Samaritan Choice 2020 Formulary
Note: This plan has limits on Opioid Medications. See below for details.
Opioid anti-tussive limits:
Liquids: Maximum of 240ML per fill.
Tablets/Capsules: Maximum 7-day supply per fill.
Short-acting Opioid (SAO) Limits:
New to therapy: Maximum of 49 MED and Maximum 7-day supply per fill.
Experience with therapy: Maximum of 90 MED.
Long-acting Opioid (LOA) Limits: PA required and Maximum of 90 MED.