Prescribed Drugs Provider Manual - Iowa Department of Human ...

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage108DateAugust 1, 2013Product√ IndicatesPA RequiredMAC per Tablet,ML or GMAmmonium lactate lotion 12% 0.0933AquADEKs capsules √ 0.1489AquADEKs tabs √ 0.5306AquADEKs solution √ 0.3678Bacterostatic sodium chloride injection 0.9% 0.0459Bacterostatic water for injection 0.0240Bacterostatic parabens water for injection 0.0420Calcionate syrup 1.8 gm/5 √ 0.0417Calcium carbonate 500 mg chewable tablets √ 0.0205Calcium carbonate 750 mg chewable tablets √ 0.0381Calcium carbonate 1000 mg chewable tablets √ 0.0469Calcium carbonate 1250 mg chewable tablets √ 0.1026Calcium carbonate 1250 mg/5 ml suspension √ 0.0579Calcium carbonate 600 mg tablets √ 0.0440Calcium carbonate-vitamin D 500 mg/200 unit √ 0.0468Calcium carbonate-vitamin D 600 mg/200 unit tablets √ 0.0294Calcium carbonate-vitamin D 600/400 unit tablets √ 0.0516Calcium gluconate 650 mg tablets √ 0.0152Calcium lactate 650 mg tablets √ 0.0232Calvite P&D tablets √ 0.1846Cerovite Jr chewable tablets √ 0.0551Cerovite liquid √ 0.0228Cholecalciferol 400 Unit tablets √ 0.0249Epoprostenolol diluents (Flolan) 0.5 mg 12.72Epoprostenolol diluents (Flolan) 1.5 mg 40.04Ferrex 150 capsules plus √ 1.2769Ferrous fumarate 325 mg tablets 0.0181Ferrous gluconate 325 mg tablets 0.0462Ferrous sulfate 75 mg/0.6 ml drops 0.0388Ferrous sulfate 75 mg/ml drops 0.1629Ferrous sulfate 220 mg/5 ml elixir 0.0127Ferrous sulfate 325 mg tablets 0.0246Mag-delay tablets √ 0.1198Magnesium oxide 400 mg tablets √ 0.0852Magonate 1000 mg/5 ml liquid √ 0.0267Maximum D3 capsules √ 0.9900Metronidazole powder 1.5775Multiple vitamins tablets √ 0.0261Nephro-Vite tablets √ 0.1107Niacin 50 mg tablets 0.0185Niacin 100 mg tablets 0.0239Niacin 250 mg tablets 0.0369Niacin 500 mg tablets 0.0372