Sample Notes Page - CareFirst BlueCross BlueShield
Prescription Drug Detail

Brand Name
Brand Tier
Generic Name
Generic Tier
RELPAX
 
(Tier 3)
 
Not
Available
Not
Available

Prior Authorization Required: No
Quantity Limit: 6 tablets per 34 days
Category: Pain management (analgesics)
Maintenance Drug: No
Notes: Subject to Quantity vs Time Limitation/MDL.
Attachments: Triptan Quantity Limit Form.pdf