Sample Notes Page - CareFirst BlueCross BlueShield
Prescription Drug Detail

Brand Name
Brand Tier
Generic Name
Generic Tier
IMITREX (ALL FORMS)
 
(Tier 3)
 
sumatriptan
(Tier 1)

Prior Authorization Required: No
Quantity Limit: Imitrex oral - 27 tablets per 34 days; Imitrex injection - 4 kits (8 injections) per 34 days; Imitrex nasal spray - 6 bottles per 34 days
Category: Pain management (analgesics)
Maintenance Drug: No
Notes: Subject to Quantity vs Time Limitation/MDL. Imitrex inj, nasal spray and tablets available as generic; therefore, moved to tier 3.
Attachments: Triptan Quantity Limit Form.pdf