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 PoliciesPage77DateAugust 1, 2013Drug ProductSingulair 4 mg granules(montelukast)Singulair 4 mg chew tablets(montelukast)Singulair 5 mg chew tablets(montelukast)Singulair 10 mg tablets(montelukast)Days’Quantity Supply30 3030 3030 3030 30CommentsSoma 350 mg (carisoprodol) 120 30Sonata 5 mg (zaleplon) 30 30Sonata 10 mg (zaleplon) 60 30Spiriva cap handihaler pkg size 30 30 30(tiotropium bromide)Strattera 10 mg (atomoxetine) 60 30Strattera 18 mg (atomoxetine) 60 30Strattera 25 mg (atomoxetine) 60 30Strattera 40 mg (atomoxetine) 60 30Strattera 60 mg (atomoxetine) 30 30Strattera 80 mg (atomoxetine) 30 30Strattera 100 mg (atomoxetine) 30 30Stribild (elvitegravir/cobicistat/30 30emtricitabine/ten<strong>of</strong>ovir/disoproxilfumarate)Sudafed 30 mg (pseudoephedrine) 72 30 Allowed for acumulative 90 days per12 month periodSudafed 60 mg (pseudoephedrine) 72 30 Allowed for acumulative 90 days per12 month periodSudafed 30 mg/5 ml(pseudoephedrine)Sutent 12.5 mg (sunitinib) 90 30Sutent 25 mg (sunitinib) 30 30Sutent 50 mg (sunitinib) 30 30Talacen (pentazocine/180 30acetaminophen)Tenex 1 mg (guanfacine) 90 30Tenex 2 mg (guanfacine) 90 30Terazol 3 (terconazole vaginal 20 gm 30cream 0.8%)Terazol 7 (terconazole vaginalcream 0.4%)45 gm 30240 ml 30 Allowed for acumulative 90 days per12 month period
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