Inhaled Meds – Oral Quantity Limits list Max Billable Units per 30 Dose Form Brand Name Generic Name Drug Strength Days (ea) (ml) (gm) Advair Diskus / 100-50mcg; 250-50mcg; 500-50mcg 60 = 1 ea Advair HFA Fluticasone/Salmeterol 45-21mcg; 115-21mcg; 230-21mcg 8 or 12 = 1 inhaler gm Airduo Digihaler Fluticasone/Salmeterol 55-14mcg; 113-14mcg; 232-14mcg 1 = 1 inhaler ea Airduo Respiclick Fluticasone/Salmeterol 55-14mcg; 113-14mcg; 232-14mcg 1 = 1 inhaler ea Refer to Proair HFA, Proventil Albuterol HFA Albuterol 90mcg HFA, and Ventolin HFA = gm 2 inhalers Alvesco 80mcg 6.1 = 1 inhaler gm Alvesco Ciclesonide 160mcg 12.2 = 2 inhalers gm / Anoro Ellipta 62.5-25mcg 60 = 1 inhaler ea trifenatate Arcapta Neohaler 75mcg 30 =1 inhaler ea Armonair Digihaler Fluticasone 55mcg; 113mcg; 232mcg 1 = 1 inhaler ea Arnuity Ellipta Fluticasone 50mcg; 100mcg; 200mcg 30 = 1 inhaler ea Asmanex HFA 50mcg; 100mcg; 200mcg 13 = 1 inhaler gm Asmanex Twisthaler Mometasone 110mcg 1 = 1 inhaler ea Asmanex Twisthaler Mometasone 220mcg 1 = 1 inhaler ea Atrovent HFA Ipratropium 17mcg 25.8 = 2 inhalers gm Glycopyrrolate/ Bevespi Aerosphere 9-4.8mcg 10.7 = 1 inhaler gm fumarate /vilanterol Breo Ellipta 100-25mcg; 200-25mcg 60 = 1 inhaler ea trifenatate /glycopyrrolate/ Breztri Aerosphere 160-9-4.8mcg 10.7 = 1 inhaler gm formoterol fumarate Combivent Respimat /albuterol 20-100mcg 4 = 1 inhaler gm /formoterol Duaklir Pressair 400-12mcg 1 = 1 inhaler ea fumarate mometasone furoate/formoterol Dulera 50-5mcg; 100-5mcg; 200-5mcg 13 = 1 inhaler gm fumarate dihydrate Flovent Diskus Fluticasone 50mcg; 100mcg 60 = 1 diskus ea Flovent Diskus Fluticasone 250mcg 120 = 2 diskus ea Flovent HFA Fluticasone 44mcg 10.6 = 1 inhaler gm Original Effective 08/16/2019 Implemented 11/3/2020 Inhaled Meds – Oral Inhalers Quantity Limits list Max Billable Units per 30 Dose Form Brand Name Generic Name Drug Strength Days (ea) (ml) (gm) Flovent HFA Fluticasone 110mcg 12 = 1 inhaler gm Flovent HFA Fluticasone 220mcg 24 = 2 inhalers gm Incruse Ellipta Umeclidinium 62.5mcg 30 = 1 inhaler ea Levalbuterol HFA Levalbuterol 45mcg 30 = 2 inhalers gm Proair Digihaler Albuterol 90mcg 2 = 2 inhalers ea ProAir HFA Albuterol 90mcg 17 = 2 inhalers gm ProAir Respiclick Albuterol 97mcg 2 = 2 inhalers ea Proventil HFA Albuterol 90mcg 13.4 =2 inhalers gm Pulmicort Flexhaler Budesonide 90mcg 1 = 1 inhaler ea Pulmicort Flexhaler Budesonide 180mcg 1 = 1 inhaler ea Qvar Oral Inhaler Beclomethasone dipropionate 40mcg 17.4 = 2 inhalers gm Qvar Redihaler beclomethasone dipropionate 40mcg 10.6 = 1 inhaler gm Qvar Redihaler Beclomethasone dipropionate 80mcg 21.2 = 2 inhalers gm Seebri Neohaler Glycopyrrolate 15.6mcg 60 = 1 inhaler ea Serevent Diskus Salmeterol 50mcg 60 = 1 inhaler ea Spiriva Handihaler Tiotropium 18mcg 30 = 1 kit ea Spiriva Respimat Tiotropium 1.25mcg; 2.5mcg 4 = 1 inhaler gm Stiolto Respimat / 2.5-2.5mcg 4 = 1 inhaler gm Striverdi Respimat olodaterol 2.5mcg 4 = 1 inhaler gm Budesonide/formoterol fumarate Symbicort 80-4.5mcg; 160-4.5mcg 10.2 = 1 inhaler gm dihydrate fluticasone furoate/umeclidinium 100-62.5-25mcg Trelegy Ellipta 60 = 1 inhaler ea bromide/ vilanterol trifenatate 200-62.5-25mcg Tudorza Pressair aclidinium bromide 400mcg 1 = 1 inhaler ea Utibron Neohaler Indacaterol/glycopyrrolate 27.5-15.6mcg 60 = 1 inhaler ea Ventolin HFA Albuterol 90mcg 16 or 36 =2 inhalers gm Wixela Fluticasone/Salmeterol 100-50mcg; 250-50mcg; 500-50mcg 60 = 1 inhaler ea Xopenex HFA Levalbuterol 45mcg 30 = 2 inhalers gm

Original Effective 08/16/2019 Implemented 11/3/2020 Inhaled Meds – Solutions Quantity Limits list

Max Billable Units per 30 Dose Form Brand Name Generic Name Drug Strength Days (ea) (ml) (gm)

Albuterol Albuterol sulfate 0.083% vial Neb = 2.5mg/3ml 375ml ml ml Albuterol Albuterol sulfate 0.5% inhalation solution 60ml ml Albuterol Albuterol sulfate 2.5mg/0.5ml vial Neb 60ml = 4 boxes ml AccuNeb Albuterol sulfate 0.63mg/3ml vial Neb 375ml ml AccuNeb Albuterol sulfate 1.25mg/3ml vial Neb 375ml ml Atrovent Ipratropium bromide 0.02% vial Neb 300ml ml Brovana tartrate 15mcg/2ml vial Neb 120ml ml Duoneb Ipratropium bromide/ Albuterol 0.5mg-3mg/3ml vial Neb 540ml ml Intal Cromolyn sodium 20mg/2ml vial Neb 240ml ml Lonhala Magnair Glycopyrrolate 25mcg 60ml = 1 kit of starter or refill ml Perforomist Formoterol fumarate 20mcg/2ml vial Neb 120ml ml Pulmicort Respules Budesonide 0.25mg/2ml; 0.5mg/2ml amp Neb 120ml ml Pulmicort Respules Budesonide 1mg/2ml amp Neb 60ml 0.31mg/3ml; 0.63mg/3ml; 1.25mg/3ml ml Xopenex Levalbuterol 288ml vial Neb ea Xopenex Concentrate Levalbuterol 1.25mg/0.5ml 90 vials ml Yupelri 175mcg/3ml vial Neb 90ml

Original Effective 08/16/2019 Implemented 11/3/2020