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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage75DateAugust 1, 2013Drug ProductPulmicort flexhaler 180 mcg/dose(budesonide)Qvar 40 mcg (beclomethasonedipropionate)Qvar 80 mcg (beclomethasonedipropionate)Days’Quantity Supply2 303 inhalers(21.9 gm)3 inhalers(21.9 gm)Remeron 15 mg (mirtazapine) 45 30Remeron 30 mg (mirtazapine) 30 30Remeron 45 mg (mirtazapine) 30 30Remeron SolTab 15 mg45 30(mirtazapine ODT)Remeron SolTab 30 mg30 30(mirtazapine ODT)Remeron SolTab 45 mg30 30(mirtazapine ODT)Restoril 7.5 mg (temazepam) 30 30Restoril 15 mg (temazepam) 30 30Restoril 22.5 mg (temazepam) 30 30Restoril 30 mg (temazepam) 30 30Revlimid 2.5 mg (lenalidomide) 30 30Revlimid 5 mg (lenalidomide) 30 30Revlimid 10 mg (lenalidomide) 60 30Revlimid 15 mg (lenalidomide) 30 30Revlimid 25 mg (lenalidomide) 30 30Rhinocort aqua sus (budesonide) 8.6 gm 30Risperdal 0.5 mg M-tab120 30(risperidone)Risperdal 1 mg M-tab (risperidone) 120 30Risperdal 2 mg M-TAB90 30(risperidone)Risperdal 3 mg M-TAB60 30(risperidone)Risperdal 4 mg M-TAB60 30(risperidone)Risperdal Consta 12.5 mg syringe 2 syringes 28(risperidone)Risperdal Consta 25 mg syringe 2 syringes 28(risperidone)Risperdal Consta 37.5 mg syringe 2 syringes 28(risperidone)Risperdal Consta 50 mg syringe(risperidone)2 syringes 283030Comments
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage76DateAugust 1, 2013Drug ProductQuantityDays’SupplyRisperdal 0.25 mg (risperidone) 120 30Risperdal 0.5 mg (risperidone) 120 30Risperdal 1 mg (risperidone) 120 30Risperidal 2 mg (risperidone) 90 30Risperidal 3 mg (risperidone) 60 30Risperidal 4 mg (risperidone) 60 30Ritalin LA 10 mg (methylphenidate 30 30ER)Ritalin LA 20 mg (methylphenidate 30 30ER)Ritalin LA 30 mg (methylphenidate 60 30ER)Ritalin LA 40 mg (methylphenidate 30 30ER)Ritalin SR 20 mg (methylphenidate 90 30ER)Robinul 1 mg (glycopyrrolate) 90 30Robinul Forte 2 mg (glycopyrrolate) 120 30Robitussin DM Syrup(dextromethorphan-guaifenesin10-100 mg/5 ml)Rozerem 8 mg (ramelteon) 30 30Ryzolt 100 mg (tramadol ER) 30 30Ryzolt 200 mg (tramadol ER) 30 30Ryzolt 300 mg (tramadol ER) 30 30Saphris 5 mg (asenapine) 60 30Saphris 10 mg (asenapine) 60 30Savella 12.5 mg (milnacipran) 60 30Savella 25 mg (milnacipran) 60 30Savella 50 mg (milnacipran) 60 30Savella 100 mg (milnacipran) 60 30Serax 10 mg (oxazepam) 120 30Serax 15 mg (oxazepam) 120 30Serax 30 mg (oxazepam) 120 30Serevent diskus 60 blisters(salmeterol)Comments240 ml 30 Allowed for acumulative 90 days per12 month period1 package(60)Seroquel 25 mg (quetiapine) 90 30Seroquel 50 mg (quetiapine) 90 30Seroquel 100 mg (quetiapine) 90 30Seroquel 200 mg (quetiapine) 90 30Seroquel 300 mg (quetiapine) 60 30Seroquel 400 mg (quetiapine) 60 3030
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