Buprenorphine HCl/Naloxo 8-2 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.**
Brimonidine 0.1% & 0.15% ophthalmic solution (Alphagan P™)
Buprenorphine HCl/Naloxone 2.1-0.3MG Subl film (Bunavail) 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.**
Budesonide/Formoterol (Symbicort™)
Budesonide/Formoterol 160-4.5 MCG/ACT 10.2 GM (Symbicort) Aero
Non-Formulary Use Criteria: **1. COPD patients must have failed anticholinergic agent tiotropium (Spiriva ).**
ARIPiprazole Lauroxil IM Syringe 1064 MG/3.9ML (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**
Budesonide/Formoterol 160-4.5 MCG/ACT Inh 6 gm (Symbicort Inhalation Aerosol 160-4.5 Aero MCG/ACT)
Non-Formulary Use Criteria: **1. COPD patients must have failed anticholinergic agent tiotropium (Spiriva ).**