Inhaled Meds Oral Inhalers Quantity Limits list

Brand Name

Advair Diskus Advair HFA

Airduo Digihaler Airduo Respiclick

Albuterol HFA

Alvesco Alvesco Anoro Ellipta Arcapta Neohaler Armonair Digihaler Arnuity Ellipta Asmanex HFA Asmanex Twisthaler Asmanex Twisthaler Atrovent HFA Bevespi Aerosphere

Breo Ellipta

Breztri Aerosphere Combivent Respimat

Duaklir Pressair

Dulera Flovent Diskus Flovent Diskus Flovent HFA

Inhaled Meds ? Oral Inhalers Quantity Limits list

Generic Name

Drug Strength

Max Billable Units per 30 Days

Dose Form (ea) (ml) (gm)

Fluticasone/Salmeterol

100-50mcg; 250-50mcg; 500-50mcg

60 = 1 inhaler

ea

Fluticasone/Salmeterol

45-21mcg; 115-21mcg; 230-21mcg

8 or 12 = 1 inhaler

gm

Fluticasone/Salmeterol

55-14mcg; 113-14mcg; 232-14mcg

1 = 1 inhaler

ea

Fluticasone/Salmeterol Albuterol Ciclesonide

55-14mcg; 113-14mcg; 232-14mcg

1 = 1 inhaler

ea

90mcg

Refer to Proair HFA, Proventil

HFA, and Ventolin HFA =

gm

2 inhalers

80mcg

6.1 = 1 inhaler

gm

Ciclesonide

Umeclidinium bromide/vilanterol trifenatate

Indacaterol

160mcg 62.5-25mcg

75mcg

12.2 = 2 inhalers

gm

60 = 1 inhaler

ea

30 =1 inhaler

ea

Fluticasone

55mcg; 113mcg; 232mcg

1 = 1 inhaler

ea

Fluticasone

50mcg; 100mcg; 200mcg

30 = 1 inhaler

ea

Mometasone

50mcg; 100mcg; 200mcg

13 = 1 inhaler

gm

Mometasone

110mcg

1 = 1 inhaler

ea

Mometasone

220mcg

1 = 1 inhaler

ea

Ipratropium

17mcg

25.8 = 2 inhalers

gm

Glycopyrrolate/formoterol fumarate

fluticasone furoate/vilanterol trifenatate

Budesonide/glycopyrrolate/ formoterol fumarate

9-4.8mcg 100-25mcg; 200-25mcg

160-9-4.8mcg

10.7 = 1 inhaler

gm

60 = 1 inhaler

ea

10.7 = 1 inhaler

gm

ipratropium bromide/albuterol

20-100mcg

4 = 1 inhaler

gm

aclidinium bromide/formoterol fumarate

400-12mcg

1 = 1 inhaler

ea

mometasone furoate/formoterol fumarate dihydrate

50-5mcg; 100-5mcg; 200-5mcg

13 = 1 inhaler

gm

Fluticasone

50mcg; 100mcg

60 = 1 diskus

ea

Fluticasone

250mcg

120 = 2 diskus

ea

Fluticasone

44mcg

10.6 = 1 inhaler

gm

Original Effective 08/16/2019 Implemented 11/3/2020

Brand Name Flovent HFA Flovent HFA Incruse Ellipta Levalbuterol HFA Proair Digihaler ProAir HFA ProAir Respiclick Proventil HFA Pulmicort Flexhaler Pulmicort Flexhaler Qvar Oral Inhaler Qvar Redihaler Qvar Redihaler Seebri Neohaler Serevent Diskus Spiriva Handihaler Spiriva Respimat Stiolto Respimat Striverdi Respimat

Symbicort

Trelegy Ellipta

Tudorza Pressair Utibron Neohaler

Ventolin HFA Wixela

Xopenex HFA

Inhaled Meds ? Oral Inhalers Quantity Limits list

Generic Name

Drug Strength

Max Billable Units per 30 Days

Fluticasone

110mcg

12 = 1 inhaler

Fluticasone

220mcg

24 = 2 inhalers

Umeclidinium

62.5mcg

30 = 1 inhaler

Levalbuterol

45mcg

30 = 2 inhalers

Albuterol

90mcg

2 = 2 inhalers

Albuterol

90mcg

17 = 2 inhalers

Albuterol

97mcg

2 = 2 inhalers

Albuterol

90mcg

13.4 =2 inhalers

Budesonide

90mcg

1 = 1 inhaler

Budesonide

180mcg

1 = 1 inhaler

Beclomethasone dipropionate

40mcg

17.4 = 2 inhalers

beclomethasone dipropionate

40mcg

10.6 = 1 inhaler

Beclomethasone dipropionate

80mcg

21.2 = 2 inhalers

Glycopyrrolate

15.6mcg

60 = 1 inhaler

Salmeterol

50mcg

60 = 1 inhaler

Tiotropium

18mcg

30 = 1 kit

Tiotropium

1.25mcg; 2.5mcg

4 = 1 inhaler

tiotropium bromide/olodaterol

2.5-2.5mcg

4 = 1 inhaler

olodaterol

Budesonide/formoterol fumarate dihydrate

fluticasone furoate/umeclidinium bromide/ vilanterol trifenatate

aclidinium bromide

2.5mcg

80-4.5mcg; 160-4.5mcg 100-62.5-25mcg 200-62.5-25mcg 400mcg

4 = 1 inhaler 10.2 = 1 inhaler 60 = 1 inhaler

1 = 1 inhaler

Indacaterol/glycopyrrolate

27.5-15.6mcg

60 = 1 inhaler

Albuterol

90mcg

16 or 36 =2 inhalers

Fluticasone/Salmeterol

100-50mcg; 250-50mcg; 500-50mcg

60 = 1 inhaler

Levalbuterol

45mcg

30 = 2 inhalers

Dose Form (ea) (ml) (gm)

gm gm ea gm ea gm ea gm ea ea gm gm gm ea ea ea gm gm gm

gm

ea

ea ea gm ea gm

Original Effective 08/16/2019 Implemented 11/3/2020

Brand Name

Albuterol Albuterol Albuterol AccuNeb AccuNeb Atrovent Brovana Duoneb

Intal Lonhala Magnair

Perforomist Pulmicort Respules Pulmicort Respules

Xopenex Xopenex Concentrate

Yupelri

Inhaled Meds ? Nebulizer Solutions Quantity Limits list

Generic Name

Drug Strength

Max Billable Units per 30 Days

Dose Form (ea) (ml) (gm)

Albuterol sulfate

0.083% vial Neb = 2.5mg/3ml

375ml

ml

Albuterol sulfate

0.5% inhalation solution

60ml

ml

Albuterol sulfate

2.5mg/0.5ml vial Neb

60ml = 4 boxes

ml

Albuterol sulfate

0.63mg/3ml vial Neb

375ml

ml

Albuterol sulfate

1.25mg/3ml vial Neb

375ml

ml

Ipratropium bromide

0.02% vial Neb

300ml

ml

Arformoterol tartrate

15mcg/2ml vial Neb

120ml

ml

Ipratropium bromide/ Albuterol

0.5mg-3mg/3ml vial Neb

540ml

ml

Cromolyn sodium

20mg/2ml vial Neb

240ml

ml

Glycopyrrolate

25mcg

60ml = 1 kit of starter or refill

ml

Formoterol fumarate

20mcg/2ml vial Neb

120ml

ml

Budesonide

0.25mg/2ml; 0.5mg/2ml amp Neb

120ml

ml

Budesonide

1mg/2ml amp Neb

60ml

ml

Levalbuterol

0.31mg/3ml; 0.63mg/3ml; 1.25mg/3ml vial Neb

288ml

ml

Levalbuterol

1.25mg/0.5ml

90 vials

ea

Revefenacin

175mcg/3ml vial Neb

90ml

ml

Original Effective 08/16/2019 Implemented 11/3/2020

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download