Max Days 100 NCPDP 76- Plan Limitations Exceeded (includes Maintenance Medications) /For PA, call ACS at 1-800-932-3918. Note: When AHFS codes are used, all sub classifications beginning with the digits specified are included.
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DEA = 2
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All Schedule II Narcotics
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GSN = 004964, 044980
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Leuprolide 3-month kit
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DCC = R
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Insulin Syringes
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AHFS = 24:04
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Cardiac Drugs
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AHFS = 24:06
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Antilipemic Agents
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AHFS = 24:08
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Hypotensive agents
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AHFS = 24:12
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Vasodilating agents
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AHFS = 24:12.08
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Vasodilating Agents
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AHFS = 24:16
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Sclerosin Agents
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AHFS = 24:20
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Alpha-adrenergic blocking agents
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AHFS = 24:24
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Beta-adrenergic blocking agents
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AHFS = 24:28
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Calcium channel blocking agents
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AHFS = 24:32
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Renin-angiotensin-aldosterone system inhibitors
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AHFS = 28:12:12
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Hydantoins
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AHFS = 28:12:16
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Oxazolidinediones
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AHFS = 28:12:92
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Anticonvulsants miscellaneous
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HIC3 = C1D
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AHFS 40:12 (Replacement Solutions)
Potassium supplements only
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Listed products only
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AHFS = 40:28
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Diuretics
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AHFS = 56:24
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Lipotropic agents
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AHFS = 68:16
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Estrogens and antiestrogens
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AHFS = 68:20
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Antidiabetic agents
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AHFS = 68:20.08
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Insulins
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AHFS = 68:20.20
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Sulfonylureas
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AHFS = 68:22
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Antihypoglycemic agents
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AHFS = 68:24
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Parathyroid
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AHFS = 68:32
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Progestins
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AHFS = 68:36
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Thyroid and Antithyroid agents
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AHFS = 68:36.04
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Thyroid Agents
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AHFS = 88:00
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Vitamins
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Legend products only
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HSN = 001879, 001878, 001877
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AHFS 28:12.12 (Hydantoins)
Phenytoin
Phenytoin Sodium
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Listed products only
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-
HSN = 000739; and
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Route = oral
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HIC3 = C3B; or HSN = 001025, 001029, 006485, 001024, 001095, 001086; and
Dosage Form = TC
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AHFS 20:04.04 (Iron preparations)
Oral products in which ferrous sulfate is the only active ingredient
Chewable tablets of any ferrous salt when combined with vitamin C, multivits, multivits + minerals, or other minerals in the formulation
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Listed products only
Note: OTC is not a requirement for these chewable Fe products (per regs)
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AHFS = 24:20
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Alpha-Adrenergic Blocking Agents
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AHFS = 24:24
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Beta-Adrenergic Blocking Agents
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AHFS = 24:28
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Calcium-Channel Blocking Agents
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AHFS = 24:32
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Renin-Angiotensin System Inhibitors
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AHFS = 24:32.04
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Angiotensin-Converting Enzyme Inhibitors
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AHFS = 24:32.08
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Angiotensin II Receptor Antagonists
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AHFS = 88:08:00
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Vitamin B Complex
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AHFS = 88:28:00
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Multivitamin Preparations
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GSN 026098
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Depo-Provera Contraceptive 150mg/ml Disposable Syringe
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GSN 017584
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Depo-Provera Contraceptive 150mg/ml Vial
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