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
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