Acetaminophen-Codeine #2

acetaminophen-codeine #2 oral tablet300-15 mg / Quantity Limit: 400 EA Per 30 Days

Acetaminophen-Codeine #3

acetaminophen-codeine #3 oral tablet300-30 mg / Quantity Limit: 400 EA Per 30 Days

Acetaminophen-Codeine #4

acetaminophen-codeine #4 oral tablet300-60 mg / Quantity Limit: 400 EA Per 30 Days

Acetaminophen-Codeine

acetaminophen-codeine oral solution120-12 mg/5ml / Quantity Limit: 5000 ML Per 30 Days

ALPRAZolam ER

alprazolam er oral tablet extended release 24 hour0.5 mg, 1 mg, 2 mg, 3 mg / Quantity Limit: 120 EA Per 30 Days

ALPRAZolam Intensol

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML / Quantity Limit: 300 ML Per 30 Days

ALPRAZolam

alprazolam oral tablet0.25 mg, 0.5 mg / Quantity Limit: 120 EA Per 30 Days
alprazolam oral tablet1 mg / Quantity Limit: 180 EA Per 30 Days
alprazolam oral tablet2 mg / Quantity Limit: 150 EA Per 30 Days
alprazolam oral tablet dispersible0.25 mg / Quantity Limit: 720 EA Per 30 Days
alprazolam oral tablet dispersible0.5 mg / Quantity Limit: 180 EA Per 30 Days
alprazolam oral tablet dispersible1 mg / Quantity Limit: 360 EA Per 30 Days
alprazolam oral tablet dispersible2 mg / Quantity Limit: 150 EA Per 30 Days

Ascomp-Codeine

ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG / Quantity Limit: 180 EA Per 30 Days

Butalbital-APAP-Caff-Cod

butalbital-apap-caff-cod oral capsule50-300-40-30 mg / Quantity Limit: 180 EA Per 30 Days
butalbital-apap-caff-cod oral capsule50-325-40-30 mg / Quantity Limit: 370 EA Per 30 Days

Butalbital-ASA-Caff-Codeine

butalbital-asa-caff-codeine oral capsule50-325-40-30 mg / Quantity Limit: 180 EA Per 30 Days

Chantix Continuing Month Pak

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG / Quantity Limit: 56 EA Per 28 Days

Chantix

CHANTIX ORAL TABLET 0.5 MG / Quantity Limit: 60 EA Per 30 Days
CHANTIX ORAL TABLET 1 MG / Quantity Limit: 180 EA Per 90 Days

Chantix Starting Month Pak

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 / Quantity Limit: 53 EA Per 30 Days

ChlordiazePOXIDE HCl

chlordiazepoxide hcl oral capsule10 mg, 25 mg, 5 mg / Quantity Limit: 120 EA Per 30 Days

Clorazepate Dipotassium

clorazepate dipotassium oral tablet15 mg, 3.75 mg, 7.5 mg / Quantity Limit: 180 EA Per 30 Days

Cystaran

CYSTARAN OPHTHALMIC SOLUTION 0.44 % / Quantity Limit: 60 ML Per 30 Days

Diazepam Intensol

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML / Quantity Limit: 240 ML Per 30 Days

Diazepam

diazepam oral solution1 mg/ml / Quantity Limit: 1200 ML Per 30 Days
diazepam oral tablet10 mg / Quantity Limit: 120 EA Per 30 Days

DiazePAM

diazepam oral tablet2 mg / Quantity Limit: 600 EA Per 30 Days
diazepam oral tablet5 mg / Quantity Limit: 240 EA Per 30 Days

Dronabinol

dronabinol oral capsule10 mg, 2.5 mg, 5 mg / Quantity Limit: 60 EA Per 30 Days

Eletriptan Hydrobromide

eletriptan hydrobromide oral tablet20 mg, 40 mg / Quantity Limit: 9 EA Per 30 Days

Ergotamine-Caffeine

ergotamine-caffeine oral tablet1-100 mg / Quantity Limit: 40 EA Per 28 Days

Estazolam

estazolam oral tablet1 mg / Quantity Limit: 60 EA Per 30 Days
estazolam oral tablet2 mg / Quantity Limit: 30 EA Per 30 Days

FentaNYL

fentanyl transdermal patch 72 hour100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr / Quantity Limit: 10 EA Per 30 Days

Flurazepam HCl

flurazepam hcl oral capsule15 mg / Quantity Limit: 60 EA Per 30 Days
flurazepam hcl oral capsule30 mg / Quantity Limit: 30 EA Per 30 Days

Fosamax Plus D

FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT / Quantity Limit: 4 EA Per 28 Days

Granisetron HCl

granisetron hcl oral tablet1 mg / Quantity Limit: 60 EA Per 30 Days

Hydrocodone-Acetaminophen

hydrocodone-acetaminophen oral solution7.5-325 mg/15ml / Quantity Limit: 5500 ML Per 30 Days
hydrocodone-acetaminophen oral tablet10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg / Quantity Limit: 370 EA Per 30 Days

Hydrocodone-Ibuprofen

hydrocodone-ibuprofen oral tablet10-200 mg, 5-200 mg, 7.5-200 mg / Quantity Limit: 150 EA Per 30 Days

Lidocaine

lidocaine external patch5 % / Quantity Limit: 90 EA Per 30 Days

LORazepam Intensol

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML / Quantity Limit: 240 ML Per 30 Days

LORazepam

lorazepam oral tablet0.5 mg, 1 mg, 2 mg / Quantity Limit: 150 EA Per 30 Days

Ondansetron HCl

ondansetron hcl oral tablet24 mg / Quantity Limit: 30 EA Per 30 Days
ondansetron hcl oral tablet4 mg, 8 mg / Quantity Limit: 90 EA Per 30 Days

Ondansetron

ondansetron oral tablet dispersible4 mg, 8 mg / Quantity Limit: 90 EA Per 30 Days

Oxazepam

oxazepam oral capsule10 mg, 15 mg, 30 mg / Quantity Limit: 120 EA Per 30 Days

Oxycodone-Acetaminophen

oxycodone-acetaminophen oral solution5-325 mg/5ml / Quantity Limit: 1800 ML Per 30 Days
oxycodone-acetaminophen oral tablet10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg / Quantity Limit: 370 EA Per 30 Days

Oxycodone-Aspirin

oxycodone-aspirin oral tablet4.8355-325 mg / Quantity Limit: 360 EA Per 30 Days

Oxycodone-Ibuprofen

oxycodone-ibuprofen oral tablet5-400 mg / Quantity Limit: 360 EA Per 30 Days

Relpax

RELPAX ORAL TABLET 20 MG, 40 MG / Quantity Limit: 9 EA Per 30 Days

Sancuso

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR / Quantity Limit: 4 EA Per 28 Days

Spritam

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG / Quantity Limit: 90 EA Per 30 Days
SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG / Quantity Limit: 120 EA Per 30 Days

SUMAtriptan Succinate

sumatriptan succinate oral tablet100 mg, 25 mg, 50 mg / Quantity Limit: 9 EA Per 30 Days
sumatriptan succinate subcutaneous solution6 mg/0.5ml / Quantity Limit: 10 ML Per 30 Days
sumatriptan succinate subcutaneous solution auto-injector4 mg/0.5ml, 6 mg/0.5ml / Quantity Limit: 4.5 ML Per 30 Days
sumatriptan succinate subcutaneous solution prefilled syringe6 mg/0.5ml / Quantity Limit: 4.5 ML Per 30 Days

Syndros

SYNDROS ORAL SOLUTION 5 MG/ML / Quantity Limit: 120 ML Per 30 Days

Temazepam

temazepam oral capsule15 mg, 22.5 mg, 30 mg / Quantity Limit: 30 EA Per 30 Days
temazepam oral capsule7.5 mg / Quantity Limit: 120 EA Per 30 Days

TraMADol HCl

tramadol hcl oral tablet50 mg / Quantity Limit: 240 EA Per 30 Days

Tramadol-Acetaminophen

tramadol-acetaminophen oral tablet37.5-325 mg / Quantity Limit: 370 EA Per 30 Days

Triazolam

triazolam oral tablet0.125 mg / Quantity Limit: 30 EA Per 30 Days
triazolam oral tablet0.25 mg / Quantity Limit: 60 EA Per 30 Days

Vraylar

VRAYLAR ORAL CAPSULE 1.5 MG / Quantity Limit: 120 EA Per 30 Days
VRAYLAR ORAL CAPSULE 3 MG / Quantity Limit: 60 EA Per 30 Days
VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG / Quantity Limit: 30 EA Per 30 Days

Zaleplon

zaleplon oral capsule10 mg / Quantity Limit: 60 EA Per 30 Days
zaleplon oral capsule5 mg / Quantity Limit: 30 EA Per 30 Days

Zolpidem Tartrate

zolpidem tartrate oral tablet10 mg, 5 mg / Quantity Limit: 30 EA Per 30 Days
zolpidem tartrate sublingual tablet sublingual1.75 mg, 3.5 mg / Quantity Limit: 30 EA Per 30 Days

Formulary ID: 18327 Version 6

Last Updated: 01/01/2018

1

Index

1

A

Acetaminophen-Codeine...... 1

Acetaminophen-Codeine #2...... 1

Acetaminophen-Codeine #3...... 1

Acetaminophen-Codeine #4...... 1

ALPRAZolam...... 1

ALPRAZolam ER...... 1

ALPRAZolam Intensol...... 1

Ascomp-Codeine...... 2

B

Butalbital-APAP-Caff-Cod...... 2

Butalbital-ASA-Caff-Codeine...... 2

C

Chantix...... 3

Chantix Continuing Month Pak...... 3

Chantix Starting Month Pak...... 3

ChlordiazePOXIDE HCl...... 3

Clorazepate Dipotassium...... 3

Cystaran...... 3

D

Diazepam...... 4

DiazePAM...... 4

Diazepam Intensol...... 4

Dronabinol...... 4

E

Eletriptan Hydrobromide...... 4

Ergotamine-Caffeine...... 4

Estazolam...... 5

F

FentaNYL...... 5

Flurazepam HCl...... 5

Fosamax Plus D...... 5

G

Granisetron HCl...... 5

H

Hydrocodone-Acetaminophen...... 6

Hydrocodone-Ibuprofen...... 6

L

Lidocaine...... 6

LORazepam...... 6

LORazepam Intensol...... 6

O

Ondansetron...... 7

Ondansetron HCl...... 6

Oxazepam...... 7

Oxycodone-Acetaminophen...... 7

Oxycodone-Aspirin...... 7

Oxycodone-Ibuprofen...... 7

R

Relpax...... 7

S

Sancuso...... 8

Spritam...... 8

SUMAtriptan Succinate...... 8

Syndros...... 8

T

Temazepam...... 8

TraMADol HCl...... 9

Tramadol-Acetaminophen...... 9

Triazolam...... 9

V

Vraylar...... 9

Z

Zaleplon...... 9

Zolpidem Tartrate...... 10

1

1