96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

ADMINISTRATION DIN

Table: ADMINISTRATION DIN
Drug strength and dosage form DIN Brand name Manufacturer code
Miscellaneous 00903725 REFUSAL TO FILL UNK

BASES-EMULSIONS

Limited use benefit (prior approval required).

For the treatment of atopic dermatitis in children 0 to 18 years old.

Coverage is limited to 450 grams per month.

Table: BASES-EMULSIONS
Drug strength and dosage form DIN Brand name Manufacturer code
ST Cream 99000385 EMOLLIENT FOR CHILDREN WPC

DEVICE (METHADONE)

Limited use benefit (prior approval is not required).

Coverage is granted for 1 device.

Table: DEVICE (METHADONE)
Drug strength and dosage form DIN Brand name Manufacturer code
Miscellaneous 91500016 METHADONE LOCK BOX UNK

INFANT FORMULATION

Limited use benefit (prior approval required).

Infant formula coverage for children < 1 year of age (corrected gestational age for prematurity).

Coverage for infant formula is provided for medically necessary conditions until the first year of gestational age. Examples of medically necessary conditions include: cow's milk protein allergy, failure to thrive, contraindications for breast feeding, prematurity or low birth weight. On an exception basis, other conditions will be considered with the appropriate rationale for medically necessary.

Table: INFANT FORMULATION
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 95900000 ALIMENTUM ABB
Oral Liquid 95900001 ALIMENTUM UNK
Oral Liquid 95900003 ENFAMIL A+ MJO
Oral Liquid 95900007 ENFAMIL A+ READY TO FEED MJO
Oral Liquid 95900152 ENFAMIL ENFACARE A+ MJO
Oral Liquid 95900012 ENFAMIL LOWER IRON RTF MJO
Oral Liquid 95900026 NUTRAMIGEN A+ MJO
Powder 95900047 ALIMENTUM PDR (400G) ABB
Powder 95900164 ENFAMIL A+ 663G PDR MJO
Powder 95900009 ENFAMIL ENFACARE A+ 363G PDR MJO
Powder 95900155 ENFAMIL LOW IRON FORMULA 900GM MJO
Powder 95900025 NEOCATE W/ DHA & ARA 400G PDR UNK
Powder 95900027 NUTRAMIGEN A+ LGG 561G PDR MJO
Powder 95900035 PURAMINO A+ PDR MJO
Powder 95900036 SIMILAC ADVANCE NEOSURE 363G UNK
Powder 95900044 SIMILAC PM 60/40 450G PDR UNK

NUTRITIONAL SUPPLEMENT

Table: NUTRITIONAL SUPPLEMENT
Drug strength and dosage form DIN Brand name Manufacturer code
Powder 09991319 SOURCE THICKEN UP 227G NVC

THICKENING AGENT

Table: THICKENING AGENT
Drug strength and dosage form DIN Brand name Manufacturer code
Kit 09991194 SIMPLY THICK 64OZ BOTTLE PUMP UNK
Powder 12137029 RESOURCE THICKEN CLEAR NVC
Powder 09991163 RESOURCE THICKEN UP 6.4G NVC

THICKENING GEL

Table: THICKENING GEL
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 09991164 SIMPLY THICK HONEY UNK
Oral Liquid 09991035 SIMPLY THICK NECTAR UNK

WATER

Table: WATER
Drug strength and dosage form DIN Brand name Manufacturer code
Solution 00905178 STERILE WATER UNK
Solution 99002264 STERILE WATER UNK
Syringe 09991563 STERILE WATER PF UNK
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