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2023

Samaritan Choice

For questions please call:

Members: 1-800-832-4580, TTY 1-800-735-2900

Providers: 1-888-435-2396

 

Note: This plan has limits on Opioid Medications. See page footer for details.

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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.

Copays listed are for a one month supply. 
Formulary Effective Date: 12/01/2023
Updated:
12/2023

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