol sulfate vial Neb 375ml ml AccuNeb Albuterol sulfate vial Neb 375ml ml Atrovent Ipratropium bromide vial Neb 300ml ml Brovana Arformoterol tartrate 15mcg/2ml vial Neb 120ml ml Duoneb Ipratropium bromide/ Albuterol vial Neb 540ml ml Intal Cromolyn sodium 20mg/2ml vial Neb 240ml ml Lonhala Magnair Glycopyrrolate 25mcg 60ml = 1 kit of starter or refill ml Perforomist Formoterol fumarate 20mcg/2ml vial Neb 120ml ml Pulmicort Respules Budesonide.
6 Amp Neb 120ml ml Pulmicort Respules Budesonide 1mg/2ml amp Neb 60ml ml Xopenex Levalbuterol ; ; vial Neb 288ml ml Xopenex Concentrate Levalbuterol 90 vials ea Yupelri Revefenacin 175mcg/3ml vial Neb 90ml ml
