Maximum Standard Doses

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.

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