O bs te tr ics C li ni c W orksh ee t (con ti n ue d)

Transcription

Medical Access Program
Provider Handbook
April 2016
TABLE OF CONTENTS
Section 1:
INTRODUCTION
Section 2:
ENROLLMENT AND DISCHARGE
Section 3:
COVERAGE VERIFICATION
Section 4:
CO-PAYMENTS, GROUPS AND PLANS
Section 5:
SERVICES AND AUTHORIZATIONS
Section 6:
HEALTH SERVICES
Section 7:
CCC CLINICAL PROTOCOLS
Section 8:
CONTRACTED PROVIDERS
Section 9:
CLAIMS
Section 10: SPECIALTY CARE
Section 11:
PHARMACY SERVICES
Section 12:
COMMUNITY CARE — WOMEN’S HEALTH CENTER
Section 13:
QUICK REFERENCE: CONTACTS AND HELPFUL NUMBERS
Section 14:
FREQUENTLY ASKED QUESTIONS
1. INTRODUCTION
Disclaimer
Information in the Provider Handbook is current as of the date
of release with revisions. All efforts are made to maintain the
accuracy of the information found within.
It is the responsibility of the provider to verify that the most
current revision documents of the handbook are used for the
provision of services.
Medical Access Program Handbook
The member manual contains useful information on the MAP
Program and can be accessed using the link below
Medical Access Program Handbook
MAP Website
http://www.medicalaccessprogram.net/
Central Health Eligibility Website
http://www.cheligibility.net
2. ENROLLMENT
ENROLLMENT
ELIGIBILITY OFFICES
COVERAGE
MAP RENEWAL AND/OR EXPIRED COVERAGE
CHANGE OF ADDRESS
LOST MAP ID CARD
CUSTOMER SERVICE CALL CENTER
DISCHARGE FROM PRACTICE
ENROLLMENT
ELIGIBILITY OFFICES
Visit the Central Health Eligibility website for a current listing of MAP eligibility
offices, addresses, and phone numbers.
http://www.cheligibility.net/en/sites/
COVERAGE
MAP enrollees are given a pink identification card, which states the effective
and expiration dates of coverage, co-payments, and other important
information.
The length of issuance for MAP coverage may range from one month to one year
and is dependent on the enrollee’s circumstances as determined during the
enrollment process.
The MAP card does not guarantee coverage.
Services, supplies, or equipment provided without active MAP coverage will not
be reimbursed.
:> To verify coverage, visit the Provider Self Service website at
https://www9.medicaider.com/medicaid/manager/login.asp
MAP RENEWAL and/or EXPIRED COVERAGE
Enrollees are encouraged to call our Customer Service Call Center at
(512) 978-8130 two to three (2-3) weeks in advance of her or his MAP
expiration date to schedule an enrollment/eligibility appointment.
CHANGE OF ADDRESS
An enrollee should be referred to the Customer Service Call Center at
(512) 978-8130 to report a change of address.
LOST MAP ID CARD
An enrollee should be referred to the Customer Service Call Center at (512) 9788130 to obtain a replacement MAP identification card.
CUSTOMER SERVICE PHONE LINE
The Medical Access Program Customer Service Call Center is available to
enrollees and providers for benefit information, general information, setting
eligibility appointments or reporting changes. The phone number is (512) 9788130.
PROVIDER PRACTICE DISCHARGE NOTIFICATION PROCESS
There are situations in which a Provider may discharge a MAP Enrollee from their
medical practice. If a provider has decided to discharge a patient from their
practice, the provider should contact the MAP Customer Service number at 512978-8130 for instructions on how to notify all applicable parties during the
discharge process.
3. COVERAGE VERIFICATION
COVERAGE VERIFICATION
How to read a MAP identification card
The MAP card does not guarantee coverage. To verify coverage, visit the Provider Self
Service at www.medicaider.com/medicaid/manager/start.asp.
1
2
4
6
8
3
5
7
9
10
3
7
9
MAP Card Legend
1.
ID#: Enrollee’s Master Record Number. In this case, the MR# is 474238.
2.
Group: This is the Group Identifier for the enrollee’s level of coverage issued.
3.
Plan: This is the enrollee’s coverage plan type.
4.
EFF: This is the effective date of the enrollee’s coverage. The format is
MM/DD/YYYY.
EXP: This is the expiration date of the enrollee’s coverage. The format is
MM/DD/YYYY.
5.
6.
This is where you will see the enrollee’s name. The format is first name, middle name,
last name.
7.
DOB: This is where you will see the enrollee’s date of birth. The format is
M/D/YYYY.
8.
CO-PAY: OP ($1o) IP ($3o) ER ($25): This is the co-pay amounts to be requested from
the enrollee at time of service.
In some exceptional cases an enrollee’s co-pay may be zero ($0). These cases will be
documented at the time of an enrollment/eligibility interview and the zero co-pay
printed on the ID card.
For further information regarding co-payments, groups, and plans see section 4.
9.
Dental: This is the co-pay amount to be requested from the enrollee at time of
service.
10.
RX: This is the co-pay amount to be requested from the enrollee per eligible
prescription.
In some exceptional cases an enrollee’s co-pay may be zero ($0). These cases will be
documented at the time of an enrollment/eligibility interview and the zero co-pay
printed on the ID card.
Central Health
Provider Self Service
Registration & Instructions
Provider Self Service Registration
Section I
Registering for Provider Self Service
Step 1
To use the Provider Self-Service website, you must first register on the provider eligibility
registration webpage. Generally, the turnaround time for the registration process is three
business days.
Using the most current version of Internet Explorer web browser, go to
www.medicalaccessprogram.net. To access the website and its range of functions, you must
use Internet Explorer version 9.0 or higher.
Once you are on the main page for the Medical Access Program website, you must choose
the tab labeled For Providers.
Step 2
On the “For Providers” page, you will see a link called “Online Agreement and fill
out the pre- registration form”. Click on the link, this will lead to the provider
eligibility registration page.
Step 3
Please read the Online Access Agreement for Provider Self Service and scroll to the
bottom of the page to register.
Please enter the requested information in the appropriate boxes. Once the information
is entered completely, please click on the Submit button found at the bottom of the
page.
Once you submit your information, you will receive an email indicating there was a
successful submission.
You should receive two emails within three business days of a successful submission.
One email will include:
Your user name
The CHASSIS Software Web Address
Technical Support
Provider Self-Service Instructions
Reminders
Second email will include:
Your temporary password
A reminder to change the temporary password upon first use
Provider Self Service Instructions
Section II
Logging into CHASSIS Software
Step 1
In order to access the Provider Self Service, you must use Internet Explorer verion 9.0 or
higher. Go to the Provider Self Service log in page found in the email sent to you after
registering. Type in your username and password.
Step 2
Once you are on the Provider Self Service page, make sure the radio button, “Verify
Eligibility” is selected.
Step 3
Enter the client’s information into the provided fields.
You must use a combination of information in order to obtain results. The combinations
are listed below and are also found on the webpage itself.
1.
2.
3.
4.
Last name, first name, birth date or
Social Security Number and birth date or
Social Security Number and last name or
Master Record # (unique number assigned by an organization to identify a person)
The date or date range of service is required in every search.
Step 4
Viewing the client’s enrollment information
Upper Right Hand: Client Information
 Master Record: Listed as the ID # on the MAP card; also known as an enrollment
number, Name, Birth Date, Gender, Address, Phone
Upper Left Hand: Search Information
 The information entered to reach this screen.
Lower Portion of the screen: Program Eligibility
 Segment Dates: Effective Date, End Date, Certification Date
 Program: Details the type of medical benefits coverage the enrollee currently has
along with the co-pay responsibilities of the enrollee
 Riders: Rider A indicates Dental benefits, Rider B indicates Prescription Drug
benefits along with copays
 Fee Scale: Not Used
 PCP: Primary Care Provider enrollee is assigned
 Other: Not Used
Step 5
Based on the search criteria entered if there is no match in the database the screen below
will appear.
When this screen is displayed there are two possible reasons why:
1. The client does not have current medical coverage during the date(s) of service
entered or
2. The criteria entered on the Eligibility Verification Report page may have been
entered incorrectly. Please return to the Eligibility Verification Report page using
the Back button found on the lower portion of the screen in blue. Enter the correct
information.
Provider Self Service Instructions
Section III
Resetting Your Password
Step 1
If you incorrectly enter your password on the first log on, you will receive this error
message “Invalid User Name or Password”.
Step 2
If you enter your password incorrectly a second time, a statement and hyperlink that
states “Forgot your password?” “E-mail it to me” will appear on the screen. Click on the “Email it to me” hyperlink. Your password will be emailed to the email address you provided
during the registration process.
If you enter your password incorrectly a third time, you will lock yourself out of your
Provider Self Service account. Then you will need to email
[email protected] to request a reset of your account password.
4. CO-PAYMENTS, GROUPS, AND PLANS
CO-PAYMENTS, GROUPS and PLANS
The MAP card does not guarantee coverage. To verify coverage, visit the Provider Self Service
website at www.medicaider.com/medicaid/manager/start.asp.
GROUP
CBRACKFQ
CBRACKFQ
PLAN
CBRACKFQ
CPENDSSI
Out-patient Contract
PCPs Contract
Specialty
Providers
Urgent care
In-patient
Emergency Room
Dental office visit
Partial Dentures
Full Dentures
$1o co-pay or
$o co-pay if noted on MAP card
$1o co-pay or
$3o co-pay or
$25 co-pay or
$1o co-pay or
$35 per partial or
$5o per plate or
$3o co-pay or
$25 co-pay or
$1o co-pay or
$35 per partial or
$5o per plate or
$7 co-pay for 1-3o day supply or
$14 co-pay for 31-9o* day supply or
$7 co-pay for 1-3o day supply or
$14 co-pay for 31-9o* day supply or
*90-day supply on selected drugs
only
*90-day supply on selected drugs
only
$1o co-pay for 1-30 day supply or
$20 co-pay for 31-90* day supply or
$1o co-pay for 1-30 day supply or
Pharmacy
Formulary
Non-Formulary
5. SERVICES AND AUTHORIZATIONS
Medical Access Program
SERVICES AND AUTHORIZATIONS
Services
Prior Authorizations
Vasectomy Referrals
Services and Authorization Matrix
Seton Health Plan Pre-Certification Form
Seton Health Plan Coverage Guidelines for Varicose Vein
Referral
Seton Health Plan Polysomnography — Sleep Study
Authorization For m
MAP Exclusions
Services
Community Care Collaborative (CCC) arranges for healthcare services for Travis County residents
who are not eligible for other private or public insurance programs. To ensure a complement of
services, Community Care Collaborative continues to evaluate services for MAP enrollees.
Through contractual agreements, the Medical Access Program (MAP) provides access to health
care through networks of established providers. The CCC is directly responsible for primary care
services, dental services, and selected specialty services.
The CCC contracts with Seton Health Plan (SHP) for hospital-based and specialty, diagnostic,
durable medical equipment services, and home health services as well as utilization management
which includes prior authorizations.
:> See document entitled “Services and Authorizations Matrix.”
:> Please visit www.setonhealthplan.com/providers/ for the latest version.
Prior Authorizations
Prior authorization is the process used to authorize designated medically necessary services.
The majority of services do not require authorization.
The primary care office submits the prior authorization request, which provides the medical
information related to the services requested.
The request is reviewed, and is authorized (approved) or denied. An authorization
number is issued when a request is authorized.
:> MAP Authorization Form: See documents entitled:
D “Pre-Certification Form”
D “Polysomnography — Sleep Study Authorization Form”
D “Varicose Vein Referral (Coverage Guidelines)”
:> Please visit www.setonhealthplan.com/providers/ for the latest version.
Vasectomy Referrals
Vasectomy is a covered service for MAP clients. MAP clients must be referred to The Urology Team for a
vasectomy
Referral Process:

Primary Care Provider identifies an eligible MAP client who desires to have the procedure
performed.

MAP client is issued the Vasectomy Voucher by the Primary Care Provider.

MAP client is responsible for calling The Urology Team at PH: (512) 231-1444 to schedule an
appointment.

MAP client is to present the Vasectomy Voucher at the time of the scheduled appointment at The
Urology Team office.
MAP Vasectomy Voucher:
Services and Authorizations Matrix
Services
Acupuncture
MAP
NB
Ambulance, Emergent ground
D
Ambulance, Non-emergent, ground
P
Ambulance, Non-emergent, air
P
Behavioral Health, Inpatient including substance abuse
NB
Behavioral Health, Outpatient - Office Visits for BH or Substance
Abuse
NB
Behavioral Health, Outpatient - Intensive Outpatient Program
NB
Behavioral Health - Psychological Testing
NB
Behavioral Health - ECT (Electroconvulsive Therapy)
NB
Biofeedback
NB
Chemotherapy
CPT code: 90870
D
Chiropractic
NB
Cognitive Training / Retraining
NB
Cosmetic Surgery
Notes
P/NB
Certain procedures are covered for medical necessity; prior authorization required in all cases
Cyberknife and related pre-treatment imaging/services
P
Consultation and follow-up visit with Ron Wilson MD require authorization. Treatment provided by
charity (from Cyberknife vendor), three per quarter.
Dental: including general dentistry & orthognathic services, dental
trauma, oral surgery, and dentures
D
MAP Dental Services: contact 512-978-9895 for RBJ Dental Clinic; 512-978-9880 for Northeast
Dental Clinic; 512-978-9865 for South Austin Clinic
Dialysis
Emergency Services, hospital ER
NB
D
Experimental / Investigational
NB
Genetic Counseling
P/D
Private Office/Clinic
Genetic Testing
NB
Includes the following tests: BRCA1&2 (ovarian and breast cancer); MLH1&2 (hereditary
nonpolyposis colorectal cancer-HNPCC); APC (familial adenomatous polyposis-FAP); Oncotype DX
test; Codes: S3818-S3820, S3822-S3823, S3828-S3831, S3833-S3834, S3854; NOT COVERED APOE epilson 4-(susceptibility to Alzheimer's), S3852
Hearing Aids
NB
Health Education - (Diabetes; Nutrition)
Home Health Care / Home Infusion
Hospice
Vasectomy
See comment
Diabetic education and nutrition responsibility of contracted primary care providers.
P
NB
D
Ancillary supplies/equipment may be covered under MAP if no other funding program available.
Provider referral required to the Urology Team. Use the Vasectomy Voucher.
Hospital Services
Inpatient
Scheduled (Elective)
P
P
Rehab Facility
NB
Trauma / ER Admit
P/N
Observation (Trauma / ER)
D
Recuperative Care
P
Skilled Nursing Facility
NB
Observation and Outpatient Surgery (elective) ***
Biopsy - w/ or w/o image guided
D
See "biopsy codes, etc." list for codes
Cataract removal w/ IOLens
D
CPT codes: 66820-66821, 66825, 66830, 66840, 66850, 66852, 66982-66985
Services
MAP
Notes
Cholecystectomy, laparoscopic
D
CPT codes: 47562-47564; outpatient only
Circumcision
D
CPT codes: 54150-54163
DaVinci Robot assisted surgery
P
Available at SMCA &SMCW
Hernia Repair
D
CPT codes: 39501, 39503, 39540-43337, 49491-49496, 49500-49501, 49505, 49507, 4952049521, 49525, 49540, 49550, 49553, 49555, 49557, 49560-49561, 49565-49568, 49570, 49572,
49580, 49582, 49585, 49587, 49590, 49650-49659
Lumbar Puncture
D
CPT code: 62270
Port-a-cath insertion / removal: includes Insert tunneled CV cath
D
CPT codes: 36555-36558, 36560-36561, 36566, 36568-36569, 36570-36571, 36576, 36578,
36580-36585, 36595-36596, 76937
Infertility (diagnostic testing for definitive diagnosis)
NB
Infertility Treatment
NB
1) No authorization through SHP.
2) Medication needs to be arranged through Patient Pharmacy Assistance Programs (PPAP).
3) Coverage of outpatient infusions limited to UMCB Shivers Specialty Clinic.
Specialty Injectable / infusion Medications
see note
Laser Assisted Uvulopalatoplasty
P
Laser (Excimer) Treatment
P
Lymphedema Management / Therapy
Neuropsychological Testing
Oral Surgery / TMJ
CPT codes: 96920-96922
P/see comment Only benefit when provided at SHF rehab department
NB
CPT codes: 96118-96120
D
Orthodontia (pre / post surgical)
NB
Transplants
NB
Varicose Vein Treatment
~ Including but not limited to: Chemotherapy agents, Botox, Bisphosphonates (Boniva, Fosamax,
Reclast, etc.); Osteoclast Inhibitors (Prolia) Depo-Provera, IGG, Lupron Depot, DMAD (Remicade;
Orencia; Humira, etc.); Viscosupplements: (Supartz, Synvisc, Euflexxa, Hyalgan, Orthovisc, etc.)
Synagis, Tysabri, Xolair, Provenge; 17 Alpha hydroxyprogesterone caproate (17P)
P
Outpatient Therapeutic Studies
Arthrogram
P
CPT code: 21116, 23350, 24220, 25246, 27093-27096, 27370, 27648, 70328-70332, 73040,
73085, 73115, 73525, 73542, 73580, 73615
Bronchoscopy
D
CPT codes: 31622-31656
Cardiac Cath / EP studies/Ablation
D
CPT codes: 93451-93461, 93503-93533, 93600-93662
Colonoscopy; Sigmoidoscopy
D
CPT codes: 45355, 45378-45387, 45391-45392, 45330-45345
Doppler Study - Arterial/venous
D
CPT codes: 93922-93924, 93971, 93886-93888, 93926-93990
Echocardiogram; EKG; Holter Monitor
D
CPT codes: EKG - 93010, 93300, 93305; Holter Monitor - 93224-93227, 93230-93237;
Echocardiograms - 93025, 93303-93304, 93306, 93308, 93312-93314, 93318, 93320-93321,
93350
EEG
D
CPT codes: 95816, 95819
EGD
D
CPT codes: 43200-43259
Hysterosalpingography (HSG) / Sonohysterography (SIS)
P
CPT codes: 58340, 74740
Stress Test - Cardiac (ETT)
D
CPT codes: 93015-93024
Visual Field Testing
D
CPT codes: 92081-92083; NB for charity patient who resides outside Travis County
Pain Management Procedures
P-limited
coverage
Limited to: Acute back pain (not chronic pain); Dx: herniated disc with radiculopathy; unresponsive
to conservative treatment (i.e. PT, NSAIDs); Treatment limited to epidural steroid injection (ESI)
maximum of 3 per 12 month period
MAP
Prolotherapy
NB
Sleep Study
P
Notes
CPT code: 95811
Radiology / Imaging
Imaging Services Not Listed
D
Anesthesia for Imaging
D
Angiography / Venography
D
Barium Enema
D
CPT codes: 74270-74280
Bone Density Study (Dexa Scan)
D
CPT codes: 77071-77084; only available at SSW
Ca Scoring (Heart Saver CT)
NB
CT Myelogram
P
CT Scan
P
CT Cardiac Angiography
P
CT Colonoscopy (Virtual Colonoscopy)
CPT code: 01922
NB
CPT codes: 62284, 62290-62291
Not a covered benefit of Medicare, therefore not covered
Image Guided Biopsy
D
IVP (Intravenous Pyelogram)
D
CPT codes: 74400-74415, 74420
Mammography (screening)
D
Community resources available; CPT codes: 77051-77057
CPT codes: 78000-79999
Nuclear Medicine (NM)
Bone Scan
D
MRA
P
MRI
P
MRI - Breast
P
MRI - Open
P
Not available at SFH (try SNW - have large semi-open)
Nuclear Med Stress Test
D
CPT codes: 78451-78454
Perfusion Studies; spect
D
CPT codes: 78451-78454, 78472-78473, 78494, 78496
PET Scan
P
Not available at SFH (ARA)
Thyroid Scan/Uptake
D
CPT codes: 78012-78099
Upper GI
D
CPT codes: 74246-74249
Other NM not listed
P
Includes, but not limited to, CPT codes: 79000-79999
Radiation Therapy
D
Referral to Specialist (private office and specialty clinics)
D/P
CPT codes: 78300-78320, 78350-78351, 78399
Direct access to UMCB & DCMCCT Marnie Paul Specialty Clinics; Prior-authorization
required for private practice; See Ophthalmologist grid for treatment of eye disorders
Rehab Services
Cardiac Rehab
PT, OT, ST (therapy)
Wound Care
DME (quantity limits apply)
D
P>8vists
D
**D<$250
P>$250
Blood glucose monitor w/ voice synthesis
P
E2100; MAP members access through Pharmacy benefit
Compression Support Hose / Stockings (over the counter)
D
Over the Counter; A6530-A6541; Limit 2 pair per year
Continuous Glucose Monitor (CGS) and supplies
P
Services
MAP
Notes
Custom items: DME, orthotics and prosthetics, shoe inserts
P
Diabetic Shoes and Inserts (over the counter)
D
A5500, A5512
Disposable Supplies, including wound care supplies
D
No custom DME items
Insulin Pumps and Supplies
P
Lymphedema Pumps & Stockings
P
Orthotics
P**
Prosthetics
P
When no other funding source available
Apnea Monitor
D
E0618-E0619
Bedside Commode
D
E0163-E0168
Bili lights (phototherapy)
D
E0202
BIPAP
P
E0470-E0472; Approved for 3 months initial usage, then compliance report for continued rental of
CPAP/ BIPAP
Rental items requiring authorization regardless of dollar
amount:
Breast Pump
NB
E0602-E0604; Available through community resources
Compressors (high volume)
D
E0575, E0580, E0585
CPAP
P
E0601
CPM; Dynamic splinting; PMD
P
E0935, E1800-E1840
Enteral Therapy, supplies and formula, nutrition
P**
B4034-B4036, B4150-B4160
Feeding pump (Enteral Therapy)
P**
B9000-B9006, B9998-B9999; if valid authorization on file for pump, then authorization includes the
B4034-B4036 listed above
Hospital Beds and Accessories
P
E0250-E0270, E0277-E0300
Humidifier, w/ equipment (Nebulizer)
D
E0550-E0562
Jaw motion rehab system (CPM)
P
E1700-E1702
Oxygen and Related Respiratory Equipment
P
E0424-E0500, E1353-E1390, E1392, E1405-E1406
Patient Lifts
P
E0621-E0636
Powered air flotation bed / mattress (low air loss)
NB
E0193
Powered / Nonpowered overlay for mattress
P
E0371-E0373
Pressure-relief pads; alternating; air; water mattress
P
E0180-E0187, E0194-E0199
Pulse Oximeter
P
CPT codes: 94760-94762;
Not covered: E0445 & A4606 (as excluded by Medicare)
Safety enclosure frame / canopy for use with hospital bed
P
E0316
Suction Machine
P
E0600, E2000
TENS
D
E0720-E0730
Neuromuscular and bone growth stimulators
P
E0744-E0765
Wheelchairs
P
E1050-E1298, K0001-K0014
Wound V.A.C. (Negative pressure wound therapy)
Arrange thru
E2402
facility PT Dept.
Notes:
** Subject to plan limitations
*** Outpatient surgery/procedure performed in facility - not to include office procedure
Abbreviations:
D - Direct access no authorization required for this service.
P - Plan approval required by phone/fax with medical information
NB - Not a benefit
SFH - Seton Family of Hospitals
Prior-Authorization Form
* Plan Name
SmartHealth 500
SmartHealth HDHP 1300
*Request
Date:
*Phone # and Ext
(Include area code):
*Patient Name:
Referral Type:
□ Routine
Medical Management Dept.
□ Urgent (Service in next 72hrs)
Phone #: (512) 324-3135
Fax #: (512) 380-4253
Seton Care Plus
MAP
Charity (attach demographic sheet
City/County Community Clinic
with address/phone number(s), etc) *
(CCHC/COTHER)
TERM DATE:
*Submitted by
(Name):
*Return Fax #
(include area code):
*Patient’s ID Number:
*DOB:
NPI:
*Requesting Provider
or Clinic name:
*Requested Specialist
or Service:
*Requested
# of visits:
*ICD-10 Codes:
NPI:
*Proposed Date
of Service:
*Diagnosis
Description:
*Description:
*CPT or HCPCS
Codes:
NPI:
*Facility Name (for Inpatient or
Outpatient Services):
*□ Inpatient
□ Outpatient
□ Observation □ In Office □ Imaging
□ DME/Home Health □ Therapy
*Reason for referral (please attach pertinent clinical/progress notes or provide clinical narrative, including
duration of problem, types of treatment, pertinent physical findings, pertinent testing results):
*Workman’s
Compensation:
*Other Insurance
Coverage:
YES
YES
Coordination of Benefits (Other Insurance)
YES
NO
*MVA
Date of Injury:
Subrogation:
NO
Subscriber
Name of
Name and ID #:
Insurance:
NO
TO BE COMPLETED BY SETON HEALTH PLAN MEDICAL MANAGEMENT SERVICES
Authorization
Number:
Number of Visits or
Services Approved:
Comments/Questions:
Authorization
Dates:
* In order to process request, all required fields with asterisks must be completed.
NOTICE OF CONFIDENTIALITY – This document is intended solely for the use of the individual identity to which it is addressed and may contain
information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this notice is not the intended recipient or
individual responsible for delivering the message to the intended recipient, you are hereby advised that any dissemination, distribution or copying of this
information is strictly prohibited. If you have received this communication in error, please advise us immediately by telephone and destroy these papers
12.1.2015
Seton Health Plan
Coverage Guidelines
Varicose Vein Referral
Policy:
1) Seton Health Plan (SHP) will review Medical Assistance Program (MAP) patient
referrals for varicose vein evaluations.
2) Primary care physician will submit varicose vein evaluation requests to SHP and
include supporting documentation (i.e. conservative measures taken, physical
findings and related test results).
3) SHP will approve an evaluation visit at Austin Radiology Associates (ARA) if the
following criteria have been met:
> No significant symptomatic improvement in response to 3-month trial of fitted
elastic support hose AND
> Objective complications — symptoms causing clinically significant functional
impairment as indicated by 1 or more of the following: AND
o Leg pain
o Leg fatigue
o Leg edema
> Ultrasound lower extremities to RIO DVT OR
> 1 or more of the following complications or recurrent symptoms:
o Bleeding from a varicosity that has eroded skin
o Large superficial varices around skin ulcer
o Persistent or recurrent venous stasis ulcer
4) Initial evaluation authorization for ARA will include the following:
> 99241 — Consult x 2
> 93970 — Duplex Doppler
5) If ARA determines that intervention is required they will contact SHP to obtain
authorization. Procedure codes for EVLT will depend on patient’s condition and may
include the following codes: 36478; 37799; 37765; 37766; 36470; 36471; 36479
Pre-Certification Form
Medical Management Dept.
Phone #: (512) 324-3135
Fax #: (512) 324-1936
Polysomnography- Sleep Study Authorization Form
This form should be completed by the person who has a thorough knowledge of the patient’s current clinical presentation and his/her
treatment history. Please complete ALL parts as clearly and as specifically as possible. Omissions, generalities, and illegibility will result
in the form being returned as an incomplete request.
Plan Name
Seton Care Plus
Charity
*Request
Date:
*Patient Name:
*DOB:
*Submitted
by:
MAP
CitylCounty Community Clinic (CCHC)
*Phone #:
*Fax:
*Patient’s ID Number:
Diagnosis and ICD 10 code:
*PCP or Requesting Provider Name:
REQUEST FOR INITIAL POLYSOMNOGRAM — SPLIT NIGHT (CPAP applied half night if AASM criteria met)
(Both Sections Need To Be Completed)
u Patient awakens with a sense of gasping, choking, or suffocations
u An observer of the patient’s sleep reports repeated pauses in breathing, lasting more than 10 seconds, gasping or choking during sleep
u Awakening of the patient in a state of terror later attributed to the inability to move air through his/her upper airway
u Patient has to fight off sleep while engaging in activities or actually falls asleep unintentionally in the absence of such apparent causes as use of
potentially sedating medications, etc.
Epworth Sleepiness Scale (Required)
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent
times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to
choose the most appropriate number for each situation:
0 = would never doze; 1 = slight chance of dozing; 2= moderate chance of dozing;
3- high chance of dozing
Situation
Chance of dozing (score 0 — 3)
Sitting and reading
Watching TV
Sitting, inactive in public placed (e.g. theater or meeting)
As a passenger in a car for an hour without a break
Lying down at rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL
o
OTHER CLINICAL FINDINGS:
o
REQUEST FOR REPEAT SLEEP STUDY
E
E
E
Indication is following a recent positive first night sleep study, where titration was not performed .
Copy of previous sleep study submitted with this request
Other indication: Please provide details as to why another sleep study is required:
Requesting Provider
Signature and Date:
SHP AUTHORIZATION
NUMBER:
COMMENTS:
Conum/internal guidelines/current guidelines/Polysomnography Request Form 2_22.2011 DRAFT
AUTH
DATES:
MAP EXCLUSIONS
Services and related items excluded from coverage by the Medical Assistance Program
(MAP) include but are not limited to the following list. MAP does not cover items on this
list.
The list of MAP benefits and exclusions are also listed on the MAP Handbook located at:
https://www.dropbox.com/s/gpngym7stmf2je2/MAP%20Handbook%20English%20Feb%2
015%202016.pdf?dl=0
1.
All services that have been denied through pre-authorization by the
Medical Assistance Program;
2.
Services not provided within the MAP designated network, unless pre-authorized;
3.
Services and supplies to any individual who is a resident or inmate in a
public institution;
4.
In-patient hospital and related services for a patient in an institution for
tuberculosis, mental disease, or a nursing section of a public institution for
the intellectually disabled;
5.
Services provided for any work-related illness, injury or complication thereof
arising out of the course of employment for which Worker’s Compensation
Benefits or any other similar regulation of the United States are provided or
should be provided according to the laws of the state, territory or subdivision
thereof governing the employer under which such illness or injury occurred;
6.
Services or supplies provided in connection with cosmetic surgery except as
required for the repair of accidental injury if the initial treatment is received
within 12 months of the accident in which the injury was sustained, or for
improvement of the functioning of a malformed body member, or when prior
authorization is obtained for other medically necessary purposes;
7.
Services, supplies and medications for which benefits are available under a
manufacturer’s Patient Benefit Program, or any other contract policy or
insurance which would have been available in the absence of the Medical
Assistance Program;
8.
Services payable by any health, accident, or other insurance coverage; or by
any private or other governmental benefit system, or any legally liable third
party;
9.
Services, supplies or medications considered experimental or investigational, i.e.,
services and items which have not been approved for marketing by the Food and
Drug Administration Services;
10.
Supplies or medication related to infertility;
11.
Any services to include, but not be limited to, drugs, surgery, medical or
psychiatric care or treatment for transsexualism, gender dysphoria, sexual reassignment or sex change;
12.
Procedures that relate to obesity, obesity therapy and/or special diets (including
medically supervised fasting and liquid nutrition) related to weight reduction
whether necessitated by surgery or a specifically identified medical condition;
13.
14.
Services provided by an interpreter;
Services provided by a relative of the enrollee or a member of his or her
household;
15.
Services and supplies that are provided under any governmental plan or law under
which the individual is or could be covered (e.g., Victims of Crime, Texas
Rehabilitation Commission, Veteran’s Benefits, Medicare, Medicaid, TRICARE,
CHAMPUS, etc.);
16.
Co-insurance fees and deductibles. MAP is not a secondary payer for any other
insurance or governmental health care program, nor does MAP coordinate benefits
with any other payer;
17.
Services not medically necessary, which are not incident to and necessary for the
treatment of an injury or illness;
18.
Acute hospital services and supplies provided as an inpatient to the extent that it is
established upon review of the claim submitted that the enrollee’s condition did
not require a hospital level of care and could have been provided safely at a lesser
level of care;
19.
Services resulting from or in connection with the commission of any illegal act,
occupation or event (including the commission of a crime or violation of conditions
of probation) if the covered individual is incarcerated;
20.
Services resulting from or in connection with any acts of war, declared or
undeclared, or any type of military conflict, charges incurred due to diseases
contracted or injuries sustained in any country while such country is at war or
while en route to or from any such country at war, charges resulting from
illness/injuries incurred while engaged in military services;
21.
Inpatient and Intensive outpatient rehabilitation;
22.
Charges for custodial or sanitaria care, rest cures, or for respite care;
23.
Care and treatment of mental and/or nervous disorders, psychiatric treatment or
individual, family, or group counseling services unless as a co-morbidity or
secondary diagnosis during a medical inpatient stay or in a primary care setting.
24.
Treatment programs for substance abuse and/or detoxification.
25.
Non-emergency air transport;
26.
Private room except when appropriate documentation of medical necessity is
provided;
27.
Chiropractic services/treatment;
28.
Rolfing;
29.
Acupuncture, acupressure, or biofeedback;
30.
Services rendered by a massage therapist;
31.
Hypnosis;
32.
Eye refractions, eye glasses, eye exercises, contact lenses, or other corrective
devices, including materials and supplies, or for the fitting or examinations for
prescribing, fitting or changing of these items;
33.
Whole blood or packed red cells that are available at no cost to the client;
34.
Autologous blood donations;
35.
Blood clotting factors;
36.
Luxury/entertainment items (e.g., TV, video, beauty aids, etc.);
37.
Charges/fees for completing or filing required forms/pre-authorizations;
38.
Charges which accumulate during any period of time in which the client removes
rental equipment from the delivery site and fails to immediately notify the Medical
Assistance Program of the new location;
39.
Autopsies;
40.
Cellular Therapy;
41.
Chemolase injections (Chemodiactin, Chymopapain);
42.
Chemonucleolysis intervertebral disc;
43.
Dermabrasion;
44.
Dialysis (in-patient or out-patient) or supplies related to dialysis, except for acute
conditions not related to chronic renal failure while in the inpatient setting;
45.
Educational counseling;
46.
Ergonovine provocation test;
47.
Fabric wrapping of abdominal aneurysms;
48.
49.
Hair analysis;
Histamine therapy - intravenous;
50.
Professional component of Hospice Services
51.
Hyperactivity testing;
52.
Hyperthermia;
53.
Immunotherapy for malignant disease;
54.
Immunizations required for travel outside the United States;
55.
Implantations (e.g., silicone, saline, penile, etc.);
56.
Joint sclerotherapy;
57.
Laetrile therapy;
58.
Organ transplants, medications and/or treatments associated with the transplant;
59.
Orthodontic treatment, root canal, crown, and bridge procedures;
60.
Specialized pain management programs and/or treatment designed to provide
chronic pain care unless provided through contracted MAP providers
61.
Prosthetic eye or facial quarter;
62.
Radial and hexagonal keratotomy or refractive
surgeries; keratoprosthesis/refractive keratoplasty;
63.
Routine circumcision for clients one year of age or older;
64.
65.
Sterilization reversal;
Tattooing and/or tattoo removal;
66.
67.
Thermogram;
TORCH screen;
68.
Adaptive equipment for daily living such as eating utensils, reachers, handheld
shower extensions, etc.;
69.
Admission kits;
70.
Air cleaners/purifiers;
71.
Any equipment, supplements, or supplies not ordered by a physician or provider
and/or not considered appropriate and necessary to treat a documented medical
condition/disease process;
72.
Augmentive communication devices, e.g., TTY device, artificial voice box, and
machinery of this nature;
73.
Bed cradles;
74.
Bladder stimulators (pacemakers);
75.
76.
Car seats;
Cervical pillows;
77.
Electric wheelchairs or scooters (outpatient);
78.
Enuresis monitors;
79.
Equipment or services not primarily and customarily used to serve a medical
purpose (e.g., an air conditioner might be used to lower room temperature to
reduce fluid loss in a cardiac patient or a whirlpool bath might be used in the
treatment of osteoarthritis, however because the primary and customary use of
these items is a non-medical one, they cannot be considered as medical
equipment);
80.
Evaluations for learning disabilities;
81.
Feeding supplements (e.g., Ensure, Osmolyte) and supplies for long-term use;
82.
Hearing aids;
83.
Home and vehicle modifications, including ramps, tub rails/bars;
84.
Humidifiers, except when used with respiratory equipment (e.g., oxygen
concentrators, CPAP/BIPAP, nebulizers, or for clients with a tracheostomy ;
85.
Over bed tables;
86.
Implantable medication pumps and related supplies, with the exception of insulin
pumps and related supplies;
87.
Prosthetic breasts and mastectomy bras;
88.
Thermometers;
89.
Vocational, educational, exercise, and recreational equipment;
90.
Waist/gait belts;
91.
Whirlpool baths and saunas;
92.
Treatment or correction of temporomandibular joint (TMJ) dysfunction;
93.
Refills or prescriptions in excess of the number specified by the Doctor, or refills
dispensed one year or more after the date of the Doctor’s original order.
6. HEALTH SERVICES
Health Services
Case Management
Credentialing
Compliments and Complaints
CCC Clinical Protocols
Health Services
Case Management
The purpose of the case management program is to maintain MAP patients in a
quality oriented and medically appropriate environment, promoting optimal
outcomes through early intervention cost effectiveness, while utilizing
community and other available resources. The case management program
promotes accessibility, availability, and effectiveness of care. It also strives to
improve quality of life outcomes and monitor cost of care.
Case Management Activities:
1. Assist in locating and linking to alternative sources of care and
funding.
2. Negotiate fair and accurate reimbursement.
3. Assist primary care physician to provide quality care by offering
coordination of services needed for the patient.
4. Eliminate barriers to care and services by providing innovative
solutions that will meet the patient’s need in a cost effective manner.
5. Involve the patient and the family throughout the case management
process.
6. Serve as an advocate to coordinate and optimally utilize health care
and community related services for the patient.
7. Assist in the transition of care with the different delivery points
through the continuum of healthcare services.
COMPLEX CASE MANAGEMENT REFERRAL FORM
Please see below for submittal instructions
REFERRAL SOURCE
Referral Date: ________________Referral Name: ________________________________________
Referral sources: □ Provider □ Member/Relative □ UM □ Community Agency □ Other
(Please check one)
Phone no. of referral source: ___________________ Fax no. of referral source: _________________
MAP MEMBER INFORMATION
Member name: ________________________________ DOB: _________________ □ Male □ Female
MAP ID #:__________ Home Address: ___________________________ Language: ______________
Member home no.:_____________ cell: _____________ work: ____________ other: ____________
REASON FOR REFERRAL
Reason for Referral/need for case management:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Other diagnoses affecting Member:
Diagnosis #1:________________ Diagnosis #2:______________ Diagnosis #3:___________________
Are other providers involved in care: □ No □Yes
If yes, who? ________________________ _______________________ _____________________
Priority status of referral:
□ Urgent: needs to be contacted within 2 working days
□ Standard: needs to be contacted within 7 working days
Please Submit Referral Form to the CCC Medical Management Department via:
Phone: 512-978-8300 or fax 512-901-9787
Credentialing
The Provider will participate in the formal process through which the
Community Care Collaborative or its designee collects, verifies, and
evaluates the professional credentials and qualifications of licensed
individual providers against the criteria, standards, and requirements
established by the District for providing health care services to Eligible
Patients. Provider Credentialing for MAP is handled by Seton Health Plan.
The Community Care Collaborative endeavors to provide the best medical
care to the persons it serves. The CCC invites enrollees to let us know
when they receive exceptional services and when they feel the services
were not successful in meeting their specific needs.
The CCC encourages enrollees to discuss any concerns or questions about
their treatment or medical care with her or his primary care provider. If
the enrollee is unable to resolve issues with the primary care office, please
give the enrollee our telephone number (512) 978-8150.
7. CCC- CLINICAL PROTOCOLS
Community Care Collaborative Clinical Protocols
The following Community Care Collaborative clinical protocols can be accessed
via the CCC website:
Adult Health- Clinical Protocols
 Type 2 Diabetes Mellitus Protocol
 Depression & Generalized Anxiety Disorder Protocol
 Hypertension Protocol
 Heart Failure Protocol
 Tobacco Protocol
 Hepatitis C Protocol
 Normal Interval OB Care Protocol
 Prevention of Type 2 Diabetes in Adults Protocol
 Chest Pain Protocol
Website: http://www.ccc-ids.org/clinicalprotocols/
Password: ccc
8. CONTRACTED PROVIDERS
CONTRACTED PROVIDERS
Primary Care
Dental Services
Diabetic Retinal Screening
Durable Medical Equipment
Home Health Services
Home Infusion Therapy
Orthotics and Prosthetics
Radiation Oncology
Urgent Care
PRIMARY CARE: CommUnity Care
http://communitycaretx.org/locations/
A.K. Black
ARCH
Blackstock Family Health Center
David Powell
Del Valle
East Austin
Manor
North Central Health Center
Oak Hill
928 Blackson Avenue
Austin, TX 78752
Telephone: 512-978-9740
Fax: 512-978-9741
500 East Seventh Street Austin,
TX 78701
Telephone: 512-978-9920
Fax: 5112-978-8129
1313 Red River
Suite 100 Austin,
TX 78702
Telephone: 512-324-8600
4614 North IH-35
Austin, TX 78751
Telephone: 512-978-9100
Fax: 512-901-9751
3518 FM 973
Austin, TX 78617
Telephone: 512-978-9760
Fax: 512-978-9767
211 Comal Street
Austin, TX 78702
Telephone: 512-978-9200
Fax: 512-978-9238
600 West Carrie Manor
Manor, Texas 78653
Telephone: 512-978-9780
Fax: 512-978-9781
1210 West Braker Ln.
Austin, TX 78758 Telephone:
512 978-9300
Fax: 512-279-2556
8656 Highway 71 West
Suite C
Austin, TX 78735
Telephone: 512-978-9820
Fax: 512-978-9830
Continued: CommUnity Care
15822 Foothill Farms Loop
Pflugerville, TX 78660
Pflugerville
Telephone: 512-978-9840
Fax: 512-978-9860
1000 E. 41st St.
Suite 960 Austin,
Hancock
TX 78751
Telephone: 512-978-9940
Fax: 512-901-9702
2802 Webberville Road
Austin, TX 78702
Rosewood Zaragosa
Telephone: 512-978-9400
Fax: 512-901-9726
825 East Rundberg Lane, B-1
Austin, TX 78753
Rundberg
Telephone: 512-978-9600
Fax: 512-978-9601
Sandra Joy Anderson Health & Wellness 1705 E. 11th Street
Austin, TX 78702
Center
Telephone: 512-978-8400
Fax: 512-901-9785
2529 South First Street
Austin, TX 78704
South Austin
Telephone: 512-978-9500
Fax: 512-978-9558
2901 Montopolis Drive
Austin, TX 78741
Southeast Health and Wellness Center
Telephone: 512-978-9901
and Internal Medicine Clinic
Fax: 512-901-9765
6801 South IH-35
Suite 1-E
Austin, TX 78745
William Cannon
Telephone: 512-978-9960
Fax: 512-978-9961
PRIMARY CARE: Lone Star Circle of Care
Ben White Health Center
1221 W. Ben White Blvd, Suite B-200
Austin, TX 78704
Phone: 877-800-5722
Fax: 512-448-1311
Lake Aire Medical Center
Pediatrics, Family, Behavioral Health
2423 Williams Dr
Georgetown, TX 78628
Phone: 877-800-5722
Fax: 512-864-7238
Family Care Center at Northwest
Pediatrics, Family, OB/GYN, BH
11111 Research Blvd.
Austin, TX 78759
Phone: 877-800-5722
Fax: 512-605-6400
Round Rock Health Clinic- Pediatrics and BH
2120 North Mays, Suite 430
Round Rock, TX 78664
Phone: 877-800-5722
Fax: 512-255-5268
TAMU Pediatrics, Family, Behavioral Health
3950 N. AW Grimes, Suite n201
Phone: 877-800-5722
Fax: 512-218-0515
Dell Children’s Circle of Care Pediatrics at Whitestone
Fax:
1730 E. Whitestone Blvd.
Cedar Park, TX 78613
Phone: 877-800-5722
Fax: 512-259-1994
Dell Children’s Circle of Care Pediatrics at Hutto
123 Ed Schmidt Blvd., Suite 140
Hutto, TX 78634
Phone: 877-800-5722
Fax: 512-846-2072
Health Center at Taylor
305 Mallard Lane
Taylor, TX 76574
Phone: 877-800-5722
Fax: 512-352-6112
Georgetown Women’s Center OB/GYN
1900 Scenic Dr., Suite 3326
Phone: 877-800-5722
Fax: 512-869-1788
Round Rock OB/Gyn
2300 Round Rock Ave, Suite 208
Phone: 877-800-5722
Fax: 512-255-5307
PRIMARY CARE- OTHER
People’s Community Clinic
El Buen Samaritano
2909 North IH-35
Austin, TX 78722
Telephone: 512-478-4939
Fax: 512-708-1835
7000 Woodhue Dr.
Austin, TX 78745
Telephone: 512-439-0700
DENTAL SERVICES: CommUnity Care
http://communitycaretx.org/locations/
RBJ Dental Clinic
North Central Dental Clinic
South Austin Dental Clinic
Southeast Health and Wellness Center
Ben White Dental
15 Waller Street
Austin, TX 78702
Telephone: 512-978-9895
Fax: 512-978-9900
1210 W. Braker Ln, 2nd floor
Austin, TX 78758
Telephone: 512-978-9880
Fax: 512-279-2556
2529 South First St.
Austin, TX 78704
Telephone: 512-978-9865
Fax: 512-978-9558
2901 Montopolis Drive
Austin, TX 78741
Telephone: 512-978-9901
1221 W. Ben White, Suite 112B
Austin, TX 78704
Phone: 512-978-9700
Fax: 512-279-2307
DIABETIC RETINAL SCREENING
801 West 38th Street, Suite 200
Austin, TX 78705
Austin Retina Associates
170 Deepwood Drive, Suite 105
Telephone: 512-451-0103
Fax: 512-451-9276
Brian B. Berger, MD
3705 Medical Parkway, Suite 410
Austin, TX 78705
Telephone: 512-454-4851
Fax: 512-454-5853
Richard B. Briggs, MD
6801 Manchaca Road
Austin, TX 78745
Telephone: 512-444-2015
Fax: 512-444-2010
DURABLE MEDICAL EQUIPMENT
Animas Diabetes Care
Austin Wheelchair Company
A&P Quality Care Medical
Edgepark Medical Supplies
AAA Oxygen & Medical Supply
Applied Orthotics
The Comfort Store
Travis Medical
Telephone: 877-937-7867
Fax: 866-212-1852
5555 N Lamar Blvd #D107
Austin, TX 78751
Telephone: 512-452-7988
8220 Cross Park Dr #100
Austin, TX 78754
Telephone: 512-452-5111
1810 Summit Commerce Park
Twinsburg, OH 44087
Telephone: 888-394-5375
Fax: 330-425-4355
2801 Oakmont Dr #1400
Telephone: 512-248-2888
7801 N Lamar Blvd F30
Austin, TX 78752
Telephone: 512-380-0259
7301 Burnet Rd #200n
Austin, TX 78757
Telephone: 512-323-6181
1104 W. 34th Street
Austin, TX 78705
Telephone: 800-458-4590
Fax: 512-454-9521
HOME HEALTH SERVICES
Balex Healthcare Services
Gilead Health Care
Guardian Healthcare
7703 N Lamar Blvd #115
Austin, TX 78752
Telephone: 512-762-6966
8100 Cameron Rd B200
Austin, TX 78754
Telephone: 512-323-5858
8716 N. Mopac Expy, Ste. 320
Austin, TX 78759
Telephone: 512-863-3842
Fax: 512-863-2018
HOME INFUSION THERAPY
Infusion Partners dba CarePoint Partners
5446 W US Hwy 290 Svc Rd #203
Austin, TX 78735
Telephone: 512-637-4949
Fax: 855-737-4299
Coram Healthcare
1905-A Kramer Ln, Ste 500
Austin, TX 78758
Telephone: 512-832-1330
Fax: 512-832-1240
ORTHOTIC & PROSTHETICS
Applied Orthotics
Hanger Orthotics & Prosthetics
The Orthotic Specialist
7801 North Lamar Blvd., Suite F-30
Austin, TX 78752
Telephone: 512-380-0259
Fax: 512-380-0281
10910 Domain Dr., Suite 300
Austin, TX 78758
Telephone: 512-377-3800
2102 Blalock Drive, Suite 102
Austin, TX 78758
Telephone: 512-490-1255
Fax: 512-490-1297
RADIATION ONCOLOGY
Austin Cancer Center – Central Austin
Austin Cancer Center - Northwest Austin
Austin Cancer Center – North Austin
Austin Cancer Center - Lakeway
Austin Cancer Center - Kyle
2600 East MLK Jr. Blvd.
Austin, TX 78702
Telephone: 512-505-5500
Fax: 512-334-2883
11111 Research Blvd., LL2
Austin, TX 78759
Telephone: 512-505-5500
Fax: 512-334-2883
12221 North MoPac Expressway
Austin, TX 78758
Telephone: 512-505-5500
Fax: 512-334-2883
200 Medical Parkway
Lakeway, TX 78738
Telephone: 512-505-5500
Fax: 512-334-2883
1180 Seton Parkway, Ste 150
Kyle, TX 78640
Telephone: 512-505-5500
Fax: 512-334-2883
URGENT CARE
NextCare Urgent Care
Austin — William Cannon
Austin — Cedar Park
NextCare Urgent Care Round
Rock
Georgetown
6001 West William Cannon #302
Austin, TX 78749
Telephone: 888-381-4858
351 Cypress Creek Rd #103
Cedar Park, TX 78613
Telephone: 888-381-4858
1240 East Palm Valley Road
Telephone: 888-381-4858
900 North Austin Avenue #105
Telephone: 888-381-4858
9. CLAIMS
MAP Plan
Responsible for:
Third Party
Administrator:
Submit Electronic
Claims:
Submit Paper Claims:
CCC- MAP
Payment of primary care services, dental
services, custom orthotics, and selected specialty
services.
Seton Health
Plan/MediView
Seton Health Plan
EDI Vendor ID:
TCMAP
Travis County MAP
PO Box 14447
Austin, TX 78761
Seton- MAP
Hospital based and specialty services,
diagnostics, home health, and durable medical
equipment services
Seton Health
Plan/MediView
EDI Vendor ID:
SHMAP
Seton MAP
PO Box 14447
Austin, TX 78761
Claims processing:
Claims are processed as they are received. Claims must be submitted within 95
days from date of service.
Payment:
Check or Electronic Funds Transfer (EFT) is made by Seton Health Plan
To enroll with EFT and ERA with Seton Health Plan use the following link to
access the EFT and ERA forms.
EFT Form:
http://www.setonhealthplan.com/providers/EFT%20Authorization%20Agreement.
pdf
ERA Form: http://www.setonhealthplan.com/providers/ERA%20Enrollment.pdf
Explanation of Benefits (EOB):
Seton Health Plan will send a corresponding EOB to the provider. To access EOBs
online providers can use the Seton Health Plan Provider Self Service Center.
To access the Provider Self Service Center, use the following link for registered
users: https://www.mediview.net/cmsweb/webinquiry.asp
If you are a first time user, use the following link for forms and instructions to set
up access to the Seton Health Plan Provider Self Service Center:
http://setonhealthplan.com/providers/physician_selfservice_center/
Appeals:
Providers can submit claims reconsideration using the Seton Health Plan Claim
Reconsideration Face Sheet.
:> See additional document entitled “Seton Health Plan Claim Reconsideration Face
Sheet and instructions.”
Check Status of Claims:
By Phone: Providers can call MediView to check on claims status- 512-421-5664
Online: Seton Health Plan Provider Self Portal Center can also be used to
check claim status and status of authorizations.
To access the Provider Self Service Center, use the following link for registered
users: https://www.mediview.net/cmsweb/webinquiry.asp
If you are a first time user, use the following link for forms and instructions to set
up access to the Seton Health Plan Provider Self Service Center:
http://setonhealthplan.com/providers/physician_selfservice_center/
Subrogation:
Subrogation is the right to recover amounts paid by a government-sponsored
plan that are the obligation of other payers (such as an insurance company). If
you are injured or become ill under circumstances in which a third party may
legally be obligated to pay the medical, dental and/or pharmacy expenses, MAP
will pay your covered expenses. MAP reserves the right, however, to be
reimbursed for all medical expenses from the settlement or judgment paid by a
third party. Other providers may also have subrogation rights in any settlement
or judgment made by a third party.
CLAIM RECONSIDERATION FACE SHEET
Date:_______________________
To:
Seton Health Plan Benefit Administrators
Phone:
(512) 421-5664
P.O Box 14447
Austin, TX 78761
Fax:
(512) 421-4860
From*: ____________________ Phone*:__________________
Member Name*:______________________________ Member ID*:
Fax: __________________
____________________
Claim Number*:______________________________ Date(s) of Service: _________________
State Reason for Reconsideration (this form is not for Retro Authorization requests)*:
Attachments are required for reconsideration review.
Check Appropriate Reason:
 Processed as Inpatient vs. Observation stay
 History & Physical
 Copy of physician’s order for observation
 Past filing deadline
 SmartHealth Explanation of Benefits
 Documentation with date of original submission to another carrier (certified mail receipt, other carrier’s EOB,
electronic filing report, etc.)
 Reimbursement Adjustment
 SmartHealth Explanation of Benefits (EOB) or other payor EOB
Explanation:
 Other:
 UB92/HCFA
 Explanation of Benefits

History & Physical/Office Notes

Discharge Summary
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
MediView Internal Use Only:
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Provider Education:
Yes
No
Summary:
*Required fields. Incomplete requests will result in claim reconsideration to be rejected.
Revised 3/1/15
MAP CLAIM RECONSIDERATION FACE
SHEET INSTRUCTIONS
1.
Each claim reconsideration is to be submitted in writing with the
“Claim Reconsideration Face Sheet” and supporting
attachments listed under each category “Reason for
Reconsideration.”
2.
Reconsideration’s and attachments can be mailed or
electronically submitted to:
□ CCC MAP electronic claims to:
Seton Health Plan/MediView
EDI Vendor ID: TCMAP
CCC MAP paper claims to:
Travis County MAP
P.O. Box 14447
Austin, TX 78661
□ SHP MAP electronic claims to:
Seton Health Plan/MediView
EDI Vendor ID: SHMAP
SHP MAP paper claims to:
Seton MAP
P.O. Box 14447
Austin, TX 78661
3.
Required fields to be completed:
□ Submitting person’s name, phone and fax number
□ Claim number
□ Reason for reconsideration
□ Applicable attachments
□ Member name and ID number
4.
Incomplete requests will result in claim reconsideration
rejection.
5.
Resubmissions and Claims Status Checks are not appeals.
Call Customer Service at 512-421-5664 for claim status
checks
10. SPECIALTY CARE
University Medical Center
at Brackenridge
Specialty Clinics
University Medical Center Brackenridge
Specialty Clinics
Table of Contents
Clinic Rotation Schedule
5
Asthma Clinic
7
Breast Surgery Clinic
8
Cardiology Clinic
10
12
Cardiology Clinic Worksheet
Dermatology Clinic
13
Endocrinology Clinic
_____ 14
16
Endocrinology Clinic Worksheet
ENT Clinic
______18
ENT Ov erb o ok Fax Re ques t
Eye (Ophthalmology) Clinic
Foot Clinic
_____20
22
_________________________________________________________________24
Fracture Clinic
______________________________________________________________25
Gastroenterology Clinic
______________________________________________________ 26
Gastr oe nte r ol og y Clinic Worksheet ________________________ 27
Gynecology/Oncology Clinic
__________________________________________________33
Hematology Clinic _____________________________________________________________35
Hematology Clinic Worksheet __________________________________________36
Neurology Clinic
___________________________________________________________ 38
Neurology Clinic Worksheet ___________________________________________ 40
EMG Referral Form
Oncology Clinic
_________________________________________________________ 42
____________________________________________________________ 44
Orthopedic Clinic
___________________________________________________________ 46
Pulmonary Clinic
____________________________________________________________47
Specialty Clinics
Table of Contents (continued)
Renal/Hypertension Clinic
Renal /H ype rte nsi on Cli nic Work she et
Rheumatology Clinic
R h e u m a t o l o g y Cli nic Work she et
48
49
50
51
Surgery Clinic
53
Urology Clinic
55
U r o l o g y Cli nic Work she et
57
Referral Form — UMCB Specialty Clinics
58
Seton Imaging and Radiology — Required Labs
59
Diagnostic Order Forms
60
Audiology Testing
62
Cardiology Electroneurodiagnostic Testing
64
Physical Therapy
66
Map of Seton Rehabilitation Facilities
67
Directions to Paul Bass Clinic (English)
68
Directions to Paul Bass Clinic (Spanish)
69
Map of Paul Bass Clinic
70
First-Time Referring Physician Setup Form
Physician Exclusions List Search
Physician License Practice Status
Specialty Clinics
Specialty Clinics
Friday
Thursday
Wednesday
Tuesday
Monday
Day
Specialty Clinic
Anticoag
Breast
Cardiology
Cast/Fractures
Medicine
Psychiatry
Urology
Surgical Oncology
Anticoag
Dermatology
Eye
Gyn/Onc
Hem/Onc
Medicine
Orthopedics
Rheumatology
Surgery
Anticoag
Asthma/Allergy
Eye (Ophthalmology)
GI
Hem/Onc
Medicine
Renal
Surgery
Anticoag
Endocrinology
ENT
Hem/Onc
Medicine
Neurology
Palliative Care
Surgery
Anticoag
Derm Suture Removal
Eye-Visual Fields
Hem/Onc
Medicine
Neurology
Neuro Epilepsy
Neuro Trauma
Podiatry
Pulmonary
Rheumatology
UTHSCSA
Frequency
1st, 3rd
each week
2nd, 3rd, 4th
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
2nd, 4th
each week
each week
each week
each week
each week
each week
each week
each week
1st, 2nd, 3rd
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
2nd
2nd, 4th
1st, 3rd
1st, 3rd
each week
2nd, 4th
Location
Sub-Specialty 220
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Paul Bass Clinic
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Sub-Specialty 220
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Paul Bass Clinic
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Paul Bass Clinic
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Paul Bass Clinic
Shivers 217
Pg.5
Specialty Clinics
PAUL BASS CLINIC
MONDAY
AM
TUESDAY
Cardio 2, 3, 4 wk
Derm wkly
Psychiatry wkly
Rheum wkly
WEDNESDAY
GI wkly
THURSDAY
FRIDAY
Endo wkly
Pulm 1, 3 wk
ENT 1, 2, 3 wk
Rheum wkly
Derm. Suture Removal
Medicine wkly
Medicine wkly
Medicine wkly
Medicine wkly
Medicine wkly
PM
SHIVERS CENTER
MONDAY
AM
PM
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Surg/Onc wkly
Hem/Onc wkly
Hem/Onc wkly
Hem/Onc wkly
Hem/Onc wkly
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
Palliative Med Wkly
Chemo/Infusion
Chemo/Infusion
Breast Surgery wkly
Gyn/Onc wkly
Hem/Onc wkly
Hem/Onc wkly
UTHSCSA 2,4 wk
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
SUITE 220 Sub-Specialties
MONDAY
Cast wkly
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Anti-coag. Wkly
Anti-coag. Wkly
Anti-coag. Wkly
Anti-coag. Wkly
Orthopedics wkly
Eye wkly
Neurology wkly
Eye Visual Field wkly
Renal 1,2,3,4 wk
EMG
Neuro Trauma 2,4 wk
AM
Neuro Epi 2 wk
PM
Anti-coag. 1, 3 wk
Surgery wkly
Asthma 2,4 wk
Urology wkly
Eye wkly
Allergy/Pulm 2, 4 wk
Surgery wkly
Pg.6
Surgery wkly
Neurology wkly
Podiatry 1, 3 wk
University Medical Center at Brackenridge
Specialty Clinics
Asthma Clinic
Appropriate patients for referral:
•
•
•
•
•
•
•
Patients with refractory asthma having difficulty controlling symptoms despite
appropriate treatment
Patients needing evaluation of their current asthma management plan
Patients with recent ED visit or hospitalization for asthma
Patients with chronic urticaria
Patients with immunodeficiency
Patients with chronic sinusitis
Patients needing skin testing for allergen avoidance counseling
Documentation required for scheduling an appointment:
1.
2.
3.
4.
Completed Referral form
Past Medical History (PMH)
Current medication list
Most recent progress note describing condition for which patient is being
referred.
5. If reports are available, include with referral. If patient has not had testing, reports
are not required for scheduling appointment.
Examples of report: chest films, pulmonary function testing, labs, skin testing
results.
Revised May 2015
Pg.7
Specialty Clinics
Breast Surgery Clinic
Scope
•
•
To evaluate and treat newly diagnosed breast cancer patients.
To provide consultation and care that is beyond the routine abilities of the
primary care physicians.
Appropriate patients for referral include:
•
•
•
•
•
•
•
•
•
•
Positive pathology per biopsy
Obvious tumor growth by exam (nipple inversion, dimpling, peau d ‘orange,
ulceration)
Bloody nipple discharge
Fibro adenomas over 2 cm
BRCA positive patients
Abscess unresolved by full course of antibiotics
BIRADS 3, 4, and 5 Mammogram and US (please see additional information
under breast mass below)
Breast Papilloma’s
Paget’s disease
Atypical Hyperplasia
Please do NOT refer the following patients:
•
•
•
•
•
•
•
•
•
•
•
Fibro adenomas under 2 cm
Breast Cyst
Breast pain
Benign masses diagnosed by pathology
Extra breast tissue
Extra nipple
Nipple discharge with abnormal prolactin levels
High risk patients for BRCA testing (please refer to the Myriad website for
assistance)
Mastitis
Breast mass on exam but normal imaging (BRADS 1-2). Recommendation:
Repeat imaging as suggested by radiology along with clinical breast exam.
Consider ultrasound guided biopsy if clinically indicated.
Axillary mass with normal breast imaging
Documentation required for scheduling all appointments:
• Completed referral form
• Mammogram or ultrasound within the past 3 months
• History and Physical
• Current medications
Pg.8
Specialty Clinics
Breast Mass
•
If Mammogram or ultrasound suggests biopsy, please obtain biopsy and refer
with FINAL pathology report. For microcalcifications, order stereotactic biopsy.
For breast mass, order ultrasound guided biopsy. To schedule either of these at
a Seton facility call Central Scheduling at 512-324-1199.
Nipple Discharge
•
•
Serum Prolactin level
cytology of nipple discharge
•
•
BRCA results
Any surgical reports related to BRCA results (mastectomy/oopherectomy)
Revised May 2015
Pg.9
Specialty Clinics
Cardiology Clinic
Scope:
•
•
Cardiology consultation
On-going cardiology care for some chronic cardiac conditions which require
adjustment in Therapy. Once stable, ongoing follow up by PCP.
•
•
•
•
•
•
•
•
•
CAD (Coronary Artery Disease) previously evaluated with stress test or
angiogram
Uncontrolled Angina despite appropriate medical treatment
Refractory Heart failure CHF (Congestive Heart Failure) previously evaluated
with echocardiogram and with symptoms despite standard treatment
Documented arrhythmias (excluding PACs and PVCs)
Syncope (suspicious of cardiac source) – refer after EKG, Echo and Holter have
been performed
Documented significant valvular disease
Newly diagnosed CHF
New onset or unstable AFIB
Patients discharged from the hospital requiring Cardiology follow up will be seen
no later than 1 week.
Please do NOT refer patients with the following:
•
•
•
•
•
•
Atypical chest pain without stress test results
Dizziness (refer to ENT)
Palpitations without documented arrhythmia
Pre-operative clearance without a cardiac problem
Pediatric patients age < 18
Pacemaker/ICD Management (refer to Cardiac Electrophysiology)
1.
2.
3.
4.
referred.
5. EKG within the last 3 months
Pg.10
Specialty Clinics
6. Other studies if appropriate including those on the following worksheet (e.g.,
stress test, echo, Holter Monitor, etc.)
Revised May 2015
Pg.11
Specialty Clinics
Cardiology Clinic Worksheet
Chest Pain
•
•
Normal EKG:
o Patient able to exercise�Exercise stress test results
o Patient unable to exercise�Pharmacologic SPECT results
Abnormal EKG:
o Patient able to exercise�Exercise SPECT results
o Patient unable to exercise�Pharmacologic SPECT results
Refractory CHF
•
•
•
EKG results
Echocardiogram results
Chest X-Ray results/film
Pulmonary HTN
•
•
EKG results
Arrhythmia
•
•
12 lead EKG
24 hour holter monitor digital recording
Heart Murmur
•
Revised May 2015
Pg.12
Specialty Clinics
Dermatology Clinic
Scope:
•
To provide general dermatology consultation and diagnostic testing with referral
back to the Primary Care Physician for management.
•
•
•
•
•
•
•
General skin problems - < 4 cm or located on face or scalp
Symptomatic skin lesions or moles
Lesions or moles suspicious for cancer
Dermatoses such as psoriasis, eczema, contact dermatitis, etc
Alopecia (hair loss)
Onchymycosis
Keloids
•
•
•
•
•
Cosmetic Problems
Acne
Rosacea
Pediatric patients age <18
Eyelid lesions – refer to Eye Clinic
•
•
•
•
•
•
referred.
Documentation of prior treatment
Final path report if biopsy was done
Revised May 2015
Pg.13
Specialty Clinics
Endocrinology Clinic
Scope
•
To provide consultations at a subspecialty level in endocrinology.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Lipid Abnormalities in a patient with family or personal history of early CVD, inability
to achieve LDL-C<100 and/or non-HDL-C<130 in a patient with CVD or a CVD
equivalent who cannot tolerate a statin or who is taking a maximum dose of statin
and Hypertriglyceridemia, defined as fasting Tg level>500 or non-fasting >800
Thyroid Nodule
Thyroid Cancer
Hyperthryoidism
Difficult to Control Hypothyroidism
Osteoporosis and osteopenia
Calcium and Parathyroid Disorders
Pituitary Masses and Disorders
Adrenal Masses and Disorders
Amenorrhea & Galactorrhea
Hypogonadism; referral for new diagnoses must include two low testosterone levels
collected on separate days before 9AM
Type 1 Diabetics
Type 2 Diabetics requiring ≥ 300 units of insulin daily or U-500 insulin
Diabetes being managed with an insulin pump
•
•
•
Pediatric patients < 18 years old
Diabetic patients unless already using an Insulin Pump or requiring ≥ 300 units of
insulin daily or U-500 insulin
Gender Dysphoria / Transsexual Patients
•
•
•
•
referred.
Pg.14
Specialty Clinics
•
•
Recent pertinent labs (Appropriate labs per worksheet, drawn within the past
month, substantiating the disorder. Please send lab flow sheets if they exist.)
Recent pertinent scans or X-rays
Revised May 2015
Pg.15
Specialty Clinics
Endocrinology Clinic Worksheet
•
Difficult to Control Lipid Abnormalities
o Fasting Lipid Panel
o Fasting Glucose
•
Thyroid Nodule
o Thyroid Ultrasound within past 12 months for nodules ≥ 1cm
o TSH
o Free T4
•
Hyperthyroidism
o TSH
o Free T 4
o I-123 Iodine uptake and scan
•
Difficult to Control Hypothyroidism
o TSH
o Free T4
•
Osteoporosis
o DXA Scan Results
o CMP
o TSH
o Intact PTH
o 25 (OH) Vitamin D
o SPEP
o UPEP
o 24 hour urine for calcium and creatinine
•
Calcium and Parathyroid Disorders
o Intact PTH
o Serum Calcium
o Serum Albumin
o 24 hour urine for calcium and creatinine
Revised May 2015
Pg.16
Specialty Clinics
Endocrinology Clinic Worksheet (continued)
•
Pituitary Masses and Disorders
o MRI of the Sella Turcica
o Serum Prolactin Level
o TSH
o Free T 4
o LH
o FSH
o IGF-1
o 8am Serum Cortisol Level
•
Adrenal Masses and Disorders
o BMP
o 8am Plasma Renin Activity
o Aldosterone
o 24 hour urine for Free Cortisol, Creatinine, Metanephrines and Catecholamines
•
Amenorrhea & Galactorrhea
o Prolactin level
o TSH
o FSH
o LH
• Diabetes
o Hgb A1C
o CMP
o Fasting Lipid Panel
o Urine spot microalbumin and creatinine
•
Hypogonadism
o 8am Total Testosterone
o Prolactin level
o TSH
o FSH
o LH
o For patients age < 40: Ferritin, Serum Iron, TIBC
Revised May 2015
Pg.17
Specialty Clinics
ENT Clinic
(Head and Neck Surgery)
•
Provide care that is beyond the routine abilities of primary care physicians. Patients
referred to the clinic should have problems that may require surgery or advanced
ENT physician care.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Masses in the head and neck
Suspected Cancer
Thyroid Masses
Parathyroid Masses
Bleeding from unknown ENT source
Chronic draining ear discharge persistent despite 3 weeks of treatment with
appropriate topical and oral antibiotics
Hoarseness persistent greater than 6 weeks
Chronic Recurrent Tonsillitis with 4 or more episodes in the past year and/or 2-3
episodes annually over multiple years
Chronic Recurrent Sinusitis evident on CT scan after 3 weeks of appropriate
antibiotic treatment
Obstructive Sleep Apnea (must have completed Sleep Study prior to referral)(less
than 1 yr.)
Vertigo persistent for greater than 6 weeks – need Audio
Tinnitus (must have audiogram prior to referral)
Tympanic Membrane Perforation (must have audiogram prior to referral)
Conductive Hearing Loss (see Note below)
Unilateral Sensorineural Hearing Loss (see Note below)
Bilateral Sensorineural Hearing Loss in individuals less than age 65 (see Note
below)
Ankyloglossia (Tongue tie)
Impacted ear was
Snoring
Tonsilar hypertrophy
Deviated septum
NOTE: Hearing loss must be documented by a formal audiogram at UMCB prior to ENT
referral. Based on UMCB audiogram results, patients may be scheduled in ENT
clinic or referred back to the primary care physician.
Ears with drainage do not need Audiology.
Pg.18
Specialty Clinics
•
•
•
Colds, minor infections, routine sinus problems
TMJ Disorder
Patient with obstructive sleep apnea already on machine and doing well.
•
•
•
•
•
•
•
•
referred.
Brief synopsis of prior pertinent treatments
Pertinent imaging studies (send with patient if available)
Pertinent negatives studies (eg. nl EKG, nl CT of brain)
If another specialty has seen patient, send copy of their notes.
Revised May 2015
Pg.19
Specialty Clinics
ENT Overbook Fax Request
This form must be filled out entirely and faxed to (512) 380-7508. This form applies only to
overbook requests from the Clinic for MAP patients.
Patient Name:
Authorization Number (if
required)
Reason for
Referral:
Please see patient:
Next Clinic
4-8 weeks
9-12 weeks
Please provide a brief medical justification for overbooking the patient:
Pg.20
Specialty Clinics
Referring
Clinic:
Clinic Phone#:
Clinic Fax#
Referring
Physician:
Patient Contact
Information:
Please fax the completed form along with copies of pertinent physician findings, laboratory
studies, and radiological studies. You should receive this form back within 1 week with an
appointment time and date. It is the primary care clinic’s responsibility to notify the patient
with their appointment date and time. If you do not receive the form within 1 week you may
need to re-fax.
For Office Use Only:
Approved
Denied
Recommendations
Revised May 2015
Pg.21
Specialty Clinics
Eye (Ophthalmology) Clinic
Scope
•
To provide medical and surgical evaluation and management of patients with visual
or ocular disorders.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Blurred vision, unexplained (not related to glasses)
Persistent red eyes greater than 1 week
ALL red eyes with pain or decreased vision
Eye pain
Glaucoma or at risk patients (Positive family history, race, high myopes)
Cataracts – no overbooks allowed per physician
Exophthalmos
Advancing Pterygia
Strabismus or diplopia (double vision)
Lid lesions (cancer or Herpes Zoster)
Abnormal lid contour (ectropion, entropion)
Screening for patients taking Plaquenil
Increased intracranial pressure (Pseudotumor)
Structural brain abnormalities suspected of impairing visual pathway (e.g. pituitary
tumors, A-V malformations, etc.)
Macular degeneration
Diabetic patients for retinal screening
•
•
•
•
•
Sudden change in vision (refer to ED)
Flashing lights and floaters (refer to ED)
Patients needing glasses or contact lenses (no refraction is done in the eye clinic)
Hypertensive patients without ocular symptoms
Note: Children failing their vision test at school need to be referred to the Lion's
Club (through the school nurse) where free glasses will be provided.
•
•
•
•
referred.
Pg.22
Specialty Clinics
•
Blurry vision, cataracts, glaucoma need optometrist note
Revised May 2015
Pg.23
Specialty Clinics
Foot Clinic
Scope
•
Examination and treatment (medical and surgical) of ankle and foot pathology.
•
•
•
•
•
•
•
Foot / ankle deformities*
Bunions *
Ingrown toe nails
Plantar fasciitis (does not need xray)
Ganglion cyst
Foot / ankle pain (need xray)
Ulcerations of the foot in diabetes / neuropathies (no work up needed)
•
•
•
•
Referrals for routine foot care including diabetic foot checks
Referrals for toenail debridement and/or onychomycosis**
Referrals for orthotics (we cannot get these for patients)
•
•
•
•
referred.
•
*Pre-examination x-rays – usually a standing AP and lateral of the affected foot
(feet) is required. X-rays need to be sent to the clinic with the patient
**refer to Derm
Xrays must be less than 1 year old
Revised May 2015
Pg.24
Specialty Clinics
Fracture Clinic
Scope:
•
To evaluate and stabilize acute closed fractures involving upper & lower
extremities, and manage splinting, casting and x-rays. All other non-traumatic
orthopedic issues should be referred to Ortho Clinic. No emergency care is
rendered in Fracture Clinic.
•
•
•
•
Patients age 15 and above with acute closed fractures or dislocations verified by
x-ray
Patients with old fractures if experiencing new or worsening pain or deformity, or
patients with new complaints about prior fracture surgery
Sprains and strains seen in the ED
Avulsion fractures, suspected avulsion fractures and stress fractures
Please do NOT refer the following:
•
•
•
•
•
Suspected fractures not verified by x-ray
Fractures in pediatric patients age 14 and younger (should be referred to DCMC
Clinics)
Open fractures (send to ED)
Chronic orthopedic issues – Arthritis, Rotator Cuff Tear, Carpal Tunnel Syndrome
(should be referred to Ortho Clinic)
Fractures and injuries involving the hand and wrist including navicular/scaphoid
injuries (should be referred to Plastic Surgery/Hand Clinic)
•
•
•
•
Radiographs (actual x-ray films, not just transcribed report)
Pertinent ER reports / clinical reports
Pertinent consult reports
Pertinent operative reports
NOTE: Referral RN to review, then print to Xray Room printer: BH/POB/2/Xray
Revised May 2015
Pg.25
Specialty Clinics
Gastroenterology Clinic
Scope
•
To evaluate complaints and/or abnormal objective findings attributed to the GI
system including liver & pancreas and to recommend diagnostic testing, therapy
and continuing care for these patients.
•
Please see worksheet
The following are NOT appropriate for referral:
•
•
Pediatric patients < 18 years old
Incomplete work up (see worksheet below for recommendations)
•
•
•
Completed referral form including documentation as indicated by worksheet
Most recent lab and imaging results
Specific question being asked
Revised May 2015
Pg.26
Specialty Clinics
Gastroenterology Clinic Worksheet
1. GI Bleeding (occult or symptomatic)
a. CBC
b. Iron, Ferritin
b. Medication history
2. Iron Deficiency Anemia and no evident source
(if no iron deficiency consider hematological evaluation prior to GI referral)
a. CBC
b. Iron, TIBC or Ferritin
c. Stool hemoccult.
3. Abnormal Liver Tests [LFTs First assess alcohol use and review medication
causes
a. Abnormal LFTs on 2 sets of results at least 6 weeks apart
b. Abdominal liver ultrasound
c. Ferritin, Iron, TIBC
d. Acute Viral hepatitis panel
4. Cirrhosis
a. CBC, PT/INR, CMP
b. Acute Viral Hepatitis Panel, hepatitis A antibody total, Hepatitis B surface antibody
total, and Hepatitis B core antibody total.
c. Abdominal/liver ultrasound
d. Documentation of ETOH history
Pg.27
Specialty Clinics
e. Document Hepatitis A and B vaccination according to serologies. (Do not exclude
patient if this is not included but other materials are present.)
f. Recommend Flu/Pneumovax.
5. Hepatitis C Antibody Positive [HCV Ab +]
Check the following and refer to GI if HCV is present by PCR.
a. HCV RNA PCR quantitative & genotype
b. CMP, CBC, HIV antibody
c. Hepatitis A total antibody
d. Hepatitis B surface antigen, surface antibody, core total antibody
e. Abdominal/ liver Ultrasound
6. Hepatitis B Surface Antigen Positive [HBSAg +]
Check the following and refer if HBV is present by PCR.
a. HBV DNA PCR quantitative
b. Hepatitis B surface antigen, surface antibody, e antigen and e antibody
c. CMP, CBC, HIV antibody
d. Hepatitis A total antibody
e. Hepatitis C antibody
f. Abdominal/liver Ultrasound
7. Inflammatory Bowel Disease
a. Previous History
b. Most recent endoscopy and colonoscopy reports
Pg.28
Specialty Clinics
c. Pathology reports.
d. LFTs, CBC, CMP
e. Recommend Pneumovax vaccination
f. Document Hepatitis A and B vaccination according to serologies. (Do not exclude
patient if this is not included but other materials are present.)
g. Recommend flu shot (Must check the type of IBD therapy that the patient is getting
before flu shot).
8. Family History of Colon Polyps or Cancer [any age]
Refer to GI Clinic if 1st degree family history- Age and what relative, 10 years of
diagnosis of relative
9. Chronic Diarrhea (> 3 weeks duration) (refer to GI Clinic for any 1 or more of the
following):
I. Diagnostic uncertainty despite history, physical examination, and laboratory testing
including:
a. CBC, CMP and sedimentation rate
b. Stool C&S, O&P X3
c. C. difficile toxin
d. Stool WBCs
e. HIV
f. Thyroid studies
g. Fecal occult blood X 3
If appropriate clinical history: Celiac panel, Qualitative Fecal fat. Giardia antigen,
cyclospora, microspora, cryptosporidium.
II. History or findings suggestive of malabsorption, or colonic or terminal ileal disease
Pg.29
Specialty Clinics
III. Previous surgery involving extensive resection of ileum, right colon, bypass
procedures, or cholecystectomy
10. Abdominal Pain (refer to GI Clinic for any 1 or more of the following):
I. Diagnostic or therapeutic uncertainty after evaluation, including ALL of the following:
a. Laboratory testing (CBC, CMP, serum amylase, serum lipase, urinalysis, urine
pregnancy test)
b. Noninvasive imaging studies (plain x-rays, ultrasonography, and/or computed
tomography)
II. Abdominal pain in special populations, including 1 or more of the following:
a. Patients > 50 years old
b. HIV-positive patients
c. Immunosuppressed patients
11. Dysphagia
Get ESOPHAGRAM on all patients
12. Dyspepsia (refer to GI Clinic for any 1 or more of the following):
a. Persistent symptoms despite negative H. pylori stool antigen or Urea Breath test
testing and 4 week PPI trial
b. Persistent symptoms despite positive Helicobacter pylori stool antigen or Urea Breath
test testing and eradication therapy.
The Urea Breath test is a good option instead of the stool antigen with the following
precautions:
Patient must fast at least one hour prior to testing
Pg.30
Specialty Clinics
The patient should not take:
Antimicrobials within 4 weeks prior to testing.
Proton pump inhibitors or bismuth preparations within 2 weeks prior to testing.
H2 antaganist within 3 days prior to testing.
Phenylketonuria patients should not have Urea breath test.
Wait a minimum of 4 weeks following treatment prior to Urea Breath testing-because of
false negative results.
c. Patients with 1 or more of the following:
Involuntary weight loss
Gastrointestinal bleeding
Dysphagia
Odynophagia
Unexplained iron-deficiency anemia
Persistent vomiting
Palpable mass or lymphadenopathy
Jaundice
Family history of upper gastrointestinal cancer
Patients 50 years of age or older
13. Gastroesophageal Reflux Disease (GERD) (refer to GI Clinic for any 1 or more of
the following):
a. Symptoms of heartburn or regurgitation that have not responded to 8 week PPI
trial
b. Symptoms of laryngeal origin (eg, dyspnea, cough, hoarseness) that have not
responded to 8 week PPI trial
c. Suspected complicated GERD, as indicated by 1 or more of the following:
Pg.31
Specialty Clinics
Dysphagia
Odynophagia
Bleeding
Weight loss
Early satiety
Choking
Anorexia
Frequent vomiting
d. Symptoms of GERD that have lasted longer than 5 years
14. Chronic Constipation
a. Documentation of fiber, laxatives, stool softeners tried
b. Acute bowel habit change
c. List of medications
d. TSH
e. Serum Calcium
f. CBC
15. Suspected Gastroparesis
FOUR HOUR Gastric Emptying Study
Revised May 2015
Pg.32
Specialty Clinics
Gynecology/Oncology Clinic
Scope
•
•
To evaluate newly diagnosed and recurrent or previously treated gynecologic
type cancers.
To evaluate pelvic masses with suspicion for gynecological malignancies.
•
•
•
•
•
•
Any invasive gynecological cancer, newly diagnosed or recurrent
Pelvic masses suspicious for invasive gynecological cancer
Patients receiving treatment for their gynecological cancer
Patients needing surveillance for their gynecological cancer
VIN II and III
Do NOT refer the following patients (Unless there has been a doctor to doctor consult
and is approved by the Gyn/Onc clinic physician)
•
•
•
Any pre-invasive cancers
o CIN I, II, III
o VIN I
o HGSIL or LGSIL on pap smear
o Carcinoma in situ
Fibroids
Simple ovarian cyst
Documentation required for scheduling an appointment
•
o Completed referral form
o History and physical with documented gynecology exam
o Current medication list and co-morbidities
o Patient demographics
o If already diagnosed, pathology confirming cancer diagnosis
o If previously treated for diagnosis, send all oncology notes and all
treatment records (chemotherapy records, surgical records, radiation
records)
Pg.33
Specialty Clinics
•
Additional information needed for Ovarian Cancer:
o Any pertinent abdominal or pelvic imaging
o CA125
o Supporting documentation for recurrence if suspected
o If metastatic disease present, send supporting documentation for
metastatic locations.
•
Additional information needed for Endometrial, Cervical, and Uterine
Cancers:
o Any pertinent abdominal or pelvic imaging
o If metastatic disease present, send supporting documentation for
metastatic locations.
o Supporting documentation for recurrence if suspected
•
Additional information needed for pelvic masses suspicious for invasive
cancer
o Cat Scan or Ultrasound confirming mass
•
o BRCA results
o Any abdominal or pelvic imaging done
o CA 125
o Any surgical reports related to BRCA results (mastectomy/oophorectomy)
PLEASE SEND LAST PAP SMEAR IF AVAILABLE FOR ALL REFERRALS
DO NOT ASK FOR PAST MEDICAL HISTORY
Revised May 2015
Pg.34
Specialty Clinics
Hematology
Scope
•
•
To provide specialty expertise in the evaluation and management of blood
disorders beyond the scope of primary care physicians.
To prioritize limited availability to patients with malignancies or complex
hematologic disorders
•
•
•
•
•
•
Persistent, severe anemia after complete evaluation and treatment
Severe and/or clinically significant
o thrombocytopenia
o thrombocytosis
o leukopenia
o leukocytosis
Monoclonal gammopathy
Sickle Cell disease
Hypercoagulable state
Bleeding disorder
•
•
•
•
•
•
Completed referral form
Patient demographics
Current medication list and co-morbidities or problem list
Two most recent provider notes
Recent pertinent labs (See worksheet by diagnosis, drawn within the past 6
months, substantiating the disorder. Please send actual lab results not hand
written flow sheets.)
If previously treated by a Hematologist, send all hematology notes and previous
treatment records.
Additional information needed from previous 6 months (IF APPLICABLE)
•
•
•
•
•
Notes from all consultants (inpatient and outpatient)
Discharge summaries from relevant hospitalizations
All operative reports
Diagnostic procedure reports (endoscopy, bronchoscopy, biopsies)
All radiology reports
Revised May 2015
Pg.35
Specialty Clinics
Hematology Referral Worksheet
•
Persistent, severe anemia after complete evaluation and treatment
o Three consecutive CBC’s within the last year at least 1 month apart, most
recent within 1 month of referral, with hemoglobin less than 10.0
o TIBC, Ferritin, Serum Iron, B12 level, Folate level, TSH
o Iron deficiency is not appropriate for referral unless a complete GI
evaluation has been performed (colonoscopy and upper endoscopy)
o Anemia of renal insufficiency should be treated by nephrologist and is not
appropriate for referral
•
Thrombocytosis
recent within 1 month of referral
o Persistent platelet count > 600
o Peripheral Smear
o Iron deficiency has been ruled out
•
Thrombocytopenia
o Persistent platelet count < 100, or two platelet counts < 50
o 1 CBC in citrated (blue top) tube to evaluate for clumping
•
Leukopenia
o Persistent absolute neutrophil count less than 1500
o Lymphopenia is not appropriate for referral
•
Leukocytosis
o Physician documentation excluding infection
o Persistent absolute neutrophil count > 20,000
o Persistent absolute lymphocyte count > 10,000
•
Monoclonal gammopathy
o Serum protein electrophoresis (SPEP)
o Serum immunofixation
o Urine protein electrophoresis
o CBC, CMP
Pg.36
Specialty Clinics
•
Sickle Cell disease
o Hemoglobin electrophoresis documenting diagnosis
•
Hypercoagulable state (high risk thrombo-embolic event: DVT, PE, or
atypical arterial event)
o All radiology reports documenting thrombosis
o Coumadin flowsheets if applicable
o Specific question from referring physician, written on referral form, which
is to be addressed by consultant
•
Bleeding disorder
o Documentation of clinically significant bleeding
o All related labs
Revised May 2015
Pg.37
Specialty Clinics
Neurology Clinic
Scope
•
•
Neurology consultation
Follow-up of complex neurological patients
•
•
•
•
•
•
•
•
•
Central Nervous System Diseases
Parkinson's Disease
Multiple Sclerosis
Epilepsy not stable on a single medication (do not refer if seizure free ≥ 1 year)—
must have current EEG within 6 months of appointment ((((MD to review)))
Gait Disturbance
Tremors that have not responded to trial of at least one medication
Migraines persistent despite at least one prophylactic medication
Back Pain—must have radicular signs and symptoms
Peripheral Neuropathy (for suspected Carpal Tunnel Syndrome please use EMG
referral form)
•
•
•
•
•
•
•
•
•
Disability Evaluations
Patients with suspected Carpal Tunnel Syndrome (please use EMG referral form)
Back pain with positive MRI without radicular signs/symptoms
Chronic Non-specific Pain (Complex Regional Pain Syndrome, Fibromyalgia, etc)
Patients needing Pain Management
Bell’s Palsy unless recurrent
Patients with known Neurosurgery Needs (refer directly to Neurosurgery)
Lime Disease
Please Note: Appointments for EMGs are scheduled internally only
•
•
•
•
referred.
Pg.38
Specialty Clinics
•
•
Previous diagnostic evaluations, including any head imaging
Previous subspecialty evaluation
Revised May 2015
Note: Neuro Epilepsy schedule comes from Liz Wedberg, NP
Pg.39
Specialty Clinics
Neurology Clinic Worksheet
Back Pain (acute only with no neurological signs)
D
D
Problem list and problem list
MRI
Carpal Tunnel Syndrome
D
EMG Referral Form
Seizures (do not refer if seizure free for 1 year)
D
D
D
Medication List and Problem list
EEG (within the last 6 months)
Anticonvulsant levels
Parkinson’s Disease
D
Medication list and problem list
Migraines (that have failed at least one prophylactic med)
D
Problem list and medication list.
Multiple Sclerosis
D
Gait Disturbances
D
Problem list and medication list
Peripheral Neuropathy
D
D
Problem list and medication list
Fasting glucose, B12, folate, TSH, ANA, CK, Sjogren, Viral hepatitis panel, HIV if
indicated, immunoelectrophoresis with fixation
Pg.40
Specialty Clinics
Tremors (that have not responded to at least one drug trial)
D
Memory loss
D
D
D
D
MRI brain
TSH, B12, RPR
EEG
Revised May 2015
Pg.41
Specialty Clinics
EMG Referral Form
Fax: (512) 380-7508
Patient Name / DOB:
Referring Clinic:
Referring Provider:
•
•
Patients with suspected CTS without trial of appropriate conservative therapy
o Rest and wrist splinting for at least 1 month
Patients with chronic pain without new focal symptoms/signs:
o Fibromyalgia
o Complex Regional Pain Syndrome
Reason for Referral:
□
□
Numbness/Paresthesias/Tingling
Pain
□
□
Weakness/Fatigue
Increased CK, Possible Myopathy
Prior treatment:
Prior EMG’s Date & Reason:
Other pertinent test results:
Extremity Affected:
□
□
□
□
□
Arm
Leg
Face/Tongue
Diaphragm/Trunk/Abdomen
Other:
Pg. 42
Side:
□
□
□
□
Right
Left
Right + Left
Other:
Specialty Clinics
Duration of Symptoms:
□
<4 weeks (it takes 3-6 weeks to fully develop EMG abnormalities after nerve injury;
schedule EMG on appropriate date, otherwise, repeat EMG may be necessary)
□
□
□
□
>4 weeks
>3 months
>6 months
>1 year
Other Medical Problems (i.e. – DM, HIV, Alcohol Abuse):
Physician Signature:
Revised May 2015
Pg. 43
Specialty Clinics
Oncology Clinic
Scope
•
To evaluate and treat patients who have been diagnosed with cancer or treated for
cancer.
•
•
•
•
Newly diagnosed cancers
Recurrent cancers
Patients receiving treatment for cancer
Patients needing follow-up for previously treated cancer
Do NOT refer the following patients:
•
Patients suspicious for malignancy but no biopsy (pathology) confirming cancer.
Biopsy Exception: Suspected Hepatocellular Carcinoma can be seen without a biopsy
if liver imaging is diagnostic of HCC and AFP is elevated
•
•
•
•
Thyroid cancer that has not spread (non-metastatic)
Prostate cancer that has not spread
Kidney cancer that has not spread
Skin Cancer (except metastatic melanoma)
•
•
•
•
•
•
•
Current referral form
Patient demographics
Current medication list and co-morbidities or problem list
Two most recent provider notes
Original pathology report confirming tissue diagnosis
If previously treated for cancer diagnosis, all oncology notes and treatment records
(chemotherapy flow sheets, operative notes)
If recurrence suspected, send supporting documentation (radiology, biopsies,
pathology)
Additional information needed related to cancer (IF APPLICABLE)
•
•
•
•
Notes from all consultants (inpatient and outpatient)
All operative reports
Diagnostic procedure reports (endoscopy, bronchoscopy)
All radiology reports
Pg. 44
Specialty Clinics
NOTE: If additional documentation or testing is required, a request will be FAXED back to the
referring clinic outlining the specific data needed. If the referral is incomplete or
seems inappropriate, the MD will be consulted, and his recommendations will be
stated on the form.
Revised May 2015
Pg. 45
Specialty Clinics
Orthopedic Clinic
Scope:
•
To provide consultation and orthopedic care for orthopedic problems which are unable to
be managed in outlying primary care clinics. Surgery may be arranged as indicated.
•
•
•
•
•
•
•
•
•
Musculoskeletal complaints including problems involving joints, tendons and muscles after
appropriate screening and adequate conservative care in the primary clinics
Chronic arthritis
Chronic tendonitis
Ganglion cyst
Arthralgia
Carpal tunnel (need EMG report)
Achilles tendon mass
Trigger finger (no xray needed)
Acute worsening arthritis
•
•
•
•
•
•
•
•
Acute closed fractures verified by x-ray (refer to Cast Clinic)
Acute infections or injuries (send to ER)
Neck pain and injuries (refer to Neurology Clinic)
Foot problems (refer to Foot Clinic)
Pediatric patients age 17 and under (refer to DCMC Ortho Clinic)
Patients needing prostheses
Acute or chronic low back pain
Back, feet or hand problems
•
•
•
•
•
•
•
•
•
Most recent progress note describing condition for which patient is being referred.
Imaging of involved anatomic structure
Lab/Imaging results can be more than 6 months but less than 1 year
Specific statement of concern or question to be answered regarding orthopedic complaint
Description, including time and duration, of conservative treatment
Relevant lab data
Revised May 2015
Pg. 46
Specialty Clinics
Pulmonary Clinic
Scope:
•
Evaluate patients with pulmonary disease beyond the scope of internal medicine and
family practice.
•
•
•
•
•
•
•
Steroid dependent / difficulty with controlling asthma
Lung mass
Interstitial lung disease
Sleep apnea—must have current sleep studies (within 3 months of appointment)
Newly diagnosed COPD
Unstable COPD
Emphysema
•
•
•
Stable/chronic low-level COPD (chronic obstructive pulmonary disease)
Asthma (send to Asthma clinic)
Pediatric patients
•
•
•
•
•
•
•
•
Current Chest X-ray (within the past 3 months) and old films if available
Copy of prior work-up including any pulmonary function tests, CT scans, labs, etc.
Results of any skin tests performed elsewhere (with dates & techniques).
Current Pulmonary Function Tests (within 3 months of appointment)
Revised May 2015
Pg. 47
Specialty Clinics
Renal/Hypertension Clinic
Scope
•
Evaluate and treat patients with renal insufficiency, significant proteinuria, past renal
transplant, SLE with possible nephropathy, and refractory hypertension.
•
•
•
•
•
Renal Insufficiency (men Cr ≥ 1.4, women Cr ≥ 1.2 or SLE with any increase)
Proteinuria ≥ 500mg/day (urine protein/urine creatinine ratio ≥ 0.5)
Uncontrolled Hypertension (persistent SBP ≥ 160 despite compliance with 3 or more
antihypertensive medications)
Renal Transplant
SLE with abnormal urinalysis or increased creatinine
•
•
•
•
Kidney stones (refer to Urology Clinic.)
Hematuria with normal renal function and no proteinuria (refer to Urology Clinic)
Proteinuria on dipstick alone (must have qualitative urine protein/urine creatinine ratio ≥
0.5)
Pediatric patients (age<18)
•
•
•
•
•
•
•
•
Labs need to be within 1 month at the time of referral
Renal ultrasound need to be within last 6 months
Retinal exam need to be within last 2 years
For Hospital and ER follow up, lab work 48 hours before appointment date
Revised May 2015
Pg. 48
Specialty Clinics
Renal/Hypertension Clinic Worksheet
•
Increased Creatinine
o CMP
o CBC
o Urinalysis with micro
o Renal Ultrasound (with post-void residual if age ≥ 50 or diabetic)
o If diabetic, need Hbg A1C and ophthalmic exam results with referral papers
• Proteinuria
o
o
o
o
•
Hypertension
o
o
o
o
o
•
CMP
Urinalysis with micro
Urine protein/urine creatinine ratio
If diabetic, need Hbg A1C and ophthalmic exam results sent before renal appointment
CMP
Complete urinalysis
Renal Ultrasound if abnormal creatinine
Echocardiogram if available
Past medication trials
Renal Transplant
o
Immunosuppressive (cyclosporine, prograf, or cellcept) trough level taken 15 minutes
before medication dose
o CMP
o CBC
•
SLE
o CMP
o CBC
o Urinalysis with micro
o Urine protein/urine creatinine ratio
o Renal Ultrasound
Revised May 2015
Pg. 49
Specialty Clinics
Rheumatology Clinic
Scope:
•
To provide consultations at a subspecialty level in rheumatology.
•
•
•
•
•
•
•
•
•
(+)RF, (+)ANA titer =/> 1/160, (+) CCP
Rheumatoid Arthritis
Systemic Lupus Erythematosis
Gout
Ankylosing Spondylitis
Reiter’s Syndrome
Psoriatic Arthritis
Scleroderma
Muscle Diseases
o Polymyositis
o Dermatomyositis
•
•
•
•
Osteoarthritis
Fibromyalgia
Chronic Pain
Migraines
•
•
•
•
•
Recent pertinent lab (Complete lab profile, drawn within the past month, substantiating the
disorder. Please send lab flow sheets if they exist.)
Need CBC, CMP, Urinalysis, ESR, RF, ANA, CCP
•
Recent pertinent scans or X-rays
Revised May 2015
Pg. 50
Specialty Clinics
Rheumatology Clinic Worksheet
o
+ANA (R/O SLE or Lupus-like syndrome) & Connective Tissue Disease
o ANA Panel with ANA titer =/> 1/160
o Anticardiolipins,
o lupus anticoagulant
o ESR
o CBC
o CPK
o Beta 2 Glycoprotein
o Hepatitis Panel
o
+RF
o Anti CCP ab
o Hepatitis screening panel
o Serum immunofixation
o Bilateral wrist and hand films
o ANA Panel
o Anticardiolipins,
o lupus anticoagulant
o ESR
o CBC
o CPK
o *Negative Quantiferon TB or documented treatment of TB or documented negative PPD
o
Gout
o Joint fluid crystal results
o Uric acid level, CBC, CMP
o List of Medications
o Past Medical history
o
Ankylosing Spondylitis (spondyloarthropathy)
o SI joint films (2 views)
o HLAB 27 (Lab)
o
Sclerdoderma
o ANA Panel with ANA titer
o CPK
o Chest Xray
o Barium swallow
Pg. 51
Specialty Clinics
o Hep screening panel
o
Muscle Diseases
o Polynyositis
o Dermatomyositis
o CPK
o ESR
o Chest Xray
o Barium swallow
o
Psoriatic Arthritis
o Anti CCP ab
o ANA Panel
o UA
o CBC
o CMP
o ESR
o Hepatitis panel
*Only needed if patient has a history of positive TB test
Revised May 2015
Pg. 52
Specialty Clinics
Surgery Clinic
Scope
•
•
•
Seeing referrals from outlying clinics
Seeing referrals from other Brackenridge outpatient clinics
Follow-up of surgical and trauma patients
Appropriate patients for referral include: (any referrals outside this list will need to be
Pre-approved by the surgeon) *(If suspicious for malignancy refer to Surgical
Oncology)*
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Any hospital follow-up from general / trauma surgical service
* Abdominal mass
Ventral hernia / Incisional hernia**
Umbilical hernia / mass**
Inguinal hernia / mass**
Groin hernia / mass**
Thyroid mass / tumor / nodule / goiter (Team B)
Parathyroid hyperplasia / nodule / adenoma (Team B)
Lymph node biopsy / lymphadenopathy (((ASK MD IF IMAGING IS REQUIRED)))
*Pancreatic cyst / pseudocyst / mass / tumor / nodule
Splenomegaly
*Liver / hepatic mass / tumor / nodule
Gallstones / gallbladder / cholecystitis / biliary colic
*Stomach mass / tumor / nodule / ulcer
*Colon mass / tumor / nodule
Bowel obstruction
*Rectal mass / tumor / nodule / pain
Anal fissure / abscess
Guaiac / hemoccult positive / blood in stool (no colon screenings; limit 2
colon evals per day).
Diverticulosis / diverticulitis
Appendicitis
Hemorrhoids
Hidradenitis
Melanoma
Port-a-cath placement / removal / chemotherapy access
Pilonidal cyst / abscess – any size, no xray
Pg. 53
Specialty Clinics
•
•
•
•
•
•
•
•
•
•
•
•
•
Small lipomas, cysts, or skin lesions less than 4 cm (Refer to Derm)
GI bleeding which has not had H/H, stool guaiac
Vague abdominal pain
Breast Masses/Breast Disease (Refer to Shivers Center Breast Clinic)
Testicular Masses
Pediatric patients
Screening Colonoscopy (((ASK MD)))
Patient requesting cosmetic surgery evaluation
Cancer (Refer to Shivers Center)
Varicose Veins
Hyperhydrosis
Hydrocele – refer to Urology
Cystocele – refer to Urogyn
•
•
•
•
•
•
•
•
Include H&H and stool Guaiac if referring for GI bleeding
Does referring physician wish patient to return after consult or desire surgical
team to manage the problem patient is referred for
Study results indicating need for surgery
Pertinent X-ray films and reports
Revised May 2015
Pg. 54
Specialty Clinics
Urology Clinic
Scope:
•
Urology care for adults.
•
•
•
•
•
•
•
•
Cancers of urinary tract (kidney, bladder, prostate, testicular)
Obstructing kidney stones or stones > 1 cm (need non contrast CT prior)
Hematuria (CT/IVP and urine cytology prior) document x 2 with micro. UA
Urinary retention (after failed alpha blocker and voiding trial)
Elevated PSA (confirmed with repeat value)
PCKD without renal failure
Peyronies
Phimosis
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Proteinuria (Refer to Renal Clinic)
Skin rashes in genital area
Acute UTI's
Circumcisions (elective)
Vasectomy or reversals
Infertility
Cystocele in women (Urogyn)
PCKD with renal failure (Renal Clinic)
Erectile Dysfunction
Urinary incontinence for women (Urogyn)
Sexual Dysfunction
BPH
Chronic testicular pain
Hydrocele – unless patient is having persistent pain for 2-3 months
Urinary incontinence for men
•
•
Completed referral form, problem list, and medication list
Urinalysis and any other current, pertinent lab results. (Labs should be less than 3
months)
Pg. 55
•
Specialty Clinics
Pertinent X-ray films (CT or US) and reports (should be less than 3 months)
Revised May 2015
Pg. 56
Specialty Clinics
Urology Clinic Worksheet
•
UTI – chronic or reoccurring only:
o Send urine culture results – recent to appointment <3 months
o IVP
•
Hematuria and Micro hematuria:
o IVP (Priority)(or CT scan abdominal /pelvis with contrast), microscopic urinalysis (at least
2) documenting abnormal # of blood cells and absence of active infection
o Urine Cytology
•
Urinary Frequency:
• UA
• Urine Culture
• PSA required for men
•
Kidney Stones:
o IVP or CT/abd/pelvis
•
Scrotal/Testicular Mass/Testicular Pain:
o Scrotal Ultrasound
•
Prostate Problem:
o PSA
o Urine culture
Note:
If unable to do IVP (eg: allergic to contrast) get a Renal (abdominal) Ultrasound
Revised May 2015
Pg. 57
Specialty Clinics
FAX Transmittal — Specialty Clinics — MAP Patients
Paul Bass Clinic — FAX #324-8074/324-8072
Shivers — Breast/Hem/Onc Clinic — FAX #324-7972/324-7138
Sub-specialty Clinic — FAX #324-7857/324-8203
From Clinic:
Fax:
Contact Name:
Contact Phone:
Pages (including fax transmittal):
Re:
NOTE: Appointment information will be faxed to the PCP clinic within 72 business hours of receiving a completed
referral with all pertinent documentation. The PCP clinic is responsible for notifying the patient of the specialty
appointment.
Comments:
The information contained in this facsimile message is legally privileged and confidential information intended only for the
use of the entity named above. If the reader of this transmission is not the intended recipient, you are hereby notified that
any dissemination, distribution or copying of this transmission is strictly prohibited. If you received this transmission in
error, please immediately notify us by telephone to arrange for return of the original documents.
Pg. 58
Specialty Clinics
Seton Imaging and Radiology — Required Labs
Labs required prior to scheduled test:
1. ULTRASOUND
a. Labs: PT, PTT CBC w/platelets, total INR
i. US Guided Breast localization
ii. US Breast tissue specimen
iii. US Biospy Abdomen
iv. US Guided Biopsy Breast
v. US Biopsy Lung/mediastinum
vi. US guided amniocentesis
vii. US guided Biopsy
viii. US Guided Biopsy Liver
ix. US Guided Biopsy Renal
x. US Guided Cyst Aspiration
xi. US Guided paracentesis
xii. US guided Percutaneous drainage
xiii. US guided RAD SEEDS
xiv. US guide THER FLD
xv. US guided thoracentesis
xvi. US mammography core biopsy left
xvii. US mammography core biopsy right
xviii. US Mammo cyst additional left/right
xix. US Mammo cyst aspiration
xx. US mammo needle placement left/right
xxi. US Sed IV/IM/NHL
xxii. US sed ORL/REC/NA
2. FLUOROSCOPY
a. LABS: PT/PTT CBC w/platelets and total INR
i. Lumbar puncture
ii. C2 puncture w/injection (BUN, Creat.)
iii. C2 puncture
iv. Flouro needle biopsy
(ALL FLUORO EXAMS WITH IV CONTRAST REQUIRES BUN AND CREATININE)
Pg. 59
Specialty Clinics
Seton Imaging and Radiology — Required Labs ( c o n ti n ue d)
3. CAT SCAN
a. Labs: PT/PTT, CBC w/platelets and total INR, BUN and CREAT
i. CT Biopsy- Abdomen
ii. CT Biopsy Bone
iii. CT biopsy Lung Left
iv. CT Biopsy Lung Right
v. CT Biopsy Liver
vi. CT Biopsy Pancreas
vii. CT Biopsy Pleura left
viii. CT Biopsy Pleura right
ix. CT Biopsy Renal left
x. CT Biopsy Renal right
xi. CT Cervical Puncture
xii. CT C1/C2 Puncture
xiii. CT Drainage Lung left
xiv. CT Drainage Lunt right
xv. CT Drainage liver
xvi. CT drainage pancreas
xvii. CT drainage peritoneal
xviii. CT drainage retroperitoneal abscess
xix. CT drainage renal left
xx. CT drainage renal right
xxi. CT drainage Subdiaphragm/subphrenic
xxii. CT Guided Cyst aspiration
xxiii. CT guided lumb kypho
xxiv. CT guided lumb vert
xxv. CT guide needle biopsy
xxvi. CT guide percutaneous drainage
xxvii. CT guide RFA
xxviii. CT guide RTF placement
xxix. CT injection Lumbar or Thoracic Spine
(BUN and CREATININE REQUIRED FOR ALL CT EXAMS WITH IV CONTRAST)
4. MRI
a. Labs: PT/PTT CBC w/platelets Total INR
i. MR guided needle placement
(All MRI EXAMS WITH IV CONTRAST REQUIRE BUN AND CREATININE)
5. NUCLEAR MEDICINE
a. Labs: PT, PTT, CBC w/platelets INR
i. NM lymphoscintgraph — breast(labs needed for surgery
Pg. 60
Diagnostic Order Forms
Specialty Clinics
See attached order forms for the following:
□ Audiology Testing
o Phone 324-9999 x 77826
o Fax 380-7508
□ Cardiology Electroneurodiagnostic Testing
o Phone 324-1375
o Fax 380-4263
□ Physical Therapy (OP Wound Care; OP OT Low Vision; OP MBS)
o Phone 324-7600
o Fax 324-7566
□ Pulmonary Function Test
□ Pulmonary Function Lab
o Phone 324-1375
o Fax 380-4263
Pg. 61
Specialty Clinics
Adult Audiology Request Form
Phone: 512-324-9999 x77826
Fax: 512-380-7508
Please COMPLETE this updated Physician Order form for ADULT audiology referrals
> Please include a demographics sheet,
& please encourage your patients to show up for their appointments
Requesting:
D Basic Audio
D Other
THIS VISIT
FROM:
D REQUIRES AUTHORIZATION
PHONE:
Authorization #:
FAX:
D DOES NOT REQUIRE AUTHORIZATION
***Referrals without a fax number will be rejected***
(Must be)
Full Name of Referring Physician:
M.D. or D.O.
Name of Patient’s PCP:
Diagnosis/Reason for Referral (Check ALL that apply):
D Decreased hearing
D Otitis/inflammation of ear D Speech delay
D Unilateral/asymmetric loss D TM perforation
Pg. 62
D Tinnitus
Specialty Clinics
D Sudden hearing loss
D Discharge from ear
D Vertigo/dizziness
D Ear Pain
D Adverse affects of medication
D Other
Patient name:_
Date of birth
/
/
Contact Numbers:_
Insurance Company:
_Group or ID#:
x
_Date:
Physician Signature and Date Required
Pg. 63
Specialty Clinics
Pg. 64
Specialty Clinics
Pg. 65
Specialty Clinics
Pg. 66
Specialty Clinics
Pg. 67
Specialty Clinics
Directions to Paul Bass Clinic:
Directions from the Clinical Education Center (CEC) parking garage:
(ONLY pink map card holders can receive a parking validation)
□ The parking garage is located on the access road of 1-35 South, on the corner of 15th street
□ Park in the parking garage and enter through the main entrance of the Clinical Education Center (CEC)
□ Walk toward the right, passing the first set of elevators, and then follow the signs of the Paul Bass Clinic
until the second set of elevators.
□ Take the elevators down to Lower Level (LL).
□ Make a right when you get out of the elevators and follow the signs to the Paul Bass Clinic.
Directions from the Brackenridge Hospital parking garage:
(ONLY pink map card holders can receive a parking validation)
□
□
□
□
□
□
The parking garage is located on the corner of 15th Street and Red River.
Take the parking garage elevator to Level 4.
Follow the hallway to the entrance of Brackenridge Hospital.
Pass the first set of elevators, and then follow the long hallway until you reach the second set of elevators.
Take the elevators down of Lower Level (LL).
Make a right when you get out of the elevators and follow the signs to the Paul Bass Clinic.
Directions from the Capital Metro bus stop: 10 & 20
□ Enter the hospital through the main entrance located on the 1st floor.
□ Pass the first set of elevators, pass the cafeteria, and then follow the long hallway until you get to the second set of
elevators.
□ Take the elevators down to the Lower Level (LL).
□ Turn to the right when you get off the elevator and follow the signs to the Paul Bass Clinic.
Directions from the Capital Metro bus stop: 37
□ Get off the bus on the corner of Red River and 15th Street.
□ Enter the hospital through the main entrance located on the 1st floor.
□ Pass the first set of elevators, pass the cafeteria, and then follow the long hallway until you get to the second set of
elevators.
□ Take the elevators down to the Lower Level (LL).
□ Turn to the right when you get off the elevator and follow the signs to the Paul Bass Clinic.
Pg. 68
Specialty Clinics
Instrucciones si entre en el estacionamiento de CEC:
(SOLAMENTE los recipientes de la tarjeta de MAP rosada pueden recibir la validación del estacionamiento)
□ El estacionamiento está localizado en la carretera de acceso de 1-35 Sur, en la esquina de Calle 15.
□ Estaciónese en el estacionamiento y entre en la entrada mayor del Centro de Educación Clinica (CEC).
□ Camine hacia la derecha, pase los primeros elevadores, luego siga los signos de la Clinica de Paul Bass hasta los
segundos elevadores.
□ Tome los elevadores abajo al Piso LL.
□ Dase una vuelta a la derecha cuando salga del elevador y siga los signos hacia la Clinica de Paul Bass.
Instrucciones si entre en el estacionamiento del Hospital de Brackenridge:
(SOLAMENTE los recipientes de la tarjeta de MAP rosada pueden recibir la validación del estacionamiento)
□
□
□
□
□
□
El estacionamiento está localizado en la esquina de Calle 15 y Red River.
Tome el elevador del estacionamiento al Nivel 4.
Siga el vestibulo hacia la entrada del hospital de Brackenridge.
Pase los primeros elevadores y siga el largo vestibulo hasta los segundos elevadores.
Tome los elevadores abajo al Piso LL.
Dase una vuelta a la derecha cuando salga del elevador y siga los signos hacia la Clinica de Paul Bass.
Instrucciones desde la parada de Autobñs: 10 y 20
□
□
□
□
Entre en el hospital por la entrada mayor localizada en el primer piso.
Pase los primeros elevadores, pase la cafeteria, luego siga el largo vestibulo hasta los segundos elevadores.
Tome los elevadores abajo al Piso LL.
Dase una vuelta a la derecha cuando salga del elevador y siga los signos hacia la Clinica de Paul Bass.
Instrucciones desde la parada de Autobñs: 37
□ Salga del autobüs en la esquina de Red River y Calle 15.
□ Entre en el hospital por la entrada mayor localizada en el primer piso.
□ Pase los primeros elevadores, pase la cafeteria, luego siga el largo vestibulo hasta los segundos
elevadores.
□ Tome los elevadores abajo al Piso LL.
□ Dase una vuelta a la derecha cuando salga del elevador y siga los signos hacia la Clinica de Paul Bass.
Pg. 69
Pg. 70
Brackenridge
Specialty Clinics
University Medical Center Brackenridge Specialty Clinics
REFERRAL FORM
This form is intended to assure prompt communication back to requesting providers. Please Fax
referral form and supporting documents to (512)380-7508.
*Check Specialty Preference (Check one):
Asthma
Cardiology
Cast
Dermatology
Endocrinology
Nephrology
Neurology
Ophthalmology
Orthopedic
Podiatry
Gastroenterology
Pulmonology
Rheumatology
Surgery
ENT
Urology
First Available
No Preference
*Patient Name:
*Telephone:
*Primary Language:
*Alternative Number:
Address:
*Insurance Information (Plan Name):
City:
*DOB:
State:
*Policy number:
Authorization number (if applicable):
Exp Date:
Pg. 71
Zip:
*Exp Date
*Referring Clinic:
*Telephone:
*Date:
*Referring Physician:
*Fax:
*Submitted by:
Reason for the Referral (please include appropriate diagnosis and attach pertinent clinical/progress notes or provide clinical
narrative, including duration of problem, types of treatment, pertinent physical findings, pertinent testing results, diagnostic
work-ups, including lab and imaging supporting documents):
Overbook Request Information (Please specify below in detail reason for overbook):
(For CommUnityCare Use) Appointment date:
Time:
* In order to process request all required fields must be completed
NOTICE OF CONFIDENTIALITY – This document is intended solely for the use of the individual identity to which it is addressed and may contain
information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this notice is not the intended recipient or
individual responsible for delivering the message to the intended recipient, you are hereby advised that any dissemination, distribution or copying of this
information is strictly prohibited If you have received this communication in error please advise us immediately by telephone and destroy these papers
Pg. 72
Pg. 73
Pg. 74
Pg. 75
Pg. 76
11. PHARMACY SERVICES
PHARMACY SERVICES
Pharmacy Co-payments
MAP Network Pharmacies
MAP Formulary
Non-Formulary Medication Request
Patient Assistance Programs (PAP) Medication Interim Fill
MAP Pharmacy Hotline
PHARMACY SERVICES
Pharmacy Co-payments
GROUP
CBRACKFQ
CBRACKFQ
PLAN
CBRACKFQ
CPENDSSI
Formulary Drug
$7 co-pay for 1-30 day supply or
$14 co-pay for 31-90* day supply
or
$0 co-pay if noted on MAP card
* 90-day supply on selected drugs
only
Non-Formulary Drug
$7 co-pay for 1-30 day supply
or
only
or
or
only
* 90-day supply on selected drugs only
MAP Network Pharmacies
A list of in-network pharmacies can be found on MAP website:
http://www.medicalaccessprogram.net/get-care/sites-pharmacy/
:> See document entitled “MAP Network Pharmacies.”
MAP Formulary
:> See document entitled “MAP Formulary.”
Non-Formulary Medication Request
Submit a Medication Override Request Form if the patient cannot tolerate generic or
formulary medication and requires a medication that is nonformulary.
:> See document entitled “Medication Override Request Form.”
Patient Assistance Programs (PAP) Medications
If a patient is eligible for Patient Assistance Program (PAP) medications, Provider should:
a. submit PAP paperwork on behalf of the patient and
b. submit a Medication Override Request Form for consideration of an interim fill.
:> See document entitled “Medication Override Request Form.”
MAP Pharmacy Hotline:
Telephone: (512) 978-8139
Fax: (512) 901-9763
Call the Pharmacy Hotline if you have questions or need copies of MAP pharmacy
documents.
Pharmacy Locations
MAP clients assigned to CommUnityCare can use one of the listed pharmacies:

















H-E-B (512-478-8086) 2701 E. Seventh St., 78702
H-E-B (512-926-0586) 7112 Ed Bluestein Blvd., 78723
H-E-B (512-442-1578) 2400 S. Congress Ave., 78704
H-E-B (512-448-3353) 2508 E. Riverside Dr., 78741
H-E-B (512-441-3692) 6607 S. IH35, 78744
H-E-B (512-282-0990) 2110 New Slaughter Ln., 78748
H-E-B (512-301-9772) 5800 W. Slaughter Ln., 78749
H-E-B (512-837-9580) 9414 N. Lamar Blvd., 78753
H-E-B (512-459-8308) 1000 E. 41 St., 78751
H-E-B (512-339-6644) 12407 N. Mopac, 78758
H-E-B (512-251-5286) 1434 Wells Branch Pkwy., 78660
H-E-B (512-336-7706) 7301 N FM 620, 78726
H-E-B (512-474-2662) 1801 E 51st St, 78723
Rite-Away Pharmacy (512-827-2600) 730 West Stassney Lane, Suite 160,
78745
Lamar Plaza (512-442-6777) 1132 S. Lamar Blvd., 78704
38th St. Pharmacy (512-458-3784) 711 W. 38th St. #C3, 78705
Southeast Health & Wellness Center (512-978-9901) 2901 Montopolis Dr.,
78741
Medical Access Program (MAP) Formulary- 2016
AHFS Classification
100000 ANTINEOPLASTIC AGENTS
120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
120808 ANTIMUSCARINICS/ANTISPASMODICS
121208 BETA-ADRENERGIC AGONISTS
121212 ALPHA- AND BETA-ADRENERGIC AGONISTS
121212 ALPHA- AND BETA-ADRENERGIC AGONISTS
121604 ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
122012 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
122012 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
HYDROXYUR CAP 500MG PAR 100@
LETROZOL TAB 2.5MG UD+ AHP 30
MEGESTR AC OS 40MG/ML SKY 20@
MEGESTR TAB 40MG ROX 100
MERCAPTOPUR TAB 50MG ROX 25@
METHOTREXATE 2.5MG TAB AVK 100
TAMOXIFEN CITR TB 10MG MYL 60@
TAMOXIFEN CITR TB 20MG MYL 30@
BETHANECOL TB 10MG UD AHP 100
BETHANECOL TB 25MG UD AHP 100
DONEPEZIL 10MG TAB GOLD 30
DONEPEZIL 5MG TAB GOLD 30
GALANTAM TAB 4MG UD UDL 30@
GALANTAM TAB 8MG UD UDL 30@
PILOCAR TAB 5MG ACTA 100@
PILOCARP HCL TAB 7.5MG MARL100
CHLORDIAZ+CLIN+BR5/2.5MGOCE1C@
DICYCLOM CAP 10MG LANN 100@
DICYCLOM O/S 10MG/5ML Q/P 16Z@
DICYCLOM TAB 20MG WAT 100@
HYOSCYAM ER TB .375MG BCPI100@
HYOS SUL O/D TB.125MG BCPI100
HYOS SUL SUBL TB.125MG BCPI100
HYOS SUL ORAL TB.125MG BCPI100
IPRATRO INH SOL 0.02%UDNEPH25@
RR IPRATRO BR/ALBU 3MLUDNEPH30
PROVENTIL HFA INH 6.7GM 200DSE
ALBUTEROL INH 0.5% HI-T 20ML@
ALBUTEROL SYRP 2MG TEV 16OZ@
ALBUTEROL SUL TAB 2MG MUT 100@
ALBUTEROL SUL TAB 4MG MUT 100@
ALBUTEROL INH 0.083%MYL 3ML30@
EPIPEN JR .15MG .3ML 1:2M 2PK
EPIPEN 0.3MG 0.3ML 1:1M 2PK
TAMSUL HYD CAP 0.4MG AURO100@
CARISOPRODOL 350MG TAB VEN100@
CHLORZOX TAB 500MG WAT 100@
CYCLOBENZA HCI TAB10MG MARL100
CYCLOBENZ TAB 5MG UD+ AHP 30
METAXALONE TAB 800MG UD AHP30
METHOCARB TAB 500MG UD AVK50
METHOCARB TAB 750MG UD AVK50
TIZANIDINE CAP 2MG MYL 150
TIZANIDINE CAP 4MG MYL 150
TIZANIDINE TAB 2MG UD+ AHP 30
TIZANIDINE TAB4MG UD MMP10X10@
BACLOFEN TAB 10MG AVK 90
BACLOFEN TAB 20MG UD AHP 100
GenericName
HYDROXYUREA
LETROZOLE
MEGESTROL ACETATE
MEGESTROL ACETATE
MERCAPTOPURINE
METHOTREXATE SODIUM
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
BETHANECHOL CHLORIDE
BETHANECHOL CHLORIDE
DONEPEZIL HCL
DONEPEZIL HCL
GALANTAMINE HBR
GALANTAMINE HBR
PILOCARPINE HCL
PILOCARPINE HCL
CHLORDIAZEPOXIDE/CLIDINIUM BR
DICYCLOMINE HCL
DICYCLOMINE HCL
DICYCLOMINE HCL
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE
IPRATROPIUM BROMIDE
IPRATROPIUM/ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALBUTEROL SULFATE
EPINEPHRINE
EPINEPHRINE
TAMSULOSIN HCL
CARISOPRODOL
CHLORZOXAZONE
CYCLOBENZAPRINE HCL
CYCLOBENZAPRINE HCL
METAXALONE
METHOCARBAMOL
METHOCARBAMOL
TIZANIDINE HCL
TIZANIDINE HCL
TIZANIDINE HCL
TIZANIDINE HCL
BACLOFEN
BACLOFEN
Generic Dose
Form
CAPSULE
TABLET
ORAL SUSP
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
SOLUTION
TABLET
TAB ER 12H
TAB RAPDIS
TAB SUBL
TABLET
SOLUTION
AMPUL-NEB
HFA AER AD
SOLUTION
SYRUP
TABLET
TABLET
VIAL-NEB
AUTO INJCT
AUTO INJCT
CAP ER 24H
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
Dose Strength
Description
Name
500 MG
2.5 MG
400MG/10ML
40 MG
50 MG
2.5 MG
10 MG
20 MG
10 MG
25 MG
10 MG
5 MG
4 MG
8 MG
5 MG
7.5 MG
5 MG-2.5MG
10 MG
10 MG/5 ML
20 MG
0.375 MG
0.125 MG
0.125 MG
0.125 MG
0.2 MG/ML
0.5-3MG/3
90 MCG
5 MG/ML
2 MG/5 ML
2 MG
4 MG
2.5 MG/3ML
0.15MG/0.3
0.3MG/0.3
0.4 MG
350 MG
500 MG
10 MG
5 MG
800 MG
500 MG
750 MG
2 MG
4 MG
2 MG
4 MG
10 MG
20 MG
Comments
AHFS Classification
129200 AUTONOMIC DRUGS, MISCELLANEOUS
201204 ANTICOAGULANTS
201218 PLATELET-AGGREGATION INHIBITORS
202400 HEMORRHEOLOGIC AGENTS
202816 HEMOSTATICS
240404 ANTIARRHYTHMIC AGENTS
240408 CARDIOTONIC AGENTS
240408 CARDIOTONIC AGENTS
240604 BILE ACID SEQUESTRANTS
240606 FIBRIC ACID DERIVATIVES
240608 HMG-COA REDUCTASE INHIBITORS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
NICOTINE PATCH S-2 14MG NOV 7
HEPAR CPJ 5MU 1ML SLMPK HW 50
HEPAR SOD MDV 50MU 10ML SKY25@
JANTOVEN TAB 1MG
100
JANTOVEN TAB 10MG
100
JANTOVEN TAB 2MG
100
JANTOVEN TAB 2.5MG
100
JANTOVEN TAB 3MG
100
JANTOVEN TAB 4MG
100
JANTOVEN TAB 5MG
100
COUMADIN TAB 6MG
100
COUMADIN TAB 7.5MG
100
CILOSTAZ TAB 100MG SAN 60@
CILOSTAZ TAB 50MG UD+ AHP 30
CLOPIDOGREL TAB 75MG VEN30@
PENTOXIFYL ER TB 400MG AVK 100
AMINOCAP AC SOL 25% VERS 8OZ
RR AMIODARONE TB 200MG UDL 25@
FLECAIN ACET TB100MG UDAVK5X10
FLECAIN ACET TB50MG UD AVK5X10
DIGOX TAB 125MCG PAR 100@
DIGOX TAB 250MCG PAR 100@
CHOLESTYR PW 4GM/5GM U/S 60@
CHOLESTYR PW 4GM/5GM U/S378GM@
PREVALITE PWD 4GM PKT U/S 42@
PREVALITE PWD CAN42DSU/S231GM@
FENOFIBRATE TAB 160MG AVK 30
FENOFIBR TB 54MG UD+ AHP 30
FENOFIBR CP 134MG UD AHP 20
FENOFIBR CAP 200MG UD AHP 30@
FENOFIBRATE CAP 67MG MYLN 90@
GEMFIBR TAB 600MG UD AVK 50
ATORVASTATIN 10MG UD GOLD 100
LOVASTAT TAB 10MG UD AVK 5X10
PRAVAST SOD TAB 10MG GLEN 90@
PRAVAST NA TAB 20MG APX 90@
PRAVAST TAB 40MG SAN 90@
PRAVAST NA TB 80MG UD AHP 30
SIMVASTATIN TB 10MG UD AVK5X10
GenericName
NICOTINE
NICOTINE
NICOTINE
HEPARIN SODIUM PORCINE
HEPARIN SODIUM PORCINE
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
WARFARIN SODIUM
CILOSTAZOL
CILOSTAZOL
CLOPIDOGREL BISULFATE
PENTOXIFYLLINE
AMINOCAPROIC ACID
AMIODARONE HCL
FLECAINIDE ACETATE
FLECAINIDE ACETATE
DIGOXIN
DIGOXIN
CHOLESTYRAMINE (WITH SUGAR)
CHOLESTYRAMINE (WITH SUGAR)
CHOLESTYRAMINE/ASPARTAME
CHOLESTYRAMINE/ASPARTAME
FENOFIBRATE
FENOFIBRATE
FENOFIBRATE MICRONIZED
GEMFIBROZIL
ATORVASTATIN CALCIUM
LOVASTATIN
LOVASTATIN
LOVASTATIN
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
Generic Dose
Form
PATCH TD24
PATCH TD24
PATCH TD24
CARTRIDGE
VIAL
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET ER
SOLUTION
TABLET
TABLET
TABLET
TABLET
TABLET
POWD PACK
POWDER
POWD PACK
POWDER
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
Dose Strength
Description
Name
14MG/24HR
21 MG/24HR
7MG/24HR
5000/ML(1)
5000/ML
1 MG
10 MG
2 MG
2.5 MG
3 MG
4 MG
5 MG
6 MG
7.5 MG
100 MG
50 MG
75 MG
400 MG
250 MG/ML
200 MG
100 MG
50 MG
125 MCG
250 MCG
4G
4G
4G
4G
160 MG
54 MG
134MG
200 MG
67 MG
600 MG
10 MG
20 MG
40 MG
80 MG
10 MG
20 MG
40 MG
10 MG
20 MG
40 MG
80 MG
10 MG
20 MG
40 MG
Comments
AHFS Classification
240692 ANTILIPEMIC AGENTS, MISCELLANEOUS
240816 CENTRAL ALPHA-AGONISTS
240820 DIRECT VASODILATORS
241208 NITRATES AND NITRITES
242000 ALPHA-ADRENERGIC BLOCKING AGENTS
242400 BETA-ADRENERGIC BLOCKING AGENTS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
NIASPAN ER TAB 1000MG
90
90
90
CLONIDINE 0.1MG/D PATCH ACT 4@
CLONIDINE TAB 0.1MG Q/P 90@
CLONIDINE TAB 0.2MG Q/P 100@
CLONIDINE HCI TAB .3MG UNI500@
METHYLD TAB 250MG TEV 100@
METHYLDOPA TAB 500MG ACC 100@
HYDRALZNE HCITB UD10MGMMP10X10
HYDRALAZ HCL TAB 100MG STR100@
MINOXIDIL TAB 10MG MUT 100@
MINOXIDIL TAB 2.5MG AVK 90
ISOSOR DIN TAB 10MG UD AHP100@
ISOSOR DIN TAB 20MG UD AHP100@
ISOSOR OR TB 30MG PAR 100@
ISOSOR DIN TAB 5MG PAR 100
ISOSOR MON ER TB 120MG UDAVK50
ISOSOR MON ER TB 30MG UDMMP100
ISOSOR MON ER TB 60MG UDMMP100
ISOSOR MON TB 10MG KREM 100@
ISOSOR MON TB 20MG ACTA 100@
NITRO TD PATCH-A 0.1MG MYL 30@
NITROGLYC TRNS DRM.2MG HERC30@
NITROGLYC TRNS DRM.4MG HERC30@
NITROSTAT SUBL TAB 0.3MG 100
NITROSTAT SUBL TAB 0.4MG 4X25
NITROSTAT SUBL TAB 0.6MG 100
CARDURA XL TAB 4MG
30
CARDURA XL TAB 8MG
30
DOXAZOSIN TAB 1MG UD+ AHP 30
DOXAZOSIN TAB 8MG GRE 100
PRAZOSIN CAP 1MG TEV 100@
TERAZOSIN HCL CAP 1MG MYLN 1C@
TERAZOSIN HCL CP 10MG MYLN 1C@
ATENOL TAB 100MG
AVK 45
ATENOL TAB 25MG
AVK 45
GenericName
SIMVASTATIN
NIACIN
NIACIN
NIACIN
CLONIDINE
CLONIDINE
CLONIDINE
CLONIDINE HCL
CLONIDINE HCL
CLONIDINE HCL
METHYLDOPA
METHYLDOPA
HYDRALAZINE HCL
HYDRALAZINE HCL
HYDRALAZINE HCL
HYDRALAZINE HCL
MINOXIDIL
MINOXIDIL
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
PRAZOSIN HCL
PRAZOSIN HCL
PRAZOSIN HCL
TERAZOSIN HCL
TERAZOSIN HCL
TERAZOSIN HCL
TERAZOSIN HCL
ATENOLOL
ATENOLOL
Generic Dose
Form
TABLET
TAB ER 24H
TAB ER 24H
TAB ER 24H
PATCH TDWK
PATCH TDWK
PATCH TDWK
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TAB ER 24H
TAB ER 24H
TAB ER 24H
TABLET
TABLET
PATCH TD24
PATCH TD24
PATCH TD24
TAB SUBL
TAB SUBL
TAB SUBL
TAB ER 24
TAB ER 24
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
Dose Strength
Description
Name
5 MG
1000 MG
500 MG
750 MG
0.1MG/24HR
0.2MG/24HR
0.3MG/24HR
0.1 MG
0.2 MG
0.3 MG
250 MG
500 MG
10 MG
100 MG
25 MG
50 MG
10 MG
2.5 MG
10 MG
20 MG
30 MG
5 MG
120 MG
30 MG
60 MG
10 MG
20 MG
0.1MG/HR
0.2MG/HR
0.4MG/HR
0.3 MG
0.4 MG
0.6 MG
4 MG
8 MG
1 MG
2 MG
4 MG
8 MG
1 MG
2 MG
5 MG
1 MG
10 MG
2 MG
5 MG
100 MG
25 MG
Comments
AHFS Classification
242808 DIHYDROPYRIDINES
242892 CALCIUM-CHANNEL BLOCKING AGENTS,
MISC.
MISC.
MISC.
MISC.
MISC.
MISC.
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
ATENOL TAB 50MG
AVK 45
ATENOL+CHL TAB 1C/25 WAT 100@
ATENOL+CHL TAB 50/25 WAT 100@
BISOPR+HCTZ 10/6.25MG UNIC 30@
BISOPR+HCTZ 2.5/6.25MG UNIC30@
BISOPR+HCTZ 5/6.25MG UNIC 30@
CARVEDILOL TB 12.5MGUD AHP100@
CARVEDILOL TB 25MG AVK 90
CARVEDILOL TB3.125MG UDAHP1C@
CARVEDILOL TB 6.25MGUD AHP100@
LABETALO HCI TB 100MG COUN100@
METOPROL TRT TB100MG UDMMP100@
METOPRO TRT TB 25MG UD MMP100@
METOPROL TRT TB50MG UD MMP100@
NADOLOL TB 20MG UD AHP 30
NADOLOL TB 40MG UD AHP 30
NADOLOL TAB 80MG GRE
100
PROPRAN ER CAP 120MG BRECK 500
PROPRANOLOL TAB 10MG 100 NSTR
PROPRANOLOL TAB 20MG NSTR 100
SOTALOL AF TAB 120MG MYLN 100
SOTALOL AF TAB 160MG MYLN 100
SOTALO HCL TB 80MG UD AHP 100@
AMLODIPINE BES 10MG UD AVK50@
AMLODIPINE BES 2.5MG UD AVK 50
AMLODIPINE BES 5MG UD AVK 50@
AMLODIPINE BENZ 10/20 UD+AHP20
AMLO BESY+BNZ 10/40MG DR/R 1C@
AMLODIPINE CP 2.5/10MG WAT 100
AMLODIPINE CP 5/10MG WAT 100
AMLODIPINE CP 5/20MG WAT 100
AMLO BESY+BENZ 5/40MG DR/R 1C@
NIFEDIPINE CAP 10MG AVK UD50
NIFEDIPINE CAP 20MG AVK UD50
DILTIAZEM ER CP 120MG MYLN 1C@
DILTIAZEM SR CP 60MG UD UDL1C@
DILTIAZEM ER CP 90MG MYLN 100@
CARTIA XT CAP 120MG WAT 90@
GenericName
ATENOLOL
ATENOLOL/CHLORTHALIDONE
ATENOLOL/CHLORTHALIDONE
BISOPROLOL FUMARATE/HCTZ
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
LABETALOL HCL
LABETALOL HCL
LABETALOL HCL
METOPROLOL TARTRATE
METOPROLOL TARTRATE
METOPROLOL TARTRATE
NADOLOL
NADOLOL
NADOLOL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
SOTALOL HCL
SOTALOL HCL
SOTALOL HCL
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE/BENAZEPRIL
NIFEDIPINE
NIFEDIPINE
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
Generic Dose
Form
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAP SA 24H
CAP SA 24H
CAP SA 24H
CAP SA 24H
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAP ER 12H
CAP ER 12H
CAP ER 12H
CAP ER 24H
CAP ER 24H
CAP ER 24H
Dose Strength
Description
Name
50 MG
100MG-25MG
50 MG-25MG
10-6.25MG
2.5-6.25MG
5-6.25MG
12.5 MG
25 MG
3.125 MG
6.25 MG
100 MG
200 MG
300 MG
100 MG
25 MG
50 MG
20 MG
40 MG
80 MG
120 MG
160 MG
60 MG
80 MG
10 MG
20 MG
40 MG
60 MG
80 MG
120 MG
160 MG
80 MG
10 MG
2.5 MG
5 MG
10 MG-20MG
10 MG-40MG
2.5MG-10MG
5 MG-10 MG
5 MG-20 MG
5 MG-40 MG
10 MG
20 MG
120 MG
60 MG
90 MG
120 MG
180 MG
240 MG
Comments
AHFS Classification
242892 CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
243204 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
DILTIAZEM CD CAP 360MG OCEA 90
DILTIAZEM XR CP 120MG APX 100@
DILTIAZEM ER CP 180MG APX 100@
DILTIAZEM XR CP 240MG APX 100@
TAZTIA XT CAP 120MG WAT 30@
DILTIAZ HCL ER CP 420MG VAL 90
DILTIAZEM TAB 120MG TEV 100@
VERAPAM SR CAP 120MG WAT 100@
VERAPAM ER CAP 180MG MYLN 100@
VERAPAM TAB 120MG WHT WAT 100@
VERAPAMIL TAB 40MG WAT 100@
VERAPAM TAB 80MG UD UDL 100
VERAPAM ER TAB 120MG IVA 100@
VERAPAM ER TAB 180MG IVA 100@
VERAPAM ER TB 240MG UD AHP100
BENAZEP TAB 10MG UD AVK 50
BENAZEP TAB 40MG UD+ AHP 30
BENAZEP HCTZ 10/12.5MG SAN100@
BENZEP HYD TB 20/12.5MG RIS100
BENAZ HCTZ FCT 20/25MG APOT100
CAPTOPR TAB 100MG MYL 100@
CAPTOPR TAB 12.5MG MYL 100@
CAPTOPR HCTZ TAB 25/15 MYL 1C@
CAPTOPR HCTZ TAB 25/25 MYL 1C@
ENALAPR MAL TAB 10MG VAL 30
ENALAPR MAL TAB 2.5MG VAL 30
ENALAPR TAB 10MG/25MG VAL 100
ENALAPR HCTZ TB 12.5MG APX 100
FOSINOP TAB 10MG SAN 90@
FOSINOP SO/HCTZ 10/12.5 CIT 30
GenericName
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
BENAZEPRIL HCL
BENAZEPRIL HCL
BENAZEPRIL HCL
BENAZEPRIL HCL
BENAZEPRIL/HYDROCHLOROTHIAZIDE
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL/HYDROCHLOROTHIAZIDE
CAPTOPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL/HYDROCHLOROTHIAZIDE
FOSINOPRIL SODIUM
FOSINOPRIL SODIUM
FOSINOPRIL SODIUM
FOSINOPRIL/HYDROCHLOROTHIAZIDE
Generic Dose
Form
CAP ER 24H
CAP ER 24H
CAP ER DEG
CAP ER DEG
CAP ER DEG
CAPSULE ER
CAPSULE ER
CAPSULE ER
CAPSULE ER
CAPSULE ER
CAPSULE ER
TABLET
TABLET
TABLET
TABLET
CAP24H PEL
CAP24H PEL
CAP24H PEL
CAP24H PEL
TABLET
TABLET
TABLET
TABLET ER
TABLET ER
TABLET ER
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
Dose Strength
Description
Name
300 MG
360 MG
120 MG
180 MG
240 MG
120 MG
180 MG
240 MG
300 MG
360 MG
420MG
120 MG
30 MG
60 MG
90 MG
120 MG
180 MG
240 MG
360 MG
120 MG
40 MG
80 MG
120 MG
180 MG
240 MG
10 MG
20 MG
40 MG
5 MG
10-12.5MG
20-12.5 MG
20-25MG
100 MG
12.5 MG
25 MG
50 MG
25 MG-15MG
25 MG-25MG
10 MG
2.5 MG
20 MG
5 MG
10 MG-25MG
5MG-12.5MG
10 MG
20 MG
40 MG
10-12.5MG
Comments
AHFS Classification
243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS
243220 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
280804 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
LISINOPRIL TB 10MG EXEL 45
LISINOPR TAB 2.5MG UD+ AHP 30
LISINOPR+HCTZ10/12.5MGUD+AHP30
LISINOPR+HCTZ20/12.5MGUD+AHP30
LISINOPR+HCTZ 20/25MGUD+AHP30
QUINAPRIL TAB 10MG GRE 90@
QUINAPRIL TAB 40MG LUPI 90@
QUINAPR TAB 20/12.5MG APX 90
QUINAPRIL TAB 20/25MG APX 90
RAMIPRIL CAP 10MG ACC 100@
RAMIPRIL CAP 2.5MG ACCO 100@
RAMIPRIL CAP 5MG ACCO 100@
IRBESART TAB 150MG UD AHP30
IRBESARTAN TAB 300MG SOLC 30@
IRBESARTAN TAB 75MG LUP 30
IRBES/HCTZ TB150/12.5MGSOLC30@
IRBESART-HCTZ300/12.5MGSOLC30@
LOSARTAN POT TAB 100MG VIRT30@
LOSARTAN POT TB 25MG UD AVK 50
LOSARTAN POT TAB 50MG VIRT 30@
LOSARTAN HCTZ 100/12.5 AVK 30
LOSARTAN HCTZ 100/25 AVK 30
LOSARTAN HCTZ 50/12.5 AVK 30
SPIRONOL TAB 100MG CAD 100
SPIRONOL TAB 25MG AMN 100@
SPIRONOL TAB 50MG CAD 100
BUTAL+AS+CA 50/325/40 WAT 100@
VOLTAREN GEL 1%
100GM
DICLOFEN SOD 100MG ER SAN 100
DICLOFEN SOD DR 25MG PACK 100@
DICLOFEN DR TAB 50MG ACTA 60@
DICLOFEN TAB 75MG ACTA 60@
ETODOLAC CAP 200MG ANI 100@
ETODOLAC CAP 300MG ANI 100@
ETODOL ER TAB 500MG ZYD 60@
ETODOLAC TB 400MG UD AHP 30
ETODOLAC TAB 500MG SAN 100@
IBUPROFEN TAB 400MG GOLD 20
IBUPROFEN TAB 600MG AVK 90
IBUPROFEN TAB 800MG GOLD 30
INDOMETHACIN CP 25MG AVK 50
INDOMETHACIN CP 50MG AVK 50
GenericName
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL/HYDROCHLOROTHIAZIDE
QUINAPRIL HCL
QUINAPRIL HCL
QUINAPRIL HCL
QUINAPRIL HCL
QUINAPRIL/HYDROCHLOROTHIAZIDE
QUINAPRIL/HYDROCHLOROTHIAZIDE
RAMIPRIL
RAMIPRIL
RAMIPRIL
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN/HYDROCHLOROTHIAZIDE
IRBESARTAN/HYDROCHLOROTHIAZIDE
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN/HYDROCHLOROTHIAZIDE
SPIRONOLACTONE
SPIRONOLACTONE
SPIRONOLACTONE
BUTALBITAL/ASPIRIN/CAFFEINE
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
ETODOLAC
ETODOLAC
ETODOLAC
ETODOLAC
ETODOLAC
IBUPROFEN
IBUPROFEN
IBUPROFEN
INDOMETHACIN
INDOMETHACIN
Generic Dose
Form
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
GEL (GRAM)
TAB ER 24H
TABLET DR
TABLET DR
TABLET DR
CAPSULE
CAPSULE
TAB ER 24H
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
Dose Strength
Description
Name
10 MG
2.5 MG
20 MG
30 MG
40 MG
5 MG
10-12.5MG
20-12.5 MG
20-25MG
10 MG
20 MG
40 MG
5 MG
20-12.5 MG
20-25MG
10 MG
2.5 MG
5 MG
150 MG
300 MG
75 MG
150-12.5MG
300-12.5MG
100 MG
25 MG
50 MG
100-12.5MG
100MG-25MG
50-12.5 MG
100 MG
25 MG
50 MG
50-325-40
1%
100 MG
25 MG
50 MG
75 MG
200 MG
300 MG
500 MG
400 MG
500 MG
400 MG
600 MG
800 MG
25 MG
50 MG
Comments
AHFS Classification
280808 OPIATE AGONISTS
280892 ANALGESICS AND ANTIPYRETICS, MISC.
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
INDOMETHACIN CAP 75MG UD AVK50
KETOPROFEN CAP 50MG MYLN 100
KETOPROFEN CAP 75MG AVK 90
MELOXICAM TAB 15MG CIP 100
MELOXICAM TAB 7.5MG CIP 100
NABUMET TAB 500MG UD AHP 100@
NABUMET TAB 750MG AVK 100
NAPROXEN TAB 250MG UD AVK 50
NAPROXEN SOD TB 275MG UD AVK50
NAPROXEN SOD TB 550MG GLEN100@
SALSALATE TAB UD 750MG AVK 50
ACETAM+COD TB #2 AURO 100@
ACETAM+COD TB 3C/30 AURO 1000
APAP+COD TAB 60MG Q/P 100@
FIORICET+COD CAP 30MG 100
HYDROC B+AC TB 10/750 MALL100
HYDROC B+AC 10/325 UD AVK 50@
HYDROC B+AC TB10/500MG MAL100
HYDROCOD+AP TB 2.5/5C WAT 100
HYDROC B+AC 5/325 UD AVK 50@
HYDROC B+AP 7.5/325 UD AHP 80
HYDROC B+AC TB 7.5/5C MALL 1C
HYDROCOD+IBU 7.5/200 AHP UD80
HYDROMORPH TAB 2MG MALL 100@
HYDROMORPH TAB 4MG ROX 100@
HYDROMORPH TAB 8MG UD+ AHP 30
METHADONE TB 10MG UD AHP 100@
METHADONE TAB 5MG ROX 100@
MORPHI SULF ER CAP3OMG ACT60@
MORPH SULF O/S10MG/5ML ROX15ML
MORPHINE SUOS100MG/5MLPADD30ML
MORPHINE IR TAB 15MG ROX 100@
MORPHINE IR TAB 30MG ROX 100@
MORPHINE SU ER 15MG UD AHP 100
MORPHINE SU ER 30MG UD AHP 100
MORPHINE ER TB 60MG RHODE 100@
OXYCODONE HCL CP 5MG GAVI 100
OXYCOD HCL TAB 5MG RHOD 100@
ENDOCET TB 10/325MG ENDO 100@
ROXICET TAB 5/325MG ROX 100
ENDOCET TB 7.5/325MG ENDO 100@
TRAMADOL TAB 50MG SKY UD 100@
TRAMADOL + ACET 37.5/325 AVK50
BUTALB+AC+CA50/300/40MGAVK100
ESGIC CAP
100
BUTALB+AC+CA 50/325/40MG UD50@
GenericName
INDOMETHACIN
KETOPROFEN
KETOPROFEN
MELOXICAM
MELOXICAM
NABUMETONE
NABUMETONE
NAPROXEN
NAPROXEN
NAPROXEN
NAPROXEN SODIUM
NAPROXEN SODIUM
SALSALATE
ACETAMINOPHEN WITH CODEINE
BUTALBIT/ACETAMIN/CAFF/CODEINE
HYDROCODONE/ACETAMINOPHEN
HYDROCODONE/IBUPROFEN
HYDROMORPHONE HCL
HYDROMORPHONE HCL
HYDROMORPHONE HCL
METHADONE HCL
METHADONE HCL
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
OXYCODONE HCL
OXYCODONE HCL
OXYCODONE HCL/ACETAMINOPHEN
TRAMADOL HCL
TRAMADOL HCL/ACETAMINOPHEN
BUTALB/ACETAMINOPHEN/CAFFEINE
Generic Dose
Form
CAPSULE ER
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAP ER PEL
SOLUTION
SOLUTION
TABLET
TABLET
TABLET ER
TABLET ER
TABLET ER
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
Dose Strength
Description
Name
75 MG
50 MG
75 MG
15 MG
7.5 MG
500 MG
750 MG
250 MG
375 MG
500 MG
275 MG
550 MG
750 MG
300MG-15MG
300MG-30MG
300MG-60MG
50-325-30
10-750MG
10MG-325MG
10MG-500MG
2.5-500 MG
5 MG-325MG
7.5-325MG
7.5-500MG
7.5-200 MG
2 MG
4 MG
8 MG
10 MG
5 MG
30 MG
10 MG/5 ML
100 MG/5ML
15 MG
30 MG
15 MG
30 MG
60 MG
5 MG
5 MG
10MG-325MG
5 MG-325MG
7.5-325MG
50 MG
37.5-325MG
50-300-40
50-325-40
50-325-40
Comments
AHFS Classification
281000 OPIATE ANTAGONISTS
281204 BARBITURATES (ANTICONVULSANTS)
281204 BARBITURATES (ANTICONVULSANTS)
281208 BENZODIAZEPINES (ANTICONVULSANTS)
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281212 HYDANTOINS
281292 ANTICONVULSANTS, MISCELLANEOUS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
ISO+DIC+APAP65/100/325MG AVK90
NALTREXONE TAB 50MG UD P/D 30
PRIMIDONE TAB 250MG UD AVK 50@
PRIMIDONE TAB 50MG UD AVK 50@
CLONAZEP TAB 0.5MG Q/P 15@
CLONAZEP TAB 1MG Q/P 15@
CLONAZEP TAB 2MG Q/P 30@
PEGANONE TAB 250MG
100
CEREBYX 100MG/2ML PF PFIZ 25
PHENYT OS 100MG/4ML UD VIS 50
DILANTIN-125 SUSP
8OZ
DILANTIN INFATAB 50MG 100
DILANTIN CAP 100MG
100
PHENYTEK CAP 200MG
30
DILANTIN CAP 30MG
100
PHENYTEK CAP 300MG
30
CARBAMAZ ER CAP 100MG APX 120
CARBAMAZ ER CAP 200MG APX 120
CARBAMAZ CH TB 100MG TAR 100@
TEGRETOL-XR ER TB 100MG 100
CARBAMAZ ER TB 200MG UD AHP 30
CARBAMAZ ER TB 400MG UD AHP 30
EPITOL TAB 200MG TEV 100
DIVALP ER TB 250MG UD MMP8X10@
DIVALP ER TB 500MG UD MMP8X10@
DIVALP DR TAB 125MG U/S 100@
DIVALP SOD DR TB 250MG UDAHP60
DIVALP SOD DR TB500MG UDAHP20@
GABAPENT CAP 100MG UD SKY 100@
GABAPENT CAP 300MG ACTA 100@
GABAPENT CAP 400MG UD AVK 5X10
GABAPENTIN TB 600MG UD AVK5X10
GABAPENTIN TB 800MG UD AVK3X10
LEVETIRAC OS100MG/ML LUPI473ML
LEVETIRACET OS 100MG/5ML PAI40
LEVETIRAC TB 1000MG UD AHP100
LEVETIRAC TB 250MG UD MMP10X10
LEVETIRAC TB 500MG UD AHP 100
LEVETIRAC TB 750MG UD AHP 100@
OXCARBAZEP OS 300/5MLAVK 250ML
OXCARBAZ TAB 150MG CAD 100
VALPROIC ACID CP 250MG U/S 100
VALPROIC OS 250MG/5ML HI-T 40
VALPROIC OS 500MG/10ML HI-T100
VALPROIC SYRP 250MG/5ML P/D 50
ZONISAMIDE CAP 100MG UD AHP50@
GenericName
ISOMETHEPT/DICHLPHN/ACETAMINOP
NALTREXONE HCL
PRIMIDONE
PRIMIDONE
CLONAZEPAM
CLONAZEPAM
CLONAZEPAM
ETHOTOIN
FOSPHENYTOIN SODIUM
PHENYTOIN
PHENYTOIN
PHENYTOIN
PHENYTOIN SODIUM EXTENDED
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
DIVALPROEX SODIUM
DIVALPROEX SODIUM
DIVALPROEX SODIUM
DIVALPROEX SODIUM
DIVALPROEX SODIUM
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
OXCARBAZEPINE
OXCARBAZEPINE
OXCARBAZEPINE
OXCARBAZEPINE
VALPROIC ACID
VALPROIC ACID (AS SODIUM SALT)
ZONISAMIDE
Generic Dose
Form
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
VIAL
ORAL SUSP
ORAL SUSP
TAB CHEW
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CPMP 12HR
CPMP 12HR
TAB CHEW
TAB ER 12H
TAB ER 12H
TAB ER 12H
TABLET
TAB ER 24H
TAB ER 24H
TABLET DR
TABLET DR
TABLET DR
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
SOLUTION
SOLUTION
TABLET
TABLET
TABLET
TABLET
ORAL SUSP
TABLET
TABLET
TABLET
CAPSULE
SOLUTION
SOLUTION
SYRINGE
CAPSULE
Dose Strength
Description
Name
65-100-325
50 MG
250 MG
50 MG
0.5 MG
1 MG
2 MG
250 MG
100MG PE/2
100 MG/4ML
125 MG/5ML
50 MG
100 MG
200 MG
30 MG
300 MG
100 MG
200 MG
100 MG
100 MG
200 MG
400 MG
200 MG
250 MG
500 MG
125 MG
250 MG
500 MG
100 MG
300 MG
400 MG
600 MG
800 MG
100 MG/ML
500 MG/5ML
1000 MG
250 MG
500 MG
750 MG
300 MG/5ML
150 MG
300 MG
600 MG
250 MG
250 MG/5ML
500MG/10ML
250 MG/5ML
100 MG
Comments
AHFS Classification
281604 ANTIDEPRESSANTS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
ZONISAMIDE CAP 50MG GLEN 100@
AMITRIP TAB 10MG 100 NSTR@
AMITRIP HCL TAB 100MG ACC 100
AMITRIP HCL TAB 75MG ACC 100
BUPROPIO ER TAB 150MG ACTA 30@
BUPROPRI HCI ER TB300MG ZYD30@
BUPROPIO HCL TAB 1CMG MYLN100@
BUPROPIO HCL TAB 75MG MYLN100@
BUPROP HCI ER TB100MG UDAHP100
BUPROPION HCL ER TB 150MG 60
BUPROPION HCL TB 200MG 60 NSTR
CITALOPRAM TAB 10MG UD AHP100
CITALOPRAM TAB 20MG UD AHP100@
CITALOPRAM TAB 40MG DR/R 30
DOXEPIN CAP 10MG MYLN 100@
DOXEPIN CAP 150MG PAR 50@
ESCITAL OX OS 5MG TARO 5ML@
ESCITALOP TB 10MG UDMMP 10X10@
ESCITALOP TB20MG UD MMP 10X10@
ESCITALOP TAB 5MG CAMB 90
FLUOXET CAP 10MG UD AVK 5X10
FLUOXET CAP 20MG UD AVK 5X10
FLUOXET CAP 40MG UD AVK 50
FLUOXET TAB 10MG MYLN 30@
FLUOXET TAB 20MG MYLN 30@
FLUVOXAMIN TAB 100MG APX 100@
FLUVOXAMIN TAB 50MG UD+ AHP 30
IMIPRAM TAB 10MG MUT 100@
MIRTAZAP TAB 15MG AURO 30
MIRTAZAP TAB 30MG AURO 30
MIRTAZAP TAB 45MG AURO 30@
NORTRIP HYD CAP 10MG TARO500@
NORTRIPTYL HYD CP 25MG TAR 90@
NORTRIP HYD CAP 50MG TARO 500@
NORTRIPTYL HYD CP 75MG TAR 90@
PAROXETIN ER TB 12.5MG MYL 30@
PAROXETIN ER TAB 25MG MYLN 30@
PAROXETIN TB 37.5MG CR APX 30
PAROXETIN TAB 10MG AURO 30
GenericName
ZONISAMIDE
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
BUPROPION HCL
BUPROPION HCL
BUPROPION HCL
BUPROPION HCL
BUPROPION HCL
BUPROPION HCL
BUPROPION HCL
CITALOPRAM HYDROBROMIDE
DOXEPIN HCL
DOXEPIN HCL
DOXEPIN HCL
DOXEPIN HCL
DOXEPIN HCL
DOXEPIN HCL
ESCITALOPRAM OXALATE
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUVOXAMINE MALEATE
FLUVOXAMINE MALEATE
IMIPRAMINE HCL
IMIPRAMINE HCL
IMIPRAMINE HCL
MIRTAZAPINE
MIRTAZAPINE
MIRTAZAPINE
NORTRIPTYLINE HCL
NORTRIPTYLINE HCL
NORTRIPTYLINE HCL
NORTRIPTYLINE HCL
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
Generic Dose
Form
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TAB ER 24H
TAB ER 24H
TABLET
TABLET
TABLET ER
TABLET ER
TABLET ER
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
SOLUTION
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
CAPSULE
TAB ER 24H
TAB ER 24H
TAB ER 24H
TABLET
Dose Strength
Description
Name
50 MG
10 MG
100 MG
150 MG
25 MG
50 MG
75 MG
150 MG
300 MG
100 MG
75 MG
100 MG
150 MG
200 MG
10 MG
20 MG
40 MG
10 MG
100 MG
150 MG
25 MG
50 MG
75 MG
5 MG/5 ML
10 MG
20 MG
5 MG
10 MG
20 MG
40 MG
10 MG
20 MG
100 MG
50 MG
10 MG
25 MG
50 MG
15 MG
30 MG
45 MG
10 MG
25 MG
50 MG
75 MG
12.5 MG
25 MG
37.5 MG
10 MG
Comments
AHFS Classification
281608 ANTIPSYCHOTIC AGENTS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
SERTRALIN TAB 100MG CAMB 30@
SERTRALIN TAB 100MG GRE 5000@=
SERTRALIN TAB 25MG UD UDL 100@
SERTRALIN TAB 50MG UD UDL100@
SERTRALIN TAB 50MG GRE 5000@
TRAZOD TAB 100MG UD AHP 100
TRAZOD TAB 150MG AVK 500
TRAZOD TAB 300MG AVK 100
TRAZOD TAB 50MG UD AHP 100
VENLAF ER CAP 150MG UD SKY100@
VENLAF ER CP 37.5MG UD AHP100@
VENLAF ER CP UD 75MG MMP10X10
VENLAF ER TAB 150MG CARA 30
VENLAF ER TAB 225MG UPS 90@
VENLAF ER TAB 37.5MG CARA 30
VENLAF ER TAB 75MG CARA 30
VENLAFAXINE HCL TB100MG HERI90
VENLAFAXINE HCL TB 25MG HERI90
VENLAFAX HCL TB 37.5MG HERI90
CHLORPROM TAB 10MG SAN 100
CHLORPROM TAB 100MG SAN 100
CHLORPROM TAB 200MG SAN 100@
CHLORPROM TAB 25MG U/S 100@
CHLORPROM TAB 50MG U/S 100@
FLUPHENAZ TB 1MG LANN 100@
FLUPHENAZ TB 10MG LANN 100@
FLUPHENAZ TB 2.5MG LANN 100@
FLUPHENAZ TB 5MG UD+ AHP 30
HALOP TAB 0.5MG SAN 100@
HALOP TAB 1MG
SAN 100@
HALOP TAB 10MG UD MMP 100@
HALOPERIDOL TAB 2MG SAN 100@
HALOP TAB 20MG UD AHP 30
HALOPERIDOL TAB 5MG ZYD 100
LOXAPINE CAP 10MG MARL 100
LOXAPINE CAP 25MG UD AHP 30@
LOXAPINE CAP 50MG UD AHP 30@
PERPHEN TAB 16MG UD+ AHP 30
PERPHEN TAB 2MG UD AHP 30
PERPHEN TAB 4MG Q/P 100@
PERPHEN TAB 8MG Q/P 100@
QUETIAPIN FUM TB 200MG AVK 90
QUETIAPIN FUM TB 25MG TEV 100@
GenericName
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
TRAZODONE HCL
TRAZODONE HCL
TRAZODONE HCL
TRAZODONE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
VENLAFAXINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
FLUPHENAZINE HCL
FLUPHENAZINE HCL
FLUPHENAZINE HCL
FLUPHENAZINE HCL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
LOXAPINE SUCCINATE
LOXAPINE SUCCINATE
LOXAPINE SUCCINATE
PERPHENAZINE
PERPHENAZINE
PERPHENAZINE
PERPHENAZINE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
Generic Dose
Form
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAP ER 24H
CAP ER 24H
CAP ER 24H
TAB ER 24
TAB ER 24
TAB ER 24
TAB ER 24
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
Dose Strength
Description
Name
20 MG
30 MG
40 MG
100 MG
100MG
25 MG
50 MG
50MG
100 MG
150 MG
300 MG
50 MG
150 MG
37.5 MG
75 MG
150 MG
225 MG
37.5 MG
75 MG
100 MG
25 MG
37.5 MG
50 MG
75 MG
10 MG
100 MG
200 MG
25 MG
50 MG
1 MG
10 MG
2.5 MG
5 MG
0.5 MG
1 MG
10 MG
2 MG
20 MG
5 MG
10 MG
25 MG
50 MG
16 MG
2 MG
4 MG
8 MG
200 MG
25 MG
Comments
1
0
AHFS Classification
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282004 AMPHETAMINES
282032 RESPIRATORY AND CNS STIMULANTS
282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
QUETIAPINE TAB 300MG AVK 60
RISPERID OS 1MG/ML BRECK 1OZ@
RISPERIDONE TB .25MG AJAN 60@
RISPERID TAB 0.5MG UD AVK 50
RISPERID TAB 1MG UD AVK 50
THIOTHIX CAP 10MG MYL 100@
DEXTROAMPH SUL TB 5MGAURO 100@
AMPHET SLT ER CP 10MG UDAHP30
MIX AMPHET SLT ERCP15MGTEV1C@
MIX AMPHET SLT ERCP25MGTEV100@
MIX AMPHET SLT ERCP5MGTEV 100@
AMPHETA SALT TB 10MG CARA 100@
AMPHET SALTS TB12.5MG CORE100@
AMPHETAM SALT TB 15MG MAL 100@
AMPHETAM SALT TB 5MG AURO 100@
AMPHETAM SALTS TB7.5MGCORE100@
METHYLPH CD ER CP 10MG TEV100@
METADATE CD CAP 30MG
100
METADATE CD CAP 50MG
100
METHYLPHEN ER CP 20MG ACTA100@
METHYLPHEN TAB 10MG UD+ AHP30
METHYLPHEN TAB 20MG UD+ AHP 30
METHYLPHEN TB 5MG UD+AHP30
METHYLPHEN HCI TAB 10MG KVK60
METHYLPHEN HCI TAB 20MG KVK60
PHENOB 20MG/5ML SOL PACK473ML@
PHENOB TAB 100MG WEST 500@
PHENOB TAB 32.4MG UD+ AHP 30
PHENOB TAB 1GR
Q/P 100@
ALPRAZO TAB 0.25MG UD SKY 100@
ALPRAZO TAB 0.5MG UD SKY 100@
GenericName
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
THIOTHIXENE
THIOTHIXENE
THIOTHIXENE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE/AMPHETAMINE
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
ALPRAZOLAM
ALPRAZOLAM
Generic Dose
Form
TABLET
TABLET
TABLET
SOLUTION
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
CAP ER 24H
CAP ER 24H
CAP ER 24H
CAP ER 24H
CAP ER 24H
CAP ER 24H
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CPBP 30-70
CPBP 30-70
CPBP 30-70
CPBP 30-70
CPBP 30-70
CPBP 30-70
CPBP 50-50
TABLET
TABLET
TABLET
TABLET ER
TABLET ER
ELIXIR
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
Dose Strength
Description
Name
300 MG
400 MG
50 MG
1 MG/ML
0.25 MG
0.5 MG
1 MG
2 MG
3 MG
4 MG
10 MG
2 MG
5 MG
5 MG
10 MG
15 MG
20 MG
25 MG
30 MG
5 MG
10 MG
12.5 MG
15 MG
20 MG
30 MG
5 MG
7.5 MG
10 MG
20 MG
30 MG
40 MG
50 MG
60 MG
20 MG
10 MG
20 MG
5 MG
10 MG
20 MG
20 MG/5 ML
100 MG
15 MG
30 MG
32.4 MG
60 MG
64.8 MG
0.25 MG
0.5 MG
Comments
Limit 2 capsule per day
AHFS Classification
282492 ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.
282800 ANTIMANIC AGENTS
283228 SELECTIVE SEROTONIN AGONISTS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
ALPRAZOL TAB 1MG UD SKY 100@
ALPRAZOL TAB 2MG MYL 100@
CHLORDIAZ CAP 10MG BARR 100@
CHLORDIAZ CAP 25MG BARR 100@
CLORAZEP TAB 15MG TAR 100@
CLORAZEP DIP TB 3.75MGUD+AHP30
CLORAZEP TAB 7.5MG TAR 100@
DIAZEPAM TAB 10MG Q/P 30@
DIAZEPAM TAB 2MG Q/P 30@
DIAZEPAM TAB 5MG Q/P 30
FLURAZEP CP 15MG MYL 100@
FLURAZEP CP 30MG MYLN 100@
LORAZEP TAB 0.5MG Q/P 100@
LORAZEP TAB 1MG Q/P 100@
LORAZEP TAB 2MG Q/P 100@
OXAZEPAM CAP 10MG SAN 100@
TEMAZEPAM CAP 15MG Q/P 100
TEMAZEPAM CAP 30MG Q/P 100
TEMAZEP CP 7.5MG UD MMP 3X10@
BUSPIR HCL TAB 10MG ZYD 500@
BUSPIR HCL TB 30MG AVK 500
BUSPIR HCL TB 7.5MG AVK 90
HYDROXY HYD SYRP SILA 16OZ@
HYDROXYZ TAB 10MG GLEN 100@
HYDROXYZ PAM CP 100MG BARR100@
HYDROXYZ PAM CAP25MG UDAHP100@
HYDROXYZ PAM CAP 50MG RIS 500
ZOLPIDEM TAB 10MG UD ROX 100
ZOLPIDEM TART TAB 5MG AHP 100
LITHIUM CARB CP 150MG GLEN100@
LITHIUM CARB CP 300MG CAMB 100
LITHIUM CAR TAB 300MG CARA100@
LITHIUM CARB ER TB300MG UD100@
LITHIUM TAB 450MG UD AHP 100@
SUMATRIP NASAL 20MG UD SAN 6@
SUMATRIP NASAL 5MG UD SAN 6@
SUMATRIP INJ REFIL 6MG SAN 2@
SUMATRIP PFS 6MG/0.5ML DR/R 2@
SUMATRIPTAN TB100MGUD9NSTAR@
SUMATRIP TAB 25MG UD 9 NSTAR@
SUMATRIP TAB 50MG BP 9 NSTAR@
SUMATRIP INJ 6MG/0.5ML WEST 5@
GenericName
ALPRAZOLAM
ALPRAZOLAM
CHLORDIAZEPOXIDE HCL
CHLORDIAZEPOXIDE HCL
CLORAZEPATE DIPOTASSIUM
DIAZEPAM
DIAZEPAM
DIAZEPAM
FLURAZEPAM HCL
FLURAZEPAM HCL
LORAZEPAM
LORAZEPAM
LORAZEPAM
OXAZEPAM
OXAZEPAM
OXAZEPAM
TEMAZEPAM
TEMAZEPAM
TEMAZEPAM
BUSPIRONE HCL
BUSPIRONE HCL
BUSPIRONE HCL
BUSPIRONE HCL
BUSPIRONE HCL
HYDROXYZINE HCL
HYDROXYZINE HCL
HYDROXYZINE HCL
HYDROXYZINE HCL
HYDROXYZINE PAMOATE
HYDROXYZINE PAMOATE
HYDROXYZINE PAMOATE
ZOLPIDEM TARTRATE
ZOLPIDEM TARTRATE
LITHIUM CARBONATE
LITHIUM CARBONATE
LITHIUM CARBONATE
LITHIUM CARBONATE
LITHIUM CARBONATE
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN SUCCINATE
Generic Dose
Form
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
SOLUTION
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
TABLET ER
TABLET ER
SPRAY
SPRAY
CARTRIDGE
PEN INJCTR
TABLET
TABLET
TABLET
VIAL
Dose Strength
Description
Comments
Name
1 MG
2 MG
10 MG
25 MG
15 MG
3.75 MG
7.5 MG
10 MG
2 MG
5 MG
15 MG
30 MG
0.5 MG
1 MG
2 MG
10 MG
15 MG
30 MG
15 MG
30 MG
7.5 MG
10 MG
15 MG
30 MG
5 MG
7.5 MG
10 MG/5 ML
10 MG
25 MG
50 MG
100 MG
25 MG
50 MG
10 MG
5 MG
150 MG
300 MG
300 MG
300 MG
450 MG
20 MG
5 MG
6 MG/0.5ML
6 MG/0.5ML
100 MG
Limit 9 tablets/month
25 MG
50 MG
6 MG/0.5ML
AHFS Classification
283604 ADAMANTANES (CNS)
283604 ADAMANTANES (CNS)
283608 ANTICHOLINERGIC AGENTS (CNS)
283612 CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
283616 DOPAMINE PRECURSORS
283620 DOPAMINE RECEPTOR AGONISTS
362600 DIABETES MELLITUS
368812 KETONES
400800 ALKALINIZING AGENTS
401000 AMMONIA DETOXICANTS
401000 AMMONIA DETOXICANTS
401200 REPLACEMENT PREPARATIONS
401818 POTASSIUM-REMOVING AGENTS
401818 POTASSIUM-REMOVING AGENTS
401819 PHOSPHATE-REMOVING AGENTS
402808 LOOP DIURETICS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
AMANTAD CAP 100MG UD AVK 50
AMANTAD TAB 100MG U/S 100@
BENZTROP MES TB 0.5MG AVK UD50
BENZTROP MES TB 1MG AVK UD 50
BENZTROP MES TB 2MG AVK UD 50
TRIHEXPH TAB 2MG WAT 100@
TRIHEXYPH TAB 5MG UD AHP 30@
ENTCAPONE TB 200MG UD MYLN 30@
CARBID+LEV ODT 10/100 CARA100
CARBID+LEV ODT 25/100 CARA100@
CARBID+LEV OTD 25/250 MYL 100@
CARBID+LEV TB 10/100 ACTA 100@
CARB/LEVO TB 25/100MG GOLD 100
CARBID+LEV TB 25/250 ACTA 100@
CARBID+LEV CR 25/1C UD MMP100
CARBID+LEV ER 50/200 MYLN 1C@
BROMOCRIP TAB 2.5MG MYLN 30
CABERGOLIN TAB 0.5MG TEV 8@
PRAMIP DIHYD TB .125MGUD+AHP30
PRAMIPEXOLE .25MG TAB VEN90@
PRAMIPEXOLE .5MG TAB VEN90@
PRAMIPEXOLE 1MG TAB VEN90@
PRAMIPEXOLE 1.5MG TAB VEN90@
ROPINIROL TB 0.25MG UD AHP100@
ROPINIROL TB 0.5MG UD AHP 30@
ROPINIROL TB 1MG UD AHP 100@
ROPINIROLE TB 2MG UD AHP 30@
ROPINIROLE TB 3MG HERI 100@
ROPINIROLE TB 4MG HERI 100@
SM TRUETEST STRIP E3054-25 25
KETOCARE TEST STRIPS
50
POTASS CIT ER TB10MEQ UD+AHP20
CONSTULOSE SOL10G/15MLACTA8OZ@
LACTULOSE OS 20GM/30MLUDVIS50@
POT CHL ER CAP 10MEQ AMN100@
KLOR-CON PWD PKT 20MEQ UD 30
KLOR-CON E/R TAB M10
90
KLOR-CON E/R TAB M20
90
KLOR-CON E/R TAB 10MEQ 100
POT CHLRO TAB 20EMEQ ZYD500@
SOD CHL SOL 3% SUV 4ML 60
SOD CHL SOL 7% SUV 4ML 60
SPS SUS 30GM 120ML+EZ-EM+TBKIT
SOD POLY SULF 15G/60ML ROX500
CALCIUM ACET CP 667MG EXEL 200
RENVELA TAB 800MG
270
RENAGEL TAB 800MG
180
FUROSEM TAB 20MG MMP 100
GenericName
AMANTADINE HCL
AMANTADINE HCL
BENZTROPINE MESYLATE
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HCL
ENTACAPONE
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
CARBIDOPA/LEVODOPA
BROMOCRIPTINE MESYLATE
CABERGOLINE
PRAMIPEXOLE DI-HCL
PRAMIPEXOLE DI-HCL
PRAMIPEXOLE DI-HCL
PRAMIPEXOLE DI-HCL
PRAMIPEXOLE DI-HCL
ROPINIROLE HCL
ROPINIROLE HCL
ROPINIROLE HCL
ROPINIROLE HCL
ROPINIROLE HCL
ROPINIROLE HCL
BLOOD SUGAR DIAGNOSTIC
URINE ACETONE TEST STRIPS
POTASSIUM CITRATE
LACTULOSE
LACTULOSE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
SODIUM CHLORIDE FOR INHALATION
SODIUM CHLORIDE FOR INHALATION
SODIUM POLYSTYRENE SULFONATE
SODIUM POLYSTYRENE SULFONATE
CALCIUM ACETATE
SEVELAMER CARBONATE
SEVELAMER HCL
FUROSEMIDE
Generic Dose
Form
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TAB RAPDIS
TAB RAPDIS
TAB RAPDIS
TABLET
TABLET
TABLET
TABLET ER
TABLET ER
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
STRIP
STRIP
TABLET ER
SOLUTION
SOLUTION
CAPSULE ER
PACKET
TAB ER PRT
TAB ER PRT
TABLET ER
TABLET ER
VIAL-NEB
VIAL-NEB
ENEMA
ORAL SUSP
CAPSULE
TABLET
TABLET
TABLET
Dose Strength
Description
Name
100 MG
100 MG
0.5 MG
1 MG
2 MG
2 MG
5 MG
200 MG
10MG-100MG
25MG-100MG
25MG-250MG
10MG-100MG
25MG-100MG
25MG-250MG
25MG-100MG
50MG-200MG
2.5 MG
0.5 MG
0.125 MG
0.25 MG
0.5 MG
1 MG
1.5 MG
0.25 MG
0.5 MG
1 MG
2 MG
3 MG
4 MG
10 MEQ
10 G/15 ML
20 G/30 ML
10 MEQ
20 MEQ
10 MEQ
20 MEQ
10 MEQ
20 MEQ
3%
7%
30G/120ML
15 G/60 ML
667 MG
800 MG
800 MG
20 MG
Comments
AHFS Classification
402816 POTASSIUM-SPARING DIURETICS
402820 THIAZIDE DIURETICS
402824 THIAZIDE-LIKE DIURETICS
404000 URICOSURIC AGENTS
40412 PHENOTHIAZINE DERIVATIVES
40420 PROPYLAMINE DERIVATIVES
40492 FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
40492 FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
40800 SECOND GENERATION ANTIHISTAMINES
40800 SECOND GENERATION ANTIHISTAMINES
480800 ANTITUSSIVES
480800 ANTITUSSIVES
480800 ANTITUSSIVES
480800 ANTITUSSIVES
480800 ANTITUSSIVES
480800 ANTITUSSIVES
480800 ANTITUSSIVES
481008 CORTICOSTEROIDS (RESPIRATORY TRACT)
481008 CORTICOSTEROIDS (RESPIRATORY TRACT)
481024 LEUKOTRIENE MODIFIERS
481032 MAST-CELL STABLILIZERS
520200 ANTIALLERGIC AGENTS
520404 ANTIBACTERIALS (EENT)
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
FUROSEM TAB 40MG Q/P 100@
FUROSEM TAB 80MG Q/P 90@
AMILOR+HCTZ TB 5/50 BARR 100@
HYDROCHLOROTH TB 25MG MARL 100
TRIAM+HCTZ CP 50/25 RD SAN100@
TRIAMTER+HCTZ 37.5/25 UD+AHP30
TRIAM+HCTZ TB 75/50 WAT 100@
HYDROCHLOROTH CP 12.5MG CIT500
HYDROCHL TAB 12.5MG ACTA 100@
HYDROCHL TAB 25MG HERI 1000@
HYDROCHL TAB 50MG IVA 100@
CHLORTH TAB 25MG MYL 100@
CHLORTH TAB 50MG MYL 100@
INDAPAM TAB 1.25MG MYLN 100@
METOLAZON TAB 10MG UPS 100@
METOLAZON TAB 2.5MG UPS 100@
METOLAZON TAB 5MG MYLN 100@
PROBEN TAB 500MG MARL 100
PROMETH+PHENYL6.25/5MG AKOR16Z
PROMETH HCI SUPP12.5MG REN12@
PROMETH HCI SUPP 25MG REN12@
PROMETH HCI SUPP 50MG REN12@
PROMETH SYRP6.25/5MLCARA120ML@
PROMETH HCL TAB 12.5MG KVK100@
PROMETH TAB 25MG UD MMP 10X10
PROMETH TAB 50MG ZYD 100
SUDOGEST TAB CLD&ALLER MMP 24@
CYPROHEPT SYRP 2MG ACTA 16OZ@
CYPROHEPT HCI TAB 4MG CORE100
LEVOCET DIH OS 2.5/5 TARO 4OZ@
LEVOCET DIHYD TAB 5MG UD+AHP30
BENZONATATE SG CP 100MG LIB100
BENZONATATE SG CP 200MG LIB100
BROMFED DM COUGH SYRP 118ML
GUAIFEN+COD SYRP AF/SFP/A 4OZ@
HYDROMET SYRP ACTA 16OZ@
GUAIFEN DAC O/S PACK 16OZ@
PROMETH DM SYRP Q/P 4OZ@
QVAR MDI W/CNTR 40MCG 120-DOSE
QVAR MDI W/CNTR 80MCG 120-DOSE
MONTELUK CHWTB 4MG AURO 30@
MONTELUK SOD TB5MG CHW WEST30
MONTELUKAST 10MG TAB CAM 30
CROMOL SOD OPH 4% VAL 10ML
PATANOL OPTH SOL 0.1% 5ML
BACITRACIN OPT/OINT PERR 3/1GM
CIPROFLOX O/S 0.3% FAL 2.5ML@
CILOXAN OPTH OINT 0.3% 3.5GM
GenericName
FUROSEMIDE
FUROSEMIDE
AMILORIDE/HYDROCHLOROTHIAZIDE
TRIAMTERENE/HYDROCHLOROTHIAZID
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
CHLORTHALIDONE
CHLORTHALIDONE
INDAPAMIDE
METOLAZONE
METOLAZONE
METOLAZONE
PROBENECID
PHENYLEPHRINE HCL/PROMETH HCL
PROMETHAZINE HCL
PROMETHAZINE HCL
PROMETHAZINE HCL
PROMETHAZINE HCL
PROMETHAZINE HCL
PROMETHAZINE HCL
PROMETHAZINE HCL
PSEUDOEPHED/CHLORPHENIRAMINE
CYPROHEPTADINE HCL
CYPROHEPTADINE HCL
LEVOCETIRIZINE DIHYDROCHLORIDE
LEVOCETIRIZINE DIHYDROCHLORIDE
BENZONATATE
BENZONATATE
D-METHORPHAN HB/P-EPD HCL/BPM
GUAIFENESIN/CODEINE PHOSPHATE
HYDROCODONE BIT/HOMATROP ME-BR
P-EPHED HCL/CODEINE/GUAIFEN
PROMETHAZINE/DEXTROMETHORPHAN
BECLOMETHASONE DIPROPIONATE
BECLOMETHASONE DIPROPIONATE
MONTELUKAST SODIUM
MONTELUKAST SODIUM
MONTELUKAST SODIUM
CROMOLYN SODIUM
OLOPATADINE HCL
BACITRACIN
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
Generic Dose
Form
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
TABLET
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
SYRUP
SUPP.RECT
SUPP.RECT
SUPP.RECT
SYRUP
TABLET
TABLET
TABLET
TABLET
SYRUP
TABLET
SOLUTION
TABLET
CAPSULE
CAPSULE
SYRUP
LIQUID
SYRUP
SYRUP
SYRUP
AER W/ADAP
AER W/ADAP
TAB CHEW
TAB CHEW
TABLET
DROPS
DROPS
OINT. (G)
DROPS
OINT. (G)
Dose Strength
Description
Name
40 MG
80 MG
5 MG-50 MG
37.5-25 MG
50 MG-25MG
37.5-25 MG
75 MG-50MG
12.5 MG
12.5 MG
25 MG
50 MG
25 MG
50 MG
1.25 MG
10 MG
2.5 MG
5 MG
500 MG
5-6.25MG/5
12.5 MG
25 MG
50 MG
6.25MG/5ML
12.5 MG
25 MG
50 MG
60 MG-4 MG
2 MG/5 ML
4 MG
2.5 MG/5ML
5 MG
100 MG
200 MG
10-30-2/5
100-10MG/5
5-1.5 MG/5
30-10-100
6.25-15/5
40 MCG
80 MCG
4 MG
5 MG
10 MG
4%
0.10%
500 UNIT/G
0.30%
0.30%
Comments
AHFS Classification
520492 EENT ANTI-INFECTIVES, MISCELLANEOUS
520492 EENT ANTI-INFECTIVES, MISCELLANEOUS
520808 CORTICOSTEROIDS (EENT)
520820 EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
521600 LOCAL ANESTHETICS (EENT)
521600 LOCAL ANESTHETICS (EENT)
522400 MYDRIATICS
522400 MYDRIATICS
524004 ALPHA-ADRENERGIC AGONISTS (EENT)
524004 ALPHA-ADRENERGIC AGONISTS (EENT)
524008 BETA-ADRENERGIC BLOCKING AGENTS (EENT)
524012 CARBONIC ANHYDRASE INHIBITORS (EENT)
524020 MIOTICS
524020 MIOTICS
524028 PROSTAGLANDIN ANALOGS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
CIPRODEX OTIC SUSP
7.5ML
CIPRO HC OTIC SUSP
10ML
DOXYCYC HYC TAB 20MG
60
ILOTYCIN OPT/OINT
1GM
GENTAMI SUL OPH SOL .3%PERR5ML
GARAMYCIN OPT/OINT PF 3.5GM
VIGAMOX OPTH SOL
3ML
NEOMY+POL B/DX O/SUS B&L 5ML@
NEOMY+POL B SUL OPH PERR 3.5GM
NEO-POLY OINT
FERA 3.5GM
NEOMY+POLY B+HYD O/S FAL 10ML@
NEOMY+POL B+HYD O/S FAL 7.5ML@
NEOMY+POL+HY OTI SOL FAL 10ML@
NEOMY+POL B SUL OPH B&L 10ML@
OFLOXACIN OPH 0.3% B&L 5ML@
BLEPH-10 OPHTH SOL 10% 5ML
TOBRAMY O/S 0.3% FAL 5ML@
TOBRAMYC+DEXAM OS FAL 2.5ML@
ACETIC ACID OTIC SOL MOR 15ML@
HYDROCORT 1% AC+OS 2% TAR10ML@
FLUNISOLI NSL SOL.025%RISI25ML
FLUTICAS NAS SP 50MCG APX16GM@
LOTEMAX OPH SUSP 0.5% B&L 5ML
PREDNISOL AC OPH 1% FAL 15ML@
PREDNISOL SOD OP/SOL1%B&L10ML@
TRIAM ACE NAS SPR WINT 16.5G
DICLOFEN SOD OPH 0.1%FAL2.5ML@
FLURBIPR SOD OS.03% B&L 2.5ML@
KETOR O/S 0.4% APX 5ML
KETOR O/S 0.5% APX 5ML
PHARMAPURE OT/CRE SOL PUR 14ML
ANTIPYR BENZ OS 5.5/1.4% VIRT
CYCLOGYL 1% DT
2ML
CYCLOGYL 2% DT
2ML
BRIMONID OPH SOL 0.15%FAL 5ML@
BRIMONID OPH SOL 0.2% B&L10ML@
LEVOBUN HCL OPH 0.5% ACTA 5ML
TIMOLOL MAL OPH .25% RIS 5ML
TIMOLOL MAL OPH .50% RIS 5ML
TIMOLOL OPH GL/F 0.5% FAL 5ML@
ACETAZOL ER CP UD 500MG AHP30@
ACETAZOL TAB 250MG TAR 100@
AZOPT
10ML
DORZOLAMIDE 2% O/S ACTA 10ML
DORZOL/TIMOL 2/.5% O/S ACT10ML
PILOCAR OPHT SOL 1% FAL 15ML@
PILOCAR OPHT SOL 2% FAL 15ML@
LUMIGAN OPH SOL 0.01% 2.5ML
GenericName
CIPROFLOXACIN HCL/DEXAMETH
CIPROFLOXACIN/HYDROCORTISONE
DOXYCYCLINE HYCLATE
ERYTHROMYCIN BASE
GENTAMICIN SULFATE
GENTAMICIN SULFATE
MOXIFLOXACIN HCL
NEO/POLYMYX B SULF/DEXAMETH
NEO/POLYMYX B SULF/DEXAMETH
NEOMYCIN SU/BACITRA/POLYMYXIN
NEOMYCIN/POLYMYXIN B SULF/HC
NEOMYCIN/POLYMYXN B/GRAMICIDIN
OFLOXACIN
SULFACETAMIDE SODIUM
TOBRAMYCIN
TOBRAMYCIN/DEXAMETHASONE
ACETIC ACID
ACETIC ACID/HYDROCORTISONE
FLUNISOLIDE
FLUTICASONE PROPIONATE
LOTEPREDNOL ETABONATE
PREDNISOLONE ACETATE
PREDNISOLONE SOD PHOSPHATE
TRIAMCINOLONE ACETONIDE
DICLOFENAC SODIUM
FLURBIPROFEN SODIUM
KETOROLAC TROMETHAMINE
KETOROLAC TROMETHAMINE
ANTIPYRINE/BENZOCAINE
ANTIPYRINE/BENZOCAINE
CYCLOPENTOLATE HCL
CYCLOPENTOLATE HCL
BRIMONIDINE TARTRATE
BRIMONIDINE TARTRATE
LEVOBUNOLOL HCL
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
ACETAZOLAMIDE
ACETAZOLAMIDE
BRINZOLAMIDE
DORZOLAMIDE HCL
DORZOLAMIDE HCL/TIMOLOL MALEAT
PILOCARPINE HCL
PILOCARPINE HCL
BIMATOPROST
Generic Dose
Form
DROPS SUSP
DROPS SUSP
TABLET
OINT. (G)
DROPS
OINT. (G)
DROPS
DROPS SUSP
OINT. (G)
OINT. (G)
DROPS SUSP
DROPS SUSP
SOLUTION
DROPS
DROPS
DROPS
DROPS
DROPS SUSP
SOLUTION
DROPS
SPRAY
SPRAY SUSP
DROPS SUSP
DROPS SUSP
DROPS
SPRAY
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
DROPS
SOL-GEL
CAPSULE ER
TABLET
DROPS SUSP
DROPS
DROPS
DROPS
DROPS
DROPS
Dose Strength
Description
Name
0.3 %-0.1%
0.2 %-1 %
20 MG
5 MG/G
0.30%
0.30%
0.50%
0.10%
3.5-10K-.1
3.5MG-400
3.5-10K-1
3.5-10K-10
3.5-10K-1
1.75MG-10K
0.30%
10%
0.30%
0.3 %-0.1%
2%
2 %-1 %
25 MCG
50 MCG
0.50%
1%
1%
55 MCG
0.10%
0.03%
0.40%
0.50%
5.4 %-1.4%
5.5 %-1.4%
1%
2%
0.15%
0.20%
0.50%
0.25%
0.50%
0.50%
500 MG
250 MG
1%
2%
22.3-6.8/1
1%
2%
0.01%
Comments
AHFS Classification
560800 ANTIDIARRHEA AGENTS
560800 ANTIDIARRHEA AGENTS
561200 CATHARTICS AND LAXATIVES
561400 CHOLELITHOLYTIC AGENTS
561600 DIGESTANTS
561600 DIGESTANTS
561600 DIGESTANTS
561600 DIGESTANTS
561600 DIGESTANTS
561600 DIGESTANTS
561600 DIGESTANTS
561600 DIGESTANTS
562208 ANTIHISTAMINES (GI DRUGS)
562208 ANTIHISTAMINES (GI DRUGS)
562220 5-HT3 RECEPTOR ANTAGONISTS
562812 HISTAMINE H2-ANTAGONISTS
562828 PROSTAGLANDINS
562828 PROSTAGLANDINS
562832 PROTECTANTS
562832 PROTECTANTS
562836 PROTON-PUMP INHIBITORS
562836 PROTON-PUMP INHIBITORS
563200 PROKINETIC AGENTS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
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FORMULARY
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FORMULARY
Brand Name
LATANOP OS 0.005% A/R 2.5ML
TRAVOPROST SOL .004% PAR2.5ML@
DIPHENOX+ATR SOL 2MG ROX 60ML@
DIPHENOX+ATR TB 2.5MG GRE 100@
GOLYTELY SOL PINEAPLE 4000ML
PEG-3350+ELECT O/S KREM 4LT@
TRILYTE O/S W/FLV PK WALL 4L@
URSODIOL CAP 300MG MMP 100
URSODIOL TAB 250MG GPC 100
URSODIOL TAB 500MG PRAS 100
PANCREAZE CAP 10500U 100
CREON 12000 CAP
100
PANCREAZE CAP 16800U 100
CREON 24000 CAP
100
CREON 36000 CAP
100
CREON 3000 CAP
70
PANCREAZE CAP 4200U
100
CREON 6000 CAP
100
PROCHLORP TAB 10MG UD+ AHP 30
PROCHLORP TAB 5MG MYLN 100@
ONDANS OD TAB 4MG MYLN 30@
ONDANS OD TAB 8MG MYLN 10@
ONDANS TAB 4MG UD SAN 3@
ONDANSET TAB 8MG UD SAN 3
FAMOTID O/S 40MG/5ML PAD 50ML
HEARTBURN RELF TAB MAX MMP 50
FAMOTID TAB 40MG UD AVK 5X10
RANITID CAP 150MG DR/R 60@
RANITID CAP 300MG SAN 30@
RANITID O/S 15MG/ML CARA 16OZ
RANITID TAB 150MG MMP 24
RANITIDINE TAB 300MG AVK UD50
MISOPROST TAB 100MCG IVA 60
MISOPROSTOL TAB 200MCG TEV 60
CARAFATE SUSP 1GM
14OZ
SUCRALFATE TAB 1GM UD UDL 100
PANTOPRAZ TAB 20MG PRA 90@
PANTOPRA SOD DR 40MG UDAHP 80@
METOCLOPR SYRP UD 10ML P/A100
METOCLOPR OS 5/5ML AF ANI16OZ@
METOCLOPR TAB 10MG AVK 90
METOCLOPR TAB 5MG AVK 90
DEXAMETH O/S 1MG ROX 30ML@
DEXAMETH TAB 0.5MG PAR 100@
DEXAMETH TAB 0.75MG ROX 100@
DEXAMETH TAB 1MG ROX 100@
GenericName
LATANOPROST
TRAVOPROST (BENZALKONIUM)
DIPHENOXYLATE HCL/ATROPINE
DIPHENOXYLATE HCL/ATROPINE
PEG 3350/NA SULF BICARB CL/KCL
PEG 3350/NA SULF BICARB CL/KCL
SODIUM CHLORIDE/NAHCO3/KCL/PEG
URSODIOL
URSODIOL
URSODIOL
LIPASE/PROTEASE/AMYLASE
PROCHLORPERAZINE MALEATE
PROCHLORPERAZINE MALEATE
ONDANSETRON
ONDANSETRON
ONDANSETRON HCL
ONDANSETRON HCL
FAMOTIDINE
FAMOTIDINE
FAMOTIDINE
RANITIDINE HCL
RANITIDINE HCL
RANITIDINE HCL
RANITIDINE HCL
RANITIDINE HCL
MISOPROSTOL
MISOPROSTOL
SUCRALFATE
SUCRALFATE
PANTOPRAZOLE SODIUM
PANTOPRAZOLE SODIUM
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
Generic Dose
Form
DROPS
DROPS
LIQUID
TABLET
SOLN RECON
SOLN RECON
SOLN RECON
CAPSULE
TABLET
TABLET
CAPSULE DR
CAPSULE DR
CAPSULE DR
CAPSULE DR
CAPSULE DR
CAPSULE DR
CAPSULE DR
CAPSULE DR
TABLET
TABLET
TAB RAPDIS
TAB RAPDIS
TABLET
TABLET
ORAL SUSP
TABLET
TABLET
CAPSULE
CAPSULE
SYRUP
TABLET
TABLET
TABLET
TABLET
ORAL SUSP
TABLET
TABLET DR
TABLET DR
SOLUTION
SOLUTION
TABLET
TABLET
DROPS
TABLET
TABLET
TABLET
TABLET
TABLET
Dose Strength
Description
Name
0.01%
0.00%
2.5-.025/5
2.5-.025MG
236-22.74G
240-22.72G
420G
300 MG
250 MG
500 MG
10.5K-25K
12K-38K-60
16.8-40-70
24-76-120K
36-114-180
3-9.5-15K
4.2K-10K
6K-19K-30K
10 MG
5 MG
4 MG
8 MG
4 MG
8 MG
40MG/5ML
20 MG
40 MG
150 MG
300 MG
15 MG/ML
150 MG
300 MG
100 MCG
200 MCG
1 G/10 ML
1G
20 MG
40 MG
10 MG/10ML
5 MG/5 ML
10 MG
5 MG
1 MG/ML
0.5 MG
0.75 MG
1 MG
2 MG
4 MG
Comments
AHFS Classification
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680400 ADRENALS
680800 ANDROGENS
680800 ANDROGENS
681200 CONTRACEPTIVES
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681604 ESTROGENS
681612 ESTROGEN AGONIST-ANTAGONISTS
682004 BIGUANIDES
682004 BIGUANIDES
Formulary?
FORMULARY
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FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
FLUDROC TAB 0.1MG UD AVK 50@
HYDROCORT TAB 10MG Q/P 100@
HYDROCORT TAB 20MG Q/P 100@
HYDROCORT TAB 5MG UD+ AHP 30
METHYLPRED TAB 4MG BRECK 21@
METHYLPRED TB 4MG UD AHP100@
PREDNISOL SYRP 15/5 Q/P 240ML
PREDNISOL SOD O/S MOR 8OZ@
PREDNISON TAB 10MG Q/P 21@
PREDNISON TB 5MG UNIPK Q/P 21@
PREDNISON TAB 1MG Q/P 100@
PREDNISON TAB 10MG WAT 100
PREDNISON TAB 2.5MG Q/P 100@
PREDNISON TAB 20MG SKY UD 100
PREDNISON TAB 5MG CAD 100@
PREDNISON TAB 50MG ROX 100@
ANDROGEL 1% 2.5GM UD
30
ANDROGEL 1% 5GM UD
30
DROSPIR/ETH TB 3/.03MG LUPI 84
MYZILRA TAB Q/P
3X28@
DELYLA .1MG/.02MG TAB RAN 28@
KURVELO TAB .15MG/.3MG LUPI 3
JENCYCLA TAB 0.35MG LUPI 3
LARIN 1.5MG/0.03MG 3X21 NSTR@
GILDESS TAB 1/0.02MG Q/P 3X21@
JUNEL FE 1.5MG/30MCG BARR6X28@
WERA TAB 0.5/0.035MG 3X28NSTR@
NORTREL TAB 1/35 BARR 3X21@
CYCLAFEM 7/7/70.5/0.035QP3X28@
NORGEST/EE 0.25/0.035GLEN3X28@
TRI-EST 35+180/215/250 3X28SAN
ELINEST TB 0.3/0.03MG6X28NSTR@
ESTRADIOL TAB 0.5MG UD AVK 50
ESTRADIOL TAB 1MG UD AVK 50
ESTRADIOL TAB 2MG UD AVK 50
PREMPRO TAB 0.3/1.5MG
28
PREMPRO TAB 0.45/1.5MG 28
PREMPRO TAB 0.625/2.5MG 28
PREMPRO TAB 0.625/5MG
28
PREMARIN VAG CRM 0.625MG 30GM
PREMARIN TAB 0.3MG
100
PREMARIN TAB 0.45MG
100
PREMARIN TAB 0.625MG
100
PREMARIN TAB 0.9MG
100
PREMARIN TAB 1.25MG
100
EVISTA TAB 60MG
30
METFORM ER TB 500MG GOLD 60
METFORM HCL ERTB750MG AVK UD30
GenericName
FLUDROCORTISONE ACETATE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
METHYLPREDNISOLONE
METHYLPREDNISOLONE
PREDNISOLONE
PREDNISOLONE SOD PHOSPHATE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
TESTOSTERONE
TESTOSTERONE
ETHINYL ESTRADIOL/DROSPIRENONE
LEVONORGESTREL-ETHIN ESTRADIOL
NORETHINDRONE
NORETHINDRONE AC-ETH ESTRADIOL
NORETHINDRONE AC-ETH ESTRADIOL
NORETHINDRONE-E.ESTRADIOL-IRON
NORETHINDRONE-ETHINYL ESTRAD
NORGESTIMATE-ETHINYL ESTRADIOL
NORGESTIMATE-ETHINYL ESTRADIOL
NORGESTREL-ETHINYL ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTROGEN CON/M-PROGEST ACET
ESTROGENS CONJUGATED
RALOXIFENE HCL
METFORMIN HCL
METFORMIN HCL
Generic Dose
Form
TABLET
TABLET
TABLET
TABLET
TAB DS PK
TABLET
SOLUTION
SOLUTION
TAB DS PK
TAB DS PK
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
GEL PACKET
GEL PACKET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CREAM/APPL
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TAB ER 24H
TAB ER 24H
Dose Strength
Description
Name
0.1 MG
10 MG
20 MG
5 MG
4 MG
4 MG
15 MG/5 ML
15 MG/5 ML
10 MG
5 MG
1 MG
10 MG
2.5 MG
20 MG
5 MG
50 MG
25MG(1%)
50 MG (1%)
0.03MG-3MG
6/5/2010
0.1-0.02
0.15-0.03
0.35 MG
1.5-0.03MG
1MG-20MCG
1.5-30(21)
0.5-0.035
1 MG-35MCG
7 DAYS X 3
0.25-0.035
7DAYSX3 28
0.3-0.03MG
0.5 MG
1 MG
2 MG
0.3-1.5MG
0.45-1.5MG
0.625-2.5
0.625-5 MG
0.625 MG/G
0.3 MG
0.45MG
0.625 MG
0.9 MG
1.25 MG
60 MG
500 MG
750 MG
Comments
AHFS Classification
682004 BIGUANIDES
682004 BIGUANIDES
682004 BIGUANIDES
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682008 INSULINS
682016 MEGLITINIDES
682016 MEGLITINIDES
682020 SULFONYLUREAS
682028 THIAZOLIDINEDIONES
682212 GLYCOGENOLYTIC AGENTS
682212 GLYCOGENOLYTIC AGENTS
682400 PARATHYROID
682800 PITUITARY
682800 PITUITARY
682800 PITUITARY
682800 PITUITARY
683200 PROGESTINS
Formulary?
FORMULARY
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FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
METFORM TB 1000MG BB AMN100@
METFORM TAB 500MG MMP 60
METFORM IR TB 850MGUD GOLD 60
NOVOLOG PENFILL 100U 3ML 5
NOVOLOG F/PEN PREF SYR 3ML 5
NOVOLOG VIAL 100U
10ML
NOVOLOG 70/30 FLEX PEN 3ML 5
NOVOLOG 70/30 VL
10ML
HUMALOG CART 3-ML
5
HUMALOG KWIK PEN 3ML
5
HUMALOG VIAL 100U
3ML
HUMULIN 70/30 PEN
5
HUMULIN 70/30 MDV
10ML
HUMULIN N PEN
5
HUMULIN N NPH INSUL U100 10ML
HUMALOG KWIK PEN 75/25
5
HUMALOG VIAL 75/25
10ML
HUMULIN R REG INSUL U100 10ML
NATEGLIN TAB 120MG UD AHP 30
NATEGLIN TAB 60MG UD AHP 30
GLIMEPIR TAB 1MG UD+ AHP 30
GLIMEPIRIDE TAB 2MG VIRT 100
GLIMEPIRIDE TAB 4MG VIRT 100
GLIPIZIDE XL TB 10MG GRE 100
GLIPIZIDE ER TB 2.5MG WAT 30@
GLIPIZIDE XL TB 5MG GRE 100
GLIPIZIDE TAB 10MG MYLN 100@
GLIPIZIDE TAB 5MG MYL 100@
GLIPIZIDE MET 2.5/250 TEV100@
GLIPIZIDE MET 2.5/500 TEV100@
GLIPIZIDE MET 5/500MG TEV100@
GLYBURIDE D TAB 1.25MG TEV 50@
GLYBURIDE TAB 2.5MG AVK 500
GLYBURIDE TAB 5MG UD AHP100
GLYBURIDE MET 1.25/250 ACT100@
GLYBURIDE ME TB 2.5/5C ACT100@
GLYBURIDE MET 5/500MG UD+AHP30
PIOGLITAZONE TAB 15MG MACL 30@
PIOGLITAZONE TB 30MG TEVA 30@
PIOGLITAZONE TAB 45MG MACL 30@
GLUCAGON EMERG KIT 1MG+SYR 1ML
GLUCAGEN HYPOKIT NOVO 7065-15
CALCITON SALMNAS200IUPAR3.7ML@
DDAVP NASAL SPR BOTTLE 5ML
DESMOPR ACE RHNL TB FER 2.5ML
DESMOPR NASAL SOL.01% B&L 5ML@
DESMOPR TAB 0.2MG
100
MEDROXYPR TAB 10MG BARR 100@
GenericName
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART PROTAM & ASPART
INSULIN ASPART PROTAM & ASPART
INSULIN LISPRO
INSULIN LISPRO
INSULIN LISPRO
INSULIN NPH HUM/REG INSULIN HM
INSULIN NPH HUM/REG INSULIN HM
INSULIN NPH HUMAN ISOPHANE
INSULIN NPH HUMAN ISOPHANE
INSULIN NPL/INSULIN LISPRO
INSULIN NPL/INSULIN LISPRO
INSULIN REGULAR HUMAN
NATEGLINIDE
NATEGLINIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE
GLIPIZIDE
GLIPIZIDE
GLIPIZIDE
GLIPIZIDE/METFORMIN HCL
GLYBURIDE
GLYBURIDE
GLYBURIDE
GLYBURIDE/METFORMIN HCL
PIOGLITAZONE HCL
PIOGLITAZONE HCL
PIOGLITAZONE HCL
GLUCAGON HUMAN RECOMBINANT
GLUCAGON HUMAN RECOMBINANT
CALCITONIN SALMON SYNTHETIC
DESMOPRESSIN (NONREFRIGERATED)
DESMOPRESSIN ACETATE
MEDROXYPROGESTERONE ACETATE
Generic Dose
Form
TABLET
TABLET
TABLET
CARTRIDGE
INSULN PEN
VIAL
INSULN PEN
VIAL
CARTRIDGE
INSULN PEN
VIAL
INSULN PEN
VIAL
INSULN PEN
VIAL
INSULN PEN
VIAL
VIAL
TABLET
TABLET
TABLET
TABLET
TABLET
TAB ER 24
TAB ER 24
TAB ER 24
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
KIT
VIAL
SPRAY/PUMP
SPRAY/PUMP
SOLUTION
SPRAY/PUMP
TABLET
TABLET
Dose Strength
Description
Name
1000 MG
500 MG
850 MG
100/ML
100/ML
100/ML
70-30/ML
70-30/ML
100/ML
100/ML
100/ML
70-30/ML
70-30/ML
100/ML (3)
100/ML
75-25/ML
75-25/ML
100/ML
120 MG
60 MG
1 MG
2 MG
4 MG
10 MG
2.5 MG
5 MG
10 MG
5 MG
2.5-250 MG
2.5-500 MG
5 MG-500MG
1.25 MG
2.5 MG
5 MG
1.25-250MG
2.5-500 MG
5 MG-500MG
15 MG
30 MG
45 MG
1 MG
1 MG
200/SPRAY
10/SPRAY
0.1 MG/ML
10/SPRAY
0.2 MG
10 MG
Comments
AHFS Classification
683200 PROGESTINS
683200 PROGESTINS
683200 PROGESTINS
683200 PROGESTINS
683604 THYROID AGENTS
683608 ANTITHYROID AGENTS
683608 ANTITHYROID AGENTS
80800 ANTHELMINTICS
80800 ANTHELMINTICS
81202 AMINOGLYCOSIDES
81206 CEPHALOSPORINS
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81212 MACROLIDES
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
MEDROXYPR TAB 2.5MG BARR 100@
MEDROXYPR TAB 5MG BARR 100@
NORETHINDR TAB 5MG UD AVK 50
ENDOMETRIN VAG INSERT TAB 21
LIOTHYRON SOD TB 25MCG SIG100@
LIOTHYRON TAB 5MCG MYL 100
LIOTHYRON TAB 50MCG MYL 100@
METHIMAZ TAB 10MG HERI 100
METHIMAZ TAB 5MG HERI 100
ALBENZA TAB 200MG
2
STROMECTOL TAB 3MG
20
NEOMY SUL TB 500MG BRECK 100@
CEFDINIR CAP 300MG DAVA 60@
CEFDIN OS 125MG/5ML DAVA 60ML
CEFDIN OS 250MG/5ML DAVA 100ML
CEFUROX AXET TB 250MG AURO 20@
CEFUROX AXET TB 500MG AURO 20@
CEPHALEX CAP 250MG UD AVK 5X10
CEPHALEX CAP 500MG UD AVK 5X10
CEPHALEX O/S 250/5MLLUPI100ML@
CEPHALEX TAB 250MG TEV 100@
CEPHALEX TAB 500MG TEV 100@
AZITHROMY OS 100MG/5MLTEV15ML
AZITHROMY OS 200MG/5ML TEV15ML
AZITHROMY TAB 250MG UD AVK 50
AZITHROMY TB 500MG BP TEV 1X3@
AZITHROMY TAB 600MG UD AHP20@
CLARITHR OS 125MG/5ML SAN50ML@
CLARITHR TB 250MG CIT 60
CLARITHR TAB 500MG UD AHP 30
ERYTHROMYCIN DR CAP 250MG 100
ERYTHROMY BASE TAB 250MG 100
ERYTHROMY BASE TAB 500MG 100
ERY-TAB 250MG DR
100
ERY-TAB 333MG DR
100
ERY-TAB 500MG E/C
100
ERYTHROMY ETH TAB 400MG 100
ERYTHR STEAR TAB 250MG 100
AMOXICIL CAP 250MG TEV 100@
AMOXICIL CAP 500MG TEV 50@
AMOXICIL SUS 125MG TEV 100ML@
AMOXICIL O/S 200/5ML TEV 50ML@
AMOXICIL O/S 250/5ML Q/P 80ML
AMOXICIL O/S 400/5ML TEV 50ML@
AMOXICIL CHW TB 250MG TEV 1C@
AMOXICIL TAB 500MG CIT 100
AMOXICIL TAB 875MG CIT 100@
AUGMENTIN 125 O/S
75ML
GenericName
NORETHINDRONE ACETATE
PROGESTERONE MICRONIZED
LIOTHYRONINE SODIUM
LIOTHYRONINE SODIUM
LIOTHYRONINE SODIUM
METHIMAZOLE
METHIMAZOLE
ALBENDAZOLE
IVERMECTIN
NEOMYCIN SULFATE
CEFDINIR
CEFDINIR
CEFDINIR
CEFUROXIME AXETIL
CEFUROXIME AXETIL
CEPHALEXIN
CEPHALEXIN
CEPHALEXIN
CEPHALEXIN
CEPHALEXIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE
ERYTHROMYCIN ETHYLSUCCINATE
ERYTHROMYCIN STEARATE
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN
AMOXICILLIN/POTASSIUM CLAV
Generic Dose
Form
TABLET
TABLET
TABLET
INSERT
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
CAPSULE
SUSP RECON
SUSP RECON
TABLET
TABLET
CAPSULE
CAPSULE
SUSP RECON
TABLET
TABLET
SUSP RECON
SUSP RECON
TABLET
TABLET
TABLET
SUSP RECON
TABLET
TABLET
CAPSULE DR
TABLET
TABLET
TABLET DR
TABLET DR
TABLET DR
TABLET
TABLET
CAPSULE
CAPSULE
SUSP RECON
SUSP RECON
SUSP RECON
SUSP RECON
TAB CHEW
TABLET
TABLET
SUSP RECON
Dose Strength
Description
Name
2.5 MG
5 MG
5 MG
100 MG
25 MCG
5 MCG
50 MCG
10 MG
5 MG
200 MG
3 MG
500 MG
300 MG
125 MG/5ML
250 MG/5ML
250 MG
500 MG
250 MG
500 MG
250 MG/5ML
250 MG
500 MG
100 MG/5ML
200 MG/5ML
250 MG
500 MG
600 MG
125 MG/5ML
250 MG
500 MG
250 MG
250 MG
500 MG
250 MG
333 MG
500 MG
400 MG
250 MG
250 MG
500 MG
125 MG/5ML
200 MG/5ML
250 MG/5ML
400 MG/5ML
250 MG
500 MG
875 MG
125-31.25/
Comments
AHFS Classification
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81216 PENICILLINS
81218 QUINOLONES
81218 QUINOLONES
81218 QUINOLONES
81218 QUINOLONES
81218 QUINOLONES
81218 QUINOLONES
81220 SULFONAMIDES (SYSTEMIC)
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81224 TETRACYCLINES
81228 ANTIBACTERIALS, MISCELLANEOUS
81228 ANTIBACTERIALS, MISCELLANEOUS
81404 ALLYLAMINES
81408 AZOLES
81408 AZOLES
81408 AZOLES
81408 AZOLES
81408 AZOLES
81428 POLYENES
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
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FORMULARY
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FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
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FORMULARY
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FORMULARY
Brand Name
AMOXICIL CLV 2C/28.5MGSAN50ML@
AMOXICIL CLV 250/62.5 MOR75ML@
AMOXICIL CLV 400/57MG SAN75ML@
AUGMENT ES OS 600MG DR/R 125ML
AMOXICI CLV 2CMG/28.5MG TEV20@
AMOXICIL CLV ER1000/62.5SAN28@
AMOXICIL CLV+POT250/12530NSTA@
AMOXICIL CLVPOT500/12520NSTAR@
AMOXICIL CLV+POT875/12520NSTA@
DICLOXAC CAP 250MG SAN 100@
DICLOXAC CAP 500MG SAN 100@
PENICIL-VK O/S 125MG TEV 1CML@
PENICIL-VK O/S 250MG TEV 1CML@
PENICIL-V POT TB 250MG CIT 100
PENICILL V POT TB500MG CIT1000
CIPROFLOX TAB 250MG AVK 100
CIPROFLOX TAB 500MG BLU 20
CIPROFLOX TAB 750MG 50 NSTAR@
LEVOFLOXACIN TAB 250MG UD QP50
LEVOFLOX TAB 500MG QUAL 50
LEVOFLOXACIN TAB 750MG UD QP50
SULFAM+TRI OS CHRY AURO 473ML@
SULFAM+TRI OS 20MLGRP UDHIT40
SULFAM+TRI TB 400/80 UD+AHP 30
SULFAM+TRI TB 800/160 UD AVK30
SULFAS TAB 500MG UD AVK 50@
DOXYCYCLINE CAP 100MG UD AHP30
DOXYCYCLINE CAP 50MG DAVA 50
DOXYCYC HYC TAB 100MG BLU 20
DOXYCYC MONO CP 100MG UD+AHP20
DOXYCYCLINE MONO CP 50MGLUP100
DOXCYCLN CP USP 75MG LUPI 100@
DOXYCYC MONO TB 100MG HERI 50@
MINOCYC HCL CP 100MG AVK UD 30
MINOCYC HCL CP 50MG AVK UD 50
MINOCYCLIN CAP 75MG WAT 100@
MINOCYCLINE HCL TB 100MG AVK60
MINOCYCLINE HCL TB 50MG AVK 90
MINOCYCLIN TAB 75MG PAR 100@
CLINDAMY CAP 150MG UD AVK 5X10
CLINDAMY CAP 300MG UD AVK 5X10
TERBINAF TAB 250MG HARR 30@
FLUCONAZ O/S 40MG/ML ROX 35ML
FLUCONAZOLE TB 100MG PACK 30
FLUCONAZ TAB 150MG DR/R 12
FLUCONAZOLE TAB 200MG PACK 30
FLUCONAZ TAB 50MG DR/R 30
NYSTATIN O/S 100MU 5ML SKY 50@
GenericName
DICLOXACILLIN SODIUM
DICLOXACILLIN SODIUM
PENICILLIN V POTASSIUM
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
LEVOFLOXACIN
LEVOFLOXACIN
LEVOFLOXACIN
SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFASALAZINE
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE
DOXYCYCLINE MONOHYDRATE
MINOCYCLINE HCL
MINOCYCLINE HCL
MINOCYCLINE HCL
MINOCYCLINE HCL
MINOCYCLINE HCL
MINOCYCLINE HCL
CLINDAMYCIN HCL
CLINDAMYCIN HCL
TERBINAFINE HCL
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
NYSTATIN
Generic Dose
Form
SUSP RECON
SUSP RECON
SUSP RECON
SUSP RECON
TAB CHEW
TAB ER 12H
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
SOLN RECON
SOLN RECON
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
ORAL SUSP
ORAL SUSP
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
TABLET
SUSP RECON
TABLET
TABLET
TABLET
TABLET
ORAL SUSP
Dose Strength
Description
Name
200-28.5/5
250-62.5/5
400-57MG/5
600-42.9/5
200-28.5MG
1000-62.5
250-125 MG
500-125 MG
875-125 MG
250 MG
500 MG
125 MG/5ML
250 MG/5ML
250 MG
500 MG
250 MG
500 MG
750 MG
250 MG
500 MG
750 MG
200-40MG/5
800-160/20
400MG-80MG
800-160 MG
500 MG
100 MG
50 MG
100 MG
100 MG
50 MG
75 MG
100 MG
100 MG
50 MG
75 MG
100 MG
50 MG
75 MG
150 MG
300 MG
250 MG
40 MG/ML
100 MG
150 MG
200 MG
50 MG
100000/ML
Comments
2
0
AHFS Classification
81428 POLYENES
81428 POLYENES
81428 POLYENES
81492 ANTIFUNGALS, MISCELLANEOUS
81828 NEURAMINIDASE INHIBITORS
81832 NUCLEOSIDES AND NUCLEOTIDES
83008 ANTIMALARIALS
83092 ANTIPROTOZOALS, MISCELLANEOUS
83092 ANTIPROTOZOALS, MISCELLANEOUS
83600 URINARY ANTI-INFECTIVES
840404 ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
840406 ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
840408 ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
NYSTATIN PWD
PADD 150MU
NYSTATIN PWD
PADD 50MU
NYSTATIN TAB 500MU MUT 100@
GRISEOFULV OS 125/5ML Q/P 4OZ@
GRIFULVIN V TAB 500MG 100
GRIS-PEG TAB 125MG
100
GRIS-PEG TAB 250MG
100
TAMIFLU CAP 30MG BP 10 NR
TAMIFLU O/S 6MG/ML 60ML NR
RELENZA DSKHLR 5MG
5X4
ACYCLOVIR CAP 200MG UD AHP100@
ACYCLOVIR TAB 400MG UD AHP100@
ACYCLOVIR TB 800MG UD AVK 50
VALACYCL TAB 1GM UD AHP 30@
VALACYCLOVIR TAB 500MG CIP 30
HYDROXYCH TAB 200MG AVK 100
METRONID TAB 250MG UD AHP 100@
METRONID TAB 500MG WAT 50@
NITROFURAN OS 25MG CARA 5ML@
NITROFURAN CAP 100MG UDAHP100@
NITROFURAN CAP 50MG UD AHP100@
NITROFURAN CAP 100MG MYLN 100@
CLINDAMY PH VAG CRM GRE 40GM@
CLINDAMY GEL USP 1% FOUG 30GM@
CLINDAMY PH LOT 1% GRE 60ML@
CLINDAMY PHOS TS 1% ACTA30ML
ERYTHR TOP SOL 2% FOUG 60ML
METRONIDAZ CRM 0.75% PRAS45G@
METRONID GEL 0.75% PRAS 45GM@
METROGEL TOP GEL 1%
60GM
METROGEL VAGINAL .75% TBE 70GM
METROGEL 1% PUMP
55GM
METRONIDAZ LOT 0.75% PRAS 2OZ@
MUPIROCIN OINT 2% PERR 22GM@
ACYCLOVIR 5% OINT ACT 30GM@
CICLOPIR GEL 0.77% GLEN 45GM@
CICLOPIR SHAM 1% TAR 120ML
CICLOPIR TOP SOL 8% HARR 6.6ML
CICLOPIR CRM 0.77% FOU 15GM
CLOTRIMAZ+BETAM CRM ACTA 15GM@
CLOTRIMAZ+BETAM LOT TAR 30ML@
KETOCONAZOLE CRM 2% TAR 15GM@
KETOCONAZOLE SHAM 2% SAN 4OZ@
NYSTATIN CRM 100MU FOUG 30GM@
NYSTATIN OIN 100MU FOUG 15GM@
NYSTATIN TOP PWD X-G 15GM
GenericName
NYSTATIN
NYSTATIN
NYSTATIN
GRISEOFULVIN MICROSIZE
GRISEOFULVIN MICROSIZE
GRISEOFULVIN ULTRAMICROSIZE
GRISEOFULVIN ULTRAMICROSIZE
OSELTAMIVIR PHOSPHATE
ZANAMIVIR
ACYCLOVIR
ACYCLOVIR
ACYCLOVIR
VALACYCLOVIR HCL
VALACYCLOVIR HCL
HYDROXYCHLOROQUINE SULFATE
METRONIDAZOLE
METRONIDAZOLE
NITROFURANTOIN
NITROFURANTOIN MACROCRYSTAL
NITROFURANTOIN MACROCRYSTAL
NITROFURANTOIN MONOHYD/M-CRYST
CLINDAMYCIN PHOSPHATE
ERYTHROMYCIN BASE/ETHANOL
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
MUPIROCIN
ACYCLOVIR
CICLOPIROX
CICLOPIROX
CICLOPIROX
CICLOPIROX OLAMINE
CLOTRIMAZOLE/BETAMETHASONE DIP
CLOTRIMAZOLE/BETAMETHASONE DIP
KETOCONAZOLE
KETOCONAZOLE
NYSTATIN
NYSTATIN
NYSTATIN
Generic Dose
Form
POWDER(EA)
POWDER(EA)
TABLET
ORAL SUSP
TABLET
TABLET
TABLET
CAPSULE
CAPSULE
CAPSULE
SUSP RECON
BLST W/DEV
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
ORAL SUSP
CAPSULE
CAPSULE
CAPSULE
CREAM/APPL
GEL (GRAM)
LOTION
SOLUTION
SOLUTION
CREAM (G)
GEL (GRAM)
GEL (GRAM)
GEL W/APPL
GEL W/PUMP
LOTION
OINT. (G)
OINT. (G)
GEL (GRAM)
SHAMPOO
SOLUTION
CREAM (G)
CREAM (G)
LOTION
CREAM (G)
SHAMPOO
CREAM (G)
OINT. (G)
POWDER
Dose Strength
Description
Name
150MM UNIT
50MM UNIT
500K UNIT
125 MG/5ML
500 MG
125 MG
250 MG
30 MG
45 MG
75 MG
6 MG/ML
5 MG
200 MG
400 MG
800 MG
1000 MG
500 MG
200 MG
250 MG
500 MG
25 MG/5 ML
100 MG
50 MG
100 MG
2%
1%
1%
1%
2%
0.75%
0.75%
1%
0.75%
1%
0.75%
2%
5%
0.77%
1%
8%
0.77%
1 %-0.05 %
1 %-0.05 %
2%
2%
100000/G
100000/G
100000/G
Comments
AHFS Classification
840412 SCABICIDES AND PEDICULICIDES
840492 LOCAL ANTI-INFECTIVES, MISCELLANEOUS
840600 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
840800 ANTIPRURITICS AND LOCAL ANESTHETICS
840800 ANTIPRURITICS AND LOCAL ANESTHETICS
841600 CELL STIMULANTS AND PROLIFERANTS
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
NYSTAT+TRIAM CRM 0.1% ACTA15GM
NYSTATIN+TRIAM OINT SAN 30GM@
TERCON CRM 0.4% WAT 45GM
LINDANE LOTION 1% WOCK 60ML@
LINDANE SHAMPOO 1% WOCK 60ML@
PERMETHRIN CRM 5% PERR 60GM@
PERMETHRIN LOT 1% ALPH 59ML
SILVADENE CRM 1%TUBE PFIZ25G
BETAMET DIP CRM 0.05%TAR 15GM@
BETAMET DIP LO 0.05%FOUG 60ML@
BETAMET DIP OI 0.05%FOUG 45GM@
BETAMET VAL CR 0.1% FOUG 45GM@
BETAMET VAL LO 0.1% FOUG 60ML@
BETAMET VAL OI 0.1% FOUG 15GM@
BETAMET DIP AU 0.05% SAN 15GM
BETAMET DIP AU 0.05%FOUG 15GM@
CLOBETASOL CRM .05% ACT 30GM@
CLOBETASOL LOT 0.05% TAR 59ML
CLOBETAS PR OI 0.05% FOU 60GM@
CLOBETAS T/S 0.05% ACTA 50ML
CLOBETAS EM CR 0.05% FOU 15GM@
DESONIDE CRM 0.05% G&W 15GM@
DESONIDE OIN 0.05% PERR 15GM@
FLUOCINOL AC BDY.01%AMN118ML@
FLUOCIN SCLP OIL 0.01% SET 4Z@
FLUOCINON CRM 0.05% ACTA 15GM@
FLUOCINON GEL 0.05% TEV 60GM
FLUOCINON ONT 0.05% TEV 15GM@
FLUOCINO TS 0.05% COUN 20ML@
HYDROCORT CRM 2.5% TAR 28.35GM
PROCTOZ HC CRM 2.5% RIS 30GM
HYDROCORT LOT 2.5% FOUG 2OZ@
HYDROCORT OINT 2.5% PERR454GM@
CORTIFOAM
15GM
GRX HICORT SUPP 25MG GER 12
TRIAMCIN CRM 0.025% FOUG 15GM@
TRIAMCINOL CRM Q/P 30GM/0.1%@
TRIAMCIN CRM 0.5% FOUG 15GM@
TRIAMCIN LOT 0.025% MOR 2OZ@
TRIAMCIN LOT 0.1% Q/P 60ML@
TRIAMCIN OINT .025% FOUG 80GM@
TRIAMCIN OINT 0.05% CMP 430GM
TRIAMCIN OINT 0.1% FOUG 15GM@
TRIAMCIN OINT 0.5% PERR 15GM@
PHENAZ TAB 100MG ECI 100@
PHENAZ TAB 200MG ECI 100@
TRETINOIN CRM .025%SPEA45GM@
TRETIN CREAM 0.05% SPEA 20GM@
GenericName
NYSTATIN/TRIAMCIN
NYSTATIN/TRIAMCIN
TERCONAZOLE
LINDANE
LINDANE
PERMETHRIN
PERMETHRIN
SILVER SULFADIAZINE
BETAMETHASONE DIPROPIONATE
BETAMETHASONE VALERATE
BETAMETHASONE/PROPYLENE GLYC
BETAMETHASONE/PROPYLENE GLYC
CLOBETASOL PROPIONATE
CLOBETASOL PROPIONATE/EMOLL
DESONIDE
DESONIDE
FLUOCINOLONE ACETONIDE
FLUOCINOLONE/SHOWER CAP
FLUOCINONIDE
FLUOCINONIDE
FLUOCINONIDE
FLUOCINONIDE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE ACETATE
HYDROCORTISONE ACETATE
PHENAZOPYRIDINE HCL
PHENAZOPYRIDINE HCL
TRETINOIN
TRETINOIN
Generic Dose
Form
CREAM (G)
OINT. (G)
CREAM/APPL
LOTION
SHAMPOO
CREAM (G)
LIQUID
CREAM (G)
CREAM (G)
LOTION
OINT. (G)
CREAM (G)
LOTION
OINT. (G)
CREAM (G)
OINT. (G)
CREAM (G)
LOTION
OINT. (G)
SOLUTION
CREAM (G)
CREAM (G)
OINT. (G)
OIL
OIL
CREAM (G)
GEL (GRAM)
OINT. (G)
SOLUTION
CREAM (G)
CREAM/APPL
LOTION
OINT. (G)
FOAM/APPL
SUPP.RECT
CREAM (G)
CREAM (G)
CREAM (G)
LOTION
LOTION
OINT. (G)
OINT. (G)
OINT. (G)
OINT. (G)
TABLET
TABLET
CREAM (G)
CREAM (G)
Dose Strength
Description
Name
100000-0.1
100000-0.1
0.40%
1%
1%
5%
1%
1%
0.05%
0.05%
0.05%
0.10%
0.10%
0.10%
0.05%
0.05%
0.05%
0.05%
0.05%
0.05%
0.05%
0.05%
0.05%
0.01%
0.01%
0.05%
0.05%
0.05%
0.05%
2.50%
2.50%
2.50%
2.50%
10%
25 MG
0.03%
0.10%
0.50%
0.03%
0.10%
0.03%
0.05%
0.10%
0.50%
100 MG
200 MG
0.03%
0.05%
Comments
AHFS Classification
842800 KERATOLYTIC AGENTS
842800 KERATOLYTIC AGENTS
845004 DEPIGMENTING AGENTS
848000 SUNSCREEN AGENTS
849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS
861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS
881600 VITAMIN D
881600 VITAMIN D
881600 VITAMIN D
881600 VITAMIN D
881600 VITAMIN D
882400 VITAMIN K ACTIVITY
920400 ALCOHOL DETERRENTS
920800 5-ALPHA-REDUCTASE INHIBITORS
921600 ANTIGOUT AGENTS
922400 BONE RESORPTION INHIBITORS
923600 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
923600 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
924400 IMMUNOSUPPRESSIVE AGENTS
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
TRETINOIN CREAM .1% SPEA 45GM@
TRETIN GEL 0.01% SPEA 15GM@
TRETINOIN GEL 0.025% ROUS15GM@
TRETIN GEL MICR .04% SPEA20GM@
TRETIN GEL MICR .1% SPEA 20GM@
TRETIN GEL MICR .04% SPEA50GM@
TRETIN GEL MICR .1% SPEA 50GM@
TRETINOIN EMOL 0.05% SUNV 40GM
BENZOYL GEL 5% MMP 1.5OZ@
CARB-O-PHILIC CRM 40% GER 3OZ
MELPAQUE HP 4% CRM STRA 1OZ@
NUQUIN HP CRM 4%
1OZ
AZELEX CREAM 20%
30GM
CALCIPOTR CRM .005% PRAS 60G@
CALCIPOTR OINT 0.005% TAR60GM@
CALCIPOTR T/S 0.005% HI-T 60ML
FLUOROUR CRM 5% TAR 40GM@
IMIQUIMOD CRM 5% PERR 12
ELIDEL CREAM 1%
100GM
CONDYLOX GEL 0.5%
3.5GM
PODOFIL T/S 0.5% WAT 3.5ML@
THEOPHY ER TAB 100MG AVK 90
THEOPHY ER TAB 300MG AVK 90
CALCITRIOL CP.25MCG UD AHP100
CALCITRIOL 0.5MCG CAP GOLD 100
VIT D CAP 5000IU MMP 100
VIT D3 50,000 IU NIVA 12
VITAMIN D CAP 1.25MG STR 100
MEPHYTON TAB 5MG
100
DISULFIR TAB 250MG ROX 30
FINASTER TAB 5MG MYLN 30@
ALLOPURINOL 100MG TAB GOLD 90
ALLOPURINOL TAB 300MG 30 NSTR
COLCHICINE TB 0.6MG PRAS 100@
ALENDRONAT TB 10MG UD UDL 20@
ALENDRONATE 35MG VIRT 4 @
ALENDRONAT TB 5MG TEV 30@
ALENDRONAT SOD TB 70MG SUN 4@
RISEDRONATE SOD 35MG TAB ACT 4
RISEDRONATE TAB 5MG TEVA 30@
LEFLUNOM TAB 10MG TRIG 30@
LEFLUNOM TAB 20MG TRIG 30@
AZATHIOPRIN TAB 50MG AMN 100@
TRUECONTROL G/S LVL0 M5H01-83
TRUECONTROL G/S LVL1 M5H01-80
TRUE TEST CONT L2 3ML E5H01-81
TRUERESULT METER E4H01-81
AEROCHAMBER+MASK SML 013535
GenericName
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN MICROSPHERES
TRETINOIN/EMOLLIENT BASE
BENZOYL PEROXIDE
UREA
HYDROQUINONE/FERRIC OXIDE
DIOXYBENZONE/PDO/HYDROQUINONE
AZELAIC ACID
CALCIPOTRIENE
CALCIPOTRIENE
CALCIPOTRIENE
FLUOROURACIL
IMIQUIMOD
PIMECROLIMUS
PODOFILOX
PODOFILOX
THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ANHYDROUS
CALCITRIOL
CALCITRIOL
CHOLECALCIFEROL (VITAMIN D3)
CHOLECALCIFEROL (VITAMIN D3)
ERGOCALCIFEROL (VITAMIN D2)
PHYTONADIONE
DISULFIRAM
FINASTERIDE
ALLOPURINOL
ALLOPURINOL
COLCHICINE
ALENDRONATE SODIUM
ALENDRONATE SODIUM
ALENDRONATE SODIUM
ALENDRONATE SODIUM
RISEDRONATE SODIUM
RISEDRONATE SODIUM
LEFLUNOMIDE
LEFLUNOMIDE
AZATHIOPRINE
BLOOD-GLUCOSE CONTROL HIGH
BLOOD-GLUCOSE CONTROL LOW
BLOOD-GLUCOSE CONTROL NORMAL
BLOOD-GLUCOSE METER
INHALER ASSIST DEVICES
Generic Dose
Form
CREAM (G)
GEL (GRAM)
GEL (GRAM)
GEL (GRAM)
GEL (GRAM)
GEL W/PUMP
GEL W/PUMP
CREAM (G)
GEL (GRAM)
CREAM (G)
CREAM (G)
CREAM (G)
CREAM (G)
CREAM (G)
OINT. (G)
SOLUTION
CREAM (G)
CREAM PACK
CREAM (G)
GEL (GRAM)
SOLUTION
TAB ER 12H
TAB ER 12H
CAPSULE
CAPSULE
CAPSULE
CAPSULE
CAPSULE
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
TABLET
EACH
EACH
EACH
KIT
SPACER
Dose Strength
Description
Name
0.10%
0.01%
0.03%
0.04%
0.10%
0.04%
0.10%
0.05%
5%
40%
4%
3%-5%-4%
20%
0.01%
0.01%
0.01%
5%
5%
1%
0.50%
0.50%
100 MG
300 MG
0.25 MCG
0.5 MCG
5000 UNIT
50000 UNIT
50000 UNIT
5 MG
250 MG
5 MG
100 MG
300 MG
0.6 MG
10 MG
35 MG
5 MG
70 MG
35 MG
5 MG
10 MG
20 MG
50 MG
Comments
AHFS Classification
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
940000 DEVICES
Formulary?
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
FORMULARY
Brand Name
OPTICHAMB LGE MASK HS81311-010
LANCET MPD ULT THIN 26GA BX100
TRUEPLUS SFTY LANCET 28G 100
TRUEPLUS LANCET 30G 100
TRUEPLUS LANCET 33G M/COLR 100
TRUEPLUS LANCING DEVICE
PEN NDL NOVOTWIST 30G 8MM 100
PEN NEEDL PIC IN 30G 8MM 100
PEN NDL NOVOTWIST 32G 5MM 100
PEN NDL NOVOFINE 32G 4MM 100
PEN NDL NOVOFINE 32G 6MM 100
PEN NDL ESY-T 32GX3/16 100
PEN NEEDL PIC IN 32G 8MM 100
PEAK FLOW METER
PF9940
UNIFINE PENTP 12MM 1/2X29G 100
UNIFINE PENTP 6MM 31G 30
UNIFINE PENTP 4MM 32G
30
NOVOFINE AUTOCVR 30G
100
TRUEPLUS SYR .3CC 29G CT100
SYR INS S/C 3/10CC 30GX1/2 100
INS SYRNGE D/G 28GX1/2CC DS100
INS SYRINGE D/P 29GX1/2CCDS100
INS SYRNGE YEL 30GX1/2CC DS100
SYR INS S/C 1/2CC 30GX1/2 100
SYR INS MIS 0.5/30G BX100
SYR INS THNP 1/2CC 31GX3/8 100
SYR INS 1ML 27GX5/8
100
INS SYRINGE BLU 28GX1CC DS100
TRUEPLUS SYR 1CC 28G CT100
INS SYRINGE RED 29GX1CC DS100
INS SYRINGE PINK 30GX1CC DS100
SYR INS S/C 1CC 30GX1/2 100
SYR INS THNP 1CC 31GX3/8 CT100
GenericName
INHALER ASSIST DEVICE ACCESORY
LANCETS
LANCETS
LANCETS
LANCETS
LANCING DEVICE
NEEDLES INSULIN DISPOSABLE
PEAK FLOW METER
PEN NEEDLE DIABETIC
PEN NEEDLE DIABETIC
PEN NEEDLE DIABETIC
PEN NEEDLE DIABETIC
PEN NEEDLE DIABETIC
PEN NEEDLE DIABETIC SAFETY
SYRING W-NDL DISP INSUL 0.3 ML
SYRINGE & NEEDLE INSULIN 1 ML
Generic Dose
Form
EACH
EACH
EACH
EACH
EACH
EACH
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
EACH
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DIS NEEDLE
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
DISP SYRIN
Dose Strength
Description
Name
26 GAUGE
28 GAUGE
30 GAUGE
33 GAUGE
30GX1/3"
30GX5/16"
32 GX 1/5"
32 GX 1/6"
32G X 1/4"
32GX3/16"
32GX5/16"
29 G X1/2"
31 G X1/4"
31 GX3/16"
31 GX5/16"
32GX 5/32"
30GX1/3"
29 G X1/2"
30GX1/2"
30GX5/16"
31 GX5/16"
28 GAUGE
28GX1/2"
29 G X1/2"
29 GAUGE
30 GAUGE
30GX1/2"
30GX3/8"
30GX5/16"
31 GX5/16"
31GX3/8"
27GX5/8"
28 GAUGE
28GX1/2"
29 G X1/2"
29 GAUGE
30 GAUGE
30GX1/2"
30GX5/16"
31 GX5/16"
31GX3/8"
Comments
MEDICATION OVERRIDE REQUEST FORM
To:
MAP Pharmacy staff
Request date:
FAX: 512-901-9763
Telephone: 512-978-8139
Number of pages:
From:
Prescribing Physician/Provider
Telephone number
Office Contact Person
Fax number
Instructions:
1. Complete the Medication Override Request Form to request evaluation for nonformulary medications and interim fill
2. Use a separate form for each request. Please attached any additional
supporting documentation.
3. Pharmacy staff will send a fax disposition back to the Office Contact Person.
MEMBER INFORMATION
Member ID:
DOB:
Last Name:
First name:
PREVIOUS MEDICATION THERAPIES FOR CONDITION (include notes and supporting
documentation).
1. Medication name:
Reason for change:
2. Medication name:
Reason for change:
3.
Medication name:
Reason for change:
REQUESTED MEDICATION INFORMATION
Medication name:
Dose:
Duration:
Diagnosis:
Medical Necessity: D Non-Formulary Medication D Interim Fill D Other
If other describe here:
FOR INTERNAL USE ONLY
APPROVAL: D YES
D NO
rev: 01-07-2016
12. COMMUNITY CARE WOMEN’S
HEALTH CENTER
Women’s Health Center
FAX Transmittal -MAP Patients
1313 Red River, Suite 320, Austin, TX 78701
Fax- 512-279-7367
From Cli nic:
Fax:
Con tac t Nam e:
Con tac t Phon e:
Pages (i ncluding fax tra nsmi tt al)
Re:
NOTE: Appointment information will be faxed to the PCP clinic within 72 business hours of
receiving a completed referral with all pertinent documentation. The PCP clinic is responsible
for notifying the patient of the specialty appointment.
Comments:
The information contained in this facsimile message is legally privileged and confidential
information intended only for the use of the entity named above. If the reader of this
transmission is not the intended recipient, you are hereby notified that any
dissemination, distribution or copying of this transmission is strictly prohibited. If you
received this transmission in error, please immediately notify us by telephone to arrange
for return of the original documents.
CommUnityCare Women’s Health Center
Professional Office Building
1313 Red River, 3rd Floor, Suite 320
(512) 978-8870
□ From the 2nd Floor of the Parking Garage, pass the parking garage elevators and
turn right.
Go down a short hallway until you get to the automatic doors.
When you enter through the automatic doors, you will be located on the 2nd Floor
of the Professional Office Building.
Take the elevador to the 3rd Floor.
As you come out of the elevator, turn right and then at the corner turn right again to
get to the CommUnityCare Women’s Health Center (Suite 320).
Enter through the door and sign in at the check-in desk.
□
□
□
□
□
Elevator
Clinical Education Center (CEC)
Labor & Delivery
Brackenridge
Employee Elevators
Chapel
Public
Elevator
Public
Elevator
Information
Desk
Gift Shop
Second
Floor
Coffee Shop
Parking Garage
W
A
L
K
W
A
Y
Professional Office Building
CommUnityCare
Women’s Health Center
Suite 320
YOU ARE
HERE
nd
2 Floor
Parking Garage Elevators
ENTER ON 2nd Floor
3rd Floor
Elevator
Go up to Restroom
3rd Floor
CommUnityCare Centro de Salud para Mujeres
Edificio de Oficinas Profesionales
1313 Red River, Piso 3, Sala 320
(512) 978-8870
□ Desde Piso 2 del Estacionamiento, pase los elevadores del estacionamiento, y
dase una vuelta a la derecha.
□ Camine hasta que llega a la puerta automática.
□ Cuando entre por la puerta automática, usted estará en el Piso 2 del Edificio de
Oficinas Profesionales.
□ Tome el elevador hasta Piso 3.
□ Saliendo del elevador, dase una vuelta a la derecha y en la esquina otra vez a la
derecha para llegar a la Clinica de Embarazo y Ginecologia (Sala 320).
□ Entre por la puerta y presentese a la ventana de recepción.
Elevador
Centro de Educación Clinica (CEC)
Centro Universitario de Medicina
Brackenridge
Sala de Parto Elevadores de
Empleados
Capilla
Elevador
Público
Elevador
Público
Información
Tienda de Regalos
Segundo
Piso
Cafeteria
Estacionamiento
P
U
E
N
T
E
Edificio de Oficinas Profesionales
CommUnityCare Women’s Health
Sala 320
USTED ESTA
AQUi
PISO 2
Elevadores del Estacionamiento
ENTRE EN Piso 2
Piso 3
Elevador
CommUnityCare
Women’s Health
Brackenridge Professional Office Building
CommUnityCare — Women’s Health
Table of Contents
Clinic Rotation Schedule_______________________________________________________3
Genetic Counseling ___________________________________________________________4
Gynecology Clinic _____________________________________________________________5
Gynecology Clinic Worksheet ___________________________________________________6
Gyn Procedures - LEEPs & Colpos _______________________________________________9
Obstetrics Clinic _____________________________________________________________10
Guidelines for Diabetes in Pregnancy ____________________________________________18
Appendix A _________________________________________________________________22
Appendix B
_____23
Appendix C
_____24
Ultrasounds — Level II
_____25
Pg. 2
Pg. 3
Genetic Counseling
Scope
□ Genetic Risk Assessment and Testing
□ Candidates for amniocentesis must be ≤ 20 weeks gestation on the day of their genetic clinic
appointment
□ Advanced Maternal Age (AMA): maternal age D 35 years old at delivery and patient consents to an amnio;
must watch video; see below.
□ Abnormal TAST screening test; amnio may or may not be indicated
□ Family history of birth defects, mental retardation, or genetic diseases
□ Personal history of birth defects, mental retardation, or genetic disease
□ Exposure to teratogens such as alcohol, drugs, and medications for maternal diseases (e.g.
Insulin-dependent diabetes). Patient may prefer to call Texas Teratogen Information Service
for free pregnancy exposure/risk counseling at 1-800-733-4727.
□ Abnormal ultrasound findings (fetal abnormalities)
□ Recurrent Pregnancy Loss (D 2 SAB)
□ Consanguineous matings
IMPORTANT! Before scheduling an appointment for genetic counseling, patient must
watch video titled, “Prenatal Diagnosis of Birth Defects: Amniocentesis”.
□
□
□
□
Completed referral form
Pertinent Lab results (TAST, hemoglobin electrophoresis, blood type, etc.)
Ultrasound report(s)
Title V Screening Document, if eligible
NOTE: Instruct patient to report to specialty clinic appointment no earlier than 15-30 minutes prior to
appointment time.
Pg. 4
Gynecology Clinic
Scope:
□ To evaluate moderate to highly complex gynecologic problems, and pre- & post- surgical
patients.
□
□
□
□
□
□
□
□
Post-menopausal bleeding
Pelvic pain
Endometriosis
Missed AB & Threatened AB
Abnormal gynecological diagnoses
Pelvic Mass
Menometrorrhagia
Pelvic prolapse/urinary incontinence
Please do NOT refer the following patients to the Gyn clinic:
□ Desire for sterilization — Refer patient to AWH at 322-2100 for work-up and scheduling.
□ Infertility
□ Completed referral form
□ Copy of recent documentation (i.e. chart notes)
□ Recently drawn labs, pap smear and gyn probe results
See worksheet on next page for more information.
Pg. 5
Gynecology Clinic Worksheet
1. Abnormal Pap/Colposcopy/LEEP—
a. ASCUS +HPV or higher (ASC-H, LGSIL, HGSIL, AGUS, CIS regardless of HPV)
b. Except:
□ If patient is 20 years or younger:
o ASC-US, LGSIL (regardless of HPV)—repeat Pap in 1 year
o If the repeat pap is ASC-US, LGSIL—repeat Pap again in 1 year
o If third pap has any abnormality, refer for colposcopy
□ Pregnancy
o We will now start deferring colpo on LGSIL and ASCUS paps until 8 weeks
Postpartum
o Refer ASC-H, AGUS, HGSIL, CIS at any time
c. Requires:
□ Results of Pap generating referral
□ Results of any previous abnormal paps, colposcopies and biopsies
□ Date of last known menstrual period
□ Last GC/CT (within the last year)
2. Abortion (Miscarriage)—
a. Threatened, incomplete, complete, missed, etc
b. Requires:
□ Type and Screen, CBC, Ultrasound, all known quant HCGs, last Pap and GC/CT (within
1 year)
3. C-section staple removal—
a. For Pfannensteil skin incisions, the staples should be removed prior to hospital discharge. If
not, will be overbooked in next gyn clinic day.
b. For vertical skin incisions, these should be booked in the resident’s continuity clinic 7-10
days after the surgery was done.
BOTH OF THESE APPOINTMENTS SHOULD BE MADE BY THE RESIDENT AND
PLACED ON THE CHART PRIOR TO THE PATIENT’S DISCHARGE FROM THE
HOSPITAL.
c. If this is being generated by an outside source, requires:
□ Patient name and contact information
□ Location, date and type of surgery (C-section with or without BTL)
4.
Ectopic pregnancy—
a. Call L&D attending cell phone for further direction 450-3775
Pg. 6
G yn ec ol o g y C li n i c W o r ks h e et ( c o n ti n ue d)
5. Foley catheter following gyn surgery done at Brackenridge—
a. Should be scheduled by resident surgeon into resident’s continuity clinic prior to patient’s discharge from
hospital
b. If not, then should be scheduled into continuity clinic of the resident who did the surgery
c. If this is being generated by an outside source, requires:
□ Patient name and contact information,
□ Date, location of surgery, and type of surgery (as best can be determined)
6. Infertility—
a. We cannot accept patients for this referral.
b. Patients can be referred to Texas Fertility Center
7. IUD insertion—
a. We cannot accept patients for this referral.
b. Patients should be referred to primary care provider.
8. IUD removal—
a. Can be scheduled in gyn clinic;
b. If unable to be removed in gyn clinic, will require internal referral via Dr. Held for
treatment/removal at AWH.
c. Requires:
D Last note documenting reason for referral, last Pap and GC/CT, ultrasound if done (i.e., if there are
not strings noted so that intrauterine placement can be determined)
9.
Molar Pregnancy—
a. Call L&D attending cell phone for further direction 450-3775
10. Post-Op D&Cs—
a. Should be scheduled in resident surgeon’s continuity clinic by the resident.
b. If not, is scheduled in resident surgeon’s continuity clinic
c. Requires (if referral from outside):
□ Patient name and contact information,
□ Date and location of surgery
Pg. 7
G yn ec ol o g y C li n i c W o r ks h e et ( c o n ti n ue d)
11. Postmenopausal Bleeding—
a. Vaginal bleeding after 6 months or more of amenorrhea
b. Requires:
□ Last Pap and GC/CT (within last year),
□ pelvic ultrasound,
□ CBC, TSH,
□ clinic notes discussing issue/referral
12. Pelvic Pain—
a. Requires:
□ All clinic notes addressing this issue
13. Endometriosis—
a. Requires:
14. Pelvic Mass—
a. Requires:
□ Copies of any imaging studies done,
15. Menometrorrhagia—
a. Requires:
□ CBC, TSH,
16. Pelvic Prolapse/Urinary Incontinence—
a. Requires:
□ UA with C/S,
□ Clinic notes addressing this issue
17. Sterilization—
a. We do not accept referrals for this; refer these patients to AWH 322-2100
Pg. 8
Gyn Procedures - LEEPs & Colpos
Scope
□ To perform LEEPs and Colpos.
Appropriate patients for referral into Gyn Procedures include:
□ Abnormal PAP results
□ Cervical Dysplasia
□
□
□
□
Pap results
Biopsy results
Gen probe
Colpo Target Sheet or NextGen GYN Colposcopy document (needed for LEEPs only)
appointment time.
Pg. 9
Obstetrics Clinic
(OB High Risk, OB Diabetes and OB Testing)
Scope:
□ To evaluate high-risk obstetric patients.
□ Hypertension (Chronic or Pregnancy Induced)
□ Diabetes — refer to OB Diabetic Clinic on Mondays if diabetes management is desired. Nutrition
counseling without diabetic management is also available.
□ History of spontaneous abortions or premature births
□ Placenta Previa / Preterm Labor:
o If Suspected — refer to USG Clinic
o If Diagnosed w/ previous USG — refer to OB High Risk Clinic
□ Late Entry into Care (No prenatal care prior to 30 weeks gestation)
□ Multiple Gestation
□ Previous C-section
□ Large/small for dates — refer only after evaluated by an OB physician.
□ Post Date — refer to OB Testing Clinic
□ Cholestasis of pregnancy
□ Breech > 36 weeks
□ Medical disorders complicating pregnancy including:
o AIDs/HIV positive
o Thyroid Disorder o
Renal Disorder
o Drug Dependence
o Lupus
o Seizure Disorder
□ ACOG (IOB) Forms
□ Results of recent labs and pathology results (i.e. pap smears and biopsies)
appointment time.
See worksheet on next page for more information
Pg. 10
O b s te tr ics C li ni c W o r k s h ee t
1. Abnormal TAST—
a. Needs an ultrasound to confirm dates
□ If dates confirmed, then referral is to genetics to discuss amniocentesis
□ Genetics can only be scheduled if gestation is <20 weeks
b. Requires:
□ IOB and master EMR copy (which includes all prenatal visits and info to date),
□ all prenatal labs (including Pap and GC/CT),
□ results of abnormal TAST,
□ copy of ultrasound confirming dates
2. Amniocentesis—(For AMA or other genetics reasons, requires genetics referral)
a. Genetics can only be scheduled if gestation is <20 weeks
b. Requires:
□ all prenatal labs (including TAST if done),
□ Pap and GC/CT,
□ copy of ultrasound (if done)
3. C-section scheduling—(if does not meet dating criteria)
a. Previous C-section-b. Requires:
□ copy of any ultrasounds
4. Anatomy scan (Level II Ultrasound or Targeted Ultrasound)—
a. Reserved for patients with concerns on routine scan done at NE, HROB, or at a radiology facility (ie
ARA)
b. If for AMA, patient should see genetics first, and must be sent before 20 weeks gestation.
c. Requires:
□ IOB and master EMR coy (which includes all prenatal visits and info to date),
□ copy of ultrasound generating referral
Pg. 11
O b s te tr ics C li ni c W o r k s h ee t (c o n ti n ue d)
5. Diabetes (pregnant)—
a. See Guidelines for Diabetes in Pregnancj at end of Obstetrics Clinic Worksheet.
b. Known diagnosis of diabetes prior to pregnancy (please send information on how long
patient has been a diabetic, pre-pregnancy medications and treatment, pre-pregnancy diabetes complications,
and last hemoglobin A1C (done within the last 3 months)
c. Requires:
□ IOB
□ all prenatal labs
□ copy of ultrasound (to document viability or if before viability, all quantitative HCGs)
□ results of GTT testing, hemoglobin A1C, with information as noted below in
Guidelines for Diabetes in Pregnancy
□ if known diabetic, 24 hour urine for protein and creatinine clearance, TSH, free T4, TAST
(if appropriate)
6. Genetics—
a. AMA; abnormal TAST; family history of birth defects, mental retardation, or genetic diseases; personal
history of birth defects, mental retardation or genetic disease; exposure to
teratogens, abnormal ultrasound findings, recurrent pregnancy loss (2 or more), consanguineous
mating
b. Requires:
□ all prenatal labs (including TAST, hemoglobin electrophoresis, Pap,
GC/CT),
□ documentation of specific reason for referral and all supporting information,
□ copy of any ultrasounds done
7. NST—
a. Postdates pregnancy (41 wks) or A1 (diet controlled) GDM (40 weeks)
b. Done on Mon, Tues, Thurs and Fri (Mon, Thurs, Fri preferred)
c. Requires:
□ all prenatal labs including Pap, GC/CT, GBS and date of its collection,
□ copy of all ultrasounds
8. Pregnancy and Hypertension (Chronic or Pregnancy Induced)—
a. Requires:
□ Prenatal labs (including Pap and GC/CT), TSH, Free T4, 24 hour urine for
creatinine clearance and total protein
Pg. 12
9. History of 2 or more spontaneous abortions (<14 wks)—
a. Genetics referral (see above);
b. Send Lupus Anticoagulant and Anticardiolipin Antibodies; if abnormal, then refer.
c. Requires:
□ prenatal labs (including Pap and GC/CT),
□ abnormal lab results as above
10. Pregnancy and history of previous second trimester loss (14-24 weeks)—
a. Send Lupus Anticoagulant and Anticardiolipin Antibodies, Protein C, Protein S, Factor V Leiden,
Antithrombin III, MTHFR mutation
b. Requires:
□ prenatal labs (including Pap and GC/CT), lab results as above
11. Pregnancy and history of premature birth (24-36 weeks)—
a. Provide protection against recurrent preterm birth
b. Requires:
□ Singleton pregnancy 15-24 weeks with a documented previous delivery prior to 37 weeks.
□ No multiple gestations known fetal anomaly, progesterone or heparin use in this pregnancy,
current or planned cervical cerclage, CHTN requiring medication,
seizure disorder, delivery planned outside of Brackenridge or AWH.
□ Ultrasound required between 14 and 20-6/7 weeks to confirm dating and identify major fetal
abnormalities.
□ Must sign release of information to obtain records from previous pregnancy ending in preterm
delivery (singleton between 20 and 36-6/7 weeks gestation due to
spontaneous preterm labor or PPROM).
□ Patient must be willing to attend weekly appointments at HROB and receive weekly
progesterone shots from 24-37 weeks of pregnancy
□ copy of all ultrasounds
Pg. 13
1. Placenta Previa—
a. Confirmed by ultrasound between 24-28 weeks of gestation
b. Requires:
□ copies of all ultrasounds;
□ DO NOT COLLECT PAP AND GC/CT IF NOT DONE PRIOR TO 24-28
WEEK DIAGNOSIS
2. Multiple gestation—
a. Confirmed by ultrasound (we must have a copy of this ultrasound)
b. Requires:
□ copies of all ultrasounds
3. Large/small for dates—
a. Only refer once confirmed by OB physician; Fundal height must be more than 3 cm off of
gestational age
b. Requires:
□ OB and master EMR copy (which includes all prenatal visits and info to date),
□ ultrasound done (either by ARA or NE) confirming <10% EFW for gestational age,
>90% EFW for gestational age, AFI<5cm or AFI >25cm
4. Cholestasis of pregnancy—
a. Pruritis without skin changes; Elevated liver function tests; Elevated fasting bile acids
b. Requires:
□ Pruritis without skin changes with either (or both) elevated liver function tests or
elevated fasting bile acids
□ copies of abnormal labs,
□ copies of any ultrasounds
5. Breech >36 weeks—
a. Requires:
□ copies of any ultrasounds
Pg. 14
6. HIV/AIDS and pregnancy—
a. Requires:
□ most recent viral load and CD4 count,
□ Hepatitis C antibody,
□ any ultrasounds,
□ copies of last clinic notes detailing disease diagnosis, co-morbid conditions or defining illnesses
and treatment
7. Thyroid disorder and pregnancy—
a. Requires:
□ all prenatal labs (including Pap and GC/CT), TSH, Free T4,
□ any ultrasounds,
□ copies of last clinic notes detailing thyroid disease diagnosis and duration of disease and treatment,
□ copy of last endocrine consultation if done.
8. Renal disorder and pregnancy—
a. Requires:
□ copy of any ultrasounds done (pregnancy or renal),
□ copies of last clinic notes detailing renal disorder/diagnosis, duration of disease and treatment,
□ copy of last renal consultation if done,
□ 24 hour urine protein for creatinine clearance and total protein, CMP (complete
metabolic panel) with calcium and phosphorus
9. Drug Dependence and pregnancy—
a. Requires:
□ urine and serum drug screen results,
□ copy of any ultrasounds done,
□ copies of last clinic notes outlining drugs of use/abuse and duration as well as past treatment
Pg. 15
10. Lupus and pregnancy—
a. Requires:
□ 24 hour urine for creatinine clearance and total protein,
□ ANA, anti-Ro and anti-La antibodies, CMP (complete metabolic panel) with calcium and
phosphorus,
□ copy of last clinic notes detailing diagnosis, duration of disease,
manifestations, treatment,
□ copy of last rheumatology consult if done
11. Seizure disorder and pregnancy—
a. Requires:
□ copy of last CT scan and EEG if done,
□ copy of last neurology consult if done, copy of any ultrasounds done
a. At time of recognition of need for referral, start patient on 4mg folic acid daily
12. Mental illness and pregnancy—
a. We do not accept referrals for this diagnosis. Please refer to MHMR or private psychiatry.
If there are any questions regarding the safety of psychiatric medications in pregnancy, please call the L&D cell
phone (450-3775), and the appropriate follow-up can be arranged. Patient
may prefer to call Texas Teratogen Jnformation Service for free pregnancy exposure/risk counseling at 1800-733-4727.
13. Cardiac disease and pregnancy—
a. Requires:
□ last EKG if done,
□ last echo if done,
□ last cardiology consultation if done,
□ last clinic notes detailing diagnosis and treatment
Pg. 16
14. Hepatic disease and pregnancy—
a. Requires:
□ copy of any ultrasounds done, liver function tests, coagulation tests (PT, PTT, INR),
hepatitis panel,
□ last GI consultation if done,
□ last abdominal ultrasound if done,
□ last clinic notes detailing diagnosis and treatment
Pg. 17
Guidelines for Diabetes in Pregnancy
Effective Date 7/1/11
*This document does not define a standard of care, nor is it intended to dictate an exclusive course of management.
There are other accepted strategies for the management of diabetes in pregnancy.
I.
Screening for gestational diabetes mellitus (GDM) (from Metzger BE, et al. Diabetes Care 2010,
33:676-681)
A. Universal screening at 24-28 weeks. If pregestational diabetes is present by history, then
screening is not necessary. Management will be with insulin. Further assessment as described in
Appendix A.
B. Selected screening early in pregnancy should be performed at the first prenatal visit.
1. Indications for select early screening:
a. History of gestational diabetes in a prior pregnancy
b. Previous macrosomic infant (>4000 gm)
c. Family history of diabetes in first degree relative
d. Obesity (BMI > 30)
e. Unexplained stillbirth in previous pregnancy
f. Maternal age at delivery to be > 35
2. Diagnostic Criteria for overt diabetes (to be measured on high risk women described as above)
First prenatal visit
Measure AIC (this is the preferred method; others listed below)
To diagnose overt diabetes in pregnancy
Measure of glycemia
FPG‡
A1C‡
Random plasma glucose
Consensus threshold
>7.0 mmol/l (126 mg/dl)
>6.5% (DCCT/UKPDS standardized)
>11.1 mmol/l (200 mg/dl) + confirmations
* ‡One of these must be met to identify the patient as having overt diabetes in pregnancy. sIf a random plasma glucose is the initial
measure, the tentative diagnosis of overt diabetes in pregnancy should be confirmed by FPG or A1C using DCCT/UKPDSstandardized assay
3. If overt diabetes is diagnosed, then treatment and follow-up as for preexisting diabetes. Refer
to High Risk OB (HROB).
4. If results are not diagnostic of overt diabetes and fasting plasma glucose >5.1
mmol/l(92 mg/dl) but <7.0 mmol/l (126 mg/dl), then diagnose as GDM. Management as
described in section II and III of this document. It the fasting
plasma glucose is <5.1 mmol/l (92 mg/dl), test for GDM from 24 to 28 weeks’ gestation
with a 75-g OGTT
Pg. 18
G uid e li ne s f o r D ia b e tes i n P r e g na nc y (C o nti n u e d)
C. If the early screen at first prenatal visit is negative (<5.1 mmol/1 or <92 mg/dl), then repeat at 24-28 weeks.
Screen with a 2hr 75gm oral glucose tolerance test (75gm OGTT)
D. Screen with 75 gm oral glucose tolerance test:
1. Diagnostic Criteria:
1. Positive screen when any one or more values is elevated
2. Method:
1. At least 8 hours of fasting prior to 75gm glucose screen
1. Fasting blood glucose followed by a 2 hour 75gm oral glucose
tolerance test
2. Plasma glucose at 1, and 2 hours after ingestion of glucose
3. Diagnosis of gestational diabetes: at least one abnormal value: Fasting >
92 mg/dl
1 hour >
180 mg/dl
2 hour >
153 mg/dl
4. Diagnosis of overt diabetes if fasting plasma glucose is > 126 mg/dl. Refer to HROB.
Management with insulin and further assessment as described in Appendix A.
II.
Management
A. Refer to Diabetes Education (see Appendix B for summary of education)
B. Diet
1. Arrange Nutritional counseling
2. IDEAL body weight (IDBW): 5 ft= 100lb. + 5lb. for every inch >5 ft.
3. Caloric intake: 30K cal/kg/day if body weight is IDBW +/- 20%.
This may be adjusted by dietician depending on body weight.
4. CHO, 40%; Protein, 20%- 30%; fat, 20%-30%.
5. 3 Meals and 2- 3 snacks daily.
C. Glucose monitoring four times daily: Fasting and 2hr glucose after breakfast, lunch
and dinner
D. Issue Glucometer and give education. A glucose log must be kept by patients. Check
fasting glucose and 2 hours after main meals (2 hr pc); four times daily. Record mean
fasting and mean 2 hr pc values each visit in the progress note.
E. If the mean fasting glucose is greater than 92 mg/dl, or the mean 2 hour post prandial
glucose is greater than 120 mg/dl, refer the patient to the High Risk
Obstetrics clinic within one week.
F. If the mean fasting glucose is greater than 120 mg/dl or if 2 hour glucose mean is
greater than 200 mg/dl then, this patient needs immediate evaluation. Consult with the UMCB
faculty at 512-450-3775.
Pg. 19
G uid e li ne s f o r D ia b e tes i n P r e g na nc j ( C o nti n ue d)
III.
Therapy — women needing therapy other than diet should be referred to HROB.
A. Insulin (Humulin)
Initial calculation for total dose:
.8 units/kg/IBW daily — first trimester
.9 units/kg/IBW daily — second trimester
1.0 units/kg/IBW daily — third trimester
2/3 AM (3/4 NPH, ¼ Humalog) — @ breakfast
1/3 PM (1/2 NPH, ½ Humalog) — Humalog @ supper; NPH @ bedtime snack
B. Oral Agent Therapy — see Appendix C. In general this is reserved for gestational
diabetes only. Overt or preexisting diabetes should be managed with insulin in almost all
cases.
IV.
V.
Antenatal Testing
A. A1 diabetes
Fetal movement chart at 36 weeks
NST twice weekly at 40 weeks
B. A2 diabetes (uncomplicated)
NST weekly at 32 weeks; twice weekly at 36 weeks
C. Pregestational or overt diabetes (uncomplicated) Fetal
movement chart at 28weeks NST twice
weekly at 32 weeks
D. Diabetes complicated by hypertension, other evidence of vascular disease, renal or
eye involvement, or other significant medial or obstetric complications.
E. Other interventions and testing as indicated by clinical finding
Delivery
A. Al diabetes at 4l weeks
B. Medically managed or insulin dependent diabetes 38.5 to 40 weeks depending on control and
patient reliability
C. Delivery prior to 38.5 week may require amniocentesis for pulmonary maturity, unless an absolute
indication for delivery based on maternal or fetal condition exists. There is considerable controversy
surrounding this issue.
Pg. 20
A p p e nd ix A
Early Assessment (< 20 weeks) - Overt or Pregestational Diabetes
MATERNAL
Physical Exam
Evaluate for:
Possible Tests
Recommendation
HTN
Retinopathy
EKG
Retinal evaluation
Goiter
Nephropathy
T4, TSH 24 hr urine
Collection for Cr. Cl.
Ophthalmology Consult
Consult with appropriate
Medical or MFM consult if
and total protein, and required urine
culture
Obesity
Glucometer (test 4 times daily)
Glycemic Control
Nutritional Counseling
regarding obesity
Hb A1C
Diabetic Counseling
Dietician consult
FETA L
Gestational Age Assessment
Physical Exam
Early ultrasound if possible
Anatomic Assessment
Appropriate fetal screening
MFM Consult in all cases
(1st or 2nd trimester
ultrasound for dating)
MS-AFP at 15 0/7
(even if they had a 1st
trimester screening) This is
valid through 20 0/7 weeks Targeted
ultrasound at
18 -22 weeks for anatomy
Fetal echocardiogram at 24 weeks
Pg. 21
A p p e nd ix B
Guidelines for Diabetes Education
1.
Patients new to the OB Diabetic Clinic are provided education on Mondays, in a class setting. Education is
provided in the client’s primary language. The template is for 3 classes
of 4 patients each at 8:30am, 10:00 am and 11:30 am. Patients are instructed on importance of good
control of blood sugar during pregnancy, as well as possible complication with poor
control. Patients are encouraged to walk for exercise, unless medically prohibited. They are also instructed on
exercise precautions. They are instructed on use of the glucose log, timing
of testing for fasting and 2 hours after meals, and glucose logs. MAP patients are provided with a Contour
Meter and instructed in its use as well as in the use of the control solution. Documentation is recorded in
NextGen.
2.
Patients are counseled on a 2000 calorie Gestational Diabetes meal plan of 3 meals and 3 snacks.
Reference materials are provided for the meal plan, food safety, risk reduction of
Type 2 Diabetes (when applicable) and healthy food habits for infants and children. Food models are used to
demonstrate sample meals, snacks and food portion sizes and patients
are evaluated on their knowledge of foods high in carbohydrates. Patients are also provided with a 1 week
food log to record their intake and are asked to return it at their next clinic
visit. The dietitian will review the food log with the patient and provide feedback.
Documentation is recorded in NextGen.
3.
Tuesdays, the dietitian and nurse educator are available in the clinic to follow up on patients taught the
previous week in class, to teach patient needing Glyburide or insulin and to see any patients referred by the
physician. We like to follow up with any patients who have been discharged from the hospital.
4.
Please order insulin dose in increments of 2. We try to teach all patients needing insulin on the 1 cc insulin
syringes which are marked only in 2’s, so even numbers of insulin can
confusing to our clients.
Pg. 22
A p p e nd ix C
Oral Agent Therapy for Gestational Diabetes (NEJM 2OOO: 343:1134-8)
Hyperglycemia Not
Controlled by Diet
and requiring Therapy
Physician review. Decision to
start Glyburide
Start Glyburide 2.5 mg q. a.m.
Follow up in One Week
Patient Experiencing Hypoglycemia
Yes
Consider decreasing oral agent
and change food plan
No
Blood Glucose Improving
as expected
Yes
Patients remains on oral
agent.
No Increase
Oral Agent
(Glyburide)
Recommended Dose Adjustments (mg)
Increase once weekly Up
to 6 week period
Start
a.m.
Next
a.m.
Next
am-pm
Next
am-pm
Max
am-pm
2.5 mg
5 mg
5mg/lOmg
lOmg/5mg
lOmg/lOmg
am = before breakfast pm =
bedtime
Pg. 23
Glucose control achieved?
Yes
No
Continue dose
Switch to insulin
Ultrasounds — Level II
Scope:
□ To perform Level II Targeted Ultrasounds for high-risk OB patients.
Appropriate patients for referral into include:
□ Rh disease
□ Fetal anomaly identified on a prior scan
□ Targeted anatomy scan for diseases and situations where there is a known risk of increased incidence of fetal
abnormalities (e.g. seizure disorder, Class B Diabetes, Congenital Heart Disease)
□ Targeted anatomy scan for history of a prior infant with an abnormality
□ Abnormal TAST and only if they want Genetic Counseling
□ AMA (Advance Maternal Age) only if they want Genetic Counseling
□ Targeted scan for known twins
□ Growth scans for known twins
□ Suspected pelvic mass
□ Suspected uterine anomaly
Please do NOT refer the following patients to our clinic:
□
□
□
□
Level I (routine) Ultrasounds
Dating/Unsure of last menstrual period
Size greater/less than dates
Fetal Presentation
□ ACOG
□ Any completed USG results
appointment time.
Pg. 24
GUIDELINES FOR DIABETES IN PREGNANCY
EFFECTIVE DATE 7/1/11
*This document does not define a standard of care, nor is it intended to dictate an exclusive
course of management. There are other accepted strategies for the management of diabetes in
pregnancy.
I.
Screening for gestational diabetes mellitus (GDM) (from Metzger BE, et al. Diabetes
Care 2010, 33:676-681)
A. Universal screening at 24-28 weeks
If pregestational diabetes is present by history, then screening is not necessary.
Management will be with insulin. Further assessment as described in Appendix A.
B. Selected screening early in pregnancy should be performed at the first prenatal visit.
1. Indications for select early screening:
a. History of gestational diabetes in a prior pregnancy
b. Previous macrosomic infant (>4000 gm)
c. Family history of diabetes in first degree relative
d. Obesity (BMI > 30)
e. Unexplained stillbirth in previous pregnancy
f. Maternal age at delivery to be > 35
2. Diagnostic Criteria for overt diabetes (to be measured on high risk women
described as above)
First prenatal visit
Measure AIC (this is the preferred method; others listed below)
To diagnose overt diabetes in pregnancy
Measure of glycemia
Consensus threshold
FPG‡
>7.0 mmol/l (126 mg/dl)
A1C‡
>6.5% (DCCT/UKPDS standardized)
Random plasma glucose
>11.1 mmol/l (200 mg/dl) + confirmation§
* ‡One of these must be met to identify the patient as having overt diabetes in pregnancy. §If a random
plasma glucose is the initial measure, the tentative diagnosis of overt diabetes in pregnancy should be
confirmed by FPG or A1C using DCCT/UKPDS-standardized assay
.
3. If overt diabetes is diagnosed, then treatment and follow-up as for preexisting
diabetes. Refer to High Risk OB (HROB).
4. If results are not diagnostic of overt diabetes and fasting plasma glucose >5.1 mmol/l
(92 mg/dl) but <7.0 mmol/l (126 mg/dl), then diagnose as GDM. Management as
described in section II and III of this document. It the fasting plasma glucose is <5.1
mmol/l (92 mg/dl), test for GDM from 24 to 28 weeks’ gestation with a 75-g OGTT
Revised 6/24/11
C. If the early screen at first prenatal visit is negative (<5.1 mmol/1 or <92 mg/dl),
then repeat at 24-28 weeks. Screen with a 2hr 75gm oral glucose tolerance test
(75gm OGTT)
D. Screen with 75 gm oral glucose tolerance test:
1. Diagnostic Criteria:
1.
Positive screen when any one or more values is elevated
2. Method:
1. At least 8 hours of fasting prior to 75gm glucose screen
2. Fasting blood glucose followed by a 2 hour 75gm oral glucose
tolerance test
3.
Plasma glucose at 1, and 2 hours after ingestion of glucose
3. Diagnosis of gestational diabetes: at least one abnormal
value: Fasting>
92 mg/dl
1 hour >
180 mg/dl
2 hour >
153 mg/dl
4. Diagnosis of overt diabetes if fasting plasma glucose is > 126 mg/dl. Refer to
HROB. Management with insulin and further assessment as described in
Appendix A.
II.
Management
A. Refer to Diabetes Education (see Appendix B for summary of education)
B. Diet
1.
Arrange Nutritional counseling
2.
IDEAL body weight (IDBW): 5 ft= 100lb. + 5lb. for every inch
>5 ft.
3.
Caloric intake: 30K cal/kg/day if body weight is IDBW +/- 20%.
This may be adjusted by dietician depending on body weight.
4.
CHO, 40%; Protein,20%- 30%; fat, 20%-30%.
5.
3 Meals and 2- 3 snacks daily.
C. Glucose monitoring four times daily: Fasting and 2hr glucose after breakfast,
lunch and dinner
D. Issue Glucometer and give education. A glucose log must be kept by patients.
Check fasting glucose and 2 hours after main meals (2 hr pc); four times daily.
Record mean fasting and mean 2 hr pc values each visit in the progress note.
E. If the mean fasting glucose is greater than 92 mg/dl, or the mean 2 hour post
prandial glucose is greater than 120 mg/dl, refer the patient to the High Risk
Obstetrics clinic within one week.
Revised 6/24/11
F. If the mean fasting glucose is greater than 120 mg/dl or if 2 hour glucose mean is
greater than 200 mg/dl then, this patient needs immediate evaluation. Consult
with the UMCB faculty at 512-450-3775.
III.
Therapy — women needing therapy other than diet should be referred to HROB.
A. Insulin (Humulin)
Initial calculation for total dose:
.8 units/kg/IBW daily — first trimester
.9 units/kg/IBW daily — second trimester
1.0 units/kg/IBW daily — third trimester
2/3 AM (3/4 NPH, ¼ Humalog) — @ breakfast
1/3 PM (1/2 NPH, ½ Humalog) — Humalog @ supper; NPH @ bedtime snack
B. Oral Agent Therapy — see Appendix C. In general this is reserved for gestational
diabetes only. Overt or preexisting diabetes should be managed with insulin in
almost all cases.
IV.
V.
Antenatal Testing
A. A1 diabetes
B. A2 diabetes (uncomplicated)
NST weekly at 32 weeks; twice weekly at 36 weeks
C. Pregestational or overt diabetes
(uncomplicated) Fetal movement chart
at 28weeks
D. Diabetes complicated by hypertension, other evidence of vascular disease,
renal or eye involvement, or other significant medial or obstetric complications.
E. Other interventions and testing as indicated by clinical finding
Delivery
A. A1 diabetes at 41 weeks
B. Medically managed or insulin dependent diabetes 38.5 to 40 weeks depending on
control and patient reliability
C. Delivery prior to 38.5 week may require amniocentesis for pulmonary maturity,
unless an absolute indication for delivery based on maternal or fetal condition
exists. There is considerable controversy surrounding this issue.
Revised 6/24/11
Appendix A
Early Assessment (< 20 weeks)
Overt or Pregestational
Diabetes
MATERNAL
Physical Exam
Possible Tests
Recommendation
EKG
Retinal evaluation
T4, TSH 24 hr urine
Collection for Cr. Cl.
and total protein, and
urine culture
Ophthalmology Consult
Consult with appropriate
Medical or MFM consult if
required
Evaluate for:
HTN
Retinopathy
Goiter
Nephropathy
Obesity
Glucometer (test 4 times daily)
Glycemic Control
regarding obesity
Hb A1C
Diabetic Counseling
Dietician consult
FETAL
Gestational Age Assessment
Physical Exam
Early ultrasound if possible
Anatomic Assessment
MFM Consult in all cases
Appropriate fetal
st
nd
screening (1 or 2
trimester ultrasound for
dating)
MS-AFP at 15 0/7
(even if they had a 1st
trimester screening) This is
valid through 20 0/7 weeks
Targeted ultrasound at
18 -22 weeks for anatomy
Fetal echocardiogram at 24 weeks
Revised 6/24/11
Appendix B
CommUnityCare Diabetes and Pregnancy Clinic
Guidelines for Diabetes Education
1.
Patients new to the OB Diabetic Clinic are provided education on Mondays, in a class
setting. Education is provided in the client’s primary language. The template is for 3
classes of 4 patients each at 9am, 10:30 am and 12 noon. Patients are instructed on
importance of good control of blood sugar during pregnancy, as well as possible
complication with poor control. Patients are encouraged to walk for exercise, unless
medically prohibited. They are also instructed on exercise precautions. They are
instructed on use of the glucose log, timing of testing for fasting and 2 hours after meals,
and glucose logs. MAP patients are provided with a Contour Meter and instructed in its
use as well as in the use of the control solution. Documentation is recorded in NextGen.
2.
Patients are counseled on a 2000 calorie Gestational Diabetes meal plan of 3 meals and
3 snacks. Reference materials are provided for the meal plan, food safety, risk reduction
of Type 2 Diabetes (when applicable) and healthy food habits for infants and children.
Food models are used to demonstrate sample meals, snacks and food portion sizes and
patients are evaluated on their knowledge of foods high in carbohydrates. Patients are
also provided with a 1 week food log to record their intake and are asked to return it at
their next clinic visit. The dietitian will review the food log with the patient and provide
feedback. Documentation is recorded in NextGen.
3.
Tuesdays, the dietitian and nurse educator are available in the clinic to follow up on
patients taught the previous week in class, to teach patient needing Glyburide or insulin
and to see any patients referred by the physician. We like to follow up with any patients
who have been discharged from the hospital.
4.
Please order insulin dose in increments of 2. We try to teach all patients needing insulin
on the 1 cc insulin syringes which are marked only in 2’s, so even numbers of insulin can
confusing to our clients.
Thank you,
Bea Guerra, RN and Dahlia Gamez, RN, CDE
Revised 6/24/11
Appendix C
Oral Agent Therapy for Gestational Diabetes (NEJM 2OOO: 343:11348) Hyperglycemia Not
Controlled by Diet
and requiring
Therapy
Physician review.
Decision to start
Glyburide
Start Glyburide 2.5 mg q. a.m.
Follow up in One Week
Patient Experiencing Hypoglycemia
Yes
Consider decreasing or agent
And change food plan
No
Blood Glucose Improving
as expected
Yes
Patients remains on oral
agent.
No
Increase Oral Agent
(Glyburide)
Recommended Dose Adjustments (mg)
Increase once weekly
Up to 6 week period
Start
Next
Next
Next
Max
a.m.
a.m.
am-pm
am-pm
am-pm
Yes
No
2.5 mg
5 mg
1Omg/1Omg
Continue dose
Switch to insulin
5mg/1Omg 1Omg/5mg
am = before
breakfast pm =
bedtime
Glucose control achieved?
Effective date 7/1/11
13. QUICK REFERENCE: CONTACTS AND
HELPFUL NUMBERS
MAP Contact Information for Services Rendered
On and After November 26, 2015
Department
Benefits and Eligibility Verification
Phone/Fax
Online:
www.medicaider.com/medicaid/mana
ger/start.asp.
Telephone: 512-978-8130
Case Management
Telephone: 512-978-8300 Option 2
CCC Fax: 512-901-9787
Claims and/or Appeals (Electronic)
Seton Health Plan/MediView:
CCC MAP EDI Vendor ID: TCMAP
Seton MAP EDI Vendor ID: SHMAP
Claims and/or Appeals (Paper)
Claims Customer Service
CCC MAP
Travis County MAP
PO Box 14447
Austin, TX 78761
SHP MAP
PO Box 14447
Austin, TX 78761
512-421-5664
Community Care Collaborative
1111 E. Cesar Chavez St.
Austin, TX 78702
Telephone: 512-978-8300
Credentialing
512-324-3125
MAP Customer Service
MAP Enrollment
512-978-8130
Health Service – authorization and
medical management (UM)
512-324-3135
Secure Fax: 512-380-4253
Pharmacy Hotline
Telephone: 512-978-8139
Fax: 512-901-9763
512-324-3125
Seton Health Plan Provider Relations
Bus Service (Public Transportation)
Capital Metro: 512-474-1200
CARTS: 512-478-7433
14. FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS
MAP Enrollment
Who may quality for MAP?
o Travis County residents with family incomes at or below 100 percent of
the Federal Poverty Index Guidelines (FPIG) and have no other health
care coverage (such as Medicaid or Medicare).
o Travis County residents who are disabled or elderly with incomes at or
below 200 percent of the Federal Poverty Index Guidelines and have
no other health care coverage (such as Medicaid or Medicare).
o Travis County residents with Medicaid or Medicare will not qualify for
MAP benefits. Persons who do not qualify for MAP may be eligible for
other programs that offer health care services at reduced rates.
What color is the MAP card?
The MAP card is pink.
What is the length of issuance for MAP coverage?
The length of issuance for MAP coverage may range from one month to
one year and is dependent on the enrollee’s circumstances as determined
during the enrollment process.
What if an enrollee lost her/his MAP card?
An enrollee should be referred to the Customer Service Call Center at (512)
978-8130 to obtain a replacement MAP identification card.
To verify coverage, visit the Provider Self Service website.
What if an enrollee wants to report a change of address?
An enrollee should be referred to the Customer Service Call Center at (512)
978-8130 to report a change of address.
Coverage Verification
How do I verify MAP coverage and co-payments?
Providers can verify an enrollee’s MAP information on-line using the
Provider Self-Service website using the below link:
www.medicaider.com/medicaid/manager/start.asp
You will find instructions on how to register for the Provider Self-Service,
and reading the MAP ID card in this handbook.
What if an enrollee has expired MAP coverage?
Enrollees are encouraged to call the Customer Service Call Center at (512)
978-8130 two to three (2-3) weeks in advance of her or his MAP expiration
date to schedule an enrollment/eligibility appointment.
Pharmacy Services
Which pharmacies are in the MAP network?
The list of MAP network pharmacies is included in this handbook. For
additional information contact the MAP Pharmacy hotline at (512) 9788139.
What medications are covered by MAP?
MAP covers most medications needed by enrollees. The MAP Formulary is
included in this handbook. For additional information contact the MAP
Pharmacy hotline at (512) 978-8139.
What if the enrollee cannot tolerate generic or formulary medications?
The provider may submit a Medication Override Request Form on the enrollee’s behalf. For
additional information contact the MAP Pharmacy hotline at (512) 978-8139.
Where can I get the Medication Override Request Form?
The form is included in this handbook. For additional information contact the MAP Pharmacy
hotline at (512) 978-8139.
What can I do if I receive calls from enrollees about pharmacy services?
All callers inquiring about pharmacy services should be directed to the MAP Pharmacy Hotline
at (512) 978-8139.
What if the enrollee is not satisfied with treatment or medical care?
Please encourage enrollees to discuss any concerns or questions about her or his treatment or
medical care with his/her primary care provider. If the enrollee is unable to resolve issues
with the primary care office, please give the enrollee our telephone number (512) 978-8150.

O bs te tr ics C li ni c W orksh ee t (con ti n ue d)

Transcription

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