Agewell 2020
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Acetaminophen-Codeine #3 acetaminophen-codeine #3 oral tablet 300- Quantity Limit: 400 EA Per 30 30 mg Days Acetaminophen-Codeine acetaminophen-codeine oral solution 120- Quantity Limit: 5000 ML Per 30 12 mg/5ml Days acetaminophen-codeine oral tablet 300-15 Quantity Limit: 400 EA Per 30 mg, 300-60 mg Days Alfuzosin HCl ER alfuzosin hcl er oral tablet extended release Quantity Limit: 30 EA Per 30 24 hour 10 mg Days ALPRAZolam Intensol ALPRAZOLAM INTENSOL ORAL Quantity Limit: 300 ML Per 30 CONCENTRATE 1 MG/ML Days ALPRAZolam alprazolam oral tablet 0.25 mg, 0.5 mg Quantity Limit: 120 EA Per 30 Days alprazolam oral tablet 1 mg Quantity Limit: 180 EA Per 30 Days alprazolam oral tablet 2 mg Quantity Limit: 150 EA Per 30 Days Updated 4/01/2020 1 ARIPiprazole aripiprazole oral solution 1 mg/ml Quantity Limit: 750 ML Per 30 Days Ascomp-Codeine ASCOMP-CODEINE ORAL CAPSULE Quantity Limit: 180 EA Per 30 50-325-40-30 MG Days Biktarvy BIKTARVY ORAL TABLET 50-200-25 Quantity Limit: 30 EA Per 30 MG Days Butalbital-APAP-Caff-Cod butalbital-apap-caff-cod oral capsule 50- Quantity Limit: 370 EA Per 30 325-40-30 mg Days Butalbital-APAP-Caffeine butalbital-apap-caffeine oral tablet 50-325- Quantity Limit: 180 EA Per 30 40 mg Days Butalbital-ASA-Caff-Codeine butalbital-asa-caff-codeine oral capsule 50- Quantity Limit: 180 EA Per 30 325-40-30 mg Days Chantix Continuing Month Pak CHANTIX CONTINUING MONTH PAK Quantity Limit: 56 EA Per 28 ORAL TABLET 1 MG Days 2 Chantix CHANTIX ORAL TABLET 0.5 MG Quantity Limit: 60 EA Per 30 Days CHANTIX ORAL TABLET 1 MG Quantity Limit: 180 EA Per 90 Days Chantix Starting Month Pak CHANTIX STARTING MONTH PAK Quantity Limit: 53 EA Per 30 ORAL TABLET 0.5 MG X 11 & 1 MG X Days 42 Clorazepate Dipotassium clorazepate dipotassium oral tablet 15 mg, Quantity Limit: 180 EA Per 30 3.75 mg, 7.5 mg Days Daliresp DALIRESP ORAL TABLET 250 MCG, Quantity Limit: 30 EA Per 30 500 MCG Days Diazepam diazepam oral concentrate 5 mg/ml Quantity Limit: 240 ML Per 30 Days DiazePAM diazepam oral solution 5 mg/5ml Quantity Limit: 1200 ML Per 30 Days diazepam oral tablet 2 mg Quantity Limit: 600 EA Per 30 Days Updated 4/01/2020 3 diazePAM diazepam oral tablet 10 mg Quantity Limit: 120 EA Per 30 Days diazepam oral tablet 5 mg Quantity Limit: 240 EA Per 30 Days Dificid DIFICID ORAL TABLET 200 MG Quantity Limit: 20 EA Per 10 Days Drizalma Sprinkle DRIZALMA SPRINKLE ORAL CAPSULE Quantity Limit: 60 EA Per 30 DELAYED RELEASE SPRINKLE 20 MG, Days 30 MG, 40 MG, 60 MG Dronabinol dronabinol oral capsule 10 mg, 2.5 mg, 5 Quantity Limit: 60 EA Per 30 mg Days Endari ENDARI ORAL PACKET 5 GM Quantity Limit: 180 EA Per 30 Days Ergotamine-Caffeine ergotamine-caffeine oral tablet 1-100 mg Quantity Limit: 40 EA Per 28 Days 4 Estazolam estazolam oral tablet 1 mg Quantity Limit: 60 EA Per 30 Days estazolam oral tablet 2 mg Quantity Limit: 30 EA Per 30 Days FentaNYL Citrate fentanyl citrate buccal lozenge on a handle Quantity Limit: 120 EA Per 30 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, Days 600 mcg, 800 mcg FentaNYL fentanyl transdermal patch 72 hour 100 Quantity Limit: 10 EA Per 30 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, Days 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr Flurazepam HCl flurazepam hcl oral capsule 15 mg Quantity Limit: 60 EA Per 30 Days flurazepam hcl oral capsule 30 mg Quantity Limit: 30 EA Per 30 Days Galafold GALAFOLD ORAL CAPSULE 123 MG Quantity Limit: 15 EA Per 30 Days Updated 4/01/2020 5 Granisetron HCl granisetron hcl oral tablet 1 mg Quantity Limit: 60 EA Per 30 Days HYDROcodone-Acetaminophen hydrocodone-acetaminophen oral solution Quantity Limit: 5500 ML Per 30 7.5-325 mg/15ml Days hydrocodone-acetaminophen oral tablet 10- Quantity Limit: 370 EA Per 30 325 mg, 5-325 mg, 7.5-325 mg Days Hydrocodone-Ibuprofen hydrocodone-ibuprofen oral tablet 5-200 Quantity Limit: 150 EA Per 30 mg, 7.5-200 mg Days Lidocaine lidocaine external ointment 5 % Quantity Limit: 50 GM Per 30 Days lidocaine external patch 5 % Quantity Limit: 90 EA Per 30 Days LORazepam lorazepam oral concentrate 2 mg/ml Quantity Limit: 240 ML Per 30 Days lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Quantity Limit: 150 EA Per 30 Days 6 Modafinil modafinil oral tablet 100 mg, 200 mg Quantity Limit: 30 EA Per 30 Days Ondansetron HCl ondansetron hcl oral tablet 24 mg Quantity Limit: 30 EA Per 30 Days ondansetron hcl oral tablet 4 mg, 8 mg Quantity Limit: 90 EA Per 30 Days Ondansetron ondansetron oral tablet dispersible 4 mg, 8 Quantity Limit: 90 EA Per 30 mg Days Oxycodone-Acetaminophen oxycodone-acetaminophen oral tablet 10- Quantity Limit: 370 EA Per 30 325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg Days oxyCODONE-Aspirin oxycodone-aspirin oral tablet 4.8355-325 Quantity Limit: 360 EA Per 30 mg Days Oxycodone-Ibuprofen oxycodone-ibuprofen oral tablet 5-400 mg Quantity Limit: 360 EA Per 30 Days Updated 4/01/2020 7 Symfi Lo SYMFI LO ORAL TABLET 400-300-300 Quantity Limit: 30 EA Per 30 MG Days Symfi SYMFI ORAL TABLET 600-300-300 MG Quantity Limit: 30 EA Per 30 Days Syndros SYNDROS ORAL SOLUTION 5 MG/ML Quantity Limit: 120 ML Per 30 Days Tegsedi TEGSEDI SUBCUTANEOUS SOLUTION Quantity Limit: 6 ML Per 28 Days PREFILLED SYRINGE 284 MG/1.5ML Temazepam temazepam oral capsule 15 mg, 22.5 mg, 30 Quantity Limit: 30 EA Per 30 mg Days temazepam oral capsule 7.5 mg Quantity Limit: 120 EA Per 30 Days Tolterodine Tartrate ER tolterodine tartrate er oral capsule extended Quantity Limit: 30 EA Per 30 release 24 hour 2 mg, 4 mg Days 8 traMADol HCl tramadol hcl oral tablet 100 mg Quantity Limit: 120 EA Per 30 Days tramadol hcl oral tablet 50 mg Quantity Limit: 240 EA Per 30 Days Tramadol-Acetaminophen tramadol-acetaminophen oral tablet 37.5- Quantity Limit: 370 EA Per 30 325 mg Days Triazolam triazolam oral tablet 0.125 mg Quantity Limit: 30 EA Per 30 Days triazolam oral tablet 0.25 mg Quantity Limit: 60 EA Per 30 Days Vizimpro VIZIMPRO ORAL TABLET 15 MG, 30 Quantity Limit: 30 EA Per 30 MG, 45 MG Days Vyndamax VYNDAMAX ORAL CAPSULE 61 MG Quantity Limit: 30 EA Per 30 Days Updated 4/01/2020 9 Zaleplon zaleplon oral capsule 10 mg Quantity Limit: 60 EA Per 30 Days zaleplon oral capsule 5 mg Quantity Limit: 30 EA Per 30 Days Zolpidem Tartrate zolpidem tartrate oral tablet 10 mg, 5 mg Quantity Limit: 30 EA Per 30 Days ZTlido ZTLIDO EXTERNAL PATCH 1.8 % Quantity Limit: 90 EA Per 30 Days 10 Index A G Acetaminophen-Codeine............................. 1 Galafold....................................................... 5 Acetaminophen-Codeine #3........................ 1 Granisetron HCl .......................................... 6 Alfuzosin HCl ER ....................................... 1 H ALPRAZolam ............................................. 1 HYDROcodone-Acetaminophen ................ 6 ALPRAZolam Intensol ............................... 1 Hydrocodone-Ibuprofen .............................. 6 ARIPiprazole............................................... 2 L Ascomp-Codeine......................................... 2 Lidocaine..................................................... 6 B LORazepam ................................................ 6 Biktarvy....................................................... 2 M Butalbital-APAP-Caff-Cod ......................... 2 Modafinil..................................................... 7 Butalbital-APAP-Caffeine .......................... 2 O Butalbital-ASA-Caff-Codeine .................... 2 Ondansetron ................................................ 7 C Ondansetron HCl ........................................ 7 Chantix ........................................................ 3 Oxycodone-Acetaminophen ....................... 7 Chantix Continuing Month Pak .................. 2 oxyCODONE-Aspirin................................. 7 Chantix Starting Month Pak........................ 3 Oxycodone-Ibuprofen ................................. 7 Clorazepate Dipotassium ............................ 3 S D Symfi ........................................................... 8 Daliresp ....................................................... 3 Symfi Lo ..................................................... 8 diazePAM ................................................... 4 Syndros ....................................................... 8 Diazepam .................................................... 3 T DiazePAM................................................... 3 Tegsedi ........................................................ 8 Dificid ......................................................... 4 Temazepam ................................................. 8 Drizalma Sprinkle ....................................... 4 Tolterodine Tartrate ER .............................. 8 Dronabinol .................................................. 4 traMADol HCl ............................................ 9 E Tramadol-Acetaminophen .......................... 9 Endari .......................................................... 4 Triazolam .................................................... 9 Ergotamine-Caffeine ................................... 4 V Estazolam .................................................... 5 Vizimpro ..................................................... 9 F Vyndamax ................................................... 9 FentaNYL ................................................... 5 Z FentaNYL Citrate........................................ 5 Zaleplon .................................................... 10 Flurazepam HCl .......................................... 5 Zolpidem Tartrate ..................................... 10 ZTlido ....................................................... 10 11 .