Peach State Provider Office Manual - Peach State Health Plan ...

Common Brand Name(s) Product Description Covered Brand Product Limitations/Restrictions(Generic: PHOSLO)URINARY ANTI-INFECTIVESCalcium Acetate (Phosphate Binder) Cap 667MGMethenamine Mandelate Tab 0.5 GMMethenamine Mandelate Tab 1 GMNitrofurantoin Susp 25 MG/5MLMANDELAMINEMANDELAMINEFURADANTINPA, Limited to Ages 6 and Under; DailyDosage=40(Generic: MACRODANTIN)Nitrofurantoin Macrocrystalline Cap 50 MG(Generic: MACRODANTIN) Nitrofurantoin Macrocrystalline Cap 100 MGNitrofurantoin Monohydrate Macrocrystalline(Generic: MACROBID)Cap 100 MG*Methenamine-Hyos-Meth Blue-Sod Phos-Phen Sal Tab 81.6 MG***URINARY ANTISPASMODICS(Generic: URECHOLINE) Bethanechol Chloride Tab 5 MG URECHOLINE(Generic: URECHOLINE) Bethanechol Chloride Tab 10 MG(Generic: URECHOLINE) Bethanechol Chloride Tab 25 MG(Generic: URECHOLINE) Bethanechol Chloride Tab 50 MG(Generic: URISPAS)Flavoxate HCl Tab 100 MG(Generic: DITROPAN) Oxybutynin Chloride Tab 5 MG Max Qty=93/31 days(Generic: DITROPAN) Oxybutynin Chloride Syrup 5 MG/5ML Max Qty=496/31 days(Generic: DITROPAN XL) Oxybutynin Chloride Tab SR 24HR 5 MG Max Qty=62/31 days(Generic: DITROPAN XL) Oxybutynin Chloride Tab SR 24HR 10 MG Max Qty=62/31 days(Generic: DITROPAN XL) Oxybutynin Chloride Tab SR 24HR 15 MG Max Qty=62/31 daysTolterodine Tartrate Tab 1 MG DETROL Max Qty=62/31 daysTolterodine Tartrate Tab 2 MG DETROL Max Qty=62/31 daysTolterodine Tartrate Cap SR 24HR 2 MG DETROL LA Daily Dosage=1Tolterodine Tartrate Cap SR 24HR 4 MG DETROL LA Max Qty=31/31 daysVAGINAL PRODUCTS(Generic: CLEOCIN) Clindamycin Phosphate Vaginal Cream 2%(Generic: METROGEL-VAG) Metronidazole Vaginal Gel 0.75% Min DS=30; Package Limit=1/claimButoconazole Nitrate (One Dose) VaginalCream 2%GYNAZOLE-1(Generic: GYNE-LOTRIM) Clotrimazole Vaginal Tab 200 MG Max Qty=6/31 days(Generic: GYNE-LOTRIM,MYCELEX-7) Clotrimazole Vaginal Cream 1% Max Qty=45/31 days(Generic: GYNE-LOTRIMI) Clotrimazole Vaginal Cream 2% Max Qty=31/31 days(Generic: MONISTAT 7) Miconazole Nitrate Vaginal Cream 2% Max Qty=45/31 days(Generic: MONISTAT 3)Miconazole Nitrate Vaginal Cream 4% (200MG/5GM) Max Qty=45/31 days(Generic: MONISTAT 7) Miconazole Nitrate Vaginal Suppos 100 MG Max Qty=7/31 daysMiconazole Nitrate Vaginal Suppos 200 MG MICONAZOLE 3 Max Qty=3/31 daysMiconazole Nitrate Vaginal Supp 200 MG &(Generic: MONISTAT 3) 2% Cream 9 GM Kit Package Limit=1/claim(Generic: TERAZOL 7) Terconazole Vaginal Cream 0.4%(Generic: TERAZOL 3) Terconazole Vaginal Cream 0.8%(Generic: TERAZOL 3)Terconazole Vaginal Suppos 80 MG(Generic: MONISTAT 1,VAGISTAT-1) Tioconazole Vaginal Oint 6.5%Estradiol Vaginal Cream 0.1 MG/GM ESTRACE VAG Max Qty=43/31 daysEstrogens, Conjugated Vaginal Cream 0.625MG/GMPREMARIN VAGLimited to Female; From age 0 through 40:Max Qty=43/365 days; From age 40 through999: Max Qty=43/30 days39 of 70