Michigan Department of Community Health Co-pay and Quantity Limitations Benefit Plan Co-pay Information Group ID Coverage Co-pay INCARCE Incarcerated Medicaid No coverage No coverage patients SHPDUAL CSHCSCAID Health Plan with Medicaid and CSHCS Children's Special HealthCare Services with Medicaid Standard Standard with Children's special health SHP5ONLY Health Plan with CSHCS Select mental health and CSHCS5ONLY Children's Special HealthCare Services Standard with Children's special health HPHKFULLCAID Health Plan with Medicaid Select mental health and HKFULLCAID Healthy Kids Medicaid Standard FULLREFCAID Full Refugee Medicaid Standard HPFULLCAID Health Plan Full Medicaid Select mental health and FULLCAID Full Medicaid Standard MOMS EMERREFCAID HKEMERGCAID Maternity Outpatient Medical Services Emergency Refugee Medicaid Healthy Kids Emergency Medicaid Pregnancy related medications Standard Standard EMERGCAID Emergency Medicaid Standard SMPCOP State Medical Plan- County Plan Coverage Select mental health and $1.00 1
Group ID Coverage Co-pay SMPFULL State Medical Plan Standard $1.00 SMPEMERG State Medical Plan Emergency Standard $1.00 HPTMACAID Health Plan Full Medicaid Select mental health and HPTMAPLUS Health Plan Full Medicaid Select mental health and Antiviral TMAPLUSFULL Full Medicaid Standard TMACAID Full Medicaid Standard TMAEMERG Emergency Medicaid Standard TMAPLUSEMERG Emergency Medicaid Standard FAMILYPLAN Family Planning Waiver Pregnancy prevention and related medications QMB Qualified Medicare beneficiary Medicare Part B covered drugs Quantity Limitations Drug Code Azithromycin 1g tabs (Zithromax) Azithromycin 250mg tabs (Zithromax) Azithromycin 500mg tabs (Zithromax) Azithromycin 600mg tabs (Zithromax) Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 3 per fill 1 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days 2
Advair HFA Aerobid Aerobid M Drug Code Albuterol HFA 90mcg Aldara Alinia 500mg, Alinia Susp Amerge 1mg, 2.5mg Amitiza Anaphylaxis Therapy Agents Anzemet Asmanex 220mcg (120) Asmanex 220mcg (14) Asmanex 220mcg (30) Asmanex 220mcg (60) Atrovent HFA Avelox Avonex 30mcg Avonex 30mcg kit Axert Azithromycin susp (Zithromax) Boniva 150mg Buproprion SR (Zyban) 180 every 30 days 0.5 per day 0.5 per day 1. 36 every 112 days 9 per fill Maximum of 90 days supply per lifetime 3 per fill 10 per fill 0. 0.5 per day 0.3 per day 0. 0.9 per day 1 9 per fill 1 every 14 days 0.04 per day 60 every 30 days Butorphanol Tartrate (Stadol NS) 15 every 30 days Catapres TTS Cedax Cefaclor (Ceclor) Cefadroxil (Duricef) Cefdinir (Omnicef) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cefuroxime (Ceftin) 1 1 4 4 3
Celebrex Celexa solution Chantix Drug Code Ciprofloxacin (Cipro) Citalopram 10mg( Celexa) Clarithromycin (Biaxin) Combivent 1 per day. No more than 30 within 30 days 1,360 per fill. No more than 168 per 366 days 4 1 per day Condoms 1. No more than 36 within 30 days Copaxone Diaphragms Disposable Insulin syringes/supplies Duac CS Elidel Emend 125/80mg Emend 125mg Emend 40mg Emend 80mg Fentanyl Citrate (Actiq) Fentanyl patches (Duragesic) Fentora Flovent HFA 110mcg Flovent HFA 220 Flovent HFA 44mcg Fluconazole 150mg (Diflucan) Fluoxetine 10mg (Sarafem) Fluoxetine 10mg(Prozac) Fluoxetine 40mg(Prozac) Foradil Fosamax plus D 1 per fill 300 per fill 1 per fill 30 grams every 30 days 3 per fill 1 per fill 1 per fill 120 every 24 days 10 per fill 120 every 24 days 2.1 per day 1.3 per day 4.3 per day 3 68 per fill 0.9 per day 4
Frova Drug Code Glucagon emergency kit Granisetron (Kytril) Solution Granisetron 1mg (Kytril) Insulins Itraconazole (Sporanox) Janumet Januvia Ketorolac Tromethamine tabs (Toradol) Kristalose 10g Kristalose 20g Lactulose Lescol 40mg Levaquin 250mg & 500mg Levaquin 750mg Lexapro Lidoderm Lipitor Lyrica (all other strengths) Lyrica 225mg & 300mg Marinol Maxair Maxalt Nicotine Gum Nicotine Patches 18 per fill 150ml per fill 15 per fill 90 per fill 8 1 per day 21 per fill 6 per day 1. 180 per day 3 1 30 per rolling 30 days 90 every 30 days 60 every 30 days 120 every 30 days 0.5 per day 1 306 every 34 days 30 every 30 days Nonoxynol 9 1. No more than 36 within 30 days Noroxin Ondansetron (Zofran) Liquid Ondansetron tablets (Zofran) Ondansetron tablets (Zofran) 75 per fill 15 per fill 10 per fill 5
Drug Code Oral Contraceptives Oxycodone Extended release(oxycontin) Paroxetine (Paxil) Paroxetine CR ( Paxil CR) Peak Flow Meter Pegasys 180mcg kit Plan B Polyethylene Glycol (Miralax) Pravastatin (Pravachol) PrevPac Protopic Pulmicort Flexhaler Pulmozyme QVAR 40mcg QVAR 80mcg Rebif 44mcg Regranex Relenza Relpax Remodulin 10mg/ml Remodulin 1mg/1ml Remodulin 2.5mg/ml Remodulin 5mg/ml Risperdal Consta Sancuso Sarafem 20mg Selzentry Serevent Diskus Sertraline (Zoloft) Sertraline 100mg (Zoloft) 91 per fill 6 per day 4 every 365 days 1 per fill. No more than 0.4 per day 30 grams every 30 days 75 every 30 days 1.3 per day 0.8 per day 0.25 per day 30 grams per lifetime 20 per fill 1 40 per fill 400 per fill 160 per fill 80 per fill 2 syringes every 24 days 1 patch every 5 days 10 68 every 34 days 68 per fill 6
Drug Code Sertraline (Zoloft) Solution Simvastatin (Zocor) Spiriva Sporanox Liquid Streptomycin Sulfate Suboxone 2mg-0.5mg Suboxone 8mg-2mg Sumatriptan 20mg Nasal spray Sumatriptan 5mg Nasal spray Sumatriptan Succinate Sumatriptan Succinate 4mg/0.5 Sumatriptan Succinate 4mg/0.5 kit Sumatriptan Succinate 4mg/0.5 pen Sumatriptan Succinate 6mg/0.5 Sumatriptan Succinate 6mg/0.5 kit Sumatriptan Succinate 6mg/0.5 pen Suprax Symbicort 340 per fill 840 per fill 28 every 25 days 4 per day 3 per day 18 per fill 1 20. Taclonex oint 15 per day. No more than 28 every 365 days Taclonex Scalp Tamiflu caps Tamiflu susp Terbinafine (Lamisil) Triazolam (Halcion) 15 per day. No more than 28 days worth 365 days 1 50 per fill 8 10 every 30 days 7
Drug Code Vyvanse Xifaxan 200mg Zomig Zyvox Nuvaring Samsca 1 per day 9 per fill 1 1 per 21 days 30 day supply per fill Acetaminophen High Dose - Quantity Per Fill Edits Drug Max Daily Dose APAP 120 mg/codeine 12 mg/15 ml elixir 166.5 ml APAP 120 mg/hydrocodone 5mg/5ml liq. 166.5 ml APAP 160 mg tab 25 tabs APAP 160 mg tab chew 25 tabs APAP 167 mg/hydrocodone 2.5 mg/15 ml 120 ml APAP 300 mg/codeine 30 mg tab 13.3 tabs APAP 300 mg/codeine 60 mg cap 13.3 caps APAP 325 cap APAP 325 mg tab 12.3 tabs APAP 325 mg/codeine 15 mg cap APAP 325 mg/codeine 30 mg cap APAP 325 mg/codeine 60 mg cap APAP 325 mg/hydrocodone 10 mg tab 12.3 tabs APAP 325 mg/oxycodone 5 mg 61.5 ml APAP 325 mg/oxycodone 5 mg tab 12.3 tabs APAP 325 mg/propoxyphene nap. 50 mg 12.3 tabs APAP 325mg/codeine 30mg caps. APAP 356.4 mg/dihyrodcodeine 16 mg cap 11.2 caps APAP 400 mg/hydrocodone 10 mg tab 10 tabs APAP 400 mg/hydrocodone 5mg tab 10 tabs APAP 400 mg/hydrocodone 7.5 mg tabs 10 tabs APAP 500 mg cap 8 caps APAP 500 mg tab 8 caps 8
Drug APAP 500 mg/hydrocodone 10 mg tab APAP 500 mg/hydrocodone 2.5 mg tab APAP 500 mg/hydrocodone 5mg cap APAP 500 mg/hydrocodone 7.5 mg tab APAP 500 mg/hyrodocone 5 mg tab APAP 500 mg/oxycodone 5 mg tab APAP 500 mg/propoxyphene nap. 100 mg APAP 500mg/oxycodone 5 mg cap APAP 650 mg/codeine 30mg tabs APAP 650 mg/hydrocodone 10 mg tab APAP 650 mg/hydrocodone 7.5 mg tab APAP 650 mg/propoxyphene 65 mg tab APAP 660 mg/hydrocodone 10 mg tab APAP 750 mg//hyrodcodone 7.5 mg tab 8 caps 5.3 tabs Max Daily Dose 9