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

Common Brand Name(s) Product Description Covered Brand Product Limitations/RestrictionsFluorometholone Ophth Oint 0.1% FML, FML S.O.P. Max Qty=4/31 daysPrednisolone Acetate Ophth Susp 0.12% PRED MILD Max Qty=10/31 days(Generic: ECONOPRED PL,OMNIPRED, PRED FORTE) Prednisolone Acetate Ophth Susp 1% Package Limit=1/31 daysPrednisolone Sodium Phosphate Ophth Soln1% PRED SOD PHO Package Limit=1/31 daysRimexolone Ophth Susp 1%VEXOLGentamicin-Prednisolone Ace Ophth Susp 0.3-1% PRED-G Package Limit=1/claimSulfacetamide Sodium-Prednisolone OphthSusp 10-0.2%BLEPHAMIDE,PREDNIS/SULF,SULF/PREDNIS Package Limit=1/31 daysSulfacetamide Sodium-Prednisolone OphthSoln 10-0.25% Max Qty=10/31 daysSulfacetamide Sodium-Prednisolone OphthOint 10-0.2%BLEPHAMIDETobramycin-Dexamethasone Ophth Susp 0.3-(Generic: TOBRADEX)0.1% Package Limit=1/31 daysTobramycin-Dexamethasone Ophth Oint 0.3-0.1% TOBRADEX Max Qty=4/31 daysNeomycin-Polymyxin-Dexamethasone Ophth(Generic: MAXITROL)Susp 0.1% Max Qty=10/31 days(Generic: MAXITROL)Neomycin-Polymyxin-Dexamethasone OphthOint 0.1% Max Qty=4/31 days(Generic: CORTISPORIN) Neomycin-Polymyxin-HC Ophth Susp NEO/POLY/HC Max Qty=15/31 daysNeomycin-Polymyxin-Prednisolone AceOphth Susp 0.5% (new)POLY-PREDLatanoprost Ophth Soln 0.005% XALATAN Max Qty=5/31 days(Generic: ISO ATROPINE) Atropine Sulfate Ophth Soln 1% ATROPINE SOLAtropine Sulfate Ophth Oint 1%Cyclopentolate HCl Ophth Soln 0.5% CYCLOGYL Max Qty=15/31 days(Generic: CYCLOGYL) Cyclopentolate HCl Ophth Soln 1%Cyclopentolate HCl Ophth Soln 2% CYCLOGYL Package Limit=1/31 daysHomatropine HBr Ophth Soln 2% ISO HOMATROP Max Qty=15/31 days(Generic: ISO HOMATROP) Homatropine HBr Ophth Soln 5%Tropicamide Ophth Soln 0.5%(Generic: MYDRIACYL) Tropicamide Ophth Soln 1%(Generic: ALBALON, NAPHCONFORT) Naphazoline HCl Ophth Soln 0.1%(Generic: MYDFRIN) Phenylephrine HCl Ophth Soln 2.5% Max Qty=5/31 days; Max Qty=5/31 daysCarbachol Ophth Soln 1.5%ISO CARBACHOCarbachol Ophth Soln 3%ISO CARBACHO(Generic: ISO CARPINE) Pilocarpine HCl Ophth Soln 0.5%PILOCARPINE, PILOPTIC-1/2(Generic: ISOPTO CARP) Pilocarpine HCl Ophth Soln 1%(Generic: ISOPTO CARP) Pilocarpine HCl Ophth Soln 2%(Generic: ISOPTO CARP) Pilocarpine HCl Ophth Soln 3% PILOCARPINE, PILOPTIC-3(Generic: ISOPTO CARP) Pilocarpine HCl Ophth Soln 4%Pilocarpine HCl Ophth Soln 6%Dipivefrin HCl Ophth Soln 0.1%PROPINE(Generic: IOPIDINE)Apraclonidine HCl Ophth Soln 0.5% (BaseEquivalent)Apraclonidine HCl Ophth Soln 1% (BaseEquivalent)IOPIDINEBrimonidine Tartrate Ophth Soln 0.2% Package Limit=1/31 days(Generic: OPTIVAR) Azelastine HCl Ophth Soln 0.05% OPTIVAR Max Qty=6/31 days; Retail onlyStep Therapy(Generic: CROLOM) Cromolyn Sodium Ophth Soln 4% Package Limit=1/claim60 of 70