AVMED 4 TIER AND 5 TIER FORMULARY QUANTITY LIMIT TABLE
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- Dominick Cannon
- 6 years ago
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1 Effective 4/1/2018 AVMED 4 TIER AND 5 TIER FORMULARY QUANTITY LIMIT TABLE Generic Name Brand Name Quantity Limit Description Comments ABACAVIR SOLN 20 MG/ML ZIAGEN 900ml every 30 days ABACAVIR TAB 300 MG ZIAGEN 60 every 30 days ABACAVIR -LAMIVUDINE TAB MG EPZICOM 30 every 30 days ABACAVIR -LAMIVUDINE-ZIDOVUDINE TAB MG TRIZIVIR 60 every 30 days ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB MG TRIUMEQ 30 every 30 days ACETAMINOPHEN W/ CODEINE SUSP MG/5ML CAPITAL/CODEINE 2700ml every 30 days ACETAMINOPHEN W/ CODEINE TAB 15MG/300MG TYLENOL/CODEINE 400 every 30 days ACETAMINOPHEN W/ CODEINE TAB 30MG/300MG TYLENOL/CODEINE 360 every 30 days ACETAMINOPHEN W/ CODEINE TAB 60MG/300MG TYLENOL/CODEINE 180 every 30 days ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 320.5/30/16MG, 325/30/16MG, 356.4/30/16MG APAP/CAFF/DIHYDROCODEINE 300 every 30 days ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 712.8/60/32MG APAP/CAFF/DIHYDROCODEINE 150 every 30 days ACYCLOVIR OINT 5% ZOVIRAX 30gm every 30 days ALBUTEROL SULFATE AER POW BA 108 MCG/ACT PROAIR RESPICLICK 2 inhalers every 30 days ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT PROAIR HFA 2 inhalers every 30 days ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) ALBUTEROL NEB 0.083% 375ml every 30 days ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) ALBUTEROL NEB 0.5% 60ml every 30 days ALBUTEROL SULFATE SOLN NEBU-all strengths ACCUNEB 375ml every 30 days ALMOTRIPTAN TABS-all strengths AXERT 12 every 30 days ALPROSTADIL FOR INJ EDEX 6 units every 30 days ALPROSTADIL INJ CAVERJECT 6 units every 30 days ALPROSTADIL URETHRAL PELLET MUSE 6 units every 30 days AMPHETAMINE ER DISINTEGRATING TAB-12.5mg 15.7mg, 18.8mg ADZENYS XR-ODT 30 every 30 days AMPHETAMINE ER DISINTEGRATING TAB-3.1mg, 6.3mg, 9.4mg ADZENYS XR-ODT 60 every 30 days AMPHETAMINE ER ORAL SUSP -1.25MG/ML ADZENYS ER ORAL SUSP 450ml every 30 days AMPHETAMINE EXTENDED RELEASE SUSP 2.5 MG/ML DYANAVEL XR 240ml every 30 days AMPHETAMINE SULFATE TAB- all strengths EVEKEO 120 every 30 days AMPHETAMINE-DEXTROAMPHETAMINE 3-BEAD CAP ER 24HR 12.5mg, 25mg MYDAYIS 60 every 30 days AMPHETAMINE-DEXTROAMPHETAMINE 3-BEAD CAP ER 24HR 37.5mg, 50mg MYDAYIS 30 every 30 days AMPHETAMINE-DEXTROAMPHETAMINE TAB- 15mg, 20mg ADDERALL 60 every 30 days AMPHETAMINE-DEXTROAMPHETAMINE TAB- 30mg ADDERALL 30 every 30 days AMPHETAMINE-DEXTROAMPHETAMINE TAB- 5mg, 7.5mg, 10mg,12.5mg ADDERALL 90 every 30 days
2 APREPITANT CAPSULE 125 MG EMEND CAP 125MG 2 every 30 days APREPITANT CAPSULE 40 MG EMEND CAP 40MG 3 every 6 months APREPITANT CAPSULE 80 MG EMEND CAP 80MG 4 every 30 days APREPITANT CAPSULE THERAPY PACK 80 & 125 MG EMEND PAK 80 & packs (6 ) every 30 days APREPITANT FOR ORAL SUSP 125MG/5ML EMEND 125MG SUSP 6 Kits every 30 days APREPITANT INJECTION 150MG EMEND INJECTION 2 every 30 days APREPITANT IV EMULSION 130 MG/18ML CINVANTI 2 vials every 28 days ARFORMOTEROL SOLN NEBU 15 MCG/2ML (BASE EQUIV) BROVANA 120ml every 30 days ASPIRIN/CAFFEINE/DIHYDROCODEINE 356.4/30/16MG ASPIRIN/CAFF/DIHYDROCODEINE 300 every 30 days ASPIRIN/OXYCODONE TABS ASPIRIN/OXYCODONE 360 Every 30 days ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP MG SYNALGOS-DC 300 every 30 days ATAZANAVIR -COBICISTAT TAB MG EVOTAZ 30 every 30 days ATAZANAVIR SULFATE CAP 200mg REYATAZ 200mg 60 every 30 days ATAZANAVIR SULFATE CAP-except 200mg REYATAZ 30 every 30 days ATOMOXETINE CAP-10mg, 18mg, 25mg STRATTERA 120 every 30 days ATOMOXETINE CAP-40mg STRATTERA 60 every 30 days ATOMOXETINE CAP-60mg, 80mg, 100mg STRATTERA 30 every 30 days AZELASTINE HCL NASAL SPRAY 0.15% (205.5 MCG/SPRAY) ASTEPRO 2 bottles every 30 days AZELASTINE HCL-FLUTICASONE NASAL SPRAY MCG/ACT DYMISTA 1 bottle every 30 days BECLOMETHASONE INHALER-all strengths QVAR 2 inhalers every 30 days BECLOMETHASONE INHALER-all strengths QVAR RediHaler 2 inhalers every 30 days BETAMETHASONE DIPROPIONATE OINT 0.05% DIPROSONE 210gm every 30 days BUDESONIDE INHAL AERO POWD-180MCG PULMICORT INH 2 inhalers every 30 days BUDESONIDE INHAL AERO POWD-90MCG PULMICORT INH 3 inhalers every 30 days BUDESONIDE INHALATION SUSP-0.25MG PULMICORT SUS 180ml every 30 days BUDESONIDE INHALATION SUSP-0.5MG PULMICORT SUS 120ml every 30 days BUDESONIDE INHALATION SUSP-1MG PULMICORT SUS 60ml every 30 days BUDESONIDE-FORMOTEROL AEROSOL-all strengths SYMBICORT 1 inhaler every 30 days BUPRENORPHINE HCL BUCCAL FILM 75MCG, 150MCG,300MCG AND 450MCG ONLY BELBUCA 60 Every 30 days BUPRENORPHINE HCL BUCCAL FILM 75MCG, 600MCG,750MCG AND 900MCG ONLY BELBUCA 60 Every 30 days Initial limit is 0, Post limit PA reqd BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3mg SUBOXONE 60 every 30 days BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5mg, 4-1mg,8-2mg SUBOXONE 90 every 30 days BUPRENORPHINE HCL-NALOXONE HCL SL TAB - all other strengths ZUBSOLV 90 every 30 days BUPRENORPHINE HCL-NALOXONE HCL SL TAB MG ZUBSOLV 30 every 30 days BUPRENORPHINE HCL-NALOXONE HCL SL TAB MG ZUBSOLV 60 every 30 days
3 BUPRENORPHINE TD PATCH WEEKLY-15MCG AND 20MCG BUTRANS 4 patches every 28 days Initial limit is 0, Post limit PA reqd BUPRENORPHINE TD PATCH WEEKLY-5MCG, 7.5MCG AND 10MCG ONLY BUTRANS 4 patches every 28 days BUPRENORPHINE-NALOXONE BUCCAL FILM mg, mg BUNAVAIL 90 every 30 days BUPRENORPHINE-NALOXONE BUCCAL FILM 6.3-1mg BUNAVAIL 60 every 30 days BUTALBITAL 25MG-ACETAMINOPHEN 325MG TAB ALLZITAL 96 every 30 days BUTALBITAL-ACETAMINOPHEN TAB BUTAL/APAP TAB 48 every 30 days BUTALBITAL-ACETAMINOPHEN-CAFF W/ CODEINE BUTAL/APAP/CAFF/CODEINE 48 every 30 days BUTALBITAL-ACETAMINOPHEN-CAFFEINE SOLN MG/15ML VANATOL LQ 720ml every 30 days BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB BUTAL/APAP/ CAFF TAB 48 every 30 days BUTALBITAL-ASPIRIN-CAFF W/ CODEINE BUTAL/ASP/CAFF/CODEINE 48 every 30 days BUTALBITAL-ASPIRIN-CAFFEINE BUTAL/ASP/CAFF 48 every 30 days BUTORPHANOL TARTRATE NASAL SOLN 10 MG/ML BUTORPHANOL SOL 10MG/ML 2 bottles every 30 days COBICISTAT TAB 150 MG TYBOST 30 every 30 days CODEINE SULFATE ORAL SOLN 30MG/5ML CODEINE SULFATE ORAL SOLN 210ml every 30 days CODEINE SULFATE TAB- all strengths CODEINE SULFATE TABLETS 42 every 30 days CROMOLYN SODIUM SOLN NEBU 20 MG/2ML CROMOLYN SOD NEB 20MG/2ML 240ml every 30 days DARUNAVIR ETHANOLATE SUSP 100 MG/ML PREZISTA SUS 100MG/ML 400ml every 30 days DARUNAVIR ETHANOLATE TAB 800 MG PREZISTA TAB 800MG 30 every 30 days DARUNAVIR ETHANOLATE TAB -all strengths except 800mg PREZISTA 60 every 30 days DARUNAVIR-COBICISTAT TAB MG PREZCOBIX 30 every 30 days DELAVIRDINE MESYLATE TAB -all strengths RESCRIPTOR 180 every 30 days DEXMETHYLPHENIDATE HCL TAB -10mg FOCALIN 60 every 30 days DEXMETHYLPHENIDATE HCL TAB -2.5mg 5mg FOCALIN 120 every 30 days DEXMETHYLPHENIDATE HCL TAB -25mg, 30mg, 35mg, 40mg FOCALIN XR 30 every 30 days DEXMETHYLPHENIDATE HCL XR TAB -5mg, 10mg, 15mg, 20mg FOCALIN XR 60 every 30 days DEXTROAMPHETAMINE SULFATE CAP SR 24HR- 15mg DEXEDRINE CR 60 every 30 days DEXTROAMPHETAMINE SULFATE CAP SR 24HR- 5mg, 10mg DEXEDRINE CR 120 every 30 days DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML PROCENTRA 1200ml every 30 days DEXTROAMPHETAMINE SULFATE TAB 15mg, 20mg ZENZEDI 60 every 30 days DEXTROAMPHETAMINE SULFATE TAB -15mg, 20mg DEXEDRINE TAB 60 every 30 days DEXTROAMPHETAMINE SULFATE TAB 2.5mg, 5mg, 7.5mg, 10mg ZENZEDI 120 every 30 days DEXTROAMPHETAMINE SULFATE TAB -2.5mg, 5mg, 7.5mg, 10mg DEXEDRINE TAB 120 every 30 days DEXTROAMPHETAMINE SULFATE TAB 30mg ZENZEDI 30 every 30 days DEXTROAMPHETAMINE SULFATE TAB -30mg DEXEDRINE TAB 30 every 30 days DICLOFENAC SODIUM GEL 3% SOLARAZE 100gm every 30days DICLOFENAC SODIUM GEL 1% VOLTAREN 1000gm every 30 days
4 DIHYDROERGOTAMINE MESYLATE NASAL SPRAY 4 MG/ML MIGRANAL 8 units every 30 days DOLASETRON MESYLATE IV INJ 20 MG/ML ANZEMET 15ml Every 6 months DOLASETRON MESYLATE TAB -all strengths ANZEMET TAB 6 every 30 days DOLUTEGRAVIR SODIUM TAB 50 MG TIVICAY 60 every 30 days DOXEPIN CREAM 5% PRUDOXIN 60gm every 30days DRONABINOL CAP -all strengths MARINOL 60 every 30 days EFAVIRENZ - all strengths SUSTIVA 30 every 30 days EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB MG ATRIPLA 30 every 30 days ELETRIPTAN-all strengths RELPAX 12 every 30 days ELVITEGRAV-COBICIS-EMTRICITAB-TENOFOV TAB MG STRIBILD 30 every 30 days ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIR TABS GENVOYA 30 every 30 days EMTRICITABINE CAPS 200 MG EMTRIVA 30 every 30 days EMTRICITABINE SOLN 10 MG/ML EMTRIVA SOLN 75ml every 30 days EMTRICITABINE-RILPIVIRINE-TENOFOVIR AF TAB MG ODEFSEY 30 every 30 days EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB MG COMPLERA 30 every 30 days EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TAB MG DESCOVY 30 every 30 days EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB MG TRUVADA 30 every 30 days ETRAVIRINE TAB 100 MG AND 200MG INTELENCE 100MG AND 200MG 60 every 30 days ETRAVIRINE TAB 25 MG INTELENCE TAB 25MG 120 every 30 days FENTANYL CITRATE BUCCAL SOLUBLE FILM- all strengths ONSOLIS 120 every 30 days FENTANYL CITRATE BUCCAL TAB- all strengths FENTORA 120 every 30 days FENTANYL CITRATE LOZENGE ON A HANDLE -all strengths ACTIQ 120 every 30 days FENTANYL CITRATE NASAL SPRAY 100 MCG/ACT -all strengths LAZANDA 30 doses every 30 days FENTANYL CITRATE SL TAB -all strengths ABSTRAL 120 every 30 days FENTANYL SUBLINGUAL SPRAY - except 1200MCG and 1600MCG SUBSYS 120 every 30 days FENTANYL SUBLINGUAL SPRAY 1200 MCG AND 1600MCG SUBSYS 240 every 30 days FENTANYL TD PATCH 72HR-12MCG, 25MCG AND 37.5MCG DURAGESIC 10 patches every 30 days FENTANYL TD PATCH 72HR-50MCG, 62.5MCG, 75MCG, 87.5MCG AND 100MCG DURAGESIC 10 patches every 30 days Initial limit is 0, Post limit PA reqd FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%) FLUNISOLIDE 3 bottles every 30 days FLUOCINONIDE CREAM 0.05% LIDEX 150gm every 30 days FLUTICASONE FUROATE AEROSOL -all strengths ARNUITY ELLIPTA 1 inhaler every 30 days FLUTICASONE FUROATE NASAL SUSP 27.5 MCG/SPRAY VERAMYST 1 bottle every 30 days 1 pack (60 blisters) every 30 FLUTICASONE FUROATE/UMECLIDINIUM/VILANTEROL TRELEGY ELLIPTA days FLUTICASONE FUROATE-VILANTEROL AERO-all strengths BREO ELLIPTA 1 inhaler every 30 days
5 FLUTICASONE PROPIONATE NASAL SPRAY -93MCG/SPRAY XHANCE 2 packs(16ml) every 30 days FLUTICASONE PROPIONATE AEROSOL-100MCG AND 250MCG FLOVENT DISKUS 4 inhalers every 30 days FLUTICASONE PROPIONATE AEROSOL-50MCG FLOVENT DISKUS 3 inhalers every 30 days FLUTICASONE PROPIONATE HFA INHALER-all strengths FLOVENT HFA 2 inhalers every 30 days FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT FLONASE 1 bottle every 30 days FLUTICASONE-SALMETEROL AER POWDER BA- all strengths AIRDUO RESPICLICK 1 inhaler every 30 days FLUTICASONE-SALMETEROL AEROSOL -all strengths ADVAIR DISKUS 1 inhaler every 30 days FLUTICASONE-SALMETEROL INHALER-all strengths ADVAIR HFA 1 inhaler every 30 days FORMOTEROL FUMARATE INHAL CAP 12 MCG FORADIL AEROLIZER 60 every 30 days FORMOTEROL FUMARATE SOLN NEBU 20 MCG/2ML PERFOROMIST 120ml every 30 days FOSAMPRENAVIR CALCIUM SUSP 50 MG/ML LEXIVA 120ml every 30 days FOSAMPRENAVIR CALCIUM TAB 700 MG LEXIVA 120 every 30 days FROVATRIPTAN 2.5MG TAB FROVA 18 every 30 days GLUCOSE BLOOD TEST STRIP ONE TOUCH 200 every 30 days GLYCOPYRROLATE INHAL CAP 15.6 MCG SEEBRI NEOHALER 1 inhaler every 30 days GLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL MCG/ACT BEVESPI AEROSPHERE 1 inhaler every 30 days GRANISETRON EXTENDED RELEASE INJ PREFILLED SYR 10 MG/0.4ML SUSTOL 0.8ML every 30 days GRANISETRON HCL INJ 1 MG/ML and 0.1MG/ML KYTRIL 2ml every 30 days GRANISETRON HCL TAB 1 MG GRANISETRON 12 every 30 days GRANISETRON TD PATCH 3.1 MG/24HR SANCUSO 2 patches every 30 days HYDROCODONE BITARTRATE CAP ER 12HR ABUSE-DETERRENT 10MG, 15MG, 20MG, 30MG AND 40MG ZOHYDRO ER 60 Every 30 days HYDROCODONE BITARTRATE CAP ER 12HR ABUSE-DETERRENT 50MG ZOHYDRO ER 60 Every 30 days Initial limit is 0, Post limit PA reqd HYDROCODONE BITARTRATE TAB ER 24HR DETER 100 MG HYSINGLA ER 60 Every 30 days Initial limit is 0, Post limit PA reqd HYDROCODONE BITARTRATE TAB ER 24HR DETER 120 MG HYSINGLA ER 30 Every 30 days Initial limit is 0, Post limit PA reqd HYDROCODONE BITARTRATE TAB ER 24HR DETER 20MG, 30MG, 40MG, 60MG AND 80MG HYSINGLA ER 30 Every 30 days HYDROCODONE-ACETAMINOPHEN SOLN MG/15ML HYRDOCODONE/ACETAMINOPHEN 2025ml every 30 days HYDROCODONE-ACETAMINOPHEN SOLN MG/15ML, MG/15ML, MG/15ML HYRDOCODONE/ACETAMINOPHEN 2700ml every 30 days HYDROCODONE-ACETAMINOPHEN SOLN MG/15ML HYRDOCODONE/ACETAMINOPHEN 2700ml every 30 days HYDROCODONE-ACETAMINOPHEN TAB MG, MG, MG, MG, MG HYRDOCODONE/ACETAMINOPHEN 180 every 30 days HYDROCODONE-ACETAMINOPHEN TAB MG HYRDOCODONE/ACETAMINOPHEN 360 every 30 days HYDROCODONE-ACETAMINOPHEN TAB MG, 5-300MG, 5-325MG, 5-400MG, 5-500MG HYRDOCODONE/ACETAMINOPHEN 240 every 30 days
6 HYDROCODONE-ACETAMINOPHEN TAB MG, MG, MG, MG, MG HYRDOCODONE/ACETAMINOPHEN 180 every 30 days HYDROCODONE-ACETAMINOPHEN TAB MG, MG, MG HYRDOCODONE/ACETAMINOPHEN 150 every 30 days HYDROCODONE-IBUPROFEN TAB-all strengths VICOPROFEN 50 every 30 days HYDROMORPHONE HCL LIQD 1 MG/ML DILAUDID 600ml every 30 days HYDROMORPHONE HCL TAB ER 24HR 32 MG EXALGO 32MG 30 every 30 days Initial limit is 0, Post limit PA reqd HYDROMORPHONE HCL TAB ER 24HR 8MG, 12 MG and 16MG EXALGO 30 every 30 days HYDROMORPHONE SUPPS 3MG HYDROMORPHONE SUPPS 120 every 30 days HYDROMORPHONE TABS 2MG HYDROMORPHONE TABS 180 every 30 days HYDROMORPHONE TABS 4MG HYDROMORPHONE TABS 150 every 30 days HYDROMORPHONE TABS 8MG HYDROMORPHONE TABS 60 every 30 days INDACATEROL MALEATE INHAL POWDER CAP 75 MCG ARCAPTA I box (30) every 30 days INDACATEROL-GLYCOPYRROLATE INHAL CAP MCG UTIBRON NEOHALER 1 inhaler every 30 days INDINAVIR SULFATE CAP-all strengths CRIXIVAN 150 every 30 days IPRATROPIUM BROMIDE HFA INHAL AEROSOL 17 MCG/ACT ATROVENT HFA 2 inhalers every 30 days IPRATROPIUM BROMIDE INHAL SOLN 0.02% IPRATROPIUM 375ml every 30 days IPRATROPIUM-ALBUTEROL INHAL SOLN MCG/ACT COMBIVENT RESPIMAT 2 inhalers every 30 days IPRATROPIUM-ALBUTEROL NEBU SOLN (3) MG/3ML DUONEB 540ml every 30 days LAMIVUDINE TAB-all strengths EPIVIR 60 every 30 days LEVALBUTEROL HCL SOLN NEBU CONC 1.25 MG/0.5ML XOPENEX CONC NEB 45ml every 30 days LEVALBUTEROL HCL SOLN NEBU-all strengths XOPENEX 288ml every 30 days LEVORPHANOL 2MG TAB LEVO DROMORAN 120 every 30 days LIDOCAINE GEL 2% LIDOTREX 30gm every 30 days LIDOCAINE GEL 4% TOPICAINE 30gm every 30 days LIDOCAINE HCL SOLN 4% LIDOCAINE HCL 50ml every 30 days LIDOCAINE OINT 5% LIDOCAINE 50gm every 30 days LIDOCAINE-PRILOCAINE CREAM % EMLA 30gm every 30 days LIDOCAINE-TETRACAINE CREAM 7-7% PLIAGLIS 30gm every 30 days LIDOCAINE-TETRACAINE TOPICAL PATCH MG SYNERA 2 patches every 30 days LISDEXAMFETAMINE DIMESYLATE CAP - 10mg, 20mg, 30mg VYVANSE 60 every 30 days LISDEXAMFETAMINE DIMESYLATE CAP- 40mg, 50mg, 60mg, 70mg VYVANSE 30 every 30 days LOPINAVIR-RITONAVIR SOLN MG/5ML KALETRA 600ml every 30 days LOPINAVIR-RITONAVIR TAB-all strengths KALETRA 120 every 30 days MEPERIDINE ORAL SOLN 50MG/5ML MEPERIDINE ORAL SOLN 90ml for 3 days limit MEPERIDINE TABS- 50MG AND 100MG MEPERIDINE TABS 18 tabs for 3 days limit
7 METHADONE DISP TAB 40MG METHADOSE 40MG 9 every 30 days METHADONE HCL CONC 10 MG/ML METHADONE INTENSOL 90ml every 30 days METHADONE HCL TAB 5 MG AND 10MG DOLOPHINE 90 Every 30 days METHADONE ORAL CONC 10MG/ML METHADOSE ORAL CONC 30ml every 30 days METHADONE ORAL SOLN 5MG/5ML AND 10MG/5ML METHADONE 450ml Every 30 days METHAMPHETAMINE HCL TAB 5 MG DESOXYN 150 every 30 days METHYLPHENIDATE ER DISINTEGRATING TAB- all strengths COTEMPLA XR-ODT 60 every 30 days METHYLPHENIDATE HCL CAP CR-10mg, 20mg, 30mg METADATE CD 60 every 30 days METHYLPHENIDATE HCL CAP CR-40mg, 50mg, 60mg METADATE CD 30 every 30 days METHYLPHENIDATE HCL CAP ER 24HR (XR)- 10mg, 15mg, 20mg 30mg APTENSIO XR 60 every 30 days METHYLPHENIDATE HCL CAP ER 24HR (XR)- 40mg, 50mg, 60mg APTENSIO XR 30 every 30 days METHYLPHENIDATE HCL CHEW TABS-all strengths METHYLIN CHEW 180 every 30 days METHYLPHENIDATE HCL FOR ER SUSP 25 MG/5ML QUILLIVANT 360ml every 30 days METHYLPHENIDATE HCL ORAL SOLN -10MG/5ML METHYLIN SOLN 900ml every 30 days METHYLPHENIDATE HCL ORAL SOLN -5MG/5ML METHYLIN SOLN 1800ml every 30 days METHYLPHENIDATE HCL TAB CR-10mg, 20mg METADATE ER 90 every 30 days METHYLPHENIDATE HCL TAB ER 10mg, 20mg,30mg RITALIN LA 60 every 30 days METHYLPHENIDATE HCL TAB ER 40mg, 60mg RITALIN LA 30 every 30 days METHYLPHENIDATE HCL TAB SA OSM- 18mg, 27mg, 36mg CONCERTA 60 every 30 days METHYLPHENIDATE HCL TAB SA OSM-54mg and 72mg CONCERTA 30 every 30 days METHYLPHENIDATE HCL TAB-20mg RITALIN 90 every 30 days METHYLPHENIDATE HCL TAB-5mg, 10mg RITALIN 180 every 30 days METHYLPHENIDATE TD PATCH- all strengths DAYTRANA 30 every 30 days MOMETASONE FUROATE INHAL POWD-all strengths ASMANEX INH 2 inhaler every 30 days MOMETASONE FUROATE INHAL-all strengths ASMANEX HFA 1 inhaler every 30 days MOMETASONE FUROATE NASAL SUSP 50 MCG/ACT NASONEX 2 bottles every 30 days MORPHINE SULFATE BEADS CAP SR 24HR- 120mg AVINZA 30 every 30 days Initial limit is 0, Post limit PA reqd MORPHINE SULFATE BEADS CAP SR 24HR-all strengths except 120mg AVINZA 30 every 30 days MORPHINE SULFATE CAP SR 24HR-100MG KADIAN 60 every 30 days Initial limit is 0, Post limit PA reqd MORPHINE SULFATE CAP SR 24HR-10MG, 20MG, 30MG AND 40MG KADIAN 60 every 30 days MORPHINE SULFATE CAP SR 24HR-130MG, 150MG AND 200MG KADIAN 30 every 30 days Initial limit is 0, Post limit PA reqd MORPHINE SULFATE CAP SR 24HR-50MG, 60MG, 70MG AND 80MG KADIAN 30 every 30 days MORPHINE SULFATE CONC ORAL SOLN MORPHINE SULFATE CONC SOLN 135ml every 30 days MORPHINE SULFATE IR TABS 15MG MORPHINE SULFATE IR TABS 180 every 30 days MORPHINE SULFATE IR TABS 30MG MORPHINE SULFATE IR TABS 90 every 30 days MORPHINE SULFATE ORAL SOLN 10 MG/5ML MORPHINE SULFATE ORAL SOLN 900ml every 30 days MORPHINE SULFATE ORAL SOLN 20 MG/5ML MORPHINE SULFATE ORAL SOLN 675ml every 30 days
8 MORPHINE SULFATE SUPP 20MG MORPHINE SULFATE SUPPS 120 every 30 days MORPHINE SULFATE SUPP 30MG MORPHINE SULFATE SUPPS 90 every 30 days MORPHINE SULFATE SUPP 5MG AND 10MG MORPHINE SULFATE SUPPS 180 every 30 days MORPHINE SULFATE TAB ER 12HR DETER 15MG AND 30MG MORPHABOND ER 60 Every 30 days MORPHINE SULFATE TAB ER 12HR DETER 60MG AND 100MG MORPHABOND ER 60 Every 30 days Initial limit is 0, Post limit PA reqd MORPHINE SULFATE TAB ER ABUSE-DETERRENT 15 MG and 30MG ONLY ARYMO ER 15MG and 30MG 90 every 30 days MORPHINE SULFATE TAB ER ABUSE-DETERRENT 60MG ARYMO ER 60MG 90 every 30 days Initial limit is 0, Post limit PA reqd MORPHINE SULFATE TAB SR 12HR 100MG AND 200MG MS CONTIN 60 Every 30 days Initial limit is 0, Post limit PA reqd MORPHINE SULFATE TAB SR 12HR 15MG AND 30MG MS CONTIN 90 every 30 days MORPHINE SULFATE TAB SR 12HR 60MG MS CONTIN 90 every 30 days Initial limit is 0, Post limit PA reqd MORPHINE-NALTREXONE CAP CR 100-4MG EMBEDA 60 Every 30 days Initial limit is 0, Post limit PA reqd MORPHINE-NALTREXONE CAP CR MG AND MG EMBEDA 60 Every 30 days MORPHINE-NALTREXONE CAP CR 50-2MG, MG, MG EMBEDA 30 Every 30 days NABILONE CAP 1 MG CESAMET 18 every 30 days NALOXONE NASAL SPRAY NARCAN SPRAY 2 Cartons(4 sprays) every 180 days NARATRIPTAN HCL TAB 2.5 MG AMERGE 2.5MG 12 every 30 days NELFINAVIR MESYLATE TAB-all strengths VIRACEPT 120 every 30 days NETUPITANT-PALONOSETRON CAP MG AKYNZEO 2 every 30 days NEVIRAPINE TAB 200 MG VIRAMUNE 200MG 60 every 30 days NEVIRAPINE TAB SR 24HR 100 MG VIRAMUNE XR 100MG 120 every 30 days NEVIRAPINE TAB SR 24HR 400 MG VIRAMUNE XR 400MG 30 every 30 days OLODATEROL HCL INHAL SOLN 2.5 MCG/ACT STRIVERDI RESPIMAT 1 inhaler every 30 days OLOPATADINE HCL NASAL SOLN 0.6% PATANASE 1 bottle every 30 days OSELTAMIVIR PHOSPHATE CAP-30mg TAMIFLU 40 every 90 days OSELTAMIVIR PHOSPHATE CAP-45mg and 75mg TAMIFLU 20 every 90 days OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML TAMIFLU SUSP 300ml every 90 days OXYCODONE CAP ER 12HR ABUSE-DETERRENT 36MG XTAMPZA ER 90 Every 30 days Initial limit is 0, Post limit PA reqd OXYCODONE CAP ER 12HR ABUSE-DETERRENT 9MG, 13.5MG, 18MG AND 27MG XTAMPZA ER 60 Every 30 days OXYCODONE HCL CAPS/TABS 5MG, 7.5MG, 10MG OXYCODONE 180 every 30 days OXYCODONE HCL ORAL SOLN 5MG/5ML OXYCODONE 900 every 30 days OXYCODONE HCL TABS 15MG OXYCODONE 120 every 30 days OXYCODONE HCL TABS 20MG OXYCODONE 90 every 30 days OXYCODONE HCL TABS 30MG OXYCODONE 60 every 30 days OXYCODONE HCL CONC SOLN 20 MG/ML OXYCODONE 90ml every 30 days
9 OXYCODONE HCL TAB ER 12HR-10MG,15MG, 20MG AND 30MG OXYCONTIN 60 every 30 days OXYCODONE HCL TAB ER 12HR-40MG OXYCONTIN 90 every 30 days Initial limit is 0, Post limit PA reqd OXYCODONE HCL TAB ER 12HR-60MG AND 80MG OXYCONTIN 60 every 30 days Initial limit is 0, Post limit PA reqd OXYCODONE W/ ACETAMINOPHEN ER TAB MG XARTEMIS XR 120 every 30 days OXYCODONE W/ ACETAMINOPHEN SOLN MG/5ML ROXICET SOLN 1800ml every 30 days OXYCODONE W/ ACETAMINOPHEN TAB MG, 5-300MG, MG PERCOCET 5-325MG 360 every 30days OXYCODONE W/ ACETAMINOPHEN TAB MG OXYCODONE/ ACETAMINOPHEN 300 every 30 days OXYCODONE W/ ACETAMINOPHEN TAB MG, MG, MG, MG PERCOCET every 28 days OXYCODONE W/ ACETAMINOPHEN TAB MG, MG, MG, MG, MG PERCOCET MG 180 every 28 days OXYCODONE-IBUPROFEN TAB MG OXYCODONE/IBUPRPOFEN 28 every 30 days OXYMORPHONE HCL TAB ER 12HR-20MG OPANA ER 90 every 30 days Initial limit is 0, Post limit PA reqd OXYMORPHONE HCL TAB ER 12HR-30MG AND 40MG OPANA ER 60 every 30 days Initial limit is 0, Post limit PA reqd OXYMORPHONE HCL TAB ER 12HR-5MG, 7.5MG, 10MG AND 15MG OPANA ER 60 every 30 days OXYMORPHONE TAB 10MG OXYMORPHONE 90 every 30 days OXYMORPHONE TAB 5MG OXYMORPHONE 180 every 30 days PALONOSETRON HCL IV SOLN ALOXI 10ml every 30 days PENTAZOCINE-ACETAMINOPHEN TAB MG PENTAZOCINE/APAP 180 every 30 days PENTAZOCINE-NALOXONE TAB MG PENTAZOCINE/NALOXONE 120 every 30 days RALTEGRAVIR POTASSIUM TAB-all strengths ISENTRESS 60 every 30 days RILPIVIRINE HCL TAB 25 MG (BASE EQUIVALENT) EDURANT 30 every 30 days RIZATRIPTAN BENZOATE ODT-all strengths MAXALT-MLT 18 every 30 days RIZATRIPTAN BENZOATE TAB-all strengths MAXALT 18 every 30 days ROLAPITANT HCL INJ 166.5MG/92.5ML (BASE EQUIV) VARUBI 2 vials every 30 days ROLAPITANT HCL TAB 90 MG (BASE EQUIV) VARUBI 2 packs (4) every 30 days SALMETEROL XINAFOATE AER POW BA 50 MCG/DOSE SEREVENT DISKUS 1 Diskus (60 doses) every 30 days SAQUINAVIR MESYLATE CAP 200 MG INVIRASE 200MG 270 every 30 days SAQUINAVIR MESYLATE TAB 500 MG INVIRASE 500MG 210 every 30 days SODIUM OXYBATE ORAL SOLUTION 500 MG/ML XYREM 540ml Every 30 days STAVUDINE CAP-all strengths ZERIT 60 every 30 days SUMATRIPTAN NASAL SPRAY-20MG IMITREX SPRAY 12 sprays every 30 days SUMATRIPTAN NASAL SPRAY-5MG IMITREX SPRAY 24 sprays every 30 days SUMATRIPTAN SUCCINATE EXHALER POWDER 11 MG/NOSEPIECE ONZETRA XSAIL 1 kit ( 16 pcs) every 30 days SUMATRIPTAN SUCCINATE INJECTION 4MG IMITREX INJ 18 Inj (9ml) every 30 days
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