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AHFS Therapeutic AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 0.667000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 0.750000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 1.500000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 2.000000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 2.500000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 3.000000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 3.750000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 6.000000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 7.500000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE Medical Exception Required 282032 RESPIRATORY AND CNS STIMULANTS 000007 CAFFEINE/DEXTROSE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000008 CAFFEINE/MULTIVITAMIN PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000009 CAFFEINE/ETHYL ALCOHOL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000010 CAFFEINE/SODIUM BENZOATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000011 CAFFEINE CITRATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000012 CAFFEINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000013 THEOPHYLLINE/POTASSIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000014 THEOPHYLLINE/IODINATD GLYCEROL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000015 THEOPHYLLINE IN DEXTROSE 5 % PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000016 THEOPHYLL/ISOPROT/EPD/POT IOD PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000017 THEOPHYLLINE/EPHED/P.I./PHENOB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000018 THEOPHYLL/EPHEDRINE/PHENOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000019 THEOPHYLLINE/EPHED/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000020 THEOPHYLLINE/EPHED/HYDROXYZINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000022 THEOPHYLLINE/EPHEDRINE/PYRIL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000023 THEOPHYLLINE/EPHEDRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000024 THEOPHYLL/PSEUDOEPHED/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000025 THEOPHYLLINE ANHYDROUS PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000026 THEOPHYLLINE SOD GLY PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000027 AMINOPHYLLINE IN 0.9 % NACL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000028 AMINOPHYLLINE/POTASSIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000030 AMINOPHYLLINE/EPHED/POT IOD/PB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000032 AMINOPHYLLINE/EPHED/PHENOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000033 AMINOPHYLLINE/EPHED/AMOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000034 AMINOPHYLLINE/EPHED/PENTOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000035 AMINOPHYLLINE/EPHEDRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000036 AMINOPHYLLINE/PPA/CPM/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000037 AMINOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000038 DYPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000039 OXTRIPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 1 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000042 GUAIFENESIN/THEOPHYLL/EPHED/PB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000043 GUAIFEN/THEOPHYLL/EPD/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000044 GUAIFEN/THEOPHYLLINE/EPHED/COD PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000045 GUAIFEN/THEOPHYLL/EPHED/PYRIL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000047 GUAIFENESIN/THEOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000048 GUAIFENESIN/THEOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000049 GUAIF/AMINOPHY/EPHED/PHENOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000050 GUAIFENESIN/AMINOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000051 GUAIF/DYPHYLLIN/EPHED/PHENBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000052 GUAIFEN/DYPHYLLINE/P‐EPHEDRINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000053 GUAIFENESIN/DYPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000054 GUAIFENESIN/OXTRIPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000056 NOSCAPINE/THEOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121208 BETA‐ADRENERGIC AGONISTS 000060 ISOPROTERENOL/CALCIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000064 EPHEDRINE/POTASSIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000065 EPHEDRINE/PHENOBARBITAL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000066 EPHEDRINE SULFATE/AMOBARBITAL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000067 EPHEDRINE SULFATE/SECOBARBITAL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 680400 ADRENALS 000070 BECLOMETHASONE DIPROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 000070 BECLOMETHASONE DIPROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 000070 BECLOMETHASONE DIPROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 680400 ADRENALS 000072 FLUNISOLIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 000072 FLUNISOLIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 000072 FLUNISOLIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 240404 ANTIARRHYTHMIC AGENTS 000073
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