Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days acetaminophen-codeine #2 tab 300-15 ORAL TABLET 400 30 mg acetaminophen-codeine #3 tab 300-30 ORAL TABLET 400 30 mg acetaminophen-codeine #4 tab 300-60 ORAL TABLET 400 30 mg acetaminophen-codeine solution 120-12 SOLUTION 5000 30 mg/5ml acetaminophen-codeine tab 300-15 mg ORAL TABLET 400 30 acetaminophen-codeine tab 300-30 mg ORAL TABLET 400 30 acetaminophen-codeine tab 300-60 mg ORAL TABLET 400 30 acyclovir ointment 5 % TOPICAL OINTMENT 15 15
ADVAIR DISKUS AER POW BA 100 DRY POWDER INHALER 60 30 50 MCG/DOSE ADVAIR DISKUS AER POW BA 250 DRY POWDER INHALER 60 30 50 MCG/DOSE ADVAIR DISKUS AER POW BA 500 DRY POWDER INHALER 60 30 50 MCG/DOSE ADVAIR HFA AEROSOL 115-21 METERED DOSE INHALER 12 30 MCG/ACT ADVAIR HFA AEROSOL 230-21 METERED DOSE INHALER 12 30 MCG/ACT ADVAIR HFA AEROSOL 45-21 METERED DOSE INHALER 12 30 MCG/ACT
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days ALINIA RECON SUSP 100 MG/5ML ORAL SUSPENSION 180 30 ALINIA TAB 500 MG ORAL TABLET 6 3 ALOXI 0.075 MG/1.5ML INJECTABLE SOLUTION 5 7 ALOXI SOLUTION 0.25 MG/5ML INJECTABLE SOLUTION 5 7 AMITIZA CAP 24 MCG ORAL CAPSULE 60 30 AMITIZA CAP 8 MCG ORAL CAPSULE 60 30 amlodipine besy-benazepril hcl cap 10 ORAL CAPSULE 30 30 20 mg amlodipine besy-benazepril hcl cap 2.5 ORAL CAPSULE 30 30 10 mg amlodipine besy-benazepril hcl cap 5-10 ORAL CAPSULE 30 30 mg amlodipine besy-benazepril hcl cap 5-20 ORAL CAPSULE 30 30 mg anastrozole tab 1 mg ORAL TABLET 30 30 ANDRODERM PATCH 24HR 2 TRANSDERMAL PATCH 30 30 MG/24HR ANDRODERM PATCH 24HR 4 TRANSDERMAL PATCH 30 30 MG/24HR aripiprazole tab 10 mg ORAL TABLET 30 30 aripiprazole tab 15 mg ORAL TABLET 30 30 aripiprazole tab 2 mg ORAL TABLET 30 30 aripiprazole tab 20 mg ORAL TABLET 30 30 aripiprazole tab 30 mg ORAL TABLET 30 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days aripiprazole tab 5 mg ORAL TABLET 30 30 atorvastatin calcium tab 10 mg ORAL TABLET 30 30 atorvastatin calcium tab 20 mg ORAL TABLET 30 30 atorvastatin calcium tab 40 mg ORAL TABLET 30 30 atorvastatin calcium tab 80 mg ORAL TABLET 30 30 AVONEX KIT 30 MCG INJECTABLE SOLUTION 4 30 AVONEX PEN KIT 30 MCG/0.5ML INJECTABLE SOLUTION 4 30 AVONEX PREFILLED KIT 30 INJECTABLE SOLUTION 4 30 MCG/0.5ML azithromycin recon susp 100 mg/5ml SUSPENSION 120 30 azithromycin recon susp 200 mg/5ml SUSPENSION 120 30 budesonide suspension 0.25 mg/2ml SUSPENSION 240 30 budesonide suspension 0.5 mg/2ml SUSPENSION 120 30 butalbital-apap-caff-cod cap 50-325-40 ORAL CAPSULE 370 30 30 mg CHANTIX CONTINUING MONTH ORAL TABLET 56 28 CHANTIX STARTING MONTH PAK ORAL TABLET 53 30 CHANTIX TAB 0.5 MG ORAL TABLET 11 30 CHANTIX TAB 1 MG ORAL TABLET 180 90 citalopram hydrobromide 10 mg ORAL TABLET 90 30 citalopram hydrobromide 40 mg ORAL TABLET 45 30 citalopram hydrobromide tab 10 mg ORAL TABLET 90 30
citalopram hydrobromide tab 20 mg ORAL TABLET 90 30
citalopram hydrobromide tab 40 mg ORAL TABLET 45 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days DENAVIR CREAM 1 % TOPICAL CREAM 1.5 10
diazepam tab 10 mg ORAL TABLET 120 30 diazepam tab 2 mg ORAL TABLET 240 30 diazepam tab 5 mg ORAL TABLET 240 30 diclofenac gel 3% TOPICAL GEL 100 30 dronabinol cap 10 mg ORAL CAPSULE 60 30 dronabinol cap 2.5 mg ORAL CAPSULE 60 30 dronabinol cap 5 mg ORAL CAPSULE 60 30 duloxetine hcl cp dr part 20 mg ENTERIC COATED CAPSULE 60 30 duloxetine hcl cp dr part 30 mg ENTERIC COATED CAPSULE 60 30 duloxetine hcl cp dr part 60 mg ENTERIC COATED CAPSULE 60 30 ELIDEL CREAM 1 % TOPICAL CREAM 30 30 EMSAM PATCH 24HR 12 MG/24HR TRANSDERMAL PATCH 30 30 EMSAM PATCH 24HR 6 MG/24HR TRANSDERMAL PATCH 30 30 EMSAM PATCH 24HR 9 MG/24HR TRANSDERMAL PATCH 30 30 ENBREL KIT 25 MG INJECTABLE SOLUTION 16 30 ENBREL SOLN PRSYR 50 MG/ML PREFILLED SYRINGE 8 28 ENBREL SURECLICK SOLN A-INJ 50 PREFILLED SYRINGE 8 28 endocet tab 10-325 mg ORAL TABLET 370 30 endocet tab 5-325 mg ORAL TABLET 370 30 endocet tab 7.5-325 mg ORAL TABLET 370 30 enoxaparin sodium solution 100 mg/ml SOLUTION 20 10 enoxaparin sodium solution 120 SOLUTION 20 10 enoxaparin sodium solution 150 mg/ml SOLUTION 20 10 enoxaparin sodium solution 30 mg/0.3ml SOLUTION 20 10
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days enoxaparin sodium solution 300 mg/3ml SOLUTION 20 10 enoxaparin sodium solution 40 mg/0.4ml SOLUTION 20 10 enoxaparin sodium solution 60 mg/0.6ml SOLUTION 20 10 enoxaparin sodium solution 80 mg/0.8ml SOLUTION 20 10 escitalopram oxalate solution 5 mg/5ml SOLUTION 600 30 escitalopram oxalate tab 10 mg ORAL TABLET 30 30 escitalopram oxalate tab 20 mg ORAL TABLET 30 30 escitalopram oxalate tab 5 mg ORAL TABLET 30 30 famciclovir tab 125 mg ORAL TABLET 21 10 famciclovir tab 250 mg ORAL TABLET 68 34 famciclovir tab 500 mg ORAL TABLET 21 7 fentanyl 100 mcg/hr TRANSDERMAL PATCH 10 30 fentanyl 12 mcg/hr TRANSDERMAL PATCH 10 30 fentanyl 25 mcg/hr TRANSDERMAL PATCH 10 30 fentanyl 75 mcg/hr TRANSDERMAL PATCH 10 30 fentanyl citrate loz handle 1200 mcg LOZENGE 120 30 fentanyl citrate loz handle 1600 mcg LOZENGE 120 30 fentanyl citrate loz handle 200 mcg LOZENGE 120 30 fentanyl citrate loz handle 400 mcg LOZENGE 120 30 fentanyl citrate loz handle 600 mcg LOZENGE 120 30 fentanyl citrate loz handle 800 mcg LOZENGE 120 30 fentanyl patch 72hr 100 mcg/hr TRANSDERMAL PATCH 10 30 fentanyl patch 72hr 12 mcg/hr TRANSDERMAL PATCH 10 30 fentanyl patch 72hr 25 mcg/hr TRANSDERMAL PATCH 10 30 FENTANYL PATCH 72HR 37.5 TRANSDERMAL PATCH 10 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days fentanyl patch 72hr 50 mcg/hr TRANSDERMAL PATCH 10 30 FENTANYL PATCH 72HR TRANSDERMAL PATCH 10 30 fentanyl patch 72hr 75 mcg/hr TRANSDERMAL PATCH 10 30 FENTANYL PATCH 72HR 87.5 TRANSDERMAL PATCH 10 30 fluticasone propionate suspension 50 SUSPENSION 16 30 FORTEO SOLUTION 600 PREFILLED SYRINGE 2.4 28 FRAGMIN SOLUTION 10000 PREFILLED SYRINGE 9.5 5 FRAGMIN SOLUTION 12500 PREFILLED SYRINGE 2.5 5 FRAGMIN SOLUTION 15000 PREFILLED SYRINGE 3 5 FRAGMIN SOLUTION 18000 PREFILLED SYRINGE 3.6 5 FRAGMIN SOLUTION 2500 PREFILLED SYRINGE 2 5 FRAGMIN SOLUTION 25000 PREFILLED SYRINGE 19 5 FRAGMIN SOLUTION 5000 PREFILLED SYRINGE 3 5 UNIT/0.2ML FRAGMIN SOLUTION 7500 PREFILLED SYRINGE 1.5 5 FRAGMIN SOLUTION 95000 PREFILLED SYRINGE 19 5 UNIT/3.8ML gabapentin 100 mg ORAL CAPSULE 540 30 gabapentin 300 mg ORAL CAPSULE 360 30
gabapentin 400 mg ORAL CAPSULE 270 30
gabapentin cap 100 mg ORAL CAPSULE 540 30 gabapentin cap 300 mg ORAL CAPSULE 360 30
gabapentin cap 400 mg ORAL CAPSULE 270 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days gabapentin tab 600 mg ORAL TABLET 120 30
gabapentin tab 800 mg ORAL TABLET 120 30
galantamine hydrobromide er cap EXTENDED RELEASE CAPSULE 90 30 er 24h 8 mg galantamine hydrobromide tab 12 ORAL TABLET 60 30 mg galantamine hydrobromide tab 4 ORAL TABLET 180 30 mg GAUZE PADS & DRESSINGS NA 120 30 PADS 2 X 2 GLEEVEC TAB 100 MG ORAL TABLET 90 30
GLEEVEC TAB 400 MG ORAL TABLET 60 30 HUMIRA PEDIATRIC CROHNS PREFILLED SYRINGE 8 28 HUMIRA PEN PEN KIT 40 MG/0.8ML PREFILLED SYRINGE 8 28 HUMIRA PEN-CROHNS STARTER PREFILLED SYRINGE 8 28 HUMIRA PEN -PSORIASIS STARTER PREFILLED SYRINGE 8 28 HUMIRA PREF SY KT 10 MG/0.2ML PREFILLED SYRINGE 8 28 HUMIRA PREF SY KT 20 MG/0.4ML PREFILLED SYRINGE 8 28 HUMIRA PREF SY KT 40 MG/0.8ML PREFILLED SYRINGE 8 28 hydrocodone-acetaminophen solution SOLUTION 5500 30 2.5-108 mg/5ml hydrocodone-acetaminophen solution 5 SOLUTION 5500 30 hydrocodone-acetaminophen solution SOLUTION 5500 30 7.5-325 mg/15ml hydrocodone-acetaminophen tab 10-325 ORAL TABLET 370 30 mg
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days hydrocodone-acetaminophen tab 2.5-325 ORAL TABLET 370 30 mg hydrocodone-acetaminophen tab 5-325 ORAL TABLET 370 30 mg hydrocodone-acetaminophen tab 7.5-325 ORAL TABLET 370 30 mg hydrocodone-acetaminophen tab 10 ORAL TABLET 400 30 300mg hydrocodone-acetaminophen tab 5 ORAL TABLET 400 30 300mg hydrocodone-acetaminophen tab 7.5 ORAL TABLET 400 30 300mg ibandronate sodium tab 150 mg ORAL TABLET 1 30
INVEGA TAB ER 24H 1.5 MG EXTENDED RELEASE TABLET 30 30
INVEGA TAB ER 24H 3 MG EXTENDED RELEASE TABLET 30 30 INVEGA TAB ER 24H 6 MG EXTENDED RELEASE TABLET 60 30 INVEGA TAB ER 24H 9 MG EXTENDED RELEASE TABLET 45 30 ipratropium bromide solution 0.03 % SOLUTION 30 30
ipratropium bromide solution 0.06 % SOLUTION 30 30
ipratropium-albuterol solution 0.5-2.5 SOLUTION 540 30 (3) mg/3ml JENTADUETO TAB 2.5-1000 MG ORAL TABLET 60 30
JENTADUETO TAB 2.5-500 MG ORAL TABLET 60 30
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H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days JENTADUETO TAB 2.5-850 MG ORAL TABLET 60 30 KINERET SOLN PRSYR 100 PREFILLED SYRINGE 18.76 28 MG/0.67ML LANTUS INJ SOLOSTAR PREFILLED SYRINGE 30 30
LATUDA TAB 120 MG ORAL TABLET 90 90 LATUDA TAB 20 MG ORAL TABLET 180 30 LATUDA TAB 40 MG ORAL TABLET 180 90 LATUDA TAB 60 MG ORAL TABLET 180 30 LATUDA TAB 80 MG ORAL TABLET 90 90 levalbuterol hcl nebu soln 0.31 mg/3ml INHALANT SOLUTION 540 30 levalbuterol hcl nebu soln 0.63 mg/3ml INHALANT SOLUTION 540 30 levalbuterol hcl nebu soln 1.25 mg/0.5ml INHALANT SOLUTION 90 30 levalbuterol hcl nebu soln 1.25 mg/3ml INHALANT SOLUTION 90 30 lidocaine patch 5 % TRANSDERMAL PATCH 270 90 LINZESS CAP 145 MCG ORAL CAPSULE 30 30 LINZESS CAP 290 MCG ORAL CAPSULE 30 30 lorazepam tab 0.5 mg ORAL TABLET 120 30 lorazepam tab 1 mg ORAL TABLET 90 30 lorazepam tab 2 mg ORAL TABLET 60 30 lorcet plus tab 7.5-325 mg ORAL TABLET 370 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days LYRICA CAP 100 MG ORAL CAPSULE 120 30 LYRICA CAP 150 MG ORAL CAPSULE 120 30 LYRICA CAP 200 MG ORAL CAPSULE 90 30 LYRICA CAP 225 MG ORAL CAPSULE 60 30 LYRICA CAP 25 MG ORAL CAPSULE 120 30 LYRICA CAP 300 MG ORAL CAPSULE 60 30 LYRICA CAP 50 MG ORAL CAPSULE 120 30 LYRICA CAP 75 MG ORAL CAPSULE 120 30 LYRICA SOLUTION 20 MG/ML ORAL SOLUTION 946 30 methadone hcl tab 10 mg ORAL TABLET 240 30 methadone hcl tab 5 mg ORAL TABLET 240 30 MORPHINE SULFATE ER BEADS EXTENDED RELEASE CAPSULE 90 30 CAP ER 24H 30 MG MORPHINE SULFATE ER BEADS EXTENDED RELEASE CAPSULE 90 30 CAP ER 24H 45 MG MORPHINE SULFATE ER BEADS EXTENDED RELEASE CAPSULE 90 30 CAP ER 24H 60 MG MORPHINE SULFATE ER BEADS EXTENDED RELEASE CAPSULE 90 30 CAP ER 24H 75 MG MORPHINE SULFATE ER BEADS EXTENDED RELEASE CAPSULE 90 30 CAP ER 24H 90 MG
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days morphine sulfate er cap er 24h 10 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er cap er 24h 100 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er cap er 24h 20 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er cap er 24h 30 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er cap er 24h 50 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er cap er 24h 60 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er cap er 24h 80 mg EXTENDED RELEASE CAPSULE 90 30 morphine sulfate er tab er 100 mg EXTENDED RELEASE TABLET 90 30 morphine sulfate er tab er 15 mg EXTENDED RELEASE TABLET 90 30 morphine sulfate er tab er 200 mg EXTENDED RELEASE TABLET 60 30 morphine sulfate er tab er 30 mg EXTENDED RELEASE TABLET 90 30 morphine sulfate er tab er 60 mg EXTENDED RELEASE TABLET 90 30 MOZOBIL SOLUTION 24 MG/1.2ML INJECTABLE SOLUTION 9.6 30 naratriptan hcl tab 1 mg ORAL TABLET 54 84 naratriptan hcl tab 2.5 mg ORAL TABLET 54 84 NEEDLES, INSULIN DISP., SAFETY MISC 120 30 NEULASTA DELIVERY KIT PREFILLED SYRINGE 1.2 28 SOLUTION 6 MG/0.6ML NEULASTA SOLUTION 6 MG/0.6ML PREFILLED SYRINGE 1.2 28 NEUPOGEN SOLUTION 300 SOLUTION 4 28 MCG/ML NEXAVAR TAB 200 MG ORAL TABLET 120 30 NUCYNTA ER TAB ER 12H 100 MG EXTENDED RELEASE TABLET 60 30 NUCYNTA ER TAB ER 12H 150 MG EXTENDED RELEASE TABLET 60 30 NUCYNTA ER TAB ER 12H 200 MG EXTENDED RELEASE TABLET 60 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days NUCYNTA ER TAB ER 12H 250 MG EXTENDED RELEASE TABLET 60 30 NUCYNTA ER TAB ER 12H 50 MG EXTENDED RELEASE TABLET 60 30 NUCYNTA TAB 100 MG ORAL TABLET 180 30 NUCYNTA TAB 50 MG ORAL TABLET 180 30 NUCYNTA TAB 75 MG ORAL TABLET 180 30 olanzapine tab 10 mg ORAL TABLET 60 30 olanzapine tab 15 mg ORAL TABLET 11 30 olanzapine tab 2.5 mg ORAL TABLET 53 30 olanzapine tab 20 mg ORAL TABLET 30 30 olanzapine tab 5 mg ORAL TABLET 90 90 olanzapine tab 7.5 mg ORAL TABLET 180 30 olanzapine tab disp 10 mg DISINTEGRATING TABLET 60 30 olanzapine tab disp 15 mg DISINTEGRATING TABLET 180 90 olanzapine tab disp 20 mg DISINTEGRATING TABLET 30 30 olanzapine tab disp 5 mg DISINTEGRATING TABLET 120 30 ondansetron hcl 4 mg ORAL TABLET 15 5 ondansetron hcl 4 mg/2ml SOLUTION 160 30 ondansetron hcl 40 mg/20ml SOLUTION 160 30 ondansetron hcl 8 mg ORAL TABLET 15 5 ondansetron hcl solution 4 mg/2ml SOLUTION 160 30 ondansetron hcl solution 40 mg/20ml SOLUTION 160 30 ondansetron hcl tab 24 mg ORAL TABLET 30 30 ondansetron hcl tab 4 mg ORAL TABLET 15 5 ondansetron hcl tab 8 mg ORAL TABLET 15 5 ondansetron tab disp 4 mg DISINTEGRATING TABLET 15 5
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days ondansetron tab disp 8 mg DISINTEGRATING TABLET 15 5 OXYCODONE HCL ER TB12 DETER EXTENDED RELEASE TABLET 120 30 10 MG OXYCODONE HCL ER TB12 DETER EXTENDED RELEASE TABLET 120 30 20 MG OXYCODONE HCL ER TB12 DETER EXTENDED RELEASE TABLET 120 30 40 MG OXYCODONE HCL ER TB12 DETER EXTENDED RELEASE TABLET 120 30 80 MG oxycodone-acetaminophen tab 10-325 ORAL TABLET 370 30 mg oxycodone-acetaminophen tab 2.5-325 ORAL TABLET 370 30 mg oxycodone-acetaminophen tab 5-325 mg ORAL TABLET 370 30 oxycodone-acetaminophen tab 7.5-325 ORAL TABLET 370 30 mg OXYCONTIN TB12 DETER 15 MG EXTENDED RELEASE TABLET 120 30 OXYCONTIN TB12 DETER 30 MG EXTENDED RELEASE TABLET 120 30 OXYCONTIN TB12 DETER 60 MG EXTENDED RELEASE TABLET 120 30 oxymorphone hcl er tab er 12h 10 mg EXTENDED RELEASE TABLET 120 30 oxymorphone hcl er tab er 12h 15 mg EXTENDED RELEASE TABLET 60 30 oxymorphone hcl er tab er 12h 20 mg EXTENDED RELEASE TABLET 120 30 oxymorphone hcl er tab er 12h 30 mg EXTENDED RELEASE TABLET 120 30 oxymorphone hcl er tab er 12h 40 mg EXTENDED RELEASE TABLET 120 30 oxymorphone hcl er tab er 12h 5 mg EXTENDED RELEASE TABLET 120 30 oxymorphone hcl er tab er 12h 7.5 mg EXTENDED RELEASE TABLET 90 30 pantoprazole sodium tab dr 20 mg ENTERIC COATED TABLET 60 30 pantoprazole sodium tab dr 40 mg ENTERIC COATED TABLET 60 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days paroxetine hcl 10 mg ORAL TABLET 90 30 paroxetine hcl 20 mg ORAL TABLET 90 30 paroxetine hcl 30 mg ORAL TABLET 60 30 paroxetine hcl 40 mg ORAL TABLET 45 30 paroxetine hcl tab 10 mg ORAL TABLET 90 30 paroxetine hcl tab 20 mg ORAL TABLET 90 30 paroxetine hcl tab 30 mg ORAL TABLET 60 30 paroxetine hcl tab 40 mg ORAL TABLET 45 30 PEG-INTRON KIT 120 MCG/0.5ML INJECTABLE SOLUTION 4 28 PEG-INTRON KIT 150 MCG/0.5ML INJECTABLE SOLUTION 4 28 PEG-INTRON KIT 50 MCG/0.5ML INJECTABLE SOLUTION 4 30 PEG-INTRON KIT 80 MCG/0.5ML INJECTABLE SOLUTION 4 28 PEG-INTRON REDIPEN KIT 120 INJECTABLE SOLUTION 4 30 MCG/0.5ML PEG-INTRON REDIPEN KIT 150 INJECTABLE SOLUTION 4 30 MCG/0.5ML PEG-INTRON REDIPEN KIT 50 INJECTABLE SOLUTION 4 30 MCG/0.5ML PEG-INTRON REDIPEN KIT 80 INJECTABLE SOLUTION 4 30 MCG/0.5ML PEG-INTRON REDIPEN PAK 4 KIT INJECTABLE SOLUTION 4 30 120 MCG/0.5ML PEG-INTRON REDIPEN PAK 4 KIT INJECTABLE SOLUTION 4 30 150 MCG/0.5ML PEG-INTRON REDIPEN PAK 4 KIT 50 INJECTABLE SOLUTION 4 30 MCG/0.5ML PEG-INTRON REDIPEN PAK 4 KIT 80 INJECTABLE SOLUTION 4 30 MCG/0.5ML
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days PEGASYS KIT 180 MCG/0.5ML INJECTABLE SOLUTION 4 30 PEGASYS PROCLICK SOLUTION PREFILLED SYRINGE 4 30 135 MCG/0.5ML PEGASYS PROCLICK SOLUTION PREFILLED SYRINGE 4 30 180 MCG/0.5ML PEGASYS SOLUTION 180 PREFILLED SYRINGE 4 30 MCG/0.5ML PEGINTRON KIT 120 MCG/0.5ML INJECTABLE SOLUTION 4 28 PEGINTRON KIT 150 MCG/0.5ML INJECTABLE SOLUTION 4 28 PEGINTRON KIT 50 MCG/0.5ML INJECTABLE SOLUTION 4 30 PEGINTRON KIT 80 MCG/0.5ML INJECTABLE SOLUTION 4 28 pioglitazone hcl tab 15 mg ORAL TABLET 30 30 pioglitazone hcl tab 30 mg ORAL TABLET 30 30 pioglitazone hcl tab 45 mg ORAL TABLET 30 30 pioglitazone hcl-metformin hcl tab 15 ORAL TABLET 90 30 500 mg pioglitazone hcl-metformin hcl tab 15 ORAL TABLET 90 30 850 mg PRADAXA CAP 150 MG ORAL CAPSULE 180 90 PRADAXA CAP 75 MG ORAL CAPSULE 180 90 PRISTIQ TAB ER 24H 100 MG EXTENDED RELEASE TABLET 30 30 PRISTIQ TAB ER 24H 50 MG EXTENDED RELEASE TABLET 30 30 PROCRIT SOLUTION 10000 UNIT/ML INJECTABLE SOLUTION 36 84 PROCRIT SOLUTION 2000 UNIT/ML INJECTABLE SOLUTION 22 30 PROCRIT SOLUTION 20000 UNIT/ML INJECTABLE SOLUTION 12 28 PROCRIT SOLUTION 3000 UNIT/ML INJECTABLE SOLUTION 15 30 PROCRIT SOLUTION 4000 UNIT/ML INJECTABLE SOLUTION 12 28
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days PROCRIT SOLUTION 40000 UNIT/ML INJECTABLE SOLUTION 6 28 quetiapine fumarate tab 100 mg ORAL TABLET 270 90 quetiapine fumarate tab 200 mg ORAL TABLET 270 90 quetiapine fumarate tab 25 mg ORAL TABLET 180 90 quetiapine fumarate tab 300 mg ORAL TABLET 180 90 quetiapine fumarate tab 400 mg ORAL TABLET 180 90 quetiapine fumarate tab 50 mg ORAL TABLET 270 90 REBIF REBIDOSE SOLUTION 22 PREFILLED SYRINGE 12 30 MCG/0.5ML REBIF REBIDOSE SOLUTION 44 PREFILLED SYRINGE 12 30 MCG/0.5ML REBIF REBIDOSE TITRATION PACK SOLUTION 12 30 SOLUTION 6X8.8 & 6X22 MCG REBIF SOLUTION 22 MCG/0.5ML PREFILLED SYRINGE 12 30 REBIF SOLUTION 44 MCG/0.5ML PREFILLED SYRINGE 12 30 RESTASIS EMULSION 0.05 % OPHTHALMIC SUSPENSION 64 30 risperidone m-tab tab disp 0.5 mg DISINTEGRATING TABLET 90 30 risperidone m-tab tab disp 1 mg DISINTEGRATING TABLET 60 30 risperidone m-tab tab disp 2 mg DISINTEGRATING TABLET 60 30 risperidone m-tab tab disp 3 mg DISINTEGRATING TABLET 60 30 risperidone m-tab tab disp 4 mg DISINTEGRATING TABLET 120 30 risperidone solution 1 mg/ml SOLUTION 480 30 risperidone tab 0.25 mg ORAL TABLET 90 30 risperidone tab 0.5 mg ORAL TABLET 90 30 risperidone tab 1 mg ORAL TABLET 60 30 risperidone tab 2 mg ORAL TABLET 60 30 risperidone tab 3 mg ORAL TABLET 60 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days risperidone tab 4 mg ORAL TABLET 120 30 risperidone tab disp 0.25 mg DISINTEGRATING TABLET 90 30 risperidone tab disp 0.5 mg DISINTEGRATING TABLET 90 30 risperidone tab disp 1 mg DISINTEGRATING TABLET 60 30 risperidone tab disp 2 mg DISINTEGRATING TABLET 60 30 risperidone tab disp 3 mg DISINTEGRATING TABLET 60 30 risperidone tab disp 4 mg DISINTEGRATING TABLET 120 30 ROZEREM TAB 8 MG ORAL TABLET 30 30 SAVELLA TAB 100 MG ORAL TABLET 60 30 SAVELLA TAB 12.5 MG ORAL TABLET 60 30 SAVELLA TAB 25 MG ORAL TABLET 60 30 SAVELLA TAB 50 MG ORAL TABLET 60 30 SEROQUEL XR TAB ER 24H 150 MG EXTENDED RELEASE TABLET 180 90 SEROQUEL XR TAB ER 24H 200 MG EXTENDED RELEASE TABLET 270 90 SEROQUEL XR TAB ER 24H 300 MG EXTENDED RELEASE TABLET 180 90 SEROQUEL XR TAB ER 24H 400 MG EXTENDED RELEASE TABLET 180 90 SEROQUEL XR TAB ER 24H 50 MG EXTENDED RELEASE TABLET 270 90 sertraline hcl 100 mg ORAL TABLET 60 30 sertraline hcl 25 mg ORAL TABLET 90 30 sertraline hcl 50 mg ORAL TABLET 90 30 sertraline hcl tab 100 mg ORAL TABLET 60 30 sertraline hcl tab 25 mg ORAL TABLET 90 30 sertraline hcl tab 50 mg ORAL TABLET 90 30 sildenafil citrate tab 20 mg ORAL TABLET 90 30 SPIRIVA CAP HANDIHALER ORAL INHALATION 30 30 SPIRIVA SPR RESPIMAT ORAL INHALATION 30 30 sumatriptan succinate 100 mg ORAL TABLET 9 30 H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days sumatriptan succinate 50 mg ORAL TABLET 9 30 sumatriptan succinate 6 mg/0.5ml SOLUTION 10 30 sumatriptan succinate refill soln cart 4 PREFILLED SYRINGE 4.5 30 mg/0.5ml sumatriptan succinate refill soln cart 6 PREFILLED SYRINGE 4.5 30 mg/0.5ml sumatriptan succinate soln a-inj 4 PREFILLED SYRINGE 4.5 30 mg/0.5ml sumatriptan succinate soln a-inj 6 PREFILLED SYRINGE 4.5 30 mg/0.5ml sumatriptan succinate soln prsyr 6 PREFILLED SYRINGE 4.5 30 mg/0.5ml sumatriptan succinate solution 6 SOLUTION 10 30 mg/0.5ml sumatriptan succinate tab 100 mg ORAL TABLET 9 30 sumatriptan succinate tab 25 mg ORAL TABLET 9 30 sumatriptan succinate tab 50 mg ORAL TABLET 9 30 SYMBICORT AEROSOL 160-4.5 METERED DOSE INHALER 10.2 30 MCG/ACT SYMBICORT AEROSOL 80-4.5 METERED DOSE INHALER 10.2 30 MCG/ACT TAMIFLU CAP 45 MG ORAL CAPSULE 35 30 TAMIFLU CAP 75 MG ORAL CAPSULE 40 10 TAZORAC GEL 0.05 % TOPICAL GEL 100 30 TAZORAC GEL 0.1 % TOPICAL GEL 100 30 temazepam cap 15 mg ORAL CAPSULE 30 30 temazepam cap 22.5 mg ORAL CAPSULE 30 30 temazepam cap 30 mg ORAL CAPSULE 30 30
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.
Elderplan 2016 Formulary Quantity Limits
Drug Name Dose Form Quantity Limit Amount Quantity Limit Days temazepam cap 7.5 mg ORAL CAPSULE 120 30 TRADJENTA TAB 5 MG ORAL TABLET 30 30 tramadol-acetaminophen tab 37.5-325 ORAL TABLET 370 30 mg triazolam tab 0.125 mg ORAL TABLET 30 30 triazolam tab 0.25 mg ORAL TABLET 60 30 valacyclovir hcl tab 1 gm ORAL TABLET 34 34 valacyclovir hcl tab 500 mg ORAL TABLET 34 34 venlafaxine hcl er cap er 24h 150 mg EXTENDED RELEASE CAPSULE 90 90 venlafaxine hcl er cap er 24h 37.5 mg EXTENDED RELEASE CAPSULE 180 90 venlafaxine hcl er cap er 24h 75 mg EXTENDED RELEASE CAPSULE 90 90 ZETIA TAB 10 MG ORAL TABLET 30 30 zolpidem tartrate 10 mg ORAL TABLET 30 30 zolpidem tartrate 5 mg ORAL TABLET 60 30 zolpidem tartrate er tab 12.5 mg ORAL TABLET 30 30 zolpidem tartrate er tab 6.25 mg ORAL TABLET 30 30 ZOSTAVAX RECON SOLN 19400 INJECTABLE SUSPENSION 1 999 UNT/0.65ML
H8029_2016 Formulary ID: 16200 Version 7 Last Updated: 08/19/2015 Effective Date: 01/01/2016 *Brand name drugs are capitalized, generic drugs are lower-case and italicized.