Prescribed Drugs Provider Manual - Iowa Department of Human ...
Prescribed Drugs Provider Manual - Iowa Department of Human ...
Prescribed Drugs Provider Manual - Iowa Department of Human ...
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<strong>Iowa</strong><strong>Department</strong><strong>of</strong> <strong>Human</strong>Services<strong>Provider</strong> and Chapter<strong>Prescribed</strong> <strong>Drugs</strong>Chapter III. <strong>Provider</strong>-Specific PoliciesPage70DateAugust 1, 2013Drug ProductQuantityDays’SupplyCommentsIntuniv 1 mg (guanfacine ER) 30 30Intuniv 2 mg (guanfacine ER) 30 30Intuniv 3 mg (guanfacine ER) 30 30Intuniv 4 mg (guanfacine ER) 30 30Invega 3 mg (paliperidone) 30 30Invega 6 mg (paliperidone) 60 30Invega 9 mg (paliperidone) 30 30Invega Sustenna 39 mg syringe 1 syringe 30(paliperidone palmitate)Invega Sustenna 78 mg syringe 1 syringe 30(paliperidone palmitate)Invega Sustenna 117 mg syringe 1 syringe 30(paliperidone palmitate)Invega Sustenna 156 mg syringe 1 syringe 30(paliperidone palmitate)Invega Sustenna 234 mg syringe 1 syringe 30(paliperidone palmitate)Kalydeco (ivacaftor) 60 30Korlym (mifepristone) 120 30Latuda 20 mg (lurasidone) 30 30Latuda 40 mg (lurasidone) 30 30Latuda 80 mg (lurasidone) 60 30Latuda 120 mg (lurasidone) 30 30Lescol 20 mg (fluvastatin) 30 30Lexapro 5 mg (escitalopram) 15 30Lexapro 10 mg (escitalopram) 15 30Lexapro 20 mg (escitalopram) 60 30Lidoderm patch (lidocaine) 90 30 Maximum <strong>of</strong> 30 patchesallowed for initial fillLipitor 10 mg (atorvastatin) 30 30Lipitor 20 mg (atorvastatin) 30 30Lipitor 40 mg (atorvastatin) 45 30Liquicet (hydrocodone/2700 ml 30acetaminophen)Lorazepam intensol 2 mg/ml150 ml 30(lorazepam)Lorcet 10/650 mg (hydrocodone/ 180 30acetaminophen)Lorcet Plus (hydrocodone/acetaminophen)180 30
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