PA PAP

(Pennsylvania Patient Assistance Program)

 

Provider Bulletin

April 11, 2008

 

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                               April 3, 2008

 
 

 

 

 

 


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