The HI Medicaid Fee-For-Service (FFS) Pharmacy Program may also Maximum Standard Doses (MSDs) to specific drugs. The Prescriber must request a prior authorization (PA) and complete an 1144B Form when the MSD must be exceeded.
One month is defined as 30 days. The MSDs, listed in alphabetical order, and their effective dates are as follows. These drugs can also be found listed alphabetically under the PA Criteria section under Drug Coverage.
*Note: Only new prescriptions will be allowed for drugs to treat impotence. In addition, a Recipient is allowed one drug unit (defined as a tablet, suppository, amp, etc.) per month only.
Drug Name
|
Strength(s)
|
MSDs
|
Effective Date
|
ABRAXANE
|
100 mg vial
|
8 vials per month
|
07.14.2005
|
ACTONEL
|
35 mg tablet
|
4 tablets per month
|
07.14.2005
|
AMERGE
|
1 mg tablet
2.5 mg tablet
|
9 tablets per month
|
02.14.2003
|
AXERT
|
6.25 mg tab`let
12.5 mg tablet
|
6 tablets per month
|
02.14.2003
|
ATROVENT
|
18 mcg inhaler
|
29.4 grams per month
|
07.14.2005
|
ATROVENT HFA
|
17 mcg inhaler
|
25.8 grams per month
|
07.14.2005
|
BONIVA
|
150 mg tablet
|
1 tablet per month
|
07.14.2005
|
CAMPTOSAR
|
20 mg/ml
|
60 mls per month
|
07.14.2005
|
CARISOPRODOL
|
350 mg tablet
|
120 tablets per month
|
07.14.2005
|
COMBIVENT
|
103-18 mcg inhaler
|
29.4 grams per month
|
07.14.2005
|
COMBUNOX
|
Tablet
|
4 tablets/day
|
07.14.2005
|
DIFLUCAN
|
50 mg tablet
100 mg tablet
200 mg tablet
|
60 tablets per month
|
02.14.2003
|
150 mg tablet
|
2 tablets per month
|
02.14.2003
|
EPOGEN
|
2,000 U/ml vial
3,000 U/ml vial
4,000 U/ml vial
10,000 U/ml vial
20,000 U/ml vial
40,000 U/ml vial
|
33 ml total per month
|
05.19.2003
|
FOSAMAX AND FOSAMAX + D
|
35 mg tablet
70 mg tablet
|
4 tablets per month
|
07.14.2005
|
70 mg suspension
|
300mls per month
|
07.14.2005
|
FROVA
|
2.5 mg tablet
|
9 tablets per month
|
02.14.2003
|
HEPSERA
|
10mg tablet
|
1 tablet per day
|
02.25.2005
|
HERCEPTIN
(PA Criteria apply)
|
440 mg vial
|
3 vials per month
|
02.14.2003
|
Drug Name
|
Strength(s)
|
MSDs
|
Effective Date
|
HYCAMTIN
|
4 mg powder for injection
|
8 vials per month
|
02.14.2003
|
IMITREX
|
25 mg tablet
50 mg tablet
100 mg tablet
|
9 tablets per month
|
02.14.2003
|
6 mg/0.5 ml syringe kit
6 mg/0.5 ml refill kit
|
2 kits (4 syringes) per month
|
02.14.2003
|
6 mg/0.5 ml vial
|
2 vials per month
|
02.14.2003
|
5 mg nasal spray
20 mg nasal spray
|
6 nasal spray devices per month
|
02.14.2003
|
LIPITOR
(PA Criteria apply)
|
10 mg tablet
20 mg tablet
40 mg tablet
80 mg tablet
|
30 tablets per month
|
05.19.2003
|
LOTRONEX
|
0.5 mg tablet
1 mg tablet
|
30 tablets per month for the 1st month and up to
60 tablets per month thereafter
|
|
MAXALT
|
5 mg tablet
10 mg tablet
|
6 tablets per month
|
02.14.2003
|
5 mg MLT tablet
10 mg MLT tablet
|
6 tablets per month
|
02.14.2003
|
MERREM
|
1 gram vial
1gram infusion bottle
|
180 vials/bottles per month
|
07.14.2005
|
500 mg vial
500 mg infusion bottle
|
360 vials/bottles per month
|
07.14.2005
|
NEPHROVITE, NEPHRO-VITERX, NEPHRO-VITE FE
|
All Tablets
|
Plan 200: 1 tablet/day
|
|
ONTAK
|
150 mcg/ml vial
|
8 vials per month
|
07.14.2005
|
OXANDRIN
|
2.5 mg tablet
10 mg tablet
|
20 mg per day
|
04.27.2005
|
PROCRIT
|
2,000 U/ml vial
3,000 U/ml vial
4,000 U/ml vial
10,000 U/ml vial
20,000 U/ml vial
40,000 U/ml vial
|
33 ml total per month
|
05.19.2003
|
PULMICORT TURBUHALER
|
200 mcg canister
|
2 canisters per month
|
02.14.2003
|
RELENZA
|
5 mg Diskhaler
|
5 day supply
|
08.01.2001
|
RELPAX
|
20 mg tablet
40 mg tablet
|
6 tablets per month
|
06.16.2003
|
REMICADE
|
100 mg vial
|
20 vials per month
|
07.14.2003
|
RHINOCORT AQUA
|
32 mcg nasal spray
|
Adults (³12): 8.6 grams per month
Children: 8.6 grams per 2 months (60 days)
|
07.14.2005
|
RITUXAN
|
10 mg/ml
|
400 mls per month
|
02.14.2003
|
SPORANOX
|
100 mg capsule
|
120 capsules per month
|
08.01.2001
|
TAMIFLU
|
Oral Suspension
75 mg Gelcap
|
2 capsules per day or 3 bottles per 5 days
|
11.01.2001
|
TORADOL
|
10 mg tablet
|
20 tablets per month
|
02.14.2003
|
TORADOL
|
30 mg/ml
15mg/ml
30 mg/ml Tubex
30 mg/ml Syringe
15mg/ml Tubex
|
5 days supply
|
02.14.2003
|
UNASYN PIGGYBACK
|
1.5 gram piggyback vial
3 gram piggyback vial
|
8 piggyback vials per day
|
05.19.2003
|
Drug Name
|
Strength(s)
|
MSDs
|
Effective Date
|
VICON FORTE
|
Capsule
|
Covered for LTC; 1 capsule/day
|
|
ZELNORM
|
2 mg tablet
6 mg tablet
|
60 tablets per month
|
|
ZOFRAN
|
4 mg tablet
8 mg tablet
|
12 tablets per month
|
02.14.2003
|
4 mg ODT tablet
8 mg ODT tablet
|
12 ODT tablets per month
|
02.14.2003
|
24 mg tablet
|
2 tablets per month
|
02.14.2003
|
4 mg / 5 ml oral solution
|
150 mls per month
|
02.14.2003
|
ZOMIG
|
2.5 mg tablet
5 mg tablet
|
6 tablets per month
|
02.14.2003
|
2.5 mg ZMT tab
5 mg ZMT tablet
|
6 tablets per month
|
02.14.2003
|
5 mg nasal spray
|
6 per month
|
02.14.2003
|
ZYVOX
|
100mg / 5ml suspension
200mg / 100 ml IV solution
600 mg tablet
600 mg / 300 ml IV solution
|
14 days supply
|
02.14.2003
|
Please note: Multivitamins and Geriatric supplements are covered for Long-Term Care patients with a maximum daily dose of 1 tablet/day or 5 ml/day.
