Asset Publisher
Oral Inhalers Quantity Limit Program Summary
Policy Number: PH-1191
This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace.
POLICY REVIEW CYCLE
|
Effective Date |
Date of Origin |
|
7/1/2023 |
|
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 |
|
|
|||||||||
|
|
Indacaterol-Glycopyrrolate Inhal Cap 27.5-15.6 MCG |
|
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Advair diskus ; Wixela inhub |
Fluticasone-Salmeterol Aer Powder BA 100-50 MCG/DOSE |
100-50 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Advair diskus ; Wixela inhub |
Fluticasone-Salmeterol Aer Powder BA 250-50 MCG/DOSE |
0 ; 250-50 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Advair diskus ; Wixela inhub |
Fluticasone-Salmeterol Aer Powder BA 500-50 MCG/DOSE |
500-50 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Advair hfa |
Fluticasone-Salmeterol Inhal Aerosol 115-21 MCG/ACT |
115-21 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Advair hfa |
Fluticasone-Salmeterol Inhal Aerosol 230-21 MCG/ACT |
230-21 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Advair hfa |
Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT |
45-21 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo digihaler 113/14 |
Fluticasone-Salmeterol Aer Powder BA |
113-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo digihaler 232/14 |
Fluticasone-Salmeterol Aer Powder BA |
232-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo digihaler 55/14 |
Fluticasone-Salmeterol Aer Powder BA |
55-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo respiclick 113/14 |
Fluticasone-Salmeterol Aer Powder BA 113-14 MCG/ACT |
113-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo respiclick 113/14 |
Fluticasone-Salmeterol Aer Powder BA 113-14 MCG/ACT |
113-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo respiclick 232/14 |
Fluticasone-Salmeterol Aer Powder BA 232-14 MCG/ACT |
232-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo respiclick 232/14 |
Fluticasone-Salmeterol Aer Powder BA 232-14 MCG/ACT |
232-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo respiclick 55/14 |
Fluticasone-Salmeterol Aer Powder BA 55-14 MCG/ACT |
55-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Airduo respiclick 55/14 |
Fluticasone-Salmeterol Aer Powder BA 55-14 MCG/ACT |
55-14 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Alvesco |
Ciclesonide Inhal Aerosol 160 MCG/ACT |
160 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Alvesco |
Ciclesonide Inhal Aerosol 80 MCG/ACT |
80 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Anoro ellipta |
Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/INH |
62.5-25 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Armonair digihaler |
Fluticasone Propionate Aer Pow BA |
55 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Armonair digihaler |
Fluticasone Propionate Aer Pow BA |
113 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Armonair digihaler |
Fluticasone Propionate Aer Pow BA |
232 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Arnuity ellipta |
Fluticasone Furoate Aerosol Powder Breath Activ 100 MCG/ACT |
100 MCG/ACT |
30 |
Blisters |
30 |
DAYS |
|
|
|
|
Arnuity ellipta |
Fluticasone Furoate Aerosol Powder Breath Activ 200 MCG/ACT |
200 MCG/ACT |
30 |
Blisters |
30 |
DAYS |
|
|
|
|
Arnuity ellipta |
Fluticasone Furoate Aerosol Powder Breath Activ 50 MCG/ACT |
50 MCG/ACT |
30 |
Blisters |
30 |
DAYS |
|
|
|
|
Asmanex hfa |
Mometasone Furoate Inhal Aerosol Suspension 100 MCG/ACT |
100 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Asmanex hfa |
Mometasone Furoate Inhal Aerosol Suspension 200 MCG/ACT |
200 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Asmanex hfa |
Mometasone Furoate Inhal Aerosol Suspension 50 MCG/ACT |
50 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Asmanex twisthaler 120 me ; Asmanex twisthaler 14 met ; Asmanex twisthaler 30 met ; Asmanex twisthaler 60 met |
Mometasone Furoate Inhal Powd 220 MCG/INH (Breath Activated) |
220 MCG/INH |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Asmanex twisthaler 30 met ; Asmanex twisthaler 7 mete |
Mometasone Furoate Inhal Powd 110 MCG/INH (Breath Activated) |
110 MCG/INH |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Atrovent hfa |
Ipratropium Bromide HFA Inhal Aerosol 17 MCG/ACT |
17 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Bevespi aerosphere |
Glycopyrrolate-Formoterol Fumarate Aerosol 9-4.8 MCG/ACT |
9-4.8 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 100-25 MCG/INH |
100-25 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 100-25 MCG/INH |
100-25 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 200-25 MCG/INH |
200-25 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 200-25 MCG/INH |
200-25 MCG/ACT |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Breztri aerosphere |
Budesonide-Glycopyrrolate-Formoterol Aers |
160-9-4.8 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Combivent respimat |
Ipratropium-Albuterol Inhal Aerosol Soln 20-100 MCG/ACT |
20-100 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Duaklir pressair |
Aclidinium Br-Formoterol Fum Aero Pow Br Act 400-12 MCG/ACT |
400-12 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Dulera |
Mometasone Furoate-Formoterol Fumarate Aerosol 100-5 MCG/ACT |
100-5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Dulera |
Mometasone Furoate-Formoterol Fumarate Aerosol 200-5 MCG/ACT |
200-5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Dulera |
Mometasone Furoate-Formoterol Fumarate Aerosol 50-5 MCG/ACT |
50-5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Flovent diskus |
Fluticasone Propionate Aer Pow BA 100 MCG/BLISTER |
100 MCG/BLIST |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Flovent diskus |
Fluticasone Propionate Aer Pow BA 250 MCG/BLISTER |
250 MCG/BLIST |
240 |
Blisters |
30 |
DAYS |
|
|
|
|
Flovent diskus |
Fluticasone Propionate Aer Pow BA 50 MCG/BLISTER |
50 MCG/BLIST |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve) |
110 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve) |
110 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve) |
220 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve) |
220 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve) |
44 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve) |
44 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Incruse ellipta |
Umeclidinium Br Aero Powd Breath Act 62.5 MCG/INH (Base Eq) |
62.5 MCG/INH |
30 |
Blisters |
30 |
DAYS |
|
|
|
|
Proair digihaler |
Albuterol Sulfate Aer Pow BA |
108 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Proair respiclick |
Albuterol Sulfate Aer Pow BA 108 MCG/ACT (90 MCG Base Equiv) |
108 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Pulmicort flexhaler |
Budesonide Inhal Aero Powd 180 MCG/ACT (Breath Activated) |
180 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Pulmicort flexhaler |
Budesonide Inhal Aero Powd 90 MCG/ACT (Breath Activated) |
90 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Qvar redihaler |
Beclomethasone Diprop HFA Breath Act Inh Aer 40 MCG/ACT |
40 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Qvar redihaler |
Beclomethasone Diprop HFA Breath Act Inh Aer 80 MCG/ACT |
80 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Serevent diskus |
Salmeterol Xinafoate Aer Pow BA 50 MCG/DOSE (Base Equiv) |
50 MCG/DOSE |
60 |
Blisters |
30 |
DAYS |
|
|
|
|
Spiriva handihaler |
Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv) |
18 MCG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Spiriva respimat |
Tiotropium Bromide Monohydrate Inhal Aerosol 1.25 MCG/ACT |
1.25 MCG/ACT |
1 |
Cartridge |
30 |
DAYS |
|
|
|
|
Spiriva respimat |
Tiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACT |
2.5 MCG/ACT |
1 |
Cartridge |
30 |
DAYS |
|
|
|
|
Stiolto respimat |
Tiotropium Br-Olodaterol Inhal Aero Soln 2.5-2.5 MCG/ACT |
2.5-2.5 MCG/ACT |
1 |
Cartridge |
30 |
DAYS |
|
|
|
|
Striverdi respimat |
Olodaterol HCl Inhal Aerosol Soln 2.5 MCG/ACT (Base Equiv) |
2.5 MCG/ACT |
1 |
Cartridge |
30 |
DAYS |
|
|
|
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT |
160-4.5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT |
160-4.5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT |
80-4.5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT |
80-4.5 MCG/ACT |
3 |
Inhalers |
30 |
DAYS |
|
|
|
|
Trelegy ellipta |
Fluticasone-Umeclidinium-Vilanterol AEPB |
200-62.5-25 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Trelegy ellipta |
Fluticasone-Umeclidinium-Vilanterol AEPB 100-62.5-25 MCG/INH |
100-62.5-25 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Tudorza pressair |
Aclidinium Bromide Aerosol Powd Breath Activated 400 MCG/ACT |
400 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
|
Xopenex hfa |
Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv) |
45 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
|
Xopenex hfa |
Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv) |
45 MCG/ACT |
2 |
Inhalers |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
Indacaterol-Glycopyrrolate Inhal Cap 27.5-15.6 MCG |
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Advair diskus ; Wixela inhub |
Fluticasone-Salmeterol Aer Powder BA 100-50 MCG/DOSE |
100-50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Advair diskus ; Wixela inhub |
Fluticasone-Salmeterol Aer Powder BA 250-50 MCG/DOSE |
0 ; 250-50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Advair diskus ; Wixela inhub |
Fluticasone-Salmeterol Aer Powder BA 500-50 MCG/DOSE |
500-50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Advair hfa |
Fluticasone-Salmeterol Inhal Aerosol 115-21 MCG/ACT |
115-21 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Advair hfa |
Fluticasone-Salmeterol Inhal Aerosol 230-21 MCG/ACT |
230-21 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Advair hfa |
Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT |
45-21 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo digihaler 113/14 |
Fluticasone-Salmeterol Aer Powder BA |
113-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo digihaler 232/14 |
Fluticasone-Salmeterol Aer Powder BA |
232-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo digihaler 55/14 |
Fluticasone-Salmeterol Aer Powder BA |
55-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo respiclick 113/14 |
Fluticasone-Salmeterol Aer Powder BA 113-14 MCG/ACT |
113-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo respiclick 113/14 |
Fluticasone-Salmeterol Aer Powder BA 113-14 MCG/ACT |
113-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo respiclick 232/14 |
Fluticasone-Salmeterol Aer Powder BA 232-14 MCG/ACT |
232-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo respiclick 232/14 |
Fluticasone-Salmeterol Aer Powder BA 232-14 MCG/ACT |
232-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo respiclick 55/14 |
Fluticasone-Salmeterol Aer Powder BA 55-14 MCG/ACT |
55-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Airduo respiclick 55/14 |
Fluticasone-Salmeterol Aer Powder BA 55-14 MCG/ACT |
55-14 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Alvesco |
Ciclesonide Inhal Aerosol 160 MCG/ACT |
160 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Alvesco |
Ciclesonide Inhal Aerosol 80 MCG/ACT |
80 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Anoro ellipta |
Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/INH |
62.5-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Armonair digihaler |
Fluticasone Propionate Aer Pow BA |
232 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Armonair digihaler |
Fluticasone Propionate Aer Pow BA |
55 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Armonair digihaler |
Fluticasone Propionate Aer Pow BA |
113 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Arnuity ellipta |
Fluticasone Furoate Aerosol Powder Breath Activ 100 MCG/ACT |
100 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Arnuity ellipta |
Fluticasone Furoate Aerosol Powder Breath Activ 200 MCG/ACT |
200 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Arnuity ellipta |
Fluticasone Furoate Aerosol Powder Breath Activ 50 MCG/ACT |
50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Asmanex hfa |
Mometasone Furoate Inhal Aerosol Suspension 100 MCG/ACT |
100 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Asmanex hfa |
Mometasone Furoate Inhal Aerosol Suspension 200 MCG/ACT |
200 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Asmanex hfa |
Mometasone Furoate Inhal Aerosol Suspension 50 MCG/ACT |
50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Asmanex twisthaler 120 me ; Asmanex twisthaler 14 met ; Asmanex twisthaler 30 met ; Asmanex twisthaler 60 met |
Mometasone Furoate Inhal Powd 220 MCG/INH (Breath Activated) |
220 MCG/INH |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Asmanex twisthaler 30 met ; Asmanex twisthaler 7 mete |
Mometasone Furoate Inhal Powd 110 MCG/INH (Breath Activated) |
110 MCG/INH |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Atrovent hfa |
Ipratropium Bromide HFA Inhal Aerosol 17 MCG/ACT |
17 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Bevespi aerosphere |
Glycopyrrolate-Formoterol Fumarate Aerosol 9-4.8 MCG/ACT |
9-4.8 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 100-25 MCG/INH |
100-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 100-25 MCG/INH |
100-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 200-25 MCG/INH |
200-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Breo ellipta |
Fluticasone Furoate-Vilanterol Aero Powd BA 200-25 MCG/INH |
200-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Breztri aerosphere |
Budesonide-Glycopyrrolate-Formoterol Aers |
160-9-4.8 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Combivent respimat |
Ipratropium-Albuterol Inhal Aerosol Soln 20-100 MCG/ACT |
20-100 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Duaklir pressair |
Aclidinium Br-Formoterol Fum Aero Pow Br Act 400-12 MCG/ACT |
400-12 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dulera |
Mometasone Furoate-Formoterol Fumarate Aerosol 100-5 MCG/ACT |
100-5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dulera |
Mometasone Furoate-Formoterol Fumarate Aerosol 200-5 MCG/ACT |
200-5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dulera |
Mometasone Furoate-Formoterol Fumarate Aerosol 50-5 MCG/ACT |
50-5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent diskus |
Fluticasone Propionate Aer Pow BA 100 MCG/BLISTER |
100 MCG/BLIST |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent diskus |
Fluticasone Propionate Aer Pow BA 250 MCG/BLISTER |
250 MCG/BLIST |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent diskus |
Fluticasone Propionate Aer Pow BA 50 MCG/BLISTER |
50 MCG/BLIST |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve) |
110 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve) |
110 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve) |
220 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve) |
220 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve) |
44 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flovent hfa |
Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve) |
44 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Incruse ellipta |
Umeclidinium Br Aero Powd Breath Act 62.5 MCG/INH (Base Eq) |
62.5 MCG/INH |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Proair digihaler |
Albuterol Sulfate Aer Pow BA |
108 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Proair hfa ; Proventil hfa ; Ventolin hfa |
Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) |
108 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Proair respiclick |
Albuterol Sulfate Aer Pow BA 108 MCG/ACT (90 MCG Base Equiv) |
108 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Pulmicort flexhaler |
Budesonide Inhal Aero Powd 180 MCG/ACT (Breath Activated) |
180 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Pulmicort flexhaler |
Budesonide Inhal Aero Powd 90 MCG/ACT (Breath Activated) |
90 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Qvar redihaler |
Beclomethasone Diprop HFA Breath Act Inh Aer 40 MCG/ACT |
40 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Qvar redihaler |
Beclomethasone Diprop HFA Breath Act Inh Aer 80 MCG/ACT |
80 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Serevent diskus |
Salmeterol Xinafoate Aer Pow BA 50 MCG/DOSE (Base Equiv) |
50 MCG/DOSE |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Spiriva handihaler |
Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv) |
18 MCG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Spiriva respimat |
Tiotropium Bromide Monohydrate Inhal Aerosol 1.25 MCG/ACT |
1.25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Spiriva respimat |
Tiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACT |
2.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Stiolto respimat |
Tiotropium Br-Olodaterol Inhal Aero Soln 2.5-2.5 MCG/ACT |
2.5-2.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Striverdi respimat |
Olodaterol HCl Inhal Aerosol Soln 2.5 MCG/ACT (Base Equiv) |
2.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT |
160-4.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT |
160-4.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT |
80-4.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symbicort |
Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT |
80-4.5 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Trelegy ellipta |
Fluticasone-Umeclidinium-Vilanterol AEPB |
200-62.5-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Trelegy ellipta |
Fluticasone-Umeclidinium-Vilanterol AEPB 100-62.5-25 MCG/INH |
100-62.5-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tudorza pressair |
Aclidinium Bromide Aerosol Powd Breath Activated 400 MCG/ACT |
400 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Xopenex hfa |
Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv) |
45 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Xopenex hfa |
Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv) |
45 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
|
|
Evaluation Quantities above the program quantity limit for the Target Agent(s) will be approved when ONE of the following is 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.
Commercial _ PS _ Oral Inhalers Quantity Limit _ProgSum_ 7/1/2023