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Antitussive Combination Products Quantity Limit Program Summary
Policy Number: PH-1195
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
04-01-2024 |
|
FDA APPROVED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
Hydrocod Polst-Chlorphen Polst Cap ER 12HR 10-8 MG |
|
20 |
Capsules |
30 |
DAYS |
Not covered for patients less than 18 years of age. |
|
|
|
Hydrocod Polst-Chlorphen Polst ER Susp 10-8 MG/5ML |
10-8 MG/5ML |
100 |
mLs |
30 |
DAYS |
Not covered for patients less than 18 years of age. |
|
|
Tuxarin er |
Codeine Phos-Chlorpheniramine Maleate Tab ER 12HR 54.3-8 MG |
54.3-8 MG |
20 |
Tablets |
30 |
DAYS |
Not covered for patients less than 18 years of age. |
|
|
Tuzistra xr |
Codeine Polist-Chlorphen Polist ER Susp 14.7-2.8 MG/5ML |
14.7-2.8 MG/5ML |
200 |
mLs |
30 |
DAYS |
Not covered for patients less than 18 years of age. |
|
|
ADDITIONAL QUANTITY LIMIT INFORMATION
Wildcard |
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Additional QL Information |
Targeted NDCs When Exclusions Exist |
Effective Date |
Term Date |
|
|||||||
43995202366930 |
|
Hydrocod Polst-Chlorphen Polst Cap ER 12HR 10-8 MG |
|
Not covered for patients less than 18 years of age. |
|
|
04-01-2024 |
4399520236G110 |
|
Hydrocod Polst-Chlorphen Polst ER Susp 10-8 MG/5ML |
10-8 MG/5ML |
Not covered for patients less than 18 years of age. |
|
|
|
43995202327430 |
Tuxarin er |
Codeine Phos-Chlorpheniramine Maleate Tab ER 12HR 54.3-8 MG |
54.3-8 MG |
Not covered for patients less than 18 years of age. |
|
|
|
4399520231G120 |
Tuzistra xr |
Codeine Polist-Chlorphen Polist ER Susp 14.7-2.8 MG/5ML |
14.7-2.8 MG/5ML |
Not covered for patients less than 18 years of age. |
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
Hydrocod Polst-Chlorphen Polst Cap ER 12HR 10-8 MG |
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocod Polst-Chlorphen Polst ER Susp 10-8 MG/5ML |
10-8 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tuxarin er |
Codeine Phos-Chlorpheniramine Maleate Tab ER 12HR 54.3-8 MG |
54.3-8 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tuzistra xr |
Codeine Polist-Chlorphen Polist ER Susp 14.7-2.8 MG/5ML |
14.7-2.8 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity Limit for the Target Agent(s) will be approved when BOTH of the following are met:
Length of Approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
ALBP _ Commercial _ CS _ Antitussive_Combination_Products_QL _ProgSum_ 04-01-2024 _© Copyright Prime Therapeutics LLC. February 2024 All Rights Reserved