Effective June 1: New Quantity Limits for Medicaid and CHIP

Date: 04/28/21

Beginning June 1, 2021, Superior HealthPlan will implement new quantity limits to decrease overutilization, encourage dose consolidation and implement safety measures.

The medications affected by these new quantity limits are listed below:

PRODUCT NAME	PLAN LIMITS
Alclometasone cream 0.05%	60gm per 30 days
Alclometasone ointment 0.05%	60gm per 30 days
Arazlo lotion 0.045%	45gm per 30 days
Braftovi 75mg capsule	6 tablets per day
Breztri Aerosphere Inhaler	10.7gm per 30 days
Dupixent Pen-Injector 300mg/2mL	4mL per 28 days
Dupixent Pre-filled Syringe 200mg/1.14mL	2.28mL per 28 days
Extina (ketoconazole) 2% Foam	100gm per 30 days
Gavreto 100mg capsule	4 capsules per day
Inqovi 35mg-100mg tablet	5 tablets per 28 days
Mektovi 15mg tablet	6 tablets per day
Meprobamate 200mg tablet	6 tablets per day
Meprobamate 400mg tablet	6 tablets per day
Onureg 200mg tablets	14 tablets per 28 days
Onureg 300mg tablets	14 tablets per 28 days
Retevmo 40mg capsule	6 capsules per day
Retevmo 80mg capsule	4 capsules per day
Rukobia ER 600mg tablet	2 tablets per day
Triamcinolone acetonide cream 0.5%	2gm per day
Xywav 0.5gm/mL	18mL per day

For a complete list of all Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP quantity limits for Superior, please visit Superior’s Pharmacy Resources webpage.

For questions regarding any of the drugs listed above, or utilization management or prior authorization for these drugs, please contact the Superior Pharmacy Department at 1-800-218-7453, ext. 22080.