Aripiprazole is now a Non-formulary item as of 09/27/2010 , No new scripts may be written without a non-formulary request approval, all existing scripts must be tapered off
per protocol and/or switched to a formulary agent prior to 3/26/2011 ****
**MLP Requires Cosign**
Budesonide/Formoterol 80-4.5 MCG/ACT Inh 6.9gm (Symbicort)
Non-Formulary Use Criteria: **1. COPD patients must have failed anticholinergic agent tiotropium (Spiriva ).**
ARIPiprazole Lauroxil IM Syringe 882 MG/3.2ML (Aristada)
Aripiprazole is now a Non-formulary item as of 09/27/2010 , No new scripts may be written without a non-formulary request approval, all existing scripts must be tapered off
per protocol and/or switched to a formulary agent prior to 3/26/2011 ****
**MLP Requires Cosign**
Buprenorphine (Subutex™, Suboxone™)
atomoxetine (Strattera™)
Buprenorphine HCl/Naloxo 12-3 MG Sublingual Film (Suboxone) Film
Non-Formulary Use Criteria: **1. Will only be approved for detoxification, not for pain or maintenance therapy.**2. Prescribing physician MUST have buprenoprhine certification and DHHS-SAMHSA waiver. These must be submitted with request.**
**3.Only buprenoprhine/naloxone ( Suboxone) will be approved.**
Baclofen (Lioresal™)
Buprenorphine HCl/Naloxo 2-0.5MG Sublingual Film (Suboxone sublingual film) Film
Non-Formulary Use Criteria: **1. Will only be approved for detoxification, not for pain or maintenance therapy.**2. Prescribing physician MUST have buprenoprhine certification and DHHS-SAMHSA waiver. These must be submitted with request.**
**3.Only buprenoprhine/naloxone ( Suboxone) will be approved.**
Becaplermin (Regranex™)
Buprenorphine HCl/Naloxo 4-1 MG Sublingual Film (Suboxone) Film
Non-Formulary Use Criteria: **1. Will only be approved for detoxification, not for pain or maintenance therapy.**2. Prescribing physician MUST have buprenoprhine certification and DHHS-SAMHSA waiver. These must be submitted with request.**
**3.Only buprenoprhine/naloxone ( Suboxone) will be approved.**