Pharmacy Providers

April 2003 # 03-3

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PHARMACY PROVIDERS
Policy and Procedure Update

is the fiscal agent and administrator of the Kansas Medicaid Program for the Kansas Department of Social and Rehabilitation Services

REFERRED DRUG LIST – THIRD LISTING

f Preferred Drugs will become effective May 9, 2003. New prescriptions drugs will require prior authorization as of May 9, 2003. �Dispense as tions, and existing refills on non-preferred drugs will override prior uirements until date of service July 1, 2003. Physicians are encouraged ispense as written� override unless there is a medical necessity for a non-

f a non-preferred drug is prescribed without a DAW, written documentation from the prescribing physician for consideration. The table(s) indicating -preferred drugs within the therapeutic classes can be found in Appendix II rovider Manual.

n will be granted for one (1) year.

on Request forms (which may be duplicated) have been updated since the lease use these new forms found in Appendix III of the Pharmacy Provider website listed below. Prior authorization forms may also be obtained by uthorization Unit at 1-800-285-4978.

ed drug MUST be requested on the appropriate Prior Authorization ach form is specific for each group. Otherwise, these forms will be ender without initiation of the Prior Authorization process.

ur cooperation and assistance.

ebsite: http://www.srskansas.org/hcp/medicalpolicy/pharmacy/

___________________________________

questions, please contact the Medical Assistance Customer Service Center at(in-state providers) or (785) 274-5990 between 7:30 a.m. - 5:30 p.m.,

Friday.

anuals constitute proof of notification of program changes to Kansasnce providers. Please read these publications carefully and keep themnce.

MARCH 2003 PAGE TWO

PROSPECTIVE DRUG UTILIZATION REVIEW (PRO-DUR) CHANGE Claims processed as of May 1, 2003, will begin auto-denying the Pro-DUR edit, Above Maximum Dose. The �Above Maximum Dose� edit occurs when the daily dose is greater than the recommended maximum dose for a beneficiary�s age. Providers may override the �Above Maximum Dose� edit if the patient meets the State-specified criteria by utilizing a combination of select NCPDP DUR Conflict, Intervention and Outcome Codes listed below: Criteria – Physician contacted and approved dose. DUR Conflict, Intervention and Outcome Codes – HD, M0 and 1G The provider must maintain documentation of override reason and codes. It is recommended this documentation is kept on the original prescription. For further details on auto-deny Pro-DUR edits, reference Section 8400 under �Prospective Drug Utilization Review� of the Pharmacy Provider Manual. ___________________________________ LIMIT OF 5 SINGLE-SOURCE PRESCRIPTION CLAIMS PER CALENDAR

MONTH

The limit of 5 single-source prescription claims per calendar month has been in effect as of April 1, 2003. Since then, many questions have been raised regarding this policy. Below are several clarifications for providers:

• Documentation of �Medical Necessity� is good for up to six (6) months. • The form in the March 2003 bulletin is an example and does NOT have to be used. Providers may

develop their own form, document the information on the back of the prescription or use any other means of documenting the �Medical Necessity� information.

• Providers may use one form documenting �Medical Necessity� for several of a beneficiary�s scheduled medications

• Every single-source prescription claim (except for the exclusions specifically outlined in the policy and in the March 2003 Bulletin) filled for a beneficiary within the same calendar month will count towards the limitation.

• Drug Utilization Review (DUR) edits take precedence over this edit. Therefore, if a beneficiary�s claim sets this edit and a DUR auto-deny edit, the provider must try and resolve the highest-ranking auto-deny DUR edit. If the patient does not meet the criteria to override the highest-ranking DUR edit, then the beneficiary may pay for the medication out-of-pocket.

MARCH 2003 PAGE THREE • The NCPDP Reject Code that appears when reaching this limit is �76� or �Plan Limitations

Exceeded�. • Even though the provider uses the NCPDP DUR Conflict Code of �AD� to override the 5 single-

source prescription claims per calendar month edit, KMAP does NOT send this Conflict Code value to providers in the NCPDP DUR Response area.

• Providers submitting claims on paper must document the �AD� override code in the �Remarks� section (field 16) on the paper claim form. The provider must link the line number to the code.

• Providers submitting via EMC may only resolve this edit issue via a paper claim form or POS. • There is NOT a list of NDCs considered single-source, multi-source or excluded. Providers may

contact the medical assistance number 1-800-933-6593 to inquire about an NDC. • NDCs may move back and forth between single-source, multi-source and excluded at any time.

PRIOR AUTHORIZATION OF COX II INHIBITORS

The Prior Authorization requirements for COX II Inhibitors are NOT related to the Preferred Drug List. All COX II Inhibitors for beneficiaries under the age of 65 require Prior Authorization. The COX II Inhibitors are not covered for Medikan beneficiaries.

FEDERAL UPPER LIMIT CHANGES

Effective with dates-of-service on and after May 11, 2003, the following products will have FUL changes from their current FUL pricing: Deletions: Desoximetasone 0.25%, Cream Diflunisal 500mg, Tabs Theophylline 100mg, Tabs, E.R. Theophylline 200mg, Tabs, E.R. Increases: Amiloride HCl; HCTZ 5mg/50mg, Tabs 0.06750 Amitriptyline HCl 150mg, Tabs 0.24300 Ampicillin/Ampicillin Trihydrate 250mg, Caps 0.17360 Ampicillin/Ampicillin Trihydrate 500mg, Caps 0.29910 Benzonatate 100mg, Caps 0.43870 Bumetanide 1mg, Tabs 0.28140 Bumetanide 2mg, Tabs 0.47080 Cholestyramine Light 4gm Resin, Packet 1.27670 Cholestyramine 4gm Resin, Packet 1.27670 Minocycline 50mg, Caps 0.90000 Minocycline 100mg, Caps 1.80000 Tolazamine 250mg, Tabs 0.40050 Verapamil 240mg, Tabs, E.R. 0.43500

MARCH 2003 PAGE FOUR Decreases: Amiodarone 200mg, Tabs 1.68750 Hydroxyzine Pam 50mg, Caps 0.10130 Methocarbamol 500mg, Tabs 0.19430

MAXIMUM ALLOWABLE COST (MAC) CHANGES The following MAC prices are effective for claims with dates-of-service on and after May 23, 2003. The prices may be a decrease (D), an increase (I) and/or new (N). Increases and/or decreases may be related to previous MAC or FUL prices. Refer to section 8400 of the Pharmacy Provider Manual under �Pharmacy Pricing� for additional reimbursement information. Amiodarone 200mg, Tabs 0.58000 D/N *

Amitriptyline 10mg, Tabs 0.04900 D/N Amitriptyline 25mg, Tabs 0.05300 D/N Amitriptyline 75mg, Tabs 0.11200 D/N Amphetamine Salt Mixture, 5mg, Tabs 1.12000 N Amphetamine Salt Mixture, 10mg, Tabs 1.12000 N Amphetamine Salt Mixture, 20mg, Tabs 1.12000 N Amphetamine Salt Mixture, 30mg, Tabs 1.12000 N Atenolol 25mg, Tabs 0.08200 D/N Benzonatate 100mg, Caps 0.28000 D/N * Cefadroxil 500mg, Caps 0.98000 D Clonidine 0.1mg, Tabs 0.07000 D/N Clonidine 0.2mg, Tabs 0.11200 D/N Clonidine 0.3mg, Tabs 0.14000 D/N Desoximetasone 0.25%, Cm, Gm 1.03000 N* Desoximetasone 0.25%, Oint, less than 60 Gms 1.20000 I Desoximetasone 0.25%, Oint, 60 Gms or greater 1.00000 I Furosemide 80mg, Tabs 0.09400 D/N Gemfibrozil 600mg, Tabs 0.30300 D/N Hydralazine 25mg, Tabs 0.05600 N Hydrocortisone 1%, Lotion 0.04000 D/N Hydroxyzine Pamoate 25mg, Caps 0.07000 D/N Hydroxyzine Pamoate 50mg, Caps 0.08400 D/N * Labetalol 100mg, Tabs 0.21000 D Labetalol 200mg, Tabs 0.33600 I Labetalol 300mg, Tabs 0.53200 I Lovastatin 10mg, Tabs 0.58000 D Lovastatin 20mg, Tabs 1.05000 D Lovastatin 40mg, Tabs 1.75000 D Methylprednisolone 4mg, Tabs 0.16800 D/N Methocarbamol 500mg, Tabs 0.15400 D/N * Methocarbamol 750mg, Tabs 0.28000 N Minocycline 100mg, Caps 1.40000 D/N *

MARCH 2003 PAGE FIVE

Naproxen 500mg, Tabs 0.12600 D/N Penicillin V Potassium 250mg/5ml, 200ml 0.02100 N Prednisone 5mg, Tabs 0.03400 N Prednisone 10mg, Tabs 0.04200 N Prednisone 20mg, Tabs 0.07000 N Propranolol 20mg, Tabs 0.06300 D/N

Propranolol/HCTZ 40/25mg, Tabs 0.08100 D/N Propranolol/HCTZ 80/25mg, Tabs 0.12100 D/N

Selenium Sulfide 2.5%, Lotion 0.03500 D/N Sulindac 200mg, Tabs 0.42000 D/N Tamoxifen 10mg, Tabs 0.54000 N Tamoxifen 20mg, Tabs 0.54000 N Theophylline 300mg, ER, Tabs 0.19600 N Thioradazine 10mg, Tabs 0.16800 I Thiothixene 1mg, Caps 0.11200 D/N Triamcinolone 0.1%, Paste 1.15000 N Valproic Acid 250mg, Caps 0.14000 D/N Verapamil 80mg, Tabs 0.07000 D/N * Price is affected by FUL change 5/11/2003, and will return to MAC pricing 5/23/2003. The most recent 2003 MAC and FUL price changes will be updated in Appendix I of the Pharmacy Provider Manual at a later date.

RETROACTIVE PRICE INCREASE - CYCLOBENZAPRINE 10MG TABS

On April 21, 2003, cyclobenzaprine 10mg was removed from FUL pricing of 0.08580 per tablet to a MAC price of 0.22000 per tablet EFFECTIVE FOR CLAIMS WITH DATES-OF-SERVICE ON AND AFTER APRIL 1, 2003. If you submitted claims for cyclobenzaprine 10mg tablets between April 1, 2003 and April 21, 2003, you may submit an adjustment for each claim.

PHARMACY PROVIDER MANUAL REVISIONS Remove: Replace With:

8-15 to 8-18 8-15 to 8-20 AI-1 to AI-26 AI-1 to AI-26 AII-1 AII-1

8400. Prospective Drug Utilization Review (PDUR) Kansas Medicaid is required through OBRA to perform PDUR. An incoming pharmacy claim goes through certain checks within the pharmacy system to determine if any potential problems exist by dispensing a medication. That information is then returned to the provider. The provider utilizes this information to determine the best course of therapy for the patient. In the past the PDUR edits only reported to the provider. As of October 2, 2000, Kansas Medicaid has PDUR edits that pay-but-report and auto-deny claims. For purposes of simplification, only the auto-deny DUR edits are discussed. A list of the pay-but-report edits can be obtained by contacting the Kansas Medicaid Provider Assistance Unit. Auto Deny DUR Edits: (These edits are in hierarchy order.)

PPI (Proton Pump Inhibitors) Acute Dosing Exceeds 60 Days: DUR auto-deny edit occurring when a patient�s Proton Pump Inhibitor (PPI) dosing is at or above acute dosing for greater than 60 days. Prior Authorization (PA) is required to continue at or above acute dosing. NOTE: If daily PPI dose is lowered to a maintenance dose, this edit will not post.

Exceeds 34 Days Supply: DUR edit that will auto-deny when the days supply on the current claim is greater than 34 days.

Refill Too Soon: DUR edit that will auto-deny when the same medication has been filled by the SAME provider and less than 80% of supply has been used.

Duplicate Therapy: DUR edit that will auto-deny when the same medication has been previously filled by ANOTHER provider and less than 80% of supply has been used.

Pregnancy Category X Drug With 650 (Pregnancy) Diagnosis: DUR edit that will auto-deny when claim for drug that is a category X is submitted for a female consumer who has a pregnancy diagnosis code in claims history within the past 280 days. Above Maximum Dose This DUR edit occurs when the daily dose is greater than the recommended maximum dose for the beneficiary's age.

Therapeutic Duplication: DUR edit that will auto-deny when a prescription is filled within 80% of the remaining supply of another prescription which is considered therapeutically equivalent by Kansas Medicaid. Including: (a) H2 Antagonists vs. PPIs (b) NSAIDS vs. Cox II Inhibitors

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PHARMACY PROVIDER MANUAL 04/03 BENEFITS & LIMITATIONS

8-15

8400. Allowed Exceptions for Auto-Deny DUR Edits:

In order to override an auto-deny DUR edit, the provider must determine if the prescription meets the criteria in the following chart for the highest ranking edit listed in order under �Auto-Deny DUR Edits�. Patients that do not meet the criteria for the highest ranking auto-deny edit set may pay for the medication out-of-pocket. The provider must maintain documentation for the reason the denial was overridden and input the proper override values on the claim in the NCPDP DUR Conflict, Intervention, and Outcome fields.

NOTE: Overrides are not allowed for stolen or vacation medications.

DUR Edit Allowed Exceptions

Above Maximum Dose � Physician contacted and has approved dosage Duplicate Therapy * Therapy change, all consumers

* Lost/spilled medications, KBH ONLY

Exceeds 34 Day Supply * A single unit dispensed (such as Depo Provera® at 150 mg) exceeds 34 days.

* A child�s school requires a separate medication suppply * Primary insurance requires more than a 34 day supply to be

dispensed, AND the primary made a payment. (In this case if the other insurance makes a payment, then the system will automatically override this DUR edit.)

Pregnancy Category X * Patient is not pregnant

* Physician and patient are aware of the drug�s teratogenic effects and authorization to dispense has been given after the pharmacist consults with the physician.

Refill Too Soon * Therapy change, all consumers

* Lost/spilled medications, KBH ONLY

Therapeutic Duplication * Drug/dosage change verified by the physician Guidelines To Help Identify DUR Edits: Claims setting DUR edits can auto-deny and/or pay-but-report. Any set will return pertinent information to the provider, including the DUR Conflict Code, in the DUR Response Data fields. Providers can receive up to three edits in this area. The first edit returned to the provider in the DUR Response Data fields is considered the most significant. If more than three DUR edits set on a claim, the provider�s DUR Overflow indicator is populated. In this case the provider may contact the Provider Assistance Unit for further DUR information. Also, any auto-deny edit set will cause an NCPDP Reject Code to be returned to the provider. This reject code along with the DUR Response Data and Conflict Code helps a provider determine what edit set. ________________________________ PHARMACY PROVIDER MANUAL 04/03 BENEFITS & LIMITATIONS 8-16

8400. The following table contains information to help a provider determine what auto-deny DUR edit was set, and if Prior Authorization or provider intervention is necessary. Remember, provider action requires certain criteria to be met as explained on the previous page.

DUR EXCEPTION

NCPDP REJECT

CODE

REJECT CODE

DEFINITION

OVERRIDE ALLOWED VIA PA OR PROVIDER

DUR

CONFLICT CODE

DUR

INTERVENTION CODE

DUR

OUTCOME CODE

PPIs at Acute Dosing > 60 Days

88

DUR Reject Error

PA

MX

Exceeds 34 Days Supply

76

Plan Limitations Exceeded

Provider - If criteria met

MX

MR

1B

Refill Too Soon

79

Refill Too Soon


ER

M0 M0

KBH ONLY

M0 P0 M0

1C 1D

KBH ONLY

1B 1B 1G

Duplicate Therapy

79

Refill Too Soon


ID

M0 M0

KBH ONLY M0 P0 M0

1C 1D

KBH ONLY 1B 1B 1G

Pregnancy, Category X

88

DUR Reject Error


PG

M0

P0

R0

1A 1B 1G 1A 1B 1G 1A 1B 1G

Therapeutic Duplication

88

DUR Reject Error


TD

M0

1E

Above Maximum Dose

88 DUR Reject Effor


HD M0 1G

________________________________ PHARMACY PROVIDER MANUAL 04/03

BENEFITS & LIMITATIONS 8-17

8400. Benefits Non-Covered:

The consumer is allotted money for miscellaneous expenditures within their monthly budget; consequently, some pharmacy items are not covered. The following represent examples of items that are not covered:

$ Medical supplies (as determined by FDA) $ Over-the-counter laxatives and stool softeners $ Over-the-counter nutritional supplements such as vitamins and minerals $ Routine feminine hygiene products $ Topical antiseptic and first aid preparations

Therapeutic categories generally not covered are drugs are:

DESI less-than-effective drugs and their Identical, Related, and Similar (IRS) drugs $ Benzodiazepines $ Cosmetic purposes $ Symptomatic relief of cough and colds $ Drugs designated by the Secretary of Health and Human Services $ Drugs with a manufacturer imposed restricted distribution system which requires the

additional purchase of associated tests or services from the manufacturer or its designee

$ Promotion of fertility $ Gender-specific medications if prescribed to the gender for which they are not FDA-

approved or medically necessary $ Hair growth $ Non legend (OTC) $ Weight reduction with exception of those requiring prior authorization $ Weight gain

_________________________________ PHARMACY PROVIDER MANUAL 04/03 BENEFITS & LIMITATIONS 8-18

8400

SINGLE-SOURCE PERSCRIPTION CLAIM LIMITATIONS Effective with DOS on or after April 1, 2003, there will be a limit of 5 single-source prescription drug claims allowed per beneficiary per calendar month. The following will be excluded from the limit edit: KBH beneficiaries Antiretroviral drugs State-specified anti-rejection drugs used for transplant patients State-specified anti-emetics State-specified chemotherapy drugs Interferons Immune Globulins Antihemophilic drugs Atypical antipsychotics All covered contraceptives All compound drug (until October 2003) Note: All prescriptions for insulin, Levothroid® , Synthroid® and Levoxyl® will price as single-source but be counted as multi-source for this policy (therefore, they are excluded from this edit). Note: PRESCRIPTION LIMIT OVERRIDE CODE AND CRITERIA Pharmacists should submit the prescription limit override code if:

1) Medical necessity from physician 2) The monthly prescription limit has been met

If a beneficiary meets the above criteria, the pharmacy provider should enter the “AD” DUR conflict code. No intervention and outcome codes are necessary. If a claim denies for DUR and this edit, the DUR takes precedence. In this case, the provider must see if the patient meets the criteria to override the highest-ranking DUR edit set on the claim. If so, the provider may override with the appropriate DUR override codes and document this intervention. If not, then the beneficiary may pay for the medication out-of-pocket. Pharmacists must not use the override code for a prescription until after the monthly prescription limit has been reached and medical necessity has been shown. Pharmacists will be audited for appropriate utilization of the prescription limit override code (“AD”).

_________________________________ PHARMACY PROVIDER MANUAL 04/03

BENEFITS & LIMITATIONS 8-19

8400 The limit of 5 single-source prescription claims per calendar month has been in effect as of April 1, 2003. Since then, many questions have been raised regarding this policy. Below are several clarifications for providers:

• Documentation of �Medical Necessity� is good for up to six (6) months. • The form in the March 2003 bulletin does NOT have to be used. This is an example providers may

use. Or, providers may develop their own form, document the information on the back of the prescription or use any other means of documenting the �Medical Necessity� information.

• Providers may use one form documenting �Medical Necessity� for several of a beneficiary�s scheduled medications. If a new single-source prescription claim is requested and denies for this edit, the provider must get �Medical Necessity� documentation. KEEP IN MIND the �blanket� form with �Medical Necessity� may be used ONLY for the patients regularly scheduled medications.

• Any time a single-source prescription claim is filled for a beneficiary within the same calendar month, regardless of if it is a refill or not, will count towards the limitation.

• The NCPDP Reject Code that appears when reaching this limit is �76� or �Plan Limitations Exceeded�.

• Drug Utilization Review (DUR) edits take precedence over this edit. Therefore, if a beneficiary�s claim sets this edit and a DUR auto-deny edit, the provider must try and resolve the highest-ranking auto-deny DUR edit. If the patient does not meet the criteria to override the highest-ranking DUR edit, then the beneficiary may pay for the medication out-of-pocket.

• Even though the provider uses the NCPDP DUR Conflict Code of �AD� to override the 5 single-source prescription claims per calendar month edit, KMAP does NOT send this Conflict Code value to providers in the NCPDP DUR Response area.

• Providers submitting claims on paper must document the �AD� override code in the �Remarks� section (field 16) on the paper claim form. The provider must link the line number to the code.

• Providers submitting via EMC may only resolve this edit issue via a paper claim form or POS. • There is NOT a list of NDCs considered single-source, multi-source or excluded. Providers may

contact the Medical Assistance Customer Service Center at 1-800-933-6593 (between 7:30 A.M & 5:30 P.M.) to inquire about an NDC.

• NDCs may move back and forth between single-source, multi-source and excluded at any time.

_________________________________ PHARMACY PROVIDER MANUAL 04/03 BENEFITS & LIMITATIONS 8-20

APPENDIX I

FEDERAL UPPER LIMIT (FUL)/MAXIMUM ALLOWABLE COST (MAC) LISTING Product reimbursement for select multiple-source products will be the lesser of the Estimated Acquisition Cost (EAC) or Maximum Allowable Cost (MAC) as determined by SRS or the Federal Upper Limit (FUL) as determined by CMS. There may be some NDCs within the listing that are not covered due to lack of drug rebate. Pricing is expressed on a per unit basis (e.g., tablet, capsule, ml, gram).

INDICATORS ***PA is required to override FUL/MAC and pay EAC only for medications listed with the ***.

FEDERAL COMMONLY UPPER MAC KNOWN

GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Acebutolol Hydrochloride

Eq. 200 mg base, Cap, Oral, 100 0.4612 Sectral Eq. 400 mg base, Cap, Oral, 100 0.6713

Acetaminophen; Codeine Phosphate

300mg; 15mg, Tab, Oral, 100 0.1500 Tylenol/codeine 300mg; 30mg, Tab, Oral, 100 0.2137 300mg; 60mg, Tab, Oral, 100 0.2812

Acetaminophen; Hydrocodone Bitartrate

500mg; 5mg, Cap, Oral, 100 0.1943 Lortab-7/500 500mg; 5mg, Tab, Oral, 100 0.1153 Vicodin-ES 500mg; 7.5mg, Tab, Oral, 100 0.1913 500mg; 10mg, Tab, Oral, 100 0.4603 650mg; 7.5mg, Tab, Oral, 100 0.1550 650mg; 10mg, Tab, Oral, 100 0.1852 750mg; 7.5mg, Tab, Oral, 100 0.1548 660mg; 10mg, Tab, Oral, 100 0.4500 167mg; 2.5mg/5ml, Oral, Elixir 0.1014 500mg;/15ml; 7.5 mg/15ml, Elixir, Oral, 473 ml 0.1014

_______________________________ PHARMACY RPOVIDER MANUAL 04/03

APPENDIX I AI-1


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Acetaminophen; Oxycodone HCL

500mg; 5mg, Cap, Oral, 100 0.2137 Tylox, oxilox 325mg; 5mg, Tab, Oral, 100 0.1192 Roxicet, Percocet

Acetaminophen; Propoxyphene HCL

650 mg; 65 mg, Tab, Oral, 100 0.1688 Wygesic Acetaminophen; Propoxyphere Napsylate

650mg; 100mg; Tab, Oral, 100 0.2250 Darvocet-N100 Acetazolamide

250mg, Tab, Oral, 100 0.2454 Acetylcysteine

10%, Soln, Inhalation; Oral, up to 29ml 0.5280 Mucomyst-10 10% Soln 30ml or greater 0.3000 20%, Soln, Inhalation; Oral, all 0.5400 Mucomyst

Acyclovir

200 mg, Cap, Oral, 100 0.2500 Zovirax 400 mg, Tab, Oral, 100 0.2500 800 mg, Tab, Oral, 100 0.4113

Albuterol Sulfate

Eq. 0.083% base, Soln, Inhalation 3 ml 0.1450 Eq. 0.5% base, Soln, 0.3360 Inhalation 20 ml 0.09mgl Aerosol 0.8823

Allopurinol

100mg, Tab, Oral, 100 0.0784 Zyloprim 300mg, Tab, Oral, 100 0.1671

_______________________________ PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I AI-2


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Alprazolam

0.25mg, Tab, Oral, 100 0.0400 Xanax 0.5mg, Tab, Oral, 100 0.0450 1mg, Tab, Oral, 100 0.0450 2mg, Tab, Oral 0.0900

Amantadine HCL

50mg/5ml, Syrup, Oral, 480ml 0.0656 Amiloride HCL; Hydrochlorothiazide

Eq. 5mg Anhydrous; 50mg, Tab 0.0659 Moduretic Oral, 100

Aminophylline

100mg, Tab, Oral, 100 0.0278 200mg; Tab, Oral, 100 0.0390

Amiodarone HCL

200mg, Tab, Oral, 500 1.9907 Cordarone, Pacerone Amitriptyline HCL

10mg, Tab, Oral, 100 0.04900 Elavil 25mg, Tab, Oral, 100 0.05300 50mg, Tab, Oral, 100 0.0666 75mg, Tab, Oral, 100 0.120 100mg, Tab, Oral, 100 0.1500 150mg, Tab, Oral, 100 0.2396

Amitriptyline HCL; Perphenazine

10mg; 2mg, Tab, Oral, 100 0.0704 Etrafon 2-10 25mg; 2mg, Tab, Oral, 100 0.0869 Etrafon 2-25

Amoxapine

50mg, Tab, Oral, 100 0.5425

_______________________________

PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I

AI-3


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Amoxicillin

250mg, Cap, Oral, 100 0.0636 Trimox, Wymox 500mg, Cap, Oral, 100 0.1272 125mg/5ml, Pwd for Rec, Oral, 150 0.0201 125 mg, Chewable Tab 0.0800 250 mg, Chewable Tab 0.1500

Ampicillia/Ampicillin Trihydrate 250mg capsule oral 0.1295 500mg capsuale oral 0.2171

Aspirin; Carisoprodol

325mg; 200mg, Tab, Oral, 100 0.3522 Soma Compound Aspirin; Oxycodone HCL; Oxycodone Terephthalate

325mg; 4.5mg; 0.38mg, Tab 0.1500 Atenolol

25mg, Tab, Oral, 100 0.1595 Tenormin 50mg, Tab, Oral, 100 0.0885 100mg, Tab, Oral, 100 0.1650

Atenolol; Chlorthalidone

50mg; 25mg, Tab, Oral, 100 0.1762 Tenoretic 100mg; 25mg, Tab, Oral, 100 0.2549

Atropine Sulfate; Diphenoxylate HCL

0.025mg, 2.5mg, Tab, Oral, 100 0.3743 Lomotil,Lonox Benzonatate

100mg, Cap, Oral, 100 0.2800 Tessalo Perle _______________________________ PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I AI-4


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Benztropine Mesylate

0.5mg, Tab, Oral, 100 0.1227 Cogentin 1mg, Tab, Oral, 100 0.1403 2mg, Tab, Oral, 100 0.1930

Betamethasone Dipropionate

Eq. 0.05% base, Cream, Topical, 15gm 0.2300 Diprosone Eq. 0.05% base, Lotion, Topical, 60ml 0.1437 Maxivate

Betamethasone Valerate

Eq. 0.1% base, Cream, Topical, 45gm 0.1197 Eq. 0.1% base, Lotion, Topical, 60ml 0.1087

Bisoprolol Fumarate; Hydrochlorothiazide

2.5mg; 6.25mg, Tab, Oral, 100 0.8250 5mg; 6.25mg, Tab, Oral, 100 0.8250 10mg; 6.25mg, Tab, Oral, 30 0.8250

Brompheniramine Maleate; Dextromethorphan Hydrobromide; Phenylpropanolamine HCL

2mg/5ml; 10mg/5ml; 12.5mg/5ml, Poly-Histine DM Syrup, Oral, 480ml 0.0175

Bumetanide

0.5mg,Tab, Oral, 100 0.1743 Bumex 1mg, Tab, Oral, 100 0.2348 2mg, Tab, Oral, 100 0.4272


APPENDIX I AI-5


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Buspirone

5mg, Tab 0.2200 10mg, Tab 0.2600 15mg, Tab 0.4000 30mg, Tab 0.9000

Captopril

12.5mg, Tab, Oral, 100 0.0398 Capoten 25mg, Tab, Oral, 100 0.0442 50mg, Tab, Oral, 100 0.0892 100 mg, Tab, Oral, 100 0.1867

Captopril; Hydrochlorothiazide

25mg; 15mg, Tab, Oral, 100 0.2359 Capozide 25mg: 25mg Tab Oral 0.2360 50mg; 25mg, Tab, Oral, 100 0.3702

Carbamazepine ***

200mg Tab, Oral, 100 0.1388 Tegretol Carbidopa; Levodopa

10mg; 100mg; Tab, Oral, 100 0.3644 Sinemet 25mg; 100mg; Tab, Oral, 100 0.3915 25mg; 250 mg, Tab, Oral, 100 0.4657

Carisoprodol

350mg, Tab, Oral, 100 0.3743 Soma Carteolol HCL

1% Soln Drops, Ophth, 10ml 3.6675 *** Requires PA to override FUL/MAC and pay at EAC _______________________________ PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I AI-6


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Cefaclor

Eq. 250mg base, Cap, Oral, 100 0.3780 Ceclor Eq. 500mg base, Cap, Oral, 100 0.7490 Eq. 125mg base/5ml, Pwd for Rec, Oral 150 0.1107 Eq. 187mg base/5ml, Pwd for Rec, Oral 100 0.1661 Eq. 250mg base/5ml, Pwd for Rec, Oral 150 0.2995 Eq. 375mg base/5ml, Pwd for Rec, Oral 100 0.4492

Cefadroxil Hydrate

500mg, Cap, Oral 0.9800 Cephalexin

Eq. 250mg base, Cap 0.2513 Keflex Eq. 500mg base, Cap 0.4446

Chlorpheniramine Maleate

4mg, Tab, Oral, 100 0.0171 Chlor-Trimeton Chlorpropamide

100mg, Tab, Oral, 100 0.1837 Diabinese 250mg, Tab, Oral, 100 0.3885

Chlorthalidone

25mg, Tab, Oral, 100 0.0509 Hygroton 50mg, Tab, Oral, 100 0.0558

Chlorzoxazone

500mg, Tab, Oral, 100 0.1085


APPENDIX I AI-7


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Cholestyramine (regular)

Eq. 4gm Resin/Packet, Pwd, Oral, 60pk 1.2212 Questran

Cholestyramine Aspartame (light)

Eq. 4gm Resin/Scoop, Prevalite Pwd, Oral 210gm or greater 0.15714 Locholest Light

Cimetidine

200mg, Tab, Oral, 100 0.1238 Tagamet 300mg, Tab, Oral, 100 0.1313 400mg, Tab, Oral, 100 0.1537 800mg, Tab, Oral, 100 0.2775

Cimetidine HCL

Eq. 300mg base/5ml Soln, Oral, 240ml 0.1139

Clindamycin HCL

Eq. 150mg base, Cap, Oral, 100 0.5000 Cleocin HCL Clindamycin Phosphate

Eq. 1% base, Soln, Topical 60ml 0.2060 Clobetasol Propionate

0.05%, Cream, Topical, 30gm 0.8315 Clomipramine HCL

25mg, Cap, Oral, 100 0.3322 Anafranil 50mg, Cap, Oral, 100 0.5138 75mg, Cap, Oral, 100 0.5772

Clonazepam***

0.5mg, Tab 0.2000 Klonopin 1mg, Tab 0.2100 2mg, Tab 0.3000



GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Clonidine HCL

0.1mg, Tab, Oral, 100 0.0700 Catapres 0.2mg, Tab, Oral, 100 0.1120 0.3mg, Tab, Oral, 100 0.1400

Clorazepate Dipotassium

3.75mg, Tab, Oral, 100 0.8350 Tranxene 7.5mg, Tab, Oral, 100 1.0388 15mg, Tab, Oral, 100 1.4094

Clozapine***

25mg 0.9000 Clozaril 100mg 1.9000

*** Requires PA to override FUL/MAC and pay at EAC Cromolyn Sodium

4% Soln/Drops, Ophth, 10ml 3.3750 Cyclobenzaprine HCL

10mg, Tab, Oral, 100 0.2200 Flexeril Cyclopentolate HCL

1%, per ml, up to 14ml 2.2700 Cyclogyl 1%, per ml, 15ml or greater 0.4500

Desmopressin spray, 0.1mg/ml 21.7500 DDAVP Desonide

0.05% Cream, per gram, up to 59 grams 0.4050 Tridesilon 0.05% Cream, per gram, 60 grams or greater 0.3000 0.05% Ointment, per gram, up to 59 grams 0.4050 Desowen 0.05% Ointment, per gram, 60 grams or greater 0.3000

Desoximetasone

0.25%, Cream, Topical 60gm 0.6180 Topicort 0.25% Oint, per gram, up to 59 grams 0.7500 0.25% Oint, per gram, 60 grams or greater 0.4500


APPENDIX I AI-9


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Dexamethasone

0.5mg/5ml Elixir, Oral, 240ml 0.0625 Decadron Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate

0.1%; Eq. 3.5mg base/gm; 10,000u/gm, Oint, Ophth 3.5 gm 1.0713 Maxitrol

Diazepam

2mg, Tab, Oral, 100 0.0423 Valium 5mg, Tab, Oral, 100 0.0718 10mg, Tab, Oral, 100 0.1417

Diclofenac Potassium

50mg, Tab, Oral, 100 0.8625 Cataflam Diclofenac Sodium

50mg, Tab, Delayed Release, Oral, 100 0.4748 Voltaren 75mg, Tab, Delayed Release, Oral, 100 0.5850

Dicyclomine HCL

10mg, Cap, Oral, 100 0.1222 Bentyl 20mg, Tab, Oral, 100 0.1185

Diflunisal

500mg, Tab, Oral, 60 1.0000 Dolobid Diltiazem HCL

30mg, Tab, Oral, 100 0.1019 Cardizem 60mg, Tab, Oral, 100 0.1114 90mg, Tab, Oral, 100 0.2312 120mg, Tab, Oral, 100 0.2331

Diphenhydramine HCL

12.5mg/5ml, Elixir, Oral 120ml 0.0137



GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Dipivefrin HCL

0.1%, Soln/Drops, Ophth 5ml 0.8700 Propine Doxazosin Mesylate

1mg, Tab, Oral, 100 0.5918 2mg, Tab, Oral, 100 0.5918 4mg, Tab, Oral, 100 0.6210 8mg, Tab, Oral, 100 0.6518

Doxepin HCL

10mg, Cap 0.0600 Sinequan 25mg, Cap 0.0800 50mg, Cap 0.0900 75mg, Cap 0.2052 100mg, Cap 0.1500 150mg, Cap 0.3500 Eq. 10mg base/ml, Concentrate, Oral, 120ml 0.1145

Doxycycline Hyclate

Eq. 50mg base, Cap Oral, 50 0.0915 Eq. 100mg base, Cap, Oral, 50 0.1050 Vibramycin Eq. 100mg base, Tab, Oral, 50 0.1287

Enalapril

2.5mg, Tab 0.1100 Vasotec 5mg, Tab 0.1300 10mg, Tab 0.1400 20mg, Tab 0.1900

Erythromycin

250mg Cap, Delayed Release Pellets Oral, 100 0.1889 E-Mycin, Erygel, Ery C 2% Gel, Topical, per gram 0.5500 Up to 59 grams 2% Gel, Topical, per gram 0.6000 60 grams or greater 2% Soln, Topical 60ml 0.0687

Estradiol

0.5mg, Tab, Oral, 100 0.1791 1mg, Tab, Oral, 100 0.1932 2mg, Tab, Oral, 100 0.3060


APPENDIX I AI-11


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Estropipate

0.75mg, Tab 0.2500 Ogen 1.5mg, Tab 0.3450 3mg, Tab 0.7940

Etodolac

200mg, Cap, Oral, 100 0.4800 Lodine 400mg, Tab, Oral, 100 0.3600 500mg, Tab, Oral, 100 1.0032

Famotidine

20mg, Tab 0.1500 40mg, Tab 0.2500

Fenoprofen Calcium

Eq. 600mg base, Tab, Oral, 100 0.2400 Nalfon Fluocinolone Acetonide

0.01%, Soln, Topical, 60ml 0.1172 Fluocinonide

0.05%, Cream, Topical, 60gm 0.1789 0.05%, Soln, Topical, 60ml 0.2483 0.05%, Gel, per gram, 0.4965 Up to 59 grams 0.05%, Gel, per gram, 0.3500 60 grams or greater

Fluorometholone

0.1%, Suspension/Drops, Ophth 5ml 1.6590 FML Fluoxetine

10mg, Cap 0.1500 20mg, Cap 0.1750 40mg, Cap 3.5000 10mg, tab 0.1400 20mg, tab 1.0000 20mg, Solution 0.2500



GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Fluphenazine HCL

1mg, Tab, Oral, 100 0.2273 Prolixin 2.5mg, Tab, Oral, 100 0.2775 5mg, Tab, Oral, 100 0.3546 10mg, Tab, Oral, 100 0.5099

Flurbiprofen

100mg, Tab, Oral, 100 0.3600 Ansaid Flurbiprofen Sodium

0.03%, Soln/Drops, Ophth, 2ml 4.0679 Furosemide

10mg/ml, Solution, Oral 60ml 0.1300 Lasix 20mg, Tab, Oral, 100 0.0563 40mg, Tab, Oral, 100 0.0599 80mg, Tab, Oral, 100 0.09400

Gemfibrozil

600mg, Tab, Oral, 500 0.3030 Gentamicin Sulfate

Eq. 0.3% base, Soln/Drops, per ml 0.6000 Glipizide

5mg, Tab, Oral, 100 0.0699 Glucotrol 10mg, Tab, Oral, 100 0.0944

Glyburide

1.5mg, Tab, Oral, 100 0.2549 Glynase 3mg, Tab, Oral, 100 0.3202

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate

0.025mg/ml; Eq. 1.75mg base/ml 10,000 units/ml, Soln/Drops, Ophth 10ml 2.2185 Neoptic, Neosporin

_______________________________


AI-13


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Guanfacine HCL

Eq. 1mg base, Tab, Oral, 100 0.5250 Tenex Eq. 2mg base, Tab, Oral, 100 0.7200

Haloperidol

2mg/ml, Conc., per ml, up to 119 ml 0.1500 2mg/ml, Conc., per ml, 120 ml or greater 0.0700

Homatropine Methylbromide; Hydrocodone Bitartrate

1.5mg/5ml, 5mg/5ml, Syrup, Oral 480ml 0.0280 Hycodan

Hydralazine HCL

10mg, Tab, Oral, 100 0.0354 Apresoline 25mg, Tab, Oral, 100 0.0560

Hydrochlorothiazide

25mg, Tab 0.1200 50mg, Tab 0.1200

Hydrochlorothiazide; Propranolol HCL

25mg; 40mg, Tab, Oral, 100 0.08100 Inderide 25mg; 80mg, Tab, Oral, 100 0.12100

Hydrochlorothiazide; Spironolactone

25mg; 25mg, Tab, Oral, 100 0.3463 Aldactazide Hydrochlorothiazide; Triamterene

25mg; 37.5mg, Cap, Oral, 100 0.3177 Dyazide 25mg; 37.5mg, Tab, Oral, 100 0.1932 Maxide 50mg; 75mg, Tab, Oral, 100 0.0488

Hydrocortisone

0.5%, Cream, Topical, 30gm 0.0375 Cortaid, Hytone 1%, Cream, Topical, 30gm 0.0585 2.5%, Cream, Topical, 30gm 0.1820 1% Lotion, Topical, 120ml 0.0400 2.5%, Lotion, Topical, 59ml 0.6814 1%, Oint, Topical, 30gm 0.0560 2.5% Oint, per gram, 0.1500 Up to 450 grams 2.5% Oint, per gram, 0.0881 451 grams or greater



GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Hydroxychloroquine Sulfate

200mg, Tab, Oral, 100 0.8535 Plaquenil Hydroxyzine Pamoate

Eq. 25mg HCL, Cap, Oral, 100 0.0700 Vistaril Eq. 50mg HCL, Cap, Oral, 100 0. 0.0840

Ibuprofen

400mg, Tab 0.0400 Motrin 600mg, Tab 0.0550 800mg, Tab 0.0800

Imipramine HCL

10mg, Tab, Oral, 100 0.2500 Tofranil 25mg, Tab, Oral, 100 0.3500 50mg, Tab, Oral, 100 0.4500

Indapamide

1.25mg, Tab, Oral, 100 0.1035 Lozol 2.5mg, Tab, Oral, 100 0.1125

Isoniazid

300mg, Tab, Oral, 100 0.0890 INH Isosorbide Dinitrate

5mg, Tab, Oral, 100 0.0242 Isordil 10mg, Tab, Oral, 100 0.0281 20mg, Tab, Oral, 100 0.0291 2.5mg, Tab, Sublingual, 100 0.0488


APPENDIX I AI-15


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Isosorbide Mononitrate

10mg, Tab, Oral, 100 0.6110 ISMO 20mg, Tab, Oral, 100 0.4950 60mg, Tab, Extended Release Oral, 100 0.7492

Ketoconazole

200mg, Tab, Oral, 100 2.7750 Nizoral Ketoprofen

50mg, Cap, Oral, 100 0.4749 Orudis 75mg, Cap, Oral, 100 0.4058

Ketorolac Tromethamine

10mg, Tab, Oral, 100 0.6773 Toradol Labetalol HCL

100mg, Tab, Oral, 100 0.2813 Normodyne, Trandate 200mg, Tab, Oral, 100 0.2672 300mg, Tab, Oral, 100 0.4688

Lactulose

10gm/15ml, Soln, Oral 480ml 0.0219 Duphalac Levobunolol HCL

0.25% Ophth., ml 1.2600 Betagan 0.5%, Soln/Drops, Ophth 10ml 1.4925

Lidocaine HCL

2% Soln, Oral 100 ml 0.0278 Lisinopril 2.5mg, Tab 0.1000 5mg, Tab 0.1250 10mg, Tab 0.2000 20mg, Tab 0.2800 30mg, Tab 0.3000 40mg, Tab 0.4500 _______________________________ PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I AI-16


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Lisinopril; HCTZ 10mg; 12.5mg Tab, Oral 0.645 20mg; 12.5mg, Tab, Oral 0.6983 20mg; 25mg, Tab, Oral 0.7065 Lovastatin

10mg, Tab 0.6500 20mg, Tab 1.1250 40mg, Tab 1.8750

Meclizine HCL

12.5mg, Tab, Oral, 100 0.0599 Antivert 25mg, Tab, Oral, 100 0.0717

Medroxyprogesterone Acetate

2.5mg, Tab, Oral, 100 0.2025 5mg, Tab, Oral, 100 0.3061 Provera, Cycrin 10mg, Tab, Oral, 100 0.2488

Megestrol Acetate

20mg, Tab, Oral, 100 0.3489 Megace 40mg, Tab, Oral, 100 0.6755

Meperidine HCL

50mg, Tab, Oral, 100 0.5370 100mg, Tab, Oral, 100 1.0347

Metformin

500mg, Tab 0.4000 850mg, Tab 0.4100 1000mg, Tab 0.4750

Methazolamide

25mg, Tab, Oral, 100 0.3150 Neptazane 50mg, Tab, Oral, 100 0.4650

Methenamine Mandelate

1gm, Tab, Oral, 100 0.2923 Methocarbamol

500mg, Tab, Oral, 100 0.1962 Robaxin _______________________________


AI-17


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Methotrexate Sodium

Eq. 2.5mg base, Tab, Oral, 100 1.2637 Methylphenidate HCL

5mg, Tab, Oral, 100 0.3020 Ritalin 10mg, Tab, Oral, 100 0.3750 20mg, Tab, Oral, 100 0.6180

Methylprednisolone

4mg, Tab, Oral, 100 0.1680 Medrol Metoclopramide HCL

Eq. 5mg base/5ml, Soln, Oral, 480ml 0.0155 Eq. 5mg base, Tab, Oral, 100 0.1842 Reglan Eq. 10mg base, Tab, Oral, 100 0.1095

Metoprolol Tartrate

50mg, Tab, Oral, 100 0.0500 Lopressor 100mg, Tab, Oral, 100 0.0600

Metronidazole

250mg, Tab, Oral, 100 0.0849 Flagyl 500mg, Tab, Oral, 100 0.2184

Mexiletine HCL

200 mg, Cap, Oral, 100 0.9712 Minocycline HCL

Eq. 50mg base, Cap, Oral, 100 0.3936 Minocin Eq. 100mg base, Cap, Oral, 50 1.4000

Minoxidil

2.5mg, Tab, Oral, 100 0.3170 Loniten 10mg, Tab, Oral, 100 0.6000

Mirtazapine 15mg, Tab, Oral 2.000 30mg, Tab, Oral 2.100 _______________________________ PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I AI-18


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Nadolol

20mg, Tab, Oral, 100 0.4650 Corgard 40mg, Tab, Oral, 100 0.4289 80mg, Tab, Oral, 100 0.8025 120mg, Tab, Oral, 100 0.5000 160mg, Tab, Oral, 100 0.6000

Naltrexone HCL

50mg, Tab, Oral, 100 4.0400 Naphazoline Hydrochloride Naphcon Forte

0.1%, Soln/Drops, Opcon Ophth 15ml 0.3140 Vasocon

Naproxen

250mg, Tab, Oral, 100 0.1044 Naprosyn 375mg, Tab, Oral, 100 0.1383 500mg, Tab, Oral, 100 0.1260 375mg, Tab, Delayed Release Oral, 100 0.6750

Naproxen Sodium

220mg, Tab (200mg base) 0.0800 Niacin

500mg, Tab, Oral, 100 0.0390 Nicolar Nicardipine HCL

20mg, Cap, Oral, 100 0.2000 Cardene 30mg, Cap, Oral, 100 0.3000

Nifedipine

10mg, Cap, Oral, 100 0.1237 Nitroglycerin

0.3mg SL, Tab 0.0700 0.4mg SL, Tab 0.0700

Nizatidine 150mg,Cap, Oral 1.8307 300mg, Cap, Oral 3.6615


APPENDIX I AI-19


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Nortriptyline HCL

Eq. 10mg base, Cap, Oral, 100 0.1019 Pamelor Eq. 25mg base, Cap, Oral, 100 0.1406 Eq. 50mg base, Cap, Oral, 100 0.1722 Eq. 75mg base, Cap, Oral, 100 0.2203

Nystatin

100,000u/gm, Cream, Topical, 30gm 0.0755 Nilstat 100,000u/gm, Oint, Topical, 15gm 0.1019 100,000u/ml, Susp, Oral, 60ml 0.1757

Nystatin; Triamcinolone Acetonide

100,000u/gm 0.1% Cream, Topical, 30gm 0.0975 Mycotriacet II 100,000u/gm 0.1% Oint, Topical, 30gm 0.0975

Orphenadrine Citrate

100mg, Tab, Extended Release, Oral, 100 1.8225

Oxaprozine 600mg, Tab, Oral 100 0.6758 Oxybutynin Chloride

5mg, Tab, Oral, 100 0.1260 Ditropan 5mg/ml, Oral, Syrup 0.0500

Palivizumab

50mg, vial 573.5572 Synagis 100mg, vial 1050.000

Penicillin V Potassium

Eq. 250mg base/5ml, Pwd/Recon, Oral, 200 0.0210

Pentoxifylline

400mg, Tab, Ext. Release, Oral, 100 0.3000 Perphenazine

2mg, Tab, Oral, 100 0.2801 Trilafon 4mg, Tab, Oral, 100 0.3448 16mg, Tab, Oral, 100 0.6377



GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Pindolol

5mg, Tab, Oral, 100 0.1537 Visken 10mg, Tab, Oral, 100 0.1973

Piroxicam

10mg, Cap, Oral, 100 0.0788 Feldene 20mg, Cap, Oral, 100 0.0830

Polymyxin B Sulfate; Trimethoprim Sulfate

10,000u/ml, Eq. 1mg base/ml Soln/Drops, Ophth 10ml 1.2360

Potassium Chloride

8 Meq Tab, Ext. Release, Oral, 100 0.0772 Slow-K Prednisolone

15mg/5ml, Syrup, Oral, 480ml 0.2081 Prednisolone Acetate

1%, Suspension/Drops, Ophth 10ml 1.6950 Prednisone

5mg, Tab, Oral, 100 0.03400 Deltasone 10mg, Tab, Oral, 100 0.04200 Orasone 20mg, Tab, Oral, 100 0.0700

Primidone ***

250mg, Tab, Oral, 100 0.6405 Mysoline Probenecid

500mg, Tab, Oral, 100 0.7059 Prochlorperazine Maleate

Eq. 5mg base, Tab, Oral, 100 0.3986 Eq. 10mg base, Tab, Oral, 100 0.5766

Promethazine HCL

6.25mg/5ml, Syrup, Oral, 120ml 0.0264 Phenergan *** Requires PA to override FUL/MAC and pay at EAC


APPENDIX I AI-21


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Propranolol HCL

10mg, Tab, Oral, 100 0.0585 20mg, Tab, Oral, 100 0.06300 40mg, Tab, Oral, 100 0.0848 80mg, Tab, Oral, 100 0.1140

Pseudoephedrine HCL; Triprolidine HCL

60mg; 2.5mg, Tab, Oral, 100 0.0336 Ranitidine HCL

150mg, Tab 0.1000 Zantac 300mg, Tab 0.2000 150mg, Cap 0.6500 300mg, Cap 1.2000

Selegiline HCL

5mg, Cap 1.7000 5mg, Tab 0.3500

Selenium Sulfide

2.5% Lotion/Shampoo, Topical 120ml 0.0350 Selsun

Silver Sulfadiazine

1%, Cream, 85gm 0.1100 Silvadene Spironolactone

25mg, Tab, Oral, 100 0.3000 Aldactone Sucralfate

1gm, Tab, Oral, 100 0.3690 Sulfacetamide Sodium

10%, Soln/Drops, Ophth 15ml 0.1530



GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Sulfamethoxazole; Trimethoprim

400mg; 80mg, Tab, Oral, 100 0.1325 Bactrim 800mg; 160mg, Tab, Oral, 100 0.1590 Septra

Sulfasalazine

500mg, Tab, Oral, 100 0.1757 Azulfidine Sulfinpyrazone

100mg, Tab, Oral 0.3000 Sulindac

150mg, Tab, Oral, 100 0.2625 Clinoril 200mg, Tab, Oral, 100 0.4200

Terazosin HCL

Eq. 1mg base, Cap, Oral, 100 1.5413 Eq. 2mg base, Cap, Oral, 100 1.5413 Eq. 5mg base, Cap, Oral, 100 1.5413 Eq. 10mg base, Cap, Oral, 100 1.5413

Tetracycline HCL

500mg, Cap, Oral, 100 0.0975 Sumycin Theophylline

100mg, Tab, Ext. Release, Oral, 100 0.1184 200mg, Tab, Ext. Release, Oral, 100 0.1607 300mg, Tab, Ext. Release, Oral, 100 0.1960

Thioridazine HCL

10mg, Tab 0.1680 15mg, Tab 0.1950 25mg, Tab 0.1090 50mg, Tab 0.3885 100mg, Tab 0.2250 150mg, Tab 0.9500 200mg, Tab 0.9000

Thiothixene

1mg, Cap, Oral, 100 0.1120 Navane 2mg, Cap, Oral, 100 0.1860 5mg, Cap, Oral, 100 0.2963 10mg, Cap, Oral, 100 0.4065

_____________________________ PHARMACY RPOVIDER MANUAL 04/03

APPENDIX I AI-23


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Ticlopidine HCL

250mg, Tab, Oral, 60 1.5119 Timolol Maleate Eq. 0.25% base, Soln/Drops 0.6975 Timoptic,Blocadren Eq. 0.5% base Soln/Drops 0.9000 Ophth 15ml Tizanidine HCL 2mg, Tab 0.8071 4mg, Tab 0.9520 Tobramycin

0.3%, Soln/Drops, Ophth 5 ml 1.1850 Tobrex

Tolazamide

250mg, Tab, Oral, 100 0.1864 Tolinase Tolmetin Sodium

Eq. 200mg, base, Tab, Oral 0.3000 Eq. 400mg base, Cap, Oral 0.6500

Tramadol HCL Ultram 50mg, Tab 0.2000 Trazodone HCL

50mg, Tab, Oral, 100 0.0684 Desyrel 100mg, Tab, Oral, 100 0.0952 150mg, Tab, Oral, 100 0.3113

Tretinoin 0.025% cream, Top 1.6000 Triamcinolone Acetonide

0.025%, Cream, Topical, 80gm 0.0364 Kenalog 0.1%, Cream, Topical, 80gm 0.0448 0.5%, Cream, Topical, 15gm 0.1889 0.1%, Oint, Topical, 80gm 0.0502 0.1%, Paste Dental 5gm 1.1500

Trifluoperazine HCL Eq. 1mg base, Tab, Oral, 100 0.2433 Stelazine Eq. 2mg base, Tab, Oral, 100 0.3552 Eq. 5mg base, Tab, Oral, 100 0.4271 Eq. 10mg base, Tab, Oral, 100 0.5403 ______________________________

PHARMACY RPOVIDER MANUAL 04/03 APPENDIX I AI-24


GENERIC NAME LIMIT/UNIT PRICING BRAND NAME(S) Trihexyphenidyl HCL

2mg, Tab, Oral, 100 0.1275 5mg, Tab, Oral, 100 0.2580

0.7000

Tropicamide

0.5%, Soln/Drops, Ophth 15ml 0.6550 Mydriacyl 1%, Soln/Drops, Ophth 15ml Valproic Acid ***

250mg, Cap, Oral, 100 0.1400 Depakene 250mg/5ml Syrup, Oral, 480 ml 0.0594

Verapamil HCL

120mg, Cap, Ext. Release, Oral, 100 0.7500 Calan, Verelan, 180mg, Cap, Ext. Release, Oral, 100 0.8700 Isoptin SR 240mg, Cap, Ext. Release, Oral, 100 0.9900 40mg, Tab, Oral, 100 0.1963 80mg, Tab, Oral, 100 0.0700 120mg, Tab 0.1110 180mg, Tab, Ext. Release, Oral, 100 0.4350 240mg, Tab, Ext. Release, Oral, 100 0.3683

Vit. B-12-IF,C,Fe,FA, Cap 0.3500 Foltrin, Trinsicon Warfarin Sodium***

1mg Tab 0.3900 2mg, Tab 0.4500 2.5mg, Tab 0.4500 3mg, Tab 0.4500 4mg, Tab 0.4500 5mg, Tab 0.4500 6mg, Tab 0.5000 7.5mg, Tab 0.5000 10mg, Tab 0.5000

*** Requires PA to override FUL/MAC and pay at EAC


APPENDIX I AI-25

ACE Inhibitors PRIOR AUTHORIZATION REQUEST FORM

Preferred Drug(s) that DO NOT require PA Non-Preferred Drug(s) that DO require PA Captopril(Capoten®), Enalapril(Vasotec®), Benazepril(Lotensin®), Fosinopril(Monopril®), Lisinopril(Zestril®& Prinivil®) Moexipril(Univasc®), Perindopril(Aceon®), Quinapril(Accupril®), Ramipril(Altace®), & Trandolapril(Mavik®)

** Indicates REQUIRED information

CONSUMER INFORMATION ** Name:__________________________________ **Medicaid Number: __________________

PHARMACY INFORMATION ** Name:__________________________________ **Phone Number: ____________________

Medicaid Number #:________________________ NDC:_____________________________

PRESCRIBING PHYSICIAN INFORMATION ** Name:__________________________________ **Medicaid Number: __________________

** Phone Number: __________________________

** Indicate: Non-Preferred Drug prescribed: ________________

Other:_____________________ ** Indicate: Preferred Drug tried: _________________________ Length of trial: _____________

** Check the appropriate box indicating medical necessity for the Non-Preferred Drug:

Medical intolerance to the Preferred Drug. Please specify:______________________________

_____________________________________________________________________________

Treatment failure to the Preferred Drug. Please specify:________________________________

_____________________________________________________________________________

** Prescribing Physician�s signature: _________________________________Date: ___________

FAX completed form to the Prior Authorization Unit @ 1-800-913-2229 (274-5956 Topeka). If the pharmacy provider has started a Prior Authorization request and this information is not received within 15 working days, the PA request will be denied for information not received.

ARB’s PRIOR AUTHORIZATION REQUEST FORM

Preferred Drug(s) that DO NOT require PA Non-Preferred Drug(s) that DO require PA Losartan(Cozaar®) & Telmisartan(Micardis®) Candesartan(Atacand®), Eprosartan(Teveten®), Irbesartan(Avapro®), Olmesartan(Benicar®), & Valsartan(Diovan®)






** Phone Number: __________________________





_____________________________________________________________________________


_____________________________________________________________________________



BETA-BLOCKERS PRIOR AUTHORIZATION REQUEST FORM

Preferred Drug(s) that DO NOT require PA Non-Preferred Drug(s) that DO require PA Atenolol(Tenormin®), Metoprolol(Lopressor®), Betaxolol(Kerlone®), Bisoprolol(Zebeta®), Propranolol(Inderal®), Sotalol(Betapace®), Carteolol(Cartrol®), Nadolol(Corgard®), Acebutolol(Sectral®), Metoprolol XL Penbutolol(Levatol®), Pindolol(Visken®), (Toprol XL®) Timolol(Blocadren®)






** Phone Number: __________________________





_____________________________________________________________________________


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Calcium Channel Blockers PRIOR AUTHORIZATION REQUEST FORM

Preferred Drug(s) that DO NOT require PA Non-Preferred Drug(s) that DO require PA Diltiazem(Cardizem®), Diltia XT®, Tiazac®, Cardizem SR®, Cardizem CD®, Cartia XT®, Verapamil(Calan®), Calan SR®, & Verelan® Diltiazem XR®, Dilacor XR®, Covera-HS®, Verelan PM® Dihydropyridines Preferred Drug(s) the DO NOT require PA Non-Preferred Drug(s) that DO require PA Nisoldipine(Sular®), Amlodipine(Norvasc®), Nifedipine Sustained Release, Nifedical XL®, Felodipine(Plendil®), Nimodipine(Nimotop®), Procardia XL® Isradipine(Dynacirc®&Dynacirc CR®), Bepridil(Vascor®), Nicardipine(Cardene®& Cardene SR®), & Adalat CC®

** Indicates REQUIRED information CONSUMER INFORMATION

** Name:__________________________________ **Medicaid Number: __________________

PHARMACY INFORMATION

** Name:__________________________________ **Phone Number: ____________________


PRESCRIBING PHYSICIAN INFORMATION

** Name:__________________________________ **Medicaid Number: __________________

** Phone Number: __________________________

** Indicate: Non-Preferred Drug prescribed: _______________

Other:_____________________ ** Indicate: Preferred Drug tried: ________________________ Length of trial: ______________



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** Prescribing Physician�s signature: _________________________________Date: ___________ FAX completed form to the Prior Authorization Unit @ 1-800-913-2229 (274-5956 Topeka). If the pharmacy provider has started a Prior Authorization request and this information is not received within

15 working days, the PA request will be denied for information not received.

Pharmacy Providers

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