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Search the formulary for limited home health supplies and vitamin and mineral products.  If this search is unavailable please contact the Vendor Drug Program.

Drug Name/Description FLUOXETINE HCL 20 MG CAPSULE
NDC # 68645013054  
Package Size 30
Units EA
Over the Counter (OTC)


Maximum Allowable Cost .10853
MAC Date 04/05/2011
Wholesale Estimated Acquisition Cost .42783
Direct Estimated Acquisition Cost .00000
Warehouse Cost .04606
340B .06200
Premium Preferred Generic Incentive No

Medicaid Program Details

Medicaid Effective Date 08/26/2009
Medicaid End Date 00/00/0000 
PDL Prior Authorization Required No
PDL Prior Authorization Effective Date 07/22/2008
PDL Therapeutic Class List others in this class
Clinical Prior Authorization Required No
Compound Only: Medicaid

CHIP Program Details

CHIP Effective Date 08/26/2009
CHIP End Date 00/00/0000     
Compound Only: CHIP

CSHCN Program Details

CSHCN Effective Date 08/26/2009
CSHCN End Date 00/00/0000 
Compound Only: CSHCN

KHC Program Details

KHC Effective Date  
KHC End Date     
Compound Only: KHC