PA PAP
(
Provider Bulletin
Effective
immediately, PAP will begin enrolling eligible patients into a new program.
Cardholders accepted into PAP receive a paper card (example
below) bearing the cardholder’s name, copay amounts and a code identifying the
medication they are eligible to receive. As with PACE/PACENET cards, no ID
number is printed on the card because of HIPAA regulations. Providers may
either ask the cardholder or contact Provider Services for this information.
The cardholder’s beginning date of eligibility for the specific program in
which the cardholder is enrolled also appears on the card.
The
medication codes and their
respective maximum daily allowable doses appear on the reverse side of this bulletin.
Copay
$6.00 Generic 0U $9.00
Brand John Cardholder
Medication
code
Questions may be directed to
Provider Services at
1-800-835-4080.
Antidepressant Medications—Subgroup 0
|
Drug Name |
Generic |
Maximum Daily Dose |
|
Wellbutrin®-W |
Bupropion-B |
450mg/day |
|
Celexa®-U |
Citalopram-I |
40mg/day |
|
Anafranil®-A |
Clomipramine-4 |
250mg/day |
|
Prozac®-P |
Fluoxetine-F |
60mg/day |
|
Remeron®-3 |
Mirtazapine-M |
45mg/day |
|
Serzone®-S |
Nefazodone-N |
600mg/day |
|
Paxil®-1 |
Paroxetine-2 |
40mg/day |
|
Zoloft®-Z |
Sertraline-5 |
200mg/day |
|
Desyrel®-D |
Trazodone-T |
400mg/day |
|
Effexor®-E |
Venlafaxine-V |
225mg/day |
|
Paxil CR®-1 |
Paroxetine-2 |
50mg/day |
|
Lexapro®-H |
Escitalopram |
20mg/day |
|
Wellbutrin XR®-W |
Bupropion-B |
400mg/day |
|
Prozac Weekly-P |
Fluoxetine |
90mg/week |
Antipsychotic Medications—Subgroup 0
|
Drug Name |
Generic |
Maximum Daily Dose |
|
Clozaril®-J |
Clozapine-K |
100mg/day |
|
Risperdal®-R |
Risperidone |
6mg/day |
|
Seroquel®-Q |
Quetiapine |
400mg/day |
|
Zyprexa®-X |
Olanzapine |
10mg/day |
|
Geodon®-G |
Ziprasidone |
160mg/day |
|
Abilify®-Y |
Aripiprazole |
15mg/day |
Other—Subgroup 2
|
Drug Name |
Generic |
Maximum Daily Dose |
|
Buspar®-B |
Buspirone-A |
60mg/day |