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 PoliciesPage74DateAugust 1, 2013Drug ProductPremarin 0.625 mg (conjugatedestrogens)Premarin vaginal cream(conjugated estrogens)Days’Quantity Supply30 301 tube(42.5 gm)30CommentsPrevacid 15 mg (lansoprazole) 30 30 Prior authorizationrequired for more than60 days <strong>of</strong> PPI therapyPrevacid 30 mg (lansoprazole) 30 30 Prior authorizationrequired for more than60 days <strong>of</strong> PPI therapyPrevacid SoluTabs 15 mg30 30(lansoprazole)Prevacid SoluTabs 30 mg30 30(lansoprazole)Prilosec 10 mg (omeprazole) 30 30Prilosec 20 mg (omeprazole) 30 30Prilosec 40 mg (omeprazole) 30 30Pristiq 50 mg (desvenlafaxine) 30 30Pristiq 100 mg (desvenlafaxine) 30 30Proair HFA 8.5 gm (albuterol) 3 inhalers 30(25.5 gm)Procardia XL 30 mg (nifedipine ER) 30 30Procardia XL 60 mg (nifedipine ER) 30 30Procardia XL 90 mg (nifedipine ER) 30 30Procentra 5 mg/5 ml1800 ml 30(dextroamphetamine)Prosom 1 mg (estazolam) 30 30Prosom 2 mg (estazolam) 30 30Protonix 20 mg (pantoprazole) 30 30 Prior authorizationrequired for more than60 days <strong>of</strong> PPI therapyProtonix 40 mg (pantoprazole) 30 30 Prior authorizationrequired for more than60 days <strong>of</strong> PPI therapyProvigil 100 mg (modafinil) 30 30Provigil 200 mg (modafinil) 60 30Prozac 20 mg/5 ml solution600 ml 30(fluoxetine)Prozac 10 mg tablet (fluoxetine) 45 30Prozac 10 mg capsule (fluoxetine) 30 30Prozac 20 mg (fluoxetine) 120 30Prozac 40 mg (fluoxetine) 60 30
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