Neuromuscular
Skeletal Muscle Relaxants

Brand/Generic Name
(Generics in italics)		 Dosage/Strength Status Restrictions Notes Cost Sharing
Soma Compound/Codeine generic.gif (400 bytes)
Carisoprodol-Aspirin-Codeine		 Tab - 200-325-16 mg   nonform.gif (510 bytes)     Tier 3

Key for Product(s) Listed Above
Formulary Non-Formulary Prior Authorization Not Reimbursed
Quantity Limit   Generic Available (Most Generics
Available at Tier 1)		 Step Therapy Notes

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