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Maximum Allowable Daily Dosage and ... - Optima Health

Maximum Allowable Daily Dosage and Quantity Limits April 2019. With the safety of our members in mind, we regularly review recommendations from the Food and Drug Administration (FDA) and evidence-based treatment guidelines from the medical literature with our Pharmacy and Therapeutics Committee and network specialists. All have advised Optima Health to implement Maximum Daily Dosage limits for certain classes of drugs as recommended by the FDA. Please note that benefits have not changed. There may be rare exceptions necessitating the use of higher than recommended dosages of medications and Pharmacy Care Services will review dosing exception requests on a case-by-case basis via the Maximum Daily Dosage Limit Exceptions Request Form found on the Optima Health website. Please note that quantity limits apply to any FDA-approved generic equivalents.

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Transcription of Maximum Allowable Daily Dosage and ... - Optima Health

1 Maximum Allowable Daily Dosage and Quantity Limits April 2019. With the safety of our members in mind, we regularly review recommendations from the Food and Drug Administration (FDA) and evidence-based treatment guidelines from the medical literature with our Pharmacy and Therapeutics Committee and network specialists. All have advised Optima Health to implement Maximum Daily Dosage limits for certain classes of drugs as recommended by the FDA. Please note that benefits have not changed. There may be rare exceptions necessitating the use of higher than recommended dosages of medications and Pharmacy Care Services will review dosing exception requests on a case-by-case basis via the Maximum Daily Dosage Limit Exceptions Request Form found on the Optima Health website. Please note that quantity limits apply to any FDA-approved generic equivalents.

2 Contact Optima Health Member Services at the number on the back of your member ID card if you have any questions regarding your coverage of benefits. LABEL NAME QTY. LIMIT LABEL NAME QTY. LIMIT. ACETAMINOPHEN-CAFFEINE- AMERGE TAB 9 TABS/30 DAY. DIHYDROCODEINE CAP 10 CAPS/DAY. AMPHET/DEXTR TAB 10MG 6 TABS/DAY. MG (TREZIX). ACETAMINOPHEN W/ CODEINE AMPHET/DEXTR TAB TABS/DAY. 10 TABS/DAY. TAB 300-15 MG. AMPHET/DEXTR TAB 15MG 4 TABS/DAY. ACETAMINOPHEN W/ CODEINE. 10 TABS/DAY AMPHET/DEXTR TAB 20MG 3 TABS/DAY. TAB 300-30 MG. ACETAMINOPHEN W/ CODEINE AMPHET/DEXTR TAB 30MG 2 TABS/DAY. 10 TABS/DAY AMPHET/DEXTR TAB 5MG 12 TABS/DAY. TAB 300-60 MG. ACETAMINOPHEN W/ CODEINE AMPHET/DEXTR TAB 8 TABS/DAY. 150 ML/DAY. SOLN 120-12 MG/5ML AMPHETAMINE CAP 10MG ER 6 CAPS/DAY. ACETAMINOPHEN W/ CODEINE AMPHETAMINE CAP 15MG ER 4 CAPS/DAY.

3 150 ML/DAY. SUSP 120-12 MG/5ML AMPHETAMINE CAP 20MG ER 3 CAPS/DAY. ASPIRIN-CAFFEINE- AMPHETAMINE CAP 25MG ER CAPS/DAY. DIHYDROCODEINE CAP 10 CAPS/DAY AMPHETAMINE CAP 30MG ER 2 CAPS/DAY. MG. AMPHETAMINE CAP 5MG ER 12 CAPS/DAY. ADEMPAS TAB 15 TABS/DAY. AMPYRA TAB 60 TABS/30 DAYS. ADEMPAS TAB 1MG 7 TABS/DAY. ANZEMET TAB 10 TABS/RX. ADEMPAS TAB 5 TABS/DAY. APTENSIO XR CAP 60 MG/DAY. ADEMPAS TAB 2MG 3 TABS/DAY. AQUORAL AER 40 ML/30 DAYS. ADEMPAS TAB 3 TABS/DAY. ARIPIPRAZOLE TAB 30 MG/DAY. ADDERALL TAB 10MG 6 TABS/DAY. ARMODAFINIL TAB 250 MG/DAY. ADDERALL TAB TABS/DAY. ARYMO ER TAB 15MG 6 TABS/DAY. ADDERALL TAB 15MG 4 TABS/DAY. ARYMO ER TAB 30MG 3 TABS/DAY. ADDERALL TAB 20MG 3 TABS/DAY. ARYMO ER TAB 60MG 2 TABS/DAY. ADDERALL TAB 30MG 2 TABS/DAY. AURYXIA TAB 360 TABS/30 DAYS. ADDERALL TAB 5MG 12 TABS/DAY. AUSTEDO TAB 6MG 8 TABS/DAY.

4 ADDERALL TAB 8 TABS/DAY. AUSTEDO TAB 9MG TABS/DAY. ADDERALL XR CAP 10MG 6 CAPS/DAY. AUSTEDO TAB 12MG 4 TABS/DAY. ADDERALL XR CAP 15MG 4 CAPS/DAY. BELBUCA MIS 75 MCG 2 FILMS/DAY. ADDERALL XR CAP 20MG 3 CAPS/DAY. BELBUCA MIS 150 MCG 2 FILMS/DAY. ADDERALL XR CAP 25MG CAPS/DAY. BELBUCA MIS 300 MCG 2 FILMS/DAY. ADDERALL XR CAP 30MG 2 CAPS/DAY. BELBUCA MIS 450 MCG 2 FILMS/DAY. ADDERALL XR CAP 5MG 12 CAPS/DAY. BELBUCA MIS 600 MCG 2 FILMS/DAY. ADZENYS XR TAB, ER SOLUTION (15ML)/DAY. BELBUCA MIS 750 MCG 2 FILMS/DAY. AIMOVIG INJ 70MG/ML 2 SYR(2ML)/30 DAYS. BELBUCA MIS 900 MCG 2 FILMS/DAY. 1 SYR( )/30. AJOVY INJ 225 BELSOMRA TAB 30 TABS/30 DAYS. DAYS. BEVYXXA CAP 43 CAPS/365 DAY. ALECENSA CAP 150MG 8 CAPS/DAY. BUNAVAIL MIS 4 FILMS/DAY. ALLZITAL TAB 25-325MG 12 TABS/DAY. BUNAVAIL MIS 2 FILMS/DAY. ALMOTRIPTAN TAB 12 TABS/30 DAYS.

5 BUNAVAIL MIS 1 FILM/DAY. AKYNZEO CAP 1 CAP/28 DAY. BUPREN/NALOX SUB TAB 24 MG/DAY. AMBIEN TAB 10MG 30 TABS/30 DAY. BUPREN/NALOX SUB FILM 24 MG/DAY. AMBIEN TAB 5MG 60 CAPS/30 DAY. BUPRENORPHIN SUB TAB 24 MG/DAY. AMBIEN CR TAB 30 TABS/30 DAY. AMBIEN CR TAB 30 TABS/30 DAY BUPRENORPHIN SUB 2MG (Medicaid) 3 TABS/DAY. AMERGE TAB 1MG 9 TABS/30 DAY BUPRENORPHIN SUB 8MG (Medicaid) 2 TABS/DAY. This document is updated quarterly and is current at the time of printing. It is provided as a reference and is subject to change. Not all drugs listed may be covered under every Plan. Some drugs may require prior authorization or a step-edit. Please check the website, for updates. April 2019 Rev: 3/29/2019. 1. Maximum Allowable Daily Dosage and Quantity Limits April 2019. LABEL NAME QTY. LIMIT LABEL NAME QTY. LIMIT. BUPROBAN TAB 150MG TWO 90 DAY CLOZAPINE TAB 100/ODT 9 TABS/DAY.

6 SUPPLIES/183 DAYS. CLOZAPINE TAB 100MG 9 TABS/DAY. BUPROPION TAB 100MG TABS/DAY. CLOZAPINE TAB 72 TABS/DAY. BUPROPION TAB 100MG ER TABS/DAY. CLOZAPINE TAB 150/ODT 6 TABS/DAY. BUPROPION TAB 100MG SR TABS/DAY. TWO 90 DAY CLOZAPINE TAB 200/ODT TABS/DAY. BUPROPION TAB 150MG. SUPPLIES/183 DAYS CLOZAPINE TAB 200MG TABS/DAY. BUPROPION TAB 150MG ER 3 TABS/DAY CLOZAPINE TAB 25MG 36 TABS/DAY. BUPROPION TAB 150MG SR 3 TABS/DAY CLOZAPINE TAB 25MG ODT 36 TABS/DAY. BUPROPION TAB 200MG ER TABS/DAY CLOZAPINE TAB 50MG 18 TABS/DAY. BUPROPION TAB 75MG 6 TABS/DAY CLOZARIL TAB 100MG 9 TABS/DAY. BUPROPN HCL TAB 150MG XL 3 TABS/DAY CLOZARIL TAB 25MG 36 TABS/DAY. BUPROPN HCL TAB 300MG XL TABS/DAY CODEINE SULFATE TAB 15 MG 24 TABS/DAY. BUTAL/APAP TAB 50-325MG 6 TABS/DAY CODEINE SULFATE TAB 30 MG 12 TABS/DAY. BUTALBITAL-ACETAMINOPHEN- CODEINE SULFATE TAB 60 MG 6 TABS/DAY.

7 6 TABS/DAY. CAFF W/ COD CAP 50-300-40-30 MG. CODEINE SULFATE ORAL SOLN 30. BUTALBITAL-ACETAMINOPHEN- 60 ML/DAY. 6 TABS/DAY MG/5ML. CAFF W/ COD CAP 50-325-40-30 MG. COMETRIQ KIT 60 MG 84 CAPS/30 DAYS. BUTALBITAL-ASPIRIN-CAFF W/. 6 TABS/DAY COMETRIQ KIT 100 MG 56 CAPS/30 DAYS. CODEINE CAP 50-325-40-30 MG. COMETRIQ KIT 140 MG 112 CAPS/30 DAYS. BUTORPHANOL TARTRATE NASAL. 2 BOTTLES/30 DAYS CONCERTA TAB 18MG 4 TABS/DAY. SOLN 10 MG/ML. BUTRANS DIS 10 MCG/HR 4 PATCHES/DAY CONCERTA TAB 27MG TABS/DAY. BUTRANS DIS 15 MCG/HR 4 PATCHES/DAY CONCERTA TAB 36MG 2 TABS/DAY. CONCERTA TAB 54MG TABS/DAY. BUTRANS DIS 20 MCG/HR 4 PATCHES/DAY. COTEMPLA TAB 6 TABS/DAY. BUTRANS DIS 5 MCG/HR 4 PATCHES/DAY COTEMPLA TAB 3 TABS/DAY. BUTRANS DIS 4 PATCHES/DAY COTEMPLA TAB 2 TABS/DAY. CABOMETYX TAB 20MG 1 TAB/DAY CUPRIMINE CAP 250MG 16 CAPS/DAY.

8 CABOMETYX TAB 40MG 1 TAB/DAY CYMBALTA CAP 20MG 6 CAPS/DAY. CABOMETYX TAB 60MG 1 TAB/DAY CYMBALTA CAP 30MG 4 CAPS/DAY. CALCIUM ACETATE (Eliphos ) 360 TABS/30 DAY CYMBALTA CAP 60MG 2 CAPS/DAY. CALCIUM ACETATE (Phoslo ) 360 TABS/30 DAY D-PENAMINE TAB 125MG 32 TABS/DAY. CALQUENCE CAP 100MG 2 CAPS/DAY DAYTRANA DIS 1 PATCH/DAY. CAMBIA SACHET 9 SACHETS/30 DAYS DESOXYN TAB 5MG 5 TABS/DAY. CELECOXIB CAP 50 MG 8 CAPS/DAY DESVENLAFAXINE TAB 100MG ER 100 MG/DAY. CELECOXIB CAP 100 MG 4 CAPS/DAY DESVENLAFAX TAB 50MG ER 100 MG/DAY. CELECOXIB CAP 200 MG 2 CAPS/DAY DEXEDRINE CAP 10MG CR 6 CAPS/DAY. CELECOXIB CAP 400 MG 1 CAP/DAY DEXEDRINE CAP 15MG CR 4 CAPS/DAY. CELEXA TAB 10MG 4 TABS/DAY DEXEDRINE CAP 5MG CR 12 CAPS/DAY. CELEXA TAB 20MG 2 TABS/DAY DEXEDRINE TAB 10MG 6 TABS/DAY. CELEXA TAB 40MG 1 TAB/DAY DEXEDRINE TAB 5MG 12 TABS/DAY.

9 CERDELGA CAP 84MG 2 CAPS/DAY DEXMETHYLPH CAP 15MG ER CAPS/DAY. CAPHOSOL SOL 120 ML/30 DAYS DEXMETHYLPH CAP 30MG ER CAPS/DAY. TWO 90 DAY DEXMETHYLPH CAP 40MG ER 1 CAP/DAY. CHANTIX. SUPPLIES/183 DAYS DEXMETHYLPH TAB 10MG 2 TABS/DAY. CHLORPROMAZ TAB 100MG 8 TABS/DAY DEXMETHYLPH TAB 8 TABS/DAY. CHLORPROMAZ TAB 10MG 80 TABS/DAY DEXMETHYLPH TAB 5MG 4 TABS/DAY. CHLORPROMAZ TAB 200MG 4 TABS/DAY DEXMETHYLPHE CAP 10MG ER 4 CAPS/DAY. CHLORPROMAZ TAB 25MG 32 TABS/DAY DEXMETHYLPHE CAP 20MG ER 2 CAPS/DAY. CHLORPROMAZ TAB 50MG 16 TABS/DAY DEXMETHYLPHE CAP 5MG ER 8 CAPS/DAY. CIALIS TAB 10MG 4 TABS/30 DAY DEXTROAMPHET CAP 10MG ER 6 CAPS/DAY. CIALIS TAB 5 TABS/30 DAY DEXTROAMPHET CAP 15MG ER 4 CAPS/DAY. CIALIS TAB 20MG 4 TABS/30 DAY DEXTROAMPHET CAP 5MG ER 12 CAPS/DAY. CIALIS TAB 5MG 4 TABS/30 DAY DEXTROAMPHET TAB 10MG 6 TABS/DAY.

10 CITALOPRAM SOL 10MG/5ML 20 ML/DAY DEXTROAMPHET TAB 5MG 12 TABS/DAY. CITALOPRAM TAB 10MG 4 TABS/DAY DIFICID TAB 200MG 20 TABS/10 DAYS. CITALOPRAM TAB 20MG 2 TABS/DAY DIHYDROERGOT SPRAY. 8 BOTTLES/30 DAYS. CITALOPRAM TAB 40MG 1 TABS/DAY (Migranal ). CITALOPRAM TAB OVER 60 20 MG/DAY DULOXETINE CAP 20MG 6 CAPS/DAY. This document is updated quarterly and is current at the time of printing. It is provided as a reference and is subject to change. Not all drugs listed may be covered under every Plan. Some drugs may require prior authorization or a step-edit. Please check the website, for updates. April 2019 Rev: 3/29/2019. 2. Maximum Allowable Daily Dosage and Quantity Limits April 2019. LABEL NAME QTY. LIMIT LABEL NAME QTY. LIMIT. DULOXETINE CAP 30MG 4 CAPS/DAY FENTANYL CITRATE LOZENGE 800 4 LOZ/DAY. DULOXETINE CAP 40MG 3 CAPS/DAY MCG.


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