Tivorbex (indomethacin) Drug Quantity Management Policy - Per Rx
Defines Drug Quantity Management quantity limits and exception criteria for Tivorbex (indomethacin 20 mg capsules) for Cigna-administered benefit plans; applies to pharmacy dispensing (retail and home delivery).
No material clinical or coverage changes in this revision.
Coverage and Exception Criteria
Quantity limit exceptions
Exceptions to the stated quantity limits are covered as medically necessary when the following criteria are met
Approvals provided for 1 year
Approvals provided for 1 year
EXCEPTIONS TO THE QUANTITY LIMITS LISTED ABOVE ARE COVERED AS MEDICALLY NECESSARY WHEN THE FOLLOWING CRITERIA ARE MET. ANY OTHER EXCEPTION IS CONSIDERED NOT MEDICALLY NECESSARY.
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