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Catamount BlueSM Prescription Drug Quantity Limits If your doctor prescribes a drug in an amount that exceeds certain criteria, we may ask for documentation.
Pain Medications |
Prior Approval (PA) Form |
Quantity Limits | Duragesic
Oxycontin
Narcotics containing
Acetaminophen
Toradol (Ketoralac) | Duragesic
Oxycontin
Narcotics containing Acetaminophen
Toradol
| 10 patches per 30 days
120 tabs per 30 days
500mg - 240 tabs per 30 days
325mg - 360 tabs per 30 days
20 tabs per 30 days |
Test Strips |
Prior Approval (PA) Form |
Quantity Limits | Diabetic/Glucose Test Strips
| Diabetic Test Strips
| 300 strips per 30 days
|
Anti-emetics |
Prior Approval (PA) Form |
Quantity Limits | Anzmet
Emend
Kytril
Zofran | Anzmet
Emend
Kytril
Zofran
| 50mg - 4 tabs; 100mg - 2 tabs/copay
80mg/125mg/Tripak - 6 tabs/copay
40mg - 1 tab per copay
1mg - 4 tabs per copay
4mg- 15 tabs/copay;
8mg - 9 tabs/copay;
24mg - 3 tabs/copay |
Anti-Fungals |
Prior Approval (PA) Form |
Quantity Limits | | Diflucan | Diflucan
| 150mg tabs - 1 tab per copay |
Injections |
Prior Approval (PA) Form |
Quantity Limits | | Epipen | Epipen
| 1 kit per copay |
Other |
Prior Approval (PA) Form |
Quantity Limits | Januvia
Lyrica | Januvia
Lyrica
| 30/30
90/30 |
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