PACE

Provider Bulletin

February 11, 2005

 

Prospective Drug Utilization (ProDur) Additions

 

Effective Monday, February 14, 2005 this criteria will be applied to the following drugs:

 

Drug Name

Initial Maximum Dose

Maximum Dose

Comments

Crestor®

(rosuvastatin calcium)

5 mg.

40 mg.

Claim will Deny with NCPDP error of 88 HD.  Medical exception will not be granted without the Program receiving approvable documentation from prescriber. 

Risperdal®;

Risperdal®

M-Tab (resperidone)

0.5 mg.

6 mg.

Claim will Deny with NCPDP error of 88 HD.  Provider should call PACE Provider Services. Medical exception may be granted if certain criteria are met.

Namenda®

5 mg.

20 mg.

Claim will Deny with NCPDP error of 88 HD.  Provider should call PACE Provider Services. Medical exception may be granted if certain criteria are met.

Prevacid® ; NapralPAC™

(naproxen and lansoprazole)

N/A

1000 mg.

Claim will Deny with NCPDP error of 88 HD.  Provider should call PACE Provider Services. Medical exception may be granted if certain criteria are met.

Caduet®

(amlodipine and atorvastatin calcium)

N/A

80 mg.

Claim will Deny with NCPDP error of 88 HD.  Medical exception will not be granted without the Program receiving approvable documentation from prescriber.

 

Symbyax®

(fluoxetine HCL and olanzapine)

N/A

N/A

Claim will Deny with NCPDP error of 88 HD.  Medical exception will not be granted without the Program receiving approvable documentation from prescriber.

Pravigard PAC

(buffered aspirin and pravastatin sodium)

N/A

N/A

Claim will Deny with NCPDP error of 88 HD.  Medical exception will not be granted without the Program receiving approvable documentation from prescriber.

 

 

Questions may be directed to PACE Provider Services at

 

1-800-835-4080.

 

 

PPB-05-004