The following is a list of drugs with quantity limits for Blue Medicare HMO/PPO:
| Drugs That Have Quantity Limits | Utilization Management Criteria | Physician Request |
|---|---|---|
| Butorphanol nasal spray (Stadol) | Butorphanol Nasal Spray | Use Butorphanol Fax Request Form |
| Ketorolac tablets (Toradol) | Toradol Tablets | Use Toradol Fax Request Form |
| Triptans | Use Triptans Fax Request Form |
To view PDF documents you need Adobe Acrobat Reader.
The information on this page is current as of 11/04/08.
© 2008, Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.