CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A
Commercial Non‑Formulary Quantity Limits — NURTEC TAB 75MG ODT
Defines quantity and daily limits for the non‑formulary medication NURTEC TAB 75MG ODT for commercial members of Neighborhood Health Plan of Rhode Island.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicyCommercial Non‑Formulary Quantity Limits — NURTEC TAB 75MG ODT
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionApply commercial non‑formulary quantity limits: approved quantity 18 per 30 days and daily limit 0.6 for NURTEC TAB 75MG ODT.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
18/30dapproved quantity
0.6daily limit
67701060707220Target GPI
Coverage Criteria
Non‑formulary quantity limits
Coverage stance and limits for NURTEC TAB 75MG ODT:
ALL of the following
- NURTEC TAB 75MG ODT: Approved quantity = 18 per 30 days18 per 30 days
- NURTEC TAB 75MG ODT: Daily limit (quantity per day) = 0.60.6
- Target GPI = 67701060707220
Identifier for product mapping
Commercial non-formulary quantity limits set for NURTEC TAB 75MG ODT: approved quantity 18 per 30 days and daily limit 0.6.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicyCommercial Non‑Formulary Quantity Limits — NURTEC TAB 75MG ODT
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionApply commercial non‑formulary quantity limits: approved quantity 18 per 30 days and daily limit 0.6 for NURTEC TAB 75MG ODT.
SourceLink
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