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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

Prior Authorization

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

Medicaid Program Details

Medicaid Effective Date 08/26/2009
Medicaid End Date 00/00/0000 
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