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Quantity Levels

Some medications have specific limits for each prescription or refill to ensure you receive the recommended and appropriate dose and length of therapy.

Pre-authorization is required for any quantity that exceeds a PEHP quantity level limit. PEHP may require an additional copayment if pre-authorization is granted.

R = Retail, M = Mail, SA = Specialty Accredo, ME = Medical

 Drug NameQuantity Levels
1. ACANYA GEL
R: 50 ML PER 30 DAYS
M: 150 ML PER 90 DAYS
2. ACARBOSE 100MG
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS
3. ACARBOSE 25 MG
R: 270 UNITS PER 30 DAYS
M: 810 UNITS PER 90 DAYS
4. ACARBOSE 50 MG
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS
5. ACE AEROSOL CLOUD ENHANCER
R: LIMITED TO ONE INHALER PER CALENARD YEAR
M: LIMITED TO ONE INHALER PER CALENDAR YEAR
6. ACEON
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS
7. ACIPHEX 20 MG
R: 60 UNITS PER 30 DAYS
M: 180 UNITS PER 90 DAYS
8. ACTIQ
R: 120 UNITS PER 30 DAYS
M: 120 UNITS PER 30 DAYS
9. ACTONEL 150 MG
R: 1 UNIT PER 30 DAYS
M: 3 UNITS PER 90 DAYS
10. ACTONEL 30 MG
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS
11. ACTONEL 35 MG
R: 4 UNITS PER 30 DAYS
M: 12 UNITS PER 90 DAYS
12. ACTONEL 5 MG
R: 30 UNITS PER 30 DAYS
M: 90 UNITS PER 90 DAYS
13. ACTONEL 75 MG
R: 2 UNITS PER 30 DAYS
M: 6 UNITS PER 90 DAYS
14. ACTONEL D 35MG/500
R: 1 PACKAGE PER 30 DAYS
M: 3 PACKAGES PER 90 DAYS
15. ACTOPLUS MET
R: 90 UNITS PER 30 DAYS
M: 270 UNITS PER 90 DAYS
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Beginning July 1, 2010

PEHP will no longer be administering any CHIP medical or dental plans.

PEHP will continue to pay CHIP claims with dates of service prior to July 1, 2010.

Start preparing now....

Start preparing now for the electronic healthcare transactions change to Version 5010 and the ICD-10 conversion. Speak with your practice management vendor or clearinghouse about these coming changes.