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Samaritan Choice Formulary

Note: This plan has limits on Opioid Medications. See below 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.

Formulary Effective Date: 11/01/2019
Updated:
11/2019

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