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InterCommunity Health Network CCO Formulary

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


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*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants**Alternative Medicines**Aminoglycosides**Analgesics - Anti-Inflammatory**Analgesics - Nonnarcotic**Analgesics - Opioid**Androgens-Anabolic**Anorectal Agents**Antacids**Anthelmintics**Antianginal Agents**Antianxiety Agents**Antiarrhythmics**Antiasthmatic And Bronchodilator Agents**Anticoagulants**Anticonvulsants**Antidiabetics**Antidiarrheal/Probiotic Agents**Antidiarrheals**Antidotes And Specific Antagonists**Antidotes**Antiemetics**Antifungals**Antihistamines**Antihyperlipidemics**Antihypertensives**Anti-Infective Agents - Misc.**Antimalarials**Antimyasthenic/Cholinergic Agents**Antimycobacterial Agents**Antineoplastics And Adjunctive Therapies**Antiparkinson Agents**Antiparkinson And Related Therapy Agents**Antipsychotics/Antimanic Agents**Antivirals**Assorted Classes**Beta Blockers**Biologicals Misc**Calcium Channel Blockers**Cardiotonics**Cardiovascular Agents - Misc.**Cephalosporins**Contraceptives**Corticosteroids**Cough/Cold/Allergy**Dermatologicals**Diagnostic Products**Digestive Aids**Diuretics**Endocrine And Metabolic Agents - Misc.**Estrogens**Fluoroquinolones**Gastrointestinal Agents - Misc.**Genitourinary Agents - Miscellaneous**Gout Agents**Hematological Agents - Misc.**Hematopoietic Agents**Hypnotics**Hypnotics/Sedatives/Sleep Disorder Agents**Laxatives**Macrolides**Medical Devices And Supplies**Medical Devices**Migraine Products**Minerals & Electrolytes**Miscellaneous Therapeutic Classes**Mouth/Throat/Dental Agents**Multivitamins**Musculoskeletal Therapy Agents**Nasal Agents - Systemic And Topical**Nutrients**Ophthalmic Agents**Otic Agents**Oxytocics**Penicillins**Progestins**Psychotherapeutic And Neurological Agents - Misc.**Tetracyclines**Thyroid Agents**Ulcer Drugs**Ulcer Drugs/Antispasmodics/Anticholinergics**Urinary Anti-Infectives**Urinary Antispasmodics**Vaccines**Vaginal Products**Vasopressors**Vitamins*
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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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