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Facilities are eligible for the same coverage as ODB patients. Cost estimate may not reflect changing drug costs and or pharmacy dispensing fees. LU limited use. Medications covered by ODB include Chlorpromazine Largactil ; : tablets, liquid, suppository and injectable. Delta-9-tetrahydrocannabinol * Marinol ; : capsules. Dexamethasone Decadron ; : tablets and injectable. Docusate Calcium Surfalk ; : capsules. Docusate Sodium Colace ; : capsule and liquid. Domperidone Motilium ; : tablets. Haloperidol Haldol ; : tablets, liquid, suppository and injectable. Lorazepam Ativsn ; : tablets. Meclizine Bonamine ; : tablets. Methotrimeprazine Nozinan ; : tablets, liquid and injectable. Metoclopramide Maxeran ; : liquid and tablets. Morphine Injectable 15 mg ml strength only ; . Nabilone Cesamet ; : capsules. Ondansetron Zofran ; : tablets and injectable. Prochlorperazine Stemetil ; : tablets, suppository and injectable. * LU required - see ODB formulary codes listed below or consult pharmacist. Exceptions medications NOT covered by ODB ; Dimenhydrinate Gravol ; - all forms. Injectable 50 mg ml. Hyoscine Buscopan ; . Lorazepam Atovan ; - po tablets covered. Injectable. Sublingual tablets. Metoclopramide Maxeran ; . Morphine injectable - only 15 mg ml amps covered. Octreotide Sandostatin ; . Scopolamine 0.4 mg ml. $14.00 + fee for 3x5 ml vials. 20 mg ml x 10 x 1ml amp $50.00 + fee. 10 x 1 amps $22.00 + fee. 30 x 1 tabs $14.00 + fee. 10 mg 2 ml x 10 amps $50.00 + fee. 2 mg ml x 10 amps $7.00 + fee. 100 mcg.ml x 5 x amps $55.00 + fee. 10 x 1 $15.00 + fee. Ativan oral© 2007 |
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