Anti-Infectives
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Anti-Infectives |
Drugs
|
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 |