2013 Formulary (List of Covered Drugs) - Advantage Peach State ...

Opioid Analgesics, Long-actingDrug NameDrugTierASTRAMORPH INJECTION 0.5MG/ML 4ASTRAMORPH INJECTION 1MG/ML 4DURAMORPH INJECTION 0.5MG/ML 4DURAMORPH INJECTION 1MG/ML 4fentanyl patch 72 hour 100mcg/hr 1fentanyl patch 72 hour 12mcg/hr 1fentanyl patch 72 hour 25mcg/hr 1fentanyl patch 72 hour 50mcg/hr 1fentanyl patch 72 hour 75mcg/hr 1levorphanol tartrate tablet 2mg 1methadone hcl concentrate 10mg/ml 1METHADONE HCL INJECTION 10MG/ML 4methadone hcl solution 10mg/5ml 1methadone hcl solution 5mg/5ml 1methadone hcl tablet 10mg 1methadone hcl tablet 5mg 1methadose tablet 10mg 1Requirements/Limitsmorphine sulfate er tablet extended release 12 hour 100mg 1 QL (180 EA per 30 days)morphine sulfate er tablet extended release 12 hour 15mg 1 QL (120 EA per 30 days)morphine sulfate er tablet extended release 12 hour 200mg 1 QL (120 EA per 30 days)morphine sulfate er tablet extended release 12 hour 30mg 1 QL (120 EA per 30 days)morphine sulfate er tablet extended release 12 hour 60mg 1 QL (120 EA per 30 days)morphine sulfate solution 10mg/5ml 1morphine sulfate solution 20mg/5ml 1morphine sulfate tablet 15mg 1morphine sulfate tablet 30mg 12