ANALGESICS ANALGESICS

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1 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug ANALGESICS ANALGESICS acetaminophen-codeine oral solution /5 ml (5 ml), /5 ml, /12.5 ml acetaminophen-codeine oral tablet , , ascomp with codeine oral capsule butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule PA PA PA butalbital-acetaminophen oral tablet PA butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule carisoprodol-asa-codeine oral tablet PA PA PA PA carisoprodol-aspirin oral tablet PA codeine-butalbital-asa-caff oral capsule hydrocodone-acetaminophen oral tablet , , 5-325, hydrocodone-ibuprofen oral tablet , 5-200, PA ibuprofen-oxycodone oral tablet

2 Name of Drug oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet pentazocine-naloxone oral tablet PA tramadol-acetaminophen oral tablet NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 100, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 24 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical gel 1 %, 3 % DICLOZOR TOPICAL KIT 1 % diflunisal oral tablet 500 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 24 hr 400, 500, 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 PA indomethacin oral capsule, extended release 75 PA ketoprofen oral capsule 50, 75 ketorolac oral tablet 10 PA; QL (20 EA per 30 days) meclofenamate oral capsule 100, 50 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen oral suspension 125 /5 ml naproxen oral tablet 250, 375, 500 2

3 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 275, 550 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 ZORVOLEX ORAL CAPSULE 18 MG, 35 MG ST OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour QL (4 EA per 28 days) fentanyl transdermal patch 72 hour 100 mcg/hr PA; QL (10 EA per 30 days) fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour QL (10 EA per 30 days) methadone oral solution 10 /5 ml QL (1200 ML per 30 days) methadone oral solution 5 /5 ml QL (2400 ML per 30 days) methadone oral tablet 10 PA; QL (240 EA per 30 days) methadone oral tablet 5 QL (180 EA per 30 days) morphine oral tablet extended release 100, 200 morphine oral tablet extended release 15, 30, 60 oxycodone oral tablet,oral only,ext.rel.12 hr 10, 15, 20, 30, 40, 60, 80 OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate injection solution 1 /ml, 2 /ml butorphanol tartrate nasal spray,non-aerosol 10 /ml duramorph (pf) injection solution 0.5 /ml, 1 /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

4 Name of Drug fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection solution 1 /ml, 2 /ml, 4 /ml PA; QL (120 EA per 30 days) hydromorphone injection syringe 2 /ml hydromorphone oral tablet 2, 4, 8 QL (120 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY ; QL (600 EA per 30 days) ; QL (150 EA per 30 days) meperidine oral solution 50 /5 ml PA; QL (900 ML per 30 days) meperidine oral tablet 100, 50 PA; QL (180 EA per 30 days) morphine oral tablet 15, 30 QL (120 EA per 30 days) nalbuphine injection solution 10 /ml, 20 /ml B/D oxycodone oral solution 5 /5 ml QL (5400 ML per 30 days) oxycodone oral tablet 10, 15, 20, 30, 5 QL (120 EA per 30 days) tramadol oral tablet 50 QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS ACCUCAINE KIT KIT 10 MG/ML (1 %) ANODYNE LPT TOPICAL KIT % dermacinrx empricaine topical kit % LEVA SET TOPICAL KIT % lidocaine (pf) injection solution 10 /ml (1 %), 5 /ml (0.5 %) lidocaine hcl injection solution 5 /ml (0.5 %) lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane jelly in applicator 2 % 4

5 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % PA; QL (90 EA per 30 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream % lidocaine-prilocaine topical kit % LIDOPAC TOPICAL KIT 5 % lidopril topical kit % lidopril xr topical kit % LIDO-PRILO CAINE PACK TOPICAL KIT % liprozonepak topical kit % livixil pak topical kit % lp lite pak topical kit % MEDOLOR PAK TOPICAL KIT % prilolid topical kit % ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 disulfiram oral tablet 250, 500 naltrexone oral tablet 50 OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet 2, 8 buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 OPIOID REVERSAL AGENTS naloxone injection solution 0.4 /ml naloxone injection syringe 1 /ml 5

6 Name of Drug SMOKING CESSATION AGENTS buproban oral tablet extended release 12 hr 150 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 (42) NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML ANTIBACTERIALS AMINOGLYCOSIDES amikacin injection solution 1,000 /4 ml, 500 /2 ml gentak ophthalmic (eye) ointment 0.3 % (3 /gram) QL (106 EA per 365 days) gentamicin injection solution 20 /2 ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin sulfate (ped) (pf) injection solution 20 /2 ml gentamicin sulfate (pf) intravenous solution 100 /10 ml, 60 /6 ml gentamicin sulfate (pf) intravenous solution 80 /8 ml gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % neomycin oral tablet 500 paromomycin oral capsule 250 streptomycin intramuscular recon soln 1 gram 6

7 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin in % nacl inhalation solution for nebulization 300 /5 ml B/D tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection recon soln 1.2 gram tobramycin sulfate injection solution 10 /ml, 40 /ml tobramycin with nebulizer inhalation solution for nebulization 300 /5 ml tobramycin-dexamethasone ophthalmic (eye) drops,suspension % ANTIBACTERIALS, OTHER B/D acetic acid otic (ear) solution 2 % 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 2 % chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 300, 75 clindamycin in 0.9 % sod chlor intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml 7

8 Name of Drug clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml), 150 /ml clindamycin phosphate intravenous solution 300 /2 ml, 600 /4 ml, 900 /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 2 % clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 % colistin (colistimethate na) injection recon soln 150 daptomycin intravenous recon soln 500 PA lincomycin injection solution 300 /ml linezolid intravenous parenteral solution 600 /300 ml linezolid oral suspension for reconstitution 100 /5 ml PA PA linezolid oral tablet 600 PA linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml PA methenamine hippurate oral tablet 1 gram metro i.v. intravenous piggyback 500 /100 ml metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml metronidazole oral capsule 375 metronidazole oral tablet 250, 500 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical gel with pump 1 % 8

9 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment 2 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b gu irrigation solution ,000 unit/ml neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops ,000 unit-0.025/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , unit-/ml nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 nitrofurantoin monohyd/m-cryst oral capsule 100 (75/25) polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 /ml SYNERCID INTRAVENOUS RECON SOLN 500 MG PA; QL (360 EA per 365 days) PA; QL (180 EA per 365 days) PA; QL (360 EA per 365 days) trimethoprim oral tablet 100 vancomycin in 0.9% sodium cl intravenous piggyback 1 gram/200 ml, 500 /100 ml, 750 /150 ml B/D 9

10 Name of Drug vancomycin in 0.9% sodium cl intravenous solution 1.25 gram/250 ml, 750 /150 ml vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml, 500 /100 ml, 750 /150 ml B/D B/D vancomycin injection recon soln 100 gram B/D vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 B/D vancomycin oral capsule 125, 250 PA XIFAXAN ORAL TABLET 200 MG ; QL (9 EA per 3 days) XIFAXAN ORAL TABLET 550 MG ; QL (60 EA per 30 days) BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 250, 500 cefaclor oral tablet extended release 12 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /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 cefdinir oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefepime in dextrose 5 % intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml cefepime injection recon soln 1 gram, 2 gram cefotaxime injection recon soln 1 gram, 2 gram, 500 cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 10

11 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 200 cefprozil oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime in d5w intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ceftazidime injection recon soln 1 gram, 2 gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250, 500 ceftriaxone injection recon soln 100 gram ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250, 500 cefuroxime sodium intravenous recon soln 1.5 gram cephalexin oral capsule 250, 500 cephalexin oral suspension for reconstitution 125 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 SUPRAX ORAL CAPSULE 400 MG TAZICEF INJECTION RECON SOLN 1 GRAM, 2 GRAM, 6 GRAM TAZICEF INTRAVENOUS RECON SOLN 1 GRAM, 2 GRAM TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 11

12 Name of Drug BETA-LACTAM, OTHER aztreonam injection recon soln 1 gram, 2 gram DORIBAX INTRAVENOUS RECON SOLN 500 MG doripenem intravenous recon soln 250, 500 PA imipenem-cilastatin intravenous recon soln 250, 500 PA INVANZ INJECTION RECON SOLN 1 GRAM INVANZ INTRAVENOUS RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 meropenem-0.9% sodium chloride intravenous piggyback 1 gram/50 ml, 500 /50 ml VABOMERE INTRAVENOUS RECON SOLN 2 GRAM BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 125 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 125, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension for reconstitution 125 /5 ml, 250 /5 ml 12

13 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug ampicillin sodium injection recon soln 1 gram, 10 gram, 125, 2 gram, 250, 500 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 BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml nafcillin injection recon soln 1 gram, 2 gram nafcillin intravenous recon soln 1 gram, 2 gram penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 125 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 piperacillin-tazobactam intravenous recon soln 13.5 gram piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram MACROLIDES azithromycin intravenous recon soln 500, 500 (2 /ml) azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 /5 ml, 200 /5 ml 13

14 Name of Drug azithromycin oral tablet 250, 250 (6 pack), 500, 500 (3 pack), 600 clarithromycin oral suspension for reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 ery pads topical swab 2 % erythrocin (as stearate) oral tablet 250 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) erythromycin oral tablet 250, 500 erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/250 ML ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000, 500 ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin lactate intravenous solution 200 /20 ml, 400 /40 ml levofloxacin in d5w intravenous piggyback 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /10 ml levofloxacin oral tablet 250, 500,

15 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 moxifloxacin-sod.ace,sul-water intravenous piggyback 400 /250 ml ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 300, 400 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 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , TETRACYCLINES demeclocycline oral tablet 150, 300 doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon soln

16 Name of Drug doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 150, 50, 75 minocycline oral capsule 100, 50, 75 minocycline oral tablet 100, 50, 75 MORGIDOX 1X 50 KIT 50 MG morgidox oral capsule 50 ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 100 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet 1,000, 250, 500, 750 levetiracetam oral tablet extended release 24 hr 500, 750 ROWEEPRA ORAL TABLET 1,000 MG, 750 MG roweepra oral tablet 500 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG ST; QL (60 EA per 30 days) ST; QL (120 EA per 30 days) 16

17 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5 ml LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 100, 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG QL (40 EA per 30 days) QL (20 EA per 30 days) DIASTAT RECTAL KIT 2.5 MG QL (5 EA per 30 days) diazepam rectal kit PA; QL (40 EA per 30 days) diazepam rectal kit 2.5 QL (5 EA per 30 days) diazepam rectal kit QL (20 EA per 30 days) divalproex oral capsule, delayed rel sprinkle 125 divalproex oral tablet extended release 24 hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 125, 250, 500 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5 ml, 250 /5 ml (5 ml), 300 /6 ml (6 ml) gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET 12 MG, 16 MG ONFI ORAL SUSPENSION 2.5 MG/ML ; QL (480 ML per 30 days) 17

18 Name of Drug ONFI ORAL TABLET 10 MG, 20 MG ; QL (60 EA per 30 days) phenobarbital oral elixir 20 /5 ml (4 /ml) PA phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 PA primidone oral tablet 250, 50 SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG ; QL (180 EA per 30 days) tiagabine oral tablet 2, 4 valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution 250 /5 ml, 250 /5 ml (5 ml), 500 /10 ml (10 ml) valproic acid oral capsule 250 vigabatrin oral powder in packet 500 PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML ST FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet extended release 24hr 100, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25, 5 ST; QL (30 EA per 30 days) topiramate oral capsule, sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG ST; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG ST; QL (60 EA per 30 days) 18

19 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug BANZEL ORAL SUSPENSION 40 MG/ML ; QL (2400 ML per 30 days) BANZEL ORAL TABLET 200 MG, 400 MG ; QL (240 EA per 30 days) carbamazepine oral capsule, er multiphase 12 hr 100, 200, 300 carbamazepine oral suspension 100 /5 ml carbamazepine oral tablet 200 carbamazepine oral tablet extended release 12 hr 100, 200, 400 carbamazepine oral tablet,chewable 100 DILANTIN ORAL CAPSULE 30 MG epitol oral tablet 200 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG fosphenytoin injection solution 100 pe/2 ml, 500 pe/10 ml oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 150, 300, 600 PEGANONE ORAL TABLET 250 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG phenytoin oral suspension 100 /4 ml, 125 /5 ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium intravenous solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML ST; QL (1200 ML per 30 days) 19

20 Name of Drug VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid oral tablet 1 PA CHOLINESTERASE INHIBITORS donepezil oral tablet 10, 23, 5 donepezil oral tablet,disintegrating 10, 5 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 13.3 /24 hour, 4.6 /24 hr, 9.5 /24 hr ST; QL (60 EA per 30 days) N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral tablet 10, 5 memantine oral tablets,dose pack 5-10 NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 ST ST; QL (30 EA per 30 days) bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release 12 hr 100, 150, 200 bupropion hcl oral tablet extended release 24 hr 150, 300 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG mirtazapine oral tablet 15, 30, 45,

21 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug mirtazapine oral tablet,disintegrating 15, 30, 45 nefazodone oral tablet 100, 150, 200, 250, 50 perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 trazodone oral tablet 100, 150, 300, 50 MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR PA MARPLAN ORAL TABLET 10 MG phenelzine oral tablet 15 tranylcypromine oral tablet 10 SSRIS/ SNRIS citalopram oral solution 10 /5 ml citalopram oral tablet 10, 20, 40 desvenlafaxine succinate oral tablet extended release 24 hr 100, 25, 50 duloxetine oral capsule,delayed release(dr/ec) 20, 30, 60 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 20, 5 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG ST ST fluoxetine oral capsule 10, 20, 40 21

22 Name of Drug fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 20 /5 ml (4 /ml) fluoxetine oral tablet 10, 20 fluvoxamine oral tablet 100, 25, 50 maprotiline oral tablet 25, 50, 75 paroxetine hcl oral tablet 10, 20, 30, 40 paroxetine hcl oral tablet extended release 24 hr 12.5, 25, 37.5 PAXIL ORAL SUSPENSION 10 MG/5 ML sertraline oral concentrate 20 /ml sertraline oral tablet 100, 25, 50 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150, 37.5, 75 venlafaxine oral tablet 100, 25, 37.5, 50, 75 venlafaxine oral tablet extended release 24hr 150, 225, 37.5, 75 VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) TRICYCLICS amitriptyline oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 ST ST ST PA clomipramine oral capsule 25, 50, 75 PA desipramine oral tablet 10, 100, 150, 25, 50, 75 doxepin oral capsule 10, 100, 150, 25, 50, 75 PA 22

23 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug doxepin oral concentrate 10 /ml PA imipramine hcl oral tablet 10, 25, 50 PA imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline oral capsule 10, 25, 50, 75 PA nortriptyline oral solution 10 /5 ml protriptyline oral tablet 10, 5 trimipramine oral capsule 100, 25, 50 PA ANTIEMETICS ANTIEMETICS, OTHER chlorpromazine injection solution 25 /ml chlorpromazine oral tablet 10, 100, 200, 25, 50 compro rectal suppository 25 diphenhydramine hcl injection solution 50 /ml PA meclizine oral tablet 12.5, 25 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 10, 5 perphenazine oral tablet 16, 2, 4, 8 phenadoz rectal suppository 12.5 PA prochlorperazine edisylate injection solution 10 /2 ml (5 /ml), 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 promethazine oral syrup 6.25 /5 ml PA promethazine oral tablet 12.5, 25, 50 PA promethazine rectal suppository 12.5, 25 PA 23

24 Name of Drug promethegan rectal suppository 25, 50 PA scopolamine base transdermal patch 3 day 1 over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS trimethobenzamide oral capsule 300 PA EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 125, 40, 80 B/D aprepitant oral capsule,dose pack 125 (1)- 80 (2) B/D dronabinol oral capsule 10, 2.5, 5 B/D EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution 1 /ml (1 ml), 100 mcg/ml granisetron hcl intravenous solution 1 /ml, 1 /ml (1 ml) B/D B/D B/D granisetron hcl oral tablet 1 B/D ondansetron hcl (pf) injection solution 4 /2 ml ondansetron hcl (pf) injection syringe 4 /2 ml ondansetron hcl intravenous solution 2 /ml ondansetron hcl oral solution 4 /5 ml B/D ondansetron hcl oral tablet 24 B/D; QL (15 EA per 30 days) ondansetron hcl oral tablet 4, 8 B/D ondansetron oral tablet,disintegrating 4, 8 B/D SYNDROS ORAL SOLUTION 5 MG/ML ANTIFUNGALS ANTIFUNGALS abelcet intravenous suspension 5 /ml B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG B/D amphotericin b injection recon soln 50 B/D 24

25 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50, 70 PA 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 clotrimazole topical cream 1 % clotrimazole topical solution 1 % econazole topical cream 1 % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG fluconazole in dextrose(iso-o) intravenous piggyback 200 /100 ml, 400 /200 ml fluconazole in nacl (iso-osm) intravenous piggyback 100 /50 ml, 200 /100 ml, 400 /200 ml fluconazole oral suspension for reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 flucytosine oral capsule 250 flucytosine oral capsule 500 griseofulvin microsize oral suspension 125 /5 ml itraconazole oral capsule 100 ketoconazole oral tablet 200 ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % 25

26 Name of Drug MENTAX TOPICAL CREAM 1 % MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nyata 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 nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 250 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 voriconazole intravenous solution 200 voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) voriconazole oral tablet 200, 50 ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100, 300 colchicine oral capsule 0.6 colchicine oral tablet 0.6 probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 MG ST ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS 26

27 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug ala-cort topical cream 1 %, 2.5 % 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 % betamethasone, augmented topical ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % cormax scalp solution 0.05 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.25 % dexamethasone intensol oral drops 1 /ml dexamethasone oral elixir 0.5 /5 ml 27

28 Name of Drug dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 dexamethasone sodium phos (pf) injection solution 10 /ml dexamethasone sodium phosphate injection solution 10 /ml, 4 /ml dexamethasone sodium phosphate injection syringe 4 /ml fluocinolone topical cream 0.01 %, % fluocinolone topical ointment % fluocinolone topical solution 0.01 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluocinonide-emollient topical cream 0.05 % fluticasone topical cream 0.05 % fluticasone topical lotion 0.05 % fluticasone topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical cream 0.1 % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution 0.1 % hydrocortisone butyr-emollient topical cream 0.1 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical cream with perineal applicator 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % 28

29 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablets,dose pack 4 methylprednisolone sodium succ injection recon soln 40 methylprednisolone sodium succ intravenous recon soln 1,000 mometasone topical cream 0.1 % mometasone topical ointment 0.1 % mometasone topical solution 0.1 % prednisolone sodium phosphate oral solution 15 /5 ml (3 /ml), 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 prednisone oral tablets,dose pack 10, 10 (48 pack), 5, 5 (48 pack) RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 MG, 2 MG, 5 MG triamcinolone acetonide topical cream %, 0.1 %, 0.5 % triamcinolone acetonide topical lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % triderm topical cream 0.1 % ANTIMIGRAINE AGENTS 29

30 Name of Drug ERGOT ALKALOIDS dihydroergotamine injection solution 1 /ml PA dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. (4 /ml) ergotamine-caffeine oral tablet SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS QL (8 ML per 30 days) rizatriptan oral tablet 10, 5 QL (12 EA per 30 days) rizatriptan oral tablet,disintegrating 10, 5 QL (12 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 /actuation, 5 /actuation sumatriptan succinate oral tablet 100, 25, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml, 6 /0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution 6 /0.5 ml sumatriptan succinate subcutaneous syringe 6 /0.5 ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine oral tablet 125 pyridostigmine bromide oral tablet 60 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100, 25 rifabutin oral capsule 150 ANTITUBERCULARS CAPASTAT INJECTION RECON SOLN 1 GRAM QL (12 EA per 30 days) QL (12 EA per 30 days) QL (4 ML per 30 days) QL (4 ML per 30 days) QL (4 ML per 30 days) QL (4 ML per 30 days) ethambutol oral tablet 100,

31 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifampin intravenous recon soln 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS BICNU INTRAVENOUS RECON SOLN 100 MG busulfan intravenous solution 60 /10 ml PA carboplatin intravenous recon soln 150 B/D carboplatin intravenous solution 10 /ml B/D cisplatin intravenous solution 1 /ml B/D cyclophosphamide oral capsule 25, 50 B/D dacarbazine intravenous recon soln 200 B/D EMCYT ORAL CAPSULE 140 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG ifosfamide intravenous recon soln 1 gram B/D LEUKERAN ORAL TABLET 2 MG MATULANE ORAL CAPSULE 50 MG melphalan hcl intravenous recon soln 50 B/D 31

32 Name of Drug MUSTARGEN INJECTION RECON SOLN 10 MG oxaliplatin intravenous solution 100 /20 ml B/D thiotepa injection recon soln 15 B/D TREANDA INTRAVENOUS RECON SOLN 100 MG VALCHLOR TOPICAL GEL % ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ANTIANDROGENS bicalutamide oral tablet 50 flutamide oral capsule 125 nilutamide oral tablet 150 XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 250 MG, 500 MG ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ANTIESTROGENS/MODIFIERS DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML ; LA FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML tamoxifen oral tablet 10, 20 ANTIMETABOLITES ALIMTA INTRAVENOUS RECON SOLN 500 MG ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML 32

33 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug cladribine intravenous solution 10 /10 ml B/D cytarabine (pf) injection solution 100 /5 ml (20 /ml), 2 gram/20 ml (100 /ml), 20 /ml B/D cytarabine injection solution 20 /ml B/D DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG FLUDARABINE INTRAVENOUS RECON SOLN 50 MG fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 /10 ml B/D fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % gemcitabine intravenous recon soln 1 gram, 2 gram, 200 gemcitabine intravenous solution 1 gram/26.3 ml (38 /ml), 2 gram/52.6 ml (38 /ml), 200 /5.26 ml (38 /ml) B/D B/D hydroxyurea oral capsule 500 mercaptopurine oral tablet 50 NIPENT INTRAVENOUS RECON SOLN 10 MG PURIXAN ORAL SUSPENSION 20 MG/ML TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS adriamycin intravenous solution 20 /10 ml B/D PICATO TOPICAL GEL %, 0.05 % ANTINEOPLASTICS, OTHER azacitidine injection recon soln 100 PA BELEODAQ INTRAVENOUS RECON SOLN 500 MG 33

34 Name of Drug bleomycin injection recon soln 30 unit B/D clofarabine intravenous solution 20 /20 ml daunorubicin intravenous solution 5 /ml B/D decitabine intravenous recon soln 50 B/D dexrazoxane hcl intravenous recon soln 250 B/D doxorubicin intravenous solution 50 /25 ml B/D doxorubicin, peg-liposomal intravenous suspension 2 /ml PA epirubicin intravenous solution 200 /100 ml B/D ERWINAZE INJECTION RECON SOLN 10,000 UNIT FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FLUDARABINE INTRAVENOUS SOLUTION 50 MG/2 ML FUSILEV INTRAVENOUS RECON SOLN 50 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML) B/D idarubicin intravenous solution 1 /ml B/D ISTODAX INTRAVENOUS RECON SOLN 10 MG/2 ML KADCYLA INTRAVENOUS RECON SOLN 100 MG KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG leucovorin calcium injection recon soln 100, 200, 350, 50, 500 B/D 34

35 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug leucovorin calcium oral tablet 10, 15, 25, 5 LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 50 MG PA levoleucovorin intravenous solution 10 /ml B/D LONSURF ORAL TABLET MG, MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG, 150 MG mesna intravenous solution 100 /ml B/D MESNEX ORAL TABLET 400 MG mitomycin intravenous recon soln 20, 40, 5 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG B/D ODOMZO ORAL CAPSULE 200 MG PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TOTECT INTRAVENOUS RECON SOLN 500 MG TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG 35

36 Name of Drug VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinblastine intravenous solution 1 /ml B/D vincristine intravenous solution 1 /ml B/D vinorelbine intravenous solution 50 /5 ml B/D VYXEOS INTRAVENOUS RECON SOLN MG YONDELIS INTRAVENOUS RECON SOLN 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 exemestane oral tablet 25 letrozole oral tablet 2.5 ENZYME INHIBITORS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG docetaxel intravenous solution 10 /ml B/D docetaxel intravenous solution 160 /16 ml (10 /ml), 160 /8 ml (20 /ml), 20 /2 ml (10 /ml), 20 /ml (1 ml), 80 /4 ml (20 /ml), 80 /8 ml (10 /ml) ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG B/D etoposide intravenous solution 20 /ml B/D IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG irinotecan intravenous solution 100 /5 ml B/D JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) mitoxantrone intravenous concentrate 2 /ml 36

37 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug paclitaxel intravenous concentrate 6 /ml B/D topotecan intravenous recon soln 4 PA topotecan intravenous solution 4 /4 ml (1 /ml) MOLECULAR TARGET INHIBITORS AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA ALECENSA ORAL CAPSULE 150 MG ALUNBRIG ORAL TABLET 30 MG BOSULIF ORAL TABLET 100 MG, 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG, 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG ERIVEDGE ORAL CAPSULE 150 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ICLUSIG ORAL TABLET 15 MG, 45 MG IDHIFA ORAL TABLET 100 MG, 50 MG imatinib oral tablet 100, 400 PA IMBRUVICA ORAL CAPSULE 140 MG INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 250 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 37

38 Name of Drug LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) MEKINIST ORAL TABLET 0.5 MG, 2 MG NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 200 MG OFEV ORAL CAPSULE 100 MG, 150 MG RYDAPT ORAL CAPSULE 25 MG SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) TYKERB ORAL TABLET 250 MG VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 240 MG ZYKADIA ORAL CAPSULE 150 MG MONOCLONAL ANTIBODIES AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML 38

39 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML HERCEPTIN INTRAVENOUS RECON SOLN 440 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) 39

40 Name of Drug VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) RETINOIDS bexarotene oral capsule 75 PANRETIN TOPICAL GEL 0.1 % TARGRETIN TOPICAL GEL 1 % tretinoin (chemotherapy) oral capsule 10 ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 ANTIPROTOZOALS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet , chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine oral tablet 200 mefloquine oral tablet 250 NEBUPENT INHALATION RECON SOLN 300 MG B/D PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 PEDICULICIDES/ SCABICIDES 40

41 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug lindane topical shampoo 1 % malathion topical lotion 0.5 % permethrin topical cream 5 % ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine oral tablet 0.5, 1, 2 PA trihexyphenidyl oral elixir 0.4 /ml PA trihexyphenidyl oral tablet 2, 5 PA ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML entacapone oral tablet 200 GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG, 68.5 MG tolcapone oral tablet 100 DOPAMINE AGONISTS bromocriptine oral capsule 5 bromocriptine oral tablet 2.5 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS 41

42 Name of Drug carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet extended release , MONOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline oral tablet 0.5, 1 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 ANTIPSYCHOTICS 1ST GENERATION/ TYPICAL fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5 ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 loxapine succinate oral capsule 10 QL (120 EA per 30 days) loxapine succinate oral capsule 25, 50 loxapine succinate oral capsule 5 QL (90 EA per 30 days) pimozide oral tablet 1, 2 thioridazine oral tablet 10, 100, 25, 50 PA thiothixene oral capsule 1, 10, 2, 5 trifluoperazine oral tablet 1, 10, 2, 5 2ND GENERATION/ ATYPICAL 42

43 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ; QL (1 EA per 28 days) ; QL (1 EA per 28 days) aripiprazole oral solution 1 /ml QL (900 ML per 30 days) aripiprazole oral tablet 10, 15, 2, 20, 30, 5 aripiprazole oral tablet,disintegrating 10, 15 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2) GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML QL (30 EA per 30 days) QL (60 EA per 30 days) ; QL (3.9 ML per 56 days) ; QL (1.6 ML per 28 days) ; QL (2.4 ML per 28 days) ; QL (3.2 ML per 28 days) ST; QL (60 EA per 30 days) ST ; QL (12 EA per 30 days) ; QL (0.75 ML per 28 days) ; QL (1 ML per 28 days) 43

44 Name of Drug INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG ; QL (1.5 ML per 28 days) ; QL (0.25 ML per 28 days) ; QL (0.5 ML per 28 days) ; QL (0.875 ML per 84 days) ; QL (1.315 ML per 84 days) ; QL (1.75 ML per 84 days) ; QL (2.625 ML per 84 days) ST; QL (30 EA per 30 days) NUPLAZID ORAL TABLET 17 MG ; QL (60 EA per 30 days) olanzapine intramuscular recon soln 10 QL (90 EA per 30 days) olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet,disintegrating 10, 15, 20, 5 paliperidone oral tablet extended release 24hr 1.5, 3, 9 paliperidone oral tablet extended release 24hr 6 quetiapine oral tablet 100, 200, 300, 400 QL (30 EA per 30 days) QL (30 EA per 30 days) PA; QL (30 EA per 30 days) PA; QL (60 EA per 30 days) QL (60 EA per 30 days) quetiapine oral tablet 25, 50 QL (90 EA per 30 days) quetiapine oral tablet extended release 24 hr 150, 200 quetiapine oral tablet extended release 24 hr 300, 400, 50 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG QL (30 EA per 30 days) QL (60 EA per 30 days) ; QL (30 EA per 30 days) 44

45 Tier Standard Member Formulary Formulary ID: Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML ; QL (2 EA per 28 days) risperidone oral solution 1 /ml QL (240 ML per 30 days) risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet,disintegrating 0.25, 0.5, 1, 2, 3, 4 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG 6TH GENERATION/ ATYPICAL RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG TREATMENT-RESISTANT QL (60 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) ST; QL (30 EA per 30 days) ST; QL (28 EA per 28 days) QL (60 EA per 30 days) ; QL (2 EA per 30 days) ; QL (1 EA per 30 days) QL (60 EA per 30 days) clozapine oral tablet 100 QL (270 EA per 30 days) clozapine oral tablet 200 QL (120 EA per 30 days) clozapine oral tablet 25, 50 QL (90 EA per 30 days) clozapine oral tablet,disintegrating 100 QL (270 EA per 30 days) 45

46 Name of Drug clozapine oral tablet,disintegrating 12.5, 25 clozapine oral tablet,disintegrating 150 QL (180 EA per 30 days) clozapine oral tablet,disintegrating 200 QL (120 EA per 30 days) VERSACLOZ ORAL SUSPENSION 50 MG/ML QL (540 ML per 30 days) ANTISPASTICITY AGENTS ANTISPASTICITY AGENTS baclofen oral tablet 10, 20 dantrolene oral capsule 100, 25, 50 tizanidine oral tablet 2, 4 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS cidofovir intravenous solution 75 /ml ganciclovir sodium intravenous recon soln 500 B/D valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % ST ANTI-HEPATITIS B (HBV) AGENTS ADEFOVIR ORAL TABLET 10 MG BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML lamivudine oral solution 10 /ml lamivudine oral tablet 100 QL (30 EA per 30 days) lamivudine oral tablet 150 QL (60 EA per 30 days) lamivudine oral tablet 300 QL (30 EA per 30 days) 46

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