APREPITANT Kansas Health Advantage (HMO SNP) 2018 Formulary Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil Oral Tablet 150, 200, 250, 50 BUPAP Bupap Oral Tablet 50-300 BUPRENORPHINE HCL Buprenorphine HCl Sublingual Tablet Sublingual 2 Buprenorphine HCl Sublingual Tablet Sublingual 8 Quantity Limit: 240 EA Per 30 Days BUTALBITAL-ACETAMINOPHEN Butalbital-Acetaminophen Oral Tablet 50-325 BUTALBITAL-APAP-CAFF-COD Butalbital-APAP-Caff-Cod Oral Capsule 50-325- 40-30 BUTALBITAL-APAP-CAFFEINE Butalbital-APAP-Caffeine Oral Tablet 50-325-40 BUTALBITAL-ASA-CAFF-CODEINE Butalbital-ASA-Caff-Codeine Oral Capsule 50-325-40-30 1
BUTORPHANOL TARTRATE Butorphanol Tartrate Nasal Solution 10 /ML Quantity Limit: 10 ML Per 30 Days CELECOXIB Celecoxib Oral Capsule 100, 200, 400, 50 CYSTARAN Cystaran Ophthalmic Solution 0.44 % Quantity Limit: 60 ML Per 30 Days DIGITEK Digitek Oral Tablet 125 MCG DIGOX Digox Oral Tablet 125 MCG DIGOXIN Digoxin Oral Tablet 125 MCG DIHYDROERGOTAMINE MESYLATE Dihydroergotamine Mesylate Nasal Solution 4 /ML Quantity Limit: 24 ML Per 28 Days DRONABINOL Dronabinol Oral Capsule 10, 2.5, 5 ELETRIPTAN HYDROBROMIDE Eletriptan Hydrobromide Oral Tablet 20, 40 Quantity Limit: 9 EA Per 30 Days EPINEPHRINE EPINEPHrine Injection Solution Auto-Injector 0.15 /0.3ML, 0.3 /0.3ML 2
ERGOTAMINE-CAFFEINE Ergotamine-Caffeine Oral Tablet 1-100 Quantity Limit: 40 EA Per 28 Days FLURAZEPAM HCL Flurazepam HCl Oral Capsule 15 Flurazepam HCl Oral Capsule 30 GRANISETRON HCL Granisetron HCl Oral Tablet 1 LATANOPROST Latanoprost Ophthalmic Solution 0.005 % Quantity Limit: 2.5 ML Per 25 Days LIDOCAINE Lidocaine External Patch 5 % LIDOCAINE-PRILOCAINE Lidocaine-Prilocaine External Cream 2.5-2.5 % Quantity Limit: 30 GM Per 30 Days MODAFINIL Modafinil Oral Tablet 100, 200 MONUROL Monurol Oral Packet 3 GM NARATRIPTAN HCL Naratriptan HCl Oral Tablet 1, 2.5 Quantity Limit: 12 EA Per 30 Days NARCAN Narcan Nasal Liquid 4 /0.1ML 3
ONDANSETRON HCL Ondansetron HCl Oral Tablet 24 Ondansetron HCl Oral Tablet 4 Ondansetron HCl Oral Tablet 8 ONDANSETRON Ondansetron Oral Tablet Dispersible 4 Ondansetron Oral Tablet Dispersible 8 PROAIR HFA ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Quantity Limit: 17 GM Per 30 Days PROAIR RESPICLICK ProAir RespiClick Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT ROZEREM Rozerem Oral Tablet 8 SPRITAM Spritam Oral Tablet Disintegrating Soluble 1000 Spritam Oral Tablet Disintegrating Soluble 250, 500, 750 SUBOXONE Suboxone Sublingual Film 12-3, 2-0.5, 4-1 Suboxone Sublingual Film 8-2 4
SUMATRIPTAN SUCCINATE SUMAtriptan Succinate Oral Tablet 100, 25, 50 Quantity Limit: 9 EA Per 30 Days TEMAZEPAM Temazepam Oral Capsule 15, 22.5, 30 Temazepam Oral Capsule 7.5 TOBI PODHALER Tobi Podhaler Inhalation Capsule 28 Quantity Limit: 224 EA Per 56 Days TRAMADOL HCL TraMADol HCl Oral Tablet 50 Quantity Limit: 240 EA Per 30 Days TRAMADOL-ACETAMINOPHEN Tramadol-Acetaminophen Oral Tablet 37.5-325 Quantity Limit: 240 EA Per 30 Days VALCHLOR Valchlor External Gel 0.016 % Quantity Limit: 60 GM Per 30 Days VARUBI Varubi Oral Tablet 90 Quantity Limit: 8 EA Per 30 Days VRAYLAR Vraylar Oral Capsule 1.5 Vraylar Oral Capsule 3 Vraylar Oral Capsule 4.5, 6 XGEVA Xgeva Subcutaneous Solution 120 /1.7ML Quantity Limit: 1.7 ML Per 28 Days 5
ZALEPLON Kansas Health Advantage (HMO SNP) 2018 Formulary Zaleplon Oral Capsule 5 ZOLPIDEM TARTRATE Zolpidem Tartrate Oral Tablet 5 6
Alphabetical Listing A Aprepitant... 1 Armodafinil... 1 B Bupap... 1 Buprenorphine HCl... 1 Butalbital-Acetaminophen... 1 Butalbital-APAP-Caff-Cod... 1 Butalbital-APAP-Caffeine... 1 Butalbital-ASA-Caff-Codeine... 1 Butorphanol Tartrate... 2 C Celecoxib... 2 Cystaran... 2 D Digitek... 2 Digox... 2 Digoxin... 2 Dihydroergotamine Mesylate... 2 Dronabinol... 2 E Eletriptan Hydrobromide... 2 EPINEPHrine... 2 Ergotamine-Caffeine... 3 F Flurazepam HCl... 3 G Granisetron HCl... 3 L Latanoprost... 3 Lidocaine... 3 Lidocaine-Prilocaine... 3 M Modafinil... 3 Monurol... 3 N Naratriptan HCl... 3 Narcan... 3 O Ondansetron... 4 Ondansetron HCl... 4 P ProAir HFA... 4 ProAir RespiClick... 4 R Rozerem... 4 S Spritam... 4 Suboxone... 4 SUMAtriptan Succinate... 5 T Temazepam... 5 Tobi Podhaler... 5 TraMADol HCl... 5 Tramadol-Acetaminophen... 5 V Valchlor... 5 Varubi... 5 Vraylar... 5 X Xgeva... 5 Z Zaleplon... 6 Zolpidem Tartrate... 6 7