Pediculicide Products
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Pediculicide Products |
Drugs
|
Quantity Limits
|
Eurax (Crotamiton) 10 % Cream
|
60 gms per 30 Days |
Eurax (Crotamiton) 10 % Lotion
|
60 mls per 30 Days |
Eurax (Crotamiton) 10 % Suspension
|
60 mls per 30 Days |
Lindane 1% Lotion
|
60 mls per 7 Days |
Lindane 1% Shampoo
|
60 mls per 7 Days |
Ovide (Malathion) 0.5% Lotion
|
59 mls per 7 Days |
Permethrin 1% Liquid
|
120 - 240 mls per 7 Days |
Permethrin 5% Cream
|
60 gms per 7 Days |
Ulesfia (Benzyl Alcohol) 5% Topical Lotion
|
908 mls per 30 days |