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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:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) is greater than the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does not have a maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication

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