Responsible Quantity Program Effective 4/1/10. Abilify oral solution
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1 Abilify Abilify Discmelt Abilify oral solution Aciphex Actiq Page 1 of ml 120 units Actonel 5 mg, 30 mg Actonel 35 mg 4 tabs Actonel 75 mg 2 tabs Actonel 150 mg 1 tab Actonel with Calcium Adcirca Adderall (amphetamine-dextroamphetamine mixed salts) Adderall (amphetamine-dextroamphetamine mixed salts) Adderall XR (amphetamine-dextroamphetamine ext-release) Advair Diskus Advair HFA 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg 1 28-day blister pack 20 mg 1 canister Advicor , , Advicor Aerobid, Aerobid M Aerospan Altoprev 3 inhalers Alvesco 80 mcg Alvesco 160 mcg 2 inhaler Ambien (zolpidem) Ambien CR Amerge 1 mg 18 tabs Amerge 2.5 mg 9 tabs Anzemet 50 mg 14 tabs Anzemet 100 mg 7 tabs Arixtra Asmanex Astelin Astepro 30 syringes / 3 months Atrovent (ipratropium) 0.03% Atrovent (ipratropium) 0.06% 3 inhalers Atrovent HFA
2 Avinza Page 2 of 9 Axert 6.25 mg 24 tabs Axert 12.5 mg 12 tabs Azmacort 3 inhalers Bancap-HC (hydrocodone-acetaminophen) caps Beconase AQ Bepreve Boniva 2.5 mg 30 tablets Boniva 150 mg 1 tablet Byetta pre-filled pen (60 doses) 1 pen Capital and Codeine 5010 ml Celebrex 50 mg, 100 mg, 200 mg Celebrex 400 mg Cesamet 56 caps Clozaril (clozapine) 25 mg, 50 mg Clozaril (clozapine) 100 mg 270 tabs Clozaril (clozapine) 200 mg 120 tabs Combivent Combunox (oxycodone-ibuprofen) 28 tabs Concerta 18 mg, 27 mg, 54 mg Concerta 36 mg Crestor 5 mg, 10 mg, 20 mg 45 tabs Crestor 40 mg Cymbalta 20 mg, 30 mg Cymbalta 60 mg Darvocet N-50 (propoxyphene napsylateacetaminophen) Darvocet N-100 (propoxyphene napsylateacetaminophen) Daytrana Detrol Detrol LA Dexedrine Spansule (dextroamphetamine sulfate ext-release) diabetic test strips (all brands) tabs tabs 30 patches 90 caps 204 strips/discs Ditropan XL (oxybutynin ext-release) 5 mg Ditropan XL (oxybutynin ext-release) 10 mg, 15 mg Dolgic LQ Dolgic Plus 5400 ml 150 tabs
3 Duragesic (fentanyl transdermal patch) Edular Effexor (venlafaxine) Page 3 of 9 15 patches Effexor XR 37.5 mg, 150 mg Effexor XR 75 mg 90 caps Embeda , , , Embeda tabs Emend 80 mg 4 caps Emend 125 mg 2 caps Emend Therapy Pack Enablex Endodan (oxycodone-aspirin) 2 Therapy Packs 3 Esgic (butalbital-acetaminophen-caffeine) or tabs Esgic Plus (butalbital-acetaminophencaffeine) caps or tabs Fanapt all strengths Fanapt titration pack FazaClo Fentanyl citrate transmucosal Fentora 7 kits 270 tabs 120 units 120 tabs Fioricet (butalbital-acetaminophen-caffeine) Fioricet w/codeine (butalbital/acetaminophen/caffeine/codeine) Fiorinal (butalbital-aspirin-caffeine) Fiorinal (butalbital-aspirin-caffeine) Fiorinal w/codeine (butalbital-aspirin-caffeinecodeine) Flector patch Flonase (fluticasone) patches Flovent Diskus 50 mcg, 100 mcg 1 carton Flovent Diskus 250 mcg 4 cartons Flovent HFA 44 mcg, 110 mcg Flovent HFA 220 mcg flunisolide nasal soln 25 mcg / spray 3 inhalers Focalin (dexmethylphenidate) Focalin XR all strengths Foradil Aerolizer 1 blister pack (12 or 60) Fosamax (alendronate) 5 mg, 10 mg, 40 mg
4 Fosamax oral soln Page 4 of ml (4 bottles) Fosamax (alendronate) 35 mg, 70 mg 4 tabs Fosamax Plus D 4 tabs Fragmin syringe, all strengths 30 syringes / 3 months Fragmin vial, all strengths 10 vials / 3 months Frova Gelnique Geodon glucose Test Strips (all brands) Hycet 12 tabs 30 sachets 204 strips/discs 3600 ml Ibudone tabs Imitrex nasal soln, 5 mg 36 spray units Imitrex nasal soln, 20 mg 12 spray units Imitrex (sumatriptan) 25 mg 36 tabs Imitrex (sumatriptan) 50 mg 18 tabs Imitrex (sumatriptan) 100 mg 9 tabs Imitrex (sumatriptan) syringe, vial 4 mg / 0.5 ml 6 ml (12 inj) Imitrex (sumatriptan) syringe, vial 6 mg / 0.5 ml 4 ml (8 inj) Innohep vials, 2 ml 15 vials / 3 months Invega 3 mg, 9 mg Invega 6 mg Invega ER 1.5mg Intal Inhaler Janumet Januvia Kadian 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 3 inhalers Kadian 100 mg, 200mg 120 caps Kapidex ketorolac 21 tabs Kytril (granisetron) 1 mg 14 tabs Lescol Lescol XL Letairis Lipitor 10 mg, 20 mg, 40 mg 45 tabs Lipitor 80 mg Livalo all strengths Lorcet (hydrocodone-acetaminophen) caps
5 Page 5 of 9 Lorcet Plus (hydrocodone-acetaminophen) tabs Lortab (hydrocodone-acetaminophen) , 5-500, tabs Lortab (hydrocodone-acetaminophen) tabs Lortab elixir (hydrocodone-acetaminophen) 3600 ml Lovenox syringe, all strengths 30 syringes / 3 months Lovenox vial, 300 mg / 3 ml 10 vials / 3 months Lumigan Lunesta Lyrica 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg 2.5 ml 90 caps Lyrica 225 mg, 300 mg Magnacet Maxair Autohaler 300 tabs 1 canister Maxalt, Maxalt-MLT 5 mg 24 tabs Maxalt, Maxalt-MLT 10 mg 12 tabs Maxidone (hydrocodone/acetaminophen) tabs Metadate CD Metadate ER (methylphenidate ext-release) 10 mg, 20 mg 90 caps Mevacor (lovastatin) Migranal 8 ampules MS Contin (morphine sulfate ext-release) 15 mg, 30 mg, 60 mg 120 tabs MS Contin (morphine sulfate ext-release) 100 mg, 200 mg 180 tabs Nasacort AQ Nasarel (flunisolide) Nasonex 3 inhalers Nexium 20 mg, 40 mg 30 packets / caps Norco (hydrocodone-acetaminophen) Nucynta Nuvigil Omnaris tabs ondansetron 24 mg 7 tabs Onglyza Onsolis Opana ER 120 films Oramorph SR 15 mg, 30 mg, 60 mg 120 tabs Oramorph SR 100 mg 180 tabs oxybutynin syrup 600 ml oxybutynin tabs 5 mg 120 tabs
6 OxyContin (oxycodone ext-release) Oxytrol Patanase Pennsaid Percocet (oxycodone-acetaminophen) , 5-325, , Page 6 of 9 8 patches 30 ml 3 Percocet (oxycodone-acetaminophen) tabs Percocet (oxycodone-acetaminophen) tabs Percodan (oxycodone-aspirin) Phrenilin Forte caps Pravachol (pravastatin) 10 mg, 20 mg, 40 mg 45 tabs Pravachol (pravastatin) 80 mg Prevacid Prevacid Solutab Prilosec (omeprazole delayed-release ) Prilosec suspension packet 2.5 mg 60 packs Prilosec suspension packet 10 mg 30 packs Primalev Pristiq ProAir HFA Protonix (pantoprazole delayed-release) Proventil HFA Provigil 3 30 packets / caps Pulmicort Flexhaler 90 mcg Pulmicort Flexhaler 180 mcg Qualaquin (quinine sulfate) 42 capsules / 3 months Qvar 40 mcg Qvar 80 mcg 3 inhalers Relenza 20 discs / 6 months Relpax 20 mg 12 tabs Relpax 40 mg 6 tabs Reprexain (hydrocodone-ibuprofen) tabs Revatio Rhinocort Aqua Risperdal (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg Risperdal (risperidone) 4 mg 120 tabs Risperdal oral solution (risperidone) 480 ml Risperdal M-tab (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg,
7 3 mg Page 7 of 9 Risperdal M-tab (risperidone) 4 mg 120 tabs Ritalin (methylphenidate) 5 mg, 10 mg Ritalin (methylphenidate) 20 mg Ritalin LA Ritalin SR (methylphenidate ext-release) Roxicet (oxycodone-acetaminophen) tabs Roxicet solution Rozerem Ryzolt 1800 ml Samsca 15 mg Samsca 30 mg Sanctura Sanctura XR Sancuso Saphris Savella Savella Dosepak Seroquel 25 mg, 50 mg, 100 mg 200 mg 4 patches 1 pack Seroquel 300 mg, 400 mg Seroquel XR 50 mg, 300 mg, 400 mg Seroquel XR 150 mg, 200 mg Serevent Diskus Simcor Spiriva Handihaler Sonata (zaleplon) Strattera 10 mg, 18 mg, 25 mg, 40 mg, 60 mg 1 package Strattera 80 mg, 100 mg Sumatriptan nasal soln, 5 mg 36 spray units Sumatriptan nasal soln, 20 mg 12 spray units Sumatriptan syringe, 6mg / 0.5ml 4 ml / 8 injections Sumatriptan syringe, 4mg / 0.5ml 6 ml / 12 injections Sumatriptan vial, 4mg / 0.5ml 6 ml / 12 injections Sumavel DosePro Symbicort 12 injections
8 Symbyax Page 8 of 9 Tamiflu susp, 12 mg / ml 75 ml / 6 months Tamiflu 30 mg 20 caps / 6 months Tamiflu 45 mg, 75 mg 10 caps / 6 months Toviaz Tracleer Travatan, Travatan Z Treximet Tylenol w/codeine (acetaminophen-codeine) Tylenol w/codeine elixir (acetaminophencodeine) 2.5 ml 18 tabs ml Tylox (oxycodone-acetaminophen) caps Ultram ER Venlafaxine ER 75 mg Venlafaxine ER 37.5 mg, 150 mg, 225 mg Ventolin HFA Veramyst Vesicare 2 canisters Vicodin (hydrocodone-acetaminophen) 5-500, tabs Vicodin ES (hydrocodone-acetaminophen) tabs Vicodin HP (hydrocodone-acetaminophen) tabs Vicoprofen (hydrocodone-ibuprofen) Voltaren gel 150 tabs 300 grams Vytorin 10-10, 10-20, tabs Vytorin Vyvanse Xalatan Xopenex HFA 2.5 ml 2 canisters Zegerid 20 mg, 40 mg 30 packets/caps Zetia Zocor (simvastatin) 5 mg, 10 mg, 40 mg 45 tabs Zocor (simvastatin) 20 mg Zocor (simvastatin) 80 mg Zofran (ondansetron) oral soln 100 ml (2 bottles) Zofran, Zofran ODT (ondansetron) 4 mg 42 tabs Zofran, Zofran ODT (ondansetron) 8 mg 21 tabs Zomig nasal soln 12 units Zomig, Zomig ZMT 2.5 mg 18 tabs
9 Page 9 of 9 Zomig, Zomig ZMT 5 mg 9 tabs Zydone Zyprexa, Zyprexa Zydis 300 tabs
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