Acetaminophen-Codeine #2
acetaminophen-codeine #2 oral tablet300-15 mg / Quantity Limit: 400 EA Per 30 DaysAcetaminophen-Codeine #3
acetaminophen-codeine #3 oral tablet300-30 mg / Quantity Limit: 400 EA Per 30 DaysAcetaminophen-Codeine #4
acetaminophen-codeine #4 oral tablet300-60 mg / Quantity Limit: 400 EA Per 30 DaysAcetaminophen-Codeine
acetaminophen-codeine oral solution120-12 mg/5ml / Quantity Limit: 5000 ML Per 30 Daysacetaminophen-codeine oral tablet300-15 mg, 300-60 mg / Quantity Limit: 400 EA 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 DaysALPRAZolamIntensol
ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML / Quantity Limit: 300 ML Per 30 DaysALPRAZolam
alprazolam oral tablet0.25 mg, 0.5 mg / Quantity Limit: 120 EA Per 30 Daysalprazolam 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
ARIPiprazole
aripiprazole oral solution1 mg/ml / Quantity Limit: 750 ML Per 30 DaysAscomp-Codeine
ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG / Quantity Limit: 180 EA Per 30 DaysButalbital-APAP-Caff-Cod
butalbital-apap-caff-cod oral capsule50-300-40-30 mg / Quantity Limit: 180 EA Per 30 Daysbutalbital-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 DaysChantix Continuing Month Pak
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG / Quantity Limit: 56 EA Per 28 DaysChantix
CHANTIX ORAL TABLET 0.5 MG / Quantity Limit: 60 EA Per 30 DaysCHANTIX 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 DaysChlordiazePOXIDEHCl
chlordiazepoxidehcl oral capsule10 mg, 25 mg, 5 mg / Quantity Limit: 120 EA Per 30 DaysClorazepate Dipotassium
clorazepate dipotassium oral tablet15 mg, 3.75 mg, 7.5 mg / Quantity Limit: 180 EA Per 30 DaysCystaran
CYSTARAN OPHTHALMIC SOLUTION 0.44 % / Quantity Limit: 60 ML Per 30 DaysDiazepam Intensol
DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML / Quantity Limit: 240 ML Per 30 DaysDiazepam
diazepam oral solution1 mg/ml / Quantity Limit: 1200 ML Per 30 DaysDiazePAM
diazepam oral tablet10 mg / Quantity Limit: 120 EA Per 30 Daysdiazepam 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 DaysEletriptanHydrobromide
eletriptanhydrobromide oral tablet20 mg, 40 mg / Quantity Limit: 9 EA Per 30 DaysErgotamine-Caffeine
ergotamine-caffeine oral tablet1-100 mg / Quantity Limit: 40 EA Per 28 DaysEstazolam
estazolam oral tablet1 mg / Quantity Limit: 60 EA Per 30 Daysestazolam 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 DaysFlurazepamHCl
flurazepamhcl oral capsule15 mg / Quantity Limit: 60 EA Per 30 Daysflurazepamhcl 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 DaysGranisetronHCl
granisetronhcl oral tablet1 mg / Quantity Limit: 60 EA Per 30 DaysHydrocodone-Acetaminophen
hydrocodone-acetaminophen oral solution7.5-325 mg/15ml / Quantity Limit: 5500 ML Per 30 Dayshydrocodone-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 DaysLidocaine
lidocaine external patch5 % / Quantity Limit: 90 EA Per 30 DaysLORazepamIntensol
LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML / Quantity Limit: 240 ML Per 30 DaysLORazepam
lorazepam oral concentrate2 mg/ml / Quantity Limit: 240 ML Per 30 Dayslorazepam 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 Daysondansetron 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 DaysOxazepam
oxazepam oral capsule10 mg, 15 mg, 30 mg / Quantity Limit: 120 EA Per 30 DaysOxycodone-Acetaminophen
oxycodone-acetaminophen oral solution5-325 mg/5ml / Quantity Limit: 1800 ML Per 30 Daysoxycodone-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 DaysOxycodone-Ibuprofen
oxycodone-ibuprofen oral tablet5-400 mg / Quantity Limit: 360 EA Per 30 DaysRelpax
RELPAX ORAL TABLET 20 MG, 40 MG / Quantity Limit: 9 EA Per 30 DaysSancuso
SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR / Quantity Limit: 4 EA Per 28 DaysSpritam
SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG / Quantity Limit: 90 EA Per 30 DaysSPRITAM 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 Dayssumatriptan 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
Syndros
SYNDROS ORAL SOLUTION 5 MG/ML / Quantity Limit: 120 ML Per 30 DaysTemazepam
temazepam oral capsule15 mg, 22.5 mg, 30 mg / Quantity Limit: 30 EA Per 30 Daystemazepam oral capsule7.5 mg / Quantity Limit: 120 EA Per 30 Days
TraMADolHCl
tramadol hcl oral tablet50 mg / Quantity Limit: 240 EA Per 30 DaysTramadol-Acetaminophen
tramadol-acetaminophen oral tablet37.5-325 mg / Quantity Limit: 370 EA Per 30 DaysTriazolam
triazolam oral tablet0.125 mg / Quantity Limit: 30 EA Per 30 Daystriazolam oral tablet0.25 mg / Quantity Limit: 60 EA Per 30 Days
Vraylar
VRAYLAR ORAL CAPSULE 1.5 MG / Quantity Limit: 120 EA Per 30 DaysVRAYLAR 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 Dayszaleplon 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 Dayszolpidem tartrate sublingual tablet sublingual1.75 mg, 3.5 mg / Quantity Limit: 30 EA Per 30 Days
Formulary ID: 18328 Version 8
Last Updated: 04/01/2018
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Index
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A
Acetaminophen-Codeine...... 1
Acetaminophen-Codeine #2...... 1
Acetaminophen-Codeine #3...... 1
Acetaminophen-Codeine #4...... 1
ALPRAZolam...... 2
ALPRAZolam ER...... 1
ALPRAZolam Intensol...... 1
ARIPiprazole...... 2
Ascomp-Codeine...... 2
B
Butalbital-APAP-Caff-Cod...... 2
Butalbital-ASA-Caff-Codeine...... 3
C
Chantix...... 3
Chantix Continuing Month Pak...... 3
Chantix Starting Month Pak...... 3
ChlordiazePOXIDE HCl...... 3
Clorazepate Dipotassium...... 4
Cystaran...... 4
D
Diazepam...... 4
DiazePAM...... 4
Diazepam Intensol...... 4
Dronabinol...... 4
E
Eletriptan Hydrobromide...... 5
Ergotamine-Caffeine...... 5
Estazolam...... 5
F
FentaNYL...... 5
Flurazepam HCl...... 5
Fosamax Plus D...... 6
G
Granisetron HCl...... 6
H
Hydrocodone-Acetaminophen...... 6
Hydrocodone-Ibuprofen...... 6
L
Lidocaine...... 6
LORazepam...... 7
LORazepam Intensol...... 6
O
Ondansetron...... 7
Ondansetron HCl...... 7
Oxazepam...... 7
Oxycodone-Acetaminophen...... 7
Oxycodone-Aspirin...... 8
Oxycodone-Ibuprofen...... 8
R
Relpax...... 8
S
Sancuso...... 8
Spritam...... 8
SUMAtriptan Succinate...... 8
Syndros...... 9
T
Temazepam...... 9
TraMADol HCl...... 9
Tramadol-Acetaminophen...... 9
Triazolam...... 9
V
Vraylar...... 10
Z
Zaleplon...... 10
Zolpidem Tartrate...... 10
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