Allergy Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override

Allergy Medications - Oral and Nasal
Drugs	Quantity Limits
Astelin (Azelastine HCL) 137mcg Nasal Spray/Pump	30 mls per 30 Days
Astepro (Azelastine HCL) 137mcg and 205.5mcg Nasal Spray/Pump	30 mls per 30 Days
Atrovent (Ipratropium Bromide) 21mcg and 42mcg Nasal Spray	30 mls per 30 Days
Beconase AQ (Beclomethasone Dipropionate) 42mcg Nasal Spray	50 gms per 30 Days
Flonase (Fluticasone Propionate) 50mcg Nasal Spray Suspension	16 gms per 30 Days
Nasacort AQ (Triamcinolone Acetonide) 55mcg Nasal Spray	33 gms per 30 Days
Nasalide (Flunisolide) 0.25% Nasal Spray	75 mls per 30 Days
Nasarel (Flunisolide) 29mcg Nasal Spray	75 mls per 30 Days
Nasonex (Mometasone Furoate) 50mcg Nasal Spray/Pump	17 gms per 30 Days
Omnaris (Ciclesonide) 50mcg Nasal Spray/Pump	12.5 gms per 30 Days
Patanase (Olopatadine HCL) 0.6% Nasal Spray/Pump	30.5 gms per 30 Days
Rhinocort Aqua (Budesonide) 32mcg Nasal Spray/Pump	9 gms per 30 Days
Veramyst (Fluticasone Furoate) 27.5mcg Nasal Spray Suspension	10 gms per 30 Days
Zyrtec (Cetirizine HCL) 5mg and 10mg Tablets and Chewable Tablets	30 Tablets per 30 Days