Hawaii Prescription Benefits

Welcome!

Xerox welcomes you to our Hawaii Medicaid Fee-for-Service website. Xerox has been the prescriptions benefit manager for the State of Hawaii Medicaid Fee-for-Service Program since 8/1/01. Please click on the appropriate subject to the left and you will be directed to the site of your choosing.

Pharmacy Alert QExA Recipients With State Pharmacy Assistance Plan (SPAP) Copayments - UPDATE 2/23/09

CCS Implementation 1/1/09

CCS Argus Instructions 1/1/09

NEW - CMS Federal Upper Limit (FUL) Memos

Tamper Resistant Prescription Pad (TRPP)

NCPDP Letter to Medicaid Directors 07/17/2008

Click here for FAQs from CMS regarding Tamper-Resistant Paper Prescription Pads

TRPP – Pharmacist Fact Sheet

NOTE: All supplies are to be submitted to the Xerox Fiscal Agent for processing and reimbursement. Supplies can include DME, Diabetic, Medical, Prosthetic, Orthotic, etc. Supplies must be billed by HCPCS codes and not NDC numbers. For questions, please contact the Xerox Fiscal Agent at 808-952-5570 or 800-235-4378.

To All Hawaii Medicaid Providers

As part of CMS’ continuing effort to remove non-drug items from the Medicaid Drug Rebate (MDR) system, the following products will be deleted from the MDR Master file of covered outpatient drugs:

Hydrocodone Product Deletions from MDR, as reported August 27, 2008

Product Deletions from MDR, as reported May 6, 2008

00003  2910    Naloxone Hydrochloride Inj
00015  3351    Rubex
00067  0041    Benefiber
00067  0042    Benefiber
00245  0053    Feratab
00590  5215    Acetylcysteine Solution
24478  0101    Mykidz Iron
52747  0307    Hemocyte
58914  0010    Adex's
58914  0011    Aquadeks
58914  0212    Adek Peiatric Drops
58914  0214    Aquadeks
63717  0037    Suphera Cream
63717  0703    Triant HC
63717  0714    Nariz HC Suspension
63717  0710    Dytan HC Suspension
68453  0400    Duratuss HD Elixir
00095  0067    Pneumotussin 2.5 Cough syrup
00131  2055    Guaimax D Tablets
00182  1042    Guaifenesin/DM Tablets 600MG/30MG 100
00551  0189    Gua-SR Tablets
00603  5543    Q-Bid LA 250
00642  0421    Tusso-HC
00642  6451    Tusso-DMR
00677  1487    Guaifenesin 600MG/Pseudoephedrine 60MG Tab 100
10914  0100    Guaifenesin 900MG/Phenylephrine Hydrochloride 25 MG
10914  0200    Guaifenesin 1200MG/Phenylephrine Hydrochloride 25 MG
10914  0300    Phenylephrine HCL 15 MG; Guaifenesin 600MG
14629  0203    Extendryl HC
14629  0204    Extendryl G
51674  0126    Prolex D Tablets
51674  0126    Prolex
51674  0127    Proset D Tablets
51991  0428    Guiafen PE Tablets
51991  0428    Guiafen DM Tablets
51991  0428    Guiafen II DM
52152  0139    AmiBid DM Tabs (100)
52152  0246    Guaif. & Dextromethorphan ER Tabs
53489  0424    Guaifenesin 600 MG / Pseudoephedrine 120 MG Long Acting
53489  0425    Guaifenesin 600 MG / Pseudoephedrine 60 MG Long Acting
57664  0222    Miraphen PSE (Guaifenesin/Pseuodephedrine 600/120MG)
57664  0317    Miraphen PE (Guaifenesin/Pseuodephedrine 300/20MG)
57664  0355    Guaifenesin/Dextromethorphan 600/30MG)
58117  0214    Guaifenex PSE/60
58117  0373    Guaifenex GP Extended-Release Tablets
58117  0109    Bromfenex
58117  0020    Bromfenex PD
58117  0208    Guaifenex PSE/120
58117  0213    Guaifenex DM
58117  0413    Guaifenex PSE-80 Tablets
58117  0478    Guaifenex PSE 85 Tabs 100's
58177  0078    Phenavent Caps
58177  0079    Phenavent Ped
58177  0095    Phenavent LA Caps 30's
58177  0444    Phenavent S 100's
58605  0530    Allfen DM
58605  0613    Allfen
58605  0621    Allfen DM
58605  0630    Allfen DM
58605  0713    Allfen C
58605  0721    Allfen CX
58869  0411    Touro DM
58869  0441    Touro CC
58869  0445    Touro CC-LD
58869  0581    Touro HC
58869  0635    Touro LA-LD
58869  0636    Touro LA
59196  0112    Sympak Cough/Cold BP
59196  0120    Sympak DM
59310  0120    Muco-fen 1200
59702  0191    Sudex Tablets
60258  0252    GFN 1200/DM 20/PE 40 Tablets
60258  0256    Ganidin NR Liquid
60258  0263    GFN 1200/DM 60 Tablets
60258  0264    GFN 600/PSE60/DM30 Tablets
60258  0266    GFN PSE Tablets
60258  0267    GFN 1000/DM 60 Tablets
60258  0269    GFN 600/Phenylephrine 20 MG Tabs
60258  0274    GFN 600/Phenylephrine 40
60258  0275    Guaifenesin 400MG Tablets
60258  0277    G/P 1200/75
60258  0284    GFN 1200/Phenylephrine 40
60575  0078    Respa DM
60575  0078    Respa 1st
60575  0078    Trikof-D
60575  0078    Respa BR
60575  0078    Respa PE
62022  0132    Entex PSE Capsules
62022  0333    Entex LA Capsules
62022  0334    Entex ER
62037  0827    Generic Entex LA 30/400 MG
63717  0240    Xpect -AT Tablets
63717  0241    Xpect -PE Tablets
63717  0705    Xpect -HC
64125  0126    Guaifenesin & Dextromethorphan HBR 1200/60MG Tablets
64376  0033    Pseudo GG TR Tabs
64376  0539    Guaiphen PD TR Tab
68025  0002    Zotex LA Caplets
68025  0005    Zotex GP Caplets
68025  0018    Zotex LAX Caplets
68025  0020    Zotex GPX Caplets
68025  0023    Zotex DMX
68453  0612    Duratuss Tablets
68453  0615    Duratuss Tabs
68453  0640    Duratuss GP
68453  0645    Duratuss GP Tabs
68453  0750    Duratuss A Tabs
68453  0770    Duratuss PE Tablets
68453  0795    Duratuss DA Tablets

Non-Drug Products Deleted By CMS, Effective 1/28/08

00074  0103    Vi-Daylin Drops Multivitamin
00074  0105    Vi-Daylin ADC Drp ADC Vitamin Drops
00074  0116    Vi-Daylin/Iron Drp Multivitamin with Iron
00074  0117    Vi-Dayuir ADC Dr Multivitamin Iron ADC
00074  3606    Vi-Daylin Multivitamin Liquid
00074  4519    Vi-Daylin Chew Multivitamin Supplement
00074  6992    Vi-Daylin w/Iron Multivitamin with Iron
00904  0518    Vitamin B-6

00904  0520    Vitamin B-6
00904  2641    Certa-Vite w/Luten Tabs
00904  5486    Certa-Vite Senior w/Luten Tabs
00904  5493    Certa-Vite Performance Tablets
49281  0880    BCG Live Intravesical
51645  0826    Oyster Shell Calcium 250+D Tabs
51645  0827    Oyster Shell Calcium 500 Tabs
51645  0828    Oyster Shell Calcium 500+D Tabs
51645  0829    Oyster Shell Calcium 500+D Tabs Chewable Tabs
00406  8050    Leuprolide Acetate
00406  8061    Desmopressin Acetate
00406  8074    Calcitonin (Salmon)

Non-Drug Products Deleted By CMS, Effective 7/1/07

00135-0025 GERITOL TONIC
00135-0026 GERITOL COMPLETE TABLET
00135-0027 GERITOL EXTEND CAPLETS

00182-0418 OYST-CAL D TABLETS
00182-1576 OYST-CAL 500
00182-4439 OYST-CAL D 500 TABLETS

00281-4285 CHROMAGEN

00472-1469 FERROUS SULFATE DROPS

00536-4103 OYSCO D/CALCIUM SUPPLEMENT TABS
00536-4106 OYSTCO 500 TABLS
00536-7817 OYSCO 500 + D

16103-0360 OYSTER SHELL CALCIUM
16103-0361 OYSTER SHELL CALCIUM + VITAMIN D

24385-0644 OYSTER SHELL CALCIUM
24385-0912 OYSTER SHELL CALCIUM 250 MG

49348-0061 OYSTER SHELL CALCIUM 250 MG. W/VIT D
49348-0264 OYSTER SHELL CALCIUM 500 MG. W/VIT D
49348-0323 OYSTER SHELL CALC+D
49348-0330 OYSTER SHELL+D

52569-0232 OYSTER SHELL CALCIUM

51645-0760 FERROUS SULFATE 325MG TABLETS FC (GREEN)
51645-0761 FERROUS SULFATE 325MG TABLETS FC (RED)

52569-0468 FERROUS SULFATE 325 MG

60258-0127 OYSTER CALCIUM 500MG + D TABLETS

62107-0049 OYSTER SHELL CALCIUM 500MG
62107-0073 OYSTER SHELL CALCIUM 250MG PLUS VITAMIN D
62107-0075 OYSTER SHELL CALCIUM 500MG PLUS VITAMIN D

63739-0041 CALCIUM (AS OYSTER SHELL) W/VITAMIN D TABL 250MG
63739-0291 CALCIUM (AS OYSTER SHELL) W/VIT. D 500MG/200IU

64011-0129 CHROMAGEN
64011-0198 CHROMAGEN CAPLET

Non-Drug Products Deleted by CMS; Effective 1-1-07

00904-5118 Pediatric Electrolyte Fruit Flavored
00904-5119 Pediatric Electrolyte Bubblegum
00904-5276 Pediatric Electrolyte Grape Dyed
00904-7659 Pediatric Electrolyte Solution Unflavored
00904-7660 Pediatric Electrolyte Solution Fruit Flavored
00904-7850 Pediatric Electrolyte/Bubble Gum Flavored
66977-0222 Oramagierx

Non-Drug Iron Products Deleted By CMS; Effective 10/1/06

00121-0530-05  FERROUS SULFATE LIQUID
00182-1201-40  FERROUS SULFATE ELIXIR
00182-4028-01  FERROUS SULFATE TABLETS
00182-4028-10  FERROUS SULFATE TABLETS
00182-4028-89  FERROUS SULFATE TABLETS
00182-4029-01  FERROUS SULFATE TABLETS
00182-4030-10  FERROUS SULFATE TABLETS
0Q182-4082-0l  FERROUS OLUCONATE TABLETS
00182-4476-29  SLOW FE
00245-0061-01  FERROUS GLUCONATE
00245-0108-01  FERROUS SULFATE ENTERIC COATED TABLETS
00245-0108-10  FERROUS SULFATE ENTERIC COATED TABLETS
00472-1465-16  FERROUS SULFATE ELIXIR
00472-1465-28  FERROUS SULFATE ELIXIR
00472-1465-95  FERROUS SULFATE DROPS
00536-0650-85  FERROUS SULFATE ELIXIR A
00536-3478-07  FERROUS SULFATE
00536-3478-08  FERROUS SULFATE
00574-0508-01  FERROUS GLUCONATE
00574-0508-10  FERROUS GLUCONATE
00574-0508-11  FERROUS GLUCONATE
00574-0608-01  FERROUS OLUCONATE E.C.
00574-0608-10  FERROUS GLUCONATE E.C.
00574-0608-11  FERROUS GLUCONATE E.C
Q0603-0179-29  FERROUS SULFATE
00603-0179-32  FERROUS SULFATE
00603-0762-47  FERROUS SULFATE DROPS
00603-0763-58  FERROUS SULFATE ELLX
00677-0069-01  FERROUS GLTJCONATE
00677-0070-01  FERROUS SULFATE
00677-0070-10  FERROUS SULFATE
00677-0071-01  FERROUS SULFATE
00677-0071-10  FERROUS SULFATE
00677 -0527-33  FERROUS SULFATE
00677 -0990-06  MULTI FERROUS FOLIC
17714-0024-01  FERROUS SULFATE TABLET
17714-0024-10  FERROUS SULFATE TABLET
24385-0137-78  ON TABS, FERROUS SULFATE
24385-0528-65  FERROUS SULFATE SLOW
24385-0630-50  FERROUS SULFATE SOLUTION DROPS
24385-0875-78  FERROUS SULFATE IRON TABS
49348-0454-80  FERROUS SULFATE DROPS
49348-0455-10  FERROUS SULFATE-IRON SUPPLEMENT
49483-0008-04  FERROUS SULFATE
49483-0027-04  FERROUS SULFATE
50383-0630-50  FERROUS SULFATE SOLUTION DROPS
50383-0778-16  FERROUS SULFATE ELXIR
51552-0310-06  FERROUS SULFATE GRAN
51552-0586-06  FERROUS SULFATE DRIED PWD
51552-1084-06  FERROUS GLUCONATE DIHYDRATE
51552-1084-07  FERROUS GLUCONATE DIHYDRATE
52569-0466-21  FERROUS SULFATE BLISTER PACK
52735-001 9-01  VIT FERROUS SULFATE
52735-0360-08  FP FERROUS SULFATE SLOW
54738-0091-01  FERROUS SULFATE TABS
54738-0091-03  FERROUS SULFATE TABS
54738-0091-13  FERROUS SULFATE TABS
54838-0001-80  FERROUS SULFATE ELIXIR
54838-0002-50  FERROUS SULFATE DROPS
59743-0801-10  FERROUS SULFATE TABLETS
60258-0182-01  FERROUS FUMERATE
60432-0057-50  FERROUS SULFATE DROPS
60432-0066-16  FERROUS SULFATE ELXIR
62107-0044-01  FERROUSUL
63739-0102-01  FERROUS SULFATE
63739-0102-03  FERROUS SULFATE
63139-0259-01  FERROUS SULFATE
63739-0259-03  FERROUS SULFATE
63868-0682-01  FERROUS SULFATE