Blue Cross Blue Shield of Mississippi Quantity Limits
Cocet Plus (acetaminophen/codeine), 6 tablets per day. Combunox. Primalev (oxycodone/acetaminophen) 2.5 mg/ 300 mg tablet, 12 tablets per day. Primalev.
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If a member's benefit plan includes quantity limits, the following drugs are subject to limitation(s). If these limits are not appropriate for your patient, you may submit a Prescription Drug Benefit Appeal Form.
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Quantity limits are based on recommendations from the manufacturers and the U.S. Food and Drug Administration (FDA), as well as accepted medical practices for dosing. Quantity limits help ensure that your patients receive the proper dose and recommended duration of therapy for their condition, while minimizing potential for adverse events, inappropriate therapy, and excessive cost.
The following Proton Pump Inhibitors (PPIs) are limited to one prescription drug per therapeutic class within a 30 day supply. For example, members may only received a total of 30 capsules, tablets or packets per 30 days.
10 tablets per month.
Aciphex Kapidex/Dexilant Lansopraxole Nexium Omeprazole Pantoprazole Prevacid Prilosec Protonix.
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, Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company.. An independent licensee of the Blue Cross and Blue Shield Association.
The list will be updated periodically. Members should always refer to the my Blue website for their coverage details.
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