QUANTITY LIMIT CRITERIA
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1 DRUG CLASS INHALATION BRAND NAME (generic) QUANTITY LIMIT CRITERIA SHORT ACTING BETA2-ADRENERGIC AGONIST ORAL (albuterol inhalation solution) PROAIR HFA PROAIR RESPICLICK PROVENTIL HFA VENTOLIN HFA XOPENEX SOLUTION XOPENEX CONCENTRATE XOPENEX HFA Status: CVS Caremark Criteria Type: Quantity Limit POLICY FDA-APPROVED INDICATIONS Albuterol Inhalation Solution 0.021% and 0.042% Albuterol sulfate inhalation solution 0.021% and 0.042% is indicated for the relief of bronchospasm in patients 2 to years of age with asthma (reversible obstructive airway disease). Albuterol Inhalation Solution 0.083% Albuterol sulfate inhalation solution 0.083% is indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm. Beta Agonists-Short Acting Oral Inhalation Limit Policy CVS Caremark is an independent company that provides pharmacy benefit management services to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. members. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association Page 1 of 5
2 Albuterol Inhalation Solution 0.5% Albuterol sulfate inhalation solution 0.5% is indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm. ProAir HFA Proair HFA Inhalation Aerosol is indicated for the treatment or prevention of bronchospasm in patients 4 years of age and older with reversible obstructive airway disease. Exercise-Induced Proair HFA Inhalation Aerosol is indicated for the prevention of exercise induced bronchospasm in patients 4 years of age and older. ProAir RespiClick ProAir RespiClick (albuterol sulfate) inhalation powder is indicated for the treatment or prevention of bronchospasm in patients 4 years of age and older with reversible obstructive airway disease. Exercise-Induced ProAir RespiClick is indicated for the prevention of exercise-induced bronchospasm in patients 4 years of age and older. Proventil HFA Proventil HFA Inhalation Aerosol is indicated in adults and children 4 years of age and older for the treatment or prevention of bronchospasm with reversible obstructive airway disease and for the prevention of exercise-induced bronchospasm. Ventolin HFA Ventolin HFA is indicated for the treatment or prevention of bronchospasm in patients 4 years of age and older with reversible obstructive airway disease. Exercise-Induced Ventolin HFA is indicated for the prevention of exercise-induced bronchospasm in patients 4 years of age and older. Solution (levalbuterol HCl) Inhalation Solution is indicated for the treatment or prevention of bronchospasm in adults, adolescents, and children 6 years of age and older with reversible obstructive airway disease. Concentrate (levalbuterol HCl) Inhalation Solution Concentrate is indicated for the treatment or prevention of bronchospasm in adults, adolescents, and children 6 years of age and older with reversible obstructive airway disease. HFA HFA is indicated for the treatment or prevention of bronchospasm in adults, adolescents, and children 4 years of age and older with reversible obstructive airway disease. REFERENCES 1. Albuterol sulfate 0.63mg and 1.25mg inhalation solution [package insert]. Orlando, FL: Nephron Pharmaceuticals Corporation; March Albuterol sulfate 0.63mg and 1.25mg inhalation solution [package insert]. Morgantown, WV: Mylan Pharmaceuticals Inc.; January Albuterol sulfate 0.021% and 0.042% inhalation solution [package insert]. Corona, CA: Watson Laboratories Inc.; September Albuterol 0.083% inhalation solution [package insert]. E. Windsor, NJ: Aurobindo Pharma USA LLC; January Page 2 of 5
3 5. Albuterol 0.5% inhalation solution [package insert]. Tampa, FL: Bausch & Lomb Incorporated; February Albuterol 0.5% inhalation solution [package insert]. Orlando, FL: Nephron Pharmaceuticals Corporation; November Levalbuterol inhalation solution [package insert]. Princeton, NJ: Dr. Reddy's Laboratories, Inc.; September ProAir HFA [package insert]. Horsham, PA: Teva Respiratory; July ProAir RespiClick [package insert]. Horsham, PA: Teva Respiratory; September Proventil HFA [package insert]. Whitehouse Station, NJ: Merck&Co., Inc.; December Ventolin HFA [package insert]. Research Triangle Park, NC: GlaxoSmithKline; December inhalation solution [package insert]. Marlborough, MA: Sunovion Pharmaceuticals, Inc.; January inhalation solution, concentrate [package insert]. Marlborough, MA: Sunovion Pharmaceuticals, Inc.; January HFA [package insert]. Marlborough, MA: Sunovion Pharmaceuticals, Inc.; February LIMIT CRITERIA PLEASE NOTE: Since manufacturer package sizes may vary, it is the discretion of the dispensing pharmacy to fill quantities per package size up to these quantity limits. In such cases the filling limit and day supply may be less than what is indicated. Medication* Albuterol 0.021%, 0.63mg / 3mL and 0.042%, 1.25mg / 3mL Inhalation Solution Albuterol 0.083%, 2.5mg / 3mL Inhalation Solution Maintenance Dose Maximum Daily Dose 4 vials (3mL 4 vials (3mL Package Size 60 vials (3mL 1 Month Limit* 3 Months Limit* 5 packages (5 15 packages (375 4 packages (0 packages (360 5 packages (5 15 packages (375 4 packages (0 packages (360 2 packages (0 6 packages (360 Page 3 of 5
4 Albuterol 0.5%, 2.5mg / 0.5mL Inhalation Solution ProAir HFA ProAir RespiClick Proventil HFA Ventolin HFA 0.31mg,0.63mg, 1.25 mg / 3 ml Levalbuterol Inhalation Solution Concentrate 1.25mg / 0.5mL HFA 0.25mL-0.5mL three times 1 vial (0.5mL) three times 1-2 every 4 to 6 hours 2mL 3 vials (3mL 3 vials (0.5mL 20mL per bottle 30 vials (0.5mL 200 per 8.5gm 200 per inhaler 200 per 6.7gm 60 per 8gm 200 per 18gm 24 vials (3mL 30 vials (0.5mL 200 per 15gm 3 packages (20mL / 25 9 packages (20mL / 75 4 packages (0 vials x 0.5mL) / 25 packages (360vials x 0.5mL) / 75 2 packages (8.5gm / 25 6 packages (8.5gm / 75 2 packages / 25 6 packages / 75 2 packages (6.7gm / 25 6 packages (6.7gm / 75 6 packages (8gm / packages (8gm / 75 2 packages (18gm / 25 6 packages (18gm / 75 4 packages (96 vials x 3mL) / 25 packages (288 4 packages (100 packages (300 3 packages (90 vials x 3mL) / 25 9 packages (270 3 package (90 vials x 0.5mL) / 25 9 packages (270 vials x 0.5mL) / 75 2 packages (15gm / 25 6 packages (15gm / 75 Page 4 of 5
5 *The duration of 25 is used for a 30-day fill period and 75 is used for a 90-day fill period to allow time for refill processing. *The limit criteria apply to both brand and generic, if available. Page 5 of 5
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