2018 Formulary. (List of Covered Drugs)

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1 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: Version #: 11 This formulary was updated on 03/0/018. For more recent information or other questions, please contact AmeriHealth Caritas VIP Care at or, for TTY users, 711, seven days a week, 8 a.m. to 8 p.m., or visit Y0093_FOR_8890_Accepted_ _FINAL07

2 AmeriHealth Caritas VIP Care 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID: 18390, Version Number 11 This formulary was updated on 03/0/018. For more recent information or other questions, please contact AmeriHealth Caritas VIP Care at or, for TTY users, 711, seven days a week, 8 a.m. to 8 p.m., or visit i

3 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means AmeriHealth First. When it refers to plan or our plan, it means AmeriHealth Caritas VIP Care. This document includes a list of the drugs (formulary) for our plan, which is current as of 03/018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 018, and from time to time during the year. What is the AmeriHealth Caritas VIP Care Formulary? A formulary is a list of covered drugs selected by AmeriHealth Caritas VIP Care in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. AmeriHealth Caritas VIP Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an AmeriHealth Caritas VIP Care network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary; add prior authorization, quantity limits and/or step therapy restrictions on a drug; or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 03/018. To get updated information about the drugs covered by AmeriHealth Caritas VIP Care, please contact us. Our contact information appears on the front and back cover pages. The formulary is updated at times throughout the year, and the list of drugs may change. If there are negative changes to the formulary outside of routine maintenance updates, such as removing a drug from our formulary; adding prior authorization, quantity limits, and/or step therapy restrictions to a drug; or changing a tiered cost-sharing status, our plan will mail you a written notice. ii

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 116. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? AmeriHealth Caritas VIP Care covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: AmeriHealth Caritas VIP Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AmeriHealth Caritas VIP Care before you fill your prescriptions. If you don t get approval, AmeriHealth Caritas VIP Care may not cover the drug. Quantity Limits: For certain drugs, AmeriHealth Caritas VIP Care limits the amount of the drug that AmeriHealth Caritas VIP Care will cover. For example, AmeriHealth Caritas VIP Care provides 30 tablets per prescription for digoxin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, AmeriHealth Caritas VIP Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AmeriHealth Caritas VIP Care may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth Caritas VIP Care will then cover Drug B. iii

5 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appear on the front and back cover pages. You can ask AmeriHealth Caritas VIP Care to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the AmeriHealth Caritas VIP Care formulary? on page iv for information about how to request an exception. What are over-the counter (OTC) drugs? Our plan also covers certain over-the-counter drugs. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. For more information, call Member Services (phone numbers are printed on the back cover of this booklet). What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that AmeriHealth Caritas VIP Care does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by AmeriHealth Caritas VIP Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AmeriHealth Caritas VIP Care. You can ask AmeriHealth Caritas VIP Care to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the AmeriHealth Caritas VIP Care Formulary? You can ask AmeriHealth Caritas VIP Care to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, AmeriHealth Caritas VIP Care limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. iv

6 Generally, AmeriHealth Caritas VIP Care will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who: Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short-term planning taken into account (often under 8 hours). Are discharged from a hospital to home. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary. End a long-term care facility stay and return to the community. v

7 If a member has more than one change in level of care in a month, the pharmacy will have to call our plan to request an extension of the transition policy. For more information For more detailed information about your AmeriHealth Caritas VIP Care prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about AmeriHealth Caritas VIP Care, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/seven days a week. TTY users should call Or visit vi

8 AmeriHealth Caritas VIP Care s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by AmeriHealth Caritas VIP Care. If you have trouble finding your drug in the list, turn to the Index that begins on page 116. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the Requirements/Limits column tells you if AmeriHealth Caritas VIP Care has any special requirements for coverage of your drug. List of Abbreviations B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. QL: Quantity Limit. For certain drugs, AmeriHealth Caritas VIP Care limits the amount of the drug that the plan will cover. For example, our plan provides twelve tablets per prescription for sumatriptan succinate. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, AmeriHealth Caritas VIP Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AmeriHealth Caritas VIP Care may not cover drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth Caritas VIP Care will then cover Drug B. PA: Prior Authorization. AmeriHealth Caritas VIP Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AmeriHealth Caritas VIP Care before you fill your prescriptions. If you don't get approval, AmeriHealth Caritas VIP Care may not cover the drug. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 8 a.m. to 8 p.m., seven days per week. TTY users should call 711. MO: Mail Order. This prescription may be filled by an AmeriHealth Caritas VIP Care network mail order pharmacy. Please review your Pharmacy Directory for more information about which pharmacies offer mail order service. For more information consult your Pharmacy Directory or call our Member Services Department at , from 8 a.m. to 8 p.m., seven days per week. TTY/TDD users should call 711. AmeriHealth Caritas VIP Care is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medical Assistance program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the state and Medicare. AmeriHealth Caritas VIP Care is available in Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and Westmoreland counties. The Formulary may change at any time. You will receive notice when necessary. vii

9 Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal. AmeriHealth Caritas VIP Care complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available. Call (TTY 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711) (TTY 711) viii

10 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits ANALGESICS - TREATMENT OF PAIN ANALGESICS acetaminophen-codeine oral solution 10 mg-1 mg /5 ml (5 ml), 10-1 mg/5 ml, 300 mg-30 mg /1.5 ml acetaminophen-codeine oral tablet mg, mg, mg ascomp with codeine oral capsule mg butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg PA PA PA butalbital-acetaminophen oral tablet mg PA butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg carisoprodol-asa-codeine oral tablet mg PA PA PA PA carisoprodol-aspirin oral tablet mg PA codeine-butalbital-asa-caff oral capsule mg hydrocodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen oral tablet mg, 5-00 mg, mg ibuprofen-oxycodone oral tablet mg oxycodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg PA; MO 1

11 Drug Name Drug Tier Requirements/Limits oxycodone-aspirin oral tablet mg pentazocine-naloxone oral tablet mg PA tramadol-acetaminophen oral tablet mg NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 100 mg, 00 mg, 400 mg, 50 mg COMFORT PAC-IBUPROFEN KIT 800 MG COMFORT PAC-MELOXICAM KIT 15 MG COMFORT PAC-NAPROXEN KIT 500 MG diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 4 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 % diclofenac sodium topical gel 3 % 5 MO DICLOZOR TOPICAL KIT 1 % diflunisal oral tablet 500 mg etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 4 hr 400 mg, 500 mg, 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 5 mg, 50 mg PA; MO indomethacin oral capsule, extended release 75 mg PA; MO ketoprofen oral capsule 50 mg, 75 mg ketorolac oral tablet 10 mg PA; MO meclofenamate oral capsule 100 mg, 50 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 15 mg/5 ml

12 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits naproxen oral tablet 50 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg piroxicam oral capsule 10 mg, 0 mg sulindac oral tablet 150 mg, 00 mg ZORVOLEX ORAL CAPSULE 18 MG, 35 MG 3 ST; MO OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour ; QL (4 EA per 8 days) fentanyl transdermal patch 7 hour 100 mcg/hr PA; QL (10 EA per 30 days) fentanyl transdermal patch 7 hour 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour QL (10 EA per 30 days) methadone oral solution 10 mg/5 ml QL (100 ML per 30 days) methadone oral solution 5 mg/5 ml QL (400 ML per 30 days) methadone oral tablet 10 mg PA; QL (40 EA per 30 days) methadone oral tablet 5 mg QL (180 EA per 30 days) morphine oral tablet extended release 100 mg, 00 mg morphine oral tablet extended release 15 mg, 30 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.1 hr 10 mg, 15 mg, 0 mg, 30 mg, 40 mg, 60 mg, 80 mg OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate injection solution 1 mg/ml, mg/ml butorphanol tartrate nasal spray,non-aerosol 10 mg/ml duramorph (pf) injection solution 0.5 mg/ml, 1 mg/ml PA; QL (60 EA per 30 days) QL (60 EA per 30 days) PA; QL (60 EA per 30 days) QL (5 ML per 30 days) B/D 3

13 Drug Name Drug Tier Requirements/Limits fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone injection solution 1 mg/ml, mg/ml, 4 mg/ml hydromorphone injection syringe mg/ml PA; QL (10 EA per 30 days) hydromorphone oral tablet mg, 4 mg, 8 mg QL (10 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY 3 PA; QL (600 EA per 30 days) 3 PA; QL (150 EA per 30 days) meperidine oral solution 50 mg/5 ml PA; QL (900 ML per 30 days) meperidine oral tablet 100 mg, 50 mg PA; QL (180 EA per 30 days) morphine oral tablet 15 mg, 30 mg QL (10 EA per 30 days) nalbuphine injection solution 10 mg/ml, 0 mg/ml B/D oxycodone oral solution 5 mg/5 ml QL (5400 ML per 30 days) oxycodone oral tablet 10 mg, 15 mg, 0 mg, 30 mg, 5 mg QL (10 EA per 30 days) tramadol oral tablet 50 mg QL (40 EA per 30 days) ANESTHETICS - LOCAL TREATMENT OF PAIN LOCAL ANESTHETICS ACCUCAINE KIT KIT 10 MG/ML (1 %) ANODYNE LPT TOPICAL KIT.5-.5 % dermacinrx empricaine topical kit.5-.5 % LEVA SET TOPICAL KIT.5-.5 % lidocaine (pf) injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 5 mg/ml (0.5 %) lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % 4

14 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % PA; MO; QL (90 EA per 30 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % LIDOPAC TOPICAL KIT 5 % lidopril topical kit.5-.5 % lidopril xr topical kit.5-.5 % LIDO-PRILO CAINE PACK TOPICAL KIT.5-.5 % liprozonepak topical kit.5-.5 % livixil pak topical kit.5-.5 % MEDOLOR PAK TOPICAL KIT.5-.5 % prilolid topical kit.5-.5 % ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS - TREATMENT OF SUBSTANCE ABUSE DISORDERS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 mg disulfiram oral tablet 50 mg, 500 mg naltrexone oral tablet 50 mg OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet mg, 8 mg buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg OPIOID REVERSAL AGENTS naloxone injection solution 0.4 mg/ml naloxone injection syringe 1 mg/ml 5

15 Drug Name Drug Tier Requirements/Limits SMOKING CESSATION AGENTS buproban oral tablet extended release 1 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG ; QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (336 EA per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML ; QL (106 EA per 365 days) 4 MO 4 MO ANTIBACTERIALS - TREATMENT OF BACTERIAL INFECTIONS AMINOGLYCOSIDES amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin injection solution 0 mg/ ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin sulfate (ped) (pf) injection solution 0 mg/ ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % neomycin oral tablet 500 mg paromomycin oral capsule 50 mg streptomycin intramuscular recon soln 1 gram TOBRADEX OPHTHALMIC (EYE) OINTMENT % 6

16 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits tobramycin in 0.5 % nacl inhalation solution for nebulization 300 mg/5 ml 5 B/D tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection recon soln 1. gram tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml tobramycin-dexamethasone ophthalmic (eye) drops,suspension % ANTIBACTERIALS, OTHER 5 B/D acetic acid otic (ear) solution % ak-poly-bac ophthalmic (eye) ointment ,000 unit/gram bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram BACTROBAN NASAL NASAL OINTMENT % chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 0.9 % sod chlor intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin palmitate hcl oral recon soln 75 mg/5 ml 4 MO clindamycin pediatric oral recon soln 75 mg/5 ml 7

17 Drug Name Drug Tier Requirements/Limits clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous solution 300 mg/ ml, 600 mg/4 ml, 900 mg/6 ml clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % clindamycin phosphate vaginal cream % clindamycin-benzoyl peroxide topical gel 1. %(1 % base) -5 % colistin (colistimethate na) injection recon soln 150 mg daptomycin intravenous recon soln 500 mg lincomycin injection solution 300 mg/ml linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml ; MO linezolid oral tablet 600 mg ; MO linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml methenamine hippurate oral tablet 1 gram metro i.v. intravenous piggyback 500 mg/100 ml metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral capsule 375 mg metronidazole oral tablet 50 mg, 500 mg metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical gel with pump 1 % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment % 8

18 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b gu irrigation solution 40 mg-00,000 unit/ml neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.05mg/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , mg-unit-mg/ml nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/5) polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml SYNERCID INTRAVENOUS RECON SOLN 500 MG ; QL (360 EA per 365 days) ; QL (180 EA per 365 days) ; QL (360 EA per 365 days) trimethoprim oral tablet 100 mg vancomycin in 0.9 % sodium chl intravenous piggyback 1 gram/00 ml, 500 mg/100 ml, 750 mg/150 ml vancomycin in 0.9 % sodium chl intravenous solution 1.5 gram/50 ml, 750 mg/150 ml B/D; MO B/D; MO 9

19 Drug Name Drug Tier Requirements/Limits vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 mg/100 ml, 750 mg/150 ml B/D vancomycin injection recon soln 100 gram B/D; MO vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg VANCOMYCIN ORAL CAPSULE 15 MG, 50 MG B/D 4 PA; MO XIFAXAN ORAL TABLET 00 MG 4 PA; MO; QL (9 EA per 3 days) XIFAXAN ORAL TABLET 550 MG ; MO; QL (60 EA per 30 days) BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 50 mg, 500 mg cefaclor oral tablet extended release 1 hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram cefazolin intravenous recon soln 1 gram cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefepime in dextrose 5 % intravenous piggyback 1 gram/50 ml, gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml, gram/100 ml cefepime injection recon soln 1 gram, gram cefotaxime injection recon soln 1 gram, gram, 500 mg cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, gram 10

20 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 00 mg cefprozil oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftazidime in d5w intravenous piggyback 1 gram/50 ml, gram/50 ml ceftazidime injection recon soln 1 gram, gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 100 gram ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium intravenous recon soln 1.5 gram cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG 4 MO TAZICEF INJECTION RECON SOLN 1 GRAM, GRAM, 6 GRAM TAZICEF INTRAVENOUS RECON SOLN 1 GRAM, GRAM TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG BETA-LACTAM, OTHER aztreonam injection recon soln 1 gram, gram 4 PA 11

21 Drug Name Drug Tier Requirements/Limits doripenem intravenous recon soln 50 mg, 500 mg PA imipenem-cilastatin intravenous recon soln 50 mg, 500 mg PA INVANZ INJECTION RECON SOLN 1 GRAM 4 PA INVANZ INTRAVENOUS RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg meropenem-0.9% sodium chloride intravenous piggyback 1 gram/50 ml, 500 mg/50 ml VABOMERE INTRAVENOUS RECON SOLN GRAM BETA-LACTAM, PENICILLINS 4 PA 1 ; MO amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension for reconstitution 15 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 1 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 50 mg, 500 mg ampicillin oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15 mg, gram, 50 mg, 500 mg ampicillin sodium intravenous recon soln 1 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram, 3 gram

22 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML 4 MO dicloxacillin oral capsule 50 mg, 500 mg nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml, gram/100 ml nafcillin injection recon soln 1 gram, gram nafcillin intravenous recon soln 1 gram, gram penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 15 mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg piperacillin-tazobactam intravenous recon soln 13.5 gram piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram MACROLIDES azithromycin intravenous recon soln 500 mg, 500 mg ( mg/ml) azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release 4 hr 500 mg ery pads topical swab % 13

23 Drug Name Drug Tier Requirements/Limits erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 mg/5 ml 4 MO erythromycin ethylsuccinate oral tablet 400 mg erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral tablet 50 mg, 500 mg erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/50 ML ciprofloxacin (mixture) oral tablet, er multiphase 4 hr 1,000 mg, 500 mg 14 4 ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 100 mg ciprofloxacin hcl oral tablet 50 mg, 500 mg, 750 mg ciprofloxacin lactate intravenous solution 00 mg/0 ml, 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 50 mg/10 ml levofloxacin oral tablet 50 mg, 500 mg levofloxacin oral tablet 750 mg MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin in nacl (iso-osm) intravenous piggyback 400 mg/50 ml moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 mg moxifloxacin-sod.ace,sul-water intravenous piggyback 400 mg/50 ml

24 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 300 mg, 400 mg VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % SULFONAMIDES silver sulfadiazine topical cream 1 % ssd topical cream 1 % sulfacetamide sodium (acne) topical suspension 10 % sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg TETRACYCLINES demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg 15

25 Drug Name Drug Tier Requirements/Limits minocycline oral tablet 100 mg, 50 mg, 75 mg MORGIDOX 1X 50 KIT 50 MG morgidox oral capsule 50 mg ANTICONVULSANTS - TREATMENT OF SEIZURES ANTICONVULSANTS, OTHER BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML ; MO BRIVIACT ORAL SOLUTION 10 MG/ML ; MO BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 100 mg/ml, 500 mg/5 ml (5 ml) levetiracetam oral tablet 1,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 4 hr 500 mg, 750 mg ROWEEPRA ORAL TABLET 1,000 MG, 750 MG ; MO 16 roweepra oral tablet 500 mg ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 4 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 50 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG 4 MO ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5 ml LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG 4 ST; MO; QL (60 EA per 30 days) 5 ST; MO; QL (10 EA per 30 days)

26 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits LYRICA ORAL SOLUTION 0 MG/ML zonisamide oral capsule 100 mg, 5 mg, 50 mg GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG 4 MO; QL (40 EA per 30 days) 4 MO; QL (0 EA per 30 days) DIASTAT RECTAL KIT.5 MG 4 MO; QL (5 EA per 30 days) diazepam rectal kit mg ; QL (40 EA per 30 days) diazepam rectal kit.5 mg ; QL (5 EA per 30 days) diazepam rectal kit mg ; QL (0 EA per 30 days) divalproex oral capsule, delayed rel sprinkle 15 mg divalproex oral tablet extended release 4 hr 50 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 15 mg, 50 mg, 500 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 50 mg/5 ml, 50 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG 4 MO ONFI ORAL SUSPENSION.5 MG/ML 4 PA; MO; QL (480 ML per 30 days) ONFI ORAL TABLET 10 MG 4 PA; MO; QL (60 EA per 30 days) ONFI ORAL TABLET 0 MG ; MO; QL (60 EA per 30 days) phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) PA; MO phenobarbital oral tablet 100 mg, 15 mg, 16. mg, 30 mg, 3.4 mg, 60 mg, 64.8 mg, 97. mg PA; MO primidone oral tablet 50 mg, 50 mg SABRIL ORAL POWDER IN PACKET 500 MG 4 PA SABRIL ORAL TABLET 500 MG 4 PA; QL (180 EA per 30 days) 17

27 Drug Name Drug Tier Requirements/Limits tiagabine oral tablet mg, 4 mg valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 50 mg/5 ml, 50 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) valproic acid oral capsule 50 mg vigabatrin oral powder in packet 500 mg 4 PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4 ST; MO FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 100 mg, 150 mg, 00 mg, 5 mg lamotrigine oral tablet extended release 4hr 100 mg, 00 mg, 5 mg, 50 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg 4 ST; MO; QL (30 EA per 30 days) topiramate oral capsule, sprinkle 15 mg, 5 mg topiramate oral tablet 100 mg, 00 mg, 5 mg, 50 mg SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 00 MG 4 ST; MO; QL (30 EA per 30 days) APTIOM ORAL TABLET 400 MG, 800 MG 5 ST; MO; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG 4 ST; MO; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML ; MO; QL (400 ML per 30 days) BANZEL ORAL TABLET 00 MG 4 PA; MO; QL (40 EA per 30 days) BANZEL ORAL TABLET 400 MG ; MO; QL (40 EA per 30 days) carbamazepine oral capsule, er multiphase 1 hr 100 mg, 00 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 00 mg 18

28 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits carbamazepine oral tablet extended release 1 hr 100 mg, 00 mg, 400 mg carbamazepine oral tablet,chewable 100 mg DILANTIN ORAL CAPSULE 30 MG 4 MO epitol oral tablet 00 mg EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 100 MG, 00 MG, 300 MG fosphenytoin injection solution 100 mg pe/ ml, 500 mg pe/10 ml oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) 4 MO oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 50 MG 4 MO PHENYTEK ORAL CAPSULE 00 MG, 300 MG phenytoin oral suspension 100 mg/4 ml, 15 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 00 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML 5 ST; MO; QL (100 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG ANTIDEMENTIA AGENTS - MANAGEMENT OF DEMENTIA ANTIDEMENTIA AGENTS, OTHER ergoloid oral tablet 1 mg PA; MO CHOLINESTERASE INHIBITORS donepezil oral tablet 10 mg, 3 mg, 5 mg 4 4 ST; MO; QL (60 EA per 30 days) 19

29 Drug Name Drug Tier Requirements/Limits donepezil oral tablet,disintegrating 10 mg, 5 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 4 hour 13.3 mg/4 hour, 4.6 mg/4 hr, 9.5 mg/4 hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral capsule,sprinkle,er 4hr 14 mg, 1 mg, 8 mg, 7 mg memantine oral tablet 10 mg, 5 mg memantine oral tablets,dose pack 5-10 mg NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG ANTIDEPRESSANTS - TREATMENT OF DEPRESSION ANTIDEPRESSANTS, OTHER bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 mg 4 ST; MO; QL (30 EA per 30 days) 4 ST; MO 4 ST; MO; QL (30 EA per 30 days) bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 1 hr 100 mg, 150 mg, 00 mg bupropion hcl oral tablet extended release 4 hr 150 mg, 300 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 450 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 00 mg, 50 mg, 50 mg perphenazine-amitriptyline oral tablet -10 mg, - 5 mg, 4-10 mg, 4-5 mg, 4-50 mg trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg MONOAMINE OXIDASE INHIBITORS 4 MO PA; MO 0

30 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits EMSAM TRANSDERMAL PATCH 4 HOUR 1 MG/4 HR, 6 MG/4 HR, 9 MG/4 HR 4 MO MARPLAN ORAL TABLET 10 MG 4 MO phenelzine oral tablet 15 mg tranylcypromine oral tablet 10 mg SSRIS/ SNRIS citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 0 mg, 40 mg desvenlafaxine succinate oral tablet extended release 4 hr 100 mg, 5 mg, 50 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg, 30 mg, 60 mg escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 0 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 10 MG, 0 MG, 40 MG, 80 MG 4 ST; MO 4 ST; MO fluoxetine oral capsule 10 mg, 0 mg, 40 mg fluoxetine oral capsule,delayed release(dr/ec) 90 mg fluoxetine oral solution 0 mg/5 ml (4 mg/ml) fluoxetine oral tablet 10 mg, 0 mg fluvoxamine oral tablet 100 mg, 5 mg, 50 mg maprotiline oral tablet 5 mg, 50 mg, 75 mg paroxetine hcl oral tablet 10 mg, 0 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 4 hr 1.5 mg, 5 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML 4 MO 1

31 Drug Name Drug Tier Requirements/Limits sertraline oral concentrate 0 mg/ml sertraline oral tablet 100 mg, 5 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release 4hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 5 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 4hr 150 mg, 5 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) TRICYCLICS amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 5 mg, 50 mg 4 ST; MO 4 ST; MO 4 ST; MO PA; MO clomipramine oral capsule 5 mg, 50 mg, 75 mg PA; MO desipramine oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg PA; MO doxepin oral concentrate 10 mg/ml PA; MO imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA; MO imipramine pamoate oral capsule 100 mg, 15 mg, 150 mg, 75 mg nortriptyline oral capsule 10 mg, 5 mg, 50 mg, 75 mg PA; MO nortriptyline oral solution 10 mg/5 ml protriptyline oral tablet 10 mg, 5 mg trimipramine oral capsule 100 mg, 5 mg, 50 mg PA; MO ANTIEMETICS - TREATMENT OF VOMITING OR NAUSEA ANTIEMETICS, OTHER chlorpromazine injection solution 5 mg/ml

32 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits chlorpromazine oral tablet 10 mg, 100 mg, 00 mg, 5 mg, 50 mg compro rectal suppository 5 mg diphenhydramine hcl injection solution 50 mg/ml PA; MO meclizine oral tablet 1.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg perphenazine oral tablet 16 mg, mg, 4 mg, 8 mg phenadoz rectal suppository 1.5 mg PA; MO prochlorperazine edisylate injection solution 10 mg/ ml (5 mg/ml), 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 5 mg promethazine oral syrup 6.5 mg/5 ml PA; MO promethazine oral tablet 1.5 mg, 5 mg, 50 mg PA; MO promethazine rectal suppository 1.5 mg, 5 mg PA; MO promethegan rectal suppository 5 mg, 50 mg PA; MO scopolamine base transdermal patch 3 day 1 mg over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS 4 MO trimethobenzamide oral capsule 300 mg PA; MO EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 15 mg, 40 mg, 80 mg B/D; MO aprepitant oral capsule,dose pack 15 mg (1)- 80 mg () B/D; MO dronabinol oral capsule 10 mg,.5 mg, 5 mg B/D; MO EMEND ORAL SUSPENSION FOR RECONSTITUTION 15 MG (5 MG/ ML FINAL CONC.) 4 B/D; MO 3

33 Drug Name Drug Tier Requirements/Limits granisetron (pf) intravenous solution 1 mg/ml (1 ml), 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) B/D B/D granisetron hcl oral tablet 1 mg B/D; MO ondansetron hcl (pf) injection solution 4 mg/ ml ondansetron hcl (pf) injection syringe 4 mg/ ml ondansetron hcl intravenous solution mg/ml ondansetron hcl oral solution 4 mg/5 ml B/D; MO ondansetron hcl oral tablet 4 mg B/D; MO; QL (15 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg 1 B/D; MO ondansetron oral tablet,disintegrating 4 mg, 8 mg B/D; MO SYNDROS ORAL SOLUTION 5 MG/ML ; MO ANTIFUNGALS - TREATMENT OF FUNGAL OR YEAST INFECTIONS ANTIFUNGALS abelcet intravenous suspension 5 mg/ml B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG 4 B/D amphotericin b injection recon soln 50 mg B/D CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50 mg, 70 mg ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % econazole topical cream 1 % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG 4 PA 4

34 018 5 Tier Standard- AmeriHealth Caritas VIP Care Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits fluconazole in dextrose(iso-o) intravenous piggyback 00 mg/100 ml, 400 mg/00 ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 00 mg/100 ml, 400 mg/00 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg flucytosine oral capsule 500 mg griseofulvin microsize oral suspension 15 mg/5 ml itraconazole oral capsule 100 mg ketoconazole oral tablet 00 mg ketoconazole topical cream % ketoconazole topical shampoo % MENTAX TOPICAL CREAM 1 % 4 MO MYCAMINE INTRAVENOUS RECON SOLN 100 MG MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG 4 PA 4 PA; MO ; MO nyamyc topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram 5

35 Drug Name Drug Tier Requirements/Limits nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 50 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous solution 00 mg voriconazole oral suspension for reconstitution 00 mg/5 ml (40 mg/ml) 5 MO voriconazole oral tablet 00 mg 5 MO voriconazole oral tablet 50 mg ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS ANTIGOUT AGENTS allopurinol oral tablet 100 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG 3 ST; MO ANTI-INFLAMMATORY AGENTS - TREATMENT OF INFLAMMATION GLUCOCORTICOIDS ala-cort topical cream 1 %,.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % 6

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